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2014 Comprehensive Dual Eligible Preferred Drug List (List of Covered Drugs) ‘Ohana Health Plan 00 9 Please read: This document contains information about the drugs we cover in this plan. Last updated (01/01/2014) Ohana Dual Eligible Cough & Cold Drug List Non-Preferred Drugs Preferred Drugs ANTITUSSIVES,NON-NARCOTIC Benzonatate TESSALON 200 MG CAPSULE BENZONATATE 100 MG CAPSULE BENZONATATE 200 MG CAPSULE Dextromethorphan Polistirex DELSYM 30 MG/5 ML EXTENDED-RELEASE SUSPENSION Dextromethorphan HBr ROBITUSSIN PEDIATRIC COUGH SYP Dextromethorphan HBr/Menthol DELSYM COUGH RELIEF PLUS LOZENGE NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST Brompheniramine/Dextromethorphan HBr/Pseudoephedrine HCl ALLANHIST PDX DROPS BROMFED DM SYRUP BROMHIST PDX DROPS ENDACOF-PD DROPS BROTAPP DM LIQUID Q-TAPP DM ELIXIR Brophenaramine/Dextromethorphan HBr/Phenylephrine HCl COLD/COUGH CHILDRENS ELIXIR RYNEX DM DIMAPHEN DM ELIXIR Chlorpheniramine/Dextromethorphan HBr/Phenylephrine HCl C-PHEN DM PD-COF SYRUP RONDEX-DM SYRUP SILDEC PE-DM SYRUP DE-CHLOR DM LIQUID CORFEN DM NOHIST-DM TRI-DEX PE Chlorpheniramine/Dextromethorphan HBr/Pseudoephedrine HCl PEDIATRIC COUGH-COLD LIQUID KIDKARE COUGH/COLD MESEHIST DM Dexchlorpheniramine/Pseudoephedrine HCl/Chlophedianol HCl VANACOF LIQUID Chlorpheniramine/Dextromethorphan HBr DIMETAPP LONG-ACTING COUGH LIQ ROBITUSSIN LONG ACTING LIQUID Promethazine HCl/Dextromethorphan HBr PROMETHAZINE-DM SYRUP NON-NARC ANTITUSS-1ST GEN. ANTIHIST-ANALGESIC COMBINATION Dextromethorphan HBr/Acetaminophen/Doxylamine DELSYM NIGHTTIME MULTI-SYMPTOM EXPECTORANTS DECONGESTANT-EXPECTORANT COMBINATIONS Guaifenesin/Phenylephrine HCl DONATUSSIN DROPS PE-GUAI DROPS DESPEC LIQUID Last updated 01/01/14 RESCON-GG LIQUID Page 1 of 2 Ohana Dual Eligible Cough & Cold Drug List Non-Preferred Drugs Preferred Drugs NON-NARCOTIC DECONGESTANT-EXPECTORANT-ANTITUSSIVE Guaifenesin/Dextromethorphan HBr/Phenylephreine ROBAFEN CF SYRUP NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB. Dextromethorphan HBr/Guaifenesin DURATUSS DM ELIXIR SIMUC-DM ELIXIR SU-TUSS DM ELIXIR MUCUS RELIEF COUGH LIQUID DIABETIC TUSSIN DM LIQUID GUAIFENESIN DM SYRUP Q-TUSSIN-DM SYRUP EXTRA ACTION COUGH SILTUSSIN DM COUGH SYRUP REFENESEN DM SILTUSSIN DM DAS COUGH SYRUP MUCOSA DM ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE Chlorpheniramine/Hydrocodone Polistirex TUSSIONEX PENNKINETIC SUSP TUSSICAPS (min. age 6 years old) HYDROCODONE-CHLORPHENIRAMINE SUSPENSION (min. age 6 years old) Codeine Phosphate/Promethazine HCl PROMETHAZINE-CODEINE SYRUP (min. age 6 years old) NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT Dexbrompheniramine/Hydrocodone Bit/Phenylephrine HCl CYTUSS-HC NR SYRUP HC 2.5-PE 5-DBROM 1 MG SYRUP HC/PE/DBROM SYRUP Codeine/Phenylephrine HCl/Promethazine PROMETH VC W/COD SYRUP PROMETHAZINE VC/COD SYRUP Pseudoephedrine HCl/Codeine/Chlorpheniramine PHENYLHISTINE DH NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATION Hydrocodone Bit/Homatropine HYDROCODONE-HOMATROPINE HYDROMET SYRUP NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION Guaifenesin/Hydrocodone Bit HYDROCODONE-GUAIFENESIN SYRUP NARCOF SYRUP TUSSICLEAR DH SYRUP Codeine Phosphate/Guaifenesin CHERATUSSIN AC SYRUP GUAIFENESIN-CODEINE SYRUP IOPHEN C-NR NARCOTIC ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMBINATIONS Codeine Phosphate/Guaifenesin/Pseudoephedrine HCl CHERATUSSIN DAC SYRUP Last updated 01/01/14 Page 2 of 2 UPPERCASE = Brand name drugs italics = Generic drugs Drug Name Preference Details P = Preferred Dagger (†) = N/A Asterisk (*) = N/A Asterisk (**) = N/A Asterisk (***) = N/A XX = N/A Coverage Details PA = Prior Authorization ST = Step Therapy QL = Quantity Limit AL = Age Limit OTC = OTC- Covered w/Rx Preference Details Coverage Details *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexia nts* *Anti-Obesity Agents** *Lipase Inhibitors*** XENICAL ORAL CAPSULE 120 MG P PA P OTC P OTC Ibuprofen ORAL SUSPENSION 100 MG/5ML P OTC Ibuprofen ORAL TABLET 200 MG P OTC *Alternative Medicines* *Alternative Medicine - C's** *Alternative Medicine - Ch's*** Charcoal ORAL CAPSULE 200 MG *Alternative Medicine - M's** *Alternative Medicine - Me's*** Melatonin Maximum Strength ORAL TABLET 5 MG *Analgesics - Anti-Inflammatory* *Nonsteroidal Anti-Inflammatory Agents (Nsaids)** *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** 1 Drug Name Ibuprofen Junior Strength ORAL TABLET CHEWABLE 100 MG Preference Details Coverage Details P OTC ACEPHEN RE SUPPOSITORY 120 MG, 325 MG, 650 MG P OTC Acetaminophen ORAL SOLUTION 160 MG/5ML P OTC Acetaminophen ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s)) Acetaminophen ORAL TABLET 500 MG P OTC; QL (186 EA per 31 day(s)) Acetaminophen ORAL TABLET CHEWABLE 80 MG P OTC APAP ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s)) APAP Extra Strength ORAL TABLET 500 MG P OTC; QL (186 EA per 31 day(s)) Childrens Non-ASA Pain Relief ORAL TABLET CHEWABLE 80 MG P OTC Childrens Non-Aspirin ORAL TABLET CHEWABLE 80 MG P OTC Childrens Non-Aspirin Pain ORAL TABLET CHEWABLE 80 MG P OTC Childrens Pain Reliever ORAL TABLET CHEWABLE 80 MG P OTC Childrens Silapap ORAL LIQUID† 160 MG/5ML P OTC Childrens Tactinal ORAL TABLET CHEWABLE 80 MG P OTC Ed-APAP ORAL LIQUID† 160 MG/5ML P OTC Mapap ORAL CAPSULE 500 MG P OTC; QL (186 EA per 31 day(s)) Mapap ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s)) Mapap ORAL TABLET 500 MG P OTC; QL (186 EA per 31 day(s)) Mapap ORAL TABLET CHEWABLE 80 MG P OTC Mapap Arthritis Pain ORAL TABLET EXTENDEDRELEASE* 650 MG P OTC; QL (93 EA per 31 day(s)) Maxapap Maximum Strength ORAL TABLET 500 MG P OTC; QL (186 EA per 31 day(s)) Maxapap Regular Strength ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s)) *Analgesics - Nonnarcotic* *Analgesics Other** *Analgesics Other*** 2 Drug Name Preference Details Coverage Details Non-Aspirin ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s)) Non-Aspirin Extra Strength ORAL TABLET 500 MG P OTC; QL (186 EA per 31 day(s)) Non-Aspirin Pain Relief ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s)) Nortemp Infants ORAL SUSPENSION 80 MG/0.8ML P OTC Pain & Fever Childrens ORAL SOLUTION 160 MG/5ML P OTC Pain Relief ORAL TABLET 500 MG P OTC; QL (186 EA per 31 day(s)) Pain Relief Extra Strength ORAL TABLET 500 MG P OTC; QL (186 EA per 31 day(s)) PHARBETOL ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s)) PHARBETOL EXTRA STRENGTH ORAL TABLET 500 MG P OTC; QL (186 EA per 31 day(s)) Q-PAP ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s)) Tactinal ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s)) Tactinal Extra Strength ORAL TABLET 500 MG P OTC; QL (186 EA per 31 day(s)) P OTC Aspirin ORAL TABLET 325 MG, 81 MG P OTC Aspirin ORAL TABLET CHEWABLE 81 MG P OTC Aspirin ORAL TABLET DELAYED RELEASE 81 MG P OTC Aspirin Childrens ORAL TABLET CHEWABLE 81 MG P OTC Aspirin EC ORAL TABLET DELAYED RELEASE 325 MG, 81 MG P OTC Aspirin EC Low Dose ORAL TABLET DELAYED RELEASE 81 MG P OTC Aspirin Low Dose ORAL TABLET 81 MG P OTC ECPIRIN ORAL TABLET DELAYED RELEASE 325 MG P OTC *Salicylates** *Salicylate Combinations*** Tri-Buffered Aspirin ORAL TABLET 325 MG *Salicylates*** *Anorectal Agents* *Rectal Combinations** 3 Drug Name Preference Details Coverage Details *Rectal Combinations - Misc.*** FORMULATION R RE OINTMENT 0.25-3-14-71.9 % P OTC Hem-Prep RE SUPPOSITORY 0.25-3-85.5 % P OTC Alamag Plus ORAL TABLET CHEWABLE 200-200-25 MG P OTC ALMACONE ORAL SUSPENSION 200-200-20 MG/5ML P OTC Antacid ORAL SUSPENSION 200-200-20 MG/5ML P OTC Antacid Anti-Gas ORAL SUSPENSION 200-200-20 MG/5ML P OTC Antacid Anti-Gas Max Strength ORAL SUSPENSION 400-400-40 MG/5ML P OTC Antacid Extra Strength ORAL SUSPENSION 400-400-40 MG/5ML P OTC Antacid I ORAL SUSPENSION 200-200-20 MG/5ML P OTC Antacid III ORAL SUSPENSION 400-400-40 MG/5ML P OTC Geri-Lanta ORAL SUSPENSION 200-200-20 MG/5ML P OTC MAALOX ADVANCED ORAL SUSPENSION 200-200-20 MG/5ML P OTC MAALOX ADVANCED MAX ST ORAL SUSPENSION 400-400-40 MG/5ML P OTC MAALOX MAX ORAL SUSPENSION 400-400-40 MG/5ML P OTC MAALOX MULTI SYMPTOM MAX ST ORAL SUSPENSION 400-400-40 MG/5ML P OTC MAALOX REGULAR STRENGTH ORAL SUSPENSION 200-200-20 MG/5ML P OTC Milantex ORAL SUSPENSION 200-200-20 MG/5ML P OTC Milantex Extra Strength ORAL SUSPENSION 400-400-40 MG/5ML P OTC *Antacids* *Antacid Combinations** *Antacid & Simethicone*** 4 Drug Name MINTOX PLUS ORAL TABLET CHEWABLE 200-200-25 MG Preference Details Coverage Details P OTC ACID GONE ORAL TABLET CHEWABLE 160-105 MG, 80-20 MG P OTC MI-ACID ORAL TABLET CHEWABLE 700-300 MG P OTC P OTC P OTC Alcalak ORAL TABLET CHEWABLE 420 MG P OTC Antacid ORAL TABLET CHEWABLE 420 MG, 500 MG P OTC CAL-GEST ANTACID ORAL TABLET CHEWABLE 500 MG P OTC Calcium Antacid ORAL TABLET CHEWABLE 500 MG P OTC Calcium Antacid Extra Strength ORAL TABLET CHEWABLE 750 MG P OTC Calcium Carbonate Antacid ORAL TABLET 648 MG P OTC Calcium Carbonate Antacid ORAL TABLET CHEWABLE 500 MG P OTC MAALOX ORAL TABLET CHEWABLE 600 MG P OTC TITRALAC ORAL TABLET CHEWABLE 420 MG P OTC *Antacid Combinations*** *Antacids - Aluminum Salts** *Antacids - Aluminum Salts*** Aluminum Hydroxide Gel ORAL SUSPENSION 320 MG/5ML *Antacids - Bicarbonate** *Antacids - Bicarbonate*** Sodium Bicarbonate ORAL TABLET 325 MG, 650 MG *Antacids - Calcium Salts** *Antacids - Calcium Salts*** *Antidiabetics* *Diabetic Other** *Diabetic Other*** 5 Drug Name Preference Details Coverage Details BD GLUCOSE ORAL TABLET CHEWABLE 5 GM P OTC Glucose ORAL TABLET CHEWABLE 4 GM P OTC Ultilet Glucose ORAL TABLET CHEWABLE 4 GM P OTC Bismatrol ORAL SUSPENSION 262 MG/15ML P OTC Bismatrol ORAL TABLET CHEWABLE 262 MG P OTC Bismuth ORAL TABLET CHEWABLE 262 MG P OTC Diotame ORAL TABLET CHEWABLE 262 MG P OTC Kao-Tin ORAL SUSPENSION 262 MG/15ML P OTC KAOPECTATE ORAL SUSPENSION 262 MG/15ML P OTC KAOPECTATE EXTRA STRENGTH ORAL SUSPENSION 525 MG/15ML P OTC Pink Bismuth ORAL SUSPENSION 262 MG/15ML P OTC Pink Bismuth ORAL TABLET CHEWABLE 262 MG P OTC Stomach Relief ORAL SUSPENSION 262 MG/15ML, 527 MG/30ML P OTC Stomach Relief ORAL TABLET CHEWABLE 262 MG P OTC Stomach Relief Plus ORAL SUSPENSION 525 MG/15ML P OTC Anti-Diarrheal ORAL LIQUID† 1 MG/5ML P OTC LOPERAMIDE A-D ORAL TABLET 2 MG P OTC Loperamide HCl ORAL LIQUID† 1 MG/5ML P OTC *Antidiarrheals* *Antidiarrheal Agents - Misc.** *Antidiarrheal Agents - Misc.