Download Additional prescription drug coverage Part D drugs

Additional prescription drug coverage
Your plan includes extra coverage for certain drugs as shown in the chart below. These drugs are either
not generally covered under Medicare Part D or are covered at a different tier or cost level than the one
shown in your plan’s formulary (drug list). This is not a complete list of prescription drugs and supplies
covered by our plan. For a complete list, please contact Customer Service using the information provided
on the front and back cover pages.
Part D drugs
Your plan covers some of your Medicare prescription drugs at a lower drug tier or copay than your
formulary. Although the prescription drugs in this chart may also be in your Abridged Formulary
(drug list), you will pay a $0 copay for these prescription drugs. If you have questions see, your Evidence
of Coverage (EOC).
$0 Copay
$0 Copay
Acarbose Tablet 100mg
Glipizide/Metformin Tablet 2.5-500mg
Acarbose Tablet 25mg
Glipizide/Metformin Tablet 5-500mg
Acarbose Tablet 50mg
Glucagon Kit 1mg
Alcohol Swabs
Glyburide Micronized Tablet 1.5mg
Chlorpropamide Tablet 100mg
Glyburide Micronized Tablet 3mg
Chlorpropamide Tablet 250mg
Glyburide Micronized Tablet 6mg
Glimepiride Tablet 1mg
Glyburide Tablet 1.25mg
Glimepiride Tablet 2mg
Glyburide Tablet 2.5mg
Glimepiride Tablet 4mg
Glyburide Tablet 5mg
Glipizide ER Tablet 10mg
Glyburide/Metformin Tablet 1.25-250mg
Glipizide ER Tablet 2.5mg
Glyburide/Metformin Tablet 2.5-500mg
Glipizide ER Tablet 5mg
Glyburide/Metformin Tablet 5-500mg
Glipizide Tablet 10mg
Humalog Injection 100/ml
Glipizide Tablet 5mg
Humalog Mix Injection 50/50
Glipizide XL Tablet 10mg
Humalog Mix Sus 75/25
Glipizide XL Tablet 2.5mg
Humulin Injection 70/30
Glipizide XL Tablet 5mg
Humulin N Injection U-100
Glipizide/Metformin Tablet 2.5-250mg
Humulin R Injection U-500
Y0066_PDP3533343_000
$0 Copay
$0 Copay
Humulin R Injection U-100
Novolog Injection 100/ml
Insulin Syringe 0.3ml
Novolog Mix Injection 70/30
Insulin Syringe 0.5ml
Pioglitazone Tablet 15mg
Insulin Syringe 1ml
Pioglitazone Tablet 30mg
Metformin ER Tablet 1000mg
Pioglitazone Tablet 45mg
Metformin Tablet 1000mg
Pioglitazone/Glimepiride Tablet 30-2mg
Metformin Tablet 500mg
Pioglitazone/Glimepiride Tablet 30-4mg
Metformin Tablet 500mg ER
Pioglitazone/Metformin Tablet 15-500mg
Metformin Tablet 750mg ER
Pioglitazone/Metformin Tablet 15-850mg
Metformin Tablet 850mg
Repaglinide Tablet 0.5mg
Nateglinide Tablet 120mg
Repaglinide Tablet 1mg
Nateglinide Tablet 60mg
Repaglinide Tablet 2mg
Novolin Injection 70/30
Tolazamide Tablet 250mg
Novolin N Injection U-100
Tolazamide Tablet 500mg
Novolin R Injection U-100
Tolbutamide Tablet 500mg
The amounts you pay for these prescription drugs and supplies DO apply to your Medicare Part D outof-pocket costs. Payments for these prescription drugs and supplies (made by you or the plan) are
treated the same as payments made for drugs in your plan’s formulary. These drugs and supplies are part
of your Medicare prescription drug coverage.1
Non-Part D drugs
These additional covered prescription drugs are not included in the Part D plan. These prescription
drugs are covered in addition to the prescription drugs in your plan’s formulary. Although you pay the
retail copay or mail service copay for these prescription drugs, the amounts you pay do not apply to your
Medicare Part D out-of-pocket costs. Payments made for these additional prescription drugs (made by
you or the plan) are treated differently from payments made for the drugs in your plan’s formulary.
These payments do not help you move through the Part D prescription drug stages. This means they do
not help you move into or out of the coverage gap (the Catastrophic Level Threshold).2
Because this coverage is in addition to your Part D drug coverage, the appeals and grievance process is
different for these drugs. For information on the appeals and grievance process for these drugs, please
contact Customer Service using the information provided on the front and back cover pages.
If you get Extra Help from Medicare to pay for your drugs, it will not apply to these additional covered
drugs.
$0 Copay
$0 Copay
Accu-Chek Test Active
Insta-Glucos Gel 40%
Accu-Chek Test Comfort
Ketocare
Accu-Chek Test Compact
Ketocare Urine Test Strips
Accu-Chek Test Curve
Lancet Devices
Accu-Chek Test Drum
Lancets
Accu-Chek Test Smart
Lancets Kits
CVS Glucose Gel 40%
Onetouch Test
Fasttake Test Strips
Onetouch Test Ultra Blue
Glucagon Emergency Kit
Onetouch Test Verio
Glucose Gel 40%
Onetouch Test Verio IQ
Glucose Gel 40%
RA Glucose Gel
Glutose 15 Gel 40%
Surestep Pro Test
Glutose 45 Gel 40%
Surestep Test
The cost tier for each prescription drug is shown in the table below. You pay the same copay or
coinsurance for these drugs as shown in your Summary of Benefits and Evidence of Coverage.
Drug
Tier
2-Deoxy-D Powder Glucose
3
Accu-Chek Kit Compact
2
Accu-Chek Kit Fastclix
1
Accu-Chek Kit Multiclix
1
Accu-Chek Kit Softclix
1
ACD/Fluoride Drops 0.25mg
1
Ace Aero Cld Mis Enhancer
3
Aceon Tablet 4mg
3
Aceon Tablet 8mg
3
Acid Jelly Gel Vag/Appl
1
Acthrel Injection 100mcg
3
Actifoam Mis 12.7X8.9
3
Actifoam Mis 7X5X0.6
3
Activase Injection 100mg
2
Activase Injection 50mg
2
Acunol Tablet 600mg
3
Adcetris Injection 50mg
3
Adipex-P Capsule 37.5mg
3
Adipex-P Tablet 37.5mg
3
Adoxa Tablet 100mg
3
Adoxa Tablet 50mg
3
Adoxa Tablet 75mg
3
Adoxa Pak 1/ Tablet 100mg
3
Adoxa Pak 1/ Tablet 150mg
3
Adoxa Pak 2/ Tablet 100mg
3
Adrenal C Tablet Formula
2
Drug
Tier
Adrenalin Solution 1:1000
3
Adult Mask
3
Advanced Mis Am/Pm
2
Advanced Dna Kit Collection
1
Advate Injection 1000Unit
3
Advate Injection 1500Unit
3
Advate Injection 2000Unit
3
Advate Injection 250Unit
3
Advate Injection 3000Unit
3
Advate Injection 4000Unit
3
Advate Injection 500Unit
3
Aerchamber Pls Mis Flow-Vu
2
Aerchamber Pls Mis Lrg Mask
2
Aerchamber Pls Mis Sm Mask
2
Aero Otic HC Solution
1
Aerochamber Mis Plus
2
Aerohist Tablet 8-2.5mg
3
AeroSolution Mask Mis Adult
3
Ahist Tablet 12mg
3
Akorn Balance Solution Salt Op
1
Ala Quin Cream 3-0.5%
1
Alahist AC Liquid 7.5-10
3
Alahist DHC Liquid 7.5-3
3
Alba-Derm Cream
3
Albatussin Capsule
3
Albatussin Liquid NN
3
Alcohol Prep Pad
1
Alcortin A Gel
3
Drug
Tier
Alferon N Injection 5mu/ml
3
Aliclen Shampoo 6%
1
Ali-Flex Tablet 50-500mg
1
Alkeran Tablet 2mg
2
Allfen CD Tablet 400-10mg
3
Allfen CDX Liquid
3
Allfen CDX Tablet 400-20mg
3
Alodox Kit 20mg
3
Aloquin Gel 1.25-1%
3
Alpain Tablet
1
Alphanate Injection VWF/HUM
3
Alphanine SD Injection 1000Unit
3
Alphanine SD Injection 1500Unit
3
Alphanine SD Injection 500Unit
3
Altacaine Solution 0.5% Op
1
Altafluor Solution 0.25-0.4
1
Altafrin Solution 10% Op
1
Altafrin Solution 2.5% Op
1
Altera Neb Mis Handset
3
Aluvea Cream 39%
3
Alz-Nac Tablet
1
Amantadine Syrup 50mg/5ml
1
Ambifed CD Tablet
3
Ambifed CDX Tablet
3
Ambifed-G Tablet CDX
3
Ambifed-G CD Tablet
3
Aminoac Acid Solution 1.5% Irr
1
Aminobezoate Potassium Powder
1
Drug
Tier
Ammonia Arom Inhalation
3
Amyl Nitrite Inhalation 0.3ml
3
Amyvid Injection
3
Anacaine Ointment
3
Analpram E Kit
3
Analpram-HC Cream 1-2.5%
3
Analpram-HC Cream Singles
3
Anaspaz Tablet 0.125mg
3
Anastrozole Powder
3
Andehist Syrup 4-60mg/5
3
Antipyrine/Benzocaine Solution Otic
1
Antivenin Kit Lat Mact
3
