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Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 *

Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 *

Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 *

1-DAY ANBESOL BESIVANCE 3 DAY VAGINAL ANESTHETIC ORAL GEL BETADINE 3-DAY VAGINAL CREAM ANTIFUNGAL ACETATE-SOD PHOS ABSORICA APRACLONIDINE HCL BETAMETHASONE SOD PHOS-ACETATE ABSTRAL ARISTOSPAN BETAMETHASONE SOD PHOS-WATER ACETAMIN-CAFF-DIHYDROCODEINE ARIXTRA BETHANECHOL CHLORIDE ACETAMINOPHEN-CODEINE ARYMO ER BICILLIN C-R ACETIC ACID-ALUMINUM ASA-BUTALB-CAFFEINE-CODEINE BICILLIN L-A ACTIQ ASCOMP WITH CODEINE BILTRICIDE ACTISEP ASPERCREME LIDOCAINE BISACODYL ACULAR ASPIRIN-CAFFEINE-DIHYDROCODEIN BISA-LAX ACULAR LS ATHLETE'S FOOT BLEPH-10 ACYCLOVIR ATHLETIC FOOT CREAM BLEPHAMIDE ACYCLOVIR SODIUM AUGMENTIN BLEPHAMIDE S.O.P. ADDERALL XR AUGMENTIN ES-600 BRIMONIDINE TARTRATE ADHANSIA XR AUGMENTIN XR BROMFENAC SODIUM ADZENYS ER AVC BROMSITE ADZENYS XR-ODT AVELOX BROVANA AEMCOLO AVELOX IV BSS AFREZZA AVIDOXY BSS PLUS AFTERA AVYCAZ EC A-HYDROCORT AZACTAM BUDESONIDE ER AK-POLY-BAC AZACTAM-ISO-OSMOTIC DEXTROSE BUPRENEX ALAWAY AZASITE BUPRENORPHINE ALBENDAZOLE AZELASTINE HCL BUPRENORPHINE HCL ALBENZA AZITHROMYCIN BUPRENORPHINE-NALOXONE ALBUTEROL SULFATE AZO URINARY PAIN RELIEF BURN RELIEF ALBUTEROL SULFATE HFA AZO URINARY TRACT DEFENSE BUTALB-ACETAMINOPH-CAFF-CODEIN ALFENTANIL HCL AZO URINARY TRACT HEALTH BUTALB-CAFF-ACETAMINOPH-CODEIN ALLERGY EYE DROPS AZOPT BUTALBITAL COMPOUND-CODEINE ALOCANE EMERGENCY BURN AZTREONAM BUTALBITAL-ASPIRIN-CAFFEINE ALOPHEN PILLS BABY TEETHING GEL BUTORPHANOL TARTRATE ALPHAGAN P BABY TEETHING PAIN MEDICINE BYDUREON ALREX BACIGUENT BYDUREON BCISE ALTACHLORE BACIIM BYDUREON PEN ALTAFLUOR BACITRACIN BYETTA ALTAFLUOR BENOX BACITRACIN-POLYMYXIN CALCITONIN-SALMON AMNESTEEM BACTRIM CANK-OXIDE AMOXICILLIN BACTRIM DS CAPITAL W-CODEINE AMOXICILLIN-CLAVULANATE POT ER BASAGLAR KWIKPEN U-100 CARBAMOXIDE AMOXICILLIN-CLAVULANATE POTASS BAXDELA CAYSTON AMPHETAMINE SULFATE BELBUCA CEDAX AMPICILLIN SODIUM BELLADONNA-OPIUM CEFACLOR AMPICILLIN TRIHYDRATE BENZACLIN CEFACLOR ER AMPICILLIN-SULBACTAM BENZAMYCIN CEFADROXIL AMYTAL SODIUM BENZ-O-STHETIC CEFAZOLIN SODIUM ANASPAZ BEPREVE CEFAZOLIN SODIUM-DEXTROSE

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Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 *

