CalViva Health Medi-Cal Preferred Drug List
The CalViva Health Medi-Cal Preferred Drug List (PDL) includes drugs covered by CalViva Health. The drug list is updated each month and may change. To get the most up-to-date information or a printed copy, call Member Services at 1-888-893-1569 (TTY: 711).
The latest drug list can be viewed on our website at https://www.calvivahealth.org/members-info/. It is also available on our web site in a machine readable format. Go to “Formulary List” Use the “Formulary List” link to view the list of drugs covered by CalViva Health Medi- Cal.
PLEASE THROW AWAY ALL PREVIOUS VERSIONS OF THE DRUG LIST
CV_Drug List Front Matter_ENGLISH_2.5.20 Table of Contents
What is the CalViva Health Medi-Cal PDL?...... iii
How do I use the CalViva Health Medi-Cal PDL?...... iii
How do I find a drug in the Drug List?...... iii
How are the drugs listed in the categorical list?...... iv
What if my drug is not on the CalViva Health Medi-Cal PDL?...... iv
Can I go to any pharmacy?...... v
Are there any limits on my drug coverage?...... v
Are there limits on opioid pain drugs?...... v
What is Morphine Milligram Equivalent (MME) Dosing?...... v
How can I get an exception to the rules for the drug coverage?...... vi
What if I’m a new member?...... vi
What are over-the-counter drugs?...... vi
Are brand name drugs covered?...... vi
What is a generic drug?...... vi
Will the pharmacist give me a generic drug if one is available?...... vi
Are there any excluded or carve-out drugs?...... vi
What is California Children’s Services?...... vii
What about drugs I get from my doctor or in my doctor’s office?...... vii
Definitions…………………..……………………………………………………………..vii
Categorical list of prescription drugs……………………………………………………..1
Alphabetical index of prescription drugs………………………………………….Index 1
ii Welcome to CalViva Health
What is the CalViva Health Medi-Cal PDL? The drug list includes drugs used to treat common diseases or health problems. A team of doctors and pharmacists meet regularly to decide which drugs should be on the drug list. The team reviews current and new drugs and choose drugs that work best and are safe. This drug list is updated each month. These changes may include the form a drug comes in (i.e. tablet or capsule) or if a drug has a limit on the amount that can be filled at one time. Changes may also include if a drug requires prior authorization, step therapy, or if a drug is no longer covered on the drug list.
How do I use the CalViva Health Medi-Cal PDL? Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the drug list. Brand name and generic drugs are listed in the index. Next to your drug, you will see the page number where you can find your drug.
The table below has descriptions of the limits that may appear on the drug list:
Abbreviation Term What it means AL Age Limit Some drugs are only covered for certain ages. These drugs are carved out by the Department of Health Care Services. This means these drugs are covered by the CO Carve Out Medi-Cal Fee-for-Service program and can be billed to the State by the pharmacy. F Formulary These drugs are covered on the Drug List. These drugs are not covered on the Drug List. If your NF Non-Formulary doctor feels you need a drug that is not covered, he or she can ask us to make an exception. Your doctor must ask for approval from CalViva Health PA Prior Authorization before some drugs will be covered. QL Quantity Limit Some drugs are only covered for a certain amount. These drugs are made in both prescription form and Over- RX/OTC Prescription and OTC the-counter (OTC) form. In some cases, you must first try certain drugs before CalViva Health covers another drug for your health condition. ST Step Therapy For example, if Drug A and Drug B both treat your health condition, CalViva Health may not cover Drug B unless you try Drug A first. These drugs are specialty drugs. You can only get these Specialty Pharmacy SP drugs from a specialty pharmacy. All prescriptions must Program be filled by the listed specialty pharmacy.
How do I find a drug in the Drug List? You can search for a drug by using the search tool. Drugs can be found in alphabetical order or by medical condition. There are three ways to find out if your drug is covered.
iii Search Tool: Open the List of Drugs (PDF). Hold down the “Control” (Ctrl) and “F” keys. When the search box appears, type the name of your drug. Press the “Enter” key.
Alphabetical Index: The index at the end of the PDF lists the names of generic and brand name drugs from A to Z. Once you find a drug name, go to the page number listed to see if the drug is covered.
Therapeutic Category: The drugs are grouped into categories. The categories may also be grouped by the class to which the drug is in. If you know what category your drug is in, look on the list to find the category. You can then look for your drug in that category.
A drug will not be on the list if a generic equivalent for a brand name drug is not offered. A drug may not be found if it is not covered. Even though a drug is on the drug list, it does not mean that your doctor will prescribe the drug for your medical condition.
How are the drugs listed in the categorical list? A drug is listed alphabetically by its brand and generic names in its category and class.
The generic drug name for a brand drug is included after the brand name in parentheses in bold lowercase and italicized letters.
Brand Drug Example: EPOGEN (epoetin alfa)
If a generic equivalent for a brand name drug is on the list and covered, the generic drug will be on the list apart from the brand name drug. It will be in bold lowercase and italicized letters.
Generic Drug Example: esomeprazole magnesium cap delayed release
If a generic drug is marketed under a trademark protected brand name, the brand name will be on the list in all CAPITAL letters. It will appear after the generic name in parentheses. It will be in regular typeface with first letter of each word capitalized.
Generic Drug Marketed Under A Brand Name Example: (Levothyroxine Sodium) LEVOXYL
What if my drug is not on the CalViva Health Medi-Cal PDL? If your drug is not on the drug list, call Member Services at 1-888-893-1569 and ask if your drug is covered. If your drug is not on the list, you can ask your doctor if there is a drug on the list that will work the same way. If your doctor wants you to have a drug that is not on the list, your doctor can ask us to make an exception. See the section, “How can I get an exception to the rules for the drug coverage?” for more information.
iv Can I go to any pharmacy? Members must use a pharmacy in the retail network. These pharmacies have a contract with CalViva Health. To find a pharmacy, call Member Services at 1-888-893-1569.
Some drugs are only covered when they come from a specialty pharmacy. Specialty drugs are used to treat ongoing or complex conditions. They also may need special handling or training to ensure safe use. The specialty pharmacy will mail drugs to your home, to your work, or to another address you choose. Specialty drugs may also be sent to your doctor’s office. Specialty drugs are listed in the Requirements/Limits column on the drug list. Drugs that do not have a specialty pharmacy listed in the Requirements/Limits column on the drug list can be filled at any pharmacy in the network.
You can ask for an exception to have a specialty drug filled at a retail network pharmacy if: How you take your drug has changed and you need to fill the drug right now. Your drug is going to arrive late or always arrives late. You have an urgent need for a drug and did not understand how to get the drug from the specialty pharmacy. You have an emergency and cannot wait for the drug to come from the specialty pharmacy.
If you cannot use a specialty pharmacy, you can ask for an exception to get all your drugs filled at a retail network pharmacy if: You do not have a mailing address or a way to get your drugs by mail. Your doctor’s office gives the drugs to you. Using a specialty pharmacy is a hardship for you.
If you need an exception, you must ask us. Your doctor or your pharmacy may also ask for an exception. To ask us for an exception, please call CalViva Health Member Services at 1-888-893- 1569 (TTY: 711). We are here 24 hours a day, seven days a week.
Are there any limits on my drug coverage? Some drugs have limits on coverage. These limits are noted in the Requirements/Limits column on the drug list.
Are there limits on opioid pain drugs? Prior Authorization is not required for short term use of most opioid pain drugs. You can get a 7 day supply of these drugs when your doctor orders them for you the first time. There are quantity limits on all opioid pain drugs based on Morphine Milligram Equivalents (MME). You may need prior authorization if you need more than a 7 day supply. This limit does not apply if you are being treated for cancer or sickle cell.
What is Morphine Milligram Equivalent (MME) Dosing? MME dosing is a tool used to make sure you take a safe dose of opioid pain drugs. This tool helps measure the amount of opioid pain drugs you take each day. The recommended limit for most opioid pain drugs is 90 MME per day. The quantity limits on the drug list are less than or the same as 90 MME per day. Your doctor may ask for prior authorization if the dose you need is more than 90 MME per day. This limit does not apply if you are being treated for cancer or sickle cell.
How can I get an exception to the rules for the drug coverage?
v Your doctor can ask for an exception to our rules for drug coverage. Your doctor can ask us to cover a drug if it is not on the drug list. Your doctor can ask us to make an exception to limits on a drug. For example, if a drug has a limit of 1 tablet per day, your doctor can ask us to cover more. To ask for an exception, your doctor can fax a prior authorization request to us at1-800-977-8226. After we receive the request, we will make a decision and notify your doctor within 24 hours. If we deny the request, we will send you and your doctor a letter and tell you how to file an appeal. If we do not respond to a request within 24 hours, the request will be approved. If we approve a drug for you, you can continue to get the drug from CalViva Health as long as the drug works for you and your doctor wants you to stay on the drug.
What if I’m a new member? If you are a new member in our plan, you may be taking drugs that are not on our drug list. You may also be taking a drug that is on our drug list, but the drug now has limits. You should talk to your doctor to see if you can change to a drug on the list. Your doctor may ask us for an exception to cover a drug you have been taking. See the section, “How can I get an exception to the rules for the drug coverage?” for more information.
What are over-the-counter drugs? Over-the-counter (OTC) drugs are drugs you can buy without a prescription. The CalViva Health Medi-Cal PDL covers OTC drugs just like those found on the State Medi-Cal List of Contract Drugs. If you want CalViva Health to cover an OTC drug on the drug list, your doctor must write a prescription for that drug.
Are brand name drugs covered? Your pharmacy benefit does not cover brand name drugs when a generic drug is available. A brand name drug may be covered if a generic drug is not available. Your doctor may also ask us to cover a brand name drug if he/she thinks it will work the best for you.
What is a generic drug? A generic drug has the same active ingredient and works the same way as the brand name drug. Generic drugs are safe and effective.
Will the pharmacist give me a generic drug if one is available? Yes. A pharmacy may give you a generic drug unless your doctor says that you must have the brand name drug.
Are there any excluded or carve-out drugs? Excluded drugs The CalViva Health Medi-Cal PDL is similar to the State Medi-Cal List of Contract Drugs. The following types of drugs are not a covered benefit and not on the PDL: Multivitamins Erectile or sexual dysfunction drugs Drugs used for cosmetic reasons or hair growth Drugs that are considered experimental Drugs used to treat infertility
vi OTC cough and cold drugs OTC adult acetaminophen
Drug Efficacy Study and Implementation Drugs (DESI) DESI products and other related drugs are not covered by CalViva Health Medi-Cal. The Food and Drug Administration has defined them as less than effective. There is a lack of proof these drugs are safe and effective.
Carve-out drugs Some drugs are carved out by the Department of Health Care Services. This means that these drugs are covered by the Medi-Cal Fee-for-Service program. The following types of drugs are carved out: Select psychiatric drugs Select HIV AIDS treatment drugs Select alcohol, heroin detoxification, and dependency treatment drugs Select drugs to treat hemophilia
What is California Children’s Services? California Children’s Services (CCS) is a state program for children (up to 21 years old) with certain health problems. Some drugs for CCS covered health problems are not covered by CalViva Health.
Only doctors approved by CCS can order drugs used to treat CCS covered health problems. These drugs are not covered by CalViva Health. The Pharmacy must bill CCS for these drugs. If you are at the pharmacy and you are not in the CCS system, call Member Services at 1-888-893-1569. Member Services can help you enroll with CCS. They may also help you get an emergency supply of your drug.
What about drugs I get from my doctor or in my doctor’s office? Some drugs that are given to you by your doctor may be covered under your medical benefit. You may be able to get these drugs from a retail pharmacy. Your doctor may also give them to you in the office. We will work with your doctor to find the best way for you to get these drugs. If you have questions about these drugs, please call Member Services at 1-888-893-1569.
Definitions
Brand Name Drug: Is a drug that is marketed under a proprietary, trademark-protected name. A brand drug is listed in this formulary in all CAPITAL letters.
Exception Request: Is a request for coverage of a prescription drug. If an enrollee, his or her designee, or prescribing health care provider submits an exception request for coverage of a prescription drug, the health plan must cover the prescription drug when the drug is determined to be medically necessary to treat the enrollee’s condition
Formulary: Is also referred to as the Preferred Drug List, is the complete list of prescription drugs preferred for use and eligible for coverage under a health plan, and includes all drugs covered under the outpatient prescription drug benefit of the health plan.
vii Generic Drug: Is a drug that is the same as its brand name drug equivalent in dosage, safety, strength, how it is taken, quality, effect and intended use. A generic drug is listed in the drug list in bold and italicized lowercase letters.
Medically Necessary: Is health care benefits needed to diagnose, treat, or prevent a medical condition or its symptoms and that meet accepted standards of medicine. Plans usually do not cover health care benefits that are not medically necessary.
Member: Is a person enrolled in a health plan who is entitled to receive services from the plan.
Non-Formulary Drug: Is a prescription drug that is not listed on the Preferred Drug List.
Preferred Drug List: Is also referred to as the Formulary, is the complete list of prescription drugs preferred for use and eligible for coverage under a health plan, and includes all drugs covered under the outpatient prescription drug benefit of the health plan.
Prescribing Provider: Is a health care provider authorized to write a prescription to treat a medical condition for a health plan member.
Prescription: Is an oral, written, or electronic order by a prescribing provider for a specific member that contains the name of the prescription drug, the quantity of the prescribed drug, the date of issue, the name and contact information of the prescribing provider, the signature of the prescribing provider if the prescription is in writing, and if requested by the member, the medical condition or purpose for which the drug is being prescribed.
Prescription Drug: Is a drug that is prescribed by the enrollee’s prescribing provider and requires a prescription under applicable law.
Prior Authorization: Is a health plan’s requirement that the member or the member's prescribing provider obtain the health plan’s authorization for a prescription drug before the health plan will cover the drug. The health plan shall grant a prior authorization when it is medically necessary for the member to obtain the drug.
Quantity Limit: Is a restriction on the number of doses or any other limitations on the quantity of a prescription drug a health plan will cover during a specific time period.
Specialty Drugs: Specialty Drugs include drugs that are made using biotechnology, drugs that must be distributed through a specialty pharmacy, drugs that require special training for self- administration, or drugs that require regular monitoring of care by a pharmacy.
Step Therapy: Is a process specifying the sequence in which different prescription drugs for a given medical condition and medically appropriate for a particular patient are prescribed. The health plan may require the member to try one or more drugs to treat the member's medical condition before the health plan will cover a particular drug for the condition pursuant to a step therapy request. If the member's prescribing provider submits a request for step therapy exception, the health plans shall make exceptions to step therapy when the criteria is met.
viii For more information about your pharmacy benefits, please review your Member Handbook or call Member Services at 1-888-893-1569.
ix CalViva Health Medi-Cal Daim Ntawm Npe Tshuaj Muaj Yees Uas Nyiam Siv
CalViva Health Medi-Cal Preferred Drug List (Daim Ntawm Npe Tshuaj Muaj Yees Uas Nyiam Siv, PDL) muaj xam nrog rau tshuaj muaj yees uas tau txais kev pab them nqi duav (roos) los ntawm CalViva Health. Daim ntawv npe tshuaj muaj yees yuav raug kho txhua hli thiab tej zaum yuav hloov pauv. Txhawm rau kom tau txais cov lus qhia paub los sis daim ntawm luam tawm uas kho tshiab tshaj plaws, hu rau Cov Kev Pab Cuam Rau Tswv Cuab ntawm 1-888-893-1569 (TTY: 711).
Muaj peev xwm mus saib tau daim ntawv npe tshuaj muaj yees tshiab tshaj plaws nyob rau ntawm peb qhov website (lub vas sab) ntawm https://www.calvivahealth.org/members-info/. Tsis tas li ntawd, nws kuj tseem muaj ua hom ntawv uas nyeem tau hauv lub tshuab nyob rau hauv peb qhov web site (lub vas sab) tib si. Mus rau ntawm “Daim Ntawv Npe Tus Qauv Tshuaj” Siv qhov link (chaw txuas) “Daim Ntawv Npe Tus Qauv Tshuaj” lso mus saib daim ntawv npe cov tshuaj muaj yees uas tau txais kev pab them nqi duav (roos) los ntawm CalViva Health Medi-Cal.
THOV MUAB COV DAIM NTAWV NPE TSHUAJ MUAJ YEES DHAU LOS POV TSEG KOM TAG NRHO
CV_Sab Xub Ntiag Ntawm Daim Ntawv Npe Tshuaj_HMONG_2.5.20 Kev Teeb Tsim Cov Ntsiab Lus CalViva Health Medi-Cal PDL yog dab tsi? ...... iii Kuv yuav siv CalViva Health Medi-Cal PDL li cas? ...... iii Kuv yuav tshawb nrhiav ib yam tshuaj muaj yees rau hauv Daim Ntawv Npe Tshuaj Muaj Yees tau li cas? ...... iv Cov tshuaj muaj yees uas muaj npe tso rau hauv hom tshuaj no yog zoo li cas? ...... v Yog kuv yam tshuaj muaj yees tsis muaj nyob rau hauv CalViva Health Medi-Cal PDL yuav zoo li cas? ...... v Kuv puas tuaj yeem mus rau ntawm ib lub khw muag tshuaj? ...... vi Puas muaj ciam txwv rau ntawm kuv cov tshuaj muaj yees uas raug pab them nqi duav roos?...... vi Puas muaj ciam txwv rau cov tshuaj muaj yees uas muaj kuab yeeb xyaws? ...... vii Kev Siv Morphine Milligram Equivalent (MME) Yog Li Cas? ...... vii Kuv tuaj yeem tau txais kev zam rau ntawm cov cai kav rau hom tshuaj muaj yees uas raug pab them nqi duav roos no tau li cas?...... vii Yog kuv yog ib tug tswv cuab tshiab yuav zoo li cas? ...... vii Cov tshuaj muaj yees uas yuav sab nrauv los yog tshuaj dab tsi? ...... viii Cov tshuaj muaj npe lag luam puas raug pab them nqi duav roos? ...... viii Ib yam tshuaj muaj yees uas nquag siv yog dab tsi? ...... viii Tus kws muag tshuaj puas muab ib yam tshuaj muaj yees uas nquag siv rau kuv yog tias muaj? ...... viii Puas muaj kev cais los sis pab them cov nqi tshuaj muaj yees? ...... viii California Children’s Services yog dab tsi? ...... ix Kuv puas tau txais cov tshuaj muaj yees los ntawm kuv tus kws kho mob los sis rau hauv kub tus kws kho mob lub tsev hauj lwm?...... ix Cov ntsiab lus ...... ix
Daim ntawv npe hom cov tshuaj sau hauv daim ntawv yuav tshuaj ...... 1
Nplooj ntawv teeb txheeb txog cov ntaub ntawv raws tus tsiaj ntawv ntawm cov tshuaj sau hauv daim ntawv yuav tshuaj ...... Nplooj ntawv teeb txheeb txog cov ntaub ntawv 1
ii Zoo siab txais tos tuaj rau ntawm CalViva Health
CalViva Health Medi-Cal PDL yog dab tsi? Cov npe tshuaj muaj yees muaj cov tshuaj muaj yees raug siv los kho cov kab mob los sis tej teeb meem rau kev noj qab haus huv uas nquag tshwm sim. Ib pawg kws kho mob thiab cov kws muag tshuaj yuav nquag los sib tham thiab txiav txim siab txog hom cov tshuaj muaj yees uas yuav raug muab tso ntxiv rau ntawm cov npe tshuaj muaj yees. Pawg kws kho mob yuav tshuaj xyuas cov tshuaj muaj yees tshiab thiab cov siv tam sim no thiab xaiv cov tshuaj muaj yees uas siv tau zoo thiab nyab xeeb tshaj plaws. Daim ntawv npe tshuaj muaj yees raug kho txhua hli. Yam pauv hloov no yuav nrog ib yam tshuaj muaj yees uas ntim rau hauv (xws li cov tshuaj ntsiav los sis ntim hauv plhaub) los sis ib yam tshuaj muaj yees uas yuav raug siv me ntsis rau thaum ib zaug. Tej zaum kuj yuav muaj kev pauv hloov yog yuav tsum tau siv ib qho tshuaj muaj yees ua ntej tau kev tso cai, cov qib pib kev kho mob, los sis yog tsis pab them nqi duav roos rau ib qho tshuaj muaj yees nyob ntawm cov npe tshuaj muaj yees mus ntxiv lawm.
Kuv yuav siv CalViva Health Medi-Cal PDL li cas? Saib koj cov tshuaj muaj yees rau hauv daim ntawv teeb xeeb uas nyob tom qab kawg ntawm phau ntawv no. Daim ntawv teeb xeeb sau txhua cov npe tshuaj muaj yees nyob rau ntawm daim ntawv teev npe tshuaj muaj yees. Hom lub npe tshuaj thiab cov tshuaj muaj yees yeej raug sau tseg rau hauv daim ntawv teeb xeeb no lawm. Nyob puab ib sab ntawm koj cov tshuaj muaj yees, koj yuav pom tus nab npawb nplooj ntawv uas koj tuaj yeem nrhiav tau koj cov tshuaj muaj yees.
Daim ntawv hauv qab no piav qhia txog qhov txwv siv ntau tsawg rau ntawm cov npe tshuaj muaj yees:
Lo lus sau Ntsiab lus Nws txhais tau li cas luv Qee cov tshuaj muaj yees tsuas raug pab them nqi duav AL Lub Hnub Nyoog Txwv roos rau qee cov hnub nyoog xwb. Cov tshuaj muaj yees no raug pab them nqi los ntawm Lub Chaw Ua Hauj Lwm ntsig txog Cov Kev Pab Cuam Saib Xyuas Kev Noj Qab Haus Huv (Department of Health CO Kev Pab Them Nqi Care Services). Qhov no txhais tau tias cov tshuaj muaj yees no raug pab them nqi duav roos los ntawm Medi-Cal qhov muaj nqi-rau-kev pab cuam thiab tuaj yeem sau daim ntawv nqi mus rau lub khw muag tshuaj ntawm Lub Xeev. Cov tshuaj muaj yees no raug pab them nqi duav roos F Tus qauv tshuaj raws li Cov Npe Tshuaj Muaj Yees. Cov tshuaj muaj yees no tsis raug pab them nqi duav roos raws li Cov Npe Tshuaj Muaj Yees. Yog koj tus kws kho Tsis yog-Tus qauv NF mob xav tias yuav tsum siv ib yam tshuaj muaj yees uas tshuaj tsis raug pab them nqi duav roos rau koj, nws tuaj yeem thov kom peb zam. Koj tus kws kho mob yuav tsum thov kev pom zoo los PA Kev Tso Cai Ua Ntej ntawm CalViva Health ua ntej yuav pab them nqi duav roos rau qee cov tshuaj muaj yees.
iii Lo lus sau Ntsiab lus Nws txhais tau li cas luv Qee cov tshuaj muaj yees tsuas raug pab them nqi duav QL Ciam Txwv Qhov Ntau roos rau qee qhov ciam txwv xwb. Cov tshuaj muaj yees no raug tsim ua tau ob hom xws Daim ntawv sau yuav RX/OTC hom tshuaj muaj daim ntawv sau yuav tshuaj thiab hom tshuaj thiab OTC tshuaj yuav sab nrauv los (OTC). Hauv qee kis, koj yuav tsum xub sim qee cov tshuaj muaj yees ua ntej CalViva Health pab them nqi duav roos rau ib yam tshuaj muaj yees kho koj tus mob. Cov Qib Pib Kev Kho ST Piv txwv, yog tau siv ob co tshuaj xws li Cov Tshuaj Muaj Mob Yees A thiab Tshuaj Muaj Yees B kho koj tus mob, CalViva Health yuav tsis pab them nqi duav roos rau hom Tshuaj Muaj Yees B tshwj tsis yog koj xub sim siv hom Tshuaj Muaj Yees A lawm. Cov tshuaj muaj yees no yog cov tshuaj muaj yees tshwj xeeb. Koj tsuas tau cov tshuaj muaj yees no los ntawm ib Lub Khw Muag Tshuaj SP lub khw muag tshuaj xwb. Txhua yam tshuaj muaj daim Tshwj Xeeb ntawv sau yuav tshuaj yuav tsum raug sau ntawv yuav ntxiv los ntawm cov npe khw muag tshuaj tshwj xeeb.
Kuv yuav tshawb nrhiav ib yam tshuaj muaj yees rau hauv Daim Ntawv Npe Tshuaj Muaj Yees tau li cas? Koj tuaj yeem siv qhov twj tshawb nrhiav los tshawb nrhiav ib yam tshuaj muaj yees. Tuaj yeem tshawb nrhiav pom cov tshuaj muaj yees raws li cov niam ntawv los sis raws qhov txheej txheem kev kho mob. Nws muaj peb txoj hau kev tshawb nrhiav yog koj yam tshuaj muaj yees raug pab them nqi duav roos.
Qhov Twj Siv Tshawb Nrhiav: Qhib Daim Ntawv Npe ntawm Cov Tshuaj Muaj Yees (PDF). Nias tuav cov ntaus ntawv “Control” (Ctrl) thiab “F”. Thaum tshwm sim kem tshawb nrhiav, ntaus lub npe ntawm koj yam tshuaj muaj yees nkag rau. Nias qhov ntaus ntawv “Enter”.
Daim Ntawv Teeb Xeeb Cov Niam Ntawv Raws Txheej Txheem: Daim ntawv teeb xeeb uas tso rau tom qab kawg ntawm daim ntawv PDF no sau cov npe tshuaj muaj yees uas nquag siv thiab cov tshuaj muaj npe lag luam los ntawm A txog Z. Kiag thaum koj tshawb nrhiav pom ib yam tshuaj muaj yees lub npe lawm, mus rau ntawm tus nab npawb nplooj ntawv teev tseg ntawm mus saib seb puas yog tshuaj muaj yees uas raug pab them nqi duav roos.
Hom Tshuaj Kho Mob: Cov tshuaj muaj yees raug muab faib tso ua ke raws hom tshuaj. Cov tshuaj no kuj raug muab faib tso ua ke raws hom tshuaj muaj yees uas muaj nyob rau hauv. Yog koj paub hom tshuaj ntawm koj cov tshuaj muaj yees uas muaj nyob rau hauv lawm, saib ntwm daim ntawv npe tshuaj mus tshawb nrhiav hom tshuaj ntawd. Dhau ntawd ces koj tuaj yeem mus saib koj cov tshuaj muaj yees uas nyob rau hom tshuaj ntawd.
iv Yuav tsis muaj ib yam tshuaj muaj yees nyob rau hauv daim ntawv npe tshuaj yog muab ib yam tshuaj muaj yees uas nquag siv tam rau ib cov tshuaj muaj npe lag luam. Tej zaum yuav tshawb nrhiav tsis pom ib yam tshuaj muaj yees yog nws tsis raug pab them nqi duav roos. Txawm tias yam tshuaj muaj yees no yuav muaj nyob rau ntawm daim ntawv npe tshuaj los xij, tsis txhais tau tias koj tus kws kho mob yuav sau yuav hom tshuaj muaj yees no los siv kho koj qhov txheej txheem kev kho mob.
Cov tshuaj muaj yees uas muaj npe tso rau hauv hom tshuaj no yog zoo li cas? Ib yam tshuaj muaj yees raug sau npe raws cov niam ntawv ntawm nws hom tshuaj muaj npe thiab cov npe tshuaj nquag siv nyob hauv nws hom tshuaj thiab theem tshuaj.
Cov npe tshuaj nquag siv tam rau hom tshuaj muaj npe ntawm tshuaj muaj yees yeej muaj nrog ua ke rau tom qab hom tshuaj muaj npe raug sau rau hauv ob txoj kab thaiv ua cov niam ntawv tuab qis thiab cov niam ntawv vau.
Piv Txwm Ntawm Yam Tshuaj Muaj Yees Uas Muaj Npe: EPOGEN (epoetin alfa)
Yig siv ib hom tshuaj uas nquag siv tam rau ib hom tshuaj muaj yees uas muaj npe nyob rau ntawm cov npe tshuaj thiab raug pab them nqi duav roos, hom tshuaj uas nquag siv no yuav raug sau faib tawm mus ntawm cov tshuaj muaj npe lag luam. Nws yuav raug sau ua cov niam ntawv tuab qis thiab cov niam ntawv vau.
Piv Txwm Hom Tshuaj Muaj Yees Uas Nquag Siv: esomeprazole magnesium cap raug siv ntaug tus mob
Yog ib yam tshuaj muaj yees uas nquag siv muaj muag raws li ib lub cim ua lag luam uas raug pov thaiv raws li hom tshuaj muaj npe, hom tshuaj muaj npe no yuav tsum raug sau ua txhua cov niam ntawv LOJ. Nws yuav tshwm sim tom qab sau hom tshuaj uas nquag siv tso rau hauv ob txoj kab thaiv. Nws raug sau ua tus niam ntawv me nrog rau thawj tus niam ntawv loj.
Piv Txwv Ntawm Cov Tshuaj Muaj Yees Uas Nquag Siv Muaj Muag Raws Ib Yam Tshuaj Muaj Npe: (Levothyroxine Sodium) LEVOXYL
Yog kuv yam tshuaj muaj yees tsis muaj nyob rau hauv CalViva Health Medi-Cal PDL yuav zoo li cas? Yog koj cov tshuaj muaj yees tsis muaj nyob rau daim ntawv npe tshuaj no, hu rau Cov Kev Pab Cuam Rau Tswv Cuab rau ntawm 1-888-893-1569 thiab nug seb koj cov tshuaj muaj yees no puas yog yam raug pab them nqi duav roos. Yog koj cov tshuaj muaj yees tsis muaj nyob rau daim ntawv npe tshuaj no, koj tuaj yeem nug koj tus kws kho mob seb puas muaj ib yam tshuaj muaj yees nyob ntawm daim ntawv npe tshuaj no ntxim zoo ib yam nkaus li koj hom tshuaj. Yog koj tus kws kho
v mob xav siv ib yam tshuaj muaj yees uas tsis muaj nyob rau ntawm daim ntawv npe tshuaj no rau koj, koj tus kws kho mob tuaj yeem thov kom peb zam. Saib ntawm tshooj ntawv, “Kuv tuaj yeem tau txais kev zam rau ntawm cov cai kav rau hom tshuaj muaj yees uas raug pab them nqi duav roos no tau li cas?” yog xav paub ntau ntxiv.
Kuv puas tuaj yeem mus rau ntawm ib lub khw muag tshuaj? Cov tswv cuab yuav tsum siv ib lub khw muag tshuaj uas sib koom hauj lwm ua ke. Cov khw muag tshuaj no tau cog lus nrog CalViva Health. Xav nrhiav ib ib lub khw muag tshuaj, hu rau Cov Kev Pab Cuam Rau Tswv Cuab rau ntawm 1-888-893-1569.
Qee cov tshuaj muaj yees tsuas raug pab them nqi duav roos thaum tuaj ntawm ib lub khw muag tshuaj tshwj xeeb xwb. Cov tshuaj muaj yees tshwj xeeb uas raug siv los kho mob mus ntxiv los sis kho mob rau tej yam mob loj. Lawv yuav tsum tau ua tib zoo saib xyuas tshwj xeeb los sis muab kev cob qhia txog kev siv cov tshuaj no kom muaj kev nyab xeeb. Lub khw muag tshuaj tshwj xeeb yuav xa cov tshuaj muaj yees no mus tom koj lub tsev, mus rau tom lub chaw ua hauj lwm, los sis mus rau ntawm ib qhov chaw nyob uas koj xaiv. Cov tshuaj muaj yees tshwj xeeb no kuj raug xa mus rau tom koj tus kws kho mob lub chaw ua hauj lwm. Cov tshuaj muaj yees tshwj xeeb uas muaj npe nyob hauv kab ntawv cov cai Yuav Tsum Muaj/Ciam Txwv ntawm daim ntawv npe tshuaj muaj yees. Cov tshuaj muaj yees uas tsis muaj nyob rau hauv lub khw muag tshuaj tshwj xeeb nyob hauv kab ntawv cov cai Yuav Tsum Muaj/Ciam Txwv ntawm daim ntawv npe tshuaj muaj yees tuaj yeem tshawb nrhiav pom rau ntawm ib lub khw muag tshuaj hauv lub chaw koom hauj lwm ua ke.
Koj tuaj yeem thov kev zam rau kev yuav ib yam tshuaj tshwj xeeb rau ntawm ib lub khw muag tshuaj uas sib koom hauj lwm ua ke yog: Yuav ua li cas thaum hloov koj cov tshuaj muaj yees lawm thiab koj yuav tsum tau yuav ntxiv yam tshuaj muaj yees kiag tam sim no. Koj cov tshuaj muaj yees los txog lig los sis ib txwm los txog lig. Koj xav siv ib yam tshuaj muaj yees sai sai thiab koj tsis nkag siab tias yuav tau yam tshuaj muaj yees no los ntawm lub khw muag tshuaj tshwj xeeb li cas. Koj muaj ib qho mob xwm txheej ceev thiab tsis tuaj yeem tos cov tshuaj muaj yees los ntawm lub khw muag tshuaj tshwj xeeb.
Koj tsis tuaj yeem siv ib lub khw muag tshuaj tshwj xeeb, koj tuaj yeem thov kev zam thiaj tau txais koj txhua cov tshuaj muaj yees rau ntawm ib lub khw muag tshuaj uas sib koom hauj lwm ua ke yog: Koj tsis muaj chaw nyob xa ntawv los sis yog koj nyob deb lawv yuav xa koj cov tshuaj muaj yees tuaj rau koj. Koj tus kws kho mob lub tsev ua hauj lwm yuav muab cov tshuaj muaj yees rau koj. Kev siv ib lub khw muag tshuaj tshwj xeeb yog ib qho nyuaj rau koj.
Yog koj xav tau kev zam, koj yuav tsum thov peb: Koj tus kws kho mob los sis koj lub khw muag tshuaj kuj yuav thov kev zam rau koj. Xav thov kom peb muab kev zam, hu rau Cov Kev Pab Cuam Rau Tswv Cuab ntawm CalViva Health rau ntawm 1-888-893-1569 (TTY: 711). Peb tuaj ntawm no txhua 24 teev hauv ib hnub, xya hnub hauv ib as thiv.
Puas muaj ciam txwv rau ntawm kuv cov tshuaj muaj yees uas raug pab them nqi duav roos? Qee cov tshuaj muaj yees muaj ciam txwv txog kev pab them nqi duav roos. Cov ciam txwv no raug sau tseg rau hauv kab ntawv cov cai Yuav Tsum Muaj/Ciam Txwv ntawm daim ntawv npe tshuaj muaj yees.
vi Puas muaj ciam txwv rau cov tshuaj muaj yees uas muaj kuab yeeb xyaws? Tsis tas yuav tsum muab Kev Tso Cai Ua Ntej rau kev siv cov tshuaj muaj yees uas muaj kuab yeeb xyaws rau ib lub sij hawm luv. Koj tuaj yeem tau txais cov tshuaj muaj yees no rau hauv lub sij hawm 7 hnub thaum koj tus kws kho mob txib yuav thawj zaug rau koj. Muaj ciam txwv qhov ntau rau txhua cov tshuaj muaj yees uas muaj kuab yeeb xyaws raws li Morphine Milligram Equivalents (MME). Koj yuav tsum tau kev tso cai ua ntej yog koj xav siv cov tshuaj no ntev dua 7 hnub. Yuav tsis siv tus ciam txwv no yog tias koj tseem raug kho tus kab mob khees xaws los sis kab mob keeb ntshav sickle cell.
Kev Siv Morphine Milligram Equivalent (MME) Yog Li Cas? Kev siv MME yog ib qho cuab yeej raug siv los saib xyuas kom koj noj cov tshuaj muaj yees uas muaj kuab xyeeb xyaw ntawd tau nyab xeeb. Qhov cuab yeej no pab ntsuas cov tshuaj muaj yees uas muaj kuab yeeb xyaw uas koj noj txhua hnub. Tus ciam txwv qhia noj cov tshuaj muaj yees uas muaj kuab yeeb xyaw yog 90 MME rau hauv ib hnub. Tus ciam txwv qhov ntau rau daim ntawv npe tshuaj muaj yees yog tsawg dua los sis ntau ib yam li 90 MME rau hauv ib hnub. Koj tus kws kho mob yuav tau thov kev tso cai ua ntej yog koj xav noj cov tshuaj ntau dua 90 MME rau hauv ib hnub. Yuav tsis siv tus ciam txwv no yog tias koj tseem raug kho tus kab mob khees xaws los sis kab mob keeb ntshav sickle cell.
Kuv tuaj yeem tau txais kev zam rau ntawm cov cai kav rau hom tshuaj muaj yees uas raug pab them nqi duav roos no tau li cas? Koj tus kws kho mob tuaj yeem thov kev zam rau ntawm peb cov cai kav rau hom tshuaj muaj yees uas raug pab them nqi duav roos. Yog koj tus kws kho mob tuaj yeem thov kom peb pab them tus nqi duav roos rau ib yam tshuaj muaj yees uas tsis muaj nyob rau ntawm daim ntawv npe tshuaj muaj yees no. Yog koj tus kws kho mob tuaj yeem thov kom peb zam rau cov ciam txwv ntawm ib yam tshuaj muaj yees. Piv txwv, yog ib yam tshuaj muaj yees twg raug txwv pub noj 1 ntsiav rau hauv ib hnub, koj tus kws kho mob tuaj yeem thov kom peb pab them ntau ntxiv. Xav thov kev zam, koj tus kws kho mob tuaj yeem xa daim ntawv thov muab kev tso cai ua ntej mus rau peb rau ntawm 1-800-977-8226. Tom qab peb tau txais koj daim ntawv thov, peb yuav txiav txim siab thiab ceeb toom rau koj tus kws kho mob rau hauv lub sij hawm 24 teev. Yog peb tsis kam lees daim ntawv thov, peb yuav xa ib tsab ntawv tuaj qhia rau koj thiab koj tus kws kho mob txog qhov yuav thov hais kom rov qab txiav txim dua tau li cas. Yog peb tsis teb daim ntawv thov rau hauv lub sij hawm 24 teev, txhais tau tias tau pom zoo txais daim ntawv thov lawm. Yog peb pom zoo ib yam tshuaj muaj yees rau koj, koj tuaj yeem tau txais yam tshuaj muaj yees no los ntawm CalViva Health mus ntxiv raws li yam tshuaj muaj yees no tseem ntxim rau koj thiab koj tus kws kho mob xav kom koj siv yam tshuaj muaj yees no mus ntxiv.
Yog kuv yog ib tug tswv cuab tshiab yuav zoo li cas? Yog tias koj yog ib tug tswv cuab tshiab rau hauv peb daim phiaj xwm, tej zaum koj yuav siv cov tshuaj muaj yees uas tsis muaj nyob rau ntawm peb daim ntawv npe tshuaj muaj yees. Koj kuj tuaj yeem siv ib yam tshuaj muaj yees uas nyobb rau hauv peb daim ntawv npe tshuaj muaj yees tau, tab sis tam sim no muaj hom tshuaj muaj yees no tsawg lawm. Koj yuav tsum tham nrog koj tus kws kho mob seb koj puas tuaj yeem hloov ib yam tshuaj muaj yees nyob rau daim ntawv npe tshuaj no. Koj tus kws kho mob yuav thov kom peb zam rau ib yam tshuaj muaj yees uas raug pab them nqi duav roos uas koj tseem tab tom siv ntawd. Saib ntawm tshooj ntawv, “Kuv tuaj yeem tau txais kev
vii zam rau ntawm cov cai kav rau hom tshuaj muaj yees uas raug pab them nqi duav roos no tau li cas?” yog xav paub ntau ntxiv.
Cov tshuaj muaj yees uas yuav sab nrauv los yog tshuaj dab tsi? Cov tshuaj muaj yees uas yuav sab nrauv los (OTC) yog cov tshuaj muaj yees uas koj tuaj yeem yuav tau yam tsis tas muaj daim ntawv sau yuav tshuaj. CalViva Health Medi-Cal PDL pab them nqi duav roos rau cov tshuaj muaj yees OTC ib yam nkaus li cov tshuaj uas muaj nyob rau ntawm Lub Xeev Daim Ntawv Npe Tshuaj Muaj Yees ntawm Medi-Cal. Yog koj xav kom CalViva Health pab them cov nqi duav roos rau ib yam tshuaj muaj yees OTC uas muaj nyob rau ntawm daim ntawv npe tshuaj muaj yees, koj tus kws kho ob yuav tsum sau ib daim ntawv sau yuav tshuaj.
Cov tshuaj muaj npe lag luam puas raug pab them nqi duav roos? Cov nyiaj pab ntawm koj lub khw muag tshuaj tsis pab them nqi duav roos rau cov tshuaj muaj npe lag luam thaum muaj ib yam tshuaj muaj yees uas nquag siv lawm. Yog tsis muaj ib yam tshuaj muaj yees uas nquag siv lawm ces tej zaum yuav pab them nqi duav roos rau yam tshuaj muaj npe lag luam ntawd. Koj tus kws kho mob kuj yuav thov kom peb pab them nqi duav roos rau ib yam tshuaj muaj npe lag luam yog nws xav tias yuav ntxim zoo rau koj.
Ib yam tshuaj muaj yees uas nquag siv yog dab tsi? Ib yam tshuaj muaj yees uas nquag siv yeej muaj tib yam tshuaj siv tov uas ua hauj lwm tau zoo ib yam nkaus li cov tshuaj muaj npe lag luam. Cov tshuaj muaj yees uas nquag siv no yeej nyab xeeb thiab ntxim zoo.
Tus kws muag tshuaj puas muab ib yam tshuaj muaj yees uas nquag siv rau kuv yog tias muaj? Muab. Lub khw muag tshuaj yuav muab ib yam tshuaj muaj yees uas nquag siv rau koj, tshwj tsis yog koj tus kws kho mob hais tias yuav tsum siv cov tshuaj muaj npe lag luam rau koj xwb.
Puas muaj kev cais los sis pab them cov nqi tshuaj muaj yees? Cov tshuaj muaj yees uas raug cais CalViva Health Medi-Cal PDL yeej zoo ib yam nkaus li Lub Xeev Daim Ntawv Npe Tshuaj Muaj Yees ntawm Medi-Cal. Hom tshuaj muaj yees nram qab no tsis raug pab them nqi duav roos thiab tsis muaj nyob rau ntawm PDL: Ntau hom tshuaj muaj zog Erectile los sis cov tshuaj muaj yees uas pab txhawb kev sib deev kom muaj zog tuaj Cov tshuaj muaj yees uas raug siv kom zoo nkauj los sis cog plaub hau Cov tshuaj muaj yees uas raug siv sim kho mob Cov tshuaj muaj yees uas raug siv los tswj kom txhob muaj me nyuam taus Cov tshuaj muaj yees OTC zoo hnoos thiab khaub thuas Cov tshuaj OTC acetaminophen rau cov neeg loj
Cov Tshuaj Muaj Yees Uas Raug Siv Los Tshawb Nrhiav Qhov Ntxim Ntawm Yam Tshuaj (Drug Efficacy Study and Implementation Drugs, DESI) Cov tshuaj ntawm DESI thiab lwm cov tshuaj muaj yees uas tsis raug pab them nqi duav roos los ntawm CalViva Health Medi-Cal. Lub Chaw Tswj Khoom Noj thiab Tshuaj Muaj Yees tau hais kom tsim cov tshuaj no ntxim zoo tsawg dua. Tseem tsis tau muaj cov ntaub ntawv pov thawj qhia tau tias cov tshuaj muaj yees no muaj kev nyab xeeb thiab ntxim zoo.
viii Cov tshuaj muaj yees uas raug pab them nqi Qee cov tshuaj muaj yees raug pab them nqi los ntawm Lub Chaw Ua Hauj Lwm ntsig txog Cov Kev Pab Cuam Saib Xyuas Kev Noj Qab Haus Huv (Department of Health Care Services). Qhov no txhais tau tias cov tshuaj muaj yees no raug pab them nqi duav roos los ntawm Medi-Cal qhov muaj nqi-rau-kev pab cuam. Hom tshuaj muaj yees nram qab no raug pab them nqi: Xaiv cov tshuaj muaj yees zoo rau mob puas hlwb Xaiv cov tshuaj muaj yees kho HIV KAB MOB EJ (AIDS) Xaiv cov tshuaj cawv, tshuaj kho kev haus tshuaj heroin, thiab cov tshuaj muaj yees kho mob Xaiv cov tshuaj muaj yees kho kab mob los ntshav tsis paub tu
California Children’s Services yog dab tsi? California Children’s Services (CCS) yog ib qho kev pab txhawb hauv lub xeev rau cov me nyuam yaus (hnub nyoog txog 21 xyoos) uas muaj tej yam teeb meem rau kev noj qab haus huv. Qee cov tshuaj muaj yees siv rau CCS raug pab them nqi duav roos rau cov teeb meem kev noj qab haus huv uas tsis raug pab them nqi duav roos los ntawm CalViva Health.
Tsuas yog cov kws kho mob raug pom zoo los ntawm CCS xwb thiaj li tuaj yeem txib yuav cov tshuaj muaj yees uas raug siv kho CCS thiab raug pab them nqi duav roos rau tej teeb meem kev noj qab haus huv. Cov tshuaj muaj yees no tsis raug pab them nqi duav roos los ntawm CalViva Health. Lub Khw Muag Tshuaj yuav tsum sau daim ntawv nqi CCS rau cov tshuaj muaj yees no. Yog koj koom nrog lub khw muag tshuaj thiab koj tsis nyob rau hauv CCS, hu rau Cov Kev Pab Cuam Rau Tswv Cuab rau ntawm 1-888-893-1569. Cov Kev Pab Cuam Rau Tswv Cuab tuaj yeem pab koj tso npe nrog CCS. Lawv kuj pab kom koj tau txais koj cov tshuaj muaj yees kho rau qhov mob xwm txheej ceev.
Kuv puas tau txais cov tshuaj muaj yees los ntawm kuv tus kws kho mob los sis rau hauv kub tus kws kho mob lub tsev hauj lwm? Qee cov tshuaj muaj yees uas raug muab rau koj los ntawm koj tus kws kho mob tej zaum raug pab them nqi duav roos raws li koj tus txiaj ntsig kho mob. Tej zaum koj tuaj yeem tau txais cov tshuaj muaj yees no los ntawm ib lub khw muag tshuaj. Koj tus kws kho mob kuj yuav muab cov tshuaj no rau koj thaum koj nyob hauv lub tsev kuaj mob. Peb yuav ua hauj lwm nrog koj tus kws kho mob los tshawb nrhiav txoj hau kev zoo tshaj plaws kom koj tau txais koj cov tshuaj muaj yees. Yog tias koj muaj lus nug txog cov tshuaj muaj yees no, thov hu rau Cov Kev Pab Cuam Rau Tswv Cuab rau ntawm 1-888-893-1569.
Cov ntsiab lus
Cov Tshuaj Muaj Npe Lag Luam: Yog ib yam tshuaj muaj yees uas muaj muag rau hauv ib lub chaw muag tshuaj ntiag tug, lub npe raug pov thaiv-raws li lub cim lag luam. Ib yam tshuaj muaj npe lag luam muaj npe nyob rau hauv tus qauv tshuaj no hauv txhua cov niam ntawv LOJ.
Thov Kev Zam: Yog ib qho kev thov pab them nyiaj rau ib cov tshuaj sau hauv daim ntawv yuav tshuaj. Yog ib tug neeg tso npe, nws tus neeg ua hauj lwm tam, los sis tus kws muab kev saib xyuas mob nkeeg xa ib daim ntawv thov zam kom pab them nyiaj rau ib cov tshuaj sau hauv daim ntawv yuav tshuaj, daim phiaj xwm kev kho mob yuav tsum pab them nyiaj rau cov tshuaj sau hauv daim ntawv yuav tshuaj thaum pom tias yuav tsum tau siv hom tshuaj muaj yees no kho mob rau tus neeg tso npe.
ix Tus qauv tshuaj: Yog hais txog Daim Ntawm Npe Tshuaj Muaj Yees Uas Nyiam Siv, yog ib daim ntawv npe ntawm cov tshuaj sau hauv daim ntawv yuav tshuaj uas nyiam siv thiab muaj cai raug pab them nyiaj raws li daim phiaj xwm kev kho mob, thiab suav txog txhua tshuaj muaj yees uas raug pab them nqi duav roos raws li kis tus neeg mob sab nrauv cov txiaj ntsig ntawm cov tshuaj sau hauv daim ntawv yuav tshuaj ntawm daim phiaj xwm kev kho mob.
