Health Share of Oregon/Providence (Medicaid) - Providence Health Plan

Health Share of Oregon/Providence (Medicaid) To help find a drug see the back of the document for an alphabetical listing

Drug Name

Status*

Requirements/Limits

Analgesics 8 HOUR

OTC

8 HOUR PAIN RELIEF

OTC

8 HOUR PAIN RELIEVER

OTC

ACEPHEN (325 MG, 650 MG)

OTC

ACETADRYL

OTC

acetaminophen (80mg/0.8ml drops susp, 120 mg supp.rect, 160 mg/5ml oral susp, 160 mg/5ml solution, 160 mg/5ml elixir, 160 mg/5ml liquid, 325/10.15 solution, 325 mg tablet, 500 mg tablet, 500 mg/5ml liquid, 650mg/20.3 solution, 650 mg tablet er, 650 mg supp.rect)

OTC

ACETAMINOPHEN PM

OTC

ACETAMINOPHEN PM XTRA STRENGTH

OTC

acetaminophen/diphenhydramine hcl

OTC

alagesic lq

Generic

ARTHRITIS PAIN

OTC

ARTHRITIS PAIN RELIEF (ARTHRITIS ER 650 MG CAPLT, ARTHRITIS RELF ER 650 MG, ARTHRITIS RLF ER 650 MG, CVS ARTHRITIS ER 650 MG, GNP ARTHRIT RLF ER 650 MG, HM ARTHRITIS ER 650 MG, KRO ARTHRIT RLF ER 650 MG, PUB ARTHRITIS ER 650 MG, PV ARTHRITIS ER 650 MG, QC ARTHRITIS ER 650 MG, RA ARTHRITIS ER 650 MG, SB ARTHRITIS ER 650 MG, SM ARTHRITIS ER 650 MG, SM ARTHRITIS RELF ER 650)

OTC

ARTHRITIS PAIN RELIEVER

OTC

aspirin (500 mg tablet dr, 600 mg supp.rect, 650 mg tablet dr)

OTC

ATHENOL

OTC

BETATEMP

OTC

*Specialty medications are only available through the Providence specialty network. See introduction. ^A formulary brand drug becomes non-formulary when it becomes available as a generic drug. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 1 LAST UPDATE 10/2015


Drug Name

Status*

butalbital/acetaminophen

Generic

butalbital/acetaminophen/caffeine (capsule, tablet)

Generic

butalbital/aspirin/caffeine

Generic

capacet

Generic

CHILD PAIN REL-FEVER REDUCER

OTC

CHILDREN'S FEVER REDUCER

OTC

CHILDREN'S FEVER REDUCING

OTC

CHILDREN'S MEDI-TABS

OTC

CHILDREN'S NON-ASPIRIN (CHILD NONASPIRIN 160 MG/5 ML, CVS CHILD NONASA 80 MG TB CHW, NON-ASA CHILDREN'S TAB CHEW, NON-ASA PAIN RELIEF TB CHEW, NON-ASPIRIN 160 MG/5 ML SUSP, NON-ASPIRIN CHILD 80 MG TAB, NON-ASPIRIN CHILD 120 MG SUP, NON-ASPIRIN CHILD'S DROPS, PV CHILD NON-ASA 80 MG TB CHEW, PV CHILD NON-ASPIRIN 160 MG/5, PV CHILDREN'S NON-ASA LIQ, RA NONASPIRIN 160 MG/5 ML)

OTC

CHILDREN'S PAIN & FEVER (CHILD PAIN & FEVER 160 MG/5 ML, CHILD PAINFEVER 80 MG TAB CHW, GNP CHILD PAIN-FEVER 160 MG/5, GNP CHL PAINFEVER 160 MG/5 ML, HM CHLD PAINFEVER 160 MG/5 ML, KRO CHILD PAINFEVER 160 MG/5, SM CHILD PAIN & FEVER 160 MG/5)

OTC

CHILDREN'S PAIN RELIEF

OTC

CHILDREN'S PAIN RELIEVER (CHILD'S SUSP, EQ CHILD'S SUSP, EQL CHILD'S SUSP, SB CHILD'S SUSP, SM 80 MG TAB, SM CHEW TAB, SM CHILD'S SUSP)

OTC

CHILDREN'S Q-PAP

OTC

CHILDREN'S SILAPAP

OTC

CHILDREN'S TACTINAL

OTC

Requirements/Limits



Drug Name

Status*

EAZZZE THE PAIN

OTC

ED-APAP

OTC

EXTRA STRENGTH NON-ASPIRIN

OTC

FEVER REDUCER & PAIN RELIEVER

OTC

FEVERALL (120 MG, 325 MG, 650 MG)

OTC

HEADACHE PM

OTC

HEADACHE PM FORMULA

OTC

INFANT FEVER-PAIN RELIEVER

OTC

INFANT PAIN & FEVER

OTC

INFANT PAIN RELIEF

OTC

INFANT'S NON-ASPIRIN

OTC

INFANT'S PAIN RELIEF

OTC

INFANT'S PAIN RELIEVER

OTC

INFANTS' MAPAP

OTC

INFANTS' PAIN & FEVER

OTC

INFANTS' PAIN RELIEF

OTC

INFANTS' PAIN RELIEVER

OTC

LITTLE REMEDIES FEVER & PAIN

OTC

MAPAP (80 MG TABLET CHEW, 160 MG/5 ML ELIXIR, 160 MG/5 ML SUSPENSION, 325 MG TABLET, 500 MG TABLET, 500 MG/15 ML LIQUID, 500 MG CAPLET, 500 MG GELCAP, 500 MG CAPSULE)

OTC

MAPAP ARTHRITIS PAIN

OTC

MAPAP PM

OTC

MASOPHEN

OTC

MEDI-TABS

OTC

MEDI-TABS EXTRA STRENGTH

OTC

MEDI-TABS PM

OTC

Requirements/Limits



Drug Name

Status*

NIGHT TIME PAIN MEDICINE

OTC

NON-ASPIRIN (CVS NON-ASA 80 MG TABLET CHW, MEDI-FIRST NON-ASPIRIN 325 MG, NON-ASPIRIN 80 MG TAB CHEW, NON-ASPIRIN 160 MG/5 ML ELIX, NON-ASPIRIN 325 MG TABLET, PV NON-ASPIRIN 325 MG TABLET, SB NONASPIRIN 80 MG TAB CHW, SB NONASPIRIN 325 MG TABLET, V-R NONASPIRIN INFANT DRPS)

OTC

NON-ASPIRIN 8 HOUR

OTC

NON-ASPIRIN EXTRA STRENGTH (CVS NON-ASPIRIN 500 MG GELTAB, CVS NON-ASPIRIN 500 MG CAPLET, CVS NON-ASPIRIN 500 MG TABLET, NON ASPIRIN 500 MG CAPLET, NON-ASPIRIN 500 MG GELTAB, NON-ASPIRIN 500 MG GELCAP, NON-ASPIRIN 500 MG SOFTGEL, NON-ASPIRIN 500 MG TABLET, NON-ASPIRIN 500 MG CAPLET, NON-ASPIRIN X-STR 167 MG/5 ML, PV NON-ASPIRIN 500 MG SOFTGEL, RA NON-ASPIRIN 500 MG CAPLET, SB NONASPIRIN 500 MG CAPLET, SM NONASPIRIN 500 MG CAPLET)

OTC

NON-ASPIRIN JR STRENGTH

OTC

NON-ASPIRIN PAIN RELIEF

OTC

NON-ASPIRIN PM

OTC

NON-ASPIRIN PM EX-STRENGTH

OTC

NORTEMP

OTC

PAIN & FEVER (& 500 MG CAPLET, & 500 MG TABLET)

OTC

PAIN & SLEEP

OTC

Requirements/Limits



Drug Name

Status*

PAIN RELIEF (CVS RELIEF 500 MG GELCAP, EQL RELIEF 500 MG TABLET, EQL RELIEF 500 MG CAPLET, EQL RELIEF 500 MG GELTAB, EQL RLF 160 MG/5 ML LIQ, GNP RELIEF 500 MG GELCAP, GNP RELIEF ER 650 MG CPLT, HM RELIEF 500 MG CAPLET, HM RELIEF 500 MG TABLET, PUB RELIEF 500 MG TABLET, PUB RELIEF 500 MG GELTAB, PUB RELIEF 500 MG CAPLET, PV RELIEF 500 MG TABLET, RELIEF 160 MG/5 ML LIQUID, RELIEF 325 MG TABLET, RELIEF 500 MG GELTAB, RELIEF 500 MG CAPLET, RELIEF 500 MG CAPSULE, RELIEF 500 MG GELCAP, RELIEF 500 MG TABLET, RELIEF ER 650 MG CAPLET, SM RELIEF 500 MG GELCAP)

OTC

PAIN RELIEF ADULT

OTC

PAIN RELIEF EXTRA STRENGTH (CVS 500 MG CAPLET, CVS 500 MG EZ-TAB, GNP 500 MG CAPLET, PV 500 MG CAPLET)

OTC

PAIN RELIEF PM

OTC

PAIN RELIEVER (325 MG TABLET, CVS 500 MG CPLT, EQ 500 MG CAPLET, ER 650 MG CAPLET, GNP 325 MG TAB, GNP 500 MG TAB, GNP 500 MG CAPLT, HM 325 MG TABLET, HM 500 MG TABLET, SB 500 MG CAPLET, SB 500 MG GELCAP, SM 325 MG TABLET, SM 500 MG GELTAB, 500 MG CAPLET, 500 MG GELCAP, 500 MG TABLET, SM 500 MG TABLET, SM 500 MG CAPLET)

OTC

PAIN RELIEVER JUNIOR STRENGTH

OTC

PAIN RELIEVER PM

OTC

PAIN RELIEVER-FEVER REDUCER

OTC

PEDIACARE FEVER REDUCER

OTC

PHARBETOL

OTC

Q-PAP (80 MG/0.8 ML DROPS, 160 MG/5 ML LIQUID, 160 MG/5 ML SOLUTION, 325 MG TABLET)

OTC

Requirements/Limits



Drug Name

Status*

Q-PAP EXTRA STRENGTH

OTC

SHAKE THAT ACHE

OTC

TACTINAL

OTC

tencon 50-325 mg tablet

Generic

TENSION HEADACHE RELIEVER

OTC

TYLENOL PM EXTRA STRENGTH

OTC

TYLOPHEN

OTC

vanatol lq

Generic

WAL-NADOL PM

OTC

zebutal capsule

Generic

Requirements/Limits

Nonsteroidal Anti-inflammatory Drugs ADULT LOW DOSE ASPIRIN EC

OTC

ADVIL JR STR 100 MG TAB CHEW

OTC

ALL DAY PAIN RELIEF (CVS PAIN RLF 220 MG TB, EQL RLF 220 MG CAPLET, GNP PAIN RLF 220 MG TB, PAIN RELIEF 220 MG TAB, PAIN RLF 220 MG CAPLET, SM RELIEF 220 MG CAPLT, SM RELIEF 220 MG TAB)

OTC

ALL DAY RELIEF

OTC

ASPIR 81

OTC

ASPIR-LOW

OTC

ASPIR-TRIN

OTC

aspirin (81 mg tab chew, 81 mg tablet dr, 300 mg supp.rect, 325 mg tablet, bayer 325 mg caplet, bayer 325 mg tablet, 325 mg tablet dr)

OTC

aspirin 975 mg tablet dr

Generic

celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule)

Generic

PA, QL (2 PER DAY)

celecoxib 400 mg capsule

Generic

PA, QL (1 PER DAY)

CHILD IBUPROFEN

OTC



Drug Name

Status*

CHILDREN'S ADVIL

OTC

CHILDREN'S IBUPROFEN

OTC

CHILDREN'S MEDI-PROFEN

OTC

CHILDREN'S PROFEN IB

OTC

CHILDREN'S PROFENIB

OTC

choline sal/mag salicylate 500 mg/5ml liquid

Generic

diclofenac potassium

Generic

diclofenac sodium (25 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr, 100 mg tab er 24h)

Generic

diflunisal

Generic

ECOTRIN EC 81 MG TABLET

OTC

ECPIRIN

OTC

etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tablet, 500 mg tab er 24h, 600 mg tab er 24h)

Generic

fenoprofen calcium 600 mg tablet

Generic

FLANAX 220 MG TABLET

OTC

flurbiprofen (50 mg tablet, 100 mg tablet)

Generic

I-PRIN

OTC

IBU-DROPS

OTC

ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet)

Generic

ibuprofen (50 mg/1.25 drops susp, 100 mg/5ml oral susp, 100 mg tab chew, 200 mg capsule, 200 mg tablet)

OTC

INDOCIN (25 MG/5 ML SUSPENSION, 50 MG SUPPOSITORY)

Brand

indomethacin (25 mg capsule, 50 mg capsule, 75 mg capsule er)

Generic

Requirements/Limits



Drug Name

Status*

INFANTS IBU-DROPS

OTC

INFANTS MEDI-PROFEN

OTC

INFANTS PROFENIB

OTC

ketoprofen (50 mg capsule, 75 mg capsule, 200 mg cap24h pel)

Generic

ketorolac tromethamine 10 mg tablet

Generic

meclofenamate sodium (50 mg capsule, 100 mg capsule)

Generic

MEDI-PROFEN

OTC

MEDIPROXEN

OTC

meloxicam (7.5 mg tablet, 15 mg tablet)

Generic

MINIPRIN

OTC

MOTRIN IB

OTC

nabumetone (500 mg tablet, 750 mg tablet)

Generic

NAPRELAN CR 500 MG TABLET

Brand

naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet dr, 500 mg tablet)

Generic

naproxen sodium (275 mg tablet, 550 mg tablet)

Generic

naproxen sodium 220 mg tablet

OTC

naproxen sodium 500 mg tbmp 24hr

Brand

oxaprozin

Generic

piroxicam (10 mg capsule, 20 mg capsule)

Generic

PROVIL

OTC

ST. JOSEPH ASPIRIN

OTC

sulindac (150 mg tablet, 200 mg tablet)

Generic

tolmetin sodium

Generic

Requirements/Limits



Drug Name

Status*

WAL-PROXEN

OTC

Requirements/Limits

Opioid Analgesics, Long-acting fentanyl (12 mcg/hr patch td72, 25mcg/hr patch td72, 50mcg/hr patch td72, 75mcg/hr patch td72, 100 mcg/hr patch td72)

Generic

QL (15 PER 30 DAYS)

KADIAN ER 200 MG CAPSULE

Brand

methadone hcl (5 mg/5 ml solution, 5 mg tablet, 10 mg/5 ml solution, 10 mg/ml oral conc, 10 mg tablet, 40 mg tablet sol)

Generic

methadone intensol

Generic

methadose 40 mg tablet dispr

Generic

morphine sulfate (15 mg tablet er, 30 mg cap er pel, 30 mg tablet er, 50 mg cap er pel, 60 mg cap er pel, 60 mg tablet er, 80 mg cap er pel, 100 mg cap er pel, 100 mg tablet er, 200 mg tablet er)

Generic

oxycodone hcl (10 mg tab er 12h, 20 mg tab er 12h, 40 mg tab er 12h, 80 mg tab er 12h)

Brand

PA, QL (90 PER 30 DAYS)

OXYCONTIN

Brand


tramadol hcl (100 mg tbmp 24hr, 100 mg tab er 24h, 200 mg tbmp 24hr, 200 mg tab er 24h, 300 mg tab er 24h, 300 mg tbmp 24hr)

Generic

Opioid Analgesics, Short-acting acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg/12.5 solution, 300mg-30mg tablet, 300mg60mg tablet, 300mg-15mg tablet)

Generic

PA (PA for ages 5 and under)

ascomp with codeine

Generic

PA

butalbit/acetamin/caff/codeine 50-32530 capsule

Generic


butorphanol tartrate (1 mg/ml vial, 2 mg/ml vial)

Generic

PA



Drug Name

Status*

Requirements/Limits

butorphanol tartrate 10 mg/ml spray

Generic

co-gesic

Generic

codeine phosphate/butalbital/aspirin/caffeine

Generic

PA

codeine phosphate/carisoprodol/aspirin

Generic


codeine sulfate (15 mg tablet, 30 mg tablet, 60 mg tablet)

Generic


endocet

Generic

endodan

Generic

hydrocodone bitartrate/acetaminophen (2.5-167/5 solution, 2.5-500 mg tablet, 5 mg-325mg tablet, 5 mg-500mg tablet, 5-334mg/10 solution, 7.5500/15 solution, 7.5-325/15 solution, 7.5-325mg tablet, 7.5-750mg tablet, 7.5-650 mg tablet, 7.5-500mg tablet, 10mg-325mg tablet, 10-660mg tablet, 10mg-650mg tablet, 10mg-500mg tablet)

Generic

hydrocodone/ibuprofen

Generic

hydromorphone hcl (1 mg/ml liquid, 2 mg tablet, 3 mg supp.rect, 4 mg tablet, 8 mg tablet)

Generic

ibudone 5-200 mg tablet

Generic

lorcet

Generic

lorcet hd

Generic

lorcet plus 7.5-325 mg tablet

Generic

lortab (5-325 mg tablet, 5-500 tablet, 7.5-325 mg tablet, 10-325 mg tablet)

Generic

meperidine hcl (50 mg tablet, 50 mg/5 ml solution, 100 mg tablet)

Generic

meperitab

Generic



Drug Name

Status*

Requirements/Limits

morphine sulfate (5 mg supp.rect, 10 mg supp.rect, 10 mg/5 ml solution, 15 mg tablet, 20 mg supp.rect, 20 mg/5 ml solution, 30 mg tablet, 30 mg supp.rect, 100 mg/5ml solution)

Generic

oxycodone hcl (5 mg/5 ml solution, 5 mg capsule, 5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg/ml oral conc, 20 mg tablet, 30 mg tablet)

Generic

oxycodone hcl/acetaminophen

Generic

oxycodone hcl/aspirin

Generic

oxymorphone hcl 10 mg tablet

Generic

PA, QL (4 PER DAY)

oxymorphone hcl 5 mg tablet

Generic

PA, QL (8 PER DAY)

pentazocine hcl/acetaminophen

Generic

pentazocine hcl/naloxone hcl

Generic

reprexain 10-200 mg tablet

Generic

ROXICET 5-325 ORAL SOLUTION

Brand

roxicet 5-325 tablet

Generic

stagesic

Generic

tramadol hcl 50 mg tablet

Generic

tramadol hcl/acetaminophen

Generic

xylon 10

Generic

QL (240 PER 30 DAYS)

Anesthetics Local Anesthetics glydo

Generic

lidocaine 5 % oint. (g)

Generic

lidocaine 5%(700mg) adh. patch

Generic

lidocaine hcl (2 % solution, 2 % jel/pf app, 2 % jel (ml), 4 % solution, 40 mg/ml solution)

Generic

lidocaine/prilocaine (2.5 %-2.5% cream (g), 2.5 %-2.5% kit)

Generic




Drug Name

Status*

relador pak

Generic

relador pak plus

Generic

Requirements/Limits

Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium

Generic

depade

Generic

disulfiram (250 mg tablet, 500 mg tablet)

Generic

naltrexone hcl 50 mg tablet

Generic

revia

Generic

Opioid Antagonists buprenorphine hcl/naloxone hcl

Generic

Smoking Cessation Agents buproban

Generic

CHANTIX

Brand

NICODERM CQ

OTC

nicotine (7mg/24hr patch td24, 14mg/24hr patch td24, 21 mg/24hr patch td24, 22 mg/24hr patch td24)

OTC

NTS

OTC

Anti-inflammatory Agents Glucocorticoids alclometasone dipropionate

Generic

amcinonide 0.1 % cream (g)

Generic

ANTI-ITCH (1% LOTION, 1% CREAM, CVS 1% CREAM, EQL 1% CREAM, RA 1% CREAM)

OTC

anusol-hc 2.5% cream

Generic



Drug Name

Status*

apexicon e

Generic

AQUANIL HC

OTC

BETA HC

OTC

betamethasone dipropionate (0.05 % lotion, 0.05 % gel (gram), 0.05 % cream (g), 0.05 % oint. (g))

Generic

betamethasone dipropionate/propylene glycol (0.05 % cream (g), 0.05 % oint. (g), 0.05 % lotion)

Generic

betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g))

Generic

clobetasol propionate (0.05 % solution, 0.05 % shampoo, 0.05 % cream (g), 0.05 % foam, 0.05 % oint. (g), 0.05 % gel (gram))

Generic

clobetasol propionate/emollient base

Generic

clodan 0.05% shampoo

Generic

cormax

Generic

CORTISONE

OTC

CORTIZONE-10 (1% LOTION, 1% CREME)

OTC

CORTIZONE-10 PLUS

OTC

DERMAREST ECZEMA

OTC

desonide (0.05 % lotion, 0.05 % cream (g), 0.05 % oint. (g))

Generic

desoximetasone

Generic

ECZEMA ANTI-ITCH

OTC

fludrocortisone acetate 0.1 mg tablet

Generic

fluocinolone acetonide (0.01 % cream (g), 0.01 % oil, 0.01 % solution, 0.025 % oint. (g), 0.025 % cream (g))

