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Download MCD-HI STAT 2 - Ohana Health Plan
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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 (08/01/2014) 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 07/31/14 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 Codeine Phosphate/Guaifenesin TUSSICLEAR DH SYRUP CHERATUSSIN AC SYRUP GUAIFENESIN-CODEINE SYRUP IOPHEN C-NR NARCOTIC ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMBINATIONS Codeine Phosphate/Guaifenesin/Pseudoephedrine HCl CHERATUSSIN DAC SYRUP Last updated 07/31/14 Page 2 of 2 Drug Name Preference Details Coverage Details *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexi ants* *Anti-Obesity Agents**-*Lipase Inhibitors*** XENICAL ORAL CAPSULE 120 MG P PA P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC ibuprofen oral suspension 100 mg/5ml P Notes (OTC-Covered w/Rx); OTC ibuprofen oral tablet 200 mg P Notes (OTC-Covered w/Rx); OTC ibuprofen junior strength oral tablet chewable 100 mg P Notes (OTC-Covered w/Rx); OTC ACEPHEN SUPPOSITORY 120 MG, 325 MG, 650 MG P Notes (OTC-Covered w/Rx); OTC acetaminophen oral solution 160 mg/5ml P Notes (OTC-Covered w/Rx); OTC acetaminophen oral tablet 325 mg P Notes (OTC-Covered w/Rx); OTC; QL (279 EA per 31 days) acetaminophen oral tablet 500 mg P Notes (OTC-Covered w/Rx); OTC; QL (186 EA per 31 days) *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)*** *Analgesics - Nonnarcotic* *Analgesics Other**-*Analgesics Other*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 1 Drug Name Preference Details Coverage Details apap oral tablet 325 mg P Notes (OTC-Covered w/Rx); OTC; QL (279 EA per 31 days) apap extra strength oral tablet 500 mg P Notes (OTC-Covered w/Rx); OTC; QL (186 EA per 31 days) childrens non-asa pain relief oral tablet chewable 80 mg P Notes (OTC-Covered w/Rx); OTC childrens non-aspirin oral tablet chewable 80 mg P Notes (OTC-Covered w/Rx); OTC childrens non-aspirin pain oral tablet chewable 80 mg P Notes (OTC-Covered w/Rx); OTC childrens pain reliever oral tablet chewable 80 mg P Notes (OTC-Covered w/Rx); OTC childrens silapap oral liquid† 160 mg/5ml P Notes (OTC-Covered w/Rx); OTC childrens tactinal oral tablet chewable 80 mg P Notes (OTC-Covered w/Rx); OTC ed-apap oral liquid† 160 mg/5ml P Notes (OTC-Covered w/Rx); OTC mapap oral capsule 500 mg P Notes (OTC-Covered w/Rx); OTC; QL (186 EA per 31 days) mapap oral tablet 325 mg P Notes (OTC-Covered w/Rx); OTC; QL (279 EA per 31 days) mapap oral tablet 500 mg P Notes (OTC-Covered w/Rx); OTC; QL (186 EA per 31 days) mapap oral tablet chewable 80 mg P Notes (OTC-Covered w/Rx); OTC mapap arthritis pain oral tablet extendedrelease* 650 mg P Notes (OTC-Covered w/Rx); OTC; QL (93 EA per 31 days) maxapap maximum strength oral tablet 500 mg P Notes (OTC-Covered w/Rx); OTC; QL (186 EA per 31 days) maxapap regular strength oral tablet 325 mg P Notes (OTC-Covered w/Rx); OTC; QL (279 EA per 31 days) non-aspirin oral tablet 325 mg P Notes (OTC-Covered w/Rx); OTC; QL (279 EA per 31 days) non-aspirin extra strength oral tablet 500 mg P Notes (OTC-Covered w/Rx); OTC; QL (186 EA per 31 days) non-aspirin pain relief oral tablet 325 mg P Notes (OTC-Covered w/Rx); OTC; QL (279 EA per 31 days) nortemp infants oral suspension 80 mg/0.8ml P Notes (OTC-Covered w/Rx); OTC pain & fever childrens oral solution 160 mg/5ml P Notes (OTC-Covered w/Rx); OTC pain relief oral tablet 500 mg P Notes (OTC-Covered w/Rx); OTC; QL (186 EA per 31 days) P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 2 Drug Name Preference Details Coverage Details pain relief extra strength oral tablet 500 mg P Notes (OTC-Covered w/Rx); OTC; QL (186 EA per 31 days) PHARBETOL ORAL TABLET 325 MG P Notes (OTC-Covered w/Rx); OTC; QL (279 EA per 31 days) PHARBETOL EXTRA STRENGTH ORAL TABLET 500 MG P Notes (OTC-Covered w/Rx); OTC; QL (186 EA per 31 days) q-pap oral tablet 325 mg P Notes (OTC-Covered w/Rx); OTC; QL (279 EA per 31 days) tactinal oral tablet 325 mg P Notes (OTC-Covered w/Rx); OTC; QL (279 EA per 31 days) tactinal extra strength oral tablet 500 mg P Notes (OTC-Covered w/Rx); OTC; QL (186 EA per 31 days) P Notes (OTC-Covered w/Rx); OTC aspirin oral tablet 325 mg, 81 mg P Notes (OTC-Covered w/Rx); OTC aspirin oral tablet chewable 81 mg P Notes (OTC-Covered w/Rx); OTC aspirin oral tablet delayed release 81 mg P Notes (OTC-Covered w/Rx); OTC aspirin adult low strength oral tablet delayed release 81 mg P Notes (OTC-Covered w/Rx); OTC aspirin childrens oral tablet chewable 81 mg P Notes (OTC-Covered w/Rx); OTC aspirin ec oral tablet delayed release 325 mg, 81 mg P Notes (OTC-Covered w/Rx); OTC aspirin ec low dose oral tablet delayed release 81 mg P Notes (OTC-Covered w/Rx); OTC aspirin low dose oral tablet 81 mg P Notes (OTC-Covered w/Rx); OTC ECPIRIN ORAL TABLET DELAYED RELEASE 325 MG P Notes (OTC-Covered w/Rx); OTC FORMULATION R OINTMENT 0.25-3-14-71.9 % P Notes (OTC-Covered w/Rx); OTC hem-prep suppository 0.25-3-85.5 % P Notes (OTC-Covered w/Rx); OTC *Salicylates**-*Salicylate Combinations*** tri-buffered aspirin oral tablet 325 mg *Salicylates**-*Salicylates*** *Anorectal Agents* *Rectal Combinations**-*Rectal Combinations - Misc.*** *Antacids* *Antacid Combinations**-*Antacid & Simethicone*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 3 Drug Name Preference Details Coverage Details alamag plus oral tablet chewable 200-200-25 mg P Notes (OTC-Covered w/Rx); OTC ALMACONE ORAL SUSPENSION 200-200-20 MG/5ML P Notes (OTC-Covered w/Rx); OTC antacid oral suspension 200-200-20 mg/5ml P Notes (OTC-Covered w/Rx); OTC antacid anti-gas oral suspension 200-200-20 mg/5ml P Notes (OTC-Covered w/Rx); OTC antacid anti-gas max strength oral suspension 400-400-40 mg/5ml P Notes (OTC-Covered w/Rx); OTC antacid extra strength oral suspension 400-400-40 mg/5ml P Notes (OTC-Covered w/Rx); OTC antacid i oral suspension 200-200-20 mg/5ml P Notes (OTC-Covered w/Rx); OTC antacid iii oral suspension 400-400-40 mg/5ml P Notes (OTC-Covered w/Rx); OTC geri-lanta oral suspension 200-200-20 mg/5ml P Notes (OTC-Covered w/Rx); OTC MAALOX ADVANCED ORAL SUSPENSION 200-200-20 MG/5ML P Notes (OTC-Covered w/Rx); OTC MAALOX ADVANCED MAX ST ORAL SUSPENSION 400-400-40 MG/5ML P Notes (OTC-Covered w/Rx); OTC MAALOX MAX ORAL SUSPENSION 400-400-40 MG/5ML P Notes (OTC-Covered w/Rx); OTC MAALOX MULTI SYMPTOM MAX ST ORAL SUSPENSION 400-400-40 MG/5ML P Notes (OTC-Covered w/Rx); OTC MAALOX REGULAR STRENGTH ORAL SUSPENSION 200-200-20 MG/5ML P Notes (OTC-Covered w/Rx); OTC milantex oral suspension 200-200-20 mg/5ml P Notes (OTC-Covered w/Rx); OTC milantex extra strength oral suspension 400-400-40 mg/5ml P Notes (OTC-Covered w/Rx); OTC MINTOX PLUS ORAL TABLET CHEWABLE 200-200-25 MG P Notes (OTC-Covered w/Rx); OTC ACID GONE ORAL TABLET CHEWABLE 160-105 MG, 80-20 MG P Notes (OTC-Covered w/Rx); OTC MI-ACID ORAL TABLET CHEWABLE 700-300 MG P Notes (OTC-Covered w/Rx); OTC *Antacid Combinations**-*Antacid Combinations*** *Antacids - Aluminum Salts**-*Antacids Aluminum Salts*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 4 Drug Name aluminum hydroxide gel oral suspension 320 mg/5ml Preference Details Coverage Details P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC alcalak oral tablet chewable 420 mg P Notes (OTC-Covered w/Rx); OTC antacid oral tablet chewable 420 mg, 500 mg P Notes (OTC-Covered w/Rx); OTC CAL-GEST ANTACID ORAL TABLET CHEWABLE 500 MG P Notes (OTC-Covered w/Rx); OTC calcium antacid oral tablet chewable 500 mg P Notes (OTC-Covered w/Rx); OTC calcium antacid extra strength oral tablet chewable 750 mg P Notes (OTC-Covered w/Rx); OTC calcium carbonate antacid oral tablet 648 mg P Notes (OTC-Covered w/Rx); OTC calcium carbonate antacid oral tablet chewable 500 mg P Notes (OTC-Covered w/Rx); OTC MAALOX ORAL TABLET CHEWABLE 600 MG P Notes (OTC- Covered w/Rx); OTC TITRALAC ORAL TABLET CHEWABLE 420 MG P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC BD GLUCOSE ORAL TABLET CHEWABLE 5 GM P Notes (OTC-Covered w/Rx); OTC glucose oral tablet chewable 4 gm P Notes (OTC-Covered w/Rx); OTC ultilet glucose oral tablet chewable 4 gm P Notes (OTC-Covered w/Rx); OTC bismatrol oral suspension 262 mg/15ml P Notes (OTC-Covered w/Rx); OTC bismatrol oral tablet chewable 262 mg P Notes (OTC-Covered w/Rx); OTC bismuth oral tablet chewable 262 mg P Notes (OTC-Covered w/Rx); OTC diotame oral tablet chewable 262 mg P Notes (OTC-Covered w/Rx); OTC kao-tin oral suspension 262 mg/15ml P Notes (OTC-Covered w/Rx); OTC *Antacids - Bicarbonate**-*Antacids Bicarbonate*** sodium bicarbonate oral tablet 325 mg, 650 mg *Antacids - Calcium Salts**-*Antacids Calcium Salts*** *Antacids - Magnesium Salts**-*Antacids Magnesium Salts*** magnesium oxide oral tablet 400 mg *Antidiabetics* *Diabetic Other**-*Diabetic Other*** *Antidiarrheals* *Antidiarrheal Agents - Misc.**-*Antidiarrheal Agents - Misc.*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 5 Drug Name Preference Details Coverage Details KAOPECTATE ORAL SUSPENSION 262 MG/15ML P Notes (OTC-Covered w/Rx); OTC KAOPECTATE EXTRA STRENGTH ORAL SUSPENSION 525 MG/15ML P Notes (OTC-Covered w/Rx); OTC pink bismuth oral suspension 262 mg/15ml P Notes (OTC-Covered w/Rx); OTC pink bismuth oral tablet chewable 262 mg P Notes (OTC-Covered w/Rx); OTC stomach relief oral suspension 262 mg/15ml, 527 mg/30ml P Notes (OTC-Covered w/Rx); OTC stomach relief oral tablet chewable 262 mg P Notes (OTC-Covered w/Rx); OTC stomach relief plus oral suspension 525 mg/15ml P Notes (OTC-Covered w/Rx); OTC anti-diarrheal oral liquid† 1 mg/5ml P Notes (OTC-Covered w/Rx); OTC LOPERAMIDE A-D ORAL TABLET 2 MG P Notes (OTC-Covered w/Rx); OTC loperamide hcl oral liquid† 1 mg/5ml P Notes (OTC-Covered w/Rx); OTC actidose-aqua oral liquid† 15 gm/72ml, 25 gm/120ml, 50 gm/240ml P Notes (OTC-Covered w/Rx); OTC actidose/sorbitol oral liquid† 25 gm/120ml, 50 gm/240ml P Notes (OTC-Covered w/Rx); OTC charcoal oral capsule 260 mg P Notes (OTC-Covered w/Rx); OTC charcoal activated oral tablet 250 mg P Notes (OTC-Covered w/Rx); OTC CHARCOCAPS ORAL CAPSULE 260 MG P Notes (OTC-Covered w/Rx); OTC ipecac oral syrup P Notes (OTC-Covered w/Rx); OTC KERR INSTA-CHAR ORAL LIQUID† 25 GM/120ML, 50 GM/240ML P Notes (OTC-Covered w/Rx); OTC KERR INSTA-CHAR IN SORBITOL ORAL LIQUID† 25 GM/120ML, 50 GM/240ML P Notes (OTC-Covered w/Rx); OTC LITTLE REMEDIES POISON TREAT ORAL SUSPENSION RECONSTITUTED 15 GM/120ML P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC *Antiperistaltic Agents**-*Antiperistaltic Agents*** *Antidotes* *Antidotes**-*Antidotes*** *Antiemetics* *Antiemetics Anticholinergic**-*Antiemetics Anticholinergic*** meclizine hcl oral tablet 12.5 mg, 25 mg P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 6 Drug Name Preference Details Coverage Details *Antihistamines* *Antihistamines Alkylamines**-*Antihistamines Alkylamines*** aller-chlor oral syrup 2 mg/5ml P Notes (OTC-Covered w/Rx); OTC aller-chlor oral tablet 4 mg P Notes (OTC-Covered w/Rx); OTC allergy oral tablet 4 mg P Notes (OTC-Covered w/Rx); OTC allergy relief oral tablet 4 mg P Notes (OTC-Covered w/Rx); OTC chlorhist oral tablet 4 mg P Notes (OTC-Covered w/Rx); OTC chlorphen oral tablet 4 mg P Notes (OTC-Covered w/Rx); OTC DIABETIC TUSSIN ALLERGY ORAL SYRUP 2 MG/5ML P Notes (OTC-Covered w/Rx); OTC aler-cap oral capsule 25 mg P Notes (OTC-Covered w/Rx); OTC aler-dryl oral tablet 50 mg P Notes (OTC-Covered w/Rx); OTC alertab oral tablet 25 mg P Notes (OTC-Covered w/Rx); OTC allergy relief childrens oral liquid† 12.5 mg/5ml P Notes (OTC-Covered w/Rx); OTC altaryl oral elixir 12.5 mg/5ml P Notes (OTC-Covered w/Rx); OTC altaryl oral syrup 12.5 mg/5ml P Notes (OTC-Covered w/Rx); OTC anti-hist oral capsule 25 mg P Notes (OTC-Covered w/Rx); OTC anti-hist allergy oral tablet 25 mg P Notes (OTC-Covered w/Rx); OTC BANOPHEN ORAL CAPSULE 25 MG P Notes (OTC-Covered w/Rx); OTC BANOPHEN ORAL LIQUID† 12.5 MG/5ML P Notes (OTC-Covered w/Rx); OTC BANOPHEN ORAL TABLET 25 MG P Notes (OTC-Covered w/Rx); OTC BENADRYL ALLERGY CHILDRENS ORAL LIQUID† 12.5 MG/5ML P Notes (OTC-Covered w/Rx); OTC complete allergy medication oral tablet 25 mg P Notes (OTC-Covered w/Rx); OTC complete allergy