Effective December 1, 2017
MISSOURI ACA MEMBER PRESCRIPTION DRUG LIST 2016 ALPHABETICAL LIST For Missouri EPO and PPO ACA members with an insurance plan that includes a prescription drug benefit
1
Table of Contents
ANTI - INFECTIVES .......................................................................................................................................... 6 ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS .......................................................................... 13 AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ........................................................................... 18 CARDIOVASCULAR, HYPERTENSION & LIPIDS ..................................................................................... 33 DERMATOLOGICALS/TOPICAL THERAPY ............................................................................................... 42 DIAGNOSTICS & MISCELLANEOUS AGENTS .......................................................................................... 51 EAR, NOSE & THROAT MEDICATIONS...................................................................................................... 53 ENDOCRINE/DIABETES ................................................................................................................................ 54 GASTROENTEROLOGY ................................................................................................................................. 74 IMMUNOLOGY, VACCINES & BIOTECHNOLOGY .................................................................................. 81 MUSCULOSKELETAL & RHEUMATOLOGY ............................................................................................. 84 OBSTETRICS & GYNECOLOGY ................................................................................................................... 85 OPHTHALMOLOGY ........................................................................................................................................ 91 RESPIRATORY, ALLERGY, COUGH & COLD ............................................................................................ 94 UROLOGICALS ................................................................................................................................................ 99 VITAMINS, HEMATINICS & ELECTROLYTES ........................................................................................ 100 Index ................................................................................................................................................................. 111
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List of Abbreviations 1: Generic 2: Preferred Brand 3: Non Preferred Brand and Specialty Drugs 4: Specialty Drugs 5: Zero Cost Share Preventive Drugs 6: Medical Service Drugs
ACA: Affordable Care Act. LA: Limited Availability. This prescription may be available only at certain specialty pharmacies. For more information, please call Customer Service. M: Maintenance Medications MSD: Medical Service Drug. This product is only covered under the medical benefit. OTC: Over the Counter. An OTC drug is a non-prescription drug. PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
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Discrimination is Against the Law Blue KC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue KC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue KC: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: ○ Qualified sign language interpreters ○ Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: ○ Qualified interpreters ○ Information written in other languages If you need these services,
[email protected].
contact
Customer
Service,
844-395-7126
(Toll
free),
If you believe that Blue KC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Appeals Department, PO Box 419169, Kansas City, MO 64141-6169, 816-395-3537, TTY: 816-8425607,
[email protected]. You can file a grievance in person or by mail, or email. If you need help filing a grievance, the Appeals Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. If you, or someone you’re helping, has questions about Blue KC, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-844-395-7126. Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue KC, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-395-7126. Chinese: 如果您,或是您正在協助的對象,有關於 Blue KC方面的問題,您 有權利免費以您的母語得到幫助和 訊息。洽詢一位翻譯員,請撥電話1-844-395-7126。 Vietnamese: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Blue KC, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-395-7126. German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Blue KC haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-844-395-7126 an.
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Drug Name
Drug Tier
Requirements / Limits
ANTI - INFECTIVES ANTIFUNGAL AGENTS
Drug Name
Drug Tier
griseofulvin microsize
1
griseofulvin ultramicrosize
1
GRIS-PEG (ULTRAMICROSIZ E)
3
itraconazole
1
ketoconazole
1
LAMISIL
3
Requirements / Limits
AMBISOME
6
MSD
amphotericin b
6
MSD
ANCOBON
3
CANCIDAS
6
clotrimazole
1
CRESEMBA INTRAVENOUS
6
CRESEMBA ORAL
2
NOXAFIL
2
DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTIO N
3
nystatin
1
ONMEL
3
ORAVIG
3
DIFLUCAN ORAL TABLET 100 MG, 200 MG, 50 MG
3
SPORANOX
2
SPORANOX PULSEPAK
3
DIFLUCAN ORAL TABLET 150 MG
3
QL
terbinafine hcl
1
VFEND
3
ERAXIS(WATER DILUENT)
6
MSD
VFEND IV
6
MSD
fluconazole in dextrose(iso-o)
6
MSD
voriconazole intravenous
6
MSD
fluconazole in nacl (iso-osm)
6
MSD
voriconazole oral
1
fluconazole oral suspension for reconstitution
1
fluconazole oral tablet 100 mg, 200 mg, 50 mg
1
fluconazole oral tablet 150 mg
1
flucytosine
1
MSD MSD
QL
QL
QL
ANTIVIRALS
QL
abacavir
1
LA
abacavir-lamivudine
1
LA
abacavirlamivudinezidovudine
1
LA
acyclovir
1
adefovir
1
amantadine hcl
1
M
APTIVUS
2
LA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 6
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
LA
GENVOYA
2
LA PA; ST; LA; QL
ATRIPLA
2
BARACLUDE ORAL SOLUTION
2
HARVONI
4
BARACLUDE ORAL TABLET
3
HEPSERA
3
INTELENCE
2
LA
cidofovir
6
MSD
INVIRASE
2
LA
COMBIVIR
3
LA
ISENTRESS
2
LA
COMPLERA
2
LA
KALETRA
2
LA
CRIXIVAN
2
LA
LA
3
LA
lamivudine oral solution
1
DAKLINZA DESCOVY
3
LA
1
didanosine
1
LA
lamivudine oral tablet 100 mg
EDURANT
2
LA
1
LA
EMTRIVA
2
LA
lamivudine oral tablet 150 mg, 300 mg
entecavir
1
1
LA
EPCLUSA
3
ST; LA
lamivudinezidovudine
EPIVIR HBV ORAL SOLUTION
2
LEXIVA
2
LA
nevirapine
1
LA
EPIVIR HBV ORAL TABLET
3
NORVIR
2
LA
ODEFSEY
3
LA
EPIVIR ORAL SOLUTION
2
LA
OLYSIO
3
ST; LA; QL
EPIVIR ORAL TABLET
3
LA
PREZCOBIX
3
LA
PREZISTA
2
LA
EPZICOM
3
LA
2
QL
EVOTAZ
3
LA
RELENZA DISKHALER
famciclovir
1
QL
RESCRIPTOR
2
LA
FAMVIR
3
QL
RETROVIR
3
LA
FLUMADINE
3
REYATAZ
2
LA
foscarnet
6
MSD
rimantadine
1
FOSCAVIR
6
MSD
SELZENTRY
2
PA; LA
FUZEON
3
LA
SITAVIG
3
QL
SOVALDI
3
ST; LA; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 7
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
ZIAGEN ORAL TABLET
3
LA
zidovudine
1
LA
ZOVIRAX
3
stavudine
1
LA
STRIBILD
2
LA
SUSTIVA
2
LA
SYNAGIS
6
MSD
TAMIFLU
2
QL
CEPHALOSPORINS
TECHNIVIE
3
LA
AVYCAZ
6
TIVICAY
2
LA
CEDAX
3
TRIUMEQ
2
LA
cefaclor
1
TRIZIVIR
3
LA
cefadroxil
1
TRUVADA
2
LA
cefazolin
6
MSD
TYBOST
3
LA
6
MSD
TYZEKA
2
CEFAZOLIN IN 0.9% SOD CHLORIDE
valacyclovir
1
QL
6
MSD
VALCYTE
3
valganciclovir
1
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml
VALTREX
3
QL
6
MSD
VIDEX 2 GRAM PEDIATRIC
2
LA
VIDEX EC
3
LA
VIEKIRA PAK
3
PA; LA; QL
CEFAZOLIN IN DEXTROSE (ISOOS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML
VIEKIRA XR
3
PA; LA
cefdinir
1
VIRACEPT
2
LA
cefditoren pivoxil
1
VIRAMUNE
3
LA
cefepime
6
MSD
VIRAMUNE XR
3
LA
6
MSD
VIRAZOLE
4
LA
cefepime in dextrose,iso-osm
VIREAD
2
LA
cefixime
1
VITEKTA
3
LA
CEFOTAN
6
MSD
ZEPATIER
4
ST; LA
cefotaxime
6
MSD
ZERIT
3
LA
cefotetan
6
MSD
ZIAGEN ORAL SOLUTION
2
LA
cefoxitin
6
MSD
cefpodoxime
1
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 8
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
cefprozil
1
E.E.S. GRANULES
2
ceftibuten
1
ERYPED 200
2
CEFTIN
3
ERYPED 400
2
ceftriaxone in dextrose,iso-os
6
MSD
1
ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg
6
MSD
ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg
2
CEFTRIAXONE INJECTION RECON SOLN 100 GRAM
6
ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG erythrocin (as stearate)
1
cefuroxime axetil
1
erythromycin
1
cefuroxime sodium
6
1
cephalexin
1
erythromycin ethylsuccinate
CLAFORAN
6
MSD
PCE
3
CLAFORAN IN DEXTROSE(ISOOSM)
6
MSD
ZITHROMAX
3
ZMAX
3
KEFLEX
3
MAXIPIME
6
SPECTRACEF
MSD
MSD
Requirements / Limits
MISCELLANEOUS ANTIINFECTIVES MSD
ALBENZA
2
3
ALINIA
2
SUPRAX
3
amikacin
6
TAZICEF
6
MSD
atovaquone
1
TEFLARO
6
MSD
1
ZINACEF
6
MSD
atovaquoneproguanil
ERYTHROMYCINS & OTHER MACROLIDES
BETHKIS
6
BILTRICIDE
3
azithromycin
1
CAPASTAT
6
MSD
BIAXIN
3
CAYSTON
3
LA; QL
clarithromycin
1
6
MSD
DIFICID
3
chloramphenicol sod succinate
e.e.s. 400
1
MSD
MSD; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 9
Drug Name
Drug Tier
Requirements / Limits
chloroquine phosphate
1
CLEOCIN INJECTION
6
MSD
cleocin intravenous solution 300 mg/2 ml
6
MSD
CLEOCIN INTRAVENOUS SOLUTION 600 MG/4 ML, 900 MG/6 ML
6
MSD
CLEOCIN ORAL
3
CLIN SINGLE USE
6
clindamycin hcl
1
clindamycin palmitate hcl
1
clindamycin pediatric
1
clindamycin phosphate
6
COARTEM
2
colistin (colistimethate na)
Drug Name
Drug Tier
Requirements / Limits
FLAGYL
3
FLAGYL ER
3
gentamicin
6
gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml
1
GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML
3
gentamicin sulfate (ped) (pf)
1
MSD
gentamicin sulfate (pf) intravenous solution 100 mg/10 ml
1
6
MSD
3
COLY-MYCIN M PARENTERAL
6
MSD
GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML
CUBICIN
6
MSD
hydroxychloroquine
1
M
CUBICIN RF
6
MSD
imipenem-cilastatin
6
MSD
CYCLOSERINE
3
IMPAVIDO
3
LA
dapsone
1
M
INVANZ
6
MSD
daptomycin
6
MSD
isoniazid
1
DARAPRIM
2
LA
ivermectin
1
DORIBAX
6
MSD
KETEK
3
EMVERM
2
KITABIS PAK
3
LA
ethambutol
1
LINCOCIN
6
MSD
MSD
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 10
Drug Name
Drug Tier
Requirements / Limits
Drug Name
lincomycin
6
MSD
RIFADIN
3
linezolid intravenous
6
MSD
RIFAMATE
3
linezolid oral
1
PA
rifampin
1
MALARONE
3
RIFATER
3
MALARONE PEDIATRIC
3
SIRTURO
2
SIVEXTRO
3
PA
mefloquine
1
STREPTOMYCIN
6
MSD
MEPRON
3
STROMECTOL
2
meropenem
6
MSD
TINDAMAX
3
MEROPENEM0.9% SODIUM CHLORIDE
6
MSD
tinidazole
1
TOBI
3
QL
MERREM
6
MSD
TOBI PODHALER
2
QL
metro i.v.
6
MSD
1
QL
metronidazole
1
tobramycin in 0.225 % nacl
metronidazole in nacl (iso-os)
6
TOBRAMYCIN WITH NEBULIZER
4
LA
MYAMBUTOL
3
TRECATOR
3
MYCOBUTIN
3
TYGACIL
6
NEBUPENT
2
XIFAXAN
2
neomycin
1
ZYVOX INTRAVENOUS
6
MSD
paromomycin
1
ZYVOX ORAL
2
PA
PASER
3
PLAQUENIL
3
M
polymyxin b sulfate
6
MSD
PRIFTIN
2
PRIMAQUINE
3
PRIMAXIN IV
6
pyrazinamide
MSD
QL
Drug Tier
Requirements / Limits
MSD
PENICILLINS amoxicillin
1
amoxicillin-pot clavulanate
1
M
ampicillin
1
MSD
ampicillin sodium
6
MSD
1
ampicillin-sulbactam
6
MSD
QUALAQUIN
3
3
quinine sulfate
1
AUGMENTIN ES600
rifabutin
1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 11
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
ciprofloxacin
1
ciprofloxacin (mixture)
1
ciprofloxacin hcl
1
FACTIVE
3
LEVAQUIN
3
levofloxacin in d5w
6
MSD
levofloxacin intravenous
6
MSD
levofloxacin oral
1
moxifloxacin
1
ofloxacin
1
AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N 125-31.25 MG/5 ML
2
AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N 250-62.5 MG/5 ML
3
AUGMENTIN ORAL TABLET
3
AUGMENTIN XR
3
BICILLIN C-R
6
dicloxacillin
1
BACTRIM
3
MOXATAG
3
BACTRIM DS
3
nafcillin
6
MSD
sulfadiazine
1
oxacillin
6
MSD
1
oxacillin in dextrose(iso-osm)
6
MSD
sulfamethoxazoletrimethoprim sulfatrim
1
penicillin g potassium
6
penicillin v potassium
1
pfizerpen-g
6
MSD
piperacillintazobactam
6
MSD
UNASYN
6
QUINOLONES
MSD
MSD
MSD
Requirements / Limits
SULFA'S & RELATED AGENTS
TETRACYCLINES ACTICLATE
3
avidoxy
1
AVIDOXY DK
3
BENZODOX 30
3
BENZODOX 60
3
demeclocycline
1
DORYX
3
ST ST
AVELOX
3
DORYX MPC
3
AVELOX ABC PACK
3
doxycycline hyclate
1 1
CIPRO
3
CIPRO XR
3
doxycycline monohydrate oral capsule
ST ST
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 12
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
ST
MACROBID
3
MACRODANTIN
3
methenamine hippurate
1
methenamine mandelate
1
MONUROL
3
nitrofurantoin
1
nitrofurantoin macrocrystal
1
nitrofurantoin monohyd/m-cryst
1
DOXYCYCLINE MONOHYDRATE ORAL CAPSULE,IR DELAY REL,BIPHASE
3
doxycycline monohydrate oral suspension for reconstitution
1
doxycycline monohydrate oral tablet
1
MINOCIN
3
minocycline
1
PRIMSOL
3
mondoxyne nl
1
trimethoprim
1
MONODOX
3
morgidox
1
MORGIDOX 1X 50
3
ST
MORGIDOX 2X100
3
ST
ORACEA
3
ST
SOLODYN
3
ST
TARGADOX
3
ST
tetracycline
1
VIBRAMYCIN ORAL CAPSULE
3
VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTIO N
3
VIBRAMYCIN ORAL SYRUP
3
ST
ST
ST
Requirements / Limits
VANCOMYCIN VANCOCIN
3
VANCOMYCIN IN 0.9% SODIUM CL
6
MSD
VANCOMYCIN IN DEXTROSE 5 %
6
MSD
vancomycin intravenous
6
MSD
vancomycin oral
1
VIBATIV
6
MSD
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS
URINARY TRACT AGENTS FURADANTIN
3
HIPREX
3
amifostine crystalline
6
MSD
dexrazoxane hcl
6
MSD
ELITEK
6
MSD
ETHYOL
6
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 13
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
FUSILEV
6
MSD
ASTAGRAF XL
3
KEPIVANCE
6
MSD
AVASTIN
6
MSD
leucovorin calcium injection
1
LA
azacitidine
6
MSD
AZASAN
2
leucovorin calcium oral
1
azathioprine
1
levoleucovorin
6
MSD
BELEODAQ
6
MSD
mesna
6
MSD
BENDEKA
6
MSD
MESNEX INTRAVENOUS
6
MSD
bexarotene
1
bicalutamide
1
MESNEX ORAL
2
BICNU
6
MSD
VISTOGARD
2
bleo 15k
6
MSD
VORAXAZE
6
MSD
bleomycin
6
MSD
XGEVA
6
MSD
BOSULIF
3
LA
ZINECARD (AS HCL)
6
MSD
BUSULFEX
6
MSD
CABOMETYX
3
CAMPATH
6
MSD
CAMPTOSAR
6
MSD
capecitabine
1
CAPRELSA
2
carboplatin
6
CASODEX
3
CELLCEPT INTRAVENOUS
6
CELLCEPT ORAL CAPSULE
3
CELLCEPT ORAL SUSPENSION FOR RECONSTITUTIO N
2
CELLCEPT ORAL TABLET
3
cisplatin
6
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ABRAXANE
6
MSD
ADCETRIS
6
MSD
adrucil
6
MSD
AFINITOR
2
AFINITOR DISPERZ
2
ALECENSA
3
LA
ALKERAN INTRAVENOUS
6
MSD
ALKERAN ORAL
2
anastrozole
1
ARIMIDEX
3
AROMASIN
3
ARRANON
6
MSD
ARZERRA
6
MSD
MSD MSD
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 14
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
ELIGARD (4 MONTH)
3
LA
ELIGARD (6 MONTH)
3
LA
ELLENCE
6
MSD
EMCYT
2
EMPLICITI
6
ENVARSUS XR
3
epirubicin
6
MSD
ERBITUX
6
MSD
ERIVEDGE
2
LA
ERWINAZE
6
MSD
etoposide intravenous
6
MSD
etoposide oral
1
EVOMELA
6
exemestane
1
FARESTON
2
FARYDAK
3
FASLODEX
6
FEMARA
3
FIRMAGON KIT W DILUENT SYRINGE
4
LA
floxuridine
6
MSD
fludarabine
6
MSD
fluorouracil
6
MSD
flutamide
1
FOLOTYN
6
MSD
cladribine
6
MSD
CLOLAR
6
MSD
COMETRIQ
3
COSMEGEN
6
MSD
COTELLIC
3
LA
cyclophosphamide intravenous
6
MSD
CYCLOPHOSPHA MIDE ORAL
2
cyclosporine intravenous
1
cyclosporine modified
1
cyclosporine oral
1
CYRAMZA
6
MSD
cytarabine
6
MSD
cytarabine (pf)
6
MSD
dacarbazine
6
MSD
DACOGEN
6
MSD
DARZALEX
6
MSD
daunorubicin
6
MSD
decitabine
6
MSD
DOCEFREZ
6
MSD
docetaxel
6
MSD
DOXIL
6
MSD
doxorubicin
6
MSD
doxorubicin, pegliposomal
6
MSD
DROXIA
2
ELIGARD
3
LA
GAZYVA
6
MSD
ELIGARD (3 MONTH)
3
LA
gemcitabine
6
MSD
GEMZAR
6
MSD
LA
MSD
MSD
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 15
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
gengraf
1
KYPROLIS
6
GILOTRIF
2
LENVIMA
2
GLEEVEC
3
letrozole
1
GLEOSTINE
2
LEUKERAN
2
GLIADEL WAFER
3
leuprolide
1
LA
HALAVEN
6
MSD
lipodox 50
6
MSD
HERCEPTIN
6
MSD
LONSURF
3
HEXALEN
2
3
LA
HYCAMTIN INTRAVENOUS
6
MSD
HYCAMTIN ORAL
3
LA
LUPRON DEPOT (3 MONTH) INTRAMUSCULA R SYRINGE KIT 11.25 MG
HYDREA
3
4
LA
hydroxyurea
1
IBRANCE
2
ICLUSIG
3
LA
LUPRON DEPOT (3 MONTH) INTRAMUSCULA R SYRINGE KIT 22.5 MG
IDAMYCIN PFS
6
MSD
LUPRON DEPOT (4 MONTH)
4
LA
idarubicin
6
MSD
LA
6
MSD
LUPRON DEPOT (6 MONTH)
4
IFEX ifosfamide
6
MSD
3
LA
ifosfamide-mesna
6
MSD
imatinib
1
LUPRON DEPOT INTRAMUSCULA R SYRINGE KIT 3.75 MG
IMBRUVICA
3
4
LA
IMURAN
3
INLYTA
3
LA
LUPRON DEPOT INTRAMUSCULA R SYRINGE KIT 7.5 MG
IRESSA
3
LA
3
LA
irinotecan
6
MSD
LUPRON DEPOTPED
ISTODAX
6
MSD
LYNPARZA
2
LA
IXEMPRA
6
MSD
LYSODREN
2
JAKAFI
3
LA
MARQIBO
6
JEVTANA
6
MSD
MATULANE
2
KADCYLA
6
MSD
MEGACE
3
LA
MSD
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 16
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
MEGACE ES
3
PERJETA
6
MSD
megestrol
1
PORTRAZZA
6
MSD
MEKINIST
2
PROGRAF
3
melphalan hcl
6
PURIXAN
3
mercaptopurine
1
RAPAMUNE
2
methotrexate sodium
1
RITUXAN
6
MSD
methotrexate sodium (pf)
1
SANDIMMUNE INTRAVENOUS
4
LA
mitomycin
6
MSD
3
mitoxantrone
6
MSD
SANDIMMUNE ORAL CAPSULE
MUSTARGEN
6
MSD
SANDIMMUNE ORAL SOLUTION
2
mycophenolate mofetil
1
SANDOSTATIN
4
LA
mycophenolate sodium
1
SANDOSTATIN LAR DEPOT
6
MSD
MYFORTIC
3
SIGNIFOR
6
MSD
MYLERAN
3
LA
SIGNIFOR LAR
6
PA; MSD
NAVELBINE
6
MSD
SIMULECT
6
MSD
NEORAL
3
sirolimus
1
NEXAVAR
2
SOLTAMOX
3
NILANDRON
3
SOMATULINE DEPOT
4
nilutamide
1
SPRYCEL
2
NINLARO
3
LA
STIVARGA
2
NIPENT
6
MSD
SUPPRELIN LA
6
NULOJIX
6
MSD
SUTENT
2
octreotide acetate
1
LA
SYLVANT
6
MSD
ODOMZO
3
SYNRIBO
6
MSD
ONCASPAR
6
MSD
TABLOID
2
ONIVYDE
6
MSD
tacrolimus
1
OPDIVO
6
MSD
TAFINLAR
2
oxaliplatin
6
MSD
TAGRISSO
2
MSD
LA
LA
MSD
paclitaxel 6 MSD You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 17
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
tamoxifen
1
vincasar pfs
6
MSD
TARCEVA
2
vincristine
6
MSD
TARGRETIN ORAL
3
vinorelbine
6
MSD
VOTRIENT
2
TARGRETIN TOPICAL
2
XALKORI
2
TASIGNA
2
XELODA
3
TAXOTERE
6
MSD
XTANDI
2
TECENTRIQ
6
MSD
YERVOY
6
MSD
TEMODAR
3
YONDELIS
6
MSD
temozolomide
1
ZALTRAP
6
MSD
TENIPOSIDE
6
ZANOSAR
6
MSD
THALOMID
2
ZELBORAF
3
LA
thiotepa
6
MSD
ZOLADEX
6
MSD
toposar
6
MSD
ZOLINZA
2
topotecan
6
MSD
ZORTRESS
2
TORISEL
6
MSD
ZYDELIG
2
TREANDA
6
MSD
ZYKADIA
2
TRELSTAR
6
MSD
ZYTIGA
2
tretinoin (chemotherapy)
1
AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
TREXALL
2
ANTICONVULSANTS
TRISENOX
6
TYKERB
2
VANTAS
6
VECTIBIX
MSD
MSD
ACTIVE-PAC
3
APTIOM
3
MSD
BANZEL
2
6
MSD
BRIVIACT
3
VELCADE
6
MSD
carbamazepine
1
VENCLEXTA
2
CARBATROL
3
VENCLEXTA STARTING PACK
2
CELONTIN
2
clonazepam
1
VIDAZA
6
MSD
DEPACON
6
vinblastine
6
MSD
LA
M
ST
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 18
Drug Name
Drug Tier
Requirements / Limits
Drug Name
DEPAKENE
3
PA; ST
6
MSD
DEPAKOTE
3
PA; ST
KEPPRA INTRAVENOUS
DEPAKOTE ER
3
PA; ST
KEPPRA ORAL
3
ST
DEPAKOTE SPRINKLES
3
PA; ST
KEPPRA XR
3
ST
KLONOPIN
3
DIASTAT
3
LAMICTAL
3
ST
DIASTAT ACUDIAL
3
LAMICTAL ODT
3
ST ST
1
LAMICTAL ODT STARTER (BLUE)
3
diazepam DILANTIN
2
3
ST
DILANTIN EXTENDED
3
LAMICTAL ODT STARTER (GREEN)
DILANTIN INFATABS
3
LAMICTAL ODT STARTER (ORANGE)
3
ST
DILANTIN-125
3
3
ST
divalproex
1
epitol
1
LAMICTAL STARTER (BLUE) KIT
EQUETRO
3
3
ST
ethosuximide
1
LAMICTAL STARTER (GREEN) KIT
felbamate
1
3
ST
FELBATOL
3
LAMICTAL STARTER (ORANGE) KIT
fosphenytoin
6
LAMICTAL XR
3
ST
FYCOMPA
3
ST
1
LAMICTAL XR STARTER (BLUE)
3
gabapentin GABITRIL ORAL TABLET 12 MG, 16 MG
2
LAMICTAL XR STARTER (GREEN)
3
ST
GABITRIL ORAL TABLET 2 MG, 4 MG
3
LAMICTAL XR STARTER (ORANGE)
3
ST
GRALISE
3
ST
lamotrigine
1
GRALISE 30-DAY STARTER PACK
3
ST
levetiracetam intravenous
6
MSD
Drug Tier
Requirements / Limits
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 19
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
levetiracetam oral
1
LYRICA
2
MYSOLINE
3
NEURONTIN
3
ONFI
2
oxcarbazepine
1
OXTELLAR XR
3
PEGANONE
2
phenobarbital
1
PHENYTEK
3
phenytoin
1
phenytoin sodium extended
1
POTIGA
2
APOKYN
2
LA
primidone
1
AZILECT
3
M
QUDEXY XR
3
benztropine
1
roweepra
1
bromocriptine
1
SABRIL
3
LA
carbidopa
1
M
SMARTRX GABAKIT
3
M
carbidopa-levodopa
1
M
1
M
SMARTRX GABAV KIT
3
M
carbidopa-levodopaentacapone COMTAN
3
M
SPRITAM
3
DUOPA
6
MSD
TEGRETOL
3
ELDEPRYL
3
M
TEGRETOL XR
3
entacapone
1
M
tiagabine
1
LODOSYN
3
M
TOPAMAX
3
MIRAPEX
3
M
topiramate oral capsule, sprinkle
1
MIRAPEX ER
3
M
NEUPRO
3
M
TOPIRAMATE ORAL CAPSULE,SPRINK LE,ER 24HR
3
PARLODEL
3
pramipexole
1
ST ST
ST
topiramate oral tablet
1
TRILEPTAL
3
TROKENDI XR
3
valproate sodium
6
valproic acid
1
valproic acid (as sodium salt)
1
VIMPAT
2
ZARONTIN
3
ZONEGRAN
3
zonisamide
1
Requirements / Limits
ST MSD
ANTIPARKINSONISM AGENTS
ST
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 20
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
REQUIP
3
M
IMITREX NASAL
3
QL
REQUIP XL
3
M
IMITREX ORAL
3
ST; QL
ropinirole
1
M
3
QL
RYTARY
3
M
IMITREX STATDOSE KIT REFILL
selegiline hcl
1
M
QL
3
M
IMITREX STATDOSE PEN
3
SINEMET SINEMET CR
3
M
3
QL
STALEVO 100
3
M
IMITREX SUBCUTANEOUS
STALEVO 125
3
M
isometh-dichloralacetaminophn
1
STALEVO 150
3
M
3
M
isomethepten-cafacetaminophen
1
STALEVO 200 STALEVO 50
3
M
MAXALT
3
ST; QL
STALEVO 75
3
M
MAXALT-MLT
3
ST; QL
TASMAR
2
M
migergot
1
tolcapone
1
M
MIGRANAL
3
trihexyphenidyl
1
MIGRANOW
3
ZELAPAR
3
naratriptan
1
nodolor
1
M
MIGRAINE & CLUSTER HEADACHE THERAPY
QL QL
ONZETRA XSAIL
3
almotriptan malate
1
QL
QL
PRODRIN
3
ALSUMA
3
QL
RELPAX
3
ST; QL
AMERGE
3
ST; QL
rizatriptan
1
QL
AXERT
3
ST; QL
sumatriptan
1
QL
CAFERGOT
3
1
QL
D.H.E.45
3
sumatriptan succinate
dihydroergotamine injection
1
SUMAVEL DOSEPRO
3
QL
dihydroergotamine nasal
1
QL
TREXIMET ORAL TABLET 10-60 MG
3
ST
FROVA
3
ST; QL
3
ST; QL
frovatriptan
1
QL
TREXIMET ORAL TABLET 85-500 MG
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 21
Drug Name
Drug Tier
Requirements / Limits
Drug Name NAMENDA XR ORAL CAP,SPRINKLE,E R 24HR DOSE PACK
2
M
NAMENDA XR ORAL CAPSULE,SPRINK LE,ER 24HR
2
ST; M
NAMZARIC
3
ST
ZEMBRACE SYMTOUCH
3
QL
zolmitriptan
1
QL
ZOMIG NASAL
2
QL
ZOMIG ORAL
3
ST; QL
ZOMIG ZMT
3
ST; QL
MISCELLANEOUS NEUROLOGICAL THERAPY
Drug Tier
Requirements / Limits
AMPYRA
3
LA
NUEDEXTA
2
PA
ARICEPT
3
ST; M
RAZADYNE
3
ST; M
donepezil oral tablet 10 mg, 5 mg
1
M
RAZADYNE ER
3
ST; M
donepezil oral tablet 23 mg
1
ST; M
rivastigmine
1
M
rivastigmine tartrate
1
M
donepezil oral tablet,disintegrating
1
tetrabenazine
1
PA
TYSABRI
6
MSD
EXELON
3
ST; M
XENAZINE
3
PA
galantamine
1
M
HORIZANT
3
ST
MUSCLE RELAXANTS & ANTISPASMODIC THERAPY
KEVEYIS
3
PA
AMRIX
3
memantine oral solution
1
M
baclofen
1
M
BRIDION
6
MSD
memantine oral tablet
1
M
carisoprodol
1
MEMANTINE ORAL TABLETS,DOSE PACK
3
M
carisoprodol-asacodeine
1
carisoprodol-aspirin
1
chlorzoxazone
1
NAMENDA
3
ST; M
cyclobenzaprine
1
NAMENDA TITRATION PAK
2
M
DANTRIUM
3
M
dantrolene
1
M
FEXMID
3
LORZONE
3
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 22
Drug Name
Drug Tier
meprobamate
1
MESTINON ORAL SYRUP
2
MESTINON ORAL TABLET
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
ascomp with codeine
1
M
aspirin-caffeinedihydrocodein
1
3
M
BELBUCA
3
BUPAP
3
MESTINON TIMESPAN
2
M
buprenorphine hcl
1
metaxall
1
butalbital compound w/codeine
1
metaxalone
1
1
methocarbamol injection
6
butalbitalacetaminop-caf-cod
1
butalbitalacetaminophen
1
methocarbamol oral orphenadrine citrate
1
1
PARAFON FORTE DSC
3
butalbitalacetaminophen-caff
1
pyridostigmine bromide
1
butalbital-aspirincaffeine BUTRANS
3
ROBAXIN INJECTION
6
capacet
1
3
CAPITAL WITH CODEINE
3
ROBAXIN ORAL ROBAXIN-750
3
codeine sulfate
1
SKELAXIN
3
1
SOMA
3
codeine-butalbitalasa-caff
tizanidine
1
M
DEMEROL
3
ZANAFLEX
3
M
DILAUDID
3
diskets
1
DOLOPHINE
3
DURAGESIC
3
EMBEDA
3
endocet
1
ESGIC
3
EXALGO ER
3
ST; QL
fentanyl citrate
1
PA; QL
MSD
M MSD
NARCOTIC ANALGESICS ABSTRAL
3
acetaminophen-caffdihydrocod
1
acetaminophencodeine
1
ACTIQ
3
ALLZITAL
3
PA; QL
PA; QL
ST; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 23
Drug Name
Drug Tier
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
1
FENTANYL TRANSDERMAL PATCH 72 HOUR 37.5 MCG/HOUR, 62.5 MCG/HOUR, 87.5 MCG/HOUR
3
FENTANYLBUPIVACAINENACL (PF)
6
FENTORA
3
FIORICET
3
FIORICET WITH CODEINE
3
FIORINAL
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
HYSINGLA ER
3
IBUDONE
3
ibuprofen-oxycodone
1
IONSYS
3
KADIAN
3
ST; QL
LAZANDA
3
PA; QL
levorphanol tartrate
1
lorcet (hydrocodone)
1
lorcet hd
1
lorcet plus
1
lortab 10-325
1
lortab 5-325
1
lortab 7.5-325
1
LORTAB ELIXIR
3
3
margesic
1
FIORINALCODEINE #3
3
marten-tab
1
meperidine
1
HYCET
3
methadone
1
hydrocodoneacetaminophen
1
methadose
1
hydrocodoneibuprofen
1
morphine (pf)
6 1
HYDROMORPHO NE IN 0.9 % NACL
6
morphine concentrate morphine injection
6
MSD
hydromorphone oral liquid
1
6
MSD
hydromorphone oral tablet
1
MORPHINE INTRAMUSCULA R
6
MSD
hydromorphone oral tablet extended release 24 hr
1
morphine intravenous cartridge 10 mg/ml, 2 mg/ml, 4 mg/ml
hydromorphone rectal
1
MSD
PA; QL
MSD
QL
ST; QL
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 24
Drug Name
Drug Tier
Requirements / Limits
Drug Name
MSD
OPANA
3
OPANA ER
3
OXAYDO
3
oxycodone oral capsule
1
oxycodone oral concentrate
1
oxycodone oral solution
1
oxycodone oral tablet
1
OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR
3
oxycodoneacetaminophen
1
oxycodone-aspirin
1
OXYCONTIN
3
oxymorphone oral tablet
1
oxymorphone oral tablet extended release 12 hr
1
PERCOCET
3
PRIMLEV
3
PROBUPHINE
6
reprexain
1
ROXICODONE
3
SUBSYS
3
SYNALGOS-DC
3
tencon
1
TREZIX
3
MORPHINE INTRAVENOUS CARTRIDGE 8 MG/ML
6
morphine intravenous pt controlled analgesia syring
6
morphine intravenous solution 10 mg/ml, 100 mg/4 ml, 25 mg/ml, 250 mg/10 ml, 50 mg/ml
6
MORPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML
6
MSD
MORPHINE INTRAVENOUS SYRINGE 10 MG/ML, 8 MG/ML
6
MSD
morphine intravenous syringe 2 mg/ml, 4 mg/ml
6
morphine oral capsule, er multiphase 24 hr
1
morphine oral capsule,extend.relea se pellets
1
morphine oral solution
1
morphine oral tablet
1
morphine oral tablet extended release
1
morphine rectal
1
MS CONTIN
3
NORCO
3
MSD
MSD
MSD
QL
QL
QL
ST; QL
Drug Tier
Requirements / Limits ST; QL
ST; QL
ST; QL
QL
MSD
PA; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 25
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
TYLENOLCODEINE #3
3
butorphanol tartrate nasal
1
QL
TYLENOLCODEINE #4
3
CAMBIA
3
ST; QL
CAPXIB
3
VANATOL LQ
3
CELEBREX
3
ST; M
verdrocet
1
celecoxib
1
ST; M
vicodin
1
children's aspirin
5
ACA; OTC
vicodin es
1 1
choline,magnesium salicylate
1
vicodin hp XARTEMIS XR
3
CONZIP
3
ST; QL
XODOL 10/300
3
DAYPRO
3
ST; M
XODOL 5/300
3
3
M
XODOL 7.5/300
3
DERMACINRX LEXITRAL
XTAMPZA ER
3
diclofenac potassium
1
xylon 10
1
diclofenac sodium oral
1
M
zamicet
1
M
1
diclofenac sodium topical drops
1
zebutal ZOHYDRO ER
3
diclofenac sodium topical gel
1
ST; M
diclofenacmisoprostol
1
M
DICLOTRAL
3
M
DICLOZOR
3
M
diflunisal
1
M
DISALCID
3
DS PREP PAK
3
M
DUEXIS
3
ST; M
e.c. prin
5
ACA; OTC
EC-NAPROSYN
3
ST; M
ecotrin
5
ACA; OTC
ecotrin low strength
5
ACA; OTC
ST; QL
ST; QL
NON-NARCOTIC ANALGESICS ANAPROX DS
3
ST; M
ARTHROTEC 50
3
ST; M
ARTHROTEC 75
3
ST; M
aspir-81
5
ACA; OTC
aspirin
5
ACA; OTC
aspirin low dose
5
ACA; OTC
aspir-low
5
ACA; OTC
aspir-trin
5
ACA; OTC
BUNAVAIL
3
PA; QL
buprenorphinenaloxone
1
PA; QL
butorphanol tartrate injection
6
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 26
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
enteric coated aspirin
5
ACA; OTC
MOBIC ORAL TABLET 15 MG
3
ST; M
etodolac
1
M
3
ST; M; QL
EVZIO
3
QL
MOBIC ORAL TABLET 7.5 MG
FELDENE
3
ST; M
nabumetone
1
M
FENOPROFEN ORAL CAPSULE
3
ST; M
nalbuphine
6
MSD
NALFON
3
ST; M
fenoprofen oral tablet
1
naloxone
6
MSD
naltrexone
1
FENORTHO
3
ST; M
NAPRELAN CR
3
ST; M
FLECTOR
3
ST; QL
NAPROSYN
3
ST; M
flurbiprofen
1
M
naproxen
1
M
ibuprofen
1
M
naproxen sodium
1
M
INDOCIN ORAL
3
ST
NARCAN
2
INDOCIN RECTAL
3
NUCYNTA
3
QL
indomethacin
1
NUCYNTA ER
3
ST; QL
INFLAMMA-K
3
M
M
1
M
NUDICLO SOLUPAK
3
ketoprofen ketorolac injection
6
MSD
oxaprozin
1
M
ketorolac intramuscular
6
MSD
PENNSAID
3
ST; M
1
QL
pentazocinenaloxone
1
ketorolac oral klofensaid ii
1
ST; M
piroxicam
1
M
LIDOXIB
3
PONSTEL
3
ST
lite coat aspirin
5
ACA; OTC
REVIA
3
meclofenamate
1
M
salsalate
1
mefenamic acid
1
SPRIX
3
ST; QL
meloxicam oral suspension
1
M
SUBOXONE
3
PA; QL
sulindac
1
M
meloxicam oral tablet 15 mg
1
M
3
M
meloxicam oral tablet 7.5 mg
1
M; QL
SURE RESULT DSS PREMIUM PACK
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 27
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
TALWIN
6
MSD
ZIPSOR
3
ST
TIVORBEX
3
ST; M
3
ST; M; QL
tolmetin
1
M
ZORVOLEX ORAL CAPSULE 18 MG
TORONOVA II SUIK
6
MSD
ZORVOLEX ORAL CAPSULE 35 MG
3
ST; M
TORONOVA SUIK
6
MSD
ZUBSOLV
2
PA; QL
TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 17-83
3
ST; QL
TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 25-75
