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Download MCD-KY STAT 2 - WellCare of Kentucky
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2014 Comprehensive Dual Preferred Drug List (List of Covered Drugs) WellCare of Kentucky 00 9 Please read: This document contains information about the drugs we cover in this plan. Last updated (10/01/2014) Kentucky 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 Kentucky 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 This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name Preference Details Coverage Details *Alternative Medicines* *Alternative Medicine - M's**-*Alternative Medicine - Me's*** P OTC ibuprofen oral suspension 100 mg/5ml P OTC ibuprofen oral tablet 200 mg *Analgesics - Nonnarcotic* P OTC acetaminophen oral solution 160 mg/5ml P OTC acetaminophen oral tablet 325 mg P OTC; QL (279 EA per 31 days) acetaminophen oral tablet 500 mg P OTC; QL (186 EA per 31 days) apap oral tablet 325 mg P OTC; QL (279 EA per 31 days) apap extra strength oral tablet 500 mg P OTC; QL (186 EA per 31 days) childrens non-asa pain relief oral tablet chewable 80 mg P OTC childrens non-aspirin oral tablet chewable 80 mg P OTC childrens pain reliever oral tablet chewable 80 mg P OTC childrens silapap oral liquid† 160 mg/5ml P OTC childrens tactinal oral tablet chewable 80 mg P OTC ed-apap oral liquid† 160 mg/5ml P OTC mapap oral capsule 500 mg P OTC; QL (186 EA per 31 days) mapap oral tablet 325 mg P OTC; QL (279 EA per 31 days) mapap oral tablet 500 mg P OTC; QL (186 EA per 31 days) mapap oral tablet chewable 80 mg P OTC melatonin maximum strength oral tablet 5 mg *Analgesics - Anti-Inflammatory* *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** *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 mapap arthritis pain oral tablet extendedrelease* 650 mg P OTC; QL (93 EA per 31 days) maxapap maximum strength oral tablet 500 mg P OTC; QL (186 EA per 31 days) maxapap regular strength oral tablet 325 mg P OTC; QL (279 EA per 31 days) non-aspirin oral tablet 325 mg P OTC; QL (279 EA per 31 days) non-aspirin extra strength oral tablet 500 mg P OTC; QL (186 EA per 31 days) non-aspirin pain relief oral tablet 325 mg P OTC; QL (279 EA per 31 days) nortemp infants oral suspension 80 mg/0.8ml P OTC pain & fever childrens oral solution 160 mg/5ml P OTC pain relief oral tablet 500 mg P OTC; QL (186 EA per 31 days) pain relief extra strength oral tablet 500 mg P OTC; QL (186 EA per 31 days) PHARBETOL ORAL TABLET 325 MG P OTC; QL (279 EA per 31 days) PHARBETOL EXTRA STRENGTH ORAL TABLET 500 MG P OTC; QL (186 EA per 31 days) q-pap oral tablet 325 mg P OTC; QL (279 EA per 31 days) tactinal oral tablet 325 mg P OTC; QL (279 EA per 31 days) tactinal extra strength oral tablet 500 mg *Salicylates**-*Salicylate Combinations*** P OTC; QL (186 EA per 31 days) tri-buffered aspirin oral tablet 325 mg *Salicylates**-*Salicylates*** P OTC aspirin oral tablet 325 mg, 81 mg P OTC aspirin oral tablet chewable 81 mg P OTC aspirin oral tablet delayed release 81 mg P OTC aspirin adult low strength oral tablet delayed release 81 mg P OTC aspirin childrens oral tablet chewable 81 mg P OTC aspirin ec oral tablet delayed release 325 mg, 81 mg P OTC aspirin ec low dose oral tablet delayed release 81 mg P OTC aspirin low dose oral tablet 81 mg P OTC P OTC ECPIRIN ORAL TABLET DELAYED RELEASE 325 MG *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 2 Drug Name Preference Details Coverage Details alamag plus oral tablet chewable 200-200-25 mg P OTC ALMACONE ORAL SUSPENSION 200-200-20 MG/5ML P OTC antacid oral suspension 200-200-20 mg/5ml P OTC antacid anti-gas oral suspension 200-200-20 mg/5ml P OTC antacid anti-gas max strength oral suspension 400-400-40 mg/5ml P OTC antacid extra strength oral suspension 400-400-40 mg/5ml P OTC antacid i oral suspension 200-200-20 mg/5ml P OTC antacid iii oral suspension 400-400-40 mg/5ml P OTC geri-lanta oral suspension 200-200-20 mg/5ml P OTC MAALOX ADVANCED ORAL SUSPENSION 200-200-20 MG/5ML P OTC MAALOX ADVANCED MAX ST ORAL SUSPENSION 400-400-40 MG/5ML P OTC MAALOX MAX ORAL SUSPENSION 400-400-40 MG/5ML P OTC MAALOX MULTI SYMPTOM MAX ST ORAL SUSPENSION 400-400-40 MG/5ML P OTC MAALOX REGULAR STRENGTH ORAL SUSPENSION 200-200-20 MG/5ML P OTC milantex oral suspension 200-200-20 mg/5ml P OTC milantex extra strength oral suspension 400-400-40 mg/5ml P OTC P OTC P OTC P OTC P OTC MINTOX PLUS ORAL TABLET CHEWABLE 200-200-25 MG *Antacid Combinations**-*Antacid Combinations*** ACID GONE ORAL TABLET CHEWABLE 160-105 MG, 80-20 MG MI-ACID ORAL TABLET CHEWABLE 700-300 MG *Antacids - Aluminum Salts**-*Antacids Aluminum Salts*** aluminum hydroxide gel oral suspension 320 mg/5ml 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 *Antacids - Bicarbonate**-*Antacids Bicarbonate*** sodium bicarbonate oral tablet 325 mg, 650 mg *Antacids - Calcium Salts**-*Antacids Calcium Salts*** P OTC alcalak oral tablet chewable 420 mg P OTC antacid oral tablet chewable 420 mg, 500 mg P OTC CAL-GEST ANTACID ORAL TABLET CHEWABLE 500 MG P OTC calcium antacid oral tablet chewable 500 mg P OTC calcium antacid extra strength oral tablet chewable 750 mg P OTC calcium carbonate antacid oral tablet 648 mg P OTC calcium carbonate antacid oral tablet chewable 500 mg P OTC MAALOX ORAL TABLET CHEWABLE 600 MG P OTC P OTC P OTC P OTC bismatrol oral suspension 262 mg/15ml P OTC bismatrol oral tablet chewable 262 mg P OTC bismuth oral tablet chewable 262 mg P OTC diotame oral tablet chewable 262 mg P OTC kao-tin oral suspension 262 mg/15ml P OTC KAOPECTATE ORAL SUSPENSION 262 MG/15ML P OTC KAOPECTATE EXTRA STRENGTH ORAL SUSPENSION 525 MG/15ML P OTC pink bismuth oral suspension 262 mg/15ml P OTC TITRALAC ORAL TABLET CHEWABLE 420 MG *Antidiabetics* *Diabetic Other**-*Diabetic Other*** BD GLUCOSE ORAL TABLET CHEWABLE 5 GM glucose oral tablet chewable 4 gm *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 4 Drug Name Preference Details Coverage Details pink bismuth oral tablet chewable 262 mg P OTC stomach relief oral suspension 262 mg/15ml, 527 mg/30ml P OTC stomach relief oral tablet chewable 262 mg P OTC stomach relief plus oral suspension 525 mg/15ml *Antiperistaltic Agents**-*Antiperistaltic Agents*** P OTC anti-diarrheal oral liquid† 1 mg/5ml P OTC LOPERAMIDE A-D ORAL TABLET 2 MG P OTC loperamide hcl oral liquid† 1 mg/5ml *Antidotes* P OTC P OTC P OTC aller-chlor oral syrup 2 mg/5ml P OTC aller-chlor oral tablet 4 mg P OTC allergy oral tablet 4 mg P OTC allergy relief oral tablet 4 mg P OTC chlorhist oral tablet 4 mg P OTC chlorphen oral tablet 4 mg P OTC P OTC aler-cap oral capsule 25 mg P OTC aler-dryl oral tablet 50 mg P OTC alertab oral tablet 25 mg P OTC allergy relief childrens oral liquid† 12.5 mg/5ml P OTC *Antidotes**-*Antidotes*** ipecac oral syrup *Antiemetics* *Antiemetics - Anticholinergic**-*Antiemetics Anticholinergic*** meclizine hcl oral tablet 12.5 mg, 25 mg *Antihistamines* *Antihistamines Alkylamines**-*Antihistamines Alkylamines*** DIABETIC TUSSIN ALLERGY ORAL SYRUP 2 MG/5ML *Antihistamines Ethanolamines**-*Antihistamines Ethanolamines*** altaryl oral elixir 12.5 mg/5ml P OTC 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 altaryl oral syrup 12.5 mg/5ml P OTC anti-hist allergy oral tablet 25 mg P OTC BANOPHEN ORAL CAPSULE 25 MG P OTC BANOPHEN ORAL LIQUID† 12.5 MG/5ML P OTC BANOPHEN ORAL TABLET 25 MG P OTC BENADRYL ALLERGY CHILDRENS ORAL LIQUID† 12.5 MG/5ML P OTC complete allergy medication oral tablet 25 mg P OTC complete allergy relief oral tablet 25 mg P OTC diphenhist oral capsule 25 mg P OTC diphenhist oral liquid† 12.5 mg/5ml P OTC diphenhist oral tablet 25 mg P OTC diphenhydramine hcl oral capsule 25 mg, 50 mg P OTC diphenhydramine hcl oral tablet 25 mg P OTC DORMIN ORAL CAPSULE 25 MG P OTC genahist oral capsule 25 mg P OTC pharbedryl oral capsule 25 mg, 50 mg P OTC q-dryl oral capsule 25 mg P OTC q-dryl oral liquid† 12.5 mg/5ml P OTC quenalin oral syrup 12.5 mg/5ml P OTC SCOT-TUSSIN ALLERGY RELIEF ORAL LIQUID† 12.5 MG/5ML P OTC siladryl allergy oral liquid† 12.5 mg/5ml P OTC silphen cough