Generic

fluocinonide (0.05 % gel (gram), 0.05 % solution, 0.05 % cream (g), 0.05 % oint. (g))

Generic

fluocinonide/emollient base

Generic

Requirements/Limits



Drug Name

Status*

fluticasone propionate (0.05 % lotion, 0.05 % cream (g))

Generic

halobetasol propionate

Generic

HYDRO SKIN

OTC

hydrocortisone (1 % cream (g), 2.5 % lotion, 2.5 % cream (g), 2.5 % oint. (g))

Generic

hydrocortisone (1 % lotion, 1 % packet)

OTC

hydrocortisone acetate 1 % cream (g)

OTC

hydrocortisone butyrate 0.1 % cream (g)

Generic

HYDROCORTISONE PLUS 12

OTC

hydrocortisone/aloe vera 1 % cream (g)

OTC

HYDROCREAM

OTC

HYDROSKIN

OTC

methylprednisolone

Generic

millipred 5 mg tablet

Generic

millipred dp

Generic

neomycin sulfate/polymyxin b sulfate/hydrocortisone (drops susp, solution)

Generic

NEOSPORIN 1% ANTI-ITCH CREAM

OTC

NOBLE FORMULA HC 1% CREAM

OTC

nystatin/triamcinolone acetonide

Generic

oralone

Generic

prednisolone 15 mg/5 ml solution

Generic

prednisolone sod phosphate (5 mg/5 ml solution, 10 mg tab rapdis, 15 mg tab rapdis, 15 mg/5 ml solution, 30 mg tab rapdis)

Generic

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5 mg tab ds pk, 10 mg tab ds pk, 10 mg tablet, 20 mg tablet, 50 mg tablet)

Generic

Requirements/Limits



Drug Name

Status*

prednisone intensol

Generic

PREPARATION H HC 1% CREAM

OTC

proctocream-hc

Generic

RECORT PLUS

OTC

SOOTHING CARE

OTC

triamcinolone acetonide (0.025 % cream (g), 0.025 % oint. (g), 0.025 % lotion, 0.1 % lotion, 0.1 % oint. (g), 0.1 % cream (g), 0.1 % paste (g), 0.5 % oint. (g), 0.5 % cream (g))

Generic

triderm

Generic

Requirements/Limits

Antibacterials Aminoglycosides garamycin 0.3% eye drops

Generic

gentak

Generic

gentamicin sulfate (0.1 % oint. (g), 0.1 % cream (g), 0.3 % oint. (g), 0.3 % drops)

Generic

neomycin sulfate 500 mg tablet

Generic

TOBI PODHALER

Specialty

TOBRADEX EYE OINTMENT

Brand

tobramycin 0.3 % drops

Generic

tobramycin in 0.225 % sodium chloride

Generic

LA

Antibacterials, Other acetasol hc

Generic

acetic acid 2 % solution

Generic

acetic acid/aluminum acetate

Generic

acetic acid/hydrocortisone

Generic

ANTIBIOTIC

OTC

ANTIBIOTIC + PAIN RELIEF (RA RLF OINT, RELIEF OINT)

OTC



Drug Name

Status*

bacitracin (500 oint. (g), 500 packet)

OTC

bacitracin zinc (500 oint. (g), 500 oint.(ea))

OTC

bacitracin/polymyxin b sulfate (50010k/g oint. (g), packet)

OTC

BACITRAYCIN PLUS 500 UNIT/GM

OTC

chlorhexidine gluconate 0.12 % mouthwash

Generic

clindacin etz 1% pledget

Generic

clindacin p

Generic

clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mg capsule)

Generic

clindamycin palmitate hcl

Generic

clindamycin phosphate (1 % foam, 1 % lotion, 1 % med. swab, 1 % gel (gram), 1 % solution, 2 % cream/appl)

Generic

cycloserine 250 mg capsule

Generic

erythromycin ethylsuccinate/sulfisoxazole acetyl

Generic

FLAGYL ER

Brand

linezolid 600 mg tablet

Brand

MACRODANTIN 25 MG CAPSULE

Brand

methenamine hippurate

Generic

metronidazole (0.75 % gel (gram), 0.75 % gel w/appl, 0.75 % lotion, 250 mg tablet, 375 mg capsule, 500 mg tablet)

Generic

MONUROL

Brand

mupirocin 2 % oint. (g)

Generic

nitrofurantoin 25 mg/5 ml oral susp

Generic

nitrofurantoin macrocrystal (50 mg capsule, 100 mg capsule)

Generic

nitrofurantoin monohydrate/macrocrystals

Generic

Requirements/Limits



Drug Name

Status*

Requirements/Limits

paroex

Generic

periogard

Generic

rosadan 0.75% gel

Generic

SIVEXTRO 200 MG TABLET

Specialty

PA

tinidazole (250 mg tablet, 500 mg tablet)

Generic

PA

TRI-BIOZENE

OTC

trimethoprim 100 mg tablet

Generic

TRIPLE ANTIBIOTIC (, CVS, EQ, GNP, HM, KRO, PUB, PV, RA, SB, SM)

OTC

TRIPLE ANTIBIOTIC EXTRA

OTC

TRIPLE ANTIBIOTIC PLUS

OTC

TRIPLE ANTIBIOTIC-PAIN RELIEF

OTC

vancomycin hcl (125 mg capsule, 250 mg capsule)

Generic

vandazole

Generic

XIFAXAN 200 MG TABLET

Brand


XIFAXAN 550 MG TABLET

Brand


ZYVOX (100 MG/5 ML SUSPENSION, 600 MG TABLET)

Brand

Beta-lactam, Cephalosporins CEDAX 90 MG/5 ML SUSPENSION

Brand

cefaclor (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg capsule, 375 mg/5ml susp recon, 500 mg tab er 12h, 500 mg capsule)

Generic

cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule)

Generic

cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule)

Generic

cefpodoxime proxetil (100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet)

Generic



Drug Name

Status*

cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet)

Generic

ceftibuten (180 mg/5ml susp recon, 400 mg capsule)

Generic

CEFTIN (125 ML ORAL SUSP, 250 ML ORAL SUSP)

Brand

cefuroxime axetil

Generic

cephalexin (125 mg/5ml susp recon, 250 mg tablet, 250 mg capsule, 250 mg/5ml susp recon, 500 mg tablet, 500 mg capsule)

Generic

Requirements/Limits

Beta-lactam, Penicillins amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 875 mg tablet)

Generic

amoxicillin/potassium clavulanate (20028.5mg tab chew, 200-28.5/5 susp recon, 250-125 mg tablet, 250-62.5/5 susp recon, 400-57mg tab chew, 40057mg/5 susp recon, 500-125 mg tablet, 600-42.9/5 susp recon, 875-125 mg tablet, 1000-62.5 tab er 12h)

Generic

ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule)

Generic

AUGMENTIN 125-31.25 MG/5 ML

Brand

dicloxacillin sodium

Generic

penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet)

Generic

Macrolides AKNE-MYCIN

Brand



Drug Name

Status*

azithromycin (100 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 600 mg tablet)

Generic

clarithromycin (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet)

Generic

DIFICID

Brand

E.E.S. 200

Brand

ery

Generic

ERY-TAB

Brand

erygel

Generic

ERYPED 200

Brand

ERYPED 400

Brand

ERYTHROCIN STEARATE

Brand

erythromycin base (5 mg/g oint. (g), 250 mg tablet, 250 mg capsule dr, 500 mg tablet)

Generic

erythromycin base/ethyl alcohol (2 % med. swab, 2 % solution, 2 % gel (gram))

Generic

erythromycin ethylsuccinate 400 mg tablet

Generic

Requirements/Limits

PA

Quinolones ciprofloxacin

Generic

ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750 mg tablet)

Generic

ciprofloxacin/ciprofloxacin hcl

Generic

gatifloxacin

Generic

levofloxacin (0.5 % drops, 250mg/10ml solution, 250 mg tablet, 500 mg tablet, 750 mg tablet)

Generic

moxifloxacin hcl 400 mg tablet

Generic



Drug Name

Status*

ofloxacin (0.3 % drops, 200 mg tablet, 300 mg tablet, 400 mg tablet)

Generic

Requirements/Limits

Sulfonamides bleph-10

Generic

silver sulfadiazine 1 % cream (g)

Generic

sulfacetamide sodium 10 % drops

Generic

sulfamethoxazole/trimethoprim (20040mg/5 oral susp, 400mg-80mg tablet, 800-160/20 oral susp, 800-160 mg tablet)

Generic

sulfamide

Generic

Tetracyclines avidoxy

Generic

demeclocycline hcl

Generic

doxycycline hyclate (50 mg capsule, 100 mg capsule, 100 mg tablet)

Generic

doxycycline monohydrate (25 mg/5 ml susp recon, 50 mg capsule, 50 mg tablet, 75 mg tablet, 100 mg tablet, 100 mg capsule)

Generic

dynacin (50 mg tablet, 100 mg tablet)

Generic

minocycline hcl (50 mg tablet, 50 mg capsule, 75 mg capsule, 75 mg tablet, 100 mg capsule, 100 mg tablet)

Generic

mondoxyne nl (nl 50 mg capsule, nl 100 mg capsule)

Generic

morgidox 100 mg capsule

Generic

OCUDOX

Brand

tetracycline hcl (250 mg capsule, 500 mg capsule)

Generic

VIBRAMYCIN 50 MG/5 ML SYRUP

Brand



Drug Name

Status*

Requirements/Limits

Anticonvulsants Anticonvulsants, Other acetazolamide (125 mg tablet, 250 mg tablet)

Generic

levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tab er 24h, 500 mg/5ml solution, 500 mg tablet, 750 mg tab er 24h, 750 mg tablet, 1000 mg tablet)

Generic

primidone (50 mg tablet, 250 mg tablet)

Generic

Calcium Channel Modifying Agents CELONTIN

Brand

ethosuximide (250 mg/5ml solution, 250 mg capsule)

Generic

LYRICA (20 MG/ML ORAL SOLUTION, 25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300 MG CAPSULE)

Brand

zonisamide (25 mg capsule, 50 mg capsule, 100 mg capsule)

Generic

PA

Gamma-aminobutyric Acid (GABA) Augmenting Agents DIASTAT

Brand

diazepam (5-7.5-10mg kit, 12.5-15-20 kit)

Generic

diazepam 2.5 mg kit

Brand

gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 400 mg capsule, 600 mg tablet, 800 mg tablet)

Generic

GABITRIL (12 MG TABLET, 16 MG TABLET)

Brand

ONFI (5 MG TABLET, 10 MG TABLET, 20 MG TABLET)

Brand




Drug Name

Status*

Requirements/Limits

ONFI 2.5 MG/ML SUSPENSION

Brand

PA

phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet)

Generic

SABRIL

Brand

tiagabine hcl

Generic

LA

Glutamate Reducing Agents felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp)

Generic

topiragen

Generic

topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet)

Generic

topiramate (25 mg cap spr 24, 50 mg cap spr 24, 100 mg cap spr 24, 150 mg cap spr 24, 200 mg cap spr 24)

Generic

PA

Sodium Channel Agents APTIOM

Brand

BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET)

Brand

carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg/5ml oral susp, 200 mg tablet, 200 mg tab er 12h, 200 mg cpmp 12hr, 300 mg cpmp 12hr, 400 mg tab er 12h)

Generic

DILANTIN 30 MG CAPSULE

Brand

epitol

Generic

oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet)

Generic

PEGANONE

Brand

phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp)

Generic

PA



Drug Name

Status*

phenytoin sodium extended

Generic

TEGRETOL XR 100 MG TABLET

Brand

VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET)

Brand

Requirements/Limits

Antidementia Agents Cholinesterase Inhibitors donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tablet, 10 mg tab rapdis)

Generic

EXELON 2 MG/ML ORAL SOLUTION

Brand

galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg tablet, 12 mg tablet)

Generic

rivastigmine

Generic

rivastigmine tartrate

Generic

N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (5 mg tablet, 10 mg tablet)

Generic

memantine hcl 5 mg-10 mg tab ds pk

Generic

NAMENDA 10 MG/5 ML SOLUTION

Brand

QL (60 PER 30 DAYS)

QL (360 ML PER 30 DAYS)

Antidepressants Antidepressants, Other budeprion sr 150 mg tablet

Generic

bupropion hcl 150 mg tablet er

Generic

Antiemetics Antiemetics, Other AMBIZINE

OTC

compro

Generic



Drug Name

Status*

Requirements/Limits

DICLEGIS

Brand

QL (60 PER 30 DAYS)

DRAMAMINE LESS DROWSY

OTC

hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg tablet, 50 mg tablet)

Generic

hydroxyzine pamoate (25 mg capsule, 50 mg capsule, 100 mg capsule)

Generic

meclizine hcl (12.5 mg tablet, 25 mg tablet)

Generic

meclizine hcl 25 mg tab chew

OTC

MEDI-MECLIZINE

OTC

metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/10ml solution)

Generic

MOTION RELIEF

OTC

MOTION SICKNESS (GNP SICKNES 25 MG TAB, SICKNESS 25 MG TABLET, SM SICKNES 25 MG TABLET, SM SICKNESS 25 MG TAB)

OTC

MOTION SICKNESS II

OTC

MOTION SICKNESS RELIEF (CVS RELIEF TAB, EQ 25 MG TAB, RA RELIEF TAB, RA RLF TB CHEW, RELIEF TB CHEW)

OTC

MOTION SICKNESS RELIEF II

OTC

MOTION-TIME

OTC

phenadoz

Generic

prochlorperazine

Generic

prochlorperazine maleate (5 mg tablet, 10 mg tablet)

Generic

promethazine hcl (6.25mg/5ml syrup, 12.5 mg supp.rect, 12.5 mg tablet, 25 mg tablet, 25 mg/ml vial, 25 mg supp.rect, 50 mg supp.rect, 50 mg tablet)

Generic

promethegan

Generic



Drug Name

Status*

trimethobenzamide hcl 300 mg capsule

Generic

VERTICALM

OTC

Requirements/Limits

Emetogenic Therapy Adjuncts EMEND (80 MG CAPSULE, 125 MG CAPSULE, TRIFOLD PACK)

Brand

ondansetron

Generic

ondansetron hcl (4 mg/5 ml solution, 4 mg tablet, 8 mg tablet, 24 mg tablet)

Generic

QL (4 PER 30 DAYS)

Antifungals 1-DAY

OTC

3 DAY VAGINAL

OTC

3-DAY VAGINAL CREAM

OTC

ANTI-FUNGAL CREAM

OTC

ANTIFUNGAL (1% CREAM, EQL 1% CREAM, GNP 1% CREAM, SM 1% CREAM)

OTC

ANTIFUNGAL CREAM (2% CREAM, CARRINGTON 2% CREAM)

OTC

ATHLETE'S FOOT (EQ 1% CREAM, 2% POWDER)

OTC

ATHLETE'S FOOT SPRAY

OTC

ATHLETIC FOOT CREAM

OTC

BAZA ANTIFUNGAL

OTC

ciclodan 0.77% cream

Generic

ciclopirox (0.77 % gel (gram), 1 % shampoo)

Generic

ciclopirox olamine (0.77 % cream (g), 0.77 % suspension)

Generic

CLOTRIM ANTIFUNGAL

OTC

clotrimazole (1 % cream (g), 1 % solution, 10 mg troche)

Generic



Drug Name

Status*

clotrimazole (1 % cream/appl, 2 % cream/appl, 100 mg tablet)

OTC

CLOTRIMAZOLE AF

OTC

CVS ANTI-FUNGAL 2% POWDER

OTC

CVS ITCH RELIEF 1% CREAM

OTC

DESENEX (2% POWDER, 2% SPRAY POWDER)

OTC

econazole nitrate 1 % cream (g)

Generic

fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet)

Generic

flucytosine (250 mg capsule, 500 mg capsule)

Generic

griseofulvin ultramicrosize

Generic

griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet)

Generic

GYNE-LOTRIMIN

OTC

GYNE-LOTRIMIN-7

OTC

INZO ANTIFUNGAL

OTC

itraconazole 100 mg capsule

Generic

JOCK ITCH (EQ 1% CREAM, 1% CREAM)

OTC

JOCK ITCH RELIEF

OTC

ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo)

Generic

ketodan 2% foam

Generic

KRO ATHLETE'S FOOT CREAM

OTC

LOTRIMIN AF (1% CREAM, 2% SPRAY POWDER, 2% POWDER)

OTC

MICATIN

OTC

miconazole nitrate (2 % cream (g), 2 % cream/appl, 2 % aero powd, 100 mg supp.vag, 200 mg-2 % kit, 200 mg-2 % cmb pf crm, powder)

OTC

Requirements/Limits

PA



Drug Name

Status*

miconazole nitrate 200 mg supp.vag

Generic

MICONAZORB AF

OTC

MICRO-GUARD

OTC

MIRANEL AF

OTC

MONISTAT 3 (3 4% CREAM, 3 COMBO PACK)

OTC

NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET)

Brand

NUZOLE

OTC

nyamyc

Generic

nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500mm unit powder(ea), 500k unit tablet, 100000/ml oral susp, 100000/g powder, 100000/g cream (g), 100000/g oint. (g))

Generic

nystop

Generic

OXISTAT (1% CREAM, 1% LOTION)

Brand

pedi-dri

Generic

REMEDY ANTIFUNGAL (2% POWDER, 2% CREAM)

OTC

REMEDY PHYTOPLEX ANTIFUNGAL 2%

OTC

RINGWORM

OTC

SECURA ANTIFUNGAL

OTC

SPORANOX 10 MG/ML SOLUTION

Brand

terbinafine hcl 250 mg tablet

Generic

terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag)

Generic

tioconazole

OTC

TIOCONAZOLE 1

OTC

TIOCONAZOLE-1

OTC

tolnaftate 1 % cream (g)

OTC

VAGISTAT-3

OTC

Requirements/Limits

PA



Drug Name

Status*

voriconazole (200 mg tablet, 200 mg/5ml susp recon)

Generic

ZEASORB 2% POWDER

OTC

Requirements/Limits

Antigout Agents allopurinol (100 mg tablet, 300 mg tablet)

Generic

colchicine 0.6 mg tablet

Brand

colchicine/probenecid

Generic

COLCRYS

Brand

probenecid

Generic

QL (60 PER 30 DAYS) QL (60 PER 30 DAYS)

Antimigraine Agents Ergot Alkaloids cafergot

Generic

dihydroergotamine mesylate 0.5mg/spry spray/pump

Brand

ergotamine tartrate/caffeine

Generic

migergot

Generic

MIGRANAL

Brand

QL (3.5 ML PER 30 DAYS)


Prophylactic timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet)

Generic

Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl

Generic

QL (18 PER 30 DAYS)

rizatriptan benzoate

Generic

QL (24 PER 30 DAYS)

sumatriptan (5 mg spray, 20 mg spray)

Generic

QL (6 PER 30 DAYS)

sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet)

Generic

QL (18 PER 30 DAYS)

sumatriptan succinate (4 pen injctr, 4 cartridge, 6 pen injctr, 6 syringe, 6 cartridge, 6 vial)

Generic




Drug Name

Status*

Requirements/Limits

zolmitriptan (2.5 mg tab rapdis, 2.5 mg tablet, 5 mg tab rapdis, 5 mg tablet)

Generic

QL (12 PER 30 DAYS)

ZOMIG (2.5 MG SPRAY, 5 MG SPRAY)

Brand

QL (12 PER 30 DAYS)

Antimyasthenic Agents Parasympathomimetics MESTINON 60 MG/5 ML SYRUP

Brand

pyridostigmine bromide (60 mg tablet, 180 mg tablet er)

Generic

Antimycobacterials Antimycobacterials, Other dapsone (25 mg tablet, 100 mg tablet)

Generic

rifabutin

Generic

Antituberculars ethambutol hcl

Generic

isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet)

Generic

pyrazinamide

Generic

RIFAMATE

Brand

rifampin (150 mg capsule, 300 mg capsule)

Generic

SIRTURO

Specialty

LA

ALKERAN 2 MG TABLET

Brand

PA

CEENU

Brand

CYCLOPHOSPHAMIDE CAPSULES

Brand

cyclophosphamide tablets

Generic

Antineoplastics Alkylating Agents



Drug Name

Status*

Requirements/Limits

GLEOSTINE

Brand

LEUKERAN

Brand

lomustine

Brand

MATULANE

Specialty

MYLERAN

Brand

temozolomide

Specialty

PA

VALCHLOR

Specialty

LA

POMALYST

Specialty

PA

REVLIMID

Specialty

PA, LA

THALOMID

Specialty

Antiangiogenic Agents

Antiestrogens/Modifiers EMCYT

Specialty

FARESTON

Brand

SOLTAMOX

Brand

tamoxifen citrate (10 mg tablet, 20 mg tablet)

Generic

Antimetabolites capecitabine

Generic

DROXIA

Brand

hydroxyurea 500 mg capsule

Generic

mercaptopurine 50 mg tablet

Generic

methotrexate sodium (2.5 mg tablet, 25 mg/ml vial)