Yam Tshuaj Nquag Siv: Yog ib yam tshuaj muaj yees uas siv tau zoo ib yam nkaus li hom tshuaj muaj npe lag luam, muaj kev nyab xeeb, muaj kuab tshuaj ntau, siv tshuaj li cas, ntxim zoo li cas, kev ntxim thiab kev nyiam siv. Ib yam tshuaj nquag siv yog muaj npe nyob rau daim ntawv npe tshuaj muaj yees uas raug sau ua cov niam ntawv tuab thiab cov niam ntawv vau.
Kev Tsim Nyog Kho Mob: Yog cov txiaj ntsig kev kho mob uas yuav tsum tau tshuaj xyuas tus mob, kho, los sis tiv thaiv tus mob los sis nws cov yeeb yam mob thiab yeej raug lees raws li cov qauv tshuaj kho mob lawm. Daim phiaj xwm ib txwm tsis pab them nyiaj rau cov txiaj ntsig kev kho mob uas tsis tsim nyog kho mob.
Tswv Cuab: Yog ib tug neeg tso npe rau hauv ib qho phiaj xwm kev kho mob uas muaj cai tau txais kev saib xyuas los ntawm daim phiaj xwm.
Tsis Yog-Tus Qauv Tshuaj Muaj Yees: Yog ib cov tshuaj sau hauv daim ntawv yuav tshuaj uas tsis muaj npe nyob rau Daim Ntawm Npe Tshuaj Muaj Yees Uas Nyiam Siv.
Daim Ntawm Npe Tshuaj Muaj Yees Uas Nyiam Siv: Kuj yog hais txog raws li yog Tus Qauv Tshuaj, yog cov npe ntawm cov tshuaj sau hauv daim ntawv yuav tshuaj uas nyiam siv thiab muaj cai raug pab them nyiaj rau hauv ib qho phiaj xwm kev kho mob, thiab suav tag nrho tshuaj muaj yees uas raug pab them nqi duav roos rau tus neeg mob sab nrauv raws cov txiaj ntsig ntawm cov tshuaj sau hauv daim ntawv yuav tshuaj ntawm qhov phiaj xwm kev kho mob.
Tus Kws Kho Mob Sau Ntawv Yuav Tshuaj: Yog ib tug kws kho mob uas muaj cai sau ib daim ntawv yuav tshuaj los kho mob rau ib tug tswv cuab qhov phiaj xwm kev kho mob.
Daim ntawv sau yuav tshuaj: Yog hais ntawm qhov ncauj, sau ntawv, los sis sau daim ntawv rau hauv electronic mus txib yuav tshuaj los ntawm ib tug kws kho mob sau ntawv yuav tshuaj rau ib tug tswv cuab tshwj xeeb uas muaj lub npe ntawm cov tshuaj sau hauv daim ntawv yuav tshuaj, qhov ntau tsawg ntawm tshuaj muaj yees, hnub tsim tshuaj, lub npe thiab tej ntaub ntawv siv sib txuas lus ntawm tus kws kho mob sau ntawv yuav tshuaj, kos npe ntawm tus kho mob sau ntawv yuav tshuaj yog sau ntawv yuav tshuaj, thiab yog tau thov los ntawm tus tswv cuab, qhov txheej txheem kev kho mob los sis lub hom phiaj siv cov tshuaj muaj yees ntawd.
Cov Tshuaj Sau Hauv Daim Ntawv Yuav Tshuaj: Yog ib yam tshuaj muaj yees uas raug yuav los ntawm ib tug neeg tso npe tus kws kho mob sau ntawv yuav tshuaj thiab yuav tsum muaj daim ntawv sau yauv tshuaj raws li txoj cai lij choj.
Kev Tso Cai Ua Ntej: Yog ib daim phiaj xwm kev kho mob uas tus tswv cuab los sis tus tswv cuab tus kws kho mob sau ntawv yuav tshuaj tau kev tso cai daim phiaj xwm kev kho mob rau cov tshuaj sau hauv daim ntawv yuav tshuaj ua ntej daim phiaj xwm kev kho mob yuav pab them nyiaj rau yam tshuaj muaj yees no. Daim phiaj xwm kev kho mob yuav muab kev tso cai ua ntej thaum tsim nyog yuav kho mob rau tus tswv cuab los ntawm cov tshuaj muaj yees.
x Ciam Txwv Qhov Ntau: Yog ib qho kev txwv txog kev siv tshuaj ntau tsawg los sis lwm cov kev txwv siv tshuaj ntau tsawg rau cov tshuaj sau hauv daim ntawv yuav tshuaj ntawm ib qho phiaj xwm kev kho mob yuav pab them nyiaj rau ib lub sij hawm tshwj xeeb twg.
Cov Tshuaj Tshwj Xeeb: Cov Tshuaj Tshwj Xeeb muaj xws li tshuaj muaj yees uas raug siv rau biotechnology, cov tshuaj muaj yees uas yuav tsum raug muag raws ntawm ib lub khw muag tshuaj tshwj xeeb, cov tshuaj muaj yees uas yuav tsum muab kev cob qhia tshwj xeeb rau yus tus kheej siv, los sis cov tshuaj muaj yees uas yuav tsum soj qab xyuas los ntawm ib lub khw muag tshuaj.
Cov Qib Pib Kev Kho Mob: Yog ib qho txheej txheem tshwj xeeb kev txib yuav cov tshuaj sau hauv daim ntawv yuav tshuaj sib txawv siv rau ib qho txheej txheem kev kho mob thiab tsim nyog yuav tau kho rau ib tug neeg mob tshwj xeeb. Tej zaum qhov phiaj xwm kev kho mob yuav kom tus tswv cuab sim ib yam tshuaj los sis ntau cov tshuaj muaj yees los kho qhov muaj mob ntawm tus tswv cuab ua ntej qhov phiaj xwm kev kho mob yuav pab them nyiaj rau ib yam tshuaj muaj yees tshwj xeeb raws li daim ntawv thov cov qib pib kev kho mob. Yog tus tswv cuab tus kws kho mob sau ntawv yuav tshuaj xa ib daim ntawv thov zam cov qib pib kev kho mob, qhov phiaj xwm kev kho mob yuav pub zam rau cov qib pib kev kho mob thaum raug raws li tus qauv raug pab.
Yog xav paub ntau ntxiv txog cov txiaj ntsig ntawm koj lub khw muag tshuaj, thov saib koj Phau Ntawv Qhia Rau Tus Tswv Cuab los sis hu rau Cov Kev Pab Cuam Rau Tswv Cuab rau ntawm 1-888-893-1569.
xi Medi-Cal de CalViva Health Lista de Medicamentos Preferidos
En la Lista de Medicamentos Preferidos (por sus siglas en inglés, PDL) de Medi-Cal de CalViva Health, se incluyen medicamentos cubiertos por CalViva Health. Esta lista se actualiza todos los meses y puede cambiar. Para obtener la informaci n más actualizada o una copia impresa, comuníquese con el Departamento de Servicios al Afiliado al 1-888-893-1569 (TTY: 711).
Puede encontrar la Lista de Medicamentos más reciente en nuestro sitio web, en https://www.calvivahealth.org/members-info/. Allí también se encuentra disponible una versi n en formato de lectura electr nica. Vaya a “Lista de Medicinas del Formulario”. Utilice este enlace para ver la lista de los medicamentos cubiertos por Medi-Cal de CalViva Health.
DESECHE TODAS LAS VERSIONES ANTERIORES DE LA LISTA DE MEDICAMENTOS
CV_Drug List Front Matter_SPANISH_2.5.20 Índice
¿Qué es la PDL de Medi-Cal de CalViva Health? ...... iii
¿C mo uso la PDL de Medi-Cal de CalViva Health? ...... iii
¿C mo encuentro un medicamento en la Lista de Medicamentos? ...... iv
¿C mo figuran los medicamentos en la lista por categorías? ...... iv
¿Qué ocurre si mi medicamento no se encuentra en la PDL de Medi-Cal de CalViva Health? ...... v
¿Puedo ir a cualquier farmacia? ...... v
¿Mi cobertura de medicamentos tiene límites? ...... vi
¿Existe alg n límite para los opioides que alivian el dolor? ...... vi
¿Qué es la dosificaci n seg n los miligramos equivalentes de morfina? ...... vi
¿C mo obtengo una excepci n a las reglas para la cobertura de medicamentos? ...... vi
¿Qué ocurre si soy un nuevo afiliado? ...... vii
¿Qué son los medicamentos de venta libre? ...... vii
¿Los medicamentos de marca están cubiertos? ...... vii
¿Qué es un medicamento genérico? ...... vii
¿El farmacéutico me dará un medicamento genérico si hay uno disponible? ...... vii
¿Hay medicamentos excluidos o exceptuados? ...... vii
¿Qué es Servicios para Ni os de California? ...... viii
¿Qué ocurre con los medicamentos que recibo de mi médico o en el consultorio de mi médico? ...... viii
Definiciones ...... viii
Lista de medicamentos que requieren receta médica agrupados por categorías ...... 1
Índice alfabético de medicamentos que requieren receta médica ...... Índice 1
ii Bienvenido a CalViva Health
¿Qué es la PDL de Medi-Cal de CalViva Health? Es una lista en la que se incluyen los medicamentos usados para tratar problemas de salud o enfermedades comunes. Un equipo de médicos y farmacéuticos se re ne peri dicamente para decidir qué medicamentos deben incluirse en la lista. El equipo revisa los medicamentos nuevos y existentes, y elige los más eficaces y seguros. La Lista de Medicamentos se actualiza todos los meses. Los cambios pueden incluir la presentaci n de un medicamento (p. ej., tabletas o cápsulas) o si existe un límite para la cantidad de medicamento que puede surtirse en una sola vez. Los cambios también pueden ser para indicar si un medicamento requiere autorizaci n previa o terapia escalonada, o si un medicamento deja de estar incluido en la lista.
¿C mo uso la PDL de Medi-Cal de CalViva Health? Busque el medicamento en el índice que está al final de este cuadernillo. En el índice, se enumeran todos los medicamentos de la lista, incluidos los de marca y los genéricos. Junto al nombre del medicamento, figura el n mero de página donde puede encontrarlo.
En la siguiente tabla, se describen los límites que pueden aparecer en la Lista de Medicamentos.
Abreviatura Término Significado Algunos medicamentos solamente están cubiertos para AL Límite de edad personas de determinada edad. Estos medicamentos han sido exceptuados desde el Departamento de Servicios de Atenci n Médica. Esto CO Exceptuado significa que los medicamentos están cubiertos por el Programa de Pago por Servicio de Medi-Cal, y la farmacia puede facturarlos al estado. Estos medicamentos están incluidos en la Lista de F Formulario Medicamentos. Estos medicamentos no están incluidos en la Lista de Medicamentos. Su médico puede solicitarnos que hagamos NF Fuera del Formulario una excepci n si cree que usted necesita un medicamento que no está cubierto. El médico debe pedir la aprobaci n de CalViva Health PA Autorizaci n previa antes de que se cubran algunos medicamentos. Para algunos medicamentos, solo se cubre una cantidad QL Límite de cantidad específica. Con receta médica y de Estos medicamentos están disponibles de las dos formas: RX/OTC venta libre con receta médica y de venta libre. En algunos casos, debe probar determinados medicamentos antes de que en CalViva Health se cubra otro medicamento para su afecci n de salud. ST Terapia escalonada Por ejemplo, si el medicamento A y el medicamento B tratan su afecci n de salud, es posible que en CalViva Health no se cubra el medicamento B si usted no prueba primero el medicamento A.
iii Abreviatura Término Significado Estos son medicamentos especializados. Solo puede Programa de Farmacia obtenerlos en farmacias especializadas. Todas las recetas SP Especializada médicas se deben surtir en las farmacias especializadas incluidas en la lista.
¿C mo encuentro un medicamento en la Lista de Medicamentos? Puede usar la herramienta de b squeda para encontrar un medicamento. Los medicamentos pueden buscarse por orden alfabético o por afecci n médica. Hay tres maneras de averiguar si su medicamento está cubierto:
Herramienta de B squeda: Abra la Lista de Medicamentos (PDF). Presione las teclas “Control” (Ctrl) y “F”. Cuando aparezca el cuadro de b squeda, escriba el nombre de su medicamento. Presione la tecla “Enter”.
Índice Alfabético: El índice al final del documento PDF incluye los nombres de los medicamentos genéricos y de marca de la “A” a la “Z”. Cuando encuentre el nombre de un medicamento, vaya a la página indicada para saber si el medicamento está cubierto.
Categoría Terapéutica: Los medicamentos se agrupan en categorías. Las categorías también pueden agruparse seg n la clase a la que pertenece el medicamento. Si sabe a qué categoría pertenece su medicamento, b squela en la lista. Luego, puede buscar su medicamento en esa categoría.
No se incluirán en la lista los medicamentos que no tengan un equivalente genérico para el medicamento de marca. Los medicamentos que no estén cubiertos no se encontrarán en la lista. El hecho de que un medicamento esté incluido en la lista no significa que el médico se lo recetará para su afecci n médica.
¿C mo figuran los medicamentos en la lista por categorías? Los medicamentos se ordenan alfabéticamente por sus nombres de marca y genérico en la categoría y la clase correspondientes.
iv El nombre genérico de un medicamento de marca se incluye después de la marca, entre paréntesis, con min scula, en negrita y en cursiva.
Ejemplo de un Medicamento de Marca: EPOGEN (epoetin alfa)
Si un equivalente genérico para el medicamento de marca se incluye en la lista y está cubierto, figurará en la lista aparte del medicamento de marca. Estará escrito con min scula, en cursiva y en negrita.
Ejemplo de un Medicamento Genérico: esomeprazole magnesium cap delayed release
Si un medicamento genérico se comercializa bajo una marca registrada, la marca figurará en la lista con MAYÚSCULAS en todas las letras. Se ubicará después del nombre genérico, que aparecerá entre paréntesis, sin formato y con may scula en la primera letra de cada palabra.
Ejemplo de un Medicamento Genérico Comercializado bajo una Marca: (Levothyroxine Sodium) LEVOXYL
¿Qué ocurre si mi medicamento no se encuentra en la PDL de Medi-Cal de CalViva Health? Si el medicamento que necesita no está en la lista, comuníquese con el Departamento de Servicios al Afiliado al 1-888-893-1569 y pregunte si el medicamento está cubierto. Si el medicamento no se encuentra en la lista, preg ntele al médico si hay otro medicamento incluido en la lista que tenga los mismos efectos. Su médico puede solicitarnos que hagamos una excepci n si quiere que usted tome un medicamento que no está en la lista. Consulte la secci n “¿C mo obtengo una excepci n a las reglas para la cobertura de medicamentos?” para obtener más informaci n.
¿Puedo ir a cualquier farmacia? Los afiliados deben ir a las farmacias de venta minorista de la red. Estas farmacias tienen contrato con CalViva Health. Para encontrar una farmacia, comuníquese con el Departamento de Servicios al Afiliado al 1-888-893-1569.
Algunos medicamentos solo están cubiertos cuando provienen de una farmacia especializada. Los medicamentos especializados se usan para tratar afecciones cr nicas o complejas. Además, es posible que requieran manipulaci n o indicaciones especiales para garantizar que se administren de manera segura. Desde la farmacia especializada, se enviarán los medicamentos a su casa, a su lugar de trabajo o a otra direcci n de preferencia. También podrán enviarse medicamentos especializados al consultorio de su médico. Estos medicamentos figuran en la columna “Requisitos/Límites” de la Lista de Medicamentos. Los medicamentos que no incluyan una farmacia especializada en la columna “Requisitos/Límites” de la Lista de Medicamentos podrán surtirse en cualquier farmacia de la red.
Puede solicitar una excepci n para surtir un medicamento especializado en una farmacia de venta minorista de la red en los siguientes casos: Cambi la manera en que toma el medicamento, y necesita surtirlo ahora mismo. Su medicamento tardará en llegar o siempre tarda en llegar. Necesita un medicamento con urgencia y no entendi c mo obtenerlo en la farmacia especializada. Tiene una emergencia y no puede esperar a que el medicamento llegue de la farmacia especializada.
v Si no puede obtener los servicios de una farmacia especializada, solicite una excepci n para obtener todos los medicamentos en una farmacia de venta minorista de la red en los siguientes casos: No tiene una direcci n postal ni otra manera de recibir los medicamentos por correo. Obtiene los medicamentos en el consultorio del médico. Le resulta complicado obtener los servicios de una farmacia especializada.
Si necesita una excepci n, debe solicitárnosla. El médico o la farmacia también pueden hacerlo. Para solicitar una excepci n, comuníquese con el Departamento de Servicios al Afiliado de CalViva Health al 1-888-893-1569 (TTY: 711). Estamos disponibles las 24 horas del día, los siete días de la semana.
¿Mi cobertura de medicamentos tiene límites? Se aplican límites a la cobertura de algunos medicamentos. Estos límites se describen en la columna “Requisitos/Límites” de la Lista de Medicamentos.
¿Existe alg n límite para los opioides que alivian el dolor? No se requiere autorizaci n previa para el uso a corto plazo de la mayoría de los opioides que alivian el dolor. Puede obtener un suministro para 7 días de estos medicamentos cuando el médico se los recete por primera vez. Se aplican límites de cantidad a todos los opioides que alivian el dolor en funci n de los miligramos equivalentes de morfina (por sus siglas en inglés, MME). Es probable que deba solicitar autorizaci n previa si necesita un suministro para más de 7 días. Este límite no se aplicará si está recibiendo un tratamiento para el cáncer o la anemia falciforme.
¿Qué es la dosificaci n seg n los miligramos equivalentes de morfina? La dosificaci n seg n los MME es una herramienta que se utiliza para garantizar que usted toma una dosis segura de opioides que alivian el dolor. Esta herramienta ayuda a medir la cantidad de opioides que alivian el dolor que toma por día. El límite recomendado para la mayoría de estos medicamentos es de 90 MME por día. Los límites de cantidad en la Lista de Medicamentos son de 90 MME, o una dosis menor, por día. El médico puede solicitar una autorizaci n previa si usted necesita una dosis mayor de 90 MME por día. Este límite no se aplicará si está recibiendo un tratamiento para el cáncer o la anemia falciforme.
¿C mo obtengo una excepci n a las reglas para la cobertura de medicamentos? Su médico puede solicitar una excepci n a nuestras reglas para la cobertura de medicamentos. Puede solicitarnos la cobertura de un medicamento que no está en la lista. Puede solicitarnos que hagamos una excepci n a los límites de un medicamento. Por ejemplo, si un medicamento está sujeto a un límite de 1 tableta por día, el médico puede solicitar que ampliemos la cobertura. Para pedir la excepci n, el médico puede enviarnos una solicitud de autorizaci n previa por fax al 1-800-977-8226. Tomaremos una decisi n y se la comunicaremos a su médico dentro de las 24 horas de haber recibido la solicitud. Si la rechazamos, les enviaremos una carta a usted y a su médico, y les explicaremos c mo presentar una apelaci n. Si no respondemos dentro de las 24 horas, la solicitud será aprobada. Si aprobamos un medicamento, puede continuar obteniéndolo a través de CalViva Health tanto tiempo como sea efectivo para usted y el médico le indique que contin e tomándolo.
vi ¿Qué ocurre si soy un nuevo afiliado? Si se inscribi recientemente en nuestro plan, es posible que esté tomando medicamentos que no están en nuestra Lista de Medicamentos. También es posible que esté tomando un medicamento que está incluido en nuestra lista, pero con límites. Debe hablar con su médico para saber si puede comenzar a tomar un medicamento que esté incluido en la lista. Es posible que su médico solicite una excepci n para que brindemos cobertura del medicamento que está tomando. Consulte la secci n “¿C mo obtengo una excepci n a las reglas para la cobertura de medicamentos?” para obtener más informaci n.
¿Qué son los medicamentos de venta libre? Los medicamentos de venta libre son los que se compran sin receta médica. En la PDL de Medi-Cal de CalViva Health, se incluyen medicamentos de venta libre como los que se encuentran en la Lista de Medicamentos por Contrato de Medi-Cal del estado. Si quiere que en CalViva Health se brinde cobertura para un medicamento de venta libre de la lista, el médico deberá recetarlo.
¿Los medicamentos de marca están cubiertos? Su beneficio de farmacia no cubre medicamentos de marca cuando hay un medicamento genérico disponible. Puede brindarse cobertura para el medicamento de marca si no hay disponible un medicamento genérico. El médico también puede solicitarnos que brindemos cobertura para un medicamento de marca si considera que será mejor para usted.
¿Qué es un medicamento genérico? Un medicamento genérico contiene el mismo ingrediente activo y produce los mismos efectos que el medicamento de marca. Los medicamentos genéricos son seguros y eficaces.
¿El farmacéutico me dará un medicamento genérico si hay uno disponible? Sí. En la farmacia, le darán un medicamento genérico, salvo que el médico haya indicado que usted debe tomar el medicamento de marca.
¿Hay medicamentos excluidos o exceptuados? Medicamentos excluidos La PDL de Medi-Cal de CalViva Health es similar a la Lista de Medicamentos por Contrato de Medi-Cal del estado. Los siguientes tipos de medicamentos no son un beneficio cubierto y no están incluidos en la PDL: multivitaminas; medicamentos para la disfunci n sexual o eréctil; medicamentos que se administran con fines cosméticos o para el crecimiento del cabello; medicamentos considerados experimentales; medicamentos para tratar la infertilidad; medicamentos de venta libre contra la tos y el resfrío; acetaminofén de venta libre para adultos.
Medicamentos del programa Implementaci n del Estudio de la Eficacia de los Medicamentos Medi-Cal de CalViva Health no brinda cobertura para los productos del programa Implementaci n del Estudio de la Eficacia de los Medicamentos ni para otros medicamentos relacionados. La Administraci n de Alimentos y Medicamentos los ha definido como menos que eficaces. No hay pruebas de que estos medicamentos sean seguros y eficaces.
vii Medicamentos exceptuados Desde el Departamento de Servicios de Atenci n Médica, se han exceptuado algunos medicamentos. Esto significa que los medicamentos están cubiertos por el Programa de Pago por Servicio de Medi-Cal. Los siguientes tipos de medicamentos están exceptuados: determinados medicamentos para el tratamiento de problemas psiquiátricos; determinados medicamentos para el tratamiento del VIH o sida; determinados medicamentos para el tratamiento del alcoholismo, la desintoxicaci n de la heroína y el tratamiento por dependencia; determinados medicamentos para el tratamiento de la hemofilia.
¿Qué es Servicios para Ni os de California? Servicios para Ni os de California (por sus siglas en inglés, CCS) es un programa estatal para los ni os (hasta los 21 a os) con ciertos problemas de salud. Algunos medicamentos para los problemas de salud cubiertos por CCS no están cubiertos por CalViva Health.
Solo los médicos aprobados por CCS pueden solicitar los medicamentos que se utilizan para tratar los problemas de salud cubiertos por CCS. Estos medicamentos no están cubiertos por CalViva Health. La farmacia debe facturar estos medicamentos a CCS. Si usted se encuentra en la farmacia y a n no figura en el sistema de CCS, comuníquese con el Departamento de Servicios al Afiliado al 1-888-893-1569. Desde el Departamento de Servicios al Afiliado pueden ayudarlo a inscribirse en CCS. También pueden ayudarlo a obtener un suministro de emergencia de su medicamento.
¿Qué ocurre con los medicamentos que recibo de mi médico o en el consultorio de mi médico? Algunos medicamentos que le da el médico pueden estar cubiertos conforme a su beneficio médico. Puede obtenerlos en una farmacia de venta minorista. El médico también puede entregárselos en el consultorio. Hablaremos con su médico a fin de encontrar la manera más conveniente para usted de obtener estos medicamentos. Si tiene preguntas sobre estos medicamentos, llame al Departamento de Servicios al Afiliado al 1-888-893-1569.
Definiciones
Afiliado: Es una persona inscrita en un plan de salud que tienen derecho a recibir servicios a través del plan.
Autorizaci n Previa: Es un requisito del plan de salud conforme al cual el afiliado o el proveedor que receta deben obtener la autorizaci n del plan para un medicamento que requiere receta médica antes de que este se cubra. El plan de salud otorgará la autorizaci n previa cuando sea médicamente necesario para el afiliado obtener el medicamento.
Formulario: También denominado Lista de Medicamentos Preferidos. Es la lista completa de los medicamentos que requieren receta médica preferidos para el uso y elegibles para la cobertura conforme a un plan de salud. Incluye todos los medicamentos cubiertos conforme al beneficio de medicamentos que requieren receta médica para pacientes ambulatorios del plan de salud.
viii Límite de Cantidad: Es una restricci n sobre la cantidad de dosis o cualquier otra limitaci n respecto de la cantidad de un medicamento que requiere receta médica que el plan de salud cubrirá durante un período específico.
Lista de Medicamentos Preferidos: También denominada Formulario. Es la lista completa de los medicamentos que requieren receta médica preferidos para el uso y elegibles para la cobertura conforme a un plan de salud. Incluye todos los medicamentos cubiertos conforme al beneficio de medicamentos que requieren receta médica para pacientes ambulatorios del plan de salud.
Médicamente Necesario: Son beneficios de atenci n de salud necesarios para diagnosticar, tratar o prevenir una afecci n médica o sus síntomas, que cumplen con las normas de medicina aceptadas. Por lo general, los planes no brindan cobertura para los beneficios de atenci n de salud que no son médicamente necesarios.
Medicamento de Marca: Es un medicamento que se comercializa bajo una marca con registro de propiedad. En este Formulario, los medicamentos de marca figuran con MAYÚSCULAS en todas las letras.
Medicamento fuera del Formulario: Es un medicamento que requiere receta médica que no está incluido en la Lista de Medicamentos Preferidos.
Medicamento Genérico: Es un medicamento idéntico al medicamento de marca, equivalente en dosis, seguridad, potencia, modo de administraci n, calidad, efecto y uso previsto. Los medicamentos genéricos se incluyen en la lista con min scula, en negrita y en cursiva.
Medicamento que Requiere Receta Médica: Es un medicamento que receta el proveedor de la persona inscrita y que requiere una receta médica conforme a la ley correspondiente.
Medicamentos Especializados: Los medicamentos especializados incluyen medicamentos que se fabrican con biotecnología, medicamentos que deben distribuirse a través de farmacias especializadas, medicamentos que requieren instrucciones especiales para su autoadministraci n o medicamentos que requieren el control de atenci n peri dico de una farmacia.
Proveedor que Receta: Es un proveedor de atenci n de salud autorizado a expedir una receta médica a un afiliado del plan de salud para tratar una afecci n médica.
Receta Médica: Es una orden oral, escrita o electr nica emitida por un proveedor que receta para un afiliado específico, en la que figuran el nombre y la cantidad del medicamento recetado, la fecha de emisi n, el nombre y la informaci n de contacto del proveedor que receta, su firma si es una receta escrita y, si el afiliado lo solicita, la afecci n médica o el prop sito por los que se receta el medicamento.
Solicitud de Excepci n: Es una solicitud de cobertura de un medicamento que requiere receta médica. Si una persona inscrita en el plan, la persona designada por ella o el proveedor de atenci n de salud que receta presentan una solicitud de excepci n para la cobertura de un medicamento que requiere receta médica, el plan de salud debe brindar cobertura para el medicamento cuando se determine que este es médicamente necesario para tratar la afecci n de la persona inscrita.
ix Terapia Escalonada: Es un proceso que especifica la secuencia en que deben recetarse diferentes medicamentos que requieren receta médica para una afecci n específica y médicamente adecuados para un paciente en particular. El plan de salud puede exigir que el afiliado pruebe uno o más medicamentos para tratar su afecci n médica antes de cubrir un medicamento en particular para dicha afecci n conforme a una solicitud de terapia escalonada. Si el proveedor que emite la receta del afiliado presenta una solicitud de excepci n de la terapia escalonada, el plan de salud deberá otorgar dicha excepci n, siempre que se cumpla con los criterios.
Si desea obtener más informaci n sobre sus beneficios de farmacia, revise el Manual del Afiliado o comuníquese con el Departamento de Servicios al Afiliado al 1-888-893-1569.
x Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- VYVANSE CAPS 10 MG, PA; QL(1 ea OBESITY/ANOREXIANTS - Drugs to Treat 20 MG, 30 MG, 40 MG, 50 daily) ADHD, Sleep and Eating Disorders MG, 60 MG, 70 MG F (lisdexamfetamine Amphetamines dimesylate) (Dextroamphetamine QL(3 ea daily) Sulfate) ZENZEDI TABS 10 F Analeptics MG caffeine citrate soln F QL(45 ml per (Dextroamphetamine fill retail) Sulfate) ZENZEDI TABS 5 F Anorexiants Non-Amphetamine MG benzphetamine hcl tabs PA QL(1 ea daily) F amphetamine- 25 mg dextroamphetamine cp24 1.25 mg-1.25 mg- diethylpropion hcl tabs F PA 1.25 mg-1.25 mg, 2.5 PA mg-2.5 mg-2.5 mg-2.5 diethylpropion hcl tb24 F mg, 3.75 mg-3.75 mg- F LOMAIRA TABS PA F 3.75 mg-3.75 mg, 5 (phentermine hcl) mg-5 mg-5 mg-5 mg, PA 6.25 mg-6.25 mg-6.25 phentermine hcl caps F mg-6.25 mg, 7.5 mg- phentermine hcl tabs F PA 7.5 mg-7.5 mg-7.5 mg amphetamine- QSYMIA CP24 PA dextroamphetamine (phentermine hcl- F tabs 1.25 mg-1.25 mg- topiramate) 1.25 mg-1.25 mg, Anti-Obesity Agents 1.875 mg-1.875 mg- ALLI CAPS (orlistat) F PA 1.875 mg-1.875 mg, BELVIQ TABS PA 2.5 mg-2.5 mg-2.5 mg- F F 2.5 mg, 3.125 mg- (lorcaserin hcl) BELVIQ XR TB24 PA 3.125 mg-3.125 mg- F 3.125 mg, 3.75 mg- (lorcaserin hcl) 3.75 mg-3.75 mg-3.75 CONTRAVE TB12 PA mg, 5 mg-5 mg-5 mg-5 (naltrexone hcl- F mg, 7.5 mg-7.5 mg-7.5 bupropion hcl) mg-7.5 mg SAXENDA SOPN PA dextroamphetamine (liraglutide (weight F sulfate cp24 10 mg, 15 F management)) mg, 5 mg XENICAL CAPS (orlistat) F PA QL(3 ea daily) dextroamphetamine F sulfate tabs 10 mg Attention-Deficit/Hyperactivity Disorder (ADHD) F dextroamphetamine F atomoxetine hcl caps sulfate tabs 5 mg clonidine hcl (adhd) F tb12
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily) QL(160 ea per guanfacine hcl (adhd) F tb24 paromomycin sulfate F fill retail)1 rtl caps MAX fill,30 rtl Stimulants - Misc. day(s) supply, PA TOBI PODHALER CAPS AL(At least 21 armodafinil tabs F F (tobramycin) yrs old); SP QL(2 ea daily); dexmethylphenidate hcl AL(At least 21 AL(At least 6 tobramycin nebu 300 F tabs 10 mg, 2.5 mg, 5 F mg/4ml yrs old) mg yrs old) PA; SP QL(1 ea daily); tobramycin nebu 300 F methylphenidate hcl mg/5ml cpcr 10 mg, 40 mg, 50 F AL(At least 6 mg, 60 mg yrs old) tobramycin sulfate soln F PA methylphenidate hcl QL(2 ea daily); PA F AL(At least 6 tobramycin sulfate solr F cpcr 20 mg, 30 mg yrs old) ANALGESICS - ANTI-INFLAMMATORY - Drugs methylphenidate hcl to Treat Pain, Swelling, Muscle and Joint tabs 10 mg, 20 mg, 5 F Conditions mg Anti-TNF-alpha - Monoclonal Antibodies QL(1 ea daily) methylphenidate hcl F HUMIRA PEDIATRIC PA; SP- tb24 18 mg, 27 mg CROHNS DISEASE AcariaHealth;S STARTER PACK PSKT F P methylphenidate hcl F tb24 36 mg, 54 mg (adalimumab) methylphenidate hcl HUMIRA PEN PNKT PA; SP- F F AcariaHealth;S tbcr 10 mg, 20 mg (adalimumab) P methylphenidate hcl QL(1 ea daily) HUMIRA PEN-CD/UC/HS PA; SP- tbcr 18 mg, 27 mg, 54 F STARTER PNKT F AcariaHealth;S mg (adalimumab) P QL(2 ea daily) HUMIRA PEN-PEDIATRIC PA; SP- methylphenidate hcl F tbcr 36 mg UC STARTER PACK F AcariaHealth;S PNKT (adalimumab) P F PA; QL(1 ea modafinil tabs daily) HUMIRA PEN-PS/UV PA; SP- STARTER PNKT F AcariaHealth;S AMINOGLYCOSIDES - Drugs to Treat Bacterial P Infections (adalimumab) HUMIRA PSKT PA; SP- Aminoglycosides F AcariaHealth;S ARIKAYCE SUSP PA (adalimumab) P (amikacin sulfate F SIMPONI ARIA SOLN PA; SP- liposome) F AcariaHealth;S (golimumab) PA P gentamicin in saline F soln Antirheumatic - Enzyme Inhibitors KITABIS PAK NEBU PA; SP XELJANZ TABS 10 MG, 5 PA; SP- Acaria F F (tobramycin) MG (tofacitinib citrate) Health;SP XELJANZ XR TB24 11 MG PA; SP- Acaria neomycin sulfate tabs F F (tofacitinib citrate) Health;SP To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XELJANZ XR TB24 22 MG PA; SP- (Ibuprofen) ADDAPRIN, F AcariaHealth;S ADVIL JUNIOR (tofacitinib citrate) P STRENGTH, CVS IBUPROFEN, CVS Antirheumatic Antimetabolites IBUPROFEN IB, DYSPEL, METHOTREXATE TABS EQ IBUPROFEN, EQL (methotrexate sodium F IBUPROFEN, GNP (antirheumatic)) IBUPROFEN, GOODSENSE Gold Compounds IBUPROFEN, HM RIDAURA CAPS IBUPROFEN, HM F (auranofin) IBUPROFEN IB, IBU, IBU- 200, KLS IBUPROFEN, F Interleukin-1beta Blockers KLS IBUPROFEN IB, ILARIS SOLN PA; SP- MEDI-PROFEN, MEIJER F AcariaHealth;S (canakinumab) IBUPROFEN, MOTRIN IB, P PROVIL, PX IBUPROFEN, Interleukin-6 Receptor Inhibitors QC IBUPROFEN, QC IBUPROFEN IB, RA PAIN ACTEMRA SOLN IV 200 PA; SP- RELIEF IBUPROFEN, SB MG/10ML, 400 MG/20ML, F AcariaHealth;S IBUPROFEN, SM 80 MG/4ML (tocilizumab) P IBUPROFEN, SM KEVZARA SOAJ PA; SP- IBUPROFEN IB, SM F (sarilumab) AcariaHealth IBUPROFEN JR, TGT IBUPROFEN, WAL- KEVZARA SOSY PA; SP- F PROFEN TABS (sarilumab) AcariaHealth Nonsteroidal Anti-inflammatory Agents (NSAIDs) (Diclofenac Potassium) F CATAFLAM TABS
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Ibuprofen) ADVIL JUNIOR (Ibuprofen) CHILDRENS RX/OTC STRENGTH, CVS IBUPROFEN, CHILDRENS IBUPROFEN JUNIOR IBUPROFEN 100, STRENGTH, EQ CHILDRENS MEDI- IBUPROFEN JUNIOR PROFEN, CVS STRENGTH, EQL CHILDRENS IBUPROFEN, IBUPROFEN JUNIOR CVS IBUPROFEN STRENGTH, GNP CHILDRENS, CVS IBUPROFEN CHILDRENS, IBUPROFEN INFANTS, GNP IBUPROFEN JUNIOR EQ IBUPROFEN STRENGTH, CHILDRENS, EQ GOODSENSE IBUPROFEN INFANTS, IBUPROFEN JUNIOR EQL CHILDRENS STRENGTH, HM IBUPROFEN, EQL IBUPROFEN, HM F IBUPROFEN INFANTS, IBUPROFEN IB/JUNIOR GNP CHILDRENS STRENGTH, IBUPROFEN IBUPROFEN, GNP 100 JUNIOR STRENGTH, IBUPROFEN INFANTS, IBUPROFEN JUNIOR GOODSENSE STRENGTH, PX IBUPROFEN CHILDRENS, IBUPROFEN JUNIOR GOODSENSE STRENGTH, RA IBUPROFEN INFANTS, IBUPROFEN JUNIOR HM IBUPROFEN STRENGTH, SM CHILDRENS, HM IBUPROFEN IB, SM IBUPROFEN INFANTS, F IBUPROFEN IB HYVEE IBUPROFEN CHILDRENS, TGT CHILDRENS, IBUPROFEN IBUPROFEN JUNIOR CHILDRENS, IBUPROFEN STRENGTH CHEW INFANTS, IBUPROFEN (Ibuprofen) ADVIL LIQUI- INFANTS DROPS, GELS MINIS, CVS INFANTS IBUPROFEN, IBUPROFEN, CVS MEDI-PROFEN, PX IBUPROFEN LIQUID CHILDRENS PROFEN IB, FILLED, EQ IBUPROFEN, PX INFANTS PROFEN IB, EQL IBUPROFEN, GNP QC CHILDRENS IBUPROFEN, IBUPROFEN, QC IBUPROFEN INFANTS, GOODSENSE F IBUPROFEN, HM RA IBUPROFEN IBUPROFEN, KS CHILDRENS, RA IBUPROFEN, MEDI- IBUPROFEN INFANTS, SB PROFEN, MOTRIN IB, QC INFANTS IBUPROFEN, IBUPROFEN, SM SM CHILDRENS IBUPROFEN, TGT IBUPROFEN, SM IBUPROFEN, WAL- INFANTS IBUPROFEN, PROFEN CAPS TGT CHILDRENS IBUPROFEN, TGT IBUPROFEN CHILDRENS, TGT INFANTS IBUPROFEN SUSP
