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

You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies. 103

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