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Comprehensive PREFERRED DRUG LIST WSI 2016 PAGE 1 LAST UPDATED 04/2017 LEGEND TYPE DESCRIPTION QL Quantity Limit There is a limit on the amount of drug covered per prescription, or within a specific time frame. PA Prior Authorization Prior Authorization required before prescription can be filled. Max Daily Dose A limit on the number of times the drug can be taken per day. Custom This drug has unique restrictions. MDD C PAGE 2 LAST UPDATED 04/2017 LIST OF COVERED OVER-THE-COUNTER MEDICATIONS PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS ANALGESICS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS ibuprofen tab 200 mg generic adult aspirin ec low strength 81 mg tab dr generic advil junior strength 100 mg chew tab generic ALKA-SELTZER EXTRA STRENGTH 500 MG EFFER TAB aspirin effervescent BRAND anacin 81 mg tab dr generic ASCRIPTIN MS 500-33-33-237 MG TAB aspirin buffered (al hydrox-mg hydrox-ca carb) BRAND aspir-81 81 mg tab dr generic aspir-low 81 mg tab dr generic aspirin 300 mg suppos generic aspirin 81 mg tab generic aspirin 81 mg tab dr generic aspirin adult low dose 81 mg tab dr generic aspirin adult low strength 81 mg tab dr generic aspirin ec 81 mg tab dr generic aspirin ec lo-dose 81 mg tab dr generic aspirin ec low dose 81 mg tab dr generic aspirin ec low strength 81 mg tab dr generic aspirin low dose 81 mg tab dr generic backache relief extra strength 580 mg tab generic bayer aspirin ec low dose 81 mg tab dr generic bayer low dose 81 mg tab dr generic bayer low strength 81 mg tab dr generic BC FAST PAIN RELIEF ARTHRITIS 742-222-38 MG PACKET aspirin-salicylamide-caffeine BRAND PAGE 3 C Non-Formulary Drug C Non-Formulary Drug C Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE child ibuprofen 100 mg/5ml suspension generic childrens ibuprofen 100 100 mg/5ml suspension generic childrens ibuprofen 100 mg/5ml suspension generic childrens medi-profen 100 mg/5ml suspension generic childs ibuprofen 100 mg/5ml suspension generic cope 400-32 mg tab generic cvs aspirin 81 mg tab dr generic cvs aspirin adult low strength 81 mg tab dr generic cvs aspirin ec 81 mg tab dr generic cvs aspirin low dose 81 mg tab dr generic cvs childrens ibuprofen 100 mg/5ml suspension generic cvs effervescent antacid 325-1000-1916 mg effer tab generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic ibuprofen tab 200 mg generic cvs ibuprofen junior strength 100 mg chew tab generic doans extra strength 580 mg tab generic ibuprofen tab 200 mg generic ec-81 aspirin 81 mg tab dr generic ecotrin low strength 81 mg tab dr generic effervescent antacid/pain rel 325-1000-1916 mg effer tab LIMITS & RESTRICTIONS C Non-Formulary Drug C Non-Formulary Drug C Non-Formulary Drug generic C Non-Formulary Drug effervescent pain relief 325 mg effer tab generic C Non-Formulary Drug effervescent pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug eq adult aspirin low strength 81 mg tab dr generic eq antacid & pain relief 325 mg effer tab generic C Non-Formulary Drug eq aspirin adult low dose 81 mg tab dr generic eq aspirin low dose 81 mg tab dr generic eq childrens ibuprofen 100 mg/5ml suspension generic eq effervescent pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug PAGE 4 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic eq ibuprofen junior 100 mg chew tab generic eql adult aspirin low strength 81 mg tab dr generic eql antacid/pain relief 325-1000-1916 mg effer tab generic eql aspirin ec 81 mg tab dr generic eql aspirin low dose 81 mg tab dr generic eql childrens ibuprofen 100 mg/5ml suspension generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic eql ibuprofen junior strength 100 mg chew tab generic ibuprofen tab 200 mg generic gnp adult aspirin low strength 81 mg tab dr generic gnp aspirin 81 mg tab dr generic gnp aspirin low dose 81 mg tab dr generic gnp childrens ibuprofen 100 mg/5ml suspension generic gnp effervescent antacid/pain 325-1000-1916 mg effer tab generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic gnp ibuprofen junior strength 100 mg chew tab generic goodsense aspirin low dose 81 mg tab dr generic goodsense ibuprofen childrens 100 mg/5ml suspension generic GOODYS EXTRA STRENGTH 520-260-32.5 MG PACKET aspirin-acetaminophen-caffeine BRAND h-e-b aspirin 81 mg tab dr generic halfprin 81 mg tab dr generic hm aspirin ec low dose 81 mg tab dr generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic hm ibuprofen childrens 100 mg/5ml suspension generic PAGE 5 LIMITS & RESTRICTIONS C Non-Formulary Drug C Non-Formulary Drug C Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE ibuprofen tab 200 mg generic hyvee ibuprofen childrens 100 mg/5ml suspension generic ibuprofen tab 200 mg generic ibuprofen tab 200 mg generic ibuprofen 100 mg/5ml suspension generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic ibuprofen childrens 100 mg/5ml suspension generic ibuprofen junior strength 100 mg chew tab generic kls aspirin low dose 81 mg tab dr generic ibuprofen tab 200 mg generic ibuprofen tab 200 mg generic kp aspirin 81 mg tab dr generic ibuprofen cap 200 mg generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic medi-seltzer 325 mg effer tab generic ibuprofen tab 200 mg generic ibuprofen cap 200 mg generic miniprin low dose 81 mg tab dr generic ibuprofen tab 200 mg generic neutralin 325-1000-1916 mg effer tab LIMITS & RESTRICTIONS C Non-Formulary Drug generic C Non-Formulary Drug p-a-c 400-32 mg tab generic C Non-Formulary Drug ibuprofen tab 200 mg generic px childrens profen ib 100 mg/5ml suspension generic px effervescent 325-1000-1916 mg effer tab generic C Non-Formulary Drug px enteric aspirin 81 mg tab dr generic ibuprofen tab 200 mg generic px ibuprofen junior strength 100 mg chew tab generic PAGE 6 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE qc aspirin low dose 81 mg tab dr generic qc childrens ibuprofen 100 mg/5ml suspension generic qc effervescent antacid/pain 325-1000-1916 mg effer tab generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic ibuprofen tab 200 mg generic ra antacid pain relief 325-1000-1916 mg effer tab generic ra aspirin adult low strength 81 mg tab dr generic ra aspirin ec 81 mg tab dr generic ra aspirin ec adult low st 81 mg tab dr generic ra backache relief 580 mg tab generic ra ibuprofen 100 mg/5ml suspension generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic ra ibuprofen childrens 100 mg/5ml suspension generic ra ibuprofen junior strength 100 mg chew tab generic sb aspirin 81 mg tab dr generic sb aspirin adult low strength 81 mg tab dr generic sb childrens ibuprofen 100 mg/5ml suspension generic sb effervescent pain relief 325-1000-1916 mg effer tab generic ibuprofen tab 200 mg generic sb low dose asa ec 81 mg tab dr generic sm aspirin adult low strength 81 mg tab dr generic sm aspirin ec low strength 81 mg tab dr generic sm aspirin low dose 81 mg tab dr generic sm childrens ibuprofen 100 mg/5ml suspension generic sm effervescent pain relief 325-1000-1916 mg effer tab generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic PAGE 7 LIMITS & RESTRICTIONS C Non-Formulary Drug C Non-Formulary Drug C Non-Formulary Drug C Non-Formulary Drug C Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE sm ibuprofen ib 100 mg chew tab generic ibuprofen tab 200 mg generic st joseph aspirin 81 mg tab dr generic tgt aspirin 81 mg tab dr generic tgt aspirin low dose 81 mg tab dr generic tgt childrens ibuprofen 100 mg/5ml suspension generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic tgt ibuprofen childrens 100 mg/5ml suspension generic tgt ibuprofen junior strength 100 mg chew tab generic th aspirin low dose 81 mg tab dr generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic VANQUISH 227-194-33 MG TAB aspirin-acetaminophen-caffeine (buffered) BRAND ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic zee-zeltzer 325-1000-1916 mg tbef LIMITS & RESTRICTIONS C Non-Formulary Drug generic C Non-Formulary Drug anesthetic maximum strength 20 % gel generic PA benz-o-sthetic 20 % gel generic PA BENZODENT 20 % CREAM benzocaine (dental) BRAND cvs oral anesthetic max str 20 % gel generic PA hurricaine 20 % gel generic PA intense toothache pain relief 20 % gel generic PA orabase maximum strength 20 % gel generic PA oral analgesic max st 20 % gel generic PA ANESTHETICS LOCAL ANESTHETICS PAGE 8 LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS oral pain relief max st 20 % gel generic PA orastat maximum strength 20 % gel generic PA ra anesthetic oral 20 % gel generic PA PRODUCT DESCRIPTION ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS SMOKING CESSATION AGENTS cvs nicotine polacrilex 2 mg gum generic cvs nicotine polacrilex 4 mg gum generic cvs nicotine polacrilex 4 mg lozenge generic PA eq nicotine 2 mg gum generic PA eq nicotine 4 mg gum generic eq nicotine 4 mg lozenge generic PA eq nicotine polacrilex 2 mg gum generic PA eq nicotine polacrilex 4 mg gum generic eq nicotine polacrilex 4 mg lozenge generic PA eql nicotine 4 mg lozenge generic PA eql nicotine polacrilex 2 mg gum generic PA eql nicotine polacrilex 4 mg gum generic eql nicotine polacrilex 4 mg lozenge generic PA gnp nicotine polacrilex 2 mg gum generic PA gnp nicotine polacrilex 4 mg gum generic gnp nicotine polacrilex 4 mg lozenge generic goodsense nicotine 4 mg gum generic hm nicotine polacrilex 2 mg gum generic hm nicotine polacrilex 4 mg gum generic hm nicotine polacrilex 4 mg lozenge generic PA kls quit2 2 mg gum generic PA kls quit4 4 mg gum generic PAGE 9 PA PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS kls quit4 4 mg lozenge generic PA nicorelief 2 mg gum generic PA nicorelief 4 mg gum generic nicorelief 4 mg lozenge generic PA nicotine mini 4 mg lozenge generic PA nicotine polacrilex 2 mg gum generic PA nicotine polacrilex 4 mg gum generic nicotine polacrilex 4 mg lozenge generic PA px stop smoking aid 2 mg gum generic PA px stop smoking aid 4 mg gum generic px stop smoking aid 4 mg lozenge generic qc nicotine polacrilex 4 mg gum generic ra mini nicotine 4 mg lozenge generic PA ra nicotine 2 mg gum generic PA ra nicotine 4 mg gum generic ra nicotine polacrilex 2 mg gum generic ra nicotine polacrilex 4 mg gum generic ra nicotine polacrilex 4 mg lozenge generic sm nicotine 4 mg gum generic sm nicotine polacrilex 2 mg gum generic sm nicotine polacrilex 4 mg gum generic sm nicotine polacrilex 4 mg lozenge generic PA sw nicotine polacrilex 2 mg gum generic PA sw nicotine polacrilex 4 mg gum generic sw nicotine polacrilex 4 mg lozenge generic PA tgt nicotine 2 mg gum generic PA tgt nicotine 4 mg gum generic PRODUCT DESCRIPTION PAGE 10 PA PA PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS tgt nicotine polacrilex 2 mg gum generic PA tgt nicotine polacrilex 4 mg gum generic tgt nicotine polacrilex 4 mg lozenge generic PA thrive 2 mg gum generic PA thrive 4 mg gum generic PRODUCT DESCRIPTION ANTIEMETICS ANTIEMETICS, OTHER ambizine 25 mg tab generic COCA COLA SYRUP phosphorated carbohydrate w/caffeine BRAND cvs motion sickness ii 25 mg tab generic dramamine less drowsy 25 mg tab generic eq motion sickness relief 25 mg tab generic eql motion sickness relief 25 mg tab generic gnp motion sickness relief 25 mg tab generic hm motion relief 25 mg tab generic MAREZINE 50 MG TAB cyclizine hcl BRAND meclizine hcl 12.5 mg tab generic meclizine hcl 25 mg tab generic medi-meclizine 25 mg tab generic motion sickness relief ii 25 mg tab generic ra motion sickness relief 25 mg tab generic sm motion sickness 25 mg tab generic th motion relief 25 mg tab generic wal-dram ii 25 mg tab generic ANTIFUNGALS anti-fungal 1 % cream generic anti-fungal 2 % crea generic PA antifungal 2 % cream generic PA PAGE 11 LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS athletes foot 2 % powder generic PA AZOLEN TINCTURE 2 % SOLUTION miconazole nitrate (topical) BRAND baza antifungal 2 % cream generic PA carrington antifungal 2 % cream generic PA clotrimazole 1 % crea generic PA clotrimazole 1 % cream generic clotrimazole 1 % cream generic clotrimazole af 1 % cream generic clotrimazole anti-fungal 1 % cream generic clotrimazole grx 1 % cream generic clotrimazole-7 1 % cream generic critic-aid clear af 2 % ointment generic cvs anti-fungal 2 % powder generic cvs clotrimazole 1 % cream generic cvs itch relief 1 % cream generic cvs miconazole 3 combo pack 200 & 2 mg-% (9gm) kit generic cvs miconazole 3-day combo 200 & 2 mg-% (9gm) kit generic cvs miconazole 7 2 % cream generic PA cvs miconazole nitrate 2 % cream generic PA cvs ringworm 1 % cream generic dermafungal 2 % ointment generic dermagran af 2 % ointment generic desenex 1 % cream generic desenex 2 % powder generic eq antifungal 1 % cream generic eq athletes foot 1 % cream generic eq jock itch 1 % cream generic eq miconazole 3 combo pack 200 & 2 mg-% (9gm) kit generic PRODUCT DESCRIPTION PAGE 12 PA PA PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS eq miconazole 7 2 % cream generic PA eq miconazole 7 day treatment 2 % cream generic PA eql antifungal 1 % cream generic eql athletes foot 1 % cream generic eql miconazole 3 200 & 2 mg-% (9gm) kit generic eql miconazole 7 2 % cream generic FUNGOID TINCTURE 2 % SOLUTION miconazole nitrate (topical) BRAND gnp athletes foot 1 % cream generic gnp miconazole 3 200 & 2 mg-% (9gm) kit generic gnp miconazole 7 2 % cream generic PA gnp miconazorb af 2 % powder generic PA jock itch 1 % cream generic jock itch relief 1 % cream generic kp clotrimazole 1 % cream generic kp miconazole nitrate 2 % cream generic PA lotrimin af 2 % powder generic PA LOTRIMIN ULTRA 1 % CREAM butenafine hcl BRAND PA micaderm 2 % cream generic PA miconazole 3 4 % cream generic PA miconazole 3 combo pack 200 & 2 mg-% (9gm) kit generic miconazole 7 2 % cream generic PA miconazole nitrate 2 % cream generic PA miconazole nitrate 2 % cream generic PA miconazorb af 2 % powder generic PA micro guard 2 % cream generic PA micro guard 2 % powder generic PA PRODUCT DESCRIPTION PAGE 13 PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS MIRANEL AF 2 % SOLUTION miconazole nitrate (topical) BRAND mitrazol 2 % powder generic PA MONISTAT 7 COMBO PACK APP 100 & 2 MG-% (9GM) KIT miconazole nitrate vaginal BRAND PA neosporin af 2 % cream generic PA podactin 2 % cream generic PA pro-ex antifungal 1 % cream generic px athletic foot 1 % cream generic px miconazole 3-day combo 200 & 2 mg-% (9gm) kit generic qc 3 day 4 % cream generic qc clotrimazole 1 % cream generic qc miconazole 7 2 % cream generic PA ra antifungal 2 % cream generic PA ra athletes foot 1 % cream generic ra clotrimazole 1 % cream generic ra clotrimazole 7 1 % cream generic ra jock itch 1 % cream generic ra miconazole 3 combo pack 200 & 2 mg-% (9gm) kit generic ra miconazole 7 2 % cream generic PA remedy antifungal 2 % cream generic PA remedy antifungal 2 % powder generic PA remedy antifungal clear 2 % ointment generic remedy phytoplex antifungal 2 % powder generic sb clotrimazole foot 1 % cream generic secura antifungal 2 % cream generic PA secura antifungal extra thick 2 % cream generic PA shopko athletes foot 1 % cream generic PAGE 14 PA PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS sm antifungal clotrimazole 1 % cream generic sm antifungal miconazole 2 % cream generic PA sm clotrimazole vaginal 1 % cream generic PA sm miconazole 3 200 & 2 mg-% (9gm) kit generic sm miconazole 7 2 % cream generic PA soothe & cool inzo antifungal 2 % cream generic PA tetterine 2 % ointment generic tgt clotrimazole 1 % cream generic tgt miconazole 3 combo pack 200 & 2 mg-% (9gm) kit generic tgt miconazole 3 combo pack 200 & 2 mg-% (9gm) kit generic tgt miconazole 7 2 % cream generic th clotrimazole 1 % cream generic tineacide 2 % cream generic triple paste af 2 % ointment generic vagistat-3 200 & 2 mg-% (9gm) kit generic zeasorb-af 2 % powder generic PA pamix 50 mg/ml suspension generic C Non-Formulary Drug pin-x 50 mg/ml suspension generic C Non-Formulary Drug PIN-X 720.5 MG CHEW TAB pyrantel pamoate BRAND C Non-Formulary Drug PA PA ANTIPARASITICS ANTIHELMINTHICS BLOOD GLUCOSE REGULATORS GLYCEMIC AGENTS glucose 4 gm chew tab PAGE 15 generic LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS cvs fish oil 1200 mg cap generic PA cvs natural fish oil 1200 mg cap generic PA eql fish oil 1200 mg cap generic PA eql omega 3 fish oil 1200 mg cap generic PA fish oil 1200 mg cap generic PA fish oil burp-less 1200 mg cap generic PA fish oil double strength 1200 mg cap generic PA fish oil extra strength 1200 mg cap generic PA fish oil maximum strength 1200 mg cap generic PA hm fish oil 1200 mg cap generic PA kp fish oil 1200 mg cap generic PA omega 3 1200 mg cap generic PA omega-3 fish oil 1200 mg cap generic PA sea-omega 30 1200 mg cap generic PA sm fish oil 1200 mg cap generic PA sm omega-3 fish oil 1200 mg cap generic PA SYSTANE OMEGA-3 HEALTHY TEARS 500 MG CAP DR omega-3 fatty acids BRAND PA th fish oil extra strength 1200 mg cap generic PA theragran-m fish oil conc 1200 mg cap generic PA acetaminophen 100 mg/ml solution generic C Non-Formulary Drug acetaminophen 80 mg/0.8ml solution generic C Non-Formulary Drug PRODUCT DESCRIPTION CARDIOVASCULAR AGENTS DYSLIPIDEMICS, OTHER CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM, OTHER PAGE 16 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS little remedies for fever 160 mg/5ml liquid generic C Non-Formulary Drug q-pap infants 80 mg/0.8ml solution generic C Non-Formulary Drug antiseptic mouth rinse liquid generic PA antiseptic oral rinse 0.05 % liquid generic PA BIOTENE MOISTURIZING MOUTH SOLUTION artificial saliva BRAND BIOTENE ORALBALANCE DRY MOUTH LIQUID artificial saliva BRAND CURASORE 1 % LIQUID pramoxine hcl (dental) BRAND PA cvs antiseptic mouth rinse liquid generic PA CVS DRY MOUTH SOLUTION artificial saliva BRAND cvs mouthwash liquid generic PA cvs sore throat max strength 15-2.6 mg lozenge generic PA dobells solution generic PA dry mouth mouthwash liquid generic PA DRY MOUTH SPRAY SOLUTION artificial saliva BRAND eql antiseptic mouthrinse liquid generic EQL DRY MOUTH ORAL RINSE SOLUTION artificial saliva BRAND eql mouthwash/gargle liquid generic PA fresh n'free liquid generic PA gnp dry mouth mouthwash liquid generic PA goodsense mouthwash liquid generic PA MOI-STIR SOLUTION artificial saliva BRAND MOUTH KOTE SOLUTION artificial saliva BRAND DENTAL AND ORAL AGENTS PAGE 17 PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS mouthwash/gargle liquid generic PA ORAL RELIEF SPRAY SOLUTION artificial saliva BRAND ra antiseptic mouth rinse liquid generic RA DRY MOUTH SOLUTION artificial saliva BRAND ra mouthwash alcohol free liquid generic PA ra mouthwash/gargle liquid generic PA sm antiseptic mouth rinse liquid generic PA sm mouth rinse antiseptic liquid generic PA sore throat relief 10 mg lozenge generic PA trocaine throat 10 mg lozenge generic PA ZILACTIN 10 % GEL benzyl alcohol (anesthetic) BRAND PA acne foaming wash 10 % liquid generic PA acne medication 10 10 % gel generic PA acne medication 5 5 % gel generic ACNE MEDICATION 5 5 % LOTION benzoyl peroxide BRAND acne pimple medication 10 % gel generic acne treatment 10 % bar generic acne treatment 10 % gel generic PA acne wash 2 % liquid generic PA acne-clear 10 % gel generic PA al12 12 % lotion generic PA allergy 2-0.1 % cream generic ALOE GRANDE 10000-1500 UNIT/30ML LOTION vitamins a & e BRAND PRODUCT DESCRIPTION PA DERMATOLOGICAL AGENTS PAGE 18 PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS alph-e-cream cream generic PA aluminum acetate solution generic PA amlactin 12 % lotion generic PA ammonium lactate 12 % lotion generic PA anti-dandruff 1 % shampoo generic anti-itch 1-0.1 % cream generic anti-itch 2-0.1 % cream generic anti-itch intensive healing 1 % lotion generic anti-itch maximum strength 1 % cream generic anti-itch maximum strength 2 % cream generic antifungal foot/sneaker spray 1 % aero powd generic antifungal spray powder 1 % aero powd generic aquanil hc 1 % lotion generic arnica 20 % tincture generic PRODUCT DESCRIPTION PA C aveeno anti-itch max st 1 % cream generic baby vitamin a & d ointment generic bacitracin zinc 500 unit/gm ointment generic bacitracin zinc 500 unit/gm ointment generic BALNETAR 2.5 % EMULSION coal tar extract BRAND banophen 2-0.1 % cream generic baza clear 96 % ointment generic PA beauty lotion lotion generic PA BENADRYL ITCH RELIEF 2-0.1 % STICK diphenhydramine-zinc acetate BRAND bengay pain relief + massage 2.5 % gel generic bengay vanishing scent 2.5 % gel generic benzoyl peroxide 10 % gel generic PAGE 19 Non-Formulary Drug PA PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS benzoyl peroxide 5 % gel generic benzoyl peroxide wash 10 % liquid generic PA benzoyl peroxide wash 5 % liquid generic PA beta hc 1 % lotion generic biofreeze 4 % gel generic PA biofreeze colorless 4 % gel generic PA biofreeze roll-on 4 % gel generic PA biofreeze roll-on colorless 4 % gel generic PA BP CLEANSING 4 % LOTION benzoyl peroxide BRAND bp gel 10 % gel generic bp gel 5 % gel generic bp wash 10 % liquid generic PA bp wash 5 % liquid generic PA bpo-10 wash 10 % liquid generic PA bpo-5 wash 5 % liquid generic PA BRASIVOL PASTE aluminum oxide BRAND PA caldecort 1 % cream generic CAPSAGEL EXTRA STRENGTH 0.05 % GEL capsaicin BRAND castellani paint 1.5 % liquid generic castellani paint modified 1.5 % liquid generic CHIGGEREX 2 % OINTMENT benzocaine (topical) BRAND clean & clear advantage 2 % liquid generic PA clean & clear advantage 3-in-1 2 % liquid generic PA CLEAN & CLEAR ADVANTAGE 3-IN-1 5 % LOTION benzoyl peroxide BRAND clean & clear advantage scrub 2 % liquid generic PAGE 20 PA C Non-Formulary Drug PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS clean & clear advantage wash 2 % liquid generic PA clean & clear continuous wash 2 % liquid generic PA clean & clear deep cleaning 2 % liquid generic PA clean & clear oil absorbing 2 % liquid generic PA clean & clear persa-gel ex st 5 % gel generic clean & clear persa-gel max st 10 % gel generic PA clearasil daily clear 2 % liquid generic PA clearplex v 5 % gel generic cocoa butter lotion generic PA COCOA BUTTER PETROLEUM JELLY GEL emollient BRAND PA cocoa butter skin cream generic PA collagen cream generic PA complete moisture lotion generic PA cortaid advanced 12 hour 1 % cream generic cortaid intensive therapy 1 % cream generic cortaid maximum strength 1 % cream generic corticool 1 % gel generic cortizone-10 1 % gel generic cortizone-10 1 % ointment generic cortizone-10 diabetics skin 1 % lotion generic cortizone-10 eczema 1 % lotion generic cortizone-10 hydratensive 1 % lotion generic cvs acne cleansing 10 % bar generic cvs acne foaming face wash 10 % liquid generic PA cvs acne treatment 10 % gel generic PA cvs adv acne spot treatment 2 % liquid generic PA cvs advanced 3-in-1 cleanser 5 % liquid generic PA PRODUCT DESCRIPTION PAGE 21 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS cvs af spray powder 1 % aero powd generic cvs anti-dandruff 1 % lotion generic cvs anti-itch max str 2 % cream generic cvs anti-itch maximum strength 1 % cream generic cvs bacitracin 500 unit/gm ointment generic cvs bacitracin zinc 500 unit/gm ointment generic cvs cortisone + max st 1 % cream generic cvs cortisone cooling relief 1 % gel generic cvs cortisone intense healing 1 % cream generic cvs cortisone intensive heal 1 % cream generic cvs cortisone long-lasting 1 % lotion generic cvs cortisone maximum strength 1 % cream generic cvs cortisone maximum strength 1 % ointment generic cvs creamy acne face wash 4 % liquid generic PA cvs dry skin care lotion generic PA cvs dual action cleanser/mask 3.5 % liquid generic cvs eczema anti-itch 1 % cream generic cvs extra moisturizing lotion generic PA cvs foaming acne face wash 10 % liquid generic PA cvs foot & sneaker 1 % aero powd generic cvs gentle skin cleanser lotion generic cvs hair regrowth for men 5 % solution generic PA PA C Non-Formulary Drug cvs hair regrowth for women 2 % solution generic C Non-Formulary Drug cvs hair regrowth womens 2 % solution generic C Non-Formulary Drug cvs hemorrhoidal 0.25-3-85.5 % suppos generic PA cvs hydrating skin treatment 12 % lotion generic PA cvs hydrocortisone anti-itch 1 % cream generic PAGE 22 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS cvs hydrocortisone max st 1 % cream generic cvs hydrocortisone plus max st 1 % cream generic cvs itch relief 1-0.1 % cream generic cvs itch relief extra strength 2-0.1 % cream generic cvs lanolin cream generic PA cvs medicated wipes 50 % pad generic PA cvs moisturizing lotion generic PA cvs moisturizing cream generic PA cvs moisturizing extra dry cream generic PA cvs moisturizing lotion generic PA cvs pure glycerin 99.5 % liquid generic cvs skin treatment 12 % lotion generic cvs sore muscle rub 2.5 % gel generic cvs special care lotion generic PA cvs vitamin a & d ointment generic PA cvs vitamin e moisturizing 30000 unit cream generic daily face wash 2 % liquid generic dandrex 1 % shampoo generic dandruff shampoo 1 % lotion generic DEMAREST PLUS 2-1 % LIQUID diphenhydramine-menthol BRAND dermadaily lotion generic dermarest eczema 1 % lotion generic dermavantage lotion generic PA DERMAZINC BABY 0.25 % LIQUID antiseborrheic products, misc. BRAND PA DERMAZINC SCALP LIQUID antiseborrheic products, misc. BRAND PA dhea 1 % cream generic PA PAGE 23 PA PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS DI-DELAMINE 1-0.5 % LIQUID diphenhydramine-tripelenamine BRAND diphenhydramine-zinc acetate 2-0.1 % cream generic dmae cream generic PA dml lotion generic PA dr jh mcleans volcanic oil liquid generic DURAFLEX COMFORT GEL menthol-methyl salicylate (liniments) BRAND e-cream 6000 unit cream generic elta lotion generic PA ELTA TAR 2 % CREAM coal tar extract BRAND PA eq anti-itch extra strength 2-0.1 % cream generic eq anti-itch max strength 1 % cream generic eq athletes foot 1 % aero powd generic eq hemorrhoidal 50 % pad generic eq hydrocortisone max st 1 % cream generic eq hydrocortisone plus 1 % cream generic eq hygienic cleansing wipes pad generic PA eq vitamins a & d ointment generic PA eql absolute moisture dry skin lotion generic PA eql acne scrub pink grapefruit 2 % liquid generic PA eql advanced recovery lotion generic PA eql advanced skin therapy lotion generic PA eql aloe after sun lotion generic PA eql anti-itch extra strength 2-0.1 % cream generic eql anti-itch intensive heal 1 % cream generic eql anti-itch maximum strength 1 % cream generic eql anti-itch maximum strength 1 % ointment generic PAGE 24 PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS eql apricot scrub 2 % liquid generic PA eql athletes foot 1 % aero powd generic eql bacitracin zinc 500 unit/gm ointment generic eql hair regrowth 5 % solution generic PRODUCT DESCRIPTION PA C Non-Formulary Drug PA eql hair regrowth for men 5 % solution generic C Non-Formulary Drug C Non-Formulary Drug eql hair regrowth for women 2 % solution generic eql hemorrhoidal 0.25-3-12-18 % cream generic eql hemorrhoidal 0.25-3-85.5 % suppos generic eql medicated dandruff 1 % lotion generic eql medicated wipes 50 % pad generic first aid antibiotic 4 % ointment generic FLEXALL ULTRA PLUS 3.1-16-10 % GEL camphor-menthol-methyl salicylate BRAND PA FUNGI-NAIL 25 % SOLUTION undecylenic acid BRAND PA gentian violet 1 % solution generic PA geri-hydrolac 12 12 % lotion generic PA geri-hydrolac 12 12 % lotion generic PA glycerin 99.5 % liquid generic glycerin liquid generic gnp anti-itch 2-0.1 % cream generic gnp bacitracin zinc 500 unit/gm ointment generic gnp glycerin 99.5 % liquid generic gnp hemorrhoidal 0.25-3-85.5 % suppos generic gnp hydro-lotion 1 % lotion generic gnp hydrocortisone max st 1 % ointment generic gnp hydrocortisone plus 1 % cream generic PAGE 25 PA PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS gnp hygienic cleansing 50 % pad generic PA gnp medicated wipes 50 % pad generic PA GORDOCHOM 25 % SOLUTION undecylenic acid BRAND PA gordomatic 92 % lotion generic PA GORDONS-VITE A 100000 UNIT LOTION vitamin a (topical) BRAND PA gordons-vite e 1500 unit/30gm cream generic grx vitamin e 1000/112 g cream generic hair regrowth treatment men 5 % solution generic PRODUCT DESCRIPTION PA C hem-prep 0.25-3-85.5 % suppos generic PA hemorrhoid 0.25-3-85.5 % suppos generic PA hemorrhoidal 0.25-3-12-18 % cream generic hemorrhoidal 0.25-3-85.5 % suppos generic PA hemorrhoidal 50 % pad generic PA hemorrhoidal 51 % suppos generic PA hemorrhoidal hygiene 50 % pad generic PA hemorrhoidal relief 0.25-3-85.5 % suppos generic PA hm glycerin 99.5 % liquid generic hydro skin maximum strength 1 % lotion generic hydrocortisone 1 % cream generic hydrocortisone 1 % cream generic hydrocortisone 1 % lotion generic hydrocortisone 1 % lotion generic hydrocortisone 1 % ointment generic hydrocortisone intensive heal 1 % cream generic hydrocortisone max st 1 % cream generic hydrocortisone max st/12 moist 1 % cream generic PAGE 26 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE hydrocortisone plus 1 % cream generic hydrocortisone plus 12 1 % cream generic hydroskin 1 % cream generic hydroskin 1 % lotion generic ionil-t 1 % shampoo generic itch relief 2 % cream generic itch relief extra strength 2-0.1 % cream generic IVY BLOCK 5 % LOTION bentoquatam BRAND IVY DRY 2 % LOTION zinc acetate (topical) BRAND jock itch spray 1 % aero powd generic jock itch spray powder 1 % aero powd generic KERA TEK 28%-16% GEL menthol-methyl salicylate (liniments) BRAND kericort 10 1 % cream generic kls minoxidil 5 % solution generic LIMITS & RESTRICTIONS PA PA C kp bacitracin zinc 500 unit/gm ointment generic kp benzoyl peroxide 10 % gel generic kp benzoyl peroxide 5 % gel generic kp benzoyl peroxide wash 10 % liquid generic PA kp benzoyl peroxide wash 5 % liquid generic PA kp hydrocortisone 1 % cream generic kp hydrocortisone max st 1 % ointment generic lactic acid e 10-3500 %-unt/30gm cream generic lamisil af defense 1 % aero powd generic LIQUIMAT 5 % LOTION sulfur BRAND PA lubricating lotion lotion generic PA lubrisilk lotion generic PA PAGE 27 Non-Formulary Drug PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS lubriskin lotion generic PA med-derm hydrocortisone 1 % cream generic medicated cleansing 50 % pad generic PA medicated wipes 50 % pad generic PA medicated wipes pad generic PA meijer hydrocortisone 1 % cream generic MERCUROCLEAR 2.5-0.133 % LIQUID lidocaine-benzalkonium BRAND mg217 psoriasis anit-itch 1 % gel generic MINERAL OIL-HYDROPHIL PETROLAT OINTMENT mineral oil-hydrophilic petrolatum BRAND C minerin lotion generic PA minoxidil 2 % solution generic C minoxidil 5 % soln generic PRODUCT DESCRIPTION Non-Formulary Drug Non-Formulary Drug PA C Non-Formulary Drug PA minoxidil 5 % solution generic minoxidil for men 2 % solution generic minoxidil for men 5 % solution generic C Non-Formulary Drug C Non-Formulary Drug PA C Non-Formulary Drug Non-Formulary Drug minoxidil for women 2 % solution generic C moisture lotion generic PA moisture recovery lotion generic PA moisturizing cream cream generic PA moisturizing lotion lotion generic PA moisturizing sensitive skin lotion generic PA moisturizing vitamin e/aloe lotion generic PA monistat soothing care 1 % cream generic PAGE 28 LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS MYCO NAIL A 25 % SOLUTION undecylenic acid BRAND PA neosporin eczema essent max st 1 % cream generic neutrogena body clear wash 2 % liquid generic PA neutrogena oil-free acne wash 2 % liquid generic PA NEUTROGENA T/GEL CONDITIONER 0.5 % LIQUID coal tar extract BRAND PA neutrogena t/gel ex st 1 % shampoo generic NEW TEROCIN 0.025-10-25 % LOTION capsaicin-menthol-methyl salicylate BRAND noble formula hc 1 % cream generic noble formula s 2 % liquid generic PA OC8 7 % GEL benzoyl peroxide BRAND PA odor control foot & sneaker 1 % aero powd generic odor eaters foot/sneaker spray 1 % aero powd generic OUTGRO PAIN RELIEF 20 % LIQUID benzocaine (topical) BRAND PA P & S LIQUID antiseborrheic products, misc. BRAND PA panoxyl 10 % bar generic PANOXYL 3 % GEL benzoyl peroxide BRAND panoxyl aqua 10 % gel generic PA panoxyl wash 10 % liquid generic PA PANTHODERM 2 % CREAM dexpanthenol (topical) BRAND pc-tar 1 % shampoo generic PERNOX 1.5-2 % LOTION salicylic acid & sulfur (keratolytic) BRAND PA polar frost 4 % gel generic PA pre-moistened witch hazel 50 % pad generic PA PRODUCT DESCRIPTION PAGE 29 LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS preparation h 50 % pad generic PA preparation h for women 20 % pad generic PA preparation h hydrocortisone 1 % cream generic preparation h totables wipes 50 % pad generic PA PREVACARE ANTIMICROBIAL 60 % GEL ethyl alcohol (skin cleanser) BRAND PA procomycin 4 % ointment generic PROPA PH ACNE MED CLEANSING 0.6 % LOTION salicylic acid BRAND PA propa ph foaming face wash 2 % liquid generic PA px hemorrhoidal 0.25-3-85.5 % suppos generic PA px hydrocream 1 % cream generic px minoxidil for men 5 % solution generic PRODUCT DESCRIPTION PA C Non-Formulary Drug C Non-Formulary Drug px minoxidil for women 2 % solution generic qc anti-itch extra strength 2-0.1 % cream generic qc glycerin 99.5 % liquid generic qc hydrocortisone 1 % cream generic qc hydrocortisone max st 1 % cream generic qc medicated pre-moistened 50 % pad generic PA ra acne cleanser oil-free 2 % liquid generic PA ra advanced recovery lotion generic PA ra allergy 2-0.1 % cream generic RA ANTI-FUNGAL FOOT CARE 25 % SOLUTION undecylenic acid BRAND ra anti-itch maximum strength 1 % cream generic ra anti-itch maximum strength 1 % ointment generic ra apricot scrub 2 % liquid generic PA ra baby care vit a&d to go ointment generic PA PAGE 30 PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS ra bacitracin 500 unit/gm ointment generic ra bacitracin zinc first aid 500 unit/gm ointment generic ra calming daily moisturizing cream generic ra dandruff shampoo 1 % lotion generic ra derma lotion generic PA ra gentle skin lotion generic PA ra glycerin liquid generic ra hair regrowth ex st for men 5 % solution generic PA PA C Non-Formulary Drug Non-Formulary Drug ra hair regrowth for women 2 % solution generic C ra hemorrhoid relief medicated 50 % pad generic PA ra hemorrhoidal 0.25-3-12-18 % cream generic ra hemorrhoidal 0.25-3-85.5 % suppos generic ra hydrocortisone max st 1 % cream generic ra hydrocortisone plus 12 1 % cream generic ra jock itch max st 1 % aero powd generic ra medicated wipes 50 % pad generic PA ra moisturizing oatmeal 1.25 % lotion generic PA ra moisturizing therapy cream generic PA ra pain care muscle & joint 2.5 % gel generic ra renewal acne treatment 10 % gel generic PA ra renewal cocoa butter lotion generic PA ra renewal dandruff 1 % shampoo generic ra renewal moisturizing cream generic PA ra total moisture lotion generic PA ra vitamin a & d ointment generic PA ra vitamin e-vit a & d 20000 unit cream generic PA PAGE 31 PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS ra vitamin e-vit a & d 4000 unit cream generic PA ra vitamins a & d ointment generic PA recort plus 1 % cream generic rederm 1 % lotion generic refreshing aloe lotion generic PA SARDOETTES PAD emollient BRAND PA sarnol-hc 1 % lotion generic sb anti-itch maximum strength 2-0.1 % cream generic sb hydrocortisone 1 % cream generic sb hydrocortisone max st 1 % ointment generic sb hydrocortisone plus 1 % cream generic sb triple antibiotic 4 % ointment generic scholls odor destroyers sport 1 % aero powd generic sm allergy maximum strength 2 % cream generic sm anti-itch extra strength 2-0.1 % cream generic sm athletes foot 1 % aero powd generic sm dry skin therapy lotion generic sm glycerin 99.5 % liquid generic sm hemorrhoidal 0.25-3-12-18 % cream generic sm hemorrhoidal 51 % suppos generic sm hydrocortisone 1 % cream generic sm hydrocortisone max st 1 % ointment generic sm medicated wipes 50 % pad generic PA softden lotion generic PA STYPTOCAINE 46 % LIQUID aluminum sulfate (topical astringent) BRAND tgt anti-itch maximum strength 1 % cream generic tgt anti-itch maximum strength 1 % ointment generic tgt anti-itch plus oatmeal 1 % cream generic PRODUCT DESCRIPTION PAGE 32 PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS tgt anti-itch/aloe/vit e 1 % cream generic tgt antifungal spray powder 1 % aero powd generic tgt hair regrowth for women 2 % solution generic C tgt hemorrhoidal 0.25-3-85.5 % suppos generic PA tgt itch relief extra strength 2-0.1 % cream generic tgt medicated hemorrhoidal 50 % pad generic PA tgt medicated wipe/witch hazel 50 % pad generic PA tgt minoxidil hair regrowth 5 % solution generic Non-Formulary Drug PA C th hydrocortisone 1 % cream generic thera-derm lotion generic theracort 1 % lotion generic therapeutic bath lotn generic PA tn dickinsons witch hazel 50 % pad generic PA tn dickinsons witch hazel pad generic PA tolnaftate 1 % aero powd generic tru-micin 10 % lotion generic tucks 50 % pad generic PA tucks medicated cooling 50 % pad generic PA tucks take alongs 50 % pad generic PA ultracin t 10 % lotion generic vitamin e 100 % cream generic vitamin e 1000 unit cream generic vitamin e 30000 unit/60gm cream generic vitamin e cream generic vitamin e skin 4000 unit cream generic PA vitamin e with panthenol cream generic PA vitamin e-vit a & d cream generic PA PAGE 33 Non-Formulary Drug PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS vitamins a & d ointment generic PA vitec lotion generic wal-dryl 2-0.1 % cream generic xtra-care lotion generic yagers liniment 3.1-8.2 % liquid generic PRODUCT DESCRIPTION GASTROINTESTINAL AGENTS GASTROINTESTINAL AGENTS, OTHER acid gone 95-358 mg/15ml suspension generic alamag plus 200-200-25 mg chew tab generic almacone 200-200-25 mg chew tab generic antacid 550-110 mg chew tab generic antacid extra strength 675-135 mg chew tab generic loperamide hcl tab 2 mg generic anti-gas ultra strength 180 mg cap generic calcium rich supreme antacid 400-135 mg/5ml suspension generic cvs antacid 550-110 mg chew tab generic cvs antacid supreme 400-135 mg/5ml suspension generic loperamide hcl tab 2 mg generic cvs dairy relief 9000 unit chew tab generic cvs dairy relief fast acting 9000 unit chew tab generic cvs gas relief 80 mg chew tab generic cvs gas relief ultra strength 180 mg cap generic cvs infants gas relief 20 mg/0.3ml suspension generic dairy-digestive 9000 unit chew tab generic loperamide hcl tab 2 mg generic drxchoice gas relief 80 mg chew tab generic eq antacid extra strength 675-135 mg chew tab generic loperamide hcl tab 2 mg generic eq dairy digestive fast acting 9000 unit chew tab generic PAGE 34 PA PA PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS eq infants gas relief 40 mg/0.6ml suspension generic loperamide hcl tab 2 mg generic eql gas relief ultra strength 180 mg cap generic eql infants gas relief 20 mg/0.3ml suspension generic gas relief 180 mg cap generic gas relief 20 mg/0.3ml suspension generic gas relief 80 mg chew tab generic gas relief ultra strength 180 mg cap generic gas-x ultra strength 180 mg cap generic geri-lanta supreme 400-135 mg/5ml suspension generic gnp antacid 550-110 mg chew tab generic loperamide hcl tab 2 mg generic gnp anti-gas 180 mg cap generic gnp fast acting dairy relief 9000 unit chew tab generic gnp foaming antacid 95-358 mg/15ml suspension generic gnp gas relief 80 mg chew tab generic gnp infants gas relief 20 mg/0.3ml suspension generic loperamide hcl tab 2 mg generic hm gas relief 80 mg chew tab generic hm gas relief infants drops 20 mg/0.3ml suspension generic infants gas relief 20 mg/0.3ml suspension generic infants gas relief 40 mg/0.6ml suspension generic infants simethicone 20 mg/0.3ml suspension generic loperamide hcl tab 2 mg generic lactose fast acting relief 9000 unit chew tab generic little remedies for tummys 20 mg/0.3ml suspension generic little tummys gas relief 20 mg/0.3ml suspension generic loperamide hcl tab 2 mg generic PA loperamide hcl tab 2 mg generic PA PAGE 35 PA PA PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE magnesium oxide 400 mg tab generic loperamide hcl tab 2 mg generic mi-acid gas relief 80 mg chew tab generic mintox plus 200-200-25 mg chew tab generic mytab gas 80 mg chew tab generic pediacare infants gas relief 20 mg/0.3ml suspension generic loperamide hcl tab 2 mg generic px gas relief infants 20 mg/0.3ml suspension generic px gas relief ultra strength 180 mg cap generic loperamide hcl tab 2 mg generic qc anti-gas 180 mg cap generic qc gas relief 80 mg chew tab generic quick action dairy relief 9000 unit chew tab generic loperamide hcl tab 2 mg generic ra dairy relief fast acting 9000 unit chew tab generic ra gas relief 40 mg/0.6ml suspension generic ra gas relief 80 mg chew tab generic ra gas relief ultra strength 180 mg cap generic ra gas relief/infants 20 mg/0.3ml suspension generic rolaids 550-110 mg chew tab generic loperamide hcl tab 2 mg generic sb anti-gas 180 mg cap generic sb gas relief 40 mg/0.6ml suspension generic simeped 40 mg/0.6ml suspension generic simethicone 180 mg cap generic simethicone 20 mg/0.3ml suspension generic simethicone 40 mg/0.6ml suspension generic simethicone 80 mg chew generic simethicone 80 mg chew tab generic PAGE 36 LIMITS & RESTRICTIONS PA PA PA PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS loperamide hcl tab 2 mg generic PA sm gas relief 80 mg chew tab generic sm gas relief antiflatuent 180 mg cap generic sm gas relief infants 20 mg/0.3ml suspension generic