Preferred Drug List (PDL) OREGON HEALTH PLAN TrilliumOHP.com
1-877-600-5472 TTY: 711
MCA_EK16V5 Approved 01/01/2019 OHP-TRIL-17-195 Pharmacy Program
Trillium Community Health Plan’s goal is to offer the right drug coverage to our members. We work with doctors and pharmacists to make sure we offer drugs used to treat many conditions and illnesses. Trillium covers prescription and some over the counter drugs when they are ordered by a licensed prescriber. The pharmacy program does not cover all drugs. Some drugs need our prior approval. Some have a limit on the amount of drug that can be given.
Sometimes you must get Trillium’s prior approval. Even with approval, we will not pay if you are no longer on OHP or if the treatment isn’t covered by OHP. To be paid, the treatment must follow treatment guidelines. This might include step therapy, meaning trying less costly treatment options first.
Medications newly approved by the FDA (Food and Drug Administration) require prior- approval until reviewed by our Pharmacy and Therapeutics Committee.
Filling a Prescription
You can have your prescriptions filled at a Trillium network pharmacy. At the pharmacy, you will need to give the pharmacist your prescription and your ID card. You can find a pharmacy that is in network by calling a Trillium Member Services Representative at 541-485-2155; Toll Free: 1-877-600-5472, or by using the Find a Provider tool on our website at https://providersearch.trilliumhealthplan.com. You do not have to pay for covered drugs.
The Trillium preferred drug list has a large number of brand name and generic drugs on it. Trillium asks that doctors prescribe medication from the Trillium preferred drug list for their patients who are members of Trillium. Some drugs will need your doctor to submit a prior approval request before the medication can be given to you at the pharmacy. These drugs are on the prior approval list. All prior approval reviews are done by a licensed clinical pharmacist using the Trillium Pharmacy and Therapeutics Committee’s guidelines.
Trillium will cover the drug if it is decided that:
1. There is a medical reason that you need the specific drug. 2. Other drugs on the preferred drug list have not worked for you.
Once approved, your doctor will be contacted.
If the information given does not meet requirements for the requested drug, we will contact you and your doctor, and tell you about the appeal process.
Generic Drugs
Generic drugs work the same as brand name drugs. When there is a generic drug available, your doctor will need to ask for a prior approval for the brand name drug. We will review the prior authorization and cover the brand name drug if there is a medical reason you need the brand name drug.
Specialty Drugs
Retail pharmacies do not have specialty drugs. You can get these drugs from our specialty pharmacy, AcariaHealth. Your doctor may need to ask for a prior approval for you to receive a specialty drug.
Over-the-Counter Medications
Trillium will pay for over the counter drugs that are on the preferred drug list. To be covered, your doctor will need to write you a prescription for the drug.
72-Hour Emergency Supply Policy
If you have an urgent need for a drug, your doctor can ask Trillium for an urgent preapproval. Trillium will look at these requests within 24 hours. If we cannot look at the request in time, Trillium will let the pharmacy give you the drug for three days.
Step Therapy
Some drugs listed on the Trillium preferred drug list may need you to try other drugs before you can receive the step therapy drug. If Trillium has a record that you have tried this drug, the step therapy drug is covered. If Trillium does not have a record that you have tried this drug, your doctor may need to submit a prior approval.
Dispensing Limits, Quantity Limits, and Age Limits
Trillium may limit how much of a drug you can get at one time. You may get up to a 30 day supply for each new or refill of a non-controlled drug. Most prescriptions can be refilled after 24 days. Some drugs on the Trillium preferred drug list may have an age limit, which is set by the Food and Drug Administration (FDA). If your doctor feels that you have a medical reason for getting a larger amount of the drug, or that you should receive a drug even if you do not meet the age limit, they can ask for a prior approval.
Appropriate Use and Safety Edits
Your health and safety are important to Trillium. One way we keep you safe is through Point-of-Sale (POS) changes at the time a prescription is processed at the pharmacy. These changes are based on FDA recommendations and promote safe and effective medication use.
Pharmacy Benefit Exclusions
These medications are not covered by Trillium:
Medications that do not have an FDA-approved use; Medications that are not medically necessary; Experimental or investigation medications; Medication products for a diagnosis that is not covered by the Oregon Health Plan; Medications that are an excluded service under the Oregon Health Plan; Medications to treat mental illness (therapeutic classes 7 and 11); Medications to help you get pregnant; Home pregnancy kits; Cosmetic or hair-growth medications; and Medicare Part D covered drugs for dual members.
Mail Order Program
If you are taking a drug to treat a long-term medical condition or illness, you may be able to get a 60-day supply of your drug by mail. Please contact a Trillium Member Service Representative if you have any questions.
Do you think Trillium Community Health Plan (TCHP) has treated you unfairly? Trillium must follow state and federal civil rights laws. It cannot treat people unfairly in any of its programs or activities because of a person’s:
Age Gender identity Race Sexual orientation Color Marital status Religion Disability National Origin Sex
Everyone has a right to enter, exit and use buildings and services. They also have the right to get information in a way they understand. Trillium will make reasonable changes to policies, practices, and procedures by talking with you about your needs.
To report concerns or to get more information, please contact Member Services at 541- 485-2155; Toll Free: 1-877-600-5472; TTY: 1-877-600-5473, Monday through Friday, 8:00 a.m. to 5:00 p.m. At other times – including Saturday, Sunday, and federal holidays – you can leave a voicemail. We will return your call the following business day. The call is free.
You also have a right to file a civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights. Contact that office one of these ways:
Web: www.hhs.gov Email: [email protected] Phone: 1-800-368-1019, 1-800-537-7697 (TDD) Mail: 200 Independence Ave., SW, Room 509F HHH Bldg. Washington, D.C. 20201
English ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call 1-877-600-5472; TTY: 1-877-600-5473.
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Cushite XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-877-600-5472; TTY: 1-877-600-5473.
Deutsch (German)
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verf gung. Rufnummer: 1-877-600-5472; TTY: 1-877-600-5473.
(Farsi) ف را یس هجوت : رگا به نابز یسراف وگتفگ یم ،دينک يهست تال ینابز تروصب ناگيار یارب امش سامت ديريگب . مهارف یم دشاب . اب .TTY: 1-877-600-5473 ;1-877-600-5472
Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-877-600-5472; TTY: 1-877-600-5473
ภาษาไทย (Thai) เรียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร. 1-877-600-5472; TTY: 1-877-600- 5473.
Tier Definition:
F Preferred Drugs NF Non-formulary CO Carve Out Drugs
Legend Description AL Age Limit Drug is limited to specific age. Prior PA Prior Authorization required before prescription can be filled. Authorization There is a limit on the amount of drug covered per prescription, or QL Quantity Limit within a specific time frame. Rx/OTC Rx/OTC Product has both Rx and OTC National Drug Codes. Specialty drugs are high-cost drugs used to treat complex or rare Specialty conditions, such as multiple sclerosis, rheumatoid arthritis, SP Drug hepatitis C, and hemophilia and may be limited to a specific pharmacy. Requires trial and failure of one or more preferred products prior to ST Step Therapy coverage.
Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- clonidine hcl (adhd) tb12 CO OBESITY/ANOREXIANTS - Drugs to Treat ADHD, Sleep and Eating Disorders guanfacine hcl (adhd) tb24 CO Amphetamines INTUNIV TB24 (guanfacine CO ADDERALL TABS hcl (adhd)) (amphetamine- NF KAPVAY TB12 (clonidine CO dextroamphetamine) hcl (adhd)) ADDERALL XR CP24 QL(2 ea daily) STRATTERA CAPS CO (amphetamine- NF (atomoxetine hcl) dextroamphetamine) Stimulants - Misc. ADZENYS ER SUER NF (amphetamine) armodafinil tabs CO amphetamine- QL(2 ea daily) dextroamphetamine cp24 CONCERTA TBCR NF QL(2 ea daily) 1.25 mg-1.25 mg-1.25 mg- (methylphenidate hcl) 1.25 mg, 2.5 mg-2.5 mg- dexmethylphenidate hcl QL(2 ea daily) 2.5 mg-2.5 mg, 3.75 mg- F cp24 35 mg, 10 mg, 15 mg, F 3.75 mg-3.75 mg-3.75 mg, 20 mg, 25 mg, 30 mg, 40 5 mg-5 mg-5 mg-5 mg, mg, 5 mg 6.25 mg-6.25 mg-6.25 mg- dexmethylphenidate hcl F 6.25 mg, 7.5 mg-7.5 mg- tabs 2.5 mg, 10 mg, 5 mg 7.5 mg-7.5 mg FOCALIN TABS NF amphetamine- (dexmethylphenidate hcl) dextroamphetamine tabs 1.25 mg-1.25 mg-1.25 mg- FOCALIN XR CP24 NF QL(2 ea daily) 1.25 mg, 1.875 mg-1.875 (dexmethylphenidate hcl) mg-1.875 mg-1.875 mg, methylphenidate hcl cp24 QL(2 ea daily) 10 mg, 20 mg, 30 mg, 40 F 2.5 mg-2.5 mg-2.5 mg-2.5 F mg, 3.125 mg-3.125 mg- mg 3.125 mg-3.125 mg, 3.75 methylphenidate hcl cpcr QL(2 ea daily) mg-3.75 mg-3.75 mg-3.75 40 mg, 60 mg, 10 mg, 20 F mg, 5 mg-5 mg-5 mg-5 mg, mg, 30 mg, 50 mg 7.5 mg-7.5 mg-7.5 mg-7.5 methylphenidate hcl tabs F mg 10 mg, 20 mg, 5 mg DEXEDRINE CP24 PA; QL(2 ea methylphenidate hcl tb24 QL(2 ea daily) (dextroamphetamine NF daily) 18 mg, 27 mg, 36 mg, 54 F sulfate) mg dextroamphetamine sulfate F PA; QL(2 ea methylphenidate hcl tbcr 10 QL(2 ea daily) cp24 10 mg, 15 mg, 5 mg daily) mg, 20 mg, 54 mg, 18 mg, F dextroamphetamine sulfate F 27 mg, 36 mg tabs 5 mg, 10 mg modafinil tabs CO VYVANSE CAPS 10 MG, PA; QL(2 ea 20 MG, 30 MG, 40 MG, 50 F daily) NUVIGIL TABS CO MG, 60 MG, 70 MG (armodafinil) Attention-Deficit/Hyperactivity Disorder (ADHD) PROVIGIL TABS CO (modafinil) atomoxetine hcl caps CO RELEXXII TBCR NF
Oregon Trillium OHP Updated September 1, 2021
1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RITALIN LA CP24 NF QL(2 ea daily) paromomycin sulfate caps F SP (methylphenidate hcl) SP RITALIN TABS NF TOBI NEBU (tobramycin) NF (methylphenidate hcl) tobramycin nebu 300 F SP ALTERNATIVE MEDICINES mg/5ml Alternative Medicine - C's ANALGESICS - ANTI-INFLAMMATORY - Drugs coenzyme q10 PA; QL(3 ea to Treat Pain, Swelling, Muscle and Joint (ubidecarenone) caps 50 F daily) Conditions mg, 30 mg, 100 mg Anti-TNF-alpha - Monoclonal Antibodies cranberry (vaccinium QL(3 ea daily) HUMIRA PEDIATRIC PA; QL(0.11 ea macrocarpon) tabs 450 mg, F CROHNS DISEASE F daily); SP 300 mg, 400 mg, 500 mg STARTER PACK PSKT CRANBERRY EXTRACT QL(3 ea daily) F HUMIRA PEN PNKT 40 F PA; QL(0.15 ea TABS 250 MG MG/0.4ML, 40 MG/0.8ML daily); SP CRANBERRY TABS 125 QL(3 ea daily) F HUMIRA PEN PNKT 80 F PA; QL(0.11 ea MG, 600 MG MG/0.8ML daily); SP PA; QL(3 ea Q-GEL CAPS F HUMIRA PEN-CD/UC/HS PA; QL(0.15 ea daily) STARTER PNKT 40 F daily); SP Alternative Medicine - S's MG/0.8ML HUMIRA PEN-CD/UC/HS PA; QL(0.11 ea st john's wort (hypericum CO perforatum) caps STARTER PNKT 80 F daily); SP MG/0.8ML st john's wort (hypericum CO perforatum) tabs HUMIRA PEN-PEDIATRIC PA; QL(0.11 ea UC STARTER PACK F daily); SP ST JOHNS WORT CAPS CO PNKT 1000 MG, 450 MG HUMIRA PEN-PS/UV F PA; QL(0.11 ea Alternative Medicine Combinations STARTER PNKT daily); SP glucosamine-chondroitin QL(3 ea daily) HUMIRA PEN-PS/UV F PA; QL(0.15 ea caps 400 mg-500 mg, 500 F STARTER PNKT daily); SP mg-400 mg HUMIRA PSKT 10 PA; QL(0.072 glucosamine-chondroitin QL(3 ea daily) MG/0.1ML, 10 MG/0.2ML, F ea daily); SP tabs 400 mg-500 mg, 400 F 20 MG/0.2ML, 20 mg-500 mg-500 mg-400 MG/0.4ML mg HUMIRA PSKT 40 F PA; QL(0.15 ea AMINOGLYCOSIDES - Drugs to Treat Bacterial MG/0.4ML, 40 MG/0.8ML daily); SP Infections SIMPONI SOAJ 100 F PA; QL(0.072 Aminoglycosides MG/ML ml daily); SP PA; SP SIMPONI SOAJ 50 F PA; QL(0.018 ARIKAYCE SUSP F MG/0.5ML ml daily); SP SIMPONI SOSY 100 PA; QL(0.072 HUMATIN CAPS NF SP F (paromomycin sulfate) MG/ML ml daily); SP SIMPONI SOSY 50 PA; QL(0.018 KITABIS PAK NEBU NF SP F (tobramycin) MG/0.5ML ml daily); SP neomycin sulfate tabs F Antirheumatic - Enzyme Inhibitors
Oregon Trillium OHP Updated September 1, 2021
2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XELJANZ TABS 10 MG, 5 F PA; QL(2 ea ibuprofen susp 40 mg/ml, F MG daily); SP 50 mg/1.25ml ibuprofen tabs 100 mg, 400 XELJANZ XR TB24 F PA; QL(1 ea daily); SP mg, 600 mg, 800 mg, 200 F mg Interleukin-6 Receptor Inhibitors INDOCIN SUSP OR 25 PA; QL(0.082 F KEVZARA SOAJ F MG/5ML ml daily); SP indomethacin caps 25 mg, PA; QL(0.082 F KEVZARA SOSY F 50 mg ml daily); SP INFANTS ADVIL SUSP NF Nonsteroidal Anti-inflammatory Agents (NSAIDs) (ibuprofen) ADVIL CAPS (ibuprofen) NF ketoprofen caps 50 mg, 75 F mg ADVIL MIGRAINE CAPS NF KETOROLAC PA (ibuprofen) TROMETHAMINE SOLN F ADVIL TABS (ibuprofen) NF NA 15.75 MG/SPRAY ketorolac tromethamine F ALEVE ARTHRITIS TABS NF tabs or 10 mg (naproxen sodium) meloxicam tabs 15 mg, 7.5 F ALEVE TABS (naproxen NF mg sodium) CELEBREX CAPS 100 PA; QL(2 ea MOBIC TABS (meloxicam) NF MG, 200 MG, 50 MG NF daily) MOTRIN INFANTS NF (celecoxib) DROPS SUSP (ibuprofen) CELEBREX CAPS 400 MG NF PA; QL(1 ea (celecoxib) daily) nabumetone tabs F celecoxib caps 100 mg, PA; QL(2 ea F NAPROSYN SUSP NF 200 mg, 50 mg daily) (naproxen) PA; QL(1 ea celecoxib caps 400 mg F NAPROSYN TABS NF daily) (naproxen) CHILDRENS ADVIL SUSP RX/OTC NF naproxen sodium tabs 550 F (ibuprofen) mg, 275 mg, 220 mg CHILDRENS MOTRIN NF RX/OTC SUSP (ibuprofen) naproxen susp F diclofenac potassium tabs F naproxen tabs F diclofenac sodium tb24 F naproxen tbec F diclofenac sodium tbec F SPRIX SOLN F PA
EC-NAPROSYN TBEC NF sulindac tabs F (naproxen) flurbiprofen tabs F Phosphodiesterase 4 (PDE4) Inhibitors PA; QL(2 ea OTEZLA TABS F ibuprofen caps 200 mg F daily); SP OTEZLA TBPK F PA; SP ibuprofen susp 100 mg/5ml F RX/OTC
Oregon Trillium OHP Updated September 1, 2021
3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Pyrimidine Synthesis Inhibitors acetaminophen chew or 80 F mg, 160 mg ARAVA TABS NF QL(1 ea daily) (leflunomide) acetaminophen elix or 160 F mg/5ml, 80 mg/2.5ml QL(1 ea daily) leflunomide tabs F acetaminophen liqd or 1000 mg/30ml, 160 F Soluble Tumor Necrosis Factor Receptor Agents mg/5ml, 500 mg/15ml ENBREL MINI SOCT F PA; QL(0.29 ml acetaminophen soln or 100 daily); SP mg/ml, 160 mg/5ml, 325 F ENBREL SOLN 25 F PA; QL(0.29 ml mg/10.15ml, 650 MG/0.5ML daily); SP mg/20.3ml PA; QL(0.29 ea ENBREL SOLR 25 MG F acetaminophen supp re F daily); SP 650 mg, 120 mg ENBREL SOSY 25 F PA; QL(0.29 ml acetaminophen susp or MG/0.5ML, 50 MG/ML daily); SP 160 mg/5ml, 650 F mg/20.3ml, 80 mg/2.5ml ENBREL SURECLICK F PA; QL(0.29 ml SOAJ daily); SP acetaminophen tabs or 325 F ANALGESICS - NonNarcotic - Drugs to Treat mg, 500 mg Pain, Muscle and Joint Conditions acetaminophen tbcr or 650 F mg Analgesic Combinations FEVERALL INFANTS F butalbital-acetaminophen SUPP tabs 325 mg-50 mg, 50 F mg-325 mg FEVERALL JUNIOR F STRENGTH SUPP butalbital-acetaminophen- NORTEMP INFANTS caffeine caps 40 mg-50 F F mg-300 mg, 40 mg-50 mg- SUSP 325 mg TYLENOL 8 HOUR butalbital-acetaminophen- ARTHRITISPAIN TBCR NF caffeine tabs 40 mg-50 mg- F (acetaminophen) 325 mg TYLENOL 8 HOUR TBCR NF (acetaminophen) butalbital-aspirin-caffeine F caps TYLENOL CHILDRENS BUTALBITAL/ACETAMINO CHEWABLES/PAIN + NF PHEN CAPS (butalbital- NF FEVER CHEW acetaminophen) (acetaminophen) TYLENOL CHILDRENS ESGIC TABS (butalbital- NF NF acetaminophen-caffeine) SUSP (acetaminophen) FIORICET CAPS TYLENOL EXTRA (butalbital-acetaminophen- NF STRENGTH TABS NF caffeine) (acetaminophen) TYLENOL FOR FIORINAL CAPS NF (butalbital-aspirin-caffeine) CHILDREN/ADULTS NF SUSP (acetaminophen) Analgesics Other TYLENOL INFANTS acetaminophen caps or F PAIN+FEVER SUSP NF 500 mg (acetaminophen)
Oregon Trillium OHP Updated September 1, 2021
4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYLENOL INFANTS SUSP NF Smart PA; Max (acetaminophen) DILAUDID TABS OR 2 7 days per fill, 2 MG, 4 MG, 8 MG NF fills per 180 TYLENOL TABS NF (acetaminophen) (hydromorphone hcl) days;QL(12 ea daily) Salicylates DOLOPHINE TABS NF PA aspirin chew or 81 mg F (methadone hcl) DURAGESIC PT72 NF PA ASPIRIN SUPP RE 300 F (fentanyl) MG, 600 MG fentanyl pt72 td 100 PA aspirin tabs or 500 mg, 325 F mcg/hr, 12 mcg/hr, 25 F mg mcg/hr, 50 mcg/hr, 75 aspirin tbec or 325 mg, 81 F mcg/hr mg FENTORA TABS (fentanyl NF ECOTRIN MAXIMUM NF citrate) STRENGTH TBEC Smart PA; Max ECOTRIN REGULAR 7 days per fill, 2 STRENGTH TBEC NF HYDROMORPHONE HCL F fills per 180 (aspirin) SUPP RE 3 MG days;QL(12 ea daily) ECOTRIN TBEC (aspirin) NF Smart PA; Max salsalate tabs F 7 days per fill, 2 hydromorphone hcl tabs or F fills per 180 2 mg, 4 mg, 8 mg ANALGESICS - OPIOID - Drugs to Treat Pain, days;QL(12 ea Muscle and Joint Conditions daily) Smart PA; Max Opioid Agonists 7 days per fill, 2 Smart PA; Max meperidine hcl tabs or 50 F fills per 180 7 days per fill, 2 mg days;QL(12 ea fills per 180 daily) CODEINE SULFATE TABS F days;QL(12 ea 15 MG, 60 MG methadone hcl tabs or 5 F PA daily); AL(At mg, 10 mg least 12 yrs old) MORPHINE SULFATE SOLN IV 10 MG/ML NF Smart PA; Max ) 7 days per fill, 2 (morphine sulfate fills per 180 morphine sulfate soln or 10 F PA codeine sulfate tabs 30 mg F days;QL(12 ea mg/5ml, 20 mg/5ml daily); AL(At Smart PA; Max least 12 yrs 7 days per fill, 2 old) morphine sulfate tabs or 15 F fills per 180 mg, 30 mg days;QL(12 ea CONZIP CP24 (tramadol NF hcl) daily) DILAUDID SOLN IJ 1 PA; QL(36 ea morphine sulfate tbcr or F per 31 days MG/ML, 2 MG/ML NF 100 mg (hydromorphone hcl) retail) PA; QL(240 ea morphine sulfate tbcr or 15 F per 31 days mg retail)
Oregon Trillium OHP Updated September 1, 2021
5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(30 ea Smart PA; Max morphine sulfate tbcr or F per 31 days 7 days per fill, 2 200 mg retail) ROXICODONE TABS NF fills per 180 (oxycodone hcl) PA; QL(120 ea days;QL(12 ea morphine sulfate tbcr or 30 F per 31 days daily) mg retail) Smart PA; Max PA; QL(60 ea 7 days per fill, 2 morphine sulfate tbcr or 60 F per 31 days fills per 180 mg retail) tramadol hcl tabs 50 mg F days;QL(12 ea daily); AL(At PA; QL(36 ea least 18 yrs MS CONTIN TBCR 100 NF MG (morphine sulfate) per 31 days old) retail) Smart PA; Max PA; QL(240 ea 7 days per fill, 2 MS CONTIN TBCR 15 MG NF per 31 days (morphine sulfate) fills per 180 retail) ULTRAM TABS (tramadol NF ) days;QL(12 ea PA; QL(30 ea hcl daily); AL(At MS CONTIN TBCR 200 NF MG (morphine sulfate) per 31 days least 18 yrs retail) old) PA; QL(120 ea Opioid Combinations MS CONTIN TBCR 30 MG NF per 31 days (morphine sulfate) retail) QL(500 ml per acetaminophen w/ codeine 365 days PA; QL(60 ea soln 12 mg/5ml-120 MS CONTIN TBCR 60 MG F retail); AL(At NF per 31 days mg/5ml, 120 mg/5ml-12 least 12 yrs (morphine sulfate) mg/5ml retail) old) Smart PA; Max Smart PA; Max 7 days per fill, 2 7 days per fill, 2 OXAYDO TABS 5 MG F fills per 180 acetaminophen w/ codeine fills per 180 days;QL(12 ea tabs 15 mg-300 mg, 60 mg- F days;QL(12 ea daily) 300 mg, 30 mg-300 mg daily); AL(At Smart PA; Max least 12 yrs 7 days per fill, 2 old) oxycodone hcl caps 5 mg F fills per 180 Smart PA; Max days;QL(12 ea 7 days per fill, 2 daily) fills per 180 150ml/365 butalbital-acetaminophen- F days;QL(12 ea caffeine w/ codeine caps oxycodone hcl soln 5 F days;QL(150 daily); AL(At mg/5ml ml per 365 least 12 yrs days retail) old) oxycodone hcl t12a 15 mg, PA Smart PA; Max 30 mg, 60 mg, 80 mg, 10 F 7 days per fill, 2 mg, 20 mg, 40 mg fills per 180 butalbital-aspirin-caffeine F days;QL(12 ea Smart PA; Max w/cod caps 7 days per fill, 2 daily); AL(At oxycodone hcl tabs 10 mg, F fills per 180 least 12 yrs 20 mg, 15 mg, 30 mg, 5 mg days;QL(12 ea old) daily)
Oregon Trillium OHP Updated September 1, 2021
6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Smart PA; Max Smart PA; Max 7 days per fill, 2 7 days per fill, 2 FIORICET/CODEINE fills per 180 TYLENOL/CODEINE #4 fills per 180 CAPS (butalbital- NF NF acetaminophen-caffeine w/ days;QL(12 ea TABS (acetaminophen w/ days;QL(12 ea ) daily); AL(At codeine) daily); AL(At codeine least 12 yrs least 12 yrs old) old) Smart PA; Max Opioid Partial Agonists 7 days per fill, 2 buprenorphine hcl subl sl 2 F QL(3 ea daily) FIORINAL/CODEINE #3 fills per 180 mg, 8 mg CAPS (butalbital-aspirin- NF days;QL(12 ea caffeine w/cod) daily); AL(At buprenorphine hcl- F QL(3 ea daily) least 12 yrs naloxone hcl dihydrate film old) buprenorphine hcl- F QL(3 ea daily) hydrocodone- QL(500 ml per naloxone hcl dihydrate subl acetaminophen soln 2.5 365 days retail) SUBOXONE FILM QL(3 ea daily) mg/5ml-108 mg/5ml, 5 F (buprenorphine hcl- NF mg/10ml-217 mg/10ml, 7.5 naloxone hcl dihydrate) mg/15ml-325 mg/15ml ZUBSOLV SUBL 0.36 MG- NF PA hydrocodone- Smart PA; Max 1.4 MG, 1.4 MG-5.7 MG acetaminophen tabs 10 7 days per fill, 2 mg-300 mg, 5 mg-300 mg, fills per 180 ANDROGENS-ANABOLIC - Drugs to Regulate 7.5 mg-300 mg, 5 mg-325 F days;QL(12 ea Hormones mg, 10 mg-325 mg, 325 daily) Androgens mg-10 mg, 325 mg-7.5 mg, ANDROGEL GEL 25 7.5 mg-325 mg MG/2.5GM, 50 MG/5GM NF Smart PA; Max (testosterone) NORCO TABS 7 days per fill, 2 (hydrocodone- NF fills per 180 danazol caps F acetaminophen) days;QL(12 ea DEPO-TESTOSTERONE AL(At least 17 daily) SOLN (testosterone NF yrs old) Smart PA; Max cypionate) 7 days per fill, 2 oxycodone w/ TESTIM GEL NF F fills per 180 (testosterone) acetaminophen tabs days;QL(12 ea daily) testosterone cypionate soln F AL(At least 17 im 100 mg/ml, 200 mg/ml yrs old) Smart PA; Max PERCOCET TABS 7 days per fill, 2 testosterone enanthate F AL(At least 17 (oxycodone w/ NF fills per 180 soln im yrs old) acetaminophen) days;QL(12 ea VOGELXO GEL NF daily) (testosterone) Smart PA; Max VOGELXO PUMP GEL NF 7 days per fill, 2 (testosterone) TYLENOL/CODEINE #3 fills per 180 ANORECTAL AND RELATED PRODUCTS - TABS (acetaminophen w/ NF days;QL(12 ea Rectal Drugs to Treat Pain, Swelling and Itching codeine) daily); AL(At least 12 yrs Intrarectal Steroids old) CORTENEMA ENEM (hydrocortisone NF (intrarectal)) Oregon Trillium OHP Updated September 1, 2021
7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CORTIFOAM FOAM F CVS ANTACID SOFT CHEWS ULTRA F STRENGTH CHEW hydrocortisone (intrarectal) F enem MAALOX CHEW F Rectal Combinations TUMS CHEW (calcium F PROCTOFOAM HC FOAM F carbonate (antacid)) TUMS CHEWY BITES Rectal Steroids CHEW (calcium carbonate NF ANUSOL-HC CREA NF (antacid)) (hydrocortisone (rectal)) TUMS CHEWY DELIGHTS F hydrocortisone (rectal) crea F CHEW 2.5 % TUMS E-X 750 CHEW ANTACIDS (calcium carbonate NF (antacid)) Antacid Combinations TUMS EXTRA STRENGTH 750 CHEW (calcium NF alum & mag hydrox- F simethicone chew carbonate (antacid)) TUMS LASTING EFFECTS alum & mag hydrox- F simethicone liqd CHEW (calcium carbonate F (antacid)) alum & mag hydrox- F simethicone susp TUMS SMOOTHIES CHEW (calcium carbonate NF DI-GEL SUSP 25 MG/5ML- F 87 MG/5ML-282 MG/5ML (antacid)) TUMS ULTRA 1000 CHEW GELUSIL CHEW (alum & NF mag hydrox-simethicone) (calcium carbonate NF (antacid)) HYVEE ADVANCED Antacids - Magnesium Salts ANTACID MAXIMUM NF STRENGTH SUSP (alum & MAGNESIUM OXIDE F mag hydrox-simethicone) CAPS 400 MG Antacids - Bicarbonate magnesium oxide tabs 400 F mg, 420 mg, 250 mg sodium bicarbonate F (antacid) tabs URO MAG CAPS F Antacids - Calcium Salts URO-MAG CAPS F ANTACID CHEW F ANTHELMINTICS - Drugs to Treat Worm ANTACID SOFT CHEWS F Infections CHEW Anthelmintics calcium carbonate F (antacid) chew BILTRICIDE TABS NF (praziquantel) calcium carbonate F (antacid) susp ivermectin tabs or 3 mg F CALCIUM CARBONATE F TABS 648 MG praziquantel tabs F
pyrantel pamoate susp F
Oregon Trillium OHP Updated September 1, 2021
8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STROMECTOL TABS NF vancomycin hcl solr iv 5 (ivermectin) gm, 500 mg, 750 mg, 1 gm, F 1000 mg ANTI-INFECTIVE AGENTS - MISC. - Drugs to Treat Bacterial Infections VANCOMYCIN HYDROCHLORIDE/DEXT Anti-infective Agents - Misc. ROSE SOLN 1 GM/200ML- F 5 %, 5 %-500 MG/100ML, FLAGYL TABS 500 MG NF (metronidazole) 750 MG/150ML-5 % VANCOMYCIN metronidazole tabs or 250 F mg, 500 mg HYDROCHLORIDE/SODIU F M CHLORIDE SOLN PRIMSOL SOLN F VANCOMYCIN SOLN 0.9 %-750 MG/150ML, 500 F F trimethoprim tabs MG/100ML-0.9 % Anti-infective Misc. - Combinations Leprostatics BACTRIM DS TABS dapsone tabs F (sulfamethoxazole- NF trimethoprim) Lincosamides BACTRIM TABS CLEOCIN CAPS OR 75 (sulfamethoxazole- NF MG, 150 MG, 300 MG NF trimethoprim) (clindamycin hcl) sulfamethoxazole- CLEOCIN PEDIATRIC trimethoprim susp or 200 F GRANULES SOLR NF mg/5ml-40 mg/5ml, 40 (clindamycin palmitate mg/5ml-200 mg/5ml hydrochloride) sulfamethoxazole- trimethoprim tabs or 160 clindamycin hcl caps F mg-800 mg, 400 mg-80 F clindamycin palmitate F mg, 80 mg-400 mg, 800 hydrochloride solr mg-160 mg Oxazolidinones Cyclic Lipopeptides linezolid susr or 100 F PA DAPTOMYCIN SOLR 350 NF mg/5ml MG (daptomycin) PA Glycopeptides linezolid tabs or 600 mg F VANCOCIN CAPS QL(2 ea daily) NF ZYVOX SUSR OR 100 NF PA (vancomycin hcl) MG/5ML (linezolid) VANCOCIN HCL CAPS QL(4 ea daily) NF ZYVOX TABS OR 600 MG NF PA (vancomycin hcl) (linezolid) vancomycin hcl caps or F QL(4 ea daily) Urinary Anti-infectives 125 mg FURADANTIN SUSP NF vancomycin hcl caps or F QL(2 ea daily) (nitrofurantoin) 250 mg MACROBID CAPS VANCOMYCIN HCL SOLN F (nitrofurantoin monohyd NF IV 0.9 %-1 GM/200ML macro)
Oregon Trillium OHP Updated September 1, 2021
9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MACRODANTIN CAPS hydroxyzine hcl syrp or 10 F 100 MG, 50 MG NF mg/5ml (nitrofurantoin hydroxyzine hcl tabs or 10 F macrocrystal) mg, 25 mg, 50 mg nitrofurantoin macrocrystal F caps 100 mg, 50 mg hydroxyzine pamoate caps F nitrofurantoin monohyd F meprobamate tabs CO macro caps VISTARIL CAPS NF nitrofurantoin susp F (hydroxyzine pamoate) ANTIANGINAL AGENTS - Drugs to Treat Chest Benzodiazepines Pain ALPRAZOLAM INTENSOL CO Nitrates CONC ISORDIL TITRADOSE alprazolam tabs CO TABS 5 MG (isosorbide NF dinitrate) alprazolam tb24 CO isosorbide dinitrate tabs 30 F mg, 10 mg, 20 mg, 5 mg alprazolam tbdp CO isosorbide dinitrate tbcr 40 F mg ATIVAN TABS OR 0.5 MG, CO 1 MG, 2 MG (lorazepam) isosorbide mononitrate F tabs chlordiazepoxide hcl caps CO isosorbide mononitrate F clorazepate dipotassium CO tb24 tabs NITRO-DUR PT24 0.1 diazepam conc or 5 mg/ml CO MG/HR, 0.2 MG/HR, 0.4 NF MG/HR, 0.6 MG/HR DIAZEPAM SOAJ IM 10 CO (nitroglycerin) MG/2ML NITRO-DUR PT24 0.3 F DIAZEPAM SOLN IJ 5 CO MG/HR, 0.8 MG/HR MG/ML nitroglycerin pt24 td 0.1 diazepam soln ij 5 mg/ml, CO mg/hr, 0.2 mg/hr, 0.4 F 50 mg/10ml mg/hr, 0.6 mg/hr diazepam soln or 5 mg/5ml CO nitroglycerin subl sl 0.3 mg, F 0.4 mg, 0.6 mg diazepam tabs or 10 mg, 2 CO NITROSTAT SUBL NF mg, 5 mg (nitroglycerin) lorazepam conc or 2 mg/ml CO ANTIANXIETY AGENTS - Drugs to Treat Anxiety lorazepam tabs or 0.5 mg, CO Antianxiety Agents - Misc. 1 mg, 2 mg buspirone hcl tabs CO oxazepam caps CO
DROPERIDOL SOLN CO TRANXENE T TABS CO (clorazepate dipotassium) droperidol soln CO VALIUM TABS (diazepam) CO
Oregon Trillium OHP Updated September 1, 2021
10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XANAX TABS (alprazolam) CO montelukast sodium chew F
XANAX XR TB24 CO montelukast sodium pack F (alprazolam) ANTIARRHYTHMICS - Drugs to treat abnormal montelukast sodium tabs F heart rhythms SINGULAIR CHEW NF Antiarrhythmics Type I-A (montelukast sodium) disopyramide phosphate F SINGULAIR PACK NF caps (montelukast sodium) NORPACE CAPS NF SINGULAIR TABS NF (disopyramide phosphate) (montelukast sodium) NORPACE CR CP12 F zafirlukast tabs F quinidine gluconate tbcr F Steroid Inhalants QL(1 ea daily) quinidine sulfate tabs F ARNUITY ELLIPTA AEPB F budesonide (inhalation) AL(Up to 8 yrs Antiarrhythmics Type I-B susp 0.25 mg/2ml, 0.5 F old ) mexiletine hcl caps 150 F mg/2ml mg, 200 mg, 250 mg FLOVENT DISKUS AEPB F Antiarrhythmics Type I-C flecainide acetate tabs F FLOVENT HFA AERO F PULMICORT FLEXHALER propafenone hcl tabs 150 F F mg, 225 mg, 300 mg AEPB PULMICORT SUSP 0.25 AL(Up to 8 yrs Antiarrhythmics Type III MG/2ML, 0.5 MG/2ML NF old ) amiodarone hcl tabs or 100 F (budesonide (inhalation)) mg, 200 mg, 400 mg QVAR REDIHALER AERB F ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions Sympathomimetics Anti-Inflammatory Agents ADVAIR DISKUS AEPB NF (fluticasone-salmeterol) cromolyn sodium nebu F AIRDUO RESPICLICK Bronchodilators - Anticholinergics 113/14 AEPB (fluticasone- NF salmeterol) ATROVENT HFA AERS F AIRDUO RESPICLICK 232/14 AEPB (fluticasone- NF INCRUSE ELLIPTA AEPB F salmeterol) AIRDUO RESPICLICK ipratropium bromide soln F 55/14 AEPB (fluticasone- NF salmeterol) TUDORZA PRESSAIR F AEPB albuterol sulfate aers in 108 F mcg/act Leukotriene Modulators ALBUTEROL SULFATE F ACCOLATE TABS NF NEBU IN 0.5 % (zafirlukast) Oregon Trillium OHP Updated September 1, 2021
11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits albuterol sulfate nebu in XOPENEX HFA AERO F 0.63 mg/3ml, 1.25 mg/3ml, F (levalbuterol tartrate) 0.083 %, 0.5 %, 2.5 XOPENEX NEBU NF mg/0.5ml (levalbuterol hcl) albuterol sulfate syrp or 2 F mg/5ml Xanthines ELIXOPHYLLIN ELIX F albuterol sulfate tabs or 2 F mg, 4 mg theophylline soln 80 F albuterol sulfate tb12 or 4 F mg/15ml mg, 8 mg theophylline tb12 100 mg, F budesonide-formoterol F 200 mg, 300 mg, 450 mg fumarate dihydrate aero theophylline tb24 400 mg, F COMBIVENT RESPIMAT F 600 mg AERS fluticasone-salmeterol aepb ANTICOAGULANTS - Blood Thinners 14 mcg/act-113 mcg/act, F 14 mcg/act-232 mcg/act, Coumarin Anticoagulants 14 mcg/act-55 mcg/act COUMADIN TABS NF fluticasone-salmeterol aepb 1 rtl pack lmt (warfarin sodium) 50 mcg/dose-500 amt,30 rtl pack warfarin sodium tabs F mcg/dose, 50 mcg/dose- F lmt day(s), 100 mcg/dose, 50 Direct Factor Xa Inhibitors mcg/dose-250 mcg/dose QL(42 ea per BEVYXXA CAPS F ipratropium-albuterol soln F 42 days retail) QL(74 ea per levalbuterol hcl nebu F ELIQUIS STARTER PACK 30 days retail)2 F rtl MAX fill,365 Generic TBPK levalbuterol tartrate aero F rtl day(s) Required supply, PROAIR HFA AERS F QL(2 ea daily) (albuterol sulfate) ELIQUIS TABS F PROAIR RESPICLICK F Heparins And Heparinoid-Like Agents AEPB QL(6 ml PROVENTIL HFA AERS enoxaparin sodium soln ij F daily,84 ml per F 300 mg/3ml (albuterol sulfate) 14 days retail) SEREVENT DISKUS F QL(60 ea per QL(2 ml AEPB 30 days retail) enoxaparin sodium soln sc F daily,28 ml per 100 mg/ml, 150 mg/ml SYMBICORT AERO 14 days retail) (budesonide-formoterol NF QL(1.6 ml fumarate dihydrate) enoxaparin sodium soln sc F daily,23 ml per 120 mg/0.8ml, 80 mg/0.8ml terbutaline sulfate tabs or F 14 days retail) 2.5 mg, 5 mg QL(0.6 ml VENTOLIN HFA AERS enoxaparin sodium soln sc F daily,9 ml per F 30 mg/0.3ml (albuterol sulfate) 14 days retail) XOPENEX QL(0.8 ml CONCENTRATE NEBU NF enoxaparin sodium soln sc F daily,12 ml per 40 mg/0.4ml (levalbuterol hcl) 14 days retail)
Oregon Trillium OHP Updated September 1, 2021
12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1.2 ml Generic enoxaparin sodium soln sc F daily,17 ml per Required;QL(1 60 mg/0.6ml diazepam (anticonvulsant) F 14 days retail) gel 10 mg ea per 31 days FRAGMIN SOLN 10000 Max 5 fills per retail) UNIT/ML, 12500 30 days;SP diazepam (anticonvulsant) F QL(1 ea per 31 UNIT/0.5ML, 15000 gel 2.5 mg, 20 mg days retail) UNIT/0.6ML, 18000 F KLONOPIN TABS NF UNT/0.72ML, 2500 (clonazepam) UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 PA; QL(10 ea UNIT/0.3ML NAYZILAM SOLN F per 30 days retail) HEPARIN LOCK FLUSH SOLN (heparin sodium NF ONFI TABS 10 MG NF PA; QL(4 ea (porcine) lock flush) (clobazam) daily) LOVENOX SOLN IJ 300 QL(6 ml ONFI TABS 20 MG NF PA; QL(2 ea MG/3ML (enoxaparin NF daily,84 ml per (clobazam) daily) sodium) 14 days retail) PA; QL(10 ea LOVENOX SOLN SC 100 QL(2 ml VALTOCO LIQD F per 30 days MG/ML, 150 MG/ML NF daily,28 ml per retail) (enoxaparin sodium) 14 days retail) PA; QL(10 ea LOVENOX SOLN SC 120 QL(1.6 ml VALTOCO LQPK F per 30 days MG/0.8ML, 80 MG/0.8ML NF daily,23 ml per retail) (enoxaparin sodium) 14 days retail) Anticonvulsants - Misc. LOVENOX SOLN SC 30 QL(0.6 ml BANZEL TABS 200 MG NF PA; QL(6 ea MG/0.3ML (enoxaparin NF daily,9 ml per (rufinamide) daily); SP sodium) 14 days retail) BANZEL TABS 400 MG F PA; QL(8 ea LOVENOX SOLN SC 40 QL(0.8 ml (rufinamide) daily); SP MG/0.4ML (enoxaparin NF daily,12 ml per carbamazepine chew or F sodium) 14 days retail) 100 mg LOVENOX SOLN SC 60 QL(1.2 ml carbamazepine cp12 or F MG/0.6ML (enoxaparin NF daily,17 ml per 100 mg, 200 mg, 300 mg sodium) 14 days retail) CARBAMAZEPINE POWD F ANTICONVULSANTS - Drugs to Treat Seizures XX carbamazepine susp or F Anticonvulsants - Benzodiazepines 100 mg/5ml PA; QL(4 ea clobazam tabs 10 mg F carbamazepine tabs or 200 F daily) mg PA; QL(2 ea clobazam tabs 20 mg F carbamazepine tb12 or 100 F daily) mg, 200 mg, 400 mg clonazepam tabs 0.5 mg, 1 F CARBATROL CP12 F mg, 2 mg (carbamazepine) DIASTAT ACUDIAL GEL QL(1 ea per 31 gabapentin caps 100 mg, F QL(9 ea daily) (diazepam F days retail) 300 mg, 400 mg (anticonvulsant)) QL(6 ea daily) DIASTAT PEDIATRIC GEL QL(1 ea per 31 gabapentin tabs 600 mg F (diazepam F days retail) QL(4 ea daily) (anticonvulsant)) gabapentin tabs 800 mg F
Oregon Trillium OHP Updated September 1, 2021
13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KEPPRA SOLN OR 100 F lamotrigine tbdp or 100 mg, CO MG/ML (levetiracetam) 200 mg, 25 mg, 50 mg KEPPRA TABS OR 250 levetiracetam soln or 100 F MG, 1000 MG, 750 MG, F mg/ml, 500 mg/5ml 500 MG (levetiracetam) levetiracetam tabs or 250 F KEPPRA XR TB24 F mg, 1000 mg, 750 mg, 500 (levetiracetam) mg LAMICTAL CHEWABLE levetiracetam tb24 or 500 F DISPERSIBLE CHEW CO mg, 750 mg (lamotrigine) LYRICA CAPS 100 MG, PA; QL(2 ea LAMICTAL ODT KIT CO 225 MG, 300 MG, 50 MG, NF daily) 75 MG (pregabalin) LAMICTAL ODT KIT CO LYRICA CAPS 150 MG, PA; QL(3 ea (lamotrigine) 200 MG, 25 MG NF daily) LAMICTAL ODT TBDP 100 (pregabalin) MG, 200 MG, 25 MG, 50 CO MYSOLINE TABS NF MG (lamotrigine) (primidone) LAMICTAL STARTER/NOT NEURONTIN CAPS 100 QL(9 ea daily) TAKING CO MG, 300 MG, 400 MG F CARBAMAZEPINE KIT (gabapentin) (lamotrigine) NEURONTIN TABS 600 F QL(6 ea daily) LAMICTAL MG (gabapentin) STARTER/TAKING NEURONTIN TABS 800 F QL(4 ea daily) CARBAMAZEPINE/NOT CO MG (gabapentin) TAKING VALPROATE KIT (lamotrigine) oxcarbazepine susp F LAMICTAL oxcarbazepine tabs F STARTER/TAKING CO VALPROATE KIT (lamotrigine) pregabalin caps 100 mg, PA; QL(2 ea 225 mg, 300 mg, 50 mg, 75 F daily) LAMICTAL TABS CO mg (lamotrigine) pregabalin caps 150 mg, F PA; QL(3 ea LAMICTAL XR KIT CO 200 mg, 25 mg daily) LAMICTAL XR TB24 100 primidone tabs F MG, 200 MG, 250 MG, 300 CO MG, 25 MG, 50 MG QUDEXY XR CS24 NF (lamotrigine) (topiramate) PA; QL(6 ea lamotrigine chew or 25 mg, CO rufinamide tabs 200 mg F 5 mg daily); SP PA; QL(8 ea rufinamide tabs 400 mg F lamotrigine kit or 25 mg, CO daily); SP TEGRETOL SUSP lamotrigine tabs or 100 mg, CO F 150 mg, 200 mg, 25 mg (carbamazepine) lamotrigine tb24 or 100 mg, TEGRETOL TABS F 200 mg, 250 mg, 300 mg, CO (carbamazepine) 25 mg, 50 mg TEGRETOL-XR TB12 F (carbamazepine) Oregon Trillium OHP Updated September 1, 2021
14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPAMAX SPRINKLE F ethosuximide caps F CPSP (topiramate) TOPAMAX TABS F ethosuximide soln F (topiramate) ZARONTIN CAPS topiramate cpsp 15 mg, 25 F NF mg (ethosuximide) ZARONTIN SOLN topiramate tabs 100 mg, F NF 200 mg, 25 mg, 50 mg (ethosuximide) Valproic Acid TRILEPTAL SUSP F (oxcarbazepine) DEPACON SOLN CO (valproate sodium) TRILEPTAL TABS F (oxcarbazepine) DEPAKENE CAPS CO (valproic acid) VIMPAT TABS OR 100 F PA; QL(4 ea MG, 50 MG daily) DEPAKOTE ER TB24 CO (divalproex sodium) VIMPAT TABS OR 150 F PA; QL(2 ea MG, 200 MG daily) DEPAKOTE SPRINKLES CO CSDR (divalproex sodium) ZONEGRAN CAPS NF (zonisamide) DEPAKOTE TBEC CO (divalproex sodium) zonisamide caps F divalproex sodium csdr or CO GABA Modulators 125 mg divalproex sodium tb24 or GABITRIL TABS (tiagabine NF CO hcl) 250 mg, 500 mg divalproex sodium tbec or CO tiagabine hcl tabs F 125 mg, 250 mg, 500 mg Hydantoins valproate sodium soln iv CO 100 mg/ml, 500 mg/5ml DILANTIN CAPS 100 MG (phenytoin sodium F valproate sodium soln or CO extended) 250 mg/5ml DILANTIN CAPS 30 MG F valproic acid caps or CO
DILANTIN INFATABS NF ANTIDEPRESSANTS - Drugs to Treat CHEW (phenytoin) Depression DILANTIN-125 SUSP NF Alpha-2 Receptor Antagonists (Tetracyclics) (phenytoin) PHENYTEK CAPS mirtazapine tabs CO (phenytoin sodium F extended) mirtazapine tbdp CO phenytoin chew F REMERON SOLTAB TBDP CO (mirtazapine) phenytoin sodium extended F REMERON TABS CO caps (mirtazapine) phenytoin susp F Antidepressants - Misc. Succinimides APLENZIN TB24 CO
Oregon Trillium OHP Updated September 1, 2021
15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits bupropion hcl tabs CO fluoxetine hcl caps CO bupropion hcl tb12 CO fluoxetine hcl cpdr CO bupropion hcl tb24 CO fluoxetine hcl soln CO
FORFIVO XL TB24 CO fluoxetine hcl tabs CO (bupropion hcl) FLUOXETINE maprotiline hcl tabs CO HYDROCHLORIDE TABS CO (fluoxetine hcl) WELLBUTRIN SR TB12 CO (bupropion hcl) fluvoxamine maleate cp24 CO WELLBUTRIN XL TB24 CO (bupropion hcl) fluvoxamine maleate tabs CO GABA Receptor Modulator - Neuroactive Steroid LEXAPRO TABS CO ZULRESSO SOLN CO SP (escitalopram oxalate) paroxetine hcl tabs CO Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 CO paroxetine hcl tb24 CO
PAXIL CR TB24 CO MARPLAN TABS CO (paroxetine hcl) NARDIL TABS (phenelzine CO PAXIL SUSP 10 MG/5ML CO sulfate) PAXIL TABS 10 MG, 20 PARNATE TABS CO (tranylcypromine sulfate) MG, 30 MG, 40 MG CO (paroxetine hcl) phenelzine sulfate tabs CO PEXEVA TABS CO tranylcypromine sulfate CO tabs PROZAC CAPS (fluoxetine CO hcl) N-Methyl-D-aspartic acid (NMDA) Receptor sertraline hcl conc CO SPRAVATO 56MG DOSE CO SOPK sertraline hcl tabs CO SPRAVATO 84MG DOSE CO SOPK ZOLOFT CONC (sertraline CO Selective Serotonin Reuptake Inhibitors (SSRIs) hcl) ZOLOFT TABS (sertraline CELEXA TABS (citalopram CO CO hydrobromide) hcl) citalopram hydrobromide CO Serotonin Modulators soln nefazodone hcl tabs CO citalopram hydrobromide CO tabs trazodone hcl tabs CO escitalopram oxalate soln CO TRINTELLIX TABS CO escitalopram oxalate tabs CO
Oregon Trillium OHP Updated September 1, 2021
16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIIBRYD STARTER PACK CO doxepin hcl conc CO KIT VIIBRYD TABS CO imipramine hcl tabs CO Serotonin-Norepinephrine Reuptake Inhibitors imipramine pamoate caps CO CYMBALTA CPEP CO NORPRAMIN TABS CO (duloxetine hcl) (desipramine hcl) DESVENLAFAXINE ER CO TB24 nortriptyline hcl caps CO desvenlafaxine succinate CO tb24 nortriptyline hcl soln CO desvenlafaxine tb24 CO PAMELOR CAPS CO (nortriptyline hcl) DRIZALMA SPRINKLE CO CSDR protriptyline hcl tabs CO duloxetine hcl cpep or 20 CO TOFRANIL TABS CO mg, 40 mg, 60 mg, 30 mg (imipramine hcl) EFFEXOR XR CP24 CO trimipramine maleate caps CO (venlafaxine hcl) FETZIMA CP24 CO ANTIDIABETICS - Drugs to Regulate Blood Sugar FETZIMA TITRATION CO PACK C4PK Alpha-Glucosidase Inhibitors acarbose tabs F KHEDEZLA TB24 CO (desvenlafaxine) PRECOSE TABS NF PRISTIQ TB24 CO (acarbose) (desvenlafaxine succinate) Antidiabetic Combinations venlafaxine hcl cp24 CO ACTOPLUS MET TABS (pioglitazone hcl-metformin NF venlafaxine hcl tabs CO hcl) venlafaxine hcl tb24 CO alogliptin-metformin hcl F Generic tabs Required Generic Tricyclic Agents alogliptin-pioglitazone tabs F Required amitriptyline hcl tabs CO DUETACT TABS (pioglitazone hcl- NF amoxapine tabs CO glimepiride) PA; QL(2 ea ANAFRANIL CAPS CO JANUMET TABS F (clomipramine hcl) daily) clomipramine hcl caps CO pioglitazone hcl-glimepiride F tabs desipramine hcl tabs CO pioglitazone hcl-metformin F hcl tabs PA; QL(2 ea doxepin hcl caps CO SEGLUROMET TABS F daily)
Oregon Trillium OHP Updated September 1, 2021
17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Biguanides Incretin Mimetic Agents (GLP-1 Receptor metformin hcl tabs 1000 PA; QL(0.13 ml F BYDUREON BCISE AUIJ F mg, 500 mg, 850 mg daily) metformin hcl tb24 500 mg, F BYDUREON PEN PEN F PA; QL(0.15 ea 750 mg daily) Diabetic Other BYETTA SOPN 10 F PA; QL(0.08 ml MCG/0.04ML daily) BAQSIMI ONE PACK F QL(0.069 ea POWD daily) BYETTA SOPN 5 F PA; QL(0.04 ml MCG/0.02ML daily) BAQSIMI TWO PACK QL(0.069 ea F PA; QL(0.072 POWD daily) TRULICITY SOPN F ml daily) BD GLUCOSE CHEW F VICTOZA SOPN F PA; QL(0.3 ml daily) CVS GLUCOSE CHEW 4 F GM Insulin Sensitizing Agents CVS SOFT GLUCOSE F ACTOS TABS (pioglitazone NF CHEW hcl) DEX4 QUICK DISSOLVE F GLUCOSE CHEW pioglitazone hcl tabs F dextrose (diabetic use) gel F Insulin 15 gm/38gm, 40 % ADMELOG SOLN F GLUCAGEN HYPOKIT F SOLR ADMELOG SOLOSTAR F glucagon (rdna) kit F SOPN BASAGLAR KWIKPEN F GLUCAGON SOPN EMERGENCY KIT KIT NF (glucagon (rdna)) HUMALOG MIX 50/50 F KWIKPEN SUPN GLUCOSE CHEW 4 GM F HUMALOG MIX 50/50 F SUSP GNP GLUCOSE CHEW 4 F GM HUMALOG MIX 75/25 F KWIKPEN SUPN GNP QUICK DISSOLVE F GLUCOSE CHEW HUMALOG MIX 75/25 F SUSP QL(0.02 ml GVOKE PFS SOSY F daily) HUMULIN 70/30 KWIKPEN F SUPN LEADER QUICK DISSOLVE GLUCOSE F HUMULIN 70/30 SUSP F CHEW HUMULIN N KWIKPEN F SM GLUCOSE CHEW 4 F SUPN GM HUMULIN N SUSP F WALGREENS GLUCOSE F CHEW 4 GM HUMULIN R SOLN F Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Generic HUMULIN R U-500 alogliptin benzoate tabs F F Required (CONCENTRATED) SOLN
Oregon Trillium OHP Updated September 1, 2021
18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HUMULIN R U-500 QL(18 ml per PA; QL(1 ea F STEGLATRO TABS 15 MG F KWIKPEN SOPN 30 days retail) daily) INSULIN ASPART STEGLATRO TABS 5 MG F PA; QL(2 ea PROTAMINE/INSULIN F daily) ASPART FLEXPEN SUPN Sulfonylureas INSULIN ASPART PROTAMINE/INSULIN F AMARYL TABS NF (glimepiride) ASPART SUSP INSULIN LISPRO glimepiride tabs F PROTAMINE/INSULIN F LISPRO KWIKPEN SUPN glipizide tabs F NOVOLIN 70/30 FLEXPEN F RELION SUPN glipizide tb24 F NOVOLIN 70/30 FLEXPEN F GLUCOTROL TABS NF SUPN (glipizide) NOVOLIN 70/30 RELION F GLUCOTROL XL TB24 NF SUSP (glipizide) NOVOLIN 70/30 SUSP F glyburide micronized tabs F NOVOLIN N FLEXPEN F glyburide tabs 1.25 mg, 2.5 F RELION SUPN mg, 5 mg NOVOLIN N FLEXPEN F GLYNASE TABS (glyburide NF SUPN micronized) NOVOLIN N RELION F SUSP tolbutamide tabs F NOVOLIN N SUSP F ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea NOVOLIN R RELION F SOLN Antidiarrheal/Probiotic Agents - Misc. bismuth subsalicylate chew F NOVOLIN R SOLN F 262 mg NOVOLOG MIX 70/30 bismuth subsalicylate susp PREFILLED FLEXPEN F 1050 mg/30ml, 525 F RELION SUPN mg/15ml, 262 mg/15ml, NOVOLOG MIX 70/30 525 mg/30ml, 527 mg/30ml PREFILLED FLEXPEN F bismuth subsalicylate tabs F SUPN 262 mg PEPTO BISMOL TABS NOVOLOG MIX 70/30 F NF RELION SUSP (bismuth subsalicylate) PEPTO-BISMOL CHEW NOVOLOG MIX 70/30 F NF SUSP (bismuth subsalicylate) QL(1 ml daily) PEPTO-BISMOL MAX SEMGLEE SOLN F STRENGTH SUSP NF (bismuth subsalicylate) SEMGLEE SOPN F QL(1 ml daily) PEPTO-BISMOL SUSP NF Sodium-Glucose Co-Transporter 2 (SGLT2) (bismuth subsalicylate)
Oregon Trillium OHP Updated September 1, 2021
19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEPTO-BISMOL TO-GO meclizine hcl tabs F RX/OTC CHEW (bismuth NF subsalicylate) Antiemetics - Miscellaneous Antiperistaltic Agents dronabinol caps F PA diphenoxylate w/ atropine liqd 0.025 mg/5ml-2.5 F MARINOL CAPS NF PA mg/5ml (dronabinol) diphenoxylate w/ atropine QL(8 ea daily) Substance P/Neurokinin 1 (NK1) Receptor tabs 0.025 mg-2.5 mg, 2.5 F EMEND SOLR IV 150 MG mg-0.025 mg (fosaprepitant NF IMODIUM A-D CAPS 2 MG NF QL(8 ea daily); dimeglumine) (loperamide hcl) RX/OTC ANTIFUNGALS - Drugs to Treat Fungal Infections IMODIUM A-D TABS 2 MG NF QL(8 ea daily) (loperamide hcl) Antifungals LOMOTIL TABS NF QL(8 ea daily) (diphenoxylate w/ atropine) nystatin tabs F QL(8 ea daily); loperamide hcl caps 2 mg F RX/OTC terbinafine hcl tabs F loperamide hcl tabs 2 mg F QL(8 ea daily) Imidazole-Related Antifungals DIFLUCAN SUSR 10 QL(100 ml per ANTIDOTES AND SPECIFIC ANTAGONISTS MG/ML, 40 MG/ML NF 365 days retail) (fluconazole) Opioid Antagonists DIFLUCAN TABS 100 MG, QL(14 ea per naltrexone hcl tabs F 200 MG, 50 MG, 150 MG NF 31 days retail) (fluconazole) NARCAN LIQD F fluconazole susr 10 mg/ml, F QL(100 ml per 40 mg/ml 365 days retail) QL(1 ea per 28 VIVITROL SUSR F days retail); SP fluconazole tabs 100 mg, F QL(14 ea per 200 mg, 50 mg, 150 mg 31 days retail) ANTIEMETICS - Drugs to Treat Nausea and PA Vomiting itraconazole caps 100 mg F 5-HT3 Receptor Antagonists ketoconazole tabs F ondansetron hcl soln or 4 F QL(60 ml per mg/5ml 365 days retail) SPORANOX CAPS 100 NF PA MG (itraconazole) ondansetron hcl tabs or 24 F QL(1 ea daily) mg SPORANOX PULSEPAK NF PA CAPS (itraconazole) ondansetron hcl tabs or 4 F QL(4 ea daily) mg, 8 mg VFEND TABS 200 MG, 50 NF PA MG (voriconazole) ondansetron tbdp F QL(4 ea daily) voriconazole tabs or 200 F PA mg, 50 mg ZOFRAN TABS NF QL(4 ea daily) (ondansetron hcl) ANTIHISTAMINES - Drugs to Treat Allergies Antiemetics - Anticholinergic Antihistamines - Alkylamines meclizine hcl chew F RX/OTC
Oregon Trillium OHP Updated September 1, 2021
20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHLOR-TRIMETON TABS CLARITIN CHEW 5 MG NF 4 MG (chlorpheniramine NF (loratadine) maleate) CLARITIN CHILDRENS NF chlorpheniramine maleate F CHEW (loratadine) tabs 4 mg CLARITIN REDITABS NF Antihistamines - Ethanolamines TBDP 10 MG (loratadine) CLARITIN SYRP 5 NF ALER-DRYL TABS F MG/5ML (loratadine) BENADRYL ALLERGY CLARITIN TABS 10 MG NF CAPS (diphenhydramine NF (loratadine) hcl) fexofenadine hcl tabs 60 F QL(1 ea daily) BENADRYL ALLERGY mg, 180 mg CHILDRENS CHEW NF (diphenhydramine hcl) loratadine chew 5 mg F BENADRYL ALLERGY loratadine soln 5 mg/5ml F CHILDRENS LIQD NF (diphenhydramine hcl) loratadine syrp 5 mg/5ml F BENADRYL ALLERGY TABS (diphenhydramine NF loratadine tabs 10 mg F hcl) BENADRYL ALLERGY loratadine tbdp 10 mg F ULTRATABS TABS NF (diphenhydramine hcl) ZYRTEC ALLERGY TABS NF (cetirizine hcl) diphenhydramine hcl caps F or 50 mg, 25 mg ZYRTEC CHILDRENS RX/OTC ALLERGY SOLN (cetirizine NF diphenhydramine hcl chew F or 12.5 mg hcl) Antihistamines - Phenothiazines diphenhydramine hcl elix or F 12.5 mg/5ml promethazine hcl soln or F diphenhydramine hcl liqd or 6.25 mg/5ml 12.5 mg/5ml, 25 mg/10ml, F promethazine hcl supp re F 50 mg/20ml 50 mg, 12.5 mg, 25 mg diphenhydramine hcl tabs F promethazine hcl syrp or F or 25 mg 6.25 mg/5ml Antihistamines - Non-Sedating promethazine hcl tabs or F 25 mg, 12.5 mg, 50 mg ALLEGRA ALLERGY NF QL(1 ea daily) TABS (fexofenadine hcl) Antihistamines - Piperidines cetirizine hcl soln 1 mg/ml, F RX/OTC cyproheptadine hcl syrp F 5 mg/5ml cetirizine hcl syrp 1 mg/ml, F RX/OTC cyproheptadine hcl tabs F 5 mg/5ml ANTIHYPERLIPIDEMICS - Drugs to Treat High cetirizine hcl tabs 5 mg, 10 F mg Cholesterol CLARITIN ALLERGY Antihyperlipidemics - Combinations CHILDRENS SYRP NF (loratadine) ezetimibe-simvastatin tabs F
Oregon Trillium OHP Updated September 1, 2021
21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VYTORIN TABS NF TRICOR TABS NF (ezetimibe-simvastatin) (fenofibrate) Bile Acid Sequestrants TRIGLIDE TABS NF (fenofibrate) cholestyramine light pack F HMG CoA Reductase Inhibitors cholestyramine light powd F atorvastatin calcium tabs F QL(1 ea daily) 10 mg, 20 mg cholestyramine pack F atorvastatin calcium tabs F 40 mg, 80 mg cholestyramine powd F ST; 3 months CRESTOR TABS NF atorvastatin COLESTID FLAVORED NF (rosuvastatin calcium) 80mg first;QL(1 GRAN (colestipol hcl) ea daily) COLESTID FLAVORED NF LIPITOR TABS 10 MG, 20 NF QL(1 ea daily) PACK (colestipol hcl) MG (atorvastatin calcium) COLESTID GRAN NF LIPITOR TABS 40 MG, 80 NF (colestipol hcl) MG (atorvastatin calcium) COLESTID PACK NF (colestipol hcl) lovastatin tabs F COLESTID TABS NF PRAVACHOL TABS NF (colestipol hcl) (pravastatin sodium) colestipol hcl gran F pravastatin sodium tabs F colestipol hcl pack F ST; 3 months atorvastatin rosuvastatin calcium tabs F colestipol hcl tabs F 80mg first;QL(1 ea daily) QUESTRAN LIGHT POWD NF simvastatin tabs 5 mg, 80 F (cholestyramine light) mg, 10 mg, 20 mg, 40 mg QUESTRAN PACK NF ZOCOR TABS NF (cholestyramine) (simvastatin) QUESTRAN POWD NF (cholestyramine) Intestinal Cholesterol Absorption Inhibitors Fibric Acid Derivatives ezetimibe tabs F fenofibrate micronized caps F ZETIA TABS (ezetimibe) NF fenofibrate tabs 145 mg, 48 F Nicotinic Acid Derivatives mg, 54 mg, 160 mg niacin (antihyperlipidemic) F FIBRICOR TABS NF tabs (fenofibric acid) niacin (antihyperlipidemic) F gemfibrozil tabs F tbcr NIASPAN TBCR (niacin LIPOFEN CAPS NF NF (fenofibrate) (antihyperlipidemic)) ANTIHYPERTENSIVES - Drugs to Treat High LOPID TABS (gemfibrozil) NF Blood Pressure
Oregon Trillium OHP Updated September 1, 2021
22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACE Inhibitors CARDURA TABS NF (doxazosin mesylate) ACCUPRIL TABS NF (quinapril hcl) CATAPRES TABS NF (clonidine hcl) ALTACE CAPS (ramipril) NF CLONIDINE HCL POWD F XX benazepril hcl tabs F clonidine hcl tabs or 0.1 F mg, 0.2 mg, 0.3 mg captopril tabs F CLONIDINE F enalapril maleate tabs 10 F HYDROCHLORIDE POWD mg, 2.5 mg, 20 mg, 5 mg doxazosin mesylate tabs or F fosinopril sodium tabs F 1 mg, 2 mg, 4 mg, 8 mg guanfacine hcl tabs F lisinopril tabs F methyldopa tabs F LOTENSIN TABS NF (benazepril hcl) MINIPRESS CAPS NF moexipril hcl tabs F (prazosin hcl) prazosin hcl caps F perindopril erbumine tabs F terazosin hcl caps F PRINIVIL TABS (lisinopril) NF Antihypertensive Combinations quinapril hcl tabs F ACCURETIC TABS (quinapril- NF ramipril caps F hydrochlorothiazide) atenolol & chlorthalidone F trandolapril tabs F tabs VASOTEC TABS (enalapril NF AVALIDE TABS maleate) (irbesartan- NF hydrochlorothiazide) ZESTRIL TABS (lisinopril) NF benazepril & F Angiotensin II Receptor Antagonists hydrochlorothiazide tabs BENAZEPRIL AVAPRO TABS NF (irbesartan) HCL/HYDROCHLOROTHI F AZIDE TABS COZAAR TABS (losartan NF potassium) bisoprolol & F hydrochlorothiazide tabs DIOVAN TABS (valsartan) NF QL(1 ea daily) captopril & F hydrochlorothiazide tabs irbesartan tabs F DIOVAN HCT TABS QL(1 ea daily) (valsartan- NF losartan potassium tabs or F 100 mg, 25 mg, 50 mg hydrochlorothiazide) QL(1 ea daily) enalapril maleate & F valsartan tabs F hydrochlorothiazide tabs Antiadrenergic Antihypertensives
Oregon Trillium OHP Updated September 1, 2021
23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYZAAR TABS (losartan mefloquine hcl tabs F potassium & NF hydrochlorothiazide) PLAQUENIL TABS (hydroxychloroquine F irbesartan- F hydrochlorothiazide tabs sulfate) lisinopril & F primaquine phosphate tabs F hydrochlorothiazide tabs PRIMAQUINE losartan potassium & F hydrochlorothiazide tabs PHOSPHATE TABS NF (primaquine phosphate) LOTENSIN HCT TABS (benazepril & NF pyrimethamine tabs F SP hydrochlorothiazide) ANTIMYASTHENIC/CHOLINERGIC AGENTS quinapril- F hydrochlorothiazide tabs Antimyasthenic/Cholinergic Agents TENORETIC 100 TABS NF (atenolol & chlorthalidone) MESTINON SOLN NF (pyridostigmine bromide) TENORETIC 50 TABS NF (atenolol & chlorthalidone) MESTINON TABS NF (pyridostigmine bromide) valsartan- F QL(1 ea daily) hydrochlorothiazide tabs pyridostigmine bromide F soln 60 mg/5ml VASERETIC TABS (enalapril maleate & NF pyridostigmine bromide F hydrochlorothiazide) tabs 60 mg PA; QL(10 ea ZESTORETIC TABS RUZURGI TABS F (lisinopril & NF daily); SP hydrochlorothiazide) ANTIMYCOBACTERIAL AGENTS - Drugs to ZIAC TABS (bisoprolol & NF Treat Tuberculosis (Bacterial Infections) hydrochlorothiazide) Antimycobacterial Agents Direct Renin Inhibitors ethambutol hcl tabs F TEKTURNA TABS NF (aliskiren fumarate) isoniazid syrp or 50 mg/5ml F Vasodilators isoniazid tabs or 100 mg, F hydralazine hcl tabs or 100 F 300 mg mg, 25 mg, 50 mg, 10 mg MYAMBUTOL TABS NF ANTIMALARIALS - Drugs to Treat Malaria (ethambutol hcl) (Parasitic Infections) QL(72 ea per PRIFTIN TABS F Antimalarials 365 days retail) chloroquine phosphate F pyrazinamide tabs F tabs SP RIFADIN CAPS OR 150 NF DARAPRIM TABS F MG, 300 MG (rifampin) rifampin caps or 150 mg, hydroxychloroquine sulfate F F tabs 300 mg QL(2 ea per 30 KRINTAFEL TABS F ANTINEOPLASTICS AND ADJUNCTIVE days retail) THERAPIES - Drugs to Treat Cancer
Oregon Trillium OHP Updated September 1, 2021
24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Alkylating Agents hydroxyurea caps F TEPADINA SOLR NF SP (thiotepa) Chemotherapy Rescue/Antidote/Protective Agents Antimetabolites leucovorin calcium tabs or F 25 mg, 5 mg, 10 mg SP cytarabine soln F Mitotic Inhibitors GEMCITABINE DOCETAXEL CONC 20 SP HYDROCHLORIDE SOLN MG/ML, 80 MG/4ML NF 1 GM/10ML, 2 GM/20ML, NF (docetaxel) 200 MG/2ML (gemcitabine TAXOTERE CONC NF SP hcl) (docetaxel) mercaptopurine tabs F ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinson's Disease methotrexate sodium soln ij F 250 mg/10ml, 50 mg/2ml Antiparkinson Anticholinergics benztropine mesylate tabs methotrexate sodium tabs F F or 2.5 mg or 0.5 mg, 1 mg, 2 mg TABLOID TABS F SP trihexyphenidyl hcl soln F
TREXALL TABS F trihexyphenidyl hcl tabs F Antineoplastic - Hormonal and Related Agents Antiparkinson COMT Inhibitors anastrozole tabs F COMTAN TABS NF (entacapone) ARIMIDEX TABS NF (anastrozole) entacapone tabs F FASLODEX SOLN NF Antiparkinson Dopaminergics (fulvestrant) amantadine hcl caps F FEMARA TABS (letrozole) NF amantadine hcl syrp F letrozole tabs F amantadine hcl tabs F megestrol acetate susp F bromocriptine mesylate F megestrol acetate tabs F caps bromocriptine mesylate F tamoxifen citrate tabs F tabs carbidopa-levodopa tabs Antineoplastic Antibiotics 10 mg-100 mg, 25 mg-100 F DAUNORUBICIN SP mg, 25 mg-250 mg HYDROCHLORIDE SOLN NF carbidopa-levodopa tbcr 50 20 MG/4ML (daunorubicin mg-200 mg, 100 mg-25 F hcl) mg, 25 mg-100 mg Antineoplastics Misc. carbidopa-levodopa- F entacapone tabs HYDREA CAPS NF (hydroxyurea)
Oregon Trillium OHP Updated September 1, 2021
25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MIRAPEX TABS lithium carbonate tabs CO (pramipexole NF dihydrochloride) lithium carbonate tbcr CO PARLODEL CAPS NF (bromocriptine mesylate) LITHIUM SOLN CO PARLODEL TABS NF (bromocriptine mesylate) LITHOBID TBCR (lithium CO carbonate) pramipexole Antipsychotics - Misc. dihydrochloride tabs 0.125 F mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg CAPLYTA CAPS CO ropinirole hydrochloride EQUETRO CP12 CO tabs 0.25 mg, 3 mg, 0.5 F mg, 1 mg, 2 mg, 4 mg, 5 GEODON CAPS CO mg (ziprasidone hcl) SINEMET CR TBCR NF GEODON SOLR CO (carbidopa-levodopa) (ziprasidone mesylate) SINEMET TABS NF (carbidopa-levodopa) LATUDA TABS CO STALEVO 100 TABS NUPLAZID CAPS CO (carbidopa-levodopa- NF entacapone) NUPLAZID TABS CO STALEVO 125 TABS (carbidopa-levodopa- NF VRAYLAR CAPS CO entacapone) STALEVO 150 TABS VRAYLAR CPPK CO (carbidopa-levodopa- NF entacapone) ziprasidone hcl caps CO STALEVO 200 TABS (carbidopa-levodopa- NF ziprasidone mesylate solr CO entacapone) STALEVO 50 TABS Benzisoxazoles (carbidopa-levodopa- NF FANAPT TABS CO entacapone) STALEVO 75 TABS FANAPT TITRATION CO (carbidopa-levodopa- NF PACK TABS entacapone) INVEGA SUSTENNA CO SUSY Antiparkinson Monoamine Oxidase Inhibitors INVEGA TB24 CO selegiline hcl caps F (paliperidone) selegiline hcl tabs F INVEGA TRINZA SUSY CO ANTIPSYCHOTICS/ANTIMANIC AGENTS - paliperidone tb24 CO Drugs to Treat Mood Disorders PERSERIS PRSY CO SP Antimanic Agents RISPERDAL CONSTA CO lithium carbonate caps CO SRER Oregon Trillium OHP Updated September 1, 2021
26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RISPERDAL SOLN CO quetiapine fumarate tabs CO (risperidone) RISPERDAL TABS CO quetiapine fumarate tb24 CO (risperidone) SAPHRIS SUBL 10 MG, risperidone soln CO 2.5 MG, 5 MG (asenapine CO maleate) risperidone tabs CO SAPHRIS SUBL 5 MG CO risperidone tbdp CO SECUADO PT24 CO Butyrophenones SEROQUEL TABS CO HALDOL DECANOATE (quetiapine fumarate) 100 SOLN (haloperidol CO decanoate) SEROQUEL XR TB24 CO (quetiapine fumarate) HALDOL DECANOATE 50 SOLN (haloperidol CO VERSACLOZ SUSP CO decanoate) ZYPREXA RELPREVV CO HALDOL SOLN CO SUSR (haloperidol lactate) ZYPREXA SOLR CO haloperidol decanoate soln CO (olanzapine) ZYPREXA TABS CO haloperidol lactate conc CO (olanzapine) ZYPREXA ZYDIS TBDP CO haloperidol lactate soln CO (olanzapine) haloperidol tabs CO Dihydroindolones Dibenzapines molindone hcl tabs CO ADASUVE AEPB CO Phenothiazines chlorpromazine hcl soln CO asenapine maleate subl CO chlorpromazine hcl tabs CO clozapine tabs CO CHLORPROMAZINE clozapine tbdp CO HYDROCHLORIDE CONC CO 100 MG/ML CLOZARIL TABS CO (clozapine) fluphenazine decanoate CO soln FAZACLO TBDP CO (clozapine) fluphenazine hcl conc CO loxapine succinate caps CO fluphenazine hcl elix CO olanzapine solr CO fluphenazine hcl soln CO olanzapine tabs CO fluphenazine hcl tabs CO olanzapine tbdp CO
Oregon Trillium OHP Updated September 1, 2021
27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits perphenazine tabs CO ANTIVIRALS - Drugs to Treat Viral Infections prochlorperazine maleate F Antiretrovirals tabs abacavir sulfate soln F prochlorperazine supp F abacavir sulfate tabs F thioridazine hcl tabs CO abacavir sulfate-lamivudine F QL(1 ea daily) trifluoperazine hcl tabs CO tabs abacavir sulfate- F Quinolinone Derivatives lamivudine-zidovudine tabs ABILIFY MAINTENA PRSY CO APTIVUS CAPS F
ABILIFY MAINTENA SRER CO APTIVUS SOLN F
ABILIFY MYCITE TABS CO atazanavir sulfate caps 300 F mg ABILIFY TABS CO ATRIPLA TABS (efavirenz- (aripiprazole) emtricitabine-tenofovir NF aripiprazole soln CO disoproxil fumarate) BIKTARVY TABS F aripiprazole tabs CO CIMDUO TABS F aripiprazole tbdp CO COMBIVIR TABS NF ARISTADA INITIO PRSY CO (lamivudine-zidovudine) COMPLERA TABS F ST ARISTADA PRSY CO CRIXIVAN CAPS F REXULTI TABS CO DELSTRIGO TABS F ST; QL(1 ea Thioxanthenes daily) thiothixene caps CO DESCOVY TABS F
ANTISEPTICS & DISINFECTANTS didanosine cpdr F
Iodine Antiseptics DOVATO TABS F BETADINE SOLN 10 % NF (povidone-iodine) EDURANT TABS F BETADINE SURGICAL F SCRUB SOLN efavirenz caps F FIRST AID ANTISEPTIC F OINTMENT OINT efavirenz tabs F povidone-iodine oint 10 % F efavirenz-emtricitabine- tenofovir disoproxil F povidone-iodine soln 7.5 F fumarate tabs %, 10 %
Oregon Trillium OHP Updated September 1, 2021
28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits efavirenz-lamivudine- LEXIVA SUSP 50 MG/ML F tenofovir disoproxil F fumarate tabs LEXIVA TABS 700 MG NF (fosamprenavir calcium) emtricitabine caps F lopinavir-ritonavir tabs 100 F emtricitabine-tenofovir mg-25 mg, 50 mg-200 mg disoproxil fumarate tabs F 200 mg-300 mg, 300 mg- nevirapine susp F 200 mg nevirapine tabs F EMTRIVA CAPS 200 MG NF (emtricitabine) nevirapine tb24 F EMTRIVA SOLN 10 F MG/ML NORVIR SOLN 80 MG/ML NF EPIVIR SOLN (lamivudine) NF NORVIR TABS 100 MG NF (ritonavir) EPIVIR TABS (lamivudine) NF ODEFSEY TABS F ST EPZICOM TABS (abacavir NF QL(1 ea daily) sulfate-lamivudine) PIFELTRO TABS F etravirine tabs F PREZCOBIX TABS F EVOTAZ TABS F PREZISTA TABS 150 MG, F 600 MG, 75 MG, 800 MG fosamprenavir calcium tabs F RESCRIPTOR TABS F GENVOYA TABS F RETROVIR CAPS NF (zidovudine) INTELENCE TABS 100 NF MG, 200 MG (etravirine) RETROVIR SYRP NF (zidovudine) INTELENCE TABS 25 MG F REYATAZ CAPS 300 MG NF INVIRASE TABS F (atazanavir sulfate) ritonavir tabs F ISENTRESS HD TABS F QL(2 ea daily) RUKOBIA TB12 F PA ISENTRESS TABS 400 F MG SELZENTRY TABS 150 F JULUCA TABS F MG, 300 MG STAVUDINE CAPS 15 MG, F KALETRA TABS 100 MG- 20 MG, 30 MG, 40 MG 25 MG, 200 MG-50 MG, 50 NF MG-200 MG (lopinavir- stavudine caps 15 mg, 20 F ritonavir) mg, 30 mg, 40 mg lamivudine soln F STRIBILD TABS F lamivudine tabs F SUSTIVA CAPS (efavirenz) NF lamivudine-zidovudine tabs F SUSTIVA TABS (efavirenz) NF
Oregon Trillium OHP Updated September 1, 2021