oral syrup 12.5 mg/5ml P OTC SIMPLY ALLERGY ORAL TABLET 25 MG P OTC total allergy oral tablet 25 mg P OTC P OTC cetirizine hcl oral tablet 10 mg, 5 mg P OTC cetirizine hcl childrens oral solution 1 mg/ml P OTC cetirizine hcl childrens alrgy oral syrup 1 mg/ml P OTC TOTAL ALLERGY MEDICINE ORAL LIQUID† 12.5 MG/5ML *Antihistamines Non-Sedating**-*Antihistamines Non-Sedating*** 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 childrens loratadine oral syrup 5 mg/5ml P OTC; QL (310 ML per 31 days) loratadine oral tablet 10 mg P OTC loratadine hives relief oral solution 5 mg/5ml *Antiseptics & Disinfectants* P OTC; QL (300 ML per 31 days) P OTC P OTC ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG P OTC BROTAPP ORAL LIQUID† 1-15 MG/5ML P OTC Q-TAPP ORAL ELIXIR 1-15 MG/5ML *Expectorants**-*Expectorants*** P OTC mucus relief oral tablet 400 mg P OTC refenesen oral tablet 200 mg P OTC refenesen 400 oral tablet 400 mg P OTC robafen oral syrup 100 mg/5ml *Misc. Respiratory Inhalants**-*Misc. Respiratory Inhalants*** P OTC P OTC bacitracin-neomycin-polymyxin external ointment 400-5-5000 P OTC double antibiotic external ointment 500-10000 unit/gm P OTC P OTC *Iodine Antiseptics**-*Iodine Antiseptics*** OPERAND POVIDONE-IODINE EXTERNAL SOLUTION 10 % povidone-iodine external solution 10 % *Cough/Cold/Allergy* *Cough/Cold/Allergy Combinations**-*Decongestant & Antihistamine*** sodium chloride inhalation nebulization solution 0.9 % *Dermatologicals* *Antibiotics - Topical**-*Antibiotic Mixtures Topical*** triple antibiotic external ointment 3.5-400-5000 , 5-400-5000 *Antibiotics - Topical**-*Antibiotics 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 7 Drug Name Preference Details Coverage Details bacitracin external ointment 500 unit/gm P OTC bacitracin zinc external ointment 500 unit/gm *Antifungals - Topical**-*Antifungals Topical*** P OTC terbinafine hcl external cream 1 % *Antifungals - Topical**-*Imidazole-Related Antifungals - Topical*** P OTC clotrimazole external solution 1 % *Antihistamines-Topical**-*Antihistamines Topical*** P OTC anti-itch maximum strength external cream 2 % P OTC BENADRYL ITCH STOPPING EXTERNAL 2 % P OTC P OTC AVEENO ANTI-ITCH MAX ST EXTERNAL CREAM 1 % P OTC hydrocortisone external cream 0.5 %, 1 % P OTC hydrocortisone external ointment 0.5 %, 1 % P OTC hydrocortisone max st external cream 1 % P OTC hydrocortisone max st/12 moist external cream 1 % P OTC HYDROSKIN EXTERNAL CREAM 1 % P OTC kp hydrocortisone external cream 1 % P OTC PREPARATION H HYDROCORTISONE EXTERNAL CREAM 1 % P OTC tgt anti-itch/aloe/vit e external cream 1 % *Corticosteroids - Topical**-*Topical Steroid Combinations*** P OTC hydrocortisone-aloe external cream 1 % P OTC sm hydrocortisone plus external cream 1 % *Scabicides & Pediculicides**-*Scabicides & Pediculicides*** P OTC permethrin external lotion 1 % *Gastrointestinal Agents - Misc.* P OTC; QL (60 ML per 31 days) itch relief external cream 2 % *Corticosteroids - Topical**-*Corticosteroids Topical*** *Antiflatulents**-*Antiflatulents*** 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 mi-acid gas relief oral tablet chewable 80 mg P OTC mytab gas oral tablet chewable 80 mg P OTC simethicone oral suspension 40 mg/0.6ml P OTC simethicone oral tablet chewable 80 mg *Hematopoietic Agents* P OTC *Cobalamins**-*Cobalamins*** cyanocobalamin injection solution 1000 mcg/ml P vitamin b-12 oral tablet 1000 mcg, 500 mcg P OTC vitamin b-12 sublingual tablet sublingual 1000 mcg P OTC P OTC folic acid oral tablet 1 mg *Iron**-*Iron*** P OTC ferro-bob oral tablet 325 (65 fe) mg P OTC ferrous sulfate oral elixir 220 (44 fe) mg/5ml P OTC ferrous sulfate oral tablet 325 (65 fe) mg P OTC ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg P OTC ferrousul oral tablet 325 (65 fe) mg P OTC iron oral tablet 325 (65 fe) mg, 90 (18 fe) mg *Hypnotics* P OTC acetaminophen pm oral tablet 500-25 mg P OTC; QL (62 EA per 31 Days) headache pm oral tablet 25-500 mg P OTC; QL (62 EA per 31 days) mapap pm oral tablet 500-25 mg P OTC; QL (62 EA per 31 days) pain relief pm extra strength oral tablet 500-25 mg P OTC; QL (62 EA per 31 days) pain reliever pm oral tablet 500-25 mg *Antihistamine Hypnotics**-*Antihistamine Hypnotics*** P OTC; QL (62 EA per 31 days) compoz oral capsule 50 mg P OTC compoz oral tablet 50 mg P OTC NYTOL ORAL TABLET 25 MG P OTC vitamin b-12 er oral tablet extendedrelease* 1000 mcg *Folic Acid/Folates**-*Folic Acid/Folates*** *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 9 Drug Name Preference Details Coverage Details SIMPLY SLEEP ORAL TABLET 25 MG P OTC sleep tabs oral tablet 25 mg P OTC sleep-tabs oral tablet 25 mg P OTC SOMINEX ORAL TABLET 25 MG P OTC SOMINEX MAXIMUM STRENGTH ORAL TABLET 50 MG P OTC P OTC fiber oral tablet 625 mg P OTC fiber laxative oral tablet 625 mg P OTC fiber therapy oral powder 58.6 % P OTC fiber-lax oral tablet 625 mg P OTC FIBERGEN ORAL TABLET 625 MG P OTC KONSYL ORAL PACKET 100 % P OTC KONSYL FIBER ORAL TABLET 625 MG P OTC METAMUCIL ORAL POWDER 30.9 % P OTC METAMUCIL MULTIHEALTH FIBER ORAL POWDER 58.6 % P OTC METAMUCIL SMOOTH TEXTURE ORAL PACKET 28 % P OTC METAMUCIL SMOOTH TEXTURE ORAL POWDER 28.3 %, 58.6 % P OTC natural fiber therapy oral powder 30.9 %, 48.57 % P OTC natural vegetable fiber oral powder 48.57 % P OTC REGULOID ORAL CAPSULE 0.52 GM *Laxative Combinations**-*Laxatives & Dss*** P OTC DOC-Q-LAX ORAL TABLET 8.6-50 MG P OTC PERI-COLACE ORAL TABLET 8.6-50 MG P OTC senna plus oral tablet 8.6-50 mg P OTC senna s oral tablet 8.6-50 mg P OTC senna-docusate sodium oral tablet 8.6-50 mg P OTC senna-s oral tablet 8.6-50 mg P OTC senna-time s oral tablet 8.6-50 mg P OTC tetra-formula nighttime sleep oral tablet 50 mg *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 10 Drug Name SENNALAX-S ORAL TABLET 8.6-50 MG Preference Details Coverage Details P OTC P OTC sorbitol oral solution 70 % *Saline Laxatives**-*Saline Laxative Mixtures*** P OTC enema enema 7-19 gm/118ml P OTC P OTC citrate of magnesia oral solution 1.745 gm/30ml P OTC CITROMA ORAL SOLUTION 1.745 GM/30ML P OTC DULCOLAX MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML P OTC magnesium citrate oral solution 1.745 gm/30ml P OTC P OTC BISAC-EVAC SUPPOSITORY 10 MG P OTC biscolax suppository 10 mg P OTC CARTERS LITTLE PILLS ORAL TABLET DELAYED RELEASE 5 MG P OTC correct oral tablet delayed release 5 mg P OTC CORRECTOL ORAL TABLET DELAYED RELEASE 5 MG P OTC ducodyl oral tablet delayed release 5 mg P OTC EX-LAX ORAL TABLET CHEWABLE 15 MG P OTC EX-LAX ULTRA ORAL TABLET DELAYED RELEASE 5 MG P OTC FEENAMINT ORAL TABLET DELAYED RELEASE 5 MG P OTC FLEET LAXATIVE ORAL TABLET DELAYED RELEASE 5 MG P OTC sennosides-docusate sodium oral tablet 8.6-50 mg *Laxatives - Miscellaneous**-*Laxatives Miscellaneous*** sm oral saline laxative oral solution 2.7-7.2 gm/5ml *Saline Laxatives**-*Saline Laxatives*** milk of magnesia oral suspension 400 mg/5ml, 7.75 % *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 11 Drug Name Preference Details Coverage Details gentle laxative oral tablet delayed release 5 mg P OTC laxative suppository 10 mg P OTC natural senna laxative oral tablet 64.8-324 mg P OTC senexon oral liquid† 8.8 mg/5ml P OTC senexon oral tablet 8.6 mg P OTC senna oral syrup 8.8 mg/5ml P OTC senna oral tablet 15 mg, 8.6 mg P OTC senna lax oral tablet 8.6 mg P OTC senna laxative oral tablet 8.6 mg P OTC senna maximum strength oral tablet 25 mg P OTC SENNA SMOOTH ORAL TABLET 15 MG P OTC senna-lax oral tablet 8.6 mg P OTC senna-tabs oral tablet 8.6 mg P OTC senna-time oral tablet 8.6 mg P OTC SENNACON ORAL TABLET 8.6 MG P OTC SENNO ORAL TABLET 8.6 MG P OTC stimulant laxative oral tablet delayed release 5 mg P OTC P OTC CORRECTOL EXTRA GENTLE ORAL CAPSULE 100 MG P OTC d.o.s. oral capsule 250 mg P OTC diocto oral liquid† 50 mg/5ml P OTC diocto oral syrup 60 mg/15ml P OTC docqlace oral capsule 100 mg P OTC docu soft oral capsule 100 mg P OTC docusate sodium oral tablet 100 mg P OTC DOCUSIL ORAL CAPSULE 100 MG P OTC dok oral capsule 100 mg, 250 mg P OTC dok oral tablet 100 mg P OTC dss oral capsule 100 mg, 250 