relief oral tablet 25 mg P Notes (OTC-Covered w/Rx); OTC diphenhist oral capsule 25 mg P Notes (OTC-Covered w/Rx); OTC diphenhist oral liquid† 12.5 mg/5ml P Notes (OTC-Covered w/Rx); OTC diphenhist oral tablet 25 mg P Notes (OTC-Covered w/Rx); OTC diphenhydramine hcl oral capsule 25 mg, 50 mg P Notes (OTC-Covered w/Rx); OTC diphenhydramine hcl oral tablet 25 mg P Notes (OTC-Covered w/Rx); OTC *Antihistamines Ethanolamines**-*Antihistamines Ethanolamines*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 7 Drug Name Preference Details Coverage Details DORMIN ORAL CAPSULE 25 MG P Notes (OTC-Covered w/Rx); OTC genahist oral capsule 25 mg P Notes (OTC-Covered w/Rx); OTC pharbedryl oral capsule 25 mg, 50 mg P Notes (OTC-Covered w/Rx); OTC q-dryl oral capsule 25 mg P Notes (OTC-Covered w/Rx); OTC q-dryl oral liquid† 12.5 mg/5ml P Notes (OTC-Covered w/Rx); OTC quenalin oral syrup 12.5 mg/5ml P Notes (OTC-Covered w/Rx); OTC SCOT-TUSSIN ALLERGY RELIEF ORAL LIQUID† 12.5 MG/5ML P Notes (OTC-Covered w/Rx); OTC siladryl allergy oral liquid† 12.5 mg/5ml P Notes (OTC-Covered w/Rx); OTC silphen cough oral syrup 12.5 mg/5ml P Notes (OTC-Covered w/Rx); OTC SIMPLY ALLERGY ORAL TABLET 25 MG P Notes (OTC-Covered w/Rx); OTC total allergy oral tablet 25 mg P Notes (OTC-Covered w/Rx); OTC TOTAL ALLERGY MEDICINE ORAL LIQUID† 12.5 MG/5ML P Notes (OTC-Covered w/Rx); OTC cetirizine hcl oral tablet 10 mg, 5 mg P Notes (OTC-Covered w/Rx); OTC cetirizine hcl childrens oral solution 1 mg/ml P Notes (OTC-Covered w/Rx); OTC cetirizine hcl childrens alrgy oral syrup 1 mg/ml P Notes (OTC-Covered w/Rx); OTC loratadine oral tablet 10 mg P Notes (OTC-Covered w/Rx); OTC loratadine hives relief oral solution 5 mg/5ml P Notes (OTC-Covered w/Rx); OTC; QL (300 ML per 31 days) OPERAND POVIDONE-IODINE EXTERNAL SOLUTION 10 % P Notes (OTC-Covered w/Rx); OTC povidone-iodine external ointment 10 % P Notes (OTC-Covered w/Rx); OTC povidone-iodine external solution 10 % P Notes (OTC-Covered w/Rx); OTC povidone-iodine external swab 10 %, 7.5 % P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC *Antihistamines Non-Sedating**-*Antihistamines Non-Sedating*** *Antiseptics & Disinfectants* *Iodine Antiseptics**-*Iodine Antiseptics*** *Assorted Classes* *Assorted Classes**-*Assorted Classes*** gelatin oral capsule 650 mg *Cough/Cold/Allergy* P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 8 Drug Name Preference Details Coverage Details *Cough/Cold/Allergy Combinations**-*Decongestant & Antihistamine*** ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG P Notes (OTC-Covered w/Rx); OTC BROTAPP ORAL LIQUID† 1-15 MG/5ML P Notes (OTC-Covered w/Rx); OTC Q-TAPP ORAL ELIXIR 1-15 MG/5ML P Notes (OTC-Covered w/Rx); OTC mucus relief oral tablet 400 mg P Notes (OTC-Covered w/Rx); OTC refenesen oral tablet 200 mg P Notes (OTC-Covered w/Rx); OTC refenesen 400 oral tablet 400 mg P Notes (OTC-Covered w/Rx); OTC robafen oral syrup 100 mg/5ml P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC acne medication external lotion 10 % P Notes (OTC-Covered w/Rx); OTC acne medication 10 external 10 % P Notes (OTC-Covered w/Rx); OTC acne-clear external 10 % P Notes (OTC-Covered w/Rx); OTC benzoyl peroxide external 10 %, 5 % P Notes (OTC-Covered w/Rx); OTC CLEAN & CLEAR PERSA-GEL EX ST EXTERNAL 5 % P Notes (OTC-Covered w/Rx); OTC CLEAN & CLEAR PERSA-GEL MAX ST EXTERNAL 10 % P Notes (OTC-Covered w/Rx); OTC CLEARPLEX V EXTERNAL 5 % P Notes (OTC-Covered w/Rx); OTC CLEARSKIN EXTERNAL CREAM 10 % P Notes (OTC-Covered w/Rx); OTC NEUTROGENA ON-THE-SPOT EXTERNAL CREAM 2.5 % P Notes (OTC-Covered w/Rx); OTC PANOXYL WASH EXTERNAL LIQUID† 10 % P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC *Expectorants**-*Expectorants*** *Misc. Respiratory Inhalants**-*Misc. Respiratory Inhalants*** sodium chloride inhalation nebulization solution 0.9 % *Dermatologicals* *Acne Products**-*Acne Products*** *Antibiotics - Topical**-*Antibiotic Mixtures Topical*** bacitracin-neomycin-polymyxin external ointment 400-5-5000 P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 9 Drug Name Preference Details Coverage Details double antibiotic external ointment 500-10000 unit/gm P Notes (OTC-Covered w/Rx); OTC triple antibiotic external ointment 3.5-400-5000 , 5-400-5000 P Notes (OTC-Covered w/Rx); OTC bacitracin external ointment 500 unit/gm P Notes (OTC-Covered w/Rx); OTC bacitracin zinc external ointment 500 unit/gm P Notes (OTC-Covered w/Rx); OTC anti-fungal external powder 1 % P Notes (OTC-Covered w/Rx); OTC terbinafine hcl external cream 1 % P Notes (OTC-Covered w/Rx); OTC tolnaftate external cream 1 % P Notes (OTC-Covered w/Rx); OTC tolnaftate external solution 1 % P Notes (OTC-Covered w/Rx); OTC tolnaftate antifungal external cream 1 % P Notes (OTC-Covered w/Rx); OTC clotrimazole external cream 1 % P Notes (OTC-Covered w/Rx); OTC clotrimazole external solution 1 % P Notes (OTC-Covered w/Rx); OTC clotrimazole anti-fungal external cream 1 % P Notes (OTC-Covered w/Rx); OTC allergy external cream 2 % P Notes (OTC-Covered w/Rx); OTC anti-itch maximum strength external cream 2 % P Notes (OTC-Covered w/Rx); OTC BENADRYL ITCH STOPPING EXTERNAL 2 % P Notes (OTC-Covered w/Rx); OTC itch relief external cream 2 % P Notes (OTC-Covered w/Rx); OTC AVEENO ANTI-ITCH MAX ST EXTERNAL CREAM 1% P Notes (OTC-Covered w/Rx); OTC hydrocortisone external cream 0.5 % P Notes (OTC-Covered w/Rx); OTC hydrocortisone external ointment 0.5 %, 1 % P Notes (OTC-Covered w/Rx); OTC hydrocortisone max st external cream 1 % P Notes (OTC-Covered w/Rx); OTC hydrocortisone max st/12 moist external cream 1 % P Notes (OTC-Covered w/Rx); OTC *Antibiotics - Topical**-*Antibiotics Topical*** *Antifungals - Topical**-*Antifungals Topical*** *Antifungals - Topical**-*Imidazole-Related Antifungals - Topical*** *Antihistamines-Topical**-*Antihistamines Topical*** *Corticosteroids - Topical**-*Corticosteroids - Topical*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 10 Drug Name Preference Details Coverage Details HYDROSKIN EXTERNAL CREAM 1 % P Notes (OTC-Covered w/Rx); OTC kp hydrocortisone external cream 1 % P Notes (OTC-Covered w/Rx); OTC PREPARATION H HYDROCORTISONE EXTERNAL CREAM 1 % P Notes (OTC-Covered w/Rx); OTC tgt anti-itch/aloe/vit e external cream 1 % P Notes (OTC-Covered w/Rx); OTC hydrocortisone-aloe external cream 1 % P Notes (OTC-Covered w/Rx); OTC sm hydrocortisone plus external cream 1 % P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC A-200 AEROSOL† 0.5 % P Notes (OTC-Covered w/Rx); OTC permethrin external lotion 1 % P Notes (OTC-Covered w/Rx); OTC; QL (60 ML per 31 days) COPPERTONE SUNBLOCK SPF15 EXTERNAL LOTION P Notes (OTC-Covered w/Rx); OTC NEUTROGENA MOISTURE SPF15 EXTERNAL LOTION P Notes (OTC-Covered w/Rx); OTC BETA CARE BETATAR GEL EXTERNAL SHAMPOO 2.5 % P Notes (OTC-Covered w/Rx); OTC ELTA TAR EXTERNAL CREAM 2 % P Notes (OTC-Covered w/Rx); OTC IONIL-T EXTERNAL SHAMPOO 1 % P Notes (OTC-Covered w/Rx); OTC MG217 MEDICATED TAR EXTERNAL SHAMPOO 15 % P Notes (OTC-Covered w/Rx); OTC NEUTROGENA T/GEL EX ST EXTERNAL SHAMPOO 1 % P Notes (OTC-Covered w/Rx); OTC pc-tar external shampoo 1 % P Notes (OTC-Covered w/Rx); OTC TERA-GEL TAR EXTERNAL SHAMPOO 0.5 % P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC *Corticosteroids - Topical**-*Topical Steroid Combinations*** *Misc. Topical**-*Misc. Topical*** PREPARATION H EXTERNAL PAD 50 % *Scabicides & Pediculicides**-*Scabicides & Pediculicides*** *Sunscreens**-*Sunscreens*** *Tar Products**-*Tar Products*** *Gastrointestinal Agents - Misc.* *Antiflatulents**-*Antiflatulents*** mi-acid gas relief oral tablet chewable 80 mg P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 11 Drug Name Preference Details Coverage Details mytab gas oral tablet chewable 80 mg P Notes (OTC-Covered w/Rx); OTC simethicone oral suspension 40 mg/0.6ml P Notes (OTC-Covered w/Rx); OTC simethicone oral tablet chewable 80 mg P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC *Genitourinary Agents - Miscellaneous* *Urinary Analgesics**-*Urinary Analgesics*** phenazopyridine hcl oral tablet 95 mg *Hematopoietic Agents* *Cobalamins**-*Cobalamins*** cyanocobalamin injection solution 1000 mcg/ml P vitamin b-12 oral tablet 1000 mcg, 250 mcg, 500 mcg P Notes (OTC-Covered w/Rx); OTC vitamin b-12 sublingual tablet sublingual 1000 mcg P Notes (OTC-Covered w/Rx); OTC vitamin b-12 er oral tablet extendedrelease* 1000 mcg P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC ferro-bob oral tablet 325 (65 fe) mg P Notes (OTC-Covered w/Rx); OTC ferrous sulfate oral elixir 220 (44 fe) mg/5ml P Notes (OTC-Covered w/Rx); OTC ferrous sulfate oral solution 75 (15 fe) mg/ml P Notes (OTC- Covered w/Rx); OTC ferrous sulfate oral tablet 325 (65 fe) mg P Notes (OTC-Covered w/Rx); OTC ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg P Notes (OTC-Covered w/Rx); OTC ferrousul oral tablet 325 (65 fe) mg P Notes (OTC-Covered w/Rx); OTC iron oral tablet 325 (65 fe) mg, 90 (18 fe) mg P Notes (OTC-Covered w/Rx); OTC acetaminophen pm oral tablet 500-25 mg P Notes (OTC-Covered w/Rx); OTC; QL (62 EA per 31 Days) headache pm oral tablet 25-500 mg P Notes (OTC-Covered w/Rx); OTC; QL (62 EA per 31 days) mapap pm oral tablet 500-25 mg P Notes (OTC-Covered w/Rx); OTC; QL (62 EA per 31 days) *Folic Acid/Folates**-*Folic Acid/Folates*** folic acid oral tablet 1 mg *Iron**-*Iron*** *Hypnotics* *Antihistamine Hypnotics**-*Antihistamine Hypnotic Combinations*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 12 Drug Name Preference Details Coverage Details pain relief pm extra strength oral tablet 500-25 mg P Notes (OTC-Covered w/Rx); OTC; QL (62 EA per 31 days) pain reliever pm oral tablet 500-25 mg P Notes (OTC-Covered w/Rx); OTC; QL (62 EA per 31 days) compoz oral capsule 50 mg P Notes (OTC-Covered w/Rx); OTC compoz oral tablet 50 mg P Notes (OTC-Covered w/Rx); OTC NYTOL ORAL TABLET 25 MG P Notes (OTC-Covered w/Rx); OTC SIMPLY SLEEP ORAL TABLET 25 MG P Notes (OTC-Covered w/Rx); OTC sleep tabs oral tablet 25 mg P Notes (OTC-Covered w/Rx); OTC sleep-tabs oral tablet 25 mg P Notes (OTC-Covered w/Rx); OTC SOMINEX ORAL TABLET 25 MG P Notes (OTC-Covered w/Rx); OTC SOMINEX MAXIMUM STRENGTH ORAL TABLET 50 MG P Notes (OTC-Covered w/Rx); OTC tetra-formula nighttime sleep oral tablet 50 mg P Notes (OTC-Covered w/Rx); OTC fiber oral tablet 625 mg P Notes (OTC-Covered w/Rx); OTC fiber laxative oral tablet 625 mg P Notes (OTC-Covered w/Rx); OTC fiber therapy oral powder 58.6 % P Notes (OTC-Covered w/Rx); OTC fiber-lax oral tablet 625 mg P Notes (OTC-Covered w/Rx); OTC FIBERGEN ORAL TABLET 625 MG P Notes (OTC-Covered w/Rx); OTC KONSYL ORAL PACKET 100 % P Notes (OTC-Covered w/Rx); OTC KONSYL FIBER ORAL TABLET 625 MG P Notes (OTC-Covered w/Rx); OTC METAMUCIL ORAL POWDER 30.9 % P Notes (OTC-Covered w/Rx); OTC METAMUCIL MULTIHEALTH FIBER ORAL POWDER 58.6 % P Notes (OTC-Covered w/Rx); OTC METAMUCIL SMOOTH TEXTURE ORAL PACKET 28 % P Notes (OTC-Covered w/Rx); OTC METAMUCIL SMOOTH TEXTURE ORAL POWDER 28.3 %, 58.6 % P Notes (OTC-Covered w/Rx); OTC natural fiber therapy oral powder 30.9 %, 48.57 % P Notes (OTC-Covered w/Rx); OTC natural vegetable fiber oral powder 48.57 % P Notes (OTC-Covered w/Rx); OTC REGULOID ORAL CAPSULE 0.52 GM P Notes (OTC-Covered w/Rx); OTC *Antihistamine Hypnotics**-*Antihistamine Hypnotics*** *Laxatives* *Bulk Laxatives**-*Bulk Laxatives*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 13 Drug Name Preference Details Coverage Details *Laxative Combinations**-*Laxatives & Dss*** DOC-Q-LAX ORAL TABLET 8.6-50 MG P Notes (OTC-Covered w/Rx); OTC PERI-COLACE ORAL TABLET 8.6-50 MG P Notes (OTC-Covered w/Rx); OTC senna plus oral tablet 8.6-50 mg P Notes (OTC-Covered w/Rx); OTC senna s oral tablet 8.6-50 mg P Notes (OTC-Covered w/Rx); OTC senna-docusate sodium oral tablet 8.6-50 mg P Notes (OTC-Covered w/Rx); OTC senna-s oral tablet 8.6-50 mg P Notes (OTC-Covered w/Rx); OTC senna-time s oral tablet 8.6-50 mg P Notes (OTC-Covered w/Rx); OTC SENNALAX-S ORAL TABLET 8.6-50 MG P Notes (OTC-Covered w/Rx); OTC sennosides-docusate sodium oral tablet 8.6-50 mg P Notes (OTC-Covered w/Rx); OTC glycerin (adult) suppository 2.1 gm P Notes (OTC-Covered w/Rx); OTC glycerin (pediatric) suppository 1.2 