3
tramadol oral tablet
1
QL
tramadol oral tablet extended release 24 hr
1
QL
tramadol oral tablet, er multiphase 24 hr
1
QL
tramadolacetaminophen
1
QL
ULTRACET
3
ST; QL
ULTRAM
3
ST; QL
ULTRAM ER
3
ST; QL
VIMOVO
3
ST; M
VIVITROL
6
MSD
VIVLODEX
3
ST; M
VOLTAREN
3
ST; M
VOLTAREN-XR
3
ST; M
VOPAC MDS
3
M
XELITRAL
3
M
XRYLIX
3
M
ST; QL
PSYCHOTHERAPEUTIC DRUGS ABILIFY
3
QL
ABILIFY MAINTENA
6
MSD
ADASUVE
3
ADDERALL
3
ADDERALL XR
3
PA; ST
ADDYI
3
PA
ADZENYS XRODT
3
ST
alprazolam
1
alprazolam intensol
1
AMBIEN
3
ST; QL
AMBIEN CR
3
ST; QL
amitriptyline
1
amitriptylinechlordiazepoxide
1
amoxapine
1
ANAFRANIL
3
APLENZIN
3
ST; M; QL
APTENSIO XR
3
PA; ST
aripiprazole oral solution
1
aripiprazole oral tablet
1
QL
aripiprazole oral tablet,disintegrating
1
QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 28
Drug Name
Drug Tier
Requirements / Limits
Drug Name
ARISTADA
6
MSD
3
armodafinil
1
ST
ATIVAN
3
BELSOMRA
3
ST
CLOZAPINE ORAL TABLET,DISINTE GRATING 150 MG, 200 MG
BRISDELLE
3
ST; M; QL
CLOZARIL
3
bupropion hcl oral tablet
1
M
CONCERTA
3
PA; ST
CYMBALTA
3
ST; M; QL
bupropion hcl oral tablet extended release
1
DAYTRANA
3
PA; ST
desipramine
1
bupropion hcl oral tablet extended release 24 hr 150 mg
1
DESOXYN
3
DESVENLAFAXIN E
3
ST; M; QL
bupropion hcl oral tablet extended release 24 hr 300 mg
1
DESVENLAFAXIN E FUMARATE
3
ST; M
dexedrine
1
buspirone
1
ST
3
CELEXA
3
chlordiazepoxide hcl
1
chlorpromazine
1
DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE 10 MG, 5 MG
3
BUTISOL
citalopram
1
3
PA; ST
clomipramine
1
clonidine hcl
1
DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE 15 MG
clorazepate dipotassium
1
dexmethylphenidate
1
clozapine oral tablet
1
dextroamphetamine
1
clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg
1
dextroamphetamineamphetamine
1
diazepam injection
6
diazepam intensol
1
diazepam oral
1
DORAL
3
doxepin
1
M; QL
M
M; QL
M ST; M; QL
M
Drug Tier
Requirements / Limits
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 29
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
FLUOXETINE ORAL TABLET 60 MG
3
fluphenazine decanoate
1
fluphenazine hcl
1
flurazepam
1
fluvoxamine
1
FOCALIN
3
FOCALIN XR
3
PA; ST
FORFIVO XL
3
ST; M
GEODON INTRAMUSCULA R
3
GEODON ORAL
3
guanfacine
1
guanidine
1
HALCION
3
duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg
1
M; QL
duloxetine oral capsule,delayed release(dr/ec) 40 mg
1
M
DYANAVEL XR
3
PA; ST
EDLUAR
3
ST; QL
EFFEXOR XR
3
ST; M; QL
EMSAM
3
M
ergoloid
1
M
escitalopram oxalate
1
M
estazolam
1
eszopiclone
1
EVEKEO
3
FANAPT
3
FAZACLO
3
FETZIMA
3
ST; M; QL
HALDOL
3
flumazenil
6
MSD
3
fluoxetine oral capsule 10 mg, 40 mg
1
M; QL
HALDOL DECANOATE haloperidol
1
1
haloperidol decanoate
1
fluoxetine oral capsule 20 mg
haloperidol lactate
1
fluoxetine oral capsule,delayed release(dr/ec)
1
HETLIOZ
3
imipramine hcl
1
fluoxetine oral solution
1
M
imipramine pamoate
1
INTERMEZZO
3
ST; QL
fluoxetine oral tablet 10 mg
1
M; QL
INTUNIV ER
3
ST
fluoxetine oral tablet 20 mg
1
M
QL QL
M M; QL
ST
M; QL
QL
LA; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 30
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
QL
NORPRAMIN
3
nortriptyline
1
NUPLAZID
3
LA
NUVIGIL
3
PA
olanzapine intramuscular
6
MSD
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 5 mg, 7.5 mg
1
QL
INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 6 MG, 9 MG
3
IRENKA
3
ST; M
KAPVAY
3
ST
KHEDEZLA
3
ST; M; QL
LATUDA
3
QL
LEXAPRO ORAL SOLUTION
3
ST; M
olanzapine oral tablet 20 mg
1
LEXAPRO ORAL TABLET
3
ST; M; QL
olanzapine oral tablet,disintegrating
1
lithium carbonate
1
olanzapinefluoxetine
1
lithium citrate
1
OLEPTRO ER
3
LITHOBID
3
ORAP
3
lorazepam
1
oxazepam
1
lorazepam intensol
1
paliperidone
1
loxapine succinate
1
PAMELOR
3
LUNESTA
3
PARNATE
3
M
maprotiline
1
paroxetine hcl
1
M; QL
MARPLAN
3
M
PAXIL CR
3
ST; M; QL
METADATE CD
3
PA; ST
ST; M
1
PAXIL ORAL SUSPENSION
3
metadate er methamphetamine
1
3
ST; M; QL
METHYLIN
3
PAXIL ORAL TABLET
methylphenidate
1
perphenazine
1
mirtazapine
1
perphenazineamitriptyline
1
modafinil
1
PEXEVA
3
ST; M; QL
molindone
1
phenelzine
1
M
NARDIL
3
M
pimozide
1
nefazodone
1
M
ST; QL
PA
QL
QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 31
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
ST; M; QL
risperidone oral tablet
1
QL
risperidone oral tablet,disintegrating
1
QL
RITALIN
3
RITALIN LA
3
PA; ST
ROZEREM
2
ST; QL
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG
3
3
QL
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 50 MG
3
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG
3
procentra
1
protriptyline
1
PROVIGIL
3
PA
PROZAC ORAL CAPSULE 10 MG, 40 MG
3
ST; M; QL
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG
PROZAC ORAL CAPSULE 20 MG
3
ST; M
SARAFEM ORAL TABLET 10 MG
3
ST; M; QL
PROZAC WEEKLY
3
ST; M; QL
SARAFEM ORAL TABLET 20 MG
3
ST; M
quazepam
1
seconal sodium
1
quetiapine
1
QL
SEROQUEL
3
QL
QUILLICHEW ER
3
ST
SEROQUEL XR
3
QL
QUILLIVANT XR
3
PA; ST
1
M
REMERON
3
sertraline oral concentrate
REMERON SOLTAB
3
sertraline oral tablet
1
M; QL
SILENOR
3
ST; QL
RESTORIL
3
SONATA
3
ST; QL
REXULTI
3
STRATTERA
2
ST
RISPERDAL MTAB
3
SURMONTIL
3
RISPERDAL ORAL SOLUTION
3
SYMBYAX
3
temazepam
1
RISPERDAL ORAL TABLET
3
thioridazine
1
thiothixene
1
risperidone oral solution
1
TOFRANIL
3
ST; M
QL
QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 32
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
TRANXENE TTAB
3
zaleplon
1 1
tranylcypromine
1
zenzedi oral tablet 10 mg, 5 mg
trazodone
1
3
triazolam
1
trifluoperazine
1
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG
trimipramine
1
ziprasidone hcl
1
QL
TRINTELLIX
3
ST; QL
3
ST; M
VALIUM
3
ZOLOFT ORAL CONCENTRATE
venlafaxine oral capsule,extended release 24hr 150 mg
1
M
ZOLOFT ORAL TABLET
3
ST; M; QL
zolpidem
1
QL
venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg
1
ZOLPIMIST
3
ST
ZYPREXA INTRAMUSCULA R
6
MSD
venlafaxine oral tablet
1
M; QL
3
QL
venlafaxine oral tablet extended release 24hr
1
M; QL
ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 5 MG, 7.5 MG
3
ZYPREXA ORAL TABLET 20 MG
3
VERSACLOZ VIIBRYD ORAL TABLET
3
ST; M; QL
ZYPREXA ZYDIS
3
VIIBRYD ORAL TABLETS,DOSE PACK
3
ST; QL
CARDIOVASCULAR, HYPERTENSION & LIPIDS
VRAYLAR
3
VYVANSE
2
WELLBUTRIN SR
M
M; QL
QL
QL
ANTIARRHYTHMIC AGENTS amiodarone
1
M
PA; ST
BETAPACE
3
M
3
ST; M; QL
BETAPACE AF
3
M
WELLBUTRIN XL
3
ST; M; QL
1
M
XANAX
3
disopyramide phosphate
XANAX XR
3
dofetilide
1
XYREM
3
flecainide
1
M
mexiletine
1
M
LA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 33
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
amlodipinevalsartan
1
M
amlodipinevalsartan-hcthiazid
1
M
ATACAND
3
ST; M
ATACAND HCT
3
ST; M
atenolol
1
M
1
M
MULTAQ
3
M
NORPACE
3
M
NORPACE CR
3
M
pacerone
1
M
procainamide
6
MSD
propafenone
1
M
quinidine gluconate
1
M
quinidine sulfate
1
M
atenololchlorthalidone
RYTHMOL
3
M
AVALIDE
3
ST; M
RYTHMOL SR
3
M
AVAPRO
3
ST; M
sotalol
1
M
AZOR
3
ST; M
sotalol af
1
M
benazepril
1
M
SOTYLIZE
2
M
1
M
TIKOSYN
3
benazeprilhydrochlorothiazide BENICAR
3
ST; M
BENICAR HCT
3
ST; M
betaxolol
1
M
BIDIL
3
M
bisoprolol fumarate
1
M
bisoprololhydrochlorothiazide
1
M
BREVIBLOC
6
MSD
ANTIHYPERTENSIVE THERAPY ACCUPRIL
3
M
ACCURETIC
3
M
acebutolol
1
M
ACEON
3
M
ADALAT CC
3
ST; M
afeditab cr
1
M
ALDACTAZIDE
3
M
MSD
3
M
BREVIBLOC IN NACL (ISO-OSM)
6
ALDACTONE ALTACE
3
M
bumetanide
1
M
amiloride
1
M
BYSTOLIC
3
ST; M
amiloridehydrochlorothiazide
1
M
BYVALSON
3
ST; M
CALAN
3
ST; M
amlodipine
1
M
CALAN SR
3
ST; M
amlodipinebenazepril
1
M
candesartan
1
M
candesartanhydrochlorothiazid
1
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 34
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
captopril
1
M
CORGARD
3
ST; M
captoprilhydrochlorothiazide
1
M
CORZIDE
3
ST; M
COZAAR
3
ST; M
CARDENE IV
6
MSD
DEMADEX
3
M
CARDENE IV IN DEXTROSE
6
MSD
DEMSER
2
CARDENE IV IN SODIUM CHLORIDE
6
MSD
DIBENZYLINE
3
diltiazem
1
M
DIOVAN
3
ST; M
CARDIZEM
3
M
DIOVAN HCT
3
ST; M
CARDIZEM CD
3
M
DIURIL
3
M
CARDIZEM LA
3
M
DIURIL IV
6
MSD
CARDURA
3
ST; M; QL
doxazosin
1
M; QL
CARDURA XL
3
ST; M; QL
DUTOPROL
2
ST; M
carvedilol
1
M
DYAZIDE
3
M
CATAPRES
3
M
DYRENIUM
3
M
CATAPRES-TTS-1
3
M; QL
EDARBI
3
ST; M
CATAPRES-TTS-2
3
M; QL
EDARBYCLOR
3
ST; M
CATAPRES-TTS-3
3
M; QL
EDECRIN
3
M
chlorothiazide
1
M
enalapril maleate
1
M
chlorothiazide sodium
6
MSD
enalaprilhydrochlorothiazide
1
M
chlorthalidone
1
M
EPANED
3
M
clonidine
1
M; QL
eplerenone
1
M
clonidine hcl
1
M
6
MSD
clorpres oral tablet 0.1-15 mg, 0.2-15 mg
1
M
epoprostenol (glycine) eprosartan
1
M
CLORPRES ORAL TABLET 0.3-15 MG
3
esmolol
6
MSD
ethacrynate sodium
6
MSD
ethacrynic acid
1
M
COREG
3
ST; M
EXFORGE
3
ST; M
COREG CR
3
ST; M
EXFORGE HCT
2
ST; M
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 35
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
losartanhydrochlorothiazide
1
M
LOTENSIN
3
M
LOTENSIN HCT
3
M
LOTREL
3
M
felodipine
1
M
FLOLAN
6
MSD
fosinopril
1
M
fosinoprilhydrochlorothiazide
1
M
furosemide injection
6
MSD
MAVIK
3
M
furosemide oral
1
M
MAXZIDE
3
M
guanfacine
1
M
MAXZIDE-25MG
3
M
HEMANGEOL
3
methyclothiazide
1
M
hydralazine injection
6
MSD
methyldopa
1
M
hydralazine oral
1
M
1
M
hydrochlorothiazide
1
M
methyldopahydrochlorothiazide
HYZAAR
3
ST; M
methyldopate
6
MSD
indapamide
1
M
metolazone
1
M
INDERAL LA
3
ST; M
metoprolol succinate
1
M
INDERAL XL
3
ST; M
metoprolol tahydrochlorothiaz
1
M
INNOPRAN XL
3
ST; M
metoprolol tartrate
1
M
INSPRA
3
M
MICARDIS
3
ST; M
irbesartan
1
M
MICARDIS HCT
3
ST; M
irbesartanhydrochlorothiazide
1
M
MICROZIDE
3
M
isradipine
1
M
MINIPRESS
3
M
labetalol
1
M
minoxidil
1
M
LASIX
3
M
moexipril
1
M
LEVATOL
3
ST; M
moexiprilhydrochlorothiazide
1
M
lisinopril
1
M
nadolol
1
M
lisinoprilhydrochlorothiazide
1
M
nadololbendroflumethiazide
1
M
LOPRESSOR
3
ST; M
MSD
3
ST; M
nicardipine intravenous
6
LOPRESSOR HCT losartan
1
M
nicardipine oral
1
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 36
Drug Name
Drug Tier
Requirements / Limits
Drug Name
nifedical xl
Drug Tier
Requirements / Limits
1
M
1
M
nifedipine
1
M
spironolactonhydrochlorothiaz
nimodipine
1
SULAR
3
ST; M
nisoldipine
1
M
TARKA
3
M
NORVASC
3
ST; M
TEKTURNA
3
M
NYMALIZE
3
TEKTURNA HCT
3
M
ORENITRAM
4
M; LA
telmisartan
1
M
perindopril erbumine
1
M
telmisartanamlodipine
1
M
phenoxybenzamine
1
telmisartanhydrochlorothiazid
1
M
phentolamine
6
MSD
TENEX
3
M
pindolol
1
M
TENORETIC 100
3
ST; M
prazosin
1
M
TENORETIC 50
3
ST; M
PRESTALIA
3
ST; M
TENORMIN
3
ST; M
PRINIVIL
3
M
terazosin
1
M; QL
PROCARDIA
3
ST; M
TIAZAC
3
M
PROCARDIA XL
3
ST; M
timolol maleate
1
M
propranolol
1
M
TOPROL XL
3
ST; M
propranololhydrochlorothiazid
1
M
torsemide
1
M
QBRELIS
3
M
trandolapril
1
M
quinapril
1
M
trandolaprilverapamil
1
M
quinaprilhydrochlorothiazide
1
M
triamterenehydrochlorothiazid
1
M
ramipril
1
M
TRIBENZOR
3
ST; M
REMODULIN
6
MSD
TWYNSTA
3
ST; M
reserpine
1
M
UPTRAVI
3
M; LA
SECTRAL
3
ST; M
valsartan
1
M
SODIUM EDECRIN
6
MSD
valsartanhydrochlorothiazide
1
M
spironolactone
1
M
VASERETIC
3
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 37
Drug Name
Drug Tier
Requirements / Limits
Drug Name
VASOTEC
3
M
6
MSD
veletri
6
MSD
ARGATROBAN IN NACL (ISO-OS)
verapamil
1
M
ARIXTRA
3
LA
VERELAN
3
ST; M
aspirin-dipyridamole
1
M
VERELAN PM
3
ST; M
BEBULIN
6
MSD
ZEBETA
3
ST; M
BENEFIX
6
MSD
ZESTORETIC
3
M
BRILINTA ORAL TABLET 60 MG
3
M
ZESTRIL
3
M
2
M
ZIAC
3
ST; M
BRILINTA ORAL TABLET 90 MG CEPROTIN (BLUE BAR)
6
MSD
CEPROTIN (GREEN BAR)
6
MSD
cilostazol
1
M
CARDIAC GLYCOSIDES
Drug Tier
Requirements / Limits
digitek
1
M
digox
1
M
digoxin injection
6
MSD
digoxin oral
1
M
6
MSD
clopidogrel oral tablet 300 mg
1
LANOXIN INJECTION
M
3
M
clopidogrel oral tablet 75 mg
1
LANOXIN ORAL LANOXIN PEDIATRIC
6
MSD
COAGADEX
6
MSD
CORIFACT
6
MSD
COAGULATION THERAPY
COUMADIN
3
ADVATE
6
MSD
dipyridamole
1
M
ADYNOVATE
6
MSD
DURLAZA
3
M
AFSTYLA
6
MSD
EFFIENT
3
M
AGGRENOX
2
M
ELIQUIS
2
PA
ALPHANATE
6
MSD
ELOCTATE
6
MSD
ALPHANINE SD
6
MSD
MSD
6
MSD
AMICAR
2
enoxaparin subcutaneous solution
6
ALPROLIX ARGATROBAN
6
MSD
1
ARGATROBAN IN 0.9 % SOD CHLOR
6
MSD
enoxaparin subcutaneous syringe FEIBA NF
6
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 38
Drug Name
Drug Tier
Requirements / Limits
Drug Name
fondaparinux
1
FRAGMIN
3
HELIXATE FS
6
MSD
HEMOFIL M HIGH
6
MSD
HEMOFIL M LOW
6
MSD
HEMOFIL M MID
6
MSD
HEMOFIL M SUPER HIGH
6
MSD
hep flush-10 (pf)
LA
heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml
1
heparin, porcine (pf)
1
HUMATE-P
6
MSD
IDELVION
6
MSD
1
IXINITY
6
MSD
heparin (porcine)
1
jantoven
1
HEPARIN (PORCINE) IN 0.9% NACL
6
KOATE-DVI
6
MSD
KOGENATE FS
6
MSD
KOVALTRY
6
MSD
heparin (porcine) in 5 % dex
6
6
MSD
heparin (porcine) in nacl (pf)
1
LOVENOX SUBCUTANEOUS SOLUTION
6
MSD
heparin flush(porcine)0.9nacl
6
MSD
LOVENOX SUBCUTANEOUS SYRINGE
3
heparin flush
MEPHYTON
2
MONOCLATE-P
6
heparin lock flush
1
monoject prefill (pf)
1
heparin lock flush (porcine)
1
MONONINE
6
MSD
heparin lockflush(porcine)(pf )
1
NOVOEIGHT
6
MSD
NOVOSEVEN RT
6
MSD
NPLATE
6
MSD
HEPARIN(PORCIN E) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML
3
NUWIQ
6
MSD
OBIZUR
6
MSD
pentoxifylline
1
M
PLAVIX ORAL TABLET 300 MG
3
PLAVIX ORAL TABLET 75 MG
3
MSD
MSD
Drug Tier
Requirements / Limits
MSD
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 39
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
PRADAXA
3
PA; M
atorvastatin
1
M; QL
PRAXBIND
6
MSD
CADUET
3
ST; M; QL
PROFILNINE
6
MSD
1
M
PROMACTA
2
PA
cholestyramine (with sugar)
RECOMBINATE
6
MSD
cholestyramine light
1
M
RIASTAP
6
MSD
COLESTID
3
ST; M
RIXUBIS
6
MSD
COLESTID FLAVORED
3
ST; M
SAVAYSA
3
PA
colestipol
1
M
ticlopidine
1
M
CRESTOR
3
ST; M; QL
tranexamic acid
6
MSD
M
6
MSD
fenofibrate micronized
1
TRETTEN VONVENDI
6
MSD
1
M
warfarin
1
fenofibrate nanocrystallized
WILATE
6
MSD
FENOFIBRATE ORAL CAPSULE
3
ST; M
XARELTO ORAL TABLET 10 MG
2
fenofibrate oral tablet
1
M
XARELTO ORAL TABLET 15 MG, 20 MG
2
fenofibric acid
1
M
1
M
XARELTO ORAL TABLETS,DOSE PACK
2
fenofibric acid (choline) FENOGLIDE
3
ST; M
FIBRICOR
3
ST; M
XYNTHA
6
MSD
fluvastatin
1
M; QL
XYNTHA SOLOFUSE
6
MSD
gemfibrozil
1
M
YOSPRALA
3
M
JUXTAPID
3
LA
ZONTIVITY
3
PA; M
KYNAMRO
4
LA
LESCOL
3
ST; M; QL
LESCOL XL
3
ST; M; QL
PA
PA
LIPID/CHOLESTEROL LOWERING AGENTS
Requirements / Limits
ALTOPREV
3
ST; M; QL
LIPITOR
3
ST; M; QL
amlodipineatorvastatin
1
M; QL
LIPOFEN
3
ST; M
LIVALO
3
ST; M; QL
ANTARA
3
LOFIBRA
3
ST; M
ST; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 40
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
LOPID
3
M
VYTORIN 10-40
3
ST; M; QL
lovastatin
1
M; QL
VYTORIN 10-80
3
ST; M; QL
LOVAZA
3
PA; M
WELCHOL
3
ST; M
niacin
1
M
ZETIA
2
ST; M
NIACOR
3
M
ZOCOR
3
ST; M; QL
NIASPAN EXTENDEDRELEASE
3
M
MISCELLANEOUS CARDIOVASCULAR AGENTS
omega-3 acid ethyl esters
1
PA; M
PRALUENT PEN
3
PRALUENT SYRINGE
3
PRAVACHOL
3
ST; M; QL
DILATRATE-SR
3
pravastatin
1
M; QL
GONITRO
3
prevalite
1
M
ISOCHRON
3
M
QUESTRAN
3
ST; M
ISORDIL
3
M
QUESTRAN LIGHT
3
ST; M
ISORDIL TITRADOSE
3
M
REPATHA PUSHTRONEX
3
PA; LA
isosorbide dinitrate
1
M M
3
PA; LA
isosorbide mononitrate
1
REPATHA SURECLICK
MINITRAN
3
M
REPATHA SYRINGE
3
PA; LA
nitro-bid
1
M
rosuvastatin
1
M; QL
NITRO-DUR
3
M
simvastatin
1
M; QL
nitroglycerin oral
1
M
TRICOR
3
ST; M
nitroglycerin sublingual
1
TRIGLIDE
3
ST; M
3
ST; M
nitroglycerin transdermal
1
TRILIPIX VASCEPA
2
PA; M
1
VYTORIN 10-10
3
ST; M; QL
nitroglycerin translingual
VYTORIN 10-20
3
ST; M; QL
NITROLINGUAL
3
CORLANOR
2
PA; M
ENTRESTO
2
PA; M
PA; LA
RANEXA
3
M
PA; LA
VECAMYL
3
NITRATES M
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 41
Drug Name
Drug Tier
NITROMIST
3
NITROSTAT
3
nitro-time
1
Requirements / Limits
M
DERMATOLOGICALS/TOPICA L THERAPY ANTIPSORIATIC / ANTISEBORRHEIC
Drug Name
Drug Tier
OVACE PLUS TOPICAL CLEANSER,EXTE NDED RELEASE
3
OVACE PLUS TOPICAL CREAM
3
OVACE PLUS TOPICAL FOAM
3
OVACE PLUS TOPICAL LOTION
3 3
Requirements / Limits
ST
ST
acitretin
1
ANALPRAM-HC
3
calcipotriene
1
OVACE PLUS WASH
calcipotrienebetamethasone
1
PRAMOSONE
3
ST
PRAMOSONE E
3
ST
calcitrene
1 1
PROMISEB COMPLETE
3
calcitriol COAL TAR
2
seb-prev
1
COSENTYX
4
PA; LA
selenium sulfide
1
COSENTYX (2 SYRINGES)
4
PA; LA
SELRX
3
SORIATANE
3
COSENTYX PEN
4
PA; LA
SORILUX
3
COSENTYX PEN (2 PENS)
4
PA; LA
STELARA INTRAVENOUS
6
PA; ST; MSD
DOVONEX
3
6
MSD
drithocreme hp
1
STELARA SUBCUTANEOUS
ENSTILAR
3
1
EPIFOAM
3
sulfacetamide sodium
hydrocortisonepramoxine
1
TACLONEX
3 4
ST; LA
OVACE
3
TALTZ AUTOINJECTOR
OVACE PLUS SHAMPOO
3
TALTZ AUTOINJECTOR (2 PACK)
4
ST; LA
TALTZ AUTOINJECTOR (3 PACK)
4
ST; LA
ST
ST
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 42
Drug Name
Drug Tier
Requirements / Limits
Drug Name SALVAX DUO PLUS
3
ULTRASAL-ER
3
VIRASAL
3
TALTZ SYRINGE
4
ST; LA
TALTZ SYRINGE (2 PACK)
4
ST; LA
TALTZ SYRINGE (3 PACK)
4
TERSI FOAM
3
VECTICAL
3
ZITHRANOL
3
ZITHRANOL-RR
3
ST; LA
3
silver sulfadiazine
1
ssd
1
thermazene
1
Requirements / Limits
MISCELLANEOUS DERMATOLOGICALS
BURN THERAPY SILVADENE
Drug Tier
KERATOLYTICS
ALEVICYN ANTIPRURITIC
3
ALEVICYN ANTIPRURITIC SG
3
AMELUZ
6
ATOPICLAIR
3
ATRAPRO CP
3
ATRAPRO HYDROGEL
3
avo cream
1 3
BENSAL HP
3
INOVA 4-1
3
ST
BIAFINE EMULSION
INOVA 8-2
3
ST
bp-50% urea
1
KERALYT RX
3
CARAC
3
KERALYT SCALP COMPLETE
3
celacyn
1
cem-urea
1
PODOCON
3
CERACADE
3
POTASSIUM HYDROXIDE
3
CERAMAX
3
CONDYLOX
3
salacyn
1
CORTANE-B
3
SALEX
3 1
DERMASORB XM COMPLETE KIT
3
salicylic acid salicylic acid erceramides
1
diclofenac sodium
1
doxepin
1
SALKERA
3
EFUDEX
3
salvax
1
eletone
1
ELIDEL
3
MSD
PA
ST
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 43
Drug Name
Drug Tier
emulsion sb
Requirements / Limits
Drug Name
Drug Tier
1
NEOSALUS
3
ENTTY
3
nivatopic plus
1
EPICERAM
3
3
FLUOROPLEX
3
OXSORALEN ULTRA
FLUOROURACIL TOPICAL CREAM 0.5 %
3
PANRETIN
3
PICATO
3
podofilox
1
fluorouracil topical cream 5 %
1
PRESERA
3
fluorouracil topical solution
1
PROMISEB
3
PROTOPIC
3
GORDONS UREA
3
pruclair
1
hpr
1
prudoxin
1
hpr plus
1
prumyx
1
hpr plus hydrogel
1
prutect
1
HPR PLUS-MB HYDROGEL
3
QUTENZA
6
rea lo 39
1
HYDRO 35
3
rea lo 40
1
HYDRO 40
3
REGRANEX
2
HYLATOPIC
3
remeven
1
HYLATOPICPLUS
3
RESTIZAN
3
KERAFOAM
3
RYNODERM
3
KERALAC
3
silver nitrate
1
lactic acid
1
1
lactic acid e
1
silver nitrate applicators
latrix
1
SOLARAZE
3
LOUTREX
3
sonafine
1
luxamend
1
sp antipruritic
1
mb hydrogel
1
sp scar management
1
mb hydrogel (cyclomethicone)
1
tacrolimus
1
TOLAK
3
methoxsalen rapid
1
Requirements / Limits
ST
MSD
QL
PA
ST
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 44
Drug Name
Drug Tier
UMECTA TOPICAL EMULSION
3
umecta topical foam
1
URAMAXIN
3
URAMAXIN GT
3
urea
1
urea nail stick
1
urea-hyaluronate sodium
1
ure-k
1
UREVAZ
3
UTOPIC
3
VALCHLOR
3
VEREGEN
3
XCLAIR
3
ZANABIN ZONALON
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
AVAR TOPICAL FOAM
3
ST
AVAR TOPICAL PADS, MEDICATED
3
ST
AVAR-E GREEN
3
ST
AVAR-E LS
3
ST
avita topical cream
1
AVITA TOPICAL GEL
3
AZELEX
3
ST
BENZACLIN
3
ST
BENZACLIN PUMP
3
ST
BENZAMYCIN
3
ST
BENZEFOAM
3
ST
BENZEFOAM ULTRA
3
ST
3 3
benzepro
1
THERAPY FOR ACNE
benzoyl peroxide
1
ABSORICA
3
bp 10-1
1
ACANYA
3
ST
bpo
1
ACZONE
3
ST
claravis
1
adapalene topical cream
1
cleansing wash
1
CLEOCIN T
3
ST
adapalene topical gel
1
CLINDACIN ETZ
3
ST
adapalene topical gel with pump
1
clindacin p
1
CLINDACIN PAC
3
ST
ADAPALENE TOPICAL LOTION
3
CLINDAGEL
3
ST
1
ATRALIN
3
clindamycin phosphate
AVAR LS
3
1
avar topical cleanser
1
clindamycin-benzoyl peroxide
LA
ST
ST
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 45
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
clindamycintretinoin
1
RETIN-A MICRO
3 3
DIFFERIN
3
ST
RETIN-A MICRO PUMP
DUAC
3
ST
1
EPIDUO
3
ST
rosadan topical cream
EPIDUO FORTE
3
ST
rosadan topical gel
1
ery pads
1
3
ST
erygel
1
erythromycin with ethanol
1
ROSADAN TOPICAL KIT, CLEANSER AND GEL
3
ST
erythromycinbenzoyl peroxide
1
ROSADAN TOPICAL KIT,CLEANSER AND CREAM
EVOCLIN
3
ST
ROSANIL
3
ST
FABIOR
3
PA
ROSULA
3
ST
FINACEA
3
ST
3
ST
rosula cleansing cloths
1
INOVA METROCREAM
3
ST
SOOLANTRA
3
METROGEL
3
ST
ss 10-2
1
METROLOTION
3
ST
sss 10-5
1
metronidazole
1
1
MIRVASO
3
sulfacetamide sodium-sulfur
myorisan
1
sulfacetamide sodsulfur-urea
1
neuac
1 3
ST
sulfacetamidesulfur-cleansr23
1
NEUAC KIT NORITATE
3
ST
sulfacleanse 8-4
1
NUOX
3
ST
1
ONEXTON
3
ST
sulfact na-sulavobnz-otn-ocsa
PLEXION
3
ST
SUMADAN
3
ST
PLEXION CLEANSING CLOTHS
3
ST
SUMADAN XLT
3
ST
SUMAXIN
3
ST
SUMAXIN CP
3
ST
RETIN-A
3
SUMAXIN TS
3
ST
ST
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 46
Drug Name
Drug Tier
Requirements / Limits
Drug Name
TAZORAC
2
tretinoin
1
tretinoin microspheres
1
TRETIN-X
3
TRETIN-X CREAM KIT
3
VANOXIDE-HC
3
VELTIN
3
zenatane
PA
lidopin topical cream 3 %
1
LIDOPIN TOPICAL CREAM 3.25 %
3
lidopril
1
LIDOPRIL XR
3
LIDORX
3
ST
LIDOTRAL
3
ST
LIDOVEX
3
1
LIVIXIL PAK
3
zencia
1
LP LITE PAK
3
ZIANA
3
lta pre-attached
1
NOVACORT (WITH ALOE)
3
PLIAGLIS
3
relador pak
1
relador pak plus
1
SYNERA
3
ZINGO
6
ST
TOPICAL ANESTHETICS ASTERO
3
BUCALSEP
3
dermacinrx prizopak
1
ethyl chloride
1
glydo
1
LDO PLUS
3
lidocaine hcl
1
lidocaine hclhydrocortison ac
1
lidocaine topical adhesive patch,medicated
1
lidocaine topical ointment
1
lidocaine viscous
Drug Tier
Requirements / Limits
MSD
TOPICAL ANTIBACTERIALS ALTABAX
3
BACTROBAN
3
CENTANY
3
CENTANY AT
3
CORTISPORIN
3
gentamicin
1
1
KLARON
3
lidocaine-prilocaine
1
mupirocin
1
LIDOCAINETETRACAINE
3
mupirocin calcium
1
NEO-SYNALAR
3
LIDODERM
3 1
NEO-SYNALAR KIT
3
lido-k
ST
PA
ST
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 47
Drug Name
Drug Tier
sulfacetamide sodium (acne)
1
SULFAMYLON TOPICAL CREAM
2
SULFAMYLON TOPICAL PACKET
3
Requirements / Limits
Drug Name
Drug Tier
NAFTIFINE TOPICAL CREAM 1%
3
naftifine topical cream 2 %
1
NAFTIN
3
TOPICAL ANTIFUNGALS
NIZORAL
3
ciclodan
1
nyamyc
1
CICLODAN KIT
3
nystatin
1
ciclopirox
1
1
ciclopirox-urecamph-menth-euc
1
nystatintriamcinolone nystop
1
clotrimazolebetamethasone
1
oxiconazole
1
OXISTAT
3
CNL 8 NAIL
3
PENLAC
3
DERMACINRX THERAZOLE PAK
3
TRIACETIN
2
econazole
1
TRIPLE DYE
3
ECOZA
3
VUSION
3
ERTACZO
3
XOLEGEL
3
EXELDERM
3
EXODERM
3
EXTINA
3
JUBLIA
3
KERYDIN
3
ketoconazole
1
LOPROX
3
LOPROX (AS OLAMINE)
3
LOPROX KIT
3
LOTRISONE
3
LUZU
3
Requirements / Limits
TOPICAL ANTIVIRALS acyclovir
1
DENAVIR
3
XERESE
3
ZOVIRAX TOPICAL CREAM
2
ZOVIRAX TOPICAL OINTMENT
3
TOPICAL CORTICOSTEROIDS ADVANCED ALLERGY COLLECT KIT
3
ALA-SCALP
3
ST
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 48
Drug Name
Drug Tier
alclometasone
1
amcinonide
1
ANUSOL-HC
3
apexicon e
1
AQUA GLYCOLIC HC
3
betamethasone dipropionate
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
DERMASMOOTHE/FS SCALP OIL
3
ST
DERMASORB HC COMPLETE KIT
3
ST
DERMASORB TA COMPLETE KIT
3
ST
1
DERMATOP
3
ST
1
DERMAWERX SDS
3
betamethasone valerate
DERMAZONE
3
betamethasone, augmented
1
DESONATE
3
CAPEX
3
desonide
1
clobetasol
1
DESOWEN
3
clobetasol-emollient
1
desoximetasone
1
CLOBEX
3
ST
diflorasone
1
CLOCORTOLONE PIVALATE
3
ST
DIPROLENE
3
ST
DIPROLENE AF
3
ST
clodan
1
ELOCON
3
ST
CLODAN KIT
3
ST
fluocinolone
1
CLODERM
3
ST
1
CORDRAN
3
ST
fluocinolone and shower cap
CORDRAN TAPE LARGE ROLL
3
ST
fluocinonide
1
fluocinonide-e
1
cormax
1
flurandrenolide
1
CUTIVATE
3
ST
fluticasone
1
DERMACINRX SILAPAK
3
ST
halobetasol propionate
1
DERMACINRX SILAZONE
3
HALOG
3
hydrocortisone
1
DERMASMOOTHE/FS BODY OIL
3
hydrocortisone butyrate
1
ST ST
ST
ST
ST ST
ST
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 49
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
TEXACORT
3
ST
TOPICORT
3
ST
triamcinolone acetonide
1
trianex
1
triderm
1
TRI-SILA
3
ULTRAVATE
3
ST
ULTRAVATE X
3
ST
VANOS
3
ST ST
hydrocortisone butyr-emollient
1
hydrocortisone valerate
1
hydrocortisone-min oil-wht pet
1
KENALOG
3
ST
LOCOID
3
ST
LOCOID LIPOCREAM
3
ST
LUXIQ
3
mometasone
1
VERDESO
3
NOXIPAK
3
3
NUTRIARX
3
WHYTEDERM TDPAK
OLUX
3
ST
WHYTEDERM TRILASIL PAK
3
OLUX-E
3
ST
XILAPAK
3
PANDEL
3
ST
prednicarbate
1
PSORCON
3
SANADERMRX
3
TOPICAL SCABICIDES / PEDICULICIDES
scalacort
1
ELIMITE
3
SCALACORT DK
3
ST
EURAX
3
SERNIVO
3
ST
lindane
1
SILAZONE-II
3
LYCELLE
3
SURE RESULT TAC PAK
3
malathion
1
SYNALAR
3
ST
NATROBA
3
SYNALAR CREAM KIT
3
ST
OVIDE
3
permethrin
1
SYNALAR OINTMENT KIT
3
ST
SKLICE
3
spinosad
1
SYNALAR TS
3
ST
ULESFIA
3
TEMOVATE
3
ST
ST
ST
TOPICAL ENZYMES SANTYL
ST
Requirements / Limits
2
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 50
Drug Name
Drug Tier
Requirements / Limits
DIAGNOSTICS & MISCELLANEOUS AGENTS IRRIGATING SOLUTIONS
Drug Name
Drug Tier
Requirements / Limits
CARNITOR
3
M
CARNITOR (SUGAR-FREE)
3
M
cevimeline
1
M
CHEMET
2
disulfiram
1
etidronate disodium
1
M
lactated ringers
1
PHYSIOLYTE
3
PHYSIOSOL IRRIGATION
3
ringers
1
EVOXAC
3
M
SORBITOLMANNITOL
3
EXJADE
3
LA
3
LA
tis-u-sol pentalyte
1
FERRIPROX ORAL SOLUTION
VASHE WOUND THERAPY
3
FERRIPROX ORAL TABLET
2
LA
MISCELLANEOUS AGENTS
FERRLECIT
6
MSD
acamprosate
1
GLASSIA
6
MSD
ACTONEL
3
ST; QL
ic green
6
MSD
ADAGEN
6
MSD
INCRELEX
3
PA; LA
AGRYLIN
3
M
indocyanine green
6
MSD
alendronate
1
M; QL
INFASURF
3
AMMONUL
6
MSD
JADENU
3
LA
AMPHADASE
6
MSD
6
MSD
anagrelide
1
M
KIT PREP OF TC99MMEBROFENIN
ANTABUSE
3
levocarnitine
1
M
ARALAST NP
6
MSD
1
M
bd pre-filled normal saline
6
MSD
levocarnitine (with sugar) LIPOCHOL PLUS
3
BUPHENYL ORAL POWDER
3
LITHOSTAT
3
BUPHENYL ORAL TABLET
2
METOPIRONE
3
midodrine
1
caffeine citrated
1
6
CARBAGLU
2
monoject 0.9% sodium chloride
LA
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 51
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
monoject prefill advanced ns
6
MSD
sodium ferric gluconat-sucrose
6
monoject prefill saline flush
6
MSD
sodium phenylbutyrate
1
normal saline flush
6
MSD
SOLIRIS
6
NORTHERA
3
LA
SURVANTA
3
ORFADIN ORAL CAPSULE
2
LA
SWABFLUSH
6
SYPRINE
3
ORFADIN ORAL SUSPENSION
3
syrex sodium chloride 0.9%
6
pilocarpine hcl
1
THIOLA
3
PROLASTIN-C
6 3
water for irrigation, sterile
1
RADIOGARDASE RAVICTI
2
LA
XURIDEN
2
RECLAST
6
MSD
ZEMAIRA
6
MSD
RILUTEK
3
6
PA; MSD
riluzole
1
risedronate
1
SALAGEN
3
ZOLEDRONIC ACID-MANNITOLWATER INTRAVENOUS PIGGYBACK
sodium benzoate-sod phenylacet
6
MSD
zoledronic acidmannitol-water intravenous solution
6
MSD
sodium chlor 0.9% bacteriostat
6
MSD
sodium chloride 0.9 % injection solution
6
MSD
bupropion hcl (smoking deter)
5
M
sodium chloride 0.9 % injection syringe
6
MSD
CHANTIX
5
ACA
5
ACA
SODIUM CHLORIDE 0.9 % INJECTION SYRINGE, WITH SWAB CAP
6
MSD
CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX
5
ACA
sodium chloride 0.9 % intravenous
6
LA
MSD
QL
MSD
MSD MSD MSD
SMOKING DETERRENTS
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 52
Drug Name
Drug Tier
Requirements / Limits
Drug Name
ACA; OTC
EAR, NOSE & THROAT MEDICATIONS
NICODERM CQ TRANSDERMAL PATCH 24 HOUR 14 MG/24 HR, 7 MG/24 HR
5
NICODERM CQ TRANSDERMAL PATCH 24 HOUR 21 MG/24 HR
5
nicorelief
5
ACA; OTC
NICORETTE BUCCAL GUM
5
OTC
NICORETTE BUCCAL LOZENGE
5
nicotine (polacrilex)
5
nicotine transdermal patch 24 hour 14 mg/24 hr, 7 mg/24 hr
5
nicotine transdermal patch 24 hour 21 mg/24 hr
5
nicotine transdermal patch, td daily, sequential
5
NICOTROL
Drug Tier
Requirements / Limits
MISCELLANEOUS AGENTS ARESTIN
4
ASTEPRO
3
azelastine nasal aerosol,spray
1
azelastine nasal spray,non-aerosol
1
BACTROBAN NASAL
2
chlorhexidine gluconate
1
ACA; OTC
CLINPRO 5000
3
ACA; OTC
DEBACTEROL
2
denta 5000 plus
1
M
dentagel
1
M
EPISIL
3
fluoridex daily defense
1
M
ACA; OTC
FLUORIDEX SENSITIVITY RELIEF
3
M
5
ACA
GELCLAIR
3
NICOTROL NS
5
ACA
GELX
3
nts step 1
5
M; ACA; OTC
ipratropium bromide
1
quit 2 buccal gum
5
ACA; OTC
MUGARD
3
QUIT 2 BUCCAL LOZENGE
5
ACA; OTC
olopatadine
1
quit 4 buccal gum
5
ACA; OTC
oralone
1
QUIT 4 BUCCAL LOZENGE
5
ACA; OTC
ORAMAGICRX
3
PATANASE
3
stop smoking aid
5
ACA; OTC
PERIDEX
3
ZYBAN
5
M; ACA
periogard
1
M; ACA; OTC
ACA; OTC
M; ACA; OTC
LA QL
M
QL QL
QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 53
Drug Name
Drug Tier
Requirements / Limits
pilocarpine hcl
1
PREVIDENT
3
M
PREVIDENT 5000 BOOSTER PLUS
3
M
PREVIDENT 5000 DRY MOUTH
3
M
PREVIDENT 5000 ENAMEL PROTECT
3
M
PREVIDENT 5000 PLUS
3
PREVIDENT 5000 SENSITIVE
3
Q-CARE RX Q4
3
SALAGEN
3
sf
1
M
sf 5000 plus
1
M
sodium fluoride
1
M
triamcinolone acetonide
1
TYZINE
3
MISCELLANEOUS OTIC PREPARATIONS
Drug Name
Drug Tier
hydrocortisoneacetic acid
1
ofloxacin
1
OTIPRIO
3
Requirements / Limits
OTIC STEROID / ANTIBIOTIC CIPRO HC
3
CIPRODEX
2
COLY-MYCIN S
3
M
neomycinpolymyxin-hc
1
M
OTOVEL
3
ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR H.P.
