Wellcare of New Jersey Supplemental Preferred Drug List

2021 Supplemental Preferred Drug List (List of Covered Drugs)

Lista de medicamentos preferidos y suplementarios (Lista de medicamentos cubiertos)

WellCare of New Jersey 00

Please read: This document contains information about the drugs we cover in this plan.

Lea: este documento contiene información sobre los medicamentos que cubrimos bajo este plan.

Last updated (10/01/2021) Última actualización (10/01/2021)

CAD_68012M State Approved 04232021 ©WellCare 2021 NJ1JMDCVR72576M_0121 092-21-6 Drug Name Preference Details Coverage Details *Alternative Medicines* *Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 mg P melatonin oral tablet 12 mg P *Analgesics - Anti-Inflammatory* *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** childrens ibuprofen oral suspension 40 mg/ml P ibuprofen oral suspension 100 mg/5ml P ibuprofen oral tablet 200 mg P naproxen sodium oral tablet 220 mg P *Analgesics - Nonnarcotic* *Analgesics Other*** ACEPHEN RECTAL SUPPOSITORY 325 P MG, 650 MG acetaminophen oral solution 160 mg/5ml P acetaminophen oral tablet 325 mg P QL (279 EA per 31 days) acetaminophen oral tablet 500 mg P QL (186 EA per 31 days) acetaminophen oral tablet chewable 325 mg P apap extra strength oral tablet 500 mg P QL (186 EA per 31 days) apap oral tablet 325 mg P QL (279 EA per 31 days) childrens non-asa pain relief oral tablet P chewable 80 mg childrens non-aspirin oral tablet chewable 80 P mg childrens pain reliever oral tablet chewable P 80 mg childrens silapap oral liquid 160 mg/5ml P childrens tactinal oral tablet chewable 80 mg P ed-apap oral liquid 160 mg/5ml P infants silapap oral solution 100 mg/ml P mapap arthritis pain oral tablet extended P QL (93 EA per 31 days) release 650 mg MAPAP CHILDRENS ORAL SUSPENSION P 160 MG/5ML mapap oral capsule 500 mg P QL (186 EA per 31 days) mapap oral liquid 160 mg/5ml P

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 1 Drug Name Preference Details Coverage Details mapap oral tablet 325 mg P QL (279 EA per 31 days) mapap oral tablet 500 mg P QL (186 EA per 31 days) mapap oral tablet chewable 80 mg P maxapap maximum strength oral tablet 500 P QL (186 EA per 31 days) mg maxapap regular strength oral tablet 325 mg P QL (279 EA per 31 days) non-aspirin extra strength oral tablet 500 mg P QL (186 EA per 31 days) non-aspirin oral tablet 325 mg P QL (279 EA per 31 days) non-aspirin pain relief oral tablet 325 mg P QL (279 EA per 31 days) nortemp infants oral suspension 80 mg/0.8ml P pain & fever childrens oral solution 160 P mg/5ml pain relief extra strength oral tablet 500 mg P QL (186 EA per 31 days) pain relief oral tablet 500 mg P QL (186 EA per 31 days) PHARBETOL EXTRA STRENGTH ORAL P QL (186 EA per 31 days) TABLET 500 MG PHARBETOL ORAL TABLET 325 MG P QL (279 EA per 31 days) q-pap oral tablet 325 mg P QL (279 EA per 31 days) tactinal extra strength oral tablet 500 mg P QL (186 EA per 31 days) tactinal oral tablet 325 mg P QL (279 EA per 31 days) *Salicylate Combinations*** tri-buffered aspirin oral tablet 325 mg P *Salicylates*** aspirin childrens oral tablet chewable 81 mg P aspirin ec low dose oral tablet delayed P release 81 mg aspirin ec oral tablet delayed release 325 mg P aspirin oral tablet 325 mg, 81 mg P aspirin oral tablet chewable 81 mg P aspirin rectal suppository 300 mg, 600 mg P ECPIRIN ORAL TABLET DELAYED P RELEASE 325 MG *Anorectal And Related Products* *Rectal Combinations - Misc.*** eq hemorrhoidal rectal suppository 0.25- P 85.39 %

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 2 Drug Name Preference Details Coverage Details hemorrhoidal rectal suppository 0.25-3-85.5 P %, 0.25-85.39 % *Antacids* *Antacid & Simethicone*** antacid anti-gas max strength oral P suspension 400-400-40 mg/5ml antacid anti-gas oral suspension 200-200-20 P mg/5ml antacid extra strength oral suspension 400- P 400-40 mg/5ml antacid iii oral suspension 400-400-40 P mg/5ml MAALOX ADVANCED MAX ST ORAL P SUSPENSION 400-400-40 MG/5ML MAALOX MAX ORAL SUSPENSION 400- P 400-40 MG/5ML MAALOX MULTI SYMPTOM MAX ST ORAL P SUSPENSION 400-400-40 MG/5ML milantex extra strength oral suspension 400- P 400-40 mg/5ml MINTOX PLUS ORAL TABLET CHEWABLE P 200-200-25 MG *Antacid Combinations*** ACID GONE ORAL TABLET CHEWABLE P 160-105 MG gnp foaming antacid oral tablet chewable 80- P 20 mg MI-ACID ORAL TABLET CHEWABLE 700- P 300 MG *Antacids - Aluminum Salts*** aluminum hydroxide gel oral suspension 320 P mg/5ml *Antacids - Bicarbonate*** sodium bicarbonate oral tablet 325 mg, 650 P mg *Antacids - Calcium Salts*** antacid oral tablet chewable 500 mg P calcium antacid extra strength oral tablet P chewable 750 mg

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 3 Drug Name Preference Details Coverage Details calcium antacid oral tablet chewable 500 mg P calcium carbonate antacid oral suspension P 1250 mg/5ml calcium carbonate antacid oral tablet 648 mg P calcium carbonate antacid oral tablet P chewable 500 mg CAL-GEST ANTACID ORAL TABLET P CHEWABLE 500 MG MAALOX ORAL TABLET CHEWABLE 600 P MG TITRALAC ORAL TABLET CHEWABLE 420 P MG *Antacids - Magnesium Salts*** magnesium oxide oral tablet 250 mg, 400 P mg, 420 mg *Anthelmintics* *Anthelmintics*** reeses pinworm medicine oral suspension P 144 (50 base) mg/ml *Antidiabetics* *Diabetic Other*** BD GLUCOSE ORAL TABLET CHEWABLE P 5 GM glucose oral tablet chewable 4 gm P *Antidiarrheal/Probiotic Agents* *Antidiarrheal/Probiotic Agents - Misc.*** bismatrol oral suspension 262 mg/15ml P bismatrol oral tablet chewable 262 mg P bismuth oral tablet chewable 262 mg P diotame oral tablet chewable 262 mg P KAOPECTATE EXTRA STRENGTH ORAL P SUSPENSION 525 MG/15ML KAOPECTATE ORAL SUSPENSION 262 P MG/15ML KAO-TIN ORAL SUSPENSION 262 P MG/15ML pink bismuth oral suspension 262 mg/15ml P pink bismuth oral tablet chewable 262 mg P