gm P Notes (OTC-Covered w/Rx); OTC sorbitol oral solution 70 % P Notes (OTC-Covered w/Rx); OTC enema enema 7-19 gm/118ml P Notes (OTC-Covered w/Rx); OTC sm oral saline laxative oral solution 2.7-7.2 gm/5ml P Notes (OTC-Covered w/Rx); OTC citrate of magnesia oral solution 1.745 gm/30ml P Notes (OTC-Covered w/Rx); OTC CITROMA ORAL SOLUTION 1.745 GM/30ML P Notes (OTC-Covered w/Rx); OTC DULCOLAX MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML P Notes (OTC-Covered w/Rx); OTC magnesium citrate oral solution 1.745 gm/30ml P Notes (OTC- Covered w/Rx); OTC milk of magnesia oral suspension 400 mg/5ml, 7.75 % P Notes (OTC-Covered w/Rx); OTC BISAC-EVAC ORAL TABLET DELAYED RELEASE 5 MG P Notes (OTC-Covered w/Rx); OTC BISAC-EVAC SUPPOSITORY 10 MG P Notes (OTC-Covered w/Rx); OTC biscolax suppository 10 mg P Notes (OTC-Covered w/Rx); OTC *Laxatives - Miscellaneous**-*Laxatives Miscellaneous*** *Saline Laxatives**-*Saline Laxative Mixtures*** *Saline Laxatives**-*Saline Laxatives*** *Stimulant Laxatives**-*Stimulant Laxatives*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 14 Drug Name Preference Details Coverage Details CARTERS LITTLE PILLS ORAL TABLET DELAYED RELEASE 5 MG P Notes (OTC-Covered w/Rx); OTC correct oral tablet delayed release 5 mg P Notes (OTC-Covered w/Rx); OTC CORRECTOL ORAL TABLET DELAYED RELEASE 5 MG P Notes (OTC-Covered w/Rx); OTC ducodyl oral tablet delayed release 5 mg P Notes (OTC-Covered w/Rx); OTC EX-LAX ORAL TABLET CHEWABLE 15 MG P Notes (OTC-Covered w/Rx); OTC EX-LAX ULTRA ORAL TABLET DELAYED RELEASE 5 MG P Notes (OTC-Covered w/Rx); OTC FEENAMINT ORAL TABLET DELAYED RELEASE 5 MG P Notes (OTC-Covered w/Rx); OTC FLEET LAXATIVE ORAL TABLET DELAYED RELEASE 5 MG P Notes (OTC-Covered w/Rx); OTC gentle laxative oral tablet delayed release 5 mg P Notes (OTC-Covered w/Rx); OTC laxative suppository 10 mg P Notes (OTC-Covered w/Rx); OTC magic bullets suppository 10 mg P Notes (OTC-Covered w/Rx); OTC natural senna laxative oral tablet 64.8-324 mg P Notes (OTC-Covered w/Rx); OTC senexon oral liquid† 8.8 mg/5ml P Notes (OTC-Covered w/Rx); OTC senexon oral tablet 8.6 mg P Notes (OTC-Covered w/Rx); OTC senna oral syrup 8.8 mg/5ml P Notes (OTC-Covered w/Rx); OTC senna oral tablet 15 mg, 8.6 mg P Notes (OTC-Covered w/Rx); OTC senna lax oral tablet 8.6 mg P Notes (OTC-Covered w/Rx); OTC senna laxative oral tablet 8.6 mg P Notes (OTC-Covered w/Rx); OTC senna maximum strength oral tablet 25 mg P Notes (OTC-Covered w/Rx); OTC SENNA SMOOTH ORAL TABLET 15 MG P Notes (OTC-Covered w/Rx); OTC senna-lax oral tablet 8.6 mg P Notes (OTC-Covered w/Rx); OTC senna-tabs oral tablet 8.6 mg P Notes (OTC-Covered w/Rx); OTC senna-time oral tablet 8.6 mg P Notes (OTC-Covered w/Rx); OTC SENNACON ORAL TABLET 8.6 MG P Notes (OTC-Covered w/Rx); OTC SENNO ORAL TABLET 8.6 MG P Notes (OTC-Covered w/Rx); OTC stimulant laxative oral tablet delayed release 5 mg P Notes (OTC-Covered w/Rx); OTC womens laxative oral tablet delayed release 5 mg P Notes (OTC-Covered w/Rx); OTC *Surfactant Laxatives**-*Surfactant Laxatives*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 15 Drug Name Preference Details Coverage Details CORRECTOL EXTRA GENTLE ORAL CAPSULE 100 MG P Notes (OTC-Covered w/Rx); OTC d.o.s. oral capsule 250 mg P Notes (OTC-Covered w/Rx); OTC diocto oral liquid† 50 mg/5ml P Notes (OTC-Covered w/Rx); OTC diocto oral syrup 60 mg/15ml P Notes (OTC-Covered w/Rx); OTC docqlace oral capsule 100 mg P Notes (OTC-Covered w/Rx); OTC docu soft oral capsule 100 mg P Notes (OTC-Covered w/Rx); OTC docusate sodium oral tablet 100 mg P Notes (OTC-Covered w/Rx); OTC DOCUSIL ORAL CAPSULE 100 MG P Notes (OTC-Covered w/Rx); OTC dok oral capsule 100 mg, 250 mg P Notes (OTC-Covered w/Rx); OTC dok oral tablet 100 mg P Notes (OTC-Covered w/Rx); OTC dss oral capsule 100 mg, 250 mg P Notes (OTC-Covered w/Rx); OTC DULCOLAX STOOL SOFTENER ORAL CAPSULE 100 MG P Notes (OTC-Covered w/Rx); OTC ENEMEEZ MINI ENEMA 283 MG P Notes (OTC-Covered w/Rx); OTC kao-tin oral capsule 240 mg P Notes (OTC-Covered w/Rx); OTC laxa basic oral capsule 100 mg, 250 mg P Notes (OTC-Covered w/Rx); OTC silace oral liquid† 150 mg/15ml P Notes (OTC-Covered w/Rx); OTC silace oral syrup 60 mg/15ml P Notes (OTC-Covered w/Rx); OTC SOF-LAX ORAL CAPSULE 100 MG P Notes (OTC-Covered w/Rx); OTC stool softener oral capsule 100 mg, 250 mg P Notes (OTC-Covered w/Rx); OTC stool softener laxative dc oral capsule 240 mg P Notes (OTC-Covered w/Rx); OTC sur-q-lax oral capsule 240 mg P Notes (OTC-Covered w/Rx); OTC SURFAK ORAL CAPSULE 240 MG P Notes (OTC-Covered w/Rx); OTC ACE AEROSOL CLOUD ENHANCER P QL (2 EA per 365 days) IN-CHECK DIAL FLOW TRAINER DEVICE P QL (2 EA per 365 days) inhaler companions P Notes (OTC-Covered w/Rx); OTC; QL (2 EA per 365 days) PFLEX P QL (2 EA per 365 days) THRESHOLD IMT P QL (2 EA per 365 days) THRESHOLD PEP DEVICE P QL (2 EA per 365 days) *Medical Devices* *Respiratory Therapy Supplies**-*Respiratory Therapy Supplies*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 16 Drug Name WINDMILL TRAINER Preference Details Coverage Details P QL (2 EA per 365 days) AEROCHAMBER MV P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU LARGE P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU SMALL P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU W/MASK P QL (2 EA per 365 days) AEROCHAMBER W/FLOWSIGNAL P QL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS P QL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS CHAMBR P QL (2 EA per 365 days) EASIVENT P QL (2 EA per 365 days) MICROCHAMBER P QL (2 EA per 365 days) MICROSPACER P QL (2 EA per 365 days) OPTICHAMBER ADVANTAGE P QL (2 EA per 365 days) OPTIHALER P QL (2 EA per 365 days) OPTIHALER DEVICE P QL (2 EA per 365 days) POCKET CHAMBER DEVICE P QL (2 EA per 365 days) POCKET SPACER DEVICE P QL (2 EA per 365 days) WATCHHALER DEVICE P QL (2 EA per 365 days) calcium oral tablet 500-125 mg-unit P Notes (OTC-Covered w/Rx); OTC calcium + d3 oral tablet 600-200 mg-unit P Notes (OTC-Covered w/Rx); OTC calcium 600-d oral tablet 600-400 mg-unit P Notes (OTC-Covered w/Rx); OTC calcium carbonate-vitamin d oral tablet 500-400 mg-unit, 600-400 mg-unit P Notes (OTC-Covered w/Rx); OTC calcium high potency/vitamin d oral tablet 600-200 mg-unit P Notes (OTC-Covered w/Rx); OTC calcium-carb 600 + d oral tablet 600-125 mg-unit P Notes (OTC-Covered w/Rx); OTC calcium-vitamin d oral tablet 500-125 mg-unit, 600-125 mg-unit, 600-200 mg-unit P Notes (OTC-Covered w/Rx); OTC *Respiratory Therapy Supplies**-*Spacer/Aerosol-Holding Chambers & Supplies*** *Minerals & Electrolytes* *Calcium**-*Calcium Combinations*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 17 Drug Name Preference Details Coverage Details CALTRATE 600+D ORAL TABLET 600-800 MG-UNIT P Notes (OTC-Covered w/Rx); OTC liquid calcium/vitamin d oral capsule 600-200 mg-unit P Notes (OTC-Covered w/Rx); OTC OYSCO 500+D ORAL TABLET 500-200 MG-UNIT P Notes (OTC-Covered w/Rx); OTC OYSCO D ORAL TABLET 250-125 MG-UNIT P Notes (OTC-Covered w/Rx); OTC oyst-cal d oral tablet 250-125 mg-unit P Notes (OTC-Covered w/Rx); OTC oyster calcium + d oral tablet 250-125 mg-unit P Notes (OTC-Covered w/Rx); OTC oyster shell calcium + d oral tablet 500-400 mg-unit P Notes (OTC-Covered w/Rx); OTC oyster shell calcium 500 + d oral tablet 500-125 mg-unit P Notes (OTC-Covered w/Rx); OTC oyster shell calcium/d oral tablet 250-125 mg-unit, 500-200 mg-unit P Notes (OTC-Covered w/Rx); OTC oyster shell calcium/vitamin d oral tablet 500-200 mg-unit P Notes (OTC-Covered w/Rx); OTC oyster shell/vitamin d oral tablet 600-125 mg-unit P Notes (OTC-Covered w/Rx); OTC CAL-CARB FORTE ORAL TABLET 1250 MG P Notes (OTC-Covered w/Rx); OTC calcarb 600 oral tablet 1500 mg P Notes (OTC-Covered w/Rx); OTC CALCI-CHEW ORAL TABLET CHEWABLE 1250 MG P Notes (OTC-Covered w/Rx); OTC calcium 600 oral tablet 600 mg P Notes (OTC-Covered w/Rx); OTC calcium carbonate oral suspension 1250 mg/5ml P Notes (OTC-Covered w/Rx); OTC calcium carbonate oral tablet 1250 mg, 1500 mg, 600 mg P Notes (OTC-Covered w/Rx); OTC calcium high potency oral tablet 600 mg P Notes (OTC-Covered w/Rx); OTC calcium oyster shell oral tablet 1250 mg P Notes (OTC-Covered w/Rx); OTC calcium-carb 600 oral tablet 600 mg P Notes (OTC-Covered w/Rx); OTC CALTRATE 600 ORAL TABLET 1500 MG P Notes (OTC-Covered w/Rx); OTC OYSCO 500 ORAL TABLET 500 MG P Notes (OTC-Covered w/Rx); OTC OYSTERCAL ORAL TABLET 500 MG P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC; QL (4000 ML per 31 days) *Calcium**-*Calcium*** *Electrolyte Mixtures**-*Electrolytes Oral*** ORALYTE FREEZER POPS ORAL SOLUTION P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 18 Drug Name Preference Details Coverage Details REHYDRALYTE ORAL SOLUTION P Notes (OTC-Covered w/Rx); OTC; QL (4000 ML per 31 days) revital freezer pops oral solution P Notes (OTC-Covered w/Rx); OTC; QL (4000 ML per 31 days) revital liquid squeezers oral solution P Notes (OTC-Covered w/Rx); OTC; QL (4000 ML per 31 days) mag-delay oral tablet extendedrelease* 535 (64 mg) mg P Notes (OTC-Covered w/Rx); OTC mag-sr oral tablet extendedrelease* 535 (64 mg) mg P Notes (OTC-Covered w/Rx); OTC MAG-TAB SR ORAL TABLET EXTENDEDRELEASE* 84 MG (7MEQ) P Notes (OTC-Covered w/Rx); OTC MAG64 ORAL TABLET EXTENDEDRELEASE* 535 (64 MG) MG P Notes (OTC-Covered w/Rx); OTC magnacaps oral capsule 100 mg P Notes (OTC-Covered w/Rx); OTC magnesium oral tablet 250 mg P Notes (OTC-Covered w/Rx); OTC magnesium oxide oral tablet 400 (240 mg) mg P Notes (OTC-Covered w/Rx); OTC MAGNESIUM-OXIDE ORAL TABLET 400 (241.3 MG) MG P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC ORAZINC ORAL CAPSULE 220 MG P Notes (OTC-Covered w/Rx); OTC zinc oral tablet 25 mg, 50 mg P Notes (OTC-Covered w/Rx); OTC zinc gluconate oral tablet 100 mg, 30 mg, 50 mg P Notes (OTC-Covered w/Rx); OTC zinc methionate oral capsule 50 mg P Notes (OTC-Covered w/Rx); OTC zinc picolinate oral tablet 25 mg P Notes (OTC-Covered w/Rx); OTC zinc sulfate oral capsule 220 mg P Notes (OTC-Covered w/Rx); OTC zinc sulfate oral tablet 220 (50 zn) mg P Notes (OTC-Covered w/Rx); OTC zinc-220 oral capsule 220 mg P Notes (OTC-Covered w/Rx); OTC *Magnesium**-*Magnesium*** *Sodium**-*Sodium*** sodium chloride oral tablet 1 gm *Zinc**-*Zinc*** *Multivitamins* *B-Complex W/ Folic Acid**-*B-Complex W/ C & Folic Acid*** NEPHRONEX ORAL TABLET P P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 19 Drug Name Preference Details Coverage Details 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 Notes (OTC-Covered w/Rx); OTC centavite oral liquid† P Notes (OTC-Covered w/Rx); OTC centavite a-z complete-mineral oral tablet P Notes (OTC-Covered w/Rx); OTC CEROVITE ADVANCED FORMULA ORAL TABLET P Notes (OTC-Covered w/Rx); OTC CERTAVITE/ANTIOXIDANTS ORAL LIQUID† P Notes (OTC-Covered w/Rx); OTC formula twenty-one oral tablet P Notes (OTC-Covered w/Rx); OTC gerivite complete oral tablet P Notes (OTC-Covered w/Rx); OTC golden age vitamin/minerals oral liquid† P Notes (OTC-Covered w/Rx); OTC multivitamin & mineral oral liquid† P Notes (OTC-Covered w/Rx); OTC SUPER NU-THERA ORAL TABLET P Notes (OTC-Covered w/Rx); OTC thera vital m oral tablet P Notes (OTC-Covered w/Rx); OTC therabasic-m oral tablet P Notes (OTC-Covered w/Rx); OTC therapeutic liquid oral solution P Notes (OTC-Covered w/Rx); OTC therapeutic-m oral tablet P Notes (OTC-Covered w/Rx); OTC TOTAL FORMULA 3 ORAL TABLET P Notes (OTC-Covered w/Rx); OTC daily multiple vitamins oral tablet P Notes (OTC-Covered w/Rx); OTC daily vite oral tablet P Notes (OTC-Covered w/Rx); OTC daily vites oral tablet P Notes (OTC-Covered w/Rx); OTC multi-day oral tablet P Notes (OTC-Covered w/Rx); OTC multi-vitamin oral tablet P Notes (OTC-Covered w/Rx); OTC multi-vitamins oral tablet P Notes (OTC-Covered w/Rx); OTC once daily oral tablet P Notes (OTC-Covered w/Rx); OTC one-daily multi vitamins oral tablet P Notes (OTC-Covered w/Rx); OTC THERA ORAL TABLET P Notes (OTC-Covered w/Rx); OTC thera-tabs oral tablet P Notes (OTC-Covered w/Rx); OTC THERA/BETA-CAROTENE ORAL TABLET P Notes (OTC-Covered w/Rx); OTC therapeutic oral tablet P Notes (OTC-Covered w/Rx); OTC *Multivitamins**-*Multivitamins*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 20 Drug Name Preference Details Coverage Details *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*** vitamins for hair oral tablet P Notes (OTC-Covered w/Rx); OTC altamist spray nasal solution 0.65 % P Notes (OTC-Covered w/Rx); OTC AYR NASAL SOLUTION 0.65 % P Notes (OTC-Covered w/Rx); OTC deep sea nasal spray nasal solution 0.65 % P Notes (OTC-Covered w/Rx); OTC HUMIST NASAL SOLUTION 0.65 % P Notes (OTC-Covered w/Rx); OTC LITTLE NOSES SALINE NASAL SOLUTION 0.65 % P Notes (OTC-Covered w/Rx); OTC na-zone nasal solution 0.65 % P Notes (OTC-Covered w/Rx); OTC NASAL MOIST NASAL SOLUTION 0.65 % P Notes (OTC-Covered w/Rx); OTC OCEAN FOR KIDS NASAL SOLUTION 0.65 % P Notes (OTC-Covered w/Rx); OTC saline mist spray nasal solution 0.65 % P Notes (OTC-Covered w/Rx); OTC saline nasal spray nasal solution 0.65 % P Notes (OTC-Covered w/Rx); OTC sea soft nasal mist nasal solution 0.65 % P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC nasal decongestant oral syrup 30 mg/5ml P Notes (OTC-Covered w/Rx); OTC pseudoephedrine hcl oral tablet 30 mg, 60 mg P Notes (OTC-Covered w/Rx); OTC *Nasal Agents - Systemic And Topical* *Nasal Agents - Misc.