OHSU HEALTH SERVICES FORMULARY
Effective January 1, 2020
LAST UPDATED: September 27, 2021 Introduction The formulary is a list of drugs that are covered. The list is from a healthcare team that makes sure drugs are safe and effective. We update the formulary at least once a year. We will tell you about changes that affect you at least 30 days ahead of time. How to search You can look for drugs on the formulary in a couple of ways: By Use: Drugs used for the same medical reason are listed together. For example, drugs used to treat infections are listed under “Antibiotics.” Alphabetically: Drugs are also listed in alphabetical order with page number. Limits and restrictions Drugs that have limits or need more information before they are covered, are listed in these ways:
Type Description Your provider will need to fill out a form and send it to us so Prior Approval (PA) we can review if the drug is covered Step Therapy (ST) You may need to first try another drug or series of drugs Quantity Limit (QL) A limited amount of drug is covered without our approval These drugs are covered only for certain ages. If you are Age Limit (AL1) younger or older than the age listed, we will need more information from your provider before we will cover the drug Specialty Drug (S) You will need to fill the drug at a specialty pharmacy
Drugs not covered Drugs that are not covered include the following: Drugs not on the formulary Drugs not used for approved medical reasons Drugs used for conditions not covered by the Oregon Health Plan Drugs used for research Drugs used for cosmetic reasons Mental health drugs are not listed on the formulary, but are covered by the Oregon Health Authority drug program. How to request an exception Drugs not listed on the formulary may not be covered. Your provider can send in a form asking that we cover the drug for you. This form can be found on our website at: www.ohsu.edu/healthshare. Once we receive this form, we will see if we are able to cover the drug. We may contact your provider for more information.
OHP-HSO-18-231
Pharmacy network Most of the drugs on the formulary can be filled at our retail pharmacies. Specialty drugs are filled at a specialty pharmacy. For information about pharmacies in our network, contact Member Services at the number below. More information If you have questions or need information, visit our website or contact Member Services Monday through Friday 8:00am to 5:00pm PST. Website: www.ohsu.edu/healthshare Phone: 844-827-6572 TTY: 1-800-735-2900
OHP-HSO-18-231
LEGEND TYPE DESCRIPTION
There is a limit on the amount of this drug that is covered per QL Quantity Limit prescription, or within a specific time frame.
You (or your physician) are required to get prior authorization before PA Prior Authorization you fill your prescription for this drug. Without prior approval, we may not cover this drug.
In some cases, you may be required to first try certain drugs to treat ST Step Therapy your medical condition before we will cover another drug for that condition.
GL Gender Limit This prescription drug may only be covered for a single gender.
This prescription drug may only be covered if you meet the minimum AL1 Age Limit or maximum age limit.
Specialty drugs are high-cost drugs used to treat complex or rare S Specialty Drug conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia.
PAGE 1 LAST UPDATED 09/2021 LIST OF COVERED PRESCRIPTION MEDICATIONS
DRUG LIMITS & RESTRICTIONS ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
all day pain relief 220 mg tab all day pain rlf 220 mg caplet all day relief 220 mg caplet all day relief 220 mg tablet arthritis pain reliever 1% gel aspir ec 81 mg tablet aspir-low ec 81 mg tablet aspir-trin ec 325 mg tablet aspirin 325 mg tablet aspirin 81 mg chewable tablet aspirin ec 325 mg caplet aspirin ec 325 mg tablet aspirin ec 81 mg tablet bayer aspirin 325 mg caplet bayer aspirin 325 mg tablet BAYER ASPIRIN 81 MG CHEW TAB aspirin butalbital-asa-caffeine cap
celecoxib 100 mg capsule QL 60 capsules / 30 days
celecoxib 200 mg capsule QL 60 capsules / 30 days
celecoxib 50 mg capsule QL 60 capsules / 30 days
child aspirin 81 mg chew tab child aspirin 81 mg tab chew child ibuprofen 100mg/5ml syrg child ibuprofen 200 mg/10 ml children ibuprofen 100 mg/5 ml
PAGE 2 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS cvs aspirin 325 mg caplet cvs aspirin 325 mg tablet cvs aspirin 81 mg chewable tab cvs aspirin ec 325 mg tablet cvs aspirin ec 81 mg tablet cvs chld ibuprofen 100 mg/5 ml cvs diclofenac sodium 1% gel cvs ibuprofen 200 mg caplet cvs ibuprofen 200 mg tablet cvs ibuprofen jr str 100 mg tb cvs inf ibuprofen 50 mg/1.25ml cvs naproxen sod 220 mg caplet cvs naproxen sod 220 mg tablet diclofenac sod dr 50 mg tab diclofenac sod dr 75 mg tab diclofenac sod ec 50 mg tab diclofenac sod ec 75 mg tab diclofenac sod er 100 mg tab diclofenac sodium 1% gel ec-naproxen dr 375 mg tablet ec-naproxen dr 500 mg tablet ECOTRIN EC 325 MG TABLET aspirin ecotrin ec 81 mg tablet ecpirin ec 325 mg tablet eq aspirin 325 mg tablet eq aspirin 81 mg chewable tab eq aspirin ec 325 mg tablet eq aspirin ec 81 mg tablet eq child ibuprofen 100 mg/5 ml eq ibuprofen 200 mg caplet
PAGE 3 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS eq ibuprofen 200 mg tablet eq ibuprofen jr str 100 mg tab eq inf ibuprofen 50 mg/1.25 ml eq naproxen sod 220 mg caplet eq naproxen sod 220 mg tablet eql aspirin 325 mg tablet eql aspirin 81 mg chewable tab eql aspirin ec 325 mg tablet eql aspirin ec 81 mg tablet eql chld ibuprofen 100 mg/5 ml eql ibuprofen 200 mg caplet eql ibuprofen 200 mg tablet eql ibuprofen jr 100 mg tb chw eql inf ibuprofen 50 mg/1.25ml eql naproxen sod 220 mg caplet eql naproxen sod 220 mg tablet flanax 220 mg tablet gnp all day pain rlf 220 mg tb gnp aspirin 325 mg tablet gnp aspirin 81 mg chewable tab gnp aspirin ec 325 mg tablet gnp aspirin ec 81 mg tablet gnp chld ibuprofen 100 mg/5 ml gnp ibuprofen 100 mg chew tab gnp ibuprofen 200 mg caplet gnp ibuprofen 200 mg tablet gnp ibuprofen jr str 100 mg tb gnp inf ibuprofen 50 mg/1.25ml gnp naproxen sod 220 mg caplet gnp naproxen sod 220 mg tablet
PAGE 4 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS gs aspirin 325 mg tablet gs aspirin 81 mg chewable tab gs aspirin ec 325 mg tablet gs aspirin ec 81 mg tablet gs child ibuprofen 100 mg/5 ml gs ibuprofen 100 mg chew tab gs ibuprofen 200 mg caplet gs ibuprofen 200 mg tablet gs inf ibuprofen 50 mg/1.25 ml gs naproxen sod 220 mg caplet gs naproxen sod 220 mg tablet gs naproxen sodium 220 mg tab hm arthritis pain 1% gel hm aspirin 325 mg tablet hm aspirin 81 mg chewable tab hm aspirin ec 325 mg tablet hm aspirin ec 81 mg tablet hm child ibuprofen 100 mg/5 ml hm ibuprofen 200 mg caplet hm ibuprofen 200 mg tablet hm ibuprofen ib 100 mg chew tb hm ibuprofen ib 200 mg caplet hm ibuprofen ib 200 mg tablet hm ibuprofen jr str 100 mg chw hm inf ibuprofen 50 mg/1.25 ml hm naproxen sod 220 mg caplet i-prin 200 mg tablet ibu 400 mg tablet ibu 600 mg tablet ibu 800 mg tablet
PAGE 5 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS ibu-200 200 mg tablet ibuprofen 100 mg/5 ml susp ibuprofen 200 mg caplet ibuprofen 200 mg tablet ibuprofen 400 mg tablet ibuprofen 600 mg tablet ibuprofen 800 mg tablet ibuprofen jr str 100 mg chew ibuprofen jr str 100 mg tb chw indomethacin 25 mg capsule indomethacin 50 mg capsule indomethacin er 75 mg capsule infant ibuprofen 50 mg/1.25 ml infant ibuprofen 50 mg/1.25 ml infant ibuprofen 50 mg/1.25 ml
ketorolac 10 mg tablet QL 20 tablets / 30 days
ketorolac 30 mg/ml vial QL 10 / 30 day(s)
kro all day rlf 220 mg caplet kro aspirin 325 mg tablet kro aspirin 81 mg chewable tab kro aspirin ec 81 mg tablet kro chld ibuprofen 100 mg/5 ml kro ibuprofen 200 mg caplet kro ibuprofen 200 mg tablet kro ibuprofen jr str 100 mg tb kro naproxen sod 220 mg caplet low dose aspirin ec 81 mg tab meloxicam 15 mg tablet
meloxicam 7.5 mg tablet QL 60 / 30 day(s)
nabumetone 500 mg tablet
PAGE 6 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS nabumetone 750 mg tablet naproxen 250 mg tablet naproxen 375 mg tablet naproxen 500 mg kit naproxen 500 mg tablet naproxen dr 375 mg tablet naproxen dr 500 mg tablet naproxen sodium 220 mg caplet naproxen sodium 220 mg tablet naproxen sodium 275 mg tab naproxen sodium 550 mg tab naproxen sodium ds 550 mg tab piroxicam 10 mg capsule piroxicam 20 mg capsule provil 200 mg tablet pub all day relief 220 mg tab pub all day rlf 220 mg caplet pub aspirin 325 mg tablet pub aspirin 81 mg chewable tab pub children's profen ib susp pub children's profenib susp pub ibuprofen 200 mg tablet pub ibuprofen jr 100 mg chew pub inf profenib 50 mg/1.25 ml pub naproxen sod 220 mg tablet qc aspirin 325 mg tablet qc aspirin 81 mg chewable tab qc aspirin ec 325 mg tablet qc aspirin ec 81 mg tablet qc child ibuprofen 100 mg/5 ml
PAGE 7 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS qc diclofenac sodium 1% gel qc ibuprofen 200 mg caplet qc ibuprofen 200 mg tablet qc ibuprofen ib 200 mg caplet qc ibuprofen ib 200 mg tablet qc inf ibuprofen 50 mg/1.25 ml qc lo-dose aspirin ec 81 mg tb qc naproxen sod 220 mg tablet ra aspirin 325 mg tablet ra aspirin 81 mg chewable tab ra aspirin ec 325 mg tablet ra aspirin ec 81 mg tablet ra child ibuprofen 100 mg/5 ml ra ibuprofen 100 mg/5 ml susp ra ibuprofen 200 mg caplet ra ibuprofen 200 mg tablet ra ibuprofen jr str 100 mg chw ra inf ibuprofen 50 mg/1.25 ml ra naproxen sod 220 mg tablet sm all day relief 220 mg caplt sm all day relief 220 mg tab sm arthritis pain 1% gel sm aspirin 325 mg tablet sm aspirin 81 mg chewable tab sm aspirin ec 325 mg tablet sm aspirin ec 81 mg tablet sm child aspirin 81 mg chw tab sm ibuprofen 100 mg/5 ml susp sm ibuprofen 200 mg caplet sm ibuprofen 200 mg tablet
PAGE 8 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS sm ibuprofen ib 100 mg chew tb sm ibuprofen ib 200 mg caplet sm ibuprofen ib 200 mg caplet sm ibuprofen ib 200 mg tablet sm inf ibuprofen 50 mg/1.25 ml sm naproxen sod 220 mg caplet sm naproxen sod 220 mg tablet sulindac 150 mg tablet sulindac 200 mg tablet VOLTAREN ARTHRITIS PAIN 1% GEL diclofenac sodium wal-profen 200 mg caplet wal-profen 200 mg tablet wal-proxen 220 mg caplet wal-proxen 220 mg tablet OPIOID ANALGESICS, LONG-ACTING
QL 10 / 30 DAYS fentanyl 100 mcg/hr patch PA
QL 10 / 30 DAYS fentanyl 12 mcg/hr patch PA
QL 10 / 30 DAYS fentanyl 25 mcg/hr patch PA
QL 10 / 30 DAYS fentanyl 50 mcg/hr patch PA
QL 10 / 30 DAYS fentanyl 75 mcg/hr patch PA
QL 60 / 30 DAYS morphine sulf er 100 mg tablet PA
QL 90 / 30 DAYS morphine sulf er 15 mg tablet PA
PAGE 9 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 60 / 30 DAYS morphine sulf er 200 mg tablet PA
QL 90 / 30 DAYS morphine sulf er 30 mg tablet PA
QL 90 / 30 DAYS morphine sulf er 60 mg tablet PA
QL 60 / 30 DAYS oxycodone hcl er 10 mg tablet PA
QL 60 / 30 DAYS oxycodone hcl er 15 mg tablet PA
QL 60 / 30 DAYS oxycodone hcl er 20 mg tablet PA
QL 60 / 30 DAYS oxycodone hcl er 30 mg tablet PA
QL 60 / 30 DAYS oxycodone hcl er 40 mg tablet PA
QL 60 / 30 DAYS oxycodone hcl er 60 mg tablet PA
QL 60 / 30 DAYS oxycodone hcl er 80 mg tablet PA
OXYCONTIN ER 10 MG TABLET QL 60 / 30 DAYS oxycodone hcl PA
OXYCONTIN ER 15 MG TABLET QL 60 / 30 DAYS oxycodone hcl PA
OXYCONTIN ER 20 MG TABLET QL 60 / 30 DAYS oxycodone hcl PA
OXYCONTIN ER 30 MG TABLET QL 60 / 30 DAYS oxycodone hcl PA
OXYCONTIN ER 40 MG TABLET QL 60 / 30 DAYS oxycodone hcl PA
PAGE 10 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
OXYCONTIN ER 60 MG TABLET QL 60 / 30 DAYS oxycodone hcl PA
OXYCONTIN ER 80 MG TABLET QL 60 / 30 DAYS oxycodone hcl PA
OPIOID ANALGESICS, SHORT-ACTING
acetamin-codein 300-30 mg/12.5 acetaminop-codeine 120-12 mg/5 acetaminophen-cod #2 tablet acetaminophen-cod #3 tablet acetaminophen-cod #4 tablet belladonna-opium 16.2-30 supp endocet 10-325 mg tablet endocet 2.5-325 mg tablet endocet 5-325 tablet endocet 7.5-325 mg tablet hydrocodone-acetamin 10-325 mg hydrocodone-acetamin 2.5-108/5 hydrocodone-acetamin 2.5-325 hydrocodone-acetamin 5-217/10 hydrocodone-acetamin 5-300 mg hydrocodone-acetamin 5-325 mg hydrocodone-acetamin 7.5-325 hydrocodone-acetamn 7.5-325/15 morphine sulf 10 mg suppos morphine sulf 10 mg/5 ml soln morphine sulf 100 mg/5 ml conc morphine sulf 20 mg suppos morphine sulf 20 mg/5 ml soln morphine sulf 30 mg suppos morphine sulf 5 mg suppos
PAGE 11 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS morphine sulfate ir 15 mg tab morphine sulfate ir 30 mg tab oxycodon-acetaminophen 2.5-325 oxycodon-acetaminophen 7.5-325 oxycodone hcl 10 mg tablet oxycodone hcl 100 mg/5 ml conc oxycodone hcl 15 mg tablet oxycodone hcl 20 mg tablet oxycodone hcl 30 mg tablet oxycodone hcl 5 mg tablet oxycodone hcl 5 mg/5 ml soln oxycodone-acetaminophen 10-325 oxycodone-acetaminophen 5-325 oxycodone-acetaminophn 2.5-325 oxycodone-acetaminophn 7.5-325 oxycodone-aspirin 4.8355-325 tramadol hcl 50 mg tablet tramadol-acetaminophn 37.5-325 ANESTHETICS
LOCAL ANESTHETICS
lidocaine 2% viscous soln lidocaine 5% ointment lidocaine hcl 4% solution lidocaine hcl 4% solution lidocaine-prilocaine cream midazolam hcl 1 mg/ml vial midazolam hcl 1 mg/ml vial midazolam hcl 10 mg/10 ml vial midazolam hcl 10 mg/2 ml vial midazolam hcl 10 mg/2 ml vial
PAGE 12 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS midazolam hcl 2 mg/2 ml vial midazolam hcl 2 mg/2 ml vial midazolam hcl 25 mg/5 ml vial midazolam hcl 5 mg/5 ml vial midazolam hcl 5 mg/5 ml vial midazolam hcl 5 mg/ml vial midazolam hcl 5 mg/ml vial midazolam hcl 5 mg/ml vial midazolam hcl 5 mg/ml vial midazolam hcl 50 mg/10 ml vial ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calc dr 333 mg tab disulfiram 250 mg tablet disulfiram 500 mg tablet naltrexone 50 mg tablet OPIOID DEPENDENCE
buprenorphin-naloxon 8-2 mg sl QL 90 / 30 day(s)
buprenorphine 2 mg tablet sl QL 90 / 30 day(s)
buprenorphine 8 mg tablet sl QL 90 / 30 day(s)
buprenorphine-nalox 12-3mg flm QL 60 / 30 DAYS
buprenorphine-nalox 2-0.5mg fm QL 90 / 30 DAYS
buprenorphine-nalox 2-0.5mg tb QL 90 / 30 day(s)
buprenorphine-nalox 4-1mg film QL 90 / 30 DAYS
buprenorphine-nalox 8-2 mg tab QL 90 / 30 day(s)
buprenorphine-nalox 8-2mg film QL 90 / 30 DAYS
buprenorphn-naloxn 2-0.5 mg sl QL 90 / 30 day(s)
PAGE 13 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS OPIOID REVERSAL AGENTS
naloxone 0.4 mg/ml carpuject naloxone 0.4 mg/ml vial naloxone 2 mg auto-injector naloxone 2 mg/2 ml syringe naloxone 4 mg/10 ml vial NARCAN 4 MG NASAL SPRAY naloxone hcl SMOKING CESSATION AGENTS
apo-varenicline 0.5 mg tablet QL 2 tablets / day
apo-varenicline 1 mg tablet QL 2 tablets / day
bupropion hcl sr 150 mg tablet QL 60 tablets / 30 days
CHANTIX 0.5 MG TABLET QL 2 tablets / day varenicline tartrate CHANTIX 1 MG CONT MONTH BOX QL 2 tablets / day varenicline tartrate CHANTIX 1 MG TABLET QL 2 tablets / day varenicline tartrate CHANTIX STARTING MONTH BOX QL 2 tablets / day varenicline tartrate
cvs nicotine 14 mg/24hr patch QL 1 patch / day
cvs nicotine 2 mg chewing gum QL 24 pieces / day
cvs nicotine 2 mg lozenge QL 20 lozenges / day
cvs nicotine 2 mg mini lozenge QL 1344 pieces / 180 days
cvs nicotine 21 mg/24hr patch QL 1 patch / day
cvs nicotine 4 mg chewing gum QL 24 pieces / day
cvs nicotine 4 mg lozenge QL 20 lozenges / day
cvs nicotine 4 mg mini lozenge QL 1344 pieces / 180 days
cvs nicotine 7 mg/24hr patch QL 1 patch / day
eq nicotine 14 mg/24hr patch QL 1 patch / day
PAGE 14 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
eq nicotine 2 mg chewing gum QL 24 pieces / day
eq nicotine 2 mg lozenge QL 20 lozenges / day
eq nicotine 2 mg mini lozenge QL 1344 pieces / 180 days
eq nicotine 21 mg/24hr patch QL 1 patch / day
eq nicotine 4 mg chewing gum QL 24 pieces / day
eq nicotine 4 mg lozenge QL 20 lozenges / day
eq nicotine 7 mg/24hr patch QL 1 patch / day
eql nicotine 2 mg chewing gum QL 24 pieces / day
eql nicotine 2 mg lozenge QL 20 lozenges / day
eql nicotine 4 mg chewing gum QL 24 pieces / day
eql nicotine 4 mg lozenge QL 20 lozenges / day
gnp nicotine 14 mg/24hr patch QL 1 patch / day
gnp nicotine 2 mg chewing gum QL 24 pieces / day
gnp nicotine 2 mg lozenge QL 20 lozenges / day
gnp nicotine 2 mg mini lozenge QL 1344 pieces / 180 days
gnp nicotine 21 mg/24hr patch QL 1 patch / day
gnp nicotine 4 mg chewing gum QL 24 pieces / day
gnp nicotine 4 mg lozenge QL 20 lozenges / day
gnp nicotine 4 mg mini lozenge QL 1344 pieces / 180 days
gnp nicotine 7 mg/24hr patch QL 1 patch / day
gs nicotine 2 mg chewing gum QL 24 pieces / day
gs nicotine 2 mg lozenge QL 20 lozenges / day
gs nicotine 2 mg mini lozenge QL 1344 pieces / 180 days
gs nicotine 4 mg chewing gum QL 24 pieces / day
gs nicotine 4 mg lozenge QL 20 lozenges / day
PAGE 15 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
gs nicotine 4 mg mini lozenge QL 1344 pieces / 180 days
hm nicotine 14 mg/24hr patch QL 1 patch / day
hm nicotine 2 mg chewing gum QL 24 pieces / day
hm nicotine 2 mg lozenge QL 20 lozenges / day
hm nicotine 2 mg mini lozenge QL 1344 pieces / 180 days
hm nicotine 21 mg/24hr patch QL 1 patch / day
hm nicotine 4 mg chewing gum QL 24 pieces / day
hm nicotine 4 mg lozenge QL 20 lozenges / day
hm nicotine 4 mg mini lozenge QL 1344 pieces / 180 days
hm nicotine 7 mg/24hr patch QL 1 patch / day
kro nicotine 14 mg/24hr patch QL 1 patch / day
kro nicotine 2 mg chewing gum QL 24 pieces / day
kro nicotine 2 mg lozenge QL 20 lozenges / day
kro nicotine 2 mg mini lozenge QL 1344 pieces / 180 days
kro nicotine 21 mg/24hr patch QL 1 patch / day
kro nicotine 4 mg chewing gum QL 24 pieces / day
kro nicotine 4 mg lozenge QL 20 lozenges / day
kro nicotine 4 mg mini lozenge QL 1344 pieces / 180 days
kro nicotine 7 mg/24hr patch QL 1 patch / day
nicotine 14 mg/24hr patch QL 1 patch / day
nicotine 2 mg chewing gum QL 24 pieces / day
nicotine 2 mg lozenge QL 20 lozenges / day
nicotine 2 mg mini lozenge QL 20 lozenges / day
nicotine 21 mg/24hr patch QL 1 patch / day
nicotine 4 mg chewing gum QL 24 pieces / day
PAGE 16 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
nicotine 4 mg lozenge QL 20 lozenges / day
nicotine 4 mg mini lozenge QL 20 lozenges / day
nicotine 7 mg/24hr patch QL 1 patch / day
nicotine transdermal system QL 1 patch / day
NICOTROL CARTRIDGE INHALER QL 16 cartridges / day nicotine ST
NICOTROL NS 10 MG/ML SPRAY QL 4 ml / day nicotine ST
pub stop smoking aid 2 mg lozg QL 1344 pieces / 180 days
pub stop smoking aid 4 mg lozg QL 1344 pieces / 180 days
qc nicotine 14 mg/24hr patch QL 1 patch / day
qc nicotine 21 mg/24hr patch QL 1 patch / day
quit 2 mg chewing gum QL 1344 pieces / 180 days
quit 2 mg lozenge QL 20 / day(s)
quit 4 mg chewing gum QL 1344 pieces / 180 days
quit 4 mg lozenge QL 20 / day(s)
ra nicotine 14 mg/24hr patch QL 1 patch / day
ra nicotine 2 mg chewing gum QL 24 pieces / day
ra nicotine 2 mg lozenge QL 20 lozenges / day
ra nicotine 2 mg mini lozenge QL 1344 pieces / 180 days
ra nicotine 21 mg/24hr patch QL 1 patch / day
ra nicotine 4 mg chewing gum QL 24 pieces / day
ra nicotine 4 mg lozenge QL 20 lozenges / day
ra nicotine 4 mg mini lozenge QL 1344 pieces / 180 days
ra nicotine 7 mg/24hr patch QL 1 patch / day
sm nicotine 14 mg/24hr patch QL 1 patch / day
PAGE 17 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
sm nicotine 2 mg chewing gum QL 24 pieces / day
sm nicotine 2 mg lozenge QL 20 lozenges / day
sm nicotine 21 mg/24hr patch QL 1 patch / day
sm nicotine 4 mg chewing gum QL 24 pieces / day
sm nicotine 4 mg lozenge QL 20 lozenges / day
sm nicotine 7 mg/24hr patch QL 1 patch / day
sw nicotine 2 mg chewing gum QL 24 pieces / day
sw nicotine 2 mg lozenge QL 20 lozenges / day
sw nicotine 4 mg chewing gum QL 24 pieces / day
sw nicotine 4 mg lozenge QL 20 lozenges / day
varenicline 0.5 mg tablet QL 2 tablets / day
varenicline 1 mg tablet QL 2 tablets / day
ANTIBACTERIALS
AMINOGLYCOSIDES
QL 236 ML / 28 DAYS ARIKAYCE 590 MG/8.4 ML VIAL PA amikacin sulfate liposomal with nebulizer accessories S Specialty Drug
gentamicin 0.1% cream gentamicin 0.1% ointment gentamicin 0.3% eye ointment neomycin 500 mg tablet paromomycin 250 mg capsule ANTIBACTERIALS, OTHER
acetic acid 2% ear solution acetic acid-aluminum drops bacitracin 500 unit/gm ointmnt bacitracin 500 unit/gm ointmnt bacitracin zn 500 unit/gm oint
PAGE 18 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS bacitracin zn 500 unit/gm oint bacitracin zn 500 unit/gm oint bacitraycin plus 500 unit/gm clindamycin (pedi) 75 mg/5 ml clindamycin 2% vaginal cream clindamycin hcl 150 mg capsule clindamycin hcl 300 mg capsule clindamycin hcl 75 mg capsule clindamycin pediatr 75 mg/5 ml cvs bacitracin zn 500 unit/gm eq bacitracin zn 500 unit/gm eql bacitracin zn 500 unit/gm FURADANTIN 25 MG/5 ML SUSP nitrofurantoin gnp bacitracin zn 500 unit/gm hm bacitracin zn 500 unit/gm linezolid 100 mg/5 ml susp linezolid 600 mg tablet metronidazole 250 mg tablet metronidazole 375 mg capsule metronidazole 500 mg tablet metronidazole vaginal 0.75% gl nitrofurantoin 25 mg/5 ml susp nitrofurantoin mcr 100 mg cap nitrofurantoin mcr 50 mg cap nitrofurantoin mono-mcr 100 mg phosphasal tablet qc bacitracin 500 unit/gm oint ra bacitracin zn 500 unit/gm trimethoprim 100 mg tablet
vancomycin 250 mg/5 ml soln QL 150 / 90 day(s)
PAGE 19 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS vancomycin hcl 125 mg capsule vancomycin hcl 250 mg capsule VANDAZOLE VAGINAL 0.75% GEL metronidazole wal-sporin first aid ointment XIFAXAN 550 MG TABLET PA rifaximin BETA-LACTAM, CEPHALOSPORINS
cefaclor 250 mg capsule cefaclor 500 mg capsule cefadroxil 1 gm tablet cefadroxil 250 mg/5 ml susp cefadroxil 500 mg capsule cefadroxil 500 mg/5 ml susp cefdinir 125 mg/5 ml susp cefdinir 250 mg/5 ml susp cefdinir 300 mg capsule cefixime 400 mg capsule cefpodoxime 100 mg tablet cefpodoxime 100 mg/5 ml susp cefpodoxime 200 mg tablet cefpodoxime 50 mg/5 ml susp cefprozil 125 mg/5 ml susp cefprozil 250 mg tablet cefprozil 250 mg/5 ml susp cefprozil 500 mg tablet cefuroxime axetil 250 mg tab cefuroxime axetil 500 mg tab cephalexin 125 mg/5 ml susp cephalexin 250 mg capsule cephalexin 250 mg/5 ml susp
PAGE 20 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS cephalexin 500 mg capsule BETA-LACTAM, PENICILLINS
amox-clav 200-28.5 mg tab chew amox-clav 200-28.5 mg/5 ml sus amox-clav 250-125 mg tablet amox-clav 250-62.5 mg/5 ml sus amox-clav 400-57 mg tab chew amox-clav 400-57 mg/5 ml susp amox-clav 500-125 mg tablet amox-clav 600-42.9 mg/5 ml sus amox-clav 875-125 mg tablet amox-clav er 1,000-62.5 mg tab amoxicillin 125 mg tab chew amoxicillin 125 mg/5 ml susp amoxicillin 200 mg/5 ml susp amoxicillin 250 mg capsule amoxicillin 250 mg tab chew amoxicillin 250 mg/5 ml susp amoxicillin 400 mg/5 ml susp amoxicillin 500 mg capsule amoxicillin 500 mg tablet amoxicillin 875 mg tablet ampicillin 250 mg capsule ampicillin 500 mg capsule dicloxacillin 250 mg capsule dicloxacillin 500 mg capsule penicillin vk 125 mg/5 ml soln penicillin vk 250 mg tablet penicillin vk 250 mg/5 ml soln penicillin vk 500 mg tablet
PAGE 21 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS MACROLIDES
azithromycin 1 gm pwd packet azithromycin 100 mg/5 ml susp azithromycin 200 mg/5 ml susp azithromycin 250 mg tablet azithromycin 500 mg tablet azithromycin 600 mg tablet clarithromycin 125 mg/5 ml sus clarithromycin 250 mg tablet clarithromycin 250 mg/5 ml sus clarithromycin 500 mg tablet clarithromycin er 500 mg tab QUINOLONES
ciprofloxacin 0.3% eye drop ciprofloxacin 250 mg/5 ml susp ciprofloxacin 500 mg/5 ml susp ciprofloxacin hcl 100 mg tab ciprofloxacin hcl 250 mg tab ciprofloxacin hcl 500 mg tab ciprofloxacin hcl 750 mg tab levofloxacin 25 mg/ml solution levofloxacin 250 mg tablet levofloxacin 250 mg/10 ml soln levofloxacin 500 mg tablet levofloxacin 500 mg/20 ml soln levofloxacin 750 mg tablet moxifloxacin hcl 400 mg tablet SULFONAMIDES
sulfadiazine 500 mg tablet sulfamethoxazole-tmp ds tablet
PAGE 22 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS sulfamethoxazole-tmp ss tablet sulfamethoxazole-tmp susp sulfamethoxazole-tmp susp THERMAZENE 1% CREAM silver sulfadiazine TETRACYCLINES
avidoxy 100 mg tablet doxycycline 25 mg/5 ml susp doxycycline hyclate 100 mg cap doxycycline hyclate 100 mg tab doxycycline hyclate 20 mg tab doxycycline hyclate 50 mg cap doxycycline mono 100 mg cap doxycycline mono 100 mg tablet doxycycline mono 50 mg cap doxycycline mono 50 mg tablet doxycycline mono 75 mg tablet minocycline 100 mg capsule minocycline 50 mg capsule minocycline 75 mg capsule mondoxyne nl 100 mg capsule mondoxyne nl 50 mg capsule morgidox 100 mg capsule morgidox 50 mg capsule okebo 100 mg capsule ANTICONVULSANTS
ANTICONVULSANTS, OTHER
QL 90 / 30 DAYS DIACOMIT 250 MG CAPSULE PA stiripentol S Specialty Drug
QL 90 / 30 DAYS DIACOMIT 250 MG POWDER PACKET PA stiripentol S Specialty Drug
PAGE 23 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 180 / 30 DAYS DIACOMIT 500 MG CAPSULE PA stiripentol S Specialty Drug
QL 180 / 30 DAYS DIACOMIT 500 MG POWDER PACKET PA stiripentol S Specialty Drug
EPIDIOLEX 100 MG/ML SOLUTION PA cannabidiol (cbd)
felbamate 400 mg tablet QL 120 / 30 DAYS
felbamate 600 mg tablet QL 180 / 30 DAYS
QL 900 / 30 DAYS felbamate 600 mg/5 ml susp AL1 12 to 999 yrs old
QL 360 / 30 day(s) FINTEPLA 2.2 MG/ML SOLUTION PA fenfluramine hcl S Specialty Drug
levetiracetam 1,000 mg tablet levetiracetam 100 mg/ml soln levetiracetam 1000 mg/10 ml levetiracetam 250 mg tablet levetiracetam 500 mg tablet levetiracetam 500 mg/5 ml soln levetiracetam 750 mg tablet levetiracetam er 500 mg tablet levetiracetam er 750 mg tablet roweepra 1,000 mg tablet roweepra 500 mg tablet roweepra 750 mg tablet roweepra xr 500 mg tablet roweepra xr 750 mg tablet topiramate 100 mg tablet
PAGE 24 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS topiramate 15 mg sprinkle cap topiramate 200 mg tablet topiramate 25 mg sprinkle cap topiramate 25 mg tablet topiramate 50 mg tablet
XCOPRI 100 MG TABLET QL 60 / 30 DAYS cenobamate PA
XCOPRI 12.5-25 MG TITRATION PK QL 28 / 28 DAYS cenobamate PA
XCOPRI 150 MG TABLET QL 60 / 30 DAYS cenobamate PA
XCOPRI 150-200 MG TITRATION PK QL 28 / 28 DAYS cenobamate PA
XCOPRI 200 MG TABLET QL 60 / 30 DAYS cenobamate PA
XCOPRI 250 MG DAILY DOSE PACK QL 56 / 28 DAYS cenobamate PA
XCOPRI 350 MG DAILY DOSE PACK QL 56 / 28 DAYS cenobamate PA
XCOPRI 50 MG TABLET QL 60 / 30 DAYS cenobamate PA
XCOPRI 50-100 MG TITRATION PAK QL 28 / 28 DAYS cenobamate PA
CALCIUM CHANNEL MODIFYING AGENTS
ethosuximide 250 mg capsule ethosuximide 250 mg/5 ml soln GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
QL 60 / 30 DAYS clobazam 10 mg tablet PA
PAGE 25 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
clobazam 2.5 mg/ml suspension PA
QL 60 / 30 DAYS clobazam 20 mg tablet PA
diazepam 10 mg rectal gel syst diazepam 2.5 mg rectal gel sys diazepam 20 mg rectal gel syst gabapentin 100 mg capsule gabapentin 250 mg/5 ml soln gabapentin 300 mg capsule gabapentin 400 mg capsule gabapentin 600 mg tablet gabapentin 800 mg tablet phenobarbital 100 mg tablet phenobarbital 15 mg tablet phenobarbital 16.2 mg tablet phenobarbital 20 mg/5 ml elix phenobarbital 20 mg/5 ml soln phenobarbital 30 mg tablet phenobarbital 32.4 mg tablet phenobarbital 60 mg tablet phenobarbital 64.8 mg tablet phenobarbital 97.2 mg tablet primidone 250 mg tablet primidone 50 mg tablet
tiagabine hcl 12 mg tablet QL 120 / 30 DAYS
tiagabine hcl 16 mg tablet QL 90 / 30 DAYS
tiagabine hcl 2 mg tablet QL 120 / 30 DAYS
tiagabine hcl 4 mg tablet QL 120 / 30 DAYS
PA vigabatrin 500 mg powder packt S Specialty Drug
PAGE 26 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
PA vigabatrin 500 mg tablet S Specialty Drug
PA vigadrone 500 mg powder packet S Specialty Drug
SODIUM CHANNEL AGENTS
carbamazepine 100 mg tab chew carbamazepine 100 mg/5 ml susp carbamazepine 200 mg tablet carbamazepine 200 mg/10ml susp carbamazepine er 100 mg cap carbamazepine er 100 mg tablet carbamazepine er 200 mg cap carbamazepine er 200 mg tablet carbamazepine er 300 mg cap carbamazepine er 400 mg tablet DILANTIN 30 MG CAPSULE phenytoin sodium extended epitol 200 mg tablet oxcarbazepine 150 mg tablet oxcarbazepine 300 mg tablet oxcarbazepine 300 mg/5 ml susp oxcarbazepine 600 mg tablet phenytoin 125 mg/5 ml susp phenytoin 50 mg infatab phenytoin 50 mg tablet chew phenytoin sod ext 100 mg cap phenytoin sod ext 200 mg cap phenytoin sod ext 300 mg cap
rufinamide 200 mg tablet PA
rufinamide 40 mg/ml suspension PA
PAGE 27 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
rufinamide 400 mg tablet PA
VIMPAT 10 MG/ML SOLUTION PA lacosamide VIMPAT 100 MG TABLET PA lacosamide VIMPAT 150 MG TABLET PA lacosamide VIMPAT 200 MG TABLET PA lacosamide VIMPAT 50 MG TABLET PA lacosamide zonisamide 100 mg capsule zonisamide 25 mg capsule zonisamide 50 mg capsule ANTIDEMENTIA AGENTS
CHOLINESTERASE INHIBITORS
donepezil hcl 10 mg tablet donepezil hcl 23 mg tablet donepezil hcl 5 mg tablet donepezil hcl odt 10 mg tablet donepezil hcl odt 5 mg tablet galantamine 4 mg/ml oral soln galantamine er 16 mg capsule galantamine er 24 mg capsule galantamine er 8 mg capsule galantamine hbr 12 mg tablet galantamine hbr 4 mg tablet galantamine hbr 8 mg tablet rivastigmine 1.5 mg capsule rivastigmine 13.3 mg/24hr ptch rivastigmine 3 mg capsule rivastigmine 4.5 mg capsule
PAGE 28 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS rivastigmine 4.6 mg/24hr patch rivastigmine 6 mg capsule rivastigmine 9.5 mg/24hr patch N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine 5-10 mg titration pk memantine hcl 10 mg tablet memantine hcl 2 mg/ml solution memantine hcl 5 mg tablet ANTIEMETICS
ANTIEMETICS, OTHER
compro 25 mg suppository cvs motion sickness 25 mg tab cvs motion sickness ii tablet cvs motion sickness relief tab dramamine less drowsy 25 mg tb eq motion sickness 25 mg tab eql motion sickness 25 mg tab gnp motion sicknes 25 mg tab gnp motion sickness rlf 25 mg hm motion relief 25 mg tablet hm motion relief 25 mg tablet kro motion sickness ii tablet meclizine 12.5 mg caplet meclizine 12.5 mg tablet meclizine 25 mg tablet meclizine 25 mg tablet chew medi-meclizine 25 mg tablet metoclopramide 10 mg tablet metoclopramide 10 mg/10 ml sol metoclopramide 5 mg tablet
PAGE 29 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS metoclopramide 5 mg/5 ml soln motion relief 25 mg tablet motion sickness 25 mg tablet motion sickness relief tb chew motion sickness rlf 25 mg tab motion-time 25 mg tablet chew phenadoz 12.5 mg suppository phenadoz 25 mg suppository prochlorperazine 10 mg tab prochlorperazine 25 mg supp prochlorperazine 5 mg tablet promethazine 12.5 mg suppos promethazine 25 mg suppository promethazine 50 mg tablet promethegan 12.5 mg suppos promethegan 25 mg suppository promethegan 50 mg suppository ra motion sickness rlf tb chew sm motion sickness 25 mg tab TRAVEL SICKNESS 25 MG TAB CHEW meclizine hcl travel-ease 25 mg tablet trimethobenzamide 300 mg cap EMETOGENIC THERAPY ADJUNCTS
aprepitant 125 mg capsule ST
aprepitant 125-80-80 mg pack ST
aprepitant 40 mg capsule ST
aprepitant 80 mg capsule ST
dronabinol 10 mg capsule dronabinol 2.5 mg capsule
PAGE 30 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS dronabinol 5 mg capsule
granisetron hcl 1 mg tablet QL 6 tablets / 30 days
ondansetron 4 mg/5 ml solution QL 100 ml / 30 days
ondansetron hcl 24 mg tablet QL 1 tablet / 30 days
ondansetron hcl 4 mg tablet ondansetron hcl 8 mg tablet ondansetron odt 4 mg tablet ondansetron odt 8 mg tablet ANTIFUNGALS
ciclodan 0.77% cream ciclopirox 0.77% cream ciclopirox 0.77% topical susp clotrimazole 1% topical cream clotrimazole 1% vaginal cream clotrimazole 10 mg troche clotrimazole-3 2% cream clotrimazole-7 vaginal cream cvs clotrimazole 1% top cream cvs clotrimazole-3 2% cream cvs itch relief 1% top cream
cvs miconazole 3 combo pack QL 24 g / 30 days
cvs miconazole 3 combo pack QL 1 pack / 30 days
cvs miconazole 7 cream QL 45 g / 30 days
cvs ringworm 1% cream econazole nitrate 1% cream
eq miconazole 2% vaginal cream QL 45 g / 30 days
eq miconazole 7 cream QL 45 g / 30 days
eql miconazole 7 cream QL 45 g / 30 days
fluconazole 10 mg/ml susp
PAGE 31 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS fluconazole 100 mg tablet fluconazole 150 mg tablet fluconazole 200 mg tablet fluconazole 40 mg/ml susp fluconazole 50 mg tablet gnp clotrimazole-3 2% cream
gnp miconazole 3 combo pack QL 1 pack / 30 days
gnp miconazole 7 cream QL 45 g / 30 days
griseofulvin 125 mg/5 ml susp
gs miconazole 3 combo pack QL 1 pack / 30 days
gs miconazole 7 cream QL 45 g / 30 days
itraconazole 10 mg/ml solution
itraconazole 100 mg capsule QL 30 capsules / 30 days
ketoconazole 2% cream ketoconazole 200 mg tablet
kro miconazole 3 combo pack QL 1 pack / 30 days
kro miconazole 7 cream QL 45 g / 30 days
miconazole 2% vaginal cream QL 45 g / 30 days
miconazole 3 combo pack QL 24 g / 30 days
miconazole 3 combo pack QL 1 pack / 30 days
miconazole 7 100 mg vag supp QL 7 suppositories / 30 days
miconazole 7 cream QL 45 g / 30 days
miconazole-7 cream QL 45 g / 30 days
nyamyc 100,000 unit/gm powder nystatin 100,000 unit/gm cream nystatin 100,000 unit/gm oint nystatin 100,000 unit/gm powd nystatin 100,000 unit/ml susp
PAGE 32 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS nystatin 500,000 unit oral tab nystatin 500,000 unit/5 ml sus nystop 100,000 unit/gm powder pub athletic foot 1% cream
pub miconazole3day combo pack QL 1 pack / 30 days
qc clotrimazole 1% top cream qc clotrimazole 1% vag cream
qc miconazole-7 cream QL 45 g / 30 days
ra clotrimazole 1% top cream ra clotrimazole 1% vag cream
ra miconazole 3 combo pack QL 24 g / 30 days
ra miconazole 3 combo pack QL 1 pack / 30 days
ra miconazole 7 cream QL 45 g / 30 days
sm clotrimazole 1% top cream sm clotrimazole 1% vag cream
sm miconazole 2% vaginal cream QL 45 g / 30 days
sm miconazole 3 combo pack QL 24 g / 30 days
sm miconazole 3 combo pack QL 1 pack / 30 days
sm miconazole 7 100 mg vag sup QL 7 suppositories / 30 days
sm miconazole 7 cream QL 45 g / 30 days
terbinafine hcl 250 mg tablet
terconazole 0.4% cream QL 45 g / 30 days
terconazole 0.8% cream QL 20 g / 30 days
terconazole 80 mg suppository QL 3 suppositories / 30 days
voriconazole 200 mg tablet PA
voriconazole 40 mg/ml susp PA
voriconazole 50 mg tablet PA
PAGE 33 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS ANTIGOUT AGENTS
allopurinol 100 mg tablet allopurinol 300 mg tablet colchicine 0.6 mg capsule colchicine 0.6 mg tablet probenecid 500 mg tablet ANTIMIGRAINE AGENTS
PROPHYLACTIC
AIMOVIG 140 MG/ML AUTOINJECTOR PA erenumab-aooe S Specialty Drug
AIMOVIG 70 MG/ML AUTOINJECTOR PA erenumab-aooe S Specialty Drug
EMGALITY 120 MG/ML PEN PA galcanezumab-gnlm S Specialty Drug
EMGALITY 120 MG/ML SYRINGE PA galcanezumab-gnlm S Specialty Drug
EMGALITY 300 MG (100 MG X3SYR) PA galcanezumab-gnlm S Specialty Drug