*** *Antiperistaltic Agents** *Antiperistaltic Agents*** *Antidotes* *Antidotes** *Antidotes*** 6 Drug Name Preference Details Coverage Details Actidose-Aqua ORAL LIQUID† 15 GM/72ML, 25 GM/120ML, 50 GM/240ML P OTC Actidose/Sorbitol ORAL LIQUID† 25 GM/120ML, 50 GM/240ML P OTC Charcoal ORAL CAPSULE 260 MG P OTC Charcoal Activated ORAL TABLET 250 MG P OTC CHARCOCAPS ORAL CAPSULE 260 MG P OTC Ipecac ORAL SYRUP P OTC KERR INSTA-CHAR ORAL LIQUID† 25 GM/120ML, 50 GM/240ML P OTC KERR INSTA-CHAR IN SORBITOL ORAL LIQUID† 25 GM/120ML, 50 GM/240ML P OTC LITTLE REMEDIES POISON TREAT ORAL SUSPENSION RECONSTITUTED 15 GM/120ML P OTC P OTC Aller-Chlor ORAL SYRUP 2 MG/5ML P OTC Aller-Chlor ORAL TABLET 4 MG P OTC Allergy ORAL TABLET 4 MG P OTC Allergy Relief ORAL TABLET 4 MG P OTC ChlorHist ORAL TABLET 4 MG P OTC Chlorphen ORAL TABLET 4 MG P OTC DIABETIC TUSSIN ALLERGY ORAL SYRUP 2 MG/5ML P OTC Aler-Cap ORAL CAPSULE 25 MG P OTC Aler-Dryl ORAL TABLET 50 MG P OTC AlerTab ORAL TABLET 25 MG P OTC Allergy Relief Childrens ORAL LIQUID† 12.5 MG/5ML P OTC *Antiemetics* *Antiemetics - Anticholinergic** *Antiemetics - Anticholinergic*** Meclizine HCl ORAL TABLET 12.5 MG, 25 MG *Antihistamines* *Antihistamines - Alkylamines** *Antihistamines - Alkylamines*** *Antihistamines - Ethanolamines** *Antihistamines - Ethanolamines*** 7 Drug Name Preference Details Coverage Details Altaryl ORAL ELIXIR 12.5 MG/5ML P OTC Altaryl ORAL SYRUP 12.5 MG/5ML P OTC Anti-Hist ORAL CAPSULE 25 MG P OTC Anti-Hist Allergy ORAL TABLET 25 MG P OTC BANOPHEN ORAL CAPSULE 25 MG P OTC BANOPHEN ORAL LIQUID† 12.5 MG/5ML P OTC BANOPHEN ORAL TABLET 25 MG P OTC BENADRYL ALLERGY CHILDRENS ORAL LIQUID† 12.5 MG/5ML P OTC Complete Allergy Medication ORAL TABLET 25 MG P OTC Complete Allergy Relief ORAL TABLET 25 MG P OTC Diphenhist ORAL CAPSULE 25 MG P OTC Diphenhist ORAL LIQUID† 12.5 MG/5ML P OTC Diphenhist ORAL TABLET 25 MG P OTC DiphenhydrAMINE HCl ORAL CAPSULE 25 MG, 50 MG P OTC DiphenhydrAMINE HCl ORAL TABLET 25 MG P OTC DORMIN ORAL CAPSULE 25 MG P OTC Genahist ORAL CAPSULE 25 MG P OTC Pharbedryl ORAL CAPSULE 25 MG, 50 MG P OTC Q-Dryl ORAL CAPSULE 25 MG P OTC Q-Dryl ORAL LIQUID† 12.5 MG/5ML P OTC Quenalin ORAL SYRUP 12.5 MG/5ML P OTC SCOT-TUSSIN ALLERGY RELIEF ORAL LIQUID† 12.5 MG/5ML P OTC Siladryl Allergy ORAL LIQUID† 12.5 MG/5ML P OTC Silphen Cough ORAL SYRUP 12.5 MG/5ML P OTC SIMPLY ALLERGY ORAL TABLET 25 MG P OTC Total Allergy ORAL TABLET 25 MG P OTC TOTAL ALLERGY MEDICINE ORAL LIQUID† 12.5 MG/5ML P OTC *Antihistamines - Non-Sedating** 8 Drug Name Preference Details Coverage Details *Antihistamines - Non-Sedating*** Cetirizine HCl ORAL TABLET 10 MG, 5 MG P OTC Cetirizine HCl Childrens ORAL SOLUTION 1 MG/ML P OTC Cetirizine HCl Childrens Alrgy ORAL SYRUP 1 MG/ML P OTC Loratadine ORAL TABLET 10 MG P OTC Loratadine Hives Relief ORAL SOLUTION 5 MG/5ML P OTC; QL (300 ML per 31 day(s)) OPERAND POVIDONE-IODINE EXTERNAL SOLUTION 10 % P OTC Povidone-Iodine EXTERNAL OINTMENT 10 % P OTC Povidone-Iodine EXTERNAL SOLUTION 10 % P OTC Povidone-Iodine EXTERNAL SWAB 10 %, 7.5 % P OTC P OTC ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG P OTC BROTAPP ORAL LIQUID† 1-15 MG/5ML P OTC Q-TAPP ORAL ELIXIR 1-15 MG/5ML P OTC Mucus Relief ORAL TABLET 400 MG P OTC Refenesen ORAL TABLET 200 MG P OTC Refenesen 400 ORAL TABLET 400 MG P OTC Robafen ORAL SYRUP 100 MG/5ML P OTC *Antiseptics & Disinfectants* *Iodine Antiseptics** *Iodine Antiseptics*** *Assorted Classes* *Assorted Classes** *Assorted Classes*** Gelatin ORAL CAPSULE 650 MG *Cough/Cold/Allergy* *Cough/Cold/Allergy Combinations** *Decongestant & Antihistamine*** *Expectorants** *Expectorants*** 9 Drug Name Preference Details Coverage Details *Misc. Respiratory Inhalants** *Misc. Respiratory Inhalants*** Sodium Chloride INHALATION NEBULIZATION SOLUTION 0.9 % P OTC Acne Medication EXTERNAL LOTION 10 % P OTC Acne Medication 10 EXTERNAL GEL 10 % P OTC Acne-Clear EXTERNAL GEL 10 % P OTC Benzoyl Peroxide EXTERNAL GEL 10 %, 5 % P OTC CLEAN & CLEAR PERSA-GEL EX ST EXTERNAL GEL 5 % P OTC CLEAN & CLEAR PERSA-GEL MAX ST EXTERNAL GEL 10 % P OTC CLEARPLEX V EXTERNAL GEL 5 % P OTC CLEARSKIN EXTERNAL CREAM 10 % P OTC NEUTROGENA ON-THE-SPOT EXTERNAL CREAM 2.5 % P OTC PANOXYL WASH EXTERNAL LIQUID† 10 % P OTC Bacitracin-Neomycin-Polymyxin EXTERNAL OINTMENT 400-5-5000 P OTC Double Antibiotic EXTERNAL OINTMENT 500-10000 UNIT/GM P OTC Triple Antibiotic EXTERNAL OINTMENT 3.5-400-5000 , 5-400-5000 P OTC Bacitracin EXTERNAL OINTMENT 500 UNIT/GM P OTC Bacitracin Zinc EXTERNAL OINTMENT 500 UNIT/GM P OTC Anti-Fungal EXTERNAL POWDER 1 % P OTC Terbinafine HCl EXTERNAL CREAM 1 % P OTC *Dermatologicals* *Acne Products** *Acne Products*** *Antibiotics - Topical** *Antibiotic Mixtures Topical*** *Antibiotics - Topical*** *Antifungals - Topical** *Antifungals - Topical*** 10 Drug Name Preference Details Coverage Details Tolnaftate EXTERNAL CREAM 1 % P OTC Tolnaftate EXTERNAL SOLUTION 1 % P OTC Tolnaftate Antifungal EXTERNAL CREAM 1 % P OTC Clotrimazole EXTERNAL CREAM 1 % P OTC Clotrimazole EXTERNAL SOLUTION 1 % P OTC Clotrimazole Anti-Fungal EXTERNAL CREAM 1 % P OTC Allergy EXTERNAL CREAM 2 % P OTC Anti-Itch Maximum Strength EXTERNAL CREAM 2 % P OTC BENADRYL ITCH STOPPING EXTERNAL GEL 2 % P OTC Itch Relief EXTERNAL CREAM 2 % P OTC Hydrocortisone EXTERNAL CREAM 0.5 % P OTC Hydrocortisone EXTERNAL OINTMENT 0.5 %, 1 % P OTC Hydrocortisone Max St EXTERNAL CREAM 1% P OTC Hydrocortisone Max St/12 Moist EXTERNAL CREAM 1 % P OTC HYDROSKIN EXTERNAL CREAM 1 % P OTC PREPARATION H HYDROCORTISONE EXTERNAL CREAM 1 % P OTC P OTC P OTC P OTC *Imidazole-Related Antifungals - Topical*** *Antihistamines-Topical** *Antihistamines - Topical*** *Corticosteroids - Topical** *Corticosteroids - Topical*** *Topical Steroid Combinations*** Hydrocortisone-Aloe EXTERNAL CREAM 1 % *Misc. Topical** *Misc. Topical*** PREPARATION H EXTERNAL PAD 50 % *Scabicides & Pediculicides** *Scabicides & Pediculicides*** A-200 XX AEROSOL† 0.5 % 11 Drug Name Preference Details Coverage Details P OTC; QL (60 ML per 31 day(s)) COPPERTONE SUNBLOCK SPF15 EXTERNAL LOTION P OTC NEUTROGENA MOISTURE SPF15 EXTERNAL LOTION P OTC BETA CARE BETATAR GEL EXTERNAL SHAMPOO 2.5 % P OTC ELTA TAR EXTERNAL CREAM 2 % P OTC IONIL-T EXTERNAL SHAMPOO 1 % P OTC MG217 MEDICATED TAR EXTERNAL SHAMPOO 15 % P OTC NEUTROGENA T/GEL EX ST EXTERNAL SHAMPOO 1 % P OTC PC-Tar EXTERNAL SHAMPOO 1 % P OTC TERA-GEL TAR EXTERNAL SHAMPOO 0.5 % P OTC Mi-Acid Gas Relief ORAL TABLET CHEWABLE 80 MG P OTC Mytab Gas ORAL TABLET CHEWABLE 80 MG P OTC Simethicone ORAL SUSPENSION 40 MG/0.6ML P OTC Simethicone ORAL TABLET CHEWABLE 80 MG P OTC P OTC Permethrin EXTERNAL LOTION 1 % *Sunscreens** *Sunscreens*** *Tar Products** *Tar Products*** *Gastrointestinal Agents - Misc.* *Antiflatulents** *Antiflatulents*** *Genitourinary Agents - Miscellaneous* *Urinary Analgesics** *Urinary Analgesics*** Phenazopyridine HCl ORAL TABLET 95 MG *Hematopoietic Agents* *Cobalamins** *Cobalamins*** 12 Drug Name Preference Details Coverage Details Cyanocobalamin INJECTION SOLUTION 1000 MCG/ML P Vitamin B-12 ORAL TABLET 1000 MCG, 250 MCG, 500 MCG P OTC Vitamin B-12 SUBLINGUAL TABLET SUBLINGUAL 1000 MCG P OTC Vitamin B-12 ER ORAL TABLET EXTENDEDRELEASE* 1000 MCG P OTC P OTC Ferro-Bob ORAL TABLET 325 (65 Fe) MG P OTC Ferrous Sulfate ORAL ELIXIR 220 (44 Fe) MG/5ML P OTC Ferrous Sulfate ORAL SOLUTION 75 (15 Fe) MG/ML P OTC Ferrous Sulfate ORAL TABLET 325 (65 Fe) MG P OTC Ferrous Sulfate ORAL TABLET DELAYED RELEASE 324 (65 Fe) MG, 325 (65 Fe) MG P OTC FerrouSul ORAL TABLET 325 (65 Fe) MG P OTC Iron ORAL TABLET 325 (65 Fe) MG, 90 (18 Fe) MG P OTC Acetaminophen PM ORAL TABLET 500-25 MG P OTC; QL (62 EA per 31 Day(s)) Headache PM ORAL TABLET 25-500 MG P OTC; QL (62 EA per 31 day(s)) Mapap PM ORAL TABLET 500-25 MG P OTC; QL (62 EA per 31 day(s)) Pain Relief PM Extra Strength ORAL TABLET 500-25 MG P OTC; QL (62 EA per 31 day(s)) Pain Reliever PM ORAL TABLET 500-25 MG P OTC; QL (62 EA per 31 day(s)) Compoz ORAL CAPSULE 50 MG P OTC Compoz ORAL TABLET 50 MG P OTC *Folic Acid/Folates** *Folic Acid/Folates*** Folic Acid ORAL TABLET 1 MG *Iron** *Iron*** *Hypnotics* *Antihistamine Hypnotics** *Antihistamine Hypnotic Combinations*** *Antihistamine Hypnotics*** 13 Drug Name Preference Details Coverage Details NYTOL ORAL TABLET 25 MG P OTC SIMPLY SLEEP ORAL TABLET 25 MG P OTC Sleep Tabs ORAL TABLET 25 MG P OTC Sleep-Tabs ORAL TABLET 25 MG P OTC SOMINEX ORAL TABLET 25 MG P OTC SOMINEX MAXIMUM STRENGTH ORAL TABLET 50 MG P OTC Tetra-Formula Nighttime Sleep ORAL TABLET 50 MG P OTC Fiber ORAL TABLET 625 MG P OTC Fiber Laxative ORAL TABLET 625 MG P OTC Fiber Therapy ORAL POWDER 58.6 % P OTC Fiber-Lax ORAL TABLET 625 MG P OTC FIBERGEN ORAL TABLET 625 MG P OTC KONSYL ORAL PACKET 100 % P OTC KONSYL FIBER ORAL TABLET 625 MG P OTC METAMUCIL ORAL POWDER 30.9 % P OTC METAMUCIL MULTIHEALTH FIBER ORAL POWDER 58.6 % P OTC METAMUCIL SMOOTH TEXTURE ORAL PACKET 28 % P OTC METAMUCIL SMOOTH TEXTURE ORAL POWDER 28.3 %, 58.6 % P OTC Natural Fiber Therapy ORAL POWDER 30.9 %, 48.57 % P OTC Natural Vegetable Fiber ORAL POWDER 48.57 % P OTC REGULOID ORAL CAPSULE 0.52 GM P OTC DOC-Q-LAX ORAL TABLET 8.6-50 MG P OTC PERI-COLACE ORAL TABLET 8.6-50 MG P OTC Senna Plus ORAL TABLET 8.6-50 MG P OTC Senna S ORAL TABLET 8.6-50 MG P OTC *Laxatives* *Bulk Laxatives** *Bulk Laxatives*** *Laxative Combinations** *Laxatives & Dss*** 14 Drug Name Preference Details Coverage Details Senna-Docusate Sodium ORAL TABLET 8.6-50 MG P OTC Senna-S ORAL TABLET 8.6-50 MG P OTC Senna-Time S ORAL TABLET 8.6-50 MG P OTC SENNALAX-S ORAL TABLET 8.6-50 MG P OTC Sennosides-Docusate Sodium ORAL TABLET 8.6-50 MG P OTC P OTC Enema RE ENEMA 7-19 GM/118ML P OTC SM Oral Saline Laxative ORAL SOLUTION 2.7-7.2 GM/5ML P OTC Citrate of Magnesia ORAL SOLUTION 1.745 GM/30ML P OTC CITROMA ORAL SOLUTION 1.745 GM/30ML P OTC DULCOLAX MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML P OTC Magnesium Citrate ORAL SOLUTION 1.745 GM/30ML P OTC Milk of Magnesia ORAL SUSPENSION 400 MG/5ML, 7.75 % P OTC BISAC-EVAC ORAL TABLET DELAYED RELEASE 5 MG P OTC BISAC-EVAC RE SUPPOSITORY 10 MG P OTC Biscolax RE SUPPOSITORY 10 MG P OTC CARTERS LITTLE PILLS ORAL TABLET DELAYED RELEASE 5 MG P OTC Correct ORAL TABLET DELAYED RELEASE 5 MG P OTC CORRECTOL ORAL TABLET DELAYED RELEASE 5 MG P OTC *Laxatives - Miscellaneous** *Laxatives - Miscellaneous*** Sorbitol ORAL SOLUTION 70 % *Saline Laxatives** *Saline Laxative Mixtures*** *Saline Laxatives*** *Stimulant Laxatives** *Stimulant Laxatives*** 15 Drug Name Preference Details Coverage Details Ducodyl ORAL TABLET DELAYED RELEASE 5 MG P OTC EX-LAX ORAL TABLET CHEWABLE 15 MG P OTC EX-LAX ULTRA ORAL TABLET DELAYED RELEASE 5 MG P OTC FEENAMINT ORAL TABLET DELAYED RELEASE 5 MG P OTC FLEET LAXATIVE ORAL TABLET DELAYED RELEASE 5 MG P OTC Gentle Laxative ORAL TABLET DELAYED RELEASE 5 MG P OTC Laxative RE SUPPOSITORY 10 MG P OTC Magic Bullets RE SUPPOSITORY 10 MG P OTC Natural Senna Laxative ORAL TABLET 64.8-324 MG P OTC Senexon ORAL LIQUID† 8.8 MG/5ML P OTC Senexon ORAL TABLET 8.6 MG P OTC Senna ORAL SYRUP 8.8 MG/5ML P OTC Senna ORAL TABLET 15 MG, 8.6 MG P OTC Senna Lax ORAL TABLET 8.6 MG P OTC Senna Laxative ORAL TABLET 8.6 MG P OTC Senna Maximum Strength ORAL TABLET 25 MG P OTC SENNA SMOOTH ORAL TABLET 15 MG P OTC Senna-Lax ORAL TABLET 8.6 MG P OTC Senna-Tabs ORAL TABLET 8.6 MG P OTC Senna-Time ORAL TABLET 8.6 MG P OTC SENNACON ORAL TABLET 8.6 MG P OTC SENNO ORAL TABLET 8.6 MG P OTC Stimulant Laxative