Generic

methotrexate sodium/pf (1 g vial, 25 mg/ml vial)

Generic

PURIXAN

Brand

RHEUMATREX

Brand

TABLOID

Brand



Drug Name

Status*

TREXALL

Brand

Requirements/Limits

Antineoplastics, Other ALFERON N

Specialty

PA

FARYDAK

Specialty


flutamide

Generic

HEXALEN

Specialty

imiquimod 5 % cream pack

Generic

INTRON A (6 MILLION UNIT/ML VL, 10 MILLION UNIT/ML, 10 MILLION UNITS VIL, 18 MILLION UNITS VIL, 50 MILLION UNITS VIL)

Specialty

leucovorin calcium 5 mg tablet

Generic

SYLATRON

Specialty

PA

SYLATRON 4-PACK

Specialty

PA

Aromatase Inhibitors, 3rd Generation anastrozole 1 mg tablet

Generic

exemestane

Generic

letrozole 2.5 mg tablet

Generic

Enzyme Inhibitors BOSULIF

Specialty

PA

etoposide 50 mg capsule

Generic

GILOTRIF

Specialty

PA

HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE)

Specialty

PA

IMBRUVICA

Specialty

PA

INLYTA

Specialty

PA, LA

JAKAFI

Specialty

PA, LA

LYNPARZA

Specialty

PA, LA

MEKINIST

Specialty

PA



Drug Name

Status*

Requirements/Limits

TAFINLAR

Specialty

PA

VOTRIENT

Specialty

PA

ZELBORAF

Specialty

PA

ZYTIGA

Specialty

PA

AFINITOR

Specialty

PA

AFINITOR DISPERZ

Specialty

PA

CAPRELSA

Specialty

PA

COMETRIQ

Specialty

PA, LA

ERIVEDGE

Specialty

PA

GLEEVEC

Specialty

PA

IBRANCE

Specialty

PA

ICLUSIG

Specialty

PA

LENVIMA

Specialty

PA, LA

NEXAVAR

Specialty

PA

SPRYCEL

Specialty

PA

STIVARGA

Specialty

PA

SUTENT

Specialty

PA

TARCEVA

Specialty

PA

TASIGNA

Specialty

PA

TYKERB

Specialty

PA

vandetanib

Specialty

PA

XALKORI

Specialty

PA, LA

ZOLINZA

Specialty

PA

ZYDELIG

Specialty


ZYKADIA

Specialty

PA

Specialty

PA

Molecular Target Inhibitors

Retinoids bexarotene



Drug Name

Status*

Requirements/Limits

TARGRETIN 1% GEL

Specialty

PA

tretinoin 10 mg capsule

Specialty

PA

Antiparasitics Anthelmintics ALBENZA

Brand

ivermectin 3 mg tablet

Generic

Antiprotozoals atovaquone

Specialty

PA

chloroquine phosphate (250 mg tablet, 500 mg tablet)

Generic

PA

DARAPRIM

Brand

PA

hydroxychloroquine sulfate 200 mg tablet

Generic

mefloquine hcl

Generic

NEBUPENT

Brand

primaquine phosphate

Generic

PA PA

Pediculicides/Scabicides elimite

Generic

LICE CREAM RINSE

OTC

LICE KILLING (EQ SHAMPOO, KRO SHAMPOO, SM SHAMPOO, V-R SHAMPOO)

OTC

LICE TREATMENT (GNP 1% CRM RINS, HM 1% LOTION, PV PERMETHRIN, RA 1% CRM RINSE, SM 1% CRM RINSE, 1% CREME RINSE, SM PERMETHRIN)

OTC

lindane

Generic

permethrin 1 % liquid

OTC

permethrin 5 % cream (g)

Generic

ULESFIA

Brand



Drug Name

Status*

Requirements/Limits

Antiparkinson Agents Anticholinergics benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet)

Generic

trihexyphenidyl hcl (2 mg/5 ml elixir, 2 mg tablet, 5 mg tablet)

Generic

Antiparkinson Agents, Other amantadine hcl (50 mg/5 ml solution, 100 mg tablet, 100 mg capsule)

Generic

carbidopa/levodopa/entacapone

Generic

entacapone

Generic

Dopamine Agonists bromocriptine mesylate (2.5 mg tablet, 5 mg capsule)

Generic

pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet)

Generic

ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet)

Generic

Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors carbidopa 25 mg tablet

Generic

carbidopa/levodopa (10mg-100mg tablet, 25mg-250mg tablet, 25mg100mg tablet er, 25mg-100mg tablet, 50mg-200mg tablet er)

Generic

Monoamine Oxidase B (MAO-B) Inhibitors AZILECT

Brand

selegiline hcl (5 mg tablet, 5 mg capsule)

Generic



Drug Name

Status*

Requirements/Limits

Antispasticity Agents baclofen (10 mg tablet, 20 mg tablet)

Generic

dantrolene sodium (25 mg capsule, 50 mg capsule, 100 mg capsule)

Generic

MYRBETRIQ

Brand

tizanidine hcl (2 mg tablet, 4 mg tablet)

Generic

PA

Antivirals Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors EDURANT

Brand

INTELENCE

Brand

nevirapine (50 mg/5 ml oral susp, 200 mg tablet, 400 mg tab er 24h)

Generic

RESCRIPTOR 100 MG TABLET

Brand

SUSTIVA

Brand

VIRAMUNE XR 100 MG TABLET

Brand

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors abacavir sulfate

Generic

abacavir sulfate/lamivudine/zidovudine

Generic

COMPLERA

Brand

didanosine

Generic

EMTRIVA 200 MG CAPSULE

Brand

EPZICOM

Brand

lamivudine (10 mg/ml solution, 150 mg tablet, 300 mg tablet)

Generic

lamivudine/zidovudine

Generic

stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule)

Generic



Drug Name

Status*

TRUVADA

Brand

VIDEX

Brand

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG TABLET, POWDER)

Brand

ZIAGEN 20 MG/ML SOLUTION

Brand

zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet)

Generic

Requirements/Limits

Anti-HIV Agents, Other ATRIPLA

Brand

FUZEON

Brand

ISENTRESS (100 MG POWDER PACKET, 400 MG TABLET)

Brand

SELZENTRY

Brand

STRIBILD

Brand

TIVICAY

Brand

TRIUMEQ

Brand

TYBOST

Brand

VITEKTA

Brand

Anti-HIV Agents, Protease Inhibitors APTIVUS 250 MG CAPSULE

Brand

CRIXIVAN

Brand

EVOTAZ

Brand

INVIRASE

Brand

KALETRA (100-25 MG TABLET, 200-50 MG TABLET, 400-100/5 ML ORAL SOLU)

Brand

LEXIVA 700 MG TABLET

Brand

NORVIR (80 MG/ML SOLUTION, 100 MG TABLET, 100 MG SOFTGEL CAP)

Brand

PREZCOBIX

Specialty



Drug Name

Status*

PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET)

Brand

REYATAZ

Brand

VIRACEPT

Brand

Requirements/Limits

Anti-cytomegalovirus (CMV) Agents VALCYTE 50 MG/ML SOLUTION

Brand

valganciclovir hcl

Generic

ZIRGAN

Brand

QL (60 PER 30 DAYS)

Anti-influenza Agents RELENZA

Brand

rimantadine hcl

Generic

TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE, 45 MG CAPSULE, 75 MG CAPSULE)

Brand

Antihepatitis Agents adefovir dipivoxil

Specialty

BARACLUDE 0.05 MG/ML SOLUTION

Specialty

entecavir

Specialty

EPIVIR HBV 25 MG/5 ML SOLN

Brand

HARVONI

Specialty

INCIVEK

Specialty

INFERGEN

Specialty

lamivudine 100 mg tablet

Generic

MODERIBA

Specialty

OLYSIO

Specialty

PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 ML SYRINGE)

Specialty

PEGASYS PROCLICK

Specialty





Drug Name

Status*

Requirements/Limits

PEGINTRON

Specialty

PEGINTRON REDIPEN

Specialty

REBETOL 40 MG/ML SOLUTION

Specialty

RIBAPAK

Specialty

RIBASPHERE

Specialty

RIBASPHERE RIBAPAK

Specialty

RIBATAB

Specialty

ribavirin (200 mg capsule, 200 mg tablet, 400 mg tablet, 600 mg tablet)

Specialty

SOVALDI

Specialty

TYZEKA

Specialty

VICTRELIS

Specialty

PA

VIEKIRA PAK

Specialty



Antiherpetic Agents acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet)

Generic

DENAVIR

Brand

famciclovir

Generic

trifluridine 1 % drops

Generic

valacyclovir hcl (500 mg tablet, 1000 mg tablet)

Generic

PA

Anxiolytics Anxiolytics, Other clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tablet, 0.5 mg tab rapdis, 1 mg tab rapdis, 1 mg tablet, 2 mg tab rapdis, 2 mg tablet)

Generic



Drug Name

Status*

Requirements/Limits

Blood Glucose Regulators Antidiabetic Agents acarbose

Generic

ACTOPLUS MET XR

Brand

BYDUREON

Brand

ST

BYDUREON PEN

Brand

ST

BYETTA

Brand

ST

chlorpropamide

Generic

FARXIGA

Brand

glimepiride

Generic

glipizide (2.5 mg tab er 24, 5 mg tablet, 5 mg tab er 24, 10 mg tab er 24, 10 mg tablet)

Generic

glipizide/metformin hcl

Generic

glyburide

Generic

glyburide,micronized

Generic

glyburide/metformin hcl

Generic

GLYXAMBI

Brand

PA

INVOKAMET

Brand

PA

INVOKANA

Brand

PA

JANUMET

Brand

PA

JANUMET XR

Brand

PA

JANUVIA

Brand

PA

JARDIANCE

Brand

PA

JENTADUETO

Brand

PA

KAZANO

Brand

PA

KOMBIGLYZE XR

Brand

PA

metformin hcl (500 mg tablet, 500 mg tab er 24h, 750 mg tab er 24h, 850 mg tablet, 1000 mg tablet)

Generic

PA



Drug Name

Status*

Requirements/Limits

NESINA

Brand

PA

ONGLYZA

Brand

PA

OSENI

Brand

PA

pioglitazone hcl

Generic

pioglitazone hcl/glimepiride

Generic

pioglitazone hcl/metformin hcl

Generic

RIOMET

Brand

SYMLINPEN 120

Brand

PA

SYMLINPEN 60

Brand

PA

tolazamide

Generic

TRADJENTA

Brand

PA

VICTOZA 2-PAK

Brand

ST

VICTOZA 3-PAK

Brand

ST

XIGDUO XR

Brand

PA

Glycemic Agents GLUCAGEN 1MG HYPOKIT

Brand

GLUCAGON EMERGENCY KIT

Brand

Insulins APIDRA

Brand

APIDRA SOLOSTAR

Brand

HUMALOG

Brand

HUMALOG KWIKPEN U-100

Brand

HUMALOG KWIKPEN U-200

Brand

HUMALOG MIX 50-50

Brand

HUMALOG MIX 50-50 KWIKPEN

Brand

HUMALOG MIX 75-25

Brand

HUMALOG MIX 75-25 KWIKPEN

Brand

HUMULIN 70-30

OTC



Drug Name

Status*

HUMULIN 70/30 KWIKPEN

OTC

HUMULIN N

OTC

HUMULIN N KWIKPEN

OTC

HUMULIN R

OTC

LANTUS

Brand

LANTUS SOLOSTAR

Brand

LEVEMIR

Brand

LEVEMIR FLEXPEN

Brand

LEVEMIR FLEXTOUCH

Brand

NOVOLIN 70-30

OTC

NOVOLIN N

OTC

NOVOLIN R

OTC

NOVOLOG

Brand

NOVOLOG FLEXPEN

Brand

NOVOLOG MIX 70-30

Brand

NOVOLOG MIX 70-30 FLEXPEN

Brand

TOUJEO SOLOSTAR

Brand

Requirements/Limits

Blood Products/Modifiers/ Volume Expanders Anticoagulants ELIQUIS

Brand

enoxaparin sodium

Generic

fondaparinux sodium

Generic

FRAGMIN

Specialty

heparin 50 units/5 ml (10/ml)

Generic

heparin sodium,porcine (10 unit/ml vial, 10 unit/ml syringe, 100/ml (1) syringe, 100/ml vial, 500/5 ml syringe, 1000/ml vial, 5000/ml vial, 10000/ml vial, 20000/ml vial)

Generic



Drug Name

Status*

heparin sodium,porcine/pf (10 unit/ml syringe, 10 unit/ml vial, 100/ml (1) vial, 500/5 ml syringe, 1000/10 ml syringe, 1000/ml vial)

Generic

jantoven

Generic

monoject prefill advanced (30 units/3 ml (10/ml), 100 unit/10 ml (10/ml), 500 unit/5 ml (100/ml), 1,000 unit/10 (100/ml))

Generic

PRADAXA

Brand

SAVAYSA

Brand

warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet, 6 mg tablet, 7.5 mg tablet, 10 mg tablet)

Generic

XARELTO

Brand

Requirements/Limits

Blood Formation Modifiers anagrelide hcl

Generic

ARANESP

Specialty

PA

EPOGEN

Specialty

PA

GRANIX

Brand

LEUKINE (250 MCG VIAL, 500 MCG/ML VIAL)

Specialty

NEULASTA

Specialty

NEUMEGA

Specialty

NEUPOGEN

Specialty

PROCRIT

Specialty

PA

PROMACTA

Specialty

PA

Coagulants tranexamic acid 650 mg tablet

Generic



Drug Name

Status*

Requirements/Limits

Platelet Modifying Agents AGGRENOX

Brand

aspirin/dipyridamole

Brand

BRILINTA 90 MG TABLET

Brand

cilostazol

Generic

clopidogrel bisulfate 75 mg tablet

Generic

dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet)

Generic

EFFIENT

Brand

ticlopidine hcl

Generic

Cardiovascular Agents Alpha-adrenergic Agonists clonidine

Generic

clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet)

Generic

guanfacine hcl (1 mg tablet, 2 mg tablet)

Generic

methyldopa

Generic

midodrine hcl (2.5 mg tablet, 5 mg tablet)

Generic

Alpha-adrenergic Blocking Agents doxazosin mesylate (1 mg tablet, 2 mg tablet, 4 mg tablet, 8 mg tablet)

Generic

prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule)

Generic

reserpine (0.1 mg tablet, 0.25 mg tablet)

Generic

terazosin hcl

Generic



Drug Name

Status*

Requirements/Limits

Angiotensin II Receptor Antagonists candesartan cilexetil

Generic

irbesartan

Generic

losartan potassium

Generic

valsartan

Generic

Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet)

Generic

captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet)

Generic

enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet)

Generic

EPANED

Brand

fosinopril sodium

Generic

lisinopril (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet)

Generic

moexipril hcl

Generic

perindopril erbumine

Generic

quinapril hcl

Generic

ramipril

Generic

trandolapril 1 mg tablet

Generic

Antiarrhythmics amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet)

Generic

disopyramide phosphate

Generic

flecainide acetate

Generic

mexiletine hcl (150 mg capsule, 200 mg capsule, 250 mg capsule)

Generic

MULTAQ

Brand

NORPACE CR

Brand



Drug Name

Status*

pacerone 200 mg tablet

Generic

propafenone hcl (150 mg tablet, 225 mg tablet, 300 mg tablet)

Generic

quinidine gluconate 324 mg tablet er

Generic

quinidine sulfate (200 mg tablet, 300 mg tablet er, 300 mg tablet)

Generic

sorine

Generic

sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mg tablet)

Generic

verapamil hcl (40 mg tablet, 80 mg tablet, 120 mg tablet)

Generic

Requirements/Limits

Beta-adrenergic Blocking Agents acebutolol hcl (200 mg capsule, 400 mg capsule)

Generic

atenolol (25 mg tablet, 50 mg tablet, 100 mg tablet)

Generic

betaxolol hcl (10 mg tablet, 20 mg tablet)

Generic

bisoprolol fumarate

Generic

carvedilol

Generic

COREG CR

Brand

esmolol hcl

Generic

INDERAL XL

Brand

INNOPRAN XL

Brand

labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet)

Generic

LEVATOL

Brand

metoprolol succinate

Generic

metoprolol tartrate (25 mg tablet, 50 mg tablet, 100 mg tablet)

Generic

nadolol (20 mg tablet, 40 mg tablet, 80 mg tablet)

Generic



Drug Name

Status*

pindolol

Generic

propranolol hcl (10 mg tablet, 20 mg/5 ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, 60 mg cap sa 24h, 60 mg tablet, 80 mg tablet, 80 mg cap sa 24h, 120 mg cap sa 24h, 160 mg cap sa 24h)

Generic

Requirements/Limits

Calcium Channel Blocking Agents afeditab cr

Generic

amlodipine besylate (2.5 mg tablet, 5 mg tablet, 10 mg tablet)

Generic

CARDENE SR

Brand

CARDIZEM LA 120 MG TABLET

Brand

cartia xt

Generic

dilt-cd

Generic

dilt-xr

Generic

diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mg tablet, 90 mg cap er 12h, 90 mg tablet, 120 mg cap er 12h, 120 mg cap er 24h, 120 mg cap er deg, 120 mg capsule er, 120 mg tablet, 180 mg cap er 24h, 180 mg capsule er, 180 mg tab er 24h, 180 mg cap er deg, 240 mg tab er 24h, 240 mg cap er deg, 240 mg cap er 24h, 240 mg capsule er, 300 mg capsule er, 300 mg cap er 24h, 360 mg cap er 24h, 360 mg capsule er, 360 mg tab er 24h, 420mg tab er 24h, 420mg capsule er)

Generic

diltiazem hcl 300 mg tab er 24h

Generic

diltzac er

Generic

felodipine

Generic

matzim la (180 mg tablet, 240 mg tablet, 360 mg tablet, 420 mg tablet)

Generic

matzim la 300 mg tablet

Generic

nicardipine hcl (20 mg capsule, 30 mg capsule)

Generic

PA

PA



Drug Name

Status*

nifediac cc

Generic

nifedical xl

Generic

nifedipine (10 mg capsule, 20 mg capsule, 30 mg tab er 24, 30 mg tablet er, 60 mg tablet er, 60 mg tab er 24, 90 mg tab er 24, 90 mg tablet er)

Generic

nimodipine 30 mg capsule

Generic

nisoldipine (8.5mg tab er 24h, 17 mg tab er 24h, 25.5 mg tab er 24h, 34 mg tab er 24h)

Generic

taztia xt

Generic

verapamil hcl (100 mg cap24h pct, 120 mg tablet er, 120 mg cap24h pel, 180 mg cap24h pel, 180 mg tablet er, 200 mg cap24h pct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct, 360 mg cap24h pel)

Generic

Requirements/Limits

Cardiovascular Agents, Other amiloride hcl/hydrochlorothiazide

Generic

amlodipine besylate/atorvastatin calcium

Generic

amlodipine besylate/benazepril hcl (5 mg-40 mg capsule, 10 mg-40mg capsule)

Generic

amlodipine besylate/valsartan

Generic

atenolol/chlorthalidone

Generic

benazepril hcl/hydrochlorothiazide

Generic

bisoprolol fumarate/hydrochlorothiazide

Generic

captopril/hydrochlorothiazide

Generic

clorpres

Generic

digitek

Generic

digox

Generic

digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet)

Generic



Drug Name

Status*

enalapril maleate/hydrochlorothiazide

Generic

fosinopril sodium/hydrochlorothiazide

Generic

irbesartan/hydrochlorothiazide

Generic

LANOXIN (62.5 MCG TABLET, 187.5 MCG TABLET)

Brand

lisinopril/hydrochlorothiazide

Generic

losartan potassium/hydrochlorothiazide

Generic

methyldopa/hydrochlorothiazide

Generic

metoprolol tartrate/hydrochlorothiazide

Generic

pentoxifylline 400 mg tablet er

Generic

propranolol hcl/hydrochlorothiazide

Generic

quinapril hcl/hydrochlorothiazide

Generic

spironolactone/hydrochlorothiazide

Generic

triamterene/hydrochlorothiazide

Generic

valsartan/hydrochlorothiazide

Generic

Requirements/Limits

Diuretics, Carbonic Anhydrase Inhibitors acetazolamide 500 mg capsule er

Generic

methazolamide (25 mg tablet, 50 mg tablet)

Generic

Diuretics, Loop bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet)

Generic

EDECRIN

Brand

ethacrynate sodium

Generic

furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, 80 mg tablet)

Generic

torsemide (5 mg tablet, 10 mg tablet, 20 mg tablet, 100 mg tablet)

Generic



Drug Name

Status*

Requirements/Limits

Diuretics, Potassium-sparing amiloride hcl

Generic

eplerenone

Generic

spironolactone (25 mg tablet, 50 mg tablet, 100 mg tablet)

Generic

Diuretics, Thiazide chlorothiazide

Generic

chlorthalidone

Generic

hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 25 mg tablet, 50 mg tablet)