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 4 Drug Name Preference Details Coverage Details stomach relief oral suspension 262 mg/15ml, P 527 mg/30ml stomach relief oral tablet chewable 262 mg P stomach relief plus oral suspension 525 P mg/15ml *Antiperistaltic Agents*** anti-diarrheal oral liquid 1 mg/5ml P LOPERAMIDE A-D ORAL TABLET 2 MG P loperamide hcl oral liquid 1 mg/5ml P *Antidotes And Specific Antagonists* *Antidotes And Specific Antagonists*** ipecac oral syrup P sm ipecac syrup oral syrup P *Antiemetics* *Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5 mg, 25 mg P travel sickness oral tablet chewable 25 mg P *Antihistamines* *Antihistamines - Alkylamines*** aller-chlor oral syrup 2 mg/5ml P aller-chlor oral tablet 4 mg P allergy oral tablet 4 mg P allergy relief oral tablet 4 mg P chlorhist oral tablet 4 mg P DIABETIC TUSSIN ALLERGY ORAL P SYRUP 2 MG/5ML *Antihistamines - Ethanolamines*** aler-cap oral capsule 25 mg P aler-dryl oral tablet 50 mg P alertab oral tablet 25 mg P allergy relief childrens oral liquid 12.5 mg/5ml P altaryl oral elixir 12.5 mg/5ml P altaryl oral syrup 12.5 mg/5ml P anti-hist allergy oral tablet 25 mg P BANOPHEN ORAL CAPSULE 25 MG P BANOPHEN ORAL LIQUID 12.5 MG/5ML P

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 5 Drug Name Preference Details Coverage Details BANOPHEN ORAL TABLET 25 MG P BENADRYL ALLERGY CHILDRENS ORAL P LIQUID 12.5 MG/5ML complete allergy medication oral tablet 25 mg P complete allergy relief oral tablet 25 mg P diphenhist oral capsule 25 mg P diphenhist oral liquid 12.5 mg/5ml P diphenhist oral tablet 25 mg P diphenhydramine hcl oral capsule 25 mg, 50 P mg diphenhydramine hcl oral tablet 25 mg P genahist oral capsule 25 mg P pharbedryl oral capsule 25 mg, 50 mg P q-dryl oral capsule 25 mg P q-dryl oral liquid 12.5 mg/5ml P SCOT-TUSSIN ALLERGY RELIEF ORAL P LIQUID 12.5 MG/5ML siladryl allergy oral liquid 12.5 mg/5ml P silphen cough oral syrup 12.5 mg/5ml P TOTAL ALLERGY MEDICINE ORAL LIQUID P 12.5 MG/5ML total allergy oral tablet 25 mg P *Antihistamines - Non-Sedating*** ALLEGRA ALLERGY CHILDRENS ORAL P TABLET 30 MG allergy oral tablet dispersible 10 mg P cetirizine hcl childrens alrgy oral syrup 1 P QL (300 ML per 31 days) mg/ml cetirizine hcl childrens oral solution 1 mg/ml P QL (300 ML per 31 days) cetirizine hcl oral syrup 5 mg/5ml P QL (300 ML per 31 days) cetirizine hcl oral tablet 10 mg, 5 mg P childrens loratadine oral syrup 5 mg/5ml P QL (310 ML per 31 days) fexofenadine hcl oral tablet 180 mg, 60 mg P loratadine childrens oral solution 5 mg/5ml P QL (310 ML per 31 days) loratadine hives relief oral solution 5 mg/5ml P QL (310 ML per 31 days) loratadine oral tablet 10 mg P

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 6 Drug Name Preference Details Coverage Details *Antiseptics & Disinfectants* *Chlorine Antiseptic Combinations*** dakins external solution 0.4-0.5 % P *Chlorine Antiseptics*** chlorhexidine gluconate external liquid 4 % P QL (480 ML per 31 days) dakins (1/2 strength) external solution 0.25 % P dakins (1/4 strength) external solution 0.125 P % *Iodine Antiseptics*** OPERAND POVIDONE-IODINE EXTERNAL P SOLUTION 10 % povidone-iodine external solution 10 % P *Cough/Cold/Allergy* *Antitussive - Nonnarcotic*** benzonatate oral capsule 100 mg, 200 mg P DELSYM ORAL SUSPENSION EXTENDED P RELEASE 30 MG/5ML ROBITUSSIN CHILDRENS COUGH LA P ORAL SYRUP 7.5 MG/5ML *Antitussive - Opioid*** hydrocodone-homatropine oral syrup 5-1.5 P mg/5ml hydrocodone-homatropine oral tablet 5-1.5 P mg *Antitussive-Antihistamine-Analgesic*** DELSYM NIGHT TIME MULTI-SYMPT P ORAL LIQUID 15-6.25-325 MG/15ML *Antitussive-Expectorant*** cheratussin ac oral syrup 100-10 mg/5ml P diabetic siltussin-dm oral liquid 100-10 P mg/5ml DIABETIC TUSSIN MAX ST ORAL LIQUID P 10-200 MG/5ML extra action cough oral syrup 100-10 mg/5ml P MUCINEX FAST-MAX DM MAX ORAL P LIQUID 20-400 MG/20ML mucus relief dm cough oral tablet 20-400 mg P

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 7 Drug Name Preference Details Coverage Details *Antitussive-Expectorants- Decongestant*** cheratussin dac oral solution 30-10-100 P mg/5ml robafen cf cough/cold oral syrup 5-10-100 P mg/5ml *Decongestant & Antihistamine*** ALAVERT ALLERGY/SINUS ORAL TABLET P EXTENDED RELEASE 12 HOUR 5-120 MG ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 P HOUR 60-120 MG allergy relief/nasal decongest oral tablet P extended release 24 hour 10-240 mg BROTAPP ORAL LIQUID 1-15 MG/5ML P cetirizine-pseudoephedrine er oral tablet P extended release 12 hour 5-120 mg fexofenadine-pseudoephed er oral tablet P extended release 24 hour 180-240 mg maxifed tr oral tablet 1.25-30 mg P Q-TAPP ORAL ELIXIR 1-15 MG/5ML P triprolidine-pse oral tablet 2.5-60 mg P *Decongestant W/ Expectorant*** tussin pe oral liquid 5-100 mg/5ml P *Expectorants*** chest congestion relief oral tablet 400 mg P diabetic siltussin das-na oral liquid 100 P mg/5ml mucus relief oral tablet 400 mg P refenesen 400 oral tablet 400 mg P refenesen oral tablet 200 mg P robafen oral syrup 100 mg/5ml P *Misc. Respiratory Inhalants*** BRONCHO SALINE INHALATION P AEROSOL SOLUTION 0.9 % sodium chloride inhalation nebulization P solution 0.9 %