Antivenin ml Kit
3
Anucort-HC Suppository 25mg
1
AnuSolution-HC Suppository 25mg
3
AphthaSolution PST 5%
3
Apptrim Capsule
2
Apptrim Life Capsule Bariatric
2
Apptrim Life Capsule Obesity
2
Apptrim-D Capsule
2
Ap-Zel Tablet
2
Aralen Tablet 500mg
3
Aridol Kit
3
Aristospan Injection 20mg/ml
3
Armour Thyroid Tablet 120mg
3
Armour Thyroid Tablet 15mg
3
Armour Thyroid Tablet 180mg
3
Armour Thyroid Tablet 240mg
3
Drug
Tier
Armour Thyroid Tablet 300mg
3
Armour Thyroid Tablet 30mg
3
Armour Thyroid Tablet 60mg
3
Armour Thyroid Tablet 90mg
3
Artiss Solution 10ml
3
Artiss Solution 2ml
3
Artiss Solution 4ml
3
Arzol Silver Nitrate Applicator
3
Ascensia Liquid Norm Con
2
Ascensia Mis Autodisc
3
Ascor L 500 Injection 500mg/ml
1
Ascor L NC Injection 500mg/ml
1
Ascorbic Acid Gra
2
Ascorbic Acid Injection 500mg/ml
1
Asthma Rx Tablet
3
Astringyn Solution 259mg/gm
3
At Last Kit Glucose
2
Atopiclair Cream
3
Atrapro CP Kit
3
Atrapro Derm Spray
3
Atrohist LA Tablet CR
3
Atrohist SR Capsule Sprinkle
3
Atropen Injection 0.25mg
3
Atropen Injection 0.5mg
3
Atropen Injection 1mg
3
Atropen Injection 2mg
3
Atropin Care Solution 1% Op
1
Atropine Powder Sulfate
3
Drug
Tier
Atropine Powder USP
3
Atropine Sulfate Injection 0.4/0.5
1
Atropine Sulfate Injection 0.4mg/ml
1
Atropine Sulfate Injection 1mg/ml
1
Atropine Sulfate Ointmenttment 1% Op
1
Atropine Sulfate Solution 1% Op
1
Atropinum Sub Composit
3
Auralgan Solution 5.5-1.4%
3
Aurax Solution 5.5-1.4%
1
Aurodex Solution Otic
1
Aurstat Kit
3
Aurstat Kit Hydrogel
3
Aurstat Anti Gel-Itch
3
Autolet II Kit Clinisaf
1
Autolet Lite Kit Starter
1
Availnex Chew 750mg
2
Avar Gel Green
3
Avar Cleanse Emu 10-5%
1
Avar LS Liquid 10-2%
3
Avar-E Emollient Cream 10-5%
3
Avar-E Green Cream 10-5%
3
Avar-E LS Cream 10-2%
3
Avidoxy DK Kit
3
Avitene Pad 35X35mm
3
Avitene Pad 70X35mm
3
Avitene Pad 70X70mm
3
Avitene Powder Flour
2
Avitene Syringe Mis 1gm
3
Drug
Tier
Avo Cream
1
Axid Capsule 150mg
3
Axid Capsule 300mg
3
Axona Powder
2
AZ Cream
3
B6 Folic Acid Capsule
1
Baclofen Powder
3
Bacmin Tablet
2
Bal Salt Solution Op
1
Bar-Test Tablet 650mg
3
Base Cream Liposome
3
Base W301 Cream
3
Bayer Breeze Liquid Normal Control
2
Bayer Breeze Mis 2 Test
3
Bayer Contor Liquid Normal Control
2
Bayer Contor Solution Next
2
B-D UF Syringe Mis .3CC/30G
2
Bebulin Injection 200-1200
3
Bebulin VH Injection 200-1200
3
Belladonna Alkaloids/Phenobarbital Tablet 16.2mg
1
Belladonna/Opium Suppository 16.2-60
3
Belviq Tablet 10mg
3
Benefix Injection 1000Unit
3
Benefix Injection 2000Unit
3
Benefix Injection 250Unit
3
Benefix Injection 3000Unit
3
Benefix Injection 500Unit
3
Bensal HP Ointmenttment
3
Drug
Tier
Benzac AC Liquid 5% Wash
3
Benzac W Liquid 5% Wash
3
Benzaldehyde Elixer
3
Benzalkonium Solution NF
3
Benzefoam Aer 5.3%
3
Benzefoam Aer 9.8%
3
Benzepro Aer 5.3%
1
Benzepro SC Aer 9.8%
3
Benziq Gel 5.25%
3
Benziq LS Gel 2.75%
3
Benziq Wash Liquid 5.25%
3
BenzointCompound Tin
3
Benzonatate Capsule 100mg
1
Benzonatate Capsule 200mg
1
Benzoyl Peroxide Aer 5.3%
1
Benzoyl Peroxide Lotion 9%
1
Benzoyl Peroxide Pad 3%
1
Benzoyl Peroxide Pad 6%
1
Benzoyl Peroxide Aer 9.8%
1
Benzoyl Peroxide Kit Acne Pack
1
Benzphetamine Tablet 50mg
1
Betadine Solution 5% Op
3
Biafine
3
Biferarx Tablet
2
Bio Glo Test 1mg Op
1
Biogesic Tablet 30-500mg
1
Bionect Cream 0.2%
3
Bionect Gel 0.2%
3
Drug
Tier
Bionect Spray 0.2%
3
Biopeptide Cream Base
3
Bioregesic Tablet 50-650mg
3
Bio-Statin Capsule 1000000
3
Bio-Statin Capsule 500000
3
Bismuth Subc Powder
3
BL Decongest Tablet CR
1
BL Trip Anti Ointment W/Liduid 4%
1
Bluestar
3
Blunt Needle Mis 18Gx2"
3
Bontril PDM Tablet 35mg
3
Boric Acid Gra
3
Botox Cosmetic Injection 100Unit
2
Botox Cosmetic Injection 50Unit
2
BP 10-1
1
BP Cleansing Emu 10-4%
1
BP Wash Liquid 2.5%
1
BP Wash Liquid 7%
1
BPO Gel 4%
1
BPO Gel 8%
1
BPO Cloths 3%
1
BPO Cloths 6%
1
BPO Cloths 9%
1
BPO Creamy Kit 8% Wash
3
Bravelle Injection 75Unit
2
Brompheniramine Chew 12mg
1
Broncomar-1 Elixer
3
Broncopectol Syrup
3
Drug
Tier
Brondil Liquid
3
Bucalsep Solution
3
Bucalsep Spray
3
Bupivacaine Injection 0.75%
1
Bupivacaine Powder HCL
3
Calafol Rx Tablet
2
Calcium Powder Folinate
3
Caldolor Injection 400/4ml
3
Caldolor Injection 800/8ml
3
Carbadopa/Levodopa Tablet 25-100mg
1
Carbaphen 12 Liquid
3
Carbaphen 12 Suspension Ped
3
Carbin/PSE/ Syrup DM
1
Carbogel Gel 940
3
Carbohol Gel 940
3
Carbomer Gel Aqueous
3
Carbomer Gel Hydroalc
3
Carboplatin Injection 450/45ml
1
Carboplatin Injection 50mg/5ml
1
Cardiotek Rx Tablet
2
Caromega Tablet
2
Carticel Imp
3
Cascara Ext Sagrada
1
Cathflo Acti Injection Vase
3
Caverject Injection 20mcg
2
Caverject Injection 40mcg
2
Caverject Kit 10mcg
2
Caverject Kit 20mcg
2
Drug
Tier
Cefditoren Tablet 400mg
1
Cem-Urea Solution 45%
1
Cerefolin Tablet
2
CerefolinTablet NAC
2
Cerisa Wash Emu 10-1%
1
Cerovel Gel 40%
1
Cerovel Lotion 40%
1
Cesinex Suspension
2
Cetraxal Solution 0.2%
3
Cetrotide Kit 0.25mg
2
Cetrotide Kit 3mg
2
CGU WC Liquid
3
Chemstrip Test -10 SG
2
Chemstrip Test Strips
3
Chemstrip Test UGK
2
Chemstrip 10 Test MD
2
Chemstrip 2 Test GP
2
Chemstrip 5 Test OB
2
Chemstrip 7 Test
2
Chemstrip 9 Test Strips
2
Chemstrip K Test
2
Cheratussin Solution DAC
1
Cheratussin Syrup AA
1
Cherry Syrup
3
Chlordiazepoxide/Clidinium Capsule 5-2.5mg
1
Chlorpromazine Powder HCL
3
Chlorthalidone Tablet 100mg
1
Chlorzoxazone Tablet 250mg
1
Drug
Tier
Choline Magnesium Trisalicylate Liquid 500/5ml
1
Choline Magnesium Trisalicylate Tablet 1000mg
1
Choice DM Kit Risk Test
2
Cholac Syrup 10gm/15
1
Chorionic Powder Gonadotropin
3
Chrysaderm Cream Day
3
Chrysaderm Cream Night
3
Cialis Tablet 10mg
2
Cialis Tablet 20mg
2
Ciprofloxacin Solution 0.2%
1
Cisplatin Powder
3
Citric Acid/ Solution Sodium Citrate
1
Citrolith Tablet
3
Clarifoam EF Aer 10-5%
3
Claris Wash 10-4%
1
Clearplex X Gel 10%
3
Clenia Cream 10-5%
3
Clinoril Tablet 200mg
3
Clomid Tablet 50mg
2
Clomiphene Tablet 50mg
1
Coal Tar Solution 20%
3
Coca Cola Syrup
3
Cocaine HCL Solution 10%
1
Cocaine HCL Solution 4%
1
Cod Liver Oil
2
Codeine Sulfate Solution 30mg/5ml
1
Cold Cream
1
Collodion Liquid Flexible
3
Drug
Tier
Colyte Solution
3
Colyte/Flavor Solution Packs
3
Colyte-Flav Solution
3
Compound 347 Liquid
1
Concentrate Cream
3
Congestant Tablet
1
Conversion Baby SZ1
3
Conversion Baby SZ2
3
Conversion Baby SZ3
3
Cordran 24X3 Tap Sml 24IN
3
Corifact Kit
3
Cortalo Gel 2%
1
Cortane-B Drop AQ Otic
3
Cortane-B Drop Otic
3
Cortane-B Lotion
3
Cortenema ENE 100mg
3
Cortic-ND Drop
1
Cortrosyn Injection 0.25mg
3
Corvita Tablet
1
Corvite Tablet
2
Cosyntropin Injection 0.25mg
3
Cosyntropin Injection 0.25mg
1
CoTablet A Tablet 4-10mg
3
CoTablet AX Tablet 4-20mg
3
CoTabletflu Tablet 20-4-500
3
Covaryx Tablet
1
Covaryx HS Tablet
1
CPB WC Liquid
3
Drug
Tier
Cream Base Cream
3
Creamsylate Solution 25% Otic
3
Crofab Injection
3
Cryoserv Solution
3
CVS Ketone Test Care
2
Cyanide Anti Kit Package Unit
3
Cyanocobalamin Powder
2
Cyanocobalamin Cry
2
Cyanocobalamin Injection 1000mcg
1
Cyclacillin Tablet 500mg
1
Cyclobenzaprine Cream 20mg/gm
1
Cyclophosphate Powder
3
Cyclophosphate Powder USP
3
Cyotic Drop
1
Cytra K Gra Crystals
1
Cytra-2 Solution
1
Cytra-3 Syrup
1
Cytra-K Solution
1
Dacarbazine Powder
3
Debacterol Solution 30-50%
3
Decara Capsule 25000Unt
2
Decon-A Elixer 2-5mg/5M
3
Decon-G Drop 2-1-40mg
3
Deconsal Tablet L.A.