sm gas relief infants drops 40 mg/0.6ml suspension generic tgt antacid extra strength 675-135 mg chew tab generic loperamide hcl tab 2 mg generic th antacid supreme 400-135 mg/5ml suspension generic loperamide hcl tab 2 mg generic PA URO-MAG 140 MG CAP magnesium oxide BRAND PA acid control maximum strength 150 mg tab generic MDD 2 per day acid controller 10 mg tab generic MDD 2 per day acid controller complete 10-800-165 mg chew tab generic acid reducer + antacid 10-800-165 mg chew tab generic acid reducer 10 mg tab generic MDD 2 per day acid reducer 150 mg tab generic MDD 2 per day acid reducer 200 mg tab generic MDD 1 per day acid reducer 75 mg tab generic MDD 2 per day acid reducer maximum strength 150 mg tab generic MDD 2 per day acid relief 200 mg tab generic MDD 1 per day cimetidine 200 200 mg tab generic MDD 1 per day cimetidine 200 mg tab generic MDD 1 per day cimetidine 200 mg tabs generic MDD 1 per day cimetidine acid reducer 200 mg tab generic MDD 1 per day cvs acid reducer 10 mg tab generic MDD 2 per day PRODUCT DESCRIPTION PA HISTAMINE2 (H2) RECEPTOR ANTAGONISTS PAGE 37 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE cvs acid reducer max st 150 mg tab generic cvs dual action complete 10-800-165 mg chew tab generic cvs heartburn relief 200 mg tab LIMITS & RESTRICTIONS MDD 2 per day generic MDD 1 per day cvs ranitidine 75 mg tab generic MDD 2 per day dual action complete 10-800-165 mg chew tab generic duo fusion 10-800-165 mg chew tab generic eq acid reducer 10 mg tab generic MDD 2 per day eq acid reducer 150 mg tab generic MDD 2 per day eq acid reducer 200 mg tab generic MDD 1 per day eq acid reducer 75 mg tab generic MDD 2 per day eq acid reducer complete 10-800-165 mg chew tab generic eq heartburn relief 200 mg tab generic MDD 1 per day eq ranitidine 75 mg tab generic MDD 2 per day eql acid reducer 150 mg tab generic MDD 2 per day eql acid reducer 200 mg tab generic MDD 1 per day eql acid reducer 75 mg tab generic MDD 2 per day eql dual action complete 10-800-165 mg chew tab generic eql heartburn prevention 10 mg tab generic MDD 2 per day eql heartburn relief 75 mg tab generic MDD 2 per day eql heartburn relief max st 150 mg tab generic MDD 2 per day famotidine 10 mg tab generic MDD 2 per day gnp acid control 150 max st 150 mg tab generic MDD 2 per day gnp acid control 75 75 mg tab generic MDD 2 per day gnp acid reducer 10 mg tab generic MDD 2 per day gnp acid reducer 75 mg tab generic MDD 2 per day gnp dual action complete 10-800-165 mg chew tab generic PAGE 38 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS gnp heartburn relief 200 200 mg tab generic MDD 1 per day gnp heartburn relief 200 mg tab generic MDD 1 per day goodsense acid reducer 150 mg tab generic MDD 2 per day goodsense acid reducer 75 mg tab generic MDD 2 per day heartburn relief 10 mg tab generic MDD 2 per day heartburn relief 150 max st 150 mg tab generic MDD 2 per day heartburn relief 200 mg tab generic MDD 1 per day heartburn relief 75 mg tab generic MDD 2 per day heartburn relief max st 150 mg tab generic MDD 2 per day hm acid reducer 150 mg tab generic MDD 2 per day hm acid reducer 75 mg tab generic MDD 2 per day hm acid reducer max strength 150 mg tab generic MDD 2 per day hm complete dual action 10-800-165 mg chew tab generic hm famotidine 10 mg tab generic MDD 2 per day kls acid controller complete 10-800-165 mg chew tab generic kls acid reducer 75 mg tab generic MDD 2 per day kls acid reducer max st 150 mg tab generic MDD 2 per day px acid reducer 10 mg tab generic MDD 2 per day px acid reducer 200 mg tab generic MDD 1 per day px acid reducer 75 mg tab generic MDD 2 per day px acid reducer max st 150 mg tab generic MDD 2 per day px dual action 10-800-165 mg chew tab generic px ranitidine 75 mg tab generic MDD 2 per day qc acid controller 10 mg tab generic MDD 2 per day ra acid reducer 10 mg tab generic MDD 2 per day ra acid reducer 200 mg tab generic MDD 1 per day PAGE 39 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS ra acid reducer 75 mg tab generic MDD 2 per day ra acid reducer max st 150 mg tab generic MDD 2 per day ra dual action complete 10-800-165 mg chew tab generic ranitidine acid reducer 75 mg tab generic MDD 2 per day ranitidine hcl 150 mg tab generic MDD 2 per day ranitidine hcl 75 mg tab generic MDD 2 per day sb acid controller 10 mg tab generic MDD 2 per day sb acid reducer 10 mg tab generic MDD 2 per day sb acid reducer 150 mg tab generic MDD 2 per day sb acid reducer ranitidine 75 mg tab generic MDD 2 per day sb cimetidine 200 mg tab generic MDD 1 per day sm acid reducer 10 mg tab generic MDD 2 per day sm acid reducer 200 mg tab generic MDD 1 per day sm acid reducer 75 mg tab generic MDD 2 per day sm acid reducer max st 150 mg tab generic MDD 2 per day sm complete dual action 10-800-165 mg chew tab generic sw acid reducer 150 max st 150 mg tab generic MDD 2 per day tgt acid controller complete 10-800-165 mg chew tab generic tgt acid reducer 10 mg tab generic MDD 2 per day tgt acid reducer 200 mg tab generic MDD 1 per day tgt acid reducer 75 mg tab generic MDD 2 per day tgt acid reducer complete 10-800-165 mg chew tab generic th famotidine 10 10 mg tab generic MDD 2 per day tums dual action 10-800-165 mg chew tab generic wal-zan 150 maximum strength 150 mg tab generic MDD 2 per day wal-zan 75 75 mg tab generic MDD 2 per day PAGE 40 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS LAXATIVES bisacodyl laxative suppos 10 mg generic bisacodyl laxative suppos 10 mg generic bisacodyl laxative suppos 10 mg generic bisacodyl laxative suppos 10 mg generic calcium polycarbophil 625 mg tab generic bisacodyl laxative suppos 10 mg generic cvs fiber laxative 625 mg tab generic bisacodyl laxative suppos 10 mg generic cvs glycerin adult 2 gm suppos generic cvs glycerin child 2 gm suppos generic cvs laxative dietary supplemnt 500 mg tab generic senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic milk of magnesia suspension 400 mg/5ml generic cvs natural daily fiber 58.6 % powder generic cvs natural fiber supplement 58.6 % powder generic cvs phosphate saline laxative 2.7-7.2 gm/15ml solution generic cvs stool softener 50 mg cap generic diocto 60 mg/15ml syrup generic docusate sodium 60 mg/15ml syrup generic milk of magnesia suspension 400 mg/5ml generic eq fiber laxative 625 mg tab generic eq fiber therapy 625 mg tab generic senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic eq natural fiber laxative 58.6 % powder generic eql fiber laxative 625 mg tab generic bisacodyl laxative suppos 10 mg generic senna maximum strength tab 25 mg generic PAGE 41 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic milk of magnesia suspension 400 mg/5ml generic eql natural fiber 58.6 % powder generic fiber 625 mg tab generic fiber laxative 625 mg tab generic fiber laxative 625 mg tabs generic fiber plus calcium cap generic fiber therapy 2 gm/10.2gm powder generic fiber therapy 2 gm/19gm powder generic fiber therapy 58.6 % powder generic fiber-caps 625 mg tab generic fiber-lax 625 mg tab generic fibergen 625 mg tab generic genfiber 50 % powd generic bisacodyl laxative suppos 10 mg generic geri-mucil 68 % powder generic glycerin (adult) 2 gm suppos generic glycerin (child) 1.2 gm suppos generic glycerin (infants & children) 1.2 gm suppos generic glycerin (pediatric) 1.2 gm suppos generic glycerin adult 2 gm suppos generic gnp fiber-caps 625 mg tab generic gnp glycerin (infant) 1.2 gm suppos generic gnp glycerin child 1.2 gm suppos generic bisacodyl laxative suppos 10 mg generic senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic gnp stool softener 60 mg/15ml syrup generic hm fiber 58.6 % powder generic PAGE 42 LIMITS & RESTRICTIONS LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE bisacodyl laxative suppos 10 mg generic milk of magnesia suspension 400 mg/5ml generic kls fiber-tabs 625 mg tab generic kls natural psyllium fiber 58.6 % powder generic KONDREMUL 50 % EMULSION mineral oil BRAND KONSYL 60.3 % POWDER psyllium BRAND KONSYL 71.67 % POWDER psyllium BRAND konsyl fiber 625 mg tab generic KONSYL-D 52.3 % POWDER psyllium BRAND bisacodyl laxative suppos 10 mg generic senna maximum strength tab 25 mg generic senna maximum strength tab 25 mg generic METAMUCIL MULTIHEALTH FIBER 55.46 % POWDER psyllium BRAND metamucil multihealth fiber 58.6 % powder generic metamucil smooth texture 58.6 % powder generic METAMUCIL WAFER psyllium BRAND milk of magnesia suspension 400 mg/5ml generic milk of magnesia suspension 400 mg/5ml generic milk of magnesia suspension 400 mg/5ml generic milk of magnesia suspension 400 mg/5ml generic NAT-RUL PSYLLIUM SEED HUSKS 500 MG CAP psyllium BRAND natrul colon care 100 % powder generic natural fiber 58.6 % powder generic natural fiber laxative 58.6 % powder generic natural fiber laxative 68 % powder generic natural fiber therapy 30 % powder generic PAGE 43 LIMITS & RESTRICTIONS LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE natural psyllium seed 100 % powder generic milk of magnesia suspension 400 mg/5ml generic phosphate laxative 0.9-2.4 gm/5ml solution generic phosphate laxative 2.7-7.2 gm/15ml solution generic psyldex 30 % powder generic psyllium 58.6 % powder generic psyllium husk 100 % powder generic px fiber 625 mg tab generic milk of magnesia suspension 400 mg/5ml generic bisacodyl laxative suppos 10 mg generic senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic qc natural vegetable 95 % powder generic ra col-rite 50 mg cap generic bisacodyl laxative suppos 10 mg generic ra fiber 58.6 % powder generic ra fiber therapy 625 mg tab generic ra fiber-cap 625 mg tab generic ra fiber-tab 625 mg tab generic senna maximum strength tab 25 mg generic senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic ra oral saline laxative 0.9-2.4 gm/5ml solution generic ra oral saline laxative 2.7-7.2 gm/15ml solution generic ra saline laxative 2.7-7.2 gm/5ml solution generic bisacodyl laxative suppos 10 mg generic reguloid 58.6 % powder generic reguloid 68 % powder generic saline laxative 0.9-2.4 gm/5ml solution generic sani-supp adult 2 gm suppos generic PAGE 44 LIMITS & RESTRICTIONS LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE sani-supp pediatric 1.2 gm suppos generic sb fib lax orange 30 % powder generic sb fiber laxative 625 mg tab generic sb glycerin pediatric 1.2 gm suppos generic bisacodyl laxative suppos 10 mg generic milk of magnesia suspension 400 mg/5ml generic senna maximum strength tab 25 mg generic senna maximum strength tab 25 mg generic silace 60 mg/15ml syrup generic sm fiber 58.6 % powder generic sm fiber 625 mg tab generic sm fiber laxative 625 mg tab generic sm glycerin pediatric 1.2 gm suppos generic bisacodyl laxative suppos 10 mg generic senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic milk of magnesia suspension 400 mg/5ml generic sm oral saline laxative 0.9-2.4 gm/5ml solution generic sm oral saline laxative 2.7-7.2 gm/5ml solution generic senna maximum strength tab 25 mg generic soluble fiber therapy 2 g/19 g powder generic sorbulax 100 % powder generic tgt fiber laxative 625 mg tab generic tgt fiber therapy 58.6 % powder generic senna maximum strength tab 25 mg generic senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic milk of magnesia suspension 400 mg/5ml generic bisacodyl laxative suppos 10 mg generic wal-mucil 100 % powder generic PAGE 45 LIMITS & RESTRICTIONS LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE wal-mucil 58.6 % powder generic wal-mucil plus calcium 1g-60mg cap generic wal-mucil plus calcium cap generic LIMITS & RESTRICTIONS PROTON PUMP INHIBITORS cvs lansoprazole 15 mg cap dr generic MDD 2 per day eq lansoprazole 15 mg cap dr generic MDD 2 per day eql lansoprazole 15 mg cap dr generic MDD 2 per day gnp lansoprazole 15 mg cap dr generic MDD 2 per day goodsense lansoprazole 15 mg cap dr generic MDD 2 per day heartburn relief 24 hour 15 mg cap dr generic MDD 2 per day heartburn treatment 24 hour 15 mg cap dr generic MDD 2 per day hm lansoprazole 15 mg cap dr generic MDD 2 per day kls lansoprazole 15 mg cap dr generic MDD 2 per day lansoprazole 15 mg cap dr generic MDD 2 per day ra lansoprazole 15 mg cap dr generic MDD 2 per day sm lansoprazole 15 mg cap dr generic MDD 2 per day GENITOURINARY AGENTS GENITOURINARY AGENTS, OTHER azo dine 95 mg tab generic azo tabs 95 mg tab generic azo urinary pain relief 95 mg tab generic azo-gesic 95 mg tab generic azo-standard 95 mg tab generic cvs urinary pain relief 95 mg tab generic eq urinary pain relief 95 mg tab generic gnp urinary pain relief 95 mg tab generic phenazo 95 mg tab generic phenazopyridine hcl 95 mg tab generic PAGE 46 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE qc azo 95 mg tab generic ra urinary pain relief 95 mg tab generic ra urinary tract pain relief 95 mg tab generic sb urinary pain relief 95 mg tab generic sm urinary pain relief 95 mg tab generic th urinary pain relief 95 mg tab generic TRIMO-SAN 0.025 % GEL oxyquinolone sulfate vaginal BRAND urinary pain relief 95 mg tab generic uristat 95 mg tab generic LIMITS & RESTRICTIONS HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) PROGESTINS aftera 1.5 mg tab generic PA econtra ez 1.5 mg tab generic PA fallback solo 1.5 mg tab generic PA levonorgestrel 1.5 mg tab generic PA my way 1.5 mg tab generic PA next choice one dose 1.5 mg tab generic PA opcicon one-step 1.5 mg tab generic PA option 2 1.5 mg tab generic PA react 1.5 mg tab generic PA take action 1.5 mg tab generic PA MISCELLANEOUS THERAPEUTIC AGENTS PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % 8 hour pain relief 650 mg tab er PAGE 47 generic generic C Non-Formulary Drug C Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE 8 hour pain reliever 650 mg tab er generic a1c test at-home kit generic acetaminophen 160 mg/5ml liquid generic acetaminophen 325 mg tab generic acetaminophen 8 hour 650 mg tab er LIMITS & RESTRICTIONS C Non-Formulary Drug C Non-Formulary Drug generic C Non-Formulary Drug acetaminophen 80 mg chew tab generic C Non-Formulary Drug acetaminophen er 650 mg tab er generic C Non-Formulary Drug acetaminophen rapid tabs child 80 mg tab disp generic actidose/sorbitol 25 gm/120ml liquid generic actidose/sorbitol 50 gm/240ml liquid generic activated vegetable charcoal 260 mg cap generic PA ADVANCED CARE CHOLESTEROL KIT cholesterol test BRAND PA afrin childrens 0.25 % solution generic C aminofen 325 mg tab generic 12 hour nasal relief spray solution 0.05 % generic Non-Formulary Drug PA C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C antiseptic 10 % solution generic apap 325 mg tab generic APAP 500 500 MG/5ML LIQUID acetaminophen BRAND PA apap 80 mg chew tab generic C aphen 325 mg tab generic AQUAFRESH ADVANCED PASTE dentifrices BRAND PAGE 48 Non-Formulary Drug PA Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS AQUAFRESH CAVITY PROTECTION 0.15 % PASTE dentifrices BRAND AQUAFRESH DR SEUSS 0.15 % PASTE dentifrices BRAND AQUAFRESH EXTRA FRESH PASTE dentifrices BRAND AQUAFRESH EXTREME CLEAN 0.15 % PASTE dentifrices BRAND AQUAFRESH EXTREME CLEAN 0.25 % PASTE dentifrices BRAND AQUAFRESH FOR KIDS PASTE dentifrices BRAND AQUAFRESH PASTE dentifrices BRAND AQUAFRESH SENSITIVE 5 % PASTE dentifrices BRAND AQUAFRESH TARTAR CONTROL PASTE dentifrices BRAND AQUAFRESH WHITENING PASTE dentifrices BRAND arthritis pain 650 mg tab er generic C Non-Formulary Drug arthritis pain relief 650 mg tab er generic C Non-Formulary Drug arthritis pain reliever 650 mg tab er generic C Non-Formulary Drug AZO TEST STRIP leukocyte test BRAND PA AZOSTIX STRIP bun test BRAND PA BABY ORAJEL TOOTH/GUM CLEANSER 2-0.12 % GEL oral hygiene products BRAND PA BETADINE SPRAY 5 % AERO SOLN povidone-iodine BRAND PA BIOTENE DRY MOUTH GENTLE PASTE dentifrices BRAND BIOTENE DRY MOUTH PASTE dentifrices BRAND BIOTENE PBF DRY MOUTH PASTE dentifrices BRAND PAGE 49 LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS BUG ITCH RELEAF SOLUTION misc natural products BRAND PA CA-REZZ 0.25 % LIQUID triclosan BRAND charcoal 260 mg cap generic PA charcoal activated 250 mg tab generic PA charcocaps 260 mg cap generic PA childrens acetaminophen 80 mg chew tab generic C Non-Formulary Drug childrens acetaminophen 80 mg tab disp generic childrens apap 80 mg chew tab generic C Non-Formulary Drug childrens mapap rapid tabs 80 mg tab disp generic childrens medi-tabs 80 mg chew tab generic C Non-Formulary Drug childrens non-asa pain relief 80 mg chew tab generic C Non-Formulary Drug childrens non-aspirin 80 mg chew tab generic C Non-Formulary Drug childrens non-aspirin 80 mg tab disp generic childrens pain reliever 80 mg chew tab generic C Non-Formulary Drug childrens pain reliever 80 mg tab disp generic childrens silapap 160 mg/5ml liquid generic C Non-Formulary Drug childrens silfedrine 15 mg/5ml liquid generic C Non-Formulary Drug childrens tactinal 80 mg chew tab generic C Non-Formulary Drug COLGATE PLATINUM 0.76 % PASTE dentifrices BRAND CREST 0.243 % PASTE dentifrices BRAND CREST PASTE dentifrices BRAND CREST TARTAR CONTROL PASTE dentifrices BRAND CREST TC/BAKING SODA PASTE dentifrices BRAND CURITY POVIDONE-IODINE PAINT 1 % SOLUTION povidone-iodine BRAND PRODUCT DESCRIPTION PAGE 50 PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE cvs 8 hour pain relief 650 mg tab er generic cvs acetaminophen 325 mg tab generic cvs arthritis pain relief 650 mg tab er generic cvs at home a1c test kit generic cvs childs non-aspirin 80 mg chew tab generic CVS EPSOM SALT GRANULES magnesium sulfate (laxative) BRAND phenylephrine hcl tab 10 mg generic LIMITS & RESTRICTIONS C Non-Formulary Drug C Non-Formulary Drug C Non-Formulary Drug PA C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug cvs non-aspirin childrens 80 mg chew tab generic C Non-Formulary Drug cvs non-aspirin jr 160 mg chew tab generic C Non-Formulary Drug cvs pain relief regular st 325 mg tab generic cvs povidone-iodine 10 % solution generic phenylephrine hcl tab 10 mg generic PA PA C Non-Formulary Drug Non-Formulary Drug cvs tension headache 500-65 mg tab generic C digital pregnancy test generic PA ed-apap 160 mg/5ml liquid generic C ELIXSURE CONGESTION 15 MG/5ML GEL pseudoephedrine hcl BRAND PA EPSOM SALT GRANULES magnesium sulfate (laxative) BRAND EPSOM SALT 495 MG/5 G GRANULES magnesium sulfate (laxative) BRAND EPSOM SALT GRANULES magnesium sulfate (laxative) BRAND eq 8hr arthritis pain relief 650 mg tab er generic eq acetaminophen 325 mg tab generic PAGE 51 C Non-Formulary Drug Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS eq acetaminophen childrens 80 mg tab disp generic eq arthritis pain 650 mg tab er generic C Non-Formulary Drug eq childrens pain reliever 80 mg chew tab generic C Non-Formulary Drug eq first aid antiseptic 10 % solution generic PA eq menstrual complete 500-60-15 mg tab generic C phenylephrine hcl tab 10 mg generic Non-Formulary Drug PA C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug Non-Formulary Drug eq pain reliever 325 mg tab generic eq pain reliever junior 160 mg chew tab generic C eq povidone-iodine 10 % solution generic PA phenylephrine hcl tab 10 mg generic PA C Non-Formulary Drug C Non-Formulary Drug eql acetaminophen 325 mg tab generic eql acetaminophen 8 hour 650 mg tab er generic eql acetaminophen 80 mg tab disp generic eql arthritis pain relief 650 mg tab er generic C Non-Formulary Drug eql childrens nasal decongest 15 mg/5ml liquid generic C Non-Formulary Drug EQL EPSOM SALT GRANULES magnesium sulfate (laxative) BRAND eql menstrual relief max st 500-60-15 mg tab generic C Non-Formulary Drug phenylephrine hcl tab 10 mg generic PA C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C PAGE 52 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE eql pain relief 325 mg tab generic 12 hour nasal relief spray solution 0.05 % generic LIMITS & RESTRICTIONS PA C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C fattibase ointment generic FEVERALL 80 MG SUPPOS acetaminophen BRAND FEVERALL INFANTS 80 MG SUPPOS acetaminophen BRAND 12 hour nasal relief spray solution 0.05 % generic Non-Formulary Drug PA C genebs 325 mg tabs generic 12 hour nasal relief spray solution 0.05 % generic Non-Formulary Drug PA C Non-Formulary Drug gnp 8 hour pain relief 650 mg tab er generic C Non-Formulary Drug gnp 8 hour pain reliever 650 mg tab er generic C Non-Formulary Drug gnp arthritis pain relief 650 mg tab er generic C Non-Formulary Drug gnp childrens easy-melts 80 mg tab disp generic gnp headache relief 500-65 mg tab generic C Non-Formulary Drug phenylephrine hcl tab 10 mg generic PA C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C gnp pain relief 325 mg tab PAGE 53 Non-Formulary Drug generic LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS gnp povidone-iodine 10 % solution generic PA gnp suphedrin 15 mg/5ml liquid generic C goodsense pain relief 325 mg tab generic grx dyne 10 % solution generic HEMATEST TAB occult blood BRAND hm arthritis pain relief 650 mg tab er generic phenylephrine hcl tab 10 mg generic PRODUCT DESCRIPTION Non-Formulary Drug PA C Non-Formulary Drug PA C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C hm pain reliever 325 mg tab generic hm povidone-iodine 10 % solution generic 12 hour nasal relief spray solution 0.05 % generic Non-Formulary Drug PA PA C HOME ACCESS EXPRESS HIV-1 TEST KIT hiv-1 test BRAND PA HOME ACCESS HIV-1 TEST SYSTEM KIT hiv-1 test BRAND PA inositol hexanicotinate powder generic PA iodine whirlpool concentrate 10 % solution generic PA isopropyl alcohol 50 % solution generic IVY ITCH RELEAF SOLUTION misc natural products BRAND kerr insta-char in sorbitol 25 gm/120ml liquid generic kerr insta-char in sorbitol 50 gm/240ml liquid generic kls arthritis pain 650 mg tab er generic 12 hour nasal relief spray solution 0.05 % generic Non-Formulary Drug PA C Non-Formulary Drug PA C Non-Formulary Drug PA phenylephrine hcl tab 10 mg generic C PAGE 54 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS liquid pain relief 160 mg/5ml liquid generic C Non-Formulary Drug little remedies for fever 160 mg/5ml liquid generic C Non-Formulary Drug 12 hour nasal relief spray solution 0.05 % generic PA C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug mapap 160 mg/5ml liquid generic C Non-Formulary Drug mapap 160 mg/5ml liquid generic C Non-Formulary Drug mapap 325 mg tab generic mapap 80 mg chew tab generic C Non-Formulary Drug mapap arthritis pain 650 mg tab er generic C Non-Formulary Drug mapap childrens 80 mg tab disp generic MAPAP HEADACHE PLUS 500-250 MG TAB acetaminophen w/ calcium carbonate BRAND C Non-Formulary Drug maxapap regular strength 325 mg tab generic medi-tabs 325 mg tab generic medi-tabs junior strength 160 mg chew tab generic C Non-Formulary Drug meijer aspirin free 325 mg tab generic meijer jr st aspirin free 160 mg chew tab generic C Non-Formulary Drug menstrual relief max strength 500-60-15 mg tab generic C Non-Formulary Drug midol teen 500-25 mg tab generic C Non-Formulary Drug ms-aid 500-25 mg tab generic C Non-Formulary Drug 12 hour nasal relief spray solution 0.05 % generic PA C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C PAGE 55 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C PAGE 56 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS NEO-SYNEPHRINE 0.5 % SOLUTION phenylephrine hcl BRAND C Non-Formulary Drug NASAL DECONGESTANT SOLUTION 1 % phenylephrine hcl BRAND C Non-Formulary Drug NEO-SYNEPHRINE COLD & SINUS 0.5 % SOLUTION phenylephrine hcl BRAND C Non-Formulary Drug NASAL DECONGESTANT SOLUTION 1 % phenylephrine hcl BRAND C Non-Formulary Drug 12 hour nasal relief spray solution 0.05 % generic PA C Non-Formulary Drug non-aspirin 325 mg tab generic non-aspirin 8 hour 650 mg tab er generic C Non-Formulary Drug non-aspirin childrens 160 mg/5ml liquid generic C Non-Formulary Drug non-aspirin jr strength 160 mg chew tab generic C Non-Formulary Drug non-aspirin pain relief 325 mg tab generic phenylephrine hcl tab 10 mg generic PA C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C operand povidone-iodine 10 % solution generic PA ORAJEL BABY TOOTH/GUM 2-0.12 % GEL oral hygiene products BRAND PA 12 hour nasal relief spray solution 0.05 % generic Non-Formulary Drug PA pain & fever 325 mg tab generic pain & fever childrens 80 mg chew tab generic pain relief 325 mg tab generic pain relief 8 hour 650 mg tab er generic pain relief regular strength 325 mg tab generic pain reliever 325 mg tab generic PEARL DROPS EXTRA STRENGTH PASTE dentifrices BRAND PAGE 57 C Non-Formulary Drug C Non-Formulary Drug C Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE PEDIACARE CHILDRENS DECONGEST 2.5 MG/5ML SOLUTION phenylephrine hcl (oral) BRAND peg blend 59%-39%-2% ointment generic peg ointment base 40 %-60 % ointment generic pharbetol 325 mg tab generic phenylephrine hcl tab 10 mg generic LIMITS & RESTRICTIONS PA C Non-Formulary Drug PA C Non-Formulary Drug C Non-Formulary Drug phenylgesic 30-325 mg tabs generic phosphatidylcholine 100 % powder generic phosphatidylcholine powder generic povidone-iodine 10 % solution generic PA pregnancy test test generic PA pvp prep 10 % solution generic PA px arthritis pain relief 650 mg tab er generic C phenylephrine hcl tab 10 mg generic Non-Formulary Drug PA C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug C Non-Formulary Drug q-pap 160 mg/5ml liquid generic q-pap 325 mg tab generic qc acetaminophen 8 hours 650 mg tab er generic C Non-Formulary Drug qc arthritis pain relief 650 mg tab er generic C Non-Formulary Drug 12 hour nasal relief spray solution 0.05 % generic PA C PAGE 58 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic qc non-aspirin 8 hour 650 mg tab er generic qc pain relief 325 mg tab generic qc povidone iodine 10 % solution generic phenylephrine hcl tab 10 mg generic C Non-Formulary Drug C Non-Formulary Drug PA PA C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug C Non-Formulary Drug C Non-Formulary Drug ra 8 hour pain relief 650 mg tab er generic ra acetaminophen 325 mg tab generic ra acetaminophen 650 mg tab er generic ra acetaminophen rapid melts 80 mg tab disp generic ra antiseptic 10 % solution generic PA ra arthritis pain relief 650 mg tab er generic C Non-Formulary Drug RA EPSOM SALT 495 MG/5 G GRANULES magnesium sulfate (laxative) BRAND RA EPSOM SALT LAVENDER 100 % GRANULES magnesium sulfate (laxative) BRAND RA FLUORIDE TOOTHPASTE 0.15 % PASTE dentifrices BRAND ra menstrual complete 500-60-15 mg tab generic C Non-Formulary Drug ra menstrual relief 500-60-15 mg tab generic C Non-Formulary Drug phenylephrine hcl tab 10 mg generic PA C PAGE 59 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C RA SENSITIVE TOOTHPASTE/FL 5-0.14 % PASTE dentifrices BRAND 12 hour nasal relief spray solution 0.05 % generic Non-Formulary Drug PA C Non-Formulary Drug PA phenylephrine hcl tab 10 mg generic ra tension headache 500-65 mg tab generic RA WHITENING TOOTHPASTE/FL 0.76 % PASTE dentifrices BRAND rhinall 0.25 % solution generic 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug C Non-Formulary Drug C Non-Formulary Drug PA sb arthritis pain relief 650 mg tab er generic sb childrens non-aspirin 80 mg tab disp generic 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug C Non-Formulary Drug PA C Non-Formulary Drug C Non-Formulary Drug Non-Formulary Drug sb non-aspirin 160 mg chew tab generic sb non-aspirin 325 mg tab generic sb non-aspirin 80 mg chew tab generic C sb povidone-iodine 10 % solution generic PA 12 hour nasal relief spray solution 0.05 % generic PA C PAGE 60 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE SENSITIVE EXTRA WHITENING 5-0.243 % PASTE dentifrices BRAND SENSITIVE TOOTHPASTE/FLUORIDE 5-0.243 % PASTE dentifrices BRAND SENSODYNE MAXIMUM STRENGTH 5-0.13 % PASTE dentifrices BRAND SENSODYNE MAXIMUM STRENGTH 5-0.15 % PASTE dentifrices BRAND SENSODYNE MAXIMUM STRENGTH 5-0.25 % PASTE dentifrices BRAND SENSODYNE PASTE dentifrices BRAND SENSODYNE PRONAMEL 5-0.25 % PASTE dentifrices BRAND SENSODYNE PRONAMEL PASTE dentifrices BRAND SENSODYNE TARTAR CONTROL 5-0.145 % PASTE dentifrices BRAND SENSODYNE/BAKING SODA PASTE dentifrices BRAND 12 hour nasal relief spray solution 0.05 % generic LIMITS & RESTRICTIONS PA C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C PAGE 61 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS sm 8 hour pain relief 650 mg tab er generic C Non-Formulary Drug sm adult nasal decongestant 15 mg/5ml liquid generic C Non-Formulary Drug sm arthritis pain relief 650 mg tab er generic C Non-Formulary Drug phenylephrine hcl tab 10 mg generic PA C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug sm pain reliever 325 mg tab generic sm pain reliever 8 hour ex st 650 mg tab er generic C Non-Formulary Drug sm pain reliever jr st 160 mg chew tab generic C Non-Formulary Drug sm povidone-iodine 10 % solution generic PA sm tension headache 500-65 mg tab generic C SUDAFED 24 HOUR 240 MG TAB ER 24H pseudoephedrine hcl BRAND SUDAFED PE CHILDRENS 2.5 MG/5ML SOLUTION phenylephrine hcl (oral) BRAND phenylephrine hcl tab 10 mg generic Non-Formulary Drug PA C Non-Formulary Drug PA C Non-Formulary Drug PA tactinal 325 mg tab generic tension headache 500-65 mg tab generic PAGE 62 C Non-Formulary Drug C Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE tension headache relief 500-65 mg tab generic tgt acetaminophen melts child 80 mg tab disp generic tgt arthritis pain relief 650 mg tab er LIMITS & RESTRICTIONS C Non-Formulary Drug generic C Non-Formulary Drug tgt menstrual relief 500-60-15 mg tab generic C Non-Formulary Drug 12 hour nasal relief spray solution 0.05 % generic PA C Non-Formulary Drug PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic th arthritis pain relief 650 mg tab er generic phenylephrine hcl tab 10 mg generic C Non-Formulary Drug C Non-Formulary Drug PA C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug PA 12 hour nasal relief spray solution 0.05 % generic C tylenol childrens meltaways 80 mg tab disp generic 12 hour nasal relief spray solution 0.05 % generic Non-Formulary Drug PA C VIADENT ADVANCED CARE 0.8-2 % PASTE dentifrices BRAND VIADENT FLUORIDE PASTE dentifrices BRAND VIADENT PASTE dentifrices BRAND VIADENT PLAQUE PASTE dentifrices BRAND PAGE 63 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS VICKS SINEX 0.5 % SOLUTION phenylephrine hcl BRAND C Non-Formulary Drug VICKS SINEX ULTRAFINE MIST 0.5 % SOLUTION phenylephrine hcl BRAND C Non-Formulary Drug phenylephrine hcl tab 10 mg generic PA C Non-Formulary Drug womens menstrual relief 500-25 mg tab generic C Non-Formulary Drug womens tylenol 500-25 mg tab generic C Non-Formulary Drug advanced lubricant 0.05-1 % solution generic C Non-Formulary Drug akwa tears renewed 0.1-0.3 % solution generic alaway 0.025 % solution generic alaway childrens allergy 0.025 % solution generic allergy eye 0.025-0.3 % solution generic C Non-Formulary Drug allergy eye drops 0.025 % solution generic altazine 0.05 % solution generic artificial tears 0.1-0.3 % solution generic artificial tears 0.1-0.3 % solution generic artificial tears 0.2-0.2-1 % solution generic C Non-Formulary Drug artificial tears 1-0.3 % solution generic C Non-Formulary Drug artificial tears 1.4 % solution generic biolle gel tears 1 % gel generic C Non-Formulary Drug bion tears 0.1-0.3 % solution generic claritin eye 0.025 % solution generic cvs allergy eye drops 0.025 % solution generic cvs antihistamine eye drops 0.025 % solution generic cvs artificial tears 1-0.3 % solution generic C Non-Formulary Drug cvs dry eye relief 0.2-0.2-1 % solution generic C Non-Formulary Drug OPHTHALMIC AGENTS OPHTHALMIC AGENTS, OTHER PAGE 64 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE cvs eye allergy relief 0.025-0.3 % solution generic cvs eye drops 0.05 % solution generic cvs eye itch relief 0.025 % solution generic cvs lubricant drops 1 % gel LIMITS & RESTRICTIONS C Non-Formulary Drug generic C Non-Formulary Drug cvs lubricant eye drops 0.4-0.3 % solution generic C Non-Formulary Drug cvs maximum redness relief 0.03-0.5 % solution generic C Non-Formulary Drug cvs natural tears 0.1-0.3 % solution generic cvs redness relief 0.012-0.2 % solution generic C Non-Formulary Drug eq artificial tears 1-0.3 % solution generic C Non-Formulary Drug eq eye allergy relief 0.027-0.315 % solution generic PA eq eye drops 0.05 % solution generic eq eye itch relief 0.025 % solution generic eq itchy eye drops 0.025 % solution generic eq lubricant eye drops 0.4-0.3 % solution generic eql eye drops 0.05 % solution generic eye allergy relief 0.025-0.3 % solution C Non-Formulary Drug generic C Non-Formulary Drug eye allergy relief 0.027-0.315 % solution generic PA eye drops 0.012-0.2 % solution generic C Non-Formulary Drug eye drops 0.05 % solution generic eye drops extra 0.05-1 % solution generic C Non-Formulary Drug eye itch relief 0.025 % solution generic GENTEAL MILD 0.2 % SOLUTION hypromellose (ophth) BRAND C Non-Formulary Drug GENTEAL SEVERE 0.3 % GEL hypromellose (ophth) BRAND C Non-Formulary Drug genteal tears 0.1-0.2-0.3 % solution generic genteal tears 0.1-0.3 % solution generic gnp eye drops 0.05 % solution generic gnp eye itch relief 0.025 % solution generic PAGE 65 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS gnp itchy eye 0.025 % solution generic gnp lubricant eye drops 0.4-0.3 % solution generic C Non-Formulary Drug gnp ultra lubricant eye drops 0.4-0.3 % solution generic C Non-Formulary Drug goniosoft 2.5 % solution generic C Non-Formulary Drug goniotaire 2.5 % solution generic C Non-Formulary Drug goniovisc 2.5 % solution generic C Non-Formulary Drug goodsense eye drops 0.05 % solution generic hm dry eye relief 0.2-0.2-1 % solution generic C Non-Formulary Drug hm eye drops 0.05 % solution generic hm eye itch relief 0.025 % solution generic hm lubricating tears 0.4-0.3 % solution generic C Non-Formulary Drug HYPOTEARS 1-1 % SOLUTION polyethylene glycol-polyvinyl alcohol (ophth) BRAND C Non-Formulary Drug ISOPTO TEARS 0.5 % SOLUTION hypromellose (ophth) BRAND C Non-Formulary Drug just tears eye drops solution generic ketotifen fumarate 0.025 % solution generic kp ketotifen fumarate 0.025 % solution generic liquitears 1.4 % solution generic lubricant drops 1.4 % solution generic lubricant eye drops 0.4-0.3 % solution generic C Non-Formulary Drug lubricant eye drops 0.4-0.3 % solution generic C Non-Formulary Drug lubricating eye drops 0.4-0.3 % solution generic C Non-Formulary Drug murine for red eyes 0.05 % solution generic MURO 128 2 % SOLUTION sodium chloride hypertonic BRAND natural balance tears 0.4 % solution generic natural balance tears 70.01-0.3 % solution generic natures tears 0.1-0.3 % solution generic PAGE 66 PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE natures tears 0.4 % solution generic natures tears 0.4 % solution generic opti-clear 0.05 % solution generic optics mini drops 1.4-0.6 % solution generic polyvinyl alcohol 1.4 % solution generic px sterile eye drops 0.05 % solution generic ra antihistamine eye drops 0.025 % solution generic ra artificial tears 1-0.3 % solution LIMITS & RESTRICTIONS C Non-Formulary Drug generic C Non-Formulary Drug ra eye allergy relief 0.027-0.315 % solution generic PA ra eye drops extra 0.05-1 % solution generic C Non-Formulary Drug ra eye itch relief 0.025 % solution generic ra lubricant eye 0.1-0.3 % solution generic ra lubricant eye 0.4-0.3 % solution generic C Non-Formulary Drug ra lubricant eye 1-0.3 % solution generic C Non-Formulary Drug ra sterile eye drops 0.012-0.2 % solution generic C Non-Formulary Drug ra sterile eye drops 0.03-0.5 % solution generic C Non-Formulary Drug redness reliever eye drops 0.05 % solution generic REFRESH CELLUVISC 1 % SOLUTION carboxymethylcellulose sodium (ophth) BRAND C Non-Formulary Drug REFRESH LIQUIGEL 1 % SOLUTION carboxymethylcellulose sodium (ophth) BRAND C Non-Formulary Drug sm artificial tears 0.5%-0.6% solution generic sm dry eye relief 0.2-0.2-1 % solution generic C Non-Formulary Drug sm eye drops 0.05 % solution generic sm eye itch relief 0.025 % solution generic sm lubricant eye drops 0.4-0.3 % solution generic C Non-Formulary Drug sm lubricating tears 0.4-0.3 % solution generic C Non-Formulary Drug soothe hydration 1.25 % solution generic soothe xp 1%-4.5% solution generic PAGE 67 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS soothe xp xtra protection solution generic systane contacts solution generic SYSTANE OVERNIGHT THERAPY 0.3 % GEL hypromellose (ophth) BRAND tears again 1.4 % solution generic tears again advanced eyelid 0.4 % solution generic tears again solution generic tears naturale free 0.1-0.3 % solution generic tears naturale ii solution generic tears pure 0.1-0.3 % solution generic tetrahydrozoline hcl 0.05 % solution generic tgt eye allergy relief 0.027-0.315 % solution generic tgt eye itch relief 0.025 % solution generic TGT LUBRICANT EYE DROPS 0.95 % SOLUTION propylene glycol (ophth) BRAND C Non-Formulary Drug tgt lubricant eye drops 1-0.3 % solution generic C Non-Formulary Drug tgt lubricant redness reliever 0.03-0.5 % solution generic C Non-Formulary Drug tgt redness reliever 0.012-0.2 % solution generic C Non-Formulary Drug th eye drop original 0.05 % solution generic th eye drop tears 0.2-0.2-1 % solution generic C Non-Formulary Drug THERATEARS 0.25 % SOLUTION carboxymethylcellulose sodium (ophth) BRAND C Non-Formulary Drug THERATEARS 0.25 % SOLUTION carboxymethylcellulose sodium (ophth) BRAND C Non-Formulary Drug theratears allergy 0.025 % solution generic ultra lubricant eye drops 0.4-0.3 % solution generic C Non-Formulary Drug VISINE MAXIMUM REDNESS RELIEF 0.05-0.2-0.36-1 % SOLUTION tetrahydrozoline-glycerin-hypromellose-peg 400 BRAND C Non-Formulary Drug VISINE TEARS 0.2-0.36-1 % SOLUTION glycerin-hypromellose-polyethylene glycol 400 BRAND C Non-Formulary Drug VISINE TIRED EYE RELIEF 0.2-0.36-1 % SOLUTION glycerin-hypromellose-polyethylene glycol 400 BRAND C Non-Formulary Drug PAGE 68 C Non-Formulary Drug PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS visine-a 0.025-0.3 % solution generic C Non-Formulary Drug VISINE-LR 0.025 % SOLUTION oxymetazoline hcl (ophth) BRAND C Non-Formulary Drug VIVA DROPS 1 % SOLUTION polysorbate 80 (ophth) BRAND C Non-Formulary Drug VIVA DROPS 1 % SOLUTION polysorbate 80 (ophth) BRAND C Non-Formulary Drug wal-zyr 0.025 % solution generic zyrtec itchy eye 0.025 % solution generic OTIC AGENTS auraphene-b 6.5 % solution generic C Non-Formulary Drug auro eardrops 6.5 % solution generic C Non-Formulary Drug carbamoxide ear drops 6.5 % solution generic C Non-Formulary Drug cvs ear drops 6.5 % solution generic C Non-Formulary Drug cvs ear wax removal system 6.5 % solution generic C Non-Formulary Drug e-r-o ear drops 6.5 % solution generic C Non-Formulary Drug e-r-o ear wax removal system 6.5 % solution generic C Non-Formulary Drug ear drops 6.5 % solution generic C Non-Formulary Drug ear drops earwax aid 6.5 % solution generic C Non-Formulary Drug ear wax drops 6.5 % solution generic C Non-Formulary Drug ear wax removal aid 6.5 % solution generic C Non-Formulary Drug ear wax removal drops 6.5 % solution generic C Non-Formulary Drug ear wax removal kit 6.5 % solution generic C Non-Formulary Drug ear wax removal system 6.5 % solution generic C Non-Formulary Drug ear wax remover 6.5 % solution generic C Non-Formulary Drug earwax removal kit 6.5 % solution generic C Non-Formulary Drug earwax treatment drops 6.5 % solution generic C Non-Formulary Drug eq ear wax removal aid 6.5 % solution generic C Non-Formulary Drug PAGE 69 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS eql ear drops 6.5 % solution generic C Non-Formulary Drug gnp ear drops 6.5 % solution generic C Non-Formulary Drug gnp ear systems 6.5 % solution generic C Non-Formulary Drug hm earwax removal aid 6.5 % solution generic C Non-Formulary Drug hm earwax removal kit 6.5 % solution generic C Non-Formulary Drug murine ear 6.5 % solution generic C Non-Formulary Drug murine ear wax removal system 6.5 % solution generic C Non-Formulary Drug otix 6.5 % solution generic C Non-Formulary Drug qc ear wax removal 6.5 % solution generic C Non-Formulary Drug ra ear drops 6.5 % solution generic C Non-Formulary Drug ra earwax removal kit 6.5 % solution generic C Non-Formulary Drug sb ear wax remover 6.5 % solution generic C Non-Formulary Drug sm ear drops 6.5 % solution generic C Non-Formulary Drug thera-ear 6.5 % solution generic C Non-Formulary Drug BRAND PA loratadine tab 10 mg generic MDD diphenhydramine hcl cap 25 mg generic C cetirizine hcl chew tab 10 mg generic RESPIRATORY TRACT/PULMONARY AGENTS ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS FLONASE SENSIMIST 27.5 MCG/SPRAY SUSPENSION fluticasone furoate ANTIHISTAMINES 1 per day Non-Formulary Drug PA MDD aller-chlor 2 mg/5ml syrup generic C fexofenadine hcl tab 180 mg generic MDD fexofenadine hcl tab 60 mg generic 1 per day Non-Formulary Drug 1 per day PA MDD PAGE 70 2 per day LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS aller-ease childrens 30 mg/5ml suspension generic PA loratadine tab 10 mg generic MDD 1 per day fexofenadine hcl tab 180 mg generic MDD 1 per day diphenhydramine hcl cap 25 mg generic C childrens loratadine syrup 5 mg/5ml generic PA diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug allergy rapid melts childrens 12.5 mg chew tab generic C Non-Formulary Drug loratadine tab 10 mg generic MDD 1 