mg P OTC DULCOLAX STOOL SOFTENER ORAL CAPSULE 100 MG P OTC womens laxative oral tablet delayed release 5 mg *Surfactant Laxatives**-*Surfactant Laxatives*** kao-tin oral capsule 240 mg P OTC 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 laxa basic oral capsule 100 mg P OTC silace oral liquid† 150 mg/15ml P OTC silace oral syrup 60 mg/15ml P OTC SOF-LAX ORAL CAPSULE 100 MG P OTC stool softener oral capsule 100 mg, 250 mg P OTC stool softener laxative dc oral capsule 240 mg P OTC sur-q-lax oral capsule 240 mg P OTC SURFAK ORAL CAPSULE 240 MG *Medical Devices* P 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) 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) WINDMILL TRAINER *Respiratory Therapy Supplies**-*Spacer/Aerosol-Holding Chambers & Supplies*** 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) *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 13 Drug Name Preference Details Coverage Details 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 *Minerals & Electrolytes* P QL (2 EA per 365 days) calcium oral tablet 500-125 mg-unit P OTC calcium + d3 oral tablet 600-200 mg-unit P OTC calcium 600-d oral tablet 600-400 mg-unit P OTC calcium carbonate-vitamin d oral tablet 500-400 mg-unit, 600-400 mg-unit P OTC calcium high potency/vitamin d oral tablet 600-200 mg-unit P OTC calcium-carb 600 + d oral tablet 600-125 mg-unit P OTC calcium-vitamin d oral tablet 500-125 mg-unit, 600-125 mg-unit, 600-200 mg-unit P OTC CALTRATE 600+D ORAL TABLET 600-800 MG-UNIT P OTC liquid calcium/vitamin d oral capsule 600-200 mg-unit P OTC OYSCO 500+D ORAL TABLET 500-200 MG-UNIT P OTC OYSCO D ORAL TABLET 250-125 MG-UNIT P OTC oyst-cal d oral tablet 250-125 mg-unit P OTC oyster calcium + d oral tablet 250-125 mg-unit P OTC oyster shell calcium + d oral tablet 500-400 mg-unit P OTC oyster shell calcium 500 + d oral tablet 500-125 mg-unit P OTC oyster shell calcium/d oral tablet 250-125 mg-unit, 500-200 mg-unit P OTC oyster shell calcium/vitamin d oral tablet 500-200 mg-unit P OTC P OTC *Calcium**-*Calcium Combinations*** oyster shell/vitamin d oral tablet 600-125 mg-unit *Calcium**-*Calcium*** 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 CAL-CARB FORTE ORAL TABLET 1250 MG P OTC calcarb 600 oral tablet 1500 mg P OTC CALCI-CHEW ORAL TABLET CHEWABLE 1250 MG P OTC calcium 600 oral tablet 600 mg P OTC calcium carbonate oral suspension 1250 mg/5ml P OTC calcium carbonate oral tablet 1250 mg, 600 mg P OTC calcium high potency oral tablet 600 mg P OTC calcium oyster shell oral tablet 1250 mg P OTC calcium-carb 600 oral tablet 600 mg P OTC CALTRATE 600 ORAL TABLET 1500 MG P OTC OYSCO 500 ORAL TABLET 500 MG P OTC OYSTERCAL ORAL TABLET 500 MG *Magnesium**-*Magnesium*** P OTC mag-delay oral tablet extendedrelease* 535 (64 mg) mg P OTC mag-sr oral tablet extendedrelease* 535 (64 mg) mg P OTC MAG-TAB SR ORAL TABLET EXTENDEDRELEASE* 84 MG (7MEQ) P OTC MAG64 ORAL TABLET EXTENDEDRELEASE* 535 (64 MG) MG P OTC magnacaps oral capsule 100 mg P OTC magnesium oral tablet 250 mg P OTC magnesium oxide oral tablet 400 (240 mg) mg P OTC P OTC ORAZINC ORAL CAPSULE 220 MG P OTC zinc sulfate oral capsule 220 mg P OTC zinc sulfate oral tablet 220 (50 zn) mg P OTC zinc-220 oral capsule 220 mg *Multivitamins* P OTC MAGNESIUM-OXIDE ORAL TABLET 400 (241.3 MG) MG *Zinc**-*Zinc*** *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 15 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 *Multiple Vitamins W/ Minerals**-*Multiple Vitamins W/ Minerals*** P centamin oral liquid† P OTC centavite oral liquid† P OTC centavite a-z complete-mineral oral tablet P OTC CEROVITE ADVANCED FORMULA ORAL TABLET P OTC CERTAVITE/ANTIOXIDANTS ORAL LIQUID† P OTC formula twenty-one oral tablet P OTC gerivite complete oral tablet P OTC golden age vitamin/minerals oral liquid† P OTC multivitamin & mineral oral liquid† P OTC SUPER NU-THERA ORAL TABLET P OTC thera vital m oral tablet P OTC therabasic-m oral tablet P OTC therapeutic liquid oral solution P OTC therapeutic-m oral tablet P OTC TOTAL FORMULA 3 ORAL TABLET *Multivitamins**-*Multivitamins*** P OTC daily multiple vitamins oral tablet P OTC daily vite oral tablet P OTC daily vites oral tablet P OTC multi-day oral tablet P OTC multi-vitamin oral tablet P OTC multi-vitamins oral tablet P OTC once daily oral tablet P OTC one-daily multi vitamins oral tablet P OTC THERA ORAL TABLET P OTC thera-tabs oral tablet P OTC THERA/BETA-CAROTENE ORAL TABLET P OTC therapeutic oral tablet P OTC 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 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 0.5 mg P multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg P multivitamins/fluoride oral tablet chewable 0.25 mg *Specialty Vitamins Products**-*Specialty Vitamins Products*** P P OTC altamist spray nasal solution 0.65 % P OTC AYR NASAL SOLUTION 0.65 % P OTC deep sea nasal spray nasal solution 0.65 % P OTC HUMIST NASAL SOLUTION 0.65 % P OTC LITTLE NOSES SALINE NASAL SOLUTION 0.65 % P OTC na-zone nasal solution 0.65 % P OTC NASAL MOIST NASAL SOLUTION 0.65 % P OTC OCEAN FOR KIDS NASAL SOLUTION 0.65 % P OTC saline mist spray nasal solution 0.65 % P OTC saline nasal spray nasal solution 0.65 % P OTC sea soft nasal mist nasal solution 0.65 % *Nasal Antiallergy**-*Nasal Mast Cell Stabilizers*** P OTC P OTC P OTC vitamins for hair oral tablet *Nasal Agents - Systemic And Topical* *Nasal Agents - Misc.**-*Nasal Agents Misc.*** cromolyn sodium nasal aerosol, solution 5.2 mg/act *Sympathomimetic Decongestants**-*Systemic Decongestants*** pseudoephedrine hcl oral tablet 30 mg, 60 mg *Ophthalmic Agents* 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 *Artificial Tears And Lubricants**-*Artificial Tear And Lubricant Combinations*** P OTC P OTC P OTC P OTC tears again ophthalmic solution *Artificial Tears And Lubricants**-*Artificial Tears And Lubricants*** P OTC artificial tears ophthalmic solution 1.4 % P OTC; QL (15 ML per 31 days) liquitears ophthalmic solution 1.4 % P OTC; QL (15 ML per 31 Days) polyvinyl alcohol ophthalmic solution 1.4 % *Ophthalmics - Misc.**-*Ophthalmic Antiallergic*** P OTC; QL (15 ML per 31 Days) P OTC P OTC auraphene-b otic solution 6.5 % P OTC AURO EARDROPS OTIC SOLUTION 6.5 % P OTC E-R-O EAR DROPS OTIC SOLUTION 6.5 % P OTC E-R-O EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % P OTC ear drops earwax aid otic solution 6.5 % P OTC earwax treatment drops otic solution 6.5 % P OTC MURINE EAR OTIC SOLUTION 6.5 % P OTC MURINE EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % P OTC artificial tears ophthalmic ointment 83-15 % HYPOTEARS OPHTHALMIC SOLUTION 1-1 % *Artificial Tears And Lubricants**-*Artificial Tear Ointments*** tears again ophthalmic ointment ULTRA FRESH PM OPHTHALMIC OINTMENT *Artificial Tears And Lubricants**-*Artificial Tear Solutions*** ALAWAY OPHTHALMIC SOLUTION 0.025 % ketotifen fumarate ophthalmic solution 0.025 % *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 18 Drug Name Preference Details Coverage Details OTIX OTIC SOLUTION 6.5 % P OTC thera-ear otic solution 6.5 % *Psychotherapeutic And Neurological Agents Misc.* P OTC P OTC; QL (70 EA per 365 days) P OTC P OTC CALCIFEROL ORAL SOLUTION 8000 UNIT/ML P OTC vitamin d oral tablet 400 unit P OTC vitamin d (ergocalciferol) oral capsule 50000 unit P QL (4 EA per 28 days) vitamin d-400 oral tablet 400 unit P OTC vitamin d3 oral capsule 2000 unit P OTC vitamin d3 oral tablet 1000 unit, 400 unit *Oil Soluble Vitamins**-*Vitamin K*** P OTC vitamin k (phytonadione) oral tablet 100 mcg *Water Soluble Vitamins**-*Vitamin C*** P OTC ascorbic acid oral tablet 1000 mg, 250 mg, 500 mg P OTC ascorbic acid oral tablet chewable 250 mg P OTC c-500 oral tablet chewable 500 mg P OTC vitamin c oral syrup 500 mg/5ml P OTC vitamin c oral tablet 100 mg, 1000 mg, 250 mg, 500 mg P OTC vitamin c oral tablet chewable 100 mg, 250 mg P OTC *Smoking Deterrents**-*Smoking Deterrents*** nicotine transdermal patch 24 hr 14 mg/24hr, 21 mg/24hr, 7 mg/24hr *Ulcer Drugs* *Proton Pump Inhibitors**-*Proton Pump Inhibitors*** omeprazole oral tablet delayed release 20 mg *Vaginal Products* *Vaginal Anti-Infectives**-*Imidazole-Related Antifungals*** miconazole nitrate vaginal cream 2 % *Vitamins* *Oil Soluble Vitamins**-*Vitamin D*** 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 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 Index ACE AEROSOL CLOUD ENHANCER ............................................................................................... acetaminophen aluminum hydroxide gel 13 ................................................................................................... acetaminophen pm ................................................................................................... ACID GONE ................................................................................................... AEROCHAMBER MV 3 antacid .................................................................. 