CEFDINIR CLEOCIN PEDIATRIC DEBROX CEFDITOREN PIVOXIL CLEOCIN PHOSPHATE DECADRON CEFIXIME CLEOCIN PHOSPHATE IN D5W DEFERASIROX CEFOTAN CLINDAMYCIN HCL DEFERIPRONE CEFOTAXIME SODIUM CLINDAMYCIN PALMITATE HCL DELTASONE CEFOTETAN CLINDAMYCIN PEDIATRIC DEMECLOCYCLINE HCL CEFOXITIN CLINDAMYCIN PHOS-BENZOYL PEROX DEMEROL CEFOXITIN SODIUM CLINDAMYCIN PHOSPHATE DEPO-MEDROL CEFPODOXIME PROXETIL CLINDAMYCIN PHOSPHATE-D5W DERMATOP CEFPROZIL CLINDAMYCIN-0.9% NACL DERMOTIC CEFTAZIDIME CLINDAMYCIN-BENZOYL PEROXIDE DESOXYN CEFTIBUTEN CLINDESSE DEXABLISS CEFTIN CLOTRIMAZOLE CEFTRIAXONE CLOTRIMAZOLE AF LA CEFUROXIME CLOTRIMAZOLE-3 DEXAMETHASONE ACETATE-SOD PHOS CEFUROXIME SODIUM CLOTRIMAZOLE-7 DEXAMETHASONE INTENSOL CEFUROXIME SODIUM-0.9% NACL CLOZAPINE DEXAMETHASONE SODIUM PHOSPHATE CELESTONE CLOZAPINE ODT DEXAMETHASONE-0.9% NACL CELLCEPT CLOZARIL DEXAMETHASONE-MOXIFLOXACIN CEPACOL SORE THROAT COCAINE HCL DEXEDRINE CEPHALEXIN CODEINE PHOSPHATE DEXMETHYLPHENIDATE HCL CEQUA CODEINE SULFATE DEXMETHYLPHENIDATE HCL ER CESAMET COLISTIMETHATE DEXONTO CETROTIDE COLLYRIUM DEXPAK CHEMET COLY-MYCIN M PARENTERAL DEXTENZA CHILDREN'S ALAWAY COLY-MYCIN S DEXTROAMPHETAMINE SULFATE CHLORASEPTIC SORE THROAT COMBIPATCH DEXTROAMPHETAMINE SULFATE ER CILOXAN COMPLETE LICE TREATMENT DEXTROAMPHETAMINE-AMPHET ER CIPRO CONZIP DEXTROAMPHETAMINE-AMPHETAMINE CIPRO HC COREMINO DEXYCU CIPRO I.V. CORTANE-B DICLOFENAC SODIUM CIPRODEX CORTEF DICLOXACILLIN SODIUM CIPROFLOXACIN ACETATE DIFLUCAN CIPROFLOXACIN ER CORTISPORIN-TC DIHYDROCODEINE BITARTRATE CIPROFLOXACIN HCL COTEMPLA XR-ODT DILATRATE-SR CIPROFLOXACIN-D5W COUMADIN DILAUDID CIPROFLOXACIN-DEXAMETHASONE CRESEMBA DISKETS CITRATE OF MAGNESIA CROMOLYN SODIUM DITROPAN XL CITROMA CROTAN DOLOPHINE HCL CLAFORAN CYCLOSPORINE DORYX CLARAVIS CYCLOSPORINE IN KLARITY DORZOLAMIDE CLARITHROMYCIN CYSTARAN DORZOLAMIDE HCL CLARITHROMYCIN ER CYSTEX PLUS DOXY 100 CLEARLAX DALVANCE DOXYCYCLINE HYCLATE CLENPIQ DARIFENACIN ER DOXYCYCLINE MONOHYDRATE CLEOCIN DAXBIA DRONABINOL CLEOCIN HCL DAYTRANA DSUVIA

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Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 *