per day fexofenadine hcl tab 180 mg generic MDD 1 per day diphenhydramine hcl cap 25 mg generic C childrens loratadine syrup 5 mg/5ml generic PA fexofenadine hcl tab 60 mg generic PRODUCT DESCRIPTION Non-Formulary Drug Non-Formulary Drug PA MDD childrens loratadine syrup 5 mg/5ml generic cetirizine hcl chew tab 10 mg generic 2 per day PA PA MDD 1 per day childrens loratadine syrup 5 mg/5ml generic PA clemastine fumarate tab 1.34 mg generic C Non-Formulary Drug altaryl 12.5 mg/5ml syrup generic C Non-Formulary Drug diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug diphenhydramine hcl cap 50 mg generic PA benadryl allergy 25 mg strp generic PA C Non-Formulary Drug PA cetirizine hcl chew tab 10 mg cetirizine hcl 5 mg tab PAGE 71 generic generic MDD 1 per day MDD 1 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS childrens complete allergy 12.5 mg chew tab generic C Non-Formulary Drug childrens loratadine syrup 5 mg/5ml generic PA childrens loratadine syrup 5 mg/5ml generic PA childrens loratadine syrup 5 mg/5ml generic PA clemastine fumarate tab 1.34 mg generic C Non-Formulary Drug diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug cvs allergy childrens 12.5 mg chew tab generic C Non-Formulary Drug loratadine tab 10 mg generic MDD 1 per day fexofenadine hcl tab 180 mg generic MDD 1 per day fexofenadine hcl tab 60 mg generic PA MDD cvs allergy relief childrens 30 mg/5ml suspension generic PA childrens loratadine syrup 5 mg/5ml generic PA cetirizine hcl chew tab 10 mg generic 2 per day PA MDD 1 per day 1 per day loratadine tab 10 mg generic MDD clemastine fumarate tab 1.34 mg generic C Non-Formulary Drug diabetic tussin allergy 2 mg/5ml syrup generic C Non-Formulary Drug diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug diphenhydramine hcl cap 50 mg generic PA diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug ED CHLORPED 2 MG/ML LIQUID chlorpheniramine maleate BRAND C Non-Formulary Drug PAGE 72 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS ed chlorped jr 2 mg/5ml syrup generic C Non-Formulary Drug diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug loratadine tab 10 mg generic MDD 1 per day fexofenadine hcl tab 180 mg generic MDD 1 per day diphenhydramine hcl cap 25 mg generic C childrens loratadine syrup 5 mg/5ml generic PA childrens loratadine syrup 5 mg/5ml generic PA clemastine fumarate tab 1.34 mg generic C loratadine tab 10 mg generic MDD 1 per day fexofenadine hcl tab 180 mg generic MDD 1 per day diphenhydramine hcl cap 25 mg generic C eql allergy childrens 30 mg/5ml suspension generic PA loratadine tab 10 mg generic MDD diphenhydramine hcl cap 25 mg generic C childrens loratadine syrup 5 mg/5ml generic PA clemastine fumarate tab 1.34 mg generic C fexofenadine hcl tab 180 mg generic MDD fexofenadine hcl tab 60 mg generic Non-Formulary Drug Non-Formulary Drug Non-Formulary Drug 1 per day Non-Formulary Drug Non-Formulary Drug 1 per day PA MDD 2 per day fexofenadine hcl childrens 30 mg/5ml suspension generic PA diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug fexofenadine hcl tab 180 mg generic MDD clemastine fumarate tab 1.34 mg generic C loratadine tab 10 mg generic MDD PAGE 73 1 per day Non-Formulary Drug 1 per day LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS childrens loratadine syrup 5 mg/5ml generic PA childrens loratadine syrup 5 mg/5ml generic PA fexofenadine hcl tab 180 mg generic MDD diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug HISTEX 2.5 MG/5ML SYRUP triprolidine hcl BRAND C Non-Formulary Drug diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug loratadine tab 10 mg generic MDD diphenhydramine hcl cap 25 mg generic C fexofenadine hcl tab 180 mg generic MDD fexofenadine hcl tab 60 mg generic PRODUCT DESCRIPTION 1 per day 1 per day Non-Formulary Drug 1 per day PA MDD 2 per day 1 per day loratadine tab 10 mg generic MDD childrens loratadine syrup 5 mg/5ml generic PA J-TAN PD 1 MG/ML LIQUID brompheniramine maleate BRAND fexofenadine hcl tab 180 mg generic MDD 1 per day loratadine tab 10 mg generic MDD 1 per day kp cetirizine hcl 5 mg tab generic MDD 1 per day diphenhydramine hcl cap 50 mg generic PA fexofenadine hcl tab 180 mg generic MDD fexofenadine hcl tab 60 mg generic PA C Non-Formulary Drug 1 per day PA MDD 2 per day loratadine tab 10 mg generic MDD 1 per day loratadine tab 10 mg generic MDD 1 per day loratadine tab 10 mg generic MDD 1 per day childrens loratadine syrup 5 mg/5ml generic PA PAGE 74 LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS childrens loratadine syrup 5 mg/5ml generic PA childrens loratadine syrup 5 mg/5ml generic PA childrens loratadine syrup 5 mg/5ml generic PA childrens loratadine syrup 5 mg/5ml generic PA diphenhydramine hcl cap 25 mg generic C loratadine tab 10 mg generic MDD diphenhydramine hcl cap 25 mg generic C childrens loratadine syrup 5 mg/5ml generic PA fexofenadine hcl tab 180 mg generic MDD diphenhydramine hcl cap 25 mg generic C diphenhydramine hcl cap 50 mg generic PA diphenhydramine hcl cap 25 mg generic C diphenhydramine hcl cap 50 mg generic PA diphenhydramine hcl cap 25 mg generic C fexofenadine hcl tab 180 mg generic MDD 1 per day loratadine tab 10 mg generic MDD 1 per day clemastine fumarate tab 1.34 mg generic C Non-Formulary Drug diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug childrens loratadine syrup 5 mg/5ml generic PA loratadine tab 10 mg generic MDD 1 per day loratadine tab 10 mg generic MDD 1 per day quenalin 12.5 mg/5ml syrup generic C Non-Formulary Drug diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug fexofenadine hcl tab 180 mg generic MDD diphenhydramine hcl cap 25 mg generic C PRODUCT DESCRIPTION PAGE 75 Non-Formulary Drug 1 per day Non-Formulary Drug 1 per day Non-Formulary Drug Non-Formulary Drug Non-Formulary Drug 1 per day Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PA cetirizine hcl chew tab 10 mg generic MDD 1 per day 1 per day loratadine tab 10 mg generic MDD childrens loratadine syrup 5 mg/5ml generic PA childrens loratadine syrup 5 mg/5ml generic PA diphenhydramine hcl cap 25 mg generic C loratadine tab 10 mg generic MDD childrens loratadine syrup 5 mg/5ml generic PA loratadine tab 10 mg generic MDD silphen cough 12.5 mg/5ml syrup generic C Non-Formulary Drug clemastine fumarate tab 1.34 mg generic C Non-Formulary Drug diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug loratadine tab 10 mg generic MDD childrens loratadine syrup 5 mg/5ml generic PA fexofenadine hcl tab 180 mg generic MDD fexofenadine hcl tab 60 mg generic Non-Formulary Drug 1 per day 1 per day 1 per day 1 per day PA MDD 2 per day 1 per day loratadine tab 10 mg generic MDD childrens loratadine syrup 5 mg/5ml generic PA loratadine tab 10 mg generic MDD 1 per day fexofenadine hcl tab 180 mg generic MDD 1 per day diphenhydramine hcl cap 25 mg generic C childrens loratadine syrup 5 mg/5ml generic PA diphenhydramine hcl cap 25 mg generic C loratadine tab 10 mg generic MDD TRIAMINIC COUGH/RUNNY NOSE 12.5 MG STRIP diphenhydramine hcl BRAND C PAGE 76 Non-Formulary Drug Non-Formulary Drug 1 per day Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS diphenhydramine hcl cap 25 mg generic C fexofenadine hcl tab 180 mg generic MDD fexofenadine hcl tab 60 mg generic Non-Formulary Drug 1 per day PA MDD wal-fex childrens 30 mg/5ml suspension generic PA clemastine fumarate tab 1.34 mg generic C loratadine tab 10 mg generic MDD childrens loratadine syrup 5 mg/5ml generic PA childrens loratadine syrup 5 mg/5ml generic PA cetirizine hcl chew tab 10 mg generic 2 per day Non-Formulary Drug 1 per day PA MDD 1 per day BRONCHODILATORS, SYMPATHOMIMETIC PRIMATENE MIST 0.22 MG/ACT AERO SOLN epinephrine (base) PA BRAND C Non-Formulary Drug RESPIRATORY TRACT AGENTS, OTHER 666 cold preparation 10-5-325 mg/15ml liquid generic acetadryl 25-500 mg tab generic ALDEX-CT 12.5-5 MG CHEW TAB diphenhydramine hcl-phenylephrine hcl tannate BRAND alka-seltzer pls sinus & cough 10-5-325 mg cap generic alka-seltzer plus day cold/flu 10-5-325 mg cap generic all day pain relf sinus/cold d 120-220 mg tab er 12h generic all-nite cold & flu nighttime 30-12.5-650 mg/30ml liquid generic all-nite multi-sympt cold/flu 15-6.25-325 mg/15ml liquid generic allergy multi-symptom 2-5-325 mg tab generic allergy multi-symptom daytime 2-5-325 mg tab generic ambi 10peh/400gfn 10-400 mg tab generic PA ambi 40pse/400gfn 40-400 mg tab generic PA PAGE 77 PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS ambi 60pse/4cpm 60-4 mg tab generic ap-hist dm 7.5-4-15 mg/5ml liquid generic bidex 400 mg tab generic PA biogtuss 10-15-300 mg/5ml liquid generic PA bpm-dm-phen 5-2-10 mg/5ml syrup generic PA BROHIST D 4-10 MG TAB brompheniramine & phenyleph BRAND PA bronchial asthma relief 12.5-200 mg tab generic brontuss sf nr 10-15-300 mg/5ml liquid generic PA BROVEX PSE DM 40-4-20 MG TAB pseudoephed-bromphen-dm BRAND PA buckleys chest congestion 100 mg/5ml liquid generic PA CAPMIST DM 30-30-400 MG TAB pseudoephedrine w/ dm-gg BRAND PA cardec dm 3.5-1-3 mg/ml liquid generic PA chest congestion childrens 100 mg/5ml liquid generic PA chest congestion relief 400 mg tab generic PA chest congestion relief pe 10-400 mg tab generic PA chest congestion/sinus relief 10-400 mg tab generic PA childrens advil cold 15-100 mg/5ml suspension generic PA childrens cold & allergy 1-2.5 mg/5ml elixir generic childrens cough 5-100 mg/5ml liquid generic PA childrens mucus relief cough 5-100 mg/5ml liquid generic PA childrens mucus relief expect 100 mg/5ml liquid generic PA childrens plus flu 2.5-1-5-160 mg/5ml suspension generic PA childrens plus multi-sympt cld 2.5-1-5-160 mg/5ml suspension generic PA CODITUSS DM 5-8.33-10 MG/5ML SYRUP phenylephrine-pyrilamine-dm BRAND PAGE 78 LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS CODITUSSIN AC 200-10 MG/5ML LIQUID guaifenesin-codeine BRAND PA cold & allergy 1-2.5 mg/5ml elixir generic cold & allergy childrens 1-2.5 mg/5ml elixir generic cold & cough childrens 2.5-1-5 mg/5ml elixir generic PA cold & flu severe 5-10-200-325 mg tab generic PA cold & flu severe daytime 5-10-200-325 mg tab generic PA cold & flu severe daytime 5-10-200-325 mg/15ml liquid generic PA cold head congest severe day 5-325-200 mg tab generic PA cold head congestion severe 5-10-200-325 mg tab generic PA cold multi-symptom severe day 5-10-200-325 mg tab generic PA cold/allergy childrens 1-2.5 mg/5ml elixir generic cold/cough childrens 2.5-1-5 mg/5ml elixir generic PA cold/cough dm childrens 2.5-1-5 mg/5ml elixir generic PA cold/flu relief 10-5-325 mg/15ml liquid generic cold/flu relief nighttime 15-6.25-325 mg/15ml liquid generic corfen-dm 10-4-15 mg/5ml liquid generic coricidin d cold/flu/sinus 2-5-325 mg tab generic coricidin hbp nighttime cold 15-6.25-325 mg/15ml liquid generic cough & cold 4-30 mg tab generic cough dm 30 mg/5ml susp generic cough dm childrens 30 mg/5ml susp generic cough relief 15 mg/5ml liquid generic coughtab 200 mg tab generic PA cvs allergy relief d 180-240 mg tab er 24h generic C Non-Formulary Drug cvs allergy relief d 60-120 mg tab er 12h generic C Non-Formulary Drug cvs allergy-d 25-10 mg tab generic cvs bronchial asthma relief 12.5-200 mg tab generic PRODUCT DESCRIPTION PAGE 79 PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS cvs chest congest/cough child 5-100 mg/5ml liquid generic PA cvs chest congestion childrens 100 mg/5ml liquid generic PA cvs chest congestion relief 400 mg tab generic PA cvs chest congestion relief pe 10-400 mg tab generic PA cvs childrens multi-sympt cld 2.5-1-5-160 mg/5ml suspension generic PA cvs cold & allergy childrens 1-2.5 mg/5ml elixir generic cvs cold & cough dm childrens 2.5-1-5 mg/5ml elixir generic cvs cold & cough nighttime 6.25-2.5 mg/5ml liquid generic cvs cold/allergy childrens 1-2.5 mg/5ml elixir generic cvs cold/cough dm childrens 2.5-1-5 mg/5ml elixir generic cvs cough dm 30 mg/5ml susp generic cvs cough dm childrens 30 mg/5ml susp generic cvs daytime cold/flu relief 10-5-325 mg/15ml liquid generic cvs dm maximum adult 5-100 mg/5ml liquid generic PA cvs flu relief childrens 2.5-1-5-160 mg/5ml suspension generic PA cvs flu/severe cold daytime 10-5-325 mg/15ml liquid generic cvs mucus extended release 1200 mg tab er 12h generic cvs mucus extended release 600 mg tab er 12h generic cvs nighttime cold/flu relief 15-6.25-325 mg/15ml liquid generic cvs sinus & cold-d 120-220 mg tab er 12h generic cvs sinus pain/congest night 2-5-325 mg tab generic cvs sinus relief pressure/pain 5-325-200 mg tab generic cvs stuffy nose & cold child 2.5-100 mg/5ml liquid generic cvs tussin adult chest congest 100 mg/5ml liquid generic cvs tussin long-acting 15 mg/5ml liquid generic day time cold/flu relief 10-5-325 mg/15ml liquid generic day time multi-sympt cold/flu 10-5-325 mg/15ml liquid generic PRODUCT DESCRIPTION PAGE 80 PA PA PA PA PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS day time pe cold/flu relief 10-5-325 mg cap generic day-time cold/flu relief 10-5-325 mg cap generic day-time cold/flu relief 10-5-325 mg/15ml liquid generic day-time pe cold/flu relief 10-5-325 mg cap generic daytime cold & flu relief plus 10-5-325 mg cap generic DAYTIME COLD MEDICINE 325-15 MG/15ML LIQUID acetaminophen w/ dm BRAND daytime cold/flu relief 10-5-325 mg cap generic daytime cold/flu relief 10-5-325 mg/15ml liquid generic daytime severe cold & flu 5-10-200-325 mg tab generic decongestant plus 4-60 mg tab generic delsym cgh/chest cong dm child 5-100 mg/5ml liquid generic PA delsym cough/chest congest dm 5-100 mg/5ml liquid generic PA delsym nght time cgh/cld child 12.5-5 mg/5ml liquid generic PA delsym night cgh/cold children 6.25-2.5 mg/5ml liquid generic delsym night time cough/cold 6.25-2.5 mg/5ml liquid generic delsym night time multi-sympt 15-6.25-325 mg/15ml liquid generic desgen pediatric 2.5-5-50 mg/ml liquid generic despec dm 5-10-100 mg/5ml syrup generic despec dm-g 5-10-100 mg/5ml syrup generic despec eda 2.5-5-50 mg/ml liquid generic despec-tab 40-400 mg tab generic PA DEX-TUSS 300-10 MG/5ML LIQUID guaifenesin-codeine BRAND PA dextromethorphan polistirex er 30 mg/5ml susp generic diabetic siltussin das-na 100 mg/5ml liquid generic PA diabetic tussin 100 mg/5ml liquid generic PA DIABETIC TUSSIN COLD/FLU 325-4-15 MG CAP dextromethorphan-acetaminophen-chlorpheniramine BRAND diabetic tussin mucus relief 400 mg tab generic PAGE 81 PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS dimaphen childrens 1-2.5 mg/5ml elixir generic dimaphen dm cold/cough 2.5-1-5 mg/5ml elixir generic PA dimaphen dm cold/cough child 2.5-1-5 mg/5ml elixir generic PA dimetane dx 30-2-10 mg/5ml syrup generic PA dimetapp night cold/congestion 6.25-2.5 mg/5ml liquid generic dm max maximum strength 20-400 mg/20ml liquid generic dm-guaifenesin er 60-1200 mg tab er 12h generic dristan cold 2-5-325 mg tab generic ed-a-hist dm 10-4-15 mg/5ml liquid generic endacof-c 2-10 mg/5ml liquid generic eq allergy relief 2-5-325 mg tab generic eq allergy/sinus headache 12.5-30-500 mg tab generic eq cold flu & sore throat 5-10-200-325 mg tab generic PA eq cold multi-symptom severe 5-10-200-325 mg tab generic PA eq cold relief 30-15-200-325 mg tab generic PA eq cold/cough dm 15-1-5 mg/5ml elixir generic eq cold/cough dm childrens 2.5-1-5 mg/5ml elixir generic PA eq cough childrens 5-100 mg/5ml liquid generic PA eq cough dm 30 mg/5ml susp generic eq daytime cold/flu ms relief 10-5-325 mg cap generic eq daytime cold/flu ms relief 10-5-325 mg/15ml liquid generic eq flu relief 30-500-15 mg tab generic eq ibuprofen cold childrens 15-100 mg/5ml suspension generic eq mucus er 600 mg tab er 12h generic eq night time cold & cough 6.25-2.5 mg/5ml liquid generic eq nitetime cold/flu ms relief 15-6.25-325 mg cap generic eq nitetime cold/flu ms relief 15-6.25-325 mg/15ml liquid generic eq sinus congestion & pain 5-325-200 mg tab generic PAGE 82 PA PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS eq tussin 100 mg/5ml liquid generic PA eql allergy multi-symptom 2-5-325 mg tab generic eql allergy/sinus headache 12.5-30-500 mg tab generic eql childrens pain relief plus 2.5-1-5-160 mg/5ml suspension generic PA eql childrens plus cold multi 2.5-1-5-160 mg/5ml suspension generic PA eql cold head congestion day 5-10-200-325 mg tab generic PA eql cold multi-symptom severe 5-10-200-325 mg tab generic PA eql cough & cold relief hbp 4-30 mg tab generic PA eql cough dm 30 mg/5ml susp generic eql daytime cold & flu relief 10-5-325 mg cap generic eql daytime cold & flu relief 10-5-325 mg/15ml liquid generic eql daytime cold/flu relief 10-5-325 mg cap generic eql daytime cold/flu relief 10-5-325 mg/15ml liquid generic eql daytime severe cold/flu 5-10-200-325 mg/15ml liquid generic PA eql flu/severe cold/congestion 60-4-30-1000 mg packet generic PA eql ibuprofen cold childrens 15-100 mg/5ml suspension generic PA eql mucus-dm maximum strength 60-1200 mg tab er 12h generic eql mucus-er 600 mg tab er 12h generic eql mucus-er maximum strength 1200 mg tab er 12h generic eql nighttime cold & flu 15-6.25-325 mg/15ml liquid generic eql nighttime cold/flu relief 15-6.25-325 mg cap generic eql nighttime cold/flu relief 30-12.5-650 mg/30ml liquid generic eql pain relief/cold 30-15-200-325 mg tab generic PA eql pressure & pain pls/mucus 5-325-200 mg tab generic PA eql severe cold 30-500-15 mg tab generic eql sinus congestion/pain day 5-325-200 mg tab generic eql triacting cold/cough 15-1-5 mg/5ml elixir generic PRODUCT DESCRIPTION PAGE 83 PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS eql triacting cold/cough 15-1-7.5 mg/5ml liquid generic eql tussin cf cgh/cold/congest 30-10-100 mg/5ml liquid generic eql tussin mucus/chest congest 100 mg/5ml liquid generic PA ESOCOR P 30-4-30 MG/5ML SUSPENSION pseudoephedrine-chlorphen-dm BRAND PA exefen dmx 60-20-400 mg tab generic PA fenesin ir 400 mg tab generic PA fenesin pe ir 10-400 mg tab generic PA fexofenadine-pseudoephed er 180-240 mg tab er 24h generic C Non-Formulary Drug fexofenadine-pseudoephed er 60-120 mg tab er 12h generic C Non-Formulary Drug flu relief therapy daytime 10-5-325 mg/15ml liquid generic g-fen ex 400 mg tab generic g-supress dx pediatric 2.5-5-50 mg/ml liquid generic gnp allergy multi-symptom 2-5-325 mg tab generic gnp allergy-d allergy & conges 60-120 mg tab er 12h generic C gnp childrens ibuprofen cold 15-100 mg/5ml suspension generic PA gnp childrens pain relief/cold 2.5-1-5-160 mg/5ml suspension generic PA gnp childrens plus multi-sympt 2.5-1-5-160 mg/5ml suspension generic PA gnp cold head congestion 5-10-200-325 mg tab generic PA gnp cold relief cold & flu 5-10-200-325 mg tab generic PA gnp cold relief daytime 5-10-200-325 mg tab generic PA gnp cold relief multi-symptom 5-10-200-325 mg tab generic PA gnp cold severe congestion day 5-10-200-325 mg tab generic PA gnp cold/allergy childrens 1-2.5 mg/5ml elixir generic gnp cold/cough childrens 2.5-1-5 mg/5ml elixir generic gnp cough dm er 30 mg/5ml susp generic PAGE 84 PA Non-Formulary Drug PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS gnp cough relief 15 mg/5ml liquid generic gnp day time cold/flu 10-5-325 mg cap generic gnp day time cold/flu relief 10-5-325 mg/15ml liquid generic gnp flu relief therapy daytime 10-5-325 mg/15ml liquid generic gnp mucus er 1200 mg tab er 12h generic PA gnp mucus relief 400 mg tab generic PA gnp mucus relief childrens 100 mg/5ml liquid generic PA gnp mucus relief cold & sinus 5-325-200 mg tab generic PA gnp mucus relief cold flu 5-10-200-325 mg tab generic PA gnp mucus relief congest/cold 5-10-200-325 mg tab generic PA gnp mucus relief cough child 5-100 mg/5ml liquid generic PA gnp mucus relief dm max 5-100 mg/5ml liquid generic PA gnp mucus relief pe 10-400 mg tab generic PA gnp mucus-er 600 mg tab er 12h generic gnp multi-symptom cold daytime 5-10-200-325 mg/15ml liquid generic gnp night time cold & flu 15-6.25-325 mg cap generic gnp night time cold & flu 15-6.25-325 mg/15ml liquid generic gnp night time cold-flu 15-6.25-325 mg cap generic gnp sinus & cold-d 120-220 mg tab er 12h generic gnp sinus congest/pain night 2-5-325 mg tab generic gnp sinus relief congest/pain 2-5-325 mg tab generic gnp sinus relief congest/pain 5-325-200 mg tab generic PA gnp tab tussin 400 mg tab generic PA gnp triacting night time child 6.25-2.5 mg/5ml liquid generic gnp tussin cf cough & cold 5-10-100 mg/5ml syrup generic gnp tussin mucus & chest cong 100 mg/5ml liquid generic PA goodsense day time cold & flu 5-10-200-325 mg tab generic PA PAGE 85 PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS goodsense day time cold & flu 5-10-200-325 mg/15ml liquid generic PA goodsense daytime 10-5-325 mg cap generic goodsense mucus relief 400 mg tab generic PA guaifenesin 100 mg/5ml liquid generic PA guaifenesin 100 mg/5ml solution generic PA guaifenesin 200 mg tab generic PA guaifenesin 200 mg/10ml solution generic PA guaifenesin 300 mg/15ml solution generic PA guaifenesin 400 mg tab generic PA guaifenesin 400 mg tabs generic PA guaifenesin er 1200 mg tab er 12h generic PA guaifenesin er 600 mg tab er 12h generic hist-pse 0.938-10 mg/ml liquid generic hm chest congestion relief 400 mg tab generic hm cold & allergy childrens 1-2.5 mg/5ml elixir generic hm cold & cough childrens 2.5-1-5 mg/5ml elixir generic hm cough dm 30 mg/5ml susp generic hm cough relief 15 mg/5ml liquid generic hm day time 10-5-325 mg cap generic hm daytime cold & flu 10-5-325 mg/15ml liquid generic hm mucus er 1200 mg tab er 12h generic hm mucus er 600 mg tab er 12h generic hm mucus relief dm max st 60-1200 mg tab er 12h generic hm mucus relief fm cold/flu 5-10-200-325 mg tab generic PA hm mucus relief fm cold/sinus 5-325-200 mg tab generic PA hm mucus relief fm severe 5-10-200-325 mg tab generic PA hm night time cold & flu 15-6.25-325 mg cap generic PRODUCT DESCRIPTION PAGE 86 PA PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS hm night time cold & flu 15-6.25-325 mg/15ml liquid generic hm night time ms cold & flu 15-6.25-325 mg cap generic hm severe cold/flu 5-10-200-325 mg tab generic PA hm sinus & cold-d 120-220 mg tab er 12h generic PA hm tussin adult 100 mg/5ml liquid generic PA iophen-nr 100 mg/5ml liquid generic PA kls mucus relief chest 400 mg tab generic PA kls multi-symptom cold child 2.5-1-5-160 mg/5ml suspension generic PA liquibid 400 mg tab generic PA liquibid d-r 10-400 mg tab generic PA lohist-peb 4-10 mg/5ml liquid generic PA m-hist dm 7.5-4-15 mg/5ml liquid generic MAXICHLOR DM 4-20 MG TAB chlorpheniramine-dm BRAND MAXICHLOR PEH DM 10-4-20 MG TAB phenylephrine-chlorphen-dm BRAND MAXIFED DM 40-20-400 MG TAB pseudoephedrine w/ dm-gg BRAND medicidin-d 2-5-325 mg tab generic mucaphed 10-400 mg tab generic PA mucinex chest congestion child 100 mg/5ml liquid generic PA mucinex cough childrens 5-100 mg/5ml liquid generic PA mucinex fast-max cold & sinus 10-5-325 mg cap generic mucinex fast-max cold & sinus 5-325-200 mg tab generic PA mucinex fast-max cold flu 5-10-200-325 mg tab generic PA mucinex fast-max congest cold 5-10-200-325 mg tab generic PA mucinex fast-max dm max 20-400 mg/20ml liquid generic PA mucinex fast-max severe cold 5-10-200-325 mg tab generic PA PAGE 87 PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS MUCINEX FOR KIDS 50 MG PACKET guaifenesin BRAND PA mucinex sinus-max congestion 5-325-200 mg tab generic PA mucinex sinus-max press & pain 5-325-200 mg tab generic PA mucosa 400 mg tab generic PA mucus relief 400 mg tab generic PA mucus relief chest congestion 400 mg tab generic PA mucus relief chest congestion 400 mg/20ml liquid generic PA mucus relief childrens 100 mg/5ml liquid generic PA mucus relief cold flu throat 5-10-200-325 mg tab generic PA mucus relief cough childrens 5-100 mg/5ml liquid generic PA mucus relief d 10-400 mg tab generic PA mucus relief d 40-400 mg tab generic PA mucus relief dm 60-1200 mg tab er 12h generic mucus relief dm max 20-400 mg/20ml liquid generic PA mucus relief dm max 5-100 mg/5ml liquid generic PA mucus relief er 600 mg tab er 12h generic mucus relief pe 10-400 mg tab generic PA mucus relief plus 5-10-200-325 mg tab generic PA mucus relief severe cold 5-10-200-325 mg tab generic PA mucus relief sinus pressure 5-325-200 mg tab generic PA mucus relief sinus severe cong 5-325-200 mg tab generic PA mucus-dm max 60-1200 mg tab er 12h generic mucus-er 600 mg tab er 12h generic mucusrelief sinus 10-400 mg tab generic PA multi-symptom cold childrens 2.5-1-5-160 mg/5ml suspension generic PA PRODUCT DESCRIPTION PAGE 88 LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS multi-symptom cold plus child 2.5-1-5-160 mg/5ml suspension generic PA nasohist 1-2 mg/ml liquid generic night time cold/flu relief 15-6.25-325 mg cap generic night time cough/cold child 6.25-2.5 mg/5ml liquid generic night time cough/cold relief 6.25-2.5 mg/5ml liquid generic night time ms cold/flu relief 15-6.25-325 mg/15ml liquid generic night time sinus/pain 2-5-325 mg tab generic night-time cold/flu relief 15-6.25-325 mg cap generic nighttime cold/flu relief 15-6.25-325 mg cap generic nighttime pain plus sleep 25-500 mg/15ml liquid generic nite time multi-symptom relief 15-6.25-325 mg cap generic nite-time cold/flu 15-6.25-325 mg cap generic nite-time cold/flu relief 15-6.25-325 mg cap generic nite-time cold/flu relief 15-6.25-325 mg/15ml liquid generic nite-time cold/flu relief 30-12.5-650 mg/30ml liquid generic niva-hist dm 7.5-4-15 mg/5ml liquid generic nohist-dm 10-4-15 mg/5ml liquid generic non-aspirin severe congestion 5-10-200-325 mg tab generic nortuss-de 2.5-5-50 mg/ml liquid generic nu-copd 10-400 mg tab generic PA organ-i nr 200 mg tab generic PA pa mucus relief 600 mg tab er 12h generic pain relief cold congestion 5-10-200-325 mg tab generic PA pain relief plus multi-symptom 2.5-1-5-160 mg/5ml suspension generic PA pedi-atric nightrest 15-1-7.5 mg/5ml liquid generic pediacare child allergy/cold 12.5-5 mg/5ml liquid generic PA pediacare childrens nightrest 12.5-5 mg/5ml solution generic PA phenylephrine-guaifenesin 10-400 mg tab generic PA PRODUCT DESCRIPTION PAGE 89 PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS POLY-VENT IR 45-400 MG TAB pseudoephedrine-guaifenesin BRAND PA pseudoeph-bromphen-dm 30-2-10 mg/5ml syrup generic PA pseudoeph-chlorphen-dm 9-0.8-3 mg/ml solution generic pseudoephedrine-dm-gg 30-10-100 mg/5ml liquid generic px allergy sinus pe 2-5-325 mg tab generic px daytime cold/flu relief 10-5-325 mg/15ml liquid generic px daytime pe 10-5-325 mg cap generic px dibromm cold/allergy child 1-2.5 mg/5ml elixir generic px dibromm dm cold/cough child 2.5-1-5 mg/5ml elixir generic px nitetime cold/flu relief 15-6.25-325 mg cap generic px severe cold 5-10-200-325 mg tab generic PA px tussin 100 mg/5ml solution generic PA q-tapp dm 15-1-5 mg/5ml elixir generic q-tussin 100 mg/5ml solution generic qc allergy relief multi-sympt 2-5-325 mg tab generic qc cold head congestion day 5-10-200-325 mg tab generic PA qc cold multi-symptom daytime 5-10-200-325 mg tab generic PA qc cold relief plus multi-symp 2.5-1-5-160 mg/5ml suspension generic PA qc cough relief 15 mg/5ml liquid generic qc daytime cold/flu 10-5-325 mg cap generic qc flu relief therapy daytime 10-5-325 mg/15ml liquid generic qc medifin 400 400 mg tab generic PA qc medifin mucus relief child 100 mg/5ml liquid generic PA qc nighttime multi-symptom 15-6.25-325 mg cap generic qc sinus congest/pain severe 5-325-200 mg tab generic ra allergy multi-symptom 2-5-325 mg tab generic ra allergy plus sinus 25-10 mg tab generic PRODUCT DESCRIPTION PAGE 90 PA PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS ra allergy relief-d 60-120 mg tab er 12h generic ra childrens cold & allergy 1-2.5 mg/5ml elixir generic ra childrens flu relief plus 2.5-1-5-160 mg/5ml suspension generic PA ra childrens plus cold 2.5-1-5-160 mg/5ml suspension generic PA ra cold & allergy 1-2.5 mg/5ml elixir generic ra cold & cough childrens 2.5-1-5 mg/5ml elixir generic PA ra cold multi-symptom daytime 5-10-200-325 mg tab generic PA ra cold/cough dm 2.5-1-5 mg/5ml elixir generic PA ra cold/flu multi-symptom nite 15-6.25-325 mg cap generic ra cold/flu relief daytime 10-5-325 mg cap generic ra cold/flu relief nighttime 15-6.25-325 mg cap generic ra cough dm 30 mg/5ml susp generic ra day time cold/flu formula 10-5-325 mg/15ml liquid generic ra daytime multi-symp cold/flu 10-5-325 mg cap generic ra daytime multi-symptom cold 10-5-325 mg cap generic ra head congest cold daytime 5-10-200-325 mg tab generic PA ra ibuprofen cold childrens 15-100 mg/5ml suspension generic PA ra mucus relief 400 mg tab generic PA ra mucus relief 600 mg tab er 12h generic ra mucus relief chest 400 mg tab generic PA ra mucus relief plus 5-10-200-325 mg tab generic PA ra mucus relief sinus 10-400 mg tab generic PA ra sinus congest/pain relief 5-325-200 mg tab generic PA ra suphedrine 4-60 mg tab generic ra tussin chest congestion 100 mg/5ml liquid generic ra tussin long acting cough 15 mg/5ml liquid generic recofen d 5-100 mg/5ml liquid generic PAGE 91 C Non-Formulary Drug PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS reeses onetab congest/cough 10-400 mg tab generic PA refenesen 200 mg tab generic PA refenesen 400 400 mg tab generic PA refenesen pe 10-400 mg tab generic PA relcof dm 7.5-4-15 mg/5ml liquid generic RELHIST BP 4-10 MG TAB brompheniramine & phenyleph BRAND RESCON DM 30-2-10 MG/5ML SYRUP pseudoephedrine-chlorphen-dm BRAND robafen cf cough/cold 5-10-100 mg/5ml syrup generic robitussin 12 hour cough 30 mg/5ml susp generic robitussin 12 hour cough child 30 mg/5ml susp generic robitussin cold+flu daytime 10-5-325 mg cap generic robitussin cold+flu nighttime 15-6.25-325 mg cap generic robitussin cough+chest cong dm 20-400 mg/20ml liquid generic PA robitussin cough+chest cong dm 5-100 mg/5ml liquid generic PA robitussin lingering la cough 15 mg/5ml liquid generic robitussin mucus+chest congest 100 mg/5ml liquid generic PA robitussin night cgh/cold/flu 2.5-1-5-160 mg/5ml suspension generic PA robitussin night time cgh/cold 6.25-2.5 mg/5ml liquid generic robitussin peak cold nasal rlf 2-5-325 mg tab generic RU-HIST D 4-10 MG TAB brompheniramine & phenyleph BRAND rynex pe 1-2.5 mg/5ml elixir generic sb allergy multi-symptom 2-5-325 mg tab generic sb allergy/sinus/headache 12.5-30-500 mg tab generic sb bronchial 12.5-200 mg tab generic sb childrens multisympt cold 2.5-1-5-160 mg/5ml suspension generic sb cold & allergy childrens 1-2.5 mg/5ml elixir generic PRODUCT DESCRIPTION PAGE 92 PA PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS sb cold & cough dm childrens 2.5-1-5 mg/5ml elixir generic PA sb cold & cough hbp 4-30 mg tab generic PA sb cold & flu severe 5-10-200-325 mg tab generic PA sb cold head congestion severe 5-10-200-325 mg tab generic PA sb cold medicine 30-15-200-325 mg tab generic PA sb cold multi-symptom severe 5-10-200-325 mg tab generic PA sb cough relief 15 mg/5ml liquid generic sb coughtab 200 mg tab generic sb day time cold/flu relief 10-5-325 mg cap generic sb daytime 10-5-325 mg/15ml liquid generic sb flu relief therapy daytime 10-5-325 mg/15ml liquid generic sb mucus relief 400 mg tab generic PA sb mucus relief pe 10-400 mg tab generic PA sb night time cold/flu relief 15-6.25-325 mg cap generic sb pseudoephedrine plus 4-60 mg tab generic sb severe cold congestion 30-15-200-325 mg tab generic PA sb sinus congestion/pain 5-325-200 mg tab generic PA sb sinus congestion/pain night 2-5-325 mg tab generic scot-tussin expectorant 100 mg/5ml liquid generic PA severe sinus congestion & pain 5-325-200 mg tab generic PA siltussin das 100 mg/5ml liquid generic PA sinus & cold-d 120-220 mg tab er 12h generic PA sinus congestion/pain night 2-5-325 mg tab generic sm allergy multi-symptom 2-5-325 mg tab generic sm allergy/sinus headache 12.5-30-500 mg tab generic sm chest congestion relief 400 mg tab generic PA sm chest congestion relief pe 10-400 mg tab generic PA PRODUCT DESCRIPTION PAGE 93 PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS sm childrens plus ms cold 2.5-1-5-160 mg/5ml suspension generic PA sm cold & allergy childrens 1-2.5 mg/5ml elixir generic sm cold & cough childrens 15-1-5 mg/5ml elixir generic sm cold & cough dm childrens 2.5-1-5 mg/5ml elixir generic PA sm cold & flu severe 5-10-200-325 mg tab generic PA sm cold head congestion 5-10-200-325 mg tab generic PA sm day time cold & flu relief 10-5-325 mg/15ml liquid generic sm day time non drowsy 10-5-325 mg cap generic sm day time pe cold/flu relief 10-5-325 mg cap generic sm ibuprofren cold childrens 15-100 mg/5ml suspension generic sm mucus er 600 mg tab er 12h generic sm mucus relief childrens 100 mg/5ml liquid generic PA sm mucus relief cough children 5-100 mg/5ml liquid generic PA sm night time cold & flu 15-6.25-325 mg cap generic sm nite time cold & flu 15-6.25-325 mg/15ml liquid generic sm nite time cold & flu relief 15-6.25-325 mg cap generic sm pain reliever cold 30-15-200-325 mg tab generic sm sinus & allergy max st 4-60 mg tab generic sm sinus & cold-d 120-220 mg tab er 12h generic sm tussin cf 30-10-100 mg/5ml liquid generic sm tussin mucus+chest congest 100 mg/5ml liquid generic PA sudafed pe non-drying sinus 5-200 mg tab generic PA sudafed pe pressure+pain+mucus 5-325-200 mg tab generic PA sudafed pressure+pain 12 hr 120-220 mg tab er 12h generic PA sudogest sinus/allergy 4-60 mg tab generic supress-dx pediatric 2.5-5-50 mg/ml liquid generic tabtussin 400 mg tab generic PRODUCT DESCRIPTION PAGE 94 PA PA PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS TG 45PSE/400GFN 45-400 MG TAB pseudoephedrine-guaifenesin BRAND PA tgq 7.5peh/4brm/15dm 7.5-4-15 mg/5ml liquid generic tgt allergy+ congestion relief 60-120 mg tab er 12h generic C tgt cold/cough childrens 2.5-1-5 mg/5ml elixir generic PA tgt cold/cough relief night 6.25-2.5 mg/5ml liquid generic tgt cold/flu relief day time 10-5-325 mg/15ml liquid generic tgt cold/flu relief day-time 10-5-325 mg cap generic tgt cold/flu relief nighttime 15-6.25-325 mg cap generic tgt mucus relief childrens 100 mg/5ml liquid generic PA tgt mucus relief cough child 5-100 mg/5ml liquid generic PA tgt multi-symptom cold child 2.5-1-5-160 mg/5ml suspension generic PA tgt pain reliever pm ex st 25-500 mg tab generic tgt severe cold relief 5-10-200-325 mg tab generic PA th chest congestion relief 400 mg tab generic PA th chest congestion relief pe 10-400 mg tab generic PA th childrens mucus relief cgh 5-100 mg/5ml liquid generic PA th cold & allergy 1-2.5 mg/5ml elixir generic th day time cold/flu relief 10-5-325 mg cap generic th day time cold/flu relief 10-5-325 mg/15ml liquid generic th nite time cold/flu relief 15-6.25-325 mg cap generic th severe cold multi-symptom 5-10-200-325 mg tab generic PA th tussin 100 mg/5ml liquid generic PA theraflu expressmax 20-10-650 mg/30ml liquid generic theraflu warming relief day 10-5-325 mg/15ml liquid generic tl-hist dm 7.5-4-15 mg/5ml liquid generic tl-hist pd 1-7.5 mg/ml liquid generic TRIACTIN CHEST CONGESTION 50 MG/5ML SOLUTION guaifenesin BRAND PRODUCT DESCRIPTION PAGE 95 Non-Formulary Drug PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS triacting night time cold/cgh 6.25-2.5 mg/5ml liquid generic triacting nightime cold&cough 6.25-2.5 mg/5ml liquid generic triaminic fever & cold 2.5-1-5-160 mg/5ml suspension generic trigofen 1-2 mg/ml liquid generic trip-pse 0.938-10 mg/ml liquid generic tussi-pres pe pediatric 2.5-100 mg/5ml liquid generic tussin 100 mg/5ml liquid generic tussin cf 30-10-100 mg/5ml liquid generic tussin cold/congestion 30-10-200 mg cap generic tussin cough long-acting 15 mg/5ml liquid generic tussin mucus & chest congest 100 mg/5ml liquid generic PA tussin mucus+chest congestion 100 mg/5ml liquid generic PA tylenol allergy multi-symptom 2-5-325 mg tab generic TYLENOL CHILDRENS PLUS CLD/CGH 5-2.5-160 MG/5ML SUSPENSION dextromethorphan-phenylephrine-acetaminophen BRAND tylenol sinus congestion/pain 2-5-325 mg tab generic vicks dayquil cold & flu 10-5-325 mg cap generic vicks dayquil cold & flu 10-5-325 mg/15ml liquid generic vicks dayquil multi-symptom 10-5-325 mg cap generic vicks dayquil severe cold/flu 5-10-200-325 mg tab generic PA vicks dayquil severe cold/flu 5-10-200-325 mg/15ml liquid generic PA vicks nyquil cold & flu 15-6.25-325 mg cap generic vicks nyquil cold & flu night 15-6.25-325 mg cap generic virdec dm 3.5-1-3 mg/ml liquid generic wal-dryl pe allergy & sinus 25-10 mg tab generic WAL-DRYL-D 25-60 MG TAB diphenhydramine & pseudoephed BRAND wal-dryl-d allergy/sinus 25-10 mg tab generic wal-fex d allergy & congestion 180-240 mg tab er 24h generic PAGE 96 PA PA PA PA PA PA C Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS wal-fex d allergy & congestion 60-120 mg tab er 12h generic wal-finate-d 4-60 mg tab generic wal-flu severe cold & cough 10-5-325 mg/15ml liquid generic wal-phed pe triple relief 5-325-200 mg tab generic wal-phed sinus/allergy 4-60 mg tab generic wal-tap childrens 1-2.5 mg/5ml elixir generic wal-tap dm cold/cough 15-1-5 mg/5ml elixir generic wal-tap dm cold/cough 2.5-1-5 mg/5ml elixir generic wal-tussin cf 30-10-100 mg/5ml liquid generic wal-tussin chest congestion 100 mg/5ml liquid generic wal-tussin cough long acting 15 mg/5ml liquid generic xpect 400 mg tab generic PA Z-DEX 2.5-3-35 MG/ML LIQUID phenylephrine w/ dm-gg BRAND PA zoden dm 1.5-1-3 mg/ml liquid generic PA C Non-Formulary Drug PA PA PA SLEEP DISORDER AGENTS SLEEP DISORDERS, OTHER cvs ibuprofen pm 200-38 mg tab generic cvs sleep-aid nighttime 25 mg tab generic PA C Non-Formulary Drug PA cvs ultra sleep 25 mg tab generic C eq ibuprofen pm 200-38 mg tab generic eq sleep aid 25 mg tab generic Non-Formulary Drug PA C eql ibuprofen pm 200-38 mg tab generic eql sleep aid 25 mg tab generic Non-Formulary Drug PA C gnp ibuprofen pm 200-38 mg tab PAGE 97 Non-Formulary Drug generic LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PA gnp sleep aid 25 mg tab generic C Non-Formulary Drug PA hm sleep aid 25 mg tab generic C ibuprofen pm 200-38 mg tab generic kls sleep aid 25 mg tab generic Non-Formulary Drug PA C Non-Formulary Drug PA medi-sleep 25 mg tab generic C motrin pm 200-38 mg tab generic nitetime sleep-aid 25 mg tab generic Non-Formulary Drug PA C ra ibuprofen pm 200-38 mg tab generic ra night sleep aid 25 mg tab generic Non-Formulary Drug PA C Non-Formulary Drug PA ra sleep aid 25 mg tab generic C Non-Formulary Drug PA sleep aid 25 mg tab generic C sm ibuprofen pm 200-38 mg tab generic sm sleep aid 25 mg tab generic Non-Formulary Drug PA C tgt ibuprofen pm 200-38 mg tab generic TYLENOL PM EXTRA STRENGTH 1000-50 MG/30ML LIQUID diphenhydramine-acetaminophen (sleep) BRAND wal-som 25 mg tab generic Non-Formulary Drug PA C PAGE 98 Non-Formulary Drug LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS BIFERA 28 MG TAB polysaccharide iron complex-iron heme polypeptide BRAND PA bprotected pedia iron 75 (15 fe) mg/ml solution generic PA CAL-GLU 500 MG CAP calcium gluconate BRAND PA calcitrate 950 mg tab generic PA CALCIUM CITRATE 1040 MG TAB calcium citrate BRAND PA calcium citrate 950 mg tab generic PA calcium lactate 100 mg tab generic cvs iron 325 (65 fe) mg tab generic DUOFER 28 MG TAB polysaccharide iron complex-iron heme polypeptide BRAND eql iron supplement therapy 325 mg tab generic feosol 325 (65 fe) mg tab generic FEOSOL BIFERA 28 MG TAB polysaccharide iron complex-iron heme polypeptide BRAND PA fer-iron 75 (15 fe) mg/ml solution generic PA ferro-bob 325 (65 fe) mg tab generic ferrous sulfate 220 (44 fe) mg/5ml liquid generic ferrous sulfate 325 (65 fe) mg tab generic ferrous sulfate 325 (65 fe) mg tabs generic ferrous sulfate 75 (15 fe) mg/ml solution generic PA ferrous sulfate 75 (15 fe) mg/ml solution generic PA ferrousul 325 (65 fe) mg tab generic FLORICAL 8.3-364 MG CAP sodium fluoride w/ calcium carbonate BRAND gnp iron 325 (65 fe) mg tab generic HOMOCYSTEINE FORMULA 800-50-100 MCG-MG-MCG TAB folic acid-vitamin b6-vitamin b12 BRAND PRODUCT DESCRIPTION THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES ELECTROLYTE/MINERAL REPLACEMENT PAGE 99 PA PA PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS iron 325 (65 fe) mg tab generic iron high-potency 325 mg tab generic iron supplement 325 (65 fe) mg tab generic iron supplement childrens 75 (15 fe) mg/ml solution generic kp ferrous sulfate 325 (65 fe) mg tab generic mag-g 500 (27 mg) mg tab generic PA MAG-TAB SR 84 MG (7MEQ) TAB ER magnesium lactate BRAND PA magnesium 27 500 (27 mg) mg tab generic PA magonate 500 (27 mg) mg tab generic PA meijer ferrous sulfate 325 (65 fe) mg tab generic MYKIDZ IRON 10 15 MG/1.5ML SUSPENSION iron BRAND PA POSTURE 600-280 MG TAB calcium & phosphorus BRAND PA qc ferrous sulfate 325 (65 fe) mg tab generic ra iron 325 (65 fe) mg tab generic sm iron 325 (65 fe) mg tab generic th iron 325 (65 fe) mg tab generic a thru z advanced 18-500-300 tab generic a thru z advanced 18mg-0.4mg tab generic a thru z advanced adult tab generic a thru z advanced tab generic a thru z high potency 0.4-162-18 tab generic a thru z high potency tab generic a thru z select .4-300-250 tab generic a thru z select 0.4-162-18 tab generic a thru z select 50+ advanced .4-300-250 tab generic a thru z select 50+ mens tab generic a thru z select 500-250mcg chew tab generic a thru z select 500-300mcg tab generic PAGE 100 PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS a thru z select advanced .4-300-250 tab generic a thru z select