Generic

indapamide

Generic

methyclothiazide

Generic

metolazone

Generic

Dyslipidemics, Fibric Acid Derivatives fenofibrate (54 mg tablet, 160 mg tablet)

Generic

fenofibrate nanocrystallized

Generic

fenofibrate,micronized (67 mg capsule, 134mg capsule, 200 mg capsule)

Generic

fenofibric acid

Generic

fenofibric acid (choline)

Generic

gemfibrozil 600 mg tablet

Generic

lofibra

Generic

TRIGLIDE

Brand

Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium

Generic

CRESTOR

Brand

fluvastatin sodium (20 mg capsule, 40 mg capsule)

Generic



Drug Name

Status*

lovastatin

Generic

pravastatin sodium

Generic

simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet)

Generic

Requirements/Limits

Dyslipidemics, Other cholestyramine (with sugar) (4 g powder, 4 g powd pack)

Generic

cholestyramine/aspartame 4 g powd pack

Generic

COLESTID FLAVORED GRANULES

Brand

colestid granules

Generic

colestipol hcl (1 g tablet, 5 g packet, 5 g granules)

Generic

ENDUR-ACIN SR 500 MG TABLET

OTC

JUXTAPID

Specialty

PA, LA

KYNAMRO

Specialty

PA, LA

niacin (500 mg tablet er, 500 mg tablet, 1000 mg tablet er)

OTC

niacin (inositol niacinate) 500 mg tablet

OTC

omega-3 fatty acids (500 mg capsule, 500 mg capsule dr, 1000 mg capsule)

OTC

omega-3 fatty acids/docosahexanoic acid/epa/fish oil (oil 250-500 mg capsule, oil 300-1000mg capsule, oil 1000 mg capsule)

OTC

omega-3 fatty acids/fish oil (oil 3001000mg capsule, oil 300-500 mg capsule, oil 340-1000mg capsule)

OTC

omega-3 fatty acids/vitamin e

OTC

prevalite packet

Generic

SLO-NIACIN 500 MG TABLET

OTC

SUPER OMEGA-3 SOFTGEL

OTC

ZETIA

Brand

PA



Drug Name

Status*

Requirements/Limits

Vasodilators, Direct-acting Arterial hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet)

Generic

minoxidil (2.5 mg tablet, 10 mg tablet)

Generic

Vasodilators, Direct-acting Arterial/Venous isochron

Generic

isosorbide dinitrate

Generic

isosorbide mononitrate

Generic

minitran

Generic

NITRO-BID

Brand

NITRO-DUR (0.3 PATCH, 0.8 PATCH)

Brand

nitro-time

Generic

nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24, 0.6mg/hr patch td24, 2.5 mg capsule er, 6.5 mg capsule er, 9 mg capsule er)

Generic

NITROSTAT

Brand

Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines dextroamphetamine sulfsaccharate/amphetamine sulfaspartate (5 mg cap er 24h, 10 mg cap er 24h, 15 mg cap er 24h, 25 mg cap er 24h, 30 mg cap er 24h)

Generic

dextroamphetamine sulfsaccharate/amphetamine sulfaspartate (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 12.5 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet)

Generic

dextroamphetamine sulfate (5 mg tablet, 5 mg capsule er, 10 mg tablet, 10 mg capsule er, 15 mg capsule er)

Generic

QL (1 PER DAY)



Drug Name

Status*

Requirements/Limits

dextroamphetamine/amphetamine 20 mg cap er 24h

Generic

QL (2 PER DAY)

VYVANSE

Brand

QL (1 PER DAY)

zenzedi (5 mg tablet, 10 mg tablet)

Generic

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines DAYTRANA

Brand

QL (30 PER 30 DAYS)

metadate er

Generic

QL (3 PER DAY)

methylphenidate hcl (10 mg cpbp 3070, 20 mg cpbp 30-70, 30 mg cpbp 3070, 40 mg cpbp 30-70, 50 mg cpbp 3070, 60 mg cpbp 30-70)

Generic

QL (30 PER 30 DAYS)

methylphenidate hcl (2.5 mg tab chew, 5 mg tablet, 5 mg tab chew, 10 mg tablet, 10 mg tablet er, 10 mg/5 ml solution, 10 mg tab chew, 18 mg tab er 24, 20 mg tablet, 20 mg cpbp 50-50, 27 mg tab er 24, 30 mg cpbp 50-50, 36 mg tab er 24, 40 mg cpbp 50-50, 54 mg tab er 24)

Generic

methylphenidate hcl 20 mg tablet er

Generic

QL (3 PER DAY)

RITALIN LA (10 MG CAPSULE, 60 MG CAPSULE)

Brand

QL (1 PER DAY)

BETASERON 0.3 MG KIT

Specialty


BETASERON 0.3 MG VIAL

Specialty


EXTAVIA 0.3 MG KIT

Specialty


EXTAVIA 0.3 MG VIAL

Specialty


GILENYA

Specialty


NUEDEXTA

Brand

PA

riluzole

Generic

tetrabenazine

Specialty

Central Nervous System Agents, Other

PA, LA



Drug Name

Status*

Requirements/Limits

AMPYRA

Specialty

PA, LA, QL (60 PER 30 DAYS)

AUBAGIO

Specialty


AVONEX (SYR 30 MCG, SYR 30 MCG KT)

Specialty

AVONEX ADMINISTRATION PACK

Specialty

AVONEX PEN

Specialty

COPAXONE 20 MG/ML SYRINGE

Specialty


COPAXONE 40 MG/ML SYRINGE

Specialty


GLATOPA

Specialty


PLEGRIDY

Specialty


PLEGRIDY PEN

Specialty


REBIF (22 ML SYRINGE, 44 ML SYRINGE)

Specialty


REBIF REBIDOSE (22 ML, 44 ML)

Specialty


REBIF REBIDOSE TITRATION PACK

Specialty


TECFIDERA

Specialty

QL (60 PER 30 DAYS)

Multiple Sclerosis Agents

Dental and Oral Agents ANTICAVITY FLUORIDE

OTC

denta 5000 plus

Generic

dentagel

Generic

FLUOR-A-DAY (0.25 MG TAB CHEW, 0.5 MG TAB CHEW, 1 MG TABLET CHEW)

Brand

fluoridex daily defense

Generic

fluoritab (0.125 mg/drp drops, 0.5 mg tablet chew)

Generic

ludent fluoride

Generic

PHOS-FLUR

OTC

pilocarpine hcl (5 mg tablet, 7.5 mg tablet)

Generic

prevident 1.1% gel

Generic



Drug Name

Status*

sf

Generic

sf 5000 plus

Generic

sodium fluoride (0.2 % solution, 0.25(0.55) tab chew, 0.5(1.1)mg tab chew, 1mg(2.2mg) tab chew)

Generic

Requirements/Limits

Dermatological Agents ALLERGY CREAM

OTC

ALLERGY RELIEF SPRAY

OTC

ANTI-ITCH (2% SPRAY, CVS 2% CREAM, 2% CREAM, EQ CREAM, GNP 2% CREAM, QC CREAM, RA SPRAY, SB 2%0.1% CREAM, SM 2% CREAM, SM SPRAY)

OTC

BANOPHEN ANTI-ITCH

OTC

BENADRYL ITCH STOPPING CRM

OTC

DESITIN CLEAR

OTC

diphenhydramine hcl 2 % cream (g)

OTC

DRY SKIN THERAPY

OTC

ITCH RELIEF (CREAM, CVS CREAM, CVS SPRAY)

OTC

PV ALLERGY 2% CREAM

OTC

SELSUN BLUE

OTC

SKIN PROTECTANT A & D

OTC

VITAMIN A & D GRX

OTC

vitamins a and d oint. (g)

OTC

vits a & d/white pet/lanolin oint. (g)

OTC

WAL-DRYL (2%-0.1% CREAM, ANTI-ITCH SPRAY)

OTC

acitretin

Generic

ANTI-ITCH CREAM

OTC

calcipotriene (0.005 % cream (g), 0.005 % oint. (g), 0.005 % solution)

Generic



Drug Name

Status*

Requirements/Limits

calcitrene

Generic

clotrimazole/betamethasone dipropionate (1 %-0.05 % lotion, 1 %0.05 % cream (g))

Generic

CLOVERINE

OTC

CONDYLOX 0.5% GEL

Brand

cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mg/ml solution)

Generic

DRITHOCREME HP

Brand

ELIDEL

Brand

gengraf (25 mg capsule, 100 mg/ml solution, 100 mg capsule)

Generic

HYDROLATUM

OTC

LOBANA BATH OIL

OTC

MAPO

OTC

mineral oil oil

OTC

mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution)

Generic

petrolatum,white (jelly (g), oint pack, oint. (g))

OTC

petrolatum,white/lanolin

OTC

podofilox 0.5 % solution

Generic

PROTECTIVE OINTMENT

OTC

REGRANEX

Brand

SECURA PROTECTIVE OINTMENT

OTC

selenium sulfide (2.25 % shampoo, 2.5 % suspension)

Generic

STELARA 45 MG/0.5 ML SYRINGE

Specialty


STELARA 90 MG/ML SYRINGE

Specialty


tacrolimus (0.03 % oint. (g), 0.1 % oint. (g))

Generic

PA

trianex

Generic

PA

PA



Drug Name

Status*

vaseline white petroleum

Generic

VOLTAREN

Brand

Requirements/Limits

Enzyme Replacement/ Modifiers BUPHENYL 500 MG TABLET

Specialty

PA

CARBAGLU

Brand

CERDELGA

Specialty

CREON

Brand

ELELYSO

Specialty

KUVAN

Specialty

ORFADIN 2 MG CAPSULE

Specialty

pancrelipase 5,000

Generic

RAVICTI

Specialty

LA

sodium phenylbutyrate 0.94 g/g powder

Specialty

PA

ZENPEP (DR 3,000 CAPSULE, DR 10,000 CAPSULE, DR 15,000 CAPSULE, DR 20,000 CAPSULE, DR 25,000 CAPSULE, DR 40,000 CAPSULE)

Brand

PA, LA

Gastrointestinal Agents Antispasmodics, Gastrointestinal ANTI-DIARRHEA

OTC



Drug Name

Status*

ANTI-DIARRHEAL (ANTI-DIARRHEAL 1 MG/5 ML SOLN, ANTI-DIARRHEAL 1 MG/5 ML LIQ, ANTI-DIARRHEAL 2 MG CAPLET, ANTI-DIARRHEAL 2 MG TABLET, ANTI-DIARRHEAL 2 MG SOFTGEL, CVS ANTI-DIARRHEAL 2 MG SFTGEL, CVS ANTI-DIARRHEAL 2 MG CAPLET, EQ ANTI-DIARRHEAL 2 MG CAPLET, EQL ANTI-DIARRHEAL 1 MG/5 ML, EQL ANTI-DIARRHEAL 2 MG CAPLET, GNP ANTI-DIARRHEAL 2 MG CAPLET, HM ANTI-DIARRHEAL 2 MG CAPLET, KRO ANTI-DIARRHEAL 2 MG CAPLET, PV ANTI-DIARRHEAL 2 MG CAPLET, QC ANTI-DIARRHEAL 2 MG CAPLET, QC ANTI-DIARRHEAL 2 MG SOFTGEL, RA ANTI DIARRHEAL 2 MG CAPLET, RA ANTI-DIARRHEAL 1 MG/5 ML, RA ANTI-DIARRHEAL 2 MG CAPLET, RA ANTI-DIARRHEAL 2 MG SOFTGEL, SM ANTI-DIARRHEAL 1 MG/5 ML, SM ANTI-DIARRHEAL 2 MG CAPLET, SM ANTI-DIARRHEAL 2 MG SOFTGEL, V-R ANTI-DIARRHEAL 2 MG CAPLET)

OTC

CUVPOSA

Brand

DIAMODE

OTC

dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 mg tablet)

Generic

glycopyrrolate (1 mg tablet, 2 mg tablet)

Generic

LO-PERAMIDE

OTC

loperamide hcl (1 mg/5 ml liquid, 2 mg tablet)

OTC

loperamide hcl 2 mg capsule

Generic

ULTRA A-D

OTC

Requirements/Limits

PA

Gastrointestinal Agents, Other ACID CONTROL (150 MG TABLET, GNP 150 MG TABLET)

OTC

ACID GONE

OTC



Drug Name

Status*

ACID GONE ANTACID

OTC

ACID REDUCER (CVS 150 MG TABLET, EQ 75 MG TABLET, EQ 150 MG TABLET, GNP 75 MG TABLET, HM 75 MG TABLET, PUB 75 MG TABLET, 75 MG TABLET, PV 75 MG TABLET, PV 150 MG TABLET, RA 75 MG TABLET, RA 150 MG TABLET, SB 75 MG TABLET, SB 150 MG TABLET, SM 75 MG TABLET, V-R 75 MG TABLET, 150 MG TABLET, HM 150 MG TABLET, SM 150 MG TABLET)

OTC

ACID REDUCER 150

OTC

ADVANCED ANTACID

OTC

ADVANCED ANTACID-ANTIGAS

OTC

ALMACONE LIQUID

OTC

ALMACONE-2

OTC

aluminum hydroxide (320 oral susp, 600 oral susp)

OTC

ANALPRAM HC 2.5% LOTION

Brand

ANTACID & ANTIGAS

OTC

ANTACID & GAS RELIEF

OTC

Requirements/Limits



Drug Name

Status*

ANTACID (EQ 500 MG CHEW TABLET, EQL 500 MG CHEW TABLET, 500 MG CHEW TABLET, 500 MG CHEWABLE TABLET, 675-135 MG TAB CHEW, CVS 750 MG CHEW TABLET, CVS KIDS 750 MG CHEW, CVS LIQUID, CVS MAX STRENGTH LIQ, EQ EXTRA STR TAB CHEW, EQ LIQUID, EQL CHEW TAB, EQL LIQUID, EQL SUSPENSION, EX-STR 750 MG TAB CHEW, EX-STR TABLET CHEW, GNP 500 MG CHEW TABLET, GNP 750 MG TAB CHEW, 750 MG CHEW TB, GNP SUSPENSION, KRO 500 MG CHEW TABLET, LIQUID, PUB 500 MG CHEW TABLET, PV 675-135 MG TAB CHEW, PV SUSPENSION, QC 500 MG CHEW TABLET, QC SUSPENSION, RA 500 MG CHEW TABLET, SB 500 MG CHEW TABLET, SB SUSPENSION, SM 500 MG CHEW TABLET, SM SUSPENSION, SUSPENSION)

OTC

ANTACID ANTI-GAS DOUBLE STR

OTC

ANTACID EXTRA STRENGTH (CVS XTRA STR CHEW TAB, EQ EX-STR CHEW TABLET, EQ EXTRA STR CHEW TAB, EQL XTRA STR CHEW TAB, EXTRA STRENGTH CHW TAB, GNP EXT STRGTH CHW TAB, GNP XTRA STR CHEW TAB, KRO 750 MG CHEW TABLET, PV EXTRA STRENGTH SUSP, QC XTRA STR CHEW TAB, RA XTRA STR CHEW TAB, SB XTRA STR CHEW TAB, SM EX-STR TAB CHEW, SM XTRA STR CHEW TAB, V-R XTRA STR CHEW TAB, VR X-S TAB CHEW, XTRA STRENGTH CHEW TAB)

OTC

ANTACID II PLUS SIMETHICONE

OTC

ANTACID II WITH SIMETHICONE

OTC

ANTACID M

OTC

ANTACID MAXIMUM STRENGTH (EQ TABLET CHEWABLE, MAXIMUM STRENGTH LIQ, PV MAX STRENGTH SUSP)

OTC

Requirements/Limits



Drug Name

Status*

ANTACID PLUS ANTI-GAS

OTC

ANTACID PLUS EXTRA STRENGTH

OTC

ANTACID TABLET

OTC

ANTACID ULTRA STRENGTH (CVS ULTRA TAB CHEW, EQ ULTRA STR TAB CHEW, KRO 1,000 MG CHEW TAB, RA ULTRA TAB CHEW, ULTRA STR 1,000 MG CHW, ULTRA STR TAB CHEWABLE)

OTC

ANTACID WITH SIMETHICONE

OTC

ANTACID-ANTIGAS (ANTACID ANTI-GAS LIQUID, ANTACID-ANTIGAS LIQUID, CVS ANTACID-ANTIGAS LIQUID, CVS ANTACID-ANTIGAS MAX STR LQ, GNP ANTACID ANTI-GAS LIQUID, HM ANTACID ANTI-GAS SUSPENSION, HM ANTACID-ANTIGAS SUSPENSION, KRO ANTACID-ANTIGAS LIQUID, PUB ANTACID-ANTI GAS SUSP, PV ANTACIDANTIGAS SUSPENSION, QC ANTACIDANTIGAS MAX STR, QC ANTACIDANTIGAS SUSPENSION, RA ANTACIDANTIGAS LIQUID, RA ANTACID-ANTIGAS SUSPENSION, SB ANTACID-ANTIGAS LIQUID, SM ANTACID ANTI-GAS LIQUID, SM ANTACID-ANTIGAS LIQUID)

OTC

ANTI-GAS (CVS 180 MG, QC 180 MG, ULTRA STR, V-R 166 MG)

OTC

APRISO

Brand

ASACOL HD

Brand

BAN-ACID

OTC

BISMATROL TABLET CHEW

OTC

bismuth subsalicylate 262 mg tab chew

OTC

CAL-GEST

OTC

CALCI-CHEW

OTC

CALCIUM ANTACID

OTC

Requirements/Limits



Drug Name

Status*

calcium carbonate (200(500)mg tab chew, 300mg(750) tab chew, 400(1000) tab chew, 500 mg/5ml oral susp, 500(1250) tab chew)

OTC

CANASA

Brand

CHENODAL

Specialty

CHILDREN'S PEPTO

OTC

CHILDREN'S SOOTHE

OTC

CITROMA

OTC

COMFORT GEL

OTC

DELZICOL

Brand

DIOTAME

OTC

diphenoxylate hcl/atropine sulfate (2.5.025mg tablet, 2.5-.025/5 liquid)

Generic

FLANAX ANTACID LIQUID

OTC

FLAVOR CHEWS ANTACID

OTC

FOAMING ANTACID (GNP LIQUID, GNP TAB CHW, LIQUID, PV CHEW TABLET, SM TABLET CHEW, TABLET CHEW)

OTC

FULYZAQ

Brand

GAS FREE

OTC

Requirements/Limits

PA, LA

PA



Drug Name

Status*

GAS RELIEF (CVS GAS RELIEF 80 MG TAB CHEW, CVS GAS RELIEF 125 MG CHEW TAB, CVS GAS RELIEF 125 MG SOFTGEL, CVS GAS RELIEF EX-STR DROPS, EQ GAS RELIEF 125 MG SOFTGEL, EQL GAS RELIEF 125 MG SOFTGEL, EQL GAS RELIEF 180 MG SOFTGEL, EQL GAS RELIEF DROPS, GAS RELIEF 20 MG/0.3 ML DROPS, GAS RELIEF 40 MG/0.6 ML DROPS, GAS RELIEF 80 MG TABLET CHEW, GAS RELIEF 125 TABLET CHEW, GAS RELIEF 125 MG SOFTGEL, GAS RELIEF 125 MG CHEW TABLET, GAS RELIEF 180 MG SOFTGEL, GAS RELIEF DROPS, GNP GAS RELIEF 125 MG CHEW TAB, GNP GAS RELIEF 125 MG SFTG, GNP GAS RELIEF 125 MG SOFTGEL, GNP GAS RELIEF 125 TAB CHEW, GNP GAS RELIEF DROPS, GS GAS RELIEF 125 MG SOFTGEL, HM GAS RELIEF 80 MG TAB CHEW, HM GAS RELIEF 125 MG SOFTGEL, KRO GAS RELIEF 180 MG SOFTGEL, PUB GAS RELIEF 125 MG SOFTGEL, PUB GAS RELIEF 180 MG SOFTGEL, PV GAS RELIEF 125 MG CHEW TAB, PV GAS RELIEF 125 MG SOFTGEL, PV GAS RELIEF 180 MG SOFTGEL, QC GAS RELIEF 80 MG TAB CHEW, QC GAS RELIEF 125 MG TAB CHEW, RA GAS RELIEF 40 MG/0.6 ML DP, RA GAS RELIEF 80 MG TAB CHEW, RA GAS RELIEF 125 MG TAB CHEW, RA GAS RELIEF 125 MG SOFTGEL, SB GAS RELIEF 40 MG/0.6 ML DRP, SM GAS REL ANTIFLATUENT 180 MG, SM GAS RELIEF 125 MG SOFTGEL, V-R GAS RELIEF 80 MG TAB CHEW)