3, 4 antacid anti-gas ................................................................................................... 3 antacid anti-gas max strength ................................................................................................... 3 antacid extra strength ................................................................................................... 3 antacid i ...................................................................... 3 antacid iii .................................................................. 3 anti-diarrheal ................................................................................................... 5 anti-hist allergy ................................................................................................... 6 anti-itch maximum strength ................................................................................................... 8 apap ................................................................................. 1 apap extra strength ................................................................................................... 1 artificial tears ............................................................................................... 18 ascorbic acid ............................................................................................... 19 aspirin ........................................................................... 2 aspirin adult low strength ................................................................................................... 2 aspirin childrens ................................................................................................... 2 aspirin ec ................................................................... 2 aspirin ec low dose ................................................................................................... 2 aspirin low dose ................................................................................................... 2 auraphene-b ............................................................................................... 18 AURO EARDROPS ............................................................................................... 18 AVEENO ANTI-ITCH MAX ST ......................................................................................... 8 AYR ............................................................................. 17 bacitracin .................................................................. 8 bacitracin zinc ................................................................................................... 8 bacitracin-neomycin-polymyxin ................................................................................................... 7 BANOPHEN ................................................................................................... 6 BD GLUCOSE ................................................................................................... 4 ................................................................................................... 1 9 3 ............................................................................................... 13 AEROCHAMBER PLUS FLO-VU ................................................................. 13 AEROCHAMBER PLUS FLO-VU LARGE ............................................................................................... 13 AEROCHAMBER PLUS FLO-VU SMALL ............................................................................................... 13 AEROCHAMBER PLUS FLO-VU W/MASK ............................................................................................... 13 AEROCHAMBER W/FLOWSIGNAL ............................................................................................... 13 AEROCHAMBER Z-STAT PLUS ........................................................................... 13 AEROCHAMBER Z-STAT PLUS CHAMBR ............................................................................................... 13 alamag plus ............................................................ 3 ALAVERT ALLERGY/SINUS ................................................................................................... 7 ALAWAY ........................................................... 18 alcalak .......................................................................... 4 aler-cap ....................................................................... 5 aler-dryl ...................................................................... 5 alertab ........................................................................... 5 aller-chlor ................................................................ 5 allergy ........................................................................... 5 allergy relief ................................................................................................... 5 allergy relief childrens ................................................................................................... 5 ALMACONE ................................................................................................... 3 altamist spray ............................................................................................... 17 altaryl .................................................................... 5, 6 BENADRYL ALLERGY CHILDRENS 6 BENADRYL ITCH STOPPING ........................................................... 8 BISAC-EVAC ............................................................................................... 11 biscolax ................................................................... 11 bismatrol ................................................................... 4 bismuth ........................................................................ 4 BROTAPP .............................................................. 7 c-500 ............................................................................ 19 calcarb 600 ......................................................... 15 CAL-CARB FORTE ............................................................................................... 15 CALCI-CHEW ............................................................................................... 15 CALCIFEROL ............................................................................................... 19 calcium ..................................................................... 14 calcium + d3 ............................................................................................... 14 calcium 600 ........................................................ 15 calcium 600-d ............................................................................................... 14 calcium antacid ................................................................................................... 4 calcium antacid extra strength ................................................................................................... 4 calcium carbonate ............................................................................................... 15 calcium carbonate antacid ................................................................................................... 