29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SYMFI LO TABS zidovudine caps F (efavirenz-lamivudine- NF tenofovir disoproxil zidovudine syrp F fumarate) SYMFI TABS (efavirenz- zidovudine tabs F lamivudine-tenofovir NF disoproxil fumarate) CMV Agents ST; QL(1 ea SYMTUZA TABS F VALCYTE TABS 450 MG NF 200 per daily) (valganciclovir hcl) lifetime; TEMIXYS TABS F valganciclovir hcl tabs 450 F 200 per mg lifetime; tenofovir disoproxil F fumarate tabs Hepatitis Agents EPIVIR HBV SOLN 5 F TIVICAY TABS 50 MG F MG/ML EPIVIR HBV TABS 100 NF TRIUMEQ TABS F MG (lamivudine (hbv)) TRIZIVIR TABS (abacavir lamivudine (hbv) tabs F sulfate-lamivudine- NF zidovudine) MAVYRET TABS F PA; SP TRUVADA TABS 200 MG- PEGASYS PROCLICK PA; SP 300 MG (emtricitabine- NF F tenofovir disoproxil SOLN fumarate) PEGASYS SOLN F PA; SP TYBOST TABS F PEGINTRON KIT F PA; SP VIDEX EC CPDR NF SOFOSBUVIR/VELPATAS F PA; SP VIR TABS VIDEXPEDIATRIC SOLR F Herpes Agents VIRACEPT TABS F acyclovir caps F VIRAMUNE SUSP NF (nevirapine) acyclovir susp F VIRAMUNE TABS NF (nevirapine) acyclovir tabs F VIRAMUNE XR TB24 NF QL(2 ea daily) (nevirapine) famciclovir tabs F VIREAD TABS 150 MG, F valacyclovir hcl tabs F QL(2 ea daily) 200 MG, 250 MG VIREAD TABS 300 MG VALTREX TABS NF QL(2 ea daily) (tenofovir disoproxil NF (valacyclovir hcl) fumarate) ZOVIRAX CAPS OR 200 NF MG (acyclovir) ZIAGEN SOLN (abacavir NF sulfate) ZOVIRAX SUSP OR 200 NF MG/5ML (acyclovir) ZIAGEN TABS (abacavir NF sulfate) ZOVIRAX TABS OR 400 NF MG, 800 MG (acyclovir) Oregon Trillium OHP Updated September 1, 2021
30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Influenza Agents metoprolol succinate tb24 F QL(1 ea daily) FLUMADINE TABS NF (rimantadine hydrochloride) metoprolol tartrate tabs or F 100 mg, 25 mg, 50 mg oseltamivir phosphate caps F QL(20 ea per or 30 mg 180 days retail) TENORMIN TABS NF (atenolol) oseltamivir phosphate caps F QL(10 ea per or 45 mg 180 days retail) TOPROL XL TB24 NF QL(1 ea daily) (metoprolol succinate) oseltamivir phosphate caps F QL(14 ea per or 75 mg 180 days retail) Beta Blockers Non-Selective 300mls/ 180 BETAPACE TABS (sotalol NF hcl) oseltamivir phosphate susr F days;QL(180 or 6 mg/ml ml per 180 CORGARD TABS (nadolol) NF days retail) 10 per 180 INDERAL LA CP24 NF (propranolol hcl) RELENZA DISKHALER F days;QL(20 ea AEPB per 180 days retail) nadolol tabs F rimantadine hydrochloride F pindolol tabs F tabs propranolol hcl cp24 or 60 TAMIFLU CAPS 30 MG NF QL(20 ea per (oseltamivir phosphate) 180 days retail) mg, 80 mg, 120 mg, 160 F mg TAMIFLU CAPS 45 MG NF QL(10 ea per (oseltamivir phosphate) 180 days retail) propranolol hcl soln or 20 F QL(1000 ml per mg/5ml 30 days retail) TAMIFLU CAPS 75 MG NF QL(14 ea per (oseltamivir phosphate) 180 days retail) propranolol hcl soln or 40 F QL(500 ml per 300mls/ 180 mg/5ml 30 days retail) propranolol hcl tabs or 10 TAMIFLU SUSR 6 MG/ML NF days;QL(180 (oseltamivir phosphate) ml per 180 mg, 20 mg, 80 mg, 40 mg, F days retail) 60 mg BETA BLOCKERS - Drugs to Treat High Blood sotalol hcl tabs F Pressure CALCIUM CHANNEL BLOCKERS - Drugs to Alpha-Beta Blockers Treat High Blood Pressure carvedilol tabs F Calcium Channel Blockers ADALAT CC TB24 NF COREG TABS (carvedilol) NF (nifedipine) labetalol hcl tabs or 100 F amlodipine besylate tabs F mg, 200 mg, 300 mg Beta Blockers Cardio-Selective CALAN SR TBCR NF (verapamil hcl) atenolol tabs F CALAN TABS (verapamil NF hcl) bisoprolol fumarate tabs or F 10 mg, 5 mg CARDIZEM CD CP24 (diltiazem hcl coated NF LOPRESSOR TABS NF beads) (metoprolol tartrate)
Oregon Trillium OHP Updated September 1, 2021
31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARDIZEM TABS NF digoxin soln or 0.05 mg/ml F (diltiazem hcl) diltiazem hcl coated beads digoxin tabs or 0.25 mg, cp24 120 mg, 180 mg, 240 F 250 mcg, 0.125 mg, 125 F mg, 300 mg, 360 mg mcg LANOXIN TABS OR 250 diltiazem hcl cp12 or 120 F NF mg, 60 mg, 90 mg MCG, 125 MCG (digoxin) diltiazem hcl cp24 or 120 F CARDIOVASCULAR AGENTS - MISC. - Drugs to mg, 180 mg, 240 mg Treat Heart and Circulation Conditions diltiazem hcl extended F Cardioplegic Solutions release beads cp24 PLEGISOL SOLN NF diltiazem hcl tabs or 120 F (cardioplegic soln) mg, 30 mg, 60 mg, 90 mg Pulmonary Hypertension - Endothelin Receptor felodipine tb24 F PA; QL(1 ea ambrisentan tabs 10 mg F nicardipine hcl caps or 20 daily); SP F PA; QL(2 ea mg, 30 mg ambrisentan tabs 5 mg F daily); SP nifedipine caps F PA; QL(2 ea bosentan tabs F daily); SP nifedipine tb24 F LETAIRIS TABS 10 MG NF PA; QL(1 ea NORVASC TABS NF (ambrisentan) daily); SP (amlodipine besylate) LETAIRIS TABS 5 MG NF PA; QL(2 ea PROCARDIA CAPS NF (ambrisentan) daily); SP (nifedipine) PA; QL(1 ea OPSUMIT TABS F PROCARDIA XL TB24 NF daily); SP (nifedipine) TRACLEER TABS 125 NF PA; QL(2 ea TIAZAC CP24 (diltiazem MG, 62.5 MG (bosentan) daily); SP hcl extended release NF TRACLEER TBSO 32 MG F PA; QL(4 ea beads) daily); SP verapamil hcl cp24 or 100 Pulmonary Hypertension - Phosphodiesterase mg, 300 mg, 360 mg, 120 F mg, 180 mg, 200 mg, 240 ADCIRCA TABS (tadalafil NF PA; QL(2 ea mg (pulmonary hypertension)) daily); SP REVATIO TABS OR 20 PA; QL(3 ea verapamil hcl tabs or 40 F mg, 120 mg, 80 mg MG (sildenafil citrate NF daily); SP (pulmonary hypertension)) verapamil hcl tbcr or 120 F mg, 180 mg, 240 mg sildenafil citrate (pulmonary PA; QL(3 ea hypertension) tabs or 20 F daily); SP VERELAN CP24 NF (verapamil hcl) mg tadalafil (pulmonary PA; QL(2 ea VERELAN PM CP24 F F (verapamil hcl) hypertension) tabs daily); SP CARDIOTONICS - Drugs to Treat Heart Failure Pulmonary Hypertension - Sol Guanylate Cyclase and Abnormal Heart Rhythm ADEMPAS TABS F PA; QL(3 ea daily); SP Cardiac Glycosides Transthyretin Stabilizers
Oregon Trillium OHP Updated September 1, 2021
32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VYNDAMAX CAPS F PA; QL(1 ea LAMOTRIGINE POWD XX CO daily); SP VYNDAQEL CAPS F PA; QL(4 ea Bulk Chemicals - M's daily); SP METRONIDAZOLE F CEPHALOSPORINS - Drugs to Treat Bacterial BENZOATE POWD Infections Bulk Chemicals - V's Cephalosporins - 1st Generation SODIUM VALPROATE CO POWD cefadroxil caps F VALPROATE SODIUM CO cefadroxil susr F POWD XX Liquids cefadroxil tabs F GLYCERIN LIQD 99 %, F RX/OTC 99.5 %, cephalexin caps 750 mg, F 250 mg, 500 mg GLYCERINE LIQD F RX/OTC cephalexin susr 125 F mg/5ml, 250 mg/5ml CONTRACEPTIVES - Drugs to Prevent Pregnancy KEFLEX CAPS NF (cephalexin) Combination Contraceptives - Oral Cephalosporins - 2nd Generation desogestrel & ethinyl F estradiol tabs cefaclor caps F desogestrel-ethinyl F estradiol (biphasic) tabs cefaclor susr F desogestrel-ethinyl F cefprozil susr F estradiol (triphasic) tabs drospirenone-ethinyl F cefprozil tabs F estradiol tabs ESTROSTEP FE TABS cefuroxime axetil tabs F (norethindrone acetate- NF ethinyl estradiol-fe) Cephalosporins - 3rd Generation ethynodiol diacet & eth F cefdinir caps F estrad tabs levonorgestrel & eth F cefdinir susr F estradiol tabs levonorgestrel-eth estradiol F cefpodoxime proxetil susr F (triphasic) tabs levonorgestrel-ethinyl cefpodoxime proxetil tabs F estradiol (91-day) tabs 0.03 F mg-0.15 mg, 0.15 mg-0.03 ceftriaxone sodium solr ij 1 F gm, 2 gm, 250 mg, 500 mg mg, levonorgestrel-ethinyl ceftriaxone sodium solr iv 1 F F gm, 2 gm, 10 gm estradiol (continuous) tabs LOSEASONIQUE TABS CHEMICALS (levonorgestrel-ethinyl NF estradiol (91-day)) Bulk Chemicals - L's
Oregon Trillium OHP Updated September 1, 2021
33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MIRCETTE TABS etonogestrel-ethinyl F (desogestrel-ethinyl NF estradiol ring estradiol (biphasic)) NUVARING RING norethin acet & estrad-fe norethin acet & (etonogestrel-ethinyl NF tabs 1.5 mg-30 mcg-75 mg, F estrad-fe tabs estradiol) 1 mg-20 mcg-75 mg, 75 (24) is NF; mg-1 mg-20 mcg Copper Contraceptives - IUD PARAGARD SP norethindrone & eth F estradiol tabs INTRAUTERINE COPPER F CONTRACEPTIVE T380A norethindrone acet & eth F IUD estra tabs Emergency Contraceptives norethindrone acetate- F ethinyl estradiol-fe tabs ELLA TABS F norethindrone-eth estradiol F (triphasic) tabs levonorgestrel (emergency F oc) tabs norgestimate-ethinyl F estradiol (triphasic) tabs PLAN B ONE-STEP TABS (levonorgestrel (emergency NF norgestimate-ethinyl F oc)) estradiol tabs Progestin Contraceptives - IUD norgestrel & ethinyl F estradiol tabs KYLEENA IUD F SP ORTHO TRI-CYCLEN LO TABS (norgestimate-ethinyl NF LILETTA IUD F SP estradiol (triphasic)) SP ORTHO-NOVUM 1/35 MIRENA IUD F TABS (norethindrone & eth NF SP estradiol) SKYLA IUD F ORTHO-NOVUM 7/7/7 TABS (norethindrone-eth NF Progestin Contraceptives - Implants estradiol (triphasic)) NEXPLANON IMPL F SP SEASONIQUE TABS (levonorgestrel-ethinyl NF Progestin Contraceptives - Injectable estradiol (91-day)) DEPO-PROVERA QL(1 ml per fill CONTRACEPTIVE SUSP NF retail) TYBLUME CHEW F (medroxyprogesterone YASMIN 28 TABS acetate (contraceptive)) (drospirenone-ethinyl NF DEPO-PROVERA estradiol) CONTRACEPTIVE SUSY NF (medroxyprogesterone YAZ TABS (drospirenone- NF ethinyl estradiol) acetate (contraceptive)) DEPO-SUBQ PROVERA F Combination Contraceptives - Transdermal 104 SUSY norelgestromin-ethinyl QL(10 ea per estradiol ptwk 35 F fill retail) medroxyprogesterone QL(1 ml per fill mcg/24hr-150 mcg/24hr acetate (contraceptive) F retail) susp Combination Contraceptives - Vaginal
Oregon Trillium OHP Updated September 1, 2021
34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits medroxyprogesterone MEDROL TABS 16 MG, 32 acetate (contraceptive) F MG, 8 MG, 4 MG NF susy (methylprednisolone) Progestin Contraceptives - Oral MEDROL TABS 2 MG F norethindrone F (contraceptive) tabs methylprednisolone tabs F ORTHO MICRONOR TABS (norethindrone NF methylprednisolone tbpk F (contraceptive)) MILLIPRED TABS F CORTICOSTEROIDS - Steroid Hormone Drugs to Treat Systemic Swelling Conditions PEDIAPRED SOLN Glucocorticosteroids (prednisolone sodium NF phosphate) budesonide cpep 3 mg F prednisolone sodium phosphate soln or 15 F CELESTONE SOLUSPAN mg/5ml, 5 mg/5ml, 6.7 SUSP (betamethasone sod NF mg/5ml phosphate & acetate) CELESTONE-SOLUSPAN prednisolone soln F SUSP (betamethasone sod NF phosphate & acetate) prednisone soln F CORTEF TABS NF (hydrocortisone) prednisone tabs F cortisone acetate tabs F prednisone tbpk F DEPO-MEDROL SUSP 40 QL(10 ea per SOLU-CORTEF SOLR F MG/ML NF 365 days retail) (methylprednisolone acetate) Mineralocorticoids dexamethasone elix 0.5 F fludrocortisone acetate tabs F mg/5ml COUGH/COLD/ALLERGY - Drugs to Treat DEXAMETHASONE F INTENSOL CONC Cough, Cold and Allergy Symptoms Antitussives dexamethasone soln 0.5 F mg/5ml benzonatate caps 100 mg, F dexamethasone tabs 1 mg, 200 mg 1.5 mg, 2 mg, 4 mg, 0.5 F DELSYM COUGH mg, 0.75 mg, 6 mg CHILDRENS SUER NF (dextromethorphan ENTOCORT EC CPEP NF (budesonide) polistirex) hydrocortisone tabs F DELSYM SUER (dextromethorphan NF polistirex) KENALOG-40 SUSP NF (triamcinolone acetonide) dextromethorphan F polistirex lqcr MEDROL DOSEPAK TBPK NF (methylprednisolone) dextromethorphan F polistirex suer
Oregon Trillium OHP Updated September 1, 2021
35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYCODAN SYRP AL(At least 18 M-CLEAR WC SOLN F (hydrocodone w/ NF yrs old) homatropine) MAR-COF CG EXPECTORANT LIQD NF hydrocodone w/ F AL(At least 18 homatropine syrp yrs old) (guaifenesin-codeine) promethazine w/codeine AL(At least 18 hydrocodone w/ F AL(At least 18 F homatropine tabs yrs old) soln yrs old) promethazine w/codeine AL(At least 18 TESSALON PERLES NF F CAPS (benzonatate) syrp yrs old) Cough/Cold/Allergy Combinations promethazine-dm syrp F CHERACOL PLUS LIQD ROBITUSSIN PEAK COLD (dextromethorphan- NF DM SYRP NF guaifenesin) (dextromethorphan- CHERACOL-D COUGH guaifenesin) LIQD (dextromethorphan- NF SUPRESS DM PEDIATRIC F guaifenesin) LIQD dextromethorphan- VICKS DAYQUIL MUCUS F guaifenesin liqd 20 mg/5ml- CONTROL DM LIQD 300 mg/5ml-300 mg/5ml-20 mg/5ml, 200 mg/5ml-30 Expectorants mg/5ml, 200 mg/5ml-30 GILTUSS EX MAXIMUM F mg/5ml-200 mg/5ml-30 STRENGTH LIQD mg/5ml, 30 mg/5ml-30 mg/5ml-200 mg/5ml-200 guaifenesin liqd F mg/5ml, 10 mg/5ml-200 mg/5ml, 20 mg/10ml-400 guaifenesin soln F mg/10ml, 200 mg/5ml-10 F mg/5ml, 100 mg/5ml-5 guaifenesin syrp F mg/5ml, 20 mg/20ml-400 mg/20ml, 400 mg/20ml-20 guaifenesin tabs F mg/20ml, 5 mg/5ml-100 mg/5ml, 10 mg/5ml-100 guaifenesin tb12 F mg/5ml, 100 mg/5ml-10 mg/5ml, 15 mg/7.5ml-150 MUCINEX MAXIMUM mg/7.5ml, 20 mg/10ml-200 STRENGTH TB12 NF mg/10ml, 200 mg/10ml-20 (guaifenesin) mg/10ml MUCINEX TB12 NF dextromethorphan- (guaifenesin) guaifenesin syrp 10 Misc. Respiratory Inhalants mg/5ml-10 mg/5ml-100 F mg/5ml-100 mg/5ml, 100 HYPER-SAL NEBU NF mg/5ml-10 mg/5ml (sodium chloride (inhalant)) HYPERSAL NEBU 7 % NF guaifenesin-codeine liqd F (sodium chloride (inhalant)) sodium chloride (inhalant) F guaifenesin-codeine soln F aers guaifenesin-codeine syrp F sodium chloride (inhalant) F nebu
Oregon Trillium OHP Updated September 1, 2021
36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Mucolytics POLYSPORIN OINT NF (bacitracin-polymyxin b) acetylcysteine soln F Antifungals - Topical DERMATOLOGICALS - Drugs to Treat Skin butenafine hcl crea F RX/OTC Conditions CICLODAN SOLUTION NF Acne Products KIT KIT (ciclopirox) CLEOCIN-T GEL (clindamycin phosphate NF clotrimazole (topical) crea F RX/OTC (topical)) CLINDAGEL GEL econazole nitrate crea F (clindamycin phosphate NF EXELDERM CREA NF (topical)) (sulconazole nitrate) DIFFERIN GEL 0.1 % PA; RX/OTC F EXELDERM SOLN NF (adapalene) (sulconazole nitrate) DIFFERIN GEL 0.1 % RX/OTC NF GENTIAN VIOLET SOLN 1 F (adapalene) % RETIN-A CREA 0.05 % NF PA (tretinoin) gentian violet soln 2 % F PA tretinoin crea 0.05 % F GNP GENTIAN VIOLET F SOLN Anti-inflammatory Agents - Topical ketoconazole (topical) crea F 2 % FLECTOR PTCH NF (diclofenac epolamine) LAMISIL AT CREA NF Antibiotics - Topical (terbinafine hcl (topical)) LAMISIL AT JOCK ITCH BACIGUENT OINT EX NF (bacitracin (topical)) CREA (terbinafine hcl NF (topical)) bacitracin (topical) oint F LOTRIMIN AF CREA NF RX/OTC (clotrimazole (topical)) bacitracin zinc oint F LOTRIMIN AF JOCK ITCH RX/OTC CREA (clotrimazole NF bacitracin-polymyxin b oint F (topical)) CENTANY OINT F LOTRIMIN ULTRA CREA NF RX/OTC (butenafine hcl) gentamicin sulfate (topical) F crea LUZU CREA (luliconazole) NF RX/OTC gentamicin sulfate (topical) F MENTAX CREA F oint MICATIN CREA mupirocin oint F (miconazole nitrate NF (topical)) neomycin-bacitracin- F polymyxin oint miconazole nitrate (topical) F NEOSPORIN ORIGINAL crea OINT (neomycin-bacitracin- NF nystatin (topical) crea F polymyxin)
Oregon Trillium OHP Updated September 1, 2021
37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nystatin (topical) oint F TALTZ SOSY F PA; QL(0.67 ml daily); SP QL(2 gm daily) nystatin (topical) powd F VECTICAL OINT (calcitriol NF (topical)) nystatin-triamcinolone crea F Burn Products SILVADENE CREA (silver NF nystatin-triamcinolone oint F sulfadiazine) terbinafine hcl (topical) F silver sulfadiazine crea F crea TINACTIN CREA NF Corticosteroids - Topical (tolnaftate) ALA-SCALP LOTN F tolnaftate crea F APEXICON E CREA F VUSION OINT (miconazole-zinc oxide- NF betamethasone F 1 rtl pack lmt white petrolatum) dipropionate (topical) crea per fill, Antineoplastic or Premalignant Lesion Agents - betamethasone F dipropionate (topical) lotn CARAC CREA (fluorouracil NF (topical)) betamethasone F dipropionate (topical) oint EFUDEX CREA NF (fluorouracil (topical)) betamethasone dipropionate augmented F fluorouracil (topical) crea 5 F % crea betamethasone fluorouracil (topical) soln 2 F %, 5 % dipropionate augmented F oint Antipruritics - Topical betamethasone valerate F PRUDOXIN CREA NF crea 0.1 % (doxepin hcl (antipruritic)) betamethasone valerate F ZONALON CREA (doxepin NF lotn 0.1 % hcl (antipruritic)) betamethasone valerate F Antipsoriatics oint 0.1 % PA CLODERM CREA NF acitretin caps F (clocortolone pivalate) calcipotriene crea F desonide crea F calcipotriene oint F desonide oint F DOVONEX CREA NF DESOWEN CREA NF (calcipotriene) (desonide) DRITHO-CREME HP F desoximetasone crea 0.25 F CREA % SORIATANE CAPS NF PA desoximetasone gel 0.05 % F (acitretin) desoximetasone oint 0.05 TALTZ SOAJ F PA; QL(0.67 ml F daily); SP %, 0.25 %
Oregon Trillium OHP Updated September 1, 2021
38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diflorasone diacetate crea F hydrocortisone (topical) oint F 2.5 %, 0.5 % diflorasone diacetate oint F hydrocortisone acetate F (topical) crea DIPROLENE AF CREA hydrocortisone butyrate F (betamethasone NF crea dipropionate augmented) hydrocortisone butyrate F DIPROLENE OINT oint (betamethasone NF dipropionate augmented) hydrocortisone butyrate F soln ELOCON CREA NF (mometasone furoate) hydrocortisone valerate F crea EPIFOAM FOAM F hydrocortisone valerate oint F fluocinolone acetonide crea F 0.01 %, 0.025 % hydrocortisone-aloe vera F crea fluocinolone acetonide oint F 0.025 % LOCOID CREA NF (hydrocortisone butyrate) fluocinolone acetonide soln F 0.01 % LOCOID SOLN NF (hydrocortisone butyrate) fluocinonide crea 0.05 % F mometasone furoate crea F fluocinonide emulsified F base crea mometasone furoate oint F fluocinonide gel 0.05 % F mometasone furoate soln F fluocinonide oint 0.05 % F MONISTAT SOOTHING RX/OTC CARE ITCH RELIEF CREA NF fluocinonide soln 0.05 % F (hydrocortisone (topical)) prednicarbate crea F fluticasone propionate crea F 0.05 % prednicarbate oint F fluticasone propionate oint F 0.005 % PSORCON CREA F halobetasol propionate F crea SYNALAR CREA NF halobetasol propionate oint F (fluocinolone acetonide) SYNALAR OINT NF hydrocortisone (topical) F RX/OTC (fluocinolone acetonide) crea 1 % SYNALAR SOLN NF hydrocortisone (topical) F (fluocinolone acetonide) crea 2.5 %, 0.5 % TACLONEX SUSP hydrocortisone (topical) F (calcipotriene- NF lotn 2.5 %, 2 %, 1 % betamethasone dipropionate) hydrocortisone (topical) F RX/OTC oint 1 % TOPICORT CREA 0.25 % NF (desoximetasone)
Oregon Trillium OHP Updated September 1, 2021
39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPICORT GEL 0.05 % NF CAPZASIN-HP CREA NF (desoximetasone) (capsaicin) TOPICORT OINT 0.05 %, NF 1 rtl pack lmt 0.25 % (desoximetasone) lidocaine hcl crea ex 4 % F amt,30 rtl pack triamcinolone acetonide lmt day(s), (topical) crea 0.025 %, 0.5 F Limit 1 %, 0.1 % Package per 30 days 1 rtl pack triamcinolone acetonide lidocaine hcl crea ex 4 % F (topical) lotn 0.025 %, 0.1 F lmt amt,30 rtl % pack lmt day(s), triamcinolone acetonide (topical) oint 0.025 %, 0.1 F QL(120 gm per %, 0.5 % lidocaine hcl gel ex 2 % F 30 days retail); RX/OTC TRIDESILON CREA NF (desonide) QL(120 ml per lidocaine hcl gel ex 2 % F 30 days retail); Emollient/Keratolytic Agents RX/OTC HYDRO 35 FOAM (urea in QL(120 ml per NF lidocaine hcl gel ex 2 % F lactic acid vehicle) 30 days retail) QL(120 ml per Immunomodulating Agents - Topical lidocaine hcl prsy ex 2 % F 30 days retail) ALDARA CREA NF (imiquimod) PA; QL(30 gm lidocaine-prilocaine crea F per 30 days imiquimod crea 5 % F retail) PA ZYCLARA CREA NF lidocaine-prilocaine kit F (imiquimod) Use ZYCLARA PUMP CREA NF 3.75 % (imiquimod) LMX 4 CREA (lidocaine) NF Aspercreme w/ Lidocaine 4% Immunosuppressive Agents - Topical Use ELIDEL CREA PA PREDATOR CREA NF Aspercreme w/ NF (lidocaine hcl) (pimecrolimus) Lidocaine 4% pimecrolimus crea F PA Misc. Topical aluminum sulfate & calcium PROTOPIC OINT NF PA F (tacrolimus (topical)) acetate pack PA PA is required tacrolimus (topical) oint F for F compounding Keratolytic/Antimitotic Agents BORIC ACID GRAN of 600mg podofilox soln F capsules;RX/O TC Local Anesthetics - Topical DOMEBORO PACK (aluminum sulfate & NF ARTHRITIS PAIN F RELIEVING CREA calcium acetate) capsaicin crea 0.075 %, F lubricants gel F 0.025 %, 0.1 % Rosacea Agents
Oregon Trillium OHP Updated September 1, 2021
40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORACEA CPDR NF FORA GTEL BLOOD Limit 2 (doxycycline (rosacea)) KETONE TEST STRIPS F packages per STRP 31 days SOOLANTRA CREA NF (ivermectin (rosacea)) Limit 2 GOJJI BLOOD KETONE F TEST STRIPS STRP packages per Scabicides & Pediculicides 31 days CVS LICE SOLUTION KIT F NOVA MAX PLUS Limit 2 3-STEP KIT KETONE TESTSTRIPS F packages per ELIMITE CREA NF STRP 31 days (permethrin) Limit 2 PRECISION XTRA STRP F EURAX LOTN (crotamiton) NF VI packages per 31 days malathion lotn F Limit 2 PTS PANELS KETONE F packages per TEST STRP NATROBA SUSP NF 31 days (spinosad) INSULIN NIX CREME RINSE LIQD F USERS (permethrin) LIMITED TO OVIDE LOTN (malathion) NF 450 PER 90 RELION TRUE METRIX DAYS, NON- permethrin aero F BLOODGLUCOSE TEST F INSULIN STRIPS STRP USERS LIMITED TO F permethrin crea 100 PER 90 DAYS permethrin liqd F ;RX/OTC permethrin lotn F INSULIN USERS LIMITED TO pyrethrins-piperonyl F butoxide liqd 450 PER 90 TRUE METRIX BLOOD DAYS, NON- pyrethrins-piperonyl F GLUCOSETEST STRIPS F butoxide sham STRP INSULIN USERS pyrethrins-piperonyl LIMITED TO butoxide-permethrin-nit F 100 PER 90 remover kit DAYS RX/OTC RID AERO (permethrin) NF INSULIN USERS RID COMPLETE LICE LIMITED TO ELIMINATION KIT 450 PER 90 (pyrethrins-piperonyl NF TRUETRACK TEST STRP F DAYS, NON- butoxide-permethrin-nit INSULIN remover) USERS RID LIQD (pyrethrins- NF LIMITED TO piperonyl butoxide) 100 PER 90 DAYS RX/OTC DIAGNOSTIC PRODUCTS DIETARY PRODUCTS/DIETARY MANAGEMENT Diagnostic Tests PRODUCTS Dietary Management Products Oregon Trillium OHP Updated September 1, 2021
41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELFOLATE TABS F triamterene & F hydrochlorothiazide tabs l-methylfolate tabs 15 mg, F Loop Diuretics 7.5 mg bumetanide tabs or 0.5 mg, F Nutritional Substitutes 1 mg, 2 mg SACCHARIN SODIUM RX/OTC F BUMEX TABS NF POWD (bumetanide) SODIUM SACCHARIN RX/OTC F furosemide soln or 10 F POWD mg/ml, 8 mg/ml DIGESTIVE AIDS - Drugs to Treat Low Digestive furosemide tabs or 20 mg, F Enzymes 40 mg, 80 mg Digestive Enzymes LASIX TABS (furosemide) NF CREON CPEP F torsemide tabs F PANCREAZE CPEP F Potassium Sparing Diuretics DIURETICS - Drugs to Treat Heart, Circulation ALDACTONE TABS NF Conditions and Blood Pressure (spironolactone) Carbonic Anhydrase Inhibitors amiloride hcl tabs F acetazolamide cp12 F spironolactone tabs F acetazolamide tabs F Thiazides and Thiazide-Like Diuretics methazolamide tabs F chlorthalidone tabs F Diuretic Combinations hydrochlorothiazide caps F ALDACTAZIDE TABS 25 MG-25 MG (spironolactone NF hydrochlorothiazide tabs F & hydrochlorothiazide) indapamide tabs F amiloride & F hydrochlorothiazide tabs metolazone tabs F DYAZIDE CAPS (triamterene & NF ENDOCRINE AND METABOLIC AGENTS - hydrochlorothiazide) MISC. - Drugs to Treat Bone Disease and MAXZIDE TABS Regulate Hormones (triamterene & NF Bone Density Regulators hydrochlorothiazide) alendronate sodium tabs MAXZIDE-25 TABS 35 mg, 40 mg, 5 mg, 70 F (triamterene & NF mg, 10 mg hydrochlorothiazide) calcitonin (salmon) soln na F spironolactone & F 200 unit/act hydrochlorothiazide tabs etidronate disodium tabs F triamterene & F hydrochlorothiazide caps FOSAMAX TABS NF (alendronate sodium)
Oregon Trillium OHP Updated September 1, 2021
42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYMLOS SOPN F PA; SP CLIMARA PRO PTWK F
Growth Hormones COMBIPATCH PTTW F PA; SP ZOMACTON SOLR F Estrogens Hormone Receptor Modulators ESTRACE TABS OR 0.5 AL(At least 17 MG, 1 MG, 2 MG NF yrs old) EVISTA TABS (raloxifene NF ) hcl) (estradiol estradiol tabs or 0.5 mg, 1 F AL(At least 17 raloxifene hcl tabs F mg, 2 mg yrs old) Metabolic Modifiers FLUOROQUINOLONES - Drugs to Treat Bacterial Infections calcitriol caps or 0.25 mcg, F 0.5 mcg Fluoroquinolones CARNITOR TABS OR 330 CIPRO SUSR 5 GM/100ML NF MG (levocarnitine NF (metabolic modifiers)) CIPRO SUSR 500 MG/5ML F levocarnitine (metabolic F modifiers) tabs 330 mg CIPRO TABS 250 MG, 500 NF MG (ciprofloxacin hcl) ROCALTROL CAPS 0.25 NF MCG, 0.5 MCG (calcitriol) ciprofloxacin hcl tabs F Posterior Pituitary Hormones ciprofloxacin susr F DDAVP SOLN NA 0.01 % F LEVAQUIN TABS NF DDAVP SOLN NA 0.01 % (levofloxacin) (desmopressin acetate NF levofloxacin tabs or 250 F spray) mg, 500 mg, 750 mg DDAVP TABS OR 0.1 MG, 0.2 MG (desmopressin NF moxifloxacin hcl tabs F acetate) ofloxacin tabs F desmopressin acetate F spray refrigerated soln GASTROINTESTINAL AGENTS - MISC. - desmopressin acetate F Miscellaneous Gastrointestinal Drugs spray soln Antiflatulents desmopressin acetate tabs F or 0.1 mg, 0.2 mg GAS-X CHEW NF (simethicone) Prolactin Inhibitors GAS-X EXTRA cabergoline tabs F STRENGTH CHEW 125 NF MG (simethicone) Vasopressin Receptor Antagonists PHAZYME CAPS NF JYNARQUE TBPK 15 MG, F PA; SP (simethicone) PHAZYME ULTRA ESTROGENS - Hormone Replacement/Modifying STRENGTH CAPS NF Drugs (simethicone) Estrogen Combinations simethicone caps 180 mg F
Oregon Trillium OHP Updated September 1, 2021
43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits simethicone chew 80 mg, F LIALDA TBEC NF 125 mg (mesalamine) Gallstone Solubilizing Agents mesalamine cp24 F ACTIGALL CAPS NF (ursodiol) mesalamine cpdr F
URSO 250 TABS (ursodiol) NF mesalamine enem F URSO FORTE TABS NF (ursodiol) mesalamine supp F ursodiol caps 300 mg F mesalamine tbec F ursodiol tabs 250 mg, 500 F mg PENTASA CPCR F Gastrointestinal Stimulants sulfasalazine tabs F metoclopramide hcl soln or F 10 mg/10ml, 5 mg/5ml sulfasalazine tbec F metoclopramide hcl tabs or F 10 mg, 5 mg Intestinal Acidifiers lactulose (encephalopathy) REGLAN TABS NF F (metoclopramide hcl) soln Inflammatory Bowel Agents Phosphate Binder Agents calcium acetate (phosphate APRISO CP24 NF F (mesalamine) binder) caps calcium acetate (phosphate RX/OTC ASACOL HD TBEC NF F (mesalamine) binder) tabs RENAGEL TABS PA; QL(6 ea AZULFIDINE EN-TABS NF NF TBEC (sulfasalazine) (sevelamer hcl) daily) RENVELA TABS 800 MG PA; QL(6 ea AZULFIDINE TABS NF NF (sulfasalazine) (sevelamer carbonate) daily) sevelamer carbonate tabs F PA; QL(6 ea balsalazide disodium caps F 800 mg daily) PA; QL(12 ea CANASA SUPP NF sevelamer hcl tabs 400 mg F (mesalamine) daily) PA; QL(6 ea PA; SP sevelamer hcl tabs 800 mg F CIMZIA KIT 200 MG F daily) PA; QL(0.15 ea CIMZIA KIT 200 MG/ML F GENITOURINARY AGENTS - MISCELLANEOUS daily); SP - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System CIMZIA STARTER KIT KIT F PA; QL(0.11 ea daily); SP Acidifiers COLAZAL CAPS NF (balsalazide disodium) K-PHOS NO 2 TABS F DELZICOL CPDR NF (mesalamine) Alkalinizers potassium citrate F DIPENTUM CAPS F (alkalinizer) tbcr
Oregon Trillium OHP Updated September 1, 2021
44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sodium citrate & citric acid RX/OTC COLCRYS TABS NF soln 334 mg/5ml-334 F (colchicine) mg/5ml-500 mg/5ml-500 QL(6 ea per fill mg/5ml MITIGARE CAPS NF retail)1 rtl MAX UROCIT-K 10 TBCR (colchicine) fill,30 rtl day(s) (potassium citrate NF supply, (alkalinizer)) ZYLOPRIM TABS NF UROCIT-K 15 TBCR (allopurinol) (potassium citrate NF (alkalinizer)) Uricosurics UROCIT-K 5 TBCR probenecid tabs F (potassium citrate NF (alkalinizer)) HEMATOLOGICAL AGENTS - MISC. - Drugs to Treat Blood Disorders Interstitial Cystitis Agents Antihemophilic Products ELMIRON CAPS F ADVATE SOLR F PA; SP Prostatic Hypertrophy Agents ADYNOVATE SOLR 1000 PA; SP finasteride tabs F UNIT, 1500 UNIT, 2000 F UNIT, 250 UNIT, 500 UNIT FLOMAX CAPS NF (tamsulosin hcl) ALPHANATE SOLR F PA; SP PROSCAR TABS NF ALPHANATE/VON PA; SP (finasteride) WILLEBRANDFACTOR F RAPAFLO CAPS 4 MG NF COMPLEX/HUMAN SOLR (silodosin) ALPHANINE SD SOLR F PA; SP tamsulosin hcl caps F ALPROLIX SOLR F PA; SP Urinary Analgesics PA; SP phenazopyridine hcl tabs F BENEFIX KIT F 100 mg, 200 mg, 95 mg CORIFACT KIT F PA; SP PYRIDIUM TABS NF (phenazopyridine hcl) ELOCTATE SOLR 1000 PA; SP GOUT AGENTS - Drugs to Treat Gout UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 F Gout Agent Combinations UNIT, 4000 UNIT, 500 UNIT, 5000 UNIT, 750 colchicine w/ probenecid F AGE QL(Age 6 tabs to 30,) UNIT PA; SP Gout Agents FEIBA SOLR F allopurinol tabs F HELIXATE FS KIT F PA; SP QL(6 ea per fill PA; SP retail)1 rtl MAX HEMOFIL M SOLR F colchicine caps F fill,30 rtl day(s) PA; SP supply, HUMATE-P SOLR F colchicine tabs F
Oregon Trillium OHP Updated September 1, 2021
45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits IDELVION SOLR 1000 PA; SP clopidogrel bisulfate tabs or F UNIT, 2000 UNIT, 500 F 300 mg, 75 mg UNIT dipyridamole tabs F IXINITY SOLR 1000 UNIT, PA; SP 2000 UNIT, 250 UNIT, F PLAVIX TABS (clopidogrel NF 3000 UNIT, 500 UNIT bisulfate) KOATE SOLR F PA; SP HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders PA; SP KOATE-DVI SOLR F Cobalamins KOGENATE FS KIT F PA; SP B-12 TABS 2000 MCG F
KOVALTRY SOLR F PA; SP cyanocobalamin soln ij F 1000 mcg/ml MONONINE SOLR F PA; SP cyanocobalamin subl sl 1000 mcg, 3000 mcg, 500 F NOVOEIGHT SOLR 2000 PA; SP mcg, 5000 mcg UNIT, 3000 UNIT, 500 F cyanocobalamin tabs or 50 UNIT mcg, 250 mcg, 1000 mcg, F NOVOSEVEN RT SOLR F PA; SP 100 mcg, 500 mcg cyanocobalamin tbcr or NUWIQ KIT 1000 UNIT, F PA; SP 1500 mcg, 2000 mcg, 1000 F 2000 UNIT, 500 UNIT mcg, 120 mg-1000 mcg PA; SP RECOMBINATE SOLR F VITAMIN B-12 SUBL SL F 6000 MCG PA; SP RIXUBIS SOLR F Folic Acid/Folates RX/OTC WILATE KIT F PA; SP folic acid tabs or 1 mg F
PA; SP folic acid tabs or 800 mcg, F XYNTHA KIT F 400 mcg XYNTHA SOLOFUSE KIT F PA; SP Hematopoietic Growth Factors PA; SP Hematorheologic Agents EPOGEN SOLN F pentoxifylline tbcr F PROCRIT SOLN 10000 PA; SP UNIT/ML, 2000 UNIT/ML, Plasma Proteins 20000 UNIT/ML, 3000 F UNIT/ML, 4000 UNIT/ML, THROMBATE III SOLR F PA; SP 40000 UNIT/ML RETACRIT SOLN 10000 PA; SP THROMBATE III W/10 ML F PA; SP STERILE WATER SOLR UNIT/ML, 2000 UNIT/ML, 20000 UNIT/2ML, 20000 F Platelet Aggregation Inhibitors UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 AGRYLIN CAPS NF (anagrelide hcl) UNIT/ML PA; SP anagrelide hcl caps F ZARXIO SOSY F cilostazol tabs F Iron
Oregon Trillium OHP Updated September 1, 2021
46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FE GLUCONATE TABS F SLOW FE TBCR (ferrous F sulfate) FEMIRON TABS F SLOW RELEASE IRON F TBCR FER-IN-SOL SOLN NF SPATONE PUR-ABSORB F (ferrous sulfate) IRON LIQD FERRETTS TABS F HEMOSTATICS - Drugs to Stop Bleeding/Treat Blood Disorders FERRIMIN 150 TABS F Hemostatics - Systemic FERROUS FUMARATE F AMICAR SOLN 0.25 NF QL(60 ml per TABS 29 MG GM/ML (aminocaproic acid) fill retail); SP ferrous fumarate tabs 324 F AMICAR TABS 1000 MG NF SP mg (aminocaproic acid) FERROUS GLUCONATE F aminocaproic acid soln or F QL(60 ml per TABS 324 MG 0.25 gm/ml fill retail); SP ferrous gluconate tabs 324 F LYSTEDA TABS NF QL(32 ea per mg, 240 mg, 27 mg (tranexamic acid) 28 days retail) ferrous sulfate elix or 220 F tranexamic acid tabs or 650 F QL(32 ea per mg/5ml mg 28 days retail) FERROUS SULFATE LIQD F HYPNOTICS/SEDATIVES/SLEEP DISORDER OR 220 MG/5ML AGENTS ferrous sulfate soln or 15 F mg/ml Antihistamine Hypnotics doxylamine succinate ferrous sulfate syrp or 300 F F mg/5ml (sleep) tabs UNISOM SLEEPTABS ferrous sulfate tabs or 28 F mg, 325 mg, 65 mg TABS (doxylamine NF succinate (sleep)) ferrous sulfate tbcr or 50 mg, 143 mg, 142 mg, 45 F Barbiturate Hypnotics mg phenobarbital elix F FERROUS SULFATE F TBEC OR 324 MG phenobarbital soln F ferrous sulfate tbec or 325 F mg phenobarbital tabs F HEMOCYTE TABS (ferrous F fumarate) Non-Barbiturate Hypnotics AMBIEN TABS (zolpidem HIGH POTENCY IRON F NF CAPS tartrate) IRON SLOW RELEASE F DORAL TABS (quazepam) NF TBCR RESTORIL CAPS 15 MG, NF QL(2 ea daily) IRON TBCR 140 MG F 7.5 MG (temazepam) RESTORIL CAPS 22.5 NF QL(1 ea daily) IRON TBCR 18 MG F MG, 30 MG (temazepam) polysaccharide iron F temazepam caps 15 mg, F QL(2 ea daily) complex caps 7.5 mg Oregon Trillium OHP Updated September 1, 2021
47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits temazepam caps 22.5 mg, F QL(1 ea daily) psyllium powd 33 %, 68 %, 30 mg 95 %, 30 %, 100 %, 30.9 F %, , 48.57 %, 58.6 %, 28.3 zaleplon caps F % zolpidem tartrate tabs or 10 F Laxative Combinations mg, 5 mg COLYTE-FLAVOR PACKS LAXATIVES - Bowel Treatment Drugs SOLR (peg 3350-kcl-sod NF bicarb-sod chloride-sod Bulk Laxatives sulfate) GOLYTELY SOLR 2.82 calcium polycarbophil tabs F GM-5.53 GM-6.36 GM-21.5 F CITRUCEL FIBER GM-227.1 GM LAXATIVE POWD NF GOLYTELY SOLR 2.97 (methylcellulose (laxative)) GM-5.86 GM-6.74 GM- 22.74 GM-236 GM (peg NF CVS DAILY FIBER PACK F 3350-kcl-sod bicarb-sod chloride-sod sulfate) CVS NATURAL FIBER F SUPPLEMENT PACK MOVIPREP SOLR (peg 3350-kcl-nacl-na sulfate-na NF EVAC POWD (psyllium) NF ascorbate-ascorbic acid) NULYTELY SOLR (peg FIBERCON TABS (calcium NF polycarbophil) 3350-potassium chloride- NF sod bicarbonate-sod HYDROCIL INSTANT NF POWD (psyllium) chloride) NULYTELY/FLAVOR KONSYL DAILY FIBER F PACK 100 % PACKS SOLR (peg 3350- NF potassium chloride-sod KONSYL DAILY FIBER NF bicarbonate-sod chloride) POWD 100 % (psyllium) peg 3350-kcl-nacl-na KONSYL ORIGINAL DAILY F sulfate-na ascorbate- F FIBER PACK ascorbic acid solr KONSYL-D POWD F peg 3350-kcl-sod bicarb- sod chloride-sod sulfate F METAMUCIL CAPS 0.52 NF solr ) GM (psyllium peg 3350-potassium METAMUCIL ORIGINAL chloride-sod bicarbonate- F TEXTURE POWD NF sod chloride solr (psyllium) sennosides-docusate F METAMUCIL PACK 28 % F sodium tabs SENOKOT S TABS METAMUCIL POWD 48.57 NF (sennosides-docusate NF % (psyllium) sodium) methylcellulose (laxative) F SUPREP BOWEL PREP F powd KIT SOLN psyllium caps 0.52 gm, 520 F mg Laxatives - Miscellaneous glycerin (laxative) supp 1 F gm, 2 gm, 2.1 gm, 1.2 gm
Oregon Trillium OHP Updated September 1, 2021
48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLYCERIN ADULT SUPP F sodium phosphates enem 798mls per 30 (glycerin (laxative)) 19 gm/118ml-7 gm/118ml, F days;QL(798 6 gm/133ml-16 gm/133ml, ml per 31 days lactulose soln 10 gm/15ml, F 20 gm/30ml 7 gm/118ml-19 gm/118ml retail) MIRALAX MIX-IN PAX sodium phosphates enem F 798mls per 30 PACK (polyethylene glycol NF 3.5 gm/59ml-9.5 gm/59ml days; 3350) Stimulant Laxatives MIRALAX PACK NF (polyethylene glycol 3350) bisacodyl supp F MIRALAX POWD NF bisacodyl tbec F (polyethylene glycol 3350) DULCOLAX SUPP PEDIA-LAX SUPP RE 1 NF NF GM (glycerin (laxative)) (bisacodyl) DULCOLAX TBEC polyethylene glycol 3350 F NF pack (bisacodyl) EX-LAX TABS polyethylene glycol 3350 F NF powd (sennosides) SORBITOL SOLN OR 70 F sennosides liqd 8.8 mg/5ml F % sennosides syrp 8.8 F Saline Laxatives mg/5ml 798mls per 30 sennosides tabs 17.2 mg, F FLEET ENEMA ENEM F days;QL(798 15 mg, 25 mg, 8.6 mg (sodium phosphates) ml per 31 days retail) SENOKOT TABS NF (sennosides) 798mls per 30 FLEET ENEMA SIX PACK Surfactant Laxatives ENEM ( F days;QL(798 sodium ml per 31 days phosphates) COLACE CAPS (docusate NF retail) sodium) FLEET PEDIATRIC ENEM 798mls per 30 F COLACE CLEAR CAPS NF (sodium phosphates) days; (docusate sodium) magnesium citrate soln F 1.745 gm/30ml, docusate calcium caps F magnesium hydroxide susp docusate sodium caps or F 1200 mg/15ml, 2400 F 50 mg, 250 mg, 100 mg mg/30ml, 400 mg/5ml, 7.75 docusate sodium liqd or %, 100 mg/10ml, 150 F PEDIA-LAX CHEW OR 400 F mg/15ml, 50 mg/5ml MG LOCAL ANESTHETICS-Parenteral - Drugs for PHILLIPS MILK OF Numbing MAGNESIA CHEWABLE F CHEW Local Anesthetics - Amides PHILLIPS MILK OF BUPIVACAINE F MAGNESIA F FISIOPHARMA SOLN CONCENTRATED SUSP bupivacaine hcl soln ij 0.25 F %, 0.5 %, 0.75 % PHILLIPS MILK OF F MAGNESIA SUSP MARCAINE SOLN NF (bupivacaine hcl) Oregon Trillium OHP Updated September 1, 2021
49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NAROPIN SOLN 5 MG/ML, NF erythromycin F 2 MG/ML (ropivacaine hcl) ethylsuccinate tabs 400 mg ZINGO JTAJ (lidocaine hcl NF erythromycin stearate tabs F (local anesth.)) MACROLIDES - Drugs to Treat Bacterial MEDICAL DEVICES AND SUPPLIES Infections Contraceptives Azithromycin AIMSCO LUBRICATED F QL(3.34 ea azithromycin pack or 1 gm F MISC daily) CONDOMS-MISC F azithromycin susr or 100 F mg/5ml, 200 mg/5ml DUREX EXTRA F QL(3.34 ea azithromycin tabs or 250 F SENSITIVE DEVI daily) mg, 500 mg, 600 mg FANTASY LUBRICATED F QL(3.34 ea ZITHROMAX PACK OR 1 NF MISC daily) GM (azithromycin) FANTASY QL(3.34 ea ZITHROMAX SUSR OR LUBRICATED/SPERMICID F daily) 100 MG/5ML, 200 MG/5ML NF E MISC (azithromycin) FC FEMALE CONDOM F QL(36 ea per ZITHROMAX TABS OR MISC 31 days retail) 250 MG, 500 MG, 600 MG NF (azithromycin) FC2 FEMALE CONDOM F QL(36 ea per MISC 31 days retail) ZITHROMAX TRI-PAK NF TABS (azithromycin) K-Y ME & YOU EXTRA F QL(3.34 ea LUBRICATED DEVI daily) ZITHROMAX Z-PAK TABS NF (azithromycin) K-Y ME & YOU INTENSE F QL(3.34 ea DEVI daily) Clarithromycin KAMELEON LUBRICATED F QL(3.34 ea clarithromycin susr F MISC daily) QL(3.34 ea KIMONO COLORS DEVI F clarithromycin tabs F daily) KIMONO LUBRICATED F QL(3.34 ea clarithromycin tb24 F MISC daily) KIMONO MICRO THIN QL(3.34 ea Erythromycins PLUS SPERMICIDE F daily) ERYPED 400 SUSR LUBRICATED MISC (erythromycin NF KIMONO PLUS QL(3.34 ea ethylsuccinate) SPERMICIDE F daily) erythromycin base cpep F LUBRICATED MISC KIMONO PLUS QL(3.34 ea erythromycin base tabs F SPERMICIDE/LUBRICATE F daily) D MISC erythromycin base tbec F KIMONO PS LUBRICATED F QL(3.34 ea erythromycin MISC daily) ethylsuccinate susr 400 F KIMONO PS PLUS QL(3.34 ea mg/5ml SPERMICIDE/LUBRICATE F daily) D MISC
Oregon Trillium OHP Updated September 1, 2021
50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KIMONO SENSATION F QL(3.34 ea TRUSTEX WITH QL(3.34 ea LUBRICATED MISC daily) NONOXYNOL- F daily) KIMONO SENSATION QL(3.34 ea 9/RIBBED/STUDDED PLUS SPERMICIDE F daily) MISC LUBRICATED MISC TRUSTEX/RIA F QL(3.34 ea LUBRICATED MISC daily) KIMONO SPECIAL DEVI F QL(3.34 ea daily) TRUSTEX/RIA QL(3.34 ea LUBRICATED F daily) MAXX LUBRICATED MISC F QL(3.34 ea daily) SPERMICIDE MISC TRUSTEX/RIA QL(3.34 ea MAXX PLUS SPERMICIDE F QL(3.34 ea LUBRICATED MISC daily) LUBRICATED/SPERMICID F daily) E MISC PREMIUM CONDOMS F QL(3.34 ea LUBRICATED MISC daily) WIDE-SEAL SILICONE DIAPHRAGM KIT 60 F REALITY LATEX QL(3.34 ea DPRH CONDOMS/LUBRICATED F daily) MISC WIDE-SEAL SILICONE DIAPHRAGM KIT 65 F REALITY LATEX/ULTRA F QL(3.34 ea DPRH TEXTURED DEVI daily) WIDE-SEAL SILICONE REALITY LATEX/ULTRA F QL(3.34 ea DIAPHRAGM KIT 70 F THIN DEVI daily) DPRH TRUSTEX COLOR F QL(3.34 ea WIDE-SEAL SILICONE CONDOMS + LUBE MISC daily) DIAPHRAGM KIT 75 F TRUSTEX LUBRICATED F QL(3.34 ea DPRH EXTRALARGE MISC daily) WIDE-SEAL SILICONE TRUSTEX LUBRICATED F QL(3.34 ea DIAPHRAGM KIT 80 F EXTRASTRENGTH MISC daily) DPRH TRUSTEX LUBRICATED F QL(3.34 ea WIDE-SEAL SILICONE MISC daily) DIAPHRAGM KIT 85 F TRUSTEX QL(3.34 ea DPRH LUBRICATED/RIBBED/ST F daily) WIDE-SEAL SILICONE UDDED MISC DIAPHRAGM KIT 90 F TRUSTEX QL(3.34 ea DPRH LUBRICATED/SPERMICID F daily) WIDE-SEAL SILICONE E EXTRA LARGE MISC DIAPHRAGM KIT 95 F TRUSTEX QL(3.34 ea DPRH LUBRICATED/SPERMICID F daily) Diabetic Supplies E EXTRA STRENGTH MISC 1ST TIER UNILET QL(600 ea per COMFORTOUCH F 90 days retail) TRUSTEX QL(3.34 ea LANCETS 28G MISC LUBRICATED/SPERMICID F daily) E MISC 1ST TIER UNILET QL(600 ea per COMFORTOUCH F 90 days retail) TRUSTEX NATURAL QL(3.34 ea LANCETS 30G MISC CONDOMS F daily) +LUBE/LUBRICATED ADJUSTABLE LANCING F QL(1 ea per MISC DEVICE MISC 180 days retail) ADVOCATE LANCING F QL(1 ea per DEVICE MISC 180 days retail)
Oregon Trillium OHP Updated September 1, 2021
51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVOCATE RAPID-SAFE F QL(1 ea per COMFORT ASSURED QL(600 ea per LANCING DEVICE MISC 180 days retail) LANCETS SUPER THIN F 90 days retail) 28G MISC AGAMATRIX ULTRA-THIN F QL(600 ea per LANCETS 33G MISC 90 days retail) COMFORT LANCETS F QL(600 ea per MISC 90 days retail) AIMSCO TWIST LANCETS F QL(600 ea per 32G MISC 90 days retail) CVS LANCETS 21G MISC F QL(600 ea per 90 days retail) AIMSCO TWIST LANCETS F QL(600 ea per 33G MISC 90 days retail) CVS LANCETS MICRO F QL(600 ea per THIN 33G MISC 90 days retail) ALTERNATE SITE F QL(1 ea per LANCING DEVICE MISC 180 days retail) CVS LANCETS MICRO- F QL(600 ea per AQUA LANCE QL(1 ea per THIN 33G MISC 90 days retail) F ADJUSTABLE LANCING 180 days retail) CVS LANCETS ORIGINAL F QL(600 ea per DEVICE DEVI MISC 90 days retail) AURORA LANCET SUPER F QL(600 ea per CVS LANCETS THIN 26G F QL(600 ea per THIN30G MISC 90 days retail) MISC 90 days retail) AURORA LANCET THIN F QL(200 ea per CVS LANCETS ULTRA F QL(600 ea per 23G MISC 90 days retail) THIN 30G MISC 90 days retail) QL(1 ea per CVS LANCETS ULTRA- QL(600 ea per AUTO-LANCET MINI MISC F F 180 days retail) THIN 30G MISC 90 days retail) QL(1 ea per CVS LANCING DEVICE QL(1 ea per AUTO-LANCET MISC F F 180 days retail) MISC 180 days retail) AUTOLET IMPRESSION F QL(1 ea per CVS ULTRA THIN F QL(600 ea per LANCING DEVICE MISC 180 days retail) LANCETS MISC 90 days retail) AUTOLET LANCING F QL(1 ea per DIATHRIVE LANCETS F QL(600 ea per DEVICE MISC 180 days retail) MISC 90 days retail) QL(1 ea per DIATHRIVE LANCETS QL(600 ea per AUTOLET MINI MISC F F 180 days retail) ULTRA THIN 30G MISC 90 days retail) QL(1 ea per DIATHRIVE LANCING QL(1 ea per AUTOLET PLUS MISC F F 180 days retail) DEVICE MISC 180 days retail) BD LANCET ULTRAFINE F QL(600 ea per DROPLET GENTEEL F QL(1 ea per 30G MISC 90 days retail) LANCING DEVICE MISC 180 days retail) CARDIOCOM LANCING F QL(1 ea per DROPLET LANCETS F QL(600 ea per DEVICE MISC 180 days retail) ULTRA THIN 30G MISC 90 days retail) CAREONE ADVANCED F QL(1 ea per DROPLET LANCING F QL(1 ea per LANCINGDEVICE MISC 180 days retail) DEVICE MISC 180 days retail) CAREONE LANCET F QL(600 ea per DRUG MART QL(1 ea per SUPER THIN/30G MISC 90 days retail) ADJUSTABLE LANCING F 180 days retail) DEVICE MISC CAREONE LANCET THIN F QL(200 ea per MISC 90 days retail) DRUG MART LANCETS F QL(600 ea per THIN MISC 90 days retail) CARESENS LANCETS F QL(600 ea per MISC 90 days retail) DRUG MART UNILET QL(600 ea per CARETOUCH LANCING QL(1 ea per LANCETSSUPER THIN F 90 days retail) DEVICEWITH EJECTOR F 180 days retail) 30G MISC MISC DRUG MART UNILET QL(200 ea per LANCETSULTRA THIN F 90 days retail) CLEANLET LANCETS 28G F QL(600 ea per MISC 90 days retail) 28G MISC
Oregon Trillium OHP Updated September 1, 2021
52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DRUG MART UNILET QL(600 ea per EQL THIN LANCETS 26G F QL(600 ea per MICRO THIN LANCETS F 90 days retail) MISC 90 days retail) 33G MISC EZ-LETS LANCETS 26G F QL(600 ea per E-Z JECT LANCETS 21G F QL(600 ea per SUPER-SOFT MISC 90 days retail) MISC 90 days retail) EZ-LETS LANCETS 28G F QL(600 ea per E-Z JECT LANCETS F QL(600 ea per ULTRA-SOFT MISC 90 days retail) COLOR MISC 90 days retail) EZ-LETS LANCETS 30G F QL(600 ea per QL(600 ea per MISC 90 days retail) E-Z JECT LANCETS MISC F 90 days retail) QL(600 ea per FORA LANCETS MISC F E-Z JECT LANCETS F QL(600 ea per 90 days retail) SUPER THIN 30G MISC 90 days retail) FORA LANCING DEVICE F QL(1 ea per E-Z JECT LANCETS THIN F QL(600 ea per MISC 180 days retail) 26G MISC 90 days retail) FORA LANCING F QL(1 ea per E-ZJECT LANCETS F QL(600 ea per DEVICE/CLEARCAP MISC 180 days retail) MICRO-THIN 33G MISC 90 days retail) FREDS PHARMACY QL(1 ea per EASY MINI EJECT F QL(1 ea per AUTOLET LANCING F 180 days retail) LANCING DEVICE MISC 180 days retail) DEVICE MISC EASY MINI LANCING F QL(1 ea per FREDS PHARMACY QL(600 ea per DEVICE MISC 180 days retail) UNILET LANCETS SUPER F 90 days retail) THIN 30G MISC EASY TOUCH LANCETS F QL(600 ea per 26G/PULL-TOP MISC 90 days retail) FREDS PHARMACY QL(200 ea per UNILET LANCETS ULTRA F 90 days retail) EASY TOUCH LANCETS F QL(600 ea per 28G/PULL-TOP MISC 90 days retail) THIN 28G MISC GENTEEL LANCING QL(1 ea per EASY TOUCH LANCETS F QL(600 ea per 28G/TWIST MISC 90 days retail) DEVICE/GLORIOUS F 180 days retail) GOLD MISC EASY TOUCH LANCETS F QL(600 ea per 30G/PULL-TOP MISC 90 days retail) GENTEEL LANCING QL(1 ea per DEVICE/PRECIOUS F 180 days retail) EASY TOUCH LANCETS F QL(600 ea per PLATINUM MISC 30G/TWIST MISC 90 days retail) GENTEEL LANCING QL(1 ea per EASY TOUCH LANCETS F QL(600 ea per DEVICE/STATELY SILVER F 180 days retail) 32G/PULL-TOP MISC 90 days retail) MISC EASY TOUCH LANCETS F QL(600 ea per GENTEEL PLUS LANCING QL(1 ea per 32G/TWIST MISC 90 days retail) DEVICE/BUFF BLACK F 180 days retail) EASY TOUCH LANCETS F QL(600 ea per MISC 33G/TWIST MISC 90 days retail) GENTEEL PLUS LANCING QL(1 ea per EASY TOUCH LANCING F QL(1 ea per DEVICE/BUTTERFLY F 180 days retail) DEVICE/EJECTOR MISC 180 days retail) BLUE MISC EMBRACE LANCING QL(1 ea per GENTEEL PLUS LANCING QL(1 ea per DEVICE WITH EJECTOR F 180 days retail) DEVICE/PLAYFUL F 180 days retail) MISC PURPLE MISC EQL COLOR LANCETS F QL(600 ea per GENTEEL PLUS LANCING QL(1 ea per 21G MISC 90 days retail) DEVICE/PRINCESS PINK F 180 days retail) MISC EQL COLOR LANCETS F QL(600 ea per MICRO THIN 33G MISC 90 days retail) GENTEEL PLUS LANCING QL(1 ea per DEVICE/WILLOWY WHITE F 180 days retail) EQL SUPER THIN F QL(600 ea per LANCETS 30G MISC 90 days retail) MISC
Oregon Trillium OHP Updated September 1, 2021
53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GENTLE-LET GP F QL(600 ea per GOODSENSE LANCETS QL(600 ea per LANCETS MISC 90 days retail) ULTRA-THIN 30G F 90 days retail) GENTLE-LET LANCETS QL(600 ea per UNIVERSAL MISC GENERAL PURPOSE F 90 days retail) GOODSENSE LANCING F QL(1 ea per STYLE/FINE POINT MISC DEVICE MISC 180 days retail) GENTLE-LET LANCETS QL(600 ea per H-E-B INCONTROL QL(1 ea per GENERAL PURPOSE F 90 days retail) ADVANCEDLANCING F 180 days retail) STYLE/MEDIUM POINT DEVICE MISC MISC H-E-B INCONTROL QL(600 ea per GENTLE-LET LANCETS QL(600 ea per LANCETS MICRO THIN F 90 days retail) SAFETY STYLE/FINE F 90 days retail) 33G MISC POINT MISC H-E-B INCONTROL QL(600 ea per GENTLE-LET LANCETS QL(600 ea per LANCETS SUPER THIN F 90 days retail) SAFETY STYLE/MEDIUM F 90 days retail) 30G MISC POINT MISC H-E-B INCONTROL QL(200 ea per GLOBAL LANCING F QL(1 ea per LANCETS ULTRA THIN F 90 days retail) DEVICE MISC 180 days retail) 28G MISC QL(600 ea per HEALTH CARE LANCING QL(1 ea per GNP LANCETS 21G MISC F F 90 days retail) DEVICE MISC 180 days retail) GNP LANCETS MICRO F QL(600 ea per HEALTHY ACCENTS QL(1 ea per THIN 33G MISC 90 days retail) AUTOLET IMPRESSION F 180 days retail) LANCING DEVICE MISC GNP LANCETS SUPER F QL(600 ea per THIN 30G MISC 90 days retail) HEALTHY ACCENTS QL(600 ea per UNILET LANCETS SUPER F 90 days retail) GNP LANCETS THIN 26G F QL(600 ea per MISC 90 days retail) THIN 30G MISC QL(600 ea per GNP LANCETS THIN F QL(600 ea per HY-VEE LANCETS MISC F MISC 90 days retail) 90 days retail) GOJJI LANCING QL(1 ea per HY-VEE THIN LANCETS F QL(600 ea per DEVICE/CLEAR CAP F 180 days retail) MISC 90 days retail) MISC IN TOUCH LANCING F QL(1 ea per DEVICE MISC 180 days retail) GOJJI STERILE LANCETS F QL(600 ea per 30G MISC 90 days retail) QL(200 ea per KINNEY LANCETS MISC F GOODSENSE COLOR QL(600 ea per 90 days retail) LANCETS MICRO-THIN F 90 days retail) KINNEY THIN LANCETS F QL(200 ea per 33G UNIVERSAL MISC MISC 90 days retail) GOODSENSE LANCETS QL(600 ea per F KROGER AUTOLET F QL(1 ea per MICRO-THIN 33G MISC 90 days retail) LANCING DEVICE MISC 180 days retail) GOODSENSE LANCETS QL(600 ea per KROGER HEALTHPRO QL(600 ea per MICRO-THIN 33G F 90 days retail) TWIST LANCETS/26G F 90 days retail) UNIVERSAL MISC MISC GOODSENSE LANCETS QL(600 ea per KROGER LANCETS 21G F QL(600 ea per ULTRA-THIN 26G F 90 days retail) MISC 90 days retail) UNIVERSAL MISC KROGER LANCETS F QL(600 ea per GOODSENSE LANCETS F QL(600 ea per MICRO THIN33G MISC 90 days retail) ULTRA-THIN 30G MISC 90 days retail) KROGER LANCETS MISC F QL(600 ea per 90 days retail)
Oregon Trillium OHP Updated September 1, 2021
54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KROGER LANCETS F QL(600 ea per LIVE BETTER LANCET F QL(600 ea per SUPER THIN MISC 90 days retail) SUPERTHIN 30G MISC 90 days retail) KROGER LANCETS THIN F QL(600 ea per LIVE BETTER LANCET F QL(600 ea per 26G MISC 90 days retail) ULTRATHIN 28G MISC 90 days retail) KROGER LANCETS THIN F QL(600 ea per LONGS LANCETS F QL(600 ea per MISC 90 days retail) STANDARD MISC 90 days retail) KROGER LANCETS F QL(600 ea per LONGS LANCETS THIN F QL(600 ea per ULTRATHIN30G MISC 90 days retail) MISC 90 days retail) KROGER LANCING QL(1 ea per F MEDISENSE THIN F QL(600 ea per DEVICE MISC 180 days retail) LANCETS MISC 90 days retail) LANCET DEVICE F QL(1 ea per MEIJER COLOR QL(600 ea per ADJUSTABLE MISC 180 days retail) LANCETS UNIVERSAL F 90 days retail) 33G MISC LANCET DEVICE WITH F QL(1 ea per EJECTOR MISC 180 days retail) MEIJER LANCETS MISC F QL(600 ea per 90 days retail) LANCETS 26G TWIST F QL(600 ea per TOP MISC 90 days retail) MEIJER LANCETS THIN F QL(600 ea per QL(600 ea per MISC 90 days retail) LANCETS 28G MISC F 90 days retail) MEIJER LANCETS F QL(600 ea per QL(600 ea per UNIVERSAL21G MISC 90 days retail) LANCETS 30G MISC F 90 days retail) MEIJER LANCETS F QL(600 ea per QL(600 ea per UNIVERSAL30G MISC 90 days retail) LANCETS MISC F 90 days retail) MEIJER LANCETS F QL(600 ea per UNIVERSAL33G MISC 90 days retail) LANCETS SAFETY SEAL F QL(600 ea per 21G MISC 90 days retail) MEIJER SUPER THIN F QL(600 ea per LANCETS MISC 90 days retail) LANCETS SAFETY SEAL F QL(600 ea per 26G MISC 90 days retail) MICROLET NEXT MISC F QL(1 ea per 180 days retail) LANCETS SAFETY SEAL F QL(600 ea per 28G MISC 90 days retail) MINI LANCING DEVICE F QL(1 ea per QL(600 ea per MISC 180 days retail) LANCETS THIN MISC F 90 days retail) MM LANCING DEVICE F QL(1 ea per MISC 180 days retail) LANCETS ULTRA THIN F QL(600 ea per MISC 90 days retail) MM TWIST LANCETS F QL(600 ea per MISC 90 days retail) LANCING DEVICE F QL(1 ea per ADJUSTABLE MISC 180 days retail) MONOLET LANCETS F QL(600 ea per QL(1 ea per MISC 90 days retail) LANCING DEVICE MISC F 180 days retail) MONOLET OPD LANCETS F QL(600 ea per QL(1 ea per MISC 90 days retail) LANZO MISC F 180 days retail) MULTI-LANCET DEVICE F QL(1 ea per MISC 180 days retail) LEADER ADVANCED F QL(1 ea per QL(600 ea per LANCING DEVICE MISC 180 days retail) NOVA SUREFLEX F LANCETS MISC 90 days retail) LIBERTY MINI LANCING F QL(1 ea per DEVICE MISC 180 days retail) NOVA SUREFLEX F QL(1 ea per LANCING DEVICE MISC 180 days retail) LITE TOUCH LANCING F QL(1 ea per PEN MISC 180 days retail) ON CALL LANCING F QL(1 ea per DEVICE MISC 180 days retail) LIVE BETTER ADVANCED F QL(1 ea per LANCING DEVICE MISC 180 days retail) Oregon Trillium OHP Updated September 1, 2021
55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ON CALL PLUS LANCING QL(1 ea per F QC LANCETS ULTRA F QL(600 ea per DEVICE MISC 180 days retail) THIN MISC 90 days retail) ONETOUCH DELICA QL(1 ea per F QC UNILET LANCETS F QL(600 ea per LANCING DEVICE MISC 180 days retail) 28G/ULTRA THIN MISC 90 days retail) ONETOUCH DELICA QL(1 ea per QC UNILET LANCETS F QL(600 ea per PLUS LANCING DEVICE F 180 days retail) 33G/MICRO THIN MISC 90 days retail) MISC RA E-ZJECT LANCETS F QL(600 ea per ONETOUCH DELICA QL(1 ea per 28G MISC 90 days retail) SAFETY LACING DEVICE F 180 days retail) RA E-ZJECT LANCETS F QL(600 ea per MISC THIN 26G MISC 90 days retail) PC LANCETS SUPER QL(600 ea per F RA E-ZJECT LANCETS F QL(600 ea per THIN 30G MISC 90 days retail) THIN 28G MISC 90 days retail) PERFECT LANCETS 30G QL(600 ea per F RA E-ZJECT LANCETS F QL(600 ea per MISC 90 days retail) ULTRATHIN 30G MISC 90 days retail) PHARMACY COUNTER QL(600 ea per F REALITY LANCETS MISC F QL(600 ea per LANCETS MISC 90 days retail) 90 days retail) PRECISION THINS GP QL(600 ea per F RELION 2-IN-1 LANCET F QL(1 ea per LANCET MISC 90 days retail) DEVICES 30G MISC 180 days retail) PREFERRED PLUS QL(600 ea per RELION 2-IN-1 LANCING F QL(1 ea per LANCETS COLORED 21G F 90 days retail) DEVICE 25G MISC 180 days retail) MISC RELION 2-IN-1 LANCING F QL(1 ea per PREFERRED PLUS QL(600 ea per DEVICE 30G MISC 180 days retail) LANCETS SUPER THIN F 90 days retail) 30G MISC RELION LANCETS F QL(600 ea per MICRO-THIN33G MISC 90 days retail) PREFERRED PLUS F QL(600 ea per LANCETS THIN 26G MISC 90 days retail) RELION LANCETS THIN F QL(600 ea per 26G MISC 90 days retail) PRODIGY LANCING F QL(1 ea per DEVICE MISC 180 days retail) RELION LANCETS F QL(600 ea per ULTRA-THIN30G MISC 90 days retail) PRODIGY TWIST TOP F QL(600 ea per LANCETS MISC 90 days retail) RELION LANCING F QL(1 ea per DEVICE MISC 180 days retail) PSS SELECT GP F QL(600 ea per LANCETS MISC 90 days retail) RELION ULTRA THIN F QL(600 ea per LANCETS/30G MISC 90 days retail) PSS SELECT SAFETY F QL(600 ea per LANCETS MISC 90 days retail) RELION ULTRA THIN F QL(600 ea per LANCETS30G MISC 90 days retail) PX ADVANCED LANCING F QL(1 ea per DEVICE MISC 180 days retail) RELION ULTRA THIN QL(600 ea per PLUS LANCETS 32G F 90 days retail) PX LANCET AUTO F QL(1 ea per MISC INJECTOR MISC 180 days retail) RELION ULTRA THIN QL(600 ea per PX LANCETS MICROTHIN F QL(600 ea per PLUS LANCETS 33G F 90 days retail) 33G MISC 90 days retail) MISC PX LANCETS ULTRA QL(600 ea per F REXALL LANCETS ULTRA F QL(600 ea per THIN MISC 90 days retail) THIN MISC 90 days retail) QC ADVANCED LANCING QL(1 ea per F RIGHTEST GD500 F QL(1 ea per DEVICE MISC 180 days retail) LANCING DEVICE MISC 180 days retail) QC LANCETS SUPER QL(600 ea per QL(600 ea per F RIGHTEST GL300 F THIN MISC 90 days retail) LANCETS MISC 90 days retail)
Oregon Trillium OHP Updated September 1, 2021
56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFETY SEAL LANCETS QL(600 ea per F SURE-PEN MISC F QL(1 ea per 28G MISC 90 days retail) 180 days retail) SAFETY SEAL LANCETS F QL(600 ea per SURELITE LANCETS F QL(600 ea per 30G MISC 90 days retail) MISC 90 days retail) QL(600 ea per TECHLITE AST LANCETS QL(600 ea per SB LANCETS THIN MISC F F 90 days retail) MISC 90 days retail) SB LANCETS ULTRA F QL(600 ea per TECHLITE LANCETS 30G F QL(600 ea per THIN MISC 90 days retail) MISC 90 days retail) SELECT-LITE LANCING QL(1 ea per F TECHLITE LANCETS F QL(600 ea per DEVICE MISC 180 days retail) MISC 90 days retail) SHOPKO AUTOLET F QL(1 ea per TGT LANCET MICRO F QL(600 ea per LANCING DEVICE MISC 180 days retail) THIN 33G MISC 90 days retail) SHOPKO UNILET QL(600 ea per TGT LANCET THIN 26G F QL(600 ea per LANCETS SUPER THIN F 90 days retail) MISC 90 days retail) 30G MISC TGT LANCET ULTRA F QL(600 ea per SHOPKO UNILET QL(200 ea per THIN 30G MISC 90 days retail) LANCETS ULTRA THIN F 90 days retail) TGT LANCING DEVICE F QL(1 ea per 28G MISC MISC 180 days retail) SIMPLE DIAGNOSTICS QL(1 ea per F THINLETS GP LANCETS F QL(600 ea per LANCING DEVICE MISC 180 days retail) MISC 90 days retail) SM MICRO THIN F QL(600 ea per TODAYS HEALTH QL(1 ea per LANCETS 33G MISC 90 days retail) ADVANCED LANCING F 180 days retail) SM TRUEDRAW LANCING F QL(1 ea per DEVICE MISC DEVICE MISC 180 days retail) TODAYS HEALTH SUPER F QL(600 ea per SMART DIABETES QL(1 ea per THINLANCETS 30G MISC 90 days retail) VANTAGE LANCING F 180 days retail) TODAYS HEALTH ULTRA F QL(200 ea per DEVICE MISC THINLANCETS 28G MISC 90 days retail) SMART SENSE COLOR QL(600 ea per TOPCARE LANCETS F QL(600 ea per LANCETS UNIVERSAL F 90 days retail) MICRO-THIN 33G MISC 90 days retail) 33G MISC TRUE METRIX CONTROL Limit 1 package SMART SENSE QL(600 ea per SOLUTION LEVEL 1 F per 90 days STANDARD LANCETS F 90 days retail) SOLN UNIVERSAL 21G MISC TRUE METRIX CONTROL Limit 1 package SMART SENSE SUPER QL(600 ea per SOLUTION LEVEL 2 F per 90 days THIN LANCETS F 90 days retail) SOLN UNIVERSAL 30G MISC TRUE METRIX CONTROL Limit 1 package SMART SENSE THIN QL(600 ea per SOLUTION LEVEL 3 F per 90 days LANCETSUNIVERSAL F 90 days retail) SOLN 26G MISC TRUECONTROL Limit 1 package SOLUS V2 LANCING F QL(1 ea per GLUCOSE CONTROL F per 90 days DEVICE MISC 180 days retail) LEVEL 0 LIQD QL(600 ea per STERILANCE TL MISC F TRUECONTROL Limit 1 package 90 days retail) GLUCOSE CONTROL F per 90 days SUPER THIN LANCETS F QL(600 ea per LEVEL 1 LIQD MISC 90 days retail) TRUEDRAW LANCING F QL(1 ea per SURE COMFORT F QL(1 ea per DEVICE MISC 180 days retail) LANCING PEN MISC 180 days retail) Oregon Trillium OHP Updated September 1, 2021
57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUEPLUS LANCETS F QL(600 ea per VALUE PLUS LANCETS F QL(600 ea per 26G MISC 90 days retail) STANDARD 21G MISC 90 days retail) TRUEPLUS LANCETS F QL(600 ea per VALUE PLUS LANCETS F QL(600 ea per 28G MISC 90 days retail) SUPERTHIN 30G MISC 90 days retail) TRUEPLUS LANCETS F QL(600 ea per VALUE PLUS LANCETS F QL(600 ea per 28G SUPER THIN MISC 90 days retail) THIN 26G MISC 90 days retail) TRUEPLUS LANCETS F QL(600 ea per VALUE PLUS LANCING F QL(1 ea per 30G MISC 90 days retail) DEVICE MISC 180 days retail) TRUEPLUS LANCETS QL(600 ea per F VALUMARK LANCET F QL(600 ea per 30G ULTRA THIN MISC 90 days retail) SUPER THIN 30G MISC 90 days retail) TRUEPLUS LANCETS F QL(600 ea per VALUMARK LANCET F QL(200 ea per 33G MISC 90 days retail) ULTRA THIN 28G MISC 90 days retail) ULTI-LANCE AUTOMATIC/ F QL(1 ea per VIDA MIA AUTOLET F QL(1 ea per CLEAR TIP MISC 180 days retail) LANCINGDEVICE MISC 180 days retail) ULTILET CLASSIC F QL(600 ea per VIDA MIA UNILET QL(600 ea per LANCETS MISC 90 days retail) LANCETS SUPER THIN F 90 days retail) 30G MISC UNILET COMFORTOUCH F QL(600 ea per LANCET MISC 90 days retail) VIDA MIA UNILET QL(200 ea per LANCETS ULTRA THIN F 90 days retail) UNILET EXCELITE II MISC F QL(600 ea per 90 days retail) 28G MISC VIVAGUARD LANCING QL(1 ea per UNILET EXCELITE MISC F QL(600 ea per F 90 days retail) DEVICE MISC 180 days retail) WALGREENS COMFORT QL(600 ea per UNILET G.P. LANCET F QL(600 ea per MISC 90 days retail) ASSUREDLANCETS F 90 days retail) MICRO THIN/33G MISC UNILET G.P. SUPERLITE F QL(600 ea per LANCET MISC 90 days retail) WALGREENS COMFORT QL(600 ea per ASSUREDLANCETS F 90 days retail) UNILET GP 28 ULTRA F QL(600 ea per SUPER THIN/28G MISC THIN MISC 90 days retail) WALGREENS THIN F QL(600 ea per UNILET LANCET MISC F QL(600 ea per LANCETS MISC 90 days retail) 90 days retail) Misc. Devices UNILET LANCETS F QL(600 ea per MICRO-THIN33G MISC 90 days retail) QL(400 ea per ALCOHOL PREP PADS F 30 days retail); UNILET LANCETS F QL(600 ea per PADS SUPER-THIN30G MISC 90 days retail) RX/OTC QL(400 ea per UNILET LANCETS F QL(600 ea per ULTRA-THIN 28G MISC 90 days retail) ALCOHOL SWABS PADS F 30 days retail); RX/OTC UNILET SUPERLITE F QL(600 ea per LANCET MISC 90 days retail) AMEDA PURELY YOURS QL(1 ea per BREASTPUMP/HYGIENIKI F 365 days UNIVERSAL 1 LANCETS F QL(600 ea per T MISC retail); RX/OTC THIN26G MISC 90 days retail) AMEDA PURELY YOURS QL(1 ea per UNIVERSAL 1 LANCETS F QL(600 ea per ELECTRIC BREAST F 365 days ULTRA THIN 30G MISC 90 days retail) PUMP/HYGIENIKIT MISC retail); RX/OTC UNIVERSAL 1 QL(600 ea per QL(400 ea per LANCETS/33G/MICRO- F 90 days retail) BD SWABS SINGLE USE F BUTTERFLY PADS 30 days retail); THIN MISC RX/OTC
Oregon Trillium OHP Updated September 1, 2021
58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD SWABS SINGLE USE QL(400 ea per QL(400 ea per F 30 days retail); HM STERILE ALCOHOL F 30 days retail); PADS PREP PADS PADS RX/OTC RX/OTC QL (1 ea per QL(1 ea per Breast pump F 365 days KANESON BREAST F PUMP/NURSER MISC 365 days retail); RX/OTC retail); RX/OTC CURITY ALCOHOL QL(400 ea per MEIJER ALCOHOL QL(400 ea per PREPS/MEDIUM 2 PLY F 30 days retail); SWABS EXTRA-THICK F 30 days retail); PADS RX/OTC PADS RX/OTC CURITY ALCOHOL QL(400 ea per QL (1 ea per F 30 days retail); PILL SPLITTER F 365 days SWABS PADS RX/OTC retail); RX/OTC QL(1 ea per QL(1 ea per CVS PILL SPLITTER MISC F 365 days PILL SPLITTER MISC F 365 days retail); RX/OTC retail); RX/OTC QL(400 ea per PILL SPLITTER MISC F RX/OTC CVS PREP PADS PADS F 30 days retail); RX/OTC PUMP IN STYLE QL(1 ea per QL(1 ea per ADVANCED DOUBLE F 365 days DELUXE SAFETY TABLET F 365 days BREASTPUMP MISC retail); RX/OTC CUTTER MISC retail); RX/OTC PUMP IN STYLE QL(1 ea per QL(1 ea per ADVANCED DOUBLE F 365 days DELUXE TABLET F BREASTPUMP/BACKPAC retail); RX/OTC CUTTER MISC 365 days retail); RX/OTC K MISC EASY TOUCH ALCOHOL QL(400 ea per QL(400 ea per QC ALCOHOL SWABS F 30 days retail); PREP PADS/MEDIUM F 30 days retail); PADS PADS RX/OTC RX/OTC QL(400 ea per QL(400 ea per RA ALCOHOL SWABS EQL ALCOHOL SWABS F F 30 days retail); PADS 30 days retail); PADS RX/OTC RX/OTC EZY DOSE ORIGINAL QL(1 ea per QL(400 ea per TABLETCUTTER/DAILY F 365 days REALITY SWABS PADS F 30 days retail); DOSE MISC retail); RX/OTC RX/OTC QL(400 ea per QL(1 ea per RELION ALCOHOL EZY DOSE TABLET F F 30 days retail); CUTTER ORIGINAL MISC 365 days SWABS PADS retail); RX/OTC RX/OTC QL(400 ea per QL(400 ea per SB ALCOHOL PREP FIFTY50 ALCOHOL PREP F F 30 days retail); PADS PADS 30 days retail); PADS PADS RX/OTC RX/OTC QL(400 ea per QL(400 ea per SHOPKO ALCOHOL GNP ALCOHOL SWABS F F 30 days retail); PADS 30 days retail); SWABS PADS RX/OTC RX/OTC QL(400 ea per SIGNATURE PRO RX/OTC H-E-B INCONTROL F DOUBLE ELECTRIC F ALCOHOL PADS PADS 30 days retail); RX/OTC BREAST PUMP MISC QL(1 ea per HARMONY BREASTPUMP F 365 days MISC retail); RX/OTC Oregon Trillium OHP Updated September 1, 2021
