Arizona Complete Health-Complete Care Plan Lista de ......Lista de medicamentos preferentes para...

Arizona Complete Health-Complete Care Plan Lista de medicamentos preferentes para salud mental

La lista de medicamentos para salud mental de Arizona Complete Health-Complete Care Plan incluye todos los medicamentos para salud mental que figuran en la Lista de medicamentos para salud mental (BHDL) de AHCCCS. No es una lista completa de todos los medicamentos cubiertos para salud mental. Si necesita un medicamento que no figura en la lista de medicamentos para salud mental, su médico puede solicitar autorización previa para cubrir el medicamento. La lista de medicamentos se actualiza con frecuencia y puede cambiar. Puede ver la lista de medicamentos más reciente en www.azcompletehealth.com/providers/pharmacy.html

https://www.azcompletehealth.com/providers/pharmacy.html

Programa de farmacia

Arizona Complete Health-Complete Care Plan proporciona farmacoterapia adecuada, de alta calidad y rentable a todos los afiliados de Arizona Complete Health-Complete Care Plan. Arizona Complete Health-Complete Care Plan cubre medicamentos recetados y ciertos medicamentos de venta libre (OTC) cuando son indicados por un médico. Algunos medicamentos requieren autorización previa (PA) o tienen límites para la edad, dosis y cantidades máximas. Los medicamentos genéricos tienen el mismo principio activo que sus equivalentes con nombre de marca y deben usarse como primera línea de tratamiento. Esto se aplica a menos que se indique concretamente que se prefiere una marca. Si no hay un medicamento genérico disponible, puede haber más de un medicamento de nombre de marca que se pueda usar en su tratamiento. La Lista de medicamentos preferentes (PDL) de salud mental de Arizona Complete Health-Complete Care Plan se revisa con frecuencia por nuestro Comité de Farmacia y Tratamientos (P&T) de Arizona Complete Health. Esto ayuda a promover el uso apropiado y rentable de los medicamentos.

Límites de dosis

Puede obtener hasta un suministro máximo de treinta (30) días por cada nueva receta médica o reabastecimiento de la mayoría de medicamentos. Puede obtener hasta un suministro de noventa (90) días si:

• El medicamento está prescrito para una enfermedad crónica • Usted va a estar fuera del área de servicio durante un largo periodo de

tiempo • La receta está limitada al periodo de tiempo

Debe haber transcurrido un total del 85 % del suministro de 30 días antes de que se pueda reabastecer la receta médica para la mayoría de los medicamentos.

Autorización previa y otros límites Algunos medicamentos que figuran en la PDL de salud mental de Arizona Complete Health-Complete Care Plan pueden requerir autorización previa (PA). Su médico o farmacéutico solicitará una PA para usted. La información deberá ser presentada por el practicante o farmacéutico en el formulario de autorización previa de medicamentos. Puede encontrar este documento en el sitio web de Arizona Complete Health-Complete Care Plan en https://www.azcompletehealth.com/providers/pharmacy.html. Pueden enviar la PA por fax al 1-855-554-5233 o su proveedor médico puede enviar una solicitud de PA electrónicamente a https://www.covermymeds.com/epa/envolverx/

Arizona Complete Health-Complete Care Plan cubrirá el medicamento si:

https://www.azcompletehealth.com/providers/pharmacy.html

https://www.covermymeds.com/main/prior-authorization-forms/envolverx/

1. Existe un motivo médico de salud mental que requiera el medicamento específico 2. Dependiendo del medicamento, otros medicamentos en la PDL no han funcionado

Los medicamentos antipsicóticos y el litio en la lista de medicamentos requieren una autorización previa si no fueron recetados por un especialista en salud mental u otro especialista aprobado. Si la solicitud es aprobada, Arizona Complete Health-Complete Care Plan informa al médico por fax. Si la información clínica no cumple con los criterios de cobertura para el medicamento solicitado, Arizona Complete Health-Complete Care Plan revisará la solicitud y les informará a usted y su médico sobre nuestra decisión. También le informaremos sobre medicamentos alternativos, si estuviesen disponibles, y le proporcionaremos información sobre lo que puede hacer para apelar nuestra decisión si no está de acuerdo con ella.

Abreviación Significado Cómo funciona

AL Límite de edad Algunos medicamentos solo están cubiertos para ciertas edades.

F Formulario Estos medicamentos están cubiertos por Arizona Complete Health-Complete Care Plan.

MP

Producto de mantenimiento

Estos medicamentos se utilizan para el tratamiento de afecciones o enfermedades a largo plazo.

NF Fuera del formulario

Estos medicamentos requieren autorización para estar cubiertos por Arizona Complete Health-Complete Care Plan.

PA Autorización previa

Su médico debe solicitar la aprobación de Arizona Complete Health-Complete Care Plan antes de cubrir algunos medicamentos.

QL Límite de cantidad

Algunos medicamentos solo están cubiertos para una cantidad determinada.

SP Producto especial

Se utilizan para el tratamiento de afecciones complejas o raras como hepatitis C o artritis reumatoide.

ST Terapia escalonada

En algunos casos, primero debe probar ciertos medicamentos antes de que Arizona Complete Health-Complete Care Plan cubra otro medicamento para su afección médica. Por ejemplo, si el Medicamento A y el Medicamento B tratan su afección médica, Arizona Complete Health-Complete Care Plan puede no cubrir el Medicamento B a menos que pruebe primero el Medicamento A.

Solicitudes por necesidad médica

Si un afiliado de Arizona Complete Health-Complete Care Plan necesita un medicamento para tratar una afección de salud mental que no figura en la PDL, su médico puede presentar una solicitud por necesidad médica (MN) para el medicamento.

Política de suministro de emergencia

Las leyes estatales y federales exigen que una farmacia dispense un suministro de hasta 4 días a cualquier afiliado que espera una determinación de PA. El propósito es evitar la interrupción del tratamiento o retrasos en el inicio del tratamiento. Las farmacias incluidas están autorizadas a proporcionar un suministro de hasta 4 días de medicamentos tradicionales (no especiales) para salud mental. Solicite a su farmacia que llame al Servicio de asistencia a farmacias al 1-888-624-1131 para obtener ayuda para reabastecer el suministro de emergencia de 4 días.

Exclusiones

La lista de medicamentos de Arizona Complete Health-Complete Care Plan no incluye ciertos medicamentos. Los siguientes tipos de medicamentos están excluidos de la cobertura. Tampoco están disponibles como suministro de emergencia de 4 días.

• Los medicamentos que se consideran experimentales o de investigación (los afiliados que estén inscritos pueden participar en servicios experimentales; no obstante, AHCCCS no reembolsará dicho servicio experimental de acuerdo con la normativa A.A.C. R9-22-203)

• Medicamentos de estudios de eficacia e implementación de medicamentos (DESI) • Prótesis, aparatos y dispositivos • Medicamentos para tratar afecciones de salud física • Vitaminas y minerales orales o medicamentos de venta libre, con la excepción de

los que figuran en la PDL o si un afiliado tiene déficit de una vitamina que no figure en la PDL siempre que esta trate una afección de salud mental.

• Suplementos nutricionales • Marihuana médica • Los medicamentos elegibles para la cobertura de Medicare Part D (para afiliados

elegibles de Medicare); los copagos y costos compartidos para medicamentos de salud mental están cubiertos para los afiliados de SMI que también sean elegibles para Medicare.

Productos recién aprobados

Arizona Complete Health-Complete Care Plan revisa los nuevos medicamentos para determinar su seguridad y efectividad antes de agregarlos a la PDL. Durante este período, el acceso a estos medicamentos se considerará mediante el proceso de revisión de PA.

Cómo reabastecer una receta médica

Puede reabastecer su receta médica en una farmacia de la red de Arizona Complete Health-Complete Care Plan. Puede encontrar una farmacia cercana poniéndose en contacto con los servicios para afiliados de Arizona Complete Health-Complete Care Plan. Cuando seleccione una farmacia, traiga con usted su tarjeta de identificación de Arizona Complete Health-Complete Care Plan. La farmacia necesitará la información que figura en la tarjeta para reabastecer su receta médica.

Para obtener más información sobre sus beneficios de farmacia, consulte su Guía para afiliados o llame a los servicios para afiliados al 888-788-4408 (TTY/TDY 711).

Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating DisordersAmphetaminesADDERALL TABS 1.875MG-1.875 MG-1.875 MG-1.875 MG, 3.125 MG-3.125MG-3.125 MG-3.125 MG,1.25 MG-1.25 MG-1.25MG-1.25 MG, 2.5 MG-2.5MG-2.5 MG-2.5 MG, 5 MG-5 MG-5 MG-5 MG, 7.5 MG-7.5 MG-7.5 MG-7.5 MG(amphetamine-dextroamphetamine)

F

QL(2 ea daily);AL(At least 6yrs old)

ADDERALL TABS 3.75MG-3.75 MG-3.75 MG-3.75MG (amphetamine-dextroamphetamine)

F

QL(2 ea daily)

ADDERALL XR CP24 1.25MG-1.25 MG-1.25 MG-1.25MG, 2.5 MG-2.5 MG-2.5MG-2.5 MG, 3.75 MG-3.75MG-3.75 MG-3.75 MG,6.25 MG-6.25 MG-6.25MG-6.25 MG, 7.5 MG-7.5MG-7.5 MG-7.5 MG(amphetamine-dextroamphetamine)

F


ADDERALL XR CP24 5MG-5 MG-5 MG-5 MG(amphetamine-dextroamphetamine)

F


ADZENYS ER SUER(amphetamine) NF

amphetamine-dextroamphetamine tabs1.875 mg-1.875 mg-1.875mg-1.875 mg, 3.125 mg-3.125 mg-3.125 mg-3.125mg, 1.25 mg-1.25 mg-1.25mg-1.25 mg, 2.5 mg-2.5mg-2.5 mg-2.5 mg, 5 mg-5mg-5 mg-5 mg, 7.5 mg-7.5mg-7.5 mg-7.5 mg

F


amphetamine-dextroamphetamine tabs3.75 mg-3.75 mg-3.75 mg-3.75 mg

F

QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

VYVANSE CAPS FQL(1 ea daily);AL(At least 6yrs old)

VYVANSE CHEW FQL(1 ea daily);AL(At least 6yrs old)

Attention-Deficit/Hyperactivity Disorder (ADHD)

atomoxetine hcl caps FQL(1 ea daily);AL(At least 6yrs old)

clonidine hcl (adhd) tb12 FQL(4 ea daily);AL(At least 6yrs old)

guanfacine hcl (adhd) tb24 FQL(1 ea daily);AL(At least 6yrs old)

INTUNIV TB24 (guanfacinehcl (adhd)) NF


STRATTERA CAPS(atomoxetine hcl) NF


Stimulants - Misc.