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Ibuprofen) CHILDRENS (Ibuprofen) RA IBUPROFEN, CHILDRENS IBUPROFEN CAPS 200 F IBUPROFEN 100, MG CHILDRENS MEDI- (Ibuprofen) RA RX/OTC PROFEN, CVS IBUPROFEN SUSP 100 F CHILDRENS IBUPROFEN, MG/5ML CVS IBUPROFEN CHILDRENS, CVS (Ibuprofen) RA IBUPROFEN INFANTS, IBUPROFEN TABS 200 F EQ IBUPROFEN MG CHILDRENS, EQ (Nabumetone) RELAFEN F IBUPROFEN INFANTS, TABS EQL CHILDRENS (Naproxen Sodium) ALL IBUPROFEN, EQL DAY PAIN RELIEF, ALL IBUPROFEN INFANTS, DAY RELIEF, CVS ALL GNP CHILDRENS DAY PAIN RELIEF, CVS IBUPROFEN, GNP NAPROXEN SODIUM, EQ IBUPROFEN INFANTS, ALL DAY PAIN RELIEF, GOODSENSE EQ NAPROXEN SODIUM, IBUPROFEN CHILDRENS, EQL NAPROXEN GOODSENSE SODIUM, FLANAX PAIN IBUPROFEN INFANTS, RELIEF, GNP ALL DAY HM IBUPROFEN PAIN RELIEF, GNP CHILDRENS, HM NAPROXEN, GNP IBUPROFEN INFANTS, F NAPROXEN SODIUM, HYVEE IBUPROFEN GOODSENSE F CHILDRENS, IBUPROFEN NAPROXEN SODIUM, HM CHILDRENS, IBUPROFEN NAPROXEN SODIUM, HY- INFANTS, IBUPROFEN VEE ALL DAY RELIEF, INFANTS DROPS, KLS NAPROXEN INFANTS IBUPROFEN, SODIUM, MEDIPROXEN, MEDI-PROFEN, PX PAMPRIN ALL DAY CHILDRENS PROFEN IB, MAXIMUM STRENGTH, PX INFANTS PROFEN IB, PX ALL DAY RELIEF, QC QC CHILDRENS NAPROXEN SODIUM, RA IBUPROFEN, QC NAPROXEN SODIUM, SB IBUPROFEN INFANTS, NAPROXEN SODIUM, SM RA IBUPROFEN NAPROXEN SODIUM, CHILDRENS, RA TGT NAPROXEN SODIUM IBUPROFEN INFANTS, SB TABS INFANTS IBUPROFEN, (Naproxen Sodium) CVS SM CHILDRENS NAPROXEN SODIUM, EQ IBUPROFEN, SM NAPROXEN SODIUM, INFANTS IBUPROFEN, EQL NAPROXEN TGT CHILDRENS SODIUM, GNP F IBUPROFEN, TGT NAPROXEN SODIUM, HM IBUPROFEN CHILDRENS, NAPROXEN SODIUM, SM TGT INFANTS NAPROXEN SODIUM, IBUPROFEN SUSP TGT NAPROXEN SODIUM CAPS
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Naproxen) EC- F meclofenamate sodium F NAPROXEN TBEC caps F PA celecoxib caps meloxicam tabs 15 mg, F 7.5 mg diclofenac potassium F tabs nabumetone tabs F F diclofenac sodium tb24 naproxen sodium caps F 220 mg diclofenac sodium tbec F naproxen sodium tabs etodolac caps F 220 mg, 275 mg, 550 F mg etodolac tabs F naproxen susp F etodolac tb24 F naproxen tabs F fenoprofen calcium F tabs 600 mg naproxen tbec F flurbiprofen tabs F oxaprozin tabs F ibuprofen caps 200 mg F piroxicam caps F RX/OTC ibuprofen susp 100 F sulindac tabs F mg/5ml ibuprofen tabs 200 mg, tolmetin sodium caps F 400 mg, 600 mg, 800 F mg tolmetin sodium tabs F INDOCIN SUPP Phosphodiesterase 4 (PDE4) Inhibitors F (indomethacin) OTEZLA TABS PA; SP F INDOCIN SUSP (apremilast) F (indomethacin) OTEZLA TBPK PA; SP F (apremilast) indomethacin caps 25 F mg, 50 mg Pyrimidine Synthesis Inhibitors indomethacin cpcr 75 F leflunomide tabs F mg Selective Costimulation Modulators ketoprofen caps or 50 F mg, 75 mg ORENCIA CLICKJECT PA; SP- F AcariaHealth;S ketoprofen cp24 or 200 F SOAJ (abatacept) P mg ORENCIA SOLR PA; SP- QL(20 ea per F AcariaHealth;S (abatacept) ketorolac tromethamine F 30 days retail); P tabs or 10 mg AL(At least 17 yrs old) ORENCIA SOSY PA; SP- F AcariaHealth;S (abatacept) P
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Soluble Tumor Necrosis Factor Receptor Agents (Acetaminophen) AL(Up to 21 yrs ACETAMINOPHEN old ) ENBREL MINI SOCT PA; SP- F AcariaHealth;S JUNIOR STRENGTH, ACETAMINOPHEN RAPID (etanercept) P TABSCHILDRENS, ENBREL SOLR 25 MG PA; SP- CHILDRENS PAIN F AcariaHealth;S (etanercept) RELIEVER, EQ P ACETAMINOPHEN ENBREL SOSY 25 PA; SP- CHILDRENS, EQL MG/0.5ML, 50 MG/ML F AcariaHealth;S ACETAMINOPHEN, EQL F (etanercept) P ACETAMINOPHEN RAPID TABS, GNP CHILDRENS ENBREL SURECLICK PA; SP- EASY-MELTS, QC NON- F AcariaHealth;S SOAJ (etanercept) ASPIRIN JR STRENGTH, P SB CHILDRENS NON- ANALGESICS - NonNarcotic - Drugs to Treat ASPIRIN, SB NON- Pain, Muscle and Joint Conditions ASPIRIN JR STRENGTH, SM RAPID MELTS Analgesic Combinations JUNIOR TBDP (Butalbital-Acetaminophen) F (Acetaminophen) APRA, TENCON TABS CHILDRENS ASPIRIN (Butalbital-Acetaminophen- F FREE, MEDI-TABS F Caffeine) BAC TABS CHILDRENS, PAIN (Butalbital-Acetaminophen- RELIEF CHILDRENS ELIX Caffeine) ESGIC, F ZEBUTAL CAPS butalbital- acetaminophen tabs F 325 mg-50 mg, 50 mg- 325 mg butalbital- acetaminophen- F caffeine caps 40 mg-50 mg-325 mg butalbital- acetaminophen- F caffeine tabs 40 mg-50 mg-325 mg butalbital-aspirin- F caffeine caps BUTALBITAL/ASPIRIN/CA FFEINE TABS (butalbital-aspirin- F caffeine) Analgesics Other
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Acetaminophen) RELIEVER, RA AUROPHEN CHILDRENS, CHILDRENS NON- BETATEMP CHILDRENS, ASPIRIN, RA FEVER CVS INFANTS PAIN REDUCER & PAIN RELIEF, CVS PAIN & RELIEVER INFANTS, RA FEVER CHILDRENS, CVS FEVER REDUCER/PAIN PAIN & FEVER INFANTS, RELIEVER CHILDRENS, EQ PAIN & FEVER RA FEVER INFANTS, EQL REDUCER/PAIN ACETAMINOPHEN RELIEVER INFANTS, SB CHILDRENS, EQL PAIN RELIEVER ACETAMINOPHEN CHILDRENS, SM PAIN & INFANTS, EQL FEVER CHILDRENS, SM CHILDRENS PAIN PAIN & FEVER INFANTS, RELIEF, GNP INFANTS SM PAIN RELIEVER PAIN RELIEF, GNP CHILDRENS, TGT INFANTS PAIN/FEVER, ACETAMINOPHEN GNP PAIN & FEVER CHILDRENS, TGT CHILDRENS, GNP PAIN & CHILDRENS FEVER INFANTS, ACETAMINOPHEN SUSP GOODSENSE PAIN & (Acetaminophen) AL(Up to 21 yrs FEVER CHILDRENS, CHILDRENS F old ) GOODSENSE PAIN & ACETAMINOPHEN TBDP FEVER INFANTS, HM 80 MG PAIN & FEVER (Acetaminophen) CHILDRENS, HM PAIN & F CHILDRENS FEVER INFANTS, HM ACETAMINOPHEN, PAIN RELIEVER CHILDRENS NON- CHILDRENS, HM PAIN ASPIRIN, CVS PAIN RELIEVER CHILDRENS RELIEF CHILDRENS, EQ F DYE-FREE, HM PAIN PAIN & FEVER RELIEVER INFANTS, CHILDRENS, PAIN & INFANTS PAIN & FEVER, FEVER CHILDRENS, QC NON-ASPIRIN NON-ASPIRIN CHILDRENS, NORTEMP, CHILDRENS SUSP 160 PAIN & FEVER MG/5ML CHILDRENS/DYE-FREE, PAIN & FEVER INFANTS, PAIN RELIEF CHILDRENS, PANADOL CHILDRENS, PANADOL INFANT, PEDIACARE CHILDREN, PEDIACARE FEVER REDUCER/PAIN RELIEVER/INFANT, PEDIACARE INFANTS, PX CHILDRENS PAIN RELIEF, QC PAIN RELIEF CHILDRENS, QC PAIN RELIEF INFANTS, RA CHILDRENS FEVER REDUCER & PAIN To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Acetaminophen) AL(Up to 21 yrs (Acetaminophen) CVS AL(Up to 21 yrs CHILDRENS APAP, old ) PAIN RELIEF old ) CHILDRENS MEDI-TABS, CHILDRENS, EQ PAIN & CHILDRENS PAIN FEVER CHILDRENS, PAIN F RELIEVER, CHILDRENS & FEVER CHILDRENS, TACTINAL, CVS CHILDS QC NON-ASPIRIN NON-ASPIRIN, CVS NON- CHILDRENS CHEW 160 ASPIRIN CHILDRENS, MG GNP PAIN RELIEF, HM AL(Up to 21 yrs acetaminophen chew F ACETAMINOPHEN F old ) CHILDRENS, MAPAP or 160 mg CHILDRENS, MEDI-TABS acetaminophen elix or F JUNOR STRENGTH, 160 mg/5ml MEIJER JR STRENGTH ASPIRIN FREE, NON- acetaminophen liqd or F ASPIRIN JUNIOR 160 mg/5ml STRENGTH, RA acetaminophen soln or ACETAMINOPHEN 160 mg/5ml, 325 CHILDRENS, SB NON- F ASPIRIN CHEW mg/10.15ml, 650 mg/20.3ml (Acetaminophen) AL(Up to 21 yrs CHILDRENS NON- F old ) acetaminophen supp re F ASPIRIN CHEW 80 MG 120 mg (Acetaminophen) acetaminophen susp or CHILDRENS SILAPAP, 160 mg/5ml, 650 F ED-APAP, LIQUID ACETAMINOPHEN, mg/20.3ml FEVERALL INFANTS AL(Up to 21 yrs LIQUID PAIN RELIEF, F LITTLE REMEDIES SUPP (acetaminophen) old ) FEVER/PAIN RELIEVER NORTEMP INFANTS F F CHILDRENS, LITTLE SUSP (acetaminophen) REMEDIES FOR FEVERS FEVER/PAIN RELIEVER Salicylates CHILDRENS, LITTLE (Aspirin Buffered (Cal REMEDIES FOR FEVERS Carb-Mag Carb-Mag FEVER/PAIN RELIEVER Oxide)) CVS BUFFERED INFANT, M-PAP LIQD ASPIRIN, SM ASPIRIN F (Acetaminophen) CVS TRI-BUFFERED, TRI- FEVER REDUCING BUFFERED ASPIRIN CHILDRENS, FEVER TABS REDUCER CHILDRENS, F FEVERALL CHILDRENS, PAIN RELIEVER/FEVER REDUCER CHILDRENS SUPP
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) ADULT ASPIRIN STRENGTH, SM ASPIRIN REGIMEN, ASPIR-LOW, ENTERIC COATED, ST ASPIRIN 81, ASPIRIN JOSEPH ASPIRIN, TGT ADULT LOW DOSE, ASPIRIN, TGT ASPIRIN ASPIRIN ADULT LOW LOW DOSE, TGT STRENGTH, ASPIRIN EC ENTERIC-COATED LOW DOSE, ASPIRIN ASPIRIN TBEC ENTERIC COATED (Aspirin) ASPIRIN 81 LOW ADULT LOW STRENGTH, DOSE, ASPIRIN ADULT ASPIRIN LOW DOSE, LOW STRENGTH, BAYER ASPIRIN, BAYER ASPIRIN CHILDRENS, ASPIRIN EC LOW DOSE, ASPIRIN LOW DOSE, BAYER ASPIRIN ASPIRIN LOW REGIMEN, BAYER LOW STRENGTH, BAYER DOSE, CVS ASPIRIN, CHEWABLE LOW DOSE, CVS ASPIRIN ADULT CHILDRENS ASPIRIN, LOW STRENGTH, CVS CHILDRENS ASPIRIN ASPIRIN EC, CVS LOW STRENGTH, CVS ASPIRIN LOW DOSE, CVS ASPIRIN ADULT LOW ASPIRIN LOW DOSE, EQ ASPIRIN LOW STRENGTH, ECOTRIN DOSE, EQL ASPIRIN LOW LOW STRENGTH, DOSE, GNP ADULT ECPIRIN, EQ ASPIRIN ASPIRIN LOW ADULT LOW DOSE, EQ STRENGTH, ASPIRIN EC, EQL GOODSENSE ASPIRIN, ASPIRIN EC, EQL F GOODSENSE ASPIRIN F ASPIRIN LOW DOSE, ADULT LOW STRENGTH, GNP ASPIRIN, GNP HM ASPIRIN, PX ASPIRIN, ASPIRIN LOW DOSE, QC ASPIRIN LOW DOSE, GOODSENSE ASPIRIN, QC CHEWABLE ASPIRIN GOODSENSE ASPIRIN LOW DOSE, QC LOW DOSE, H-E-B CHILDRENS ASPIRIN, RA ASPIRIN, HM ASPIRIN, ASPIRIN ADULT LOW HM ASPIRIN EC, HM DOSE, RA ASPIRIN ASPIRIN EC LOW DOSE, ADULT LOW STRENGTH, KLS ASPIRIN EC, KLS RA ASPIRIN CHILDRENS, ASPIRIN LOW DOSE, KP SB CHILDRENS ASPIRIN, ASPIRIN, MEIJER SM ASPIRIN ADULT LOW ASPIRIN EC, MINIPRIN STRENGTH, SM ASPIRIN LOW DOSE, PX ENTERIC LOW DOSE, SM ASPIRIN, QC ASPIRIN, CHILDRENS ASPIRIN, ST QC ASPIRIN LOW DOSE, JOSEPH LOW DOSE QC ENTERIC ASPIRIN, ASPIRIN, TGT ASPIRIN, RA ASPIRIN EC, RA TGT CHILDRENS ASPIRIN EC ADULT LOW ASPIRIN CHEW STRENGTH, SB ASPIRIN, SB ASPIRIN ADULT LOW STRENGTH, SB ASPIRIN EC, SB LOW DOSE ASA EC, SM ASPIRIN ADULT LOW STRENGTH, SM ASPIRIN EC LOW To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) ASPIRIN ADULT, (Methadone Hcl) PA; QL(1 ea BAYER ADVANCED METHADOSE TBSO 40 F daily) ASPIRIN REGULAR MG STRENGTH, BAYER (Morphine Sulfate) F PA; QL(10 ml ASPIRIN, CVS ASPIRIN, DURAMORPH SOLN daily) EQ ASPIRIN, EQL ASPIRIN, GNP ASPIRIN, CODEINE SULFATE TABS QL(6 ea daily) GOODSENSE ASPIRIN, 15 MG, 60 MG (codeine F GOODSENSE ASPIRIN sulfate) ADULTS, HM ADULT F QL(6 ea daily) codeine sulfate tabs 30 F ASPIRIN, HM ASPIRIN, mg MEDIQUE ASPIRIN, NORWICH ASPIRIN, PX fentanyl pt72 td 100 QL(0.34 ea ASPIRIN, QC ASPIRIN, RA daily) mcg/hr, 12 mcg/hr, 25 F ASPIRIN, RA PAIN mcg/hr, 50 mcg/hr, 75 RELIEF ASPIRIN, SB mcg/hr ASPIRIN, SM ADULT QL(20 ml daily) ASPIRIN, SM ASPIRIN, hydromorphone hcl liqd F TGT ASPIRIN TABS or 1 mg/ml aspirin buffered (cal HYDROMORPHONE HCL QL(4 ea daily) carb-mag carb-mag F SUPP RE 3 MG F oxide) tabs (hydromorphone hcl) hydromorphone hcl QL(6 ea daily) aspirin chew or 81 mg F F tabs or 2 mg, 4 mg ASPIRIN SUPP RE 300 QL(3 ea daily) F hydromorphone hcl F MG, 600 MG (aspirin) tabs or 8 mg aspirin tabs or 325 mg F hydromorphone hcl QL(1 ea daily) tb24 or 12 mg, 16 mg, F aspirin tbec or 325 mg, F 81 mg 8 mg KADIAN CP24 200 MG QL(1 ea daily) BUFFERIN EXTRA F STRENGTH TABS (morphine sulfate) QL(16 ml daily) (aspirin buffered (cal F meperidine hcl soln or F carb-mag carb-mag 50 mg/5ml oxide)) QL(6 ea daily) meperidine hcl tabs or F diflunisal tabs F 50 mg PA; QL(3 ml methadone hcl conc or F salsalate tabs F 10 mg/ml daily) PA; QL(15 ml ANALGESICS - OPIOID - Drugs to Treat Pain, methadone hcl soln or F daily) Muscle and Joint Conditions 10 mg/5ml Opioid Agonists methadone hcl soln or PA; QL(30 ml F daily) (Methadone Hcl) PA; QL(3 ml 5 mg/5ml METHADONE daily) PA; QL(3 ea F methadone hcl tabs or F HYDROCHLORIDE 10 mg daily) INTENSOL CONC PA; QL(6 ea methadone hcl tabs or F 5 mg daily) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(1 ea PA; QL(30 ml methadone hcl tbso or F morphine sulfate soln iv F 40 mg daily) 1 mg/ml daily) QL(1 ea daily) PA; QL(9 ml morphine sulfate beads F morphine sulfate soln iv F cp24 10 mg/ml daily) morphine sulfate cp24 QL(1 ea daily) MORPHINE SULFATE PA; QL(18 ml SOLN IV 150 MG/30ML F daily) or 10 mg, 100 mg, 20 F mg, 30 mg, 50 mg, 60 (morphine sulfate) PA; QL(22 ml mg, 80 mg morphine sulfate soln iv F MORPHINE SULFATE PA; QL(6 ml 4 mg/ml daily) DEVI IM 10 MG/0.7ML F daily) PA; QL(1 ml morphine sulfate soln iv F (morphine sulfate) 50 mg/ml daily) morphine sulfate soln ij PA; QL(10 ml PA; QL(11 ml F morphine sulfate soln iv F 0.5 mg/ml, 1 mg/ml daily) 8 mg/ml daily) MORPHINE SULFATE PA; QL(10 ml morphine sulfate soln QL(16 ml daily) SOLN IJ 1 MG/ML F daily) or 10 mg/5ml, 20 F (morphine sulfate) mg/5ml morphine sulfate soln ij PA; QL(9 ml F morphine sulfate soln QL(4 ml daily) 10 mg/ml daily) or 100 mg/5ml, 20 F MORPHINE SULFATE PA; QL(9 ml mg/ml SOLN IJ 10 MG/ML F daily) QL(6 ea daily) (morphine sulfate) morphine sulfate supp F MORPHINE SULFATE PA; QL(24 ml re 10 mg, 5 mg QL(4 ea daily) SOLN IJ 2 MG/ML F daily) morphine sulfate supp F (morphine sulfate) re 20 mg MORPHINE SULFATE PA; QL(25 ml QL(3 ea daily) morphine sulfate supp F SOLN IJ 2 MG/ML F daily) re 30 mg (morphine sulfate) QL(6 ea daily) morphine sulfate tabs F MORPHINE SULFATE PA; QL(22 ml or 15 mg SOLN IJ 4 MG/ML F daily) QL(3 ea daily) (morphine sulfate) morphine sulfate tabs F MORPHINE SULFATE PA; QL(18 ml or 30 mg QL(2 ea daily) SOLN IJ 5 MG/ML F daily) morphine sulfate tbcr or F (morphine sulfate) 100 mg, 200 mg, 60 mg PA; QL(11 ml morphine sulfate tbcr or QL(3 ea daily) morphine sulfate soln ij F F 8 mg/ml daily) 15 mg, 30 mg MORPHINE SULFATE PA; QL(11 ml NUCYNTA ER TB12 PA; QL(2 ea F SOLN IJ 8 MG/ML F daily) (tapentadol hcl) daily) (morphine sulfate) OXAYDO TABS 5 MG QL(6 ea daily) F MORPHINE SULFATE PA; QL(10 ml (oxycodone hcl) SOLN IV 0.5 MG/ML, 2 daily) QL(6 ea daily) F oxycodone hcl caps 5 F MG/ML (morphine mg sulfate) QL(3 ml daily) oxycodone hcl conc F 100 mg/5ml To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(30 ml daily) QL(90 ml daily) oxycodone hcl soln 5 F hydrocodone- mg/5ml acetaminophen soln oxycodone hcl t12a 10 PA; QL(2 ea 2.5 mg/5ml-108 F daily) mg/5ml, 5 mg/10ml-217 mg, 15 mg, 20 mg, 30 F mg, 40 mg, 60 mg, 80 mg/10ml, 7.5 mg/15ml- mg 325 mg/15ml QL(6 ea daily) hydrocodone- QL(8 ea daily) oxycodone hcl tabs 10 F mg, 5 mg acetaminophen tabs 10 QL(4 ea daily) mg-300 mg, 10 mg-325 oxycodone hcl tabs 15 F mg mg, 5 mg-300 mg, 5 F mg-325 mg, 7.5 mg- QL(3 ea daily) oxycodone hcl tabs 20 F 300 mg, 7.5 mg-325 mg mg QL(2 ea daily) oxycodone hcl tabs 30 F oxycodone w/ QL(6 ea daily) mg acetaminophen tabs 10 QL(8 ea daily) F tramadol hcl tabs 50 F mg-325 mg, 5 mg-325 mg mg, 7.5 mg-325 mg Opioid Combinations oxycodone-aspirin tabs F QL(6 ea daily) (Butalbital-Aspirin-Caffeine QL(4 ea daily) W/Cod) F tramadol- QL(4 ea daily); ASCOMP/CODEINE CAPS F AL(At least 18 acetaminophen tabs yrs old) (Hydrocodone- QL(8 ea daily) Opioid Partial Agonists Acetaminophen) LORCET, F LORCET HD, LORCET BELBUCA FILM CO PLUS TABS (buprenorphine hcl) (Oxycodone W/ QL(6 ea daily) BUNAVAIL FILM Acetaminophen) ENDOCET TABS 10 MG- F (buprenorphine hcl- CO 325 MG, 5 MG-325 MG, naloxone hcl dihydrate) 7.5 MG-325 MG BUPRENEX SOLN CO acetaminophen w/ QL(30 ml daily) (buprenorphine hcl) codeine soln 12 F buprenorphine hcl film CO mg/5ml-120 mg/5ml acetaminophen w/ QL(6 ea daily) buprenorphine hcl soln CO codeine tabs 15 mg- F 300 mg, 30 mg-300 buprenorphine hcl subl CO mg, 60 mg-300 mg buprenorphine hcl- butalbital- QL(4 ea daily) naloxone hcl dihydrate CO film acetaminophen- F caffeine w/ codeine buprenorphine hcl- caps naloxone hcl dihydrate CO QL(4 ea daily) subl butalbital-aspirin- F caffeine w/cod caps buprenorphine ptwk CO
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BUTRANS PTWK VOGELXO GEL CO F (buprenorphine) (testosterone) PROBUPHINE IMPLANT VOGELXO PUMP GEL F KIT IMPL CO (testosterone) (buprenorphine hcl) ANORECTAL AND RELATED PRODUCTS - SUBLOCADE SOSY CO Rectal Drugs to Treat Pain, Swelling and Itching (buprenorphine) Intrarectal Steroids SUBOXONE FILM (Hydrocortisone (buprenorphine hcl- CO (Intrarectal)) COLOCORT F naloxone hcl dihydrate) ENEM ZUBSOLV SUBL CORTIFOAM FOAM (buprenorphine hcl- CO (hydrocortisone acetate F naloxone hcl dihydrate) (intrarectal)) ANDROGENS-ANABOLIC - Drugs to Regulate hydrocortisone F Hormones (intrarectal) enem Anabolic Steroids Rectal Combinations oxandrolone tabs F (Lidocaine-Hydrocortisone Acetate (Rectal)) F Androgens LIDOCORT CREA ANDRODERM PT24 QL(1 ea daily) (Phenylephrine-Shark Liver F (testosterone) Oil-Cocoa Butter) HEMORRHOIDAL danazol caps F SUPPOSITORIES, PX F HEMORRHOIDAL, RA METHITEST TABS F HEMORRHOIDAL SUPP (methyltestosterone) 0.25 %-3 %-85.5 % methyltestosterone F (Phenylephrine-Shark Liver caps Oil-Cocoa Butter) testosterone cypionate QL(0.134 ml HEMORRHOIDAL F daily) SUPPOSITORIES, PX F soln ij 200 mg/ml HEMORRHOIDAL, RA TESTOSTERONE QL(0.134 ml HEMORRHOIDAL SUPP CYPIONATE SOLN IJ 200 daily) RE 0.25 %-3 %-85.5 % F MG/ML (testosterone (Phenylephrine-Shark Liver QL(60 gm per cypionate) Oil-Mineral Oil-Petrolatum) fill retail) PA PX HEMORRHOIDAL, RA F testosterone cypionate F HEMORRHOIDAL OINT soln im 100 mg/ml RE 0.25 %-3 %-14 %-71.9 QL(0.134 ml % testosterone cypionate F soln im 200 mg/ml daily) (Phenylephrine-Shark Liver QL(60 gm per testosterone gel 1 %, Oil-Mineral Oil-Petrolatum) F fill retail) SB HEMORRHOID OINT 1.62 %, 20.25 RE F mg/1.25gm, 25 ANALPRAM-HC LOTN 1 mg/2.5gm, 40.5 %-2.5 % (hydrocortisone F mg/2.5gm, 50 mg/5gm acetate w/ pramoxine)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Alum & Mag Hydrox- hydrocortisone acetate F w/ pramoxine crea Simethicone) ALMACONE, ALMACONE DOUBLE lidocaine- STRENGTH, hydrocortisone acetate F ALUMINA/MAGNESIA/SIM (rectal) crea ex 0.5 %-3 ETHICONE, ANTACID + % ANTI-GAS LIQUID lidocaine- QL(2 ea per fill MAXIMUM STRENGTH, retail) ANTACID ADVANCED, hydrocortisone acetate F ANTACID ANTI-GAS, (rectal) kit re 0.5 %-3 ANTACID ANTI-GAS %, 1 %-3 %, 2.5 %-3 % MAXIMUMSTRENGTH, PROCTOFOAM HC FOAM ANTACID ANTI-GAS REGULARSTRENGTH, (hydrocortisone acetate F ANTACID EXTRA w/ pramoxine) STRENGTH ANTI-GAS, Rectal Local Anesthetics ANTACID FAST RELIEF, ANTACID I, ANTACID III, pramoxine hcl (rectal) F ANTACID LIQUID, foam ANTACID M, ANTACID Rectal Steroids MAXIMUM STRENGTH, ANTACID PLUS ANTI-GAS (Hydrocortisone (Rectal)) FAST ACTING, ANTACID PROCTO-MED HC, PLUS ANTI-GAS RELIEF, PROCTO-PAK, F ANTACID PLUS ANTI-GAS PROCTOSOL HC, RELIEF MAXIMUM F PROCTOZONE-HC CREA STRENGTH, ANTACID REGULAR STRENGTH, hydrocortisone (rectal) F crea ANTACID/ANTI-GAS, ANTACID/ANTIGAS Vasodilating Agents LIQUID, RECTIV OINT ANTACID/SIMETHICONE (nitroglycerin (intra- F DOUBLE STRENGTH, anal)) COMFORT GEL, COMFORT GEL ANTACID ANTACIDS ANTI-GAS, COMFORT GEL ANTACID ANTI-GAS Antacid Combinations MAXIMUM STRENGTH, COMFORT GEL ANTACID& ANTI-GAS, CVS ANTACID PLUS ANTIGAS, CVS ANTACID/ANTI-GAS, CVS ANTACID/ANTI-GAS LIQUID, EQ ANTACID, EQ ANTACID MAXIMUM STRENGTH, EQ ANTACID/ANTI-GAS, EQL ANTACID ADVANCED MAXIMUM STRENGTH, EQL ANTACID/ANTI-GAS, FAST ACTING ANTACID To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PLUSANTI-GAS ANTACID ADVANCED MAXIMUM STRENGTH, MAXIMUM STRENGTH, GERI-LANTA, GERI-MOX, SM ANTACID ANTI-GAS, GNP ANTACID & ANTI- SM ANTACID MAXIMUM GAS/REGULAR STRENGTH, SM STRENGTH, GNP ANTACID/ANTIGAS, TGT ANTACID AND ANTI- ANTACID ANTI-GAS GAS/MAXIMUM REGULAR STRENGTH STRENGTH, GNP SUSP ANTACID ANTI-GAS, GNP (Alum & Mag Hydrox- ANTACID ANTI- Simethicone) ANTACID GAS/MAXIMUM SUSP 0.2 %-40 MG/10ML- STRENGTH, GNP 400 MG/10ML-400 ANTACID/REGULAR MG/10ML, 20 MG/5ML-200 F STRENGTH, MG/5ML-200 MG/5ML, 40 GOODSENSE ANTACID & MG/10ML-400 MG/10ML- GAS RELIEF REGULAR 400 MG/10ML, 40 STRENGTH, HM MG/5ML-400 MG/5ML-400 ADVANCED ANTACID MG/5ML MAXIMUM STRENGTH, (Alum & Mag Hydrox- HM ANTACID, HM Simethicone) MAALOX ANTACID ANTI-GAS MAX, PX ANTACID F EXTRASTRENGTH, HM MAXIMUM STRENGTH ANTACID/ANTIGAS, SUSP 40 MG/5ML-400 MAALOX MULTI MG/5ML-400 MG/5ML SYMPTOM MAXIMUM STRENGTH, MEIJER (Alum & Mag Hydrox- ANTACID ANTI-GAS, Simethicone) MAG-AL F MEIJER ANTACID PLUS, MAG-AL PLUS XS MAXIMUM STRENGTH, LIQD MI-ACID, MI-ACID (Alum & Mag Hydrox- MAXIMUM STRENGTH, Simethicone) MINTOX F MILANTEX, MILANTEX PLUS CHEW EXTRA STRENGTH, alum & mag hydrox- MINTOX MAXIMUM F STRENGTH, MINTOX simethicone susp REGULAR STRENGTH, SM FOAMING ANTACID MYLANTA MAXIMUM CHEW (aluminum F STRENGTH, PX ANTACID hydroxide-mag trisil) REGULAR STRENGTH, QC ANTACID, QC Antacids - Aluminum Salts ANTACID/ANTI-GAS, QC ALUMINUM HYDROXIDE ANTACID/ANTI-GAS SUSP (aluminum F MAXIMUM STRENGTH, hydroxide gel) RA ANTACID/ANTI-GAS, RA ANTACID/ANTIGAS Antacids - Bicarbonate MAXIMUM STRENGTH, sodium bicarbonate F RA ANTACID/GAS RELIEF (antacid) tabs MAXIMUM STRENGTH, SB ANTACID ANTI-GAS, Antacids - Calcium Salts SM ANTACID, SM ANTACID ADVANCED, SM To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Calcium Carbonate ANTACID, SB ANTACID (Antacid)) ANTACID EXTRA STRENGTH, SM CALCIUM EXTRA ANTACID, SM CALCIUM STRENGTH, ANTACID ANTACID, SM CALCIUM CALCIUM REGULAR ANTACID STRENGTH, ANTACID EXTRASTRENGTH, SM CALCIUM RICH, ANTACID SMOOTH ANTACID FLAVOR CHEWS, CAL- EXTRA STRENGTH, GEST ANTACID, TUMS SMOOTHIES CALCIUM ANTACID, CHEW CALCIUM ANTACID (Calcium Carbonate EXTRA STRENGTH, CVS (Antacid)) ANTACID F ANTACID EXTRA, CVS CHEW 500 MG, 750 MG ANTACID EXTRA (Calcium Carbonate STRENGTH, CVS (Antacid)) ANTACID ANTACID KIDS, CVS EXTRA STRENGTH, GNP CHEWY NOT CHALKY ANTACID EXTRA F FLAVOR CHEWS, CVS STRENGTH, TGT SMOOTH ANTACID ANTACID EXTRA EXTRASTRENGTH, EQ STRENGTH CHEW 750 ANTACID, EQ ANTACID MG EXTRA STRENGTH, EQL ANTACID, EQL ANTACID calcium carbonate F EXTRA STRENGTH, GNP (antacid) chew ANTACID, GOODSENSE calcium carbonate F ANTACID/EXTRA F STRENGTH, (antacid) susp GOODSENSE CALCIUM CARBONATE ANTACID/REGULAR TABS 648 MG (calcium F STRENGTH, HEALTHY carbonate (antacid)) MAMA TAME THE FLAME, HM ANTACID EXTRA MAALOX CHEW STRENGTH, HM ANTACID (calcium carbonate F REGULAR STRENGTH, (antacid)) HM CALCIUM ANTACID, Antacids - Magnesium Salts HM CALCIUM ANTACID EXTRASTRENGTH, HM (Magnesium Oxide) HM CALCIUM ANTACID MAGNESIUM TABS 400 F SMOOTHDISSOLVE, HM MG CALCIUM ANTACID magnesium oxide tabs F SMOOTHDISSOLVE 400 mg EXTRA STRENGTH, LONG LASTING ANTHELMINTICS - Drugs to Treat Worm ANTACID, PX ANTACID Infections EXTRA STRENGTH, PX Anthelmintics CALCIUM ANTACID REGULAR STRENGTH, (Pyrantel Pamoate) CVS QC ANTACID, QC PINWORM TREATMENT, ANTACID EXTRA PIN-AWAY, PINWORM F STRENGTH, RA MEDICINE, REESES ANTACID, RA ANTACID PINWORM MEDICINE EXTRA STRENGTH, SB SUSP To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(12 ea per sulfamethoxazole- fill retail)1 rtl albendazole tabs F trimethoprim tabs or F MAX fill,30 rtl 160 mg-800 mg, 80 day(s) supply, mg-400 mg EMVERM CHEW QL(2 ea per fill F (mebendazole) retail) Antiprotozoal Agents QL(20 ea per atovaquone susp F QL(10 ml daily) F fill retail)1 rtl praziquantel tabs MAX fill,30 rtl Chloramphenicols day(s) supply, PA chloramphenicol F ANTI-INFECTIVE AGENTS - MISC. - Drugs to sodium succinate solr Treat Bacterial Infections Glycopeptides Anti-infective Agents - Misc. FIRVANQ SOLR QL(300 ml per IMPAVIDO CAPS F fill retail) F (vancomycin hcl) (miltefosine) QL(4 ea daily) vancomycin hcl caps or F metronidazole caps or F 125 mg 375 mg vancomycin hcl caps or QL(8 ea daily) PA F metronidazole in nacl F 250 mg soln vancomycin hcl solr iv 1 F METRONIDAZOLE SOLN PA gm, 1000 mg, 500 mg IV 5 MG/ML F PA (metronidazole) vancomycin hcl solr iv 1.5 gm, 10 gm, 100 gm, F metronidazole tabs or F 5 gm, 750 mg 250 mg, 500 mg VANCOMYCIN PA trimethoprim tabs F HYDROCHLORIDE SOLN IV 1000 MG/10ML, 1250 Anti-infective Misc. - Combinations MG/12.5ML, 1500 F (Methenamine-Hyosc- MG/15ML, 1750 Methylene Blue-Sod Phos- MG/17.5ML, 2000 MG/20ML, 750 MG/7.5ML Phenyl Sal) F PHOSPHASAL, URETRON (vancomycin hcl) D/S, URIN D/S, UTIRA-C VANCOMYCIN PA TABS HYDROCHLORIDE SOLR (Sulfamethoxazole- IV 1.5 GM, 250 MG F Trimethoprim) SULFATRIM F (vancomycin hcl) PEDIATRIC SUSP VANCOMYCIN QL(300 ml per sulfamethoxazole- PA HYDROCHLORIDE SOLR fill retail) trimethoprim soln iv 80 F OR 250 MG/5ML F mg/5ml-400 mg/5ml (vancomycin hcl) sulfamethoxazole- Leprostatics trimethoprim susp or 40 F dapsone tabs F mg/5ml-200 mg/5ml Lincosamides
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEOCIN PHOSPHATE PA NITRO-DUR PT24 0.3 SOLN IV 300 MG/2ML, 600 MG/HR, 0.8 MG/HR F MG/4ML, 900 MG/6ML F (nitroglycerin) (clindamycin nitroglycerin pt24 td 0.1 phosphate) mg/hr, 0.2 mg/hr, 0.4 F clindamycin hcl caps F mg/hr, 0.6 mg/hr nitroglycerin subl sl 0.3 clindamycin palmitate F F hydrochloride solr mg, 0.4 mg, 0.6 mg PA ANTIANXIETY AGENTS - Drugs to Treat Anxiety clindamycin phosphate F soln Antianxiety Agents - Misc. Oxazolidinones buspirone hcl tabs F SIVEXTRO TABS PA; QL(6 ea F (tedizolid phosphate) per fill retail) hydroxyzine hcl syrp F Urinary Anti-infectives hydroxyzine hcl tabs F methenamine F mandelate tabs hydroxyzine pamoate F caps nitrofurantoin F macrocrystal caps meprobamate tabs F nitrofurantoin monohyd F macro caps Benzodiazepines (Lorazepam) LORAZEPAM F nitrofurantoin susp F INTENSOL CONC ANTIANGINAL AGENTS - Drugs to Treat Chest alprazolam tabs 0.25 F Pain mg, 0.5 mg, 1 mg, 2 mg Nitrates chlordiazepoxide hcl F caps (Nitroglycerin) MINITRAN F PT24 clorazepate F (Nitroglycerin) NITRO- F dipotassium tabs TIME CPCR diazepam soln 5 DILATRATE SR CPCR F F mg/5ml (isosorbide dinitrate) diazepam tabs 10 mg, F isosorbide dinitrate F 2 mg, 5 mg tabs lorazepam conc F isosorbide dinitrate tbcr F lorazepam tabs F isosorbide mononitrate F tabs oxazepam caps 10 mg, F 15 mg, 30 mg isosorbide mononitrate F tb24 ANTIARRHYTHMICS - Drugs to treat abnormal NITRO-BID OINT heart rhythms F (nitroglycerin) Antiarrhythmics Type I-A
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; SP- disopyramide F FASENRA SOSY phosphate caps F AcariaHealth;S (benralizumab) P NORPACE CAPS PA; SP- ( F NUCALA SOLR 100 MG disopyramide F AcariaHealth;S phosphate) (mepolizumab) P NORPACE CR CP12 XOLAIR SOLR PA; SP- (disopyramide F F AcariaHealth;S phosphate) (omalizumab) P F PA XOLAIR SOSY PA; SP- procainamide hcl soln F AcariaHealth;S (omalizumab) P quinidine gluconate F tbcr Asthma and Bronchodilator Agent Combinations quinidine sulfate tabs F (Dyphylline-Guaifenesin) F DIFIL-G FORTE LIQD Antiarrhythmics Type I-B Bronchodilators - Anticholinergics mexiletine hcl caps 150 F ATROVENT HFA AERS mg, 200 mg, 250 mg (ipratropium bromide F Antiarrhythmics Type I-C hfa) INCRUSE ELLIPTA AEPB F F flecainide acetate tabs (umeclidinium bromide) propafenone hcl cp12 F ipratropium bromide F soln propafenone hcl tabs F SPIRIVA HANDIHALER QL(1 ea daily) CAPS ( Antiarrhythmics Type III tiotropium F bromide monohydrate) (Amiodarone Hcl) F PACERONE TABS SPIRIVA RESPIMAT QL(0.14 gm AERS (tiotropium F daily) amiodarone hcl tabs F bromide monohydrate) dofetilide caps F TUDORZA PRESSAIR AEPB (aclidinium F MULTAQ TABS F bromide) (dronedarone hcl) Leukotriene Modulators ANTIASTHMATIC AND BRONCHODILATOR montelukast sodium QL(1 ea daily) AGENTS - Drugs to Treat Lung Conditions F chew Anti-Inflammatory Agents QL(1 ea daily) montelukast sodium F cromolyn sodium nebu F pack QL(1 ea daily) Antiasthmatic - Monoclonal Antibodies montelukast sodium F tabs CINQAIR SOLN PA; SP- F AcariaHealth;S zafirlukast tabs F (reslizumab) P Steroid Inhalants
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ARNUITY ELLIPTA AEPB Limit 1 inhaler FLOVENT HFA AERO 110 QL(12 gm per ( per month;QL(1 MCG/ACT, 220 MCG/ACT fill retail,12 gm fluticasone furoate F F (inhalation)) ea daily) (fluticasone propionate per 25 days retail) ASMANEX HFA AERO 100 Limit 1 inhaler hfa) MCG/ACT, 200 MCG/ACT per FLOVENT HFA AERO 44 (mometasone furoate F month;QL(0.44 MCG/ACT (fluticasone F (inhalation)) gm daily) propionate hfa) ASMANEX TWISTHALER Limit 1 Inhaler PULMICORT FLEXHALER 120 METERED DOSES per AEPB ( F budesonide F AEPB (mometasone month;QL(0.03 (inhalation)) 4 ea daily) furoate (inhalation)) QVAR REDIHALER AERB QL(0.36 gm ASMANEX TWISTHALER Limit 1 Inhaler 40 MCG/ACT daily) 14 METERED DOSES per ( F F beclomethasone AEPB (mometasone month;QL(0.03 dipropionate hfa) 4 ea daily) furoate (inhalation)) QVAR REDIHALER AERB QL(0.72 gm ASMANEX TWISTHALER Limit 1 Inhaler 80 MCG/ACT daily) 30 METERED DOSES per ( F F beclomethasone AEPB (mometasone month;QL(0.03 dipropionate hfa) furoate (inhalation)) 4 ea daily) Sympathomimetics ASMANEX TWISTHALER Limit 1 Inhaler 60 METERED DOSES per (Fluticasone-Salmeterol) F QL(2 ea daily) WIXELA INHUB AEPB AEPB (mometasone F month;QL(0.03 ADVAIR HFA AERO PA; QL(0.4 gm furoate (inhalation)) 4 ea daily) F (fluticasone-salmeterol) daily) ASMANEX TWISTHALER Limit 1 Inhaler 7 METERED DOSES per albuterol sulfate aers in QL(0.45 gm F daily) AEPB (mometasone F month;QL(0.03 108 mcg/act ) 4 ea daily) QL(1.2 gm furoate (inhalation) albuterol sulfate aers in F budesonide (inhalation) QL(8 ml daily) 108 mcg/act daily) F QL(0.57 gm susp 0.25 mg/2ml albuterol sulfate aers in F budesonide (inhalation) QL(4 ml daily) 108 mcg/act daily) susp 0.5 mg/2ml, 1 F albuterol sulfate nebu mg/2ml in 0.083 %, 0.5 %, 0.63 F FLOVENT DISKUS AEPB QL(2 ea daily) mg/3ml, 1.25 mg/3ml, 100 MCG/BLIST 2.5 mg/0.5ml F (fluticasone propionate ALBUTEROL SULFATE (inhalation)) NEBU IN 0.5 % (albuterol F FLOVENT DISKUS AEPB QL(8 ea daily) sulfate) 250 MCG/BLIST F albuterol sulfate syrp or F (fluticasone propionate 2 mg/5ml (inhalation)) albuterol sulfate tabs or FLOVENT DISKUS AEPB F 50 MCG/BLIST 2 mg, 4 mg F (fluticasone propionate albuterol sulfate tb12 or F (inhalation)) 4 mg, 8 mg
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANORO ELLIPTA AEPB QL(2 ea daily) SEREVENT DISKUS QL(2 ea daily) (umeclidinium- F AEPB (salmeterol F vilanterol) xinafoate) BEVESPI AEROSPHERE QL(0.36 gm STIOLTO RESPIMAT Limit 1 inhaler AERO (glycopyrrolate- F daily) AERS (tiotropium F per formoterol fumarate) month;QL(0.14 bromide-olodaterol hcl) gm daily) BREO ELLIPTA AEPB 25 PA; Limit 1 MCG/INH-100 MCG/INH inhaler per STRIVERDI RESPIMAT QL(0.14 gm F daily) (fluticasone furoate- F month;QL(2 ea AERS (olodaterol hcl) daily) vilanterol) terbutaline sulfate tabs F BREO ELLIPTA AEPB 25 PA MCG/INH-200 MCG/INH TRELEGY ELLIPTA AEPB QL(2 ea daily) (fluticasone furoate- F (fluticasone- F vilanterol) umeclidinium-vilanterol) budesonide-formoterol Xanthines fumarate dihydrate F aminophylline soln F PA aero ELIXOPHYLLIN ELIX COMBIVENT RESPIMAT F (theophylline) AERS (ipratropium- F THEO-24 CP24 albuterol) F (theophylline) DULERA AERO PA ( theophylline soln 80 QL(475 ml per mometasone furoate- F fill retail) formoterol fumarate F mg/15ml dihydrate) theophylline tb12 100 fluticasone-salmeterol QL(0.04 ea mg, 200 mg, 300 mg, F aepb 14 mcg/act-113 daily) 450 mg mcg/act, 14 mcg/act- F theophylline tb24 400 F 232 mcg/act, 14 mg, 600 mg mcg/act-55 mcg/act ANTICOAGULANTS - Blood Thinners fluticasone-salmeterol QL(2 ea daily) aepb 50 mcg/act-100 Coumarin Anticoagulants mcg/act, 50 mcg/act- (Warfarin Sodium) F 250 mcg/act, 50 JANTOVEN TABS COUMADIN TABS mcg/dose-100 F F mcg/dose, 50 (warfarin sodium) mcg/dose-250 warfarin sodium tabs F mcg/dose, 50 mcg/dose-500 Direct Factor Xa Inhibitors mcg/dose QL(42 ea per BEVYXXA CAPS ipratropium-albuterol F fill retail,42 ea F (betrixaban maleate) per 42 days soln retail) ELIQUIS STARTER PACK F TBPK (apixaban) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELIQUIS TABS F AMPA Glutamate Receptor Antagonists (apixaban) FYCOMPA SUSP F XARELTO STARTER (perampanel) PACK TBPK F FYCOMPA TABS ) F (rivaroxaban (perampanel) XARELTO TABS 10 MG QL(1 ea F daily,35 ea per Anticonvulsants - Benzodiazepines (rivaroxaban) 180 days retail) clonazepam tabs F XARELTO TABS 15 MG, F 20 MG (rivaroxaban) clonazepam tbdp F Heparins And Heparinoid-Like Agents diazepam F enoxaparin sodium QL(14 ml per 7 (anticonvulsant) gel F days retail)3 rtl soln sc 100 mg/ml, 150 MAX fill,180 rtl NAYZILAM SOLN PA; QL(10 ea mg/ml day(s) supply, (midazolam F per 30 days (anticonvulsant)) retail) enoxaparin sodium QL(12 ml per 7 F days retail)3 rtl Anticonvulsants - Misc. soln sc 120 mg/0.8ml, MAX fill,180 rtl 80 mg/0.8ml (Carbamazepine) EPITOL F day(s) supply, TABS QL(5 ml per 7 (Lamotrigine) SUBVENITE F enoxaparin sodium F days retail)3 rtl TABS soln sc 30 mg/0.3ml MAX fill,180 rtl day(s) supply, (Levetiracetam) F ROWEEPRA TABS QL(6 ml per 7 (Levetiracetam) ST enoxaparin sodium F days retail)3 rtl F soln sc 40 mg/0.4ml MAX fill,180 rtl ROWEEPRA XR TB24 day(s) supply, carbamazepine chew F QL(9 ml per 7 enoxaparin sodium F days retail)3 rtl carbamazepine cp12 F soln sc 60 mg/0.6ml MAX fill,180 rtl day(s) supply, carbamazepine susp F PA heparin sod (porcine) in F d5w soln carbamazepine tabs F heparin sodium F carbamazepine tb12 F (porcine) soln HEPARIN PA gabapentin caps F SODIUM/DEXTROSE SOLN (heparin sod F gabapentin soln F (porcine) in d5w) gabapentin tabs F Thrombin Inhibitors PRADAXA CAPS PA lamotrigine chew 25 F (dabigatran etexilate F mg, 5 mg mesylate) lamotrigine tabs 100 mg, 150 mg, 200 mg, F ANTICONVULSANTS - Drugs to Treat Seizures 25 mg
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lamotrigine tb24 100 ST (Vigabatrin) VIGADRONE F SP- mg, 200 mg, 25 mg, PACK Caremark;SP F GABITRIL TABS 4 MG 250 mg, 300 mg, 50 F mg (tiagabine hcl) levetiracetam soln 100 F tiagabine hcl tabs F mg/ml, 500 mg/5ml F SP- levetiracetam tabs vigabatrin pack Caremark;SP 1000 mg, 250 mg, 500 F SP-Accredo;SP mg, 750 mg vigabatrin tabs F ST Hydantoins levetiracetam tb24 500 F mg, 750 mg (Phenytoin) PHENYTOIN F INFATABS CHEW oxcarbazepine susp F DILANTIN CAPS 100 MG oxcarbazepine tabs F (phenytoin sodium F extended) primidone tabs F DILANTIN CAPS 30 MG SP (phenytoin sodium F rufinamide susp F extended) SP DILANTIN INFATABS rufinamide tabs F F CHEW (phenytoin) TEGRETOL SUSP DILANTIN-125 SUSP F F (carbamazepine) (phenytoin) TEGRETOL TABS F (carbamazepine) phenytoin chew F TEGRETOL-XR TB12 F phenytoin sodium F (carbamazepine) extended caps topiramate cpsp or 15 F phenytoin susp F mg, 25 mg topiramate tabs or 100 Succinimides CELONTIN CAPS mg, 200 mg, 25 mg, 50 F F mg (methsuximide) VIMPAT SOLN F ethosuximide caps F (lacosamide) VIMPAT TABS ethosuximide soln F F (lacosamide) ZARONTIN CAPS F zonisamide caps F (ethosuximide) ZARONTIN SOLN F Carbamates (ethosuximide) felbamate susp F Valproic Acid DEPAKENE CAPS felbamate tabs F F (valproic acid) GABA Modulators To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits divalproex sodium csdr F Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram QL(20 ml daily) divalproex sodium tb24 F hydrobromide soln 10 F mg/5ml divalproex sodium tbec F citalopram QL(4 ea daily) valproate sodium soln F hydrobromide tabs 10 F mg valproic acid caps F citalopram QL(2 ea daily) ANTIDEPRESSANTS - Drugs to Treat hydrobromide tabs 20 F Depression mg Alpha-2 Receptor Antagonists (Tetracyclics) citalopram QL(1 ea daily) hydrobromide tabs 40 F mirtazapine tabs F mg mirtazapine tbdp F escitalopram oxalate F soln Antidepressants - Misc. escitalopram oxalate F bupropion hcl tabs 100 F tabs mg, 75 mg fluoxetine hcl caps 10 F bupropion hcl tb12 100 F mg, 20 mg, 40 mg mg, 150 mg fluoxetine hcl soln 20 QL(2 ea daily) F bupropion hcl tb12 200 F mg/5ml mg fluoxetine hcl tabs 10 QL(3 ea daily) F bupropion hcl tb24 150 F mg, 20 mg mg fluvoxamine maleate QL(1 ea daily) F bupropion hcl tb24 300 F cp24 mg fluvoxamine maleate F maprotiline hcl tabs F tabs Monoamine Oxidase Inhibitors (MAOIs) paroxetine hcl tabs F EMSAM PT24 CO paroxetine hcl tb24 F (selegiline) MARPLAN TABS PAXIL SUSP 10 MG/5ML CO F (isocarboxazid) (paroxetine hcl) NARDIL TABS CO sertraline hcl conc F (phenelzine sulfate) PARNATE TABS sertraline hcl tabs F ( CO tranylcypromine Serotonin Modulators sulfate) nefazodone hcl tabs F phenelzine sulfate tabs CO trazodone hcl tabs F tranylcypromine sulfate CO tabs To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIIBRYD TABS PA F ANTIDIABETICS - Drugs to Regulate Blood (vilazodone hcl) Sugar Serotonin-Norepinephrine Reuptake Inhibitors Alpha-Glucosidase Inhibitors DESVENLAFAXINE ER ST F acarbose tabs F TB24 (desvenlafaxine) Antidiabetic - Amylin Analogs desvenlafaxine F SYMLINPEN 120 SOPN PA succinate tb24 F (pramlintide acetate) desvenlafaxine tb24 F ST SYMLINPEN 60 SOPN PA F QL(2 ea daily) (pramlintide acetate) duloxetine hcl cpep 20 F mg, 30 mg, 60 mg Antidiabetic Combinations KHEDEZLA TB24 ST F alogliptin-metformin hcl F (desvenlafaxine) tabs venlafaxine hcl cp24 alogliptin-pioglitazone F 150 mg, 37.5 mg, 75 F tabs mg glipizide-metformin hcl F venlafaxine hcl tabs tabs 100 mg, 25 mg, 37.5 F mg, 50 mg, 75 mg glyburide-metformin F tabs venlafaxine hcl tb24 INVOKAMET TABS PA 150 mg, 225 mg, 75 F mg (canagliflozin- F metformin hcl) QL(1 ea daily) venlafaxine hcl tb24 F INVOKAMET XR TB24 PA 37.5 mg (canagliflozin- F Tricyclic Agents metformin hcl) amitriptyline hcl tabs F JANUMET TABS PA (sitagliptin-metformin F amoxapine tabs F hcl) JANUMET XR TB24 PA clomipramine hcl caps F (sitagliptin-metformin F hcl) desipramine hcl tabs F JENTADUETO TABS PA; AL(At least doxepin hcl caps F (linagliptin-metformin F 18 yrs old) hcl) doxepin hcl conc F KOMBIGLYZE XR TB24 PA (saxagliptin-metformin F imipramine hcl tabs F hcl) QL(1 ea daily) nortriptyline hcl caps F pioglitazone hcl- F glimepiride tabs nortriptyline hcl soln F pioglitazone hcl- F metformin hcl tabs protriptyline hcl tabs F