59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SIGNATURE PRO QL(1 ea per 30-35ML SYRINGE/LUER RX/OTC HEALTHCAREDOUBLE F 365 days SLIPTIP/ECCENTRIC TIP F ELECTRIC BREAST retail); RX/OTC MISC PUMP MISC 3ML LUER LOCK SAFETY RX/OTC F SIMPLYGO BREAST QL(1 ea per SYRINGES 3ML/22G X 1 F 365 days 1/2" MISC PUMP/DUAL MISC retail); RX/OTC 3ML LUER LOCK SAFETY RX/OTC F SIMPLYGO BREAST QL(1 ea per SYRINGES/3ML/21G X 1 F 365 days 1/2" MISC PUMP/SINGLE MISC retail); RX/OTC 3ML LUER LOCK SAFETY F SM ALCOHOL PREP QL(400 ea per SYRINGES/3ML/22G X 1" F 30 days retail); MISC PADS PADS RX/OTC 3ML LUER LOCK SAFETY RX/OTC QL(1 ea per SYRINGES/3ML/23G X 1" F TABLET CUTTER MISC F 365 days MISC retail); RX/OTC 3ML LUER LOCK SAFETY RX/OTC TABLET QL(1 ea per SYRINGES/3ML/25G X 1" F CUTTER/DELUXE F 365 days MISC SAFETY MISC retail); RX/OTC 3ML LUER LOCK SAFETY RX/OTC QL(400 ea per SYRINGES/3ML/25G X F TGT ALCOHOL SWABS F 5/8" MISC PADS 30 days retail); RX/OTC 3ML LUER-LOK SYRINGE F RX/OTC QL(400 ea per 22GX 1-1/2" MISC ULTICARE ALCOHOL F 30 days retail); SWABS PADS 3ML LUER-LOK F RX/OTC RX/OTC SYRINGE21G X 1" MISC WEBCOL ALCOHOL QL(400 ea per 3ML LUER-LOK RX/OTC PREP LARGE 1 PLY F 30 days retail); SYRINGE21G X 1-1/2" F PADS RX/OTC MISC WEBCOL ALCOHOL QL(400 ea per 3ML LUER-LOK F PREP LARGE 2 PLY F 30 days retail); SYRINGE22G X 1" MISC PADS RX/OTC 3ML LUER-LOK F RX/OTC WEBCOL ALCOHOL QL(400 ea per SYRINGE25G X 5/8" MISC PREP MEDIUM 2 PLY F 30 days retail); PADS RX/OTC 3ML LUER-LOK TIP SYRINGE25G X 1-1/2" F Parenteral Therapy Supplies MISC 1ML SYRINGE/NEEDLE RX/OTC 3ML SYRINGE/18G X 1- F RX/OTC SLIP TIP 25GX5/8" SUB-Q F 1/2"/LUER LOCK TIP MISC MISC 3ML SYRINGE/20G X F RX/OTC 2-3ML SYRINGE/LUER F RX/OTC 1"/LUER LOCK TIP MISC LOCK TIP MISC 3ML SYRINGE/20G X F RX/OTC 2-3ML SYRINGE/LUER F RX/OTC 1"/LUER SLIP TIP MISC SLIP TIP MISC 3ML SYRINGE/20G X 1- F RX/OTC 30-35ML RX/OTC 1/2"/LUER LOCK TIP MISC SYRINGE/CATHETERTIP F 3ML SYRINGE/21G X F RX/OTC MISC 1"/LUER LOCK TIP MISC 30-35ML SYRINGE/LUER RX/OTC F 3ML SYRINGE/21G X F RX/OTC LOCKTIP MISC 1"/LUER SLIP TIP MISC Oregon Trillium OHP Updated September 1, 2021
60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 3ML SYRINGE/21G X 1- RX/OTC ADVOCATE INSULIN QL(6 ea daily); 1/2"/LUER LOCK TIP F SYRINGE/U- F RX/OTC MISC 100/0.3ML/30GX5/16" 3ML SYRINGE/21G X 1- MISC 1/4"/LUER LOCK TIP F ADVOCATE INSULIN QL(6 ea daily) MISC SYRINGE/U- F 3ML SYRINGE/22G 1- RX/OTC 100/0.3ML/31GX5/16" 1/2"/LUER LOCK TIP F MISC MISC ADVOCATE INSULIN QL(6 ea daily); SYRINGE/U- F RX/OTC 3ML SYRINGE/22G X F 1"/LUER LOCK TIP MISC 100/0.5ML/29GX1/2" MISC 3ML SYRINGE/22G X 1- ADVOCATE INSULIN QL(6 ea daily); 1/4"/LUER LOCK TIP F SYRINGE/U- F RX/OTC MISC 100/0.5ML/30GX5/16" MISC 3ML SYRINGE/22G X 3/4"/LUER LOCK TIP F ADVOCATE INSULIN QL(6 ea daily) MISC SYRINGE/U- F 100/0.5ML/31GX5/16" 3ML SYRINGE/22G X F MISC 3/4"/LUER SLIP TIP MISC ADVOCATE INSULIN QL(6 ea daily); 3ML SYRINGE/25G X F RX/OTC SYRINGE/U- F RX/OTC 1"/LUER LOCK TIP MISC 100/1ML/29GX1/2" MISC 3ML SYRINGE/27G X 1- RX/OTC ADVOCATE INSULIN QL(6 ea daily); 1/4"/LUER LOCK TIP F SYRINGE/U- F RX/OTC MISC 100/1ML/30GX5/16" MISC 3ML SYRINGE/INTERLINK RX/OTC ADVOCATE INSULIN QL(6 ea daily) SYRINGE CANNULA F SYRINGE/U- F MISC 100/1ML/31GX5/16" MISC 3ML SYRINGE/INTERLINK RX/OTC ASSURE ID INSULIN QL(6 ea daily); VIAL ACCESS CANNULA F SAFETYSYRINGE/U- F RX/OTC MISC 100/0.5ML/29G X 1/2" 3ML SYRINGE/LUER F RX/OTC MISC LOCK TIP MISC ASSURE ID INSULIN QL(6 ea daily); 3ML SYRINGE/LUER F RX/OTC SAFETYSYRINGE/U- F RX/OTC LOCK TIP23GX1" MISC 100/1ML/29G X 1/2" MISC 3ML SYRINGE/LUER B-D INSULIN SYRINGE QL(6 ea daily) LOCK TIP25G X 1-1/2" F ULTRAFINE II/0.3ML/31G F MISC X 5/16" MISC 3ML SYRINGE/LUER SLIP F RX/OTC B-D INSULIN SYRINGE QL(6 ea daily) TIP23GX1" MISC ULTRAFINE II/0.5ML/31G F 3ML SYRINGE/NEEDLE RX/OTC X 5/16" MISC REGULAR WALL LUER- F B-D INSULIN SYRINGE QL(6 ea daily) LOK 25GX5/8" SUB-Q ULTRAFINE II/1ML/31G X F MISC 5/16" MISC ADVOCATE INSULIN QL(6 ea daily); B-D INSULIN SYRINGE QL(6 ea daily) SYRINGE/U- F RX/OTC ULTRAFINE/0.3ML/30G X F 100/0.3ML/29GX1/2" MISC 1/2" MISC
Oregon Trillium OHP Updated September 1, 2021
61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits B-D INSULIN SYRINGE QL(6 ea daily) BD 3ML RX/OTC F ULTRAFINE/0.5ML/30G X SYRINGE/SAFETYGLIDE F 1/2" MISC SHIELDING IM NEEDLE BD LO-DOSE INSULIN QL(6 ea daily); 22GX1-1/2" MISC SYRINGE MICROFINE F RX/OTC BD 3ML RX/OTC IV/0.5ML/28G X 1/2" MISC SYRINGE/SAFETYGLIDE F BD 1ML SHIELDING IM NEEDLE 23GX1" MISC SYRINGE/NEEDLE/SLIP F TIP/SUBQ/26G X 5/8" BD 3ML RX/OTC MISC SYRINGE/SAFETYGLIDE F BD 1ML RX/OTC SHIELDING NEEDLE 25GX5/8" MISC SYRINGE/SAFETYGLIDE F SHIELDING NEEDLE 25G BD AUTOSHIELD DUO F QL(6 ea daily) X 5/8" MISC 30G X 5MM MISC BD 1ML TUBERCULIN F RX/OTC BD BLUNT FILL RX/OTC SYRINGESLIP-TIP MISC NEEDLE/18GX 1-1/2" F BD 3ML LUER-LOCK RX/OTC MISC SYRINGE18G X 1 1/2" F BD DISPOSABLE NEEDLE RX/OTC MISC 23GX1" PRECISION F BD 3ML LUER-LOK RX/OTC GLIDE MISC F SYRINGE 18G X 1 1/2" BD DISPOSABLE NEEDLE F MISC 23GX1-1/4" MISC BD 3ML LUER-LOK RX/OTC BD DISPOSABLE NEEDLE F RX/OTC SYRINGE 20G X 1-1/2" F 27GX1-1/4" MISC MISC BD DISPOSABLE NEEDLE F BD 3ML LUER-LOK F RX/OTC REGULAR BEVEL 22G X SYRINGE/20G X 1" MISC 3/4" MISC BD 3ML LUER-LOK F RX/OTC BD DISPOSABLE NEEDLE RX/OTC SYRINGE/21G X 1" MISC REGULAR BEVEL 25GX1" F BD 3ML LUER-LOK RX/OTC MISC SYRINGE/21G X 1-1/2" F BD DISPOSABLE NEEDLE RX/OTC MISC REGULAR BEVEL THIN F WALL 18G X 1" MISC BD 3ML LUER-LOK F RX/OTC SYRINGE/23G X 1" MISC BD DISPOSABLE F BD 3ML LUER-LOK NEEDLE/30GX1" MISC SYRINGE/23G X 1-1/2" F BD ECLIPSE SYRINGE F RX/OTC MISC 3ML/21G X 1" MISC BD 3ML LUER-LOK F RX/OTC BD ECLIPSE SYRINGE SYRINGE/25G X 1" MISC LUER-LOK/3ML/22G X 1" F BD 3ML LUER-LOK MISC SYRINGE/26G X 5/8" F BD ECLIPSE SYRINGE RX/OTC MISC LUER-LOK/3ML/25G X 1" F MISC BD 3ML SYRINGE LUER- F RX/OTC LOK TIP MISC BD ECLIPSE SYRINGE RX/OTC SLIP TIP/1ML/25G X 5/8" F BD 3ML SYRINGE SLIP F RX/OTC TIP MISC MISC
Oregon Trillium OHP Updated September 1, 2021
62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD ECLIPSE RX/OTC BD HYPODERMIC F RX/OTC SYRINGE/3ML/23G X 1" F NEEDLES 21GX2" MISC MISC BD HYPODERMIC F RX/OTC BD ECLIPSE RX/OTC NEEDLES 22GX1" MISC SYRINGE/3ML/25GX5/8" F BD HYPODERMIC F RX/OTC MISC NEEDLES 22GX1.5" MISC BD ECLIPSE RX/OTC BD HYPODERMIC F RX/OTC SYRINGE/LUER- F NEEDLES 23GX3/4" MISC LOK/3ML/22G X 1-1/2" MISC BD HYPODERMIC F RX/OTC NEEDLES 25GX1.5" MISC BD HYPODERMIC F NEEDLE 26GX3/8" MISC BD HYPODERMIC F RX/OTC NEEDLES 26GX1/2" MISC BD HYPODERMIC NEEDLE REGULAR F BD INSULIN SYRINGE QL(6 ea daily); BEVEL 26GX5/8" MISC LUER-LOK/U-100/1ML F RX/OTC MISC BD HYPODERMIC RX/OTC BD INSULIN SYRINGE QL(6 ea daily); NEEDLE REGULAR F BEVEL THIN WALL 18G X MICROFINE IV/U- F RX/OTC 1-1/2" MISC 100/0.5ML/28G X 1/2" MISC BD HYPODERMIC RX/OTC BD INSULIN SYRINGE QL(6 ea daily) NEEDLE REGULAR F BEVEL THIN WALL MICROFINE IV/U- F 21GX1" MISC 100/1ML/27G X 5/8" MISC BD HYPODERMIC RX/OTC BD INSULIN SYRINGE QL(6 ea daily); MICROFINE IV/U- F RX/OTC NEEDLE REGULAR F BEVEL THIN WALL 100/1ML/28G X 1/2" MISC 21GX1-1/2" MISC BD INSULIN SYRINGE QL(6 ea daily); BD HYPODERMIC RX/OTC MICROFINE/U- F RX/OTC 100/0.5ML/28G X 1/2" NEEDLE REGULAR F BEVEL THIN WALL MISC 23GX1" MISC BD INSULIN SYRINGE QL(6 ea daily) BD HYPODERMIC MICROFINE/U- F 100/1ML/27G X 5/8" MISC NEEDLE REGULAR F BEVEL THIN WALL BD INSULIN SYRINGE QL(6 ea daily); 23GX1-1/2" MISC MICROFINE/U- F RX/OTC 100/1ML/28G X 1/2" MISC BD HYPODERMIC F RX/OTC NEEDLES 16GX1" MISC BD INSULIN SYRINGE QL(6 ea daily); SAFETYGLIDE/1ML/29G X F RX/OTC BD HYPODERMIC F RX/OTC NEEDLES 18GX1" MISC 1/2" MISC BD INSULIN SYRINGE QL(6 ea daily); BD HYPODERMIC F RX/OTC F NEEDLES 18GX1.5" MISC SLIP TIP/U-100/1ML MISC RX/OTC BD INSULIN SYRINGE QL(6 ea daily) BD HYPODERMIC F RX/OTC NEEDLES 19GX1" MISC ULTRA-FINE/0.3ML/30G X F 12.7MM MISC BD HYPODERMIC F RX/OTC NEEDLES 19GX1.5" MISC BD INSULIN SYRINGE QL(6 ea daily) ULTRA-FINE/0.3ML/31G X F BD HYPODERMIC F RX/OTC 8MM MISC NEEDLES 21GX1" MISC
Oregon Trillium OHP Updated September 1, 2021
63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE QL(6 ea daily) BD INSULIN SYRINGE QL(6 ea daily) F ULTRA-FINE/0.5ML/30G X ULTRAFINE/U- F 12.7MM MISC 100/1ML/31G X 5/16" BD INSULIN SYRINGE QL(6 ea daily) MISC ULTRA-FINE/0.5ML/31G X F BD INSULIN QL(6 ea daily); 8MM MISC SYRINGE/0.3ML/29G X F RX/OTC BD INSULIN SYRINGE QL(6 ea daily) 12.7MM MISC ULTRA-FINE/1/2 F BD INSULIN QL(6 ea daily); UNIT/0.3ML/31G X 8MM SYRINGE/0.5ML/29G X F RX/OTC MISC 12.7MM MISC BD INSULIN SYRINGE QL(6 ea daily) BD INSULIN QL(6 ea daily); ULTRA-FINE/1ML/30G X F SYRINGE/1ML/27G X F RX/OTC 12.7MM MISC 12.7MM MISC BD INSULIN SYRINGE QL(6 ea daily) BD INSULIN QL(6 ea daily); ULTRA-FINE/1ML/31G X F SYRINGE/1ML/29G X F RX/OTC 8MM MISC 12.7MM MISC BD INSULIN SYRINGE QL(6 ea daily) BD INSULIN QL(6 ea daily) ULTRAFINE HALF- F SYRINGE/DETACHABLE F UNIT/0.3ML/31G X 5/16" NEEDLE/U-100/1ML/25G MISC X 1" MISC BD INSULIN SYRINGE QL(6 ea daily) BD INSULIN QL(6 ea daily) F ULTRAFINE/0.3ML/30G X SYRINGE/DETACHABLE F 1/2" MISC NEEDLE/U-100/1ML/25G BD INSULIN SYRINGE QL(6 ea daily) X 5/8" MISC ULTRAFINE/0.3ML/31G X F BD INSULIN QL(6 ea daily) 5/16" MISC SYRINGE/DETACHABLE F BD INSULIN SYRINGE QL(6 ea daily) NEEDLE/U-100/1ML/26G ULTRAFINE/0.5ML/30G X F X 1/2" MISC 1/2" MISC BD INSULIN SYRINGE/U- F QL(6 ea daily); BD INSULIN SYRINGE QL(6 ea daily) 100/1ML/27G X 1/2" MISC RX/OTC ULTRAFINE/0.5ML/31G X F BD INSULIN SYRINGE/U- QL(6 ea daily) 5/16" MISC 100/2ML/27.5G X 5/8" F BD INSULIN SYRINGE QL(6 ea daily) MISC ULTRAFINE/1ML/30G X F BD INSULIN SYRINGE/U- QL(6 ea daily) 1/2" MISC 500/0.5ML/31G X 6MM F BD INSULIN SYRINGE QL(6 ea daily); MISC ULTRAFINE/U- F RX/OTC BD INTEGRA 3ML RX/OTC 100/0.3ML/29G X 1/2" SYRINGE MISC W/RETRACTING F BD INSULIN SYRINGE QL(6 ea daily); NEEDLE/21G X 1-1/2" MISC ULTRAFINE/U- F RX/OTC 100/0.5ML/29G X 1/2" BD INTEGRA 3ML RX/OTC MISC SYRINGE F BD INSULIN SYRINGE QL(6 ea daily); W/RETRACTING ULTRAFINE/U- F RX/OTC NEEDLE/25G X 1" MISC 100/1ML/29G X 1/2" MISC BD INTEGRA RX/OTC SYRINGE/3ML/21G X 1" F MISC
Oregon Trillium OHP Updated September 1, 2021
64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INTEGRA RX/OTC BD SAFETYGLIDE QL(6 ea daily); SYRINGE/3ML/22G X 1.5" F INSULIN F RX/OTC MISC SYRINGE/0.3ML/29G X BD INTEGRA RX/OTC 1/2" MISC SYRINGE/3ML/23G X 1" F BD SAFETYGLIDE QL(6 ea daily); MISC INSULIN F RX/OTC BD INTEGRA RX/OTC SYRINGE/0.3ML/31G X SYRINGE/3ML/25G X 5/8 F 15/64" MISC MISC BD SAFETYGLIDE QL(6 ea daily) BD LUER-LOK SYRINGE RX/OTC INSULIN F W/ECLIPSE NEEDLE F SYRINGE/0.3ML/31G X MISC 5/16" MISC BD SAFETYGLIDE QL(6 ea daily) BD NEEDLE/16G X 1-1/2" F RX/OTC MISC INSULIN F SYRINGE/0.5ML/31G X BD NEEDLE/18G 1-1/2" F RX/OTC 15/64" MISC MISC BD SAFETYGLIDE QL(6 ea daily) BD NEEDLE/19G X 1" RX/OTC F INSULIN F MISC SYRINGE/1ML/31G X BD NEEDLE/20G X 1" F RX/OTC 15/64" MISC MISC BD SAFETYGLIDE QL(6 ea daily); BD NEEDLE/20G X 1-1/2" RX/OTC F INSULIN F RX/OTC MISC SYSYRINGE/0.5ML/30G X 5/16" MISC BD NEEDLE/21G 1-1/2" F RX/OTC MISC BD SAFETYGLIDE RX/OTC SYRINGE 3ML/25GX1" F BD NEEDLE/22G X 1-1/2" F RX/OTC MISC MISC BD NEEDLE/25G X 5/8" RX/OTC QL(2 ea per 30 F BD SHARPS COLLECTOR F MISC MISC days retail); RX/OTC BD NEEDLE/25G X 7/8" F MISC BD SHARPS QL(2 ea per 30 COLLECTOR/EXTRALAR F days retail); BD NEEDLE/27G X 1/2" F RX/OTC MISC GE MISC RX/OTC BD SHARPS QL(2 ea per 30 BD NEEDLE/30G X 1/2" F MISC COLLECTOR/SMALL F days retail); MISC RX/OTC QL(2 ea per 30 BD NESTABLE SHARPS F days retail); QL(2 ea per 30 COLLECTOR MISC BD SHARPS CONTAINER F RX/OTC HOME MISC days retail); RX/OTC BD PEN NEEDLES F QL (6 ea daily); RX/OTC QL(2 ea per 30 BD SHARPS DISPOSAL F BY MAIL 1.4 QUART MISC days retail); BD SAFETY-GLIDE QL(6 ea daily); RX/OTC INSULIN F RX/OTC SYRINGE/0.5ML/29G X BD SYRINGE LUER- F RX/OTC 1/2" MISC LOK/1ML MISC BD SAFETY-LOK INSULIN QL(6 ea daily); BD SYRINGE SLIP TIP F RX/OTC 1ML MISC SYRINGE/PERM F RX/OTC NEEDLE/UF/1ML/29G X 1/2" MISC Oregon Trillium OHP Updated September 1, 2021
65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD VEO INSULIN QL(6 ea daily) CAREONE INSULIN QL(6 ea daily) SYRINGE ULTR-FINE/U- F SYRINGES/1ML/31GX5/16 F 100/0.5ML/31G X 15/64" " MISC MISC CAREPOINT SAFETY 1ST BD VEO INSULIN QL(6 ea daily); SYRINGE/NEEDLE F SYRINGE ULTRA- F RX/OTC 1ML/23G X 1" MISC AFINE/0.3ML/31G X 6MM CAREPOINT SAFETY 1ST RX/OTC MISC SYRINGE/NEEDLE F BD VEO INSULIN QL(6 ea daily); 1ML/25G X 1" MISC SYRINGE ULTRA- F RX/OTC CARETOUCH INSULIN QL(6 ea daily) FINE/0.3ML/31G X 6MM SYRINGE/U-100/1ML/28G F MISC X 5/16" MISC BD VEO INSULIN QL(6 ea daily) CARETOUCH INSULIN QL(6 ea daily) SYRINGE ULTRA- F SYRINGE/U-100/1ML/29G F FINE/0.5ML/31G X 6MM X 5/16" MISC MISC CLEVER CHOICE QL(6 ea daily); BD VEO INSULIN QL(6 ea daily); COMFORT EZINSULIN F RX/OTC SYRINGE ULTRA- F RX/OTC SYRINGE/0.3ML/29G X FINE/1/2 UNIT/0.3ML/31G 1/2" MISC X 6MM MISC CLEVER CHOICE QL(6 ea daily) BD VEO INSULIN QL(6 ea daily) COMFORT EZINSULIN F SYRINGE ULTRA- F SYRINGE/0.3ML/30G X FINE/1ML/31G X 6MM 1/2" MISC MISC CLEVER CHOICE QL(6 ea daily); BD VEO INSULIN QL(6 ea daily); COMFORT EZINSULIN F RX/OTC SYRINGE ULTRA-FINE/U- F RX/OTC SYRINGE/0.3ML/30G X 100/0.3ML/31G X 15/64" 5/16" MISC MISC CLEVER CHOICE QL(6 ea daily) BD VEO INSULIN QL(6 ea daily) COMFORT EZINSULIN F SYRINGE ULTRA-FINE/U- F SYRINGE/0.3ML/31G X 100/1ML/31G X 15/64" 5/16" MISC MISC CLEVER CHOICE QL(6 ea daily); CAREONE INSULIN QL(6 ea daily) COMFORT EZINSULIN F RX/OTC SYRINGES/0.3ML/30G X F SYRINGE/0.5ML/28G X 1/2" MISC 1/2" MISC CAREONE INSULIN QL(6 ea daily) CLEVER CHOICE QL(6 ea daily); SYRINGES/0.3ML/31G X F COMFORT EZINSULIN F RX/OTC 5/16" MISC SYRINGE/0.5ML/29G X CAREONE INSULIN QL(6 ea daily) 1/2" MISC SYRINGES/0.5ML/30G X F CLEVER CHOICE QL(6 ea daily) 1/2" MISC COMFORT EZINSULIN F CAREONE INSULIN QL(6 ea daily) SYRINGE/0.5ML/30G X SYRINGES/0.5ML/31G X F 1/2" MISC 5/16" MISC CLEVER CHOICE QL(6 ea daily); CAREONE INSULIN QL(6 ea daily) COMFORT EZINSULIN F RX/OTC SYRINGES/1ML/30G X F SYRINGE/0.5ML/30G X 1/2" MISC 5/16" MISC
Oregon Trillium OHP Updated September 1, 2021
66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE QL(6 ea daily) COMFORT ASSIST QL(6 ea daily); COMFORT EZINSULIN F INSULIN F RX/OTC SYRINGE/0.5ML/31G X SYRINGE/1ML/29G X 1/2" 5/16" MISC MISC CLEVER CHOICE QL(6 ea daily) COMFORT ASSIST QL(6 ea daily); COMFORT EZINSULIN F INSULIN F RX/OTC SYRINGE/1.0ML/30G X SYRINGE/1ML/30G X 1/2" MISC 5/16" MISC CLEVER CHOICE QL(6 ea daily); COMFORT ASSIST QL(6 ea daily) COMFORT EZINSULIN F RX/OTC INSULIN F SYRINGE/1ML/28G X 1/2" SYRINGE/1ML/31G X MISC 5/16" MISC CLEVER CHOICE QL(6 ea daily); COMFORT EZ INSULIN QL(6 ea daily) COMFORT EZINSULIN F RX/OTC SYRINGE/U- F SYRINGE/1ML/29G X 1/2" 100/0.5ML/31G X 5/16" MISC MISC CLEVER CHOICE QL(6 ea daily); COMFORT EZ INSULIN QL(6 ea daily) COMFORT EZINSULIN F RX/OTC SYRINGE/U-100/1ML/31G F SYRINGE/1ML/30G X X 5/16" MISC 5/16" MISC COMPLETE NEEDLE QL(2 ea per 30 CLEVER CHOICE QL(6 ea daily) COLLECTION & F days retail); COMFORT EZINSULIN F DISPOSAL SYSTEM MISC RX/OTC SYRINGE/U- DIALYSIS SAFETY 100/1ML/31GX5/16" MISC SYRINGES/LOW DEAD F COMFORT ASSIST QL(6 ea daily); SPACE 1ML/22GX1-1/2" INSULIN SYRINGE F RX/OTC MISC 0.3ML/29G X 1/2" MISC DIALYSIS SAFETY RX/OTC COMFORT ASSIST QL(6 ea daily); SYRINGES/LOW DEAD F INSULIN F RX/OTC SPACE 3ML/22GX1-1/2" SYRINGE/0.3ML/30G X MISC 5/16" MISC DROPLET INSULIN QL(6 ea daily); COMFORT ASSIST QL(6 ea daily) SYRINGE 0.3ML/29G X F RX/OTC INSULIN F 1/2" MISC SYRINGE/0.3ML/31G X DROPLET INSULIN QL(6 ea daily); 5/16" MISC SYRINGE 0.5ML/29G X F RX/OTC COMFORT ASSIST QL(6 ea daily); 1/2" MISC INSULIN F RX/OTC DROPLET INSULIN QL(6 ea daily); SYRINGE/0.5ML/29G X SYRINGE 1ML/29G X 1/2" F RX/OTC 1/2" MISC MISC COMFORT ASSIST QL(6 ea daily); DROPLET INSULIN QL(6 ea daily) INSULIN F RX/OTC SYRINGE U-100/0.3/31G X F SYRINGE/0.5ML/30G X 5/16" MISC 5/16" MISC DROPLET INSULIN QL(6 ea daily) COMFORT ASSIST QL(6 ea daily) SYRINGE U- F INSULIN F 100/0.3ML/30G X 1/2" SYRINGE/0.5ML/31G X MISC 5/16" MISC
Oregon Trillium OHP Updated September 1, 2021
67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET INSULIN QL(6 ea daily); DROPLET INSULIN QL(6 ea daily) SYRINGE U- F RX/OTC SYRINGE/U- F 100/0.3ML/30G X 5/16" 100/0.5ML/31G X 5/16" MISC MISC DROPLET INSULIN QL(6 ea daily); DROPLET INSULIN QL(6 ea daily) SYRINGE U- F RX/OTC SYRINGE/U-100/1ML/30G F 100/0.3ML/31G X 15/64" X 1/2" MISC MISC DROPLET INSULIN QL(6 ea daily) DROPLET INSULIN QL(6 ea daily) SYRINGE/U-100/1ML/31G F SYRINGE U- F X 15/64" MISC 100/0.5ML/30G X 1/2" DROPLET INSULIN QL(6 ea daily) MISC SYRINGE/U-100/1ML/31G F DROPLET INSULIN QL(6 ea daily); X 5/16" MISC SYRINGE U- F RX/OTC EASY COMFORT INSULIN QL(6 ea daily); 100/0.5ML/30G X 5/16" SYRINGE/0.5ML/30G X F RX/OTC MISC 5/16" MISC DROPLET INSULIN QL(6 ea daily) EASY COMFORT INSULIN QL(6 ea daily) SYRINGE U- F SYRINGE/0.5ML/31G X F 100/0.5ML/31G X 5/16" 5/16" MISC MISC EASY COMFORT INSULIN QL(6 ea daily); DROPLET INSULIN QL(6 ea daily) SYRINGE/1ML/30G X F RX/OTC SYRINGE U-100/1ML/30G F 5/16" MISC X 1/2" MISC EASY COMFORT INSULIN QL(6 ea daily) DROPLET INSULIN QL(6 ea daily); SYRINGE/1ML/31G X F SYRINGE U-100/1ML/30G F RX/OTC 5/16" MISC X 5/16" MISC EASY COMFORT INSULIN QL(6 ea daily) DROPLET INSULIN QL(6 ea daily) SYRINGE/U- F SYRINGE U-100/1ML/31G F 100/0.5ML/30G X 1/2" X 15/64" MISC MISC DROPLET INSULIN QL(6 ea daily) EASY COMFORT INSULIN QL(6 ea daily) SYRINGE U-100/1ML/31G F SYRINGE/U-100/1ML/30G F X 5/16" MISC X 1/2" MISC DROPLET INSULIN QL(6 ea daily); EASY TOUCH FLIPLOCK F RX/OTC SYRINGE/U- F RX/OTC NEEDLES 18GX1" MISC 100/0.3ML/31G X 15/64" MISC EASY TOUCH FLIPLOCK RX/OTC NEEDLES 18GX1-1/2" F DROPLET INSULIN QL(6 ea daily) MISC SYRINGE/U- F 100/0.3ML/31G X 5/16" EASY TOUCH FLIPLOCK F RX/OTC MISC NEEDLES 19GX1" MISC DROPLET INSULIN QL(6 ea daily) EASY TOUCH FLIPLOCK F RX/OTC NEEDLES 20GX1" MISC SYRINGE/U- F 100/0.5ML/30G X 1/2" EASY TOUCH FLIPLOCK RX/OTC MISC NEEDLES 20GX1-1/2" F DROPLET INSULIN QL(6 ea daily) MISC EASY TOUCH FLIPLOCK RX/OTC SYRINGE/U- F F 100/0.5ML/31G X 15/64" NEEDLES 21GX1" MISC MISC
Oregon Trillium OHP Updated September 1, 2021
68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH FLIPLOCK RX/OTC EASY TOUCH FLIPLOCK RX/OTC NEEDLES 21GX1-1/2" F SAFETTY SYRINGES F MISC 3ML/18GX1-1/2" MISC EASY TOUCH FLIPLOCK F RX/OTC EASY TOUCH FLIPLOCK QL(6 ea daily); NEEDLES 22GX1" MISC SAFETY INSULIN F RX/OTC EASY TOUCH FLIPLOCK RX/OTC SYRINGE 1ML/29GX1/2" NEEDLES 22GX1-1/2" F MISC MISC EASY TOUCH FLIPLOCK QL(6 ea daily) SAFETY INSULIN EASY TOUCH FLIPLOCK F F NEEDLES 22GX3/4" MISC SYRINGE 1ML/30GX1/2" MISC EASY TOUCH FLIPLOCK F RX/OTC NEEDLES 23GX1" MISC EASY TOUCH FLIPLOCK QL(6 ea daily); SAFETY INSULIN F RX/OTC EASY TOUCH FLIPLOCK SYRINGE 1ML/30GX5/16" NEEDLES 23GX1-1/2" F MISC MISC EASY TOUCH FLIPLOCK QL(6 ea daily) EASY TOUCH FLIPLOCK RX/OTC F SAFETY INSULIN F NEEDLES 23GX5/8" MISC SYRINGE 1ML/31GX5/16" EASY TOUCH FLIPLOCK F RX/OTC MISC NEEDLES 25GX1" MISC EASY TOUCH FLIPLOCK RX/OTC EASY TOUCH FLIPLOCK RX/OTC SAFETY SYRINGE F NEEDLES 25GX1-1/2" F 1ML/25GX1" MISC MISC EASY TOUCH FLIPLOCK EASY TOUCH FLIPLOCK F RX/OTC SAFETY SYRINGE F NEEDLES 25GX5/8" MISC 1ML/26GX3/8" MISC EASY TOUCH FLIPLOCK F RX/OTC EASY TOUCH FLIPLOCK NEEDLES 26GX1/2" MISC SAFETY SYRINGE F 1ML/27GX1/2" MISC EASY TOUCH FLIPLOCK F NEEDLES 27GX1" MISC EASY TOUCH FLIPLOCK SAFETY SYRINGE F EASY TOUCH FLIPLOCK F RX/OTC NEEDLES 27GX1/2" MISC 3ML/19GX1" MISC EASY TOUCH FLIPLOCK EASY TOUCH FLIPLOCK F NEEDLES 28GX1/2" MISC SAFETY SYRINGE F 3ML/19GX1.5" MISC EASY TOUCH FLIPLOCK F NEEDLES 29GX1/2" MISC EASY TOUCH FLIPLOCK RX/OTC SAFETY SYRINGE F EASY TOUCH FLIPLOCK F NEEDLES 30GX1/2" MISC 3ML/21GX1" MISC EASY TOUCH FLIPLOCK EASY TOUCH FLIPLOCK NEEDLES 30GX5/16" F SAFETY SYRINGE F MISC 3ML/22GX1" MISC EASY TOUCH FLIPLOCK EASY TOUCH FLIPLOCK RX/OTC NEEDLES 31GX5/16" F SAFETY SYRINGE F MISC 3ML/22GX1-1/2" MISC EASY TOUCH FLIPLOCK RX/OTC EASY TOUCH FLIPLOCK RX/OTC NEEDLLES 19GX1-1/2" F SAFETY SYRINGE F MISC 3ML/23GX1" MISC
Oregon Trillium OHP Updated September 1, 2021
69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH FLIPLOCK EASY TOUCH INSULIN QL(6 ea daily); SAFETY SYRINGE F SYRINGE/0.3ML/30G X F RX/OTC 3ML/23GX1-1/2" MISC 5/16" MISC EASY TOUCH FLIPLOCK RX/OTC EASY TOUCH INSULIN QL(6 ea daily) SAFETY SYRINGE F SYRINGE/0.3ML/31G X F 3ML/25GX1" MISC 5/16" MISC EASY TOUCH FLIPLOCK RX/OTC EASY TOUCH INSULIN QL(6 ea daily); SAFETY SYRINGE F SYRINGE/0.5ML/29G X F RX/OTC 3ML/25GX5/8" MISC 1/2" MISC EASY TOUCH FLIPLOCK RX/OTC EASY TOUCH INSULIN QL(6 ea daily); SAFETY SYRINGES F SYRINGE/0.5ML/30G X F RX/OTC 3ML/18GX1" MISC 5/16" MISC EASY TOUCH FLIPLOCK RX/OTC EASY TOUCH INSULIN QL(6 ea daily); SAFETY SYRINGES F SYRINGE/1ML/30G X F RX/OTC 3ML/20GX1" MISC 5/16" MISC EASY TOUCH FLIPLOCK RX/OTC EASY TOUCH INSULIN QL(6 ea daily); F SAFETY SYRINGES SYRINGE/SAFETY/U- F RX/OTC 3ML/20GX1-1/2" MISC 100/0.5ML/29G X 1/2" EASY TOUCH FLIPLOCK RX/OTC MISC SAFETY SYRINGES F EASY TOUCH INSULIN QL(6 ea daily); 3ML/21GX1-1/2" MISC SYRINGE/SAFETY/U- F RX/OTC EASY TOUCH FLURINGE RX/OTC 100/0.5ML/30G X 5/16" MISC FLIPLOCK SAFETY F SYRINGE 1ML/25GX1" EASY TOUCH INSULIN QL(6 ea daily); MISC SYRINGE/SAFETY/U- F RX/OTC EASY TOUCH FLURINGE RX/OTC 100/1ML/29G X 1/2" MISC FLIPLOCK SAFETY F EASY TOUCH INSULIN QL(6 ea daily) SYRINGE 1ML/25GX5/8" SYRINGE/SAFETY/U- F MISC 100/1ML/30G X 1/2" MISC EASY TOUCH FLURINGE RX/OTC EASY TOUCH INSULIN QL(6 ea daily) FLU TRAY F SYRINGE/U- F SYRINGE/1ML/25G X 1" 100/0.3ML/30G X 1/2" MISC MISC EASY TOUCH FLURINGE RX/OTC EASY TOUCH INSULIN QL(6 ea daily) SHEATHLOCK SAFETY F SYRINGE/U- F SYRINGE 1ML/25GX1" 100/0.5ML/27G X 1/2" MISC MISC EASY TOUCH FLURINGE RX/OTC EASY TOUCH INSULIN QL(6 ea daily); SHEATHLOCK SAFETY F SYRINGE/U- F RX/OTC SYRINGE 1ML/25GX5/8" 100/0.5ML/28G X 1/2" MISC MISC EASY TOUCH FLURINGE RX/OTC EASY TOUCH INSULIN QL(6 ea daily); F SYRINGE/1ML/25G X 1" SYRINGE/U- F RX/OTC MISC 100/0.5ML/29G X 1/2" EASY TOUCH FLURINGE RX/OTC MISC SYRINGE/1ML/25G X 5/8" F MISC
Oregon Trillium OHP Updated September 1, 2021
70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH INSULIN QL(6 ea daily) EASY TOUCH SAFETY RX/OTC SYRINGE/U- F SYRINGE/3ML/25G X 5/8" F 100/0.5ML/30G X 1/2" MISC MISC EASY TOUCH QL(6 ea daily); EASY TOUCH INSULIN QL(6 ea daily) SHEATHLOCK SAFETY F RX/OTC SYRINGE/U- F INSULIN SYRINGE 100/0.5ML/31G X 5/16" 1ML/29GX1/2" MISC MISC EASY TOUCH QL(6 ea daily); EASY TOUCH INSULIN QL(6 ea daily); SHEATHLOCK SAFETY F RX/OTC SYRINGE/U-100/1ML/27G F RX/OTC INSULIN SYRINGE X 1/2" MISC 1ML/30GX5/16" MISC EASY TOUCH INSULIN QL(6 ea daily); EASY TOUCH QL(6 ea daily) F SYRINGE/U-100/1ML/28G RX/OTC SHEATHLOCK SAFETY F X 1/2" MISC INSULIN SYRINGE EASY TOUCH INSULIN QL(6 ea daily); 1ML/31GX5/16" MISC SYRINGE/U-100/1ML/29G F RX/OTC EASY TOUCH QL(6 ea daily) X 1/2" MISC SHEATHLOCK SAFETY F EASY TOUCH INSULIN QL(6 ea daily) SYRINGE 1ML/30GX1/2" SYRINGE/U-100/1ML/30G F MISC X 1/2" MISC EASY TOUCH RX/OTC EASY TOUCH INSULIN QL(6 ea daily) SHEATHLOCK SAFETY F SYRINGE/U-100/1ML/31G F SYRINGE 3ML/21GX1" X 5/16" MISC MISC EASY TOUCH SAFETY RX/OTC EASY TOUCH RX/OTC SYRINGE/1ML/25G X 1" F SHEATHLOCK SAFETY F MISC SYRINGE 3ML/21GX1-1/2" MISC EASY TOUCH SAFETY RX/OTC SYRINGE/1ML/25G X 5/8" F EASY TOUCH MISC SHEATHLOCK SAFETY F SYRINGE 3ML/22GX1" EASY TOUCH SAFETY RX/OTC MISC SYRINGE/3ML/20G X 1" F MISC EASY TOUCH RX/OTC SHEATHLOCK SAFETY F EASY TOUCH SAFETY RX/OTC SYRINGE 3ML/22GX1-1/2" SYRINGE/3ML/21G X 1" F MISC MISC EASY TOUCH RX/OTC EASY TOUCH SAFETY SHEATHLOCK SAFETY F SYRINGE/3ML/22G X 1" F SYRINGE 3ML/23GX1" MISC MISC EASY TOUCH SAFETY RX/OTC EASY TOUCH RX/OTC SYRINGE/3ML/22G X 1- F SHEATHLOCK SAFETY F 1/2" MISC SYRINGE 3ML/25GX1" EASY TOUCH SAFETY RX/OTC MISC SYRINGE/3ML/23G X 1" F EASY TOUCH RX/OTC MISC SHEATHLOCK SAFETY F EASY TOUCH SAFETY RX/OTC SYRINGE 3ML/25GX5/8" SYRINGE/3ML/25G X 1" F MISC MISC
Oregon Trillium OHP Updated September 1, 2021
71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH ELITE-THIN INSULIN QL(6 ea daily); TUBERCULIN SYRINGE/U-100/1ML/29G F RX/OTC SHEATHLOCK SAFETY F X 1/2" MISC SYRINGE 1ML/26GX5/8" ELITE-THIN INSULIN QL(6 ea daily) MISC SYRINGE/U-100/1ML/31G F EASYPOINT RX/OTC X 5/16" MISC NEEDLE/SYRINGE F EQL INSULIN QL(6 ea daily); 3ML/18G X 1" MISC SYRINGE/0.3ML/29G X F RX/OTC EASYPOINT RX/OTC 1/2" MISC NEEDLE/SYRINGE F EQL INSULIN QL(6 ea daily); 3ML/18G X 1-1/2" MISC SYRINGE/0.3ML/30G X F RX/OTC ELITE-THIN INSULIN QL(6 ea daily) 5/16" MISC SYRINGE/0.3ML/31G X F EQL INSULIN QL(6 ea daily) 5/16" MISC SYRINGE/0.3ML/31G X F ELITE-THIN INSULIN QL(6 ea daily); 5/16" MISC SYRINGE/0.5ML/29G X F RX/OTC EQL INSULIN QL(6 ea daily); 1/2" MISC SYRINGE/0.5ML/29G X F RX/OTC ELITE-THIN INSULIN QL(6 ea daily); 1/2" MISC SYRINGE/0.5ML/30G X F RX/OTC EQL INSULIN QL(6 ea daily); 5/16" MISC SYRINGE/0.5ML/30G X F RX/OTC ELITE-THIN INSULIN QL(6 ea daily) 5/16" MISC SYRINGE/1ML/29G X F EQL INSULIN QL(6 ea daily) 5/16" MISC SYRINGE/0.5ML/31G X F ELITE-THIN INSULIN QL(6 ea daily); 5/16" MISC SYRINGE/1ML/30G X F RX/OTC EQL INSULIN QL(6 ea daily); 5/16" MISC SYRINGE/1ML/29G X 1/2" F RX/OTC ELITE-THIN INSULIN QL(6 ea daily); MISC SYRINGE/U- F RX/OTC EQL INSULIN QL(6 ea daily); 100/0.5ML/28G X 1/2" SYRINGE/1ML/30G X F RX/OTC MISC 5/16" MISC ELITE-THIN INSULIN QL(6 ea daily) EQL INSULIN QL(6 ea daily) SYRINGE/U- F SYRINGE/1ML/31G X F 100/0.5ML/28G X 5/16" 5/16" MISC MISC EXEL COMFORT POINT QL(6 ea daily); ELITE-THIN INSULIN QL(6 ea daily) INSULIN F RX/OTC SYRINGE/U- F SYRINGE/0.3ML/29G X 100/0.5ML/29G X 5/16" 1/2" MISC MISC EXEL COMFORT POINT QL(6 ea daily); ELITE-THIN INSULIN QL(6 ea daily) INSULIN F RX/OTC SYRINGE/U- F SYRINGE/0.3ML/30G X 100/0.5ML/31G X 5/16" 5/16" MISC MISC EXEL COMFORT POINT QL(6 ea daily); ELITE-THIN INSULIN QL(6 ea daily); INSULIN F RX/OTC SYRINGE/U-100/1ML/28G F RX/OTC SYRINGE/0.5ML/28G X X 1/2" MISC 1/2" MISC ELITE-THIN INSULIN QL(6 ea daily) SYRINGE/U-100/1ML/28G F X 5/16" MISC
Oregon Trillium OHP Updated September 1, 2021
72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXEL COMFORT POINT QL(6 ea daily); GLOBAL EASY GLIDE QL(6 ea daily); INSULIN F RX/OTC INSULIN F RX/OTC SYRINGE/0.5ML/29G X SYRINGE/0.3ML/31G X 1/2" MISC 15/64" MISC EXEL COMFORT POINT QL(6 ea daily); GLOBAL EASY GLIDE QL(6 ea daily) INSULIN F RX/OTC INSULIN F SYRINGE/0.5ML/30G X SYRINGE/0.5ML/31G X 5/16" MISC 15/64" MISC EXEL COMFORT POINT QL(6 ea daily); GLOBAL EASY GLIDE QL(6 ea daily) INSULIN F RX/OTC INSULIN F SYRINGE/1ML/28G X 1/2" SYRINGE/1ML/31G X MISC 15/64" MISC EXEL COMFORT POINT QL(6 ea daily); GLOBAL EASY GLIDE QL(6 ea daily) INSULIN F RX/OTC INSULINSYRINGE/U- F SYRINGE/1ML/29G X 1/2" 100/0.3ML/31G X 5/16" MISC MISC EXEL COMFORT POINT QL(6 ea daily); GLOBAL INJECT EASE QL(6 ea daily); INSULIN F RX/OTC INSULIN SYRINGE/U- F RX/OTC SYRINGE/1ML/30G X 100/0.3ML/29G X 1/2" 5/16" MISC MISC FIFTY50 SUPERIOR QL(6 ea daily) GLOBAL INJECT EASE QL(6 ea daily) COMFORTINSULIN F INSULIN SYRINGE/U- F SYRINGE/0.3ML/31G X 100/0.3ML/30G X 1/2" 5/16" MISC MISC FIFTY50 SUPERIOR QL(6 ea daily) GLOBAL INJECT EASE QL(6 ea daily); COMFORTINSULIN F INSULIN SYRINGE/U- F RX/OTC SYRINGE/0.5ML/31G X 100/0.3ML/30G X 5/16" 5/16" MISC MISC FIFTY50 SUPERIOR QL(6 ea daily) GLOBAL INJECT EASE QL(6 ea daily) COMFORTINSULIN F INSULIN SYRINGE/U- F SYRINGE/1ML/31G X 100/0.3ML/31G X 5/16" 5/16" MISC MISC FREESTYLE PRECISION QL(6 ea daily); GLOBAL INJECT EASE QL(6 ea daily); INSULIN SYRINGE/U- F RX/OTC INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/30G X 5/16" 100/0.5ML/28G X 1/2" MISC MISC FREESTYLE PRECISION QL(6 ea daily) GLOBAL INJECT EASE QL(6 ea daily); INSULIN SYRINGE/U- F INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/31G X 5/16" 100/0.5ML/29G X 1/2" MISC MISC FREESTYLE PRECISION QL(6 ea daily) GLOBAL INJECT EASE QL(6 ea daily) INSULIN SYRINGE/U- F INSULIN SYRINGE/U- F 100/1ML/31G X 5/16" 100/0.5ML/30G X 1/2" MISC MISC FREESTYLE PRECISION QL(6 ea daily); GLOBAL INJECT EASE QL(6 ea daily); INSULIN SYRINGES/U- F RX/OTC INSULIN SYRINGE/U- F RX/OTC 100/1ML/30G X 5/16" 100/0.5ML/30G X 5/16" MISC MISC
Oregon Trillium OHP Updated September 1, 2021
73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLOBAL INJECT EASE QL(6 ea daily) GLUCOPRO INSULIN QL(6 ea daily); INSULIN SYRINGE/U- F SYRINGE/U- F RX/OTC 100/0.5ML/31G X 5/16" 100/0.5ML/30G X 5/16" MISC MISC GLOBAL INJECT EASE QL(6 ea daily); GLUCOPRO INSULIN QL(6 ea daily) F INSULIN SYRINGE/U- RX/OTC SYRINGE/U- F 100/1ML/28G X 1/2" MISC 100/0.5ML/31G X 5/16" GLOBAL INJECT EASE QL(6 ea daily); MISC INSULIN SYRINGE/U- F RX/OTC GLUCOPRO INSULIN QL(6 ea daily) 100/1ML/29G X 1/2" MISC SYRINGE/U-100/1ML/30G F GLOBAL INJECT EASE QL(6 ea daily) X 1/2" MISC INSULIN SYRINGE/U- F GLUCOPRO INSULIN QL(6 ea daily); 100/1ML/30G X 1/2" MISC SYRINGE/U-100/1ML/30G F RX/OTC GLOBAL INJECT EASE QL(6 ea daily); X 5/16" MISC INSULIN SYRINGE/U- F RX/OTC GLUCOPRO INSULIN QL(6 ea daily) 100/1ML/30G X 5/16" SYRINGE/U-100/1ML/31G F MISC X 5/16" MISC GLOBAL INJECT EASE QL(6 ea daily) GNP INSULIN QL(6 ea daily); INSULIN SYRINGE/U- F SYRINGE/0.3ML/29G X F RX/OTC 100/1ML/31G X 5/16" 1/2" MISC MISC GNP INSULIN QL(6 ea daily); GLOBAL INSULIN QL(6 ea daily) SYRINGE/0.3ML/30G X F RX/OTC SYRINGE/U- F 5/16" MISC 100/0.3ML/30G X 1/2" GNP INSULIN QL(6 ea daily) MISC SYRINGE/0.3ML/31G X F GLOBAL INSULIN QL(6 ea daily); 5/16" MISC SYRINGES/U- F RX/OTC GNP INSULIN QL(6 ea daily); 100/0.3ML/30GX5/16" SYRINGE/0.5ML/28G X F RX/OTC MISC 1/2" MISC GLUCOPRO INSULIN QL(6 ea daily) GNP INSULIN QL(6 ea daily); SYRINGE/U- F SYRINGE/0.5ML/29G X F RX/OTC 100/0.3ML/30G X 1/2" 1/2" MISC MISC GNP INSULIN QL(6 ea daily); GLUCOPRO INSULIN QL(6 ea daily); SYRINGE/0.5ML/30G X F RX/OTC SYRINGE/U- F RX/OTC 5/16" MISC 100/0.3ML/30G X 5/16" MISC GNP INSULIN QL(6 ea daily) SYRINGE/0.5ML/31G X F GLUCOPRO INSULIN QL(6 ea daily) 5/16" MISC SYRINGE/U- F 100/0.3ML/31G X 5/16" GNP INSULIN QL(6 ea daily); MISC SYRINGE/1ML/28G X 1/2" F RX/OTC MISC GLUCOPRO INSULIN QL(6 ea daily) GNP INSULIN QL(6 ea daily); SYRINGE/U- F 100/0.5ML/30G X 1/2" SYRINGE/1ML/29G X 1/2" F RX/OTC MISC MISC GNP INSULIN QL(6 ea daily); SYRINGE/1ML/30G X F RX/OTC 5/16" MISC
Oregon Trillium OHP Updated September 1, 2021
74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP INSULIN QL(6 ea daily) GUARDIAN SHARPS QL(2 ea per 30 SYRINGE/1ML/31G X F COLLECTORNESTABLE F days retail); 5/16" MISC NON-VENTED 8 QT MISC RX/OTC GNP ULTRA COMFORT QL(6 ea daily); GUARDIAN SHARPS QL(2 ea per 30 INSULIN F RX/OTC COLLECTORNESTABLE F days retail); SYRINGE/0.3ML/29G X OPEN 14 QT MISC RX/OTC 1/2" MISC GUARDIAN SHARPS QL(2 ea per 30 GNP ULTRA COMFORT QL(6 ea daily); COLLECTORNESTABLE F days retail); INSULIN F RX/OTC OPEN TOP 6 GAL MISC RX/OTC SYRINGE/0.3ML/30G X GUARDIAN SHARPS QL(2 ea per 30 5/16" SHORT MISC COLLECTORNESTABLE F days retail); GNP ULTRA COMFORT QL(6 ea daily); OPEN TOP NV 6 GAL RX/OTC INSULIN F RX/OTC MISC SYRINGE/0.5ML/28G X GUARDIAN SHARPS QL(2 ea per 30 1/2" MISC COLLECTORNESTABLE F days retail); GNP ULTRA COMFORT QL(6 ea daily); SMALL FUNNEL 14 QT RX/OTC INSULIN F RX/OTC MISC SYRINGE/0.5ML/29G X GUARDIAN SHARPS QL(2 ea per 30 1/2" MISC COLLECTORNESTABLE F days retail); GNP ULTRA COMFORT QL(6 ea daily); SMALL FUNNEL NV 14 QT RX/OTC INSULIN F RX/OTC MISC SYRINGE/1ML/28G X 1/2" GUARDIAN SHARPS QL(2 ea per 30 MISC COLLECTORONE-PIECE F days retail); GNP ULTRA COMFORT QL(6 ea daily); HOME CARE 1QT MISC RX/OTC INSULIN F RX/OTC GUARDIAN SHARPS QL(2 ea per 30 SYRINGE/1ML/29G X 1/2" COLLECTORONE-PIECE F days retail); MISC LARGE 8.2 QT MISC RX/OTC GUARDIAN SHARPS QL(2 ea per 30 GUARDIAN SHARPS QL(2 ea per 30 COLLECTORHORIZONTA F days retail); COLLECTORONE-PIECE F days retail); L NESTABLE 5.4 QT MISC RX/OTC LARGE NON-VENTED 8.2 RX/OTC GUARDIAN SHARPS QL(2 ea per 30 QT MISC COLLECTORHORIZONTA F days retail); GUARDIAN SHARPS QL(2 ea per 30 L PRE-ASSEMBLED 5.4 RX/OTC COLLECTORONE-PIECE F days retail); QT MISC MEDIUM 6.9 QT MISC RX/OTC GUARDIAN SHARPS QL(2 ea per 30 GUARDIAN SHARPS QL(2 ea per 30 COLLECTORNESTABLE F days retail); COLLECTORONE-PIECE F days retail); 16 GAL MISC RX/OTC MEDIUM NON-VENTED RX/OTC GUARDIAN SHARPS QL(2 ea per 30 6.9 QT MISC COLLECTORNESTABLE 8 F days retail); GUARDIAN SHARPS QL(2 ea per 30 QT MISC RX/OTC COLLECTORONE-PIECE F days retail); GUARDIAN SHARPS QL(2 ea per 30 OFFSET NECK 9.2 QT RX/OTC COLLECTORNESTABLE F days retail); MISC LARGE FUNNEL 14 QT RX/OTC GUARDIAN SHARPS QL(2 ea per 30 MISC COLLECTORONE-PIECE F days retail); GUARDIAN SHARPS QL(2 ea per 30 PHLEBOTOMY 1QT MISC RX/OTC COLLECTORNESTABLE F days retail); LARGE FUNNEL 6 GAL RX/OTC MISC
Oregon Trillium OHP Updated September 1, 2021
75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GUARDIAN SHARPS QL(2 ea per 30 HM ULTICARE INSULIN QL(6 ea daily) COLLECTORONE-PIECE F days retail); SYRINGE/1ML/30G X 1/2" F X-L LARGE FUNNEL 5 RX/OTC MISC GAL MISC HM ULTICARE INSULIN QL(6 ea daily) GUARDIAN SHARPS QL(2 ea per 30 SYRINGE/U- F COLLECTORONE-PIECE F days retail); 100/0.3ML/31G X 5/16" X-L OPEN TOP 5 GAL RX/OTC MISC MISC INSULIN QL(6 ea daily) GUARDIAN SHARPS QL(2 ea per 30 SYRINGE/0.3ML/29G X 1" F COLLECTORONE-PIECE F days retail); MISC X-L OPEN TOP NV 5 GAL RX/OTC INSULIN QL(6 ea daily); MISC SYRINGE/0.3ML/29G X F RX/OTC GUARDIAN SHARPS QL(2 ea per 30 1/2" MISC COLLECTORSIDE ENTRY F days retail); INSULIN QL(6 ea daily); NESTABLE 5.4 QT MISC RX/OTC SYRINGE/0.3ML/30G X F RX/OTC GUARDIAN SHARPS QL(2 ea per 30 5/16" MISC COLLECTORSIDE ENTRY F days retail); INSULIN QL(6 ea daily) PRE-ASSEMBLED 5.4 QT RX/OTC SYRINGE/0.3ML/31G X F MISC 5/16" MISC GUARDIAN SHARPS QL(2 ea per 30 INSULIN QL(6 ea daily) COLLECTORVERTICAL F days retail); SYRINGE/0.5ML/27G X F ENTRY 3.2 QT MISC RX/OTC 1/2" MISC GUARDIAN SHARPS QL(2 ea per 30 INSULIN QL(6 ea daily); COLLECTORVERTICAL F days retail); SYRINGE/0.5ML/28G X F RX/OTC ENTRY NON-VENTED 3.2 RX/OTC 1/2" MISC QT MISC INSULIN QL(6 ea daily) HEALTHWISE INSULIN QL(6 ea daily); SYRINGE/0.5ML/30G X F SYRINGE/U- F RX/OTC 1/2" MISC 100/0.3ML/30G X 5/16" MISC INSULIN QL(6 ea daily); SYRINGE/0.5ML/30G X F RX/OTC HEALTHWISE INSULIN QL(6 ea daily) 5/16" MISC SYRINGE/U- F 100/0.3ML/31G X 5/16" INSULIN QL(6 ea daily) MISC SYRINGE/0.5ML/31G X F 5/16" MISC HEALTHWISE INSULIN QL(6 ea daily); INSULIN QL(6 ea daily); SYRINGE/U- F RX/OTC 100/0.5ML/30G X 5/16" SYRINGE/1ML/28G X 1/2" F RX/OTC MISC MISC HEALTHWISE INSULIN QL(6 ea daily) INSULIN QL(6 ea daily); SYRINGE/1ML/29G X 1/2" F RX/OTC SYRINGE/U- F 100/0.5ML/31G X 5/16" MISC MISC INSULIN QL(6 ea daily); HEALTHWISE INSULIN QL(6 ea daily); SYRINGE/1ML/30G X F RX/OTC SYRINGE/U-100/1ML/30G F RX/OTC 5/16" MISC X 5/16" MISC INSULIN QL(6 ea daily); HEALTHWISE INSULIN QL(6 ea daily) SYRINGE/NEEDLE F RX/OTC SYRINGE/U-100/1ML/31G F 0.3ML/30G X 5/16" MISC X 5/16" MISC
Oregon Trillium OHP Updated September 1, 2021
76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN QL(6 ea daily) INSULIN QL(6 ea daily); SYRINGE/NEEDLE F SYRINGES/0.5ML/29GX1/ F RX/OTC 0.3ML/31G X 5/16" MISC 2" MISC INSULIN QL(6 ea daily); INSULIN QL(6 ea daily); SYRINGE/NEEDLE F RX/OTC SYRINGES/0.5ML/30GX5/ F RX/OTC 0.5ML/29G X 1/2" MISC 16" MISC INSULIN QL(6 ea daily); INSULIN QL(6 ea daily) SYRINGE/NEEDLE F RX/OTC SYRINGES/0.5ML/31GX F 0.5ML/30G X 5/16" MISC 5/16" MISC INSULIN QL(6 ea daily) INSULIN QL(6 ea daily) SYRINGE/NEEDLE F SYRINGES/0.5ML/31GX5/ F 0.5ML/31G X 5/16" MISC 16" MISC INSULIN QL(6 ea daily); INSULIN QL(6 ea daily); SYRINGE/NEEDLE F RX/OTC SYRINGES/1ML/27GX/1/2" F RX/OTC 1ML/29G X 1/2" MISC MISC INSULIN QL(6 ea daily); INSULIN QL(6 ea daily); SYRINGE/NEEDLE F RX/OTC SYRINGES/1ML/27GX1/2" F RX/OTC 1ML/30G X 5/16" MISC MISC INSULIN QL(6 ea daily) INSULIN QL(6 ea daily); SYRINGE/NEEDLE F SYRINGES/1ML/28GX1/2" F RX/OTC 1ML/31G X 5/16" MISC MISC INSULIN SYRINGE/U- QL(6 ea daily); INSULIN QL(6 ea daily); 100/0.3ML/29G X 1/2" F RX/OTC SYRINGES/1ML/29GX1/2" F RX/OTC MISC MISC INSULIN SYRINGE/U- QL(6 ea daily); INSULIN QL(6 ea daily) 100/0.5ML/29G X 1/2" F RX/OTC SYRINGES/1ML/30GX1/2" F MISC MISC INSULIN SYRINGE/U- F QL(6 ea daily); INSULIN QL(6 ea daily) 100/1ML/29G X 1/2" MISC RX/OTC SYRINGES/1ML/31GX5/16 F INSULIN SYRINGE/U- QL(6 ea daily) " MISC 100/1ML/30G X 5/16" F KINRAY INSULIN QL(6 ea daily) MISC SYRINGE PREFERRED F INSULIN SYRINGE/U- QL(6 ea daily); PLUS/0.3ML/31G X 5/16" 100/1ML/30G X 5/16" F RX/OTC MISC MISC KINRAY INSULIN QL(6 ea daily) INSULIN SYRINGE/U- QL(6 ea daily) SYRINGE PREFERRED F 100/1ML/31G X 5/16" F PLUS/0.5ML/31G X 5/16" MISC MISC QL (6 ea daily); KINRAY INSULIN QL(6 ea daily) INSULIN SYRINGES-MISC F RX/OTC SYRINGE PREFERRED F PLUS/1ML/31G X 5/16" INSULIN QL(6 ea daily) MISC SYRINGES/0.5ML/27GX1/ F 2" MISC KINRAY INSULIN QL(6 ea daily); SYRINGE/0.5ML/29G X F RX/OTC INSULIN QL(6 ea daily); 1/2" MISC SYRINGES/0.5ML/28GX1/ F RX/OTC 2" MISC
Oregon Trillium OHP Updated September 1, 2021
77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KMART VALU PLUS QL(6 ea daily) LEADER INSULIN QL(6 ea daily); INSULIN F SYRINGE/0.3ML/30G X F RX/OTC SYRINGE/0.3ML/30G 5/16" MISC MISC LEADER INSULIN QL(6 ea daily) KMART VALU PLUS QL(6 ea daily) SYRINGE/0.3ML/31G X F INSULIN F 5/16" MISC SYRINGE/0.5ML/29G LEADER INSULIN QL(6 ea daily); MISC SYRINGE/0.5ML/28G X F RX/OTC KMART VALU PLUS QL(6 ea daily) 1/2" MISC INSULIN F LEADER INSULIN QL(6 ea daily); SYRINGE/0.5ML/30G SYRINGE/0.5ML/29G X F RX/OTC MISC 1/2" MISC KMART VALU PLUS QL(6 ea daily); LEADER INSULIN QL(6 ea daily); INSULIN F RX/OTC SYRINGE/0.5ML/30G X F RX/OTC SYRINGE/1ML/29G MISC 5/16" MISC KMART VALU PLUS QL(6 ea daily); LEADER INSULIN QL(6 ea daily) INSULIN F RX/OTC SYRINGE/0.5ML/31G X F SYRINGE/1ML/30G MISC 5/16" MISC KROGER INSULIN QL(6 ea daily); LEADER INSULIN QL(6 ea daily); SYRINGE/0.3ML/29G X F RX/OTC SYRINGE/1ML/28G X 1/2" F RX/OTC 1/2" MISC MISC KROGER INSULIN QL(6 ea daily); LEADER INSULIN QL(6 ea daily); SYRINGE/0.3ML/30G X F RX/OTC SYRINGE/1ML/29G X 1/2" F RX/OTC 5/16" MISC MISC KROGER INSULIN QL(6 ea daily) LEADER INSULIN QL(6 ea daily); SYRINGE/0.3ML/31G X F SYRINGE/1ML/30G X F RX/OTC 5/16" MISC 5/16" MISC KROGER INSULIN QL(6 ea daily); LEADER INSULIN QL(6 ea daily) SYRINGE/0.5ML/29G X F RX/OTC SYRINGE/1ML/31G X F 1/2" MISC 5/16" MISC KROGER INSULIN QL(6 ea daily); LITETOUCH INSULIN QL(6 ea daily); SYRINGE/0.5ML/30G X F RX/OTC SYRINGE/0.3ML/29G X F RX/OTC 5/16" MISC 1/2" MISC KROGER INSULIN QL(6 ea daily) LITETOUCH INSULIN QL(6 ea daily); SYRINGE/0.5ML/31G X F SYRINGE/0.3ML/30G X F RX/OTC 5/16" MISC 5/16" MISC KROGER INSULIN QL(6 ea daily); LITETOUCH INSULIN QL(6 ea daily) SYRINGE/1ML/29G X 1/2" F RX/OTC SYRINGE/0.3ML/31G X F MISC 5/16" MISC KROGER INSULIN QL(6 ea daily); LITETOUCH INSULIN QL(6 ea daily); SYRINGE/1ML/30G X F RX/OTC SYRINGE/0.5ML/30G X F RX/OTC 5/16" MISC 5/16" MISC KROGER INSULIN QL(6 ea daily) LITETOUCH INSULIN QL(6 ea daily) SYRINGE/1ML/31G X F SYRINGE/0.5ML/31G X F 5/16" MISC 5/16" MISC LEADER INSULIN QL(6 ea daily); LITETOUCH INSULIN QL(6 ea daily); SYRINGE/0.3ML/29G X F RX/OTC SYRINGE/1ML/30G X F RX/OTC 1/2" MISC 5/16" MISC Oregon Trillium OHP Updated September 1, 2021
78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITETOUCH INSULIN QL(6 ea daily); MAGELLAN INSULIN QL(6 ea daily); SYRINGE/U- F RX/OTC SAFETY SYRINGE/U- F RX/OTC 100/0.3ML/30G X 5/16" 100/0.5ML/29G X 1/2" MISC MISC LITETOUCH INSULIN QL(6 ea daily) MAGELLAN INSULIN QL(6 ea daily); SYRINGE/U- F SAFETY SYRINGE/U- F RX/OTC 100/0.3ML/31G X 5/16" 100/0.5ML/30G X 5/16" MISC MISC LITETOUCH INSULIN QL(6 ea daily); MAGELLAN INSULIN QL(6 ea daily); SYRINGE/U- F RX/OTC SAFETY SYRINGE/U- F RX/OTC 100/0.5ML/28G X 1/2" 100/1ML/29G X 1/2" MISC MISC MAGELLAN INSULIN QL(6 ea daily); LITETOUCH INSULIN QL(6 ea daily); SAFETY SYRINGE/U- F RX/OTC SYRINGE/U- F RX/OTC 100/1ML/30G X 5/16" 100/0.5ML/29G X 1/2" MISC MISC MAGELLAN LITETOUCH INSULIN QL(6 ea daily); SYRINGE/HYPODERMIC SYRINGE/U- F RX/OTC SAFETY F 100/0.5ML/30G X 5/16" NEEDLE/1ML/23G X 1" MISC MISC LITETOUCH INSULIN QL(6 ea daily) MAXI-COMFORT INSULIN QL(6 ea daily); F SYRINGE/U- F SYRINGE/U- RX/OTC 100/0.5ML/31G X 5/16" 100/0.5ML/28GX1/2" MISC MISC MAXI-COMFORT INSULIN QL(6 ea daily); LITETOUCH INSULIN QL(6 ea daily); SYRINGE/U- F RX/OTC SYRINGE/U-100/1ML/28G F RX/OTC 100/1ML/28GX1/2" MISC X 1/2" MISC MAXICOMFORT INSULIN QL(6 ea daily); LITETOUCH INSULIN QL(6 ea daily); SYRINGES 27G X 1/2" F RX/OTC SYRINGE/U-100/1ML/29G F RX/OTC MISC X 1/2" MISC MAXICOMFORT INSULIN QL(6 ea daily) LITETOUCH INSULIN QL(6 ea daily); SYRINGES 27G X 1/2" F SYRINGE/U-100/1ML/30G F RX/OTC MISC X 5/16" MISC MEDIC INSULIN QL(6 ea daily); LITETOUCH INSULIN QL(6 ea daily) SYRINGE/0.3ML/30G X F RX/OTC SYRINGE/U-100/1ML/31G F 5/16" MISC X 5/16" MISC MEDIC INSULIN QL(6 ea daily); LONGS INSULIN QL(6 ea daily) SYRINGE/0.5ML/30G X F RX/OTC SYRINGE/0.5ML/31G X F 5/16" MISC 5/16" MISC MM INSULIN SYRINGE/U- QL(6 ea daily); MAGELLAN INSULIN QL(6 ea daily); 100/0.3ML/30G X 5/16" F RX/OTC SAFETY SYRINGE/U- F RX/OTC MISC 100/0.3ML/29G X 1/2" MM INSULIN SYRINGE/U- QL(6 ea daily) MISC 100/0.3ML/31G X 5/16" F MAGELLAN INSULIN QL(6 ea daily); MISC SAFETY SYRINGE/U- F RX/OTC MM INSULIN SYRINGE/U- QL(6 ea daily); 100/0.3ML/30G X 5/16" 100/1/2ML/30G X 5/16" F RX/OTC MISC MISC
Oregon Trillium OHP Updated September 1, 2021
79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MM INSULIN SYRINGE/U- QL(6 ea daily) MONOJECT INSULIN QL(6 ea daily); F 100/1/2ML/31G X 5/16" SYRINGE/SAFETY/PERM F RX/OTC MISC NEEDLE/0.5ML/29G X 1/2" MM INSULIN SYRINGE/U- QL(6 ea daily); MISC 100/1ML/30G X 5/16" F RX/OTC MONOJECT INSULIN QL(6 ea daily); MISC SYRINGE/SAFETY/PERM F RX/OTC MM INSULIN SYRINGE/U- QL(6 ea daily) NEEDLE/1ML/29G X 1/2" 100/1ML/31G X 5/16" F MISC MISC MONOJECT INSULIN QL(6 ea daily); MONOJECT 1ML LUER RX/OTC SYRINGE/SOFTPACK/1M F RX/OTC LOCK TUBERCULIN F L/27G X 1/2" MISC SYRINGE/TIP CAP MISC MONOJECT INSULIN QL(6 ea daily); MONOJECT 3ML RX/OTC SYRINGE/SOFTPACK/U- F RX/OTC 100/0.5ML/28G X 1/2" SYRINGE/STANDARD F HYPODERMIC MISC NEEDLE/21GX1-1/2" MISC MONOJECT INSULIN QL(6 ea daily); MONOJECT BLUNTIP RX/OTC SYRINGE/U- F RX/OTC SYRINGE/3ML/CANNULA/ F 100/0.3ML/30G X 5/16" IV ACCESS MISC MISC MONOJECT INSULIN QL(6 ea daily); MONOJECT INSULIN F QL(6 ea daily); SYRINGE/1ML MISC RX/OTC SYRINGE/U- F RX/OTC 100/0.5ML/30G X 5/16" MONOJECT INSULIN QL(6 ea daily) MISC SYRINGE/1ML/31G X F 5/16" MISC MONOJECT INSULIN QL(6 ea daily); SYRINGE/U-100/1ML/28G F RX/OTC MONOJECT INSULIN QL(6 ea daily) X 1/2" MISC SYRINGE/DETACH F NEEDLE/1ML/25G X 5/8" MONOJECT INSULIN QL(6 ea daily); MISC SYRINGE/U-100/1ML/30G F RX/OTC X 5/16" MISC MONOJECT INSULIN QL(6 ea daily); MONOJECT INSULIN QL(6 ea daily); SYRINGE/DETACH F RX/OTC NEEDLE/1ML/27G X 1/2" SYRINGEREGULAR LUER F RX/OTC MISC TIP/SOFTPACK/1ML MISC MONOJECT INSULIN QL(6 ea daily); MONOJECT LIFESHIELD RX/OTC BLUNTCANNULA/LUER SYRINGE/PERM F RX/OTC F NEEDLE/1ML/28G X 1/2" LOCK SYR/3ML/18G X 1" MISC MISC MONOJECT INSULIN QL(6 ea daily); MONOJECT MAGELLAN SYRINGE/SAFETY SYRINGE/PERM F RX/OTC F NEEDLE/U-100/0.5ML/28G NEEDLE/1ML/23G X 1" X 1/2" MISC MISC MONOJECT INSULIN QL(6 ea daily); MONOJECT MAGELLAN RX/OTC SYRINGE/SAFETY SYRINGE/SAFETY/PERM F RX/OTC F NEEDLE/0.3ML/29G X 1/2" NEEDLE/1ML/25G X 1" MISC MISC MONOJECT INSULIN QL(6 ea daily); MONOJECT MAGELLAN RX/OTC SYRINGE/SAFETY SYRINGE/SAFETY/PERM F RX/OTC F NEEDLE/0.3ML/29GX1/2" NEEDLE/1ML/25G X 5/8" MISC MISC
Oregon Trillium OHP Updated September 1, 2021
80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT MAGELLAN RX/OTC MONOJECT RX/OTC SYRINGE/SAFETY F SYRINGE/LUER F NEEDLE/3ML/20G X 1" LOCK/3ML MISC MISC MONOJECT RX/OTC MONOJECT MAGELLAN RX/OTC SYRINGE/LUER F SYRINGE/SAFETY F LOCK/3ML/20G X 1" MISC NEEDLE/3ML/20G X 1-1/2" MONOJECT RX/OTC MISC SYRINGE/LUER F MONOJECT MAGELLAN RX/OTC LOCK/3ML/20G X 1-1/2" SYRINGE/SAFETY F MISC NEEDLE/3ML/21G X 1" MONOJECT MISC SYRINGE/LUER F MONOJECT MAGELLAN RX/OTC LOCK/3ML/20G X 3/4" SYRINGE/SAFETY F MISC NEEDLE/3ML/21G X 1-1/2" MONOJECT MISC SYRINGE/LUER F MONOJECT MAGELLAN LOCK/3ML/22G X 1" MISC SYRINGE/SAFETY F MONOJECT RX/OTC NEEDLE/3ML/22G X 1" SYRINGE/LUER F MISC LOCK/3ML/22G X 1-1/2" MONOJECT MAGELLAN RX/OTC MISC SYRINGE/SAFETY F MONOJECT RX/OTC NEEDLE/3ML/22G X 1-1/2" SYRINGE/LUER F MISC LOCK/3ML/23G X 1" MISC MONOJECT MAGELLAN RX/OTC MONOJECT RX/OTC SYRINGE/SAFETY F SYRINGE/LUER F NEEDLE/3ML/23G X 1" LOCK/3ML/25G X 1" MISC MISC MONOJECT RX/OTC MONOJECT MAGELLAN RX/OTC SYRINGE/LUER F SYRINGE/SAFETY F LOCK/3ML/25G X 5/8" NEEDLE/3ML/25G X 1" MISC MISC MONOJECT RX/OTC MONOJECT MAGELLAN RX/OTC SYRINGE/LUER F SYRINGE/SAFETY F LOCK/3ML/27G X 1-1/4" NEEDLE/3ML/25G X 5/8" MISC MISC MONOJECT RX/OTC MONOJECT SHARPS QL(2 ea per 30 SYRINGE/LUER-LOCK F CONTAINER/14 QUART F days retail); TIP/3ML MISC MISC RX/OTC MONOJECT RX/OTC MONOJECT RX/OTC SYRINGE/LUER- F SYRINGE/CATHETERTIP/ F LOCK/3ML/21G X 1" MISC 35ML MISC MONOJECT RX/OTC MONOJECT RX/OTC SYRINGE/LUER- F SYRINGE/ECCENTRIC F LOCK/3ML/21G X 1-1/2" LUER/35ML MISC MISC MONOJECT RX/OTC MONOJECT RX/OTC SYRINGE/LUER F SYRINGE/REG F LOCK/35ML MISC LUER/35ML MISC
Oregon Trillium OHP Updated September 1, 2021
81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT RX/OTC MONOJECT RX/OTC SYRINGE/REG LUER/3ML F SYRINGE/STANDARDHY MISC PODERMIC F MONOJECT RX/OTC NEEDLE/3ML/25GX5/8" SYRINGE/REGULARTIP/3 F MISC ML MISC MONOJECT RX/OTC MONOJECT RX/OTC SYRINGE/STANDARDHY SYRINGE/STANDARDHY PODERMIC F PODERMIC F NEEDLE/3ML/27GX1-1/4" NEEDLE/3ML/20GX1" MISC MISC MONOJECT TUBERCULIN RX/OTC MONOJECT RX/OTC SYRINGE SOFTPACK F SYRINGE/STANDARDHY 1ML REGULAR LUER TIP PODERMIC F MISC NEEDLE/3ML/20GX1-1/2" MONOJECT TUBERCULIN RX/OTC MISC SYRINGE/WITHOUT F MONOJECT RX/OTC NEEDLE/REG LUER/1ML SYRINGE/STANDARDHY MISC PODERMIC F MONOJECT ULTRA QL(6 ea daily); NEEDLE/3ML/21GX1" COMFORT INSULIN F RX/OTC MISC SYRINGE/0.3ML/29G X MONOJECT 1/2" MISC SYRINGE/STANDARDHY MONOJECT ULTRA QL(6 ea daily); F PODERMIC COMFORT INSULIN F RX/OTC NEEDLE/3ML/22GX1" SYRINGE/0.3ML/30G X MISC 5/16" MISC MONOJECT RX/OTC MONOJECT ULTRA QL(6 ea daily) SYRINGE/STANDARDHY COMFORT INSULIN F PODERMIC F SYRINGE/0.3ML/31G X NEEDLE/3ML/22GX1-1/2" 5/16" MISC MISC MONOJECT ULTRA QL(6 ea daily); MONOJECT RX/OTC COMFORT INSULIN F RX/OTC SYRINGE/STANDARDHY SYRINGE/0.5ML/28G X PODERMIC F 1/2" MISC NEEDLE/3ML/23GX1" MONOJECT ULTRA QL(6 ea daily); MISC COMFORT INSULIN F RX/OTC MONOJECT RX/OTC SYRINGE/0.5ML/29G X SYRINGE/STANDARDHY 1/2" MISC PODERMIC F MONOJECT ULTRA QL(6 ea daily); NEEDLE/3ML/25GX1" COMFORT INSULIN F RX/OTC MISC SYRINGE/0.5ML/30G X MONOJECT 5/16" MISC SYRINGE/STANDARDHY MONOJECT ULTRA QL(6 ea daily) PODERMIC F COMFORT INSULIN F NEEDLE/3ML/25GX1-1/4" SYRINGE/0.5ML/31G X MISC 5/16" MISC
Oregon Trillium OHP Updated September 1, 2021
82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT ULTRA QL(6 ea daily); PRECISION SURE-DOSE QL(6 ea daily); COMFORT INSULIN F RX/OTC PLUSINSULIN F RX/OTC SYRINGE/1ML/28G X 1/2" SYRINGE/0.3ML/29G X MISC 1/2" MISC MONOJECT ULTRA QL(6 ea daily); PRECISION SURE-DOSE QL(6 ea daily); COMFORT INSULIN F RX/OTC PLUSINSULIN F RX/OTC SYRINGE/1ML/29G X 1/2" SYRINGE/1ML/29G X 1/2" MISC MISC MS INSULIN QL(6 ea daily) PREFERRED PLUS QL(6 ea daily); F SYRINGE/0.3ML/31G X INSULIN SYRINGE/U- F RX/OTC 5/16" MISC 100/0.3ML/29G X 1/2" MS INSULIN QL(6 ea daily) MISC SYRINGE/0.5ML/31G X F PREFERRED PLUS QL(6 ea daily); 5/16" MISC INSULIN SYRINGE/U- F RX/OTC MS INSULIN QL(6 ea daily) 100/0.3ML/30G X 5/16" SYRINGE/1ML/31G X F MISC 5/16" MISC PREFERRED PLUS QL(6 ea daily); NOKOR ADMIX NEEDLE RX/OTC INSULIN SYRINGE/U- F RX/OTC THIN WALL NON-CORING F 100/0.5ML/28G X 1/2" 16G X 1" MISC MISC NOKOR ADMIX NEEDLE RX/OTC PREFERRED PLUS QL(6 ea daily); THIN WALL NON-CORING F INSULIN SYRINGE/U- F RX/OTC 18G X 1-1/2" MISC 100/0.5ML/29G X 1/2" MISC QL(2 ea per 30 PHLEBOTOMY SHARPS F days retail); PREFERRED PLUS QL(6 ea daily); CONTAINER MISC RX/OTC INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/30G X 5/16" PRECISION SURE-DOSE QL(6 ea daily); MISC INSULIN F RX/OTC SYRINGE/0.3ML/30G X PREFERRED PLUS QL(6 ea daily); 5/16" MISC INSULIN SYRINGE/U- F RX/OTC 100/1ML/28G X 1/2" MISC PRECISION SURE-DOSE QL(6 ea daily); PREFERRED PLUS QL(6 ea daily); INSULIN F RX/OTC SYRINGE/0.5ML/28G X INSULIN SYRINGE/U- F RX/OTC 1/2" MISC 100/1ML/29G X 1/2" MISC PRECISION SURE-DOSE QL(6 ea daily); PREFERRED PLUS QL(6 ea daily); INSULIN SYRINGE/U- RX/OTC INSULIN F RX/OTC F SYRINGE/0.5ML/29G X 100/1ML/30G X 5/16" 1/2" MISC MISC PRECISION SURE-DOSE QL(6 ea daily) PRO COMFORT INSULIN QL(6 ea daily) SYRINGES/0.5ML/30G X F INSULIN F SYRINGE/0.5ML/30G X 1/2" MISC 3/8" MISC PRO COMFORT INSULIN QL(6 ea daily); PRECISION SURE-DOSE QL(6 ea daily); SYRINGES/0.5ML/30G X F RX/OTC 5/16" MISC INSULIN F RX/OTC SYRINGE/1ML/28G X 1/2" PRO COMFORT INSULIN QL(6 ea daily) MISC SYRINGES/0.5ML/31G X F 5/16" MISC
Oregon Trillium OHP Updated September 1, 2021
83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRO COMFORT INSULIN QL(6 ea daily) RELION INSULIN QL(6 ea daily) SYRINGES/1ML/30G X F SYRINGE 0.5ML/31G X F 1/2" MISC 15/64" MISC PRO COMFORT INSULIN QL(6 ea daily); RELION INSULIN QL(6 ea daily) SYRINGES/1ML/30G X F RX/OTC SYRINGE F 5/16" MISC 1ML/31GX15/64" MISC PRO COMFORT INSULIN QL(6 ea daily) RELION INSULIN QL(6 ea daily); SYRINGES/1ML/31G X F SYRINGE/U- F RX/OTC 5/16" MISC 100/0.3ML/31G X 15/64" PRODIGY INSULIN QL(6 ea daily) MISC SYRING/U-100/0.3ML/31G F RELION INSULIN QL(6 ea daily) X 5/16" MISC SYRINGE/U- F PRODIGY INSULIN QL(6 ea daily) 100/0.3ML/31G X 5/16" SYRINGE/1/2ML/31G X F MISC 5/16" MISC RELION INSULIN QL(6 ea daily); PRODIGY INSULIN QL(6 ea daily); SYRINGE/U- F RX/OTC SYRINGE/1ML/28G X 1/2" F RX/OTC 100/0.5ML/29G X 1/2" MISC MISC PX INSULIN SYRINGE/U- QL(6 ea daily) RELION INSULIN QL(6 ea daily) 100/0.5ML/30G X 1/2" F SYRINGE/U- F MISC 100/0.5ML/31G X 5/16" MISC RA INSULIN QL(6 ea daily); SYRINGE/0.5ML/29G X F RX/OTC RELION INSULIN QL(6 ea daily) 1/2" MISC SYRINGE/U-100/1ML/31G F X 15/64" MISC RA INSULIN QL(6 ea daily); SYRINGE/1ML/29G X 1/2" F RX/OTC RELION INSULIN QL(6 ea daily) MISC SYRINGE/U-100/1ML/31G F X 5/16" MISC RA INSULIN SYRINGE/U- QL(6 ea daily); 100/0.5ML/30G X 5/16" F RX/OTC SAFESNAP INSULIN QL(6 ea daily); MISC SYRINGE/0.3ML/30G X F RX/OTC 5/16" MISC RA INSULIN SYRINGE/U- QL(6 ea daily); 100/1 ML/30G X 5/16" F RX/OTC SAFESNAP INSULIN QL(6 ea daily); MISC SYRINGE/0.5ML/29G X F RX/OTC 1/2" MISC REALITY INSULIN QL(6 ea daily); SAFESNAP INSULIN QL(6 ea daily); SYRINGE/U- F RX/OTC 100/0.5ML/28G X 1/2" SYRINGE/0.5ML/30G X F RX/OTC MISC 5/16" MISC REALITY INSULIN QL(6 ea daily); SAFESNAP INSULIN QL(6 ea daily); SYRINGE/1ML/28G X 1/2" F RX/OTC SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" MISC MISC SAFESNAP INSULIN QL(6 ea daily); REALITY INSULIN QL(6 ea daily); SYRINGE/1ML/29G X 1/2" F RX/OTC SYRINGE/U-100/1ML/28G F RX/OTC MISC X 1/2" MISC SAFESNAP RX/OTC REALITY INSULIN QL(6 ea daily); SYRINGE/NEEDLE/3ML/2 F SYRINGE/U-100/1ML/29G F RX/OTC 0G X 1" MISC X 1/2" MISC
Oregon Trillium OHP Updated September 1, 2021
84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFESNAP RX/OTC SAFETY RX/OTC SYRINGE/NEEDLE/3ML/2 F SYRINGES/NEEDLE F 0G X 1-1/2" MISC 3ML/20GX1" MISC SAFESNAP RX/OTC SAFETY RX/OTC SYRINGE/NEEDLE/3ML/2 F SYRINGES/NEEDLE F 1G X 1" MISC 3ML/20GX1-1/2" MISC SAFESNAP RX/OTC SAFETY RX/OTC SYRINGE/NEEDLE/3ML/2 F SYRINGES/NEEDLE F 1G X 1-1/2" MISC 3ML/21GX1" MISC SAFESNAP SAFETY RX/OTC SYRINGE/NEEDLE/3ML/2 F SYRINGES/NEEDLE F 2G X 1" MISC 3ML/21GX1-1/2" MISC SAFESNAP RX/OTC SAFETY SYRINGE/NEEDLE/3ML/2 F SYRINGES/NEEDLE F 2G X 1-1/2" MISC 3ML/22GX1" MISC SAFESNAP RX/OTC SAFETY RX/OTC SYRINGE/NEEDLE/3ML/2 F SYRINGES/NEEDLE F 3G X 1" MISC 3ML/22GX1-1/2" MISC SAFESNAP SAFETY RX/OTC SYRINGE/NEEDLE/3ML/2 F SYRINGES/NEEDLE F 3G X 1-1/2" MISC 3ML/23GX1" MISC SAFESNAP RX/OTC SAFETY RX/OTC SYRINGE/NEEDLE/3ML/2 F SYRINGES/NEEDLE F 5G X 1" MISC 3ML/25GX5/8" MISC SAFESNAP RX/OTC SAFETY-GARD SYRINGE/NEEDLE/3ML/2 F SHIELDED NEEDLE 18G F 5G X 5/8" MISC MISC SAFETY INSULIN QL(6 ea daily); SAFETY-GARD SYRINGES F RX/OTC SHIELDED NEEDLE 20G F 0.5ML/29GX1/2" MISC MISC SAFETY INSULIN QL(6 ea daily); SAFETY-LOK RX/OTC SYRINGES F RX/OTC SYRINGE/NEEDLE3ML F 0.5ML/30GX5/16" MISC LUER-LOK 21GX1-1/2" SAFETY INSULIN QL(6 ea daily); MISC SYRINGES 1ML/27GX1/2" F RX/OTC SAFETY-LOK MISC SYRINGE/NEEDLE3ML F SAFETY INSULIN QL(6 ea daily); LUER-LOK 22GX1" MISC SYRINGES 1ML/29GX1/2" F RX/OTC SAFETY-LOK RX/OTC MISC SYRINGE/NEEDLE3ML F SAFETY INSULIN QL(6 ea daily) LUER-LOK 22GX1-1/2" SYRINGES 1ML/30GX1/2" F MISC MISC SAFETY-LOK RX/OTC SAFETY RX/OTC SYRINGE/NEEDLE3ML F SYRINGES/NEEDLE F LUER-LOK 23GX1" MISC 1ML/25GX5/8" MISC SAFETY-LOK RX/OTC SAFETY SYRINGE/NEEDLE3ML F SYRINGES/NEEDLE F LUER-LOK 25GX5/8" 1ML/27GX1/2" MISC MISC Oregon Trillium OHP Updated September 1, 2021
85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SB INSULIN SYRINGE/U- QL(6 ea daily); SURE COMFORT QL(6 ea daily) F 100/0.5ML/29G X 1/2" RX/OTC INSULIN SYRINGE/U- F MISC 100/0.3ML/31G X 5/16" SB INSULIN SYRINGE/U- QL(6 ea daily); MISC 100/0.5ML/30G X 5/16" F RX/OTC SURE COMFORT QL(6 ea daily); MISC INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/28G X 1/2" SB INSULIN SYRINGE/U- F QL(6 ea daily); 100/1ML/29G X 1/2" MISC RX/OTC MISC SB INSULIN SYRINGE/U- QL(6 ea daily); SURE COMFORT QL(6 ea daily); 100/1ML/30G X 5/16" F RX/OTC INSULIN SYRINGE/U- F RX/OTC MISC 100/0.5ML/29G X 1/2" MISC SB INSULIN SYRINGE/U- QL(6 ea daily) 100/1ML/31G X 5/16" F SURE COMFORT QL(6 ea daily) MISC INSULIN SYRINGE/U- F 100/0.5ML/30G X 1/2" SECURESAFE SAFETY QL(6 ea daily); MISC INSULIN SYRINGES/U- F RX/OTC 100/0.5ML/29GX1/2" MISC SURE COMFORT QL(6 ea daily); INSULIN SYRINGE/U- F RX/OTC SECURESAFE SAFETY QL(6 ea daily); 100/0.5ML/30G X 5/16" INSULIN SYRINGES/U- F RX/OTC MISC 100/1ML/29GX1/2" MISC SURE COMFORT QL(6 ea daily) SECURESAFE RX/OTC INSULIN SYRINGE/U- F SYRINGE/NEEDLE/1ML/2 F 100/0.5ML/31G X 5/16 5G X 1" MISC MISC SECURESAFE RX/OTC SURE COMFORT QL(6 ea daily); SYRINGE/NEEDLE/3ML/2 F INSULIN SYRINGE/U- F RX/OTC 0G X 1" MISC 100/1ML/28G X 1/2" MISC QL(2 ea per 30 SURE COMFORT QL(6 ea daily); SHARP CONTAINER F days retail); MISC INSULIN SYRINGE/U- F RX/OTC RX/OTC 100/1ML/29G X 1/2" MISC QL(2 ea per 30 SURE COMFORT QL(6 ea daily) SHARPS DISPOSAL BY F days retail); MAIL SYSTEM MISC INSULIN SYRINGE/U- F RX/OTC 100/1ML/30G X 1/2" MISC SURE COMFORT QL(6 ea daily); SURE COMFORT QL(6 ea daily); INSULIN SYRINGE/U- RX/OTC F INSULIN SYRINGE/U- F RX/OTC 100/0.3ML/29G X 1/2" 100/1ML/30G X 5/16" MISC MISC SURE COMFORT QL(6 ea daily) SURE COMFORT QL(6 ea daily) INSULIN SYRINGE/U- F INSULIN SYRINGE/U- F 100/0.3ML/30G X 1/2" 100/1ML/31G X 5/16" MISC MISC SURE COMFORT QL(6 ea daily); SURE-JECT INSULIN QL(6 ea daily); INSULIN SYRINGE/U- RX/OTC F SYRINGE/U- F RX/OTC 100/0.3ML/30G X 5/16" 100/0.3ML/29G X 1/2" MISC MISC SURE COMFORT QL(6 ea daily) INSULIN SYRINGE/U- F 100/0.3ML/31G X 5/16 MISC
Oregon Trillium OHP Updated September 1, 2021
86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE-JECT INSULIN QL(6 ea daily); SYRINGE/LUER F RX/OTC SYRINGE/U- F RX/OTC LOCK/3ML/21G X 1" MISC 100/0.3ML/30G X 5/16" SYRINGE/LUER RX/OTC MISC LOCK/3ML/21G X 1-1/2" F SURE-JECT INSULIN QL(6 ea daily) MISC SYRINGE/U- F SYRINGE/LUER F RX/OTC 100/0.3ML/31G X 5/16" LOCK/3ML/21GX1" MISC MISC SYRINGE/LUER RX/OTC SURE-JECT INSULIN QL(6 ea daily); LOCK/3ML/21GX1-1/2" F SYRINGE/U- F RX/OTC MISC 100/0.5ML/28G X 1/2" MISC SYRINGE/LUER F LOCK/3ML/22G X 1" MISC SURE-JECT INSULIN QL(6 ea daily); SYRINGE/LUER RX/OTC SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" LOCK/3ML/22G X 1-1/2" F MISC MISC SURE-JECT INSULIN QL(6 ea daily); SYRINGE/LUER F LOCK/3ML/22GX1" MISC SYRINGE/U- F RX/OTC 100/0.5ML/30G X 5/16" SYRINGE/LUER RX/OTC MISC LOCK/3ML/22GX1-1/2" F SURE-JECT INSULIN QL(6 ea daily) MISC SYRINGE/LUER RX/OTC SYRINGE/U- F F 100/0.5ML/31G X 5/16" LOCK/3ML/23G X 1" MISC MISC SYRINGE/LUER SURE-JECT INSULIN QL(6 ea daily); LOCK/3ML/23G X 1-1/2" F SYRINGE/U-100/1ML/28G F RX/OTC MISC X 1/2" MISC SYRINGE/LUER F RX/OTC SURE-JECT INSULIN QL(6 ea daily); LOCK/3ML/23GX1" MISC SYRINGE/U-100/1ML/29G F RX/OTC SYRINGE/LUER F RX/OTC X 1/2" MISC LOCK/3ML/25G X 1" MISC SURE-JECT INSULIN QL(6 ea daily); SYRINGE/LUER SYRINGE/U-100/1ML/30G F RX/OTC LOCK/3ML/25G X 1-1/2" F X 5/16" MISC MISC SURE-JECT INSULIN QL(6 ea daily) SYRINGE/LUER RX/OTC SYRINGE/U-100/1ML/31G F LOCK/3ML/25G X 5/8" F X 5/16" MISC MISC SYRINGE/BLUNT RX/OTC F SYRINGE/LUER F RX/OTC PLASTIC CANNULA MISC LOCK/3ML/25GX1" MISC SYRINGE/LUER RX/OTC F SYRINGE/LUER F RX/OTC LOCK/3ML MISC LOCK/3ML/25GX5/8" MISC SYRINGE/LUER RX/OTC F SYRINGE/LUER SLIP/1ML F RX/OTC LOCK/3ML/20G X 1" MISC MISC SYRINGE/LUER RX/OTC SYRINGE/LUER F RX/OTC LOCK/3ML/20G X 1-1/2" F SLIP/1ML/25G X 5/8" MISC MISC SYRINGE/LUER F SYRINGE/LUER RX/OTC SLIP/1ML/26G X 3/8" MISC LOCK/3ML/20GX1-1/2" F SYRINGE/LUER F MISC SLIP/1ML/27G X 1/2" MISC Oregon Trillium OHP Updated September 1, 2021
87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SYRINGE/LUER F RX/OTC TECHLITE INSULIN QL(6 ea daily) SLIP/35ML MISC SYRINGEU- F 100/0.5ML/31G X 15/64" SYRINGE/LUER SLIP/3ML F RX/OTC MISC MISC TECHLITE INSULIN QL(6 ea daily) SYRINGES/LUER F RX/OTC LOCK/1ML/20GX1" MISC SYRINGEU- F 100/0.5ML/31G X 5/16" SYRINGES/LUER RX/OTC MISC LOCK/WITHOUT F NEEDLE/3ML MISC TECHLITE INSULIN QL(6 ea daily); SYRINGEU-100/1ML/29G F RX/OTC SYRINGES/LUER F RX/OTC X 1/2" MISC SLIP/1ML/25GX5/8" MISC TECHLITE INSULIN QL(6 ea daily) SYRINGES/LUER RX/OTC SYRINGEU-100/1ML/30G F SLIP/WITHOUT F X 1/2" MISC NEEDLE/1ML MISC TECHLITE INSULIN QL(6 ea daily); TECHLITE INSULIN QL(6 ea daily); SYRINGEU-100/1ML/30G F RX/OTC SYRINGEU- F RX/OTC X 5/16" MISC 100/0.3ML/29G X 1/2" MISC TECHLITE INSULIN QL(6 ea daily) SYRINGEU-100/1ML/31G F TECHLITE INSULIN QL(6 ea daily) X 15/64" MISC SYRINGEU- F 100/0.3ML/30G X 1/2" TECHLITE INSULIN QL(6 ea daily) MISC SYRINGEU-100/1ML/31G F X 5/16" MISC TECHLITE INSULIN QL(6 ea daily); TOPCARE ULTRA QL(6 ea daily); SYRINGEU- F RX/OTC 100/0.3ML/30G X 5/16" COMFORT INSULIN F RX/OTC MISC SYRINGE/0.3ML/30G X 5/16" MISC TECHLITE INSULIN QL(6 ea daily); TOPCARE ULTRA QL(6 ea daily) SYRINGEU- F RX/OTC 100/0.3ML/31G X 15/64" COMFORT INSULIN F MISC SYRINGE/0.3ML/31G X 5/16" MISC TECHLITE INSULIN QL(6 ea daily) TOPCARE ULTRA QL(6 ea daily); SYRINGEU- F 100/0.3ML/31G X 5/16" COMFORT INSULIN F RX/OTC MISC SYRINGE/0.5ML/30G X 5/16" MISC TECHLITE INSULIN QL(6 ea daily); TOPCARE ULTRA QL(6 ea daily) SYRINGEU- F RX/OTC 100/0.5ML/29G X 1/2" COMFORT INSULIN F MISC SYRINGE/0.5ML/31G X 5/16" MISC TECHLITE INSULIN QL(6 ea daily) TOPCARE ULTRA QL(6 ea daily); SYRINGEU- F 100/0.5ML/30G X 1/2" COMFORT INSULIN F RX/OTC MISC SYRINGE/1ML/30G X 5/16" MISC TECHLITE INSULIN QL(6 ea daily); TOPCARE ULTRA QL(6 ea daily) SYRINGEU- F RX/OTC 100/0.5ML/30G X 5/16" COMFORT INSULIN F MISC SYRINGE/1ML/31G X 5/16" MISC
Oregon Trillium OHP Updated September 1, 2021
88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPCARE ULTRA QL(6 ea daily); TRUEPLUS INSULIN QL(6 ea daily) COMFORT INSULIN RX/OTC SYRINGE/U- F SYRINGE/U- F 100/0.3ML/31G X 5/16" 100/0.3ML/29G X 1/2" MISC MISC TRUEPLUS INSULIN QL(6 ea daily); TOPCARE ULTRA QL(6 ea daily); SYRINGE/U- F RX/OTC COMFORT INSULIN RX/OTC 100/0.5ML/28G X 1/2" SYRINGE/U- F MISC 100/0.5ML/29G X 1/2" TRUEPLUS INSULIN QL(6 ea daily); MISC SYRINGE/U- F RX/OTC TOPCARE ULTRA QL(6 ea daily); 100/0.5ML/29G X 1/2" COMFORT INSULIN F RX/OTC MISC SYRINGE/U-100/1ML/29G TRUEPLUS INSULIN QL(6 ea daily); X 1/2" MISC SYRINGE/U- F RX/OTC TRUE COMFORT INSULIN QL(6 ea daily) 100/0.5ML/30G X 5/16" SYRINGE/0.5ML/31G X F MISC 5/16" MISC TRUEPLUS INSULIN QL(6 ea daily) TRUE COMFORT INSULIN QL(6 ea daily) SYRINGE/U- F SYRINGE/1ML/31G X F 100/0.5ML/31G X 5/16" 5/16" MISC MISC TRUE COMFORT PRO QL(6 ea daily); TRUEPLUS INSULIN QL(6 ea daily); INSULINSYRINGE/0.5ML/ F RX/OTC SYRINGE/U-100/1ML/28G F RX/OTC 30G X 5/16" MISC X 1/2" MISC TRUE COMFORT PRO QL(6 ea daily) TRUEPLUS INSULIN QL(6 ea daily); INSULINSYRINGE/0.5ML/ F SYRINGE/U-100/1ML/29G F RX/OTC 31G X 5/16" MISC X 1/2" MISC TRUE COMFORT PRO QL(6 ea daily); TRUEPLUS INSULIN QL(6 ea daily); INSULINSYRINGE/1ML/30 F RX/OTC SYRINGE/U-100/1ML/30G F RX/OTC G X 5/16" MISC X 5/16" MISC TRUE COMFORT PRO QL(6 ea daily) TRUEPLUS INSULIN QL(6 ea daily) INSULINSYRINGE/1ML/31 F SYRINGE/U-100/1ML/31G F G X 5/16" MISC X 5/16" MISC TRUE COMFORT PRO QL(6 ea daily) ULTICARE INSULIN QL(6 ea daily); INSULINSYRINGE/U- F SAFETY F RX/OTC 100/0.5ML/30G X 1/2" SYRINGE/0.5ML/29G X MISC 1/2" MISC TRUE COMFORT PRO QL(6 ea daily) ULTICARE INSULIN QL(6 ea daily); F INSULINSYRINGE/U- SAFETY F RX/OTC 100/1ML/30G X 1/2" MISC SYRINGE/1ML/29G X 1/2" TRUEPLUS INSULIN QL(6 ea daily); MISC SYRINGE/U- F RX/OTC ULTICARE INSULIN QL(6 ea daily); 100/0.3ML/29G X 1/2" SYRINGE/0.3ML/29G X F RX/OTC MISC 1/2" MISC TRUEPLUS INSULIN QL(6 ea daily); ULTICARE INSULIN QL(6 ea daily) SYRINGE/U- F RX/OTC SYRINGE/0.3ML/30G X F 100/0.3ML/30G X 5/16" 1/2" MISC MISC
Oregon Trillium OHP Updated September 1, 2021