1
Deconsal SR Capsule Sprinkle
1
Deconsal-II Tablet
3
Delos Lotion 3.5%
3
Deltasone Tablet 20mg
1
Drug
Tier
Denatured Solution Alcohol
3
Denavir Cream 1%
3
Depade Tablet 50mg
1
Deplin Tablet 15mg
2
Deplin Tablet 7.5mg
2
Deplin 15 Capsule
2
Deplin 7.5 Capsule
2
Dermazene Cream 1%
1
Desowen Ointment Kit 0.05%
3
Despec-EXP Syrup
1
Despec-PDC Liquid
3
Dexamethasone Phosphate Solution 0.1% Op
1
Dexamethasone Sodium Powder Phosphate
3
Dexamethasone Tablet 0.75mg
1
Dexferrum Injection 50mg/ml
1
Dialyvite Tablet
1
Dialyvite Tablet 3000
2
Dialyvite Tablet 5000
2
Dialyvite Tablet Suprem D
2
Dialyvite Tablet Zinc
2
Diatx ZN Tablet
2
Diclegis Tablet 10-10mg
3
Didrex Tablet 50mg
3
Diethylpropion Tablet 25mg
1
Diethylpropion Tablet 75mg ER
1
Difil-G 400 Tablet
1
Difil-G Fort Liquid 100-100
1
Digex NF Capsule
3
Drug
Tier
Digibar 190 Suspension
3
Digifab Injection 40mg
3
Dihydroergot Powder Mesylate
3
Dilatrate SR Capsule 40mg
2
Dimethyl Solution Sulfoxide
3
Discus Sub Composit
3
Dextromethorphan/Chlorpheniramine/Phenylephrine Drop
1
DMR Antigen Therapy
3
Dobells Solution
1
Docetaxel Injection 20/0.5ml
1
Docetaxel Injection 80mg/2ml
1
Dologesic Liquid 30-500mg
3
Dologesic Tablet 30-500mg
1
Dolorex Tablet 50-500mg
1
Donatuss DC Syrup
3
Donnatal Elixer
3
Donnatal Tablet
3
Donnatal Tablet Extentab
2
Doral Tablet 15mg
3
Doxazosin Tablet 8mg
1
Doxycycline Powder Hyclate
3
Doxytex Liquid
3
Drisdol Capsule 50000Unit
2
Dritho-Cream HP 1%
2
DrySolution Solution 20%
3
Duraxin Capsule
1
Dynacirc CR Tablet 5mg
3
Easivent
3
Drug
Tier
Easivent Mask LG
3
Easivent Mask Small
3
Easivent Mask Medium
3
Easymax Solution Normal
2
Echinacea Sub Composit
3
Eczemol Tablet
3
ED Chlorped Suspension 2mg/ml
3
ED-Chlor-Tan Tablet 8mg
3
Edex Kit 10mcg
2
Edex Kit 20mcg
2
Edex Kit 40mcg
2
ED-Flex Capsule
1
ED-Spaz Tablet 0.125mg
1
Eemt Tablet
1
Eemt HS Tablet
1
EES/Sulfisoxazole Suspension 200-600
1
Effer-K Tablet 25meq EF
1
Eflow SCF Aerosol
3
Eletone Cream
3
Embrace
2
Embrace Solution Low
2
Embrace Test Blood Glucose
3
Emollient Cream
3
Emulsion SB Emu
3
Endo Avitene 10mm Diameter
3
Endo Avitene 5mm Diameter
3
Entero VU Powder 13%
3
Entero VU Suspension 13%
3
Drug
Tier
Entero VU Suspension 24%
3
Epiceram
3
Epidrin Capsule
1
Epinephrine HCL Solution 2% Op
1
Epinephrine Injection 0.15mg
3
Epinephrine Injection 0.3mg
3
Episil Liquid
3
Episone Cream
1
Equagesic Tablet 200-325
3
Erapid Neb Handset
3
Ergocalciferole Capsule 50000Unit
1
Ertaczo Cream 2%
3
Erwinaze Injection 10000Unit
3
Escavite Chew
2
Esopho-Cat Cream 3%
3
EST Estrogen Tablet Mtest
1
EST Estrogen Tablet MTest DS
1
EST Estrogen Tablet MTest HS
1
Estrad Val Injection 10mg/ml
1
Estriol Powder Micronized
3
Estrogel
3
Ethrane Inhalation
3
Ethyl Chloride Aer Fine Pin
1
Ethyl Chloride Aer FN Strm
1
Ethyl Chloride Aer Med Jet
1
Ethyl Chloride Aer Med Strm
1
Ethyl Chloride Aer Mist
1
Ethyl Chloride Aer Spray
1
Drug
Tier
Ethyol Injection 500mg
3
Etoposide Capsule 50mg
1
Etoposide Powder
3
Eucalyptus Oil
1
Euflexxa Injection 10mg/ml
3
Evicel Kit 2ml
3
Evicel Kit 5ml
3
Evithrom Solution 800-1200
3
Exactacain Aer
1
Exactuss Liquid
3
Exalgo Tablet 32mg
3
Exoderm Lotion 25-1%
1
Exotic-HC Drop Otic
1
E-Z Spacer
3
E-Z Spacer Body Grd
3
E-Z-Cat Dry Pak
3
E-Z-Disk Tablet 700mg
3
E-Z-Dose
3
E-Z-HD Suspension 98%
3
Ezide Tablet 50mg
1
E-Z-Paque Suspension 60%
3
E-Z-Paque Suspension 96%
3
E-Z-Paste Cream 60%
3
Fe C Plus Tablet
1
Feiba NF Injection
3
Feiba VH Injection Immuno
3
Fem Ph Gel
3
Femhrt 1/5 Tablet
3
Drug
Tier
Femtrace Tablet 0.45mg
3
Femtrace Tablet 0.9mg
3
Feraheme Injection 510/17ml
2
Ferocon Capsule
1
Ferotrinsic Capsule
1
Ferralet 90 Tablet
2
Ferraplus 90 Tablet
1
Ferrex 28 Tablet
1
Ferric Gluco Injection 12.5mg/ml
1
Ferrlecit Injection 12.5mg/ml
2
Filter Air PP
3
First Dukes Suspension MouthWash
3
First-Marys Suspension MouthWash
3
First-Mouthwash Suspension Blm
3
First-Omepra Suspension 2mg/ml
3
First-Testos Cream MC 2%
3
First-Testos Ointment 2%
3
Flavor Blend Suspension
3
Flavor Plus Liquid
3
Flavor Sweet Liquid S/F
3
Flavor Sweet Syrup
3
Flebogamma Injection 5%
3
Flexeril Tablet 10mg
3
Flexeril Tablet 5mg
3
Flow-Eze Vented
1
Flu Vaccine Capsulee Fear
3
Flu Vaccine Injection
3
Flucaine Solution 0.25-0.5
1
Drug
Tier
Fludara Injection 50mg
3
Fluoracaine Solution Op
3
Fluore-Benox Solution 0.25-0.4
1
Fluorescein/ Solution Proparac
1
Fluorets Test 1mg Op
1
Fluor-I-Stri Test 1mg Op
1
Fluoroplex Cream 1%
2
Fluorouracil Powder
3
Fluorouracil Powder USP
3
Fluorouracil Powder USP/NF
3
Fluoxetine Capsule 10mg
1
Fluoxetine Capsule 20mg
1
Flura-Safe Solution
3
Fluress Solution Op
3
Flurox Solution Op
1
Flutter
3
Folastin Tablet
1
Folbee AR Tablet
2
Folbee Plus Tablet
1
Folbee Plus Tablet CZ
1
Folbic Tablet
1
Folbic RF Tablet
2
Folgard OS Tablet
2
Folic Acid Tablet
1
Folic Acid Tablet 1mg
1
Folivane-F Capsule
2
Follistim AQ Injection 150Unit
2
Follistim AQ Injection 300Unit
2
Drug
Tier
Follistim AQ Injection 600Unit
2
Follistim AQ Injection 75Unit
2
Follistim AQ Injection 900Unit
2
Foltanx Tablet
1
Foltanx RF Capsule
2
Foltrate Tablet
2
Foltrin Capsule
1
Foltx Tablet
2
Food Color Liquid Blue
3
Forane Solution
3
Formadon Solution
3
Formaldehyde Solution 10%
1
Formaldehyde Solution 37%
3
Fortavit Capsule
2
Fortigan Capsule
1
Fosteum Capsule
2
Freedom Cream Derma-D
3
Freedom Cream Derma-N
3
First-Hydrocort Gel 10%
3
Ful-Glo Test 0.6mg Op
3
Ful-Glo Test 1mg Op
1
Ganirelix AC Injection
3
Gastrinex NF Capsule
1
Gastrografin Solution 66-10%
3
Gastromark Suspension 175mcg
3
Gebauers Spray Aer /Stretch
3
Gelclair Gel
3
Gelfilm Envelope
2
Drug
Tier
Gelfilm Op
3
Gelfoam Dental 4
3
Gelfoam Spon Com
3
Gelfoam Spong 50
3
Gelfoam Spong100
3
Gelfoam Spong200
3
Gelfoam Powder
3
Gelfoam Spng Mis 12-7mm
3
Gelixer Gel
3
Genadur Liquid
3
Gene-Xene Tablet 15mg
1
Gene-Xene Tablet 3.75mg
1
Gene-Xene Tablet 7.5mg
1
GG/Codeine Solution 100-10/5
1
Gilphex TR Tablet 10-388mg
3
Giltuss Liquid
3
Giltuss Liquid Ped-C
3
Giltuss Ped Liquid
3
Giltuss TR Capsule 7-14-288
3
Giltuss TR Tablet
3
Glipizide Powder