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SEGLUROMET TABS QL(2 ea daily) glucagon (rdna) kit F QL(1 ea per fill (ertugliflozin-metformin F retail) hcl) GLUCOSE CHEW 4 GM SOLIQUA 100/33 SOPN PA (dextrose (diabetic F (insulin glargine- F use)) lixisenatide) GNP GLUCOSE CHEW 4 SYNJARDY TABS PA GM (dextrose (diabetic F (empagliflozin- F use)) metformin hcl) GNP QUICK DISSOLVE GLUCOSE CHEW SYNJARDY XR TB24 PA F (empagliflozin- F (dextrose (diabetic metformin hcl) use)) XULTOPHY 100/3.6 SOPN PA GVOKE PFS SOSY QL(0.02 ml F daily) (insulin degludec- F (glucagon) liraglutide) KORLYM TABS PA; SP (mifepristone F Biguanides (hyperglycemia)) metformin hcl tabs LEADER QUICK 1000 mg, 500 mg, 850 F DISSOLVE GLUCOSE mg CHEW (dextrose F metformin hcl tb24 500 F (diabetic use)) mg, 750 mg SM GLUCOSE CHEW 4 Diabetic Other GM (dextrose (diabetic F BAQSIMI ONE PACK QL(0.069 ea use)) F POWD (glucagon) daily) WALGREENS GLUCOSE BAQSIMI TWO PACK QL(0.069 ea CHEW 4 GM (dextrose F F POWD (glucagon) daily) (diabetic use)) BD GLUCOSE CHEW Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (dextrose (diabetic F alogliptin benzoate tabs F use)) JANUVIA TABS PA CVS GLUCOSE CHEW 4 F GM (dextrose (diabetic F (sitagliptin phosphate) ONGLYZA TABS PA use)) F CVS SOFT GLUCOSE (saxagliptin hcl) TRADJENTA TABS PA CHEW (dextrose F F (diabetic use)) (linagliptin) DEX4 QUICK DISSOLVE Dopamine Receptor Agonists - Antidiabetic GLUCOSE CHEW F CYCLOSET TABS (dextrose (diabetic (bromocriptine F use)) mesylate (diabetes)) GLUCAGEN HYPOKIT Incretin Mimetic Agents (GLP-1 Receptor SOLR (glucagon hcl F ADLYXIN SOPN PA (rdna)) F (lixisenatide) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADLYXIN STARTER PACK PA HUMULIN 70/30 KWIKPEN F PNKT (lixisenatide) SUPN (insulin nph F BYDUREON BCISE AUIJ PA isophane & reg F (exenatide) (human)) BYDUREON PEN PEN PA HUMULIN 70/30 SUSP F (exenatide) (insulin nph isophane & F BYETTA SOPN PA reg (human)) F (exenatide) HUMULIN N KWIKPEN TRULICITY SOPN 0.75 PA SUPN (insulin nph F MG/0.5ML, 1.5 MG/0.5ML F (human) (isophane)) (dulaglutide) HUMULIN N SUSP VICTOZA SOPN PA (insulin nph (human) F F (liraglutide) (isophane)) HUMULIN R SOLN Insulin Sensitizing Agents (insulin regular F AVANDIA TABS F (human)) (rosiglitazone maleate) HUMULIN R U-500 Limit 20 per F month;QL(0.67 pioglitazone hcl tabs (CONCENTRATED) F SOLN (insulin regular ml daily) Insulin (human)) ADMELOG SOLN ( QL(1.67 ml insulin F HUMULIN R U-500 Limit 20 per lispro) daily) KWIKPEN SOPN (insulin F month;QL(0.67 ADMELOG SOLOSTAR QL(30 ml per regular (human)) ml daily) F SOPN (insulin lispro) 30 days retail) INSULIN ASPART QL(30 ml per PROTAMINE/INSULIN 30 days retail) BASAGLAR KWIKPEN Limit 50mls per F month;QL(1.67 ASPART FLEXPEN SUPN SOPN (insulin glargine) ml daily) (insulin aspart F HUMALOG MIX 50/50 protamine & aspart KWIKPEN SUPN (insulin (human)) F lispro protamine & INSULIN ASPART QL(40 ml per lispro) PROTAMINE/INSULIN 30 days retail) HUMALOG MIX 50/50 ASPART SUSP (insulin F SUSP (insulin lispro F aspart protamine & protamine & lispro) aspart (human)) HUMALOG MIX 75/25 INSULIN LISPRO PROTAMINE/INSULIN KWIKPEN SUPN (insulin F LISPRO KWIKPEN SUPN F lispro protamine & (insulin lispro protamine lispro) & lispro) HUMALOG MIX 75/25 NOVOLIN 70/30 FLEXPEN SUSP (insulin lispro F RELION SUPN (insulin protamine & lispro) nph isophane & reg F (human))
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NOVOLIN 70/30 FLEXPEN NOVOLOG MIX 70/30 QL(40 ml per SUPN (insulin nph SUSP (insulin aspart 30 days retail) isophane & reg F protamine & aspart F (human)) (human)) NOVOLIN 70/30 RELION Meglitinide Analogues SUSP (insulin nph isophane & reg F nateglinide tabs F (human)) Sodium-Glucose Co-Transporter 2 (SGLT2) NOVOLIN 70/30 SUSP INVOKANA TABS PA F (insulin nph isophane & F (canagliflozin) reg (human)) JARDIANCE TABS PA F NOVOLIN N FLEXPEN (empagliflozin) RELION SUPN (insulin F STEGLATRO TABS QL(1 ea daily) nph (human) (isophane)) (ertugliflozin l- F NOVOLIN N FLEXPEN pyroglutamic acid) SUPN (insulin nph F (human) (isophane)) Sulfonylureas (Glipizide) GLIPIZIDE XL F NOVOLIN N RELION TB24 SUSP (insulin nph F (human) (isophane)) glimepiride tabs F NOVOLIN N SUSP glipizide tabs F (insulin nph (human) F (isophane)) glipizide tb24 F NOVOLIN R RELION SOLN (insulin regular F glyburide micronized F (human)) tabs NOVOLIN R SOLN glyburide tabs F (insulin regular F (human)) tolbutamide tabs F NOVOLOG MIX 70/30 QL(30 ml per PREFILLED FLEXPEN 30 days retail) ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea RELION SUPN (insulin F aspart protamine & Antidiarrheal/Probiotic Agents - Misc. aspart (human)) NOVOLOG MIX 70/30 QL(30 ml per PREFILLED FLEXPEN 30 days retail) SUPN (insulin aspart F protamine & aspart (human)) NOVOLOG MIX 70/30 QL(40 ml per RELION SUSP (insulin 30 days retail) aspart protamine & F aspart (human))
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Bismuth Subsalicylate) RELIEF ULTRA SUSP BISMATROL, BISMATROL MAXIMUM STRENGTH, (Bismuth Subsalicylate) CVS STOMACH RELIEF, BISMATROL, CVS CVS STOMACH RELIEF BISMUTH, CVS MAXIMUM STRENGTH, STOMACH RELIEF, EQ DIARRHEA, DIOTAME PINK-BISMUTH, EQL INSTYDOSE, EQ STOMACH RELIEF, GNP STOMACH RELIEF, EQL PINK BISMUTH, STOMACH RELIEF, EQL GOODSENSE STOMACH F STOMACH RELIEF RELIEF, HM STOMACH MAXIMUM STRENGTH, RELIEF, MEDI-BISMUTH, GERI-PECTATE, GNP PEPTIC RELIEF, PX STOMACH RELIEF, GNP STOMACH RELIEF, QC STOMACH RELIEF PINK BISMUTH, RA PINK MAXIMUM STRENGTH, BISMUTH, SM STOMACH GNP ULTRA STOMACH RELIEF, STOMACH RELIEF, GOODSENSE RELIEF CHEW STOMACH RELIEF, (Bismuth Subsalicylate) GOODSENSE STOMACH CVS ANTI-DIARRHEAL F RELIEF/MAXIMUM SUSP 262 MG/15ML STRENGTH, HM STOMACH RELIEF, HM (Bismuth Subsalicylate) STOMACH RELIEF CVS BISMUTH, CVS MAXIMUMSTRENGTH, STOMACH RELIEF, EQL STOMACH RELIEF, GNP HM STOMACH RELIEF F ULTRA, KAOPECTATE, PINK BISMUTH, F KAOPECTATE EXTRA KAOPECTATE, QC PINK STRENGTH, PINK BISMUTH, SB BISMUTH, BISMUTH, PINK BISMUTH SM STOMACH RELIEF, MAXIMUM STRENGTH, TGT STOMACH RELIEF PX STOMACH RELIEF, PX TABS STOMACH RELIEF (Bismuth Subsalicylate) MAXIMUM STRENGTH, SOOTHE CHEW OR 262 F QC DIARRHEA RELIEF, MG QC PINK BISMUTH, RA (Bismuth Subsalicylate) STOMACH RELIEF, RA SOOTHE SUSP OR 262 F STOMACH RELIEF MG/15ML, 525 MG/30ML MAXIMUM STRENGTH, (Bismuth Subsalicylate) SM STOMACH RELIEF, SOOTHE TABS OR 262 F SM STOMACH RELIEF MG LIQUID, SM STOMACH RELIEF bismuth subsalicylate F MAXIMUMSTRENGTH, chew SOOTHE MAXIMUM bismuth subsalicylate STRENGTH, STOMACH F RELIEF, STOMACH susp RELIEF EXTRA Antiperistaltic Agents STRENGTH, STOMACH RELIEF MAXIMUM STRENGTH, STOMACH RELIEF PLUS, STOMACH To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Loperamide Hcl) ANTI- QL(8 ea daily); Antidotes - Chelating Agents DIARRHEAL, CVS ANTI- RX/OTC CHEMET CAPS DIARRHEAL, HM ANTI- F DIARRHEAL, HM F (succimer) LOPERAMIDE HCL, SM deferasirox pack 180 PA; SP- ANTI-DIARRHEAL CAPS 2 F AcariaHealth;S MG mg, 360 mg, 90 mg P (Loperamide Hcl) ANTI- QL(8 ea daily) PA; SP deferasirox tabs 180 F DIARRHEAL, CVS ANTI- mg, 360 mg, 90 mg DIARRHEAL, HM ANTI- F DIARRHEAL, SM ANTI- Antidotes and Specific Antagonists DIARRHEAL TABS 2 MG VISTOGARD PACK (Loperamide Hcl) QL(8 ea daily) (uridine triacetate F DIAMODE, EQ ANTI- (emergency treatment)) DIARRHEAL, EQL ANTI- DIARRHEAL, GNP ANTI- Opioid Antagonists DIARRHEAL, KLS ANTI- EVZIO SOAJ ( naloxone CO DIARRHEAL, MEIJER hcl) ANTI-DIARRHEAL, MM F ANTI-DIARRHEAL, PX naloxone hcl soaj CO ANTI-DIARRHEAL, QC ANTI-DIARRHEAL, RA naloxone hcl soct CO ANTI-DIARRHEAL, SB ANTI-DIARRHEA, SR naloxone hcl soln CO ANTI-DIARRHEAL, TGT ANTI-DIARRHEAL TABS naloxone hcl sosy CO (Loperamide Hcl) EQ QL(8 ea daily); ANTI-DIARRHEAL, GNP RX/OTC naltrexone hcl tabs CO ANTI-DIARRHEAL, QC F ANTI-DIARRHEAL, RA NALTREXONE IMPL ANTI-DIARRHEAL, TGT (naltrexone- CO LOPERAMIDE HCL CAPS triamcinolone) ANTI-DIARRHEAL LIQD 1 QL(40 ml daily) NARCAN LIQD CO MG/5ML (loperamide F (naloxone hcl) hcl) VIVITROL SUSR CO (naltrexone) diphenoxylate w/ F atropine liqd ANTIEMETICS - Drugs to Treat Nausea and Vomiting diphenoxylate w/ F atropine tabs 5-HT3 Receptor Antagonists loperamide hcl caps 2 QL(8 ea daily); F granisetron hcl soln F PA mg RX/OTC QL(8 ea daily) F PA loperamide hcl tabs 2 F granisetron hcl tabs mg QL(50 ml per ondansetron hcl soln 4 F paregoric tinc F mg/5ml fill retail) QL(20 ea per ondansetron hcl tabs 4 F ANTIDOTES AND SPECIFIC ANTAGONISTS mg, 8 mg 30 days retail)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(20 ea per DRAMAMINE CHEW ondansetron tbdp F F 30 days retail) (dimenhydrinate) Antiemetics - Anticholinergic meclizine hcl chew F RX/OTC (Dimenhydrinate) CVS MOTION SICKNESS, meclizine hcl tabs F RX/OTC DRIMINATE, EQ MOTION SICKNESS RELIEF, trimethobenzamide hcl F GOODSENSE MOTION caps SICKNESS, HM MOTION F SICKNESS, QC MOTION Antiemetics - Miscellaneous SICKNESS RELIEF, SB Limit 2 fills per MOTION SICKNESS, SM BONJESTA TBCR year;QL(1 ea MOTION SICKNESS F daily)2 rtl MAX RELIEF, TRAV-TABS, (doxylamine-pyridoxine) fill,365 rtl WAL-DRAM TABS day(s) supply, (Dimenhydrinate) GNP Limit 2 fills per MOTION SICKNESS doxylamine-pyridoxine year;QL(2 ea RELIEF, HM MOTION F daily)2 rtl MAX SICKNESS RELIEF, tbec fill,365 rtl day(s) supply, MOTION SICKNESS F RELIEF, RA MOTION PA SICKNESS RELIEF, SM dronabinol caps F MOTION SICKNESS, TRAVEL SICKNESS TABS Substance P/Neurokinin 1 (NK1) Receptor 50 MG aprepitant caps F 1 rtl pack lmt (Meclizine Hcl) BONINE, RX/OTC per fill, QL(1 ea per fill CVS MOTION SICKNESS F aprepitant caps 125 mg F RELIEF, MOTION-TIME, retail) QC TRAVEL EASE CHEW aprepitant caps 40 mg F (Meclizine Hcl) CVS RX/OTC MOTION SICKNESS II, aprepitant caps 80 mg F QL(2 ea per fill CVS MOTION SICKNESS retail) LESSDROWSY aprepitant misc F 1 rtl pack lmt FORMULA, DRAMAMINE F per fill, LESS DROWSY, EQL MOTION SICKNESS ANTIFUNGALS - Drugs to Treat Fungal Infections RELIEF, HM MOTION RELIEF, TRAVEL-EASE, Antifungals WAL-DRAM II TABS griseofulvin microsize F (Meclizine Hcl) GNP RX/OTC susp MOTION SICKNESS griseofulvin microsize RELIEF, HM MOTION F F SICKNESS RELIEF, SM tabs MOTION SICKNESS TABS griseofulvin F 25 MG ultramicrosize tabs (Meclizine Hcl) MOTION RX/OTC SICKNESS RELIEF, RA nystatin tabs F MOTION SICKNESS F F QL(90 ea per RELIEF, TRAVEL terbinafine hcl tabs 365 days retail) SICKNESS CHEW 25 MG To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Imidazole-Related Antifungals (Chlorpheniramine Maleate) DIABETIC F fluconazole susr F TUSSIN ALLERGY, ED CHLORPED JR SYRP fluconazole tabs F (Dexchlorpheniramine F PA Maleate) RYCLORA SOLN itraconazole caps 100 F mg chlorpheniramine F maleate tabs 4 mg ketoconazole tabs F dexchlorpheniramine F voriconazole susr F maleate soln Antihistamines - Ethanolamines voriconazole tabs F (Clemastine Fumarate) DAYHIST ALLERGY 12 ANTIHISTAMINES - Drugs to Treat Allergies HOUR RELIEF, GNP F DAYHIST ALLERGY, PX Antihistamines - Alkylamines DAYHIST ALLERGY, SM (Chlorpheniramine ALLERGY RELIEF TABS Maleate) ALLER-CHLOR, (Diphenhydramine Hcl) ALLERGY TABLETS, ALER-CAP, COMPLETE ALLERGY-TIME, ALLERGY MEDICINE, CHLORHIST, EQ CVS ALLERGY, CHLORTABS, EQL DIPHENHIST, EQL ALLERGY, GNP ALLERGY RELIEF, GNP ALLERGY, GNP ALLERGY ALLERGY, GNP ALLERGY RELIEF, GOODSENSE RELIEF, HM ALLERGY ALLERGY RELIEF, HM RELIEF, HM ALLGERY ALLERGY RELIEF, F MULTI SYMPTOM, KP PHARBECHLOR, QC DIPHENHYDRAMINE F ALLERGY RELIEF 4- HCL, MEDI-PHEDRYL, HOUR, QC CHLOR- MEIJER ANTIHISTAMINE PHENIRAMINE, RA ALLERGY, PHARBEDRYL, ALLERGY RELIEF, RA PX ALLERGY, RA CHLORPHENIRAMINE ALLERGY MEDICATION, MALEATE, SB RA ALLERGY RELIEF, SB CHLORPHENIRAMINE, ALLERGY, SM ALLERGY SM ALLERGY 4 HOUR, RELIEF, TGT ALLERGY WAL-FINATE TABS RELIEF, WAL-DRYL (Chlorpheniramine ALLERGY CAPS Maleate) ALLERGY, ALLERGY RELIEF, CVS F ALLERGY RELIEF TABS 4 MG (Chlorpheniramine Maleate) ALLERGY, ALLERGY RELIEF, CVS F ALLERGY RELIEF TABS OR 4 MG
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Diphenhydramine Hcl) (Diphenhydramine Hcl) ALERTAB, ALKA- ALLERGY CHILDRENS, SELTZER PLUS ALLERGY AURODRYL ALLERGY FAST RELIEF FORMULA, CHILDRENS, CVS ANTI-HIST ALLERGY, ALLERGY RELIEF COMPLETE ALLERGY ADULTMAXIMUM MEDICINE, COMPLETE STRENGTH, CVS ALLERGY RELIEF, CHILDRENS ALLERGY, DIPHEN, EQL ALLERGY, CVS CHILDRENS EQL ALLERGY RELIEF, ALLERGY RELIEF, DYE- GERI-DRYL ALLERGY FREE ALLERGY RELIEF RELIEF, GNP ALLERGY, CHILDRENS, EQL GNP ALLERGY RELIEF, CHILDRENS ALLERGY, HM ALLERGY, HM GERI-DRYL, GNP ALLERGY RELIEF, KLS F ALLERGY ALLERGY MEDICINE, PX ANTIHISTAMINE, GNP ALLERGY, QC ALLERGY COMPLETE ALLERGY ANTIHISTAMINECHILDRE MEDICINE, QLEARQUIL NS, GNP CHILDRENS NIGHTTIME ALLEGY ALLERGY, H-E-B RELIEF, RA ALLERGY, RA CHILDRENS ALLERGY, ALLERGY MEDICATION, HM ALLERGY RELIEF RA COMPLETE CHILDRENS, LIQUID ALLERGY, SB ALLERGY ALLERGY RELIEF, M- MEDICINE, SM ALLERGY DRYL, NARAMIN, F RELIEF, TGT ALLERGY PEDIACARE CHILDRENS RELIEF, TOTAL ALLERGY, PX ALLERGY, ALLERGY, WAL-DRYL QC ALLERGY ALLERGY TABS CHILDRENS, RA ALLERGY, RA ALLERGY MEDICATION CHILDRENS, RA DIPHEDRYL ALLERGY, SB ALLERGY MEDICINE, SILADRYL ALLERGY, SM ALLERGY RELIEF, SM ALLERGY RELIEF CHILDRENS, TGT ALLERGY RELIEF CHILDRENS, TGT ALLERGY RELIEF CHILDRENS DYE FREE, TOTAL ALLERGY MEDICINE, WAL-DRYL ALLERGY, WAL-DRYL ALLERGY CHILDRENS, WAL-DRYL ALLERGY DYE-FREECHILDRENS LIQD
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Diphenhydramine Hcl) clemastine fumarate F ALLERGY RELIEF tabs CHILDRENS, CVS ALLERGY RELIEF diphenhydramine hcl F caps CHILDRENS, EQ F ALLERGY RELIEF diphenhydramine hcl CHILDRENS, RA F ALLERGY RELIEF chew CHILDRENS LIQD 12.5 diphenhydramine hcl F MG/5ML elix (Diphenhydramine Hcl) diphenhydramine hcl F ALLERGY, ALLERGY liqd RELIEF, BANOPHEN, CVS ALLERGY RELIEF, EQ F diphenhydramine hcl F ALLERGY RELIEF, QC tabs ALLERGY RELIEF TABS 25 MG Antihistamines - Non-Sedating (Diphenhydramine Hcl) (Cetirizine Hcl) ALL DAY QL(240 ml per ALLERGY, ALLERGY ALLERGY CHILDRENS, fill retail); RELIEF, BANOPHEN, CVS ALL-DAY ALLERGY RX/OTC ALLERGY RELIEF, EQ F CHILDRENS, CETIRIZINE ALLERGY RELIEF, QC HCL ALLERGY ALLERGY RELIEF TABS CHILDRENS, CETIRIZINE OR 25 MG HCL CHILDRENSALLERGY, (Diphenhydramine Hcl) CETIRIZINE ALLERGY, ALLERGY HYDROCHLORIDECHILD RELIEF, CVS ALLERGY F RENS ALLERGY, EQL ALL RELIEF, EQ ALLERGY DAY ALLERGY RELIEF CAPS 25 MG CHILDRENS, GNP ALL (Diphenhydramine Hcl) DAY ALLERGY ALLERGY, ALLERGY CHILDRENS, RELIEF, CVS ALLERGY F GOODSENSE ALL DAY RELIEF, EQ ALLERGY ALLERGYCHILDRENS, RELIEF CAPS OR 25 MG HM ALL DAY ALLERGY F (Diphenhydramine Hcl) CHILDRENS, HM BANOPHEN CAPS OR 25 F CETIRIZINE HCL MG, 50 MG CHILDRENS, KLS ALLER- TEC CHILDRENS, PX (Diphenhydramine Hcl) CHILDRENS ALLERGY, CVS ALLERGY RELIEF F QC CHILDRENS LIQD 25 MG/10ML ALLERGY, SB (Diphenhydramine Hcl) DI- F CETIRIZINE HCL PHEN, DIPHEN ELIX CHILDRENS, SM ALL DAY (Diphenhydramine Hcl) ALLERGY CHILDRENS, GNP ALLERGY RELIEF F TGT ALL DAY ALLERGY CHEW RELIEF CHILDRENS, ALER-DRYL TABS WAL-ZYR ALL DAY F ALLERGY CHILDRENS, (diphenhydramine hcl) WAL-ZYR ALL DAY ALLERGYCHILDRENS SOLN To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Cetirizine Hcl) ALL DAY (Cetirizine Hcl) QL(240 ml per ALLERGY, ALLERGY CETIRIZINE HCL fill retail); 24HOUR CHILDRENS, EQ F RX/OTC INDOOR/OUTDOOR, ALLERGY RELIEF SOLN ALLERGY OR 1 MG/ML RELIEF/INDOOR/OUTDO (Cetirizine Hcl) OR, CVS CETIRIZINE HCL INDOOR/OUTDOOR CHILDRENS, WAL-ZYR F ALLERGY RELIEF, EQL CHILDRENS CHEW 10 ALL DAY ALLERGY, GNP MG, 5 MG ALL DAY ALLERGY, GOODSENSE ALL DAY (Cetirizine Hcl) CVS QL(240 ml per ALLERGY RELIEF fill retail); ALLERGY, HM ALL DAY F ALLERGY, HM ALLERGY CHILDRENS, EQ F RX/OTC RELIEF, HM CETIRIZINE ALLERGY RELIEF HYDROCHLORIDE, KLS CHILDRENS, WAL-ZYR ALLER-TEC, KP SOLN 5 MG/5ML CETIRIZINE HCL, KP (Cetirizine Hcl) EQ CETIRIZINE CETIRIZINE F HYDROCHLORIDE, PX HYDROCHLORIDE ALLERGY RELIEF, QC CHILDRENS CHEW ALL DAY ALLERGY, RA (Cetirizine Hcl) QC QL(240 ml per ALLERGY RELIEF, SB ALLERGY RELIEF F fill retail); ALLERGY, SM ALL DAY CHILDRENS SYRP 1 RX/OTC ALLERGY, TGT ALL DAY MG/ML ALLERGY RELIEF TABS (Cetirizine Hcl) RA QL(240 ml per (Cetirizine Hcl) ALLERGY QL(240 ml per ALLERGY RELIEF F fill retail); RELIEF CHILDRENS, RA fill retail); CHILDRENS SYRP 5 RX/OTC ALLERGY RELIEF F RX/OTC MG/5ML CHILDRENS, WAL-ZYR CHILDRENS SOLN 1 MG/ML, 5 MG/5ML (Cetirizine Hcl) ALLERGY RELIEF, CVS ALLERGY RELIEF, EQ ALLERGY F RELIEF, QC ALLERGY RELIEF, WAL-ZYR TABS 10 MG (Cetirizine Hcl) ALLERGY RELIEF, CVS ALLERGY RELIEF, EQ ALLERGY F RELIEF, QC ALLERGY RELIEF, WAL-ZYR TABS OR 10 MG (Cetirizine Hcl) QL(240 ml per CETIRIZINE HCL fill retail); CHILDRENS, EQ F RX/OTC ALLERGY RELIEF SOLN 1 MG/ML
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Fexofenadine Hcl) 24HR (Levocetirizine RX/OTC ALLERGY RELIEF, Dihydrochloride) ALLERGY ALLER-EASE, ALLERGY RELIEF 24HR, CVS F 24-HR, ALLERGY RELIEF ALLERGY RELIEF TABS 5 24HR/INDOOR/OUTDOOR MG , EQL ALLER-EASE, GNP (Levocetirizine RX/OTC ALLERGY RELIEF, Dihydrochloride) GNP F GOODSENSE ALLER- ALLERGY RELIEF 24 EASE, HM ALLERGY HOUR TABS RELIEF, HM FEXOFENADINE (Loratadine) ALAVERT, EQ HYDROCHLORIDE, KLS LORATADINE, GNP ALLER-FEX, KP LORATADINE, HM FEXOFENADINE HCL, MM ALLERGY RELIEF, MEIJER ALLERGY FEXOFENADINE F HYDROCHLORIDE, PX RELIEF, PX ALLERGY ALLERGY RELIEF, QC RELIEF, SB ALLERGY FEXOFENADINE RELIEF, SM ALLERGY HYDROCHLORIDE, RA RELIEF, SM LORATADINE F ALLERGY RELIEF, RA ALLERGY RELIEF, TGT ALLERGY RELIEF 24 ALLERGY RELIEF, HOUR, SM TRIAMINIC FEXOFENADINE HCL, SM ALLERCHEWS, WAL-ITIN, FEXOFENADINE WAL-ITIN ALLER-MELTS, HYDROCHLORIDE, TGT WAL-ITIN ALLERGY ALLERGY RELIEF, WAL- RELIEF REDITABS, WAL- FEX, WAL-FEX 24 HOUR VERT TBDP ALLERGY, WAL-FEX (Loratadine) ALLERGY ALLERGY, WAL-FEX CHILDRENS, ALLERGY ALLERGY 12 HOUR TABS RELIEF CHILD, (Fexofenadine Hcl) CHILDRENS ALLERGY RELIEF 24HR, LORATADINE, CLARITIN EQ ALLERGY RELIEF, QC F ALLERGY CHILDRENS, ALLERGY RELIEF TABS EQ ALLERGY 180 MG CHILDRENS, GNP LORATADINE, HM (Fexofenadine Hcl) LORATADINE ALLERGY RELIEF 24HR, CHILDRENS, MEIJER F EQ ALLERGY RELIEF, QC F LORATADINE, RA ALLERGY RELIEF TABS LORATADINE, SB OR 180 MG LORATADINE, SM (Fexofenadine Hcl) ALLERGY CHILDRENS, ALLERGY RELIEF, CVS F SM CHILDRENS ALLERGY RELIEF TABS LORATADINE, SM 180 MG, 60 MG LORATADINE, TGT (Fexofenadine Hcl) LORATADINE CHILDRENS, WAL-ITIN ALLERGY RELIEF, CVS F ALLERGY RELIEF TABS SYRP OR 180 MG, 60 MG
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Loratadine) ALLERGY (Loratadine) ALLERGY, RELIEF CHILDRENS, CVS ALLERGY RELIEF, CVS ALLERGY RELIEF ALLERGY RELIEF, EQ F CHILDRENS, EQ ALLERGY RELIEF TABS ALLERGY RELIEF 10 MG CHILDRENS, F (Loratadine) ALLERGY, LORATADINE ALLERGY RELIEF, CVS CHILDRENS, QC ALLERGY RELIEF, EQ F ALLERGY RELIEF ALLERGY RELIEF TABS CHILDRENS SYRP 5 OR 10 MG MG/5ML (Loratadine) CHILDRENS (Loratadine) ALLERGY LORATADINE, WAL-ITIN F RELIEF CHILDRENS, GNP CHILDRENS SOLN LORATADINE F CHILDRENS SOLN 5 cetirizine hcl chew 10 F MG/5ML mg, 5 mg (Loratadine) ALLERGY cetirizine hcl soln 1 QL(240 ml per RELIEF LORATADINE, EQ F fill retail); LORATADINE, EQL mg/ml, 5 mg/5ml RX/OTC ALLERGY RELIEF, GNP cetirizine hcl tabs 10 F LORATADINE, mg, 5 mg GOODSENSE ALLERGY CLARITIN REDITABS RELIEF, HM F LORATADINE, KLS TBDP 5 MG (loratadine) ALLERCLEAR, KP LORATADINE, fexofenadine hcl tabs F LORADAMED, MEIJER levocetirizine RX/OTC ALLERGY RELIEF, PX ALLERGY RELIEF, QC F dihydrochloride tabs 5 F LORATADINE ALLERGY mg RELIEF, QLEARQUIL ALL loratadine syrp 5 F DAY & ALLNIGHT 24 mg/5ml HOUR ALLERGY RELIEF, RA ALLERGY RELIEF 24 loratadine tabs 10 mg F HOUR, RA LORATADINE, SB LORATADINE, SB Antihistamines - Phenothiazines LORATADINE ALLERGY (Promethazine Hcl) RELIEF, SM PHENADOZ, F LORATADINE, TGT PROMETHEGAN SUPP ALLERGY RELIEF, WAL- ITIN TABS promethazine hcl soln F (Loratadine) ALLERGY or 6.25 mg/5ml promethazine hcl supp RELIEF, CVS ALLERGY F RELIEF, QC ALLERGY re 12.5 mg, 25 mg, 50 F RELIEF TBDP 10 MG mg (Loratadine) ALLERGY promethazine hcl syrp F RELIEF, CVS ALLERGY F RELIEF, QC ALLERGY or 6.25 mg/5ml RELIEF TBDP OR 10 MG
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits promethazine hcl tabs fenofibrate tabs 54 mg F QL(3 ea daily) or 12.5 mg, 25 mg, 50 F mg gemfibrozil tabs F Antihistamines - Piperidines TRIGLIDE TABS QL(1 ea daily) F (fenofibrate) cyproheptadine hcl F syrp HMG CoA Reductase Inhibitors cyproheptadine hcl QL(1 ea daily) F atorvastatin calcium F tabs tabs ANTIHYPERLIPIDEMICS - Drugs to Treat High F QL(1 ea daily) Cholesterol fluvastatin sodium caps Antihyperlipidemics - Combinations fluvastatin sodium tb24 F QL(1 ea daily) ezetimibe-simvastatin ST; QL(1 ea QL(1.5 ea F daily) lovastatin tabs 10 mg, F tabs 20 mg daily) Bile Acid Sequestrants lovastatin tabs 40 mg F QL(2 ea daily) (Cholestyramine Light) F PREVALITE PACK pravastatin sodium tabs F QL(1 ea daily) (Cholestyramine Light) F ST; QL(1 ea PREVALITE POWD rosuvastatin calcium F cholestyramine light tabs daily) F QL(1 ea daily) pack simvastatin tabs 10 mg, F 20 mg, 40 mg, 5 mg cholestyramine light F powd simvastatin tabs 80 mg F PA cholestyramine pack F Intestinal Cholesterol Absorption Inhibitors cholestyramine powd F ezetimibe tabs F ST colestipol hcl gran 5 gm F Nicotinic Acid Derivatives (Niacin colestipol hcl tabs 1 gm F (Antihyperlipidemic)) F NIACOR TABS Fibric Acid Derivatives niacin fenofibrate micronized F (antihyperlipidemic) F caps 130 mg, 43 mg tabs QL(1 ea daily) fenofibrate micronized F niacin caps 134 mg, 200 mg (antihyperlipidemic) F QL(2 ea daily) fenofibrate micronized F tbcr caps 67 mg ANTIHYPERTENSIVES - Drugs to Treat High fenofibrate tabs 160 mg F QL(1 ea daily) Blood Pressure FENOFIBRATE TABS 160 QL(1 ea daily) ACE Inhibitors F MG (fenofibrate) benazepril hcl tabs F
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits captopril tabs F guanfacine hcl tabs F enalapril maleate tabs methyldopa tabs F 10 mg, 2.5 mg, 20 mg, F 5 mg prazosin hcl caps F fosinopril sodium tabs F terazosin hcl caps F lisinopril tabs F Antihypertensive Combinations amlodipine besylate- QL(1 ea daily) moexipril hcl tabs F F benazepril hcl caps quinapril hcl tabs F amlodipine besylate- ST F QL(2 ea daily) olmesartan medoxomil ramipril caps F tabs QL(1 ea daily) amlodipine besylate- ST trandolapril tabs 1 mg, F F 2 mg valsartan tabs trandolapril tabs 4 mg F QL(2 ea daily) amlodipine-valsartan- ST hydrochlorothiazide F Agents for Pheochromocytoma tabs SP- atenolol & F metyrosine caps F AcariaHealth;S chlorthalidone tabs P benazepril & phenoxybenzamine hcl F caps hydrochlorothiazide F tabs Angiotensin II Receptor Antagonists BENAZEPRIL HCL/HYDROCHLOROTHI candesartan cilexetil F tabs AZIDE TABS (benazepril F & hydrochlorothiazide) irbesartan tabs F bisoprolol & losartan potassium hydrochlorothiazide F tabs or 100 mg, 25 mg, F tabs 50 mg candesartan cilexetil- ST olmesartan medoxomil F hydrochlorothiazide F tabs tabs telmisartan tabs F captopril & hydrochlorothiazide F valsartan tabs F QL(1 ea daily) tabs Antiadrenergic Antihypertensives DUTOPROL TB24 12.5 MG-50 MG (metoprolol & F clonidine hcl tabs F hydrochlorothiazide) doxazosin mesylate enalapril maleate & tabs or 1 mg, 2 mg, 4 F hydrochlorothiazide F mg, 8 mg tabs To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXFORGE HCT TABS ST propranolol & (amlodipine-valsartan- F hydrochlorothiazide F hydrochlorothiazide) tabs fosinopril sodium & quinapril- hydrochlorothiazide F hydrochlorothiazide F tabs tabs irbesartan- telmisartan-amlodipine F hydrochlorothiazide F tabs tabs telmisartan- lisinopril & hydrochlorothiazide F hydrochlorothiazide F tabs tabs trandolapril-verapamil F losartan potassium & hcl tbcr hydrochlorothiazide F valsartan- QL(1 ea daily) tabs hydrochlorothiazide F methyldopa & tabs F hydrochlorothiazide Vasodilators tabs hydralazine hcl tabs or metoprolol & 10 mg, 100 mg, 25 mg, F hydrochlorothiazide F 50 mg tabs METOPROLOL QL(1 ea daily) minoxidil tabs F SUCCINATE ER/HYDROCHLOROTHIA ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections) ZIDE TB24 12.5 MG-100 F MG, 12.5 MG-25 MG Antimalarial Combinations (metoprolol & QL(1 ea daily) atovaquone-proguanil F hydrochlorothiazide) hcl tabs METOPROLOL COARTEM TABS QL(24 ea per SUCCINATE fill retail) ER/HYDROCHLOROTHIA (artemether- F ZIDE TB24 12.5 MG-50 F lumefantrine) MG (metoprolol & Antimalarials hydrochlorothiazide) QL(2 ea daily) chloroquine phosphate F olmesartan medoxomil- ST tabs 250 mg amlodipine- QL(8 ea per 56 F chloroquine phosphate F hydrochlorothiazide tabs 500 mg days retail) tabs hydroxychloroquine F olmesartan medoxomil- ST sulfate tabs hydrochlorothiazide F KRINTAFEL TABS QL(2 ea per 30 F tabs (tafenoquine succinate) days retail) mefloquine hcl tabs F
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits YONDELIS SOLR PA; SP- ANTIMYASTHENIC/CHOLINERGIC AGENTS F AcariaHealth;S (trabectedin) Antimyasthenic/Cholinergic Agents P Antimetabolites pyridostigmine bromide F tabs 60 mg SP- capecitabine tabs 150 F mg AcariaHealth pyridostigmine bromide F tbcr 180 mg capecitabine tabs 500 SP- F AcariaHealth;S ANTIMYCOBACTERIAL AGENTS - Drugs to mg P Treat Tuberculosis (Bacterial Infections) F PA; SP Antimycobacterial Agents decitabine solr ethambutol hcl tabs F mercaptopurine tabs or F methotrexate sodium isoniazid syrp or 50 F F mg/5ml soln methotrexate sodium isoniazid tabs or 100 F F mg, 300 mg tabs PRIFTIN TABS PURIXAN SUSP F F (rifapentine) (mercaptopurine) F TABLOID TABS SP- pyrazinamide tabs F AcariaHealth;S (thioguanine) P rifabutin caps F TREXALL TABS F rifampin caps F (methotrexate sodium) XATMEP SOLN PA; SP TRECATOR TABS F F (methotrexate) (ethionamide) Antineoplastic - Angiogenesis Inhibitors ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer AVASTIN SOLN PA; SP- F AcariaHealth;S Alkylating Agents (bevacizumab) P GLEOSTINE CAPS F CYRAMZA SOLN PA; SP- (lomustine) F AcariaHealth;S (ramucirumab) LEUKERAN TABS P F (chlorambucil) PA; SP- INLYTA TABS (axitinib) F AcariaHealth;S melphalan tabs F P MYLERAN TABS LENVIMA 10 MG DAILY PA; SP F (busulfan) DOSE CPPK (lenvatinib F temozolomide caps SP- mesylate) 100 mg, 20 mg, 250 F AcariaHealth;S LENVIMA 14 MG DAILY PA; SP mg, 5 mg P DOSE CPPK (lenvatinib F mesylate) SP- temozolomide caps F 140 mg, 180 mg AcariaHealth
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LENVIMA 18 MG DAILY PA; SP- VENCLEXTA STARTING PA DOSE CPPK (lenvatinib F Biologics;SP PACK TBPK F mesylate) (venetoclax) VENCLEXTA TABS PA LENVIMA 20 MG DAILY PA; SP F DOSE CPPK (lenvatinib F (venetoclax) mesylate) Antineoplastic - Cellular Immunotherapy LENVIMA 24 MG DAILY PA; SP KYMRIAH SUSP PA; SP F DOSE CPPK (lenvatinib F (tisagenlecleucel) mesylate) PROVENGE SUSP PA F LENVIMA 8 MG DAILY PA; SP- (sipuleucel-t) DOSE CPPK (lenvatinib F Biologics;SP Antineoplastic - EGFR Inhibitors mesylate) erlotinib hcl tabs 100 PA; SP- ZALTRAP SOLN (ziv- PA; SP- F AcariaHealth;S F AcariaHealth;S mg, 25 mg P aflibercept) P PA; SP erlotinib hcl tabs 150 F Antineoplastic - Anti-HER2 Agents mg PA; SP- HERCEPTIN SOLR GILOTRIF TABS ( PA; SP F AcariaHealth;S afatinib F (trastuzumab) P dimaleate) PA; SP PERJETA SOLN PA; SP- IRESSA TABS (gefitinib) F F AcariaHealth;S (pertuzumab) TAGRISSO TABS PA; SP P F ( ) Antineoplastic - Antibodies osimertinib mesylate Antineoplastic - Hedgehog Pathway Inhibitors DARZALEX SOLN 100 PA; SP- F AcariaHealth;S ERIVEDGE CAPS PA; SP MG/5ML (daratumumab) F P (vismodegib) DARZALEX SOLN 400 PA; SP- ODOMZO CAPS SP F MG/20ML F AcariaHealth (sonidegib phosphate) (daratumumab) Antineoplastic - Hormonal and Related Agents EMPLICITI SOLR PA; SP- F AcariaHealth;S abiraterone acetate PA; SP- (elotuzumab) P F AcariaHealth;S tabs P KADCYLA SOLR (ado- PA; SP- trastuzumab F AcariaHealth;S anastrozole tabs F emtansine) P bicalutamide tabs F OPDIVO SOLN PA; SP- F AcariaHealth;S (nivolumab) ELIGARD KIT (leuprolide PA; SP- P F AcariaHealth;S acetate (3 month)) P RITUXAN SOLN PA; SP- F AcariaHealth;S (rituximab) ELIGARD KIT (leuprolide PA; SP- P F AcariaHealth;S acetate (4 month)) Antineoplastic - BCL-2 Inhibitors P ELIGARD KIT (leuprolide PA; SP- F AcariaHealth;S acetate (6 month)) P To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELIGARD KIT (leuprolide PA; SP- megestrol acetate susp F F AcariaHealth;S acetate) P megestrol acetate tabs F EMCYT CAPS SP- (estramustine F AcariaHealth;S tamoxifen citrate tabs F phosphate sodium) P PA ERLEADA TABS PA; SP-Acaria toremifene citrate tabs F F (apalutamide) Health;SP TRELSTAR MIXJECT PA; SP- exemestane tabs F SUSR (triptorelin F AcariaHealth;S pamoate) P FIRMAGON SOLR 120 PA; SP VANTAS KIT (histrelin PA; SP- MG/VIAL (degarelix F F AcariaHealth;S acetate) acetate) P PA; SP- XTANDI CAPS 40 MG PA; SP FIRMAGON SOLR 80 MG F F AcariaHealth;S (enzalutamide) (degarelix acetate) P YONSA TABS PA F flutamide caps F (abiraterone acetate) hydroxyprogesterone PA; SP ZOLADEX IMPL PA; SP- F AcariaHealth;S caproate F (goserelin acetate) P (antineoplastic) soln Antineoplastic - Immunomodulators letrozole tabs F POMALYST CAPS PA; SP F PA; SP- (pomalidomide) leuprolide acetate kit F AcariaHealth;S Antineoplastic - PDGFR-alpha Inhibitors P LARTRUVO SOLN PA; SP- PA; SP- F LUPRON DEPOT (1- (olaratumab) Accredo;SP MONTH) KIT 3.75 MG F AcariaHealth;S (leuprolide acetate) P Antineoplastic Antibiotics LUPRON DEPOT (1- PA; SP- (Doxorubicin Hcl) F PA ADRIAMYCIN SOLN MONTH) KIT 7.5 MG F AcariaHealth (leuprolide acetate) (Doxorubicin Hcl) PA ADRIAMYCIN, F LUPRON DEPOT (3- PA; SP- ADRIAMYCIN SOLR F AcariaHealth;S MONTH) KIT (leuprolide PA acetate (3 month)) P bleomycin sulfate solr F LUPRON DEPOT (4- PA; SP- PA doxorubicin hcl soln 2 F MONTH) KIT (leuprolide F AcariaHealth;S mg/ml, 200 mg/100ml acetate (4 month)) P PA; SP- LUPRON DEPOT (6- PA; SP- mitoxantrone hcl conc F AcariaHealth;S MONTH) KIT (leuprolide F AcariaHealth;S P acetate (6 month)) P Antineoplastic Combinations LYSODREN TABS SP- F AcariaHealth;S KISQALI FEMARA 200 PA; SP (mitotane) P DOSE TBPK (ribociclib F succinate-letrozole)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KISQALI FEMARA 400 PA; SP COTELLIC TABS PA; SP F DOSE TBPK (ribociclib F (cobimetinib fumarate) succinate-letrozole) PA; SP- KISQALI FEMARA 600 PA; SP everolimus tabs F AcariaHealth;S DOSE TBPK (ribociclib F P FARYDAK CAPS PA; SP succinate-letrozole) F LONSURF TABS PA; SP (panobinostat lactate) F (trifluridine-tipiracil) IBRANCE CAPS PA; SP-Acaria F Health;SP RITUXAN HYCELA SOLN PA; SP- (palbociclib) AcariaHealth;S IBRANCE TABS PA; SP-Acaria (rituximab- F F hyaluronidase human) P (palbociclib) Health;SP Antineoplastic Enzyme Inhibitors ICLUSIG TABS 10 MG, 15 PA; QL(1 ea MG, 30 MG, 45 MG F daily); SP AFINITOR DISPERZ TBSO PA; SP F (ponatinib hcl) (everolimus) IDHIFA TABS PA; SP- F AFINITOR TABS 10 MG PA; SP- (enasidenib mesylate) Accredo;SP F AcariaHealth;S (everolimus) P imatinib mesylate tabs F PA; SP ALECENSA CAPS PA; SP F IMBRUVICA CAPS 140 PA; SP (alectinib hcl) F MG (ibrutinib) ALUNBRIG TABS 180 MG, PA; SP- F IMBRUVICA CAPS 70 MG PA; SP- 90 MG (brigatinib) Caremark;SP F (ibrutinib) Biologics;SP ALUNBRIG TABS 30 MG PA; SP F IMBRUVICA TABS 140 PA; QL(1 ea (brigatinib) MG, 280 MG, 420 MG, 560 F daily) ALUNBRIG TBPK PA; SP- MG (ibrutinib) F Caremark;SP (brigatinib) JAKAFI TABS 10 MG, 15 SP BOSULIF TABS 100 MG, PA; SP- MG, 20 MG, 5 MG F F AcariaHealth;S (ruxolitinib phosphate) 500 MG (bosutinib) P JAKAFI TABS 25 MG BRAFTOVI CAPS PA F F (ruxolitinib phosphate) (encorafenib) KISQALI TBPK (ribociclib PA; SP CABOMETYX TABS PA; SP F F succinate) (cabozantinib s-malate) SP CALQUENCE CAPS PA lapatinib ditosylate tabs F F (acalabrutinib) LYNPARZA TABS PA; SP- CAPRELSA TABS 100 MG PA; SP- F Biologics;SP F (olaparib) (vandetanib) Biologics;SP MEKINIST TABS PA; SP CAPRELSA TABS 300 MG PA; SP F (trametinib dimethyl F (vandetanib) sulfoxide) COMETRIQ KIT PA; SP MEKTOVI TABS PA F F (cabozantinib s-malate) (binimetinib) COPIKTRA CAPS PA NERLYNX TABS PA; SP F F (duvelisib) (neratinib maleate)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEXAVAR TABS PA; SP MATULANE CAPS F F (sorafenib tosylate) (procarbazine hcl) NINLARO CAPS PA; SP SYLATRON KIT PA; SP- F (ixazomib citrate) (peginterferon alfa-2b F AcariaHealth RUBRACA TABS PA; SP (antineoplastic)) F (rucaparib