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 8 Drug Name Preference Details Coverage Details *Non-Narc Antitussive-Antihistamine*** DIMETAPP LONG ACT COUGH/COLD P ORAL SYRUP 1-7.5 MG/5ML promethazine-dm oral syrup 6.25-15 mg/5ml P ROBITUSSIN CHILD COUGH/COLD LA P ORAL LIQUID 1-7.5 MG/5ML *Non-Narc Antitussive-Decongestant- Antihistamine*** brotapp dm oral liquid 15-1-5 mg/5ml P cold/cough childrens oral elixir 2.5-1-5 P mg/5ml corfen-dm oral liquid 10-4-15 mg/5ml P kidkare cough/cold oral liquid 15-1-5 mg/5ml P nohist-dm oral liquid 10-4-15 mg/5ml P rynex dm oral liquid 2.5-1-5 mg/5ml P VANACOF ORAL LIQUID 30-1-12.5 MG/5ML P *Opioid Antitussive-Antihistamine*** hydrocod polst-cpm polst er oral suspension P extended release 10-8 mg/5ml promethazine-codeine oral syrup 6.25-10 P mg/5ml TUSSICAPS ORAL CAPSULE EXTENDED P RELEASE 12 HOUR 10-8 MG, 5-4 MG *Opioid Antitussive-Decongestant- Antihistamine*** phenylhistine dh oral liquid 30-2-10 mg/5ml P promethazine vc/codeine oral syrup 6.25-5- P 10 mg/5ml *Dermatologicals* *Acne Products*** acne medication 5 external lotion 5 % P benzoyl peroxide cleanser external liquid 6 % P benzoyl peroxide external gel 10 %, 5 % P PANOXYL WASH EXTERNAL LIQUID 10 % P *Antibiotic Mixtures Topical*** bacitracin-neomycin-polymyxin external P ointment 400-5-5000

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 9 Drug Name Preference Details Coverage Details double antibiotic external ointment 500- P 10000 unit/gm triple antibiotic external ointment 3.5-400- P 5000 , 5-400-5000 *Antibiotics - Topical*** bacitracin external ointment 500 unit/gm P bacitracin zinc external ointment 500 unit/gm P *Antifungals - Topical*** anti-fungal external powder 1 % P terbinafine hcl external cream 1 % P *Antihistamines - Topical*** anti-itch maximum strength external cream 2 P % BENADRYL ITCH STOPPING EXTERNAL P GEL 2 % itch relief external cream 2 % P *Corticosteroids - Topical*** AVEENO ANTI-ITCH MAX ST EXTERNAL P CREAM 1 % hydrocortisone external cream 0.5 %, 1 % P hydrocortisone external lotion 1 % P hydrocortisone external ointment 0.5 %, 1 % P hydrocortisone max st external cream 1 % P hydrocortisone max st/12 moist external P cream 1 % HYDROSKIN EXTERNAL CREAM 1 % P kp hydrocortisone external cream 1 % P PREPARATION H EXTERNAL CREAM 1 % P tgt anti-itch/aloe/vit e external cream 1 % P *Emollients*** AMLACTIN EXTERNAL LOTION 12 % P QL (400 GM per 31 days) ammonium lactate external cream 12 % P QL (400 GM per 31 days) ammonium lactate external lotion 12 % P QL (400 GM per 31 days) *Imidazole-Related Antifungals - Topical*** clotrimazole external cream 1 % P clotrimazole external solution 1 % P

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 10 Drug Name Preference Details Coverage Details *Keratolytic/Antimitotic Agents*** CLEAR AWAY 1-STEP WART REMOVER P EXTERNAL PAD 40 % COMPOUND W EXTERNAL LIQUID 17 % P COMPOUND W MAXIMUM STRENGTH P EXTERNAL GEL 17 % FREEZONE EXTERNAL LIQUID 17.6 % P SALACTIC FILM EXTERNAL SOLUTION 17 P % *Local Anesthetics - Topical*** capsaicin external cream 0.025 % P QL (60 GM per 30 days) *Scabicides & Pediculicides*** permethrin external lotion 1 % P *Tar Products*** TERA-GEL TAR EXTERNAL SHAMPOO 0.5 P % *Topical Steroid Combinations*** hydrocortisone-aloe external cream 1 % P sm hydrocortisone plus external cream 1 % P *Gastrointestinal Agents - Misc.* *Antiflatulents*** mi-acid gas relief oral tablet chewable 80 mg P mytab gas oral tablet chewable 80 mg P simethicone oral suspension 40 mg/0.6ml P simethicone oral tablet chewable 80 mg P *Genitourinary Agents - Miscellaneous* *Urinary Analgesics*** AZO URINARY PAIN RELIEF ORAL P TABLET 99.5 MG phenazopyridine hcl oral tablet 95 mg P urinary pain relief max st oral tablet 97.5 mg P *Hematopoietic Agents* *Cobalamins*** cyanocobalamin injection solution 1000 P mcg/ml vitamin b-12 er oral tablet extended release P 1000 mcg

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 11 Drug Name Preference Details Coverage Details vitamin b-12 oral tablet 1000 mcg, 250 mcg, P 500 mcg vitamin b-12 sublingual tablet sublingual P 1000 mcg *Folic Acid/Folates*** folic acid oral tablet 1 mg, 400 mcg, 800 mcg P *Iron*** ferro-bob oral tablet 325 (65 fe) mg P ferrous sulfate oral elixir 220 (44 fe) mg/5ml P ferrous sulfate oral tablet 325 (65 fe) mg P ferrous sulfate oral tablet delayed release P 324 (65 fe) mg, 325 (65 fe) mg ferrousul oral tablet 325 (65 fe) mg P iron oral tablet 325 (65 fe) mg, 90 (18 fe) mg P POLY-IRON 150 ORAL CAPSULE 150 MG P slow release iron oral tablet extended release P 160 (50 fe) mg *Hypnotics/Sedatives/Sleep Disorder Agents* *Antihistamine Hypnotic Combinations*** headache pm oral tablet 25-500 mg P QL (62 EA per 31 days) mapap pm oral tablet 500-25 mg P QL (62 EA per 31 days) pain relief pm extra strength oral tablet 500- P QL (62 EA per 31 days) 25 mg pain reliever pm oral tablet 500-25 mg P QL (62 EA per 31 days) *Antihistamine Hypnotics*** compoz oral capsule 50 mg P compoz oral tablet 50 mg P diphenhydramine hcl (sleep) oral tablet 50 P mg NYTOL ORAL TABLET 25 MG P SIMPLY SLEEP ORAL TABLET 25 MG P sleep tabs oral tablet 25 mg P sleep-tabs oral tablet 25 mg P SOMINEX ORAL TABLET 25 MG P tetra-formula nighttime sleep oral tablet 50 P mg