ORAL TABLET DELAYED RELEASE 5 MG P OTC Womens Laxative ORAL TABLET DELAYED RELEASE 5 MG P OTC P OTC *Surfactant Laxatives** *Surfactant Laxatives*** CORRECTOL EXTRA GENTLE ORAL CAPSULE 100 MG 16 Drug Name Preference Details Coverage Details D.O.S. ORAL CAPSULE 250 MG P OTC Diocto ORAL LIQUID† 50 MG/5ML P OTC Diocto ORAL SYRUP 60 MG/15ML P OTC DocQLace ORAL CAPSULE 100 MG P OTC Docu Soft ORAL CAPSULE 100 MG P OTC Docusate Sodium ORAL TABLET 100 MG P OTC DOCUSIL ORAL CAPSULE 100 MG P OTC DOK ORAL CAPSULE 100 MG, 250 MG P OTC DOK ORAL TABLET 100 MG P OTC DSS ORAL CAPSULE 100 MG, 250 MG P OTC DULCOLAX STOOL SOFTENER ORAL CAPSULE 100 MG P OTC ENEMEEZ MINI RE ENEMA 283 MG P OTC Kao-Tin ORAL CAPSULE 240 MG P OTC Laxa Basic ORAL CAPSULE 100 MG, 250 MG P OTC Silace ORAL LIQUID† 150 MG/15ML P OTC Silace ORAL SYRUP 60 MG/15ML P OTC SOF-LAX ORAL CAPSULE 100 MG P OTC Stool Softener ORAL CAPSULE 100 MG, 250 MG P OTC Stool Softener Laxative DC ORAL CAPSULE 240 MG P OTC Sur-Q-Lax ORAL CAPSULE 240 MG P OTC SURFAK ORAL CAPSULE 240 MG P OTC ACE AEROSOL CLOUD ENHANCER XX MISC P QL (2 EA per 365 day(s)) IN-CHECK DIAL FLOW TRAINER XX DEVICE P QL (2 EA per 365 day(s)) Inhaler Companions XX MISC P OTC; QL (2 EA per 365 day(s)) PFLEX XX MISC P QL (2 EA per 365 day(s)) THRESHOLD IMT XX MISC P QL (2 EA per 365 day(s)) THRESHOLD PEP XX DEVICE P QL (2 EA per 365 day(s)) WINDMILL TRAINER XX MISC P QL (2 EA per 365 day(s)) *Medical Devices* *Respiratory Therapy Supplies** *Respiratory Therapy Supplies*** 17 Drug Name Preference Details Coverage Details *Spacer/Aerosol-Holding Chambers & Supplies*** AEROCHAMBER MV XX MISC P QL (2 EA per 365 day(s)) AEROCHAMBER PLUS FLO-VU XX MISC P QL (2 EA per 365 day(s)) AEROCHAMBER PLUS FLO-VU LARGE XX MISC P QL (2 EA per 365 day(s)) AEROCHAMBER PLUS FLO-VU SMALL XX MISC P QL (2 EA per 365 day(s)) AEROCHAMBER PLUS FLO-VU W/MASK XX MISC P QL (2 EA per 365 day(s)) AEROCHAMBER W/FLOWSIGNAL XX MISC P QL (2 EA per 365 day(s)) AEROCHAMBER Z-STAT PLUS XX MISC P QL (2 EA per 365 day(s)) AEROCHAMBER Z-STAT PLUS CHAMBR XX MISC P QL (2 EA per 365 day(s)) EASIVENT XX MISC P QL (2 EA per 365 day(s)) MICROCHAMBER XX MISC P QL (2 EA per 365 day(s)) MICROSPACER XX MISC P QL (2 EA per 365 day(s)) OPTICHAMBER ADVANTAGE XX MISC P QL (2 EA per 365 day(s)) OPTIHALER XX DEVICE P QL (2 EA per 365 day(s)) OPTIHALER XX MISC P QL (2 EA per 365 day(s)) POCKET CHAMBER XX DEVICE P QL (2 EA per 365 day(s)) POCKET SPACER XX DEVICE P QL (2 EA per 365 day(s)) WATCHHALER XX DEVICE P QL (2 EA per 365 day(s)) Calcium ORAL TABLET 500-125 MG-UNIT P OTC Calcium + D3 ORAL TABLET 600-200 MG-UNIT P OTC Calcium 600-D ORAL TABLET 600-400 MG-UNIT P OTC Calcium Carbonate-Vitamin D ORAL TABLET 500-400 MG-UNIT, 600-400 MG-UNIT P OTC Calcium High Potency/Vitamin D ORAL TABLET 600-200 MG-UNIT P OTC *Minerals & Electrolytes* *Calcium** *Calcium Combinations*** 18 Drug Name Preference Details Coverage Details Calcium-Carb 600 + D ORAL TABLET 600-125 MG-UNIT P OTC Calcium-Vitamin D ORAL TABLET 500-125 MG-UNIT, 600-125 MG-UNIT, 600-200 MG-UNIT P OTC CALTRATE 600+D ORAL TABLET 600-800 MG-UNIT P OTC Liquid Calcium/Vitamin D ORAL CAPSULE 600-200 MG-UNIT P OTC OS-CAL 500 + D ORAL TABLET 500-200 MG-UNIT P OTC OYSCO 500+D ORAL TABLET 500-200 MG-UNIT P OTC OYSCO D ORAL TABLET 250-125 MG-UNIT P OTC Oyst-Cal D ORAL TABLET 250-125 MG-UNIT P OTC Oyster Calcium + D ORAL TABLET 250-125 MG-UNIT P OTC Oyster Shell Calcium + D ORAL TABLET 500-400 MG-UNIT P OTC Oyster Shell Calcium 500 + D ORAL TABLET 500-125 MG-UNIT P OTC Oyster Shell Calcium/D ORAL TABLET 250-125 MG-UNIT, 500-200 MG-UNIT P OTC Oyster Shell Calcium/Vitamin D ORAL TABLET 500-200 MG-UNIT P OTC Oyster Shell/Vitamin D ORAL TABLET 600-125 MG-UNIT P OTC CAL-CARB FORTE ORAL TABLET 1250 MG P OTC Calcarb 600 ORAL TABLET 1500 MG P OTC CALCI-CHEW ORAL TABLET CHEWABLE 1250 MG P OTC Calcium 600 ORAL TABLET 600 MG P OTC Calcium Carbonate ORAL SUSPENSION 1250 MG/5ML P OTC Calcium Carbonate ORAL TABLET 1250 MG, 1500 MG, 600 MG P OTC *Calcium*** 19 Drug Name Preference Details Coverage Details Calcium High Potency ORAL TABLET 600 MG P OTC Calcium Oyster Shell ORAL TABLET 1250 MG P OTC Calcium-Carb 600 ORAL TABLET 600 MG P OTC CALTRATE 600 ORAL TABLET 1500 MG P OTC OS-CAL ORAL TABLET CHEWABLE 1250 MG P OTC OYSCO 500 ORAL TABLET 500 MG P OTC OYSTERCAL ORAL TABLET 500 MG P OTC ORALYTE FREEZER POPS ORAL SOLUTION P OTC; QL (4000 ML per 31 day(s)) REHYDRALYTE ORAL SOLUTION P OTC; QL (4000 ML per 31 day(s)) ReVital Freezer Pops ORAL SOLUTION P OTC; QL (4000 ML per 31 day(s)) ReVital Liquid Squeezers ORAL SOLUTION P OTC; QL (4000 ML per 31 day(s)) Mag-Delay ORAL TABLET EXTENDEDRELEASE* 535 (64 Mg) MG P OTC Mag-SR ORAL TABLET EXTENDEDRELEASE* 535 (64 Mg) MG P OTC MAG-TAB SR ORAL TABLET EXTENDEDRELEASE* 84 MG (7MEQ) P OTC MAG64 ORAL TABLET EXTENDEDRELEASE* 535 (64 MG) MG P OTC Magnacaps ORAL CAPSULE 100 MG P OTC Magnesium ORAL TABLET 250 MG P OTC Magnesium Oxide ORAL TABLET 400 (240 Mg) MG P OTC MAGNESIUM-OXIDE ORAL TABLET 400 (241.3 MG) MG P OTC P OTC *Electrolyte Mixtures** *Electrolytes Oral*** *Magnesium** *Magnesium*** *Sodium** *Sodium*** Sodium Chloride ORAL TABLET 1 GM 20 Drug Name Preference Details Coverage Details *Zinc** *Zinc*** ORAZINC ORAL CAPSULE 220 MG P OTC Zinc ORAL TABLET 25 MG, 50 MG P OTC Zinc Gluconate ORAL TABLET 100 MG, 30 MG, 50 MG P OTC Zinc Methionate ORAL CAPSULE 50 MG P OTC Zinc Picolinate ORAL TABLET 25 MG P OTC Zinc Sulfate ORAL CAPSULE 220 MG P OTC Zinc Sulfate ORAL TABLET 220 (50 Zn) MG P OTC Zinc-220 ORAL CAPSULE 220 MG P OTC *Multivitamins* *B-Complex W/ Folic Acid** *B-Complex W/ C & Folic Acid*** NEPHRONEX ORAL TABLET P Rena-Vite Rx ORAL TABLET 1 MG P RENAL ORAL CAPSULE 1 MG P Reno Caps ORAL CAPSULE 1 MG P *Multiple Vitamins W/ Minerals** *Multiple Vitamins W/ Minerals*** Centamin ORAL LIQUID† P OTC CentaVite ORAL LIQUID† P OTC Centavite A-Z Complete-Mineral ORAL TABLET P OTC CEROVITE ADVANCED FORMULA ORAL TABLET P OTC CERTAVITE/ANTIOXIDANTS ORAL LIQUID† P OTC Formula Twenty-One ORAL TABLET P OTC Gerivite Complete ORAL TABLET P OTC Golden Age Vitamin/Minerals ORAL LIQUID† P OTC Multivitamin & Mineral ORAL LIQUID† P OTC SUPER NU-THERA ORAL TABLET P OTC Thera Vital M ORAL TABLET P OTC Therabasic-M ORAL TABLET P OTC 21 Drug Name Preference Details Coverage Details Therapeutic Liquid ORAL SOLUTION P OTC Therapeutic-M ORAL TABLET P OTC TOTAL FORMULA 3 ORAL TABLET P OTC Daily Multiple Vitamins ORAL TABLET P OTC Daily Vite ORAL TABLET P OTC Daily Vites ORAL TABLET P OTC Multi-Day ORAL TABLET P OTC Multi-Vitamin ORAL TABLET P OTC Multi-Vitamins ORAL TABLET P OTC Once Daily ORAL TABLET P OTC One-Daily Multi Vitamins ORAL TABLET P OTC THERA ORAL TABLET P OTC Thera-Tabs ORAL TABLET P OTC THERA/BETA-CAROTENE ORAL TABLET P OTC Therapeutic ORAL TABLET P OTC *Multivitamins** *Multivitamins*** *Ped Mv W/ Fluoride** *Ped Mv W/ Fluoride*** Multi-Vit/Fluoride ORAL SOLUTION 0.25 MG/ML, 0.5 MG/ML P Multi-Vitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG P Multivitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG P Multivitamins/Fluoride ORAL TABLET CHEWABLE 0.25 MG P *Specialty Vitamins Products** *Specialty Vitamins Products*** P OTC Altamist Spray NASAL SOLUTION 0.65 % P OTC AYR NASAL SOLUTION 0.65 % P OTC Vitamins for Hair ORAL TABLET *Nasal Agents - Systemic And Topical* *Nasal Agents - Misc.** *Nasal Agents - Misc.*** 22 Drug Name Preference Details Coverage Details Deep Sea Nasal Spray NASAL SOLUTION 0.65 % P OTC HUMIST NASAL SOLUTION 0.65 % P OTC LITTLE NOSES SALINE NASAL SOLUTION 0.65 % P OTC Na-Zone NASAL SOLUTION 0.65 % P OTC NASAL MOIST NASAL SOLUTION 0.65 % P OTC OCEAN FOR KIDS NASAL SOLUTION 0.65 % P OTC Saline Mist Spray NASAL SOLUTION 0.65 % P OTC Saline Nasal Spray NASAL SOLUTION 0.65 % P OTC Sea Soft Nasal Mist NASAL SOLUTION 0.65 % P OTC P OTC Nasal Decongestant ORAL SYRUP 30 MG/5ML P OTC Pseudoephedrine HCl ORAL TABLET 30 MG, 60 MG P OTC SUDAFED 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HR* 120 MG P OTC Artificial Tears OPHTHALMIC OINTMENT 83-15 % P OTC HYPOTEARS OPHTHALMIC SOLUTION 1-1 % P OTC Tears Again OPHTHALMIC OINTMENT P OTC ULTRA FRESH PM OPHTHALMIC OINTMENT P OTC *Nasal Antiallergy** *Nasal Mast Cell Stabilizers*** Cromolyn Sodium NASAL AEROSOL, SOLUTION 5.2 MG/ACT *Sympathomimetic Decongestants** *Systemic Decongestants*** *Ophthalmic Agents* *Artificial Tears And Lubricants** *Artificial Tear And Lubricant Combinations*** *Artificial Tear Ointments*** *Artificial Tear Solutions*** 23 Drug Name Preference Details Coverage Details P OTC Artificial Tears OPHTHALMIC SOLUTION 1.4 % P OTC; QL (15 ML per 31 day(s)) Liquitears OPHTHALMIC SOLUTION 1.4 % P OTC; QL (15 ML per 31 Day(s)) Polyvinyl Alcohol OPHTHALMIC SOLUTION 1.4 % P OTC; QL (15 ML per 31 Day(s)) ALAWAY OPHTHALMIC SOLUTION 0.025 % P OTC Ketotifen Fumarate OPHTHALMIC SOLUTION 0.025 % P OTC Auraphene-B OTIC SOLUTION 6.5 % P OTC AURO EARDROPS OTIC SOLUTION 6.5 % P OTC E-R-O EAR DROPS OTIC SOLUTION 6.5 % P OTC E-R-O EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % P OTC Ear Drops Earwax Aid OTIC SOLUTION 6.5 % P OTC Earwax Treatment Drops OTIC SOLUTION 6.5 % P OTC MURINE EAR OTIC SOLUTION 6.5 % P OTC MURINE EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % P OTC OTIX OTIC SOLUTION 6.5 % P OTC Thera-Ear OTIC SOLUTION 6.5 % P OTC P OTC; QL (70 EA per 365 day(s)) Tears Again OPHTHALMIC SOLUTION *Artificial Tears And Lubricants*** *Ophthalmics - Misc.** *Ophthalmic Antiallergic*** *Otic Agents* *Otic Agents - Miscellaneous** *Otic Agents - Miscellaneous*** *Psychotherapeutic And Neurological Agents Misc.* *Smoking Deterrents** *Smoking Deterrents*** Nicotine TRANSDERMAL PATCH 24 HR 14 MG/24HR, 21 MG/24HR, 7 MG/24HR 24 Drug Name Preference Details Coverage Details P OTC; QL (2016 EA per 365 day(s)) Acid Reducer ORAL TABLET 75 MG P OTC Cimetidine ORAL TABLET 200 MG P OTC Cimetidine Acid Reducer ORAL TABLET 200 MG P OTC Famotidine ORAL TABLET 10 MG P OTC Heartburn Relief ORAL TABLET 10 MG, 200 MG P OTC Heartburn Relief Max St ORAL TABLET 20 MG P OTC Ranitidine Acid Reducer ORAL TABLET 75 MG P OTC P OTC ENCARE VAGINAL SUPPOSITORY 100 MG P OTC OPTIONS CONCEPTROL VAGINAL GEL 4% P OTC VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM 12.5 % P OTC Miconazole 3 Combo Pack VAGINAL KIT 200-2 MG-% (9GM) P OTC Miconazole 7 VAGINAL CREAM 2 % P OTC Miconazole 7 VAGINAL SUPPOSITORY 100 MG P OTC Miconazole Nitrate VAGINAL CREAM 2 % P OTC Nicotine Polacrilex MOUTH/THROAT GUM 2 MG, 4 MG *Ulcer Drugs* *H-2 Antagonists** *H-2 Antagonists*** *Proton Pump Inhibitors** *Proton Pump Inhibitors*** Omeprazole ORAL TABLET DELAYED RELEASE 20 MG *Vaginal Products* *Spermicides** *Spermicides*** *Vaginal Anti-Infectives** *Imidazole-Related Antifungals*** 25 Drug Name Miconazole Nitrate VAGINAL SUPPOSITORY 100 MG Preference Details Coverage Details P OTC CALCIFEROL ORAL SOLUTION 8000 UNIT/ML P OTC Vitamin D ORAL TABLET 400 UNIT P OTC Vitamin D (Ergocalciferol) ORAL CAPSULE 50000 UNIT P QL (4 EA per 31 day(s)) Vitamin D-400 ORAL TABLET 400 UNIT P OTC Vitamin D3 ORAL CAPSULE 2000 UNIT P OTC Vitamin D3 ORAL TABLET 1000 UNIT, 400 UNIT P OTC *Vitamins* *Oil Soluble Vitamins** *Vitamin D*** *Vitamin K*** MEPHYTON ORAL TABLET 5 MG P *Water Soluble Vitamins** *Vitamin B-3*** ENDUR-ACIN ORAL TABLET EXTENDEDRELEASE* 250 MG, 500 MG P OTC Niacin ORAL TABLET 100 MG, 250 MG, 50 MG, 500 MG P OTC Niacin ER ORAL CAPSULE EXTENDED RELEASE* 250 MG, 500 MG P OTC Niacin ER ORAL TABLET EXTENDEDRELEASE* 250 MG, 500 MG, 750 MG P OTC Niacin-50 ORAL TABLET 50 MG P OTC SLO-NIACIN ORAL TABLET EXTENDEDRELEASE* 250 MG P OTC Ascorbic Acid ORAL TABLET 1000 MG, 250 MG, 500 MG P OTC Ascorbic Acid ORAL TABLET CHEWABLE 250 MG P OTC C-500 ORAL TABLET CHEWABLE 500 MG P OTC Vitamin C ORAL SYRUP 500 MG/5ML P OTC Vitamin C ORAL TABLET 100 MG, 1000 MG, 250 MG, 500 MG P OTC *Vitamin C*** 26 Drug Name Vitamin C ORAL TABLET CHEWABLE 100 MG, 250 MG Preference Details Coverage Details P OTC 27 28 Index A-200 XX AEROSOL† 0.5 % ................................................................................................ 