**-*Nasal Agents Misc.*** *Nasal Antiallergy**-*Nasal Mast Cell Stabilizers*** cromolyn sodium nasal aerosol, solution 5.2 mg/act *Sympathomimetic Decongestants**-*Systemic Decongestants*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 21 Drug Name SUDAFED 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HR* 120 MG Preference Details Coverage Details P Notes (OTC-Covered w/Rx); OTC artificial tears ophthalmic ointment 83-15 % P Notes (OTC-Covered w/Rx); OTC HYPOTEARS OPHTHALMIC SOLUTION 1-1 % P Notes (OTC-Covered w/Rx); OTC tears again ophthalmic ointment P Notes (OTC-Covered w/Rx); OTC ULTRA FRESH PM OPHTHALMIC OINTMENT P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC artificial tears ophthalmic solution 1.4 % P Notes (OTC-Covered w/Rx); OTC; QL (15 ML per 31 days) liquitears ophthalmic solution 1.4 % P Notes (OTC-Covered w/Rx); OTC; QL (15 ML per 31 Days) polyvinyl alcohol ophthalmic solution 1.4 % P Notes (OTC-Covered w/Rx); OTC; QL (15 ML per 31 Days) ALAWAY OPHTHALMIC SOLUTION 0.025 % P Notes (OTC-Covered w/Rx); OTC ketotifen fumarate ophthalmic solution 0.025 % P Notes (OTC-Covered w/Rx); OTC auraphene-b otic solution 6.5 % P Notes (OTC-Covered w/Rx); OTC AURO EARDROPS OTIC SOLUTION 6.5 % P Notes (OTC-Covered w/Rx); OTC E-R-O EAR DROPS OTIC SOLUTION 6.5 % P Notes (OTC-Covered w/Rx); OTC E-R-O EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % P Notes (OTC-Covered w/Rx); OTC ear drops earwax aid otic solution 6.5 % P Notes (OTC-Covered w/Rx); OTC earwax treatment drops otic solution 6.5 % P Notes (OTC-Covered w/Rx); OTC *Ophthalmic Agents* *Artificial Tears And Lubricants**-*Artificial Tear And Lubricant Combinations*** *Artificial Tears And Lubricants**-*Artificial Tear Ointments*** *Artificial Tears And Lubricants**-*Artificial Tear Solutions*** tears again ophthalmic solution *Artificial Tears And Lubricants**-*Artificial Tears And Lubricants*** *Ophthalmics - Misc.**-*Ophthalmic Antiallergic*** *Otic Agents* *Otic Agents - Miscellaneous**-*Otic Agents Miscellaneous*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 22 Drug Name Preference Details Coverage Details MURINE EAR OTIC SOLUTION 6.5 % P Notes (OTC-Covered w/Rx); OTC MURINE EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % P Notes (OTC-Covered w/Rx); OTC OTIX OTIC SOLUTION 6.5 % P Notes (OTC-Covered w/Rx); OTC thera-ear otic solution 6.5 % P Notes (OTC-Covered w/Rx); OTC nicotine transdermal patch 24 hr 14 mg/24hr, 21 mg/24hr, 7 mg/24hr P Notes (OTC-Covered w/Rx); OTC; QL (70 EA per 365 days) nicotine polacrilex mouth/throat gum 2 mg, 4 mg P Notes (OTC-Covered w/Rx); OTC; QL (2016 EA per 365 days) acid reducer oral tablet 75 mg P Notes (OTC-Covered w/Rx); OTC cimetidine oral tablet 200 mg P Notes (OTC-Covered w/Rx); OTC cimetidine acid reducer oral tablet 200 mg P Notes (OTC-Covered w/Rx); OTC famotidine oral tablet 10 mg P Notes (OTC-Covered w/Rx); OTC heartburn relief oral tablet 10 mg, 200 mg P Notes (OTC-Covered w/Rx); OTC heartburn relief max st oral tablet 20 mg P Notes (OTC-Covered w/Rx); OTC ranitidine acid reducer oral tablet 75 mg P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC ENCARE VAGINAL SUPPOSITORY 100 MG P Notes (OTC-Covered w/Rx); OTC OPTIONS CONCEPTROL VAGINAL 4 % P Notes (OTC-Covered w/Rx); OTC VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM 12.5 % P Notes (OTC-Covered w/Rx); OTC P Notes (OTC-Covered w/Rx); OTC *Psychotherapeutic And Neurological Agents - Misc.* *Smoking Deterrents**-*Smoking Deterrents*** *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*** miconazole 3 combo pack vaginal kit 200-2 mg-% (9gm) P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 23 Drug Name Preference Details Coverage Details miconazole 7 vaginal cream 2 % P Notes (OTC-Covered w/Rx); OTC miconazole 7 vaginal suppository 100 mg P Notes (OTC-Covered w/Rx); OTC miconazole nitrate vaginal cream 2 % P Notes (OTC-Covered w/Rx); OTC miconazole nitrate vaginal suppository 100 mg P Notes (OTC-Covered w/Rx); OTC CALCIFEROL ORAL SOLUTION 8000 UNIT/ML P Notes (OTC-Covered w/Rx); OTC vitamin d oral tablet 400 unit P Notes (OTC-Covered w/Rx); OTC vitamin d (ergocalciferol) oral capsule 50000 unit P QL (4 EA per 28 days) vitamin d-400 oral tablet 400 unit P Notes (OTC-Covered w/Rx); OTC vitamin d3 oral capsule 2000 unit P Notes (OTC-Covered w/Rx); OTC vitamin d3 oral tablet 1000 unit, 400 unit P Notes (OTC-Covered w/Rx); OTC *Vitamins* *Oil Soluble Vitamins**-*Vitamin D*** *Oil Soluble Vitamins**-*Vitamin K*** MEPHYTON ORAL TABLET 5 MG P *Water Soluble Vitamins**-*Vitamin B-3*** ENDUR-ACIN ORAL TABLET EXTENDEDRELEASE* 250 MG, 500 MG P Notes (OTC-Covered w/Rx); OTC niacin oral tablet 100 mg, 250 mg, 50 mg, 500 mg P Notes (OTC-Covered w/Rx); OTC niacin er oral capsule extended release* 250 mg, 500 mg P Notes (OTC-Covered w/Rx); OTC niacin er oral tablet extendedrelease* 250 mg, 500 mg, 750 mg P Notes (OTC-Covered w/Rx); OTC niacin-50 oral tablet 50 mg P Notes (OTC-Covered w/Rx); OTC SLO-NIACIN ORAL TABLET EXTENDEDRELEASE* 250 MG P Notes (OTC-Covered w/Rx); OTC ascorbic acid oral tablet 1000 mg, 250 mg, 500 mg P Notes (OTC-Covered w/Rx); OTC ascorbic acid oral tablet chewable 250 mg P Notes (OTC-Covered w/Rx); OTC c-500 oral tablet chewable 500 mg P Notes (OTC-Covered w/Rx); OTC vitamin c oral syrup 500 mg/5ml P Notes (OTC-Covered w/Rx); OTC vitamin c oral tablet 100 mg, 1000 mg, 250 mg, 500 mg P Notes (OTC-Covered w/Rx); OTC vitamin c oral tablet chewable 100 mg, 250 mg P Notes (OTC-Covered w/Rx); OTC *Water Soluble Vitamins**-*Vitamin C*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 24 Index 21 altaryl .............................................................................................. 7 aluminum hydroxide gel ....................................................................................................................... 5 antacid ................................................................................. 4, 5 antacid anti-gas ....................................................................................................................... 4 antacid anti-gas max strength ....................................................................................................................... 4 antacid extra strength ....................................................................................................................... 4 antacid i ...................................................................................... 4 antacid iii .................................................................................. 4 anti-diarrheal ....................................................................................................................... 6 anti-fungal ....................................................................... 10 anti-hist ...................................................................................... 7 anti-hist allergy ....................................................................................................................... 7 anti-itch maximum strength .................................................................................................................. 10 apap ................................................................................................... 2 apap extra strength ....................................................................................................................... 2 artificial tears .................................................................................................................. 22 ascorbic acid ................................................................. 24 aspirin ............................................................................................ 3 aspirin adult low strength ....................................................................................................................... 3 aspirin childrens ....................................................................................................................... 3 aspirin ec ................................................................................... 3 aspirin ec low dose ....................................................................................................................... 3 aspirin low dose ....................................................................................................................... 3 auraphene-b ................................................................. 22 AURO EARDROPS .................................................................................................................. 22 AVEENO ANTI-ITCH MAX ST .................................................................................................................. 10 AYR .................................................................................................. 21 bacitracin ............................................................................ 10 bacitracin zinc .................................................................................................................. 10 bacitracin-neomycin-polymyxin ....................................................................................................................... 9 BANOPHEN ........................................................................... 7 .................................................................................................................. BD GLUCOSE ...................................................................... 5 BENADRYL ALLERGY CHILDRENS ....................................................................................................................... 7 BENADRYL ITCH STOPPING .................................................................................................................. 10 benzoyl peroxide ....................................................................................................................... 9 BETA CARE BETATAR GEL .................................................................................................................. 11 BISAC-EVAC ................................................................... 14 biscolax ................................................................................... 14 bismatrol ................................................................................... 5 bismuth ........................................................................................ 5 BROTAPP .................................................................................. 9 c-500 .......................................................................................... 24 calcarb 600 ..................................................................... 18 CAL-CARB FORTE .................................................................................................................. 18 CALCI-CHEW ................................................................ 18 CALCIFEROL ................................................................... 