advanced tab generic a thru z select tab generic a thru z select ultimate women tab generic a thru z ultimate mens tab generic abc plus senior adults 50+ .4-300-250 tab generic abc plus senior tab generic abc plus tab generic adult gummy chew tab generic advanced multi ea chew tab generic airborne 250-12.5mg chew tab generic airborne chew tab generic airborne gummies 333-1.7 mg chew tab generic akedamins 0.2-7.5mg chew tab generic antioxidant a/c/e/selenium tab generic antioxidant formula tab generic antioxidant protection formula tab generic antioxidant tab generic antioxidant vitamins tab generic b complex-c-biotin-e-fa 0.4 mg tab generic b complex-c-folic acid tab generic PA b-12 100 mcg tab generic PA b-12 50 mcg tab generic b-complex balanced 400mcg-500 tab generic PA b-complex/vitamin c tab generic PA b-complex/vitamin c 400 mcg tab generic PA b-complex/vitamin c tab generic PA b-redi/red hearts/red roosters tab generic biotin plus/calcium/vit d3 200mg-450 tab generic PAGE 101 LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS brewers yeast 487.5 mg tab generic PA brewers yeast 500 mg tab generic PA brewers yeast tab generic PA calcet plus tab generic carnitine 250 mg cap generic carravite tab generic centavite a-z complete-mineral 27mg-0.4mg tab generic centravites 0.4-162-18 tab generic centravites 50 plus tab generic centravites tab generic century mature tab generic century tab generic cerovite advanced formula 18mg-0.4mg tab generic cerovite senior tab generic certa plus 0.4-18-250 tab generic certagen tab generic certavite/antioxidants 0.4-18-250 tab generic certavite/antioxidants 18mg-0.4mg tab generic choline 648 mg cap generic companion 0.4 mg tab generic compete tab generic complere tab generic complete daily/lutein tab generic complete energy tab generic complete senior tab generic complete tab generic complete womens tab generic cvs daily energy 250-0.4 mg tab generic cvs daily gummies 200 mcg chew tab generic PRODUCT DESCRIPTION PAGE 102 PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE cvs daily gummies chew tab generic cvs daily multiple fe/ca/zn tab generic cvs daily multiple for men 0.4 mg tab generic cvs daily multiple for men 50+ tab generic cvs daily multiple for men tab generic cvs daily multiple for women 500-18-0.4 tab generic cvs daily multiple for women tab generic cvs daily multiple plus min tab generic cvs daily multiple women 50+ 0.4 mg tab generic cvs daily multiple women 50+ 400mcg-120 tab generic cvs daily teen 18mg-0.4mg tab generic cvs folic acid 400 mcg tab generic cvs mens daily gummies chew tab generic cvs spectravite advanced .4-300-250 tab generic cvs spectravite advanced 18mg-0.4mg tab generic cvs spectravite chew tab generic cvs spectravite performance tab generic cvs spectravite senior 500-300mcg tab generic cvs spectravite senior tab generic cvs spectravite tab generic cvs spectravite ultra mens 8-200-600 tab generic cvs spectravite womens senior 8-400-300 tab generic cvs stress formula tab generic cvs vision formula 1000-60-2 tab generic cvs vitamin b-12 100 mcg tab generic cvs womens active daily 18mg-0.4mg tab generic cvs womens daily gummies chew tab generic daily betic tab generic daily combo multi vitamins 18mg-0.4mg tab generic daily diet support tab generic PAGE 103 LIMITS & RESTRICTIONS PA PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE daily mens health formula tab generic daily multi 18mg-0.4mg tab generic daily multi 50+ tab generic daily multiple vitamins/min tab generic daily multiple weight loss 18-0.4-27 tab generic daily vitamin formula+minerals tab generic daily womens health formula tab generic daily-vitamin maximum formula tab generic diabetes health formula 500-250mcg tab generic dialyvite 800/ultra d 0.8mg-2000 tab generic doctors choice men tab generic ecolovit tab generic ELDERTONIC ELIXIR multiple vitamins w/ minerals BRAND ELLIS TONIC ELIXIR multiple vitamins w/ minerals BRAND enviro-stress tab generic eq complete multivit adult 50+ .4-300-250 tab generic eq one daily womens health tab generic eq one daily womens pro-active 300-18-0.4 tab generic eql b complex tab generic eql central-vite .4-300-250 tab generic eql central-vite performance tab generic eql central-vite select tab generic eql century .4-300-250 tab generic eql century cardio health 3-200-400 tab generic eql century mature 500-300mcg tab generic eql century mature men 50+ tab generic eql century mature women 50+ tab generic eql folic acid 400 mcg tab generic eql gummy adult chew tab generic PAGE 104 LIMITS & RESTRICTIONS PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS eql one daily 50 plus tab generic eql one daily dieters support 18-0.4-32 tab generic eql one daily maximum 18mg-0.4mg tab generic eql one daily mens 50+ advance tab generic eql one daily mens health tab generic eql one daily womens 50+ adv tab generic eql super b complex/vitamin c tab generic eql ultimate mens century tab generic eql ultimate womens century 0.4mg-18mg tab generic eql vision formula tab generic essentia 18mg-0.4mg tab generic essential balance tab generic eye support tab generic eye vitamins & minerals tab generic eye-vite extra plus lutein 1000-300-2 tab generic eye-vites tab generic eyeprotect tab generic fa-8 0.8 mg cap generic PA ferrex 150 150 mg cap generic PA ferric x-150 150 mg cap generic PA ferus 150 mg cap generic PA folic acid 0.8 mg cap generic PA folic acid 400 mcg tab generic PA formula twenty-one tab generic generix t tabs generic gerivite complete tab generic gnp century 18mg-0.4mg tab generic gnp century active performance 18-0.4-50 tab generic gnp century adult formula tab generic PAGE 105 PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE gnp century adults 50+ senior .4-300-250 tab generic gnp century adults 50+ senior tab generic gnp century cardio health 3-200-400 tab generic gnp century mature .4-300-250 tab generic gnp century ultimate mens 300-600mcg tab generic gnp century ultimate mens 8-200-600 tab generic gnp century ultimate womens 18mg-0.4mg tab generic gnp century ultimate womens 8-400-300 tab generic gnp diabetic support formula 167-100-83 tab generic gnp folic acid 400 mcg tab generic gnp hair/skin/nails 3.3 mg-25 tab generic gnp hair/skin/nails tab generic gnp healthy eyes 1000-60-2 tab generic gnp maximum one daily 0.4mg-18mg tab generic gnp mega multi for men 200-175mcg tab generic gnp mega multi for women 13.5mg-200 tab generic gnp one daily maximum 0.4mg-18mg tab generic gnp one daily mens 50+advanced tab generic gnp one daily mens health 50+ 400-600mcg tab generic gnp one daily mens/lycopene 0.4mg-600 tab generic gnp one daily womens 300-18-0.4 tab generic gnp one daily womens 50+ 0.4 mg tab generic gnp one daily womens 50+ 400mcg-120 tab generic gnp opti-vitamins tab generic gnp therapeutic-m 9mg-0.4mg tab generic gnp womens one daily 27mg-0.4mg tab generic hair formula extra strength tab generic hair skin and nails formula tab generic hair vitamins tab generic hair/skin/nails tab generic PAGE 106 LIMITS & RESTRICTIONS PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS hair/skin/nails tab generic hair/skin/nails/biotin 1 mg-66.7 tab generic healthy eyes 1000-60-2 tab generic healthy eyes tab generic healthy eyes/lutein tab generic hi-kovite 2-part formula tab generic hi-potency multi-vitamin tab generic hm antioxidant vitamins 1000-60-2 tab generic hm complete 18mg-0.4mg tab generic hm complete 50+ .4-300-250 tab generic hm folic acid 400 mcg tab generic hm multivitamin adult gummy chew tab generic hm vitamin b complex/vitamin c tab generic i-vite 1000-60-2 tab generic i-vite protect 7160-113 tab generic icaps mv 1.66-0.83 tab generic iferex 150 150 mg cap generic PA inositol 500 mg tab generic PA inositol 650 mg tab generic kp adults 50+ daily formula .4-300-250 tab generic kp adults daily formula 18mg-0.4mg tab generic kp b complex-c 18-250-400 tab generic kp mens 50+ daily formula 400-300mcg tab generic kp mens daily formula 0.4 mg tab generic kp womens 50+ daily formula 400mcg-120 tab generic kp womens daily formula 500-18-0.4 tab generic l-carnitine 250 mg cap generic lecithin concentrate 400 mg cap generic levocarnitine 1 gm/10ml solution generic PAGE 107 PA PA PA PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE macuvite eye care tab generic macuvite tab generic macuvite/lutein 5k-60-30-2 tab generic maximum blue label tab generic maximum daily green 5mg-133mcg tab generic maximum green label tab generic maximum red label tab generic mccarnitine 330 mg tab generic mediplex plus tab generic mega vm-80 tab generic meijer advanced formula .4-300-250 tab generic meijer advanced formula tab generic memory vite tab generic mens hair formula ultra man tab generic mens life pack tab generic mens multiple vitamin/lycopene tab generic mens multivitamin plus tab generic methionine 500 mg tab generic milltrium advanced formula tab generic milltrium cardio tab generic milltrium senior tab generic multi + omega-3 adult gummies chew tab generic multi adult gummies chew tab generic multi complete/iron 18mg-0.4mg tab generic multi for her 18-600-80 tab generic multi for her 50+ 0.4mg-250 tab generic multi for him 0.4-2-250 tab generic multi for him 50+ 0.4-2-250 tab generic multi vitamin/minerals tab generic multi-day plus minerals tab generic PAGE 108 LIMITS & RESTRICTIONS LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE multi-day weight trim tab generic multi-lean tab generic multi-vitamin gummies 200-137.5 chew tab generic multi-vitamin menopausal tab generic multi-vitamin/minerals tab generic multilex tab generic multilex-t&m tab generic multimineral plus tab generic multiple vit/minerals/no iron tab generic multiple vitamins/womens tab generic multivital 0.4-162-18 chew tab generic multivital 0.4-162-18 tab generic multivital 18-500-300 tab generic multivital performance tab generic multivital platinum 500-300mcg tab generic multivital platinum silver 500-250mcg chew tab generic multivital platinum tab generic multivital-m tab generic multivitamin adults tab generic multivitamin adults 50+ tab generic multivitamin adults 50+ tab generic multivitamin gummies adult 200 mcg chew tab generic multivitamin gummies adult chew tab generic multivitamin gummies adults chew tab generic multivitamin gummies mens chew tab generic multivitamin gummies womens chew tab generic multivitamin men tab generic multivitamin men 50+ tab generic multivitamin women tab generic multivitamin women 50+ tab generic PAGE 109 LIMITS & RESTRICTIONS LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS multivitamin women 50+ tab generic multivitamin women tab generic multivitamin/extra vitamin d3 chew tab generic multivitamins 1000-800 chew tab generic myamulti tab generic myferon 150 150 mg cap generic PA nu-iron 150 mg cap generic PA ocusoft vms tab generic ocutabs tab generic ocutabs-lutein tab generic ocuvite tab generic ocuvite extra tab generic ocuvite eye + multi tab generic ocuvite eye heatlh gummies chew tab generic one daily 50 plus tab generic one daily adults 50+ 0.4 mg tab generic one daily calcium/iron tab generic one daily complete 0.4mg-18mg tab generic one daily complete for men tab generic one daily complete tab generic one daily for men 50+ advanced 400-600mcg tab generic one daily for men/lycopene 0.4mg-600 tab generic one daily for women 0.4mg-18mg tab generic one daily for women 50+ adv 400mcg-120 tab generic one daily healthy weight adv 200-0.4mg tab generic one daily healthy weight tab generic one daily maximum 0.4mg-18mg tab generic one daily mens 50+ multivit tab generic one daily mens 50+/lycopene tab generic one daily mens health 0.4mg-600 tab generic PAGE 110 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS one daily mens tab generic one daily multivit/iron-free tab generic one daily multivitamin adult tab generic one daily multivitamin adult tab generic one daily multivitamin men tab generic one daily multivitamin women tab generic one daily plus iron tab generic one daily plus minerals tab generic one daily womens 50 plus 0.4 mg tab generic one daily womens 50+ 400mcg-120 tab generic one daily womens tab generic one daily/minerals tab generic one-a-day teen advantage/her 18mg-0.4mg tab generic optic-vites tab generic optic-vites with lutein tab generic optimum pms tab generic orthovite tab generic osteoprime ultra tab generic poly-iron 150 150 mg cap generic PA polysaccharide iron complex 150 mg cap generic PA PROFERRIN ES 12 MG TAB iron heme polypeptide BRAND PA prosight tab generic px advanced formula multivits tab generic px b complex/vitamin c tab generic px complete senior multivits tab generic px folic acid 400 mcg tab generic px mens multivitamins 0.4mg-600 tab generic qc daily multivit/multimineral 18mg-0.4mg tab generic qc mens daily multivitamin 0.4mg-600 tab generic PAGE 111 PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE qc multi-vite 18mg-0.4mg tab generic qc multi-vite 50 & over tab generic qc multi-vite plus tab generic qc therin-m 9mg-0.4mg tab generic qc womens daily multivitamin 18mg-0.4mg tab generic quintabs-m 10mg-0.4mg tab generic ra central-vite 18mg-0.4mg tab generic ra central-vite energy 18-0.4-50 tab generic ra central-vite mens mature tab generic ra central-vite select tab generic ra central-vite senior .4-300-250 tab generic ra central-vite womens mature 8-400-300 tab generic ra central-vite/antioxidants .4-300-250 tab generic ra central-vite/antioxidants 18-500-300 tab generic ra folic acid 400 mcg tab generic ra hair/skin/nails tab generic ra mature womens dietary supp tab generic ra one daily energy formula tab generic ra one daily gummy vites 200 mcg chew tab generic ra one daily maximum 0.4mg-18mg tab generic ra one daily mens 50+ w/vit d3 400mcg-120 tab generic ra one daily mens multi tab generic ra one daily mens/vit d-3 400-300mcg tab generic ra one daily womens 450-18-0.4 tab generic ra stress formula advanced 0.4 mg tab generic ra stress formula energy 300-4-0.4 tab generic ra therapeutic m plus beta car 18mg-0.4mg tab generic ra vision vite plus zinc tab generic ra vitamin b-12 100 mcg tab generic ra whole source dietary mature tab generic PAGE 112 LIMITS & RESTRICTIONS PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE ra whole source dietary men tab generic ra whole source dietary tab generic ra whole source for men tab generic ra whole source womens tab generic renal tab generic savision tab generic sclerex tab generic senior multivitamin plus tab generic senior tabs tab generic sentry 18-500-300 tab generic sentry adult 18-500-300 tab generic sentry senior .4-300-250 tab generic sentry senior 500-300mcg tab generic sm antioxidant vitamins 1000-60-2 tab generic sm b super vitamin complex tab generic sm complete 18mg-0.4mg tab generic sm complete 50+ .4-300-250 tab generic sm complete 50+ ultimate mens 300-600mcg tab generic sm complete 50+ ultimate women 8-400-300 tab generic sm complete advanced formula 18-500-300 tab generic sm complete advanced formula 18mg-0.4mg tab generic sm complete advanced formula 27mg-0.4mg tab generic sm complete senior formula .4-300-250 tab generic sm complete senior formula tab generic sm complete tab generic sm daily diet support tab generic sm folic acid 400 mcg tab generic sm hair/skin/nails tab generic sm opti-vitamins 1000-60-2 tab generic sm vitamin b-12 100 mcg tab generic PAGE 113 LIMITS & RESTRICTIONS PA PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS stress 500 b-complex tab generic PA stress 500 b-complex/zinc tab generic stress b-complex/c/zinc tab generic stress formula tab generic stresstabs advanced tab generic sunvite active adult 50+ tab generic sunvite advanced 18-400-300 tab generic super 28 formula tab generic super antioxidant tab generic super aytinal 50 plus tab generic super aytinal tab generic super b-complex/vit c/fa 400 mcg tab generic PA super b-complex/vit c/fa tab generic PA super multiple 400 mcg tab generic super nu-thera tab generic super thera vite m tab generic super vikaps tab generic super vita-mins tab generic sure guard anti-oxidant plus tab generic sure guard multi vit/mineral tab generic tab-a-vite maximum tab generic tgt multivitamin/multimineral tab generic th complete multi 18-500-300 tab generic th complete multi 50+ 500-300mcg tab generic th folic acid 400 mcg tab generic th premium daily multiple 18mg-0.4mg tab generic th theradex-m 9mg-400mcg tab generic th vision vitamins 1000-60-2 tab generic th vitamin b12 100 mcg tab generic PRODUCT DESCRIPTION PAGE 114 PA PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE th womens daily 27mg-400 tab generic thera vital m tab generic thera vital-m tab generic thera-m 27mg-0.4mg tab generic thera-m 9mg-400mcg tab generic thera-m tab generic thera-m tabs generic thera-mill m tab generic therabasic-m tab generic theradex m tab generic theradex m/beta carotene tab generic therapeutic formula/hematinics tab generic therapeutic m 27mg-0.4mg tab generic therapeutic multivit/mineral 27mg-0.4mg tab generic therapeutic-m tab generic therapeutic-m 9mg-0.4mg tab generic therapeutic-m/lutein 0.4mg-250 tab generic theratrum complete 50 plus tab generic theratrum complete tab generic theravim-m 27mg-0.4mg tab generic thrive for life womens tab generic total formula 2 tab generic total formula 3 tab generic total formula tab generic trueplus diabetic multivitamin 500-10 mcg tab generic ultra antioxidant formula tab generic ultra freeda 267 mcg tab generic ultra freeda/iron 6mg-267mcg tab generic ultra vita-time tab generic ultrachoice adv formula mature tab generic PAGE 115 LIMITS & RESTRICTIONS LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE ultrachoice advanced formula tab generic vision formula 2 tab generic vision formula/lutein 1000-60-2 tab generic vision vitamins tab generic visivites tab generic visivites/lutein tab generic vita hair tab generic vita-bee/c tab generic vitabasic complete tab generic vitabasic senior tab generic vitamin b-12 100 mcg tab generic vitamin b-12 50 mcg tab generic vitamin b12 100 mcg tab generic vitamins a-d-e/selenium 10000-400 tab generic vitamins/minerals tab generic vitatrum .4-18-3500 chew tab generic vitatrum complete 18mg-0.4mg tab generic vitatrum complete tab generic viteyes companion/lycopene tab generic vitrum senior tab generic womens daily form/fa/ca/fe 27mg-0.4mg tab generic womens daily formula tab generic womens life pack tab generic womens multivitamin tab generic womens multivitamin plus tab generic womens one daily 27mg-0.4mg tab generic yl folic acid 400 mcg tab generic your life multi mens 50+ tab generic your life multi womens 50+ tab generic PAGE 116 LIMITS & RESTRICTIONS PA PA PA PA LAST UPDATED 04/2017 LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS ANALGESICS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS celecoxib 100 mg cap generic MDD 2 per day celecoxib 200 mg cap generic MDD 2 per day celecoxib 400 mg cap generic MDD 2 per day celecoxib 50 mg cap generic MDD 2 per day diclofenac potassium 50 mg tab generic diclofenac sodium 1.5 % solution generic diclofenac sodium 25 mg tab dr generic diclofenac sodium er 100 mg tab er 24h generic diclofenac-misoprostol 50-0.2 mg tab dr generic DUEXIS 800-26.6 MG TAB ibuprofen-famotidine BRAND C Non-Formulary Drug EQUAGESIC 200-325 MG TAB meprobamate-aspirin BRAND C Non-Formulary Drug etodolac 200 mg cap generic etodolac er 400 mg tab er 24h generic etodolac er 500 mg tab er 24h generic fenoprofen calcium 400 mg cap generic FLECTOR 1.3 % PATCH diclofenac epolamine BRAND ibu 800 mg tabs generic ibuprofen 100 mg/5ml suspension generic ibuprofen 400 mg tab generic ibuprofen 600 mg tab generic ibuprofen 800 mg tab generic INDOCIN 25 MG/5ML SUSPENSION indomethacin BRAND indomethacin 50 mg cap generic PAGE 117 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS ketoprofen 50 mg cap generic klofensaid ii 1.5 % solution generic mefenamic acid 250 mg cap generic C meloxicam 7.5 mg tab generic MDD NAPRELAN 750 MG TAB ER 24H naproxen sodium BRAND naproxen 125 mg/5ml suspension generic naproxen 500 mg tab generic naproxen dr 375 mg tab dr generic naproxen kit 500 mg tab generic naproxen sodium 550 mg tab generic naproxen sodium er 500 mg tab er 24h generic piroxicam 10 mg cap generic SPRIX 15.75 MG/SPRAY SOLUTION ketorolac tromethamine BRAND tolmetin sodium 400 mg cap generic VIMOVO 375-20 MG TAB DR naproxen-esomeprazole magnesium BRAND VIMOVO 500-20 MG TAB DR naproxen-esomeprazole magnesium BRAND ZIPSOR 25 MG CAP diclofenac potassium C Non-Formulary Drug 2 per day Non-Formulary Drug PA C Non-Formulary Drug PA C Non-Formulary Drug BRAND C Non-Formulary Drug ZORVOLEX 18 MG CAP diclofenac BRAND C Non-Formulary Drug ZORVOLEX 35 MG CAP diclofenac BRAND C Non-Formulary Drug OPIOID ANALGESICS, LONG-ACTING EMBEDA 20-0.8 MG CAP ER morphine-naltrexone BRAND EMBEDA 50-2 MG CAP ER morphine-naltrexone BRAND fentanyl 75 mcg/hr patch 72hr generic PA PA MDD PAGE 118 0.5 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PA hydromorphone hcl er 16 mg tb24 deter generic MDD QL HYSINGLA ER 100 MG TB24 DETER hydrocodone bitartrate BRAND 1 per day 30 / 30 days PA MDD QL 1 per day 30 / 30 days HYSINGLA ER 60 MG TB24 DETER hydrocodone bitartrate BRAND HYSINGLA ER 80 MG TB24 DETER hydrocodone bitartrate BRAND methadone hcl 10 mg/5ml solution generic PA methadone hcl 10 mg/ml conc generic PA methadone hcl 40 mg tab sol generic PA methadone hcl 5 mg tab generic methadone hcl 5 mg/5ml solution generic PA methadone hcl intensol 10 mg/ml conc generic PA methadose 40 mg tab sol generic PA morphine sulfate er 100 mg cap er 24h generic morphine sulfate er 100 mg tab er generic morphine sulfate er (tab 15 mg, tab 30 mg, tab 60 mg, tab 100 mg, tab 200 mg) generic morphine sulfate er 15 mg tab er generic PA morphine sulfate er (tab 15 mg, tab 30 mg, tab 60 mg, tab 100 mg, tab 200 mg) generic PA morphine sulfate er 200 mg tab er generic PA morphine sulfate er (tab 15 mg, tab 30 mg, tab 60 mg, tab 100 mg, tab 200 mg) generic PA morphine sulfate er 60 mg cap er 24h generic PA morphine sulfate er beads 45 mg cap er 24h generic MDD 1 per day morphine sulfate er beads 60 mg cap er 24h generic MDD 1 per day PAGE 119 MDD QL MDD 1 per day 30 / 30 days 1 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PA morphine sulfate er beads 90 mg cap er 24h generic MDD NUCYNTA ER 100 MG TAB ER 12H tapentadol hcl QL BRAND MDD QL NUCYNTA ER 200 MG TAB ER 12H tapentadol hcl BRAND QL BRAND OPANA ER 20 MG TB12 DETER oxymorphone hcl BRAND OPANA ER 40 MG TB12 DETER oxymorphone hcl BRAND oxycodone hcl er 15 mg tb12 deter generic 60 / 30 days 2 per day 60 / 30 days PA MDD NUCYNTA ER 50 MG TAB ER 12H tapentadol hcl 1 per day MDD 2 per day 60 / 30 days 2 per day PA PA MDD 3 per day 6 per day oxycodone hcl er 80 mg tb12 deter generic MDD tramadol hcl er (biphasic) 100 mg tab er 24h generic C Non-Formulary Drug tramadol hcl er (biphasic) 200 mg tab er 24h generic C Non-Formulary Drug tramadol hcl er (biphasic) 300 mg tab er 24h generic C Non-Formulary Drug QL tramadol hcl er 100 mg tab er 24h generic PA MDD QL tramadol hcl er 300 mg tab er 24h generic 2 per day 30 / 30 days PA MDD 2 per day PA ZOHYDRO ER 10 MG CP12 DETER hydrocodone bitartrate BRAND ZOHYDRO ER 15 MG CP12 DETER hydrocodone bitartrate BRAND ZOHYDRO ER 20 MG CAP ER 12H hydrocodone bitartrate BRAND PAGE 120 30 / 30 days MDD 1 per day PA MDD C 1 per day Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PA ZOHYDRO ER 20 MG CP12 DETER hydrocodone bitartrate BRAND ZOHYDRO ER 30 MG CAP ER 12H hydrocodone bitartrate BRAND ZOHYDRO ER 30 MG CP12 DETER hydrocodone bitartrate BRAND ZOHYDRO ER 40 MG CAP ER 12H hydrocodone bitartrate BRAND ZOHYDRO ER 40 MG CP12 DETER hydrocodone bitartrate BRAND ZOHYDRO ER 50 MG CAP ER 12H hydrocodone bitartrate BRAND ZOHYDRO ER 50 MG CP12 DETER hydrocodone bitartrate BRAND MDD C 1 per day Non-Formulary Drug PA MDD C 2 per day Non-Formulary Drug PA MDD C 2 per day Non-Formulary Drug PA MDD 2 per day MDD 1 per day OPIOID ANALGESICS, SHORT-ACTING ABSTRAL 400 MCG SL TAB fentanyl citrate BRAND ABSTRAL 800 MCG SL TAB fentanyl citrate BRAND acetaminophen-codeine 120-12 mg/5ml solution generic ascomp-codeine 50-325-40-30 mg cap generic aspirin-caff-dihydrocodeine 356.4-30-16 mg cap generic C belladonna alkaloids-opium 16.2-60 mg suppos generic PA belladonna-opium 16.2-30 mg suppos generic C Non-Formulary Drug butalbital compound/codeine 50-325-40-30 mg cap generic butalbital-apap-caff-cod 50-325-40-30 mg cap generic butalbital-asa-caff-codeine 50-325-40-30 mg cap generic carisoprodol-aspirin-codeine 200-325-16 mg tab generic C Non-Formulary Drug co-gesic 5-500 mg tab generic codeine sulfate 30 mg tab generic PAGE 121 PA MDD 1 per day Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS codeine sulfate 60 mg tab generic codeine sulfate 60 mg tabs generic endocet 10-325 mg tab generic endocet 7.5-325 mg tab generic fentanyl citrate 1600 mcg loz handle generic MDD 1 per day fentanyl citrate 400 mcg loz handle generic MDD 1 per day fentanyl citrate 600 mcg loz handle generic PA FENTORA 200 MCG TAB fentanyl citrate BRAND FENTORA 400 MCG TAB fentanyl citrate BRAND FENTORA 600 MCG TAB fentanyl citrate BRAND FENTORA 800 MCG TAB fentanyl citrate BRAND hydrocodone-acetaminophen 10-300 mg tab generic hydrocodone-acetaminophen 10-325 mg/15ml solution generic hydrocodone-acetaminophen 10-660 mg tab generic hydrocodone-acetaminophen 10-750 mg tab generic hydrocodone-acetaminophen 2.5-108 mg/5ml solution MDD 1 per day MDD 1 per day PA MDD 1 per day PA MDD 1 per day PA MDD 1 per day C Non-Formulary Drug generic C Non-Formulary Drug hydrocodone-acetaminophen 5-217 mg/10ml solution generic C Non-Formulary Drug hydrocodone-acetaminophen 5-300 mg tab generic C Non-Formulary Drug hydrocodone-acetaminophen 5-500 mg tab generic hydrocodone-acetaminophen 7.5-300 mg tab generic C Non-Formulary Drug hydrocodone-acetaminophen 7.5-325 mg tab generic hydrocodone-acetaminophen 7.5-325 mg/15ml solution generic C Non-Formulary Drug hydrocodone-acetaminophen 7.5-500 mg/15ml soln generic hydrocodone-acetaminophen 7.5-500 mg/15ml solution generic PAGE 122 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS hydrocodone-ibuprofen 10-200 mg tab generic C Non-Formulary Drug hydrocodone-ibuprofen 2.5-200 mg tab generic C Non-Formulary Drug hydrocodone-ibuprofen 5-200 mg tab generic C Non-Formulary Drug hydrocodone-ibuprofen 7.5-200 mg tab generic hydromorphone hcl 4 mg tab generic ibudone 5-200 mg tab generic C Non-Formulary Drug LAZANDA 100 MCG/ACT SOLUTION fentanyl citrate BRAND C Non-Formulary Drug LAZANDA 400 MCG/ACT SOLUTION fentanyl citrate BRAND C Non-Formulary Drug lorcet plus 7.5-325 mg tab generic lortab 7.5-325 mg tab generic meperidine hcl 100 mg tab generic C Non-Formulary Drug meperidine hcl 50 mg tab generic C Non-Formulary Drug meperidine hcl 50 mg/5ml solution generic C Non-Formulary Drug meperitab 50 mg tab generic C Non-Formulary Drug morphine sulfate (concentrate) 10 mg/0.5ml solution generic morphine sulfate (concentrate) 100 mg/5ml solution generic morphine sulfate (concentrate) 20 mg/ml solution generic morphine sulfate 10 mg suppos generic morphine sulfate 10 mg/5ml solution generic morphine sulfate 20 mg suppos generic morphine sulfate 30 mg suppos generic morphine sulfate 30 mg tab generic OXAYDO 5 MG TAB DETER oxycodone hcl BRAND C Non-Formulary Drug OXAYDO 7.5 MG TAB DETER oxycodone hcl BRAND C Non-Formulary Drug OXECTA 5 MG TAB DETER oxycodone hcl BRAND C Non-Formulary Drug OXECTA 7.5 MG TAB DETER oxycodone hcl BRAND C Non-Formulary Drug PAGE 123 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS oxycodone hcl 15 mg tab generic oxycodone hcl 20 mg tab generic oxycodone hcl 30 mg tab generic oxycodone-acetaminophen 10-325 mg tab generic oxycodone-acetaminophen 2.5-325 mg tab generic OXYCODONE-ACETAMINOPHEN 5-325 MG/5ML SOLUTION oxycodone w/ acetaminophen BRAND oxycodone-acetaminophen 7.5-325 mg tab generic oxymorphone hcl 5 mg tab generic pentazocine-naloxone hcl 50-0.5 mg tab generic PRIMLEV 10-300 MG TAB oxycodone w/ acetaminophen BRAND PA PRIMLEV 5-300 MG TAB oxycodone w/ acetaminophen BRAND PA PRIMLEV 7.5-300 MG TAB oxycodone w/ acetaminophen BRAND PA reprexain 10-200 mg tab generic C ROXICET 5-325 MG/5ML SOLUTION oxycodone w/ acetaminophen BRAND tramadol-acetaminophen 37.5-325 mg tab generic TREZIX 356.4-30-16 MG CAP acetaminophen-caff-dihydrocod BRAND vicodin 5-300 mg tab generic C Non-Formulary Drug vicodin es 7.5-300 mg tab generic C Non-Formulary Drug vicodin hp 10-300 mg tab generic C Non-Formulary Drug vicodin hp 10-660 mg tab generic XARTEMIS XR 7.5-325 MG TAB ER oxycodone w/ acetaminophen BRAND C Non-Formulary Drug XOLOX 10-500 MG TAB oxycodone w/ acetaminophen BRAND xylon 10-200 mg tab generic C Non-Formulary Drug PAGE 124 C MDD Non-Formulary Drug Non-Formulary Drug 10 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS zamicet 10-325 mg/15ml solution generic ZYDONE 10-400 MG TAB hydrocodone-acetaminophen BRAND C Non-Formulary Drug ZYDONE 5-400 MG TAB hydrocodone-acetaminophen BRAND C Non-Formulary Drug ZYDONE 7.5-400 MG TAB hydrocodone-acetaminophen BRAND C Non-Formulary Drug generic PA ANESTHETICS LOCAL ANESTHETICS lidocaine-prilocaine 2.5-2.5 % cream ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ANTI-CRAVING disulfiram 250 mg tab generic OPIOID DEPENDENCE TREATMENTS buprenorphine hcl 2 mg sl tab generic C Non-Formulary Drug buprenorphine hcl 8 mg sl tab generic C Non-Formulary Drug buprenorphine hcl-naloxone hcl 2-0.5 mg sl tab generic C Non-Formulary Drug buprenorphine hcl-naloxone hcl 8-2 mg sl tab generic C Non-Formulary Drug ZUBSOLV 1.4-0.36 MG SL TAB buprenorphine hcl-naloxone hcl dihydrate BRAND C Non-Formulary Drug ZUBSOLV 5.7-1.4 MG SL TAB buprenorphine hcl-naloxone hcl dihydrate BRAND C Non-Formulary Drug NICOTROL 10 MG INHALER nicotine BRAND C Non-Formulary Drug NICOTROL NS 10 MG/ML SOLUTION nicotine BRAND C Non-Formulary Drug C Non-Formulary Drug SMOKING CESSATION AGENTS ANTIBACTERIALS AMINOGLYCOSIDES gentamicin sulfate 0.1 % ointment generic paromomycin sulfate 250 mg cap generic PAGE 125 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS tobramycin 0.3 % solution generic tobrasol 0.3 % solution generic YODOXIN 210 MG TAB iodoquinol BRAND C Non-Formulary Drug YODOXIN 650 MG TAB iodoquinol BRAND C Non-Formulary Drug acetic acid 0.25 % solution generic PA BACTROBAN NASAL 2 % OINTMENT mupirocin calcium BRAND C CLEOCIN 100 MG SUPPOS clindamycin phosphate vaginal BRAND PA clindamycin hcl 75 mg cap generic clindamycin palmitate hcl 75 mg/5ml recon soln generic clindamycin phosphate 1 % lotion generic e.s.p. 200-600 mg/5ml recon susp generic C Non-Formulary Drug erythromycin-sulfisoxazole 200-600 mg/5ml recon susp generic C Non-Formulary Drug FIRST-VANCOMYCIN 25 25 MG/ML SOLUTION vancomycin hcl BRAND PA FLAGYL ER 750 MG TAB ER 24H metronidazole BRAND hyolev mb 81 mg tab generic methenamine hippurate 1 gm tab generic methenamine mandelate 0.5 gm tab generic methenamine mandelate 1 gm tab generic metronidazole gel 0.75 % generic metronidazole 250 mg tab generic metronidazole 250 mg tabs generic mupirocin 2 % ointment generic neomycin-polymyxin b gu 40-200000 solution generic nitrofurantoin macrocrystal 25 mg cap generic nitrofurantoin macrocrystal 50 mg cap generic ANTIBACTERIALS, OTHER PAGE 126 Non-Formulary Drug PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE nitrofurantoin monohyd macro 100 mg cap generic PRIMSOL 50 MG/5ML SOLUTION trimethoprim hcl BRAND metronidazole gel 0.75 % generic tinidazole 500 mg tab generic urelle 81 mg tab generic uro-458 81 mg tab generic uro-l 81 mg tab generic uroav-81 81 mg tab generic vancomycin hcl 125 mg cap LIMITS & RESTRICTIONS C Non-Formulary Drug generic C Non-Formulary Drug vancomycin hcl 250 mg cap generic C Non-Formulary Drug XIFAXAN 200 MG TAB rifaximin BRAND PA XIFAXAN 550 MG TAB rifaximin BRAND PA CEDAX 180 MG/5ML RECON SUSP ceftibuten BRAND C Non-Formulary Drug CEDAX 400 MG CAP ceftibuten BRAND C Non-Formulary Drug CEDAX 90 MG/5ML RECON SUSP ceftibuten BRAND C Non-Formulary Drug cefaclor 125 mg/5ml recon susp generic C Non-Formulary Drug cefaclor 250 mg cap generic C Non-Formulary Drug cefaclor 250 mg/5ml recon susp generic C Non-Formulary Drug cefaclor 375 mg/5ml recon susp generic C Non-Formulary Drug cefaclor 500 mg cap generic C Non-Formulary Drug cefaclor 500 mg caps generic C Non-Formulary Drug cefaclor er 500 mg tab er 12h generic C Non-Formulary Drug cefadroxil 1 gm tab generic cefadroxil 250 mg/5ml recon susp generic BETA-LACTAM, CEPHALOSPORINS PAGE 127 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS cefadroxil 500 mg/5ml recon susp generic cefdinir 250 mg/5ml recon susp generic cefditoren pivoxil 200 mg tab generic C Non-Formulary Drug cefditoren pivoxil 400 mg tab generic C Non-Formulary Drug cefixime 100 mg/5ml recon susp generic C Non-Formulary Drug cefixime 200 mg/5ml recon susp generic C Non-Formulary Drug cefpodoxime proxetil 100 mg tab generic C Non-Formulary Drug cefpodoxime proxetil 100 mg/5ml recon susp generic C Non-Formulary Drug cefpodoxime proxetil 200 mg tab generic C Non-Formulary Drug cefpodoxime proxetil 50 mg/5ml recon susp generic C Non-Formulary Drug cefprozil 500 mg tab generic CEFTIBUTEN 180 MG/5ML RECON SUSP ceftibuten BRAND C Non-Formulary Drug CEFTIBUTEN 400 MG CAP ceftibuten BRAND C Non-Formulary Drug cefuroxime axetil 250 mg tab generic cephalexin 125 mg/5ml recon susp generic cephalexin 250 mg cap generic cephalexin 500 mg cap generic cephalexin 750 mg cap generic SUPRAX 100 MG CHEW TAB cefixime BRAND C Non-Formulary Drug SUPRAX 200 MG CHEW TAB cefixime BRAND C Non-Formulary Drug SUPRAX 400 MG CAP cefixime BRAND C Non-Formulary Drug SUPRAX 400 MG TAB cefixime BRAND C Non-Formulary Drug C Non-Formulary Drug BETA-LACTAM, PENICILLINS amoxicillin 875 mg tab generic AMOXICILLIN ER 775 MG TAB ER 24H amoxicillin BRAND PAGE 128 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE amoxicillin-pot clavulanate 200-28.5 mg chew tab generic amoxicillin-pot clavulanate 250-125 mg tab generic amoxicillin-pot clavulanate 600-42.9 mg/5ml recon susp generic AMPICILLIN 250 MG/5ML RECON SUSP ampicillin BRAND ampicillin 500 mg cap generic AUGMENTIN 125-31.25 MG/5ML RECON SUSP amoxicillin & pot clavulanate BRAND dicloxacillin sodium 500 mg cap generic MOXATAG 775 MG TAB ER 24H amoxicillin BRAND penicillin v potassium 125 mg/5ml recon soln generic penicillin v potassium 250 mg tab generic penicillin v potassium 250 mg/5ml recon soln generic LIMITS & RESTRICTIONS C Non-Formulary Drug C Non-Formulary Drug MACROLIDES AKNE-MYCIN 2 % OINTMENT erythromycin (acne aid) BRAND AZASITE 1 % SOLUTION azithromycin (ophth) BRAND azithromycin 1 gm packet generic azithromycin 200 mg/5ml recon susp generic azithromycin 250 mg tab generic azithromycin 600 mg tab generic clarithromycin 250 mg tab generic clarithromycin 250 mg/5ml recon susp generic DIFICID 200 MG TAB fidaxomicin PA C Non-Formulary Drug BRAND C Non-Formulary Drug ery 2 % pad generic PA ERY-TAB 250 MG TAB DR erythromycin base BRAND ERY-TAB 333 MG TAB DR erythromycin base BRAND ERYPED 400 400 MG/5ML RECON SUSP erythromycin ethylsuccinate BRAND PAGE 129 C Non-Formulary Drug LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS erythromycin 2 % pad generic PA erythromycin 5 mg/gm ointment generic erythromycin base 500 mg tab generic erythromycin ethylsuccinate 200 mg/5ml recon susp generic ilotycin 5 mg/gm ointment generic PCE 333 MG TAB DR erythromycin base (coated) BRAND romycin 5 mg/gm ointment generic ZMAX 2 GM RECON SUSP azithromycin BRAND C Non-Formulary Drug ZMAX 2 GM SUSR azithromycin BRAND C Non-Formulary Drug ZMAX PEDIATRIC 2 GM SUSR azithromycin BRAND C Non-Formulary Drug PRODUCT DESCRIPTION QUINOLONES CILOXAN 0.3 % OINTMENT ciprofloxacin hcl (ophth) BRAND ciprofloxacin 250 mg/5ml (5%) recon susp generic ciprofloxacin hcl 0.2 % solution generic C Non-Formulary Drug ciprofloxacin-ciproflox hcl er 1000 mg tab er 24h generic C Non-Formulary Drug FACTIVE 320 MG TAB gemifloxacin mesylate BRAND C Non-Formulary Drug gatifloxacin 0.5 % solution generic C Non-Formulary Drug levofloxacin 0.5 % solution generic PA levofloxacin 250 mg tab generic MDD 1 per day levofloxacin 750 mg tab generic MDD 1 per day NOROXIN 400 MG TAB norfloxacin BRAND C ofloxacin 0.3 % solution generic ofloxacin 0.3 % solution generic PA ofloxacin 200 mg tab generic C PAGE 130 Non-Formulary Drug Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS ofloxacin 200 mg tabs generic C Non-Formulary Drug ofloxacin 300 mg tab generic C Non-Formulary Drug ofloxacin 400 mg tab generic C Non-Formulary Drug VIGAMOX 0.5 % SOLUTION moxifloxacin hcl (ophth) BRAND PA AVC VAGINAL 15 % CREAM sulfanilamide vaginal BRAND PA silver sulfadiazine 1 % cream generic ssd 1 % cream generic ssd af 1 % cream generic sulfadiazine 500 mg tab generic thermazene 1 % cream generic SULFONAMIDES C Non-Formulary Drug TETRACYCLINES ACTICLATE 150 MG TAB doxycycline hyclate BRAND C Non-Formulary Drug ACTICLATE 75 MG TAB doxycycline hyclate BRAND C Non-Formulary Drug avidoxy 100 mg tab generic demeclocycline hcl 150 mg tab generic C Non-Formulary Drug demeclocycline hcl 300 mg tab generic C Non-Formulary Drug DOXYCYCLINE 40 MG CAP DR doxycycline (rosacea) BRAND C Non-Formulary Drug doxycycline hyclate 100 mg tab generic doxycycline hyclate 100 mg tab dr generic C Non-Formulary Drug doxycycline hyclate 150 mg tab dr generic C Non-Formulary Drug doxycycline hyclate 20 mg tab generic C Non-Formulary Drug doxycycline hyclate 200 mg tab dr generic C Non-Formulary Drug doxycycline hyclate 50 mg tab dr generic C Non-Formulary Drug doxycycline hyclate 75 mg tab dr generic C Non-Formulary Drug PAGE 131 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE doxycycline monohydrate 100 mg tab generic doxycycline monohydrate 150 mg cap generic doxycycline monohydrate 150 mg tab generic doxycycline monohydrate 25 mg/5ml recon susp generic doxycycline monohydrate 75 mg cap generic minocycline hcl 100 mg tab LIMITS & RESTRICTIONS C Non-Formulary Drug C Non-Formulary Drug generic C Non-Formulary Drug minocycline hcl 50 mg tab generic C Non-Formulary Drug minocycline hcl 75 mg tab generic C Non-Formulary Drug minocycline hcl er 135 mg tab er 24h generic PA minocycline hcl er 45 mg tab er 24h generic minocycline hcl er 90 mg tab er 24h generic mondoxyne nl 75 mg cap generic ORACEA 40 MG CAP DR doxycycline (rosacea) BRAND C Non-Formulary Drug ORAXYL 20 MG CAP doxycycline hyclate BRAND C Non-Formulary Drug SOLODYN 105 MG TAB ER 24H minocycline hcl BRAND C Non-Formulary Drug SOLODYN 115 MG TAB ER 24H minocycline hcl BRAND C Non-Formulary Drug SOLODYN 55 MG TAB ER 24H minocycline hcl BRAND C Non-Formulary Drug SOLODYN 65 MG TAB ER 24H minocycline hcl BRAND C Non-Formulary Drug SOLODYN 80 MG TAB ER 24H minocycline hcl BRAND C Non-Formulary Drug TARGADOX 50 MG TAB doxycycline hyclate BRAND C Non-Formulary Drug tetracycline hcl 500 mg cap generic tetracycline hcl 500 mg caps generic VIBRAMYCIN 50 MG/5ML SYRUP doxycycline calcium BRAND C Non-Formulary Drug PAGE 132 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS ANTICONVULSANTS ANTICONVULSANTS, OTHER FYCOMPA 2 MG TAB perampanel BRAND FYCOMPA 4 MG TAB perampanel BRAND levetiracetam 500 mg tab generic levetiracetam 750 mg tab generic PA POTIGA 400 MG TAB ezogabine BRAND PA roweepra 500 mg tab generic PA CALCIUM CHANNEL MODIFYING AGENTS ethosuximide 250 mg cap generic PA ethosuximide 250 mg/5ml solution generic PA GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS diazepam 2.5 mg gel generic diazepam 20 mg gel generic divalproex sodium 125 mg cap dr generic divalproex sodium 125 mg cap sprink generic gabapentin 100 mg cap generic gabapentin 400 mg cap generic gabapentin 600 mg tab generic gabapentin 800 mg tab generic GABITRIL 12 MG TAB tiagabine hcl BRAND PA GRALISE 300 MG TAB gabapentin (once-daily) BRAND C Non-Formulary Drug GRALISE 600 MG TAB gabapentin (once-daily) BRAND C Non-Formulary Drug GRALISE STARTER 300 & 600 MG MISC gabapentin (once-daily) BRAND C Non-Formulary Drug ONFI 2.5 MG/ML SUSPENSION clobazam BRAND PA PAGE 133 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS ONFI 20 MG TAB clobazam BRAND phenobarbital 15 mg tab generic PA phenobarbital 30 mg tab generic PA primidone 50 mg tab generic SABRIL 500 MG PACKET vigabatrin BRAND C Non-Formulary Drug SABRIL 500 MG TAB vigabatrin BRAND C Non-Formulary Drug STAVZOR 250 MG CAP DR valproic acid BRAND tiagabine hcl 2 mg tab generic tiagabine hcl 4 mg tab generic PA GLUTAMATE REDUCING AGENTS felbamate 400 mg tab generic PA lamotrigine 100 mg tab disp generic PA lamotrigine 5 mg chew tab generic PA topiragen 200 mg tab generic topiragen 50 mg tab generic PA topiramate 15 mg cap sprink generic PA topiramate 200 mg tab generic topiramate 50 mg tab generic PA TROKENDI XR 100 MG CAP ER 24H topiramate BRAND C Non-Formulary Drug TROKENDI XR 200 MG CAP ER 24H topiramate BRAND C Non-Formulary Drug TROKENDI XR 25 MG CAP ER 24H topiramate BRAND C Non-Formulary Drug TROKENDI XR 50 MG CAP ER 24H topiramate BRAND C Non-Formulary Drug PAGE 134 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS SODIUM CHANNEL AGENTS APTIOM 400 MG TAB eslicarbazepine acetate BRAND APTIOM 600 MG TAB eslicarbazepine acetate BRAND BANZEL 200 MG TAB rufinamide BRAND C Non-Formulary Drug BANZEL 40 MG/ML SUSPENSION rufinamide