camsylate) SP- tretinoin F RYDAPT CAPS PA; SP (chemotherapy) caps AcariaHealth F (midostaurin) Chemotherapy Rescue/Antidote/Protective Agents SPRYCEL TABS PA; SP F leucovorin calcium tabs (dasatinib) or 10 mg, 15 mg, 25 F STIVARGA TABS PA; SP- mg, 5 mg F AcariaHealth;S (regorafenib) P Mitotic Inhibitors PA; SP DOCETAXEL CONC 160 PA; SP- sunitinib malate caps F MG/8ML, 20 MG/ML, 200 AcariaHealth;S F TAFINLAR CAPS PA; SP MG/10ML, 80 MG/4ML P F (dabrafenib mesylate) (docetaxel) docetaxel conc 160 PA; SP- TASIGNA CAPS 150 MG, PA; SP- F AcariaHealth;S mg/8ml, 20 mg/ml, 80 F AcariaHealth;S 200 MG (nilotinib hcl) P mg/4ml P TIBSOVO TABS PA; SP F DOCETAXEL CONC 20 PA; SP- (ivosidenib) MG/ML, 80 MG/4ML F AcariaHealth;S VOTRIENT TABS PA; SP (docetaxel) P F (pazopanib hcl) docetaxel soln 160 PA; SP- AcariaHealth;S XALKORI CAPS PA; SP- mg/16ml, 20 mg/2ml, F F AcariaHealth;S 80 mg/8ml P (crizotinib) P DOCETAXEL SOLN 160 PA; SP- ZEJULA CAPS ( PA; SP niraparib F MG/16ML, 20 MG/2ML, 80 F AcariaHealth;S tosylate) MG/8ML (docetaxel) P ZELBORAF TABS PA; SP F etoposide caps or 50 SP- (vemurafenib) F AcariaHealth;S mg P ZOLINZA CAPS PA; SP- F AcariaHealth;S HALAVEN SOLN (eribulin PA; SP- (vorinostat) P F AcariaHealth;S mesylate) ZYDELIG TABS PA; SP P F (idelalisib) IXEMPRA KIT SOLR PA; SP- F AcariaHealth;S Antineoplastics Misc. (ixabepilone) P ACTIMMUNE SOLN PA; SP- F F PA (interferon gamma-1b) Caremark vincristine sulfate soln bexarotene caps F PA; SP Topoisomerase I Inhibitors HYCAMTIN CAPS OR 0.25 PA; SP- hydroxyurea caps F MG, 1 MG (topotecan F AcariaHealth hcl)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; SP- carbidopa-levodopa irinotecan hcl soln F AcariaHealth;S tabs 10 mg-100 mg, 25 F P mg-100 mg, 25 mg-250 topotecan hcl soln 4 PA; SP- mg F AcariaHealth mg/4ml carbidopa-levodopa TOPOTECAN HCL SOLN PA; SP- tbcr 25 mg-100 mg, 50 F 4 MG/4ML (topotecan F AcariaHealth mg-200 mg hcl) GOCOVRI CP24 CO F PA; SP- (amantadine hcl) topotecan hcl solr 4 mg AcariaHealth OSMOLEX ER T4PK CO ANTIPARKINSON AND RELATED THERAPY (amantadine hcl) AGENTS - Drugs to Treat Parkinson's Disease OSMOLEX ER TB24 CO Antiparkinson Adjunctive Therapy (amantadine hcl) carbidopa tabs F pramipexole dihydrochloride tabs Antiparkinson Anticholinergics 0.125 mg, 0.25 mg, 0.5 F benztropine mesylate CO mg, 0.75 mg, 1 mg, 1.5 soln mg benztropine mesylate CO ropinirole hydrochloride F tabs tabs COGENTIN SOLN CO ropinirole hydrochloride F (benztropine mesylate) tb24 trihexyphenidyl hcl soln CO Antiparkinson Monoamine Oxidase Inhibitors trihexyphenidyl hcl tabs CO selegiline hcl caps F Antiparkinson COMT Inhibitors selegiline hcl tabs F entacapone tabs F ANTIPSYCHOTICS/ANTIMANIC AGENTS - Drugs to Treat Mood Disorders Antiparkinson Dopaminergics Antimanic Agents amantadine hcl caps CO lithium carbonate caps CO amantadine hcl syrp CO lithium carbonate tabs CO amantadine hcl tabs CO lithium carbonate tbcr CO bromocriptine mesylate F caps LITHIUM SOLN (lithium) CO bromocriptine mesylate LITHOBID TBCR ( F lithium CO tabs carbonate) Antipsychotics - Misc. CAPLYTA CAPS CO (lumateperone tosylate)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GEODON CAPS CO risperidone soln CO (ziprasidone hcl) GEODON SOLR risperidone tabs CO CO (ziprasidone mesylate) LATUDA TABS risperidone tbdp CO CO (lurasidone hcl) Butyrophenones NUPLAZID CAPS CO HALDOL DECANOATE (pimavanserin tartrate) 100 SOLN (haloperidol CO NUPLAZID TABS CO decanoate) (pimavanserin tartrate) HALDOL DECANOATE 50 VRAYLAR CAPS CO SOLN (haloperidol CO (cariprazine hcl) decanoate) VRAYLAR CPPK HALDOL SOLN CO CO (cariprazine hcl) (haloperidol lactate) ziprasidone hcl caps CO haloperidol decanoate CO soln ziprasidone mesylate CO solr haloperidol lactate conc CO Benzisoxazoles haloperidol lactate soln CO FANAPT TABS CO (iloperidone) haloperidol tabs or 0.5 FANAPT TITRATION mg, 1 mg, 10 mg, 2 mg, CO PACK TABS CO 20 mg, 5 mg (iloperidone) Dibenzapines INVEGA SUSTENNA ADASUVE AEPB CO SUSY (paliperidone CO (loxapine) palmitate) asenapine maleate INVEGA TB24 CO CO subl (paliperidone) CO INVEGA TRINZA SUSY clozapine tabs CO (paliperidone palmitate) clozapine tbdp CO paliperidone tb24 CO CLOZARIL TABS CO PERSERIS PRSY (clozapine) CO (risperidone) FAZACLO TBDP CO RISPERDAL CONSTA (clozapine) SRER (risperidone CO loxapine succinate CO microspheres) caps RISPERDAL SOLN CO olanzapine solr CO (risperidone) RISPERDAL TABS CO CO olanzapine tabs (risperidone)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits olanzapine tbdp CO fluphenazine hcl conc CO quetiapine fumarate CO fluphenazine hcl elix CO tabs fluphenazine hcl soln CO quetiapine fumarate CO tb24 fluphenazine hcl tabs CO SAPHRIS SUBL 10 MG, 2.5 MG, 5 MG (asenapine CO perphenazine tabs CO maleate) SAPHRIS SUBL 5 MG prochlorperazine CO F (asenapine maleate) maleate tabs SECUADO PT24 F CO prochlorperazine supp (asenapine) SEROQUEL TABS thioridazine hcl tabs CO CO (quetiapine fumarate) trifluoperazine hcl tabs CO SEROQUEL XR TB24 CO (quetiapine fumarate) Quinolinone Derivatives VERSACLOZ SUSP ABILIFY MAINTENA PRSY CO CO (clozapine) (aripiprazole) ZYPREXA RELPREVV ABILIFY MAINTENA SRER CO SUSR (olanzapine CO (aripiprazole) pamoate) ABILIFY MYCITE TABS CO ZYPREXA SOLR (aripiprazole) CO (olanzapine) ABILIFY TABS CO ZYPREXA TABS (aripiprazole) CO (olanzapine) aripiprazole soln CO ZYPREXA ZYDIS TBDP CO (olanzapine) aripiprazole tabs CO Dihydroindolones aripiprazole tbdp CO molindone hcl tabs CO ARISTADA INITIO PRSY CO Phenothiazines (aripiprazole lauroxil) (Prochlorperazine) ARISTADA PRSY F CO COMPRO SUPP (aripiprazole lauroxil) chlorpromazine hcl soln REXULTI TABS CO CO ij 25 mg/ml, 50 mg/2ml (brexpiprazole) chlorpromazine hcl Thioxanthenes tabs or 10 mg, 100 mg, CO 200 mg, 25 mg, 50 mg thiothixene caps CO fluphenazine CO ANTISEPTICS & DISINFECTANTS decanoate soln Antiseptic Combinations
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXCEL AP SWAB hydrogen peroxide soln F (povidone-iodine & F ex 3 % isopropyl alcohol) HYDROGEN PEROXIDE IV PREP WIPES PADS SOLN EX 3 % (hydrogen F (antiseptic products, F peroxide) misc.) hydrogen peroxide soln F MICROCLENS WIPES xx 30 % PADS (antiseptic F HYLAMEND FIRST AID products, misc.) ANTISEPTIC GEL F UNI-SOLVE PADS (hydrogen peroxide) (antiseptic products, F KERR TRIPLE DYE SWAB F misc.) (triple dye) Antiseptics & Disinfectants PHENOL EZ SWABS F (Hydrogen Peroxide) CVS SWAB (phenol) HYDROGEN PEROXIDE, PHENOL LIQD EX F EQ HYDROGEN (phenol) PEROXIDE, EQL HYDROGEN PEROXIDE, Chlorine Antiseptics GNP HYDROGEN (Benzalkonium Chloride) PEROXIDE, GOODSENSE ANTISEPTIC SPRAY, CVS HYDROGEN PEROXIDE, MERTHIOLATE, EQL HM HYDROGEN ANTIBACTERIAL HAND F PEROXIDE, MEIJER F SOAP, EQL HAND SOAP, HYDROGEN PEROXIDE, HANDCLENS 2 IN 1 PX HYDROGEN FOAMINGSANITIZER/LOT PEROXIDE, QC ION, MERTHIOLATE LIQD HYDROGEN PEROXIDE, (Benzalkonium Chloride) RA HYDROGEN BZK ANTISEPTIC PEROXIDE, SM TOWELETTES, EQ F HYDROGEN PEROXIDE, ANTIBACTERIAL HANDS TGT HYDROGEN &FACE WIPES MISC PEROXIDE SOLN (Benzethonium Chloride) CETYLCIDE-G CONC F F MICROKLENZ LIQD (glutaral) DERMA CIDOL 2000 LIQD (chloroxylenol F (antiseptic)) QL(90 ml per formaldehyde soln 10 F % fill retail) FORMALDEHYDE SOLN RX/OTC F 37 % (formaldehyde) GLUTARALDEHYDE F SOLN EX 25 % (glutaral) GNP HYDROGEN PEROXIDE WIPES MISC F (hydrogen peroxide) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Chlorhexidine Gluconate) BENZALKONIUM ANTISEPTIC SKIN CHLORIDE CONC 50 % F CLEANSER, CVS (benzalkonium chloride) ANTISEPTIC SKIN CLEANSER, CVS HAND benzalkonium chloride F WASH ADVANCED misc 0.13 % ANTIBACTERIAL, DYNA- BENZALKONIUM HEX 2, DYNA-HEX 4, GNP F CHLORIDE SOLN F ANTISEPTIC SKIN (benzalkonium chloride) CLEANSER, HM ANTISEPTIC SKIN BENZALKONIUM RX/OTC CLEANSER, RA CHLORIDE SOLN 50 % F ANTISEPTIC SKIN (benzalkonium chloride) CLEANSER, SM BIOPATCH ANTISEPTIC SKIN ANTIMICROBIAL CLEANSER SOLN DRESSING/1" DISK/4MM F (Chlorhexidine Gluconate) HOLE MISC BETASEPT SURGICAL F (chlorhexidine SCRUB LIQD gluconate) (Chlorhexidine Gluconate) BIOPATCH CHLORHEXIDINE F ANTIMICROBIAL GLUCONATE SOLN EX 2 DRESSING/1" DISK/7MM % HOLE MISC F (Sodium Hypochlorite) H- (chlorhexidine CHLOR 12, HYSEPT F gluconate) SOLN BIOPATCH (Triclosan) ANTIMICROBIAL ANTIBACTERIAL LIQUID DRESSING/3/4" SOAP, RA RENEWAL DISK/1.5MM HOLE MISC F ANTIBACTERIALHAND F (chlorhexidine SOAP REFILL, SM ANTIBACTERIAL LIQUID gluconate) SOAP LIQD BIOPATCH PROTECTIVE AMERIWASH LOTN DISKWITH F CHG/1"DISK/4MM HOLE (triclosan) F MISC (chlorhexidine ANASEPT gluconate) ANTIMICROBIAL SKIN & F CA-REZZ CREA 0.3 % WOUND GEL GEL F (sodium hypochlorite) (triclosan) ANASEPT LIQD ( CA-REZZ GENTLE LIQD sodium F F hypochlorite) (triclosan) ANTISEPTIC WOUND & CA-REZZ MOISTURE SKIN CLEANSER LIQD BARRIER CREA F (benzethonium F (triclosan) chloride) CA-REZZ NORISC CREAM CREA (benzethonium F chloride)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CA-REZZ NORISC LIQD EQL ANTIBACTERIAL F ( ) FOAMINGHAND WASH triclosan F CAVILON SKIN LIQD (benzalkonium CLEANSER LIQD chloride) (benzalkonium F GERMBLOC HEALTH chloride) FOAM (benzalkonium F CHLORHEXIDINE chloride) GLUCONATE CLOTH GERMBLOC HEALTH F PADS (chlorhexidine HAND SANITIZER LOTN F gluconate) (benzalkonium chloride) CHLORHEXIDINE GOLD BOND FIRST AID GLUCONATE LIQD EX 2 QUICK SPRAY LIQD % (chlorhexidine F (benzethonium F gluconate) chloride-menthol) GOLD BOND ULTIMATE chlorhexidine gluconate F liqd ex 4 % HAND SANITIZER SHEER MOISTURE LIQD CHLORHEXIDINE F GLUCONATE SOLN XX 20 (benzethonium % (chlorhexidine F chloride) gluconate) GOLD BOND ULTIMATE HAND CLORPACTIN WCS-90 SANITIZER/MOISTURIZE F POWD (oxychlorosene F R LIQD (benzethonium sodium) chloride) CURECHROME SOLN H-CHLOR 6 SOLN F (benzalkonium F (sodium hypochlorite) chloride) H-CHLOR WOUND GEL F CURX ANTIMICROBIAL (sodium hypochlorite) GEL (benzalkonium F MERTHIOLATE chloride) TINCTURE TINC DI-DAK-SOL SOLN F F (benzalkonium (sodium hypochlorite) chloride-alcohol) DIABET-X DAILY OXYZAL WET DRESSING PREVENTIONSKIN F SOLN (benzalkonium THERAPY CREA chloride w/ F (triclosan) oxyquinoline sulfate) DIABETIC BASICS HEALTHY FOOT LOTN REMEDY F ANTIMICROBIAL (benzalkonium CLEANSER LIQD F chloride) (benzalkonium chloride) EQL ANTIBACTERIAL TEGADERM CHG DEODORANT SOAP BAR F DRESSING/2-3/4"X3-3/8" (triclosan) MISC (chlorhexidine F gluconate)
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52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TEGADERM CHG (Povidone-Iodine) DRESSING/3-1/2"X4-1/2" APLICARE POVIDONE- MISC (chlorhexidine F IODINESCRUB, gluconate) APLICARE POVIDONE/IODINE, CVS TEGADERM CHG POVIDONE-IODINE, EQ DRESSING/4"X4-3/4" F FIRST AID ANTISEPTIC, MISC (chlorhexidine EQ POVIDONE-IODINE, ) gluconate GNP POVIDONE-IODINE, F TEGADERM CHG HM POVIDONE-IODINE, DRESSING/4"X6-1/8" PVP PREP, PVP SCRUB, MISC (chlorhexidine F QC POVIDONE IODINE, RA ANTISEPTIC, SB gluconate) POVIDONE-IODINE, triclosan liqd F SCRUB CARE POVIDONE- WALTZ FREE HAND IODINE/PAINT, SM SANITIZER LOTN POVIDONE-IODINE SOLN F (benzalkonium (Povidone-Iodine) chloride) CLOROX NASAL F WALTZ FREE HAND ANTISEPTIC SWABS SANITZER FOAM SWAB (benzalkonium F APLICARE chloride) POVIDONE/IODINE GEL F (povidone-iodine) Disinfectants BETADINE SOLN 5 % F CETYLCIDE II CONC (povidone-iodine) (disinfectant products, F BETADINE SURGICAL misc.) SCRUB SOLN F CREOLIN LIQD (povidone-iodine) (disinfectant products, F CVS IODINE TINCTURE RX/OTC F misc.) TINC (iodine (topical)) Iodine Antiseptics DECOLORIZED IODINE RX/OTC F TINC (iodine (topical)) FIRST AID ANTISEPTIC OINTMENT OINT F (povidone-iodine) GNP IODIDES TINCTURE RX/OTC F TINC (iodine (topical)) GNP IODINE TINCTURE RX/OTC F TINC (iodine (topical)) GOODSENSE IODINE RX/OTC F TINC (iodine (topical)) HM IODIDES TINCTURE RX/OTC F TINC (iodine (topical))
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53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HM IODINE TINCTURE RX/OTC KENDALL WET SKIN F TINC (iodine (topical)) SCRUB PACK KIT F IODEX OINT ( (povidone-iodine) iodine F (topical)) LUGOLS STRONG IODEX/METHYL IODINE SOLN (iodine F SALICYLATE OINT (topical)) ( F iodine-methyl povidone-iodine oint 10 F salicylate) % IODINE TINCTURE MILD RX/OTC POVIDONE-IODINE PREP F TINC (iodine (topical)) PAD PADS (povidone- F IODINE TINCTURE iodine) STRONG DECOLORIZED F POVIDONE-IODINE PREP TINC (iodine (topical)) PADS PADS (povidone- F IODINE TINCTURE iodine) STRONG TINC (iodine F POVIDONE-IODINE (topical)) SCRUB LARGE WINGED F IODINE TINCTURE TINC RX/OTC SPONGE MISC F (iodine (topical)) (povidone-iodine) IODOFLEX PADS POVIDONE-IODINE F ( ) SCRUB SMALL WINGED cadexomer iodine SPONGE MISC F IODOSORB GEL F (povidone-iodine) ( ) cadexomer iodine POVIDONE-IODINE KENDALL GEL SKIN SCRUB SPONGE STICKS F SCRUB PACK/LARGE MISC (povidone-iodine) WINGED SPONGES KIT F (povidone-iodine) povidone-iodine soln F KENDALL GEL SKIN 10 % SCRUB PACK/SMALL povidone-iodine swab F WINGED SPONGES KIT F 10 % (povidone-iodine) POVIDONE-IODINE SWAB F KENDALL MINOR WET 7.5 % (povidone-iodine) SKIN SCRUB PACK KIT F QC IODIDES TINCTURE RX/OTC F (povidone-iodine) TINC (iodine (topical)) KENDALL SPONGE QC IODINE TINCTURE RX/OTC STICK/PVP MISC F F TINC (iodine (topical)) (povidone-iodine) RA FIRST AID IODINE RX/OTC KENDALL VAGINAL PREP F TINC (iodine (topical)) PACK KIT (povidone- F SM IODIDES TINCTURE RX/OTC iodine) F TINC (iodine (topical)) KENDALL VAGINAL PREP SM IODINE TINCTURE RX/OTC TRAY KIT (povidone- F F iodine) TINC (iodine (topical)) ANTIVIRALS - Drugs to Treat Viral Infections
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54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antiretrovirals didanosine cpdr F abacavir sulfate soln CO DOVATO TABS (dolutegravir sodium- CO abacavir sulfate tabs CO lamivudine) EDURANT TABS abacavir sulfate- CO CO lamivudine tabs (rilpivirine hcl) abacavir sulfate- efavirenz caps CO lamivudine-zidovudine CO tabs efavirenz tabs CO APTIVUS CAPS CO efavirenz-emtricitabine- (tipranavir) tenofovir disoproxil CO APTIVUS SOLN CO fumarate tabs (tipranavir) efavirenz-lamivudine- atazanavir sulfate caps CO tenofovir disoproxil CO ATRIPLA TABS fumarate tabs (efavirenz- emtricitabine caps CO emtricitabine-tenofovir CO disoproxil fumarate) emtricitabine-tenofovir disoproxil fumarate CO BIKTARVY TABS tabs (bictegravir- CO EMTRIVA CAPS 200 MG emtricitabine-tenofovir CO alafenamide fumarate) (emtricitabine) EMTRIVA SOLN 10 CIMDUO TABS CO (lamivudine-tenofovir CO MG/ML (emtricitabine) EPIVIR SOLN disoproxil fumarate) CO COMBIVIR TABS (lamivudine) CO EPIVIR TABS (lamivudine-zidovudine) CO COMPLERA TABS (lamivudine) (emtricitabine- EPZICOM TABS rilpivirine-tenofovir CO (abacavir sulfate- CO disoproxil fumarate) lamivudine) CRIXIVAN CAPS CO CO etravirine tabs (indinavir sulfate) EVOTAZ TABS DELSTRIGO TABS (atazanavir sulfate- CO (doravirine-lamivudine- cobicistat) tenofovir disoproxil CO fumarate) fosamprenavir calcium CO tabs DESCOVY TABS FUZEON SOLR (emtricitabine-tenofovir CO CO alafenamide fumarate) (enfuvirtide)
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55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GENVOYA TABS nevirapine tabs CO (elvitegravir-cobicistat- CO emtricitabine-tenofovir nevirapine tb24 CO alafenamide) NORVIR PACK 100 MG INTELENCE TABS 100 CO CO (ritonavir) MG, 200 MG (etravirine) NORVIR SOLN 80 MG/ML INTELENCE TABS 25 MG CO CO (ritonavir) (etravirine) NORVIR TABS 100 MG INVIRASE TABS CO CO (ritonavir) (saquinavir mesylate) ODEFSEY TABS ISENTRESS CHEW CO (emtricitabine- (raltegravir potassium) rilpivirine-tenofovir CO ISENTRESS HD TABS CO alafenamide fumarate) ( ) raltegravir potassium PIFELTRO TABS ISENTRESS PACK CO CO (doravirine) ( ) raltegravir potassium PREZCOBIX TABS ISENTRESS TABS CO CO (darunavir-cobicistat) ( ) raltegravir potassium PREZISTA SUSP CO JULUCA TABS (darunavir ethanolate) ( CO dolutegravir sodium- PREZISTA TABS rilpivirine hcl) CO (darunavir ethanolate) KALETRA SOLN CO RESCRIPTOR TABS (lopinavir-ritonavir) CO (delavirdine mesylate) KALETRA TABS CO REYATAZ CAPS 150 MG, (lopinavir-ritonavir) 200 MG, 300 MG CO lamivudine soln CO (atazanavir sulfate) REYATAZ PACK 50 MG CO lamivudine tabs CO (atazanavir sulfate) lamivudine-zidovudine CO ritonavir tabs CO tabs SELZENTRY SOLN CO LEXIVA SUSP 50 MG/ML (maraviroc) (fosamprenavir CO SELZENTRY TABS calcium) CO (maraviroc) LEXIVA TABS 700 MG (fosamprenavir CO stavudine caps 15 mg, CO calcium) 20 mg, 30 mg, 40 mg STAVUDINE CAPS 15 MG, lopinavir-ritonavir soln CO 20 MG, 30 MG, 40 MG CO (stavudine) lopinavir-ritonavir tabs CO nevirapine susp CO
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56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STRIBILD TABS VIDEX EC CPDR 125 MG F (elvitegravir-cobicistat- (didanosine) CO emtricitabine-tenofovir VIDEXPEDIATRIC SOLR F df) (didanosine) SUSTIVA CAPS VIRACEPT TABS CO CO (efavirenz) (nelfinavir mesylate) SUSTIVA TABS VIRAMUNE SUSP CO CO (efavirenz) (nevirapine) SYMFI LO TABS VIRAMUNE TABS (efavirenz-lamivudine- CO CO (nevirapine) tenofovir disoproxil VIRAMUNE XR TB24 CO fumarate) (nevirapine) SYMFI TABS (efavirenz- VIREAD POWD 40 MG/GM lamivudine-tenofovir CO (tenofovir disoproxil CO disoproxil fumarate) fumarate) SYMTUZA TABS VIREAD TABS 150 MG, (darunavir-cobicistat- 200 MG, 250 MG CO emtricitabine-tenofovir (tenofovir disoproxil CO alafenamide) fumarate) TEMIXYS TABS VIREAD TABS 300 MG (lamivudine-tenofovir CO (tenofovir disoproxil CO disoproxil fumarate) fumarate) ZIAGEN SOLN (abacavir tenofovir disoproxil CO CO fumarate tabs sulfate) TIVICAY PD TBSO ZIAGEN TABS ( CO abacavir CO (dolutegravir sodium) sulfate) TIVICAY TABS CO zidovudine caps F SP (dolutegravir sodium) TRIUMEQ TABS zidovudine syrp F SP (abacavir-dolutegravir- CO SP lamivudine) zidovudine tabs F TRIZIVIR TABS (abacavir CMV Agents CO sulfate-lamivudine- PA zidovudine) cidofovir soln F TROGARZO SOLN QL(21 ml CO (ibalizumab-uiyk) valganciclovir hcl solr F daily); AL(At TRUVADA TABS 50 mg/ml least 21 yrs old) (emtricitabine-tenofovir CO disoproxil fumarate) valganciclovir hcl tabs F TYBOST TABS 450 mg CO (cobicistat) Hepatitis Agents
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57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Ribavirin (Hepatitis C)) PA; SP- VEMLIDY TABS RIBASPHERE CAPS 200 F AcariaHealth;S (tenofovir alafenamide CO MG P fumarate) (Ribavirin (Hepatitis C)) PA; SP- RIBASPHERE TABS 200 F AcariaHealth;S Herpes Agents MG, 600 MG P acyclovir caps F adefovir dipivoxil tabs F SP acyclovir susp F BARACLUDE SOLN 0.05 F MG/ML (entecavir) acyclovir tabs F SP entecavir tabs 0.5 mg F famciclovir tabs F entecavir tabs 1 mg F valacyclovir hcl tabs F EPIVIR HBV SOLN 5 Influenza Agents MG/ML (lamivudine CO QL(20 ea per (hbv)) oseltamivir phosphate F caps or 30 mg 30 days retail) EPIVIR HBV TABS 100 CO QL(10 ea per MG (lamivudine (hbv)) oseltamivir phosphate F caps or 45 mg, 75 mg 30 days retail) lamivudine (hbv) tabs CO QL(120 ml per oseltamivir phosphate F PEGASYS PROCLICK PA; SP- susr or 6 mg/ml 30 days retail) SOLN (peginterferon F AcariaHealth;S RELENZA DISKHALER AL(At least 5 P F alfa-2a) AEPB (zanamivir) yrs old) PEGASYS SOLN PA; SP- rimantadine F AcariaHealth;S F (peginterferon alfa-2a) P hydrochloride tabs TAMIFLU CAPS 30 MG QL(20 ea per PEGINTRON KIT PA; SP- F F AcariaHealth;S (oseltamivir phosphate) 30 days retail) (peginterferon alfa-2b) P TAMIFLU CAPS 45 MG, 75 QL(10 ea per RIBASPHERE RIBAPAK PA; SP- MG (oseltamivir F 30 days retail) TBPK (ribavirin F AcariaHealth;S phosphate) (hepatitis c)) P TAMIFLU SUSR 6 MG/ML QL(120 ml per F RIBASPHERE TABS 400 PA; SP- (oseltamivir phosphate) 30 days retail) MG (ribavirin (hepatitis F AcariaHealth;S BETA BLOCKERS - Drugs to Treat High Blood c)) P Pressure ribavirin (hepatitis c) PA; SP- Alpha-Beta Blockers F AcariaHealth;S caps QL(1 ea daily) P carvedilol phosphate F cp24 ribavirin (hepatitis c) PA; SP- F AcariaHealth;S carvedilol tabs F tabs P PA; SP- Acaria F sofosbuvir-velpatasvir F labetalol hcl tabs tabs Health;SP Beta Blockers Cardio-Selective
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits acebutolol hcl caps F (Diltiazem Hcl Extended Release Beads) TAZTIA F atenolol tabs F XT, TIADYLT ER CP24 (Diltiazem Hcl) DILT-XR F CP24 bisoprolol fumarate F tabs or 10 mg, 5 mg amlodipine besylate QL(1 ea daily) tabs or 10 mg, 2.5 mg, F metoprolol succinate F tb24 5 mg diltiazem hcl coated metoprolol tartrate tabs F 100 mg, 25 mg, 50 mg beads cp24 120 mg, F Beta Blockers Non-Selective 180 mg, 240 mg, 300 mg, 360 mg (Sotalol Hcl) SORINE F TABS diltiazem hcl cp12 120 F HEMANGEOL SOLN PA mg, 60 mg, 90 mg F (propranolol hcl) diltiazem hcl cp24 180 F nadolol tabs F mg, 240 mg diltiazem hcl extended F pindolol tabs F release beads cp24 propranolol hcl cp24 or diltiazem hcl tabs 120 120 mg, 160 mg, 60 F mg, 30 mg, 60 mg, 90 F mg, 80 mg mg PA felodipine tb24 F propranolol hcl soln iv 1 F mg/ml nicardipine hcl caps F propranolol hcl soln or F 20 mg/5ml, 40 mg/5ml nifedipine caps 10 mg, F propranolol hcl tabs or 20 mg 10 mg, 20 mg, 40 mg, F QL(1 ea daily) nifedipine tb24 30 mg, F 60 mg, 80 mg 90 mg sotalol hcl (afib/afl) tabs F nifedipine tb24 60 mg F QL(2 ea daily) sotalol hcl tabs F QL(12 ea nimodipine caps F daily,252 ea SOTYLIZE SOLN ( per 21 days sotalol F hcl) retail) nisoldipine tb24 17 mg, F timolol maleate tabs F 25.5 mg, 34 mg, 8.5 mg CALCIUM CHANNEL BLOCKERS - Drugs to NYMALIZE SOLN 30 Treat High Blood Pressure MG/10ML, 60 MG/20ML F Calcium Channel Blockers (nimodipine) (Diltiazem Hcl Coated F Beads) CARTIA XT CP24
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59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits verapamil hcl cp24 or Pulmonary Hypertension - Phosphodiesterase 100 mg, 120 mg, 180 F (Tadalafil (Pulmonary PA; SP mg, 200 mg, 240 mg, Hypertension)) ALYQ F 300 mg, 360 mg TABS PA tadalafil (pulmonary PA; SP verapamil hcl soln iv F F 2.5 mg/ml hypertension) tabs CEPHALOSPORINS - Drugs to Treat Bacterial verapamil hcl tabs or F 120 mg, 40 mg, 80 mg Infections verapamil hcl tbcr or Cephalosporins - 1st Generation 120 mg, 180 mg, 240 F cefadroxil caps F mg VERELAN CP24 360 MG cefadroxil susr F F (verapamil hcl) VERELAN PM CP24 cefadroxil tabs F F (verapamil hcl) CEFAZOLIN PA CARDIOTONICS - Drugs to Treat Heart Failure SODIUM/SODIUM and Abnormal Heart Rhythm CHLORIDE SOLN F (cefazolin sodium in Cardiac Glycosides sodium chloride) (Digoxin) DIGITEK, DIGOX F CEFAZOLIN/SODIUM PA TABS CHLORIDE SOLN F digoxin soln or 0.05 F (cefazolin sodium in mg/ml sodium chloride) digoxin tabs or 0.125 F cephalexin caps 250 F mg, 125 mcg, 250 mcg mg, 500 mg LANOXIN TABS OR 125 F cephalexin susr 125 F MCG, 250 MCG (digoxin) mg/5ml, 250 mg/5ml CARDIOVASCULAR AGENTS - MISC. - Drugs to cephalexin tabs 250 F Treat Heart and Circulation Conditions mg, 500 mg Prostaglandin Vasodilators Cephalosporins - 2nd Generation F PA; SP- treprostinil soln Caremark cefaclor caps F VENTAVIS SOLN PA; SP- F F (iloprost) Caremark cefaclor susr Pulmonary Hypertension - Endothelin Receptor cefprozil susr F PA; SP ambrisentan tabs F cefprozil tabs F SP bosentan tabs 125 mg F cefuroxime axetil tabs F bosentan tabs 62.5 mg F Cephalosporins - 3rd Generation TRACLEER TBSO 32 MG F cefdinir caps F (bosentan)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cefdinir susr F (Drospirenone-Ethinyl 365 day supply Estradiol) GIANVI, allowed; JASMIEL, LO- cefpodoxime proxetil F susr ZUMANDIMINE, LORYNA, F NIKKI, OCELLA, SYEDA, cefpodoxime proxetil F VESTURA, ZARAH, tabs ZUMANDIMINE TABS ceftriaxone sodium solr (Ethynodiol Diacet & Eth 365 day supply ij 1 gm, 250 mg, 500 F Estrad) KELNOR 1/35, F allowed; mg KELNOR 1/50, ZOVIA 1/35, ZOVIA 1/35E TABS CEFTRIAXONE SODIUM PA SOLR IJ 100 GM (Levonorgestrel & Eth 365 day supply F Estradiol) AFIRMELLE, allowed; (ceftriaxone sodium) ALTAVERA, AUBRA, PA AUBRA EQ, AVIANE, ceftriaxone sodium solr F ij 2 gm AYUNA, CHATEAL, CHATEAL EQ, DELYLA, PA ceftriaxone sodium solr F FALMINA, KURVELO, F iv 1 gm, 10 gm, 2 gm LARISSIA, LESSINA, LEVORA 0.15/30-28, CHEMICALS LILLOW, LUTERA, Bulk Chemicals - H's MARLISSA, ORSYTHIA, PORTIA-28, SRONYX, HALOPERIDOL POWD XX CO VIENVA TABS (haloperidol (bulk)) (Levonorgestrel-Eth 365 day supply CONTRACEPTIVES - Drugs to Prevent Estradiol (Triphasic)) allowed; Pregnancy ENPRESSE-28, F LEVONEST, TRIVORA-28 Combination Contraceptives - Oral TABS (Desogestrel & Ethinyl 365 day supply (Levonorgestrel-Ethinyl 365 day supply Estradiol) APRI, CYRED, allowed; Estradiol (91-Day)) allowed; CYRED EQ, AMETHIA, AMETHIA LO, EMOQUETTE, ENSKYCE, F ASHLYNA, CAMRESE, ISIBLOOM, JULEBER, CAMRESE LO, DAYSEE, F KALLIGA, RECLIPSEN ICLEVIA, INTROVALE, TABS JAIMIESS, JOLESSA, (Desogestrel-Ethinyl 365 day supply LOJAIMIESS, SETLAKIN, Estradiol (Biphasic)) allowed; SIMPESSE TABS AZURETTE, BEKYREE, F (Levonorgestrel-Ethinyl 365 day supply KARIVA, PIMTREA, Estradiol (91-Day)) allowed;QL(1 SIMLIYA, VIORELE, AMETHIA, AMETHIA LO, ea daily) VOLNEA TABS ASHLYNA, CAMRESE, (Desogestrel-Ethinyl 365 day supply CAMRESE LO, DAYSEE, F Estradiol (Triphasic)) F allowed; ICLEVIA, INTROVALE, CAZIANT, VELIVET TABS JAIMIESS, JOLESSA, LOJAIMIESS, SETLAKIN, SIMPESSE TABS
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Norethin Acet & Estrad- 365 day supply (Norethindrone Acet & Eth 365 day supply Fe) AUROVELA 24 FE, allowed; Estra) AUROVELA 1.5/30, allowed;QL(1 AUROVELA FE 1.5/30, AUROVELA 1/20, HAILEY ea daily) AUROVELA FE 1/20, 1.5/30, JUNEL 1.5/30, BLISOVI 24 FE, BLISOVI JUNEL 1/20, LARIN 1.5/30, F FE 1.5/30, BLISOVI FE LARIN 1/20, LOESTRIN 1/20, HAILEY 24 FE, 1.5/30-21, LOESTRIN HAILEY FE 1.5/30, HAILEY 1/20-21, MICROGESTIN FE 1/20, JUNEL FE 1.5/30, 1.5/30, MICROGESTIN JUNEL FE 1/20, JUNEL FE F 1/20 TABS 24, LARIN 24 FE, LARIN (Norethindrone Acetate- 365 day supply FE 1.5/30, LARIN FE 1/20, Ethinyl Estradiol-Fe) TILIA F allowed; LOESTRIN FE 1.5/30, FE, TRI-LEGEST FE TABS LOESTRIN FE 1/20, MICROGESTIN 24 FE, (Norethindrone-Eth 365 day supply MICROGESTIN FE 1.5/30, Estradiol (Triphasic)) allowed; MICROGESTIN FE 1/20, ALYACEN 7/7/7, TARINA 24 FE, TARINA ARANELLE, CYCLAFEM F FE 1/20, TARINA FE 1/20 7/7/7, DASETTA 7/7/7, EQ TABS LEENA, NORTREL 7/7/7, NYLIA 7/7/7, PIRMELLA (Norethindrone & Eth 365 day supply 7/7/7 TABS Estradiol) ALYACEN 1/35, allowed; BALZIVA, BRIELLYN, (Norgestimate-Ethinyl 365 day supply CYCLAFEM 1/35, Estradiol (Triphasic)) TRI allowed; FEMYNOR, TRI- DASETTA 1/35, NECON F 0.5/35-28, NORTREL ESTARYLLA, TRI-LINYAH, 0.5/35 (28), NORTREL TRI-LO-ESTARYLLA, TRI- 1/35, PHILITH, PIRMELLA LO-MARZIA, TRI-LO-MILI, F 1/35, VYFEMLA, WERA TRI-LO-SPRINTEC, TRI- TABS MILI, TRI-NYMYO, TRI- PREVIFEM, TRI- (Norethindrone & Ethinyl 365 day supply SPRINTEC, TRI-VYLIBRA, Estradiol-Fe) KAITLIB FE, F allowed; TRI-VYLIBRA LO TABS LAYOLIS FE, WYMZYA FE CHEW (Norgestimate-Ethinyl 365 day supply Estradiol) ESTARYLLA, allowed; (Norethindrone Acet & Eth 365 day supply FEMYNOR, MILI, MONO- F Estra) AUROVELA 1.5/30, allowed; LINYAH, NYMYO, AUROVELA 1/20, HAILEY PREVIFEM, SPRINTEC 1.5/30, JUNEL 1.5/30, 28, VYLIBRA TABS JUNEL 1/20, LARIN 1.5/30, F LARIN 1/20, LOESTRIN (Norgestrel & Ethinyl 365 day supply 1.5/30-21, LOESTRIN Estradiol) CRYSELLE-28, allowed; 1/20-21, MICROGESTIN ELINEST, LOW- F 1.5/30, MICROGESTIN OGESTREL, OGESTREL 1/20 TABS TABS 365 day supply desogestrel & ethinyl F estradiol tabs allowed; 365 day supply desogestrel-ethinyl F estradiol (biphasic) tabs allowed; 365 day supply drospirenone-ethinyl F estradiol tabs allowed; To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 365 day supply (Levonorgestrel QL(6 ea per ethynodiol diacet & eth F estrad tabs allowed; (Emergency Oc)) AFTERA, 365 days retail) AFTERPILL, ECONTRA 365 day supply levonorgestrel & eth F EZ, ECONTRA ONE- estradiol tabs allowed; STEP, MY CHOICE, MY F levonorgestrel-eth 365 day supply WAY, NEW DAY, F allowed; OPCICON ONE-STEP, estradiol (triphasic) OPTION 2, PREVENTEZA, tabs REACT, TAKE ACTION 365 day supply TABS levonorgestrel-ethinyl F estradiol (91-day) tabs allowed; ELLA TABS (ulipristal QL(6 ea per F 365 days retail) levonorgestrel-ethinyl 365 day supply acetate) F allowed;QL(1 QL(6 ea per estradiol (91-day) tabs levonorgestrel F ea daily) (emergency oc) tabs 365 days retail) norethin acet & estrad- 365 day supply allowed; Progestin Contraceptives - Injectable fe tabs 1 mg-20 mcg- F 75 mg, 1.5 mg-30 mcg- DEPO-SUBQ PROVERA QL(1 ml per fill 75 mg 104 SUSY retail) (medroxyprogesterone F 365 day supply norethindrone & ethinyl F acetate (contraceptive)) estradiol-fe chew allowed; medroxyprogesterone QL(1 ml per fill norethindrone acet & 365 day supply F retail) allowed;QL(1 acetate (contraceptive) eth estra tabs 1 mg-20 F susp mcg ea daily) medroxyprogesterone QL(1 ml per fill norethindrone acet & 365 day supply F retail) allowed; acetate (contraceptive) eth estra tabs 1.5 mg- F susy 30 mcg norgestimate-ethinyl 365 day supply Progestin Contraceptives - Oral F allowed; (Norethindrone 365 day supply estradiol (triphasic) (Contraceptive)) CAMILA, allowed; tabs DEBLITANE, ERRIN, 365 day supply HEATHER, INCASSIA, norgestimate-ethinyl F estradiol tabs allowed; JENCYCLA, LYLEQ, F LYZA, NORA-BE, TYBLUME CHEW 365 day supply NORLYDA, NORLYROC, (levonorgestrel & eth F allowed; SHAROBEL, TULANA estradiol) TABS 365 day supply Combination Contraceptives - Transdermal norethindrone F (contraceptive) tabs allowed; (Norelgestromin-Ethinyl F 365 day supply Estradiol) XULANE PTWK allowed; CORTICOSTEROIDS - Steroid Hormone Drugs to Combination Contraceptives - Vaginal Treat Systemic Swelling Conditions (Etonogestrel-Ethinyl F 365 day supply Glucocorticosteroids Estradiol) ELURYNG RING allowed; (Dexamethasone) F 365 day supply DECADRON ELIX etonogestrel-ethinyl F estradiol ring allowed; (Dexamethasone) F Emergency Contraceptives DECADRON TABS
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREDNISONE INTENSOL budesonide cpep 3 mg F F CONC (prednisone) cortisone acetate tabs F prednisone soln F dexamethasone elix F 0.5 mg/5ml prednisone tabs F DEXAMETHASONE prednisone tbpk F INTENSOL CONC F (dexamethasone) Mineralocorticoids QL(5 ml daily) dexamethasone fludrocortisone acetate F tabs sodium phosphate soln F 120 mg/30ml, 20 COUGH/COLD/ALLERGY - Drugs to Treat mg/5ml, 4 mg/ml Cough, Cold and Allergy Symptoms DEXAMETHASONE QL(5 ml daily) Antitussives SODIUM PHOSPHATE (Hydrocodone W/ SOLN 4 MG/ML F ( Homatropine) HYDROMET F dexamethasone SYRP sodium phosphate) benzonatate caps 100 F dexamethasone soln F mg, 200 mg 0.5 mg/5ml hydrocodone w/ F dexamethasone tabs homatropine syrp 0.5 mg, 0.75 mg, 1 mg, F 1.5 mg, 2 mg, 4 mg, 6 hydrocodone w/ F mg homatropine tabs Cough/Cold/Allergy Combinations hydrocortisone tabs F (Brompheniramine & MEDROL TABS 2 MG Phenyleph) CHILDRENS F (methylprednisolone) COLD & ALLERGY, COLD & ALLERGY, methylprednisolone F COLD/ALLERGY tabs CHILDRENS, DIMAPHEN CHILDRENS, GNP COLD methylprednisolone F tbpk & ALLERGY CHILDRENS, HM COLD & ALLERGY F MILLIPRED TABS F CHILDRENS, PX (prednisolone) DIBROMM prednisolone sodium COLD/ALLERGY phosphate soln or 15 CHILDRENS, RYNEX PE, F SB COLD & ALLERGY mg/5ml, 5 mg/5ml, 6.7 CHILDRENS, SM COLD & mg/5ml ALLERGY CHILDRENS prednisolone sodium QL(150 ml per ELIX phosphate soln or 20 F fill retail) mg/5ml prednisolone soln F
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Brompheniramine & (Chlorpheniramine & Phenyleph) COLD & Phenylephrine) CVS ALLERGY CHILDRENS, F SINUS & ALLERGY CVS COLD & ALLERGY MAXIMUM STRENGTH, CHILDRENS ELIX 1 CVS SINUS PE & MG/5ML-2.5 MG/5ML ALLERGY MAXIMUM (Brompheniramine & STRENGTH, ED A-HIST, Pseudoeph) RYNEX PSE F EQ SUPHEDRINE PE LIQD SINUS &ALLERGY, EQL SINUS & ALLERGY PE, F (Brompheniramine & GNP SINUS & ALLERGY Pseudoeph) SM COLD & RELIEF PE, RA ALLERGY CHILDRENS, F SUPHEDRINE PE, SB WAL-TAP COLD & ALLERFED COLD & ALLERGY ELIX ALLERGY, SB SINUS & (Cetirizine- ALLERGY MAXIMUM Pseudoephedrine) 12 STRENGTH, SM COLD & HOUR ALLERGY-D, ALL ALLERGY PE, WAL-PHED DAY ALLERGY D, ALL PE SINUS/ALLERGY DAY ALLERGY D-12, ALL TABS DAY ALLERGY-D, ALLERGY D-12, ALLERGY RELIEF D, ALLERGY RELIEF NASAL DECONGESTANT, ALLERGY RELIEF-D, CVS ALLERGY RELIEF-D, EQ ALLERGY RELIEF NASAL F DECONGESTANT, EQL ALL DAY ALLERGY-D, GNP ALL DAY ALLERGY- D, GOODSENSE ALL DAY ALLERGY-D, HM ALLERGY COMPLETE-D, KLS ALLER-TEC D, PX ALLERGY RELIEF D, RA CETIRI-D, SHOPKO ALLERGY RELIEF-D, SM ALL DAY ALLERGY-D, SW ALLERGY RELIEF-D, WAL-ZYR D TB12 (Cetirizine- Pseudoephedrine) TGT ALLERGY+ CONGESTION F RELIEF-D TB12 5 MG-120 MG
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Dextromethorphan- CONGESTION LIQD Guaifenesin) BIOCOTRON, CVS (Diphenhydramine- TUSSIN DM, DIABETIC Phenylephrine) SILTUSSIN-DM, DIABETIC BENADRYL ALLERGY TUSSIN DM, DIABETIC PLUS CONGESTION F TUSSIN FOR CHILDREN, ULTRATABS, WAL-DRYL GILTUSS COUGH & PE ALLERGY/SINUS CHEST CONGESTION, TABS GILTUSS COUGH & (Diphenhydramine- CHEST CONGESTION Phenylephrine) CVS F CHILDRENS, GILTUSS ALLERGY/CONGESTION DIABETIC COUGH CHILDRENS SOLN &COLD, GILTUSS HONEY COUGH & CHEST (Diphenhydramine- CONGESTION, GILTUSS Phenylephrine- HONEY COUGH & CHEST Acetaminophen) GNP CONGESTION ALLERGY PLUS SINUS CHILDRENS, GNP HEADACHE, MUCINEX TUSSIN DM, GNP TUSSIN FAST-MAX NIGHT TIME DM COUGH, GUAIASORB COLD & FLU MAXIMUM DM, HM TUSSIN ADULT STRENGTH, QC COUGH & CHEST ALLERGY/SINUS CONGESTION DM, MAXI- HEADACHE, SB F TUSS G, PX TUSSIN DM, ALLERGY & COLD PE, SB SEVERE COLD PE, QC TUSSIN DM COUGH & F CHEST THERAFLU CONGESTION/ADULT, RA EXPRESSMAX SEVERE TUSSIN COUGH, RA COLD & COUGH TUSSIN COUGH/CHEST NIGHTTIME, WAL-DRYL CONGESTION DM, RA ALLERGY/SINUS TUSSIN DM, ROBAFEN HEADACHE, WAL-PHED DM COUGH, ROBAFEN PE SEVERE COLD TABS DM COUGH/CHEST (Guaifenesin-Codeine) G CONGESTION, ROBAFEN TUSSIN AC, MAXI-TUSS F DM PEAK COLD AC, VIRTUSSIN A/C SOLN COUGH/CHEST (Guaifenesin-Codeine) CONGESTION, GUAIATUSSIN AC, F ROBITUSSIN PEAK COLD GUAIFENESIN AC SYRP COUGH+ CHEST (Guaifenesin-Codeine) F CONGESTION DM, SAFE VIRTUSSIN AC/ALC LIQD TUSSIN DM ADULT, SB COUGH CONTROL DM, SILTUSSIN DM DAS, SORBUGEN NR, TGT COUGH FORMULA DM, TUSNEL DIABETIC, TUSSIN DM, TUSSIN DM COUGH + CHEST CONGESTION, WAL- TUSSIN DM, WAL-TUSSIN DM COUGH & CHEST To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Loratadine & (Loratadine & Pseudoephedrine) Pseudoephedrine) ALAVERT ALLERGY RELIEF D, ALLERGY/SINUS, ALLERGY RELIEF D-24, ALLERGY & ALLERGY RELIEF-D, CONGESTION RELIEF, ALLERGY RELIEF/NASAL ALLERGY RELIEF D-12, DECONGESTANT, ALLERGY RELIEF-D, CVS ALLERGY-RELIEF-D, CVS ALLERGY RELIEF-D12, ALLERGY RELIEF-D, EQL EQ ALLERGY & ALLERGY/CONGESTION CONGESTION RELIEF, RELIEF, GNP ALLERGY & GNP LORATADINE-D CONGESTIONRELIEF, 12HR, HM ALLERGY & F HM ALLERGY RELIEF & CONGESTION, KLS NASALDECONGESTANT, ALLERCLEAR D-12 HR, KLS ALLERCLEAR D- F KLS ALLERCLEAR D- 24HR, KLS ALLERCLEAR- 12HR, LORATADINE-D D 24HR, LORATADINE-D 12HR, MEIJER ALLERGY 24HR, PX ALLERGY RELIEF-D, PX ALLERGY RELIEF D, QC RELIEF D, RA LORATADINE-D, RA ALLERGY/CONGESTION ALLERGY RELIEF & RELIEF, SHOPKO NASALDECONGESTANT, ALLERGY RELIEF-D, SM RA LORATA-D, SB LORATADINE D 12HR, ALLERGY RELIEF/NASAL WAL-ITIN D TB12 DECONGESTANT, SM LORATA-DINE D, TGT ALLERGY & CONGESTIONRELIEF, WAL-ITIN D 24 HOUR TB24 (Pseudoephedrine- Ibuprofen) CVS COLD & SINUS RELIEF, HM COLD & SINUS RELIEF, IBUPROFEN COLD & SINUS, PX IBUPROFEN COLD & SINUS, QC F IBUPROFEN COLD/SINUS, RA IBU- PROFEN COLD/SINUS, SM COLD & SINUS RELIEF, WAL-PROFEN COLD & SINUS TABS (Triprolidine & Pseudoephedrine) APRODINE, ED A-HIST F PSE, EQL COLD & ALLERGY, WAL-ACT TABS