6
MSD
CORTEF
3
M
cortisone
1
CORTROSYN
6
MSD
cosyntropin
6
MSD
deltasone
1
dexamethasone
1 1
acetasol hc
1
dexamethasone intensol
acetic acid
1
DEXPAK 10 DAY
3
acetic acidaluminum acetate
1
DEXPAK 13 DAY
3
DEXPAK 6 DAY
3
CETRAXAL
3
fludrocortisone
1
M
ciprofloxacin hcl
1
hydrocortisone
1
M
DERMOTIC OIL
3
MEDROL
3
floxin
1
MEDROL (PAK)
3
fluocinolone acetonide oil
1
methylprednisolone
1
millipred dp
1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 54
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
MILLIPRED ORAL SOLUTION
3
ADVOCATE TEST STRIPS
3
OTC
millipred oral tablet
1
3
OTC
ORAPRED ODT
3
AGAMATRIX AMP TEST STRIPS
PEDIAPRED
3
ASSURE 4 STRIPS
3
OTC
prednisolone
1
ASSURE PLATINUM
3
OTC
prednisolone sodium phosphate
1
ASSURE PRISM MULTI STRIP
3
OTC
prednisone
1
OTC
1
RAYOS
3
BIONIME RIGHTEST TEST STRIPS
3
prednisone intensol veripred 20
1
BLOOD GLUCOSE TEST
3
OTC
BREEZE 2 TEST STRIPS
3
OTC
CARESENS N TEST STRIPS
3
OTC
CLEVER CHOICE MICRO TEST STRIP
3
OTC
CLEVER CHOICE PRO
3
OTC
CLEVER CHOICE TEST STRIPS
3
OTC
ANTITHYROID AGENTS methimazole
1
M
propylthiouracil
1
M
SSKI
3
M
TAPAZOLE
3
M
BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES ACCU-CHEK AVIVA PLUS TEST STRP
3
OTC
ACCU-CHEK COMPACT TEST
3
OTC
CLEVER CHOICE VOICE+ TEST
3
OTC
ACCU-CHEK SMARTVIEW TEST STRIP
3
OTC
CONTOUR NEXT STRIPS
3
OTC
ACCUTREND GLUCOSE
3
OTC
CONTOUR TEST STRIPS
3
OTC
ADVANCED GLUC METER TEST STRIP
3
OTC
CONTROL AST TEST
3
OTC
3
OTC
ADVOCATE REDICODE
3
COOL GLUCOSE TEST STRIP DIATRUE PLUS TEST STRIP
3
OTC
OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 55
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
EASY PLUS II TEST
3
OTC
EZ SMART PLUS TEST
3
OTC
EASY STEP
3
OTC
EZ SMART TEST
3
OTC
EASY TALK GLUCOSE TEST
3
OTC
FIFTY50 TEST STRIP
3
OTC
EASY TOUCH TEST STRIP
3
OTC
FORA D10
3
OTC
FORA D15G
3
OTC
EASY TRAK GLUCOSE TEST
3
OTC
FORA D20
3
OTC
EASYGLUCO PLUS
3
OTC
FORA D40-G31 TEST STRIPS
3
OTC
EASYGLUCO TEST
3
OTC
FORA G20
3
OTC
FORA G30A
3
OTC
EASYMAX
3
OTC
3
OTC
ELEMENT COMPACT TEST STRIPS
3
OTC
FORA GD50 TEST STRIPS FORA TEST STRIP
3
OTC OTC
3
FORA TN'G VOICE TEST STRIPS
3
ELEMENT TEST STRIPS
FORA V10
3
OTC
EMBRACE BLOOD GLUCOSE SYSTEM
3
OTC
FORA V12 GLUCOSE
3
OTC
EMBRACE EVO TEST STRIPS
3
OTC
FORA V20
3
OTC
FORACARE GD20
3
OTC
EMBRACE PRO TEST STRIPS
3
OTC
FORACARE GD40
3
OTC
3
OTC
EVENCARE G2
3
OTC
EVENCARE G3 TEST
3
OTC
FORTISCARE GLUCOSE TEST STRIPS
2
OTC
EVENCARE MINI GLUCOSE TEST STR
3
FREESTYLE INSULINX
2
OTC
EVENCARE TEST
3
OTC
FREESTYLE INSULINX TEST STRIPS
EVOLUTION TEST STRIPS
3
OTC
FREESTYLE LITE STRIPS
2
OTC
OTC
OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 56
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
FREESTYLE PRECISION NEO STRIPS
3
OTC
MICRODOT BLOOD GLUCOSE SYSTEM
3
OTC
FREESTYLE TEST
2
OTC
3
OTC
GE100 BLOOD GLUCOSE TEST STRIP
3
OTC
MYGLUCOHEALT H NEUTEK 2TEK TEST STRIPS
3
OTC
GENSTRIP TEST STRIP
3
OTC
NOVA MAX GLUCOSE TEST
3
OTC
GLUCO NAVII TEST STRIP
3
OTC
3
OTC
GLUCOCARD 01 SENSOR PLUS
3
OTC
ON CALL EXPRESS TEST STRIP
3
OTC
GLUCOCARD EXPRESSION
3
ON CALL PLUS TEST STRIP
3
OTC
GLUCOCARD SHINE TEST STRIPS
3
ON CALL VIVID TEST STRIP ONETOUCH ULTRA TEST
3
OTC
GLUCOCARD VITAL SENSOR
3
OTC
ONETOUCH VERIO
3
OTC
GLUCOCARD VITAL TEST STRIPS
3
OTC
OPTIUM EZ
3
OTC
OPTIUM TEST
3
OTC
GLUCOCOM GLUCOSE
3
OPTUMRX
3
OTC
3
OTC
GM100
3
OTC
PHARMACIST CHOICE
GMATE TEST STRIPS
3
OTC
PRECISION PCX PLUS TEST
3
OTC
HEALTHPRO TEST STRIPS
3
OTC
PRECISION PCX TEST
3
OTC
INFINITY TEST STRIPS
3
OTC
PRECISION POINT OF CARE TEST
3
OTC
LIBERTY TEST
3
OTC
PRECISION Q-I-D TEST
3
OTC
MICRO BLOOD GLUCOSE
3
OTC
PRECISION XTRA TEST
3
OTC
PREMIUM V10
3
OTC
OTC OTC
OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 57
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
PRODIGY NO CODING
3
OTC
WAVESENSE JAZZ
3
OTC
QUINTET AC
3
OTC
3
OTC
REFUAH PLUS
3
OTC
WAVESENSE PRESTO
RELION CONFIRM-MICRO
3
OTC
DIABETES, SUPPLIES, & DURABLE MEDICAL EQUIPMENT
RELION PRIME TEST STRIPS
3
OTC
GLUCAGEN DIAGNOSTIC KIT
2
REVEAL TEST STRIP
3
OTC
GLUCAGON HCL
3
RIGHTEST GS550 TEST STRIPS
3
OTC
GLUCAGEN HYPOKIT
2
SMART SENSE TEST STRIPS
3
OTC
2
SMARTEST TEST
3
OTC
GLUCAGON EMERGENCY KIT (HUMAN)
SOLUS V2 TEST STRIPS
3
OTC
PROGLYCEM
2
SURE-TEST EASYPLUS MINI
3
OTC
INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQU
TELCARE TEST STRIPS
3
OTC
1ST TIER UNIFINE PENTIPS
2
M; OTC
TEST N'GO TEST
3
OTC
2
OTC
TRUE METRIX GLUCOSE TEST STRIP
3
OTC
1ST TIER UNILET COMFORTOUCH
3
OTC
TRUETEST TEST STRIPS
3
2TEK GLUCOSE/BLOOD PRESSURE
3
OTC
TRUETRACK TEST
3
OTC
ACCU-CHEK AVIVA CONNECT METER
ULTIMA TEST STRIPS
3
OTC
ACCU-CHEK AVIVA PLUS METER
3
OTC
ULTRATRAK
3
OTC
OTC
3
OTC
ACCU-CHEK COMP BLUE CONT, M-H
3
ULTRATRAK ULTIMATE UNISTRIP1 TEST STRIP
3
OTC
GLUCOSE ELEVATING AGENTS
OTC
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 58
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
ADVOCATE LANCET
2
OTC
ACCU-CHEK COMPACT PLUS CONTROL
3
OTC
OTC
2
OTC
ADVOCATE LOW CONTROL
3
ACCU-CHEK FASTCLIX
2
M; OTC
ACCU-CHEK NANO
3
OTC
ADVOCATE PEN NEEDLES
OTC
2
OTC
ADVOCATE RAPID-SAFE LANCING
2
ACCU-CHEK SAFE-T-PRO ACCU-CHEK SMARTVIEW CONTRL SOL
3
OTC
ADVOCATE REDICODE DUO METER
3
OTC
ACCU-CHEK SOFTCLIX LANCET DEV
2
OTC
ADVOCATE REDICODE GLU MONITOR
3
OTC
ACCU-CHEK SOFTCLIX LANCETS
2
OTC
ADVOCATE REDICODE+ CTRL LOW
3
OTC
ACCU-CHEK VOICEMATE
3
OTC
3
OTC
ACCUTREND GLUCOSE CONTROL
3
OTC
AGAMATRIX AMP GLUC MONITOR SYS AGAMATRIX CONTROL HIGH
3
OTC
ACTI-LANCE LANCETS
2
OTC
ALTERNATE SITE LANCET
2
OTC
ADJUSTABLE LANCING DEVICE
2
OTC
ALTERNATE SITE LANCING DEVICE
2
OTC
ADVANCED GLUCOSE METER
3
OTC
AQUA LANCE LANCING DEVICE
2
OTC
ADVANCED LANCING DEVICE
2
OTC
3
OTC
ADVANCED TRAVEL LANCETS
2
OTC
ASSURE 4 CONTROL SOLUTION
3
OTC
ADVOCATE BLOOD GLUCOSE MONITOR
3
ASSURE DOSE NORMAL CONTROL
2
OTC
ADVOCATE DUO
3
ASSURE HAEMOLANCE PLUS
OTC
OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 59
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
BIONIME RIGHTEST GM300 SYSTEM
3
OTC
BLOOD GLUCOSE CONTROL, NORMAL
3
OTC
BLOOD-GLUCOSE METER
3
OTC
BREEZE 2 CONTROL SOLUTION,HIGH
3
OTC
BULLSEYE MINI SAFETY LANCETS
2
OTC
CAREFINE PEN NEEDLE
2
M; OTC
CAREONE THIN LANCET
2
OTC
CARESENS CONTROL A NORMAL
3
OTC
CARESENS N
3
OTC OTC
ASSURE LANCE
2
OTC
ASSURE LANCE PLUS
2
OTC
ASSURE PLATINUM
3
OTC
ASSURE PRISM CONTROL 1-2 SOLN
3
OTC
ASSURE PRISM MULTI METER
3
OTC
AUTOJECT 2 INJECTION DEVICE
2
OTC
AUTO-LANCET MINI
2
OTC
AUTOLET IMPRESSION LANC DEV
2
OTC
AUTOLET LANCING DEVICE
2
OTC
AUTOLET PLUS LANCING DEVICE
2
OTC
BD AUTOSHIELD PEN NEEDLE
2
M; OTC
CARESENS N VOICE
3
BD INSULIN PEN NEEDLE UF SHORT
2
M
CLEO 90 INFUSION SET 24"
2 3
OTC
BD LANCET DEVICE
2
CLEVER CHEK BLOOD GLUCOSE
2
OTC
BD MICROTAINER LANCET
2
CLEVER CHEK LANCETS
3
OTC
BD ULTRA FINE LANCETS
2
CLEVER CHOICE GLUCOSE MONITOR
3
OTC
BD ULTRA-FINE NANO PEN NEEDLES
2
CLEVER CHOICE LEVEL 2 CONTROL CLEVER CHOICE MICRO
3
OTC
OTC OTC
OTC M; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 60
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
DIATRUE CONTROL SOLN NORMAL
3
OTC
DIATRUE PLUS BLOOD GLUCOSE MET
3
OTC
CLEVER CHOICE PRO
3
OTC
CLICKFINE
2
M; OTC
COAGUCHEK LANCETS
2
OTC
COLOR LANCETS
2
OTC
OTC
2
M; OTC
DROPLET LANCETS
2
COMFORT EZ PEN NEEDLES
OTC
2
OTC
DROPLET LANCING DEVICE
2
COMFORT LANCETS
M; OTC
2
DROPLET PEN NEEDLE
2
COMFORT SHORT INSULIN PUMP 23"
EASY CLICK LANCING DEVICE
2
OTC
CONTOUR CONTROL SOLUTION, NML
3
OTC
EASY COMFORT LANCETS
2
OTC
CONTOUR LINK
3
OTC
EASY COMFORT PEN NEEDLES
2
M; OTC
CONTOUR NEXT EZ METER
3
OTC
EASY MINI EJECT LANCING DEVICE
2
OTC
CONTOUR NEXT LEV 2 CONTROL SOL
3
OTC
EASY PLUS II BLOOD GLUCOSE MET
3
OTC
CONTOUR NEXT LINK
3
OTC
3
OTC
CONTOUR NEXT METER
3
OTC
EASY STEP BLOOD GLUCOSE METER
OTC
3
OTC
EASY TALK BLOOD GLUCOSE METER
3
CONTOUR NEXT USB METER CONTROL AST MONITORING SYSTEM
3
OTC
EASY TOUCH FLIPLOCK NEEDLE
3
M
COOL BLOOD GLUCOSE METER
3
OTC
3
OTC
COOL CONTROL A SOLUTION
3
OTC
EASY TOUCH GLUCOSE MONITOR
3
M
DEXCOM G5 RECEIVER
3
EASY TOUCH HYPODERMIC NEEDLE
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 61
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
ELEMENT NORMAL CONTROL
3
OTC
ELEMENT PLUS BLOOD GLUCOSE KIT
3
OTC
EMBRACE BLOOD GLUCOSE SYSTEM
3
OTC
EMBRACE EVO LEVEL 1
3
OTC
EMBRACE GLUCOSE CONTROL LOW
3
OTC
EMBRACE PRO GLUCOSE METER
3
OTC
EVENCARE
3
OTC
EVENCARE G2
3
OTC
3
OTC
EASY TOUCH LANCING DEVICE
2
OTC
EASY TRAK BLOOD GLUCOSE METER
3
OTC
EASYGLUCO MONITORING SYSTEM
3
EASYGLUCO PLUS
3
EASYGLUCO PLUS NORMAL CONTROL
3
EASYMAX L BLOOD GLUCOSE METER
3
EASYMAX LOW CONTROL
3
EASYMAX NG
3
OTC
EASYMAX NORMAL CONTROL
3
OTC
EVENCARE G3 GLUCOSE METER
3
OTC
EASYMAX V SPEAKING GLUCOSE SYS
3
OTC
EVENCARE MINI MONITOR SYSTEM
3
OTC
EASYMAX V2 BLOOD GLUCOSE METER
3
OTC
EVOLUTION BLOOD GLUCOSE METER
3
OTC
ELEMENT COMPACT GLUCOSE METER
3
OTC
EVOLUTION NORMAL CONTROL e-z ject lancets
1
OTC
ELEMENT COMPACT NORMAL CONTROL
3
EZ SMART LANCETS
2
OTC
EZ SMART PLUS SYSTEM
3
OTC
ELEMENT COMPACT V GLUCOSE MTR
3
EZ SMART SYSTEM
3
OTC
OTC
OTC OTC
OTC
OTC
OTC
OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 62
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
FORACARE GD40B GLUCOSE METER
3
OTC
FORACARE GDH LOW CONTROL
3
OTC
FORACARE LANCETS
2
OTC
FORTISCARE BLOOD GLUCOSE SYST
3
OTC
FORTISCARE NORMAL
3
OTC
FREESTYLE CONTROL
2
OTC
FREESTYLE FLASH SYSTEM
2
OTC
FIFTY50 SAFETY SEAL LANCETS
2
OTC
FILTER NEEDLES
3
M
FINE 30 UNIVERSAL LANCETS
2
OTC
FINGERSTIX LANCETS
2
FORA D10
3
OTC
FORA D20
3
OTC
FORA G20
3
OTC
FORA G30A
3
OTC
FORA GD50 BLOOD GLUCOSE SYSTEM
3
OTC
FORA LANCING DEVICE
2
OTC
FREESTYLE FREEDOM
2
OTC
FORA NORMAL CONTROL
3
OTC
FREESTYLE FREEDOM LITE
2
OTC
FORA TEST N'GO VOICE METER
3
OTC
FREESTYLE INSULINX
2
OTC
FORA TN'G VOICE METER
3
OTC
FREESTYLE LANCETS
2
OTC
FORA V10
3
OTC
2
OTC
FORA V10-V12D10-D20
3
OTC
FREESTYLE LITE METER
3
OTC
FORA V12 BLOOD GLUCOSE SYSTEM
3
FREESTYLE PRECISION NEO METER
2
OTC
FORA V20
3
OTC
FREESTYLE SIDEKICK II
FORA V30A
3
OTC
FREESTYLE SYSTEM KIT
2
OTC
FORACARE GD20 GLUCOSE METER
3
OTC
FREESTYLE UNISTIK 2
2
OTC
FORACARE GD40A GLUCOSE METER
3
OTC
OTC
OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 63
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
GMATE SMART METER
3
OTC
GMATE SMART STARTER
3
OTC
GMATE VOICE METER
3
OTC
HEALTHPRO GLUCOSE MONITOR
3
OTC
3
OTC
GE100 BLOOD GLUCOSE SYSTEM
3
OTC
GE100 CONTROL SOLUTION NORMAL
3
OTC
GLUCO NAVII GLUCOSE MONITOR
3
OTC
GLUCOCARD 01 METER
3
OTC
GLUCOCARD 01 NORMAL CONTROL
3
OTC
HEALTHPRO HIGH-LOW CONTROL
2
OTC
GLUCOCARD EXPRESSION
3
OTC
HEALTHY ACCENTS AUTOLET
M; OTC
3
OTC
HEALTHY ACCENTS UNIFINE PENTIP
2
GLUCOCARD SHINE METER GLUCOCARD VITAL
3
OTC
2
OTC
GLUCOCOM BLOOD GLUCOSE
3
OTC
HEALTHY ACCENTS UNILET LANCET
2
GLUCOCOM CONTROL NORMAL
3
HUMAPEN LUXURA HD HYPOLANCE AST LANCING
2
OTC
GLUCOCOM LANCETS
2
OTC
INCONTROL LANCING DEVICE
2
OTC
GLUCOSE CONTROL
3
OTC
INCONTROL PEN NEEDLE
2
M; OTC
GM100
3
OTC
2
OTC
GMATE CONTROL SOLUTION, NORMAL
3
OTC
INCONTROL SUPER THIN LANCETS
2
OTC
GMATE LANCETS
2
OTC
INCONTROL ULTRA THIN LANCETS
GMATE LANCING DEVICE
2
OTC
INFINITY CONTROL SOLUTION NORM
3
OTC
OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 64
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
INFINITY STARTER KIT
3
OTC
MEDLANCE PLUS SPECIAL BLADE
2
OTC
INJECT EASE LANCETS
2
OTC
MICRO THIN LANCETS
2
OTC
INSUPEN
2
M; OTC
3
OTC
INVACARE LANCETS
2
OTC
MICRODOT BLOOD GLUCOSE SYSTEM
JAZZ WIRELESS 2 METER KIT
3
OTC
MICROLET LANCET
2
OTC
LANCETS
2
OTC
MINI LANCING DEVICE
2
OTC
LANCETS,THIN
2
OTC
M; OTC
2
OTC
MINI ULTRATHIN II
2
LANCING DEVICE LANCING SYSTEM
2
OTC
MONOLET LANCETS
2
OTC
LANZO LANCING DEVICE
2
OTC
MONOLET THIN LANCETS
2
OTC
LIBERTY BLOOD GLUCOSE MONITOR
3
OTC
MULTI-LANCET DEVICE 2
2
OTC OTC
3
OTC
MYGLUCOHEALT H
3
LIBERTY LEV 1 GLUCOSE CONTROL
3
OTC
LIBERTY LEV 2 GLUCOSE CONTROL
3
OTC
MYGLUCOHEALT H CONTROL SOLUTION MYGLUCOHEALT H LANCETS
2
OTC
LITE TOUCH LANCETS
2
OTC
3
OTC
MEDISENSE
3
OTC
NOVA MAX BLOOD GLUCOSE METER
MEDISENSE GLUCOSE KETONE
3
OTC
NOVA MAX GLUCOSE CONTROL
3
OTC
MEDISENSE THIN LANCETS
2
OTC
NOVA SAFETY LANCETS
2
OTC
MEDLANCE PLUS LANCETS
2
OTC
NOVA SUREFLEX LANCETS
2
OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 65
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
NOVAMAX PLUS GLU-KET
3
OTC
ONETOUCH ULTRA CONTROL
3
OTC
NOVOFINE 32
2
M; OTC
3
OTC
NOVOFINE AUTOCOVER
2
M; OTC
ONETOUCH ULTRA2
3
OTC
NOVOFINE PLUS
2
ONETOUCH ULTRAMINI
NOVOPEN ECHO
3
2
OTC
NOVOTWIST
2
M; OTC
ONETOUCH ULTRASOFT LANCETS
ON CALL EXPRESS CONTROL
3
OTC
ONETOUCH VERIO FLEX
3
OTC OTC
3
OTC
ONETOUCH VERIO IQ METER
3
ON CALL EXPRESS METER
OTC
2
OTC
ONETOUCH VERIO SYNC
3
ON CALL LANCET ON CALL LANCING DEVICE
2
OTC
ONETOUCH VERIO SYSTEM
3
OTC
ON CALL PLUS CONTROL
3
OTC
ON-THE-GO LANCETS
2
OTC
ON CALL PLUS LANCET
2
OTC
OPTUMRX
3
OTC
PEN NEEDLE
2
M; OTC
ON CALL PLUS LANCING DEVICE
2
OTC
PEN NEEDLE, DIABETIC
2
M; OTC
ON CALL PLUS METER
3
OTC
PENTIPS
2
M; OTC
ON CALL VIVID CONTROL
3
OTC
PHARMACIST CHOICE GLUCOSE SYS
3
OTC
ON CALL VIVID METER
3
OTC
PHASEAL PROTECTOR
3
M
ON CALL VIVID PAL METER
3
OTC
POLY HUB NEEDLE
2
M
ONETOUCH DELICA LANC DEVICE
2
OTC
PRECISION XTRA MONITOR
3
OTC
ONETOUCH SURESOFT LANCING DEV
2
OTC
PREMIUM BLOOD GLUCOSE MONITOR
3
OTC
M; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 66
Drug Name
Drug Tier
Requirements / Limits
Drug Name REFUAH PLUS GLUCOSE MONITOR
3
OTC
RELIAMED LANCET
2
OTC
RELIAMED MINI LANCING DEVICE
2
OTC
RELIAMED SAFETY SEAL LANCETS
2
OTC
RELION ALL-INONE METER
3
OTC
OTC
RELION CONFIRM
3
OTC
3
OTC
OTC
RELION MICRO GLUCOSE MONITOR RELION NEEDLES
2
M; OTC
RELION PEN NEEDLES
2
M; OTC
RELION PRIME METER
3
OTC
RELION THIN LANCETS
2
OTC
RELION ULTRA THIN PLUS LANCETS
2
OTC
REVEAL BLOOD GLUCOSE METER
3
OTC
RIGHTEST CONTROL SOLUTION HIGH
3
OTC
RIGHTEST GD500 LANCING DEVICE
2
OTC
RIGHTEST GL300 LANCETS
2
OTC
RIGHTEST GM550 SYSTEM
3
OTC
PREMIUM V10
3
OTC
PRESSURE ACTIVATED LANCETS
2
OTC
PRESTO PRO BLOOD GLUCOSE METER
3
PRO COMFORT LANCETS
2
OTC
PRODIGY AUTOCODE METER
3
OTC
PRODIGY AUTOCODE MONITOR SYST
3
PRODIGY CONTROL SOLUTION, LOW
3
PRODIGY CONTROL SOLUTION,HIGH
3
PRODIGY LANCETS
2
PRODIGY LANCING DEVICE
2
PRODIGY POCKET METER
3
OTC
PRODIGY TWIST TOP LANCET
2
OTC
PRODIGY VOICE GLUCOSE METER
3
OTC
QUINTET BLOOD GLUCOSE METER
3
OTC
REFUAH PLUS GLUCOSE CONTROL
3
OTC
OTC
OTC
OTC OTC
Drug Tier
Requirements / Limits
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 67
Drug Name
Drug Tier
Requirements / Limits
Drug Name
SAFETY LANCETS
2
OTC
3
OTC
SAFETY SEAL LANCETS
2
OTC
SOLUS V2 CONTROL SOLUTION,HIGH
2
OTC
SAFETY-LET LANCETS
2
SOLUS V2 LANCETS
2
OTC
SIDEKICK BLOOD GLUCOSE SYSTEM
3
SOLUS V2 LANCING DEVICE STERILANCE TL
2
OTC
2
OTC
SINGLE-LET
2
OTC
SUPER THIN LANCETS
SMART SENSE LANCETS
2
OTC
SURE COMFORT LANCETS
2
OTC
SMART SENSE MONITORING SYSTEM
3
OTC
SURE COMFORT LANCING PEN
2
OTC M; OTC
2
OTC
SURE COMFORT PEN NEEDLE
2
SMARTDIABETES VANTAGE
2
M; OTC
SMARTEST CONTROL
3
OTC
SURE-FINE PEN NEEDLES
OTC
3
OTC
SUREFLEX LANCING DEVICE
2
SMARTEST EJECT SMARTEST LANCET
2
OTC
SURE-LANCE
2
OTC
2
OTC
SMARTEST PERSONA STARTER
3
OTC
SURE-PEN LANCING DEVICE
3
OTC
SMARTEST PRONTO STARTER
3
OTC
SURE-TEST EASYPLUS MINI METER SURE-TOUCH LANCET
2
OTC
SMARTEST PROTEGE
3
T:30 INFUSION SET
2
SNAP INSULIN PUMP CONTROLLER
2
T:90 INFUSION SET 23"
2
SOFT TOUCH LANCETS
2
T:SLIM
2
T:SLIM G4
2
SOLUS V2 AUDIBLE METER
3
TECHLITE LANCETS
2
OTC OTC
OTC
OTC OTC
Drug Tier
Requirements / Limits
OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 68
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
TECHLITE PEN NEEDLE
2
M; OTC
TRUETRACK SMART SYSTEM
3
OTC
TELCARE BGM
3
OTC
2
M; OTC
TELCARE BLOOD GLUCOSE KIT
3
OTC
ULTICARE PEN NEEDLE ULTI-LANCE
2
OTC
TELCARE CONTROL
3
OTC
ULTILET BASIC LANCETS
2
OTC
TEST N'GO BLOOD GLUCOSE SYSTEM
3
OTC
ULTILET CLASSIC LANCETS
2
OTC
2
OTC
TOPCARE UNIVERSAL1 LANCET
2
ULTILET LANCETS ULTILET SAFETY LANCETS
2
OTC
TRUE METRIX AIR GLUCOSE METER
3
OTC
ULTIMA MONITOR
3
OTC
TRUE METRIX GLUCOSE METER
3
OTC
ULTRA THIN LANCETS
2
OTC
TRUE METRIX LEVEL 1
3
OTC
ULTRA THIN PLUS LANCETS
2
OTC
TRUE2GO BLOOD GLUCOSE SYSTEM
3
OTC
ULTRA TLC LANCETS
2
OTC
2
OTC
TRUECONTROL LEVEL 0
3
ULTRALANCE LANCETS
2
M; OTC
TRUEDRAW LANCING DEVICE
2
ULTRA-THIN II INS PEN NEEDLES
3
OTC
TRUEPLUS LANCETS
2
ULTRATRAK GLUCOSE METER
3
OTC
TRUERESULT BLOOD GLUCOSE SYSTM
3
ULTRATRAK ULTIMATE UNIFINE PENTIPS
2
M; OTC M; OTC
3
OTC
UNIFINE PENTIPS PLUS
2
TRUETEST LOW GLUCOSE CONTROL
2
OTC
TRUETRACK BLOOD GLUCOSE SYSTEM
3
OTC
UNILET COMFORTOUCH LANCET
OTC
OTC OTC OTC OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 69
Drug Name
Drug Tier
Requirements / Limits
Drug Name WAVESENSE PRESTO
UNILET EXCELITE II LANCET
2
OTC
UNILET EXCELITE LANCET
2
OTC
UNILET GP LANCET
2
UNILET LANCET
Drug Tier
Requirements / Limits
3
OTC
AFREZZA
3
M
APIDRA
3
M
OTC
APIDRA SOLOSTAR
3
M
2
OTC
HUMALOG
2
M
UNISTIK 2 DEVICE
2
OTC
HUMALOG KWIKPEN
2
M
UNISTIK 2 NORMAL LANCET,DEVICE
2
OTC
HUMALOG MIX 50-50
2
M M
2
OTC
HUMALOG MIX 50-50 KWIKPEN
2
UNISTIK 3 UNISTIK 3 EXTRA LANCET
2
OTC
HUMALOG MIX 75-25
2
M
UNISTIK CZT LANCET
2
OTC
HUMALOG MIX 75-25 KWIKPEN
2
M
UNISTIK SAFETY
2
OTC
HUMULIN 70/30
2
M
UNISTIK TOUCH LANCETS
2
OTC
HUMULIN 70/30 KWIKPEN
2
M
UNISTRIP LOW CONTROL
3
OTC
HUMULIN N
2
M M
2
OTC
HUMULIN N KWIKPEN
2
UNIVERSAL 1 LANCETS
HUMULIN R
2
M
VGO 20
6
MSD
M
6
MSD
HUMULIN R U-500 (CONC) KWIKPEN
2
VGO 30 VGO 40
6
MSD
2
M
VOCALPOINT GLUCOSE CONTROL
3
OTC
HUMULIN R U-500 (CONCENTRATED ) LANTUS
2
M
WAVESENSE AMP
3
OTC
2
M
WAVESENSE CONTROL SOLUTION
3
OTC
LANTUS SOLOSTAR LEVEMIR
2
M
INSULIN THERAPY
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 70
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
M
CERDELGA
3
LA
CEREZYME
6
MSD
danazol
1
DDAVP
3
M
3
PA
LEVEMIR FLEXTOUCH
2
NOVOLIN 70/30
3
M
NOVOLIN N
3
M
NOVOLIN R
3
M
NOVOLOG
3
M
DEPOTESTOSTERONE
NOVOLOG FLEXPEN
3
M
desmopressin
1
M MSD
3
M
doxercalciferol intravenous
6
NOVOLOG MIX 70-30
doxercalciferol oral
1
M
NOVOLOG MIX 70-30 FLEXPEN
3
M
ELAPRASE
6
MSD
NOVOLOG PENFILL
3
M
ELELYSO
6
MSD
FABRAZYME
6
MSD
TOUJEO SOLOSTAR
3
FORTESTA
3
PA
GANIRELIX
4
ST; LA
TRESIBA FLEXTOUCH U100
3
M
HECTOROL INTRAVENOUS
6
MSD
TRESIBA FLEXTOUCH U200
3
M
HECTOROL ORAL
3
M
KORLYM
3
PA; LA
KUVAN
2
PA; LA
MISCELLANEOUS HORMONES
LUMIZYME
6
MSD
ALDURAZYME
6
METHITEST
2
ANADROL-50
3
methyltestosterone
1
ANDRODERM
3
PA
6
MSD
ANDROGEL
3
PA
MIACALCIN INJECTION
ANDROID
3
3
M
androxy
1
MIACALCIN NASAL
AVEED
6
MSD
MYALEPT
2
LA
AXIRON
2
PA
NAGLAZYME
6
MSD
cabergoline
1
M; QL
NATESTO
3
PA
calcitonin (salmon)
1
M
NATPARA
3
PA; LA
calcitriol
1
M
OXANDRIN
3
M
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 71
Drug Name
Drug Tier
Requirements / Limits
oxandrolone
1
pamidronate
6
MSD
PARICALCITOL HEMODIALYSIS PORT INJECTION
6
MSD
paricalcitol intravenous
6
MSD
paricalcitol oral
1
M
ROCALTROL
3
M
SAMSCA
2
PA; QL
SENSIPAR
2
PA
SOMAVERT
3
LA
STIMATE
2
M
STRENSIQ
3
LA
STRIANT
3
PA
SYNAREL
3
TESTIM
3
TESTONE CIK
3
testosterone cypionate
Drug Name
Drug Tier
Requirements / Limits
TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 10 MG/0.5 GRAM /ACTUATION
3
PA
testosterone transdermal gel in packet
1
PA
TESTRED
3
VIMIZIM
6
MSD
VOGELXO
3
PA
VPRIV
6
MSD
ZAVESCA
2
ZEMPLAR INTRAVENOUS
6
MSD
ZEMPLAR ORAL
3
M
PA
zoledronic acid
6
MSD
6
MSD
1
PA
ZOLEDRONIC ACID-MANNITOLWATER
testosterone enanthate
1
PA
ZOMETA
6
MSD
TESTOSTERONE TRANSDERMAL GEL
3
PA
NON-INSULIN HYPOGLYCEMIC AGENTS
testosterone transdermal gel in metered-dose pump 1.25 gram/ actuation (1 %)
1
PA
acarbose
1
M
ACTOPLUS MET
3
ST; M; QL
ACTOPLUS MET XR
2
ST; M; QL
ACTOS
3
ST; M; QL
ALOGLIPTIN
3
M; QL
ALOGLIPTINMETFORMIN
3
M; QL
ALOGLIPTINPIOGLITAZONE
3
M; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 72
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
AMARYL
3
M
INVOKAMET XR
3
M
AVANDIA
3
ST; M; QL
INVOKANA
2
M; QL
BYDUREON SUBCUTANEOUS PEN INJECTOR
2
PA; M
JANUMET
2
M; QL
JANUMET XR
2
M; QL
BYDUREON SUBCUTANEOUS SUSPENSION,EXT ENDED REL RECON
2
JANUVIA
2
M; QL
JARDIANCE
3
M
JENTADUETO
2
M; QL
JENTADUETO XR
2
M
BYETTA
2
PA; M; QL
KAZANO
3
M; QL
chlorpropamide
1
M
KOMBIGLYZE XR
3
M; QL
CYCLOSET
3
M
1
M
DUETACT
3
ST; M; QL
metformin oral tablet
FARXIGA
3
M
1
M
FORTAMET
3
ST; M
metformin oral tablet extended release 24 hr
glimepiride
1
M
1
ST; M
glipizide
1
M
metformin oral tablet extended release 24hr
glipizide-metformin
1
M
1
ST; M
GLUCOPHAGE
3
ST; M
GLUCOPHAGE XR
3
ST; M
metformin oral tablet,er gast.retention 24 hr
GLUCOTROL
3
M
miglitol
1
M
GLUCOTROL XL
3
M
nateglinide
1
M
GLUCOVANCE
3
M
NESINA
3
M; QL
GLUMETZA
3
ST; M
ONGLYZA
3
M; QL
glyburide
1
M
OSENI
3
M; QL
glyburide micronized
1
M
pioglitazone
1
M; QL
1
M; QL
glyburide-metformin
1
M
pioglitazoneglimepiride
GLYNASE
3
M
pioglitazonemetformin
1
M; QL
GLYSET
3
M
PRANDIN
3
M
GLYXAMBI
3
M
PRECOSE
3
M
INVOKAMET
2
M
PA; M; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 73
Drug Name
Drug Tier
Requirements / Limits
Drug Name
repaglinide
1
M
np thyroid
1
M
repaglinidemetformin
1
M; QL
SYNTHROID
3
M
THYROLAR-1
2
M
RIOMET
2
ST; M
THYROLAR-1/2
2
M
STARLIX
3
M
THYROLAR-1/4
2
M
SYMLINPEN 120
2
PA; M; QL
THYROLAR-2
2
M
SYMLINPEN 60
2
PA; M; QL
THYROLAR-3
2
M
SYNJARDY
3
M
TIROSINT
3
M
TANZEUM
3
PA; M; QL
unithroid
1
M
tolazamide
1
M
westhroid
1
M
tolbutamide
1
M
WP THYROID
3
M
TRADJENTA
2
QL
TRULICITY
3
PA; M; QL
VICTOZA 2-PAK
3
PA; M; QL
ANTIDIARRHEALS & ANTISPASMODICS
VICTOZA 3-PAK
3
PA; M; QL
anaspaz
1
XIGDUO XR
3
M
atropine
6 1
M
belladonna alkaloids-opium belladonna-opium
1
BENTYL INTRAMUSCULA R
6
BENTYL ORAL
3
chlordiazepoxideclidinium
1
CUVPOSA
3
dicyclomine intramuscular
6
THYROID HORMONES
Drug Tier
GASTROENTEROLOGY
ARMOUR THYROID
2
CYTOMEL
3
M
LEVO-T
3
M
LEVOTHYROXINE INTRAVENOUS RECON SOLN 100 MCG
6
MSD
levothyroxine intravenous recon soln 200 mcg, 500 mcg
6
levothyroxine oral
1
M
dicyclomine oral
1
levoxyl
1
M
1
liothyronine
1
M
diphenoxylateatropine
nature-throid
1
M
DONNATAL
3
MSD
Requirements / Limits
MSD
MSD
MSD
ed-spaz 1 You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 74
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
glycopyrrolate
1
alosetron
1
M
hyoscyamine sulfate
1
ALOXI
6
MSD; QL
hyosyne
1
AMITIZA
3
LEVBID
3
ANALPRAM E
3
LEVSIN
3
ANALPRAM-HC
3
LEVSIN/SL
3
3
LIBRAX (WITH CLIDINIUM)
3
ANALPRAM-HC SINGLES anucort-hc
1
LOMOTIL
3
ANUSOL-HC
3
methscopolamine
1
ANZEMET
3
QL
MOTOFEN
3
APRISO
2
M
MYTESI
3
ASACOL HD
3
M
NULEV
3
AURYXIA
3
opium tincture
1
AZULFIDINE
3
M
oscimin
1
3
M
oscimin sl
1
AZULFIDINE ENTABS
oscimin sr
1
balsalazide
1
paregoric
1
bisacodyl
5
ACA; OTC
phenohytro
1
bisa-lax
5
ACA; OTC
propantheline
1
budesonide
1
ROBINUL
3
calcium acetate
1
ROBINUL FORTE
3
CANASA
2
M
SYMAX DUOTAB
3
CESAMET
3
QL
symax fastabs
1
CHENODAL
2
PA; LA
symax-sl
1
CHOLBAM
2
symax-sr
1
CIMZIA
4
PA; ST; LA
CIMZIA POWDER FOR RECONST
4
PA; ST; LA
citrate of magnesia
5
ACA; OTC
citroma
5
ACA; OTC
clearlax
5
ACA; OTC
MISCELLANEOUS GASTROINTESTINAL AGENTS ACTIGALL
3
M
AKYNZEO
2
QL
alophen
5
ACA; OTC
COLAZAL 3 You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 75
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
colocort
1
gavilyte-c
5
ACA
COLYTE WITH FLAVOR PACKS
3
gavilyte-g
5
ACA
5
ACA
COMPAZINE
3
gavilyte-h and bisacodyl
compro
1
gavilyte-n
5
ACA
constulose
1
generlac
1
CORTENEMA
3
gentle laxative
5
ACA; OTC
CORTIFOAM
2
gentlelax
5
ACA; OTC
CREON
2
GIAZO
3
cromolyn
1
5
CYSTADANE
2
GOLYTELY ORAL POWDER IN PACKET
DELZICOL
3 3
GOLYTELY ORAL RECON SOLN
3
DICLEGIS DIPENTUM
3
granisetron hcl
1
QL
dronabinol
1
healthylax
5
ACA; OTC
ducodyl
5
hemmorex-hc
1
eliphos
1
hydrocortisone
1
EMEND ORAL CAPSULE
2
QL
hydrocortisone acetate
1
EMEND ORAL CAPSULE,DOSE PACK
2
QL
hydrocortisonepramoxine
1
KAYEXALATE
3
EMEND ORAL SUSPENSION FOR RECONSTITUTIO N
2
kionex
1
kionex (with sorbitol)
1
ENTOCORT EC
3
KRISTALOSE
3
ENTYVIO
6
lactulose
1
enulose
1
laxa clear
5
ACA; OTC
FOSRENOL
3
laxative (bisacodyl)
5
ACA; OTC
GASTROCROM
3
laxative feminine
5
ACA; OTC
GATTEX 30-VIAL
3
LA
laxative peg 3350
5
ACA; OTC
gavilax
5
ACA; OTC
LIALDA
3
M
M M ACA; OTC
MSD
ACA
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 76
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
LIDOCAINE HCLHYDROCORTISO N AC RECTAL CREAM 3 %-1 % (7 GRAM)
3
MICORT-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 % (4 GRAM)
3
ST
lidocaine hclhydrocortison ac rectal cream 3-0.5 %
1
milk of magnesia
5
ACA; OTC
milk of magnesia concentrated
5
ACA; OTC
LIDOCAINE HCLHYDROCORTISO N AC RECTAL GEL
3
miralax
5
ACA; OTC
MOVANTIK
3
MOVIPREP
5
lidocaine hclhydrocortison ac rectal kit
1
NOVACORT
3 3
lidocainehydrocortisone-aloe
1
NULYTELY WITH FLAVOR PACKS OCALIVA
3
PA; LA
LINZESS
2
ondansetron
1
QL
LOTRONEX
3
ondansetron hcl (pf)
6
MSD
MAGNEBIND 400
3
6
MSD
magnesium citrate
5
ondansetron hcl intravenous
MARINOL
3
ondansetron hcl oral
1
QL
MESALAMINE ORAL
3
oral saline laxative
5
ACA; OTC
OSMOPREP
5
ACA
mesalamine rectal
1
PANCREAZE
3
mesalamine with cleansing wipe
1
peg 3350electrolytes
5
ACA
metoclopramide hcl injection
6
peg3350
5
ACA; OTC
peg-electrolyte soln
5
ACA
metoclopramide hcl oral
1
peg-prep
5
ACA
MICORT-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %
3
PENTASA
2
M
PERTZYE
3
PHOSLYRA
3
phosphate laxative
5
M ACA; OTC M
MSD
ACA
ACA; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 77
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
sodium polystyrene sulfonate rectal enema 30 gram/120 ml
1
SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML
3
SOLESTA
6
sps (with sorbitol)
1
Requirements / Limits
polyethylene glycol 3350
5
ACA
powderlax
5
ACA; OTC
pramcort
1
PREPOPIK
5
prochlorperazine
1
prochlorperazine edisylate
6
prochlorperazine maleate
1
PROCORT
3
SUCRAID
2
LA
PROCTOCORT
3
sulfasalazine
1
M
PROCTOFOAM HC
3
SUPREP BOWEL PREP KIT
5
ACA
procto-med hc
1
SUSTOL
6
MSD
proctosol hc
1
MSD
1
purelax
5
TIGAN INTRAMUSCULA R
6
proctozone-hc RECTIV
2
TIGAN ORAL
3
REGLAN
3
TRANSDERMSCOP
3
RELISTOR ORAL
3 2
trilyte with flavor packets
5
RELISTOR SUBCUTANEOUS
trimethobenzamide
1
REMICADE
6
UCERIS ORAL
2
RENAGEL
3
UCERIS RECTAL
3
RENVELA
2
URSO 250
3
M
ROWASA
3
URSO FORTE
3
M
SANCUSO
3
ursodiol
1
M
SFROWASA
3
VARUBI
2
smoothlax
5
VELPHORO
3
sodium polystyrene sulfonate oral
1
VELTASSA
3
VIBERZI
2
ACA MSD
ACA; OTC
MSD
QL ACA; OTC
MSD
ACA
LA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 78
Drug Name
Drug Tier
Requirements / Limits
VIOKACE
2
woman's laxative
5
ACA; OTC
women's gentle laxative(bisac)
5
women's laxative (bisacodyl)
5
ZENPEP
3
ZOFRAN (AS HYDROCHLORID E) INTRAVENOUS
6
MSD
ZOFRAN (AS HYDROCHLORID E) ORAL
3
QL
ZOFRAN ODT
3
QL
ZUPLENZ
3
QL
ACIPHEX
3
ACIPHEX SPRINKLE
3
amoxicilclarithromylansopraz
1
carafate oral suspension
1
CARAFATE ORAL TABLET
Drug Name
Drug Tier
Requirements / Limits
1
M
ACA; OTC
esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg
6
MSD
ACA; OTC
esomeprazole sodium ESOMEPRAZOLE STRONTIUM ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 24.65 MG
3
ST; M; QL
3
ST; M
ST; M
ESOMEPRAZOLE STRONTIUM ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 49.3 MG
ST; M; QL
famotidine (pf)
6
MSD
famotidine (pf)-nacl (iso-os)
6
MSD
famotidine intravenous
6
MSD
M
famotidine oral
1
M M; QL
M
lansoprazole oral capsule,delayed release(dr/ec) 15 mg
1
3
cimetidine
1
M
1
M
cimetidine hcl
1
M
lansoprazole oral capsule,delayed release(dr/ec) 30 mg
CYTOTEC
3
M
misoprostol
1
M
DEXILANT
3
ST; M; QL
NEXIUM IV
6
MSD
esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg
1
M; QL
NEXIUM ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 20 MG
3
ST; M; QL
ULCER THERAPY
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 79
Drug Name
Drug Tier
Requirements / Limits
Drug Name
ST; M
pantoprazole oral tablet,delayed release (dr/ec) 20 mg
1
M; QL
pantoprazole oral tablet,delayed release (dr/ec) 40 mg
1
M
PEPCID
3
M
PREVACID ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 15 MG
3
ST; M; QL
PREVACID ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 30 MG
3
ST; M
PREVACID SOLUTAB ORAL TABLET,DISINTE GRAT, DELAY REL 15 MG
3
ST; M; QL
PREVACID SOLUTAB ORAL TABLET,DISINTE GRAT, DELAY REL 30 MG
3
ST; M
PREVPAC
3
PRILOSEC
3
ST; M; QL
PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET
3
ST; M
PROTONIX ORAL TABLET,DELAYE D RELEASE (DR/EC) 20 MG
3
ST; M; QL
NEXIUM ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 40 MG
3
NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 10 MG, 2.5 MG, 20 MG, 5 MG
3
NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 40 MG
3
ST; M
nizatidine
1
M
OMECLAMOXPAK
3
QL
omeprazole oral capsule,delayed release(dr/ec) 10 mg
1
M; QL
omeprazole oral capsule,delayed release(dr/ec) 20 mg, 40 mg
1
omeprazole-sodium bicarbonate oral capsule 20-1.1 mggram
1
ST; M; QL
omeprazole-sodium bicarbonate oral capsule 40-1.1 mggram
1
ST; M
omeprazole-sodium bicarbonate oral packet 20-1,680 mg
1
omeprazole-sodium bicarbonate oral packet 40-1,680 mg
1
ST; M; QL
M
ST; QL
ST
Drug Tier
Requirements / Limits
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 80
Drug Name
Drug Tier
Requirements / Limits
Drug Name
ST; M
ZARXIO
PROTONIX ORAL TABLET,DELAYE D RELEASE (DR/EC) 40 MG
3
PYLERA
3
rabeprazole
1
M
ranitidine hcl
1
M
sucralfate
1
M
ZANTAC
3
M
ZEGERID ORAL CAPSULE 20-1.1 MG-GRAM
3
ST; M; QL
ZEGERID ORAL CAPSULE 40-1.1 MG-GRAM
3
ZEGERID ORAL PACKET 20-1,680 MG
3
ST; QL
ZEGERID ORAL PACKET 40-1,680 MG
3
ST
Drug Tier 6
Requirements / Limits MSD
GROWTH HORMONES
ST; M
EGRIFTA
3
PA; LA
GENOTROPIN
4
PA; ST; LA
GENOTROPIN MINIQUICK
4
PA; ST; LA
HUMATROPE
4
PA; ST; LA
NORDITROPIN FLEXPRO
4
PA; ST; LA
NUTROPIN AQ
4
PA; ST; LA
NUTROPIN AQ NUSPIN
4
PA; ST; LA
OMNITROPE
3
PA; LA
SAIZEN
4
PA; ST; LA
SAIZEN CLICK.EASY
4
PA; ST; LA
SEROSTIM
4
PA; LA
ZOMACTON
3
PA; ST
ZORBTIVE
4
PA; LA
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY
INTERFERONS AUBAGIO
4
PA; LA
BIOTECHNOLOGY DRUGS
AVONEX
3
PA; LA; QL
ARANESP (IN POLYSORBATE)
6
MSD
AVONEX (WITH ALBUMIN)
3
PA; LA; QL
EPOGEN
6
MSD
BETASERON
4
GRANIX
6
MSD
PA; ST; LA; QL
LEUKINE
6
MSD
3
ST; LA; QL
MIRCERA
6
MSD
MOZOBIL
6
MSD
COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML
NEULASTA
6
MSD; QL
4
ST; LA; QL
NEUPOGEN
6
MSD
PROCRIT
6
MSD
COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 81
Drug Name
Drug Tier
Requirements / Limits
Drug Name
COPEGUS
4
ST; LA
INTERLEUKINS
EXTAVIA SUBCUTANEOUS KIT
3
PA; LA; QL
ACTIMMUNE
3
ALDARA
3
EXTAVIA SUBCUTANEOUS RECON SOLN
2
ALFERON N
6
MSD
ARCALYST
3
PA; ST; LA
ILARIS (PF)
6
MSD
GILENYA
3
PA; LA
imiquimod
1
glatopa
1
LA; QL
INTRON A
3
LA
LEMTRADA
6
MSD
KINERET
4
PA; ST; LA
moderiba
1
ST; LA
PROLEUKIN
6
MSD
moderiba dose pack
1
ST; LA
ZYCLARA
3
PEGASYS
3
PA; LA; QL
PEGASYS PROCLICK
3
PA; LA; QL
PEGINTRON
4
PA; LA; QL
PEGINTRON REDIPEN
4
PA; LA; QL
PLEGRIDY
4
POMALYST
2
REBETOL
PA; QL
Drug Tier
Requirements / Limits
LA
VACCINES & MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF)
6
MSD
ADACEL(TDAP ADOLESN/ADULT )(PF)
6
MSD
ST; LA; QL
AFLURIA 20162017
2
4
ST; LA
2
REBIF (WITH ALBUMIN)
3
PA; LA; QL
AFLURIA 20162017 (PF)
2
REBIF REBIDOSE
3
PA; LA; QL
AFLURIA QUAD 2016-2017 (PF)
REBIF TITRATION PACK
3
PA; LA; QL
ATGAM
6
MSD
6
MSD
REVLIMID
2
BCG VACCINE, LIVE (PF)
ribasphere
1
ST; LA
BIVIGAM
6
MSD
ribasphere ribapak
1
ST; LA
BOOSTRIX TDAP
6
MSD
ribavirin
1
ST; LA
CARIMUNE NF NANOFILTERED
6
MSD
SYLATRON
3
LA
CUVITRU
6
PA; MSD
TECFIDERA
3
PA; LA
DYSPORT
6
MSD
ZINBRYTA
3
ST; LA
ENGERIX-B (PF)
6
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 82
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
MSD
FLUZONE QUAD 2016-2017 (PF)
2
Requirements / Limits
ENGERIX-B PEDIATRIC (PF)
6
EZ FLU 2016-17 (AFLURIA) (PF)
3
FLUZONE QUAD PEDI 2016-17 (PF)
2
EZ FLU 2016-17 (FLUVIRIN) (PF)
3
GAMASTAN S/D
6
MSD
6
MSD
EZ FLU1617(FLUZON QD PED)(PF)
3
GAMMAGARD LIQUID
6
MSD
FLEBOGAMMA DIF
6
GAMMAGARD SD (IGA < 1 MCG/ML) GAMMAKED
6
MSD
FLUAD 2016-2017 (65 YR UP)(PF)
2
GAMMAPLEX
6
MSD
FLUARIX QUAD 2016-2017 (PF)
2
GAMUNEX-C
6
MSD
GRASTEK
2
PA
FLUBLOK 20162017 (PF)
2
HAVRIX (PF)
6
MSD
HEPAGAM B
6
MSD
FLUCELVAX QUAD 2016-2017 (PF)
2
HIBERIX (PF)
6
MSD
HIZENTRA
6
MSD
FLULAVAL QUAD 2016-2017
2
HYPERHEP B S/D
6
MSD
6
MSD
FLULAVAL QUAD 2016-2017 (PF)
2
HYPERHEP B S-D NEONATAL
6
MSD
FLUMIST QUAD 2016-2017
6
HYPERRAB S/D (PF) HYQVIA
6
MSD
FLUVIRIN 20162017
2
IMOGAM RABIESHT (PF)
6
MSD
FLUVIRIN 20162017 (PF)
2
KINRIX (PF)
6
MSD
FLUZONE HIGHDOSE 2016-17 (PF)
2
MENACTRA (PF)
6
MSD
6
MSD
FLUZONE INTRADERM QUAD 2016-17
2
MENOMUNE A/C/Y/W-135 MENOMUNE A/C/Y/W-135 (PF)
6
MSD
FLUZONE QUAD 2016-2017
2
MENVEO A-C-YW-135-DIP (PF)
6
MSD
MSD
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 83
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
M-M-R II (PF)
6
MSD
GOUT THERAPY
MYOBLOC
6
MSD
allopurinol
1
NABI-HB
6
MSD
COLCHICINE
3
OCTAGAM
6
MSD
COLCRYS
2
ORALAIR
3
PA; LA
KRYSTEXXA
6
PEDIARIX (PF)
6
MSD
MITIGARE
2
PENTACEL ACTHIB COMPONENT (PF)
6
MSD
probenecid
1
M
probenecidcolchicine
1
M
PNEUMOVAX 23
6
MSD
ULORIC
2
PA; ST; M
PRIVIGEN
6
MSD
ZURAMPIC
3
M
PROQUAD (PF)
6
MSD
ZYLOPRIM
3
M
PROVENGE
6
MSD
QUADRACEL (PF)
6
MSD
RAGWITEK
2
PA
RECOMBIVAX HB (PF)
6
MSD
TENIVAC (PF)
6
TETANUS,DIPHTH ERIA TOX PED(PF)
6
TETANUSDIPHTHERIA TOXOIDS-TD
6
THYMOGLOBULI N
6
TWINRIX (PF)
M
MSD
OSTEOPOROSIS THERAPY ACTONEL
3
ST; M; QL
alendronate
1
M; QL
ATELVIA
3
ST; M; QL
MSD
BINOSTO
3
ST; M; QL
MSD
BONIVA INTRAVENOUS
6
MSD
BONIVA ORAL
3
ST; M; QL
EVISTA
3
PA; M
FORTEO
2
PA; LA; QL
MSD
FOSAMAX
3
ST; M; QL
3
ST; M; QL
6
MSD
FOSAMAX PLUS D
TYPHIM VI
6
MSD
ibandronate intravenous
6
MSD
VAQTA (PF)
6
MSD
ibandronate oral
1
M; QL
VARIZIG
6
MSD
PROLIA
6
MSD
YF-VAX (PF)
6
MSD
raloxifene
1
PA; M
risedronate
1
M; QL
MSD
MUSCULOSKELETAL & RHEUMATOLOGY
OTHER RHEUMATOLOGICALS
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 84
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
SAVELLA ORAL TABLETS,DOSE PACK
2
ST; QL
SIMPONI
4
PA; ST; LA
ACTEMRA INTRAVENOUS
6
MSD
ACTEMRA SUBCUTANEOUS
3
PA; ST; LA
ARAVA
3
QL
SIMPONI ARIA
6
MSD
BENLYSTA
6
MSD
XELJANZ
4
ST; LA
CUPRIMINE
2
M
XELJANZ XR
3
ST; LA
DEPEN TITRATABS
2
M
OBSTETRICS & GYNECOLOGY
ENBREL
3
PA; ST; LA; QL
ENBREL SURECLICK
3
PA; ST; LA; QL
HUMIRA
3
PA; ST; LA; QL
HUMIRA PEDIATRIC CROHN'S START
2
PA; ST; QL
HUMIRA PEN CROHN'S-UC-HS START
3
leflunomide
DIAPHRAGMS AND OTHER NONORAL CONTRACEPTIVES CAYA CONTOURED
5
ACA
FC2 FEMALE CONDOM
5
ACA; OTC
FEMCAP
5
ACA
KYLEENA
6
MSD
PA; ST; LA; QL
LILETTA
5
ACA
MIRENA
5
ACA
1
QL
PARAGARD T 380A
5
MSD; ACA
ORENCIA
2
PA; ST; LA
SKYLA
5
ACA
ORENCIA (WITH MALTOSE)
6
MSD
WIDE-SEAL DIAPHRAGM
5
ACA
ORENCIA CLICKJECT
2
PA; ST; LA
OTEZLA
3
ST; LA
ACTIVELLA
3
M
OTEZLA STARTER
3
ST; LA
ALORA
3
M; QL
amabelz
1
M
OTREXUP (PF)
4
LA
ANGELIQ
3
M
RASUVO (PF)
4
LA
AYGESTIN
3
M
RIDAURA
2
M
camila
5
M; ACA
SAVELLA ORAL TABLET
2
ST; M; QL
CLIMARA
3
M; QL
CLIMARA PRO
3
M; QL
ESTROGENS & PROGESTINS
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 85
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
M
fyavolv
1
M
COMBIPATCH
3
covaryx
1
heather
5
M; ACA
covaryx h.s.
1
6
PA; MSD
CRINONE
3
hydroxyprogesterone caproate
deblitane
5
jencycla
5
M; ACA
DELESTROGEN
3
jevantique lo
1
M
DEPO-ESTRADIOL
3
jinteli
1
M
DEPO-PROVERA
5
ACA; QL
jolivette
5
M; ACA
DEPO-SUBQ PROVERA 104
5
ACA; QL
lopreeza
1
M
lyza
5
M; ACA
DIVIGEL
3
MAKENA
6
MSD
DUAVEE
3
5
ACA; QL
eemt
1
medroxyprogesteron e intramuscular
eemt hs
1
medroxyprogesteron e oral
1
M
ELESTRIN
3
M; QL
MENEST
2
M
errin
5
M; ACA
MENOSTAR
3
M; QL
ESTRACE
3
M
mimvey
1
M
estradiol oral
1
M
mimvey lo
1
M
estradiol transdermal
1
M; QL
MINIVELLE
3
M; QL
estradiol valerate
1
nora-be
5
M; ACA
estradiolnorethindrone acet
1
M
norethindrone (contraceptive)
5
M; ACA
ESTRING
3
M
norethindrone acetate
1
M
ESTROGEL
3
M; QL
M
1
norethindrone ac-eth estradiol
1
estrogensmethyltestosterone
norlyroc
5
M; ACA
estropipate
1
M
NOR-QD
5
ST; M; ACA
EVAMIST
3
QL
5
ST; M; ACA
FEMHRT LOW DOSE
3
M
ORTHO MICRONOR PREFEST
3
M
FEMRING
3
M
PREMARIN
3
M
M; ACA
M; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 86
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
PREMPHASE
3
M
NUVESSA
3
PREMPRO
3
M
OSPHENA
3
progesterone micronized
1
M
PREPIDIL
3
PROSTIN E2
3
PROMETRIUM
3
M
RELAGARD
3
PROVERA
3
M
TERAZOL 7
3
sharobel
5
M; ACA
terconazole
1
VAGIFEM
3
M
3
M; QL
TODAY CONTRACEPTIVE SPONGE
5
VIVELLE-DOT
tranexamic acid
1
vaginal contraceptive foam
5
vandazole
1
VCF CONTRACEPTIVE FILM
5
ACA; OTC
VCF CONTRACEPTIVE GEL
5
ACA; OTC
xulane
5
M; ACA
MISCELLANEOUS OB/GYN
ACA; OTC
AVC VAGINAL
3
CERVIDIL
3
CLEOCIN
3
clindamycin phosphate
1
CLINDESSE
3
CONCEPTROL
5
fem ph
1
GYNAZOLE-1
3
gynol ii
5
ACA; OTC
isoxsuprine
1
M
LUPANETA PACK (1 MONTH)
3
AFTERA
5
ACA; OTC; QL
LUPANETA PACK (3 MONTH)
3
altavera (28)
5
M; ACA
alyacen 1/35 (28)
5
M; ACA
LYSTEDA
3
alyacen 7/7/7 (28)
5
M; ACA
METROGEL VAGINAL
3
amethia
5
M; ACA
metronidazole
1
amethia lo
5
M; ACA
MIFEPREX
4
LA
amethyst
5
M; ACA
NEXPLANON
5
MSD
apri
5
M; ACA
NUVARING
5
M; ACA
aranelle (28)
5
M; ACA
ACA; OTC
ACA; OTC
ORAL CONTRACEPTIVES & RELATED AGENTS
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 87
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
drospirenone-ethinyl estradiol
5
M; ACA
econtra ez
5
ACA; OTC; QL
elinest
5
M; ACA
ELLA
5
ACA; QL
emoquette
5
M; ACA
enpresse
5
M; ACA
enskyce
5
M; ACA
estarylla
5
M; ACA
ESTROSTEP FE-28
5
ST; M; ACA
fallback solo
5
ACA; OTC; QL
ashlyna
5
M; ACA
aubra
5
M; ACA
aviane
5
M; ACA
azurette (28)
5
M; ACA
balziva (28)
5
M; ACA
bekyree (28)
5
M; ACA
BEYAZ
5
ST; M; ACA
blisovi 24 fe
5
M; ACA
blisovi fe 1.5/30 (28)
5
M; ACA
blisovi fe 1/20 (28)
5
M; ACA
BREVICON (28)
5
ST; M; ACA
briellyn
5
M; ACA
camrese
5
M; ACA
falmina (28)
5
M; ACA
camrese lo
5
M; ACA
FEMCON FE
5
ST; M; ACA
caziant (28)
5
M; ACA
GENERESS FE
5
ST; ACA
chateal
5
M; ACA
gianvi (28)
5
M; ACA
cryselle (28)
5
M; ACA
gildagia
5
M; ACA
cyclafem 1/35 (28)
5
M; ACA
introvale
5
M; ACA
cyclafem 7/7/7 (28)
5
M; ACA
jolessa
5
M; ACA
CYCLESSA (28)
5
ST; M; ACA
juleber
5
M; ACA
cyred
5
M; ACA
junel 1.5/30 (21)
5
M; ACA
dasetta 1/35 (28)
5
M; ACA
junel 1/20 (21)
5
M; ACA
dasetta 7/7/7 (28)
5
M; ACA
junel fe 1.5/30 (28)
5
M; ACA
daysee
5
M; ACA
junel fe 1/20 (28)
5
M; ACA
delyla (28)
5
M; ACA
junel fe 24
5
M; ACA
desoge.estradiol/e.estradio l
5
M; ACA
kaitlib fe
5
ACA
kariva (28)
5
M; ACA
DESOGEN
5
ST; M; ACA
kelnor 1/35 (28)
5
M; ACA
desogestrel-ethinyl estradiol
5
M; ACA
kimidess (28)
5
M; ACA
kurvelo
5
M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 88
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
M; ACA
marlissa
5
M; ACA
microgestin 1.5/30 (21)
5
M; ACA
microgestin 1/20 (21)
5
M; ACA
MICROGESTIN 24 FE
5
ST; M; ACA
microgestin fe 1.5/30 (28)
5
M; ACA
5
M; ACA
l norgest/e.estradiole.estrad
5
larin 1.5/30 (21)
5
M; ACA
larin 1/20 (21)
5
M; ACA
larin 24 fe
5
M; ACA
larin fe 1.5/30 (28)
5
M; ACA
larin fe 1/20 (28)
5
M; ACA
larissia
5
M; ACA
layolis fe
5
ACA
leena 28
5
M; ACA
microgestin fe 1/20 (28)
lessina
5
M; ACA
MINASTRIN 24 FE
5
ST; M; ACA
levonest (28)
5
M; ACA
MIRCETTE (28)
5
ST; M; ACA
levonorgestrel
5
ACA; OTC; QL
mono-linyah
5
M; ACA
mononessa (28)
5
M; ACA
levonorgestrelethinyl estrad
5
M; ACA
my way
5
ACA; OTC; QL
levonorg-eth estrad triphasic
5
M; ACA
myzilra
5
M; ACA
NATAZIA
5
ST; M; ACA
levora-28
5
M; ACA
necon 0.5/35 (28)
5
M; ACA
LO LOESTRIN FE
5
ST; M; ACA
necon 1/35 (28)
5
M; ACA
LOESTRIN 1.5/30 (21)
5
ST; M; ACA
necon 1/50 (28)
5
M; ACA
LOESTRIN 1/20 (21)
5
ST; M; ACA
necon 10/11 (28)
5
M; ACA
necon 7/7/7 (28)
5
M; ACA
LOESTRIN FE 1.5/30 (28-DAY)
5
ST; M; ACA
next choice one dose
5
ACA; OTC; QL
LOESTRIN FE 1/20 (28-DAY)
5
ST; M; ACA
nikki (28)
5
M; ACA ACA
5
M; ACA
noreth-ethinyl estradiol-iron
5
lomedia 24 fe loryna (28)
5
M; ACA
5
M; ACA
LOSEASONIQUE
5
ST; M; ACA
norethindrone ac-eth estradiol
low-ogestrel (28)
5
M; ACA
norethindronee.estradiol-iron
5
M; ACA
lutera (28)
5
M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 89
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
M
portia
5
M; ACA
previfem
5
M; ACA
QUARTETTE
5
ST; M; ACA
quasense
5
M; ACA
react
5
ACA; OTC; QL
reclipsen (28)
5
M; ACA
SAFYRAL
5
ST; M; ACA
SEASONIQUE
5
ST; M; ACA
norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg25 mcg
5
norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg35 mcg (28), 0.25-35 mg-mcg
5
NORINYL 1+35 (28)
5
nortrel 0.5/35 (28)
5
M; ACA
setlakin
5
M; ACA
nortrel 1/35 (21)
5
M; ACA
sprintec (28)
5
M; ACA
nortrel 7/7/7 (28)
5
M; ACA
sronyx
5
M; ACA
ocella
5
M; ACA
syeda
5
M; ACA
ogestrel (28)
5
M; ACA
TAKE ACTION
5
opcicon one-step
5
ACA; OTC; QL
ACA; OTC; QL
tarina fe 1/20 (28)
5
M; ACA
M; ACA
ST; M; ACA
orsythia
5
M; ACA
TAYTULLA
3
ST; M
ORTHO TRICYCLEN (28)
5
ST; M; ACA
tilia fe
5
M; ACA
ORTHO TRICYCLEN LO (28)
5