89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN QL(6 ea daily); ULTICARE INSULIN QL(6 ea daily) SYRINGE/0.3ML/30G X F RX/OTC SYRINGE/U- F 5/16" MISC 100/0.3ML/30G X 1/2" ULTICARE INSULIN QL(6 ea daily); MISC SYRINGE/0.5ML/28G X F RX/OTC ULTICARE INSULIN QL(6 ea daily) 1/2" MISC SYRINGE/U- F ULTICARE INSULIN QL(6 ea daily); 100/0.3ML/31G X 5/16" SYRINGE/0.5ML/29G X F RX/OTC MISC 1/2" MISC ULTICARE INSULIN QL(6 ea daily) ULTICARE INSULIN QL(6 ea daily) SYRINGE/U- F SYRINGE/0.5ML/30G X F 100/0.5ML/30G X 1/2" 1/2" MISC MISC ULTICARE INSULIN QL(6 ea daily); ULTICARE INSULIN QL(6 ea daily) SYRINGE/0.5ML/30G X F RX/OTC SYRINGE/U- F 5/16" MISC 100/0.5ML/31G X 5/16" MISC ULTICARE INSULIN QL(6 ea daily); SYRINGE/1ML/28G X 1/2" F RX/OTC ULTICARE INSULIN QL(6 ea daily) MISC SYRINGE/U-100/1ML/30G F X 1/2" MISC ULTICARE INSULIN QL(6 ea daily); SYRINGE/1ML/29G X 1/2" F RX/OTC ULTICARE INSULIN QL(6 ea daily) MISC SYRINGE/U-100/1ML/31G F X 5/16" MISC ULTICARE INSULIN QL(6 ea daily) SYRINGE/1ML/30G X 1/2" F ULTICARE INSULIN QL(6 ea daily) MISC SYRINGEULTRAFINE U- F 100/0.3ML/31G X 5/16" ULTICARE INSULIN QL(6 ea daily); MISC SYRINGE/1ML/30G X F RX/OTC 5/16" MISC ULTICARE INSULIN QL(6 ea daily) SYRINGEULTRAFINE U- F ULTICARE INSULIN QL(6 ea daily); 100/0.5ML/31G X 5/16" SYRINGE/SHORT/0.3ML/3 F RX/OTC MISC 0G X 5/16" MISC ULTICARE INSULIN QL(6 ea daily) ULTICARE INSULIN QL(6 ea daily) SYRINGEULTRAFINE U- F SYRINGE/SHORT/0.3ML/3 F 100/1ML/31G X 5/16" 1G X 5/16" MISC MISC ULTICARE INSULIN QL(6 ea daily); ULTICARE SAFETY SYRINGE/SHORT/0.5ML/3 F RX/OTC SYRINGE/LOW DEAD F 0G X 5/16" MISC SPACE/1.5ML/22GX1-1/2" ULTICARE INSULIN QL(6 ea daily) MISC SYRINGE/SHORT/0.5ML/3 F ULTICARE SYRINGE/LOW 1G X 5/16" MISC DEADSPACE/1.5ML/22G F ULTICARE INSULIN QL(6 ea daily); X1-1/2" MISC SYRINGE/SHORT/1ML/30 F RX/OTC ULTICARE SYRINGE/LOW G X 5/16" MISC DEADSPACE/1ML/22G F ULTICARE INSULIN QL(6 ea daily) X1-1/2" MISC SYRINGE/SHORT/1ML/31 F ULTICARE SYRINGE/LOW RX/OTC G X 5/16" MISC DEADSPACE/3ML/22G F X1-1/2" MISC
Oregon Trillium OHP Updated September 1, 2021
90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE TUBERCULIN ULTILET INSULIN QL(6 ea daily) SAFETSYRINGES/1ML/27 F SYRINGE/0.3ML/31G X F G X 5/8" MISC 8MM MISC ULTICARE TUBERCULIN ULTILET INSULIN QL(6 ea daily); SAFETSYRINGES/1ML/28 F SYRINGE/0.5ML/30G X F RX/OTC G X 1/2" MISC 8MM MISC ULTICARE TUBERCULIN ULTILET INSULIN QL(6 ea daily); SAFETY F SYRINGE/1ML/30G X F RX/OTC SYRINGES/1ML/27G X 8MM MISC 1/2" MISC ULTILET INSULIN QL(6 ea daily) ULTIGUARD SAFEPACK QL(6 ea daily) SYRINGE/1ML/31G X F INSULIN SYRINGE F 8MM MISC 0.3ML/30G X ULTILET INSULIN QL(6 ea daily) 1/2"/SHARPS C MISC SYRINGE/SHORT/0.3ML/3 F ULTIGUARD SAFEPACK QL(6 ea daily) 0G X 12.7MM MISC INSULIN SYRINGE 1/2ML F ULTILET INSULIN QL(6 ea daily); 30G X 1/2"/SHARPS C SYRINGE/SHORT/0.3ML/3 F RX/OTC MISC 0G X 5/16" MISC ULTIGUARD SAFEPACK QL(6 ea daily) ULTILET INSULIN QL(6 ea daily) INSULIN SYRINGE 1ML F SYRINGE/SHORT/0.3ML/3 F 30G X 1/2"/SHARPS CON 1G X 5/16" MISC MISC ULTILET INSULIN QL(6 ea daily); ULTIGUARD SAFEPACK QL(6 ea daily) SYRINGE/SHORT/0.5ML/3 F RX/OTC INSULIN SYRINGE 1ML F 0G X 5/16" MISC 31G X 5/16"/SHARPS CO MISC ULTILET INSULIN QL(6 ea daily) SYRINGE/SHORT/0.5ML/3 F ULTIGUARD SAFEPACK QL(6 ea daily) 1G X 5/16" MISC INSULIN F SYRINGE/0.3ML/30G X ULTILET INSULIN QL(6 ea daily); 1/2"/SHARPS C MISC SYRINGE/SHORT/1ML/30 F RX/OTC G X 5/16" MISC ULTIGUARD SAFEPACK QL(6 ea daily) ULTILET INSULIN QL(6 ea daily) INSULIN F SYRINGE/0.3ML/31G X SYRINGE/SHORT/1ML/31 F 5/16"/SHARPS MISC G X 5/16" MISC ULTIGUARD SAFEPACK QL(6 ea daily) ULTILET INSULIN QL(6 ea daily) SYRINGE/U- INSULIN F F SYRINGE/0.5ML/30G X 100/0.5ML/30G X 1/2" 1/2"/SHARPS C MISC MISC ULTIGUARD QL(6 ea daily) ULTILET INSULIN QL(6 ea daily) SAFEPACK/SYRINGE/NE SYRINGE/U- F EDLE/31G X F 100/0.5ML/31GX6MM 5/16"/SHARPS CONTAIN MISC MISC ULTILET INSULIN QL(6 ea daily) SYRINGE/U-100/1ML/30G F ULTILET INSULIN F QL(6 ea daily); SYRINGE 31X6MM MISC RX/OTC X 1/2" MISC ULTILET INSULIN QL(6 ea daily); ULTILET SHARPS QL(2 ea per 30 SYRINGE/0.3ML/30G X F RX/OTC CONTAINER1 QUART F days retail); 8MM MISC MISC RX/OTC
Oregon Trillium OHP Updated September 1, 2021
91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTILET SHARPS QL(2 ea per 30 ULTRA FLO INSULIN QL(6 ea daily) CONTAINER2 QUART F days retail); SYRINGE 1ML/30GX1/2" F MISC RX/OTC MISC ULTRA COMFORT QL(6 ea daily); ULTRA FLO INSULIN QL(6 ea daily); INSULIN SYRINGE/U- F RX/OTC SYRINGE 1ML/30GX5/16" F RX/OTC 100/0.3ML/30G X 5/16" MISC MISC ULTRA FLO INSULIN QL(6 ea daily) ULTRA FLO INSULIN QL(6 ea daily); SYRINGE 1ML/31GX5/16" F SYRINGE 0.3ML/29G X F RX/OTC MISC 1/2" MISC ULTRA-COMFORT QL(6 ea daily); ULTRA FLO INSULIN QL(6 ea daily) INSULIN SYRINGE/U- F RX/OTC SYRINGE 0.3ML/30GX1/2" F 100/0.3ML/29G X 1/2" MISC MISC ULTRA FLO INSULIN QL(6 ea daily); ULTRA-COMFORT QL(6 ea daily); SYRINGE F RX/OTC INSULIN SYRINGE/U- F RX/OTC 0.3ML/30GX5/16" MISC 100/0.3ML/30G X 5/16" ULTRA FLO INSULIN QL(6 ea daily) MISC SYRINGE F ULTRA-COMFORT QL(6 ea daily) 0.3ML/31GX5/16" MISC INSULIN SYRINGE/U- F ULTRA FLO INSULIN QL(6 ea daily); 100/0.3ML/31G X 5/16" SYRINGE 0.5ML/29GX1/2" F RX/OTC MISC MISC ULTRA-COMFORT QL(6 ea daily); ULTRA FLO INSULIN QL(6 ea daily) INSULIN SYRINGE/U- F RX/OTC SYRINGE 0.5ML/30GX1/2" F 100/0.5ML/28G X 1/2" MISC MISC ULTRA FLO INSULIN QL(6 ea daily); ULTRA-COMFORT QL(6 ea daily); SYRINGE F RX/OTC INSULIN SYRINGE/U- F RX/OTC 0.5ML/30GX5/16" MISC 100/0.5ML/29G X 1/2" MISC ULTRA FLO INSULIN QL(6 ea daily) SYRINGE F ULTRA-COMFORT QL(6 ea daily); 0.5ML/31GX5/16" MISC INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/30G X 5/16" ULTRA FLO INSULIN QL(6 ea daily) MISC SYRINGE 1/2 F UNIT/0.3ML/30GX1/2" ULTRA-COMFORT QL(6 ea daily) MISC INSULIN SYRINGE/U- F 100/0.5ML/31G X 5/16" ULTRA FLO INSULIN QL(6 ea daily); MISC SYRINGE 1/2 F RX/OTC UNIT/0.3ML/30GX5/16" ULTRA-COMFORT QL(6 ea daily); MISC INSULIN SYRINGE/U- F RX/OTC 100/1ML/28G X 1/2" MISC ULTRA FLO INSULIN QL(6 ea daily) ULTRA-COMFORT QL(6 ea daily); SYRINGE 1/2 F UNIT/0.3ML/31GX5/16" INSULIN SYRINGE/U- F RX/OTC MISC 100/1ML/29G X 1/2" MISC ULTRA FLO INSULIN QL(6 ea daily); ULTRA-COMFORT QL(6 ea daily); SYRINGE 1M/29GX1/2" F RX/OTC INSULIN SYRINGE/U- F RX/OTC MISC 100/1ML/30G X 5/16" MISC
Oregon Trillium OHP Updated September 1, 2021
92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA-COMFORT QL(6 ea daily) ULTRACARE INSULIN QL(6 ea daily) INSULIN SYRINGE/U- F SYRINGE/U- F 100/1ML/31G X 5/16" 100/0.5ML/31G X 5/16" MISC MISC ULTRA-THIN II INSULIN QL(6 ea daily); ULTRACARE INSULIN QL(6 ea daily) SYRINGE SHORT/U- F RX/OTC SYRINGE/U-100/1ML/30G F 100/0.3ML/30GX5/16" X 1/2" MISC MISC ULTRACARE INSULIN QL(6 ea daily); ULTRA-THIN II INSULIN QL(6 ea daily) SYRINGE/U-100/1ML/30G F RX/OTC SYRINGE SHORT/U- F X 5/16" MISC 100/0.3ML/31GX5/16" ULTRACARE INSULIN QL(6 ea daily) MISC SYRINGE/U-100/1ML/31G F ULTRA-THIN II INSULIN QL(6 ea daily); X 5/16" MISC SYRINGE SHORT/U- F RX/OTC VALUE HEALTH INSULIN QL(6 ea daily); 100/0.5ML/30GX5/16" SYRINGE/U- F RX/OTC MISC 100/0.5ML/29G X 1/2" ULTRA-THIN II INSULIN QL(6 ea daily) MISC SYRINGE SHORT/U- F VALUE HEALTH INSULIN QL(6 ea daily); 100/0.5ML/31GX5/16" SYRINGE/U-100/1ML/29G F RX/OTC MISC X 1/2" MISC ULTRA-THIN II INSULIN QL(6 ea daily); VANISHPOINT INSULIN QL(6 ea daily) SYRINGE SHORT/U- F RX/OTC SYRINGE/0.5ML/30G X F 100/1ML/30GX5/16" MISC 1/2" MISC ULTRA-THIN II INSULIN QL(6 ea daily) VANISHPOINT INSULIN QL(6 ea daily); SYRINGE SHORT/U- F SYRINGE/0.5ML/30G X F RX/OTC 100/1ML/31GX5/16" MISC 5/16" MISC ULTRA-THIN II INSULIN QL(6 ea daily); VANISHPOINT INSULIN QL(6 ea daily); SYRINGE/U- F RX/OTC SYRINGE/1ML/29G X 1/2" F RX/OTC 100/0.5ML/29GX1/2" MISC MISC ULTRA-THIN II INSULIN QL(6 ea daily); VANISHPOINT INSULIN QL(6 ea daily) SYRINGE/U- F RX/OTC SYRINGE/1ML/29G X F 100/1ML/29GX1/2" MISC 5/16" MISC ULTRACARE INSULIN QL(6 ea daily); VANISHPOINT INSULIN QL(6 ea daily); SYRINGE/U- F RX/OTC SYRINGE/1ML/30G X F RX/OTC 100/0.3ML/30G X 5/16" 5/16" MISC MISC VANISHPOINT SAFETY RX/OTC ULTRACARE INSULIN QL(6 ea daily) SYRINGE/3ML/20GX1" F SYRINGE/U- F MISC 100/0.3ML/31G X 5/16" MISC VANISHPOINT SAFETY RX/OTC SYRINGE/3ML/20GX1-1/2" F ULTRACARE INSULIN QL(6 ea daily) MISC SYRINGE/U- F 100/0.5ML/30G X 1/2" VANISHPOINT SAFETY RX/OTC MISC SYRINGE/3ML/21GX1" F MISC ULTRACARE INSULIN QL(6 ea daily); VANISHPOINT SAFETY RX/OTC SYRINGE/U- F RX/OTC 100/0.5ML/30G X 5/16" SYRINGE/3ML/21GX1-1/2" F MISC MISC
Oregon Trillium OHP Updated September 1, 2021
93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VANISHPOINT SAFETY VANISHPOINT SYRINGE/3ML/22GX1" F SYRINGE/3ML/23G X 1- F MISC 1/2" MISC VANISHPOINT SAFETY RX/OTC VANISHPOINT RX/OTC SYRINGE/3ML/22GX1-1/2" F SYRINGE/3ML/25G X 1" F MISC MISC VANISHPOINT SAFETY RX/OTC VANISHPOINT SYRINGE/3ML/23GX1" F SYRINGE/3ML/25G X 1- F MISC 1/2" MISC VANISHPOINT SAFETY VANISHPOINT RX/OTC SYRINGE/3ML/23GX1-1/2" F SYRINGE/3ML/25G X 5/8" F MISC MISC VANISHPOINT SAFETY RX/OTC VP INSULIN SYRINGE/U- QL(6 ea daily); SYRINGE/3ML/25GX1" F 100/0.3ML/29G X 1/2" F RX/OTC MISC MISC VANISHPOINT SAFETY YALE NEEDLES 21G X 1- F SYRINGE/3ML/25GX1-1/2" F 1/4" MISC MISC ZEVRX INSULIN QL(6 ea daily) VANISHPOINT SAFETY RX/OTC SYRINGE/0.5ML/30G X F SYRINGE/3ML/25GX5/8" F 1/2" MISC MISC ZEVRX INSULIN QL(6 ea daily); VANISHPOINT SAFETY SYRINGE/0.5ML/30G X F RX/OTC SYRINGE/3ML/27GX1-1/2" F 5/16" MISC MISC ZEVRX INSULIN QL(6 ea daily) VANISHPOINT RX/OTC SYRINGE/1ML/30G X 1/2" F SYRINGE/1ML/25G X 1" F MISC MISC ZEVRX INSULIN QL(6 ea daily); VANISHPOINT RX/OTC SYRINGE/1ML/30G X F RX/OTC SYRINGE/3ML/20G X 1" F 5/16" MISC MISC Respiratory Therapy Supplies VANISHPOINT RX/OTC SYRINGE/3ML/20G X 1- F ADULT MASK DEVI F RX/OTC 1/2" MISC RX/OTC VANISHPOINT RX/OTC AEROBIKA DEVI F SYRINGE/3ML/21G X 1" F AEROCHAMBER MINI RX/OTC MISC AEROSOLCHAMBER F VANISHPOINT RX/OTC DEVI SYRINGE/3ML/21G X 1- F AEROCHAMBER MV F RX/OTC 1/2" MISC MISC VANISHPOINT AEROCHAMBER PLUS F RX/OTC SYRINGE/3ML/22G X 1" F FLOW VU MISC MISC AEROCHAMBER PLUS F RX/OTC VANISHPOINT RX/OTC FLOW-VU MISC SYRINGE/3ML/22G X 1- F 1/2" MISC AEROCHAMBER PLUS RX/OTC FLOW-VU/LARGE MASK F VANISHPOINT RX/OTC MISC SYRINGE/3ML/23G X 1" F MISC Oregon Trillium OHP Updated September 1, 2021
94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AEROCHAMBER PLUS RX/OTC F BREATHE EASE/SMALL F RX/OTC FLOW-VU/MASK MISC MASK DEVI AEROCHAMBER PLUS RX/OTC BREATHERITE RX/OTC FLOW-VU/MEDIUM MASK F COLLAPSIBLEADULT F MISC SPACER W/MASK MISC AEROCHAMBER PLUS RX/OTC BREATHERITE RX/OTC FLOW-VU/SMALL MASK F COLLAPSIBLECHILD F MISC SPACER W/MASK MISC AEROCHAMBER Z-STAT RX/OTC BREATHERITE RX/OTC PLUS VALVED HOLDING F COLLAPSIBLEINFANT F CHAMBER W/FLOW VU SPACER W/MASK MISC MISC BREATHERITE RX/OTC AEROCHAMBER Z-STAT RX/OTC F COLLAPSIBLESMALL F PLUS/FLOWSIGNAL MISC CHILD SPACER W/MASK MISC AEROCHAMBER Z-STAT F RX/OTC PLUS/LARGE MASK MISC BREATHERITE RX/OTC AEROCHAMBER Z-STAT RX/OTC COLLAPSIBLESPACER F PLUS/MEDIUM MASK F W/ NEONATE MASK MISC MISC BREATHERITE MISC F RX/OTC AEROCHAMBER Z-STAT F RX/OTC PLUS/SMALL MASK MISC BREATHERITE RIGID F RX/OTC SPACERW/MASK MISC AEROCHAMBER/FLOWSI F RX/OTC GNAL MISC BREATHERITE VALVED RX/OTC AEROVENT PLUS RX/OTC MDI F CHAMBER/COLLAPSIBLE HOLDING F CHAMBER/COLLAPSIBLE DEVI DEVI BREATHERITE VALVED RX/OTC MDI CHAMBER/RIGID F ALL FLOW 1000 PFT F RX/OTC FILTER DEVI DEVI BREATHERITE W/LARGE RX/OTC ALL FLOW 2000 PFT F RX/OTC F FILTER DEVI MASK MISC BREATHERITE RX/OTC ALL FLOW 3000 PFT F RX/OTC F FILTER DEVI W/MEDIUM MASK MISC BREATHERITE W/SMALL RX/OTC ALL FLOW 4000 PFT F RX/OTC F FILTER DEVI MASK MISC CLEVER CHOICE ANTI- RX/OTC ALL FLOW 5000 PFT F RX/OTC FILTER DEVI STATICVALVED HOLDING F ALL FLOW 6000 PFT F RX/OTC CHAMBER/ADULT LARGE FILTER DEVI DEVI ALL FLOW 7000 PFT F RX/OTC CLEVER CHOICE ANTI- RX/OTC FILTER DEVI STATICVALVED F ARIAL CHAMBER DEVI F RX/OTC HOLDING CHAMBER/MEDIUM DEVI BREATHE EASE/LARGE F RX/OTC MASK DEVI BREATHE EASE/MEDIUM F RX/OTC MASK DEVI Oregon Trillium OHP Updated September 1, 2021
95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE ANTI- RX/OTC EASY FLOW F RX/OTC STATICVALVED BLACK/YELLOW DEVI HOLDING F EASY FLOW WHITE/BLUE F RX/OTC CHAMBER/MEDIUM/3 DEVI YEA DEVI EASY FLOW F RX/OTC CLEVER CHOICE ANTI- RX/OTC WHITE/GREEN DEVI STATICVALVED F HOLDING EASY FLOW WHITE/PINK F RX/OTC CHAMBER/SMALL DEVI DEVI CLEVER CHOICE ANTI- RX/OTC EASY FLOW F RX/OTC STATICVALVED WHITE/WHITE DEVI HOLDING F EASY FLOW F RX/OTC CHAMBER/SMALL WHITE/YELLOW DEVI INFANT DEVI EQ SPACE CHAMBER F RX/OTC ANTI-STATIC DEVI CO MONITOR DEVI F RX/OTC EQ SPACE CHAMBER RX/OTC COMPACT SPACE RX/OTC ANTI-STATIC/LARGE F CHAMBER/ANTI-STATIC F MASK DEVI DEVI EQ SPACE CHAMBER RX/OTC COMPACT SPACE RX/OTC ANTI-STATIC/MEDIUM F CHAMBER/ANTI- F MASK DEVI STATIC/LARGE MASK EQ SPACE CHAMBER RX/OTC DEVI ANTI-STATIC/SMALL F COMPACT SPACE RX/OTC MASK DEVI CHAMBER/ANTI- F FLEXICHAMBER ADULT F RX/OTC STATIC/MEDIUM MASK MASK/SMALL MISC DEVI FLEXICHAMBER CHILD F RX/OTC COMPACT SPACE RX/OTC MASK/LARGE MISC CHAMBER/ANTI- F STATIC/SMALL MASK FLEXICHAMBER CHILD F RX/OTC DEVI MASK/SMALL MISC RX/OTC EASIVENT MISC F RX/OTC FLEXICHAMBER DEVI F IN-CHECK DIAL RX/OTC EASIVENT/MASK-LARGE F RX/OTC MISC INSPIRATORYFLOW F TRAINER DEVI EASIVENT/MASK- F RX/OTC MEDIUM MISC IN-CHECK INSPIRATORY RX/OTC FLOWMETER/NASAL F EASIVENT/MASK-SMALL F RX/OTC WITH MASK DEVI MISC IN-CHECK INSPIRATORY F RX/OTC EASY FLOW BLACK/BLUE F RX/OTC FLOWMETER/ORAL DEVI DEVI INSPIRACHAMBER/ANTI- RX/OTC EASY FLOW RX/OTC F STATIC F BLACK/ORANGE DEVI VALVED/MOUTHPIECE EASY FLOW BLACK/RED F RX/OTC DEVI DEVI INSPIRACHAMBER/LARG F RX/OTC EASY FLOW F RX/OTC E DEVI BLACK/WHITE DEVI
Oregon Trillium OHP Updated September 1, 2021
96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSPIRACHAMBER/SOOT RX/OTC OPTICHAMBER RX/OTC HERMASK/INSPIRAMASK F DIAMOND/LARGEFACE F /MEDIUM DEVI MASK DEVI INSPIRACHAMBER/SOOT RX/OTC OPTICHAMBER RX/OTC HERMASK/INSPIRAMASK F DIAMOND/MEDIUM FACE F /SMALL DEVI MASK MISC INSPIREASE DRUG F RX/OTC OPTICHAMBER RX/OTC DELIVERYSYSTEM MISC DIAMOND/SMALLFACE F MASK MISC LITEAIRE DEVI F RX/OTC OPTICHAMBER FACE F RX/OTC MASK/LARGE MISC MASK VORTEX/BABY F RX/OTC WHIRL DUCKLING MISC OPTICHAMBER FACE F RX/OTC MASK RX/OTC MASK/MEDIUM MISC VORTEX/CHILD/FROG F OPTICHAMBER FACE F RX/OTC MISC MASK/SMALL MISC MASK VORTEX/SPINNER RX/OTC F OPTIHALER MDI DRUG F RX/OTC THE DUCK MISC DELIVERY SYSTEM DEVI MASK RX/OTC RX/OTC VORTEX/TODDLER/LADY F OPTIHALER MISC F BUG MISC PANDA MASK LARGE F RX/OTC MICROCHAMBER DEVI F RX/OTC MISC PANDA MASK MEDIUM F RX/OTC MICROCHAMBER MISC F RX/OTC MISC PANDA MASK SMALL F RX/OTC MICROSPACER MISC F RX/OTC MISC RX/OTC PARI MANUAL F RX/OTC MISTASSIST DEVI F INTERRUPTER DEVI PARI TREK S COMBO RX/OTC NEBULIZER CUP/TUBING F RX/OTC F DEVI PACK DEVI PEDIATRIC PANDA MASK RX/OTC OMBRA TABLE TOP F RX/OTC F COMPRESSOR DEVI MISC ONE FLOW FVC RX/OTC POCKET CHAMBER DEVI F RX/OTC MONITORING F SPIROMETER DEVI POCKET SPACER DEVI F RX/OTC OPTICHAMBER RX/OTC ADVANTAGE/LARGE F PRIMEAIRE DUAL- RX/OTC MASK MISC VALVED HOLDING F CHAMBER DEVI OPTICHAMBER RX/OTC ADVANTAGE/MEDIUM F PRO COMFORT INHALER RX/OTC FACE MASK MISC SPACER CHAMBER F ADULT MISC OPTICHAMBER RX/OTC ADVANTAGE/SMALL F PRO COMFORT INHALER RX/OTC FACE MASK MISC SPACER CHAMBER F CHILD MISC OPTICHAMBER F RX/OTC DIAMOND MISC PRO COMFORT INHALER RX/OTC SPACER CHAMBER F INFANT DEVI
Oregon Trillium OHP Updated September 1, 2021
97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROCARE SPACER RX/OTC 10/30 F D.H.E. 45 SOLN days;QL(10 ml CHAMBER W/ADULT (dihydroergotamine NF MASK DEVI mesylate) per 31 days PROCARE SPACER RX/OTC retail) CHAMBER W/CHILD F 10/30 MASK DEVI dihydroergotamine F days;QL(10 ml RX/OTC mesylate soln ij 1 mg/ml per 31 days QUAKE DEVI F retail) RITEFLO DEVI F RX/OTC 8/30 days;QL(8 dihydroergotamine F ml per 31 days mesylate soln na 4 mg/ml SPACERS AND RX/OTC retail) BREATHING CHAMBERS- F MIGRANAL SOLN MISC (dihydroergotamine NF mesylate) SPIRO PD DEVI F RX/OTC Serotonin Agonists THRESHOLD PEP DEVI F RX/OTC AMERGE TABS NF QL(12 ea per (naratriptan hcl) 31 days retail) VALVED HOLDING F RX/OTC CHAMBER DEVI IMITREX SOLN NA 20 QL(6 ea per 31 MG/ACT, 5 MG/ACT NF days retail) VORTEX HOLDING RX/OTC (sumatriptan) CHAMBER/MASK/CHILDS F DEVI QL(2.5 ml per IMITREX SOLN SC 6 30 days retail); VORTEX HOLDING RX/OTC MG/0.5ML (sumatriptan NF succinate) AL(At least 12 CHAMBER/MASK/CHILDS F yrs old) /FROG DEVI Max Fills = 3 VORTEX HOLDING RX/OTC IMITREX STATDOSE per 31 CHAMBER/MASK/TODDL F REFILL SOCT (sumatriptan NF succinate) days;QL(0.1 ml ER DEVI daily) VORTEX HOLDING RX/OTC Max Fills = 3 CHAMBER/MASK/TODDL F IMITREX STATDOSE NF per 31 ER/LADY BUG DEVI SYSTEM SOAJ days;QL(0.1 ml (sumatriptan succinate) VORTEX VALVED RX/OTC daily) HOLDING CHAMBER F 12/31 DEVI IMITREX TABS OR 50 MG, NF days;QL(12 ea RX/OTC 100 MG, 25 MG per 31 days WATCHHALER DEVI F (sumatriptan succinate) retail) MIGRAINE PRODUCTS - Drugs to Treat Migraine MAXALT TABS (rizatriptan NF QL(12 ea per Headaches benzoate) 31 days retail) Migraine Combinations MAXALT-MLT TBDP NF QL(12 ea per CAFERGOT TABS (rizatriptan benzoate) 31 days retail) NF QL(12 ea per (ergotamine w/ caffeine) naratriptan hcl tabs F ergotamine w/ caffeine 31 days retail) F QL(12 ea per supp rizatriptan benzoate tabs F 31 days retail) ergotamine w/ caffeine tabs F QL(12 ea per rizatriptan benzoate tbdp F Migraine Products 31 days retail)
Oregon Trillium OHP Updated September 1, 2021
98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6 ea per 31 sumatriptan soln F calcium carbonate- days retail) cholecalciferol tabs 125 Max Fills = 3 unit-250 mg, 125 unit-500 mg, 3.12 mcg-250 mg, 200 sumatriptan succinate soaj F per 31 sc 4 mg/0.5ml, 6 mg/0.5ml days;QL(0.1 ml unit-600 mg, 5 mcg-600 daily) mg, 10 mcg-500 mg, 400 unit-400 unit-500 mg-500 F Max Fills = 3 mg, 200 unit-500 mg, 5 sumatriptan succinate soct F per 31 mcg-500 mg, 10 mcg-600 sc 4 mg/0.5ml, 6 mg/0.5ml days;QL(0.1 ml mg, 400 unit-600 mg, 600 daily) mg-400 unit, 20 mcg-600 QL(2.5 ml per mg, 400 unit-600 mg-600 sumatriptan succinate soln F 30 days retail); mg-800 unit sc 6 mg/0.5ml AL(At least 12 calcium carbonate-vitamin F yrs old) d caps 200 unit-600 mg Max Fills = 3 calcium carbonate-vitamin sumatriptan succinate sosy F per 31 d tabs 125 unit-250 mg, sc 6 mg/0.5ml days;QL(0.1 ml 125 unit-600 mg, 125 unit- daily) 500 mg, 400 unit-500 mg, F 12/31 200 unit-600 mg, 200 unit- sumatriptan succinate tabs F days;QL(12 ea 200 unit-500 mg-500 mg, or 50 mg, 100 mg, 25 mg per 31 days 500 mg-200 unit, 400 unit- retail) 600 mg, 600 mg-400 unit MINERALS & ELECTROLYTES CALCIUM CHEW 100 F UNIT-500 MG Bicarbonates CALCIUM CHEW 500 MG F sodium bicarbonate soln iv F 4.2 %, 7.5 %, 8.4 % CALCIUM CHEWS CHEW F Calcium CALCIUM CITRATE TABS F CAL-CITRATE PLUS F 1040 MG, 250 MG VITAMIND TABS calcium citrate tabs 200 F CAL-MINT CHEW F mg, 950 mg CALCIUM CITRATE W/D F CALCET PETITES TABS F TABS CALCIUM CITRATE F CALCIUM 1000 + D TABS F W/VITAMIN D TABS calcium citrate-vitamin d CALCIUM CARBONATE F CHEW 260 MG, 500 MG tabs 200 unit-250 mg, 200 calcium carbonate tabs mg-250 unit, 6.25 mcg-200 F 1250 mg, 500 mg, 600 mg, F mg, 200 unit-315 mg, 5 1500 mg mcg-315 mg, 250 unit-315 mg, 6.25 mcg-315 mg calcium carbonate- cholecalciferol chew 100 CALCIUM PLUS VITAMIN F unit-500 mg, 500 mg-600 F D CAPS unit, 10 mcg-500 mg, 400 CALCIUM TABS 200 UNIT- F unit-500 mg 600 MG calcium tabs 600 mg F
Oregon Trillium OHP Updated September 1, 2021
99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CALTRATE 600+D3 TABS CERASPORT SOLN 4 (calcium carbonate- NF MEQ/L-6 MEQ/L-18 F cholecalciferol) MEQ/L-20 MEQ/L CHELATED CALCIUM F DEXTROSE 5%/NACL TABS 0.3% SOLN (dextrose w/ NF sodium chloride) CHEWABLE CALCIUM/D3 F WAFR DEXTROSE/SODIUM CITRACAL + D3 CHLORIDE SOLN NF MAXIMUM TABS (calcium NF (dextrose w/ sodium citrate-vitamin d) chloride) CITRACAL MAXIMUM ENFAMIL ENFALYTE F TABS (calcium citrate- NF SOLN vitamin d) EQUALYTE SOLN (oral F CITRACAL electrolytes) PETITES/VITAMIND TABS NF HYDRALYTE FREEZER F (calcium citrate-vitamin d) POPS SOLN EQL CALCIUM/VITAMIN D F HYDRALYTE SOLN 16 CAPS GM/L-20 MEQ/L-45 OYSTER SHELL MEQ/L-45 MEQ/L-90 CALCIUM PLUS VITAMIN F MEQ/L, 210 MG/250ML- F D TABS 270 MG/250ML, 45 MEQ/L- 16 GM/L-20 MEQ/L-45 OYSTER SHELL MEQ/L-90 MEQ/L CALCIUM/VITAMIN D F TABS KINDERLYTE PREMAX SOLN 3.1 MG/360ML-320 oyster shell tabs F MG/360ML-620 MG/360ML-630 F PARVA-CAL TABS F MG/360ML, 3.1 MG/360ML-330 QC CALCIUM 500MG/D3 F MG/360ML-620 TABS MG/360ML-630 MG/360ML RA CALCIUM TABS F KINDERLYTE SOLN 3.1 MG/360ML-300 RA CALCIUM/BORON F MG/360ML-445 TABS MG/360ML-560 F RA OYSTER SHELL MG/360ML, 3.1 CALCIUM/VITAMIN D F MG/360ML-300 TABS MG/360ML-460 MG/360ML-570 MG/360ML UPCAL D POWD 500 F MG/5GM-500 UNIT/5GM oral electrolytes soln F Electrolyte Mixtures PEDIALYTE ADVANCED BIOLYTE SOLN F CARE SOLN (oral F electrolytes) CERALYTE 70 SOLN 20 PEDIALYTE FREEZER MEQ/L-30 MEQ/L-60 F POPS SOLN (oral F MEQ/L-70 MEQ/L electrolytes) CERASPORT EX1 SOLN F PEDIALYTE SINGLES F SOLN (oral electrolytes) Oregon Trillium OHP Updated September 1, 2021
100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEDIALYTE SOLN 0.5 magnesium oxide (mg F MG/59ML-1.2 MEQ/59ML- supplement) tabs 1.5 GM/59ML-2.1 MAGNESIUM OXIDE F MEQ/59ML-2.7 CAPS 400 MG MEQ/59ML, 20 MEQ/L-25 GM/L-30 MEQ/L-35 magnesium tabs 100 mg, F MEQ/L-45 MEQ/L, 35 250 mg MEQ/L-20 MEQ/L-25 MAGNESIUM TABS 200 F GM/L-30 MEQ/L-45 F MG, 500 MG MEQ/L, 4.7 MEQ/237ML- MAGOX 400 TABS 8.3 MEQ/237ML-10.6 (magnesium oxide (mg NF MEQ/237ML, 5 GM/L-20 supplement)) GM/L-20 MEQ/L-35 MEQ/L-45 MEQ/L, 7.8 Phosphate MG/L-20 MEQ/L-25 GM/L- K-PHOS NEUTRAL TABS 35 MEQ/L-45 MEQ/L (oral (pot phosphate monobasic NF electrolytes) w/ sod phosphate dibasic & monobasic) Fluoride pot phosphate monobasic FLUORABON SOLN F w/ sod phosphate dibasic & F monobasic tabs sodium fluoride chew 0.25 F mg, 0.5 mg, 1 mg, 2.2 mg Potassium K-TAB TBCR 20 MEQ, 10 sodium fluoride soln 0.125 F NF mg/drop MEQ (potassium chloride) K-TAB TBCR 8 MEQ sodium fluoride soln 0.5 F RX/OTC F mg/ml (potassium chloride) potassium chloride cpcr or sodium fluoride tabs 0.5 F F mg, 1 mg 10 meq, 8 meq Magnesium potassium chloride microencapsulated crystals F MAG-200 TABS er tbcr 20 meq, 10 meq (magnesium oxide (mg F supplement)) potassium chloride pack or F 20 meq MAG-G TABS F potassium chloride soln or F 20 %, 10 % MAGNESIUM CAPS 400 F MG potassium chloride tbcr or F 20 meq, 10 meq, 8 meq MAGNESIUM F ELEMENTAL TABS 30 MG Sodium sodium chloride soln iv 0.9 MAGNESIUM EXTRA F F STRENGTH CAPS % MAGNESIUM MISCELLANEOUS THERAPEUTIC CLASSES GLUCONATE TABS 250 F MG, 500 MG, 550 MG Chelating Agents magnesium gluconate tabs F CUPRIMINE CAPS NF 27.5 mg, 500 mg (penicillamine) magnesium oxide (mg F supplement) caps penicillamine caps F
Oregon Trillium OHP Updated September 1, 2021
101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Immunosuppressive Agents RAPAMUNE TABS 0.5 MG NF (sirolimus) azathioprine tabs or 50 mg F SANDIMMUNE CAPS OR 100 MG, 25 MG F CELLCEPT CAPS NF (mycophenolate mofetil) (cyclosporine) SANDIMMUNE SOLN OR CELLCEPT SUSR NF F (mycophenolate mofetil) 100 MG/ML CELLCEPT TABS NF sirolimus soln 1 mg/ml F (mycophenolate mofetil) sirolimus tabs 0.5 mg F cyclosporine caps or 100 F mg, 25 mg cyclosporine modified (for SP tacrolimus caps F microemulsion) caps 50 F mg, 100 mg, 25 mg Irrigation Solutions cyclosporine modified (for SP water for irrigation, sterile F microemulsion) soln 100 F soln mg/ml Potassium Removing Agents GENGRAF CAPS SP sodium polystyrene F PA (cyclosporine modified (for NF sulfonate powd microemulsion)) sodium polystyrene F PA GENGRAF SOLN SP sulfonate susp (cyclosporine modified (for NF microemulsion)) MOUTH/THROAT/DENTAL AGENTS IMURAN TABS NF Anesthetics Topical Oral (azathioprine) QL(100 ml per mycophenolate mofetil F lidocaine hcl (mouth-throat) F fill retail,900 ml caps or 250 mg soln 2 % per 30 days mycophenolate mofetil susr F retail) or 200 mg/ml Anti-infectives - Throat mycophenolate mofetil tabs F or 500 mg clotrimazole troc F mycophenolate sodium F nystatin (mouth-throat) F tbec susp MYFORTIC TBEC NF (mycophenolate sodium) Antiseptics - Mouth/Throat NEORAL CAPS SP chlorhexidine gluconate F (cyclosporine modified (for NF (mouth-throat) soln microemulsion)) PERIDEX SOLN NEORAL SOLN SP (chlorhexidine gluconate NF (cyclosporine modified (for NF (mouth-throat)) microemulsion)) Dental Products PROGRAF CAPS OR 0.5 PREVIDENT 5000 PLUS MG, 1 MG, 5 MG NF CREA (sodium fluoride NF (tacrolimus) (dental)) RAPAMUNE SOLN 1 NF PREVIDENT RINSE SOLN NF MG/ML (sirolimus) (sodium fluoride (dental))
Oregon Trillium OHP Updated September 1, 2021
102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sodium fluoride (dental) F b complex w/ c tabs 15 mg- crea dt 1.1 % 5 mg-10 mg-10 mg-50 mg- 300 mg, 15 mg-5 mg-10 sodium fluoride (dental) F soln mt 0.2 %, 0.05 % mg-10.2 mg-50 mg-300 mg, 2 mg-5 mcg-5.5 mg-15 Steroids - Mouth/Throat/Dental mcg-20 mg-25 mg-100 mg- 100 mg-400 mcg, 2 mg-5 triamcinolone acetonide F (mouth) pste mcg-6 mg-15 mcg-20 mg- 25 mg-100 mg-100 mg-100 Throat Products - Misc. mg-150 mg, 25 mg-5 mg- cevimeline hcl caps F 5.5 mg-20 mg-25 mg-60 mg-100 mcg-400 mcg-1000 EVOXAC CAPS NF mcg, 5 mg-10 mcg-10 mg- (cevimeline hcl) 15 mg-20 mg-100 mg-500 mg, 5 mg-10 mcg-10 mg- pilocarpine hcl (oral) tabs F 15 mg-20 mg-50 mg-300 mg, 5 mg-10 mcg-10 mg- SALAGEN TABS NF (pilocarpine hcl (oral)) 15 mg-20 mg-80 mg-100 mg-500 mg, 5 mg-10 mg- MULTIVITAMINS 10 mg-15 mg-50 mg-300 F mcg-300 mg-400 mcg, 5 B-Complex w/ C mg-10 mg-10 mg-15 mg-50 b complex w/ c caps 5 mg- mg-300 mg, 5 mg-10 mg- 10 mg-10 mg-15 mg-50 10.2 mg-15 mg-50 mg-150 mg-300 mg, 5 mg-10 mg- F mg-300 mg, 5 mg-10 mg- 10.2 mg-15 mg-50 mg-300 10.2 mg-15 mg-50 mg-300 mg mg, 5 mg-10 mg-14.3 mg- 15 mg-50 mg-175 mg-300 mg, 5 mg-10 mg-14.3 mg- 15 mg-50 mg-300 mg, 5 mg-5 mg-10 mg-10 mg- 10.2 mg-10.2 mg-15 mg-15 mg-50 mg-50 mg-300 mg- 300 mg, 5 mg-5.5 mg-20 mg-25 mg-25 mg-60 mg- 100 mcg-400 mcg-1000 mcg, 5 mg-6 mcg-10 mg- 10.2 mg-15 mg-50 mg-300 mg-400 mcg B-Complex w/ Folic Acid B COMPLEX + C TR TBCR F b-complex w/ c & folic acid RX/OTC caps 1 mg-1.5 mg-1.7 mg-5 mg-6 mcg-10 mg-20 mg- 100 mg-150 mcg, 5 mg-1 F mg-1.5 mg-1.7 mg-6 mcg- 10 mg-20 mg-100 mg-150 mcg
Oregon Trillium OHP Updated September 1, 2021
103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits b-complex w/ c & folic acid RX/OTC mg-5.5 mg-20 mg-25 mg- tabs 0.01 mcg-1 mg-1.5 25 mg-60 mg-100 mcg-400 mg-1.7 mg-10 mg-10 mg- mcg-1000 mcg, 5 mg-6 20 mg-60 mg-300 mcg, 1 mcg-10 mg-10.2 mg-15 mg-1 mg-1.5 mg-1.5 mg- mg-50 mg-300 mg-400 1.7 mg-1.7 mg-6 mcg-6 mcg, 5.5 mg-15 mcg-25 mcg-10 mg-10 mg-10 mg- mg-30 mcg-150 mg-400 10 mg-20 mg-20 mg-100 mcg-100 mg-2 mg-20 mg, mg-100 mg-300 mcg-300 50 mcg-50 mcg-50 mg-50 mcg, 1 mg-1 mg-1.5 mg- mg-50 mg-50 mg-50 mg- 1.7 mg-8 mg-20 mg-30 400 mcg-500 mg, 50 mg-50 mcg-200 mg-300 mcg, 1 mcg-50 mcg-50 mg-50 mg- mg-1.5 mg-1.7 mg-6 mcg- 50 mg-50 mg-400 mcg-500 10 mg-10 mg-20 mg-100 mg mg-300 mcg, 1 mg-1.5 mg- b-complex w/ c & folic acid 1.7 mg-6 mcg-10 mg-10 tabs 1.5 mg-0.006 mg-0.3 mg-20 mg-60 mg-300 mcg, mg-0.8 mg-1.7 mg-10 mg- 1.5 mg-0.006 mg-0.3 mg-1 10 mg-20 mg-60 mg, 1.5 mg-1.7 mg-10 mg-10 mg- mg-1.7 mg-6 mcg-10 mg- F 20 mg-100 mg, 1.5 mg-1.7 10 mg-20 mg-60 mg-300 mg-5 mg-6 mcg-10 mg-20 mcg-800 mcg, 20 mg-1.5 mg-100 mg-150 mcg-1000 mg-1.7 mg-6 mcg-10 mg- mcg, 1.5 mg-1.7 mg-6 10 mg-60 mg-300 mcg-800 mcg-10 mg-10 mg-20 mg- mcg 100 mg-300 mcg-1000 B-complex w/ C and FA F RX/OTC mcg, 0.5 mg-4 mg-5 mcg- F 15 mg-15 mg-18 mg-100 mg-500 mg, 1 mg-1 mg-1 mg-5 mg-10 mg-10 mg-12 mcg-20 mg-30 unit-45 mcg-100 mg-400 mcg-500 mg, 2 mg-5 mg-15 mcg-20 mg-25 mg-30 mcg-100 mg- 150 mg-400 mcg, 2 mg-5.5 mg-15 mcg-20 mg-25 mg- 30 mcg-100 mg-150 mg- 400 mcg, 20 mg-2 mg-5 mg-15 mcg-25 mg-30 mcg- 100 mg-150 mg-400 mcg, 25 mg-5 mg-5.5 mg-20 mg- 25 mg-60 mg-100 mcg-100 mg-400 mcg-1000 mcg, 5 mg-10 mg-10.2 mg-15 mg- 50 mg-300 mcg-300 mg- 400 mcg, 5 mg-5 mg-10 mcg-10 mg-18 mg-45 mg- 250 mg-400 mcg, 5 mg-5 mg-5 mg-10 mg-25 mg-120 mg-250 mcg-300 mcg-400 mcg, 5 mg-5 mg-5 mg-15 mcg-25 mg-37.5 mcg-50 mg-150 mg-200 mcg, 5 Oregon Trillium OHP Updated September 1, 2021
104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits b-complex w/biotin & folic mg-100 mg-200 mg-400 acid tabs 0.3 mg-25 mcg- mcg, 50 mcg-50 mcg-50 25 mcg-25 mg-25 mg-25 mg-50 mg-50 mg-50 mg-50 mg-25 mg-25 mg, 0.4 mg- mg-50 mg-50 mg-50 mg- 50 mcg-50 mg-50 mg-50 400 mcg mg-50 mg-50 mg, 1.5 mg- B-COMPLEX/FOLIC F 1.7 mg-2 mg-6 mcg-20 mg- ACID/VITAMIN C TBCR 30 mcg-200 mcg, 10 mcg- DIALYVITE 800/IRON F 10 mg-10 mg-10 mg-10 TABS mg-20 mg-20 mg-25 mcg- 30 mg-100 mcg-100 mg- DIALYVITE 800/ZINC 15 F 200 mg, 100 mcg-0.4 mg- TABS 30 mg-100 mcg-100 mcg- DIALYVITE 800/ZINC F 100 mg-100 mg-100 mg- TABS 100 mg-100 mg-100 mg, FULL SPECTRUM F 100 mcg-100 mcg-100 mg- B/VITAMIN C TABS 100 mg-100 mg-100 mg- 100 mg-100 mg-100 mg- NEPHRO-VITE RX TABS RX/OTC 100 mg-400 mcg, 100 mcg- (b-complex w/ c & folic NF 100 mcg-100 mg-100 mg- acid) 100 mg-100 mg-100 mg- NEPHRO-VITE TABS (b- F 400 mcg, 12.5 mcg-12.5 complex w/ c & folic acid) mg-12.5 mg-25 mcg-50 SM B-COMPLEX/VITAMIN F RX/OTC mcg-50 mg-50 mg-50 mg, C TABS 12.5 mcg-45 mcg-50 mg-5 VITALINE BIOTIN FORTE F mg-12.5 mg-50 mg-50 mg- F TABS 180 mg-400 mcg, 25 mcg- 25 mcg-25 mg-25 mg-25 VITALINE BIOTIN F mg-25 mg-100 mg-400 FORTE/ZINC TABS mcg, 25 mcg-5 mg-5 mg-5 WEST-VITE W/FOLIC F mg-20 mg-25 mcg-40 mg- ACID TABS 50 mcg-50 mcg-50 mg-100 B-Complex w/ Minerals mcg, 30 mg-100 mg-100 mcg-100 mcg-100 mcg-100 b-complex w/ minerals liqd F mg-100 mg-100 mg-100 mg-100 mg-400 mcg, 5 Iron w/ Vitamins mg-12.5 mcg-12.5 mg-45 mcg-50 mg-50 mg-50 mg- 180 mg-400 mcg, 5 mg-5 mg-7.5 mg-12.5 mcg-12.5 mg-25 mg-50 mcg-50 mg- 125 mcg-125 mg-200 mcg, 50 mcg-50 mcg-50 mcg-50 mg-50 mg-50 mg-50 mg-50 mg-50 mg-50 mg-400 mcg, 50 mcg-50 mcg-50 mg-50 mg-50 mg-50 mg-50 mg- 100 mcg, 50 mcg-50 mcg- 50 mg-50 mg-50 mg-50 mg-50 mg-400 mcg, 50 mcg-50 mcg-50 mg-50 mg- 50 mg-50 mg-50 mg-50 Oregon Trillium OHP Updated September 1, 2021
105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits iron w/ vitamins tabs 0.38 RX/OTC AIRBORNE+GOOD REST mg-1 mcg-1 mcg-1.5 mg- CHEW 2.23 MG-0.03 MG- 1.7 mg-1.8 mg-2 mg-2.4 0.33 MG-1.67 MG-3.33 F mg-6.7 mcg-12 mcg-13 MG-5 MCG-20 MCG-66.67 mg-13.5 mg-16 mg-20 mg- MG 20 mg-24 mcg-30 unit-36 AIRBORNE+NATURAL F RX/OTC mg-44 mcg-57 mg-86 mg- ENERGY LIQD 118 mg-120 mcg-148 mg- AIRBORNE+PROBIOTIC 400 unit-6100 unit, 1 mg- F F 1.1 mg-1.8 mg-2.5 mg-5 CHEW mcg-15 mg-30 unit-60 mg- ALGAE BASED CALCIUM F RX/OTC 65 mg-125 mg-400 unit- TABS 6000 unit, 1 mg-2 mg-3 ALIVE ENERGY 50+ TABS F RX/OTC mcg-4 mg-4.8 mg-10 mg- 60 mg-100 mg-150 mg, 4.8 ALIVE MENS ENERGY F RX/OTC mg-2 mg-3 mcg-4 mg-10 TABS mg-31 mg-60 mg-100 mg- ALIVE MULTI-VITAMIN 150 mg CHEW 0.85 MG-1.8 MG-2 Multiple Vitamins w/ Iron MG-2.4 MCG-2.5 MG-5 MG-7.5 MG-10 MCG-15 F multiple vitamins w/ iron F tabs MCG-20 MG-45 MG-75 MCG-120 MCG-150 MCG- TAB-A-VITE 162.5 MCG-450 MCG MULTIVITAMIN/IRON AND F BETA-CAROTENE TABS ALIVE MULTI-VITAMIN RX/OTC LIQD 1 MG/30ML-2 Multiple Vitamins w/ Minerals MG/30ML-4 MG/30ML-5 MG/30ML-10 MCG/30ML- ABC COMPLETE SENIOR F RX/OTC WOMENS 50+ TABS 15 MG/30ML-20 MG/30ML- RX/OTC 25 MG/30ML-25 MG/30ML- ACTIVNUTRIENTS CAPS F 25 MG/30ML-25 MG/30ML- 25 MG/30ML-30 MG/30ML- ADULT ONE DAILY F GUMMIES CHEW 40 MG/30ML-40 MG/30ML- 50 MG/30ML-50 MG/30ML- ADVANCED DIABETIC RX/OTC 50 MG/30ML-60 MG/30ML- F MULTIVITAMIN FORMULA F 70 MCG/30ML-75 TABS MCG/30ML-80 MCG/30ML- AIRBORNE CHEW 0.03 118.6 MG/30ML-125 MG-0.33 MG-1.67 MG-2.23 MG/30ML-133 MG/30ML- MG-3.33 MG-5 MCG-20 150 MCG/30ML-200 MCG, 0.75 MG-2 MG-3.38 MCG/30ML-200 MG-3.75 MCG-10 MG-10 MCG/30ML-300 MG-150 MCG, 1 MG-3.15 F MCG/30ML-400 MCG-3.35 MG-7.5 MG-65 MCG/30ML-500 MG/30ML- MG, 2.23 MG-0.03 MG- 3000 MCG/30ML 0.33 MG-1.67 MG-3.33 ALIVE ONCE DAILY RX/OTC MG-5 MCG-20 MCG, 7.5 WOMENS 50+ ULTRA F MG-1 MG-3.15 MCG-3.35 POTENCY TABS MG-65 MG-150 MG ALIVE ONCE DAILY RX/OTC AIRBORNE KIDS CHEW F WOMENS ULTRA F POTENCY TABS
Oregon Trillium OHP Updated September 1, 2021
106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALIVE WOMENS 50+ BIO-35 GLUTEN-FREE F RX/OTC CHEW 0.65 MG-0.85 MG- CAPS 1.35 MG-2 MG-2.4 MCG- BIO-35 IRON FREE CAPS F RX/OTC 7.5 MG-7.5 MG-15 MCG- F 15 MG-20 MCG-25 MG-50 RX/OTC MG-75 MCG-75 MCG-120 BIOCAL CAPS F MCG-150 MCG-150 MCG- RX/OTC 165 MCG-225 MCG BIOSUPP LIQD F ALIVE WOMENS 50+ RX/OTC RX/OTC TABS 2 MG-4 MG-4.5 MG- BIOTECT PLUS LIQD F 5 MG-5.1 MG-6 MG-15 BURIED TREASURE RX/OTC MG-20 MG-22.5 MG-30 ACTIVE 55PLUS SENIOR F UNIT-50 MG-60 MCG-70 COMPLEX LIQD MCG-75 MCG-90 MG-100 F MCG-150 MCG-150 MCG- CAL-DAY 1000 TABS F RX/OTC 180 MCG-300 MCG-300 MCG-400 MCG-500 MG- CELEBRATE MULTI- RX/OTC 900 MCG-1000 UNIT-3500 COMPLETE18 CAPS UNIT 0.666 MG-0.666 MG-1.133 MG-1.333 MG-2 MG-5 MG- ALIVE WOMENS ENERGY F RX/OTC 6 MG-6.666 MG-10 UNIT- TABS 13.333 MCG-13.333 MG- F ALIVE WOMENS GUMMY F 25 MCG-30 MG-33.333 VITAMINS CHEW MG-46.666 MCG-50 MCG- 66.666 MCG-166.666 ANTIOXIDANT FORMULA F RX/OTC TABS MCG-200 MCG-266.666 AQUADEKS CHEW 0.75 MCG-1000 UNIT-1666.666 MG-0.85 MG-0.95 MG-5 UNIT MG-5 MG-5 MG-5 MG-6 CELEBRATE MULTI- MCG-6 MG-15 MG-35 MG- F COMPLETE18 CHEW 2 37.5 MCG-50 MCG-50 MG-2 MG-3.4 MG-4 MG-6 UNIT-100 MCG-350 MCG- MG-15 MG-18 MG-20 MG- 400 UNIT-9083.5 UNIT 30 UNIT-40 MCG-40 MG- F AZO HORMONAL RX/OTC 75 MCG-90 MG-100 MG- HEALTH CYCLE CARE & F 140 MCG-150 MCG-200 COMFORT TABS MCG-500 MCG-600 MCG- 800 MCG-3000 UNIT-5000 AZO HORMONAL RX/OTC UNIT HEALTH HAPPY CYCLE F TABS CELEBRATE MULTI- RX/OTC COMPLETE36 CAPS BACMIN TABS F RX/OTC 0.666 MG-1 MG-1.333 MG- 4 MG-4 MG-6.666 MG-10 BARIATRIC FUSION F MG-12 MG-13.333 MG-20 CHEW UNIT-25 MCG-33.333 MG- F BARIATRIC RX/OTC 40 MCG-46.666 MCG-50 MULTIVITAMINS/IRON F MCG-60 MG-66.666 MCG- CAPS 166.666 MCG-200 MCG- RX/OTC 200 MCG-1000 UNIT- BASIC AM TABS F 3333.333 UNIT BASIC PM TABS F RX/OTC
Oregon Trillium OHP Updated September 1, 2021
107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CELEBRATE MULTI- CELEBRATE MULTI- RX/OTC COMPLETE36 CHEW 1 COMPLETE60 CAPS 1 MG-1.5 MG-2 MG-6 MG-6 MG-4 MG-0.666 MG-1.333 MG-10 MG-15 MG-18 MG-4 MG-6.666 MG-10 MCG-20 MG-30 UNIT-37.5 MG-13.333 MG-20 MG-20 MCG-50 MG-60 MCG-70 UNIT-25 MCG-33.333 MG- F MCG-75 MCG-90 MG-100 40 MCG-46.666 MCG-50 MCG-250 MCG-300 MCG- MCG-60 MG-66.666 MCG- 400 MCG-1500 UNIT-5000 200 MCG-266.666 MCG- UNIT, 1 MG-1.5 MG-2 MG- 333.333 MCG-1000 UNIT- 6 MG-6 MG-10 MG-15 MG- 3333.333 UNIT 18 MG-20 MG-30 UNIT- CELEBRATE MULTI- 37.5 MCG-50 MG-60 F COMPLETE60 CHEW 1 MCG-70 MCG-75 MCG-90 MG-1.5 MG-2 MG-6 MG-6 MG-100 MCG-250 MCG- MG-10 MG-15 MG-20 MG- 300 MCG-400 MCG-1500 30 MG-30 UNIT-37.5 MCG- F UNIT-5000 UNIT, 6 MG-1 60 MCG-70 MCG-75 MCG- MG-1.5 MG-2 MG-6 MG-10 90 MG-100 MCG-300 MG-15 MG-18 MCG-20 MCG-400 MCG-500 MCG- MG-30 UNIT-37.5 MCG-50 500 MG-1500 UNIT-5000 MG-60 MCG-70 MCG-75 UNIT MCG-90 MG-100 MCG- 250 MCG-300 MCG-400 CELLULAR SECURITY F RX/OTC MCG-1500 UNIT-5000 CAPS UNIT CENTRAVITES 50 PLUS F RX/OTC CELEBRATE MULTI- RX/OTC TABS COMPLETE45 CAPS 4 CENTRAVITES ADULTS F RX/OTC MG-0.666 MG-1 MG-1.33 TABS MG-4 MG-6.666 MG-10 CENTRUM ADULTS TABS RX/OTC MG-13.333 MG-15 MG-20 (multiple vitamins w/ F UNIT-25 MCG-33.333 MG- F minerals) 40 MCG-46.666 MCG-50 RX/OTC MCG-60 MG-66.666 MCG- CENTRUM CARDIO TABS F 200 MCG-266.666 MCG- CENTRUM CHEW 2 MG-1 333.333 MCG-1000 UNIT- MG-1.5 MG-1.7 MG-2 MG- 3333.333 UNIT 6 MCG-10 MCG-10 MG-15 CELEBRATE MULTI- MG-18 MG-20 MCG-20 F COMPLETE45 CHEW 1 MCG-20 MG-30 UNIT-40 MG-1.5 MG-2 MG-6 MG-6 MG-45 MCG-50 MG-60 MG-10 MG-15 MG-20 MG- MG-108 MG-150 MCG-400 22.5 MG-30 UNIT-37.5 F MCG-400 UNIT-3500 UNIT MCG-50 MG-60 MCG-70 CENTRUM FLAVOR F MCG-75 MCG-90 MG-100 BURST ADULT CHEW MCG-300 MCG-400 MCG- 500 MCG-1500 UNIT-5000 CENTRUM FLAVOR F UNIT BURST CHEW CENTRUM FRESH/FRUITY ADULTS F 50+ CHEW
Oregon Trillium OHP Updated September 1, 2021
108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CENTRUM LIQD 1.1 RX/OTC CENTRUM MG/15ML-1.7 MG/15ML-2 MULTIGUMMIES MEN F MG/15ML-2 MG/15ML-3 CHEW MG/15ML-6 MCG/15ML-9 CENTRUM MG/15ML-10 MG/15ML-20 MULTIGUMMIES MULTI F MG/15ML-25 MCG/15ML- +OMEGA 3 CHEW 25 MCG/15ML-30 UNIT/15ML-60 MG/15ML- CENTRUM 150 MCG/15ML-300 MULTIGUMMIES WOMEN F MCG/15ML-400 CHEW UNIT/15ML-1300 CENTRUM SILVER RX/OTC 50+MEN TABS (multiple F UNIT/15ML, 1.5 MG/15ML- F 1.7 MG/15ML-2 MG/15ML- vitamins w/ minerals) 2.5 MG/15ML-3 MG/15ML- CENTRUM SILVER RX/OTC 6 MCG/15ML-9 MG/15ML- 50+WOMEN TABS F 10 MG/15ML-20 MG/15ML- (multiple vitamins w/ 25 MCG/15ML-25 minerals) MCG/15ML-30 CENTRUM SILVER RX/OTC UNIT/15ML-60 MG/15ML- ADULT 50+ TABS (multiple F 150 MCG/15ML-300 vitamins w/ minerals) MCG/15ML-400 UNIT/15ML-2500 CENTRUM SILVER CHEW UNIT/15ML (multiple 2 MG-2.2 MG-2.7 MG-4 vitamins w/ minerals) MG-4.5 MG-5 MCG-7 MG- 10 MCG-10 MCG-10 MG- CENTRUM MEN TABS 0.9 RX/OTC 12 MG-15 MG-22.5 MCG- F MG-1.2 MG-1.3 MG-2 MG- 25 MCG-25 MCG-45 MCG- 2.3 MG-6 MCG-8 MG-11 50 MG-70 UNIT-75 MG- MG-15 MG-16 MG-20 MG- 100 MCG-100 MCG-125 20.3 MG-25 MCG-35 MG-200 MG-250 MCG-400 MCG-40 MCG-50 MCG-60 F UNIT-500 MCG-4000 UNIT MCG-72 MG-80 MG-90 MG-100 MCG-100 MG-150 MCG-200 MCG-210 MG- 600 MCG-1050 MCG (multiple vitamins w/ minerals) CENTRUM MEN TABS 2 RX/OTC MG-0.9 MG-1.2 MG-1.3 MG-2 MG-2.3 MG-5 MCG- 6 MCG-8 MG-10 MCG-10 MCG-11 MG-16 MG-20 MG-35 MCG-45 UNIT-50 F MCG-60 MCG-72 MG-80 MG-100 MCG-100 MG-150 MCG-200 MCG-210 MG- 15 MG-40 MCG-90 MG- 600 MCG-1000 UNIT-3500 UNIT CENTRUM MULTIGUMMIES ADULTS F CHEW
Oregon Trillium OHP Updated September 1, 2021
109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CENTRUM SILVER TABS RX/OTC 3500 UNIT (multiple 0.5 MG-1.5 MG-1.7 MG-2 vitamins w/ minerals) MG-2.3 MG-3 MG-5 MCG- CENTRUM SILVER F RX/OTC 10 MCG-10 MG-11 MG-20 ULTRA WOMENS TABS MG-20 MG-25 MCG-30 CENTRUM SPECIALIST F RX/OTC MCG-30 MCG-45 MCG-45 HEART TABS MCG-50 MG-50 UNIT-55 MCG-60 MG-72 MG-80 CENTRUM SPECIALIST F RX/OTC MG-150 MCG-150 MCG- IMMUNE SUPPORT TABS 220 MG-400 MCG-500 CENTRUM SPECIALIST F RX/OTC UNIT-2500 UNIT, 0.5 MG- VISION TABS 2.3 MG-1.5 MG-1.7 MG-2 CENTRUM TABS 0.5 MG- RX/OTC MG-3 MG-5 MCG-10 2 MG-1.5 MG-1.7 MG-2 MCG-10 MG-11 MG-20 MG-2.3 MG-5 MCG-6 MG-20 MG-25 MCG-30 MCG-10 MCG-10 MCG-10 MCG-30 MCG-45 MCG-45 MG-11 MG-18 MG-20 MG- MCG-50 MG-50 UNIT-55 20 MG-25 MCG-30 MCG- MCG-60 MG-72 MG-80 30 UNIT-35 MCG-45 MCG- F MG-150 MCG-150 MCG- 50 MG-55 MCG-60 MG-72 220 MG-400 MCG-500 MG-75 MCG-80 MG-150 UNIT-2500 UNIT, 2 MG-1.5 MCG-200 MG-400 MCG- MG-1.7 MG-2 MG-2 MG-3 400 UNIT-3500 UNIT MG-5 MCG-10 MCG-10 (multiple vitamins w/ MCG-10 MG-15 MG-20 minerals) MCG-20 MG-25 MCG-30 CENTRUM ULTRA RX/OTC MCG-45 UNIT-48 MG-60 F F MG-72 MG-75 MCG-80 WOMENS TABS MG-100 MG-150 MCG-150 CENTRUM VITAMINTS F MCG-150 MCG-200 MG- CHEW 250 MCG-300 MCG-400 CENTRUM WOMEN TABS RX/OTC MCG-400 UNIT-3500 (multiple vitamins w/ F UNIT, 2 MG-2 MG-1.5 MG- minerals) 1.7 MG-2 MG-3 MG-5 CERTAVITE SENIOR F RX/OTC MCG-10 MCG-10 MCG-10 TABS MG-15 MG-20 MCG-20 MG-25 MCG-30 MCG-45 CERTAVITE RX/OTC UNIT-48 MG-60 MG-72 SENIOR/ANTIOXIDANT F MG-75 MCG-80 MG-100 NUTRIENTS TABS MG-150 MCG-150 MCG- CERTAVITE/ANTIOXIDAN F RX/OTC 150 MCG-200 MG-250 TS TABS MCG-300 MCG-400 MCG- CHOICEFUL RX/OTC 400 UNIT-3500 UNIT, 3 MULTIVITAMIN CAPS 1 MG-1.5 MG-1.7 MG-2 MG- MG-1.5 MG-1.9 MG-5 2 MG-2 MG-5 MCG-10 MCG-8 MG-15 MG-18 MG- F MCG-10 MCG-10 MG-15 30 MG-80 MCG-170 UNIT- MG-20 MCG-20 MG-25 180 MCG-700 MCG-1000 MCG-30 MCG-45 UNIT-48 UNIT-14000 UNIT MG-60 MG-72 MG-75 MCG-80 MG-100 MG-150 MCG-150 MCG-150 MCG- 200 MG-250 MCG-300 MCG-400 MCG-400 UNIT- Oregon Trillium OHP Updated September 1, 2021
110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHOICEFUL CVS SPECTRAVITE MULTIVITAMIN CHEW 1.2 ADULT 50+ CHEW 2 MG- MG-1.4 MG-1.5 MG-6 2.2 MG-2.7 MG-4 MG-4.5 MCG-8 MG-10 MG-15 MG- F MG-5 MCG-7 MG-10 MCG- 60 MG-80 MCG-180 MCG- 10 MCG-10 MG-12 MG-15 180 UNIT-600 MCG-800 MG-25 MCG-25 MCG-25 F UNIT-13000 UNIT MCG-45 MCG-50 MG-70 UNIT-75 MG-100 MCG-100 CLINICAL NUTRIENTS 45- F RX/OTC PLUS WOMEN TABS MCG-125 MG-150 MCG- 200 MG-250 MCG-400 CLINICAL NUTRIENTS 50- F RX/OTC UNIT-500 MCG-4000 UNIT PLUS MEN TABS CVS SPECTRAVITE RX/OTC CLINICAL NUTRIENTS F RX/OTC ADULT 50+ TABS 0.5 MG- ANTIOXIDANT CAPS 1.5 MG-1.7 MG-2 MG-2.3 CLINICAL NUTRIENTS RX/OTC MG-3 MG-5 MCG-10 MCG- FOR FEMALE TEENS F 10 MG-11 MG-19 MCG-20 TABS MG-20 MG-22.5 MG-25 MCG-25 MCG-30 MCG-30 CLINICAL NUTRIENTS F RX/OTC FOR MALE TEENS TABS MCG-45 MCG-50 MCG-50 MG-60 MG-72 MG-80 MG- CLINICAL NUTRIENTS F RX/OTC FOR MEN TABS 150 MCG-220 MG-250 MCG-300 MCG-400 MCG- F CLINICAL NUTRIENTS F RX/OTC 750 MCG, 0.5 MG-1.5 MG- FOR WOMEN TABS 3 MG-1.7 MG-2 MG-2.3 CORVITE TABS (multiple MG-5 MCG-10 MCG-10 vitamins w/ minerals & folic NF MG-11 MG-19 MCG-20 acid) MG-20 MG-25 MCG-30 CULTURELLE MCG-30 MCG-45 MCG-50 PROBIOTICS + F MCG-50 MG-50 UNIT-60 MULTIVITAMIN CHEW MG-72 MG-80 MG-150 MCG-220 MG-250 MCG- CVS ADULT 50+ EYE F RX/OTC HEALTH CAPS 300 MCG-400 MCG-1000 UNIT-2500 UNIT CVS AIRSHIELD IMMUNITY SUPPORT F CVS SPECTRAVITE F RX/OTC CHEW ADULTS TABS CVS SPECTRAVITE RX/OTC CVS EYE HEALTH ADULT F RX/OTC F 50+ CAPS ULTRA MEN50+ TABS CVS SPECTRAVITE RX/OTC CVS ONE DAILY MENS F RX/OTC 50+ ADVANCED TABS ULTRA MENS HEALTH F SENIOR TABS CVS ONE DAILY RX/OTC WOMENS 50+ADVANCED F CVS SPECTRAVITE RX/OTC TABS ULTRA MENS HEALTH F TABS CVS SPECTRAVITE F RX/OTC ULTRA WOMEN TABS CVS SPECTRAVITE RX/OTC ULTRA WOMENS F HEALTH SENIOR TABS
Oregon Trillium OHP Updated September 1, 2021
111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS SPECTRAVITE RX/OTC EQ MULTIVITAMINS F ULTRA WOMENS F ADULT GUMMY CHEW HEALTH TABS EQ ONE DAILY MENS 50+ F RX/OTC CVS SPECTRAVITE F TABS WOMEN CHEW EQ ONE DAILY MENS F RX/OTC CVS VISION HEALTH F RX/OTC HEALTH TABS CAPS EQ ONE DAILY WOMENS F RX/OTC DAYAVITE TABS F RX/OTC 50+ TABS EQ ONE DAILY WOMENS F RX/OTC DECUBI-VITE CAPS F RX/OTC HEALTH TABS EQL CENTURY MATURE F RX/OTC DEKAS BARIATRIC F ADULTS50+ TABS CHEW EQL CENTURY MENS F RX/OTC DEKAS PLUS CAPS 1.5 RX/OTC TABS MG-1.7 MG-1.9 MG-10 MG-10 MG-10 MG-12 EQL CENTURY WOMENS F RX/OTC MCG-12 MG-75 MCG-75 TABS MCG-75 MG-100 MCG- EQL ONE DAILY ADULT F 101 MG-200 MCG-1000 GUMMIES CHEW MCG-5450 MCG, 1.5 MG- F EQL ONE DAILY MENS F RX/OTC 1.7 MG-1.9 MG-10 MG-10 TABS MG-10 MG-12 MCG-12 ESTROVEN MENOPAUSE F RX/OTC MG-75 MCG-75 MG-100 SUPPLEMENT TABS MCG-150 UNIT-200 MCG- 1000 MCG-3000 UNIT- EYE HEALTH CAPS F RX/OTC 18167 UNIT DEKAS PLUS CHEW 1.5 EYE HEALTH/LUTEIN F RX/OTC MG-1.7 MG-1.9 MG-10 TABS MG-10 MG-10 MG-12 EYE RX/OTC MCG-12 MG-70 MG-75 F MULTIVITAMIN/LUTEIN F MCG-100 MCG-100 UNIT- TABS 200 MCG-1000 MCG-2000 EYE RX/OTC UNIT-18167 UNIT MULTIVITAMIN/SODIUM F TABS DERMACINRX RIBOTIN-E F RX/OTC TABS FITNESS TABS FOR MEN F RX/OTC AM/PM/LYCOPENE TABS DERMACINRX F RX/OTC ZINTREXYL-C TABS FITNESS TABS FOR RX/OTC RX/OTC WOMEN F DERMAVITE TABS F AM/PM/LYCOPENE TABS EMERGEN-C IMMUNE F FOLIKA-CI TABS F RX/OTC PLUS/VITAMIN D CHEW EMERGEN-C VITAMIN C FOLIKA-MG TABS F RX/OTC CHEW 30 MG-1 MG-2.5 F MG-15 UNIT-150 MCG- FOLITIN-Z TABS F RX/OTC 500 MG EQ COMPLETE RX/OTC FORTAVIT CAPS F RX/OTC MULTIVITAMINADULTS F UNDER 50 TABS FORTAVIT LIQD F RX/OTC
Oregon Trillium OHP Updated September 1, 2021
112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FOSFREE TABS (multiple F RX/OTC K-PAX IMMUNE RX/OTC vitamins w/ minerals) SUPPORT FORMULA F RX/OTC PROFESSIONAL FREEDAVITE TABS F STRENGTH TABS GENADEK STEP 1 CAPS F RX/OTC K-PAX IMMUNE RX/OTC SUPPORT FORMULA F RX/OTC SINGLE STRENGTH GENADEK STEP 2 CAPS F CAPS GERI-FREEDA SENIOR RX/OTC F LUTEIN F RX/OTC FORMULA TABS PLUS/ZEAXANTHIN TABS HAIR SKIN & NAILS RX/OTC MACULAR VITAMIN F RX/OTC ADVANCED FORMULA F BENEFIT TABS TABS MEGA MULTI FOR MEN F RX/OTC HAIR/SKIN/NAILS CAPS RX/OTC TABS 2500 MCG-0.9 MG-11 MG- F MEGA MULTI FOR F RX/OTC 100 MG-2500 UNIT WOMEN TABS HIGH POTENCY RX/OTC MEGA MULTIVITAMIN F RX/OTC MULTIVITAMIN/BETA- F FOR MEN TABS CAROTENE TABS MEGA MULTIVITAMIN F RX/OTC HIGH POTENCY RX/OTC FOR WOMEN TABS MULTIVITAMIN/FOLIC F ACID TABS MEGAVITE FRUITS & F RX/OTC VEGGIES TABS HM COMPLETE 50+ F RX/OTC MENS ULTIMATE TABS MEGAVITE GOLDEN F RX/OTC YEARS 55+ TABS HM COMPLETE 50+ RX/OTC WOMENS ULTIMATE F MENS 50+ ADVANCED F RX/OTC TABS CAPS MENS 50+ MULTI RX/OTC HM COMPLETE MEN F RX/OTC TABS VITAMIN &MINERAL F FORMULA TABS RX/OTC HM COMPLETE TABS F MENS MULTI VITAMIN & RX/OTC MINERAL FORMULA F HM HAIR/SKIN/NAILS F RX/OTC TABS TABS MENS MULTIVITAMIN HM ONE DAILY MENS F RX/OTC CHEW 2 MG-2.5 MG-5 TABS MG-7.5 MCG-7.5 MG-8.75 F HM ONE DAILY WOMENS F RX/OTC MCG-10 MCG-27.5 MCG- TABS 37.5 MG-50 MCG-75 MCG- HYLAZINC TABS F RX/OTC 200 MCG-300 MCG MENS MULTIVITAMIN RX/OTC ICAPS AREDS FORMULA F RX/OTC TABS 2 MG-1.35 MG-1.7 TABS MG-2 MG-3 MG-15 MG-18 MCG-18 MG-20 MCG-22.5 IMMUNE SUPPORT F F CHEW UNIT-110 MCG-120 MCG- K-PAX IMMUNE RX/OTC 140 MG-210 MG-16 MG-60 MG-75 MCG-300 MCG-400 SUPPORT FORMULA F DOUBLE STRENGTH MCG-700 UNIT-3500 UNIT CAPS MULTI-BETIC DIABETES F RX/OTC TABS Oregon Trillium OHP Updated September 1, 2021
113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MULTI-VITAMIN F RX/OTC multiple vitamins w/ RX/OTC MONOCAPS TABS minerals caps 0.33 mg- RX/OTC 0.33 mg-0.5 mg-0.83 mg- MULTI-VITE LIQD F 1.67 mg-3.3 mg-3.3 mg- RX/OTC 0.67 mg-1.67 mcg-1.67 MULTILEX T&M TABS F mg-4 mg-6.7 mg-6.7 mg- RX/OTC 8.3 mg-16.5 mg-16.7 mcg- MULTILEX TABS F 16.7 mcg-16.7 mg-20 mg- 20 mg-20.8 mcg-25 mg- 33.3 mcg-33.3 mcg-33.3 mcg-33.3 mg-33.3 mg-33.3 mg-33.3 mg-41.7 mg-50 mcg-66.7 unit-66.7 unit- 83.3 mg-83.3 mg-83.3 mg- 133.3 mcg-166.7 mcg- 833.3 unit, 0.333 mg-1 mg- 1.667 mg-1.667 mg-1.667 mg-2.5 mg-2.667 mcg- 3.333 mg-4.167 mcg-5 mg- 8.333 mg-8.333 mg-10 mg- 10 mg-10 unit-20 mg-30 mg-133.333 mcg-666.667 unit-1666.667 mcg- 1666.667 unit, 0.4 mg-1.5 mg-1.7 mg-2 mg-2 mg-2.6 mg-6 mcg-10 mcg-10 mcg- F 10 mcg-10 mg-15 mg-20 mg-27 mg-30 mcg-30 unit- 37.5 mg-60 mg-100 mg- 100 mg-130 mg-150 mcg- 400 unit-1500 unit-5000 unit, 0.5 mg-0.567 mg- 0.667 mg-0.667 mg-1.667 mg-2 mcg-3 mg-3.333 mg- 5 mg-6.667 mg-10 unit-20 mg-20 mg-33.333 mg- 33.333 mg-50 mcg-66.667 mg-83.333 mg-133.333 mcg-133.333 mg-166.667 mg-200 mcg-2000 unit, 0.5 mg-0.75 mg-0.85 mg-30 mg-135 mg-150 mcg-175 mg-200 unit-215 mg-250 mg-613.5 mg-1500 mcg, 0.8 mg-34.8 mg-200 unit- 226 mg-14320 unit, 0.8 mg- 5 mg-34.8 mg-200 unit-226 mg, 0.9 mg-1 mg-1.2 mg- 1.3 mg-1.3 mg-2 mg-2.3 mg-2.4 mcg-7 mg-10 mg- 10 unit-16 mg-34 mcg-45 mg-240 mcg-280 mg-600 Oregon Trillium OHP Updated September 1, 2021
114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg, 1 mg-1 mg-1.7 mg- mcg-150 mcg-400 mcg- 2.7 mg-3.3 mcg-4.3 mcg- 1000 unit-2500 unit, 1.5 4.3 mg-5.7 mg-8.3 unit- mg-1.7 mg-2 mg-2 mg-4 11.3 mg-14 mcg-14 mcg- mg-6 mcg-10 mg-15 mg-18 42.3 mcg-42.3 mcg-42.3 mg-20 mcg-20 mg-30 mcg- mg-56.7 mg-56.7 mg-85 40 mcg-40 mg-45 mcg-50 mg-106.3 unit-255 mcg- unit-60 mg-100 mg-120 2973 unit, 1 mg-1 mg-5 mcg-150 mcg-600 mcg- mg-10 mg-200 unit-250 1000 unit-2500 unit, 1.5 mg, 1 mg-1 mg-5 mg-10 mg-1.7 mg-2 mg-4 mg-4 mg-90 mg-250 mg, 1 mg-1 mg-10 mg-15 mg-18 mcg- mg-5 mg-12.5 mg-200 unit- 20 mg-22.5 mg-25 mcg-30 250 mg, 1 mg-1 mg-5 mg- mcg-40 mcg-40 mcg-40 40 mg-200 unit-250 mg, 1 mg-45 mcg-60 mg-100 mg- mg-1 mg-5 mg-5 mg-7.5 120 mcg-150 mcg-400 mg-10 mg-10 mg-10 mg-20 mcg-750 mcg, 1.5 mg-1.7 mg-25 mcg-100 mcg-200 mg-2 mg-4 mg-6 mg-10 unit-250 mg-500 unit, 1 mg-15 mg-20 mg-25 mcg- mg-1 mg-5 mg-9 mg-30 30 mcg-60 mg-60 unit-70 unit-90 mg-150 mg-160 mcg-75 mcg-80 mcg-100 mg-250 mg, 1 mg-1.5 mg- mg-120 mcg-150 mcg-200 7.5 mg-15 mcg-200 unit- mg-400 mcg-1000 unit- 250 mg-10000 unit, 1 mg-2 2500 unit, 1.7 mg-2 mg-2 mg-2 mg-3 mg-5 mg-6 mg- mg-2 mg-3 mg-4 mg-4 mg- 7 mg-10 mcg-10 mcg-25 5 mcg-6 mg-9.5 mg-10 mg-30 mg-30 mg-32 mg- mcg-10 mcg-10 mg-15 300 mcg-315 mg-1000 mcg-15 mg-16 mg-18 mg- mcg, 1 mg-2 mg-4 mg-5 20 mcg-20 mg-20 mg-21 mg-10 mcg-10 mg-10 mg- mg-30 mcg-33 unit-70 mcg- 25 mg-50 unit-70 mg-80 72 mg-75 mcg-100 mcg- mg-150 mg-8000 unit, 1 120 mcg-150 mcg-150 mg-5 mg-20 unit-26.667 mcg-234 mcg-552 mcg-600 mg-88.333 mg-273.333 mcg-1000 unit-2500 unit, unit-491.667 mg-1000 unit, 10 mg-15 mg-18 mg-20 1 mg-5 mg-90 mg-150 mg- mg-25 mg-30 mcg-70 mcg- 160 mg-250 mg-30 unit-1 90 mg-300 mcg-400 unit, mg-9 mg, 1.133 mg-3.333 10000 unit-25 mcg-125 mg-0.667 mg-1 mg-1.333 unit-200 mg, 2 mg-0.4 mg- mg-3.333 mg-4 mg-5 mg- 1.5 mg-1.7 mg-2 mg-2.6 6.667 mg-10 mg-10 mg-10 mg-6 mcg-10 mcg-10 mcg- mg-10 mg-10 unit-15 mg- 10 mcg-10 mg-20 mg-27 16.667 mg-23.333 mcg-25 mg-30 mcg-37.5 mg-100 mcg-33.333 mcg-33.333 mg-100 mg-130 mg-150 mg-40 mcg-40 mg-50 mcg- mcg-400 unit-1500 unit- 133.333 mg-200 mcg- 5000 unit-15 mg-30 unit-60 266.667 mcg-1000 unit- mg, 2 mg-1 mg-1.5 mg-1.7 3333.333 unit, 1.5 mg-1.7 mg-2 mg-2 mg-6 mcg-10 mg-2 mg-2 mg-4 mg-6 mg-20 mg-30 mcg-30 mg- mcg-10 mg-15 mg-18 mg- 40 mg-70 mcg-75 mcg-100 20 mcg-20 mg-30 mcg-40 mcg-120 mcg-120 mg-150 mcg-40 mg-45 mcg-50 mcg-200 mcg-500 mcg- unit-60 mg-100 mg-120 2000 unit-5000 unit-30 unit- Oregon Trillium OHP Updated September 1, 2021
115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 15 mg, 2 mg-15 mg-30 1000 unit-2500 unit, 5 mcg- unit-60 mg, 2 mg-2 mg-5 0.5 mg-0.5 mg-3.75 mg-25 mg-15 mg-1.2 mg-1.7 mg-3 mg-68.75 unit-100 mcg-300 mg-16 mg-18 mcg-20 mcg- mg-375 mg, 5 mg-1 mg-1 30 mcg-45 unit-90 mg-100 mg-5 mg-5 mg-7.5 mg-10 mg-105 mcg-120 mcg-120 mg-15 mg-25 mcg-25 mg- mg-210 mg-400 mcg-400 25 mg-25 mg-25 mg-25 unit-600 mcg-3500 unit, 2 mg-25 mg-25 unit-30 mcg- mg-3 mg-3 mg-6 mg-12 35 mg-50 mg-50 mg-70 mcg-15 unit-25 mcg-25 mcg-75 mcg-100 mcg-100 mcg-25 mg-25 mg-50 mg- mcg-100 mg-150 mcg-150 50 mg-250 mg-500 unit- mcg-150 mg-250 mcg-400 800 mcg-2500 unit, 2 mg-4 mcg-400 unit-10000 unit, 5 mg-4 mg-5 mcg-2 mg-3.4 mg-1 mg-2 mg-4 mg-10 mg-4.5 mg-6 mg-6 mg-9.5 mcg-10 mg-10 mg-25 mg- mg-10 mcg-10 mcg-10 mg- 50 unit-70 mg-80 mg-150 16 mg-20 mcg-20 mg-20 mg-8000 unit, 50 mcg-400 mg-21 mg-22.5 mg-25 unit-500 mg-25000 unit, mcg-30 mcg-33 unit-72 500 mg-25 mg-45 mg-100 mg-90 mcg-100 mcg-105 unit, 6 mg-13.5 mg-15 mg- mcg-150 mcg-150 mcg-180 60 mg, 7.5 mg-50 mcg-400 mcg-234 mcg-400 mcg-552 unit-500 mg, 9 mg-1 mg-1 mcg-1000 unit-2500 unit, 2 mg-5 mg-30 unit-90 mg- mg-5 mg-5 mg-7.2 mg-15 150 mg-160 mg-250 mg mg-25 mg-25 mg-25 mg-25 mg-25 mg-25 mg-25 mg-50 mg-100 mcg-100 mg-100 unit-150 mcg-150 mcg-150 mg-200 mcg-200 mcg-300 mcg-400 mcg-400 unit- 5000 unit, 2 mg-6 mg-1.5 mg-1.7 mg-4 mg-10 mg-15 mg-20 mg-25 mcg-30 mcg- 60 mg-60 unit-70 mcg-75 mcg-80 mcg-100 mg-120 mcg-150 mcg-200 mg-400 mcg-1000 unit-2500 unit, 2 mg-6 mg-15 mg-22 mg-30 unit-60 mg, 226 mg-0.8 mg-34.8 mg-200 mg-14320 unit, 226 mg-0.8 mg-34.8 mg-200 unit-14320 unit, 25 mcg-100 unit-200 mg-5000 unit, 3.333 mg-6.667 mg- 16.667 unit-33.333 mg- 133.333 mg-166.667 mg, 4 mg-1.5 mg-1.7 mg-2 mg-4 mg-10 mg-15 mg-18 mcg- 20 mg-30 mcg-40 mcg-40 mcg-40 mg-45 mcg-50 unit-60 mg-100 mg-120 mcg-150 mcg-400 mcg- Oregon Trillium OHP Updated September 1, 2021
116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits multiple vitamins w/ 1250 unit, 1 mg-2.5 mg-20 minerals chew 0.033 mg- unit-30 mcg-5 mcg-5 mg-20 0.333 mg-1.667 mg-2.233 mcg-30 mg-40 mcg-75 mg-3.333 mg-5 mcg-20 mcg-200 mcg-200 unit- mcg-250 mg, 0.5 mg-1.25 2000 unit, 1 mg-2.5 mg-4 mg-2.5 mcg-10 mcg-10 mcg-5 mcg-5 mg-9 mg- unit-15 mcg-15 mg-20 17.5 mg-30 mg-40 mcg-75 mcg-37.5 mcg-100 unit- mcg-200 mcg-600 mcg, 1 1000 unit, 0.5 mg-2.5 mg- mg-2.5 mg-4 mcg-5 mg-20 4.5 mg-15 unit-50 mg, 0.7 unit-30 mg-40 mcg-75 mcg- mg-0.75 mg-2 mg-3.38 mg- 200 mcg-400 unit-2000 3.75 mcg-5 mg-150 mcg- unit, 1 mg-2.5 mg-5 mcg-5 250 mg, 0.75 mg-2 mg- mg-20 mcg-20 unit-30 mcg- 3.75 mcg-7.5 unit-10 mg- 30 mg-40 mcg-75 mcg-200 11.25 mg-250 mg-500 unit, mcg-200 unit-2000 unit, 1 0.75 mg-2 mg-3.75 mcg- mg-3 mcg-3.75 mg-5 mg- 7.5 unit-10 mg-250 mg-500 10 mg-15 unit-30 mg-37.5 unit, 0.75 mg-3.75 mcg-7.5 mcg-75 mcg-200 mcg-500 unit-10 mg-250 mg-500 unit-1250 unit, 1.5 mg-2 unit-2 mg, 0.9 mg-1.9 mg-3 mg-5 mg-5 mg-6 mcg-7.5 mcg-5 mg-5 mg-10 mg-10 mcg-7.5 unit-15 mg-18.75 unit-25 mg-25 mg-113.5 mcg-20 mcg-60 mcg-75 mg-200 mcg-1000 unit- mcg-137.5 mcg-200 mcg- 1250 unit, 1 mg-1 mg-1 400 unit-1250 unit, 15 mg-1 mg-1.7 mg-2 mg-5 mg-6.25 mg-1.25 mg-4.5 mcg-15 unit-20 mcg-50 mg-75 mcg- mg-7.5 mg-7.5 mg-10 mg- F 10 mg-10 mg-15 mg-22.5 200 mcg-400 unit-1250 mg-25 mcg-25 mg-35 mcg- unit, 2.233 mg-0.033 mg- 45 mg-60 mcg-75 mcg-75 0.333 mg-1.667 mg-3.333 mg-75 unit-300 mcg-400 mg-5 mcg-20 mcg-250 mg, mcg-500 mcg-500 mcg- 2.5 mg-2.5 mg-3 mg-7.5 1500 unit-5000 unit, 1 mg-1 mcg-15 unit-22.5 mg-37.5 mg-2.5 mg-2.5 mg-3 mcg-5 mcg-55 mcg-75 mcg-80 mg-7.5 unit-20 mcg-30 mcg-500 unit-1250 unit, 2.5 mcg-30 mg-140 mg-150 mg-2.5 mg-5 mg-7.5 mcg- mcg-200 mcg-400 unit- 15 unit-20 mcg-30 mcg- 1250 unit, 1 mg-1.25 mg- 37.5 mg-55 mcg-75 mcg- 4.5 mcg-15 mg-15 unit-20 200 mcg-200 unit-300 mcg- mcg-50 mg-75 mcg-200 2000 unit, 3.333 unit-0.033 mcg-400 unit-1250 unit, 1 mg-0.333 mg-3.333 mg-5 mg-1.5 mg-1.7 mg-2 mg-2 mcg-66.666 unit-333.333 mg-6 mcg-10 mg-10 unit- mg, 4 mg-2 mg-2.2 mg-2.7 15 mg-18 mg-20 mcg-20 mg-4.5 mg-5 mcg-7 mg-10 mg-20 mg-40 mg-45 mcg- mcg-10 mcg-10 mg-12 mg- 50 mg-60 mg-60 unit-108 15 mg-22.5 mcg-25 mcg-25 mg-150 mcg-400 mcg-400 mcg-45 mcg-50 mg-70 unit- unit-3500 unit, 1 mg-1.9 75 mg-100 mcg-100 mcg- mg-2 mg-3 mcg-5 mg-9 125 mg-200 mg-250 mcg- mcg-9.4 mcg-10 mg-15 400 unit-500 mcg-4000 unit mcg-15 mg-15 unit-19 mcg-20 mcg-60 mcg-75 mcg-150 mcg-200 unit- Oregon Trillium OHP Updated September 1, 2021
117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits multiple vitamins w/ RX/OTC mcg/5ml-5 mg/5ml-7.5 minerals liqd 1.5 mg/15ml- mg/5ml-7.5 mg/5ml-10 1.7 mg/15ml-2 mg/15ml-2 mg/5ml-12.5 mg/5ml-25 mg/15ml-3 mg/15ml-6 mcg/5ml-75 mg/5ml-100 mcg/15ml-9 mg/15ml-10 unit/5ml-200 mcg/5ml-225 mg/15ml-20 mg/15ml-25 mg/5ml-750 mcg/5ml-2500 mcg/15ml-25 mcg/15ml-30 unit/5ml-250 mg/5ml-25 unit/15ml-60 mg/15ml-150 mcg/5ml mcg/15ml-300 mcg/15ml, multiple vitamins w/ F RX/OTC 1.5 mg/15ml-1.7 mg/15ml-2 minerals tabs mg/15ml-2 mg/15ml-3 mg/15ml-6 mcg/15ml-9 mg/15ml-10 mg/15ml-20 mg/15ml-25 mcg/15ml-25 mcg/15ml-30 unit/15ml-60 mg/15ml-150 mcg/15ml- 300 mcg/15ml-1000 unit/15ml-1300 unit/15ml, 1.5 mg/15ml-1.7 mg/15ml-2 mg/15ml-2 mg/15ml-3 mg/15ml-6 mcg/15ml-9 mg/15ml-10 mg/15ml-20 mg/15ml-25 mcg/15ml-25 mcg/15ml-30 unit/15ml-60 mg/15ml-150 mcg/15ml- 300 mcg/15ml-400 F unit/15ml-1300 unit/15ml, 1.5 mg/15ml-1.7 mg/15ml-2 mg/15ml-2 mg/15ml-3 mg/15ml-6 mcg/15ml-9 mg/15ml-10 mg/15ml-20 mg/15ml-25 mcg/15ml-30 unit/15ml-60 mg/15ml-150 mcg/15ml-250 mcg/15ml- 300 mcg/15ml-400 unit/15ml, 15 mg/15ml-2.25 mg/15ml-2.55 mg/15ml-3 mg/15ml-15 mg/15ml-18 mcg/15ml-37 mg/15ml-45 mg/15ml-45 unit/15ml-75 mg/15ml-90 mg/15ml-112.5 mcg/15ml-150 mcg/15ml- 300 mcg/15ml-600 unit/15ml-5250 unit/15ml, 2 mg/15ml-10 mg/15ml-15 mcg/15ml-15 mg/15ml-15 mg/15ml-50 mcg/15ml-50 mg/15ml-50 mg/15ml-50 mg/15ml-50 mg/15ml-150 mcg/15ml-800 mcg/15ml- 1000 mg/15ml-5000 unit/15ml, 2.5 unit/5ml-5 Oregon Trillium OHP Updated September 1, 2021
118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits multiple vitamins w/ RX/OTC 10 mg-15 mg-30 mcg-30 minerals tabs 0.05 mg-1.1 mcg-30 mg-30 mg-30 mg- mg-1.1 mg-2 mg-2.3 mg-5 30 mg-30 mg-35 mcg-50 mcg-5 mg-5 mg-8 mg-10 unit-100 mg-150 mcg-300 mcg-14 mg-15 mg-20 mg- mg-400 mcg-400 unit-5000 30 mcg-35 unit-50 mcg-50 unit, 0.33 mg-0.67 mg-3.3 mcg-50 mcg-50 mcg-50 mg-3.3 mg-3.3 mg-5 unit- mg-55 mcg-72 mg-80 mg- 11.7 mg-33.3 mg-41.7 mg- 100 mg-150 mcg-150 mcg- 50 mcg-66.7 mg-100 mg- 300 mcg-400 mcg-500 mg- 140 unit-1400 unit, 0.35 800 unit-3500 unit, 0.075 mg-0.75 mg-0.85 mg-1 mg- mg-0.38 mg-0.5 mg-0.5 1 mg-2.5 mcg-2.5 mg-3 mg-0.83 mg-0.9 mg-1.5 mg-3.75 mg-5 mcg-5 mcg- mcg-1.67 mg-2.5 mg-2.5 5 mg-10 mcg-10 mg-12.5 mg-2.5 mg-6.25 mcg-7.5 mcg-15 mcg-15 unit-16 mcg-10 mcg-18.75 mcg- mcg-20 mg-29 mg-30 mg- 21.15 mg-25 mg-30 mcg- 32 mg-37.5 mcg-40 mg-54 35 mg-37.5 mcg-83.25 mg- mg-60 mcg-75 mcg-100 100 mcg-100 unit-107.5 mcg-200 mcg-200 unit-400 unit-128 mg, 0.08 mg-1.67 mg-1750 unit, 0.37 mg-0.5 mg-2.5 mg-4.16 mg-4.16 mg-1 mcg-1 mg-1.5 mg-2.5 mg-4.16 mg-4.16 mg-4.16 mg-2.5 mg-2.5 mg-5 mg-15 mg-4.16 mg-7.9 mg-10.4 mg-15 unit-60 mg-75 mcg- mcg-12.5 mcg-16.7 mcg- 80 mg-100 mg-400 mcg- 16.7 mcg-16.7 unit-16.7 400 unit-5000 unit, 0.375 unit-33.3 mcg-41.7 mg- F mg-0.5 mg-1 mcg-1 mg-1.5 52.08 mg-250 mg-2083.3 mg-2.5 mg-2.5 mg-5 mg- unit, 0.1 mg-0.15 mg-0.8 7.5 mg-15 mg-15 unit-60 mg-3 mg-5 mg-20 mg-20 mg-75 mcg-80 mg-100 mg- mg-22.5 mg-25 mg-25 mg- 400 mcg-400 unit-5000 27 mg-30 unit-50 mcg-50 unit, 0.4 mg-0.8 mg-1.3 mg-100 mg-500 mg-5000 mg-7 mg-10 mg-10 mg-18 unit, 0.125 mg-0.161 mg- mg-25 mcg-25 mg-25 mg- 0.4 mg-1.25 mg-2 mg-5 50 unit-100 mg-300 mg, 0.4 mg-6 mcg-10 mg-10 mg-15 mg-1.2 mg-1.7 mg-2 mg-6 mg-20 mg-24 mg-30 unit- mcg-15 mg-18 mg-20 mg- 100 mg-100 mg-150 mcg- 60 mg-100 mg-125 mg-150 250 mg-400 unit-10000 mcg-160 mg-400 unit-5000 unit, 0.15 mg-0.5 mg-5 mg- unit, 0.4 mg-1.5 mg-1.7 6 mg-7 mg-10 mg-10 mg- mg-2 mg-6 mcg-10 mcg-20 25 mg-30 mg-30 mg-30 mg-30 unit-45 mg-60 mg- mg-30 mg-50 mg-80 mcg- 400 unit-3000 unit, 0.4 mg- 80 mcg-80 mg-80 mg-80 1.5 mg-1.7 mg-2 mg-6 mg-80 mg-80 mg-80 mg-80 mcg-10 mg-15 mg-20 mg- mg-80 mg-100 unit-250 27 mg-30 unit-60 mg-400 mg-400 mcg-1000 unit- unit-450 mg-5000 unit, 0.4 25000 unit, 0.15 mg-1 mg- mg-1.5 mg-1.7 mg-2 mg-6 1 mg-1.5 mg-1.7 mg-3 mcg-10 mg-20 mg-30 unit- mcg-5 mg-5 mg-5.5 unit-10 45 mg-60 mg-400 unit- mg-10 mg-15 mg-30 mg- 3000 unit, 0.4 mg-1.5 mg- 100 mg-400 unit-10000 1.7 mg-2 mg-6 mcg-10 mg- unit, 0.2 mg-2 mg-7.5 mg- 20 mg-30 unit-60 mg-400 Oregon Trillium OHP Updated September 1, 2021
119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits unit-5000 unit, 0.4 mg-100 mg-75 mg-80 mg-100 mg- unit-113 mg-7160 unit-17.4 150 mcg-200 mg-400 mcg- mg, 0.4 mg-17.4 mg-100 800 unit-3500 unit, 0.5 mg- unit-113 mg-7160 unit, 0.4 1.1 mg-1.1 mg-2 mg-2.3 mg-2 mg-3 mg-3 mg-3.4 mg-5 mcg-5 mg-5 mg-8 mg-5 mg-7.5 mg-7.5 mg-9 mg-10 mcg-14 mg-15 mg- mcg-10 mcg-10 mg-15 15.8 mg-20 mg-22 mcg-25 mcg-15 mcg-15 mcg-15 mcg-30 mcg-50 mcg-50 mg-27 mg-30 mg-30 unit- mcg-50 mcg-52 mcg-72 41 mg-100 mg-120 mg-150 mg-80 mg-100 mg-100 mg- mcg-400 unit-5500 unit, 0.4 150 mcg-300 mcg-300 mg- mg-2 mg-3 mg-3 mg-3.4 400 mcg-1050 mcg, 0.5 mg-5 mg-7.5 mg-7.5 mg-9 mg-1.1 mg-1.1 mg-2 mg- mcg-10 mcg-10 mg-15 2.3 mg-5 mcg-5 mg-5 mg-8 mcg-15 mcg-15 mg-20 mg- mg-10 mcg-14 mg-15 mg- 27 mg-30 mcg-30 unit-31 17.5 mg-20 mg-22 mcg-25 mg-40 mg-90 mg-100 mg- mcg-30 mcg-50 mcg-50 150 mcg-400 unit-2500 mcg-50 mcg-52 mcg-72 unit-2500 unit, 0.4 mg-2 mg-80 mg-100 mg-100 mg- mg-3 mg-3 mg-3.4 mg-5 150 mcg-300 mcg-300 mg- mg-7.5 mg-7.5 mg-9 mcg- 400 mcg-1052 mcg, 0.5 10 mcg-10 mg-15 mcg-15 mg-1.1 mg-1.1 mg-2 mg- mcg-15 mg-27 mg-30 mg- 2.3 mg-5 mcg-5 mg-5 mg-8 30 unit-31 mg-35 mcg-40 mg-10 mcg-14 mg-15 mg- mg-90 mg-100 mg-150 20 mg-22 mcg-30 mcg-35 mcg-400 unit-1250 unit- unit-50 mcg-50 mcg-50 5000 unit, 0.5 mg-0.5 mg-1 mcg-52 mcg-72 mg-80 mg- mg-1 mg-1 mg-1 mg-1 mg- 100 mg-100 mg-150 mcg- 2 mg-2 mg-2 mg-3.5 mg- 300 mcg-300 mg-400 mcg- 4.5 mg-5 mg-5.1 mg-6 mg- 800 unit-3500 unit, 0.5 mg- 6.5 mcg-7.5 mg-10 mg-10 1.1 mg-1.1 mg-2 mg-2.3 mg-10 mg-13 mcg-13 mcg- mg-5 mcg-5 mg-5 mg-8 15 mg-18 mg-24 mcg-25 mg-10 mcg-14 mg-15 mg- mg-25 mg-40 mg-60 mcg- 20 mg-30 mcg-35 unit-50 60 unit-80 mcg-80 mg-90 mcg-50 mcg-50 mcg-50 mg-100 mg-100 mg-120 mcg-50 mg-55 mcg-72 mg- mg-150 mcg-165 mg-200 80 mg-100 mg-150 mcg- mcg-200 mcg-200 mcg-275 150 mcg-300 mcg-400 mcg-300 mcg-400 mcg-400 mcg-500 mg-800 unit-3500 unit-5000 unit, 0.5 mg-1 unit, 0.5 mg-1.1 mg-1.1 mg-7.5 mg-9 mg-10 mcg- mg-2 mg-2.3 mg-5 mcg-5 10 mg-10 mg-10 mg-10 mg-5 mg-8 mg-10 mcg-14 mg-10 mg-10 mg-10 mg- mg-15 mg-20 mg-30 mcg- 17.5 mcg-30 mcg-30 unit- 35 unit-50 mcg-50 mcg-50 35 mg-60 mg-75 mcg-100 mcg-50 mcg-50 mg-55 mg-120 mg-200 mg-400 mcg-72 mg-80 mg-100 mg- mcg-400 unit-5000 unit, 0.5 150 mcg-150 mg-300 mcg- mg-1.1 mg-1.1 mg-1.8 mg- 400 mcg-500 mg-800 unit- 2 mg-6 mcg-8 mg-14 mg- 3500 unit, 0.5 mg-1.1 mg- 15 mg-18 mcg-18 mg-20 1.1 mg-2 mg-2.3 mg-5 mg- mg-32 mcg-35 unit-40 5 mg-8 mg-10 mcg-14 mg- mcg-50 mcg-50 mcg-72 15 mg-15.7 mg-20 mg-22 Oregon Trillium OHP Updated September 1, 2021
120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg-25 mcg-30 mcg-50 mcg-10 mg-11 mg-19 mcg- mcg-50 mcg-50 mcg-52 20 mg-20 mg-25 mcg-30 mcg-72 mg-80 mg-100 mg- mcg-30 mcg-45 mcg-50 100 mg-150 mcg-300 mcg- mcg-50 mg-50 unit-60 mg- 300 mg-400 mcg-1050 72 mg-80 mg-150 mg-220 mcg, 0.5 mg-1.5 mg-1.7 mg-250 mcg-300 mcg-400 mg-2 mg-2 mg-2.3 mg-5 mcg-1000 unit-2500 unit, mcg-10 mcg-10 mcg-10 0.5 mg-1.5 mg-1.7 mg-2 mg-11 mg-18 mg-20 mg-20 mg-2.3 mg-3 mg-5 mcg-10 mg-25 mcg-30 mcg-30 mcg-10 mg-11 mg-20 mg- unit-35 mg-45 mcg-50 mg- 20 mg-25 mcg-30 mcg-30 55 mcg-60 mg-72 mg-75 mcg-45 mcg-45 mcg-50 mcg-80 mg-150 mcg-200 mg-50 unit-55 mcg-60 mg- mg-400 unit-3500 unit, 0.5 72 mg-80 mg-100 mcg-150 mg-1.5 mg-1.7 mg-2 mg-2 mcg-220 mg-250 mcg-300 mg-2.3 mg-5 mcg-6 mcg- mcg-400 mcg-500 unit- 10 mcg-10 mcg-10 mcg-10 2500 unit, 0.5 mg-1.5 mg- mg-11 mg-13.5 mg-18 mg- 1.7 mg-2 mg-2.3 mg-3 mg- 20 mg-20 mg-25 mcg-30 5 mcg-10 mcg-10 mg-11 mcg-35 mcg-45 mcg-50 mg-20 mg-20 mg-25 mcg- mg-55 mcg-60 mg-72 mg- 30 mcg-30 mcg-45 mcg-45 75 mcg-80 mg-150 mcg- mcg-50 mg-50 unit-55 mcg- 200 mg-400 mcg-1050 60 mg-72 mg-80 mg-150 mcg, 0.5 mg-1.5 mg-1.7 mcg-150 mcg-220 mg-250 mg-2 mg-2 mg-2.3 mg-5 mcg-300 mcg-400 mcg-500 mcg-6 mcg-10 mcg-10 unit-2500 unit, 0.5 mg-1.5 mcg-10 mg-11 mg-18 mg- mg-1.7 mg-2 mg-2.3 mg-3 20 mg-20 mg-25 mcg-30 mg-5 mcg-10 mcg-10 mg- mcg-30 unit-35 mcg-45 11 mg-20 mg-20 mg-25 mcg-50 mg-55 mcg-60 mg- mcg-30 mcg-30 mcg-45 72 mg-75 mcg-80 mg-150 mcg-45 mcg-50 mg-50 unit- mcg-200 mg-400 mcg-400 55 mcg-60 mg-80 mg-150 unit-3500 unit, 0.5 mg-1.5 mcg-150 mcg-220 mg-250 mg-1.7 mg-2 mg-2 mg-2.3 mcg-300 mcg-400 mcg-500 mg-6 mcg-10 mcg-10 mcg- unit-2500 unit, 0.5 mg-1.5 10 mg-11 mg-13.5 mg-18 mg-1.7 mg-2 mg-2.3 mg-3 mg-20 mg-20 mg-25 mcg- mg-5 mcg-10 mcg-10 mg- 25 mcg-30 mcg-35 mcg-45 11 mg-20 mg-20 mg-25 mcg-50 mg-55 mcg-60 mg- mcg-30 mcg-45 mcg-45 72 mg-80 mg-150 mcg-200 mcg-50 mg-50 unit-55 mcg- mg-400 mcg-1050 mcg, 0.5 72 mg-80 mg-150 mcg-150 mg-1.5 mg-1.7 mg-2 mg- mcg-250 mcg-300 mcg-400 2.3 mg-3 mg-5 mcg-10 mcg-500 unit-2500 unit-220 mcg-10 mg-11 mg-19 mcg- mg-30 mcg-60 mg, 0.5 mg- 20 mg-20 mg-25 mcg-30 1.5 mg-1.7 mg-2 mg-4 mg- mcg-30 mcg-45 mcg-50 5 mcg-6 mg-10 mcg-10 mcg-50 mg-50 unit-60 mg- mg-15 mg-20 mg-20 mg-21 72 mg-80 mg-150 mcg-220 mcg-25 mcg-27 mg-30 mg-250 mcg-300 mcg-400 mcg-50 mcg-60 mcg-60 mcg-500 unit-2500 unit, 0.5 mcg-72 mg-75 mg-80 mg- mg-1.5 mg-1.7 mg-2 mg- 100 mcg-120 mg-150 mcg- 2.3 mg-3 mg-5 mcg-10 210 mg-300 mcg-300 mcg- Oregon Trillium OHP Updated September 1, 2021