APTENSIO XR CP24(methylphenidate hcl) F


CONCERTA TBCR 18 MG,27 MG, 36 MG(methylphenidate hcl)

FQL(2 ea daily);AL(At least 6yrs old)

CONCERTA TBCR 54 MG(methylphenidate hcl) F


DAYTRANA PTCH FQL(1 ea daily);AL(At least 6yrs old)

dexmethylphenidate hcltabs 10 mg, 2.5 mg, 5 mg F


FOCALIN TABS(dexmethylphenidate hcl) NF


FOCALIN XR CP24 10MG, 15 MG, 20 MG, 5 MG(dexmethylphenidate hcl)


FOCALIN XR CP24 35MG, 40 MG, 25 MG, 30 MG(dexmethylphenidate hcl)


Arizona Complete Health - Complete Care Plan Behavioral Health Actualizada 2/2021

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Drug Name DrugTier

Requirements/Limits

METHYLIN SOLN(methylphenidate hcl) F

QL(10 mldaily); AL(Atleast 6 yrs old)

methylphenidate hcl cp24or 10 mg, 20 mg, 30 mg F


methylphenidate hcl cp24or 40 mg, 60 mg F


methylphenidate hcl cpcr or40 mg, 10 mg, 20 mg, 30mg, 50 mg, 60 mg


methylphenidate hcl tabs or20 mg, 10 mg, 5 mg F


RITALIN LA CP24 10 MG(methylphenidate hcl) F


RITALIN LA CP24 20 MG,30 MG (methylphenidatehcl)

NFQL(2 ea daily);AL(At least 6yrs old)

RITALIN LA CP24 40 MG(methylphenidate hcl) NF


RITALIN TABS(methylphenidate hcl) NF


ALTERNATIVE MEDICINES

Alternative Medicine CombinationsFLAX + DHA CAPS F

HM OMEGA-3-6-9 FATTYACIDS CAPS F

OMEGA 3-6-9 COMPLEXCAPS F

OMEGA-3-6-9 CAPS F

RA OMEGA 3-6-9 CAPS F

SM OMEGA-3 CAPS F

SM OMEGA-3-6-9 FATTYACIDS CAPS F

SUPER OMEGA-3 CAPS F

Drug Name DrugTier

Requirements/Limits

TRIPLE OMEGA-3-6-9CAPS F

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint ConditionsOpioid AgonistsDILAUDID SOLN IJ 1MG/ML, 2 MG/ML(hydromorphone hcl)

NF

MORPHINE SULFATESOLN IV 10 MG/ML(morphine sulfate)

NF

Opioid Partial Agonists

buprenorphine hcl subl sl 2mg F

PA Req'dunless memberis pregnant ornursing.Prescriber mustnote ICD-10diagnosis codeon prescription.O09.91;O09.92;O09.93-Supervision ofhigh riskpregnancy,postpartumnursingmothers. Firstdigit Letter, 2nddigit zeroQL(12ea daily)


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Drug Name DrugTier

Requirements/Limits

buprenorphine hcl subl sl 8mg F

PA Req'dunless memberis pregnant ornursing.Prescriber mustnote ICD-10diagnosis codeon prescription.O09.91;O09.92;O09.93-Supervision ofhigh riskpregnancy,postpartumnursingmothers. Firstdigit Letter, 2nddigit zeroQL(3ea daily)

buprenorphine hcl-naloxone hcl dihydrate subl0.5 mg-2 mg

FQL(12 ea daily)

buprenorphine hcl-naloxone hcl dihydrate subl2 mg-8 mg

FQL(3 ea daily)

SUBLOCADE SOSY F PA

SUBOXONE FILM 0.5 MG-2 MG (buprenorphine hcl-naloxone hcl dihydrate)

FQL(12 eadaily); AL(Atleast 6 yrs old)

SUBOXONE FILM 1 MG-4MG (buprenorphine hcl-naloxone hcl dihydrate)


SUBOXONE FILM 12 MG-3 MG (buprenorphine hcl-naloxone hcl dihydrate)


SUBOXONE FILM 2 MG-8MG (buprenorphine hcl-naloxone hcl dihydrate)


ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial InfectionsCyclic LipopeptidesDAPTOMYCIN SOLR 350MG NF

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.

Drug Name DrugTier

Requirements/Limits

buspirone hcl tabs or 10mg, 5 mg, 15 mg, 7.5 mg F


buspirone hcl tabs or 30mg F


hydroxyzine hcl soln im 25mg/ml, 50 mg/ml F PA

hydroxyzine hcl syrp or 10mg/5ml F QL(4 ml daily)

hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg F QL(8 ea daily)

hydroxyzine pamoate capsor 100 mg F


hydroxyzine pamoate capsor 25 mg, 50 mg F QL(4 ea daily)

VISTARIL CAPS(hydroxyzine pamoate) NF QL(4 ea daily)

Benzodiazepines

ALPRAZOLAM INTENSOLCONC F

Limit 1anxiolytic per30 days;QL(60ml per 15 daysretail); AL(Atleast 6 yrs old)

alprazolam tabs or 0.25mg, 0.5 mg, 1 mg F

Limit 1anxiolytic per30 days;QL(4ea daily); AL(Atleast 6 yrs old)

alprazolam tabs or 2 mg F


alprazolam tb24 or 0.5 mg,1 mg, 2 mg, 3 mg F


alprazolam tbdp or 0.25mg, 0.5 mg, 1 mg F



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Drug Name DrugTier

Requirements/Limits

alprazolam tbdp or 2 mg F


ATIVAN SOLN IJ 4MG/ML, 2 MG/ML(lorazepam)

NFPA

ATIVAN TABS OR 0.5 MG,1 MG (lorazepam) NF


ATIVAN TABS OR 2 MG(lorazepam) NF


chlordiazepoxide hcl caps FQL(2 ea daily);AL(At least 6yrs old)

clorazepate dipotassiumtabs 15 mg F


clorazepate dipotassiumtabs 3.75 mg, 7.5 mg F


diazepam conc or 5 mg/ml FQL(2 ml daily);AL(At least 6yrs old)

DIAZEPAM SOAJ IM 10MG/2ML F PA

diazepam soln ij 5 mg/ml F PA

diazepam soln or 5 mg/5ml FQL(10 mldaily); AL(Atleast 6 yrs old)

diazepam tabs or 10 mg, 2mg, 5 mg F


lorazepam conc or 2 mg/ml FQL(2 ml daily);AL(At least 6yrs old)

lorazepam soln ij 4 mg/ml,2 mg/ml, 20 mg/10ml F PA

lorazepam tabs or 0.5 mg,1 mg F


Drug Name DrugTier

Requirements/Limits

lorazepam tabs or 2 mg F


oxazepam caps 30 mg, 10mg, 15 mg F


TRANXENE T TABS(clorazepate dipotassium) NF


VALIUM TABS (diazepam) NFQL(4 ea daily);AL(At least 6yrs old)

XANAX TABS 0.25 MG,0.5 MG, 1 MG (alprazolam) NF


XANAX TABS 2 MG(alprazolam) NF


XANAX XR TB24(alprazolam) NF


ANTICONVULSANTS - Drugs to Treat Seizures

Anticonvulsants - Benzodiazepines

clonazepam tabs or 0.5mg, 1 mg F


clonazepam tabs or 2 mg FQL(2 ea daily);AL(At least 6yrs old)

clonazepam tbdp or 0.125mg, 0.25 mg, 0.5 mg, 1 mg F


clonazepam tbdp or 2 mg FQL(2 ea daily);AL(At least 6yrs old)

DIASTAT ACUDIAL GEL(diazepam(anticonvulsant))

NF


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Drug Name DrugTier

Requirements/Limits

DIASTAT PEDIATRIC GEL(diazepam(anticonvulsant))

NF

KLONOPIN TABS 0.5 MG,1 MG (clonazepam) NF


KLONOPIN TABS 2 MG(clonazepam) NF


Anticonvulsants - Misc.carbamazepine chew or100 mg F

carbamazepine cp12 or100 mg, 200 mg, 300 mg F

carbamazepine susp or100 mg/5ml F

carbamazepine tabs or 200mg F

carbamazepine tb12 or 100mg, 200 mg, 400 mg F

CARBATROL CP12(carbamazepine) NF

gabapentin caps or 100mg, 300 mg, 400 mg F AL(At least 6

yrs old)gabapentin soln or 250mg/5ml, 300 mg/6ml F AL(At least 6

yrs old)gabapentin tabs or 600 mg,800 mg F AL(At least 6

yrs old)LAMICTAL CHEWABLEDISPERSIBLE CHEW(lamotrigine)

NFAL(At least 6yrs old)

LAMICTAL ODT TBDP 100MG, 200 MG, 25 MG, 50MG (lamotrigine)


LAMICTAL TABS(lamotrigine) NF AL(At least 6

yrs old)LAMICTAL XR TB24 100MG, 25 MG, 50 MG(lamotrigine)

NFQL(3 ea daily)

LAMICTAL XR TB24 200MG, 250 MG, 300 MG(lamotrigine)

NFQL(2 ea daily)

lamotrigine chew or 25 mg,5 mg F AL(At least 6

yrs old)lamotrigine tabs or 100 mg,150 mg, 200 mg, 25 mg F AL(At least 6

yrs old)

Drug Name DrugTier

Requirements/Limits

lamotrigine tb24 or 100 mg,25 mg, 50 mg F QL(3 ea daily)

lamotrigine tb24 or 200 mg,250 mg, 300 mg F QL(2 ea daily)

lamotrigine tbdp or 100 mg,200 mg, 25 mg, 50 mg F AL(At least 6

yrs old)NEURONTIN CAPS(gabapentin) NF AL(At least 6

yrs old)NEURONTIN SOLN(gabapentin) NF AL(At least 6

yrs old)NEURONTIN TABS(gabapentin) NF AL(At least 6

yrs old)

oxcarbazepine susp F AL(At least 6yrs old)

oxcarbazepine tabs F AL(At least 6yrs old)

QUDEXY XR CS24(topiramate) NF

TEGRETOL SUSP(carbamazepine) NF

TEGRETOL TABS(carbamazepine) NF

TEGRETOL-XR TB12(carbamazepine) NF

TOPAMAX SPRINKLECPSP (topiramate) NF AL(At least 6

yrs old)TOPAMAX TABS(topiramate) NF AL(At least 6

yrs old)topiramate cpsp or 15 mg,25 mg F AL(At least 6

yrs old)topiramate tabs or 100 mg,200 mg, 25 mg, 50 mg F AL(At least 6

yrs old)TRILEPTAL SUSP(oxcarbazepine) NF AL(At least 6

yrs old)TRILEPTAL TABS(oxcarbazepine) NF AL(At least 6

yrs old)Valproic AcidDEPAKENE CAPS(valproic acid) NF

DEPAKENE SOLN(valproate sodium) NF

DEPAKOTE ER TB24(divalproex sodium) NF

DEPAKOTE SPRINKLESCSDR (divalproex sodium) NF


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Drug Name DrugTier

Requirements/Limits

DEPAKOTE TBEC(divalproex sodium) NF

divalproex sodium csdr or125 mg F

divalproex sodium tb24 or250 mg, 500 mg F

divalproex sodium tbec or125 mg, 250 mg, 500 mg F

valproate sodium soln or250 mg/5ml F

valproic acid caps or F

ANTIDEPRESSANTS - Drugs to TreatDepressionAlpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine tabs or 7.5 mg,15 mg, 30 mg, 45 mg F


mirtazapine tbdp or 15 mg,30 mg, 45 mg F


REMERON SOLTAB TBDP(mirtazapine) NF


REMERON TABS(mirtazapine) NF


Antidepressants - Misc.

bupropion hcl tabs or 100mg, 75 mg F


bupropion hcl tb12 or 200mg, 100 mg, 150 mg F


bupropion hcl tb24 or 150mg, 300 mg F


bupropion hcl tb24 or 450mg F PA

FORFIVO XL TB24(bupropion hcl) F PA

maprotiline hcl tabs F AL(At least 6yrs old)