24 calcium .................................................................................... 17 calcium + d3 ................................................................... 17 calcium 600 .................................................................... 18 calcium 600-d .................................................................................................................. 17 calcium antacid ....................................................................................................................... 5 calcium antacid extra strength ....................................................................................................................... 5 calcium carbonate .................................................................................................................. 18 calcium carbonate antacid ....................................................................................................................... 5 calcium carbonate-vitamin d .................................................................................................................. 17 calcium high potency .................................................................................................................. 18 calcium high potency/vitamin d .................................................................................................................. 17 calcium oyster shell .................................................................................................................. 18 calcium-carb 600 .................................................................................................................. 18 calcium-carb 600 + d .................................................................................................................. 17 calcium-vitamin d .................................................................................................................. 17 CAL-GEST ANTACID ....................................................................................................................... 5 Index altamist spray Index Index A-200 ......................................................................................... 11 ACE AEROSOL CLOUD ENHANCER .................................................................................................................. 16 ACEPHEN .................................................................................. 1 acetaminophen ....................................................................................................................... 1 acetaminophen pm .................................................................................................................. 12 ACID GONE ............................................................................ 4 acid reducer .................................................................... 23 acne medication ....................................................................................................................... 9 acne medication 10 ....................................................................................................................... 9 acne-clear .............................................................................. 9 actidose/sorbitol ....................................................................................................................... 6 actidose-aqua ....................................................................................................................... 6 AEROCHAMBER MV .................................................................................................................. 17 AEROCHAMBER PLUS FLO-VU .................................................................................................................. 17 AEROCHAMBER PLUS FLO-VU LARGE ........................................................................................ 17 AEROCHAMBER PLUS FLO-VU SMALL ........................................................................................ 17 AEROCHAMBER PLUS FLO-VU W/MASK ................................................................................ 17 AEROCHAMBER W/FLOWSIGNAL .................................................................................................................. 17 AEROCHAMBER Z-STAT PLUS .................................................................................................................. 17 AEROCHAMBER Z-STAT PLUS CHAMBR ................................................................................ 17 alamag plus .......................................................................... 4 ALAVERT ALLERGY/SINUS ....................................................................................................................... 9 ALAWAY ................................................................................ 22 alcalak ........................................................................................... 5 aler-cap ...................................................................................... 7 aler-dryl ..................................................................................... 7 alertab ........................................................................................... 7 aller-chlor ............................................................................... 7 allergy ............................................................................... 7, 10 allergy relief ........................................................................ 7 allergy relief childrens ....................................................................................................................... 7 ALMACONE .......................................................................... 4 P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 25 .................................................................................................................. CALTRATE 600+D .................................................................................................................. CARTERS LITTLE PILLS 18 18 15 centamin ............................................................................... 20 centavite ............................................................................... 20 centavite a-z complete-mineral .................................................................................................................. 20 CEROVITE ADVANCED FORMULA .................................................................................................................. 20 CERTAVITE/ANTIOXIDANTS .................................................................................................................. 20 cetirizine hcl ........................................................................ 8 cetirizine hcl childrens ....................................................................................................................... 8 cetirizine hcl childrens alrgy ....................................................................................................................... 8 charcoal ............................................................................. 1, 6 charcoal activated ....................................................................................................................... 6 CHARCOCAPS ....................................................................................................................... 6 childrens non-asa pain relief ....................................................................................................................... 2 childrens non-aspirin ....................................................................................................................... 2 childrens non-aspirin pain ....................................................................................................................... 2 childrens pain reliever ....................................................................................................................... 2 childrens silapap ....................................................................................................................... 2 childrens tactinal ....................................................................................................................... 2 chlorhist ..................................................................................... 7 chlorphen ................................................................................. 7 cimetidine ........................................................................... 23 cimetidine acid reducer .................................................................................................................. 23 citrate of magnesia .................................................................................................................. 14 CITROMA ............................................................................. 14 CLEAN & CLEAR PERSA-GEL EX ST ............................................................................................................. 9 CLEAN & CLEAR PERSA-GEL MAX ST ............................................................................................................. 9 CLEARPLEX V .................................................................... 9 CLEARSKIN ............................................................................ 9 clotrimazole .................................................................... 10 .................................................................................................................. .................................................................................................................. complete allergy medication ECPIRIN ......................................................................................... 3 ed-apap ....................................................................................... 2 ELTA TAR ............................................................................. 11 ENCARE ................................................................................... 23 ENDUR-ACIN ................................................................ 24 enema ........................................................................................ 14 ENEMEEZ MINI .................................................................................................................. 16 E-R-O EAR DROPS .................................................................................................................. 22 E-R-O EAR WAX REMOVAL SYSTEM .................................................................................... 22 EX-LAX ..................................................................................... 15 EX-LAX ULTRA .................................................................................................................. 15 famotidine ......................................................................... 23 FEENAMINT ..................................................................... 15 ferro-bob ............................................................................. 12 ferrous sulfate .................................................................................................................. 12 ferrousul ............................................................................... 12 fiber ............................................................................................... 13 fiber laxative .................................................................. 13 fiber therapy .................................................................. 13 FIBERGEN ............................................................................ 13 fiber-lax ................................................................................. 13 FLEET LAXATIVE .................................................................................................................. 15 folic acid ................................................................................ 