OTC

GAS RELIEF 80

OTC

GAS-X EXTRA STRENGTH SOFTGEL

OTC

GAS-X ULTRA STRENGTH

OTC

GATTEX

Specialty

GAVISCON 80-14.2 MG TAB CHEW

OTC

GELUSIL ANTACID & ANTIGAS LIQ

OTC

Requirements/Limits

PA



Drug Name

Status*

GERI-LANTA

OTC

GERI-MOX

OTC

HEARTBURN ANTACID

OTC

HEARTBURN RELIEF (CVS RELIEF CHEW TAB, EQL RELIEF 75 MG TAB, EQL RELIEF 150 MG TB, EQL RLF 150 MG TAB, KRO RELIEF 150 MG TB, RELIEF 75 MG TABLET, RELIEF 150 MG TABLET)

OTC

HEARTBURN RELIEF 150

OTC

INFANT GAS RELIEF

OTC

INFANTS' GAS RELIEF

OTC

ipecac

OTC

lansoprazole/amoxicillin trihydrate/clarithromycin

Generic

LIALDA

Brand

LIQUID ANTACID

OTC

MAALOX MAXIMUM STRENGTH

OTC

MAG-AL PLUS XS

OTC

MAGLOX

OTC

magnesium citrate solution

OTC

MASANTI

OTC

MEDI-BISMUTH

OTC

mesalamine 4 g/60 ml enema

Generic

MI ACID

OTC

MI-ACID (MI ACID SUSPENSION, MIACID GAS 80 MG TAB CHEW)

OTC

MILANTEX

OTC

MINTOX

OTC

MINTOX MAXIMUM STRENGTH

OTC

MYLANTA GAS MAXIMUM STRENGTH

OTC

MYLANTEX DOUBLE-STRENGTH

OTC

Requirements/Limits



Drug Name

Status*

MYTAB GAS

OTC

MYTAB GAS MAXIMUM STRENGTH

OTC

PENTASA

Brand

PEP-T-MED

OTC

PEPTIC RELIEF 262 MG CHEW TAB

OTC

PINK BISMUTH (EQ TABLET CHEW, GNP TABLET CHEW, PV TABLET CHEW, QC TABLET CHEW, RA TABLET CHEW, TABLET CHEW)

OTC

PROCTOFOAM-HC

Brand

propantheline bromide 15 mg tablet

Generic

PYLERA

Brand

ranitidine hcl 150 mg tablet

Generic

ranitidine hcl 75 mg tablet

OTC

RI-GEL

OTC

RI-GEL II

OTC

RI-MAG

OTC

RI-MOX

OTC

RI-MOX PLUS

OTC

RIGINIC

OTC

RULOX

OTC

simethicone (40mg/0.6ml drops susp, 80 mg tab chew, 125 mg tab chew, 125 mg capsule, 180 mg capsule)

OTC

SMOOTH ANTACID

OTC

SOOTHE 262 MG CHEWABLE TABLET

OTC

STOMACH RELIEF (CVS RLF 262 MG CHEW TB, EQL RLF 262 MG CHEW TB, HM RLF 262 MG CHEW TAB, PUB RLF 262 MG CHEW TB, RELIEF 262 MG CHEW TAB, SM RLF 262 MG CHEW TAB)

OTC

sulfasalazine (500 mg tablet, 500 mg tablet dr)

Generic

Requirements/Limits



Drug Name

Status*

sulfazine

Generic

sulfazine ec

Generic

ULTRA STRENGTH ANTACID

OTC

ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet)

Generic

WAL-ZAN 150

OTC

WAL-ZAN 75

OTC

ZANTAC 75

OTC

Requirements/Limits

Histamine2 (H2) Receptor Antagonists ACID CONTROL 20 MG TABLET

OTC

ACID CONTROLLER (20 MG TABLET, CVS 20 MG TAB)

OTC

ACID REDUCER (EQ 20 MG TABLET, EQ 200 MG TABLET, EQL 200 MG TABLET, GNP 20 MG TABLET, KRO 200 MG TABLET, PUB 200 MG TABLET, PV 20 MG TABLET, RA 20 MG TABLET, RA 200 MG TABLET, SM 20 MG TABLET, 20 MG TABLET, SM 200 MG TABLET, 200 MG TABLET)

OTC

ACID RELIEF

OTC

cimetidine (300 mg tablet, 400 mg tablet, 800 mg tablet)

Generic

cimetidine 200 mg tablet

OTC

cimetidine hcl

Generic

famotidine (20 mg tablet, 40 mg tablet)

Generic

HEARTBURN PREVENTION (EQL PREVEN 20 MG TAB, KRO PREVEN 20 MG TAB, PREVENTION 20 MG TAB)

OTC

HEARTBURN RELIEF (RELIEF 20 MG TABLET, RELIEF 200 MG TABLET, SM RELIEF 200 MG TAB, V-R RELF 200 MG TB)

OTC

nizatidine (150 mg capsule, 300 mg capsule)

Generic



Drug Name

Status*

PEPCID AC 20 MG TABLET

OTC

ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 300 mg tablet, 300 mg capsule)

Generic

Requirements/Limits

Irritable Bowel Syndrome Agents alosetron hcl

Generic

PA

Laxatives ADULT GLYCERIN

OTC

ALOPHEN PILLS

OTC

BISA-LAX

OTC

BISACODYL (5 MG TABLET DR, FLEET EC 5 MG TAB, 10 MG SUPP.RECT)

OTC

BISCOLAX

OTC

castor oil

OTC

CHILD SUPPOSITORY

OTC

CHOCOLATED LAXATIVE

OTC

CITRUCEL 500 MG CAPLET

OTC

CLEARLAX

OTC

COL-RITE

OTC

constulose

Generic

CURAD ENEMA

OTC

DIOCTYL

OTC

DOC-Q-LACE

OTC

DOC-Q-LAX

OTC

DOCU LIQUID

OTC

DOCU SOFT

OTC

DOCUPRENE

OTC

docusate calcium

OTC

docusate sodium (50 mg/5 ml liquid, 60 mg/15ml syrup, 100 mg tablet, 100 mg capsule, 250 mg capsule)

OTC



Drug Name

Status*

DOCUSIL

OTC

DOK 100 MG TABLET

OTC

DOK PLUS

OTC

DSS

OTC

DUCODYL

OTC

DULCOLAX STOOL SOFTENER

OTC

ENEMA (ENEMA, ENEMA READY TO USE, ENEMA READY-TO-USE, ENEMA TWIN PACK, EQ ENEMA, EQL ENEMA READY TO USE, GNP ENEMA READY TO USE, HM ENEMA READY TO USE, HM ENEMA READY TO USE TWIN PAK, PV ENEMA, PV ENEMA READY TO USE, QC READY TO USE ENEMA, RA ENEMA TWIN PACK, SM ENEMA READY TO USE)

OTC

ENEMA DISPOSABLE

OTC

enulose

Generic

EQ DAILY FIBER LAXATIVE POWDER

OTC

EVAC-U-GEN

OTC

EX-LAX CHOCOLATE

OTC

FAST RELIEF LAXATIVE

OTC

FIBER (HM 500 MG CAPLET, 625 MG TABLET, HM POWDER, PUB 625 MG CAPLET, SM POWDER, TABLET)

OTC

FIBER LAX

OTC

FIBER LAXATIVE (EQL 625 MG CPLT, 625 MG TABLET, CVS 625 MG CPLT, KRO 625 MG CPLT, PV 625 MG CAPLT, PV POWDER, RA POWDER, SB 625 MG TAB, SM 500 MG CPLT, 625 MG CAPLET, SM 625 MG TAB)

OTC

FIBER SMOOTH

OTC

FIBER TABS

OTC

Requirements/Limits



Drug Name

Status*

FIBER THERAPY (500 MG CAPLET, CAPLET, CVS 500 MG CAPLT, EQ 625 MG CAPLET, EQ CAPLET, EQ POWDER, EQL 500 MG CPLT, EQL CAPLET, GNP 500 MG CAPLT, POWDER, PV 500 MG CAPLET, PV POWDER)

OTC

FIBER-LAX

OTC

FIBER-TABS

OTC

FLEET PEDIA-LAX SUPPOSITORIES

OTC

GAVILAX

OTC

gavilyte-c

Generic

gavilyte-g

Generic

gavilyte-n

Generic

generlac

Generic

GENTLE LAXATIVE

OTC

GENTLELAX

OTC

GERI-KOT

OTC

GERI-MUCIL

OTC

glycerin (adult supp.rect, pediatric supp.rect)

OTC

GLYCOLAX

OTC

HEALTHYLAX

OTC

HYDROCIL INSTANT PACKET

OTC

INFANT GLYCERIN

OTC

KAO-TIN 240 MG SOFTGEL

OTC

KONSYL (ORIGINAL POWDER, PSYLLIUM POWDER)

OTC

KONSYL EASY MIX

OTC

KONSYL FIBER

OTC

KONSYL FORMULA-D

OTC

KONSYL-D

OTC

Requirements/Limits



Drug Name

Status*

KRISTALOSE

Brand

lactulose

Generic

LAX STOOL SOFTENER WITH SENNA

OTC

LAXA CLEAR

OTC

LAXACIN

OTC

LAXATIVE (PUB EC 5 MG TABLET, 5 MG TABLET, CVS 15 MG PILLS, EC 5 MG TABLET, EQL EC 5 MG TABLET, GNP EC 5 MG TABLET, HM EC 5 MG TABLET, PV 5 MG TAB, PV EC 5 MG TABLET, SM TABLET, V-R CHOCOLATE)

OTC

LAXATIVE DIETARY SUPPLEMENT

OTC

LAXATIVE FEMININE

OTC

LAXATIVE PEG 3350

OTC

LAXATIVE SUPPOSITORY

OTC

MAGIC BULLET

OTC

magnesium hydroxide (400 mg/5ml oral susp, 2400 mg/10 oral susp)

OTC

magnesium oxide (250 mg tablet, 500 mg tablet)

OTC

MEDI-LAXX

OTC

MEDI-NATURAL

OTC

MEDI-NATURAL SENNA STOOL SOFT

OTC

METAMUCIL POWDER

OTC

METAMUCIL SUGAR FREE

OTC

MINERAL OIL (OIL ENEMA, OIL, HEAVY, OIL LAXATIVE)

OTC

MINERAL OIL EXTRA HEAVY

OTC

MOVE IT ALONG

OTC

MOVIPREP

Brand

NATURAL DAILY FIBER

OTC

NATURAL FIBER (EQ LAXATIVE POWD, GNP POWDER, LAX POWDER)

OTC

Requirements/Limits



Drug Name

Status*

NATURAL FIBER LAXATIVE

OTC

NATURAL FIBER POWDER

OTC

NATURAL FIBER SUPPLEMENT

OTC

NATURAL SENNA LAXATIVE

OTC

NATURAL VEGETABLE POWDER

OTC

nulytely with flavor packs

Generic

ORAL SALINE LAXATIVE

OTC

ORAL SALINE LAXATIVE KIT

OTC

P-COL RITE

OTC

PEDIA-LAX STOOL SOFTENER

OTC

peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl

Generic

PEG3350

OTC

PHILLIPS

OTC

PHILLIPS' LAXATIVE

OTC

PHOSPHATE ENEMA

OTC

PHOSPHATE LAXATIVE

OTC

polyethylene glycol 3350 (3350 17g powd pack, 3350 17g/dose powder)

Generic

POWDERLAX

OTC

PREPARATION CLEANSING

OTC

PROMOLAXIN

OTC

psyllium husk/aspartame

OTC

PURE & GENTLE SALINE ENEMA

OTC

PURELAX (POWDER, POWDER PACKET)

OTC

QC NATURAL VEG LAXATIVE TABLET

OTC

READY TO USE ENEMA

OTC

REGULOID (LAXATIVE POWDER, POWDER, POWDER ORANGE)

OTC

SALINE ENEMA

OTC

Requirements/Limits



Drug Name

Status*

SEN-O-TAB

OTC

SENEXON (8.8 MG/5 ML LIQUID, TABLET)

OTC

SENEXON-S

OTC

SENNA (HM SENNA 8.6 MG TABLET, PV SENNA 8.6 MG TABLET, QC SENNA LAXATIVE 8.6 MG TAB, RA SENNA 8.6 MG TABLET, SENNA 8.6 MG TABLET, SENNA LAXATIVE 8.6 MG TAB, SENNA LAXATIVE 8.6 MG TABLET, SENNA-TIME 8.6 MG TABLET)

OTC

SENNA LAX

OTC

SENNA LAXATIVE (CVS 8.6 MG TAB, EQL 8.6 MG TAB, SM 8.6 MG TAB, TABLET)

OTC

SENNA PLUS

OTC

SENNA S

OTC

SENNA-S

OTC

SENNA-TIME S

OTC

SENNALAX-S

OTC

SENNO

OTC

sennosides

OTC

sennosides/docusate sodium

OTC

SILACE

OTC

SMOOTHLAX (POWDER, POWDER PACKET)

OTC

sodium chloride/sodium bicarbonate/potassium chloride/peg

Generic

SOF-LAX

OTC

SOLUBLE FIBER

OTC

sorbitol solution 70 % solution

OTC

STIMULANT LAXATIVE PLUS

OTC

Requirements/Limits



Drug Name

Status*

STOOL SOFTENER (CVS SOFTENER 50 MG SFTGL, CVS SOFTENER 100 MG CAP, CVS SOFTENER 100 MG SFTG, CVS SOFTENER 250 MG SFGL, CVS SOFTENER SOFTGEL, EQ SOFTENER 100 MG CAP, EQ SOFTENER 100 MG SFTGL, EQL SOFTENER 100 MG SFGL, EQL SOFTENER TABLET, GNP SOFTENER 50 MG/5 ML, GNP SOFTENER 100 MG SFGL, GNP SOFTENER 250 MG SFGL, GNP SOFTENER SYRUP, HM SOFTENER 100 MG SFTGL, HM SOFTENER 250 MG SFTGL, PV SOFTENER 100 MG CAP, PV SOFTENER 100 MG SFTGL, QC SOFTENER 100 MG CAP, QC SOFTENER 100 MG SFTGL, QC SOFTENER-LAX TABLET, RA SOFTENER 100 MG SFTGL, RA SOFTENER 100 MG CAP, SM NAT LAX PLUS SOFTENER, SM SOFTENER 100 MG SFTGL, SM SOFTENER 240 MG SFTGL, SM SOFTENER 250 MG SFTGL, SM SOFTENER TABLET, SOFTENER 50 MG/5 ML LIQ, SOFTENER 100 MG TABLET, SOFTENER 100 MG SOFTGEL, SOFTENER 100 MG CAPSULE, SOFTENER 240 MG CAPS, SOFTENER 240 MG SOFTGEL, SOFTENER 250 MG SOFTGEL, SOFTENER SYRUP, SOFTENER TABLET, SOFTENER-LAXATIVE TAB, V-R SOFTENER TABLET)

OTC

STOOL SOFTENER-LAXATIVE

OTC

STOOL SOFTENER-STIMULANT LAX

OTC

SUPPOSITORY

OTC

SUPREP

Brand

trilyte with flavor packets

Generic

VEGETABLE LAXATIVE

OTC

WAL-MUCIL 100% NATURAL FIBER

OTC

WAL-MUCIL NATURAL FIBER LAX

OTC

WOMAN'S LAXATIVE

OTC

WOMEN'S GENTLE LAXATIVE

OTC

Requirements/Limits



Drug Name

Status*

WOMEN'S LAXATIVE

OTC

WOMENS STOOL SOFTENER

OTC

Requirements/Limits

Protectants CARAFATE 1 GM/10 ML SUSP

Brand

misoprostol (100 mcg tablet, 200 mcg tablet)

Generic

sucralfate 1 g tablet

Generic

Proton Pump Inhibitors ACID CONTROLLER (10 MG TABLET, CVS 10 MG TAB, EQ 10 MG TAB, QC 10 MG TAB)

OTC

ACID REDUCER (EQ 10 MG TABLET, GNP 10 MG TABLET, PUB 10 MG TABLET, PV 10 MG TABLET, RA 10 MG TABLET, SM 10 MG TABLET, V-R 10 MG TABLET, 10 MG TABLET)

OTC

famotidine 10 mg tablet

OTC

HEARTBURN PREVENTION (EQL TAB, KRO TAB, TAB)

OTC

HEARTBURN RELIEF 10 MG TABLET

OTC

HEARTBURN RELIEF 24 HOUR

OTC

HEARTBURN TREATMENT 24 HOUR

OTC

lansoprazole (15 mg capsule dr, 30 mg capsule dr)

Generic

omeprazole (10 mg capsule dr, 20 mg capsule dr, 40 mg capsule dr)

Generic

omeprazole 20 mg tablet dr

OTC

omeprazole magnesium

OTC

pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr)

Generic

PREVACID 30 MG SOLUTAB

Brand

PRILOSEC OTC

OTC



Drug Name

Status*

PROTONIX 40 MG SUSPENSION

Brand

rabeprazole sodium

Generic

Requirements/Limits

Genitourinary Agents Antispasmodics, Urinary flavoxate hcl

Generic

oxybutynin chloride (5 mg/5 ml syrup, 5 mg tablet, 5 mg tab er 24, 10 mg tab er 24, 15 mg tab er 24)

Generic

OXYTROL

Brand

tolterodine tartrate

Generic

trospium chloride 20 mg tablet

Generic

Benign Prostatic Hypertrophy Agents alfuzosin hcl

Generic

finasteride 5 mg tablet

Generic

tamsulosin hcl

Generic

Genitourinary Agents, Other AZO

OTC

AZO-TABS

OTC

bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg tablet, 50 mg tablet)

Generic

cytra-k oral solution

Generic

ELMIRON

Brand

methylergonovine maleate 0.2 mg tablet

Generic

potassium citrate/citric acid 1100-334/5 solution

Generic

PROCYSBI

Brand

PV AZO DINE 95 MG TABLET

OTC

PA, LA



Drug Name

Status*

URINARY PAIN RELIEF (CVS RLF 95 MG TAB, EQ RLF 95 MG TAB, GNP RLF 95 MG TAB, KRO RLF 95 MG TAB, PV RLF 95 MG TAB, RELIEF 95 MG TAB, SB RLF 95 MG TAB, SM RLF 95 MG TAB, V-R RLF 95 MG TAB)

OTC

URINARY TRACT

OTC

URISTAT 95 MG TABLET

OTC

virtrate-k

Generic

Requirements/Limits

Phosphate Binders AURYXIA

Brand

PA

calcium acetate 667 mg capsule

Generic

RENAGEL

Brand

PA

RENVELA

Brand

PA

sevelamer carbonate

Brand

PA

Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Glucocorticoids/Mineralocorticoids ANTI-ITCH (EQL 1%, RA 1%, 1%)

OTC

budesonide 3 mg capdr - er

Generic

CHILDREN'S NASACORT

OTC

CORTIZONE-10 1% OINTMENT

OTC

dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet)

Generic

dexamethasone intensol

Generic

dexamethasone sod phosphate 0.1 % drops

Generic

DEXPAK 13 DAY 1.5 MG TABLET

Brand

diclofenac sodium 0.1 % drops

Generic

EPIFOAM

Brand

PA



Drug Name

Status*

Requirements/Limits

FLONASE ALLERGY RELIEF

OTC

PA

FLOVENT DISKUS

Brand

FLOVENT HFA

Brand

fluocinolone acetonide oil

Generic

fluorometholone

Generic

fluticasone propionate 50 mcg spray susp

Generic

FML FORTE

Brand

FML S.O.P.