WELLBUTRIN SR TB12(bupropion hcl) NF


Drug Name DrugTier

Requirements/Limits

WELLBUTRIN XL TB24(bupropion hcl) NF


N-Methyl-D-aspartic acid (NMDA) ReceptorSPRAVATO 56MG DOSESOPK F PA; SP

SPRAVATO 84MG DOSESOPK F PA; SP

Selective Serotonin Reuptake Inhibitors (SSRIs)

CELEXA TABS 10 MG(citalopram hydrobromide) NF


CELEXA TABS 20 MG, 40MG (citalopramhydrobromide)


citalopram hydrobromidesoln 10 mg/5ml F

QL(20 mldaily); AL(Atleast 6 yrs old -Up to 12 yrsold)

citalopram hydrobromidetabs 10 mg F


citalopram hydrobromidetabs 20 mg, 40 mg F


escitalopram oxalate tabs10 mg, 20 mg F


escitalopram oxalate tabs 5mg F


fluoxetine hcl caps or 10mg, 40 mg F


fluoxetine hcl caps or 20mg F


fluoxetine hcl soln or 20mg/5ml F


fluvoxamine maleate tabs100 mg F



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Drug Name DrugTier

Requirements/Limits





LEXAPRO TABS 10 MG,20 MG (escitalopramoxalate)


LEXAPRO TABS 5 MG(escitalopram oxalate) NF


paroxetine hcl tabs 30 mg,10 mg, 20 mg F


paroxetine hcl tabs 40 mg FQL(1.5 eadaily); AL(Atleast 6 yrs old)

PAXIL TABS 30 MG, 10MG, 20 MG (paroxetinehcl)


PAXIL TABS 40 MG(paroxetine hcl) NF

QL(1.5 eadaily); AL(Atleast 6 yrs old)

PROZAC CAPS 10 MG, 40MG (fluoxetine hcl) NF


PROZAC CAPS 20 MG(fluoxetine hcl) NF


sertraline hcl conc or 20mg/ml F


sertraline hcl tabs or 100mg F


sertraline hcl tabs or 25 mg FQL(3 ea daily);AL(At least 6yrs old)

sertraline hcl tabs or 50 mg FQL(4 ea daily);AL(At least 6yrs old)

Drug Name DrugTier

Requirements/Limits

ZOLOFT CONC 20 MG/ML(sertraline hcl) NF


ZOLOFT TABS 100 MG(sertraline hcl) NF






Serotonin Modulators

trazodone hcl tabs or 100mg F








Serotonin-Norepinephrine Reuptake Inhibitors

CYMBALTA CPEP 20 MG,30 MG (duloxetine hcl) NF


CYMBALTA CPEP 60 MG(duloxetine hcl) NF


duloxetine hcl cpep or 20mg, 30 mg F


duloxetine hcl cpep or 60mg F


EFFEXOR XR CP24 150MG (venlafaxine hcl) NF


EFFEXOR XR CP24 37.5MG, 75 MG (venlafaxinehcl)



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Drug Name DrugTier

Requirements/Limits

KHEDEZLA TB24(desvenlafaxine) NF

venlafaxine hcl cp24 150mg F


venlafaxine hcl cp24 37.5mg, 75 mg F


venlafaxine hcl tabs 100mg, 37.5 mg, 50 mg F


venlafaxine hcl tabs 25 mg FQL(4 ea daily);AL(At least 6yrs old)

venlafaxine hcl tabs 75 mg FQL(5 ea daily);AL(At least 6yrs old)

Tricyclic Agentsamitriptyline hcl tabs or 10mg, 50 mg, 150 mg, 100mg, 25 mg, 75 mg

FAL(At least 6yrs old)

amoxapine tabs F AL(At least 6yrs old)

ANAFRANIL CAPS(clomipramine hcl) NF AL(At least 6

yrs old)clomipramine hcl caps or25 mg, 50 mg, 75 mg F AL(At least 6

yrs old)desipramine hcl tabs or 10mg, 100 mg, 150 mg, 25mg, 50 mg, 75 mg


doxepin hcl caps or 150mg, 100 mg, 25 mg, 10 mg,50 mg, 75 mg


doxepin hcl conc or 10mg/ml F

QL(6 ml daily);AL(At least 6yrs old)

imipramine hcl tabs or 10mg, 25 mg, 50 mg F AL(At least 6

yrs old)

imipramine pamoate caps F AL(At least 6yrs old)

NORPRAMIN TABS(desipramine hcl) NF AL(At least 6

yrs old)nortriptyline hcl caps or 10mg, 25 mg, 50 mg, 75 mg F AL(At least 6

yrs old)nortriptyline hcl soln or 10mg/5ml F AL(At least 6

yrs old)

Drug Name DrugTier

Requirements/Limits

PAMELOR CAPS(nortriptyline hcl) NF AL(At least 6

yrs old)

protriptyline hcl tabs F AL(At least 6yrs old)

SURMONTIL CAPS(trimipramine maleate) NF AL(At least 6

yrs old)TOFRANIL TABS(imipramine hcl) NF AL(At least 6

yrs old)trimipramine maleate capsor 100 mg, 25 mg, 50 mg F AL(At least 6

yrs old)

ANTIDOTES AND SPECIFIC ANTAGONISTS

Opioid Antagonistsnaloxone hcl soct ij 0.4mg/ml F AL(At least 6

yrs old)naloxone hcl soln ij 0.4mg/ml, 4 mg/10ml F AL(At least 6

yrs old)naloxone hcl sosy ij 2mg/2ml F AL(At least 6

yrs old)

naltrexone hcl tabs or F AL(At least 6yrs old)

NARCAN LIQD F AL(At least 6yrs old)

VIVITROL SUSR F AL(At least 6yrs old); SP

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Ethanolamines

ALER-DRYL TABS F AL(At least 6yrs old)

BENADRYL ALLERGYCAPS (diphenhydraminehcl)


BENADRYL ALLERGYCHILDRENS CHEW 12.5MG (diphenhydramine hcl)


BENADRYL ALLERGYCHILDRENS LIQD 12.5MG/5ML (diphenhydraminehcl)

NF

AL(At least 6yrs old);RX/OTC

BENADRYL ALLERGYTABS (diphenhydraminehcl)


diphenhydramine hcl capsor 50 mg, 25 mg F AL(At least 6

yrs old)


8

Drug Name DrugTier

Requirements/Limits

diphenhydramine hcl chewor 12.5 mg F AL(At least 6

yrs old)

diphenhydramine hcl elix or12.5 mg/5ml F


diphenhydramine hcl liqd or12.5 mg/5ml, 25 mg/10ml,50 mg/20ml

FAL(At least 6yrs old);RX/OTC

diphenhydramine hcl liqd or6.25 mg/ml F AL(At least 6

yrs old)diphenhydramine hcl tabsor 25 mg F AL(At least 6

yrs old)VANAMINE PD LIQD(diphenhydramine hcl) NF AL(At least 6

yrs old)Antihistamines - Piperidinescyproheptadine hcl tabs or4 mg F AL(At least 6

yrs old)ANTIHYPERTENSIVES - Drugs to Treat HighBlood PressureAntiadrenergic AntihypertensivesCATAPRES TABS(clonidine hcl) NF AL(At least 6

yrs old)clonidine hcl tabs or 0.1mg, 0.2 mg, 0.3 mg F AL(At least 6

yrs old)

guanfacine hcl tabs F AL(At least 6yrs old)

MINIPRESS CAPS(prazosin hcl) NF AL(At least 6

yrs old)

prazosin hcl caps F AL(At least 6yrs old)

ANTIPARKINSON AND RELATED THERAPYAGENTS - Drugs to Treat Parkinson's DiseaseAntiparkinson Anticholinergicsbenztropine mesylate solnij 1 mg/ml F PA

benztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg F AL(At least 6

yrs old)COGENTIN SOLN(benztropine mesylate) NF PA

trihexyphenidyl hcl soln 0.4mg/ml F

trihexyphenidyl hcl tabs 2mg, 5 mg F AL(At least 6

yrs old)Antiparkinson Dopaminergics

Drug Name DrugTier

Requirements/Limits

amantadine hcl caps or 100mg F

amantadine hcl syrp or 50mg/5ml F

STALEVO 100 TABS NF

STALEVO 75 TABS NF

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood DisordersAntimanic Agentslithium carbonate caps or300 mg, 150 mg, 600 mg F

lithium carbonate tabs or300 mg F

lithium carbonate tbcr or300 mg, 450 mg F

LITHIUM SOLN F

LITHOBID TBCR (lithiumcarbonate) NF

Antipsychotics - Misc.GEODON CAPS OR 20MG, 40 MG, 60 MG(ziprasidone hcl)


GEODON CAPS OR 80MG (ziprasidone hcl) NF


GEODON SOLR IM 20 MG(ziprasidone mesylate) NF PA; AL(At least

18 yrs old)

LATUDA TABS FQL(1 ea daily);AL(At least 6yrs old)

ziprasidone hcl caps 20mg, 40 mg, 60 mg F


ziprasidone hcl caps 80 mg FQL(2 ea daily);AL(At least 6yrs old)

ziprasidone mesylate solr F PA; AL(At least18 yrs old)

Benzisoxazoles


9

Drug Name DrugTier

Requirements/Limits

INVEGA SUSTENNASUSY F

Limit 1 per 4weeks;;1 rtlpack lmtamt,28 rtl packlmt day(s),;AL(At least 18yrs old); SP

INVEGA TRINZA SUSY F

Try InvegaSustenna first;Limit 1 per 3months;1 rtlpack lmtamt,90 rtl packlmt day(s),;AL(At least 18yrs old); SP

RISPERDAL CONSTASRER F

Limit 2 per 4weeks;;2 rtlMAX fill,28 rtlday(s) supply,;AL(At least 18yrs old); SP

RISPERDAL SOLN 1MG/ML (risperidone) NF

QL(8 mldaily,240 mlper 30 daysretail); AL(Atleast 6 yrs old)

RISPERDAL TABS 0.25MG, 0.5 MG (risperidone) NF


RISPERDAL TABS 1 MG,2 MG (risperidone) NF


RISPERDAL TABS 3 MG,4 MG (risperidone) NF


risperidone soln 1 mg/ml F

QL(8 mldaily,240 mlper 30 daysretail); AL(Atleast 6 yrs old)

risperidone tabs 0.25 mg,0.5 mg F


risperidone tabs 1 mg, 2mg F


Drug Name DrugTier

Requirements/Limits

risperidone tabs 3 mg, 4mg F


risperidone tbdp 0.25 mg, 3mg, 4 mg, 0.5 mg, 1 mg, 2mg


ButyrophenonesHALDOL DECANOATE100 SOLN (haloperidoldecanoate)


HALDOL DECANOATE 50SOLN (haloperidoldecanoate)


HALDOL SOLN(haloperidol lactate) NF AL(At least 6

yrs old)haloperidol decanoate solnim 100 mg/ml, 50 mg/ml F AL(At least 18

yrs old)

haloperidol lactate conc F AL(At least 6yrs old)

haloperidol lactate soln F AL(At least 6yrs old)

haloperidol tabs or 0.5 mg,1 mg, 10 mg, 2 mg, 20 mg,5 mg


Dibenzapines

clozapine tabs FQL(5 ea daily);AL(At least 18yrs old)

clozapine tbdp FQL(5 ea daily);AL(At least 18yrs old)

CLOZARIL TABS(clozapine) NF


FAZACLO TBDP 100 MG,12.5 MG, 25 MG(clozapine)