3
Glucocard 01 Test Sensor
3
Glucocard 01 Test Strips
3
Glucocard Test Vital
3
Glucose Bits Chew 1gm
2
Glucose Shot Liquid 15/59ml
1
Glucose Shot Liquid 15gm
1
Glutose 15 Gel 40%
1
Drug
Tier
Glutose 45 Gel 40%
1
Glyburide Powder
3
Glycine Solution 1.5% Irr
1
GNP Decongestant Tablet Adv Form
1
GNP Glucose Chew 4gm
2
Gonal-F Injection 1050Unit
2
Gonal-F Injection 450Unit
2
Gonal-F RFF Injection 300
2
Gonal-F RFF Injection 450
2
Gonal-F RFF Injection 75Unit
2
Gonal-F RFF Injection 900
2
Gordofilm Solution
3
Gordons Urea Ointment 40%
3
Grafco Silvr Mis Nit Appl
1
Granulex Aer
3
Green Soap Tin
3
Guaiatussin Syrup AC
1
Guaifenesin Solution DAC
1
Guaifenesin Syrup AC
1
Halac Kit
1
Halotionin Cream 1%
3
HC AC/Aloe Gel 2%
1
HC Pramoxine Cream 1-1%
1
HC Pramoxine Cream 1-2.5%
1
HC Pramoxine Cream 2.5-1%
1
HDC DM Syrup
1
Helixate FS Injection 1000Unit
3
Helixate FS Injection 2000Unit
3
Drug
Tier
Helixate FS Injection 250Unit
3
Helixate FS Injection 3000Unit
3
Helixate FS Injection 500Unit
3
Helixate FS Solution 1000Unit
3
Helixate FS Solution 250Unit
3
Helixate FS Solution 500Unit
3
Hemetablet
2
Hemofil M Injection 220-400
3
Hemofil M Injection 401-800
3
Hemofil M Solution 501-2000
3
Hemofil M Solution 801-1500
3
Hemorrhoidal Suppository -HC 25mg
1
Hemril-30 Suppository 30mg
1
Heparin Flush-10 Injection 10Unit/ml
1
Hepagam B Injection
3
Heparin Lock Injection 100/ml
1
Heparin Lock Injection 10Unit/ml
1
Heparin Sodium Injection 5000U
1
Homatropaire Solution 5% Op
1
Homatropine Solution 5% Op
1
HPR Aer
1
HPR Plus Aer
1
HPR Plus Cream
3
HPR Plus MB Kit Hydrogel
3
Humapen Memoir
2
Humate-P Injection 600Unit
3
Humate-P Solution 1200Unit
3
Humate-P Solution 2400Unit
3
Drug
Tier
Humco Base Cream Pain
3
Humibid L.A. Tablet 600mg
3
Humibid Spri Capsule 300mg
3
Humibid-DM Tablet
3
Hyalgan Injection 20mg/2ml
3
Hyaluronate Gel 0.2%
1
Hycamtin Capsule 0.25mg
3
Hycamtin Capsule 1mg
3
Hydrocodone Polst-Chlorpheniramine Liquid Lor Pols
1
Hydro 35 Aer
3
Hydro 40 Aer Foam
3
Hydrocodone/Homatropine Syrup 5-1.5/5
1
Hydrocodone/ Tablet Homatrope
1
Hydrocortasone AC Suppository 25mg
1
Hydrocortasone AC Suppository 30mg
1
Hydrocortasone Cream Lodoquin
1
Hydrocortasone Kit Pramoxin
1
Hydrogel
1
Hydromet Syrup 5-1.5/5
1
Hydromorphone Suppository 3mg
1
Hydrophen Syrup
1
Hydroxyurea Powder
3
Hygel 0.2%
1
Hylatopc Pls Kit /Aurstat
3
Hylatopic Aer
3
Hylatopic Aer Plus
3
Hylatopic Cream Plus
3
Hylira Gel 0.2%
3
Drug
Tier
Hylira Lotion 0.1%
3
Hyomax-SL 0.125mg
1
Hyophen Tablet
1
Hyoscyamine Drop 0.125/ml
1
Hyoscyamine Elixer 0.125/5
1
Hyoscyamine Sub 0.125mg
1
Hyoscyamine Tablet 0.125mg
1
Hyoscyamine Tablet 0.375 ER
1
Hyoscyamine Tablet 0.375 SR
1
Hyoscyamine Drop 0.125/ml
1
Hyoscyamine Elixer 0.125/5
1
Hypercare Solution 20%
1
Hyperhep B Injection S/D
3
Hyperrab S/D Injection 150/ml
3
Hypersal Neb 3.5%
3
Hypersal Neb 7%
3
Hyper-Sal Neb 7%
3
Hypertet S/D Injection 250/ml
3
Ibuprofen Cream 10%
1
Icar-C Plus Tablet
2
Imogam Rabie Injection 150/ml
3
Infed Injection 50mg/ml
1
Infumorph Injection 10mg/ml
3
Infumorph Injection 25mg/ml
3
Inova Kit 4%
3
Inova Kit 8%
3
Inova 4/1 Kit Acne Con
3
Inova 8/2 Kit Acne Con
3
Drug
Tier
Inspirease System
3
Insulin Syringe 0.3/29G
2
Insulin Syringe 0.3/30G
2
Insulin Syringe 0.3/31G
2
Insulin Syringe 0.5/28G
2
Insulin Syringe 0.5/29G
2
Insulin Syringe 0.5/30G
2
Insulin Syringe 0.5/31G
2
Insulin Syringe 1ml/28G
2
Insulin Syringe 1ml/29G
2
Insulin Syringe 1ml/30G
2
Insulin Syringe 1ml/31G
2
Integra F Capsule
2
Introl Solution 75%
3
Iodine Tin 2%
1
Iodine Tin 2% Mild
1
Iodine Tin Strong
3
Iophen C-NR Liquid 100-10/5
1
Iso Atropine Solution 1% Op
3
Iso Carbacho Solution 1.5% Op
2
Iso Carbacho Solution 3% Op
2
Iso Homatrope Solution 2% Op
2
Iso Homatrope Solution 5% Op
3
Iso Hyoscine Solution 0.25% Op
3
Isoflurane Solution
1
Isometheptene/Acetaminophen Capsule Dichloralphenazone
1
Isometheptene/Caffeine Tablet /Acetaminophen
1
Isoproteren Aer 131mcg
1
Drug
Tier
IsoxSuprine Tablet 10mg
1
IsoxSuprine Tablet HCL 20mg
1
J-Cof DHC Liquid
3
Jetrea Injection 2.5mg/ml
3
J-Max DHC Liquid
3
JNT/Tunnel/ Kit Trigger
1
K-Effervesce Tablet 25meq
1
Kerafoam Aer 30%
3
Kerafoam 42 Aer 42%
3
Keralyt Gel 6%
3
Keralyt Kit Scalp 6%
3
Kerlone Tablet 10mg
3
Kerlone Tablet 20mg
3
Kerr Triple Dye Swab
3
Ketocare Test
2
Keto-Diastix Test
2
Ketostix Test
2
Ketostix Test Strip
2
K-Lor Powder 20meq
3
Klor-Con
1
Powder 20meq
Klor-Con/Ef Tablet 25meq FR
1
Klor-Con-25 Powder 25meq
1
Koate-Dvi Injection 1000Unit
3
Koate-Dvi Injection 250Unit
3
Koate-Dvi Injection 500Unit
3
Kogenate FS Injection 1000/bs
3
Kogenate FS Injection 1000Unit
3
Kogenate FS Injection 2000/bs
3
Drug
Tier
Kogenate FS Injection 2000Unit
3
Kogenate FS Injection 250/bs
3
Kogenate FS Injection 250Unit
3
Kogenate FS Injection 3000/bs
3
Kogenate FS Injection 3000Unit
3
Kogenate FS Injection 500/bs
3
Kogenate FS Injection 500Unit
3
K-Phos Tablet
3
K-Phos Tablet Neutral
3
K-Phos Tablet No 2
3
K-Prime Tablet 25meq EF
1
Krisgel 100 Gel
3
Krog Glucose Chew 4gm
2
K-Vescent Powder 20meq
1
K-Vescent Tablet 25meq EF
1
Kyprolis Solution 60mg
3
Lactic Acid Cream /Vit E
1
Lactic Acid Cream E
1
Lactic Acid Lotion 10%
1
Lactulose Solution 10gm/15
1
Lactulose Syrup 10gm/15
1
Lancets Ultra Thin 30G
1
Lancing Device
1
Lanolin Ointment
1
Lanolin Anhy Ointment
3
Lansoprazole Suspension 3mg/ml
3
Lartus Liquid
3
Latrix Suspension 50%
3
Drug
Tier
Latrix XM Emu 45%
3
Lavoclen-4 Kit Acne Wash
1
Lavoclen-4 Liquid Cream Wash
3
Lavoclen-8 Kit Acne Wash
1
Lavoclen-8 Liquid Cream Wash
3
Lecithin Gel
3
Lemohist Capsule Plus
3
Leucovorin Powder Calcium
3
Leuprolide Powder Acetate
3
Levacet Tablet
3
Levbid Tablet 0.375 ER
3
Levitra Tablet 10mg
3
Levitra Tablet 2.5mg
3
Levitra Tablet 20mg
3
Levitra Tablet 5mg
3
Levsin Tablet 0.125mg
3
Levsin/SL Sub 0.125mg
3
Librax Capsule 5-2.5mg
3
Lidazone Cream
1
Lidocaine Cream 3%
1
Lidocaine Lotion 3%
1
Lidocaine/HC Cream 3%-0.5%
1
Lidocaine/HC Kit 2-2%
1
Lidocaine/HC Kit 3%-0.5%
1
Lidocaine/HC Kit 3%-1%
1
Lidocaine/HC Kit 3-2.5%
1