DUCODYL EVEKEO ODT GAMASTAN DULCOLAX EXALGO GAMASTAN S-D DURAMORPH EYE IRRIGATING SOLUTION GANIRELIX ACETATE DUREZOL EYE ITCH RELIEF GATIFLOXACIN DVORAH EYE WASH GATIFLOXACIN-DEXAMETHASONE DXEVO EYE-STREAM GAVILAX DYANAVEL XR FACTIVE GAVILYTE-C E.E.S. 200 FALLBACK SOLO GAVILYTE-G E.E.S. 400 FAMCICLOVIR GAVILYTE-H AND BISACODYL EAR DROPS FAMOTIDINE GAVILYTE-N EAR DROPS FOR SWIMMERS FAZACLO GELNIQUE EAR DRYING AGENT FENTANYL GENTAK EAR SYSTEM FENTANYL BASE GENTAMICIN SULFATE EAR WAX REMOVAL FENTANYL CITRATE GENTLE LAXATIVE EARWAX TREATMENT DROPS FENTANYL CITRATE-0.9% NACL GENTLELAX ECONTRA EZ FENTANYL CITRATE-STERILE WATER GIALAX ECONTRA ONE-STEP FENTANYL-BUPIVACAINE-0.9% NACL GLYCOLAX ED-SPAZ FENTANYL-ROPIVACAINE-0.9% NACL GLY-OXIDE EHA FERRIPROX GOLYTELY ELESTAT FERRIPROX (2 TIMES A DAY) GONITRO ELIMITE FIORICET WITH CODEINE GOPRELTO ELLA FIORINAL WITH CODEINE #3 GYNAZOLE 1 ELURYNG FIRST-MOUTHWASH BLM GYNE-LOTRIMIN EMADINE FLAC OTIC OIL GYNE-LOTRIMIN-7 EMVERM FLAGYL HEALTHYLAX ENABLEX FLAREX HIDEX ENDOCET FLAVOXATE HCL HIPREX ENDOMETRIN FLOWTUSS HUMALOG ENOXAPARIN SODIUM FLUCONAZOLE HUMALOG JUNIOR KWIKPEN ENTOCORT EC FLUCONAZOLE IN DEXTROSE HUMALOG KWIKPEN U-100 EPINASTINE HCL FLUCONAZOLE IN SALINE HUMALOG KWIKPEN U-200 EPINEPHRINE FLUCONAZOLE-NACL HUMALOG MIX 50-50 EPIPEN ACETATE HUMALOG MIX 50-50 KWIKPEN EPIPEN 2-PAK ACETONIDE OIL HUMALOG MIX 75-25 EPIPEN JR FLUORESCEIN-PROPARACAINE HUMALOG MIX 75-25 KWIKPEN EPIPEN JR 2-PAK HUMULIN 70/30 KWIKPEN ERYPED 200 FLURBIPROFEN SODIUM HUMULIN 70-30 ERYPED 400 FLUROX HUMULIN N ERY-TAB FML HUMULIN N KWIKPEN ERYTHROCIN LACTOBIONATE FONDAPARINUX SODIUM HUMULIN R ERYTHROCIN STEARATE FORADIL HUMULIN R U-500 ERYTHROMYCIN FORTAZ HUMULIN R U-500 KWIKPEN ERYTHROMYCIN ETHYLSUCCINATE FORTAZ IN ISO-OSMOTIC DEXTROSE HURRICAINE ERYTHROMYCIN-BENZOYL PEROXIDE FRAGMIN HYCOFENIX -ETHINYL ESTRADIOL FURADANTIN HYDROCOD-CPM-PSEUDOEPHEDRINE EURAX FUZEON HYDROCODONE BITARTRATE EVEKEO GABAPENTIN HYDROCODONE BITARTRATE ER

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Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 *