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 12 Drug Name Preference Details Coverage Details *Laxatives* *Bulk Laxatives*** fiber laxative oral tablet 625 mg P fiber oral tablet 625 mg P FIBERGEN ORAL TABLET 625 MG P fiber-lax oral tablet 625 mg P konsyl daily fiber oral packet 100 % P KONSYL FIBER ORAL TABLET 625 MG P METAMUCIL ORAL CAPSULE 0.36 GM, P 0.52 GM METAMUCIL ORAL WAFER P METAMUCIL SMOOTH TEXTURE ORAL P PACKET 28 % METAMUCIL SMOOTH TEXTURE ORAL P POWDER 28.3 %, 58.6 % natural fiber therapy oral powder 30.9 %, P 48.57 % natural vegetable fiber oral powder 48.57 % P REGULOID ORAL CAPSULE 0.52 GM P *Laxatives - Miscellaneous*** cvs glycerin adult rectal suppository 2 gm P sorbitol oral solution 70 % P *Laxatives & Dss*** DOC-Q-LAX ORAL TABLET 8.6-50 MG P PERI-COLACE ORAL TABLET 8.6-50 MG P senna plus oral tablet 8.6-50 mg P senna s oral tablet 8.6-50 mg P senna-docusate sodium oral tablet 8.6-50 mg P SENNALAX-S ORAL TABLET 8.6-50 MG P senna-s oral tablet 8.6-50 mg P senna-time s oral tablet 8.6-50 mg P sennosides-docusate sodium oral tablet 8.6- P 50 mg *Saline Laxative Mixtures*** enema rectal enema 7-19 gm/118ml P phosphate laxative oral solution 0.9-2.4 P gm/5ml P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 13 Drug Name Preference Details Coverage Details *Saline Laxatives*** citrate of magnesia oral solution 1.745 P gm/30ml CITROMA ORAL SOLUTION 1.745 P GM/30ML DULCOLAX MILK OF MAGNESIA ORAL P SUSPENSION 400 MG/5ML magnesium citrate oral solution 1.745 P gm/30ml milk of magnesia oral suspension 400 P mg/5ml, 7.75 % *Stimulant Laxatives*** BISAC-EVAC RECTAL SUPPOSITORY 10 P MG biscolax rectal suppository 10 mg P CARTERS LITTLE PILLS ORAL TABLET P DELAYED RELEASE 5 MG correct oral tablet delayed release 5 mg P CORRECTOL ORAL TABLET DELAYED P RELEASE 5 MG ducodyl oral tablet delayed release 5 mg P EX-LAX ORAL TABLET CHEWABLE 15 MG P EX-LAX ULTRA ORAL TABLET DELAYED P RELEASE 5 MG FEENAMINT ORAL TABLET DELAYED P RELEASE 5 MG FLEET LAXATIVE ORAL TABLET P DELAYED RELEASE 5 MG gentle laxative oral tablet delayed release 5 P mg laxative rectal suppository 10 mg P natural senna laxative oral tablet 64.8-324 P mg senexon oral liquid 8.8 mg/5ml P senexon oral tablet 8.6 mg P senna lax oral tablet 8.6 mg P senna laxative oral tablet 25 mg, 8.6 mg P senna oral syrup 8.8 mg/5ml P senna oral tablet 8.6 mg P P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 14 Drug Name Preference Details Coverage Details SENNA SMOOTH ORAL TABLET 15 MG P SENNACON ORAL TABLET 8.6 MG P senna-lax oral tablet 8.6 mg P senna-tabs oral tablet 8.6 mg P senna-time oral tablet 8.6 mg P SENNO ORAL TABLET 8.6 MG P stimulant laxative oral tablet delayed release P 5 mg womens laxative oral tablet delayed release P 5 mg *Surfactant Laxatives*** CORRECTOL EXTRA GENTLE ORAL P CAPSULE 100 MG diocto oral liquid 50 mg/5ml P diocto oral syrup 60 mg/15ml P docqlace oral capsule 100 mg P docu soft oral capsule 100 mg P docusate calcium oral capsule 240 mg P docusate sodium oral capsule 250 mg P docusate sodium oral tablet 100 mg P DOCUSIL ORAL CAPSULE 100 MG P DOK ORAL CAPSULE 100 MG, 250 MG P DOK ORAL TABLET 100 MG P dss oral capsule 100 mg, 250 mg P DULCOLAX STOOL SOFTENER ORAL P CAPSULE 100 MG KAO-TIN ORAL CAPSULE 240 MG P laxa basic oral capsule 100 mg P silace oral liquid 150 mg/15ml P silace oral syrup 60 mg/15ml P SOF-LAX ORAL CAPSULE 100 MG P stool softener oral capsule 100 mg, 250 mg P SURFAK ORAL CAPSULE 240 MG P *Medical Devices And Supplies* *Respiratory Therapy Supplies*** ACE AEROSOL CLOUD ENHANCER P QL (2 EA per 365 days)

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 15 Drug Name Preference Details Coverage Details IN-CHECK DIAL FLOW TRAINER DEVICE P QL (2 EA per 365 days) PFLEX P QL (2 EA per 365 days) THRESHOLD IMT P QL (2 EA per 365 days) THRESHOLD PEP DEVICE P QL (2 EA per 365 days) WINDMILL TRAINER P QL (2 EA per 365 days) *Spacer/Aerosol-Holding Chambers & Supplies*** AEROCHAMBER MV P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU LARGE P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU SMALL P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU W/MASK P QL (2 EA per 365 days) AEROCHAMBER W/FLOWSIGNAL P QL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS P QL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS CHAMBR P QL (2 EA per 365 days) EASIVENT P QL (2 EA per 365 days) MICROCHAMBER P QL (2 EA per 365 days) MICROSPACER P QL (2 EA per 365 days) OPTICHAMBER ADVANTAGE P QL (2 EA per 365 days) OPTICHAMBER FACE MASK-LARGE P QL (2 EA per 365 days) OPTICHAMBER FACE MASK-MEDIUM P QL (2 EA per 365 days) OPTICHAMBER FACE MASK-SMALL P QL (2 EA per 365 days) OPTIHALER P QL (2 EA per 365 days) OPTIHALER DEVICE P QL (2 EA per 365 days) POCKET CHAMBER DEVICE P QL (2 EA per 365 days) POCKET SPACER DEVICE P QL (2 EA per 365 days) WATCHHALER DEVICE P QL (2 EA per 365 days) *Minerals & Electrolytes* *Calcium Combinations*** calcium + d3 oral tablet 600-200 mg-unit P calcium 600-d oral tablet 600-400 mg-unit P calcium carb-cholecalciferol oral tablet 500- P 125 mg-unit calcium carbonate-vitamin d oral tablet 500- P 400 mg-unit, 600-400 mg-unit