SEROTONIN (5-HT) RECEPTOR AGONIST
naratriptan 1 mg tablet QL 9 tablets / 30 days
naratriptan 2.5 mg tablet QL 9 tablets / 30 days
naratriptan hcl 1 mg tablet QL 9 tablets / 30 days
naratriptan hcl 2.5 mg tablet QL 9 tablets / 30 days
rizatriptan 10 mg odt QL 9 / 30 DAYS
rizatriptan 10 mg tablet QL 9 / 30 DAYS
rizatriptan 5 mg odt QL 9 / 30 DAYS
rizatriptan 5 mg tablet QL 9 / 30 DAYS
sumatriptan 20 mg nasal spray QL 6 nasal spray device / 30 days
PAGE 34 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
sumatriptan 4 mg/0.5 ml cart QL 3 ML / 30 DAYS
sumatriptan 4 mg/0.5 ml inject QL 3 ML / 30 DAYS
sumatriptan 5 mg nasal spray QL 6 nasal spray device / 30 days
sumatriptan 6 mg/0.5 ml cart QL 3 ML / 30 DAYS
sumatriptan 6 mg/0.5 ml inject QL 3 ML / 30 DAYS
sumatriptan 6 mg/0.5 ml syrng QL 3 / 30 DAYS
sumatriptan 6 mg/0.5 ml vial QL 3 ML / 30 DAYS
sumatriptan succ 100 mg tablet QL 9 tablets / 30 days
sumatriptan succ 25 mg tablet QL 9 tablets / 30 days
sumatriptan succ 50 mg tablet QL 9 tablets / 30 days
zolmitriptan 2.5 mg odt QL 9 tablets / 30 days
zolmitriptan 2.5 mg tablet QL 9 tablets / 30 days
zolmitriptan 5 mg odt QL 9 tablets / 30 days
zolmitriptan 5 mg tablet QL 9 tablets / 30 days
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
pyridostigmine 60 mg/5 ml soln pyridostigmine br 60 mg tablet ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone 100 mg tablet dapsone 25 mg tablet ANTITUBERCULARS
ethambutol hcl 100 mg tablet ethambutol hcl 400 mg tablet isoniazid 100 mg tablet isoniazid 300 mg tablet
PAGE 35 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS isoniazid 50 mg/5 ml solution
PRETOMANID 200 MG TABLET QL 30 / 30 day(s) pretomanid PA
PRIFTIN 150 MG TABLET rifapentine pyrazinamide 500 mg tablet RIFAMATE CAPSULE rifampin/isoniazid rifampin 150 mg capsule rifampin 300 mg capsule SIRTURO 100 MG TABLET PA bedaquiline fumarate SIRTURO 20 MG TABLET PA bedaquiline fumarate ANTINEOPLASTICS
ALKYLATING AGENTS
cyclophosphamide 25 mg capsule S Specialty Drug
cyclophosphamide 25 mg tablet S Specialty Drug
cyclophosphamide 50 mg capsule S Specialty Drug
cyclophosphamide 50 mg tablet S Specialty Drug
GLEOSTINE 10 MG CAPSULE PA lomustine S Specialty Drug
GLEOSTINE 100 MG CAPSULE PA lomustine S Specialty Drug
GLEOSTINE 40 MG CAPSULE PA lomustine S Specialty Drug
HEXALEN 50 MG CAPSULE S Specialty Drug altretamine LEUKERAN 2 MG TABLET S Specialty Drug chlorambucil MATULANE 50 MG CAPSULE S Specialty Drug procarbazine hcl
PAGE 36 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS MYLERAN 2 MG TABLET S Specialty Drug busulfan
QL 120 / 30 DAYS
temozolomide 100 mg capsule PA
S Specialty Drug
QL 90 / 30 DAYS
temozolomide 140 mg capsule PA
S Specialty Drug
QL 60 / 30 DAYS
temozolomide 180 mg capsule PA
S Specialty Drug
QL 120 / 30 DAYS
temozolomide 20 mg capsule PA
S Specialty Drug
QL 60 / 30 DAYS
temozolomide 250 mg capsule PA
S Specialty Drug
QL 90 / 30 DAYS
temozolomide 5 mg capsule PA
S Specialty Drug
ANTIANDROGENS
QL 60 / 30 DAYS
abiraterone 500 mg tablet PA
S Specialty Drug
QL 60 / 30 DAYS
abiraterone acetate 250 mg tab PA
S Specialty Drug
bicalutamide 50 mg tablet
QL 120 / 30 day(s) ERLEADA 60 MG TABLET PA apalutamide S Specialty Drug
PAGE 37 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS flutamide 125 mg capsule
nilutamide 150 mg tablet S Specialty Drug
NUBEQA 300 MG TABLET QL 120 / 30 DAYS darolutamide PA
toremifene citrate 60 mg tab
QL 120 / 30 day(s) XTANDI 40 MG CAPSULE PA enzalutamide S Specialty Drug
QL 120 / 30 DAYS XTANDI 40 MG TABLET PA enzalutamide S Specialty Drug
QL 120 / 30 DAYS XTANDI 80 MG TABLET PA enzalutamide S Specialty Drug
ANTIANGIOGENIC AGENTS
QL 21 / 28 DAYS POMALYST 1 MG CAPSULE PA pomalidomide S Specialty Drug
QL 21 / 28 DAYS POMALYST 2 MG CAPSULE PA pomalidomide S Specialty Drug
QL 21 / 28 DAYS POMALYST 3 MG CAPSULE PA pomalidomide S Specialty Drug
QL 21 / 28 DAYS POMALYST 4 MG CAPSULE PA pomalidomide S Specialty Drug
REVLIMID 10 MG CAPSULE PA lenalidomide S Specialty Drug
REVLIMID 15 MG CAPSULE PA lenalidomide S Specialty Drug
PAGE 38 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
REVLIMID 2.5 MG CAPSULE PA lenalidomide S Specialty Drug
REVLIMID 20 MG CAPSULE PA lenalidomide S Specialty Drug
REVLIMID 25 MG CAPSULE PA lenalidomide S Specialty Drug
REVLIMID 5 MG CAPSULE PA lenalidomide S Specialty Drug
QL 60 / 30 DAYS TEPMETKO 225 MG TABLET PA tepotinib hcl S Specialty Drug
ANTIESTROGENS/MODIFIERS
EMCYT 140 MG CAPSULE estramustine phosphate sodium tamoxifen 10 mg tablet tamoxifen 20 mg tablet ANTIMETABOLITES
capecitabine 150 mg tablet S Specialty Drug
capecitabine 500 mg tablet S Specialty Drug
DROXIA 200 MG CAPSULE hydroxyurea DROXIA 300 MG CAPSULE hydroxyurea DROXIA 400 MG CAPSULE hydroxyurea hydroxyurea 500 mg capsule mercaptopurine 50 mg tablet
TABLOID 40 MG TABLET PA thioguanine S Specialty Drug
PAGE 39 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS ANTINEOPLASTICS, OTHER
QL 30 / 30 DAYS AYVAKIT 100 MG TABLET PA avapritinib S Specialty Drug
QL 30 / 30 DAYS AYVAKIT 200 MG TABLET PA avapritinib S Specialty Drug
QL 30 / 30 DAYS AYVAKIT 25 MG TABLET PA avapritinib S Specialty Drug
QL 30 / 30 DAYS AYVAKIT 300 MG TABLET PA avapritinib S Specialty Drug
QL 30 / 30 DAYS AYVAKIT 50 MG TABLET PA avapritinib S Specialty Drug
BRUKINSA 80 MG CAPSULE QL 120 / 30 DAYS zanubrutinib PA
QL 21 / 28 DAYS FOTIVDA 0.89 MG CAPSULE PA tivozanib hcl S Specialty Drug
QL 21 / 28 DAYS FOTIVDA 1.34 MG CAPSULE PA tivozanib hcl S Specialty Drug
QL 30 / 30 DAYS IDHIFA 100 MG TABLET PA enasidenib mesylate S Specialty Drug
QL 30 / 30 DAYS IDHIFA 50 MG TABLET PA enasidenib mesylate S Specialty Drug
PAGE 40 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 5 / 28 DAYS INQOVI 35 MG-100 MG TABLET PA decitabine/cedazuridine S Specialty Drug
INREBIC 100 MG CAPSULE QL 120 / 30 DAYS fedratinib dihydrochloride PA
leucovorin calcium 10 mg tab leucovorin calcium 15 mg tab leucovorin calcium 25 mg tab leucovorin calcium 5 mg tab
LONSURF 15 MG-6.14 MG TABLET PA trifluridine/tipiracil hcl S Specialty Drug
LONSURF 20 MG-8.19 MG TABLET PA trifluridine/tipiracil hcl S Specialty Drug
QL 240 / 30 DAYS LUMAKRAS 120 MG TABLET PA sotorasib S Specialty Drug
QL 3 / 28 DAYS NINLARO 2.3 MG CAPSULE PA ixazomib citrate S Specialty Drug
QL 3 / 28 DAYS NINLARO 3 MG CAPSULE PA ixazomib citrate S Specialty Drug
QL 3 / 28 DAYS NINLARO 4 MG CAPSULE PA ixazomib citrate S Specialty Drug
QL 14 / 28 DAYS ONUREG 200 MG TABLET PA azacitidine S Specialty Drug
QL 14 / 28 DAYS ONUREG 300 MG TABLET PA azacitidine S Specialty Drug
PAGE 41 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 120 CAPSULES / 30 RETEVMO 40 MG CAPSULE DAYS selpercatinib PA S Specialty Drug
QL 120 CAPSULES / 30 RETEVMO 80 MG CAPSULE DAYS selpercatinib PA S Specialty Drug
ROZLYTREK 100 MG CAPSULE QL 90 / 30 DAYS entrectinib PA
ROZLYTREK 200 MG CAPSULE QL 90 / 30 DAYS entrectinib PA
QL 120 TABLETS / 30 TABRECTA 150 MG TABLET DAYS capmatinib hydrochloride PA S Specialty Drug
QL 120 TABLETS / 30 TABRECTA 200 MG TABLET DAYS capmatinib hydrochloride PA S Specialty Drug
QL 240 / 30 day(s) TAZVERIK 200 MG TABLET PA tazemetostat hydrobromide S Specialty Drug
QL 120 / 30 DAYS UKONIQ 200 MG TABLET PA umbralisib tosylate S Specialty Drug
QL 8 / 28 day(s) XPOVIO 100 MG ONCE WEEKLY DOSE PA selinexor S Specialty Drug
QL 8 / 28 DAYS XPOVIO 40 MG ONCE WEEKLY DOSE PA selinexor S Specialty Drug
QL 8 / 28 day(s) XPOVIO 40 MG TWICE WEEKLY DOSE PA selinexor S Specialty Drug
PAGE 42 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 4 / 28 day(s) XPOVIO 60 MG ONCE WEEKLY DOSE PA selinexor S Specialty Drug
QL 24 / 28 DAYS XPOVIO 60 MG TWICE WEEKLY DOSE PA selinexor S Specialty Drug
QL 8 / 28 day(s) XPOVIO 80 MG ONCE WEEKLY DOSE PA selinexor S Specialty Drug
QL 32 / 28 DAYS XPOVIO 80 MG TWICE WEEKLY DOSE PA selinexor S Specialty Drug
ZOLADEX 3.6 MG IMPLANT SYRN S Specialty Drug goserelin acetate
QL 120 / 30 DAYS ZOLINZA 100 MG CAPSULE PA vorinostat S Specialty Drug
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole 1 mg tablet exemestane 25 mg tablet letrozole 2.5 mg tablet ENZYME INHIBITORS
etoposide 50 mg capsule S Specialty Drug
QL 120 / 30 DAYS GAVRETO 100 MG CAPSULE PA pralsetinib S Specialty Drug
MOLECULAR TARGET INHIBITORS
QL 30 / 30 DAYS AFINITOR 10 MG TABLET PA everolimus S Specialty Drug
PAGE 43 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 30 / 30 DAYS AFINITOR DISPERZ 2 MG TABLET PA everolimus S Specialty Drug
QL 30 / 30 DAYS AFINITOR DISPERZ 3 MG TABLET PA everolimus S Specialty Drug
QL 30 / 30 DAYS AFINITOR DISPERZ 5 MG TABLET PA everolimus S Specialty Drug
QL 240 / 30 DAYS ALECENSA 150 MG CAPSULE PA alectinib hcl S Specialty Drug
QL 30 / 30 DAYS ALUNBRIG 180 MG TABLET PA brigatinib S Specialty Drug
QL 60 / 30 DAYS ALUNBRIG 30 MG TABLET PA brigatinib S Specialty Drug
QL 30 / 30 DAYS ALUNBRIG 90 MG TABLET PA brigatinib S Specialty Drug
QL 30 / 30 DAYS ALUNBRIG 90 MG-180 MG TAB PACK PA brigatinib S Specialty Drug
QL 84 / 28 DAYS BALVERSA 3 MG TABLET PA erdafitinib S Specialty Drug
QL 56 / 28 day(s) BALVERSA 4 MG TABLET PA erdafitinib S Specialty Drug
PAGE 44 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 28 / 28 DAYS BALVERSA 5 MG TABLET PA erdafitinib S Specialty Drug
QL 60 / 30 DAYS BOSULIF 100 MG TABLET PA bosutinib S Specialty Drug
QL 30 / 30 DAYS BOSULIF 400 MG TABLET PA bosutinib S Specialty Drug
QL 30 / 30 DAYS BOSULIF 500 MG TABLET PA bosutinib S Specialty Drug
QL 180 / 30 DAYS BRAFTOVI 50 MG CAPSULE PA encorafenib S Specialty Drug
QL 180 / 30 DAYS BRAFTOVI 75 MG CAPSULE PA encorafenib S Specialty Drug
QL 30 / 30 DAYS CABOMETYX 20 MG TABLET PA cabozantinib s-malate S Specialty Drug
QL 60 / 30 DAYS CABOMETYX 40 MG TABLET PA cabozantinib s-malate S Specialty Drug
QL 30 / 30 DAYS CABOMETYX 60 MG TABLET PA cabozantinib s-malate S Specialty Drug
QL 60 / 30 day(s) CALQUENCE 100 MG CAPSULE PA acalabrutinib S Specialty Drug
PAGE 45 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
CAPRELSA 100 MG TABLET PA vandetanib S Specialty Drug
CAPRELSA 300 MG TABLET PA vandetanib S Specialty Drug
QL 112 / 28 DAYS COMETRIQ 100 MG DAILY-DOSE PK PA cabozantinib s-malate S Specialty Drug
QL 56 / 28 DAYS COMETRIQ 140 MG DAILY-DOSE PK PA cabozantinib s-malate S Specialty Drug
QL 84 / 28 DAYS COMETRIQ 60 MG DAILY-DOSE PACK PA cabozantinib s-malate S Specialty Drug
QL 56 / 28 DAYS COPIKTRA 15 MG CAPSULE PA duvelisib S Specialty Drug
QL 90 / 30 DAYS COTELLIC 20 MG TABLET PA cobimetinib fumarate S Specialty Drug
QL 30 / 30 DAYS DAURISMO 100 MG TABLET PA glasdegib maleate S Specialty Drug
QL 30 / 30 DAYS DAURISMO 25 MG TABLET PA glasdegib maleate S Specialty Drug
QL 28 / 28 DAYS ERIVEDGE 150 MG CAPSULE PA vismodegib S Specialty Drug
QL 30 / 30 DAYS
erlotinib hcl 100 mg tablet PA
S Specialty Drug
PAGE 46 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 30 / 30 DAYS
erlotinib hcl 150 mg tablet PA
S Specialty Drug
QL 90 / 30 DAYS
erlotinib hcl 25 mg tablet PA
S Specialty Drug
QL 30 / 30 DAYS everolimus 2.5 mg tablet PA
QL 30 / 30 DAYS everolimus 5 mg tablet PA
QL 30 / 30 DAYS everolimus 7.5 mg tablet PA
QL 6 / 21 DAYS FARYDAK 10 MG CAPSULE PA panobinostat lactate S Specialty Drug
QL 6 / 21 DAYS FARYDAK 15 MG CAPSULE PA panobinostat lactate S Specialty Drug
QL 6 / 21 DAYS FARYDAK 20 MG CAPSULE PA panobinostat lactate S Specialty Drug
QL 30 / 30 DAYS GILOTRIF 20 MG TABLET PA afatinib dimaleate S Specialty Drug
QL 30 / 30 DAYS GILOTRIF 30 MG TABLET PA afatinib dimaleate S Specialty Drug
QL 30 / 30 DAYS GILOTRIF 40 MG TABLET PA afatinib dimaleate S Specialty Drug
PAGE 47 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 21 / 28 DAYS IBRANCE 100 MG CAPSULE PA palbociclib S Specialty Drug
IBRANCE 100 MG TABLET QL 21 / 28 DAYS palbociclib PA
QL 21 / 28 DAYS IBRANCE 125 MG CAPSULE PA palbociclib S Specialty Drug
IBRANCE 125 MG TABLET QL 21 / 28 DAYS palbociclib PA
QL 21 / 28 DAYS IBRANCE 75 MG CAPSULE PA palbociclib S Specialty Drug
IBRANCE 75 MG TABLET QL 21 / 28 DAYS palbociclib PA
QL 30 / 30 day(s) ICLUSIG 10 MG TABLET PA ponatinib hcl S Specialty Drug
QL 30 / 30 day(s) ICLUSIG 15 MG TABLET PA ponatinib hcl S Specialty Drug
QL 30 / 30 DAYS ICLUSIG 30 MG TABLET PA ponatinib hcl S Specialty Drug
QL 30 / 30 DAYS ICLUSIG 45 MG TABLET PA ponatinib hcl S Specialty Drug
QL 90 / 30 DAYS
imatinib mesylate 100 mg tab PA
S Specialty Drug
PAGE 48 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 60 / 30 DAYS
imatinib mesylate 400 mg tab PA
S Specialty Drug
QL 30 / 30 day(s) IMBRUVICA 140 MG CAPSULE PA ibrutinib S Specialty Drug
QL 30 / 30 day(s) IMBRUVICA 140 MG TABLET PA ibrutinib S Specialty Drug
QL 30 / 30 day(s) IMBRUVICA 280 MG TABLET PA ibrutinib S Specialty Drug
QL 30 / 30 day(s) IMBRUVICA 420 MG TABLET PA ibrutinib S Specialty Drug
QL 30 / 30 day(s) IMBRUVICA 560 MG TABLET PA ibrutinib S Specialty Drug
QL 30 / 30 day(s) IMBRUVICA 70 MG CAPSULE PA ibrutinib S Specialty Drug
QL 180 / 30 DAYS INLYTA 1 MG TABLET PA axitinib S Specialty Drug
QL 120 / 30 DAYS INLYTA 5 MG TABLET PA axitinib S Specialty Drug
QL 30 / 30 DAYS IRESSA 250 MG TABLET PA gefitinib S Specialty Drug
PAGE 49 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 60 / 30 DAYS JAKAFI 10 MG TABLET PA ruxolitinib phosphate S Specialty Drug
QL 60 / 30 DAYS JAKAFI 15 MG TABLET PA ruxolitinib phosphate S Specialty Drug
QL 60 / 30 DAYS JAKAFI 20 MG TABLET PA ruxolitinib phosphate S Specialty Drug
QL 60 / 30 DAYS JAKAFI 25 MG TABLET PA ruxolitinib phosphate S Specialty Drug
QL 60 / 30 DAYS JAKAFI 5 MG TABLET PA ruxolitinib phosphate S Specialty Drug
QL 21 / 28 DAYS KISQALI 200 MG DAILY DOSE PA ribociclib succinate S Specialty Drug
QL 42 / 28 DAYS KISQALI 400 MG DAILY DOSE PA ribociclib succinate S Specialty Drug
QL 63 / 28 DAYS KISQALI 600 MG DAILY DOSE PA ribociclib succinate S Specialty Drug
QL 120 CAPSULES / 30 KOSELUGO 10 MG CAPSULE DAYS selumetinib sulfate/vitamin e tpgs PA S Specialty Drug
QL 120 CAPSULES / 30 KOSELUGO 25 MG CAPSULE DAYS selumetinib sulfate/vitamin e tpgs PA S Specialty Drug
PAGE 50 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
PA lapatinib 250 mg tablet S Specialty Drug
QL 30 / 30 DAYS LENVIMA 10 MG DAILY DOSE PA lenvatinib mesylate S Specialty Drug
QL 90 / 30 DAYS LENVIMA 12 MG DAILY DOSE PA lenvatinib mesylate S Specialty Drug
QL 60 / 30 DAYS LENVIMA 14 MG DAILY DOSE PA lenvatinib mesylate S Specialty Drug
QL 90 / 30 DAYS LENVIMA 18 MG DAILY DOSE PA lenvatinib mesylate S Specialty Drug
QL 60 / 30 DAYS LENVIMA 20 MG DAILY DOSE PA lenvatinib mesylate S Specialty Drug
QL 90 / 30 DAYS LENVIMA 24 MG DAILY DOSE PA lenvatinib mesylate S Specialty Drug
QL 30 / 30 DAYS LENVIMA 4 MG CAPSULE PA lenvatinib mesylate S Specialty Drug
QL 60 / 30 DAYS LENVIMA 8 MG DAILY DOSE PA lenvatinib mesylate S Specialty Drug
LORBRENA 100 MG TABLET QL 30 / 30 DAYS lorlatinib PA
LORBRENA 25 MG TABLET QL 30 / 30 DAYS lorlatinib PA
PAGE 51 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
LYNPARZA 100 MG TABLET PA olaparib S Specialty Drug
LYNPARZA 150 MG TABLET PA olaparib S Specialty Drug
LYNPARZA 50 MG CAPSULE PA olaparib S Specialty Drug
QL 30 / 30 DAYS MEKINIST 0.5 MG TABLET PA trametinib dimethyl sulfoxide S Specialty Drug
QL 30 / 30 DAYS MEKINIST 2 MG TABLET PA trametinib dimethyl sulfoxide S Specialty Drug
QL 180 / 30 DAYS MEKTOVI 15 MG TABLET PA binimetinib S Specialty Drug
QL 180 / 30 DAYS NERLYNX 40 MG TABLET PA neratinib maleate S Specialty Drug
QL 120 / 30 DAYS NEXAVAR 200 MG TABLET PA sorafenib tosylate S Specialty Drug
QL 30 / 30 DAYS ODOMZO 200 MG CAPSULE PA sonidegib phosphate S Specialty Drug
QL 14 / 21 day(s) PEMAZYRE 13.5 MG TABLET PA pemigatinib S Specialty Drug
QL 14 / 21 day(s) PEMAZYRE 4.5 MG TABLET PA pemigatinib S Specialty Drug
PAGE 52 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 14 / 21 day(s) PEMAZYRE 9 MG TABLET PA pemigatinib S Specialty Drug
QL 56 / 28 DAYS PIQRAY 200 MG DAILY DOSE PA alpelisib S Specialty Drug
QL 56 / 28 DAYS PIQRAY 250 MG DAILY DOSE PA alpelisib S Specialty Drug
QL 56 / 28 day(s) PIQRAY 300 MG DAILY DOSE PA alpelisib S Specialty Drug
QL 90 / 30 day(s) QINLOCK 50 MG TABLET PA ripretinib S Specialty Drug
QL 120 / 30 DAYS RUBRACA 200 MG TABLET PA rucaparib camsylate S Specialty Drug
QL 120 / 30 DAYS RUBRACA 250 MG TABLET PA rucaparib camsylate S Specialty Drug
QL 120 / 30 DAYS RUBRACA 300 MG TABLET PA rucaparib camsylate S Specialty Drug
QL 112 / 28 DAYS RYDAPT 25 MG CAPSULE PA midostaurin S Specialty Drug
QL 30 / 30 DAYS SPRYCEL 100 MG TABLET PA dasatinib S Specialty Drug
PAGE 53 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 30 / 30 DAYS SPRYCEL 140 MG TABLET PA dasatinib S Specialty Drug
QL 60 / 30 DAYS SPRYCEL 20 MG TABLET PA dasatinib S Specialty Drug
QL 30 / 30 DAYS SPRYCEL 50 MG TABLET PA dasatinib S Specialty Drug
QL 30 / 30 DAYS SPRYCEL 70 MG TABLET PA dasatinib S Specialty Drug
QL 30 / 30 DAYS SPRYCEL 80 MG TABLET PA dasatinib S Specialty Drug
PA sunitinib malate 12.5 mg cap S Specialty Drug
PA sunitinib malate 25 mg capsule S Specialty Drug
PA sunitinib malate 37.5 mg cap S Specialty Drug
PA sunitinib malate 50 mg capsule S Specialty Drug
QL 120 / 30 DAYS TAFINLAR 50 MG CAPSULE PA dabrafenib mesylate S Specialty Drug
QL 120 / 30 DAYS TAFINLAR 75 MG CAPSULE PA dabrafenib mesylate S Specialty Drug
QL 30 / 30 DAYS TAGRISSO 40 MG TABLET PA osimertinib mesylate S Specialty Drug
PAGE 54 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 30 / 30 DAYS TAGRISSO 80 MG TABLET PA osimertinib mesylate S Specialty Drug
TALZENNA 0.25 MG CAPSULE QL 90 / 30 DAYS talazoparib tosylate PA
TALZENNA 1 MG CAPSULE QL 30 / 30 DAYS talazoparib tosylate PA
QL 112 / 28 DAYS TASIGNA 150 MG CAPSULE PA nilotinib hcl S Specialty Drug
QL 112 / 28 DAYS TASIGNA 200 MG CAPSULE PA nilotinib hcl S Specialty Drug
QL 120 / 30 DAYS TASIGNA 50 MG CAPSULE PA nilotinib hcl S Specialty Drug
QL 60 / 30 day(s) TIBSOVO 250 MG TABLET PA ivosidenib S Specialty Drug
QL 120 / 30 day(s) TUKYSA 150 MG TABLET PA tucatinib S Specialty Drug
QL 120 / 30 day(s) TUKYSA 50 MG TABLET PA tucatinib S Specialty Drug
TURALIO 200 MG CAPSULE QL 120 / 30 DAYS pexidartinib hydrochloride PA
QL 30 / 30 DAYS VENCLEXTA 10 MG TAB (10MG X 2) PA venetoclax S Specialty Drug
PAGE 55 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 30 / 30 DAYS VENCLEXTA 10 MG TABLET PA venetoclax S Specialty Drug
QL 120 / 30 DAYS VENCLEXTA 100 MG TABLET PA venetoclax S Specialty Drug
QL 120 / 30 DAYS VENCLEXTA 50 MG TABLET PA venetoclax S Specialty Drug
QL 120 / 30 DAYS VENCLEXTA STARTING PACK PA venetoclax S Specialty Drug
QL 56 / 28 DAYS VERZENIO 100 MG TABLET PA abemaciclib S Specialty Drug
QL 56 / 28 DAYS VERZENIO 150 MG TABLET PA abemaciclib S Specialty Drug
QL 56 / 28 DAYS VERZENIO 200 MG TABLET PA abemaciclib S Specialty Drug
QL 56 / 28 DAYS VERZENIO 50 MG TABLET PA abemaciclib S Specialty Drug
QL 60 / 30 DAYS VITRAKVI 100 MG CAPSULE PA larotrectinib sulfate S Specialty Drug
QL 60 / 30 DAYS VITRAKVI 20 MG/ML SOLUTION PA larotrectinib sulfate S Specialty Drug
PAGE 56 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 60 / 30 DAYS VITRAKVI 25 MG CAPSULE PA larotrectinib sulfate S Specialty Drug
QL 30 / 30 DAYS VIZIMPRO 15 MG TABLET PA dacomitinib S Specialty Drug
QL 30 / 30 DAYS VIZIMPRO 30 MG TABLET PA dacomitinib S Specialty Drug
QL 30 / 30 DAYS VIZIMPRO 45 MG TABLET PA dacomitinib S Specialty Drug
QL 120 / 30 DAYS VOTRIENT 200 MG TABLET PA pazopanib hcl S Specialty Drug
QL 60 / 30 DAYS XALKORI 200 MG CAPSULE PA crizotinib S Specialty Drug
QL 60 / 30 DAYS XALKORI 250 MG CAPSULE PA crizotinib S Specialty Drug
XOSPATA 40 MG TABLET QL 90 / 30 DAYS gilteritinib fumarate PA
QL 90 / 30 DAYS ZEJULA 100 MG CAPSULE PA niraparib tosylate S Specialty Drug
QL 240 / 30 DAYS ZELBORAF 240 MG TABLET PA vemurafenib S Specialty Drug
QL 60 / 30 DAYS ZYDELIG 100 MG TABLET PA idelalisib S Specialty Drug
PAGE 57 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 60 / 30 DAYS ZYDELIG 150 MG TABLET PA idelalisib S Specialty Drug
QL 90 / 30 DAYS ZYKADIA 150 MG CAPSULE PA ceritinib S Specialty Drug
QL 90 / 30 DAYS ZYKADIA 150 MG TABLET PA ceritinib S Specialty Drug
RETINOIDS
bexarotene 75 mg capsule S Specialty Drug
tretinoin 10 mg capsule TREATMENT ADJUNCTS
MESNEX 400 MG TABLET S Specialty Drug mesna ANTIPARASITICS
ANTHELMINTHICS
albendazole 200 mg tablet
ivermectin 3 mg tablet PA
ANTIPROTOZOALS
atovaquone 750 mg/5 ml susp
QL 240 / 365 day(s) benznidazole 100 mg tablet PA
QL 720 / 365 day(s) benznidazole 12.5 mg tablet PA
chloroquine ph 250 mg tablet chloroquine ph 500 mg tablet hydroxychloroquine 200 mg tab KRINTAFEL 150 MG TABLET tafenoquine succinate
PAGE 58 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS mefloquine hcl 250 mg tablet
QL 1 / 28 DAYS pentamidine 300 mg inhal powdr S Specialty Drug
primaquine 26.3 mg tablet ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine mes 0.5 mg tab benztropine mes 1 mg tablet benztropine mes 2 mg tablet trihexyphenidyl 2 mg tablet trihexyphenidyl 5 mg tablet ANTIPARKINSON AGENTS, OTHER
amantadine 100 mg capsule amantadine 100 mg tablet amantadine 100 mg/10 ml soln amantadine 50 mg/5 ml solution carbidopa-levodopa 100 mg-enta carbidopa-levodopa 125 mg-enta carbidopa-levodopa 150 mg-enta carbidopa-levodopa 200 mg-enta carbidopa-levodopa 50 mg-enta carbidopa-levodopa 75 mg-enta entacapone 200 mg tablet DOPAMINE AGONISTS
bromocriptine 2.5 mg tablet bromocriptine 5 mg capsule
QL 150 / 30 day(s) KYNMOBI 10 MG SL FILM PA apomorphine hcl S Specialty Drug
QL 150 / 30 day(s) KYNMOBI 15 MG SL FILM PA apomorphine hcl S Specialty Drug
PAGE 59 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 150 / 30 day(s) KYNMOBI 20 MG SL FILM PA apomorphine hcl S Specialty Drug
QL 150 / 30 day(s) KYNMOBI 25 MG SL FILM PA apomorphine hcl S Specialty Drug
QL 150 / 30 day(s) KYNMOBI 30 MG SL FILM PA apomorphine hcl S Specialty Drug
pramipexole 0.125 mg tablet pramipexole 0.25 mg tablet pramipexole 0.5 mg tablet pramipexole 0.75 mg tablet pramipexole 1 mg tablet pramipexole 1.5 mg tablet ropinirole hcl 0.25 mg tablet ropinirole hcl 0.5 mg tablet ropinirole hcl 1 mg tablet ropinirole hcl 2 mg tablet ropinirole hcl 3 mg tablet ropinirole hcl 4 mg tablet ropinirole hcl 5 mg tablet DOPAMINE PRECURSORS AND/OR L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa 25 mg tablet carbidopa-levo 10-100 mg odt carbidopa-levo 25-100 mg odt carbidopa-levo 25-250 mg odt carbidopa-levo er 25-100 tab carbidopa-levo er 50-200 tab carbidopa-levodopa 10-100 tab
PAGE 60 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS carbidopa-levodopa 25-100 tab carbidopa-levodopa 25-250 tab MONOAMINE OXIDASE B (MAO-B) INHIBITORS
selegiline hcl 5 mg capsule selegiline hcl 5 mg tablet ANTISPASTICITY AGENTS
baclofen 10 mg tablet baclofen 20 mg tablet dantrolene sodium 100 mg cap dantrolene sodium 25 mg cap dantrolene sodium 50 mg cap tizanidine hcl 2 mg tablet tizanidine hcl 4 mg tablet ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
PREVYMIS 240 MG TABLET QL 100 / 365 day(s) letermovir PA
PREVYMIS 480 MG TABLET QL 100 / 365 day(s) letermovir PA
valganciclovir 450 mg tablet QL 400 / 365 day(s)
valganciclovir hcl 50 mg/ml ANTI-HEPATITIS B (HBV) AGENTS
adefovir dipivoxil 10 mg tab BARACLUDE 0.05 MG/ML SOLUTION entecavir entecavir 0.5 mg tablet entecavir 1 mg tablet EPIVIR HBV 25 MG/5 ML SOLN lamivudine lamivudine 100 mg tablet
PAGE 61 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS lamivudine hbv 100 mg tablet ANTI-HEPATITIS C (HCV) AGENTS
MAVYRET 100-40 MG TABLET PA glecaprevir/pibrentasvir S Specialty Drug
PA sofosbuvir-velpatasvir 400-100 S Specialty Drug
VOSEVI 400-100-100 MG TABLET PA sofosbuvir/velpatasvir/voxilaprevir S Specialty Drug
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
BIKTARVY 50-200-25 MG TABLET QL 30 / 30 day(s) bictegravir sodium/emtricitabine/tenofovir alafenamide fumar DOVATO 50-300 MG TABLET QL 30 / 30 DAYS dolutegravir sodium/lamivudine GENVOYA TABLET QL 30 / 30 DAYS elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide ISENTRESS 100 MG POWDER PACKET raltegravir potassium ISENTRESS 100 MG TABLET CHEW raltegravir potassium ISENTRESS 25 MG TABLET CHEW raltegravir potassium ISENTRESS 400 MG TABLET QL 60 / 30 DAYS raltegravir potassium ISENTRESS HD 600 MG TABLET QL 60 / 30 DAYS raltegravir potassium JULUCA 50-25 MG TABLET QL 30 / 30 DAYS dolutegravir sodium/rilpivirine hcl STRIBILD TABLET QL 30 / 30 DAYS elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil TIVICAY 10 MG TABLET QL 60 / 30 DAYS dolutegravir sodium TIVICAY 25 MG TABLET QL 60 / 30 DAYS dolutegravir sodium TIVICAY 50 MG TABLET QL 60 / 30 DAYS dolutegravir sodium
PAGE 62 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS TIVICAY PD 5 MG TAB FOR SUSP QL 180 / 30 day(s) dolutegravir sodium ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
COMPLERA TABLET QL 30 / 30 DAYS emtricitabine/rilpivirine hcl/tenofovir disoproxil fumarate DELSTRIGO 100-300-300 MG TAB QL 30 / 30 day(s) doravirine/lamivudine/tenofovir disoproxil fumarate EDURANT 25 MG TABLET rilpivirine hcl
efavir-lamiv-tenof 400-300-300 QL 30 / 30 day(s)
efavir-lamiv-tenof 600-300-300 QL 30 / 30 day(s)
efavirenz 200 mg capsule efavirenz 50 mg capsule efavirenz 600 mg tablet etravirine 100 mg tablet etravirine 200 mg tablet INTELENCE 25 MG TABLET etravirine nevirapine 200 mg tablet nevirapine 50 mg/5 ml susp
nevirapine er 100 mg tablet QL 90 / 30 DAYS
nevirapine er 400 mg tablet QL 30 / 30 DAYS
ODEFSEY TABLET QL 30 / 30 DAYS emtricitabine/rilpivirine hcl/tenofovir alafenamide fumarate PIFELTRO 100 MG TABLET QL 30 / 30 day(s) doravirine ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir 20 mg/ml solution abacavir 300 mg tablet
abacavir-lamivudine 600-300 mg QL 30 / 30 DAYS
abacavir-lamivudine-zidov tab CIMDUO 300-300 MG TABLET QL 30 / 30 day(s) lamivudine/tenofovir disoproxil fumarate
PAGE 63 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS DESCOVY 200-25 MG TABLET QL 30 / 30 DAYS emtricitabine/tenofovir alafenamide fumarate
emtricitabine-tenofv 100-150mg QL 30 / 30 DAYS
emtricitabine-tenofv 133-200mg QL 30 / 30 DAYS
emtricitabine-tenofv 167-250mg QL 30 / 30 DAYS
emtricitabine-tenofv 200-300mg QL 30 / 30 DAYS
lamivudine 10 mg/ml oral soln lamivudine 150 mg tablet lamivudine 300 mg tablet lamivudine-zidovudine tablet lamivudine-zidovudine tablet stavudine 15 mg capsule stavudine 20 mg capsule stavudine 30 mg capsule stavudine 40 mg capsule tenofovir disop fum 300 mg tb TRIUMEQ 600-50-300 MG TABLET QL 30 / 30 DAYS abacavir sulfate/dolutegravir sodium/lamivudine VIDEX 2 GM PEDIATRIC SOLN didanosine VIDEX 4 GM PEDIATRIC SOLN didanosine VIREAD 150 MG TABLET QL 30 / 30 DAYS tenofovir disoproxil fumarate VIREAD 200 MG TABLET QL 30 / 30 DAYS tenofovir disoproxil fumarate VIREAD 250 MG TABLET QL 30 / 30 DAYS tenofovir disoproxil fumarate VIREAD POWDER tenofovir disoproxil fumarate zidovudine 100 mg capsule zidovudine 300 mg tablet zidovudine 50 mg/5 ml syrup
PAGE 64 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS ANTI-HIV AGENTS, OTHER
FUZEON 90 MG VIAL QL 60 / 30 DAYS enfuvirtide
RUKOBIA ER 600 MG TABLET QL 60 tablets / 30 days fostemsavir tromethamine PA
SELZENTRY 150 MG TABLET QL 60 / 30 DAYS maraviroc SELZENTRY 20 MG/ML ORAL SOLN maraviroc SELZENTRY 25 MG TABLET maraviroc SELZENTRY 300 MG TABLET maraviroc SELZENTRY 75 MG TABLET maraviroc ANTI-HIV AGENTS, PROTEASE INHIBITORS (PI)
atazanavir sulfate 150 mg cap QL 30 / 30 DAYS
atazanavir sulfate 200 mg cap atazanavir sulfate 300 mg cap EVOTAZ 300 MG-150 MG TABLET QL 30 / 30 DAYS atazanavir sulfate/cobicistat INVIRASE 200 MG CAPSULE saquinavir mesylate INVIRASE 500 MG TABLET saquinavir mesylate lopinavir-ritonavir 80-20mg/ml lopinavir-ritonavr 100-25mg tb lopinavir-ritonavr 200-50mg tb NORVIR 100 MG POWDER PACKET ritonavir NORVIR 100 MG SOFTGEL CAP ritonavir NORVIR 80 MG/ML SOLUTION ritonavir PREZCOBIX 800 MG-150 MG TABLET QL 30 / 30 DAYS darunavir ethanolate/cobicistat
PAGE 65 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS PREZISTA 100 MG/ML SUSPENSION darunavir ethanolate PREZISTA 150 MG TABLET darunavir ethanolate PREZISTA 600 MG TABLET darunavir ethanolate PREZISTA 75 MG TABLET darunavir ethanolate PREZISTA 800 MG TABLET QL 30 / 30 DAYS darunavir ethanolate REYATAZ 50 MG POWDER PACKET atazanavir sulfate ritonavir 100 mg tablet SYMTUZA 800-150-200-10 MG TAB QL 30 / 30 day(s) darunavir eth/cobicistat/emtricitabine/tenofovir alafenamide ANTI-INFLUENZA AGENTS
oseltamivir 6 mg/ml suspension QL 180 / 30 day(s)
oseltamivir phos 30 mg capsule QL 20 / 90 day(s)
oseltamivir phos 45 mg capsule QL 10 / 90 day(s)
oseltamivir phos 75 mg capsule QL 10 / 90 day(s)
RELENZA 5 MG DISKHALER QL 20 / 90 day(s) zanamivir rimantadine hcl 100 mg tablet ANTIHERPETIC AGENTS
acyclovir 200 mg capsule acyclovir 200 mg/5 ml susp acyclovir 400 mg tablet acyclovir 800 mg tablet famciclovir 125 mg tablet famciclovir 250 mg tablet famciclovir 500 mg tablet trifluridine 1% eye drops valacyclovir hcl 1 gram tablet
PAGE 66 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS valacyclovir hcl 500 mg tablet ANXIOLYTICS
ANXIOLYTICS, OTHER
triazolam 0.125 mg tablet QL 15 tablets / 30 days
triazolam 0.25 mg tablet QL 15 tablets / 30 days
BENZODIAZEPINES
clonazepam 0.125 mg dis tab QL 120 / 30 DAYS
clonazepam 0.125 mg odt QL 120 / 30 DAYS
clonazepam 0.25 mg odt QL 120 / 30 DAYS
clonazepam 0.5 mg dis tablet QL 120 / 30 DAYS
clonazepam 0.5 mg odt QL 120 / 30 DAYS
clonazepam 0.5 mg tablet
clonazepam 1 mg dis tablet QL 120 / 30 DAYS
clonazepam 1 mg odt QL 120 / 30 DAYS
clonazepam 1 mg tablet
clonazepam 2 mg odt QL 60 / 30 DAYS
clonazepam 2 mg tablet BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
acarbose 100 mg tablet acarbose 25 mg tablet acarbose 50 mg tablet
QL 30 / 30 DAYS alogliptin 12.5 mg tablet ST
QL 30 / 30 DAYS alogliptin 25 mg tablet ST
QL 30 / 30 DAYS alogliptin 6.25 mg tablet ST
PAGE 67 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
FARXIGA 10 MG TABLET QL 30 / 30 DAYS dapagliflozin propanediol PA
FARXIGA 5 MG TABLET QL 30 / 30 DAYS dapagliflozin propanediol PA
glimepiride 1 mg tablet glimepiride 2 mg tablet glimepiride 4 mg tablet glipizide 10 mg tablet glipizide 5 mg tablet glipizide er 10 mg tablet glipizide er 2.5 mg tablet glipizide er 5 mg tablet glipizide xl 10 mg tablet glipizide xl 2.5 mg tablet glipizide xl 5 mg tablet glyburid-metformin 1.25-250 mg glyburide 1.25 mg tablet glyburide 2.5 mg tablet glyburide 5 mg tablet glyburide micro 1.5 mg tab glyburide micro 3 mg tablet glyburide micro 6 mg tablet glyburide-metformin 2.5-500 mg glyburide-metformin 5-500 mg
JARDIANCE 10 MG TABLET QL 30 / 30 DAYS empagliflozin PA
JARDIANCE 25 MG TABLET QL 30 / 30 DAYS empagliflozin PA
metformin hcl 1,000 mg tablet metformin hcl 500 mg tablet
PAGE 68 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS metformin hcl 850 mg tablet metformin hcl er 500 mg tablet metformin hcl er 750 mg tablet
OZEMPIC 0.25-0.5 MG/DOSE PEN QL 1.5 / 28 DAYS semaglutide PA
OZEMPIC 1 MG/DOSE (2 MG/1.5ML) QL 3 / 28 DAYS semaglutide PA
OZEMPIC 1 MG/DOSE (4 MG/3 ML) QL 3 / 28 DAYS semaglutide PA
pioglitazone hcl 15 mg tablet QL 30 tablets / 30 days
pioglitazone hcl 30 mg tablet QL 30 tablets / 30 days
pioglitazone hcl 45 mg tablet QL 30 tablets / 30 days
SEGLUROMET 2.5-1,000 MG TABLET QL 60 / 30 DAYS ertugliflozin pidolate/metformin hcl ST
SEGLUROMET 2.5-500 MG TABLET QL 60 / 30 DAYS ertugliflozin pidolate/metformin hcl ST
SEGLUROMET 7.5-1,000 MG TABLET QL 60 / 30 DAYS ertugliflozin pidolate/metformin hcl ST
SEGLUROMET 7.5-500 MG TABLET QL 60 / 30 DAYS ertugliflozin pidolate/metformin hcl ST
STEGLATRO 15 MG TABLET QL 30 / 30 DAYS ertugliflozin pidolate ST
STEGLATRO 5 MG TABLET QL 30 / 30 DAYS ertugliflozin pidolate ST
SYNJARDY 12.5-1,000 MG TABLET QL 60 / 30 DAYS empagliflozin/metformin hcl PA
SYNJARDY 12.5-500 MG TABLET QL 60 / 30 DAYS empagliflozin/metformin hcl PA
SYNJARDY 5-1,000 MG TABLET QL 60 / 30 DAYS empagliflozin/metformin hcl PA
PAGE 69 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
SYNJARDY 5-500 MG TABLET QL 60 / 30 DAYS empagliflozin/metformin hcl PA
SYNJARDY XR 10-1,000 MG TABLET QL 30 / 30 DAYS empagliflozin/metformin hcl PA
SYNJARDY XR 12.5-1,000 MG TAB QL 60 / 30 DAYS empagliflozin/metformin hcl PA
SYNJARDY XR 25-1,000 MG TABLET QL 30 / 30 DAYS empagliflozin/metformin hcl PA
SYNJARDY XR 5-1,000 MG TABLET QL 60 / 30 DAYS empagliflozin/metformin hcl PA
TRULICITY 0.75 MG/0.5 ML PEN QL 2 / 28 day(s) dulaglutide PA
TRULICITY 1.5 MG/0.5 ML PEN QL 2 / 28 day(s) dulaglutide PA
TRULICITY 3 MG/0.5 ML PEN QL 2 / 28 DAYS dulaglutide PA
TRULICITY 4.5 MG/0.5 ML PEN QL 2 / 28 DAYS dulaglutide PA
VICTOZA 2-PAK 18 MG/3 ML PEN QL 6 ML / 30 DAYS liraglutide PA
VICTOZA 3-PAK 18 MG/3 ML PEN QL 9 ML / 30 DAYS liraglutide PA
XIGDUO XR 10 MG-1,000 MG TAB QL 30 / 30 DAYS dapagliflozin propanediol/metformin hcl PA
XIGDUO XR 10 MG-500 MG TABLET QL 30 / 30 DAYS dapagliflozin propanediol/metformin hcl PA
XIGDUO XR 2.5 MG-1,000 MG TAB QL 60 / 30 DAYS dapagliflozin propanediol/metformin hcl PA
XIGDUO XR 5 MG-1,000 MG TABLET QL 60 / 30 DAYS dapagliflozin propanediol/metformin hcl PA
PAGE 70 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
XIGDUO XR 5 MG-500 MG TABLET QL 30 / 30 DAYS dapagliflozin propanediol/metformin hcl PA
GLYCEMIC AGENTS
BAQSIMI 3 MG SPRAY ONE PACK glucagon BAQSIMI 3 MG SPRAY TWO PACK glucagon cvs glucose 40% gel cvs glucose liquid shot dex4 glucose 40% gel GLUCAGEN 1 MG HYPOKIT glucagon glucagon 1 mg emergency kit GLUCAGON 1 MG EMERGENCY KIT glucagon GLUCAGON 1 MG EMERGENCY KIT glucagon hcl glucagon 1 mg vial gluco shot liquid glucose glucose 40% gel glucose liquid glutose-15 gel glutose-45 gel glutose-5 gel gs glucose liquid shot GVOKE HYPOPEN 1-PK 1 MG/0.2 ML glucagon GVOKE HYPOPEN 1PK 0.5MG/0.1 ML glucagon GVOKE HYPOPEN 2-PK 1 MG/0.2 ML glucagon GVOKE HYPOPEN 2PK 0.5MG/0.1 ML glucagon GVOKE PFS 1-PK 1 MG/0.2 ML SYR glucagon
PAGE 71 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS GVOKE PFS 1PK 0.5MG/0.1 ML SYR glucagon GVOKE PFS 2-PK 1 MG/0.2 ML SYR glucagon GVOKE PFS 2PK 0.5MG/0.1 ML SYR glucagon kroger glucose 40% gel relion glucose gel 15 gram relion glucose liquid value plus glucose 40% gel INSULINS
ADMELOG 100 UNIT/ML VIAL insulin lispro ADMELOG SOLOSTAR 100 UNIT/ML insulin lispro BASAGLAR 100 UNIT/ML KWIKPEN insulin glargine,human recombinant analog HUMULIN 70-30 VIAL insulin nph human isophane/insulin regular, human HUMULIN N 100 UNIT/ML VIAL insulin nph human isophane HUMULIN R 100 UNIT/ML VIAL insulin regular, human HUMULIN R 500 UNIT/ML KWIKPEN insulin regular, human INSULIN LISPRO JR 100 UNIT/ML AL1 0 to 17 yrs old insulin lispro INSULIN LISPRO MIX 75-25 KWKPN insulin lispro protamine and insulin lispro NOVOLIN 70-30 100 UNIT/ML VIAL insulin nph human isophane/insulin regular, human NOVOLIN N 100 UNIT/ML VIAL insulin nph human isophane NOVOLIN R 100 UNIT/ML VIAL insulin regular, human RELION NOVOLIN 70-30 VIAL insulin nph human isophane/insulin regular, human