4 calcium carbonate-vitamin d ............................................................................................... 14 calcium high potency ............................................................................................... 15 calcium high potency/vitamin d ............................................................................................... 14 calcium oyster shell ............................................................................................... 15 calcium-carb 600 ............................................................................................... 15 calcium-carb 600 + d ............................................................................................... 14 calcium-vitamin d ............................................................................................... 14 CAL-GEST ANTACID ................................................................................................... 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 21 CALTRATE 600 ............................................................................................... CALTRATE 600+D ............................................................................................... CARTERS LITTLE PILLS 15 14 ............................................................................................... 11 centamin ................................................................. 16 centavite ................................................................. 16 centavite a-z complete-mineral ............................................................................................... 16 CEROVITE ADVANCED FORMULA ............................................................................................... 16 CERTAVITE/ANTIOXIDANT S .......................................................................................... 16 cetirizine hcl ................................................................................................... 6 cetirizine hcl childrens ................................................................................................... 6 cetirizine hcl childrens alrgy ................................................................................................... 6 childrens loratadine ................................................................................................... 7 childrens non-asa pain relief ................................................................................................... 1 childrens non-aspirin ................................................................................................... 1 childrens pain reliever ................................................................................................... 1 childrens silapap ................................................................................................... 1 childrens tactinal ................................................................................................... 1 chlorhist ...................................................................... 5 chlorphen .................................................................. 5 citrate of magnesia ............................................................................................... 11 CITROMA ......................................................... 11 clotrimazole ................................................................................................... 8 complete allergy medication ................................................................................................... 6 complete allergy relief ................................................................................................... 6 compoz ......................................................................... 9 correct ....................................................................... 11 CORRECTOL ............................................................................................... 11 CORRECTOL EXTRA GENTLE .............................................................. 12 cromolyn sodium ............................................................................................... 17 cyanocobalamin ................................................................................................... 9 d.o.s. ............................................................................ 12 daily multiple vitamins ............................................................................................... 16 daily vite ................................................................. 16 daily vites .............................................................. 16 deep sea nasal spray ............................................................................................... 17 DIABETIC TUSSIN ALLERGY ............................................................ 5 diocto .......................................................................... 12 diotame ........................................................................ 4 diphenhist ................................................................. 6 diphenhydramine hcl ................................................................................................... 6 docqlace .................................................................. 12 DOC-Q-LAX ............................................................................................... 10 docu soft ................................................................. 12 docusate sodium ............................................................................................... 12 DOCUSIL ........................................................... 12 dok ................................................................................. 12 DORMIN ................................................................ 6 double antibiotic ................................................................................................... 7 dss ................................................................................... 12 ducodyl ..................................................................... 11 DULCOLAX MILK OF MAGNESIA ............................................................................................... 11 DULCOLAX STOOL SOFTENER ............................................................................................... 12 ear drops earwax aid ............................................................................................... 18 earwax treatment drops ............................................................................................... 18 EASIVENT ............................................................................................... 13 ECPIRIN .................................................................. 2 ed-apap ........................................................................ 1 enema ......................................................................... 11 E-R-O EAR DROPS ............................................................................................... 18 E-R-O EAR WAX REMOVAL SYSTEM ............................................................... 18 EX-LAX ................................................................. 11 EX-LAX ULTRA ............................................................................................... 11 FEENAMINT ............................................................................................... 11 ferro-bob .................................................................... 9 ferrous sulfate ................................................................................................... 9 ferrousul ..................................................................... 9 fiber .............................................................................. 10 fiber laxative ............................................................................................... 10 fiber therapy ............................................................................................... 