BRAND C Non-Formulary Drug BANZEL 400 MG TAB rufinamide BRAND C Non-Formulary Drug carbamazepine 100 mg/5ml suspension generic PA carbamazepine er 300 mg cap er 12h generic carbamazepine er 400 mg tab er 12h generic oxcarbazepine 150 mg tab generic OXTELLAR XR 150 MG TAB ER 24H oxcarbazepine BRAND C Non-Formulary Drug OXTELLAR XR 300 MG TAB ER 24H oxcarbazepine BRAND C Non-Formulary Drug OXTELLAR XR 600 MG TAB ER 24H oxcarbazepine BRAND C Non-Formulary Drug PEGANONE 250 MG TAB ethotoin BRAND C Non-Formulary Drug phenytoin sodium extended 200 mg cap generic VIMPAT 100 MG TAB lacosamide BRAND VIMPAT 150 MG TAB lacosamide BRAND PA VIMPAT 200 MG TAB lacosamide BRAND PA donepezil hcl 10 mg tab generic C Non-Formulary Drug donepezil hcl 10 mg tab disp generic C Non-Formulary Drug ANTIDEMENTIA AGENTS CHOLINESTERASE INHIBITORS PAGE 135 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS donepezil hcl 23 mg tab generic C Non-Formulary Drug donepezil hcl 5 mg tab generic C Non-Formulary Drug donepezil hcl 5 mg tab disp generic C Non-Formulary Drug EXELON 2 MG/ML SOLUTION rivastigmine tartrate BRAND C Non-Formulary Drug galantamine hydrobromide 12 mg tab generic C Non-Formulary Drug galantamine hydrobromide 4 mg tab generic C Non-Formulary Drug galantamine hydrobromide 4 mg/ml solution generic C Non-Formulary Drug galantamine hydrobromide 8 mg tab generic C Non-Formulary Drug galantamine hydrobromide er 16 mg cap er 24h generic C Non-Formulary Drug galantamine hydrobromide er 24 mg cap er 24h generic C Non-Formulary Drug galantamine hydrobromide er 8 mg cap er 24h generic C Non-Formulary Drug rivastigmine tartrate 1.5 mg cap generic C Non-Formulary Drug rivastigmine tartrate 3 mg cap generic C Non-Formulary Drug rivastigmine tartrate 4.5 mg cap generic C Non-Formulary Drug rivastigmine tartrate 6 mg cap generic C Non-Formulary Drug N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST PA memantine hcl 10 mg tab generic MDD 2 per day NAMENDA XR 14 MG CAP ER 24H memantine hcl BRAND C Non-Formulary Drug NAMENDA XR 21 MG CAP ER 24H memantine hcl BRAND C Non-Formulary Drug NAMENDA XR 28 MG CAP ER 24H memantine hcl BRAND C Non-Formulary Drug NAMENDA XR 7 MG CAP ER 24H memantine hcl BRAND C Non-Formulary Drug PAGE 136 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER APLENZIN 174 MG TAB ER 24H bupropion hydrobromide BRAND C Non-Formulary Drug APLENZIN 348 MG TAB ER 24H bupropion hydrobromide BRAND C Non-Formulary Drug APLENZIN 522 MG TAB ER 24H bupropion hydrobromide BRAND C Non-Formulary Drug budeprion xl 300 mg tab er 24h generic MDD bupropion hcl tab sr 12hr 200 mg generic 1 per day PA MDD 2 per day 1 per day bupropion hcl er (xl) 300 mg tab er 24h generic MDD chlordiazepoxide-amitriptyline 10-25 mg tab generic C Non-Formulary Drug chlordiazepoxide-amitriptyline 5-12.5 mg tab generic C Non-Formulary Drug mirtazapine 15 mg tab generic MDD 1 per day mirtazapine 45 mg tab disp generic MDD 1 per day olanzapine-fluoxetine hcl 12-25 mg cap generic C Non-Formulary Drug olanzapine-fluoxetine hcl 12-50 mg cap generic C Non-Formulary Drug olanzapine-fluoxetine hcl 3-25 mg cap generic C Non-Formulary Drug olanzapine-fluoxetine hcl 6-25 mg cap generic C Non-Formulary Drug olanzapine-fluoxetine hcl 6-50 mg cap generic C Non-Formulary Drug perphenazine-amitriptyline 2-10 mg tab generic C Non-Formulary Drug perphenazine-amitriptyline 2-25 mg tab generic C Non-Formulary Drug perphenazine-amitriptyline 4-10 mg tab generic C Non-Formulary Drug perphenazine-amitriptyline 4-25 mg tab generic C Non-Formulary Drug perphenazine-amitriptyline 4-50 mg tab generic C Non-Formulary Drug PAGE 137 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS MONOAMINE OXIDASE INHIBITORS EMSAM 12 MG/24HR PATCH 24HR selegiline BRAND C Non-Formulary Drug EMSAM 6 MG/24HR PATCH 24HR selegiline BRAND C Non-Formulary Drug EMSAM 9 MG/24HR PATCH 24HR selegiline BRAND C Non-Formulary Drug EMSAM 9 MG/24HR PT24 selegiline BRAND C Non-Formulary Drug tranylcypromine sulfate 10 mg tab generic PA SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR BRINTELLIX 10 MG TAB vortioxetine hbr BRAND C Non-Formulary Drug BRINTELLIX 20 MG TAB vortioxetine hbr BRAND C Non-Formulary Drug BRINTELLIX 5 MG TAB vortioxetine hbr BRAND C Non-Formulary Drug BRISDELLE 7.5 MG CAP paroxetine mesylate (vasomotor) BRAND C Non-Formulary Drug citalopram hydrobromide 10 mg/5ml solution generic PA citalopram hydrobromide 20 mg tab generic PA MDD 1 per day DESVENLAFAXINE FUMARATE ER 100 MG TAB ER 24H desvenlafaxine fumarate BRAND C Non-Formulary Drug DESVENLAFAXINE FUMARATE ER 50 MG TAB ER 24H desvenlafaxine fumarate BRAND C Non-Formulary Drug desvenlafaxine succinate er 100 mg tab er 24h generic PA desvenlafaxine succinate er 50 mg tab er 24h generic fluoxetine hcl (pmdd) 10 mg cap generic C Non-Formulary Drug fluoxetine hcl (pmdd) 10 mg tab generic C Non-Formulary Drug fluoxetine hcl (pmdd) 20 mg cap generic C Non-Formulary Drug fluoxetine hcl (pmdd) 20 mg tab generic C Non-Formulary Drug PAGE 138 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PA fluoxetine hcl 20 mg tab generic MDD fluoxetine hcl 20 mg/5ml solution generic fluoxetine hcl 40 mg cap generic 2 per day PA MDD 2 per day fluvoxamine maleate 100 mg tab generic fluvoxamine maleate er 100 mg cap er 24h generic C Non-Formulary Drug fluvoxamine maleate er 150 mg cap er 24h generic C Non-Formulary Drug maprotiline hcl 25 mg tab generic C Non-Formulary Drug maprotiline hcl 50 mg tab generic C Non-Formulary Drug maprotiline hcl 75 mg tab generic C Non-Formulary Drug nefazodone hcl 100 mg tab generic C Non-Formulary Drug nefazodone hcl 150 mg tab generic C Non-Formulary Drug nefazodone hcl 200 mg tab generic C Non-Formulary Drug nefazodone hcl 250 mg tab generic C Non-Formulary Drug nefazodone hcl 50 mg tab generic C Non-Formulary Drug OLEPTRO 150 MG TAB ER 24H trazodone hcl BRAND C Non-Formulary Drug OLEPTRO 300 MG TAB ER 24H trazodone hcl BRAND C Non-Formulary Drug paroxetine hcl 10 mg tab generic PA MDD paroxetine hcl 10 mg/5ml suspension generic paroxetine hcl 20 mg tab generic 1 per day PA PA MDD 1 per day PA paroxetine hcl 30 mg tab generic MDD 1 per day PA paroxetine hcl er 37.5 mg tab er 24h generic MDD PAGE 139 1 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PEXEVA 10 MG TAB paroxetine mesylate BRAND C Non-Formulary Drug PEXEVA 20 MG TAB paroxetine mesylate BRAND C Non-Formulary Drug PEXEVA 30 MG TAB paroxetine mesylate BRAND C Non-Formulary Drug PEXEVA 40 MG TAB paroxetine mesylate BRAND C Non-Formulary Drug selfemra 10 mg cap generic C Non-Formulary Drug selfemra 20 mg cap generic C Non-Formulary Drug trazodone hcl 100 mg tab generic TRINTELLIX 10 MG TAB vortioxetine hbr BRAND C Non-Formulary Drug TRINTELLIX 20 MG TAB vortioxetine hbr BRAND C Non-Formulary Drug TRINTELLIX 5 MG TAB vortioxetine hbr BRAND C Non-Formulary Drug venlafaxine hcl er 150 mg cap er 24h generic venlafaxine hcl er 150 mg tab er 24h generic venlafaxine hcl er 37.5 mg cap er 24h generic venlafaxine hcl er 37.5 mg tab er 24h generic VIIBRYD 10 MG TAB vilazodone hcl BRAND VIIBRYD 20 MG TAB vilazodone hcl BRAND VIIBRYD 40 MG TAB vilazodone hcl BRAND MDD C MDD C MDD 1 per day Non-Formulary Drug 1 per day Non-Formulary Drug 1 per day C Non-Formulary Drug TRICYCLICS amitriptyline hcl 150 mg tab generic amitriptyline hcl 25 mg tab generic amoxapine 100 mg tab generic C Non-Formulary Drug amoxapine 150 mg tab generic C Non-Formulary Drug PAGE 140 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS amoxapine 25 mg tab generic C Non-Formulary Drug amoxapine 50 mg tab generic C Non-Formulary Drug clomipramine hcl 75 mg cap generic desipramine hcl 10 mg tab generic desipramine hcl 25 mg tab generic desipramine hcl 50 mg tab generic doxepin hcl 10 mg cap generic doxepin hcl 10 mg caps generic doxepin hcl 100 mg cap generic doxepin hcl 150 mg cap generic imipramine hcl 25 mg tab generic imipramine hcl 50 mg tab generic imipramine pamoate 100 mg cap generic C Non-Formulary Drug imipramine pamoate 125 mg cap generic C Non-Formulary Drug imipramine pamoate 150 mg cap generic C Non-Formulary Drug imipramine pamoate 75 mg cap generic C Non-Formulary Drug nortriptyline hcl 10 mg/5ml solution generic nortriptyline hcl 75 mg cap generic protriptyline hcl 10 mg tab generic C Non-Formulary Drug protriptyline hcl 5 mg tab generic C Non-Formulary Drug trimipramine maleate 100 mg cap generic C Non-Formulary Drug trimipramine maleate 25 mg cap generic C Non-Formulary Drug trimipramine maleate 50 mg cap generic C Non-Formulary Drug DICLEGIS 10-10 MG TAB DR doxylamine-pyridoxine BRAND C Non-Formulary Drug meclizine hcl 12.5 mg tab generic ANTIEMETICS ANTIEMETICS, OTHER PAGE 141 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS meclizine hcl 25 mg tab generic metoclopramide hcl 5 mg tab generic perphenazine 16 mg tab generic perphenazine 2 mg tab generic PA perphenazine 8 mg tab generic PA prochlorperazine maleate 5 mg tab generic TRANSDERM-SCOP (1.5 MG) 1 MG/3DAYS PATCH 72HR scopolamine BRAND trimethobenzamide hcl 300 mg cap generic EMETOGENIC THERAPY ADJUNCTS ANZEMET 100 MG TAB dolasetron mesylate BRAND aprepitant 125 mg cap generic PA MDD 1 per day PA aprepitant 40 mg cap generic MDD 1 per day dronabinol 10 mg cap generic ondansetron hcl 24 mg tab generic ondansetron hcl 4 mg/5ml solution generic SANCUSO 3.1 MG/24HR PATCH granisetron BRAND VARUBI 90 MG TAB rolapitant hcl BRAND C Non-Formulary Drug ZUPLENZ 4 MG FILM ondansetron BRAND C Non-Formulary Drug ZUPLENZ 8 MG FILM ondansetron BRAND C Non-Formulary Drug BIO-STATIN 1000000 UNIT CAP nystatin BRAND C Non-Formulary Drug BIO-STATIN 500000 UNIT CAP nystatin BRAND C Non-Formulary Drug PA PA ANTIFUNGALS PAGE 142 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PA ciclodan 8 % solution generic MDD ciclopirox 1 % shampoo generic ciclopirox 8 % solution generic 0.24 per day PA PA MDD 0.24 per day clotrimazole 1 % cream generic clotrimazole 10 mg lozenge generic PA clotrimazole 10 mg troche generic PA clotrimazole anti-fungal 1 % cream generic ECOZA 1 % FOAM econazole nitrate BRAND C ERTACZO 2 % CREAM sertaconazole nitrate BRAND PA fluconazole 10 mg/ml recon susp generic fluconazole 150 mg tab generic fluconazole 50 mg tab generic flucytosine 250 mg cap generic C Non-Formulary Drug flucytosine 500 mg cap generic C Non-Formulary Drug griseofulvin microsize 125 mg/5ml suspension generic griseofulvin microsize 500 mg tab generic griseofulvin ultramicrosize 125 mg tab generic C Non-Formulary Drug griseofulvin ultramicrosize 250 mg tab generic C Non-Formulary Drug itraconazole 100 mg cap generic JUBLIA 10 % SOLUTION efinaconazole BRAND C Non-Formulary Drug LAMISIL 125 MG PACKET terbinafine hcl BRAND C Non-Formulary Drug LAMISIL 187.5 MG PACKET terbinafine hcl BRAND C Non-Formulary Drug LUZU 1 % CREAM luliconazole BRAND C Non-Formulary Drug PAGE 143 Non-Formulary Drug LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS MENTAX 1 % CREAM butenafine hcl BRAND PA miconazole 3 200 & 2 mg-% (9gm) kit generic naftifine hcl 2 % cream generic PA NAFTIN 2 % GEL naftifine hcl BRAND PA NOXAFIL 100 MG TAB DR posaconazole BRAND PA nystatin 500000 unit tab generic PA nystatin-triamcinolone 100000-0.1 unit/gm-% ointment generic ONMEL 200 MG TAB itraconazole BRAND C OXISTAT 1 % LOTION oxiconazole nitrate BRAND PA SPORANOX 10 MG/ML SOLUTION itraconazole BRAND C terbinafine hcl 250 mg tab generic terbinafine hcl 250 mg tabs generic terconazole 0.4 % cream generic voriconazole 200 mg tab generic zazole 0.4 % cream generic PRODUCT DESCRIPTION Non-Formulary Drug Non-Formulary Drug PA ANTIGOUT AGENTS colchicine 0.6 mg tab generic PA ULORIC 80 MG TAB febuxostat BRAND PA dihydroergotamine mesylate 4 mg/ml solution generic C ergotamine-caffeine 1-100 mg tab generic PA generic MDD ANTIMIGRAINE AGENTS ERGOT ALKALOIDS Non-Formulary Drug SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS almotriptan malate 12.5 mg tab PAGE 144 0.4 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS frovatriptan succinate 2.5 mg tab generic C naratriptan hcl 1 mg tab generic PA naratriptan hcl 2.5 mg tab generic PA RELPAX 20 MG TAB eletriptan hydrobromide BRAND MDD rizatriptan benzoate orally disintegrating tab 5 mg generic Non-Formulary Drug 0.4 per day PA MDD 0.4 per day PA sumatriptan nasal spray (5 mg/act, 20 mg/act) generic MDD 0.4 per day PA sumatriptan succinate 25 mg tab generic MDD 0.6 per day PA TREXIMET 85-500 MG TAB sumatriptan-naproxen sodium BRAND zolmitriptan 2.5 mg tab generic zolmitriptan 2.5 mg tab disp generic MDD 0.14 per day MDD 0.4 per day PA MDD 0.4 per day ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS MYTELASE 10 MG TAB ambenonium chloride BRAND PA pyridostigmine bromide 60 mg tab generic PA ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER rifabutin 150 mg cap generic ANTITUBERCULARS isoniazid 100 mg tab generic isoniazid 300 mg tab generic PA ISONIAZID 50 MG/5ML SYRUP isoniazid BRAND PA PAGE 145 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PRIFTIN 150 MG TAB rifapentine BRAND C rifampin 300 mg cap generic PA RIFATER 50-120-300 MG TAB isoniazid-rifampin w/ pyrazinamide BRAND PA TRECATOR 250 MG TAB ethionamide BRAND PA cyclophosphamide 25 mg tab generic PA cyclophosphamide 50 mg tab generic PA MYLERAN 2 MG TAB busulfan BRAND PA temozolomide 5 mg cap generic Non-Formulary Drug ANTINEOPLASTICS ALKYLATING AGENTS ANTIANDROGENS flutamide 125 mg cap generic nilutamide 150 mg tab generic ZYTIGA 250 MG TAB abiraterone acetate BRAND PA PA ANTIANGIOGENIC AGENTS POMALYST 2 MG CAP pomalidomide BRAND POMALYST 3 MG CAP pomalidomide BRAND REVLIMID 5 MG CAP lenalidomide BRAND THALOMID 150 MG CAP thalidomide BRAND PA PA ANTIESTROGENS/MODIFIERS FARESTON 60 MG TAB toremifene citrate BRAND tamoxifen citrate 20 mg tab generic PAGE 146 LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS capecitabine 150 mg tab generic PA DROXIA 300 MG CAP hydroxyurea (sickle cell anemia) BRAND PA DROXIA 400 MG CAP hydroxyurea (sickle cell anemia) BRAND mercaptopurine 50 mg tab generic TABLOID 40 MG TAB thioguanine BRAND PRODUCT DESCRIPTION ANTIMETABOLITES PA ANTINEOPLASTICS, OTHER FARYDAK 15 MG CAP panobinostat lactate BRAND FARYDAK 20 MG CAP panobinostat lactate BRAND PA HEMANGEOL 4.28 MG/ML SOLUTION propranolol hcl BRAND C leucovorin calcium 15 mg tab generic PA leucovorin calcium 5 mg tab generic Non-Formulary Drug AROMATASE INHIBITORS, 3RD GENERATION exemestane 25 mg tab generic MOLECULAR TARGET INHIBITORS AFINITOR 10 MG TAB everolimus BRAND AFINITOR 5 MG TAB everolimus BRAND AFINITOR 7.5 MG TAB everolimus BRAND BOSULIF 500 MG TAB bosutinib BRAND PA COMETRIQ (100 MG DAILY DOSE) 1 X 80 & 1 X 20 MG KIT cabozantinib s-malate BRAND PA GILOTRIF 20 MG TAB afatinib dimaleate BRAND PA GILOTRIF 30 MG TAB afatinib dimaleate BRAND PAGE 147 LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS GILOTRIF 40 MG TAB afatinib dimaleate BRAND PA IBRANCE 75 MG CAP palbociclib BRAND ICLUSIG 15 MG TAB ponatinib hcl BRAND PA imatinib mesylate 400 mg tab generic PA IRESSA 250 MG TAB gefitinib BRAND PA JAKAFI 10 MG TAB ruxolitinib phosphate BRAND JAKAFI 15 MG TAB ruxolitinib phosphate BRAND JAKAFI 20 MG TAB ruxolitinib phosphate BRAND JAKAFI 25 MG TAB ruxolitinib phosphate BRAND PA LENVIMA 10 MG DAILY DOSE 10 MG CAP THPK lenvatinib mesylate BRAND PA LENVIMA 20 MG DAILY DOSE 10 (2) MG CAP THPK lenvatinib mesylate BRAND PA MEKINIST 0.5 MG TAB trametinib dimethyl sulfoxide BRAND PA SPRYCEL 140 MG TAB dasatinib BRAND SUTENT 37.5 MG CAP sunitinib malate BRAND PA TARCEVA 100 MG TAB erlotinib hcl BRAND PA TASIGNA 200 MG CAP nilotinib hcl BRAND PA TYKERB 250 MG TAB lapatinib ditosylate BRAND PA VOTRIENT 200 MG TAB pazopanib hcl BRAND XALKORI 200 MG CAP crizotinib BRAND PRODUCT DESCRIPTION PAGE 148 PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION ZYDELIG 150 MG TAB idelalisib BRAND/GENE LIMITS & RESTRICTIONS BRAND RETINOIDS bexarotene 75 mg cap generic PA TARGRETIN 1 % GEL bexarotene (topical) BRAND PA tretinoin 10 mg cap generic ANTIPARASITICS ANTIHELMINTHICS mebendazole 100 mg chew tab generic PA SOOLANTRA 1 % CREAM ivermectin (rosacea) BRAND PA ALINIA 100 MG/5ML RECON SUSP nitazoxanide BRAND PA atovaquone-proguanil hcl 62.5-25 mg tab generic PA chloroquine phosphate 250 mg tab generic PA COARTEM 20-120 MG TAB artemether-lumefantrine BRAND PA DARAPRIM 25 MG TAB pyrimethamine BRAND C hydroxychloroquine sulfate 200 mg tab generic mefloquine hcl 250 mg tab generic primaquine phosphate 26.3 mg tab generic quinine sulfate 324 mg cap generic PA EURAX 10 % CREAM crotamiton BRAND C EURAX 10 % LOTION crotamiton BRAND ANTIPROTOZOALS Non-Formulary Drug PA PEDICULICIDES/SCABICIDES PAGE 149 Non-Formulary Drug PA C Non-Formulary Drug LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS benztropine mesylate 0.5 mg tab generic PA benztropine mesylate 2 mg tab generic PRODUCT DESCRIPTION ANTIPARKINSON AGENTS ANTICHOLINERGICS ANTIPARKINSON AGENTS, OTHER amantadine hcl 100 mg tab generic PA carbidopa-levodopa-entacapone 12.5-50-200 mg tab generic C Non-Formulary Drug carbidopa-levodopa-entacapone 18.75-75-200 mg tab generic C Non-Formulary Drug carbidopa-levodopa-entacapone 25-100-200 mg tab generic C Non-Formulary Drug carbidopa-levodopa-entacapone 31.25-125-200 mg tab generic C Non-Formulary Drug carbidopa-levodopa-entacapone 37.5-150-200 mg tab generic C Non-Formulary Drug carbidopa-levodopa-entacapone 50-200-200 mg tab generic C Non-Formulary Drug tolcapone 100 mg tab generic C Non-Formulary Drug DOPAMINE AGONISTS bromocriptine mesylate 5 mg cap generic bromocriptine mesylate 5 mg cap generic pramipexole dihydrochloride 0.5 mg tab generic pramipexole dihydrochloride 0.75 mg tab generic ropinirole hcl 0.25 mg tab generic ropinirole hcl 0.5 mg tab generic MDD 2 per day PA ropinirole hcl 1 mg tab generic ropinirole hcl er 12 mg tab er 24h generic ropinirole hcl er 6 mg tab er 24h generic MDD 2 per day MDD 2 per day PA DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa 25 mg tab generic carbidopa & levodopa odt 10-100 mg generic PAGE 150 C Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS carbidopa & levodopa odt 25-100 mg generic C Non-Formulary Drug carbidopa-levodopa 25-250 mg tab generic PA carbidopa & levodopa odt 25-250 mg generic C Non-Formulary Drug rasagiline mesylate 0.5 mg tab generic C Non-Formulary Drug rasagiline mesylate 1 mg tab generic C Non-Formulary Drug selegiline hcl 5 mg tab generic PA ZELAPAR 1.25 MG TAB DISP selegiline hcl BRAND PA ADASUVE 10 MG AER POW BA loxapine BRAND C chlorpromazine hcl 25 mg tab generic PA chlorpromazine hcl 50 mg tab generic fluphenazine hcl 1 mg tab generic C Non-Formulary Drug fluphenazine hcl 10 mg tab generic C Non-Formulary Drug fluphenazine hcl 2.5 mg tab generic C Non-Formulary Drug fluphenazine hcl 2.5 mg/5ml elixir generic C Non-Formulary Drug fluphenazine hcl 5 mg tab generic C Non-Formulary Drug fluphenazine hcl 5 mg/ml conc generic C Non-Formulary Drug haloperidol 1 mg tab generic PA haloperidol 2 mg tab generic haloperidol 5 mg tab generic loxapine succinate 10 mg cap generic C Non-Formulary Drug loxapine succinate 25 mg cap generic C Non-Formulary Drug loxapine succinate 5 mg cap generic C Non-Formulary Drug MONOAMINE OXIDASE B (MAO-B) INHIBITORS ANTIPSYCHOTICS 1ST GENERATION/TYPICAL PAGE 151 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS loxapine succinate 50 mg cap generic C Non-Formulary Drug pimozide 1 mg tab generic C Non-Formulary Drug pimozide 2 mg tab generic C Non-Formulary Drug thioridazine hcl 10 mg tab generic C Non-Formulary Drug thioridazine hcl 100 mg tab generic C Non-Formulary Drug thioridazine hcl 25 mg tab generic C Non-Formulary Drug thioridazine hcl 50 mg tab generic C Non-Formulary Drug thiothixene 1 mg cap generic C Non-Formulary Drug thiothixene 10 mg cap generic C Non-Formulary Drug thiothixene 2 mg cap generic C Non-Formulary Drug thiothixene 5 mg cap generic C Non-Formulary Drug trifluoperazine hcl 1 mg tab generic C Non-Formulary Drug trifluoperazine hcl 10 mg tab generic C Non-Formulary Drug trifluoperazine hcl 2 mg tab generic C Non-Formulary Drug trifluoperazine hcl 5 mg tab generic C Non-Formulary Drug aripiprazole 1 mg/ml solution generic PA aripiprazole 10 mg tab generic PA FANAPT 1 MG TAB iloperidone BRAND C Non-Formulary Drug FANAPT 10 MG TAB iloperidone BRAND C Non-Formulary Drug FANAPT 12 MG TAB iloperidone BRAND C Non-Formulary Drug FANAPT 2 MG TAB iloperidone BRAND C Non-Formulary Drug FANAPT 4 MG TAB iloperidone BRAND C Non-Formulary Drug FANAPT 6 MG TAB iloperidone BRAND C Non-Formulary Drug 2ND GENERATION/ATYPICAL PAGE 152 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS FANAPT 8 MG TAB iloperidone BRAND C Non-Formulary Drug FANAPT TITRATION PACK 1 & 2 & 4 & 6 MG TAB iloperidone BRAND C Non-Formulary Drug LATUDA 20 MG TAB lurasidone hcl BRAND C Non-Formulary Drug LATUDA 60 MG TAB lurasidone hcl BRAND C Non-Formulary Drug olanzapine 15 mg tab generic PA MDD 2 per day PA olanzapine 15 mg tab disp generic MDD 2 per day PA olanzapine 2.5 mg tab generic MDD 2 per day paliperidone er 1.5 mg tab er 24h generic C Non-Formulary Drug paliperidone er 3 mg tab er 24h generic C Non-Formulary Drug paliperidone er 6 mg tab er 24h generic C Non-Formulary Drug paliperidone er 9 mg tab er 24h generic C Non-Formulary Drug quetiapine fumarate 200 mg tab generic quetiapine fumarate 300 mg tab generic PA REXULTI 0.25 MG TAB brexpiprazole BRAND PA REXULTI 0.5 MG TAB brexpiprazole BRAND PA REXULTI 1 MG TAB brexpiprazole BRAND PA REXULTI 2 MG TAB brexpiprazole BRAND PA REXULTI 3 MG TAB brexpiprazole BRAND PA REXULTI 4 MG TAB brexpiprazole BRAND PA risperidone orally disintegrating tab 0.25 mg generic MDD PAGE 153 2 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PA risperidone orally disintegrating tab 0.5 mg generic MDD 2 per day risperidone 1 mg tab generic MDD 2 per day risperidone orally disintegrating tab 1 mg generic MDD 2 per day risperidone orally disintegrating tab 2 mg generic MDD 2 per day risperidone orally disintegrating tab 0.5 mg generic PA MDD 2 per day risperidone orally disintegrating tab 1 mg generic MDD 2 per day risperidone orally disintegrating tab 2 mg generic MDD 2 per day SAPHRIS 10 MG SL TAB asenapine maleate BRAND C Non-Formulary Drug SAPHRIS 5 MG SL TAB asenapine maleate BRAND C Non-Formulary Drug ziprasidone hcl 20 mg cap generic MDD ziprasidone hcl 80 mg cap generic 2 per day PA MDD 2 per day TREATMENT-RESISTANT clozapine orally disintegrating tab 100 mg generic C Non-Formulary Drug clozapine orally disintegrating tab 12.5 mg generic C Non-Formulary Drug clozapine 150 mg tab disp generic C Non-Formulary Drug clozapine 200 mg tab generic PA clozapine 200 mg tab disp generic C Non-Formulary Drug clozapine orally disintegrating tab 25 mg generic C Non-Formulary Drug ANTISPASTICITY AGENTS baclofen 20 mg tab generic dantrolene sodium 25 mg cap generic dantrolene sodium 50 mg cap generic PA tizanidine hcl 2 mg cap generic C PAGE 154 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS tizanidine hcl 2 mg tab generic tizanidine hcl 2 mg tab generic tizanidine hcl 4 mg cap generic C Non-Formulary Drug tizanidine hcl 6 mg cap generic C Non-Formulary Drug ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS valganciclovir hcl 50 mg/ml recon soln generic ANTI-HEPATITIS B (HBV) AGENTS BARACLUDE 0.05 MG/ML SOLUTION entecavir BRAND entecavir 0.5 mg tab generic PA EPIVIR HBV 5 MG/ML SOLUTION lamivudine (hbv) BRAND PA DAKLINZA 30 MG TAB daclatasvir dihydrochloride BRAND PA DAKLINZA 60 MG TAB daclatasvir dihydrochloride BRAND PA DAKLINZA 90 MG TAB daclatasvir dihydrochloride BRAND PA HARVONI 90-400 MG TAB ledipasvir-sofosbuvir BRAND PA MODERIBA 1200 DOSE PACK 600 MG TAB ribavirin (hepatitis c) BRAND PA MODERIBA 800 DOSE PACK 400 MG TAB ribavirin (hepatitis c) BRAND OLYSIO 150 MG CAP simeprevir sodium BRAND PA REBETOL 40 MG/ML SOLUTION ribavirin (hepatitis c) BRAND C RIBASPHERE 400 MG TAB ribavirin (hepatitis c) BRAND RIBASPHERE 600 MG TAB ribavirin (hepatitis c) BRAND ANTI-HEPATITIS C (HCV) AGENTS PAGE 155 Non-Formulary Drug PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS RIBASPHERE RIBAPAK 400 MG TAB ribavirin (hepatitis c) BRAND RIBASPHERE RIBAPAK 600 MG TAB ribavirin (hepatitis c) BRAND RIBATAB 400 MG TAB ribavirin (hepatitis c) BRAND RIBATAB 600 MG TAB ribavirin (hepatitis c) BRAND SOVALDI 400 MG TAB sofosbuvir BRAND TECHNIVIE 12.5-75-50 MG TAB ombitasvir-paritaprevir-ritonavir BRAND PA VIEKIRA PAK 12.5-75-50 &250 MG TAB THPK ombitasvir-paritaprevir-ritonavir & dasabuvir BRAND PA ZEPATIER 50-100 MG TAB elbasvir-grazoprevir BRAND PA GENVOYA 150-150-200-10 MG TAB elvitegravir-cobicistat-emtricitabine-tenofovir alafenamide BRAND PA ISENTRESS 100 MG PACKET raltegravir potassium BRAND C ISENTRESS 400 MG TAB raltegravir potassium BRAND PA STRIBILD 150-150-200-300 MG TAB elvitegravir-cobicistat-emtricitabine-tenofovir df BRAND PA TIVICAY 50 MG TAB dolutegravir sodium BRAND PA PA PA ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI) Non-Formulary Drug ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI) COMPLERA 200-25-300 MG TAB emtricitabine-rilpivirine-tenofovir disoproxil fumarate BRAND PA nevirapine 200 mg tab generic PA nevirapine 50 mg/5ml suspension generic nevirapine er 100 mg tab er 24h generic ODEFSEY 200-25-25 MG TAB emtricitabine-rilpivirine-tenofovir alafenamide fumarate BRAND RESCRIPTOR 200 MG TAB delavirdine mesylate BRAND PAGE 156 PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI) abacavir sulfate 300 mg tab generic abacavir-lamivudine-zidovudine 300-150-300 mg tab generic PA DESCOVY 200-25 MG TAB emtricitabine-tenofovir alafenamide fumarate BRAND PA didanosine 200 mg cap dr generic EMTRIVA 10 MG/ML SOLUTION emtricitabine BRAND stavudine 1 mg/ml recon soln generic stavudine 40 mg cap generic TRUVADA 200-300 MG TAB emtricitabine-tenofovir disoproxil fumarate BRAND VIDEX 4 GM RECON SOLN didanosine BRAND PA VIREAD 150 MG TAB tenofovir disoproxil fumarate BRAND PA VIREAD 200 MG TAB tenofovir disoproxil fumarate BRAND VIREAD 300 MG TAB tenofovir disoproxil fumarate BRAND PA VIREAD 40 MG/GM POWDER tenofovir disoproxil fumarate BRAND PA ZIAGEN 20 MG/ML SOLUTION abacavir sulfate BRAND PA zidovudine 50 mg/5ml syrup generic PA SELZENTRY 150 MG TAB maraviroc BRAND PA TYBOST 150 MG TAB cobicistat BRAND PA ANTI-HIV AGENTS, OTHER ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS 250 MG CAP tipranavir BRAND EVOTAZ 300-150 MG TAB atazanavir sulfate-cobicistat BRAND PAGE 157 PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS INVIRASE 200 MG CAP saquinavir mesylate BRAND PA LEXIVA 50 MG/ML SUSPENSION fosamprenavir calcium BRAND PA LEXIVA 700 MG TAB fosamprenavir calcium BRAND PA lopinavir-ritonavir 400-100 mg/5ml solution generic PA NORVIR 100 MG TAB ritonavir BRAND PREZISTA 100 MG/ML SUSPENSION darunavir ethanolate BRAND PA PREZISTA 300 MG TABS darunavir ethanolate BRAND PA PREZISTA 75 MG TAB darunavir ethanolate BRAND PA REYATAZ 200 MG CAP atazanavir sulfate BRAND VIRACEPT 250 MG TAB nelfinavir mesylate BRAND VIRACEPT 625 MG TAB nelfinavir mesylate BRAND PRODUCT DESCRIPTION PA ANTI-INFLUENZA AGENTS oseltamivir phosphate 45 mg cap generic rimantadine hcl 100 mg tab generic TAMIFLU 6 MG/ML RECON SUSP oseltamivir phosphate BRAND C Non-Formulary Drug ANTIHERPETIC AGENTS acyclovir 400 mg tab generic acyclovir 5 % ointment generic acyclovir 800 mg tab generic PA famciclovir 125 mg tab generic PA SITAVIG 50 MG TAB acyclovir BRAND C Non-Formulary Drug trifluridine 1 % solution generic C Non-Formulary Drug PAGE 158 PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS buspirone hcl 30 mg tab generic PA buspirone hcl 5 mg tab generic PA meprobamate 200 mg tab generic C Non-Formulary Drug meprobamate 400 mg tab generic C Non-Formulary Drug alprazolam 0.25 mg tab disp generic C Non-Formulary Drug alprazolam 0.5 mg tab disp generic C Non-Formulary Drug alprazolam 1 mg tab disp generic C Non-Formulary Drug alprazolam 2 mg tab disp generic C Non-Formulary Drug alprazolam er 1 mg tab er 24h generic alprazolam xr 1 mg tab er 24h generic clonazepam 0.5 mg tab disp generic clonazepam 2 mg tab disp generic clorazepate dipotassium 15 mg tab generic clorazepate dipotassium 7.5 mg tab generic diazepam 1 mg/ml solution generic diazepam 2 mg tab generic lorazepam 0.5 mg tab generic lorazepam 1 mg tab generic oxazepam 10 mg cap generic oxazepam 15 mg cap generic PRODUCT DESCRIPTION ANXIOLYTICS ANXIOLYTICS, OTHER BENZODIAZEPINES BIPOLAR AGENTS MOOD STABILIZERS lithium 8 meq/5ml solution generic PA lithium carbonate 600 mg cap generic PA lithium carbonate er 300 mg tab er generic PAGE 159 LAST UPDATED 04/2017 PRODUCT DESCRIPTION lithium carbonate er 450 mg tab er BRAND/GENE LIMITS & RESTRICTIONS generic PA BLOOD GLUCOSE REGULATORS ANTIDIABETIC AGENTS acarbose 25 mg tab generic acarbose 50 mg tab generic AVANDAMET 2-1000 MG TAB rosiglitazone maleate-metformin hcl BRAND AVANDAMET 4-500 MG TAB rosiglitazone maleate-metformin hcl PA PA MDD 2 per day BRAND MDD 2 per day AVANDARYL 4-1 MG TAB rosiglitazone maleate-glimepiride BRAND PA AVANDARYL 4-2 MG TAB rosiglitazone maleate-glimepiride BRAND PA AVANDARYL 4-4 MG TAB rosiglitazone maleate-glimepiride BRAND PA AVANDARYL 8-2 MG TAB rosiglitazone maleate-glimepiride BRAND PA AVANDARYL 8-4 MG TAB rosiglitazone maleate-glimepiride BRAND PA AVANDIA 4 MG TAB rosiglitazone maleate BRAND BYDUREON 2 MG RECON SUSP exenatide BRAND PA BYDUREON 2 MG SRER exenatide BRAND PA chlorpropamide 100 mg tab generic C Non-Formulary Drug chlorpropamide 250 mg tab generic C Non-Formulary Drug FARXIGA 10 MG TAB dapagliflozin propanediol BRAND FARXIGA 5 MG TAB dapagliflozin propanediol BRAND glimepiride 4 mg tab generic MDD glipizide 10 mg tab generic PA PAGE 160 PA MDD 2 per day 2 per day LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS glipizide-metformin hcl 5-500 mg tab generic PA glyburide 5 mg tab generic PA glyburide micronized 6 mg tab generic glyburide-metformin 2.5-500 mg tab generic PA INVOKANA 100 MG TAB canagliflozin BRAND PA INVOKANA 300 MG TAB canagliflozin BRAND JANUMET 50-1000 MG TAB sitagliptin-metformin hcl BRAND PA JANUVIA 25 MG TAB sitagliptin phosphate BRAND PA KOMBIGLYZE XR 5-1000 MG TAB ER 24H saxagliptin-metformin hcl BRAND PA metformin hcl 1000 mg tab generic metformin hcl 500 mg tab generic metformin hcl 850 mg tab generic metformin hcl er (osm) 1000 mg tab er 24h generic C Non-Formulary Drug metformin hcl er (osm) 500 mg tab er 24h generic C Non-Formulary Drug metformin hcl er 750 mg tab er 24h generic PA miglitol 100 mg tab generic PA nateglinide 120 mg tab generic PA ONGLYZA 2.5 MG TAB saxagliptin hcl BRAND PA pioglitazone hcl-glimepiride 30-2 mg tab generic PA pioglitazone hcl-metformin hcl 15-500 mg tab generic SYMLINPEN 60 1500 MCG/1.5ML SOLN PEN pramlintide acetate BRAND PA SYNJARDY 12.5-1000 MG TAB empagliflozin-metformin hcl BRAND PA SYNJARDY 12.5-500 MG TAB empagliflozin-metformin hcl BRAND PA PRODUCT DESCRIPTION PAGE 161 PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS SYNJARDY 5-1000 MG TAB empagliflozin-metformin hcl BRAND PA SYNJARDY 5-500 MG TAB empagliflozin-metformin hcl BRAND PA tolazamide 250 mg tab generic C Non-Formulary Drug tolazamide 250 mg tabs generic C Non-Formulary Drug tolazamide 500 mg tab generic C Non-Formulary Drug PRODUCT DESCRIPTION GLYCEMIC AGENTS PROGLYCEM 50 MG/ML SUSPENSION diazoxide BRAND INSULINS HUMALOG 100 UNIT/ML SOLUTION insulin lispro (human) BRAND HUMALOG MIX 50/50 (50-50) 100 UNIT/ML SUSPENSION insulin lispro protamine & lispro (human) BRAND HUMULIN 70/30 (70-30) 100 UNIT/ML SUSPENSION insulin nph isophane & reg (human) BRAND HUMULIN R U-500 (CONCENTRATED) 500 UNIT/ML SOLUTION insulin regular (human) BRAND PA LANTUS 100 UNIT/ML SOLUTION insulin glargine BRAND PA LEVEMIR 100 UNIT/ML SOLUTION insulin detemir BRAND NOVOLIN 70/30 (70-30) 100 UNIT/ML SUSPENSION insulin nph isophane & reg (human) BRAND NOVOLIN 70/30 RELION (70-30) 100 UNIT/ML SUSPENSION insulin nph isophane & reg (human) BRAND NOVOLOG MIX 70/30 (70-30) 100 UNIT/ML SUSPENSION insulin aspart protamine & aspart (human) BRAND RELION 70/30 (70-30) 100 UNIT/ML SUSPENSION insulin isophane & reg (human) BRAND TRESIBA FLEXTOUCH 100 UNIT/ML SOLN PEN insulin degludec BRAND PAGE 162 PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION TRESIBA FLEXTOUCH 200 UNIT/ML SOLN PEN insulin degludec BRAND/GENE LIMITS & RESTRICTIONS BRAND PA BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS ANTICOAGULANTS fondaparinux sodium 10 mg/0.8ml solution generic fondaparinux sodium 2.5 mg/0.5ml solution generic FRAGMIN 12500 UNIT/0.5ML SOLUTION dalteparin sodium BRAND FRAGMIN 15000 UNIT/0.6ML SOLUTION dalteparin sodium BRAND FRAGMIN 18000 UNT/0.72ML SOLUTION dalteparin sodium BRAND FRAGMIN 7500 UNIT/0.3ML SOLUTION dalteparin sodium BRAND heparin sodium (porcine) 10000 unit/ml solution generic HEPARIN SODIUM (PORCINE) 2000 UNIT/ML SOLUTION heparin sodium (porcine) BRAND heparin sodium (porcine) 20000 unit/ml solution generic jantoven 10 mg tab generic jantoven 3 mg tab generic jantoven 6 mg tab generic jantoven 7.5 mg tab generic PRADAXA 75 MG CAP dabigatran etexilate mesylate BRAND warfarin sodium 10 mg tab generic warfarin sodium 3 mg tab generic warfarin sodium 6 mg tab generic warfarin sodium 7.5 mg tab generic XARELTO 10 MG TAB rivaroxaban BRAND PA generic PA BLOOD FORMATION MODIFIERS anagrelide hcl 0.5 mg cap PAGE 163 LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS ARANESP (ALBUMIN FREE) 300 MCG/ML SOLUTION darbepoetin alfa BRAND PA ARANESP (ALBUMIN FREE) 60 MCG/ML SOLUTION darbepoetin alfa BRAND LEUKINE 500 MCG/ML SOLUTION sargramostim BRAND PA MOZOBIL 24 MG/1.2ML SOLUTION plerixafor BRAND PA PROMACTA 50 MG TAB eltrombopag olamine BRAND PA ZARXIO 300 MCG/0.5ML SOLN PRSYR filgrastim-sndz BRAND C Non-Formulary Drug ZARXIO 480 MCG/0.8ML SOLN PRSYR filgrastim-sndz BRAND C Non-Formulary Drug Non-Formulary Drug PRODUCT DESCRIPTION COAGULANTS aminocaproic acid 1000 mg tab generic aminocaproic acid 500 mg tab generic tranexamic acid 650 mg tab generic PLATELET MODIFYING AGENTS BRILINTA 90 MG TAB ticagrelor BRAND C clopidogrel bisulfate 300 mg tab generic PA dipyridamole 25 mg tab generic PA dipyridamole 75 mg tab generic PA CARDIOVASCULAR AGENTS ALPHA-ADRENERGIC AGONISTS clonidine hcl 0.1 mg tab generic clonidine hcl 0.1 mg/24hr patch wk generic clonidine hcl 0.2 mg tab generic clonidine hcl 0.3 mg tab generic clonidine hcl 0.3 mg/24hr patch wk generic guanfacine hcl 1 mg tab generic PAGE 164 PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS guanfacine hcl 2 mg tab generic methyldopa 250 mg tab generic C Non-Formulary Drug methyldopa 500 mg tab generic C Non-Formulary Drug doxazosin mesylate 4 mg tab generic MDD prazosin hcl 2 mg cap generic PA ALPHA-ADRENERGIC BLOCKING AGENTS 1.5 per day ANGIOTENSIN II RECEPTOR ANTAGONISTS PA candesartan cilexetil 4 mg tab generic MDD 1.5 per day EDARBI 40 MG TAB azilsartan medoxomil BRAND C Non-Formulary Drug EDARBI 80 MG TAB azilsartan medoxomil BRAND C Non-Formulary Drug eprosartan mesylate 600 mg tab generic irbesartan 150 mg tab generic PA irbesartan 300 mg tab generic losartan potassium 100 mg tab generic MDD 1 per day MDD 1 per day PA MDD olmesartan medoxomil 5 mg tab generic telmisartan 40 mg tab generic 1 per day PA PA telmisartan 80 mg tab generic valsartan 40 mg tab generic MDD 1.5 per day MDD 1 per day PA MDD 1 per day PA valsartan 80 mg tab generic MDD PAGE 165 1 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS benazepril hcl 10 mg tab generic MDD captopril 12.5 mg tab generic PA captopril 50 mg tab generic enalapril maleate 2.5 mg tab generic lisinopril 2.5 mg tab generic 2 per day PA MDD 2 per day PA lisinopril 2.5 mg tabs generic MDD 2 per day PA lisinopril 20 mg tab generic MDD 2 per day PA lisinopril 20 mg tabs generic MDD 2 per day PA lisinopril 30 mg tab generic moexipril hcl 15 mg tab generic perindopril erbumine 2 mg tab generic MDD 2 per day MDD 1 per day C MDD perindopril erbumine 4 mg tab generic C MDD perindopril erbumine 8 mg tab generic C Non-Formulary Drug 1 per day Non-Formulary Drug 2 per day Non-Formulary Drug PA quinapril hcl 10 mg tab generic quinapril hcl 40 mg tab generic ramipril 1.25 mg cap generic MDD 2 per day MDD 2 per day PA MDD 1 per day PA ramipril 5 mg cap generic MDD PAGE 166 1 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PA trandolapril 1 mg tab generic MDD 1 per day ANTIARRHYTHMICS amiodarone hcl 100 mg tab generic C Non-Formulary Drug amiodarone hcl 400 mg tab generic C Non-Formulary Drug disopyramide phosphate 100 mg cap generic PA dofetilide 250 mcg cap generic PA dofetilide 500 mcg cap generic PA MULTAQ 400 MG TAB dronedarone hcl BRAND C Non-Formulary Drug pacerone 100 mg tab generic C Non-Formulary Drug pacerone 400 mg tab generic C Non-Formulary Drug propafenone hcl 150 mg tab generic C Non-Formulary Drug propafenone hcl 225 mg tab generic C Non-Formulary Drug propafenone hcl 300 mg tab generic C Non-Formulary Drug propafenone hcl er 225 mg cap er 12h generic C Non-Formulary Drug propafenone hcl er 325 mg cap er 12h generic C Non-Formulary Drug propafenone hcl er 425 mg cap er 12h generic C Non-Formulary Drug quinidine gluconate er 324 mg tab er generic PA sorine 120 mg tab generic sotalol hcl (af) 160 mg tab generic sotalol hcl (af) 80 mg tab generic sotalol hcl 120 mg tab generic PA BETA-ADRENERGIC BLOCKING AGENTS atenolol 100 mg tab generic PA atenolol 25 mg tab generic PA atenolol 50 mg tab generic PA PAGE 167 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS betaxolol hcl 10 mg tab generic C Non-Formulary Drug betaxolol hcl 20 mg tab generic C Non-Formulary Drug carvedilol 3.125 mg tab generic PA LEVATOL 20 MG TAB penbutolol sulfate BRAND C metoprolol tartrate 100 mg tab generic PA metoprolol tartrate 25 mg tab generic metoprolol tartrate 50 mg tab generic PA nadolol 80 mg tab generic PA pindolol 10 mg tab generic propranolol hcl 10 mg tab generic propranolol hcl 20 mg tab generic propranolol hcl 20 mg/5ml solution generic propranolol hcl 40 mg/5ml solution generic propranolol hcl er 160 mg cap er 24h generic propranolol hcl er 60 mg cap er 24h generic PA timolol maleate 10 mg tab generic PA timolol maleate 20 mg tab generic Non-Formulary Drug CALCIUM CHANNEL BLOCKING AGENTS PA afeditab cr 60 mg tab er 24h generic MDD 2 per day PA amlodipine besylate 2.5 mg tab generic MDD 1 per day 1.5 per day amlodipine besylate 5 mg tab generic MDD CARDENE SR 30 MG CAP ER 12H nicardipine hcl BRAND C Non-Formulary Drug CARDENE SR 60 MG CAP ER 12H nicardipine hcl BRAND C Non-Formulary Drug cartia xt 300 mg cap er 24h generic MDD PAGE 168 1 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS dilt-cd 300 mg cap er 24h generic MDD 1 per day diltiazem cd 300 mg cap er 24h generic MDD 1 per day diltiazem hcl 120 mg tab generic PA diltiazem hcl 60 mg tab generic PA diltiazem hcl er 60 mg cap er 12h generic PA diltiazem hcl er 90 mg cap er 12h generic PA diltiazem hcl er beads 420 mg cap er 24h generic PA MDD 1 per day PA diltiazem hcl er coated beads 240 mg tab er 24h generic MDD 1 per day diltiazem hcl er coated beads 300 mg cap er 24h generic MDD 1 per day diltiazem hcl er coated beads 360 mg tab er 24h generic MDD 1 per day felodipine er 10 mg tab er 24h generic MDD 2 per day isradipine 2.5 mg cap generic C Non-Formulary Drug isradipine 5 mg cap generic C Non-Formulary Drug matzim la 240 mg tab er 24h generic PA MDD 1 per day 1 per day matzim la 360 mg tab er 24h generic MDD nicardipine hcl 20 mg cap generic C Non-Formulary Drug nicardipine hcl 30 mg cap generic C Non-Formulary Drug nifediac cc 60 mg tab er 24h generic PA MDD nifedipine 10 mg cap generic nifedipine 20 mg cap generic nifedipine er 60 mg tab er 24h generic 2 per day PA PA MDD nimodipine 30 mg cap PAGE 169 generic 2 per day PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS MDD nisoldipine er 17 mg tab er 24h generic C MDD nisoldipine er 20 mg tab er 24h generic C MDD nisoldipine er 25.5 mg tab er 24h generic C MDD nisoldipine er 30 mg tab er 24h generic C MDD nisoldipine er 34 mg tab er 24h generic C MDD nisoldipine er 40 mg tab er 24h generic C MDD nisoldipine er 8.5 mg tab er 24h generic C verapamil hcl 120 mg tab generic verapamil hcl er 100 mg cap er 24h generic verapamil hcl er 120 mg tab er generic MDD 1 per day Non-Formulary Drug 1 per day Non-Formulary Drug 1 per day Non-Formulary Drug 1 per day Non-Formulary Drug 1 per day Non-Formulary Drug 1 per day Non-Formulary Drug 1 per day Non-Formulary Drug 2 per day PA MDD 2 per day PA verapamil hcl er 120 mg tbcr generic MDD 2 per day PA verapamil hcl er 180 mg cap er 24h generic MDD 2 per day PA verapamil hcl er 180 mg tab er generic MDD 2 per day PA verapamil hcl er 240 mg cap er 24h generic MDD 2 per day PA verapamil hcl er 240 mg tab er generic MDD PAGE 170 2 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS CARDIOVASCULAR AGENTS, OTHER amiloride-hydrochlorothiazide 5-50 mg tab generic amlodipine besy-benazepril hcl 5-20 mg cap generic amlodipine besy-benazepril hcl 5-40 mg cap generic amlodipine besylate-valsartan 5-160 mg tab generic amlodipine-atorvastatin 10-10 mg tab generic C Non-Formulary Drug amlodipine-atorvastatin 10-20 mg tab generic C Non-Formulary Drug amlodipine-atorvastatin 10-40 mg tab generic C Non-Formulary Drug amlodipine-atorvastatin 10-80 mg tab generic C Non-Formulary Drug amlodipine-atorvastatin 2.5-10 mg