ST; M; ACA
tri-estarylla
5
M; ACA
tri-legest fe
5
M; ACA
ORTHO-CYCLEN (28)
5
tri-linyah
5
M; ACA
tri-lo-estarylla
5
M; ACA
ORTHO-NOVUM 1/35 (28)
5
ST; M; ACA
tri-lo-marzia
5
M; ACA
ORTHO-NOVUM 7/7/7 (28)
5
ST; M; ACA
tri-lo-sprintec
5
M; ACA
trinessa (28)
5
M; ACA
OVCON-35 (28)
5
ST; M; ACA
trinessa lo
5
M; ACA
philith
5
M; ACA
TRI-NORINYL (28)
5
ST; M; ACA
pimtrea (28)
5
M; ACA
tri-previfem (28)
5
M; ACA
pirmella
5
M; ACA
tri-sprintec (28)
5
M; ACA
PLAN B ONESTEP
5
ACA; QL
trivora (28)
5
M; ACA
ST; M; ACA
velivet triphasic 5 M; ACA regimen (28) You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 90
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
vestura (28)
5
M; ACA
ILOTYCIN
3
vienva
5
M; ACA
levofloxacin
1
viorele (28)
5
M; ACA
MOXEZA
3
vyfemla (28)
5
M; ACA
NATACYN
2
wera (28)
5
M; ACA
1
wymzya fe
5
M; ACA
neomycinbacitracinpolymyxin
YASMIN (28)
5
ST; M; ACA
1
YAZ (28)
5
ST; M; ACA
zarah
5
M; ACA
neomycinpolymyxingramicidin
zenchent (28)
5
M; ACA
neo-polycin
1
zenchent fe
5
M; ACA
3
zovia 1/35e (28)
5
M; ACA
NEOSPORIN (NEO-POLYMGRAMICID)
zovia 1/50e (28)
5
M; ACA
OCUFLOX
3
ofloxacin
1
polycin
1
polymyxin b sulftrimethoprim
1
POLYTRIM
3
tobramycin
1
TOBREX
3
VIGAMOX
3 3
OXYTOCICS methergine
1
OPHTHALMOLOGY ANTIBIOTICS AZASITE
3
bacitracin
1
bacitracinpolymyxin b
1
BESIVANCE
3
ZYMAXID
BETADINE OPHTHALMIC PREP
3
ANTIVIRALS
CILOXAN
3
ciprofloxacin hcl
1
erythromycin
1
gatifloxacin
1
gentak
1
gentamicin
1
trifluridine
1
VIROPTIC
3
ZIRGAN
3
Requirements / Limits
M
M
BETA-BLOCKERS BETAGAN
3
M
betaxolol
1
M
BETIMOL
3
M
BETOPTIC S
3
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 91
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
carteolol
1
M
ALCAINE
3
ISTALOL
3
M
ALOCRIL
3
levobunolol
1
M
ALOMIDE
3
metipranolol
1
M
altacaine
1
timolol maleate
1
M
altafluor
1
TIMOPTIC
3
M
AVENOVA
3
TIMOPTIC OCUDOSE (PF)
3
M
azelastine
1
BEPREVE
3
TIMOPTIC-XE
3
M
Requirements / Limits
cromolyn
1
CHOLINESTERASE INHIBITOR MIOTICS
CYSTARAN
2
PHOSPHOLINE IODIDE
ELESTAT
3
EMADINE
3
CYCLOPLEGIC MYDRIATICS
epinastine
1
atropine
1
M
EYLEA
6
CYCLOGYL
3
M
flucaine
1
cyclopentolate
1
M
1
homatropaire
1
M
fluoresceinbenoxinate
homatropine hbr
1
M
fluoresceinproparacaine
1
ISOPTO ATROPINE
3
M
flurox
1
M
6
3
JETREA (PF)
MYDRIACYL PAREMYD
3
LACRISERT
3 3
1
LASTACAFT
tropicamide
LUCENTIS
6
MSD
MACUGEN
6
MSD
olopatadine
1
OMIDRIA
6
PATADAY
3
PATANOL
3
PAZEO
3
proparacaine
1
2
M
M
DIRECT ACTING MIOTICS ISOPTO CARPINE
3
MIOCHOL-E
3
pilocarpine hcl
1
MISCELLANEOUS OPHTHALMOLOGICS acuicyn
1
AKTEN (PF)
3
M M
LA
MSD
MSD
MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 92
Drug Name
Drug Tier
Requirements / Limits
Drug Name
RESTASIS
2
tetcaine
PA; M; QL
AZOPT
3
M
1
bimatoprost
1
PA; ST; M
tetracaine hcl
1
COMBIGAN
3
M
tetracaine hcl (pf)
1
COSOPT
3
M
TETRAVISC
3
COSOPT (PF)
3
M
TETRAVISC FORTE
3
dorzolamide
1
M
dorzolamide-timolol
1
M
VISUDYNE
6
MSD
latanoprost
1
PA; ST; M
VITRASE
6
MSD
LUMIGAN
3
ST; M
XIIDRA
3
M; QL
MITOSOL
3
SIMBRINZA
3
M
TRAVATAN Z
3
ST; M
TRUSOPT
3
M
XALATAN
3
ST; M
ZIOPTAN (PF)
3
ST; M
NON-STEROIDAL ANTIINFLAMMATORY AGENTS ACULAR
3
ACULAR LS
3
ACUVAIL (PF)
3
bromfenac
1
BROMSITE
3
diclofenac sodium
1
flurbiprofen sodium
1
ILEVRO
3
ketorolac
1
NEVANAC
3
OCUFEN
3
PROLENSA
3
Drug Tier
Requirements / Limits
STEROID-ANTIBIOTIC COMBINATIONS
ORAL DRUGS FOR GLAUCOMA acetazolamide
1
M
DIAMOX SEQUELS
3
M
methazolamide
1
M
NEPTAZANE
3
M
OTHER GLAUCOMA DRUGS
MAXITROL
3
neomycinbacitracin-poly-hc
1
neomycin-polymyxin b-dexameth
1
neomycinpolymyxin-hc
1
neo-polycin hc
1
PRED-G
3
PRED-G S.O.P.
3
TOBRADEX
3
TOBRADEX ST
3
tobramycindexamethasone
1
ZYLET
3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 93
Drug Name
Drug Tier
Requirements / Limits
STEROIDS
Drug Name
Drug Tier
Requirements / Limits
SYMPATHOMIMETICS
ALREX
3
ALPHAGAN P OPHTHALMIC DROPS 0.1 %
2
M
dexamethasone sodium phosphate
1
DUREZOL
3
3
M
3
ALPHAGAN P OPHTHALMIC DROPS 0.15 %
FLAREX fluorometholone
1
apraclonidine
1
M
FML FORTE
3
brimonidine
1
M
FML LIQUIFILM
3
IOPIDINE
3
M
FML S.O.P.
3
ILUVIEN
6
VASOCONSTRICTOR DECONGESTANTS
LOTEMAX
3
CYCLOMYDRIL
3
MAXIDEX
3
phenylephrine hcl
1
OMNIPRED
3
OZURDEX
6
RESPIRATORY, ALLERGY, COUGH & COLD
PRED FORTE
3
PRED MILD
2
prednisolone acetate
1
prednisolone sodium phosphate
1
RETISERT
6
STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE
3
BLEPHAMIDE S.O.P.
3
sulfacetamideprednisolone
1
SULFONAMIDES
MSD
MSD
M
ANTIHISTAMINE & ANTIALLERGENIC AGENTS
MSD
ADRENACLICK
3
QL
arbinoxa
1
carbinoxamine maleate
1
cetirizine
1
CLARINEX ORAL SYRUP
3
CLARINEX ORAL TABLET
3
clemastine
1
cyproheptadine
1
desloratadine
1
QL
QL
BLEPH-10
3
diphenhydramine hcl
6
MSD
sulfacetamide sodium
1
epinephrine
1
QL
EPIPEN 2-PAK
3
QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 94
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
EPIPEN JR 2-PAK
3
QL
guaifenesin dac
1
EPISNAP
6
MSD
HISTEX-AC
3
hydroxyzine hcl
1
HYCOFENIX
3
hydroxyzine pamoate
1
hydrocodonechlorpheniramine
1
KARBINAL ER
3
1
levocetirizine oral solution
1
hydrocodone-cpmpseudoephed
1
levocetirizine oral tablet
1
hydrocodonehomatropine hydromet
1
phenadoz
1
iophen c-nr
1
phenergan
1
lortuss ex
1
promethazine
1
MAR-COF BP
3
promethegan
1
MAR-COF CG
3
VISTARIL
3
m-clear wc
1
XYZAL ORAL SOLUTION
3
M-END MAX D
3
M-END PE
3
XYZAL ORAL TABLET
3
NINJACOF-XG
3
OBREDON
3
phenylhistine dh
1
POLY-TUSSIN AC
3
promethazine vc
1
promethazine vccodeine
1
QL
QL
COUGH & COLD THERAPY benzonatate
1
BROMFED DM
3
brompheniraminepseudoeph-dm
1
CAPCOF
3
centergy
1
promethazinecodeine
1
cheratussin ac
1
promethazine-dm
1
cheratussin dac
1
1
CLARINEX-D 12 HOUR
3
promethazinephenyleph-codeine
3
codeine-guaifenesin
1
FLOWTUSS
3
PRO-RED AC (W/ DEXCHLORPHENI R)
guaifenesin ac
1
relcof c
1
QL
Requirements / Limits
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 95
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
RESPA-AR
3
ZODRYL DEC 30
2
REZIRA
3
ZODRYL DEC 35
3
rydex
1
ZODRYL DEC 40
3
SEMPREX-D
3
ZODRYL DEC 50
3
TESSALON PERLES
3
ZODRYL DEC 60
3
ZODRYL DEC 80
3
tusnel c
1
ZONATUSS
3
TUSNEL PEDIATRIC
3
Z-TUSS AC
3
TUSSICAPS
3
ZUTRIPRO
3
tussigon
1
TUSSIONEX PENNKINETIC ER
3
TUZISTRA XR
3
virtussin ac
1
virtussin dac
1
VITUZ
3
ZODRYL AC 25
3
ZODRYL AC 30
3
ZODRYL AC 35
3
ZODRYL AC 40
2
ZODRYL AC 50
3
ZODRYL AC 60
3
ZODRYL AC 80
3
ZODRYL DAC 25
3
ZODRYL DAC 30
3
ZODRYL DAC 35
3
ZODRYL DAC 40
Requirements / Limits
PULMONARY AGENTS ACCOLATE
3
M
acetylcysteine
1
ADCIRCA
4
PA; ST; LA; QL
ADEMPAS
2
M; LA
ADRENALIN
3
ADVAIR DISKUS
3
PA; M; QL
ADVAIR HFA
3
PA; M; QL
AEROSPAN
3
M
albuterol sulfate inhalation
1
albuterol sulfate oral
1
M
ALVESCO
3
M; QL
ANORO ELLIPTA
2
M; QL
ARCAPTA NEOHALER
3
M; QL
3
M
3
ARNUITY ELLIPTA
ZODRYL DAC 50
3
ASMANEX HFA
3
M
ZODRYL DAC 60
3
ASMANEX TWISTHALER
3
M; QL
ZODRYL DAC 80
3
ATROVENT HFA 2 M; QL ZODRYL DEC 25 3 You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 96
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
FORADIL AEROLIZER
2
HYPER-SAL
3
INCRUSE ELLIPTA
2
M
ipratropium bromide
1
M
ipratropiumalbuterol
1
QL
KALBITOR
6
MSD
KALYDECO
3
PA; LA
LETAIRIS
3
PA; ST; M
levalbuterol hcl
1
LEVALBUTEROL TARTRATE
3
metaproterenol
1
M
BECONASE AQ
3
ST; QL
BERINERT
6
MSD
BEVESPI AEROSPHERE
3
M
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE
3
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 200-25 MCG/DOSE
3
BROVANA
3
M; QL
budesonide inhalation
1
M; QL
budesonide nasal
1
QL
mometasone
1
QL
CINRYZE
6
MSD
montelukast
1
M
COMBIVENT RESPIMAT
2
QL
NASONEX
3
ST; QL
NEBUSAL
3
cromolyn
1
NUCALA
6
MSD
CUROSURF
3
OFEV
3
PA; LA; QL
DALIRESP
3
PA
OMNARIS
3
ST; QL
DULERA
2
PA; M; QL
OPSUMIT
2
PA; ST; M
DYMISTA
3
ST; QL
ORKAMBI
3
PA; LA
ELIXOPHYLLIN
3
M
PERFOROMIST
2
M; QL
ESBRIET
3
PA; LA; QL
PROAIR HFA
2
QL
FIRAZYR
3
PA; LA
3
M; QL
PROAIR RESPICLICK
2
FLOVENT DISKUS FLOVENT HFA
3
M; QL
PROVENTIL HFA
3
QL
flunisolide
1
QL
3
M; QL
fluticasone
1
QL
PULMICORT FLEXHALER
PA; M; QL
PA; M
M
QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 97
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
M; QL
SPIRIVA WITH HANDIHALER
3
M; QL
STIOLTO RESPIMAT
3
M
STRIVERDI RESPIMAT
3
M
SURFAXIN
3
SYMBICORT
2
PA; M; QL
terbutaline oral
1
M
terbutaline subcutaneous
1
THEO-24
3
M
theochron
1
M
theophylline
1
M
TICANASE
3
TICASPRAY
3
TRACLEER
3
PA; M; LA
triamcinolone acetonide
1
QL
PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 0.25 MG/2 ML, 0.5 MG/2 ML
3
PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/2 ML
2
pulmosal
1
PULMOZYME
2
QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION
3
QNASL NASAL HFA AEROSOL INHALER 80 MCG/ACTUATION
3
QVAR
2
M; QL
REVATIO INTRAVENOUS
3
PA; LA
TUDORZA PRESSAIR
2
M; QL
REVATIO ORAL SUSPENSION FOR RECONSTITUTIO N
3
PA; ST; QL
TYVASO
6
MSD
TYVASO REFILL KIT
6
MSD
REVATIO ORAL TABLET
4
PA; ST; LA; QL
TYVASO STARTER KIT
6
MSD
RUCONEST
6
MSD
VENTAVIS
6
MSD
SEREVENT DISKUS
3
M; QL
VENTOLIN HFA
3
QL
VERAMYST
3
ST; QL
sildenafil
1
PA; LA; QL
VOSPIRE ER
3
M
SINGULAIR
3
M
XOLAIR
6
MSD; QL
sodium chloride
1
XOPENEX
3
SPIRIVA RESPIMAT
3
M; QL
ST
ST; QL
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 98
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
XOPENEX CONCENTRATE
3
dutasteridetamsulosin
1
ST; M
XOPENEX HFA
3
finasteride
1
M
zafirlukast
1
M
FLOMAX
3
ST; M
ZETONNA
3
ST; QL
JALYN
3
ST; M
ZYFLO
3
M
PROSCAR
3
ST; M
ZYFLO CR
3
M
RAPAFLO
3
ST; M
UROLOGICALS
tamsulosin
1
M
ANTICHOLINERGICS & ANTISPASMODICS
UROXATRAL
3
ST; M
CHOLINERGIC STIMULANTS
darifenacin
1
M
bethanechol chloride
1
DETROL
3
ST; M
URECHOLINE
3
DETROL LA
3
ST; M
MISCELLANEOUS UROLOGICALS
DITROPAN XL
3
ST; M
6
ENABLEX
3
ST; M
AMMONIUM CHLORIDE
flavoxate
1
M
azuphen mb
1
GELNIQUE
3
ST; M; QL
CYSTAGON
2
MYRBETRIQ
3
ST; M
cytra k crystals
1
oxybutynin chloride
1
M
cytra-2
1
OXYTROL
3
ST; M; QL
cytra-3
1
tolterodine
1
M
cytra-k
1
TOVIAZ
3
ST; M
ELMIRON
2
trospium
1
M
hyolev mb
1
VESICARE
3
ST; M
hyophen
1
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
INDIOMIN MB
3
K-PHOS NO 2
2
alfuzosin
1
M
2
AVODART
3
ST; M
K-PHOS ORIGINAL
CIALIS
3
PA; QL
methen-sod phosmeth blue-hyos
1
dutasteride
1
ST; M
ORACIT
3
phosphasal
1
MSD
LA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 99
Drug Name
Drug Tier
Requirements / Limits
pot,sodium citratecitric acid
1
potassium citrate
1
potassium citratecitric acid
1
PROCYSBI
3
SHOHL'S MODIFIED
3
sodium citrate-citric acid
1
tricitrates
1
ur n-c
1
uramit mb
1
URELLE
3
uretron d-s
1
URIBEL
3
urimar-t
1
urin ds
1
uro-458
1
UROCIT-K 10
3
M
UROCIT-K 15
3
M
UROCIT-K 5
3
M
urogesic-blue
1
urolet mb
1
uro-mp
1
urophen mb
1
UROQID-ACID NO.2
3
uryl
1
ustell
1
UTA
3
utira-c
1
M
Drug Name
Drug Tier
virtrate-2
1
virtrate-3
1
virtrate-k
1
Requirements / Limits
URINARY ANESTHETICS LA
phenazopyridine
1
PYRIDIUM
3
VITAMINS, HEMATINICS & ELECTROLYTES ELECTROLYTES calcium 500 + d
5
ACA; OTC
calcium 500 with d
5
ACA; OTC
calcium 600 + d(3)
5
ACA; OTC
calcium 600 with vitamin d3
5
ACA; OTC
calcium carb and citrate-vitd3
5
ACA; OTC
calcium carbonatevitamin d3
5
ACA; OTC
calcium citrate + d
5
ACA; OTC
calcium citratevitamin d2
5
ACA; OTC
calcium citratevitamin d3
5
ACA; OTC
CALCIUM GLUCONATE IN 0.9% NACL
6
MSD
calcium with vitamin d
5
ACA; OTC
citrus calcium
5
ACA; OTC
EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ
3
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 100
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
M
potassium acetate
6
MSD
potassium bicarb and chloride
1
M
potassium bicarbcitric acid
1
M
potassium chloride
1
M
potassium chloride in 0.9%nacl
6
MSD
sodium chloride
6
MSD
effer-k oral tablet, effervescent 25 meq
1
GALZIN
3
hi-cal plus vit d
5
ACA; OTC
k-effervescent
1
M
klor-con
1
M
klor-con 10
1
M
klor-con 8
1
M
klor-con m10
1
M
MSD
1
M
sodium chloride 0.45 %
6
klor-con m15 klor-con m20
1
M
sodium chloride 3 %
6
MSD
klor-con sprinkle
1
M
sodium chloride 5 %
6
MSD
KLOR-CON/25
3
M
6
MSD
klor-con/ef
1
M
SODIUM PHOSPHATE IN 0.9 % NACL
k-phos-neutral
1
strong iodine
1
k-sol
1
M
virt-phos 250 neutral
1
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ
3
M
k-tab oral tablet extended release 8 meq
1
lugols
1
oysco 500/d
5
ACA; OTC
oysco d
5
oyster shell + d3
M
MISCELLANEOUS VITAMINS, HEMATINICS, & ELECTROLYTES FORTAVIT
3
ISOLYTE-S
6
MSD
VITAMINS & HEMATINICS ACTIVE FE
3
ACTIVE OB
3 3
ACA; OTC
ANIMI-3 WITH VITAMIN D
5
ACA; OTC
ATABEX EC
3
oyster shell calciumvit d3
5
ACA; OTC
b complete
1
OTC
5
ACA; OTC
oystercal-d
5
ACA; OTC
b complex-vitamin b12
phospha 250 neutral
1
5
ACA; OTC
POTABA
3
b complex-vitamin cfolic acid
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 101
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
B-12 COMPLIANCE
6
MSD
CITRANATAL BCALM (FE GLUC)
3
b-50 complex
5
ACA; OTC
3
BACMIN
3
CITRANATAL DHA (ALGAL OIL)
balanced b-100
5
ACA; OTC
3
balanced b-100 complex
5
ACA; OTC
CITRANATAL HARMONY (IRON FUM) classic prenatal
5
balanced b-50
5
ACA; OTC
c-nate dha
1
bal-care dha
1
M
3
COMPLETE FORMULATION D3000
3
BAL-CARE DHA ESSENTIAL b-complex with vitamin c oral tablet
5
ACA; OTC
3
M
b-complex with vitamin c oral tablet 400-500 mcg-mg
1
OTC
COMPLETE FORMULATION PEDIATRIC complete natal dha
1
completenate
1
BIFERA RX
3
complex b-100
1
CADEAU DHA
3
CONCEPT DHA
3
calcium pnv
1
CONCEPT OB
3
calcium-folic acidvitamin d
1
corvita
1
centratex
1
corvita 150
1
chewable multivita,b,d,e,k,zn
1
CORVITE
3
CORVITE 150
3
children's iron
1
OTC
CORVITE FE
3
cholecalciferol (vitamin d3)
5
ACA; OTC
CORVITE FREE
3
1
M
cyanocobalamin (vitamin b-12)
1
ciferex CITRANATAL (DUAL-IRON)
3
delta d3
5
ACA; OTC M
3
DERMACINRX PUREFOLIX
3
CITRANATAL 90 DHA (ALGAL OIL)
dialyvite
1
CITRANATAL ASSURE
3
DIALYVITE 3000
3
DIALYVITE 5000
3
M
ACA; OTC
OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 102
Drug Name
Drug Tier
Requirements / Limits
Drug Name
dialyvite 800
5
DIALYVITE 800 WITH IRON
3
DIALYVITE SUPREME D
3
dothelle dha
ACA; OTC
ferocon
1
FERRALET 90 DUAL-IRON DELIVERY
3
ferraplus 90
1
1
ferrocite plus
1
DUET DHA BALANCED
3
ferrogels forte
1
ferrous sulfate
1
OTC
DUET DHA WITH OMEGA-3
3
FLORIVA
3
M
DURACHOL
3
M
5
M; ACA
d-vi-sol
5
ACA; OTC
FLORIVA (FLUORIDEVITAMIN D3)
d-vita
5
ACA; OTC
FLORIVA PLUS
3
M
ELDERCAPS
3
FLUORABON
5
M; ACA
ENBRACE HR
3
FLUOR-A-DAY
5
M; ACA
ergocalciferol (vitamin d2) oral capsule
1
fluor-a-day (with xylitol)
1
M
5
M; ACA
ergocalciferol (vitamin d2) oral tablet
5
FLUORITAB ORAL DROPS
5
M; ACA
ESCAVITE
3
fluoritab oral tablet,chewable 0.5 mg fluoride (1.1 mg)
ESCAVITE D
3
M
1
M
ESCAVITE LQ
3
M
fluoritab oral tablet,chewable 1 mg fluoride (2.2 mg)
EXPECTA PRENATAL
5
ACA; OTC
FLURA-DROPS
5
M; ACA
EXTRA-VIRT PLUS DHA
2
focalgin 90 dha
1
focalgin ca
1
FA-8
5
focalgin dss
1
fabb
1
folbecal
1
fe c plus
1
folbee
1
fer-iron
1
folbee plus
1
FERIVA 21-7 TABLET
3
FOLET ONE
3
FOLGARD OS
3
ACA; OTC
M; ACA; OTC
OTC
Drug Tier
Requirements / Limits
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Drug Name
Drug Tier
FOLGARD RX
3
folic acid oral tablet 1 mg
1
folic acid oral tablet 400 mcg, 800 mcg
5
folic acid-vit b6-vit b12
1
folivane-f
1
folivane-ob
1
folivane-plus
1
FOLIXAPURE
3
folplex 2.2
1
foltabs 800
1
FOLTRATE
3
full spectrum bvitamin c
5
FUSION PLUS
3
FUSION SPRINKLES
3
hematinic plus vit/minerals
1
hematinic/folic acid
Requirements / Limits
Drug Name
Drug Tier
Requirements / Limits
INJECTAFER
6
INTEGRA F
3
INTEGRA PLUS
3
IROSPAN 24/6
3
kobee
1
KOSHER PRENATAL PLUS IRON
3
kpn
1
levomefolate dha
1
ludent fluoride oral tablet,chewable 0.25 mg fluorid (0.55 mg), 0.5 mg fluoride (1.1 mg)
5
M; ACA
ludent fluoride oral tablet,chewable 1 mg fluoride (2.2 mg)
1
M
M.V.I.-12 (WITHOUT VITAMIN K)
6
MSD
macnatal cn dha
1
1
MARNATAL-F
3
hematogen
1
MAXARON FORTE
3
hematogen fa
1 1
MAXFE (FOLATEDOCUSATE)
3
hematogen forte HEMATRON-AF
3
MAXINATE
3
hemenatal ob
1
multigen folic
1
hemenatal ob + dha
1
multigen plus
1
hemetab
1
5
ACA
HEMOCYTE-F
3
multi-vit with fluoride-iron
HEMOCYTE-PLUS
3
multi-vitamin with fluoride oral drops
5
ACA
ICAR-C PLUS
3
M M; ACA; OTC
M OTC ACA; OTC
MSD
OTC
OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 104
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
ACA
NEEVODHA (WITH ALGAL OIL)
3
nephplex rx
1
NEPHROCAPS
3
NEPHROCAPS QT
3
NEPHRON FA
3
nephro-vite rx
1
NESTABS
3
NESTABS ABC
3
NESTABS DHA
3
NEURIN-SL
3
newgen
1
NEXA PLUS
3
NEXAVIR
3
NIVA-PLUS
3
NOXIFOL-D3
3
NUTRICAP
3
OB COMPLETE
3
OB COMPLETE GOLD
3
OB COMPLETE ONE
3
OB COMPLETE PETITE
3
OB COMPLETE PREMIER
3
multi-vitamin with fluoride oral tablet,chewable 0.25 mg, 0.5 mg
5
multi-vitamin with fluoride oral tablet,chewable 1 mg
1
multivitamins with fluoride oral tablet,chewable 0.25 mg, 0.5 mg
5
multivitamins with fluoride oral tablet,chewable 1 mg
1
mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg
5
mvc-fluoride oral tablet,chewable 1 mg
1
M-VIT
3
mynatal
1
mynatal advance
1
mynatal plus
1
mynatal-z
1
mynate 90 plus
1
mynephrocaps
1
NASCOBAL
3
NATACHEW (FE BIS-GLYCINATE)
3
OB COMPLETE WITH DHA
3
NATELLE ONE
3
obstetrix dha
1
natural b-100 complex
5
OBSTETRIX EC
3
OBTREX DHA
3
O-CAL FA
3
ACA
ACA
M
ACA; OTC
Requirements / Limits
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 105
Drug Name
Drug Tier
Requirements / Limits
O-CAL PRENATAL
3
ONE A DAY WOMEN'S PRENATAL DHA
5
ONE DAILY PRENATAL ORAL COMBO PACK 28 MG IRON- 800 MCG
5
one daily prenatal oral combo pack 28800-440 mg-mcg-mg
5
ortho d
1
M
oyster shell calciumvit d2
5
ACA; OTC
PAIRE OB PLUS DHA
3
PED MULTIVITAMINSA,B,D,E,K,ZN
3
perry prenatal
5
PHYSICIANS EZ USE B-12
6
pnv 29-1
1
pnv ob+dha
1
pnv-dha
1
pnv-dha + docusate
1
pnv-ferrous fumarate-docu-fa
1
pnv-omega
1
pnv-select
1
pnv-vp-u
1
POLY-VI-FLOR
3
POLY-VI-FLOR FS
3
Drug Name
Drug Tier
Requirements / Limits
POLY-VI-FLOR WITH IRON
3
poly-vita (iron)
1
OTC
poly-vitamin with iron
1
OTC
pr natal 400
1
pr natal 400 ec
1
pr natal 430
1
pr natal 430 ec
1
PREFERA-OB
3
PREFERA-OB ONE
3
PREFERA-OB PLUS DHA
3
prena1 chew
1
prena1 pearl
1
prena1 true
1
prenaissance
1
prenaissance next
1
ACA; OTC
prenaissance plus
1
MSD
PRENATA
3
prenatabs fa
1
prenatabs rx
1
prenatal
5
ACA; OTC
prenatal complete
5
ACA; OTC
prenatal formula
5
ACA; OTC
prenatal multi-dha (algal oil)
1
OTC
prenatal one daily
5
ACA; OTC
prenatal plus
1
prenatal plus (calcium carb)
1
ACA; OTC
ACA; OTC
ACA; OTC
M
M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 106
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
ACA; OTC
PROVIDA OB
3
PURALOR CI
3
PUREFE OB PLUS
3
PUREFE PLUS
3
purevit dualfe plus
1
QUFLORA FE
3
M
QUFLORA PEDIATRIC
3
M
QUFLORA PEDIATRIC DROPS
3
M
relnate dha
1
renal caps
1
rena-vite
5
rena-vite rx
1
reno caps
1
REVESTA
3
M
risacal-d
5
ACA; OTC
R-NATAL OB
3
ROXIFOL-D
3
rulavite dha
1
prenatal vit#96ferrous fum-fa
5
prenatal vitamin
5
prenatal vitamin plus low iron
1
prenatal vitamin with minerals
5
prenatal-u
1
PRENATE AM
3
PRENATE CHEWABLE
3
PRENATE DHA (FERR ASP GLYCIN)
3
PRENATE ELITE (IRON ASP GLYC)
3
PRENATE ENHANCE
3
PRENATE ESSENTIAL(IRONASP-GL)
3
PRENATE MINI (FERR ASP GLYCIN)
3
PRENATE PIXIE
3
SELECT-OB
3
PRENATE RESTORE
3
SELECT-OB (FOLIC ACID)
3
PRENATE STAR
3
3
preplus
1
SELECT-OB + DHA
PREQUE 10
3
se-natal 19
1
pretab
1
se-natal 19 (with docusate)
1
PROFERRINFORTE
2
se-tan plus
1
PROTECT IRON
3
sodium fluoride oral drops
5
PROVIDA DHA
3
ACA; OTC
ACA; OTC
Requirements / Limits M
ACA; OTC
M
M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 107
Drug Name
Drug Tier
Requirements / Limits
Drug Name
Drug Tier
M; ACA
thrivite-19
1
tl gard rx
1
tl g-fol os
1
tl icon
1
tl-hem 150
1
total b/c
1
TRICARE
3
TRICARE PRENATAL
3
TRICARE PRENATAL DHA ONE
3
TRICARE PRENATAL WITH DHA
3
tricon
1
TRIFERIC
6
trigels-f forte
1
trinatal gt
1
trinatal rx 1
1
trinate
1
triphrocaps
1
Requirements / Limits
sodium fluoride oral tablet,chewable 0.25 mg fluorid (0.55 mg), 0.5 mg fluoride (1.1 mg)
5
sodium fluoride oral tablet,chewable 1 mg fluoride (2.2 mg)
1
SOFTGELS MULTIVITA,B,D,E,K,ZN
3
stress formula
5
ACA; OTC
stress formula with iron
1
OTC
stress formula with iron(sulf)
1
OTC
STROVITE FORTE
3
STROVITE ONE
3
super b complexvitamin c
1
super b maxi complex
1
super b-50 complex plus
1
OTC
super quints
1
OTC
super quints b-50
5
ACA; OTC
triple vitamin with fluoride
5
superplex-t
1
OTC
TRISTART DHA
3
SUPERVITE
3
tri-tabs dha
1
TANDEM PLUS
3
triveen-duo dha
1
taron forte
1
TRI-VI-FLOR
3
taron-c dha
1
5
ACA
taron-prex prenataldha
1
tri-vit with fluoride and iron
5
ACA
TEXAVITE LQ
3
tri-vitamin with fluoride
THRIVITE RX
3
trust natal dha
1
M
M
OTC OTC
M
OTC
MSD
ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 108
Drug Name
Drug Tier
Requirements / Limits
UDAMIN SP
3
VITA-BEE WITH C
5
ultimatecare one
1
VITAFOL
3
ultimatecare one nf
1
3
ultra b-100 complex
1
VITAFOL FE+ (WITH DOCUSATE)
v-c forte
1 1
VITAFOL GUMMIES
3
vemavite-prx-2 vic-forte
1
VITAFOL NANO
3
vinate care
1
VITAFOL ULTRA
3
vinate dha
1
vitafol-ob
1
VINATE DHA RF
3
3
vinate ii
1
VITAFOLOB+DHA
vinate m
1
VITAFOL-ONE
3
vinate one
1
VITAL-D RX
3
vinate ultra
1
VITAMED MD ONE RX
3
virt-advance
1 1
VITAMED MD PLUS RX
3
virt-c dha VIRT-CAPS
3
3
virt-gard
1
VITAMEDMD REDICHEW RX
virt-nate
1
vitamin b complex
5
ACA; OTC
virt-nate dha
1
vitamin d3
5
ACA; OTC
virt-pn
1
vitamins a,c,d and fluoride
5
ACA
virt-pn dha
1
VITAPEARL
3
virt-pn plus
1
VITA-RESPA
3
VIRTPREX
3
VITATRUE
3
virt-select
1
VIVA DHA
3
virt-vite
1
vol-care rx
1
virt-vite gt
1
vol-nate
1
VIRT-VITE PLUS
3
vol-plus
1
vit 3
1
vol-tab rx
1
vit b complex-folic acid
5
vp-ch plus
1
OTC
M ACA; OTC
Drug Name
Drug Tier
Requirements / Limits ACA; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 109
Drug Name
Drug Tier
vp-ch-pnv
1
vp-ggr-b6
1
vp-heme ob
1
vp-heme one
1
VP-PNV-DHA
3
vp-vite rx
1
wee care
1
zatean-ch
1
zatean-pn dha
1
zatean-pn plus
1
zavara
1
zingiber
1
zolate
1
Requirements / Limits
OTC
M M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 110
Index 1 1ST TIER UNIFINE PENTIPS .......................................... 54 1ST TIER UNILET COMFORTOUCH ........... 54 2 2TEK GLUCOSE/BLOOD PRESSURE ...................... 54 A abacavir .................................. 3 abacavir-lamivudine ............... 3 abacavir-lamivudinezidovudine .......................... 3 ABILIFY .............................. 25 ABILIFY MAINTENA ........ 25 ABRAXANE ........................ 11 ABSORICA .......................... 41 ABSTRAL............................ 20 acamprosate .......................... 47 ACANYA ............................. 41 acarbose ................................ 68 ACCOLATE......................... 92 ACCU-CHEK AVIVA CONNECT METER ........ 54 ACCU-CHEK AVIVA PLUS METER ............................ 54 ACCU-CHEK AVIVA PLUS TEST STRP ...................... 51 ACCU-CHEK COMP BLUE CONT, M-H ..................... 54 ACCU-CHEK COMPACT PLUS CONTROL ............ 54 ACCU-CHEK COMPACT TEST ................................ 51 ACCU-CHEK FASTCLIX .. 54 ACCU-CHEK NANO .......... 55 ACCU-CHEK SAFE-T-PRO .......................................... 55 ACCU-CHEK SMARTVIEW CONTRL SOL ................. 55 ACCU-CHEK SMARTVIEW TEST STRIP .................... 51 ACCU-CHEK SOFTCLIX LANCET DEV ................. 55 ACCU-CHEK SOFTCLIX LANCETS ........................ 55
ACCU-CHEK VOICEMATE .......................................... 55 ACCUPRIL .......................... 30 ACCURETIC ....................... 30 ACCUTREND GLUCOSE .. 51 ACCUTREND GLUCOSE CONTROL ....................... 55 acebutolol ............................. 30 ACEON ................................ 30 acetaminophen-caffdihydrocod ........................ 20 acetaminophen-codeine ........ 20 acetasol hc ............................ 50 acetazolamide ....................... 88 acetic acid ............................. 50 acetic acid-aluminum acetate50 acetylcysteine ....................... 92 ACIPHEX ............................. 74 ACIPHEX SPRINKLE......... 74 acitretin ................................. 38 ACTEMRA .......................... 80 ACTHAR H.P. ..................... 50 ACTHIB (PF) ....................... 78 ACTICLATE .......................... 9 ACTIGALL .......................... 71 ACTI-LANCE LANCETS ... 55 ACTIMMUNE ..................... 78 ACTIQ .................................. 20 ACTIVE FE .......................... 97 ACTIVE OB ......................... 97 ACTIVELLA........................ 81 ACTIVE-PAC ...................... 15 ACTONEL ..................... 47, 80 ACTOPLUS MET ................ 68 ACTOPLUS MET XR ......... 68 ACTOS ................................. 68 acuicyn.................................. 87 ACULAR.............................. 88 ACULAR LS ........................ 88 ACUVAIL (PF) .................... 88 acyclovir ........................... 3, 44 ACZONE .............................. 41 ADACEL(TDAP ADOLESN/ADULT)(PF) 78 ADAGEN ............................. 47 ADALAT CC ....................... 30 111
adapalene ..............................41 ADAPALENE ......................41 ADASUVE ...........................25 ADCETRIS...........................11 ADCIRCA ............................92 ADDERALL.........................25 ADDERALL XR ..................25 ADDYI .................................25 adefovir ...................................3 ADEMPAS ...........................92 ADJUSTABLE LANCING DEVICE ...........................55 ADRENACLICK .................90 ADRENALIN .......................92 adrucil ...................................11 ADVAIR DISKUS ...............92 ADVAIR HFA......................92 ADVANCED ALLERGY COLLECT KIT ................45 ADVANCED GLUC METER TEST STRIP .....................51 ADVANCED GLUCOSE METER.............................55 ADVANCED LANCING DEVICE ...........................55 ADVANCED TRAVEL LANCETS ........................55 ADVATE ..............................34 ADVOCATE BLOOD GLUCOSE MONITOR ....55 ADVOCATE DUO ..............55 ADVOCATE LANCET .......55 ADVOCATE LOW CONTROL .......................55 ADVOCATE PEN NEEDLES ..........................................55 ADVOCATE RAPID-SAFE LANCING ........................55 ADVOCATE REDI-CODE..51 ADVOCATE REDI-CODE DUO METER ...................55 ADVOCATE REDI-CODE GLU MONITOR ..............55 ADVOCATE REDI-CODE+ CTRL LOW ......................55 ADVOCATE TEST STRIPS 51
ADYNOVATE ..................... 34 ADZENYS XR-ODT ........... 25 AEROSPAN ......................... 92 afeditab cr ............................. 30 AFINITOR ........................... 11 AFINITOR DISPERZ .......... 11 AFLURIA 2016-2017 .......... 78 AFLURIA 2016-2017 (PF) .. 78 AFLURIA QUAD 2016-2017 (PF) ................................... 78 AFREZZA ............................ 66 AFSTYLA ............................ 34 AFTERA .............................. 83 AGAMATRIX AMP GLUC MONITOR SYS ............... 55 AGAMATRIX AMP TEST STRIPS ............................. 51 AGAMATRIX CONTROL HIGH ................................ 55 AGGRENOX ....................... 34 AGRYLIN ............................ 47 AKTEN (PF) ........................ 87 AKYNZEO........................... 71 ALA-SCALP ........................ 45 ALBENZA ............................. 6 albuterol sulfate .................... 92 ALCAINE ............................ 87 alclometasone ....................... 45 ALDACTAZIDE .................. 30 ALDACTONE ..................... 30 ALDARA ............................. 78 ALDURAZYME .................. 67 ALECENSA ......................... 11 alendronate ..................... 47, 80 ALEVICYN ANTIPRURITIC .......................................... 39 ALEVICYN ANTIPRURITIC SG ..................................... 39 ALFERON N........................ 78 alfuzosin ............................... 94 ALINIA .................................. 6 ALKERAN ........................... 11 allopurinol ............................ 80 ALLZITAL........................... 20 almotriptan malate ................ 18 ALOCRIL............................. 87 ALOGLIPTIN ...................... 68 ALOGLIPTIN-METFORMIN .......................................... 68
ALOGLIPTINPIOGLITAZONE ............. 68 ALOMIDE............................ 88 alophen ................................. 71 ALORA ................................ 81 alosetron ............................... 71 ALOXI.................................. 71 ALPHAGAN P ..................... 89 ALPHANATE ...................... 34 ALPHANINE SD ................. 34 alprazolam ............................ 25 alprazolam intensol............... 25 ALPROLIX .......................... 34 ALREX ................................. 89 ALSUMA ............................. 18 ALTABAX ........................... 43 altacaine ................................ 88 ALTACE .............................. 30 altafluor ................................ 88 altavera (28) .......................... 83 ALTERNATE SITE LANCET .......................................... 55 ALTERNATE SITE LANCING DEVICE ........ 55 ALTOPREV ......................... 36 ALVESCO............................ 92 alyacen 1/35 (28) .................. 83 alyacen 7/7/7 (28) ................. 83 amabelz ................................. 81 amantadine hcl ........................ 3 AMARYL............................. 68 AMBIEN .............................. 25 AMBIEN CR ........................ 25 AMBISOME .......................... 3 amcinonide ........................... 45 AMELUZ ............................. 39 AMERGE ............................. 18 amethia ................................. 83 amethia lo ............................. 83 amethyst................................ 83 AMICAR .............................. 34 amifostine crystalline ........... 10 amikacin ................................. 6 amiloride............................... 30 amiloride-hydrochlorothiazide .......................................... 30 amiodarone ........................... 30 AMITIZA ............................. 71 amitriptyline ......................... 25 112
amitriptyline-chlordiazepoxide ..........................................25 amlodipine ............................30 amlodipine-atorvastatin ........36 amlodipine-benazepril ..........30 amlodipine-valsartan ............30 amlodipine-valsartan-hcthiazid ..........................................31 AMMONIUM CHLORIDE .95 AMMONUL .........................47 amoxapine.............................25 amoxicil-clarithromy-lansopraz ..........................................74 amoxicillin ..............................8 amoxicillin-pot clavulanate ....8 AMPHADASE .....................47 amphotericin b ........................3 ampicillin ................................8 ampicillin sodium ...................8 ampicillin-sulbactam ..............8 AMPYRA .............................18 AMRIX .................................19 ANADROL-50 .....................67 ANAFRANIL .......................25 anagrelide .............................47 ANALPRAM E ....................71 ANALPRAM-HC ...........38, 71 ANALPRAM-HC SINGLES71 ANAPROX DS .....................22 anaspaz .................................70 anastrozole ............................11 ANCOBON ............................3 ANDRODERM ....................67 ANDROGEL ........................67 ANDROID ............................67 androxy .................................67 ANGELIQ ............................81 ANIMI-3 WITH VITAMIN D ..........................................97 ANORO ELLIPTA ...............92 ANTABUSE .........................47 ANTARA .............................36 anucort-hc .............................71 ANUSOL-HC .................45, 71 ANZEMET ...........................71 apexicon e .............................45 APIDRA ...............................66 APIDRA SOLOSTAR..........66 APLENZIN...........................25 APOKYN .............................17
apraclonidine ........................ 90 apri........................................ 83 APRISO ................................ 71 APTENSIO XR .................... 25 APTIOM............................... 15 APTIVUS ............................... 3 AQUA GLYCOLIC HC....... 45 AQUA LANCE LANCING DEVICE ........................... 55 ARALAST NP ..................... 47 aranelle (28).......................... 83 ARANESP (IN POLYSORBATE) ............ 76 ARAVA................................ 80 arbinoxa ................................ 90 ARCALYST ......................... 78 ARCAPTA NEOHALER..... 92 ARESTIN ............................. 49 ARGATROBAN .................. 34 ARGATROBAN IN 0.9 % SOD CHLOR ................... 34 ARGATROBAN IN NACL (ISO-OS) .......................... 34 ARICEPT ............................. 18 ARIMIDEX .......................... 11 aripiprazole ........................... 25 ARISTADA .......................... 25 ARIXTRA ............................ 34 armodafinil ........................... 25 ARMOUR THYROID ......... 70 ARNUITY ELLIPTA ........... 92 AROMASIN......................... 11 ARRANON .......................... 11 ARTHROTEC 50 ................. 22 ARTHROTEC 75 ................. 22 ARZERRA ........................... 11 ASACOL HD ....................... 71 ascomp with codeine ............ 20 ashlyna .................................. 83 ASMANEX HFA ................. 92 ASMANEX TWISTHALER 92 aspir-81 ................................. 22 aspirin ................................... 23 aspirin low dose.................... 23 aspirin-caffeine-dihydrocodein .......................................... 20 aspirin-dipyridamole ............ 34 aspir-low ............................... 23 aspir-trin ............................... 23
ASSURE 4 CONTROL SOLUTION ...................... 55 ASSURE 4 STRIPS.............. 51 ASSURE DOSE NORMAL CONTROL ....................... 55 ASSURE HAEMOLANCE PLUS ................................ 55 ASSURE LANCE ................ 55 ASSURE LANCE PLUS...... 55 ASSURE PLATINUM ... 51, 56 ASSURE PRISM CONTROL 1-2 SOLN ......................... 56 ASSURE PRISM MULTI METER ............................ 56 ASSURE PRISM MULTI STRIP ............................... 51 ASTAGRAF XL................... 11 ASTEPRO ............................ 49 ASTERO .............................. 43 ATABEX EC ........................ 97 ATACAND .......................... 31 ATACAND HCT ................. 31 ATELVIA ............................. 80 atenolol ................................. 31 atenolol-chlorthalidone ......... 31 ATGAM ............................... 78 ATIVAN ............................... 25 ATOPICLAIR ...................... 39 atorvastatin ........................... 36 atovaquone.............................. 6 atovaquone-proguanil ............. 6 ATRALIN ............................ 41 ATRAPRO CP ..................... 39 ATRAPRO HYDROGEL .... 39 ATRIPLA ............................... 3 atropine ........................... 70, 87 ATROVENT HFA ............... 92 AUBAGIO............................ 77 aubra ..................................... 83 AUGMENTIN .................... 8, 9 AUGMENTIN ES-600 ........... 8 AUGMENTIN XR ................. 9 AURYXIA............................ 71 AUTOJECT 2 INJECTION DEVICE ........................... 56 AUTO-LANCET MINI ........ 56 AUTOLET IMPRESSION LANC DEV ...................... 56 AUTOLET LANCING DEVICE ........................... 56 113
AUTOLET PLUS LANCING DEVICE ...........................56 AVALIDE ............................31 AVANDIA ...........................68 AVAPRO ..............................31 avar .......................................41 AVAR ...................................41 AVAR LS .............................41 AVAR-E GREEN .................41 AVAR-E LS .........................41 AVASTIN.............................11 AVC VAGINAL ..................82 AVEED.................................67 AVELOX ................................9 AVELOX ABC PACK ...........9 AVENOVA ..........................88 aviane ....................................83 avidoxy ...................................9 AVIDOXY DK .......................9 avita ......................................41 AVITA ..................................41 avo cream..............................39 AVODART...........................94 AVONEX .............................77 AVONEX (WITH ALBUMIN) ..........................................77 AVYCAZ ...............................5 AXERT .................................18 AXIRON...............................67 AYGESTIN ..........................81 azacitidine .............................11 AZASAN ..............................11 AZASITE .............................86 azathioprine ..........................11 azelastine ........................49, 88 AZELEX...............................41 AZILECT .............................17 azithromycin ...........................6 AZOPT .................................88 AZOR ...................................31 AZULFIDINE ......................71 AZULFIDINE EN-TABS ....71 azuphen mb ...........................95 azurette (28) ..........................83 B b complete ............................97 b complex-vitamin b12 .........97 b complex-vitamin c-folic acid ..........................................97 B-12 COMPLIANCE ...........97
b-50 complex ........................ 97 bacitracin .............................. 86 bacitracin-polymyxin b ........ 86 baclofen ................................ 19 BACMIN .............................. 97 BACTRIM .............................. 9 BACTRIM DS........................ 9 BACTROBAN ..................... 43 BACTROBAN NASAL ....... 49 balanced b-100 ..................... 97 balanced b-100 complex....... 97 balanced b-50 ....................... 97 bal-care dha .......................... 97 BAL-CARE DHA ESSENTIAL..................... 97 balsalazide ............................ 71 balziva (28)........................... 83 BANZEL .............................. 15 BARACLUDE ....................... 4 BCG VACCINE, LIVE (PF) 78 b-complex with vitamin c ..... 97 BD AUTOSHIELD PEN NEEDLE .......................... 56 BD INSULIN PEN NEEDLE UF SHORT ....................... 56 BD LANCET DEVICE ........ 56 BD MICROTAINER LANCET .......................... 56 bd pre-filled normal saline ... 47 BD ULTRA FINE LANCETS .......................................... 56 BD ULTRA-FINE NANO PEN NEEDLES................ 56 BEBULIN............................. 34 BECONASE AQ .................. 92 bekyree (28).......................... 83 BELBUCA ........................... 20 BELEODAQ ........................ 11 belladonna alkaloids-opium . 70 belladonna-opium ................. 70 BELSOMRA ........................ 25 benazepril ............................. 31 benazepril-hydrochlorothiazide .......................................... 31 BENDEKA ........................... 11 BENEFIX ............................. 34 BENICAR ............................ 31 BENICAR HCT ................... 31 BENLYSTA ......................... 80 BENSAL HP ........................ 39
BENTYL .............................. 70 BENZACLIN ....................... 41 BENZACLIN PUMP ........... 41 BENZAMYCIN ................... 41 BENZEFOAM...................... 41 BENZEFOAM ULTRA ....... 41 benzepro ............................... 41 BENZODOX 30 ..................... 9 BENZODOX 60 ..................... 9 benzonatate ........................... 90 benzoyl peroxide .................. 41 benztropine ........................... 17 BEPREVE ............................ 88 BERINERT .......................... 92 BESIVANCE........................ 86 BETADINE OPHTHALMIC PREP ................................ 86 BETAGAN ........................... 87 betamethasone dipropionate . 45 betamethasone valerate......... 45 betamethasone, augmented ... 45 BETAPACE ......................... 30 BETAPACE AF ................... 30 BETASERON ...................... 77 betaxolol ......................... 31, 87 bethanechol chloride............. 95 BETHKIS ............................... 6 BETIMOL ............................ 87 BETOPTIC S ........................ 87 BEVESPI AEROSPHERE ... 92 bexarotene ............................ 11 BEYAZ ................................. 83 BIAFINE EMULSION......... 39 BIAXIN .................................. 6 bicalutamide ......................... 11 BICILLIN C-R ....................... 9 BICNU.................................. 11 BIDIL ................................... 31 BIFERA RX ......................... 97 BILTRICIDE .......................... 6 bimatoprost ........................... 88 BINOSTO ............................. 80 BIONIME RIGHTEST GM300 SYSTEM ............. 56 BIONIME RIGHTEST TEST STRIPS ............................. 51 bisacodyl ............................... 71 bisa-lax ................................. 71 bisoprolol fumarate............... 31 114