PAGE 72 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS RELION NOVOLIN N 100 UNIT/ML insulin nph human isophane RELION NOVOLIN R 100 UNIT/ML insulin regular, human SEMGLEE 100 UNIT/ML PEN insulin glargine,human recombinant analog SEMGLEE 100 UNIT/ML VIAL insulin glargine,human recombinant analog BLOOD PRODUCTS AND MODIFIERS
ANTICOAGULANTS
ELIQUIS 2.5 MG TABLET QL 60 / 30 DAYS apixaban ELIQUIS 5 MG TABLET apixaban ELIQUIS DVT-PE TREAT START 5MG apixaban
enoxaparin 100 mg/ml syringe QL 60 / 30 days
enoxaparin 120 mg/0.8 ml syr QL 48 / 30 DAYS
enoxaparin 150 mg/ml syringe QL 60 / 30 days
enoxaparin 30 mg/0.3 ml syr QL 18 / 30 DAYS
enoxaparin 40 mg/0.4 ml syr QL 24 / 30 DAYS
enoxaparin 60 mg/0.6 ml syr QL 36 / 30 DAYS
enoxaparin 80 mg/0.8 ml syr QL 48 / 30 DAYS
heparin 5,000 unit/ml carpujct jantoven 1 mg tablet jantoven 10 mg tablet jantoven 2 mg tablet jantoven 2.5 mg tablet jantoven 3 mg tablet jantoven 4 mg tablet jantoven 5 mg tablet jantoven 6 mg tablet
PAGE 73 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS jantoven 7.5 mg tablet warfarin sodium 1 mg tablet warfarin sodium 10 mg tablet warfarin sodium 2 mg tablet warfarin sodium 2.5 mg tablet warfarin sodium 3 mg tablet warfarin sodium 4 mg tablet warfarin sodium 5 mg tablet warfarin sodium 6 mg tablet warfarin sodium 7.5 mg tablet XARELTO 10 MG TABLET QL 30 / 30 DAYS rivaroxaban XARELTO 15 MG TABLET rivaroxaban XARELTO 2.5 MG TABLET rivaroxaban XARELTO 20 MG TABLET rivaroxaban XARELTO DVT-PE TREAT START 30D rivaroxaban BLOOD PRODUCTS AND MODIFIERS, OTHER
anagrelide hcl 0.5 mg capsule anagrelide hcl 1 mg capsule
ARANESP 100 MCG/ML VIAL PA darbepoetin alfa in polysorbate 80 S Specialty Drug
ARANESP 150 MCG/0.3 ML SYRINGE PA darbepoetin alfa in polysorbate 80 S Specialty Drug
ARANESP 150 MCG/0.75 ML VIAL PA darbepoetin alfa in polysorbate 80 S Specialty Drug
ARANESP 200 MCG/ML VIAL PA darbepoetin alfa in polysorbate 80 S Specialty Drug
ARANESP 25 MCG/0.42 ML SYRING PA darbepoetin alfa in polysorbate 80 S Specialty Drug
PAGE 74 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
ARANESP 25 MCG/ML VIAL PA darbepoetin alfa in polysorbate 80 S Specialty Drug
ARANESP 300 MCG/0.6 ML SYRINGE PA darbepoetin alfa in polysorbate 80 S Specialty Drug
ARANESP 300 MCG/ML VIAL PA darbepoetin alfa in polysorbate 80 S Specialty Drug
ARANESP 40 MCG/0.4 ML SYRINGE PA darbepoetin alfa in polysorbate 80 S Specialty Drug
ARANESP 40 MCG/ML VIAL PA darbepoetin alfa in polysorbate 80 S Specialty Drug
ARANESP 500 MCG/1 ML SYRINGE PA darbepoetin alfa in polysorbate 80 S Specialty Drug
ARANESP 60 MCG/0.3 ML SYRINGE PA darbepoetin alfa in polysorbate 80 S Specialty Drug
ARANESP 60 MCG/ML VIAL PA darbepoetin alfa in polysorbate 80 S Specialty Drug
FULPHILA 6 MG/0.6 ML SYRINGE PA pegfilgrastim-jmdb S Specialty Drug
MULPLETA 3 MG TABLET PA lusutrombopag S Specialty Drug
NIVESTYM 300 MCG/0.5 ML SYRING PA filgrastim-aafi S Specialty Drug
NIVESTYM 300 MCG/ML VIAL PA filgrastim-aafi S Specialty Drug
NIVESTYM 480 MCG/0.8 ML SYRING PA filgrastim-aafi S Specialty Drug
NIVESTYM 480 MCG/1.6 ML VIAL PA filgrastim-aafi S Specialty Drug
PROMACTA 12.5 MG SUSPEN PACKET PA eltrombopag olamine S Specialty Drug
PAGE 75 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
PROMACTA 12.5 MG TABLET PA eltrombopag olamine S Specialty Drug
PROMACTA 25 MG SUSPENSION PCKT PA eltrombopag olamine S Specialty Drug
PROMACTA 25 MG TABLET PA eltrombopag olamine S Specialty Drug
PROMACTA 50 MG TABLET PA eltrombopag olamine S Specialty Drug
PROMACTA 75 MG TABLET PA eltrombopag olamine S Specialty Drug
RETACRIT 10,000 UNIT/ML VIAL PA epoetin alfa-epbx S Specialty Drug
RETACRIT 2,000 UNIT/ML VIAL PA epoetin alfa-epbx S Specialty Drug
RETACRIT 20,000 UNIT/2 ML VIAL PA epoetin alfa-epbx S Specialty Drug
RETACRIT 20,000 UNIT/ML VIAL PA epoetin alfa-epbx S Specialty Drug
RETACRIT 3,000 UNIT/ML VIAL PA epoetin alfa-epbx S Specialty Drug
RETACRIT 4,000 UNIT/ML VIAL PA epoetin alfa-epbx S Specialty Drug
RETACRIT 40,000 UNIT/ML VIAL PA epoetin alfa-epbx S Specialty Drug
UDENYCA 6 MG/0.6 ML SYRINGE PA pegfilgrastim-cbqv HEMOSTASIS AGENTS
aminocaproic acid 0.25 gram/ml aminocaproic acid 500 mg tab MONSEL'S FERRIC SUBSULFATE SOL ferric subsulfate
PAGE 76 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS tranexamic acid 650 mg tablet PLATELET MODIFYING AGENTS
QL 30 / 30 DAYS CABLIVI 11 MG KIT PA caplacizumab-yhdp S Specialty Drug
cilostazol 100 mg tablet cilostazol 50 mg tablet clopidogrel 300 mg tablet clopidogrel 75 mg tablet dipyridamole 25 mg tablet dipyridamole 50 mg tablet dipyridamole 75 mg tablet prasugrel 10 mg tablet prasugrel 5 mg tablet
TAVALISSE 100 MG TABLET PA fostamatinib disodium S Specialty Drug
TAVALISSE 150 MG TABLET PA fostamatinib disodium S Specialty Drug
ticlopidine 250 mg tablet CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine hcl 0.1 mg tablet clonidine hcl 0.2 mg tablet clonidine hcl 0.3 mg tablet guanfacine 1 mg tablet guanfacine 2 mg tablet methyldopa 250 mg tablet methyldopa 500 mg tablet
PAGE 77 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate 1 mg tab doxazosin mesylate 2 mg tab doxazosin mesylate 4 mg tab doxazosin mesylate 8 mg tab
phenoxybenzamine hcl 10 mg cap PA
prazosin 1 mg capsule prazosin 2 mg capsule prazosin 5 mg capsule terazosin 1 mg capsule terazosin 10 mg capsule terazosin 2 mg capsule terazosin 5 mg capsule ANGIOTENSIN II RECEPTOR ANTAGONISTS
irbesartan 150 mg tablet irbesartan 300 mg tablet irbesartan 75 mg tablet losartan potassium 100 mg tab losartan potassium 25 mg tab losartan potassium 50 mg tab olmesartan medoxomil 20 mg tab olmesartan medoxomil 40 mg tab olmesartan medoxomil 5 mg tab telmisartan 20 mg tablet telmisartan 40 mg tablet telmisartan 80 mg tablet valsartan 160 mg tablet valsartan 320 mg tablet valsartan 40 mg tablet valsartan 80 mg tablet
PAGE 78 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
benazepril hcl 10 mg tablet benazepril hcl 20 mg tablet benazepril hcl 40 mg tablet benazepril hcl 5 mg tablet captopril 100 mg tablet captopril 12.5 mg tablet captopril 25 mg tablet captopril 50 mg tablet enalapril maleate 10 mg tab enalapril maleate 2.5 mg tab enalapril maleate 20 mg tab enalapril maleate 5 mg tablet fosinopril sodium 10 mg tab fosinopril sodium 20 mg tab fosinopril sodium 40 mg tab lisinopril 10 mg tablet lisinopril 2.5 mg tablet lisinopril 20 mg tablet lisinopril 30 mg tablet lisinopril 40 mg tablet lisinopril 5 mg tablet moexipril hcl 15 mg tablet moexipril hcl 7.5 mg tablet perindopril erbumine 2 mg tab perindopril erbumine 4 mg tab perindopril erbumine 8 mg tab quinapril 10 mg tablet quinapril 20 mg tablet quinapril 40 mg tablet
PAGE 79 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS quinapril 5 mg tablet ramipril 1.25 mg capsule ramipril 10 mg capsule ramipril 2.5 mg capsule ramipril 5 mg capsule trandolapril 1 mg tablet trandolapril 2 mg tablet trandolapril 4 mg tablet ANTIARRHYTHMICS
amiodarone hcl 100 mg tablet amiodarone hcl 200 mg tablet amiodarone hcl 400 mg tablet diltiazem 24h er(cd) 360 mg cp diltiazem 24hr er 360 mg cap disopyramide 100 mg capsule disopyramide 150 mg capsule dofetilide 125 mcg capsule dofetilide 250 mcg capsule dofetilide 500 mcg capsule flecainide acetate 100 mg tab flecainide acetate 150 mg tab flecainide acetate 50 mg tab mexiletine 150 mg capsule mexiletine 200 mg capsule mexiletine 250 mg capsule pacerone 200 mg tablet propafenone hcl 150 mg tablet propafenone hcl 225 mg tab propafenone hcl 300 mg tab quinidine gluc er 324 mg tab
PAGE 80 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS quinidine sulfate 200 mg tab quinidine sulfate 300 mg tab sorine 120 mg tablet sorine 160 mg tablet sorine 240 mg tablet sorine 80 mg tablet sotalol 120 mg tablet sotalol 160 mg tablet sotalol 240 mg tablet sotalol 80 mg tablet sotalol af 120 mg tablet sotalol af 160 mg tablet sotalol af 80 mg tablet BETA-ADRENERGIC BLOCKING AGENTS
acebutolol 200 mg capsule acebutolol 400 mg capsule atenolol 100 mg tablet atenolol 25 mg tablet atenolol 50 mg tablet betaxolol 10 mg tablet betaxolol 20 mg tablet bisoprolol fumarate 10 mg tab bisoprolol fumarate 5 mg tab carvedilol 12.5 mg tablet carvedilol 25 mg tablet carvedilol 3.125 mg tablet carvedilol 6.25 mg tablet labetalol hcl 100 mg tablet labetalol hcl 200 mg tablet labetalol hcl 300 mg tablet
PAGE 81 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS metoprolol succ er 100 mg tab metoprolol succ er 200 mg tab metoprolol succ er 25 mg tab metoprolol succ er 50 mg tab metoprolol tartrate 100 mg tab metoprolol tartrate 25 mg tab metoprolol tartrate 50 mg tab nadolol 20 mg tablet nadolol 40 mg tablet nadolol 80 mg tablet pindolol 10 mg tablet pindolol 5 mg tablet propranolol 10 mg tablet propranolol 20 mg tablet propranolol 20 mg/5 ml soln propranolol 40 mg tablet propranolol 40 mg/5 ml soln propranolol 60 mg tablet propranolol 80 mg tablet propranolol er 120 mg capsule propranolol er 160 mg capsule propranolol er 60 mg capsule propranolol er 80 mg capsule CALCIUM CHANNEL BLOCKING AGENTS, DIHYDROPYRIDINES
amlodipine besylate 10 mg tab amlodipine besylate 2.5 mg tab amlodipine besylate 5 mg tab felodipine er 10 mg tablet felodipine er 2.5 mg tablet felodipine er 5 mg tablet
PAGE 82 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS isradipine 2.5 mg capsule isradipine 5 mg capsule nifedipine 10 mg capsule nifedipine 20 mg capsule nifedipine er 30 mg tablet nifedipine er 30 mg tablet nifedipine er 60 mg tablet nifedipine er 60 mg tablet nifedipine er 90 mg tablet nifedipine er 90 mg tablet CALCIUM CHANNEL BLOCKING AGENTS, NONDIHYDROPYRIDINES
cartia xt 120 mg capsule cartia xt 180 mg capsule cartia xt 240 mg capsule cartia xt 300 mg capsule dilt xr 120 mg capsule dilt xr 180 mg capsule dilt xr 240 mg capsule diltiazem 120 mg tablet diltiazem 12hr er 120 mg cap diltiazem 12hr er 60 mg cap diltiazem 12hr er 90 mg cap diltiazem 24h er(cd) 120 mg cp diltiazem 24h er(cd) 180 mg cp diltiazem 24h er(cd) 240 mg cp diltiazem 24h er(cd) 300 mg cp diltiazem 24h er(xr) 120 mg cp diltiazem 24h er(xr) 180 mg cp diltiazem 24h er(xr) 240 mg cp diltiazem 24hr er 120 mg cap
PAGE 83 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS diltiazem 24hr er 180 mg cap diltiazem 24hr er 240 mg cap diltiazem 24hr er 300 mg cap diltiazem 24hr er 360 mg cap diltiazem 24hr er 420 mg cap diltiazem 30 mg tablet diltiazem 60 mg tablet diltiazem 90 mg tablet taztia xt 120 mg capsule taztia xt 180 mg capsule taztia xt 240 mg capsule taztia xt 300 mg capsule taztia xt 360 mg capsule tiadylt er 120 mg capsule tiadylt er 180 mg capsule tiadylt er 240 mg capsule tiadylt er 300 mg capsule tiadylt er 420 mg capsule verapamil 120 mg tablet verapamil 360 mg cap pellet verapamil 40 mg tablet verapamil 80 mg tablet verapamil er 120 mg capsule verapamil er 120 mg tablet verapamil er 180 mg capsule verapamil er 180 mg tablet verapamil er 240 mg capsule verapamil er 240 mg tablet verapamil er pm 100 mg capsule verapamil er pm 200 mg capsule
PAGE 84 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS verapamil er pm 300 mg capsule verapamil sr 120 mg capsule verapamil sr 180 mg capsule verapamil sr 240 mg capsule CARDIOVASCULAR AGENTS, OTHER
acetazolamide 125 mg tablet acetazolamide 250 mg tablet amiloride hcl-hctz 5-50 mg tab amlodipine-benazepril 10-20 mg amlodipine-benazepril 10-40 mg amlodipine-benazepril 2.5-10 amlodipine-benazepril 5-10 mg amlodipine-benazepril 5-20 mg amlodipine-benazepril 5-40 mg amlodipine-olmesartan 10-20 mg amlodipine-olmesartan 10-40 mg amlodipine-olmesartan 5-20 mg amlodipine-olmesartan 5-40 mg amlodipine-valsartan 10-160 mg amlodipine-valsartan 10-320 mg amlodipine-valsartan 5-160 mg amlodipine-valsartan 5-320 mg atenolol-chlorthalidone 100-25 atenolol-chlorthalidone 50-25 benazepril-hctz 10-12.5 mg tab benazepril-hctz 20-12.5 mg tab benazepril-hctz 20-25 mg tab benazepril-hctz 5-6.25 mg tab bisoprolol-hctz 10-6.25 mg tab bisoprolol-hctz 2.5-6.25 mg tb
PAGE 85 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS bisoprolol-hctz 5-6.25 mg tab CORLANOR 5 MG TABLET PA ivabradine hcl CORLANOR 5 MG/5 ML ORAL SOLN PA ivabradine hcl CORLANOR 7.5 MG TABLET PA ivabradine hcl digitek 125 mcg tablet digitek 250 mcg tablet digox 125 mcg tablet digox 250 mcg tablet digoxin 0.05 mg/ml solution digoxin 0.125 mg tablet digoxin 0.25 mg tablet digoxin 125 mcg tablet digoxin 250 mcg tablet enalapril-hctz 10-25 mg tablet enalapril-hctz 5-12.5 mg tab ENTRESTO 24 MG-26 MG TABLET QL 60 / 30 DAYS sacubitril/valsartan ENTRESTO 49 MG-51 MG TABLET QL 60 / 30 DAYS sacubitril/valsartan ENTRESTO 97 MG-103 MG TABLET QL 60 / 30 DAYS sacubitril/valsartan fosinopril-hctz 10-12.5 mg tab fosinopril-hctz 20-12.5 mg tab irbesartan-hctz 150-12.5 mg tb irbesartan-hctz 300-12.5 mg tb lisinopril-hctz 10-12.5 mg tab lisinopril-hctz 20-12.5 mg tab lisinopril-hctz 20-25 mg tab losartan-hctz 100-12.5 mg tab losartan-hctz 100-25 mg tab
PAGE 86 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS losartan-hctz 50-12.5 mg tab methyldopa-hctz 250-15 mg tab methyldopa-hctz 250-25 mg tab metoprolol-hctz 100-25 mg tab metoprolol-hctz 50-25 mg tab olmesartan-hctz 20-12.5 mg tab olmesartan-hctz 40-12.5 mg tab olmesartan-hctz 40-25 mg tab pentoxifylline er 400 mg tab quinapril-hctz 10-12.5 mg tab quinapril-hctz 20-12.5 mg tab quinapril-hctz 20-25 mg tab spironolactone-hctz 25-25 tab triamterene-hctz 37.5-25 mg cp triamterene-hctz 37.5-25 mg tb triamterene-hctz 75-50 mg tab valsartan-hctz 160-12.5 mg tab valsartan-hctz 160-25 mg tab valsartan-hctz 320-12.5 mg tab valsartan-hctz 320-25 mg tab valsartan-hctz 80-12.5 mg tab
VYNDAMAX 61 MG CAPSULE QL 30 / 30 DAYS tafamidis PA
DIURETICS, LOOP
bumetanide 0.5 mg tablet bumetanide 1 mg tablet bumetanide 2 mg tablet furosemide 10 mg/ml solution furosemide 20 mg tablet furosemide 40 mg tablet
PAGE 87 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS furosemide 40 mg/5 ml soln furosemide 80 mg tablet torsemide 10 mg tablet torsemide 100 mg tablet torsemide 20 mg tablet torsemide 5 mg tablet DIURETICS, POTASSIUM-SPARING
amiloride hcl 5 mg tablet eplerenone 25 mg tablet eplerenone 50 mg tablet spironolactone 100 mg tablet spironolactone 25 mg tablet spironolactone 50 mg tablet DIURETICS, THIAZIDE
chlorthalidone 25 mg tablet chlorthalidone 50 mg tablet hydrochlorothiazide 12.5 mg cp hydrochlorothiazide 12.5 mg tb hydrochlorothiazide 25 mg tab hydrochlorothiazide 50 mg tab indapamide 1.25 mg tablet indapamide 2.5 mg tablet metolazone 10 mg tablet metolazone 2.5 mg tablet metolazone 5 mg tablet DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
fenofibrate 134 mg capsule fenofibrate 145 mg tablet fenofibrate 145 mg tablet fenofibrate 160 mg tablet
PAGE 88 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS fenofibrate 200 mg capsule fenofibrate 48 mg tablet fenofibrate 54 mg tablet fenofibrate 67 mg capsule fenofibric acid 105 mg tablet fenofibric acid 35 mg tablet fenofibric acid dr 135 mg cap fenofibric acid dr 45 mg cap gemfibrozil 600 mg tablet DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
atorvastatin 10 mg tablet QL 30 tablets / 30 days
atorvastatin 20 mg tablet QL 30 tablets / 30 days
atorvastatin 40 mg tablet QL 30 tablets / 30 days
atorvastatin 80 mg tablet QL 30 tablets / 30 days
lovastatin 10 mg tablet QL 30 tablets / 30 days
lovastatin 20 mg tablet QL 30 / 30 DAYS
lovastatin 40 mg tablet QL 30 / 30 DAYS
pravastatin sodium 10 mg tab QL 30 tablets / 30 days
pravastatin sodium 20 mg tab QL 30 tablets / 30 days
pravastatin sodium 40 mg tab QL 30 tablets / 30 days
pravastatin sodium 80 mg tab
rosuvastatin calcium 10 mg tab QL 30 tablets / 30 days
rosuvastatin calcium 20 mg tab QL 30 tablets / 30 days
rosuvastatin calcium 40 mg tab QL 30 tablets / 30 days
rosuvastatin calcium 5 mg tab QL 30 tablets / 30 days
simvastatin 10 mg tablet QL 30 tablets / 30 days
simvastatin 20 mg tablet QL 30 tablets / 30 days
PAGE 89 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
simvastatin 40 mg tablet QL 30 tablets / 30 days
simvastatin 5 mg tablet QL 30 tablets / 30 days
simvastatin 80 mg tablet QL 30 tablets / 30 days
DYSLIPIDEMICS, OTHER
cholestyramine light packet cholestyramine light powder cholestyramine packet cholestyramine powder colestipol hcl 1 gm tablet colestipol hcl granules colestipol hcl granules packet cvs fish oil 1,200 mg softgel eql fish oil 1,200 mg softgel eql fish oil ec 1,200 mg sftgl eql omega-3 fish oil 1,000 mg ezetimibe 10 mg tablet fish oil 1,000 mg capsule fish oil 1,000 mg softgel fish oil 1,000 mg softgel fish oil 1,200 mg softgel fish oil 1,200 mg softgel fish oil 1,200 mg softgel fish oil 1,200 mg softgel fish oil conc 1,000 mg softgel hm fish oil 1,200 mg softgel niacin er 1,000 mg tablet niacin er 500 mg tablet niacin er 750 mg tablet omega 3 1,000 mg softgel omega-3 1,000 mg softgel
PAGE 90 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS omega-3 1,000 mg softgel omega-3 ethyl esters 1 gm cap omega-3 fish oil 1,000 mg sfgl omega-3 fish oil 1,200 mg sfgl PRALUENT 150 MG/ML PEN PA alirocumab PRALUENT 150 MG/ML SYRINGE PA alirocumab PRALUENT 75 MG/ML PEN PA alirocumab PRALUENT 75 MG/ML SYRINGE PA alirocumab prevalite packet prevalite powder REPATHA 140 MG/ML SURECLICK PA evolocumab REPATHA 140 MG/ML SYRINGE PA evolocumab REPATHA 420 MG/3.5ML PUSHTRONX PA evolocumab sm fish oil 1,200 mg softgel sm fish oil 1,200 mg softgel sm fish oil concentrate sfg super omega-3 softgel ultra omega-3 softgel VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine 10 mg tablet hydralazine 100 mg tablet hydralazine 25 mg tablet hydralazine 50 mg tablet minoxidil 10 mg tablet minoxidil 2.5 mg tablet
PAGE 91 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
isosorbide dinitr er 40 mg tab isosorbide dinitrate 10 mg tab isosorbide dinitrate 20 mg tab isosorbide dinitrate 30 mg tab isosorbide dinitrate 5 mg tab isosorbide mononit 10 mg tab isosorbide mononit 20 mg tab isosorbide mononit er 120 mg isosorbide mononit er 30 mg tb isosorbide mononit er 60 mg tb NITRO-BID 2% OINTMENT nitroglycerin nitroglycerin 0.1 mg/hr patch nitroglycerin 0.2 mg/hr patch nitroglycerin 0.3 mg tablet sl nitroglycerin 0.4 mg tablet sl nitroglycerin 0.4 mg/hr patch nitroglycerin 0.6 mg tablet sl nitroglycerin 0.6 mg/hr patch nitroglycerin er 2.5 mg cap nitroglycerin er 6.5 mg cap nitroglycerin er 9 mg capsule CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
dextroamp-amphet er 10 mg cap QL 60 / 30 DAYS
dextroamp-amphet er 15 mg cap QL 60 / 30 DAYS
dextroamp-amphet er 20 mg cap QL 60 / 30 DAYS
dextroamp-amphet er 25 mg cap QL 60 / 30 DAYS
dextroamp-amphet er 30 mg cap QL 60 / 30 DAYS
PAGE 92 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
dextroamp-amphet er 5 mg cap QL 60 / 30 DAYS
dextroamp-amphetam 12.5 mg tab QL 3 / 1 day(s)
dextroamp-amphetam 7.5 mg tab QL 3 / 1 day(s)
dextroamp-amphetamin 10 mg tab QL 3 / 1 day(s)
dextroamp-amphetamin 15 mg tab QL 3 / 1 day(s)
dextroamp-amphetamin 20 mg tab QL 3 / 1 day(s)
dextroamp-amphetamin 30 mg tab QL 60 / 30 day(s)
dextroamp-amphetamine 5 mg tab QL 3 / 1 day(s)
dextroamphetamine 10 mg tab QL 3 / 1 day(s)
dextroamphetamine 5 mg tab QL 3 / 1 day(s)
dextroamphetamine er 10 mg cap QL 120 / 30 DAYS
dextroamphetamine er 15 mg cap QL 120 / 30 DAYS
dextroamphetamine er 5 mg cap QL 90 / 30 DAYS
methylphenidate er(la) 20mg cp QL 30 / 30 DAYS
methylphenidate er(la) 40mg cp QL 30 / 30 DAYS
methylphenidate la 20 mg cap QL 30 / 30 DAYS
methylphenidate la 40 mg cap QL 30 / 30 DAYS
zenzedi 10 mg tablet QL 90 / 30 DAYS
zenzedi 5 mg tablet QL 90 / 30 DAYS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
dexmethylphenidate 10 mg tab QL 2 / 1 day(s)
dexmethylphenidate 2.5 mg tab QL 2 / 1 day(s)
dexmethylphenidate 5 mg tab QL 2 / 1 day(s)
dexmethylphenidate er 10 mg cp QL 30 / 30 DAYS
dexmethylphenidate er 15 mg cp QL 30 / 30 DAYS
dexmethylphenidate er 20 mg cp QL 30 / 30 DAYS
PAGE 93 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
dexmethylphenidate er 25 mg cp QL 30 / 30 DAYS
dexmethylphenidate er 30 mg cp QL 30 / 30 DAYS
dexmethylphenidate er 35 mg cp QL 30 / 30 DAYS
dexmethylphenidate er 40 mg cp QL 30 / 30 DAYS
dexmethylphenidate er 5 mg cap QL 30 / 30 DAYS
metadate er 20 mg tablet QL 90 / 30 DAYS
methylphenidate 10 mg tablet QL 90 / 30 DAYS
methylphenidate 10 mg/5 ml sol QL 900 / 30 DAYS
methylphenidate 20 mg tablet QL 90 / 30 DAYS
methylphenidate 5 mg tablet QL 90 / 30 DAYS
methylphenidate 5 mg/5 ml soln QL 1800 / 30 DAYS
methylphenidate cd 10 mg cap QL 30 / 30 DAYS
methylphenidate cd 20 mg cap QL 30 / 30 DAYS
methylphenidate cd 30 mg cap QL 30 / 30 DAYS
methylphenidate cd 40 mg cap QL 30 / 30 DAYS
methylphenidate cd 50 mg cap QL 30 / 30 DAYS
methylphenidate cd 60 mg cap QL 30 / 30 DAYS
methylphenidate er 10 mg tab QL 3 tablets / day
methylphenidate er 18 mg tab QL 1 tablet / day
methylphenidate er 20 mg tab QL 3 tablets / day
methylphenidate er 27 mg tab QL 1 tablet / day
methylphenidate er 36 mg tab QL 60 / 30 DAYS
methylphenidate er 54 mg tab QL 1 tablet / day
methylphenidate er(cd) 10mg cp QL 30 / 30 DAYS
methylphenidate er(cd) 20mg cp QL 30 / 30 DAYS
PAGE 94 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
methylphenidate er(cd) 30mg cp QL 30 / 30 DAYS
methylphenidate er(cd) 40mg cp QL 30 / 30 DAYS
methylphenidate er(cd) 50mg cp QL 30 / 30 DAYS
methylphenidate er(cd) 60mg cp QL 30 / 30 DAYS
methylphenidate er(la) 10mg cp QL 30 / 30 DAYS
methylphenidate er(la) 30mg cp QL 30 / 30 DAYS
methylphenidate la 10 mg cap QL 30 / 30 DAYS
methylphenidate la 30 mg cap QL 30 / 30 DAYS
methylphenidate la 60 mg cap QL 30 / 30 DAYS
CENTRAL NERVOUS SYSTEM, OTHER
acetaminophen 120 mg suppos acetaminophen 160 mg/5 ml liq acetaminophen 160 mg/5 ml sol acetaminophen 160 mg/5 ml susp acetaminophen 325 mg gelcap acetaminophen 325 mg tablet acetaminophen 500 mg caplet acetaminophen 500 mg caplet acetaminophen 500 mg gelcap acetaminophen 500 mg tablet acetaminophen 500 mg tablet acetaminophen 650 mg suppos betatemp 160 mg/5 ml susp butalb-acetamin-caff 50-325-40 butalb-acetamin-caff 50-325-40 butalbital-acetaminophn 50-325 child acetaminophen 160 mg child aurophen pain 160 mg/5ml child fever reducer 120 mg sup
PAGE 95 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS child fever reducer 120 mg sup child pain rel-fever 120mg sup child pain rlf 160 mg/5 ml elx child pain rlf 160 mg/5 ml sus child pain-fever 160 mg/5 ml child's mapap 160 mg tab chew child's pain reliever susp children's fever reducing supp chld acetaminophen 160 mg/5 ml chld acetaminophen 160 mg/5 ml cvs acetaminophen 325 mg gelcp cvs acetaminophen 500 mg cplt cvs acetaminophen 500 mg gelcp cvs acetaminophen 500 mg tab cvs child fever red 120 mg sup cvs child pain relief 160 mg cvs child pain rlf 160 mg/5 ml cvs child pain-fever 160 mg/5 cvs infant pain-fever 160 mg/5 cvs infnt pain rlf 160 mg/5 ml cvs non-aspirin 500 mg caplet cvs non-aspirin 500 mg geltab cvs pain relief 325 mg tablet cvs pain relief 500 mg caplet cvs pain relief 500 mg tablet cvs pain reliever 500 mg cplt ed-apap 160 mg/5 ml liquid eq acetaminophen 500 mg caplet eq acetaminophen 500 mg gelcap eq acetaminophen 500 mg tablet
PAGE 96 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS eq chld pain-fever 160 mg/5 ml eq infant pain-fever 160 mg/5 eq pain reliever 325 mg tablet eq pain reliever 500 mg caplet eql acetaminophen 500 mg cplt eql acetaminophen 500 mg gelcp eql acetaminophen 500 mg tab eql chld acetaminophn 160 mg/5 eql inf acetaminophen 160 mg/5 gnp acetaminophen 325 mg gelcp gnp acetaminophen 500 mg tab gnp child pain relief 160 mg gnp child pain-fever 160 mg/5 gnp infant pain relief susp gnp infant pain-fever 160 mg/5 gnp infnt pain rlf 160 mg/5 ml gnp pain relief 325 mg tablet gnp pain relief 500 mg caplet gnp pain relief 500 mg gelcap gnp pain relief 500 mg gelcap gnp pain reliever 325 mg tab gnp pain reliever 500 mg tab gs child fever-pain 160 mg/5ml gs child pain-fever 160 mg/5ml gs chld pain-fever 160 mg/5 ml gs infant pain-fever 160 mg/5 gs pain relief 325 mg tablet gs pain relief 500 mg caplet gs pain relief 500 mg tablet hm child acetaminophen 160 mg
PAGE 97 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS hm child pain rlf 160 mg/5 ml hm chld pain-fever 160 mg/5 ml hm infant pain rlf 160 mg/5 ml hm infant pain-fever 160 mg/5 hm pain relief 325 mg tablet hm pain relief 500 mg caplet hm pain relief 500 mg gelcap hm pain relief 500 mg tablet hm pain reliever 325 mg tablet hm pain reliever 500 mg tablet inf acetaminophen 160 mg/5 ml infant pain relief 160 mg/5 ml infant pain relief susp infant pain relv 80 mg/0.8 ml infant pain rlf 80 mg/0.8 ml infant pain-fever 160 mg/5 ml infant pain-fever 160 mg/5 ml infant's pain rlf 80 mg/0.8 ml infants pain-fever 160 mg/5 ml kro acetaminophen 325 mg tab kro acetaminophen 500 mg cplt kro child pain rlf 160 mg/5 ml kro infant pain-fever 160 mg/5 little remedies fever 160 mg/5 m-pap 160 mg/5 ml liquid mapap 325 mg tablet mapap 500 mg caplet masophen 325 mg tablet masophen 500 mg tablet non-aspirin 160 mg/5 ml susp
PAGE 98 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS non-aspirin 325 mg tablet non-aspirin 500 mg caplet non-aspirin 500 mg tablet nortemp 160 mg/5 ml susp PAIN & FEVER 325 MG TABLET acetaminophen PAIN & FEVER 500 MG TABLET acetaminophen pain relief 160 mg/5 ml liquid pain relief 325 mg tablet pain relief 500 mg caplet pain relief 500 mg gelcap pain relief 500 mg tablet pain reliever 325 mg tablet pain reliever 500 mg caplet pain reliever 500 mg gelcap pain reliever 500 mg tablet pediacare fever reducer susp pharbetol 325 mg tablet pharbetol 500 mg caplet pharbetol 500 mg tablet pub child pain rlf 160 mg/5 ml pub pain relief 500 mg caplet pub pain relief 500 mg geltab pub pain relief 500 mg tablet qc child pain rlf 160 mg/5 ml qc infant pain rlf 160 mg/5 ml qc infnt pain rlf 160 mg/5 ml qc non-aspirin 500 mg caplet qc non-aspirin 500 mg gelcap qc non-aspirin 500 mg tablet
PAGE 99 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS qc non-aspirin pain relief tb qc pain relief 325 mg tablet qc pain relief 500 mg caplet ra acetaminophen 325 mg tablet ra acetaminophen 500 mg caplet ra acetaminophen 500 mg gelcap ra acetaminophen 500 mg tablet ra athenol 325 mg tablet ra child acetaminophen 160 mg ra child fever-pain 160 mg/5ml ra fever reducer-pain 160 mg/5 ra infant fever-pain 160 mg/5 ra infant fever-pain 160 mg/5 ra non-aspirin 160 mg/5 ml ra non-aspirin 160 mg/5 ml ra non-aspirin 500 mg caplet
riluzole 50 mg tablet S Specialty Drug
shake that ache 500 mg caplet silapap 160 mg/5 ml liquid sm child's pain reliever susp sm chld pain-fever 160 mg/5 ml sm infant pain rlf 160 mg/5 ml sm infant pain-fever 160 mg/5 sm pain relief 500 mg gelcap sm pain relief 500 mg gelcap sm pain reliever 325 mg tablet sm pain reliever 500 mg caplet sm pain reliever 500 mg gelcap sm pain reliever 500 mg tablet tactinal 325 mg tablet
PAGE 100 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS tactinal 500 mg caplet tactinal 500 mg tablet FIBROMYALGIA AGENTS
QL 90 / 30 DAYS pregabalin 100 mg capsule PA
QL 90 / 30 DAYS pregabalin 150 mg capsule PA
QL 900 / 30 pregabalin 20 mg/ml solution PA
QL 90 / 30 DAYS pregabalin 200 mg capsule PA
QL 60 / 30 DAYS pregabalin 225 mg capsule PA
QL 90 / 30 DAYS pregabalin 25 mg capsule PA
QL 60 / 30 DAYS pregabalin 300 mg capsule PA
QL 90 / 30 DAYS pregabalin 50 mg capsule PA
QL 90 / 30 DAYS pregabalin 75 mg capsule PA
MULTIPLE SCLEROSIS AGENTS
QL 120 / 30 DAYS BAFIERTAM DR 95 MG CAPSULE PA monomethyl fumarate S Specialty Drug
QL 60 / 30 day(s)
dimethyl fumarate 30d start pk PA
S Specialty Drug
QL 60 / 30 day(s)
dimethyl fumarate dr 120 mg cp PA
S Specialty Drug
PAGE 101 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 60 / 30 day(s)
dimethyl fumarate dr 240 mg cp PA
S Specialty Drug
QL 1 / 30 DAYS EXTAVIA 0.3 MG KIT PA interferon beta-1b S Specialty Drug
QL 15 / 30 DAYS EXTAVIA 0.3 MG VIAL PA interferon beta-1b S Specialty Drug
QL 30 / 30 day(s) GILENYA 0.5 MG CAPSULE PA fingolimod hcl S Specialty Drug
QL 30 / 30 day(s)
glatiramer 20 mg/ml syringe PA
S Specialty Drug
QL 12 / 28 day(s)
glatiramer 40 mg/ml syringe PA
S Specialty Drug
QL 30 / 30 DAYS
glatopa 20 mg/ml syringe PA
S Specialty Drug
QL 12 / 28 DAYS
glatopa 40 mg/ml syringe PA
S Specialty Drug
KESIMPTA 20 MG/0.4 ML PEN QL 0.4 / 28 DAYS ofatumumab PA
DENTAL AND ORAL AGENTS
chlorhexidine 0.12% rinse DEBACTEROL SWABSTICK sulfuric acid/sulfonated phenol
denta 5000 plus cream AL1 Up to 16 yrs old
PAGE 102 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
dentagel 1.1% gel AL1 Up to 16 yrs old
paroex 0.12% oral rinse periogard 0.12% oral rinse
sf 1.1% gel AL1 Up to 16 yrs old
sf 5000 plus cream AL1 Up to 16 yrs old
sodium fluoride 1.1% cream AL1 Up to 16 yrs old
sodium fluoride 1.1% gel AL1 Up to 16 yrs old
sodium fluoride 5000 plus crm AL1 Up to 16 yrs old
sodium fluoride 5000 ppm cream AL1 Up to 16 yrs old
triamcinolone 0.1% paste DERMATOLOGICAL AGENTS
ACNE AND ROSACEA AGENTS
accutane 10 mg capsule accutane 20 mg capsule accutane 30 mg capsule accutane 40 mg capsule
acitretin 10 mg capsule PA
acitretin 17.5 mg capsule PA
acitretin 25 mg capsule PA
adapalene 0.1% gel PA
amnesteem 10 mg capsule amnesteem 20 mg capsule amnesteem 40 mg capsule claravis 10 mg capsule claravis 20 mg capsule claravis 30 mg capsule claravis 40 mg capsule
clind ph-benzoyl perox 1.2-5% PA
PAGE 103 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
effaclar adapalene 0.1% gel PA
isotretinoin 10 mg capsule isotretinoin 20 mg capsule isotretinoin 30 mg capsule isotretinoin 40 mg capsule myorisan 10 mg capsule myorisan 20 mg capsule myorisan 30 mg capsule myorisan 40 mg capsule
neuac gel PA
tretinoin 0.025% cream PA
zenatane 10 mg capsule zenatane 20 mg capsule zenatane 30 mg capsule zenatane 40 mg capsule DERMATITIS AND PRURITUS AGENTS
alclometasone dipr 0.05% oint alclometasone dipro 0.05% crm betamethasone dp 0.05% crm betamethasone dp 0.05% lot betamethasone va 0.1% cream betamethasone va 0.1% lotion betamethasone valer 0.1% ointm clobetasol 0.05% cream clobetasol 0.05% gel clobetasol 0.05% ointment clobetasol 0.05% solution cvs hydrocortisone 1% cream desonide 0.05% cream desonide 0.05% ointment
PAGE 104 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS desoximetasone 0.25% cream desoximetasone 0.25% ointment eq hydrocortisone 1% cream fluocinolone 0.01% cream fluocinolone 0.025% cream fluocinolone 0.025% ointment fluocinonide 0.05% gel fluocinonide 0.05% ointment fluocinonide 0.05% solution fluocinonide-e 0.05% cream fluticasone prop 0.005% oint fluticasone prop 0.05% cream gnp hydrocortisone 1% cream gnp hydrocortisone 1% ointment halobetasol prop 0.05% cream halobetasol prop 0.05% ointmnt hm hydrocortisone 1% cream hydrocortisone 1% absorbase hydrocortisone 1% cream hydrocortisone 1% ointment hydrocortisone 2.5% cream hydrocortisone 2.5% lotion hydrocortisone 2.5% ointment hydrocortisone buty 0.1% cream hydrocortisone butyr 0.1% soln hydrocortisone plus 1% cream hydrocortisone val 0.2% cream kro hydrocortisone 1% cream mometasone furoate 0.1% cream mometasone furoate 0.1% oint
PAGE 105 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS mometasone furoate 0.1% soln pv hydrocortisone 1% cream qc hydrocortisone 1% cream ra hydrocortisone 1% cream sb hydrocortisone 1% cream selenium sulfide 2.5% lotion sm hydrocortisone 1% cream sm hydrocortisone 1% ointment
tacrolimus 0.03% ointment PA
tacrolimus 0.1% ointment PA
triamcinolone 0.025% cream triamcinolone 0.025% lotion triamcinolone 0.025% oint triamcinolone 0.1% cream triamcinolone 0.1% lotion triamcinolone 0.1% ointment triamcinolone 0.5% cream triamcinolone 0.5% ointment DERMATOLOGICAL AGENTS, OTHER
adapalene 0.1% gel PA
calcipotriene 0.005% cream calcipotriene 0.005% solution clotrimazole-betamethasone crm complete lice treatment kit cvs lice killing shampoo diclofenac sodium 1% gel DRYSOL DAB-O-MATIC SOLUTION aluminum chloride DRYSOL SOLUTION aluminum chloride eq complete lice treatment kit
PAGE 106 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS eq lice killing shampoo eql lice killing shampoo FLUOROPLEX 1% CREAM fluorouracil fluorouracil 2% topical soln fluorouracil 5% cream fluorouracil 5% topical soln gnp arthritis pain 1% gel gnp lice treatment shampoo gs arthritis pain 1% gel gs lice killing shampoo hm lice killing shampoo hydrocort-pramoxine 2.5-1% crm hydroquinone 4% cream imiquimod 5% cream packet kro lice complete kit 1-2-3 kro lice killing shampoo lice killing shampoo lice treatment shampoo nystatin-triamcinolone cream nystatin-triamcinolone ointm
OTEZLA 30 MG TABLET PA apremilast S Specialty Drug
PROCTOFOAM-HC 1%-1% FOAM hydrocortisone acetate/pramoxine hcl ra lice pyrinyl shampoo rid essential lice kit rid lice killing shampoo sb lice killing shampoo silver sulfadiazine 1% cream sm lice killing shampoo
PAGE 107 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS SSD 1% CREAM silver sulfadiazine PEDICULICIDES/SCABICIDES
EURAX 10% CREAM crotamiton EURAX 10% LOTION crotamiton gnp lice treatment 1% crm rins lice treatment 1% creme rinse permethrin 5% cream ra lice treatment 1% crm rinse TOPICAL ANTI-INFECTIVES
ciclopirox 0.77% gel ciclopirox 1% shampoo DENAVIR 1% CREAM penciclovir mupirocin 2% ointment SULFAMYLON 8.5% CREAM mafenide acetate SULFAMYLON POWDER PACKET mafenide acetate ELECTROLYTES/MINERALS/METALS/VITAMINS
ELECTROLYTE/MINERAL REPLACEMENT
fluoride 0.25 mg tablet chew AL1 Up to 16 yrs old
fluoride 0.5 mg tablet chew AL1 Up to 16 yrs old
fluoride 1 mg tablet chewable AL1 Up to 16 yrs old
fluoritab 0.5 mg tablet chew AL1 Up to 16 yrs old
FLUORITAB 1 MG TABLET CHEW AL1 Up to 16 yrs old fluoride (sodium) INTRALIPID 20% IV FAT EMUL fat emulsions INTRALIPID 30% IV FAT EMUL fat emulsions
PAGE 108 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS KLOR-CON 10 MEQ TABLET potassium chloride KLOR-CON 8 MEQ TABLET potassium chloride klor-con m10 tablet klor-con m20 tablet klor-con sprinkle er 8 meq cap levocarnitine 330 mg tablet
ludent fluoride 0.25 mg tb chw AL1 Up to 16 yrs old
ludent fluoride 0.5 mg tb chew AL1 Up to 16 yrs old
ludent fluoride 1 mg tab chew AL1 Up to 16 yrs old
magnesium oxide 400 mg tablet PEDIASURE HARVEST LIQUID PA nutritional supplement,special formula,lactose free,iron/soy potassium citrate er 10 meq tb potassium citrate er 15 meq tb potassium citrate er 5 meq tab potassium cl 10% (20 meq/15ml) potassium cl 10% (40 meq/30ml) potassium cl 20% (40 meq/15ml) potassium cl er 10 meq capsule potassium cl er 10 meq tablet potassium cl er 10 meq tablet potassium cl er 15 meq tablet potassium cl er 20 meq tablet potassium cl er 20 meq tablet potassium cl er 8 meq capsule potassium cl er 8 meq tablet ra high potency iron 27 mg tab sodium chloride 0.9% irrig sodium chloride 0.9% irrig.