Lido-Hydro Gel 2.8-0.55
3
Lidoprofen Cream 5-5-2%
3
Drug
Tier
Lidorx Gel 3%
1
Lidovir Ointment 4-4%
3
Limbrel Capsule 250mg
2
Limbrel Capsule 500mg
2
Limbrel Capsule 250-50mg
2
Limbrel Capsule 500-50mg
2
Lipo Cream Base
3
Lipobase Cream Heavy
3
Lipobase Cream Regular
3
Lipodox Injection 2mg/ml
1
Lipodox 50 Injection 2mg/ml
1
Lipopen Cream
3
Lipopen Cream Plus
3
Lipopen Cream Ultra
3
Liquiduicet Solution 10-500mg
3
Lissamine Gr Test 1.5mg
3
L-Methyl- Tablet B6-B12
1
L-Methylfola Capsule Form 15
1
L-Methylfola Capsule Form 7.5
1
L-Methylfola Capsule Forte
2
L-Methylfola Capsule Forte 15
1
L-Methylfola Tablet 15mg
1
L-Methylfola Tablet 7.5mg
1
L-Methyl-MC Tablet
1
L-Methyl-MC Tablet NAC
1
LMTHF/B6/B12 Tablet
1
Loestrin Tablet 1/20-21
3
Loestrin 21 Tablet 1.5/30
3
Drug
Tier
Lomustine Capsule 100mg
1
Lomustine Capsule 10mg
1
Lomustine Capsule 40mg
1
Lugols Solution Strong
1
Lukaid Gla Emu 1gm/ml
2
Lunglaid Emu 1gm/ml
2
Lusonal Liquid
3
Luveris Injection 75Unit
3
Lycelle Gel
3
Macrodantin Capsule 50mg
3
Macugen Injection
3
Macutek Tablet
2
Martinic Capsule
1
Maxibar Suspension 210%
3
Maxifed CD Tablet
3
Maxifed CDX Tablet
3
Maxifed-G Tablet CDX
3
Maxifed-G CD Tablet
3
Maxiflu CD Tablet
3
Maxiflu CDX Tablet
3
Maxiphen CD Tablet
3
Maxiphen CDX Tablet
3
MB Hydrogel Kit
3
MD-Gastrovie Solution 66-10%
1
Med 12Hr Rel Tablet 6-120 CR
1
Med Cit Magn Solution
1
Mediderm Cream
3
MeDropx-Rx Ointment
3
Drug
Tier
Mega-C/A Plu Injection 500mg/ml
1
Megafolbic Tablet Plus RF
1
Membraneblue Solution 0.15%
3
Menopur Injection 75Unit
2
Mephyton Tablet 5mg
2
Mercaptopuri Powder
3
Mercaptopuri Powder Monohydrate
3
Mercaptopuri Powder USP
3
Metafolbic Tablet
1
MetafolbicTablet Plus
1
Metaglip Tablet 2.5-250M
3
Metanx Capsule
2
Metanx Tablet
2
Methenam Man Tablet 500mg
1
Methotrexate Powder
3
Methyl Salicylate Liquid
1
Methylfolate/Ca Tablet Me-Cbl
1
Methylfolate/Me Capsule Cbl/P5P
1
Methylfolate/Me Tablet -Cbl/Nac
1
Methylfolate/Me Tablet -Cbl/P5P
1
Methylpred Powder Acetate
3
Metopirone Capsule 250mg
3
Metronidazole Gel 1%
1
Mexar Wash Liquid 10%
1
Miconazole Powder Nitrate
3
Micro-K Capsule 8meq CR
3
Migragesic Capsule IDA
1
Migral Tablet 130mg
3
Drug
Tier
Migralam Capsule
3
Millipred DP Pak 5mg
3
Milrinone Injection 1mg/ml
1
Mimyx Cream
3
Mineral Oil Heavy
3
Minirin Spray Nasal
1
Mitomycin Powder
3
Mitomycin C Powder
3
MitoSolution Kit 0.2mg
3
Momexin Kit
3
Monoclate-P Injection 1000Unit
3
Monoclate-P Injection 1500Unit
3
Monoclate-P Injection 250Unit
3
Monoclate-P Injection 500Unit
3
Mononine Injection 1000Unit
3
Mononine Injection 250Unit
3
Mononine Injection 500Unit
3
Monsels Ferr Solution Subsulf
1
Morcomine Syrup
1
Morphine Sulfate Suppository 10mg
1
Morphine Sulfate Suppository 20mg
1
Morphine Sulfate Suppository 30mg
1
Morphine Sulfate Suppository 5mg
1
MST 600 Tablet
3
MTest HS/EST Tablet Estrogen
1
MTest/EST Tablet Estrogen
1
Mucotrol
3
Mugard Liquid
3
Drug
Tier
Multibase Cream
3
Multi-Vit/Fe Drop /Fl 0.25
1
Multivit/Fl Chew 0.25mg
1
Multivit/Fl Chew 0.5mg
1
Multivit/Fl Chew 1mg
1
Multi-Vit/Fl Chew 0.25mg
1
Multi-Vit/Fl Chew 0.5mg
1
Multi-Vit/Fl Chew 1mg
1
Multi-Vit/Fl Drop /Fe 0.25
1
Multi-Vit/Fl Drop 0.25mg
1
Multi-Vit/Fl Drop 0.5mg/ml
1
Mult-Vit/Fl Chew 0.5mg
1
Muse Suppository 1000mcg
2
Muse Suppository 125mcg
2
Muse Suppository 250mcg
2
Muse Suppository 500mcg
2
MVC-Fluoride Chew 0.25mg
1
MVC-Fluoride Chew 0.5mg
1
MVC-Fluoride Chew 1mg
1
Mydfrin Solution 2.5% Op
3
Mydral Solution 0.5% Op
1
Mydral Solution 1% Op
1
Mydriacyl Solution 1% Op
3
Mykidz Iron Suspension Fl
2
Myleran Tablet 2mg
2
Mynephrocaps
1
Myobloc Injection 10000/2
2
Myobloc Injection 2500/0.5
2
Drug
Tier
Myobloc Injection 5000/ml
2
Myoxin Suspension Otic
1
Mytussin DAC Solution
1
Na Hydroxide Solution 10%
1
Nabi-HB Injection
3
Naproderm Cream 15%
1
Nascobal Spray 500mcg
2
NataCream
3
Natalvirt Tablet FLT
2
Natroba Suspension 0.9%
3
Nature Thyroid Tablet 162.5mg
3
Nature-Thyroid Tablet 113.75mg
3
Nature-Thyroid Tablet 130mg
3
Nature-Thyroid Tablet 146.25mg
3
Nature-Thyroid Tablet 16.25mg
3
Nature-Thyroid Tablet 195mg
3
Nature-Thyroid Tablet 260mg
3
Nature-Thyroid Tablet 32.5mg
3
Nature-Thyroid Tablet 325mg
3
Nature-Thyroid Tablet 48.75mg
3
Nature-Thyroid Tablet 65mg
3
Nature-Thyroid Tablet 81.25mg
3
Nature-Thyroid Tablet 97.5mg
3
Navelbine Injection 10mg/ml
3
Navelbine Injection 50mg/5ml
3
Nebusal Neb 6%
3
Needles 22G X 1 1/2"
3
Neofrin Solution 10% Op
1
Drug
Tier
Neofrin Solution 2.5% Op
1
Neosalus Aer
3
Neosalus Cream
3
Neosalus Lotion
3
Neosalus CP Cream
3
Neotuss Plus Liquid
3
Neotuss-D Liquid
3
Nephplex Rx Tablet
2
Nephrocaps
2
Nephrocaps Tablet QT
2
Nephronex Tablet 1mg
1
Nephro-Vite Tablet Rx
2
Neurin-SL Sub
2
Neutek 2Tek Test Strips
3
Neutrasal Powder
3
Nexiclon XR Suspension 0.09/ml
3
Nexiclon XR Tablet 0.17mg
3
Nicazel Tablet
2
Nicomide Tablet
2
Nitrofuranzo Ointment 0.2%
1
Nitroglycerin Capsule 2.5mg ER
1
Nitroglycerin Capsule 6.5mg ER
1
Nitroglycerin Capsule 9mg ER
1
Nitro-Time Capsule 2.5mg CR
1
Nitro-Time Capsule 6.5mg CR
1
Nitro-Time Capsule 9mg CR
1
NocLotion-50 Solution Acd-A
3
Nodolor Capsule
1
Drug
Tier
Novacort Gel
3
Novoseven RT Injection 1mg
3
Novoseven RT Injection 2mg
3
Novoseven RT Injection 5mg
3
Novoseven RT Injection 8mg
3
NP Thyroid Tablet 30mg
1
NP Thyroid Tablet 60mg
1
NP Thyroid Tablet 90mg
1
Nucort Lotion 2%
3
Nulev Tablet 0.125mg
3
Nuox Gel 6-3%
3
Nutricap Tablet
2
Nutrivit Liquid 800-15-1
2
Nuvail Solution 16%
3
Nuvigil Tablet 150mg
3
Nuzon Gel 2%
3
Nystatin Vag Tablet 100000
1
Oasis Ultra 5 X 7CM
3
Oasis Ultra Tri Mesh
3
Oasis Wound 3X3.5CM
3
Oasis Wound 3X7CM
3
Omeprazole + Suspension Syrspend
3
Omniflex DPR
2
Omnitrope Injection 10/1.5ml
2
Omontys Injection 10mg/ml
3
Omontys Injection 20mg/2ml
3
Onetouch Lancet Device
1
Optase Gel
3
Drug
Tier
Optichamber
3
Optichamber Mask
3
Optichamber Mask Small
3
Optihaler
3
Ora-Blend Suspension
3
Ora-Blend SF Suspension
3
Oracit Solution
3
Oramagicrx Suspension
3
Ora-Plus Liquid
3
Ora-Sweet Syrup
3
Ora-Sweet SF Syrup
3
Oravig Tablet 50mg
3
Oraxyl Capsule 20mg