bisoprolol-hydrochlorothiazide ..........................................31 BIVIGAM.............................78 bleo 15k ................................ 11 bleomycin .............................11 BLEPH-10 ............................89 BLEPHAMIDE ....................89 BLEPHAMIDE S.O.P. .........89 blisovi 24 fe ..........................83 blisovi fe 1.5/30 (28) ............83 blisovi fe 1/20 (28) ...............83 BLOOD GLUCOSE CONTROL, NORMAL ....56 BLOOD GLUCOSE TEST ..51 BLOOD-GLUCOSE METER ..........................................56 BONIVA...............................80 BOOSTRIX TDAP ...............78 BOSULIF .............................11 bp 10-1 ..................................41 bp-50% urea..........................39 bpo ........................................41 BREEZE 2 CONTROL SOLUTION,HIGH ...........56 BREEZE 2 TEST STRIPS ...51 BREO ELLIPTA ..................92 BREVIBLOC .......................31 BREVIBLOC IN NACL (ISOOSM) ................................ 31 BREVICON (28) ..................83 BRIDION .............................19 briellyn ..................................83 BRILINTA ...........................34 brimonidine...........................90 BRISDELLE.........................25 BRIVIACT ...........................15 BROMFED DM ...................90 bromfenac .............................88 bromocriptine .......................17 brompheniramine-pseudoephdm .....................................90 BROMSITE ..........................88 BROVANA ..........................92 BUCALSEP ..........................43 budesonide ......................71, 92 BULLSEYE MINI SAFETY LANCETS ........................56 bumetanide ...........................31 BUNAVAIL .........................23 BUPAP .................................20
BUPHENYL......................... 47 buprenorphine hcl ................. 20 buprenorphine-naloxone....... 23 bupropion hcl........................ 25 bupropion hcl (smoking deter) .......................................... 48 buspirone .............................. 25 BUSULFEX ......................... 11 butalbital compound w/codeine .......................................... 20 butalbital-acetaminop-caf-cod .......................................... 20 butalbital-acetaminophen ..... 20 butalbital-acetaminophen-caff .......................................... 20 butalbital-aspirin-caffeine .... 20 BUTISOL ............................. 25 butorphanol tartrate .............. 23 BUTRANS ........................... 20 BYDUREON ........................ 68 BYETTA .............................. 68 BYSTOLIC .......................... 31 BYVALSON ........................ 31 C cabergoline ........................... 67 CABOMETYX..................... 11 CADEAU DHA.................... 97 CADUET .............................. 36 CAFERGOT ......................... 18 caffeine citrated .................... 47 CALAN ................................ 31 CALAN SR .......................... 31 calcipotriene ......................... 38 calcipotriene-betamethasone 38 calcitonin (salmon) ............... 67 calcitrene .............................. 38 calcitriol .......................... 38, 67 calcium 500 + d .................... 96 calcium 500 with d ............... 96 calcium 600 + d(3) ............... 96 calcium 600 with vitamin d3 96 calcium acetate ..................... 71 calcium carb and citrate-vitd3 .......................................... 96 calcium carbonate-vitamin d3 .......................................... 96 calcium citrate + d ................ 96 calcium citrate-vitamin d2 .... 96 calcium citrate-vitamin d3 .... 96
CALCIUM GLUCONATE IN 0.9% NACL ...................... 96 calcium pnv .......................... 97 calcium with vitamin d ......... 96 calcium-folic acid-vitamin d 97 CAMBIA .............................. 23 camila ................................... 81 CAMPATH .......................... 11 CAMPTOSAR...................... 11 camrese ................................. 83 camrese lo ............................. 83 CANASA.............................. 71 CANCIDAS............................ 3 candesartan ........................... 31 candesartan-hydrochlorothiazid .......................................... 31 capacet .................................. 20 CAPASTAT ........................... 6 CAPCOF .............................. 90 capecitabine .......................... 11 CAPEX ................................. 45 CAPITAL WITH CODEINE .......................................... 20 CAPRELSA.......................... 11 captopril ................................ 31 captopril-hydrochlorothiazide .......................................... 31 CAPXIB ............................... 23 CARAC ................................ 39 carafate ................................. 74 CARAFATE ......................... 75 CARBAGLU ........................ 47 carbamazepine ...................... 15 CARBATROL ...................... 15 carbidopa .............................. 17 carbidopa-levodopa .............. 17 carbidopa-levodopaentacapone ........................ 17 carbinoxamine maleate ......... 90 carboplatin ............................ 11 CARDENE IV ...................... 31 CARDENE IV IN DEXTROSE ..................... 31 CARDENE IV IN SODIUM CHLORIDE ...................... 31 CARDIZEM ......................... 31 CARDIZEM CD................... 31 CARDIZEM LA ................... 31 CARDURA .......................... 31 CARDURA XL .................... 31 115
CAREFINE PEN NEEDLE .56 CAREONE THIN LANCET 56 CARESENS CONTROL A NORMAL .........................56 CARESENS N ......................56 CARESENS N TEST STRIPS ..........................................51 CARESENS N VOICE.........56 CARIMUNE NF NANOFILTERED ............78 carisoprodol ..........................19 carisoprodol-asa-codeine ......19 carisoprodol-aspirin ..............19 CARNITOR ..........................47 CARNITOR (SUGAR-FREE) ..........................................47 carteolol ................................ 87 carvedilol ..............................31 CASODEX ...........................11 CATAPRES ..........................31 CATAPRES-TTS-1 ..............31 CATAPRES-TTS-2 ..............31 CATAPRES-TTS-3 ..............31 CAYA CONTOURED .........81 CAYSTON .............................6 caziant (28) ...........................83 CEDAX ..................................5 cefaclor ...................................5 cefadroxil ................................5 cefazolin .................................5 CEFAZOLIN IN 0.9% SOD CHLORIDE ........................5 cefazolin in dextrose (iso-os)..5 CEFAZOLIN IN DEXTROSE (ISO-OS).............................5 cefdinir ....................................5 cefditoren pivoxil....................5 cefepime .................................5 cefepime in dextrose,iso-osm .5 cefixime ..................................5 CEFOTAN ..............................5 cefotaxime ..............................5 cefotetan .................................5 cefoxitin ..................................5 cefpodoxime ...........................5 cefprozil ..................................5 ceftibuten ................................5 CEFTIN ..................................6 ceftriaxone ..............................6 CEFTRIAXONE ....................6
ceftriaxone in dextrose,iso-os . 6 cefuroxime axetil .................... 6 cefuroxime sodium ................. 6 celacyn .................................. 40 CELEBREX ......................... 23 celecoxib............................... 23 CELEXA .............................. 25 CELLCEPT .......................... 11 CELLCEPT INTRAVENOUS .......................................... 11 CELONTIN .......................... 15 cem-urea ............................... 40 CENTANY ........................... 44 CENTANY AT .................... 44 centergy ................................ 90 centratex ............................... 97 cephalexin............................... 6 CEPROTIN (BLUE BAR) ... 35 CEPROTIN (GREEN BAR) 35 CERACADE ........................ 40 CERAMAX .......................... 40 CERDELGA......................... 67 CEREZYME ........................ 67 CERVIDIL ........................... 82 CESAMET ........................... 71 cetirizine ............................... 90 CETRAXAL......................... 50 cevimeline ............................ 47 CHANTIX ............................ 48 CHANTIX CONTINUING MONTH BOX .................. 48 CHANTIX STARTING MONTH BOX .................. 49 chateal................................... 83 CHEMET ............................. 47 CHENODAL ........................ 71 cheratussin ac ....................... 90 cheratussin dac ..................... 90 chewable multivit-a,b,d,e,k,zn .......................................... 97 children's aspirin................... 23 children's iron ....................... 97 chloramphenicol sod succinate ............................................ 6 chlordiazepoxide hcl ............ 25 chlordiazepoxide-clidinium .. 70 chlorhexidine gluconate ....... 49 chloroquine phosphate............ 6 chlorothiazide ....................... 31 chlorothiazide sodium .......... 31
chlorpromazine ..................... 25 chlorpropamide ..................... 68 chlorthalidone ....................... 31 chlorzoxazone....................... 19 CHOLBAM .......................... 71 cholecalciferol (vitamin d3) . 97 cholestyramine (with sugar) . 36 cholestyramine light ............. 36 choline,magnesium salicylate .......................................... 23 CIALIS ................................. 94 ciclodan ................................ 44 CICLODAN KIT .................. 44 ciclopirox .............................. 44 ciclopirox-ure-camph-mentheuc .................................... 44 cidofovir ................................. 4 ciferex ................................... 97 cilostazol............................... 35 CILOXAN ............................ 86 cimetidine ............................. 75 cimetidine hcl ....................... 75 CIMZIA ................................ 71 CIMZIA POWDER FOR RECONST ........................ 71 CINRYZE ............................. 92 CIPRO .................................... 9 CIPRO HC ............................ 50 CIPRO XR .............................. 9 CIPRODEX .......................... 50 ciprofloxacin ........................... 9 ciprofloxacin (mixture)........... 9 ciprofloxacin hcl ......... 9, 50, 86 cisplatin ................................ 11 citalopram ............................. 25 CITRANATAL (DUALIRON) ............................... 97 CITRANATAL 90 DHA (ALGAL OIL) .................. 97 CITRANATAL ASSURE .... 97 CITRANATAL B-CALM (FE GLUC) .............................. 97 CITRANATAL DHA (ALGAL OIL) .................. 97 CITRANATAL HARMONY (IRON FUM) .................... 97 citrate of magnesia................ 71 citroma .................................. 71 citrus calcium ....................... 96 cladribine .............................. 11 116
CLAFORAN...........................6 CLAFORAN IN DEXTROSE(ISO-OSM) ....6 claravis ..................................41 CLARINEX ..........................90 CLARINEX-D 12 HOUR ....90 clarithromycin.........................6 classic prenatal......................97 cleansing wash ......................42 clearlax .................................71 clemastine .............................90 CLEO 90 INFUSION SET 24 ..........................................56 cleocin.....................................7 CLEOCIN .....................6, 7, 82 CLEOCIN T .........................42 CLEVER CHEK BLOOD GLUCOSE ........................56 CLEVER CHEK LANCETS 56 CLEVER CHOICE GLUCOSE MONITOR ....56 CLEVER CHOICE LEVEL 2 CONTROL .......................56 CLEVER CHOICE MICRO.56 CLEVER CHOICE MICRO TEST STRIP .....................51 CLEVER CHOICE PRO 51, 56 CLEVER CHOICE TEST STRIPS .............................51 CLEVER CHOICE VOICE+ TEST.................................51 CLICKFINE .........................56 CLIMARA ............................81 CLIMARA PRO ...................81 CLIN SINGLE USE ...............7 CLINDACIN ETZ ................42 clindacin p ............................42 CLINDACIN PAC ...............42 CLINDAGEL .......................42 clindamycin hcl ......................7 clindamycin palmitate hcl.......7 clindamycin pediatric .............7 clindamycin phosphate ....7, 42, 82 clindamycin-benzoyl peroxide ..........................................42 clindamycin-tretinoin ...........42 CLINDESSE.........................82 CLINPRO 5000 ....................49 clobetasol ..............................45
clobetasol-emollient ............. 45 CLOBEX .............................. 45 CLOCORTOLONE PIVALATE ...................... 45 clodan ................................... 45 CLODAN KIT...................... 45 CLODERM .......................... 45 CLOLAR .............................. 11 clomipramine........................ 25 clonazepam ........................... 15 clonidine ............................... 31 clonidine hcl ................... 25, 31 clopidogrel ............................ 35 clorazepate dipotassium ....... 25 clorpres ................................. 31 CLORPRES.......................... 31 clotrimazole ............................ 3 clotrimazole-betamethasone . 44 clozapine......................... 25, 26 CLOZAPINE ........................ 26 CLOZARIL .......................... 26 c-nate dha ............................. 97 CNL 8 NAIL ........................ 44 COAGADEX ....................... 35 COAGUCHEK LANCETS .. 57 COAL TAR .......................... 38 COARTEM ............................ 7 codeine sulfate ...................... 20 codeine-butalbital-asa-caff ... 20 codeine-guaifenesin .............. 90 COLAZAL ........................... 71 COLCHICINE ...................... 80 COLCRYS ........................... 80 COLESTID........................... 36 COLESTID FLAVORED .... 36 colestipol .............................. 36 colistin (colistimethate na) ..... 7 colocort ................................. 71 COLOR LANCETS ............. 57 COLY-MYCIN M PARENTERAL .................. 7 COLY-MYCIN S ................. 50 COLYTE WITH FLAVOR PACKS ............................. 71 COMBIGAN ........................ 88 COMBIPATCH .................... 81 COMBIVENT RESPIMAT . 92 COMBIVIR ............................ 4 COMETRIQ ......................... 11
COMFORT EZ PEN NEEDLES ........................ 57 COMFORT LANCETS ........ 57 COMFORT SHORT INSULIN PUMP 23 .......................... 57 COMPAZINE ....................... 71 COMPLERA .......................... 4 COMPLETE FORMULATION D3000 . 97 COMPLETE FORMULATION PEDIATRIC ..................... 98 complete natal dha ................ 98 completenate ......................... 98 complex b-100 ...................... 98 compro .................................. 71 COMTAN............................. 17 CONCEPT DHA .................. 98 CONCEPT OB ..................... 98 CONCEPTROL .................... 82 CONCERTA ........................ 26 CONDYLOX........................ 40 constulose ............................. 71 CONTOUR CONTROL SOLUTION, NML ........... 57 CONTOUR LINK ................ 57 CONTOUR NEXT EZ METER ............................ 57 CONTOUR NEXT LEV 2 CONTROL SOL............... 57 CONTOUR NEXT LINK .... 57 CONTOUR NEXT METER 57 CONTOUR NEXT STRIPS . 51 CONTOUR NEXT USB METER ............................ 57 CONTOUR TEST STRIPS .. 51 CONTROL AST MONITORING SYSTEM 57 CONTROL AST TEST ........ 51 CONZIP................................ 23 COOL BLOOD GLUCOSE METER ............................ 57 COOL CONTROL A SOLUTION ...................... 57 COOL GLUCOSE TEST STRIP ............................... 51 COPAXONE ........................ 77 COPEGUS ............................ 77 CORDRAN .......................... 45 117
CORDRAN TAPE LARGE ROLL ................................ 45 COREG.................................31 COREG CR ..........................31 CORGARD...........................31 CORIFACT ..........................35 CORLANOR ........................37 cormax ..................................45 CORTANE-B .......................40 CORTEF ...............................50 CORTENEMA .....................71 CORTIFOAM.......................71 cortisone ...............................50 CORTISPORIN ....................44 CORTROSYN ......................50 corvita ...................................98 corvita 150 ............................98 CORVITE .............................98 CORVITE 150 ......................98 CORVITE FE .......................98 CORVITE FREE ..................98 CORZIDE .............................31 COSENTYX .........................38 COSENTYX (2 SYRINGES) ..........................................38 COSENTYX PEN ................38 COSENTYX PEN (2 PENS) 38 COSMEGEN ........................11 COSOPT ...............................88 COSOPT (PF) .......................89 cosyntropin ...........................50 COTELLIC ...........................11 COUMADIN ........................35 covaryx .................................81 covaryx h.s. ...........................81 COZAAR ..............................32 CREON.................................71 CRESEMBA...........................3 CRESTOR ............................36 CRINONE ............................81 CRIXIVAN.............................4 cromolyn ...................71, 88, 92 cryselle (28) ..........................83 CUBICIN ................................7 CUBICIN RF ..........................7 CUPRIMINE ........................80 CUROSURF .........................92 CUTIVATE ..........................45 CUVITRU ............................78 CUVPOSA ...........................70
cyanocobalamin (vitamin b-12) .......................................... 98 cyclafem 1/35 (28) ............... 83 cyclafem 7/7/7 (28) .............. 83 CYCLESSA (28) .................. 83 cyclobenzaprine .................... 19 CYCLOGYL ........................ 87 CYCLOMYDRIL................. 90 cyclopentolate....................... 87 cyclophosphamide ................ 12 CYCLOPHOSPHAMIDE .... 12 CYCLOSERINE .................... 7 CYCLOSET ......................... 68 cyclosporine ......................... 12 cyclosporine modified .......... 12 CYMBALTA ....................... 26 cyproheptadine ..................... 90 CYRAMZA .......................... 12 cyred ..................................... 83 CYSTADANE ...................... 71 CYSTAGON ........................ 95 CYSTARAN ........................ 88 cytarabine ............................. 12 cytarabine (pf) ...................... 12 CYTOMEL........................... 70 CYTOTEC ........................... 75 cytra k crystals ...................... 95 cytra-2................................... 95 cytra-3................................... 95 cytra-k................................... 95 D D.H.E.45 ............................... 18 dacarbazine ........................... 12 DACOGEN .......................... 12 DAKLINZA ........................... 4 DALIRESP ........................... 92 danazol ................................. 67 DANTRIUM ........................ 19 dantrolene ............................. 19 dapsone ................................... 7 daptomycin ............................. 7 DARAPRIM ........................... 7 darifenacin ............................ 94 DARZALEX ........................ 12 dasetta 1/35 (28) ................... 83 dasetta 7/7/7 (28) .................. 83 daunorubicin ......................... 12 DAYPRO ............................. 23 daysee ................................... 83 DAYTRANA ....................... 26
DDAVP ................................ 67 DEBACTEROL.................... 49 deblitane ............................... 81 decitabine.............................. 12 DELESTROGEN ................. 81 delta d3 ................................. 98 deltasone ............................... 50 delyla (28)............................. 83 DELZICOL .......................... 71 DEMADEX .......................... 32 demeclocycline ....................... 9 DEMEROL........................... 20 DEMSER .............................. 32 DENAVIR ............................ 44 denta 5000 plus ..................... 49 dentagel ................................ 49 DEPACON ........................... 15 DEPAKENE ......................... 15 DEPAKOTE ......................... 15 DEPAKOTE ER ................... 15 DEPAKOTE SPRINKLES .. 15 DEPEN TITRATABS .......... 80 DEPO-ESTRADIOL ............ 81 DEPO-PROVERA................ 81 DEPO-SUBQ PROVERA 104 .......................................... 81 DEPO-TESTOSTERONE .... 67 DERMACINRX LEXITRAL .......................................... 23 dermacinrx prizopak ............. 43 DERMACINRX PUREFOLIX .......................................... 98 DERMACINRX SILAPAK . 45 DERMACINRX SILAZONE .......................................... 45 DERMACINRX THERAZOLE PAK ......... 44 DERMA-SMOOTHE/FS BODY OIL ....................... 45 DERMA-SMOOTHE/FS SCALP OIL ...................... 45 DERMASORB HC COMPLETE KIT ............. 45 DERMASORB TA COMPLETE KIT ............. 45 DERMASORB XM COMPLETE KIT ............. 40 DERMATOP ........................ 45 DERMAWERX SDS ........... 45 DERMAZONE ..................... 45 118
DERMOTIC OIL..................50 DESCOVY .............................4 desipramine...........................26 desloratadine .........................90 desmopressin ........................67 desog-e.estradiol/e.estradiol .83 DESOGEN ...........................83 desogestrel-ethinyl estradiol .84 DESONATE .........................45 desonide ................................ 45 DESOWEN...........................45 desoximetasone.....................45 DESOXYN ...........................26 DESVENLAFAXINE ..........26 DESVENLAFAXINE FUMARATE ....................26 DETROL ..............................94 DETROL LA ........................94 dexamethasone .....................50 dexamethasone intensol ........50 dexamethasone sodium phosphate ..........................89 DEXCOM G5 RECEIVER ..57 dexedrine ..............................26 DEXEDRINE SPANSULE ..26 DEXILANT ..........................75 dexmethylphenidate ..............26 DEXPAK 10 DAY ...............50 DEXPAK 13 DAY ...............50 DEXPAK 6 DAY .................50 dexrazoxane hcl ....................10 dextroamphetamine ..............26 dextroamphetamineamphetamine.....................26 dialyvite ................................ 98 DIALYVITE 3000................98 DIALYVITE 5000................98 dialyvite 800 .........................98 DIALYVITE 800 WITH IRON ..........................................98 DIALYVITE SUPREME D .98 DIAMOX SEQUELS ...........88 DIASTAT .............................15 DIASTAT ACUDIAL ..........15 DIATRUE CONTROL SOLN NORMAL .........................57 DIATRUE PLUS BLOOD GLUCOSE MET ..............57 DIATRUE PLUS TEST STRIP ..........................................51
diazepam......................... 15, 26 diazepam intensol ................. 26 DIBENZYLINE ................... 32 DICLEGIS ............................ 71 diclofenac potassium ............ 23 diclofenac sodium .... 23, 40, 88 diclofenac-misoprostol ......... 23 DICLOTRAL ....................... 23 dicloxacillin ............................ 9 DICLOZOR .......................... 23 dicyclomine .......................... 70 didanosine............................... 4 DIFFERIN ............................ 42 DIFICID ................................. 6 diflorasone ............................ 45 DIFLUCAN ............................ 3 diflunisal ............................... 23 digitek ................................... 34 digox ..................................... 34 digoxin.................................. 34 dihydroergotamine ............... 18 DILANTIN ........................... 15 DILANTIN EXTENDED .... 16 DILANTIN INFATABS ...... 16 DILANTIN-125 ................... 16 DILATRATE-SR ................. 37 DILAUDID .......................... 20 diltiazem ............................... 32 DIOVAN .............................. 32 DIOVAN HCT ..................... 32 DIPENTUM ......................... 71 diphenhydramine hcl ............ 90 diphenoxylate-atropine ......... 70 DIPROLENE ........................ 45 DIPROLENE AF.................. 45 dipyridamole......................... 35 DISALCID ........................... 23 diskets ................................... 20 disopyramide phosphate ....... 30 disulfiram ............................. 47 DITROPAN XL ................... 94 DIURIL ................................ 32 DIURIL IV ........................... 32 divalproex ............................. 16 DIVIGEL .............................. 81 DOCEFREZ ......................... 12 docetaxel............................... 12 dofetilide............................... 30 DOLOPHINE ....................... 20 donepezil ........................ 18, 19
DONNATAL ........................ 70 DORAL ................................ 26 DORIBAX .............................. 7 DORYX .................................. 9 DORYX MPC ........................ 9 dorzolamide .......................... 89 dorzolamide-timolol ............. 89 dothelle dha .......................... 98 DOVONEX .......................... 38 doxazosin .............................. 32 doxepin ........................... 26, 40 doxercalciferol ...................... 67 DOXIL.................................. 12 doxorubicin........................... 12 doxorubicin, peg-liposomal .. 12 doxycycline hyclate ................ 9 doxycycline monohydrate 9, 10 DOXYCYCLINE MONOHYDRATE ............. 9 drithocreme hp ...................... 38 dronabinol ............................. 71 DROPLET LANCETS ......... 57 DROPLET LANCING DEVICE ........................... 57 DROPLET PEN NEEDLE ... 57 drospirenone-ethinyl estradiol .......................................... 84 DROXIA .............................. 12 DS PREP PAK ..................... 23 DUAC ................................... 42 DUAVEE.............................. 81 ducodyl ................................. 71 DUET DHA BALANCED ... 98 DUET DHA WITH OMEGA-3 .......................................... 98 DUETACT ........................... 68 DUEXIS ............................... 23 DULERA .............................. 92 duloxetine ............................. 26 DUOPA ................................ 17 DURACHOL ........................ 98 DURAGESIC ....................... 20 DUREZOL ........................... 89 DURLAZA ........................... 35 dutasteride ............................ 94 dutasteride-tamsulosin .......... 94 DUTOPROL......................... 32 d-vi-sol.................................. 98 d-vita..................................... 98 DYANAVEL XR ................. 26 119
DYAZIDE ............................32 DYMISTA ............................92 DYRENIUM.........................32 DYSPORT ............................78 E e.c. prin .................................23 e.e.s. 400 .................................6 E.E.S. GRANULES ................6 EASY CLICK LANCING DEVICE ...........................57 EASY COMFORT LANCETS ..........................................57 EASY COMFORT PEN NEEDLES ........................57 EASY MINI EJECT LANCING DEVICE ........57 EASY PLUS II BLOOD GLUCOSE MET ..............57 EASY PLUS II TEST ...........52 EASY STEP .........................52 EASY STEP BLOOD GLUCOSE METER .........57 EASY TALK BLOOD GLUCOSE METER .........57 EASY TALK GLUCOSE TEST.................................52 EASY TOUCH FLIPLOCK NEEDLE...........................57 EASY TOUCH GLUCOSE MONITOR .......................57 EASY TOUCH HYPODERMIC NEEDLE ..........................................57 EASY TOUCH LANCING DEVICE ...........................57 EASY TOUCH TEST STRIP ..........................................52 EASY TRAK BLOOD GLUCOSE METER .........58 EASY TRAK GLUCOSE TEST.................................52 EASYGLUCO MONITORING SYSTEM 58 EASYGLUCO PLUS .....52, 58 EASYGLUCO PLUS NORMAL CONTROL .....58 EASYGLUCO TEST ...........52 EASYMAX ..........................52 EASYMAX L BLOOD GLUCOSE METER .........58
EASYMAX LOW CONTROL .......................................... 58 EASYMAX NG ................... 58 EASYMAX NORMAL CONTROL ....................... 58 EASYMAX V SPEAKING GLUCOSE SYS ............... 58 EASYMAX V2 BLOOD GLUCOSE METER ......... 58 EC-NAPROSYN .................. 23 econazole .............................. 44 econtra ez.............................. 84 ecotrin ................................... 23 ecotrin low strength .............. 23 ECOZA................................. 44 EDARBI ............................... 32 EDARBYCLOR ................... 32 EDECRIN............................. 32 EDLUAR .............................. 26 ed-spaz .................................. 70 EDURANT ............................. 4 eemt ...................................... 81 eemt hs.................................. 81 effer-k ................................... 96 EFFER-K.............................. 96 EFFEXOR XR...................... 26 EFFIENT .............................. 35 EFUDEX .............................. 40 EGRIFTA ............................. 77 ELAPRASE .......................... 67 ELDEPRYL ......................... 17 ELDERCAPS ....................... 98 ELELYSO ............................ 67 ELEMENT COMPACT GLUCOSE METER ......... 58 ELEMENT COMPACT NORMAL CONTROL..... 58 ELEMENT COMPACT TEST STRIPS ............................. 52 ELEMENT COMPACT V GLUCOSE MTR .............. 58 ELEMENT NORMAL CONTROL ....................... 58 ELEMENT PLUS BLOOD GLUCOSE KIT ................ 58 ELEMENT TEST STRIPS... 52 ELESTAT............................. 88 ELESTRIN ........................... 81 eletone .................................. 40 ELIDEL ................................ 40
ELIGARD ............................ 12 ELIGARD (3 MONTH) ....... 12 ELIGARD (4 MONTH) ....... 12 ELIGARD (6 MONTH) ....... 12 ELIMITE .............................. 46 elinest.................................... 84 eliphos .................................. 72 ELIQUIS .............................. 35 ELITEK ................................ 10 ELIXOPHYLLIN ................. 92 ELLA .................................... 84 ELLENCE ............................ 12 ELMIRON ............................ 95 ELOCON .............................. 45 ELOCTATE ......................... 35 EMADINE............................ 88 EMBEDA ............................. 20 EMBRACE BLOOD GLUCOSE SYSTEM . 52, 58 EMBRACE EVO LEVEL 1 . 58 EMBRACE EVO TEST STRIPS ............................. 52 EMBRACE GLUCOSE CONTROL LOW ............. 58 EMBRACE PRO GLUCOSE METER ............................ 58 EMBRACE PRO TEST STRIPS ............................. 52 EMCYT ................................ 12 EMEND ................................ 72 emoquette ............................. 84 EMPLICITI .......................... 12 EMSAM ............................... 26 EMTRIVA .............................. 4 emulsion sb ........................... 40 EMVERM .............................. 7 ENABLEX ........................... 94 enalapril maleate................... 32 enalapril-hydrochlorothiazide .......................................... 32 ENBRACE HR ..................... 98 ENBREL .............................. 80 ENBREL SURECLICK ....... 80 endocet.................................. 20 ENGERIX-B (PF) ................ 78 ENGERIX-B PEDIATRIC (PF) ................................... 78 enoxaparin ............................ 35 enpresse ................................ 84 enskyce ................................. 84 120
ENSTILAR ...........................38 entacapone ............................17 entecavir .................................4 enteric coated aspirin ............23 ENTOCORT EC ...................72 ENTRESTO ..........................37 ENTTY .................................40 ENTYVIO ............................72 enulose ..................................72 ENVARSUS XR ..................12 EPANED ..............................32 EPCLUSA ..............................4 EPICERAM ..........................40 EPIDUO ...............................42 EPIDUO FORTE ..................42 EPIFOAM.............................38 epinastine ..............................88 epinephrine ...........................90 EPIPEN 2-PAK ....................90 EPIPEN JR 2-PAK ...............90 epirubicin ..............................12 EPISIL ..................................49 EPISNAP ..............................90 epitol .....................................16 EPIVIR ...................................4 EPIVIR HBV ..........................4 eplerenone.............................32 EPOGEN ..............................76 epoprostenol (glycine) ..........32 eprosartan .............................32 EPZICOM...............................4 EQUETRO ...........................16 ERAXIS(WATER DILUENT) ............................................3 ERBITUX .............................12 ergocalciferol (vitamin d2) ...98 ergoloid .................................26 ERIVEDGE ..........................12 errin.......................................81 ERTACZO ............................44 ERWINAZE .........................12 ery pads .................................42 erygel ....................................42 ERYPED 200..........................6 ERYPED 400..........................6 ery-tab .....................................6 ERY-TAB ...............................6 erythrocin (as stearate) ...........6 erythromycin.....................6, 86 erythromycin ethylsuccinate ...6
erythromycin with ethanol ... 42 erythromycin-benzoyl peroxide .......................................... 42 ESBRIET .............................. 92 ESCAVITE........................... 98 ESCAVITE D ....................... 98 ESCAVITE LQ .................... 98 escitalopram oxalate ............. 26 ESGIC .................................. 20 esmolol ................................. 32 esomeprazole magnesium .... 75 esomeprazole sodium ........... 75 ESOMEPRAZOLE STRONTIUM................... 75 estarylla ................................ 84 estazolam .............................. 26 ESTRACE ............................ 81 estradiol ................................ 81 estradiol valerate .................. 81 estradiol-norethindrone acet . 81 ESTRING ............................. 81 ESTROGEL ......................... 81 estrogens-methyltestosterone81 estropipate ............................ 82 ESTROSTEP FE-28 ............. 84 eszopiclone ........................... 26 ethacrynate sodium ............... 32 ethacrynic acid...................... 32 ethambutol .............................. 7 ethosuximide ........................ 16 ethyl chloride ........................ 43 ETHYOL .............................. 10 etidronate disodium .............. 47 etodolac ................................ 23 etoposide............................... 12 EURAX ................................ 46 EVAMIST ............................ 82 EVEKEO .............................. 26 EVENCARE......................... 58 EVENCARE G2 ............. 52, 58 EVENCARE G3 GLUCOSE METER ............................ 58 EVENCARE G3 TEST ........ 52 EVENCARE MINI GLUCOSE TEST STR..... 52 EVENCARE MINI MONITOR SYSTEM ...... 58 EVENCARE TEST .............. 52 EVISTA ................................ 80 EVOCLIN ............................ 42
EVOLUTION BLOOD GLUCOSE METER ......... 58 EVOLUTION NORMAL CONTROL ....................... 58 EVOLUTION TEST STRIPS .......................................... 52 EVOMELA .......................... 12 EVOTAZ ................................ 4 EVOXAC ............................. 47 EVZIO .................................. 23 EXALGO ER ....................... 20 EXELDERM ........................ 44 EXELON .............................. 19 exemestane ........................... 12 EXFORGE............................ 32 EXFORGE HCT................... 32 EXJADE ............................... 47 EXODERM .......................... 44 EXPECTA PRENATAL ...... 98 EXTAVIA ............................ 77 EXTINA ............................... 44 EXTRA-VIRT PLUS DHA.. 98 EYLEA ................................. 88 EZ FLU 2016-17 (AFLURIA) (PF) ................................... 78 EZ FLU 2016-17 (FLUVIRIN) (PF) ................................... 78 EZ FLU16-17(FLUZON QD PED)(PF) .......................... 78 e-z ject lancets ...................... 58 EZ SMART LANCETS ....... 58 EZ SMART PLUS SYSTEM .......................................... 58 EZ SMART PLUS TEST ..... 52 EZ SMART SYSTEM.......... 58 EZ SMART TEST ................ 52 F FA-8...................................... 98 fabb ....................................... 98 FABIOR ............................... 42 FABRAZYME ..................... 67 FACTIVE ............................... 9 fallback solo ......................... 84 falmina (28) .......................... 84 famciclovir.............................. 4 famotidine............................. 75 famotidine (pf) ...................... 75 famotidine (pf)-nacl (iso-os) 75 FAMVIR ................................ 4 FANAPT .............................. 26 121
FARESTON .........................12 FARXIGA ............................68 FARYDAK ...........................12 FASLODEX .........................12 FAZACLO ............................26 FC2 FEMALE CONDOM ...81 fe c plus.................................98 FEIBA NF ............................35 felbamate ..............................16 FELBATOL ..........................16 FELDENE ............................23 felodipine ..............................32 fem ph ...................................82 FEMARA .............................12 FEMCAP ..............................81 FEMCON FE ........................84 FEMHRT LOW DOSE ........82 FEMRING ............................82 fenofibrate.............................37 FENOFIBRATE ...................37 fenofibrate micronized..........36 fenofibrate nanocrystallized .36 fenofibric acid .......................37 fenofibric acid (choline) .......37 FENOGLIDE ........................37 fenoprofen.............................23 FENOPROFEN ....................23 FENORTHO .........................23 fentanyl .................................20 FENTANYL .........................20 fentanyl citrate ......................20 FENTANYLBUPIVACAINE-NACL (PF) ...................................20 FENTORA ............................20 fer-iron ..................................98 FERIVA 21-7 TABLET .......98 ferocon ..................................98 FERRALET 90 DUAL-IRON DELIVERY ......................98 ferraplus 90 ...........................98 FERRIPROX ........................47 FERRLECIT .........................47 ferrocite plus .........................98 ferrogels forte .......................98 ferrous sulfate .......................98 FETZIMA .............................26 FEXMID ...............................19 FIBRICOR ............................37