Brand

HC-1% HEMORRHOID

OTC

hydrocortisone (0.5 % cream (g), 0.5 % oint. (g))

OTC

hydrocortisone (1 % oint. (g), 5 mg tablet, 10 mg tablet, 20 mg tablet)

Generic

hydrocortisone acetate (0.5 % cream (g), 1 % oint. (g))

OTC

hydrocortisone butyrate (0.1 % oint. (g), 0.1 % solution)

Generic

hydrocortisone valerate

Generic

MEDROL 2 MG TABLET

Brand

NASACORT

OTC

prednisolone acetate

Generic

PA

PA

Hormonal Agents, Stimulant/Replacement/Modifying (Other) MYALEPT

Specialty

PA

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2 mg tablet, 10/spray spray/pump)

Generic

PA

desmopressin acetate (nonrefrigerated)

Generic

PA



Drug Name

Status*

Requirements/Limits

EGRIFTA

Specialty

PA

GENOTROPIN

Specialty

PA

INCRELEX

Specialty

PA, LA

NUTROPIN 5 MG VIAL

Specialty

PA

NUTROPIN AQ (5 MG/ML VIAL, 20 MG/2ML PEN CART)

Specialty

PA

NUTROPIN AQ NUSPIN 20 PEN CART

Specialty

PA

OMNITROPE (5 ML, 10 ML)

Specialty

PA

OMNITROPE 5.8 MG VIAL

Brand

PA

SAIZEN

Specialty

PA

SEROSTIM (5 MG VIAL, 8.8 MG VIAL)

Specialty

PA

STIMATE

Brand

TEV-TROPIN

Specialty

PA

ZOMACTON 5 MG VIAL

Specialty

PA

ZORBTIVE

Specialty

PA

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Androgens ANDRODERM

Brand

PA

ANDROGEL (1.62%(1.25G) GEL PCKT, 1.62% GEL PUMP, 1.62%(2.5G) GEL PCKT)

Brand

PA

testosterone cypionate (100 mg/ml vial, 200 mg/ml vial)

Generic

testosterone enanthate 200 mg/ml vial

Generic

Estrogens AFTERA

OTC

altavera

Generic

alyacen

Generic

amethia

Generic



Drug Name

Status*

amethia lo

Generic

amethyst

Generic

apri

Generic

aranelle

Generic

ashlyna

Generic

aubra

Generic

aviane

Generic

azurette

Generic

balziva

Generic

briellyn

Generic

camrese

Generic

camrese lo

Generic

caziant

Generic

chateal

Generic

cryselle

Generic

cyclafem

Generic

cyred

Generic

dasetta

Generic

daysee

Generic

delyla

Generic

desogestrel-ethinyl estradiol

Generic

desogestrel-ethinyl estradiol/ethinyl estradiol

Generic

DUAVEE

Brand

ECONTRA EZ

OTC

elinest

Generic

emoquette

Generic

enpresse

Generic

enskyce

Generic

Requirements/Limits



Drug Name

Status*

ESTRACE 0.01% CREAM

Brand

estradiol (.025mg/24h patch tdwk, .025mg/24h patch tdsw, .0375mg/24 patch tdwk, .0375mg/24 patch tdsw, 0.05mg/24h patch tdsw, 0.05mg/24h patch tdwk, 0.06mg/24h patch tdwk, .075mg/24h patch tdwk, .075mg/24h patch tdsw, 0.1mg/24hr patch tdwk, 0.1mg/24hr patch tdsw, 0.5 mg tablet, 1 mg tablet, 2 mg tablet)

Generic

estradiol/norethindrone acetate

Generic

ESTRING

Brand

estropipate

Generic

ethinyl estradiol/drospirenone

Generic

FALLBACK SOLO

OTC

falmina

Generic

gianvi

Generic

gildagia

Generic

gildess

Generic

gildess 24 fe

Generic

gildess fe

Generic

introvale

Generic

jolessa

Generic

junel

Generic

junel fe

Generic

junel fe 24

Generic

kariva

Generic

kelnor 1-35

Generic

kimidess

Generic

kurvelo

Generic

larin

Generic

larin 24 fe

Generic

Requirements/Limits



Drug Name

Status*

larin fe

Generic

leena

Generic

lessina

Generic

levonest

Generic

levonorgestrel 1.5 mg tablet

Generic

levonorgestrel-ethinyl estradiol

Generic

levonorgestrel/ethinyl estradiol and ethinyl estradiol

Generic

levora-28

Generic

lomedia 24 fe

Generic

lopreeza

Generic

loryna

Generic

low-ogestrel

Generic

lutera

Generic

marlissa

Generic

microgestin

Generic

microgestin fe

Generic

mimvey

Generic

mimvey lo

Generic

my way

Generic

myzilra

Generic

necon (1-35-28 tablet, 1-50-28 tablet, 77-7-28 tablet, 10-11-28 tablet)

Generic

next choice one dose

Generic

nikki

Generic

norethindrone ac-eth estradiol 1mg20mcg tablet

Generic

norethindrone acetate-ethinyl estradiol/ferrous fumarate

Generic

norgestimate-ethinyl estradiol 7daysx3 28 tablet

Generic

Requirements/Limits



Drug Name

Status*

nortrel (1-35 tablet, 7-7-7-28 tablet)

Generic

NUVARING

Brand

ocella

Generic

ogestrel

Generic

OPCICON ONE-STEP

OTC

orsythia

Generic

philith

Generic

pimtrea

Generic

pirmella

Generic

portia

Generic

PREFEST

Brand

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET, VAGINAL CREAM-APPL)

Brand

PREMPHASE

Brand

PREMPRO

Brand

quasense

Generic

reclipsen

Generic

setlakin

Generic

sronyx

Generic

syeda

Generic

tarina fe

Generic

tri-estarylla

Generic

tri-linyah

Generic

tri-previfem

Generic

tri-sprintec

Generic

trinessa

Generic

trivora-28

Generic

VAGIFEM

Brand

Requirements/Limits



Drug Name

Status*

velivet

Generic

vestura

Generic

viorele

Generic

vyfemla

Generic

xulane

Generic

zarah

Generic

zenchent

Generic

zovia 1-35e

Generic

zovia 1-50e

Generic

Requirements/Limits

Progestins camila

Generic

deblitane

Generic

DEPO-SUBQ PROVERA 104

Brand

errin

Generic

heather

Generic

jencycla

Generic

jolivette

Generic

levonorgestrel 0.75 mg tablet

Generic

lyza

Generic

medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10 mg tablet)

Generic

megestrol acetate (20 mg tablet, 40 mg tablet, 400mg/10ml oral susp)

Generic

nora-be

Generic

norethindrone 0.35 mg tablet

Generic

norethindrone acetate 5 mg tablet

Generic

norlyroc

Generic

progesterone,micronized (100 mg capsule, 200 mg capsule)

Generic



Drug Name

Status*

sharobel

Generic

Requirements/Limits

Selective Estrogen Receptor Modifying Agents raloxifene hcl

Generic

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet, 175mcg tablet, 200 mcg tablet, 300 mcg tablet)

Generic

levoxyl

Generic

liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcg tablet)

Generic

NATPARA

Specialty

THYROLAR-1

Brand

THYROLAR-1/2

Brand

THYROLAR-1/4

Brand

THYROLAR-2

Brand

THYROLAR-3

Brand

unithroid (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 150 mcg tablet, 175 mcg tablet, 200 mcg tablet, 300 mcg tablet)

Generic


Hormonal Agents, Suppressant (Adrenal) LYSODREN

Brand

SIGNIFOR

Specialty

PA, LA

Hormonal Agents, Suppressant (Parathyroid) calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution)

Generic



Drug Name

Status*

Requirements/Limits

paricalcitol (1 mcg capsule, 2 mcg capsule, 4mcg capsule)

Generic

ST

SENSIPAR (30 MG TABLET, 60 MG TABLET)

Specialty

QL (60 PER 30 DAYS)

SENSIPAR 90 MG TABLET

Specialty

Hormonal Agents, Suppressant (Pituitary) ELIGARD

Brand

PA

ganirelix acetate

Brand

PA

leuprolide acetate 1 mg/0.2ml kit

Specialty

PA

octreotide acetate

Specialty

PA

SOMAVERT

Specialty

PA, LA

ZOLADEX 3.6 MG IMPLANT SYRN

Brand

PA

Hormonal Agents, Suppressant (Sex Hormones/Modifiers) Antiandrogens bicalutamide

Generic

NILANDRON

Brand

XTANDI

Specialty

PA

Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole (5 mg tablet, 10 mg tablet)

Generic

propylthiouracil 50 mg tablet

Generic

Immunological Agents Angioedema (HAE) Agents BERINERT

Specialty




Drug Name

Status*

Requirements/Limits

Immune Suppressants ASTAGRAF XL

Brand

azathioprine 50 mg tablet

Generic

cyclosporine (25 mg capsule, 100 mg capsule)

Generic

cyclosporine, modified 100 mg capsule

Generic

ENBREL (50 MG/ML SYRINGE, 50 MG/ML SURECLICK SYR)

Specialty


ENBREL 25 MG KIT

Specialty

QL (8 PER 28 DAYS)

ENBREL 25 MG/0.5 ML SYRINGE

Specialty


hecoria

Generic

HUMIRA (10 MG/0.2 ML SYRINGE, 20 MG/0.4 ML SYRINGE)

Specialty

QL (2 PER 28 DAYS)

HUMIRA (40 ML SYRINGE, 40 ML PEN)

Specialty

QL (1 PER 28 DAYS)

HUMIRA CROHN'S

Specialty

QL (1 PER 28 DAYS)

HUMIRA PEDIATRIC CROHN'S

Specialty

QL (1 PER 28 DAYS)

HUMIRA PSORIASIS

Specialty

QL (1 PER 28 DAYS)

mycophenolate mofetil (200 mg/ml susp recon, 250 mg capsule, 500 mg tablet)

Generic

mycophenolate sodium

Generic

RAPAMUNE 1 MG/ML ORAL SOLN

Brand

RESTASIS

Brand

QL (60 PER 30 DAYS)

SIMPONI (100 MG/ML PEN INJECTOR, 100 MG/ML SYRINGE)

Specialty


SIMPONI (50 ML SYRINGE, 50 ML PEN INJEC)

Specialty


sirolimus (0.5 mg tablet, 1 mg tablet, 2 mg tablet)

Generic

tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule)

Generic

ZORTRESS

Specialty



Drug Name

Status*

Requirements/Limits

GAMMAKED

Specialty

PA

GAMUNEX-C

Specialty

PA

HIZENTRA (1 GRAM/5 ML VIAL, 2 GRAM/10 ML VIAL, 4 GRAM/20 ML VIAL)

Specialty

PA

HYQVIA

Specialty

PA

ACTIMMUNE

Specialty

PA

FIRAZYR

Specialty

PA, QL (9 ML PER 30 DAYS)

leflunomide

Generic

OTEZLA (28 DAY PACK, PACK)

Specialty

PA

OTEZLA 30 MG TABLET

Specialty

PA, QL (2 PER DAY)

Immunizing Agents, Passive

Immunomodulators

Inflammatory Bowel Disease Agents Aminosalicylates balsalazide disodium

Generic

DIPENTUM

Brand

Glucocorticoids colocort

Generic

hydrocortisone 100mg/60ml enema

Generic

proctosol-hc

Generic

proctozone-hc

Generic

UCERIS 9 MG ER TABLET

Brand

PA

MISCELLANEOUS THERAPEUTIC AGENTS adenosine phosphate

OTC

ALTAMIST

OTC

CHILDREN'S SALINE NASAL SPRAY

OTC



Drug Name

Status*

DEEP SEA

OTC

EPSOM SALT

OTC

lancets (18 each, 21 each, 25 each, 26 each, 28 each, 30 each, 32 each, 33 each)

OTC

LITTLE REMEDIES

OTC

LITTLE REMEDIES STUFFY NOSE

OTC

magnesium sulfate 100 % crystals

OTC

NASAL MOISTURIZING

OTC

NASAL SPRAY (0.65% SPRAY, EQ 0.65% SPRAY)

OTC

SEA SOFT

OTC

sodium chloride 0.65 % spray

OTC

urine acetone test,strips strip

OTC

urine acetone test,tablet

OTC

urine gluc-acet comb.tst,strip

OTC

Requirements/Limits

Metabolic Bone Disease Agents alendronate sodium (5 mg tablet, 10 mg tablet, 35 mg tablet, 40 mg tablet, 70 mg/75ml solution, 70 mg tablet)

Generic

calcitonin,salmon,synthetic

Generic

doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg capsule)

Generic

etidronate disodium

Generic

fortical

Generic

ibandronate sodium 150 mg tablet

Generic

risedronate sodium (5 mg tablet, 30 mg tablet, 35 mg tablet, 150 mg tablet)

Generic

ST



Drug Name

Status*

Requirements/Limits

ACCU-CHECK (METERS & TEST STRIPS)

DME Benefit

QL

LIFESCAN (METERS & TEST STRIPS)

DME Benefit

QL

Miscellaneous Glucose Testing

Ophthalmic Agents Ophthalmic Prostaglandin and Prostamide Analogs bimatoprost

Generic

latanoprost 0.005 % drops

Generic

LUMIGAN

Brand

TRAVATAN Z

Brand

ST, QL (2.5 ML PER 30 DAYS) ST, QL (2.5 ML PER 30 DAYS)

Ophthalmic Agents, Other AKWA TEARS (1.4% DROPS, OINTMENT)

OTC

ARTIFICIAL TEARS (, 1.4 % DROPS, CVS DROPS, DROPS, EQ DROPS, RA DROPS)

OTC

BLEPHAMIDE

Brand

BLEPHAMIDE S.O.P.

Brand

CVS REDNESS RELIEF DROPS

OTC

CYSTARAN

Brand

LIQUITEARS

OTC

LUBRICANT EYE (GNP LUBRICANT 0.5% DROPS, LUBRICANT 0.5% DROPS, LUBRICANT DROPS, LUBRICANT OINTMENT, PV LUBRICANT 1.4 % DROPS, RA LUBRICANT DROPS)

OTC

LUBRICANT EYE DROPS (CVS LUBRICANT 0.5% DROPS, CVS LUBRICANT 0.6% DROPS, LUBRICANT 0.6% DROPS)

OTC

LUBRICANT PLUS

OTC

PA, LA, QL (60 ML PER 30 DAYS)



Drug Name

Status*

LUBRICATING RELIEF

OTC

LUBRIFRESH PM

OTC

MOISTURIZING LUBRICANT

OTC

mydfrin

Generic

naphazoline hcl

Generic

neo-polycin

Generic

neo-polycin hc

Generic

neofrin

Generic

neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone

Generic

neomycin sulfate/bacitracin/polymyxin b

Generic

neomycin sulfate/polymyxin b sulfate/gramicidin d

Generic

neomycin/polymyxin b sulf/hc 3.5-10k10 drops susp

Generic

neomycin/polymyxin b sulfate/dexamethasone (0.1 % drops susp, 3.5-10k-.1 oint. (g))

Generic

neosporin eye drops

Generic

phenylephrine hcl (2.5 % drops, 10 % drops)

Generic

polymyxin b sulfate/trimethoprim

Generic

polyvinyl alcohol 1.4 % drops

OTC

RA STERILE EYE DROPS

OTC

REDNESS LUBRICANT EYE DROPS

OTC

REDNESS RELIEVER EYE DROPS

OTC

REFRESH LACRI-LUBE

OTC

RESTORE TEARS

OTC

RETAINE CMC

OTC

sulfacetamide sodium 10 % oint. (g)

Generic

Requirements/Limits



Drug Name

Status*

sulfacetamide sodium/prednisolone sodium phosphate

Generic

TEARS AGAIN (1.4 % DROPS, EYE OINTMENT)

OTC

TOBRADEX ST

Brand

tobramycin/dexamethasone

Generic

ULTRA FRESH

OTC

ULTRA FRESH PM

OTC

ZYLET

Brand

Requirements/Limits

Ophthalmic Anti-allergy Agents ALOMIDE

Brand

azelastine hcl 0.05 % drops

Generic

Ophthalmic Anti-inflammatories flurbiprofen sodium

Generic

ketorolac tromethamine 0.4 % drops

Generic

LOTEMAX (0.5% EYE DROPS, 0.5% OPHTHALMIC GEL, 0.5% EYE OINTMENT)

Brand

PRED MILD

Brand

prednisolone sod phosphate 1 % drops

Generic

VEXOL

Brand

Ophthalmic Antiglaucoma Agents AZOPT

Brand

betaxolol hcl 0.5 % drops

Generic

BETIMOL

Brand

BETOPTIC S

Brand

brimonidine tartrate (0.15 % drops, 0.2 % drops)

Generic

carteolol hcl

Generic

dorzolamide hcl

Generic



Drug Name

Status*

dorzolamide hcl/timolol maleate

Generic

levobunolol hcl

Generic

pilocarpine hcl (1 % drops, 2 % drops, 4 % drops)

Generic

timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % sol-gel, 0.5 % drops)

Generic

Requirements/Limits

Otic Agents AURAPHENE-B

OTC

CARBAMOXIDE

OTC

CIPRODEX

Brand

ciprofloxacin hcl 0.2 % droperette

Generic

COLY-MYCIN S

Brand

CORTISPORIN-TC

Brand

EAR DROPS (CVS DROPS 6.5%, DROPS 6.5%, EQL DROPS 6.5%, GNP DROPS 6.5%, RA DROPS 6.5%, SM DROPS 6.5%, WAX DROPS 6.5%)

OTC

EAR HEALTH PLUS

OTC

EAR SYSTEM

OTC

EAR WAX REMOVAL

OTC

EARWAX TREATMENT

OTC

MURINE EAR WAX REMOVAL SYSTEM

OTC

Respiratory Tract Agents Anti-inflammatories, Inhaled Corticosteroids AEROSPAN

Brand

ALVESCO

Brand

ARNUITY ELLIPTA

Brand

ASMANEX

Brand

ASMANEX HFA

Brand



Drug Name

Status*

BREO ELLIPTA 100-25 MCG INH

Brand

budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1 mg/2 ml ampul-neb)

Generic

flunisolide 29mcg spray

Generic

PULMICORT FLEXHALER

Brand

QVAR

Brand

Requirements/Limits

PA

Antihistamines ALAVERT

OTC

PA

ALER-CAP

OTC

ALER-TAB

OTC

ALKA-SELTZER PLUS ALLERGY

OTC

ALL DAY ALLERGY (1 MG/ML SYRUP, EQL 10 MG TAB, GNP 10 MG TAB, HM 10 MG TAB, KRO 10 MG TAB, KRO 10 MG SFGL, SM 1 MG/ML SYR, 10 MG CHEW TAB, PV 10 MG SFTGL, 10 MG TABLET, QC 10 MG TAB, SM 10 MG TAB)

OTC

PA

ALL DAY ALLERGY RELIEF

OTC

PA

ALLER-EASE

OTC

PA

ALLER-FEX

OTC

PA

ALLER-G-TIME

OTC

ALLER-TEC

OTC

PA

ALLERCLEAR

OTC

PA

ALLERCLEAR D-12HR

OTC

PA

ALLERGY & CONGESTION

OTC

PA

ALLERGY & CONGESTION RELIEF (& RLF TAB, KRO & TAB)

OTC

PA



Drug Name

Status*

ALLERGY (KRO 4 MG TABLET, 4 MG TABLET, CVS 25 MG CAPSULE, EQL 4 MG TABLET, GNP 4 MG TABLET, 12.5 MG/5 ML LIQ, CVS 12.5 MG/5 ML LIQ, CVS 25 MG TABLET, EQL 25 MG TABLET, EQL 25 MG CAPSULE, GNP 25 MG TABLET, GNP 25 MG CAPSULE, HM 25 MG TABLET, HM 25 MG CAPSULE, KRO 25 MG CAPSULE, PUB 12.5 MG/5 ML LIQ, 25 MG SOFTGEL, CVS 25 MG SOFTGEL, EQL 12.5 MG/5 ML LIQ, 25 MG CAPSULE, GNP 25 MG SOFTGEL, KRO 25 MG TABLET, PUB 25 MG CAPSULE, RA 25 MG TABLET, 25 MG TABLET, PUB 25 MG TABLET)

OTC

ALLERGY (SB 10 MG TABLET, 10 MG TABLET)

OTC

ALLERGY 4-HOUR

OTC

ALLERGY MEDICATION

OTC

ALLERGY MEDICINE (MEDICINE 25 MG TABLET, PV MEDICINE 25 MG CAP, RA MED 25 MG TABLET, SB 12.5 MG/5 ML ELIXIR, SB MED 25 MG TABLET, SB MEDICINE 25 MG CAP)

OTC

ALLERGY RELIEF (CVS 25 MG/10 ML LIQ, CVS 50 MG/20 ML LIQ, CVS RELIEF 4 MG TABLET, EQ RELIEF 25 MG CAP, EQ RELIEF 25 MG TABLET, HM RELIEF 4 MG TABLET, RA RELIEF 25 MG TABLET, RELIEF 4 MG TABLET, RELIEF 25 MG SOFTGEL, RELIEF 25 MG CAPSULE, RELIEF 25 MG TABLET, SM RELIEF 1.34 MG TAB, SM RELIEF 12.5 MG/5 ML, SM RELIEF 25 MG CAP, SM RELIEF 25 MG SFTGEL, SM RELIEF 25 MG TABLET)

OTC

Requirements/Limits

PA



Drug Name

Status*

Requirements/Limits

ALLERGY RELIEF (CVS RELIEF 5 MG/5 ML, CVS RELIEF 10 MG TAB, CVS RELIEF 10 MG SFTGL, CVS RELIEF 10 MG ODT, CVS RELIEF 60 MG TAB, CVS RELIEF 180 MG TAB, EQ RELIEF 1 MG/ML SOLN, EQ RELIEF 10 MG TABLET, EQ RELIEF 180 MG TAB, EQL RELIEF 10 MG TAB, EQL RELIEF 10 MG ODT, GNP RELF 5 MG/5 ML SLN, GNP RELIEF 10 MG ODT, GNP RELIEF 180 MG TAB, GS RELIEF 10 MG TABLET, HM RELIEF 10 MG TABLET, HM RELIEF 10 MG ODT, KRO RELIEF 10 MG TAB, KRO RELIEF 60 MG TAB, KRO RELIEF 180 MG TAB, PUB RELIEF 10 MG TAB, PUB RELIEF 180 MG TAB, PV RELIEF 10 MG TABLET, PV RELIEF 10 MG ODT, PV RELIEF 180 MG TAB, QC RELIEF 10 MG ODT, RA RELIEF 10 MG TABLET, RA RELIEF 180 MG TAB, RELIEF 5 MG/5 ML SOLN, RELIEF 10 MG TABLET, RELIEF 10 MG ODT, RELIEF 180 MG TABLET, RELIEF SYRUP, SM RELIEF 10 MG ODT, SW RELIEF 10 MG TAB)