10 FIBERGEN ............................................................................................... 10 fiber-lax .................................................................. 10 FLEET LAXATIVE ............................................................................................... 11 folic acid .................................................................... 9 formula twenty-one ............................................................................................... 16 genahist ....................................................................... 6 gentle laxative ............................................................................................... 12 geri-lanta .................................................................. 3 gerivite complete ............................................................................................... 16 glucose .......................................................................... 4 golden age vitamin/minerals ............................................................................................... 16 headache pm ................................................................................................... 9 HUMIST ............................................................... 17 hydrocortisone ................................................................................................... 8 hydrocortisone max st ................................................................................................... 8 hydrocortisone max st/12 moist ................................................................................................... 8 hydrocortisone-aloe ................................................................................................... 8 HYDROSKIN ................................................................................................... 8 HYPOTEARS ............................................................................................... 18 ibuprofen ................................................................... 1 IN-CHECK DIAL FLOW TRAINER .......................................................... 13 ipecac ............................................................................. 5 iron .................................................................................... 9 itch relief ................................................................... 8 KAOPECTATE ................................................................................................... 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 22 KAOPECTATE EXTRA STRENGTH 4 kao-tin ............................................................... 4, 12 ketotifen fumarate ............................................................................................... 18 KONSYL .............................................................. 10 KONSYL FIBER ............................................................................................... 10 kp hydrocortisone ................................................................................................... 8 laxa basic .............................................................. 13 laxative .................................................................... 12 liquid calcium/vitamin d ............................................................................................... 14 liquitears ................................................................ 18 LITTLE NOSES SALINE ............................................................................................... 17 LOPERAMIDE A-D ................................................................................................... 5 loperamide hcl ................................................................................................... 5 loratadine ................................................................. 7 loratadine hives relief ................................................................................................... 7 MAALOX ............................................................... 4 MAALOX ADVANCED ................................................................................................... 3 MAALOX ADVANCED MAX ST ......................................................................................... 3 MAALOX MAX ................................................................................................... 3 MAALOX MULTI SYMPTOM MAX ST .................................................................... 3 MAALOX REGULAR STRENGTH ................................................................................................... 3 MAG64 .................................................................... 15 mag-delay ............................................................. 15 magnacaps ........................................................... 15 magnesium .......................................................... 15 magnesium citrate ............................................................................................... 11 magnesium oxide ............................................................................................... 15 MAGNESIUM-OXIDE ............................................................................................... 15 mag-sr ....................................................................... 15 MAG-TAB SR ............................................................................................... 15 mapap ............................................................................ 1 ................................................................................................... mapap arthritis pain 2 mapap pm ................................................................ 9 maxapap maximum strength ................................................................................................... 2 maxapap regular strength ................................................................................................... 2 meclizine hcl ................................................................................................... 5 melatonin maximum strength ................................................................................................... 1 METAMUCIL ............................................................................................... 10 METAMUCIL MULTIHEALTH FIBER ............................................................................................... 10 METAMUCIL SMOOTH TEXTURE ......................................................... 10 MI-ACID ................................................................. 3 mi-acid gas relief ................................................................................................... 9 miconazole nitrate ............................................................................................... 19 MICROCHAMBER ............................................................................................... 13 MICROSPACER ............................................................................................... 13 milantex ..................................................................... 3 milantex extra strength ................................................................................................... 3 milk of magnesia ............................................................................................... 11 MINTOX PLUS ................................................................................................... 3 mucus relief ........................................................... 7 multi-day ............................................................... 16 multi-vit/fluoride ............................................................................................... 17 multi-vitamin ............................................................................................... 