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 16 Drug Name Preference Details Coverage Details calcium high potency/vitamin d oral tablet P 600-200 mg-unit calcium oral tablet 500-125 mg-unit P calcium-carb 600 + d oral tablet 600-125 mg- P unit calcium-vitamin d oral tablet 500-125 mg- P unit, 600-125 mg-unit, 600-200 mg-unit CALTRATE 600+D ORAL TABLET 600-800 P MG-UNIT CELEBRATE CALCIUM PLUS 500 ORAL P TABLET CHEWABLE 500-333 MG-UNIT liquid calcium/vitamin d oral capsule 600-200 P mg-unit OYSCO 500+D ORAL TABLET 500-200 MG- P UNIT oyst-cal d oral tablet 250-125 mg-unit P oyster calcium + d oral tablet 250-125 mg- P unit oyster shell calcium + d oral tablet 500-400 P mg-unit oyster shell calcium 500 + d oral tablet 500- P 125 mg-unit oyster shell calcium/d oral tablet 250-125 P mg-unit, 500-200 mg-unit oyster shell calcium/vitamin d oral packet P 500-200 mg-unit oyster shell calcium/vitamin d oral tablet 250- P 125 mg-unit, 500-200 mg-unit oyster shell/vitamin d oral tablet 600-125 mg- P unit ra calcium hi-cal/vitamin d oral tablet 500-125 P mg-unit *Calcium*** CAL-CARB FORTE ORAL TABLET 1250 P (500 CA) MG CALCI-CHEW ORAL TABLET CHEWABLE P 1250 (500 CA) MG calcium 600 oral tablet 600 mg P calcium carbonate oral suspension 1250 P (500 ca) mg/5ml P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 17 Drug Name Preference Details Coverage Details calcium carbonate oral tablet 1250 (500 ca) P mg, 1500 (600 ca) mg, 600 mg calcium high potency oral tablet 600 mg P calcium lactate oral tablet 648 mg P calcium oral tablet 600 mg P calcium oyster shell oral tablet 1250 (500 ca) P mg calcium-carb 600 oral tablet 600 mg P cal-lac oral capsule 500 mg P CALTRATE 600 ORAL TABLET 1500 (600 P CA) MG OYSCO 500 ORAL TABLET 500 MG P OYSTERCAL ORAL TABLET 500 MG P *Electrolytes Oral*** ORALYTE FREEZER POPS ORAL P QL (4000 ML per 31 days) SOLUTION ORALYTE ORAL SOLUTION P QL (4000 ML per 31 days) *Magnesium*** MAG64 ORAL TABLET EXTENDED P RELEASE 535 (64 MG) MG mag-delay oral tablet extended release 535 P (64 mg) mg magnacaps oral capsule 100 mg P magnesium oral tablet 250 mg P magnesium oxide 400 oral packet 240 mg P magnesium oxide oral tablet 400 (240 mg) P mg, 400 (241.3 mg) mg, 420 (252 mg) mg MAGNESIUM-OXIDE ORAL TABLET 400 P (241.3 MG) MG MAG-TAB SR ORAL TABLET EXTENDED P RELEASE 84 MG (7MEQ) *Sodium*** sodium chloride oral tablet 1 gm P *Zinc*** ORAZINC ORAL CAPSULE 220 (50 ZN) MG P zinc gluconate oral tablet 50 mg P zinc oral tablet 50 mg P zinc sulfate oral capsule 220 (50 zn) mg P P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 18 Drug Name Preference Details Coverage Details zinc sulfate oral tablet 220 (50 zn) mg P zinc-220 oral capsule 220 (50 zn) mg P *Mouth/Throat/Dental Agents* *Lozenge - Combinations*** DELSYM COUGH RELIEF P MOUTH/THROAT LOZENGE 5-5 MG *Multivitamins* *B-Complex W/ C & Folic Acid*** NEPHRONEX ORAL TABLET P RENAL ORAL CAPSULE 1 MG P rena-vite rx oral tablet 1 mg P reno caps oral capsule 1 mg P *B-Complex W/ C*** vitamin b complex-c oral capsule P *Multiple Vitamins W/ Minerals*** centamin oral liquid P centavite a-z complete-mineral oral tablet P centavite oral liquid P CEROVITE ADVANCED FORMULA ORAL P TABLET CERTAVITE/ANTIOXIDANTS ORAL LIQUID P gerivite complete oral tablet P multivitamin & mineral oral liquid P SUPER NU-THERA ORAL TABLET P thera vital m oral tablet P therabasic-m oral tablet P thera-m oral tablet P therapeutic liquid oral solution P therapeutic-m oral tablet P TOTAL FORMULA 3 ORAL TABLET P vitamins a-d-e/selenium oral tablet P *Multivitamins*** daily multiple vitamins oral tablet P daily vite oral tablet P daily vites oral tablet P multi-day oral tablet P

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 19 Drug Name Preference Details Coverage Details multi-vitamin oral tablet P multi-vitamins oral tablet P once daily oral tablet P one-daily multi vitamins oral tablet P THERA ORAL TABLET P THERA/BETA-CAROTENE ORAL TABLET P therapeutic oral tablet P thera-tabs oral tablet P *Ped Mv W/ Iron*** polyvitamin/iron oral solution 10 mg/ml P *Pediatric Multiple Vitamins W/ C & Fa*** childrens chewable multi vits oral tablet P chewable *Pediatric Multiple Vitamins W/ C*** polyvitamin oral solution 35 mg/ml P *Pediatric Vitamins A & D W/ C*** tri-vitamin oral solution 1500-400-35 P *Prenatal Mv & Min W/Fe-Fa*** pnv prenatal plus multivit+dha oral 27-1 & P 312 mg prenatal low iron oral tablet 27-0.8 mg P *Specialty Vitamins Products*** vitamins for hair oral tablet P *Nasal Agents - Systemic And Topical* *Nasal Agents - Misc.*** altamist spray nasal solution 0.65 % P AYR NASAL SOLUTION 0.65 % P deep sea nasal spray nasal solution 0.65 % P HUMIST NASAL SOLUTION 0.65 % P LITTLE NOSES SALINE NASAL SOLUTION P 0.65 % NASAL MOIST NASAL SOLUTION 0.65 % P na-zone nasal solution 0.65 % P OCEAN FOR KIDS NASAL SOLUTION 0.65 P % saline mist spray nasal solution 0.65 % P