11 ACE AEROSOL CLOUD ENHANCER XX MISC ................ 17 ACEPHEN RE SUPPOSITORY 120 MG, 325 MG, 650 MG .................................................................................................... 2 Acetaminophen ORAL SOLUTION 160 MG/5ML .............. 2 Acetaminophen ORAL TABLET 325 MG .......................................................................... 2 Acetaminophen ORAL TABLET 500 MG .......................................................................... 2 Acetaminophen ORAL TABLET CHEWABLE 80 MG ................................ 2 Acetaminophen PM ORAL TABLET 500-25 MG ............................ 13 ACID GONE ORAL TABLET CHEWABLE 160-105 MG, 80-20 MG ................................................................... 5 Acid Reducer ORAL TABLET 75 MG ................................................................................... 25 Acne Medication 10 EXTERNAL GEL 10 % ............................................................... 10 Acne Medication EXTERNAL LOTION 10 % ................................................. 10 Acne-Clear EXTERNAL GEL 10 % ......................................................................................... 10 Actidose/Sorbitol ORAL LIQUID† 25 GM/120ML, 50 GM/240ML ............................................................. 7 Actidose-Aqua ORAL LIQUID† 15 GM/72ML, 25 GM/120ML, 50 GM/240ML ............................................................. 7 AEROCHAMBER MV XX MISC ............................................................................ 18 AEROCHAMBER PLUS FLO-VU LARGE XX MISC ................................................................................................ 18 AEROCHAMBER PLUS FLO-VU SMALL XX MISC ................................................................................................ 18 AEROCHAMBER PLUS FLO-VU W/MASK XX MISC ................................................................................................ 18 AEROCHAMBER PLUS FLO-VU XX MISC ................................ 18 AEROCHAMBER W/FLOWSIGNAL XX MISC ................................................................................................ 18 AEROCHAMBER Z-STAT PLUS CHAMBR XX MISC 18 AEROCHAMBER Z-STAT PLUS XX MISC ......................................... 18 Alamag Plus ORAL TABLET CHEWABLE 200-200-25 MG .................................................................................................... 4 ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG .................................................................................................... 9 ALAWAY OPHTHALMIC SOLUTION 0.025 % ............................. 24 Alcalak ORAL TABLET CHEWABLE 420 MG ............................ 5 Aler-Cap ORAL CAPSULE 25 MG ....................................................................................... 7 Aler-Dryl ORAL TABLET 50 MG ....................................................................................... 7 AlerTab ORAL TABLET 25 MG .................................................................................................... 7 Aller-Chlor ORAL SYRUP 2 MG/5ML ..................................................................... 7 Aller-Chlor ORAL TABLET 4 MG ....................................................................................... 7 Allergy EXTERNAL CREAM 2 % ......................................................................................... 11 Allergy ORAL TABLET 4 MG .................................................................................................... 7 Allergy Relief Childrens ORAL LIQUID† 12.5 MG/5ML .................... 7 Allergy Relief ORAL TABLET 4 MG ....................................................................................... 7 ALMACONE ORAL SUSPENSION 200-200-20 MG/5ML .................................................................... 4 Altamist Spray NASAL SOLUTION 0.65 % ................................. 22 Altaryl ORAL ELIXIR 12.5 MG/5ML ..................................................................... 8 Altaryl ORAL SYRUP 12.5 MG/5ML ..................................................................... 8 Aluminum Hydroxide Gel ORAL SUSPENSION 320 MG/5ML .................................................................................................... 5 Antacid Anti-Gas Max Strength ORAL SUSPENSION 400-400-40 MG/5ML ................................ 4 Antacid Anti-Gas ORAL SUSPENSION 200-200-20 MG/5ML ..................................................................... 4 ................................................................................................ Antacid Extra Strength ORAL SUSPENSION 400-400-40 MG/5ML ..................................................................... 4 Antacid I ORAL SUSPENSION 200-200-20 MG/5ML ................................ 4 Antacid III ORAL SUSPENSION 400-400-40 MG/5ML ..................................................................... 4 Antacid ORAL SUSPENSION 200-200-20 MG/5ML ................................ 4 Antacid ORAL TABLET CHEWABLE 420 MG, 500 MG .................................................................................................... 5 Anti-Diarrheal ORAL LIQUID† 1 MG/5ML ............................................................... 6 Anti-Fungal EXTERNAL POWDER 1 % ................................................ 10 Anti-Hist Allergy ORAL TABLET 25 MG .............................................. 8 Anti-Hist ORAL CAPSULE 25 MG ....................................................................................... 8 Anti-Itch Maximum Strength EXTERNAL CREAM 2 % ........... 11 APAP Extra Strength ORAL TABLET 500 MG .......................................... 2 APAP ORAL TABLET 325 MG .................................................................................................... 2 Artificial Tears OPHTHALMIC OINTMENT 83-15 % ........................... 23 Artificial Tears OPHTHALMIC SOLUTION 1.4 % .................................... 24 Ascorbic Acid ORAL TABLET 1000 MG, 250 MG, 500 MG ................................................................................................ 26 Ascorbic Acid ORAL TABLET CHEWABLE 250 MG ........................ 26 Aspirin Childrens ORAL TABLET CHEWABLE 81 MG .................................................................................................... 3 Aspirin EC Low Dose ORAL TABLET DELAYED RELEASE 81 MG ............................................................................. 3 Aspirin EC ORAL TABLET DELAYED RELEASE 325 MG, 81 MG ............................................................................. 3 Aspirin Low Dose ORAL TABLET 81 MG .............................................. 3 Aspirin ORAL TABLET 325 MG, 81 MG ............................................................. 3 Aspirin ORAL TABLET CHEWABLE 81 MG ................................ 3 29 Aspirin ORAL TABLET DELAYED RELEASE 81 MG 3 Auraphene-B OTIC SOLUTION 6.5 % .............................................................................. 24 AURO EARDROPS OTIC SOLUTION 6.5 % .................................... 24 AYR NASAL SOLUTION 0.65 % ......................................................................................... 22 Bacitracin EXTERNAL OINTMENT 500 UNIT/GM ................................................................................................ 10 Bacitracin Zinc EXTERNAL OINTMENT 500 UNIT/GM ................................................................................................ 10 Bacitracin-Neomycin-Polymyxin EXTERNAL OINTMENT 400-5-5000 ........................................................... 10 BANOPHEN ORAL CAPSULE 25 MG ............................................................................. 8 BANOPHEN ORAL LIQUID† 12.5 MG/5ML ..................................................... 8 BANOPHEN ORAL TABLET 25 MG ............................................................................. 8 BD GLUCOSE ORAL TABLET CHEWABLE 5 GM .................................. 6 BENADRYL ALLERGY CHILDRENS ORAL LIQUID† 12.5 MG/5ML ..................................................... 8 BENADRYL ITCH STOPPING EXTERNAL GEL 2 % ..................... 11 Benzoyl Peroxide EXTERNAL GEL 10 %, 5 % ................................................ 10 BETA CARE BETATAR GEL EXTERNAL SHAMPOO 2.5 % ................................................................................................ 12 BISAC-EVAC ORAL TABLET DELAYED RELEASE 5 MG ................................................................................................ 15 BISAC-EVAC RE SUPPOSITORY 10 MG ................. 15 Biscolax RE SUPPOSITORY 10 MG ................................................................................... 15 Bismatrol ORAL SUSPENSION 262 MG/15ML .................................................... 6 Bismatrol ORAL TABLET CHEWABLE 262 MG ............................ 6 Bismuth ORAL TABLET CHEWABLE 262 MG ............................ 6 BROTAPP ORAL LIQUID† 1-15 MG/5ML .................................................... 9 C-500 ORAL TABLET CHEWABLE 500 MG ........................ 26 .................................................................................................... 30 Calcarb 600 ORAL TABLET 1500 MG .................................................................. 19 CAL-CARB FORTE ORAL TABLET 1250 MG ................................. 19 CALCI-CHEW ORAL TABLET CHEWABLE 1250 MG .................... 19 CALCIFEROL ORAL SOLUTION 8000 UNIT/ML ................................................................................................ 26 Calcium + D3 ORAL TABLET 600-200 MG-UNIT ................................... 18 Calcium 600 ORAL TABLET 600 MG ...................................................................... 