3
Ortho Coil DPR Kit 100
2
Ortho Coil DPR Kit 105
2
Ortho Coil DPR Kit 50
2
Ortho Flat DPR Kit 55
2
Ortho Flat DPR Kit 60
2
Ortho Flat DPR Kit 65
2
Ortho Flat DPR Kit 70
2
Ortho Flat DPR Kit 75
2
Ortho Flat DPR Kit 80
2
Ortho Flat DPR Kit 85
2
Ortho Flat DPR Kit 90
2
Ortho Flat DPR Kit 95
2
Ortho Flex DPR 65mm
2
Ortho Flex DPR 70mm
2
Ortho Flex DPR 75mm
2
Drug
Tier
Ortho Flex DPR 80mm
2
Orthovisc Injection 15mg/ml
2
Oscimin Sub 0.125mg
1
Oscimin Tablet 0.125mg
1
Oscimin SR Tablet 0.375mg
1
Otic Care Drop
1
Oticin Drop 1-0.1%
1
Oticin HC Drop
3
Oto-End 10 Solution
1
Otomar Solution Otic
1
Otomax-HC Drop
1
Otozin Drop
1
Ovace Plus Cream 10%
3
Ovace Plus Gel 10% Wash
3
Ovace Plus Liquid 10% Wash
3
Ovace Plus Shampoo 10%
3
Ovace Wash Liquid 10%
3
Ovcon 50 Tablet 28
3
Ovidrel Injection
2
Oxtellar XR Tablet 150mg
3
Oxtellar XR Tablet 300mg
3
Oxtellar XR Tablet 600mg
3
Pain Ease Aer Md Strm
3
Pain Ease Aer Mist
3
Pamine FQ Kit
3
Panhematin Injection 313mg
3
Panoxyl Liquid 2.5%
3
Papaverine Injection 30mg/ml
1
Drug
Tier
Papaverine Powder HCL
3
Papaverine Solution 30mg/ml
1
Paragard IUD T380A
3
Paraldehyde Liquid
3
Paregoric Tin 2mg/5ml
1
Paremyd Solution 1-0.25%
3
Pari Trek S Kit Combo
3
PCCA Acacia Syrup Base
3
PCCA Aladerm Cream Base
3
PCCA Base Transdermal
3
PCCA Cobase Ointment #1
3
PCCA Cosmetic Cream HRT Base
3
PCCA Custom Cream Lipo-Max
3
PCCA Lipoder Cream Base
3
PCCA Liposom Cream Dehydrate
3
PCCA Liposom Cream Dry
3
PCCA Liposom Cream Normal
3
PCCA Liposom Cream Oily
3
PCCA Liposom Cream Problem
3
PCCA Liposom Cream Sensitiv
3
PCCA MVC Cream Base
3
PCCA Sweet Syrup -SF
3
PCCA Syrup Vehicle
3
PCCA Vanish Cream Base
3
PCCA Vanishi Cream Light
3
PCCA Vanpen Cream Base
3
PCCA-Plus Suspension
3
Phenylephrine/Guaifenesin Drop 1.5-20mg
1
Drug
Tier
Pediatex TD Liquid
3
Pediatex TDM Suspension
3
Peg Ointment Base L
3
Pen Needle 29Gx1/2"
2
Pen Needles 29Gx12mm
2
Pen Needles 31Gx3/16
2
Pen Needles 31Gx5/16
2
Pen Needles 31Gx6mm
2
PenCream
3
Penderm Cream
3
Penlet II Kit Blood
1
Peridex Solution 0.12%
3
Periostat Tablet
3
Petn Tablet 80mg
1
Petrolatum Ointment White
3
Petrolatum Ointment Yellow
3
Pharmabase Cream Cosmetic
3
Pharmabase Cream Heavy
3
Phena-S Liquid
3
Phenazopyridine Tablet 200mg
1
Phenazopyridine Tablet 100mg
1
Phenazopyridine Tablet 200mg
1
Phenazopyridine Tablet Plus
1
Phendimetrazine Capsule 105mg ER
1
Phendimetrazine Tablet 35mg
1
Phenflu CD Tablet
3
Phenflu CDX Tablet
3
Phentermine Capsule 15mg
1
Drug
Tier
Phentermine Capsule 30mg
1
Phentermine Capsule 37.5mg
1
Phentermine Tablet 37.5mg
1
Phentol Injection 5mg
1
Phenylephrine Solution 10% Op
1
Phenylephrine Solution 2.5% Op
1
Phospha 250 Tablet Neutral
1
Phosphasal Tablet
1
Photofrin Injection 75mg
3
Pilocarpine Solution 1% Op
1
Pilocarpine Solution 2% Op
1
Pilocarpine Solution 4% Op
1
Pinnacaine Drop 20% Otic
1
Plan B Tablet 0.75mg
3
Plo Gel Mediflo
3
Plo Mediflo Kit
3
Plo Transder Cream
3
Plo20 Base Gel
3
Podocon Solution 25%
1
Polibar Suspension 100%
3
Polibar ACB Kit 96%
3
Polibar Plus Suspension 105%
3
Poly Hist Liquid DHC
3
Poly Hist NC Liquid
3
Polyeth Glyc Ointment 8000
3
Polypeg Ointment Base
3
Poly-Tussin Liquid DHC
3
Poly-Tussin Syrup EX
3
Drug
Tier
Poly-Vi-Flor Chew 0.25mg
2
Poly-Vi-Flor Chew 0.5mg
2
Poly-Vi-Flor Chew 1mg
2
Poly-Vi-Flor Chew W/Iron
2
Poly-Vi-Flor Suspension /Iron
2
Poly-Vi-Flor Suspension 0.25/ml
2
Potassium Chloride Capsule 10meq CR
1
Potassium Chloride Liquid 10%
1
Potassium Chloride Liquid 20%
1
Potassium Chloride Solution 10% Sf
1
Potassium Chloride Tablet 10meq Cr
1
Potassium Chloride Tablet 25meq Ef
1
Potassium Hydroxide Solution 5%
3
Potassium/Chloride Tablet 25meq EF
1
Potaba Capsule 500mg
2
Potaba Tablet 500mg
2
Potassium Tablet 25meq Ef
1
PR Benzoyl Liquid 7% Wash
1
PR Cream Kit
3
Pracasil TM- Cream Plus
3
Pramcort Cream 1-1%
1
Pramosone Cream 1-2.5%
3
Pramosone Ointment 1%
3
Pramosone Ointment 2.5%
3
Pramosone E Cream 1-2.5%
3
Pramotic Drop 1-0.1%
3
Pramox Gel 1%
1
Pramoxine-HC Drop AQ Otic
1
Drug
Tier
Prascion
1
Prascion FC Pad 10-5%
1
Prascion RA Cream 10-5%
1
Precision Kit Xtra
2
Precision Test Sof-Tact
3
Precisn Xtra Test Ketone
2
Prelone Syrup 15mg/5ml
3
Prentif 22mm
2
Prentif 25mm
2
Prentif 28mm
2
Prentif 31mm
2
Prentif Fitting
2
Presera Aer
3
Probarimin Chew QT
2
Procort Cream
3
Proctocort Suppository 30mg
3
Prodrin Tablet
3
Proferrin Tablet Forte
2
Profilnine Injection 1000Unit
2
Profilnine Injection 1500Unit
2
Profilnine Injection 500Unit
2
Progesterone Powder Micronized
3
Progesterone Suppository VGS 100
2
Progesterone Suppository VGS 200
2
Progesterone Suppository VGS 25
2
Progesterone Suppository VGS 400
2
Progesterone Suppository VGS 50
2
Promar Capsule
2
Drug
Tier
Promethazine VC/ Syrup Codeine
1
Promethazine/Codeine Syrup 6.25-10
1
Promethazine Syrup DM
1
Promiseb Cream
3
Promiseb Kit Complete
3
Prop-Fluore Solution 0.5-0.25
1
Propylene GL Solution USP
3
Prosed/DS Tablet
3
Prostigmin Tablet 15mg
3
Prostin E2 Suppository 20mg
3
Protect Capsule Cardio
2
Protect Plus Capsule
2
Protect Plus Capsule NR
2
Protect Plus Liquid
2
Protectbone
2
Pruclair Cream
3
Prumyx Cream
3
Prutect
1
Psorizide Tablet Forte
3
Psorizide Tablet Ultra
3
Purified Liquid Water
3
Pyridium Tablet 100mg
3
Pyridium Tablet 200mg
3
Pyrogall ACD Ointment
3
Q2 Oral Clea Kit System
3
Q4 Oral Clea Kit System
3
Qsymia Capsule 11.25-69
3
Qsymia Capsule 15-92mg
3
Drug
Tier
Qsymia Capsule 3.75-23
3
Qsymia Capsule 7.5-46mg
3
Quazepam Tablet 15mg
3
Quinidine GL Tablet 324mg ER
1
Quintet System
2
Quintet Test Blood Glucose
3
Quintet AC System
2
Quintet AC Test Blood Glucose
3
Quintet Cont Solution HGH/Normal
2
RA E-Zject 28G
1
RA E-Zject Thin 26G
1
RA E-Zject Thin 28G
1
RA E-Zject Ultra Thin
1
RA Glucose Gel
1
Radigel
3
Raspberry Syrup
3
Rauwolfia Sub Composit
3
Readi-Cat Suspension 1.3%
3
Readi-Cat 2 Suspension 2.1%
3
Readi-Cat 2 Suspension Apple
3
Readi-Cat 2 Suspension Banana
3
Readi-Cat 2 Suspension Berry
3
Readi-Cat 2 Suspension Mochacci
3
Readi-Cat 2 Suspension Vanilla
3
Recombinate Injection