FIFTY50 SAFETY SEAL LANCETS ........................ 58 FIFTY50 TEST STRIP ........ 52 FILTER NEEDLES.............. 58 FINACEA............................. 42 finasteride ............................. 94 FINE 30 UNIVERSAL LANCETS ........................ 59 FINGERSTIX LANCETS ... 59 FIORICET ............................ 20 FIORICET WITH CODEINE .......................................... 20 FIORINAL ........................... 20 FIORINAL-CODEINE #3 ... 20 FIRAZYR ............................. 92 FIRMAGON KIT W DILUENT SYRINGE ...... 12 FLAGYL ................................ 7 FLAGYL ER .......................... 7 FLAREX .............................. 89 flavoxate ............................... 94 FLEBOGAMMA DIF .......... 78 flecainide .............................. 30 FLECTOR ............................ 23 FLOLAN .............................. 32 FLOMAX ............................. 94 FLORIVA............................. 98 FLORIVA (FLUORIDEVITAMIN D3) ................. 98 FLORIVA PLUS .................. 99 FLOVENT DISKUS ............ 92 FLOVENT HFA ................... 92 FLOWTUSS ......................... 90 floxin .................................... 50 floxuridine ............................ 12 FLUAD 2016-2017 (65 YR UP)(PF) ............................ 78 FLUARIX QUAD 2016-2017 (PF) ................................... 78 FLUBLOK 2016-2017 (PF) . 78 flucaine ................................. 88 FLUCELVAX QUAD 20162017 (PF) .......................... 78 fluconazole ............................. 3 fluconazole in dextrose(iso-o) 3 fluconazole in nacl (iso-osm) . 3 flucytosine .............................. 3 fludarabine ............................ 12 fludrocortisone ..................... 50
FLULAVAL QUAD 20162017 .................................. 78 FLULAVAL QUAD 20162017 (PF) .......................... 78 FLUMADINE ........................ 4 flumazenil ............................. 26 FLUMIST QUAD 2016-2017 .......................................... 78 flunisolide ............................. 92 fluocinolone .......................... 45 fluocinolone acetonide oil .... 50 fluocinolone and shower cap 45 fluocinonide .......................... 45 fluocinonide-e ....................... 45 FLUORABON...................... 99 FLUOR-A-DAY ................... 99 fluor-a-day (with xylitol) ...... 99 fluorescein-benoxinate ......... 88 fluorescein-proparacaine ...... 88 fluoridex daily defense ......... 49 FLUORIDEX SENSITIVITY RELIEF ............................ 49 fluoritab ................................ 99 FLUORITAB........................ 99 fluorometholone ................... 89 FLUOROPLEX .................... 40 fluorouracil ..................... 12, 40 FLUOROURACIL ............... 40 fluoxetine ........................ 26, 27 FLUOXETINE ..................... 27 fluphenazine decanoate ........ 27 fluphenazine hcl ................... 27 FLURA-DROPS ................... 99 flurandrenolide ..................... 45 flurazepam ............................ 27 flurbiprofen ........................... 23 flurbiprofen sodium .............. 88 flurox .................................... 88 flutamide............................... 12 fluticasone ...................... 46, 92 fluvastatin ............................. 37 FLUVIRIN 2016-2017 ......... 78 FLUVIRIN 2016-2017 (PF) . 78 fluvoxamine .......................... 27 FLUZONE HIGH-DOSE 2016-17 (PF)..................... 79 FLUZONE INTRADERM QUAD 2016-17 ................ 79 FLUZONE QUAD 2016-2017 .......................................... 79 122
FLUZONE QUAD 2016-2017 (PF) ...................................79 FLUZONE QUAD PEDI 2016-17 (PF) .....................79 FML FORTE ........................89 FML LIQUIFILM ................89 FML S.O.P............................89 focalgin 90 dha .....................99 focalgin ca ............................99 focalgin dss ...........................99 FOCALIN .............................27 FOCALIN XR ......................27 folbecal .................................99 folbee ....................................99 folbee plus ............................99 FOLET ONE ........................99 FOLGARD OS .....................99 FOLGARD RX .....................99 folic acid ...............................99 folic acid-vit b6-vit b12 ........99 folivane-f ..............................99 folivane-ob ............................99 folivane-plus .........................99 FOLIXAPURE .....................99 FOLOTYN ...........................12 folplex 2.2 .............................99 foltabs 800 ............................99 FOLTRATE ..........................99 fondaparinux .........................35 FORA D10......................52, 59 FORA D15G .........................52 FORA D20......................52, 59 FORA D40-G31 TEST STRIPS .............................52 FORA G20......................52, 59 FORA G30A ...................52, 59 FORA GD50 BLOOD GLUCOSE SYSTEM .......59 FORA GD50 TEST STRIPS 52 FORA LANCING DEVICE .59 FORA NORMAL CONTROL ..........................................59 FORA TEST N'GO VOICE METER.............................59 FORA TEST STRIP .............52 FORA TN'G VOICE METER ..........................................59 FORA TN'G VOICE TEST STRIPS .............................52 FORA V10......................52, 59
FORA V10-V12-D10-D20... 59 FORA V12 BLOOD GLUCOSE SYSTEM....... 59 FORA V12 GLUCOSE ........ 52 FORA V20 ..................... 52, 59 FORA V30A ........................ 59 FORACARE GD20 .............. 52 FORACARE GD20 GLUCOSE METER ......... 59 FORACARE GD40 .............. 52 FORACARE GD40A GLUCOSE METER ......... 59 FORACARE GD40B GLUCOSE METER ......... 59 FORACARE GDH LOW CONTROL ....................... 59 FORACARE LANCETS ..... 59 FORADIL AEROLIZER ..... 92 FORFIVO XL ...................... 27 FORTAMET ........................ 68 FORTAVIT .......................... 97 FORTEO .............................. 80 FORTESTA.......................... 67 FORTISCARE BLOOD GLUCOSE SYST............. 59 FORTISCARE GLUCOSE TEST STRIPS .................. 52 FORTISCARE NORMAL ... 59 FOSAMAX .......................... 80 FOSAMAX PLUS D ............ 80 foscarnet ................................. 4 FOSCAVIR ............................ 4 fosinopril .............................. 32 fosinopril-hydrochlorothiazide .......................................... 32 fosphenytoin ......................... 16 FOSRENOL ......................... 72 FRAGMIN ........................... 35 FREESTYLE CONTROL .... 59 FREESTYLE FLASH SYSTEM .......................... 59 FREESTYLE FREEDOM ... 59 FREESTYLE FREEDOM LITE ................................. 59 FREESTYLE INSULINX ... 52, 59 FREESTYLE INSULINX TEST STRIPS .................. 52 FREESTYLE LANCETS ..... 59 FREESTYLE LITE METER 59
FREESTYLE LITE STRIPS 52 FREESTYLE PRECISION NEO METER ................... 59 FREESTYLE PRECISION NEO STRIPS .................... 52 FREESTYLE SIDEKICK II 59 FREESTYLE SYSTEM KIT59 FREESTYLE TEST ............. 52 FREESTYLE UNISTIK 2 .... 59 FROVA ................................ 18 frovatriptan ........................... 18 full spectrum b-vitamin c ..... 99 FURADANTIN .................... 10 furosemide ............................ 32 FUSILEV.............................. 10 FUSION PLUS ..................... 99 FUSION SPRINKLES ......... 99 FUZEON ................................ 4 fyavolv .................................. 82 FYCOMPA........................... 16 G gabapentin ............................ 16 GABITRIL ........................... 16 galantamine .......................... 19 GALZIN ............................... 96 GAMASTAN S/D ................ 79 GAMMAGARD LIQUID .... 79 GAMMAGARD S-D (IGA < 1 MCG/ML) ........................ 79 GAMMAKED ...................... 79 GAMMAPLEX .................... 79 GAMUNEX-C...................... 79 GANIRELIX ........................ 67 GASTROCROM .................. 72 gatifloxacin ........................... 86 GATTEX 30-VIAL .............. 72 gavilax .................................. 72 gavilyte-c .............................. 72 gavilyte-g .............................. 72 gavilyte-h and bisacodyl ....... 72 gavilyte-n .............................. 72 GAZYVA ............................. 12 GE100 BLOOD GLUCOSE SYSTEM .......................... 59 GE100 BLOOD GLUCOSE TEST STRIP..................... 53 GE100 CONTROL SOLUTION NORMAL .... 59 GELCLAIR .......................... 49 GELNIQUE .......................... 94 123
GELX ...................................49 gemcitabine...........................12 gemfibrozil ...........................37 GEMZAR .............................12 GENERESS FE ....................84 generlac.................................72 gengraf ..................................12 GENOTROPIN.....................77 GENOTROPIN MINIQUICK ..........................................77 GENSTRIP TEST STRIP.....53 gentak ...................................86 gentamicin ..................7, 44, 86 gentamicin in nacl (iso-osm) ..7 GENTAMICIN IN NACL (ISO-OSM) .........................7 gentamicin sulfate (ped) (pf) ..7 gentamicin sulfate (pf) ............7 GENTAMICIN SULFATE (PF) .....................................7 gentle laxative .......................72 gentlelax ...............................72 GENVOYA ............................4 GEODON .............................27 gianvi (28) ............................84 GIAZO ..................................72 gildagia .................................84 GILENYA ............................77 GILOTRIF ............................12 GLASSIA .............................47 glatopa ..................................77 GLEEVEC ............................12 GLEOSTINE ........................12 GLIADEL WAFER ..............12 glimepiride ............................68 glipizide ................................ 69 glipizide-metformin ..............69 GLUCAGEN DIAGNOSTIC KIT ...................................54 GLUCAGEN HYPOKIT......54 GLUCAGON EMERGENCY KIT (HUMAN) .................54 GLUCAGON HCL ...............54 GLUCO NAVII GLUCOSE MONITOR .......................60 GLUCO NAVII TEST STRIP ..........................................53 GLUCOCARD 01 METER ..60 GLUCOCARD 01 NORMAL CONTROL .......................60
GLUCOCARD 01 SENSOR PLUS ................................ 53 GLUCOCARD EXPRESSION .................................... 53, 60 GLUCOCARD SHINE METER ............................ 60 GLUCOCARD SHINE TEST STRIPS ............................. 53 GLUCOCARD VITAL ........ 60 GLUCOCARD VITAL SENSOR........................... 53 GLUCOCARD VITAL TEST STRIPS ............................. 53 GLUCOCOM BLOOD GLUCOSE ....................... 60 GLUCOCOM CONTROL NORMAL......................... 60 GLUCOCOM GLUCOSE.... 53 GLUCOCOM LANCETS .... 60 GLUCOPHAGE ................... 69 GLUCOPHAGE XR ............ 69 GLUCOSE CONTROL........ 60 GLUCOTROL...................... 69 GLUCOTROL XL ............... 69 GLUCOVANCE .................. 69 GLUMETZA ........................ 69 glyburide............................... 69 glyburide micronized............ 69 glyburide-metformin ............ 69 glycopyrrolate....................... 70 glydo ..................................... 43 GLYNASE ........................... 69 GLYSET............................... 69 GLYXAMBI ........................ 69 GM100 ........................... 53, 60 GMATE CONTROL SOLUTION, NORMAL... 60 GMATE LANCETS ............. 60 GMATE LANCING DEVICE .......................................... 60 GMATE SMART METER .. 60 GMATE SMART STARTER .......................................... 60 GMATE TEST STRIPS ....... 53 GMATE VOICE METER .... 60 GOLYTELY......................... 72 GONITRO ............................ 38 GORDONS UREA ............... 40 GRALISE ............................. 16
GRALISE 30-DAY STARTER PACK ............................... 16 granisetron hcl ...................... 72 GRANIX .............................. 76 GRASTEK............................ 79 griseofulvin microsize ............ 3 griseofulvin ultramicrosize ..... 3 GRIS-PEG (ULTRAMICROSIZE) ...... 3 guaifenesin ac ....................... 90 guaifenesin dac ..................... 90 guanfacine ...................... 27, 32 guanidine .............................. 27 GYNAZOLE-1 ..................... 82 gynol ii .................................. 82 H HALAVEN ........................... 12 HALCION ............................ 27 HALDOL.............................. 27 HALDOL DECANOATE .... 27 halobetasol propionate .......... 46 HALOG ................................ 46 haloperidol ............................ 27 haloperidol decanoate ........... 27 haloperidol lactate ................ 27 HARVONI.............................. 4 HAVRIX (PF) ...................... 79 HEALTHPRO GLUCOSE MONITOR ....................... 60 HEALTHPRO HIGH-LOW CONTROL ....................... 60 HEALTHPRO TEST STRIPS .......................................... 53 HEALTHY ACCENTS AUTOLET........................ 60 HEALTHY ACCENTS UNIFINE PENTIP ........... 60 HEALTHY ACCENTS UNILET LANCET ........... 60 healthylax ............................. 72 heather .................................. 82 HECTOROL......................... 67 HELIXATE FS ..................... 35 HEMANGEOL ..................... 32 hematinic plus vit/minerals .. 99 hematinic/folic acid .............. 99 hematogen ............................ 99 hematogen fa ........................ 99 hematogen forte .................... 99 HEMATRON-AF ................. 99 124
hemenatal ob .........................99 hemenatal ob + dha ...............99 hemetab.................................99 hemmorex-hc ........................72 HEMOCYTE-F ....................99 HEMOCYTE-PLUS .............99 HEMOFIL M HIGH .............35 HEMOFIL M LOW ..............35 HEMOFIL M MID ...............35 HEMOFIL M SUPER HIGH35 hep flush-10 (pf) ...................35 HEPAGAM B .......................79 heparin (porcine) ..................35 HEPARIN (PORCINE) IN 0.9% NACL ......................35 heparin (porcine) in 5 % dex 35 heparin (porcine) in nacl (pf) 35 heparin flush .........................35 heparin flush(porcine)-0.9nacl ..........................................35 heparin lock flush .................35 heparin lock flush (porcine)..35 heparin lockflush(porcine)(pf) ..........................................35 heparin(porcine) in 0.45% nacl ..........................................35 HEPARIN(PORCINE) IN 0.45% NACL ....................35 heparin, porcine (pf) .............35 HEPSERA ..............................4 HERCEPTIN ........................12 HETLIOZ .............................27 HEXALEN ...........................13 HIBERIX (PF) ......................79 hi-cal plus vit d .....................96 HIPREX ................................ 10 HISTEX-AC .........................90 HIZENTRA ..........................79 homatropaire .........................87 homatropine hbr....................87 HORIZANT ..........................19 hpr .........................................40 hpr plus .................................40 hpr plus hydrogel ..................40 HPR PLUS-MB HYDROGEL ..........................................40 HUMALOG ..........................66 HUMALOG KWIKPEN ......66 HUMALOG MIX 50-50.......66
HUMALOG MIX 50-50 KWIKPEN ....................... 66 HUMALOG MIX 75-25 ...... 66 HUMALOG MIX 75-25 KWIKPEN ....................... 66 HUMAPEN LUXURA HD.. 60 HUMATE-P ......................... 35 HUMATROPE ..................... 77 HUMIRA .............................. 80 HUMIRA PEDIATRIC CROHN'S START ........... 80 HUMIRA PEN CROHN'SUC-HS START ................ 80 HUMULIN 70/30 ................. 66 HUMULIN 70/30 KWIKPEN .......................................... 66 HUMULIN N ....................... 66 HUMULIN N KWIKPEN .... 66 HUMULIN R ....................... 66 HUMULIN R U-500 (CONC) KWIKPEN ....................... 66 HUMULIN R U-500 (CONCENTRATED) ....... 66 HYCAMTIN ........................ 13 HYCET................................. 21 HYCOFENIX ....................... 90 hydralazine ........................... 32 HYDREA ............................. 13 HYDRO 35 ........................... 40 HYDRO 40 ........................... 40 hydrochlorothiazide .............. 32 hydrocodone-acetaminophen 21 hydrocodone-chlorpheniramine .......................................... 90 hydrocodone-cpmpseudoephed ..................... 91 hydrocodone-homatropine ... 91 hydrocodone-ibuprofen ........ 21 hydrocortisone .......... 46, 50, 72 hydrocortisone acetate .......... 72 hydrocortisone butyrate ........ 46 hydrocortisone butyr-emollient .......................................... 46 hydrocortisone valerate ........ 46 hydrocortisone-acetic acid.... 50 hydrocortisone-min oil-wht pet .......................................... 46 hydrocortisone-pramoxine .. 38, 72 hydromet............................... 91
hydromorphone .................... 21 HYDROMORPHONE IN 0.9 % NACL ........................... 21 hydroxychloroquine................ 7 hydroxyprogesterone caproate .......................................... 82 hydroxyurea .......................... 13 hydroxyzine hcl .................... 90 hydroxyzine pamoate ........... 90 HYLATOPIC ....................... 40 HYLATOPICPLUS.............. 40 hyolev mb ............................. 95 hyophen ................................ 95 hyoscyamine sulfate ............. 70 hyosyne ................................. 70 HYPERHEP B S/D .............. 79 HYPERHEP B S-D NEONATAL .................... 79 HYPERRAB S/D (PF) ......... 79 HYPER-SAL ........................ 92 HYPOLANCE AST LANCING ........................ 60 HYQVIA .............................. 79 HYSINGLA ER ................... 21 HYZAAR ............................. 32 I ibandronate ........................... 80 IBRANCE ............................ 13 IBUDONE ............................ 21 ibuprofen .............................. 23 ibuprofen-oxycodone............ 21 ic green ................................. 47 ICAR-C PLUS ...................... 99 ICLUSIG .............................. 13 IDAMYCIN PFS .................. 13 idarubicin .............................. 13 IDELVION ........................... 35 IFEX ..................................... 13 ifosfamide ............................. 13 ifosfamide-mesna ................. 13 ILARIS (PF) ......................... 78 ILEVRO ............................... 88 ILOTYCIN ........................... 86 ILUVIEN .............................. 89 imatinib................................. 13 IMBRUVICA ....................... 13 imipenem-cilastatin ................ 7 imipramine hcl ...................... 27 imipramine pamoate ............. 27 imiquimod ............................ 78 125
IMITREX .............................18 IMITREX STATDOSE KIT REFILL.............................18 IMITREX STATDOSE PEN18 IMOGAM RABIES-HT (PF) ..........................................79 IMPAVIDO ............................7 IMURAN ..............................13 INCONTROL LANCING DEVICE ...........................60 INCONTROL PEN NEEDLE ..........................................60 INCONTROL SUPER THIN LANCETS ........................60 INCONTROL ULTRA THIN LANCETS ........................60 INCRELEX ..........................47 INCRUSE ELLIPTA ............92 indapamide ...........................32 INDERAL LA ......................32 INDERAL XL ......................32 INDIOMIN MB ....................95 INDOCIN .............................23 indocyanine green .................47 indomethacin ........................23 INFASURF ...........................47 INFINITY CONTROL SOLUTION NORM .........60 INFINITY STARTER KIT ..60 INFINITY TEST STRIPS ....53 INFLAMMA-K ....................23 INJECT EASE LANCETS ...60 INJECTAFER.......................99 INLYTA ...............................13 INNOPRAN XL ...................32 INOVA .................................42 INOVA 4-1 ...........................39 INOVA 8-2 ...........................39 INSPRA ................................ 32 INSUPEN .............................60 INTEGRA F .........................99 INTEGRA PLUS ..................99 INTELENCE ..........................4 INTERMEZZO.....................27 INTRON A ...........................78 introvale ................................ 84 INTUNIV ER .......................27 INVACARE LANCETS ......61 INVANZ .................................7 INVEGA ...............................27
INVIRASE ............................. 4 INVOKAMET ...................... 69 INVOKAMET XR ............... 69 INVOKANA ........................ 69 IONSYS ............................... 21 iophen c-nr............................ 91 IOPIDINE............................. 90 ipratropium bromide....... 49, 92 ipratropium-albuterol ........... 93 irbesartan .............................. 32 irbesartan-hydrochlorothiazide .......................................... 32 IRENKA ............................... 27 IRESSA ................................ 13 irinotecan .............................. 13 IROSPAN 24/6 ..................... 99 ISENTRESS ........................... 4 ISOCHRON ......................... 38 ISOLYTE-S .......................... 97 isometh-dichloralacetaminophn ................... 18 isomethepten-cafacetaminophen .................. 18 isoniazid ................................. 7 ISOPTO ATROPINE ........... 87 ISOPTO CARPINE .............. 87 ISORDIL .............................. 38 ISORDIL TITRADOSE ....... 38 isosorbide dinitrate ............... 38 isosorbide mononitrate ......... 38 isoxsuprine ........................... 82 isradipine .............................. 32 ISTALOL ............................. 87 ISTODAX ............................ 13 itraconazole ............................ 3 ivermectin ............................... 7 IXEMPRA ............................ 13 IXINITY ............................... 35 J JADENU .............................. 47 JAKAFI ................................ 13 JALYN ................................. 94 jantoven ................................ 35 JANUMET ........................... 69 JANUMET XR..................... 69 JANUVIA............................. 69 JARDIANCE ........................ 69 JAZZ WIRELESS 2 METER KIT ................................... 61 jencycla................................. 82
JENTADUETO .................... 69 JENTADUETO XR .............. 69 JETREA (PF) ....................... 88 jevantique lo ......................... 82 JEVTANA ............................ 13 jinteli..................................... 82 jolessa ................................... 84 jolivette ................................. 82 JUBLIA ................................ 44 juleber ................................... 84 junel 1.5/30 (21) ................... 84 junel 1/20 (21) ...................... 84 junel fe 1.5/30 (28) ............... 84 junel fe 1/20 (28) .................. 84 junel fe 24 ............................. 84 JUXTAPID ........................... 37 K KADCYLA .......................... 13 KADIAN .............................. 21 kaitlib fe................................ 84 KALBITOR .......................... 93 KALETRA ............................. 4 KALYDECO ........................ 93 KAPVAY ............................. 27 KARBINAL ER ................... 90 kariva (28) ............................ 84 KAYEXALATE ................... 72 KAZANO ............................. 69 k-effervescent ....................... 96 KEFLEX ................................. 6 kelnor 1/35 (28) .................... 84 KENALOG ........................... 46 KEPIVANCE ....................... 10 KEPPRA............................... 16 KEPPRA XR ........................ 16 KERAFOAM........................ 40 KERALAC ........................... 40 KERALYT RX ..................... 39 KERALYT SCALP COMPLETE ..................... 39 KERYDIN ............................ 44 KETEK ................................... 7 ketoconazole ..................... 3, 44 ketoprofen ............................. 23 ketorolac ......................... 23, 88 KEVEYIS ............................. 19 KHEDEZLA ......................... 27 kimidess (28) ........................ 84 KINERET ............................. 78 KINRIX (PF) ........................ 79 126
kionex ...................................72 kionex (with sorbitol) ...........72 KIT PREP OF TC-99MMEBROFENIN ................47 KITABIS PAK .......................7 KLARON .............................44 klofensaid ii ..........................23 KLONOPIN ..........................16 klor-con.................................96 klor-con 10............................96 klor-con 8..............................96 klor-con m10 ........................96 klor-con m15 ........................96 klor-con m20 ........................96 klor-con sprinkle ...................96 KLOR-CON/25 ....................96 klor-con/ef ............................96 KOATE-DVI ........................35 kobee.....................................99 KOGENATE FS ...................35 KOMBIGLYZE XR .............69 KORLYM .............................67 KOSHER PRENATAL PLUS IRON ................................ 99 KOVALTRY ........................35 K-PHOS NO 2 ......................95 K-PHOS ORIGINAL ...........95 k-phos-neutral .......................96 kpn ........................................99 KRISTALOSE ......................72 KRYSTEXXA ......................80 k-sol ......................................96 k-tab ......................................96 K-TAB ..................................96 kurvelo ..................................84 KUVAN ................................ 67 KYLEENA ...........................81 KYNAMRO .........................37 KYPROLIS...........................13 L l norgest/e.estradiol-e.estrad .84 labetalol ................................ 32 LACRISERT ........................88 lactated ringers......................47 lactic acid ..............................40 lactic acid e ...........................40 lactulose ................................ 72 LAMICTAL .........................16 LAMICTAL ODT ................16
LAMICTAL ODT STARTER (BLUE) ............................. 16 LAMICTAL ODT STARTER (GREEN) .......................... 16 LAMICTAL ODT STARTER (ORANGE)....................... 16 LAMICTAL STARTER (BLUE) KIT ..................... 16 LAMICTAL STARTER (GREEN) KIT .................. 16 LAMICTAL STARTER (ORANGE) KIT ............... 16 LAMICTAL XR ................... 16 LAMICTAL XR STARTER (BLUE) ............................. 16 LAMICTAL XR STARTER (GREEN) .......................... 16 LAMICTAL XR STARTER (ORANGE)....................... 16 LAMISIL ................................ 3 lamivudine .............................. 4 lamivudine-zidovudine ........... 4 lamotrigine ........................... 16 LANCETS ............................ 61 LANCETS,THIN ................. 61 LANCING DEVICE ............ 61 LANCING SYSTEM ........... 61 LANOXIN ............................ 34 LANOXIN PEDIATRIC ...... 34 lansoprazole .......................... 75 LANTUS .............................. 66 LANTUS SOLOSTAR ........ 66 LANZO LANCING DEVICE .......................................... 61 larin 1.5/30 (21) .................... 84 larin 1/20 (21) ....................... 84 larin 24 fe ............................. 84 larin fe 1.5/30 (28) ................ 84 larin fe 1/20 (28) ................... 84 larissia................................... 84 LASIX .................................. 32 LASTACAFT ....................... 88 latanoprost ............................ 89 latrix ..................................... 40 LATUDA ............................. 27 laxa clear .............................. 72 laxative (bisacodyl) .............. 72 laxative feminine .................. 72 laxative peg 3350 ................. 72 layolis fe ............................... 84
LAZANDA ........................... 21 LDO PLUS ........................... 43 leena 28................................. 84 leflunomide........................... 80 LEMTRADA ........................ 77 LENVIMA............................ 13 LESCOL ............................... 37 LESCOL XL......................... 37 lessina ................................... 84 LETAIRIS ............................ 93 letrozole ................................ 13 leucovorin calcium ......... 10, 11 LEUKERAN ........................ 13 LEUKINE ............................. 77 leuprolide .............................. 13 levalbuterol hcl ..................... 93 LEVALBUTEROL TARTRATE ..................... 93 LEVAQUIN ........................... 9 LEVATOL............................ 32 LEVBID ............................... 70 LEVEMIR ............................ 66 LEVEMIR FLEXTOUCH ... 66 levetiracetam ........................ 16 levobunolol ........................... 87 levocarnitine ......................... 47 levocarnitine (with sugar) ..... 47 levocetirizine ........................ 90 levofloxacin ...................... 9, 86 levofloxacin in d5w ................ 9 levoleucovorin ...................... 11 levomefolate dha .................. 99 levonest (28) ......................... 84 levonorgestrel ....................... 84 levonorgestrel-ethinyl estrad 84 levonorg-eth estrad triphasic 84 levora-28 ............................... 84 levorphanol tartrate............... 21 LEVO-T................................ 70 levothyroxine ........................ 70 LEVOTHYROXINE ............ 70 levoxyl .................................. 70 LEVSIN ................................ 70 LEVSIN/SL .......................... 70 LEXAPRO............................ 27 LEXIVA ................................. 4 LIALDA ............................... 72 LIBERTY BLOOD GLUCOSE MONITOR .... 61 127
LIBERTY LEV 1 GLUCOSE CONTROL .......................61 LIBERTY LEV 2 GLUCOSE CONTROL .......................61 LIBERTY TEST ...................53 LIBRAX (WITH CLIDINIUM) ...................70 lidocaine ...............................43 lidocaine hcl..........................43 lidocaine hcl-hydrocortison ac ....................................43, 72 LIDOCAINE HCLHYDROCORTISON AC .72 lidocaine viscous ..................43 lidocaine-hydrocortisone-aloe ..........................................72 lidocaine-prilocaine ..............43 LIDOCAINE-TETRACAINE ..........................................43 LIDODERM .........................43 lido-k.....................................43 lidopin ...................................43 LIDOPIN ..............................43 lidopril ..................................43 LIDOPRIL XR .....................43 LIDORX ...............................43 LIDOTRAL ..........................43 LIDOVEX ............................43 LIDOXIB ..............................23 LILETTA ..............................81 LINCOCIN .............................7 lincomycin ..............................7 lindane ..................................46 linezolid ..................................7 LINZESS ..............................72 liothyronine...........................70 LIPITOR ...............................37 LIPOCHOL PLUS................47 lipodox 50 .............................13 LIPOFEN ..............................37 lisinopril ................................ 32 lisinopril-hydrochlorothiazide ..........................................32 lite coat aspirin .....................23 LITE TOUCH LANCETS ....61 lithium carbonate ..................27 lithium citrate........................27 LITHOBID ...........................27 LITHOSTAT ........................47 LIVALO ...............................37
LIVIXIL PAK ...................... 43 LO LOESTRIN FE............... 84 LOCOID ............................... 46 LOCOID LIPOCREAM ....... 46 LODOSYN ........................... 17 LOESTRIN 1.5/30 (21) ........ 84 LOESTRIN 1/20 (21) ........... 84 LOESTRIN FE 1.5/30 (28DAY) ................................ 84 LOESTRIN FE 1/20 (28-DAY) .......................................... 84 LOFIBRA ............................. 37 lomedia 24 fe ........................ 84 LOMOTIL ............................ 70 LONSURF............................ 13 LOPID .................................. 37 lopreeza ................................ 82 LOPRESSOR ....................... 32 LOPRESSOR HCT .............. 32 LOPROX .............................. 44 LOPROX (AS OLAMINE) .. 44 LOPROX KIT ...................... 44 lorazepam ............................. 27 lorazepam intensol................ 27 lorcet (hydrocodone) ............ 21 lorcet hd ................................ 21 lorcet plus ............................. 21 lortab 10-325 ........................ 21 lortab 5-325 .......................... 21 lortab 7.5-325 ....................... 21 LORTAB ELIXIR ................ 21 lortuss ex .............................. 91 loryna (28) ............................ 84 LORZONE ........................... 19 losartan ................................. 32 losartan-hydrochlorothiazide 32 LOSEASONIQUE ............... 84 LOTEMAX .......................... 89 LOTENSIN .......................... 32 LOTENSIN HCT ................. 32 LOTREL............................... 33 LOTRISONE ........................ 44 LOTRONEX ........................ 72 LOUTREX ........................... 40 lovastatin .............................. 37 LOVAZA ............................. 37 LOVENOX........................... 36 low-ogestrel (28) .................. 84 loxapine succinate ................ 27 LP LITE PAK....................... 43
lta pre-attached ..................... 43 LUCENTIS ........................... 88 ludent fluoride .................... 100 lugols .................................... 96 LUMIGAN ........................... 89 LUMIZYME ........................ 67 LUNESTA ............................ 27 LUPANETA PACK (1 MONTH) .......................... 82 LUPANETA PACK (3 MONTH) .......................... 82 LUPRON DEPOT ................ 13 LUPRON DEPOT (3 MONTH) .......................... 13 LUPRON DEPOT (4 MONTH) .......................... 13 LUPRON DEPOT (6 MONTH) .......................... 13 LUPRON DEPOT-PED ....... 13 lutera (28) ............................. 84 luxamend .............................. 40 LUXIQ.................................. 46 LUZU ................................... 44 LYCELLE ............................ 46 LYNPARZA ......................... 13 LYRICA ............................... 16 LYSODREN ......................... 13 LYSTEDA ............................ 82 lyza ....................................... 82 M M.V.I.-12 (WITHOUT VITAMIN K) ................. 100 macnatal cn dha .................. 100 MACROBID ........................ 10 MACRODANTIN ................ 10 MACUGEN .......................... 88 MAGNEBIND 400............... 72 magnesium citrate................. 73 MAKENA ............................ 82 MALARONE ......................... 8 MALARONE PEDIATRIC ... 8 malathion .............................. 46 maprotiline............................ 27 MAR-COF BP ...................... 91 MAR-COF CG ..................... 91 margesic................................ 21 MARINOL ........................... 73 marlissa................................. 85 MARNATAL-F .................. 100 MARPLAN .......................... 27 128
MARQIBO ...........................13 marten-tab .............................21 MATULANE ........................13 MAVIK.................................33 MAXALT .............................18 MAXALT-MLT ...................18 MAXARON FORTE ..........100 MAXFE (FOLATEDOCUSATE) .................100 MAXIDEX ...........................89 MAXINATE .......................100 MAXIPIME ............................6 MAXITROL .........................89 MAXZIDE ............................33 MAXZIDE-25MG ................33 mb hydrogel ..........................40 mb hydrogel (cyclomethicone) ..........................................40 m-clear wc ............................91 meclofenamate ......................24 MEDISENSE ........................61 MEDISENSE GLUCOSE KETONE ..........................61 MEDISENSE THIN LANCETS ........................61 MEDLANCE PLUS LANCETS ........................61 MEDLANCE PLUS SPECIAL BLADE .............................61 MEDROL .............................50 MEDROL (PAK)..................50 medroxyprogesterone ...........82 mefenamic acid .....................24 mefloquine ..............................8 MEGACE .............................13 MEGACE ES........................13 megestrol ..............................13 MEKINIST ...........................13 meloxicam ............................24 melphalan hcl........................13 memantine ............................19 MEMANTINE ......................19 MENACTRA (PF)................79 M-END MAX D ...................91 M-END PE ...........................91 MENEST ..............................82 MENOMUNE - A/C/Y/W-135 ..........................................79 MENOMUNE - A/C/Y/W-135 (PF) ...................................79
MENOSTAR ........................ 82 MENVEO A-C-Y-W-135-DIP (PF) ................................... 79 meperidine ............................ 21 MEPHYTON ........................ 36 meprobamate ........................ 19 MEPRON ............................... 8 mercaptopurine ..................... 13 meropenem ............................. 8 MEROPENEM-0.9% SODIUM CHLORIDE ....... 8 MERREM............................... 8 mesalamine ........................... 73 MESALAMINE ................... 73 mesalamine with cleansing wipe .................................. 73 mesna.................................... 11 MESNEX ............................. 11 MESTINON ......................... 19 MESTINON TIMESPAN .... 19 METADATE CD ................. 27 metadate er ........................... 27 metaproterenol ...................... 93 metaxall ................................ 19 metaxalone ........................... 19 metformin ............................. 69 methadone ............................ 21 methadose ............................. 21 methamphetamine ................ 27 methazolamide ..................... 88 methenamine hippurate ........ 10 methenamine mandelate ....... 10 methen-sod phos-meth bluehyos .................................. 95 methergine ............................ 86 methimazole ......................... 51 METHITEST ........................ 67 methocarbamol ..................... 19 methotrexate sodium ............ 13 methotrexate sodium (pf) ..... 13 methoxsalen rapid ................ 40 methscopolamine.................. 70 methyclothiazide .................. 33 methyldopa ........................... 33 methyldopahydrochlorothiazide .......... 33 methyldopate ........................ 33 METHYLIN ......................... 27 methylphenidate ................... 27 methylprednisolone .............. 50
methyltestosterone ................ 67 metipranolol.......................... 87 metoclopramide hcl .............. 73 metolazone............................ 33 METOPIRONE .................... 48 metoprolol succinate............. 33 metoprolol ta-hydrochlorothiaz .......................................... 33 metoprolol tartrate ................ 33 metro i.v.................................. 8 METROCREAM .................. 42 METROGEL ........................ 42 METROGEL VAGINAL ..... 82 METROLOTION ................. 42 metronidazole ............. 8, 42, 83 metronidazole in nacl (iso-os) 8 mexiletine ............................. 30 MIACALCIN ....................... 67 MICARDIS .......................... 33 MICARDIS HCT ................. 33 MICORT-HC........................ 73 MICRO BLOOD GLUCOSE .......................................... 53 MICRO THIN LANCETS ... 61 MICRODOT BLOOD GLUCOSE SYSTEM . 53, 61 microgestin 1.5/30 (21) ........ 85 microgestin 1/20 (21) ........... 85 MICROGESTIN 24 FE ........ 85 microgestin fe 1.5/30 (28) .... 85 microgestin fe 1/20 (28) ....... 85 MICROLET LANCET ......... 61 MICROZIDE ........................ 33 midodrine.............................. 48 MIFEPREX .......................... 83 migergot................................ 18 miglitol ................................. 69 MIGRANAL ........................ 18 MIGRANOW ....................... 18 milk of magnesia .................. 73 milk of magnesia concentrated .......................................... 73 millipred ............................... 51 MILLIPRED ......................... 51 millipred dp .......................... 51 mimvey ................................. 82 mimvey lo ............................. 82 MINASTRIN 24 FE ............. 85 MINI LANCING DEVICE .. 61 MINI ULTRA-THIN II ........ 61 129