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVIL ALLERGY & promethazine- CONGESTION TABS phenylephrine-codeine F (chlorpheniramine- F syrp phenylephrine- RYMED TABS ibuprofen) (dexchlorpheniramine- F ADVIL MULTI-SYMPTOM phenylephrine) COLD& FLU TABS (chlorpheniramine- F Misc. Respiratory Inhalants phenylephrine- (Sodium Chloride ibuprofen) (Inhalant)) NEBUSAL F NEBU 3 % cetirizine- F (Sodium Chloride pseudoephedrine tb12 (Inhalant)) SIMPLY F SALINE BABY AERS dextromethorphan- F guaifenesin liqd HYPERSAL NEBU 3.5 % DRIXORAL (sodium chloride F COLD/ALLERGY TB12 (inhalant)) (dexbrompheniramine F sodium chloride F & pseudoephedrine) (inhalant) aers 0.9 % ED CHLORPED D LIQD sodium chloride (chlorpheniramine & F (inhalant) nebu 0.9 %, F phenylephrine) 3 % guaifenesin-codeine F Mucolytics soln hydrocodone polistirex- AL(At least 6 acetylcysteine soln F yrs old) chlorpheniramine F DERMATOLOGICALS - Drugs to Treat Skin polistirex suer Conditions MAXI-TUSS PE LIQD Acne Products (brompheniramine & F Limit 45gms phenyleph) per (Adapalene) ADAPALENE F month;QL(1.5 NEXAFED SINUS TREATMENT GEL PRESSURE +PAIN TABS gm daily); (pseudoephedrine- F RX/OTC acetaminophen) promethazine & F phenylephrine syrp promethazine F w/codeine soln promethazine F w/codeine syrp promethazine-dm syrp F
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Benzoyl Peroxide) ACNE (Benzoyl Peroxide) ACNE FOAMING WASH, TREATMENT BENZEPRO CREAMY CLEANSINGBAR F WASH, CERAVE ACNE MAXIMUM STRENGTH, FOAMING CVS ACNE CLEANSING CREAMCLEANSER, CVS BAR BAR ACNE FOAMING FACE (Benzoyl Peroxide) WASH, CVS ADVANCED BENZOYL PEROXIDE 3-IN-1 EXFOLIATING F WASH, KP BENZOYL F CLEANSER, CVS PEROXIDE WASH LIQD CREAMY ACNE FACE 10 % WASH, CVS FOAMING ACNE FACE WASH, (Benzoyl Peroxide) RX/OTC PANOXYL CREAMY BENZOYL PEROXIDE WASH, PANOXYL WASH, KP BENZOYL F FOAMING WASH, PR PEROXIDE WASH LIQD 5 BENZOYL PEROXIDE % WASH LIQD (Benzoyl Peroxide) BP F (Benzoyl Peroxide) ACNE RX/OTC WASH LIQD 10 %, 7 % FOAMING WASH, (Benzoyl Peroxide) BP F RX/OTC BENZEPRO CREAMY WASH LIQD 2.5 %, 5 % WASH, CERAVE ACNE (Erythromycin (Acne Aid)) F FOAMING ERY PADS CREAMCLEANSER, CVS (Isotretinoin) ACCUTANE, QL(4 ea daily) ACNE FOAMING FACE AMNESTEEM, CLARAVIS, F WASH, CVS ADVANCED MYORISAN, ZENATANE 3-IN-1 EXFOLIATING F CAPS 10 MG CLEANSER, CVS CREAMY ACNE FACE (Isotretinoin) ACCUTANE, QL(5 ea daily) WASH, CVS FOAMING AMNESTEEM, CLARAVIS, F ACNE FACE WASH, MYORISAN, ZENATANE PANOXYL CREAMY CAPS 20 MG WASH, PANOXYL (Isotretinoin) ACCUTANE, QL(2 ea daily) FOAMING WASH, PR AMNESTEEM, CLARAVIS, F BENZOYL PEROXIDE MYORISAN, ZENATANE WASH LIQD CAPS 40 MG (Benzoyl Peroxide) ACNE (Isotretinoin) ACCUTANE, QL(3 ea daily) MEDICATION 10, ACNE CLARAVIS, MYORISAN, F MEDICATION 2.5, ACNE ZENATANE CAPS 30 MG MEDICATION 5, ACNE TREATMENT GEL, ACNE- (Tretinoin) AVITA CREA F CLEAR, BP GEL, CLEAN & CLEAR PERSA-GEL F (Tretinoin) AVITA GEL F MAXIMUM STRENGTH, ACNE MEDICATION 10 CVS ACNE TREATMENT/MAXIMUM LOTN (benzoyl F STRENGTH, KP peroxide) BENZOYL PEROXIDE ACNE MEDICATION 5 GEL LOTN (benzoyl F peroxide)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 45gms sulfacetamide sodium F F per (acne) lotn adapalene crea 0.1 % month;QL(1.5 gm daily) sulfacetamide sodium F Limit 45gms w/ sulfur lotn 5 %-10 % per tretinoin crea 0.025 %, F adapalene gel 0.1 % F month;QL(1.5 0.05 %, 0.1 % gm daily); RX/OTC tretinoin gel 0.01 %, F Limit 45gms 0.025 % Limit 50gms adapalene gel 0.3 % F per month;QL(1.5 tretinoin microsphere F per month gm daily) gel ;QL(1.67 gm BENZOYL PEROXIDE daily) CLEANSER LIQD F Anti-inflammatory Agents - Topical (benzoyl peroxide) (Diclofenac Sodium QL(6.68 gm (Topical)) ARTHRITIS daily); RX/OTC benzoyl peroxide gel F 10 %, 2.5 %, 5 % PAIN RELIEVER, ASPERCREME benzoyl peroxide- F ARTHRITIS PAIN erythromycin gel RELIEVER, CVS F clindamycin phosphate DICLOFENAC SODIIUM, F GNP ARTHRITIS PAIN, (topical) gel GOODSENSE ARTHRITIS PAIN, QC DICLOFENAC clindamycin phosphate F (topical) lotn SODIIUM GEL diclofenac sodium QL(6.68 gm clindamycin phosphate F F (topical) soln (topical) gel 1 % daily); RX/OTC Antibiotics - Topical erythromycin (acne aid) F gel (Bacitracin (Topical)) erythromycin (acne aid) ANTIBIOTIC OINTMENT, F F QC BACITRACIN, SB pads BACITRACIN OINT erythromycin (acne aid) F (Bacitracin (Topical)) soln BACITRAYCIN PLUS OINT F 500 UNIT/GM isotretinoin caps 10 mg F QL(4 ea daily) (Bacitracin Zinc) CVS F QL(5 ea daily) BACITRACIN, EQ isotretinoin caps 20 mg BACITRACIN ZINC, EQL QL(3 ea daily) BACITRACIN ZINC, GNP isotretinoin caps 30 mg F BACITRACIN ZINC, HM QL(2 ea daily) BACITRACIN, KP F isotretinoin caps 40 mg F BACITRACIN ZINC, RA SODIUM QL(30 gm per BACITRACIN, RA SULFACETAMIDE/SULFU fill retail) BACITRACIN ZINC R SUSP 5 %-10 % F FIRSTAID, SM (sulfacetamide sodium ANTIBIOTIC OINT w/ sulfur)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Bacitracin-Polymyxin B) (Neomycin-Polymyxin W/ QL(30 gm per CVS POLY BACITRACIN, Pramoxine) CVS fill retail) DOUBLE ANTIBIOTIC, HM ANTIBIOTIC PLUS, CVS DOUBLE ANTIBIOTIC, KP ANTIBIOTIC/PAIN RELIEF, DOUBLE ANTIBIOTIC, F EQ ANTIBIOTIC + PAIN NEOSPORIN, POLY RELIEF MAXIMUM BACITRACIN, RA STRENGTH, EQL DOUBLE ANTIBIOTIC, SM ANTIBIOTIC + PAIN DOUBLE ANTIBIOTIC, RELIEF MAXIMUM WAL-SPORIN OINT STRENGTH, GNP (Neomycin-Bacitracin- QL(454 gm per ANTIBIOTIC + PAIN F Polymyxin) CURAD fill retail) RELIEF, GOODSENSE TRIPLE ANTIBIOTIC, CVS ANTIBIOTIC/PAIN RELIEF, ANTIBIOTIC, EQ TRIPLE MULTI ANTIBIOTIC PLUS, ANTIBIOTIC, EQL FIRST RA ANTIBIOTIC PLUS, SM AID ANTIBIOTIC, GNP ANTIBIOTIC PLUS PAIN TRIPLE ANTIBIOTIC, HM RELIEF MAXIMUM TRIPLE ANTIBIOTIC, STRENGTH, TGT FIRST LANABIOTIC, MEDI-FIRST AID ANTIBIOTICMAXIMUM TRIPLE ANTIBIOTIC, F MEIJER TRIPLE STRENGTH CREA ANTIBIOTIC, PX TRIPLE bacitracin (topical) oint F OINTMENT, RA TRIPLE ANTIBIOTIC, SM TRIPLE F ANTIBIOTIC, SM TRIPLE bacitracin zinc oint ANTIBIOTIC ORIGINAL gentamicin sulfate F STRENGTH, TRIPLE (topical) crea ANTIBIOTIC, TRIPLE ANTIBIOTIC FIRST AID gentamicin sulfate F OINT (topical) oint (Neomycin-Bacitracin- QL(454 gm per mupirocin calcium F Polymyxin) FIRST AID fill retail) (topical) crea ANTIBIOTIC OINT 3.5 MG- F 400 UNIT-5000 UNIT, 3.5 mupirocin oint F MG/GM-500 UNIT/GM- 10000 UNIT/GM Antifungals - Topical (Neomycin-Bacitracin- QL(454 gm per Polymyxin) SB TRIPLE fill retail) ANTIBIOTIC OINT 3.5 F MG/GM-400 UNIT/GM- 5000 UNIT/GM
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Clotrimazole (Topical)) RX/OTC (Miconazole Nitrate ANTI-FUNGAL, (Topical)) CARRINGTON CLOTRIMAZOLE AF, ANTIFUNGAL, CAVILON, CLOTRIMAZOLE ANTI- KP MICONAZOLE FUNGAL, NITRATE, MICADERM, CLOTRIMAZOLE MICONAZOLE ANTIFUNGAL, ANTIFUNGAL, REMEDY F CLOTRIMAZOLE ANTIFUNGAL, SM ATHLETES FOOT, ANTIFUNGAL CLOTRIMAZOLE GRX, MICONAZOLE, SOOTHE CVS CLOTRIMAZOLE, & COOL INZO CVS ITCH RELIEF ANTIFUNGAL CREAM, ANTIFUNGAL, CVS TINEACIDE CREA RINGWORM, EQ (Nystatin (Topical)) QL(60 gm per ANTIFUNGAL, EQ NYAMYC, NYSTOP F fill retail) ATHLETES FOOT, EQ POWD JOCK ITCH, EQL F ANTIFUNGAL, EQL (Terbinafine Hcl (Topical)) ATHLETES FOOT, GNP ATHLETES FOOT AF ATHLETES FOOT, JOCK CREAM, CVS ATHLETES ITCH, JOCK ITCH RELIEF, FOOT, CVS JOCK ITCH, KP CLOTRIMAZOLE, EQ ATHLETES FOOT, PRO-EX ANTIFUNGAL, EQL ATHLETES FOOT, PX ATHLETIC FOOT, QC GNP TERBINAFINE CLOTRIMAZOLE, RA HYDROCHLORIDE, KP F ATHLETES FOOT, RA TERBINAFINE CLOTRIMAZOLE, RA HYDROCHLORIDE, QC JOCK ITCH, SB ATHLETES FOOT, RA CLOTRIMAZOLE FOOT, ANTIFUNGAL FOOT SHOPKO ATHLETES CARE, RA FOOT CARE FOOT, SM ANTIFUNGAL ANTIFUNGAL, SM CLOTRIMAZOLE, TGT ATHLETES FOOT, TGT CLOTRIMAZOLE CREA ATHLETES FOOT CREA (Clotrimazole (Topical)) RX/OTC (Terbinafine Hcl (Topical)) ATHLETES FOOT CREA 1 F ANTIFUNGAL, ATHLETES F FOOT, DESENEX CREA 1 % % (Tolnaftate) ANTIFUNGAL F (Clotrimazole (Topical)) RX/OTC CREA 1 % CVS CLOTRIMAZOLE (Tolnaftate) BLIS-TO-SOL F MAXIMUMSTRENGTH, F LIQD FUNGICURE INTENSIVE WITHNAILGUARD SOLN (Ketoconazole (Topical)) F QL(200 ml per NIZORAL A-D SHAM fill retail) (Miconazole Nitrate (Topical)) ANTIFUNGAL F CREA 2 %
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Tolnaftate) CVS ketoconazole (topical) F ANTIFUNGAL, CVS sham ATHLETES FOOT, EQ ATHLETES FOOT, EQL LAMISIL AT SPRAY SOLN ANTIFUNGAL, FUNGI- (terbinafine hcl F GUARD, FUNGOID-D, (topical)) GNP TOLNAFTATE, KP miconazole nitrate F TOLNAFTATE, QC F TOLNAFTATE, RA FOOT (topical) crea CARE ANTIFUNGAL, SB naftifine hcl crea F ANTI-FUNGAL, SM ANTIFUNGAL naftifine hcl gel F TOLNAFTATE, TGT ANTIFUNGAL, NAFTIN GEL 2 % F TOLNAFTATE (naftifine hcl) ANTIFUNGAL CREA NIZORAL A-D SHAM QL(200 ml per F (Tolnaftate) DR GS CLEAR (ketoconazole (topical)) fill retail) NAIL, FOOT REPAIR SERUM, FORMULA 3 THE nystatin (topical) crea F TREATMENT, FORMULA 7 THE SOLUTION, nystatin (topical) oint F FUNGAL NAIL ERASER, F MEDICATED ANTI- nystatin (topical) powd F QL(60 gm per FUNGAL, MYCOCIDE fill retail) CLINICAL NS nystatin-triamcinolone F ANTIFUNGAL crea TREATMENT, MYCOZYL AL, TINASPORE SOLN nystatin-triamcinolone F ALEVAZOL OINT oint F (clotrimazole (topical)) sulconazole nitrate soln F clotrimazole (topical) RX/OTC F terbinafine hcl (topical) crea F crea RX/OTC clotrimazole (topical) F soln tolnaftate crea F clotrimazole w/ F Antihistamines-Topical betamethasone crea ITCH RELIEF CREA QL(30 ml per clotrimazole w/ F (diphenhydramine hcl F betamethasone lotn fill retail) (topical)) econazole nitrate crea F Antineoplastic or Premalignant Lesion Agents - ex CARAC CREA EXELDERM SOLN F F (fluorouracil (topical)) (sulconazole nitrate) FLUOROPLEX CREA EXELDERM SOLN F F (fluorouracil (topical)) (sulconazole nitrate) fluorouracil (topical) F ketoconazole (topical) F crea 0.5 %, 5 % crea
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73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(10 ml per TAZORAC GEL 0.05 %, fluorouracil (topical) F F soln 2 %, 5 % fill retail) 0.1 % (tazarotene) PANRETIN GEL F Antiseborrheic Products (alitretinoin) (Selenium Sulfide) ANTI- PICATO GEL ( DANDRUFF SHAMPOO, F ingenol F mebutate) DANDREX SHAM (Selenium Sulfide) CVS Antipruritics - Topical ANTI-DANDRUFF, (Camphor & Menthol) QL(222 ml per DANDRUFF SHAMPOO, F ANTI-ITCH, GNP ANTI- F fill retail) EQL MEDICATED ITCH LOTN 0.5 %-0.5 % DANDRUFF LOTN (Camphor & Menthol) CVS QL(222 ml per (Sulfacetamide Sodium) QL(480 ml per ANTI-ITCH, MEN-PHOR F fill retail) SODIUM F fill retail) LOTN SULFACETAMIDE WASH Antipsoriatics LIQD 10 % selenium sulfide lotn (Calcipotriene) F F CALCITRENE OINT 2.5 % QL(480 ml per calcipotriene crea F sulfacetamide sodium F liqd fill retail) calcipotriene oint F Antivirals - Topical F QL(5 gm per fill calcipotriene soln F acyclovir topical crea retail) calcitriol (topical) oint F acyclovir topical oint F COSENTYX PA; SP Burn Products SENSOREADY PEN SOAJ F (Silver Sulfadiazine) SSD F (secukinumab) CREA COSENTYX SOSY PA; SP F (secukinumab) silver sulfadiazine crea F DRITHO-CREME HP SULFAMYLON CREA 85 F CREA (anthralin) MG/GM (mafenide F acetate) STELARA SOLN PA; SP- F AcariaHealth;S Corticosteroids - Topical (ustekinumab) P (Clobetasol Propionate STELARA SOSY PA; SP- Emollient Base) F AcariaHealth;S (ustekinumab) CLOBETASOL P PROPIONATE E, F TALTZ SOAJ PA CLOBETASOL F (ixekizumab) PROPIONATE TALTZ SOSY PA EMOLLIENT CREA F (ixekizumab) (Hydrocortisone (Topical)) F ALA-CORT CREA 2.5 % tazarotene crea F TAZORAC CREA 0.05 % F (tazarotene) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocortisone (Topical)) RX/OTC (Hydrocortisone (Topical)) RX/OTC ALA-CORT, ANTI-ITCH AQUAPHOR ITCH RELIEF MAXIMUM STRENGTH, MAXIMUM STRENGTH, CVS HYDROCORTISONE F CORTIZONE-10, CVS ANTI-ITCH, CORTISONE MAXIMUM PREPARATION H, SM STRENGTH, EQL ANTI- HYDROCORTISONE ITCH MAXIMUM CREA 1 % STRENGTH, GNP (Hydrocortisone (Topical)) RX/OTC HYDROCORTISONE ALA-CORT, ANTI-ITCH MAXIMUM STRENGTH, MAXIMUM STRENGTH, GOODSENSE ANTI-ITCH MAXIMUM STRENGTH, CVS HYDROCORTISONE F ANTI-ITCH, HYDROCORTISONE IN F PREPARATION H, SM ABSORBASE, HYDROCORTISONE HYDROCORTISONE CREA EX 1 % MAXIMUM STRENGTH, KP HYDROCORTISONE (Hydrocortisone (Topical)) MAXIMUM STRENGTH, AQUANIL HC, BETA HC, RA ANTI-ITCH/MAXIMUM CORTIZONE-10 STRENGTH, SB DIABETICS SKIN, HYDROCORTISONE CORTIZONE-10 ECZEMA, MAXIMUM STRENGTH, CORTIZONE-10 SM HYDROCORTISONE HYDRATENSIVEHEALING F MAXIMUM STRENGTH , CORTIZONE-10 OINT HYDRATENSIVESOOTHI NG, CVS CORTISONE MAXIMUM STRENGTH, DERMAREST ECZEMA, SARNOL-HC LOTN
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75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocortisone (Topical)) RX/OTC HYDROCORTISONE AVEENO ANTI-ITCH PLUS 12, SB MAXIMUMSTRENGTH, HYDROCORTISONE, TGT CORTAID MAXIMUM ANTI-ITCH PLUS STRENGTH, CURAD OATMEAL, TGT ANTI- HYDROCORTISONE, CVS ITCH/ALOE/VITAMIN E ANTI-ITCH MAXIMUM CREA STRENGTH, CVS CORTISONE INTENSE HEALING ANTI-ITCH, CVS CORTISONE MAXIMUM STRENGTH, CVS ECZEMA ANTI-ITCH MAXIMUM STRENGTH, CVS HYDROCORTISONE MAXIMUM STRENGTH, EQ 1% HYDROCORTISONE, EQ HYDROCORTISONE MAXIMUM STRENGTH, EQ HYDROCORTISONE PLUS, EQL ANTI-ITCH INTENSIVE HEALING FORMULA, EQL ANTI- ITCH MAXIMUM STRENGTH, EQL ANTI- F ITCH MAXIMUM STRENGTH PLUS 10 HEALING MOISTURIZERS, GNP HYDROCORTISONE, GNP HYDROCORTISONE PLUS, HYDROCORTISONE ANTI-ITCH, HYDROCORTISONE INTENSIVEHEALING, HYDROCORTISONE MAXIMUM STRENGTH, HYDROCORTISONE MAXIMUM STRENGTH PLUS 12 MOISTURIZERS, HYDROCORTISONE PLUS, INSTACORT 5, KERICORT 10, KP HYDROCORTISONE, MEIJER HYDROCORTISONE, NOBLE FORMULA HC, PX HYDROCREAM, RA ANTI- ITCH MAXIMUM STRENGTH, RA To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocortisone (Topical)) HYDROCORTISONE AVEENO ANTI-ITCH PLUS 12, SB MAXIMUMSTRENGTH, HYDROCORTISONE, TGT CORTAID MAXIMUM ANTI-ITCH PLUS STRENGTH, CURAD OATMEAL, TGT ANTI- HYDROCORTISONE, CVS ITCH/ALOE/VITAMIN E ANTI-ITCH MAXIMUM CREA STRENGTH, CVS (Hydrocortisone (Topical)) CORTISONE INTENSE CVS HYDROCORTISONE HEALING ANTI-ITCH, CVS ANTI-ITCH, SM F CORTISONE MAXIMUM HYDROCORTISONE STRENGTH, CVS CREA 0.5 % ECZEMA ANTI-ITCH (Hydrocortisone (Topical)) MAXIMUM STRENGTH, NOBLE FORMULA HC, CVS HYDROCORTISONE SCALP RELIEF MAXIMUM F MAXIMUM STRENGTH, STRENGTH, SCALPICIN EQ 1% MAXIMUM STRENGTH HYDROCORTISONE, EQ SOLN HYDROCORTISONE MAXIMUM STRENGTH, (Hydrocortisone (Topical)) EQ HYDROCORTISONE SM HYDROCORTISONE F PLUS, EQL ANTI-ITCH OINT 0.5 % INTENSIVE HEALING (Hydrocortisone Acetate FORMULA, EQL ANTI- (Topical)) GYNECORT 10, F ITCH MAXIMUM LANACORT 10 CREA STRENGTH, EQL ANTI- F (Hydrocortisone Acetate ITCH MAXIMUM (Topical)) VAGISIL CREA 1 F STRENGTH PLUS 10 % HEALING MOISTURIZERS, GNP HYDROCORTISONE, GNP HYDROCORTISONE PLUS, HYDROCORTISONE ANTI-ITCH, HYDROCORTISONE INTENSIVEHEALING, HYDROCORTISONE MAXIMUM STRENGTH, HYDROCORTISONE MAXIMUM STRENGTH PLUS 12 MOISTURIZERS, HYDROCORTISONE PLUS, INSTACORT 5, KERICORT 10, KP HYDROCORTISONE, MEIJER HYDROCORTISONE, NOBLE FORMULA HC, PX HYDROCREAM, RA ANTI- ITCH MAXIMUM STRENGTH, RA To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocortisone-Aloe Vera) betamethasone CORTIZONE-10 dipropionate F INTENSIVE HEALING, augmented lotn CORTIZONE-10 PLUS, CORTIZONE-10/ALOE, betamethasone GNP dipropionate F HYDROCORTISONE/ALO augmented oint E, HM HYDROCORTISONE betamethasone F PLUS, HM valerate crea 0.1 % HYDROCORTISONE/ALO betamethasone F E MAXIMUM STRENGTH, valerate lotn 0.1 % HYDROCORTISONE/ALO F E MAXIMUM STRENGTH, betamethasone F KLS HYDROCORTISONE valerate oint 0.1 % PLUS, KP CAPEX SHAM F HYDROCORTISONE/ALO ( ) E, RA fluocinolone acetonide HYDROCORTISONE clobetasol propionate F PLUS, SM crea HYDROCORTISONE PLUS, SM clobetasol propionate F HYDROCORTISONE/ALO emollient base crea E MAXIMUM STRENGTH clobetasol propionate F CREA foam (Triamcinolone Acetonide F clobetasol propionate F (Topical)) TRIDERM CREA gel APEXICON E CREA (diflorasone diacetate F clobetasol propionate F emollient base) oint betamethasone clobetasol propionate F dipropionate (topical) F soln crea desonide crea F QL(2 gm daily) betamethasone QL(2 gm daily) dipropionate (topical) F desonide oint F lotn desoximetasone crea F betamethasone 0.05 % dipropionate (topical) F QL(2 gm daily) desoximetasone crea F oint 0.25 % betamethasone QL(50 gm per QL(2 gm daily) desoximetasone gel F dipropionate F fill retail) 0.05 % augmented crea QL(2 gm daily) desoximetasone oint F betamethasone 0.25 % dipropionate F diflorasone diacetate F augmented gel crea
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78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(60 ml per diflorasone diacetate F hydrocortisone butyrate F oint soln fill retail) EPIFOAM FOAM F hydrocortisone valerate F (pramoxine-hc) crea fluocinolone acetonide F hydrocortisone valerate F crea oint fluocinolone acetonide F hydrocortisone-aloe F oil vera crea fluocinolone acetonide F mometasone furoate F oint crea fluocinolone acetonide F mometasone furoate F soln oint fluocinonide crea 0.05 QL(60 ml per F mometasone furoate F % soln fill retail) fluocinonide emulsified PRAMOSONE CREA F F base crea (pramoxine-hc) PRAMOSONE LOTN fluocinonide gel 0.05 % F F (pramoxine-hc) fluocinonide oint 0.05 F F QL(60 gm per % prednicarbate crea fill retail) QL(60 gm per fluocinonide soln 0.05 F prednicarbate oint F % fill retail) QL(60 gm per PSORCON CREA fluticasone propionate F F crea 0.05 % fill retail) (diflorasone diacetate) QL(60 gm per triamcinolone acetonide fluticasone propionate F oint 0.005 % fill retail) (topical) aers 0.147 F mg/gm halobetasol propionate F crea triamcinolone acetonide (topical) crea 0.025 %, F hydrocortisone (topical) F 0.1 %, 0.5 % crea 0.5 %, 2.5 % triamcinolone acetonide hydrocortisone (topical) RX/OTC F (topical) lotn 0.025 %, F crea 1 % 0.1 % hydrocortisone (topical) F triamcinolone acetonide lotn 1 %, 2.5 % (topical) oint 0.025 %, F hydrocortisone (topical) F 0.1 %, 0.5 % oint 0.5 %, 2.5 % Eczema Agents RX/OTC hydrocortisone (topical) F DUPIXENT SOSY 200 PA; SP-Acaria F oint 1 % MG/1.14ML (dupilumab) Health hydrocortisone acetate DUPIXENT SOSY 300 PA; SP-Acaria F F (topical) crea MG/2ML (dupilumab) Health;SP
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79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CONDYLOX GEL Emollient/Keratolytic Agents F QL(200 gm per (podofilox) (Urea) GORDONS UREA, F UREMEZ-40 CREA fill retail); podofilox soln F RX/OTC QL(100 gm per (Urea) UREA-C40 LOTN F QL(325 ml per salicylic acid gel F fill retail) fill retail) QL(325 ml per Local Anesthetics - Topical CEROVEL LOTN (urea) F fill retail) (Capsaicin) CAPSAICIN QL(43 gm per QL(200 gm per HP, CAPZIX, CVS fill retail) urea crea ex 40 % F fill retail); CAPSAICIN HP, RX/OTC DERMACINRX PENETRAL, RA F QL(325 ml per urea lotn ex 40 % fill retail) ARTHRITIS PAIN RELIEF, F SURE RESULT SR Emollients RELIEF, ZOSTRIX HIGH (Lactic Acid (Ammonium RX/OTC POTENCY, ZOSTRIX Lactate)) AL12, HIGH POTENCY AMLACTIN, AMLACTIN FOOTPAIN RELIEF CREA DAILY, CVS HYDRATING (Capsaicin) CAPSAICIN QL(60 gm per SKIN TREATMENT, CVS F HP, CAPZIX, CVS fill retail) SKIN TREATMENT, CVS CAPSAICIN HP, SKIN TREATMENT BODY DERMACINRX LOTION, GERI- PENETRAL, RA HYDROLAC 12 LOTN ARTHRITIS PAIN RELIEF, F (Lactic Acid (Ammonium RX/OTC SURE RESULT SR Lactate)) GERI- F RELIEF, ZOSTRIX HIGH HYDROLAC 12 CREA POTENCY, ZOSTRIX RX/OTC HIGH POTENCY lactic acid (ammonium F lactate) crea FOOTPAIN RELIEF CREA (Capsaicin) CAPSAICIN RX/OTC lactic acid (ammonium F HP, CAPZIX, CVS lactate) lotn CAPSAICIN HP, LACTIC ACID E CREA DERMACINRX F (lactic acid w/ vitamin e) PENETRAL, RA ARTHRITIS PAIN RELIEF, F Enzymes - Topical SURE RESULT SR SANTYL OINT RELIEF, ZOSTRIX HIGH F (collagenase) POTENCY, ZOSTRIX HIGH POTENCY Immunomodulating Agents - Topical FOOTPAIN RELIEF CREA imiquimod crea 5 % F (Dibucaine) CVS QL(57 gm per HEMORRHOIDAL & F fill retail) Immunosuppressive Agents - Topical TOPICAL ANALGESIC, PA; QL(30 gm NUPERCAINAL OINT (Lidocaine Hcl) 7T LIDO RX/OTC F per fill retail); pimecrolimus crea AL(At least 2 GEL, REGENECARE HA F yrs old) GEL Keratolytic/Antimitotic Agents
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Lidocaine Hcl) QL(2 ml daily) ETHYL ASPERCREME CHLORIDE/MEDIUM W/LIDOCAINE, STREAM AERO (ethyl F ASPERCREME/LIDOCAIN chloride) E, BENGAY LIDOCAINE, CVS LIDOCAINE lidocaine crea ex 3 % F QL(454 gm per MAXIMUM STRENGTH, fill retail) CVS PAIN lidocaine crea ex 4 % F RELIEF/MAXIMUM STRENGTH, EQ QL(454 gm per LIDOCAINE PAIN lidocaine hcl crea 3 % F fill retail); RELIEVING/MAX RX/OTC STRENGTH, GNP F QL(2 ml daily) LIDOCAINE PAIN lidocaine hcl crea 4 % F RELIEVING, GOLD BOND MULTI-SYMPTOM/ITCH & lidocaine hcl gel 2 % F PAIN RELIEF/MAXIMUM STRENGTH, LIDOCAINE lidocaine hcl prsy 2 % F PLUS, NEUROMED7, PAIN RELIEVING lidocaine hcl soln 4 % F MAXIMUM STRENGTH, PAIN lidocaine-prilocaine F RELIEVING/LIDOCAINE, crea RA PAIN RELIEF, XOLIDO REGENECARE HA LIQD F XP CREA (lidocaine hcl) (Lidocaine Hcl) GLYDO F PRSY Misc. Topical QL(454 gm per (Aluminum Sulfate & (Lidocaine Hcl) LIDOPIN F Calcium Acetate) BORO- CREA 3 % fill retail); RX/OTC PACKS, CVS ASTRINGENT SOLUTION F (Lidocaine) ANECREAM, SOOTHING RELIEF, BLUE TUBE PAIN F PEDI-BORO SOAK PAKS RELIEVING/ALOE CREA PACK ARTHRITIS PAIN QL(60 gm per (Lanolin (Topical)) AMEDA RELIEVING CREA F fill retail) TRIPLE ZERO LANOLIN, (capsaicin) HPA LANOLIN, LAN-O- SOOTHE, LANSINOH capsaicin crea 0.025 % F LANOLIN, LANSINOH F LANOLIN MINIS NIPPLE, F QL(43 gm per capsaicin crea 0.1 % fill retail) LANSINOH LANOLIN CAPZASIN-P CREA QL(43 gm per NIPPLE, MEDELA F fill retail) TENDER CARE LANOLIN (capsaicin) CREA dibucaine oint ex F QL(57 gm per (Zinc Oxide (Topical)) CVS QL(500 gm per fill retail) ZINC OXIDE, GNP ZINC fill retail) ethyl chloride aero F OXIDE, MEIJER ZINC F OXIDE, RA ZINC OXIDE ETHYL CHLORIDE/FINE OINT STREAM AERO (ethyl F chloride) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(500 gm per aluminum sulfate & F zinc oxide (topical) oint F calcium acetate pack 20 % fill retail) CALAMINE LOTN F Rosacea Agents (calamine-zinc oxide) (Metronidazole (Topical)) F CALAMINE PHENOLATED ROSADAN CREA LOTN (calamine F (Metronidazole (Topical)) F phenolated) ROSADAN GEL DRYSOL SOLN Limit 50gms F (aluminum chloride) F per azelaic acid gel month;QL(1.67 GNP CALAMINE LOTN F gm daily) (calamine-zinc oxide) metronidazole (topical) F GNP CALAMINE crea 0.75 % PHENOLATED LOTN F (calamine phenolated) metronidazole (topical) F HM CALAMINE LOTN gel 0.75 % F QL(2 gm daily) (calamine-zinc oxide) metronidazole (topical) F HYDRO-LAN CREA gel 1 % F (lanolin (topical)) metronidazole (topical) F lotn 0.75 % lanolin (topical) oint F Scabicides & Pediculicides LANOLOR CREA (lanolin F (Crotamiton) CROTAN F (topical)) LOTN MEIJER CALAMINE LOTN F (Permethrin) BEDDING (calamine-zinc oxide) SPRAY LICE TREATMENT OFF DEEP WOODS AERO QL(170 gm per STEP 3, CVS BEDDING (diethyltoluamide F fill retail) SPRAY LICE (deet)) TREATMENT, CVS LICE/BEDBUG/MITE, GNP F OFF DEEP WOODS DRY QL(113 gm per HOME AERO (diethyltoluamide F fill retail) LICE/BEDBUG/DUST (deet)) MITE SPRAY, SM PX CALAMINE LOTN BEDDING LICE F TREATMENT, STOP LICE, (calamine-zinc oxide) STOP LICE STEP 3 AERO QC CALAMINE LOTN F (Permethrin) CVS LICE (calamine) TREATMENT, GNP LICE SM CALAMINE LOTN TREATMENT, HM LICE F (calamine-zinc oxide) TREATMENT, LICE F TREATMENT, LICE SM CALAMINE TREATMENT CREME PHENOLATED LOTN F RINSE, SB LICE (calamine phenolated) TREATMENT LIQD ULTRATHON INSECT QL(170 gm per (Permethrin) LICE REPELLENT 8 AERO fill retail) F TREATMENT, RA LICE F (diethyltoluamide TREATMENT, SM LICE (deet)) TREATMENT LOTN
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pyrethrins-Piperonyl LICEMD GEL Butoxide) CVS LICE (pyrethrins-piperonyl F KILLING, EQ LICE butoxide) KILLING MAXIMUM STRENGTH, EQL LICE malathion lotn F KILLING MAXIMUMSTRENGTH, permethrin crea F GNP LICE TREATMENT, HM LICE KILLING RID ESSENTIAL LICE ELIMINATION KIT KIT MAXIMUM STRENGTH, F LICE KILLING MAXIMUM (pyrethrins-piperonyl STRENGTH, LICE F butoxide) KILLING SHAMPOO, RA SCHOOLTIME SHAMPOO LICE MAXIMUM F STRENGTH, RID LICE SHAM (nit remover) KILLING SHAMPOO, SB QL(120 ml per LICE KILLING MAXIMUM spinosad susp F fill retail,240 ml STRENGTH, SM LICE per 30 days KILLING, SM LICE retail) KILLING MAXIMUM Tar Products STRENGTH, STOP LICE MAXIMUM STRENGTH (Coal Tar Extract) CVS SHAM THERAPEUTIC, EQL THERAPEUTIC, SM ANTI- (Pyrethrins-Piperonyl DANDRUFF COAL Butoxide) SB LICE TARTHERAPEUTIC, F TREATMENT, STOP LICE F TERA-GEL TAR, MAXIMUM STRENGTH THERAPEUTIC LIQD SHAMPOO, (Pyrethrins-Piperonyl THERAPEUTIC T+PLUS Butoxide-Permethrin-Nit SHAM Remover) CVS LICE SOLUTION KIT, CVS LICE coal tar extract soln F SOLUTION KIT, LICIDE COMPLETE LICE F DIAGNOSTIC PRODUCTS TREATMENT, RA LICE SOLUTION KIT, SM LICE Diagnostic Tests SOLUTION KIT, STOP Available to LICE COMPLETE LICE ASSURE PLATINUM TEST members in TREATMENT KIT STRIPS STRP (glucose F LTC/SNF CVS LICE SOLUTION KIT blood) only;QL(10 ea 3-STEP KIT (pyrethrins- daily); RX/OTC piperonyl butoxide- F BD VERITOR SYSTEM permethrin-nit remover) FOR RAPID DETECTION OF SARS-COV-2 KIT CO EURAX CREA F (covid-19 antigen test) (crotamiton) BINAXNOW COVID-19 AG RX/OTC LICE B GONE SHAM F CARD HOME TEST KIT CO (vegetable extract) (covid-19 at home test)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BINAXNOW COVID-19 AG FREESTYLE TEST QL(10 ea CARD KIT (covid-19 CO STRIPS STRP (glucose F daily); RX/OTC antigen test) blood) CHEMSTRIP -10 WITH SG GOJJI BLOOD KETONE STRP (multiple urine F TEST STRIPS STRP F tests) (ketone blood test) CHEMSTRIP 10 MD STRP ID NOW COVID-19 F (multiple urine tests) CONTROL SWAB KIT KIT CO CHEMSTRIP 2 GP (covid-19 control test) ID NOW COVID-19 KIT STRIPS STRP (multiple F CO urine tests) (covid-19 test) CHEMSTRIP 5 OB STRP KETONE STRP (acetone F F (multiple urine tests) (urine) test) CHEMSTRIP 7 STRP KETONE TEST STRIPS F (multiple urine tests) STRP (acetone (urine) F test) CHEMSTRIP 9 STRIPS KETOSTIX STRP STRP (multiple urine F F tests) (acetone (urine) test) CHEMSTRIP-K STRP LUCIRA COVID-19 ALL-IN- F ONE TEST KIT KIT (acetone (urine) test) CO (covid-19 at home test) DIASTIX STRP (glucose LYRA DIRECT SARS- urine test-(glucose F COV-2 ASSAY KIT CO oxidase)) (covid-19 test) FORA GTEL BLOOD LYRA SARS-COV-2 KETONE TEST STRIPS F ASSAY KIT (covid-19 CO STRP (ketone blood test) test) NOVA MAX PLUS FREESTYLE INSULINX QL(10 ea KETONE TESTSTRIPS BLOODGLUCOSE TEST daily); RX/OTC F F STRP (ketone blood STRIPS STRP (glucose test) blood) PRECISION XTRA BLOOD QL(10 ea FREESTYLE INSULINX QL(10 ea GLUCOSE TEST STRIPS F daily); RX/OTC BLOODGLUCOSE TEST F daily); RX/OTC STRP (glucose blood) STRP (glucose blood) PRECISION XTRA STRP F FREESTYLE LITE TEST QL(10 ea VI (ketone blood test) STRIPS STRP (glucose F daily); RX/OTC PTS PANELS KETONE blood) TEST STRP (ketone F FREESTYLE PRECISION QL(10 ea blood test) NEO BLOOD GLUCOSE daily); RX/OTC TEST STRIPS STRP F QUICKVUE AT-HOME RX/OTC (glucose blood) COVID-19 TEST KIT CO (covid-19 at home test)
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84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QUICKVUE SARS triamterene & ANTIGEN TEST KIT CO hydrochlorothiazide F (covid-19 antigen test) tabs RELION KETONE TEST Loop Diuretics STRIPS STRP (acetone F (urine) test) bumetanide tabs F SOFIA SARS ANTIGEN furosemide soln or 10 F FIA KIT (covid-19 CO mg/ml, 8 mg/ml antigen test) furosemide tabs or 20 F SOFIA2 SARS ANTIGEN mg, 40 mg, 80 mg FIA KIT (covid-19 CO QL(1 ea daily) antigen test) torsemide tabs 10 mg, F 100 mg, 5 mg XPERT XPRESS SARS- COV-2 KIT (covid-19 CO torsemide tabs 20 mg F test) Potassium Sparing Diuretics DIGESTIVE AIDS - Drugs to Treat Low Digestive Enzymes amiloride hcl tabs F Digestive Enzymes spironolactone tabs F CREON CPEP (pancrelipase (lipase- F Thiazides and Thiazide-Like Diuretics protease-amylase)) QL(2 ea daily) chlorothiazide tabs 250 F PANCREAZE CPEP mg (pancrelipase (lipase- F QL(4 ea daily) chlorothiazide tabs 500 F protease-amylase)) mg DIURETICS - Drugs to Treat Heart, Circulation chlorthalidone tabs F Conditions and Blood Pressure Carbonic Anhydrase Inhibitors hydrochlorothiazide F caps acetazolamide cp12 F hydrochlorothiazide F acetazolamide tabs F tabs indapamide tabs F methazolamide tabs F F Diuretic Combinations metolazone tabs amiloride & QL(1 ea daily) ENDOCRINE AND METABOLIC AGENTS - hydrochlorothiazide F MISC. - Drugs to Treat Bone Disease and tabs Regulate Hormones spironolactone & Bone Density Regulators F QL(10.8 ml hydrochlorothiazide alendronate sodium F tabs soln 70 mg/75ml daily) triamterene & alendronate sodium QL(1 ea daily) hydrochlorothiazide F tabs 10 mg, 40 mg, 5 F caps mg To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.15 ea PA; SP- alendronate sodium F NORDITROPIN FLEXPRO tabs 35 mg, 70 mg daily) F AcariaHealth;S SOPN (somatropin) P calcitonin (salmon) soln QL(2 ml per 30 F days retail) OMNITROPE SOCT 10 PA; SP- ij 200 unit/ml MG/1.5ML, 5 MG/1.5ML F AcariaHealth;S P calcitonin (salmon) soln F (somatropin) na 200 unit/act ZOMACTON SOLR 5 MG PA; SP- F AcariaHealth;S etidronate disodium F (somatropin) tabs P FOSAMAX PLUS D TABS Limit 4 per Hormone Receptor Modulators month;QL(0.15 (alendronate sodium- F raloxifene hcl tabs F cholecalciferol) ea daily) PA; QL(1 ea LHRH/GnRH Agonist Analog Pituitary risedronate sodium F tabs 30 mg, 5 mg daily) FENSOLVI KIT PA; SP- AcariaHealth;S PA; QL(0.15 ea (leuprolide acetate F risedronate sodium F P tabs 35 mg daily) (cpp) (6 month)) risedronate sodium LUPRON DEPOT-PED (1- PA; SP- F MONTH) KIT (leuprolide F AcariaHealth;S tbec 35 mg acetate (cpp)) P zoledronic acid conc 4 PA; SP- PA; SP- F AcariaHealth;S LUPRON DEPOT-PED (3- AcariaHealth;S mg/5ml P MONTH) KIT (leuprolide F acetate (cpp) (3 month)) P ZOLEDRONIC ACID SOLN PA; SP- 4 MG/100ML (zoledronic F AcariaHealth;S SUPPRELIN LA KIT PA; SP- P F AcariaHealth;S acid) (histrelin acetate (cpp)) P zoledronic acid soln 4 PA; SP- SP- F AcariaHealth;S SYNAREL SOLN mg/100ml, 5 mg/100ml F AcariaHealth;S P (nafarelin acetate) P ZOLEDRONIC ACID SOLR PA F Metabolic Modifiers 4 MG (zoledronic acid) ALDURAZYME SOLN PA; SP- Corticotropin F AcariaHealth;S ( ) ACTHAR GEL PA; SP- laronidase P F (corticotropin) Caremark;SP calcitriol caps or 0.25 F Growth Hormones mcg, 0.5 mcg GENOTROPIN SOLR 5 PA; SP- calcitriol soln or 1 F F AcariaHealth;S MG (somatropin) mcg/ml P CARBAGLU TABS SP-Accredo;SP F HUMATROPE COMBO PA; SP- (carglumic acid) PACK SOLR F AcariaHealth;S PA (somatropin) P cinacalcet hcl tabs 30 F mg PA; SP- HUMATROPE SOLR PA; SP F AcariaHealth;S cinacalcet hcl tabs 60 F (somatropin) P mg, 90 mg
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FABRAZYME SOLR PA; SP- Prolactin Inhibitors F AcariaHealth;S (agalsidase beta) P cabergoline tabs F levocarnitine (metabolic F Vasopressin Receptor Antagonists modifiers) soln JYNARQUE TABS 15 MG, QL(1 ea daily); F levocarnitine (metabolic F 30 MG (tolvaptan) SP modifiers) tabs JYNARQUE TBPK 15 MG, PA F LUMIZYME SOLR PA; SP- (tolvaptan) F AcariaHealth;S (alglucosidase alfa) P F QL(1 ea daily); tolvaptan tabs SP NAGLAZYME SOLN PA; SP- F (galsulfase) Accredo;SP ESTROGENS - Hormone Replacement/Modifying Drugs paricalcitol caps F Estrogen Combinations sapropterin (Estradiol & Norethindrone QL(1 ea daily) dihydrochloride pack F Acetate) AMABELZ, F 100 mg LOPREEZA, MIMVEY, MIMVEY LO TABS SP-Caremark sapropterin (Norethindrone Acetate- dihydrochloride pack F Ethinyl Estradiol) F 500 mg FYAVOLV, JINTELI TABS sapropterin SP-Caremark CLIMARA PRO PTWK Limit 4 per 28 dihydrochloride tabs F (estradiol- F days;QL(0.15 100 mg levonorgestrel) ea daily) XURIDEN PACK ( AL(At least 21 COMBIPATCH PTTW QL(0.29 ea uridine F triacetate) yrs old) (estradiol & F daily) norethindrone acetate) Posterior Pituitary Hormones QL(1 ea daily) DDAVP SOLN NA 0.01 % estradiol & (desmopressin acetate F norethindrone acetate F refrigerated) tabs DESMOPRESSIN PA; SP- norethindrone acetate- F ACETATE SOLN NA 1.5 AcariaHealth;S ethinyl estradiol tabs F MG/ML (desmopressin P PREMPHASE TABS acetate) (conjugated estrogens- medroxyprogesterone F desmopressin acetate F spray refrigerated soln acetate) PREMPRO TABS desmopressin acetate F spray soln (conjugated estrogens- medroxyprogesterone F desmopressin acetate F acetate) tabs or 0.1 mg, 0.2 mg Estrogens STIMATE SOLN PA; SP- F AcariaHealth;S (Estradiol) DOTTI, F QL(0.29 ea (desmopressin acetate) P LYLLANA PTTW daily)