tab generic C Non-Formulary Drug amlodipine-atorvastatin 2.5-20 mg tab generic C Non-Formulary Drug amlodipine-atorvastatin 2.5-40 mg tab generic C Non-Formulary Drug amlodipine-atorvastatin 5-10 mg tab generic C Non-Formulary Drug amlodipine-atorvastatin 5-20 mg tab generic C Non-Formulary Drug amlodipine-atorvastatin 5-40 mg tab generic C Non-Formulary Drug amlodipine-atorvastatin 5-80 mg tab generic C Non-Formulary Drug amlodipine-olmesartan 10-20 mg tab generic amlodipine-olmesartan 10-40 mg tab generic amlodipine-valsartan-hctz 10-160-12.5 mg tab generic amlodipine-valsartan-hctz 10-320-25 mg tab generic PA AMTURNIDE 150-5-12.5 MG TAB aliskiren-amlodipine-hydrochlorothiazide BRAND C Non-Formulary Drug AMTURNIDE 300-10-12.5 MG TAB aliskiren-amlodipine-hydrochlorothiazide BRAND C Non-Formulary Drug AMTURNIDE 300-10-25 MG TAB aliskiren-amlodipine-hydrochlorothiazide BRAND C Non-Formulary Drug AMTURNIDE 300-5-12.5 MG TAB aliskiren-amlodipine-hydrochlorothiazide BRAND C Non-Formulary Drug AMTURNIDE 300-5-25 MG TAB aliskiren-amlodipine-hydrochlorothiazide BRAND C Non-Formulary Drug PAGE 171 PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS atenolol-chlorthalidone 50-25 mg tab generic PA benazepril-hydrochlorothiazide 20-25 mg tab generic MDD 2 per day benazepril-hydrochlorothiazide 20-25 mg tabs generic MDD 2 per day candesartan cilexetil-hctz 16-12.5 mg tab generic PRODUCT DESCRIPTION PA MDD 1.5 per day candesartan cilexetil-hctz 32-25 mg tab generic captopril-hydrochlorothiazide 50-15 mg tab generic PA CLORPRES 0.1-15 MG TAB clonidine & chlorthalidone BRAND C Non-Formulary Drug CLORPRES 0.2-15 MG TAB clonidine & chlorthalidone BRAND C Non-Formulary Drug clorpres 0.3-15 mg tabs generic C Non-Formulary Drug CORLANOR 5 MG TAB ivabradine hcl BRAND C Non-Formulary Drug CORLANOR 7.5 MG TAB ivabradine hcl BRAND C Non-Formulary Drug DEMSER 250 MG CAP metyrosine BRAND PA digitek 250 mcg tab generic PA digox 250 mcg tab generic PA digoxin 250 mcg tab generic PA EDARBYCLOR 40-12.5 MG TAB azilsartan medoxomil-chlorthalidone BRAND C Non-Formulary Drug EDARBYCLOR 40-25 MG TAB azilsartan medoxomil-chlorthalidone BRAND C Non-Formulary Drug enalapril-hydrochlorothiazide 10-25 mg tab generic ENTRESTO 24-26 MG TAB sacubitril-valsartan BRAND C Non-Formulary Drug ENTRESTO 49-51 MG TAB sacubitril-valsartan BRAND C Non-Formulary Drug ENTRESTO 97-103 MG TAB sacubitril-valsartan BRAND C Non-Formulary Drug irbesartan-hydrochlorothiazide 150-12.5 mg tab generic PA MDD PAGE 172 1 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS lisinopril-hydrochlorothiazide 10-12.5 mg tab generic MDD 1 per day lisinopril-hydrochlorothiazide 10-12.5 mg tabs generic MDD 1 per day losartan potassium-hctz 100-12.5 mg tab generic MDD 1 per day losartan potassium-hctz 50-12.5 mg tab generic PA MDD 1 per day methyldopa-hydrochlorothiazide 250-15 mg tab generic methyldopa-hydrochlorothiazide 250-25 mg tab generic PA metoprolol-hydrochlorothiazide 50-25 mg tab generic PA moexipril-hydrochlorothiazide 15-12.5 mg tab generic PA NORTHERA 100 MG CAP droxidopa BRAND C Non-Formulary Drug NORTHERA 200 MG CAP droxidopa BRAND C Non-Formulary Drug NORTHERA 300 MG CAP droxidopa BRAND C Non-Formulary Drug olmesartan medoxomil-hctz 40-12.5 mg tab generic PA PRESTALIA 14-10 MG TAB perindopril arginine-amlodipine besylate BRAND C Non-Formulary Drug PRESTALIA 3.5-2.5 MG TAB perindopril arginine-amlodipine besylate BRAND C Non-Formulary Drug PRESTALIA 7-5 MG TAB perindopril arginine-amlodipine besylate BRAND C Non-Formulary Drug propranolol-hctz 40-25 mg tab generic quinapril-hydrochlorothiazide 20-25 mg tab generic PA MDD 2 per day reserpine 0.1 mg tab generic C Non-Formulary Drug reserpine 0.25 mg tab generic C Non-Formulary Drug spironolactone-hctz 25-25 mg tab generic PA TEKAMLO 150-10 MG TAB aliskiren-amlodipine BRAND C Non-Formulary Drug TEKAMLO 150-5 MG TAB aliskiren-amlodipine BRAND C Non-Formulary Drug PAGE 173 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS TEKAMLO 300-10 MG TAB aliskiren-amlodipine BRAND C Non-Formulary Drug TEKAMLO 300-5 MG TAB aliskiren-amlodipine BRAND C Non-Formulary Drug TEKTURNA 150 MG TAB aliskiren fumarate BRAND C Non-Formulary Drug TEKTURNA 300 MG TAB aliskiren fumarate BRAND C Non-Formulary Drug telmisartan-amlodipine 80-5 mg tab generic PA telmisartan-hctz 80-12.5 mg tab generic PA MDD 1 per day telmisartan-hctz 80-25 mg tab generic PA trandolapril-verapamil hcl er 1-240 mg tab er generic C Non-Formulary Drug trandolapril-verapamil hcl er 2-180 mg tab er generic C Non-Formulary Drug trandolapril-verapamil hcl er 2-240 mg tab er generic C Non-Formulary Drug trandolapril-verapamil hcl er 4-240 mg tab er generic C Non-Formulary Drug triamterene-hctz 37.5-25 mg tab generic triamterene-hctz 50-25 mg cap generic PA bumetanide 1 mg tab generic PA bumetanide 2 mg tab generic ethacrynic acid 25 mg tab generic C furosemide 10 mg/ml solution generic PA furosemide 40 mg tab generic furosemide 40 mg/4ml solution generic furosemide 80 mg tab generic torsemide 10 mg tab generic C Non-Formulary Drug torsemide 100 mg tab generic C Non-Formulary Drug torsemide 20 mg tab generic C Non-Formulary Drug DIURETICS, LOOP PAGE 174 Non-Formulary Drug PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION torsemide 5 mg tab BRAND/GENE LIMITS & RESTRICTIONS generic C Non-Formulary Drug DYRENIUM 100 MG CAP triamterene BRAND C Non-Formulary Drug DYRENIUM 50 MG CAP triamterene BRAND C Non-Formulary Drug eplerenone 25 mg tab generic PA eplerenone 50 mg tab generic spironolactone 25 mg tab generic PA chlorothiazide 250 mg tab generic C Non-Formulary Drug chlorothiazide 500 mg tab generic C Non-Formulary Drug chlorthalidone 100 mg tab generic chlorthalidone 50 mg tab generic PA DIURIL 250 MG/5ML SUSPENSION chlorothiazide BRAND C Non-Formulary Drug indapamide 1.25 mg tab generic C Non-Formulary Drug indapamide 2.5 mg tab generic C Non-Formulary Drug methyclothiazide 5 mg tab generic C Non-Formulary Drug metolazone 2.5 mg tab generic metolazone 2.5 mg tabs generic DIURETICS, POTASSIUM-SPARING DIURETICS, THIAZIDE DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES fenofibrate 48 mg tab generic PA fenofibrate 50 mg cap generic PA fenofibrate 54 mg tab generic fenofibrate micronized 134 mg cap generic PA fenofibrate micronized 67 mg cap generic PA gemfibrozil 600 mg tab generic C PAGE 175 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS ALTOPREV 40 MG TAB ER 24H lovastatin BRAND atorvastatin calcium 40 mg tab generic PA atorvastatin calcium 80 mg tab generic fluvastatin sodium 20 mg cap generic MDD 1.5 per day MDD 1 per day MDD 1 per day C MDD fluvastatin sodium 40 mg cap generic C MDD fluvastatin sodium er 80 mg tab er 24h generic Non-Formulary Drug 2 per day Non-Formulary Drug 2 per day C Non-Formulary Drug LIVALO 1 MG TAB pitavastatin calcium BRAND C Non-Formulary Drug LIVALO 2 MG TAB pitavastatin calcium BRAND C Non-Formulary Drug LIVALO 4 MG TAB pitavastatin calcium BRAND C Non-Formulary Drug lovastatin 20 mg tab generic PA lovastatin 40 mg tab generic pravastatin sodium 40 mg tab generic MDD 1 per day MDD 2 per day PA MDD 1 per day PA pravastatin sodium 40 mg tabs generic MDD 1 per day PA pravastatin sodium 80 mg tab generic rosuvastatin calcium 40 mg tab generic rosuvastatin calcium 5 mg tab generic MDD 1 per day MDD 1 per day PA MDD PAGE 176 1 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION simvastatin 80 mg tab BRAND/GENE LIMITS & RESTRICTIONS generic MDD 1 per day ADVICOR 1000-20 MG TAB ER 24H niacin-lovastatin BRAND C Non-Formulary Drug ADVICOR 1000-40 MG TAB ER 24H niacin-lovastatin BRAND C Non-Formulary Drug ADVICOR 500-20 MG TAB ER 24H niacin-lovastatin BRAND C Non-Formulary Drug ADVICOR 750-20 MG TAB ER 24H niacin-lovastatin BRAND C Non-Formulary Drug cholestyramine 4 gm/dose powder generic PA cholestyramine light 4 gm/dose powder generic PA colestipol hcl 1 gm tab generic JUXTAPID 10 MG CAP lomitapide mesylate BRAND C Non-Formulary Drug JUXTAPID 20 MG CAP lomitapide mesylate BRAND C Non-Formulary Drug JUXTAPID 5 MG CAP lomitapide mesylate BRAND C Non-Formulary Drug LIPTRUZET 10-10 MG TAB ezetimibe-atorvastatin BRAND niacin er (antihyperlipidemic) 1000 mg tab er generic niacin er (antihyperlipidemic) 500 mg tab er generic PA PRALUENT 150 MG/ML SOLN PEN alirocumab BRAND C Non-Formulary Drug PRALUENT 150 MG/ML SOLN PRSYR alirocumab BRAND C Non-Formulary Drug PRALUENT 75 MG/ML SOLN PEN alirocumab BRAND C Non-Formulary Drug PRALUENT 75 MG/ML SOLN PRSYR alirocumab BRAND C Non-Formulary Drug prevalite 4 gm/dose powder generic PA REPATHA 140 MG/ML SOLN PRSYR evolocumab BRAND C DYSLIPIDEMICS, OTHER PAGE 177 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS REPATHA SURECLICK 140 MG/ML SOLN A-INJ evolocumab BRAND C Non-Formulary Drug SIMCOR 1000-20 MG TAB ER 24H niacin-simvastatin BRAND C Non-Formulary Drug SIMCOR 1000-40 MG TAB ER 24H niacin-simvastatin BRAND C Non-Formulary Drug SIMCOR 500-20 MG TAB ER 24H niacin-simvastatin BRAND C Non-Formulary Drug SIMCOR 500-40 MG TAB ER 24H niacin-simvastatin BRAND C Non-Formulary Drug SIMCOR 750-20 MG TAB ER 24H niacin-simvastatin BRAND C Non-Formulary Drug VASCEPA 1 GM CAP icosapent ethyl BRAND PA VYTORIN 10-10 MG TAB ezetimibe-simvastatin BRAND VYTORIN 10-80 MG TAB ezetimibe-simvastatin BRAND PA WELCHOL 3.75 GM PACKET colesevelam hcl BRAND PA WELCHOL 625 MG TAB colesevelam hcl BRAND PA VASODILATORS, DIRECT-ACTING ARTERIAL hydralazine hcl 25 mg tab generic minoxidil 10 mg tab generic VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS DILATRATE-SR 40 MG CAP ER isosorbide dinitrate BRAND C isosorbide dinitrate 5 mg tab generic PA isosorbide mononitrate er 60 mg tab er 24h generic Non-Formulary Drug PA MDD minitran 0.1 mg/hr patch 24hr generic nitro-time 2.5 mg cap er generic PA nitro-time 6.5 mg cap er generic PA PAGE 178 1.5 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS nitro-time 9 mg cap er generic nitroglycerin 0.1 mg/hr patch 24hr generic nitroglycerin 0.4 mg/spray solution generic PA nitroglycerin 0.6 mg sl tab generic PA nitroglycerin er 2.5 mg cap er generic PA nitroglycerin er 6.5 mg cap er generic PA nitroglycerin er 9 mg cap er generic CENTRAL NERVOUS SYSTEM AGENTS ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES amphetamine-dextroamphet er 5 mg cap er 24h generic dextroamphetamine sulfate er 10 mg cap er 24h generic methamphetamine hcl 5 mg tab generic C VYVANSE 20 MG CAP lisdexamfetamine dimesylate BRAND PA MDD 2 per day Non-Formulary Drug ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES DAYTRANA 10 MG/9HR PATCH methylphenidate BRAND C Non-Formulary Drug DAYTRANA 15 MG/9HR PATCH methylphenidate BRAND C Non-Formulary Drug DAYTRANA 20 MG/9HR PATCH methylphenidate BRAND C Non-Formulary Drug DAYTRANA 30 MG/9HR PATCH methylphenidate BRAND C Non-Formulary Drug dexmethylphenidate hcl 10 mg tab generic C Non-Formulary Drug dexmethylphenidate hcl 2.5 mg tab generic C Non-Formulary Drug dexmethylphenidate hcl 5 mg tab generic C Non-Formulary Drug dexmethylphenidate hcl er 10 mg cap er 24h generic C Non-Formulary Drug dexmethylphenidate hcl er 15 mg cap er 24h generic C Non-Formulary Drug dexmethylphenidate hcl er 20 mg cap er 24h generic C Non-Formulary Drug dexmethylphenidate hcl er 30 mg cap er 24h generic C Non-Formulary Drug PAGE 179 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS dexmethylphenidate hcl er 40 mg cap er 24h generic C Non-Formulary Drug dexmethylphenidate hcl er 5 mg cap er 24h generic C Non-Formulary Drug guanfacine hcl er 2 mg tab er 24h generic PA metadate er 20 mg tab er generic MDD methylin 20 mg tab generic PA methylin er 10 mg tab er generic methylin er 20 mg tab er generic MDD methylphenidate hcl 20 mg tab generic PA methylphenidate hcl er (cd) 10 mg cap er generic 1 per day 1 per day PA MDD 1 per day PA methylphenidate hcl er (cd) 40 mg cap er generic MDD 1 per day methylphenidate hcl er 10 mg tab er generic methylphenidate hcl er 18 mg tab er generic MDD 1 per day methylphenidate hcl er 20 mg tab er generic MDD 1 per day methylphenidate hcl er 27 mg tab er generic MDD 1 per day QUILLIVANT XR 25 MG/5ML RECON SUSP methylphenidate hcl BRAND STRATTERA 18 MG CAP atomoxetine hcl BRAND PA benzphetamine hcl 50 mg tab generic PA BUPAP 50-650 MG TAB butalbital-acetaminophen BRAND C Non-Formulary Drug butalbital-apap-caffeine 50-325-40 mg cap generic C Non-Formulary Drug butalbital-apap-caffeine 50-325-40 mg tab generic butalbital-apap-caffeine 50-500-40 mg tab generic C Non-Formulary Drug capacet 50-325-40 mg cap generic C Non-Formulary Drug CENTRAL NERVOUS SYSTEM, OTHER PAGE 180 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS diethylpropion hcl er 75 mg tab er 24h generic esgic 50-325-40 mg cap generic C Non-Formulary Drug margesic 50-325-40 mg cap generic C Non-Formulary Drug NUEDEXTA 20-10 MG CAP dextromethorphan hbr-quinidine sulfate BRAND C Non-Formulary Drug phentermine hcl 30 mg cap generic PA phentermine hcl 37.5 mg cap generic PA phentermine hcl 37.5 mg tab generic PA PHRENILIN FORTE 50-650 MG CAP butalbital-acetaminophen BRAND C Non-Formulary Drug riluzole 50 mg tab generic C Non-Formulary Drug SEDAPAP 50-650 MG TAB butalbital-acetaminophen BRAND C Non-Formulary Drug TENCON 50-650 MG TAB butalbital-acetaminophen BRAND C Non-Formulary Drug zebutal 50-325-40 mg cap generic C Non-Formulary Drug zebutal 50-500-40 mg cap generic C Non-Formulary Drug C Non-Formulary Drug FIBROMYALGIA AGENTS LYRICA 150 MG CAP pregabalin BRAND LYRICA 20 MG/ML SOLUTION pregabalin BRAND LYRICA 200 MG CAP pregabalin BRAND LYRICA 225 MG CAP pregabalin BRAND LYRICA 25 MG CAP pregabalin BRAND SAVELLA 50 MG TAB milnacipran hcl BRAND MULTIPLE SCLEROSIS AGENTS TECFIDERA 120 MG CAP DR dimethyl fumarate PAGE 181 BRAND LAST UPDATED 04/2017 PRODUCT DESCRIPTION TECFIDERA 240 MG CAP DR dimethyl fumarate BRAND/GENE BRAND LIMITS & RESTRICTIONS C Non-Formulary Drug DENTAL AND ORAL AGENTS AQUORAL SOLUTION artificial saliva BRAND ARESTIN 1 MG MISC minocycline hcl (subgingival) BRAND CAPHOSOL SOLUTION artificial saliva BRAND DEBACTEROL 30-50 % SOLUTION sulfuric acid-sulfonated phenolics BRAND DEBACTEROL 30-50 % SOLUTION sulfuric acid-sulfonated phenolics BRAND NUMOISYN LIQUID artificial saliva BRAND pilocarpine hcl 7.5 mg tab generic PA PA DERMATOLOGICAL AGENTS acne medication 5 5 % gel generic ala cort 1 % cream generic ammonium lactate 12 % lotion generic amnesteem 10 mg cap generic amnesteem 40 mg cap generic ANALPRAM-HC 1-2.5 % LOTION hydrocortisone acetate w/ pramoxine BRAND ANALPRAM-HC 2.5-1 % LOTION hydrocortisone acetate w/ pramoxine BRAND avar-e emollient 10-5 % cream generic PA avar-e green 10-5 % cream generic PA avita 0.025 % gel generic PA AZELEX 20 % CREAM azelaic acid (acne) BRAND PA benzoyl peroxide 10 % gel generic PA benzoyl peroxide 5 % gel generic PAGE 182 PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS benzoyl peroxide creamy wash 4 % liquid generic PA benzoyl peroxide creamy wash 8 % liquid generic PA benzoyl peroxide wash 10 % liquid generic PA benzoyl peroxide-erythromycin 5-3 % gel generic PA bp foaming wash 10 % liquid generic PA calcipotriene 0.005 % cream generic CETACAINE 2-2-14 % AEROSOL butamben-tetracaine-benzocaine BRAND claravis 10 mg cap generic claravis 40 mg cap generic PA clearplex x 10 % gel generic PA clenia 10-5 % cream generic PA clotrimazole-betamethasone 1-0.05 % lotion generic COPASIL GEL emollient BRAND DERMASORB AF 3-0.5 % KIT clioquinol-hydrocortisone & emollient BRAND ELIDEL 1 % CREAM pimecrolimus BRAND PA FINACEA 15 % GEL azelaic acid BRAND PA finasteride 1 mg tab generic C fluorouracil 0.5 % cream generic PA fluorouracil 5 % cream generic PA grafco silver nit applicator 75-25 % misc generic PA hydrocortisone 1 % cream generic hydrocortisone 1 % ointment generic hydrocortisone 1% in absorbase 1 % ointment generic hydrocortisone 2.5 % ointment generic hydrocortisone ace-pramoxine 2.5-1 % cream generic PRODUCT DESCRIPTION PAGE 183 PA PA Non-Formulary Drug LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS imiquimod 5 % cream generic PA keratol plus 50 % gel generic laclotion 12 % lotion generic PA lactic acid e 10-3500 %-unt/30gm cream generic PA lavoclen-4 creamy wash 4 % liquid generic PA lavoclen-8 creamy wash 8 % liquid generic PA LIDAMANTLE HC 3-0.5 % LOTION lidocaine-hydrocortisone acetate BRAND lidocaine hcl 3 % lotion generic myorisan 10 mg cap generic myorisan 40 mg cap generic PA PACNEX MX 4.25 % LIQUID benzoyl peroxide BRAND PA PRAMOSONE 1-2.5 % OINTMENT pramoxine-hc BRAND re 10 wash 10 % liquid generic remeven 50 % cream generic salacyn 6 % cream generic salacyn 6 % lotion generic salicylic acid 6 % crea generic salicylic acid 6 % cream generic salicylic acid 6 % lotion generic PA salicylic acid 6 % lotion generic PA salicylic acid 6 % lotn generic PA salicylic acid 6 % sham generic PA salicylic acid 6 % shampoo generic PA salitech forte 6 % lotion generic PA scalacort 2 % lotion generic PRODUCT DESCRIPTION PAGE 184 PA PA PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS se 10-5 ss 10-5 % cream generic PA seb-prev wash 10 % liquid generic PA silver nitrate 10 % solution generic silver nitrate 25 % solution generic sss 10-5 10-5 % cream generic PA sulfacetamide sodium 10 % liquid generic PA sulfacetamide sodium-sulfur 10-5 % cream generic PA sulfacetamide sodium-sulfur 10-5 % lotion generic SULFOAM 2 % SHAMPOO sulfur BRAND suphera 10-5 % cream generic TACLONEX 0.005-0.064 % SUSPENSION calcipotriene-betamethasone dipropionate BRAND tacrolimus 0.1 % ointment generic TAZORAC 0.05 % GEL tazarotene BRAND PA topisulf 10-5 % cream generic PA tretinoin 0.025 % gel generic PA tretinoin 0.05 % gel generic PA tretinoin 0.1 % cream generic PA tretinoin microsphere 0.1 % gel generic PA tretinoin microsphere pump 0.1 % gel generic PA TRI-CHLOR 80 % LIQUID trichloroacetic acid BRAND UMECTA 40 % EMULSION urea BRAND ure-k 50 % cream generic urea 50 % cream generic urealac 50 % crea generic urealac nail 50 % gel generic PRODUCT DESCRIPTION PAGE 185 PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS VANIQA 13.9 % CREAM eflornithine hcl BRAND C virti-sulf 10-5 % cream generic PA zenatane 10 mg cap generic zenatane 40 mg cap generic PA ZYCLARA 3.75 % CREAM imiquimod BRAND PA ZYCLARA PUMP 3.75 % CREAM imiquimod BRAND PA BUPHENYL 500 MG TAB sodium phenylbutyrate BRAND C Non-Formulary Drug CREON 12000 UNIT CP DR PART pancrelipase (lipase-protease-amylase) BRAND CREON 36000 UNIT CP DR PART pancrelipase (lipase-protease-amylase) BRAND CREON 6000 UNIT CP DR PART pancrelipase (lipase-protease-amylase) BRAND KUVAN 100 MG PACKET sapropterin dihydrochloride BRAND C Non-Formulary Drug KUVAN 100 MG TAB SOL sapropterin dihydrochloride BRAND C Non-Formulary Drug PANCREAZE 21000 UNIT CP DR PART pancrelipase (lipase-protease-amylase) BRAND pancrelipase (lip-prot-amyl) 5000 unit cp dr part generic PA PERTZYE 16000 UNIT CP DR PART pancrelipase (lipase-protease-amylase) BRAND PA RAVICTI 1.1 GM/ML LIQUID glycerol phenylbutyrate BRAND C Non-Formulary Drug sodium phenylbutyrate 3 gm/tsp powder generic C Non-Formulary Drug ULTRESA 13800 UNIT CP DR PART pancrelipase (lipase-protease-amylase) BRAND PA VIOKACE 10440 UNIT TAB pancrelipase (lipase-protease-amylase) BRAND PA ZENPEP 15000 UNIT CP DR PART pancrelipase (lipase-protease-amylase) BRAND PA Non-Formulary Drug ENZYME REPLACEMENT/MODIFIERS PAGE 186 LAST UPDATED 04/2017 PRODUCT DESCRIPTION ZENPEP 25000 UNIT CP DR PART pancrelipase (lipase-protease-amylase) BRAND/GENE LIMITS & RESTRICTIONS BRAND PA GASTROINTESTINAL AGENTS ANTISPASMODICS, GASTROINTESTINAL dicyclomine hcl 10 mg cap generic dicyclomine hcl 10 mg/5ml solution generic ed-spaz 0.125 mg tab disp generic glycopyrrolate 1 mg tab generic glycopyrrolate 2 mg tab generic hyomax-sl 0.125 mg sl tab generic hyoscyamine sulfate 0.125 mg sl tab generic hyoscyamine sulfate 0.125 mg subl generic hyoscyamine sulfate 0.125 mg tab generic hyoscyamine sulfate 0.125 mg tab disp generic hyoscyamine sulfate 0.125 mg tabs generic hyoscyamine sulfate 0.125 mg/5ml elixir generic hyoscyamine sulfate er 0.375 mg tab er 12h generic hyosyne 0.125 mg/5ml elixir generic methscopolamine bromide 2.5 mg tab generic nulev 0.125 mg tab disp generic oscimin 0.125 mg sl tab generic oscimin 0.125 mg tab generic oscimin 0.125 mg tab disp generic oscimin sr 0.375 mg tab er 12h generic phenohytro 16.2 mg tab generic symax fastabs 0.125 mg tab disp generic symax-sl 0.125 mg sl tab generic symax-sr 0.375 mg tab er 12h generic GASTROINTESTINAL AGENTS, OTHER diphenatol 2.5-0.025 mg tab PAGE 187 generic LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS diphenoxylate-atropine 2.5-0.025 mg tab generic diphenoxylate-atropine 2.5-0.025 mg/5ml liquid generic FULYZAQ 125 MG TAB DR crofelemer BRAND lofene 2.5-0.025 mg tab generic lonox 2.5-0.025 mg tab generic MOVANTIK 12.5 MG TAB naloxegol oxalate BRAND PA MOVANTIK 25 MG TAB naloxegol oxalate BRAND PA MYTESI 125 MG TAB DR crofelemer BRAND C Non-Formulary Drug opium 10 mg/ml (1%) tincture generic C Non-Formulary Drug ursodiol 500 mg tab generic PA XENICAL 120 MG CAP orlistat BRAND C Non-Formulary Drug HISTAMINE2 (H2) RECEPTOR ANTAGONISTS cimetidine 200 mg tab generic nizatidine 15 mg/ml solution generic nizatidine 150 mg cap generic ranitidine hcl 15 mg/ml syrup generic ranitidine hcl 150 mg tab generic ranitidine hcl 150 mg/10ml syrup generic ranitidine hcl 300 mg cap generic ranitidine hcl 300 mg tab generic ranitidine hcl 75 mg/5ml syrup generic MDD 1 per day MDD 2 per day MDD 2 per day MDD 2 per day IRRITABLE BOWEL SYNDROME AGENTS alosetron hcl 0.5 mg tab generic alosetron hcl 1 mg tab generic PA MDD VIBERZI 100 MG TAB eluxadoline PAGE 188 BRAND 2 per day PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION VIBERZI 75 MG TAB eluxadoline BRAND/GENE LIMITS & RESTRICTIONS BRAND PA LAXATIVES KRISTALOSE 10 GM PACKET lactulose BRAND KRISTALOSE 20 GM PACKET lactulose BRAND MOVIPREP 100 GM RECON SOLN peg 3350-kcl-nacl-na sulfate-na ascorbate-ascorbic acid BRAND SUCLEAR 210G-17.5G KIT na sulfate-k sulfate-mg sulfate & peg3350-nacl-na bicarbkcl BRAND C Non-Formulary Drug PROTECTANTS misoprostol 200 mcg tab generic sucralfate 1 gm tab generic PROTON PUMP INHIBITORS MDD ACIPHEX SPRINKLE 10 MG CAP SPRINK rabeprazole sodium BRAND ACIPHEX SPRINKLE 5 MG CAP SPRINK rabeprazole sodium BRAND DEXILANT 60 MG CAP DR dexlansoprazole BRAND esomeprazole magnesium 20 mg cap dr generic C MDD C MDD 2 per day Non-Formulary Drug 2 per day Non-Formulary Drug 1 per day PA MDD 1 per day 1 per day esomeprazole magnesium 40 mg cap dr generic MDD esomeprazole strontium 49.3 mg cap dr generic C lansoprazole 15 mg cap dr generic MDD NEXIUM 10 MG PACKET esomeprazole magnesium BRAND omeprazole 40 mg cap dr generic PREVACID SOLUTAB 15 MG TAB DISP lansoprazole BRAND PAGE 189 Non-Formulary Drug 2 per day PA MDD 1 per day MDD 2 per day PA MDD 2 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PA PREVACID SOLUTAB 30 MG TAB DISP lansoprazole BRAND PRILOSEC 10 MG PACKET omeprazole magnesium BRAND PA PRILOSEC 2.5 MG PACKET omeprazole magnesium BRAND PA PROTONIX 40 MG PACKET pantoprazole sodium BRAND PA MDD 2 per day GENITOURINARY AGENTS ANTISPASMODICS, URINARY darifenacin hydrobromide er 15 mg tab er 24h generic hyoscyamine 0.15 mg tab generic oxybutynin chloride er 10 mg tab er 24h generic tolterodine tartrate 1 mg tab generic MDD 2 per day PA MDD 2 per day 1 per day tolterodine tartrate er 4 mg cap er 24h generic MDD TOVIAZ 4 MG TAB ER 24H fesoterodine fumarate BRAND PA VESICARE 10 MG TAB solifenacin succinate BRAND PA BENIGN PROSTATIC HYPERTROPHY AGENTS PA CIALIS 2.5 MG TAB tadalafil BRAND dutasteride 0.5 mg cap generic terazosin hcl 1 mg cap generic MDD 1 per day PA terazosin hcl 2 mg cap generic MDD 1 per day MDD 2 per day GENITOURINARY AGENTS, OTHER av-phos 250 neutral 155-852-130 mg tab generic bethanechol chloride 10 mg tab generic bethanechol chloride 5 mg tab generic PAGE 190 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE CERVIDIL 10 MG INSERT dinoprostone BRAND CIALIS 10 MG TAB tadalafil BRAND CIALIS 20 MG TAB tadalafil LIMITS & RESTRICTIONS C Non-Formulary Drug PA MDD 0.2 per day BRAND MDD 0.2 per day LEVITRA 5 MG TAB vardenafil hcl BRAND MDD 0.2 per day LITHOSTAT 250 MG TAB acetohydroxamic acid BRAND PA MUSE 250 MCG PELLET alprostadil (vasodilator) BRAND PA phenazo 200 mg tab generic PA phenazopyridine hcl 100 mg tab generic PA phenazopyridine hcl 200 mg tab generic PA phospha 250 neutral 155-852-130 mg tab generic phospho-trin 250 neutral 155-852-130 mg tab generic pot & sod cit-cit ac 550-500-334 mg/5ml solution generic potassium citrate er 5 meq (540 mg) tab er generic PREPIDIL 0.5 MG/3GM GEL dinoprostone BRAND C Non-Formulary Drug PROSTIN E2 20 MG SUPPOS dinoprostone BRAND C Non-Formulary Drug RENACIDIN 6.602G/100 SOLUTION citric acid & d-gluconic acid BRAND PA RENACIDIN SOLUTION citric acid & d-gluconic acid BRAND PA RIMSO-50 50 % SOLUTION dimethyl sulfoxide BRAND SORBITOL 3 % SOLUTION sorbitol irrigation BRAND STAXYN 10 MG TAB DISP vardenafil hcl BRAND MDD STENDRA 100 MG TAB avanafil BRAND PA PAGE 191 PA 0.2 per day LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS STENDRA 200 MG TAB avanafil BRAND PA tricitrates 550-500-334 mg/5ml solution generic PA virt-phos 250 neutral 155-852-130 mg tab generic virtrate-3 550-500-334 mg/5ml solution generic PA FOSRENOL 1000 MG CHEW TAB lanthanum carbonate BRAND PA RENVELA 2.4 GM PACKET sevelamer carbonate BRAND RENVELA 800 MG TAB sevelamer carbonate BRAND SEVELAMER CARBONATE 800 MG TAB sevelamer carbonate BRAND PRODUCT DESCRIPTION PHOSPHATE BINDERS HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) amcinonide 0.1 % cream generic asmalpred 15 mg/5ml solution generic PA C Non-Formulary Drug PA asmalpred plus 15 mg/5ml solution generic baycadron 0.5 mg/5ml elixir generic beta-val 0.1 % cream generic betamethasone dipropionate 0.05 % cream generic betamethasone dipropionate aug 0.05 % cream generic betamethasone valerate 0.1 % cream generic betamethasone valerate 0.12 % foam generic CARMOL-HC 1-10 % CREAM hydrocortisone acetate-urea BRAND CELESTONE 0.6 MG/5ML SOLUTION betamethasone BRAND clobetasol propionate 0.05 % foam generic clobetasol propionate 0.05 % lotion generic PAGE 192 C Non-Formulary Drug C Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE clobetasol propionate 0.05 % ointment generic clobetasol propionate 0.05 % shampoo generic CLODAN 0.05 % KIT clobetasol propionate & cleanser BRAND clodan 0.05 % shampoo generic CORDRAN 4 MCG/SQCM TAPE flurandrenolide BRAND cormax 0.05 % ointment generic desonide 0.05 % cream generic desoximetasone 0.25 % cream generic desoximetasone 0.25 % ointment generic dexamethasone 0.5 mg/5ml elixir generic dexamethasone 0.5 mg/5ml solution generic dexamethasone 6 mg tab generic DEXPAK 6 DAY 1.5 MG (21) TAB THPK dexamethasone BRAND FLO-PRED 16.7 (15 BASE) MG/5ML SUSPENSION prednisolone acetate BRAND fluocinolone acetonide 0.01 % solution generic fluocinolone acetonide 0.025 % ointment generic fluocinonide 0.05 % gel generic fluocinonide 0.1 % cream generic flurandrenolide 0.05 % lotion generic fluticasone propionate 0.005 % ointment generic halobetasol propionate 0.05 % cream generic halobetasol propionate 0.05 % ointment generic HALOG 0.1 % OINTMENT halcinonide BRAND hydrocortisone 10 mg tab generic hydrocortisone 20 mg tab generic hydrocortisone 5 mg tab generic hydrocortisone butyrate 0.1 % ointment generic PAGE 193 LIMITS & RESTRICTIONS C Non-Formulary Drug PA PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE hydrocortisone valerate 0.2 % cream generic MEDROL 2 MG TAB methylprednisolone BRAND methylprednisolone 16 mg tab generic methylprednisolone 32 mg tab generic methylprednisolone 4 mg tab generic methylprednisolone 4 mg tab thpk generic methylprednisolone 8 mg tab generic mometasone furoate 0.1 % cream generic mometasone furoate 0.1 % ointment generic PANDEL 0.1 % CREAM hydrocortisone probutate BRAND prednicarbate 0.1 % ointment generic prednisolone sodium phosphate 10 mg tab disp LIMITS & RESTRICTIONS C Non-Formulary Drug C Non-Formulary Drug generic C Non-Formulary Drug prednisolone sodium phosphate 10 mg/5ml solution generic C Non-Formulary Drug prednisolone sodium phosphate 15 mg tab disp generic C Non-Formulary Drug prednisolone sodium phosphate 15 mg/5ml solution generic PA C Non-Formulary Drug prednisolone sodium phosphate 20 mg/5ml solution generic C Non-Formulary Drug prednisolone sodium phosphate 30 mg tab disp generic C Non-Formulary Drug prednisone 1 mg tab generic prednisone 5 mg tab generic prednisone 50 mg tab generic RAYOS 1 MG TAB DR prednisone BRAND C Non-Formulary Drug RAYOS 2 MG TAB DR prednisone BRAND C Non-Formulary Drug RAYOS 5 MG TAB DR prednisone BRAND C Non-Formulary Drug SYNALAR (CREAM) 0.025 % KIT fluocinolone-emollient BRAND PAGE 194 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE TOPICORT SPRAY 0.25 % LIQUID desoximetasone BRAND triamcinolone acetonide 0.025 % cream generic triamcinolone acetonide 0.025 % lotion generic triamcinolone acetonide 0.025 % ointment generic triamcinolone acetonide 0.1 % lotion generic triamcinolone acetonide 0.1 % ointment generic U-CORT 1-10 % CREAM hydrocortisone acetate-urea BRAND LIMITS & RESTRICTIONS HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) desmopressin ace spray refrig 0.01 % solution generic desmopressin acetate 0.1 mg tab generic STIMATE 1.5 MG/ML SOLUTION desmopressin acetate BRAND C Non-Formulary Drug C Non-Formulary Drug HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) ANABOLIC STEROIDS ANADROL-50 50 MG TAB oxymetholone BRAND oxandrolone 10 mg tab generic C Non-Formulary Drug ANDROGENS ANDRODERM 2 MG/24HR PATCH 24HR testosterone BRAND ANDROGEL 20.25 MG/1.25GM (1.62%) GEL testosterone BRAND PA ANDROGEL 40.5 MG/2.5GM (1.62%) GEL testosterone BRAND PA ANDROGEL PUMP 20.25 MG/ACT (1.62%) GEL testosterone BRAND PA ANDROXY 10 MG TAB fluoxymesterone BRAND C Non-Formulary Drug AXIRON 30 MG/ACT SOLUTION testosterone BRAND C Non-Formulary Drug danazol 50 mg cap generic METHITEST 10 MG TAB methyltestosterone BRAND C Non-Formulary Drug PAGE 195 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS methyltestosterone 10 mg cap generic C Non-Formulary Drug STRIANT 30 MG MISC testosterone BRAND C Non-Formulary Drug testosterone 10 mg/act (2%) gel generic C Non-Formulary Drug testosterone 12.5 mg/act (1%) gel generic PA levonorgestrel-ethinyl estrad tab 0.15-30 mg (altavera, chateal, kurvelo, levora, marlissa, portia) generic C Non-Formulary Drug norethindrone & ethinyl estradiol tab 1 mg-35 mcg (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) generic C Non-Formulary Drug norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) generic C Non-Formulary Drug levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (amethia, camrese, daysee) generic C Non-Formulary Drug levonorgest-eth estrad 91-day tab 0.1-0.02 & 0.01 mg (amethia lo, camrese lo, generic C Non-Formulary Drug levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg (amethyst) generic C Non-Formulary Drug ANGELIQ 0.25-0.5 MG TAB drospirenone-estradiol BRAND C Non-Formulary Drug ANGELIQ 0.5-1 MG TAB drospirenone-estradiol BRAND C Non-Formulary Drug desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, emoquette, enskyce, reclipsen, solia) generic C Non-Formulary Drug norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg (aranelle, leena) generic C Non-Formulary Drug levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (amethia, camrese, daysee) generic C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, delyla, falmina, lessina, lutera, orsythia, sronyx) generic C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, delyla, falmina, lessina, lutera, orsythia, sronyx) generic C Non-Formulary Drug desogestrel-ethinyl estradiol tab 0.15-0.02/0.01 mg (azurette, kariva, pimtrea, viorele, caziant, cesia, velivet) generic C Non-Formulary Drug norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (balziva, briellyn, gildagia, philith, vyfemla, zenchent) generic C Non-Formulary Drug ESTROGENS PAGE 196 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS desogestrel-ethinyl estradiol tab 0.15-0.02/0.01 mg (azurette, kariva, pimtrea, viorele, caziant, cesia, velivet) generic C Non-Formulary Drug norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (gildess, junel, larin, microgestin) generic C Non-Formulary Drug norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (gildess, junel, larin, microgestin) generic C Non-Formulary Drug norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (balziva, briellyn, gildagia, philith, vyfemla, zenchent) generic C Non-Formulary Drug levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (amethia, camrese, daysee) generic C Non-Formulary Drug levonorgest-eth estrad 91-day tab 0.1-0.02 & 0.01 mg (amethia lo, camrese lo, generic C Non-Formulary Drug caziant 0.1/0.125/0.15 -0.025 mg tab generic C Non-Formulary Drug CENESTIN 0.3 MG TAB estrogens, conjugated synthetic a BRAND C Non-Formulary Drug CENESTIN 0.45 MG TAB estrogens, conjugated synthetic a BRAND C Non-Formulary Drug CENESTIN 0.625 MG TAB estrogens, conjugated synthetic a BRAND C Non-Formulary Drug CENESTIN 0.9 MG TAB estrogens, conjugated synthetic a BRAND C Non-Formulary Drug CENESTIN 1.25 MG TAB estrogens, conjugated synthetic a BRAND C Non-Formulary Drug cesia 0.1/0.125/0.15 -0.025 mg tab generic C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.15-30 mg (altavera, chateal, kurvelo, levora, marlissa, portia) generic C Non-Formulary Drug CLIMARA PRO 0.045-0.015 MG/DAY PATCH WK estradiol-levonorgestrel BRAND PA covaryx 1.25-2.5 mg tab generic C Non-Formulary Drug covaryx hs 0.625-1.25 mg tab generic C Non-Formulary Drug norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg (cryselle, elinest, low-ogestrel) generic C Non-Formulary Drug norethindrone & ethinyl estradiol tab 1 mg-35 mcg (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) generic C Non-Formulary Drug norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) generic C Non-Formulary Drug PAGE 197 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, emoquette, enskyce, reclipsen, solia) generic C Non-Formulary Drug norethindrone & ethinyl estradiol tab 1 mg-35 mcg (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) generic C Non-Formulary Drug norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) generic C Non-Formulary Drug levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (amethia, camrese, daysee) generic C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, delyla, falmina, lessina, lutera, orsythia, sronyx) generic C Non-Formulary Drug desogestrel-ethinyl estradiol tab 0.15-0.02/0.01 mg (azurette, kariva, pimtrea, viorele, caziant, cesia, velivet) generic C Non-Formulary Drug desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, emoquette, enskyce, reclipsen, solia) generic C Non-Formulary Drug DIVIGEL 0.25 MG/0.25GM GEL estradiol BRAND C Non-Formulary Drug DIVIGEL 0.5 MG/0.5GM GEL estradiol BRAND C Non-Formulary Drug DIVIGEL 1 MG/GM GEL estradiol BRAND C Non-Formulary Drug drospirenone-ethinyl estradiol tab 3-0.02 mg(gianvi, loryna, nikki, vestura) generic C Non-Formulary Drug drospirenone-ethinyl estradiol 3-0.03 mg tab generic C Non-Formulary Drug DUAVEE 0.45-20 MG TAB conjugated estrogens-bazedoxifene BRAND C Non-Formulary Drug eemt 1.25-2.5 mg tab generic C Non-Formulary Drug eemt hs 0.625-1.25 mg tab generic C Non-Formulary Drug norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg (cryselle, elinest, low-ogestrel) generic C Non-Formulary Drug desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, emoquette, enskyce, reclipsen, solia) generic C Non-Formulary Drug ENJUVIA 0.3 MG TAB estrogens, conjugated synthetic b BRAND C Non-Formulary Drug ENJUVIA 0.45 MG TAB estrogens, conjugated synthetic b BRAND C Non-Formulary Drug ENJUVIA 0.625 MG TAB estrogens, conjugated synthetic b BRAND C Non-Formulary Drug PAGE 198 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS ENJUVIA 0.9 MG TAB estrogens, conjugated synthetic b BRAND C Non-Formulary Drug ENJUVIA 1.25 MG TAB estrogens, conjugated synthetic b BRAND C Non-Formulary Drug levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg (enpresse, levonest, myzilra, trivora) generic C Non-Formulary Drug desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, emoquette, enskyce, reclipsen, solia) generic C Non-Formulary Drug est estrogens-methyltest 1.25-2.5 mg tab generic C Non-Formulary Drug est estrogens-methyltest ds 1.25-2.5 mg tab generic C Non-Formulary Drug est estrogens-methyltest hs 0.625-1.25 mg tab generic C Non-Formulary Drug norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (estarylla, mono-linyah, mononessa, previfem, sprintec) generic C Non-Formulary Drug ESTRACE 0.1 MG/GM CREAM estradiol vaginal BRAND PA estradiol 0.05 mg/24hr patch wk generic estradiol 0.075 mg/24hr patch wk generic estradiol 0.1 mg/24hr patch wk generic estradiol 0.5 mg tab generic ESTRASORB 4.35 MG/1.74GM EMULSION estradiol BRAND estropipate 1.5 mg tab generic estropipate 3 mg tab generic PA ethynodiol diac-eth estradiol 1-50 mg-mcg tab generic C Non-Formulary Drug EVAMIST 1.53 MG/SPRAY SOLUTION estradiol BRAND C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, delyla, falmina, lessina, lutera, orsythia, sronyx) generic C Non-Formulary Drug fayosim 42-21-21-7 days tab generic C Non-Formulary Drug norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (estarylla, mono-linyah, mononessa, previfem, sprintec) generic C Non-Formulary Drug fyavolv 0.5-2.5 mg-mcg tab generic PA drospirenone-ethinyl estradiol tab 3-0.02 mg(gianvi, loryna, nikki, vestura) generic C PAGE 199 PA C Non-Formulary Drug Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (balziva, briellyn, gildagia, philith, vyfemla, zenchent) generic C Non-Formulary Drug norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (gildess, junel, larin, microgestin) generic C Non-Formulary Drug norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (gildess, junel, larin, microgestin) generic C Non-Formulary Drug jevantique lo 0.5-2.5 mg-mcg tab generic PA desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, emoquette, enskyce, reclipsen, solia) generic C Non-Formulary Drug norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (gildess, junel, larin, microgestin) generic C Non-Formulary Drug norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (gildess, junel, larin, microgestin) generic C Non-Formulary Drug desogestrel-ethinyl estradiol tab 0.15-0.02/0.01 mg (azurette, kariva, pimtrea, viorele, caziant, cesia, velivet) generic C Non-Formulary Drug ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg (kelnor, zovia) generic C Non-Formulary Drug desogestrel-ethinyl estradiol tab 0.15-0.02/0.01 mg (azurette, kariva, pimtrea, viorele, caziant, cesia, velivet) generic C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.15-30 mg (altavera, chateal, kurvelo, levora, marlissa, portia) generic C Non-Formulary Drug norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (gildess, junel, larin, microgestin) generic C Non-Formulary Drug norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (gildess, junel, larin, microgestin) generic C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, delyla, falmina, lessina, lutera, orsythia, sronyx) generic C Non-Formulary Drug norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg (aranelle, leena) generic C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, delyla, falmina, lessina, lutera, orsythia, sronyx) generic C Non-Formulary Drug levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg (enpresse, levonest, myzilra, trivora) generic C Non-Formulary Drug levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg (enpresse, levonest, myzilra, trivora) generic C Non-Formulary Drug levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg (enpresse, levonest, myzilra, trivora) generic C Non-Formulary Drug PAGE 200 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS levonorgest-eth estrad 91-day tab 0.1-0.02 & 0.01 mg (amethia lo, camrese lo, generic C Non-Formulary Drug levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (amethia, camrese, daysee) generic C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, delyla, falmina, lessina, lutera, orsythia, sronyx) generic C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.15-30 mg (altavera, chateal, kurvelo, levora, marlissa, portia) generic C Non-Formulary Drug levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg (amethyst) generic C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.15-30 mg (altavera, chateal, kurvelo, levora, marlissa, portia) generic C Non-Formulary Drug drospirenone-ethinyl estradiol tab 3-0.02 mg(gianvi, loryna, nikki, vestura) generic C Non-Formulary Drug norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg (cryselle, elinest, low-ogestrel) generic C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, delyla, falmina, lessina, lutera, orsythia, sronyx) generic C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.15-30 mg (altavera, chateal, kurvelo, levora, marlissa, portia) generic C Non-Formulary Drug norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (gildess, junel, larin, microgestin) generic C Non-Formulary Drug norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (gildess, junel, larin, microgestin) generic C Non-Formulary Drug norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (estarylla, mono-linyah, mononessa, previfem, sprintec) generic C Non-Formulary Drug norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (estarylla, mono-linyah, mononessa, previfem, sprintec) generic C Non-Formulary Drug levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg (enpresse, levonest, myzilra, trivora) generic C Non-Formulary Drug NATAZIA 3/2-2/2-3/1 MG TAB estradiol valerate-dienogest BRAND C Non-Formulary Drug norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (necon, nortrel, wera) generic C Non-Formulary Drug norethindrone & ethinyl estradiol tab 1 mg-35 mcg (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) generic C Non-Formulary Drug NECON 1/50 (28) 1-50 MG-MCG TAB norethindrone & mestranol BRAND C Non-Formulary Drug PAGE 201 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS NECON 10/11 (28) 35 MCG TAB norethindrone-eth estradiol (biphasic) BRAND C Non-Formulary Drug norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) generic C Non-Formulary Drug drospirenone-ethinyl estradiol tab 3-0.02 mg(gianvi, loryna, nikki, vestura) generic C Non-Formulary Drug norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (gildess, junel, larin, microgestin) generic C Non-Formulary Drug norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (wymzya, zenchent, zeosa) generic C Non-Formulary Drug norethindrone-eth estradiol 0.5-2.5 mg-mcg tab generic PA norgestim-eth estrad triphasic 0.18/0.215/0.25 mg-25 mcg tab generic C Non-Formulary Drug norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg (tri-estarylla, tri-linyah, tri-previfem, tri-sprintec, trinessa) generic C Non-Formulary Drug norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (estarylla, mono-linyah, mononessa, previfem, sprintec) generic C Non-Formulary Drug norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg (cryselle, elinest, low-ogestrel) generic C Non-Formulary Drug NORINYL 1+50 (28) 1-50 MG-MCG TAB norethindrone & mestranol BRAND C Non-Formulary Drug norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (necon, nortrel, wera) generic C Non-Formulary Drug norethindrone & ethinyl estradiol tab 1 mg-35 mcg (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) generic C Non-Formulary Drug norethindrone & ethinyl estradiol tab 1 mg-35 mcg (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) generic C Non-Formulary Drug norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) generic C Non-Formulary Drug NUVARING 0.12-0.015 MG/24HR RING etonogestrel-ethinyl estradiol BRAND C Non-Formulary Drug ocella 3-0.03 mg tab generic C Non-Formulary Drug OGESTREL 0.5-50 MG-MCG TAB norgestrel & ethinyl estradiol BRAND C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, delyla, falmina, lessina, lutera, orsythia, sronyx) generic C Non-Formulary Drug NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR (XULANE) norelgestromin-ethinyl estradiol BRAND C Non-Formulary Drug PAGE 202 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (balziva, briellyn, gildagia, philith, vyfemla, zenchent) generic C Non-Formulary Drug desogestrel-ethinyl estradiol tab 0.15-0.02/0.01 mg (azurette, kariva, pimtrea, viorele, caziant, cesia, velivet) generic C Non-Formulary Drug norethindrone & ethinyl estradiol tab 1 mg-35 mcg (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) generic C Non-Formulary Drug norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) generic C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.15-30 mg (altavera, chateal, kurvelo, levora, marlissa, portia) generic C Non-Formulary Drug PREMARIN 0.625 MG TAB estrogens, conjugated BRAND PREMARIN 0.9 MG TAB estrogens, conjugated BRAND PREMPRO 0.3-1.5 MG TAB conjugated estrogens-medroxyprogesterone acetate BRAND norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (estarylla, mono-linyah, mononessa, previfem, sprintec) generic C Non-Formulary Drug desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, emoquette, enskyce, reclipsen, solia) generic C Non-Formulary Drug rivelsa 42-21-21-7 days tab generic C Non-Formulary Drug desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, emoquette, enskyce, reclipsen, solia) generic C Non-Formulary Drug norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (estarylla, mono-linyah, mononessa, previfem, sprintec) generic C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, delyla, falmina, lessina, lutera, orsythia, sronyx) generic C Non-Formulary Drug syeda 3-0.03 mg tab generic C Non-Formulary Drug norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (gildess, junel, larin, microgestin) generic C Non-Formulary Drug norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mgmcg (tilia, tri-legest) generic C Non-Formulary Drug norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg (tri-estarylla, tri-linyah, tri-previfem, tri-sprintec, trinessa) generic C Non-Formulary Drug norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mgmcg (tilia, tri-legest) generic C Non-Formulary Drug PAGE 203 PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg (tri-estarylla, tri-linyah, tri-previfem, tri-sprintec, trinessa) generic C Non-Formulary Drug tri-lo-estarylla 0.18/0.215/0.25 mg-25 mcg tab generic C Non-Formulary Drug tri-lo-marzia 0.18/0.215/0.25 mg-25 mcg tab generic C Non-Formulary Drug tri-lo-sprintec 0.18/0.215/0.25 mg-25 mcg tab generic C Non-Formulary Drug norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg (tri-estarylla, tri-linyah, tri-previfem, tri-sprintec, trinessa) generic C Non-Formulary Drug norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg (tri-estarylla, tri-linyah, tri-previfem, tri-sprintec, trinessa) generic C Non-Formulary Drug norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg (tri-estarylla, tri-linyah, tri-previfem, tri-sprintec, trinessa) generic C Non-Formulary Drug trinessa lo 0.18/0.215/0.25 mg-25 mcg tab generic C Non-Formulary Drug levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg (enpresse, levonest, myzilra, trivora) generic C Non-Formulary Drug levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg (enpresse, levonest, myzilra, trivora) generic C Non-Formulary Drug velivet 0.1/0.125/0.15 -0.025 mg tab generic C Non-Formulary Drug drospirenone-ethinyl estradiol tab 3-0.02 mg(gianvi, loryna, nikki, vestura) generic C Non-Formulary Drug levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, delyla, falmina, lessina, lutera, orsythia, sronyx) generic C Non-Formulary Drug desogestrel-ethinyl estradiol tab 0.15-0.02/0.01 mg (azurette, kariva, pimtrea, viorele, caziant, cesia, velivet) generic C Non-Formulary Drug norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (balziva, briellyn, gildagia, philith, vyfemla, zenchent) generic C Non-Formulary Drug norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (necon, nortrel, wera) generic C Non-Formulary Drug norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (wymzya, zenchent, zeosa) generic C Non-Formulary Drug NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR (XULANE) norelgestromin-ethinyl estradiol BRAND C Non-Formulary Drug zarah 3-0.03 mg tab generic C Non-Formulary Drug norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (balziva, briellyn, gildagia, philith, vyfemla, zenchent) generic C Non-Formulary Drug PAGE 204 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (wymzya, zenchent, zeosa) generic C Non-Formulary Drug norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (wymzya, zenchent, zeosa) generic C Non-Formulary Drug ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg (kelnor, zovia) generic C Non-Formulary Drug zovia 1/50e (28) 1-50 mg-mcg tab generic C Non-Formulary Drug norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, sharobel) generic C Non-Formulary Drug CRINONE 8 % GEL progesterone (vaginal) BRAND norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, sharobel) generic C Non-Formulary Drug norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, sharobel) generic C Non-Formulary Drug FIRST-PROGESTERONE VGS 100 100 MG SUPPOS progesterone (vaginal) BRAND PA FIRST-PROGESTERONE VGS 200 200 MG SUPPOS progesterone (vaginal) BRAND FIRST-PROGESTERONE VGS 25 25 MG SUPPOS progesterone (vaginal) BRAND FIRST-PROGESTERONE VGS 400 400 MG SUPPOS progesterone (vaginal) BRAND norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, sharobel) generic C Non-Formulary Drug norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, sharobel) generic C Non-Formulary Drug norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, sharobel) generic C Non-Formulary Drug levonorgestrel 0.75 mg tab generic PA levonorgestrel 1.5 mg tab generic PA PROGESTINS PAGE 205 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, sharobel) generic megestrol acetate 20 mg tab generic megestrol acetate 40 mg/ml suspension generic PA megestrol acetate 400 mg/10ml suspension generic PA megestrol acetate 800 mg/20ml suspension generic PA MIRENA (52 MG) 20 MCG/24HR IUD levonorgestrel (iud) BRAND C my way 1.5 mg tab generic PA next choice 0.75 mg tab generic PA next choice one dose 1.5 mg tab generic PA norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, sharobel) generic C Non-Formulary Drug norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, sharobel) generic C Non-Formulary Drug norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, sharobel) generic C Non-Formulary Drug PROCHIEVE 8 % GEL progesterone (vaginal) BRAND progesterone micronized 200 mg cap generic norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, sharobel) generic C Non-Formulary Drug SKYLA 13.5 MG IUD levonorgestrel (iud) BRAND C Non-Formulary Drug clomiphene citrate 50 mg tab generic C Non-Formulary Drug OSPHENA 60 MG TAB ospemifene BRAND PA serophene 50 mg tab generic C C Non-Formulary Drug Non-Formulary Drug SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS PAGE 206 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) ARMOUR THYROID 120 MG TAB thyroid BRAND C Non-Formulary Drug ARMOUR THYROID 180 MG TAB thyroid BRAND C Non-Formulary Drug ARMOUR THYROID 240 MG TAB thyroid BRAND C Non-Formulary Drug ARMOUR THYROID 300 MG TAB thyroid BRAND C Non-Formulary Drug levo-t 125 mcg tab generic levo-t 150 mcg tab generic levo-t 175 mcg tab generic levo-t 88 mcg tab generic levothroid 125 mcg tab generic levothroid 150 mcg tab generic levothroid 175 mcg tab generic levothroid 88 mcg tab generic levothyroxine sodium 125 mcg tab generic levothyroxine sodium 125 mcg tabs generic levothyroxine sodium 150 mcg tab generic levothyroxine sodium 150 mcg tabs generic levothyroxine sodium 175 mcg tab generic levothyroxine sodium 88 mcg tab generic levoxyl 125 mcg tab generic levoxyl 150 mcg tab generic levoxyl 175 mcg tab generic levoxyl 88 mcg tab generic liothyronine sodium 50 mcg tab generic NATURE-THROID 130 MG TAB thyroid BRAND C Non-Formulary Drug NATURE-THROID 195 MG TAB thyroid BRAND C Non-Formulary Drug PAGE 207 PA PA PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS NATURE-THROID 32.5 MG TAB thyroid BRAND C Non-Formulary Drug NATURE-THROID 65 MG TAB thyroid BRAND C Non-Formulary Drug np thyroid 15 mg tab generic C Non-Formulary Drug np thyroid tab 30 mg generic C Non-Formulary Drug np thyroid tab 60 mg generic C Non-Formulary Drug np thyroid tab 90 mg generic C Non-Formulary Drug THYROID 65 MG TAB thyroid BRAND C Non-Formulary Drug THYROLAR-1 60 (12.5-50) MG (MCG) TAB liotrix (t3-t4) BRAND C Non-Formulary Drug THYROLAR-1/2 30 (6.25-25) MG (MCG) TAB liotrix (t3-t4) BRAND C Non-Formulary Drug THYROLAR-1/4 15 (3.1-12.5) MG (MCG) TAB liotrix (t3-t4) BRAND C Non-Formulary Drug THYROLAR-2 120 (25-100) MG (MCG) TAB liotrix (t3-t4) BRAND C Non-Formulary Drug THYROLAR-3 180 (37.5-150) MG (MCG) TAB liotrix (t3-t4) BRAND C Non-Formulary Drug unithroid 125 mcg tab generic unithroid 150 mcg tab generic unithroid 175 mcg tab generic unithroid 88 mcg tab generic unithroid direct 125 mcg tab generic unithroid direct 150 mcg tab generic unithroid direct 175 mcg tab generic unithroid direct 88 mcg tab generic PA WESTHROID 130 MG TAB thyroid BRAND C Non-Formulary Drug WESTHROID 195 MG TAB thyroid BRAND C Non-Formulary Drug WESTHROID 32.5 MG TAB thyroid BRAND C Non-Formulary Drug PAGE 208 PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS WESTHROID 65 MG TAB thyroid BRAND C Non-Formulary Drug WESTHROID-P 130 MG TAB thyroid BRAND C Non-Formulary Drug WESTHROID-P 32.5 MG TAB thyroid BRAND C Non-Formulary Drug WESTHROID-P 65 MG TAB thyroid BRAND C Non-Formulary Drug WP THYROID 130 MG TAB thyroid BRAND C Non-Formulary Drug WP THYROID 32.5 MG TAB thyroid BRAND C Non-Formulary Drug WP THYROID 65 MG TAB thyroid BRAND C Non-Formulary Drug HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) SENSIPAR 90 MG TAB cinacalcet hcl BRAND HORMONAL AGENTS, SUPPRESSANT (PITUITARY) cabergoline 0.5 mg tab generic PA SIGNIFOR 0.3 MG/ML SOLUTION pasireotide diaspartate BRAND C Non-Formulary Drug SIGNIFOR 0.6 MG/ML SOLUTION pasireotide diaspartate BRAND C Non-Formulary Drug SIGNIFOR 0.9 MG/ML SOLUTION pasireotide diaspartate BRAND C Non-Formulary Drug SYNAREL 2 MG/ML SOLUTION nafarelin acetate BRAND C Non-Formulary Drug generic PA BRAND C HORMONAL AGENTS, SUPPRESSANT (THYROID) ANTITHYROID AGENTS methimazole 10 mg tab IMMUNOLOGICAL AGENTS ANGIOEDEMA (HAE) AGENTS FIRAZYR 30 MG/3ML SOLUTION icatibant acetate PAGE 209 Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS IMMUNE SUPPRESSANTS cyclosporine 100 mg cap generic hecoria 1 mg cap generic mycophenolate mofetil 250 mg cap generic mycophenolate mofetil 500 mg tab generic RAPAMUNE 1 MG/ML SOLUTION sirolimus BRAND sirolimus 0.5 mg tab generic tacrolimus 1 mg cap generic TREXALL 7.5 MG TAB methotrexate sodium BRAND PA PA IMMUNOMODULATORS PA leflunomide 10 mg tab generic MDD RIDAURA 3 MG CAP auranofin 1 per day BRAND PA DELZICOL 400 MG CAP DR mesalamine BRAND C Non-Formulary Drug GIAZO 1.1 GM TAB balsalazide disodium BRAND C Non-Formulary Drug mesalamine 4 gm enema generic INFLAMMATORY BOWEL DISEASE AGENTS AMINOSALICYLATES GLUCOCORTICOIDS UCERIS 9 MG TAB ER 24H budesonide BRAND SULFONAMIDES sulfasalazine 500 mg tab dr generic METABOLIC BONE DISEASE AGENTS PA alendronate sodium 40 mg tab generic MDD FORTEO 600 MCG/2.4ML SOLUTION teriparatide (recombinant) PAGE 210 1 per day BRAND LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS FOSAMAX PLUS D 70-2800 MG-UNIT TAB alendronate sodium-cholecalciferol BRAND PA FOSAMAX PLUS D 70-5600 MG-UNIT TAB alendronate sodium-cholecalciferol BRAND paricalcitol 1 mcg cap generic PA paricalcitol 2 mcg cap generic PA paricalcitol 4 mcg cap generic PA risedronate sodium 150 mg tab generic risedronate sodium 35 mg tab generic SKELID 200 MG TAB tiludronate disodium BRAND ZOLEDRONIC ACID 4 MG RECON SOLN zoledronic acid BRAND PRODUCT DESCRIPTION C Non-Formulary Drug MISCELLANEOUS THERAPEUTIC AGENTS ACCU-CHEK COMPACT PLUS CARE KIT blood glucose monitoring supplies BRAND PA ALLERX DF 4-2.5 & 8-2.5 MG MISC chlorpheniramine-methscopolamine BRAND PA ALLERX DF30 4-2.5 & 8-2.5 MG MISC chlorpheniramine-methscopolamine BRAND PA ASSURE 3 METER KIT blood glucose monitoring supplies BRAND PA AT LAST BLOOD GLUCOSE SYSTEM KIT blood glucose monitoring supplies BRAND PA CHOICE DM DIABETES RISK TEST KIT blood glucose monitoring supplies BRAND PA CONTOUR NEXT ONE KIT blood glucose monitoring supplies BRAND PA DIGIBAR 190 190 % RECON SUSP barium sulfate BRAND PA E-Z-HD 98 % RECON SUSP barium sulfate BRAND PA EASYGLUCO KIT blood glucose monitoring supplies BRAND PA EVENCARE GLUCOSE MONITORING KIT blood glucose monitoring supplies BRAND PA PAGE 211 LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS FORA V10/V12/D10/D20 TEST KIT blood glucose monitoring supplies BRAND PA formadon 10 % solution generic PA formaldehyde 10 % solution generic PA FREESTYLE FLASH SYSTEM KIT blood glucose monitoring supplies BRAND PA FREESTYLE SYSTEM KIT blood glucose monitoring supplies BRAND PA GLUCOLAB GLUCOSE MONITORING KIT blood glucose monitoring supplies BRAND PA inositol hexanicotinate powder generic PA isometheptene-dichloral-apap 65-100-325 mg cap generic LIQUID E-Z-PAQUE 60 % SUSPENSION barium sulfate BRAND LIQUID POLIBAR 100 % SUSPENSION barium sulfate BRAND MI PASTE PASTE dentifrices BRAND MI PASTE PLUS PASTE dentifrices BRAND migragesic ida 325-65-100 mg cap generic NEXGEN METER KIT blood glucose monitoring supplies BRAND nodolor 325-65-100 mg cap generic phosphatidylcholine 100 % powder generic PRECISION XTRA KIT blood glucose monitoring supplies BRAND PA PRODIGY VOICEPRO BLOOD GLUCOSE KIT blood glucose monitoring supplies BRAND PA QUICKTEK KIT blood glucose monitoring supplies BRAND PA ULTIMA KIT blood glucose monitoring supplies BRAND PA PRODUCT DESCRIPTION PAGE 212 PA PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS OPHTHALMIC AGENTS OPHTHALMIC AGENTS, OTHER AKTEN 3.5 % GEL lidocaine hcl (ophth) BRAND C Non-Formulary Drug altacaine 0.5 % solution generic C Non-Formulary Drug altacaine 0.5 % solution generic C Non-Formulary Drug altafrin 10 % solution generic atropine sulfate 1 % solution generic atropine-care 1 % solution generic BLEPHAMIDE 10-0.2 % SUSPENSION sulfacetamide sod-prednisolone BRAND C Non-Formulary Drug BLEPHAMIDE S.O.P. 10-0.2 % OINTMENT sulfacetamide sod-prednisolone BRAND C Non-Formulary Drug CYCLOMYDRIL 0.2-1 % SOLUTION cyclopentolate w/ phenylephrine BRAND C Non-Formulary Drug cyclopentolate hcl 0.5 % solution generic cyclopentolate hcl 2 % solution generic CYSTARAN 0.44 % SOLUTION cysteamine hcl BRAND C Non-Formulary Drug ISOPTO HOMATROPINE 2 % SOLUTION homatropine hbr BRAND C Non-Formulary Drug ISOPTO HYOSCINE 0.25 % SOLUTION scopolamine hbr (ophth) BRAND C Non-Formulary Drug ketotifen fumarate 0.025 % solution generic LASTACAFT 0.25 % SOLUTION alcaftadine BRAND C Non-Formulary Drug mydral 0.5 % solution generic C Non-Formulary Drug mydral 1 % solution generic C Non-Formulary Drug naphazoline hcl 0.1 % solution generic C Non-Formulary Drug neo-polycin 3.5-400-10000 ointment generic neofrin 10 % solution generic neomycin-bacitracin zn-polymyx 5-400-10000 ointment generic PAGE 213 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS neomycin-polymyxin-dexameth 0.1 % suspension generic neomycin-polymyxin-dexameth 3.5-10000-0.1 suspension generic neomycin-polymyxin-gramicidin 1.75-10000-.025 solution generic neomycin-polymyxin-hc 3.5-10000-1 suspension generic parcaine 0.5 % solution generic phenylephrine hcl 10 % solution generic polyvinyl alcohol 1.4 % solution generic PRED-G 0.3-1 % SUSPENSION gentamicin-prednisolone acetate BRAND PRED-G S.O.P. 0.3-0.6 % OINTMENT gentamicin-prednisolone acetate BRAND PA proparacaine hcl 0.5 % solution generic C Non-Formulary Drug SULFACETAMIDE-PREDNISOLONE 10-0.2 % SUSPENSION sulfacetamide sod-prednisolone BRAND C Non-Formulary Drug tetcaine 0.5 % solution generic C Non-Formulary Drug tetracaine hcl 0.5 % solution generic C Non-Formulary Drug tetravisc 0.5 % solution generic C Non-Formulary Drug tetravisc 0.5 % solution generic C Non-Formulary Drug tetravisc forte 0.5 % solution generic C Non-Formulary Drug tetravisc forte 0.5 % solution generic C Non-Formulary Drug tobramycin-dexamethasone 0.3-0.1 % suspension generic triple antibiotic 5-400-10000 ointment generic tropicamide 0.5 % solution generic C Non-Formulary Drug tropicamide 1 % solution generic C Non-Formulary Drug ZYLET 0.5-0.3 % SUSPENSION loteprednol etabonate-tobramycin BRAND C Non-Formulary Drug ALOCRIL 2 % SOLUTION nedocromil sodium (ophth) BRAND C Non-Formulary Drug ALOMIDE 0.1 % SOLUTION lodoxamide tromethamine BRAND C Non-Formulary Drug C Non-Formulary Drug OPHTHALMIC ANTI-ALLERGY AGENTS PAGE 214 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS azelastine hcl 0.05 % solution generic C Non-Formulary Drug cromolyn sodium 4 % solution generic PA EMADINE 0.05 % SOLUTION emedastine difumarate BRAND C Non-Formulary Drug epinastine hcl 0.05 % solution generic C Non-Formulary Drug olopatadine hcl 0.1 % solution generic C Non-Formulary Drug PATADAY 0.2 % SOLUTION olopatadine hcl BRAND C Non-Formulary Drug ACUVAIL 0.45 % SOLUTION ketorolac tromethamine (ophth) BRAND C Non-Formulary Drug ALREX 0.2 % SUSPENSION loteprednol etabonate BRAND C Non-Formulary Drug bromfenac sodium 0.09 % solution generic C Non-Formulary Drug dexamethasone sodium phosphate 0.1 % solution generic FML 0.1 % OINTMENT fluorometholone (ophth) BRAND C Non-Formulary Drug FML FORTE 0.25 % SUSPENSION fluorometholone (ophth) BRAND C Non-Formulary Drug ketorolac tromethamine 0.4 % solution generic ketorolac tromethamine 0.5 % solution generic PA LOTEMAX 0.5 % GEL loteprednol etabonate BRAND C Non-Formulary Drug LOTEMAX 0.5 % SUSPENSION loteprednol etabonate BRAND C Non-Formulary Drug NEVANAC 0.1 % SUSPENSION nepafenac BRAND C Non-Formulary Drug OZURDEX 0.7 MG IMPLANT dexamethasone (ophth) BRAND C Non-Formulary Drug prednisolone acetate 1 % suspension generic PROLENSA 0.07 % SOLUTION bromfenac sodium (ophth) BRAND C Non-Formulary Drug RETISERT 0.59 MG IMPLANT fluocinolone acetonide (ophth) BRAND C Non-Formulary Drug OPHTHALMIC ANTI-INFLAMMATORIES PAGE 215 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS OPHTHALMIC ANTIGLAUCOMA AGENTS ALPHAGAN P 0.1 % SOLUTION brimonidine tartrate BRAND C Non-Formulary Drug apraclonidine hcl 0.5 % solution generic C Non-Formulary Drug AZOPT 1 % SUSPENSION brinzolamide BRAND C Non-Formulary Drug betaxolol hcl 0.5 % solution generic C Non-Formulary Drug BETIMOL 0.25 % SOLUTION timolol BRAND C Non-Formulary Drug BETIMOL 0.5 % SOLUTION timolol BRAND C Non-Formulary Drug BETOPTIC-S 0.25 % SUSPENSION betaxolol hcl (ophth) BRAND C Non-Formulary Drug brimonidine tartrate 0.15 % solution generic C Non-Formulary Drug brimonidine tartrate 0.2 % solution generic C Non-Formulary Drug carteolol hcl 1 % solution generic C Non-Formulary Drug IOPIDINE 1 % SOLUTION apraclonidine hcl BRAND C Non-Formulary Drug ISOPTO CARBACHOL 1.5 % SOLUTION carbachol (ophth) BRAND C Non-Formulary Drug ISOPTO CARBACHOL 3 % SOLUTION carbachol (ophth) BRAND C Non-Formulary Drug levobunolol hcl 0.25 % solution generic C Non-Formulary Drug levobunolol hcl 0.5 % solution generic C Non-Formulary Drug methazolamide 25 mg tab generic PA metipranolol 0.3 % solution generic C Non-Formulary Drug PHOSPHOLINE IODIDE 0.125 % RECON SOLN echothiophate iodide BRAND C Non-Formulary Drug pilocarpine hcl 1 % solution generic C Non-Formulary Drug pilocarpine hcl 2 % solution generic C Non-Formulary Drug pilocarpine hcl 4 % solution generic C Non-Formulary Drug PAGE 216 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS SIMBRINZA 1-0.2 % SUSPENSION brinzolamide-brimonidine tartrate BRAND C Non-Formulary Drug timolol maleate 0.25 % gel f soln generic C Non-Formulary Drug timolol maleate 0.25 % solution generic C Non-Formulary Drug timolol maleate 0.5 % gel f soln generic C Non-Formulary Drug timolol maleate 0.5 % solution generic C Non-Formulary Drug OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS bimatoprost 0.03 % solution generic C Non-Formulary Drug LUMIGAN 0.01 % SOLUTION bimatoprost BRAND C Non-Formulary Drug travoprost 0.004 % solution generic C Non-Formulary Drug ZIOPTAN 0.0015 % SOLUTION tafluprost BRAND C Non-Formulary Drug a/b otic 5.4-1.4 % solution generic C Non-Formulary Drug acetasol hc 2-1 % solution generic C Non-Formulary Drug acetic acid 2 % solution generic C Non-Formulary Drug aero otic hc 10-10-1 mg/ml solution generic PA antibiotic ear 3.5-10000-1 solution generic PA antipyrine-benzocaine 5.4-1.4 % solution generic C Non-Formulary Drug antipyrine-benzocaine 54-14 mg/ml solution generic C Non-Formulary Drug aurodex 5.4-1.4 % solution generic C Non-Formulary Drug auroguard 54-14 mg/ml solution generic C Non-Formulary Drug auroto 5.4-1.4 % solution generic C Non-Formulary Drug CIPRO HC 0.2-1 % SUSPENSION ciprofloxacin-hydrocortisone BRAND C Non-Formulary Drug CIPRODEX 0.3-0.1 % SUSPENSION ciprofloxacin-dexamethasone BRAND C Non-Formulary Drug cortic-nd 10-10-1 mg/ml solution generic PA OTIC AGENTS PAGE 217 LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS cortomycin 3.5-10000-1 solution generic PA CRESYLATE 25 % SOLUTION cresyl acetate BRAND cyotic 10-10-1 mg/ml solution generic PA exotic-hc 10-10-1 mg/ml solution generic PA fluocinolone acetonide 0.01 % oil generic C hydro ear drops 10-10-1 mg/ml soln generic PA hydrocortisone-acetic acid 1-2 % solution generic C neomycin-polymyxin-hc 1 % solution generic PA neomycin-polymyxin-hc 3.5-10000-1 solution generic PA otic care 5.4-1.4-0.0097 % solution generic C oto-end 10 10-10-1 mg/ml solution generic PA otomax-hc 10-10-1 mg/ml solution generic PA PRODUCT DESCRIPTION Non-Formulary Drug Non-Formulary Drug Non-Formulary Drug RESPIRATORY TRACT/PULMONARY AGENTS ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS ALVESCO 80 MCG/ACT AERO SOLN ciclesonide BRAND ASMANEX 120 METERED DOSES 220 MCG/INH AER POW BA mometasone furoate (inhalation) BRAND PA ASMANEX 14 METERED DOSES 220 MCG/INH AER POW BA mometasone furoate (inhalation) BRAND PA ASMANEX 30 METERED DOSES 220 MCG/INH AER POW BA mometasone furoate (inhalation) BRAND PA ASMANEX 60 METERED DOSES 220 MCG/INH AER POW BA mometasone furoate (inhalation) BRAND PA BECONASE AQ 42 MCG/SPRAY SUSPENSION beclomethasone diprop monohyd BRAND MDD budesonide 0.25 mg/2ml suspension generic PAGE 218 0.83 per day LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS budesonide 0.5 mg/2ml suspension generic PA FLOVENT DISKUS 100 MCG/BLIST AER POW BA fluticasone propionate (inhalation) BRAND FLOVENT DISKUS 50 MCG/BLIST AER POW BA fluticasone propionate (inhalation) BRAND FLOVENT HFA 110 MCG/ACT AEROSOL fluticasone propionate hfa BRAND OMNARIS 50 MCG/ACT SUSPENSION ciclesonide (nasal) BRAND QVAR 80 MCG/ACT AERO SOLN beclomethasone dipropionate BRAND VERAMYST 27.5 MCG/SPRAY SUSPENSION fluticasone furoate BRAND PA arbinoxa 4 mg tab generic C Non-Formulary Drug arbinoxa 4 mg/5ml solution generic C Non-Formulary Drug BROMPHENIRAMINE TANNATE 12 MG CHEW TAB brompheniramine tannate BRAND C Non-Formulary Drug carbinoxamine maleate 4 mg tab generic C Non-Formulary Drug carbinoxamine maleate 4 mg/5ml solution generic C Non-Formulary Drug CLARINEX 0.5 MG/ML SYRUP desloratadine BRAND C Non-Formulary Drug clemastine fumarate 0.67 mg/5ml syrup generic C Non-Formulary Drug clemastine fumarate 2.68 mg tab generic C Non-Formulary Drug cyproheptadine hcl 4 mg tab generic PA cyproheptadine hcl 4 mg tabs generic PA desloratadine 2.5 mg tab disp generic PRODUCT DESCRIPTION PA MDD 4 per day MDD 4 per day PA MDD 0.87 per day PA ANTIHISTAMINES MDD C MDD desloratadine 5 mg tab generic C PAGE 219 1 per day Non-Formulary Drug 1 per day Non-Formulary Drug LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS MDD desloratadine 5 mg tab disp generic 1 per day C Non-Formulary Drug DEXCHLORPHENIRAMINE MALEATE 2 MG/5ML SYRUP dexchlorpheniramine maleate BRAND C Non-Formulary Drug diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug diphenhydramine hcl cap 50 mg generic PA DOXYTEX 2.5 MG/2.5ML LIQUID doxylamine succinate BRAND C Non-Formulary Drug hydroxyzine hcl 10 mg/5ml solution generic hydroxyzine hcl 10 mg/5ml syrup generic hydroxyzine hcl 50 mg tab generic hydroxyzine pamoate 25 mg cap generic hydroxyzine pamoate 50 mg cap generic levocetirizine dihydrochloride 2.5 mg/5ml solution generic C Non-Formulary Drug levocetirizine dihydrochloride 5 mg tab generic C Non-Formulary Drug olopatadine hcl 0.6 % solution generic PA diphenhydramine hcl cap 50 mg generic PA promethazine hcl 12.5 mg tab generic promethazine hcl 25 mg tab generic RESPA-BR 11 MG TAB ER 12H brompheniramine maleate BRAND PA PA C Non-Formulary Drug BRONCHODILATORS, ANTICHOLINERGIC ATROVENT HFA 17 MCG/ACT AERO SOLN ipratropium bromide hfa BRAND ipratropium bromide 0.02 % solution generic ipratropium bromide 0.03 % solution generic SEEBRI NEOHALER 15.6 MCG CAP glycopyrrolate (inhalation) BRAND PA BRONCHODILATORS, SYMPATHOMIMETIC ADRENACLICK 0.15 MG/0.15ML SOLN A-INJ epinephrine PAGE 220 BRAND LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS PA ADRENALIN 0.1 % SOLUTION epinephrine hcl (nasal) BRAND albuterol sulfate (2.5 mg/3ml) 0.083% nebu soln generic albuterol sulfate (5 mg/ml) 0.5% nebu soln generic PA albuterol sulfate (5 mg/ml) 0.5% nebu soln generic PA albuterol sulfate 0.63 mg/3ml nebu soln generic albuterol sulfate 1.25 mg/3ml nebu soln generic PA albuterol sulfate 2 mg/5ml syrup generic PA albuterol sulfate 4 mg tab generic ARCAPTA NEOHALER 75 MCG CAP indacaterol maleate BRAND AUVI-Q 0.15 MG/0.15ML SOLN A-INJ epinephrine BRAND EPINEPHRINE 0.15 MG/0.15ML SOLN A-INJ epinephrine BRAND FORADIL AEROLIZER 12 MCG CAP formoterol fumarate BRAND levalbuterol hcl 0.31 mg/3ml nebu soln generic PA levalbuterol hcl 1.25 mg/0.5ml nebu soln generic PA metaproterenol sulfate 20 mg tab generic PA PERFOROMIST 20 MCG/2ML NEBU SOLN formoterol fumarate BRAND PA PROAIR HFA 108 (90 BASE) MCG/ACT AERO SOLN albuterol sulfate BRAND PROVENTIL HFA 108 (90 BASE) MCG/ACT AERO SOLN albuterol sulfate BRAND terbutaline sulfate 2.5 mg tab generic VENTOLIN HFA 108 (90 BASE) MCG/ACT AERO SOLN albuterol sulfate BRAND PAGE 221 C C Non-Formulary Drug Non-Formulary Drug PA MDD 2 per day PA MDD 1.5 per day PA MDD 1.5 per day PA PA MDD 1.5 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS CYSTIC FIBROSIS AGENTS BETHKIS 300 MG/4ML NEBU SOLN tobramycin BRAND C Non-Formulary Drug CAYSTON 75 MG RECON SOLN aztreonam lysine BRAND C Non-Formulary Drug KALYDECO 150 MG TAB ivacaftor BRAND C Non-Formulary Drug KALYDECO 50 MG PACKET ivacaftor BRAND C Non-Formulary Drug KALYDECO 75 MG PACKET ivacaftor BRAND C Non-Formulary Drug ORKAMBI 200-125 MG TAB lumacaftor-ivacaftor BRAND C Non-Formulary Drug TOBI PODHALER 28 MG CAP tobramycin BRAND C Non-Formulary Drug tobramycin 300 mg/5ml nebu soln generic C Non-Formulary Drug tobramycin pak 300 mg/5ml nebu soln generic C Non-Formulary Drug BRONDIL 100-100 MG/15ML LIQUID dyphylline-guaifenesin BRAND PA caffeine citrate oral solution 20 mg/ml generic C Non-Formulary Drug caffeine citrate oral solution 20 mg/ml generic C Non-Formulary Drug DALIRESP 500 MCG TAB roflumilast BRAND C Non-Formulary Drug DILEX-G 400 200-400 MG TAB dyphylline-guaifenesin BRAND PA LUFYLLIN 200 MG TAB dyphylline BRAND PA LUFYLLIN 400 MG TAB dyphylline BRAND PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE PULMONARY ANTIHYPERTENSIVES ADEMPAS 2.5 MG TAB riociguat BRAND PA LETAIRIS 5 MG TAB ambrisentan BRAND PA PAGE 222 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS OPSUMIT 10 MG TAB macitentan BRAND ORENITRAM 1 MG TAB ER treprostinil diolamine BRAND TRACLEER 62.5 MG TAB bosentan BRAND VENTAVIS 20 MCG/ML SOLUTION iloprost BRAND PA ADVAIR HFA 115-21 MCG/ACT AEROSOL fluticasone-salmeterol BRAND PA ANORO ELLIPTA 62.5-25 MCG/INH AER POW BA umeclidinium-vilanterol BRAND PA benzonatate 200 mg cap generic PA biotuss 10-15-300 mg/5ml liquid generic PA biotuss pediatric 2.5-5-50 mg/ml liquid generic bromfed dm 30-2-10 mg/5ml syrup generic PA CLARINEX-D 12 HOUR 2.5-120 MG TAB ER 12H desloratadine-pseudoephedrine BRAND PA CLARINEX-D 24 HOUR 5-240 MG TAB ER 24H desloratadine-pseudoephedrine BRAND cromolyn sodium 20 mg/2ml nebu soln generic PA DULERA 100-5 MCG/ACT AEROSOL mometasone furoate-formoterol fumarate dihydrate BRAND C Non-Formulary Drug DULERA 200-5 MCG/ACT AEROSOL mometasone furoate-formoterol fumarate dihydrate BRAND C Non-Formulary Drug DYMISTA 137-50 MCG/ACT SUSPENSION azelastine hcl-fluticasone propionate BRAND C Non-Formulary Drug ESBRIET 267 MG CAP pirfenidone BRAND C Non-Formulary Drug giltuss pediatric 2.5-5-50 mg/ml liqd generic GILTUSS TR 20-30-600 MG TAB ER 12H phenylephrine w/ dm-gg BRAND guaifenesin er 600 mg tab er 12h generic guaifenex la 600 mg tab er 12h generic RESPIRATORY TRACT AGENTS, OTHER PAGE 223 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS hydrocodone-homatropine 5-1.5 mg tab generic J-TAN D SR 6-30 MG TAB ER 12H brompheniramine & phenyleph BRAND nebusal 3 % nebu soln generic NEBUSAL 6 % NEBU SOLN sodium chloride (inhalant) BRAND nohist-dm 10-4-15 mg/5ml liquid generic nortuss-de 2.5-5-50 mg/ml liquid generic NORTUSS-EX 20-200 MG/5ML LIQUID dextromethorphan-guaifenesin BRAND PA OFEV 100 MG CAP nintedanib esylate BRAND C Non-Formulary Drug OFEV 150 MG CAP nintedanib esylate BRAND C Non-Formulary Drug phenylephrine-chlorphen-dm 3.5-1-3 mg/ml liquid generic PA promethazine vc 6.25-5 mg/5ml syrup generic PA promethazine vc plain 6.25-5 mg/5ml syrup generic PA promethazine vc/codeine 6.25-5-10 mg/5ml syrup generic PA promethazine-phenyleph-codeine 6.25-5-10 mg/5ml syrup generic PA promethazine-phenylephrine 6.25-5 mg/5ml syrup generic PA pseudoeph-bromphen-dm 30-2-10 mg/5ml syrup generic PA pulmosal 7 % nebu soln generic PULMOZYME 1 MG/ML SOLUTION dornase alfa BRAND RESPAHIST-II 6-19 MG TAB ER 12H brompheniramine & phenyleph BRAND rhinacon a 4-40-20 mg tbcr generic PA ribavirin 6 gm recon soln generic C rinate pediatric 4.5-5 mg/5ml susp generic PA RYNATAN 9-25 MG TAB chlorpheniramine tannate-phenylephrine tannate BRAND PA PAGE 224 PA PA C Non-Formulary Drug Non-Formulary Drug LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS rynesa 12s 30-5 mg/5ml susp generic PA SEMPREX-D 8-60 MG CAP acrivastine & pseudoephedrine BRAND PA sodium chloride 0.9 % nebu soln generic PA sodium chloride 3 % nebu soln generic sodium chloride 7 % nebu soln generic STIOLTO RESPIMAT 2.5-2.5 MCG/ACT AERO SOLN tiotropium bromide-olodaterol hcl BRAND SYMBICORT 160-4.5 MCG/ACT AEROSOL budesonide-formoterol fumarate dihydrate BRAND SYMBICORT 80-4.5 MCG/ACT AEROSOL budesonide-formoterol fumarate dihydrate BRAND TUSSICAPS 10-8 MG CAP ER 12H hydrocodone polistirex-chlorpheniramine polistirex BRAND tussigon 5-1.5 mg tab generic TYZINE 0.05 % SOLUTION tetrahydrozoline hcl BRAND TYZINE 0.1 % SOLUTION tetrahydrozoline hcl PRODUCT DESCRIPTION C Non-Formulary Drug PA C Non-Formulary Drug BRAND C Non-Formulary Drug UTIBRON NEOHALER 27.5-15.6 MCG CAP indacaterol maleate-glycopyrrolate BRAND PA VITUZ 5-4 MG/5ML SOLUTION hydrocodone-chlorpheniramine BRAND C ZOTEX PEDIATRIC 2.5-3-35 MG/ML LIQUID phenylephrine w/ dm-gg BRAND PA AMRIX 15 MG CAP ER 24H cyclobenzaprine hcl BRAND C Non-Formulary Drug AMRIX 30 MG CAP ER 24H cyclobenzaprine hcl BRAND C Non-Formulary Drug carisoprodol 250 mg tab generic C Non-Formulary Drug carisoprodol 350 mg tab generic C Non-Formulary Drug carisoprodol-aspirin 200-325 mg tab generic C Non-Formulary Drug Non-Formulary Drug SKELETAL MUSCLE RELAXANTS PAGE 225 LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS chlorzoxazone 500 mg tab generic C Non-Formulary Drug cyclobenzaprine hcl 10 mg tab generic MDD LORZONE 375 MG TAB chlorzoxazone BRAND C Non-Formulary Drug LORZONE 750 MG TAB chlorzoxazone BRAND C Non-Formulary Drug metaxall 800 mg tab generic metaxalone 800 mg tab generic methocarbamol 750 mg tab generic 3 per day SLEEP DISORDER AGENTS GABA RECEPTOR MODULATORS EDLUAR 10 MG SL TAB zolpidem tartrate BRAND C Non-Formulary Drug EDLUAR 5 MG SL TAB zolpidem tartrate BRAND C Non-Formulary Drug estazolam 1 mg tab generic C Non-Formulary Drug estazolam 2 mg tab generic C Non-Formulary Drug eszopiclone 2 mg tab generic PA MDD 2 per day PA eszopiclone 3 mg tab generic MDD quazepam 15 mg tab generic temazepam 15 mg cap generic temazepam 22.5 mg cap generic temazepam 30 mg cap generic temazepam 7.5 mg cap generic triazolam 0.125 mg tab 2 per day C Non-Formulary Drug generic C Non-Formulary Drug triazolam 0.25 mg tab generic C Non-Formulary Drug zolpidem tartrate 5 mg tab generic MDD PAGE 226 1 per day LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE LIMITS & RESTRICTIONS SLEEP DISORDERS, OTHER PA armodafinil 150 mg tab generic MDD 1 per day PA armodafinil 250 mg tab generic MDD 1 per day PA armodafinil 50 mg tab generic MDD 2 per day BUTISOL SODIUM 30 MG TAB butabarbital sodium BRAND C Non-Formulary Drug BUTISOL SODIUM 30 MG/5ML ELIXIR butabarbital sodium BRAND C Non-Formulary Drug BUTISOL SODIUM 50 MG TAB butabarbital sodium BRAND C Non-Formulary Drug flurazepam hcl 15 mg cap generic C Non-Formulary Drug flurazepam hcl 30 mg cap generic C Non-Formulary Drug HETLIOZ 20 MG CAP tasimelteon BRAND C Non-Formulary Drug SECONAL 100 MG CAP secobarbital sodium BRAND C Non-Formulary Drug XYREM 500 MG/ML SOLUTION sodium oxybate BRAND C Non-Formulary Drug kionex 15 gm/60ml suspension generic PA sodium polystyrene sulfonate 15 gm/60ml suspension generic PA sps 15 gm/60ml suspension generic PA sps 15 gm/60ml suspension generic PA SYPRINE 250 MG CAP trientine hcl BRAND THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES ELECTROLYTE/MINERAL MODIFIERS ELECTROLYTE/MINERAL REPLACEMENT airavite 2.5-25-1 mg tab PAGE 227 generic PA LAST UPDATED 04/2017 BRAND/GENE LIMITS & RESTRICTIONS av-vite fb 2.5-25-1 mg tab generic PA durlaza 162.5 mg cap er 24h generic C fa-cyanocobalamin-pyridoxine 2.5-1-25 mg tab generic PA fa-vitamin b-6-vitamin b-12 2.2-25-0.5 mg tab generic PA fabb 2.2-25-1 mg tab generic PA folbee 2.5-25-1 mg tab generic PA folcaps 2.2-25-0.5 mg tab generic PA folplex 2.2 2.2-25-0.5 mg tab generic PA klor-con 10 10 meq tab er generic PA klor-con 8 meq tab er generic nufol 2.5-25-1 mg tab generic PA potassium chloride er 10 meq tab er generic PA potassium chloride er 20 meq tab er generic potassium chloride er 8 meq tab er generic tl gard rx 2.2-25-1 mg tab generic PA virt-gard 2.2-25-1 mg tab generic PA virt-vite 2.5-25-1 mg tab generic PA b-plex 0.5 mg tab generic PA b-plex plus 27mg-0.8mg tab generic biocel 800-250mcg tab generic choice-tabs 1-1000-5 tab generic corvite free 1.25-35mg tab generic levocarnitine 1 gm/10ml solution generic levocarnitine 330 mg tab generic lysiplex plus tab generic multi-b-plus tab generic nutrifac zx 1 mg tab generic PRODUCT DESCRIPTION PAGE 228 Non-Formulary Drug PA LAST UPDATED 04/2017 PRODUCT DESCRIPTION BRAND/GENE strovite plus 27mg-0.8mg tab generic therobec 500-0.5mg tab generic vit b3-azelac-turm-fa-b6-zn-cu tab generic vita s forte 10 mg-1 mg tab generic vitacel 800-250mcg tab generic PAGE 229 LIMITS & RESTRICTIONS PA LAST UPDATED 04/2017 Index of covered drugs A Alendronate Sodium 210 Alendronate Sodium-Cholecalciferol 211 Abacavir Sulfate 157 Alinia 149 Abacavir Sulfate-Lamivudine-Zidovudine 157 Alirocumab 177 Abiraterone Acetate 146 Aliskiren Fumarate 174 Abstral 121 Aliskiren-Amlodipine Acarbose 160 Aliskiren-Amlodipine-Hydrochlorothiazide Accu-Chek Compact Plus Care 211 Alka-Seltzer Extra Strength 173,174 171 3 Acetaminophen 16,17,47,48,49,50,51,52,53,54,55,57,5 AlleRx DF 211 8,59,60,62,63 AlleRx DF30 211 Almotriptan Malate 144 Alocril 214 Acetaminophen w/ Calcium Carbonate Acetaminophen w/ Codeine Acetaminophen w/ DM Acetaminophen w/ Pamabrom Acetaminophen-Caff-Dihydrocod Acetaminophen-Caffeine Acetaminophen-Caffeine-Pyrilamine 55 121 81 55,64 Aloe Grande 18 Alomide 214 Alosetron HCl 188 51,53,60,62,63 Alphagan P 216 52,55,59,63 Alprazolam 159 124 Acetic Acid 126 Alprostadil (Vasodilator) 191 Acetic Acid (Otic) 217 Alrex 215 Acetohydroxamic Acid 191 Altoprev 176 AcipHex Sprinkle 189 Alum & Mag Hydrox-Simethicone Acne Medication 5 18 Aluminum Acetate (Burow's) 34,36 19 Acrivastine & Pseudoephedrine 225 Aluminum Hydroxide-Mag Carb Acticlate 131 Aluminum Oxide 20 Acuvail 215 Aluminum Sulfate (Topical Astringent) 32 Acyclovir 158 Alvesco 218 Acyclovir Topical 158 Amantadine HCl 150 Adasuve 151 Ambenonium Chloride 145 Adempas 222 Ambrisentan 222 Adrenaclick 220 Amcinonide 192 Adrenalin 221 Amiloride & Hydrochlorothiazide 171 Advair HFA 223 Aminocaproic Acid 164 48 Amiodarone HCl 167 177 Amitriptyline HCl 140 Amlodipine Besylate 168 Advanced Care Cholesterol Advicor Afatinib Dimaleate 147,148 34,35 Afinitor 147 Amlodipine Besylate-Atorvastatin Calcium 171 Akne-Mycin 129 Amlodipine Besylate-Benazepril HCl 171 Akten 213 Amlodipine Besylate-Olmesartan Medoxomil 171 Albuterol Sulfate 221 Amlodipine Besylate-Valsartan 171 Alcaftadine 213 Amlodipine-Valsartan-Hydrochlorothiazide 171 Aldex-CT PAGE 230 77 Amoxapine 140,141 LAST UPDATED 04/2017 Amoxicillin 128,129 Armodafinil 227 207 Amoxicillin & Pot Clavulanate 129 Armour Thyroid Amoxicillin ER 128 Arnica Amphetamine-Dextroamphetamine 179 Artemether-Lumefantrine Ampicillin 129 Artificial Saliva Amrix 225 Artificial Tear Solution Amturnide 171 Ascriptin MS Anadrol-50 195 Asenapine Maleate 154 Anagrelide HCl 163 Asmanex 120 Metered Doses 218 Analpram-HC 182 Asmanex 14 Metered Doses 218 Androderm 195 Asmanex 30 Metered Doses 218 AndroGel 195 Asmanex 60 Metered Doses 218 AndroGel Pump 195 Aspirin Androxy 195 Aspirin (Platelet Aggregation Inhibitor) Angeliq 196 Aspirin Buffered (Al Hydrox-Mg Hydrox-Ca Carb) Anoro Ellipta 223 Aspirin Effervescent Antipyrine-Benzocaine 217 Aspirin-Acetaminophen-Caffeine 5 Antipyrine-Benzocaine-Polycosanol 218 Aspirin-Acetaminophen-Caffeine (Buffered) 8 Antiseborrheic Products, Misc. Anzemet APAP 500 23,29 142 48 19 149 17,18,182 64,65,66,67,68 3 3,4,5,6,7,8 228 3 3,4,5,6,7,8 Aspirin-Caffeine 4,6 Aspirin-Caffeine-Dihydrocodeine Bitartrate 121 Aspirin-Salicylamide-Caffeine 3 Aplenzin 137 Assure 3 Meter 211 Apraclonidine HCl 216 At Last Blood Glucose System 211 Aprepitant 142 Atazanavir Sulfate 158 Aptiom 135 Atazanavir Sulfate-Cobicistat 157 Aptivus 