121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 600 mcg-1050 mcg, 0.5 150 mcg-150 mcg-220 mg- mg-1.5 mg-1.7 mg-4 mg-6 250 mcg-300 mcg-400 mg-10 mg-15 mg-20 mg-20 mcg-500 unit-2500 unit, 0.5 mg-21 mcg-25 mcg-27 mg- mg-2.3 mg-1.5 mg-1.7 mg- 30 mcg-50 mcg-60 mcg-60 2 mg-3 mg-5 mcg-10 mcg- mcg-72 mg-75 mg-80 mg- 10 mg-11 mg-20 mg-20 100 mcg-120 mg-150 mcg- mg-25 mcg-30 mcg-30 210 mg-300 mcg-300 mcg- mcg-45 mcg-45 mcg-50 600 mcg-1050 mcg, 0.5 mg-50 unit-55 mcg-60 mg- mg-1.5 mg-1.7 mg-4 mg-6 72 mg-80 mg-150 mcg-150 mg-10 mg-15 mg-20 mg-20 mcg-220 mg-300 mcg-400 mg-21 mcg-30 mcg-50 mcg-500 unit-2500 unit-250 mcg-60 mcg-60 mcg-60 mcg, 0.5 mg-2.3 mg-3 mg- unit-72 mg-75 mg-80 mg- 1.5 mg-1.7 mg-2 mg-5 100 mcg-120 mg-150 mcg- mcg-10 mcg-10 mg-11 mg- 210 mg-300 mcg-300 mcg- 20 mg-20 mg-25 mcg-30 600 mcg-600 unit-3500 mcg-30 mcg-45 mcg-45 unit, 0.5 mg-2 mg-1.5 mg- mcg-50 mg-50 unit-55 mcg- 1.7 mg-2 mg-2.3 mg-5 60 mg-72 mg-80 mg-150 mcg-6 mcg-10 mcg-10 mcg-150 mcg-220 mg-250 mcg-10 mg-11 mg-18 mg- mcg-300 mcg-400 mcg-500 20 mg-20 mg-25 mcg-30 unit-2500 unit, 0.5 mg-5 mcg-30 unit-35 mcg-45 mcg-1.1 mg-1.1 mg-2.3 mcg-50 mg-55 mcg-60 mg- mg-5 mg-5 mg-8 mg-10 72 mg-75 mcg-80 mg-150 mcg-14 mg-15 mg-15 mg- mcg-200 mg-400 mcg-400 20 mg-30 mcg-35 unit-50 unit-3500 unit, 0.5 mg-2.3 mcg-50 mcg-50 mcg-50 mg-1.1 mg-1.1 mg-2 mg-5 mcg-50 mg-55 mcg-72 mg- mcg-5 mg-5 mg-8 mg-10 80 mg-100 mg-150 mcg- mcg-14 mg-15 mg-15.8 150 mcg-300 mcg-400 mg-20 mg-22 mcg-25 mcg- mcg-500 mg-800 unit-3500 30 mcg-50 mcg-50 mcg-50 unit, 0.6 mg-0.6 mg-3.3 mcg-52 mcg-72 mg-80 mg- mg-3.5 mg-5 mg-5 mg-6.5 100 mg-100 mg-150 mcg- mg-7.2 mg-7.5 mg-10 mg- 300 mcg-300 mg-400 mcg- 10 mg-10 mg-10 mg-10 1050 mcg, 0.5 mg-2.3 mg- mg-15 mg-20 mg-25 mcg- 1.5 mg-1.7 mg-2 mg-3 mg- 25 mcg-25 mcg-25 mg-25 5 mcg-10 mcg-10 mg-11 unit-50 mg-50 unit-58 mg- mg-20 mg-20 mg-20 mg-25 125 mg-150 mcg-897 mcg- mcg-30 mcg-30 mcg-45 2500 unit, 0.6 mg-0.6 mg- mcg-45 mcg-50 mg-50 3.3 mg-3.5 mg-5 mg-5 mg- unit-55 mcg-60 mg-72 mg- 6.5 mg-7.2 mg-7.5 mg-10 80 mg-150 mcg-150 mcg- mg-10 mg-10 mg-15 mg-20 220 mg-250 mcg-300 mcg- mg-25 mcg-25 mcg-25 400 mcg-500 unit-2500 mcg-25 mg-25 unit-50 mg- unit, 0.5 mg-2.3 mg-1.5 50 mg-50 unit-54 mg-70 mg-1.7 mg-2 mg-3 mg-5 mg-150 mcg-897 mcg-2500 mcg-10 mcg-10 mg-11 mg- unit, 0.6 mg-1.2 mg-1.7 20 mg-20 mg-25 mcg-30 mg-2 mg-2 mg-3 mg-5 mg- mcg-30 mcg-45 mcg-45 15 mg-16 mg-18 mcg-20 mcg-50 mg-50 unit-55 mcg-30 mcg-45 unit-90 mg- mcg-60 mg-72 mg-80 mg- 99 mg-105 mcg-120 mcg- Oregon Trillium OHP Updated September 1, 2021
122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 120 mg-210 mg-400 mcg- unit-3500 unit, 0.7 mg-1.5 400 unit-3500 unit, 0.667 mg-1.7 mg-4 mg-5 mcg-6 mg-0.5 mg-0.667 mg-0.667 mg-10 mcg-10 mcg-10 mg- mg-0.667 mg-3.333 mg-5 15 mg-20 mg-20 mg-30 mg-5 mg-5.333 mg-8.333 mcg-50 mcg-50 mg-60 mg-10 mg-10 mg-15 mg-20 mcg-60 mcg-60 unit-72 mg- mg-20 mg-20 mg-22.333 80 mg-100 mcg-100 mcg- unit-25 mcg-25 mcg-26.667 120 mg-150 mcg-150 mcg- mcg-30 mg-33.333 mg-50 250 mg-300 mcg-300 mcg- mcg-50 mg-50 mg-66.667 600 mcg-600 unit-3500 mcg-66.667 mcg-71.667 unit, 0.7 mg-1.5 mg-1.7 mg-100 mcg-100 mg-100 mg-4 mg-5 mcg-6 mg-10 mg-166.667 mcg-200 mcg- mcg-10 mg-15 mg-15 mg- 266.667 mcg-266.667 unit- 20 mg-20 mg-30 mcg-50 1666.667 unit, 0.667 mg- mcg-50 mg-60 mcg-60 0.667 mg-1 mg-1 mg-1.667 mcg-60 unit-72 mg-80 mg- mg-1.667 mg-1.667 mg-2.5 100 mcg-100 mcg-120 mg- mg-2.5 mg-2.667 mcg- 150 mcg-150 mcg-250 mg- 3.333 mg-3.333 mg-4.167 300 mcg-300 mcg-600 mcg-4.167 mg-5 mg-5 unit- mcg-600 unit-3500 unit, 5 unit-8.333 mg-10 mg- 0.75 mcg-2 mg-2 mg-2 mg- 12.667 mg-16.667 mg- 5 mcg-10 mcg-10 mcg-10 16.667 mg-20 mg-30 mg- mg-10 mg-10 mg-18 mg-20 66.667 mcg-66.667 mg- mcg-25 mcg-30 mg-30 unit- 333.333 unit-1666.667 unit- 72 mg-80 mg-109 mg-120 1666.667 unit, 0.667 mg- mcg-150 mcg-150 mcg-250 0.667 mg-1 mg-1 mg-1.667 mcg-300 mcg-400 mcg-400 mg-1.667 mg-2.5 mg-2.667 unit-3500 unit, 0.75 mg- mcg-3.333 mg-3.333 mg-5 0.85 mg-1 mg-1 mg-1 mg-1 mg-5 unit-8.333 mg-10 mg- mg-3 mcg-5 mg-10 mg- 12.667 mg-16.667 mg- 11.5 mg-15 mcg-25 unit-35 16.667 mg-20 mg-30 mg- mcg-37.5 mcg-50 mg-60 66.667 mcg-66.667 mg- mcg-75 mcg-75 mg-5 mg-7 333.333 unit-1666.667 unit, mg-15 mcg-100 mg-150 0.667 mg-0.667 mg-1 mg- mcg-200 mcg-200 unit-500 1.667 mg-1.667 mg-2.5 unit, 0.75 mg-0.85 mg-1 mg-2.667 mcg-3.333 mg- mg-1 mg-1 mg-1 mg-3 3.333 mg-5 mg-5 unit- mcg-5 mg-7.5 mg-10 mg- 8.333 mg-10 mg-12.667 15 unit-25 mcg-25 mg-30 mg-16.667 mg-16.667 mg- mg-35 mcg-37.5 mcg-40 20 mg-30 mg-66.667 mcg- mg-45 mg-75 mcg-100 66.667 mg-333.333 unit- mcg-125 mg-150 mcg-200 1000 mcg-1666.667 unit, mcg-200 mg-200 unit-2500 0.7 mg-1.5 mg-1.7 mg-2 unit, 0.9 mg-0.9 mg-1.5 mg-4 mg-5 mcg-6 mg-10 mg-1.5 mg-1.7 mg-1.7 mg- mcg-10 mg-15 mg-20 mg- 2 mg-2 mg-2.3 mg-2.3 mg- 20 mg-30 mcg-50 mcg-50 3 mg-3 mg-5 mcg-5 mcg- mg-60 mcg-60 mcg-60 10 mcg-10 mcg-10 mg-10 unit-72 mg-80 mg-100 mg-11 mg-11 mg-20 mg-20 mcg-100 mcg-120 mg-150 mg-25 mcg-25 mcg-30 mcg-150 mcg-250 mg-300 mcg-30 mcg-30 mcg-30 mcg-300 mcg-600 mcg-600 mcg-45 mcg-45 mcg-45 Oregon Trillium OHP Updated September 1, 2021
123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg-45 mcg-50 mg-50 mg- mcg-35 mcg-45 mcg-45 50 unit-50 unit-55 mcg-55 mcg-55 mcg-55 mcg-72 mcg-72 mg-72 mg-80 mg- mg-72 mg-80 mg-80 mg-90 80 mg-90 mg-90 mg-110 mg-90 mg-100 mg-100 mg- mg-110 mg-150 mcg-150 109 mg-109 mg-150 mcg- mcg-150 mcg-150 mcg-220 150 mcg-150 mcg-150 mg-220 mg-250 mcg-250 mcg-200 mg-200 mg-250 mcg-300 mcg-300 mcg-500 mcg-250 mcg-300 mcg-300 mcg-500 mcg-500 unit-500 mcg-400 unit-400 unit-500 unit-2500 unit-2500 unit, mcg-500 mcg-3500 unit- 0.9 mg-1.1 mg-1.1 mg-1.8 3500 unit, 0.9 mg-1.5 mg- mg-2 mg-2 mg-5 mcg-6 1.7 mg-2 mg-2 mg-2.3 mg- mcg-8 mg-10 mcg-10 mcg- 5 mcg-6 mcg-10 mcg-10 14 mg-15 mg-18 mg-20 mcg-10 mg-11 mg-18 mg- mg-25 mcg-35 unit-40 20 mg-25 mcg-30 mcg-30 mcg-50 mcg-50 mcg-55 unit-35 mcg-45 mcg-55 mcg-72 mg-75 mg-80 mg- mcg-72 mg-80 mg-90 mg- 100 mg-150 mcg-150 mcg- 100 mg-109 mg-150 mcg- 400 mcg-500 mg-800 unit- 150 mcg-200 mg-250 mcg- 3500 unit, 0.9 mg-1.2 mg- 300 mcg-400 unit-500 mcg- 1.3 mg-1.7 mg-1.8 mg-3.4 3500 unit, 0.9 mg-1.5 mg- mg-5 mg-6 mcg-8 mg-16 1.7 mg-2 mg-2.3 mg-3 mg- mg-18 mg-25 mcg-25 mcg- 3 mg-0.9 mg-2.3 mg-1.5 25 mcg-27.5 mcg-75 mg- mg-1.7 mg-2 mg-5 mcg-5 150 mcg-380 mg-400 mcg- mcg-10 mcg-10 mcg-10 665 mcg-1000 mcg, 0.9 mg-10 mg-11 mg-11 mg-20 mg-1.2 mg-1.3 mg-1.7 mg- mg-20 mg-25 mcg-25 mcg- 1.8 mg-5 mg-6 mcg-7.5 30 mcg-30 mcg-30 mcg-30 mg-8 mg-16 mg-18 mg-25 mcg-45 mcg-45 mcg-45 mcg-25 mcg-25 mcg-27.5 mcg-45 mcg-50 mg-50 mg- mcg-75 mg-150 mcg-380 50 unit-50 unit-55 mcg-55 mg-400 mcg-700 mcg- mcg-72 mg-72 mg-80 mg- 1000 mcg, 0.9 mg-1.2 mg- 80 mg-90 mg-90 mg-110 1.3 mg-2 mg-2 mg-2.3 mg- mg-110 mg-150 mcg-150 5 mcg-6 mcg-8 mg-10 mcg-150 mcg-150 mcg-220 mcg-10 mcg-11 mg-15 mg- mg-220 mg-250 mcg-250 16 mg-20 mg-35 mcg-40 mcg-300 mcg-300 mcg-500 mcg-45 unit-50 mcg-60 mcg-500 mcg-500 unit-500 mcg-72 mg-80 mg-90 mg- unit-2500 unit-2500 unit, 100 mcg-100 mg-150 mcg- 0.9 mg-1.5 mg-1.7 mg-2 150 mcg-200 mcg-210 mg- mg-2.3 mg-3 mg-5 mcg-10 600 mcg-600 unit-3500 mcg-10 mg-11 mg-20 mg- unit, 0.9 mg-1.5 mg-1.7 25 mcg-30 mcg-30 mcg-45 mg-2 mg-2 mg-2 mg-0.9 mcg-45 mcg-50 mg-50 unit- mg-1.5 mg-1.7 mg-2 mg- 55 mcg-72 mg-80 mg-110 2.3 mg-2.3 mg-5 mcg-5 mg-150 mcg-150 mcg-220 mcg-6 mcg-6 mcg-10 mcg- mg-250 mcg-300 mcg-500 10 mcg-10 mcg-10 mcg-10 mcg-500 unit-2500 unit-90 mg-10 mg-11 mg-11 mg-18 mg, 0.9 mg-1.5 mg-1.7 mg- mg-18 mg-20 mg-20 mg-25 2 mg-2.3 mg-3 mg-5 mcg- mcg-25 mcg-30 mcg-30 10 mcg-10 mg-11 mg-20 mcg-30 unit-30 unit-35 mg-25 mcg-30 mcg-30 Oregon Trillium OHP Updated September 1, 2021
124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg-45 mcg-45 mcg-50 mg-150 mg-162 mg-250 mg-50 unit-55 mcg-72 mg- mg-400 unit-25000 unit, 1 80 mg-90 mg-110 mg-150 mcg-1 mg-1 mg-1 mg-2 mcg-150 mcg-220 mg-250 mg-2.5 mg-3.75 mg-4.5 mcg-300 mcg-500 mcg-500 mg-5 mcg-5 mcg-10 mg-10 unit-2500 unit, 0.9 mg-1.5 mg-19 mg-20 mg-50 mg- mg-1.7 mg-2 mg-2.3 mg-3 150 mcg-400 unit-5000 mg-5 mcg-10 mcg-10 mg- unit, 1 mcg-1 mg-1 mg-1 11 mg-20 mg-25 mcg-30 mg-2 mg-2.5 mg-3.75 mg- mcg-30 mcg-45 mcg-45 4.5 mg-5 mcg-5 mcg-10 mcg-50 mg-50 unit-55 mg-11.6 mg-15.8 mg-20 mcg-72 mg-80 mg-90 mg- mg-50 mg-150 mcg-400 150 mcg-150 mcg-220 mg- unit-5000 unit, 1 mcg-1 mg- 250 mcg-300 mcg-500 1 mg-1 mg-2.5 mg-4.5 mg- mcg-500 unit-2500 unit, 0.9 5 mcg-5 mcg-10 mg-10 mg-1.7 mg-2 mg-2 mg-2.3 mg-19 mg-20 mg-50 mg- mg-5 mcg-6 mcg-10 mcg- 150 mcg-400 unit-5000 10 mcg-10 mg-18 mg-20 unit-2 mg-3.75 mg, 1 mg- mg-25 mcg-30 mcg-35 0.5 mg-0.5 mg-1 mg-1 mg- mcg-45 mcg-55 mcg-72 1 mg-1 mg-2 mg-2 mg-2 mg-80 mg-90 mg-100 mg- mg-3.5 mg-4.5 mg-5 mg- 109 mg-150 mcg-150 mcg- 5.1 mg-6 mg-6.5 mcg-7.5 200 mg-250 mcg-300 mcg- mg-10 mg-10 mg-10 mg-13 400 unit-500 mcg-3500 mcg-13 mcg-15 mg-18 mg- unit-30 unit-1.5 mg-11 mg, 24 mcg-25 mg-25 mg-40 0.9 mg-1.7 mg-2 mg-2 mg- mg-60 mcg-60 unit-80 mcg- 2.3 mg-5 mcg-6 mcg-10 80 mg-90 mg-100 mg-100 mcg-10 mg-18 mg-20 mg- mg-120 mg-150 mcg-165 25 mcg-1.5 mg-10 mcg-11 mg-200 mcg-200 mcg-200 mg-30 mcg-30 unit-35 mcg-275 mcg-300 mcg-400 mcg-45 mcg-55 mcg-72 mcg-400 unit-5000 unit, 1 mg-80 mg-90 mg-100 mg- mg-1 mg-1 mg-1 mg-2.5 109 mg-150 mcg-150 mcg- mg-5 mg-5 mg-7.5 mg-10 200 mg-250 mcg-300 mcg- mcg-12.5 mg-12.5 mg-13.5 400 unit-500 mcg-3500 mg-25 mcg-25 mg-37.5 unit, 0.9 mg-2 mg-1.5 mg- mcg-40 mcg-40 mcg-40 1.7 mg-2 mg-2.3 mg-5 mg-40 mg-40 mg-40 mg-40 mcg-6 mcg-10 mcg-10 mg-50 mcg-50 mcg-50 unit- mcg-10 mg-11 mg-18 mg- 75 mcg-100 mg-100 mg- 20 mg-25 mcg-30 mcg-30 200 mcg-200 unit-250 mcg- unit-35 mcg-45 mcg-55 250 mg-5000 unit, 1 mg-1 mcg-72 mg-80 mg-90 mg- mg-1.5 mg-1.7 mg-3 mcg-5 100 mg-109 mg-150 mcg- mg-10 unit-20 mg-50 mg- 150 mcg-200 mg-250 mcg- 100 mcg-125 mg-150 mcg- 300 mcg-400 unit-500 mcg- 400 unit-5000 unit, 1 mg-1 3500 unit, 1 mcg-0.1 mg- mg-1.667 mg-1.667 mg- 0.25 mg-0.4 mg-2.2 mg-5 1.667 mg-1.667 mg-2.5 mg-6.15 mg-7.2 mg-12.5 mg-2.667 mcg-3.333 mg- mg-12.5 unit-15 mg-15 mg- 4.167 mcg-4.167 mg-5 mg- 15 mg-24.3 mg-25 mg-25 5 unit-8.333 mg-8.333 mg- mg-25 mg-50 mcg-50 mg- 8.333 mg-8.333 mg-10 mg- 50 mg-50 mg-53.5 mg-150 10 mg-25 mg-33.333 mg- Oregon Trillium OHP Updated September 1, 2021
125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 33.333 unit-37.5 mcg-40 mcg-400 unit-5000 unit, 1 mg-50 mg-66.667 mcg- mg-2 mg-5 mcg-1 mg-2.5 244.333 mg-1000 mcg- mg-2.5 mg-5 mg-5 mg-7.5 1666.667 unit, 1 mg-1 mg- mg-10 mcg-12.5 mg-12.5 5 mg-5 mg-6 mg-7.5 mg-10 mg-13.5 mcg-25 mcg-25 mg-15 mg-18 mg-25 mcg- mcg-37.5 mcg-40 mg-40 25 mg-25 mg-25 mg-25 mg-40 mg-40 mg-40 mg-40 mg-25 mg-25 mg-25 unit- mg-40 mg-50 mcg-50 mcg- 30 mcg-35 mg-50 mcg-50 50 mg-50 unit-75 mcg-100 mg-50 mg-75 mcg-100 mg-200 mg-200 unit-250 mcg-100 mcg-100 mg-150 mcg-250 mg-5000 unit, 1 mcg-150 mcg-150 mg-250 mg-2.5 mg-1 mg-1 mg-1 mcg-400 mcg-400 unit- mg-5 mg-5 mg-7.5 mg-10 10000 unit, 1 mg-1.5 mg- mcg-12.5 mg-12.5 mg-13.5 1.7 mg-2 mg-5 mg-5 mg-6 mg-25 mcg-25 mg-37.5 mcg-10 mg-15 mg-30 unit- mcg-40 mcg-40 mcg-40 50 mg-60 mg-200 mcg-200 mg-40 mg-40 mg-40 mg-40 mg-300 mcg-400 mcg- mg-50 mcg-50 mcg-50 unit- 1000 unit-2500 unit, 1 mg- 75 mcg-100 mg-100 mg- 1.5 mg-2.5 mg-2.5 mg-2.5 200 mcg-200 unit-250 mcg- mg-3.75 mg-4 mcg-4 mg-5 250 mg-5000 unit, 1 mg-2.5 mg-5 mg-5 mg-5 mg-7.5 mg-2.5 mg-5 mcg-5 mg-5 mg-7.5 unit-12.5 mg-15 mg-5 mg-5 mg-12.5 mg- mg-15 mg-25 mg-25 mg-30 12.5 mg-15 mcg-15 mg-15 mg-50 mg-64 mg-100 mcg- mg-15 mg-15 mg-15 mg-15 130 mg-500 unit-2500 mg-15 mg-25 mcg-25 mg- mcg-2500 unit, 1 mg-1.67 25 mg-25 mg-25 mg-35 mg-1.67 mg-1.67 mg-1.67 mg-35 mg-35 mg-37.5 mg-2.5 mg-2.67 mcg-4.17 mcg-50 mcg-50 mg-50 unit- mcg-4.17 mg-5 mg-5 unit- 75 mcg-100 mg-100 unit- 8.33 mg-8.33 mg-8.33 mg- 125 mcg-150 mg-175 mcg- 8.33 mg-10 mg-10 mg-20 200 mcg-250 mcg-5000 mg-25 mg-33.33 mg-33.33 unit, 1 mg-2.5 mg-5 mg-5 unit-37.5 mcg-50 mg-66.67 mg-5 mg-2.5 mg-5 mcg-5 mcg-66.67 mcg-100 mg- mg-12.5 mg-12.5 mg-15 1666.67 unit, 1 mg-10 mg- mcg-15 mg-15 mg-15 mg- 25 mg-25 mg-25 mg-25 15 mg-15 mg-15 mg-15 mg-33 mg-50 mcg-50 mg- mg-25 mcg-25 mg-25 mg- 60 mg-100 unit-125 mg- 25 mg-25 mg-35 mg-35 200 unit-300 mcg-500 mg- mg-35 mg-37.5 mcg-50 5000 unit, 1 mg-2 mg-3.5 mcg-50 mg-50 unit-75 mcg- mg-4.5 mg-5 mg-5 mg-5 100 mg-100 unit-125 mcg- mg-5.1 mg-6 mg-6.5 mcg- 150 mg-175 mcg-200 mcg- 7.5 mg-10 mg-10 mg-10 250 mcg-5000 unit, 1 mg- mg-10 mg-13 mcg-13 mcg- 3.5 mg-5 mg-5 mg-5.1 mg- 15 mg-18 mcg-18 mg-25 2 mg-4.5 mg-5 mg-6 mg- mg-25 mg-40 mg-60 mcg- 6.5 mcg-7.5 mg-10 mg-10 60 unit-72 mg-80 mcg-80 mg-10 mg-10 mg-13 mcg- mg-80 mg-100 mg-120 mg- 13 mcg-15 mg-18 mcg-18 150 mcg-165 mg-200 mcg- mg-25 mg-25 mg-40 mg-60 200 mcg-200 mcg-200 mcg-60 unit-72 mg-80 mcg- mcg-275 mcg-300 mcg-400 80 mg-80 mg-100 mg-120 Oregon Trillium OHP Updated September 1, 2021
126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mg-150 mcg-165 mg-200 mg-2 mg-2 mg-3 mg-5 mg- mcg-200 mcg-200 mcg-200 15 mg-18 mcg-18 mg-20 mcg-275 mcg-300 mcg-400 mcg-30 mcg-45 unit-90 mg- mcg-400 unit-5000 unit, 1.1 100 mg-105 mcg-120 mcg- mg-1.35 mg-2 mg-5 mg-5 120 mg-210 mg-400 mcg- mg-6.5 mg-10 mg-10 mg- 400 unit-600 mcg-1500 12 mcg-15 mg-20 mg-30 unit, 1.2 mg-1.7 mg-2 mg-2 mg-30 unit-50 mg-75 mg- mg-3 mg-5 mg-16 mg-18 100 mg-100 mg-150 mcg- mcg-20 mcg-30 mcg-90 150 mg-400 mcg-400 unit- mg-100 mg-105 mcg-120 5000 unit, 1.1 mg-1.7 mg-2 mcg-120 mg-210 mg-400 mg-2 mg-3 mg-5 mg-10 mcg-400 unit-600 mcg- mg-14 mg-15 mg-18 mcg- 3500 unit-45 unit-15 mg, 20 mcg-30 mcg-33 unit-70 1.333 mg-0.333 mg-0.333 mcg-75 mg-100 mg-120 mg-0.833 mg-1.333 mg- mcg-120 mg-240 mg-400 1.666 mg-1.666 mg-1.666 mcg-400 unit-3000 unit, 1.1 mg-3.333 mg-3.333 mg- mg-5 mg-0.5 mg-1.1 mg- 3.333 mg-3.333 mg-3.333 2.3 mg-5 mg-8 mg-14 mg- mg-3.333 mg-3.333 mg- 15 mg-15.8 mg-20 mg-22 3.333 mg-5 mg-5 mg-6.666 mcg-25 mcg-30 mcg-50 mg-6.666 mg-6.666 mg- mcg-50 mcg-50 mcg-52 8.333 mcg-8.333 mg-8.333 mcg-72 mg-80 mg-100 mg- mg-8.333 mg-8.333 mg- 100 mg-150 mcg-300 mcg- 8.333 mg-8.333 mg-8.333 300 mg-400 mcg-1050 mg-8.333 mg-8.333 mg- mcg, 1.2 mg-1.7 mg-2 mg- 8.333 mg-8.333 mg-8.333 2 mg-3 mg-5 mg-15 mg-16 mg-8.333 mg-10 mg- mg-18 mcg-20 mcg-22.5 11.666 mg-16.666 mcg- unit-30 mcg-60 mg-100 16.666 mcg-16.666 mg-20 mg-110 mcg-120 mcg-120 mg-25 mcg-33.333 mcg- mg-210 mg-300 mcg-400 33.333 mg-33.333 mg- mcg-700 unit-3500 unit, 1.2 33.333 mg-33.333 mg- mg-1.7 mg-2 mg-2 mg-3 33.333 mg-33.333 mg-50 mg-5 mg-15 mg-16 mg-18 mcg-83.333 mg-83.333 mcg-20 mcg-22.5 unit-30 unit-133.333 mcg-133.333 mcg-60 mg-110 mcg-120 unit-333.333 mg-333.333 mcg-120 mg-210 mg-300 mg-5000 unit, 1.35 mg-1.7 mcg-400 mcg-700 unit- mg-2 mg-2 mg-3 mg-15 3500 unit, 1.2 mg-1.7 mg-2 mg-16 mg-18 mcg-18 mg- mg-2 mg-3 mg-5 mg-15 20 mcg-22.5 unit-60 mg-75 mg-16 mg-18 mcg-20 mcg- mcg-110 mcg-120 mcg-140 30 mcg-45 unit-90 mg-100 mg-210 mg-300 mcg-400 mg-105 mcg-120 mcg-120 mcg-700 unit-3500 unit, mg-210 mg-400 mcg-400 1.35 mg-1.7 mg-3 mg-15 unit-600 mcg-3500 unit, 1.2 mg-18 mcg-2 mg-2 mg-16 mg-1.7 mg-2 mg-2 mg-3 mg-18 mg-20 mcg-22.5 mg-5 mg-15 mg-16 mg-18 unit-60 mg-75 mcg-110 mcg-20 mcg-30 mcg-45 mcg-120 mcg-140 mg-210 unit-90 mg-99 mg-105 mg-300 mcg-400 mcg-700 mcg-120 mcg-120 mg-210 unit-3500 unit, 1.5 mg-0.5 mg-400 mcg-400 unit-600 mg-0.75 mg-1.25 mg-1.75 mcg-3500 unit, 1.2 mg-1.7 mg-3.75 mg-5 mg-5 mg-5 Oregon Trillium OHP Updated September 1, 2021
127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mg-5 mg-5 mg-6.25 mg- mcg-35 mcg-45 mcg-50 11.25 mcg-12.5 mcg-12.5 mg-50 unit-72 mg-80 mg- mcg-12.5 mg-25 mcg-30 90 mg-110 mg-150 mcg- mg-32 mg-50 mcg-75 mcg- 150 mcg-220 mg-250 mcg- 75 mg-200 mcg-200 mg- 300 mcg-500 mcg-600 200 unit, 1.5 mg-1.5 mg- mcg-600 unit-2500 unit, 1.5 1.7 mg-1.7 mg-2 mg-2 mg- mg-1.5 mg-5 mg-15 unit-20 2 mg-2 mg-2 mg-3 mg-3 mg-20 mg-30 mg-400 unit- mg-5 mcg-5 mcg-10 mcg- 30 mg-50 mcg-400 mcg- 10 mcg-10 mcg-10 mcg-10 2500 unit, 1.5 mg-1.7 mg-2 mg-10 mg-15 mg-15 mg-20 mcg-2 mg-2 mg-2.5 mg-5 mcg-20 mcg-20 mg-20 mg- mcg-6 mcg-10 mcg-10 25 mcg-25 mcg-30 mcg-30 mcg-10 mg-15 mg-18 mg- mcg-45 unit-45 unit-48 mg- 20 mcg-20 mg-25 mcg-25 48 mg-60 mg-60 mg-72 mcg-25 mcg-30 mcg-30 mg-72 mg-75 mcg-75 mcg- unit-36.3 mg-40 mg-60 mg- 80 mg-80 mg-100 mg-100 100 mg-109 mg-150 mcg- mg-150 mcg-150 mcg-150 150 mcg-162 mg-400 mcg- mcg-150 mcg-150 mcg-150 400 unit-5000 unit, 1.5 mg- mcg-200 mg-200 mg-250 1.7 mg-2 mg-2 mg-2 mg-2 mcg-250 mcg-300 mcg-300 mg-5 mcg-6 mcg-10 mcg- mcg-400 mcg-400 mcg-400 10 mcg-10 mg-15 mg-18 unit-400 unit-3500 unit- mg-20 mcg-20 mg-25 mcg- 3500 unit, 1.5 mg-1.5 mg- 30 mcg-30 unit-60 mg-72 1.7 mg-1.7 mg-2 mg-2 mg- mg-75 mcg-80 mg-100 mg- 2 mg-2 mg-2 mg-6 mcg-6 108 mg-120 mcg-150 mcg- mcg-10 mcg-10 mcg-10 150 mcg-162 mg-250 mcg- mcg-10 mcg-10 mg-10 mg- 400 mcg-400 unit-5000 15 mg-15 mg-20 mcg-20 unit, 1.5 mg-1.7 mg-2 mg-2 mcg-20 mg-20 mg-25 mcg- mg-2 mg-2 mg-5 mcg-6 25 mcg-30 mcg-30 mcg-30 mcg-10 mcg-10 mcg-10 unit-30 unit-60 mg-60 mg- mg-15 mg-18 mg-20 mcg- 72 mg-72 mg-75 mcg-75 20 mg-25 mcg-30 mcg-30 mcg-80 mg-80 mg-100 mg- unit-60 mg-72 mg-75 mcg- 100 mg-120 mcg-120 mcg- 80 mg-100 mg-109 mg-120 150 mcg-150 mcg-150 mcg-150 mcg-150 mcg-162 mcg-150 mcg-162 mg-162 mg-250 mcg-300 mcg-400 mg-250 mcg-250 mcg-300 mcg-400 unit-3500 unit, 1.5 mcg-300 mcg-400 mcg-400 mg-1.7 mg-2 mg-2 mg-2 mcg-400 unit-400 unit-3500 mg-2 mg-5 mcg-6 mcg-10 unit-3500 unit, 1.5 mg-1.5 mcg-10 mcg-10 mg-15 mg- mg-1.7 mg-1.7 mg-2 mg-2 20 mcg-20 mg-30 mcg-30 mg-6 mcg-6 mcg-10 mg-10 unit-60 mg-72 mg-75 mcg- mg-15 mg-15 mg-20 mg-20 80 mg-100 mg-109 mg-120 mg-27 mg-27 mg-30 unit- mg-150 mcg-150 mcg-162 30 unit-60 mg-60 mg-400 mg-250 mcg-300 mcg-400 mcg-400 mcg-400 unit-400 mcg-400 unit-3500 unit, 1.5 unit-450 mg-450 mg-5000 mg-1.7 mg-2 mg-2 mg-2 unit-5000 unit, 1.5 mg-1.5 mg-2 mg-5 mcg-6 mcg-9 mg-1.7 mg-2 mg-2.3 mg-3 mg-10 mcg-10 mcg-10 mg- mg-5 mcg-10 mcg-10 mg- 15 mg-20 mg-25 mcg-25 12 mg-20 mg-30 mcg-30 mcg-25 mcg-30 mcg-36 Oregon Trillium OHP Updated September 1, 2021
128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mg-40 mg-50 unit-77 mg- mcg-10 mcg-10 mcg-10 100 mg-100 mg-120 mcg- mg-15 mg-18 mg-20 mcg- 120 mg-150 mcg-150 mcg- 20 mg-25 mcg-30 mcg-30 250 mcg-400 mcg-400 unit- unit-60 mg-65 mcg-72 mg- 3000 unit, 1.5 mg-1.7 mg-2 80 mg-100 mg-109 mg-150 mg-2 mg-2 mg-3 mg-5 mcg-150 mcg-160 mcg-162 mcg-10 mcg-10 mcg-10 mg-400 mcg-400 unit-5000 mg-15 mg-20 mcg-20 mg- unit, 1.5 mg-1.7 mg-2 mg-2 25 mcg-30 mcg-45 unit-48 mg-2 mg-3.5 mg-5 mcg-6 mg-60 mg-72 mg-75 mcg- mcg-10 mcg-10 mcg-10 80 mg-100 mg-150 mcg- mg-15 mg-18 mg-20 mcg- 150 mcg-150 mcg-200 mg- 20 mg-25 mcg-30 mcg-30 250 mcg-300 mcg-400 unit-60 mg-65 mcg-72 mg- mcg-400 unit-3500 unit, 1.5 80 mg-100 mg-109 mg-150 mg-1.7 mg-2 mg-2 mg-2 mcg-150 mcg-160 mg-162 mg-3 mg-5 mcg-10 mcg-10 mg-400 mcg-400 unit-5000 mcg-10 mg-15 mg-20 mcg- unit, 1.5 mg-1.7 mg-2 mg-2 20 mg-25 mcg-30 mcg-45 mg-2 mg-5 mcg-10 mcg-10 unit-48 mg-60 mg-72 mg- mcg-15 mg-18 mg-2 mg-6 75 mcg-80 mg-100 mg-150 mcg-10 mg-20 mcg-20 mg- mcg-150 mcg-150 mcg-200 25 mcg-30 mcg-30 unit-60 mg-250 mcg-400 mcg-400 mg-72 mg-75 mcg-80 mg- unit-5000 unit, 1.5 mg-1.7 100 mg-109 mg-120 mcg- mg-2 mg-2 mg-2 mg-3.5 150 mcg-150 mcg-162 mg- mg-5 mcg-6 mcg-10 mcg- 250 mcg-300 mcg-400 10 mcg-10 mcg-15 mg-18 mcg-400 unit-3500 unit, 1.5 mg-20 mcg-20 mg-25 mcg- mg-1.7 mg-2 mg-2 mg-2 30 mcg-30 unit-60 mg-65 mg-5 mg-6 mcg-10 mg-15 mcg-72 mg-80 mg-100 mg- mg-18 mg-20 mcg-22.5 109 mg-150 mcg-150 mcg- unit-25 mcg-30 mcg-50 mg- 160 mcg-162 mg-400 mcg- 60 mg-120 mcg-400 mcg- 400 unit-2500 unit, 1.5 mg- 500 mg-1000 unit-2500 1.7 mg-2 mg-2 mg-2 mg- unit, 1.5 mg-1.7 mg-2 mg-2 3.5 mg-5 mcg-6 mcg-10 mg-2 mg-5 mg-6 mcg-10 mcg-10 mcg-10 mg-15 mg- mg-15 mg-18 mg-20 mcg- 18 mg-20 mcg-20 mg-25 25 mcg-30 mcg-30 unit-50 mcg-30 mcg-30 unit-50 mg-60 mg-120 mcg-400 mg-65 mcg-72 mg-80 mg- mcg-400 unit-450 mg-2500 100 mg-109 mg-150 mcg- unit, 1.5 mg-1.7 mg-2 mg-2 150 mcg-160 mcg-162 mg- mg-2 mg-5 mg-6 mcg-10 400 mcg-400 unit-2500 mg-15 mg-18 mg-20 mcg- unit, 1.5 mg-1.7 mg-2 mg-2 25 mcg-30 mcg-30 unit-50 mg-2 mg-3.5 mg-5 mcg-6 mg-60 mg-120 mcg-400 mcg-10 mcg-10 mcg-10 mcg-450 mg-1000 unit- mg-15 mg-18 mg-20 mcg- 2500 unit, 1.5 mg-1.7 mg-2 20 mg-25 mcg-30 mcg-30 mg-2 mg-2 mg-5 mg-6 unit-60 mg-65 mcg-72 mg- mcg-10 mg-15 mg-18 mg- 80 mg-100 mg-109 mg-150 20 mcg-25 mcg-30 mcg-30 mcg-150 mcg-160 mcg-162 unit-50 mg-60 mg-120 mg-400 mcg-400 unit-2500 mcg-400 mcg-450 mg-800 unit, 1.5 mg-1.7 mg-2 mg-2 unit-2500 unit, 1.5 mg-1.7 mg-2 mg-3.5 mg-5 mcg-6 mg-2 mg-2 mg-2 mg-6 Oregon Trillium OHP Updated September 1, 2021
129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg-10 mg-15 mg-18 mg- 5000 unit, 1.5 mg-1.7 mg-2 20 mcg-20 mg-22.5 unit-25 mg-2 mg-2.5 mg-6 mcg-10 mcg-60 mg-120 mcg-150 mcg-10 mcg-10 mcg-10 mcg-300 mcg-400 mcg-500 mg-15 mg-20 mg-30 mcg- mg-1000 unit-2500 unit, 1.5 30 unit-40 mg-60 mg-100 mg-1.7 mg-2 mg-2 mg-2 mg-100 mg-130 mg-150 mg-6 mcg-10 mg-20 mcg- mcg-400 mcg-400 unit- 20 mg-25 mcg-27 mg-30 5000 unit, 1.5 mg-1.7 mg-2 mcg-60 mg-120 mcg-400 mg-2 mg-3 mg-3.5 mg-4 mcg-400 unit-450 mg-5250 mg-5 mcg-10 mcg-10 mcg- unit-15 mg-30 unit, 1.5 mg- 10 mg-15 mg-20 mcg-20 1.7 mg-2 mg-2 mg-2 mg-6 mg-25 mcg-30 mcg-45 unit- mcg-8 mg-8 mg-9 mg-10 48 mg-60 mg-72 mg-80 mcg-10 mg-15 mcg-15 mg-100 mg-130 mcg-150 mcg-15 mg-20 mg-30 mcg- mcg-150 mcg-160 mcg-200 30 unit-40 mg-60 mg-90 mg-400 mcg-400 unit-5000 mg-150 mcg-400 mcg-400 unit, 1.5 mg-1.7 mg-2 mg-2 unit-5000 unit, 1.5 mg-1.7 mg-3 mg-3.5 mg-4 mg-5 mg-2 mg-2 mg-2.5 mg-3 mcg-10 mcg-10 mcg-10 mg-4 mg-5 mcg-10 mcg-10 mg-15 mg-20 mcg-20 mg- mcg-10 mg-15 mg-20 mcg- 25 mcg-30 mcg-45 unit-48 20 mg-25 mcg-30 mcg-45 mg-60 mg-72 mg-80 mg- unit-48 mg-60 mg-72 mg- 100 mg-130 mcg-150 mcg- 80 mg-100 mg-130 mcg- 150 mcg-160 mg-200 mg- 150 mcg-150 mcg-160 400 mcg-400 unit-5000 mcg-200 mg-400 mcg-400 unit, 1.5 mg-1.7 mg-2 mg-2 unit-5000 unit, 1.5 mg-1.7 mg-3 mg-4 mg-7.5 mcg-10 mg-2 mg-2 mg-2.5 mg-5 mg-10 mg-10 mg-10 mg-15 mcg-6 mcg-10 mcg-10 mcg-15 mcg-15 mg-20 mg- mcg-10 mg-15 mcg-15 22.5 mg-25 mg-30 mcg-30 mcg-15 mcg-15 mg-18 mg- mcg-48 mg-60 unit-75 mg- 20 mg-25 mcg-30 unit-34 80 mg-100 mg-105 mcg- mg-37.5 mg-45 mcg-60 112.5 mcg-120 mg-150 mg-80 mcg-100 mg-125 mcg-180 mg-200 mg-225 mg-150 mcg-162 mg-400 mcg-300 mcg-350 mcg-400 mcg-400 unit-6000 unit, 1.5 mcg-400 unit-3000 unit- mg-1.7 mg-2 mg-2 mg-2.5 3000 unit, 1.5 mg-1.7 mg-2 mg-5 mg-6 mcg-10 mcg-10 mg-2 mg-4 mg-6 mcg-10 mcg-10 mcg-10 mg-15 mg- mg-15 mg-18 mg-20 mg-30 18 mg-20 mg-25 mcg-25 mg-50 unit-70 mcg-75 mcg- mcg-25 mcg-25 mcg-30 80 mcg-100 mg-120 mcg- mcg-30 unit-36.3 mg-40 150 mcg-162 mg-180 mg- mg-60 mg-100 mg-125 mg- 400 mcg-1000 unit-2500 150 mcg-162 mg-400 mcg- unit, 1.5 mg-1.7 mg-2 mg-2 400 unit-5000 unit, 1.5 mg- mg-5 mcg-10 mcg-10 mcg- 1.7 mg-2 mg-2 mg-2.5 mg- 10 mg-0.5 mg-2.3 mg-6 6 mcg-10 mcg-10 mcg-10 mcg-11 mg-18 mg-20 mg- mcg-10 mg-15 mg-18 mg- 20 mg-25 mcg-30 unit-35 20 mg-30 mcg-30 unit-34 mcg-45 mcg-50 mg-55 mg-37.5 mg-60 mg-100 mcg-72 mg-75 mcg-80 mg- mg-100 mg-130 mg-150 150 mcg-400 mcg-400 unit- mcg-400 mcg-400 unit- 3500 unit-200 mg-30 mcg- Oregon Trillium OHP Updated September 1, 2021
130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 60 mg, 1.5 mg-1.7 mg-2 18 mg-20 mcg-20 mg-25 mg-2 mg-6 mcg-0.5 mg-2.3 mcg-30 mcg-30 unit-60 mg- mg-5 mcg-10 mcg-10 mcg- 65 mcg-72 mg-80 mg-100 10 mg-11 mg-18 mg-20 mg-109 mg-150 mcg-150 mg-20 mg-25 mcg-30 mcg- mcg-160 mcg-162 mg-400 30 unit-35 mcg-45 mcg-50 mcg-400 unit-600 mcg- mg-55 mcg-60 mg-72 mg- 2500 unit, 1.5 mg-1.7 mg-2 75 mcg-80 mg-150 mcg- mg-5 mg-6 mcg-10 mg-15 200 mg-400 mcg-400 unit- mg-18 mg-30 unit-50 mg- 3500 unit, 1.5 mg-1.7 mg-2 60 mg-400 mcg-400 unit- mg-2 mg-6 mcg-0.9 mg-2.3 450 mg-2500 unit, 1.5 mg- mg-5 mcg-10 mcg-10 mcg- 1.7 mg-2 mg-6 mcg-10 mg- 10 mg-11 mg-18 mg-20 15 mg-20 mg-27 mg-30 mg-25 mcg-30 mcg-30 unit-60 mg-400 mcg-400 unit-35 mcg-45 mcg-55 unit-450 mg-2500 unit-2500 mcg-72 mg-80 mg-90 mg- unit, 1.5 mg-1.7 mg-2 mg-6 100 mg-109 mg-150 mcg- mcg-10 mg-15 mg-20 mg- 150 mcg-200 mg-250 mcg- 27 mg-30 unit-60 mg-400 300 mcg-400 unit-500 mcg- mcg-400 unit-450 mg-5000 3500 unit, 1.5 mg-1.7 mg-2 unit, 1.5 mg-1.7 mg-2 mg-6 mg-4 mg-4 mg-10 mg-15 mcg-10 mg-18 mg-20 mg- mg-18 mcg-20 mg-30 mcg- 30 unit-60 mg-75 mg-400 50 unit-70 mcg-75 mcg-80 mcg-400 unit-5000 unit, 1.5 mcg-100 mg-120 mcg-150 mg-1.7 mg-2 mg-6 mcg-10 mcg-162 mg-180 mg-400 mg-20 mg-30 unit-45 mg- mcg-1000 unit-2500 unit, 60 mg-400 mcg-400 unit- 1.5 mg-1.7 mg-2 mg-4 mg- 3000 unit, 1.5 mg-1.7 mg- 6 mg-10 mg-15 mg-20 mg- 2.5 mg-2.5 mg-5 mcg-7.5 25 mcg-30 mcg-60 unit-70 mg-10 mg-20 mg-25 mcg- mcg-75 mcg-80 mcg-100 30 unit-50 mcg-50 mg-50 mg-120 mcg-150 mcg-180 mg-60 mg-75 mcg-75 mcg- mg-200 mg-400 mcg-1000 100 mcg-100 mg-100 mg- unit-2500 unit, 1.5 mg-1.7 200 mcg-200 unit-250 mcg- mg-2 mg-4 mg-6 mg-10 2500 unit, 1.5 mg-1.7 mg-6 mg-15 mg-20 mg-25 mcg- mcg-10 mg-10 mg-12.5 30 mcg-60 unit-75 mcg-80 mg-20 mg-60 mg-300 mcg- mcg-100 mg-105 mcg-120 800 mcg, 1.5 mg-2 mg-1.7 mcg-150 mcg-162 mg-180 mg-2 mcg-2 mg-2.5 mg-5 mg-400 mcg-1000 unit- mcg-6 mcg-10 mcg-10 mg- 2500 unit, 1.5 mg-1.7 mg-2 18 mg-20 mcg-20 mg-25 mg-5 mcg-0.5 mg-2.3 mg-3 mcg-25 mcg-30 mcg-30 mg-10 mcg-10 mg-11 mg- unit-10 mcg-15 mg-25 mcg- 20 mg-20 mg-25 mcg-30 36.3 mg-40 mg-60 mg-100 mcg-30 mcg-45 mcg-45 mg-109 mg-150 mcg-150 mcg-50 mg-50 unit-55 mcg-162 mg-400 mcg-400 mcg-60 mg-72 mg-80 mg- unit-5000 unit, 1.5 mg-2 150 mcg-150 mcg-220 mg- mg-1.7 mg-2 mg-2 mg-3 250 mcg-300 mcg-400 mg-5 mcg-10 mcg-10 mcg- mcg-500 unit-2500 unit, 1.5 10 mg-15 mg-20 mcg-20 mg-1.7 mg-2 mg-5 mcg-2 mg-25 mcg-30 mcg-45 unit- mg-2 mg-3.5 mg-6 mcg-10 48 mg-60 mg-72 mg-75 mcg-10 mcg-10 mg-15 mg- mcg-80 mg-100 mg-150 Oregon Trillium OHP Updated September 1, 2021
131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg-150 mcg-150 mcg-200 mg-18 mg-20 mg-25 mcg- mg-250 mcg-300 mcg-400 25 mcg-25 mcg-25 mcg-30 mcg-400 unit-3500 unit, 1.5 mcg-30 unit-36.3 mg-40 mg-2 mg-2.5 mg-5 mcg-9 mg-60 mg-100 mg-125 mg- mg-10 mcg-10 mcg-10 mg- 150 mcg-150 mcg-162 mg- 15 mg-20 mg-25 mcg-25 400 mcg-400 unit-5000 mcg-25 mcg-1.7 mg-3 mg- unit, 1.7 mg-2 mg-2 mg-2.5 10 mcg-30 mcg-45 unit-48 mg-6 mcg-10 mcg-10 mcg- mg-60 mg-72 mg-80 mg- 10 mcg-15 mg-18 mg-20 100 mcg-100 mg-150 mcg- mg-3 mg-5 mcg-10 mg-25 200 mcg-200 mg-400 unit- mcg-25 mcg-25 mcg-25 6000 unit, 1.5 mg-2.3 mg-3 mcg-30 mcg-30 unit-36.3 mg-1.5 mg-1.7 mg-2 mg-5 mg-40 mg-60 mg-100 mg- mcg-10 mcg-10 mg-12 mg- 125 mg-150 mcg-150 mcg- 20 mg-30 mcg-30 mcg-35 162 mg-400 mcg-400 unit- mcg-45 mcg-50 mg-50 5000 unit, 1.7 mg-2 mg-2 unit-72 mg-80 mg-90 mg- mg-3 mg-3.5 mg-4 mg-5 110 mg-150 mcg-150 mcg- mcg-10 mcg-10 mcg-10 200 mcg-220 mg-250 mcg- mg-15 mg-15 mg-20 mcg- 300 mcg-500 mcg-600 unit- 20 mg-25 mcg-30 mcg-45 2500 unit, 1.6 mg-1.7 mg-2 unit-46 mg-60 mg-60 mg- mg-2 mg-2 mg-5 mg-6 72 mg-100 mg-130 mcg- mcg-10 mg-15 mg-18 mg- 150 mcg-150 mcg-160 20 mcg-22.5 unit-25 mcg- mcg-200 mg-400 mcg-400 30 mcg-50 mg-60 mg-120 unit-5000 unit, 1.8 mg-0.5 mcg-400 mcg-500 mg- mg-1.1 mg-1.1 mg-2 mg-2 1000 unit-2500 unit, 1.666 mg-5 mcg-6 mcg-8 mg-10 mg-0.666 mg-1 mg-1.666 mcg-10 mcg-14 mg-15 mg- mg-1.666 mg-2.5 mg-2.666 18 mcg-18 mg-20 mg-32 mcg-3.333 mg-3.333 mg- mcg-35 unit-40 mcg-50 3.333 mg-3.333 mg-5 mg-5 mcg-50 mcg-72 mg-75 mg- unit-8.333 mg-10 mg- 80 mg-100 mg-150 mcg- 16.666 mg-16.666 mg-20 200 mg-400 mcg-800 unit- mg-42.666 mg-66.666 3500 unit, 1.8 mg-0.9 mg- mcg-86.666 mg-333.333 1.1 mg-1.1 mg-2 mg-2 mg- unit-1666.666 mcg- 5 mcg-6 mcg-8 mg-10 mcg- 1666.666 unit, 1.7 mg-0.9 10 mcg-14 mg-15 mg-18 mg-1.2 mg-1.3 mg-1.8 mg- mg-20 mg-25 mcg-35 unit- 5 mg-6 mcg-7.5 mg-8 mg- 40 mcg-50 mcg-50 mcg-55 16 mg-18 mg-25 mcg-25 mcg-72 mg-75 mg-80 mg- mcg-25 mcg-27.5 mcg-75 100 mg-150 mcg-150 mcg- mg-150 mcg-380 mg-400 400 mcg-500 mg-800 unit- mcg-700 mcg-1000 mcg, 3500 unit, 1.875 mg-2 mg-2 1.7 mg-2 mg-2 mg-2 mg-5 mg-2.1 mg-2.5 mg-5 mcg- mcg-5 mg-5 mg-10 mg-15 7.5 mcg-10 mcg-10 mcg-10 mg-15 mg-20 mcg-25 mcg- mg-10 mg-10 mg-10 mg- 30 mcg-30 unit-50 mg-60 12.5 mg-15 mg-25 mg-25 mg-120 mcg-400 mcg-450 mg-27 mg-36 mg-37.5 mg-500 unit-2500 unit, 1.7 mcg-40 mg-45 unit-70 mcg- mg-2 mg-2 mg-2.5 mg-3 75 mcg-77 mg-80 mcg-100 mg-5 mcg-6 mcg-10 mcg- mg-120 mcg-120 mg-150 10 mcg-10 mcg-10 mg-15 mcg-150 mcg-250 mg-300 Oregon Trillium OHP Updated September 1, 2021
132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg-400 mcg-400 unit- mcg-50 mcg-50 mcg-50 5000 unit, 1.9 mg-2 mg-2 mcg-50 mg-55 mcg-72 mg- mg-2.1 mg-2.5 mg-7.5 80 mg-100 mg-150 mcg- mcg-10 mg-12.5 mg-15 150 mcg-300 mcg-400 mg-18 mg-25 mg-30 unit- mcg-500 mg-800 unit-3500 50 mg-60 mg-70 mcg-80 unit, 2 mg-0.5 mg-1.5 mg- mcg-200 mcg-200 mg-400 1.7 mg-2 mg-2.3 mg-5 mcg-400 unit-2500 unit, 1.9 mcg-6 mcg-10 mcg-10 mg-2 mg-2 mg-2.1 mg-2.5 mcg-10 mg-11 mg-15 mg- mg-7.5 mcg-12.5 mg-15 18 mg-20 mg-20 mg-25 mg-18 mg-25 mg-30 unit- mcg-30 mcg-30 unit-35 50 mg-60 mg-70 mcg-80 mcg-45 mcg-50 mg-55 mcg-150 mcg-300 mg-400 mcg-60 mg-72 mg-75 mcg- mcg-400 unit-2500 unit, 1.9 80 mg-150 mcg-200 mg- mg-2 mg-2 mg-2.125 mg- 400 mcg-400 unit-3500 2.5 mg-7.5 mcg-12.5 mg- unit, 2 mg-0.5 mg-1.5 mg- 15 mg-18 mg-25 mg-30 1.7 mg-2 mg-2.3 mg-5 unit-32 mg-50 mg-60 mg- mcg-6 mcg-10 mcg-10 70 mcg-80 mcg-200 mcg- mcg-10 mg-11 mg-18 mg- 300 mg-400 mcg-400 unit- 20 mg-20 mg-25 mcg-30 2500 unit, 10 mg-1.5 mg- mcg-30 unit-35 mcg-45 1.7 mg-6 mcg-10 mg-15 mcg-50 mg-55 mcg-60 mg- mg-20 mg-30 unit-70 mcg- 72 mg-75 mcg-80 mg-150 80 mg-300 mcg-800 mcg- mcg-200 mg-400 mcg-400 2000 unit, 100 mcg-200 unit-3500 unit, 2 mg-0.5 unit-250 mg-5000 unit, 113 mg-1.5 mg-1.7 mg-2.3 mg- mg-0.4 mg-17.4 mg-100 3 mg-5 mcg-10 mcg-10 unit-7160 unit, 12 mg-1.25 mg-11 mg-12.5 mcg-20 mg-1.3 mg-1.5 mg-13.5 mg-20 mg-22.75 mg-25 mg-15 mg-25 mg-30 unit- mcg-30 mcg-30 mcg-45 50 mcg-60 mg-75 mg-200 mcg-45 mcg-50 mg-55 mg-500 mg-5000 unit, mcg-60 mg-72 mg-80 mg- 16.667 mcg-53 mg- 150 mcg-150 mcg-220 mg- 133.333 unit-166.667 mg- 250 mcg-300 mcg-400 8333.333 unit, 16.667 mcg- mcg-750 mcg, 2 mg-0.5 53.333 mg-133.333 unit- mg-1.5 mg-1.7 mg-2.3 mg- 166.667 mg-8333.333 unit, 3 mg-5 mcg-10 mcg-10 17 mcg-53 mg-133 unit- mg-11 mg-19 mcg-20 mg- 167 mg-8333 unit, 2 mg- 20 mg-25 mcg-30 mcg-30 0.5 mg-1.1 mg-1.1 mg-2.3 mcg-45 mcg-50 mcg-50 mg-5 mcg-5 mg-5 mg-8 mg-50 unit-60 mg-72 mg- mg-10 mcg-14 mg-15 mg- 80 mg-150 mcg-220 mg- 20 mg-22 mcg-30 mcg-35 250 mcg-300 mcg-400 unit-50 mcg-50 mcg-50 mcg-500 unit-2500 unit, 2 mcg-52 mcg-72 mg-80 mg- mg-0.5 mg-1.5 mg-1.7 mg- 100 mg-100 mg-150 mcg- 2.3 mg-3 mg-5 mcg-10 300 mcg-300 mg-400 mcg- mcg-10 mg-11 mg-20 mg- 800 unit-3500 unit, 2 mg- 20 mg-25 mcg-30 mcg-30 0.5 mg-1.1 mg-1.1 mg-2.3 mcg-45 mcg-45 mcg-50 mg-5 mcg-5 mg-5 mg-8 mg-50 unit-55 mcg-60 mg- mg-10 mcg-14 mg-15 mg- 72 mg-80 mg-150 mcg-150 20 mg-30 mcg-35 unit-50 mcg-220 mg-250 mcg-300 Oregon Trillium OHP Updated September 1, 2021
133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg-400 mcg-500 unit- mg-16 mg-18 mcg-20 mcg- 2500 unit, 2 mg-0.5 mg-1.5 30 mcg-45 unit-90 mg-100 mg-1.7 mg-2.3 mg-3 mg-5 mg-105 mcg-120 mcg-120 mcg-10 mcg-10 mg-11 mg- mg-210 mg-400 mcg-400 20 mg-20 mg-25 mcg-30 unit-600 mcg-3500 unit, 2 mcg-30 mcg-45 mcg-45 mg-1.35 mg-1.7 mg-2 mg-3 mg-50 mg-50 unit-55 mcg- mg-15 mg-16 mg-18 mcg- 60 mg-72 mg-80 mg-150 18 mg-20 mcg-22.5 unit-60 mcg-150 mcg-220 mg-250 mg-75 mcg-110 mcg-120 mcg-300 mcg-400 mcg-500 mcg-140 mg-210 mg-300 unit-2500 unit, 2 mg-0.6 mcg-400 mcg-700 unit- mg-1.2 mg-1.7 mg-2 mg-3 3500 unit, 2 mg-1.5 mg-1.7 mg-5 mg-16 mg-18 mcg-20 mg-2 mg-2 mg-2 mg-5 mcg-30 mcg-90 mg-100 mcg-6 mcg-10 mcg-10 mg-105 mcg-120 mcg-120 mcg-10 mg-15 mg-18 mg- mg-210 mg-400 mcg-400 20 mg-25 mcg-25 mcg-30 unit-3500 unit-45 unit-15 mcg-36 mg-40 mg-50 unit- mg, 2 mg-0.9 mg-1.2 mg- 77 mg-100 mcg-100 mg- 1.3 mg-2 mg-2.3 mg-5 120 mcg-120 mg-150 mcg- mcg-6 mcg-8 mg-10 mcg- 150 mcg-250 mcg-250 mg- 10 mcg-11 mg-15 mg-16 400 mcg-400 unit-3000 mg-20 mg-25 mcg-35 mcg- unit, 2 mg-1.5 mg-1.7 mg-2 40 mcg-45 mg-50 mcg-60 mg-2 mg-3 mg-5 mcg-10 mcg-72 mg-80 mg-90 mg- mcg-10 mcg-10 mg-15 mg- 100 mcg-100 mg-150 mcg- 20 mcg-20 mg-25 mcg-30 200 mcg-210 mg-600 mcg- mcg-45 unit-48 mg-60 mg- 900 mcg, 2 mg-0.9 mg-1.2 72 mg-75 mcg-80 mg-100 mg-1.3 mg-2 mg-2.3 mg-5 mg-150 mcg-150 mcg-150 mcg-6 mcg-8 mg-10 mcg- mcg-200 mg-250 mcg-300 10 mcg-11 mg-15 mg-16 mcg-400 mcg-400 unit- mg-20 mg-35 mcg-40 mcg- 3500 unit, 2 mg-1.5 mg-1.7 45 unit-50 mcg-60 mcg-72 mg-2 mg-2 mg-3.5 mg-5 mg-80 mg-90 mg-100 mcg- mcg-6 mcg-10 mcg-10 100 mg-150 mcg-150 mcg- mcg-10 mg-15 mg-18 mg- 200 mcg-210 mg-600 mcg- 20 mcg-20 mg-25 mcg-30 600 unit-3500 unit, 2 mg- mcg-30 unit-65 mcg-72 mg- 0.9 mg-1.5 mg-1.7 mg-2.3 80 mg-90 mg-100 mg-125 mg-3 mg-5 mcg-10 mcg-10 mg-150 mcg-150 mcg-160 mg-20 mg-25 mcg-30 mcg- mcg-162 mg-400 mcg-400 30 mcg-45 mcg-45 mcg-50 unit-5000 unit, 2 mg-1.5 mg-50 unit-55 mcg-72 mg- mg-1.7 mg-2 mg-2 mg-6 80 mg-90 mg-110 mg-150 mcg-10 mg-15 mg-18 mg- mcg-150 mcg-220 mg-250 20 mcg-20 mg-22.5 unit-25 mcg-300 mcg-500 mcg-500 mcg-60 mg-120 mcg-150 unit-2500 unit-11 mg, 2 mcg-300 mcg-400 mcg-500 mg-1 mg-1.5 mg-1.7 mg-2 mg-1000 unit-2500 unit, 2 mg-5 mg-6 mcg-10 mg-15 mg-1.5 mg-1.7 mg-2 mg-2 mg-16 mg-20 mg-30 unit- mg-9 mg-10 mg-12 mcg-15 45 mg-60 mg-60 mg-150 mg-20 mg-25 mg-25 mg-30 mcg-400 mcg-400 unit- mcg-50 unit-70 mcg-75 5000 unit, 2 mg-1.2 mg-1.7 mcg-80 mcg-100 mg-120 mg-2 mg-3 mg-5 mg-15 mcg-120 mg-150 mcg-150 Oregon Trillium OHP Updated September 1, 2021
134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg-225 mg-275 mcg-400 10 mg-12 mcg-15 mg-20 mcg-400 unit-5000 unit, 2 mg-28 mcg-30 mcg-31 mg- mg-1.5 mg-1.7 mg-2 mg-2 40 mg-50 mcg-60 unit-70 mg-9 mg-10 mg-12 mcg-15 mcg-75 mcg-90 mg-100 mg-20 mg-25 mg-25 mg-50 mg-150 mcg-150 mcg-400 unit-70 mcg-75 mcg-80 mcg-400 unit-5000 unit, 2 mcg-100 mg-120 mcg-150 mg-2 mg-2.2 mg-2.5 mg-3 mcg-275 mcg-400 mcg-400 mg-9 mcg-15 mg-22.5 mg- unit-5000 unit-225 mg-30 25 mcg-25 mg-45 unit-75 mcg-120 mg-150 mcg, 2 mcg-90 mg-99 mg-100 mg- mg-1.5 mg-1.7 mg-2 mg- 105 mcg-154 mg-200 mcg- 2.5 mg-6 mcg-10 mcg-10 200 mg-400 mcg-400 unit- mcg-10 mcg-10 mg-15 mg- 450 mcg-2500 unit, 2 mg-2 18 mg-20 mg-30 mcg-30 mg-2.3 mg-2.6 mg-3 mg-9 unit-34 mg-37.5 mg-60 mg- mcg-10 mg-15 mg-18 mg- 100 mg-100 mg-130 mg- 20 mcg-25 mcg-30 mg-30 150 mcg-400 mcg-400 unit- unit-50 mg-120 mcg-120 5000 unit, 2 mg-10 mcg-2 mg-300 mcg-300 mg-400 mg-2 mg-5 mcg-10 mcg-10 mcg-800 unit-2500 unit, 2 mg-10 mg-10 mg-18 mg-20 mg-2 mg-2.4 mg-2.7 mg- mcg-25 mcg-30 unit-75 3.2 mg-5 mg-9.5 mcg-10 mcg-109 mg-120 mcg-150 mg-15 mg-18 mg-20 mcg- mcg-150 mcg-250 mcg-300 22.5 unit-25 mcg-30 mcg- mcg-400 unit-3500 unit, 2 50 mg-50 mg-60 mg-120 mg-2 mg-1.5 mg-1.7 mg-2 mcg-120 mg-300 mg-400 mg-2 mg-5 mcg-6 mcg-10 mcg-800 unit-2500 unit, 2 mcg-10 mcg-10 mg-15 mg- mg-2 mg-2.4 mg-2.7 mg- 18 mg-20 mcg-20 mg-25 3.2 mg-5 mg-9.5 mcg-10 mcg-30 mcg-30 unit-60 mg-15 mg-18 mg-20 mcg- mg-72 mg-75 mcg-80 mg- 25 mcg-30 mcg-30 unit-50 100 mg-108 mg-120 mcg- mg-60 mg-120 mcg-180 150 mcg-150 mcg-162 mg- mg-300 mg-400 mcg-800 250 mcg-400 mcg-400 unit- unit-2500 unit, 2 mg-2 mg-3 5000 unit, 2 mg-2 mg-1.5 mg-1.5 mg-1.7 mg-2 mg-5 mg-1.7 mg-2 mg-3 mg-5 mcg-10 mcg-10 mcg-10 mcg-10 mcg-10 mcg-10 mg-15 mg-20 mcg-20 mg- mg-15 mg-20 mcg-20 mg- 25 mcg-30 mcg-45 unit-48 25 mcg-30 mcg-45 unit-48 mg-60 mg-72 mg-75 mcg- mg-60 mg-72 mg-75 mcg- 80 mg-100 mg-150 mcg- 80 mg-100 mg-150 mcg- 150 mcg-150 mcg-200 mg- 150 mcg-150 mcg-200 mg- 250 mcg-300 mcg-400 250 mcg-300 mcg-400 mcg-400 unit-3500 unit, 2 mcg-400 unit-3500 unit, 2 mg-2 mg-3 mg-3 mg-3.4 mg-2 mg-1.5 mg-1.7 mg-2 mg-3.5 mg-5 mcg-7.5 mg- mg-5 mg-6 mcg-10 mg-15 7.5 mg-9 mcg-10 mcg-10 mg-18 mg-20 mcg-25 mcg- mcg-10 mg-15 mg-18 mg- 30 mcg-30 unit-50 mg-60 20 mg-21 mcg-26 mcg-28 mg-120 mcg-400 mcg-450 mcg-30 mcg-30 unit-31 mg- mg-1000 unit-2500 unit, 2 32 mcg-40 mg-90 mg-100 mg-2 mg-2 mg-3 mg-3.4 mg-150 mcg-150 mcg-400 mg-5 mcg-6 mg-7.5 mg-7.5 mcg-400 unit-5000 unit, 2 mg-9 mg-10 mcg-10 mcg- mg-2 mg-3 mg-3.4 mg-4 Oregon Trillium OHP Updated September 1, 2021
135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mg-5 mcg-5 mg-9 mg-10 unit-90 mg-100 mg-105 mcg-10 mcg-10 mg-12 mcg-120 mcg-120 mg-210 mcg-15 mg-25 mcg-25 mg-400 mcg-400 unit-600 mcg-30 unit-40 mg-40 mg- mcg-3500 unit, 2 mg-3 mg- 45 mcg-60 mg-90 mg-99 3 mg-3.4 mg-5 mg-7.5 mg- mg-100 mcg-150 mcg-150 7.5 mg-9 mcg-10 mcg-10 mcg-250 mg-300 mcg-400 mg-15 mcg-15 mcg-15 mcg-400 unit-3500 unit, 2 mcg-15 mg-18 mg-30 mg- mg-2 mg-3.5 mg-5 mcg-6 30 unit-31 mg-44 mg-100 mcg-10 mcg-1.5 mg-1.7 mg-120 mg-150 mcg-400 mg-2 mg-10 mcg-10 mg-15 mcg-400 unit-5500 unit, 2 mg-18 mg-20 mcg-20 mg- mg-3 mg-3 mg-3.4 mg-5 25 mcg-30 mcg-30 unit-60 mg-7.5 mg-9 mcg-10 mcg- mg-65 mcg-72 mg-80 mg- 10 mg-15 mcg-15 mcg-15 100 mg-109 mg-150 mcg- mcg-15 mg-18 mg-30 mg- 150 mcg-160 mcg-162 mg- 30 unit-31 mg-40 mg-100 400 mcg-400 unit-5000 mg-120 mg-150 mcg-400 unit, 2 mg-2 mg-30 unit-30 mcg-400 unit-5500 unit, 2 unit-40 mcg-40 mcg-40 mg-3 mg-3 mg-3.4 mg-5 mg-40 mg-60 mg-60 mg- mg-9 mcg-10 mcg-10 mg- 5000 unit-5000 unit, 2 mg-2 10 mg-15 mcg-15 mcg-15 mg-30 unit-40 mcg-40 mg- mcg-15 mg-27 mg-30 mg- 60 mg-5000 unit, 2 mg-2 30 unit-40 mg-100 mg-120 mg-40 mg-55 mcg-60 unit- mg-150 mcg-400 mcg-400 1000 unit-200 mg, 2 mg-2 unit-5500 unit, 2 mg-3 mg- mg-40 mg-55 mcg-60 unit- 3.4 mg-6 mg-7.5 mg-2 mg- 200 mg-1000 unit, 2 mg-2 2 mg-5 mcg-7.5 mg-9 mg- mg-5 mg-5 mg-5 mg-10 10 mcg-10 mcg-10 mg-12 mcg-10 mg-15 mg-20 mcg- mcg-15 mg-20 mg-28 mcg- 20 mg-30 mcg-30 mcg-30 30 mcg-31 mg-40 mg-60 unit-75 mcg-100 mg-100 unit-70 mcg-75 mcg-90 mg- mg-100 mg-100 mg-120 100 mg-120 mcg-150 mcg- mcg-150 mcg-250 mcg-400 150 mcg-250 mcg-400 mcg-3500 unit, 2 mg-2 mg- mcg-400 unit-5000 unit, 2 5 mg-5 mg-5 mg-10 mg-10 mg-3 mg-5 mcg-5 mg-5 mg-10 mg-18 mg-22.5 mg- mg-5 mg-7 mg-7.5 mg-7.7 25 mcg-30 mg-30 unit-75 mg-10 mcg-10 mcg-10 mg- mcg-100 mg-150 mg-150 12 mcg-15 mg-25 mcg-25 mg-400 unit-5000 unit, 2 mg-30 mg-30 unit-40 mcg- mg-2 mg-55 mcg-60 unit- 50 mcg-50 mcg-50 mcg-90 200 mg-1000 unit-40 mg, 2 mg-100 mg-125 mg-150 mg-2 mg-6 mg-10 mg-10 mcg-150 mcg-162 mg-275 mg-18 mg-25 mcg-25 mg- mcg-300 mcg-400 mcg-400 30 mcg-60 unit-10 mcg-10 unit-3500 unit, 2 mg-3 mg-5 mg-15 mg-70 mcg-75 mcg- mg-5 mg-40 mcg-40 mg-40 100 mcg-100 mcg-100 mg- mg-50 unit-200 mg-6000 100 mg-100 mg-100 mg- unit, 2 mg-3.4 mg-4 mg-4.5 150 mcg-250 mcg-400 mg-6 mg-15 mg-20 mcg-20 mcg-2000 unit-3000 unit, 2 mcg-20 mg-22.5 mg-22.5 mg-3 mg-1.2 mg-1.7 mg-2 unit-25 mcg-30 mcg-50 mg- mg-5 mg-15 mg-16 mg-18 60 mg-90 mcg-120 mg-150 mcg-20 mcg-30 mcg-45 mcg-180 mcg-400 mcg-500 Oregon Trillium OHP Updated September 1, 2021
136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mg-1000 unit-2500 unit, 2 3500 unit, 2 mg-4 mg-4 mg-3.4 mg-4 mg-4.5 mg-6 mg-4.5 mg-5 mcg-5.1 mg-6 mg-15 mg-20 mcg-20 mcg- mg-10 mcg-10 mcg-10 mg- 20 mg-22.5 mg-25 mcg-30 15 mg-18 mg-21 mcg-25 mcg-33 unit-50 mg-60 mg- mcg-25 mg-35 mg-40 mcg- 90 mcg-120 mg-150 mcg- 40 mg-45 mg-48 mg-50 180 mcg-400 mcg-405 mg- mg-60 mg-60 unit-70 mcg- 800 unit-2500 unit, 2 mg- 72.5 mg-75 mcg-80 mg- 3.4 mg-4 mg-4.5 mg-6 mg- 100 mg-120 mcg-120 mg- 15 mg-20 mcg-20 mg-22.5 150 mcg-150 mcg-250 mg-30 mcg-30 mcg-34 mg- mcg-400 mcg-400 unit- 37.5 mg-60 unit-90 mcg- 2000 unit-3000 unit, 2 mg-5 100 mg-105 mcg-120 mg- mg-6 mcg-15 mg-18 mg-30 120 mg-150 mcg-180 mcg- mg-35 mg-65 mg-100 mg- 400 mcg-400 unit-5000 125 mg-150 mcg-300 mcg- unit, 2 mg-3.4 mg-4 mg-4.5 400 mcg, 2 mg-5 mg-6 mg-6 mg-20 mcg-20 mg- mcg-15 mg-30 mg-35 mg- 22.5 mg-25 mcg-33 unit-40 100 mcg-100 mg-125 mg- mg-90 mcg-100 mg-105 150 mcg-400 mcg-500 mg, mcg-120 mg-15 mg-30 2 mg-5 mg-9 mcg-10 mcg- mcg-34 mg-120 mg-150 3 mg-3 mg-3.4 mg-10 mg- mcg-180 mcg-400 mcg-400 10 mg-15 mcg-15 mcg-15 unit-2500 unit, 2 mg-3.4 mcg-15 mg-27 mg-30 mg- mg-4.5 mg-6 mg-15 mg-20 30 unit-40 mg-100 mg-120 mcg-22.5 mg-25 mcg-4 mg-150 mcg-400 mcg-400 mg-20 mcg-20 mg-30 mcg- unit-5500 unit, 2 mg-6 mg- 33 unit-50 mg-60 mg-90 15 mg-30 unit-60 mg, 2 mcg-120 mg-150 mcg-180 mg-6 mg-3.4 mg-4 mg-4.5 mcg-400 mcg-405 mg-800 mg-15 mg-20 mcg-20 mg- unit-2500 unit, 2 mg-30 22.5 mg-22.5 unit-25 mcg- mg-40 mcg-40 mg-60 mg- 30 mcg-60 mg-90 mcg-100 5000 unit, 2 mg-30 unit-40 mg-110 mcg-120 mg-120 mcg-40 mg-60 mg-1000 mg-150 mcg-180 mcg-300 unit, 2 mg-30 unit-40 mcg- mg-400 mcg-700 unit-2500 40 mg-60 mg-5000 unit, 2 unit, 2.2 mg-3.4 mg-4.2 mg-4 mg-15 mg-20 mcg-20 mg-4.5 mg-6 mg-10 mg-20 mg-22.5 mg-3.4 mg-4.5 mcg-20 mg-24 mg-25 mcg- mg-6 mg-25 mcg-30 mcg- 27 mcg-30 mcg-30 unit-50 33 unit-40 mg-90 mcg-100 mg-90 mcg-120 mg-150 mg-105 mcg-120 mg-120 mcg-180 mcg-400 mcg-500 mg-120 mg-150 mcg-180 mg-1000 unit-3500 unit, 2.2 mcg-400 mcg-400 unit-600 mg-3.4 mg-4.2 mg-4.5 mg- mcg-2500 unit, 2 mg-4 mg- 6 mg-11.6 mg-15 mg-17.5 4 mg-4.5 mg-5 mcg-5.1 mcg-20 mcg-20 mg-24 mg- mg-6 mg-10 mcg-10 mcg- 25 mcg-30 mcg-90 mcg- 10 mg-15 mg-16 mcg-18 110 mg-117 mcg-120 mg- mg-25 mcg-40 mcg-40 mg- 120 mg-150 mcg-180 mcg- 40 mg-48 mg-50 mg-60 370 mcg-400 mcg-1046 mcg-60 mg-60 unit-70 mcg, 2.2 mg-3.4 mg-4.2 mcg-72 mg-75 mcg-80 mg- mg-4.5 mg-6 mg-13.5 mg- 100 mg-120 mcg-120 mg- 15 mg-20 mcg-20 mg-24 150 mcg-400 mcg-400 unit- mg-25 mcg-25 mcg-27 Oregon Trillium OHP Updated September 1, 2021
137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg-30 mcg-50 mg-90 mcg-10 mg-11 mg-18 mg- mcg-120 mg-150 mcg-180 20 mg-20 mg-25 mcg-30 mcg-400 mcg-500 mg- mcg-30 unit-35 mcg-45 1050 mcg, 2.2 mg-3.4 mg- mcg-50 mg-55 mcg-60 mg- 4.2 mg-4.5 mg-6 mg-15 72 mg-75 mcg-80 mg-150 mg-20 mcg-20 mg-24 mg- mcg-200 mg-400 mcg-400 25 mcg-25.5 unit-30 mcg- unit-3500 unit, 2.5 mg-0.5 90 mcg-110 mg-117 mcg- mg-0.75 mg-0.85 mg-6.25 120 mg-120 mg-150 mcg- mcg-7.5 mg-10 mg-30 unit- 180 mcg-370 mcg-400 50 mg-50 mg-60 mg-72.5 mcg-700 unit-3500 unit, 2.2 mg-100 mcg-100 mg-250 mg-3.4 mg-4.2 mg-4.5 mg- mcg-500 unit-1500 mcg- 6 mg-15 mg-20 mcg-20 2500 unit, 2.5 mg-1 mg-1 mg-24 mg-25 mcg-27 mcg- mg-2.5 mg-2.5 mg-9 mg-10 30 mcg-30 unit-50 mg-90 mg-10 mg-10 mg-11.25 mcg-120 mg-120 mg-150 mg-12.5 mcg-15 mg-15 mcg-180 mcg-400 mcg-500 unit-37.5 mcg-50 mg-75 mg-1000 unit-3500 unit, 2.2 mg-200 unit-300 mcg-2500 mg-3.4 mg-4.2 mg-4.5 mg- unit, 2.5 mg-1.7 mcg-1.7 6 mg-15 mg-20 mcg-20 mg-1.7 mg-2.5 mg-5 mg-5 mg-24 mg-25 mcg-27 mcg- mg-5 unit-8.3 mcg-8.3 mg- 30 mcg-30 unit-50 mg-90 16.7 mg-16.7 mg-28.3 mg- mcg-120 mg-150 mcg-180 33 unit-41.7 mg-66.7 mcg- mcg-400 mcg-500 mg- 83 mcg-83 mg-83 mg-250 1000 unit-3500 unit, 2.2 mcg-833 unit, 2.5 mg-1.9 mg-3.4 mg-4.2 mg-4.5 mg- mg-2 mg-2.1 mg-2.5 mg-2 6 mg-15 mg-20 mcg-20 mg-5 mcg-7.5 mcg-10 mcg- mg-24 mg-25 mcg-30 mcg- 10 mcg-12.5 mg-15 mg-18 30 unit-90 mcg-110 mg- mg-25 mcg-25 mg-25 mg- 117 mcg-120 mg-120 mg- 37.5 mcg-45 unit-70 mcg- 150 mcg-180 mcg-370 75 mcg-75 mg-77 mg-80 mcg-400 mcg-700 unit- mg-100 mg-120 mcg-120 3500 unit, 2.2 mg-3.4 mg- mg-150 mcg-150 mcg-162 4.2 mg-6 mg-15 mg-17.5 mg-300 mcg-400 mcg-400 mcg-20 mcg-20 mg-25 unit-2000 unit-3000 unit, mcg-30 mcg-90 mcg-4.5 2.5 mg-5 mg-20 mg-20 mg- mg-11.6 mg-24 mg-110 20 mg-25 mg-25 mg-50 mg-117 mcg-120 mg-150 mcg-50 mcg-50 mg-50 unit- mcg-180 mcg-210 mg-370 66 mg-100 mg-200 mcg- mcg-400 mcg-1046 mcg, 200 mcg-400 unit-500 mg- 2.3 mg-0.5 mg-1.7 mg-2 1000 mcg-5000 unit, 25 mg-2 mg-1.5 mg-5 mcg-6 mcg-200 mg-200 unit- mcg-10 mcg-10 mcg-10 10000 unit, 25 mg-1 mg-10 mg-11 mg-18 mg-20 mg-20 mg-25 mg-25 mg-33 mg-50 mg-25 mcg-30 mcg-30 mg-100 unit-25 mg-50 unit-35 mcg-45 mcg-50 mcg-80 mg-125 mg-200 mg-55 mcg-60 mg-72 mg- unit-300 mcg-500 mg-5000 75 mcg-80 mg-150 mcg- unit, 3 mg-0.05 mg-0.15 200 mg-400 mcg-400 unit- mg-1 mg-10 mg-20 mg-15 3500 unit, 2.3 mg-0.9 mg- mg-20 mcg-20 mg-25 mg- 1.5 mg-1.7 mg-2 mg-2 mg- 25 mg-50 mcg-50 mcg-50 5 mcg-6 mcg-10 mcg-10 mg-60 unit-100 mg-400 Oregon Trillium OHP Updated September 1, 2021
138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits unit-500 mg, 3 mg-0.5 mg- mcg-100 mg-400 mcg-500 1.7 mg-2 mg-2.3 mg-1.5 mg, 3 mg-5 mg-20 mcg-20 mg-5 mcg-10 mcg-10 mg- mg-20 mg-20 mg-24 mg-46 11 mg-20 mg-20 mg-25 mg-60 mg-100 mcg-100 mcg-30 mcg-30 mcg-45 mg-400 mcg-500 mg, 3.333 mcg-45 mcg-50 mg-50 mg-4.167 mcg-6 mg-7.5 unit-55 mcg-60 mg-72 mg- mg-11.667 mg-16.667 mg- 80 mg-150 mcg-150 mcg- 16.667 mg-16.667 mg- 220 mg-250 mcg-300 mcg- 33.333 mcg-33.333 mcg- 400 mcg-500 unit-2500 33.333 mg-33.333 mg- unit, 3 mg-0.5 mg-1.7 mg- 33.333 mg-33.333 mg-50 2.3 mg-1.5 mg-2 mg-5 mcg-66.667 mcg-66.667 mcg-10 mcg-10 mg-11 mg- unit-83.333 mg-100 mcg- 20 mg-20 mg-25 mcg-30 133.333 unit-266.667 mcg- mcg-30 mcg-45 mcg-45 333.333 mg-1666.667 unit, mcg-50 mg-50 unit-55 3.333 mg-4.167 mcg-7.5 mcg-60 mg-72 mg-80 mg- mg-11.667 mg-16.667 mg- 150 mcg-150 mcg-220 mg- 16.667 mg-16.667 mg- 250 mcg-300 mcg-400 33.333 mcg-33.333 mcg- mcg-500 unit-2500 unit, 3 33.333 mg-33.333 mg- mg-1.5 mg-1.7 mg-2 mg-2 33.333 mg-33.333 mg-50 mg-2 mg-10 mcg-10 mcg- mcg-66.667 mcg-66.667 10 mg-15 mg-20 mcg-25 unit-83.333 mg-100 mcg- mcg-30 mcg-45 unit-60 133.333 unit-266.667 mcg- mg-72 mg-75 mcg-80 mg- 333.333 mg-1666.667 unit, 100 mg-150 mcg-150 mcg- 3.4 mg-2 mg-3 mg-3 mg-5 150 mcg-200 mg-250 mcg- mg-9 mcg-10 mcg-10 mg- 400 mcg-400 unit-5000 10 mg-15 mcg-15 mcg-15 unit-48 mg-5 mcg-20 mg, 3 mcg-15 mg-27 mg-30 mg- mg-12 mcg-20 mg-24 mg- 30 unit-40 mg-100 mg-120 30 unit-45 mcg-77 mg-100 mg-150 mcg-400 mcg-400 mg-5 mg-10 mg-10 mg-400 unit-5500 unit, 3.5 mg-0.5 mcg-500 mg, 3 mg-2 mg-2 mg-0.6 mg-3.3 mg-5 mg-5 mg-2 mg-3.4 mg-5 mcg-6 mg-6.5 mg-7.2 mg-7.5 mg- mg-7.5 mg-7.5 mg-9 mg-10 10 mg-10 mg-10 mg-10 mcg-10 mcg-10 mg-12 mg-10 mg-15 mg-20 mg-25 mcg-15 mg-20 mg-28 mcg- mcg-25 mcg-25 mcg-25 30 mcg-31 mg-40 mg-50 mg-25 unit-50 mg-50 mg- mcg-60 unit-70 mcg-75 50 unit-54 mg-73 mg-150 mcg-90 mg-100 mg-150 mcg-897 mcg-2500 unit, 4 mcg-150 mcg-400 mcg-400 mg-0.5 mg-1.5 mg-1.7 mg- unit-5000 unit, 3 mg-2 mg- 6 mg-10 mg-15 mg-20 mg- 2.25 mg-2.6 mg-5 mg-9 20 mg-21 mcg-30 mcg-50 mcg-10 mg-15 mg-20 mg- mcg-60 mcg-60 mcg-60 25 mcg-25 mcg-25 mcg-25 unit-72 mg-75 mg-80 mg- mcg-27 mg-27 mg-30 mg- 100 mcg-120 mg-150 mcg- 34 unit-45 mcg-90 mg-100 210 mg-300 mcg-300 mcg- mg-125 mg-150 mcg-162 600 mcg-600 unit-3500 mg-300 mcg-400 mcg-400 unit, 4.5 mg-2 mg-3.4 mg-4 unit-5000 unit, 3 mg-5 mg- mg-6 mg-15 mg-20 mcg-20 10 mg-10 mg-12 mcg-20 mcg-20 mg-22.5 mg-25 mg-23.9 mg-30 unit-45 mcg-30 mcg-33 unit-50 mg- Oregon Trillium OHP Updated September 1, 2021
139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 60 mg-90 mcg-100 mcg- mg-1.5 mg-6 mcg-7 mg-10 120 mg-150 mcg-400 mcg- mg-15 mg-30 unit-50 mg- 405 mg-800 unit-2500 unit, 60 mg-200 mg-300 mcg- 4.5 mg-2 mg-3.4 mg-4 mg- 400 mcg-1000 unit-2500 6 mg-15 mg-20 mcg-20 unit, 5 mg-10 mg-10 mg-12 mg-22.5 mg-25 mcg-30 mcg-18 mg-20 mg-30 unit- mcg-33 unit-40 mg-90 45 mcg-100 mg-400 mcg- mcg-100 mg-105 mcg-120 500 mg, 5 mg-10 mg-10 mg-120 mg-120 mg-150 mg-12 mcg-20 mg-30 unit- mcg-180 mcg-400 mcg-400 45 mcg-69 mg-100 mg-400 unit-600 mcg-2500 unit, 40 mcg-500 mg, 5.1 mg-2 mg- mg-2 mg-30 unit-40 mcg- 2 mg-4.5 mg-6 mg-15 mg- 44 mg-60 mg-5000 unit, 40 15 mg-18 mcg-18 mg-20 mg-2 mg-30 unit-40 mcg- mg-30 unit-50 mg-60 mcg- 60 mg-5000 unit, 5 mcg- 60 mg-70 mcg-75 mcg-100 0.667 mg-1.667 mg-3.333 mcg-120 mcg-150 mcg-150 mg-5 mg-5 mg-16.667 mcg-300 mcg-400 mcg-500 mcg-16.667 mg-16.667 mg-700 mcg-1000 unit- mg-16.667 mg-16.667 mg- 3500 unit, 50 mcg-100 unit- 26.667 mg-33.333 mcg-50 400 unit-10000 unit, 55 mcg-66.667 mg-66.667 mcg-2 mg-2 mg-40 mg-60 mg-66.667 unit-133.333 unit-200 mg-1000 unit, 60 mg-133.333 mg-133.333 unit-2 mg-40 mg-55 mcg- unit-166.667 mg-333.333 200 mg-1000 unit, 9 mcg- mcg-333.333 mg-1666.667 0.4 mg-2 mg-2.6 mg-20.6 unit, 5 mcg-0.9 mg-2.3 mg- mg-22.5 mg-27 mg-30 mg- 1.5 mg-1.7 mg-2 mg-2 mg- 45 unit-90 mg-400 unit- 6 mcg-10 mcg-10 mcg-10 5000 unit mg-11 mg-18 mg-20 mg-25 MULTIVITAMIN ADULT F mcg-30 mcg-30 unit-35 CHEW mcg-45 mcg-55 mcg-72 MULTIVITAMIN ADULT F mg-80 mg-90 mg-100 mg- EXTRAVITAMIN C CHEW 109 mg-150 mcg-150 mcg- 200 mg-250 mcg-300 mcg- MULTIVITAMIN ADULTS F RX/OTC 400 unit-500 mcg-3500 TABS unit, 5 mg-1 mg-1 mg-5 MULTIVITAMIN MEN F RX/OTC mg-6 mg-7.5 mg-10 mg-15 TABS mg-18 mg-25 mcg-25 mg- MULTIVITAMIN TABS 1 RX/OTC 25 mg-25 mg-25 mg-25 MG-1 MG-1.5 MG-2 MG- mg-25 mg-25 unit-30 mcg- 2.5 MG-5 MG-7.5 MCG-10 F 35 mg-50 mcg-50 mg-50 MCG-10 MG-10 MG-15 mg-75 mcg-100 mcg-100 MG-15 MG-100 MG-150 mcg-100 mg-150 mcg-150 MCG-150 MG-3000 MCG mcg-150 mg-250 mcg-400 mcg-400 unit-10000 unit, 5 MULTIVITAMIN WOMEN F RX/OTC mg-1 mg-1.25 mg-3.4 mg- TABS 10 mg-25 mg-35 mg-35 MULTIVITAMIN/ZINC F RX/OTC mg-35 mg-35 mg-35 mg-70 STRESSFORMULA TABS mcg-75 mcg-125 mcg-125 mcg-125 unit-150 mcg-400 mcg-400 unit-500 mg, 5 mg-1 mg-1.7 mg-2 mg-5 Oregon Trillium OHP Updated September 1, 2021
140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MVW COMPLETE RX/OTC ONE DAILY MENS RX/OTC FORMULATION CAPS 1.5 FORMULA W/O IRON F MG-1.7 MG-1.9 MG-6 TABS MCG-10 MG-12 MG-20 F ONE DAILY WOMENS F RX/OTC MG-100 MCG-100 MG-200 TABS MCG-200 UNIT-800 MCG- 1500 UNIT-16000 UNIT ONE-A-DAY ENERGY F RX/OTC TABS MVW COMPLETE RX/OTC FORMULATIOND3000 F ONE-A-DAY FOR HER CAPS VITACRAVES TEEN F MULTI GUMMIES CHEW MVW COMPLETE RX/OTC FORMULATIOND500 F ONE-A-DAY FOR CAPS HIM/VITACRAVES TEEN F MULTI GUMMIES CHEW MVW COMPLETE RX/OTC FORMULATIONMINIS F ONE-A-DAY MENOPAUSE F RX/OTC CAPS FORMULA TABS ONE-A-DAY MENS 50+ RX/OTC NAT-RUL THERAVITE- F RX/OTC F M/HIGHPOTENCY TABS ADVANTAGE TABS RX/OTC ONE-A-DAY MENS 50+ F RX/OTC NATRUL-VITES TABS F TABS RX/OTC ONE-A-DAY MENS F RX/OTC NEOVITE TABS F HEALTH FORMULA TABS NICADAN TABS F RX/OTC ONE-A-DAY MENS PRO F RX/OTC EDGE TABS NICADAN ZX TABS F RX/OTC ONE-A-DAY MENS TABS RX/OTC 0.9 MG-1.32 MG-1.43 MG- NICAZEL FORTE TABS F RX/OTC 2.17 MG-2.3 MG-6.24 MCG-11 MG-15 MG-15.5 NICAZEL TABS F RX/OTC MG-17.6 MG-25 MCG-30 F MCG-35 MCG-43 MCG-55 NO IRON MULTIPLE RX/OTC MCG-99 MG-120 MG-150 VITAMIN/MINERALS F MCG-210 MG-240 MCG- TABS 300 MCG-900 MCG RX/OTC ONE-A-DAY MENS NUTRICAP TABS F VITACRAVES GUMMIES F CHEW OCULAR VITAMINS TABS F RX/OTC ONE-A-DAY PROACTIVE F RX/OTC 65+ TABS OCUVITE ADULT 50+ F RX/OTC CAPS ONE-A-DAY TEEN RX/OTC ADVANTAGEFOR HIM F OCUVITE ADULT F RX/OTC FORMULA CAPS TABS OCUVITE LUTEIN CAPS F RX/OTC ONE-A-DAY VITACRAVES F ADULT CHEW RX/OTC ONCOVITE TABS F ONE-A-DAY VITACRAVES F CHEW ONE A DAY MENS ONE-A-DAY VITACRAVES VITACRAVES MULTI F GUMMIES/IMMUNITY F GUMMIES CHEW SUPPORT CHEW
Oregon Trillium OHP Updated September 1, 2021
141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ONE-A-DAY VITACRAVES F OPURITY/BYPASS F SOURGUMMIES CHEW OPTIMIZED CHEW ONE-A-DAY VITACRAVES F OSTEOPRIME RX/OTC WOMENS MULTI CHEW PLUS/CALCIUM & F ONE-A-DAY WEIGHT RX/OTC MAGNESIUM TABS SMART ADVANCED TABS F PARVLEX TABS F RX/OTC (multiple vitamins w/ minerals) PHYTOMULTI TABS F RX/OTC ONE-A-DAY WOMENS RX/OTC PRESERVISION AREDS 2 RX/OTC 50+ ADVANTAGE TABS F F (multiple vitamins w/ + MULTI VITAMIN CAPS minerals) PRESERVISION AREDS 2 RX/OTC ONE-A-DAY WOMENS RX/OTC CAPS 0.4 MG-0.5 MG-2.5 50+ HEALTHY MG-17.4 MG-87.5 MG-100 ADVANTAGE TABS F UNIT-113 MG-162.5 MG- F (multiple vitamins w/ 250 MG, 1 MG-1 MG-5 minerals) MG-40 MG-200 UNIT-250 ONE-A-DAY WOMENS RX/OTC MG, 1 MG-1 MG-5 MG-40 MG-90 MG-250 MG ACTIVE MIND & BODY F TABS (multiple vitamins w/ PRESERVISION AREDS 2 minerals) CHEW 1 MG-1 MG-5 MG- F ONE-A-DAY WOMENS RX/OTC 40 MG-200 UNIT-250 MG PETITES TABS (multiple F PRESERVISION AREDS F RX/OTC vitamins w/ minerals) CAPS ONE-A-DAY WOMENS RX/OTC PRESERVISION AREDS F RX/OTC TABS PLUS HEALTHY SKIN F SUPPORT TABS (multiple PRESERVISION/LUTEIN F RX/OTC vitamins w/ minerals) CAPS ONE-A-DAY WOMENS F RX/OTC RX/OTC TABS PRO-CAL TABS F ONE-A-DAY WOMENS PROCERV HP TABS F RX/OTC VITACRAVES GUMMIES F CHEW PRORENAL+D TABS F RX/OTC ONE-DAILY MULTI CAPS F RX/OTC CAPS PRORENAL+D/OMEGA-3 F RX/OTC CAPS OPTIFAST POST F BARIATRIC CHEW PROTECT CARDIO AF F RX/OTC CAPS OPTIMUM AIRVITES F CHEW PROTECT PLUS SO F RX/OTC OPTISOURCE POST CAPS BARIATRIC SURGERY F PROTEGRA CAPS F RX/OTC CHEW OPTIVITE P.M.T. TABS RX/OTC PROVIT TABS F RX/OTC (multiple vitamins w/ F minerals) QC MULTI-VITE TABS F RX/OTC OPURITY TABS F RX/OTC QC OCUHEALTH VISION F RX/OTC SUPPORT 2 CAPS
Oregon Trillium OHP Updated September 1, 2021
142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QUIN B STRONG TABS F RX/OTC SYSTANE ICAPS AREDS2 RX/OTC TABS 1 MG-1 MG-1 MG-5 F QUINTABS-M TABS F RX/OTC MG-12.5 MG-94.3 MG-200 UNIT-250 MG RX/OTC RA CENTRAL-VITE TABS F T-VITES TABS F RX/OTC RX/OTC RENAPLEX-D TABS F THERA M PLUS TABS F RX/OTC RX/OTC REPLACE CAPS F THERA-M TABS F RX/OTC RX/OTC REQ 49+ TABS F THERA-TABS M TABS F RX/OTC RX/OTC SAVISION CAPS F THERABETIC MULTI- F RX/OTC VITAMIN TABS SENTRY SENIOR TABS F RX/OTC THERAGRAN-M RX/OTC ADVANCED 50 PLUS F SENTRY SENIOR/LUTEIN F RX/OTC TABS TABS THERAGRAN-M F RX/OTC SENTRY TABS F RX/OTC ADVANCED TABS THERAGRAN-M PREMIER F RX/OTC SIDEROL TABS F RX/OTC 50 PLUS TABS THERAGRAN-M PREMIER RX/OTC SM ONE DAILY MENS F RX/OTC F TABS TABS F RX/OTC SM ONE DAILY WOMENS F RX/OTC THERAGRAN-M TABS TABS THERAMILL FORTE CAPS F RX/OTC SOLO TABS F RX/OTC THERANATAL F RX/OTC SPECTRAVITE TABS F RX/OTC LACTATION ONE CAPS STROVITE FORTE TABS RX/OTC THEREMS-H TABS F RX/OTC 15 MG-0.1 MG-0.8 MG-3 MG-10 MG-0.15 MG-20 THEREMS-M TABS F RX/OTC MG-20 MG-25 MCG-25 MG-25 MG-50 MCG-50 F UNICOMPLEX-M TABS F RX/OTC MCG-50 MG-60 UNIT-100 MG-500 MG-1000 UNIT- VENEXA FE TABS F RX/OTC 3000 UNIT (multiple vitamins w/ minerals) VENEXA TABS F RX/OTC STROVITE ONE TABS F RX/OTC VENTRIXYL FE TABS F RX/OTC SUPER ANTIOXIDANT F RX/OTC CAPS VISTA ADVANCED F RX/OTC AREDS2 FORMULA CAPS SUPPORT LIQD F RX/OTC VISTA ADVANCED DRY F RX/OTC SYSTANE ICAPS AREDS2 EYE FORMULA CAPS RX/OTC CHEW 1 MG-1 MG-5 MG- F VITABEX CAPS F 12.5 MG-200 UNIT-250 MG
Oregon Trillium OHP Updated September 1, 2021
143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VITABEX PLUS CAPS F RX/OTC VITRUM 50+ SENIOR F RX/OTC MULTI TABS VITALINE TOTAL RX/OTC F WAL-BORN VITAMIN C F FORMULA 2 TABS CHEW VITALINE TOTAL RX/OTC F WHOLE FOOD F RX/OTC FORMULA 3 TABS MULTIVITAMIN TABS VITAMIN D3 COMPLETE F RX/OTC WOMENS 50+ MULTI RX/OTC TABS VITAMIN& MINERAL F VITAROCA PLUS TABS RX/OTC FORMULA TABS (multiple vitamins w/ F WOMENS BIOMULTIPLE F RX/OTC minerals) TABS RX/OTC VITASANA TABS F WOMENS MULTI F GUMMIES CHEW VITATRUM TABS F RX/OTC WOMENS MULTI VITAMIN RX/OTC & MINERAL FORMULA F VITEYES CLASSIC F RX/OTC TABS ADVANCED CAPS WOMENS MULTIVITAMIN VITEYES CLASSIC CAPS F RX/OTC + COLLAGEN GUMMIES F CHEW VITEYES CLASSIC RX/OTC YELETS TEENAGE F RX/OTC MACULAR SUPPORT F FORMULA TABS CAPS YOUR LIFE MULTI ADULT F VITEYES CLASSIC F RX/OTC GUMMIES CHEW MULTIIVITAMIN TABS YOUR LIFE TEEN VITEYES CLASSIC F RX/OTC MULTIVITAMIN GUMMIES F MULTIVITAMIN TABS CHEW VITEYES RX/OTC RX/OTC CLASSIC+OMEGA-3 F ZYVANA CAPS F CAPS Multivitamins VITEYES F RX/OTC CLASSIC/OMEGA-3 CAPS DEKAS ESSENTIAL CAPS F VITEYES OPTIC NERVE F RX/OTC SUPPORT TABS DEKAS ESSENTIAL LIQD F RX/OTC VITRANOL FE TABS F ESTROFACTORS TABS F VITRANOL TABS F RX/OTC HIGH POTENCY F MULTIVITAMIN TABS VITREXATE FE TABS F RX/OTC MULTI VITAMIN TABS F VITREXATE TABS F RX/OTC MULTI VITAMIN/D-3 TABS F VITREXYL TABS F RX/OTC
VITREXYL/IRON TABS F RX/OTC
VITRUM 50+ ADULT- F RX/OTC MULTI IRON FREE TABS
Oregon Trillium OHP Updated September 1, 2021
144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits multiple vitamin tabs or 0.4 5000 unit, 1.5 mg-1.7 mg-2 mg-0.4 mg-1.5 mg-1.5 mg- mg-6 mcg-10 mg-20 mg-30 1.7 mg-1.7 mg-2 mg-2 mg- unit-60 mg-400 mcg-400 6 mcg-6 mcg-10 mg-10 unit-3000 unit, 1.5 mg-1.7 mg-20 mg-20 mg-30 unit- mg-2 mg-6 mcg-10 mg-20 30 unit-60 mg-60 mg-400 mg-30 unit-60 mg-400 unit-400 unit-5000 unit- mcg-400 unit-5000 unit, 1.5 5000 unit, 0.4 mg-1.5 mg- mg-1.7 mg-2 mg-6 mcg-10 1.7 mg-2 mg-6 mcg-10 mg- mg-20 mg-30 unit-60 mg- 20 mg-30 unit-60 mg-400 75 mg-400 mcg-400 unit- unit-5000 unit, 0.4 mg-1.5 5000 unit, 1.5 mg-1.7 mg-2 mg-1.7 mg-2 mg-6 mcg-20 mg-6 mcg-10 unit-20 mg- mg-60 mg-400 unit-5000 60 mg-400 mcg-400 unit- unit, 0.4 mg-12 mcg-15 5000 unit, 1.5 mg-1.7 mg-2 mg-20 mg-30 unit-45 mcg- mg-6 mcg-15 unit-20 mg- 100 mg-600 mg, 0.4 mg-6 20 mg-60 mg-400 mcg-400 mcg-10 mg-1.5 mg-1.7 mg- unit-5000 unit, 1.5 mg-1.7 2 mg-20 mg-30 unit-60 mg- mg-2 mg-6 mcg-20 mg-60 400 unit-5000 unit, 0.4 mg- mg-125 unit-5000 unit, 1.5 6 mg-10 mg-10.3 mg-15 mg-1.7 mg-2 mg-6 mcg-20 unit-18 mcg-20 mg-100 mg-60 mg-400 mcg-400 mg-333 mg-400 unit-5000 unit-5000 unit, 1.5 mg-1.7 unit, 1 mcg-1 mg-1 mg-2 mg-2 mg-6 mcg-7.5 unit-10 mg-2.5 mg-20 mg-50 mg- mg-20 mg-45 mg-60 mg- 400 unit-5000 unit, 1 mcg-1 500 mcg-800 unit-3000 mg-1 mg-2 mg-2.5 mg-20 F unit, 1.5 mg-20 mg-1.7 mg- mg-50 mg-75 mg-400 unit- 2 mg-6 mcg-30 unit-60 mg- 5000 unit, 1 mcg-1 mg-2 400 mcg-400 unit-3000 mg-2.5 mg-7 mg-20 mg-50 unit-5000 unit, 1.7 mg-1 mg-400 unit-5000 unit, 1 mg-1 mg-1.5 mg-3 mcg-10 mg-1 mg-1.5 mg-1.7 mg-3 mcg-20 mg-50 mg-60 mg- mcg-10 mcg-20 mg-50 mg- 1200 mcg, 1.7 mg-1 mg-1 60 mg-1200 mcg, 1.5 mg- mg-1.5 mg-3 mcg-20 mg- 1.7 mg-2 mg-10 mg-20 mg- 50 mg-60 mg-400 unit- 30 unit-60 mg-400 mcg- 4000 unit, 1.7 mg-1 mg-1 400 unit-5000 unit, 1.5 mg- mg-1.5 mg-60 mg-3 mcg- 1.7 mg-2 mg-4 mg-6 mcg- 20 mg-50 mg-400 unit- 10 mcg-10 mg-13.5 mg-20 4000 unit, 10 mg-1.5 mg- mg-60 mg-400 mcg-824 1.7 mg-2 mg-25 mcg-25 mcg, 1.5 mg-1.7 mg-2 mg- mg-40 mg-50 mg-50 mg-50 6 mcg-10 mcg-20 mg-60 mg-100 mg-400 mcg-2000 mg-400 mcg-1500 mcg, 1.5 mcg-2500 unit, 10.3 mg-0.4 mg-1.7 mg-2 mg-6 mcg-10 mg-6 mg-10 mg-15 unit-18 mg-20 mg-30 mcg-30 unit- mcg-20 mg-100 mg-333 60 mg-400 mcg-400 unit- mg-400 unit-5000 unit, 2 5000 unit, 1.5 mg-1.7 mg-2 mg-1 mcg-1 mg-1 mg-2.5 mg-6 mcg-10 mg-20 mg-30 mg-20 mg-50 mg-400 unit- unit-45 mg-60 mg-400 5000 unit, 2 mg-6 mcg-20 mcg-400 unit-3000 unit, 1.5 mg-60 mg-400 mcg-400 mg-1.7 mg-2 mg-6 mcg-10 unit-5000 unit-1.5 mg-1.7 mg-20 mg-30 unit-60 mg- mg, 20 mg-1.5 mg-1.7 mg- 300 mcg-400 mcg-400 unit- 2 mg-6 mcg-10 mg-30 unit- Oregon Trillium OHP Updated September 1, 2021
145 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 60 mg-400 unit-5000 unit, MULTIVITAMIN TABS 0.1 200 unit-250 mg-10000 MG-1 MG-1.5 MG-2 MG-10 F unit, 200 unit-250 mg-5000 MCG-20 MG-28.5 MG-37.5 unit, 28.5 mg-0.1 mg-1 mg- MG-1500 MCG 2 mg-20 mg-1.5 mg-37.5 mg-400 unit-5000 unit, 3 NEOMULTIVITE TABS F mg-10 mg-10 mg-12 mcg- 20 mg-30 unit-45 mcg-100 OMNICAP TABS F mg-400 mcg-500 mg, 3 ONE DAILY ESSENTIAL F mg-3 mg-3.4 mg-9 mcg-10 TABS mg-20 mg-30 mcg-30 unit- 90 mg-400 mcg-400 unit- ONE-A-DAY ESSENTIAL F 5000 unit, 3 mg-9 mcg-10 TABS (multiple vitamin) mg-10 mg-20 mg-30 mcg- ONE-A-DAY MENS TABS 30 unit-45 mg-90 mg-400 0.4 MG-2.25 MG-2.55 MG- mcg-400 unit-5000 unit-3 3 MG-9 MCG-10 MG-20 mg-3.4 mg, 3 mg-9 mcg-10 MG-200 MG-5000 UNIT- mg-20 mg-30 mcg-90 mg- 400 UNIT-45 UNIT, 3 MG- F 400 mcg-400 unit-3 mg-3.4 0.4 MG-2.25 MG-2.55 MG- mg-30 unit-5000 unit, 40 9 MCG-10 MG-20 MG-45 mg-5 mg-10 mg-10 mg-50 UNIT-200 MG-400 UNIT- mg-62.5 mg-100 mcg-120 5000 UNIT (multiple mg-400 mcg, 5 mg-10 mg- vitamin) 10 mg-12 mcg-20 mg-30 unit-45 mcg-100 mg-400 QUINTABS TABS F mcg-500 mg, 5 mg-10 mg- 12 mcg-15 mg-20 mg-30 THERA TABS F unit-45 mcg-100 mg-400 THEREMS MULTIVITAMIN F mcg-500 mg, 5 mg-12 TABS mcg-20 mg-45 mcg-100 mg-400 mcg-500 mg-30 Ped MV w/ Fluoride unit-10 mg-10 mg, 6 mcg- RX/OTC 1.5 mg-1.7 mg-2 mg-10 FLORIVA PLUS SOLN F mg-20 mg-30 unit-60 mg- pediatric multivitamins w/fl F RX/OTC 400 mcg-400 unit-5000 chew unit, 6 mcg-20 mg-1.5 mg- 1.7 mg-2 mg-60 mg-400 pediatric multivitamins w/fl F RX/OTC mcg-400 unit-5000 unit, 9 soln mcg-10 mg-30 mcg-30 pediatric vitamins acd w/ RX/OTC unit-45 mg-90 mg-400 fluoride soln 0.25 mg/ml-35 F mcg-3 mg-10 mg-20 mg-3 mg/ml-400 unit/ml-1500 mg-3.4 mg-400 unit-5000 unit/ml unit, 9 mcg-3 mg-3 mg-3.4 pediatric vitamins acd w/ mg-10 mg-20 mg-30 mcg- fluoride soln 0.5 mg/ml-35 F 30 unit-90 mg-400 mcg- mg/ml-400 unit/ml-1500 400 unit-5000 unit unit/ml MULTIVITAMIN ADULT F QUFLORA PEDIATRIC F RX/OTC TABS CHEW QUFLORA PEDIATRIC F RX/OTC SOLN Ped MV w/ Iron Oregon Trillium OHP Updated September 1, 2021