OTC

PA

ALLERGY RELIEF D (12-HOUR TAB, CVS TABLET)

OTC

PA

ALLERGY RELIEF D12

OTC

PA

ALLERGY RELIEF-D 12 HOUR TAB

OTC

PA

ALLERGY-TIME

OTC

ALLERHIST-1

OTC

ANIMAL SHAPES PLUS IRON

OTC

ANTIHIST

OTC

ANTIHISTAMINE

OTC

BANOPHEN (12.5 MG/5 ML ELIXIR, ALLERGY 12.5 MG/5 ML, 25 MG CAPSULE, 25 MG TABLET, 50 MG CAPSULE)

OTC

BENADRYL ALLERGY (25 MG ULTRATB, 25 MG KAPGELS)

OTC

cetirizine hcl (5 mg/5 ml solution, 5 mg tablet, 5 mg tab chew, 10 mg tab chew, 10 mg tablet)

OTC

PA



Drug Name

Status*

Requirements/Limits

cetirizine hcl 1 mg/ml solution

Generic

PA

CHEWABLE MULTIVITAMIN W-IRON

OTC

CHILD CHEW + IRON

OTC

CHILD'S VITAMIN WITH IRON

OTC

CHILD'S WAL-DRYL 12.5 MG/5 ML

OTC

CHILDREN'S ALL DAY ALLERGY

OTC

PA

CHILDREN'S ALLER-TEC

OTC

PA

CHILDREN'S ALLERGY (CHILD 12.5 ML LIQ, CHILD'S 12.5 ML, CVS CHILD 12.5 ML, EQL CHILD 12.5 ML, HM CHILD 12.5 ML, PV CHILD 12.5 ML, QC CHILD 12.5 ML, 12.5 ML ELIXIR)

OTC

CHILDREN'S ALLERGY COMPLETE

OTC

CHILDREN'S ALLERGY RELIEF (CHILD REL 12.5 MG/5 ML, CHILD RLF 12.5 MG/5 ML, CHILD'S 12.5 MG/5ML, EQ CHILD 12.5 MG/5 ML, KRO CHILD 12.5 MG/5 ML, RA CHILD 12.5 MG/5 ML, SM CHILD 12.5 MG/5 ML)

OTC

CHILDREN'S ALLERGY RELIEF (CVS 10 MG CHW TB, CVS RELF 1 MG/ML, CVS RELF 1MG/ML, CVS RLF 30 MG/5, EQ RELF 1 MG/ML, EQ RELIEF SOLN, KRO RELIEF SOLN, RA RELF 1 MG/ML)

OTC

CHILDREN'S MULTIVITAMIN-IRON

OTC

CHILDREN'S VITAMIN-IRON

OTC

CHILDREN'S VITAMINS WITH IRON

OTC

CHILDREN'S WAL-FEX

OTC

PA

CHILDREN'S WAL-ZYR (CHILD 1 MG/ML SOLUTION, CHILD'S 10 MG CHEW TAB)

OTC

PA

CHILDREN'S ZYRTEC ALLERGY

OTC

PA

CHLD ALLEGRA ALLERGY 30 MG ODT

OTC

PA

CHLOR HIST

OTC

chlorpheniramine maleate 4 mg tablet

OTC

PA

PA



Drug Name

Status*

CHLORTABS

OTC

CLARITIN 10 MG LIQUI-GEL CAP

OTC

clemastine fumarate (0.67mg/5ml syrup, 2.68 mg tablet)

Generic

clemastine fumarate 1.34 mg tablet

OTC

COMPLETE ALLERGY (COMPLETE 12.5 MG/5 ML, COMPLETE 25 MG TAB, COMPLETE 25 MG CAP, COMPLT MED 25 MG CP, PV COMPLETE 25 MG SFGL, PV COMPLETE 25 MG TAB, QC COMPLETE 25 MG CAP, QC COMPLETE 25 MG CPLT, RA COMPLETE MED CPT, RA COMPLETE SOFTGEL)

OTC

COMPOZ

OTC

CVS SPECTRAVITE TABLET CHEW

OTC

cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet)

Generic

DAILYHIST-1

OTC

DAYHIST

OTC

DAYHIST ALLERGY

OTC

dimenhydrinate 50 mg tablet

OTC

DIPHEDRYL (12.5 MG/5 ML ELIXIR, ALLERGY CAPSULE, GNP 12.5 MG/5 ML ELX, GNP 25 MG TABLET, GNP ALLERGY CAP, RA 12.5 MG/5 ML ELIX, 25 MG TABLET)

OTC

DIPHEDRYL ALLERGY

OTC

DIPHENHIST (12.5 MG/5 ML SOLN, 25 MG CAPTAB, 25 MG CAPLET, 50 MG TABLET)

OTC

diphenhydramine hcl (12.5mg/5ml liquid, 12.5mg/5ml syrup, 25 mg tablet, 25 mg capsule, 50 mg capsule, 50 mg tablet)

OTC

diphenhydramine hcl 12.5mg/5ml elixir

Generic

DRIMINATE

OTC

Requirements/Limits PA



Drug Name

Status*

Requirements/Limits

ED CHLORPED JR

OTC

ED-CHLORTAN

OTC

fexofenadine hcl (30 mg/5 ml oral susp, 60 mg tablet, 180 mg tablet)

OTC

GERI-DRYL

OTC

levocetirizine dihydrochloride (2.5 mg/5ml solution, 5 mg tablet)

Generic

LITTLE ANIMALS WITH IRON

OTC

LORADAMED

OTC

PA

loratadine (5 mg/5 ml solution, 10 mg tablet, 10 mg tab rapdis)

OTC

PA

LORATADINE D

OTC

PA

LORATADINE-D (GNP 12 HOUR TAB, 12 HOUR TABLET)

OTC

PA

MEDI-PHEDRYL (12.5 MG/5 ML ELIX, 25 MG CAPSULE)

OTC

MOTION SICKNESS (50 MG TABLET, CVS 50 MG TAB, PV 50 MG TAB, SB 50 MG TAB)

OTC

MOTION SICKNESS RELIEF (GNP 50 MG TAB, HM 50 MG TAB, RA 50 MG TAB, SM 50 MG TAB)

OTC

MUCINEX ALLERGY

OTC

NIGHTTIME ALLERGY RELIEF

OTC

NIGHTTIME SLEEP AID (CVS NIGHTTIME AID CAPLET, EQ NIGHTTIME 25 MG CPLT, EQL NIGHTTIME AID CAPLET, GNP NIGHTTIME AID CAPLET, GNP NIGHTTIME AID CPLT, KRO NIGHTTIME 25 MG CPLT, NIGHT TIME 25 MG CAPLET, NIGHTTIME AID 25 MG CPLT, NIGHTTIME AID CPLT, QC NIGHTTIME 25 MG TAB, RA NIGHTTIME 25 MG TAB, RA NIGHTTIME AID CPLT)

OTC

NON-DROWSY ALLERGY

OTC

NYT-TIME SLEEP

OTC

PA

PA

PA

PA



Drug Name

Status*

NYTOL QUICKCAPS

OTC

PHARBECHLOR

OTC

PHARBEDRYL

OTC

PUB CHILDREN'S ALLERGY 1 MG/ML

OTC

PV KID'S VIT + IRON TAB CHEW

OTC

Q-DRYL (12.5 MG/5 ML LIQUID, 25 MG CAPSULE)

OTC

QUENALIN

OTC

REST SIMPLY

OTC

RESTFULLY SLEEP

OTC

SILADRYL

OTC

SILPHEN

OTC

SIMPLY SLEEP

OTC

SLEEP AID (CVS 25 MG TABLET, CVS CAPLET, EQL 25 MG CAPLET, PV 25 MG CAPLET, 25 MG TABLET, PV TABLET, RA 25 MG CAPLET, 25 MG CAPLET, SM NIGHT TIME CAPLET, TABLET)

OTC

SLEEP II

OTC

SLEEP TABLET

OTC

SLEEP TABS

OTC

TOTAL ALLERGY

OTC

TRAVEL SICKNESS (50 MG TABLET, RA 50 MG TAB)

OTC

V-R PEDIA RELIEF INF DROPS

OTC

V-R VALUDRYL 12.5 MG/5 ML ELX

OTC

VALU-DRYL ALLERGY MEDICINE

OTC

VICKS QLEARQUIL ALLERGY

OTC

VICKS QLEARQUIL NIGHT 25 MG

OTC

VITALETS

OTC

WAL-DRAM

OTC

Requirements/Limits

PA

PA



Drug Name

Status*

Requirements/Limits

WAL-DRYL (25 MG MINITAB, 25 MG CAPSULE, 25 MG SOFTGEL)

OTC

WAL-DRYL ALLERGY 12.5 MG/5 ML

OTC

WAL-FEX ALLERGY

OTC

PA

WAL-FEX D 24 HOUR

OTC

PA

WAL-FINATE

OTC

WAL-ITIN (CHILD 5 MG/5 ML SYRUP, 5 MG/5 ML SYRUP, 10 MG TABLET, 10 MG ODT)

OTC

PA

WAL-ITIN D 12 HOUR

OTC

PA

WAL-ZYR (10 MG SOFTGEL, 10 MG TABLET, SOLUTION)

OTC

PA

ZYRTEC 10 MG ODT

OTC

PA

montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab chew, 10 mg tablet)

Generic

PA

zafirlukast

Generic

QL (60 PER 30 DAYS)

Antileukotrienes

Bronchodilators, Anticholinergic ATROVENT HFA

Brand

INCRUSE ELLIPTA

Brand

ipratropium bromide 0.2 mg/ml solution

Generic

SPIRIVA

Brand

SPIRIVA RESPIMAT INHAL SPRAY

Brand

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) ELIXOPHYLLIN

Brand

THEO-24 ER 300 MG CAPSULE

Brand

theochron

Generic



Drug Name

Status*

theophylline anhydrous (80 mg/15ml elixir, 80 mg/15ml solution, 100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er 12h, 450 mg tab er 12h)

Generic

Requirements/Limits

Bronchodilators, Sympathomimetic ADVAIR DISKUS

Brand

ADVAIR HFA

Brand

albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2 mg/5 ml syrup, 2 mg tablet, 2.5 mg/3ml vial-neb, 4 mg tab er 12h, 4 mg tablet, 5 mg/ml solution, 8 mg tab er 12h)

Generic

ANORO ELLIPTA

Brand

BREO ELLIPTA 200-25 MCG INH

Brand

COMBIVENT

Brand

QL (14.7 GM PER 30 DAYS)

COMBIVENT RESPIMAT

Brand

QL (4 GM PER 30 DAYS)

EPIPEN 2-PAK

Brand

EPIPEN JR 2-PAK

Brand

FORADIL

Brand

ipratropium bromide/albuterol sulfate

Generic

metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mg tablet)

Generic

proair hfa

Generic


proair respiclick

Generic

QL (2 PER 30 DAYS)

SEREVENT DISKUS

Brand

SYMBICORT

Brand

terbutaline sulfate (2.5 mg tablet, 5 mg tablet)

Generic

ventolin hfa

Generic

XOPENEX HFA

Brand




Drug Name

Status*

Requirements/Limits

Mast Cell Stabilizers cromolyn sodium 20 mg/2 ml ampulneb

Generic

Pulmonary Antihypertensives ADCIRCA

Specialty


ADEMPAS

Specialty

PA

LETAIRIS

Specialty

PA

OPSUMIT

Specialty

PA, LA

ORENITRAM ER

Specialty

PA, LA

REVATIO 10 MG/ML ORAL SUSP

Specialty

PA

sildenafil citrate 20 mg tablet

Specialty


TRACLEER

Specialty

PA, LA

VENTAVIS

Specialty

PA

Respiratory Tract Agents, Other 12 HOUR COLD RELIEF

OTC

12 HOUR DECONGESTANT

OTC

60PSE-400GFN

OTC

ADLT WAL-TUSSIN COUGH-COLD CF

OTC

ADULT ROBITUSSIN PEAK COLD

OTC

ADULT ROBITUSSIN PEAK COLD M-S

OTC

ADULT TUSSIN CHEST CONGESTION

OTC

ADULT TUSSIN COUGH CONGEST DM

OTC

ADULT TUSSIN DM

OTC

ADULT TUSSIN MULTI-SYMP COLD

OTC

ADULT WAL-TUSSIN

OTC

ADULT WAL-TUSSIN DM

OTC

ALLERCLEAR D-24HR

OTC

PA

ALLERGY RELIEF D-24

OTC

PA



Drug Name

Status*

Requirements/Limits

ALLERGY RELIEF-NASAL DECONGEST

OTC

PA

ALLERGY-CONGESTION RELIEF

OTC

PA

ALLERGY-CONGESTION RELIEF-D

OTC

PA

AMBITUSSIN AC

OTC


ANTITUSSIVE DM

OTC

APRODINE

OTC

benzonatate

Generic

BIO-S-PRES DX

OTC

BIOCOTRON

OTC

BIOGIL

OTC

bromfed dm

Generic

BRONTUSS SF

OTC

CHERATUSSIN AC

OTC


CHERATUSSIN DAC

OTC


CHEST CONGESTION RELIEF D

OTC

CHILD MUCINEX CHEST CONGESTION

OTC

CHILDREN'S CHEST CONGESTION

OTC

CHILDREN'S COLD & ALLERGY ELXR

OTC

CHILDREN'S MUCUS RELIEF

OTC

CLARITIN 5 MG REDITABS

OTC

CONGEST-EZE

OTC

CONGESTAC

OTC

COUGH

OTC

COUGH & COLD SYRUP

OTC

COUGH AND COLD MULTI-SYMPTOM

OTC

COUGH CONTROL CF

OTC

COUGH CONTROL DM

OTC

COUGH FORMULA DM

OTC

PA



Drug Name

Status*

COUGH SYRUP

OTC

COUGH SYRUP DM

OTC

COUGH-HEAD CONGESTION RELIEF

OTC

COUGHTAB

OTC

CREO-TERPIN

OTC

d-methorphan hb/p-epd hcl/bpm 1030-2/5 syrup

OTC

DAY TIME LIQUID CAPSULE

OTC

DESGEN DM

OTC

DESPEC DM

OTC

DESPEC EDA COUGH & COLD DROPS

OTC

DIABETIC SILTUSSIN DAS-NA

OTC

DIABETIC SILTUSSIN-DM

OTC

DIABETIC TUSSIN DM LIQUID

OTC

DIABETIC TUSSIN EX

OTC

DOMETUSS-DMX

OTC

ED A-HIST PSE

OTC

ESBRIET

Specialty

EXEFEN IR

OTC

EXPECTORANT (100 MG/5 ML SYRUP, 200 MG TABLET, RA COUGH SYRUP)

OTC

EXPECTORANT COUGH SYRUP

OTC

EXPECTORANT DM COUGH SYRUP

OTC

EXTRA ACTION COUGH

OTC

G-TRON LIQUID

OTC

GERI-TUSSIN

OTC

GERI-TUSSIN DM

OTC

GRASTEK

Brand

GUAIASORB DM

OTC

Requirements/Limits

PA, LA

PA



Drug Name

Status*

Requirements/Limits

GUAIATUSSIN AC

OTC


guaifenesin (100 mg/5ml liquid, 200 mg tablet, 600 mg tab er 12h)

OTC

GUAIFENESIN AC

OTC


GUAIFENESIN DAC

OTC


guaifenesin/codeine phosphate

OTC


guaifenesin/dextromethorphan hbr (liquid, syrup)

OTC

hydrocodone bitartrate/homatropine methylbromide (5 mg-1.5mg tablet, 51.5 mg/5 syrup)

Generic

hydromet

Generic

HYPER-SAL 3.5% VIAL

Brand

INTENSE COUGH

OTC

INTENSE COUGH RELIEVER

OTC

IOPHEN DM-NR

OTC

IOPHEN NR

OTC

IOPHEN-C NR

OTC


KALYDECO

Specialty


KRO ALLERGY & CONGEST RLF TAB

OTC

PA

LOHIST-D

OTC

LONG ACTING NASAL DECONGESTANT

OTC

LORATA-D

OTC

PA

LORATA-DINE D

OTC

PA

LORATADINE-D (24HR TABLET, CVS 24HR TABLET, GNP 24HR TABLET, QC 24HR TABLET)

OTC

PA

LORTUSS EX

OTC


MEDI-PHEDRINE

OTC

MEDI-TUSSIN

OTC

MEDI-TUSSIN DM

OTC



Drug Name

Status*

Requirements/Limits

MEDI-TUSSIN DM DIABETIC

OTC

MEDIFIN EXPECTORANT MUCUS RLF

OTC

MUCINEX D

OTC

MUCINEX DM ER 600-30 MG TABLET

OTC

MUCUS DM

OTC

MUCUS ER

OTC

MUCUS RELIEF (ER 600 MG TABLET, RA ER 600 MG TAB, SB 200 MG TABLET)

OTC

MUCUS-ER

OTC

NASAL & SINUS DECONGESTANT

OTC

NASAL DECONGEST-ANTIHISTAMINE

OTC

NASAL DECONGESTANT (CVS DECONGEST 30 MG TAB, DECONGESTANT 30 MG TAB, EQL DECONGEST 30 MG TAB, GNP DECONGEST 30 MG TAB, HM DECONGEST 30 MG TAB, HM DECONGEST ER 120 MG, KRO DECONGEST 30 MG TAB, PUB DECONGEST 30 MG TAB, PUB DECONGEST ER 120 MG, PV DECONGEST 30 MG TAB, SM DECONGEST 30 MG TAB, SW DECONGESTANT 30 MG TB)

OTC

NASAL DECONGESTANT-ANTIHIST

OTC

NON-DRYING SINUS

OTC

OFEV

Specialty

PA

ORALAIR

Specialty

PA, LA

ORGAN-I NR

OTC

PEDIA RELIEF INFANT

OTC

PEDIATRIC COUGH-COLD SYRUP

OTC

phenylephrine hcl/promethazine hcl

Generic

promethazine hcl/codeine

Generic

promethazine hcl/dextromethorphan hbr

Generic




Drug Name

Status*

Requirements/Limits

promethazine/phenylephrine hcl/codeine

Generic


pseudoephedrine hcl (30 mg/5 ml liquid, 30 mg tablet, 60 mg tablet, 120 mg tablet er)

OTC

PUB ALLERGY RELIEF D TABLET

OTC

pulmosal

Generic

PULMOZYME

Specialty

PV COLD & COUGH SOFTGEL

OTC

PV SINUS & ALLERGY 120 MG CPLT

OTC

Q-TAPP

OTC

Q-TUSSIN

OTC

Q-TUSSIN DM

OTC

RAGWITEK

Brand

REFENESEN 200 MG TABLET

OTC

RI-TUSSIN

OTC

RI-TUSSIN DM

OTC

ROBAFEN

OTC

ROBAFEN CF

OTC

ROBAFEN DM COUGH

OTC

ROBAFEN-DM

OTC

RYNEX PSE

OTC

SAFETUSSIN DM

OTC

SB COUGH CONTROL SYRUP

OTC

SILTUSSIN DM

OTC

SILTUSSIN DM DAS COUGH FORMULA

OTC

SILTUSSIN SA

OTC

SINUS 12-HOUR

OTC

SM COLD & ALLERGY TABLET

OTC

SM DAY TIME COLD-FLU REL SFTGL

OTC

PA

PA



Drug Name

Status*

sodium chloride for inhalation 7 % vialneb

Generic

SORBUGEN NR

OTC

SUDOGEST

OTC

SUPHEDRIN (GNP 30 MG TABLET, 30 MG TABLET)

OTC

SUPHEDRIN 12-HOUR

OTC

SUPHEDRINE

OTC

SUPHEDRINE 12-HOUR

OTC

SUPHEDRINE SINUS CONGESTION

OTC

TRIACTING EXPECTORANT

OTC

TUSNEL C

OTC

TUSNEL DIABETIC

OTC

TUSNEL PEDIATRIC DROPS

OTC

tussigon

Generic

TUSSIN (CVS 100 MG/5 ML LIQUID, EQL 100 MG/5 ML LIQUID, GNP 100 MG/5 ML SYRUP, KRO 200 MG/10 ML SYRUP, PUB 100 MG/5 ML SYRUP, PV 100 MG/5 ML LIQUID, SM 100 MG/5 ML LIQUID, 100 MG/5 ML SYRUP, QC 100 MG/5 ML LIQUID, RA 100 MG/5 ML SYRUP)

OTC

TUSSIN CF

OTC

TUSSIN CHEST CONGESTION

OTC

TUSSIN COLD SEVERE CONGESTION

OTC

TUSSIN COUGH (CVS LIQUID, RA LIQUID)

OTC

TUSSIN COUGH DM

OTC

TUSSIN COUGH-CHEST CONGESTION

OTC

Requirements/Limits




Drug Name

Status*

Requirements/Limits

TUSSIN DM (CLEAR LIQUID, COUGH & CHEST SYRUP, COUGH SYRUP, CVS LIQUID, EQ COUGH-CHEST SYR, EQL COUGH-CHEST SYR, EQL SYRUP, GNP SYRUP, KRO LIQUID, LIQUID, PUB LIQUID, PV LIQUID, PV SYRUP, QC SYRUP, RA SYRUP, SM SYRUP, SYRUP)