19 Calcium 600-D ORAL TABLET 600-400 MG-UNIT ................................... 18 Calcium Antacid Extra Strength ORAL TABLET CHEWABLE 750 MG .......................................................................... 5 Calcium Antacid ORAL TABLET CHEWABLE 500 MG .................................................................................................... 5 Calcium Carbonate Antacid ORAL TABLET 648 MG ................... 5 Calcium Carbonate Antacid ORAL TABLET CHEWABLE 500 MG .......................................................................... 5 Calcium Carbonate ORAL SUSPENSION 1250 MG/5ML ................................................................................................ 19 Calcium Carbonate ORAL TABLET 1250 MG, 1500 MG, 600 MG ...................................................................... 19 Calcium Carbonate-Vitamin D ORAL TABLET 500-400 MG-UNIT, 600-400 MG-UNIT ................................................................................................ 18 Calcium High Potency ORAL TABLET 600 MG ...................................... 20 Calcium High Potency/Vitamin D ORAL TABLET 600-200 MG-UNIT ............................................................. 18 Calcium ORAL TABLET 500-125 MG-UNIT ................................... 18 Calcium Oyster Shell ORAL TABLET 1250 MG ................................... 20 Calcium-Carb 600 + D ORAL TABLET 600-125 MG-UNIT ................................................................................................ 19 Calcium-Carb 600 ORAL TABLET 600 MG ...................................... 20 Calcium-Vitamin D ORAL TABLET 500-125 MG-UNIT, 600-125 MG-UNIT, 600-200 MG-UNIT ............................................................. 19 CAL-GEST ANTACID ORAL TABLET CHEWABLE 500 MG .................................................................................................... 5 CALTRATE 600 ORAL TABLET 1500 MG ................................. 20 CALTRATE 600+D ORAL TABLET 600-800 MG-UNIT ................................................................................................ 19 CARTERS LITTLE PILLS ORAL TABLET DELAYED RELEASE 5 MG ........................................ 15 Centamin ORAL LIQUID† ................................................................................................ 21 Centavite A-Z Complete-Mineral ORAL TABLET ....................................... 21 CentaVite ORAL LIQUID† ................................................................................................ 21 CEROVITE ADVANCED FORMULA ORAL TABLET ................................................................................................ 21 CERTAVITE/ANTIOXIDANT S ORAL LIQUID† .................................. 21 Cetirizine HCl Childrens Alrgy ORAL SYRUP 1 MG/ML ................ 9 Cetirizine HCl Childrens ORAL SOLUTION 1 MG/ML ......................... 9 Cetirizine HCl ORAL TABLET 10 MG, 5 MG ....................................................... 9 Charcoal Activated ORAL TABLET 250 MG .......................................... 7 Charcoal ORAL CAPSULE 200 MG ....................................................................................... 1 Charcoal ORAL CAPSULE 260 MG ....................................................................................... 7 CHARCOCAPS ORAL CAPSULE 260 MG .................................... 7 Childrens Non-ASA Pain Relief ORAL TABLET CHEWABLE 80 MG ............................................................................. 2 Childrens Non-Aspirin ORAL TABLET CHEWABLE 80 MG .................................................................................................... 2 Childrens Non-Aspirin Pain ORAL TABLET CHEWABLE 80 MG ............................................................................. 2 Childrens Pain Reliever ORAL TABLET CHEWABLE 80 MG .................................................................................................... 2 Childrens Silapap ORAL LIQUID† 160 MG/5ML ...................... 2 Childrens Tactinal ORAL TABLET CHEWABLE 80 MG .................................................................................................... 2 ChlorHist ORAL TABLET 4 MG .................................................................................................... 7 Chlorphen ORAL TABLET 4 MG ....................................................................................... 7 Cimetidine Acid Reducer ORAL TABLET 200 MG ...................................... 25 Cimetidine ORAL TABLET 200 MG ................................................................................... 25 Citrate of Magnesia ORAL SOLUTION 1.745 GM/30ML ................................................................................................ 15 CITROMA ORAL SOLUTION 1.745 GM/30ML .......................................... 15 CLEAN & CLEAR PERSA-GEL EX ST EXTERNAL GEL 5 % ..................... 10 CLEAN & CLEAR PERSA-GEL MAX ST EXTERNAL GEL 10 % .................. 10 CLEARPLEX V EXTERNAL GEL 5 % .................................................................. 10 CLEARSKIN EXTERNAL CREAM 10 % ................................................. 10 Clotrimazole Anti-Fungal EXTERNAL CREAM 1 % ........... 11 Clotrimazole EXTERNAL CREAM 1 % ...................................................... 11 Clotrimazole EXTERNAL SOLUTION 1 % .......................................... 11 Complete Allergy Medication ORAL TABLET 25 MG ....................... 8 Complete Allergy Relief ORAL TABLET 25 MG .............................................. 8 Compoz ORAL CAPSULE 50 MG ................................................................................... 13 Compoz ORAL TABLET 50 MG ................................................................................................ 13 COPPERTONE SUNBLOCK SPF15 EXTERNAL LOTION ................................................................................................ 12 Correct ORAL TABLET DELAYED RELEASE 5 MG ................................................................................................ 15 CORRECTOL EXTRA GENTLE ORAL CAPSULE 100 MG .................................................................................. 16 CORRECTOL ORAL TABLET DELAYED RELEASE 5 MG ................................................................................................ 15 Cromolyn Sodium NASAL AEROSOL, SOLUTION 5.2 MG/ACT ................................................................. 23 Cyanocobalamin INJECTION SOLUTION 1000 MCG/ML ................................................................................................ 13 D.O.S. ORAL CAPSULE 250 MG ................................................................................... 17 Daily Multiple Vitamins ORAL TABLET .............................................................. 22 Daily Vite ORAL TABLET ................................................................................................ 22 Daily Vites ORAL TABLET ................................................................................................ 22 Deep Sea Nasal Spray NASAL SOLUTION 0.65 % ................................. 23 DIABETIC TUSSIN ALLERGY ORAL SYRUP 2 MG/5ML .................................................................... 7 Diocto ORAL LIQUID† 50 MG/5ML ................................................................. 17 Diocto ORAL SYRUP 60 MG/15ML ............................................................. 17 Diotame ORAL TABLET CHEWABLE 262 MG ............................ 6 Diphenhist ORAL CAPSULE 25 MG ....................................................................................... 8 Diphenhist ORAL LIQUID† 12.5 MG/5ML ..................................................................... 8 Diphenhist ORAL TABLET 25 MG ....................................................................................... 8 DiphenhydrAMINE HCl ORAL CAPSULE 25 MG, 50 MG .............. 8 DiphenhydrAMINE HCl ORAL TABLET 25 MG .............................................. 8 DocQLace ORAL CAPSULE 100 MG ...................................................................... 17 DOC-Q-LAX ORAL TABLET 8.6-50 MG ............................................................. 14 Docu Soft ORAL CAPSULE 100 MG ................................................................................... 17 Docusate Sodium ORAL TABLET 100 MG ...................................... 17 DOCUSIL ORAL CAPSULE 100 MG ..................................................................... 17 DOK ORAL CAPSULE 100 MG, 250 MG ...................................................... 17 DOK ORAL TABLET 100 MG ................................................................................................ 17 DORMIN ORAL CAPSULE 25 MG ...................................................................................... 8 Double Antibiotic EXTERNAL OINTMENT 500-10000 UNIT/GM .............................................................. 10 DSS ORAL CAPSULE 100 MG, 250 MG ...................................................................... 17 Ducodyl ORAL TABLET DELAYED RELEASE 5 MG ................................................................................................ DULCOLAX MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML ................................................................................................ 16 15 DULCOLAX STOOL SOFTENER ORAL CAPSULE 100 MG ..................................................................... 17 Ear Drops Earwax Aid OTIC SOLUTION 6.5 % .................................... 24 Earwax Treatment Drops OTIC SOLUTION 6.5 % .................................... 24 EASIVENT XX MISC ...................... 18 ECPIRIN ORAL TABLET DELAYED RELEASE 325 MG .................................................................................................... 3 Ed-APAP ORAL LIQUID† 160 MG/5ML ..................................................................... 2 ELTA TAR EXTERNAL CREAM 2 % ..................................................... 12 ENCARE VAGINAL SUPPOSITORY 100 MG .............. 25 ENDUR-ACIN ORAL TABLET EXTENDEDRELEASE* 250 MG, 500 MG .................................................... 26 Enema RE ENEMA 7-19 GM/118ML .......................................................... 15 ENEMEEZ MINI RE ENEMA 283 MG ..................................................................... 17 E-R-O EAR DROPS OTIC SOLUTION 6.5 % .................................... 24 E-R-O EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % ......................................................................................... 24 EX-LAX ORAL TABLET CHEWABLE 15 MG ........................... 16 EX-LAX ULTRA ORAL TABLET DELAYED RELEASE 5 MG ........................................ 16 Famotidine ORAL TABLET 10 MG ................................................................................... 