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 20 Drug Name Preference Details Coverage Details saline nasal spray nasal solution 0.65 % P sea soft nasal mist nasal solution 0.65 % P *Nasal Mast Cell Stabilizers*** cromolyn sodium nasal aerosol solution 5.2 P mg/act *Systemic Decongestants*** pseudoephedrine hcl oral tablet 30 mg, 60 P mg SUDAFED 12 HOUR ORAL TABLET P EXTENDED RELEASE 12 HOUR 120 MG *Ophthalmic Agents* *Artificial Tear And Lubricant Combinations*** artificial tears ophthalmic ointment 83-15 % P HYPOTEARS OPHTHALMIC SOLUTION 1-1 P % TEARS AGAIN OPHTHALMIC OINTMENT P ULTRA FRESH PM OPHTHALMIC P OINTMENT *Artificial Tear Solutions*** tears again ophthalmic solution P *Artificial Tears And Lubricants*** artificial tears ophthalmic solution 1.4 % P QL (15 ML per 31 days) liquitears ophthalmic solution 1.4 % P QL (15 ML per 31 Days) polyvinyl alcohol ophthalmic solution 1.4 % P QL (15 ML per 31 Days) *Ophthalmic Antiallergic*** ALAWAY OPHTHALMIC SOLUTION 0.025 P % ketotifen fumarate ophthalmic solution 0.025 P % *Otic Agents* *Otic Agents - Miscellaneous*** auraphene-b otic solution 6.5 % P ear drops earwax aid otic solution 6.5 % P earwax treatment drops otic solution 6.5 % P E-R-O EAR DROPS OTIC SOLUTION 6.5 % P E-R-O EAR WAX REMOVAL SYSTEM OTIC P SOLUTION 6.5 % P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 21 Drug Name Preference Details Coverage Details MURINE EAR OTIC SOLUTION 6.5 % P MURINE EAR WAX REMOVAL SYSTEM P OTIC SOLUTION 6.5 % OTIX OTIC SOLUTION 6.5 % P *Psychotherapeutic And Neurological Agents - Misc.* *Smoking Deterrents*** nicotine polacrilex mouth/throat gum 2 mg, 4 P QL (4032 EA per 365 days) mg nicotine transdermal patch 24 hour 14 P QL (70 EA per 365 days) mg/24hr, 21 mg/24hr, 7 mg/24hr *Ulcer Drugs/Antispasmodics/Anticholinergics* *H-2 Antagonists*** cimetidine oral tablet 200 mg P famotidine oral tablet 10 mg P *Proton Pump Inhibitors*** omeprazole oral tablet delayed release 20 P mg *Vaginal And Related Products* *Imidazole-Related Antifungals*** GYNE-LOTRIMIN 3 VAGINAL CREAM 2 % P miconazole 3 applicator vaginal kit 200 & 2 P mg-% (9gm) miconazole 3 combo pack vaginal kit 200 & 2 P mg-% (9gm) miconazole nitrate vaginal cream 2 % P miconazole nitrate vaginal suppository 100 P mg MONISTAT 3 VAGINAL CREAM 4 % P *Vitamins* *Vitamin A*** vitamin a oral capsule 10000 unit, 8000 unit P *Vitamin B-1*** vitamin b-1 oral tablet 100 mg, 250 mg, 50 P mg *Vitamin B-2*** vitamin b-2 oral tablet 100 mg P P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 22 Drug Name Preference Details Coverage Details *Vitamin B-3*** ENDUR-ACIN ORAL TABLET EXTENDED P RELEASE 500 MG niacin er oral capsule extended release 250 P mg, 500 mg niacin er oral tablet extended release 250 mg P niacin oral tablet 100 mg, 250 mg, 50 mg, P 500 mg *Vitamin B-6*** vitamin b-6 er oral tablet extended release P 200 mg vitamin b-6 oral tablet 100 mg, 25 mg, 250 P mg, 50 mg, 500 mg *Vitamin C*** ascorbic acid oral tablet 1000 mg, 250 mg, P 500 mg ascorbic acid oral tablet chewable 250 mg P c-500 oral tablet chewable 500 mg P vitamin c oral packet 500 mg P vitamin c oral syrup 500 mg/5ml P vitamin c oral tablet 100 mg, 1000 mg, 250 P mg, 500 mg vitamin c oral tablet chewable 100 mg, 250 P mg *Vitamin D*** CALCIFEROL ORAL SOLUTION 8000 P UNIT/ML vitamin d (ergocalciferol) oral capsule 1.25 P QL (4 EA per 28 days) mg (50000 ut) vitamin d3 oral capsule 10 mcg (400 unit), 25 P mcg (1000 ut), 50 mcg (2000 ut) vitamin d3 oral tablet 25 mcg (1000 ut) P vitamin d3 oral tablet chewable 10 mcg (400 P unit) vitamin d-400 oral tablet 10 mcg (400 unit) P *Vitamin E*** vitamin e oral capsule 400 unit P vitamin e oral tablet chewable 400 unit P