HYDROCODONE-ACETAMINOPHEN KEFLEX MACROBID HYDROCODONE-CHLORPHENIRAMNE ER KENALOG-10 MACRODANTIN HYDROCODONE-GUAIFENESIN KENALOG-40 MAFENIDE ACETATE HYDROCODONE-HOMATROPINE MBR KENALOG-80 MAGNESIUM CITRATE HYDROCODONE-IBUPROFEN MALATHION KETOROLAC TROMETHAMINE MARINOL HYDROCORTISONE-ACETIC ACID KETOTIFEN FUMARATE MAXITROL HYDROMET KLARITY-A(AZITHROMYCIN-CHONDR) MEDICATED DOUCHE HYDROMORPHONE ER LANTUS MEDIWASH HYDROMORPHONE HCL LANTUS SOLOSTAR MEDI-WASH HYDROMORPHONE HCL-0.9% NACL LATANOPROST MEDROL HYDROMORPHONE HCL-WATER LAXACLEAR ME-NAPHOS-MB-HYO 1 HYDROMORPH-ROPIVA-0.9% NACL LAXATIVE MEPERIDINE HCL HYOPHEN LAXATIVE FEMININE METADATE CD HYOSCYAMINE SULFATE LAXATIVE PEG 3350 METADATE ER HYOSCYAMINE SULFATE ER LEVAQUIN METHADONE HCL HYOSCYAMINE SULFATE SR LEVBID METHADONE HCL-0.9% NACL HYOSYNE LEVEMIR METHADONE INTENSOL HYSINGLA ER LEVEMIR FLEXTOUCH METHADOSE IBUDONE LEVOFLOXACIN METHAMPHETAMINE HCL ICATIBANT LEVOFLOXACIN-D5W METHENAMINE HIPPURATE ILEVRO LEVONORGESTREL METHENAMINE MANDELATE ILUVIEN LEVORPHANOL TARTRATE METHYLIN INFUMORPH LEVSIN METHYLPHENIDATE ER INTENSE TOOTHACHE PAIN RELIEF LEVSIN-SL METHYLPHENIDATE ER (LA) INVELTYS LICE BEDDING METHYLPHENIDATE HCL IOPIDINE LICE COMPLETE KIT 1-2-3 METHYLPHENIDATE HCL CD IPRATROPIUM-ALBUTEROL LICE KILLING METHYLPHENIDATE HCL ER (CD) IPRIVASK LICE PYRINYL SHAMPOO METHYLPHENIDATE LA ISOCHRON LICE SOLUTION ISORDIL LICE TREATMENT METHYLPREDNISOLONE ACETATE ISORDIL TITRADOSE LIDOCAINE HCL METHYLPREDNISOLONE SODIUM SUCC ISOSORBIDE DINITRATE LIDOCAINE HCL VISCOUS METHYLPREDNISOLONE-BUPIVACAINE ISOSORBIDE DINITRATE ER LIDOCAINE PLUS METRO IV ISOSORBIDE MONONITRATE LINDANE METROGEL-VAGINAL ISOSORBIDE MONONITRATE ER LOCORT METRONIDAZOLE ISOTRETINOIN LORCET 1 ITCH RELIEF LORCET HD MICONAZOLE 3 ITCHY EYE LORCET PLUS MICONAZOLE 7 ITRACONAZOLE LORTAB MICONAZOLE NITRATE IVERMECTIN LOTEMAX MICONAZOLE-7 JANTOVEN LOTEMAX SM MILK OF MAGNESIA JETREA ETABONATE MILLIPRED JOCK ITCH LYCELLE MILLIPRED DP JOCK ITCH RELIEF LYUMJEV MINITRAN JORNAY PM LYUMJEV KWIKPEN U-100 MINOCIN KADIAN LYUMJEV KWIKPEN U-200 MINOCYCLINE HCL

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Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 *