PAGE 109 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS sodium chloride 0.9% prcss sol
sodium fluoride 0.25 (0.55) mg AL1 Up to 16 yrs old
sodium fluoride 0.5 mg(1.1 mg) AL1 Up to 16 yrs old
sodium fluoride 0.5 mg/ml drop AL1 Up to 16 yrs old
sodium fluoride 1 mg (2.2 mg) AL1 Up to 16 yrs old
ELECTROLYTE/MINERAL/METAL MODIFIERS
CHEMET 100 MG CAPSULE succimer
JYNARQUE 15 MG TABLET PA tolvaptan S Specialty Drug
JYNARQUE 15 MG-15 MG TABLET PA tolvaptan S Specialty Drug
JYNARQUE 30 MG TABLET PA tolvaptan S Specialty Drug
JYNARQUE 30 MG-15 MG TABLET PA tolvaptan S Specialty Drug
JYNARQUE 45 MG-15 MG TABLET PA tolvaptan S Specialty Drug
JYNARQUE 60 MG-30 MG TABLET PA tolvaptan S Specialty Drug
JYNARQUE 90 MG-30 MG TABLET PA tolvaptan S Specialty Drug
klor-con 20 meq packet potassium cl 20 meq packet PHOSPHATE BINDERS
calcium acetate 667 mg capsule calcium acetate 667 mg gelcap calcium acetate 667 mg tablet sevelamer 0.8 gm powder packet
PAGE 110 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS sevelamer 2.4 gm powder packet sevelamer carbonate 800 mg tab sevelamer hcl 400 mg tablet sevelamer hcl 800 mg tablet POTASSIUM BINDERS
kionex 15 gm/60 ml suspension kionex powder sod polystyren sulf 15 g/60 ml sps 15 gm/60 ml suspension SPS 15 GM/60 ML SUSPENSION sodium polystyrene sulfonate/sorbitol solution sps 30 gm/120 ml enema SPS 30 GM/120 ML ENEMA SUSP sodium polystyrene sulfonate/sorbitol solution VITAMINS
b-1 100 mg tablet b-12 1,000 mcg tablet b-12 2,500 mcg tablet sl b-12 2,500 mcg tablet sl b-12 500 mcg tablet b-12 dots 500 mcg tablet b12 2,500 mcg tablet sl bd normal saline flush syringe
beef-potatoes-spinach blend PA
BENECALORIE LIQUID PA caloric supplement
boost breeze liquid PA
BOOST CALORIE SMART LIQUID PA lactose-reduced food BOOST GLUCOSE CONTROL LIQUID PA nutritional tx. glucose intolerance,lactose-free,soy/fiber BOOST HIGH PROTEIN ENERGY DRNK PA lactose-reduced food
PAGE 111 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS BOOST HIGH PROTEIN LIQUID PA lactose-reduced food
boost high protein powder PA
BOOST KID ESSENTIALS LIQUID PA pediatric nutrition with iron, lactose free
boost kid essentials liquid PA
BOOST KID ESSENTIALS-FIBER LIQ PA pediatric nutrition, iron, lactose free with fiber BOOST LIQUID PA lactose-reduced food BOOST MAX LIQUID PA nutritional supplement BOOST MAX MEN LIQUID PA nutritional supplement BOOST MEN LIQUID PA lactose-reduced food BOOST MOBILITY LIQUID PA lactose-reduced food BOOST PLUS ENERGY DRINK PA lactose-reduced food BOOST PLUS LIQUID PA lactose-reduced food BOOST SOOTHE LIQUID PA lactose-reduced food BOOST VHC NUTRITIONAL LIQUID PA nutritional therapy, lactose-reduced, with iron BOOST WOMEN LIQUID PA lactose-reduced food BREAKFAST ESSENTIALS LIQUID PA nutritional supplement calcitrate 200 mg (950 mg) tab calcium 250-vit d3 125 tablet calcium 500 mg tablet calcium 500 mg tablet calcium 500 mg-vit d3 5 mcg tb calcium 500-vit d3 200 tablet
PAGE 112 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS calcium 500-vit d3 400 tablet calcium 600 mg tablet calcium 600 mg-d3 10 mcg sfgl calcium 600 mg-vit d3 10mcg tb calcium 600-vit d3 200 tablet calcium 600-vit d3 400 caplet calcium 600-vit d3 400 tablet calcium 600mg-d3 400 unit sfgl calcium carb 1,250 mg/5 ml sus calcium cit 315 mg-d3 250 unit calcium cit 315-vit d3 250 cpt calcium cit 315-vit d3 250 tab calcium citrate - vit d caplet calcium citrate - vit d3 tab calcium citrate 200 mg caplet calcium citrate 200 mg tablet calcium citrate-vit d caplet calcium citrate-vit d3 caplet calcium citrate-vit d3 tablet calcium citrate-vit d3 tablet child ferrous sulfate 15 mg/ml children's iron 15 mg/ml drops CLASSIC PRENATAL TABLET AL1 13 to 50 yrs old prenatal vit with calcium no.126/ferrous fumarate/folic acid COMPLEAT 1 CAL TUBE FEED LIQ PA nutritional supplement/inulin/fructooligosaccharides/fiber COMPLEAT ORGANIC BLEND CHICKEN PA nutritional supplement/fiber COMPLEAT ORGANIC BLENDS PLANT PA nutritional supplement/fiber COMPLEAT PED ORG BLEND CHICKEN PA nutritional supplement/fiber
PAGE 113 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS COMPLEAT PED ORG BLENDS PLANT PA nutritional supplement/fiber
compleat pedi red 0.6 cal liq PA
compleat pediatric 1 cal liq PA
cvs b-1 100 mg tablet cvs b-12 1,000 mcg tablet cvs cal cit 315 mg-d3 250 unit cvs cal cit 315 mg-d3 6.25 mcg cvs calcium 600 mg tablet cvs folic acid 800 mcg tablet cvs iron 27 mg tablet cvs iron 65 mg tablet cvs magnesium 250 mg caplet cvs magnesium 500 mg caplet cvs magnesium 500 mg tablet
cvs nutritional shake PA
cvs prenatal gummy vitamins AL1 13 to 50 yrs old
cvs prenatal vitamins tablet AL1 13 to 50 yrs old
cvs protein nutritional shake PA
cvs vitamin b-1 100 mg tablet cvs vitamin b-12 500 mcg tab cvs vitamin b-6 100 mg tablet cyanocobalamin 1,000 mcg/ml vl cyanocobalamin 10,000 mcg/10ml cyanocobalamin 30,000 mcg/30ml DIALYVITE TABLET folic acid/vitamin b complex and vitamin c
duocal powder PA
effer-k 25 meq tablet eff EGG-PRO POWDER PA albumen (egg white)
PAGE 114 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
eggs-apples-oats puree blend PA
ENFAMIL PROSOBEE LIQUID PA infant formula,soy,iron,lac-free/dha/arachidonic acid (ara)
ensure active heart health liq PA
ensure active high protein liq PA
ensure active light liquid PA
ensure active muscle health lq PA
ensure active protein-muscl lq PA
ensure clear liquid PA
ENSURE CLEAR THERAPEUTIC LIQ PA nutritional therapy for impaired digestive function
ensure compact liquid PA
ENSURE ENLIVE LIQUID PA lactose-reduced food
ensure high protein liquid PA
ensure high protein powder PA
ensure liquid PA
ensure max protein liquid PA
ensure muscle health liquid PA
ENSURE ORIGINAL LIQUID PA lactose-reduced food
ensure original liquid PA
ENSURE ORIGINAL POWDER PA lactose-reduced food
ensure plant-based protein liq PA
ENSURE PLUS LIQUID PA lactose-reduced food ENSURE POWDER PA lactose-reduced food ENSURE PRE-SURGERY LIQUID PA maltodextrin/fructose
PAGE 115 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS ENU PRO3 PLUS POWDER PA nutritional supplement
eo28 splash drink PA
eq calcium 500-vit d3 400 tab eq calcium cit 315-vit d3 250 eq calcium citrate-d tablet
eq nutritional shake liquid PA
eq nutritional shake plus liq PA
eql calcium citrate-vit d3 cpt eql vitamin b-12 500 mcg tab eql vitamin b-6 100 mg tablet fa-8 capsules feosol 65 mg tablet ferate 27 mg tablet ferosul 325 mg tablet ferrex 150 capsule ferric x-150 capsule ferro-time 325 mg tablet ferrocite tablet ferrous fumarate 324 mg tab ferrous gluconate 240 mg tab ferrous gluconate 324 mg tab ferrous gluconate 324 mg tab ferrous sulf 15 mg iron/ml drp ferrous sulf 220 mg/5 ml elix ferrous sulf 220 mg/5 ml elix ferrous sulf 220 mg/5 ml liq ferrous sulf 300 mg/5 ml liq ferrous sulf 300 mg/6.8ml soln ferrous sulf 44 mg iron/5ml lq
PAGE 116 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS ferrous sulfate 325 mg tablet ferrousul 325 mg tablet FIBERSOURCE HN 1.2 CAL LIQUID PA nutritional supplement/inulin/fructooligosaccharides/fiber FIBERSOURCE HN LIQUID PA nutritional supplement/inulin/fructooligosaccharides/fiber fish oil 1,000 mg softgel fish oil 1,000 mg softgel fish oil 1,200 mg softgel fish oil 1,200 mg softgel fish oil dr 1,000 mg softgel FISH OIL EC 1,200 MG SOFTGEL omega-3 fatty acids/dha/epa/other omega-3s/fish oil fish oil omega-3 ec 1,200 mg fn vitamin b-12 1,000 mcg tab folic acid 0.4 mg tablet folic acid 0.8 mg tablet folic acid 1 mg tablet folic acid 1,000 mcg tablet folic acid 400 mcg tablet folic acid 800 mcg capsule folic acid 800 mcg tablet gnp b12 2,500 mcg tablet sl gnp calcium 600 mg tablet gnp calcium citrate-vit d3 tab gnp folic acid 400 mcg tablet gnp iron 65 mg tablet gnp magnesium 250 mg tablet
gnp nutritional drink liquid PA
gnp prenatal vitamins tablet AL1 13 to 50 yrs old
gnp vitamin b-1 100 mg tablet
PAGE 117 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS gnp vitamin b-12 500 mcg tab gnp vitamin b-6 100 mg tablet
gs nutrisure original shake PA
gs nutrisure plus shake PA
gs prenatal vitamins tablet AL1 13 to 50 yrs old
hi-cal liquid PA
high-protein nutritional shake PA
hm cal cit 315 mg-d3 250 unit hm calcium 600-vit d3 400 tab hm folic acid 400 mcg tablet hm iron 65 mg tablet hm magnesium 400 mg caplet
hm nutrisure plus shake PA
hm nutrition shake plus liquid PA
hm prenatal tablet AL1 13 to 50 yrs old
hm vitamin b-12 500 mcg tablet hm vitamin b-6 100 mg tablet hydroxocobalamin 1,000 mcg/ml iferex 150 capsule iron 27 mg tablet iron 27 mg tablet iron 65 mg tablet ISOSOURCE 1.5 CAL LIQUID PA lactose-reduced food/fiber ISOSOURCE 1.5 CAL TUBE FEED LQ PA lactose-reduced food/fiber ISOSOURCE HN 1.2 CAL LIQUID PA lactose-reduced food JEVITY 1 CAL LIQUID PA lactose-reduced food/fiber
PAGE 118 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS JEVITY 1.2 CAL LIQUID PA lactose-reduced food/fiber JEVITY 1.5 CAL LIQUID PA lactose-reduced food/fiber KETO FORMULA PA nutritional supplement/fiber KETOVIE PEPTIDE 4:1 LIQUID PA nutritional tx, ketogenic,whey klor-con sprinkle er 10 meq cp klor-con-ef 25 meq tab eff KPN PRENATAL TABLET AL1 13 to 50 yrs old prenatal vits with calcium no.98/ferrous fumarate/folic acid
kro prenatal vitamins tablet AL1 13 to 50 yrs old
lactated ringers irrigation levocarnitine 1 g/10 ml soln LIQUID HOPE ORIGINAL FORMULA PA nutritional supplement/fiber LIQUID HOPE PEPTIDE FORMULA PA nutritional supplement/fiber
GL Female m-natal plus tablet AL1 13 to 50 yrs old
mag-oxide 200 mg tab mag-oxide magnesium 200 mg tab magnesium 250 mg caplet magnesium 250 mg tablet magnesium 400 mg caps magnesium 400 mg softgel magnesium 400 mg tablet magnesium 500 mg tablet magnesium oxide 250 mg caplet magnesium oxide 250 mg tablet magnesium oxide 400 mg tablet magnesium oxide 500 mg tablet
PAGE 119 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS mgo 400 mg tablet MINI PRENATAL TABLET AL1 13 to 50 yrs old prenatal vitamins no.49/ferrous fumarate/folic acid
monogen powder PA
monoject 0.9% sodium cl syring monoject prefill 0.9% na syr monoject sod chlor 0.9% flush multivit-fluor 0.25 mg tab chw multivit-fluor 0.25 mg tab chw multivit-fluor 0.25 mg/ml drop multivit-fluor 0.25 mg/ml drop multivit-fluor 0.5 mg tab chew multivit-fluor 0.5 mg tab chew multivit-fluor 0.5 mg/ml drop multivit-fluor-iron 0.25 mg/ml multivit-fluoride 1 mg tab chw multivit-fluoride 1 mg tab chw multivit-iron-fluor 0.25 mg/ml myferon 150 capsule MYNATAL CAPSULE prenatal vitamins with calcium/ferrous fumarate/folic acid mynatal plus captab mynatal-z captab natural calcium 500 mg tablet NEPHRO-VITE RX TABLET vitamin b complex no.3/folic acid/ascorbic acid(vitc)/biotin normal saline flush syringe NOURISH ORIGINAL FORMULA PA nutritional supplement/fiber NOURISH PEPTIDE FORMULA PA nutritional supplement/fiber NOVAFERRUM PEDI MV-IRON DROPS pediatric multivitamin no.88/iron polysaccharide complex
PAGE 120 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS NU-IRON 150 CAPSULE iron polysaccharide complex
nutrafit liquid PA
nutrafit plus liquid PA
NUTREN 1.0 LIQUID PA nutritional supplement NUTREN 1.5 LIQUID PA nutritional supplement NUTREN 2.0 LIQUID PA nutritional supplement NUTREN FIBER 1 CAL LIQUID PA nutritional supplement/inulin/fructooligosaccharides/fiber NUTREN JUNIOR 1 CAL LIQUID PA nutritional supplement NUTREN JUNIOR FIBER 1 CAL LIQ PA nutritional supplement/inulin/fructooligosaccharides/fiber
nutritional drink liquid PA
nutritional drink mix powder PA
nutritional drink plus liquid PA
nutritional drink plus liquid PA
nutritional shake liquid PA
nutritional shake liquid PA
nutritional shake plus liquid PA
omega-3 fish oil 1,200 mg sfgl omega-3 fish oil 1,200 mg sfgl
orange chickn-carrot-brwn rice PA
os-cal 500-vit d3 200 caplet OSMOLITE 1 CAL LIQUID PA nutritional supplement OSMOLITE 1.2 CAL LIQUID PA nutritional supplement OSMOLITE 1.5 CAL LIQUID PA nutritional supplement
PAGE 121 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS oysco 500-vit d3 200 tablet oysco-500 tablet oyster shell 250 mg-d3 3.12mcg oyster shell 500-vit d3 200 tb oyster shell 500mg-vit d3 5mcg oyster shell calcium 500 mg tb oyster shell calcium-vit d tab pedia iron 15 mg/ml drop PEDIA POLY-VITE DROPS pediatric multivitamin no.171 PEDIA POLY-VITE WITH IRON DROP pediatric multivitamin no.160/ferrous sulfate PEDIA TRI-VITE DROP vitamin a palmitate/ascorbic acid/cholecalciferol (vit d3) PEDIASMART ORGANIC DAIRY POWD PA pediatric nutrition, soy with iron, lactose free/fiber PEDIASMART ORGANIC SOY POWDER PA pediatric nutrition, soy with iron, lactose free/fiber PEDIASURE 1.5 LIQUID PA pediatric nutrition with iron, lactose free PEDIASURE 1.5 WITH FIBER LIQ PA pediatric nutrition, iron, lactose free with fiber PEDIASURE ENTERAL LIQUID PA pediatric nutrition with iron, lactose free PEDIASURE ENTERAL WITH FIBER PA pediatric nutrition, iron, lactose free with fiber PEDIASURE GROW-GAIN FIBER LIQ PA pediatric nutrition, iron, lactose free with fiber PEDIASURE GROW-GAIN LIQUID PA pediatric nutrition with iron, lactose free PEDIASURE GROW-GAIN ORGANIC LQ PA pediatric nutrition with iron, lactose free PEDIASURE LIQUID PA pediatric nutrition with iron, lactose free
pediasure peptide 1.0 cal liq PA
PAGE 122 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS PEDIASURE PEPTIDE 1.5 CAL LIQ PA nutritional supplement PEDIASURE SHAKE MIX POWDER PA pediatric nutrition, milk based, with iron PEDIASURE SIDEKICKS CLEAR LIQ PA pediatric nutrition, milk based, with iron PEDIASURE SIDEKICKS LIQUID PA pediatric nutrition, iron, lactose free with fiber PEDIASURE WITH FIBER LIQUID PA pediatric nutrition, iron, lactose free with fiber
pediatric balanced nutritn liq PA
pediatric drink with fiber liq PA
PEDIATRIC PEPTIDE 1.0 LIQUID PA nutritional supplement/fiber PEDIATRIC PEPTIDE FORMULA 1.5 PA nutritional supplement/fiber PEDIATRIC STANDARD FORMULA 1.2 PA nutritional supplement/fiber PEPTAMEN AF LIQUID PA nutritional supplement no.1/fructooligosaccharides/inulin PEPTAMEN JUNIOR 1 CAL LIQUID PA nutritional supplement PEPTAMEN JUNIOR FIBER 1 CAL LQ PA nutritional supplement/inulin/fructooligosaccharides/fiber PEPTAMEN JUNIOR HP 1.2 CAL LIQ PA nutritional supplement/inulin/fructooligosaccharides PEPTAMEN JUNIOR-PREBIO1 LIQUID PA nutritional supplement/inulin/fructooligosaccharides PEPTIDE 1.0 LIQUID PA nutritional supplement/fiber PEPTIDE 1.5 LIQUID PA nutritional supplement/fiber PEPTIDE FORMULA 1.5 LIQUID PA nutritional supplement/fiber PERRY PRENATAL CAPSULE AL1 13 to 50 yrs old prenatal vits with calcium 36/ferrous fumarate/folic acid pharm chc ped iron 15mg/ml drp
PAGE 123 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS pharm choice poly-vit-iron drp pnv prenatal plus multivit tab poly-iron 150 mg capsule POLY-VI-SOL 250MCG-50MG/ML DRP pediatric multivitamin no.192 POLY-VI-SOL WITH IRON DROPS pediatric multivitamin no.189/ferrous sulfate PRENATABS FA TABLET prenatal vits with calcium no.78/ferrous fumarate/folic acid PRENATABS RX TABLET prenatal vitamin with calcium no.76/iron,carbonyl/folic acid
prenatal caplet AL1 13 to 50 yrs old
prenatal complete caplet AL1 13 to 50 yrs old
prenatal formula tablet AL1 13 to 50 yrs old
PRENATAL FORMULA-DHA SOFTGEL AL1 13 to 50 yrs old prenatal vitamins no.116/iron fumarate/folic acid/dha
prenatal gummies AL1 13 to 50 yrs old
prenatal low iron tablet
prenatal multi tablet AL1 13 to 50 yrs old
prenatal multivitamin tablet AL1 13 to 50 yrs old
prenatal multivitamin tablet AL1 13 to 50 yrs old
prenatal one daily tablet AL1 13 to 50 yrs old
prenatal plus iron tablet
prenatal tablet AL1 13 to 50 yrs old
prenatal tablet AL1 13 to 50 yrs old
prenatal tablet AL1 13 to 50 yrs old
prenatal tablet AL1 13 to 50 yrs old
prenatal tablet AL1 13 to 50 yrs old
prenatal tablet AL1 13 to 50 yrs old
prenatal tablet AL1 13 to 50 yrs old
PAGE 124 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
prenatal tablet AL1 13 to 50 yrs old
prenatal vitamin plus low iron AL1 13 to 50 yrs old
prenatal vitamin tablet AL1 13 to 50 yrs old
prenatal vitamin tablet AL1 13 to 50 yrs old
prenatal vitamins tablet AL1 13 to 50 yrs old
prenatal-u capsule PREOP POWDER PACKET PA maltodextrin/fructose
GL Female preplus ca-fe 27 mg-fa 1 mg tb AL1 13 to 50 yrs old
PROMOD LIQUID PROTEIN PA protein supplement PROMOTE LIQUID PA nutritional supplement PROMOTE WITH FIBER LIQUID PA nutritional supplement/fiber
prosource protein powder PA
protein 80% powder PA
protein 90% powder PA
protein powder PA
pyridoxine 25 mg tablet pyridoxine 50 mg tablet qc calcium 600-vit d3 400 tab
qc complete nutritional drink PA
qc prenatal tablet AL1 13 to 50 yrs old
quinoa-kale-hemp puree blend PA
ra calcium 600 mg tablet ra calcium 600-vit d3 400 tab ra calcium citrate - vit d tab ra folic acid 0.4 mg tablet
PAGE 125 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS ra folic acid 800 mcg tablet ra hi-cal plus vitamin d tab ra iron 65 mg tablet ra oyster shell 500-vit d3 200
ra prenatal formula tablet AL1 13 to 50 yrs old
ra prenatal tablet AL1 13 to 50 yrs old
ra vitamin b-1 100 mg tablet ra vitamin b-1 100 mg tablet ra vitamin b-12 100 mcg tablet ra vitamin b-6 100 mg tablet ra vitamin b-6 50 mg tablet
re-gen liquid PA
rena-vite rx tablet rena-vite tablet
replete 1 cal liquid PA
REPLETE WITH FIBER LIQUID PA nutritional supplement/inulin/fructooligosaccharides/fiber RESOURCE 2.0 LIQUID PA nutritional supplement ringers irrigation solution
salmon-oats-squash puree blend PA
scandishake powder PA
scandishake single-serv env PA
se-natal 19 chewable tablet sm cal cit 315 mg-d3 250 unit sm calcium 500 mg tablet sm calcium 500-vit d3 200 cplt sm calcium 500-vit d3 400 tab sm calcium 600 mg tablet sm calcium 600-vit d3 400 tab
PAGE 126 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS sm calcium cit 315-d3 6.5 mcg sm folic acid 0.4 mg tablet sm folic acid 400 mcg tablet sm iron 325 mg tablet sm iron 65 mg tablet sm magnesium 250 mg tablet
sm nutritional liquid PA
sm prenatal tablet AL1 13 to 50 yrs old
sm prenatal vitamins tablet AL1 13 to 50 yrs old
sm vitamin b-1 100 mg tablet sm vitamin b-12 100 mcg tablet sm vitamin b-12 500 mcg tablet sm vitamin b-6 100 mg tablet sodium chloride 0.9% (pwr inj) sodium chloride 0.9% irrig. sodium chloride 0.9% syringe sodium chloride 0.9% zr syr
sodium fluoride 0.5 mg/ml drop AL1 Up to 16 yrs old
SOL CARB POWDER PA maltodextrin STANDARD 1.4 LIQUID PA nutritional supplement/fiber STANDARD FORMULA 1.0 LIQUID PA nutritional supplement/fiber super calcium 600 mg tablet super calcium 600-vit d3 400 sv calcium 600 mg tablet sv calcium citrate-vit d3 tab sv fish oil ec 1,200 mg softgl sv folic acid 800 mcg tablet sv iron 65 mg tablet
PAGE 127 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS sv magnesium oxide 400 mg tab
sv prenatal tablet AL1 13 to 50 yrs old
sv prenatal vitamins tablet AL1 13 to 50 yrs old
sv vitamin b-12 500 mcg tablet sv vitamin b-6 100 mg tablet thiamine 100 mg tablet TRI-VI-SOL DROPS vitamin a palmitate/ascorbic acid/cholecalciferol (vit d3) tri-vit-fluor 0.25 mg/ml drop tri-vit-fluor 0.5 mg/ml drop tri-vite-fluoride 0.25 mg/ml tri-vite-fluoride 0.5 mg/ml TRINATE TABLET prenatal vits with calcium no.73/ferrous fumarate/folic acid
turkey-sweet potatoes-peaches PA
TWOCAL HN LIQUID PA nut.supplement,special formula,lactose-free with iron/fos
ultramino powder PA
ULTRIENT 1.5 LIQUID WITH ENFIT PA nutritional supplement vinate one tablet vinate-m tablet vit a,c,d-fluoride 0.25 mg/ml vit a,c,d-fluoride 0.5 mg/ml VITAFOL-OB CAPLET prenatal vits with calcium no.10/ferrous fumarate/folic acid VITAL HIGH NITROGEN PACKET PA lactose-reduced food vitamin b-1 100 mg tablet vitamin b-1 100 mg tablet vitamin b-12 1,000 mcg tablet vitamin b-12 100 mcg tablet
PAGE 128 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS vitamin b-12 2,500 mcg tab sl vitamin b-12 500 mcg tablet vitamin b-6 100 mg tablet vitamin b-6 25 mg tablet vitamin b-6 50 mg tablet vitamin b12 500 mcg tablet
GL Female westab plus tablet AL1 13 to 50 yrs old
GASTROINTESTINAL AGENTS
ANTI-CONSTIPATION AGENTS
alophen pills bisa-lax ec 5 mg tablet bisacodyl 10 mg suppository bisacodyl ec 5 mg tablet child glycerin suppository clearlax powder col-rite 250 mg softgel constulose 10 gm/15 ml soln cvs bisacodyl 10 mg suppos cvs bisacodyl ec 5 mg tablet cvs daily fiber 0.52 gram cap cvs fiber 0.52 g capsule cvs fiber therapy capsule cvs gentle laxative 10 mg supp cvs gentle laxative ec 5 mg tb cvs glycerin suppository cvs glycerin suppository cvs laxative 25 mg tablet cvs laxative pills cvs milk of magnesia susp
PAGE 129 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS cvs natural daily fiber powder cvs purelax powder cvs senna laxative 8.6 mg tab cvs senna plus tablet cvs stool softener 100 mg cap cvs stool softener 100 mg sftg cvs stool softener 250 mg sfgl cvs stool softener-laxative tb cvs stool softener-stim lax tb daily fiber capsule docusate sodium 100 mg capsule docusate sodium 100 mg softgel docusate sodium 250 mg capsule docusate sodium 250 mg softgel docusil 100 mg softgel docuzen 8.6-50 mg tablet DOK 100 MG SOFTGEL docusate sodium DOK 250 MG SOFTGEL docusate sodium dok plus tablet dss 250 mg softgel ducodyl ec 5 mg tablet dulcoease 100 mg softgel dulcolax ss 100 mg softgel enulose 10 gm/15 ml solution eq clearlax powder eq daily fiber 0.52 gram cap eq fiber therapy 0.52 gram cap eq gentle laxative dr 5 mg tab eq max str laxative pill
PAGE 130 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS eq milk of magnesia suspension eq natural laxative 8.6 mg tab eq senna-s tablet eq stool softener 100 mg sftgl eq stool softener-stim lax tab eq vegetable laxative tablet eql clearlax powder eql fiber therapy powder eql fiber therapy powder eql gentle laxative ec 5 mg tb eql laxative 25 mg tablet eql milk of magnesia susp eql senna laxative 8.6 mg tab eql senna-s tablet eql stool softener 100 mg sfgl eql stool softener-stim lax tb evac-u-gen 8.6 mg tablet fiber laxative capsule fiber powder fiber therapy powder fiber therapy powder fleet bisacodyl ec 5 mg tab gavilax powder generlac 10 gm/15 ml solution gentle laxative 10 mg supp gentle laxative 10 mg supposit gentle laxative 5 mg tablet gentle laxative ec 5 mg tablet gentlelax powder geri-kot 8.6 mg tablet
PAGE 131 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS geri-mucil powder geri-mucil powder geri-mucil powder glycerin adult suppository glycerin adult suppository glycerin pediatric suppository glycerin suppository glycerin suppository gnp bisa-lax ec 5 mg tablet gnp clearlax powder gnp gentle laxative 10 mg supp gnp gentle laxative ec 5 mg tb gnp glycerin suppository gnp glycerin suppository gnp laxative ec 5 mg tablet gnp milk of magnesia susp gnp natural fiber powder gnp natural fiber powder gnp senna lax 8.6 mg tablet gnp senna plus 8.6-50 mg tab gnp senna plus tablet gnp stool softener 100 mg sfgl gnp stool softener 250 mg sfgl gnp stool softener-stim lax tb gs clearlax powder gs milk of magnesia suspension gs senna laxative 8.6 mg tab gs stool softener 100 mg sftgl hm clearlax powder hm fiber powder
PAGE 132 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS hm gentle laxative 10 mg supp hm laxative ec 5 mg tablet hm milk of magnesia suspension hm senna 8.6 mg tablet hm senna-s tablet hm stool softener 100 mg sftgl hm stool softener 250 mg sftgl hm stool softener-laxative tab hm stool softener-stim lax tab hv milk of magnesia suspension infant & child glycerin suppos konsyl 520 mg capsule konsyl psyllium fiber powder KRISTALOSE 10 GM PACKET lactulose KRISTALOSE 20 GM PACKET lactulose kro gentle laxative ec 5 mg tb kro gentlelax 17 gram powder kro milk of magnesia susp kro stool softener 100 mg sfgl lactulose 10 gm/15 ml solution lactulose 20 gm/30 ml solution laxa basic 100 mg softgel laxaclear powder laxative 15 mg pills laxative 15 mg tablet laxative 25 mg pills laxative 25 mg tablet laxative 5 mg tablet laxative ec 5 mg tablet
PAGE 133 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS laxative feminine 5 mg tab laxative max strength pill magic bullet 10 mg suppos metamucil powder milk of magnesia suspension natural fiber lax powder natural fiber laxative powder natural fiber powder natural fiber powder natural laxative 8.6 mg tablet peg3350 100-7.5-2.691-1.01-5.9 phillips' lax liqui-gels polyethylene glycol 3350 powd powderlax powder psyllium fiber 0.52 g capsule psyllium fiber capsule psyllium seed powder pub docusate sodium 100 mg cap pub fiber capsule pub laxative ec 5 mg tablet pub milk of magnesia susp qc gentle laxative 10 mg supp qc laxative 25 mg tablet qc milk of magnesia suspension qc natura-lax 17 gm powder qc natural veg laxative tablet qc stool softener 100 mg sftgl qc stool softener-laxative tab qc women's laxative ec 5 mg tb ra bisacodyl ec 5 mg tablet
PAGE 134 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS ra col-rite 100 mg capsule ra col-rite 100 mg softgel ra col-rite 250 mg softgel ra fiber capsule ra fiber therapy capsule ra glycerin adult suppository ra glycerin pediatric supp ra laxative 25 mg pill ra laxative ec 5 mg tablet ra laxative peg 3350 powder ra milk of magnesia suspension ra multihealth fiber powder ra p-col rite tablet ra senna 8.6 mg tablet ra senna plus tablet ra senna-lax 8.6 mg tablet ra stool softener 100 mg cap ra women's laxative tablet reguloid capsule reguloid laxative powder reguloid powder reguloid powder REGULOID POWDER psyllium husk (with sugar) sen-o-tab senexon-s 50-8.6 mg tablet senna 8.6 mg tablet senna 8.8 mg/5 ml liquid senna 8.8 mg/5 ml syrup senna lax 8.6 mg tablet senna laxative 8.6 mg tablet
PAGE 135 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS senna plus 8.6-50 mg tablet senna plus tablet senna-lax 8.6 mg tablet senna-s 8.6-50 mg tablet senna-s laxative tablet senna-s tablet senna-time 8.6 mg tablet senna-time s tablet senno tablet sennosides-docusate sodium tab sm clearlax powder sm fiber capsule sm fiber powder sm gentle laxative ec 5 mg tab sm glycerin adult suppository sm glycerin pediatric suppo sm laxative tablet sm milk of magnesia suspension sm senna laxative 8.6 mg tab sm senna-s tablet sm stool softener 100 mg sftgl sm stool softener 250 mg sftgl sm stool softener-laxative tab smoothlax powder sof-lax 100 mg gelcap stimulant laxative plus tablet stool softener 100 mg capsule STOOL SOFTENER 100 MG CAPSULE docusate sodium stool softener 100 mg softgel STOOL SOFTENER 100 MG SOFTGEL docusate sodium
PAGE 136 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS stool softener 250 mg softgel STOOL SOFTENER 250 MG SOFTGEL docusate sodium stool softener-laxative tablet stool softener-stim lax tablet SUPREP BOWEL PREP KIT sodium sulfate/potassium sulfate/magnesium sulfate sw clearlax powder wal-mucil 0.52 g capsule wal-mucil 100% natural fiber wal-mucil ntrl fiber lax powd womans laxative tablet women's laxative ec 5 mg tab ANTI-DIARRHEAL AGENTS
diphenoxylat-atrop 2.5-0.025/5 diphenoxylate-atrop 2.5-0.025 hm anti-diarrheal 2 mg softgel hm loperamide 2 mg softgel loperamide 2 mg capsule ANTISPASMODICS, GASTROINTESTINAL
chlordiazepoxide-clidinium cap dicyclomine 10 mg capsule dicyclomine 10 mg/5 ml soln dicyclomine 20 mg tablet ed-spaz 0.125 mg odt hyoscyamine 0.125 mg odt hyoscyamine 0.125 mg tab sl hyoscyamine 0.125 mg/5 ml elix hyoscyamine 0.125 mg/ml drop hyoscyamine er 0.375 mg tab hyoscyamine sr 0.375 mg tab
PAGE 137 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS hyoscyamine sulf 0.125 mg tab nulev 0.125 mg chewable melt oscimin 0.125 mg tablet oscimin sl 0.125 mg tablet oscimin sr 0.375 mg tablet propantheline 15 mg tablet symax-sr 0.375 mg tablet GASTROINTESTINAL AGENTS, OTHER
ALCALAK TABLET CHEWABLE calcium carbonate antacid 500 mg chew tablet antacid 500 mg chewable tablet antacid 750 mg chewable tablet antacid 750 mg chewable tablet antacid calcium 500 mg chw tab antacid ex str 750 mg chew tab antacid ex-str 750 mg tab chew antacid ex-str tablet chew ANTACID TABLET CHEW calcium carbonate antacid xtra strength chew tab anti-diarrheal 2 mg caplet anti-diarrheal 2 mg softgel anti-diarrheal 2 mg tablet ban-acid max str 750 chew tab bismatrol 525 mg/15 ml susp bismatrol 525 mg/30 ml susp bismatrol tablet chew bismuth 262 mg tablet chew cal-gest 500 mg tablet chew calcium antacid 1,000 mg tab
PAGE 138 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS calcium antacid 500 mg chw tab calcium antacid 750 mg tb chew calcium antacid 750 mg tb chew calcium antacid ex-str tablet calcium carb 500 mg tab chew calcium carbonate 648 mg tab calcium carbonate 750 mg chew child soothe 400 mg tab chew children pepto 400 mg tab chew cvs antacid 750 mg chew tablet cvs antacid ex-str 750 mg chew cvs antacid xtra str chew tab cvs anti-diarrheal 2 mg caplet cvs anti-diarrheal 2 mg sftgel cvs anti-diarrheal suspension cvs bismuth 262 mg caplet cvs bismuth chewable tablet cvs flavor chew antacid 750 mg cvs gas relief ex-str drops cvs inft gas rlf 20 mg/0.3 ml cvs kids antacid 750 mg chew cvs smooth antacid 750 mg chew cvs stomach relf 525 mg/30 ml cvs stomach relief max str liq cvs stomach rlf 262 mg chew tb diamode 2 mg tablet diarrhea relief 262 mg/15 ml diarrhea relief suspension digestive relief caplet diotame 262 mg tablet chew
PAGE 139 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS eq antacid 500 mg chew tablet eq antacid ex-str 750 mg chew eq antacid extra str chew tab eq anti-diarrheal 2 mg caplet eq anti-diarrheal 2 mg sftgel eq inf gas relief 20 mg/0.3 ml eq stomach relief 262 mg/15 ml eq stomach rlf 262 mg chew tab eql antacid 500 mg chew tablet eql antacid ex-str 750 mg chew eql anti-diarrheal 2 mg caplet eql gas relief drops eql stomach rlf 262 mg chew tb eql stomach rlf 262 mg/15 ml eql stomach rlf 525 mg/30 ml gas relief 20 mg/0.3 ml drops gas relief drops gas relief drops 20 mg/0.3 ml gavilyte-c solution gavilyte-g solution geri-pectate 262 mg/15 ml susp gnp antacid 500 mg chew tablet gnp antacid 750 mg chew tablet gnp antacid ex-str 750 mg chew gnp antacid xtra str chew tab gnp anti-diarrheal 2 mg caplet gnp anti-diarrheal 2 mg sftgel gnp infant gas relief drops gnp k-pec suspension gnp pink bismuth caplet
PAGE 140 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS gnp pink bismuth tablet chew gnp stomach rlf 262 mg/15 ml gs antacid 500 mg chewable tab gs anti-diarrheal 2 mg caplet gs cal antacid 500 mg chew tab gs cal antacid 750 mg chew tab gs simethicone 20 mg/0.3 ml gs stomach relief 525 mg/30 ml gs stomach rlf 262 mg chew tab hm antacid 500 mg chew tablet hm antacid ex-str 750 mg chew hm anti-diarrheal 2 mg caplet hm cal antacid 500 mg chew tab hm cal antacid 750 mg chew tab hm cal antacid 750 mg chew tab hm inf gas relief 20 mg/0.3 ml hm stomach relief 525 mg/30 ml hm stomach rlf 262 mg chew tab inf gas rel 20 mg/0.3 ml drop infant gas relief drops infant gas rlf 20 mg/0.3 ml infants' gas rlf 20 mg/0.3 ml infants' simethicone drops k-pec suspension KAOPECTATE 262 MG CAPLET bismuth subsalicylate kaopectate extra strength liq kro anti-diarrheal 2 mg caplet kro stomach rlf 262 mg chew tb kro stomach rlf 262 mg/15 ml little remedies gas relief drp
PAGE 141 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS loperamide 2 mg caplet loperamide 2 mg tablet peg 3350 electrolyte soln peg 3350-electrolyte solution peg-3350 and electrolytes soln peptic relief 262 mg chew tab pink bismuth 262 mg/15 ml susp pink bismuth caplet pink bismuth tablet chew pub antacid 500 mg chew tablet pub calcium antacid 750 mg pub calcium carb 1,000 mg tab pub infants' gas relief drops pub pink bismuth max str liq pub stomach rlf 262 mg chew tb pub stomach rlf 262 mg/15 ml qc antacid 500 mg chew tablet qc antacid xtra str chew tab qc anti-diarrheal 2 mg caplet qc anti-diarrheal 2 mg softgel qc diarrhea rlf 262 mg/15 ml qc pink bismuth 262 mg caplet qc pink bismuth tablet chew ra antacid 1,000 mg chew tab ra antacid 500 mg chewable tab ra anti-diarrheal 2 mg caplet ra anti-diarrheal 2 mg softgel ra pink bismuth 262 mg/15 ml ra pink bismuth caplet ra pink bismuth tablet chew
PAGE 142 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS ra stomach relief 262 mg/15 ml ra stomach relief max str liq sm antacid 500 mg chew tablet sm antacid 750 mg chew tablet sm antacid xtra str chew tab sm anti-diarrheal 2 mg caplet sm anti-diarrheal 2 mg softgel sm cal antacid 500 mg chew tab sm cal antacid 750 mg chew tab sm cal antacid 750 mg chew tab sm inf gas relief 20 mg/0.3 ml sm stomach relief 262 mg/15 ml sm stomach relief 525 mg/30 ml sm stomach relief max str liq sm stomach rlf 262 mg chew tab soothe 262 mg caplet soothe 262 mg chewable tablet soothe 262 mg/15 ml suspension soothe regular strength susp soothe suspension stomach relief 262 mg chew tab stomach relief 262 mg/15 ml stomach relief max str liquid stomach rlf 262 mg/15 ml susp stomach rlf 525 mg/30 ml susp ultra a-d 2 mg caplet ursodiol 250 mg tablet ursodiol 300 mg capsule ursodiol 500 mg tablet
PAGE 143 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
acid control 150 mg tablet
acid control 75 mg tablet QL 60 / 30 DAYS
acid controller 10 mg tablet QL 60 tablets / 30 days
acid controller 20 mg tablet QL 60 tablets / 30 days
acid reducer 10 mg tablet QL 60 tablets / 30 days
acid reducer 150 mg tablet
acid reducer 20 mg tablet QL 60 tablets / 30 days
acid reducer 75 mg tablet QL 60 tablets / 30 days
cimetidine 200 mg tablet cimetidine 300 mg tablet cimetidine 300 mg/5 ml soln cimetidine 400 mg tablet cimetidine 400 mg/6.67 ml soln cimetidine 800 mg tablet
cvs acid controller 10 mg tab QL 60 tablets / 30 days
cvs acid controller 20 mg tab QL 60 tablets / 30 days
cvs acid reducer 150 mg tablet
cvs acid reducer 75 mg tablet QL 60 tablets / 30 days
cvs cimetidine 200 mg tablet cvs heartburn relief 200 mg tb
cvs ranitidine 75 mg tablet QL 60 tablets / 30 days
eq acid reducer 10 mg tablet QL 60 tablets / 30 days
eq acid reducer 150 mg tablet
eq acid reducer 20 mg tablet QL 60 tablets / 30 days
eq acid reducer 200 mg tablet
eq famotidine 10 mg tablet QL 60 tablets / 30 days
eq famotidine 20 mg tablet QL 60 tablets / 30 days
PAGE 144 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
eq ranitidine 150 mg tablet QL 60 tablets / 30 days
eq ranitidine 75 mg tablet QL 60 tablets / 30 days
eql acid reducer 150 mg tablet
eql acid reducer 75 mg tablet QL 60 tablets / 30 days
eql heartburn preven 20 mg tab QL 60 tablets / 30 days
eql heartburn prevention tab QL 60 tablets / 30 days
eql heartburn relief 75 mg tab QL 60 tablets / 30 days
famotidine 10 mg tablet QL 60 tablets / 30 days
famotidine 20 mg tablet QL 60 tablets / 30 days
famotidine 40 mg tablet famotidine 40 mg/5 ml susp famotidine 40 mg/5 ml susp gnp acid control 150 mg tablet
gnp acid reducer 10 mg tablet QL 60 tablets / 30 days
gnp acid reducer 20 mg tablet QL 60 tablets / 30 days
gnp acid reducer 75 mg tablet QL 60 tablets / 30 days
gnp cimetidine 200 mg tablet
gs acid reducer 10 mg tablet QL 60 tablets / 30 days
gs acid reducer 150 mg tablet
gs acid reducer 20 mg tablet QL 60 tablets / 30 days
gs acid reducer 75 mg tablet QL 60 tablets / 30 days
heartburn relief 10 mg tablet QL 60 tablets / 30 days
heartburn relief 150 mg tab heartburn relief 150 mg tablet
heartburn relief 20 mg tablet QL 60 tablets / 30 days
heartburn relief 200 mg tablet
hm acid reducer 75 mg tablet QL 60 tablets / 30 days
PAGE 145 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
hm famotidine 10 mg tablet QL 60 tablets / 30 days
hm famotidine 20 mg tablet QL 60 tablets / 30 days
kro heartburn preven 20 mg tab QL 60 tablets / 30 days
kro heartburn prevention tab QL 60 tablets / 30 days
kro heartburn relief 150 mg tb nizatidine 15 mg/ml solution nizatidine 150 mg capsule nizatidine 300 mg capsule
pub acid reducer 10 mg tablet QL 60 tablets / 30 days
pub famotidine 20 mg tablet QL 60 tablets / 30 days
pub ranitidine 150 mg tablet QL 60 tablets / 30 days
qc acid controller 10 mg tab QL 60 tablets / 30 days
ra acid reducer 10 mg tablet QL 60 tablets / 30 days
ra acid reducer 150 mg tablet
ra acid reducer 20 mg tablet QL 60 tablets / 30 days
ranitidine 15 mg/ml syrup ranitidine 150 mg capsule
ranitidine 150 mg tablet QL 60 tablets / 30 days
ranitidine 150 mg/10 ml syrup ranitidine 300 mg capsule ranitidine 300 mg tablet
ranitidine 75 mg tablet QL 60 tablets / 30 days
sm acid reducer 10 mg tablet QL 60 tablets / 30 days
sm acid reducer 150 mg tablet
sm acid reducer 20 mg tablet QL 60 tablets / 30 days
sm acid reducer 200 mg tablet
sm acid reducer 75 mg tablet QL 60 tablets / 30 days
PAGE 146 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS sm heartburn relief 200 mg tab sw acid reducer 150 mg tablet wal-zan 150 mg tablet
wal-zan 75 mg tablet QL 60 tablets / 30 days
PROTECTANTS
sucralfate 1 gm tablet sucralfate 1 gm/10 ml susp PROTON PUMP INHIBITORS
lansoprazole dr 30 mg capsule QL 30 capsules / 30 days
omeprazole dr 10 mg capsule QL 30 capsules / 30 days
omeprazole dr 20 mg capsule QL 60 capsules / 30 days
omeprazole dr 40 mg capsule QL 60 / 30 DAYS
pantoprazole sod dr 20 mg tab QL 30 tablets / 30 days
pantoprazole sod dr 40 mg tab QL 60 / 30 DAYS
GENETIC OR ENZYME OR PROTEIN DISORDER: REPLACEMENT, MODIFIERS, TREATMENT