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87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F QL(0.29 ea (Simethicone) CVS GAS QL(30 ml per ALORA PTTW (estradiol) daily) RELIEF DROPS EXTRA fill retail) estradiol pttw td 0.025 QL(0.29 ea STRENGTH, GAS RELIEF daily) INFANTS, GAS-X INFANT F mg/24hr, 0.0375 DROPS, SIMETHICONE mg/24hr, 0.05 mg/24hr, F DROPS INFANTS, TGT 0.075 mg/24hr, 0.1 GAS RELIEF INFANTS mg/24hr DROPS LIQD estradiol ptwk td 0.025 QL(0.143 ea (Simethicone) CVS GAS QL(60 ml per mg/24hr, 0.05 mg/24hr, daily) RELIEF INFANTS, CVS fill retail) INFANTS GAS RELIEF, F 0.06 mg/24hr, 0.075 EQ INFANTS GAS mg/24hr, 0.1 mg/24hr, RELIEF, EQL INFANTS 37.5 mcg/24hr GAS RELIEF, GAS estradiol tabs or 0.5 RELIEF DROPS INFANTS, F GAS RELIEF INFANTS, mg, 1 mg, 2 mg GNP INFANT GAS MENEST TABS F RELIEF, GNP INFANTS (esterified estrogens) GAS RELIEF, HM GAS PREMARIN TABS OR 0.3 RELIEF INFANTS, MG, 0.45 MG, 0.625 MG, INFANTS GAS RELIEF, F 0.9 MG, 1.25 MG F INFANTS SIMETHICONE, (estrogens, conjugated) LITTLE REMEDIES FOR TUMMYS GAS RELIEF, FLUOROQUINOLONES - Drugs to Treat Bacterial LITTLE TUMMYS GAS Infections RELIEF, MOMMYS BLISS GAS RELIEF DROPS, Fluoroquinolones PEDIACARE GAS RELIEF CIPRO SUSR 5 DROPS INFANTS, PX GM/100ML, 500 MG/5ML F GAS RELIEF INFANTS, (ciprofloxacin) SIMEPED, SM GAS RELIEF DROPS INFANTS, ciprofloxacin hcl tabs F SM GAS RELIEF INFANTS DROPS SUSP ciprofloxacin susr F levofloxacin soln 25 F mg/ml QL(14 ea per levofloxacin tabs 250 F mg, 500 mg, 750 mg fill retail) ofloxacin tabs 300 mg F
F QL(56 ea per ofloxacin tabs 400 mg fill retail) GASTROINTESTINAL AGENTS - MISC. - Miscellaneous Gastrointestinal Drugs Antiflatulents
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88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Simethicone) CVS GAS (Simethicone) EQL GAS RELIEF, CVS GAS RELIEF RELIEF, GAS-X EXTRA F EXTRA STRENGTH, DRX STRENGTH CAPS 125 CHOICE GAS RELIEF, EQ MG GAS RELIEF EXTRA (Simethicone) GAS F STRENGTH, EQL GAS RELIEF CHEW 80 MG GONE EXTRA STRENGTH, GAS RELIEF (Simethicone) PHAZYME, EXTRA STRENGTH, GNP SB GAS RELIEF CHEW F GAS RELIEF, GNP GAS 125 MG RELIEF EXTRA (Simethicone) SB GAS QL(60 ml per STRENGTH, F RELIEF SUSP 40 F fill retail) GOODSENSE GAS MG/0.6ML RELIEF EXTRA (Simethicone) SM GAS STRENGTH, HM GAS RELIEF CHEW 125 MG, F RELIEF, MI-ACID GAS 80 MG RELIEF, QC GAS RELIEF, QC GAS RELIEF EXTRA simethicone caps 125 F STRENGTH, RA GAS mg RELIEF, RA GAS RELIEF simethicone chew 125 F EXTRA STRENGTH, TGT mg, 80 mg GAS RELIEF EXTRA STRENGTH CHEW simethicone susp 40 QL(60 ml per F fill retail) (Simethicone) CVS GAS mg/0.6ml RELIEF, CVS GAS RELIEF Bile Acid Synthesis Disorder Agents EXTRA STRENGTH, EQ CHOLBAM CAPS (cholic PA; QL(5 ea GAS RELIEF, EQL GAS F daily); SP RELIEF EXTRA acid) STRENGTH, GAS RELIEF Gallstone Solubilizing Agents EXTRA STRENGTH, GNP GAS RELIEF EXTRA ursodiol caps 300 mg F STRENGTH, HM GAS RELIEF EXTRA ursodiol tabs 250 mg F STRENGTH, PX GAS F RELIEF EXTRA Gastrointestinal Antiallergy Agents STRENGTH, QC GAS cromolyn sodium F RELIEF, QC GAS RELIEF (mastocytosis) conc EXTRA STRENGTH, RA GAS RELIEF, RA GAS Gastrointestinal Chloride Channel Activators RELIEF EXTRA PA STRENGTH, SM GAS lubiprostone caps F RELIEF EXTRA STRENGTH, TGT GAS Gastrointestinal Stimulants RELIEF EXTRA metoclopramide hcl STRENGTH CAPS soln 10 mg/10ml, 5 F (Simethicone) EQL GAS QL(60 ml per mg/5ml RELIEF, GAS RELIEF F fill retail) metoclopramide hcl F SUSP 20 MG/0.3ML tabs 10 mg, 5 mg Inflammatory Bowel Agents
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89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits balsalazide disodium F calcium acetate caps (phosphate binder) F caps ENTYVIO SOLR PA; SP- F AcariaHealth;S (vedolizumab) GENITOURINARY AGENTS - MISCELLANEOUS P - Miscellaneous Drugs to Treat Reproductive INFLECTRA SOLR PA; SP- Organs and Urinary System F AcariaHealth;S (infliximab-dyyb) P Alkalinizers mesalamine cp24 or (Potassium Citrate-Citric F Acid) CYTRA K F 0.375 gm CRYSTALS, TARON- QL(12 ea daily) CRYSTALS PACK mesalamine cpdr or F 400 mg ORACIT SOLN ( sodium F citrate & citric acid) mesalamine enem re 4 F gm potassium citrate (alkalinizer) tbcr 10 F mesalamine tbec or 1.2 F gm, 800 mg meq, 1080 mg, 540 mg QL(4 ea per 28 sodium citrate & citric RX/OTC mesalamine w/ F cleanser kit days retail) acid soln 334 mg/5ml- 334 mg/5ml-500 REMICADE SOLR PA; SP- F F AcariaHealth;S mg/5ml-500 mg/5ml, (infliximab) P 334 mg/5ml-500 RENFLEXIS SOLR PA; SP- mg/5ml F AcariaHealth;S (infliximab-abda) P Genitourinary Irrigants SFROWASA ENEM (Sodium Chloride (Gu F Irrigant)) ARGYLE F (mesalamine) STERILE SALINE, CURITY STELARA SOLN PA; SP- STERILE SALINE SOLN F AcariaHealth;S (ustekinumab (iv)) P acetic acid soln F sulfasalazine tabs F sodium chloride (gu F irrigant) soln sulfasalazine tbec F Interstitial Cystitis Agents Intestinal Acidifiers ELMIRON CAPS QL(3 ea daily) (Lactulose (pentosan polysulfate F sodium) (Encephalopathy)) F ENULOSE, GENERLAC Prostatic Hypertrophy Agents SOLN alfuzosin hcl tb24 F lactulose F (encephalopathy) soln dutasteride-tamsulosin F Peripheral Opioid Receptor Antagonists hcl caps MOVANTIK TABS PA F finasteride tabs F (naloxegol oxalate) Phosphate Binder Agents To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tamsulosin hcl caps F ALPHANATE SOLR (antihemophilic Urinary Analgesics factor/von willebrand CO factor complex (Phenazopyridine Hcl) F PHENAZO TABS 200 MG (human)) ALPHANATE/VON phenazopyridine hcl F tabs WILLEBRANDFACTOR COMPLEX/HUMAN SOLR Urinary Stone Agents (antihemophilic CO tiopronin tabs F SP factor/von willebrand factor complex GOUT AGENTS - Drugs to Treat Gout (human)) ALPHANINE SD SOLR Gout Agent Combinations CO (coagulation factor ix) colchicine w/ F probenecid tabs ALPROLIX SOLR (coagulation factor ix CO Gout Agents (recomb) fc fusion protein allopurinol tabs F (rfixfc)) BENEFIX KIT colchicine tabs F (coagulation factor ix CO (recombinant)) KRYSTEXXA SOLN PA; SP- F AcariaHealth;S COAGADEX SOLR (pegloticase) P (coagulation factor x CO Uricosurics (human)) CORIFACT KIT (factor probenecid tabs F xiii concentrate CO HEMATOLOGICAL AGENTS - MISC. - Drugs to (human)) Treat Blood Disorders ELOCTATE SOLR Antihemophilic Products (antihemophilic factor CO ADVATE SOLR (rcmb) fc fusion protein(bdd-rfviiifc)) (antihemophilic factor CO (rcmb) plasma/albumin FEIBA SOLR free (rahf-pfm)) (antiinhibitor coagulant CO ADYNOVATE SOLR complex) (antihemophilic factor CO FIBRYGA SOLR (recombinant) pegylated) (fibrinogen concentrate CO AFSTYLA KIT (human)) HELIXATE FS KIT (antihemophilic factor CO (recombinant) single (antihemophilic factor CO chain) (recombinant) (rfviii)) HEMLIBRA SOLN CO (emicizumab-kxwh)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEMOFIL M SOLR NUWIQ KIT (antihemophilic factor CO (antihemophilic factor CO (human)) (rcmb) simoctocog HUMATE-P SOLR alfa(bdd-rfviii,sim)) (antihemophilic NUWIQ SOLR factor/von willebrand CO (antihemophilic factor CO factor complex (rcmb) simoctocog (human)) alfa(bdd-rfviii,sim)) IDELVION SOLR OBIZUR SOLR (coagulation factor ix (antihemophilic factor CO recomb albumin fusion CO (recombinant porcine) (rpfviii)) protein (rix-fp)) PROFILNINE SD SOLR IXINITY SOLR CO (factor ix complex) (coagulation factor ix CO PROFILNINE SOLR (recombinant)) CO (factor ix complex) JIVI SOLR (antihemophil SP REBINYN SOLR fact(rcmb) pegylated-aucl CO (bdd-rfviii peg-aucl)) (coagulation factor ix CO (recombinant) KCENTRA KIT glycopegylated) (prothrombin complex CO RECOMBINATE SOLR concentrate human) (antihemophilic factor CO KOATE SOLR (recombinant) (rfviii)) (antihemophilic factor CO RIASTAP SOLR (human)) (fibrinogen concentrate CO KOATE-DVI SOLR (human)) (antihemophilic factor CO RIXUBIS SOLR (human)) (coagulation factor ix CO KOGENATE FS KIT (recombinant)) (antihemophilic factor CO SEVENFACT SOLR (recombinant) (rfviii)) (coagulation factor viia CO KOVALTRY SOLR (recombinant)-jncw) (antihemophilic factor CO TRETTEN SOLR (rcmb) plasma/albumin free (rahf-pfm)) (coagulation factor xiii a-subunit CO MONONINE SOLR CO (recombinant)) (coagulation factor ix) NOVOEIGHT SOLR VONVENDI SOLR (von willebrand factor CO (antihemophilic factor CO (rcmb) bd truncated (bd (recombinant)) trunc-rfviii)) WILATE KIT NOVOSEVEN RT SOLR (antihemophilic (coagulation factor viia CO factor/von willebrand CO (recombinant)) factor complex (human)) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XYNTHA KIT DROXIA CAPS (antihemophilic factor CO (hydroxyurea (sickle F (rcmb) moroctocog cell anemia)) alfa(bdd-rfviii,mor)) Cobalamins XYNTHA SOLOFUSE KIT cyanocobalamin soln ij (antihemophilic factor CO F (rcmb) moroctocog 1000 mcg/ml alfa(bdd-rfviii,mor)) cyanocobalamin tabs or F Complement Inhibitors 250 mcg CINRYZE SOLR (c1 PA; SP- Folic Acid/Folates esterase inhibitor F Caremark;SP (Folic Acid) CVS FOLIC (human)) ACID, FOLATE, GNP FOLIC ACID, HM FOLIC SOLIRIS SOLN PA; SP- ACID, PX FOLIC ACID, QC F F AcariaHealth;S (eculizumab) FOLIC ACID, RA FOLIC P ACID, SM FOLIC ACID, YL Hematorheologic Agents FOLIC ACID TABS pentoxifylline tbcr F (Folic Acid) FA-8 CAPS F Platelet Aggregation Inhibitors (Folic Acid) KP FOLIC F RX/OTC ACID TABS 1 MG anagrelide hcl caps F (Folic Acid) KP FOLIC F BRILINTA TABS ACID TABS 800 MCG F FOLIC ACID CAPS OR 20 (ticagrelor) F MG, 5 MG (folic acid) cilostazol tabs F folic acid caps or 800 F mcg clopidogrel bisulfate F tabs 300 mg folic acid tabs or 1 mg F RX/OTC QL(1 ea daily) clopidogrel bisulfate F tabs 75 mg folic acid tabs or 400 F mcg, 800 mcg dipyridamole tabs F Hematopoietic Growth Factors prasugrel hcl tabs F QL(1 ea daily) ARANESP ALBUMIN PA; SP- FREE SOLN F AcariaHealth;S ZONTIVITY TABS F (darbepoetin alfa) P (vorapaxar sulfate) ARANESP ALBUMIN PA; SP- HEMATOPOIETIC AGENTS - Drugs to Treat FREE SOSY F AcariaHealth;S Blood Disorders (darbepoetin alfa) P NPLATE SOLR 250 MCG, PA; SP- Agents for Gaucher Disease F CEREZYME SOLR PA; SP- 500 MCG (romiplostim) AcariaHealth F (imiglucerase) AcariaHealth PROMACTA PACK 12.5 PA; SP- VPRIV SOLR PA; SP- MG (eltrombopag F AcariaHealth;A F AcariaHealth L(At least 21 (velaglucerase alfa) olamine) yrs old) Agents for Sickle Cell Disease
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; SP- Acaria (Ferrous Sulfate) PROMACTA PACK 25 MG F Health;AL(At BPROTECTED PEDIA (eltrombopag olamine) least 21 yrs IRON, FE-VITE IRON, old); SP IRON SUPPLEMENT F PA; SP- Acaria CHILDRENS, PC PROMACTA TABS 12.5 PEDIATRIC IRON DROPS MG, 25 MG, 50 MG, 75 MG F Health;AL(At least 21 yrs SOLN (eltrombopag olamine) old); SP (Ferrous Sulfate) CVS RETACRIT SOLN 10000 SP- IRON, EQL IRON UNIT/ML, 2000 UNIT/ML, AcariaHealth;S SUPPLEMENT THERAPY, 20000 UNIT/2ML, 3000 P FEROSUL, FERROUSUL, F UNIT/ML, 4000 UNIT/ML, GOODSENSE IRON, KP F 40000 UNIT/ML (epoetin FERROUS SULFATE, MEIJER FERROUS alfa-epbx) SULFATE, NAT-RUL RETACRIT SOLN 20000 SP- IRON, QC FERROUS UNIT/ML (epoetin alfa- F AcariaHealth SULFATE, SM IRON TABS ) ;SP epbx (Ferrous Sulfate) FE TABS F TBEC ZARXIO SOSY PA; SP- F AcariaHealth;S (Ferrous Sulfate) IRON F (filgrastim-sndz) P SUPPLEMENT ELIX Hematopoietic Mixtures (Ferrous Sulfate) RA IRON F TABS 325 MG (Ferrous Fumarate-Fa-B QL(1 ea daily) Complex-C-Zn-Mg-Mn-Cu) (Ferrous Sulfate) SLOW RELEASE IRON TBCR 50 F FERROCITE PLUS, F HEMATINIC PLUS MG VITAMINS/MINERALS, (Polysaccharide Iron HEMOCYTE-PLUS TABS Complex) FERREX 150, (Iron Combinations) RX/OTC FERRIC X-150, MYFERON F 150, NU-IRON 150, POLY- CHROMAGEN, F HEMATOGEN, IRON IRON 150 CAPS COMPLEX CAPS FERRETTS TABS F Iron (ferrous fumarate) ferrous fumarate tabs (Ferrous Fumarate) F F FERROCITE TABS 324 mg (Ferrous Gluconate) CVS ferrous gluconate tabs F IRON, FERATE, FERGON, F 240 mg, 27 mg FERROTABS, IRON 27 TABS FERROUS GLUCONATE (Ferrous Sulfate Dried) TABS 324 MG (ferrous F EQL SLOW RELEASE F gluconate) IRON, SLOW IRON TBCR ferrous sulfate elix 220 F (Ferrous Sulfate Dried) mg/5ml SLOW RELEASE IRON, F FERROUS SULFATE LIQD SM IRON SLOW RELEASE TBCR 160 MG 220 MG/5ML (ferrous F sulfate)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Diphenhydramine Hcl ferrous sulfate soln 15 F mg/ml (Sleep)) COMPOZ, CVS SLEEP AID ferrous sulfate syrp 300 F NIGHTTIME/MAXIMUM mg/5ml STRENGTH, EQ ferrous sulfate tabs 28 NIGHTTIME SLEEP AID F MAXIMUM STRENGTH, mg, 325 mg, 65 mg EQL SLEEP AID ferrous sulfate tbcr 50 F MAXIMUM STRENGTH, mg GOODSENSE SLEEP AID, FERROUS SULFATE ORMIR, QC SLEEP AID F MAXIMUM STRENGTH, TBEC 324 MG (ferrous F QC SLEEP-AID MAXIMUM sulfate) STRENGTH, RA SLEEP AID MAXIMUM ferrous sulfate tbec 325 F mg STRENGTH, SM SLEEP AID MAXIMUM IRON CHEWS PEDIATRIC F STRENGTH, TGT SLEEP CHEW (carbonyl iron) AID MAXIMUM STRENGTH, WAL-SOM polysaccharide iron F complex caps MAXIMUM STRENGTH CAPS HEMOSTATICS - Drugs to Stop Bleeding/Treat (Diphenhydramine Hcl Blood Disorders (Sleep)) COMPOZ, CVS Hemostatics - Systemic SLEEP AID, CVS SLEEP AID NIGHTTIME, EQL aminocaproic acid soln SP- F AcariaHealth;S NIGHTTIME SLEEP AID, 0.25 gm/ml P GNP NIGHTTIME SLEEP AID, GNP SLEEP AID aminocaproic acid tabs SP- NIGHTTIME, HM F AcariaHealth;S 500 mg NIGHTTIME SLEEP AID, P NIGHT TIME SLEEP AID, tranexamic acid tabs F NIGHTTIME SLEEP AID, F NIGHTTIME SLEEP-AID, HYPNOTICS/SEDATIVES/SLEEP DISORDER NYTOL, QC REST AGENTS SIMPLY, RA NIGHTTIME SLEEP AID, RA SLEEP Antihistamine Hypnotics AID, SB SLEEP, SIMPLY SLEEP, SLEEP II, SLEEP TABS, SLEEP-TABS, SM NIGHTTIME SLEEP AID, SM SLEEP AID NIGHT TIME, TGT NIGHTTIME SLEEP AID TABS (Diphenhydramine Hcl (Sleep)) CVS SLEEP-AID F NIGHTTIME, SLEEP AID TABS 25 MG
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95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Diphenhydramine Hcl QL(1 ea daily) zolpidem tartrate tabs F (Sleep)) CVS SLEEP-AID F or 10 mg, 5 mg NIGHTTIME, SLEEP AID, SLEEP-AID CAPS 50 MG LAXATIVES - Bowel Treatment Drugs (Doxylamine Succinate Bulk Laxatives (Sleep)) CVS SLEEP-AID F NIGHTTIME, SLEEP AID, (Calcium Polycarbophil) SLEEP-AID TABS 25 MG CVS FIBER LAXATIVE, (Doxylamine Succinate EQL FIBER LAXATIVE, (Sleep)) CVS ULTRA FIBER LAXATIVE, FIBER- SLEEP, EQL NIGHTTIME LAX, GNP FIBER-CAPS, F SLEEP AID, GNP SLEEP KONSYL FIBER, PX AID, HM SLEEP AID, KLS F FIBER, RA FIBER SLEEP AID, RA NIGHT THERAPY, SB FIBER SLEEP AID, RA SLEEP LAXATIVE, TGT FIBER AID, SM SLEEP AID, WAL- LAXATIVE TABS SOM TABS (Calcium Polycarbophil) EQ FIBER THERAPY, SM F diphenhydramine hcl F FIBER TABS 625 MG (sleep) tabs (Methylcellulose (Laxative)) F Barbiturate Hypnotics SOLUBLE FIBER POWD phenobarbital elix F (Psyllium) CVS DAILY FIBER, EQ FIBER F phenobarbital soln F THERAPY, REGULOID CAPS 0.52 GM phenobarbital tabs F (Psyllium) CVS FIBER, FIBER LAXATIVE, GNP Non-Barbiturate Hypnotics NATURAL FIBER, MEDI- MUCIL, PX FIBER, QC estazolam tabs F FIBER LAXATIVE, RA F PA; QL(1 ea FIBER, RA FIBER eszopiclone tabs F daily); AL(Up to THERAPY, TGT 64 yrs old ) PSYLLIUM FIBER, WAL- MUCIL CAPS flurazepam hcl caps F midazolam hcl soln ij 10 mg/10ml, 10 mg/2ml, 2 mg/2ml, 25 F mg/5ml, 5 mg/5ml, 5 mg/ml, 50 mg/10ml temazepam caps F triazolam tabs F QL(1 ea daily); zaleplon caps F AL(At least 18 yrs old)
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96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Psyllium) CVS NATURAL (Psyllium) KONSYL POWD F DAILY FIBER, EQL 30.9 % NATURAL FIBER, EQL (Psyllium) REGULOID SMOOTH TEXTURE POWD 25 %, 28.3 %, F FIBERSUPPLEMENT, 48.57 %, 51.7 %, 58.6 % GERI-MUCIL, GNP NATURAL FIBER, (Psyllium) SM FIBER GOODSENSE NATURAL POWD 28.3 %, 48.57 %, F FIBER, GOODSENSE 51.7 %, 58.6 % PSYLLIUM FIBER, HM calcium polycarbophil F FIBER POWDER, KLS tabs NATURAL PSYLLIUM CVS DAILY FIBER PACK FIBER, METAMUCIL F SMOOTH TEXTURE, 58.6 % (psyllium) METAMUCIL SMOOTH CVS NATURAL FIBER SUPPLEMENT PACK 58.6 F TEXTURESUGAR FREE, F NATURAL FIBER, % (psyllium) NATURAL FIBER DAILY FIBER PACK 51.7 LAXATIVE, NATURAL F FIBER THERAPY, % (psyllium) EQUALACTIN CHEW NATURAL PSYLLIUM F SEED INDIAN HUSKS, (calcium polycarbophil) NATURAL VEGETABLE HYDROCIL INSTANT F FIBER, PSYLDEX, QC PACK (psyllium) NATURAL VEGETABLE, RA MULTIHEALTH FIBER KONSYL DAILY FIBER SUPPLEMENT, SB FIB PACK 100 %, 28.3 %, 60.3 F LAX ORANGE, SB FIBER % (psyllium) LAXATIVE, SB NATURAL KONSYL DAILY FIBER F FIBER LAXATIVE, TGT POWD 60.3 % (psyllium) FIBER THERAPY, WAL- KONSYL ORIGINAL DAILY MUCIL POWD F (Psyllium) CVS NATURAL FIBER PACK (psyllium) FIBER SUPPLEMENT F KONSYL PACK 60.3 % F POWD 100 % (psyllium) (Psyllium) EQ DAILY KONSYL POWD 60.3 %, F F FIBER POWD 51.7 % 71.67 % (psyllium) (Psyllium) EQL FIBER KONSYL-D POWD F F THERAPY POWD 28.3 %, ( ) 48.57 % psyllium METAMUCIL CAPS 0.36 (Psyllium) FIBER F THERAPY, SM FIBER F GM (psyllium) POWDER POWD 25 % METAMUCIL FIBER PACK F (Psyllium) HM FIBER (psyllium) POWD 28.3 %, 30.9 %, F METAMUCIL PACK 28 % F 51.7 %, 58.6 % (psyllium) (Psyllium) KONSYL DAILY METAMUCIL WAFR FIBER, METAMUCIL F F POWD 28.3 % (psyllium)
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97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits psyllium caps F (Sennosides-Docusate Sodium) COLACE 2-IN-1, psyllium powd F CVS SENNA PLUS, CVS STOOL SOFTENER PLUS SM FIBER POWDER STIMULANT LAXATIVE, F POWD 27 % (psyllium) DOCUZEN, DOK PLUS, EASY-LAX PLUS, EQ UNIFIBER POWD F SENNA-S, EQ STOOL (cellulose) SOFTENER/STIMULANT Laxative Combinations LAXATIVE, EQL SENNA- S, EQL STOOL (Peg 3350-Kcl-Sod Bicarb- SOFTENER/STIMULANT Sod Chloride-Sod Sulfate) F LAXATIVE, EQL STOOL GAVILYTE-C, GAVILYTE- SOFTENER/STIMULANT G SOLR LAXATIVE OVERNIGHT (Peg 3350-Potassium RELIEF, GNP SENNA Chloride-Sod Bicarbonate- PLUS, GNP STOOL Sod Chloride) GAVILYTE- F SOFTENER/STIMULANT N/FLAVOR PACK, LAXATIVE, GOODSENSE TRILYTE SOLR STIMULANT LAXATIVE PLUS, HM SENNA-S, HM STOOL SOFTENER/LAXATIVE, HM STOOL SOFTENER/STIMULANT LAXATIVE, LAXACIN, F MEDI-NATURAL PLUS, QC SENNA-S, QC STOOL SOFTENER PLUS LAXATIVE, QC STOOL SOFTENER PLUS STIMULANT LAXATIVE, RA 2-IN-1 LAXATIVE/STOOLSOFTE NER, RA LAXATIVE & STOOL SOFTENER, RA P COL-RITE, RA SENNA PLUS, SB DOCUSATE SODIUM/SENNA, SENEXON-S, SENNA PLUS, SENNA S, SENNA- PLUS, SENNA-S, SENNA- TIME S, SM NATURAL LAXATIVE PLUSSTOOL SOFTENER, SM SENNA- S, SM STOOL SOFTENER, SM STOOL SOFTENER PLUS LAXATIVE, SM STOOL SOFTENER/STIMULANT LAXATIVE, STIMULANT LAXATIVE, STOOL To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SOFTENER + STIMULANT (Polyethylene Glycol 3350) QL(34 gm LAXATIVE, STOOL CLEARLAX, EQ daily) SOFTENER LAXATIVE, CLEARLAX, EQL STOOL SOFTENER PLUS CLEARLAX, GAVILAX, LAXATIVE, STOOL GENTLELAX, GLYCOLAX, SOFTENER PLUS GOODSENSE CLEARLAX, F STIMULANT LAXATIVE, KLS LAXACLEAR, MM STOOL CLEARLAX, QC NATURA- SOFTENER/LAXATIVE, LAX, SB POLYETHYLENE TGT SENNA LAXATIVE, GLYCOL 3350, SM TGT SENNA CLEARLAX POWD LAXATIVE/STOOLSOFTE (Polyethylene Glycol 3350) QL(34 gm NER, TGT STOOL CVS PURELAX POWD 17 F daily) SOFTENER & GM/SCOOP, STIMULANT LAXATIVE, VEGETABLE (Polyethylene Glycol 3350) LAXATIVE+STOOLSOFTE CVS PURELAX, GNP NER TABS CLEARLAX, HM F CLEARLAX, SMOOTH GOLYTELY SOLR 2.82 LAX, TGT POWDERLAX GM-5.53 GM-6.36 GM-21.5 PACK 17 GM GM-227.1 GM (peg 3350- F (Polyethylene Glycol 3350) QL(34 gm kcl-sod bicarb-sod GNP CLEARLAX, HM daily) chloride-sod sulfate) CLEARLAX, RA F peg 3350-kcl-sod LAXATIVE, SMOOTH LAX, TGT POWDERLAX POWD F bicarb-sod chloride-sod 17 GM/SCOOP sulfate solr (Polyethylene Glycol 3350) F peg 3350-potassium HEALTHYLAX PACK chloride-sod F FLEET LIQUID GLYCERIN bicarbonate-sod SUPPOSITORIES ENEM F chloride solr (glycerin (laxative)) sennosides-docusate F glycerin (laxative) supp F sodium tabs 2 gm Laxatives - Miscellaneous lactulose soln 10 F (Glycerin (Laxative)) gm/15ml, 20 gm/30ml AVEDANA GLYCERIN F polyethylene glycol F (ADULT), GLYCERIN 3350 pack 17 gm ADULT SUPP polyethylene glycol QL(34 gm (Glycerin (Laxative)) CVS daily) GLYCERIN ADULT SUPP F 3350 powd 17 F 2 GM gm/scoop (Lactulose) CONSTULOSE SORBITOL SOLN OR 70 F F SOLN % (sorbitol (laxative)) Saline Laxatives
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99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Magnesium Citrate) (Sodium Phosphates) CVS CITROMA, CVS CITRATE ENEMA DISPOSABLE, OF MAGNESIA, CVS CVS ENEMA READY-TO- MAGNESIUM CITRATE, USE, ENEMA EQ MAGNESIUM DISPOSABLE, ENEMA CITRATE, EQL READY-TO-USE, EQ MAGNESIUM CITRATE, ENEMA, EQL READY-TO- GNP MAGNESIUM USE ENEMA, GNP CITRATE, GOODSENSE F ENEMA, GOODSENSE F MAGNESIUM CITRATE, READY TO USE ENEMA, HM MAGNESIUM HM ENEMA READY-TO- CITRATE, QC USE, HM ENEMA SALINE MAGNESIUM CITRATE, LAXATIVE, PEDIATRIC RA MAGNESIUM ENEMA, PURE & GENTLE CITRATE, SB ENEMA, QC ENEMA, RA MAGNESIUM CITRATE, ENEMA, RA SALINE SM MAGNESIUM ENEMA, SM ENEMA, TGT CITRATE SOLN SALINE LAXATIVE ENEM (Magnesium Hydroxide) magnesium citrate soln F CVS MILK OF MAGNESIA, 1.745 gm/30ml, DULCOLAX LIQUID, DULCOLAX MILK OF PHILLIPS MILK OF MAGNESIA CHEWABLE MAGNESIA, EQL MILK OF F MAGNESIA, GNP MILK OF CHEW (magnesium MAGNESIA, HM MILK OF hydroxide) MAGNESIA, MILK OF F PHILLIPS MILK OF MAGNESIA, MILK OF MAGNESIA MAGNESIA CONCENTRATED SUSP F CONCENTRATE, PX MILK (magnesium hydroxide) OF MAGNESIA, QC MILK OF MAGNESIA, RA MILK PHILLIPS MILK OF MAGNESIA SUSP 800 OF MAGNESIA, SB MILK F OF MAGNESIA, SM MILK MG/5ML (magnesium OF MAGNESIA SUSP hydroxide) (Magnesium Hydroxide) sodium phosphates F PHILLIPS MILK OF F enem MAGNESIA SUSP 1200 MG/15ML, 400 MG/5ML Stimulant Laxatives
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100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Bisacodyl) ALOPHEN, (Bisacodyl) LAXATIVE, RA F BISACODYL EC, LAXATIVE TBEC 5 MG CORRECT, CORRECTOL, (Bisacodyl) LAXATIVE, RA F CVS BISACODYL, CVS C- LAXATIVE TBEC OR 5 MG LAX LAXATIVE, CVS GENTLE LAXATIVE, CVS (Sennosides) CVS SENNA, GENTLE LAXATIVE DR EDWARDS OLIVE WOMENS, DUCODYL, EQ LAXATIVE, EQ NATURAL GENTLE LAXATIVE, EQL LAXATIVE, EQ NATURAL GENTLE LAXATIVE, EQL VEGETABLE LAXATIVE, LAXATIVE, EQL WOMANS EQL SENNA LAXATIVE, LAXATIVE, EX-LAX GERI-KOT, GNP SENNA ULTRA, FEENAMINT, LAX, GOODSENSE GENTLE LAXATIVE, GNP SENNA LAXATIVE, HM BISA-LAX, GNP GENTLE SENNA, KP SENNA, LAXATIVE, GNP LAXATIVE PILLS WOMENS GENTLE REGULAR STRENGTH, LAXATIVE REGULAR LAXATIVE, GOODSENSE F BISACODYL EC, STRENGTH, MEDI-LAX, GOODSENSE WOMENS MEDI-NATURAL, LAXATIVE, HM LAXATIVE, NATURAL SENNA F KP BISACODYL, PX LAXATIVE, PERDIEM, PX LAXATIVE, QC GENTLE VEGETABLE LAXATIVE, LAXATIVE, RA WOMENS QC NATURAL LAXATIVE, SB VEGETABLE LAXATIVE, BISACODYL LAXATIVE QC SENNA, RA SENNA, EC, SB GENTLE LAX- SB SENNA-LAX, SENNA WOMEN, SM GENTLE LAXATIVE, SENNA LAXATIVE, SM WOMANS REGULAR STRENGTH, LAXATIVE, STIMULANT SENNA SMOOTH, LAXATIVE, TGT GENTLE SENNA-LAX, SENNA- LAXATIVE, TGT WOMENS TABS, SENNA-TIME, LAXATIVE, SENNO, SM SENNA VERACOLATE, WOMANS LAXATIVE, TGT SENNA, LAXATIVE, WOMENS TGT SENNA LAXATIVE LAXATIVE TBEC TABS (Bisacodyl) BISACODYL (Sennosides) EVAC-U- F LAXATIVE, CVS GEN TABS 8.6 MG BISACODYL, CVS bisacodyl supp F GENTLE LAXATIVE, FLEET BISACODYL ENEM GENTLE LAXATIVE, GNP F GENTLE LAXATIVE, HM F (bisacodyl) LAXATIVE, QC GENTLE LAXATIVE, RA FAST sennosides tabs 8.6 mg F RELIEF LAXATIVE, SB LAXATIVE, SM LAXATIVE, Surfactant Laxatives THE MAGIC BULLET SUPP (Bisacodyl) LAXATIVE F SUPP RE 10 MG
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101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Docusate Calcium) CVS (Docusate Sodium) CVS STOOL SOFTENER, GNP MINI ENEMA KIDS, DOCUSATE CALCIUM, DOCUSATE MINI, F GNP STOOL SOFTENER, DOCUSOL MINI, KAO-TIN, QC DOCUSATE ENEMEEZ MINI ENEM CALCIUM, SB STOOL F (Docusate Sodium) SOFTENER, SM DIOCTO, DOCU, DOCU, DOCUSATE CALCIUM, GNP STOOL SOFTENER, F SM STOOL SOFTENER, SILACE, STOOL STOOL SOFTENER, SOFTENER LIQD SURFAK CAPS (Docusate Sodium) (Docusate Sodium) DIOCTO, GNP STOOL F CORRECTOL EXTRA SOFTENER, SILACE GENTLE, CVS STOOL SYRP SOFTENER, DOCU SOFT, DOCUSIL, DOK, (Docusate Sodium) DOK, DULCOLAX PINK STOOL HEALTHY MAMA MOVE IT SOFTENER, DULCOLAX ALONG, HM STOOL STOOL SOFTENER, SOFTENER, F EASY-LAX, EQ STOOL PROMOLAXIN, SM SOFTENER, EQL STOOL STOOL SOFTENER, SOFTENER, GNP STOOL STOOL SOFTENER TABS SOFTENER, docusate calcium caps F GOODSENSE GENTLE STOOL SOFTENER, HM docusate sodium caps F STOOL SOFTENER, HM STOOL SOFTENER docusate sodium liqd F MAXIMUM STRENGTH, KLS STOOL SOFTENER, F KS STOOL SOFTENER, F docusate sodium syrp LAXA BASIC, MM STOOL SOFTENER LAXATIVE, docusate sodium tabs F PHILLIPS STOOL DOCUSOL PLUS MINI- SOFTENER, PX ENEMA ENEM DOCUSATE SODIUM, QC (benzocaine-docusate F STOOL SOFTENER, RA COL-RITE, RA STOOL sodium) SOFTENER, SB ENEMEEZ PLUS ENEM DOCUSATE SODIUM, SM (benzocaine-docusate F STOOL SOFTENER, sodium) STOOL SOFTENER, STOOL SOFTENER MACROLIDES - Drugs to Treat Bacterial EXTRA STRENGTH, Infections STOOL SOFTENER Azithromycin LAXATIVE, STOOL SOFTENER LAXATIVE azithromycin pack 1 gm F QL(2 ea per fill EXTRA STRENGTH, TGT retail) STOOL SOFTENER CAPS azithromycin susr 100 F mg/5ml, 200 mg/5ml azithromycin tabs 250 F mg, 500 mg, 600 mg To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Clarithromycin BAND-AID ALL-IN-ONE ADHESIVE GAUZE clarithromycin susr F PAD/LARGE PADS F (adhesive bandages) clarithromycin tabs F BAND-AID ALL-IN-ONE ADHESIVE GAUZE clarithromycin tb24 F PAD/MEDIUM PADS F Erythromycins (adhesive bandages) (Erythromycin Base) ERY- BAND-AID GAUZE PADS RX/OTC F LARGE4" X 4" PADS TAB TBEC F (Erythromycin (gauze pads & Ethylsuccinate) E.E.S. 400 F dressings) TABS BAND-AID GAUZE PADS MEDIUM 3" X 3" PADS (Erythromycin Stearate) F ERYTHROCIN STEARATE F (gauze pads & TABS dressings) erythromycin base F BAND-AID GAUZE PADS RX/OTC cpep SMALL2" X 2" PADS (gauze pads & F erythromycin base tabs F dressings) erythromycin base tbec F BAND-AID HURT-FREE NON-STICK PADS LARGE erythromycin 3" X 4" PADS (adhesive F ethylsuccinate susr 200 F bandages) mg/5ml, 400 mg/5ml BAND-AID HURT-FREE NON-STICK PADS erythromycin F ethylsuccinate tabs 400 F MEDIUM 2" X 3" PADS mg (adhesive bandages) BAND-AID MIRASORB RX/OTC MEDICAL DEVICES AND SUPPLIES GAUZE SPONGES LARGE 4" X 4" PADS F Bandages-Dressings-Tape (gauze pads & ADHESIVE dressings) PADS/LARGE/3"X4" PADS F ( ) BAND-AID QUILTVENT adhesive bandages WATERPROOF PAD ADHESIVE LARGE 2.875" X 4" PADS F PADS/MEDIUM/2"X3" (adhesive bandages) PADS ( F adhesive BIOGUARD GAUZE RX/OTC bandages) SPONGE 2"X2" 8 PLY AMD FOAM DRESSING RX/OTC PADS (gauze pads & F 4"X4" PADS (gauze F dressings) pads & dressings) BIOGUARD GAUZE RX/OTC AMD FOAM RX/OTC SPONGES 4"X4" 12 PLY DRESSING/TOPSHEET F F PADS (gauze pads & 4"X4" PADS (gauze dressings) pads & dressings) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BORDERED GAUZE RX/OTC CURITY ALL PURPOSE PADS ( SPONGES 3"X3" 4PLY gauze pads & F F dressings) PADS (gauze pads & CARRASMART FOAM RX/OTC dressings) PADS (gauze pads & F CURITY ALL PURPOSE RX/OTC SPONGES 4 PLY PADS dressings) F CARRASMART PADS RX/OTC (gauze pads & (gauze pads & F dressings) dressings) CURITY ALL PURPOSE RX/OTC SPONGES 4"X4" 4PLY COPA ISLAND RX/OTC F BORDERED FOAM PADS (gauze pads & DRESSING 4"X4" PADS F dressings) (gauze pads & CURITY ALL PURPOSE RX/OTC dressings) SPONGES 4"X4" 4PLY/SOFT POUCH PADS COPA PLUS RX/OTC F HYDROPHILIC FOAM (gauze pads & DRESSING 4"X4" PADS F dressings) (gauze pads & CURITY ALL PURPOSE RX/OTC SPONGES 4"X4" PADS dressings) F COVRSITE COVER RX/OTC (gauze pads & DRESSING PADS dressings) (gauze pads & F CURITY AMD RX/OTC dressings) ANTIMICROBIALGAUZE SPONGES 2"X2" 8 PLY COVRSITE PLUS RX/OTC F COMPOSITE DRESSING PADS (gauze pads & PADS (gauze pads & F dressings) dressings) CURITY AMD RX/OTC ANTIMICROBIALGAUZE CRUAD GAUZE PADS 4" RX/OTC SPONGES 4"X4" 12 PLY F X 4" PADS (gauze pads F PADS (gauze pads & & dressings) dressings) CURAD NON-STICK CURITY COVER SPONGE RX/OTC PADS WITHADHESIVE TABS 3"X4" PADS F 4"X4" PADS (gauze F (adhesive bandages) pads & dressings) CURITY ALL PURPOSE RX/OTC CURITY COVER SPONGES 3"X3" PADS SPONGES 2"X2" 4PLY F PADS (gauze pads & F (gauze pads & dressings) dressings) CURITY ALL PURPOSE RX/OTC CURITY COVER RX/OTC SPONGES 4"X4" PADS SPONGES 2"X2" PADS F (gauze pads & F (gauze pads & dressings) dressings)
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104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CURITY DRESSING RX/OTC CURITY GAUZE SPONGE RX/OTC SPONGES 4"X4" 6 PLY 4"X4"16 PLY PADS PADS (gauze pads & F (gauze pads & F dressings) dressings) CURITY GAUZE PADS RX/OTC CURITY GAUZE RX/OTC 2"X2" 12 PLY PADS SPONGES 4"X4" 12 PLY (gauze pads & F PADS (gauze pads & F dressings) dressings) CURITY GAUZE PADS RX/OTC CURITY GAUZE RX/OTC 2"X2" PADS ( SPONGES 4"X4" 8 PLY gauze F F pads & dressings) PADS (gauze pads & CURITY GAUZE PADS dressings) 3"X3" PADS (gauze F CURITY NON-ADHERENT STRIPS 3"X3" PADS pads & dressings) F CURITY GAUZE PADS RX/OTC (gauze pads & 4"X4" 12 PLY PADS dressings) (gauze pads & F CURITY RX/OTC dressings) SPONGES/CELLULOSEFI LLED/2"X2" PADS CURITY GAUZE SPONGE RX/OTC F 2"X2" 8 PLY PADS (gauze pads & (gauze pads & F dressings) dressings) CURITY RX/OTC SPONGES/CELLULOSEFI CURITY GAUZE SPONGE RX/OTC LLED/4"X4" PADS 2"X2"12 PLY PADS F (gauze pads & (gauze pads & F dressings) dressings) CVS ADHESIVE PAD CURITY GAUZE SPONGE 3"X3" 12 PLY PADS 4"X4" PADS (adhesive F (gauze pads & F bandages) dressings) CVS ADHESIVE PAD CURITY GAUZE SPONGE RX/OTC 6"X6" PADS (adhesive F 4"X4" 12 PLY PADS bandages) (gauze pads & F CVS ADHESIVE PADS dressings) 2.25"X3" PADS F CURITY GAUZE SPONGE RX/OTC (adhesive bandages) 4"X4" 16 PLY PADS CVS GAUZE PAD 3"X3" (gauze pads & F PADS (gauze pads & F dressings) dressings) CURITY GAUZE SPONGE RX/OTC CVS GAUZE PADS 2"X2" RX/OTC 4"X4" 8 PLY PADS 12-PLY PADS (gauze F (gauze pads & F pads & dressings) dressings) CVS GAUZE PADS 4"X4" RX/OTC 12-PLY PADS (gauze F pads & dressings)
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105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS GAUZE PADS RX/OTC DERMACEA I.V. RX/OTC STERILE 4"X4" 12-PLY SPONGES 2"X2" PADS PADS (gauze pads & F (gauze pads & F dressings) dressings) DERMACEA DRAIN RX/OTC DERMACEA NON-WOVEN RX/OTC SPONGES 4"X4" PADS SPONGES 2"X2" 4 PLY (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA GAUZE RX/OTC DERMACEA NON-WOVEN SPONGE 2"X2" 12 PLY SPONGES 3"X3" 4 PLY PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA GAUZE RX/OTC DERMACEA NON-WOVEN RX/OTC SPONGE 2"X2" 8 PLY SPONGES 4"X4" 4 PLY PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA GAUZE DERMACEA NON-WOVEN RX/OTC SPONGE 3"X3" 12 PLY SPONGES 4"X4" 6 PLY PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA GAUZE DERMACEA TYPE VII RX/OTC SPONGE 3"X3" 8 PLY GAUZE 2"X2" 12 PLY PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA GAUZE RX/OTC DERMACEA TYPE VII RX/OTC SPONGE 4"X4" 12 PLY GAUZE 2"X2" 8 PLY PADS PADS (gauze pads & F (gauze pads & F dressings) dressings) DERMACEA GAUZE RX/OTC DERMACEA TYPE VII SPONGE 4"X4" 16 PLY GAUZE 3"X3" 12 PLY PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA GAUZE RX/OTC DERMACEA TYPE VII SPONGE 4"X4" 8 PLY GAUZE 3"X3" 12PLY PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA I.V. DRAIN RX/OTC DERMACEA TYPE VII RX/OTC SPONGES 2"X2" PADS GAUZE 4"X4" 12 PLY (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA I.V. DRAIN RX/OTC DERMACEA TYPE VII RX/OTC SPONGES 4"X4" PADS GAUZE 4"X4" 16 PLY (gauze pads & F PADS (gauze pads & F dressings) dressings)
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106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMACEA TYPE VII RX/OTC EXCILON I.V. SPONGES RX/OTC GAUZE 4"X4" 8 PLY PADS 2"X2" 6 PLY PADS (gauze pads & F (gauze pads & F dressings) dressings) DERMACEA X-RAY RX/OTC GAUZE DRESSING 4"X4" RX/OTC SPONGES 4"X4" 16 PLY PADS ( F gauze pads & F PADS (gauze pads & dressings) dressings) GAUZE PADS 2"X2" PADS RX/OTC DERMALEVIN ADHESIVE RX/OTC (gauze pads & F FOAMDRESSING 4"X4" F dressings) PADS (gauze pads & GAUZE PADS 3"X3" PADS dressings) (gauze pads & F DRYMAX EXTRA PADS RX/OTC dressings) (gauze pads & F GAUZE PADS 4"X4" PADS RX/OTC dressings) (gauze pads & F EQL GAUZE PADS RX/OTC dressings) 2"X2"/SMALL PADS F GAUZE SPONGE TYPE RX/OTC (gauze pads & VII MEDI-PAK 2"X2" 8PLY dressings) PADS (gauze pads & F EQL GAUZE PADS RX/OTC dressings) 4"X4"/LARGE PADS GAUZE SPONGES 4"X4" RX/OTC (gauze pads & F 12 PLY PADS (gauze F dressings) pads & dressings) EQL GAUZE STERILE PADS 3"X3" PADS GNP STERILE GAUZE RX/OTC PADS 2"X2" PADS (gauze pads & F (gauze pads & F dressings) dressings) EXCILON AMD RX/OTC ANTIMICROBIALDRAIN GNP STERILE GAUZE PADS 3"X3" PADS SPONGES 4"X4" 6 PLY F F PADS (gauze pads & (gauze pads & dressings) dressings) EXCILON AMD RX/OTC HM ADHESIVE PADS ANTIBACTERIAL/SHEER ANTIMICROBIALNON- F WOVEN SPONGES 4"X4" F PADS (adhesive 6 PLY PADS (gauze bandages) pads & dressings) HM STERILE PADS 2"X2" RX/OTC EXCILON DRAIN RX/OTC PADS (gauze pads & F SPONGE 4"X4" PADS dressings) F (gauze pads & HM STERILE PADS PADS RX/OTC dressings) (gauze pads & F EXCILON DRAIN RX/OTC dressings) SPONGES 4"X4" 6 PLY PADS (gauze pads & F dressings)
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107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDROCELL ADHESIVE RX/OTC KENDALL HYDROPHILIC RX/OTC DRESSING 4"X4" PADS FOAMDRESSING 4"X4" (gauze pads & F PADS (gauze pads & F dressings) dressings) HYDROCELL DRESSING RX/OTC KENDALL HYDROPHILIC RX/OTC 4"X4" PADS ( FOAMPLUS DRESSING gauze F F pads & dressings) 2"X2" PADS (gauze J & J ADHESIVE LARGE pads & dressings) PADS (adhesive F KENDALL HYDROPHILIC FOAMPLUS DRESSING bandages) F J & J GAUZE 2"X2" 8 PLY RX/OTC 3"X3" PADS (gauze PADS (gauze pads & F pads & dressings) dressings) KERLIX SPONGES 4" X 4" RX/OTC J & J GAUZE 4"X4" 12 PLY RX/OTC 12 PLY PADS (gauze F PADS (gauze pads & F pads & dressings) dressings) KERLIX SPONGES 4" X 4" RX/OTC J & J GAUZE 4"X4" 8 PLY RX/OTC 16 PLY PADS (gauze F PADS (gauze pads & F pads & dressings) dressings) MIRASORB SPONGES 2" RX/OTC J & J GAUZE SPONGES RX/OTC X 2" MISC (gauze pads F 12-PLY 4" X 4" MISC & dressings) (gauze pads & F MIRASORB SPONGES 4" RX/OTC dressings) X 4" MISC (gauze pads F J & J GAUZE SPONGES RX/OTC & dressings) 16-PLY 4" X 4" MISC MOLESKIN FOAM (gauze pads & F PADDING PADS F dressings) (adhesive bandages) J & J GAUZE SPONGES RX/OTC NEXCARE ABSOLUTE 8-PLY4" X 4" MISC WATERPROOF PAD F (gauze pads & F PADS (adhesive dressings) bandages) J & J NON-STICK PADS NU GAUZE 4PLY 4"X4" RX/OTC 100LARGE PADS F PADS (gauze pads & F (adhesive bandages) dressings) KENDALL HYDROPHILIC RX/OTC NU GAUZE GENERAL- RX/OTC FOAMDRESSING 2"X2" USE SPONGES 4"X4" 4 PADS (gauze pads & F PLY MISC (gauze pads F dressings) & dressings) KENDALL HYDROPHILIC OPTIFOAM PADS (gauze RX/OTC FOAMDRESSING 3"X3" F F pads & dressings) PADS (gauze pads & POLYMEM FILM DOT dressings) PADS (adhesive F bandages)