25 FEENAMINT ORAL TABLET DELAYED RELEASE 5 MG ................................................................................................ 16 Ferro-Bob ORAL TABLET 325 (65 Fe) MG ......................................................... 13 Ferrous Sulfate ORAL ELIXIR 220 (44 Fe) MG/5ML .......................... 13 Ferrous Sulfate ORAL SOLUTION 75 (15 Fe) MG/ML ................................................................................................ 13 31 Ferrous Sulfate ORAL TABLET 325 (65 Fe) MG ............................................ 13 Ferrous Sulfate ORAL TABLET DELAYED RELEASE 324 (65 Fe) MG, 325 (65 Fe) MG .............. 13 FerrouSul ORAL TABLET 325 (65 Fe) MG ......................................................... 13 Fiber Laxative ORAL TABLET 625 MG ...................................................................... 14 Fiber ORAL TABLET 625 MG ................................................................................................ 14 Fiber Therapy ORAL POWDER 58.6 % ........................................................................... 14 FIBERGEN ORAL TABLET 625 MG ..................................................................... 14 Fiber-Lax ORAL TABLET 625 MG ................................................................................... 14 FLEET LAXATIVE ORAL TABLET DELAYED RELEASE 5 MG ........................................ 16 Folic Acid ORAL TABLET 1 MG ................................................................................... 13 Formula Twenty-One ORAL TABLET .............................................................. 21 FORMULATION R RE OINTMENT 0.25-3-14-71.9 % .................................................................................................... 4 Gelatin ORAL CAPSULE 650 MG ....................................................................................... 9 Genahist ORAL CAPSULE 25 MG ....................................................................................... 8 Gentle Laxative ORAL TABLET DELAYED RELEASE 5 MG ................................................................................................ 16 Geri-Lanta ORAL SUSPENSION 200-200-20 MG/5ML ..................................................................... 4 Gerivite Complete ORAL TABLET .............................................................. 21 Glucose ORAL TABLET CHEWABLE 4 GM .................................... 6 Golden Age Vitamin/Minerals ORAL LIQUID† ..................................... 21 Headache PM ORAL TABLET 25-500 MG ............................................................ 13 Heartburn Relief Max St ORAL TABLET 20 MG .......................................... 25 Heartburn Relief ORAL TABLET 10 MG, 200 MG ............. 25 Hem-Prep RE SUPPOSITORY 0.25-3-85.5 % ......................................................... 4 HUMIST NASAL SOLUTION 0.65 % ........................................................................... 23 32 Hydrocortisone EXTERNAL CREAM 0.5 % ................................................ 11 Hydrocortisone EXTERNAL OINTMENT 0.5 %, 1 % ................... 11 Hydrocortisone Max St EXTERNAL CREAM 1 % ........... 11 Hydrocortisone Max St/12 Moist EXTERNAL CREAM 1 % ........... 11 Hydrocortisone-Aloe EXTERNAL CREAM 1 % ........... 11 HYDROSKIN EXTERNAL CREAM 1 % ..................................................... 11 HYPOTEARS OPHTHALMIC SOLUTION 1-1 % .................................... 23 Ibuprofen Junior Strength ORAL TABLET CHEWABLE 100 MG .................................................................................................... 2 Ibuprofen ORAL SUSPENSION 100 MG/5ML ........................................................ 1 Ibuprofen ORAL TABLET 200 MG ....................................................................................... 1 IN-CHECK DIAL FLOW TRAINER XX DEVICE ............... 17 Inhaler Companions XX MISC ................................................................................................ 17 IONIL-T EXTERNAL SHAMPOO 1 % ........................................... 12 Ipecac ORAL SYRUP ......................... 7 Iron ORAL TABLET 325 (65 Fe) MG, 90 (18 Fe) MG .................. 13 Itch Relief EXTERNAL CREAM 2 % .................................................................................... 11 KAOPECTATE EXTRA STRENGTH ORAL SUSPENSION 525 MG/15ML .................................................................................................... 6 KAOPECTATE ORAL SUSPENSION 262 MG/15ML .................................................................................................... 6 Kao-Tin ORAL CAPSULE 240 MG ................................................................................... 17 Kao-Tin ORAL SUSPENSION 262 MG/15ML .................................................... 6 KERR INSTA-CHAR IN SORBITOL ORAL LIQUID† 25 GM/120ML, 50 GM/240ML .................................................................................................... 7 KERR INSTA-CHAR ORAL LIQUID† 25 GM/120ML, 50 GM/240ML ............................................................ 7 Ketotifen Fumarate OPHTHALMIC SOLUTION 0.025 % ....................................................................... 24 KONSYL FIBER ORAL TABLET 625 MG ..................................... 14 KONSYL ORAL PACKET 100 % ......................................................................................... 14 Laxa Basic ORAL CAPSULE 100 MG, 250 MG ......................................... 17 Laxative RE SUPPOSITORY 10 MG ................................................................................... 16 Liquid Calcium/Vitamin D ORAL CAPSULE 600-200 MG-UNIT ................................................................................................ 19 Liquitears OPHTHALMIC SOLUTION 1.4 % .................................... 24 LITTLE NOSES SALINE NASAL SOLUTION 0.65 % ................................................................................................ 23 LITTLE REMEDIES POISON TREAT ORAL SUSPENSION RECONSTITUTED 15 GM/120ML ............................................................ 7 LOPERAMIDE A-D ORAL TABLET 2 MG ................................................ 6 Loperamide HCl ORAL LIQUID† 1 MG/5ML ............................. 6 Loratadine Hives Relief ORAL SOLUTION 5 MG/5ML ..................... 9 Loratadine ORAL TABLET 10 MG ....................................................................................... 9 MAALOX ADVANCED MAX ST ORAL SUSPENSION 400-400-40 MG/5ML ................................ 4 MAALOX ADVANCED ORAL SUSPENSION 200-200-20 MG/5ML .................................................................... 4 MAALOX MAX ORAL SUSPENSION 400-400-40 MG/5ML .................................................................... 4 MAALOX MULTI SYMPTOM MAX ST ORAL SUSPENSION 400-400-40 MG/5ML ................................ 4 MAALOX ORAL TABLET CHEWABLE 600 MG ........................... 5 MAALOX REGULAR STRENGTH ORAL SUSPENSION 200-200-20 MG/5ML .................................................................... 4 MAG64 ORAL TABLET EXTENDEDRELEASE* 535 (64 MG) MG ..................................................... 20 Mag-Delay ORAL TABLET EXTENDEDRELEASE* 535 (64 Mg) MG ..................................................... 20 Magic Bullets RE SUPPOSITORY 10 MG .................. 16 Magnacaps ORAL CAPSULE 100 MG ...................................................................... 20 Magnesium Citrate ORAL SOLUTION 1.745 GM/30ML ................................................................................................ 15 Magnesium ORAL TABLET 250 MG ................................................................................... 20 Magnesium Oxide ORAL TABLET 400 (240 Mg) MG ................................................................................................ 20 MAGNESIUM-OXIDE ORAL TABLET 400 (241.3 MG) MG ................................................................................................ 20 Mag-SR ORAL TABLET EXTENDEDRELEASE* 535 (64 Mg) MG ..................................................... 20 MAG-TAB SR ORAL TABLET EXTENDEDRELEASE* 84 MG (7MEQ) ...................................................... 20 Mapap Arthritis Pain ORAL TABLET EXTENDEDRELEASE* 650 MG ....................................................................................... 2 Mapap ORAL CAPSULE 500 MG ....................................................................................... 2 Mapap ORAL TABLET 325 MG .................................................................................................... 2 Mapap ORAL TABLET 500 MG .................................................................................................... 2 Mapap ORAL TABLET CHEWABLE 80 MG ................................ 2 Mapap PM ORAL TABLET 500-25 MG ............................................................ 13 Maxapap Maximum Strength ORAL TABLET 500 MG ................... 2 Maxapap Regular Strength ORAL TABLET 325 MG ................... 2 Meclizine HCl ORAL TABLET 12.5 MG, 25 MG .............................................. 7 Melatonin Maximum Strength ORAL TABLET 5 MG .......................... 1 MEPHYTON ORAL TABLET 5 MG ............................................................................. 26 METAMUCIL MULTIHEALTH FIBER ORAL POWDER 58.6 % ............... 14 METAMUCIL ORAL POWDER 30.9 % ....................................... 14 METAMUCIL SMOOTH TEXTURE ORAL PACKET 28 % ......................................................................................... 14 METAMUCIL SMOOTH TEXTURE ORAL POWDER 28.3 %, 58.6 % .................................................. 14 MG217 MEDICATED TAR EXTERNAL SHAMPOO 15 % ................................................................................................ 12 Mi-Acid Gas Relief ORAL TABLET CHEWABLE 80 MG ................................................................................................ 12 MI-ACID ORAL TABLET CHEWABLE 700-300 MG .................................................................................................... 5 Miconazole 3 Combo Pack VAGINAL KIT 200-2 MG-% (9GM) ........................................................................ 25 Miconazole 7 VAGINAL CREAM 2 % ...................................................... 25 Miconazole 7 VAGINAL SUPPOSITORY 100 MG .............. 25 Miconazole Nitrate VAGINAL CREAM 2 % ...................................................... 25 Miconazole Nitrate VAGINAL SUPPOSITORY 100 MG .............. 26 MICROCHAMBER XX MISC ................................................................................................ 18 MICROSPACER XX MISC ................................................................................................ 18 Milantex Extra Strength ORAL SUSPENSION 400-400-40 MG/5ML ..................................................................... 