CREON DR 12,000 UNITS CAPSULE lipase/protease/amylase CREON DR 24,000 UNITS CAPSULE lipase/protease/amylase CREON DR 3,000 UNITS CAPSULE lipase/protease/amylase CREON DR 36,000 UNITS CAPSULE lipase/protease/amylase CREON DR 6,000 UNITS CAPSULE lipase/protease/amylase CYSTAGON 150 MG CAPSULE S Specialty Drug cysteamine bitartrate CYSTAGON 50 MG CAPSULE S Specialty Drug cysteamine bitartrate
ENDARI 5 GRAM POWDER PACKET QL 180 / 30 day(s) glutamine ST
PAGE 147 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 14 / 28 DAYS GALAFOLD 123 MG CAPSULE PA migalastat hcl S Specialty Drug
PALYNZIQ 10 MG/0.5 ML SYRINGE PA pegvaliase-pqpz S Specialty Drug
PALYNZIQ 2.5 MG/0.5 ML SYRINGE PA pegvaliase-pqpz S Specialty Drug
PALYNZIQ 20 MG/ML SYRINGE PA pegvaliase-pqpz S Specialty Drug
PA sapropterin 100 mg powder pkt S Specialty Drug
PA sapropterin 100 mg tablet S Specialty Drug
PA sapropterin 500 mg powder pkt S Specialty Drug
QL 120 / 30 DAYS VYNDAQEL 20 MG CAPSULE PA tafamidis meglumine S Specialty Drug
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
flavoxate hcl 100 mg tablet oxybutynin 5 mg tablet oxybutynin 5 mg/5 ml syrup oxybutynin cl er 10 mg tablet oxybutynin cl er 15 mg tablet
oxybutynin cl er 5 mg tablet QL 30 tablets / 30 days
solifenacin 10 mg tablet ST
solifenacin 5 mg tablet ST
tolterodine tart er 2 mg cap
PAGE 148 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS tolterodine tart er 4 mg cap tolterodine tartrate 1 mg tab tolterodine tartrate 2 mg tab trospium chloride 20 mg tablet BENIGN PROSTATIC HYPERTROPHY AGENTS
alfuzosin hcl er 10 mg tablet dutasteride 0.5 mg capsule finasteride 5 mg tablet tamsulosin hcl 0.4 mg capsule GENITOURINARY AGENTS, OTHER
bethanechol 10 mg tablet bethanechol 25 mg tablet bethanechol 5 mg tablet bethanechol 50 mg tablet cvs urinary pain rlf 95 mg tab cvs urinary pain rlf 97.5mg tb ELMIRON 100 MG CAPSULE pentosan polysulfate sodium eq urinary pain rlf 95 mg tab gnp urinary pain rlf 95 mg tab gnp urinary pain rlf 97.5 mg gynol ii 3% gel hm urinary pain rlf 95 mg tab K-PHOS #2 TABLET sodium phosphate,monobasic/potassium phosphate,monobasic K-PHOS NEUTRAL TABLET sodium phosphate,dibasic/pot phos,monob/sod phosphate mono K-PHOS ORIGINAL TABLET potassium phosphate,monobasic phenazopyridine 100 mg tab phenazopyridine 200 mg tab phospha 250 neutral tablet
PAGE 149 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS qc urinary pain rlf 95 mg tab ra urinary pain rlf 95 mg tab RENACIDIN IRRIGATION SOLUTION citric acid/gluconolactone/magnesium carbonate sm urinary pain rel 97.5 mg tb sm urinary pain rlf 95 mg tab urinary pain relief 95 mg tab urinary pain relief 97.5 mg tb vcf contraceptive foam vcf contraceptive gel HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
anti-itch 1% cream betamethasone dp 0.05% oint betamethasone dp aug 0.05% crm betamethasone va 0.1% cream cormax 0.05% solution cortizone-10 1% creme cortizone-10 1% ointment cortizone-10 plus 1% creme cortizone-10 plus creme cvs anti-itch 1% cream cvs cortisone 1% cream cvs cortisone with aloe 1% crm desonide 0.05% cream dexamethasone 0.5 mg tablet dexamethasone 0.5 mg/5 ml elx dexamethasone 0.5 mg/5 ml liq dexamethasone 0.75 mg tablet dexamethasone 1 mg tablet dexamethasone 1.5 mg tablet dexamethasone 10 mg/ml vial
PAGE 150 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS dexamethasone 100 mg/10 ml vl dexamethasone 120 mg/30 ml vl dexamethasone 2 mg tablet dexamethasone 20 mg/5 ml vial dexamethasone 4 mg tablet dexamethasone 4 mg/ml vial dexamethasone 6 mg tablet dexamethasone intensol 1 mg/ml eql anti-itch 1% cream eql anti-itch 1% ointment fludrocortisone 0.1 mg tablet fluocinonide 0.05% cream gnp hydrocort acetate 1% cr gnp hydrocortisone 0.5% crm gs anti-itch 1% cream hydrocortisone 0.5% cream hydrocortisone 0.5% cream hydrocortisone 0.5% ointment hydrocortisone 1% cream hydrocortisone 1% ointment hydrocortisone butyr 0.1% oint methylprednisolone 16 mg tab methylprednisolone 32 mg tab methylprednisolone 4 mg dosepk methylprednisolone 4 mg tablet methylprednisolone 8 mg tab mometasone furoate 0.1% soln noble formula hc 1% cream prednisolone 15 mg/5 ml soln prednisolone 15 mg/5 ml soln
PAGE 151 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS prednisolone 15 mg/5 ml syrup prednisolone 5 mg/5 ml soln prednisolone sod ph 25 mg/5 ml prednisone 1 mg tablet prednisone 10 mg tab dose pack prednisone 10 mg tablet prednisone 2.5 mg tablet prednisone 20 mg tablet prednisone 5 mg tab dose pack prednisone 5 mg tablet prednisone 5 mg/5 ml solution prednisone 50 mg tablet prednisone intensol 5 mg/ml preparation h hc 1% cream pub hydrocream 1% qc anti-itch 1% cream ra anti-itch 1% cream ra anti-itch 1% ointment sm hydrocortisone 0.5% ointmnt HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
desmopressin 0.01% solution PA
desmopressin 0.01% spray PA
desmopressin 0.1 mg/ml sol PA
desmopressin 10 mcg/0.1 ml spr PA
desmopressin acetate 0.1 mg tb PA
desmopressin acetate 0.2 mg tb PA
INCRELEX 40 MG/4 ML VIAL PA mecasermin S Specialty Drug
NORDITROPIN FLEXPRO 10 MG/1.5 PA somatropin S Specialty Drug
PAGE 152 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
NORDITROPIN FLEXPRO 15 MG/1.5 PA somatropin S Specialty Drug
NORDITROPIN FLEXPRO 30 MG/3 ML PA somatropin S Specialty Drug
NORDITROPIN FLEXPRO 5 MG/1.5 PA somatropin S Specialty Drug
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PROSTAGLANDINS)
misoprostol 100 mcg tablet misoprostol 200 mcg tablet HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANABOLIC STEROIDS
oxandrolone 10 mg tablet PA
oxandrolone 2.5 mg tablet PA
ANDROGENS
danazol 100 mg capsule danazol 200 mg capsule danazol 50 mg capsule testosteron cyp 1,000 mg/10 ml testosteron cyp 2,000 mg/10 ml testosteron enan 1,000 mg/5 ml
QL 300 / 30 DAYS testosterone 1% (50 mg/5 g) pk ST
QL 300 / 30 DAYS testosterone 50 mg/5 gram gel ST
QL 300 / 30 DAYS testosterone 50 mg/5 gram pkt ST
testosterone cyp 1,000 mg/5 ml testosterone cyp 100 mg/ml testosterone cyp 200 mg/ml
PAGE 153 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS testosterone cyp 500 mg/2.5 ml testosterone cyp 500 mg/5 ml testosterone cyp 6,000 mg/30ml testosterone enan 200 mg/ml ESTROGENS
afirmelle-28 tablet altavera-28 tablet alyacen 1-35 28 tablet alyacen 7-7-7-28 tablet amethia 0.15-0.03-0.01 mg tab amethia lo tablet amethyst 90-20 mcg tablet apri 28 day tablet aranelle 28 tablet ashlyna 0.15-0.03-0.01 mg tab aubra eq-28 tablet aubra-28 tablet aurovela 1 mg-20 mcg tablet aurovela 21 1.5-30 tablet aurovela 24 fe 1 mg-20 mcg tab aurovela fe 1-20 tablet aurovela fe 1.5 mg-30 mcg tab aviane-28 tablet ayuna-28 tablet azurette 28 day tablet balziva 28 tablet bekyree 28 day tablet blisovi 24 fe tablet blisovi fe 1-20 tablet blisovi fe 1.5-30 tablet
PAGE 154 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS briellyn tablet camrese 0.15-0.03-0.01 mg tab camrese lo tablet caziant 28 day tablet chateal eq-28 tablet chateal-28 tablet cryselle-28 tablet cyclafem 1-35-28 tablet cyclafem 7-7-7-28 tablet cyred 28 day tablet cyred eq 28 day tablet dasetta 1-35-28 tablet dasetta 7/7/7-28 tablet daysee 0.15-0.03-0.01 mg tab delyla-28 tablet desogestr-eth estrad eth estra desogestrel-ee 0.15-0.03 mg tb desogestrel-ethinyl estrad tab dolishale 90-20 mcg tablet
dotti 0.025 mg patch QL 8 / 28 DAYS
dotti 0.0375 mg patch QL 8 / 28 DAYS
dotti 0.05 mg patch QL 8 / 28 DAYS
dotti 0.075 mg patch QL 8 / 28 DAYS
dotti 0.1 mg patch QL 8 / 28 DAYS
drosp-ee-levomef 3-0.02-0.451 drosp-ee-levomef 3-0.03-0.451 drospirenone-ee 3-0.02 mg tab drospirenone-ee 3-0.03 mg tab elinest-28 tablet
PAGE 155 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS eluryng vaginal ring emoquette 28 day tablet enpresse-28 tablet enskyce 28 tablet estarylla 0.25-0.035 mg tablet estradiol 0.01% cream
estradiol 0.025 mg patch QL 8 / 28 day(s)
estradiol 0.025 mg patch(1/wk) QL 4 / 28 DAYS
estradiol 0.025 mg patch(2/wk) QL 8 / 28 day(s)
estradiol 0.0375mg patch(1/wk) QL 4 / 28 DAYS
estradiol 0.0375mg patch(2/wk) QL 8 / 28 day(s)
estradiol 0.05 mg patch (1/wk) QL 4 patches / 28 days
estradiol 0.05 mg patch (2/wk) QL 8 / 28 day(s)
estradiol 0.06 mg patch (1/wk) QL 4 / 28 DAYS
estradiol 0.075 mg patch(1/wk) QL 4 / 28 DAYS
estradiol 0.075 mg patch(2/wk) QL 8 / 28 day(s)
estradiol 0.1 mg patch (1/wk) QL 4 patches / 28 days
estradiol 0.1 mg patch (2/wk) QL 8 / 28 day(s)
estradiol 0.5 mg tablet estradiol 1 mg tablet estradiol 10 mcg vaginal insrt estradiol 2 mg tablet estradiol valerate 100 mg/5 ml estradiol valerate 200 mg/5 ml ethynodiol-eth estra 1mg-35mcg ethynodiol-eth estra 1mg-50mcg etonogestrel-ee vaginal ring falmina-28 tablet
PAGE 156 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS fayosim tablet femynor 28 tablet fyavolv 0.5 mg-2.5 mcg tablet fyavolv 1 mg-5 mcg tablet gianvi 3 mg-0.02 mg tablet gildagia 0.4 mg-0.035 mg tab gildess 1.5 mg-30 mcg tablet hailey 21 1.5 mg-30 mcg tab hailey 24 fe 1 mg-20 mcg tab hailey fe 1-20 tablet hailey fe 1.5-30 tablet iclevia 0.15 mg-0.03 mg tablet introvale 0.15-0.03 mg tablet isibloom 28 day tablet jaimiess 0.15-0.03-0.01 mg tab jasmiel 3 mg-0.02 mg tablet jinteli 1 mg-5 mcg tablet jolessa 0.15 mg-0.03 mg tablet juleber 28 day tablet junel 1 mg-20 mcg tablet junel 1.5 mg-30 mcg tablet junel fe 1 mg-20 mcg tablet junel fe 1.5 mg-30 mcg tablet junel fe 24 tablet kaitlib fe 0.8-0.025mg chew tb kalliga 28 day tablet kariva 28 day tablet kelnor 1-35 28 tablet kelnor 1-50 tablet kimidess 28 day tablet
PAGE 157 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS kurvelo-28 tablet larin 1.5 mg-30 mcg tablet larin 21 1-20 tablet larin 24 fe 1 mg-20 mcg tablet larin fe 1-20 tablet larin fe 1.5-30 tablet larissia-28 tablet LAYOLIS FE CHEWABLE TABLET norethindrone-ethinyl estradiol/ferrous fumarate leena 28 tablet lessina-28 tablet levonest-28 tablet levono-e estrad 0.15-0.03-0.01 levonor-e estrad 0.1-0.02-0.01 levonor-eth estra 0.09-0.02 mg levonor-eth estrad 0.1-0.02 mg levonor-eth estrad 0.15-0.03 levonor-eth estrad 0.15-0.03 levonor-eth estrad triphasic levonorg 0.15mg-ee 20-25-30mcg levora-28 tablet lillow-28 tablet lo-zumandimine 3 mg-0.02 mg tb lojaimiess 0.1-0.02-0.01 tab lomedia 24 fe 1 mg-20 mcg tab lopreeza 0.5 mg-0.1 mg tablet loryna 3 mg-0.02 mg tablet low-ogestrel-28 tablet lutera-28 tablet
lyllana 0.025 mg patch QL 8 / 28 DAYS
lyllana 0.0375 mg patch QL 8 / 28 DAYS
PAGE 158 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
lyllana 0.05 mg patch QL 8 / 28 DAYS
lyllana 0.075 mg patch QL 8 / 28 DAYS
lyllana 0.1 mg patch QL 8 / 28 DAYS
marlissa-28 tablet melodetta 24 fe chewable tab mibelas 24 fe chewable tablet microgestin 21 1-20 tablet microgestin 21 1.5-30 tab MICROGESTIN 24 FE 1 MG-20 MCG norethindrone acetate-ethinyl estradiol/ferrous fumarate microgestin 24 fe 1 mg-20 mcg microgestin fe 1-20 tablet microgestin fe 1.5-30 tab mili 0.25-0.035 mg tablet mono-linyah 28 tablet mononessa 28 tablet myzilra-28 tablet necon 0.5-35-28 tablet nikki 3 mg-0.02 mg tablet noret-estr-fe 0.4-0.035(21)-75 noreth-ee-fe 1-0.02(21)-75 tab noreth-ee-fe 1-0.02(24)-75 chw noreth-ee-fe 1-0.02(24)-75 tab noreth-ee-fe 1.5-0.03mg(21)-75 norethin-ee 1.5-0.03 mg(21) tb norethin-estra-fe 0.8-0.025 mg norethin-eth estrad 1 mg-5 mcg norethind-eth estrad 0.5-2.5 norethind-eth estrad 1-0.02 mg norg-ee 0.18-0.215-0.25/0.025
PAGE 159 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS norg-ee 0.18-0.215-0.25/0.035 norg-ethin estra 0.25-0.035 mg norgestimate-ee 0.25-0.035 mg nortrel 0.5-35-28 tablet nortrel 1-35 21 tablet nortrel 1-35 28 tablet nortrel 7-7-7-28 tablet nylia 7-7-7-28 tablet ocella 3 mg-0.03 mg tablet orsythia-28 tablet philith 0.4-0.035 mg tablet pimtrea 28 day tablet pirmella 1-35 28 tablet pirmella 1-35-28 tablet pirmella 7-7-7-28 tablet portia-28 tablet PREMPHASE 0.625-5 MG TABLET estrogens, conjugated/medroxyprogesterone acetate previfem tablet quasense 0.15-0.03 mg tablet rajani 28 tablet reclipsen 28 day tablet rivelsa tablet setlakin 0.15 mg-0.03 mg tab simliya 28 day tablet simpesse 0.15-0.03-0.01 mg tab sprintec 28 day tablet sronyx 0.10-0.02 mg tablet syeda 28 tablet tarina 24 fe 1 mg-20 mcg tab tarina fe 1-20 eq tablet
PAGE 160 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS tarina fe 1-20 tablet tilia fe 28 tablet tri femynor 28 tablet tri-estarylla tablet tri-legest fe-28 day tablet tri-linyah tablet tri-lo-estarylla tablet tri-lo-marzia tablet tri-lo-mili tablet tri-lo-sprintec tablet tri-mili 28 tablet tri-previfem tablet tri-sprintec tablet tri-vylibra 28 tablet tri-vylibra lo tablet trinessa lo tablet trinessa tablet trivora-28 tablet velivet 28 day tablet vestura 3 mg-0.02 mg tablet vienva-28 tablet viorele 28 day tablet volnea 0.15-0.02-0.01 mg tab vyfemla 0.4 mg-0.035 mg tablet vylibra 28 tablet wera 0.5/0.035 mg 28 tablet wymzya fe 0.4-0.035 mg chew tb wymzya fe chewable tablet xulane 150-35 mcg/day patch yuvafem 10 mcg vaginal insert
PAGE 161 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS yuvafem 10 mcg vaginal tablet zafemy 150-35 mcg/day patch zarah tablet zenchent 0.4 mg-35 mcg tablet zovia 1-35 tablet zovia 1-35e tablet zumandimine 3 mg-0.03 mg tab HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS), OTHER
amabelz 0.5 mg-0.1 mg tablet amabelz 1 mg-0.5 mg tablet estradiol-noreth 0.5-0.1 mg tb estradiol-noreth 1-0.5 mg tab lopreeza 1 mg-0.5 mg tablet mimvey 1-0.5 mg tablet mimvey lo 0.5-0.1 mg tablet PROGESTINS
aftera 1.5 mg tablet QL 1 tablet / 30 days
camila 0.35 mg tablet deblitane 0.35 mg tablet DEPO-PROVERA 400 MG/ML VIAL medroxyprogesterone acetate
econtra ez 1.5 mg tablet QL 1 tablet / 30 days
econtra one-step 1.5 mg tablet QL 1 / 30 DAYS
ELLA 30 MG TABLET QL 1 tablet / 30 days ulipristal acetate errin 0.35 mg tablet
fallback solo 1.5 mg tablet QL 1 tablet / 30 days
heather 0.35 mg tablet incassia 0.35 mg tablet jencycla 0.35 mg tablet
PAGE 162 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS jolivette tablet KYLEENA 19.5 MG SYSTEM levonorgestrel
levonorgestrel 1.5 mg tablet QL 1 tablet / 30 days
LILETTA 52 MG SYSTEM levonorgestrel lyleq 0.35 mg tablet lyza 0.35 mg tablet medroxyprogesterone 10 mg tab
medroxyprogesterone 150 mg/ml QL 1 ml syringe / 90 days
medroxyprogesterone 150 mg/ml QL 1 ml vial / 90 days
medroxyprogesterone 2.5 mg tab medroxyprogesterone 5 mg tab megestrol 20 mg tablet megestrol 40 mg tablet megestrol acet 40 mg/ml susp megestrol acet 400 mg/10 ml MIRENA 52 MG SYSTEM levonorgestrel
my choice 1.5 mg tablet QL 1 / 30 day(s)
my way 1.5 mg tablet QL 1 tablet / 30 days
new day 1.5 mg tablet QL 1 / 30 DAYS
nora-be tablet norethindrone 0.35 mg tablet norethindrone 5 mg tablet norlyda 0.35 mg tablet norlyroc 0.35 mg tablet
opcicon one-step 1.5 mg tablet QL 1 tablet / 30 days
option 2 1.5 mg tablet QL 1 / 30 day(s)
progesterone 100 mg capsule
PAGE 163 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS progesterone 200 mg capsule progesterone 500 mg/10 ml vial sharobel 0.35 mg tablet SKYLA 13.5 MG SYSTEM levonorgestrel
take action 1.5 mg tablet QL 1 tablet / 30 days
TAKE ACTION 1.5 MG TABLET QL 1 tablet / 30 days levonorgestrel tulana 0.35 mg tablet SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
raloxifene hcl 60 mg tablet HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
EUTHYROX 100 MCG TABLET levothyroxine sodium EUTHYROX 112 MCG TABLET levothyroxine sodium EUTHYROX 125 MCG TABLET levothyroxine sodium EUTHYROX 137 MCG TABLET levothyroxine sodium EUTHYROX 150 MCG TABLET levothyroxine sodium EUTHYROX 175 MCG TABLET levothyroxine sodium EUTHYROX 200 MCG TABLET levothyroxine sodium EUTHYROX 25 MCG TABLET levothyroxine sodium EUTHYROX 50 MCG TABLET levothyroxine sodium EUTHYROX 75 MCG TABLET levothyroxine sodium EUTHYROX 88 MCG TABLET levothyroxine sodium levothyroxine 100 mcg tablet
PAGE 164 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS levothyroxine 112 mcg tablet levothyroxine 125 mcg tablet levothyroxine 137 mcg tablet levothyroxine 150 mcg tablet levothyroxine 175 mcg tablet levothyroxine 200 mcg tablet levothyroxine 25 mcg tablet levothyroxine 300 mcg tablet levothyroxine 50 mcg tablet levothyroxine 75 mcg tablet levothyroxine 88 mcg tablet LEVOXYL 100 MCG TABLET levothyroxine sodium LEVOXYL 112 MCG TABLET levothyroxine sodium LEVOXYL 125 MCG TABLET levothyroxine sodium LEVOXYL 137 MCG TABLET levothyroxine sodium LEVOXYL 150 MCG TABLET levothyroxine sodium LEVOXYL 175 MCG TABLET levothyroxine sodium LEVOXYL 200 MCG TABLET levothyroxine sodium LEVOXYL 25 MCG TABLET levothyroxine sodium LEVOXYL 50 MCG TABLET levothyroxine sodium LEVOXYL 75 MCG TABLET levothyroxine sodium LEVOXYL 88 MCG TABLET levothyroxine sodium
liothyronine sod 25 mcg tab QL 30 / 30 DAYS
liothyronine sod 5 mcg tab QL 120 / 30 DAYS
PAGE 165 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
liothyronine sod 50 mcg tab QL 60 / 30 DAYS
HORMONAL AGENTS, SUPPRESSANT (ADRENAL)
LYSODREN 500 MG TABLET mitotane HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
cabergoline 0.5 mg tablet ELIGARD 22.5 MG SYRINGE KIT S Specialty Drug leuprolide acetate ELIGARD 30 MG SYRINGE KIT S Specialty Drug leuprolide acetate ELIGARD 45 MG SYRINGE KIT S Specialty Drug leuprolide acetate ELIGARD 7.5 MG SYRINGE KIT S Specialty Drug leuprolide acetate
leuprolide 2wk 1 mg/0.2 ml kit S Specialty Drug
leuprolide 2wk 14 mg/2.8 ml kt S Specialty Drug
LUPRON DEPOT-PED 11.25 MG KIT S Specialty Drug leuprolide acetate LUPRON DEPOT-PED 15 MG KIT S Specialty Drug leuprolide acetate LUPRON DEPOT-PED 7.5 MG KIT S Specialty Drug leuprolide acetate HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole 10 mg tablet methimazole 5 mg tablet propylthiouracil 50 mg tablet IMMUNOLOGICAL AGENTS
ANGIOEDEMA AGENTS
HAEGARDA 2,000 UNIT VIAL PA c1 esterase inhibitor S Specialty Drug
HAEGARDA 3,000 UNIT VIAL PA c1 esterase inhibitor S Specialty Drug
PAGE 166 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 9 ML / 30 DAYS
icatibant 30 mg/3 ml syringe PA
S Specialty Drug
IMMUNOLOGICAL AGENTS, OTHER
ACTEMRA 162 MG/0.9 ML SYRINGE PA tocilizumab S Specialty Drug
ACTEMRA ACTPEN 162 MG/0.9 ML PA tocilizumab S Specialty Drug
QL 1 / 28 DAYS COSENTYX 150 MG/ML PEN INJECT PA secukinumab S Specialty Drug
QL 1 / 28 DAYS COSENTYX 150 MG/ML SYRINGE PA secukinumab S Specialty Drug
QL 2 / 28 DAYS COSENTYX 300 MG DOSE-2 PENS PA secukinumab S Specialty Drug
QL 2 / 28 DAYS COSENTYX 300 MG DOSE-2 SYRINGE PA secukinumab S Specialty Drug
QL 0.5 / 28 DAYS COSENTYX 75 MG/0.5 ML SYRINGE PA secukinumab S Specialty Drug
QL 2.28 / 28 day(s) DUPIXENT 200 MG/1.14 ML PEN PA dupilumab S Specialty Drug
QL 2.28 / 28 DAYS DUPIXENT 200 MG/1.14 ML SYRING PA dupilumab S Specialty Drug
QL 4 / 28 DAYS DUPIXENT 300 MG/2 ML PEN PA dupilumab S Specialty Drug
PAGE 167 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 4 / 28 DAYS DUPIXENT 300 MG/2 ML SYRINGE PA dupilumab S Specialty Drug
QL 1 / 28 DAYS ENSPRYNG 120 MG/ML SYRINGE PA satralizumab-mwge S Specialty Drug
OTEZLA 28 DAY STARTER PACK PA apremilast S Specialty Drug
OTEZLA STARTER PACK PA apremilast S Specialty Drug
RIDAURA 3 MG CAPSULE auranofin
SYNAGIS 100 MG/1 ML VIAL PA palivizumab S Specialty Drug
SYNAGIS 50 MG/0.5 ML VIAL PA palivizumab S Specialty Drug
IMMUNOSTIMULANTS
INTRON A 10 MILLION UNITS VIAL S Specialty Drug interferon alfa-2b,recomb. INTRON A 18 MILLION UNIT/3 ML S Specialty Drug interferon alfa-2b,recomb. INTRON A 18 MILLION UNITS VIAL S Specialty Drug interferon alfa-2b,recomb. INTRON A 25 MILLION UNIT/2.5ML S Specialty Drug interferon alfa-2b,recomb. INTRON A 50 MILLION UNITS VIAL S Specialty Drug interferon alfa-2b,recomb. IMMUNOSUPPRESSANTS
azathioprine 50 mg tablet
QL 1 / 28 DAYS CIMZIA 200 MG VIAL KIT PA certolizumab pegol S Specialty Drug
PAGE 168 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 1 / 28 DAYS CIMZIA 2X200 MG/ML SYRINGE KIT PA certolizumab pegol S Specialty Drug
QL 3 / 28 DAYS CIMZIA 2X200 MG/ML(X3)START KT PA certolizumab pegol S Specialty Drug
cyclosporine 100 mg capsule cyclosporine 25 mg capsule cyclosporine modified 100 mg cyclosporine modified 100mg/ml cyclosporine modified 25 mg cyclosporine modified 50 mg
QL 8 vials / 28 days ENBREL 25 MG KIT PA etanercept S Specialty Drug
QL 5 ml / 28 days ENBREL 25 MG/0.5 ML SYRINGE PA etanercept S Specialty Drug
QL 5 ml / 28 days ENBREL 25 MG/0.5 ML VIAL PA etanercept S Specialty Drug
QL 4 / 28 DAYS ENBREL 50 MG/ML MINI CARTRIDGE PA etanercept S Specialty Drug
QL 4 ml / 28 days ENBREL 50 MG/ML SURECLICK PA etanercept S Specialty Drug
QL 4 ml / 28 days ENBREL 50 MG/ML SYRINGE PA etanercept S Specialty Drug
PAGE 169 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS gengraf 100 mg capsule gengraf 100 mg/ml solution gengraf 25 mg capsule gengraf 50 mg capsule
QL 2 / 28 DAYS HUMIRA 10 MG/0.2 ML SYRINGE PA adalimumab S Specialty Drug
QL 2 syringes / 28 days HUMIRA 20 MG/0.4 ML SYRINGE PA adalimumab S Specialty Drug
QL 2 syringes / 28 days HUMIRA 40 MG/0.8 ML SYRINGE PA adalimumab S Specialty Drug
QL 2 / 28 DAYS HUMIRA PEDI CROHN 40 MG/0.8 ML PA adalimumab S Specialty Drug
QL 2 pens / 28 days HUMIRA PEN 40 MG/0.8 ML PA adalimumab S Specialty Drug
QL 6 pens / 28 days HUMIRA PEN CROHN-UC-HS 40 MG PA adalimumab S Specialty Drug
QL 4 pens / 28 days HUMIRA PEN PS-UV-ADOL HS 40 MG PA adalimumab S Specialty Drug
QL 2 / 28 DAYS HUMIRA(CF) 10 MG/0.1 ML SYRING PA adalimumab S Specialty Drug
QL 2 / 28 DAYS HUMIRA(CF) 20 MG/0.2 ML SYRING PA adalimumab S Specialty Drug
PAGE 170 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 2 / 28 DAYS HUMIRA(CF) 40 MG/0.4 ML SYRING PA adalimumab S Specialty Drug
QL 2 / 28 DAYS HUMIRA(CF) PEDI CROHN 80-40 MG PA adalimumab S Specialty Drug
QL 3 / 28 DAYS HUMIRA(CF) PEDI CROHN 80MG/0.8 PA adalimumab S Specialty Drug
QL 2 / 28 DAYS HUMIRA(CF) PEN 40 MG/0.4 ML PA adalimumab S Specialty Drug
QL 2 / 28 day(s) HUMIRA(CF) PEN 80 MG/0.8 ML PA adalimumab S Specialty Drug
QL 3 / 28 DAYS HUMIRA(CF) PEN CRHN-UC-HS 80MG PA adalimumab S Specialty Drug
QL 4 / 28 DAYS HUMIRA(CF) PEN PEDI UC 80 MG PA adalimumab S Specialty Drug
QL 3 / 28 DAYS HUMIRA(CF) PEN PS-UV-AHS 80-40 PA adalimumab S Specialty Drug
leflunomide 10 mg tablet leflunomide 20 mg tablet methotrexate 1 gram/40 ml vial methotrexate 100 mg/4 ml vial methotrexate 2.5 mg tablet methotrexate 200 mg/8 ml vial
PAGE 171 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS methotrexate 25 mg/ml vial methotrexate 250 mg/10 ml vial methotrexate 250 mg/10 ml vial methotrexate 50 mg/2 ml vial methotrexate 50 mg/2 ml vial mycophenolate 200 mg/ml susp mycophenolate 250 mg capsule mycophenolate 500 mg tablet SANDIMMUNE 100 MG/ML SOLN cyclosporine sirolimus 0.5 mg tablet sirolimus 1 mg tablet sirolimus 1 mg/ml solution sirolimus 2 mg tablet tacrolimus 0.5 mg capsule tacrolimus 0.5 mg capsule (ir) tacrolimus 1 mg capsule tacrolimus 1 mg capsule (ir) tacrolimus 5 mg capsule tacrolimus 5 mg capsule (ir) VACCINES
ADACEL TDAP SYRINGE AL1 19 to 999 yrs old diphtheria,pertussis(acellular),tetanus vaccine/pf ADACEL TDAP VIAL AL1 19 to 999 yrs old diphtheria,pertussis(acellular),tetanus vaccine/pf AFLURIA QUAD 2020-2021 VIAL AL1 19 to 999 yrs old influenza virus vaccine quadrivalent 2020-21 (6 mos and up) AFLURIA QUAD 2020-21 (3YR UP) AL1 19 to 999 yrs old influenza virus vaccine quadrivalent 2020-21 (36 mos up)/pf AFLURIA QUAD 2020-21 (6-35MO) AL1 19 to 999 yrs old influenza virus vaccine quadrival 2020-21 (6 mos-35 mos)/pf AFLURIA QUAD 2021-2022 VIAL AL1 19 to 999 yrs old influenza virus vaccine quadrivalent 2021-22 (6 mos and up)
PAGE 172 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS AFLURIA QUAD 2021-22 (3YR UP) AL1 19 to 999 yrs old influenza virus vaccine quadrivalent 2021-22 (36 mos up)/pf BEXSERO PREFILLED SYRINGE AL1 19 to 25 yrs old meningococcal group b vaccine, 4-component BOOSTRIX TDAP VACCINE SYRINGE AL1 19 to 999 yrs old diphtheria,pertussis(acellular),tetanus vaccine BOOSTRIX TDAP VACCINE VIAL AL1 19 to 999 yrs old diphtheria,pertussis(acellular),tetanus vaccine COMIRNATY COVID-19 VACCINE VL QL 0.9 ml / 365 days covid-19 vaccine, mrna, bnt162b2, lnp-s (pfizer)/pf ENGERIX-B 20 MCG/ML SYRN AL1 19 to 999 yrs old hepatitis b virus vaccine recombinant/pf ENGERIX-B 20 MCG/ML VIAL AL1 19 to 999 yrs old hepatitis b virus vaccine recombinant/pf FLUAD 2020-2021 SYRINGE AL1 65 to 999 yrs old influenza vaccine tvs 2020-21 (65 yr up)/adjuvant mf59c.1/pf FLUAD QUAD 2020-2021 SYRINGE AL1 19 to 999 yrs old influenza vaccine quadrivalent 2020-21 (65 yr up)/mf59c.1/pf FLUAD QUAD 2021-2022 SYRINGE AL1 65 to 999 yrs old influenza vaccine quadrivalent 2021-22 (65 yr up)/mf59c.1/pf FLUARIX QUAD 2020-2021 SYRINGE AL1 19 to 999 yrs old influenza virus vaccine quadrival 2020-2021(6 mos and up)/pf FLUARIX QUAD 2021-2022 SYRINGE AL1 19 to 999 yrs old influenza virus vaccine quadrival 2021-2022(6 mos and up)/pf FLUBLOK QUAD 2020-2021 SYRINGE AL1 19 to 999 yrs old influenza virus vaccine qv 2020-21(18 yrs and older)rcmb/pf FLUBLOK QUAD 2021-2022 SYRINGE AL1 19 to 999 yrs old influenza virus vaccine qv 2021-22(18 yrs and older)rcmb/pf FLUCELVAX QUAD 2020-2021 SYR AL1 19 to 999 yrs old flu vaccine quad 2020-2021(4 years and older)cell derived/pf FLUCELVAX QUAD 2020-2021 VIAL AL1 19 to 999 yrs old flu vaccine quadriv 2020-2021(4 years and older)cell derived FLUCELVAX QUAD 2021-2022 SYR AL1 19 to 999 yrs old flu vaccine quad 2021-2022(2 years and older)cell derived/pf FLUCELVAX QUAD 2021-2022 VIAL AL1 19 to 999 yrs old flu vaccine quadriv 2021-2022(2 years and older)cell derived FLULAVAL QUAD 2020-2021 SYR AL1 19 to 999 yrs old influenza virus vaccine quadrival 2020-2021(6 mos and up)/pf
PAGE 173 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS FLULAVAL QUAD 2021-2022 SYR AL1 19 to 999 yrs old influenza virus vaccine quadrival 2021-2022(6 mos and up)/pf FLUMIST QUAD NASAL 2020-21 VAC AL1 19 to 999 yrs old influenza vaccine quadrivalent live 2020-2021 (2 yrs-49 yrs) FLUMIST QUAD NASAL 2021-22 VAC AL1 19 to 49 yrs old influenza vaccine quadrivalent live 2021-2022 (2 yrs-49 yrs) FLUZONE HIGH-DOSE QUAD 2020-21 AL1 65 to 999 yrs old influenza virus vaccine quadrival split 2020-21(65 yr up)/pf FLUZONE HIGH-DOSE QUAD 2021-22 AL1 65 to 999 yrs old influenza virus vaccine quadrival split 2021-22(65 yr up)/pf FLUZONE QUAD 2020-2021 SYRINGE AL1 19 to 999 yrs old influenza virus vaccine quadrival 2020-2021(6 mos and up)/pf FLUZONE QUAD 2020-2021 VIAL AL1 19 to 999 yrs old influenza virus vaccine quadrival 2020-2021(6 mos and up)/pf FLUZONE QUAD 2020-2021 VIAL AL1 19 to 999 yrs old influenza virus vaccine quadrivalent 2020-21 (6 mos and up) FLUZONE QUAD 2021-2022 SYRINGE AL1 19 to 999 yrs old influenza virus vaccine quadrival 2021-2022(6 mos and up)/pf FLUZONE QUAD 2021-2022 VIAL AL1 19 to 999 yrs old influenza virus vaccine quadrival 2021-2022(6 mos and up)/pf FLUZONE QUAD 2021-2022 VIAL AL1 19 to 999 yrs old influenza virus vaccine quadrivalent 2021-22 (6 mos and up) GARDASIL 9 SYRINGE AL1 19 to 26 yrs old human papillomavirus vaccine, 9-valent/pf GARDASIL 9 VIAL AL1 19 to 26 yrs old human papillomavirus vaccine, 9-valent/pf HAVRIX 1,440 UNITS/ML SYRINGE AL1 19 to 999 yrs old hepatitis a virus vaccine/pf HAVRIX 1,440 UNITS/ML VIAL AL1 19 to 999 yrs old hepatitis a virus vaccine/pf HAVRIX 720 UNIT/0.5 ML SYRINGE AL1 19 to 999 yrs old hepatitis a virus vaccine/pf HAVRIX 720 UNITS/0.5 ML VIAL AL1 19 to 999 yrs old hepatitis a virus vaccine/pf HEPLISAV-B 20 MCG/0.5 ML SYRNG AL1 19 to 999 yrs old hepatitis b vaccine recombinant/vaccine adjuvant cpg 1018/pf HEPLISAV-B 20 MCG/0.5 ML VIAL AL1 19 to 999 yrs old hepatitis b vaccine recombinant/vaccine adjuvant cpg 1018/pf
PAGE 174 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS JANSSEN COVID-19 VACCINE (EUA) QL 0.5 / 180 day(s) covid-19 vac, ad26.cov2.s (janssen)/pf M-M-R II VACCINE VIAL AL1 19 to 999 yrs old measles, mumps, and rubella vaccine live/pf MENACTRA VIAL AL1 19 to 999 yrs old meningococcalvaccine a,c,y,w-135,diphtheria toxoid conj/pf MENVEO A-C-Y-W-135-DIP VIAL KT AL1 19 to 999 yrs old meningococcalvaccine a,c,y,w-135,diphtheria toxoid conj/pf MODERNA COVID-19 VACCINE (EUA) QL 1.5 ml / 365 days covid-19 vaccine, mrna-1273, lnp-s (moderna)/pf PFIZER COVID-19 VACCINE (EUA) QL 0.9 ml / 365 days covid-19 vaccine, mrna, bnt162b2, lnp-s (pfizer)/pf PNEUMOVAX 23 SYRINGE AL1 19 to 999 yrs old pneumococcal 23-valent polysaccharide vaccine PNEUMOVAX 23 VIAL AL1 19 to 999 yrs old pneumococcal 23-valent polysaccharide vaccine PREVNAR 13 SYRINGE AL1 19 to 999 yrs old pneumococcal 13-valent conjugate vaccine (diphtheria crm)/pf RECOMBIVAX HB 10 MCG/ML SYR AL1 19 to 999 yrs old hepatitis b virus vaccine recombinant/pf RECOMBIVAX HB 10 MCG/ML VIAL AL1 19 to 999 yrs old hepatitis b virus vaccine recombinant/pf RECOMBIVAX HB 40 MCG/ML VIAL AL1 19 to 999 yrs old hepatitis b virus vaccine recombinant/pf RECOMBIVAX HB 5 MCG/0.5 ML SYR AL1 19 to 999 yrs old hepatitis b virus vaccine recombinant/pf RECOMBIVAX HB 5 MCG/0.5 ML VL AL1 19 to 999 yrs old hepatitis b virus vaccine recombinant/pf SHINGRIX VIAL KIT AL1 50 to 999 yrs old varicella-zoster virus glycoprotein e,rec/as01b adjuvant/pf TDVAX VIAL AL1 19 to 999 yrs old tetanus and diphtheria toxoids, adult TRUMENBA 120 MCG/0.5 ML VACCIN AL1 19 to 25 yrs old neisseria meningitidis group b, lipidated fhbp recombinant TWINRIX VACCINE SYRINGE AL1 19 to 999 yrs old hepatitis a virus and hepatitis b virus vaccine/pf VAQTA 25 UNITS/0.5 ML SYRINGE AL1 19 to 999 yrs old hepatitis a virus vaccine/pf
PAGE 175 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS VAQTA 25 UNITS/0.5 ML VIAL AL1 19 to 999 yrs old hepatitis a virus vaccine/pf VAQTA 50 UNITS/ML SYRINGE AL1 19 to 999 yrs old hepatitis a virus vaccine/pf VAQTA 50 UNITS/ML VIAL AL1 19 to 999 yrs old hepatitis a virus vaccine/pf VARIVAX VACCINE WITH DILUENT AL1 19 to 999 yrs old varicella virus vaccine live/pf ZOSTAVAX VIAL AL1 60 to 999 yrs old zoster vaccine live/pf INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
balsalazide disodium 750 mg cp
mesalamine 1,000 mg supp QL 30 / 30 day(s)
mesalamine 4 gm/60 ml enema
mesalamine dr 1.2 gm tablet QL 120 / 30 day(s)
mesalamine dr 400 mg capsule QL 180 / 30 day(s)
mesalamine er 0.375 gram cap QL 180 / 30 day(s)
sulfasalazine 500 mg tablet sulfasalazine dr 500 mg tab GLUCOCORTICOIDS
budesonide ec 3 mg capsule QL 120 / 30 DAYS
budesonide er 9 mg tablet QL 60 / 180 DAYS
CORTIFOAM 10% AEROSOL hydrocortisone acetate hydrocortisone 10 mg tablet hydrocortisone 100 mg/60 ml hydrocortisone 20 mg tablet hydrocortisone 5 mg tablet METABOLIC BONE DISEASE AGENTS
alendronate sodium 10 mg tab QL 30 tablets / 30 days
PAGE 176 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
alendronate sodium 35 mg tab QL 4 tablet / 28 days
alendronate sodium 40 mg tab QL 30 tablets / 30 days
alendronate sodium 5 mg tablet QL 30 tablets / 30 days
alendronate sodium 70 mg tab QL 4 tablet / 28 days
baby d3 400 unit/drop conc baby ddrops 400 unit/drop conc baby vit d3 10 mcg/drop conc baby vit d3 400 unit/drop conc calcidol drops calcitonin-salmon 200 units sp calcitriol 0.25 mcg capsule calcitriol 0.5 mcg capsule cvs vit d3 1,000 unit gummies cvs vit d3 1,000 unit gummies cvs vit d3 250 mcg softgel cvs vitamin d3 1,000 unit sfgl cvs vitamin d3 10 mcg softgel cvs vitamin d3 125 mcg softgel cvs vitamin d3 2,000 unit sfgl cvs vitamin d3 25 mcg gummies cvs vitamin d3 25 mcg softgel cvs vitamin d3 400 unit sftgl cvs vitamin d3 5,000 unit sfgl cvs vitamin d3 50 mcg softgel d-vi-sol 400 unit/ml liquid d3 dots 2,000 unit tablet d3-2000 unit softgel d3-50 50,000 unit capsule D3-50 50,000 UNIT CAPSULE cholecalciferol (vitamin d3)
PAGE 177 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS ddrops 1,000 unit/drop decara 10,000 unit softgel decara 50,000 unit softgel delta d3 400 unit tablet DIALYVITE VIT D3 50,000 UNIT cholecalciferol (vitamin d3) dialyvite vitamin d 5,000 unit eql vitamin d3 1,000 unit sfgl eql vitamin d3 2,000 unit sfgl eql vitamin d3 400 unit sftgl eql vitamin d3 5,000 unit sfgl ergocalciferol 200 mcg/ml drop ergocalciferol 8,000 unit/ml etidronate disodium 200 mg tab etidronate disodium 400 mg tab FORTICAL 200 UNITS NASAL SPRAY calcitonin,salmon,synthetic gnp vit d3 10mcg(400 unit) chw gnp vitamin d3 1,000 unit tab gnp vitamin d3 10 mcg tablet gnp vitamin d3 2,000 unit tab gnp vitamin d3 25 mcg tablet gnp vitamin d3 25mcg(1000 unt) gnp vitamin d3 5,000 unit tab hm vitamin d3 1,000 unit tab hm vitamin d3 2,000 unit sftgl hm vitamin d3 4,000 unit sftgl
ibandronate sodium 150 mg tab QL 1 tablet / 30 days
is-d-10,000 250 mcg softgel kids first d3 1,000 unit gummy kids vitamin d3 tab chew
PAGE 178 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS optimal d3 50,000 unit capsule pedia d-vite 400 unit/ml liq pediatric d-vite 10 mcg/ml liq pharm choice d3 400 unit/ml ra vitamin d3 1,000 unit tab ra vitamin d3 2,000 unit sfgl ra vitamin d3 2,000 unit sftgl ra vitamin d3 5,000 unit sftgl
risedronate sodium 30 mg tab QL 30 tablets / 30 days
risedronate sodium 35 mg tab QL 4 tablets / 28 days
risedronate sodium 5 mg tablet QL 30 tablets / 30 days
sm vitamin d3 1,000 unit tab sm vitamin d3 2,000 unit sftgl sm vitamin d3 25 mcg tablet sm vitamin d3 50 mcg softgel sv vitamin d3 1,000 unit gummy sv vitamin d3 1,000 unit sftgl sv vitamin d3 2,000 unit sftgl sv vitamin d3 25mcg(1000 unit) sv vitamin d3 400 unit softgel sv vitamin d3 5,000 unit sftgl thera-d 2000 tablet thera-d rapid repletion tablet thera-d sport 2,000 unit tab vit d3 125 mcg (5000 unit) tab vitajoy daily d gummy vitamin d-400 tablet vitamin d2 1.25mg(50,000 unit) vitamin d2 2,000 unit tablet vitamin d3 1,000 unit gummies
PAGE 179 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS vitamin d3 1,000 unit gummy vitamin d3 1,000 unit softgel vitamin d3 1,000 unit tab chew vitamin d3 1,000 unit tablet vitamin d3 1,000 unit/10 ml lq vitamin d3 1,250 mcg capsule vitamin d3 1.25 mg softgel vitamin d3 10 mcg/ml liquid vitamin d3 10,000 unit capsule vitamin d3 10,000 unit softgel vitamin d3 10,000 unit tablet vitamin d3 125 mcg (5000 unit) vitamin d3 125 mcg capsule vitamin d3 125 mcg softgel vitamin d3 2,000 unit softgel vitamin d3 2,000 unit tablet vitamin d3 25 mcg (1,000 unit) vitamin d3 25 mcg gummy vitamin d3 25 mcg softgel vitamin d3 25 mcg tablet vitamin d3 250 mcg tablet vitamin d3 400 unit softgel vitamin d3 400 unit tab chew vitamin d3 400 unit tablet vitamin d3 400 unit/5 ml liq vitamin d3 400 unit/ml liquid vitamin d3 5,000 unit capsule vitamin d3 5,000 unit softgel vitamin d3 5,000 unit tablet vitamin d3 5,000 unit/ml drops
PAGE 180 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS vitamin d3 50 mcg (2,000 unit) vitamin d3 50 mcg softgel vitamin d3 50 mcg tablet vitamin d3 50,000 unit capsule weekly-d 1,250 mcg softgel MISCELLANEOUS THERAPEUTIC AGENTS
1st tier unifine pentp 5mm 31g QL 200 / 30 DAYS
1st tier unifine pntip 4mm 32g QL 200 / 30 DAYS
1st tier unifine pntip 6mm 31g QL 200 / 30 DAYS
1st tier unifine pntip 8mm 31g QL 200 / 30 DAYS
1st tier unifine pntip 8mm 31g QL 200 / 30 DAYS
1st tier unifine pntp 12mm 29g QL 200 / 30 DAYS
1st tier unifine pntp 29gx1/2" QL 200 / 30 DAYS
1st tier unifine pntp 31gx1/4" QL 200 / 30 DAYS
1st tier unifine pntp 31gx3/16 QL 200 / 30 DAYS
1st tier unifine pntp 31gx5/16 QL 200 / 30 DAYS
1st tier unifine pntp 32gx5/32 QL 200 / 30 DAYS
accu-chek fastclix lancet drum QL 102 lancets / 30 days
accu-chek fastclix lancing dev QL 1 / 180 DAYS
accu-chek multiclix lancet kit QL 1 / 180 DAYS
accu-chek multiclix lancets QL 102 / 90 DAYS
accu-chek safe-t-pro 23g lanct QL 200 / 180 DAYS
accu-chek safe-t-pro plus 23g QL 200 / 180 DAYS
accu-chek softclix lancet kit QL 1 / 180 DAYS
accu-chek softclix lancets QL 100 / 90 DAYS
acticoat 7 4"x5" dressing advocate alcohol 70% prep pads
PAGE 181 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
advocate ins 0.3 ml 30gx5/16" QL 200 / 30 DAYS
advocate ins 0.3 ml 31gx5/16" QL 200 / 30 DAYS
advocate ins 0.5 ml 30gx5/16" QL 200 / 30 DAYS
advocate ins 0.5 ml 31gx5/16" QL 200 / 30 DAYS
advocate ins 1 ml 31gx5/16" QL 200 / 30 DAYS
advocate ins syr 0.3ml 29gx1/2 QL 200 / 30 DAYS
advocate ins syr 0.5ml 29gx1/2 QL 200 / 30 DAYS
advocate ins syr 1 ml 29gx1/2" QL 200 / 30 DAYS
advocate ins syr 1 ml 30gx5/16 QL 200 / 30 DAYS
advocate pen ndl 12.7mm 29g QL 200 / 30 DAYS
advocate pen needle 4mm 33g QL 200 / 30 DAYS
advocate pen needles 5mm 31g QL 200 / 30 DAYS
advocate pen needles 8mm 31g QL 200 / 30 DAYS
aerochamber mini QL 1 / 90 DAYS
aerochamber mv hold chamber QL 1 / 90 DAYS
aerochamber plus flow-vu QL 1 / 90 DAYS
aerochamber plus flow-vu large QL 1 / 90 DAYS
aerochamber plus flow-vu med QL 1 / 90 DAYS
aerochamber plus flow-vu small QL 1 / 90 DAYS
aerochamber plus w-flowsignal QL 1 / 90 DAYS
aerochamber z-stat plus large QL 1 / 90 DAYS
aerochamber z-stat plus w-flow QL 1 / 90 DAYS
aerochamber z-stat plus-med QL 1 / 90 DAYS
aerochamber z-stat plus-small QL 1 / 90 DAYS
aerotrach holding chamber QL 1 / 90 DAYS
PAGE 182 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
aerovent plus holding chamber QL 1 / 90 DAYS
aimsco latex condom air filter airs disposable nebulizer airzone peak flow meter alcohol 70% pads alcohol 70% prep pads alcohol 70% swabs alcohol 70% wipes alcohol prep pads alcohol swab alcohol swabs allergy syringe 1 ml 27gx1/2"