P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 24 Index ACE AEROSOL CLOUD anti-diarrheal...... 5 calcium antacid extra ENHANCER...... 15 anti-fungal...... 10 strength...... 3 ACEPHEN...... 1 anti-hist allergy...... 5 calcium carb-cholecalciferol.. 16 acetaminophen...... 1 anti-itch maximum strength... 10 calcium carbonate...... 17, 18 ACID GONE...... 3 apap...... 1 calcium carbonate antacid...... 4 acne medication 5...... 9 apap extra strength...... 1 calcium carbonate-vitamin d..16 AEROCHAMBER MV...... 16 artificial tears...... 21 calcium high potency...... 18 AEROCHAMBER PLUS ascorbic acid...... 23 calcium high potency/vitamin FLO-VU...... 16 aspirin...... 2 d...... 17 AEROCHAMBER PLUS aspirin childrens...... 2 calcium lactate...... 18 FLO-VU LARGE...... 16 aspirin ec...... 2 calcium oyster shell...... 18 AEROCHAMBER PLUS aspirin ec low dose...... 2 calcium-carb 600...... 18 FLO-VU SMALL...... 16 auraphene-b...... 21 calcium-carb 600 + d...... 17 AEROCHAMBER PLUS AVEENO ANTI-ITCH MAX calcium-vitamin d...... 17 FLO-VU W/MASK...... 16 ST...... 10 CAL-GEST ANTACID...... 4 AEROCHAMBER AYR...... 20 cal-lac...... 18 W/FLOWSIGNAL...... 16 AZO URINARY PAIN CALTRATE 600...... 18 AEROCHAMBER Z-STAT RELIEF...... 11 CALTRATE 600+D...... 17 PLUS...... 16 bacitracin...... 10 capsaicin...... 11 AEROCHAMBER Z-STAT bacitracin zinc...... 10 CARTERS LITTLE PILLS...... 14 PLUS CHAMBR...... 16 bacitracin-neomycin- CELEBRATE CALCIUM ALAVERT ALLERGY/SINUS...8 polymyxin...... 9 PLUS 500...... 17 ALAWAY...... 21 BANOPHEN...... 5, 6 centamin...... 19 aler-cap...... 5 BD GLUCOSE...... 4 centavite...... 19 aler-dryl...... 5 BENADRYL ALLERGY centavite a-z complete- alertab...... 5 CHILDRENS...... 6 mineral...... 19 ALLEGRA ALLERGY BENADRYL ITCH CEROVITE ADVANCED CHILDRENS...... 6 STOPPING...... 10 FORMULA...... 19 ALLEGRA-D ALLERGY & benzonatate...... 7 CERTAVITE/ANTIOXIDANT CONGESTION...... 8 benzoyl peroxide...... 9 S...... 19 aller-chlor...... 5 benzoyl peroxide cleanser...... 9 cetirizine hcl...... 6 allergy...... 5, 6 BISAC-EVAC...... 14 cetirizine hcl childrens...... 6 allergy relief...... 5 biscolax...... 14 cetirizine hcl childrens alrgy.....6 allergy relief childrens...... 5 bismatrol...... 4 cetirizine-pseudoephedrine allergy relief/nasal bismuth...... 4 er...... 8 decongest...... 8 BRONCHO SALINE...... 8 cheratussin ac...... 7 altamist spray...... 20 BROTAPP...... 8 cheratussin dac...... 8 altaryl...... 5 brotapp dm...... 9 chest congestion relief...... 8 aluminum hydroxide gel...... 3 c-500...... 23 childrens chewable multi vits. 20 AMLACTIN...... 10 CAL-CARB FORTE...... 17 childrens ibuprofen...... 1 ammonium lactate...... 10 CALCI-CHEW...... 17 childrens loratadine...... 6 antacid...... 3 CALCIFEROL...... 23 childrens non-asa pain relief....1 antacid anti-gas...... 3 calcium...... 17, 18 childrens non-aspirin...... 1 antacid anti-gas max calcium + d3...... 16 childrens pain reliever...... 1 strength...... 3 calcium 600...... 17 childrens silapap...... 1 antacid extra strength...... 3 calcium 600-d...... 16 childrens tactinal...... 1 antacid iii...... 3 calcium antacid...... 4 chlorhexidine gluconate...... 7 P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 25 chlorhist...... 5 docusate calcium...... 15 HUMIST...... 20 cimetidine...... 22 docusate sodium...... 15 hydrocod polst-cpm polst er.... 9 citrate of magnesia...... 14 DOCUSIL...... 15 hydrocodone-homatropine...... 7 CITROMA...... 14 DOK...... 15 hydrocortisone...... 10 CLEAR AWAY 1-STEP double antibiotic...... 10 hydrocortisone max st...... 10 WART REMOVER...... 11 dss...... 15 hydrocortisone max st/12 clotrimazole...... 10 ducodyl...... 14 moist...... 10 cold/cough childrens...... 9 DULCOLAX MILK OF hydrocortisone-aloe...... 11 complete allergy medication.... 6 MAGNESIA...... 14 HYDROSKIN...... 10 complete allergy relief...... 6 DULCOLAX STOOL HYPOTEARS...... 21 COMPOUND W...... 11 SOFTENER...... 15 ibuprofen...... 1 COMPOUND W MAXIMUM ear drops earwax aid...... 21 IN-CHECK DIAL FLOW STRENGTH...... 11 earwax treatment drops...... 21 TRAINER...... 16 compoz...... 12 EASIVENT...... 16 infants silapap...... 1 corfen-dm...... 9 ECPIRIN...... 2 ipecac...... 5 correct...... 14 ed-apap...... 1 iron...... 12 CORRECTOL...... 14 ENDUR-ACIN...... 23 itch relief...... 10 CORRECTOL EXTRA enema...... 13 KAOPECTATE...... 4 GENTLE...... 15 eq hemorrhoidal...... 2 KAOPECTATE EXTRA cromolyn sodium...... 21 E-R-O EAR DROPS...... 21 STRENGTH...... 4 cvs glycerin adult...... 13 E-R-O EAR WAX KAO-TIN...... 4, 15 cyanocobalamin...... 11 REMOVAL SYSTEM...... 21 ketotifen fumarate...... 21 daily multiple vitamins...... 19 EX-LAX...... 14 kidkare cough/cold...... 9 daily vite...... 19 EX-LAX ULTRA...... 14 konsyl daily fiber...... 13 daily vites...... 19 extra action cough...... 7 KONSYL FIBER...... 13 dakins...... 7 famotidine...... 22 kp hydrocortisone...... 10 dakins (1/2 strength)...... 7 FEENAMINT...... 14 laxa basic...... 15 dakins (1/4 strength)...... 7 ferro-bob...... 12 laxative...... 14 deep sea nasal spray...... 20 ferrous sulfate...... 12 liquid calcium/vitamin d...... 17 DELSYM...... 7 ferrousul...... 12 liquitears...... 21 DELSYM COUGH RELIEF....19 fexofenadine hcl...... 6 LITTLE NOSES SALINE...... 20 DELSYM NIGHT TIME fexofenadine-pseudoephed LOPERAMIDE A-D...... 5 MULTI-SYMPT...... 7 er...... 8 loperamide hcl...... 5 diabetic siltussin das-na...... 8 fiber...... 13 loratadine...... 6 diabetic siltussin-dm...... 7 fiber laxative...... 13 loratadine childrens...... 6 DIABETIC TUSSIN FIBERGEN...... 13 loratadine hives relief...... 6 ALLERGY...... 5 fiber-lax...... 13 MAALOX...... 4 DIABETIC TUSSIN MAX ST... 7 FLEET LAXATIVE...... 14 MAALOX ADVANCED MAX DIMETAPP LONG ACT folic acid...... 12 ST...... 3 COUGH/COLD...... 9 FREEZONE...... 11 MAALOX MAX...... 3 diocto...... 15 genahist...... 6 MAALOX MULTI SYMPTOM diotame...... 4 gentle laxative...... 14 MAX ST...... 3 diphenhist...... 6 gerivite complete...... 