FAZACLO TBDP 150 MG(clozapine) F


loxapine succinate caps F AL(At least 6yrs old)

olanzapine solr im 10 mg F PA

olanzapine tabs or 10 mg,5 mg F



10

Drug Name DrugTier

Requirements/Limits

olanzapine tabs or 15 mg,20 mg F


olanzapine tabs or 2.5 mg,7.5 mg F

QL(1 eadaily,30 day(s)limit); AL(Atleast 6 yrs old)

olanzapine tbdp or 10 mg,5 mg F


olanzapine tbdp or 15 mg,20 mg F


quetiapine fumarate tabs100 mg, 200 mg, 25 mg, 50mg


quetiapine fumarate tabs300 mg, 400 mg F


SEROQUEL TABS 100MG, 200 MG, 25 MG, 50MG (quetiapine fumarate)


SEROQUEL TABS 300MG, 400 MG (quetiapinefumarate)


ZYPREXA SOLR IM 10MG (olanzapine) NF PA

ZYPREXA TABS OR 10MG, 5 MG (olanzapine) NF


ZYPREXA TABS OR 15MG, 20 MG (olanzapine) NF


ZYPREXA TABS OR 2.5MG, 7.5 MG (olanzapine) NF

QL(1 eadaily,30 day(s)limit); AL(Atleast 6 yrs old)

ZYPREXA ZYDIS TBDP 10MG, 5 MG (olanzapine) NF


ZYPREXA ZYDIS TBDP 15MG, 20 MG (olanzapine) NF


Dihydroindolonesmolindone hcl tabs F PA

Phenothiazines

Drug Name DrugTier

Requirements/Limits

chlorpromazine hcl soln ij25 mg/ml, 50 mg/2ml F PA

chlorpromazine hcl tabs or200 mg, 25 mg, 10 mg, 100mg, 50 mg


fluphenazine decanoatesoln ij F AL(At least 18

yrs old)fluphenazine hcl conc or 5mg/ml F AL(At least 6

yrs old)fluphenazine hcl elix or 2.5mg/5ml F AL(At least 6

yrs old)fluphenazine hcl soln ij 2.5mg/ml F PA; AL(At least

18 yrs old)fluphenazine hcl tabs or 1mg, 10 mg, 2.5 mg, 5 mg F AL(At least 6

yrs old)perphenazine tabs or 16mg, 2 mg, 4 mg, 8 mg F AL(At least 6

yrs old)thioridazine hcl tabs or 10mg, 100 mg, 25 mg, 50 mg F AL(At least 6

yrs old)

trifluoperazine hcl tabs F AL(At least 6yrs old)

Quinolinone Derivatives

ABILIFY MAINTENA PRSY F


ABILIFY MAINTENA SRER F


ABILIFY TABS(aripiprazole) NF


aripiprazole tabs FQL(1 ea daily);AL(At least 6yrs old)


11

Drug Name DrugTier

Requirements/Limits

ARISTADA INITIO PRSY F

Limit 2 dosesper 365Days;;2 rtl MAXfill,365 rtlday(s) supply,;AL(At least 18yrs old); SP

ARISTADA PRSY 1064MG/3.9ML F

Limit 1 per 8weeks;1 rtlpack lmtamt,56 rtl packlmt day(s),;AL(At least 18yrs old); SP

ARISTADA PRSY 441MG/1.6ML, 662 MG/2.4ML,882 MG/3.2ML

F


Thioxanthenes

thiothixene caps F AL(At least 6yrs old)

BETA BLOCKERS - Drugs to Treat High BloodPressureBeta Blockers Non-Selective

CORGARD TABS (nadolol) NF

PA req age 19and up or usealternative;AL(Up to 18 yrs old)

nadolol tabs or 20 mg, 40mg, 80 mg F

PA req age 19and up or usealternative;AL(Up to 18 yrs old)

propranolol hcl tabs or 10mg, 80 mg, 20 mg, 40 mg,60 mg


CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation ConditionsPeripheral Vasodilatorsinositol niacinate caps F

NIACIN FLUSH FREECAPS F

Drug Name DrugTier

Requirements/Limits

NIACIN FLUSH-FREEEXTRA STRENGTH CAPS F

NO FLUSH NIACIN TABS F

DERMATOLOGICALS - Drugs to Treat SkinConditionsAnti-inflammatory Agents - TopicalFLECTOR PTCH NF

HEMATOPOIETIC AGENTS - Drugs to TreatBlood DisordersCobalamins

B-12 TABS F AL(At least 6yrs old)

cyanocobalamin tabs or250 mcg, 50 mcg, 1000mcg, 100 mcg, 500 mcg


Folic Acid/Folates

folic acid tabs FAL(At least 6yrs old);RX/OTC

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTSAntihistamine Hypnoticsdiphenhydramine hcl(sleep) caps 25 mg F QL(2 ea daily)

diphenhydramine hcl(sleep) caps 50 mg F QL(1 ea daily)

diphenhydramine hcl(sleep) liqd 50 mg/30ml F QL(30 ml daily)

diphenhydramine hcl(sleep) tabs 25 mg F QL(2 ea daily)

diphenhydramine hcl(sleep) tabs 50 mg F QL(1 ea daily)

diphenhydramine hcl(sleep) tbdp 25 mg F QL(2 ea daily)

NYTOL MAXIMUMSTRENGTH TABS(diphenhydramine hcl(sleep))

NF

QL(1 ea daily)

UNISOM SLEEPGELSCAPS (diphenhydraminehcl (sleep))

NFQL(1 ea daily)


12

Drug Name DrugTier

Requirements/Limits

UNISOM SLEEPMELTSTBDP (diphenhydraminehcl (sleep))

NFQL(2 ea daily)

WAL-SLEEP Z LIQUIDSHOTS LIQD F QL(50 ml daily)

ZZZQUIL CAPS 25 MG(diphenhydramine hcl(sleep))

NFQL(2 ea daily)

ZZZQUIL LIQD 50MG/30ML(diphenhydramine hcl(sleep))

NF

QL(30 ml daily)

Non-Barbiturate Hypnotics

AMBIEN TABS 10 MG(zolpidem tartrate) NF


AMBIEN TABS 5 MG(zolpidem tartrate) NF


DORAL TABS (quazepam) NF

eszopiclone tabs FQL(1 ea daily);AL(At least 6yrs old)

LUNESTA TABS(eszopiclone) NF


RESTORIL CAPS(temazepam) NF


temazepam caps FQL(1 ea daily);AL(At least 6yrs old)

zolpidem tartrate tabs or 10mg F


zolpidem tartrate tabs or 5mg F


Selective Melatonin Receptor AgonistsHETLIOZ CAPS F PA

Drug Name DrugTier

Requirements/Limits

ROZEREM TABS(ramelteon) F

ST; Try 2:temazepam,zolpidem,eszopiclone;QL(1 ea daily);AL(At least 6yrs old)

LAXATIVES - Bowel Treatment Drugs

Bulk LaxativesADVANCED FIBERCOMPLEX/ACIDOPHILUSCAPS

F

calcium polycarbophil tabs F

CITRUCEL FIBERLAXATIVE POWD(methylcellulose (laxative))

NF

CITRUCEL TABS(methylcellulose (laxative)) NF

corn dextrin powd F

CVS NATURAL FIBERSUPPLEMENT PACK F

DAILY FIBER PACK F

EQUALACTIN CHEW F

EVAC POWD (psyllium) NF

fiber chew F

FIBER COMPLETE TABS F

FIBER DIET TABS F

FIBER FORMULA CAPS F

fiber powd F

FIBERCON TABS (calciumpolycarbophil) NF

FIBEREX F15 LIQD F

HYDROCIL INSTANTPACK F

HYDROCIL INSTANTPOWD (psyllium) NF


13

Drug Name DrugTier

Requirements/Limits

KONSYL DAILY FIBERPACK 100 %, 28.3 %, 60.3%

F

KONSYL DAILY FIBERPOWD 100 % (psyllium) NF

KONSYL DAILY FIBERPOWD 60.3 % F

KONSYL ORIGINAL DAILYFIBER PACK F

KONSYL PACK F

KONSYL POWD F

KONSYL-D POWD F

METAMUCIL CAPS 0.52GM (psyllium) NF

METAMUCIL FIBER PACK F

METAMUCIL FREE &NATURAL POWD(psyllium)

NF

METAMUCILMULTIHEALTH FIBERPOWD

F

METAMUCILMULTIHEALTH FIBERSINGLES PACK

F

METAMUCIL ORIGINALTEXTURE POWD(psyllium)

NF

METAMUCIL PACK 28 % F

METAMUCIL POWD 48.57% (psyllium) NF

METAMUCIL WAFR F

methylcellulose (laxative)powd F

methylcellulose (laxative)tabs F

PROFIBER LIQD F

psyllium caps F

psyllium powd F

Drug Name DrugTier

Requirements/Limits

SM FIBER POWDERPOWD F

SOLFIBER POWD F

UNIFIBER POWD F

Laxative CombinationsCOLYTE-FLAVOR PACKSSOLR (peg 3350-kcl-sodbicarb-sod chloride-sodsulfate)

NF

Laxatives - Miscellaneouslactulose soln 10 gm/15ml,20 gm/30ml F

Saline LaxativesFLEET ENEMA ENEM(sodium phosphates) NF

FLEET ENEMA SIX PACKENEM (sodiumphosphates)

NF

FLEET PEDIATRIC ENEM(sodium phosphates) NF

magnesium citrate soln or1.745 gm/30ml, F

magnesium oxide (laxative)tabs F

PEDIA-LAX CHEW OR 400MG F

PHILLIPS MILK OFMAGNESIA CHEWABLECHEW

F

PHILLIPS TABS(magnesium oxide(laxative))