12 formula twenty-one .................................................................................................................. 20 FORMULATION R ....................................................................................................................... 3 gelatin ............................................................................................ 8 genahist ...................................................................................... 8 gentle laxative .................................................................................................................. 15 geri-lanta ................................................................................. 4 gerivite complete .................................................................................................................. 20 glucose .......................................................................................... 5 glycerin (adult) .................................................................................................................. 14 glycerin (pediatric) .................................................................................................................. 14 golden age vitamin/minerals .................................................................................................................. 20 headache pm ................................................................ 12 heartburn relief .................................................................................................................. 23 heartburn relief max st .................................................................................................................. 23 Index clotrimazole anti-fungal Index Index CALTRATE 600 10 ....................................................................................................................... complete allergy relief 7 7 compoz .................................................................................... 13 COPPERTONE SUNBLOCK SPF15 .................................................................................................................. 11 correct ...................................................................................... 15 CORRECTOL ................................................................... 15 CORRECTOL EXTRA GENTLE .................................................................................................................. 16 cromolyn sodium .................................................................................................................. 21 cyanocobalamin .................................................................................................................. 12 d.o.s. ............................................................................................. 16 daily multiple vitamins .................................................................................................................. 20 daily vite ................................................................................ 20 daily vites ............................................................................. 20 deep sea nasal spray .................................................................................................................. 21 DIABETIC TUSSIN ALLERGY ....................................................................................................................... 7 diocto ......................................................................................... 16 diotame ....................................................................................... 5 diphenhist ............................................................................... 7 diphenhydramine hcl ....................................................................................................................... 7 docqlace ................................................................................ 16 DOC-Q-LAX ................................................................... 14 docu soft ............................................................................... 16 docusate sodium .................................................................................................................. 16 DOCUSIL ................................................................................ 16 dok ................................................................................................... 16 DORMIN ....................................................................................... 8 double antibiotic .................................................................................................................. 10 dss .................................................................................................... 16 ducodyl .................................................................................... 15 DULCOLAX MILK OF MAGNESIA .................................................................................................................. 14 DULCOLAX STOOL SOFTENER .................................................................................................................. 16 ear drops earwax aid .................................................................................................................. 22 earwax treatment drops .................................................................................................................. 22 EASIVENT ............................................................................ 17 ....................................................................................................................... P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 26 miconazole nitrate ....................................................................................................................... .................................................................................................................. 8 MAALOX ..................................................................................... 5 MAALOX ADVANCED ....................................................................................................................... 4 MAALOX ADVANCED MAX ST ....................................................................................................................... 4 MAALOX MAX ....................................................................................................................... 4 MAALOX MULTI SYMPTOM MAX ST ............................................................................................................. 4 MAALOX REGULAR STRENGTH ....................................................................................................................... 4 MAG64 ..................................................................................... 19 mag-delay ......................................................................... 19 magic bullets ................................................................. 15 magnacaps ....................................................................... 19 magnesium ....................................................................... 19 magnesium citrate .................................................................................................................. 14 magnesium oxide .......................................................................................................... 5, 19 MAGNESIUM-OXIDE .................................................................................................................. 19 mag-sr ...................................................................................... 19 MAG-TAB SR ................................................................. 19 mapap ............................................................................................ 2 mapap arthritis pain ....................................................................................................................... 2 mapap pm .......................................................................... 12 maxapap maximum strength ....................................................................................................................... 2 maxapap regular strength ....................................................................................................................... 2 meclizine hcl ....................................................................... 6 melatonin maximum strength ....................................................................................................................... 1 MEPHYTON ...................................................................... 24 METAMUCIL ................................................................... 13 METAMUCIL MULTIHEALTH FIBER .................................................................................................................. 13 METAMUCIL SMOOTH TEXTURE .................................................................................................................. 13 MG217 MEDICATED TAR .................................................................................................................. 11 MI-ACID ....................................................................................... 4 mi-acid gas relief .................................................................................................................. 11 miconazole 3 combo pack .................................................................................................................. 23 miconazole 7 ................................................................. 24 Index loratadine hives relief Index Index hem-prep ................................................................................. 3 HUMIST .................................................................................... 21 hydrocortisone .................................................................................................................. 10 hydrocortisone max st .................................................................................................................. 10 hydrocortisone max st/12 moist .................................................................................................................. 10 hydrocortisone-aloe .................................................................................................................. 11 HYDROSKIN ..................................................................... 11 HYPOTEARS .................................................................... 22 ibuprofen .................................................................................. 1 ibuprofen junior strength ....................................................................................................................... 1 IN-CHECK DIAL FLOW TRAINER .................................................................................................................. 16 inhaler companions .................................................................................................................. 16 IONIL-T .................................................................................... 11 ipecac .............................................................................................. 6 iron ................................................................................................. 12 itch relief .............................................................................. 10 KAOPECTATE ................................................................... 6 KAOPECTATE EXTRA STRENGTH ....................................................................................................................... 6 kao-tin ............................................................................. 5, 16 KERR INSTA-CHAR ....................................................................................................................... 6 KERR INSTA-CHAR IN SORBITOL ....................................................................................................................... 