assure id duo-shield 30gx3/16" QL 200 / 30 DAYS
assure id duo-shield 30gx5/16" QL 200 / 30 DAYS
assure id pen needle 30gx3/16" QL 200 / 30 DAYS
assure id pen needle 30gx5/16" QL 200 / 30 DAYS
assure id pen needle 31gx3/16" QL 200 / 30 DAYS
assure id syr 0.5 ml 29gx1/2" QL 200 / 30 DAYS
assure id syr 0.5ml 31gx15/64" QL 200 / 30 DAYS
assure id syr 1 ml 29gx1/2" QL 200 / 30 DAYS
assure id syr 1 ml 31gx15/64" QL 200 / 30 DAYS
asthmapack children's care kit bd 3 ml syringe 18gx1-1/2" bd 3 ml syringe 20gx1-1/2" bd 3 ml syringe 25gx1" bd 3 ml syringe 25gx1-1/2" bd 3 ml syringe with needle
PAGE 183 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS bd 3 ml syringe with needle bd 3 ml syringe with needle bd 3 ml syringe with needle bd 3 ml syringe with needle bd 3 ml syringe with needle bd allergy syringe-needle 1 ml
bd autoshield duo ndl 5mmx30g QL 200 / 30 DAYS
bd eclipse 30gx1/2" syringe QL 200 / 30 DAYS
bd eclipse luer-lok syr 3 ml bd eclipse luer-lok syr 3 ml bd eclipse syr 3 ml 22gx1-1/2" bd eclipse syringe 3 ml 22gx1" bd eclipse syringe 3 ml 25gx1"
bd ins syr 0.3 ml 8mmx31g(1/2) QL 200 / 30 DAYS
bd ins syr u-500 1/2ml 6mmx31g QL 200 / 30 DAYS
bd ins syr uf 0.3ml 12.7mmx30g QL 200 / 30 DAYS
bd ins syr uf 0.5ml 12.7mmx30g QL 200 / 30 DAYS
bd ins syrn uf 1 ml 12.7mmx30g QL 200 / 30 DAYS
bd ins syrng 0.3 ml 29gx12.7mm QL 200 / 30 DAYS
bd ins syrng 0.5 ml 29gx12.7mm QL 200 / 30 DAYS
bd ins syrng uf 0.3 ml 8mmx31g QL 200 / 30 DAYS
bd ins syrng uf 0.5 ml 8mmx31g QL 200 / 30 DAYS
bd insulin syr 0.5 ml 28gx1/2" QL 200 / 30 DAYS
bd insulin syr 0.5 ml 29gx1/2" QL 200 / 30 DAYS
bd insulin syr 1 ml 25gx1" QL 200 / 30 DAYS
bd insulin syr 1 ml 25gx5/8" QL 200 / 30 DAYS
bd insulin syr 1 ml 26gx1/2" QL 200 / 30 DAYS
PAGE 184 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
bd insulin syr 1 ml 27gx12.7mm QL 200 / 30 DAYS
bd insulin syr 1 ml 27gx5/8" QL 200 / 30 DAYS
bd insulin syr 1 ml 28gx1/2" QL 200 / 30 DAYS
bd insulin syr 1 ml 29gx1/2" QL 200 / 30 DAYS
bd insulin syr 1 ml 29gx12.7mm QL 200 / 30 DAYS
bd insulin syr uf 1 ml 8mmx31g QL 200 / 30 DAYS
bd insulin syringe 1 ml QL 200 / 30 DAYS
bd integra syr 3 ml 22gx1 1/2" bd integra syr 3 ml 25gx5/8" bd integra syringe 3 ml 23gx1" bd integra syringe 3 ml 25gx1" bd luer-lok syr 3 ml 25gx5/8"
bd luer-lok syringe 1 ml QL 200 / 30 DAYS
bd luer-lok syringe 1ml 20gx1" QL 200 / 30 DAYS
bd nano 2 gen pen ndl 32gx4mm QL 200 / 30 DAYS
bd safetgld ins 0.3 ml 8mmx31g QL 200 / 30 DAYS
bd safetgld ins 0.3ml 13mmx29g QL 200 / 30 DAYS
bd safetgld ins 0.5 ml 8mmx30g QL 200 / 30 DAYS
bd safetgld ins 0.5ml 13mmx29g QL 200 / 30 DAYS
bd safetygld ins 1 ml 13mmx29g QL 200 / 30 DAYS
bd safetyglid ins 1 ml 6mmx31g QL 200 / 30 DAYS
bd safetyglide 3 ml syringe bd safetyglide 3 ml syringe bd safetyglide allergy 27g syr bd safetyglide allergy syringe
bd safetyglide syringe 27gx5/8 QL 200 / 30 DAYS
bd safetyglide tb 1 ml syr
PAGE 185 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS bd safetyglide tuberculin syr
bd saftygld ins 0.3 ml 6mmx31g QL 200 / 30 DAYS
bd saftygld ins 0.5 ml 6mmx31g QL 200 / 30 DAYS
bd syringe-safety glide bd tb syringe 25gx5/8" bd tb syringe 26gx3/8" bd tb syringe 27gx1/2"
bd uf micro pen needle 6mmx32g QL 200 / 30 DAYS
bd uf mini pen needle 5mmx31g QL 200 / 30 DAYS
bd uf nano pen needle 4mmx32g QL 200 / 30 DAYS
bd uf orig pen ndl 12.7mmx29g QL 200 / 30 DAYS
bd uf short pen needle 8mmx31g QL 200 / 30 DAYS
bd veo ins 0.3ml 6mmx31g (1/2) QL 200 / 30 DAYS
bd veo ins syring 1 ml 6mmx31g QL 200 / 30 DAYS
bd veo ins syrn 0.3 ml 6mmx31g QL 200 / 30 DAYS
bd veo ins syrn 0.5 ml 6mmx31g QL 200 / 30 DAYS
breatherite mdi spacer QL 1 / 90 DAYS
breatherite spacer-adult mask QL 1 / 90 DAYS
breatherite spacer-infant mask QL 1 / 90 DAYS
breatherite spacer-lg chld msk QL 1 / 90 DAYS
breatherite spacer-neonate msk QL 1 / 90 DAYS
breatherite spacer-sm chld msk QL 1 / 90 DAYS
ca ins syr 0.3 ml 30gx5/16" QL 200 / 30 DAYS
ca ins syr 0.3 ml 31gx5/16" QL 200 / 30 DAYS
ca ins syr 0.5 ml 30gx5/16" QL 200 / 30 DAYS
ca ins syr 0.5 ml 31gx5/16" QL 200 / 30 DAYS
PAGE 186 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
ca insulin syr 0.3 ml 29gx1/2" QL 200 / 30 DAYS
ca insulin syr 0.5 ml 29gx1/2" QL 200 / 30 DAYS
ca insulin syr 1 ml 29gx1/2" QL 200 / 30 DAYS
ca insulin syr 1 ml 30gx5/16" QL 200 / 30 DAYS
ca insulin syr 1 ml 31gx5/16" QL 200 / 30 DAYS
CANDIN SKIN TEST candida albicans skin test
carefine pen needle 12.7mm 29g QL 200 / 30 DAYS
carefine pen needle 4mm 32g QL 200 / 30 DAYS
carefine pen needle 5mm 32g QL 200 / 30 DAYS
carefine pen needle 6mm 31g QL 200 / 30 DAYS
carefine pen needle 8mm 30g QL 200 / 30 DAYS
carefine pen needles 6mm 32g QL 200 / 30 DAYS
carefine pen needles 8mm 31g QL 200 / 30 DAYS
careone syr 0.3 ml 30gx1/2" QL 200 / 30 DAYS
careone syr 0.5 ml 30gx1/2" QL 200 / 30 DAYS
careone syr 1 ml 30gx1/2" QL 200 / 30 DAYS
careone unifine pentip 4mm 32g QL 200 / 30 DAYS
careone unifine pentip 5mm 31g QL 200 / 30 DAYS
careone unifine pentip 6mm 31g QL 200 / 30 DAYS
careone unifine pentip 8mm 31g QL 200 / 30 DAYS
careone unifine pentp 29gx1/2" QL 200 / 30 DAYS
careone unifine pentp 31gx1/4" QL 200 / 30 DAYS
careone unifine pntp 12mm 29g QL 200 / 30 DAYS
careone unifine pntp 31gx3/16" QL 200 / 30 DAYS
careone unifine pntp 31gx5/16" QL 200 / 30 DAYS
PAGE 187 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
careone unifine pntp 32gx5/32" QL 200 / 30 DAYS
carepoint ll syr 3 ml 20gx1.5" carepoint ll syr 3 ml 21gx1" carepoint ll syr 3 ml 21gx1.5" carepoint ll syr 3 ml 22gx1" carepoint ll syr 3 ml 23gx1" carepoint ll syr 3 ml 23gx1.5" carepoint ll syr 3 ml 25g x 1" carepoint ll syr 3 ml 25gx5/8" carepoint ls syr 1 ml 25g 5/8"
caretouch pen needle 29g 12mm QL 200 / 30 DAYS
caretouch pen needle 31gx1/4" QL 200 / 30 DAYS
caretouch pen needle 31gx3/16" QL 200 / 30 DAYS
caretouch pen needle 31gx5/16" QL 200 / 30 DAYS
caretouch pen needle 32gx3/16" QL 200 / 30 DAYS
caretouch pen needle 32gx5/32" QL 200 / 30 DAYS
caretouch syr 0.3 ml 31gx5/16" QL 200 / 30 DAYS
caretouch syr 0.5 ml 30gx5/16" QL 200 / 30 DAYS
caretouch syr 0.5 ml 31gx5/16" QL 200 / 30 DAYS
caretouch syr 1 ml 28gx5/16" QL 200 / 30 DAYS
caretouch syr 1 ml 29gx5/16" QL 200 / 30 DAYS
caretouch syr 1 ml 30gx5/16" QL 200 / 30 DAYS
caretouch syr 1 ml 31gx5/16" QL 200 / 30 DAYS
carrasyn hydrogel wound dress
clever choice chamber-lrg mask QL 1 / 90 DAYS
clever choice chamber-med mask QL 1 / 90 DAYS
clever choice chamber-sm mask QL 1 / 90 DAYS
PAGE 188 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
clickfine 31g x 1/4" needles QL 200 / 30 DAYS
clickfine 31g x 5/16" needles QL 200 / 30 DAYS
clickfine pen needle 32gx5/32" QL 200 / 30 DAYS
clickfine universal 31g x 1/4" QL 200 / 30 DAYS
clickfine universal 31gx5/16" QL 200 / 30 DAYS
coal tar topical solution
comfort ez ins 0.3ml 30gx1/2" QL 200 / 30 DAYS
comfort ez ins 0.3ml 30gx5/16" QL 200 / 30 DAYS
comfort ez ins 0.5ml 31gx5/16" QL 200 / 30 DAYS
comfort ez ins 1 ml 31gx5/16" QL 200 / 30 DAYS
comfort ez insulin syr 0.3 ml QL 200 / 30 DAYS
comfort ez insulin syr 0.5 ml QL 200 / 30 DAYS
comfort ez insulin syr 0.5 ml QL 200 / 30 DAYS
comfort ez pen needle 12mm 29g QL 200 / 30 DAYS
comfort ez pen needles 4mm 32g QL 200 / 30 DAYS
comfort ez pen needles 4mm 33g QL 200 / 30 DAYS
comfort ez pen needles 5mm 31g QL 200 / 30 DAYS
comfort ez pen needles 5mm 32g QL 200 / 30 DAYS
comfort ez pen needles 5mm 33g QL 200 / 30 DAYS
comfort ez pen needles 6mm 31g QL 200 / 30 DAYS
comfort ez pen needles 6mm 32g QL 200 / 30 DAYS
comfort ez pen needles 6mm 33g QL 200 / 30 DAYS
comfort ez pen needles 8mm 31g QL 200 / 30 DAYS
comfort ez pen needles 8mm 32g QL 200 / 30 DAYS
comfort ez pen needles 8mm 33g QL 200 / 30 DAYS
comfort ez syr 0.3 ml 29gx1/2" QL 200 / 30 DAYS
PAGE 189 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
comfort ez syr 0.5 ml 28gx1/2" QL 200 / 30 DAYS
comfort ez syr 0.5 ml 29gx1/2" QL 200 / 30 DAYS
comfort ez syr 0.5 ml 30gx1/2" QL 200 / 30 DAYS
comfort ez syr 1 ml 28gx1/2" QL 200 / 30 DAYS
comfort ez syr 1 ml 29gx1/2" QL 200 / 30 DAYS
comfort ez syr 1 ml 30gx1/2" QL 200 / 30 DAYS
comfort ez syr 1 ml 30gx5/16" QL 200 / 30 DAYS
comfort point pen ndl 29gx1/2" QL 200 / 30 DAYS
comfort point pen ndl 31gx1/3" QL 200 / 30 DAYS
comfort point pen ndl 31gx1/4" QL 200 / 30 DAYS
comfort point pen ndl 31gx1/6" QL 200 / 30 DAYS
comfort touch pen ndl 31g 4mm QL 200 / 30 DAYS
comfort touch pen ndl 31g 5mm QL 200 / 30 DAYS
comfort touch pen ndl 31g 6mm QL 200 / 30 DAYS
comfort touch pen ndl 31g 8mm QL 200 / 30 DAYS
comfort touch pen ndl 32g 4mm QL 200 / 30 DAYS
comfort touch pen ndl 32g 5mm QL 200 / 30 DAYS
comfort touch pen ndl 32g 6mm QL 200 / 30 DAYS
comfort touch pen ndl 32g 8mm QL 200 / 30 DAYS
comfort touch pen ndl 33g 6mm QL 200 / 30 DAYS
comfort touch pen ndl 33gx4mm QL 200 / 30 DAYS
comfort touch pen ndl 33gx5mm QL 200 / 30 DAYS
comp-air nebulizer system
compact space chamber QL 1 / 90 DAYS
compact space chamber-lrg mask QL 1 / 90 DAYS
compact space chamber-med mask QL 1 / 90 DAYS
PAGE 190 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
compact space chamber-sm mask QL 1 / 90 DAYS
condoms lubricated
contour meter QL 1 / 2 YEARS
contour next ez meter QL 1 / 2 YEARS
contour next ez meter system QL 1 / 2 YEARS
contour next glucose meter kit QL 1 / 2 YEARS
contour next meter QL 1 / 2 YEARS
contour next one meter QL 1 / 2 YEARS
contour next test strip QL 50 / 90 day(s)
contour test strip QL 50 / 90 day(s)
COSAMIN DS CAPSULE glucosamine hcl/chondroitin sul a na/ascorbic acid/manganese curity alcohol preps cvs alcohol 70% prep pads devilbiss disposable nebulizer devilbiss pulmo-aide comprs devilbiss pulmomate compressor devilbiss travel compres-nebul
droplet 0.5 ml 29gx12.5mm(1/2) QL 200 / 30 DAYS
droplet 0.5 ml 30gx12.5mm(1/2) QL 200 / 30 DAYS
droplet ins 0.3 ml 29gx12.5mm QL 200 / 30 DAYS
droplet ins 0.3ml 30gx12.5mm QL 200 / 30 DAYS
droplet ins 0.5ml 30gx6mm(1/2) QL 200 / 30 DAYS
droplet ins 0.5ml 30gx8mm(1/2) QL 200 / 30 DAYS
droplet ins 0.5ml 31gx6mm(1/2) QL 200 / 30 DAYS
droplet ins 0.5ml 31gx8mm(1/2) QL 200 / 30 DAYS
droplet ins syr 0.3 ml 30gx6mm QL 200 / 30 DAYS
PAGE 191 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
droplet ins syr 0.3 ml 30gx8mm QL 200 / 30 DAYS
droplet ins syr 0.3 ml 31gx6mm QL 200 / 30 DAYS
droplet ins syr 0.3 ml 31gx8mm QL 200 / 30 DAYS
droplet ins syr 1 ml 30gx6mm QL 200 / 30 DAYS
droplet ins syr 1 ml 30gx8mm QL 200 / 30 DAYS
droplet ins syr 1 ml 31gx6mm QL 200 / 30 DAYS
droplet ins syr 1 ml 31gx8mm QL 200 / 30 DAYS
droplet ins syr 1ml 29gx12.5mm QL 200 / 30 DAYS
droplet ins syr 1ml 30gx12.5mm QL 200 / 30 DAYS
droplet micron 34g x 9/64" QL 200 / 30 day(s)
droplet pen needle 29gx1/2" QL 200 / 30 DAYS
droplet pen needle 29gx3/8" QL 200 / 30 DAYS
droplet pen needle 30gx5/16" QL 200 / 30 DAYS
droplet pen needle 31gx1/4" QL 200 / 30 DAYS
droplet pen needle 31gx3/16" QL 200 / 30 DAYS
droplet pen needle 31gx5/16" QL 200 / 30 DAYS
droplet pen needle 32gx1/4" QL 200 / 30 DAYS
droplet pen needle 32gx3/16" QL 200 / 30 DAYS
droplet pen needle 32gx5/16" QL 200 / 30 DAYS
droplet pen needle 32gx5/32" QL 200 / 30 DAYS
dropsafe pen needle 31gx1/4" QL 200 / 30 DAYS
dropsafe pen needle 31gx5/16" QL 200 / 30 DAYS
drug mart ultra comfort syr QL 200 / 30 DAYS
drug mart ultra comfort syr QL 200 / 30 DAYS
drug mart ultra comfort syr QL 200 / 30 DAYS
PAGE 192 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
drug mart ultra comfort syr QL 200 / 30 DAYS
drug mart ultra comfort syr QL 200 / 30 DAYS
drug mart ultra comfort syr QL 200 / 30 DAYS
drug mart ultra comfort syr QL 200 / 30 DAYS
easivent holding chamber QL 1 / 90 DAYS
easivent mask-large QL 1 / 90 DAYS
easivent mask-medium QL 1 / 90 DAYS
easivent mask-small QL 1 / 90 DAYS
easy comfort 0.3 ml syringe QL 200 / 30 DAYS
easy comfort 0.5 ml 30gx1/2" QL 200 / 30 DAYS
easy comfort 0.5 ml 31gx5/16" QL 200 / 30 DAYS
easy comfort 0.5 ml 32gx5/16" QL 200 / 30 DAYS
easy comfort 0.5 ml syringe QL 200 / 30 DAYS
easy comfort 1 ml 31gx5/16" QL 200 / 30 DAYS
easy comfort 1 ml 32gx5/16" QL 200 / 30 DAYS
easy comfort insulin 1 ml syr QL 200 / 30 DAYS
easy comfort pen ndl 31gx1/4" QL 200 / 30 DAYS
easy comfort pen ndl 32gx5/32" QL 200 / 30 DAYS
easy comfort pen ndl 33g 4mm QL 200 / 30 DAYS
easy comfort pen ndl 33g 5mm QL 200 / 30 DAYS
easy comfort pen ndl 33g 6mm QL 200 / 30 DAYS
easy comfort syr 1 ml 30gx1/2" QL 200 / 30 DAYS
easy glide ins 0.3 ml 31gx6mm QL 200 / 30 DAYS
easy glide ins 0.5 ml 31gx6mm QL 200 / 30 DAYS
easy glide ins 1 ml 31gx6mm QL 200 / 30 DAYS
PAGE 193 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
easy glide pen needle 4mm 33g QL 200 / 30 DAYS
easy touch 0.3 ml syr 30gx1/2" QL 200 / 30 DAYS
easy touch 0.5 ml syr 27gx1/2" QL 200 / 30 DAYS
easy touch 0.5 ml syr 29gx1/2" QL 200 / 30 DAYS
easy touch 0.5 ml syr 30gx1/2" QL 200 / 30 DAYS
easy touch 0.5 ml syr 30gx5/16 QL 200 / 30 DAYS
easy touch 1 ml syr 27gx1/2" QL 200 / 30 DAYS
easy touch 1 ml syr 29gx1/2" QL 200 / 30 DAYS
easy touch 1 ml syr 30gx1/2" QL 200 / 30 DAYS
easy touch 1 ml syr 30gx1/2" QL 200 / 30 DAYS
easy touch alcohol 70% pads easy touch fliplock 3 ml 18gx1 easy touch fliplock 3 ml 20gx1 easy touch fliplock 3 ml 22gx1 easy touch fliplock 3 ml 23gx1 easy touch fliplock 3 ml 25gx1 easy touch fliplok 3ml 18gx1.5 easy touch fliplok 3ml 20gx1.5 easy touch fliplok 3ml 22gx1.5 easy touch fliplok 3ml 23gx1.5 easy touch fliplok 3ml 25gx5/8
easy touch insulin 1ml 29gx1/2 QL 200 / 30 DAYS
easy touch insulin 1ml 30gx1/2 QL 200 / 30 DAYS
easy touch insulin syr 0.3 ml QL 200 / 30 DAYS
easy touch insulin syr 0.3 ml QL 200 / 30 DAYS
easy touch insulin syr 0.5 ml QL 200 / 30 DAYS
easy touch insulin syr 0.5 ml QL 200 / 30 DAYS
PAGE 194 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
easy touch insulin syr 0.5 ml QL 200 / 30 DAYS
easy touch insulin syr 0.5 ml QL 200 / 30 DAYS
easy touch insulin syr 1 ml QL 200 / 30 DAYS
easy touch insulin syr 1 ml QL 200 / 30 DAYS
easy touch insulin syr 1 ml QL 200 / 30 DAYS
easy touch insulin syr 1 ml QL 200 / 30 DAYS
easy touch insulin syr 1 ml QL 200 / 30 DAYS
easy touch insuln 1ml 29gx1/2" QL 200 / 30 DAYS
easy touch insuln 1ml 30gx1/2" QL 200 / 30 DAYS
easy touch insuln 1ml 30gx5/16 QL 200 / 30 DAYS
easy touch insuln 1ml 30gx5/16 QL 200 / 30 DAYS
easy touch insuln 1ml 31gx5/16 QL 200 / 30 DAYS
easy touch insuln 1ml 31gx5/16 QL 200 / 30 DAYS
easy touch luer lok insul 1 ml QL 200 / 30 DAYS
easy touch pen needle 29gx1/2" QL 200 / 30 DAYS
easy touch pen needle 30gx5/16 QL 200 / 30 DAYS
easy touch pen needle 31gx1/4" QL 200 / 30 DAYS
easy touch pen needle 31gx3/16 QL 200 / 30 DAYS
easy touch pen needle 31gx5/16 QL 200 / 30 DAYS
easy touch pen needle 32gx1/4" QL 200 / 30 DAYS
easy touch pen needle 32gx3/16 QL 200 / 30 DAYS
easy touch pen needle 32gx5/32 QL 200 / 30 DAYS
easy touch saf pen ndl 29g 8mm QL 200 / 30 DAYS
easy touch saf pen ndl 30g 5mm QL 200 / 30 day(s)
easy touch saf pen ndl 30g 8mm QL 200 / 30 DAYS
PAGE 195 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS easy touch sheath 3 ml 22gx1" easy touch sheath 3 ml 22gx1.5 easy touch sheath 3 ml 23gx1" easy touch sheath 3 ml 25gx1" easy touch sheath 3 ml 25gx5/8
easy touch syr 0.5ml 27g12.7mm QL 200 / 30 DAYS
easy touch syr 0.5ml 28g12.7mm QL 200 / 30 DAYS
easy touch syr 0.5ml 29g12.7mm QL 200 / 30 DAYS
easy touch syr 1 ml 27g 12.7mm QL 200 / 30 DAYS
easy touch syr 1 ml 28g 12.7mm QL 200 / 30 DAYS
easy touch syr 1 ml 29g 12.7mm QL 200 / 30 DAYS
easy touch syr 27gx1/2" 1 ml easy touch syr 3 ml 22gx1-1/2" easy touch syr 3 ml 25gx5/8" easy touch syringe 3 ml 20gx1" easy touch syringe 3 ml 22gx1" easy touch syringe 3 ml 23gx1" easy touch syringe 3 ml 25gx1" easy touch tb flp 1 ml 27gx1/2 easy touch tb flp 1 ml 28gx1/2 easy touch tb shlk 1ml 25gx5/8 easy touch tb shlk 1ml 27gx1/2 easy touch tb shlk 1ml 28gx1/2
easy touch uni-slip syr 1 ml QL 200 / 30 DAYS
easy-touch ins 1 ml 31gx5/16" QL 200 / 30 DAYS
easytouch saf pen ndl 30g 6mm QL 200 / 30 DAYS
eql alcohol 70% swabs
eql ins syr 1 ml 29gx1/2" QL 200 / 30 DAYS
PAGE 196 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
eql insul syr 0.3 ml 31gx5/16" QL 200 / 30 DAYS
eql insul syr 0.5 ml 31gx5/16" QL 200 / 30 DAYS
eql insulin 0.3 ml syringe QL 200 / 30 DAYS
eql insulin 0.3 ml syringe QL 200 / 30 DAYS
eql insulin 0.5 ml syringe QL 200 / 30 DAYS
eql insulin 0.5 ml syringe QL 200 / 30 DAYS
eql insulin 1 ml syringe QL 200 / 30 DAYS
eql insulin syr 1 ml 31gx5/16" QL 200 / 30 DAYS
exel 3 ml syrn 27g x 1 1/4"
exel ins syr u100 1 ml 28gx1/2 QL 200 / 30 DAYS
exel syringe 20gx1" 3 ml exel syringe 20gx1-1/2" 3 ml exel syringe 22gx1" 3 ml exel syringe 22gx1-1/2" 3 ml exel syringe 23gx1" 3 ml exel syringe 25gx1" 3 ml exel tb with needle 25gx5/8" exel tb with needle 26gx3/8" exel tb with needle 27gx1/2"
exel u100 0.3 ml 29gx1/2" QL 200 / 30 DAYS
exel u100 0.3 ml 30gx5/16" QL 200 / 30 DAYS
exel u100 0.5 ml 28gx1/2" QL 200 / 30 DAYS
exel u100 0.5 ml 29gx1/2" QL 200 / 30 DAYS
exel u100 0.5 ml 30gx5/16" QL 200 / 30 DAYS
exel u100 1 ml 30gx5/16" QL 200 / 30 DAYS
exel u100 ins syr 1 ml 29gx1/2 QL 200 / 30 DAYS
fantasy condom
PAGE 197 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS fc2 female condom femcap 22 mm cervical cap femcap 30 mm cervical cap fifty50 alcohol prep pads
fifty50 ins 0.3 ml 31gx5/16" QL 200 / 30 DAYS
fifty50 ins 0.5 ml 31gx5/16" QL 200 / 30 DAYS
fifty50 ins syr 1 ml 31gx5/16" QL 200 / 30 DAYS
fifty50 pen 31g x 3/16" needle QL 200 / 30 DAYS
fifty50 pen 31g x 5/16" needle QL 200 / 30 DAYS
fifty50 pen needle 32g x 1/4" QL 200 / 30 DAYS
fifty50 pen needle 32g x 5/32" QL 200 / 30 DAYS
flexichamber QL 1 / 90 DAYS
freestyle prec 0.5 ml 30gx5/16 QL 200 / 30 DAYS
freestyle prec 0.5 ml 31gx5/16 QL 200 / 30 DAYS
freestyle prec 1 ml 30gx5/16" QL 200 / 30 DAYS
freestyle prec 1 ml 31gx5/16" QL 200 / 30 DAYS
gnp alcohol swab
gnp clickfine 31g x 1/4" ndl QL 200 / 30 DAYS
gnp clickfine 31g x 5/16" ndl QL 200 / 30 DAYS
gnp ins syr 0.3 ml 29gx1/2" QL 200 / 30 DAYS
gnp insul syr 0.3 ml 31gx5/16" QL 200 / 30 DAYS
gnp insul syr 0.5 ml 31gx5/16" QL 200 / 30 DAYS
gnp insulin syr 1 ml 31gx5/16" QL 200 / 30 DAYS
gnp ult c 0.3ml 29gx1/2" (1/2) QL 200 / 30 DAYS
gnp ult cmfrt 0.5 ml 29gx1/2" QL 200 / 30 DAYS
gnp ulticare pen ndl 4mm 32g QL 200 / 30 DAYS
PAGE 198 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
gnp ulticare pen ndl 5mm 31g QL 200 / 30 DAYS
gnp ulticare pen ndl 6mm 32g QL 200 / 30 DAYS
gnp ulticare pen ndl 8mm 31g QL 200 / 30 DAYS
gnp ultr cmfrt 0.5 ml 28gx1/2" QL 200 / 30 DAYS
gnp ultr cmfrt 0.5 ml 30gx5/16 QL 200 / 30 DAYS
gnp ultr comfort 1 ml 29gx1/2" QL 200 / 30 DAYS
gnp ultra comfort 0.5 ml syr QL 200 / 30 DAYS
gnp ultra comfort 0.5 ml syr QL 200 / 30 DAYS
gnp ultra comfort 0.5 ml syr QL 200 / 30 DAYS
gnp ultra comfort 1 ml syringe QL 200 / 30 DAYS
gnp ultra comfort 1 ml syringe QL 200 / 30 DAYS
gnp ultra comfort 1 ml syringe QL 200 / 30 DAYS
gnp ultra comfort 3/10 ml syr QL 200 / 30 DAYS
gnp ultra comfrt 1 ml 28gx1/2" QL 200 / 30 DAYS
gs pen needle 31g x 1/4" QL 200 / 30 DAYS
gs pen needle 31g x 5/16" QL 200 / 30 DAYS
gs pen needle 31g x 5mm QL 200 / 30 DAYS
gs pen needle 31g x 6mm QL 200 / 30 DAYS
gs pen needle 31g x 8mm QL 200 / 30 DAYS
gs pen needle 32g x 4mm QL 200 / 30 DAYS
gs pen needle 32g x 6mm QL 200 / 30 DAYS
healthwise ins 0.3ml 30gx5/16" QL 200 / 30 DAYS
healthwise ins 0.3ml 31gx5/16" QL 200 / 30 DAYS
healthwise ins 0.5ml 30gx5/16" QL 200 / 30 DAYS
healthwise ins 0.5ml 31gx5/16" QL 200 / 30 DAYS
PAGE 199 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
healthwise ins 1 ml 30gx5/16" QL 200 / 30 DAYS
healthwise ins 1 ml 31gx5/16" QL 200 / 30 DAYS
healthwise pen needle 31g 5mm QL 200 / 30 DAYS
healthwise pen needle 31g 8mm QL 200 / 30 DAYS
healthwise pen needle 32g 4mm QL 200 / 30 DAYS
healthy accents pentip 4mm 32g QL 200 / 30 DAYS
healthy accents pentip 5mm 31g QL 200 / 30 DAYS
healthy accents pentip 6mm 31g QL 200 / 30 DAYS
healthy accents pentip 8mm 31g QL 200 / 30 DAYS
healthy accents pentp 12mm 29g QL 200 / 30 DAYS
heb unifine pntp plus 31gx3/16 QL 200 / 30 DAYS
heb unifine pntp plus 32gx5/32 QL 200 / 30 DAYS
hm alcohol 70% prep pads
hm ulticare pen needle 4mm 32g QL 200 / 30 DAYS
hm ulticare pen needle 5mm 31g QL 200 / 30 DAYS
hm ulticare pen needle 6mm 31g QL 200 / 30 DAYS
hm ulticare pen needle 8mm 31g QL 200 / 30 DAYS
incontrol pen needle 12mm 29g QL 200 / 30 DAYS
incontrol pen needle 4mm 32g QL 200 / 30 DAYS
incontrol pen needle 5mm 31g QL 200 / 30 DAYS
incontrol pen needle 6mm 31g QL 200 / 30 DAYS
incontrol pen needle 8mm 31g QL 200 / 30 DAYS
innospire elegance compres neb innospire essence compres neb innospire essence compress neb
inspirachamber QL 1 / 90 DAYS
PAGE 200 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
inspirachamber with mask-large QL 1 / 90 DAYS
inspirachamber with mask-med QL 1 / 90 DAYS
inspirachamber with mask-small QL 1 / 90 DAYS
insuflon subcutaneous cannula
insulin 1 ml syringe QL 200 / 30 DAYS
insulin 1 ml syringe QL 200 / 30 DAYS
insulin 1/2 ml syringe QL 200 / 30 DAYS
insulin 1/2 ml syringe QL 200 / 30 DAYS
insulin 3/10 ml syringe QL 200 / 30 DAYS
insulin 3/10 ml syringe QL 200 / 30 DAYS
insulin syr 0.3 ml 30gx5/16" QL 200 / 30 DAYS
insulin syr 0.3ml 31gx1/4(1/2) QL 200 / 30 DAYS
insulin syrin 0.3 ml 29gx1/2" QL 200 / 30 DAYS
insulin syrin 0.3 ml 30gx1/2" QL 200 / 30 DAYS
insulin syrin 0.3 ml 30gx5/16" QL 200 / 30 DAYS
insulin syrin 0.3 ml 31gx5/16" QL 200 / 30 DAYS
insulin syrin 0.5 ml 28gx1/2" QL 200 / 30 DAYS
insulin syrin 0.5 ml 29gx1/2" QL 200 / 30 DAYS
insulin syrin 0.5 ml 30gx1/2" QL 200 / 30 DAYS
insulin syrin 0.5 ml 30gx5/16" QL 200 / 30 DAYS
insulin syrin 0.5 ml 31gx5/16" QL 200 / 30 DAYS
insulin syrin 1 ml 29gx1/2" QL 200 / 30 DAYS
insulin syring 0.5 ml 27gx1/2" QL 200 / 30 DAYS
insulin syring 0.5 ml 29gx1/2" QL 200 / 30 DAYS
insulin syringe 0.3 ml QL 200 / 30 DAYS
insulin syringe 0.3 ml QL 200 / 30 DAYS
PAGE 201 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
insulin syringe 0.3 ml 31gx1/4 QL 200 / 30 DAYS
insulin syringe 0.5 ml QL 200 / 30 DAYS
insulin syringe 0.5 ml 31gx1/4 QL 200 / 30 DAYS
insulin syringe 1 ml QL 200 / 30 DAYS
insulin syringe 1 ml QL 200 / 30 DAYS
insulin syringe 1 ml 27gx1/2" QL 200 / 30 DAYS
insulin syringe 1 ml 28gx1/2" QL 200 / 30 DAYS
insulin syringe 1 ml 29gx1/2" QL 200 / 30 DAYS
insulin syringe 1 ml 30gx1/2" QL 200 / 30 DAYS
insulin syringe 1 ml 30gx5/16" QL 200 / 30 DAYS
insulin syringe 1 ml 31gx1/4" QL 200 / 30 DAYS
insulin syringe 1 ml 31gx5/16" QL 200 / 30 DAYS
insupen pen needle 29gx1/2" QL 200 / 30 DAYS
insupen pen needle 29gx12mm QL 200 / 30 DAYS
insupen pen needle 30gx8mm QL 200 / 30 DAYS
insupen pen needle 31gx3/16" QL 200 / 30 DAYS
insupen pen needle 31gx5/16" QL 200 / 30 DAYS
insupen pen needle 31gx6mm QL 200 / 30 DAYS
insupen pen needle 31gx8mm QL 200 / 30 DAYS
insupen pen needle 32gx4mm QL 200 / 30 DAYS
insupen pen needle 32gx5/32" QL 200 / 30 DAYS
insupen pen needle 32gx6mm QL 200 / 30 DAYS
insupen pen needle 32gx8mm QL 200 / 30 DAYS
insupen pen needle 33gx4mm QL 200 / 30 DAYS
kendall alcohol 70% prep pad kimono condoms
PAGE 202 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS kimono maxx condom kimono microthin aqua lube kimono microthin condom kimono textured condom
kinray ins syr 1 ml 31gx5/16" QL 200 / 30 DAYS
kinray syring 0.3 ml 31gx5/16" QL 200 / 30 DAYS
kinray syring 0.5 ml 31gx5/16" QL 200 / 30 DAYS
kmart valu plus syr 1/2 ml QL 200 / 30 DAYS
kmart valu plus syr 1/2 ml QL 200 / 30 DAYS
kro alcohol 70% prep pads kro alcohol 70% swabs
kro ins syr 0.3 ml 29gx1/2" QL 200 / 30 DAYS
kro ins syrin 0.3 ml 30gx5/16" QL 200 / 30 DAYS
kro ins syrin 0.3 ml 31gx5/16" QL 200 / 30 DAYS
kro ins syrin 0.5 ml 30gx5/16" QL 200 / 30 DAYS
kro ins syrin 0.5 ml 31gx5/16" QL 200 / 30 DAYS
kro ins syring 0.5 ml 29gx1/2" QL 200 / 30 DAYS
kro ins syringe 1 ml 29gx1/2" QL 200 / 30 DAYS
kro ins syringe 1 ml 30gx5/16" QL 200 / 30 DAYS
kro ins syringe 1 ml 31gx5/16" QL 200 / 30 DAYS
kro insulin syr 1 ml 30gx5/16" QL 200 / 30 DAYS
kro pen needle 4mm x 32g QL 200 / 30 DAYS
kro pen needle 4mm x 33g QL 200 / 30 day(s)
kro pen needle 5mm x 31g QL 200 / 30 DAYS
kro pen needle 6mm x 31g QL 200 / 30 DAYS
kro pen needle 8mm x 31g QL 200 / 30 DAYS
PAGE 203 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
kroger ins syr 0.3 ml 30gx5/16 QL 200 / 30 DAYS
kroger ins syr 0.5 ml 29gx1/2" QL 200 / 30 DAYS
kroger ins syr 1 ml 29gx1/2" QL 200 / 30 DAYS
kroger ins syr 1 ml 31gx5/16" QL 200 / 30 DAYS
kroger pen needles 31g x 5/16" QL 200 / 30 DAYS
kroger syr 0.5 ml 30gx5/16" QL 200 / 30 DAYS
kroger syring 0.3 ml 31gx5/16" QL 200 / 30 DAYS
lc plus nebulizer set
leader ins syr 0.3 ml 29gx1/2" QL 200 / 30 DAYS
leader ins syr 0.5 ml 28gx1/2" QL 200 / 30 DAYS
leader ins syr 0.5 ml 29gx1/2" QL 200 / 30 DAYS
leader ins syr 0.5 ml 30gx1/2" QL 200 / 30 DAYS
leader ins syr 1 ml 28gx1/2" QL 200 / 30 DAYS
leader ins syr 1 ml 29gx1/2" QL 200 / 30 DAYS
leader ins syr 1 ml 30gx5/16" QL 200 / 30 DAYS
leader ins syr 1 ml 31gx5/16" QL 200 / 30 DAYS
leader insulin syringe 0.3 ml QL 200 / 30 DAYS
leader syring 0.3 ml 31gx5/16" QL 200 / 30 DAYS
leader syring 0.5 ml 31gx5/16" QL 200 / 30 DAYS
lite touch 31gx1/4" pen needle QL 200 / 30 DAYS
lite touch insulin 0.5 ml syr QL 200 / 30 DAYS
lite touch insulin 0.5 ml syr QL 200 / 30 DAYS
lite touch insulin 0.5 ml syr QL 200 / 30 DAYS
lite touch insulin 1 ml syr QL 200 / 30 DAYS
lite touch insulin 1 ml syr QL 200 / 30 DAYS
lite touch insulin 1 ml syr QL 200 / 30 DAYS
PAGE 204 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
lite touch insulin syr 0.3 ml QL 200 / 30 DAYS
lite touch insulin syr 0.5 ml QL 200 / 30 DAYS
lite touch insulin syr 1 ml QL 200 / 30 DAYS
lite touch pen needle 29g QL 200 / 30 DAYS
lite touch pen needle 31g QL 200 / 30 DAYS
lite touch pen needle 31g QL 200 / 30 DAYS
liteaire mdi chamber QL 1 / 90 DAYS
litetouch ins 0.3 ml 29gx1/2" QL 200 / 30 DAYS
litetouch ins 0.3 ml 30gx5/16" QL 200 / 30 DAYS
litetouch ins 0.3 ml 31gx5/16" QL 200 / 30 DAYS
litetouch ins 0.5 ml 31gx5/16" QL 200 / 30 DAYS
litetouch large mask QL 1 / 90 DAYS
litetouch medium mask QL 1 / 90 DAYS
litetouch small mask QL 1 / 90 DAYS
litetouch syr 0.5 ml 28gx1/2" QL 200 / 30 DAYS
litetouch syr 0.5 ml 29gx1/2" QL 200 / 30 DAYS
litetouch syr 0.5 ml 30gx5/16" QL 200 / 30 DAYS
litetouch syrin 1 ml 28gx1/2" QL 200 / 30 DAYS
litetouch syrin 1 ml 29gx1/2" QL 200 / 30 DAYS
litetouch syrin 1 ml 30gx5/16" QL 200 / 30 DAYS
live better pen needles 8mm QL 200 / 30 DAYS
magellan insul syringe 0.3 ml QL 200 / 30 DAYS
magellan insul syringe 0.5 ml QL 200 / 30 DAYS
magellan insulin syr 0.3 ml QL 200 / 30 DAYS
magellan insulin syr 0.5 ml QL 200 / 30 DAYS
PAGE 205 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
magellan insulin syringe 1 ml QL 200 / 30 DAYS
magellan insulin syringe 1 ml QL 200 / 30 DAYS
magellan tuberculin syr 1 ml mask set with y-piece size 3
maxi-comfort ins 0.5 ml 28g QL 200 / 30 DAYS
maxi-comfort ins 1 ml 28gx1/2" QL 200 / 30 DAYS
maxicomfort ii pen ndl 31gx6mm QL 200 / 30 DAYS
maxicomfort ins 0.5ml 27gx1/2" QL 200 / 30 DAYS
maxicomfort ins 1 ml 27gx1/2" QL 200 / 30 DAYS
md-gastroview 66%-10% soln medihoney 2"x2" dressing medihoney 4"x5" dressing methylergonovine 0.2 mg tablet microair mesh nebulizer
microchamber QL 1 / 90 DAYS
microlet 2 lancing device QL 1 / 180 DAYS
microlet lancets QL 100 / 90 DAYS
microlet next lancing device QL 1 / 180 day(s)
microspacer for aerosol device QL 1 / 90 DAYS
mini ultra-thin ii pen ndl 31g QL 200 / 30 DAYS
monoject 0.5 ml syrn 28gx1/2" QL 200 / 30 DAYS
monoject 1 ml syrn 27x1/2" QL 200 / 30 DAYS
monoject 1 ml syrn 28gx1/2" QL 200 / 30 DAYS
monoject 1 ml tb syrn 25x5/8" monoject 3 ml syringe 23gx1" monoject 3 ml syringe 25gx1" monoject 3 ml syrn 22gx1-1/2"
PAGE 206 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS monoject 3 ml syrn 22gx11/2" monoject 3 ml syrn 23gx1" monoject 3 ml syrn 25gx1" monoject 3 ml syrn 25gx1.25" monoject 3 ml syrn 25gx5/8" monoject 3 ml syrn 27gx1.25" monoject 3 ml syrn 27gx11/4"
monoject insul syr u100 QL 200 / 30 DAYS
monoject insul syr u100 QL 200 / 30 DAYS
monoject insul syr u100 0.5 ml QL 200 / 30 DAYS
monoject insul syr u100 1 ml QL 200 / 30 DAYS
monoject insul syr u100 1 ml QL 200 / 30 DAYS
monoject insul syr u100 1 ml QL 200 / 30 DAYS
monoject insul syr u100 1 ml QL 200 / 30 DAYS
monoject insulin syr 0.3 ml QL 200 / 30 DAYS
monoject insulin syr 0.5 ml QL 200 / 30 DAYS
monoject insulin syr 1 ml QL 200 / 30 DAYS
monoject insulin syr u-100 QL 200 / 30 DAYS
monoject insulin syr u-100 QL 200 / 30 DAYS
monoject insulin syrn 3/10 ml QL 200 / 30 DAYS
monoject magellan syringe 3 ml monoject safety syringe
monoject syringe 0.3 ml QL 200 / 30 DAYS
monoject syringe 0.5 ml QL 200 / 30 DAYS
monoject syringe 1 ml QL 200 / 30 DAYS
monoject syringe 1 ml QL 200 / 30 DAYS
monoject syringe 3 ml 20gx1
PAGE 207 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS monoject syringe 3 ml 22gx1" monoject syrn 3 ml 20gx1-1/2" monoject syrng 20gx1" 3 ml monoject tb 1 ml syrn 26x3/8" monoject tb 1 ml syrn 27gx1/2 monoject tb 1 ml syrn 28gx1/2 monoject tb safety syringe monoject tb safety syrn 1 ml monoject tb syrn 25gx5/8" monoject tb syrn 26gx3/8" monoject tb syrn 27gx1/2" mouthpiece, sterilizable
ms ins syr 0.5 ml 29gx1/2" QL 200 / 30 DAYS
ms ins syr 1 ml 29gx1/2" QL 200 / 30 DAYS
ms ins syringe 1 ml 30gx1/2" QL 200 / 30 DAYS
ms insul syr 0.3 ml 31gx5/16" QL 200 / 30 DAYS
ms insul syr 0.5 ml 30gx1/2" QL 200 / 30 DAYS
ms insul syr 0.5 ml 31gx5/16" QL 200 / 30 DAYS
ms insulin syr 0.3 ml 29gx1/2" QL 200 / 30 DAYS
ms insulin syr 1 ml 31gx5/16" QL 200 / 30 DAYS
ms insulin syringe 0.3 ml QL 200 / 30 DAYS
ms pen needle 6mm 31g QL 200 / 30 DAYS
novofine 32g needles QL 200 / 30 DAYS
novofine autocover 30g needle QL 200 / 30 DAYS
novofine plus pen ndl 32gx1/6" QL 200 / 30 DAYS
novotwist needle 32g 5mm QL 200 / 30 DAYS
one way valved mouthpiece QL 1 / 90 DAYS
PAGE 208 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
onetouch delica 30g lancets QL 100 / 90 DAYS
onetouch delica 33g lancets QL 100 / 90 DAYS
onetouch delica lancing dev QL 1 / 180 DAYS
onetouch delica plus 30g lanct QL 100 / 90 DAYS
onetouch delica plus 33g lanct QL 100 / 90 DAYS
onetouch suresoft 18g lanc dev QL 100 / 90 DAYS
onetouch suresoft 21g lanc dev QL 100 / 90 DAYS
onetouch suresoft 28g lanc dev QL 100 / 90 DAYS
onetouch ultra test strip QL 50 / 90 day(s)
onetouch ultra2 glucose syst QL 1 / 2 YEARS
onetouch ultramini meter QL 1 / 2 YEARS
onetouch ultrasoft lancets QL 100 / 90 DAYS
onetouch verio flex meter QL 1 / 2 YEARS
onetouch verio iq meter QL 1 / 2 YEARS
onetouch verio meter QL 1 / 2 YEARS
optichamber diamond vhc QL 1 / 90 DAYS
optichamber diamond w-lrg mask QL 1 / 90 DAYS
optichamber diamond w-med mask QL 1 / 90 DAYS
optichamber diamond w-sml mask QL 1 / 90 DAYS
panda mask large QL 1 / 90 DAYS
panda mask medium QL 1 / 90 DAYS
panda mask small QL 1 / 90 DAYS
paradigm infusion 24" set paradigm infusion 42" set paradigm silhouette 18" set paradigm silhouette 23" set
PAGE 209 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS paradigm silhouette 32" set paradigm silhouette 43" set PARAGARD T 380-A IUD copper pari baby conversion kit pari baby nebulizer pari lc d nebulizer set pari lc plus nebulizer kit pari lc plus nebulizer set pari lc sprint nebulizer set
pc unifine pentips 12mm needle QL 200 / 30 DAYS
pc unifine pentips 6mm needle QL 200 / 30 DAYS
pc unifine pentips 8mm needle QL 200 / 30 DAYS
peak-air peak flow meter
pediatric medium mask QL 1 / 90 DAYS
pediatric panda mask QL 1 / 90 DAYS
pediatric small mask QL 1 / 90 DAYS
pen needle 12mm 29g QL 200 / 30 DAYS
pen needle 29g 12mm QL 200 / 30 DAYS
pen needle 30g x 5/16" QL 200 / 30 DAYS
pen needle 31g 5mm QL 200 / 30 DAYS
pen needle 31g 6mm QL 200 / 30 DAYS
pen needle 31g 8mm QL 200 / 30 DAYS
pen needle 31g x 1/4" QL 200 / 30 DAYS
pen needle 31g x 3/16" QL 200 / 30 DAYS
pen needle 31g x 5/16" QL 200 / 30 DAYS
pen needle 31g x 8mm QL 200 / 30 DAYS
pen needle 32g 4mm QL 200 / 30 DAYS
PAGE 210 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
pen needle 32g x 1/4" QL 200 / 30 DAYS
pen needle 32g x 3/16" QL 200 / 30 DAYS
pen needle 32g x 5/32" QL 200 / 30 DAYS
pen needle 33g 4mm QL 200 / 30 day(s)
pen needle 4mm 32g QL 200 / 30 DAYS
pen needle 5mm 31g QL 200 / 30 DAYS
pen needle 6mm 31g QL 200 / 30 DAYS
pen needle 8mm 31g QL 200 / 30 DAYS
pen needles 12mm 29g QL 200 / 30 DAYS
pen needles 4mm 32g QL 200 / 30 DAYS
pen needles 5mm 31g QL 200 / 30 DAYS
pen needles 6mm 31g QL 200 / 30 DAYS
pen needles 8mm 31g QL 200 / 30 DAYS
pentips pen needle 29gx1/2" QL 200 / 30 DAYS
pentips pen needle 31gx1/4" QL 200 / 30 DAYS
pentips pen needle 31gx3/16" QL 200 / 30 DAYS
pentips pen needle 31gx5/16" QL 200 / 30 DAYS
pentips pen needle 32gx5/32" QL 200 / 30 DAYS
pentips pen needle 6mm 31g QL 200 / 30 DAYS
pflex inspiratory trainer pharm choice alcohol prep pads phenol liquified pillow mask-child
pip pen needle 31g x 5mm QL 200 / 30 DAYS
pip pen needle 32g x 4mm QL 200 / 30 DAYS
pocket chamber QL 1 / 90 DAYS
PAGE 211 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS polyfin qr infusion set
pref plus ins 0.3 ml 29gx1/2" QL 200 / 30 DAYS
pref plus syr 0.5 ml 30gx5/16" QL 200 / 30 DAYS
pref plus syring 1 ml 29gx1/2" QL 200 / 30 DAYS
preferred plus 0.3 ml 30gx5/16 QL 200 / 30 DAYS
preferred plus 0.5 ml 29gx1/2" QL 200 / 30 DAYS
preferred plus syringe 0.5 ml QL 200 / 30 DAYS
preferred plus syringe 1 ml QL 200 / 30 DAYS
prefpls ins syr 1 ml 30gx5/16" QL 200 / 30 DAYS
prep ease alcohol pads
pro comfort 0.5 ml 30gx1/2" QL 200 / 30 DAYS
pro comfort 0.5 ml 30gx5/16" QL 200 / 30 DAYS
pro comfort 0.5 ml 31gx5/16" QL 200 / 30 DAYS
pro comfort 1 ml 30gx1/2" QL 200 / 30 DAYS
pro comfort 1 ml 30gx5/16" QL 200 / 30 DAYS
pro comfort 1 ml 31gx5/16" QL 200 / 30 DAYS
pro comfort pen ndl 31gx5/16" QL 200 / 30 DAYS
pro comfort pen ndl 32g x 1/4" QL 200 / 30 DAYS
pro comfort pen ndl 4mm 32g QL 200 / 30 DAYS
pro comfort pen ndl 5mm 32g QL 200 / 30 DAYS
pro comfort spacer-adult mask QL 1 / 90 DAYS
pro comfort spacer-child mask QL 1 / 90 DAYS
procare spacer with adult mask QL 1 / 90 DAYS
procare spacer with child mask QL 1 / 90 DAYS
prochamber holding chamber QL 1 / 90 DAYS
prodigy ins syr 1ml 28gx1/2" QL 200 / 30 DAYS
PAGE 212 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS prodigy mini-mist nebulizer
prodigy syrng 0.5 ml 31gx5/16" QL 200 / 30 DAYS
prodigy syrnge 0.3ml 31gx5/16" QL 200 / 30 DAYS
proneb ultra ii compressor
pub ins syrin 0.3 ml 30gx1/2" QL 200 / 30 DAYS
pub ins syringe 1 ml 30gx1/2" QL 200 / 30 DAYS
pub insul syr 0.3 ml 31gx5/16" QL 200 / 30 DAYS
pub insul syr 0.5 ml 30gx1/2" QL 200 / 30 DAYS
pub insul syr 0.5 ml 31gx5/16" QL 200 / 30 DAYS
pub insulin syr 1 ml 31gx5/16" QL 200 / 30 DAYS
pub pen 12mm 29g needles QL 200 / 30 DAYS
pub pen 8mm 31g needles QL 200 / 30 DAYS
pub pen needle 6mm 31g QL 200 / 30 DAYS
pub unifine pntp plus 31gx3/16 QL 200 / 30 DAYS
pulmo-aide compact compressor pulmo-aide compressor-nebuliz pulmoneb lt compressor nebul
pv unifine pentip plus 31gx5mm QL 200 / 30 DAYS
pv unifine pentip plus 31gx6mm QL 200 / 30 DAYS
pv unifine pentip plus 31gx8mm QL 200 / 30 DAYS
pv unifine pentip plus 32gx4mm QL 200 / 30 DAYS
qc alcohol 70% swabs
qc unifine pentips 32gx5/32" QL 200 / 30 DAYS
qc unifine pentips 4mm 32g QL 200 / 30 DAYS
ra alcohol swabs
ra ins syr 0.5 ml 29gx1/2" QL 200 / 30 DAYS
ra ins syr 0.5 ml 30gx5/16" QL 200 / 30 DAYS
PAGE 213 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
ra ins syr 1 ml 29gx1/2" QL 200 / 30 DAYS
ra ins syringe 1 ml 30gx5/16" QL 200 / 30 DAYS
ra pen needle 31gx3/16" QL 200 / 30 DAYS
ra pen needle 31gx5/16" QL 200 / 30 DAYS
radiagel
reli on 31g x 1/4" needles QL 200 / 30 DAYS
relion alcohol 70% swabs
relion ins syr 0.3 ml 29gx1/2" QL 200 / 30 DAYS
relion ins syr 0.3 ml 30gx5/16 QL 200 / 30 DAYS
relion ins syr 0.3 ml 31gx6mm QL 200 / 30 DAYS
relion ins syr 0.5 ml 29gx1/2" QL 200 / 30 DAYS
relion ins syr 0.5 ml 31gx6mm QL 200 / 30 DAYS
relion ins syr 1 ml 29gx1/2" QL 200 / 30 DAYS
relion ins syr 1 ml 30gx5/16" QL 200 / 30 DAYS
relion ins syr 1 ml 31gx15/64" QL 200 / 30 DAYS
relion ins syr 1 ml 31gx5/16" QL 200 / 30 DAYS
relion insulin syr 0.5 ml QL 200 / 30 DAYS
relion mini pen 31g x 1/4" ndl QL 200 / 30 DAYS
relion pen 29g needle QL 200 / 30 DAYS
relion pen 31g needle QL 200 / 30 DAYS
relion pen needle 29gx1/2" QL 200 / 30 DAYS
relion pen needle 31g 6mm QL 200 / 30 DAYS
relion pen needle 31gx1/4" QL 200 / 30 DAYS
relion pen needle 31gx5/16" QL 200 / 30 DAYS
relion pen needle 32gx5/32" QL 200 / 30 DAYS
relion pen needles 32gx5/32" QL 200 / 30 DAYS
PAGE 214 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
relion syr 0.5 ml 30gx5/16" QL 200 / 30 DAYS
relion syring 0.3 ml 31gx5/16" QL 200 / 30 DAYS
relion syring 0.5 ml 31gx5/16" QL 200 / 30 DAYS
restore 2"x2" dressing restore 4"x4" foam silver drsg reusable nebulizer kit
riteflo spacer QL 1 / 90 DAYS
safesnap allergy syringe 1 ml
safesnap insul syringe 0.3 ml QL 200 / 30 DAYS
safesnap insul syringe 0.5 ml QL 200 / 30 DAYS
safesnap insul syringe 0.5 ml QL 200 / 30 DAYS
safesnap insulin syringe 1 ml QL 200 / 30 DAYS