3
Recombinate Injection 220-400
3
Recombinate Injection 401-800
3
Recombinate Injection 801-1240
3
Drug
Tier
Recothrom Solution 20000Unit
3
Recothrom Solution 5000Unit
3
Rectacort-HC Suppository 25mg
1
Regenecare Gel
3
Regimex Tablet 25mg
3
Relagard Gel
3
Relagesic Tablet 50-650mg
3
Relhist Chew
3
Relion Keton Test
2
Relion Lancet Thin 26G
1
Remeven Cream 50%
3
Renal Capsule Softgel
1
Renalpren Capsule
1
Renastart Powder
2
RenaTablets Iron
2
RenaTablets
2
Rena-Vite Rx Tablet
1
Renax Tablet 2.5mg
2
Reneel Sub
3
Reno Capsule
1
Repronex Injection 75Unit
2
Req 49+ Tablet
2
Rescon-JR Tablet
3
Rescon-MX Tablet
3
Resectisol Solution 5%
3
Respa-BR Tablet 11mg
3
Revina Ointment
1
Rezira Solution 60-5/5ml
3
Drug
Tier
Rezyst IM Chew
3
Rezyst SB Chew 250mg
3
Rhinoflex Tablet 50-650mg
3
Riastap Solution 1gm
3
Ribavirin Powder
3
Rinnovi Nail Kit System
3
Risperidone Tablet 2mg
1
Rosanil Cleanser
1
Rosanil Kit
3
Rose Glo Test 1.5mg
3
Safety Needle 18Gx1"
3
Safety Needle 18Gx1.5"
3
Safety Needle 19Gx1"
3
Safety Needle 19Gx1.5"
3
Safety Needle 20Gx1"
3
Safety Needle 20Gx1.5"
3
Safety Needle 21Gx1"
3
Safety Needle 21Gx1.5"
3
Safety Needle 21Gx5/8"
3
Safety Needle 22Gx1"
3
Safety Needle 22Gx1.5"
3
Safety Needle 23Gx1"
3
Safety Needle 23Gx5/8"
3
Safety Needle 25Gx1"
3
Safety Needle 25Gx5/8"
3
Salacyn Cream 6%
1
Salacyn Lotion 6%
1
Salex Shampoo 6%
3
Drug
Tier
Salex Cream Kit 6%
3
Salex Lotion Kit 6%
3
Salicept Suspension
3
Salicylic Aer 6%
1
Salicylic AC Aer 6%
1
Salicylic AC Cream 6%
1
Salicylic AC Gel 6%
1
Salicylic AC Kit 6%
1
Salicylic AC Kit 6% Cream
1
Salicylic AC Kit 6% Lotionn
1
Salicylic AC Liquid 26%
1
Salicylic AC Liquid 27.5%
1
Salicylic AC Lotion 6%
1
Salicylic AC Shampoo 6%
1
Salkera Aer 6%
3
Salsalate Tablet 500mg
1
Salsalate Tablet 750mg
1
Salt Stable Cream
3
Salt Stable Cream LS ADV
3
Salvax Aer 6%
3
Salvax Duo Kit Plus
3
Scalacort Lotion 2%
1
Scalacort DK Kit
3
Se 10-5 SS Cream 10-5%
1
SE BPO 7-5.5 Kit Wash Kit
1
SE BPO Cloth 3%
1
SE BPO Cloth 6%
1
SE BPO Cloth 9%
1
Drug
Tier
SE BPO Wash Liquid 7%
1
Seb-Prev Liquid Wash
1
Seb-Prev Lotion 10%
1
SE-Donna Elixer PB Hyos
1
Select-Lite Kit Dev/Lanc
1
Selegiline Tablet 5mg
1
Selenium Sulfate Shampoo 2.25%
1
Selsun Shampoo 2.5%
3
Senetonic Liquid
2
Senna Powder
3
Senna Leaves
3
Serophene Tablet 50mg
1
Sevoflurane Solution
1
Shohls Solution Modified
3
Sidekick Kit System
2
Siderol Tablet
2
Silver Nitrate Ointment 10%
1
Silver Nitrate Solution 0.5%
1
Silver Nitrate Solution 10%
1
Silver Nitrate Solution 25%
1
Silver Nitrate Solution 50%
1
Simple Syrup
1
Sodium Chloride Neb 0.9%
1
Sodium Sulfate/Sulf Aer 10-5%
1
Sodium Sulfate/Sulf Cream 10-5%
1
Sodium Sulfate/Sulf 10-5%
1
Sodium Sulfate/Sulf Gel 10-5%
1
Sodium Sulfate/Sulf Kit
1
Drug
Tier
Sodium Sulfate/Sulf Liquid 9-4.5%
1
Sodium Sulfate/Sulf Liquid Wash
1
Sodium Sulfate/Sulf Lotion 10-5%
1
Sodium Sulfate/Sulf Pad 10-4%
1
Sodium Sulfate/Sulf Suspension 10-5%
1
Sodium Sulfate/Sulf Suspension 8-4%
1
Sodium Sulfacet Pad 10%
1
Sodium Powder Chloride
3
Sodium Chloride Neb 10%
1
Sodium Chloride Neb 3%
1
Sodium Chloride Neb 7%
1
Sodium Citrate Gra
3
Sodium Sulfate Liquid 10% Wash
1
Sojourn Solution
1
Solesta Injection 50-15 ml
3
Somnote Capsule 500mg
3
Sonafine
1
Sorbitol Solution 3% Irr
3
Sorbitol Solution 3.3% Irr
3
Sorbitol-Man Solution
3
Spectracef Tablet 400mg
3
Speed Gel Gel Trauma
3
Speedgel Rx Gel
3
SSS 10-4 Aer 10-4%
3
SSS 10-5 Aer 10-5%
1
Staflex Tablet 55-500mg
3
Staxyn Tablet 10mg
3
Sterymine Gel
3
Drug
Tier
Strovite Tablet
2
Strovite For Syrup
2
Strovite For Tablet
2
Strovite One Tablet
2
Strovite Plu Tablet
2
Strumeel
3
Suboxone Sub 2-0.5mg
3
Suboxone Sub 8-2mg
3
Sulf Lime Solution USP
3
Sulfacleanse Suspension 8-4%
1
Sulfadiazine Tablet 500mg
1
Sulfoam Shampoo 2%
3
Sumadan Kit
3
Sumadan Wash Liquid 9-4.5%
3
Sumatriptan Injection 4mg/0.5
1
Sumaxin Pad 10-4%
3
Sumaxin CP Kit
3
Sumaxin TS Suspension 8-4%
3
Sumaxin Wash Liquid 9-4%
3
Supartz Injection 25/2.5ml
3
Supervite Liquid
2
Supervite EC Tablet
2
Support Liquid
1
Support-500 Capsule
2
Supane Inhalation
3
Suprane Solution
3
Suprenza Tablet 15mg
3
Suprenza Tablet 30mg
3
Drug
Tier
Suprenza Tablet 37.5mg
3
Surestep Pro Test Normal Control
2
Suttar-2 Syrup
3
Suttar-SF Syrup
3
Symax DuoTablet
3
Symax FasTablet 0.125mg
1
Symax-SL Sub 0.125mg
1
Symax-SR Tablet 0.375mg
1
Synagex Capsule 1.25mg
2
Synatek Capsule
2
Synvisc Injection 8mg/ml
2
Synvisc One Injection 8mg/ml
2
Syrpalta Syrup
3
Syrpalta Syrup
1
Syrpalta Syrup Clear
1
T.R.U.E. Test
3
Tachosil Pad
3
Tacrolimus Powder
3
Tacrolimus Powder Monohyd
3
Tagitol V Suspension 40%
3
Tandem F Capsule
2
Taron Gra Crystals
1
TBC Aer
1
Tears Again Capsule Hydrate
2
Temodar Capsule 100mg
2
Temodar Capsule 140mg
2
Temodar Capsule 180mg
2
Temodar Capsule 20mg
2
Drug
Tier
Temodar Capsule 250mg
2
Temodar Capsule 5mg
2
Terbutaline Powder Sulfate
3
Terrell Solution
1
Tersi Foam Aer 2.25%
3
Testsalon Capsule 200mg
3
Testsalon Per Capsule 100mg
3
Testosterone Powder Cypionate
3
Testosterone Powder Enanthate
3
Tetcaine Solution 0.5% Op
1
Tetracaine Solution 0.5% Op
1
Tetravisc Solution 0.5% Op
1
Tetravisc Solution Forte
1
TGQ 15DM/5PE Syrup H/2CPM
1
TGQ 30/Syrup 150/15
1
TGQ 30/PSE/3 Syrup BRM/15DM
1
TGQ 50PSE/3 Syrup BRM/30DM
1
TGQ 7.5PEH/4 Liquid BRM/15DM
1
TGT Lancet 28G
1
Thalamus Sub Composit
3
Thioguanine Powder
3
Thrombat III Injection 1000Unit
3
Thrombat III Injection 500Unit
3
Thrombi-Gel Pad 10
3
Thrombi-Gel Pad 100
3
Thrombi-Gel Pad 40
3
Thrombin Kit 5000Unit
3
Thrombin-JMI Kit 20000Unit
3
Drug
Tier
Thrombin-JMI Kit 5000Unit
3
Thrombi-Pad 3"X3"
3
Thrombogen Kit 10000Unt
3
Thrombogen Solution 10000Unt
3
Thrombogen Solution 1000Unit
3
Thyrogen Injection 1.1mg
3
Tisseel Kit
3
Tisseel Solution
3
TL BPO MX Liquid 4.25%
1
TL G-Fol OS Tablet
2
TL Icon Capsule
1
TL Triseb Cream
3
TL Urea Lotion 45%
1
TL-Cermide
1
TL-Fluorivit Chew
2
Topex Topcal Spray Anesthetic
3
Tramadol HCL Capsule 150mg ER
1
Trandate Tablet 200mg
3
Transdermal Cream Pain Base
3
Tranzgel Gel
3
Traumanil Gel
3