MINOCYCLINE HCL ER NEOMYCIN-POLYMYXIN-HC ORAL SALINE LAXATIVE MINOLIRA ER NEOMYCIN-POLYMYXIN-HYDROCORT ORAMAGIC PLUS MIRALAX NEO-POLYCIN ORAPRED ODT MITIGO NEO-POLYCIN HC ORASEP MONDOXYNE NL NEUAC ORAVIG MONISTAT 1 NEW DAY ORBACTIV MONISTAT 3 NEXT CHOICE ONE DOSE OSCIMIN MONISTAT 7 NITRO-BID OSCIMIN SL MONODOX NITRO-DUR OSCIMIN SR MONUROL NITROFURANTOIN OSELTAMIVIR PHOSPHATE MORGIDOX NITROFURANTOIN MONO-MACRO OTIPRIO MORPHINE SULFATE NITROGLYCERIN OTOVEL MORPHINE SULFATE ER NITROGLYCERIN IN D5W OVIDE MORPHINE SULFATE-0.9% NACL NITROGLYCERIN PATCH OVIDREL MOUTH PAIN NITROLINGUAL OXACILLIN MOXATAG NITROMIST OXACILLIN SODIUM MOXEZA NITROSTAT OXAYDO MOXIFLOXACIN NITRO-TIME OXYBUTYNIN CHLORIDE MOXIFLOXACIN HCL NIX OXYBUTYNIN CHLORIDE ER MOXIFLOXACIN HCL-BSS NIX COMPLETE OXYCODONE HCL MOXIFLOXACIN HCL-NACL NOVAREL OXYCODONE HCL-ASPIRIN MS CONTIN NOXAFIL OXYCODONE HCL-IBUPROFEN MURINE EAR DROPS NULEV OXYCODONE HYDROCHLORIDE MURINE EAR WAX REMOVAL SYSTEM NULYTELY OXYCODONE-ACETAMINOPHEN MURO-128 NUMBRINO OXYCONTIN MUSE NUVARING OXYMORPHONE HCL MY CHOICE NUVESSA OXYMORPHONE HCL ER MY WAY NUZYRA OXYTROL MYCOPHENOLATE MOFETIL NYSTATIN OXYTROL FOR WOMEN MYDAYIS OBREDON OZEMPIC MYDRIATIC4(TROP-PROP-PE-KTRLC) OCUFLOX PAIN RELIEF MYORISAN OFLOXACIN PANLOR MYXREDLIN OKEBO PATADAY NAFCILLIN OMIDRIA PCE NAFCILLIN SODIUM OMNIPRED PEDIAPRED NALBUPHINE HCL ONMEL PEG 3350-ELECTROLYTE NALOCET OPANA PEG-3350 AND ELECTROLYTES NALOXONE HCL OPANA ER PEG3350-SOD SUL-NACL-KCL-ASB-C NALTREXONE HCL OPCICON ONE-STEP PEG-PREP NARCAN OPIUM TINCTURE PENICILLIN G POTASSIUM NATURA-LAX OPTION 2 PENICILLIN G PROCAINE NEBUPENT ORABASE PENICILLIN G SODIUM NEMBUTAL SODIUM ORAL ANALGESIC PENICILLIN GK-ISO-OSM DEXTROSE NEOMYCIN-BACITRACIN-POLY-HC ORAL ANESTHETIC PENICILLIN V POTASSIUM NEOMYCIN-BACITRACIN-POLYMYXIN ORAL ANESTHETIC PASTE PENTAM 300 NEOMYCIN-POLYMYXIN-DEXAMETH ORAL CLEANSER PENTAMIDINE ISETHIONATE NEOMYCIN-POLYMYXIN-GRAMICIDIN ORAL PAIN RELIEVER PENTAZOCINE-NALOXONE HCL

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Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 *

PENTOBARBITAL SODIUM PROLATE SPORANOX PEPCID PROLENSA SSD PERMETHRIN PROMETHAZINE HCL STOP LICE PEROXIDE SORE MOUTH CLEANSER PROMETHEGAN STROMECTOL PEROXYL DENTAL RINSE PURELAX SUBLOCADE PEROXYL ORAL CLEANSER PYRIDIUM SUBOXONE PFIZERPEN QUILLIVANT XR SUFENTANIL CITRATE PHENADOZ RADIAGUARD SULFACETAMIDE SODIUM PHENAZOPYRIDINE HCL REESE'S PINWORM SULFACETAMIDE- PHENERGAN RELENZA SULFAMETHOXAZOLE-TRIMETHOPRIM PHOSPHASAL RELEXXII SULFAMYLON PHOSPHATE LAXATIVE REMIFENTANIL HCL SULFATRIM PICATO REPREXAIN SUMMER'S EVE DOUCHE PINAWAY RESTASIS SUPRAX PINWORM MEDICINE RESTASIS MULTIDOSE SUPREP PINWORM TREATMENT RETISERT SWIM EAR PIN-X RETROVIR SWIMMER'S INSTANT EAR DRY PIPERACILLIN-TAZOBACTAM REZIRA SYMAX PLAN B ONE-STEP RHOPRESSA SYMAX DUOTAB PLENVU RID SYMAX-SL POLYCIN RINGWORM SYMAX-SR POLYETHYLENE GLYCOL 3350 RITALIN SYMJEPI POLYMYXIN B SUL-TRIMETHOPRIM RITALIN LA SYMLINPEN 120 POLYTRIM ROXICODONE SYNALGOS-DC POSACONAZOLE ROXYBOND SYNDROS POVIDONE-IODINE SANDIMMUNE TAKE ACTION POWDERLAX SECONAL SODIUM TALWIN PRAZIQUANTEL SERTRALINE HCL TAMIFLU PRE-ATTACHED LTA KIT SEYSARA TAPERDEX PRED FORTE SILVADENE TARGADOX PRED-G SILVER SULFADIAZINE TAZICEF SIMBRINZA TERAZOL 7 PREDNISOLONE SIMULECT TERCONAZOLE SKLICE TETRACYCLINE HCL PREDNISOLONE ACET-GATIFLOXACIN SMOOTHLAX THYMOGLOBULIN PREDNISOLONE ACET-MOXIFLOXACIN SOCHLOR TIMOLOL MALEATE PREDNISOLONE PHOS-GATIFLOXACIN SODIUM CHLORIDE TIMOPTIC-XE PREDNISOLONE PHOS-MOXIFLOXACIN SOLIFENACIN SUCCINATE TINDAMAX PREDNISOLONE SODIUM PHOS ODT SOLIQUA 100-33 TINIDAZOLE PREDNISOLONE SODIUM PHOSPHATE SOLODYN TIOCONAZOLE-1 SOLOSEC TOBRADEX PREDNISONE INTENSOL SOLOXIDE TOBRADEX ST PREPOPIK SOLU-CORTEF TOBRAMYCIN PRIMSOL SOLU-MEDROL TOBRAMYCIN-DEXAMETHASONE PROBUPHINE SORE THROAT LOZENGE TOBREX PROCENTRA SPECTRACEF TOLTERODINE TARTRATE PROGRAF SPINOSAD TOLTERODINE TARTRATE ER