OTC

TUSSIN DM CLEAR

OTC

TUSSIN DM COUGH

OTC

TUSSIN DM COUGH & CHEST LIQUID

OTC

TUSSIN DM COUGH-CHEST CONGEST

OTC

TUSSIN DM MAX (LIQUID, PV LIQUID)

OTC

TUSSIN HONEY

OTC

TUSSIN MUCUS-CHEST CONGESTION

OTC

TYLENOL COLD SEVERE CONGESTION

OTC

ULTRA DM FREE & CLEAR

OTC

ULTRA TUSS

OTC

V-R TUSSIN PE SYRUP

OTC

VALU-TAPP

OTC

VALU-TAPP DECONGESTANT

OTC

VIRTUSSIN AC

OTC


VIRTUSSIN DAC

OTC


WAL-ACT D COLD & ALLERGY

OTC

WAL-ITIN D

OTC

WAL-PHED 12 HOUR

OTC

WAL-PHED 30 MG TABLET

OTC

WAL-TUSSIN COUGH & COLD CF

OTC

WAL-TUSSIN DM

OTC

WAL-TUSSIN SYRUP

OTC

PA



Drug Name

Status*

Requirements/Limits

Skeletal Muscle Relaxants carisoprodol (250 mg tablet, 350 mg tablet)

Generic

carisoprodol/aspirin

Generic

chlorzoxazone

Generic

cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet)

Generic

metaxalone 800 mg tablet

Generic

methocarbamol (500 mg tablet, 750 mg tablet)

Generic

orphenadrine citrate 100 mg tablet er

Generic

orphenadrine/aspirin/caffeine 50-77060 tablet

Generic

Sleep Disorder Agents GABA Receptor Modulators flurazepam hcl

Generic

temazepam (7.5 mg capsule, 15 mg capsule, 30 mg capsule)

Generic

triazolam

Generic

Sleep Disorders, Other SLEEP AID (EQ 25 MG TABLET, GS 25 MG TABLET)

OTC

WAL-SOM 25 MG TABLET

OTC

XYREM

Specialty

PA, LA, QL (540 ML PER 30 DAYS)

Therapeutic Nutrients/ Minerals/ Electrolytes Electrolyte/Mineral Modifiers CARNITOR SF

Brand

EXJADE

Specialty



Drug Name

Status*

kionex powder

Generic

levocarnitine (with sugar)

Generic

levocarnitine 330 mg tablet

Generic

marlexate

Generic

sodium polystyrene sulfonate (50g/200ml enema, powder)

Generic

Requirements/Limits

Electrolyte/Mineral Replacement A THRU Z ADVANCED FORMULA

OTC

A THRU Z ADVANCED FORMULA TAB

OTC

A THRU Z SELECT

OTC

A THRU Z SELECT 50+ FORMULA

OTC

A-G PRO

OTC

ABC PLUS

OTC

ADULTS' 50+ DAILY FORMULA

OTC

ADULTS' DAILY FORMULA

OTC

amino acids capsule

OTC

AMINO ACTION

OTC

ANIMAL CHEWS

OTC

ANIMAL SHAPES

OTC

ANIMAL SHAPES VITAMINS

OTC

ANTIOXIDANT FORM SOFTGEL CAP

OTC

ANTIOXIDANT SOFTGEL

OTC

ANTIOXIDANT VITAMIN

OTC

ANTIOXIDANT VITAMINS

OTC

ascorbate calcium 500 mg tablet

OTC

ascorbic acid (250 mg tab chew, 250 mg tablet, 500 mg tab chew, 500 mg tablet, 500 mg tablet er, 500 mg wafer, 1000 mg tab chew)

OTC

ascorbic acid/ascorbate sodium 500 mg wafer

OTC



Drug Name

Status*

B COMPLETE

OTC

b complex with vitamin c tablet

OTC

B-12 DOTS

OTC

b-plex

Generic

BAL B-100

OTC

BAL B-50

OTC

BALANCE B-100

OTC

BALANCE B-50

OTC

BALANCED B-100 TABLET

OTC

BALANCED B-150

OTC

BALANCED B-50 (RA TABLET, SM TABLET, TABLET, V-R TABLET)

OTC

BEE-ZEE

OTC

BIOPETIT

OTC

biotin 5 mg capsule

OTC

BIOVOL

OTC

C 500 MG TIMED RELEASED

OTC

C COMPLEX 500 MG TABLET SA

OTC

ca/d3/mag ox/zinc/cop/mang/bor 600 mg-800 tablet

OTC

CALCIDOL

OTC

CALCITRATE

OTC

calcium acetate 667 mg tablet

Generic

calcium carbonate (500(1250) tablet, 600 mg tablet)

OTC

calcium carbonate,citrate/magnesium oxide,aspartate/vit d3

OTC

Requirements/Limits



Drug Name

Status*

calcium carbonate/cholecalciferol (vitamin d3) (250 mg-125 tablet, 500 mg-200 tablet, 500 mg-100 tab chew, 500 mg-400 tablet, 500 mg-600 tablet, 600 mg-125 tablet, 600 mg-200 tablet, 600 mg-400 tablet, 600 mg-800 tablet)

OTC

calcium carbonate/ergocalciferol (vitamin d2)

OTC

calcium citrate 200(950)mg tablet

OTC

calcium citrate/ergocalciferol (vitamin d2)

OTC

CALPHRON

OTC

CENTAMIN

OTC

CENTAVITE A-Z WITH MINERALS

OTC

CENTRAL VITE

OTC

CENTRAL VITE FOR SENIORS

OTC

CENTRAL-VITE (EQL TABLET, RA TABLET)

OTC

CENTRAL-VITE SELECT

OTC

CENTRAL-VITE SENIOR

OTC

CENTRAL-VITE WOMEN'S UNDER 50

OTC

CENTRAM-CARE

OTC

CENTRAVITES 50 PLUS

OTC

CENTRUM COMPLETE

OTC

CENTRUM MULTIVIT-MINERAL LIQ

OTC

CENTRUM SILVER TABLET

OTC

CENTRUM SILVER ULTRA WOMEN'S

OTC

CENTURY

OTC

CENTURY ADVANCED FORMULA

OTC

CENTURY MATURE

OTC

CENTURY ULTIMATE WOMEN'S

OTC

CEROVITE JR

OTC

Requirements/Limits



Drug Name

Status*

CERTAVITE-ANTIOXIDANT (LIQUID, TABLET)

OTC

CHEWABLE MULTI VITAMIN

OTC

CHILD CHEW VITAMIN

OTC

CHILD VITAMIN WITH MINERALS

OTC

CHILD'S VITAMIN WITH VITAMIN C

OTC

CHILDREN'S CHEW MULTIVIT-IRON

OTC

CHILDREN'S CHEWABLE COMPLETE

OTC

CHILDREN'S CHEWABLE VITAMIN

OTC

CHILDREN'S IRON

OTC

CHILDREN'S MULTIVIT W-EXTRA C

OTC

CHILDREN'S MULTIVIT-MINERALS

OTC

cholecalciferol (vitamin d3) (400 unit tablet, 400/ml drops, 400 unit capsule, 1000 unit capsule, 1000 unit tablet, 2000 unit tablet, 2000 unit capsule, 5000 unit capsule, 5000 unit tablet)

OTC

COMPLETE (ADVANCED TABLET, TABLET)

OTC

COMPLETE 50+

OTC

COMPLETE MULTI

OTC

COMPLETE MULTI 50+

OTC

COMPLETE MULTI-VIT-MINERAL

OTC

COMPLETE MULTIVITAMIN

OTC

COMPLETE PREMIUM VITAMIN

OTC

COMPLETE SENIOR

OTC

completenate

Generic

CVS IRON 27 MG TABLET

OTC

CVS SPECTRAVITE ADULT 50+ TABS

OTC

CVS SPECTRAVITE LIQUID

OTC

Requirements/Limits



Drug Name

Status*

cyanocobalamin (vitamin b-12) (100 mcg tablet, 500 mcg tablet, 1000 mcg tablet, 1000 mcg tab subl, 1000 mcg tablet er)

OTC

cyanocobalamin (vitamin b-12) 1000mcg/ml vial

Generic

D-VI-SOL

OTC

D-VITA

OTC

D3 DOTS

OTC

D3-2000

OTC

DAILY MULTIPLE (CVS DAILY TABLET, DAILY TABLET)

OTC

DAILY MULTIPLE VITAMIN

OTC

DAILY MULTIVITAMIN WITH IRON

OTC

DAILY MULTIVITAMIN-IRON

OTC

DAILY TEEN MULTI-VITAMIN

OTC

DAILY VALUE

OTC

DAILY VITAMIN

OTC

DAILY VITAMIN + IRON

OTC

DAILY VITAMIN FORMULA

OTC

DAILY VITAMIN FORMULA + IRON

OTC

DAILY VITAMIN FORMULA-MINERALS

OTC

DAILY VITE TABLET

OTC

DECUBI VITE

OTC

DELTA D3

OTC

dialyvite

Generic

DIALYVITE 800

OTC

DIALYVITE VITAMIN D

OTC

DIALYVITE ZINC

Brand

DINO-LIFE

OTC

Requirements/Limits



Drug Name

Status*

DINO-LIFE WITH EXTRA C

OTC

EAR CARE

OTC

EAR HEALTH FORMULA

OTC

ELDERCAPS

Brand

ELDERTONIC

OTC

eliphos

Generic

ELLIS TONIC

OTC

ENDUR-ACIN SR 250 MG TABLET

OTC

ENFALYTE

OTC

EQL CENTRAL-VITE PERFORMANCE

OTC

EQL ONE DAILY MEN'S TABLET

OTC

ergocalciferol (vitamin d2) (400 unit tablet, 8000/ml drops)

OTC

ergocalciferol (vitamin d2) 50000 unit capsule

Generic

ESSENTIA

OTC

FARBEE W-C

OTC

FEOSOL 65 MG TABLET

OTC

FER-IRON

OTC

FERATE 27 MG TABLET

OTC

FERGON

OTC

FEROSUL (220 MG/5 ML ELIXIR, 325 MG TABLET)

OTC

FERREX 150

OTC

ferrex 150 forte plus

Generic

FERRIC X-150

OTC

FERRO-TIME

OTC

ferrous gluconate (240(27)mg tablet, 324(38)mg tablet, 324(36)mg tablet, 324(37.5) tablet, 325 mg tablet, 325(36)mg tablet)

OTC

Requirements/Limits



Drug Name

Status*

ferrous sulfate (15 mg/ml drops, 47.5 iron tablet er, 134mg tablet, 142(45)mg tablet er, 143(45) mg tablet er, 220(44)/5 solution, 324(65)mg tablet dr, 325(65) mg tablet dr, 325(65) mg tablet)

OTC

FERROUSUL

OTC

FERUS

OTC

FLINTSTONES COMPLETE TABLET

OTC

FLINTSTONES EXTRA C TAB CHEW

OTC

FLINTSTONES PLUS CALCIUM

OTC

FLINTSTONES TABLET CHEWABLE

OTC

FLINTSTONES WITH IRON

OTC

fluoride/iron/vitamins a,c,and d

Generic

flura-drops

Generic

folbee plus

Generic

folic acid (0.4 mg tablet, 0.8 mg tablet)

OTC

folic acid 1 mg tablet

Generic

folic acid/vitamin b complex & c/rice bran

OTC

FOSFREE

OTC

FRUIT C-500

OTC

FRUITY CHEWS

OTC

FULL SPECTRUM B

OTC

GERAVIM

OTC

GERIATON

OTC

GERITOL COMPLETE

OTC

GERITOL TONIC

OTC

GUMMI BEAR MULTIVITAMIN

OTC

GUMMY SWIRLS

OTC

HAIR VITAMIN

OTC

Requirements/Limits



Drug Name

Status*

HAIR, SKIN & NAILS (CVS SKIN & TABLET, HM SKIN & CAPLET, PV SKIN & TABLET, SKIN & CAPLET, SM SKIN & CAPLET)

OTC

HAIR,SKIN & NAILS

OTC

HEALTHY EYES

OTC

HI B COMPLEX

OTC

HIGH POTENCY CALCIUM

OTC

HIGH POTENCY IRON

OTC

HIGH POTENCY MULTIVITAMIN

OTC

HIGH PROTEIN

OTC

HONEY BEARS

OTC

ICAPS PLUS

OTC

IFEREX 150

OTC

inatal advance

Generic

iron asp gly&ps cmplx/ascorb.cal/vit b12/fa/ca-thr/succ.acid

Generic

k-sol 10% (20 meq/15 ml) liq

Generic

KENWOOD THERAPEUTIC

OTC

KID'S GUMMY BEAR VITAMINS

OTC

KID'S VITAMINS

OTC

KID'S VITAMINS + EXTRA C

OTC

KID'S VITAMINS COMPLETE

OTC

klor-con 10

Generic

klor-con 8

Generic

klor-con m10

Generic

klor-con m15

Generic

klor-con m20

Generic

klor-con sprinkle

Generic

MACUVITE

OTC

Requirements/Limits



Drug Name

Status*

MACUVITE EYE CARE

OTC

MAG DELAY

OTC

MAG64

OTC

magnesium 250 mg tablet

OTC

magnesium oxide (400 mg tablet, 500 mg capsule)

OTC

MEGA MULTI W-CHELATED MINERALS

OTC

MEGA MULTIVITAMIN WITH MINERAL

OTC

MEN'S DAILY MULTIVIT-MINERAL

OTC

MEN'S MULTI-VITAMIN

OTC

MEPHYTON

Brand

MG-PLUS-PROTEIN

OTC

MGO

OTC

MILLTRIUM SENIOR

OTC

MULTI COMPLETE-IRON

OTC

MULTI-DAY PLUS IRON

OTC

MULTI-DELYN LIQUID

OTC

MULTI-VITAMIN DAILY

OTC

MULTI-VITE

OTC

MULTI-VITE 50 & OVER

OTC

multivit with calcium, iron, and other minerals

OTC

MULTIVITAL

OTC

MULTIVITAL PERFORMANCE

OTC

MULTIVITAL PLATINUM

OTC

multivitamin

OTC

multivitamin w-minerals/ferrous gluconate

OTC

multivitamin with minerals

OTC

multivitamins with iron

OTC

Requirements/Limits



Drug Name

Status*

multivitamins,ther w-minerals

OTC

MY FAVORITE MULTIPLE

OTC

MYFERON 150

OTC

mynatal advance

Generic

mynephrocaps

Generic

MYVITALIFE

OTC

natal-v rx

Generic

NATURAL B-100

OTC

niacin (50 mg tablet, 100 mg tablet, 125 mg capsule er, 250 mg capsule er, 250 mg tablet er, 250 mg tablet, 400 mg capsule er, 500 mg capsule er, 750 mg tablet er)

OTC

niva-plus

Generic

OCUTABS

OTC

OCUVITE WITH LUTEIN

OTC

omega-3 fatty acids 300 mg capsule

OTC

omega-3 fatty acids/dha/epa/other omega-3s/fish oil (oil 360-1200mg capsule, oil 720-1200mg capsule)

OTC

omega-3 fatty acids/docosahexanoic acid/epa/fish oil (oil 60 mg-90mg capsule, oil 120-180 mg capsule)

OTC

omega-3 fatty acids/fish oil (oil capsule, oil capsule dr)

OTC

ONCE DAILY

OTC

ONCOVITE

OTC

ONE DAILY (DAILY TABLET, GNP DAILY TABLET, RA DAILY MULTI-VITAMIN TAB, RA DAILY TABLET)

OTC

ONE DAILY 50 PLUS

OTC

ONE DAILY ESSENTIAL (DAILY TABLET, EQL DAILY TABLET, GNP DAILY TABLET)

OTC

Requirements/Limits



Drug Name

Status*

ONE DAILY FOR MEN

OTC

ONE DAILY FOR WOMEN

OTC

ONE DAILY FOR WOMEN 50+ ADV

OTC

ONE DAILY MAXIMUM (DAILY TABLET, GNP DAILY TABLET, RA DAILY TABLET)

OTC

ONE DAILY MEN'S HEALTH

OTC

ONE DAILY MULTIVITAMIN (DAILY TAB, DAILY TABLET)

OTC

ONE DAILY MULTIVITAMIN-IRON

OTC

ONE DAILY PLUS IRON

OTC

ONE DAILY PLUS MINERALS

OTC

ONE DAILY WITH CALCIUM-IRON

OTC

ONE DAILY WITH IRON

OTC

ONE DAILY WOMEN'S

OTC

ONE DAILY WOMEN'S 50+

OTC

ONE DAILY WOMEN'S HEALTH

OTC

ONE-A-DAY ESSENTIAL

OTC

ONE-A-DAY MAXIMUM FORMULA

OTC

ONE-A-DAY TEEN ADVANTAGE

OTC

ONE-A-DAY WOMEN'S

OTC

OPTI-VITAMIN

OTC

ORALYTE

OTC

OS-CAL 500+D3

OTC

OYSCO 500+D

OTC

OYSCO-500

OTC

OYSTERCAL-D

OTC

PARVA-CAL 500

OTC

Requirements/Limits



Drug Name

Status*

PEDIATRIC ELECTROLYTE (CVS PEDIATRIC POPS, CVS PEDIATRIC SOLN, EQL PEDIATRIC SOLN, GNP PEDIATRIC SOLN, HEB PEDIATRIC SOLN, HM PEDIATRIC SOLN, PEDI FREEZER POP, PEDIATRIC SOLN, PEDIATRIC SOLUTION, PV PEDI FREEZE POP, PV PEDIATRIC SOLN, RA PEDIATRIC SOLN, SB PEDIATRIC SOLN, SM PEDIATRIC SOLN)

OTC

PEDIATRIC FREEZER POPS

OTC

pediatric multivitamin combination no.2/sodium fluoride

Generic

pediatric multivitamin combo no.45/fluoride/ferrous sulfate

Generic

pediatric multivitamin combo no.75/fluoride/ferrous sulfate

Generic

pediatric multivitamins a,c,& d3 no.21

OTC

pediatric multivitamins a,c,& d3 no.21 with sodium fluoride

Generic

pediatric multivitamins no.16 with sodium fluoride

Generic


Generic


Generic

PHARMACIST FAVORITE MULTI-VITE

OTC

pnv 29-1

Generic

pnv-vp-u

Generic

POLY-IRON

OTC

POLY-VI-SOL

OTC

POLY-VI-SOL WITH IRON

OTC

POLY-VITA

OTC

POLY-VITA WITH IRON

OTC

POLY-VITAMIN DROPS

OTC

Requirements/Limits



Drug Name

Status*

POLYSACCHARIDE IRON

OTC

POLYVITAMIN WITH IRON (W-IRON DROPS, WITH IRON TAB CHEW)

OTC

potassium chloride (8 meq capsule er, 8 meq tablet er, 10 meq tablet er, 10 meq tab er prt, 10 meq capsule er, 20meq/15ml liquid, 20 meq tablet er, 20 meq tab er prt)

Generic

potassium chloride/potassium bicarbonate/citric acid

Generic

potassium citrate (5 tablet er, 10 tablet er, 15 tablet er)

Generic

PRE PROTEIN

OTC

prenaplus

Generic

prenatal vit w-ca,fe,fa(

Health Share of Oregon/Providence (Medicaid) - Providence Health Plan

Health Share of Oregon/Providence (Medicaid) - Providence Health Plan

Suggest Documents

Health Share of Oregon/Providence (Medicaid) - Providence Health Plan

Vision Claim Form - Providence Health Plan

Policyholder change request_102615 - Providence Health Plan

Medical claim form - Providence Health Plan

Y0085_PHP112_FILE and USE 10022011 ... - Providence Health Plan

2016 Plan Selection Form_Renewal final-3 - Providence Health Plan

Medicaid Behavioral Health Care Plan Satisfaction

2016 Plan Selection Form_Renewal final-3 - Providence Health Plan

Providence Occupational Medicine-Mill Plain - Providence Health ...

Providence Health Insurance Marketplace Formulary

Providence Health Insurance Marketplace Formulary

Public Event Secret Shopping Tool - Providence Health Plan

May 2013 - Providence Health Care

May 2013 - Providence Health Care

Health Services Initiative - Medicaid

Health Plan Effects on Patient Assessments of Medicaid Managed ...

Student Health Plan - UPMC Health Plan [PDF]

NCQA's Health Insurance Plan Rankings 2012-2013 -- Medicaid ...

Medicaid Behavioral Health Care Plan Satisfaction and Children's ...

House Republican Health Plan Would Shift $11 Billion in Medicaid ...

Overview & Action Plan for Medicaid Health Plans - Institute for ...

Overview & Action Plan for Medicaid Health Plans - Institute for ...

Important Information about your Medicaid Managed Care Health Plan

Health and Wellness Not Just Buzzwords at Providence Health Plans