safesnap insulin syringe 1 ml QL 200 / 30 DAYS
safesnap syringe 3 ml safesnap syringe 3 ml safesnap syringe 3 ml safesnap syringe 3 ml safesnap syringe 3 ml safesnap syringe 3 ml safesnap syringe 3 ml safesnap syringe 3 ml safesnap tuberculin syr 1 ml safesnap tuberculin syr 1 ml
safety pen needle 5mm x 31g QL 200 / 30 DAYS
safety syringe w-shield 3 ml safety syringe w-shield 3 ml safety syringe w-shield 3 ml safety syringe w-shield 3 ml
PAGE 215 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS safety-lok 1 ml tb syringe safety-lok 1 ml tb syringe safety-lok 3 ml syringe safety-lok 3 ml syringe safety-lok 3 ml syringe safety-lok 3 ml syringe sami the seal compressor nebul sami the seal pediatric mask saps alcohol 70% prep pads
shopko unifine pentips 4mm 32g QL 200 / 30 DAYS
shopko unifine pentips 4mm 32g QL 200 / 30 DAYS
shopko unifine pentips 5mm 31g QL 200 / 30 DAYS
shopko unifine pentips 5mm 31g QL 200 / 30 DAYS
shopko unifine pentips 8mm 31g QL 200 / 30 DAYS
shopko unifine pentips 8mm 31g QL 200 / 30 DAYS
shopko unifine pntips 12mm 29g QL 200 / 30 DAYS
shopko unifine pntips 12mm 29g QL 200 / 30 DAYS
sidestream custom nebulizer sidestream dispos nebulizer sidestream nebulizer pediatric sidestream reusable nebulizer silhouette 13mm set silhouette 17mm set
silicone mask-infant QL 1 / 90 DAYS
silicone mask-pediatric QL 1 / 90 DAYS
sm alcohol 70% prep pads sm alcohol prep pads
sm ins syr 0.5 ml 29gx1/2" QL 200 / 30 DAYS
PAGE 216 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
sm ins syr 0.5 ml 30gx5/16" QL 200 / 30 DAYS
sm ins syr 1 ml 29gx1/2" QL 200 / 30 DAYS
sm ins syring 0.3 ml 30gx5/16" QL 200 / 30 DAYS
sm ins syringe 1 ml 28gx1/2" QL 200 / 30 DAYS
sm ins syringe 1 ml 30gx5/16" QL 200 / 30 DAYS
sm insul syr 0.3 ml 31gx5/16" QL 200 / 30 DAYS
sm insul syr 0.5 ml 31gx5/16" QL 200 / 30 DAYS
sm insulin syr 0.3 ml 29gx1/2" QL 200 / 30 DAYS
sm insulin syr 0.5 ml 28gx1/2" QL 200 / 30 DAYS
sm insulin syr 1 ml 31gx5/16" QL 200 / 30 DAYS
sodium succinate powder spectragel gel dressing sterile water for irrigation
sure cmft sfty pen ndl 31g 6mm QL 200 / 30 DAYS
sure cmft sfty pen ndl 32g 4mm QL 200 / 30 DAYS
sure comfort 0.3 ml syringe QL 200 / 30 DAYS
sure comfort 0.5 ml syringe QL 200 / 30 DAYS
sure comfort 0.5 ml syringe QL 200 / 30 DAYS
sure comfort 0.5 ml syringe QL 200 / 30 DAYS
sure comfort 0.5 ml syringe QL 200 / 30 DAYS
sure comfort 0.5 ml syringe QL 200 / 30 DAYS
sure comfort 1 ml syringe QL 200 / 30 DAYS
sure comfort 1 ml syringe QL 200 / 30 DAYS
sure comfort 1 ml syringe QL 200 / 30 DAYS
sure comfort 1 ml syringe QL 200 / 30 DAYS
sure comfort 1 ml syringe QL 200 / 30 DAYS
PAGE 217 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
sure comfort 3/10 ml syringe QL 200 / 30 DAYS
sure comfort 3/10 ml syringe QL 200 / 30 DAYS
sure comfort 3/10 ml syringe QL 200 / 30 DAYS
sure comfort 3/10 ml syringe QL 200 / 30 DAYS
sure comfort 30g pen needle QL 200 / 30 DAYS
sure comfort 31g pen needle QL 200 / 30 DAYS
sure comfort alcohol prep pads
sure comfort ins 0.3ml 31gx1/4 QL 200 / 30 DAYS
sure comfort ins 0.5ml 31gx1/4 QL 200 / 30 DAYS
sure comfort ins 1 ml 31gx1/4" QL 200 / 30 DAYS
sure comfort pen ndl 29gx1/2" QL 200 / 30 DAYS
sure comfort pen ndl 31gx3/16" QL 200 / 30 DAYS
sure comfort pen ndl 32gx1/4" QL 200 / 30 DAYS
sure comfort pen ndl 32gx5/32" QL 200 / 30 DAYS
sure-fine pen needles 12.7mm QL 200 / 30 DAYS
sure-fine pen needles 5mm QL 200 / 30 DAYS
sure-fine pen needles 8mm QL 200 / 30 DAYS
sure-ject ins 0.3 ml 31gx5/16" QL 200 / 30 DAYS
sure-ject ins 0.5 ml 31gx5/16" QL 200 / 30 DAYS
sure-ject insu syr u100 0.3 ml QL 200 / 30 DAYS
sure-ject insu syr u100 0.3 ml QL 200 / 30 DAYS
sure-ject insu syr u100 0.5 ml QL 200 / 30 DAYS
sure-ject insu syr u100 0.5 ml QL 200 / 30 DAYS
sure-ject insu syr u100 0.5 ml QL 200 / 30 DAYS
sure-ject insu syr u100 1 ml QL 200 / 30 DAYS
sure-ject insul syr u100 1 ml QL 200 / 30 DAYS
PAGE 218 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
sure-ject insul syr u100 1 ml QL 200 / 30 DAYS
sure-ject insulin syringe 1 ml QL 200 / 30 DAYS
sure-prep alcohol prep pads sure-t infusion 23" set t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embol stocking t.e.d. anti-embolism stocking
techlite 0.3 ml 29gx12mm (1/2) QL 200 / 30 DAYS
techlite 0.3 ml 30gx12mm (1/2) QL 200 / 30 DAYS
techlite 0.3 ml 30gx8mm (1/2) QL 200 / 30 DAYS
techlite 0.3 ml 31gx6mm (1/2) QL 200 / 30 DAYS
PAGE 219 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
techlite 0.3 ml 31gx8mm (1/2) QL 200 / 30 DAYS
techlite 0.5 ml 29gx12mm (1/2) QL 200 / 30 DAYS
techlite 0.5 ml 30gx12mm (1/2) QL 200 / 30 DAYS
techlite 0.5 ml 30gx8mm (1/2) QL 200 / 30 DAYS
techlite 0.5 ml 31gx6mm (1/2) QL 200 / 30 DAYS
techlite 0.5 ml 31gx8mm (1/2) QL 200 / 30 DAYS
techlite ins syr 1 ml 29gx12mm QL 200 / 30 DAYS
techlite ins syr 1 ml 30gx12mm QL 200 / 30 DAYS
techlite ins syr 1 ml 30gx8mm QL 200 / 30 DAYS
techlite ins syr 1 ml 31gx6mm QL 200 / 30 DAYS
techlite ins syr 1 ml 31gx8mm QL 200 / 30 DAYS
techlite pen needle 29gx1/2" QL 200 / 30 DAYS
techlite pen needle 29gx3/8" QL 200 / 30 DAYS
techlite pen needle 31gx1/4" QL 200 / 30 DAYS
techlite pen needle 31gx3/16" QL 200 / 30 DAYS
techlite pen needle 31gx5/16" QL 200 / 30 DAYS
techlite pen needle 32gx1/4" QL 200 / 30 DAYS
techlite pen needle 32gx5/16" QL 200 / 30 DAYS
techlite pen needle 32gx5/32" QL 200 / 30 DAYS
terumo allergy 1 ml 27gx1/2"
terumo ins syr 0.3 ml 29gx1/2" QL 200 / 30 DAYS
terumo ins syringe u100-1 ml QL 200 / 30 DAYS
terumo ins syringe u100-1 ml QL 200 / 30 DAYS
terumo ins syringe u100-1 ml QL 200 / 30 DAYS
terumo ins syringe u100-1 ml QL 200 / 30 DAYS
terumo ins syringe u100-1/2 ml QL 200 / 30 DAYS
PAGE 220 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
terumo ins syringe u100-1/3 ml QL 200 / 30 DAYS
terumo ins syrng u100-1/2 ml QL 200 / 30 DAYS
terumo ins syrng u100-1/2 ml QL 200 / 30 DAYS
terumo ins syrng u100-1/2 ml QL 200 / 30 DAYS
terumo surguard2 syr 20g-3 ml terumo surguard2 syr 20g-3 ml terumo surguard2 syr 22g 3 ml terumo surguard2 syr 22g 3 ml terumo surguard2 syr 23g 3 ml terumo surguard2 syr 25g 3 ml terumo surguard2 syr 25g 3 ml terumo syringe 3 ml terumo syringe 3 ml terumo syringe 3 ml
thinpro ins syrin u100-0.3 ml QL 200 / 30 DAYS
thinpro ins syrin u100-0.3 ml QL 200 / 30 DAYS
thinpro ins syrin u100-0.3 ml QL 200 / 30 DAYS
thinpro ins syrin u100-0.5 ml QL 200 / 30 DAYS
thinpro ins syrin u100-0.5 ml QL 200 / 30 DAYS
thinpro ins syrin u100-0.5 ml QL 200 / 30 DAYS
thinpro ins syrin u100-0.5 ml QL 200 / 30 DAYS
thinpro ins syrin u100-1 ml QL 200 / 30 DAYS
thinpro ins syrin u100-1 ml QL 200 / 30 DAYS
thinpro ins syrin u100-1 ml QL 200 / 30 DAYS
thinpro ins syrin u100-1 ml QL 200 / 30 DAYS
today's hlth pn needle 6mm 31g QL 200 / 30 DAYS
topcare clickfine 31g x 1/4" QL 200 / 30 DAYS
PAGE 221 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
topcare clickfine 31g x 5/16" QL 200 / 30 DAYS
topcare ultra comfort syringe QL 200 / 30 DAYS
topcare ultra comfort syringe QL 200 / 30 DAYS
topcare ultra comfort syringe QL 200 / 30 DAYS
topcare ultra comfort syringe QL 200 / 30 DAYS
topcare ultra comfort syringe QL 200 / 30 DAYS
topcare ultra comfort syringe QL 200 / 30 DAYS
topcare ultra comfort syringe QL 200 / 30 DAYS
topcare ultra comfort syringe QL 200 / 30 DAYS
topcare ultra comfort syringe QL 200 / 30 DAYS
touch-trol suction catheter
true comfort 0.5 ml 31gx5/16" QL 200 / 30 DAYS
true comfort 1 ml 31gx5/16" QL 200 / 30 DAYS
true comfort pen ndl 31g 8mm QL 200 / 30 DAYS
true comfort pen ndl 31gx5mm QL 200 / 30 DAYS
true comfort pen ndl 31gx6mm QL 200 / 30 DAYS
true comfort pen ndl 32g 5mm QL 200 / 30 DAYS
true comfort pen ndl 32gx4mm QL 200 / 30 DAYS
trueplus syr 0.3ml 29gx1/2" QL 200 / 30 DAYS
trueplus syr 0.3ml 30gx5/16" QL 200 / 30 DAYS
trueplus syr 0.3ml 31gx5/16" QL 200 / 30 DAYS
trueplus syr 0.5ml 28gx1/2" QL 200 / 30 DAYS
trueplus syr 0.5ml 29gx1/2" QL 200 / 30 DAYS
trueplus syr 0.5ml 30gx5/16" QL 200 / 30 DAYS
trueplus syr 0.5ml 31gx5/16" QL 200 / 30 DAYS
trueplus syr 1ml 28gx1/2" QL 200 / 30 DAYS
PAGE 222 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
trueplus syr 1ml 29gx1/2" QL 200 / 30 DAYS
trueplus syr 1ml 30gx5/16" QL 200 / 30 DAYS
trueplus syr 1ml 31gx5/16" QL 200 / 30 DAYS
trustex condom trustex-ria condom truzone peak flow meter tuberculin syringe
ult cft 0.3 ml 29gx1/2" (1/2) QL 200 / 30 DAYS
ult cft 0.3 ml 30gx5/16" (1/2) QL 200 / 30 DAYS
ult cft 0.3 ml 31gx5/16" (1/2) QL 200 / 30 DAYS
ultcare ins syr 1 ml 31gx5/16" QL 200 / 30 DAYS
ulticar ins 0.3ml 31gx1/4(1/2) QL 200 / 30 DAYS
ulticare ins 0.3 ml 30gx1/2" QL 200 / 30 DAYS
ulticare ins 0.3 ml 31gx1/4" QL 200 / 30 DAYS
ulticare ins 0.5 ml 30gx1/2" QL 200 / 30 DAYS
ulticare ins 0.5 ml 31gx1/4" QL 200 / 30 DAYS
ulticare ins 1 ml 31gx1/4" QL 200 / 30 DAYS
ulticare ins safety 1ml 29x1/2 QL 200 / 30 DAYS
ulticare ins syr 1 ml 28gx1/2" QL 200 / 30 DAYS
ulticare ins syr 1 ml 29gx1/2" QL 200 / 30 DAYS
ulticare ins syr 1 ml 30gx1/2" QL 200 / 30 DAYS
ulticare lds syr 1 ml 22g 1.5" QL 200 / 30 day(s)
ulticare lds syr 3 ml 22gx1.5" QL 200 / 30 day(s)
ulticare pen ndl 12.7 mm 29g QL 200 / 30 DAYS
ulticare pen needle 31gx3/16" QL 200 / 30 DAYS
ulticare pen needle 4mm 32g QL 200 / 30 DAYS
PAGE 223 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
ulticare pen needle 6mm 31g QL 200 / 30 DAYS
ulticare pen needle 8 mm 31g QL 200 / 30 DAYS
ulticare pen needle 8mm 31g QL 200 / 30 DAYS
ulticare pen needles 12mm 29g QL 200 / 30 DAYS
ulticare pen needles 4mm 32g QL 200 / 30 DAYS
ulticare pen needles 6mm 31g QL 200 / 30 DAYS
ulticare pen needles 6mm 32g QL 200 / 30 DAYS
ulticare pen needles 8mm 31g QL 200 / 30 DAYS
ulticare safe pen ndl 5mm 30g QL 200 / 30 DAYS
ulticare safe pen ndl 8mm 30g QL 200 / 30 DAYS
ulticare safety 0.5 ml 29gx1/2 QL 200 / 30 DAYS
ulticare safety 3 ml 22gx1" ulticare safety 3 ml 22gx1-1/2 ulticare safety 3 ml 23gx1" ulticare safety 3 ml 25gx1" ulticare safety 3 ml 25gx5/8"
ulticare syr 0.3 ml 30gx1/2" QL 200 / 30 DAYS
ulticare syr 0.3 ml 30gx5/16" QL 200 / 30 DAYS
ulticare syr 0.3 ml 31gx5/16" QL 200 / 30 DAYS
ulticare syr 0.3 ml 31gx5/16" QL 200 / 30 DAYS
ulticare syr 0.5 ml 29gx1/2" QL 200 / 30 DAYS
ulticare syr 0.5 ml 30gx1/2" QL 200 / 30 DAYS
ulticare syr 0.5 ml 30gx5/16" QL 200 / 30 DAYS
ulticare syr 0.5 ml 31gx5/16" QL 200 / 30 DAYS
ulticare syr 0.5 ml 31gx5/16" QL 200 / 30 DAYS
ulticare syr 1 ml 30gx5/16" QL 200 / 30 DAYS
PAGE 224 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
ulticare syr 1 ml 31gx5/16" QL 200 / 30 DAYS
ulticare syrin 0.3 ml 29gx1/2" QL 200 / 30 DAYS
ulticare syrin 0.5 ml 28gx1/2" QL 200 / 30 DAYS
ulticare syringe 1 ml 30gx1/2" QL 200 / 30 DAYS
ulticare tb safety 1ml 25gx5/8
ultiguard safe pack 32g 4mm QL 200 / 30 DAYS
ultiguard safepack 31g 6mm QL 200 / 30 DAYS
ultiguard safepk 0.5ml 31g 8mm QL 200 / 30 DAYS
ultilet alcohol sterl swab
ultilet insulin syringe 0.3 ml QL 200 / 30 DAYS
ultilet insulin syringe 0.3 ml QL 200 / 30 DAYS
ultilet insulin syringe 0.3 ml QL 200 / 30 DAYS
ultilet insulin syringe 0.5 ml QL 200 / 30 DAYS
ultilet insulin syringe 0.5 ml QL 200 / 30 DAYS
ultilet insulin syringe 0.5 ml QL 200 / 30 DAYS
ultilet insulin syringe 1 ml QL 200 / 30 DAYS
ultilet insulin syringe 1 ml QL 200 / 30 DAYS
ultilet insulin syringe 1 ml QL 200 / 30 DAYS
ultilet pen needle 4mm 32g QL 200 / 30 DAYS
ultra comfort 0.3 ml 29gx1/2" QL 200 / 30 DAYS
ultra comfort 0.3 ml syringe QL 200 / 30 DAYS
ultra comfort 0.5 ml 28gx1/2" QL 200 / 30 DAYS
ultra comfort 0.5 ml 29gx1/2" QL 200 / 30 DAYS
ultra comfort 0.5 ml 30gx5/16" QL 200 / 30 DAYS
ultra comfort 0.5 ml 31gx5/16" QL 200 / 30 DAYS
ultra comfort 0.5 ml syringe QL 200 / 30 DAYS
PAGE 225 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
ultra comfort 0.5 ml syringe QL 200 / 30 DAYS
ultra comfort 1 ml 28gx1/2" QL 200 / 30 DAYS
ultra comfort 1 ml 29gx1/2" QL 200 / 30 DAYS
ultra comfort 1 ml 30gx5/16" QL 200 / 30 DAYS
ultra comfort 1 ml 31gx5/16" QL 200 / 30 DAYS
ultra comfort 1 ml syringe QL 200 / 30 DAYS
ultra flo 0.3ml 30g 1/2" (1/2) QL 200 / 30 DAYS
ultra flo 0.3ml 30g 5/16"(1/2) QL 200 / 30 DAYS
ultra flo 0.3ml 31g 5/16"(1/2) QL 200 / 30 DAYS
ultra flo syr 0.3 ml 29gx1/2" QL 200 / 30 DAYS
ultra flo syr 0.3 ml 30g 5/16" QL 200 / 30 DAYS
ultra flo syr 0.3 ml 31g 5/16" QL 200 / 30 DAYS
ultra flo syr 0.5 ml 29g 1/2" QL 200 / 30 DAYS
ultra thin pen ndl 32g x 4mm QL 200 / 30 DAYS
ultra-thin ii 1 ml 31gx5/16" QL 200 / 30 DAYS
ultra-thin ii ins 0.3 ml 30g QL 200 / 30 DAYS
ultra-thin ii ins 0.3 ml 31g QL 200 / 30 DAYS
ultra-thin ii ins 0.5 ml 29g QL 200 / 30 DAYS
ultra-thin ii ins 0.5 ml 30g QL 200 / 30 DAYS
ultra-thin ii ins 0.5 ml 31g QL 200 / 30 DAYS
ultra-thin ii ins syr 1 ml 29g QL 200 / 30 DAYS
ultra-thin ii ins syr 1 ml 30g QL 200 / 30 DAYS
ultra-thin ii pen ndl 29gx1/2" QL 200 / 30 DAYS
ultra-thin ii pen ndl 31gx5/16 QL 200 / 30 DAYS
ultracare ins 0.3 ml 30gx5/16" QL 200 / 30 DAYS
PAGE 226 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
ultracare ins 0.3 ml 31gx5/16" QL 200 / 30 DAYS
ultracare ins 0.5 ml 30gx1/2" QL 200 / 30 DAYS
ultracare ins 0.5 ml 30gx5/16" QL 200 / 30 DAYS
ultracare ins 0.5 ml 31gx5/16" QL 200 / 30 DAYS
ultracare ins 1 ml 30g x 5/16" QL 200 / 30 DAYS
ultracare ins 1 ml 30gx1/2" QL 200 / 30 DAYS
ultracare ins 1 ml 31g x 5/16" QL 200 / 30 DAYS
ultracare pen needle 31gx1/4" QL 200 / 30 DAYS
ultracare pen needle 31gx3/16" QL 200 / 30 DAYS
ultracare pen needle 31gx5/16" QL 200 / 30 DAYS
ultracare pen needle 32gx1/4" QL 200 / 30 DAYS
ultracare pen needle 32gx3/16" QL 200 / 30 DAYS
ultracare pen needle 32gx5/32" QL 200 / 30 DAYS
ultracare pen needle 33gx5/32" QL 200 / 30 DAYS
unifine pen needle 32g 4mm QL 200 / 30 DAYS
unifine pentips 12mm 29g QL 200 / 30 DAYS
unifine pentips 31gx3/16" QL 200 / 30 DAYS
unifine pentips 32gx1/4" QL 200 / 30 DAYS
unifine pentips 32gx5/32" QL 200 / 30 DAYS
unifine pentips 33gx5/32" QL 200 / 30 DAYS
unifine pentips 6mm 31g QL 200 / 30 DAYS
unifine pentips 6mm needle QL 200 / 30 DAYS
unifine pentips 8mm 31g QL 200 / 30 DAYS
unifine pentips 8mm needle QL 200 / 30 DAYS
unifine pentips max 30gx3/16" QL 200 / 30 day(s)
PAGE 227 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
unifine pentips needles 29g QL 200 / 30 DAYS
unifine pentips plus 29gx1/2" QL 200 / 30 DAYS
unifine pentips plus 30gx3/16" QL 200 / 30 day(s)
unifine pentips plus 31gx1/4" QL 200 / 30 DAYS
unifine pentips plus 31gx3/16" QL 200 / 30 DAYS
unifine pentips plus 31gx5/16" QL 200 / 30 DAYS
unifine pentips plus 32gx5/32" QL 200 / 30 DAYS
v-r alcohol prep pads
vanishpoint 0.5 ml 30gx1/2" sy QL 200 / 30 DAYS
vanishpoint 1 ml tb syr 25x5/8 vanishpoint 1 ml tb syr 27x1/2 vanishpoint 20gx1" 3 ml syring vanishpoint 22gx1" 3 ml syr vanishpoint 23gx1" 3 ml syring vanishpoint 23gx1-1/2 2 ml syr vanishpoint 23gx1-1/2 3 ml syr vanishpoint 25gx1" 3 ml syring vanishpoint 25gx5/8" 3 ml syr vanishpoint 3 ml 22gx1.5" syrg
vanishpoint ins 1 ml 30gx3/16" QL 200 / 30 day(s)
vanishpoint u-100 29x1/2 syr QL 200 / 30 DAYS
vios aerosol delivery system
vortex holding chamber QL 1 / 90 DAYS
vortex holding chamber-child QL 1 / 90 DAYS
vortex holding chamber-toddler QL 1 / 90 DAYS
vortex vhc frog child mask QL 1 / 90 DAYS
webcol alcohol preps wide seal diaphragm 60mm
PAGE 228 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS wide seal diaphragm 65mm wide seal diaphragm 70mm wide seal diaphragm 75mm wide seal diaphragm 80mm wide seal diaphragm 85mm wide seal diaphragm 90mm wide seal diaphragm 95mm
wm unifine pentip plus 4mm 32g QL 200 / 30 DAYS
wm unifine pentip plus 5mm 31g QL 200 / 30 DAYS
wm unifine pentip plus 6mm 31g QL 200 / 30 DAYS
wm unifine pentip plus 8mm 31g QL 200 / 30 DAYS
xeroform 5"x9" gauze strip xeroform petrol 5"x9" dressing xeroform petrolatum dress xeroform petrolatum dress xeroform petrolatum dress xeroform petrolatum dress
yourx ulticare pen ndl 4mm 32g QL 200 / 30 DAYS
yourx ulticare pen ndl 6mm 31g QL 200 / 30 DAYS
yourx ulticare pen ndl 8mm 31g QL 200 / 30 DAYS
OPHTHALMIC AGENTS
Ophthalmic Agents, Other
ak-poly-bac eye ointment OPHTHALMIC AGENTS, OTHER
atropine 1% eye drops atropine 1% eye ointment Ophthalmic Agents, Other
bacitracin-polymyxin eye oint
PAGE 229 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS OPHTHALMIC AGENTS, OTHER
cyclopentolate 1% eye drop cyclopentolate 1% eye drops Ophthalmic Agents, Other
dorzolamide-timolol eye drops OPHTHALMIC AGENTS, OTHER
homatropaire 5% eye drops homatropine 5% eye drops ISOPTO ATROPINE 1% EYE DROP atropine sulfate Ophthalmic Agents, Other
neo-bacit-poly-hc eye ointment OPHTHALMIC AGENTS, OTHER
neo-polycin eye ointment neo-polycin hc eye ointment Ophthalmic Agents, Other
neomyc-bacit-polymix eye oint neomyc-polym-dexamet eye ointm neomyc-polym-dexameth eye drop neomyc-polym-gramicid eye drop neomycin-poly-hc eye drops
QL 28 ML / 28 DAYS OXERVATE 0.002% EYE DROP PA cenegermin-bkbj S Specialty Drug
OPHTHALMIC AGENTS, OTHER
phenylephrine 10% eye drops phenylephrine 2.5% eye drop polycin eye ointment Ophthalmic Agents, Other
sulf-pred 10-0.23% eye drops
PAGE 230 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS OPHTHALMIC AGENTS, OTHER
TOBRADEX EYE OINTMENT tobramycin/dexamethasone tobramycin-dexameth ophth susp tropicamide 0.5% eye drop tropicamide 0.5% eye drops tropicamide 1% eye drop tropicamide 1% eye drops OPHTHALMIC ANTI-ALLERGY AGENTS
cromolyn 4% eye drops OPHTHALMIC ANTI-INFECTIVES
bacitracin 500 unit/gm ophth erythromycin 0.5% eye ointment gentamicin 0.3% eye drop ofloxacin 0.3% eye drops polymyxin b-tmp eye drops sulfacetamide 10% eye drops sulfacetamide 10% eye ointment tobramycin 0.3% eye drop OPHTHALMIC ANTI-INFLAMMATORIES
dexamethasone 0.1% eye drop diclofenac 0.1% eye drops fluorometholone 0.1% drops flurbiprofen 0.03% eye drop ketorolac 0.4% ophth solution ketorolac 0.5% ophth solution PRED MILD 0.12% EYE DROPS prednisolone acetate prednisolone ac 1% eye drop prednisolone acet 1% eye drop prednisolone sod 1% eye drop
PAGE 231 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS OPHTHALMIC BETA-ADRENERGIC BLOCKING AGENTS
betaxolol hcl 0.5% eye drop carteolol hcl 1% eye drops levobunolol 0.5% eye drops timolol 0.25% gel-solution timolol 0.25% gfs gel-solution timolol 0.5% gel-solution timolol 0.5% gfs gel-solution timolol maleate 0.25% eye drop timolol maleate 0.5% eye drops OPHTHALMIC INTRAOCULAR PRESSURE LOWERING AGENTS, OTHER
acetazolamide er 500 mg cap brimonidine 0.2% eye drop dorzolamide hcl 2% eye drops methazolamide 25 mg tablet methazolamide 50 mg tablet PHOSPHOLINE IODIDE 0.125% echothiophate iodide pilocarpine 1% eye drops pilocarpine 2% eye drops pilocarpine 4% eye drops Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost 0.005% eye drops OTIC AGENTS
ciproflox-dexameth otic susp PA
ciprofloxacin 0.2% otic soln hydrocortison-acetic acid soln neomycin-polymyxin-hc ear soln neomycin-polymyxin-hc ear susp ofloxacin 0.3% ear drops
PAGE 232 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS OTOVEL 0.3%-0.025% EAR DROPS ciprofloxacin hcl/fluocinolone acetonide RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
24 hour allergy 50 mcg spray PA
aller-flo 50 mcg spray PA
allergy relief 50 mcg spray PA
ARNUITY ELLIPTA 100 MCG INH QL 30 / 30 DAYS fluticasone furoate ARNUITY ELLIPTA 200 MCG INH QL 30 / 30 DAYS fluticasone furoate ARNUITY ELLIPTA 50 MCG INH QL 30 / 30 DAYS fluticasone furoate
budesonide 0.25 mg/2 ml susp QL 120 ml / 30 days
budesonide 0.5 mg/2 ml susp QL 120 ml / 30 days
budesonide 1 mg/2 ml inh susp QL 60 ml / 30 days
clarispray 50 mcg nasal spray PA
cvs fluticasone prop 50 mcg sp PA
eq allergy relief 50 mcg spray PA
eql fluticasone prop 50 mcg sp PA
FLOVENT HFA 110 MCG INHALER QL 12 g / 30 days fluticasone propionate AL1 0 to 10 yrs old
FLOVENT HFA 44 MCG INHALER QL 11 g / 30 days fluticasone propionate AL1 0 to 10 yrs old
fluticasone prop 50 mcg spray PA
fluticasone prop 50 mcg spray PA
gnp fluticasone prop 50 mcg sp PA
hm allergy relief 50 mcg spray PA
kro 24hr allergy rlf 50mcg spr PA
PAGE 233 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
qc allergy relief 50 mcg spray PA
qc fluticasone prop 50 mcg spr PA
QVAR REDIHALER 40 MCG QL 10.6 g / 30 days beclomethasone dipropionate QVAR REDIHALER 80 MCG QL 10.6 g / 30 days beclomethasone dipropionate
sm allergy relief 50 mcg spray PA
ANTIHISTAMINES
aler-caps 25 mg capsule all day allergy 10 mg tablet aller-g-time 25 mg caplet aller-tec 10 mg tablet allerclear 10 mg tablet allergy (loratadine) 10 mg tab allergy (loratadine) 10 mg tab allergy 10 mg tablet allergy 25 mg capsule allergy 25 mg softgel allergy 25 mg tablet allergy medicine 25 mg tablet allergy relief 10 mg tablet allergy relief 10 mg tablet allergy relief 25 mg capsule allergy relief 25 mg softgel allergy relief 25 mg tablet allergy relief 5 mg/5 ml soln allergy rlf (cetrzn) 10 mg tab banophen 25 mg capsule banophen 25 mg tablet banophen 50 mg capsule cetirizine hcl 1 mg/ml soln
PAGE 234 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS cetirizine hcl 1 mg/ml syrup cetirizine hcl 10 mg tablet cetirizine hcl 5 mg tablet cetirizine hcl 5 mg/5 ml soln child all day allergy 1 mg/ml child allergy 5 mg/5 ml soln child allergy relief 5 mg/5 ml child allergy rlf 12.5 mg/5 ml child cetirizine hcl 1 mg/ml child diphenhydramin 12.5 mg/5 child diphenhydramin 25mg/10ml child loratadine 5 mg/5 ml sol child loratadine 5 mg/5 ml syr child wal-itin 5 mg/5 ml soln child wal-itin 5 mg/5 ml syrup child's allergy 12.5 mg/5 ml child's wal-dryl 12.5 mg/5 ml complt allergy med 25 mg cp cvs allergy (cetrzn) 10 mg tab cvs allergy (lorat) 10 mg tab cvs allergy 25 mg capsule cvs allergy 25 mg softgel cvs allergy relief 25 mg cap cvs allergy relief 25 mg tab cvs allergy relief 5 mg/5 ml cvs allergy relief 5 mg/5 ml cvs child allergy 12.5 mg/5 ml cyproheptadine 2 mg/5 ml soln cyproheptadine 2 mg/5 ml syrup cyproheptadine 4 mg tablet
PAGE 235 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS cyproheptadine 4 mg/10 ml syrp diphedryl 12.5 mg/5 ml elixir diphen 25 mg caplet DIPHENHIST 25 MG CAPSULE diphenhydramine hcl diphenhydramine 12.5 mg/5 ml diphenhydramine 25 mg caplet diphenhydramine 25 mg capsule diphenhydramine 25 mg tablet diphenhydramine 25 mg/10 ml diphenhydramine 50 mg capsule eq allergy (lorat) 10 mg tab eq allergy relief 1 mg/ml soln eq allergy relief 10 mg tablet eq allergy relief 10 mg tablet eq allergy relief 25 mg cap eq allergy relief 25 mg tablet eq child allergy 12.5 mg/5 ml eq child allergy 5 mg/5 ml sol eq child allergy relief soln eql all day allergy 10 mg tab eql allergy 25 mg tablet eql allergy relief 10 mg tab eql allergy relief 25 mg cap eql child allergy 12.5 mg/5 ml eql chld all day aller 1 mg/ml geri-dryl 12.5 mg/5 ml liquid geri-dryl 25 mg tablet gnp all day allergy 10 mg tab gnp allergy 25 mg capsule gnp allergy 25 mg softgel
PAGE 236 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS gnp allergy 25 mg tablet gnp allergy relf 5 mg/5 ml sln gnp allergy relief 25 mg cap gnp allergy relief 25 mg lq cp gnp allergy relief 25 mg tab gnp child allergy 12.5 mg/5 ml gnp chld all day aller 1 mg/ml gnp chld loratadine 5 mg/5 ml gnp diphedryl 12.5 mg/5 ml elx gnp loratadine 10 mg tablet gnp loratadine 5 mg/5 ml syrup gs all day allergy 10 mg tab gs allergy relief 10 mg tablet gs allergy relief 25 mg cap gs allergy relief 25 mg tablet gs child all day aller 1 mg/ml gs child allergy 12.5 mg/5 ml hm all day allergy 10 mg tab hm allergy relief 10 mg tablet hm allergy relief 25 mg cap hm allergy relief 25 mg tablet hm child all day aller 1 mg/ml hm child allergy 12.5 mg/5 ml hm child cetirizine 1 mg/ml hm child loratadine 5 mg/5 ml hm loratadine 10 mg tablet hydroxyzine 10 mg/5 ml soln hydroxyzine 10 mg/5 ml syrup hydroxyzine 50 mg/25 ml syrup hydroxyzine hcl 10 mg tablet
PAGE 237 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS hydroxyzine hcl 25 mg tablet hydroxyzine hcl 50 mg tablet hydroxyzine pam 100 mg cap hydroxyzine pam 25 mg cap hydroxyzine pam 50 mg cap kro all day allergy 10 mg tab kro allergy 25 mg capsule kro allergy 25 mg tablet kro allergy relief 10 mg tab kro child allergy 12.5 mg/5 ml kro child allergy relief soln kro chld all day aller 1 mg/ml loradamed 10 mg tablet loratadine 10 mg tablet loratadine 5 mg/5 ml solution loratadine 5 mg/5 ml syrup loratadine allergy 5 mg/5 ml night allergy rlf 25 mg caplet non-drowsy allergy 10 mg tab pharbedryl 25 mg capsule pharbedryl 50 mg capsule promethazine 12.5 mg tablet promethazine 25 mg tablet promethazine 6.25 mg/5 ml soln promethazine 6.25 mg/5 ml syrp pub allergy 12.5 mg/5 ml liq pub allergy 25 mg capsule pub allergy 25 mg tablet pub allergy relief 10 mg tab pub allergy relief 10 mg tab
PAGE 238 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS qc all day allergy 10 mg tab qc child allergy 12.5 mg/5 ml qc complete allergy 25 mg cap qc complete allergy 25 mg cplt qc loratadine 10 mg tablet ra allergy 25 mg tablet ra allergy med 25 mg capsule ra allergy med 25 mg tablet ra allergy med 25 mg tablet ra allergy med capsule ra allergy relief 10 mg tablet ra allergy relief 10 mg tablet ra allergy relief 25 mg cap ra cetirizine hcl 10 mg tablet ra child allergy 5 mg/5 ml sol ra complete allergy 25 mg cplt ra diphedryl 12.5 mg/5 ml elix ra diphedryl 12.5 mg/5 ml liq ra loratadine 10 mg tablet siladryl 12.5 mg/5 ml liquid sm all day allergy 10 mg tab sm allergy relief 25 mg cap sm allergy relief 25 mg tablet sm child all day aller 1 mg/ml sm child allergy 5 mg/5 ml sol sm loratadine 10 mg tablet sm loratadine 5 mg/5 ml syrup sw allergy relief 10 mg tab total allergy 25 mg tablet wal-dryl allergy 12.5 mg/5 ml
PAGE 239 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS wal-dryl allergy 25 mg capsule wal-dryl allergy 25 mg minitab wal-dryl allergy 25 mg softgel wal-itin 5 mg/5 ml syrup wal-zyr 10 mg tablet wal-zyr solution ANTILEUKOTRIENES
montelukast sod 10 mg tablet montelukast sod 4 mg tab chew montelukast sod 5 mg tab chew zafirlukast 10 mg tablet zafirlukast 20 mg tablet BRONCHODILATORS, ANTICHOLINERGIC
ATROVENT 17 MCG HFA INHALER QL 25.8 / 30 DAYS ipratropium bromide INCRUSE ELLIPTA 62.5 MCG INH QL 30 / 30 DAYS umeclidinium bromide ipratropium br 0.02% soln SPIRIVA 18 MCG CP-HANDIHALER QL 30 capsules / 30 days tiotropium bromide SPIRIVA RESPIMAT 1.25 MCG INH QL 4 / 30 DAYS tiotropium bromide SPIRIVA RESPIMAT 2.5 MCG INH QL 4 / 30 DAYS tiotropium bromide BRONCHODILATORS, SYMPATHOMIMETIC
albuterol 100 mg/20 ml soln albuterol 2.5 mg/0.5 ml sol albuterol 5 mg/ml solution
albuterol hfa 90 mcg inhaler QL 2 / 30 day(s)
albuterol sul 0.63 mg/3 ml sol albuterol sul 1.25 mg/3 ml sol albuterol sul 2.5 mg/3 ml soln
PAGE 240 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS albuterol sulf 2 mg/5 ml syrup albuterol sulfate 2 mg tab albuterol sulfate 4 mg tab albuterol sulfate er 4 mg tab albuterol sulfate er 8 mg tab epinephrine 0.1 mg/ml syringe
epinephrine 0.15 mg auto-injct QL 2 / 30 day(s)
epinephrine 0.15 mg auto-injct QL 2 / 30 day(s)
epinephrine 0.3 mg auto-inject QL 2 / 30 day(s)
epinephrine 1 mg/10 ml abbojct levalbuterol 0.31 mg/3 ml sol levalbuterol 0.63 mg/3 ml sol levalbuterol 1.25 mg/3 ml sol
levalbuterol tar hfa 45mcg inh QL 30 / 30 DAYS
metaproterenol 10 mg tablet metaproterenol 10 mg/5 ml syr metaproterenol 20 mg tablet SEREVENT DISKUS 50 MCG QL 60 blisters / 30 days salmeterol xinafoate terbutaline sulfate 2.5 mg tab terbutaline sulfate 5 mg tab CYSTIC FIBROSIS AGENTS
QL 56 / 28 day(s) KALYDECO 150 MG TABLET PA ivacaftor S Specialty Drug
QL 56 / 28 DAYS KALYDECO 25 MG GRANULES PACKET PA ivacaftor S Specialty Drug
QL 56 / 28 day(s) KALYDECO 50 MG GRANULES PACKET PA ivacaftor S Specialty Drug
PAGE 241 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS
QL 56 / 28 day(s) KALYDECO 75 MG GRANULES PACKET PA ivacaftor S Specialty Drug
QL 112 / 28 DAYS ORKAMBI 100 MG-125 MG TABLET PA lumacaftor/ivacaftor S Specialty Drug
QL 56 / 28 day(s) ORKAMBI 100-125 MG GRANULE PKT PA lumacaftor/ivacaftor S Specialty Drug
QL 56 / 28 day(s) ORKAMBI 150-188 MG GRANULE PKT PA lumacaftor/ivacaftor S Specialty Drug
QL 112 / 28 DAYS ORKAMBI 200 MG-125 MG TABLET PA lumacaftor/ivacaftor S Specialty Drug
PULMOZYME 1 MG/ML AMPUL S Specialty Drug dornase alfa
QL 56 / 28 day(s) SYMDEKO 100/150 MG-150 MG TABS PA tezacaftor/ivacaftor S Specialty Drug
QL 56 / 28 DAYS SYMDEKO 50/75 MG-75 MG TABLETS PA tezacaftor/ivacaftor S Specialty Drug
PA tobramycin pak 300 mg/5 ml S Specialty Drug
TRIKAFTA 100-50-75 MG/150 MG QL 84 / 28 DAYS elexacaftor/tezacaftor/ivacaftor PA
QL 84 / 28 DAYS TRIKAFTA 50-25-37.5 MG/75 MG PA elexacaftor/tezacaftor/ivacaftor S Specialty Drug
PAGE 242 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS MAST CELL STABILIZERS
cromolyn 20 mg/2 ml neb soln PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
caffeine cit 60 mg/3 ml oral theochron er 100 mg tablet theochron er 200 mg tablet theochron er 300 mg tablet theophylline er 100 mg tablet theophylline er 200 mg tablet theophylline er 300 mg tab theophylline er 400 mg tablet theophylline er 450 mg tab theophylline er 600 mg tablet PULMONARY ANTIHYPERTENSIVES
PA bosentan 125 mg tablet S Specialty Drug
PA bosentan 62.5 mg tablet S Specialty Drug
QL 90 tablets / 30 days sildenafil 20 mg tablet PA
RESPIRATORY TRACT AGENTS, OTHER
acetylcysteine 10% vial acetylcysteine 20% vial adult wal-tussin liquid benzonatate 100 mg capsule benzonatate 200 mg capsule benzonatate perle 100 mg cap
QL 10.2 / 30 day(s) budesonide-formoterol 160-4.5 ST
QL 10.2 / 30 day(s) budesonide-formoterol 80-4.5 ST
PAGE 243 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS children's chest congest liq children's mucus relief liq COMBIVENT RESPIMAT 20-100 MCG QL 4 g / 30 days ipratropium bromide/albuterol sulfate cough syrup 100 mg/5 ml cvs child's chest congest liq diabetic siltussin das-na liq eql tussin mucus-chest congest fenesin ir 400 mg tablet fluticasone-salmeterol 100-50 fluticasone-salmeterol 113-14 fluticasone-salmeterol 232-14 fluticasone-salmeterol 250-50 fluticasone-salmeterol 500-50 fluticasone-salmeterol 55-14 geri-tussin 100 mg/5 ml soln geri-tussin syrup gnp tussin 100 mg/5 ml syrup gnp tussin 400 mg tablet gnp tussin mucus-con 200 mg/10 gs tussin mucus-cong 100 mg/5 gs tussin mucus-cong 200 mg/10 guaifenesin 100 mg/5 ml liquid guaifenesin 100 mg/5 ml soln guaifenesin 100 mg/5 ml syrup guaifenesin 200 mg tablet guaifenesin 200 mg/10 ml soln guaifenesin 300 mg/15 ml soln guaifenesin 400 mg caplet guaifenesin 400 mg tablet hm adult tussin chest cong liq
PAGE 244 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS hv tussin mucus-cong 200 mg/10 hydrocodone-homatropine 5-1.5 hydrocodone-homatropine soln hydrocodone-homatropine syrup hydromet 5 mg-1.5 mg/5 ml soln
iprat-albut 0.5-3(2.5) mg/3 ml QL 540 / 30 day(s)
mucosa 400 mg tablet mucus relief chest 400 mg tab mucus rlf chest congest 200 mg MUCUS-CHEST CONG 200 MG/10 ML guaifenesin promethazine vc solution promethazine vc syrup promethazine vc-codeine soln promethazine-codeine solution promethazine-codeine syrup promethazine-dm 6.25-15 mg/5ml promethazine-pe-codeine syrup promethazine-phenylephrine syr qc tussin mucus-cong 200 mg/10 ra expectorant cough syrup refenesen 400 mg tablet robafen 200 mg/10 ml syrup SCOT-TUSSIN 100 MG/5 ML LIQ guaifenesin SCOT-TUSSIN EXPECTORANT LIQUID guaifenesin siltussin sa 100 mg/5 ml syr sm tussin mucus-cong 200 mg/10 sodium chloride 0.9% inhal vl sodium chloride 7% vial
PAGE 245 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS STIOLTO RESPIMAT INHAL SPRAY QL 4 GM / 30 DAYS tiotropium bromide/olodaterol hcl
TRELEGY ELLIPTA 100-62.5-25 QL 60 / 30 DAYS fluticasone furoate/umeclidinium bromide/vilanterol trifenat ST
TRELEGY ELLIPTA 200-62.5-25 QL 60 / 30 DAYS fluticasone furoate/umeclidinium bromide/vilanterol trifenat ST
tussin 100 mg/5 ml syrup tussin 400 mg tablet tussin mucus-cong 200 mg/10 wixela 100-50 inhub wixela 250-50 inhub wixela 500-50 inhub SKELETAL MUSCLE RELAXANTS
chlorzoxazone 500 mg tablet cyclobenzaprine 10 mg tablet cyclobenzaprine 5 mg tablet methocarbamol 500 mg tablet methocarbamol 750 mg tablet orphenadrine er 100 mg tablet SLEEP DISORDER AGENTS
SLEEP PROMOTING AGENTS
flurazepam 15 mg capsule QL 15 capsules / 30 days
flurazepam 30 mg capsule QL 15 capsules / 30 days
temazepam 15 mg capsule QL 15 capsules / 30 days
temazepam 30 mg capsule QL 15 capsules / 30 days
zaleplon 10 mg capsule QL 15 capsules / 30 days
zaleplon 5 mg capsule QL 15 capsules / 30 days
zolpidem tartrate 10 mg tablet QL 30 tablets / 30 days
zolpidem tartrate 5 mg tablet QL 30 tablets / 30 days
PAGE 246 LAST UPDATED 09/2021 Index of covered drugs ALCALAK 138 A ALCLOMETASONE DIPROPIONATE 104 ABACAVIR SULFATE 63 ALCOHOL ANTISEPTIC ABACAVIR SULFATE/DOLUTEGRAVIR PADS 181,183,191,194,196,198,200,202,203,211,212, SODIUM/LAMIVUDINE 64 213,214,216,218,219,225,228 ABACAVIR SULFATE/LAMIVUDINE 63 ALECENSA 44 ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE 63 ALECTINIB HCL 44 ABEMACICLIB 56 ALENDRONATE SODIUM 176,177 ABIRATERONE ACETATE 37 ALFUZOSIN HCL 149 ACALABRUTINIB 45 ALIROCUMAB 91 ACAMPROSATE CALCIUM 13 ALLOPURINOL 34 ACARBOSE 67 ALOGLIPTIN BENZOATE 67 ACEBUTOLOL HCL 81 ALPELISIB 53 ACETAMINOPHEN 95,96,97,98,99,100,101 ALTRETAMINE 36 ACETAMINOPHEN WITH CODEINE PHOSPHATE 11 ALUMINUM CHLORIDE 106 ACETAZOLAMIDE 85,232 ALUNBRIG 44 ACETIC ACID 18 AMANTADINE HCL 59 ACETIC ACID/ALUMINUM ACETATE 18 AMIKACIN SULFATE LIPOSOMAL WITH NEBULIZER ACETYLCYSTEINE 243 ACCESSORIES 18 ACITRETIN 103 AMILORIDE HCL 88 ACTEMRA 167 AMILORIDE HCL/HYDROCHLOROTHIAZIDE 85 ACTEMRA ACTPEN 167 AMINOCAPROIC ACID 76 ACYCLOVIR 66 AMIODARONE HCL 80 ADACEL TDAP 172 AMLODIPINE BESYLATE 82 ADALIMUMAB 170,171 AMLODIPINE BESYLATE/BENAZEPRIL HCL 85 ADAPALENE 103,104,106 AMLODIPINE BESYLATE/OLMESARTAN ADEFOVIR DIPIVOXIL 61 MEDOXOMIL 85 ADMELOG 72 AMLODIPINE BESYLATE/VALSARTAN 85 ADMELOG SOLOSTAR 72 AMOXICILLIN 21 AFATINIB DIMALEATE 47 AMOXICILLIN/POTASSIUM CLAVULANATE 21 AFINITOR 43 AMPICILLIN TRIHYDRATE 21 AFINITOR DISPERZ 44 ANAGRELIDE HCL 74 AFLURIA QUAD 2020-2021 172 ANASTROZOLE 43 AFLURIA QUAD 2020-21 (3YR UP) 172 ANTACID 138 AFLURIA QUAD 2020-21 (6-35MO) 172 APALUTAMIDE 37 AFLURIA QUAD 2021-2022 172 APIXABAN 73 AFLURIA QUAD 2021-22 (3YR UP) 173 APOMORPHINE HCL 59,60 AIMOVIG AUTOINJECTOR 34 APREMILAST 107,168 ALBENDAZOLE 58 APREPITANT 30 ALBUMEN (EGG WHITE) 114 ARANESP 74,75 ALBUTEROL SULFATE 240,241 ARIKAYCE 18
PAGE 247 LAST UPDATED 09/2021 ARNUITY ELLIPTA 233 BETAMETHASONE DIPROPIONATE/PROPYLENE ASPIRIN 2,3,4,5,6,7,8 GLYCOL 150 ATAZANAVIR SULFATE 65,66 BETAMETHASONE VALERATE 104,150 ATAZANAVIR SULFATE/COBICISTAT 65 BETAXOLOL HCL 81,232 ATENOLOL 81 BETHANECHOL CHLORIDE 149 ATENOLOL/CHLORTHALIDONE 85 BEXAROTENE 58 ATORVASTATIN CALCIUM 89 BEXSERO 173 ATOVAQUONE 58 BICALUTAMIDE 37 ATROPINE SULFATE 229,230 BICTEGRAVIR ATROVENT HFA 240 SODIUM/EMTRICITABINE/TENOFOVIR AURANOFIN 168 ALAFENAMIDE FUMAR 62 AVAPRITINIB 40 BIKTARVY 62 AXITINIB 49 BINIMETINIB 52 AYVAKIT 40 BISACODYL 129,130,131,132,133,134,135,136,137 AZACITIDINE 41 BISMUTH SUBSALICYLATE 138,139,140,141,142,143 AZATHIOPRINE 168 BISMUTH AZITHROMYCIN 22 TRIBROMOPHENATE/PETROLATUM,WHITE 229 BISOPROLOL FUMARATE 81 B BISOPROLOL BACITRACIN 18,19,231 FUMARATE/HYDROCHLOROTHIAZIDE 85,86 BACITRACIN ZINC 18,19 BLOOD SUGAR DIAGNOSTIC 191,209 BACITRACIN ZINC/POLYMYXIN B SULFATE 20 BLOOD-GLUCOSE METER 191,209 BACITRACIN/POLYMYXIN B SULFATE 229,230 BOOST 112 BACLOFEN 61 BOOST CALORIE SMART 111 BAFIERTAM 101 BOOST GLUCOSE CONTROL 111 BALSALAZIDE DISODIUM 176 BOOST HIGH PROTEIN 111,112 BALVERSA 44,45 BOOST KID ESSENTIALS 112 BAQSIMI 71 BOOST KID ESSENTIALS-FIBER 112 BARACLUDE 61 BOOST MAX 112 BASAGLAR KWIKPEN U-100 72 BOOST MAX MEN 112 BAYER CHEWABLE ASPIRIN 2 BOOST MEN 112 BECLOMETHASONE DIPROPIONATE 234 BOOST MOBILITY 112 BEDAQUILINE FUMARATE 36 BOOST PLUS 112 BENAZEPRIL HCL 79 BOOST SOOTHE 112 BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 85 BOOST VHC 112 BENECALORIE 111 BOOST WOMEN 112 BENZNIDAZOLE 58 BOOSTRIX TDAP 173 BENZONATATE 243 BOSENTAN 243 BENZTROPINE MESYLATE 59 BOSULIF 45 BETAMETHASONE DIPROPIONATE 104,150 BOSUTINIB 45 BRAFTOVI 45
PAGE 248 LAST UPDATED 09/2021 BREAKFAST ESSENTIALS 112 CAPECITABINE 39 BRIGATINIB 44 CAPLACIZUMAB-YHDP 77 BRIMONIDINE TARTRATE 232 CAPMATINIB HYDROCHLORIDE 42 BROMOCRIPTINE MESYLATE 59 CAPRELSA 46 BRUKINSA 40 CAPTOPRIL 79 BUDESONIDE 176,233 CARBAMAZEPINE 27 BUDESONIDE/FORMOTEROL FUMARATE 243 CARBIDOPA 60 BUMETANIDE 87 CARBIDOPA/LEVODOPA 60,61 BUPRENORPHINE HCL 13 CARBIDOPA/LEVODOPA/ENTACAPONE 59 BUPRENORPHINE HCL/NALOXONE HCL 13 CARTEOLOL HCL 232 BUPROPION HCL 14 CARVEDILOL 81 BUSULFAN 37 CATHETER 222 BUTALBITAL/ACETAMINOPHEN 95 CEFACLOR 20 BUTALBITAL/ACETAMINOPHEN/CAFFEINE 95 CEFADROXIL 20 BUTALBITAL/ASPIRIN/CAFFEINE 2 CEFDINIR 20 CEFIXIME 20 C CEFPODOXIME PROXETIL 20 C1 ESTERASE INHIBITOR 166 CEFPROZIL 20 CABERGOLINE 166 CEFUROXIME AXETIL 20 CABLIVI 77 CELECOXIB 2 CABOMETYX 45 CENEGERMIN-BKBJ 230 CABOZANTINIB S-MALATE 45,46 CENOBAMATE 25 CAFFEINE CITRATE 243 CEPHALEXIN 20,21 CALCIPOTRIENE 106 CERITINIB 58 CALCITONIN,SALMON,SYNTHETIC 177,178 CERTOLIZUMAB PEGOL 168,169 CALCITRIOL 177 CERVICAL CAP 198 CALCIUM ACETATE 110 CETIRIZINE HCL 234,235,236,237,238,239,240 CALCIUM ALGINATE/HONEY 206 CHANTIX 14 CALCIUM CHEMET 110 CARBONATE 112,113,114,117,120,122,125,126,127,1 CHLORAMBUCIL 36 38,139,140,141,142,143 CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE 137 CALCIUM CARBONATE/CHOLECALCIFEROL CHLORHEXIDINE GLUCONATE 102,103 (VITAMIN D3) 112,113,116,118,121,122,125,126,127 CHLOROQUINE PHOSPHATE 58 CALCIUM CITRATE 112,113 CHLORTHALIDONE 88 CALCIUM CITRATE/CHOLECALCIFEROL (VITAMIN CHLORZOXAZONE 246 D3) 113,114,116,117,118,125,126,127 CHOLECALCIFEROL (VITAMIN CALORIC SUPPLEMENT 111,114 D3) 177,178,179,180,181 CALQUENCE 45 CHOLESTYRAMINE (WITH SUGAR) 90 CANDIDA ALBICANS SKIN TEST 187 CHOLESTYRAMINE/ASPARTAME 90,91 CANDIN 187 CICLOPIROX 108 CANNABIDIOL (CBD) 24 CICLOPIROX OLAMINE 31