4 Milantex ORAL SUSPENSION 200-200-20 MG/5ML ................................ 4 Milk of Magnesia ORAL SUSPENSION 400 MG/5ML, 7.75 % ........................................................................... 15 MINTOX PLUS ORAL TABLET CHEWABLE 200-200-25 MG .................................................. 5 Mucus Relief ORAL TABLET 400 MG .......................................................................... 9 Multi-Day ORAL TABLET ................................................................................................ 22 Multi-Vit/Fluoride ORAL SOLUTION 0.25 MG/ML, 0.5 MG/ML ..................................................................... 22 Multivitamin & Mineral ORAL LIQUID† ............................................................ 21 Multi-Vitamin ORAL TABLET ................................................................................................ 22 Multivitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG ................................. 22 Multi-Vitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG ................................. 22 Multi-Vitamins ORAL TABLET ................................................................................................ 22 Multivitamins/Fluoride ORAL TABLET CHEWABLE 0.25 MG ................................................................................................ 22 MURINE EAR OTIC SOLUTION 6.5 % .................................... 24 MURINE EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % .................................... 24 Mytab Gas ORAL TABLET CHEWABLE 80 MG ............................ 12 Nasal Decongestant ORAL SYRUP 30 MG/5ML ............................ 23 NASAL MOIST NASAL SOLUTION 0.65 % ................................ 23 Natural Fiber Therapy ORAL POWDER 30.9 %, 48.57 % .......... 14 Natural Senna Laxative ORAL TABLET 64.8-324 MG ....................... 16 Natural Vegetable Fiber ORAL POWDER 48.57 % ................................... 14 Na-Zone NASAL SOLUTION 0.65 % ........................................................................... 23 NEPHRONEX ORAL TABLET ................................................................................................ 21 NEUTROGENA MOISTURE SPF15 EXTERNAL LOTION ................................................................................................ 12 NEUTROGENA ON-THE-SPOT EXTERNAL CREAM 2.5 % ............................................... 10 NEUTROGENA T/GEL EX ST EXTERNAL SHAMPOO 1 % ................................................................................................ 12 Niacin ER ORAL CAPSULE EXTENDED RELEASE* 250 MG, 500 MG ...................................................... 26 Niacin ER ORAL TABLET EXTENDEDRELEASE* 250 MG, 500 MG, 750 MG ........................ 26 Niacin ORAL TABLET 100 MG, 250 MG, 50 MG, 500 MG ............... 26 Niacin-50 ORAL TABLET 50 MG ................................................................................... 26 Nicotine Polacrilex MOUTH/THROAT GUM 2 MG, 4 MG ............................................................................. 25 Nicotine TRANSDERMAL PATCH 24 HR 14 MG/24HR, 21 MG/24HR, 7 MG/24HR ................... 24 Non-Aspirin Extra Strength ORAL TABLET 500 MG ................... 3 Non-Aspirin ORAL TABLET 325 MG ....................................................................................... 3 33 Non-Aspirin Pain Relief ORAL TABLET 325 MG .......................................... 3 Nortemp Infants ORAL SUSPENSION 80 MG/0.8ML .................................................................................................... 3 NYTOL ORAL TABLET 25 MG .................................................................................. 14 OCEAN FOR KIDS NASAL SOLUTION 0.65 % ................................ 23 Omeprazole ORAL TABLET DELAYED RELEASE 20 MG ................................................................................................ 25 Once Daily ORAL TABLET ................................................................................................ 22 One-Daily Multi Vitamins ORAL TABLET .............................................................. 22 OPERAND POVIDONE-IODINE EXTERNAL SOLUTION 10 % .................................................................................................... 9 OPTICHAMBER ADVANTAGE XX MISC ........... 18 OPTIHALER XX DEVICE ................................................................................................ 18 OPTIHALER XX MISC ................ 18 OPTIONS CONCEPTROL VAGINAL GEL 4 % ............................ 25 ORALYTE FREEZER POPS ORAL SOLUTION ............................... 20 ORAZINC ORAL CAPSULE 220 MG ..................................................................... 21 OS-CAL 500 + D ORAL TABLET 500-200 MG-UNIT ................................................................................................ 19 OS-CAL ORAL TABLET CHEWABLE 1250 MG .................... 20 OTIX OTIC SOLUTION 6.5 % ................................................................................................ 24 OYSCO 500 ORAL TABLET 500 MG ..................................................................... 20 OYSCO 500+D ORAL TABLET 500-200 MG-UNIT ................................................................................................ 19 OYSCO D ORAL TABLET 250-125 MG-UNIT ................................. 19 Oyst-Cal D ORAL TABLET 250-125 MG-UNIT ................................... 19 Oyster Calcium + D ORAL TABLET 250-125 MG-UNIT ................................................................................................ 19 Oyster Shell Calcium + D ORAL TABLET 500-400 MG-UNIT ................................................................................................ 19 34 Oyster Shell Calcium 500 + D ORAL TABLET 500-125 MG-UNIT ............................................................. 19 Oyster Shell Calcium/D ORAL TABLET 250-125 MG-UNIT, 500-200 MG-UNIT ................................... 19 Oyster Shell Calcium/Vitamin D ORAL TABLET 500-200 MG-UNIT ............................................................. 19 Oyster Shell/Vitamin D ORAL TABLET 600-125 MG-UNIT ................................................................................................ 19 OYSTERCAL ORAL TABLET 500 MG ..................................................................... 20 Pain & Fever Childrens ORAL SOLUTION 160 MG/5ML .............. 3 Pain Relief Extra Strength ORAL TABLET 500 MG .......................................... 3 Pain Relief ORAL TABLET 500 MG ....................................................................................... 3 Pain Relief PM Extra Strength ORAL TABLET 500-25 MG ................................................................................................ 13 Pain Reliever PM ORAL TABLET 500-25 MG ............................ 13 PANOXYL WASH EXTERNAL LIQUID† 10 % ................................................................................................ 10 PC-Tar EXTERNAL SHAMPOO 1 % ........................................... 12 PERI-COLACE ORAL TABLET 8.6-50 MG ............................. 14 Permethrin EXTERNAL LOTION 1 % .................................................... 12 PFLEX XX MISC .................................... 17 Pharbedryl ORAL CAPSULE 25 MG, 50 MG ............................................................. 8 PHARBETOL EXTRA STRENGTH ORAL TABLET 500 MG ......................................................................... 3 PHARBETOL ORAL TABLET 325 MG ......................................................................... 3 Phenazopyridine HCl ORAL TABLET 95 MG .......................................... 12 Pink Bismuth ORAL SUSPENSION 262 MG/15ML .................................................................................................... 6 Pink Bismuth ORAL TABLET CHEWABLE 262 MG ............................ 6 POCKET CHAMBER XX DEVICE .................................................................. 18 POCKET SPACER XX DEVICE .................................................................. 18 Polyvinyl Alcohol OPHTHALMIC SOLUTION 1.4 % .............................................................................. 24 Povidone-Iodine EXTERNAL OINTMENT 10 % ........................................ 9 Povidone-Iodine EXTERNAL SOLUTION 10 % .......................................... 9 Povidone-Iodine EXTERNAL SWAB 10 %, 7.5 % ....................................... 9 PREPARATION H EXTERNAL PAD 50 % ................. 11 PREPARATION H HYDROCORTISONE EXTERNAL CREAM 1 % ................................................................................................ 11 Pseudoephedrine HCl ORAL TABLET 30 MG, 60 MG ................ 23 Q-Dryl ORAL CAPSULE 25 MG ....................................................................................... 8 Q-Dryl ORAL LIQUID† 12.5 MG/5ML ..................................................................... 8 Q-PAP ORAL TABLET 325 MG .................................................................................................... 3 Q-TAPP ORAL ELIXIR 1-15 MG/5ML .................................................................... 9 Quenalin ORAL SYRUP 12.5 MG/5ML ..................................................................... 8 Ranitidine Acid Reducer ORAL TABLET 75 MG .......................................... 25 Refenesen 400 ORAL TABLET 400 MG .......................................................................... 9 Refenesen ORAL TABLET 200 MG ....................................................................................... 9 REGULOID ORAL CAPSULE 0.52 GM ................................................................... 14 REHYDRALYTE ORAL SOLUTION ....................................................... 20 RENAL ORAL CAPSULE 1 MG .................................................................................. 21 Rena-Vite Rx ORAL TABLET 1 MG ................................................................................... 21 Reno Caps ORAL CAPSULE 1 MG ................................................................................... 21 ReVital Freezer Pops ORAL SOLUTION .................................................... 20 ReVital Liquid Squeezers ORAL SOLUTION .................................................... 20 Robafen ORAL SYRUP 100 MG/5ML ..................................................................... 9 Saline Mist Spray NASAL SOLUTION 0.65 % ................................. 23 Saline Nasal Spray NASAL SOLUTION 0.65 % ................................. 23 SCOT-TUSSIN ALLERGY RELIEF ORAL LIQUID† 12.5 MG/5ML .................................................................... 8 Sea Soft Nasal Mist NASAL SOLUTION 0.65 % ................................. 23 Senexon ORAL LIQUID† 8.8 MG/5ML ................................................................. 