NF

sodium phosphates enem F

Stimulant LaxativesAGORAL MAXIMUMSTRENGTH LIQD F

bisacodyl supp re 10 mg F

bisacodyl tbec or 5 mg F

BLACK DRAUGHT CHEW10 MG F


14

Drug Name DrugTier

Requirements/Limits

cascara sagrada caps 450mg F

CASCARA SAGRADAEXTR 1 GM/ML F

DULCOLAX SUPP(bisacodyl) NF

DULCOLAX TBEC(bisacodyl) NF

EVAC-U-GEN CHEW F

EX-LAX CHEW(sennosides) NF

EX-LAX TABS(sennosides) NF

FLEET BISACODYL ENEM F

LITTLE TUMMYSLAXATIVE LIQD F

SENNA LEAVES LEAV F

SENNA SYRP OR F

sennosides caps F

sennosides chew F

sennosides liqd F

sennosides syrp F

sennosides tabs F

SENOKOT TABS(sennosides) NF

Surfactant LaxativesCOLACE CAPS (docusatesodium) NF AL(At least 6

yrs old)docusate sodium caps or250 mg, 100 mg F AL(At least 6

yrs old)docusate sodium liqd or150 mg/15ml, 50 mg/5ml F

docusate sodium syrp or60 mg/15ml F

docusate sodium tabs or100 mg F

PEDIA-LAX LIQD OR 50MG/15ML F

Drug Name DrugTier

Requirements/Limits

MOUTH/THROAT/DENTAL AGENTS

Throat Products - Misc.AQUORAL SOLN F RX/OTC

artificial saliva lozg F RX/OTC

BIOTENE DRY MOUTHGUM GUM F

BIOTENE DRY MOUTHMOISTURIZING SPRAYSOLN

FRX/OTC

BIOTENE ORALBALANCEDRY MOUTHMOISTURIZING GEL

F

BIOTENE PBF DRYMOUTH GUM GUM F

BOCASAL PACK F

CAPHOSOL SOLN F RX/OTC

CAPHOSOL TBEF F

CVS DRY MOUTH SPRAYSOLN F RX/OTC

EQL DRY MOUTH ORALRINSE SOLN F RX/OTC

MIGHTEAFLOW GUM F

MOI-STIR SOLN F RX/OTC

MOUTH KOTE REMINTSOLN F RX/OTC

MOUTH KOTE SOLN F RX/OTC

MUCOSITISRX PACK F

NEUTRASAL PACK F

NUMOISYN LIQD F RX/OTC

NUMOISYN LOZG(artificial saliva) NF RX/OTC

ORAL RELIEF FOR DRYMOUTH& DISCOMFORTGEL

F


15

Drug Name DrugTier

Requirements/Limits

ORAL RELIEF FOR DRYMOUTH& DISCOMFORTKIT

F

ORAL RELIEF SPRAYFOR DRYMOUTH &DISCOMFORT SOLN

FRX/OTC

RA DRY MOUTH SOLN F RX/OTC

SALIVAMAX PACK F

XEROSTOMIA RELIEFSPRAY SOLN F RX/OTC

MULTIVITAMINS

Multiple Vitamins w/ Minerals

ABC COMPLETE SENIORWOMENS 50+ TABS F


ACTIVNUTRIENTS CAPS FAL(At least 6yrs old);RX/OTC

ADVANCED DIABETICMULTIVITAMIN FORMULATABS


ALIVE ENERGY 50+ TABS FAL(At least 6yrs old);RX/OTC

ALIVE MENS ENERGYTABS F


ALIVE ONCE DAILYWOMENS 50+ ULTRAPOTENCY TABS


ALIVE ONCE DAILYWOMENS ULTRAPOTENCY TABS


ALIVE WOMENS 50+TABS F


ALIVE WOMENS ENERGYTABS F


ANTIOXIDANT FORMULATABS F


Drug Name DrugTier

Requirements/Limits

AZO HORMONALHEALTH CYCLE CARE &COMFORT TABS


AZO HORMONALHEALTH HAPPY CYCLETABS


BACMIN TABS FAL(At least 6yrs old);RX/OTC

BARIATRICMULTIVITAMINS/IRONCAPS


BASIC AM TABS FAL(At least 6yrs old);RX/OTC

BASIC PM TABS FAL(At least 6yrs old);RX/OTC

BIO-35 GLUTEN-FREECAPS F


BIO-35 IRON FREE CAPS FAL(At least 6yrs old);RX/OTC

BIOCAL CAPS FAL(At least 6yrs old);RX/OTC

CAL-DAY 1000 TABS FAL(At least 6yrs old);RX/OTC

CELEBRATE MULTI-COMPLETE18 CAPS F








CELLULAR SECURITYCAPS F


CENTRAVITES 50 PLUSTABS F



16

Drug Name DrugTier

Requirements/Limits

CENTRAVITES ADULTSTABS F


CENTRUM ADULTS TABS(multiple vitamins w/minerals)

NFAL(At least 6yrs old);RX/OTC

CENTRUM CARDIO TABS FAL(At least 6yrs old);RX/OTC

CENTRUM MEN TABS 0.9MG-1.2 MG-1.3 MG-10MCG-10 MCG-100 MCG-100 MG-1000 UNIT-11MG-15 MG-150 MCG-16MG-2 MG-2 MG-2.3 MG-20MG-200 MCG-210 MG-35MCG-3500 UNIT-40 MCG-45 UNIT-5 MCG-50 MCG-6MCG-60 MCG-600 MCG-72 MG-8 MG-80 MG-90MG

F


CENTRUM MEN TABS 0.9MG-1.2 MG-1.3 MG-100MCG-100 MG-1050 MCG-11 MG-15 MG-150 MCG-16 MG-2 MG-2.3 MG-20MG-20.3 MG-200 MCG-210 MG-25 MCG-35 MCG-40 MCG-50 MCG-6 MCG-60 MCG-600 MCG-72 MG-8 MG-80 MG-90 MG(multiple vitamins w/minerals)

NF


CENTRUM SILVER50+MEN TABS (multiplevitamins w/ minerals)


CENTRUM SILVER50+WOMEN TABS(multiple vitamins w/minerals)

NF


CENTRUM SILVERADULT 50+ TABS (multiplevitamins w/ minerals)


CENTRUM SILVER TABS(multiple vitamins w/minerals)


CENTRUM SILVERULTRA WOMENS TABS F


Drug Name DrugTier

Requirements/Limits

CENTRUM SPECIALISTHEART TABS F


CENTRUM SPECIALISTIMMUNE SUPPORT TABS F


CENTRUM SPECIALISTVISION TABS F


CENTRUM TABS (multiplevitamins w/ minerals) NF


CENTRUM ULTRAWOMENS TABS F


CENTRUM WOMEN TABS(multiple vitamins w/minerals)


CERTAVITE SENIORTABS F


CERTAVITESENIOR/ANTIOXIDANTNUTRIENTS TABS


CERTAVITE/ANTIOXIDANTS TABS F


CHOICEFULMULTIVITAMIN CAPS F


CLINICAL NUTRIENTS 45-PLUS WOMEN TABS F


CLINICAL NUTRIENTS 50-PLUS MEN TABS F


CLINICAL NUTRIENTSANTIOXIDANT CAPS F


CLINICAL NUTRIENTSFOR FEMALE TEENSTABS


CLINICAL NUTRIENTSFOR MALE TEENS TABS F


CLINICAL NUTRIENTSFOR MEN TABS F



17

Drug Name DrugTier

Requirements/Limits

CLINICAL NUTRIENTSFOR WOMEN TABS F


CVS ADULT 50+ EYEHEALTH CAPS F


CVS EYE HEALTH ADULT50+ CAPS F


CVS ONE DAILY MENS50+ ADVANCED TABS F


CVS SPECTRAVITEADULT 50+ TABS F


CVS SPECTRAVITEULTRA MEN50+ TABS F


CVS SPECTRAVITEULTRA MENS HEALTHSENIOR TABS


CVS SPECTRAVITEULTRA MENS HEALTHTABS


CVS SPECTRAVITEULTRA WOMEN TABS F


CVS SPECTRAVITEULTRA WOMENSHEALTH SENIOR TABS


CVS SPECTRAVITEULTRA WOMENSHEALTH TABS


CVS VISION HEALTHCAPS F


DECUBI-VITE CAPS FAL(At least 6yrs old);RX/OTC

DEKAS PLUS CAPS FAL(At least 6yrs old);RX/OTC

DERMAVITE TABS FAL(At least 6yrs old);RX/OTC

EQ COMPLETEMULTIVITAMINADULTSUNDER 50 TABS


Drug Name DrugTier

Requirements/Limits

EQ ONE DAILY MENS 50+TABS F


EQ ONE DAILY MENSHEALTH TABS F


EQ ONE DAILY WOMENS50+ TABS F


EQ ONE DAILY WOMENSHEALTH TABS F


EQL CENTURY MATUREADULTS50+ TABS F


EQL CENTURY MENSTABS F


EQL CENTURY WOMENSTABS F


EQL ONE DAILY MENSTABS F


EYE HEALTH CAPS FAL(At least 6yrs old);RX/OTC

EYE HEALTH/LUTEINTABS F


EYEMULTIVITAMIN/LUTEINTABS


EYEMULTIVITAMIN/SODIUMTABS


FITNESS TABS FOR MENAM/PM/LYCOPENE TABS F


FITNESS TABS FORWOMENAM/PM/LYCOPENE TABS


FOLIKA-CI TABS FAL(At least 6yrs old);RX/OTC

FOLIKA-MG TABS FAL(At least 6yrs old);RX/OTC


18

Drug Name DrugTier

Requirements/Limits

FORTAVIT CAPS FAL(At least 6yrs old);RX/OTC

FOSFREE TABS (multiplevitamins w/ minerals) NF


FREEDAVITE TABS FAL(At least 6yrs old);RX/OTC

GENADEK STEP 1 CAPS FAL(At least 6yrs old);RX/OTC

GENADEK STEP 2 CAPS FAL(At least 6yrs old);RX/OTC

GERI-FREEDA SENIORFORMULA TABS F


HAIR SKIN & NAILSADVANCED FORMULATABS


HAIR/SKIN/NAILS CAPS FAL(At least 6yrs old);RX/OTC

HM COMPLETE 50+MENS ULTIMATE TABS F


HM COMPLETE 50+WOMENS ULTIMATETABS


HM COMPLETE MENTABS F


HM COMPLETE TABS FAL(At least 6yrs old);RX/OTC

HM HAIR/SKIN/NAILSTABS F


HM ONE DAILY MENSTABS F


HM ONE DAILY WOMENSTABS F


HYLAZINC TABS FAL(At least 6yrs old);RX/OTC

Drug Name DrugTier

Requirements/Limits

ICAPS AREDS FORMULATABS F


ICAPS PLUS TABS FAL(At least 6yrs old);RX/OTC

K-PAX IMMUNESUPPORT FORMULADOUBLE STRENGTHCAPS

F


K-PAX IMMUNESUPPORT FORMULAPROFESSIONALSTRENGTH TABS

F


K-PAX IMMUNESUPPORT FORMULASINGLE STRENGTHCAPS

F


LUTEINPLUS/ZEAXANTHIN TABS F


MACULAR VITAMINBENEFIT TABS F


MEGA MULTI FOR MENTABS F


MEGA MULTI FORWOMEN TABS F


MEGA MULTIVITAMINFOR MEN TABS F


MEGA MULTIVITAMINFOR WOMEN TABS F


MEGAVITE FRUITS &VEGGIES TABS F


MEGAVITE GOLDENYEARS 55+ TABS F


MENS 50+ ADVANCEDCAPS F


MENS 50+ MULTIVITAMIN &MINERALFORMULA TABS



19

Drug Name DrugTier

Requirements/Limits

MENS MULTI VITAMIN &MINERAL FORMULATABS


MENS MULTIVITAMINTABS F


MULTI-BETIC DIABETESTABS F


MULTI-VITAMINMONOCAPS TABS F


MULTILEX T&M TABS FAL(At least 6yrs old);RX/OTC

MULTILEX TABS FAL(At least 6yrs old);RX/OTC

multiple vitamins w/minerals caps F


multiple vitamins w/minerals tabs F


MULTIVITAMIN ADULTSTABS F


MULTIVITAMIN MENTABS F


MULTIVITAMIN TABS 1MG-1 MG-1.5 MG-10MCG-10 MG-10 MG-100MG-15 MG-15 MG-150MCG-150 MG-2 MG-2.5MG-3000 MCG-5 MG-7.5MCG

F


MULTIVITAMIN WOMENTABS F


MULTIVITAMIN/ZINCSTRESSFORMULA TABS F


MVW COMPLETEFORMULATION CAPS F


Drug Name DrugTier

Requirements/Limits

MVW COMPLETEFORMULATIOND3000CAPS


MVW COMPLETEFORMULATIOND500CAPS


MVW COMPLETEFORMULATIONMINISCAPS


NAT-RUL THERAVITE-M/HIGHPOTENCY TABS F


NATRUL-VITES TABS FAL(At least 6yrs old);RX/OTC

NEOVITE TABS FAL(At least 6yrs old);RX/OTC

NICADAN TABS FAL(At least 6yrs old);RX/OTC

NICADAN ZX TABS FAL(At least 6yrs old);RX/OTC

NICAZEL FORTE TABS FAL(At least 6yrs old);RX/OTC

NICAZEL TABS FAL(At least 6yrs old);RX/OTC

NO IRON MULTIPLEVITAMIN/MINERALSTABS


NUTRICAP TABS FAL(At least 6yrs old);RX/OTC

OCULAR VITAMINS TABS FAL(At least 6yrs old);RX/OTC

OCUVITE ADULT 50+CAPS F


OCUVITE ADULTFORMULA CAPS F


OCUVITE LUTEIN CAPS FAL(At least 6yrs old);RX/OTC


20

Drug Name DrugTier

Requirements/Limits

ONCOVITE TABS FAL(At least 6yrs old);RX/OTC

ONE DAILY MENSFORMULA W/O IRONTABS


ONE DAILY WOMENSTABS F


ONE-A-DAY ENERGYTABS F


ONE-A-DAY MENOPAUSEFORMULA TABS F


ONE-A-DAY MENS 50+ADVANTAGE TABS F


ONE-A-DAY MENS 50+TABS F


ONE-A-DAY MENSHEALTH FORMULA TABS F


ONE-A-DAY MENS PROEDGE TABS F


ONE-A-DAY MENS TABS0.9 MG-1.32 MG-1.43 MG-11 MG-120 MG-15 MG-15.5 MG-150 MCG-17.6MG-2.17 MG-2.3 MG-210MG-240 MCG-25 MCG-30MCG-300 MCG-35 MCG-43 MCG-55 MCG-6.24MCG-900 MCG-99 MG