146 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANIMAL SHAPES/IRON F pediatric multiple vitamin w/ CHEW minerals & c chew 1 mg- 1.5 mg-1.7 mg-2 mg-2 mg- BPROTECTED PEDIA F POLY-VITE/IRON SOLN 6 mcg-10 mcg-10 mg-15 mg-18 mg-20 mcg-20 mcg- F DINO-LIFE W/IRON & F 20 mg-30 unit-40 mg-45 ZINC CHEW mcg-50 mg-60 mg-108 mg- HONEY BEARS W/IRON F 150 mcg-400 mcg-400 unit- AND ZINC CHEW 3500 unit MULTIVITAMIN PLUS F pediatric multiple vitamin w/ RX/OTC IRON CHILDRENS CHEW minerals & c soln 0.5 PC PEDIATRIC POLY- mg/ml-0.6 mg/ml-0.6 VITAMIN DROPS/IRON F mg/ml-3 mg/ml-4 mcg/ml-5 SOLN mg/ml-6 mg/ml-15 mcg/ml- 45 mg/ml-50 unit/ml-400 pediatric multiple vitamins F w/ iron chew mcg/ml-500 unit/ml-4627 F unit/ml, 0.5 mg/ml-0.6 POLY-VI-SOL/IRON SOLN F mg/ml-0.6 mg/ml-3 mg/ml-4 mcg/ml-6 mg/ml-7.5 mg/ml- POLY-VITA/IRON SOLN F 15 mcg/ml-45 mg/ml-50 unit/ml-300 mcg/ml-400 POLY-VITE/IRON SOLN F unit/ml-3170 unit/ml Pediatric multiple vitamins F RX/OTC Ped Multi Vitamins w/Fl & FE w/ minerals Chew ped multivitamins w/fl & RX/OTC Pediatric multiple vitamins F RX/OTC iron soln 0.25 mg/ml-0.4 w/ minerals Liqd mg/ml-0.5 mg/ml-0.6 F Pediatric multiple vitamins F RX/OTC mg/ml-5 unit/ml-8 mg/ml-10 w/ minerals Soln mg/ml-35 mg/ml-400 unit/ml-1500 unit/ml Pediatric Multiple Vitamins Ped Multiple Vitamins w/ Minerals BPROTECTED PEDIA F POLY-VITE SOLN AQUADEKS LIQD 0.6 RX/OTC MG/ML-0.6 MG/ML-0.6 CULTURELLE KIDS MG/ML-2 MG/ML-3 COMPLETEMULTIVITAMI F MG/ML-3 MG/ML-5 N + PROBIOTIC CHEW CULTURELLE KIDS MG/ML-6 MG/ML-10 F MCG/ML-15 MCG/ML-15 PROBIOTIC/MULTIVITAMI F MG/ML-45 MG/ML-50 N CHEW UNIT/ML-400 MCG/ML- GERBER LIL' BRAINIES F 400 UNIT/ML-5751 CHEW UNIT/ML MULTIVITAMIN F DEKAS PLUS LIQD 0.6 CHILDRENS CHEW MG/ML-0.6 MG/ML-0.6 MG/ML-2 MG/ML-3 MULTIVITAMIN INFANT & F MG/ML-5 MG/ML-6 TODDLER SOLN MG/ML-10 MCG/ML-15 F NOVAFERRUM MCG/ML-45 MG/ML-50 PEDIATRIC F UNIT/ML-500 MCG/ML- MULTIVITAMIN LIQD 750 UNIT/ML-5751 UNIT/ML
Oregon Trillium OHP Updated September 1, 2021
147 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ONE-A-DAY VITACRAVES GNP PRENATAL TABS F GUMMIES+OMEGA-3 NF DHA CHEW (pediatric GOODSENSE PRENATAL F multiple vitamin w/ c & fa) VITAMINS TABS PC PEDIATRIC POLY- F HM ONE DAILY F VITAMIN DROPS SOLN PRENATAL COMBO MISC pediatric multiple vitamin w/ F JENLIVA c & fa chew PRENATAL/POSTNATAL F CAPS pediatric multiple vitamin w/ F extra c & fa chew KP PRENATAL F MULTIVITAMINS TABS pediatric multiple vitamins F soln KPN PRENATAL TABS F PEDIAVIT LIQD F MYNATAL CAPS F POLY-VI-SOL SOLN F MYNATE 90 PLUS TBCR F POLY-VITA SOLN F NATALVIT TABS F POLY-VITE PEDIATRIC F SOLN NIVA-PLUS TABS F RX/OTC Pediatric Vitamins O-CAL FA TABS F RX/OTC HONEY BEARS CHEW F O-CAL PRENATAL TABS F MULTIVITAMIN GUMMIES F CHILDRENS CHEW ONE-A-DAY WOMENS F Prenatal Vitamins PRENATAL MISC BRAINSTRONG F PERRY PRENATAL CAPS F PRENATAL MISC CALNA TABS F PNV TABS 29-1 TABS F PRE-NATAL FORMULA RX/OTC CENTRUM SPECIALIST F F PRENATAL MISC TABS PRENATAL 19 CHEW 1 CLASSIC PRENATAL F TABS MG-3 MG-3 MG-15 MG-20 MG-20 MG-30 UNIT-100 CLINICAL NUTRIENTS MG-7 MG-12 MCG-29 MG- PRENATAL FORMULA F 200 MG-400 UNIT-1000 F TABS UNIT, 1 MG-3 MG-3 MG-7 CO-NATAL FA TABS F RX/OTC MG-12 MCG-15 MG-20 MG-20 MG-29 MG-30 CVS PRENATAL UNIT-100 MG-200 MG-400 GUMMY/DHA/FOLIC ACID F UNIT-1000 UNIT CHEW CVS WOMENS F PRENATAL+DHA MISC ENFAMIL EXPECTA MISC F
Oregon Trillium OHP Updated September 1, 2021
148 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL 19 TABS 1 RX/OTC PRENATAL TABS 0.5 MG- MG-3 MG-3 MG-12 MCG- 0.5 MG-0.5 MG-0.75 MG- 15 MG-20 MG-20 MG-25 0.75 MG-2.5 MCG-2.5 MG- MG-29 MG-30 UNIT-400 3.75 MG-3.75 UNIT-5 MG- UNIT-7 MG-100 MG-200 6.75 MG-15 MG-25 MCG- MG-1000 UNIT, 1 MG-3 F 25 MG-50 MG-100 UNIT- MG-3 MG-7 MG-12 MCG- 200 MCG-500 UNIT, 0.8 15 MG-20 MG-20 MG-25 MG-1.7 MG-1.8 MG-2.6 F MG-29 MG-30 UNIT-100 MG-8 MCG-20 MG-25 MG- MG-200 MG-400 UNIT- 28 MG-30 UNIT-120 MG- 1000 UNIT 200 MG-400 UNIT-4000 UNIT, 1.7 MG-1.8 MG-2.6 PRENATAL AND IRON F RX/OTC TABS MG-8 MCG-20 MG-25 MG- 28 MG-30 UNIT-120 MG- PRENATAL COMPLETE F 200 MG-400 UNIT-800 TABS MCG-4000 UNIT PRENATAL FORMULA A- F PRENATAL TABS 0.8 MG- RX/OTC FREE TABS 1.7 MG-1.84 MG-2.6 MG-4 PRENATAL FORTE TABS F RX/OTC MCG-11 UNIT-18 MG-25 F MG-27 MG-100 MG-200 PRENATAL MULTI +DHA F MG-400 UNIT-4000 UNIT CAPS PRENATAL TABS 1 MG- RX/OTC PRENATAL 1.84 MG-2 MG-3 MG-10 MULTIVITAMIN + DHA F MCG-10 MG-10 MG-12 F MISC MCG-20 MG-25 MG-27 PRENATAL MG-120 MG-200 MG-1200 MULTIVITAMIN PLUS MCG DHA MISC 1.7 MG-2 MG-2 prenatal vit w/ ferrous F MG-2.5 MG-8 MCG-10 fumarate-folic acid tabs MG-15 MG-20 MG-28 MG- F prenatal vit w/ iron 30 UNIT-50 MG-60 MG- carbonyl-folic acid tabs 3 150 MCG-200 MG-300 mg-1 mg-3 mg-3 mg-3 mg- MCG-300 MG-400 UNIT- 7 mg-8 mcg-15 mg-20 mg- F 975 MCG-4000 UNIT 29 mg-30 mcg-30 unit-100 PRENATAL PLUS IRON F mg-120 mg-150 mcg-200 TABS mg-400 unit-4000 unit PRENATAL VITAMIN & F MINERAL TABS PRENATAL VITAMINS F RX/OTC PLUS LOW IRON TABS PRENATAL VITAMINS F TABS PRENATAL VITAMINS- F MISC PRENATAL+DHA MISC F
PRENATAL-U CAPS F
Oregon Trillium OHP Updated September 1, 2021
149 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL/OMEGA- F vitamins w/ lipotropics tabs 3/FOLIC ACID/IRON CAPS 0.33 mg-0.33 mg-0.33 mg- RX/OTC 1.7 mcg-1.7 mg-3.3 mg- PRENATVITE RX TABS F 100 mg-100 mg-111.3 mg- RX/OTC 111.3 mg, 0.33 mg-0.33 PREPLUS TABS F mg-0.33 mg-1.7 mcg-1.7 mg-3.3 mg-43.33 mg-100 PX PRENATAL F MULTIVITAMINS TABS mg-100 mg-111.3 mg- 111.3 mg, 0.33 mg-0.33 QC PRENATAL TABS F mg-1 mg-1.67 mcg-1.67 mg-3.33 mg-29 mg-100 RA PRENATAL TABS F mg, 0.33 mg-0.33 mg-1 mg-1.67 mcg-1.67 mg-3.33 SIMILAC PRENATAL F mg-29 mg-100 mg-111.33 EARLY SHIELD MISC mg-111.33 mg-200 mg, 0.333 mg-0.333 mg-1 mg- SM ONE DAILY F PRENATAL MISC 1.666 mcg-1.666 mg-3.333 mg-29 mg-100 mg, 0.333 THERANATAL F COMPLETE MISC mg-0.333 mg-1 mg-1.667 mcg-1.667 mg-3.333 mg- THERANATAL CORE F RX/OTC 29 mg-100 mg-111.333 NUTRITION TABS mg-111.333 mg-266.667 THRIVITE RX TABS F mg, 0.333 mg-0.333 mg-1 mg-1.67 mcg-1.67 mg-3.33 TRINATAL RX 1 TABS F mg-29 mg-100 mg-500 mg, 0.335 mg-0.335 mg-1 mg- F VINATE ONE TABS F 1.665 mcg-1.665 mg-3.335 mg-29 mg-100 mg, 0.34 mg-0.34 mg-1 mg-1.67 VOL-NATE TABS F mcg-1.67 mg-3.34 mg-29 RX/OTC mg-100 mg-111 mg-111 VOL-PLUS TABS F mg-200 mg, 10 mg-10 mg- 10 mg-10 mg-18 mg-25 VOL-TAB RX TABS F mg-25 mg-30 mg-50 mg-50 mg-50 mg-50 mg-50 mg-50 WEGMANS COMPLETE F PRENATAL+DHA MISC mg-100 mg-100 unit-150 mg-200 mcg-225 mcg-250 YOUR LIFE MULTI F mg-400 mcg-400 unit- PRENATAL CAPS 10000 unit, 100 mcg-100 Vitamins w/ Lipotropics mcg-100 mcg-100 mg-100 mg-100 mg-100 mg-100 ACTIFLOVIT EAR F HEALTH TABS mg, 100 mcg-100 mcg-100 mcg-100 mg-100 mg-100 LIPOTRIAD TABS NF mg-100 mg-100 mg-100 (vitamins w/ lipotropics) mg-100 mg-100 mg, 100 mcg-100 mcg-100 mg-100 mg-100 mg-100 mg-100 mg-100 mg-100 mg-100 mg-100 mg-200 mcg, 2 mcg-2 mg-2 mg-3 mg-3 mg-10 mg-30 mg-56 mg-83 mg-110 mg-240 mg, 3 mg- Oregon Trillium OHP Updated September 1, 2021
150 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 3.4 mg-4 mg-12 mcg-20 FLONASE ALLERGY RX/OTC mg-20 mg-20 mg-25 mg-30 RELIEF SUSP (fluticasone NF mcg-40 mg-400 mg, 50 propionate (nasal)) mcg-50 mcg-50 mcg-50 fluticasone propionate F RX/OTC mg-50 mg-50 mg-50 mg-50 (nasal) susp mg, 50 mcg-50 mcg-50 mg-50 mg-50 mg-50 mg-50 NASACORT ALLERGY F mg-50 mg-50 mg-50 mg- 24HR AERO 100 mcg, 50 mcg-50 mcg- NASACORT ALLERGY 50 mg-50 mg-50 mg-50 24HR AERO (triamcinolone NF mg-50 mg-50 mg-50 mg-50 acetonide (nasal)) mg-400 mcg, 77 mg-100 NASACORT ALLERGY mcg-100 mcg-100 mcg-100 24HR CHILDRENS AERO NF mcg-100 mcg-100 mg-100 (triamcinolone acetonide mg-100 mg-100 mg-100 (nasal)) mg-400 mcg, 8 mg-10 triamcinolone acetonide F mcg-10 mg-20 mg-30 mg- (nasal) aero 30 mg-50 mg Sympathomimetic Decongestants MUSCULOSKELETAL THERAPY AGENTS - Drugs to Treat Spasms AFRIN 12 HOUR SOLN NF (oxymetazoline hcl) Central Muscle Relaxants AFRIN ALL NIGHT baclofen tabs or 10 mg, 20 F NODRIP SOLN NF mg (oxymetazoline hcl) chlorzoxazone tabs 500 mg F AFRIN NASAL SPRAY NF SOLN (oxymetazoline hcl) cyclobenzaprine hcl tabs F AFRIN NODRIP EXTRA 10 mg, 5 mg MOISTURIZING SOLN NF methocarbamol tabs or 500 F (oxymetazoline hcl) mg, 750 mg AFRIN NODRIP ORIGINAL NF ROBAXIN-750 TABS NF SOLN (oxymetazoline hcl) (methocarbamol) AFRIN NODRIP SEVERE tizanidine hcl tabs 4 mg, 2 F CONGESTION SOLN NF mg (oxymetazoline hcl) ZANAFLEX TABS 4 MG NF AFRIN NODRIP SINUS NF (tizanidine hcl) SOLN (oxymetazoline hcl) Direct Muscle Relaxants AFRIN PUMP MIST SOLN NF (oxymetazoline hcl) DANTRIUM CAPS NF (dantrolene sodium) AFRIN SINUS SOLN NF (oxymetazoline hcl) dantrolene sodium caps or F 100 mg, 25 mg, 50 mg AFRIN SOLN NF (oxymetazoline hcl) NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus DRISTAN SPRAY SOLN NF (oxymetazoline hcl) Nasal Steroids DURATION 12 HOUR NF FLONASE ALLERGY RX/OTC SOLN (oxymetazoline hcl) RELIEF CHILDRENS NF DURATION SPRAY SOLN NF SUSP (fluticasone (oxymetazoline hcl) propionate (nasal)) Oregon Trillium OHP Updated September 1, 2021
151 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITTLE NOSES OMEGA-3 CAPS 308 MG- F DECONGESTANTNOSE F 448 MG-910 MG-1400 MG DROPS SOLN OMEGA-3 EPA FISH OIL F NEO-SYNEPHRINE CAPS COLD+ALLERGY EXTRA NF STRENGTH SOLN (phenylephrine hcl) NEO-SYNEPHRINE COLD+ALLERGY MILD F STRENGTH SOLN oxymetazoline hcl soln F phenylephrine hcl soln F pseudoephedrine hcl tabs F 60 mg, 30 mg SUDAFED CONGESTION TABS (pseudoephedrine NF hcl) SUDAFED SINUS CONGESTION TABS NF (pseudoephedrine hcl) VICKS SINEX 12 HOUR DECONGESTANT SOLN NF (oxymetazoline hcl) VICKS SINEX MOISTURIZING SOLN NF (oxymetazoline hcl) VICKS SINEX SEVERE NASALDECONGESTANT NF SOLN (oxymetazoline hcl) VICKS SINEX SEVERE NF SOLN (oxymetazoline hcl) NUTRIENTS Carbohydrates GLUCOSE NURSETTE NF SOLN (glucose) glucose soln 5 % F Misc. Nutritional Substances FISH OIL CAPS 525 MG- F 875 MG, 950 MG-1360 MG FISH OIL TRIPLE F STRENGTH CAPS FISH OIL ULTRA CAPS F
Oregon Trillium OHP Updated September 1, 2021
152 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits omega-3 fatty acids caps mg, 250 mg-500 mg-1000 450 mg-645 mg, 108 mg- mg, 3 mg-108 mg-162 mg- 162 mg-300 mg-600 mg, 1000 mg, 300 mg-400 mg- 120 mg-220 mg-600 mg, 1000 mg, 360 mg-455 mg- 175 mg-175 mg-260 mg- 900 mg-1000 mg, 5 unit- 260 mg-435 mg-435 mg, 120 mg-180 mg, 600 mg- 175 mg-260 mg-435 mg, 1000 mg, 75 mg-90 mg- 120 mg-180 mg, 5 unit-100 210 mg-1000 mg mg-160 mg-300 mg-1000 OMEGA-3 FISH OIL F mg, 90 mg-180 mg-300 EXTRA STRENGTH CAPS mg-772.5 mg, 120 mg-180 ULTRA OMEGA-3 FISH F mg-500 mg, 130 mg-320 OIL BURP-LESS CAPS mg-500 mg, 135 mg-270 mg-500 mg, 2.5 unit-200 Proteins mg-300 mg-500 mg, 200 L-CARNITINE CAPS OR F mg-300 mg-1000 mg, 27 500 MG mg-89 mg-244 mg-500 mg, 60 mg-90 mg-150 mg-500 levocarnitine caps 250 mg F mg, 60 mg-90 mg-500 mg, 108 mg-180 mg-360 mg- levocarnitine tabs 500 mg F 1200 mg, 12 mg-360 mg- 360 mg-1200 mg, 1200 OPHTHALMIC AGENTS - Drugs to Treat the Eye mg-144 mg-216 mg-360 mg, 1200 mg-360 mg, 144 Artificial Tears and Lubricants mg-180 mg-1200 mg, 144 artificial tear solution soln F mg-216 mg-1200 mg, 144 F mg-216 mg-360 mg-1200 carboxymethylcellulose May refill at mg, 15 unit-144 mg-216 sodium (ophth) soln 0.25 F 50% remaining mg-1200 mg, 2 unit-1200 %, 0.5 % mg, 216 mg-324 mg-600 mg-1200 mg, 276 mg-336 carboxymethylcellulose mg-1200 mg, 60 mg-120 sodium (ophth) soln 1 %, F mg-180 mg-1200 mg, 60 0.5 % mg-300 mg-360 mg-1200 glycerin-hypromellose- May refill at mg, 1 gm-120 mg-180 mg- polyethylene glycol 400 F 50% remaining 300 mg, 1 unit-120 mg-180 soln mg-1000 mg, 1 unit-120 MOISTURE EYES SOLN NF May refill at mg-180 mg-340 mg-1000 (propylene glycol-glycerin) 50% remaining mg, 1 unit-200 mg-300 mg- May refill at polyvinyl alcohol soln F 1000 mg, 1 unit-300 mg- 50% remaining 1000 mg, 1 unit-300 mg- 1000 mg-1000 mg, 1.8 propylene glycol-glycerin F May refill at unit-120 mg-180 mg, 10 soln 50% remaining unit-100 mg-500 mg-1000 REFRESH PLUS SOLN mg, 100 mg-150 mg-300 (carboxymethylcellulose F mg-1000 mg, 100 mg-160 sodium (ophth)) mg-1000 mg, 1000 mg-1 REFRESH TEARS SOLN May refill at mg-120 mg-180 mg, 120 (carboxymethylcellulose F 50% remaining mg-1000 mg-180 mg, 120 sodium (ophth)) mg-180 mg-300 mg-1000 mg, 180 mg-270 mg-1000 SOOTHE SOLN F mg, 250 mg-350 mg-1000 Oregon Trillium OHP Updated September 1, 2021
153 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits THERATEARS SOLN 0.25 F TIMOPTIC-XE SOLG F May refill at % (timolol maleate (ophth)) 50% remaining THERATEARS SOLN 0.25 May refill at Cycloplegic Mydriatics % (carboxymethylcellulose NF 50% remaining sodium (ophth)) ATROPINE SULFATE F May refill at SOLN OP 1 % 50% remaining VISINE DRY EYE RELIEF F May refill at May refill at ALLDAY COMFORT SOLN 50% remaining CYCLOGYL SOLN 1 % NF (cyclopentolate hcl) 50% remaining VISINE DRY EYE RELIEF F May refill at May refill at SOLN 50% remaining cyclopentolate hcl soln 1 % F 50% remaining VISINE DRY EYE SOLN May refill at NF F May refill at (glycerin-hypromellose- 50% remaining ISOPTO ATROPINE SOLN 50% remaining polyethylene glycol 400) MYDRIACYL SOLN NF May refill at white petrolatum-mineral oil F (tropicamide) 50% remaining oint May refill at tropicamide soln F Beta-blockers - Ophthalmic 50% remaining May refill at betaxolol hcl (ophth) soln F 50% remaining Miotics May refill at ISOPTO CARPINE SOLN NF May refill at BETIMOL SOLN F (pilocarpine hcl) 50% remaining 50% remaining May refill at PHOSPHOLINE IODIDE F May refill at BETOPTIC-S SUSP F SOLR 50% remaining 50% remaining May refill at F May refill at carteolol hcl (ophth) soln F pilocarpine hcl soln 50% remaining 50% remaining COSOPT SOLN May refill at Ophthalmic Adrenergic Agents NF (dorzolamide hcl-timolol 50% remaining ALPHAGAN P SOLN 0.1 % F May refill at maleate) 50% remaining dorzolamide hcl-timolol May refill at ALPHAGAN P SOLN 0.15 NF May refill at maleate soln 0.5 %-2 %, 50% remaining % (brimonidine tartrate) 50% remaining 22.3 mg/ml-6.8 mg/ml, 5 F May refill at brimonidine tartrate soln F mg/ml-20 mg/ml, 6.8 50% remaining mg/ml-22.3 mg/ml May refill at Ophthalmic Anti-infectives levobunolol hcl soln F 50% remaining bacitracin (ophthalmic) oint F timolol maleate (ophth) F May refill at solg 0.25 %, 0.5 % 50% remaining bacitracin-polymyxin b F (ophth) oint timolol maleate (ophth) F May refill at soln 0.25 %, 0.5 % 50% remaining BLEPH-10 SOLN May refill at (sulfacetamide sodium NF 50% remaining timolol maleate (ophth) F (ophth)) soln 0.5 % CILOXAN SOLN NF May refill at TIMOPTIC OCUDOSE F (ciprofloxacin hcl (ophth)) 50% remaining SOLN 0.25 % ciprofloxacin hcl (ophth) F May refill at TIMOPTIC OCUDOSE soln 50% remaining SOLN 0.5 % (timolol NF maleate (ophth)) erythromycin (ophth) oint F TIMOPTIC SOLN (timolol May refill at NF gentamicin sulfate (ophth) F maleate (ophth)) 50% remaining oint
Oregon Trillium OHP Updated September 1, 2021
154 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits gentamicin sulfate (ophth) May refill at May refill at F FML FORTE SUSP F soln 50% remaining 50% remaining May refill at levofloxacin (ophth) soln F FML LIQUIFILM SUSP NF May refill at 50% remaining (fluorometholone (ophth)) 50% remaining moxifloxacin hcl (ophth) F May refill at FML OINT F soln 50% remaining MAXITROL OINT 0.1 %- neomycin-bacitracin zn- F polymyxin oint 3.5 MG/GM-10000 NF UNIT/GM (neomycin- OCUFLOX SOLN NF May refill at (ofloxacin (ophth)) 50% remaining polymy-dexameth) May refill at MAXITROL SUSP 0.1 %- May refill at ofloxacin (ophth) soln F 50% remaining 3.5 MG/ML-10000 NF 50% remaining UNIT/ML (neomycin- polymyxin b-trimethoprim F May refill at polymy-dexameth) soln 50% remaining neomycin-polymy- POLYTRIM SOLN NF May refill at dexameth oint 0.1 %-3.5 F (polymyxin b-trimethoprim) 50% remaining mg/gm-10000 unit/gm sulfacetamide sodium F neomycin-polymy- May refill at (ophth) oint dexameth susp 0.1 %-3.5 F 50% remaining sulfacetamide sodium F May refill at mg/ml-10000 unit/ml (ophth) soln 50% remaining neomycin-polymyxin-hc F May refill at May refill at (ophth) susp 50% remaining tobramycin (ophth) soln F 50% remaining PRED FORTE SUSP May refill at TOBREX OINT F (prednisolone acetate NF 50% remaining (ophth)) TOBREX SOLN May refill at NF PRED MILD SUSP F May refill at (tobramycin (ophth)) 50% remaining 50% remaining May refill at trifluridine soln F 50% remaining PRED-G S.O.P. OINT F VIGAMOX SOLN May refill at May refill at NF PRED-G SUSP F (moxifloxacin hcl (ophth)) 50% remaining 50% remaining Ophthalmic Local Anesthetics prednisolone acetate F May refill at (ophth) susp 50% remaining tetracaine hcl (ophth) soln F PREDNISOLONE F May refill at ACETATE P-F SUSP 50% remaining Ophthalmic Steroids PREDNISOLONE SODIUM May refill at BLEPHAMIDE S.O.P. F PHOSPHATE SOLN OP 1 F 50% remaining OINT % May refill at BLEPHAMIDE SUSP F sulfacetamide sod- F May refill at 50% remaining prednisolone soln 50% remaining dexamethasone sodium F May refill at PA phosphate (ophth) soln 50% remaining TOBRADEX OINT F May refill at FLAREX SUSP F TOBRADEX SUSP PA; May refill at 50% remaining (tobramycin- NF 50% remaining ) fluorometholone (ophth) F May refill at dexamethasone susp 50% remaining tobramycin- F PA; May refill at dexamethasone susp 50% remaining
Oregon Trillium OHP Updated September 1, 2021
155 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Ophthalmics - Misc. FLOXIN OTIC SOLN NF (ofloxacin (otic)) ACULAR LS SOLN May refill at (ketorolac tromethamine NF 50% remaining ofloxacin (otic) soln F (ophth)) Otic Combinations ACULAR SOLN (ketorolac NF May refill at tromethamine (ophth)) 50% remaining CIPRO HC SUSP F AZOPT SUSP May refill at NF QL(7.5 ml per (brinzolamide) 50% remaining CIPRODEX SUSP May refill at fill retail)1 rtl brinzolamide susp F (ciprofloxacin- NF 50% remaining dexamethasone) MAX fill,30 rtl day(s) supply, diclofenac sodium (ophth) F May refill at soln 50% remaining QL(7.5 ml per ciprofloxacin- F fill retail)1 rtl DORZOLAMIDE HCL F May refill at dexamethasone susp MAX fill,30 rtl SOLN 50% remaining day(s) supply, May refill at dorzolamide hcl soln F neomycin-polymyxin-hc F 50% remaining (otic) soln May refill at flurbiprofen sodium soln F neomycin-polymyxin-hc F 50% remaining (otic) susp ketorolac tromethamine F May refill at OTOVEL SOLN (ophth) soln 50% remaining (ciprofloxacin-fluocinolone NF TRUSOPT SOLN NF May refill at acetonide) (dorzolamide hcl) 50% remaining Otic Steroids Prostaglandins - Ophthalmic hydrocortisone w/acetic May refill at F latanoprost soln F acid soln 50% remaining OXYTOCICS - Drugs to Prevent/Control Uterine LUMIGAN SOLN F May refill at Bleeding 50% remaining PA; May refill at Oxytocics methylergonovine maleate TRAVATAN Z SOLN NF 50% F (travoprost) remaining;QL(0 tabs or 0.2 mg .2 ml daily) PENICILLINS - Drugs to Treat Bacterial Infections PA; May refill at F 50% Aminopenicillins travoprost soln remaining;QL(0 .2 ml daily) amoxicillin caps F XALATAN SOLN NF May refill at (latanoprost) 50% remaining amoxicillin chew F OTIC AGENTS - Drugs to Treat the Ear amoxicillin susr F Otic Agents - Miscellaneous amoxicillin tabs F acetic acid (otic) soln F ampicillin caps F Otic Anti-infectives Natural Penicillins CETRAXAL SOLN NF (ciprofloxacin hcl (otic)) BICILLIN L-A SUSP F 600000 UNIT/ML Oregon Trillium OHP Updated September 1, 2021
156 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits penicillin v potassium solr F ALMOND OIL BITTER F RX/OTC FLAVOR LIQD penicillin v potassium tabs F ANISE EXTRACT LIQD F RX/OTC
Penicillin Combinations APPLE FLAVOR LIQD F RX/OTC amoxicillin & pot clavulanate chew 28.5 mg- F APRICOT FLAVOR LIQD F RX/OTC 200 mg, 57 mg-400 mg amoxicillin & pot BACON FLAVOR LIQD F RX/OTC clavulanate susr 57 mg/5ml-400 mg/5ml, 200 BACON FLAVOR F RX/OTC mg/5ml-28.5 mg/5ml, 250 NATURAL LIQD mg/5ml-62.5 mg/5ml, 28.5 F BANANA CONCENTRATE F RX/OTC mg/5ml-200 mg/5ml, 42.9 LIQD mg/5ml-600 mg/5ml, 600 BANANA CREAM FLAVOR F RX/OTC mg/5ml-42.9 mg/5ml, 62.5 LIQD mg/5ml-250 mg/5ml BANANA CREME FLAVOR F RX/OTC amoxicillin & pot LIQD clavulanate tabs 125 mg- BANANA FLAVOR LIQD F RX/OTC 250 mg, 125 mg-875 mg, F 250 mg-125 mg, 875 mg- 125 mg, 125 mg-500 mg, BEEF BRAISED NATURAL F RX/OTC 500 mg-125 mg FLAVOR LIQD AUGMENTIN ES-600 BEEF FLAVOR LIQD F RX/OTC SUSR (amoxicillin & pot NF clavulanate) BEEF TYPE FLAVOR F RX/OTC NATURAL LIQD AUGMENTIN SUSR 31.25 F MG/5ML-125 MG/5ML BEEF TYPE FLAVOR RX/OTC NATURALCHLORIDE F AUGMENTIN SUSR 62.5 FREE LIQD MG/5ML-250 MG/5ML NF (amoxicillin & pot BEEF TYPE FLAVOR OS F RX/OTC clavulanate) LIQD AUGMENTIN TABS 125 BITTER STOP FLAVOR F RX/OTC MG-500 MG (amoxicillin & NF LIQD pot clavulanate) BITTERNESS MASK F RX/OTC FLAVOR LIQD Penicillinase-Resistant Penicillins BITTERNESS RX/OTC dicloxacillin sodium caps F SUPPRESSOR FLAVOR F LIQD PHARMACEUTICAL ADJUVANTS BITTERNESS RX/OTC SUPRESSOR FLAVOR F Antimicrobial Agents LIQD RX/OTC METHYLPARABEN POWD F BLACKBERRY FLAVOR F RX/OTC LIQD PROPYLPARABEN POWD F RX/OTC BLUEBERRY FLAVOR F RX/OTC LIQD Flavoring Agents BUBBLE GUM F RX/OTC CONCENTRATE LIQD
Oregon Trillium OHP Updated September 1, 2021
157 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BUBBLE GUM FLAVOR F RX/OTC EUGENOL FLAVOR LIQD F RX/OTC LIQD RX/OTC BUBBLEGUM FLAVOR F RX/OTC FISH FLAVOR LIQD F LIQD RX/OTC FLAVORING EXTRACTS- F RX/OTC BUTTER FLAVOR LIQD F MISC RX/OTC BUTTER RUM FLAVOR F RX/OTC FLAVORX LIQD F LIQD RX/OTC BUTTERSCOTCH F RX/OTC GRAPE FLAVOR LIQD F FLAVOR LIQD GRILLED BEEF FLAVOR RX/OTC CARAMEL FLAVOR LIQD F RX/OTC NATURAL OIL SOLUBLE F LIQD CHEESECAKE FLAVOR F RX/OTC LIQD GRILLED CHICKEN RX/OTC FLAVOR NATURAL OIL F CHERRY FLAVOR LIQD F RX/OTC MISCIBLE LIQD GUAVA FLAVOR LIQD F RX/OTC CHICKEN (GRILLED) F RX/OTC FLAVOR LIQD HAM FLAVOR LIQD F RX/OTC CHICKEN FLAVOR LIQD F RX/OTC HONEY FLAVOR LIQD F RX/OTC CHICKEN FLAVOR OIL F RX/OTC SOLUBLE LIQD KAHLUA FLAVOR LIQD F RX/OTC CHICKEN FLAVOR F RX/OTC WATER MISCIBLE LIQD LEMON EXTRACT LIQD F RX/OTC CHICKEN ROASTED F RX/OTC CONCENTRATE LIQD LEMON FLAVOR LIQD F RX/OTC CHOCOLATE FLAVOR F RX/OTC LIQD LICORICE FLAVOR LIQD F RX/OTC CHOCOLATE HAZELNUT F RX/OTC FLAVOR LIQD LIVER CONCENTRATE F RX/OTC LIQD COCONUT FLAVOR LIQD F RX/OTC LIVER FLAVOR LIQD F RX/OTC COFFEE FLAVOR LIQD F RX/OTC MANGO FLAVOR LIQD F RX/OTC COLA FLAVOR LIQD F RX/OTC MAPLE FLAVOR LIQD F RX/OTC COTTON CANDY FLAVOR F RX/OTC LIQD MARSHMALLOW FLAVOR F RX/OTC LIQD CRAN-RASPBERRY F RX/OTC FLAVOR LIQD MINT CHOCOLATE CHIP F RX/OTC FLAVOR LIQD CREME DE MENTHE F RX/OTC FLAVOR LIQD NATURAL CARAMEL F RX/OTC LIQD CREME DEMENTHE F RX/OTC FLAVOR LIQD ORANGE CONCENTRATE F RX/OTC LIQD ENGLISH TOFFEE F RX/OTC FLAVOR LIQD ORANGE CREAM F RX/OTC FLAVOR LIQD
Oregon Trillium OHP Updated September 1, 2021
158 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORANGE FLAVOR LIQD F RX/OTC VANILLA FLAVOR LIQD F RX/OTC
ORANGE OIL FLAVOR F RX/OTC VITAMIN/IRON MASKING F RX/OTC LIQD AGENT FLAVOR LIQD PCCA SWEETNESS F RX/OTC WATERMELON FLAVOR F RX/OTC ENHANCER LIQD LIQD PEACH FLAVOR LIQD F RX/OTC WILD CHERRY FLAVOR F RX/OTC LIQD PEANUT BUTTER F RX/OTC Gelatin Capsules (Empty) FLAVOR LIQD CAPSULE CONI-SNAP #0 F RX/OTC PINA COLADA FLAVOR F RX/OTC CLEAR/CLEAR CAPS LIQD CAPSULE CONI-SNAP #0 RX/OTC PINEAPPLE FLAVOR F RX/OTC DARK BLUE/DARK BLUE F LIQD CAPS PRALINES AND CREAM RX/OTC F CAPSULE CONI-SNAP #0 F RX/OTC FLAVOR LIQD GREEN/CLEAR CAPS PUMPKIN FLAVOR LIQD F RX/OTC CAPSULE CONI-SNAP #0 RX/OTC LIGHT BLUE/WHITE F RASPBERRY FLAVOR F RX/OTC CAPS LIQD CAPSULE CONI-SNAP #0 F RX/OTC ROOT BEER FLAVOR F RX/OTC PINK/PINK CAPS LIQD CAPSULE CONI-SNAP #0 F RX/OTC SARDINE FLAVOR LIQD F RX/OTC RED/WHITE CAPS RX/OTC CAPSULE CONI-SNAP #0 F RX/OTC SHRIMP FLAVOR LIQD F WHITE/WHITE CAPS CAPSULE CONI-SNAP RX/OTC STEVIA GLYCERITE F RX/OTC LIQUID EXTRACT LIQD #0/PURPLE/OPAQUE/CLE F AR CAPS STRAWBERRY FLAVOR F RX/OTC LIQD CAPSULE CONI-SNAP F RX/OTC #00 CLEAR/CLEAR CAPS SWEETENING F RX/OTC ENHANCER LIQD CAPSULE CONI-SNAP F RX/OTC #00 WHITE/WHITE CAPS SWEETENING RX/OTC ENHANCER/FLAVORX F CAPSULE CONI-SNAP RX/OTC LIQD #000 CLEAR/CLEAR F CAPS TROPICAL PUNCH F RX/OTC FLAVOR LIQD CAPSULE CONI-SNAP #1 RX/OTC AQUABLUE/AQUA BLUE F TUNA FLAVOR LIQD F RX/OTC CAPS CAPSULE CONI-SNAP #1 RX/OTC TUNA TYPE FLAVOR OS F RX/OTC F LIQD BLUE/BLUE CAPS CAPSULE CONI-SNAP #1 RX/OTC TUTTI FRUTTI FLAVOR F RX/OTC F LIQD BLUE/PINK CAPS CAPSULE CONI-SNAP #1 RX/OTC TUTTI-FRUTTI FLAVOR F RX/OTC LIQD BLUE/POWDER BLUE F CAPS VANILLA BUTTERNUT F RX/OTC FLAVOR LIQD Oregon Trillium OHP Updated September 1, 2021
159 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAPSULE CONI-SNAP #1 RX/OTC F CAPSULE CONI-SNAP #1 F RX/OTC BROWN/IVORY CAPS YELLOW/YELLOW CAPS CAPSULE CONI-SNAP #1 RX/OTC CAPSULE CONI-SNAP #2 F RX/OTC BROWN/LIGHT BROWN F CLEAR/CLEAR CAPS CAPS CAPSULE CONI-SNAP #2 F RX/OTC CAPSULE CONI-SNAP #1 F RX/OTC WHITE CAPS CLEAR/CLEAR CAPS CAPSULE CONI-SNAP #3 F RX/OTC CAPSULE CONI-SNAP #1 RX/OTC BLUE/CLEAR CAPS DARKGREEN/DARK F CAPSULE CONI-SNAP #3 RX/OTC GREEN CAPS BROWN/LIGHT BLUE F CAPSULE CONI-SNAP #1 RX/OTC CAPS DARKGREEN/ORANGE F CAPSULE CONI-SNAP #3 F RX/OTC CAPS CLEAR/CLEAR CAPS CAPSULE CONI-SNAP #1 RX/OTC F CAPSULE CONI-SNAP #3 F RX/OTC GREEN/YELLOW CAPS DARKGREY/PINK CAPS CAPSULE CONI-SNAP #1 RX/OTC CAPSULE CONI-SNAP #3 F RX/OTC LIGHT BLUE/WHITE F GRAY/YELLOW CAPS CAPS CAPSULE CONI-SNAP #3 F RX/OTC CAPSULE CONI-SNAP #1 F RX/OTC GREEN/BLUE CAPS LIGHT GREY/PINK CAPS CAPSULE CONI-SNAP #3 F RX/OTC CAPSULE CONI-SNAP #1 F RX/OTC MAROON/BLUE CAPS ORANGE CAPS CAPSULE CONI-SNAP #3 RX/OTC CAPSULE CONI-SNAP #1 F RX/OTC MINTGREEN/MINT F PINK/AQUA BLUE CAPS GREEN CAPS CAPSULE CONI-SNAP #1 RX/OTC F CAPSULE CONI-SNAP #3 F RX/OTC PINK/CLEAR CAPS OLIVE/CLEAR CAPS CAPSULE CONI-SNAP #1 RX/OTC F CAPSULE CONI-SNAP #3 F RX/OTC PINK/PINK CAPS ORANGE/ORANGE CAPS CAPSULE CONI-SNAP #1 RX/OTC F CAPSULE CONI-SNAP #3 F RX/OTC PINK/WHITE CAPS PINK/CLEAR CAPS CAPSULE CONI-SNAP #1 RX/OTC F CAPSULE CONI-SNAP #3 F RX/OTC PINK/YELLOW CAPS PINK/PINK CAPS CAPSULE CONI-SNAP #1 RX/OTC F CAPSULE CONI-SNAP #3 F RX/OTC PURPLE/PURPLE CAPS RED/CLEAR CAPS CAPSULE CONI-SNAP #1 RX/OTC F CAPSULE CONI-SNAP #3 F RX/OTC RED/BLUE CAPS RED/RED CAPS CAPSULE CONI-SNAP #1 RX/OTC F CAPSULE CONI-SNAP #3 F RX/OTC RED/WHITE CAPS WHITE/CLEAR CAPS CAPSULE CONI-SNAP #1 RX/OTC F CAPSULE CONI-SNAP #3 F RX/OTC WHITE CAPS WHITE/WHITE CAPS CAPSULE CONI-SNAP #1 RX/OTC F CAPSULE CONI-SNAP #3 F RX/OTC WHITE/CLEAR CAPS YELLOW/YELLOW CAPS CAPSULE CONI-SNAP #1 RX/OTC F CAPSULE CONI-SNAP #4 F RX/OTC WHITE/GREEN CAPS BLACK/GREEN CAPS CAPSULE CONI-SNAP #1 RX/OTC RX/OTC F CAPSULE CONI-SNAP #4 F YELLOW/GREEN CAPS CLEAR/CLEAR CAPS
Oregon Trillium OHP Updated September 1, 2021
160 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAPSULE CONI-SNAP #4 F RX/OTC EMPTY CAPSULE SIZE 0 RX/OTC WHITE CAPS GREEN/CLEAR LOCKING F CAPS CAPSULE EZEEFIT #0 F RX/OTC CLEAR CAPS EMPTY CAPSULE SIZE 0 RX/OTC MAROON/OPAQUE F CAPSULE EZEEFIT #00 F RX/OTC CLEAR CAPS LOCKING CAPS EMPTY CAPSULE SIZE 0 RX/OTC CAPSULE SIZE 1 F RX/OTC F LACTOSE CAPS ORANGE CAPS EMPTY CAPSULE SIZE 0 RX/OTC DRCAPS SIZE 00 CLEAR F RX/OTC CAPS ORANGE/OPAQUE F LOCKING CAPS DRCAPS SIZE 1 CLEAR F RX/OTC CAPS EMPTY CAPSULE SIZE 0 F RX/OTC PINK CAPS EMPTY CAPSULE #0 RED RX/OTC TRANSLUCENT/WHITE F EMPTY CAPSULE SIZE 0 F RX/OTC CAPS PINK LOCKING CAPS EMPTY CAPSULE SIZE 0 RX/OTC EMPTY CAPSULE #00 F RX/OTC F BLACK/RED CAPS PURPLE CAPS EMPTY CAPSULE SIZE 0 RX/OTC EMPTY CAPSULE #00 F RX/OTC BLUE/WHITE CAPS PURPLE/OPAQUE F LOCKING CAPS EMPTY CAPSULE #00 F RX/OTC PINK/PINK CAPS EMPTY CAPSULE SIZE 0 F RX/OTC PURPLE/WHITE CAPS EMPTY CAPSULE #00 F RX/OTC PURPLE//PURPLE CAPS EMPTY CAPSULE SIZE 0 F RX/OTC RED CAPS EMPTY CAPSULE #00 F RX/OTC PURPLE//WHITE CAPS EMPTY CAPSULE SIZE 0 F RX/OTC RED/CLEAR CAPS EMPTY CAPSULE #00 F RX/OTC RED/WHITE CAPS EMPTY CAPSULE SIZE 0 F RX/OTC RED/WHITE CAPS EMPTY CAPSULE #00 F RX/OTC YELLOW/YELLOW CAPS EMPTY CAPSULE SIZE 0 RX/OTC RED/WHITE LOCKING F EMPTY CAPSULE SIZE 0 F RX/OTC CAPS BLUE CAPS EMPTY CAPSULE SIZE 0 F RX/OTC EMPTY CAPSULE SIZE 0 F RX/OTC WHITE CAPS BLUE/WHITE CAPS EMPTY CAPSULE SIZE 0 F RX/OTC EMPTY CAPSULE SIZE 0 F RX/OTC WHITE/CLEAR CAPS CLEAR CAPS EMPTY CAPSULE SIZE 0 F RX/OTC EMPTY CAPSULE SIZE 0 F RX/OTC WHITE/OPAQUE CAPS CLEAR LOCKING CAPS EMPTY CAPSULE SIZE 0 RX/OTC EMPTY CAPSULE SIZE 0 RX/OTC WHITE/OPAQUE F FUNCAPS LOCKING F LOCKING CAPS CAPS EMPTY CAPSULE SIZE 0 F RX/OTC EMPTY CAPSULE SIZE 0 F RX/OTC YELLOW CAPS GREEN LOCKING CAPS EMPTY CAPSULE SIZE 0 RX/OTC EMPTY CAPSULE SIZE 0 F RX/OTC YELLOW/OPAQUE F GREEN/CLEAR CAPS LOCKING CAPS
Oregon Trillium OHP Updated September 1, 2021
161 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMPTY CAPSULE SIZE 00 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC BLUE/OPAQUE LOCKING F BLUE/PINK LOCKING F CAPS CAPS EMPTY CAPSULE SIZE 00 F RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC CLEAR CAPS BLUE/PINK F TRANSLUCENT CAPS EMPTY CAPSULE SIZE 00 F RX/OTC CLEAR LOCKING CAPS EMPTY CAPSULE SIZE 1 RX/OTC BLUE/POWDER BLUE F EMPTY CAPSULE SIZE 00 F RX/OTC DARK GREEN CAPS CAPS EMPTY CAPSULE SIZE 00 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC GREEN/OPAQUE F BLUE/RED OPAQUE F LOCKING CAPS LOCKING CAPS EMPTY CAPSULE SIZE 00 RX/OTC EMPTY CAPSULE SIZE 1 F RX/OTC LIGGHT BLUE OPAQUE F BLUE/WHITE CAPS CAPS EMPTY CAPSULE SIZE 1 RX/OTC BLUETRANSLUCENT/PIN F EMPTY CAPSULE SIZE 00 F RX/OTC ORANGE CAPS K TRANSLUCENT CAPS EMPTY CAPSULE SIZE 00 RX/OTC EMPTY CAPSULE SIZE 1 F RX/OTC ORANGE/OPAQUE F BROWN/IVORY CAPS LOCKING CAPS EMPTY CAPSULE SIZE 1 RX/OTC BROWN/IVORY OPAQUE F EMPTY CAPSULE SIZE 00 F RX/OTC RED CAPS LOCKING CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 00 F RX/OTC F WHITE CAPS CLEAR CAPS EMPTY CAPSULE SIZE 00 RX/OTC EMPTY CAPSULE SIZE 1 F RX/OTC WHITE OPAQUE F CLEAR LOCKING CAPS LOCKING CAPS EMPTY CAPSULE SIZE 1 F RX/OTC DARKGREEN CAPS EMPTY CAPSULE SIZE F RX/OTC 000 CLEAR CAPS EMPTY CAPSULE SIZE 1 F RX/OTC EMPTY CAPSULE SIZE RX/OTC GREEN CAPS 000 CLEAR LOCKING F EMPTY CAPSULE SIZE 1 RX/OTC CAPS GREEN CLEAR/YELLOW F EMPTY CAPSULE SIZE RX/OTC LOCKING CAPS 000 WHITE/OPAQUE F EMPTY CAPSULE SIZE 1 RX/OTC LOCKING CAPS GREEN F EMPTY CAPSULE SIZE 1 RX/OTC TRANSLUCENT/YELLOW AQUABLUE F OPAQUE CAPS TRANSLUCENT CAPS EMPTY CAPSULE SIZE 1 F RX/OTC GREEN/ORANGE CAPS EMPTY CAPSULE SIZE 1 F RX/OTC BLUE CAPS EMPTY CAPSULE SIZE 1 F RX/OTC GREEN/WHITE CAPS EMPTY CAPSULE SIZE 1 F RX/OTC BLUE/CLEAR CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC GREEN/WHITE OPAQUE F BLUE/OPAQUE LOCKING F LOCKING CAPS CAPS EMPTY CAPSULE SIZE 1 F RX/OTC GREEN/YELLOW CAPS EMPTY CAPSULE SIZE 1 F RX/OTC BLUE/PINK CAPS Oregon Trillium OHP Updated September 1, 2021
162 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMPTY CAPSULE SIZE 1 F RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC GREY/PINK CAPS PURPLE/OPAQUE F LOCKING CAPS EMPTY CAPSULE SIZE 1 F RX/OTC IVORY CAPS EMPTY CAPSULE SIZE 1 F RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC RED CAPS LIGHT BLUE OPAQUE F EMPTY CAPSULE SIZE 1 F RX/OTC CAPS RED/BLUE CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC MAROON TRANS/CLEAR F RED/OPAQUE LOCKING F CAPS CAPS EMPTY CAPSULE SIZE 1 RX/OTC F EMPTY CAPSULE SIZE 1 F RX/OTC MINTGREEN CAPS RED/WHITE CAPS EMPTY CAPSULE SIZE 1 RX/OTC F EMPTY CAPSULE SIZE 1 F RX/OTC ORANGE CAPS WHITE CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC ORANGE OPAQUE F WHITE OPAQUE F LOCKING CAPS LOCKING CAPS EMPTY CAPSULE SIZE 1 RX/OTC F EMPTY CAPSULE SIZE 1 F RX/OTC ORANGE/CLEAR CAPS WHITE/CLEAR CAPS EMPTY CAPSULE SIZE 1 RX/OTC F EMPTY CAPSULE SIZE 1 F RX/OTC ORANGE/WHITE CAPS WHITE/OPAQUE CAPS EMPTY CAPSULE SIZE 1 RX/OTC F EMPTY CAPSULE SIZE 1 F RX/OTC ORANGE/YELLOW CAPS YELLOW CAPS EMPTY CAPSULE SIZE 1 RX/OTC F EMPTY CAPSULE SIZE 10 F RX/OTC PINK CAPS CLEAR CAPS EMPTY CAPSULE SIZE 1 RX/OTC F EMPTY CAPSULE SIZE 11 F RX/OTC PINK/CLEAR CAPS CLEAR CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 13 F RX/OTC PINK/OPAQUE LOCKING F CLEAR CAPS CAPS EMPTY CAPSULE SIZE 2 F RX/OTC EMPTY CAPSULE SIZE 1 RX/OTC BLUE CAPS PINK/POWDER BLUE F EMPTY CAPSULE SIZE 2 F RX/OTC CAPS CLEAR CAPS EMPTY CAPSULE SIZE 1 RX/OTC F EMPTY CAPSULE SIZE 2 F RX/OTC PINK/WHITE CAPS CLEAR LOCKING CAPS EMPTY CAPSULE SIZE 1 RX/OTC F EMPTY CAPSULE SIZE 2 F RX/OTC PINK/YELLOW CAPS GREEN CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 2 RX/OTC PINK/YELLOW OPAQUE F WHITE OPAQUE F LOCKING CAPS LOCKING CAPS EMPTY CAPSULE SIZE 1 RX/OTC F EMPTY CAPSULE SIZE 3 F RX/OTC POWDER BLUE CAPS BLACK/GREEN CAPS EMPTY CAPSULE SIZE 1 RX/OTC EMPTY CAPSULE SIZE 3 F RX/OTC POWDER BLUE/OPAQUE F BLUE CAPS LOCKING CAPS EMPTY CAPSULE SIZE 3 F RX/OTC EMPTY CAPSULE SIZE 1 F RX/OTC BLUE/CLEAR CAPS PURPLE CAPS Oregon Trillium OHP Updated September 1, 2021
163 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMPTY CAPSULE SIZE 3 F RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC BLUE/WHITE CAPS OLIVE/OPAQUE LOCKING F EMPTY CAPSULE SIZE 3 RX/OTC CAPS BLUEOPAQUE/CLEAR F EMPTY CAPSULE SIZE 3 F RX/OTC LOCKING CAPS ORANGE CAPS EMPTY CAPSULE SIZE 3 F RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC CLEAR CAPS ORANGE/OPAQUE F LOCKING CAPS EMPTY CAPSULE SIZE 3 F RX/OTC CLEAR LOCKING CAPS EMPTY CAPSULE SIZE 3 F RX/OTC ORANGE/WHITE CAPS EMPTY CAPSULE SIZE 3 F RX/OTC DARKGREEN CAPS EMPTY CAPSULE SIZE 3 F RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC PINK CAPS GRAY/PINK OPAQUE F EMPTY CAPSULE SIZE 3 F RX/OTC LOCKING CAPS PINK/CLEAR CAPS EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC GRAY/YELLOW OPAQUE F PINK/OPAQUE LOCKING F LOCKING CAPS CAPS EMPTY CAPSULE SIZE 3 F RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC GREEN CAPS PINK/POWDER BLUE F CAPS EMPTY CAPSULE SIZE 3 F RX/OTC GREEN/BLUE CAPS EMPTY CAPSULE SIZE 3 F RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC PINK/WHITE CAPS GREEN/BLUE LOCKING F EMPTY CAPSULE SIZE 3 F RX/OTC CAPS PINK/YELLOW CAPS EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC GREEN/BLUE F PINKOPAQUE/CLEAR F TRANSLUCENT CAPS CAPS EMPTY CAPSULE SIZE 3 F RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC GREY/PINK CAPS PINKOPAQUE/CLEAR F LOCKING CAPS EMPTY CAPSULE SIZE 3 F RX/OTC GREY/YELLOW CAPS EMPTY CAPSULE SIZE 3 F RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC POWDER BLUE CAPS LIGHT BLUE OPAQUE F EMPTY CAPSULE SIZE 3 F RX/OTC CAPS PURPLE CAPS EMPTY CAPSULE SIZE 3 RX/OTC F EMPTY CAPSULE SIZE 3 F RX/OTC MAROON/BLUE CAPS PURPLE/CLEAR CAPS EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 3 F RX/OTC MAROON/BLUE OPAQUE F RED CAPS CAPS EMPTY CAPSULE SIZE 3 F RX/OTC EMPTY CAPSULE SIZE 3 F RX/OTC RED/CLEAR CAPS MAROON/CLEAR CAPS EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 3 F RX/OTC RED/OPAQUE LOCKING F MINT GREEN CAPS CAPS EMPTY CAPSULE SIZE 3 RX/OTC F EMPTY CAPSULE SIZE 3 F RX/OTC OLIVE/CLEAR CAPS RED/WHITE CAPS
Oregon Trillium OHP Updated September 1, 2021
164 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 4 RX/OTC REDOPAQUE/CLEAR F WHITE/OPAQUE F LOCKING CAPS LOCKING CAPS EMPTY CAPSULE SIZE 3 RX/OTC F EMPTY CAPSULE SIZE 4 F RX/OTC WHITE CAPS YELLOW CAPS EMPTY CAPSULE SIZE 3 RX/OTC EMPTY CAPSULE SIZE 5 F RX/OTC WHITE OPAQUE F CLEAR CAPS LOCKING CAPS EMPTY CAPSULE SIZE 7 F RX/OTC EMPTY CAPSULE SIZE 3 RX/OTC CLEAR CAPS WHITE OPAQUE/CLEAR F EMPTY GELATIN RX/OTC LOCKING CAPS CAPSULE/SNAP F EMPTY CAPSULE SIZE 3 F RX/OTC CLOSURE #0 CAPS WHITE/CLEAR CAPS EMPTY GELATIN RX/OTC EMPTY CAPSULE SIZE 3 F RX/OTC CAPSULE/SNAP F WHITE/OPAQUE CAPS CLOSURE #00 CAPS EMPTY CAPSULE SIZE 3 F RX/OTC EMPTY GELATIN RX/OTC YELLOW CAPS CAPSULE/SNAP F EMPTY CAPSULE SIZE 3 RX/OTC CLOSURE #000 CAPS YELLOW F EMPTY GELATIN RX/OTC OPAQUE/CLEAR CAPSULE/SNAP F LOCKING CAPS CLOSURE #1 CAPS EMPTY CAPSULE SIZE 3 F RX/OTC EMPTY GELATIN RX/OTC YELLOW/CLEAR CAPS CAPSULE/SNAP F EMPTY CAPSULE SIZE 3 RX/OTC CLOSURE #2 CAPS YELLOW/OPAQUE F EMPTY GELATIN RX/OTC LOCKING CAPS CAPSULE/SNAP F EMPTY CAPSULE SIZE 4 RX/OTC CLOSURE #3 CAPS BLACK/GREEN OPAQUE F EMPTY GELATIN RX/OTC LOCKING CAPS CAPSULE/SNAP F CLOSURE #4 CAPS EMPTY CAPSULE SIZE 4 F RX/OTC BLUE/WHITE CAPS Liquid Vehicles EMPTY CAPSULE SIZE 4 RX/OTC F CHERRY CONCENTRATE F RX/OTC CLEAR CAPS SYRP EMPTY CAPSULE SIZE 4 F RX/OTC RX/OTC CLEAR LOCKING CAPS CHERRY SYRUP SYRP F EMPTY CAPSULE SIZE 4 RX/OTC FLAVOR BLEND SUSP F RX/OTC DARK BLUE/OPAQUE F LOCKING CAPS FLAVOR PLUS LIQD F RX/OTC EMPTY CAPSULE SIZE 4 F RX/OTC PURPLE CAPS FLAVOR SWEET SYRP F RX/OTC EMPTY CAPSULE SIZE 4 RX/OTC PURPLE/OPAQUE F FLAVOR SWEET-SF F RX/OTC LOCKING CAPS SYRP FLAVORING SYRUPS- RX/OTC EMPTY CAPSULE SIZE 4 F RX/OTC F RED/WHITE CAPS MISC RX/OTC EMPTY CAPSULE SIZE 4 F RX/OTC GRAPE SYRUP SYRP F WHITE CAPS Oregon Trillium OHP Updated September 1, 2021
165 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MX-SOL BLEND SF SUSP F RX/OTC SUSPENDRX WITH RX/OTC BITTER- F MX-SOL BLEND SUSP F RX/OTC BLOC/UNSWEETENED SUSP RX/OTC MX-SOL SF SYRP F SUSPENSION VEHICLE F RX/OTC SUSP MX-SOL SUSPEND SUSP F RX/OTC SWEETENING RX/OTC SUSPENDING F MX-SOL SYRP F RX/OTC COMPOUND SYRP SYRPALTA SYRP F RX/OTC ORA-BLEND SF SUSP F RX/OTC SYRSPEND SF LIQD F RX/OTC ORA-BLEND SUSP F RX/OTC SYRUP NF SYRP F RX/OTC ORA-PLUS LIQD F RX/OTC SYRUP VEHICLE SF F RX/OTC ORA-SWEET SF SYRP F RX/OTC SYRP RX/OTC ORA-SWEET SYRP F RX/OTC SYRUP VEHICLE SYRP F ORAL MIX FLAVORED RX/OTC UNISPEND ANHYDROUS F RX/OTC SUSPENDING VEHICLE F SWEETENED SUSP SUSP UNISPEND ANHYDROUS F RX/OTC UNSWEETENED SUSP ORAL MIX SF SUSP F RX/OTC VERSAFREE SYRP F RX/OTC ORAL SUSPEND LIQD F RX/OTC VERSAPLUS SYRP F RX/OTC ORAL SUSPENDING F RX/OTC COMPOUNDPLUS SUSP Pharmaceutical Excipients ORAL SYRUP FLAVORED RX/OTC F SODIUM BENZOATE F RX/OTC VEHICLE SYRP POWD RX/OTC ORAL SYRUP SF SYRP F XANTHAN GUM POWD F RX/OTC PCCA SWEET-SF SYRP F RX/OTC PROGESTINS - Hormone Replacement/Modifying Drugs PCCA SYRUP VEHICLE F RX/OTC SYRP Progestins RX/OTC hydroxyprogesterone F PA; SP PCCA-PLUS SUSP F caproate oil SIMPLE SYRUP SYRP F RX/OTC MAKENA OIL IM 250 PA; SP MG/ML NF RX/OTC (hydroxyprogesterone SOSWEET SYRP F caproate) SUSPENDRX WITH RX/OTC MAKENA SOAJ SC 275 F PA; SP BITTER- F MG/1.1ML BLOC/SWEETENED medroxyprogesterone F SUSP acetate tabs progesterone caps or 100 F mg, 200 mg Oregon Trillium OHP Updated September 1, 2021
166 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROMETRIUM CAPS NF COPAXONE SOSY 40 NF PA; QL(0.43 ml (progesterone) MG/ML (glatiramer acetate) daily); SP PROVERA TABS dimethyl fumarate cpdr 120 F PA; QL(2 ea (medroxyprogesterone NF mg, 240 mg daily); SP acetate) dimethyl fumarate misc F PA; SP PSYCHOTHERAPEUTIC AND NEUROLOGICAL PA; QL(0.5 ea AGENTS - MISC. - Drugs to Treat Mental and EXTAVIA KIT F Emotional Conditions daily); SP Agents for Chemical Dependency GILENYA CAPS 0.5 MG F PA; QL(1 ea daily); SP acamprosate calcium tbec F glatiramer acetate sosy 20 F PA; QL(1 ml mg/ml daily); SP ANTABUSE TABS NF (disulfiram) glatiramer acetate sosy 40 F PA; QL(0.43 ml mg/ml daily); SP disulfiram tabs F PLEGRIDY SOPN SC F PA; QL(0.36 ml daily); SP Anti-Cataplectic Agents PLEGRIDY SOSY SC F PA; QL(0.36 ml XYREM SOLN F PA; SP daily); SP PLEGRIDY STARTER F PA; SP Antidementia Agents PACK SOPN ARICEPT TABS (donepezil PA; QL(1 ea NF PLEGRIDY STARTER F PA; SP hydrochloride) daily) PACK SOSY donepezil hydrochloride PA; QL(1 ea F REBIF REBIDOSE SOAJ F PA; QL(0.22 ml tabs daily) daily); SP donepezil hydrochloride PA; QL(1 ea F REBIF REBIDOSE F PA; QL(0.15 ml tbdp daily) TITRATIONPACK SOAJ daily); SP Combination Psychotherapeutics REBIF SOSY F PA; QL(0.22 ml daily); SP chlordiazepoxide- CO amitriptyline tabs REBIF TITRATION PACK F PA; QL(0.15 ml SOSY daily); SP olanzapine-fluoxetine hcl CO caps TECFIDERA CPDR NF PA; QL(2 ea (dimethyl fumarate) daily); SP perphenazine-amitriptyline CO tabs TECFIDERA STARTER PA; SP PACK MISC (dimethyl NF SYMBYAX CAPS CO (olanzapine-fluoxetine hcl) fumarate) Multiple Sclerosis Agents Premenstrual Dysphoric Disorder (PMDD) Agents AUBAGIO TABS F PA; QL(1 ea fluoxetine hcl (pmdd) caps CO daily); SP AVONEX PEN AJKT F SP fluoxetine hcl (pmdd) tabs CO SP SARAFEM TABS CO AVONEX PSKT F (fluoxetine hcl (pmdd)) BETASERON KIT F PA; QL(0.5 ea Psychotherapeutic and Neurological Agents - daily); SP pimozide tabs CO COPAXONE SOSY 20 NF PA; QL(1 ml MG/ML (glatiramer acetate) daily); SP Smoking Deterrents Oregon Trillium OHP Updated September 1, 2021
167 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Max 6 months Max 6 months of Smoking of Smoking Cessation Cessation APO-VARENICLINE TABS F Therapy per NICORETTE LOZG 2 MG, NF Therapy per 365 days.;QL(2 4 MG (nicotine polacrilex) 365 ea daily) days.;QL(20 ea Max 6 months daily,540 ea of Smoking per fill retail) bupropion hcl (smoking F Cessation Max 6 months deterrent) tb12 Therapy per of Smoking 365 days.;QL(2 Cessation ea daily) NICORETTE MINI LOZG NF Therapy per Max 6 months (nicotine polacrilex) 365 of Smoking days.;QL(20 ea daily,540 ea CHANTIX CONTINUING F Cessation MONTHPAK TABS Therapy per per fill retail) 365 days.;QL(2 Max 6 months ea daily) of Smoking Max 6 months Cessation NICORETTE STARTER Therapy per of Smoking KIT GUM (nicotine NF Cessation polacrilex) 365 CHANTIX STARTING F days.;QL(24 ea MONTH PAK TABS Therapy per 365 daily,660 ea days.;QL(53 ea per fill retail) per fill retail) Max 6 months Max 6 months of Smoking of Smoking Cessation nicotine polacrilex gum 4 Therapy per F Cessation F CHANTIX TABS Therapy per mg, 2 mg 365 365 days.;QL(2 days.;QL(24 ea ea daily) daily,660 ea per fill retail) Max 6 months of Smoking Max 6 months of Smoking NICODERM CQ PT24 NF Cessation (nicotine) Therapy per Cessation 365 days.;QL(1 nicotine polacrilex lozg 2 F Therapy per ea daily) mg, 4 mg 365 days.;QL(20 ea Max 6 months daily,540 ea of Smoking per fill retail) Cessation Max 6 months NICORETTE GUM 4 MG, 2 NF Therapy per MG (nicotine polacrilex) 365 of Smoking Cessation days.;QL(24 ea nicotine pt24 F daily,660 ea Therapy per per fill retail) 365 days.;QL(1 ea daily)
Oregon Trillium OHP Updated September 1, 2021
168 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Max 6 months PA; Max 10 days supply, 2 of Smoking doxycycline (monohydrate) Cessation F fills per 365 tabs 50 mg NICOTROL INHALER F Therapy per days;QL(2 ea INHA 365 daily) days.;QL(16 ea Max 10 days daily,504 ea supply, 2 fills per fill retail) per 365 doxycycline hyclate caps or F days;QL(2 ea Max 6 months 50 mg, 100 mg of Smoking daily)2 rtl MAX Cessation fill,365 rtl NICOTROL NS SOLN F Therapy per day(s) supply, 365 days.;QL(4 Max 10 days ml daily,120 ml supply, 2 fills per fill retail) per 365 doxycycline hyclate tabs or Vasomotor Symptom Agents F days;QL(2 ea 100 mg, 20 mg daily)2 rtl MAX BRISDELLE CAPS CO fill,365 rtl (paroxetine mesylate day(s) supply, (vasomotor)) paroxetine mesylate Limited to CO select (vasomotor) caps MINOCIN CAPS OR 50 NF Diagnoses; PA MG (minocycline hcl) RESPIRATORY AGENTS - MISC. - Drugs to may be Treat Lung Conditions required Cystic Fibrosis Agents Limited to select PULMOZYME SOLN F SP minocycline hcl caps 100 F Diagnoses; PA mg, 50 mg, 75 mg may be TRIKAFTA TBPK F PA; QL(3 ea required daily); SP TARGADOX TABS NF TETRACYCLINES - Drugs to Treat Bacterial (doxycycline hyclate) Infections Max 1 fill per tetracycline hcl caps F Tetracyclines 365 days Max 10 days Max 10 days supply, 2 fills supply, 2 fills doxycycline (monohydrate) F per 365 per 365 caps 50 mg, 100 mg VIBRAMYCIN CAPS 100 NF days;QL(2 ea days;QL(2 ea MG (doxycycline hyclate) daily) daily)2 rtl MAX fill,365 rtl doxycycline (monohydrate) F susr 25 mg/5ml day(s) supply, Max 10 days VIBRAMYCIN SUSR 25 supply, 2 fills MG/5ML (doxycycline NF per 365 (monohydrate)) doxycycline (monohydrate) F days;QL(2 ea XIMINO CP24 135 MG, 45 tabs 100 mg daily)2 rtl MAX MG, 90 MG (minocycline NF fill,365 rtl hcl) day(s) supply, THYROID AGENTS - Drugs to Regulate Thyroid Hormones
Oregon Trillium OHP Updated September 1, 2021
169 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antithyroid Agents INFANRIX SUSP F methimazole tabs F Maximum of 3 F fills per propylthiouracil tabs F KINRIX SUSP lifetime;AL(Up to 17 yrs old ) TAPAZOLE TABS NF (methimazole) PEDIARIX SUSP F AL(Up to 17 yrs old ) Thyroid Hormones PENTACEL SUSR F AL(Up to 17 yrs ARMOUR THYROID TABS old ) 120 MG, 15 MG, 30 MG, F Maximum of 3 60 MG, 90 MG (thyroid) fills per QUADRACEL SUSP F ARMOUR THYROID TABS F lifetime;AL(Up 180 MG, 240 MG, 300 MG to 17 yrs old ) CYTOMEL TABS AL(Up to 17 yrs NF TDVAX SUSP F (liothyronine sodium) old ) levothyroxine sodium tabs TENIVAC INJ F AL(Up to 17 yrs or 300 mcg, 100 mcg, 112 old ) mcg, 125 mcg, 137 mcg, F TETANUS/DIPHTHERIA AL(Up to 17 yrs 150 mcg, 175 mcg, 200 TOXOIDS-ADSORBED F old ) mcg, 25 mcg, 50 mcg, 75 ADULT SUSP mcg, 88 mcg ULCER DRUGS - Drugs to Treat Bowel, Intestine liothyronine sodium tabs or F 50 mcg, 25 mcg, 5 mcg and Stomach Conditions Proton Pump Inhibitors NATURE-THROID NT-2.5 F TABS QL (1 ea daily, NATURE-THROID TABS F OMEPRAZOLE TABLET F 180 ea per 365 days retail) SYNTHROID TABS NF Antispasmodics (levothyroxine sodium) dicyclomine hcl caps or 10 F thyroid tabs F mg dicyclomine hcl soln or 10 F WESTHROID TABS F mg/5ml dicyclomine hcl tabs or 20 F WP THYROID TABS F mg glycopyrrolate tabs or 1 F TOXOIDS mg, 2 mg Toxoid Combinations hyoscyamine sulfate elix or F 0.125 mg/5ml ADACEL SUSP F hyoscyamine sulfate soln F or 0.125 mg/ml BOOSTRIX SUSP F hyoscyamine sulfate subl sl F DAPTACEL SUSP F 0.125 mg hyoscyamine sulfate tabs F DIPHTHERIA/TETANUS AL(Up to 17 yrs or 0.125 mg TOXOIDS ADSORBED F old ) hyoscyamine sulfate tb12 F PEDIATRIC SUSP or 0.375 mg Oregon Trillium OHP Updated September 1, 2021
170 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEVBID TB12 NF Max 300 ml per (hyoscyamine sulfate) fill; max 2 fills per H-2 Antagonists FIRST-OMEPRAZOLE F year;QL(300 ml cimetidine hcl soln 300 F SUSP per fill retail)2 mg/5ml rtl MAX fill,365 cimetidine tabs 200 mg F RX/OTC rtl day(s) supply, cimetidine tabs 300 mg, F RX/OTC 400 mg, 800 mg lansoprazole cpdr 15 mg F QL(150 ml per lansoprazole cpdr 30 mg F famotidine susr or 40 F fill retail)2 rtl mg/5ml MAX fill,365 rtl Max 300 ml per day(s) supply, fill; max 2 fills per famotidine tabs or 20 mg F RX/OTC OMEPRAZOLE + F year;QL(300 ml SYRSPEND SFALKA per fill retail)2 famotidine tabs or 40 mg, F SUSP 10 mg rtl MAX fill,365 rtl day(s) nizatidine caps 150 mg, F supply, 300 mg QL(1 ea daily) PEPCID AC MAXIMUM RX/OTC omeprazole cpdr 10 mg F NF STRENGTH TABS QL(1 ea daily); (famotidine) omeprazole cpdr 20 mg F RX/OTC PEPCID AC TABS 10 MG NF QL(2 ea daily) (famotidine) omeprazole cpdr 40 mg F PEPCID AC TABS 20 MG NF RX/OTC QL(1 ea daily) (famotidine) omeprazole tbec 20 mg F PEPCID TABS 20 MG RX/OTC NF pantoprazole sodium tbec F (famotidine) or 20 mg, 40 mg PEPCID TABS 40 MG NF PREVACID 24HR CPDR NF RX/OTC (famotidine) (lansoprazole) TAGAMET HB TABS RX/OTC NF PREVACID CPDR 15 MG NF RX/OTC (cimetidine) (lansoprazole) ZANTAC SOLN 25 MG/ML NF PREVACID CPDR 30 MG NF (ranitidine hcl) (lansoprazole) Misc. Anti-Ulcer PROTONIX TBEC OR 20 MG, 40 MG (pantoprazole NF CARAFATE SUSP NF (sucralfate) sodium) Ulcer Drugs - Prostaglandins CARAFATE TABS NF (sucralfate) CYTOTEC TABS NF (misoprostol) sucralfate susp F misoprostol tabs F sucralfate tabs F Ulcer Therapy Combinations Proton Pump Inhibitors
Oregon Trillium OHP Updated September 1, 2021
171 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 14 rtl MAX AL(Up to 17 yrs HIBERIX SOLR F amoxicillin-clarithromycin F day(s) old ) w/ lansoprazole misc supply,365 rtl MENACTRA INJ F Maximum of 2 lmt day(s), fills per lifetime 10 rtl MAX Maximum of 2 MENQUADFI INJ F F day(s) fills per lifetime PYLERA CAPS supply,365 rtl lmt day(s), MENVEO SOLR F Maximum of 2 fills per lifetime URINARY ANTISPASMODICS - Drugs to Treat AL(Up to 17 yrs PEDVAX HIB SUSP F Miscellaneous Bladder Spasms old ) Urinary Antispasmodic - Antimuscarinics PNEUMOVAX 23 INJ F Maximum of 2 fills per lifetime DETROL LA CP24 NF (tolterodine tartrate) PNEUMOVAX 23/1 DOSE F Maximum of 2 INJ fills per lifetime DETROL TABS (tolterodine NF tartrate) PREVNAR 13 SUSP F Maximum of 4 fills per lifetime DITROPAN XL TB24 NF QL(1 ea daily) (oxybutynin chloride) TRUMENBA SUSY F Maximum of 3 fills per lifetime oxybutynin chloride syrp 5 F mg/5ml Viral Vaccines oxybutynin chloride tabs 5 F limit 0.5 per mg 180 days;1 rtl oxybutynin chloride tb24 10 QL(1 ea daily) F AFLURIA QUADRIVALENT F pack lmt mg, 15 mg, 5 mg 2019-2020 SUSP amt,180 rtl pack lmt tolterodine tartrate cp24 F day(s), tolterodine tartrate tabs F Limit 0.25 per 180 days;1 rtl AFLURIA QUADRIVALENT pack lmt trospium chloride cp24 60 F QL(1 ea daily) F mg 2019-2020 SUSY amt,180 rtl pack lmt trospium chloride tabs 20 F QL(2 ea daily) mg day(s), limit 0.5 per Urinary Antispasmodics - Cholinergic Agonists 180 days;1 rtl bethanechol chloride tabs F AFLURIA QUADRIVALENT F pack lmt 2019-2020 SUSY amt,180 rtl URECHOLINE TABS NF pack lmt (bethanechol chloride) day(s), Urinary Antispasmodics - Direct Muscle Relaxants limit 0.5 per 180 days;1 rtl flavoxate hcl tabs F AFLURIA QUADRIVALENT F pack lmt 2020-2021 SUSP amt,180 rtl VACCINES pack lmt day(s), Bacterial Vaccines ACTHIB SOLR F AL(Up to 17 yrs old ) BEXSERO SUSY F Maximum of 2 fills per lifetime Oregon Trillium OHP Updated September 1, 2021
172 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 0.25 per limit 0.5 per 180 days;1 rtl 180 days;1 rtl AFLURIA QUADRIVALENT F pack lmt FLUAD QUADRIVALENT F pack lmt 2020-2021 SUSY amt,180 rtl 2021-2022 PRSY amt,180 rtl pack lmt pack lmt day(s), day(s), limit 0.5 per limit 0.5 per 180 days;1 rtl 180 days;1 rtl FLUAD QUADRIVALENT AFLURIA QUADRIVALENT F pack lmt F pack lmt 2020-2021 SUSY amt,180 rtl INFLUENZA VACCINE FOR ADULTS PRSY amt,180 rtl pack lmt pack lmt day(s), day(s), limit 0.5 per limit 0.5 per 180 days;1 rtl 180 days;1 rtl AFLURIA QUADRIVALENT F pack lmt FLUARIX QUADRIVALENT F pack lmt 2021-2022 SUSP amt,180 rtl 2019-2020 SUSY amt,180 rtl pack lmt pack lmt day(s), day(s), Limit 0.25 per limit 0.5 per 180 days;1 rtl 180 days;1 rtl AFLURIA QUADRIVALENT F pack lmt FLUARIX QUADRIVALENT F pack lmt 2021-2022 SUSY amt,180 rtl 2020-2021 SUSY amt,180 rtl pack lmt pack lmt day(s), day(s), limit 0.5 per limit 0.5 per 180 days;1 rtl 180 days;1 rtl AFLURIA QUADRIVALENT F pack lmt FLUARIX QUADRIVALENT F pack lmt 2021-2022 SUSY amt,180 rtl 2021-2022 SUSY amt,180 rtl pack lmt pack lmt day(s), day(s), ENGERIX-B INJ F Maximum of 3 limit 0.5 per fills per lifetime 180 days;1 rtl FLUBLOK pack lmt ENGERIX-B SUSP F Maximum of 3 QUADRIVALENT 2019- F fills per lifetime amt,180 rtl 2020 SOSY pack lmt limit 0.5 per day(s), 180 days;1 rtl pack lmt limit 0.5 per FLUAD 2019-2020 SUSY F 180 days;1 rtl amt,180 rtl FLUBLOK pack lmt QUADRIVALENT 2020- F pack lmt day(s), amt,180 rtl 2021 SOSY pack lmt limit 0.5 per day(s), 180 days;1 rtl pack lmt limit 0.5 per FLUAD 2020-2021 SUSY F 180 days;1 rtl amt,180 rtl FLUBLOK pack lmt QUADRIVALENT 2021- F pack lmt day(s), amt,180 rtl 2022 SOSY pack lmt day(s),
Oregon Trillium OHP Updated September 1, 2021
173 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUCELVAX QL(1 ml per limit 0.5 per QUADRIVALENT 2019- F 180 days retail) 180 days;1 rtl FLULAVAL 2020 SUSP F pack lmt QUADRIVALENT 2021- amt,180 rtl limit 0.5 per 2022 SUSY 180 days;1 rtl pack lmt FLUCELVAX day(s), QUADRIVALENT 2019- F pack lmt 2020 SUSY amt,180 rtl limit 0.5 per pack lmt 180 days;1 rtl day(s), FLUMIST F pack lmt FLUCELVAX QL(1 ml per QUADRIVALENT SUSP amt,180 rtl QUADRIVALENT 2020- F 180 days retail) pack lmt 2021 SUSP day(s), limit 0.5 per FLUZONE HIGH-DOSE PF F AL(At least 65 180 days;1 rtl 2019-2020 SUSY yrs old) FLUCELVAX QUADRIVALENT 2020- F pack lmt 1 rtl pack lmt amt,180 rtl amt,180 rtl 2021 SUSY pack lmt FLUZONE HIGH-DOSE PF F pack lmt day(s), 2020-2021 SUSY day(s),; AL(At FLUCELVAX QL(1 ml per least 65 yrs QUADRIVALENT 2021- F 180 days retail) old) 2022 SUSP 1 rtl pack lmt limit 0.5 per amt,180 rtl 180 days;1 rtl FLUZONE HIGH-DOSE PF F pack lmt FLUCELVAX 2021-2022 SUSY day(s),; AL(At QUADRIVALENT 2021- F pack lmt amt,180 rtl least 65 yrs 2022 SUSY pack lmt old) day(s), limit 0.5 per 180 days;1 rtl limit 0.5 per FLUZONE 180 days;1 rtl QUADRIVALENT 2019- F pack lmt FLULAVAL amt,180 rtl QUADRIVALENT 2019- F pack lmt 2020 SUSP amt,180 rtl pack lmt 2020 SUSP pack lmt day(s), day(s), limit 0.5 per 180 days;1 rtl limit 0.5 per FLUZONE 180 days;1 rtl QUADRIVALENT 2019- F pack lmt FLULAVAL amt,180 rtl QUADRIVALENT 2019- F pack lmt 2020 SUSY amt,180 rtl pack lmt 2020 SUSY pack lmt day(s), day(s), Limit 0.25 per 180 days;1 rtl limit 0.5 per FLUZONE 180 days;1 rtl QUADRIVALENT 2019- F pack lmt FLULAVAL amt,180 rtl QUADRIVALENT 2020- F pack lmt 2020 SUSY amt,180 rtl pack lmt 2021 SUSY pack lmt day(s), day(s), limit 0.5 per 180 days;1 rtl FLUZONE QUADRIVALENT 2020- F pack lmt amt,180 rtl 2021 SUSP pack lmt day(s), Oregon Trillium OHP Updated September 1, 2021
174 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits limit 0.5 per Limit 2 fills per FLUZONE 180 days;1 rtl Lifetime;QL(2 pack lmt ea per 999 QUADRIVALENT 2020- F SHINGRIX SUSR F 2021 SUSY amt,180 rtl days retail); pack lmt AL(At least 50 day(s), yrs old) limit 0.5 per F Maximum of 3 180 days;1 rtl TWINRIX SUSY fills per lifetime FLUZONE QUADRIVALENT 2021- F pack lmt Maximum of 2 amt,180 rtl 2022 SUSP F fills per pack lmt VAQTA SUSP lifetime;AL(Up day(s), to 17 yrs old ) limit 0.5 per Maximum of 2 VARIVAX INJ F FLUZONE 180 days;1 rtl fills per lifetime pack lmt QUADRIVALENT 2021- F Maximum of 1 2022 SUSY amt,180 rtl pack lmt fill per day(s), ZOSTAVAX SUSR F lifetime;AL(At least 50 yrs Maximum of 3 old) fills per F lifetime;AL(At VAGINAL AND RELATED PRODUCTS GARDASIL 9 SUSP least 9 yrs old - Up to 26 yrs Spermicides old) ENCARE SUPP F Maximum of 3 fills per OPTIONS CONCEPTROL VAGINAL NF F lifetime;AL(At GARDASIL 9 SUSY least 9 yrs old - CONTRACEPTIVE GEL Up to 26 yrs OPTIONS GYNOL II old) VAGINALCONTRACEPTIV F E GEL HAVRIX SUSP F Maximum of 2 fills per lifetime SHUR-SEAL GEL F INFLUENZA VACCINE F QL (1 ml per 2019-2020 180 days retail) TODAY SPONGE MISC F IPOL INACTIVATED IPV F AL(Up to 17 yrs INJ old ) VCF VAGINAL Maximum of 2 CONTRACEPTIVE FILM F M-M-R II SOLR F fills per lifetime FILM VCF VAGINAL RECOMBIVAX HB SUSP F 10 MCG/ML CONTRACEPTIVE FOAM F FOAM RECOMBIVAX HB SUSP F Maximum of 3 40 MCG/ML, 5 MCG/0.5ML fills per lifetime VCF VAGINAL CONTRACEPTIVEGEL F ROTARIX SUSR F AL(Up to 17 yrs GEL old ) Vaginal Anti-infectives ROTATEQ SOLN F AL(Up to 17 yrs old ) CLEOCIN CREA VA 2 % (clindamycin phosphate NF vaginal)
Oregon Trillium OHP Updated September 1, 2021
175 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clindamycin phosphate F ESTRING RING F vaginal crea PREMARIN CREA VA F CLINDESSE CREA F 0.625 MG/GM clotrimazole vaginal crea F VAGIFEM TABS (estradiol NF vaginal) GYNE-LOTRIMIN 3 CREA NF Vaginal Progestins (clotrimazole vaginal) FIRST-PROGESTERONE GYNE-LOTRIMIN CREA NF VGS 100 COMPOUNDING F (clotrimazole vaginal) KIT SUPP METROGEL-VAGINAL FIRST-PROGESTERONE GEL (metronidazole NF VGS 200 F vaginal) COMPOUNDING KIT metronidazole vaginal gel F SUPP VASOPRESSORS - Drugs to Treat Heart and miconazole nitrate vaginal F crea 4 %, 2 % Circulation Conditions Anaphylaxis Therapy Agents miconazole nitrate vaginal F kit ADRENALIN SOLN IJ 30 MG/30ML (epinephrine NF miconazole nitrate vaginal F supp 200 mg, 100 mg (anaphylaxis)) MONISTAT 1 COMBO epinephrine (anaphylaxis) Generic PACK KIT (miconazole NF soaj 0.15 mg/0.15ml, 0.15 F Required nitrate vaginal) mg/0.3ml, 0.3 mg/0.3ml MONISTAT 1 DAY OR EPIPEN 2-PAK SOAJ NF NIGHT COMBO PACK KIT NF (epinephrine (anaphylaxis)) (miconazole nitrate vaginal) EPIPEN-JR 2-PAK SOAJ F MONISTAT 3 (epinephrine (anaphylaxis)) COMBINATION PACK KIT NF Vasopressors (miconazole nitrate vaginal) midodrine hcl tabs F MONISTAT 3 CREA NF (miconazole nitrate vaginal) MONISTAT 7 SIMPLY VITAMINS CURE CREA (miconazole NF Multiple Vitamins w/ Minerals nitrate vaginal) multiple vitamins w/ F RX/OTC terconazole vaginal crea F minerals cap 0.4 %, 0.8 % multiple vitamins w/ F RX/OTC tioconazole vaginal oint F minerals chew multiple vitamins w/ F RX/OTC Vaginal Estrogens minerals liq ESTRACE CREA VA 0.1 NF MG/GM (estradiol vaginal) Oil Soluble Vitamins BABY DDROPS LIQD 400 estradiol vaginal crea F UT/0.028ML NF (cholecalciferol) estradiol vaginal tabs F
Oregon Trillium OHP Updated September 1, 2021
176 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cholecalciferol caps 1.25 B-1 TABS F mg, 400 unit, 50000 unit, F 10000 unit, 250 mcg, 125 B-2-400 CAPS F mcg, 5000 unit, 1000 unit, 25 mcg, 2000 unit, 50 mcg B-6 TABS F cholecalciferol liqd 400 ut/0.028ml, 5000 unit/ml, F B1 NATURAL TABS F 10 mcg/ml, 400 unit/ml cholecalciferol tabs 125 niacin cpcr or 500 mg, 250 F mg mcg, 5000 unit, 400 unit, F 2000 unit, 50 mcg, 1000 niacin tabs or 250 mg, 50 F unit, 25 mcg mg, 100 mg, 500 mg D-VI-SOL LIQD NF niacin tbcr or 750 mg, 250 F (cholecalciferol) mg, 500 mg DRISDOL CAPS NF NIACIN TR TBCR F (ergocalciferol) pyridoxine hcl tabs or 500 E600 CAPS F mg, 25 mg, 250 mg, 50 mg, F 100 mg ergocalciferol caps or 1.25 F mg, 50000 unit pyridoxine hcl tbcr or 200 F mg ergocalciferol soln or 200 F mcg/ml, 8000 unit/ml RIBOFLAVIN CAPS 100 F MG MAXIMUM D3 CAPS F riboflavin tabs 25 mg, 50 F mg, 100 mg MEPHYTON TABS NF (phytonadione) RIBOFLAVIN TABS 400 F phytonadione tabs or 5 mg F MG SLO-NIACIN TBCR (niacin) NF vitamin a caps 25000 unit, F 8000 unit, 10000 unit thiamine hcl tabs or 250 F mg, 50 mg, 100 mg VITAMIN D3 LIQD 1200 F UNIT/15ML thiamine mononitrate tabs F vitamin e caps or 180 mg, 100 unit, 45 mg, 1000 unit, F VITAMIN B-6 TR TBCR F 450 mg, 200 unit, 90 mg, 400 unit ST; QL(3 ea VITAMIN C TABS 100 MG F daily) vitamin e liqd or 400 F unit/15ml Water Soluble Vitamins ascorbic acid chew or 100 ST; QL(3 ea mg, 250 mg, , 500 mg, 7.5 F daily) mg-500 mg ascorbic acid tabs or 250 ST; QL(3 ea mg, 10 mg-500 mg, 14 mg- daily) 25 mg-500 mg, 25 mg-35 F mg-500 mg, 37 mg-500 mg, 500 mg-10 mg
Oregon Trillium OHP Updated September 1, 2021
177 Index 1ML SYRINGE/NEEDLE SLIP 3ML SYRINGE/21G X 1- ACTIGALL 44 TIP 25GX5/8" SUB-Q 60 1/4"/LUER LOCK TIP 61 ACTIVNUTRIENTS 106 1ST TIER UNILET 3ML SYRINGE/22G 1- COMFORTOUCH LANCETS 1/2"/LUER LOCK TIP 61 ACTOPLUS MET 17 28G 51 3ML SYRINGE/22G X 1"/LUER ACTOS 18 1ST TIER UNILET LOCK TIP 61 ACULAR 156 COMFORTOUCH LANCETS 3ML SYRINGE/22G X 1- 30G 51 1/4"/LUER LOCK TIP 61 ACULAR LS 156 2-3ML SYRINGE/LUER LOCK 3ML SYRINGE/22G X acyclovir 30 TIP 60 3/4"/LUER LOCK TIP 61 ADACEL 170 2-3ML SYRINGE/LUER SLIP TIP 3ML SYRINGE/22G X ADALAT CC 31 60 3/4"/LUER SLIP TIP 61 30-35ML 3ML SYRINGE/25G X 1"/LUER ADASUVE 27 SYRINGE/CATHETERTIP 60 LOCK TIP 61 ADCIRCA 32 30-35ML SYRINGE/LUER 3ML SYRINGE/27G X 1- ADDERALL 1 LOCKTIP 60 1/4"/LUER LOCK TIP 61 30-35ML SYRINGE/LUER 3ML SYRINGE/INTERLINK ADDERALL XR 1 SLIPTIP/ECCENTRIC TIP 60 SYRINGE CANNULA 61 ADEMPAS 32 3ML LUER LOCK SAFETY 3ML SYRINGE/INTERLINK ADJUSTABLE LANCING SYRINGES 3ML/22G X 1 1/2" VIAL ACCESS CANNULA 61 DEVICE 51 60 3ML SYRINGE/LUER LOCK ADMELOG 18 3ML LUER LOCK SAFETY TIP 61 ADMELOG SOLOSTAR 18 SYRINGES/3ML/21G X 1 1/2" 3ML SYRINGE/LUER LOCK 60 TIP23GX1" 61 ADRENALIN 176 3ML LUER LOCK SAFETY 3ML SYRINGE/LUER LOCK ADULT MASK 94 SYRINGES/3ML/22G X 1" 60 TIP25G X 1-1/2" 61 ADULT ONE DAILY 3ML LUER LOCK SAFETY 3ML SYRINGE/LUER SLIP GUMMIES 106 SYRINGES/3ML/23G X 1" 60 TIP23GX1" 61 ADVAIR DISKUS 11 3ML LUER LOCK SAFETY 3ML SYRINGE/NEEDLE ADVANCED DIABETIC SYRINGES/3ML/25G X 1" 60 REGULAR WALL LUER-LOK MULTIVITAMIN FORMULA 106 3ML LUER LOCK SAFETY 25GX5/8" SUB-Q 61 ADVATE 45 SYRINGES/3ML/25G X 5/8" 60 abacavir sulfate 28 3ML LUER-LOK SYRINGE 22GX abacavir sulfate- ADVIL 3 1-1/2" 60 lamivudine 28 ADVIL MIGRAINE 3 3ML LUER-LOK SYRINGE21G X abacavir sulfate-lamivudine- ADVOCATE INSULIN 1" 60 zidovudine 28 SYRINGE/U- 3ML LUER-LOK SYRINGE21G X ABC COMPLETE SENIOR 100/0.3ML/29GX1/2" 61 1-1/2" 60 WOMENS 50+ 106 ADVOCATE INSULIN 3ML LUER-LOK SYRINGE22G X ABILIFY 28 SYRINGE/U- 1" 60 ABILIFY MAINTENA 28 100/0.3ML/30GX5/16" 61 3ML LUER-LOK SYRINGE25G X ADVOCATE INSULIN 5/8" 60 ABILIFY MYCITE 28 SYRINGE/U- 3ML LUER-LOK TIP acamprosate calcium 167 100/0.3ML/31GX5/16" 61 SYRINGE25G X 1-1/2" 60 ADVOCATE INSULIN 3ML SYRINGE/18G X 1- acarbose 17 ACCOLATE 11 SYRINGE/U- 1/2"/LUER LOCK TIP 60 100/0.5ML/29GX1/2" 61 3ML SYRINGE/20G X 1"/LUER ACCUPRIL 23 ADVOCATE INSULIN LOCK TIP 60 ACCURETIC 23 SYRINGE/U- 3ML SYRINGE/20G X 1"/LUER acetaminophen 4 100/0.5ML/30GX5/16" 61 SLIP TIP 60 ADVOCATE INSULIN 3ML SYRINGE/20G X 1- acetaminophen w/ codeine 6 SYRINGE/U- 1/2"/LUER LOCK TIP 60 acetazolamide 42 100/0.5ML/31GX5/16" 61 3ML SYRINGE/21G X 1"/LUER ADVOCATE INSULIN LOCK TIP 60 acetic acid (otic) 156 acetylcysteine 37 SYRINGE/U-100/1ML/29GX1/2" 3ML SYRINGE/21G X 1"/LUER 61 SLIP TIP 60 acitretin 38 ADVOCATE INSULIN 3ML SYRINGE/21G X 1- ACTHIB 172 SYRINGE/U-100/1ML/30GX5/16" 61 1/2"/LUER LOCK TIP ACTIFLOVIT EAR 61 HEALTH 150