6 ketotifen fumarate .................................................................................................................. 22 KONSYL ................................................................................... 13 KONSYL FIBER .................................................................................................................. 13 kp hydrocortisone .................................................................................................................. 11 laxa basic ............................................................................. 16 laxative .................................................................................... 15 liquid calcium/vitamin d .................................................................................................................. 18 liquitears .............................................................................. 22 LITTLE NOSES SALINE .................................................................................................................. 21 LITTLE REMEDIES POISON TREAT ....................................................................................................................... 6 LOPERAMIDE A-D ....................................................................................................................... 6 loperamide hcl ....................................................................................................................... 6 loratadine ................................................................................ 8 MICROCHAMBER .................................................................................................................. MICROSPACER 24 17 17 milantex ...................................................................................... 4 milantex extra strength ....................................................................................................................... 4 milk of magnesia .................................................................................................................. 14 MINTOX PLUS ....................................................................................................................... 4 mucus relief ......................................................................... 9 multi-day ............................................................................. 20 multi-vit/fluoride .................................................................................................................. 21 multi-vitamin ............................................................... 20 multivitamin & mineral .................................................................................................................. 20 multivitamin/fluoride .................................................................................................................. 21 multi-vitamin/fluoride .................................................................................................................. 21 multi-vitamins .................................................................................................................. 20 multivitamins/fluoride .................................................................................................................. 21 MURINE EAR ................................................................... 23 MURINE EAR WAX REMOVAL SYSTEM .................................................................................... 23 mytab gas ........................................................................... 12 nasal decongestant .................................................................................................................. 21 NASAL MOIST .................................................................................................................. 21 natural fiber therapy .................................................................................................................. 13 natural senna laxative .................................................................................................................. 15 natural vegetable fiber .................................................................................................................. 13 na-zone .................................................................................. 21 NEPHRONEX .................................................................. 19 NEUTROGENA MOISTURE SPF15 .................................................................................................................. 11 NEUTROGENA ON-THE-SPOT ....................................................................................................................... 9 NEUTROGENA T/GEL EX ST .................................................................................................................. 11 niacin .......................................................................................... 24 niacin er ................................................................................. 24 .................................................................................................................. P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 27 .................................................................................................................. pain reliever pm .................................................................................................................. PANOXYL WASH robafen ........................................................................................ 9 saline mist spray .................................................................................................................. 21 saline nasal spray .................................................................................................................. 21 SCOT-TUSSIN ALLERGY RELIEF ....................................................................................................................... 8 sea soft nasal mist .................................................................................................................. 21 senexon ................................................................................... 15 senna ........................................................................................... 15 senna lax ............................................................................... 15 senna laxative .................................................................................................................. 15 senna maximum strength .................................................................................................................. 15 senna plus .......................................................................... 14 senna s ..................................................................................... 14 SENNA SMOOTH .................................................................................................................. 15 SENNACON ...................................................................... 15 senna-docusate sodium .................................................................................................................. 14 senna-lax ............................................................................. 15 SENNALAX-S ................................................................ 14 senna-s ................................................................................... 14 senna-tabs ........................................................................ 15 senna-time ....................................................................... 15 senna-time s .................................................................. 14 SENNO ....................................................................................... 15 sennosides-docusate sodium .................................................................................................................. 14 silace ............................................................................................ 16 siladryl allergy ....................................................................................................................... 8 silphen cough .................................................................... 8 simethicone ..................................................................... 12 SIMPLY ALLERGY ....................................................................................................................... 8 SIMPLY SLEEP .................................................................................................................. 13 sleep tabs ............................................................................ 13 sleep-tabs .......................................................................... 13 SLO-NIACIN .................................................................... 24 sm hydrocortisone plus .................................................................................................................. 11 sm oral saline laxative .................................................................................................................. 14 sodium bicarbonate ....................................................................................................................... 5 sodium chloride .......................................................................................................... 9, 19 Index pain relief pm extra strength Index Index niacin-50 ............................................................................. 24 nicotine ................................................................................... 23 nicotine polacrilex .................................................................................................................. 23 non-aspirin ........................................................................... 2 non-aspirin extra strength ....................................................................................................................... 2 non-aspirin pain relief ....................................................................................................................... 2 nortemp infants ....................................................................................................................... 2 NYTOL ........................................................................................ 13 OCEAN FOR KIDS .................................................................................................................. 21 omeprazole ...................................................................... 23 once daily ............................................................................ 20 one-daily multi vitamins .................................................................................................................. 20 OPERAND POVIDONE-IODINE ....................................................................................................................... 8 OPTICHAMBER ADVANTAGE .................................................................................................................. 17 OPTIHALER ....................................................................... 17 OPTIONS CONCEPTROL .................................................................................................................. 23 ORALYTE FREEZER POPS .................................................................................................................. 18 ORAZINC ............................................................................... 19 OTIX ............................................................................................... 23 OYSCO 500 ...................................................................... 18 OYSCO 500+D .................................................................................................................. 18 OYSCO D ............................................................................... 