F


ONE-A-DAY PROACTIVE65+ TABS F


ONE-A-DAY TEENADVANTAGEFOR HIMTABS


ONE-A-DAY WEIGHTSMART ADVANCED TABS(multiple vitamins w/minerals)

NF


Drug Name DrugTier

Requirements/Limits

ONE-A-DAY WOMENS50+ ADVANTAGE TABS(multiple vitamins w/minerals)

NF


ONE-A-DAY WOMENS50+ HEALTHYADVANTAGE TABS(multiple vitamins w/minerals)

NF


ONE-A-DAY WOMENSACTIVE MIND & BODYTABS (multiple vitamins w/minerals)

NF


ONE-A-DAY WOMENSPETITES TABS (multiplevitamins w/ minerals)


ONE-A-DAY WOMENSPLUS HEALTHY SKINSUPPORT TABS (multiplevitamins w/ minerals)

NF


ONE-A-DAY WOMENSTABS F


OPTIVITE P.M.T. TABS(multiple vitamins w/minerals)


OPURITY TABS FAL(At least 6yrs old);RX/OTC

OSTEOPRIMEPLUS/CALCIUM &MAGNESIUM TABS


PARVLEX TABS FAL(At least 6yrs old);RX/OTC

PHYTOMULTI TABS FAL(At least 6yrs old);RX/OTC

PRESERVISION AREDS 2+ MULTI VITAMIN CAPS F


PRESERVISION AREDS 2CAPS F


PRESERVISION AREDSCAPS F



21

Drug Name DrugTier

Requirements/Limits

PRESERVISION AREDSTABS F


PRESERVISION/LUTEINCAPS F


PRO-CAL TABS FAL(At least 6yrs old);RX/OTC

PROCERV HP TABS FAL(At least 6yrs old);RX/OTC

PRORENAL+D TABS FAL(At least 6yrs old);RX/OTC

PRORENAL+D/OMEGA-3CAPS F


PROTECT CARDIO AFCAPS F


PROTECT PLUS SOCAPS F


PROTEGRA CAPS FAL(At least 6yrs old);RX/OTC

PROVIT TABS FAL(At least 6yrs old);RX/OTC

QC MULTI-VITE TABS FAL(At least 6yrs old);RX/OTC

QC OCUHEALTH VISIONSUPPORT 2 CAPS F


QUENCH TABS FAL(At least 6yrs old);RX/OTC

QUIN B STRONG TABS FAL(At least 6yrs old);RX/OTC

QUINTABS-M TABS FAL(At least 6yrs old);RX/OTC

RA CENTRAL-VITE TABS FAL(At least 6yrs old);RX/OTC

Drug Name DrugTier

Requirements/Limits

RA CENTRAL-VITEUNDER 50MENS TABS F


RA CENTRAL-VITEUNDER 50WOMENSTABS


RENAPLEX-D TABS FAL(At least 6yrs old);RX/OTC

REPLACE CAPS FAL(At least 6yrs old);RX/OTC

REQ 49+ TABS FAL(At least 6yrs old);RX/OTC

SAVISION CAPS FAL(At least 6yrs old);RX/OTC

SENTRY SENIOR TABS FAL(At least 6yrs old);RX/OTC

SENTRY SENIOR/LUTEINTABS F


SENTRY TABS FAL(At least 6yrs old);RX/OTC

SIDEROL TABS FAL(At least 6yrs old);RX/OTC

SM ONE DAILY MENSTABS F


SM ONE DAILY WOMENSTABS F


SOLO TABS FAL(At least 6yrs old);RX/OTC

SPECTRAVITE TABS FAL(At least 6yrs old);RX/OTC

STROVITE FORTE TABS(multiple vitamins w/minerals)


STROVITE ONE TABS FAL(At least 6yrs old);RX/OTC


22

Drug Name DrugTier

Requirements/Limits

SUPER ANTIOXIDANTCAPS F


SYSTANE ICAPS AREDS2TABS F


T-VITES TABS FAL(At least 6yrs old);RX/OTC

TAB-A-VITEMULTIVITAMIN/IRON ANDBETA-CAROTENE TABS


THERA M PLUS TABS FAL(At least 6yrs old);RX/OTC

THERA-M TABS FAL(At least 6yrs old);RX/OTC

THERA-TABS M TABS FAL(At least 6yrs old);RX/OTC

THERABETIC MULTI-VITAMIN TABS F


THERAGRAN-MADVANCED 50 PLUSTABS


THERAGRAN-MADVANCED TABS F


THERAGRAN-M PREMIER50 PLUS TABS F


THERAGRAN-M PREMIERTABS F


THERAGRAN-M TABS FAL(At least 6yrs old);RX/OTC

THERAMILL FORTE CAPS FAL(At least 6yrs old);RX/OTC

THERANATALLACTATION ONE CAPS F


THEREMS-H TABS FAL(At least 6yrs old);RX/OTC

Drug Name DrugTier

Requirements/Limits

THEREMS-M TABS FAL(At least 6yrs old);RX/OTC

UNICOMPLEX-M TABS FAL(At least 6yrs old);RX/OTC

VISTA ADVANCEDAREDS2 FORMULA CAPS F


VISTA ADVANCED DRYEYE FORMULA CAPS F


VITABEX CAPS FAL(At least 6yrs old);RX/OTC

VITABEX PLUS CAPS FAL(At least 6yrs old);RX/OTC

VITALINE TOTALFORMULA 2 TABS F


VITALINE TOTALFORMULA 3 TABS F


VITAMIN D3 COMPLETETABS F


VITAROCA PLUS TABS(multiple vitamins w/minerals)


VITASANA TABS FAL(At least 6yrs old);RX/OTC

VITATRUM TABS FAL(At least 6yrs old);RX/OTC

VITREXATE FE TABS FAL(At least 6yrs old);RX/OTC

VITREXATE TABS FAL(At least 6yrs old);RX/OTC

VITREXYL TABS FAL(At least 6yrs old);RX/OTC

VITREXYL/IRON TABS FAL(At least 6yrs old);RX/OTC


23

Drug Name DrugTier

Requirements/Limits

VITRUM 50+ ADULT-MULTI IRON FREE TABS F


VITRUM 50+ SENIORMULTI TABS F


WHOLE FOODMULTIVITAMIN TABS F


WOMENS 50+ MULTIVITAMIN& MINERALFORMULA TABS


WOMENS BIOMULTIPLETABS F


WOMENS MULTI VITAMIN& MINERAL FORMULATABS


YELETS TEENAGEFORMULA TABS F


Multivitamins

ESTROFACTORS TABS F AL(At least 6yrs old)

HIGH POTENCYMULTIVITAMIN TABS F AL(At least 6

yrs old)

MULTI VITAMIN TABS F AL(At least 6yrs old)

MULTI VITAMIN/D-3 TABS F AL(At least 6yrs old)

multiple vitamin tabs F AL(At least 6yrs old)

MULTIVITAMIN ADULTTABS F AL(At least 6

yrs old)MULTIVITAMIN TABS 0.1MG-1 MG-1.5 MG-10MCG-1500 MCG-2 MG-20MG-28.5 MG-37.5 MG

F

AL(At least 6yrs old)

NEOMULTIVITE TABS F AL(At least 6yrs old)

OMNICAP TABS F AL(At least 6yrs old)

ONE-A-DAY ESSENTIALTABS (multiple vitamin) NF AL(At least 6

yrs old)

Drug Name DrugTier

Requirements/Limits

ONE-A-DAY MENS TABS0.4 MG-10 MG-2.25 MG-2.55 MG-20 MG-200 MG-3MG-400 UNIT-45 UNIT-5000 UNIT-9 MCG(multiple vitamin)

NF


QUINTABS TABS F AL(At least 6yrs old)

THERA TABS F AL(At least 6yrs old)

THEREMS MULTIVITAMINTABS F AL(At least 6

yrs old)

NUTRIENTS

Misc. Nutritional Substances

FISH OIL CAPS F AL(At least 6yrs old)

FISH OIL CHEW F AL(At least 6yrs old)

FISH OIL PEARLS CAPS F AL(At least 6yrs old)

FISH OIL TRIPLESTRENGTH CAPS F AL(At least 6

yrs old)

FISH OIL ULTRA CAPS F AL(At least 6yrs old)

HM FISH OIL CAPS F AL(At least 6yrs old)

OCEAN BLUE MINICAPSOMEGA-3 CAPS F AL(At least 6

yrs old)

OMEGA-3 CAPS F AL(At least 6yrs old)

OMEGA-3 EPA FISH OILCAPS F AL(At least 6

yrs old)

omega-3 fatty acids caps F AL(At least 6yrs old)

omega-3 fatty acids chew F AL(At least 6yrs old)

OMEGA-3 FISH OILEXTRA STRENGTH CAPS F AL(At least 6

yrs old)RA FISH OIL EXTRASTRENGTH CAPS F AL(At least 6

yrs old)RA TRIPLE STRENGTHFISH OIL CAPS F AL(At least 6

yrs old)

SALMON CAPS F AL(At least 6yrs old)


24

Drug Name DrugTier

Requirements/Limits

SALMON OIL CAPS F AL(At least 6yrs old)

SALMON OIL-1000 CAPS F AL(At least 6yrs old)

SM FISH OIL CAPS F AL(At least 6yrs old)

SUPER TWIN EPA/DHACAPS F AL(At least 6

yrs old)

ULTRA OMEGA 3 CAPS F AL(At least 6yrs old)

ULTRA OMEGA-3 FISHOIL BURP-LESS CAPS F AL(At least 6

yrs old)PSYCHOTHERAPEUTIC AND NEUROLOGICALAGENTS - MISC. - Drugs to Treat Mental andEmotional ConditionsAgents for Chemical Dependency

acamprosate calcium tbec F AL(At least 6yrs old)

ANTABUSE TABS(disulfiram) NF AL(At least 6

yrs old)disulfiram tabs or 500 mg,250 mg F AL(At least 6

yrs old)Postherpetic Neuralgia (PHN)/Neuropathic Pain

GRALISE TABS F PA; AL(At least6 yrs old)