MINIPRESS .........................33 MINITRAN ..........................38 MINIVELLE ........................82 MINOCIN.............................10 minocycline ..........................10 minoxidil...............................33 MIOCHOL-E ........................87 miralax ..................................73 MIRAPEX ............................17 MIRAPEX ER ......................17 MIRCERA ............................77 MIRCETTE (28) ..................85 MIRENA ..............................81 mirtazapine ...........................27 MIRVASO ............................42 misoprostol ...........................75 MITIGARE...........................80 mitomycin .............................14 MITOSOL ............................89 mitoxantrone .........................14 M-M-R II (PF) ......................79 MOBIC .................................24 modafinil...............................27 moderiba ...............................77 moderiba dose pack ..............77 moexipril...............................33 moexipril-hydrochlorothiazide ..........................................33 molindone .............................27 mometasone ....................46, 93 mondoxyne nl .......................10 MONOCLATE-P .................36 MONODOX .........................10 monoject 0.9% sodium chloride .............................48 monoject prefill (pf) .............36 monoject prefill advanced ns 48 monoject prefill saline flush .48 MONOLET LANCETS........61 MONOLET THIN LANCETS ..........................................61 mono-linyah ..........................85 mononessa (28) .....................85 MONONINE ........................36 montelukast...........................93 MONUROL ..........................10 morgidox...............................10 MORGIDOX 1X 50 .............10 MORGIDOX 2X100 ............10 morphine .........................21, 22
MORPHINE ......................... 21 morphine (pf)........................ 21 morphine concentrate ........... 21 MOTOFEN........................... 70 MOVANTIK ........................ 73 MOVIPREP .......................... 73 MOXATAG ........................... 9 MOXEZA ............................. 87 moxifloxacin........................... 9 MOZOBIL ............................ 77 MS CONTIN ........................ 22 MUGARD ............................ 49 MULTAQ ............................. 30 multigen folic ..................... 100 multigen plus ...................... 100 MULTI-LANCET DEVICE 2 .......................................... 61 multi-vit with fluoride-iron 100 multi-vitamin with fluoride 100 multivitamins with fluoride 100 mupirocin ............................. 44 mupirocin calcium ................ 44 MUSTARGEN ..................... 14 mvc-fluoride ....................... 100 M-VIT ................................ 100 my way ................................. 85 MYALEPT ........................... 67 MYAMBUTOL...................... 8 MYCOBUTIN ........................ 8 mycophenolate mofetil ......... 14 mycophenolate sodium ......... 14 MYDRIACYL...................... 87 MYFORTIC ......................... 14 MYGLUCOHEALTH .... 53, 61 MYGLUCOHEALTH CONTROL SOLUTION .. 61 MYGLUCOHEALTH LANCETS ........................ 61 MYLERAN .......................... 14 mynatal ............................... 100 mynatal advance ................. 100 mynatal plus ....................... 100 mynatal-z ............................ 100 mynate 90 plus ................... 100 mynephrocaps..................... 100 MYOBLOC .......................... 79 myorisan ............................... 42 MYRBETRIQ ...................... 94 MYSOLINE ......................... 16 MYTESI ............................... 70
myzilra .................................. 85 N NABI-HB ............................. 79 nabumetone .......................... 24 nadolol .................................. 33 nadolol-bendroflumethiazide 33 nafcillin ................................... 9 naftifine ................................ 44 NAFTIFINE ......................... 44 NAFTIN ............................... 44 NAGLAZYME ..................... 67 nalbuphine ............................ 24 NALFON .............................. 24 naloxone ............................... 24 naltrexone ............................. 24 NAMENDA.......................... 19 NAMENDA TITRATION PAK .................................. 19 NAMENDA XR ................... 19 NAMZARIC ......................... 19 NAPRELAN CR .................. 24 NAPROSYN ........................ 24 naproxen ............................... 24 naproxen sodium .................. 24 naratriptan ............................. 18 NARCAN ............................. 24 NARDIL ............................... 27 NASCOBAL ...................... 100 NASONEX ........................... 93 NATACHEW (FE BISGLYCINATE) ................ 100 NATACYN .......................... 87 NATAZIA ............................ 85 nateglinide ............................ 69 NATELLE ONE ................. 100 NATESTO ............................ 67 NATPARA ........................... 67 NATROBA ........................... 46 natural b-100 complex ........ 100 nature-throid ......................... 70 NAVELBINE ....................... 14 NEBUPENT ........................... 8 NEBUSAL............................ 93 necon 0.5/35 (28) .................. 85 necon 1/35 (28) ..................... 85 necon 1/50 (28) ..................... 85 necon 10/11 (28) ................... 85 necon 7/7/7 (28).................... 85 NEEVODHA (WITH ALGAL OIL) ................................ 100 130
nefazodone ............................27 neomycin ................................8 neomycin-bacitracin-poly-hc 89 neomycin-bacitracinpolymyxin .........................87 neomycin-polymyxin bdexameth...........................89 neomycin-polymyxingramicidin .........................87 neomycin-polymyxin-hc.50, 89 neo-polycin ...........................87 neo-polycin hc ......................89 NEORAL ..............................14 NEOSALUS .........................40 NEOSPORIN (NEO-POLYMGRAMICID).....................87 NEO-SYNALAR ..................44 NEO-SYNALAR KIT ..........44 nephplex rx .........................100 NEPHROCAPS ..................100 NEPHROCAPS QT ............100 NEPHRON FA ...................100 nephro-vite rx .....................100 NEPTAZANE.......................88 NESINA ...............................69 NESTABS ..........................100 NESTABS ABC .................100 NESTABS DHA .................100 neuac .....................................42 NEUAC KIT .........................42 NEULASTA .........................77 NEUPOGEN.........................77 NEUPRO ..............................17 NEURIN-SL .......................101 NEURONTIN .......................16 NEUTEK 2TEK TEST STRIPS .............................53 NEVANAC...........................88 nevirapine ...............................4 newgen ................................ 101 NEXA PLUS ......................101 NEXAVAR...........................14 NEXAVIR ..........................101 NEXIUM ..............................75 NEXIUM IV .........................75 NEXIUM PACKET..............75 NEXPLANON ......................83 next choice one dose .............85 niacin ....................................37 NIACOR ...............................37
NIASPAN EXTENDEDRELEASE ........................ 37 nicardipine ............................ 33 NICODERM CQ .................. 49 nicorelief............................... 49 NICORETTE ........................ 49 nicotine ................................. 49 nicotine (polacrilex) ............. 49 NICOTROL.......................... 49 NICOTROL NS.................... 49 nifedical xl ............................ 33 nifedipine.............................. 33 nikki (28) .............................. 85 NILANDRON ...................... 14 nilutamide ............................. 14 nimodipine............................ 33 NINJACOF-XG ................... 91 NINLARO ............................ 14 NIPENT ................................ 14 nisoldipine ............................ 33 nitro-bid ................................ 38 NITRO-DUR ........................ 38 nitrofurantoin ........................ 10 nitrofurantoin macrocrystal .. 10 nitrofurantoin monohyd/mcryst .................................. 10 nitroglycerin ......................... 38 NITROLINGUAL ................ 38 NITROMIST ........................ 38 NITROSTAT ........................ 38 nitro-time .............................. 38 NIVA-PLUS ....................... 101 nivatopic plus ....................... 40 nizatidine .............................. 75 NIZORAL ............................ 44 nodolor ................................. 18 nora-be .................................. 82 NORCO ................................ 22 NORDITROPIN FLEXPRO 77 noreth-ethinyl estradiol-iron. 85 norethindrone (contraceptive) .......................................... 82 norethindrone acetate ........... 82 norethindrone ac-eth estradiol .................................... 82, 85 norethindrone-e.estradiol-iron .......................................... 85 norgestimate-ethinyl estradiol .......................................... 85 NORINYL 1+35 (28) ........... 85
NORITATE .......................... 42 norlyroc ................................ 82 normal saline flush ............... 48 NORPACE ........................... 30 NORPACE CR ..................... 30 NORPRAMIN ...................... 28 NOR-QD .............................. 82 NORTHERA ........................ 48 nortrel 0.5/35 (28)................. 85 nortrel 1/35 (21).................... 85 nortrel 7/7/7 (28) .................. 85 nortriptyline .......................... 28 NORVASC ........................... 33 NORVIR ................................. 4 NOVA MAX BLOOD GLUCOSE METER ......... 61 NOVA MAX GLUCOSE CONTROL ....................... 61 NOVA MAX GLUCOSE TEST ................................ 53 NOVA SAFETY LANCETS61 NOVA SUREFLEX LANCETS ........................ 61 NOVACORT ........................ 73 NOVACORT (WITH ALOE) .......................................... 43 NOVAMAX PLUS GLU-KET .......................................... 61 NOVOEIGHT ...................... 36 NOVOFINE 32..................... 61 NOVOFINE AUTOCOVER 61 NOVOFINE PLUS ............... 61 NOVOLIN 70/30 .................. 66 NOVOLIN N ........................ 66 NOVOLIN R ........................ 66 NOVOLOG .......................... 66 NOVOLOG FLEXPEN ........ 66 NOVOLOG MIX 70-30 ....... 66 NOVOLOG MIX 70-30 FLEXPEN ........................ 67 NOVOLOG PENFILL ......... 67 NOVOPEN ECHO ............... 61 NOVOSEVEN RT ............... 36 NOVOTWIST ...................... 61 NOXAFIL .............................. 3 NOXIFOL-D3 .................... 101 NOXIPAK ............................ 46 np thyroid ............................. 70 NPLATE ............................... 36 nts step 1 ............................... 49 131
NUCALA .............................93 NUCYNTA...........................24 NUCYNTA ER ....................24 NUDICLO SOLUPAK .........24 NUEDEXTA ........................19 NULEV.................................70 NULOJIX .............................14 NULYTELY WITH FLAVOR PACKS .............................73 NUOX...................................42 NUPLAZID ..........................28 NUTRIARX .........................46 NUTRICAP ........................101 NUTROPIN AQ ...................77 NUTROPIN AQ NUSPIN ....77 NUVARING .........................83 NUVESSA ............................83 NUVIGIL .............................28 NUWIQ ................................ 36 nyamyc .................................44 NYMALIZE .........................33 nystatin ............................. 3, 44 nystatin-triamcinolone ..........44 nystop ...................................44 O OB COMPLETE ................101 OB COMPLETE GOLD ....101 OB COMPLETE ONE .......101 OB COMPLETE PETITE ..101 OB COMPLETE PREMIER ........................................101 OB COMPLETE WITH DHA ........................................101 OBIZUR ...............................36 OBREDON ...........................91 obstetrix dha .......................101 OBSTETRIX EC ................101 OBTREX DHA ..................101 O-CAL FA ..........................101 O-CAL PRENATAL ..........101 OCALIVA ............................73 ocella.....................................85 OCTAGAM ..........................79 octreotide acetate ..................14 OCUFEN ..............................88 OCUFLOX ...........................87 ODEFSEY ..............................4 ODOMZO.............................14 OFEV ....................................93 ofloxacin .....................9, 50, 87
ogestrel (28).......................... 85 olanzapine............................. 28 olanzapine-fluoxetine ........... 28 OLEPTRO ER ...................... 28 olopatadine ..................... 49, 88 OLUX ................................... 46 OLUX-E ............................... 46 OLYSIO ................................. 4 OMECLAMOX-PAK .......... 75 omega-3 acid ethyl esters ..... 37 omeprazole ........................... 75 omeprazole-sodium bicarbonate ................. 75, 76 OMIDRIA ............................ 88 OMNARIS ........................... 93 OMNIPRED ......................... 89 OMNITROPE....................... 77 ON CALL EXPRESS CONTROL ....................... 62 ON CALL EXPRESS METER .......................................... 62 ON CALL EXPRESS TEST STRIP ............................... 53 ON CALL LANCET ............ 62 ON CALL LANCING DEVICE ........................... 62 ON CALL PLUS CONTROL .......................................... 62 ON CALL PLUS LANCET . 62 ON CALL PLUS LANCING DEVICE ........................... 62 ON CALL PLUS METER ... 62 ON CALL PLUS TEST STRIP .......................................... 53 ON CALL VIVID CONTROL .......................................... 62 ON CALL VIVID METER .. 62 ON CALL VIVID PAL METER ............................ 62 ON CALL VIVID TEST STRIP ............................... 53 ONCASPAR ........................ 14 ondansetron .......................... 73 ondansetron hcl .................... 73 ondansetron hcl (pf) ............. 73 ONE A DAY WOMEN'S PRENATAL DHA ......... 101 one daily prenatal ............... 101 ONE DAILY PRENATAL 101
ONETOUCH DELICA LANC DEVICE ........................... 62 ONETOUCH SURESOFT LANCING DEV ............... 62 ONETOUCH ULTRA CONTROL ....................... 62 ONETOUCH ULTRA TEST .......................................... 53 ONETOUCH ULTRA2 ........ 62 ONETOUCH ULTRAMINI. 62 ONETOUCH ULTRASOFT LANCETS ........................ 62 ONETOUCH VERIO ........... 53 ONETOUCH VERIO FLEX 62 ONETOUCH VERIO IQ METER ............................ 62 ONETOUCH VERIO SYNC .......................................... 62 ONETOUCH VERIO SYSTEM .......................... 62 ONEXTON ........................... 42 ONFI..................................... 16 ONGLYZA ........................... 69 ONIVYDE ............................ 14 ONMEL .................................. 3 ON-THE-GO LANCETS ..... 62 ONZETRA XSAIL............... 18 OPANA ................................ 22 OPANA ER .......................... 22 opcicon one-step ................... 85 OPDIVO ............................... 14 opium tincture....................... 70 OPSUMIT ............................ 93 OPTIUM EZ ......................... 53 OPTIUM TEST .................... 53 OPTUMRX .................... 53, 62 ORACEA.............................. 10 ORACIT ............................... 95 oral saline laxative ................ 73 ORALAIR ............................ 79 oralone .................................. 49 ORAMAGICRX ................... 49 ORAP ................................... 28 ORAPRED ODT .................. 51 ORAVIG ................................ 3 ORENCIA ............................ 80 ORENCIA (WITH MALTOSE) ...................... 80 ORENCIA CLICKJECT ...... 80 ORENITRAM ...................... 33 132
ORFADIN ............................48 ORKAMBI ...........................93 orphenadrine citrate ..............19 orsythia .................................85 ortho d .................................101 ORTHO MICRONOR ..........82 ORTHO TRI-CYCLEN (28) 85 ORTHO TRI-CYCLEN LO (28) ...................................85 ORTHO-CYCLEN (28) .......85 ORTHO-NOVUM 1/35 (28) 85 ORTHO-NOVUM 7/7/7 (28) ..........................................85 oscimin .................................70 oscimin sl ..............................71 oscimin sr..............................71 OSENI ..................................69 OSMOPREP .........................73 OSPHENA ............................83 OTEZLA...............................80 OTEZLA STARTER ............80 OTIPRIO ..............................50 OTOVEL ..............................50 OTREXUP (PF)....................81 OVACE ................................ 38 OVACE PLUS......................38 OVACE PLUS SHAMPOO .38 OVACE PLUS WASH .........38 OVCON-35 (28) ...................85 OVIDE ..................................47 oxacillin ..................................9 oxacillin in dextrose(iso-osm) 9 oxaliplatin .............................14 OXANDRIN .........................67 oxandrolone ..........................67 oxaprozin ..............................24 OXAYDO .............................22 oxazepam ..............................28 oxcarbazepine .......................16 oxiconazole ...........................44 OXISTAT .............................44 OXSORALEN ULTRA........40 OXTELLAR XR ..................16 oxybutynin chloride ..............94 oxycodone.............................22 OXYCODONE .....................22 oxycodone-acetaminophen ...22 oxycodone-aspirin ................22 OXYCONTIN ......................22 oxymorphone ........................22
OXYTROL ........................... 94 oysco 500/d .......................... 96 oysco d.................................. 96 oyster shell + d3 ................... 96 oyster shell calcium-vit d2 . 101 oyster shell calcium-vit d3 ... 96 oystercal-d ............................ 96 OZURDEX ........................... 89 P pacerone ............................... 30 paclitaxel .............................. 14 PAIRE OB PLUS DHA ..... 101 paliperidone .......................... 28 PAMELOR ........................... 28 pamidronate .......................... 67 PANCREAZE ...................... 73 PANDEL .............................. 46 PANRETIN .......................... 40 pantoprazole ......................... 76 PARAFON FORTE DSC ..... 19 PARAGARD T 380A........... 81 paregoric ............................... 71 PAREMYD .......................... 87 paricalcitol ............................ 67 PARICALCITOL ................. 67 PARLODEL ......................... 17 PARNATE ........................... 28 paromomycin .......................... 8 paroxetine hcl ....................... 28 PASER ................................... 8 PATADAY ........................... 88 PATANASE ......................... 49 PATANOL ........................... 88 PAXIL .................................. 28 PAXIL CR ............................ 28 PAZEO ................................. 88 PCE......................................... 6 PED MULTIVITAMINSA,B,D,E,K,ZN ................ 101 PEDIAPRED ........................ 51 PEDIARIX (PF) ................... 79 peg 3350-electrolytes ........... 73 peg3350 ................................ 73 PEGANONE ........................ 16 PEGASYS ............................ 77 PEGASYS PROCLICK ....... 77 peg-electrolyte soln .............. 73 PEGINTRON ....................... 77 PEGINTRON REDIPEN ..... 77 peg-prep ................................ 73
PEN NEEDLE ...................... 62 PEN NEEDLE, DIABETIC . 62 penicillin g potassium ............. 9 penicillin v potassium............. 9 PENLAC .............................. 44 PENNSAID .......................... 24 PENTACEL ACTHIB COMPONENT (PF) ......... 79 PENTASA ............................ 73 pentazocine-naloxone ........... 24 PENTIPS .............................. 62 pentoxifylline........................ 36 PEPCID ................................ 76 PERCOCET.......................... 22 PERFOROMIST .................. 93 PERIDEX ............................. 50 perindopril erbumine ............ 33 periogard ............................... 50 PERJETA ............................. 14 permethrin ............................ 47 perphenazine ......................... 28 perphenazine-amitriptyline ... 28 perry prenatal ...................... 101 PERTZYE ............................ 73 PEXEVA .............................. 28 pfizerpen-g.............................. 9 PHARMACIST CHOICE .... 53 PHARMACIST CHOICE GLUCOSE SYS ............... 62 PHASEAL PROTECTOR .... 62 phenadoz ............................... 90 phenazopyridine ................... 95 phenelzine............................. 28 phenergan ............................. 90 phenobarbital ........................ 16 phenohytro ............................ 71 phenoxybenzamine ............... 33 phentolamine ........................ 33 phenylephrine hcl ................. 90 phenylhistine dh ................... 91 PHENYTEK ......................... 17 phenytoin .............................. 17 phenytoin sodium extended .. 17 philith.................................... 85 PHOSLYRA ......................... 73 phospha 250 neutral.............. 96 phosphasal ............................ 95 phosphate laxative ................ 73 PHOSPHOLINE IODIDE .... 87 133
PHYSICIANS EZ USE B-12 ........................................101 PHYSIOLYTE .....................47 PHYSIOSOL IRRIGATION 47 PICATO ................................ 40 pilocarpine hcl ..........48, 50, 87 pimozide ...............................28 pimtrea (28) ..........................85 pindolol .................................33 pioglitazone ..........................69 pioglitazone-glimepiride.......69 pioglitazone-metformin ........69 piperacillin-tazobactam ..........9 pirmella .................................85 piroxicam ..............................24 PLAN B ONE-STEP ............85 PLAQUENIL ..........................8 PLAVIX ...............................36 PLEGRIDY ..........................77 PLEXION .............................42 PLEXION CLEANSING CLOTHS...........................42 PLIAGLIS ............................43 PNEUMOVAX 23................79 pnv 29-1 .............................. 101 pnv ob+dha .........................101 pnv-dha ............................... 101 pnv-dha + docusate .............101 pnv-ferrous fumarate-docu-fa ........................................101 pnv-omega ..........................101 pnv-select ............................101 pnv-vp-u .............................101 PODOCON ...........................39 podofilox...............................40 POLY HUB NEEDLE ..........62 polycin ..................................87 polyethylene glycol 3350 .....73 polymyxin b sulfate ................8 polymyxin b sulf-trimethoprim ..........................................87 POLYTRIM ..........................87 POLY-TUSSIN AC ..............91 POLY-VI-FLOR.................101 POLY-VI-FLOR FS ...........101 POLY-VI-FLOR WITH IRON ........................................101 poly-vita (iron)....................101 poly-vitamin with iron ........101 POMALYST.........................77
PONSTEL ............................ 24 portia..................................... 85 PORTRAZZA ...................... 14 pot,sodium citrate-citric acid 95 POTABA .............................. 96 potassium acetate.................. 96 potassium bicarb and chloride .......................................... 96 potassium bicarb-citric acid . 96 potassium chloride................ 96 potassium chloride in 0.9%nacl .......................................... 96 potassium citrate ................... 95 potassium citrate-citric acid . 95 POTASSIUM HYDROXIDE .......................................... 39 POTIGA ............................... 17 powderlax ............................. 73 pr natal 400 ......................... 101 pr natal 400 ec .................... 101 pr natal 430 ......................... 101 pr natal 430 ec .................... 101 PRADAXA........................... 36 PRALUENT PEN ................ 37 PRALUENT SYRINGE ....... 37 pramcort ............................... 73 pramipexole .......................... 17 PRAMOSONE ..................... 38 PRAMOSONE E .................. 38 PRANDIN ............................ 69 PRAVACHOL ..................... 37 pravastatin ............................ 37 PRAXBIND ......................... 36 prazosin ................................ 33 PRECISION PCX PLUS TEST .......................................... 53 PRECISION PCX TEST ...... 53 PRECISION POINT OF CARE TEST..................... 53 PRECISION Q-I-D TEST .... 53 PRECISION XTRA MONITOR ....................... 62 PRECISION XTRA TEST ... 53 PRECOSE ............................ 69 PRED FORTE ...................... 89 PRED MILD ........................ 89 PRED-G ............................... 89 PRED-G S.O.P. .................... 89 prednicarbate ........................ 46 prednisolone ......................... 51
prednisolone acetate ............. 89 prednisolone sodium phosphate .................................... 51, 89 prednisone ............................ 51 prednisone intensol ............... 51 PREFERA-OB.................... 101 PREFERA-OB ONE .......... 101 PREFERA-OB PLUS DHA ........................................ 102 PREFEST ............................. 82 PREMARIN ......................... 82 PREMIUM BLOOD GLUCOSE MONITOR .... 62 PREMIUM V10 ............. 53, 62 PREMPHASE ...................... 82 PREMPRO ........................... 82 prena1 chew ........................ 102 prena1 pearl ........................ 102 prena1 true .......................... 102 prenaissance........................ 102 prenaissance next ................ 102 prenaissance plus ................ 102 PRENATA.......................... 102 prenatabs fa......................... 102 prenatabs rx ........................ 102 prenatal ............................... 102 prenatal complete ............... 102 prenatal formula ................. 102 prenatal multi-dha (algal oil) ........................................ 102 prenatal one daily ............... 102 prenatal plus ....................... 102 prenatal plus (calcium carb)102 prenatal vit#96-ferrous fum-fa ........................................ 102 prenatal vitamin .................. 102 prenatal vitamin plus low iron ........................................ 102 prenatal vitamin with minerals ........................................ 102 prenatal-u ............................ 102 PRENATE AM................... 102 PRENATE CHEWABLE ... 102 PRENATE DHA (FERR ASP GLYCIN)........................ 102 PRENATE ELITE (IRON ASP GLYC) ............................ 102 PRENATE ENHANCE ...... 102
134
PRENATE ESSENTIAL(IRON-ASPGL) .................................102 PRENATE MINI (FERR ASP GLYCIN) ........................102 PRENATE PIXIE ...............102 PRENATE RESTORE .......102 PRENATE STAR ...............102 PREPIDIL.............................83 preplus ................................ 102 PREPOPIK ...........................73 PREQUE 10........................102 PRESERA.............................40 PRESSURE ACTIVATED LANCETS ........................62 PRESTALIA.........................33 PRESTO PRO BLOOD GLUCOSE METER .........62 pretab ..................................102 PREVACID ..........................76 PREVACID SOLUTAB .......76 prevalite ................................ 37 PREVIDENT ........................50 PREVIDENT 5000 BOOSTER PLUS ................................ 50 PREVIDENT 5000 DRY MOUTH ...........................50 PREVIDENT 5000 ENAMEL PROTECT ........................50 PREVIDENT 5000 PLUS ....50 PREVIDENT 5000 SENSITIVE ......................50 previfem ................................ 86 PREVPAC ............................76 PREZCOBIX ..........................4 PREZISTA .............................4 PRIFTIN .................................8 PRILOSEC ...........................76 PRIMAQUINE .......................8 PRIMAXIN IV .......................8 primidone ..............................17 PRIMLEV.............................22 PRIMSOL .............................10 PRINIVIL .............................33 PRISTIQ ...............................28 PRIVIGEN ...........................79 PRO COMFORT LANCETS ..........................................62 PROAIR HFA ......................93 PROAIR RESPICLICK........93
probenecid ............................ 80 probenecid-colchicine .......... 80 PROBUPHINE ..................... 22 procainamide ........................ 30 PROCARDIA ....................... 33 PROCARDIA XL ................ 33 procentra ............................... 28 prochlorperazine ................... 73 prochlorperazine edisylate.... 73 prochlorperazine maleate ..... 73 PROCORT ........................... 73 PROCRIT ............................. 77 PROCTOCORT ................... 73 PROCTOFOAM HC ............ 73 procto-med hc ....................... 73 proctosol hc .......................... 73 proctozone-hc ....................... 73 PROCYSBI .......................... 95 PRODIGY AUTOCODE METER ............................ 63 PRODIGY AUTOCODE MONITOR SYST ............ 63 PRODIGY CONTROL SOLUTION, LOW ........... 63 PRODIGY CONTROL SOLUTION,HIGH ........... 63 PRODIGY LANCETS ......... 63 PRODIGY LANCING DEVICE ........................... 63 PRODIGY NO CODING ..... 53 PRODIGY POCKET METER .......................................... 63 PRODIGY TWIST TOP LANCET .......................... 63 PRODIGY VOICE GLUCOSE METER ............................ 63 PRODRIN ............................ 18 PROFERRIN-FORTE ........ 102 PROFILNINE....................... 36 progesterone micronized ...... 82 PROGLYCEM ..................... 54 PROGRAF ........................... 14 PROLASTIN-C .................... 48 PROLENSA ......................... 88 PROLEUKIN ....................... 78 PROLIA ............................... 80 PROMACTA........................ 36 promethazine ........................ 90 promethazine vc ................... 91 promethazine vc-codeine...... 91
promethazine-codeine .......... 91 promethazine-dm .................. 91 promethazine-phenylephcodeine.............................. 91 promethegan ......................... 90 PROMETRIUM ................... 82 PROMISEB .......................... 40 PROMISEB COMPLETE .... 38 propafenone .......................... 30 propantheline ........................ 71 proparacaine ......................... 88 propranolol ........................... 33 propranolol-hydrochlorothiazid .......................................... 33 propylthiouracil .................... 51 PROQUAD (PF)................... 79 PRO-RED AC (W/ DEXCHLORPHENIR) .... 91 PROSCAR ............................ 94 PROSTIN E2 ........................ 83 PROTECT IRON ............... 102 PROTONIX .......................... 76 PROTOPIC ........................... 40 protriptyline .......................... 28 PROVENGE......................... 79 PROVENTIL HFA ............... 93 PROVERA ........................... 82 PROVIDA DHA................. 102 PROVIDA OB .................... 102 PROVIGIL ........................... 28 PROZAC .............................. 28 PROZAC WEEKLY ............ 28 pruclair.................................. 40 prudoxin................................ 40 prumyx.................................. 40 prutect ................................... 40 PSORCON............................ 46 PULMICORT ....................... 93 PULMICORT FLEXHALER .......................................... 93 pulmosal ............................... 93 PULMOZYME ..................... 93 PURALOR CI .................... 102 PUREFE OB PLUS ............ 102 PUREFE PLUS .................. 102 purelax .................................. 73 purevit dualfe plus .............. 102 PURIXAN ............................ 14 PYLERA .............................. 76 pyrazinamide .......................... 8 135
PYRIDIUM ..........................95 pyridostigmine bromide........19 Q QBRELIS .............................33 Q-CARE RX Q4 ...................50 QNASL .................................93 QUADRACEL (PF) .............79 QUALAQUIN ........................8 QUARTETTE.......................86 quasense ................................ 86 quazepam ..............................28 QUDEXY XR .......................17 QUESTRAN .........................37 QUESTRAN LIGHT ............37 quetiapine .............................28 QUFLORA FE....................102 QUFLORA PEDIATRIC ...102 QUFLORA PEDIATRIC DROPS ...........................102 QUILLICHEW ER ...............28 QUILLIVANT XR ...............28 quinapril ................................ 33 quinapril-hydrochlorothiazide ..........................................33 quinidine gluconate ..............30 quinidine sulfate ...................30 quinine sulfate ........................8 QUINTET AC ......................53 QUINTET BLOOD GLUCOSE METER .........63 quit 2 .....................................49 QUIT 2..................................49 quit 4 .....................................49 QUIT 4..................................49 QUTENZA ...........................40 QVAR ...................................93 R rabeprazole ...........................76 RADIOGARDASE...............48 RAGWITEK .........................79 raloxifene ..............................80 ramipril .................................33 RANEXA .............................37 ranitidine hcl .........................76 RAPAFLO ............................94 RAPAMUNE ........................14 RASUVO (PF)......................81 RAVICTI ..............................48 RAYOS.................................51 RAZADYNE ........................19
RAZADYNE ER .................. 19 rea lo 39 ................................ 40 rea lo 40 ................................ 40 react ...................................... 86 REBETOL ............................ 77 REBIF (WITH ALBUMIN) . 77 REBIF REBIDOSE .............. 77 REBIF TITRATION PACK 77 RECLAST ............................ 48 reclipsen (28) ........................ 86 RECOMBINATE ................. 36 RECOMBIVAX HB (PF) .... 79 RECTIV ............................... 73 REFUAH PLUS ................... 53 REFUAH PLUS GLUCOSE CONTROL ....................... 63 REFUAH PLUS GLUCOSE MONITOR ....................... 63 REGLAN .............................. 73 REGRANEX ........................ 40 relador pak ............................ 43 relador pak plus .................... 43 RELAGARD ........................ 83 relcof c .................................. 91 RELENZA DISKHALER ...... 4 RELIAMED LANCET ........ 63 RELIAMED MINI LANCING DEVICE ........................... 63 RELIAMED SAFETY SEAL LANCETS ........................ 63 RELION ALL-IN-ONE METER ............................ 63 RELION CONFIRM ............ 63 RELION CONFIRM-MICRO .......................................... 54 RELION MICRO GLUCOSE MONITOR ....................... 63 RELION NEEDLES ............ 63 RELION PEN NEEDLES .... 63 RELION PRIME METER ... 63 RELION PRIME TEST STRIPS ............................. 54 RELION THIN LANCETS .. 63 RELION ULTRA THIN PLUS LANCETS ........................ 63 RELISTOR ..................... 73, 74 relnate dha .......................... 102 RELPAX .............................. 18 REMERON .......................... 28 REMERON SOLTAB .......... 28
remeven ................................ 40 REMICADE ......................... 74 REMODULIN ...................... 33 RENAGEL ........................... 74 renal caps ............................ 102 rena-vite .............................. 103 rena-vite rx ......................... 103 reno caps ............................. 103 RENVELA ........................... 74 repaglinide ............................ 69 repaglinide-metformin .......... 69 REPATHA PUSHTRONEX 37 REPATHA SURECLICK .... 37 REPATHA SYRINGE ......... 37 reprexain ............................... 22 REQUIP................................ 17 REQUIP XL ......................... 17 RESCRIPTOR ........................ 4 reserpine ............................... 33 RESPA-AR........................... 91 RESTASIS............................ 88 RESTIZAN ........................... 40 RESTORIL ........................... 28 RETIN-A .............................. 42 RETIN-A MICRO ................ 42 RETIN-A MICRO PUMP .... 42 RETISERT ........................... 89 RETROVIR ............................ 4 REVATIO ............................ 93 REVEAL BLOOD GLUCOSE METER ............................ 63 REVEAL TEST STRIP ........ 54 REVESTA .......................... 103 REVIA .................................. 24 REVLIMID .......................... 77 REXULTI ............................. 28 REYATAZ ............................. 4 REZIRA................................ 91 RIASTAP ............................. 36 ribasphere ............................. 78 ribasphere ribapak ................ 78 ribavirin ................................ 78 RIDAURA ............................ 81 rifabutin .................................. 8 RIFADIN ................................ 8 RIFAMATE............................ 8 rifampin .................................. 8 RIFATER ............................... 8 RIGHTEST CONTROL SOLUTION HIGH ........... 63 136
RIGHTEST GD500 LANCING DEVICE ........63 RIGHTEST GL300 LANCETS ..........................................63 RIGHTEST GM550 SYSTEM ..........................................63 RIGHTEST GS550 TEST STRIPS .............................54 RILUTEK .............................48 riluzole ..................................48 rimantadine .............................4 ringers ...................................47 RIOMET ...............................69 risacal-d .............................. 103 risedronate ......................48, 80 RISPERDAL ........................28 RISPERDAL M-TAB ..........28 risperidone ......................28, 29 RITALIN ..............................29 RITALIN LA ........................29 RITUXAN ............................14 rivastigmine ..........................19 rivastigmine tartrate ..............19 RIXUBIS ..............................36 rizatriptan ..............................18 R-NATAL OB ....................103 ROBAXIN ............................20 ROBAXIN-750.....................20 ROBINUL ............................71 ROBINUL FORTE ...............71 ROCALTROL ......................67 ropinirole ..............................17 rosadan ..................................42 ROSADAN ...........................42 ROSANIL .............................42 ROSULA ..............................42 rosula cleansing cloths ..........42 rosuvastatin ...........................37 ROWASA .............................74 roweepra ...............................17 ROXICODONE ....................22 ROXIFOL-D.......................103 ROZEREM ...........................29 RUCONEST .........................93 rulavite dha .........................103 rydex .....................................91 RYNODERM .......................41 RYTARY ..............................17 RYTHMOL ..........................30 RYTHMOL SR ....................30