Index 1 ADVOCATE INSULIN AFRIN PUMP MIST 151 ALL FLOW 2000 PFT SYRINGE/U-100/1ML/31GX5/16" AFRIN SINUS 151 FILTER 95 61 ALL FLOW 3000 PFT ADVOCATE LANCING AGAMATRIX ULTRA-THIN FILTER 95 DEVICE 51 LANCETS 33G 52 ALL FLOW 4000 PFT ADVOCATE RAPID-SAFE AGRYLIN 46 FILTER 95 LANCING DEVICE 52 AIMSCO LUBRICATED 50 ALL FLOW 5000 PFT ADYNOVATE 45 AIMSCO TWIST LANCETS FILTER 95 ADZENYS ER 1 32G 52 ALL FLOW 6000 PFT AIMSCO TWIST LANCETS FILTER 95 AEROBIKA 94 33G 52 ALL FLOW 7000 PFT AEROCHAMBER MINI AIRBORNE 106 FILTER 95 AEROSOLCHAMBER 94 AIRBORNE KIDS 106 ALLEGRA ALLERGY 21 AEROCHAMBER MV 94 allopurinol 45 AEROCHAMBER PLUS FLOW AIRBORNE+GOOD REST 106 ALMOND OIL BITTER VU 94 FLAVOR 157 AEROCHAMBER PLUS FLOW- AIRBORNE+NATURAL VU 94 ENERGY 106 alogliptin benzoate 18 AEROCHAMBER PLUS FLOW- AIRBORNE+PROBIOTIC 106 alogliptin-metformin hcl 17 VU/LARGE MASK 94 AIRDUO RESPICLICK alogliptin-pioglitazone 17 113/14 11 AEROCHAMBER PLUS FLOW- ALPHAGAN P 154 VU/MASK 95 AIRDUO RESPICLICK AEROCHAMBER PLUS FLOW- 232/14 11 ALPHANATE 45 VU/MEDIUM MASK 95 AIRDUO RESPICLICK ALPHANATE/VON AEROCHAMBER PLUS FLOW- 55/14 11 WILLEBRANDFACTOR VU/SMALL MASK 95 ALA-SCALP 38 COMPLEX/HUMAN 45 AEROCHAMBER Z-STAT PLUS albuterol sulfate 11 ALPHANINE SD 45 VALVED HOLDING CHAMBER alprazolam 10 W/FLOW VU 95 ALBUTEROL SULFATE 11 AEROCHAMBER Z-STAT albuterol sulfate 12 ALPRAZOLAM INTENSOL 10 PLUS/FLOWSIGNAL 95 ALCOHOL PREP PADS 58 ALPROLIX 45 AEROCHAMBER Z-STAT ALCOHOL SWABS 58 ALTACE 23 PLUS/LARGE MASK 95 ALDACTAZIDE 42 ALTERNATE SITE LANCING AEROCHAMBER Z-STAT DEVICE 52 PLUS/MEDIUM MASK 95 ALDACTONE 42 alum & mag hydrox- AEROCHAMBER Z-STAT ALDARA 40 simethicone 8 PLUS/SMALL MASK 95 alendronate sodium 42 aluminum sulfate & calcium AEROCHAMBER/FLOWSIGNAL acetate 40 ALER-DRYL 21 95 amantadine hcl 25 AEROVENT PLUS HOLDING ALEVE 3 AMARYL 19 CHAMBER/COLLAPSIBLE 95 ALEVE ARTHRITIS 3 AFLURIA QUADRIVALENT AMBIEN 47 ALGAE BASED 2019-2020 172 ambrisentan 32 AFLURIA QUADRIVALENT CALCIUM 106 ALIVE ENERGY 50+ 106 AMEDA PURELY YOURS 2020-2021 172 BREASTPUMP/HYGIENIKIT AFLURIA QUADRIVALENT ALIVE MENS ENERGY 106 58 2021-2022 173 ALIVE MULTI-VITAMIN 106 AMEDA PURELY YOURS AFRIN 151 ALIVE ONCE DAILY WOMENS ELECTRIC BREAST AFRIN 12 HOUR 151 50+ ULTRA POTENCY 106 PUMP/HYGIENIKIT 58 AFRIN ALL NIGHT ALIVE ONCE DAILY WOMENS AMERGE 98 NODRIP 151 ULTRA POTENCY 106 AMICAR 47 AFRIN NASAL SPRAY 151 ALIVE WOMENS 50+ 107 amiloride & AFRIN NODRIP EXTRA ALIVE WOMENS hydrochlorothiazide 42 MOISTURIZING 151 ENERGY 107 ALIVE WOMENS GUMMY amiloride hcl 42 AFRIN NODRIP ORIGINAL 151 aminocaproic acid 47 AFRIN NODRIP SEVERE VITAMINS 107 CONGESTION 151 ALL FLOW 1000 PFT amiodarone hcl 11 FILTER 95 AFRIN NODRIP SINUS 151 amitriptyline hcl 17
Index 2 amlodipine besylate 31 aspirin 5 B-12 46 amoxapine 17 ASPIRIN 5 B-2-400 177 amoxicillin 156 aspirin 5 B-6 177 amoxicillin & pot ASSURE ID INSULIN b-complex w/ c & folic clavulanate 157 SAFETYSYRINGE/U- acid 103,104 amoxicillin-clarithromycin w/ 100/0.5ML/29G X 1/2" 61 B-complex w/ C and FA 104 lansoprazole 172 ASSURE ID INSULIN b-complex w/ minerals 105 amphetamine- SAFETYSYRINGE/U- b-complex w/biotin & folic dextroamphetamine 1 100/1ML/29G X 1/2" 61 acid 105 ampicillin 156 atazanavir sulfate 28 B-COMPLEX/FOLIC ANAFRANIL 17 atenolol 31 ACID/VITAMIN C 105 anagrelide hcl 46 atenolol & chlorthalidone 23 B-D INSULIN SYRINGE anastrozole 25 ATIVAN 10 ULTRAFINE II/0.3ML/31G X 5/16" 61 ANDROGEL 7 atomoxetine hcl 1 B-D INSULIN SYRINGE ANIMAL SHAPES/IRON 147 atorvastatin calcium 22 ULTRAFINE II/0.5ML/31G X ANISE EXTRACT 157 ATRIPLA 28 5/16" 61 B-D INSULIN SYRINGE ANTABUSE 167 ATROPINE SULFATE 154 ULTRAFINE II/1ML/31G X ANTACID 8 ATROVENT HFA 11 5/16" 61 ANTACID SOFT CHEWS 8 AUBAGIO 167 B-D INSULIN SYRINGE ANTIOXIDANT FORMULA 107 AUGMENTIN 157 ULTRAFINE/0.3ML/30G X 1/2" 61 ANUSOL-HC 8 AUGMENTIN ES-600 157 B-D INSULIN SYRINGE APEXICON E 38 AURORA LANCET SUPER ULTRAFINE/0.5ML/30G X APLENZIN 15 THIN30G 52 1/2" 62 AURORA LANCET THIN B1 NATURAL 177 APO-VARENICLINE 168 23G 52 BABY DDROPS 176 APPLE FLAVOR 157 AUTO-LANCET 52 BACIGUENT 37 APRICOT FLAVOR 157 AUTO-LANCET MINI 52 APRISO 44 AUTOLET IMPRESSION bacitracin (ophthalmic) 154 APTIVUS 28 LANCING DEVICE 52 bacitracin (topical) 37 AQUA LANCE ADJUSTABLE AUTOLET LANCING bacitracin zinc 37 LANCING DEVICE 52 DEVICE 52 bacitracin-polymyxin b 37 AQUADEKS 107,147 AUTOLET MINI 52 bacitracin-polymyxin b ARAVA 4 AUTOLET PLUS 52 (ophth) 154 ARIAL CHAMBER 95 AVALIDE 23 baclofen 151 ARICEPT 167 AVAPRO 23 BACMIN 107 ARIKAYCE 2 AVONEX 167 BACON FLAVOR 157 ARIMIDEX 25 AVONEX PEN 167 BACON FLAVOR azathioprine 102 NATURAL 157 aripiprazole 28 BACTRIM 9 ARISTADA 28 azithromycin 50 AZO HORMONAL HEALTH BACTRIM DS 9 ARISTADA INITIO 28 CYCLE CARE & balsalazide disodium 44 armodafinil 1 COMFORT 107 BANANA CONCENTRATE 157 ARMOUR THYROID 170 AZO HORMONAL HEALTH BANANA CREAM FLAVOR157 HAPPY CYCLE 107 ARNUITY ELLIPTA 11 BANANA CREME FLAVOR157 ARTHRITIS PAIN AZOPT 156 RELIEVING 40 AZULFIDINE 44 BANANA FLAVOR 157 artificial tear solution 153 AZULFIDINE EN-TABS 44 BANZEL 13 ASACOL HD 44 B COMPLEX + C TR 103 BAQSIMI ONE PACK 18 ascorbic acid 177 b complex w/ c 103 BAQSIMI TWO PACK 18 asenapine maleate 27 B-1 177 BARIATRIC FUSION 107
Index 3 BARIATRIC BD DISPOSABLE NEEDLE BD HYPODERMIC NEEDLES MULTIVITAMINS/IRON 107 23GX1-1/4" 62 19GX1.5" 63 BASAGLAR KWIKPEN 18 BD DISPOSABLE NEEDLE BD HYPODERMIC NEEDLES BASIC AM 107 27GX1-1/4" 62 21GX1" 63 BD DISPOSABLE NEEDLE BD HYPODERMIC NEEDLES BASIC PM 107 REGULAR BEVEL 22G X 21GX2" 63 BD LO-DOSE INSULIN 3/4" 62 BD HYPODERMIC NEEDLES SYRINGE MICROFINE BD DISPOSABLE NEEDLE 22GX1" 63 IV/0.5ML/28G X 1/2" 62 REGULAR BEVEL BD HYPODERMIC NEEDLES BD 1ML 25GX1" 62 22GX1.5" 63 SYRINGE/NEEDLE/SLIP BD DISPOSABLE NEEDLE BD HYPODERMIC NEEDLES TIP/SUBQ/26G X 5/8" 62 REGULAR BEVEL THIN WALL 23GX3/4" 63 BD 1ML 18G X 1" 62 BD HYPODERMIC NEEDLES SYRINGE/SAFETYGLIDE BD DISPOSABLE 25GX1.5" 63 SHIELDING NEEDLE 25G X NEEDLE/30GX1" 62 BD HYPODERMIC NEEDLES 5/8" 62 BD ECLIPSE SYRINGE 26GX1/2" 63 BD 1ML TUBERCULIN 3ML/21G X 1" 62 BD INSULIN SYRINGE LUER- SYRINGESLIP-TIP 62 BD ECLIPSE SYRINGE LUER- LOK/U-100/1ML 63 BD 3ML LUER-LOCK LOK/3ML/22G X 1" 62 BD INSULIN SYRINGE SYRINGE18G X 1 1/2" 62 BD ECLIPSE SYRINGE LUER- MICROFINE IV/U- BD 3ML LUER-LOK SYRINGE LOK/3ML/25G X 1" 62 100/0.5ML/28G X 1/2" 63 18G X 1 1/2" 62 BD ECLIPSE SYRINGE SLIP BD INSULIN SYRINGE BD 3ML LUER-LOK SYRINGE TIP/1ML/25G X 5/8" 62 MICROFINE IV/U-100/1ML/27G 20G X 1-1/2" 62 BD ECLIPSE X 5/8" 63 BD 3ML LUER-LOK SYRINGE/3ML/23G X 1" 63 BD INSULIN SYRINGE SYRINGE/20G X 1" 62 BD ECLIPSE MICROFINE IV/U-100/1ML/28G BD 3ML LUER-LOK SYRINGE/3ML/25GX5/8" 63 X 1/2" 63 SYRINGE/21G X 1" 62 BD ECLIPSE SYRINGE/LUER- BD INSULIN SYRINGE BD 3ML LUER-LOK LOK/3ML/22G X 1-1/2" 63 MICROFINE/U-100/0.5ML/28G X SYRINGE/21G X 1-1/2" 62 BD GLUCOSE 18 1/2" 63 BD 3ML LUER-LOK BD HYPODERMIC NEEDLE BD INSULIN SYRINGE SYRINGE/23G X 1" 62 26GX3/8" 63 MICROFINE/U-100/1ML/27G X BD 3ML LUER-LOK BD HYPODERMIC NEEDLE 5/8" 63 SYRINGE/23G X 1-1/2" 62 REGULAR BEVEL BD INSULIN SYRINGE BD 3ML LUER-LOK 26GX5/8" 63 MICROFINE/U-100/1ML/28G X SYRINGE/25G X 1" 62 BD HYPODERMIC NEEDLE 1/2" 63 BD 3ML LUER-LOK REGULAR BEVEL THIN WALL BD INSULIN SYRINGE SYRINGE/26G X 5/8" 62 18G X 1-1/2" 63 SAFETYGLIDE/1ML/29G X BD 3ML SYRINGE LUER-LOK BD HYPODERMIC NEEDLE 1/2" 63 TIP 62 REGULAR BEVEL THIN WALL BD INSULIN SYRINGE SLIP BD 3ML SYRINGE SLIP TIP 62 21GX1" 63 TIP/U-100/1ML 63 BD 3ML BD HYPODERMIC NEEDLE BD INSULIN SYRINGE ULTRA- SYRINGE/SAFETYGLIDE REGULAR BEVEL THIN WALL FINE/0.3ML/30G X 12.7MM 63 SHIELDING IM NEEDLE 22GX1- 21GX1-1/2" 63 BD INSULIN SYRINGE ULTRA- 1/2" 62 BD HYPODERMIC NEEDLE FINE/0.3ML/31G X 8MM 63 BD 3ML REGULAR BEVEL THIN WALL BD INSULIN SYRINGE ULTRA- SYRINGE/SAFETYGLIDE 23GX1" 63 FINE/0.5ML/30G X 12.7MM 64 SHIELDING IM NEEDLE BD HYPODERMIC NEEDLE BD INSULIN SYRINGE ULTRA- 23GX1" 62 REGULAR BEVEL THIN WALL FINE/0.5ML/31G X 8MM 64 BD 3ML 23GX1-1/2" 63 BD INSULIN SYRINGE ULTRA- SYRINGE/SAFETYGLIDE BD HYPODERMIC NEEDLES FINE/1/2 UNIT/0.3ML/31G X SHIELDING NEEDLE 16GX1" 63 8MM 64 25GX5/8" 62 BD HYPODERMIC NEEDLES BD INSULIN SYRINGE ULTRA- BD AUTOSHIELD DUO 30G X 18GX1" 63 FINE/1ML/30G X 12.7MM 64 5MM 62 BD HYPODERMIC NEEDLES BD INSULIN SYRINGE ULTRA- BD BLUNT FILL NEEDLE/18GX 18GX1.5" 63 FINE/1ML/31G X 8MM 64 1-1/2" 62 BD HYPODERMIC NEEDLES BD INSULIN SYRINGE BD DISPOSABLE NEEDLE 19GX1" 63 ULTRAFINE HALF- 23GX1" PRECISION GLIDE 62 UNIT/0.3ML/31G X 5/16" 64
Index 4 BD INSULIN SYRINGE BD INTEGRA 3ML SYRINGE BD SHARPS COLLECTOR 65 ULTRAFINE/0.3ML/30G X W/RETRACTING NEEDLE/25G BD SHARPS 1/2" 64 X 1" 64 COLLECTOR/EXTRALARGE BD INSULIN SYRINGE BD INTEGRA 65 ULTRAFINE/0.3ML/31G X SYRINGE/3ML/21G X 1" 64 BD SHARPS 5/16" 64 BD INTEGRA COLLECTOR/SMALL 65 BD INSULIN SYRINGE SYRINGE/3ML/22G X 1.5" 65 BD SHARPS CONTAINER ULTRAFINE/0.5ML/30G X BD INTEGRA HOME 65 1/2" 64 SYRINGE/3ML/23G X 1" 65 BD SHARPS DISPOSAL BY BD INSULIN SYRINGE BD INTEGRA MAIL 1.4 QUART 65 ULTRAFINE/0.5ML/31G X SYRINGE/3ML/25G X 5/8 65 BD SWABS SINGLE USE 59 5/16" 64 BD LANCET ULTRAFINE 30G 52 BD SWABS SINGLE USE BD INSULIN SYRINGE 58 ULTRAFINE/1ML/30G X BD LUER-LOK SYRINGE BUTTERFLY W/ECLIPSE NEEDLE 65 BD SYRINGE LUER- 1/2" 64 LOK/1ML 65 BD INSULIN SYRINGE BD NEEDLE/16G X 1-1/2" 65 BD SYRINGE SLIP TIP 1ML 65 ULTRAFINE/U-100/0.3ML/29G X BD NEEDLE/18G 1-1/2" 65 1/2" 64 BD VEO INSULIN SYRINGE BD INSULIN SYRINGE BD NEEDLE/19G X 1" 65 ULTR-FINE/U-100/0.5ML/31G X ULTRAFINE/U-100/0.5ML/29G X BD NEEDLE/20G X 1" 65 15/64" 66 1/2" 64 BD NEEDLE/20G X 1-1/2" 65 BD VEO INSULIN SYRINGE ULTRA-AFINE/0.3ML/31G X BD INSULIN SYRINGE BD NEEDLE/21G 1-1/2" 65 ULTRAFINE/U-100/1ML/29G X 6MM 66 1/2" 64 BD NEEDLE/22G X 1-1/2" 65 BD VEO INSULIN SYRINGE BD INSULIN SYRINGE BD NEEDLE/25G X 5/8" 65 ULTRA-FINE/0.3ML/31G X ULTRAFINE/U-100/1ML/31G X BD NEEDLE/25G X 7/8" 65 6MM 66 5/16" 64 BD VEO INSULIN SYRINGE BD INSULIN BD NEEDLE/27G X 1/2" 65 ULTRA-FINE/0.5ML/31G X SYRINGE/0.3ML/29G X BD NEEDLE/30G X 1/2" 65 6MM 66 12.7MM 64 BD NESTABLE SHARPS BD VEO INSULIN SYRINGE BD INSULIN COLLECTOR 65 ULTRA-FINE/1/2 SYRINGE/0.5ML/29G X BD PEN NEEDLES 65 UNIT/0.3ML/31G X 6MM 66 12.7MM 64 BD SAFETY-GLIDE INSULIN BD VEO INSULIN SYRINGE BD INSULIN SYRINGE/1ML/27G SYRINGE/0.5ML/29G X ULTRA-FINE/1ML/31G X X 12.7MM 64 1/2" 65 6MM 66 BD INSULIN SYRINGE/1ML/29G BD SAFETY-LOK INSULIN BD VEO INSULIN SYRINGE X 12.7MM 64 SYRINGE/PERM ULTRA-FINE/U-100/0.3ML/31G BD INSULIN NEEDLE/UF/1ML/29G X X 15/64" 66 BD VEO INSULIN SYRINGE SYRINGE/DETACHABLE 1/2" 65 NEEDLE/U-100/1ML/25G X BD SAFETYGLIDE INSULIN ULTRA-FINE/U-100/1ML/31G X 1" 64 SYRINGE/0.3ML/29G X 15/64" 66 BEEF BRAISED NATURAL BD INSULIN 1/2" 65 SYRINGE/DETACHABLE BD SAFETYGLIDE INSULIN FLAVOR 157 NEEDLE/U-100/1ML/25G X SYRINGE/0.3ML/31G X BEEF FLAVOR 157 5/8" 64 15/64" 65 BEEF TYPE FLAVOR BD INSULIN BD SAFETYGLIDE INSULIN NATURAL 157 SYRINGE/DETACHABLE SYRINGE/0.3ML/31G X BEEF TYPE FLAVOR NEEDLE/U-100/1ML/26G X 5/16" 65 NATURALCHLORIDE 1/2" 64 BD SAFETYGLIDE INSULIN FREE 157 BD INSULIN SYRINGE/U- SYRINGE/0.5ML/31G X BEEF TYPE FLAVOR OS 157 100/1ML/27G X 1/2" 64 15/64" 65 BENADRYL ALLERGY 21 BD INSULIN SYRINGE/U- BD SAFETYGLIDE INSULIN 100/2ML/27.5G X 5/8" 64 BENADRYL ALLERGY SYRINGE/1ML/31G X CHILDRENS 21 BD INSULIN SYRINGE/U- 15/64" 65 500/0.5ML/31G X 6MM 64 BENADRYL ALLERGY BD SAFETYGLIDE INSULIN ULTRATABS 21 BD INTEGRA 3ML SYRINGE SYSYRINGE/0.5ML/30G X benazepril & W/RETRACTING NEEDLE/21G 5/16" 65 hydrochlorothiazide 23 X 1-1/2" 64 BD SAFETYGLIDE SYRINGE benazepril hcl 23 3ML/25GX1" 65
Index 5 BENAZEPRIL bosentan 32 BUMEX 42 HCL/HYDROCHLOROTHIAZIDE BPROTECTED PEDIA POLY- BUPIVACAINE 23 VITE 147 FISIOPHARMA 49 BENEFIX 45 BPROTECTED PEDIA POLY- bupivacaine hcl 49 benzonatate 35 VITE/IRON 147 buprenorphine hcl 7 benztropine mesylate 25 BRAINSTRONG PRENATAL 148 buprenorphine hcl-naloxone hcl dihydrate 7 BETADINE 28 Breast pump 59 bupropion hcl 16 BETADINE SURGICAL BREATHE EASE/LARGE SCRUB 28 MASK 95 bupropion hcl (smoking betamethasone dipropionate BREATHE EASE/MEDIUM deterrent) 168 (topical) 38 MASK 95 BURIED TREASURE ACTIVE betamethasone dipropionate BREATHE EASE/SMALL 55PLUS SENIOR augmented 38 MASK 95 COMPLEX 107 betamethasone valerate 38 BREATHERITE 95 buspirone hcl 10 BETAPACE 31 BREATHERITE butalbital-acetaminophen 4 BETASERON 167 COLLAPSIBLEADULT butalbital-acetaminophen- betaxolol hcl (ophth) 154 SPACER W/MASK 95 caffeine 4 BREATHERITE butalbital-acetaminophen- bethanechol chloride 172 COLLAPSIBLECHILD SPACER caffeine w/ codeine 6 BETIMOL 154 W/MASK 95 butalbital-aspirin-caffeine 4 BETOPTIC-S 154 BREATHERITE butalbital-aspirin-caffeine BEVYXXA 12 COLLAPSIBLEINFANT w/cod 6 SPACER W/MASK 95 BUTALBITAL/ACETAMINOPHEN BEXSERO 172 BREATHERITE 4 BICILLIN L-A 156 COLLAPSIBLESMALL CHILD butenafine hcl 37 BIKTARVY 28 SPACER W/MASK 95 BREATHERITE BUTTER FLAVOR 158 BILTRICIDE 8 COLLAPSIBLESPACER W/ BUTTER RUM FLAVOR 158 BIO-35 GLUTEN-FREE 107 NEONATE MASK 95 BUTTERSCOTCH BIO-35 IRON FREE 107 BREATHERITE RIGID FLAVOR 158 BIOCAL 107 SPACERW/MASK 95 BYDUREON BCISE 18 BREATHERITE VALVED MDI BYDUREON PEN 18 BIOLYTE 100 CHAMBER/COLLAPSIBLE BIOSUPP 107 95 BYETTA 18 BIOTECT PLUS 107 BREATHERITE VALVED MDI cabergoline 43 CHAMBER/RIGID 95 CAFERGOT 98 bisacodyl 49 BREATHERITE W/LARGE bismuth subsalicylate 19 CAL-CITRATE PLUS MASK 95 VITAMIND 99 bisoprolol & BREATHERITE W/MEDIUM CAL-DAY 1000 107 hydrochlorothiazide 23 MASK 95 bisoprolol fumarate 31 BREATHERITE W/SMALL CAL-MINT 99 BITTER STOP FLAVOR 157 MASK 95 CALAN 31 BITTERNESS MASK brimonidine tartrate 154 CALAN SR 31 FLAVOR 157 brinzolamide 156 CALCET PETITES 99 BITTERNESS SUPPRESSOR BRISDELLE 169 calcipotriene 38 FLAVOR 157 BITTERNESS SUPRESSOR bromocriptine mesylate 25 calcitonin (salmon) 42 FLAVOR 157 BUBBLE GUM calcitriol 43 CONCENTRATE 157 BLACKBERRY FLAVOR 157 CALCIUM 99 BUBBLE GUM FLAVOR 158 BLEPH-10 154 calcium 99 BUBBLEGUM FLAVOR 158 BLEPHAMIDE 155 CALCIUM 1000 + D 99 budesonide 35 BLEPHAMIDE S.O.P. 155 calcium acetate (phosphate budesonide (inhalation) 11 BLUEBERRY FLAVOR 157 binder) 44 budesonide-formoterol CALCIUM CARBONATE 8,99 BOOSTRIX 170 fumarate dihydrate 12 calcium carbonate 99 BORIC ACID 40 bumetanide 42
Index 6 calcium carbonate (antacid) 8 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 calcium carbonate- DARKGREEN/DARK MINTGREEN/MINT cholecalciferol 99 GREEN 160 GREEN 160 calcium carbonate-vitamin d 99 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 DARKGREEN/ORANGE 160 OLIVE/CLEAR 160 CALCIUM CHEWS 99 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CALCIUM CITRATE 99 GREEN/YELLOW 160 ORANGE/ORANGE 160 calcium citrate 99 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 LIGHT BLUE/WHITE 160 PINK/CLEAR 160 CALCIUM CITRATE W/D 99 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CALCIUM CITRATE W/VITAMIN LIGHT GREY/PINK 160 PINK/PINK 160 D 99 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 calcium citrate-vitamin d 99 ORANGE 160 RED/CLEAR 160 CALCIUM PLUS VITAMIN D 99 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 calcium polycarbophil 48 PINK/AQUA BLUE 160 RED/RED 160 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CALNA 148 PINK/CLEAR 160 WHITE/CLEAR 160 CALTRATE 600+D3 100 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CANASA 44 PINK/PINK 160 WHITE/WHITE 160 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CAPLYTA 26 PINK/WHITE 160 YELLOW/YELLOW 160 capsaicin 40 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #4 CAPSULE CONI-SNAP #0 PINK/YELLOW 160 BLACK/GREEN 160 CLEAR/CLEAR 159 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #4 CAPSULE CONI-SNAP #0 DARK PURPLE/PURPLE 160 CLEAR/CLEAR 160 BLUE/DARK BLUE 159 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #4 CAPSULE CONI-SNAP #0 RED/BLUE 160 WHITE 161 GREEN/CLEAR 159 CAPSULE CONI-SNAP #1 CAPSULE EZEEFIT #0 CAPSULE CONI-SNAP #0 RED/WHITE 160 CLEAR 161 LIGHT BLUE/WHITE 159 CAPSULE CONI-SNAP #1 CAPSULE EZEEFIT #00 CAPSULE CONI-SNAP #0 WHITE 160 CLEAR 161 PINK/PINK 159 CAPSULE CONI-SNAP #1 CAPSULE SIZE 1 CAPSULE CONI-SNAP #0 WHITE/CLEAR 160 LACTOSE 161 RED/WHITE 159 CAPSULE CONI-SNAP #1 captopril 23 CAPSULE CONI-SNAP #0 WHITE/GREEN 160 captopril & WHITE/WHITE 159 CAPSULE CONI-SNAP #1 hydrochlorothiazide 23 CAPSULE CONI-SNAP YELLOW/GREEN 160 CAPZASIN-HP 40 #0/PURPLE/OPAQUE/CLEAR CAPSULE CONI-SNAP #1 159 YELLOW/YELLOW 160 CARAC 38 CAPSULE CONI-SNAP #00 CAPSULE CONI-SNAP #2 CARAFATE 171 CLEAR/CLEAR 159 CLEAR/CLEAR 160 CARAMEL FLAVOR 158 CAPSULE CONI-SNAP #00 CAPSULE CONI-SNAP #2 WHITE/WHITE 159 WHITE 160 carbamazepine 13 CAPSULE CONI-SNAP #000 CAPSULE CONI-SNAP #3 CARBAMAZEPINE 13 CLEAR/CLEAR 159 BLUE/CLEAR 160 carbamazepine 13 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CARBATROL 13 AQUABLUE/AQUA BLUE 159 BROWN/LIGHT BLUE 160 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 carbidopa-levodopa 25 BLUE/BLUE 159 CLEAR/CLEAR 160 carbidopa-levodopa-entacapone CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 25 BLUE/PINK 159 DARKGREY/PINK 160 carboxymethylcellulose sodium CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 (ophth) 153 BLUE/POWDER BLUE 159 GRAY/YELLOW 160 CARDIOCOM LANCING CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 DEVICE 52 BROWN/IVORY 160 GREEN/BLUE 160 CARDIZEM 32 CAPSULE CONI-SNAP #1 CAPSULE CONI-SNAP #3 CARDIZEM CD 31 BROWN/LIGHT BROWN 160 MAROON/BLUE 160 CAPSULE CONI-SNAP #1 CARDURA 23 CLEAR/CLEAR 160 CAREONE ADVANCED LANCINGDEVICE 52
Index 7 CAREONE INSULIN CELESTONE SOLUSPAN 35 CERTAVITE SYRINGES/0.3ML/30G X CELESTONE-SOLUSPAN 35 SENIOR/ANTIOXIDANT 1/2" 66 NUTRIENTS 110 CAREONE INSULIN CELEXA 16 CERTAVITE/ANTIOXIDANTS SYRINGES/0.3ML/31G X CELLCEPT 102 110 5/16" 66 CELLULAR SECURITY 108 cetirizine hcl 21 CAREONE INSULIN CETRAXAL 156 SYRINGES/0.5ML/30G X CENTANY 37 1/2" 66 CENTRAVITES 50 PLUS 108 cevimeline hcl 103 CAREONE INSULIN CENTRAVITES ADULTS 108 CHANTIX 168 SYRINGES/0.5ML/31G X CENTRUM 109,110 CHANTIX CONTINUING 5/16" 66 MONTHPAK 168 CAREONE INSULIN CENTRUM ADULTS 108 CHANTIX STARTING MONTH SYRINGES/1ML/30G X 1/2" 66 CENTRUM CARDIO 108 PAK 168 CAREONE INSULIN CENTRUM FLAVOR CHEESECAKE FLAVOR 158 SYRINGES/1ML/31GX5/16" 66 BURST 108 CHELATED CALCIUM 100 CAREONE LANCET SUPER CENTRUM FLAVOR BURST THIN/30G 52 ADULT 108 CHERACOL PLUS 36 CAREONE LANCET THIN 52 CENTRUM FRESH/FRUITY CHERACOL-D COUGH 36 CAREPOINT SAFETY 1ST ADULTS 50+ 108 CHERRY CONCENTRATE 165 SYRINGE/NEEDLE 1ML/23G X CENTRUM MEN 109 CHERRY FLAVOR 158 1" 66 CENTRUM MULTIGUMMIES CAREPOINT SAFETY 1ST ADULTS 109 CHERRY SYRUP 165 SYRINGE/NEEDLE 1ML/25G X CENTRUM MULTIGUMMIES CHEWABLE CALCIUM/D3 100 1" 66 MEN 109 CHICKEN (GRILLED) CARESENS LANCETS 52 CENTRUM MULTIGUMMIES FLAVOR 158 CARETOUCH INSULIN MULTI +OMEGA 3 109 CHICKEN FLAVOR 158 SYRINGE/U-100/1ML/28G X CENTRUM MULTIGUMMIES CHICKEN FLAVOR OIL 5/16" 66 WOMEN 109 SOLUBLE 158 CARETOUCH INSULIN CENTRUM SILVER 109,110 CHICKEN FLAVOR WATER SYRINGE/U-100/1ML/29G X CENTRUM SILVER MISCIBLE 158 5/16" 66 50+MEN 109 CHICKEN ROASTED CARETOUCH LANCING CENTRUM SILVER CONCENTRATE 158 DEVICEWITH EJECTOR 52 50+WOMEN 109 CHILDRENS ADVIL 3 CARNITOR 43 CENTRUM SILVER ADULT CHILDRENS MOTRIN 3 50+ 109 carteolol hcl (ophth) 154 CENTRUM SILVER ULTRA CHLOR-TRIMETON 21 carvedilol 31 WOMENS 110 chlordiazepoxide hcl 10 CATAPRES 23 CENTRUM SPECIALIST chlordiazepoxide-amitriptyline cefaclor 33 HEART 110 167 CENTRUM SPECIALIST cefadroxil 33 chlorhexidine gluconate (mouth- IMMUNE SUPPORT 110 throat) 102 cefdinir 33 CENTRUM SPECIALIST chloroquine phosphate 24 cefpodoxime proxetil 33 PRENATAL 148 CENTRUM SPECIALIST chlorpheniramine maleate 21 cefprozil 33 VISION 110 chlorpromazine hcl 27 ceftriaxone sodium 33 CENTRUM ULTRA CHLORPROMAZINE cefuroxime axetil 33 WOMENS 110 HYDROCHLORIDE 27 CELEBRATE MULTI- CENTRUM VITAMINTS 110 chlorthalidone 42 COMPLETE18 107 CENTRUM WOMEN 110 chlorzoxazone 151 CELEBRATE MULTI- cephalexin 33 COMPLETE36 107,108 CHOCOLATE FLAVOR 158 CELEBRATE MULTI- CERALYTE 70 100 CHOCOLATE HAZELNUT COMPLETE45 108 CERASPORT 100 FLAVOR 158 CHOICEFUL CELEBRATE MULTI- CERASPORT EX1 100 COMPLETE60 108 MULTIVITAMIN 110,111 CERTAVITE SENIOR 110 CELEBREX 3 cholecalciferol 177 celecoxib 3 cholestyramine 22
Index 8 cholestyramine light 22 CLEVER CHOICE COMFORT clindamycin phosphate CICLODAN SOLUTION KIT 37 EZINSULIN vaginal 176 SYRINGE/0.3ML/29G X CLINDESSE 176 cilostazol 46 1/2" 66 CLINICAL NUTRIENTS 45-PLUS CILOXAN 154 CLEVER CHOICE COMFORT WOMEN 111 CIMDUO 28 EZINSULIN CLINICAL NUTRIENTS 50-PLUS cimetidine 171 SYRINGE/0.3ML/30G X MEN 111 1/2" 66 CLINICAL NUTRIENTS cimetidine hcl 171 CLEVER CHOICE COMFORT ANTIOXIDANT 111 CIMZIA 44 EZINSULIN CLINICAL NUTRIENTS FOR CIMZIA STARTER KIT 44 SYRINGE/0.3ML/30G X FEMALE TEENS 111 5/16" 66 CIPRO 43 CLINICAL NUTRIENTS FOR CLEVER CHOICE COMFORT MALE TEENS 111 CIPRO HC 156 EZINSULIN CLINICAL NUTRIENTS FOR CIPRODEX 156 SYRINGE/0.3ML/31G X MEN 111 ciprofloxacin 43 5/16" 66 CLINICAL NUTRIENTS FOR CLEVER CHOICE COMFORT WOMEN 111 ciprofloxacin hcl 43 EZINSULIN CLINICAL NUTRIENTS ciprofloxacin hcl (ophth) 154 SYRINGE/0.5ML/28G X PRENATAL FORMULA 148 ciprofloxacin-dexamethasone 1/2" 66 clobazam 13 156 CLEVER CHOICE COMFORT CLODERM 38 citalopram hydrobromide 16 EZINSULIN clomipramine hcl 17 CITRACAL + D3 SYRINGE/0.5ML/29G X MAXIMUM 100 1/2" 66 clonazepam 13 CITRACAL MAXIMUM 100 CLEVER CHOICE COMFORT CLONIDINE HCL 23 CITRACAL EZINSULIN clonidine hcl 23 SYRINGE/0.5ML/30G X PETITES/VITAMIND 100 clonidine hcl (adhd) 1 CITRUCEL FIBER 1/2" 66 CLEVER CHOICE COMFORT CLONIDINE LAXATIVE 48 EZINSULIN HYDROCHLORIDE 23 clarithromycin 50 SYRINGE/0.5ML/30G X clopidogrel bisulfate 46 CLARITIN 21 5/16" 66 clorazepate dipotassium 10 CLARITIN ALLERGY CLEVER CHOICE COMFORT CHILDRENS 21 EZINSULIN clotrimazole 102 CLARITIN CHILDRENS 21 SYRINGE/0.5ML/31G X clotrimazole (topical) 37 CLARITIN REDITABS 21 5/16" 67 clotrimazole vaginal 176 CLEVER CHOICE COMFORT clozapine 27 CLASSIC PRENATAL 148 EZINSULIN CLEANLET LANCETS 28G 52 SYRINGE/1.0ML/30G X CLOZARIL 27 CLEOCIN 9,175 1/2" 67 CO MONITOR 96 CLEOCIN PEDIATRIC CLEVER CHOICE COMFORT CO-NATAL FA 148 GRANULES 9 EZINSULIN COCONUT FLAVOR 158 CLEOCIN-T 37 SYRINGE/1ML/28G X 1/2" 67 CLEVER CHOICE COMFORT CODEINE SULFATE 5 CLEVER CHOICE ANTI- EZINSULIN codeine sulfate 5 STATICVALVED HOLDING SYRINGE/1ML/29G X 1/2" 67 coenzyme q10 CHAMBER/ADULT LARGE 95 CLEVER CHOICE COMFORT (ubidecarenone) 2 CLEVER CHOICE ANTI- EZINSULIN STATICVALVED HOLDING COFFEE FLAVOR 158 SYRINGE/1ML/30G X COLA FLAVOR 158 CHAMBER/MEDIUM 95 5/16" 67 CLEVER CHOICE ANTI- CLEVER CHOICE COMFORT COLACE 49 STATICVALVED HOLDING EZINSULIN SYRINGE/U- COLACE CLEAR 49 CHAMBER/MEDIUM/3 YEA 96 CLEVER CHOICE ANTI- 100/1ML/31GX5/16" 67 COLAZAL 44 STATICVALVED HOLDING CLIMARA PRO 43 colchicine 45 CHAMBER/SMALL 96 CLINDAGEL 37 colchicine w/ probenecid 45 CLEVER CHOICE ANTI- clindamycin hcl 9 COLCRYS 45 STATICVALVED HOLDING clindamycin palmitate CHAMBER/SMALL INFANT 96 hydrochloride 9 COLESTID 22
Index 9 COLESTID FLAVORED 22 CONZIP 5 CVS LANCETS MICRO THIN colestipol hcl 22 COPAXONE 167 33G 52 CVS LANCETS MICRO-THIN COLYTE-FLAVOR PACKS 48 COREG 31 33G 52 COMBIPATCH 43 CORGARD 31 CVS LANCETS ORIGINAL 52 COMBIVENT RESPIMAT 12 CORIFACT 45 CVS LANCETS THIN 26G 52 COMBIVIR 28 CORTEF 35 CVS LANCETS ULTRA THIN COMFORT ASSIST INSULIN CORTENEMA 7 30G 52 CVS LANCETS ULTRA-THIN SYRINGE 0.3ML/29G X 1/2" 67 CORTIFOAM 8 COMFORT ASSIST INSULIN 30G 52 SYRINGE/0.3ML/30G X cortisone acetate 35 CVS LANCING DEVICE 52 5/16" 67 CORVITE 111 CVS LICE SOLUTION KIT 3- COMFORT ASSIST INSULIN COSOPT 154 STEP 41 SYRINGE/0.3ML/31G X COTTON CANDY CVS NATURAL FIBER 5/16" 67 FLAVOR 158 SUPPLEMENT 48 COMFORT ASSIST INSULIN COUMADIN 12 CVS ONE DAILY MENS 50+ SYRINGE/0.5ML/29G X 1/2" 67 ADVANCED 111 COMFORT ASSIST INSULIN COZAAR 23 CVS ONE DAILY WOMENS SYRINGE/0.5ML/30G X CRAN-RASPBERRY 50+ADVANCED 111 5/16" 67 FLAVOR 158 CVS PILL SPLITTER 59 COMFORT ASSIST INSULIN CRANBERRY 2 CVS PRENATAL SYRINGE/0.5ML/31G X cranberry (vaccinium GUMMY/DHA/FOLIC ACID 148 5/16" 67 macrocarpon) 2 CVS PREP PADS 59 COMFORT ASSIST INSULIN CRANBERRY EXTRACT 2 CVS SOFT GLUCOSE 18 SYRINGE/1ML/29G X 1/2" 67 CREME DE MENTHE COMFORT ASSIST INSULIN CVS SPECTRAVITE ADULT FLAVOR 158 50+ 111 SYRINGE/1ML/30G X 5/16" 67 CREME DEMENTHE COMFORT ASSIST INSULIN CVS SPECTRAVITE FLAVOR 158 SYRINGE/1ML/31G X 5/16" 67 ADULTS 111 COMFORT ASSURED CREON 42 CVS SPECTRAVITE ULTRA LANCETS SUPER THIN CRESTOR 22 MEN50+ 111 28G 52 CRIXIVAN 28 CVS SPECTRAVITE ULTRA MENS HEALTH 111 COMFORT EZ INSULIN cromolyn sodium 11 SYRINGE/U-100/0.5ML/31G X CVS SPECTRAVITE ULTRA 5/16" 67 CULTURELLE KIDS MENS HEALTH SENIOR 111 COMFORT EZ INSULIN COMPLETEMULTIVITAMIN + CVS SPECTRAVITE ULTRA SYRINGE/U-100/1ML/31G X PROBIOTIC 147 WOMEN 111 5/16" 67 CULTURELLE KIDS CVS SPECTRAVITE ULTRA PROBIOTIC/MULTIVITAMIN COMFORT LANCETS 52 WOMENS HEALTH 112 147 CVS SPECTRAVITE ULTRA COMPACT SPACE CULTURELLE PROBIOTICS + WOMENS HEALTH CHAMBER/ANTI-STATIC 96 MULTIVITAMIN 111 SENIOR 111 COMPACT SPACE CUPRIMINE 101 CVS SPECTRAVITE CHAMBER/ANTI- WOMEN 112 STATIC/LARGE MASK 96 CURITY ALCOHOL PREPS/MEDIUM 2 PLY 59 CVS ULTRA THIN COMPACT SPACE LANCETS 52 CHAMBER/ANTI- CURITY ALCOHOL STATIC/MEDIUM MASK 96 SWABS 59 CVS VISION HEALTH 112 COMPACT SPACE CVS ADULT 50+ EYE CVS WOMENS HEALTH 111 PRENATAL+DHA 148 CHAMBER/ANTI-STATIC/SMALL CVS AIRSHIELD IMMUNITY MASK 96 cyanocobalamin 46 SUPPORT 111 COMPLERA 28 CVS ANTACID SOFT CHEWS cyclobenzaprine hcl 151 COMPLETE NEEDLE ULTRA STRENGTH 8 CYCLOGYL 154 COLLECTION & DISPOSAL CVS DAILY FIBER 48 cyclopentolate hcl 154 SYSTEM 67 CVS EYE HEALTH ADULT COMTAN 25 cyclosporine 102 50+ 111 cyclosporine modified (for CONCERTA 1 CVS GLUCOSE 18 microemulsion) 102 CONDOMS-MISC 50 CVS LANCETS 21G 52 CYMBALTA 17
Index 10 cyproheptadine hcl 21 desmopressin acetate spray DIAZEPAM 10 cytarabine 25 refrigerated 43 diazepam 10 desogestrel & ethinyl CYTOMEL 170 estradiol 33 diazepam (anticonvulsant) 13 CYTOTEC 171 desogestrel-ethinyl estradiol diclofenac potassium 3 D-VI-SOL 177 (biphasic) 33 diclofenac sodium 3 desogestrel-ethinyl estradiol D.H.E. 45 98 (triphasic) 33 diclofenac sodium (ophth) 156 danazol 7 desonide 38 dicloxacillin sodium 157 DANTRIUM 151 DESOWEN 38 dicyclomine hcl 170 dantrolene sodium 151 desoximetasone 38 didanosine 28 dapsone 9 desvenlafaxine 17 DIFFERIN 37 DAPTACEL 170 DESVENLAFAXINE ER 17 diflorasone diacetate 39 DAPTOMYCIN 9 desvenlafaxine succinate 17 DIFLUCAN 20 DARAPRIM 24 DETROL 172 digoxin 32 DAUNORUBICIN DETROL LA 172 dihydroergotamine mesylate 98 HYDROCHLORIDE 25 DEX4 QUICK DISSOLVE DILANTIN 15 DAYAVITE 112 GLUCOSE 18 DILANTIN INFATABS 15 DDAVP 43 dexamethasone 35 DILANTIN-125 15 DECUBI-VITE 112 DEXAMETHASONE DILAUDID 5 DEKAS BARIATRIC 112 INTENSOL 35 diltiazem hcl 32 DEKAS ESSENTIAL 144 dexamethasone sodium phosphate (ophth) 155 diltiazem hcl coated beads 32 DEKAS PLUS 112,147 DEXEDRINE 1 diltiazem hcl extended release DELSTRIGO 28 dexmethylphenidate hcl 1 beads 32 DELSYM 35 dextroamphetamine sulfate 1 dimethyl fumarate 167 DELSYM COUGH dextromethorphan DINO-LIFE W/IRON & CHILDRENS 35 polistirex 35 ZINC 147 DELUXE SAFETY TABLET dextromethorphan-guaifenesin DIOVAN 23 CUTTER 59 36 DIOVAN HCT 23 DELUXE TABLET CUTTER 59 dextrose (diabetic use) 18 DIPENTUM 44 DELZICOL 44 DEXTROSE 5%/NACL diphenhydramine hcl 21 DEPACON 15 0.3% 100 diphenoxylate w/ atropine 20 DEPAKENE 15 DEXTROSE/SODIUM CHLORIDE 100 DIPHTHERIA/TETANUS DEPAKOTE 15 DI-GEL 8 TOXOIDS ADSORBED DEPAKOTE ER 15 DIALYSIS SAFETY PEDIATRIC 170 DEPAKOTE SPRINKLES 15 SYRINGES/LOW DEAD DIPROLENE 39 DEPO-MEDROL 35 SPACE 1ML/22GX1-1/2" 67 DIPROLENE AF 39 DEPO-PROVERA DIALYSIS SAFETY dipyridamole 46 CONTRACEPTIVE 34 SYRINGES/LOW DEAD disopyramide phosphate 11 SPACE 3ML/22GX1-1/2" 67 DEPO-SUBQ PROVERA disulfiram 167 104 34 DIALYVITE 800/IRON 105 DEPO-TESTOSTERONE 7 DIALYVITE 800/ZINC 105 DITROPAN XL 172 DERMACINRX RIBOTIN-E 112 DIALYVITE 800/ZINC 15 105 divalproex sodium 15 DERMACINRX ZINTREXYL- DIASTAT ACUDIAL 13 DOCETAXEL 25 C 112 DIASTAT PEDIATRIC 13 docusate calcium 49 DERMAVITE 112 DIATHRIVE LANCETS 52 docusate sodium 49 DESCOVY 28 DIATHRIVE LANCETS ULTRA DOLOPHINE 5 desipramine hcl 17 THIN 30G 52 DOMEBORO 40 desmopressin acetate 43 DIATHRIVE LANCING donepezil hydrochloride 167 DEVICE 52 desmopressin acetate spray 43 DORAL 47 diazepam 10 DORZOLAMIDE HCL 156
Index 11 dorzolamide hcl 156 DROPLET INSULIN E-ZJECT LANCETS MICRO- dorzolamide hcl-timolol SYRINGE/U-100/0.3ML/31G X THIN 33G 53 maleate 154 5/16" 68 E600 177 DOVATO 28 DROPLET INSULIN EASIVENT 96 SYRINGE/U-100/0.5ML/30G X DOVONEX 38 1/2" 68 EASIVENT/MASK-LARGE 96 doxazosin mesylate 23 DROPLET INSULIN EASIVENT/MASK-MEDIUM 96 doxepin hcl 17 SYRINGE/U-100/0.5ML/31G X EASIVENT/MASK-SMALL 96 15/64" 68 EASY COMFORT INSULIN doxycycline (monohydrate) 169 DROPLET INSULIN doxycycline hyclate 169 SYRINGE/0.5ML/30G X SYRINGE/U-100/0.5ML/31G X 5/16" 68 doxylamine succinate 5/16" 68 EASY COMFORT INSULIN (sleep) 47 DROPLET INSULIN SYRINGE/0.5ML/31G X DRCAPS SIZE 00 CLEAR 161 SYRINGE/U-100/1ML/30G X 5/16" 68 DRCAPS SIZE 1 CLEAR 161 1/2" 68 EASY COMFORT INSULIN DROPLET INSULIN DRISDOL 177 SYRINGE/1ML/30G X 5/16" 68 SYRINGE/U-100/1ML/31G X EASY COMFORT INSULIN DRISTAN SPRAY 151 15/64" 68 SYRINGE/1ML/31G X 5/16" 68 DRITHO-CREME HP 38 DROPLET INSULIN EASY COMFORT INSULIN DRIZALMA SPRINKLE 17 SYRINGE/U-100/1ML/31G X SYRINGE/U-100/0.5ML/30G X 5/16" 68 dronabinol 20 1/2" 68 DROPLET LANCETS ULTRA EASY COMFORT INSULIN DROPERIDOL 10 THIN 30G 52 SYRINGE/U-100/1ML/30G X droperidol 10 DROPLET LANCING 1/2" 68 DROPLET GENTEEL LANCING DEVICE 52 drospirenone-ethinyl EASY FLOW BLACK/BLUE 96 DEVICE 52 EASY FLOW DROPLET INSULIN SYRINGE estradiol 33 DRUG MART ADJUSTABLE BLACK/ORANGE 96 0.3ML/29G X 1/2" 67 EASY FLOW BLACK/RED 96 DROPLET INSULIN SYRINGE LANCING DEVICE 52 0.5ML/29G X 1/2" 67 DRUG MART LANCETS EASY FLOW BLACK/WHITE96 DROPLET INSULIN SYRINGE THIN 52 EASY FLOW 1ML/29G X 1/2" 67 DRUG MART UNILET BLACK/YELLOW 96 DROPLET INSULIN SYRINGE LANCETSSUPER THIN EASY FLOW WHITE/BLUE 96 U-100/0.3/31G X 5/16" 67 30G 52 EASY FLOW DROPLET INSULIN SYRINGE DRUG MART UNILET WHITE/GREEN 96 LANCETSULTRA THIN U-100/0.3ML/30G X 1/2" 67 EASY FLOW WHITE/PINK 96 DROPLET INSULIN SYRINGE 28G 52 U-100/0.3ML/30G X 5/16" 68 DRUG MART UNILET MICRO EASY FLOW WHITE/WHITE96 DROPLET INSULIN SYRINGE THIN LANCETS 33G 53 EASY FLOW U-100/0.3ML/31G X 15/64" 68 DUETACT 17 WHITE/YELLOW 96 DROPLET INSULIN SYRINGE DULCOLAX 49 EASY MINI EJECT LANCING DEVICE 53 U-100/0.5ML/30G X 1/2" 68 duloxetine hcl 17 DROPLET INSULIN SYRINGE EASY MINI LANCING U-100/0.5ML/30G X 5/16" 68 DURAGESIC 5 DEVICE 53 DROPLET INSULIN SYRINGE DURATION 12 HOUR 151 EASY TOUCH ALCOHOL PREP PADS/MEDIUM 59 U-100/0.5ML/31G X 5/16" 68 DURATION SPRAY 151 DROPLET INSULIN SYRINGE EASY TOUCH FLIPLOCK DUREX EXTRA NEEDLES 18GX1" 68 U-100/1ML/30G X 1/2" 68 SENSITIVE 50 DROPLET INSULIN SYRINGE EASY TOUCH FLIPLOCK U-100/1ML/30G X 5/16" 68 DYAZIDE 42 NEEDLES 18GX1-1/2" 68 DROPLET INSULIN SYRINGE E-Z JECT LANCETS 53 EASY TOUCH FLIPLOCK U-100/1ML/31G X 15/64" 68 E-Z JECT LANCETS 21G 53 NEEDLES 19GX1" 68 DROPLET INSULIN SYRINGE EASY TOUCH FLIPLOCK E-Z JECT LANCETS NEEDLES 20GX1" 68 U-100/1ML/31G X 5/16" 68 COLOR 53 DROPLET INSULIN EASY TOUCH FLIPLOCK E-Z JECT LANCETS SUPER NEEDLES 20GX1-1/2" 68 SYRINGE/U-100/0.3ML/31G X THIN 30G 53 15/64" 68 EASY TOUCH FLIPLOCK E-Z JECT LANCETS THIN NEEDLES 21GX1" 68 26G 53
Index 12 EASY TOUCH FLIPLOCK EASY TOUCH FLIPLOCK EASY TOUCH FLURINGE NEEDLES 21GX1-1/2" 69 SAFETY SYRINGE SYRINGE/1ML/25G X 5/8" 70 EASY TOUCH FLIPLOCK 1ML/27GX1/2" 69 EASY TOUCH INSULIN NEEDLES 22GX1" 69 EASY TOUCH FLIPLOCK SYRINGE/0.3ML/30G X EASY TOUCH FLIPLOCK SAFETY SYRINGE 5/16" 70 NEEDLES 22GX1-1/2" 69 3ML/19GX1" 69 EASY TOUCH INSULIN EASY TOUCH FLIPLOCK EASY TOUCH FLIPLOCK SYRINGE/0.3ML/31G X NEEDLES 22GX3/4" 69 SAFETY SYRINGE 5/16" 70 EASY TOUCH FLIPLOCK 3ML/19GX1.5" 69 EASY TOUCH INSULIN NEEDLES 23GX1" 69 EASY TOUCH FLIPLOCK SYRINGE/0.5ML/29G X 1/2" 70 EASY TOUCH FLIPLOCK SAFETY SYRINGE EASY TOUCH INSULIN NEEDLES 23GX1-1/2" 69 3ML/21GX1" 69 SYRINGE/0.5ML/30G X EASY TOUCH FLIPLOCK EASY TOUCH FLIPLOCK 5/16" 70 NEEDLES 23GX5/8" 69 SAFETY SYRINGE EASY TOUCH INSULIN EASY TOUCH FLIPLOCK 3ML/22GX1" 69 SYRINGE/1ML/30G X 5/16" 70 NEEDLES 25GX1" 69 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH FLIPLOCK SAFETY SYRINGE SYRINGE/SAFETY/U- NEEDLES 25GX1-1/2" 69 3ML/22GX1-1/2" 69 100/0.5ML/29G X 1/2" 70 EASY TOUCH FLIPLOCK EASY TOUCH FLIPLOCK EASY TOUCH INSULIN NEEDLES 25GX5/8" 69 SAFETY SYRINGE SYRINGE/SAFETY/U- EASY TOUCH FLIPLOCK 3ML/23GX1" 69 100/0.5ML/30G X 5/16" 70 NEEDLES 26GX1/2" 69 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH FLIPLOCK SAFETY SYRINGE SYRINGE/SAFETY/U- NEEDLES 27GX1" 69 3ML/23GX1-1/2" 70 100/1ML/29G X 1/2" 70 EASY TOUCH FLIPLOCK EASY TOUCH FLIPLOCK EASY TOUCH INSULIN NEEDLES 27GX1/2" 69 SAFETY SYRINGE SYRINGE/SAFETY/U- EASY TOUCH FLIPLOCK 3ML/25GX1" 70 100/1ML/30G X 1/2" 70 NEEDLES 28GX1/2" 69 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH FLIPLOCK SAFETY SYRINGE SYRINGE/U-100/0.3ML/30G X NEEDLES 29GX1/2" 69 3ML/25GX5/8" 70 1/2" 70 EASY TOUCH FLIPLOCK EASY TOUCH FLIPLOCK EASY TOUCH INSULIN NEEDLES 30GX1/2" 69 SAFETY SYRINGES SYRINGE/U-100/0.5ML/27G X EASY TOUCH FLIPLOCK 3ML/18GX1" 70 1/2" 70 NEEDLES 30GX5/16" 69 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH FLIPLOCK SAFETY SYRINGES SYRINGE/U-100/0.5ML/28G X NEEDLES 31GX5/16" 69 3ML/20GX1" 70 1/2" 70 EASY TOUCH FLIPLOCK EASY TOUCH FLIPLOCK EASY TOUCH INSULIN NEEDLLES 19GX1-1/2" 69 SAFETY SYRINGES SYRINGE/U-100/0.5ML/29G X EASY TOUCH FLIPLOCK 3ML/20GX1-1/2" 70 1/2" 70 SAFETTY SYRINGES EASY TOUCH FLIPLOCK EASY TOUCH INSULIN 3ML/18GX1-1/2" 69 SAFETY SYRINGES SYRINGE/U-100/0.5ML/30G X EASY TOUCH FLIPLOCK 3ML/21GX1-1/2" 70 1/2" 71 SAFETY INSULIN SYRINGE EASY TOUCH FLURINGE EASY TOUCH INSULIN 1ML/29GX1/2" 69 FLIPLOCK SAFETY SYRINGE SYRINGE/U-100/0.5ML/31G X EASY TOUCH FLIPLOCK 1ML/25GX1" 70 5/16" 71 SAFETY INSULIN SYRINGE EASY TOUCH FLURINGE EASY TOUCH INSULIN 1ML/30GX1/2" 69 FLIPLOCK SAFETY SYRINGE SYRINGE/U-100/1ML/27G X EASY TOUCH FLIPLOCK 1ML/25GX5/8" 70 1/2" 71 SAFETY INSULIN SYRINGE EASY TOUCH FLURINGE FLU EASY TOUCH INSULIN 1ML/30GX5/16" 69 TRAY SYRINGE/1ML/25G X SYRINGE/U-100/1ML/28G X EASY TOUCH FLIPLOCK 1" 70 1/2" 71 SAFETY INSULIN SYRINGE EASY TOUCH FLURINGE EASY TOUCH INSULIN 1ML/31GX5/16" 69 SHEATHLOCK SAFETY SYRINGE/U-100/1ML/29G X EASY TOUCH FLIPLOCK SYRINGE 1ML/25GX1" 70 1/2" 71 SAFETY SYRINGE EASY TOUCH FLURINGE EASY TOUCH INSULIN 1ML/25GX1" 69 SHEATHLOCK SAFETY SYRINGE/U-100/1ML/30G X EASY TOUCH FLIPLOCK SYRINGE 1ML/25GX5/8" 70 1/2" 71 SAFETY SYRINGE EASY TOUCH FLURINGE 1ML/26GX3/8" 69 SYRINGE/1ML/25G X 1" 70
Index 13 EASY TOUCH INSULIN EASY TOUCH SHEATHLOCK ELITE-THIN INSULIN SYRINGE/U-100/1ML/31G X SAFETY SYRINGE SYRINGE/1ML/29G X 5/16" 72 5/16" 71 3ML/22GX1" 71 ELITE-THIN INSULIN EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK SYRINGE/1ML/30G X 5/16" 72 26G/PULL-TOP 53 SAFETY SYRINGE ELITE-THIN INSULIN EASY TOUCH LANCETS 3ML/22GX1-1/2" 71 SYRINGE/U-100/0.5ML/28G X 28G/PULL-TOP 53 EASY TOUCH SHEATHLOCK 1/2" 72 EASY TOUCH LANCETS SAFETY SYRINGE ELITE-THIN INSULIN 28G/TWIST 53 3ML/23GX1" 71 SYRINGE/U-100/0.5ML/28G X EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK 5/16" 72 30G/PULL-TOP 53 SAFETY SYRINGE ELITE-THIN INSULIN EASY TOUCH LANCETS 3ML/25GX1" 71 SYRINGE/U-100/0.5ML/29G X 30G/TWIST 53 EASY TOUCH SHEATHLOCK 5/16" 72 EASY TOUCH LANCETS SAFETY SYRINGE ELITE-THIN INSULIN 32G/PULL-TOP 53 3ML/25GX5/8" 71 SYRINGE/U-100/0.5ML/31G X EASY TOUCH LANCETS EASY TOUCH TUBERCULIN 5/16" 72 32G/TWIST 53 SHEATHLOCK SAFETY ELITE-THIN INSULIN EASY TOUCH LANCETS SYRINGE 1ML/26GX5/8" 72 SYRINGE/U-100/1ML/28G X 33G/TWIST 53 EASYPOINT 1/2" 72 EASY TOUCH LANCING NEEDLE/SYRINGE 3ML/18G X ELITE-THIN INSULIN DEVICE/EJECTOR 53 1" 72 SYRINGE/U-100/1ML/28G X EASY TOUCH SAFETY EASYPOINT 5/16" 72 SYRINGE/1ML/25G X 1" 71 NEEDLE/SYRINGE 3ML/18G X ELITE-THIN INSULIN EASY TOUCH SAFETY 1-1/2" 72 SYRINGE/U-100/1ML/29G X SYRINGE/1ML/25G X 5/8" 71 EC-NAPROSYN 3 1/2" 72 EASY TOUCH SAFETY econazole nitrate 37 ELITE-THIN INSULIN SYRINGE/3ML/20G X 1" 71 SYRINGE/U-100/1ML/31G X EASY TOUCH SAFETY ECOTRIN 5 5/16" 72 SYRINGE/3ML/21G X 1" 71 ECOTRIN MAXIMUM ELIXOPHYLLIN 12 EASY TOUCH SAFETY STRENGTH 5 SYRINGE/3ML/22G X 1" 71 ECOTRIN REGULAR ELLA 34 EASY TOUCH SAFETY STRENGTH 5 ELMIRON 45 SYRINGE/3ML/22G X 1-1/2" 71 EDURANT 28 ELOCON 39 EASY TOUCH SAFETY SYRINGE/3ML/23G X 1" 71 efavirenz 28 ELOCTATE 45 EASY TOUCH SAFETY efavirenz-emtricitabine- EMBRACE LANCING DEVICE SYRINGE/3ML/25G X 1" 71 tenofovir disoproxil WITH EJECTOR 53 EASY TOUCH SAFETY fumarate 28 EMEND 20 SYRINGE/3ML/25G X 5/8" 71 efavirenz-lamivudine-tenofovir EMERGEN-C IMMUNE EASY TOUCH SHEATHLOCK disoproxil fumarate 29 PLUS/VITAMIN D 112 SAFETY INSULIN SYRINGE EFFEXOR XR 17 EMERGEN-C VITAMIN C 112 1ML/29GX1/2" 71 EFUDEX 38 EMPTY CAPSULE #0 RED EASY TOUCH SHEATHLOCK ELFOLATE 42 TRANSLUCENT/WHITE 161 SAFETY INSULIN SYRINGE ELIDEL 40 EMPTY CAPSULE #00 1ML/30GX5/16" 71 BLACK/RED 161 EASY TOUCH SHEATHLOCK ELIMITE 41 EMPTY CAPSULE #00 SAFETY INSULIN SYRINGE ELIQUIS 12 BLUE/WHITE 161 1ML/31GX5/16" 71 ELIQUIS STARTER PACK 12 EMPTY CAPSULE #00 EASY TOUCH SHEATHLOCK PINK/PINK 161 SAFETY SYRINGE ELITE-THIN INSULIN EMPTY CAPSULE #00 SYRINGE/0.3ML/31G X 1ML/30GX1/2" 71 PURPLE//PURPLE 161 EASY TOUCH SHEATHLOCK 5/16" 72 EMPTY CAPSULE #00 ELITE-THIN INSULIN SAFETY SYRINGE PURPLE//WHITE 161 3ML/21GX1" 71 SYRINGE/0.5ML/29G X EMPTY CAPSULE #00 EASY TOUCH SHEATHLOCK 1/2" 72 RED/WHITE 161 SAFETY SYRINGE 3ML/21GX1- ELITE-THIN INSULIN EMPTY CAPSULE #00 1/2" 71 SYRINGE/0.5ML/30G X YELLOW/YELLOW 161 5/16" 72 EMPTY CAPSULE SIZE 0 BLUE 161
Index 14 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 00 EMPTY CAPSULE SIZE 1 BLUE/WHITE 161 CLEAR LOCKING 162 BROWN/IVORY OPAQUE EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 00 LOCKING 162 CLEAR 161 DARK GREEN 162 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 00 CLEAR 162 CLEAR LOCKING 161 GREEN/OPAQUE EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 LOCKING 162 CLEAR LOCKING 162 FUNCAPS LOCKING 161 EMPTY CAPSULE SIZE 00 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 LIGGHT BLUE OPAQUE 162 DARKGREEN 162 GREEN LOCKING 161 EMPTY CAPSULE SIZE 00 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 ORANGE 162 GREEN 162 GREEN/CLEAR 161 EMPTY CAPSULE SIZE 00 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 ORANGE/OPAQUE GREEN CLEAR/YELLOW GREEN/CLEAR LOCKING 161 LOCKING 162 LOCKING 162 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 00 EMPTY CAPSULE SIZE 1 MAROON/OPAQUE RED 162 GREEN LOCKING 161 EMPTY CAPSULE SIZE 00 TRANSLUCENT/YELLOW EMPTY CAPSULE SIZE 0 WHITE 162 OPAQUE 162 ORANGE 161 EMPTY CAPSULE SIZE 00 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 WHITE OPAQUE GREEN/ORANGE 162 ORANGE/OPAQUE LOCKING 162 EMPTY CAPSULE SIZE 1 LOCKING 161 EMPTY CAPSULE SIZE 000 GREEN/WHITE 162 EMPTY CAPSULE SIZE 0 CLEAR 162 EMPTY CAPSULE SIZE 1 PINK 161 EMPTY CAPSULE SIZE 000 GREEN/WHITE OPAQUE EMPTY CAPSULE SIZE 0 PINK CLEAR LOCKING 162 LOCKING 162 LOCKING 161 EMPTY CAPSULE SIZE 000 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 WHITE/OPAQUE GREEN/YELLOW 162 PURPLE 161 LOCKING 162 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 1 GREY/PINK 163 PURPLE/OPAQUE AQUABLUE EMPTY CAPSULE SIZE 1 LOCKING 161 TRANSLUCENT 162 IVORY 163 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 LIGHT PURPLE/WHITE 161 BLUE 162 BLUE OPAQUE 163 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 RED 161 BLUE/CLEAR 162 MAROON TRANS/CLEAR 163 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 RED/CLEAR 161 BLUE/OPAQUE MINTGREEN 163 EMPTY CAPSULE SIZE 0 LOCKING 162 EMPTY CAPSULE SIZE 1 RED/WHITE 161 EMPTY CAPSULE SIZE 1 ORANGE 163 EMPTY CAPSULE SIZE 0 BLUE/PINK 162 EMPTY CAPSULE SIZE 1 RED/WHITE LOCKING 161 EMPTY CAPSULE SIZE 1 ORANGE OPAQUE EMPTY CAPSULE SIZE 0 BLUE/PINK LOCKING 162 LOCKING 163 WHITE 161 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 BLUE/PINK ORANGE/CLEAR 163 WHITE/CLEAR 161 TRANSLUCENT 162 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 1 ORANGE/WHITE 163 WHITE/OPAQUE 161 BLUE/POWDER BLUE 162 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 1 ORANGE/YELLOW 163 WHITE/OPAQUE BLUE/RED OPAQUE EMPTY CAPSULE SIZE 1 LOCKING 161 LOCKING 162 PINK 163 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 YELLOW 161 BLUE/WHITE 162 PINK/CLEAR 163 EMPTY CAPSULE SIZE 0 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 1 YELLOW/OPAQUE BLUETRANSLUCENT/PINK PINK/OPAQUE LOCKING 163 LOCKING 161 TRANSLUCENT 162 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 00 EMPTY CAPSULE SIZE 1 PINK/POWDER BLUE 163 BLUE/OPAQUE LOCKING 162 BROWN/IVORY 162 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 00 PINK/WHITE 163 CLEAR 162
Index 15 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 PINK/YELLOW 163 BLUEOPAQUE/CLEAR PINK/POWDER BLUE 164 EMPTY CAPSULE SIZE 1 LOCKING 164 EMPTY CAPSULE SIZE 3 PINK/YELLOW OPAQUE EMPTY CAPSULE SIZE 3 PINK/WHITE 164 LOCKING 163 CLEAR 164 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 3 PINK/YELLOW 164 POWDER BLUE 163 CLEAR LOCKING 164 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 3 PINKOPAQUE/CLEAR 164 POWDER BLUE/OPAQUE DARKGREEN 164 EMPTY CAPSULE SIZE 3 LOCKING 163 EMPTY CAPSULE SIZE 3 PINKOPAQUE/CLEAR EMPTY CAPSULE SIZE 1 GRAY/PINK OPAQUE LOCKING 164 PURPLE 163 LOCKING 164 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 3 POWDER BLUE 164 PURPLE/OPAQUE GRAY/YELLOW OPAQUE EMPTY CAPSULE SIZE 3 LOCKING 163 LOCKING 164 PURPLE 164 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 RED 163 GREEN 164 PURPLE/CLEAR 164 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 RED/BLUE 163 GREEN/BLUE 164 RED 164 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 RED/OPAQUE LOCKING 163 GREEN/BLUE LOCKING 164 RED/CLEAR 164 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 RED/WHITE 163 GREEN/BLUE RED/OPAQUE LOCKING 164 EMPTY CAPSULE SIZE 1 TRANSLUCENT 164 EMPTY CAPSULE SIZE 3 WHITE 163 EMPTY CAPSULE SIZE 3 RED/WHITE 164 EMPTY CAPSULE SIZE 1 GREY/PINK 164 EMPTY CAPSULE SIZE 3 WHITE OPAQUE EMPTY CAPSULE SIZE 3 REDOPAQUE/CLEAR LOCKING 163 GREY/YELLOW 164 LOCKING 165 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 WHITE/CLEAR 163 LIGHT BLUE OPAQUE 164 WHITE 165 EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 WHITE/OPAQUE 163 MAROON/BLUE 164 WHITE OPAQUE EMPTY CAPSULE SIZE 1 EMPTY CAPSULE SIZE 3 LOCKING 165 YELLOW 163 MAROON/BLUE EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 10 OPAQUE 164 WHITE OPAQUE/CLEAR CLEAR 163 EMPTY CAPSULE SIZE 3 LOCKING 165 EMPTY CAPSULE SIZE 11 MAROON/CLEAR 164 EMPTY CAPSULE SIZE 3 CLEAR 163 EMPTY CAPSULE SIZE 3 WHITE/CLEAR 165 EMPTY CAPSULE SIZE 13 MINT GREEN 164 EMPTY CAPSULE SIZE 3 CLEAR 163 EMPTY CAPSULE SIZE 3 WHITE/OPAQUE 165 EMPTY CAPSULE SIZE 2 OLIVE/CLEAR 164 EMPTY CAPSULE SIZE 3 BLUE 163 EMPTY CAPSULE SIZE 3 YELLOW 165 EMPTY CAPSULE SIZE 2 OLIVE/OPAQUE EMPTY CAPSULE SIZE 3 CLEAR 163 LOCKING 164 YELLOW OPAQUE/CLEAR EMPTY CAPSULE SIZE 2 EMPTY CAPSULE SIZE 3 LOCKING 165 CLEAR LOCKING 163 ORANGE 164 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 2 EMPTY CAPSULE SIZE 3 YELLOW/CLEAR 165 GREEN 163 ORANGE/OPAQUE EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 2 LOCKING 164 YELLOW/OPAQUE WHITE OPAQUE EMPTY CAPSULE SIZE 3 LOCKING 165 LOCKING 163 ORANGE/WHITE 164 EMPTY CAPSULE SIZE 4 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 BLACK/GREEN OPAQUE BLACK/GREEN 163 PINK 164 LOCKING 165 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 4 BLUE 163 PINK/CLEAR 164 BLUE/WHITE 165 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 3 EMPTY CAPSULE SIZE 4 BLUE/CLEAR 163 PINK/OPAQUE CLEAR 165 EMPTY CAPSULE SIZE 3 LOCKING 164 EMPTY CAPSULE SIZE 4 BLUE/WHITE 164 CLEAR LOCKING 165
Index 16 EMPTY CAPSULE SIZE 4 DARK ENGLISH TOFFEE EQL INSULIN BLUE/OPAQUE LOCKING 165 FLAVOR 158 SYRINGE/0.5ML/29G X 1/2" 72 EMPTY CAPSULE SIZE 4 enoxaparin sodium 12,13 EQL INSULIN PURPLE 165 entacapone 25 SYRINGE/0.5ML/30G X EMPTY CAPSULE SIZE 4 5/16" 72 PURPLE/OPAQUE ENTOCORT EC 35 EQL INSULIN LOCKING 165 EPIFOAM 39 SYRINGE/0.5ML/31G X EMPTY CAPSULE SIZE 4 epinephrine (anaphylaxis)176 5/16" 72 RED/WHITE 165 EQL INSULIN EMPTY CAPSULE SIZE 4 EPIPEN 2-PAK 176 SYRINGE/1ML/29G X 1/2" 72 WHITE 165 EPIPEN-JR 2-PAK 176 EQL INSULIN EMPTY CAPSULE SIZE 4 EPIVIR 29 SYRINGE/1ML/30G X 5/16" 72 WHITE/OPAQUE EPIVIR HBV 30 EQL INSULIN LOCKING 165 SYRINGE/1ML/31G X 5/16" 72 EMPTY CAPSULE SIZE 4 EPOGEN 46 EQL ONE DAILY ADULT YELLOW 165 EPZICOM 29 GUMMIES 112 EMPTY CAPSULE SIZE 5 EQ COMPLETE EQL ONE DAILY MENS 112 CLEAR 165 MULTIVITAMINADULTS EQL SUPER THIN LANCETS EMPTY CAPSULE SIZE 7 UNDER 50 112 30G 53 CLEAR 165 EQ MULTIVITAMINS ADULT EQL THIN LANCETS 26G 53 EMPTY GELATIN GUMMY 112 CAPSULE/SNAP CLOSURE EQ ONE DAILY MENS EQUALYTE 100 #0 165 50+ 112 EQUETRO 26 EMPTY GELATIN EQ ONE DAILY MENS ergocalciferol 177 CAPSULE/SNAP CLOSURE HEALTH 112 ergotamine w/ caffeine 98 #00 165 EQ ONE DAILY WOMENS EMPTY GELATIN 50+ 112 ERYPED 400 50 CAPSULE/SNAP CLOSURE EQ ONE DAILY WOMENS erythromycin (ophth) 154 #000 165 HEALTH 112 erythromycin base 50 EMPTY GELATIN EQ SPACE CHAMBER ANTI- CAPSULE/SNAP CLOSURE STATIC 96 erythromycin ethylsuccinate 50 #1 165 EQ SPACE CHAMBER ANTI- erythromycin stearate 50 EMPTY GELATIN STATIC/LARGE MASK 96 escitalopram oxalate 16 CAPSULE/SNAP CLOSURE EQ SPACE CHAMBER ANTI- ESGIC 4 #2 165 STATIC/MEDIUM MASK 96 EMPTY GELATIN EQ SPACE CHAMBER ANTI- ESTRACE 43,176 CAPSULE/SNAP CLOSURE STATIC/SMALL MASK 96 estradiol 43 #3 165 EQL ALCOHOL SWABS 59 estradiol vaginal 176 EMPTY GELATIN EQL CALCIUM/VITAMIN ESTRING 176 CAPSULE/SNAP CLOSURE D 100 #4 165 EQL CENTURY MATURE ESTROFACTORS 144 EMSAM 16 ADULTS50+ 112 ESTROSTEP FE 33 emtricitabine 29 EQL CENTURY MENS 112 ESTROVEN MENOPAUSE emtricitabine-tenofovir disoproxil EQL CENTURY SUPPLEMENT 112 fumarate 29 WOMENS 112 ethambutol hcl 24 EMTRIVA 29 EQL COLOR LANCETS ethosuximide 15 enalapril maleate 23 21G 53 ethynodiol diacet & eth EQL COLOR LANCETS estrad 33 enalapril maleate & MICRO THIN 33G 53 hydrochlorothiazide 23 EQL INSULIN etidronate disodium 42 ENBREL 4 SYRINGE/0.3ML/29G X etonogestrel-ethinyl estradiol34 ENBREL MINI 4 1/2" 72 etravirine 29 ENBREL SURECLICK 4 EQL INSULIN EUGENOL FLAVOR 158 SYRINGE/0.3ML/30G X ENCARE 175 5/16" 72 EURAX 41 ENFAMIL ENFALYTE 100 EQL INSULIN EVAC 48 ENFAMIL EXPECTA 148 SYRINGE/0.3ML/31G X EVISTA 43 ENGERIX-B 173 5/16" 72 EVOTAZ 29
Index 17 EVOXAC 103 FAZACLO 27 FIORINAL 4 EX-LAX 49 FC FEMALE CONDOM 50 FIORINAL/CODEINE #3 7 EXEL COMFORT POINT FC2 FEMALE CONDOM 50 FIRST AID ANTISEPTIC INSULIN SYRINGE/0.3ML/29G X FE GLUCONATE 47 OINTMENT 28 1/2" 72 FIRST-OMEPRAZOLE 171 FEIBA 45 EXEL COMFORT POINT FIRST-PROGESTERONE VGS INSULIN SYRINGE/0.3ML/30G X felodipine 32 100 COMPOUNDING KIT 176 5/16" 72 FEMARA 25 FIRST-PROGESTERONE VGS EXEL COMFORT POINT FEMIRON 47 200 COMPOUNDING KIT 176 INSULIN SYRINGE/0.5ML/28G X FISH FLAVOR 158 1/2" 72 fenofibrate 22 EXEL COMFORT POINT fenofibrate micronized 22 FISH OIL 152 FISH OIL TRIPLE INSULIN SYRINGE/0.5ML/29G X fentanyl 5 1/2" 73 STRENGTH 152 EXEL COMFORT POINT FENTORA 5 FISH OIL ULTRA 152 INSULIN SYRINGE/0.5ML/30G X FER-IN-SOL 47 FITNESS TABS FOR MEN 5/16" 73 FERRETTS 47 AM/PM/LYCOPENE 112 EXEL COMFORT POINT FERRIMIN 150 47 FITNESS TABS FOR WOMEN INSULIN SYRINGE/1ML/28G X AM/PM/LYCOPENE 112 1/2" 73 FERROUS FUMARATE 47 FLAGYL 9 EXEL COMFORT POINT ferrous fumarate 47 FLAREX 155 INSULIN SYRINGE/1ML/29G X FERROUS GLUCONATE 47 1/2" 73 FLAVOR BLEND 165 EXEL COMFORT POINT ferrous gluconate 47 FLAVOR PLUS 165 INSULIN SYRINGE/1ML/30G X ferrous sulfate 47 FLAVOR SWEET 165 5/16" 73 FERROUS SULFATE 47 FLAVOR SWEET-SF 165 EXELDERM 37 ferrous sulfate 47 FLAVORING EXTRACTS- EXTAVIA 167 FERROUS SULFATE 47 MISC 158 EYE HEALTH 112 ferrous sulfate 47 FLAVORING SYRUPS- MISC 165 EYE HEALTH/LUTEIN 112 FETZIMA 17 FLAVORX 158 EYE MULTIVITAMIN/LUTEIN FETZIMA TITRATION 112 PACK 17 flavoxate hcl 172 EYE MULTIVITAMIN/SODIUM FEVERALL INFANTS 4 flecainide acetate 11 112 EZ-LETS LANCETS 26G FEVERALL JUNIOR FLECTOR 37 SUPER-SOFT 53 STRENGTH 4 FLEET ENEMA 49 EZ-LETS LANCETS 28G fexofenadine hcl 21 FLEET ENEMA SIX PACK 49 ULTRA-SOFT 53 FIBERCON 48 FLEET PEDIATRIC 49 EZ-LETS LANCETS 30G 53 FIBRICOR 22 FLEXICHAMBER 96 ezetimibe 22 FIFTY50 ALCOHOL PREP FLEXICHAMBER ADULT ezetimibe-simvastatin 21 PADS 59 MASK/SMALL 96 EZY DOSE ORIGINAL FIFTY50 SUPERIOR FLEXICHAMBER CHILD TABLETCUTTER/DAILY COMFORTINSULIN MASK/LARGE 96 DOSE 59 SYRINGE/0.3ML/31G X FLEXICHAMBER CHILD EZY DOSE TABLET CUTTER 5/16" 73 MASK/SMALL 96 ORIGINAL 59 FIFTY50 SUPERIOR FLOMAX 45 COMFORTINSULIN famciclovir 30 SYRINGE/0.5ML/31G X FLONASE ALLERGY famotidine 171 5/16" 73 RELIEF 151 FIFTY50 SUPERIOR FLONASE ALLERGY RELIEF FANAPT 26 CHILDRENS 151 FANAPT TITRATION PACK 26 COMFORTINSULIN SYRINGE/1ML/31G X FLORIVA PLUS 146 FANTASY LUBRICATED 50 5/16" 73 FLOVENT DISKUS 11 FANTASY finasteride 45 FLOVENT HFA 11 LUBRICATED/SPERMICIDE 50 FIORICET 4 FLOXIN OTIC 156 FASLODEX 25 FIORICET/CODEINE 7 FLUAD 2019-2020 173
Index 18 FLUAD 2020-2021 173 FLUZONE HIGH-DOSE PF FREESTYLE PRECISION FLUAD QUADRIVALENT 2021- 2019-2020 174 INSULIN SYRINGES/U- 2022 173 FLUZONE HIGH-DOSE PF 100/1ML/30G X 5/16" 73 FLUAD QUADRIVALENT 2020-2021 174 FULL SPECTRUM B/VITAMIN INFLUENZA VACCINE FOR FLUZONE HIGH-DOSE PF C 105 ADULTS 173 2021-2022 174 FURADANTIN 9 FLUARIX QUADRIVALENT FLUZONE QUADRIVALENT furosemide 42 2019-2020 174 2019-2020 173 gabapentin 13 FLUARIX QUADRIVALENT FLUZONE QUADRIVALENT 2020-2021 173 2020-2021 174 GABITRIL 15 FLUARIX QUADRIVALENT FLUZONE QUADRIVALENT GARDASIL 9 175 2021-2022 175 2021-2022 173 GAS-X 43 FLUBLOK QUADRIVALENT FML 155 GAS-X EXTRA STRENGTH 43 2019-2020 173 FML FORTE 155 GELUSIL 8 FLUBLOK QUADRIVALENT FML LIQUIFILM 155 2020-2021 173 GEMCITABINE FLUBLOK QUADRIVALENT FOCALIN 1 HYDROCHLORIDE 25 2021-2022 173 FOCALIN XR 1 gemfibrozil 22 FLUCELVAX QUADRIVALENT folic acid 46 GENADEK STEP 1 113 2019-2020 174 FLUCELVAX QUADRIVALENT FOLIKA-CI 112 GENADEK STEP 2 113 2020-2021 174 FOLIKA-MG 112 GENGRAF 102 FLUCELVAX QUADRIVALENT FOLITIN-Z 112 gentamicin sulfate (ophth) 154 2021-2022 174 FORA GTEL BLOOD KETONE gentamicin sulfate (topical) 37 fluconazole 20 TEST STRIPS 41 GENTEEL LANCING fludrocortisone acetate 35 FORA LANCETS 53 DEVICE/GLORIOUS GOLD 53 FLULAVAL QUADRIVALENT FORA LANCING DEVICE 53 GENTEEL LANCING 2019-2020 174 FORA LANCING DEVICE/PRECIOUS FLULAVAL QUADRIVALENT DEVICE/CLEARCAP 53 PLATINUM 53 2020-2021 174 FORFIVO XL 16 GENTEEL LANCING FLULAVAL QUADRIVALENT DEVICE/STATELY SILVER 53 2021-2022 174 FORTAVIT 112 GENTEEL PLUS LANCING FLUMADINE 31 FOSAMAX 42 DEVICE/BUFF BLACK 53 FLUMIST QUADRIVALENT174 fosamprenavir calcium 29 GENTEEL PLUS LANCING FOSFREE 113 DEVICE/BUTTERFLY BLUE 53 fluocinolone acetonide 39 GENTEEL PLUS LANCING fluocinonide 39 fosinopril sodium 23 DEVICE/PLAYFUL PURPLE 53 fluocinonide emulsified base 39 FRAGMIN 13 GENTEEL PLUS LANCING FLUORABON 101 FREDS PHARMACY DEVICE/PRINCESS PINK 53 AUTOLET LANCING GENTEEL PLUS LANCING fluorometholone (ophth) 155 DEVICE 53 DEVICE/WILLOWY WHITE 53 fluorouracil (topical) 38 FREDS PHARMACY UNILET GENTIAN VIOLET 37 fluoxetine hcl 16 LANCETS SUPER THIN gentian violet 37 fluoxetine hcl (pmdd) 167 30G 53 FREDS PHARMACY UNILET GENTLE-LET GP LANCETS 54 FLUOXETINE LANCETS ULTRA THIN GENTLE-LET LANCETS HYDROCHLORIDE 16 28G 53 GENERAL PURPOSE fluphenazine decanoate 27 FREEDAVITE 113 STYLE/FINE POINT 54 GENTLE-LET LANCETS fluphenazine hcl 27 FREESTYLE PRECISION flurbiprofen 3 GENERAL PURPOSE INSULIN SYRINGE/U- STYLE/MEDIUM POINT 54 flurbiprofen sodium 156 100/0.5ML/30G X 5/16" 73 GENTLE-LET LANCETS fluticasone propionate 39 FREESTYLE PRECISION SAFETY STYLE/FINE INSULIN SYRINGE/U- fluticasone propionate POINT 54 100/0.5ML/31G X 5/16" 73 GENTLE-LET LANCETS (nasal) 151 FREESTYLE PRECISION fluticasone-salmeterol 12 SAFETY STYLE/MEDIUM INSULIN SYRINGE/U- POINT 54 fluvoxamine maleate 16 100/1ML/31G X 5/16" 73 GENVOYA 29
Index 19 GEODON 26 GLOBAL INJECT EASE GLYCERIN 33 GERBER LIL' BRAINIES 147 INSULIN SYRINGE/U- glycerin (laxative) 48 100/1ML/30G X 1/2" 74 GERI-FREEDA SENIOR GLOBAL INJECT EASE GLYCERIN ADULT 49 FORMULA 113 INSULIN SYRINGE/U- glycerin-hypromellose- GILENYA 167 100/1ML/30G X 5/16" 74 polyethylene glycol 400 153 GILTUSS EX MAXIMUM GLOBAL INJECT EASE GLYCERINE 33 STRENGTH 36 INSULIN SYRINGE/U- glycopyrrolate 170 glatiramer acetate 167 100/1ML/31G X 5/16" 74 GLYNASE 19 glimepiride 19 GLOBAL INSULIN GNP ALCOHOL SWABS 59 glipizide 19 SYRINGE/U-100/0.3ML/30G X 1/2" 74 GNP GENTIAN VIOLET 37 GLOBAL EASY GLIDE INSULIN GLOBAL INSULIN SYRINGE/0.3ML/31G X GNP GLUCOSE 18 SYRINGES/U- GNP INSULIN 15/64" 73 100/0.3ML/30GX5/16" 74 GLOBAL EASY GLIDE INSULIN SYRINGE/0.3ML/29G X 1/2" 74 GLOBAL LANCING GNP INSULIN SYRINGE/0.5ML/31G X DEVICE 54 15/64" 73 SYRINGE/0.3ML/30G X GLOBAL EASY GLIDE INSULIN GLUCAGEN HYPOKIT 18 5/16" 74 SYRINGE/1ML/31G X glucagon (rdna) 18 GNP INSULIN 15/64" 73 GLUCAGON EMERGENCY SYRINGE/0.3ML/31G X GLOBAL EASY GLIDE KIT 18 5/16" 74 INSULINSYRINGE/U- GLUCOPRO INSULIN GNP INSULIN 100/0.3ML/31G X 5/16" 73 SYRINGE/U-100/0.3ML/30G X SYRINGE/0.5ML/28G X 1/2" 74 GLOBAL INJECT EASE INSULIN 1/2" 74 GNP INSULIN SYRINGE/U-100/0.3ML/29G X GLUCOPRO INSULIN SYRINGE/0.5ML/29G X 1/2" 74 1/2" 73 SYRINGE/U-100/0.3ML/30G X GNP INSULIN GLOBAL INJECT EASE INSULIN 5/16" 74 SYRINGE/0.5ML/30G X SYRINGE/U-100/0.3ML/30G X GLUCOPRO INSULIN 5/16" 74 1/2" 73 SYRINGE/U-100/0.3ML/31G X GNP INSULIN GLOBAL INJECT EASE INSULIN 5/16" 74 SYRINGE/0.5ML/31G X SYRINGE/U-100/0.3ML/30G X GLUCOPRO INSULIN 5/16" 74 5/16" 73 SYRINGE/U-100/0.5ML/30G X GNP INSULIN GLOBAL INJECT EASE INSULIN 1/2" 74 SYRINGE/1ML/28G X 1/2" 74 SYRINGE/U-100/0.3ML/31G X GLUCOPRO INSULIN GNP INSULIN 5/16" 73 SYRINGE/U-100/0.5ML/30G X SYRINGE/1ML/29G X 1/2" 74 GLOBAL INJECT EASE INSULIN 5/16" 74 GNP INSULIN SYRINGE/U-100/0.5ML/28G X GLUCOPRO INSULIN SYRINGE/1ML/30G X 5/16" 74 1/2" 73 SYRINGE/U-100/0.5ML/31G X GNP INSULIN GLOBAL INJECT EASE INSULIN 5/16" 74 SYRINGE/1ML/31G X 5/16" 75 SYRINGE/U-100/0.5ML/29G X GLUCOPRO INSULIN GNP LANCETS 21G 54 1/2" 73 SYRINGE/U-100/1ML/30G X GNP LANCETS MICRO THIN GLOBAL INJECT EASE INSULIN 1/2" 74 33G 54 SYRINGE/U-100/0.5ML/30G X GLUCOPRO INSULIN GNP LANCETS SUPER THIN 1/2" 73 SYRINGE/U-100/1ML/30G X 30G 54 GLOBAL INJECT EASE INSULIN 5/16" 74 GNP LANCETS THIN 54 SYRINGE/U-100/0.5ML/30G X GLUCOPRO INSULIN GNP LANCETS THIN 26G 54 5/16" 73 SYRINGE/U-100/1ML/31G X GLOBAL INJECT EASE INSULIN 5/16" 74 GNP PRENATAL 148 SYRINGE/U-100/0.5ML/31G X glucosamine-chondroitin 2 GNP QUICK DISSOLVE GLUCOSE 18 5/16" 74 GLUCOSE 18 GLOBAL INJECT EASE INSULIN GNP ULTRA COMFORT SYRINGE/U-100/1ML/28G X glucose 152 INSULIN SYRINGE/0.3ML/29G X 1/2" 74 GLUCOSE NURSETTE 152 1/2" 75 GLOBAL INJECT EASE INSULIN GLUCOTROL 19 GNP ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X SYRINGE/U-100/1ML/29G X GLUCOTROL XL 19 1/2" 74 5/16" SHORT 75 glyburide 19 glyburide micronized 19
Index 20 GNP ULTRA COMFORT GUARDIAN SHARPS GUARDIAN SHARPS INSULIN SYRINGE/0.5ML/28G X COLLECTORNESTABLE 16 COLLECTORONE-PIECE X-L 1/2" 75 GAL 75 OPEN TOP 5 GAL 76 GNP ULTRA COMFORT GUARDIAN SHARPS GUARDIAN SHARPS INSULIN SYRINGE/0.5ML/29G X COLLECTORNESTABLE 8 COLLECTORONE-PIECE X-L 1/2" 75 QT 75 OPEN TOP NV 5 GAL 76 GNP ULTRA COMFORT GUARDIAN SHARPS GUARDIAN SHARPS INSULIN SYRINGE/1ML/28G X COLLECTORNESTABLE COLLECTORSIDE ENTRY 1/2" 75 LARGE FUNNEL 14 QT 75 NESTABLE 5.4 QT 76 GNP ULTRA COMFORT GUARDIAN SHARPS GUARDIAN SHARPS INSULIN SYRINGE/1ML/29G X COLLECTORNESTABLE COLLECTORSIDE ENTRY PRE- 1/2" 75 LARGE FUNNEL 6 GAL 75 ASSEMBLED 5.4 QT 76 GOJJI BLOOD KETONE TEST GUARDIAN SHARPS GUARDIAN SHARPS STRIPS 41 COLLECTORNESTABLE NON- COLLECTORVERTICAL ENTRY GOJJI LANCING VENTED 8 QT 75 3.2 QT 76 DEVICE/CLEAR CAP 54 GUARDIAN SHARPS GUARDIAN SHARPS GOJJI STERILE LANCETS COLLECTORNESTABLE COLLECTORVERTICAL ENTRY 30G 54 OPEN 14 QT 75 NON-VENTED 3.2 QT 76 GOLYTELY 48 GUARDIAN SHARPS GUAVA FLAVOR 158 GOODSENSE COLOR COLLECTORNESTABLE GVOKE PFS 18 OPEN TOP 6 GAL 75 LANCETS MICRO-THIN 33G GYNE-LOTRIMIN 176 UNIVERSAL 54 GUARDIAN SHARPS GOODSENSE LANCETS COLLECTORNESTABLE GYNE-LOTRIMIN 3 176 MICRO-THIN 33G 54 OPEN TOP NV 6 GAL 75 H-E-B INCONTROL GOODSENSE LANCETS GUARDIAN SHARPS ADVANCEDLANCING MICRO-THIN 33G COLLECTORNESTABLE DEVICE 54 UNIVERSAL 54 SMALL FUNNEL 14 QT 75 H-E-B INCONTROL ALCOHOL GOODSENSE LANCETS GUARDIAN SHARPS PADS 59 ULTRA-THIN 26G COLLECTORNESTABLE H-E-B INCONTROL LANCETS UNIVERSAL 54 SMALL FUNNEL NV 14 MICRO THIN 33G 54 GOODSENSE LANCETS QT 75 H-E-B INCONTROL LANCETS ULTRA-THIN 30G 54 GUARDIAN SHARPS SUPER THIN 30G 54 GOODSENSE LANCETS COLLECTORONE-PIECE H-E-B INCONTROL LANCETS ULTRA-THIN 30G HOME CARE 1QT 75 ULTRA THIN 28G 54 UNIVERSAL 54 GUARDIAN SHARPS HAIR SKIN & NAILS ADVANCED GOODSENSE LANCING COLLECTORONE-PIECE FORMULA 113 DEVICE 54 LARGE 8.2 QT 75 HAIR/SKIN/NAILS 113 GOODSENSE PRENATAL GUARDIAN SHARPS HALDOL 27 VITAMINS 148 COLLECTORONE-PIECE HALDOL DECANOATE 100 27 GRAPE FLAVOR 158 LARGE NON-VENTED 8.2 QT 75 HALDOL DECANOATE 50 27 GRAPE SYRUP 165 GUARDIAN SHARPS GRILLED BEEF FLAVOR halobetasol propionate 39 COLLECTORONE-PIECE haloperidol 27 NATURAL OIL SOLUBLE 158 MEDIUM 6.9 QT 75 GRILLED CHICKEN FLAVOR GUARDIAN SHARPS haloperidol decanoate 27 NATURAL OIL MISCIBLE 158 COLLECTORONE-PIECE haloperidol lactate 27 guaifenesin 36 MEDIUM NON-VENTED 6.9 HAM FLAVOR 158 guaifenesin-codeine 36 QT 75 HARMONY BREASTPUMP 59 guanfacine hcl 23 GUARDIAN SHARPS COLLECTORONE-PIECE HAVRIX 175 guanfacine hcl (adhd) 1 OFFSET NECK 9.2 QT 75 HEALTH CARE LANCING GUARDIAN SHARPS GUARDIAN SHARPS DEVICE 54 COLLECTORHORIZONTAL COLLECTORONE-PIECE HEALTHWISE INSULIN NESTABLE 5.4 QT 75 PHLEBOTOMY 1QT 75 SYRINGE/U-100/0.3ML/30G X GUARDIAN SHARPS GUARDIAN SHARPS 5/16" 76 COLLECTORHORIZONTAL COLLECTORONE-PIECE X-L HEALTHWISE INSULIN PRE-ASSEMBLED 5.4 QT 75 LARGE FUNNEL 5 GAL 76 SYRINGE/U-100/0.3ML/31G X 5/16" 76
Index 21 HEALTHWISE INSULIN HUMALOG MIX 50/50 hydrocortisone-aloe vera 39 SYRINGE/U-100/0.5ML/30G X KWIKPEN 18 HYDROMORPHONE HCL 5 5/16" 76 HUMALOG MIX 75/25 18 hydromorphone hcl 5 HEALTHWISE INSULIN HUMALOG MIX 75/25 SYRINGE/U-100/0.5ML/31G X KWIKPEN 18 hydroxychloroquine sulfate 24 5/16" 76 HUMATE-P 45 hydroxyprogesterone HEALTHWISE INSULIN caproate 166 HUMATIN 2 SYRINGE/U-100/1ML/30G X hydroxyurea 25 HUMIRA 2 5/16" 76 hydroxyzine hcl 10 HEALTHWISE INSULIN HUMIRA PEDIATRIC CROHNS SYRINGE/U-100/1ML/31G X DISEASE STARTER PACK 2 hydroxyzine pamoate 10 5/16" 76 HUMIRA PEN 2 HYLAZINC 113 HEALTHY ACCENTS AUTOLET HUMIRA PEN-CD/UC/HS hyoscyamine sulfate 170 IMPRESSION LANCING STARTER 2 HYPER-SAL 36 DEVICE 54 HUMIRA PEN-PEDIATRIC UC HEALTHY ACCENTS UNILET STARTER PACK 2 HYPERSAL 36 LANCETS SUPER THIN HUMIRA PEN-PS/UV HYVEE ADVANCED ANTACID 30G 54 STARTER 2 MAXIMUM STRENGTH 8 HELIXATE FS 45 HUMULIN 70/30 18 HYZAAR 24 HEMOCYTE 47 HUMULIN 70/30 ibuprofen 3 HEMOFIL M 45 KWIKPEN 18 ICAPS AREDS FORMULA 113 HEPARIN LOCK FLUSH 13 HUMULIN N 18 IDELVION 46 HIBERIX 172 HUMULIN N KWIKPEN 18 imipramine hcl 17 HIGH POTENCY IRON 47 HUMULIN R 18 imipramine pamoate 17 HIGH POTENCY HUMULIN R U-500 imiquimod 40 (CONCENTRATED) 18 MULTIVITAMIN 144 IMITREX 98 HIGH POTENCY HUMULIN R U-500 MULTIVITAMIN/BETA- KWIKPEN 19 IMITREX STATDOSE CAROTENE 113 HY-VEE LANCETS 54 REFILL 98 HIGH POTENCY IMITREX STATDOSE HY-VEE THIN LANCETS 54 SYSTEM 98 MULTIVITAMIN/FOLIC HYCODAN 36 ACID 113 IMMUNE SUPPORT 113 hydralazine hcl 24 HM COMPLETE 113 IMODIUM A-D 20 HM COMPLETE 50+ MENS HYDRALYTE 100 IMURAN 102 ULTIMATE 113 HYDRALYTE FREEZER IN TOUCH LANCING HM COMPLETE 50+ WOMENS POPS 100 DEVICE 54 ULTIMATE 113 HYDREA 25 IN-CHECK DIAL HM COMPLETE MEN 113 HYDRO 35 40 INSPIRATORYFLOW HM HAIR/SKIN/NAILS 113 hydrochlorothiazide 42 TRAINER 96 IN-CHECK INSPIRATORY HM ONE DAILY MENS 113 HYDROCIL INSTANT 48 FLOWMETER/NASAL WITH HM ONE DAILY PRENATAL hydrocodone w/ MASK 96 COMBO 148 homatropine 36 IN-CHECK INSPIRATORY HM ONE DAILY WOMENS 113 hydrocodone- FLOWMETER/ORAL 96 HM STERILE ALCOHOL PREP acetaminophen 7 INCRUSE ELLIPTA 11 hydrocortisone 35 PADS 59 indapamide 42 HM ULTICARE INSULIN hydrocortisone (intrarectal) 8 INDERAL LA 31 SYRINGE/1ML/30G X 1/2" 76 hydrocortisone (rectal) 8 HM ULTICARE INSULIN INDOCIN 3 hydrocortisone (topical) 39 SYRINGE/U-100/0.3ML/31G X indomethacin 3 5/16" 76 hydrocortisone acetate INFANRIX 170 HONEY BEARS 148 (topical) 39 HONEY BEARS W/IRON AND hydrocortisone butyrate 39 INFANTS ADVIL 3 ZINC 147 hydrocortisone valerate 39 INFLUENZA VACCINE 2019- HONEY FLAVOR 158 hydrocortisone w/acetic 2020 175 HUMALOG MIX 50/50 18 acid 156