Premenstrual Dysphoric Disorder (PMDD) Agents

fluoxetine hcl (pmdd) caps10 mg, 20 mg F


Psychotherapeutic and Neurological Agents -

pimozide tabs F AL(At least 12yrs old)

Restless Leg Syndrome (RLS) Agents

HORIZANT TBCR 600 MG F PA; AL(At least6 yrs old)

THYROID AGENTS - Drugs to Regulate ThyroidHormonesThyroid HormonesARMOUR THYROID TABS120 MG, 30 MG, 60 MG,90 MG (thyroid)


CYTOMEL TABS(liothyronine sodium) NF AL(At least 6

yrs old)

Drug Name DrugTier

Requirements/Limits

levothyroxine sodium tabsor 300 mcg, 100 mcg, 112mcg, 125 mcg, 137 mcg,150 mcg, 175 mcg, 200mcg, 25 mcg, 50 mcg, 75mcg, 88 mcg

F


liothyronine sodium tabs or25 mcg, 5 mcg, 50 mcg F AL(At least 6

yrs old)NATURE-THROID TABS130 MG, 195 MG, 32.5MG, 65 MG


SYNTHROID TABS(levothyroxine sodium) NF AL(At least 6

yrs old)thyroid tabs or 120 mg, 30mg, 60 mg, 90 mg F AL(At least 6

yrs old)WESTHROID TABS 130MG, 195 MG, 32.5 MG, 65MG


WP THYROID TABS 130MG, 32.5 MG, 65 MG F AL(At least 6

yrs old)URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder SpasmsUrinary Antispasmodics - Cholinergic Agonistsbethanechol chloride tabsor 10 mg, 25 mg, 5 mg, 50mg


URECHOLINE TABS(bethanechol chloride) NF AL(At least 6

yrs old)VASOPRESSORS - Drugs to Treat Heart andCirculation ConditionsAnaphylaxis Therapy AgentsADRENALIN SOLN IJ 30MG/30ML NF

EPIPEN 2-PAK SOAJ(epinephrine (anaphylaxis)) NF

VITAMINS

Oil Soluble Vitamins

KEY-E CHEW OR F AL(At least 6yrs old)

vitamin e caps or 180 mg,100 unit, 45 mg, 200 unit,400 unit


VITAMIN E CHEW OR 400UNIT F AL(At least 6

yrs old)


25

Drug Name DrugTier

Requirements/Limits

Water Soluble Vitamins

B-1 TABS F AL(At least 6yrs old)

niacin cpcr F

niacin tbcr F

pyridoxine hcl tabs F AL(At least 6yrs old)

SLO-NIACIN TBCR (niacin) NF

thiamine hcl tabs F AL(At least 6yrs old)


26

IndexABC COMPLETE SENIORWOMENS 50+ 16ABILIFY 11ABILIFY MAINTENA 11acamprosate calcium 25ACTIVNUTRIENTS 16ADDERALL 1ADDERALL XR 1ADRENALIN 25ADVANCED DIABETICMULTIVITAMIN FORMULA 16ADVANCED FIBERCOMPLEX/ACIDOPHILUS 13ADZENYS ER 1AGORAL MAXIMUMSTRENGTH 14ALER-DRYL 8ALIVE ENERGY 50+ 16ALIVE MENS ENERGY 16ALIVE ONCE DAILY WOMENS50+ ULTRA POTENCY 16ALIVE ONCE DAILY WOMENSULTRA POTENCY 16ALIVE WOMENS 50+ 16ALIVE WOMENS ENERGY 16alprazolam 3ALPRAZOLAM INTENSOL 3amantadine hcl 9AMBIEN 13amitriptyline hcl 8amoxapine 8amphetamine-dextroamphetamine 1ANAFRANIL 8ANTABUSE 25ANTIOXIDANT FORMULA 16APTENSIO XR 1AQUORAL 15aripiprazole 11ARISTADA 12ARISTADA INITIO 12ARMOUR THYROID 25artificial saliva 15ATIVAN 4atomoxetine hcl 1AZO HORMONAL HEALTHCYCLE CARE & COMFORT 16AZO HORMONAL HEALTHHAPPY CYCLE 16B-1 26

B-12 12BACMIN 16BARIATRICMULTIVITAMINS/IRON 16BASIC AM 16BASIC PM 16BENADRYL ALLERGY 8BENADRYL ALLERGYCHILDRENS 8benztropine mesylate 9bethanechol chloride 25BIO-35 GLUTEN-FREE 16BIO-35 IRON FREE 16BIOCAL 16BIOTENE DRY MOUTHGUM 15BIOTENE DRY MOUTHMOISTURIZING SPRAY 15BIOTENE ORALBALANCEDRY MOUTHMOISTURIZING 15BIOTENE PBF DRY MOUTHGUM 15bisacodyl 14BLACK DRAUGHT 14BOCASAL 15buprenorphine hcl 2,3buprenorphine hcl-naloxone hcldihydrate 3bupropion hcl 6buspirone hcl 3CAL-DAY 1000 16calcium polycarbophil 13CAPHOSOL 15carbamazepine 5CARBATROL 5cascara sagrada 15CASCARA SAGRADA 15CATAPRES 9CELEBRATE MULTI-COMPLETE18 16CELEBRATE MULTI-COMPLETE36 16CELEBRATE MULTI-COMPLETE45 16CELEBRATE MULTI-COMPLETE60 16CELEXA 6CELLULAR SECURITY 16CENTRAVITES 50 PLUS 16CENTRAVITES ADULTS 17

CENTRUM 17CENTRUM ADULTS 17CENTRUM CARDIO 17CENTRUM MEN 17CENTRUM SILVER 17CENTRUM SILVER50+MEN 17CENTRUM SILVER50+WOMEN 17CENTRUM SILVER ADULT50+ 17CENTRUM SILVER ULTRAWOMENS 17CENTRUM SPECIALISTHEART 17CENTRUM SPECIALISTIMMUNE SUPPORT 17CENTRUM SPECIALISTVISION 17CENTRUM ULTRAWOMENS 17CENTRUM WOMEN 17CERTAVITE SENIOR 17CERTAVITESENIOR/ANTIOXIDANTNUTRIENTS 17CERTAVITE/ANTIOXIDANTS

17chlordiazepoxide hcl 4chlorpromazine hcl 11CHOICEFULMULTIVITAMIN 17citalopram hydrobromide 6CITRUCEL 13CITRUCEL FIBERLAXATIVE 13CLINICAL NUTRIENTS 45-PLUSWOMEN 17CLINICAL NUTRIENTS 50-PLUSMEN 17CLINICAL NUTRIENTSANTIOXIDANT 17CLINICAL NUTRIENTS FORFEMALE TEENS 17CLINICAL NUTRIENTS FORMALE TEENS 17CLINICAL NUTRIENTS FORMEN 17CLINICAL NUTRIENTS FORWOMEN 18clomipramine hcl 8clonazepam 4clonidine hcl 9clonidine hcl (adhd) 1clorazepate dipotassium 4

Index 1

clozapine 10CLOZARIL 10COGENTIN 9COLACE 15COLYTE-FLAVOR PACKS 14CONCERTA 1CORGARD 12corn dextrin 13CVS ADULT 50+ EYEHEALTH 18CVS DRY MOUTH SPRAY 15CVS EYE HEALTH ADULT50+ 18CVS NATURAL FIBERSUPPLEMENT 13CVS ONE DAILY MENS 50+ADVANCED 18CVS SPECTRAVITE ADULT50+ 18CVS SPECTRAVITE ULTRAMEN50+ 18CVS SPECTRAVITE ULTRAMENS HEALTH 18CVS SPECTRAVITE ULTRAMENS HEALTH SENIOR 18CVS SPECTRAVITE ULTRAWOMEN 18CVS SPECTRAVITE ULTRAWOMENS HEALTH 18CVS SPECTRAVITE ULTRAWOMENS HEALTHSENIOR 18CVS VISION HEALTH 18cyanocobalamin 12CYMBALTA 7cyproheptadine hcl 9CYTOMEL 25DAILY FIBER 13DAPTOMYCIN 3DAYTRANA 1DECUBI-VITE 18DEKAS PLUS 18DEPAKENE 5DEPAKOTE 6DEPAKOTE ER 5DEPAKOTE SPRINKLES 5DERMAVITE 18desipramine hcl 8dexmethylphenidate hcl 1DIASTAT ACUDIAL 4DIASTAT PEDIATRIC 5

diazepam 4DIAZEPAM 4diazepam 4DILAUDID 2diphenhydramine hcl 8,9diphenhydramine hcl(sleep) 12disulfiram 25divalproex sodium 6docusate sodium 15DORAL 13doxepin hcl 8DULCOLAX 15duloxetine hcl 7EFFEXOR XR 7EPIPEN 2-PAK 25EQ COMPLETEMULTIVITAMINADULTSUNDER 50 18EQ ONE DAILY MENS50+ 18EQ ONE DAILY MENSHEALTH 18EQ ONE DAILY WOMENS50+ 18EQ ONE DAILY WOMENSHEALTH 18EQL CENTURY MATUREADULTS50+ 18EQL CENTURY MENS 18EQL CENTURY WOMENS18EQL DRY MOUTH ORALRINSE 15EQL ONE DAILY MENS 18EQUALACTIN 13escitalopram oxalate 6ESTROFACTORS 24eszopiclone 13EVAC 13EVAC-U-GEN 15EX-LAX 15EYE HEALTH 18EYE HEALTH/LUTEIN 18EYE MULTIVITAMIN/LUTEIN

18EYE MULTIVITAMIN/SODIUM

18FAZACLO 10fiber 13FIBER COMPLETE 13FIBER DIET 13

FIBER FORMULA 13FIBERCON 13FIBEREX F15 13FISH OIL 24FISH OIL PEARLS 24FISH OIL TRIPLESTRENGTH 24FISH OIL ULTRA 24FITNESS TABS FOR MENAM/PM/LYCOPENE 18FITNESS TABS FOR WOMENAM/PM/LYCOPENE 18FLAX + DHA 2FLECTOR 12FLEET BISACODYL 15FLEET ENEMA 14FLEET ENEMA SIX PACK 14FLEET PEDIATRIC 14fluoxetine hcl 6fluoxetine hcl (pmdd) 25fluphenazine decanoate 11fluphenazine hcl 11fluvoxamine maleate 6,7FOCALIN 1FOCALIN XR 1folic acid 12FOLIKA-CI 18FOLIKA-MG 18FORFIVO XL 6FORTAVIT 19FOSFREE 19FREEDAVITE 19gabapentin 5GENADEK STEP 1 19GENADEK STEP 2 19GEODON 9GERI-FREEDA SENIORFORMULA 19GRALISE 25guanfacine hcl 9guanfacine hcl (adhd) 1HAIR SKIN & NAILS ADVANCEDFORMULA 19HAIR/SKIN/NAILS 19HALDOL 10HALDOL DECANOATE 100 10HALDOL DECANOATE 50 10haloperidol 10