19 MAG64...... 18 diphenhydramine hcl...... 6 glucose...... 4 mag-delay...... 18 diphenhydramine hcl (sleep). 12 gnp foaming antacid...... 3 magnacaps...... 18 docqlace...... 15 GYNE-LOTRIMIN 3...... 22 magnesium...... 18 DOC-Q-LAX...... 13 headache pm...... 12 magnesium citrate...... 14 docu soft...... 15 hemorrhoidal...... 3 magnesium oxide...... 4, 18 P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 26 magnesium oxide 400...... 18 nicotine...... 22 PHARBETOL...... 2 MAGNESIUM-OXIDE...... 18 nicotine polacrilex...... 22 PHARBETOL EXTRA MAG-TAB SR...... 18 nohist-dm...... 9 STRENGTH...... 2 mapap...... 1, 2 non-aspirin...... 2 phenazopyridine hcl...... 11 mapap arthritis pain...... 1 non-aspirin extra strength...... 2 phenylhistine dh...... 9 MAPAP CHILDRENS...... 1 non-aspirin pain relief...... 2 phosphate laxative...... 13 mapap pm...... 12 nortemp infants...... 2 pink bismuth...... 4 maxapap maximum strength... 2 NYTOL...... 12 pnv prenatal plus maxapap regular strength...... 2 OCEAN FOR KIDS...... 20 multivit+dha...... 20 maxifed tr...... 8 omeprazole...... 22 POCKET CHAMBER...... 16 meclizine hcl...... 5 once daily...... 20 POCKET SPACER...... 16 melatonin...... 1 one-daily multi vitamins...... 20 POLY-IRON 150...... 12 melatonin maximum strength.. 1 OPERAND POVIDONE- polyvinyl alcohol...... 21 METAMUCIL...... 13 IODINE...... 7 polyvitamin...... 20 METAMUCIL SMOOTH OPTICHAMBER polyvitamin/iron...... 20 TEXTURE...... 13 ADVANTAGE...... 16 povidone-iodine...... 7 MI-ACID...... 3 OPTICHAMBER FACE prenatal low iron...... 20 mi-acid gas relief...... 11 MASK-LARGE...... 16 PREPARATION H...... 10 miconazole 3 applicator...... 22 OPTICHAMBER FACE promethazine vc/codeine...... 9 miconazole 3 combo pack..... 22 MASK-MEDIUM...... 16 promethazine-codeine...... 9 miconazole nitrate...... 22 OPTICHAMBER FACE promethazine-dm...... 9 MICROCHAMBER...... 16 MASK-SMALL...... 16 pseudoephedrine hcl...... 21 MICROSPACER...... 16 OPTIHALER...... 16 q-dryl...... 6 milantex extra strength...... 3 ORALYTE...... 18 q-pap...... 2 milk of magnesia...... 14 ORALYTE FREEZER POPS. 18 Q-TAPP...... 8 MINTOX PLUS...... 3 ORAZINC...... 18 ra calcium hi-cal/vitamin d..... 17 MONISTAT 3...... 22 OTIX...... 22 reeses pinworm medicine...... 4 MUCINEX FAST-MAX DM OYSCO 500...... 18 refenesen...... 8 MAX...... 7 OYSCO 500+D...... 17 refenesen 400...... 8 mucus relief...... 8 oyst-cal d...... 17 REGULOID...... 13 mucus relief dm cough...... 7 oyster calcium + d...... 17 RENAL...... 19 multi-day...... 19 oyster shell calcium + d...... 17 rena-vite rx...... 19 multi-vitamin...... 20 oyster shell calcium 500 + d.. 17 reno caps...... 19 multivitamin & mineral...... 19 oyster shell calcium/d...... 17 robafen...... 8 multi-vitamins...... 20 oyster shell calcium/vitamin robafen cf cough/cold...... 8 MURINE EAR...... 22 d...... 17 ROBITUSSIN CHILD MURINE EAR WAX oyster shell/vitamin d...... 17 COUGH/COLD LA...... 9 REMOVAL SYSTEM...... 22 OYSTERCAL...... 18 ROBITUSSIN CHILDRENS mytab gas...... 11 pain & fever childrens...... 2 COUGH LA...... 7 naproxen sodium...... 1 pain relief...... 2 rynex dm...... 9 NASAL MOIST...... 20 pain relief extra strength...... 2 SALACTIC FILM...... 11 natural fiber therapy...... 13 pain relief pm extra strength.. 12 saline mist spray...... 20 natural senna laxative...... 14 pain reliever pm...... 12 saline nasal spray...... 21 natural vegetable fiber...... 13 PANOXYL WASH...... 9 SCOT-TUSSIN ALLERGY na-zone...... 20 PERI-COLACE...... 13 RELIEF...... 6 NEPHRONEX...... 19 permethrin...... 11 sea soft nasal mist...... 21 niacin...... 23 PFLEX...... 16 senexon...... 14 niacin er...... 23 pharbedryl...... 6 senna...... 14 P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 27 senna lax...... 14 THERA/BETA-CAROTENE...20 senna laxative...... 14 therabasic-m...... 19 senna plus...... 13 thera-m...... 19 senna s...... 13 therapeutic...... 20 SENNA SMOOTH...... 15 therapeutic liquid...... 19 SENNACON...... 15 therapeutic-m...... 19 senna-docusate sodium...... 13 thera-tabs...... 20 senna-lax...... 15 THRESHOLD IMT...... 16 SENNALAX-S...... 13 THRESHOLD PEP...... 16 senna-s...... 13 TITRALAC...... 4 senna-tabs...... 15 total allergy...... 6 senna-time...... 15 TOTAL ALLERGY senna-time s...... 13 MEDICINE...... 6 SENNO...... 15 TOTAL FORMULA 3...... 19 sennosides-docusate travel sickness...... 5 sodium...... 13 tri-buffered aspirin...... 2 silace...... 15 triple antibiotic...... 10 siladryl allergy...... 6 triprolidine-pse...... 8 silphen cough...... 6 tri-vitamin...... 20 simethicone...... 11 TUSSICAPS...... 9 SIMPLY SLEEP...... 12 tussin pe...... 8 sleep tabs...... 12 ULTRA FRESH PM...... 21 sleep-tabs...... 12 urinary pain relief max st...... 11 slow release iron...... 12 VANACOF...... 9 sm hydrocortisone plus...... 11 vitamin a...... 22 sm ipecac syrup...... 5 vitamin b complex-c...... 19 sodium bicarbonate...... 3 vitamin b-1...... 22 sodium chloride...... 8, 18 vitamin b-12...... 12 SOF-LAX...... 15 vitamin b-12 er...... 11 SOMINEX...... 12 vitamin b-2...... 22 sorbitol...... 13 vitamin b-6...... 23 stimulant laxative...... 15 vitamin b-6 er...... 23 stomach relief...... 5 vitamin c...... 23 stomach relief plus...... 5 vitamin d (ergocalciferol)...... 23 stool softener...... 15 vitamin d3...... 23 SUDAFED 12 HOUR...... 21 vitamin d-400...... 23 SUPER NU-THERA...... 19 vitamin e...... 23 SURFAK...... 15 vitamin k (phytonadione)...... 24 tactinal...... 2 vitamins a-d-e/selenium...... 19 tactinal extra strength...... 2 vitamins for hair...... 20 TEARS AGAIN...... 21 WATCHHALER...... 16 tears again...... 21 WINDMILL TRAINER...... 16 TERA-GEL TAR...... 11 womens laxative...... 15 terbinafine hcl...... 10 zinc...... 18 tetra-formula nighttime sleep. 12 zinc gluconate...... 18 tgt anti-itch/aloe/vit e...... 10 zinc sulfate...... 18, 19 THERA...... 20 zinc-220...... 19 thera vital m...... 19 P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 28