16 multivitamin & mineral ............................................................................................... 16 multivitamin/fluoride ............................................................................................... 17 multi-vitamin/fluoride ............................................................................................... 17 multi-vitamins ............................................................................................... 16 multivitamins/fluoride ............................................................................................... 17 MURINE EAR ............................................................................................... 18 ................................................................................................... MURINE EAR WAX REMOVAL SYSTEM 18 mytab gas ................................................................. 9 NASAL MOIST ............................................................................................... 17 natural fiber therapy ............................................................................................... 10 natural senna laxative ............................................................................................... 12 natural vegetable fiber ............................................................................................... 10 na-zone ..................................................................... 17 NEPHRONEX ............................................................................................... 15 nicotine .................................................................... 19 non-aspirin .............................................................. 2 non-aspirin extra strength ................................................................................................... 2 non-aspirin pain relief ................................................................................................... 2 nortemp infants ................................................................................................... 2 NYTOL ....................................................................... 9 OCEAN FOR KIDS ............................................................................................... 17 omeprazole ......................................................... 19 once daily .............................................................. 16 one-daily multi vitamins ............................................................................................... 16 OPERAND POVIDONE-IODINE ................................................................................................... 7 OPTICHAMBER ADVANTAGE ............................................................................................... 13 OPTIHALER .................................................................................... 13, 14 ORAZINC .......................................................... 15 OTIX ........................................................................... 19 OYSCO 500 ............................................................................................... 15 OYSCO 500+D ............................................................................................... 14 OYSCO D ............................................................ 14 oyst-cal d ............................................................... 14 oyster calcium + d ............................................................................................... 14 oyster shell calcium + d ............................................................................................... 14 oyster shell calcium 500 + d ............................................................................................... 14 ............................................................................................... 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 oyster shell calcium/d ............................................................................................... oyster shell calcium/vitamin d ............................................................................................... oyster shell/vitamin d ............................................................................................... OYSTERCAL ............................................................................................... pain & fever childrens 14 14 14 15 ................................................................................................... 2 pain relief ................................................................. 2 pain relief extra strength ................................................................................................... 2 pain relief pm extra strength ................................................................................................... 9 pain reliever pm ................................................................................................... 9 PERI-COLACE ............................................................................................... 10 permethrin ............................................................... 8 PFLEX ..................................................................... 13 pharbedryl ............................................................... 6 PHARBETOL ................................................................................................... 2 PHARBETOL EXTRA STRENGTH ................................................................................................... 2 pink bismuth ........................................................................................... 4, 5 POCKET CHAMBER ............................................................................................... 14 POCKET SPACER ............................................................................................... 14 polyvinyl alcohol ............................................................................................... 18 povidone-iodine ................................................................................................... 7 PREPARATION H HYDROCORTISONE ................................................................................................... 8 pseudoephedrine hcl ............................................................................................... 17 q-dryl .............................................................................. 6 q-pap ............................................................................... 2 Q-TAPP ...................................................................... 7 quenalin ...................................................................... 6 refenesen .................................................................... 7 refenesen 400 ................................................................................................... 7 REGULOID ............................................................................................... 10 RENAL ................................................................... 16 rena-vite rx ......................................................... 16 reno caps ................................................................ 16 robafen ......................................................................... 7 saline mist spray ............................................................................................... 17 saline nasal spray ............................................................................................... 17 SCOT-TUSSIN ALLERGY RELIEF ...................................................................... 6 sea soft nasal mist ............................................................................................... 17 senexon .................................................................... 12 senna ........................................................................... 12 senna lax ................................................................ 