18 oyst-cal d ............................................................................. 18 oyster calcium + d .................................................................................................................. 18 oyster shell calcium + d .................................................................................................................. 18 oyster shell calcium 500 + d .................................................................................................................. 18 oyster shell calcium/d .................................................................................................................. 18 oyster shell calcium/vitamin d .................................................................................................................. 18 oyster shell/vitamin d .................................................................................................................. 18 OYSTERCAL ..................................................................... 18 pain & fever childrens ....................................................................................................................... 2 pain relief ................................................................................. 2 pain relief extra strength ....................................................................................................................... 3 13 13 9 pc-tar ......................................................................................... 11 PERI-COLACE .................................................................................................................. 14 permethrin ........................................................................ 11 PFLEX ........................................................................................... 16 pharbedryl .............................................................................. 8 PHARBETOL ........................................................................ 3 PHARBETOL EXTRA STRENGTH ....................................................................................................................... 3 phenazopyridine hcl .................................................................................................................. 12 pink bismuth ....................................................................... 6 POCKET CHAMBER .................................................................................................................. 17 POCKET SPACER .................................................................................................................. 17 polyvinyl alcohol .................................................................................................................. 22 povidone-iodine ....................................................................................................................... 8 PREPARATION H .................................................................................................................. 11 PREPARATION H HYDROCORTISONE .................................................................................................................. 11 pseudoephedrine hcl .................................................................................................................. 21 q-dryl ............................................................................................... 8 q-pap ............................................................................................... 3 Q-TAPP ........................................................................................ 9 quenalin ...................................................................................... 8 ranitidine acid reducer .................................................................................................................. 23 refenesen ................................................................................. 9 refenesen 400 ....................................................................................................................... 9 REGULOID .......................................................................... 13 REHYDRALYTE .................................................................................................................. 19 RENAL ........................................................................................ 20 rena-vite rx ...................................................................... 20 reno caps ............................................................................. 20 revital freezer pops .................................................................................................................. 19 revital liquid squeezers .................................................................................................................. 19 ....................................................................................................................... P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 28 total allergy .......................................................................... 8 TOTAL ALLERGY MEDICINE ....................................................................................................................... 8 TOTAL FORMULA 3 .................................................................................................................. 20 tri-buffered aspirin ....................................................................................................................... 3 triple antibiotic .................................................................................................................. 10 ultilet glucose ................................................................... 5 ULTRA FRESH PM .................................................................................................................. 22 VCF VAGINAL CONTRACEPTIVE .................................................................................................................. 23 vitamin b-12 ................................................................. 12 vitamin b-12 er .................................................................................................................. 12 vitamin c ................................................................................ 24 vitamin d ............................................................................... 24 vitamin d (ergocalciferol) .................................................................................................................. 24 vitamin d3 .......................................................................... 24 vitamin d-400 .................................................................................................................. 24 vitamins for hair .................................................................................................................. 21 WATCHHALER .................................................................................................................. 17 WINDMILL TRAINER .................................................................................................................. 17 womens laxative .................................................................................................................. 15 XENICAL ...................................................................................... 1 zinc .................................................................................................. 19 zinc gluconate .................................................................................................................. 19 zinc methionate .................................................................................................................. 19 zinc picolinate .................................................................................................................. 19 zinc sulfate ........................................................................ 19 zinc-220 ............................................................................... 19 Index Index SOF-LAX ................................................................................ 16 SOMINEX .............................................................................. 13 SOMINEX MAXIMUM STRENGTH .................................................................................................................. 13 sorbitol .................................................................................... 14 stimulant laxative .................................................................................................................. 15 stomach relief ....................................................................................................................... 6 stomach relief plus ....................................................................................................................... 6 stool softener ............................................................... 16 stool softener laxative dc .................................................................................................................. 16 SUDAFED 12 HOUR .................................................................................................................. 22 SUPER NU-THERA .................................................................................................................. 20 SURFAK .................................................................................... 16 sur-q-lax ............................................................................... 16 tactinal ......................................................................................... 3 tactinal extra strength ....................................................................................................................... 3 tears again ........................................................................ 22 TERA-GEL TAR .................................................................................................................. 11 terbinafine hcl .................................................................................................................. 10 tetra-formula nighttime sleep .................................................................................................................. 13 tgt anti-itch/aloe/vit e .................................................................................................................. 11 THERA ........................................................................................ 20 thera vital m ................................................................... 20 THERA/BETA-CAROTENE .................................................................................................................. 20 therabasic-m ................................................................ 20 thera-ear ............................................................................. 23 therapeutic ....................................................................... 20 therapeutic liquid .................................................................................................................. 20 therapeutic-m .................................................................................................................. 20 thera-tabs ......................................................................... 20 THRESHOLD IMT .................................................................................................................. 16 THRESHOLD PEP .................................................................................................................. 16 TITRALAC ................................................................................. 5 tolnaftate ............................................................................ 10 tolnaftate antifungal .................................................................................................................. 10 P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 29
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