S SABRIL................................ 17 SAFETY LANCETS ............ 63 SAFETY SEAL LANCETS . 63 SAFETY-LET LANCETS ... 63 SAFYRAL............................ 86 SAIZEN ................................ 77 SAIZEN CLICK.EASY ....... 77 salacyn .................................. 39 SALAGEN ..................... 48, 50 SALEX ................................. 39 salicylic acid ......................... 39 salicylic acid er-ceramides ... 39 SALKERA ........................... 39 salsalate ................................ 24 salvax.................................... 39 SALVAX DUO PLUS ......... 39 SAMSCA ............................. 67 SANADERMRX .................. 46 SANCUSO ........................... 74 SANDIMMUNE .................. 14 SANDOSTATIN .................. 14 SANDOSTATIN LAR DEPOT ............................. 14 SANTYL .............................. 46 SAPHRIS (BLACK CHERRY) ........................ 29 SARAFEM ........................... 29 SAVAYSA ........................... 36 SAVELLA ............................ 81 scalacort ................................ 46 SCALACORT DK ............... 46 SEASONIQUE ..................... 86 seb-prev ................................ 38 seconal sodium ..................... 29 SECTRAL ............................ 33 SELECT-OB ...................... 103 SELECT-OB (FOLIC ACID) ........................................ 103 SELECT-OB + DHA ......... 103 selegiline hcl ......................... 17 selenium sulfide.................... 38 SELRX ................................. 38 SELZENTRY ......................... 4 SEMPREX-D ....................... 91 se-natal 19 .......................... 103 se-natal 19 (with docusate) . 103 SENSIPAR ........................... 67 SEREVENT DISKUS .......... 93 SERNIVO............................. 46
SEROQUEL ......................... 29 SEROQUEL XR................... 29 SEROSTIM .......................... 77 sertraline ............................... 29 se-tan plus ........................... 103 setlakin.................................. 86 sf 50 sf 5000 plus .......................... 50 SFROWASA ........................ 74 sharobel ................................ 82 SHOHL'S MODIFIED ......... 95 SIDEKICK BLOOD GLUCOSE SYSTEM ....... 63 SIGNIFOR............................ 14 SIGNIFOR LAR................... 14 SILAZONE-II ...................... 46 sildenafil ............................... 93 SILENOR ............................. 29 SILVADENE........................ 39 silver nitrate .......................... 41 silver nitrate applicators ....... 41 silver sulfadiazine ................. 39 SIMBRINZA ........................ 89 SIMPONI.............................. 81 SIMPONI ARIA ................... 81 SIMULECT .......................... 14 simvastatin ............................ 37 SINEMET ............................. 17 SINEMET CR ...................... 17 SINGLE-LET ....................... 63 SINGULAIR ........................ 93 sirolimus ............................... 14 SIRTURO ............................... 8 SITAVIG ................................ 4 SIVEXTRO ............................ 8 SKELAXIN .......................... 20 SKLICE ................................ 47 SKYLA ................................. 81 SMART SENSE LANCETS 64 SMART SENSE MONITORING SYSTEM 64 SMART SENSE TEST STRIPS ............................. 54 SMARTDIABETES VANTAGE ....................... 64 SMARTEST CONTROL ..... 64 SMARTEST EJECT............. 64 SMARTEST LANCET ........ 64 SMARTEST PERSONA STARTER ........................ 64 137
SMARTEST PRONTO STARTER ........................64 SMARTEST PROTEGE ......64 SMARTEST TEST ...............54 SMARTRX GABAKIT ........17 SMARTRX GABA-V KIT...17 smoothlax .............................74 SNAP INSULIN PUMP CONTROLLER ................64 sodium benzoate-sod phenylacet .........................48 sodium chlor 0.9% bacteriostat ..........................................48 sodium chloride ..............93, 96 sodium chloride 0.45 % ........96 sodium chloride 0.9 % ..........48 SODIUM CHLORIDE 0.9 % ..........................................48 sodium chloride 3 % .............97 sodium chloride 5 % .............97 sodium citrate-citric acid ......95 SODIUM EDECRIN ............33 sodium ferric gluconat-sucrose ..........................................48 sodium fluoride .............50, 103 sodium phenylbutyrate .........48 SODIUM PHOSPHATE IN 0.9 % NACL .....................97 sodium polystyrene sulfonate ..........................................74 SODIUM POLYSTYRENE SULFONATE ...................74 SOFT TOUCH LANCETS...64 SOFTGELS MULTIVITA,B,D,E,K,ZN ................103 SOLARAZE .........................41 SOLESTA.............................74 SOLIRIS ...............................48 SOLODYN ...........................10 SOLTAMOX ........................14 SOLUS V2 AUDIBLE METER.............................64 SOLUS V2 CONTROL SOLUTION,HIGH ...........64 SOLUS V2 LANCETS.........64 SOLUS V2 LANCING DEVICE ...........................64 SOLUS V2 TEST STRIPS ...54 SOMA...................................20 SOMATULINE DEPOT ......14
SOMAVERT ........................ 68 sonafine ................................ 41 SONATA .............................. 29 SOOLANTRA ...................... 42 SORBITOL-MANNITOL .... 47 SORIATANE ....................... 39 SORILUX............................. 39 sotalol ................................... 30 sotalol af ............................... 30 SOTYLIZE ........................... 30 SOVALDI .............................. 4 sp antipruritic........................ 41 sp scar management ............. 41 SPECTRACEF ....................... 6 spinosad ................................ 47 SPIRIVA RESPIMAT ......... 93 SPIRIVA WITH HANDIHALER ................ 93 spironolactone ...................... 33 spironolacton-hydrochlorothiaz .......................................... 33 SPORANOX .......................... 3 SPORANOX PULSEPAK ..... 3 sprintec (28).......................... 86 SPRITAM............................. 17 SPRIX................................... 24 SPRYCEL ............................ 14 sps (with sorbitol) ................. 74 sronyx ................................... 86 ss 10-2 .................................. 42 ssd ......................................... 39 SSKI ..................................... 51 sss 10-5 ................................. 42 STALEVO 100 ..................... 17 STALEVO 125 ..................... 17 STALEVO 150 ..................... 17 STALEVO 200 ..................... 18 STALEVO 50 ....................... 18 STALEVO 75 ....................... 18 STARLIX ............................. 69 stavudine................................. 4 STELARA ............................ 39 STERILANCE TL................ 64 STIMATE............................. 68 STIOLTO RESPIMAT ........ 93 STIVARGA .......................... 14 stop smoking aid................... 49 STRATTERA ....................... 29 STRENSIQ ........................... 68 STREPTOMYCIN ................. 8
stress formula ..................... 103 stress formula with iron ...... 103 stress formula with iron(sulf) ........................................ 103 STRIANT ............................. 68 STRIBILD .............................. 5 STRIVERDI RESPIMAT .... 94 STROMECTOL ..................... 8 strong iodine ......................... 97 STROVITE FORTE ........... 103 STROVITE ONE ............... 103 SUBOXONE ........................ 24 SUBSYS ............................... 22 SUCRAID ............................ 74 sucralfate .............................. 76 SULAR ................................. 33 sulfacetamide sodium ..... 39, 89 sulfacetamide sodium (acne) 44 sulfacetamide sodium-sulfur 42 sulfacetamide sod-sulfur-urea .......................................... 42 sulfacetamide-prednisolone .. 89 sulfacetamide-sulfur-cleansr23 .......................................... 43 sulfacleanse 8-4 .................... 43 sulfact na-sul-avobnz-otn-ocsa .......................................... 43 sulfadiazine............................. 9 sulfamethoxazole-trimethoprim ............................................ 9 SULFAMYLON ................... 44 sulfasalazine ......................... 74 sulfatrim.................................. 9 sulindac................................. 24 SUMADAN .......................... 43 SUMADAN XLT ................. 43 sumatriptan ........................... 18 sumatriptan succinate ........... 18 SUMAVEL DOSEPRO ....... 18 SUMAXIN ........................... 43 SUMAXIN CP ..................... 43 SUMAXIN TS ...................... 43 super b complex-vitamin c . 103 super b maxi complex......... 103 super b-50 complex plus..... 103 super quints......................... 103 super quints b-50 ................ 103 SUPER THIN LANCETS .... 64 superplex-t .......................... 103 SUPERVITE ...................... 103 138
SUPPRELIN LA ..................14 SUPRAX ................................6 SUPREP BOWEL PREP KIT ..........................................74 SURE COMFORT LANCETS ..........................................64 SURE COMFORT LANCING PEN...................................64 SURE COMFORT PEN NEEDLE...........................64 SURE RESULT DSS PREMIUM PACK ............24 SURE RESULT TAC PAK ..46 SURE-FINE PEN NEEDLES ..........................................64 SUREFLEX LANCING DEVICE ...........................64 SURE-LANCE .....................64 SURE-PEN LANCING DEVICE ...........................64 SURE-TEST EASYPLUS MINI .................................54 SURE-TEST EASYPLUS MINI METER ..................64 SURE-TOUCH LANCET ....64 SURFAXIN ..........................94 SURMONTIL .......................29 SURVANTA ........................48 SUSTIVA ...............................5 SUSTOL ...............................74 SUTENT ...............................14 SWABFLUSH ......................48 syeda .....................................86 SYLATRON .........................78 SYLVANT ...........................14 SYMAX DUOTAB ..............71 symax fastabs........................71 symax-sl ................................ 71 symax-sr ...............................71 SYMBICORT .......................94 SYMBYAX ..........................29 SYMLINPEN 120 ................69 SYMLINPEN 60 ..................69 SYNAGIS ...............................5 SYNALAR ...........................46 SYNALAR CREAM KIT ....46 SYNALAR OINTMENT KIT ..........................................46 SYNALAR TS......................46 SYNALGOS-DC ..................22
SYNAREL ........................... 68 SYNERA .............................. 43 SYNJARDY ......................... 69 SYNRIBO ............................ 14 SYNTHROID ....................... 70 SYPRINE ............................. 48 syrex sodium chloride 0.9% . 48 T T 30 INFUSION SET .......... 64 90 INFUSION SET 23 ..... 64 SLIM ................................ 64 SLIM G4 .......................... 64 TABLOID ............................ 14 TACLONEX ........................ 39 tacrolimus ....................... 14, 41 TAFINLAR .......................... 14 TAGRISSO .......................... 14 TAKE ACTION ................... 86 TALTZ AUTOINJECTOR .. 39 TALTZ AUTOINJECTOR (2 PACK) .............................. 39 TALTZ AUTOINJECTOR (3 PACK) .............................. 39 TALTZ SYRINGE ............... 39 TALTZ SYRINGE (2 PACK) .......................................... 39 TALTZ SYRINGE (3 PACK) .......................................... 39 TALWIN .............................. 24 TAMIFLU .............................. 5 tamoxifen.............................. 14 tamsulosin............................. 95 TANDEM PLUS ................ 103 TANZEUM .......................... 69 TAPAZOLE ......................... 51 TARCEVA ........................... 14 TARGADOX ....................... 10 TARGRETIN ....................... 14 tarina fe 1/20 (28) ................. 86 TARKA ................................ 33 taron forte ........................... 103 taron-c dha .......................... 103 taron-prex prenatal-dha ...... 103 TASIGNA ............................ 14 TASMAR ............................. 18 TAXOTERE ......................... 14 TAYTULLA......................... 86 TAZICEF ............................... 6 TAZORAC ........................... 43
TECENTRIQ ........................ 14 TECFIDERA ........................ 78 TECHLITE LANCETS ........ 64 TECHLITE PEN NEEDLE .. 64 TECHNIVIE ........................... 5 TEFLARO .............................. 6 TEGRETOL ......................... 17 TEGRETOL XR ................... 17 TEKTURNA ........................ 33 TEKTURNA HCT ............... 33 TELCARE BGM .................. 64 TELCARE BLOOD GLUCOSE KIT ................ 64 TELCARE CONTROL ........ 64 TELCARE TEST STRIPS ... 54 telmisartan ............................ 33 telmisartan-amlodipine ......... 34 telmisartan-hydrochlorothiazid .......................................... 34 temazepam ............................ 29 TEMODAR .......................... 15 TEMOVATE ........................ 46 temozolomide ....................... 15 tencon ................................... 22 TENEX ................................. 34 TENIPOSIDE ....................... 15 TENIVAC (PF) .................... 79 TENORETIC 100 ................. 34 TENORETIC 50 ................... 34 TENORMIN ......................... 34 TERAZOL 7 ......................... 83 terazosin................................ 34 terbinafine hcl ......................... 3 terbutaline ............................. 94 terconazole............................ 83 TERSI FOAM ...................... 39 TESSALON PERLES .......... 91 TEST N'GO BLOOD GLUCOSE SYSTEM ....... 64 TEST N'GO TEST ............... 54 TESTIM................................ 68 TESTONE CIK .................... 68 testosterone ........................... 68 TESTOSTERONE................ 68 testosterone cypionate .......... 68 testosterone enanthate........... 68 TESTRED ............................ 68 TETANUS,DIPHTHERIA TOX PED(PF) .................. 79 139
TETANUS-DIPHTHERIA TOXOIDS-TD ..................79 tetcaine ..................................88 tetrabenazine .........................19 tetracaine hcl .........................88 tetracaine hcl (pf) ..................88 tetracycline ...........................10 TETRAVISC ........................88 TETRAVISC FORTE ..........88 TEXACORT .........................46 TEXAVITE LQ ..................103 THALOMID .........................15 THEO-24 ..............................94 theochron ..............................94 theophylline ..........................94 thermazene ............................39 THIOLA ...............................48 thioridazine ...........................29 thiotepa .................................15 thiothixene ............................29 THRIVITE RX ...................103 thrivite-19 ...........................103 THYMOGLOBULIN ...........79 THYROLAR-1 .....................70 THYROLAR-1/2 ..................70 THYROLAR-1/4 ..................70 THYROLAR-2 .....................70 THYROLAR-3 .....................70 tiagabine ...............................17 TIAZAC ...............................34 TICANASE ..........................94 TICASPRAY ........................94 ticlopidine .............................36 TIGAN ..................................74 TIKOSYN.............................30 tilia fe ....................................86 timolol maleate ...............34, 87 TIMOPTIC ...........................87 TIMOPTIC OCUDOSE (PF) ..........................................87 TIMOPTIC-XE.....................87 TINDAMAX ..........................8 tinidazole ................................8 TIROSINT ............................70 tis-u-sol pentalyte .................47 TIVICAY ................................5 TIVORBEX ..........................24 tizanidine ..............................20 tl gard rx .............................103 tl g-fol os.............................103
tl icon .................................. 103 tl-hem 150 .......................... 103 TOBI....................................... 8 TOBI PODHALER ................ 8 TOBRADEX ........................ 89 TOBRADEX ST .................. 89 tobramycin ............................ 87 tobramycin in 0.225 % nacl ... 8 TOBRAMYCIN WITH NEBULIZER ...................... 8 tobramycin-dexamethasone.. 89 TOBREX .............................. 87 TODAY CONTRACEPTIVE SPONGE .......................... 83 TOFRANIL .......................... 29 TOLAK ................................ 41 tolazamide ............................ 69 tolbutamide ........................... 69 tolcapone .............................. 18 tolmetin................................. 24 tolterodine............................. 94 TOPAMAX .......................... 17 TOPCARE UNIVERSAL1 LANCET .......................... 65 TOPICORT .......................... 46 topiramate ............................. 17 TOPIRAMATE .................... 17 toposar .................................. 15 topotecan .............................. 15 TOPROL XL ........................ 34 TORISEL ............................. 15 TORONOVA II SUIK ......... 24 TORONOVA SUIK ............. 24 torsemide .............................. 34 total b/c ............................... 103 TOUJEO SOLOSTAR ......... 67 TOVIAZ ............................... 94 TRACLEER ......................... 94 TRADJENTA ....................... 69 tramadol ................................ 24 TRAMADOL ....................... 24 tramadol-acetaminophen ...... 24 trandolapril ........................... 34 trandolapril-verapamil .......... 34 tranexamic acid .............. 36, 83 TRANSDERM-SCOP .......... 74 TRANXENE T-TAB............ 29 tranylcypromine ................... 29 TRAVATAN Z .................... 89 trazodone .............................. 29
TREANDA ........................... 15 TRECATOR ........................... 8 TRELSTAR .......................... 15 TRESIBA FLEXTOUCH U100 .................................... 67 TRESIBA FLEXTOUCH U200 .................................... 67 tretinoin ................................ 43 tretinoin (chemotherapy) ...... 15 tretinoin microspheres .......... 43 TRETIN-X............................ 43 TRETIN-X CREAM KIT..... 43 TRETTEN ............................ 36 TREXALL ............................ 15 TREXIMET .......................... 18 TREZIX ................................ 22 TRIACETIN ......................... 44 triamcinolone acetonide 46, 50, 94 triamterene-hydrochlorothiazid .......................................... 34 trianex ................................... 46 triazolam ............................... 29 TRIBENZOR........................ 34 TRICARE ........................... 103 TRICARE PRENATAL ..... 103 TRICARE PRENATAL DHA ONE ................................ 103 TRICARE PRENATAL WITH DHA ............................... 103 tricitrates ............................... 95 tricon................................... 104 TRICOR ............................... 37 triderm .................................. 46 tri-estarylla............................ 86 TRIFERIC .......................... 104 trifluoperazine ...................... 29 trifluridine............................. 87 trigels-f forte ....................... 104 TRIGLIDE............................ 37 trihexyphenidyl ..................... 18 tri-legest fe ............................ 86 TRILEPTAL ......................... 17 tri-linyah ............................... 86 TRILIPIX ............................. 37 tri-lo-estarylla ....................... 86 tri-lo-marzia .......................... 86 tri-lo-sprintec ........................ 86 trilyte with flavor packets ..... 74 trimethobenzamide ............... 74 140
trimethoprim .........................10 trimipramine .........................29 trinatal gt .............................104 trinatal rx 1 .........................104 trinate ..................................104 trinessa (28) ..........................86 trinessa lo ..............................86 TRI-NORINYL (28) .............86 TRINTELLIX .......................29 triphrocaps ..........................104 TRIPLE DYE .......................44 triple vitamin with fluoride .104 tri-previfem (28) ...................86 TRISENOX ..........................15 TRI-SILA .............................46 tri-sprintec (28) .....................86 TRISTART DHA ...............104 tri-tabs dha ..........................104 TRIUMEQ ..............................5 triveen-duo dha ...................104 TRI-VI-FLOR.....................104 tri-vit with fluoride and iron ........................................104 tri-vitamin with fluoride .....104 trivora (28) ............................86 TRIZIVIR ...............................5 TROKENDI XR ...................17 tropicamide ...........................87 trospium ................................ 94 TRUE METRIX AIR GLUCOSE METER .........65 TRUE METRIX GLUCOSE METER.............................65 TRUE METRIX GLUCOSE TEST STRIP .....................54 TRUE METRIX LEVEL 1 ...65 TRUE2GO BLOOD GLUCOSE SYSTEM .......65 TRUECONTROL LEVEL 0 65 TRUEDRAW LANCING DEVICE ...........................65 TRUEPLUS LANCETS .......65 TRUERESULT BLOOD GLUCOSE SYSTM .........65 TRUETEST LOW GLUCOSE CONTROL .......................65 TRUETEST TEST STRIPS .54 TRUETRACK BLOOD GLUCOSE SYSTEM .......65
TRUETRACK SMART SYSTEM .......................... 65 TRUETRACK TEST ........... 54 TRULICITY ......................... 69 TRUSOPT ............................ 89 trust natal dha ..................... 104 TRUVADA ............................ 5 TUDORZA PRESSAIR ....... 94 tusnel c.................................. 91 TUSNEL PEDIATRIC ......... 91 TUSSICAPS ......................... 91 tussigon................................. 91 TUSSIONEX PENNKINETIC ER ..................................... 91 TUZISTRA XR .................... 91 TWINRIX (PF) .................... 79 TWYNSTA .......................... 34 TYBOST ................................ 5 TYGACIL .............................. 8 TYKERB .............................. 15 TYLENOL-CODEINE #3.... 22 TYLENOL-CODEINE #4.... 22 TYPHIM VI ......................... 79 TYSABRI ............................. 19 TYVASO .............................. 94 TYVASO REFILL KIT ....... 94 TYVASO STARTER KIT ... 94 TYZEKA ................................ 5 TYZINE ............................... 50 U UCERIS ................................ 74 UDAMIN SP ...................... 104 ULESFIA ............................. 47 ULORIC ............................... 80 ULTICARE PEN NEEDLE . 65 ULTI-LANCE ...................... 65 ULTILET BASIC LANCETS .......................................... 65 ULTILET CLASSIC LANCETS ........................ 65 ULTILET LANCETS .......... 65 ULTILET SAFETY LANCETS ........................ 65 ULTIMA MONITOR ........... 65 ULTIMA TEST STRIPS ...... 54 ultimatecare one ................. 104 ultimatecare one nf ............. 104 ultra b-100 complex ........... 104 ULTRA THIN LANCETS ... 65
ULTRA THIN PLUS LANCETS ........................ 65 ULTRA TLC LANCETS ..... 65 ULTRACET ......................... 24 ULTRALANCE LANCETS 65 ULTRAM ............................. 24 ULTRAM ER ....................... 24 ULTRASAL-ER ................... 39 ULTRA-THIN II INS PEN NEEDLES ........................ 65 ULTRATRAK ...................... 54 ULTRATRAK GLUCOSE METER ............................ 65 ULTRATRAK ULTIMATE54, 65 ULTRAVATE ...................... 46 ULTRAVATE X .................. 46 umecta .................................. 41 UMECTA ............................. 41 UNASYN ............................... 9 UNIFINE PENTIPS ............. 65 UNIFINE PENTIPS PLUS .. 65 UNILET COMFORTOUCH LANCET .......................... 65 UNILET EXCELITE II LANCET .......................... 65 UNILET EXCELITE LANCET .......................... 65 UNILET GP LANCET ......... 65 UNILET LANCET ............... 65 UNISTIK 2 DEVICE ........... 65 UNISTIK 2 NORMAL LANCET,DEVICE........... 66 UNISTIK 3 ........................... 66 UNISTIK 3 EXTRA LANCET .......................................... 66 UNISTIK CZT LANCET ..... 66 UNISTIK SAFETY .............. 66 UNISTIK TOUCH LANCETS .......................................... 66 UNISTRIP LOW CONTROL .......................................... 66 UNISTRIP1 TEST STRIP ... 54 unithroid ............................... 70 UNIVERSAL 1 LANCETS . 66 UPTRAVI............................. 34 ur n-c..................................... 95 URAMAXIN ........................ 41 URAMAXIN GT .................. 41 uramit mb ............................. 95 141
urea .......................................41 urea nail stick ........................41 urea-hyaluronate sodium ......41 URECHOLINE.....................95 ure-k ......................................41 URELLE ...............................95 uretron d-s .............................95 UREVAZ ..............................41 URIBEL ................................ 95 urimar-t .................................95 urin ds ...................................95 uro-458 .................................95 UROCIT-K 10 ......................95 UROCIT-K 15 ......................95 UROCIT-K 5 ........................95 urogesic-blue ........................95 urolet mb ...............................95 uro-mp ..................................95 urophen mb ...........................95 UROQID-ACID NO.2 ..........95 UROXATRAL .....................95 URSO 250 ............................74 URSO FORTE ......................74 ursodiol .................................74 uryl ........................................95 ustell .....................................95 UTA ......................................95 utira-c ....................................95 UTOPIC ................................ 41 V VAGIFEM ............................82 vaginal contraceptive foam...83 valacyclovir ............................5 VALCHLOR ........................41 VALCYTE .............................5 valganciclovir .........................5 VALIUM ..............................29 valproate sodium ..................17 valproic acid .........................17 valproic acid (as sodium salt) ..........................................17 valsartan ................................ 34 valsartan-hydrochlorothiazide ..........................................34 VALTREX .............................5 VANATOL LQ ....................22 VANCOCIN .........................10 vancomycin...........................10 VANCOMYCIN IN 0.9% SODIUM CL ....................10
VANCOMYCIN IN DEXTROSE 5 % .............. 10 vandazole .............................. 83 VANOS ................................ 46 VANOXIDE-HC .................. 43 VANTAS .............................. 15 VAQTA (PF) ........................ 80 VARIZIG ............................. 80 VARUBI............................... 74 VASCEPA............................ 37 VASERETIC ........................ 34 VASHE WOUND THERAPY .......................................... 47 VASOTEC ........................... 34 v-c forte .............................. 104 VCF CONTRACEPTIVE FILM ................................ 83 VCF CONTRACEPTIVE GEL .......................................... 83 VECAMYL .......................... 37 VECTIBIX ........................... 15 VECTICAL .......................... 39 VELCADE ........................... 15 veletri .................................... 34 velivet triphasic regimen (28) .......................................... 86 VELPHORO......................... 74 VELTASSA ......................... 74 VELTIN ............................... 43 vemavite-prx-2 ................... 104 VENCLEXTA ...................... 15 VENCLEXTA STARTING PACK ............................... 15 venlafaxine ........................... 29 VENTAVIS .......................... 94 VENTOLIN HFA ................. 94 VERAMYST ........................ 94 verapamil .............................. 34 VERDESO ........................... 46 verdrocet ............................... 22 VEREGEN ........................... 41 VERELAN ........................... 34 VERELAN PM .................... 34 veripred 20............................ 51 VERSACLOZ ...................... 29 VESICARE .......................... 94 vestura (28) ........................... 86 VFEND................................... 3 VFEND IV ............................. 3 VGO 20 ................................ 66
VGO 30 ................................ 66 VGO 40 ................................ 66 VIBATIV.............................. 10 VIBERZI .............................. 74 VIBRAMYCIN .................... 10 vic-forte .............................. 104 vicodin .................................. 22 vicodin es .............................. 22 vicodin hp ............................. 22 VICTOZA 2-PAK ................ 69 VICTOZA 3-PAK ................ 69 VIDAZA ............................... 15 VIDEX 2 GRAM PEDIATRIC ............................................ 5 VIDEX EC ............................. 5 VIEKIRA PAK....................... 5 VIEKIRA XR ......................... 5 vienva ................................... 86 VIGAMOX ........................... 87 VIIBRYD ............................. 29 VIMIZIM.............................. 68 VIMOVO.............................. 24 VIMPAT ............................... 17 vinate care........................... 104 vinate dha ........................... 104 VINATE DHA RF.............. 104 vinate ii ............................... 104 vinate m .............................. 104 vinate one ........................... 104 vinate ultra .......................... 104 vinblastine ............................ 15 vincasar pfs ........................... 15 vincristine ............................. 15 vinorelbine ............................ 15 VIOKACE ............................ 74 viorele (28) ........................... 86 VIRACEPT ............................ 5 VIRAMUNE .......................... 5 VIRAMUNE XR .................... 5 VIRASAL ............................. 39 VIRAZOLE ............................ 5 VIREAD ................................. 5 VIROPTIC............................ 87 virt-advance ........................ 104 virt-c dha............................. 104 VIRT-CAPS ....................... 104 virt-gard .............................. 104 virt-nate .............................. 104 virt-nate dha ........................ 104 virt-phos 250 neutral ............ 97 142
virt-pn .................................104 virt-pn dha ..........................104 virt-pn plus..........................104 VIRTPREX.........................104 virtrate-2 ...............................95 virtrate-3 ...............................95 virtrate-k ...............................95 virt-select ............................104 virtussin ac ............................91 virtussin dac ..........................91 virt-vite ............................... 104 virt-vite gt ...........................104 VIRT-VITE PLUS..............104 VISTARIL ............................90 VISTOGARD .......................11 VISUDYNE ..........................88 vit 3 .....................................104 vit b complex-folic acid ......104 VITA-BEE WITH C...........104 VITAFOL ...........................104 VITAFOL FE+ (WITH DOCUSATE) .................104 VITAFOL GUMMIES .......104 VITAFOL NANO ..............104 VITAFOL ULTRA .............104 vitafol-ob ............................104 VITAFOL-OB+DHA .........104 VITAFOL-ONE .................104 VITAL-D RX .....................104 VITAMED MD ONE RX ..104 VITAMED MD PLUS RX .105 VITAMEDMD REDICHEW RX...................................105 vitamin b complex ..............105 vitamin d3 ...........................105 vitamins a,c,d and fluoride .105 VITAPEARL ......................105 VITA-RESPA .....................105 VITATRUE ........................105 VITEKTA ...............................5 VITRASE .............................88 VITUZ ..................................91 VIVA DHA ........................105 VIVELLE-DOT ....................82 VIVITROL ...........................24 VIVLODEX .........................25 VOCALPOINT GLUCOSE CONTROL .......................66 VOGELXO ...........................68 vol-care rx ...........................105
vol-nate ............................... 105 vol-plus ............................... 105 vol-tab rx ............................ 105 VOLTAREN ........................ 25 VOLTAREN-XR ................. 25 VONVENDI ......................... 36 VOPAC MDS....................... 25 VORAXAZE ........................ 11 voriconazole ........................... 3 VOSPIRE ER ....................... 94 VOTRIENT .......................... 15 vp-ch plus ........................... 105 vp-ch-pnv ........................... 105 vp-ggr-b6 ............................ 105 vp-heme ob ......................... 105 vp-heme one ....................... 105 VP-PNV-DHA ................... 105 VPRIV .................................. 68 vp-vite rx ............................ 105 VRAYLAR........................... 29 VUSION ............................... 44 vyfemla (28) ......................... 86 VYTORIN 10-10.................. 37 VYTORIN 10-20.................. 37 VYTORIN 10-40.................. 37 VYTORIN 10-80.................. 37 VYVANSE ........................... 29 W warfarin ................................ 36 water for irrigation, sterile.... 48 WAVESENSE AMP ............ 66 WAVESENSE CONTROL SOLUTION ...................... 66 WAVESENSE JAZZ ........... 54 WAVESENSE PRESTO 54, 66 wee care .............................. 105 WELCHOL .......................... 37 WELLBUTRIN SR .............. 29 WELLBUTRIN XL.............. 29 wera (28) .............................. 86 westhroid .............................. 70 WHYTEDERM TDPAK...... 46 WHYTEDERM TRILASIL PAK .................................. 46 WIDE-SEAL DIAPHRAGM .......................................... 81 WILATE............................... 36 woman's laxative .................. 74 women's gentle laxative(bisac) .......................................... 74
women's laxative (bisacodyl)74 WP THYROID ..................... 70 wymzya fe ............................ 86 X XALATAN ........................... 89 XALKORI ............................ 15 XANAX................................ 29 XANAX XR ......................... 29 XARELTO ........................... 36 XARTEMIS XR ................... 22 XCLAIR ............................... 41 XELITRAL .......................... 25 XELJANZ ............................ 81 XELJANZ XR ...................... 81 XELODA.............................. 15 XENAZINE .......................... 19 XERESE ............................... 44 XGEVA ................................ 11 XIFAXAN .............................. 8 XIGDUO XR ........................ 70 XIIDRA ................................ 88 XILAPAK ............................ 46 XODOL 10/300 .................... 22 XODOL 5/300 ...................... 22 XODOL 7.5/300 ................... 22 XOLAIR ............................... 94 XOLEGEL............................ 44 XOPENEX ........................... 94 XOPENEX CONCENTRATE .......................................... 94 XOPENEX HFA .................. 94 XRYLIX ............................... 25 XTAMPZA ER..................... 22 XTANDI............................... 15 xulane ................................... 83 XURIDEN ............................ 48 xylon 10 ................................ 22 XYNTHA ............................. 36 XYNTHA SOLOFUSE ........ 36 XYREM................................ 29 XYZAL ................................ 90 Y YASMIN (28)....................... 86 YAZ (28) .............................. 86 YERVOY ............................. 15 YF-VAX (PF) ....................... 80 YONDELIS .......................... 15 YOSPRALA ......................... 36 Z zafirlukast ............................. 94 143
zaleplon.................................29 ZALTRAP ............................15 zamicet ..................................22 ZANABIN ............................41 ZANAFLEX .........................20 ZANOSAR ...........................15 ZANTAC ..............................76 zarah .....................................86 ZARONTIN ..........................17 ZARXIO ...............................77 zatean-ch .............................105 zatean-pn dha ......................105 zatean-pn plus .....................105 zavara ..................................105 ZAVESCA ............................68 ZEBETA ...............................34 zebutal...................................22 ZEGERID .............................76 ZELAPAR ............................18 ZELBORAF .........................15 ZEMAIRA ............................48 ZEMBRACE SYMTOUCH .18 ZEMPLAR ...........................68 zenatane ................................ 43 zenchent (28) ........................86 zenchent fe ............................86 zencia ....................................43 ZENPEP ...............................74 zenzedi ..................................30 ZENZEDI .............................30 ZEPATIER .............................5 ZERIT .....................................5 ZESTORETIC ......................34 ZESTRIL ..............................34 ZETIA...................................37 ZETONNA ...........................94 ZIAC .....................................34 ZIAGEN .................................5 ZIANA ..................................43 zidovudine ..............................5 ZINACEF ...............................6 ZINBRYTA ..........................78 ZINECARD (AS HCL) ........11 zingiber ............................... 105 ZINGO ..................................43 ZIOPTAN (PF) .....................89 ziprasidone hcl ......................30 ZIPSOR ................................ 25 ZIRGAN ...............................87 ZITHRANOL .......................39
ZITHRANOL-RR ................ 39 ZITHROMAX ........................ 6 ZMAX .................................... 6 ZOCOR ................................ 37 ZODRYL AC 25 .................. 91 ZODRYL AC 30 .................. 91 ZODRYL AC 35 .................. 91 ZODRYL AC 40 .................. 91 ZODRYL AC 50 .................. 91 ZODRYL AC 60 .................. 91 ZODRYL AC 80 .................. 91 ZODRYL DAC 25 ............... 91 ZODRYL DAC 30 ............... 91 ZODRYL DAC 35 ............... 91 ZODRYL DAC 40 ............... 91 ZODRYL DAC 50 ............... 91 ZODRYL DAC 60 ............... 91 ZODRYL DAC 80 ............... 91 ZODRYL DEC 25 ................ 91 ZODRYL DEC 30 ................ 91 ZODRYL DEC 35 ................ 91 ZODRYL DEC 40 ................ 91 ZODRYL DEC 50 ................ 91 ZODRYL DEC 60 ................ 91 ZODRYL DEC 80 ................ 91
ZOFRAN (AS HYDROCHLORIDE) ...... 74 ZOFRAN ODT ..................... 74 ZOHYDRO ER .................... 22 ZOLADEX ........................... 15 zolate .................................. 105 zoledronic acid ..................... 68 zoledronic acid-mannitol-water .......................................... 48 ZOLEDRONIC ACIDMANNITOL-WATER .... 48, 68 ZOLINZA ............................. 15 zolmitriptan .......................... 18 ZOLOFT ............................... 30 zolpidem ............................... 30 ZOLPIMIST ......................... 30 ZOMACTON ....................... 77 ZOMETA ............................. 68 ZOMIG ................................. 18 ZOMIG ZMT ....................... 18 ZONALON ........................... 41 ZONATUSS ......................... 92 ZONEGRAN ........................ 17 zonisamide ............................ 17
144
ZONTIVITY.........................36 ZORBTIVE ..........................77 ZORTRESS ..........................15 ZORVOLEX.........................25 zovia 1/35e (28) ....................86 zovia 1/50e (28) ....................86 ZOVIRAX ........................5, 45 Z-TUSS AC ..........................92 ZUBSOLV ............................25 ZUPLENZ ............................74 ZURAMPIC .........................80 ZUTRIPRO...........................92 ZYBAN ................................ 49 ZYCLARA ...........................78 ZYDELIG .............................15 ZYFLO .................................94 ZYFLO CR ...........................94 ZYKADIA ............................15 ZYLET .................................89 ZYLOPRIM ..........................80 ZYMAXID ...........................87 ZYPREXA ............................30 ZYPREXA ZYDIS ...............30 ZYTIGA ...............................15 ZYVOX ..................................8