Index 22 INSPIRACHAMBER/ANTI- INSULIN SYRINGE/NEEDLE INVIRASE 29 STATIC 1ML/30G X 5/16" 77 IPOL INACTIVATED IPV 175 VALVED/MOUTHPIECE 96 INSULIN SYRINGE/NEEDLE INSPIRACHAMBER/LARGE 1ML/31G X 5/16" 77 ipratropium bromide 11 96 INSULIN SYRINGE/U- ipratropium-albuterol 12 INSPIRACHAMBER/SOOTHER 100/0.3ML/29G X 1/2" 77 irbesartan 23 MASK/INSPIRAMASK/MEDIUM INSULIN SYRINGE/U- irbesartan-hydrochlorothiazide 97 100/0.5ML/29G X 1/2" 77 24 INSPIRACHAMBER/SOOTHER INSULIN SYRINGE/U- MASK/INSPIRAMASK/SMALL 100/1ML/29G X 1/2" 77 IRON 47 97 INSULIN SYRINGE/U- IRON SLOW RELEASE 47 INSPIREASE DRUG 100/1ML/30G X 5/16" 77 iron w/ vitamins 106 DELIVERYSYSTEM 97 INSULIN SYRINGE/U- ISENTRESS 29 INSULIN ASPART 100/1ML/31G X 5/16" 77 PROTAMINE/INSULIN INSULIN SYRINGES- ISENTRESS HD 29 ASPART 19 MISC 77 isoniazid 24 INSULIN ASPART INSULIN ISOPTO ATROPINE 154 SYRINGES/0.5ML/27GX1/2" PROTAMINE/INSULIN ASPART ISOPTO CARPINE 154 FLEXPEN 19 77 INSULIN LISPRO INSULIN ISORDIL TITRADOSE 10 PROTAMINE/INSULIN LISPRO SYRINGES/0.5ML/28GX1/2" isosorbide dinitrate 10 KWIKPEN 19 77 isosorbide mononitrate 10 INSULIN SYRINGE/0.3ML/29G X INSULIN 1" 76 SYRINGES/0.5ML/29GX1/2" itraconazole 20 INSULIN SYRINGE/0.3ML/29G X 77 ivermectin 8 1/2" 76 INSULIN IXINITY 46 SYRINGES/0.5ML/30GX5/16" INSULIN SYRINGE/0.3ML/30G X JANUMET 17 5/16" 76 77 INSULIN SYRINGE/0.3ML/31G X INSULIN JENLIVA 5/16" 76 SYRINGES/0.5ML/31GX PRENATAL/POSTNATAL 148 INSULIN SYRINGE/0.5ML/27G X 5/16" 77 JULUCA 29 1/2" 76 INSULIN JYNARQUE 43 INSULIN SYRINGE/0.5ML/28G X SYRINGES/0.5ML/31GX5/16" K-PAX IMMUNE SUPPORT 1/2" 76 77 FORMULA DOUBLE INSULIN SYRINGE/0.5ML/30G X INSULIN STRENGTH 113 1/2" 76 SYRINGES/1ML/27GX/1/2" K-PAX IMMUNE SUPPORT INSULIN SYRINGE/0.5ML/30G X 77 FORMULA PROFESSIONAL 5/16" 76 INSULIN STRENGTH 113 INSULIN SYRINGE/0.5ML/31G X SYRINGES/1ML/27GX1/2" K-PAX IMMUNE SUPPORT 5/16" 76 77 FORMULA SINGLE INSULIN SYRINGE/1ML/28G X INSULIN STRENGTH 113 1/2" 76 SYRINGES/1ML/28GX1/2" K-PHOS NEUTRAL 101 INSULIN SYRINGE/1ML/29G X 77 1/2" 76 INSULIN K-PHOS NO 2 44 INSULIN SYRINGE/1ML/30G X SYRINGES/1ML/29GX1/2" K-TAB 101 5/16" 76 77 K-Y ME & YOU EXTRA INSULIN SYRINGE/NEEDLE INSULIN LUBRICATED 50 0.3ML/30G X 5/16" 76 SYRINGES/1ML/30GX1/2" K-Y ME & YOU INTENSE 50 INSULIN SYRINGE/NEEDLE 77 KAHLUA FLAVOR 158 0.3ML/31G X 5/16" 77 INSULIN INSULIN SYRINGE/NEEDLE SYRINGES/1ML/31GX5/16" KALETRA 29 0.5ML/29G X 1/2" 77 77 KAMELEON LUBRICATED 50 INSULIN SYRINGE/NEEDLE INTELENCE 29 KANESON BREAST 0.5ML/30G X 5/16" 77 INTUNIV 1 PUMP/NURSER 59 INSULIN SYRINGE/NEEDLE KAPVAY 1 0.5ML/31G X 5/16" 77 INVEGA 26 INSULIN SYRINGE/NEEDLE INVEGA SUSTENNA 26 KEFLEX 33 1ML/29G X 1/2" 77 INVEGA TRINZA 26 KENALOG-40 35 KEPPRA 14
Index 23 KEPPRA XR 14 KMART VALU PLUS INSULIN KROGER LANCETS ketoconazole 20 SYRINGE/1ML/29G 78 ULTRATHIN30G 55 KMART VALU PLUS INSULIN KROGER LANCING ketoconazole (topical) 37 SYRINGE/1ML/30G 78 DEVICE 55 ketoprofen 3 KOATE 46 KYLEENA 34 KETOROLAC KOATE-DVI 46 L-CARNITINE 153 TROMETHAMINE 3 KOGENATE FS 46 l-methylfolate 42 ketorolac tromethamine 3 ketorolac tromethamine KONSYL DAILY FIBER 48 labetalol hcl 31 (ophth) 156 KONSYL ORIGINAL DAILY lactulose 49 KEVZARA 3 FIBER 48 lactulose (encephalopathy) 44 KONSYL-D 48 KHEDEZLA 17 LAMICTAL 14 KOVALTRY 46 KIMONO COLORS 50 LAMICTAL CHEWABLE KP PRENATAL KIMONO LUBRICATED 50 DISPERSIBLE 14 MULTIVITAMINS 148 LAMICTAL ODT 14 KIMONO MICRO THIN PLUS KPN PRENATAL 148 SPERMICIDE LUBRICATED50 LAMICTAL STARTER/NOT KIMONO PLUS SPERMICIDE KRINTAFEL 24 TAKING CARBAMAZEPINE 14 LUBRICATED 50 KROGER AUTOLET LANCING LAMICTAL STARTER/TAKING KIMONO PLUS DEVICE 54 CARBAMAZEPINE/NOT TAKING SPERMICIDE/LUBRICATED KROGER HEALTHPRO TWIST VALPROATE 14 50 LANCETS/26G 54 LAMICTAL STARTER/TAKING KIMONO PS LUBRICATED 50 KROGER INSULIN VALPROATE 14 SYRINGE/0.3ML/29G X KIMONO PS PLUS LAMICTAL XR 14 1/2" 78 LAMISIL AT 37 SPERMICIDE/LUBRICATED KROGER INSULIN 50 SYRINGE/0.3ML/30G X LAMISIL AT JOCK ITCH 37 KIMONO SENSATION 5/16" 78 lamivudine 29 LUBRICATED 51 KROGER INSULIN lamivudine (hbv) 30 KIMONO SENSATION PLUS SYRINGE/0.3ML/31G X SPERMICIDE LUBRICATED51 5/16" 78 lamivudine-zidovudine 29 KIMONO SPECIAL 51 KROGER INSULIN lamotrigine 14 KINDERLYTE 100 SYRINGE/0.5ML/29G X LAMOTRIGINE 33 KINDERLYTE PREMAX 100 1/2" 78 LANCET DEVICE KROGER INSULIN KINNEY LANCETS 54 ADJUSTABLE 55 SYRINGE/0.5ML/30G X LANCET DEVICE WITH KINNEY THIN LANCETS 54 5/16" 78 EJECTOR 55 KINRAY INSULIN SYRINGE KROGER INSULIN LANCETS 55 PREFERRED PLUS/0.3ML/31G SYRINGE/0.5ML/31G X X 5/16" 77 5/16" 78 LANCETS 26G TWIST TOP 55 KINRAY INSULIN SYRINGE KROGER INSULIN LANCETS 28G 55 PREFERRED PLUS/0.5ML/31G SYRINGE/1ML/29G X 1/2" 78 LANCETS 30G 55 X 5/16" 77 KROGER INSULIN LANCETS SAFETY SEAL KINRAY INSULIN SYRINGE SYRINGE/1ML/30G X 21G 55 PREFERRED PLUS/1ML/31G X 5/16" 78 LANCETS SAFETY SEAL 5/16" 77 KROGER INSULIN 26G 55 KINRAY INSULIN SYRINGE/1ML/31G X LANCETS SAFETY SEAL SYRINGE/0.5ML/29G X 1/2" 77 5/16" 78 28G 55 KINRIX 170 KROGER LANCETS 54 LANCETS THIN 55 KITABIS PAK 2 KROGER LANCETS 21G 54 LANCETS ULTRA THIN 55 KLONOPIN 13 KROGER LANCETS MICRO LANCING DEVICE 55 54 KMART VALU PLUS INSULIN THIN33G LANCING DEVICE SYRINGE/0.3ML/30G 78 KROGER LANCETS SUPER THIN 55 ADJUSTABLE 55 KMART VALU PLUS INSULIN LANOXIN 32 SYRINGE/0.5ML/29G 78 KROGER LANCETS THIN 55 KMART VALU PLUS INSULIN KROGER LANCETS THIN lansoprazole 171 SYRINGE/0.5ML/30G 78 26G 55 LANZO 55 LASIX 42
Index 24 latanoprost 156 levonorgestrel-eth estradiol LITETOUCH INSULIN LATUDA 26 (triphasic) 33 SYRINGE/U-100/0.5ML/28G X levonorgestrel-ethinyl estradiol 1/2" 79 LEADER ADVANCED LANCING (91-day) 33 LITETOUCH INSULIN DEVICE 55 levonorgestrel-ethinyl estradiol SYRINGE/U-100/0.5ML/29G X LEADER INSULIN (continuous) 33 1/2" 79 SYRINGE/0.3ML/29G X 1/2" 78 LITETOUCH INSULIN LEADER INSULIN levothyroxine sodium 170 LEXAPRO 16 SYRINGE/U-100/0.5ML/30G X SYRINGE/0.3ML/30G X 5/16" 79 5/16" 78 LEXIVA 29 LITETOUCH INSULIN LEADER INSULIN LIALDA 44 SYRINGE/U-100/0.5ML/31G X SYRINGE/0.3ML/31G X LIBERTY MINI LANCING 5/16" 79 5/16" 78 DEVICE 55 LITETOUCH INSULIN LEADER INSULIN SYRINGE/U-100/1ML/28G X SYRINGE/0.5ML/28G X 1/2" 78 LICORICE FLAVOR 158 lidocaine hcl 40 1/2" 79 LEADER INSULIN LITETOUCH INSULIN SYRINGE/0.5ML/29G X 1/2" 78 lidocaine hcl (mouth- LEADER INSULIN SYRINGE/U-100/1ML/29G X throat) 102 1/2" 79 SYRINGE/0.5ML/30G X lidocaine-prilocaine 40 LITETOUCH INSULIN 5/16" 78 LEADER INSULIN LILETTA 34 SYRINGE/U-100/1ML/30G X linezolid 9 5/16" 79 SYRINGE/0.5ML/31G X LITETOUCH INSULIN 5/16" 78 liothyronine sodium 170 SYRINGE/U-100/1ML/31G X LEADER INSULIN LIPITOR 22 SYRINGE/1ML/28G X 1/2" 78 5/16" 79 LEADER INSULIN LIPOFEN 22 LITHIUM 26 SYRINGE/1ML/29G X 1/2" 78 LIPOTRIAD 150 lithium carbonate 26 LEADER INSULIN lisinopril 23 LITHOBID 26 SYRINGE/1ML/30G X 5/16" 78 lisinopril & LITTLE NOSES LEADER INSULIN hydrochlorothiazide 24 DECONGESTANTNOSE SYRINGE/1ML/31G X 5/16" 78 LITE TOUCH LANCING DROPS 152 LEADER QUICK DISSOLVE PEN 55 LIVE BETTER ADVANCED GLUCOSE 18 LITEAIRE 97 LANCING DEVICE 55 leflunomide 4 LITETOUCH INSULIN LIVE BETTER LANCET LEMON EXTRACT 158 SYRINGE/0.3ML/29G X SUPERTHIN 30G 55 LEMON FLAVOR 158 1/2" 78 LIVE BETTER LANCET ULTRATHIN 28G 55 LETAIRIS 32 LITETOUCH INSULIN SYRINGE/0.3ML/30G X LIVER CONCENTRATE 158 letrozole 25 5/16" 78 LIVER FLAVOR 158 leucovorin calcium 25 LITETOUCH INSULIN LMX 4 40 levalbuterol hcl 12 SYRINGE/0.3ML/31G X LOCOID 39 levalbuterol tartrate 12 5/16" 78 LITETOUCH INSULIN LOMOTIL 20 LEVAQUIN 43 SYRINGE/0.5ML/30G X LONGS INSULIN LEVBID 171 5/16" 78 SYRINGE/0.5ML/31G X levetiracetam 14 LITETOUCH INSULIN 5/16" 79 SYRINGE/0.5ML/31G X levobunolol hcl 154 LONGS LANCETS 5/16" 78 STANDARD 55 levocarnitine 153 LITETOUCH INSULIN LONGS LANCETS THIN 55 levocarnitine (metabolic SYRINGE/1ML/30G X modifiers) 43 5/16" 78 loperamide hcl 20 levofloxacin 43 LITETOUCH INSULIN LOPID 22 levofloxacin (ophth) 155 SYRINGE/U-100/0.3ML/30G X lopinavir-ritonavir 29 levonorgestrel & eth 5/16" 79 LOPRESSOR 31 LITETOUCH INSULIN estradiol 33 SYRINGE/U-100/0.3ML/31G X loratadine 21 levonorgestrel (emergency lorazepam 10 oc) 34 5/16" 79 losartan potassium 23
Index 25 losartan potassium & magnesium citrate 49 meclizine hcl 20 hydrochlorothiazide 24 MAGNESIUM MEDIC INSULIN LOSEASONIQUE 33 ELEMENTAL 101 SYRINGE/0.3ML/30G X LOTENSIN 23 MAGNESIUM EXTRA 5/16" 79 LOTENSIN HCT 24 STRENGTH 101 MEDIC INSULIN MAGNESIUM SYRINGE/0.5ML/30G X LOTRIMIN AF 37 GLUCONATE 101 5/16" 79 LOTRIMIN AF JOCK ITCH 37 magnesium gluconate 101 MEDISENSE THIN LOTRIMIN ULTRA 37 magnesium hydroxide 49 LANCETS 55 MEDROL 35 lovastatin 22 MAGNESIUM OXIDE 8 MEDROL DOSEPAK 35 LOVENOX 13 magnesium oxide 8 medroxyprogesterone magnesium oxide (mg loxapine succinate 27 acetate 166 lubricants 40 supplement) 101 medroxyprogesterone acetate LUMIGAN 156 MAGOX 400 101 (contraceptive) 34 LUTEIN MAKENA 166 mefloquine hcl 24 PLUS/ZEAXANTHIN 113 malathion 41 MEGA MULTI FOR MEN 113 LUZU 37 MANGO FLAVOR 158 MEGA MULTI FOR LYRICA 14 MAPLE FLAVOR 158 WOMEN 113 LYSTEDA 47 MEGA MULTIVITAMIN FOR maprotiline hcl 16 MEN 113 M-CLEAR WC 36 MAR-COF CG MEGA MULTIVITAMIN FOR M-M-R II 175 EXPECTORANT 36 WOMEN 113 MAALOX 8 MARCAINE 49 MEGAVITE FRUITS & VEGGIES 113 MACROBID 9 MARINOL 20 MARPLAN 16 MEGAVITE GOLDEN YEARS MACRODANTIN 10 55+ 113 MARSHMALLOW MACULAR VITAMIN megestrol acetate 25 BENEFIT 113 FLAVOR 158 MASK VORTEX/BABY WHIRL MEIJER ALCOHOL SWABS MAG-200 101 DUCKLING 97 EXTRA-THICK 59 MAG-G 101 MASK MEIJER COLOR LANCETS MAGELLAN INSULIN SAFETY VORTEX/CHILD/FROG 97 UNIVERSAL 33G 55 SYRINGE/U-100/0.3ML/29G X MASK VORTEX/SPINNER MEIJER LANCETS 55 1/2" 79 THE DUCK 97 MEIJER LANCETS THIN 55 MAGELLAN INSULIN SAFETY MASK MEIJER LANCETS SYRINGE/U-100/0.3ML/30G X VORTEX/TODDLER/LADYBU UNIVERSAL21G 55 5/16" 79 G 97 MEIJER LANCETS MAGELLAN INSULIN SAFETY MAVYRET 30 UNIVERSAL30G 55 SYRINGE/U-100/0.5ML/29G X MAXALT 98 MEIJER LANCETS 1/2" 79 MAXALT-MLT 98 UNIVERSAL33G 55 MAGELLAN INSULIN SAFETY MEIJER SUPER THIN SYRINGE/U-100/0.5ML/30G X MAXI-COMFORT INSULIN LANCETS 55 SYRINGE/U- 5/16" 79 meloxicam 3 MAGELLAN INSULIN SAFETY 100/0.5ML/28GX1/2" 79 SYRINGE/U-100/1ML/29G X MAXI-COMFORT INSULIN MENACTRA 172 1/2" 79 SYRINGE/U- MENQUADFI 172 MAGELLAN INSULIN SAFETY 100/1ML/28GX1/2" 79 MENS 50+ ADVANCED 113 SYRINGE/U-100/1ML/30G X MAXICOMFORT INSULIN MENS 50+ MULTI VITAMIN SYRINGES 27G X 1/2" 79 5/16" 79 &MINERAL FORMULA 113 MAGELLAN MAXIMUM D3 177 MENS MULTI VITAMIN & SYRINGE/HYPODERMIC MAXITROL 155 MINERAL FORMULA 113 SAFETY NEEDLE/1ML/23G X MAXX LUBRICATED 51 MENS MULTIVITAMIN 113 1" 79 MAXX PLUS SPERMICIDE MENTAX 37 MAGNESIUM 101 LUBRICATED 51 MENVEO 172 magnesium 101 MAXZIDE 42 meperidine hcl 5 MAGNESIUM 101 MAXZIDE-25 42
Index 26 MEPHYTON 177 MIRAPEX 26 MONOJECT INSULIN meprobamate 10 MIRCETTE 34 SYRINGE/DETACH NEEDLE/1ML/25G X 5/8" 80 mercaptopurine 25 MIRENA 34 MONOJECT INSULIN mesalamine 44 mirtazapine 15 SYRINGE/DETACH MESTINON 24 misoprostol 171 NEEDLE/1ML/27G X 1/2" 80 MONOJECT INSULIN METAMUCIL 48 MISTASSIST 97 SYRINGE/PERM METAMUCIL ORIGINAL MITIGARE 45 NEEDLE/1ML/28G X 1/2" 80 TEXTURE 48 MM INSULIN SYRINGE/U- MONOJECT INSULIN metformin hcl 18 100/0.3ML/30G X 5/16" 79 SYRINGE/PERM NEEDLE/U- methadone hcl 5 MM INSULIN SYRINGE/U- 100/0.5ML/28G X 1/2" 80 methazolamide 42 100/0.3ML/31G X 5/16" 79 MONOJECT INSULIN MM INSULIN SYRINGE/U- SYRINGE/SAFETY/PERM methimazole 170 100/1/2ML/30G X 5/16" 79 NEEDLE/0.3ML/29G X 1/2" 80 methocarbamol 151 MM INSULIN SYRINGE/U- MONOJECT INSULIN methotrexate sodium 25 100/1/2ML/31G X 5/16" 80 SYRINGE/SAFETY/PERM MM INSULIN SYRINGE/U- methylcellulose (laxative) 48 NEEDLE/0.3ML/29GX1/2" 80 100/1ML/30G X 5/16" 80 MONOJECT INSULIN methyldopa 23 MM INSULIN SYRINGE/U- SYRINGE/SAFETY/PERM methylergonovine maleate 156 100/1ML/31G X 5/16" 80 NEEDLE/0.5ML/29G X 1/2" 80 METHYLPARABEN 157 MM LANCING DEVICE 55 MONOJECT INSULIN MM TWIST LANCETS 55 SYRINGE/SAFETY/PERM methylphenidate hcl 1 NEEDLE/1ML/29G X 1/2" 80 methylprednisolone 35 MOBIC 3 MONOJECT INSULIN metoclopramide hcl 44 modafinil 1 SYRINGE/SOFTPACK/1ML/27G metolazone 42 moexipril hcl 23 X 1/2" 80 MOISTURE EYES 153 MONOJECT INSULIN metoprolol succinate 31 SYRINGE/SOFTPACK/U- metoprolol tartrate 31 molindone hcl 27 100/0.5ML/28G X 1/2" 80 METROGEL-VAGINAL 176 mometasone furoate 39 MONOJECT INSULIN metronidazole 9 MONISTAT 1 COMBO SYRINGE/U-100/0.3ML/30G X PACK 176 5/16" 80 METRONIDAZOLE MONISTAT 1 DAY OR NIGHT MONOJECT INSULIN BENZOATE 33 COMBO PACK 176 SYRINGE/U-100/0.5ML/30G X metronidazole vaginal 176 MONISTAT 3 176 5/16" 80 mexiletine hcl 11 MONISTAT 3 COMBINATION MONOJECT INSULIN MICATIN 37 PACK 176 SYRINGE/U-100/1ML/28G X 1/2" 80 miconazole nitrate (topical) 37 MONISTAT 7 SIMPLY CURE 176 MONOJECT INSULIN miconazole nitrate vaginal 176 MONISTAT SOOTHING CARE SYRINGE/U-100/1ML/30G X MICROCHAMBER 97 ITCH RELIEF 39 5/16" 80 MICROLET NEXT 55 MONOJECT 1ML LUER LOCK MONOJECT INSULIN SYRINGEREGULAR LUER MICROSPACER 97 TUBERCULIN SYRINGE/TIP CAP 80 TIP/SOFTPACK/1ML 80 midodrine hcl 176 MONOJECT 3ML MONOJECT LIFESHIELD MIGRANAL 98 SYRINGE/STANDARD BLUNTCANNULA/LUER LOCK MILLIPRED 35 HYPODERMIC SYR/3ML/18G X 1" 80 NEEDLE/21GX1-1/2" 80 MONOJECT MAGELLAN MINI LANCING DEVICE 55 MONOJECT BLUNTIP SYRINGE/SAFETY MINIPRESS 23 SYRINGE/3ML/CANNULA/IV NEEDLE/1ML/23G X 1" 80 MINOCIN 169 ACCESS 80 MONOJECT MAGELLAN SYRINGE/SAFETY minocycline hcl 169 MONOJECT INSULIN SYRINGE/1ML 80 NEEDLE/1ML/25G X 1" 80 MINT CHOCOLATE CHIP MONOJECT INSULIN MONOJECT MAGELLAN FLAVOR 158 SYRINGE/1ML/31G X SYRINGE/SAFETY MIRALAX 49 5/16" 80 NEEDLE/1ML/25G X 5/8" 80 MIRALAX MIX-IN PAX 49
Index 27 MONOJECT MAGELLAN MONOJECT SYRINGE/LUER- MONOJECT ULTRA COMFORT SYRINGE/SAFETY LOCK/3ML/21G X 1" 81 INSULIN SYRINGE/0.3ML/29G X NEEDLE/3ML/20G X 1" 81 MONOJECT SYRINGE/LUER- 1/2" 82 MONOJECT MAGELLAN LOCK/3ML/21G X 1-1/2" 81 MONOJECT ULTRA COMFORT SYRINGE/SAFETY MONOJECT SYRINGE/REG INSULIN SYRINGE/0.3ML/30G X NEEDLE/3ML/20G X 1-1/2" 81 LUER/35ML 81 5/16" 82 MONOJECT MAGELLAN MONOJECT SYRINGE/REG MONOJECT ULTRA COMFORT SYRINGE/SAFETY LUER/3ML 82 INSULIN SYRINGE/0.3ML/31G X NEEDLE/3ML/21G X 1" 81 MONOJECT 5/16" 82 MONOJECT MAGELLAN SYRINGE/REGULARTIP/3ML MONOJECT ULTRA COMFORT SYRINGE/SAFETY 82 INSULIN SYRINGE/0.5ML/28G X NEEDLE/3ML/21G X 1-1/2" 81 MONOJECT 1/2" 82 MONOJECT MAGELLAN SYRINGE/STANDARDHYPOD MONOJECT ULTRA COMFORT SYRINGE/SAFETY ERMIC INSULIN SYRINGE/0.5ML/29G X NEEDLE/3ML/22G X 1" 81 NEEDLE/3ML/20GX1" 82 1/2" 82 MONOJECT MAGELLAN MONOJECT MONOJECT ULTRA COMFORT SYRINGE/SAFETY SYRINGE/STANDARDHYPOD INSULIN SYRINGE/0.5ML/30G X NEEDLE/3ML/22G X 1-1/2" 81 ERMIC NEEDLE/3ML/20GX1- 5/16" 82 MONOJECT MAGELLAN 1/2" 82 MONOJECT ULTRA COMFORT SYRINGE/SAFETY MONOJECT INSULIN SYRINGE/0.5ML/31G X NEEDLE/3ML/23G X 1" 81 SYRINGE/STANDARDHYPOD 5/16" 82 MONOJECT MAGELLAN ERMIC MONOJECT ULTRA COMFORT SYRINGE/SAFETY NEEDLE/3ML/21GX1" 82 INSULIN SYRINGE/1ML/28G X NEEDLE/3ML/25G X 1" 81 MONOJECT 1/2" 83 MONOJECT MAGELLAN SYRINGE/STANDARDHYPOD MONOJECT ULTRA COMFORT SYRINGE/SAFETY ERMIC INSULIN SYRINGE/1ML/29G X NEEDLE/3ML/25G X 5/8" 81 NEEDLE/3ML/22GX1" 82 1/2" 83 MONOJECT SHARPS MONOJECT MONOLET LANCETS 55 CONTAINER/14 QUART 81 SYRINGE/STANDARDHYPOD MONOLET OPD LANCETS 55 MONOJECT ERMIC NEEDLE/3ML/22GX1- SYRINGE/CATHETERTIP/35ML 1/2" 82 MONONINE 46 81 MONOJECT montelukast sodium 11 MONOJECT SYRINGE/STANDARDHYPOD MORPHINE SULFATE 5 SYRINGE/ECCENTRIC ERMIC morphine sulfate 5,6 LUER/35ML 81 NEEDLE/3ML/23GX1" 82 MONOJECT SYRINGE/LUER MONOJECT MOTRIN INFANTS DROPS 3 LOCK/35ML 81 SYRINGE/STANDARDHYPOD MOVIPREP 48 MONOJECT SYRINGE/LUER ERMIC moxifloxacin hcl 43 LOCK/3ML 81 NEEDLE/3ML/25GX1" 82 MONOJECT SYRINGE/LUER MONOJECT moxifloxacin hcl (ophth) 155 LOCK/3ML/20G X 1" 81 SYRINGE/STANDARDHYPOD MS CONTIN 6 MONOJECT SYRINGE/LUER ERMIC NEEDLE/3ML/25GX1- MS INSULIN LOCK/3ML/20G X 1-1/2" 81 1/4" 82 SYRINGE/0.3ML/31G X MONOJECT SYRINGE/LUER MONOJECT 5/16" 83 LOCK/3ML/20G X 3/4" 81 SYRINGE/STANDARDHYPOD MS INSULIN MONOJECT SYRINGE/LUER ERMIC SYRINGE/0.5ML/31G X LOCK/3ML/22G X 1" 81 NEEDLE/3ML/25GX5/8" 82 5/16" 83 MONOJECT SYRINGE/LUER MONOJECT MS INSULIN SYRINGE/1ML/31G LOCK/3ML/22G X 1-1/2" 81 SYRINGE/STANDARDHYPOD X 5/16" 83 MONOJECT SYRINGE/LUER ERMIC NEEDLE/3ML/27GX1- MUCINEX 36 LOCK/3ML/23G X 1" 81 1/4" 82 MUCINEX MAXIMUM MONOJECT SYRINGE/LUER MONOJECT TUBERCULIN STRENGTH 36 LOCK/3ML/25G X 1" 81 SYRINGE SOFTPACK 1ML MULTI VITAMIN 144 MONOJECT SYRINGE/LUER REGULAR LUER TIP 82 LOCK/3ML/25G X 5/8" 81 MONOJECT TUBERCULIN MULTI VITAMIN/D-3 144 MONOJECT SYRINGE/LUER SYRINGE/WITHOUT MULTI-BETIC DIABETES 113 LOCK/3ML/27G X 1-1/4" 81 NEEDLE/REG LUER/1ML 82 MONOJECT SYRINGE/LUER- MULTI-LANCET DEVICE 55 LOCK TIP/3ML 81
Index 28 MULTI-VITAMIN MYNATAL 148 NEPHRO-VITE RX 105 MONOCAPS 114 MYNATE 90 PLUS 148 NEURONTIN 14 MULTI-VITE 114 MYSOLINE 14 nevirapine 29 MULTILEX 114 nabumetone 3 NEXPLANON 34 MULTILEX T&M 114 nadolol 31 niacin 177 multiple vitamin 145 naltrexone hcl 20 niacin (antihyperlipidemic) 22 multiple vitamins w/ iron 106 NAPROSYN 3 NIACIN TR 177 multiple vitamins w/ minerals 118,119 naproxen 3 NIASPAN 22 multiple vitamins w/ minerals naproxen sodium 3 NICADAN 141 cap 176 naratriptan hcl 98 NICADAN ZX 141 multiple vitamins w/ minerals chew 176 NARCAN 20 nicardipine hcl 32 multiple vitamins w/ minerals NARDIL 16 NICAZEL 141 liq 176 NAROPIN 50 NICAZEL FORTE 141 multiple vitamins w/ minerals NASACORT ALLERGY NICODERM CQ 168 tabs 118 24HR 151 NICORETTE 168 MULTIVITAMIN 140,146 NASACORT ALLERGY 24HR MULTIVITAMIN ADULT 140 CHILDRENS 151 NICORETTE MINI 168 MULTIVITAMIN ADULT NAT-RUL THERAVITE- NICORETTE STARTER EXTRAVITAMIN C 140 M/HIGHPOTENCY 141 KIT 168 MULTIVITAMIN ADULTS 140 NATALVIT 148 nicotine 168 MULTIVITAMIN NATROBA 41 nicotine polacrilex 168 CHILDRENS 147 NATRUL-VITES 141 NICOTROL INHALER 169 MULTIVITAMIN GUMMIES NATURAL CARAMEL 158 NICOTROL NS 169 CHILDRENS 148 MULTIVITAMIN INFANT & NATURE-THROID 170 nifedipine 32 TODDLER 147 NATURE-THROID NT- NITRO-DUR 10 MULTIVITAMIN MEN 140 2.5 170 nitrofurantoin 10 MULTIVITAMIN PLUS IRON NAYZILAM 13 nitrofurantoin macrocrystal 10 CHILDRENS 147 NEBULIZER CUP/TUBING97 nitrofurantoin monohyd MULTIVITAMIN WOMEN 140 nefazodone hcl 16 macro 10 MULTIVITAMIN/ZINC NEO-SYNEPHRINE nitroglycerin 10 STRESSFORMULA 140 COLD+ALLERGY EXTRA NITROSTAT 10 mupirocin 37 STRENGTH 152 MVW COMPLETE NEO-SYNEPHRINE NIVA-PLUS 148 FORMULATION 141 COLD+ALLERGY MILD NIX CREME RINSE 41 MVW COMPLETE STRENGTH 152 nizatidine 171 FORMULATIOND3000 141 NEOMULTIVITE 146 NO IRON MULTIPLE MVW COMPLETE neomycin sulfate 2 VITAMIN/MINERALS 141 FORMULATIOND500 141 NOKOR ADMIX NEEDLE THIN MVW COMPLETE neomycin-bacitracin zn- polymyxin 155 WALL NON-CORING 16G X FORMULATIONMINIS 141 neomycin-bacitracin-polymyxin 1" 83 MX-SOL 166 37 NOKOR ADMIX NEEDLE THIN MX-SOL BLEND 166 neomycin-polymy- WALL NON-CORING 18G X 1- MX-SOL BLEND SF 166 dexameth 155 1/2" 83 NORCO 7 MX-SOL SF 166 neomycin-polymyxin-hc (ophth) 155 norelgestromin-ethinyl MX-SOL SUSPEND 166 neomycin-polymyxin-hc estradiol 34 MYAMBUTOL 24 (otic) 156 norethin acet & estrad-fe 34 mycophenolate mofetil 102 NEORAL 102 norethindrone & eth estradiol34 mycophenolate sodium 102 NEOSPORIN ORIGINAL 37 norethindrone MYDRIACYL 154 NEOVITE 141 (contraceptive) 35 NEPHRO-VITE 105 norethindrone acet & eth MYFORTIC 102 estra 34
Index 29 norethindrone acetate-ethinyl NUVIGIL 1 ONE-A-DAY ESSENTIAL 146 estradiol-fe 34 NUWIQ 46 ONE-A-DAY FOR HER norethindrone-eth estradiol nystatin 20 VITACRAVES TEEN MULTI (triphasic) 34 GUMMIES 141 norgestimate-ethinyl nystatin (mouth-throat) 102 ONE-A-DAY FOR estradiol 34 nystatin (topical) 37 HIM/VITACRAVES TEEN MULTI norgestimate-ethinyl estradiol nystatin-triamcinolone 38 GUMMIES 141 (triphasic) 34 ONE-A-DAY MENOPAUSE norgestrel & ethinyl estradiol 34 O-CAL FA 148 FORMULA 141 NORPACE 11 O-CAL PRENATAL 148 ONE-A-DAY MENS 141,146 NORPACE CR 11 OCUFLOX 155 ONE-A-DAY MENS 50+ 141 NORPRAMIN 17 OCULAR VITAMINS 141 ONE-A-DAY MENS 50+ NORTEMP INFANTS 4 OCUVITE ADULT 50+ 141 ADVANTAGE 141 ONE-A-DAY MENS HEALTH nortriptyline hcl 17 OCUVITE ADULT FORMULA 141 FORMULA 141 NORVASC 32 OCUVITE LUTEIN 141 ONE-A-DAY MENS PRO EDGE 141 NORVIR 29 ODEFSEY 29 NOVA MAX PLUS KETONE ONE-A-DAY MENS TESTSTRIPS 41 ofloxacin 43 VITACRAVES GUMMIES 141 NOVA SUREFLEX ofloxacin (ophth) 155 ONE-A-DAY PROACTIVE LANCETS 55 65+ 141 ofloxacin (otic) 156 ONE-A-DAY TEEN NOVA SUREFLEX LANCING olanzapine 27 DEVICE 55 ADVANTAGEFOR HIM 141 NOVAFERRUM PEDIATRIC olanzapine-fluoxetine hcl 167 ONE-A-DAY VITACRAVES 141 MULTIVITAMIN 147 OMBRA TABLE TOP ONE-A-DAY VITACRAVES NOVOEIGHT 46 COMPRESSOR 97 ADULT 141 ONE-A-DAY VITACRAVES NOVOLIN 70/30 19 OMEGA-3 152 OMEGA-3 EPA FISH OIL 152 GUMMIES+OMEGA-3 NOVOLIN 70/30 FLEXPEN 19 DHA 148 NOVOLIN 70/30 FLEXPEN omega-3 fatty acids 153 ONE-A-DAY VITACRAVES RELION 19 OMEGA-3 FISH OIL EXTRA GUMMIES/IMMUNITY NOVOLIN 70/30 RELION 19 STRENGTH 153 SUPPORT 141 NOVOLIN N 19 omeprazole 171 ONE-A-DAY VITACRAVES OMEPRAZOLE + SYRSPEND SOURGUMMIES 142 NOVOLIN N FLEXPEN 19 SFALKA 171 ONE-A-DAY VITACRAVES NOVOLIN N FLEXPEN OMEPRAZOLE TABLET 170 WOMENS MULTI 142 RELION 19 ONE-A-DAY WEIGHT SMART NOVOLIN N RELION 19 OMNICAP 146 ADVANCED 142 ON CALL LANCING ONE-A-DAY WOMENS 142 NOVOLIN R 19 DEVICE 55 NOVOLIN R RELION 19 ON CALL PLUS LANCING ONE-A-DAY WOMENS 50+ DEVICE 56 ADVANTAGE 142 NOVOLOG MIX 70/30 19 ONE-A-DAY WOMENS 50+ NOVOLOG MIX 70/30 ONCOVITE 141 HEALTHY ADVANTAGE 142 PREFILLED FLEXPEN 19 ondansetron 20 ONE-A-DAY WOMENS ACTIVE NOVOLOG MIX 70/30 ondansetron hcl 20 MIND & BODY 142 PREFILLED FLEXPEN ONE-A-DAY WOMENS RELION 19 ONE A DAY MENS VITACRAVES MULTI PETITES 142 NOVOLOG MIX 70/30 ONE-A-DAY WOMENS PLUS RELION 19 GUMMIES 141 ONE DAILY ESSENTIAL 146 HEALTHY SKIN SUPPORT142 NOVOSEVEN RT 46 ONE-A-DAY WOMENS ONE DAILY MENS FORMULA NULYTELY 48 PRENATAL 148 W/O IRON 141 ONE-A-DAY WOMENS NULYTELY/FLAVOR ONE DAILY WOMENS 141 PACKS 48 VITACRAVES GUMMIES 142 ONE FLOW FVC ONE-DAILY MULTI CAPS 142 NUPLAZID 26 MONITORING NUTRICAP 141 ONETOUCH DELICA LANCING SPIROMETER 97 DEVICE 56 NUVARING 34 ONE-A-DAY ENERGY 141 ONETOUCH DELICA PLUS LANCING DEVICE 56
Index 30 ONETOUCH DELICA SAFETY ORAL MIX FLAVORED PARI TREK S COMBO LACING DEVICE 56 SUSPENDING VEHICLE 166 PACK 97 ONFI 13 ORAL MIX SF 166 PARLODEL 26 OPSUMIT 32 ORAL SUSPEND 166 PARNATE 16 OPTICHAMBER ORAL SUSPENDING paromomycin sulfate 2 ADVANTAGE/LARGE COMPOUNDPLUS 166 paroxetine hcl 16 MASK 97 ORAL SYRUP FLAVORED OPTICHAMBER VEHICLE 166 paroxetine mesylate (vasomotor) 169 ADVANTAGE/MEDIUM FACE ORAL SYRUP SF 166 PARVA-CAL 100 MASK 97 ORANGE OPTICHAMBER CONCENTRATE 158 PARVLEX 142 ADVANTAGE/SMALL FACE ORANGE CREAM PAXIL 16 MASK 97 FLAVOR 158 PAXIL CR 16 OPTICHAMBER DIAMOND 97 ORANGE FLAVOR 159 PC LANCETS SUPER THIN OPTICHAMBER ORANGE OIL FLAVOR 159 30G 56 DIAMOND/LARGEFACE ORTHO MICRONOR 35 PC PEDIATRIC POLY-VITAMIN MASK 97 DROPS 148 OPTICHAMBER ORTHO TRI-CYCLEN LO 34 PC PEDIATRIC POLY-VITAMIN DIAMOND/MEDIUM FACE ORTHO-NOVUM 1/35 34 DROPS/IRON 147 MASK 97 ORTHO-NOVUM 7/7/7 34 PCCA SWEET-SF 166 OPTICHAMBER DIAMOND/SMALLFACE oseltamivir phosphate 31 PCCA SWEETNESS MASK 97 OSTEOPRIME ENHANCER 159 OPTICHAMBER FACE PLUS/CALCIUM & PCCA SYRUP VEHICLE 166 MASK/LARGE 97 MAGNESIUM 142 PCCA-PLUS 166 OPTICHAMBER FACE OTEZLA 3 PEACH FLAVOR 159 MASK/MEDIUM 97 OTOVEL 156 PEANUT BUTTER OPTICHAMBER FACE FLAVOR 159 MASK/SMALL 97 OVIDE 41 OXAYDO 6 ped multivitamins w/fl & OPTIFAST POST iron 147 BARIATRIC 142 oxazepam 10 PEDIA-LAX 49 OPTIHALER 97 oxcarbazepine 14 PEDIALYTE 101 OPTIHALER MDI DRUG oxybutynin chloride 172 DELIVERY SYSTEM 97 PEDIALYTE ADVANCED OPTIMUM AIRVITES 142 oxycodone hcl 6 CARE 100 oxycodone w/ PEDIALYTE FREEZER OPTIONS CONCEPTROL POPS 100 VAGINAL acetaminophen 7 CONTRACEPTIVE 175 oxymetazoline hcl 152 PEDIALYTE SINGLES 100 OPTIONS GYNOL II oyster shell 100 PEDIAPRED 35 VAGINALCONTRACEPTIVE OYSTER SHELL CALCIUM PEDIARIX 170 175 PLUS VITAMIN D 100 pediatric multiple vitamin w/ c & OPTISOURCE POST OYSTER SHELL fa 148 BARIATRIC SURGERY 142 CALCIUM/VITAMIN D 100 pediatric multiple vitamin w/ extra OPTIVITE P.M.T. 142 paliperidone 26 c & fa 148 OPURITY 142 PAMELOR 17 pediatric multiple vitamin w/ minerals & c 147 OPURITY/BYPASS PANCREAZE 42 OPTIMIZED 142 pediatric multiple vitamins 148 PANDA MASK LARGE 97 ORA-BLEND 166 pediatric multiple vitamins w/ PANDA MASK MEDIUM 97 ORA-BLEND SF 166 iron 147 PANDA MASK SMALL 97 Pediatric multiple vitamins w/ ORA-PLUS 166 pantoprazole sodium 171 minerals Chew 147 ORA-SWEET 166 Pediatric multiple vitamins w/ PARAGARD INTRAUTERINE ORA-SWEET SF 166 minerals Liqd 147 COPPER CONTRACEPTIVE Pediatric multiple vitamins w/ ORACEA 41 T380A 34 minerals Soln 147 oral electrolytes 100 PARI MANUAL pediatric multivitamins w/fl 146 INTERRUPTER 97 PEDIATRIC PANDA MASK 97
Index 31 pediatric vitamins acd w/ PHILLIPS MILK OF POLYSPORIN 37 fluoride 146 MAGNESIA 49 POLYTRIM 155 PEDIAVIT 148 PHILLIPS MILK OF polyvinyl alcohol 153 PEDVAX HIB 172 MAGNESIA CHEWABLE 49 PHILLIPS MILK OF pot phosphate monobasic w/ sod peg 3350-kcl-nacl-na sulfate-na MAGNESIA phosphate dibasic & ascorbate-ascorbic acid 48 CONCENTRATED 49 monobasic 101 peg 3350-kcl-sod bicarb-sod PHLEBOTOMY SHARPS potassium chloride 101 chloride-sod sulfate 48 CONTAINER 83 peg 3350-potassium chloride-sod potassium chloride bicarbonate-sod chloride 48 PHOSPHOLINE IODIDE 154 microencapsulated crystals PHYTOMULTI 142 er 101 PEGASYS 30 potassium citrate PEGASYS PROCLICK 30 phytonadione 177 (alkalinizer) 44 PEGINTRON 30 PIFELTRO 29 povidone-iodine 28 penicillamine 101 PILL SPLITTER 59 PRALINES AND CREAM penicillin v potassium 157 pilocarpine hcl 154 FLAVOR 159 pramipexole dihydrochloride 26 PENTACEL 170 pilocarpine hcl (oral) 103 PRAVACHOL 22 PENTASA 44 pimecrolimus 40 pravastatin sodium 22 pentoxifylline 46 pimozide 167 praziquantel 8 PEPCID 171 PINA COLADA FLAVOR 159 prazosin hcl 23 PEPCID AC 171 pindolol 31 PEPCID AC MAXIMUM PINEAPPLE FLAVOR 159 PRE-NATAL FORMULA 148 STRENGTH 171 pioglitazone hcl 18 PRECISION SURE-DOSE INSULIN SYRINGE/0.3ML/30G X PEPTO BISMOL 19 pioglitazone hcl- 5/16" 83 PEPTO-BISMOL 19 glimepiride 17 PRECISION SURE-DOSE PEPTO-BISMOL MAX pioglitazone hcl-metformin INSULIN SYRINGE/0.5ML/28G X hcl 17 STRENGTH 19 1/2" 83 PEPTO-BISMOL TO-GO 20 PLAN B ONE-STEP 34 PRECISION SURE-DOSE PERCOCET 7 PLAQUENIL 24 INSULIN SYRINGE/0.5ML/29G X PERFECT LANCETS 30G 56 PLAVIX 46 1/2" 83 PLEGISOL 32 PRECISION SURE-DOSE PERIDEX 102 INSULIN SYRINGE/0.5ML/30G X perindopril erbumine 23 PLEGRIDY 167 3/8" 83 permethrin 41 PLEGRIDY STARTER PRECISION SURE-DOSE PACK 167 INSULIN SYRINGE/1ML/28G X perphenazine 28 PNEUMOVAX 23 172 1/2" 83 perphenazine-amitriptyline 167 PNEUMOVAX 23/1 PRECISION SURE-DOSE PERRY PRENATAL 148 DOSE 172 PLUSINSULIN PERSERIS 26 PNV TABS 29-1 148 SYRINGE/0.3ML/29G X 1/2" 83 PRECISION SURE-DOSE PEXEVA 16 POCKET CHAMBER 97 PLUSINSULIN PHARMACY COUNTER POCKET SPACER 97 SYRINGE/1ML/29G X 1/2" 83 LANCETS 56 podofilox 40 PRECISION THINS GP PHAZYME 43 POLY-VI-SOL 148 LANCET 56 PHAZYME ULTRA PRECISION XTRA 41 POLY-VI-SOL/IRON 147 STRENGTH 43 PRECOSE 17 phenazopyridine hcl 45 POLY-VITA 148 PRED FORTE 155 phenelzine sulfate 16 POLY-VITA/IRON 147 PRED MILD 155 phenobarbital 47 POLY-VITE PEDIATRIC 148 PRED-G 155 phenylephrine hcl 152 POLY-VITE/IRON 147 PRED-G S.O.P. 155 PHENYTEK 15 polyethylene glycol 3350 49 PREDATOR 40 phenytoin 15 polymyxin b-trimethoprim 155 prednicarbate 39 phenytoin sodium extended 15 polysaccharide iron complex 47 prednisolone 35
Index 32 prednisolone acetate prenatal vit w/ ferrous fumarate- PRO COMFORT INSULIN (ophth) 155 folic acid 149 SYRINGES/0.5ML/30G X PREDNISOLONE ACETATE P- prenatal vit w/ iron carbonyl- 5/16" 83 F 155 folic acid 149 PRO COMFORT INSULIN prednisolone sodium PRENATAL VITAMIN & SYRINGES/0.5ML/31G X phosphate 35 MINERAL 149 5/16" 83 PREDNISOLONE SODIUM PRENATAL VITAMINS 149 PRO COMFORT INSULIN PHOSPHATE 155 PRENATAL VITAMINS PLUS SYRINGES/1ML/30G X 1/2" 84 prednisone 35 LOW IRON 149 PRO COMFORT INSULIN PREFERRED PLUS INSULIN PRENATAL VITAMINS- SYRINGES/1ML/30G X SYRINGE/U-100/0.3ML/29G X MISC 149 5/16" 84 1/2" 83 PRENATAL+DHA 149 PRO COMFORT INSULIN PREFERRED PLUS INSULIN SYRINGES/1ML/31G X PRENATAL-U 149 5/16" 84 SYRINGE/U-100/0.3ML/30G X PRENATAL/OMEGA-3/FOLIC 5/16" 83 PRO-CAL 142 PREFERRED PLUS INSULIN ACID/IRON 150 PRENATVITE RX 150 PROAIR HFA 12 SYRINGE/U-100/0.5ML/28G X PROAIR RESPICLICK 12 1/2" 83 PREPLUS 150 PREFERRED PLUS INSULIN PRESERVISION AREDS 142 probenecid 45 SYRINGE/U-100/0.5ML/29G X PRESERVISION AREDS PROCARDIA 32 1/2" 83 2 142 PROCARDIA XL 32 PREFERRED PLUS INSULIN PRESERVISION AREDS 2 + PROCARE SPACER CHAMBER SYRINGE/U-100/0.5ML/30G X MULTI VITAMIN 142 W/ADULT MASK 98 5/16" 83 PRESERVISION/LUTEIN PROCARE SPACER CHAMBER PREFERRED PLUS INSULIN 142 W/CHILD MASK 98 SYRINGE/U-100/1ML/28G X PREVACID 171 1/2" 83 PROCERV HP 142 PREFERRED PLUS INSULIN PREVACID 24HR 171 prochlorperazine 28 SYRINGE/U-100/1ML/29G X PREVIDENT 5000 PLUS 102 prochlorperazine maleate 28 1/2" 83 PREVIDENT RINSE 102 PROCRIT 46 PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/30G X PREVNAR 13 172 PROCTOFOAM HC 8 5/16" 83 PREZCOBIX 29 PRODIGY INSULIN SYRING/U- PREFERRED PLUS LANCETS PREZISTA 29 100/0.3ML/31G X 5/16" 84 PRODIGY INSULIN COLORED 21G 56 PRIFTIN 24 PREFERRED PLUS LANCETS SYRINGE/1/2ML/31G X SUPER THIN 30G 56 primaquine phosphate 24 5/16" 84 PREFERRED PLUS LANCETS PRIMAQUINE PRODIGY INSULIN THIN 26G 56 PHOSPHATE 24 SYRINGE/1ML/28G X 1/2" 84 pregabalin 14 PRIMEAIRE DUAL-VALVED PRODIGY LANCING HOLDING CHAMBER 97 DEVICE 56 176 PREMARIN primidone 14 PRODIGY TWIST TOP PREMIUM CONDOMS PRIMSOL 9 LANCETS 56 LUBRICATED 51 progesterone 166 PRINIVIL 23 PRENATAL 149 PROGRAF 102 PRISTIQ 17 PRENATAL 19 148,149 promethazine hcl 21 PRENATAL AND IRON 149 PRO COMFORT INHALER SPACER CHAMBER promethazine w/codeine 36 PRENATAL COMPLETE 149 ADULT 97 promethazine-dm 36 PRENATAL FORMULA A- PRO COMFORT INHALER PROMETRIUM 167 FREE 149 SPACER CHAMBER PRENATAL FORTE 149 CHILD 97 propafenone hcl 11 PRENATAL MULTI +DHA 149 PRO COMFORT INHALER propranolol hcl 31 PRENATAL MULTIVITAMIN + SPACER CHAMBER propylene glycol-glycerin 153 DHA 149 INFANT 97 PROPYLPARABEN 157 PRENATAL MULTIVITAMIN PRO COMFORT INSULIN PLUS DHA 149 SYRINGES/0.5ML/30G X propylthiouracil 170 PRENATAL PLUS IRON 149 1/2" 83 PRORENAL+D 142
Index 33 PRORENAL+D/OMEGA-3 142 pyrimethamine 24 RA INSULIN SYRINGE/U- PROSCAR 45 Q-GEL 2 100/0.5ML/30G X 5/16" 84 RA INSULIN SYRINGE/U-100/1 PROTECT CARDIO AF 142 QC ADVANCED LANCING ML/30G X 5/16" 84 PROTECT PLUS SO 142 DEVICE 56 RA OYSTER SHELL QC ALCOHOL SWABS 59 PROTEGRA 142 CALCIUM/VITAMIN D 100 QC CALCIUM 500MG/D3 100 PROTONIX 171 RA PRENATAL 150 QC LANCETS SUPER raloxifene hcl 43 PROTOPIC 40 THIN 56 protriptyline hcl 17 QC LANCETS ULTRA ramipril 23 PROVENTIL HFA 12 THIN 56 RAPAFLO 45 PROVERA 167 QC MULTI-VITE 142 RAPAMUNE 102 QC OCUHEALTH VISION PROVIGIL 1 RASPBERRY FLAVOR 159 SUPPORT 2 142 REALITY INSULIN SYRINGE/U- PROVIT 142 QC PRENATAL 150 100/0.5ML/28G X 1/2" 84 PROZAC 16 QC UNILET LANCETS REALITY INSULIN SYRINGE/U- PRUDOXIN 38 28G/ULTRA THIN 56 100/0.5ML/29G X 1/2" 84 pseudoephedrine hcl 152 QC UNILET LANCETS REALITY INSULIN SYRINGE/U- 33G/MICRO THIN 56 100/1ML/28G X 1/2" 84 PSORCON 39 QUADRACEL 170 REALITY INSULIN SYRINGE/U- PSS SELECT GP LANCETS 56 QUAKE 98 100/1ML/29G X 1/2" 84 PSS SELECT SAFETY REALITY LANCETS 56 QUDEXY XR 14 LANCETS 56 REALITY LATEX psyllium 48 QUESTRAN 22 CONDOMS/LUBRICATED 51 PTS PANELS KETONE QUESTRAN LIGHT 22 REALITY LATEX/ULTRA TEST 41 quetiapine fumarate 27 TEXTURED 51 PULMICORT 11 REALITY LATEX/ULTRA QUFLORA PEDIATRIC 146 THIN 51 PULMICORT FLEXHALER 11 QUIN B STRONG 143 REALITY SWABS 59 PULMOZYME 169 quinapril hcl 23 REBIF 167 PUMP IN STYLE ADVANCED quinapril-hydrochlorothiazide REBIF REBIDOSE 167 DOUBLE BREASTPUMP 59 24 REBIF REBIDOSE PUMP IN STYLE ADVANCED quinidine gluconate 11 DOUBLE TITRATIONPACK 167 BREASTPUMP/BACKPACK 59 quinidine sulfate 11 REBIF TITRATION PACK 167 PUMPKIN FLAVOR 159 QUINTABS 146 RECOMBINATE 46 PX ADVANCED LANCING QUINTABS-M 143 RECOMBIVAX HB 175 DEVICE 56 QVAR REDIHALER 11 PX INSULIN SYRINGE/U- REFRESH PLUS 153 100/0.5ML/30G X 1/2" 84 RA ALCOHOL SWABS 59 REFRESH TEARS 153 PX LANCET AUTO RA CALCIUM 100 REGLAN 44 INJECTOR 56 RA CALCIUM/BORON 100 RELENZA DISKHALER 31 PX LANCETS MICROTHIN RA CENTRAL-VITE 143 33G 56 RELEXXII 1 RA E-ZJECT LANCETS RELION 2-IN-1 LANCET PX LANCETS ULTRA THIN 56 28G 56 PX PRENATAL DEVICES 30G 56 RA E-ZJECT LANCETS THIN RELION 2-IN-1 LANCING MULTIVITAMINS 150 26G 56 DEVICE 25G 56 PYLERA 172 RA E-ZJECT LANCETS THIN RELION 2-IN-1 LANCING pyrantel pamoate 8 28G 56 DEVICE 30G 56 pyrazinamide 24 RA E-ZJECT LANCETS RELION ALCOHOL SWABS 59 ULTRATHIN 30G 56 pyrethrins-piperonyl butoxide41 RA INSULIN RELION INSULIN SYRINGE pyrethrins-piperonyl butoxide- SYRINGE/0.5ML/29G X 0.5ML/31G X 15/64" 84 RELION INSULIN SYRINGE permethrin-nit remover 41 1/2" 84 RA INSULIN 1ML/31GX15/64" 84 PYRIDIUM 45 RELION INSULIN SYRINGE/U- SYRINGE/1ML/29G X 1/2" 84 pyridostigmine bromide 24 100/0.3ML/31G X 15/64" 84 pyridoxine hcl 177
Index 34 RELION INSULIN SYRINGE/U- RIGHTEST GD500 LANCING SAFESNAP 100/0.3ML/31G X 5/16" 84 DEVICE 56 SYRINGE/NEEDLE/3ML/22G X RELION INSULIN SYRINGE/U- RIGHTEST GL300 1" 85 100/0.5ML/29G X 1/2" 84 LANCETS 56 SAFESNAP RELION INSULIN SYRINGE/U- rimantadine hydrochloride 31 SYRINGE/NEEDLE/3ML/22G X 100/0.5ML/31G X 5/16" 84 RISPERDAL 27 1-1/2" 85 RELION INSULIN SYRINGE/U- SAFESNAP 100/1ML/31G X 15/64" 84 RISPERDAL CONSTA 26 SYRINGE/NEEDLE/3ML/23G X RELION INSULIN SYRINGE/U- risperidone 27 1" 85 100/1ML/31G X 5/16" 84 RITALIN 2 SAFESNAP RELION LANCETS MICRO- RITALIN LA 2 SYRINGE/NEEDLE/3ML/23G X THIN33G 56 1-1/2" 85 RELION LANCETS THIN RITEFLO 98 SAFESNAP 26G 56 ritonavir 29 SYRINGE/NEEDLE/3ML/25G X RELION LANCETS ULTRA- RIXUBIS 46 1" 85 THIN30G 56 SAFESNAP RELION LANCING DEVICE 56 rizatriptan benzoate 98 SYRINGE/NEEDLE/3ML/25G X RELION TRUE METRIX ROBAXIN-750 151 5/8" 85 BLOODGLUCOSE TEST ROBITUSSIN PEAK COLD SAFETY INSULIN SYRINGES STRIPS 41 DM 36 0.5ML/29GX1/2" 85 RELION ULTRA THIN ROCALTROL 43 SAFETY INSULIN SYRINGES LANCETS/30G 56 ROOT BEER FLAVOR 159 0.5ML/30GX5/16" 85 RELION ULTRA THIN SAFETY INSULIN SYRINGES LANCETS30G 56 ropinirole hydrochloride 26 1ML/27GX1/2" 85 RELION ULTRA THIN PLUS rosuvastatin calcium 22 SAFETY INSULIN SYRINGES LANCETS 32G 56 ROTARIX 175 1ML/29GX1/2" 85 SAFETY INSULIN SYRINGES RELION ULTRA THIN PLUS ROTATEQ 175 LANCETS 33G 56 1ML/30GX1/2" 85 REMERON 15 ROXICODONE 6 SAFETY SEAL LANCETS 28G 57 REMERON SOLTAB 15 rufinamide 14 RUKOBIA 29 SAFETY SEAL LANCETS RENAGEL 44 30G 57 RENAPLEX-D 143 RUZURGI 24 SAFETY SYRINGES/NEEDLE RENVELA 44 SACCHARIN SODIUM 42 1ML/25GX5/8" 85 SAFESNAP INSULIN SAFETY SYRINGES/NEEDLE REPLACE 143 SYRINGE/0.3ML/30G X 1ML/27GX1/2" 85 REQ 49+ 143 5/16" 84 SAFETY SYRINGES/NEEDLE RESCRIPTOR 29 SAFESNAP INSULIN 3ML/20GX1" 85 SAFETY SYRINGES/NEEDLE RESTORIL 47 SYRINGE/0.5ML/29G X 1/2" 84 3ML/20GX1-1/2" 85 RETACRIT 46 SAFESNAP INSULIN SAFETY SYRINGES/NEEDLE RETIN-A 37 SYRINGE/0.5ML/30G X 3ML/21GX1" 85 RETROVIR 29 5/16" 84 SAFETY SYRINGES/NEEDLE 3ML/21GX1-1/2" 85 REVATIO 32 SAFESNAP INSULIN SYRINGE/1ML/28G X 1/2" 84 SAFETY SYRINGES/NEEDLE REXALL LANCETS ULTRA SAFESNAP INSULIN 3ML/22GX1" 85 THIN 56 SYRINGE/1ML/29G X 1/2" 84 SAFETY SYRINGES/NEEDLE REXULTI 28 SAFESNAP 3ML/22GX1-1/2" 85 REYATAZ 29 SYRINGE/NEEDLE/3ML/20G X SAFETY SYRINGES/NEEDLE 3ML/23GX1" 85 RIBOFLAVIN 177 1" 84 SAFESNAP SAFETY SYRINGES/NEEDLE riboflavin 177 SYRINGE/NEEDLE/3ML/20G X 3ML/25GX5/8" 85 RIBOFLAVIN 177 1-1/2" 85 SAFETY-GARD SHIELDED SAFESNAP NEEDLE 18G 85 RID 41 SAFETY-GARD SHIELDED RID COMPLETE LICE SYRINGE/NEEDLE/3ML/21G X 1" 85 NEEDLE 20G 85 ELIMINATION 41 SAFETY-LOK RIFADIN 24 SAFESNAP SYRINGE/NEEDLE/3ML/21G X SYRINGE/NEEDLE3ML LUER- rifampin 24 1-1/2" 85 LOK 21GX1-1/2" 85
Index 35 SAFETY-LOK sennosides-docusate SINEMET CR 26 SYRINGE/NEEDLE3ML LUER- sodium 48 SINGULAIR 11 LOK 22GX1" 85 SENOKOT 49 sirolimus 102 SAFETY-LOK SENOKOT S 48 SYRINGE/NEEDLE3ML LUER- SKYLA 34 SENTRY 143 LOK 22GX1-1/2" 85 SLO-NIACIN 177 SAFETY-LOK SENTRY SENIOR 143 SLOW FE 47 SYRINGE/NEEDLE3ML LUER- SENTRY LOK 23GX1" 85 SENIOR/LUTEIN 143 SLOW RELEASE IRON 47 SAFETY-LOK SEREVENT DISKUS 12 SM ALCOHOL PREP PADS 60 SYRINGE/NEEDLE3ML LUER- SEROQUEL 27 SM B-COMPLEX/VITAMIN LOK 25GX5/8" 85 C 105 SEROQUEL XR 27 SALAGEN 103 SM GLUCOSE 18 salsalate 5 sertraline hcl 16 SM MICRO THIN LANCETS SANDIMMUNE 102 sevelamer carbonate 44 33G 57 SAPHRIS 27 sevelamer hcl 44 SM ONE DAILY MENS 143 SM ONE DAILY SARAFEM 167 SHARP CONTAINER 86 SHARPS DISPOSAL BY MAIL PRENATAL 150 SARDINE FLAVOR 159 SYSTEM 86 SM ONE DAILY WOMENS 143 SAVISION 143 SHINGRIX 175 SM TRUEDRAW LANCING SB ALCOHOL PREP PADS 59 SHOPKO ALCOHOL DEVICE 57 SB INSULIN SYRINGE/U- SWABS 59 SMART DIABETES VANTAGE 100/0.5ML/29G X 1/2" 86 SHOPKO AUTOLET LANCING LANCING DEVICE 57 SB INSULIN SYRINGE/U- DEVICE 57 SMART SENSE COLOR 100/0.5ML/30G X 5/16" 86 SHOPKO UNILET LANCETS LANCETS UNIVERSAL 33G 57 SB INSULIN SYRINGE/U- SUPER THIN 30G 57 SMART SENSE STANDARD 100/1ML/29G X 1/2" 86 SHOPKO UNILET LANCETS LANCETS UNIVERSAL 21G 57 SB INSULIN SYRINGE/U- ULTRA THIN 28G 57 SMART SENSE SUPER THIN 100/1ML/30G X 5/16" 86 SHRIMP FLAVOR 159 LANCETS UNIVERSAL 30G 57 SMART SENSE THIN SB INSULIN SYRINGE/U- SHUR-SEAL 175 100/1ML/31G X 5/16" 86 LANCETSUNIVERSAL 26G 57 SB LANCETS THIN 57 SIDEROL 143 SODIUM BENZOATE 166 SIGNATURE PRO DOUBLE sodium bicarbonate 99 SB LANCETS ULTRA THIN 57 ELECTRIC BREAST SEASONIQUE 34 PUMP 59 sodium bicarbonate (antacid) 8 SECUADO 27 SIGNATURE PRO sodium chloride 101 SECURESAFE SAFETY HEALTHCAREDOUBLE sodium chloride (inhalant) 36 INSULIN SYRINGES/U- ELECTRIC BREAST sodium citrate & citric acid 45 PUMP 60 100/0.5ML/29GX1/2" 86 sodium fluoride 101 SECURESAFE SAFETY sildenafil citrate (pulmonary INSULIN SYRINGES/U- hypertension) 32 sodium fluoride (dental) 103 100/1ML/29GX1/2" 86 SILVADENE 38 sodium phosphates 49 SECURESAFE silver sulfadiazine 38 sodium polystyrene SYRINGE/NEEDLE/1ML/25G X simethicone 43,44 sulfonate 102 1" 86 SODIUM SACCHARIN 42 SECURESAFE SIMILAC PRENATAL EARLY SYRINGE/NEEDLE/3ML/20G X SHIELD 150 SODIUM VALPROATE 33 1" 86 SIMPLE DIAGNOSTICS SOFOSBUVIR/VELPATASVIR LANCING DEVICE 57 SEGLUROMET 17 30 SIMPLE SYRUP 166 SELECT-LITE LANCING SOLO 143 DEVICE 57 SIMPLYGO BREAST SOLU-CORTEF 35 PUMP/DUAL 60 SOLUS V2 LANCING selegiline hcl 26 SIMPLYGO BREAST SELZENTRY 29 DEVICE 57 PUMP/SINGLE 60 SOOLANTRA 41 SEMGLEE 19 SIMPONI 2 SOOTHE 153 sennosides 49 simvastatin 22 SORBITOL 49 SINEMET 26
Index 36 SORIATANE 38 sulindac 3 SURE-JECT INSULIN SOSWEET 166 sumatriptan 99 SYRINGE/U-100/0.3ML/29G X 1/2" 86 sotalol hcl 31 sumatriptan succinate 99 SURE-JECT INSULIN SPACERS AND BREATHING SUPER ANTIOXIDANT 143 SYRINGE/U-100/0.3ML/30G X CHAMBERS-MISC 98 SUPER THIN LANCETS 57 5/16" 87 SPATONE PUR-ABSORB SURE-JECT INSULIN IRON 47 SUPPORT 143 SYRINGE/U-100/0.3ML/31G X SPECTRAVITE 143 SUPREP BOWEL PREP 5/16" 87 KIT 48 SURE-JECT INSULIN SPIRO PD 98 SUPRESS DM spironolactone 42 SYRINGE/U-100/0.5ML/28G X PEDIATRIC 36 1/2" 87 spironolactone & SURE COMFORT INSULIN SURE-JECT INSULIN hydrochlorothiazide 42 SYRINGE/U-100/0.3ML/29G X SYRINGE/U-100/0.5ML/29G X SPORANOX 20 1/2" 86 1/2" 87 SPORANOX PULSEPAK 20 SURE COMFORT INSULIN SURE-JECT INSULIN SYRINGE/U-100/0.3ML/30G X SPRAVATO 56MG DOSE 16 SYRINGE/U-100/0.5ML/30G X 1/2" 86 5/16" 87 SPRAVATO 84MG DOSE 16 SURE COMFORT INSULIN SURE-JECT INSULIN SPRIX 3 SYRINGE/U-100/0.3ML/30G X SYRINGE/U-100/0.5ML/31G X st john's wort (hypericum 5/16" 86 5/16" 87 perforatum) 2 SURE COMFORT INSULIN SURE-JECT INSULIN ST JOHNS WORT 2 SYRINGE/U-100/0.3ML/31G X SYRINGE/U-100/1ML/28G X 5/16 86 STALEVO 100 26 1/2" 87 SURE COMFORT INSULIN SURE-JECT INSULIN STALEVO 125 26 SYRINGE/U-100/0.3ML/31G X SYRINGE/U-100/1ML/29G X STALEVO 150 26 5/16" 86 1/2" 87 SURE COMFORT INSULIN SURE-JECT INSULIN STALEVO 200 26 SYRINGE/U-100/0.5ML/28G X STALEVO 50 26 SYRINGE/U-100/1ML/30G X 1/2" 86 5/16" 87 STALEVO 75 26 SURE COMFORT INSULIN SURE-JECT INSULIN STAVUDINE 29 SYRINGE/U-100/0.5ML/29G X SYRINGE/U-100/1ML/31G X 1/2" 86 5/16" 87 stavudine 29 SURE COMFORT INSULIN STEGLATRO 19 SYRINGE/U-100/0.5ML/30G X SURE-PEN 57 STERILANCE TL 57 1/2" 86 SURELITE LANCETS 57 STEVIA GLYCERITE LIQUID SURE COMFORT INSULIN SUSPENDRX WITH BITTER- EXTRACT 159 SYRINGE/U-100/0.5ML/30G X BLOC/SWEETENED 166 5/16" 86 SUSPENDRX WITH BITTER- STRATTERA 1 SURE COMFORT INSULIN BLOC/UNSWEETENED 166 STRAWBERRY FLAVOR 159 SYRINGE/U-100/0.5ML/31G X SUSPENSION VEHICLE 166 STRIBILD 29 5/16 86 SUSTIVA 29 STROMECTOL 9 SURE COMFORT INSULIN SWEETENING SYRINGE/U-100/1ML/28G X ENHANCER 159 STROVITE FORTE 143 1/2" 86 STROVITE ONE 143 SWEETENING SURE COMFORT INSULIN ENHANCER/FLAVORX 159 SUBOXONE 7 SYRINGE/U-100/1ML/29G X SWEETENING SUSPENDING sucralfate 171 1/2" 86 COMPOUND 166 SURE COMFORT INSULIN SUDAFED CONGESTION 152 SYRINGE/U-100/1ML/30G X SYMBICORT 12 SUDAFED SINUS 1/2" 86 SYMBYAX 167 CONGESTION 152 SURE COMFORT INSULIN SYMFI 30 sulfacetamide sod- SYRINGE/U-100/1ML/30G X SYMFI LO 30 prednisolone 155 5/16" 86 sulfacetamide sodium SURE COMFORT INSULIN SYMTUZA 30 (ophth) 155 SYRINGE/U-100/1ML/31G X SYNALAR 39 sulfamethoxazole- 5/16" 86 SYNTHROID 170 trimethoprim 9 SURE COMFORT LANCING SYRINGE/BLUNT PLASTIC sulfasalazine 44 PEN 57 CANNULA 87
Index 37 SYRINGE/LUER LOCK/3ML 87 SYRPALTA 166 TECHLITE INSULIN SYRINGEU- SYRINGE/LUER LOCK/3ML/20G SYRSPEND SF 166 100/0.5ML/30G X 1/2" 88 TECHLITE INSULIN SYRINGEU- X 1" 87 SYRUP NF 166 SYRINGE/LUER LOCK/3ML/20G 100/0.5ML/30G X 5/16" 88 X 1-1/2" 87 SYRUP VEHICLE 166 TECHLITE INSULIN SYRINGEU- SYRINGE/LUER SYRUP VEHICLE SF 166 100/0.5ML/31G X 15/64" 88 LOCK/3ML/20GX1-1/2" 87 SYSTANE ICAPS TECHLITE INSULIN SYRINGEU- SYRINGE/LUER LOCK/3ML/21G AREDS2 143 100/0.5ML/31G X 5/16" 88 TECHLITE INSULIN SYRINGEU- X 1" 87 T-VITES 143 SYRINGE/LUER LOCK/3ML/21G 100/1ML/29G X 1/2" 88 TAB-A-VITE TECHLITE INSULIN SYRINGEU- X 1-1/2" 87 MULTIVITAMIN/IRON AND SYRINGE/LUER 100/1ML/30G X 1/2" 88 BETA-CAROTENE 106 LOCK/3ML/21GX1" 87 TECHLITE INSULIN SYRINGEU- SYRINGE/LUER TABLET CUTTER 60 100/1ML/30G X 5/16" 88 LOCK/3ML/21GX1-1/2" 87 TABLET CUTTER/DELUXE TECHLITE INSULIN SYRINGEU- SYRINGE/LUER LOCK/3ML/22G SAFETY 60 100/1ML/31G X 15/64" 88 X 1" 87 TABLOID 25 TECHLITE INSULIN SYRINGEU- SYRINGE/LUER LOCK/3ML/22G TACLONEX 39 100/1ML/31G X 5/16" 88 TECHLITE LANCETS 57 X 1-1/2" 87 tacrolimus 102 SYRINGE/LUER TECHLITE LANCETS 30G 57 tacrolimus (topical) 40 LOCK/3ML/22GX1" 87 TEGRETOL 14 SYRINGE/LUER tadalafil (pulmonary LOCK/3ML/22GX1-1/2" 87 hypertension) 32 TEGRETOL-XR 14 SYRINGE/LUER LOCK/3ML/23G TAGAMET HB 171 TEKTURNA 24 X 1" 87 TALTZ 38 temazepam 47,48 SYRINGE/LUER LOCK/3ML/23G X 1-1/2" 87 TAMIFLU 31 TEMIXYS 30 SYRINGE/LUER tamoxifen citrate 25 TENIVAC 170 LOCK/3ML/23GX1" 87 tamsulosin hcl 45 tenofovir disoproxil fumarate 30 SYRINGE/LUER LOCK/3ML/25G TENORETIC 100 24 X 1" 87 TAPAZOLE 170 SYRINGE/LUER LOCK/3ML/25G TARGADOX 169 TENORETIC 50 24 X 1-1/2" 87 TAXOTERE 25 TENORMIN 31 SYRINGE/LUER LOCK/3ML/25G TDVAX 170 TEPADINA 25 X 5/8" 87 SYRINGE/LUER TECFIDERA 167 terazosin hcl 23 LOCK/3ML/25GX1" 87 TECFIDERA STARTER terbinafine hcl 20 SYRINGE/LUER PACK 167 terbinafine hcl (topical) 38 TECHLITE AST LANCETS 57 LOCK/3ML/25GX5/8" 87 terbutaline sulfate 12 SYRINGE/LUER SLIP/1ML 87 TECHLITE INSULIN SYRINGE/LUER SLIP/1ML/25G SYRINGEU-100/0.3ML/29G X terconazole vaginal 176 X 5/8" 87 1/2" 88 TESSALON PERLES 36 SYRINGE/LUER SLIP/1ML/26G TECHLITE INSULIN TESTIM 7 X 3/8" 87 SYRINGEU-100/0.3ML/30G X testosterone cypionate 7 SYRINGE/LUER SLIP/1ML/27G 1/2" 88 X 1/2" 87 TECHLITE INSULIN testosterone enanthate 7 SYRINGE/LUER SLIP/35ML 88 SYRINGEU-100/0.3ML/30G X TETANUS/DIPHTHERIA 5/16" 88 TOXOIDS-ADSORBED SYRINGE/LUER SLIP/3ML 88 TECHLITE INSULIN ADULT 170 SYRINGES/LUER SYRINGEU-100/0.3ML/31G X tetracaine hcl (ophth) 155 LOCK/1ML/20GX1" 88 15/64" 88 tetracycline hcl 169 SYRINGES/LUER TECHLITE INSULIN LOCK/WITHOUT SYRINGEU-100/0.3ML/31G X TGT ALCOHOL SWABS 60 NEEDLE/3ML 88 5/16" 88 TGT LANCET MICRO THIN SYRINGES/LUER TECHLITE INSULIN 33G 57 SLIP/1ML/25GX5/8" 88 SYRINGEU-100/0.5ML/29G X TGT LANCET THIN 26G 57 SYRINGES/LUER 1/2" 88 TGT LANCET ULTRA THIN SLIP/WITHOUT 30G 57 NEEDLE/1ML 88 TGT LANCING DEVICE 57
Index 38 theophylline 12 tobramycin (ophth) 155 TRANXENE T 10 THERA 146 tobramycin- tranylcypromine sulfate 16 THERA M PLUS 143 dexamethasone 155 TRAVATAN Z 156 TOBREX 155 THERA-M 143 travoprost 156 TODAY SPONGE 175 THERA-TABS M 143 trazodone hcl 16 TODAYS HEALTH ADVANCED THERABETIC MULTI- LANCING DEVICE 57 tretinoin 37 VITAMIN 143 TODAYS HEALTH SUPER TREXALL 25 THERAGRAN-M 143 THINLANCETS 30G 57 triamcinolone acetonide THERAGRAN-M TODAYS HEALTH ULTRA (mouth) 103 ADVANCED 143 THINLANCETS 28G 57 triamcinolone acetonide THERAGRAN-M ADVANCED 50 TOFRANIL 17 (nasal) 151 PLUS 143 tolbutamide 19 triamcinolone acetonide THERAGRAN-M PREMIER143 (topical) 40 THERAGRAN-M PREMIER 50 tolnaftate 38 triamterene & PLUS 143 tolterodine tartrate 172 hydrochlorothiazide 42 THERAMILL FORTE 143 TOPAMAX 15 TRICOR 22 THERANATAL TOPAMAX SPRINKLE 15 TRIDESILON 40 COMPLETE 150 TOPCARE LANCETS MICRO- trifluoperazine hcl 28 THERANATAL CORE THIN 33G 57 trifluridine 155 NUTRITION 150 TOPCARE ULTRA COMFORT THERANATAL LACTATION INSULIN SYRINGE/0.3ML/30G TRIGLIDE 22 ONE 143 X 5/16" 88 trihexyphenidyl hcl 25 THERATEARS 154 TOPCARE ULTRA COMFORT TRIKAFTA 169 INSULIN SYRINGE/0.3ML/31G THEREMS MULTIVITAMIN 146 TRILEPTAL 15 THEREMS-H 143 X 5/16" 88 TOPCARE ULTRA COMFORT trimethoprim 9 THEREMS-M 143 INSULIN SYRINGE/0.5ML/30G trimipramine maleate 17 thiamine hcl 177 X 5/16" 88 TRINATAL RX 1 150 TOPCARE ULTRA COMFORT thiamine mononitrate 177 TRINTELLIX 16 THINLETS GP LANCETS 57 INSULIN SYRINGE/0.5ML/31G X 5/16" 88 TRIUMEQ 30 thioridazine hcl 28 TOPCARE ULTRA COMFORT TRIZIVIR 30 thiothixene 28 INSULIN SYRINGE/1ML/30G X TROPICAL PUNCH THRESHOLD PEP 98 5/16" 88 FLAVOR 159 TOPCARE ULTRA COMFORT tropicamide 154 THRIVITE RX 150 INSULIN SYRINGE/1ML/31G X THROMBATE III 46 5/16" 88 trospium chloride 172 THROMBATE III W/10 ML TOPCARE ULTRA COMFORT TRUE COMFORT INSULIN STERILE WATER 46 INSULIN SYRINGE/U- SYRINGE/0.5ML/31G X thyroid 170 100/0.3ML/29G X 1/2" 89 5/16" 89 TRUE COMFORT INSULIN tiagabine hcl 15 TOPCARE ULTRA COMFORT INSULIN SYRINGE/U- SYRINGE/1ML/31G X 5/16" 89 TIAZAC 32 100/0.5ML/29G X 1/2" 89 TRUE COMFORT PRO timolol maleate (ophth) 154 TOPCARE ULTRA COMFORT INSULINSYRINGE/0.5ML/30G X TIMOPTIC 154 INSULIN SYRINGE/U- 5/16" 89 TRUE COMFORT PRO TIMOPTIC OCUDOSE 154 100/1ML/29G X 1/2" 89 TOPICORT 39,40 INSULINSYRINGE/0.5ML/31G X TIMOPTIC-XE 154 5/16" 89 topiramate 15 TINACTIN 38 TRUE COMFORT PRO TOPROL XL 31 tioconazole vaginal 176 INSULINSYRINGE/1ML/30G X torsemide 42 5/16" 89 TIVICAY 30 TRACLEER 32 TRUE COMFORT PRO tizanidine hcl 151 INSULINSYRINGE/1ML/31G X tramadol hcl 6 TOBI 2 5/16" 89 trandolapril 23 TRUE COMFORT PRO TOBRADEX 155 tranexamic acid 47 INSULINSYRINGE/U- tobramycin 2 100/0.5ML/30G X 1/2" 89
Index 39 TRUE COMFORT PRO TRUETRACK TEST 41 TYBOST 30 INSULINSYRINGE/U- TRULICITY 18 TYLENOL 5 100/1ML/30G X 1/2" 89 TRUE METRIX BLOOD TRUMENBA 172 TYLENOL 8 HOUR 4 GLUCOSETEST STRIPS 41 TRUSOPT 156 TYLENOL 8 HOUR TRUE METRIX CONTROL TRUSTEX COLOR CONDOMS ARTHRITISPAIN 4 SOLUTION LEVEL 1 57 + LUBE 51 TYLENOL CHILDRENS 4 TRUE METRIX CONTROL TRUSTEX LUBRICATED 51 TYLENOL CHILDRENS SOLUTION LEVEL 2 57 TRUSTEX LUBRICATED CHEWABLES/PAIN + FEVER4 TRUE METRIX CONTROL EXTRALARGE 51 TYLENOL EXTRA SOLUTION LEVEL 3 57 TRUSTEX LUBRICATED STRENGTH 4 TRUECONTROL GLUCOSE EXTRASTRENGTH 51 TYLENOL FOR CONTROL LEVEL 0 57 TRUSTEX CHILDREN/ADULTS 4 TRUECONTROL GLUCOSE LUBRICATED/RIBBED/STUDD TYLENOL INFANTS 5 CONTROL LEVEL 1 57 ED 51 TYLENOL INFANTS TRUEDRAW LANCING TRUSTEX PAIN+FEVER 4 DEVICE 57 LUBRICATED/SPERMICIDE TRUEPLUS INSULIN TYLENOL/CODEINE #3 7 51 TYLENOL/CODEINE #4 7 SYRINGE/U-100/0.3ML/29G X TRUSTEX 1/2" 89 LUBRICATED/SPERMICIDE TYMLOS 43 TRUEPLUS INSULIN EXTRA LARGE 51 ULTI-LANCE AUTOMATIC/ SYRINGE/U-100/0.3ML/30G X TRUSTEX CLEAR TIP 58 5/16" 89 LUBRICATED/SPERMICIDE ULTICARE ALCOHOL TRUEPLUS INSULIN EXTRA STRENGTH 51 SWABS 60 SYRINGE/U-100/0.3ML/31G X TRUSTEX NATURAL ULTICARE INSULIN SAFETY 5/16" 89 CONDOMS SYRINGE/0.5ML/29G X 1/2" 89 TRUEPLUS INSULIN +LUBE/LUBRICATED 51 ULTICARE INSULIN SAFETY SYRINGE/U-100/0.5ML/28G X TRUSTEX WITH SYRINGE/1ML/29G X 1/2" 89 1/2" 89 NONOXYNOL- ULTICARE INSULIN TRUEPLUS INSULIN 9/RIBBED/STUDDED 51 SYRINGE/0.3ML/29G X 1/2" 89 SYRINGE/U-100/0.5ML/29G X TRUSTEX/RIA ULTICARE INSULIN 1/2" 89 LUBRICATED 51 SYRINGE/0.3ML/30G X 1/2" 89 TRUEPLUS INSULIN TRUSTEX/RIA LUBRICATED ULTICARE INSULIN SYRINGE/U-100/0.5ML/30G X SPERMICIDE 51 SYRINGE/0.3ML/30G X 5/16" 89 TRUSTEX/RIA 5/16" 90 TRUEPLUS INSULIN LUBRICATED/SPERMICIDE ULTICARE INSULIN SYRINGE/U-100/0.5ML/31G X 51 SYRINGE/0.5ML/28G X 1/2" 90 5/16" 89 TRUVADA 30 ULTICARE INSULIN TRUEPLUS INSULIN SYRINGE/0.5ML/29G X 1/2" 90 SYRINGE/U-100/1ML/28G X TUDORZA PRESSAIR 11 ULTICARE INSULIN 1/2" 89 TUMS 8 SYRINGE/0.5ML/30G X 1/2" 90 TRUEPLUS INSULIN TUMS CHEWY BITES 8 ULTICARE INSULIN SYRINGE/U-100/1ML/29G X SYRINGE/0.5ML/30G X 1/2" 89 TUMS CHEWY DELIGHTS 8 5/16" 90 TRUEPLUS INSULIN TUMS E-X 750 8 ULTICARE INSULIN SYRINGE/U-100/1ML/30G X TUMS EXTRA STRENGTH SYRINGE/1ML/28G X 1/2" 90 5/16" 89 750 8 ULTICARE INSULIN TRUEPLUS INSULIN TUMS LASTING EFFECTS 8 SYRINGE/1ML/29G X 1/2" 90 SYRINGE/U-100/1ML/31G X TUMS SMOOTHIES 8 ULTICARE INSULIN 5/16" 89 SYRINGE/1ML/30G X 1/2" 90 TRUEPLUS LANCETS 26G 58 TUMS ULTRA 1000 8 ULTICARE INSULIN TRUEPLUS LANCETS 28G 58 TUNA FLAVOR 159 SYRINGE/1ML/30G X 5/16" 90 TUNA TYPE FLAVOR ULTICARE INSULIN TRUEPLUS LANCETS 28G SYRINGE/SHORT/0.3ML/30G X SUPER THIN 58 OS 159 TUTTI FRUTTI FLAVOR 159 5/16" 90 TRUEPLUS LANCETS 30G 58 ULTICARE INSULIN TRUEPLUS LANCETS 30G TUTTI-FRUTTI FLAVOR 159 SYRINGE/SHORT/0.3ML/31G X ULTRA THIN 58 TWINRIX 175 5/16" 90 TRUEPLUS LANCETS 33G 58 TYBLUME 34
Index 40 ULTICARE INSULIN ULTICARE TUBERCULIN ULTILET INSULIN SYRINGE/SHORT/0.5ML/30G X SAFETY SYRINGES/1ML/27G SYRINGE/SHORT/0.5ML/31G X 5/16" 90 X 1/2" 91 5/16" 91 ULTICARE INSULIN ULTIGUARD SAFEPACK ULTILET INSULIN SYRINGE/SHORT/0.5ML/31G X INSULIN SYRINGE 0.3ML/30G SYRINGE/SHORT/1ML/30G X 5/16" 90 X 1/2"/SHARPS C 91 5/16" 91 ULTICARE INSULIN ULTIGUARD SAFEPACK ULTILET INSULIN SYRINGE/SHORT/1ML/30G X INSULIN SYRINGE 1/2ML 30G SYRINGE/SHORT/1ML/31G X 5/16" 90 X 1/2"/SHARPS C 91 5/16" 91 ULTICARE INSULIN ULTIGUARD SAFEPACK ULTILET INSULIN SYRINGE/U- SYRINGE/SHORT/1ML/31G X INSULIN SYRINGE 1ML 30G X 100/0.5ML/30G X 1/2" 91 5/16" 90 1/2"/SHARPS CON 91 ULTILET INSULIN SYRINGE/U- ULTICARE INSULIN ULTIGUARD SAFEPACK 100/0.5ML/31GX6MM 91 SYRINGE/U-100/0.3ML/30G X INSULIN SYRINGE 1ML 31G X ULTILET INSULIN SYRINGE/U- 1/2" 90 5/16"/SHARPS CO 91 100/1ML/30G X 1/2" 91 ULTICARE INSULIN ULTIGUARD SAFEPACK ULTILET SHARPS SYRINGE/U-100/0.3ML/31G X INSULIN SYRINGE/0.3ML/30G CONTAINER1 QUART 91 5/16" 90 X 1/2"/SHARPS C 91 ULTILET SHARPS ULTICARE INSULIN ULTIGUARD SAFEPACK CONTAINER2 QUART 92 SYRINGE/U-100/0.5ML/30G X INSULIN SYRINGE/0.3ML/31G ULTRA COMFORT INSULIN 1/2" 90 X 5/16"/SHARPS 91 SYRINGE/U-100/0.3ML/30G X ULTICARE INSULIN ULTIGUARD SAFEPACK 5/16" 92 SYRINGE/U-100/0.5ML/31G X INSULIN SYRINGE/0.5ML/30G ULTRA FLO INSULIN SYRINGE 5/16" 90 X 1/2"/SHARPS C 91 0.3ML/29G X 1/2" 92 ULTICARE INSULIN ULTIGUARD ULTRA FLO INSULIN SYRINGE SYRINGE/U-100/1ML/30G X SAFEPACK/SYRINGE/NEEDL 0.3ML/30GX1/2" 92 1/2" 90 E/31G X 5/16"/SHARPS ULTRA FLO INSULIN SYRINGE ULTICARE INSULIN CONTAIN 91 0.3ML/30GX5/16" 92 SYRINGE/U-100/1ML/31G X ULTILET CLASSIC ULTRA FLO INSULIN SYRINGE 5/16" 90 LANCETS 58 0.3ML/31GX5/16" 92 ULTICARE INSULIN ULTILET INSULIN SYRINGE ULTRA FLO INSULIN SYRINGE SYRINGEULTRAFINE U- 31X6MM 91 0.5ML/29GX1/2" 92 100/0.3ML/31G X 5/16" 90 ULTILET INSULIN ULTRA FLO INSULIN SYRINGE ULTICARE INSULIN SYRINGE/0.3ML/30G X 0.5ML/30GX1/2" 92 SYRINGEULTRAFINE U- 8MM 91 ULTRA FLO INSULIN SYRINGE 100/0.5ML/31G X 5/16" 90 ULTILET INSULIN 0.5ML/30GX5/16" 92 ULTICARE INSULIN SYRINGE/0.3ML/31G X ULTRA FLO INSULIN SYRINGE SYRINGEULTRAFINE U- 8MM 91 0.5ML/31GX5/16" 92 100/1ML/31G X 5/16" 90 ULTILET INSULIN ULTRA FLO INSULIN SYRINGE ULTICARE SAFETY SYRINGE/0.5ML/30G X 1/2 UNIT/0.3ML/30GX1/2" 92 SYRINGE/LOW DEAD 8MM 91 ULTRA FLO INSULIN SYRINGE SPACE/1.5ML/22GX1-1/2" 90 ULTILET INSULIN 1/2 UNIT/0.3ML/30GX5/16" 92 ULTICARE SYRINGE/LOW SYRINGE/1ML/30G X ULTRA FLO INSULIN SYRINGE DEADSPACE/1.5ML/22G X1- 8MM 91 1/2 UNIT/0.3ML/31GX5/16" 92 1/2" 90 ULTILET INSULIN ULTRA FLO INSULIN SYRINGE ULTICARE SYRINGE/LOW SYRINGE/1ML/31G X 1M/29GX1/2" 92 DEADSPACE/1ML/22G X1- 8MM 91 ULTRA FLO INSULIN SYRINGE 1/2" 90 ULTILET INSULIN 1ML/30GX1/2" 92 ULTICARE SYRINGE/LOW SYRINGE/SHORT/0.3ML/30G ULTRA FLO INSULIN SYRINGE DEADSPACE/3ML/22G X1- X 12.7MM 91 1ML/30GX5/16" 92 1/2" 90 ULTILET INSULIN ULTRA FLO INSULIN SYRINGE ULTICARE TUBERCULIN SYRINGE/SHORT/0.3ML/30G 1ML/31GX5/16" 92 SAFETSYRINGES/1ML/27G X X 5/16" 91 ULTRA OMEGA-3 FISH OIL 5/8" 91 ULTILET INSULIN BURP-LESS 153 ULTICARE TUBERCULIN SYRINGE/SHORT/0.3ML/31G ULTRA-COMFORT INSULIN SAFETSYRINGES/1ML/28G X X 5/16" 91 SYRINGE/U-100/0.3ML/29G X 1/2" 91 ULTILET INSULIN 1/2" 92 SYRINGE/SHORT/0.5ML/30G X 5/16" 91
Index 41 ULTRA-COMFORT INSULIN ULTRACARE INSULIN URO-MAG 8 SYRINGE/U-100/0.3ML/30G X SYRINGE/U-100/0.3ML/31G X UROCIT-K 10 45 5/16" 92 5/16" 93 ULTRA-COMFORT INSULIN ULTRACARE INSULIN UROCIT-K 15 45 SYRINGE/U-100/0.3ML/31G X SYRINGE/U-100/0.5ML/30G X UROCIT-K 5 45 5/16" 92 1/2" 93 URSO 250 44 ULTRA-COMFORT INSULIN ULTRACARE INSULIN SYRINGE/U-100/0.5ML/28G X SYRINGE/U-100/0.5ML/30G X URSO FORTE 44 1/2" 92 5/16" 93 ursodiol 44 ULTRA-COMFORT INSULIN ULTRACARE INSULIN VAGIFEM 176 SYRINGE/U-100/0.5ML/29G X SYRINGE/U-100/0.5ML/31G X valacyclovir hcl 30 1/2" 92 5/16" 93 ULTRA-COMFORT INSULIN ULTRACARE INSULIN VALCYTE 30 SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/1ML/30G X valganciclovir hcl 30 5/16" 92 1/2" 93 VALIUM 10 ULTRA-COMFORT INSULIN ULTRACARE INSULIN valproate sodium 15 SYRINGE/U-100/0.5ML/31G X SYRINGE/U-100/1ML/30G X 5/16" 92 5/16" 93 VALPROATE SODIUM 33 ULTRA-COMFORT INSULIN ULTRACARE INSULIN valproic acid 15 SYRINGE/U-100/1ML/28G X SYRINGE/U-100/1ML/31G X valsartan 23 1/2" 92 5/16" 93 valsartan-hydrochlorothiazide ULTRA-COMFORT INSULIN ULTRAM 6 24 SYRINGE/U-100/1ML/29G X UNICOMPLEX-M 143 1/2" 92 VALTOCO 13 ULTRA-COMFORT INSULIN UNILET COMFORTOUCH VALTREX 30 SYRINGE/U-100/1ML/30G X LANCET 58 VALUE HEALTH INSULIN 5/16" 92 UNILET EXCELITE 58 SYRINGE/U-100/0.5ML/29G X ULTRA-COMFORT INSULIN UNILET EXCELITE II 58 1/2" 93 SYRINGE/U-100/1ML/31G X UNILET G.P. LANCET 58 VALUE HEALTH INSULIN 5/16" 93 UNILET G.P. SUPERLITE SYRINGE/U-100/1ML/29G X ULTRA-THIN II INSULIN LANCET 58 1/2" 93 SYRINGE SHORT/U- UNILET GP 28 ULTRA VALUE PLUS LANCETS 100/0.3ML/30GX5/16" 93 THIN 58 STANDARD 21G 58 VALUE PLUS LANCETS ULTRA-THIN II INSULIN UNILET LANCET 58 SYRINGE SHORT/U- SUPERTHIN 30G 58 100/0.3ML/31GX5/16" 93 UNILET LANCETS MICRO- VALUE PLUS LANCETS THIN ULTRA-THIN II INSULIN THIN33G 58 26G 58 SYRINGE SHORT/U- UNILET LANCETS SUPER- VALUE PLUS LANCING 100/0.5ML/30GX5/16" 93 THIN30G 58 DEVICE 58 ULTRA-THIN II INSULIN UNILET LANCETS ULTRA- VALUMARK LANCET SUPER THIN 28G 58 THIN 30G 58 SYRINGE SHORT/U- UNILET SUPERLITE 100/0.5ML/31GX5/16" 93 VALUMARK LANCET ULTRA ULTRA-THIN II INSULIN LANCET 58 THIN 28G 58 SYRINGE SHORT/U- UNISOM SLEEPTABS 47 VALVED HOLDING 100/1ML/30GX5/16" 93 UNISPEND ANHYDROUS CHAMBER 98 ULTRA-THIN II INSULIN SWEETENED 166 VANCOCIN 9 SYRINGE SHORT/U- UNISPEND ANHYDROUS VANCOCIN HCL 9 100/1ML/31GX5/16" 93 UNSWEETENED 166 ULTRA-THIN II INSULIN UNIVERSAL 1 LANCETS VANCOMYCIN 9 SYRINGE/U- THIN26G 58 vancomycin hcl 9 100/0.5ML/29GX1/2" 93 UNIVERSAL 1 LANCETS VANCOMYCIN HCL 9 ULTRA THIN 30G 58 ULTRA-THIN II INSULIN vancomycin hcl 9 SYRINGE/U-100/1ML/29GX1/2" UNIVERSAL 1 LANCETS/33G/MICRO-THIN VANCOMYCIN 93 HYDROCHLORIDE/DEXTROSE ULTRACARE INSULIN 58 UPCAL D 100 9 SYRINGE/U-100/0.3ML/30G X VANCOMYCIN 5/16" 93 URECHOLINE 172 HYDROCHLORIDE/SODIUM URO MAG 8 CHLORIDE 9
Index 42 VANILLA BUTTERNUT VANISHPOINT VIMPAT 15 FLAVOR 159 SYRINGE/3ML/25G X 1- VINATE ONE 150 VANILLA FLAVOR 159 1/2" 94 VIRACEPT 30 VANISHPOINT INSULIN VANISHPOINT SYRINGE/0.5ML/30G X 1/2" 93 SYRINGE/3ML/25G X 5/8" 94 VIRAMUNE 30 VANISHPOINT INSULIN VAQTA 175 VIRAMUNE XR 30 SYRINGE/0.5ML/30G X VARIVAX 175 VIREAD 30 5/16" 93 VASERETIC 24 VANISHPOINT INSULIN VISINE DRY EYE 154 SYRINGE/1ML/29G X 1/2" 93 VASOTEC 23 VISINE DRY EYE RELIEF 154 VANISHPOINT INSULIN VCF VAGINAL VISINE DRY EYE RELIEF SYRINGE/1ML/29G X 5/16" 93 CONTRACEPTIVE FILM 175 ALLDAY COMFORT 154 VANISHPOINT INSULIN VCF VAGINAL VISTA ADVANCED AREDS2 SYRINGE/1ML/30G X 5/16" 93 CONTRACEPTIVE FORMULA 143 VANISHPOINT SAFETY FOAM 175 VISTA ADVANCED DRY EYE SYRINGE/3ML/20GX1" 93 VCF VAGINAL FORMULA 143 VANISHPOINT SAFETY CONTRACEPTIVEGEL 175 VISTARIL 10 SYRINGE/3ML/20GX1-1/2" 93 VECTICAL 38 VITABEX 143 VANISHPOINT SAFETY VENEXA 143 SYRINGE/3ML/21GX1" 93 VITABEX PLUS 144 VANISHPOINT SAFETY VENEXA FE 143 VITALINE BIOTIN FORTE 105 SYRINGE/3ML/21GX1-1/2" 93 venlafaxine hcl 17 VITALINE BIOTIN VANISHPOINT SAFETY VENTOLIN HFA 12 FORTE/ZINC 105 SYRINGE/3ML/22GX1" 94 VENTRIXYL FE 143 VITALINE TOTAL FORMULA VANISHPOINT SAFETY 2 144 SYRINGE/3ML/22GX1-1/2" 94 verapamil hcl 32 VITALINE TOTAL FORMULA VANISHPOINT SAFETY VERELAN 32 3 144 SYRINGE/3ML/23GX1" 94 VERELAN PM 32 vitamin a 177 VANISHPOINT SAFETY SYRINGE/3ML/23GX1-1/2" 94 VERSACLOZ 27 VITAMIN B-12 46 VANISHPOINT SAFETY VERSAFREE 166 VITAMIN B-6 TR 177 SYRINGE/3ML/25GX1" 94 VERSAPLUS 166 VITAMIN C 177 VANISHPOINT SAFETY VITAMIN D3 177 SYRINGE/3ML/25GX1-1/2" 94 VFEND 20 VANISHPOINT SAFETY VIBRAMYCIN 169 VITAMIN D3 COMPLETE 144 SYRINGE/3ML/25GX5/8" 94 VICKS DAYQUIL MUCUS vitamin e 177 VANISHPOINT SAFETY CONTROL DM 36 VITAMIN/IRON MASKING SYRINGE/3ML/27GX1-1/2" 94 VICKS SINEX 12 HOUR AGENT FLAVOR 159 VANISHPOINT DECONGESTANT 152 vitamins w/ lipotropics 150 SYRINGE/1ML/25G X 1" 94 VICKS SINEX VANISHPOINT MOISTURIZING 152 VITAROCA PLUS 144 SYRINGE/3ML/20G X 1" 94 VICKS SINEX SEVERE 152 VITASANA 144 VANISHPOINT VICKS SINEX SEVERE VITATRUM 144 SYRINGE/3ML/20G X 1-1/2" 94 NASALDECONGESTANT 15 VANISHPOINT VITEYES CLASSIC 144 2 VITEYES CLASSIC SYRINGE/3ML/21G X 1" 94 VICTOZA 18 VANISHPOINT ADVANCED 144 SYRINGE/3ML/21G X 1-1/2" 94 VIDA MIA AUTOLET VITEYES CLASSIC MACULAR VANISHPOINT LANCINGDEVICE 58 SUPPORT 144 SYRINGE/3ML/22G X 1" 94 VIDA MIA UNILET LANCETS VITEYES CLASSIC VANISHPOINT SUPER THIN 30G 58 MULTIIVITAMIN 144 SYRINGE/3ML/22G X 1-1/2" 94 VIDA MIA UNILET LANCETS VITEYES CLASSIC VANISHPOINT ULTRA THIN 28G 58 MULTIVITAMIN 144 SYRINGE/3ML/23G X 1" 94 VIDEX EC 30 VITEYES CLASSIC+OMEGA- VANISHPOINT VIDEXPEDIATRIC 30 3 144 VITEYES CLASSIC/OMEGA- SYRINGE/3ML/23G X 1-1/2" 94 VIGAMOX 155 VANISHPOINT 3 144 SYRINGE/3ML/25G X 1" 94 VIIBRYD 17 VITEYES OPTIC NERVE VIIBRYD STARTER PACK 17 SUPPORT 144
Index 43 VITRANOL 144 water for irrigation, sterile 102 XOPENEX 12 VITRANOL FE 144 WATERMELON FLAVOR159 XOPENEX CONCENTRATE 12 VITREXATE 144 WEBCOL ALCOHOL PREP XOPENEX HFA 12 VITREXATE FE 144 LARGE 1 PLY 60 XYNTHA 46 WEBCOL ALCOHOL PREP VITREXYL 144 LARGE 2 PLY 60 XYNTHA SOLOFUSE 46 VITREXYL/IRON 144 WEBCOL ALCOHOL PREP XYREM 167 VITRUM 50+ ADULT-MULTI MEDIUM 2 PLY 60 YALE NEEDLES 21G X 1- IRON FREE 144 WEGMANS COMPLETE 1/4" 94 VITRUM 50+ SENIOR PRENATAL+DHA 150 YASMIN 28 34 MULTI 144 WELLBUTRIN SR 16 YAZ 34 VIVAGUARD LANCING WELLBUTRIN XL 16 DEVICE 58 YELETS TEENAGE WEST-VITE W/FOLIC FORMULA 144 VIVITROL 20 ACID 105 YOUR LIFE MULTI ADULT VOGELXO 7 WESTHROID 170 GUMMIES 144 VOGELXO PUMP 7 white petrolatum-mineral YOUR LIFE MULTI VOL-NATE 150 oil 154 PRENATAL 150 WHOLE FOOD YOUR LIFE TEEN VOL-PLUS 150 MULTIVITAMIN 144 MULTIVITAMIN GUMMIES 144 VOL-TAB RX 150 WIDE-SEAL SILICONE zafirlukast 11 voriconazole 20 DIAPHRAGM KIT 60 51 zaleplon 48 WIDE-SEAL SILICONE VORTEX HOLDING ZANAFLEX 151 CHAMBER/MASK/CHILDS 98 DIAPHRAGM KIT 65 51 VORTEX HOLDING WIDE-SEAL SILICONE ZANTAC 171 CHAMBER/MASK/CHILDS/FRO DIAPHRAGM KIT 70 51 ZARONTIN 15 G 98 WIDE-SEAL SILICONE ZARXIO 46 DIAPHRAGM KIT 75 51 VORTEX HOLDING ZESTORETIC 24 CHAMBER/MASK/TODDLER WIDE-SEAL SILICONE 98 DIAPHRAGM KIT 80 51 ZESTRIL 23 VORTEX HOLDING WIDE-SEAL SILICONE ZETIA 22 CHAMBER/MASK/TODDLER/LA DIAPHRAGM KIT 85 51 ZEVRX INSULIN DY BUG 98 WIDE-SEAL SILICONE SYRINGE/0.5ML/30G X 1/2" 94 VORTEX VALVED HOLDING DIAPHRAGM KIT 90 51 ZEVRX INSULIN CHAMBER 98 WIDE-SEAL SILICONE SYRINGE/0.5ML/30G X 51 VP INSULIN SYRINGE/U- DIAPHRAGM KIT 95 5/16" 94 100/0.3ML/29G X 1/2" 94 WILATE 46 ZEVRX INSULIN VRAYLAR 26 WILD CHERRY FLAVOR 159 SYRINGE/1ML/30G X 1/2" 94 VUSION 38 WOMENS 50+ MULTI ZEVRX INSULIN VITAMIN& MINERAL SYRINGE/1ML/30G X 5/16" 94 VYNDAMAX 33 FORMULA 144 ZIAC 24 VYNDAQEL 33 WOMENS BIOMULTIPLE144 ZIAGEN 30 VYTORIN 22 WOMENS MULTI zidovudine 30 VYVANSE 1 GUMMIES 144 ZINGO 50 WAL-BORN VITAMIN C 144 WOMENS MULTI VITAMIN & 144 ziprasidone hcl 26 WALGREENS COMFORT MINERAL FORMULA WOMENS MULTIVITAMIN + ziprasidone mesylate 26 ASSUREDLANCETS MICRO COLLAGEN GUMMIES 144 THIN/33G 58 ZITHROMAX 50 WP THYROID 170 WALGREENS COMFORT ZITHROMAX TRI-PAK 50 XALATAN 156 ASSUREDLANCETS SUPER ZITHROMAX Z-PAK 50 THIN/28G 58 XANAX 11 ZOCOR 22 WALGREENS GLUCOSE 18 XANAX XR 11 ZOFRAN 20 WALGREENS THIN XANTHAN GUM 166 LANCETS 58 ZOLOFT 16 XELJANZ 3 warfarin sodium 12 zolpidem tartrate 48 XELJANZ XR 3 WATCHHALER 98 ZOMACTON 43 XIMINO 169
Index 44 ZONALON 38 ZONEGRAN 15 zonisamide 15 ZOSTAVAX 175 ZOVIRAX 30 ZUBSOLV 7 ZULRESSO 16 ZYCLARA 40 ZYCLARA PUMP 40 ZYLOPRIM 45 ZYPREXA 27 ZYPREXA RELPREVV 27 ZYPREXA ZYDIS 27 ZYRTEC ALLERGY 21 ZYRTEC CHILDRENS ALLERGY 21 ZYVANA 144 ZYVOX 9
Index 45