Treagan Otic Drop
3
Tri-Chlor Liquid 80%
3
TricitraSolution
3
TricitraTes Solution
1
Trimethobenzamide Injection 100mg/ml
1
TriphroCapsules
1
Tri-Vi-Flor Suspension 0.25/ml
2
Drug
Tier
Tri-Vi-Flor Suspension 0.5mg/ml
2
Tri-Vi-Floro Suspension 0.25/ml
2
Tri-Vi-Floro Suspension 0.5mg/ml
2
Tri-Vit/Fe Drop /Fl 0.25
1
Tri-Vit/Fl Drop 0.25mg
1
Tri-Vit/Fl Drop 0.5mg
1
Tri-Vit/Fluoride Drop 0.25mg
1
Tri-Vit/Fluoride Drop 0.5mg
1
Tri-Vita/Fl Drop 0.25mg
1
Tri-Zel Tablet
2
Trojan Non-Lub Male Condom
3
Tropazone Cream
1
Tropazone Lotion
3
Tropicamide Solution 0.5% Op
1
Tropicamide Solution 1% Op
1
Truetrack Kit System
2
Truetrack Test
3
Turpentine Solution Spirits
3
Tusnel Capsule
3
Tusnel Ped-C Syrup
3
TussiCapsules 10-8mg
3
TussiCapsules 5-4mg
3
Tussigon Tablet 5mg
3
Tussionex Suspension Ext-Rel
3
Udamin Tablet
2
Udamin SP Tablet
2
U-Kera E Cream 40%
1
Ultane Solution
3
Drug
Tier
Ultima Kit Monitor
2
Ultra Thin Lancet 28G
1
Ultra Thin Lancet 30G
1
Ultraderm Cream
3
Umecta
3
Umecta Suspension 40%
3
Umecta Mouss Aer 40%
3
Umecta Nail Suspension Film
3
Umecta PD 40-0.3%
3
Umecta PD Suspension 40-0.3%
3
Unfine PNTP 32Gx4mm
2
Unifine PNTP 31Gx5mm
2
Unifine PNTP 31Gx8mm
2
UR N-C Tablet
1
Uramaxin Aer 20%
3
Uramaxin Cream 45%
3
Uramaxin Gel 45%
3
Uramaxin Lotion 45%
3
Uramaxin GT Kit 45%
3
Uramaxin GT Solution 45%
3
Urea Cream 39%
1
Urea Cream 40%
1
Urea Cream 45%
1
Urea Cream 50%
1
Urea 50%
1
Urea Gel 40%
1
Urea Lotion 40%
1
Urea Lotion 45%
1
Drug
Tier
Urea Suspension 50%
1
Urea 40% Suspension Nail
1
Urea Hydrati Aer 35%
1
Urea Nail Gel 45%
1
Urea Nail Kit
1
Urea Nail 50%
1
Urea Topical Suspension 40%
1
Urea-C40 Lotion 40%
1
Urelief Plus Tablet
1
Urelle Tablet
3
Uretron D/S Tablet
3
Uretron D/S Tablet
1
Uribel Capsule 118mg
3
Uri-Cleanse Tablet Rx
3
Uri-Control Tablet Rx
3
Urin D/S Tablet
1
Urogesic-Tablet Blue
3
Uroqid #2 Tablet
3
Urosex Tablet
1
Uryl Tablet
3
Ustell Capsule
1
Uta Capsule 120mg
3
UtiCap
1
Utira-C Tablet
3
Utrona-C Tablet
1
Vanishing Cream
3
Vanishing Cream Base Ii
3
Vanishing Cream Botancal
3
Drug
Tier
Vanish-Pen Cream
3
Vanoxide-HC Lotion 5-0.5%
3
Varibar Hone Suspension 40%
3
Varibar Nect Suspension 40%
3
Varibar Thin Suspension Honey
3
Varibar Thin Suspension Liquid
3
Vasculera Tablet
2
Vasolex Ointment
1
Vayacog Capsule
2
Vayarin Capsule
2
Vayarol Capsule
2
V-C Forte Capsule
1
Venelex Ointment
3
Venofer Injection 20mg/ml
2
Vent Needle 16Gx1.5"
3
Vent Needle 19Gx1.5"
3
Versabase Liquid Transdermal
3
Versafree Syrup
3
Versaplus Syrup
3
Versapro Cream
3
Versatile Cream Base
3
Versiclear Lotion
1
Vertigoheel Sub
3
Viagra Tablet 100mg
3
Viagra Tablet 25mg
3
Viagra Tablet 50mg
3
Vic-Forte Capsule
1
Virasal Liquid 27.5%
3
Drug
Tier
Virti-Sulf Cream 10-5%
1
Virt-Vite Tablet Forte
1
Virt-Vite Tablet Plus
1
Visicol Tablet 1.5gm
3
Visionblue Solution 0.06%
3
Vitacirc-B Tablet
1
Vitafol Syrup
2
Vitafol Tablet
2
Vital-D Rx Tablet
2
Vitamax Ped Drop
2
Vita-Min Capsule
1
Vitamin D Capsule 50000Unit
1
Vitamin Forte Capsule
1
Vita-Respa Tablet
2
Vitaroca Plu Tablet
2
Vitrase Injection 200/ml
3
Vituz Solution 5-4mg
3
Vivotif Bern Capsule EC
3
Vol-Care Rx Tablet
1
Volumen Suspension 0.1%
3
Vortex Valve Chamber
3
Vortex/Mask Childs
3
Vortex/Mask Toddler
3
VP-GSTN Capsule
1
VP-Precip Capsule
1
V-R Alcohol Prep Pad Swabs
1
Watchhaler
3
Westhroid Tablet 113.75mg
3
Drug
Tier
Westhroid Tablet 130mg
3
Westhroid Tablet 146.25mg
3
Westhroid Tablet 16.25mg
3
Westhroid Tablet 162.50mg
3
Westhroid Tablet 195mg
3
Westhroid Tablet 260mg
3
Westhroid Tablet 32.5mg
3
Westhroid Tablet 325mg
3
Westhroid Tablet 48.75mg
3
Westhroid Tablet 65mg
3
Westhroid Tablet 81.25mg
3
Westhroid Tablet 97.5mg
3
Westhroid-P Tablet 130mg
3
Westhroid-P Tablet 16.25mg
3
Westhroid-P Tablet 32.5mg
3
Westhroid-P Tablet 48.75mg
3
Westhroid-P Tablet 65mg
3
Westhroid-P Tablet 97.5mg
3
Wheat Germ Oil
2
Wide-Seal Dpr Kit 60
2
Wide-Seal Dpr Kit 65
2
Wide-Seal Dpr Kit 70
2
Wide-Seal Dpr Kit 75
2
Wide-Seal Dpr Kit 80
2
Wide-Seal Dpr Kit 85
2
Wide-Seal Dpr Kit 90
2
Wide-Seal Dpr Kit 95
2
Wilate Injection
3
Drug
Tier
Winrho SDF Injection 15000Unt
3
Winrho SDF Injection 1500Unit
3
Winrho SDF Injection 2500Unit
3
Winrho SDF Injection 5000Unit
3
Witch Hazel Liquid USP
3
Xeloda Tablet 150mg
2
Xeloda Tablet 500mg
2
Xenaderm Ointment
3
Xerac-AC Solution 6.25%
3
Xolegel Kit Corepak
3
Xolegel Duo/ Kit Head&Shd
3
Xolegel Duo/ Kit Xolex
3
Xolox Tablet 10-500mg
3
X-Viate Cream 40%
1
X-Viate Gel 40%
3
X-Viate Lotion 40%
1
Xyntha Injection 1000Unit
3
Xyntha Injection 2000Unit
3
Xyntha Injection 250Unit
3
Xyntha Injection 500Unit
3
Xyntha Solof Injection 1000Unit
3
Xyntha Solof Injection 2000Unit
3
Xyntha Solof Injection 3000Unit
3
Xyntha Solof Injection 500Unit
3
Xyntha Solof Kit 250Unit
3
Yodoxin Tablet 210mg
2
Yodoxin Tablet 650mg
2
Zacare Kit 4%
3
Drug
Tier
Zacare Kit 8%
3
Zaclir Lotion 8%
1
Z-Cof I Suspension
3
Zencia Liquid 9-4%
1
Zevalin Kit In-111
3
Zflex Tablet
1
Zgesic Tablet 66-600mg
1
Zithranol Shampoo 1%
3
Zithranol RR Cream 1.2%
3
Zonatuss Capsule 150mg
3
Z-Pram Kit 2.35-1%
3
Zuplenz 4mg
3
Zuplenz 8mg
3
Zutripro Liquid
3
This is not a complete list of prescription drugs covered by our plan. For a complete list, please contact
Customer Service using the information provided on the front and back cover pages.
1
Information about the appeals and grievance process for these prescription drugs can be found in your
Evidence of Coverage.
2
Catastrophic Level Threshold for 2014 is $4,550. Upon reaching this threshold, the plan will pay most
of the cost for your Part D drugs.
The benefit information provided is a brief summary, not a complete description of benefits. For more
information contact the plan. Limitations, copayments, and restrictions may apply.
Formulary, pharmacy network, premium and/or copayments/coinsurance may change each plan year.
Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a
Medicare-approved Part D sponsor. Enrollment in UnitedHealthcare plans depend on contract renewal.
UHEX14PD3551688_000
Last updated January 15, 2014