16 Senexon ORAL TABLET 8.6 MG ................................................................................... 16 Senna Lax ORAL TABLET 8.6 MG ................................................................................... 16 Senna Laxative ORAL TABLET 8.6 MG ........................................................................ 16 Senna Maximum Strength ORAL TABLET 25 MG .......................................... 16 Senna ORAL SYRUP 8.8 MG/5ML ................................................................. 16 Senna ORAL TABLET 15 MG, 8.6 MG ........................................................................ 16 Senna Plus ORAL TABLET 8.6-50 MG .............................................................. 14 Senna S ORAL TABLET 8.6-50 MG ................................................................................... 14 SENNA SMOOTH ORAL TABLET 15 MG ......................................... 16 SENNACON ORAL TABLET 8.6 MG ....................................................................... 16 Senna-Docusate Sodium ORAL TABLET 8.6-50 MG .............................. 15 Senna-Lax ORAL TABLET 8.6 MG ................................................................................... 16 SENNALAX-S ORAL TABLET 8.6-50 MG ............................................................. 15 Senna-S ORAL TABLET 8.6-50 MG ................................................................................... 15 Senna-Tabs ORAL TABLET 8.6 MG ................................................................................... 16 Senna-Time ORAL TABLET 8.6 MG ................................................................................... 16 Senna-Time S ORAL TABLET 8.6-50 MG .............................................................. 15 SENNO ORAL TABLET 8.6 MG .................................................................................. 16 Sennosides-Docusate Sodium ORAL TABLET 8.6-50 MG ................................................................................................ 15 Silace ORAL LIQUID† 150 MG/15ML ............................................................. 17 Silace ORAL SYRUP 60 MG/15ML ............................................................. 17 Siladryl Allergy ORAL LIQUID† 12.5 MG/5ML ...................................................... 8 Silphen Cough ORAL SYRUP 12.5 MG/5ML ...................................................... 8 Simethicone ORAL SUSPENSION 40 MG/0.6ML ................................................................................................ 12 Simethicone ORAL TABLET CHEWABLE 80 MG ............................ 12 SIMPLY ALLERGY ORAL TABLET 25 MG ............................................ 8 SIMPLY SLEEP ORAL TABLET 25 MG ......................................... 14 Sleep Tabs ORAL TABLET 25 MG ................................................................................... 14 Sleep-Tabs ORAL TABLET 25 MG ................................................................................... 14 SLO-NIACIN ORAL TABLET EXTENDEDRELEASE* 250 MG .................................................................................. 26 SM Oral Saline Laxative ORAL SOLUTION 2.7-7.2 GM/5ML ................................................................................................ 15 Sodium Bicarbonate ORAL TABLET 325 MG, 650 MG .................................................................................................... 5 Sodium Chloride INHALATION NEBULIZATION SOLUTION 0.9 % .............................................................................. 10 Sodium Chloride ORAL TABLET 1 GM .............................................. 20 SOF-LAX ORAL CAPSULE 100 MG ..................................................................... 17 SOMINEX MAXIMUM STRENGTH ORAL TABLET 50 MG ......................................................................... 14 SOMINEX ORAL TABLET 25 MG .................................................................................. 14 Sorbitol ORAL SOLUTION 70 % ......................................................................................... 15 Stimulant Laxative ORAL TABLET DELAYED RELEASE 5 MG ............................................................................. 16 Stomach Relief ORAL SUSPENSION 262 MG/15ML, 527 MG/30ML .................................................... 6 Stomach Relief ORAL TABLET CHEWABLE 262 MG ............................ 6 Stomach Relief Plus ORAL SUSPENSION 525 MG/15ML .................................................................................................... 6 Stool Softener Laxative DC ORAL CAPSULE 240 MG ................................................................................................ 17 Stool Softener ORAL CAPSULE 100 MG, 250 MG ......................................... 17 SUDAFED 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HR* 120 MG 23 SUPER NU-THERA ORAL TABLET ................................................................. 21 SURFAK ORAL CAPSULE 240 MG ..................................................................... 17 Sur-Q-Lax ORAL CAPSULE 240 MG ...................................................................... 17 Tactinal Extra Strength ORAL TABLET 500 MG .......................................... 3 Tactinal ORAL TABLET 325 MG ....................................................................................... 3 Tears Again OPHTHALMIC OINTMENT .................................................. 23 Tears Again OPHTHALMIC SOLUTION .................................................... 24 TERA-GEL TAR EXTERNAL SHAMPOO 0.5 % ..................................... 12 Terbinafine HCl EXTERNAL CREAM 1 % ...................................................... 10 Tetra-Formula Nighttime Sleep ORAL TABLET 50 MG ................... 14 THERA ORAL TABLET ............ 22 Thera Vital M ORAL TABLET ................................................................................................ 21 THERA/BETA-CAROTENE ORAL TABLET ......................................... 22 Therabasic-M ORAL TABLET ................................................................................................ 21 Thera-Ear OTIC SOLUTION 6.5 % ......................................................................................... 24 Therapeutic Liquid ORAL SOLUTION .................................................... 22 Therapeutic ORAL TABLET ................................................................................................ 22 Therapeutic-M ORAL TABLET ................................................................................................ 22 Thera-Tabs ORAL TABLET ................................................................................................ 22 THRESHOLD IMT XX MISC ................................................................................................ 17 THRESHOLD PEP XX DEVICE .................................................................. 17 TITRALAC ORAL TABLET CHEWABLE 420 MG ........................... 5 Tolnaftate Antifungal EXTERNAL CREAM 1 % ........... 11 Tolnaftate EXTERNAL CREAM 1 % .................................................................................... 11 Tolnaftate EXTERNAL SOLUTION 1 % .......................................... 11 ................................................................................................ 35 TOTAL ALLERGY MEDICINE ORAL LIQUID† 12.5 MG/5ML ..................................................... 8 Total Allergy ORAL TABLET 25 MG ....................................................................................... 8 TOTAL FORMULA 3 ORAL TABLET ................................................................. 22 Tri-Buffered Aspirin ORAL TABLET 325 MG .......................................... 3 Triple Antibiotic EXTERNAL OINTMENT 3.5-400-5000 , 5-400-5000 ........................................................... 10 Ultilet Glucose ORAL TABLET CHEWABLE 4 GM .................................... 6 ULTRA FRESH PM OPHTHALMIC OINTMENT ................................................................................................ 23 VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM 12.5 % ................................................. 25 Vitamin B-12 ER ORAL TABLET EXTENDEDRELEASE* 1000 MCG .............................................................................. 13 Vitamin B-12 ORAL TABLET 1000 MCG, 250 MCG, 500 MCG ................................................................................................ 13 Vitamin B-12 SUBLINGUAL TABLET SUBLINGUAL 1000 MCG .............................................................................. 13 Vitamin C ORAL SYRUP 500 MG/5ML ................................................................. 26 Vitamin C ORAL TABLET 100 MG, 1000 MG, 250 MG, 500 MG ................................................................................................ 26 Vitamin C ORAL TABLET CHEWABLE 100 MG, 250 MG ................................................................................................ 27 Vitamin D (Ergocalciferol) ORAL CAPSULE 50000 UNIT ................................................................................................ 26 Vitamin D ORAL TABLET 400 UNIT ............................................................................ 26 Vitamin D3 ORAL CAPSULE 2000 UNIT ............................................................ 26 Vitamin D3 ORAL TABLET 1000 UNIT, 400 UNIT ........................ 26 Vitamin D-400 ORAL TABLET 400 UNIT ............................................................... 26 Vitamins for Hair ORAL TABLET .............................................................. 22 WATCHHALER XX DEVICE ................................................................................................ 18 36 WINDMILL TRAINER XX MISC ............................................................................ 17 Womens Laxative ORAL TABLET DELAYED RELEASE 5 MG ............................................................................. 16 XENICAL ORAL CAPSULE 120 MG ......................................................................... 1 Zinc Gluconate ORAL TABLET 100 MG, 30 MG, 50 MG ................... 21 Zinc Methionate ORAL CAPSULE 50 MG .................................... 21 Zinc ORAL TABLET 25 MG, 50 MG ................................................................................... 21 Zinc Picolinate ORAL TABLET 25 MG .......................................................................... 21 Zinc Sulfate ORAL CAPSULE 220 MG ...................................................................... 21 Zinc Sulfate ORAL TABLET 220 (50 Zn) MG ....................................................... 21 Zinc-220 ORAL CAPSULE 220 MG ................................................................................... 21
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