157 Atenolol 167 Aquafresh 49 Atenolol & Chlorthalidone 172 Aquafresh Advanced 48 Atomoxetine HCl 180 Aquafresh Cavity Protection 49 Atorvastatin Calcium 176 Aquafresh Dr Seuss 49 Atovaquone-Proguanil HCl 149 Aquafresh Extra Fresh 49 Atropine Sulfate (Ophthalmic) 213 Aquafresh Extreme Clean 49 Atrovent HFA 220 Aquafresh for Kids 49 Augmentin 129 Aquafresh Sensitive 49 Auranofin 210 Aquafresh Tartar Control 49 Auvi-Q 221 Aquafresh Whitening 49 Avanafil 191,192 Aquoral 182 Avandamet 160 Aranesp (Albumin Free) 164 Avandaryl 160 Arcapta Neohaler 221 Avandia 160 Arestin 182 AVC Vaginal 131 Aripiprazole 152 Axiron 195 PAGE 231 LAST UPDATED 04/2017 AzaSite 129 Benzocaine (Topical) Azelaic Acid 183 Benzocaine-Menthol (Mouth-Throat) Azelaic Acid (Acne) 182 Benzodent Azelastine HCl (Ophth) 215 Benzonatate Azelastine HCl-Fluticasone Propionate 223 Benzoyl Peroxide18,19,20,21,22,27,29,31,182,183,184 Azelex 182 Benzoyl Peroxide-Erythromycin 183 Azilsartan Medoxomil 165 Benzphetamine HCl 180 Azilsartan Medoxomil-Chlorthalidone 172 Benztropine Mesylate 150 Azithromycin 129,130 20,29 17 8 223 Benzyl Alcohol (Anesthetic) 18 129 Betadine Spray 49 Azo Test 49 Betamethasone 192 Azolen Tincture 12 Betamethasone Dipropionate (Topical) 192 Betamethasone Dipropionate Augmented 192 Betamethasone Valerate 192 Betaxolol HCl 168 Betaxolol HCl (Ophth) 216 Bethanechol Chloride 190 Bethkis 222 B-Complex w/ C & Folic Betimol 216 Acid Betoptic-S 216 Bexarotene 149 Bexarotene (Topical) 149 Azithromycin (Ophth) Azopt 216 Azostix 49 Aztreonam Lysine 222 B B-Complex w/ C & Calcium 101 101,103,104,105,107,111,113,114,116,228,229 B-Complex w/ C-Biotin-Vit E & Folic Acid Baby Orajel Tooth/Gum Cleanser Bacitracin Zinc 101 49 19,22,25,27,31 Bifera 99 Baclofen 154 Bimatoprost 217 Bactroban Nasal 126 Bio-Statin 142 Balnetar 19 Biotene Dry Mouth 49 Balsalazide Disodium 210 Biotene Dry Mouth Gentle 49 Banzel 135 Biotene Moisturizing Mouth 17 Baraclude 155 Biotene OralBalance Dry Mouth 17 Biotene PBF Dry Mouth 49 Barium Sulfate BC Fast Pain Relief Arthritis 211,212 3 Bisacodyl 41,42,43,44,45 Beclomethasone Diprop Monohyd 218 Blephamide 213 Beclomethasone Dipropionate 219 Blephamide S.O.P. 213 Beconase AQ 218 Blood Glucose Monitoring Supplies Belladonna Alkaloids & Opium 121 Bosentan 223 Bosulif 147 147 Benadryl Itch Relief 19 211,212 Benazepril & Hydrochlorothiazide 172 Bosutinib Benazepril HCl 166 BP Cleansing 20 20 Bentoquatam 27 Brasivol Benzocaine (Dental) 8,9 Brewers Yeast 102 Benzocaine (Mouth-Throat) 18 Brexpiprazole 153 PAGE 232 LAST UPDATED 04/2017 Brilinta 164 Brimonidine Tartrate 216 C Brintellix 138 Ca-Rezz Brinzolamide 216 Cabergoline 209 Brinzolamide-Brimonidine Tartrate 217 Cabozantinib S-Malate 147 Brisdelle 138 Caffeine Citrate 222 Brohist D 78 50 Cal-Glu 99 Bromfenac Sodium (Ophth) 215 Calcipotriene 183 Bromocriptine Mesylate 150 Calcipotriene-Betamethasone Dipropionate 185 Brompheniramine & Calcium & Phosphorus 100 Phenyleph78,79,80,82,84,86,87,90,91,92,94,95,97,224 Calcium Carbonate-Mag Hydrox Brompheniramine & Pseudoeph Calcium Citrate 99 Calcium Gluconate 99 99 95 Brompheniramine Maleate 74,220 Brompheniramine Tannate 219 Calcium Lactate Brondil 222 Calcium Polycarbophil Brovex PSE DM Budesonide Budesonide (Inhalation) Budesonide-Formoterol Fumarate Dihydrate Bug Itch ReLeaf Bumetanide BUN Test 78 210 218,219 225 50 174 49 34,35,36,37 41,42,43,44,45 Camphor-Menthol-Methyl Salicylate 25 Canagliflozin 161 Candesartan Cilexetil 165 Candesartan Cilexetil-Hydrochlorothiazide 172 Capecitabine 147 Caphosol 182 Capmist DM 78 Bupap 180 Capsagel Extra Strength 20 Buphenyl 186 Capsaicin 20 Buprenorphine HCl 125 Capsaicin-Menthol-Methyl Salicylate 29 Buprenorphine HCl-Naloxone HCl Dihydrate 125 Captopril 166 Bupropion HCl 137 Captopril & Hydrochlorothiazide 172 Bupropion Hydrobromide 137 Carbachol (Ophth) 216 Buspirone HCl 159 Carbamazepine 135 Busulfan 146 Carbamide Peroxide (Otic) Butabarbital Sodium 227 Carbidopa 69,70 150 Butalbital-Acetaminophen 180,181 Carbidopa-Levodopa 150,151 Butalbital-Acetaminophen-Caffeine 180,181 Carbidopa-Levodopa-Entacapone 150 219 Butalbital-Acetaminophen-Caffeine w/ Codeine 121 Carbinoxamine Maleate Butalbital-Aspirin-Caffeine w/Cod 121 Carboxymethylcellulose Sodium (Ophth) Butamben-Tetracaine-Benzocaine 183 Cardene SR 168 Butenafine HCl 13,144 Carisoprodol 225 Butisol Sodium 227 Carisoprodol w/ Aspirin 225 Bydureon 160 Carisoprodol w/ Aspirin & Codeine 121 Carmol-HC 192 Carteolol HCl (Ophth) 216 PAGE 233 64,65,67,68 LAST UPDATED 04/2017 Carvedilol Castellani Paint 168 Chlorthalidone 175 20 Chlorzoxazone 226 211 Cayston 222 Choice DM Diabetes Risk Test Cedax 127 Cholesterol Test 48 Cefaclor 127 Cholestyramine 177 Cefaclor Monohydrate 127 Cholestyramine Light 177 Choline Bitartrate 102 Cefadroxil 127,128 Cefdinir 128 Cialis Cefditoren Pivoxil 128 Ciclesonide 218 Cefixime 128 Ciclesonide (Nasal) 219 Cefpodoxime Proxetil 128 Ciclopirox 143 Cefprozil 128 Ciloxan 130 Ceftibuten 127,128 190,191 Cimetidine 37,38,39,40,188 Cefuroxime Axetil 128 Cinacalcet HCl 209 Celecoxib 117 Cipro HC 217 Celestone 192 Ciprodex 217 Cenestin 197 Ciprofloxacin 130 Cephalexin 128 Ciprofloxacin HCl (Ophth) 130 Cervidil 191 Ciprofloxacin HCl (Otic) 130 Cetacaine 183 Ciprofloxacin-Ciprofloxacin HCl 130 Ciprofloxacin-Dexamethasone 217 Ciprofloxacin-Hydrocortisone 217 Cetirizine HCl 70,71,72,74,76,77 Cetylpyridinium Chloride (Mouthwash) 17 Charcoal Activated 48,50 Citalopram Hydrobromide 138 Charcoal Activated-Sorbitol 48,54 Citric Acid & D-Gluconic Acid 191 Clarinex 219 Chiggerex 20 Chlordiazepoxide-Amitriptyline 137 Clarinex-D 12 Hour 223 Chloroquine Phosphate 149 Clarinex-D 24 Hour 223 Chlorothiazide 175 Clarithromycin 129 Chlorphen-Phenyltolox-PE 224 Clean & Clear Advantage 3-in-1 Chlorpheniramine & Phenylephrine Chlorpheniramine & Pseudoeph 89,96 71,72,73,75,76,77,219 Cleocin 126 Climara Pro 197 Chlorpheniramine Tannate-Phenylephrine Tannate 224 Clindamycin HCl 126 Chlorpheniramine w/ Codeine Clindamycin Palmitate Hydrochloride 126 Clindamycin Phosphate (Topical) 126 Clindamycin Phosphate Vaginal 126 Chlorpheniramine-Phenylephrine- Clioquinol-Hydrocortisone & Emollient 183 Acetaminophen 77,79,80,82,83,84,85,87,89,90,92,93,9 Clobazam 133,134 6 Clobetasol Propionate 192,193 Chlorpheniramine Maleate Chlorpheniramine-DM Chlorpheniramine-Methscopolamine 78,81,91,93,94,97 Clemastine Fumarate 20 70,72,73 82 79,83,87,93 211 Chlorpromazine HCl 151 Clobetasol Propionate & Cleanser 193 Chlorpropamide 160 Clodan 193 PAGE 234 LAST UPDATED 04/2017 Clomiphene Citrate 206 Crizotinib 148 Clomipramine HCl 141 Crofelemer 188 Clonazepam 159 Cromolyn Sodium 223 Clonidine & Chlorthalidone 172 Cromolyn Sodium (Ophth) 215 Clonidine HCl 164 Crotamiton 149 Clopidogrel Bisulfate 164 Curasore 17 Clorazepate Dipotassium 159 Curity Povidone-Iodine Paint 50 Clorpres 172 CVS Dry Mouth 17 Clotrimazole 143 CVS Epsom Salt 51 11,12,13,14,15,143 Cyanocobalamin 101,103,112,113,114,116 Clotrimazole (Topical) Clotrimazole Vaginal 12,14,15 Cyclizine HCl 11 Clotrimazole w/ Betamethasone 183 Cyclobenzaprine HCl Clozapine 154 Cyclomydril 213 Cyclopentolate HCl 213 Coal Tar Extract 19,24,27,29 225,226 Coartem 149 Cyclopentolate w/ Phenylephrine 213 Cobicistat 157 Cyclophosphamide 146 Coca Cola 11 Cyclosporine 210 Cocoa Butter Petroleum Jelly 21 Cyproheptadine HCl 219 Cystaran 213 Cysteamine HCl 213 Codeine Sulfate 121,122 Codituss DM 78 Coditussin AC 79 Colchicine 144 D Colesevelam HCl 178 Dabigatran Etexilate Mesylate 163 Colestipol HCl 177 Daclatasvir Dihydrochloride 155 50 Daklinza 155 Cometriq (100 mg Daily Dose) 147 Daliresp 222 Complera 156 Dalteparin Sodium 163 Conjugated Estrogens-Bazedoxifene 198 Danazol 195 Dantrolene Sodium 154 Colgate Platinum Conjugated Estrogens-Medroxyprogesterone Acetate 203 Dapagliflozin Propanediol 160 Contour Next One 211 Daraprim 149 CopaSil 183 Darbepoetin Alfa 164 Cordran 193 Darifenacin Hydrobromide 190 Corlanor 172 Darunavir Ethanolate 158 Creon 186 Dasatinib 148 Crest 50 Daytime Cold Medicine Crest Tartar Control 50 Daytrana 179 Crest TC/Baking Soda 50 Debacterol 182 81 Cresyl Acetate 218 Delavirdine Mesylate 156 Cresylate 218 Delzicol 210 Crinone 205 Demarest Plus PAGE 235 23 LAST UPDATED 04/2017 Demeclocycline HCl 131 Dextromethorphan- Demser 172 Guaifenesin 78,80,81,82,83,85,86,87,88,91,92,94,95,2 Dentifrices 48,49,50,57,59,60,61,63,212 Dermasorb AF 183 24 Dextromethorphan-Phenylephrine- DermaZinc Baby 23 Acetaminophen 77,79,80,81,82,83,84,85,86,87,90,91,9 DermaZinc Scalp 23 2,93,94,95,96,97 Descovy 157 Dextrose (Diabetic Use) 15 Desipramine HCl 141 Di-Delamine 24 Diabetic Tussin Cold/Flu 81 Desloratadine 219,220 Desloratadine-Pseudoephedrine 223 Diazepam 159 Desmopressin Acetate 195 Diazepam (Anticonvulsant) 133 Desmopressin Acetate Spray Refrigerated 195 Diazoxide 162 Diclegis 141 Diclofenac 118 Diclofenac Epolamine 117 Diclofenac Potassium 117,118 Desogestrel & Ethinyl Estradiol 196,198,199,200,203 Desogestrel-Ethinyl Estradiol (Biphasic) 196,197,198,200,203,204 Desogestrel-Ethinyl Estradiol (Triphasic) Desonide 197,204 193 Desoximetasone 193,195 Diclofenac Sodium 117 Diclofenac Sodium (Topical) 117,118 Desvenlafaxine Fumarate 138 Diclofenac w/ Misoprostol 117 Desvenlafaxine Fumarate ER 138 Dicloxacillin Sodium 129 Desvenlafaxine Succinate 138 Dicyclomine HCl 187 Didanosine 157 Diethylpropion HCl 181 Dex-Tuss 81 Dexamethasone 192,193 Dexamethasone (Ophth) 215 Dificid 129 Dexamethasone Sodium Phosphate (Ophth) 215 Digibar 190 211 Dexchlorpheniramine Maleate 220 Digoxin 172 Dexilant 189 Dihydroergotamine Mesylate 144 Dexlansoprazole 189 Dilatrate-SR 178 179,180 Dilex-G 400 222 Diltiazem HCl 169 Dexmethylphenidate HCl DexPak 6 Day 193 Dexpanthenol (Topical) 29 Dextroamphetamine Sulfate 179 Diltiazem HCl Coated Beads Diltiazem HCl Extended Release Beads 168,169 169 Dextromethorphan HBr 79,80,85,86,90,91,92,93,96,97 Dimethyl Fumarate 181,182 Dextromethorphan HBr-Quinidine Sulfate Dimethyl Sulfoxide 191 Dinoprostone 191 181 Dextromethorphan Polistirex 79,80,81,82,83,84,86,91,92 Dextromethorphan-AcetaminophenChlorpheniramine Diphenhydramine & Pseudoephed Diphenhydramine HCl 81 96 70,71,72,73,74,75,76,77,220 Diphenhydramine HCl (Topical) 19,22,27,32 Dextromethorphan-Doxylamine- Diphenhydramine HCl-Phenylephrine HCl Tannate 77 Acetaminophen 77,79,80,81,82,83,85,86,87,89,90,91,9 Diphenhydramine-Acetaminophen 2,93,94,95,96 Diphenhydramine-Acetaminophen (sleep) PAGE 236 77,89,95 98 LAST UPDATED 04/2017 Diphenhydramine-Menthol 23 DiphenhydraminePhenylephrine 79,80,81,82,85,89,90,92,95,96 Diphenhydramine-PseudoephedrineAcetaminophen 82,83,92,93 Diphenhydramine-Tripelenamine 24 Diphenhydramine-Zinc Acetate 18,19,23,24,25,27,30,32,33,34 Diphenoxylate w/ Atropine 187,188 Duexis 117 Dulera 223 Duofer 99 Duraflex Comfort 24 Dutasteride 190 Dymista 223 Dyphylline 222 Dyphylline-Guaifenesin 222 Dyrenium 175 Dipyridamole 164 Disopyramide Phosphate 167 E Disulfiram 125 E-Z-HD 211 Diuril 175 EasyGluco 211 Divalproex Sodium 133 Echothiophate Iodide 216 Divigel 198 Econazole Nitrate 143 Ecoza 143 Docusate Sodium 41,42,44,45 Dofetilide 167 Ed ChlorPed Dolasetron Mesylate 142 Edarbi 165 Dolutegravir Sodium 156 Edarbyclor 172 Edluar 226 Donepezil Hydrochloride 135,136 72 Dornase Alfa 224 Efinaconazole 143 Doxazosin Mesylate 165 Eflornithine HCl 186 Doxepin HCl 141 Elbasvir-Grazoprevir 156 Doxycycline 131 Eldertonic 104 Doxycycline (Monohydrate) 131,132 Eletriptan Hydrobromide 145 Doxycycline (Rosacea) 131,132 Elidel 183 Doxycycline Calcium 132 Doxycycline Hyclate 131,132 Doxylamine Succinate 220 Doxylamine Succinate (Sleep) 97,98 ElixSure Congestion 51 Ellis Tonic 104 Elta Tar 24 Eltrombopag Olamine 164 Doxylamine-Pyridoxine 141 Eluxadoline Doxytex 220 Elvitegravir-Cobicistat-Emtricitabine-Tenofovir Dronabinol 142 Alafenamide Dronedarone HCl 167 Elvitegravir-Cobicistat-Emtricitabine-Tenofovir DF 156 Drospirenone-Estradiol 196 Emadine 215 Embeda 118 Emedastine Difumarate 215 Drospirenone-Ethinyl Estradiol 198,199,201,202,203,204 188,189 156 Droxia 147 Emollient Droxidopa 173 Empagliflozin-Metformin HCl Dry Mouth Spray Duavee PAGE 237 17 198 19,21,22,23,24,26,27,28,30,31,32,33,183 161,162 Emsam 138 Emtricitabine 157 LAST UPDATED 04/2017 Emtricitabine-Rilpivirine-Tenofovir Alafenamide Fumarate Estazolam 156 Emtricitabine-Rilpivirine-Tenofovir Disoproxil 226 Esterified Estrogens & Methyltestosterone 197,198,199 Estrace 199 Fumarate 156 Estradiol Emtricitabine-Tenofovir Alafenamide Fumarate 157 Estradiol Vaginal 199 Emtricitabine-Tenofovir Disoproxil Fumarate 157 Estradiol Valerate-Dienogest 201 Emtriva 157 Estradiol-Levonorgestrel 197 Enalapril Maleate 166 Estrasorb 199 Enalapril Maleate & Hydrochlorothiazide 172 Estrogens, Conjugated 203 198,199 Estrogens, Conjugated Synthetic A 197 Entecavir 155 Estrogens, Conjugated Synthetic B 198,199 Entresto 172 Estropipate 199 Eszopiclone 226 Ethacrynic Acid 174 Ethionamide 146 Ethosuximide 133 Ethotoin 135 Enjuvia Ephedrine-Guaifenesin 78,79,92 Epinastine HCl (Ophth) 215 Epinephrine EPINEPHrine Epinephrine (Base) 220,221 221 77 198,199 Epinephrine HCl (Nasal) 221 Ethyl Alcohol (Skin Cleanser) 30 Epivir HBV 155 Ethynodiol Diacet & Eth Estrad Eplerenone 175 Etodolac 117 Eprosartan Mesylate 165 Etonogestrel-Ethinyl Estradiol 202 199,200,205 Epsom Salt 51 Eurax 149 EQL Dry Mouth Oral Rinse 17 Evamist 199 EQL Epsom Salt 52 EvenCare Glucose Monitoring 211 147 Equagesic 117 Everolimus Ergotamine w/ Caffeine 144 Evolocumab Erlotinib HCl 148 Evotaz 157 Ertaczo 143 Exelon 136 Ery-Tab 129 Exemestane 147 EryPed 400 129 Exenatide 160 129,130 Ezetimibe-Atorvastatin 177 130 Ezetimibe-Simvastatin 178 Ezogabine 133 Erythromycin (Acne Aid) Erythromycin (Ophth) Erythromycin Base 129,130 Erythromycin Base (Coated) 130 Erythromycin Ethylsuccinate 129,130 177,178 F Erythromycin-Sulfisoxazole 126 Factive 130 Esbriet 223 Famciclovir 158 Eslicarbazepine Acetate 135 Famotidine 37,38,39,40 Esocor P 84 Famotidine-Calcium Carbonate-Magnesium Esomeprazole Magnesium 189 Hydroxide Esomeprazole Strontium 189 Fanapt PAGE 238 37,38,39,40 152,153 LAST UPDATED 04/2017 Fanapt Titration Pack 153 Fluocinolone Acetonide (Ophth) 215 Fareston 146 Fluocinolone Acetonide (Otic) 218 Farxiga 160 Fluocinolone-Emollient 194 Farydak 147 Fluocinonide 193 Febuxostat 144 Fluorometholone (Ophth) 215 Felbamate 134 Fluorouracil (Topical) 183 Felodipine 169 Fluoxetine HCl 139 Fenofibrate 175 Fluoxetine HCl (PMDD) Fenofibrate Micronized 175 Fluoxymesterone 195 Fenoprofen Calcium 117 Fluphenazine HCl 151 Fentanyl 118 Flurandrenolide 193 121,122,123 Flurazepam HCl 227 Flutamide 146 Fentanyl Citrate Fentora 122 Feosol Bifera 99 Ferrous Sulfate 99,100 Fesoterodine Fumarate 190 138,140 Fluticasone Furoate 70,219 Fluticasone Propionate 193 Fluticasone Propionate (Inhalation) 219 Feverall 53 Fluticasone Propionate HFA 219 FeverAll Infants 53 Fluticasone-Salmeterol 223 Fluvastatin Sodium 176 Fluvoxamine Maleate 139 Fexofenadine HCl 70,71,72,73,74,75,76,77 Fexofenadine-Pseudoephedrine 79,84,91,95,96,97 Fidaxomicin 129 FML 215 Filgrastim-sndz 164 FML Forte 215 Finacea 183 Folic Acid 103,104,105,106,107,111,112,113,114,116 Finasteride (Alopecia) 183 Folic Acid-Vitamin B6-Vitamin B12 Firazyr 209 Fondaparinux Sodium 163 First-Progesterone VGS 100 205 FORA V10/V12/D10/D20 Test 212 First-Progesterone VGS 200 205 Foradil Aerolizer 221 First-Progesterone VGS 25 205 Formaldehyde 212 First-Progesterone VGS 400 205 Formoterol Fumarate 221 First-Vancomycin 25 126 Forteo 210 Flagyl ER 126 Fosamax Plus D 211 Flector 117 Fosamprenavir Calcium 158 25 Fosrenol 192 193 Fragmin 163 Flexall Ultra Plus Flo-Pred 99,227,228 Flonase Sensimist 70 FreeStyle Flash System 212 Florical 99 FreeStyle System 212 Flovent Diskus 219 Frovatriptan Succinate 145 Flovent HFA 219 Fulyzaq 188 Fluconazole 143 Fungi-Nail 25 Flucytosine 143 Fungoid Tincture 13 Fluocinolone Acetonide 193 Furosemide PAGE 239 174 LAST UPDATED 04/2017 Fycompa 133 Griseofulvin Ultramicrosize 143 Guaifenesin 78,79,80,81,82,83,84,85,86,87,88,89,90,9 G 1,92,93,94,95,96,97,223 Gabapentin 133 Guaifenesin-Codeine 79,81 Gabapentin (Once-Daily) 133 Guanfacine HCl Gabitril 133 Guanfacine HCl (ADHD) Galantamine Hydrobromide 136 Gatifloxacin (Ophth) 130 H Gefitinib 148 Halcinonide 193 Gemfibrozil 175 Halobetasol Propionate 193 Gemifloxacin Mesylate 130 Halog 193 Gentamicin Sulfate (Topical) 125 Haloperidol 151 Gentamicin-Prednisolone Acetate 214 Harvoni 155 147 164,165 GenTeal Mild 65 Hemangeol GenTeal Severe 65 Hematest Gentian Violet 25 Hemoglobin A1c (HbA1c) Test 180 54 48,51 Genvoya 156 Heparin Sodium (Porcine) 163 Giazo 210 Hetlioz 227 Gilotrif 147,148 Histex 74 54 Giltuss TR 223 HIV-1 Test Glimepiride 160 Homatropine HBr Glipizide 160 Home Access Express HIV-1 Test 54 Glipizide-Metformin HCl 161 Home Access HIV-1 Test System 54 GlucoLab Glucose Monitoring 212 Homocysteine Formula 99 Glyburide 161 HumaLOG 162 Glyburide Micronized 161 HumaLOG Mix 50/50 162 Glyburide-Metformin 161 HumuLIN 70/30 162 HumuLIN R U-500 (CONCENTRATED) 162 Hydralazine HCl 178 Glycerin (Laxative) Glycerin (Topical) 41,42,44,45 23,25,26,30,31,32 213 Glycerin-Hypromellose-Polyethylene Glycol Hydrocodone Bitartrate 400 Hydrocodone Polistirex-Chlorpheniramine 64,66,67,68 119,120,121 Glycerol Phenylbutyrate 186 Polistirex Glycopyrrolate 187 Hydrocodone w/ Homatropine 224,225 Glycopyrrolate (Inhalation) 220 Hydrocodone-Acetaminophen 121,122,123,124,125 Goodys Extra Strength 5 225 Hydrocodone-Chlorpheniramine 225 Gordochom 26 Hydrocodone-Ibuprofen Gordons-Vite A 26 Hydrocortisone Gralise 133 Hydrocortisone Gralise Starter 133 (Topical)19,20,21,22,23,24,25,26,27,28,29,30,31,32,33 Granisetron 142 ,182,183,184 Griseofulvin Microsize 143 Hydrocortisone Acetate w/ Pramoxine PAGE 240 123,124 193 182,183 LAST UPDATED 04/2017 Hydrocortisone Acetate-Urea 192,195 Insulin Detemir 162 Hydrocortisone Butyrate 193 Insulin Glargine 162 Hydrocortisone Probutate 194 Insulin Isophane & Reg (Human) 162 Hydrocortisone Valerate 194 Insulin Lispro (Human) 162 Hydrocortisone w/Acetic Acid 217,218 Insulin Lispro Protamine & Lispro (Human) 162 Hydromorphone HCl 119,123 Insulin NPH Isophane & Reg (Human) 162 Hydroxychloroquine Sulfate 149 Insulin Regular (Human) 162 Hydroxyurea (Sickle Cell Anemia) 147 Invirase 158 Hydroxyzine HCl 220 Invokana 161 Hydroxyzine Pamoate 220 Iodoquinol 126 Hyoscyamine 190 Iopidine 216 Hyoscyamine Sulfate 187 Ipratropium Bromide 220 HypoTears 66 Ipratropium Bromide (Nasal) 220 Hypromellose (Gonioscopic) 66 Ipratropium Bromide HFA 220 Irbesartan 165 Irbesartan-Hydrochlorothiazide 172 Iressa 148 Iron 100 Iron Heme Polypeptide 111 Isentress 156 Hypromellose (Ophth) 65,66,67,68 Hysingla ER 119 I Ibrance Ibuprofen 148 3,4,5,6,7,8,117 Ibuprofen-Diphenhydramine Citrate 97,98 Isometheptene-Dichloralphenazone- Ibuprofen-Famotidine 117 Acetaminophen 212 Icatibant Acetate 209 Isoniazid 145 Iclusig 148 Isoniazid-Rifampin w/ Pyrazinamide 146 Icosapent Ethyl 178 Isopropyl Alcohol 54 Idelalisib 149 Isopto Carbachol 216 Isopto Homatropine 213 213 Iloperidone 152,153 Iloprost 223 Isopto Hyoscine Imatinib Mesylate 148 Isopto Tears Imipramine HCl 141 Isosorbide Dinitrate 178 Imipramine Pamoate 141 Isosorbide Mononitrate 178 Imiquimod 184,186 Isotretinoin 66 182,183,184,186 Indacaterol Maleate 221 Isradipine Indacaterol Maleate-Glycopyrrolate 225 Itraconazole Indapamide 175 Ivabradine HCl 172 Indocin 117 Ivacaftor 222 Indomethacin 117 Ivermectin (Rosacea) 149 Inositol 107 Ivy Block 27 Ivy Dry 27 Ivy Itch ReLeaf 54 Inositol Niacinate (Bulk) Insulin Aspart Protamine & Aspart (Human) Insulin Degludec PAGE 241 54,212 162 169 143,144 162,163 LAST UPDATED 04/2017 Lecithin 107 Ledipasvir-Sofosbuvir 155 224 Leflunomide 210 74 Lenalidomide 146 J J-Tan D SR J-Tan PD Jakafi 148 Lenvatinib Mesylate 148 Janumet 161 Lenvima 10 MG Daily Dose 148 Januvia 161 Lenvima 20 MG Daily Dose 148 Jublia 143 Letairis 222 Juxtapid 177 Leucovorin Calcium 147 Leukine 164 K Leukocyte Test Kalydeco 222 Kera Tek 49 Levalbuterol HCl 221 27 Levatol 168 Ketoprofen 118 Levemir 162 Ketorolac Tromethamine 118 Levetiracetam 133 Ketorolac Tromethamine (Ophth) 215 Levitra 191 Levobunolol HCl 216 Ketotifen Fumarate (Ophth) Kombiglyze XR 64,65,66,67,68,69,213 161 Levocarnitine 102,107 Kondremul 43 Levocarnitine (Metabolic Modifiers) Konsyl 43 Levocetirizine Dihydrochloride 220 Konsyl-D 43 Levofloxacin 130 Kristalose 189 Levofloxacin (Ophth) 130 Kuvan 186 Levonorgestrel & Eth Estradiol L Lacosamide Lactase 34,35,36 Lactic Acid (Ammonium Lactate) Lactic Acid w/ Vitamin E 196,197,198,199,200,201,202,203,204 Levonorgestrel (Emergency OC) 135 Levonorgestrel (IUD) 27,184 47,205,206 206 Levonorgestrel-Eth Estradiol (Triphasic) 18,19,22,23,25,182,184 107,108,228 199,200,201,204 Levonorgestrel-Ethinyl Estradiol (91Day) 196,197,198,199,201,203 Lactulose 189 Levonorgestrel-Ethinyl Estradiol (Continuous) 196,201 LamISIL 143 Levothyroxine Sodium Lamivudine (HBV) 155 Lexiva 158 Lamotrigine 134 LidaMantle HC 184 Lidocaine HCl 184 213 Lansoprazole 46,189,190 207,208 Lanthanum Carbonate 192 Lidocaine HCl (Ophth) Lantus 162 Lidocaine-Benzalkonium Lapatinib Ditosylate 148 Lidocaine-Hydrocortisone Acetate 184 Lastacaft 213 Lidocaine-Prilocaine 125 Latuda 153 Liniments & Rubs Lazanda 123 Liothyronine Sodium PAGE 242 28 24,34 207 LAST UPDATED 04/2017 Liotrix (T3-T4) 208 Magnesium Lactate Liptruzet 177 Magnesium Oxide Liquid E-Z-Paque 212 Magnesium Oxide (Laxative) Liquid Polibar 212 Magnesium Salicylate Tetrahydrate Liquimat 27 100 36,37 Magnesium Sulfate (Laxative) 41 3,4,7 51,52,59 Lisdexamfetamine Dimesylate 179 Mapap Headache Plus Lisinopril 166 Maprotiline HCl 139 Lisinopril & Hydrochlorothiazide 173 Maraviroc 157 Lithium 159 Marezine 11 Maxichlor DM 87 Lithium Carbonate 159,160 55 Lithostat 191 Maxichlor PEH DM 87 Livalo 176 Maxifed DM 87 Lodoxamide Tromethamine 214 Mebendazole 149 Lomitapide Mesylate 177 Meclizine HCl 11,141,142 Loperamide HCl 34,35,36,37 Medrol 194 158 Mefenamic Acid 118 Loratadine 70,71,72,73,74,75,76,77 Mefloquine HCl 149 Lorazepam 159 Megestrol Acetate 206 Lorzone 226 Mekinist 148 Losartan Potassium 165 Meloxicam 118 Losartan Potassium & Hydrochlorothiazide 173 Memantine HCl 136 Lotemax 215 Mentax 144 Loteprednol Etabonate 215 Menthol (Topical Analgesic) Loteprednol Etabonate-Tobramycin 214 Menthol-Methyl Salicylate (Liniments) Lopinavir-Ritonavir Lotrimin Ultra 13 19,20,23,29,31 24,27 Meperidine HCl 123 Lovastatin 176 Meprobamate 159 Loxapine 151 Meprobamate-Aspirin 117 Mercaptopurine 147 Loxapine Succinate 151,152 Lufyllin 222 Mercuroclear 28 Luliconazole 143 Mesalamine 210 Lumacaftor-Ivacaftor 222 Metamucil 43 Lumigan 217 Metamucil MultiHealth Fiber 43 Lurasidone HCl 153 Metaproterenol Sulfate 221 Luzu 143 Metaxalone 226 Lyrica 181 Metformin HCl 161 Methadone HCl 119 Methamphetamine HCl 179 M Macitentan 223 Methazolamide 216 Mag-Tab SR 100 Methenamine Hippurate 126 Magnesium Gluconate 100 Methenamine Mandelate 126 Magnesium Hydroxide 41,42,43,44,45 PAGE 243 LAST UPDATED 04/2017 Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl Misoprostol 189 Sal Moderiba 1200 Dose Pack 155 126,127 Methimazole 209 Moderiba 800 Dose Pack 155 Methionine 108 Moexipril HCl 166 Methitest 195 Moexipril-Hydrochlorothiazide 173 Methocarbamol 226 Moi-Stir Methotrexate Sodium 210 Mometasone Furoate 194 Methscopolamine Bromide 187 Mometasone Furoate (Inhalation) 218 Methyclothiazide 175 Mometasone Furoate-Formoterol Fumarate Methylcellulose (Laxative) 42,45 17 Dihydrate 223 Methyldopa 165 Monistat 7 Combo Pack App 14 Methyldopa & Hydrochlorothiazide 173 Morphine Sulfate 119,123 Methylphenidate 179 Morphine Sulfate Beads 119,120 Methylphenidate HCl 180 Morphine-Naltrexone Methylprednisolone 194 Mouth Kote Methyltestosterone 195,196 118 17 Mouthwashes 17,18 Metipranolol 216 Movantik 188 Metoclopramide HCl 142 MoviPrep 189 Metolazone 175 Moxatag 129 Metoprolol & Hydrochlorothiazide 173 Moxifloxacin HCl (Ophth) 131 Metoprolol Tartrate 168 Mozobil 164 Metronidazole 126 Mucinex For Kids Metronidazole (Topical) 126,127 88 Multaq 167 111 Metyrosine 172 Multiple Vitamin MI Paste 212 Multiple Vitamins w/ MI Paste Plus 212 Minerals 100,101,102,103,104,105,106,107,108,109,11 Miconazole Nitrate (Topical) 11,12,13,14,15 Miconazole Nitrate Vaginal 12,13,14,15,144 0,111,112,113,114,115,116,228,229 Mupirocin 126 126 Miglitol 161 Mupirocin Calcium Milnacipran HCl 181 Muro 128 66 Mineral Oil 43 Muse 191 Mineral Oil-Hydrophil Petrolat 28 Myco Nail A Mineral Oil-Hydrophilic Petrolatum 28 Mycophenolate Mofetil 210 29 Minocycline HCl 132 MyKidz Iron 10 100 Minocycline HCl (Subgingival) 182 Myleran 146 Minoxidil 178 Mytelase 145 Mytesi 188 Minoxidil (Topical) Miranel AF 22,25,26,27,28,30,31,33 14 Mirena (52 MG) 206 N Mirtazapine 137 Na Sulfate-K Sulfate-Mg Sulfate & PEG3350-NaCl-Na Misc Natural Products PAGE 244 50,54 Bicarb-KCl 189 LAST UPDATED 04/2017 Nadolol 168 Niacin (Antihyperlipidemic) 177 Nafarelin Acetate 209 Niacin-Lovastatin 177 Naftifine HCl 144 Niacin-Simvastatin 178 Naftin 144 Nicardipine HCl Naloxegol Oxalate 188 Nicotine Namenda XR 136 Nicotine Polacrilex Naphazoline HCl 213 Nicotrol 125 Nicotrol NS 125 Naphazoline w/ Pheniramine 64,65,67,68,69 168,169 125 9,10,11 Naphazoline-Hypromellose 65,67,68 Nifedipine 168,169 Naphazoline-Polyethylene Glycol 300 65,67,68 Nilotinib HCl 148 Naprelan 118 Nilutamide 146 Naproxen 118 Nimodipine 169 Naproxen Sodium 118 Nintedanib Esylate 224 Naproxen-Esomeprazole Magnesium 118 Nisoldipine 170 Naratriptan HCl 145 Nitazoxanide 149 Nitrofurantoin Macrocrystal 126 127 Nat-Rul Psyllium Seed Husks 43 Natazia 201 Nitrofurantoin Monohyd Macro Nateglinide 161 Nitroglycerin Nature-Throid 207,208 178,179 Nizatidine 188 Nebusal 224 Norelgestromin-Ethinyl Estradiol 202,204 Necon 1/50 (28) 201 Norethin Acet & Estrad-Fe Necon 10/11 (28) 202 Norethindrone & Eth Nedocromil Sodium (Ophth) 214 Estradiol Nefazodone HCl 139 Norethindrone & Ethinyl Estradiol-Fe Nelfinavir Mesylate 158 Norethindrone & Mestranol 201,202 205,206 197,200,201,202,203 196,197,198,200,201,202,203,204 202,204,205 Neo-Synephrine 57 Norethindrone (Contraceptive) Neo-Synephrine Cold & Sinus 57 Norethindrone Acetate-Ethinyl Estradiol Neomycin-Bacitracin Zn-Polymyxin Norethindrone Acetate-Ethinyl Estradiol-Fe 203 Neomycin-Bacitracin-Polymyxin w/ Lidocaine 25,30,32 Norethindrone-Eth Estradiol (Biphasic) 202 Neomycin-Polymy-Dexameth 214 Norethindrone-Eth Estradiol Neomycin-Polymyxin-Gramicidin 214 (Triphasic) 196,197,198,200,202,203 Neomycin-Polymyxin-HC (Ophth) 214 Norfloxacin 130 Neomycin-Polymyxin-HC (Otic) 213,214 199,200,202 217,218 Norgestimate-Ethinyl Estradiol 199,201,202,203 Neomycin/Polymyxin B GU 126 Norgestimate-Ethinyl Estradiol (Triphasic) 202,203,204 Nepafenac 215 Norgestrel & Ethinyl Estradiol Neutrogena T/Gel Conditioner 29 197,198,201,202 Norinyl 1+50 (28) 202 Nevanac 215 Noroxin 130 Nevirapine 156 Northera 173 Nortriptyline HCl 141 New Terocin 29 NexGen Meter 212 Nortuss-Ex 224 NexIUM 189 Norvir 158 PAGE 245 LAST UPDATED 04/2017 NovoLIN 70/30 162 Opsumit 223 NovoLIN 70/30 ReliOn 162 Oracea 132 NovoLOG Mix 70/30 162 Orajel Baby Tooth/Gum Noxafil 144 Oral Hygiene Products Nucynta ER 120 Oral Relief Spray Nuedexta 181 Oraxyl 132 Numoisyn 182 Orenitram 223 NuvaRing 202 Orkambi 222 Orlistat 188 Ortho Evra 202 Oseltamivir Phosphate 158 Ospemifene 206 206 Nystatin Nystatin-Triamcinolone 142,144 144 O OC8 29 Osphena Occult Blood 54 Outgro Pain Relief 57 49,57 18 29 Odefsey 156 Oxandrolone 195 Ofev 224 Oxaydo 123 Oxazepam 159 Ofloxacin 130,131 Ofloxacin (Ophth) 130 Oxcarbazepine 135 Ofloxacin (Otic) 130 Oxecta 123 Ogestrel 202 Oxiconazole Nitrate 144 Olanzapine 153 Oxistat 144 Olanzapine-Fluoxetine HCl 137 Oxtellar XR 135 Oleptro 139 Oxybutynin Chloride 190 Olmesartan Medoxomil 165 Oxycodone HCl Olmesartan Medoxomil-Hydrochlorothiazide 173 Oxycodone w/ Acetaminophen Olopatadine HCl 215 Oxycodone-Acetaminophen Olopatadine HCl (Nasal) 220 Oxymetazoline Olysio 155 HCl Ombitasvir-Paritaprevir-Ritonavir 156 Oxymetazoline HCl (Ophth) Ombitasvir-Paritaprevir-Ritonavir & Dasabuvir 156 Oxymetholone Omega-3 Fatty Acids 16 120,123,124 69 195 Oxymorphone HCl 120,124 189 Oxyquinolone Sulfate Vaginal Omeprazole Magnesium 190 Ozurdex Omnaris 219 Ondansetron 142 P Ondansetron HCl 142 P&S 133,134 124 47,48,51,52,53,54,55,56,57,58,59,60,61,62,63 Omeprazole Onfi 122,124 47 215 29 Pacnex MX 184 Onglyza 161 Palbociclib 148 Onmel 144 Paliperidone 153 Opana ER 120 Pancreaze 186 Opium Tincture 188 Pancrelipase (Lipase-Protease-Amylase) PAGE 246 186,187 LAST UPDATED 04/2017 Pandel 194 Phenylephrine w/ DM- Panobinostat Lactate 147 GG 78,81,84,85,89,92,94,97,223,224,225 PanOxyl 29 Phenylephrine-Acetaminophen- Panthoderm 29 Guaifenesin 79,80,82,83,85,86,87,88,90,91,93,94,97 Pantoprazole Sodium 190 Phenylephrine-Brompheniramine- Paricalcitol 211 DM Paromomycin Sulfate 125 Phenylephrine-Chlorphen- Paroxetine HCl 139 DM Paroxetine Mesylate 140 Phenylephrine-Chlorpheniramine-DM w/ Paroxetine Mesylate (Vasomotor) 138 APAP Pasireotide Diaspartate 209 Phenylephrine-DM-GG w/ Pataday 215 APAP 79,81,82,83,84,85,86,87,88,89,90,91,93,94,95,9 Pazopanib HCl 148 6 PCE 130 Phenylephrine- 78,79,80,82,84,86,87,89,90,91,92,93,94,95,97 78,79,82,87,89,96,97,224 78,80,83,84,87,88,89,90,91,92,94,95,96 Pearl Drops Extra Strength 57 Guaifenesin 77,78,80,84,85,87,88,89,91,92,93,94,95,9 PediaCare Childrens Decongest 58 6 PEG 3350-KCl-NaCl-Na Sulfate-Na Ascorbate- Phenylephrine-Pyrilamine-DM 78 Ascorbic Acid 189 Phenylephrine-Shark Liver Oil-Cocoa Peganone 135 Butter Penbutolol Sulfate 168 Phenylephrine-Shark Liver Oil-Glycerin- Penicillin V Potassium 129 Petrolatum Pentazocine w/ Naloxone 124 Phenyltoloxamine-Acetaminophen Perampanel 133 Phenytoin Sodium Extended Perforomist 221 Phosphatidylcholine (Bulk) Perindopril Arginine-Amlodipine Besylate 173 Phospholine Iodide Perindopril Erbumine 166 Phosphorated Carbohydrate w/Caffeine Pernox 22,25,26,30,31,33 25,26,31,32 58 135 58,212 216 11 29 Phrenilin Forte 181 Perphenazine 142 Pilocarpine HCl 216 Perphenazine-Amitriptyline 137 Pilocarpine HCl (Oral) 182 Pertzye 186 Pimecrolimus 183 Pexeva 140 Pimozide 152 Phenazopyridine HCl Phenobarbital 46,47,191 134 Pin-X 15 Pindolol 168 Phenobarbital-Hyoscyamine-Atropine-Scopolamine 187 Pioglitazone HCl-Glimepiride 161 Phentermine HCl 181 Pioglitazone HCl-Metformin HCl 161 Phenyleph-Promethazine w/ Cod 224 Pirfenidone 223 Piroxicam 118 Pitavastatin Calcium 176 Phenylephrine HCl Plerixafor 164 (Oral) Poly-Vent IR Phenylephrine HCl Phenylephrine HCl (Ophth) 48,57,60,64 213,214 51,52,53,54,56,57,58,59,60,62,63,64 Polyethylene Glycol PAGE 247 90 53,58 LAST UPDATED 04/2017 Polyethylene Glycol-Polyvinyl Alcohol (Ophth) 66 Polyethylene Glycol-Propylene Glycol (Ophth) 65,66,67,68 Polysaccharide Iron Complex 105,107,110,111 Polysaccharide Iron Complex-Iron Heme Premarin 203 Prempro 203 Prepidil 191 Prestalia 173 Prevacare Antimicrobial 30 Polypeptide 99 Prevacid SoluTab Polysorbate 80 (Ophth) 69 Prezista 158 Priftin 146 PriLOSEC 190 149 Polyvinyl Alcohol 64,66,67,214 Polyvinyl Alcohol-Povidone (Ophth) 67 189,190 Pomalidomide 146 Primaquine Phosphate Pomalyst 146 Primatene Mist Ponatinib HCl 148 Primidone 134 Posaconazole 144 Primlev 124 Posture 100 Primsol 127 ProAir HFA 221 Pot Phosphate Monobasic w/ Sod Phosphate Dibasic Prochieve 206 & Monobasic Prochlorperazine Maleate 142 Pot & Sod Citrates w/Citric Ac 191,192 190,191,192 77 Potassium Chloride 228 Prodigy VoicePRO Blood Glucose 212 Potassium Citrate (Alkalinizer) 191 Proferrin ES 111 Potiga 133 Progesterone (Vaginal) Povidone-Iodine 48,49,50,51,52,54,57,58,59,60,62 205,206 Progesterone Micronized 206 Pradaxa 163 Proglycem 162 Praluent 177 Prolensa 215 Pramipexole Dihydrochloride 150 Promacta 164 Pramlintide Acetate 161 Promethazine & Phenylephrine 224 Pramosone 184 Promethazine HCl 220 Promethazine-Phenylephrine-Codeine 224 Pramoxine HCl (Dental) Pramoxine-HC Pramoxine-HC-Chloroxylenol 17 184 Propa pH Acne Med Cleansing 30 217,218 Propafenone HCl 167 Pravastatin Sodium 176 Proparacaine HCl 214 Prazosin HCl 165 Propranolol & Hydrochlorothiazide 173 Precision Xtra 212 Propranolol HCl Pred-G 214 Propylene Glycol (Ophth) Pred-G S.O.P. 214 Propylene Glycol-Glycerin Prednicarbate 194 Prostin E2 191 Prednisolone Acetate 193 Protonix 190 Prednisolone Acetate (Ophth) 215 Protriptyline HCl 141 Proventil HFA 221 Prednisolone Sodium Phosphate 192,194 147,168 68 64,65,67,68 Prednisone 194 Pseudoeph-CPM-DM w/APAP Pregabalin 181 Pseudoephed-Bromphen- Pregnancy Test PAGE 248 51,58 DM 83 78,82,83,90,94,97,223,224 LAST UPDATED 04/2017 Pseudoephedrine HCl Pseudoephedrine w/ DM-GG 50,51,52,54,62 78,84,87,90,94,96,97 Pseudoephedrine-AcetaminophenDextromethorphan 82,83 Rasagiline Mesylate 151 Ravicti 186 Rayos 194 Rebetol 155 Pseudoephedrine-Chlorphen-DM 84,89,90,92 Refresh Celluvisc 67 Pseudoephedrine-DM-GG w/ APAP 82,83,93,94 Refresh Liquigel 67 Relhist BP 92 Pseudoephedrine-Guaifenesin Pseudoephedrine-Ibuprofen 77,81,88,90,95 78,82,83,84,91,94 ReliOn 70/30 162 Pseudoephedrine-Naproxen Sodium 77,80,85,87,93,94 Relpax 145 Psyllium Renacidin 191 42,46 Renvela 192 224 Repatha 177 Repatha SureClick 178 41,42,43,44,45,46 Psyllium w/ Calcium Pulmozyme Pyrantel Pamoate 15 Pyridostigmine Bromide 145 Rescon DM Pyrilamine Tannate-Phenylephrine Tannate 225 Rescriptor 156 Pyrimethamine 149 Reserpine 173 Respa-BR 220 Respahist-II 224 Q 92 Quazepam 226 Retisert 215 Quetiapine Fumarate 153 Revlimid 146 QuickTek 212 Rexulti 153 Quillivant XR 180 Reyataz 158 Quinapril HCl 166 Ribasphere 155 Quinapril-Hydrochlorothiazide 173 Ribasphere RibaPak 156 Quinidine Gluconate 167 RibaTab 156 Quinine Sulfate 149 Ribavirin 224 Qvar 219 Ribavirin (Hepatitis C) R 155,156 Ridaura 210 Rifabutin 145 RA Anti-Fungal Foot Care 30 Rifampin 146 RA Dry Mouth 18 Rifapentine 146 RA Epsom Salt 59 Rifater 146 RA Epsom Salt Lavender 59 Rifaximin 127 RA Fluoride Toothpaste 59 Riluzole 181 RA Sensitive Toothpaste/Fl 60 Rimantadine Hydrochloride 158 RA Whitening Toothpaste/Fl 60 Rimso-50 191 Rabeprazole Sodium 189 Riociguat 222 Raltegravir Potassium 156 Risedronate Sodium 211 Ramipril 166 Risperidone Ranitidine HCl Rapamune PAGE 249 37,38,39,40,188 210 153,154 Ritonavir 158 Rivaroxaban 163 LAST UPDATED 04/2017 Rivastigmine Tartrate 136 Sensipar Rizatriptan Benzoate 145 Sensitive Extra Whitening 61 Roflumilast 222 Sensitive Toothpaste/Fluoride 61 Rolapitant HCl 142 Sensodyne 61 Ropinirole Hydrochloride 150 Sensodyne Maximum Strength 61 Rosiglitazone Maleate 160 Sensodyne Pronamel 61 Rosiglitazone Maleate-Glimepiride 160 Sensodyne Tartar Control 61 Rosiglitazone Maleate-Metformin HCl 160 Sensodyne/Baking Soda 61 Rosuvastatin Calcium 176 Sertaconazole Nitrate 143 Roxicet 124 Sevelamer Carbonate 192 Signifor 209 Ru-Hist D 92 209 Rufinamide 135 Silver Nitrate 185 Ruxolitinib Phosphate 148 Silver Nitrate-Potassium Nitrate 183 Rynatan 224 Silver Sulfadiazine 131 Simbrinza 217 Simcor 178 155 S Sabril 134 Simeprevir Sodium Sacubitril-Valsartan 172 Simethicone Salicylic Acid 18,20,21,23,24,25,29,30,184 Salicylic Acid & Sulfur (Keratolytic) 29 34,35,36,37 Simvastatin 177 Sirolimus 210 Sancuso 142 Sitagliptin Phosphate 161 Saphris 154 Sitagliptin-Metformin HCl 161 Sapropterin Dihydrochloride 186 Sitavig 158 Saquinavir Mesylate 158 Skelid 211 32 Skyla 206 Sardoettes Sargramostim 164 Sodium Chloride (Inhalant) Savella 181 Sodium Chloride Hypertonic 66 Saxagliptin HCl 161 Sodium Fluoride w/ Calcium Carbonate 99 Saxagliptin-Metformin HCl 161 Sodium Oxybate 227 Scopolamine 142 Sodium Phenylbutyrate 186 Scopolamine HBr (Ophth) 213 Sodium Phosphates Secobarbital Sodium 227 Sodium Polystyrene Sulfonate 227 Seconal 227 Sofosbuvir 156 Sedapap 181 Solifenacin Succinate 190 Seebri Neohaler 220 Solodyn 132 Selegiline 138 Soolantra 149 Selegiline HCl 151 Sorbitol 191 Sorbitol Irrigation 191 Selenium Sulfide 19,22,23,25,31 224,225 41,44,45 Selzentry 157 Sotalol HCl 167 Semprex-D 225 Sotalol HCl (AFIB/AFL) 167 Sennosides 41,42,43,44,45 Sovaldi 156 PAGE 250 LAST UPDATED 04/2017 Spironolactone 175 Syprine Spironolactone & Hydrochlorothiazide 173 Systane Omega-3 Healthy Tears 16 Sporanox 144 Systane Overnight Therapy 68 Sprix 118 Sprycel 148 Starch (topical) 26,32 227 T Tabloid 147 Stavudine 157 Taclonex 185 Stavzor 134 Tacrolimus 210 Staxyn 191 Tacrolimus (Topical) 185 Stendra 191,192 Stimate 195 Tafluprost 217 Stiolto Respimat 225 Tamiflu 158 Strattera 180 Tamoxifen Citrate 146 Striant 196 Tapentadol HCl 120 Stribild 156 Tarceva 148 TargaDOX 132 Styptocaine 32 Tadalafil 190,191 Suclear 189 Targretin 149 Sucralfate 189 Tasigna 148 Sudafed 24 Hour 62 Tasimelteon 227 Sudafed PE Childrens 62 Tazarotene 185 185 Sulfacetamide Sod-Prednisolone 213,214 Tazorac Sulfacetamide Sodium 184,185 Tecfidera 181,182 182,183,185,186 Technivie 156 Sulfacetamide Sodium w/ Sulfur Sulfacetamide-Prednisolone 214 Tekamlo 173,174 Sulfadiazine 131 Tekturna 174 Sulfanilamide Vaginal 131 Telmisartan 165 Sulfasalazine 210 Telmisartan-Amlodipine 174 Sulfoam 185 Telmisartan-Hydrochlorothiazide 174 Temazepam 226 Sulfur 27,185 Sulfuric Acid-Sulfonated Phenolics 182 Temozolomide 146 Sumatriptan 145 Tencon 181 Sumatriptan Succinate 145 Tenofovir Disoproxil Fumarate 157 Sumatriptan-Naproxen Sodium 145 Terazosin HCl 190 Sunitinib Malate 148 Terbinafine HCl Suprax 128 Terbutaline Sulfate 221 Sutent 148 Terconazole Vaginal 144 Symbicort 225 Teriparatide (Recombinant) 210 SymlinPen 60 161 Testosterone 195,196 Synalar (Cream) 194 Tetracaine HCl (Ophth) 213,214 Synarel 209 Tetracycline HCl 132 Tetrahydrozoline HCl 225 Synjardy PAGE 251 161,162 143,144 LAST UPDATED 04/2017 Tetrahydrozoline HCl (Ophth) Tetrahydrozoline w/ Polyethylene Glycol 64,65,66,67,68 64,65,67 Toviaz 190 Tracleer 223 Tetrahydrozoline-Glycerin-Hypromellose-PEG 400 68 Tramadol HCl 120 TG 45PSE/400GFN 95 Tramadol-Acetaminophen 124 TGT Lubricant Eye Drops 68 Trametinib Dimethyl Sulfoxide 148 Thalidomide 146 Trandolapril 167 Thalomid 146 Trandolapril-Verapamil HCl 174 Tranexamic Acid 164 Theratears 68 Thioguanine 147 Transderm-Scop (1.5 MG) 142 Thioridazine HCl 152 Tranylcypromine Sulfate 138 Thiothixene 152 Travoprost 217 Thyroid 207,208,209 Trazodone HCl 139,140 Thyrolar-1 208 Trecator 146 Thyrolar-1/2 208 Treprostinil Diolamine 223 Thyrolar-1/4 208 Tresiba FlexTouch 162,163 Thyrolar-2 208 Tretinoin 182,185 Thyrolar-3 208 Tretinoin (Chemotherapy) 149 Tretinoin Microsphere 185 Tiagabine HCl 133,134 Ticagrelor 164 Trexall 210 Tiludronate Disodium 211 Treximet 145 Timolol 216 Trezix 124 Timolol Maleate 168 Tri-Chlor 185 Timolol Maleate (Ophth) 217 Triactin Chest Congestion Tinidazole 127 Triamcinolone Acetonide (Topical) Tiotropium Bromide-Olodaterol HCl 225 Triaminic Cough/Runny Nose Tipranavir 157 Triamterene 175 Tivicay 156 Triamterene & Hydrochlorothiazide 174 Triazolam 226 185 95 195 76 Tizanidine HCl 154,155 Tobi Podhaler 222 Trichloroacetic Acid Tobramycin 222 Triclosan Tobramycin (Ophth) 126 Trientine HCl 227 Tobramycin-Dexamethasone 214 Trifluoperazine HCl 152 Tolazamide 162 Trifluridine 158 Tolcapone 150 Trimethobenzamide HCl 142 Tolmetin Sodium 118 Trimethoprim HCl 127 Trimipramine Maleate 141 Tolnaftate 19,22,24,25,27,29,31,32,33 50 Tolterodine Tartrate 190 Trimo-San Topicort Spray 195 Trintellix Topiramate 134 Triprolidine & Pseudoephedrine Toremifene Citrate 146 Triprolidine HCl Torsemide PAGE 252 174,175 Trokendi XR 47 140 86,96 74 134 LAST UPDATED 04/2017 Trolamine Salicylate Tropicamide 33 213,214 Viadent Advanced Care 63 Viadent Fluoride 63 63 Truvada 157 Viadent Plaque TussiCaps 225 Viberzi Tybost 157 Vibramycin 132 Tykerb 148 Vicks Sinex 64 64 188,189 Tylenol Childrens Plus Cld/Cgh 96 Vicks Sinex UltraFine Mist Tylenol PM Extra Strength 98 Videx 157 Viekira Pak 156 Vigabatrin 134 Vigamox 131 Tyzine 225 U U-Cort 195 Viibryd 140 Uceris 210 Vilazodone HCl 140 Uloric 144 Vimovo 118 Ultima 212 Vimpat 135 Ultresa 186 Viokace 186 Umeclidinium-Vilanterol 223 Viracept 158 Umecta 185 Viread 157 Undecylenic Acid Urea 25,26,29,30 184,185 Visine Maximum Redness Relief 68 Visine Tears 68 Visine Tired Eye Relief 68 Uro-Mag 37 Ursodiol 188 Visine-LR 69 Utibron Neohaler 225 Vitamin A (Topical) 26 Vitamin E (Topical) 23,24,26,33,34 Vitamin E w/ A & D 19,31,32,33 V Valganciclovir HCl 155 Vitamins A & D (Topical) Valproic Acid 134 Vitamins A & E Valsartan 165 Vituz Vancomycin HCl Vaniqa Vanquish 126,127 186 8 Viva Drops Voriconazole Vortioxetine HBr 19,23,24,30,31,32,34 18 225 69 144 138,140 Vardenafil HCl 191 Votrient 148 Varubi 142 Vytorin 178 Vascepa 178 Vyvanse 179 Venlafaxine HCl 140 Ventavis 223 W Ventolin HFA 221 Wal-Dryl-D Veramyst 219 Warfarin Sodium 163 Verapamil HCl 170 Welchol 178 VESIcare 190 Westhroid Viadent PAGE 253 63 Westhroid-P 96 208,209 209 LAST UPDATED 04/2017 Witch Hazel (Hamamelis Zyclara Pump 186 Virginiana) 23,24,25,26,28,29,30,31,32,33 Zydelig 149 209 Zydone 125 Zylet 214 Zytiga 146 WP Thyroid X Xalkori 148 Xarelto 163 Xartemis XR 124 Xenical 188 Xifaxan 127 Xolox 124 Xulane 204 Xyrem 227 Y Yodoxin 126 Z Z-Dex 97 Zarxio 164 Zelapar 151 Zenpep 186,187 Zepatier 156 Ziagen 157 Zidovudine 157 Zilactin 18 Zinc Acetate (Topical) 27 Zioptan 217 Ziprasidone HCl 154 Zipsor 118 Zmax 130 Zmax Pediatric 130 Zohydro ER 120,121 Zoledronic Acid 211 Zolmitriptan 145 Zolpidem Tartrate 226 Zorvolex 118 Zotex Pediatric 225 Zubsolv 125 Zuplenz 142 Zyclara 186 PAGE 254 LAST UPDATED 04/2017
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