PAGE 249 LAST UPDATED 09/2021 CILOSTAZOL 77 COMPRESSION STOCKING, KNEE HIGH, REGULAR CIMDUO 63 LENGTH, MEDIUM 219 CIMETIDINE 144,145,146,147 COMPRESSION STOCKING, KNEE HIGH, REGULAR CIMETIDINE HCL 144 LENGTH, SMALL 219 CIMZIA 168,169 COMPRESSION STOCKING,KNEE HIGH,LONG CIPROFLOXACIN 22 LENGTH, LARGE CIRCUMFER. 219 CIPROFLOXACIN HCL 22,232 COMPRESSION STOCKING,KNEE HIGH,LONG CIPROFLOXACIN HCL/DEXAMETHASONE 232 LENGTH, X-LARGE CIRCUMF. 219 CIPROFLOXACIN HCL/FLUOCINOLONE COMPRESSION STOCKING,KNEE HIGH,LONG ACETONIDE 233 LENGTH,MEDIUM CIRCUMFER. 219 CITRIC ACID/GLUCONOLACTONE/MAGNESIUM COMPRESSION STOCKING,KNEE HIGH,LONG CARBONATE 150 LENGTH,SMALL CIRCUMFEREN 219 CLARITHROMYCIN 22 COMPRESSION STOCKING,KNEE HIGH,REGULAR CLASSIC PRENATAL 113 LENGTH,LARGE CIRCUMF. 219 CLINDAMYCIN HCL 19 COMPRESSION STOCKING,KNEE HIGH,REGULAR CLINDAMYCIN PALMITATE HCL 19 LENGTH,X-LARGE CIRCUM 219 CLINDAMYCIN PHOSPHATE 19 COMPRESSION STOCKING,THIGH HIGH,LONG CLINDAMYCIN PHOSPHATE/BENZOYL LENGTH,EXTRA-LARGE CIRC 219 PEROXIDE 103,104 COMPRESSION STOCKING,THIGH HIGH,LONG CLOBAZAM 25,26 LENGTH,LARGE CIRCUMFER. 219 CLOBETASOL PROPIONATE 104,150 COMPRESSION STOCKING,THIGH HIGH,LONG CLONAZEPAM 67 LENGTH,MEDIUM CIRCUMFER 219 CLONIDINE HCL 77 COMPRESSION STOCKING,THIGH HIGH,LONG CLOPIDOGREL BISULFATE 77 LENGTH,SMALL CIRCUMFER. 219 CLOTRIMAZOLE 31,32,33 COMPRESSION STOCKING,THIGH HIGH,LONG CLOTRIMAZOLE/BETAMETHASONE LENGTH,X-SMALL CIRCUMF. 219 DIPROPIONATE 106 COMPRESSION STOCKING,THIGH HIGH,REG COAL TAR 189 LENGTH,X-LARGE CIRCUMFER 219 COBIMETINIB FUMARATE 46 COMPRESSION STOCKING,THIGH HIGH,REGULAR COLCHICINE 34 LENGTH,LARGE CIRCUMF 219 COLESTIPOL HCL 90 COMPRESSION STOCKING,THIGH HIGH,REGULAR COMBIVENT RESPIMAT 244 LENGTH,MEDIUM CIRCUM 219 COMETRIQ 46 COMPRESSION STOCKING,THIGH HIGH,REGULAR COMIRNATY 173 LENGTH,SMALL CIRCUMF 219 COMPLEAT 113 COMPRESSION STOCKING,THIGH HIGH,REGULAR COMPLEAT ORGANIC BLEND CHICKEN 113 LENGTH,X-SMALL CIRC. 219 COMPLEAT ORGANIC BLENDS PLANT 113 COMPRESSION STOCKING,THIGH HIGH,SHORT COMPLEAT PED ORG BLEND CHICKEN 113 LENGTH,LARGE CIRCUMFER 219 COMPLEAT PED ORG BLENDS PLANT 114 COMPRESSION STOCKING,THIGH HIGH,SHORT COMPLERA 63 LENGTH,MEDIUM CIRCUMF. 219
PAGE 250 LAST UPDATED 09/2021 COMPRESSION STOCKING,THIGH HIGH,SHORT DANTROLENE SODIUM 61 LENGTH,SMALL CIRCUMFER 219 DAPAGLIFLOZIN PROPANEDIOL 68 COMPRESSOR, FOR NEBULIZER 191,213 DAPAGLIFLOZIN PROPANEDIOL/METFORMIN CONDOMS, FEMALE 198 HCL 70,71 CONDOMS, LATEX, LUBRICATED 183,191,197,203 DAPSONE 35 CONDOMS, LATEX, NON-LUBRICATED 202,203,223 DARBEPOETIN ALFA IN POLYSORBATE 80 74,75 COPIKTRA 46 DAROLUTAMIDE 38 COPPER 210 DARUNAVIR CORLANOR 86 ETH/COBICISTAT/EMTRICITABINE/TENOFOVIR CORTIFOAM 176 ALAFENAMIDE 66 COSAMIN DS 191 DARUNAVIR ETHANOLATE 66 COSENTYX (2 SYRINGES) 167 DARUNAVIR ETHANOLATE/COBICISTAT 65 COSENTYX PEN 167 DASATINIB 53,54 COSENTYX PEN (2 PENS) 167 DAURISMO 46 COSENTYX SYRINGE 167 DEBACTEROL 102 COTELLIC 46 DECITABINE/CEDAZURIDINE 41 COVID-19 VAC, AD26.COV2.S (JANSSEN)/PF 175 DELSTRIGO 63 COVID-19 VACCINE, MRNA, BNT162B2, LNP-S DENAVIR 108 (PFIZER)/PF 173,175 DEPO-PROVERA 162 COVID-19 VACCINE, MRNA-1273, LNP-S DESCOVY 64 (MODERNA)/PF 175 DESMOPRESSIN ACETATE 152 CREON 147 DESMOPRESSIN ACETATE (NON- CRIZOTINIB 57 REFRIGERATED) 152 CROMOLYN SODIUM 231,243 DESOGESTREL-ETHINYL CROTAMITON 108 ESTRADIOL 154,155,156,157,160,161 CYANOCOBALAMIN (VITAMIN B- DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL 12) 111,114,116,117,118,126,127,128,129 ESTRADIOL 154,155,157,160,161 CYCLOBENZAPRINE HCL 246 DESONIDE 104,150 CYCLOPENTOLATE HCL 230 DESOXIMETASONE 105 CYCLOPHOSPHAMIDE 36 DEXAMETHASONE 150,151 CYCLOSPORINE 169,172 DEXAMETHASONE SODIUM CYCLOSPORINE, MODIFIED 169,170 PHOSPHATE 150,151,231 CYPROHEPTADINE HCL 235,236 DEXMETHYLPHENIDATE HCL 93,94 CYSTAGON 147 DEXTROAMPHETAMINE SULF- CYSTEAMINE BITARTRATE 147 SACCHARATE/AMPHETAMINE SULF- ASPARTATE 92,93 D DEXTROAMPHETAMINE SULFATE 93 D3-50 177 DEXTROSE 71,72 DABRAFENIB MESYLATE 54 DIACOMIT 23,24 DACOMITINIB 57 DIALYVITE 114 DANAZOL 153 DIALYVITE VITAMIN D3 MAX 178
PAGE 251 LAST UPDATED 09/2021 DIAPHRAGMS, WIDE SEAL 228,229 DOXYCYCLINE MONOHYDRATE 23 DIATRIZOATE MEGLUMINE/DIATRIZOATE DRONABINOL 30,31 SODIUM 206 DROSPIRENONE/ETHINYL DIAZEPAM 26 ESTRADIOL/LEVOMEFOLATE CALCIUM 155,160 DICLOFENAC SODIUM 2,3,5,8,9,106,107,231 DROXIA 39 DICLOXACILLIN SODIUM 21 DRYSOL 106 DICYCLOMINE HCL 137 DULAGLUTIDE 70 DIDANOSINE 64 DUPILUMAB 167,168 DIETARY SUPPLEMENT 126 DUPIXENT PEN 167 DIGOXIN 86 DUPIXENT SYRINGE 167,168 DILANTIN 27 DUTASTERIDE 149 DILTIAZEM HCL 80,83,84 DUVELISIB 46 DIMETHYL FUMARATE 101,102 DIPHENHIST 236 E DIPHENHYDRAMINE ECHOTHIOPHATE IODIDE 232 HCL 234,235,236,237,238,239,240 ECONAZOLE NITRATE 31 DIPHENOXYLATE HCL/ATROPINE SULFATE 137 ECOTRIN 3 DIPHTHERIA,PERTUSSIS(ACELLULAR),TETANUS EDURANT 63 VACCINE 173 EFAVIRENZ 63 DIPHTHERIA,PERTUSSIS(ACELLULAR),TETANUS EFAVIRENZ/LAMIVUDINE/TENOFOVIR DISOPROXIL VACCINE/PF 172 FUMARATE 63 DIPYRIDAMOLE 77 EGG-PRO 114 DISOPYRAMIDE PHOSPHATE 80 ELEXACAFTOR/TEZACAFTOR/IVACAFTOR 242 DISULFIRAM 13 ELIGARD 166 DOCUSATE ELIQUIS 73 SODIUM 129,130,131,132,133,134,135,136,137 ELLA 162 DOFETILIDE 80 ELMIRON 149 DOK 130 ELTROMBOPAG OLAMINE 75,76 DOLUTEGRAVIR SODIUM 62,63 ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN DOLUTEGRAVIR SODIUM/LAMIVUDINE 62 OFOVIR ALAFENAMIDE 62 DOLUTEGRAVIR SODIUM/RILPIVIRINE HCL 62 ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN DONEPEZIL HCL 28 OFOVIR DISOPROXIL 62 DORAVIRINE 63 EMCYT 39 DORAVIRINE/LAMIVUDINE/TENOFOVIR EMGALITY PEN 34 DISOPROXIL FUMARATE 63 EMGALITY SYRINGE 34 DORNASE ALFA 242 EMOLLIENT BASE 214 DORZOLAMIDE HCL 232 EMPAGLIFLOZIN 68 DORZOLAMIDE HCL/TIMOLOL MALEATE 230 EMPAGLIFLOZIN/METFORMIN HCL 69,70 DOVATO 62 EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR DOXAZOSIN MESYLATE 78 ALAFENAMIDE FUMARATE 63 DOXYCYCLINE HYCLATE 23
PAGE 252 LAST UPDATED 09/2021 EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR ERLOTINIB HCL 46,47 DISOPROXIL FUMARATE 63 ERTUGLIFLOZIN PIDOLATE 69 EMTRICITABINE/TENOFOVIR ALAFENAMIDE ERTUGLIFLOZIN PIDOLATE/METFORMIN HCL 69 FUMARATE 64 ERYTHROMYCIN BASE 231 EMTRICITABINE/TENOFOVIR DISOPROXIL ESTRADIOL 155,156,158,159,161,162 FUMARATE 64 ESTRADIOL VALERATE 156 ENALAPRIL MALEATE 79 ESTRADIOL/NORETHINDRONE ACETATE 158,162 ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE 86 ESTRAMUSTINE PHOSPHATE SODIUM 39 ENASIDENIB MESYLATE 40 ESTROGENS, ENBREL 169 CONJUGATED/MEDROXYPROGESTERONE ENBREL MINI 169 ACETATE 160 ENBREL SURECLICK 169 ETANERCEPT 169 ENCORAFENIB 45 ETHAMBUTOL HCL 35 ENDARI 147 ETHINYL ENFAMIL PROSOBEE 115 ESTRADIOL/DROSPIRENONE 155,157,158,159,160,1 ENFUVIRTIDE 65 61,162 ENGERIX-B ADULT 173 ETHOSUXIMIDE 25 ENOXAPARIN SODIUM 73 ETHYNODIOL DIACETATE-ETHINYL ENSPRYNG 168 ESTRADIOL 156,157,162 ENSURE CLEAR THERAPEUTIC 115 ETIDRONATE DISODIUM 178 ENSURE ENLIVE 115 ETONOGESTREL/ETHINYL ESTRADIOL 156 ENSURE ORIGINAL 115 ETOPOSIDE 43 ENSURE PLUS 115 ETRAVIRINE 63 ENSURE POWDER 115 EURAX 108 ENSURE PRE-SURGERY 115 EUTHYROX 164 ENTACAPONE 59 EVEROLIMUS 43,44,47 ENTECAVIR 61 EVOLOCUMAB 91 ENTRECTINIB 42 EVOTAZ 65 ENTRESTO 86 EXEMESTANE 43 ENU PRO3 PLUS 116 EXTAVIA 102 ENZALUTAMIDE 38 EZETIMIBE 90 EPIDIOLEX 24 EPINEPHRINE 241 F EPIVIR HBV 61 FAMCICLOVIR 66 EPLERENONE 88 FAMOTIDINE 144,145,146 EPOETIN ALFA-EPBX 76 FARXIGA 68 ERDAFITINIB 44,45 FARYDAK 47 ERENUMAB-AOOE 34 FAT EMULSIONS 108 ERGOCALCIFEROL (VITAMIN D2) 177,178,179 FEDRATINIB DIHYDROCHLORIDE 41 ERIVEDGE 46 FELBAMATE 24 ERLEADA 37 FELODIPINE 82
PAGE 253 LAST UPDATED 09/2021 FENFLURAMINE HCL 24 FLULAVAL QUAD 2021-2022 174 FENOFIBRATE 88,89 FLUMIST QUAD 2020-2021 174 FENOFIBRATE NANOCRYSTALLIZED 88,89 FLUMIST QUAD 2021-2022 174 FENOFIBRATE,MICRONIZED 88,89 FLUOCINOLONE ACETONIDE 105 FENOFIBRIC ACID 89 FLUOCINONIDE 105,151 FENOFIBRIC ACID (CHOLINE) 89 FLUOCINONIDE/EMOLLIENT BASE 105 FENTANYL 9 FLUORIDE (SODIUM) 102,103,108,109,110,127 FERRIC SUBSULFATE 76 FLUORITAB 108 FERROUS FUMARATE 116 FLUOROMETHOLONE 231 FERROUS GLUCONATE 114,116,118 FLUOROPLEX 107 FERROUS FLUOROURACIL 107 SULFATE 109,113,114,116,117,118,122,123,126,127 FLURAZEPAM HCL 246 FIBERSOURCE HN 117 FLURBIPROFEN SODIUM 231 FILGRASTIM-AAFI 75 FLUTAMIDE 38 FINASTERIDE 149 FLUTICASONE FUROATE 233 FINGOLIMOD HCL 102 FLUTICASONE FUROATE/UMECLIDINIUM FINTEPLA 24 BROMIDE/VILANTEROL TRIFENAT 246 FISH OIL 117 FLUTICASONE PROPIONATE 105,233,234 FLAVOXATE HCL 148 FLUTICASONE PROPIONATE/SALMETEROL FLECAINIDE ACETATE 80 XINAFOATE 244,246 FLOVENT HFA 233 FLUZONE HIGH-DOSE QUAD 2020-21 174 FLU VACCINE QUAD 2020-2021(4 YEARS AND FLUZONE HIGH-DOSE QUAD 2021-22 174 OLDER)CELL DERIVED/PF 173 FLUZONE QUAD 2020-2021 174 FLU VACCINE QUAD 2021-2022(2 YEARS AND FLUZONE QUAD 2021-2022 174 OLDER)CELL DERIVED/PF 173 FOLIC ACID 114,116,117,118,125,126,127 FLU VACCINE QUADRIV 2020-2021(4 YEARS AND FOLIC ACID/VITAMIN B COMPLEX AND VITAMIN OLDER)CELL DERIVED 173 C 114,126 FLU VACCINE QUADRIV 2021-2022(2 YEARS AND FORTICAL 178 OLDER)CELL DERIVED 173 FOSINOPRIL SODIUM 79 FLUAD 2020-2021 173 FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE 86 FLUAD QUAD 2020-2021 173 FOSTAMATINIB DISODIUM 77 FLUAD QUAD 2021-2022 173 FOSTEMSAVIR TROMETHAMINE 65 FLUARIX QUAD 2020-2021 173 FOTIVDA 40 FLUARIX QUAD 2021-2022 173 FULPHILA 75 FLUBLOK QUAD 2020-2021 173 FURADANTIN 19 FLUBLOK QUAD 2021-2022 173 FUROSEMIDE 87,88 FLUCELVAX QUAD 2020-2021 173 FUZEON 65 FLUCELVAX QUAD 2021-2022 173 FLUCONAZOLE 31,32 G FLUDROCORTISONE ACETATE 151 GABAPENTIN 26 FLULAVAL QUAD 2020-2021 173 GALAFOLD 148
PAGE 254 LAST UPDATED 09/2021 GALANTAMINE HBR 28 HALOBETASOL PROPIONATE 105 GALCANEZUMAB-GNLM 34 HAVRIX 174 GARDASIL 9 174 HEPARIN SODIUM,PORCINE 73 GAVRETO 43 HEPATITIS A VIRUS AND HEPATITIS B VIRUS GEFITINIB 49 VACCINE/PF 175 GEL DRESSING 188,217 HEPATITIS A VIRUS VACCINE/PF 174,175,176 GEMFIBROZIL 89 HEPATITIS B VACCINE RECOMBINANT/VACCINE GENTAMICIN SULFATE 18,231 ADJUVANT CPG 1018/PF 174 GENVOYA 62 HEPATITIS B VIRUS VACCINE GILENYA 102 RECOMBINANT/PF 173,175 GILOTRIF 47 HEPLISAV-B 174 GILTERITINIB FUMARATE 57 HEXALEN 36 GLASDEGIB MALEATE 46 HOMATROPINE HBR 230 GLATIRAMER ACETATE 102 HUMAN PAPILLOMAVIRUS VACCINE, 9- GLECAPREVIR/PIBRENTASVIR 62 VALENT/PF 174 GLEOSTINE 36 HUMIRA 170 GLIMEPIRIDE 68 HUMIRA PEDIATRIC CROHN'S 170 GLIPIZIDE 68 HUMIRA PEN 170 GLUCAGEN 71 HUMIRA PEN CROHN'S-UC-HS 170 GLUCAGON 71,72 HUMIRA PEN PSOR-UVEITS-ADOL HS 170 GLUCAGON EMERGENCY KIT 71 HUMIRA(CF) 170,171 GLUCAGON HCL 71 HUMIRA(CF) PEDIATRIC CROHN'S 171 GLUCOSAMINE HCL/CHONDROITIN SUL A HUMIRA(CF) PEN 171 NA/ASCORBIC ACID/MANGANESE 191 HUMIRA(CF) PEN CROHN'S-UC-HS 171 GLUTAMINE 147 HUMIRA(CF) PEN PEDIATRIC UC 171 GLYBURIDE 68 HUMIRA(CF) PEN PSOR-UV-ADOL HS 171 GLYBURIDE,MICRONIZED 68 HUMULIN 70-30 72 GLYBURIDE/METFORMIN HCL 68 HUMULIN N 72 GLYCERIN 129,132,133,135,136 HUMULIN R 72 GOSERELIN ACETATE 43 HUMULIN R U-500 KWIKPEN 72 GRANISETRON HCL 31 HYDRALAZINE HCL 91 GRISEOFULVIN, MICROSIZE 32 HYDROCHLOROTHIAZIDE 88 GUAIFENESIN 243,244,245,246 HYDROCODONE GUANFACINE HCL 77 BITARTRATE/ACETAMINOPHEN 11 GVOKE HYPOPEN 1-PACK 71 HYDROCODONE BITARTRATE/HOMATROPINE GVOKE HYPOPEN 2-PACK 71 METHYLBROMIDE 245 GVOKE PFS 1-PACK SYRINGE 71,72 HYDROCORTISONE 104,105,106,150,151,152,176 GVOKE PFS 2-PACK SYRINGE 72 HYDROCORTISONE ACETATE 151,176 HYDROCORTISONE ACETATE/PRAMOXINE H HCL 107 HAEGARDA 166 HYDROCORTISONE BUTYRATE 105,151
PAGE 255 LAST UPDATED 09/2021 HYDROCORTISONE VALERATE 105 INFLUENZA VIRUS VACCINE QUADRIVAL 2020- HYDROCORTISONE/ACETIC ACID 232 2021(6 MOS AND UP)/PF 173,174 HYDROCORTISONE/ALOE VERA 150 INFLUENZA VIRUS VACCINE QUADRIVAL 2020-21 HYDROCORTISONE/MINERAL (6 MOS-35 MOS)/PF 172 OIL/PETROLATUM,WHITE 105 INFLUENZA VIRUS VACCINE QUADRIVAL 2021- HYDROQUINONE 107 2022(6 MOS AND UP)/PF 173,174 HYDROXOCOBALAMIN 118 INFLUENZA VIRUS VACCINE QUADRIVAL SPLIT HYDROXYCHLOROQUINE SULFATE 58 2020-21(65 YR UP)/PF 174 HYDROXYUREA 39 INFLUENZA VIRUS VACCINE QUADRIVAL SPLIT HYDROXYZINE HCL 237,238 2021-22(65 YR UP)/PF 174 HYDROXYZINE PAMOATE 238 INFLUENZA VIRUS VACCINE QUADRIVALENT 2020- HYOSCYAMINE SULFATE 137,138 21 (36 MOS UP)/PF 172 INFLUENZA VIRUS VACCINE QUADRIVALENT 2020- I 21 (6 MOS AND UP) 172,174 IBANDRONATE SODIUM 178 INFLUENZA VIRUS VACCINE QUADRIVALENT 2021- IBRANCE 48 22 (36 MOS UP)/PF 173 IBRUTINIB 49 INFLUENZA VIRUS VACCINE QUADRIVALENT 2021- IBUPROFEN 2,3,4,5,6,7,8,9 22 (6 MOS AND UP) 172,174 ICATIBANT ACETATE 167 INFLUENZA VIRUS VACCINE QV 2020-21(18 YRS ICLUSIG 48 AND OLDER)RCMB/PF 173 IDELALISIB 57,58 INFLUENZA VIRUS VACCINE QV 2021-22(18 YRS IDHIFA 40 AND OLDER)RCMB/PF 173 IMATINIB MESYLATE 48,49 INHALER, ASSIST IMBRUVICA 49 DEVICES182,183,186,190,193,198,200,205,206,209,2 IMIQUIMOD 107 11,212,215,228 INCRELEX 152 INHALER, ASSIST DEVICES, INCRUSE ELLIPTA 240 ACCESSORIES 193,205,208,209,210,216 INDAPAMIDE 88 INHALER,ASSIST DEVICE WITH LARGE INDOMETHACIN 6 MASK 182,186,188,190,201,209,212 INFANT FORMULA,SOY,IRON,LAC- INHALER,ASSIST DEVICE WITH MEDIUM FREE/DHA/ARACHIDONIC ACID (ARA) 115 MASK 182,186,188,190,201,209,212,228 INFLUENZA VACCINE QUADRIVALENT 2020-21 (65 INHALER,ASSIST DEVICE WITH SMALL YR UP)/MF59C.1/PF 173 MASK 182,186,188,191,201,209,212,228 INFLUENZA VACCINE QUADRIVALENT 2021-22 (65 INLYTA 49 YR UP)/MF59C.1/PF 173 INQOVI 41 INFLUENZA VACCINE QUADRIVALENT LIVE 2020- INREBIC 41 2021 (2 YRS-49 YRS) 174 INSULIN GLARGINE,HUMAN RECOMBINANT INFLUENZA VACCINE QUADRIVALENT LIVE 2021- ANALOG 72,73 2022 (2 YRS-49 YRS) 174 INSULIN LISPRO 72 INFLUENZA VACCINE TVS 2020-21 (65 YR INSULIN LISPRO JUNIOR KWIKPEN 72 UP)/ADJUVANT MF59C.1/PF 173
PAGE 256 LAST UPDATED 09/2021 INSULIN LISPRO PROTAMINE AND INSULIN LISPRO 72 J INSULIN LISPRO PROTAMINE MIX 72 JAKAFI 50 INSULIN NPH HUMAN ISOPHANE 72,73 JANSSEN COVID-19 VACCINE (EUA) 175 INSULIN NPH HUMAN ISOPHANE/INSULIN JARDIANCE 68 REGULAR, HUMAN 72 JEVITY 1 CAL 118 INSULIN REGULAR, HUMAN 72,73 JEVITY 1.2 CAL 119 INSULIN SYRINGE-NEEDLE,SAFETY,DISPOSAL JEVITY 1.5 CAL 119 UNIT,0.5 ML 215 JULUCA 62 INTELENCE 63 JYNARQUE 110 INTERFERON ALFA-2B,RECOMB. 168 INTERFERON BETA-1B 102 K INTRALIPID 108 K-PHOS NEUTRAL 149 INTRON A 168 K-PHOS NO.2 149 INVIRASE 65 K-PHOS ORIGINAL 149 IPRATROPIUM BROMIDE 240 KALYDECO 241,242 IPRATROPIUM BROMIDE/ALBUTEROL KAOPECTATE 141 SULFATE 244,245 KESIMPTA PEN 102 IRBESARTAN 78 KETO 119 IRBESARTAN/HYDROCHLOROTHIAZIDE 86 KETOCONAZOLE 32 IRESSA 49 KETOROLAC TROMETHAMINE 6,231 IRON POLYSACCHARIDE KETOVIE PEPTIDE 4:1 119 COMPLEX 116,118,120,121,124 KISQALI 50 ISENTRESS 62 KLOR-CON 10 109 ISENTRESS HD 62 KLOR-CON 8 109 ISONIAZID 35,36 KOSELUGO 50 ISOPTO ATROPINE 230 KPN 119 ISOSORBIDE DINITRATE 92 KRINTAFEL 58 ISOSORBIDE MONONITRATE 92 KRISTALOSE 133 ISOSOURCE 1.5 CAL 118 KYLEENA 163 ISOSOURCE 1.5 CAL TUBE FEED 118 KYNMOBI 59,60 ISOSOURCE HN 118 ISOTRETINOIN 103,104 L ISRADIPINE 83 LABETALOL HCL 81 ITRACONAZOLE 32 LACOSAMIDE 28 IVABRADINE HCL 86 LACTOSE-REDUCED IVACAFTOR 241,242 FOOD 111,112,114,115,116,117,118,121,125,126,127, IVERMECTIN 58 128 IVOSIDENIB 55 LACTOSE-REDUCED FOOD/FIBER 118,119 IXAZOMIB CITRATE 41 LACTULOSE 129,130,131,133 LAMIVUDINE 61,62,64
PAGE 257 LAST UPDATED 09/2021 LAMIVUDINE/TENOFOVIR DISOPROXIL LIQUID HOPE PEPTIDE 119 FUMARATE 63 LIRAGLUTIDE 70 LAMIVUDINE/ZIDOVUDINE 64 LISINOPRIL 79 LANCETS 181,206,209 LISINOPRIL/HYDROCHLOROTHIAZIDE 86 LANCING DEVICE/LANCETS 181,206,209 LOMUSTINE 36 LANSOPRAZOLE 147 LONSURF 41 LAPATINIB DITOSYLATE 51 LOPERAMIDE HCL 137,138,139,140,141,142,143 LAROTRECTINIB SULFATE 56,57 LOPINAVIR/RITONAVIR 65 LATANOPROST 232 LORATADINE 234,235,236,237,238,239,240 LAYOLIS FE 158 LORBRENA 51 LEFLUNOMIDE 171 LORLATINIB 51 LENALIDOMIDE 38,39 LOSARTAN POTASSIUM 78 LENVATINIB MESYLATE 51 LOSARTAN LENVIMA 51 POTASSIUM/HYDROCHLOROTHIAZIDE 86,87 LETERMOVIR 61 LOVASTATIN 89 LETROZOLE 43 LUMACAFTOR/IVACAFTOR 242 LEUCOVORIN CALCIUM 41 LUMAKRAS 41 LEUKERAN 36 LUPRON DEPOT-PED 166 LEUPROLIDE ACETATE 166 LUSUTROMBOPAG 75 LEVALBUTEROL HCL 241 LYNPARZA 52 LEVALBUTEROL TARTRATE 241 LYSODREN 166 LEVETIRACETAM 24 LEVOBUNOLOL HCL 232 M LEVOCARNITINE 109 M-M-R II VACCINE 175 LEVOCARNITINE (WITH SUGAR) 119 MAFENIDE ACETATE 108 LEVOFLOXACIN 22 MAGNESIUM LEVONORGESTREL 162,163,164 HYDROXIDE 129,131,132,133,134,135,136 LEVONORGESTREL/ETHINYL MAGNESIUM ESTRADIOL 154,155,156,157,158,159,160,161 OXIDE 109,114,117,118,119,120,127,128 LEVONORGESTREL/ETHINYL ESTRADIOL AND MALTODEXTRIN 127 ETHINYL ESTRADIOL 154,155,157,158,160 MALTODEXTRIN/FRUCTOSE 115,125 LEVOTHYROXINE SODIUM 164,165 MARAVIROC 65 LEVOXYL 165 MATULANE 36 LIDOCAINE 12 MAVYRET 62 LIDOCAINE HCL 12 MEASLES, MUMPS, AND RUBELLA VACCINE LIDOCAINE/PRILOCAINE 12 LIVE/PF 175 LILETTA 163 MECASERMIN 152 LINEZOLID 19 MECLIZINE HCL 29,30 LIOTHYRONINE SODIUM 165,166 MEDROXYPROGESTERONE ACETATE 162,163 LIPASE/PROTEASE/AMYLASE 147 MEFLOQUINE HCL 59 LIQUID HOPE ORIGINAL 119 MEGESTROL ACETATE 163
PAGE 258 LAST UPDATED 09/2021 MEKINIST 52 MIGALASTAT HCL 148 MEKTOVI 52 MINI PRENATAL 120 MELOXICAM 6 MINOCYCLINE HCL 23 MEMANTINE HCL 29 MINOXIDIL 91 MENACTRA 175 MIRENA 163 MENINGOCOCCAL GROUP B VACCINE, 4- MISOPROSTOL 153 COMPONENT 173 MITOTANE 166 MENINGOCOCCALVACCINE A,C,Y,W- MODERNA COVID-19 VACCINE (EUA) 175 135,DIPHTHERIA TOXOID CONJ/PF 175 MOEXIPRIL HCL 79 MENVEO A-C-Y-W-135-DIP 175 MOMETASONE FUROATE 105,106,151 MERCAPTOPURINE 39 MONOMETHYL FUMARATE 101 MESALAMINE 176 MONSEL'S 76 MESNA 58 MONTELUKAST SODIUM 240 MESNEX 58 MORPHINE SULFATE 9,10,11,12 METAPROTERENOL SULFATE 241 MOXIFLOXACIN HCL 22 METFORMIN HCL 68,69 MUCUS-CHEST CONGESTION 245 METHAZOLAMIDE 232 MULPLETA 75 METHENAMINE/METHYLENE BLUE/SOD MULTIVITAMIN COMBINATION NO.51/FERROUS PHOS/P.SALICYLATE/HYOSCYAMINE 19 FUMARATE/FOLIC ACID 125 METHIMAZOLE 166 MUPIROCIN 108 METHOCARBAMOL 246 MYCOPHENOLATE MOFETIL 172 METHOTREXATE SODIUM 171,172 MYLERAN 37 METHOTREXATE SODIUM/PF 171,172 MYNATAL 120 METHYLDOPA 77 METHYLDOPA/HYDROCHLOROTHIAZIDE 87 N METHYLERGONOVINE MALEATE 206 NABUMETONE 6,7 METHYLPHENIDATE HCL 93,94,95 NADOLOL 82 METHYLPREDNISOLONE 151 NALOXONE HCL 14 METOCLOPRAMIDE HCL 29,30 NALTREXONE HCL 13 METOLAZONE 88 NAPROXEN 3,7 METOPROLOL SUCCINATE 82 NAPROXEN SODIUM 2,3,4,5,6,7,8,9 METOPROLOL TARTRATE 82 NARATRIPTAN HCL 34 METOPROLOL NARCAN 14 TARTRATE/HYDROCHLOROTHIAZIDE 87 NEBULIZER 183,191,204,206,210,213,216 METRONIDAZOLE 19,20 NEBULIZER MEXILETINE HCL 80 ACCESSORIES 183,206,208,210,211,215,216 MICONAZOLE NITRATE 31,32,33 NEBULIZER AND MICROGESTIN 24 FE 159 COMPRESSOR 190,191,200,213,216,228 MIDAZOLAM HCL 12,13 NEISSERIA MENINGITIDIS GROUP B, LIPIDATED MIDAZOLAM HCL/PF 12,13 FHBP RECOMBINANT 175 MIDOSTAURIN 53 NEOMYCIN SULFATE 18
PAGE 259 LAST UPDATED 09/2021 NEOMYCIN SULFATE/BACITRACIN NORETHINDRONE ACETATE-ETHINYL ZINC/POLYMYXIN B/HYDROCORTISONE 230 ESTRADIOL/FERROUS NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN FUMARATE 154,157,158,159,160,161 B 230 NORETHINDRONE-ETHINYL NEOMYCIN SULFATE/POLYMYXIN B ESTRADIOL 154,155,157,158,159,160,161,162 SULFATE/GRAMICIDIN D 230 NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS NEOMYCIN SULFATE/POLYMYXIN B FUMARATE 157,158,159,161 SULFATE/HYDROCORTISONE 230,232 NORGESTIMATE-ETHINYL NEOMYCIN/POLYMYXIN B ESTRADIOL 156,157,159,160,161 SULFATE/DEXAMETHASONE 230 NORGESTREL-ETHINYL ESTRADIOL 155,158 NEPHRO-VITE RX 120 NORVIR 65 NERATINIB MALEATE 52 NOURISH ORIGINAL 120 NERLYNX 52 NOURISH PEPTIDE 120 NEVIRAPINE 63 NOVAFERRUM PEDIATRIC MV-IRON 120 NEXAVAR 52 NOVOLIN 70-30 72 NIACIN 90 NOVOLIN N 72,73 NICOTINE 14,15,16,17,18 NOVOLIN R 72,73 NICOTINE POLACRILEX 14,15,16,17,18 NU-IRON 150 121 NICOTROL 17 NUBEQA 38 NICOTROL NS 17 NUT.SUPPLEMENT,SPECIAL FORMULA,LACTOSE- NIFEDIPINE 83 FREE WITH IRON/FOS 128 NILOTINIB HCL 55 NUTREN 1.0 121 NILUTAMIDE 38 NUTREN 1.5 121 NINLARO 41 NUTREN 2.0 121 NIRAPARIB TOSYLATE 57 NUTREN FIBER 1 CAL 121 NITRO-BID 92 NUTREN JUNIOR 121 NITROFURANTOIN 19 NUTREN JUNIOR FIBER 121 NITROFURANTOIN MACROCRYSTAL 19 NUTRITIONAL NITROFURANTOIN SUPPLEMENT 112,116,118,121,122,123,125,126,128 MONOHYDRATE/MACROCRYSTALS 19 NUTRITIONAL SUPPLEMENT NITROGLYCERIN 92 NO.1/FRUCTOOLIGOSACCHARIDES/INULIN 123 NIVESTYM 75 NUTRITIONAL SUPPLEMENT,SPECIAL NIZATIDINE 146 FORMULA,LACTOSE FREE,IRON/SOY 109 NONOXYNOL 9 149,150 NUTRITIONAL NORDITROPIN FLEXPRO 152,153 SUPPLEMENT/FIBER 111,113,114,115,119,120,121,1 NORELGESTROMIN/ETHINYL ESTRADIOL 161,162 23,125,126,127,128 NORETHINDRONE 162,163,164 NUTRITIONAL NORETHINDRONE ACETATE 163 SUPPLEMENT/INULIN/FRUCTOOLIGOSACCHARIDE NORETHINDRONE ACETATE-ETHINYL S 123 ESTRADIOL 154,157,158,159
PAGE 260 LAST UPDATED 09/2021 NUTRITIONAL OSIMERTINIB MESYLATE 54,55 SUPPLEMENT/INULIN/FRUCTOOLIGOSACCHARIDE OSMOLITE 1 CAL 121 S/FIBER 113,117,121,123,126 OSMOLITE 1.2 CAL 121 NUTRITIONAL SUPPLEMENT/MEDIUM CHAIN OSMOLITE 1.5 CAL 121 TRIGLYCERIDES 120 OTEZLA 107,168 NUTRITIONAL THERAPY FOR IMPAIRED OTOVEL 233 DIGESTIVE FUNCTION 115 OXANDROLONE 153 NUTRITIONAL THERAPY, LACTOSE-REDUCED, OXCARBAZEPINE 27 WITH IRON 112 OXERVATE 230 NUTRITIONAL TX, KETOGENIC,WHEY 119 OXYBUTYNIN CHLORIDE 148 NUTRITIONAL TX. GLUCOSE OXYCODONE HCL 10,11,12 INTOLERANCE,LACTOSE-FREE,SOY/FIBER 111 OXYCODONE HCL/ACETAMINOPHEN 11,12 NYSTATIN 32,33 OXYCODONE HCL/ASPIRIN 12 NYSTATIN/TRIAMCINOLONE ACETONIDE 107 OXYCONTIN 10,11 OZEMPIC 69 O ODEFSEY 63 P ODOMZO 52 PAIN & FEVER 99 OFATUMUMAB 102 PALBOCICLIB 48 OFLOXACIN 231,232 PALIVIZUMAB 168 OLAPARIB 52 PALYNZIQ 148 OLMESARTAN MEDOXOMIL 78 PANOBINOSTAT LACTATE 47 OLMESARTAN PANTOPRAZOLE SODIUM 147 MEDOXOMIL/HYDROCHLOROTHIAZIDE 87 PARAGARD T 380-A 210 OMEGA-3 ACID ETHYL ESTERS 91 PAROMOMYCIN SULFATE 18 OMEGA-3 FATTY ACIDS 90,91 PAZOPANIB HCL 57 OMEGA-3 FATTY ACIDS/DHA/EPA/OTHER OMEGA- PEAK FLOW METER 183,210,223 3S/FISH OIL 90,117,121,127 PEAK FLOW METER/INHALER, ASSIST OMEGA-3 FATTY ACIDS/DOCOSAHEXAENOIC DEVICES 183 ACID/EPA/FISH OIL 90,91,117,121 PEDIA POLY-VITE 122 OMEGA-3 FATTY ACIDS/DOCOSAHEXANOIC PEDIA POLY-VITE WITH IRON 122 ACID/EPA/FISH OIL 90 PEDIA TRI-VITE 122 OMEGA-3 FATTY ACIDS/FISH OIL 90,91 PEDIASMART ORGANIC DAIRY 122 OMEPRAZOLE 147 PEDIASMART ORGANIC SOY 122 ONDANSETRON 31 PEDIASURE 122,123 ONDANSETRON HCL 31 PEDIASURE 1.5 122 ONUREG 41 PEDIASURE 1.5 WITH FIBER 122 OPIUM/BELLADONNA ALKALOIDS 11 PEDIASURE ENTERAL 122 ORKAMBI 242 PEDIASURE ENTERAL WITH FIBER 122 ORPHENADRINE CITRATE 246 PEDIASURE GROW-GAIN 122 OSELTAMIVIR PHOSPHATE 66 PEDIASURE GROW-GAIN ORGANIC 122
PAGE 261 LAST UPDATED 09/2021 PEDIASURE GROW-GAIN WITH FIBER 122 PEG 3350/SODIUM SULFATE/SOD PEDIASURE HARVEST 109 CHLORIDE/KCL/ASCORBATE SOD/VIT C 134 PEDIASURE PEPTIDE 1.5 CAL 123 PEGFILGRASTIM-CBQV 76 PEDIASURE SIDEKICKS 123 PEGFILGRASTIM-JMDB 75 PEDIASURE WITH FIBER 123 PEGVALIASE-PQPZ 148 PEDIATRIC MULTIVIT WITH A,C,D3 NO.21/SODIUM PEMAZYRE 52,53 FLUORIDE 128 PEMIGATINIB 52,53 PEDIATRIC MULTIVITAMIN NO.16/SODIUM PEN NEEDLE, FLUORIDE 120 DIABETIC 181,182,185,186,187,188,189,190,192,193, PEDIATRIC MULTIVITAMIN NO.160/FERROUS 194,195,198,199,200,202,203,204,205,206,208,210,21 SULFATE 122 1,212,213,214,216,218,220,221,222,223,224,225,226, PEDIATRIC MULTIVITAMIN NO.171 122 227,228,229 PEDIATRIC MULTIVITAMIN NO.189/FERROUS PEN NEEDLE, DIABETIC DISPOSABLE, SULFATE 124 SAFETY 183,184 PEDIATRIC MULTIVITAMIN NO.192 124 PEN NEEDLE, DIABETIC, REMOVER AND PEDIATRIC MULTIVITAMIN NO.194/FERROUS DISPOSAL UNIT 225 SULFATE 124 PEN NEEDLE, DIABETIC, PEDIATRIC MULTIVITAMIN NO.2/SODIUM SAFETY 183,192,195,196,200,208,215,217,224 FLUORIDE 120 PENCICLOVIR 108 PEDIATRIC MULTIVITAMIN NO.45/SODIUM PENICILLIN V POTASSIUM 21 FLUORIDE/FERROUS SULFATE 120 PENTAMIDINE ISETHIONATE 59 PEDIATRIC MULTIVITAMIN NO.82 WITH SODIUM PENTOSAN POLYSULFATE SODIUM 149 FLUORIDE 120 PENTOXIFYLLINE 87 PEDIATRIC MULTIVITAMIN NO.88/IRON PEPTAMEN AF 123 POLYSACCHARIDE COMPLEX 120 PEPTAMEN JUNIOR 123 PEDIATRIC MULTIVITAMINS NO.17 WITH SODIUM PEPTAMEN JUNIOR FIBER 123 FLUORIDE 120 PEPTAMEN JUNIOR HP 123 PEDIATRIC NUTRITION WITH IRON, LACTOSE PEPTAMEN JUNIOR WITH PREBIO1 123 FREE 112,122,123 PEPTIDE 1.0 123 PEDIATRIC NUTRITION, IRON, LACTOSE FREE PEPTIDE 1.5 123 WITH FIBER 112,114,122,123 PEPTIDE FORMULA 1.5 123 PEDIATRIC NUTRITION, MILK BASED, WITH PERINDOPRIL ERBUMINE 79 IRON 123 PERMETHRIN 108 PEDIATRIC NUTRITION, SOY WITH IRON, PERRY PRENATAL 123 LACTOSE FREE/FIBER 122 PEXIDARTINIB HYDROCHLORIDE 55 PEDIATRIC PEPTIDE 1.0 123 PFIZER COVID-19 VACCINE (EUA) 175 PEDIATRIC PEPTIDE FORMULA 1.5 123 PHENAZOPYRIDINE HCL 149,150 PEDIATRIC STANDARD FORMULA 1.2 123 PHENOBARBITAL 26 PEG 3350/SOD SULF/SOD BICARB/SOD PHENOL 211 CHLORIDE/POTASSIUM CHLORIDE 140,142 PHENOXYBENZAMINE HCL 78 PHENYLEPHRINE HCL 230
PAGE 262 LAST UPDATED 09/2021 PHENYLEPHRINE HCL/PROMETHAZINE HCL 245 PREDNISOLONE SODIUM PHOSPHATE 151,152,231 PHENYTOIN 27 PREDNISONE 152 PHENYTOIN SODIUM EXTENDED 27 PREGABALIN 101 PHOSPHOLINE IODIDE 232 PREMPHASE 160 PIFELTRO 63 PRENATABS FA 124 PILOCARPINE HCL 232 PRENATABS RX 124 PINDOLOL 82 PRENATAL FORMULA-DHA 124 PIOGLITAZONE HCL 69 PRENATAL VIT WITH CALCIUM NO.122/FERROUS PIPERONYL BUTOXIDE/PYRETHRINS 106,107 FUMARATE/FOLIC ACID 124 PIPERONYL PRENATAL VIT WITH CALCIUM NO.126/FERROUS BUTOXIDE/PYRETHRINS/PERMETHRIN 106,107 FUMARATE/FOLIC ACID 113 PIQRAY 53 PRENATAL VIT WITH CALCIUM NO.129/FERROUS PIROXICAM 7 FUMARATE/FOLIC ACID 124 PNEUMOCOCCAL 13-VALENT CONJUGATE PRENATAL VIT WITH CALCIUM NO.130/FERROUS VACCINE (DIPHTHERIA CRM)/PF 175 FUMARATE/FOLIC ACID 124 PNEUMOCOCCAL 23-VALENT POLYSACCHARIDE PRENATAL VITAMIN 27 WITH CALCIUM/FERROUS VACCINE 175 FUMARATE/FOLIC ACID 128 PNEUMOVAX 23 175 PRENATAL VITAMIN NO.103/FOLIC ACID/OMEGA- POLY-VI-SOL 124 3S/DHA/FISH OIL 124 POLY-VI-SOL WITH IRON 124 PRENATAL VITAMIN WITH CALCIUM POLYETHYLENE GLYCOL NO.76/IRON,CARBONYL/FOLIC ACID 124 3350 129,130,131,132,133,134,135,136,137 PRENATAL VITAMINS NO.116/IRON POLYMYXIN B SULFATE/TRIMETHOPRIM 231 FUMARATE/FOLIC ACID/DHA 124 POMALIDOMIDE 38 PRENATAL VITAMINS NO.121/FERROUS POMALYST 38 FUMARATE/FOLIC ACID 124 PONATINIB HCL 48 PRENATAL VITAMINS NO.49/FERROUS POTASSIUM BICARBONATE/CITRIC ACID 114,119 FUMARATE/FOLIC ACID 120 POTASSIUM CHLORIDE 109,110,119 PRENATAL VITAMINS NO.62/FOLIC ACID/OMEGA- POTASSIUM CITRATE 109 3S/DHA/EPA/FISH OIL 114 POTASSIUM PHOSPHATE,MONOBASIC 149 PRENATAL VITAMINS WITH CALCIUM/FERROUS PRALSETINIB 43 FUMARATE/FOLIC ACID 120,124,126 PRALUENT PEN 91 PRENATAL VITS WITH CALCIUM 118/FERROUS PRALUENT SYRINGE 91 FUMARATE/FOLIC ACID 126 PRAMIPEXOLE DI-HCL 60 PRENATAL VITS WITH CALCIUM 133/FERROUS PRASUGREL HCL 77 FUMARATE/FOLIC ACID 118,119,128 PRAVASTATIN SODIUM 89 PRENATAL VITS WITH CALCIUM 136/FERROUS PRAZOSIN HCL 78 FUMARATE/FOLIC ACID 128 PRED MILD 231 PRENATAL VITS WITH CALCIUM 137/FERROUS PREDNISOLONE 151,152 FUMARATE/FOLIC ACID 114,125 PREDNISOLONE ACETATE 231 PRENATAL VITS WITH CALCIUM 36/FERROUS PREDNISOLONE ACETATE/PF 231 FUMARATE/FOLIC ACID 123
PAGE 263 LAST UPDATED 09/2021 PRENATAL VITS WITH CALCIUM 95/FERROUS PROMACTA 75,76 FUMARATE/FOLIC PROMETHAZINE HCL 30,238 ACID 117,118,124,125,126,127,128 PROMETHAZINE HCL/CODEINE 245 PRENATAL VITS WITH CALCIUM NO.10/FERROUS PROMETHAZINE HCL/DEXTROMETHORPHAN FUMARATE/FOLIC ACID 128 HBR 245 PRENATAL VITS WITH CALCIUM NO.124/FERROUS PROMETHAZINE/PHENYLEPHRINE FUMARAT/FOLIC ACID 125 HCL/CODEINE 245 PRENATAL VITS WITH CALCIUM NO.21/FERROUS PROMOD 125 FUMARATE/FOLIC ACID 124 PROMOTE 125 PRENATAL VITS WITH CALCIUM NO.72/FERROUS PROMOTE WITH FIBER 125 FUMARATE/FOLIC ACID 119,124,125,129 PROPAFENONE HCL 80 PRENATAL VITS WITH CALCIUM PROPANTHELINE BROMIDE 138 NO.72/IRON,CARBONYL/FOLIC ACID 124 PROPRANOLOL HCL 82 PRENATAL VITS WITH CALCIUM NO.73/FERROUS PROPYLTHIOURACIL 166 FUMARATE/FOLIC ACID 128 PROTEIN SUPPLEMENT 112,115,121,125 PRENATAL VITS WITH CALCIUM NO.74/FERROUS PSYLLIUM FUMARATE/FOLIC ACID 124 HUSK 129,130,131,132,133,134,135,136,137 PRENATAL VITS WITH CALCIUM NO.78/FERROUS PSYLLIUM HUSK (WITH FUMARATE/FOLIC ACID 124 SUGAR) 130,131,132,133,134,135,136,137 PRENATAL VITS WITH CALCIUM NO.93/FERROUS PSYLLIUM SEED 135 FUMARATE/FOLIC ACID 124 PSYLLIUM SEED (WITH SUGAR) 132,134 PRENATAL VITS WITH CALCIUM NO.96/FERROUS PULMOZYME 242 FUMARATE/FOLIC ACID 125 PYRAZINAMIDE 36 PRENATAL VITS WITH CALCIUM NO.98/FERROUS PYRIDOSTIGMINE BROMIDE 35 FUMARATE/FOLIC ACID 119 PYRIDOXINE HCL (VITAMIN PREOP 125 B6) 114,116,118,125,126,127,128,129 PRETOMANID 36 PREVNAR 13 175 Q PREVYMIS 61 QINLOCK 53 PREZCOBIX 65 QUINAPRIL HCL 79,80 PREZISTA 66 QUINAPRIL HCL/HYDROCHLOROTHIAZIDE 87 PRIFTIN 36 QUINIDINE GLUCONATE 80 PRIMAQUINE PHOSPHATE 59 QUINIDINE SULFATE 81 PRIMIDONE 26 QVAR REDIHALER 234 PROBENECID 34 PROCARBAZINE HCL 36 R PROCHLORPERAZINE 29,30 RALOXIFENE HCL 164 PROCHLORPERAZINE MALEATE 30 RALTEGRAVIR POTASSIUM 62 PROCTOFOAM-HC 107 RAMIPRIL 80 PROGESTERONE 164 RANITIDINE HCL 144,145,146,147 PROGESTERONE, MICRONIZED 163,164 RECOMBIVAX HB 175
PAGE 264 LAST UPDATED 09/2021 REGULOID 135 RELENZA 66 S RENACIDIN 150 SACUBITRIL/VALSARTAN 86 REPATHA PUSHTRONEX 91 SAFETY SYRINGE WITH NEEDLE, DISPOSABLE REPATHA SURECLICK 91 KIT-TRAY, 1 ML 196 REPATHA SYRINGE 91 SALMETEROL XINAFOATE 241 REPLETE WITH FIBER 126 SANDIMMUNE 172 RESOURCE 2.0 126 SAPROPTERIN DIHYDROCHLORIDE 148 RETACRIT 76 SAQUINAVIR MESYLATE 65 RETEVMO 42 SATRALIZUMAB-MWGE 168 REVLIMID 38,39 SCOT-TUSSIN 245 REYATAZ 66 SCOT-TUSSIN EXPECTORANT 245 RIBOCICLIB SUCCINATE 50 SECUKINUMAB 167 RIDAURA 168 SEGLUROMET 69 RIFAMATE 36 SELEGILINE HCL 61 RIFAMPIN 36 SELENIUM SULFIDE 106 RIFAMPIN/ISONIAZID 36 SELINEXOR 42,43 RIFAPENTINE 36 SELPERCATINIB 42 RIFAXIMIN 20 SELUMETINIB SULFATE/VITAMIN E TPGS 50 RILPIVIRINE HCL 63 SELZENTRY 65 RILUZOLE 100 SEMAGLUTIDE 69 RIMANTADINE HCL 66 SEMGLEE 73 RINGER'S SOLUTION 126 SEMGLEE PEN 73 RINGER'S SOLUTION,LACTATED 119 SENNOSIDES 129,130,131,132,133,134,135,136 RIPRETINIB 53 SENNOSIDES/DOCUSATE RISEDRONATE SODIUM 179 SODIUM 130,131,132,133,134,135,136,137 RITONAVIR 65,66 SEREVENT DISKUS 241 RIVAROXABAN 74 SEVELAMER CARBONATE 110,111 RIVASTIGMINE 28,29 SEVELAMER HCL 111 RIVASTIGMINE TARTRATE 28,29 SHINGRIX 175 RIZATRIPTAN BENZOATE 34 SILDENAFIL CITRATE 243 ROPINIROLE HCL 60 SILVER 181 ROSUVASTATIN CALCIUM 89 SILVER SULFADIAZINE 23,107,108 ROZLYTREK 42 SILVER SULFATE/FOAM BANDAGE 215 RUBRACA 53 SILVER/CALCIUM ALGINATE 215 RUCAPARIB CAMSYLATE 53 SIMETHICONE 139,140,141,142,143 RUFINAMIDE 27,28 SIMVASTATIN 89,90 RUKOBIA 65 SIROLIMUS 172 RUXOLITINIB PHOSPHATE 50 SIRTURO 36 RYDAPT 53 SKYLA 164 SODIUM CHLORIDE 0.9 % (FLUSH) 111,120,127
PAGE 265 LAST UPDATED 09/2021 SODIUM CHLORIDE FOR INHALATION 245 SUBCUTANEOUS ADMINISTRATION SET 201 SODIUM CHLORIDE IRRIGATING SUBCUTANEOUS INFUSION PUMP SOLUTION 109,110,127 ACCESSORY 209,210,212,216,219 SODIUM CHLORIDE/SODIUM SUCCIMER 110 BICARBONATE/POTASSIUM CHLORIDE/PEG 142 SUCRALFATE 147 SODIUM PHOSPHATE,DIBASIC/POT SULFACETAMIDE SODIUM 231 PHOS,MONOB/SOD PHOSPHATE MONO 149 SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE,MONOBASIC/POTASSIUM SODIUM PHOSPHATE 230 PHOSPHATE,MONOBASIC 149 SULFADIAZINE 22 SODIUM POLYSTYRENE SULFONATE 111 SULFAMETHOXAZOLE/TRIMETHOPRIM 22,23 SODIUM POLYSTYRENE SULFONATE/SORBITOL SULFAMYLON 108 SOLUTION 111 SULFASALAZINE 176 SODIUM SUCCINATE 217 SULFURIC ACID/SULFONATED PHENOL 102 SODIUM SULFATE/POTASSIUM SULINDAC 9 SULFATE/MAGNESIUM SULFATE 137 SUMATRIPTAN 34,35 SOFOSBUVIR/VELPATASVIR 62 SUMATRIPTAN SUCCINATE 35 SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR 62 SUNITINIB MALATE 54 SOL CARB 127 SUPREP 137 SOLIFENACIN SUCCINATE 148 SYMDEKO 242 SOMATROPIN 152,153 SYMTUZA 66 SONIDEGIB PHOSPHATE 52 SYNAGIS 168 SORAFENIB TOSYLATE 52 SYNJARDY 69,70 SOTALOL HCL 81 SYNJARDY XR 70 SOTORASIB 41 SYRINGE 3 ML WITH SAFETY NEEDLE,SELF- SOY PROTEIN 128 CONTAINED DISPOSAL UNIT 215 SPIRIVA 240 SYRINGE W-NEEDLE 0.3 ML,INSULIN,SAFETY W- SPIRIVA RESPIMAT 240 SELF-CONT.DIS.UNIT 215 SPIROMETERS AND ACCESSORIES 211 SYRINGE WITH NEEDLE 1 ML,INSULIN,SAFETY W- SPIRONOLACTONE 88 SELF-CON.DISP.UNIT 215 SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 87 SYRINGE WITH NEEDLE, INSULIN, SAFETY, 0.3 SPRYCEL 53,54 ML 186,205 SPS 111 SYRINGE WITH NEEDLE, INSULIN, SAFETY, 0.5 SSD 108 ML 183,186,194,205 STANDARD 1.4 127 SYRINGE WITH NEEDLE, INSULIN, SAFETY, 1 STANDARD FORMULA 1.0 127 ML 183,185,194,195,206,228 STAVUDINE 64 SYRINGE WITH NEEDLE,DISPOSABLE, 1 STEGLATRO 69 ML183,184,185,186,188,197,206,208,220,223,225,228 STIOLTO RESPIMAT 246 SYRINGE WITH NEEDLE,DISPOSABLE, 3 STIRIPENTOL 23,24 ML183,184,185,186,188,196,197,206,207,208,221,223 STOOL SOFTENER 136,137 ,228 STRIBILD 62
PAGE 266 LAST UPDATED 09/2021 SYRINGE WITH NEEDLE,DISPOSABLE,INSULIN 1 TAKE ACTION 164 ML182,184,185,186,187,188,189,190,192,193,194,195 TALAZOPARIB TOSYLATE 55 ,196,197,198,199,200,201,202,203,204,205,206,207,2 TALZENNA 55 08,212,213,214,217,218,219,220,221,222,223,224,225 TAMOXIFEN CITRATE 39 ,226,227,228 TAMSULOSIN HCL 149 SYRINGE WITH NEEDLE,INSULIN 0.3 ML (HALF TASIGNA 55 UNIT MARK) 184,186,198,201,219,220,223,226 TAVALISSE 77 SYRINGE WITH NEEDLE,INSULIN 0.5 ML (HALF TAZEMETOSTAT HYDROBROMIDE 42 UNIT MARK) 191,220 TAZVERIK 42 SYRINGE WITH NEEDLE,INSULIN DISPOSABLE 207 TDVAX 175 SYRINGE WITH NEEDLE,INSULIN,0.3 TELMISARTAN 78 ML182,184,185,186,187,188,189,191,192,193,194,197 TEMAZEPAM 246 ,198,199,201,202,203,204,205,207,208,212,213,214,2 TEMOZOLOMIDE 37 15,217,218,220,221,222,223,224,225,226,227 TENOFOVIR DISOPROXIL FUMARATE 64 SYRINGE WITH NEEDLE,INSULIN,0.5 TEPMETKO 39 ML182,184,185,186,187,188,189,190,193,194,195,196 TEPOTINIB HCL 39 ,197,198,199,201,202,203,204,205,206,207,208,212,2 TERAZOSIN HCL 78 13,214,215,216,217,218,220,221,222,223,224,225,226 TERBINAFINE HCL 33 ,227,228 TERBUTALINE SULFATE 241 SYRINGE WITHOUT NEEDLE,INSULIN DISPOSIBLE, TERCONAZOLE 33 1 ML 185,195,196 TESTOSTERONE 153 SYRINGE, INSULIN U-500 WITH NEEDLE, TESTOSTERONE CYPIONATE 153,154 DISPOSABLE, 0.5 ML 184 TESTOSTERONE ENANTHATE 153,154 SYRINGE,NEEDLE,SAFETY 1 ML,SELF-CONTAINED TETANUS AND DIPHTHERIA TOXOIDS, ADULT 175 DISPOSAL UNIT 215 TEZACAFTOR/IVACAFTOR 242 SYRINGE,SAFETY WITH NEEDLE,1 THEOPHYLLINE ANHYDROUS 243 ML 196,206,208,216 THERMAZENE 23 SYRINGE,SAFETY WITH NEEDLE,3 THIAMINE HCL 111,114,117,126,127,128 ML 184,185,194,196,207,215,216,221,224 THIAMINE MONONITRATE (VIT B1) 126,128 SYRINGE-NEEDLE,INSULIN,0.5 THIOGUANINE 39 ML/CONTAINER,EMPTY 225 TIAGABINE HCL 26 TIBSOVO 55 T TICLOPIDINE HCL 77 TABLOID 39 TIMOLOL MALEATE 232 TABRECTA 42 TIOTROPIUM BROMIDE 240 TACROLIMUS 106,172 TIOTROPIUM BROMIDE/OLODATEROL HCL 246 TAFAMIDIS 87 TIVICAY 62 TAFAMIDIS MEGLUMINE 148 TIVICAY PD 63 TAFENOQUINE SUCCINATE 58 TIVOZANIB HCL 40 TAFINLAR 54 TIZANIDINE HCL 61 TAGRISSO 54,55 TOBRADEX 231
PAGE 267 LAST UPDATED 09/2021 TOBRAMYCIN 231 UKONIQ 42 TOBRAMYCIN/DEXAMETHASONE 231 ULIPRISTAL ACETATE 162 TOBRAMYCIN/NEBULIZER 242 ULTRIENT 1.5 WITH ENFIT 128 TOCILIZUMAB 167 UMBRALISIB TOSYLATE 42 TOLTERODINE TARTRATE 148,149 UMECLIDINIUM BROMIDE 240 TOLVAPTAN 110 URSODIOL 143 TOPIRAMATE 24,25 TOREMIFENE CITRATE 38 V TORSEMIDE 88 VALACYCLOVIR HCL 66,67 TRAMADOL HCL 12 VALGANCICLOVIR HCL 61 TRAMADOL HCL/ACETAMINOPHEN 12 VALSARTAN 78 TRAMETINIB DIMETHYL SULFOXIDE 52 VALSARTAN/HYDROCHLOROTHIAZIDE 87 TRANDOLAPRIL 80 VANCOMYCIN HCL 19,20 TRANEXAMIC ACID 77 VANDAZOLE 20 TRAVEL SICKNESS 30 VANDETANIB 46 TRELEGY ELLIPTA 246 VAQTA 175,176 TRETINOIN 58,104 VARENICLINE TARTRATE 14,18 TRI-VI-SOL 128 VARICELLA VIRUS VACCINE LIVE/PF 176 TRIAMCINOLONE ACETONIDE 103,106 VARICELLA-ZOSTER VIRUS GLYCOPROTEIN TRIAMTERENE/HYDROCHLOROTHIAZIDE 87 E,REC/AS01B ADJUVANT/PF 175 TRIAZOLAM 67 VARIVAX VACCINE 176 TRIFLURIDINE 66 VEMURAFENIB 57 TRIFLURIDINE/TIPIRACIL HCL 41 VENCLEXTA 55,56 TRIHEXYPHENIDYL HCL 59 VENCLEXTA STARTING PACK 56 TRIKAFTA 242 VENETOCLAX 55,56 TRIMETHOBENZAMIDE HCL 30 VERAPAMIL HCL 84,85 TRIMETHOPRIM 19 VERZENIO 56 TRINATE 128 VICTOZA 2-PAK 70 TRIUMEQ 64 VICTOZA 3-PAK 70 TROPICAMIDE 231 VIDEX 64 TROSPIUM CHLORIDE 149 VIGABATRIN 26,27 TRULICITY 70 VIMPAT 28 TRUMENBA 175 VIREAD 64 TUCATINIB 55 VISMODEGIB 46 TUKYSA 55 VITAFOL-OB 128 TURALIO 55 VITAL HIGH NITROGEN 128 TWINRIX 175 VITAMIN A PALMITATE/ASCORBIC TWOCAL HN 128 ACID/CHOLECALCIFEROL (VIT D3) 122,128 VITAMIN B COMPLEX NO.3/FOLIC ACID/ASCORBIC U ACID(VITC)/BIOTIN 120,126 UDENYCA 76 VITRAKVI 56,57
PAGE 268 LAST UPDATED 09/2021 VIZIMPRO 57 VOLTAREN ARTHRITIS PAIN 9 VORICONAZOLE 33 VORINOSTAT 43 VOSEVI 62 VOTRIENT 57 VYNDAMAX 87 VYNDAQEL 148
W WARFARIN SODIUM 73,74 WATER FOR IRRIGATION,STERILE 217
X XALKORI 57 XARELTO 74 XCOPRI 25 XIFAXAN 20 XIGDUO XR 70,71 XOSPATA 57 XPOVIO 42,43 XTANDI 38
Z ZAFIRLUKAST 240 ZALEPLON 246 ZANAMIVIR 66 ZANUBRUTINIB 40 ZEJULA 57 ZELBORAF 57 ZIDOVUDINE 64 ZOLADEX 43 ZOLINZA 43 ZOLMITRIPTAN 35 ZOLPIDEM TARTRATE 246 ZONISAMIDE 28 ZOSTAVAX 176 ZOSTER VACCINE LIVE/PF 176 ZYDELIG 57,58 ZYKADIA 58
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