12 senna laxative ............................................................................................... 12 senna maximum strength ............................................................................................... 12 senna plus ............................................................. 10 senna s ....................................................................... 10 SENNA SMOOTH ............................................................................................... 12 SENNACON ............................................................................................... 12 senna-docusate sodium ............................................................................................... 10 senna-lax ............................................................... 12 SENNALAX-S ............................................................................................... 11 senna-s ...................................................................... 10 senna-tabs ............................................................ 12 senna-time ........................................................... 12 senna-time s ............................................................................................... 10 SENNO ................................................................... 12 sennosides-docusate sodium ............................................................................................... 11 silace ........................................................................... 13 siladryl allergy ................................................................................................... 6 silphen cough ................................................................................................... 6 simethicone ............................................................ 9 SIMPLY ALLERGY ................................................................................................... 6 SIMPLY SLEEP ............................................................................................... 10 sleep tabs ............................................................... 10 sleep-tabs .............................................................. 10 sm hydrocortisone plus ................................................................................................... 8 sm oral saline laxative ............................................................................................... sodium bicarbonate 11 ................................................................................................... sodium chloride 4 ................................................................................................... 7 SOF-LAX ............................................................. 13 SOMINEX .......................................................... 10 SOMINEX MAXIMUM STRENGTH ............................................................................................... 10 sorbitol ..................................................................... 11 stimulant laxative ............................................................................................... 12 stomach relief ................................................................................................... 5 stomach relief plus ................................................................................................... 5 stool softener ............................................................................................... 13 stool softener laxative dc ............................................................................................... 13 SUPER NU-THERA ............................................................................................... 16 SURFAK .............................................................. 13 sur-q-lax ................................................................. 13 tactinal ......................................................................... 2 tactinal extra strength ................................................................................................... 2 tears again ........................................................... 18 terbinafine hcl ................................................................................................... 8 tetra-formula nighttime sleep ............................................................................................... 10 tgt anti-itch/aloe/vit e ................................................................................................... 8 THERA ................................................................... 16 thera vital m ............................................................................................... 16 THERA/BETA-CAROTENE ............................................................................................... 16 therabasic-m ............................................................................................... 16 thera-ear ................................................................ 19 therapeutic .......................................................... 16 therapeutic liquid ............................................................................................... 16 therapeutic-m ............................................................................................... 16 thera-tabs ............................................................. 16 THRESHOLD IMT ............................................................................................... 13 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 THRESHOLD PEP ............................................................................................... TITRALAC 13 ................................................................................................... total allergy ................................................................................................... TOTAL ALLERGY MEDICINE ................................................................................................... TOTAL FORMULA 3 ............................................................................................... tri-buffered aspirin triple antibiotic ................................................................................................... ............................................................................................... vitamin b-12 6 6 16 ................................................................................................... ULTRA FRESH PM 4 2 7 18 ................................................................................................... vitamin b-12 er 9 9 vitamin c ................................................................. 19 vitamin d ................................................................ 19 vitamin d (ergocalciferol) ............................................................................................... 19 vitamin d3 ............................................................ 19 vitamin d-400 ............................................................................................... 19 vitamin k (phytonadione) ............................................................................................... 19 vitamins for hair ............................................................................................... 17 WATCHHALER ............................................................................................... 14 WINDMILL TRAINER ............................................................................................... 13 womens laxative ............................................................................................... 12 zinc sulfate .......................................................... 15 zinc-220 ................................................................... 15 ................................................................................................... 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
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