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Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 *

TOUJEO MAX SOLOSTAR URO-MP ZADITOR TOUJEO SOLOSTAR UROQID-ACID NO.2 ZAMICET TOVIAZ URYL ZCORT TRAMADOL HCL USTELL ZENATANE TRAMADOL HCL ER UTA ZENPEP TRAMADOL HCL-ACETAMINOPHEN UTIRA-C ZENZEDI TRAVOPROST VAGISTAT-3 ZERBAXA TREAGAN OTIC VALACYCLOVIR ZERVIATE TRESIBA VALACYCLOVIR HCL ZILACTIN-B TRESIBA FLEXTOUCH U-100 VALCYTE ZILRETTA TRESIBA FLEXTOUCH U-200 VALGANCICLOVIR HCL ZINACEF TREZIX VANCOCIN HCL ZIRGAN ACET-BUPIVACAINE VANCOMYCIN ZITHROMAX VANCOMYCIN HCL ZITHROMAX TRI-PAK TRIAMCINOLONE DIACETATE VANCOMYCIN HCL-D5W ZMAX TRIAMCINOLONE-MOXIFLOXACIN VANDAZOLE ZODEX TRIESENCE VERIPRED 20 ZONACORT TRIFLURIDINE VERSACLOZ ZOSYN TRILYTE WITH FLAVOR PACKETS VFEND ZOVIRAX TRIMETHOPRIM VFEND IV ZUBSOLV TRIMPEX VIBATIV ZUTRIPRO TROSPIUM CHLORIDE VIBRAMYCIN ZYLET TROSPIUM CHLORIDE ER VICODIN ZYMAXID TRULICITY VICODIN ES TRUSOPT VICODIN HP TUSSIGON VIGAMOX TUSSIONEX VILAMIT MB TYLENOL-CODEINE NO.3 VILEVEV MB TYLENOL-CODEINE NO.4 VITUZ UCERIS VIVITROL ULCEREASE VORICONAZOLE ULESFIA VYVANSE ULTIVA VYZULTA ULTRACET WAL-ZYR ULTRAM WARFARIN SODIUM UNASYN WOMAN'S LAXATIVE UR N-C WOMEN'S GENTLE LAXATIVE URECHOLINE WOMEN'S LAXATIVE URELLE XERAVA URETRON D-S XIFAXAN URIBEL XIIDRA URIMAR-T XODOL 10-300 URIN D.S. XODOL 5-300 URINARY PAIN RELIEF XODOL 7.5-300 URISTAT XOLIDO XP URO-458 XULTOPHY 100-3.6 UROGESIC-BLUE YUTIQ

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