Index 2

haloperidol decanoate 10haloperidol lactate 10HETLIOZ 13HIGH POTENCYMULTIVITAMIN 24HM COMPLETE 19HM COMPLETE 50+ MENSULTIMATE 19HM COMPLETE 50+ WOMENSULTIMATE 19HM COMPLETE MEN 19HM FISH OIL 24HM HAIR/SKIN/NAILS 19HM OMEGA-3-6-9 FATTYACIDS 2HM ONE DAILY MENS 19HM ONE DAILY WOMENS 19HORIZANT 25HYDROCIL INSTANT 13hydroxyzine hcl 3hydroxyzine pamoate 3HYLAZINC 19ICAPS AREDS FORMULA 19ICAPS PLUS 19imipramine hcl 8imipramine pamoate 8inositol niacinate 12INTUNIV 1INVEGA SUSTENNA 10INVEGA TRINZA 10K-PAX IMMUNE SUPPORTFORMULA DOUBLESTRENGTH 19K-PAX IMMUNE SUPPORTFORMULA PROFESSIONALSTRENGTH 19K-PAX IMMUNE SUPPORTFORMULA SINGLESTRENGTH 19KEY-E 25KHEDEZLA 8KLONOPIN 5KONSYL 14KONSYL DAILY FIBER 14KONSYL ORIGINAL DAILYFIBER 14KONSYL-D 14lactulose 14LAMICTAL 5LAMICTAL CHEWABLEDISPERSIBLE 5

LAMICTAL ODT 5LAMICTAL XR 5lamotrigine 5LATUDA 9levothyroxine sodium 25LEXAPRO 7liothyronine sodium 25LITHIUM 9lithium carbonate 9LITHOBID 9LITTLE TUMMYSLAXATIVE 15lorazepam 4loxapine succinate 10LUNESTA 13LUTEINPLUS/ZEAXANTHIN 19MACULAR VITAMINBENEFIT 19magnesium citrate 14magnesium oxide(laxative) 14maprotiline hcl 6MEGA MULTI FOR MEN 19MEGA MULTI FORWOMEN 19MEGA MULTIVITAMIN FORMEN 19MEGA MULTIVITAMIN FORWOMEN 19MEGAVITE FRUITS &VEGGIES 19MEGAVITE GOLDEN YEARS55+ 19MENS 50+ ADVANCED 19MENS 50+ MULTI VITAMIN&MINERAL FORMULA 19MENS MULTI VITAMIN &MINERAL FORMULA 20MENS MULTIVITAMIN 20METAMUCIL 14METAMUCIL FIBER 14METAMUCIL FREE &NATURAL 14METAMUCIL MULTIHEALTHFIBER 14METAMUCIL MULTIHEALTHFIBER SINGLES 14METAMUCIL ORIGINALTEXTURE 14methylcellulose (laxative) 14METHYLIN 2methylphenidate hcl 2

MIGHTEAFLOW 15MINIPRESS 9mirtazapine 6MOI-STIR 15molindone hcl 11MORPHINE SULFATE 2MOUTH KOTE 15MOUTH KOTE REMINT 15MUCOSITISRX 15MULTI VITAMIN 24MULTI VITAMIN/D-3 24MULTI-BETIC DIABETES 20MULTI-VITAMINMONOCAPS 20MULTILEX 20MULTILEX T&M 20multiple vitamin 24multiple vitamins w/ minerals 20MULTIVITAMIN 20,24MULTIVITAMIN ADULT 24MULTIVITAMIN ADULTS 20MULTIVITAMIN MEN 20MULTIVITAMIN WOMEN 20MULTIVITAMIN/ZINCSTRESSFORMULA 20MVW COMPLETEFORMULATION 20MVW COMPLETEFORMULATIOND3000 20MVW COMPLETEFORMULATIOND500 20MVW COMPLETEFORMULATIONMINIS 20nadolol 12naloxone hcl 8naltrexone hcl 8NARCAN 8NAT-RUL THERAVITE-M/HIGHPOTENCY 20NATRUL-VITES 20NATURE-THROID 25NEOMULTIVITE 24NEOVITE 20NEURONTIN 5NEUTRASAL 15niacin 26NIACIN FLUSH FREE 12NIACIN FLUSH-FREE EXTRASTRENGTH 12NICADAN 20

Index 3

NICADAN ZX 20NICAZEL 20NICAZEL FORTE 20NO FLUSH NIACIN 12NO IRON MULTIPLEVITAMIN/MINERALS 20NORPRAMIN 8nortriptyline hcl 8NUMOISYN 15NUTRICAP 20NYTOL MAXIMUMSTRENGTH 12OCEAN BLUE MINICAPSOMEGA-3 24OCULAR VITAMINS 20OCUVITE ADULT 50+ 20OCUVITE ADULTFORMULA 20OCUVITE LUTEIN 20olanzapine 10,11OMEGA 3-6-9 COMPLEX 2OMEGA-3 24OMEGA-3 EPA FISH OIL 24omega-3 fatty acids 24OMEGA-3 FISH OIL EXTRASTRENGTH 24OMEGA-3-6-9 2OMNICAP 24ONCOVITE 21ONE DAILY MENS FORMULAW/O IRON 21ONE DAILY WOMENS 21ONE-A-DAY ENERGY 21ONE-A-DAY ESSENTIAL 24ONE-A-DAY MENOPAUSEFORMULA 21ONE-A-DAY MENS 21,24ONE-A-DAY MENS 50+ 21ONE-A-DAY MENS 50+ADVANTAGE 21ONE-A-DAY MENS HEALTHFORMULA 21ONE-A-DAY MENS PROEDGE 21ONE-A-DAY PROACTIVE65+ 21ONE-A-DAY TEENADVANTAGEFOR HIM 21ONE-A-DAY WEIGHT SMARTADVANCED 21ONE-A-DAY WOMENS 21

ONE-A-DAY WOMENS 50+ADVANTAGE 21ONE-A-DAY WOMENS 50+HEALTHY ADVANTAGE 21ONE-A-DAY WOMENSACTIVE MIND & BODY 21ONE-A-DAY WOMENSPETITES 21ONE-A-DAY WOMENS PLUSHEALTHY SKINSUPPORT 21OPTIVITE P.M.T. 21OPURITY 21ORAL RELIEF FOR DRYMOUTH& DISCOMFORT 15ORAL RELIEF SPRAY FORDRYMOUTH &DISCOMFORT 16OSTEOPRIMEPLUS/CALCIUM &MAGNESIUM 21oxazepam 4oxcarbazepine 5PAMELOR 8paroxetine hcl 7PARVLEX 21PAXIL 7PEDIA-LAX 14,15perphenazine 11PHILLIPS 14PHILLIPS MILK OFMAGNESIA CHEWABLE 14PHYTOMULTI 21pimozide 25prazosin hcl 9PRESERVISION AREDS 21PRESERVISION AREDS 221PRESERVISION AREDS 2 +MULTI VITAMIN 21PRESERVISION/LUTEIN 22PRO-CAL 22PROCERV HP 22PROFIBER 14propranolol hcl 12PRORENAL+D 22PRORENAL+D/OMEGA-3 22PROTECT CARDIO AF 22PROTECT PLUS SO 22PROTEGRA 22protriptyline hcl 8PROVIT 22

PROZAC 7psyllium 14pyridoxine hcl 26QC MULTI-VITE 22QC OCUHEALTH VISIONSUPPORT 2 22QUDEXY XR 5QUENCH 22quetiapine fumarate 11QUIN B STRONG 22QUINTABS 24QUINTABS-M 22RA CENTRAL-VITE 22RA CENTRAL-VITE UNDER50MENS 22RA CENTRAL-VITE UNDER50WOMENS 22RA DRY MOUTH 16RA FISH OIL EXTRASTRENGTH 24RA OMEGA 3-6-9 2RA TRIPLE STRENGTH FISHOIL 24REMERON 6REMERON SOLTAB 6RENAPLEX-D 22REPLACE 22REQ 49+ 22RESTORIL 13RISPERDAL 10RISPERDAL CONSTA 10risperidone 10RITALIN 2RITALIN LA 2ROZEREM 13SALIVAMAX 16SALMON 24SALMON OIL 25SALMON OIL-1000 25SAVISION 22SENNA 15SENNA LEAVES 15sennosides 15SENOKOT 15SENTRY 22SENTRY SENIOR 22SENTRY SENIOR/LUTEIN 22SEROQUEL 11

Index 4

sertraline hcl 7SIDEROL 22SLO-NIACIN 26SM FIBER POWDER 14SM FISH OIL 25SM OMEGA-3 2SM OMEGA-3-6-9 FATTYACIDS 2SM ONE DAILY MENS 22SM ONE DAILY WOMENS 22sodium phosphates 14SOLFIBER 14SOLO 22SPECTRAVITE 22SPRAVATO 56MG DOSE 6SPRAVATO 84MG DOSE 6STALEVO 100 9STALEVO 75 9STRATTERA 1STROVITE FORTE 22STROVITE ONE 22SUBLOCADE 3SUBOXONE 3SUPER ANTIOXIDANT 23SUPER OMEGA-3 2SUPER TWIN EPA/DHA 25SURMONTIL 8SYNTHROID 25SYSTANE ICAPS AREDS2 23T-VITES 23TAB-A-VITEMULTIVITAMIN/IRON ANDBETA-CAROTENE 23TEGRETOL 5TEGRETOL-XR 5temazepam 13THERA 24THERA M PLUS 23THERA-M 23THERA-TABS M 23THERABETIC MULTI-VITAMIN 23THERAGRAN-M 23THERAGRAN-MADVANCED 23THERAGRAN-M ADVANCED 50PLUS 23THERAGRAN-M PREMIER 23

THERAGRAN-M PREMIER 50PLUS 23THERAMILL FORTE 23THERANATAL LACTATIONONE 23THEREMSMULTIVITAMIN 24THEREMS-H 23THEREMS-M 23thiamine hcl 26thioridazine hcl 11thiothixene 12thyroid 25TOFRANIL 8TOPAMAX 5TOPAMAX SPRINKLE 5topiramate 5TRANXENE T 4trazodone hcl 7trifluoperazine hcl 11trihexyphenidyl hcl 9TRILEPTAL 5trimipramine maleate 8TRIPLE OMEGA-3-6-9 2ULTRA OMEGA 3 25ULTRA OMEGA-3 FISH OILBURP-LESS 25UNICOMPLEX-M 23UNIFIBER 14UNISOM SLEEPGELS 12UNISOM SLEEPMELTS 13URECHOLINE 25VALIUM 4valproate sodium 6valproic acid 6VANAMINE PD 9venlafaxine hcl 8VISTA ADVANCED AREDS2FORMULA 23VISTA ADVANCED DRY EYEFORMULA 23VISTARIL 3VITABEX 23VITABEX PLUS 23VITALINE TOTAL FORMULA2 23VITALINE TOTAL FORMULA3 23VITAMIN D3 COMPLETE 23vitamin e 25

VITAMIN E 25VITAROCA PLUS 23VITASANA 23VITATRUM 23VITREXATE 23VITREXATE FE 23VITREXYL 23VITREXYL/IRON 23VITRUM 50+ ADULT-MULTIIRON FREE 24VITRUM 50+ SENIORMULTI 24VIVITROL 8VYVANSE 1WAL-SLEEP Z LIQUIDSHOTS 13WELLBUTRIN SR 6WELLBUTRIN XL 6WESTHROID 25WHOLE FOODMULTIVITAMIN 24WOMENS 50+ MULTI VITAMIN&MINERAL FORMULA 24WOMENS BIOMULTIPLE 24WOMENS MULTI VITAMIN &MINERAL FORMULA 24WP THYROID 25XANAX 4XANAX XR 4XEROSTOMIA RELIEFSPRAY 16YELETS TEENAGEFORMULA 24ziprasidone hcl 9ziprasidone mesylate 9ZOLOFT 7zolpidem tartrate 13ZYPREXA 11ZYPREXA ZYDIS 11ZZZQUIL 13

Index 5

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