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108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POLYMEM NON- RX/OTC RESTORE FOAM RX/OTC ADHESIVE PAD PADS DRESSING BORDERED (gauze pads & F 4"X4" PADS (gauze F dressings) pads & dressings) QC ALL PURPOSE RX/OTC RESTORE FOAM RX/OTC DRESSINGS4"X4" PADS DRESSING NON- (gauze pads & F BORDERED 4"X4" PADS F dressings) (gauze pads & QC BORDER ISLAND RX/OTC dressings) GAUZE PAD 2"X2" PADS RESTORE ODOR RX/OTC ( F ABSORBING DRESSING gauze pads & F dressings) 4"X4" PADS (gauze QC STERILE PADS PADS RX/OTC pads & dressings) (gauze pads & F RESTORE TRIO ABSORBENT DRESSING dressings) F QC STERILE PADS PADS 3"X3" PADS (gauze (gauze pads & F pads & dressings) dressings) SM ADHESIVE PADS RA FIRST AID NON-STICK 2"X3" PADS (adhesive F PADS PADS (adhesive F bandages) bandages) SM ADHESIVE PADS RA SHEER ADHESIVE 3"X4" PADS (adhesive F LARGE PADS (adhesive F bandages) bandages) SM GAUZE PADS 2"X2" RX/OTC RA STERILE PADS 2"X2" RX/OTC PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) SM GAUZE PADS 3"X3" RA STERILE PADS 3"X3" PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) SM GAUZE PADS 4"X4" RX/OTC RA STERILE PADS 4"X4" RX/OTC PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) SM STERILE PADS 2"X2" RX/OTC RAY-TEC X-RAY RX/OTC PADS (gauze pads & F DETECTABLESPONGES dressings) 4" X 4" 16 PLY MISC F SM STERILE PADS PADS RX/OTC (gauze pads & (gauze pads & F dressings) dressings) RESTORE CONTACT RX/OTC SOF-SET ADHESIVE LAYER/NON-ADHERENT PATCH PADS ( F adhesive F 2"X2" PADS (gauze bandages) pads & dressings) SOF-WICK 4"X4" PADS RX/OTC (gauze pads & F dressings) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STERILE GAUZE PADS RX/OTC FANTASY LUBRICATED 2"X2" PADS (gauze F MISC (condoms latex F pads & dressings) lubricated - male) STERILE GAUZE PADS FANTASY 3"X3" PADS ( LUBRICATED/SPERMICID gauze F F pads & dressings) E MISC (condoms latex STERILE PADS 2"X2" RX/OTC lubricated - male) PADS (gauze pads & F FC FEMALE CONDOM dressings) MISC (condoms - F STERILE PADS 3"X3" female) PADS (gauze pads & F FC2 FEMALE CONDOM dressings) MISC (condoms - F STERILE PADS 4"X4" RX/OTC female) FEMCAP DEVI ( QL(1 ea per PADS (gauze pads & F cervical F dressings) caps) 365 days retail) SURGICAL GAUZE RX/OTC K-Y ME & YOU EXTRA LUBRICATED DEVI SPONGE PADS (gauze F F pads & dressings) (condoms latex TEGADERM FOAM RX/OTC lubricated - male) DRESSING 2"X2" PADS K-Y ME & YOU INTENSE (gauze pads & F DEVI (condoms latex F dressings) lubricated - male) TEGADERM FOAM RX/OTC KAMELEON LUBRICATED DRESSING 4"X4" PADS MISC (condoms latex F F (gauze pads & lubricated - male) dressings) KIMONO COLORS DEVI THERAGAUZE PADS RX/OTC (condoms latex F (gauze pads & F lubricated - male) dressings) KIMONO LUBRICATED TOPPER DRESSING RX/OTC MISC (condoms latex F SPONGES 4"X4" MISC F lubricated - male) (gauze pads & KIMONO MICRO THIN dressings) MISC (condoms latex F Contraceptives non-lubricated - male) AIMSCO LUBRICATED KIMONO MICRO THIN MISC (condoms latex F PLUS SPERMICIDE lubricated - male) LUBRICATED MISC F (condoms latex CAYA DPRH (diaphragm QL(1 ea per fill F retail,1 ea per lubricated - male) arc-spring) 365 days retail) KIMONO PLUS DUREX EXTRA SPERMICIDE SENSITIVE DEVI LUBRICATED MISC F (condoms latex F (condoms latex lubricated - male) lubricated - male) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KIMONO PLUS REALITY LATEX/ULTRA SPERMICIDE/LUBRICATE THIN DEVI ( F condoms F D MISC (condoms latex latex lubricated - male) lubricated - male) TRUSTEX COLOR KIMONO PS LUBRICATED CONDOMS + LUBE MISC MISC (condoms latex F (condoms latex F lubricated - male) lubricated - male) KIMONO PS PLUS TRUSTEX LUBRICATED SPERMICIDE/LUBRICATE EXTRALARGE MISC D MISC (condoms latex F (condoms latex F lubricated - male) lubricated - male) KIMONO SENSATION TRUSTEX LUBRICATED LUBRICATED MISC EXTRASTRENGTH MISC (condoms latex F (condoms latex F lubricated - male) lubricated - male) KIMONO SENSATION TRUSTEX LUBRICATED PLUS SPERMICIDE MISC (condoms latex F LUBRICATED MISC F lubricated - male) (condoms latex TRUSTEX lubricated - male) LUBRICATED/RIBBED/ST KIMONO SPECIAL DEVI UDDED MISC (condoms F (condoms latex F latex lubricated - male) lubricated - male) TRUSTEX MAXX LUBRICATED MISC LUBRICATED/SPERMICID (condoms latex F E EXTRA LARGE MISC F lubricated - male) (condoms latex MAXX PLUS SPERMICIDE lubricated - male) LUBRICATED MISC TRUSTEX (condoms latex F LUBRICATED/SPERMICID lubricated - male) E EXTRA STRENGTH F OMNIFLEX DIAPHRAGM QL(1 ea per MISC (condoms latex F DPRH (diaphragms) 365 days retail) lubricated - male) PREMIUM CONDOMS TRUSTEX LUBRICATED/SPERMICID LUBRICATED MISC F (condoms latex F E MISC (condoms latex lubricated - male) lubricated - male) REALITY LATEX TRUSTEX NATURAL CONDOMS/LUBRICATED CONDOMS +LUBE/LUBRICATED MISC (condoms latex F F MISC (condoms latex lubricated - male) lubricated - male) REALITY LATEX/ULTRA TEXTURED DEVI TRUSTEX NON- F LUBRICATED MISC (condoms latex F (condoms latex non- lubricated - male) lubricated - male)
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111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUSTEX WITH ADVOCATE LANCING NONOXYNOL- DEVICE MISC (lancet F 9/RIBBED/STUDDED F devices) MISC (condoms latex ADVOCATE RAPID-SAFE lubricated - male) LANCING DEVICE MISC F TRUSTEX/RIA (lancet devices) LUBRICATED MISC F AGAMATRIX ULTRA-THIN (condoms latex LANCETS 33G MISC F lubricated - male) (lancets) TRUSTEX/RIA ALTERNATE SITE LUBRICATED LANCING DEVICE MISC F SPERMICIDE MISC F (lancet devices) (condoms latex AQUA LANCE lubricated - male) ADJUSTABLE LANCING TRUSTEX/RIA DEVICE DEVI (lancet F LUBRICATED/SPERMICID devices) E MISC (condoms latex F AQUALANCE LANCETS lubricated - male) ULTRA THIN 30G MISC F TRUSTEX/RIA NON- (lancets) LUBRICATED MISC ASSURE COMFORT (condoms latex non- F LANCETS ULTRA THIN F lubricated - male) 28G MISC (lancets) Diabetic Supplies ASSURE HAEMOLANCE 1ST TIER UNILET PLUS HIGH FLOW 18G F COMFORTOUCH F MISC (lancets) LANCETS 28G MISC ASSURE HAEMOLANCE (lancets) PLUS LOW FLOW 25G F 1ST TIER UNILET MISC (lancets) COMFORTOUCH ASSURE HAEMOLANCE LANCETS 30G MISC F PLUS MICRO FLOW 28G F (lancets) MISC (lancets) ACCU-CHEK FASTCLIX ASSURE HAEMOLANCE LANCETDEVICE KIT KIT F PLUS NORMAL FLOW F (lancets misc.) 21G MISC (lancets) ACCU-CHEK MULTICLIX ASSURE HAEMOLANCE LANCET DEVICE KIT KIT F PLUS PEDIATRIC BLADE F (lancets misc.) MISC (lancets) ACCU-CHEK SOFTCLIX ASSURE LANCE LANCETDEVICE KIT KIT F LANCETS 21G MISC F (lancets misc.) (lancets) ADJUSTABLE LANCING ASSURE LANCE F DEVICE MISC (lancet F LANCETS MISC (lancets) devices) ASSURE LANCE PLUS SAFETYLANCETS 25G F MISC (lancets) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ASSURE LANCE PLUS CAREONE LANCET THIN F SAFETYLANCETS 30G F MISC (lancets) MISC (lancets) CARETOUCH LANCING AURORA LANCET SUPER DEVICEWITH EJECTOR F F THIN30G MISC (lancets) MISC (lancet devices) AURORA LANCET THIN CARETOUCH TWIST F 23G MISC (lancets) LANCETS 30G MISC F AUTO-LANCET MINI MISC (lancets) F CLEANLET LANCETS 28G (lancet devices) F AUTO-LANCET MISC MISC (lancets) F (lancet devices) COMFORT ASSURED AUTOLET II CLINISAFE LANCETS SUPER THIN F F KIT (lancets misc.) 28G MISC (lancets) COMFORT LANCETS AUTOLET IMPRESSION F LANCING DEVICE MISC F MISC (lancets) CVS LANCETS 21G MISC (lancet devices) F AUTOLET LANCING (lancets) CVS LANCETS MICRO DEVICE MISC (lancet F F devices) THIN 33G MISC (lancets) CVS LANCETS MICRO- AUTOLET LITE F CLINISAFE KIT (lancets F THIN 33G MISC (lancets) misc.) CVS LANCETS ORIGINAL F AUTOLET LITE STARTER MISC (lancets) PACK KIT (lancets F CVS LANCETS THIN 26G F misc.) MISC (lancets) AUTOLET MINI MISC CVS LANCETS ULTRA F F (lancet devices) THIN 30G MISC (lancets) AUTOLET PLATFORMS CVS LANCETS ULTRA- F F MISC (lancets misc.) THIN 30G MISC (lancets) AUTOLET PLUS MISC CVS LANCING DEVICE F F (lancet devices) MISC (lancet devices) BD LANCET ULTRAFINE CVS ULTRA THIN F F 30G MISC (lancets) LANCETS MISC (lancets) CARDIOCOM LANCING DIATHRIVE LANCETS F DEVICE MISC (lancet F MISC (lancets) devices) DIATHRIVE LANCETS CAREONE ADVANCED ULTRA THIN 30G MISC F LANCINGDEVICE MISC F (lancets) (lancet devices) DIATHRIVE LANCING CAREONE LANCET DEVICE MISC (lancet F SUPER THIN/30G MISC F devices) (lancets)
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113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET GENTEEL EASY TOUCH LANCETS LANCING DEVICE MISC F 26G/PULL-TOP MISC F (lancet devices) (lancets) DROPLET LANCETS EASY TOUCH LANCETS ULTRA THIN 30G MISC F 28G/PULL-TOP MISC F (lancets) (lancets) DROPLET LANCING EASY TOUCH LANCETS DEVICE MISC (lancet F 28G/TWIST MISC F devices) (lancets) DRUG MART EASY TOUCH LANCETS ADJUSTABLE LANCING 30G/PULL-TOP MISC F DEVICE MISC (lancet F (lancets) devices) EASY TOUCH LANCETS DRUG MART LANCETS 30G/TWIST MISC F F THIN MISC (lancets) (lancets) DRUG MART UNILET EASY TOUCH LANCETS LANCETSSUPER THIN F 32G/PULL-TOP MISC F 30G MISC (lancets) (lancets) DRUG MART UNILET EASY TOUCH LANCETS LANCETSULTRA THIN F 32G/TWIST MISC F 28G MISC (lancets) (lancets) DRUG MART UNILET EASY TOUCH LANCETS MICRO THIN LANCETS F 33G/TWIST MISC F 33G MISC (lancets) (lancets) E-Z JECT LANCETS 21G EASY TOUCH LANCING F DEVICE/EJECTOR MISC MISC (lancets) F (lancet devices) E-Z JECT LANCETS F EMBRACE LANCING COLOR MISC (lancets) DEVICE WITH EJECTOR F E-Z JECT LANCETS MISC F MISC (lancet devices) ( ) lancets EQL COLOR LANCETS F E-Z JECT LANCETS 21G MISC (lancets) SUPER THIN 30G MISC F EQL COLOR LANCETS (lancets) MICRO THIN 33G MISC F E-Z JECT LANCETS THIN F (lancets) 26G MISC ( ) lancets EQL SUPER THIN E-ZJECT LANCETS LANCETS 30G MISC F MICRO-THIN 33G MISC F (lancets) ( ) lancets EQL THIN LANCETS 26G F EASY MINI EJECT MISC (lancets) LANCING DEVICE MISC F EZ-LETS LANCETS 26G (lancet devices) SUPER-SOFT MISC F EASY MINI LANCING (lancets) DEVICE MISC (lancet F devices)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EZ-LETS LANCETS 28G FREESTYLE PRECISION QL(1 ea per fill ULTRA-SOFT MISC F NEO BLOOD GLUCOSE retail,1 ea per (lancets) MONITORING SYSTEM F 365 days EZ-LETS LANCETS 30G KIT (blood glucose retail); RX/OTC F MISC (lancets) monitoring supplies) FORA LANCETS MISC FREESTYLE UNISTICK II F F (lancets) LANCETS MISC (lancets) FORA LANCING DEVICE GENTEEL CONTACT F MISC (lancet devices) TIPS/BLUE MISC F (lancets misc.) FORA LANCING DEVICE/CLEARCAP MISC F GENTEEL CONTACT (lancet devices) TIPS/CLEAR MISC F (lancets misc.) FREDS PHARMACY AUTOLET LANCING GENTEEL CONTACT DEVICE MISC (lancet F TIPS/GREEN MISC F devices) (lancets misc.) FREDS PHARMACY GENTEEL CONTACT TIPS/ORANGE MISC UNILET LANCETS SUPER F F THIN 30G MISC (lancets) (lancets misc.) FREDS PHARMACY GENTEEL CONTACT TIPS/RAINBOW MISC UNILET LANCETS ULTRA F F THIN 28G MISC (lancets) (lancets misc.) FREESTYLE CONTROL GENTEEL CONTACT SOLUTION HIGH/LOW TIPS/VIOLET MISC F LIQD (blood glucose F (lancets misc.) calibration) GENTEEL CONTACT TIPS/YELLOW MISC F FREESTYLE CONTROL (lancets misc.) SOLUTION LIQD (blood F ) GENTEEL LANCING glucose calibration DEVICE/GLORIOUS FREESTYLE FREEDOM QL(1 ea per fill GOLD MISC (lancet F LITE KIT ( F retail,1 ea per blood glucose 365 days devices) monitoring supplies) retail); RX/OTC GENTEEL LANCING DEVICE/PRECIOUS FREESTYLE INSULINX QL(1 ea per fill F BLOODGLUCOSE retail,1 ea per PLATINUM MISC (lancet MONITORING SYSTEM F 365 days devices) KIT (blood glucose retail); RX/OTC GENTEEL LANCING monitoring supplies) DEVICE/STATELY SILVER F FREESTYLE LANCETS MISC (lancet devices) F MISC (lancets) GENTEEL LANCING FREESTYLE LITE BLOOD QL(1 ea per fill KIT/BUTTERFLY BLUE F GLUCOSE MONITORING retail,1 ea per KIT (lancets misc.) 365 days retail) GENTEEL NOZZLES SYSTEM DEVI (blood F F glucose monitoring MISC (lancets misc.) supplies) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GENTEEL PLUS LANCING GNP LANCETS MICRO F DEVICE/BUFF BLACK F THIN 33G MISC (lancets) MISC (lancet devices) GNP LANCETS SUPER F GENTEEL PLUS LANCING THIN 30G MISC (lancets) DEVICE/BUTTERFLY GNP LANCETS THIN 26G F F BLUE MISC (lancet MISC (lancets) devices) GNP LANCETS THIN F GENTEEL PLUS LANCING MISC ( ) DEVICE/PLAYFUL lancets PURPLE MISC (lancet F GOJJI LANCING DEVICE/CLEAR CAP devices) F MISC (lancet devices) GENTEEL PLUS LANCING DEVICE/PRINCESS PINK F GOODSENSE COLOR LANCETS MICRO-THIN MISC (lancet devices) 33G UNIVERSAL MISC F GENTEEL PLUS LANCING (lancets) DEVICE/WILLOWY WHITE F GOODSENSE LANCETS MISC (lancet devices) MICRO-THIN 33G MISC F GENTLE-LET GP (lancets) LANCETS MISC F GOODSENSE LANCETS (lancets) MICRO-THIN 33G GENTLE-LET LANCETS UNIVERSAL MISC F GENERAL PURPOSE (lancets) STYLE/FINE POINT MISC F GOODSENSE LANCETS (lancets) ULTRA-THIN 26G GENTLE-LET LANCETS UNIVERSAL MISC F GENERAL PURPOSE (lancets) STYLE/MEDIUM POINT F GOODSENSE LANCETS MISC (lancets) ULTRA-THIN 30G MISC F GENTLE-LET LANCETS (lancets) SAFETY STYLE/FINE F GOODSENSE LANCETS POINT MISC (lancets) ULTRA-THIN 30G GENTLE-LET LANCETS UNIVERSAL MISC F SAFETY STYLE/MEDIUM F (lancets) POINT MISC (lancets) GOODSENSE LANCING GENTLE-LET DEVICE MISC (lancet F PLATFORMS 2.4MM MISC F devices) (lancets misc.) H-E-B INCONTROL GENTLE-LET ADVANCEDLANCING PLATFORMS 3.0MM MISC F DEVICE MISC (lancet F (lancets misc.) devices) GLOBAL LANCING H-E-B INCONTROL DEVICE MISC (lancet F LANCETS MICRO THIN F devices) 33G MISC (lancets) GNP LANCETS 21G MISC F (lancets) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits H-E-B INCONTROL IN TOUCH LANCING LANCETS SUPER THIN F DEVICE MISC (lancet F 30G MISC (lancets) devices) H-E-B INCONTROL KINNEY LANCETS MISC F LANCETS ULTRA THIN F (lancets) 28G MISC (lancets) KINNEY THIN LANCETS F HAEMOLANCE LOW MISC (lancets) FLOW LANCETS MISC F KROGER AUTOLET (lancets) LANCING DEVICE MISC F HAEMOLANCE MISC F (lancet devices) (lancets) KROGER HEALTHPRO HAEMOLANCE PLUS TWIST LANCETS/26G F HIGH FLOW MISC F MISC (lancets) (lancets) KROGER LANCETS 21G F HAEMOLANCE PLUS MISC (lancets) LOW FLOW MISC F KROGER LANCETS (lancets) MICRO THIN33G MISC F HAEMOLANCE PLUS (lancets) MAX FLOW MISC F KROGER LANCETS MISC (lancets) F (lancets) HAEMOLANCE PLUS F KROGER LANCETS MISC (lancets) SUPER THIN MISC F HAEMOLANCE PLUS (lancets) PEDIATRIC FLOW MISC F KROGER LANCETS THIN (lancets) F 26G MISC (lancets) HEALTH CARE LANCING KROGER LANCETS THIN DEVICE MISC (lancet F F MISC (lancets) devices) KROGER LANCETS HEALTHY ACCENTS ULTRATHIN30G MISC AUTOLET IMPRESSION F LANCING DEVICE MISC F (lancets) (lancet devices) KROGER LANCING HEALTHY ACCENTS DEVICE MISC (lancet F UNILET LANCETS SUPER F devices) THIN 30G MISC (lancets) LANCET DEVICE HY-VEE LANCETS MISC ADJUSTABLE MISC F F (lancets) (lancet devices) HY-VEE THIN LANCETS LANCET DEVICE WITH F MISC (lancets) EJECTOR MISC (lancet F ) HYPOLANCE AST devices LANCING KIT KIT F LANCET TRANSPORTER (lancets misc.) CASE MISC (lancets F misc.)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LANCETS 26G TWIST LIVE BETTER LANCET F TOP MISC (lancets) ULTRATHIN 28G MISC F LANCETS 28G MISC (lancets) F (lancets) LONGS LANCETS LANCETS 30G MISC STANDARD MISC F F (lancets) (lancets) LANCETS MISC LONGS LANCETS THIN F F (lancets) MISC (lancets) LANCETS SAFETY SEAL MEDISENSE THIN F F 21G MISC (lancets) LANCETS MISC (lancets) LANCETS SAFETY SEAL MEIJER COLOR F LANCETS UNIVERSAL F 26G MISC (lancets) 33G MISC (lancets) LANCETS SAFETY SEAL F MEIJER LANCETS MISC 28G MISC (lancets) F (lancets) LANCETS SUPER THIN F MEIJER LANCETS THIN 28G MISC (lancets) F MISC (lancets) LANCETS THIN MISC F MEIJER LANCETS (lancets) UNIVERSAL21G MISC F LANCETS ULTRA THIN F (lancets) MISC (lancets) MEIJER LANCETS LANCING DEVICE UNIVERSAL30G MISC F ADJUSTABLE MISC F (lancets) (lancet devices) MEIJER LANCETS LANCING DEVICE MISC UNIVERSAL33G MISC F F (lancet devices) (lancets) LANZO MISC ( MEIJER SUPER THIN lancet F F devices) LANCETS MISC (lancets) LEADER ADVANCED MICROLET NEXT MISC F LANCING DEVICE MISC F (lancet devices) (lancet devices) MINI LANCING DEVICE F LIBERTY MINI LANCING MISC (lancet devices) DEVICE MISC (lancet F MM LANCING DEVICE F devices) MISC (lancet devices) LITE TOUCH LANCING MONOLET LANCETS F PEN MISC (lancet F MISC (lancets) devices) MONOLET OPD LANCETS F LIVE BETTER ADVANCED MISC (lancets) LANCING DEVICE MISC F MULTI-LANCET DEVICE 2 (lancet devices) F KIT (lancets misc.) LIVE BETTER LANCET MULTI-LANCET DEVICE SUPERTHIN 30G MISC F F (lancets) MISC (lancet devices)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NOVA SUREFLEX PENLET II LANCETS MISC F REPLACEMENT CAPS- (lancets) REGULAR MISC (lancets F NOVA SUREFLEX misc.) LANCING DEVICE MISC F PERFECT LANCETS 30G F (lancet devices) MISC (lancets) ON CALL LANCING PHARMACY COUNTER F DEVICE MISC (lancet F LANCETS MISC (lancets) devices) PRECISION GLUCOSE ON CALL PLUS LANCING CONTROL LIQD (blood F DEVICE MISC (lancet F glucose calibration) devices) PRECISION GLUCOSE ONETOUCH DELICA CONTROLSOLUTION LANCING DEVICE MISC F (TRI- F (lancet devices) LEVEL/HI/LO/NORMAL ONETOUCH DELICA ) SOLN (blood glucose PLUS LANCING DEVICE F calibration) MISC (lancet devices) PRECISION GLUCOSE ONETOUCH DELICA KETONECONTROL SAFETY LACING DEVICE F SOLUTION 1-LOW, 1- F MISC (lancet devices) HIGH LIQD (blood ONETOUCH SURESOFT glucose calibration) LANCING DEVICE/18G F PRECISION MISC (lancets misc.) GLUCOSE/KETONECONT ROL SOLUTIONS 1-HI 1- ONETOUCH SURESOFT F LO LIQD (blood glucose LANCING DEVICE/21G F MISC (lancets misc.) calibration) PRECISION THINS GP ONETOUCH SURESOFT F LANCING DEVICE/28G F LANCET MISC (lancets) MISC (lancets misc.) PRECISION XTRA DEVI QL(1 ea per fill PC LANCETS SUPER XX (blood glucose F retail,1 ea per F 365 days retail) THIN 30G MISC (lancets) monitoring supplies) PENLET II AUTOMATIC PRECISION XTRA KIT XX QL(1 ea per fill BLOODSAMPLER KIT F (blood glucose F retail,1 ea per (lancets misc.) monitoring supplies) 365 days retail) PENLET II PREFERRED PLUS REPLACEMENT CAPS F LANCETS COLORED 21G F MISC (lancets misc.) MISC (lancets) PENLET II PREFERRED PLUS REPLACEMENT CAPS- LANCETS SUPER THIN F DEEP MISC (lancets F 30G MISC (lancets) misc.) PREFERRED PLUS LANCETS THIN 26G MISC F (lancets)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRODIGY LANCING RA E-ZJECT LANCETS F DEVICE MISC (lancet F THIN 28G MISC (lancets) devices) RA E-ZJECT LANCETS PRODIGY TWIST TOP ULTRATHIN 30G MISC F LANCETS MISC F (lancets) (lancets) READYLANCE SAFETY PSS SELECT GP LANCETS/30G/1.6MM F LANCETS MISC F MISC (lancets) (lancets) REALITY LANCETS MISC F PSS SELECT (lancets) PLATFORMS MISC F RELION 2-IN-1 LANCET (lancets misc.) DEVICES 30G MISC F PSS SELECT SAFETY (lancet devices) LANCETS MISC F RELION 2-IN-1 LANCING (lancets) DEVICE 25G MISC F PX ADVANCED LANCING (lancet devices) DEVICE MISC (lancet F RELION 2-IN-1 LANCING devices) DEVICE 30G MISC F PX LANCET AUTO (lancet devices) INJECTOR MISC (lancet F RELION LANCETS devices) MICRO-THIN33G MISC F PX LANCETS ULTRA (lancets) F RELION LANCETS THIN THIN 28G MISC (lancets) F PX LANCETS ULTRA 26G MISC (lancets) F THIN MISC (lancets) RELION LANCETS ULTRA-THIN30G MISC QC ADVANCED LANCING F ( ) DEVICE MISC (lancet F lancets devices) RELION LANCING DEVICE KIT ( QC LANCETS SUPER lancets F F ) THIN MISC (lancets) misc. RELION LANCING QC LANCETS ULTRA F THIN MISC (lancets) DEVICE MISC (lancet F devices) QC UNILET LANCETS 28G/ULTRA THIN MISC F RELION ULTRA THIN LANCETS30G MISC (lancets) F (lancets) QC UNILET LANCETS 33G/MICRO THIN MISC F RELION ULTRA THIN PLUS LANCETS 32G (lancets) F MISC (lancets) RA E-ZJECT LANCETS F RELION ULTRA THIN 28G MISC (lancets) PLUS LANCETS 33G F RA E-ZJECT LANCETS F MISC (lancets) THIN 26G MISC ( ) lancets REXALL LANCETS ULTRA F THIN MISC (lancets)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RIGHTEST GD-L500 SM TRUEDRAW LANCING ALTERNATE SITE DEVICE MISC ( F lancet F ADAPTER MISC (lancets devices) misc.) SMART DIABETES RIGHTEST GD500 VANTAGE LANCING LANCING DEVICE MISC F DEVICE MISC (lancet F (lancet devices) devices) RIGHTEST GL300 SMART SENSE COLOR LANCETS MISC F LANCETS UNIVERSAL F (lancets) 33G MISC (lancets) SAFETY LANCETS 28G F SMART SENSE MISC (lancets) STANDARD LANCETS F SAFETY SEAL LANCETS UNIVERSAL 21G MISC F 28G MISC (lancets) (lancets) SAFETY SEAL LANCETS SMART SENSE SUPER F 30G MISC ( ) THIN LANCETS lancets UNIVERSAL 30G MISC F SAPS HEALTH TWIST (lancets) TOP LANCETS 30G MISC F (lancets) SMART SENSE THIN LANCETSUNIVERSAL F SB LANCETS THIN MISC F 26G MISC (lancets) ( ) lancets SOLUS V2 LANCING SB LANCETS ULTRA F DEVICE MISC (lancet F THIN MISC (lancets) devices) SELECT-LITE STERILANCE PA MISC DEVICE/LANCETS KIT F F (lancets misc.) (lancets misc.) STERILANCE TL MISC SELECT-LITE LANCING F (lancets) DEVICE MISC (lancet F SUPER THIN LANCETS devices) F MISC (lancets) SHOPKO AUTOLET LANCING DEVICE MISC F SURE COMFORT (lancet devices) LANCETS 18G MISC F (lancets) SHOPKO UNILET LANCETS SUPER THIN F SURE COMFORT 30G MISC (lancets) LANCETS 21G MISC F (lancets) SHOPKO UNILET LANCETS ULTRA THIN F SURE COMFORT 28G MISC (lancets) LANCETS 23G MISC F (lancets) SIMPLE DIAGNOSTICS LANCING DEVICE MISC F SURE COMFORT (lancet devices) LANCETS 30G MISC F (lancets) SM MICRO THIN LANCETS 33G MISC F (lancets)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE COMFORT TRUE METRIX CONTROL QL(90 day(s) LANCING PEN MISC F SOLUTION LEVEL 2 limit) (lancet devices) SOLN (blood glucose F SURE-PEN MISC ( calibration) lancet F devices) TRUE METRIX CONTROL QL(90 day(s) SURELITE LANCETS SOLUTION LEVEL 3 limit) F F MISC (lancets) SOLN (blood glucose calibration) TECHLITE AST LANCETS F MISC (lancets) TRUECONTROL GLUCOSE CONTROL TECHLITE LANCETS 30G F F LEVEL 0 LIQD (blood MISC (lancets) glucose calibration) TECHLITE LANCETS F TRUECONTROL MISC (lancets) GLUCOSE CONTROL TGT LANCET MICRO F F LEVEL 1 LIQD (blood THIN 33G MISC (lancets) glucose calibration) TGT LANCET THIN 26G F TRUEDRAW LANCING MISC (lancets) DEVICE MISC (lancet F TGT LANCET ULTRA devices) F THIN 30G MISC (lancets) TRUEPLUS LANCETS F TGT LANCING DEVICE 26G MISC (lancets) F MISC (lancet devices) TRUEPLUS LANCETS F THINLETS GP LANCETS 28G MISC (lancets) F MISC (lancets) TRUEPLUS LANCETS TODAYS HEALTH 28G SUPER THIN MISC F ADVANCED LANCING (lancets) F DEVICE MISC (lancet TRUEPLUS LANCETS F devices) 30G MISC (lancets) TODAYS HEALTH SUPER TRUEPLUS LANCETS THINLANCETS 30G MISC F 30G ULTRA THIN MISC F (lancets) (lancets) TODAYS HEALTH ULTRA TRUEPLUS LANCETS F THINLANCETS 28G MISC F 33G MISC (lancets) (lancets) ULTI-LANCE AUTOMATIC/ TOPCARE LANCETS CLEAR TIP MISC (lancet F MICRO-THIN 33G MISC F devices) (lancets) ULTILET CLASSIC F TRUE METRIX CONTROL QL(90 day(s) LANCETS MISC (lancets) SOLUTION LEVEL 1 limit) F ULTRALANCE MISC SOLN (blood glucose F calibration) (lancets misc.) UNILET COMFORTOUCH F LANCET MISC (lancets)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNILET EXCELITE II MISC UNISTIK 3 EXTRA F SINGLE USE SAFETY (lancets) F UNILET EXCELITE MISC LANCETS/21G MISC F (lancets) (lancets misc.) UNILET G.P. LANCET UNISTIK 3 MISC (lancets F F MISC (lancets) misc.) UNILET G.P. SUPERLITE UNISTIK 3 NEONATAL F F LANCET MISC (lancets) MISC (lancets misc.) UNILET GP 28 ULTRA UNISTIK 3 NORMAL MISC F F THIN MISC (lancets) (lancets misc.) UNILET LANCET MISC UNISTIK CZT COMFORT F F (lancets) MISC (lancets misc.) UNISTIK CZT NORMAL UNILET LANCETS F MICRO-THIN33G MISC F MISC (lancets misc.) (lancets) UNISTIK NORMAL MISC F UNILET LANCETS (lancets misc.) SUPER-THIN30G MISC F UNIVERSAL 1 LANCETS F (lancets) THIN26G MISC (lancets) UNILET LANCETS UNIVERSAL 1 LANCETS ULTRA-THIN 28G MISC F ULTRA THIN 30G MISC F (lancets) (lancets) UNILET SUPERLITE F UNIVERSAL 1 LANCET MISC (lancets) LANCETS/33G/MICRO- F UNISTIK 1 MISC ( THIN MISC (lancets) lancets F misc.) VALUE PLUS LANCETS UNISTIK 2 COMFORT STANDARD 21G MISC F F MISC (lancets misc.) (lancets) UNISTIK 2 EXTRA MISC VALUE PLUS LANCETS F SUPERTHIN 30G MISC F (lancets misc.) (lancets) UNISTIK 2 MISC (lancets VALUE PLUS LANCETS F F misc.) THIN 26G MISC (lancets) UNISTIK 2 NEONATAL F VALUE PLUS LANCING MISC (lancets misc.) DEVICE MISC (lancet F UNISTIK 2 NORMAL MISC F devices) (lancets misc.) VALUMARK LANCET UNISTIK 2 SUPER MISC F SUPER THIN 30G MISC F (lancets misc.) (lancets) UNISTIK 3 COMFORT F VALUMARK LANCET MISC (lancets misc.) ULTRA THIN 28G MISC F UNISTIK 3 EXTRA MISC (lancets) F (lancets misc.) VIDA MIA AUTOLET LANCINGDEVICE MISC F (lancet devices) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIDA MIA UNILET CURITY ALCOHOL RX/OTC LANCETS SUPER THIN F SWABS PADS (alcohol F 30G MISC (lancets) swabs) VIDA MIA UNILET CVS ALCOHOL PREP RX/OTC LANCETS ULTRA THIN F PADS PADS (alcohol F 28G MISC (lancets) swabs) VIVAGUARD LANCING CVS PREP PADS PADS RX/OTC F DEVICE MISC (lancet F (alcohol swabs) devices) EASY TOUCH ALCOHOL RX/OTC WALGREENS COMFORT PREP PADS/MEDIUM F ASSUREDLANCETS PADS (alcohol swabs) MICRO THIN/33G MISC F EQL ALCOHOL SWABS RX/OTC (lancets) F PADS (alcohol swabs) WALGREENS COMFORT ASSUREDLANCETS FIFTY50 ALCOHOL PREP RX/OTC SUPER THIN/28G MISC F PADS PADS (alcohol F (lancets) swabs) GNP ALCOHOL SWABS RX/OTC WALGREENS THIN F LANCETS MISC F PADS (alcohol swabs) (lancets) H-E-B INCONTROL RX/OTC Misc. Devices ALCOHOL PADS PADS F ( ) ALCOH-WIPE 12" X 12" alcohol swabs F SHEE (alcohol sheets) MEIJER ALCOHOL RX/OTC SWABS EXTRA-THICK F ALCOHOL PREP PADS RX/OTC F PADS (alcohol swabs) PADS (alcohol swabs) QC ALCOHOL SWABS RX/OTC ALCOHOL SWABS PADS RX/OTC F F PADS (alcohol swabs) (alcohol swabs) RA ALCOHOL SWABS RX/OTC ALCOHOL SWABSTICK RX/OTC F F PADS (alcohol swabs) PADS (alcohol swabs) REALITY SWABS PADS RX/OTC F APLICARE ALCOHOL RX/OTC (alcohol swabs) SWABSTICK PADS F (alcohol swabs) RELION ALCOHOL RX/OTC SWABS PADS ( F BD SWABS SINGLE USE RX/OTC alcohol BUTTERFLY PADS F swabs) (alcohol swabs) SB ALCOHOL PREP RX/OTC BD SWABS SINGLE USE RX/OTC PADS PADS (alcohol F F PADS (alcohol swabs) swabs) CARETOUCH ALCOHOL RX/OTC SHOPKO ALCOHOL RX/OTC PREP PADS PADS F SWABS PADS (alcohol F (alcohol swabs) swabs) CURITY ALCOHOL RX/OTC SM ALCOHOL PREP RX/OTC PREPS/MEDIUM 2 PLY F PADS PADS (alcohol F PADS (alcohol swabs) swabs)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TGT ALCOHOL SWABS RX/OTC 1ST TIER UNIFINE RX/OTC F PADS ( ) PENTIPSPLUS 32GX4MM alcohol swabs F ULTICARE ALCOHOL RX/OTC MISC (insulin pen SWABS PADS (alcohol F needle) swabs) 1ST TIER UNIFINE PENTIPSPLUS 33GX4MM WEBCOL ALCOHOL RX/OTC F PREP LARGE 1 PLY F MISC (insulin pen PADS (alcohol swabs) needle) WEBCOL ALCOHOL RX/OTC 1ST TIER UNIFINE RX/OTC PENTIPSPLUS/MINI/31GX PREP LARGE 2 PLY F F PADS (alcohol swabs) 5MM MISC (insulin pen WEBCOL ALCOHOL RX/OTC needle) PREP MEDIUM 2 PLY F 1ST TIER UNIFINE RX/OTC PADS (alcohol swabs) PENTIPSPLUS/ORIGINAL/ 29GX12MM MISC (insulin F Parenteral Therapy Supplies pen needle) 1ST TIER UNIFINE RX/OTC PENTIPS/MINI/31GX5MM 1ST TIER UNIFINE F PENTIPSPLUS/ULTRA MISC (insulin pen SHORT/31GX6MM MISC F needle) (insulin pen needle) 1ST TIER UNIFINE RX/OTC 3ML LUER LOCK SAFETY RX/OTC PENTIPS29GX12MM F SYRINGES 3ML/22G X 1 MISC (insulin pen 1/2" MISC F needle) (syringe/needle (disp) 3 1ST TIER UNIFINE ml) PENTIPS31GX6MM MISC F 3ML LUER LOCK SAFETY RX/OTC (insulin pen needle) SYRINGES/3ML/21G X 1 1ST TIER UNIFINE RX/OTC 1/2" MISC F PENTIPS31GX8MM MISC F (syringe/needle (disp) 3 (insulin pen needle) ml) 1ST TIER UNIFINE RX/OTC 3ML LUER LOCK SAFETY SYRINGES/3ML/22G X 1" PENTIPS32GX4MM MISC F F (insulin pen needle) MISC (syringe/needle ) 3 ml) 1ST TIER UNIFINE (disp PENTIPS32GX6MM MISC F 3ML LUER LOCK SAFETY RX/OTC (insulin pen needle) SYRINGES/3ML/23G X 1" MISC ( F 1ST TIER UNIFINE syringe/needle PENTIPS33GX4MM MISC F (disp) 3 ml) (insulin pen needle) 3ML LUER LOCK SAFETY RX/OTC SYRINGES/3ML/25G X 1" 1ST TIER UNIFINE RX/OTC F PENTIPSPLUS 31GX8MM MISC (syringe/needle MISC (insulin pen F (disp) 3 ml) needle)
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125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 3ML LUER LOCK SAFETY RX/OTC 3ML SYRINGE/21G X RX/OTC SYRINGES/3ML/25G X 1"/LUER LOCK TIP MISC F 5/8" MISC F (syringe/needle (disp) 3 (syringe/needle (disp) 3 ml) ml) 3ML SYRINGE/21G X RX/OTC 3ML LUER-LOK SYRINGE RX/OTC 1"/LUER SLIP TIP MISC 22GX 1-1/2" MISC F F (syringe/needle (disp) 3 (syringe/needle (disp) 3 ml) ml) 3ML SYRINGE/21G X 1- RX/OTC 3ML LUER-LOK RX/OTC 1/2"/LUER LOCK TIP MISC SYRINGE21G X 1" MISC F F (syringe/needle (disp) 3 (syringe/needle (disp) 3 ml) ml) 3ML SYRINGE/21G X 1- 3ML LUER-LOK RX/OTC 1/4"/LUER LOCK TIP MISC F SYRINGE21G X 1-1/2" (syringe/needle (disp) 3 MISC (syringe/needle F ml) (disp) 3 ml) 3ML SYRINGE/22G 1- RX/OTC 1/2"/LUER LOCK TIP MISC 3ML LUER-LOK F SYRINGE22G X 1" MISC (syringe/needle (disp) 3 F (syringe/needle (disp) 3 ml) ml) 3ML SYRINGE/22G X 1"/LUER LOCK TIP MISC 3ML LUER-LOK RX/OTC F SYRINGE25G X 5/8" MISC (syringe/needle (disp) 3 F (syringe/needle (disp) 3 ml) ml) 3ML SYRINGE/22G X 1- 1/4"/LUER LOCK TIP MISC 3ML LUER-LOK TIP F SYRINGE25G X 1-1/2" (syringe/needle (disp) 3 MISC (syringe/needle F ml) (disp) 3 ml) 3ML SYRINGE/22G X 3/4"/LUER LOCK TIP MISC 3ML SYRINGE/18G X 1- RX/OTC F 1/2"/LUER LOCK TIP (syringe/needle (disp) 3 MISC (syringe/needle F ml) (disp) 3 ml) 3ML SYRINGE/22G X 3/4"/LUER SLIP TIP MISC 3ML SYRINGE/20G X RX/OTC F 1"/LUER LOCK TIP MISC (syringe/needle (disp) 3 F ml) (syringe/needle (disp) 3 ml) 3ML SYRINGE/25G X RX/OTC 1"/LUER LOCK TIP MISC 3ML SYRINGE/20G X RX/OTC F 1"/LUER SLIP TIP MISC (syringe/needle (disp) 3 F ml) (syringe/needle (disp) 3 ml) 3ML SYRINGE/27G X 1- RX/OTC 1/4"/LUER LOCK TIP MISC 3ML SYRINGE/20G X 1- RX/OTC F 1/2"/LUER LOCK TIP (syringe/needle (disp) 3 ml) MISC (syringe/needle F (disp) 3 ml)
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126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 3ML SYRINGE/LUER RX/OTC ADVOCATE INSULIN PEN RX/OTC LOCK TIP MISC NEEDLES 31GX8MM F (syringe/needle (disp) 3 MISC (insulin pen F ml) needle) 3ML SYRINGE/LUER RX/OTC ADVOCATE INSULIN PEN LOCK TIP23GX1" MISC F NEEDLES MISC (insulin F (syringe/needle (disp) 3 pen needle) ml) ADVOCATE INSULIN RX/OTC 3ML SYRINGE/LUER SYRINGE/U- LOCK TIP25G X 1-1/2" F 100/0.3ML/29GX1/2" MISC F MISC (syringe/needle (insulin syringe/needle (disp) 3 ml) u-100) 3ML SYRINGE/LUER SLIP RX/OTC ADVOCATE INSULIN RX/OTC TIP23GX1" MISC F SYRINGE/U- (syringe/needle (disp) 3 100/0.3ML/30GX5/16" F ml) MISC (insulin 3ML SYRINGE/NEEDLE RX/OTC syringe/needle u-100) REGULAR WALL LUER- LOK 25GX5/8" SUB-Q ADVOCATE INSULIN F SYRINGE/U- MISC (syringe/needle 100/0.3ML/31GX5/16" F (disp) 3 ml) MISC (insulin ABOUTTIME PEN RX/OTC syringe/needle u-100) NEEDLE 32GX 5/32" MISC F ADVOCATE INSULIN RX/OTC (insulin pen needle) SYRINGE/U- ABOUTTIME PEN RX/OTC 100/0.5ML/29GX1/2" MISC F NEEDLES 30GX 5/16" F (insulin syringe/needle MISC (insulin pen u-100) needle) ADVOCATE INSULIN RX/OTC ABOUTTIME PEN RX/OTC SYRINGE/U- NEEDLES 31G X 3/16" 100/0.5ML/30GX5/16" F F MISC (insulin pen MISC (insulin needle) syringe/needle u-100) ABOUTTIME PEN RX/OTC ADVOCATE INSULIN NEEDLES 31G X 5/16" SYRINGE/U- F MISC (insulin pen 100/0.5ML/31GX5/16" F needle) MISC (insulin ADVOCATE INSULIN PEN syringe/needle u-100) NEEDLES 29GX12.7MM ADVOCATE INSULIN RX/OTC MISC (insulin pen F SYRINGE/U- needle) 100/1ML/29GX1/2" MISC F ADVOCATE INSULIN PEN RX/OTC (insulin syringe/needle NEEDLES 31GX5MM u-100) MISC (insulin pen F needle)
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127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVOCATE INSULIN RX/OTC AURORA UNIFINE RX/OTC SYRINGE/U- PENTIPS/MINI/31GX3/16" 100/1ML/30GX5/16" MISC F MISC (insulin pen F (insulin syringe/needle needle) u-100) B-D INSULIN SYRINGE ADVOCATE INSULIN ULTRAFINE II/0.3ML/31G SYRINGE/U- X 5/16" MISC (insulin F 100/1ML/31GX5/16" MISC F syringe/needle u-100) (insulin syringe/needle B-D INSULIN SYRINGE u-100) ULTRAFINE II/0.5ML/31G ASSURE ID INSULIN RX/OTC X 5/16" MISC (insulin F SAFETYSYRINGE/U- syringe/needle u-100) 100/0.5ML/29G X 1/2" F B-D INSULIN SYRINGE MISC (insulin ULTRAFINE II/1ML/31G X syringe/needle u-100) 5/16" MISC (insulin F ASSURE ID INSULIN RX/OTC syringe/needle u-100) SAFETYSYRINGE/U- 100/1ML/29G X 1/2" MISC B-D INSULIN SYRINGE F ULTRAFINE/0.3ML/30G X (insulin syringe/needle 1/2" MISC (insulin F u-100) syringe/needle u-100) ASSURE ID SAFETY PEN NEEDLES 30G X 3/16" B-D INSULIN SYRINGE ULTRAFINE/0.5ML/30G X MISC (insulin pen F 1/2" MISC (insulin F needle) syringe/needle u-100) ASSURE ID SAFETY PEN RX/OTC NEEDLES 30G X 5/16" BD LO-DOSE INSULIN RX/OTC SYRINGE MICROFINE MISC (insulin pen F IV/0.5ML/28G X 1/2" MISC F needle) (insulin syringe/needle ASSURE ID SAFETY PEN RX/OTC u-100) NEEDLES 31G X 3/16" F BD 3ML LUER-LOCK RX/OTC MISC (insulin pen SYRINGE18G X 1 1/2" needle) MISC (syringe/needle F AURORA PEN NEEDLES RX/OTC (disp) 3 ml) 29GX12MM MISC F BD 3ML LUER-LOK RX/OTC (insulin pen needle) SYRINGE 18G X 1 1/2" AURORA PEN NEEDLES MISC (syringe/needle F 31G X6MM MISC (insulin F (disp) 3 ml) pen needle) BD 3ML LUER-LOK RX/OTC AURORA PEN NEEDLES RX/OTC SYRINGE 20G X 1-1/2" 31G X8MM MISC (insulin F MISC (syringe/needle F pen needle) (disp) 3 ml) AURORA UNIFINE RX/OTC BD 3ML LUER-LOK RX/OTC PENTIPS/32GX5/32" MISC F SYRINGE/20G X 1" MISC F (insulin pen needle) (syringe/needle (disp) 3 ml)
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128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD 3ML LUER-LOK RX/OTC BD AUTOSHIELD 29G X SYRINGE/21G X 1" MISC F 5/16" MISC (insulin pen F (syringe/needle (disp) 3 needle) ml) BD AUTOSHIELD DUO BD 3ML LUER-LOK RX/OTC 30G X 5MM MISC (insulin F SYRINGE/21G X 1-1/2" pen needle) MISC (syringe/needle F ) 3 ml) BD ECLIPSE SYRINGE RX/OTC (disp 3ML/21G X 1" MISC F BD 3ML LUER-LOK RX/OTC (syringe/needle (disp) 3 SYRINGE/23G X 1" MISC F ml) (syringe/needle (disp) 3 BD ECLIPSE SYRINGE ml) LUER-LOK/3ML/22G X 1" BD 3ML LUER-LOK MISC (syringe/needle F SYRINGE/23G X 1-1/2" (disp) 3 ml) MISC (syringe/needle F ) 3 ml) BD ECLIPSE SYRINGE RX/OTC (disp LUER-LOK/3ML/25G X 1" BD 3ML LUER-LOK RX/OTC MISC (syringe/needle F SYRINGE/25G X 1" MISC F (disp) 3 ml) (syringe/needle (disp) 3 ml) BD ECLIPSE RX/OTC SYRINGE/3ML/23G X 1" BD 3ML LUER-LOK F SYRINGE/26G X 5/8" MISC (syringe/needle MISC (syringe/needle F (disp) 3 ml) (disp) 3 ml) BD ECLIPSE RX/OTC SYRINGE/3ML/25GX5/8" BD 3ML RX/OTC F SYRINGE/SAFETYGLIDE MISC (syringe/needle SHIELDING IM NEEDLE (disp) 3 ml) 22GX1-1/2" MISC F BD ECLIPSE RX/OTC (syringe/needle (disp) 3 SYRINGE/LUER- ml) LOK/3ML/22G X 1-1/2" F BD 3ML RX/OTC MISC (syringe/needle SYRINGE/SAFETYGLIDE (disp) 3 ml) SHIELDING IM NEEDLE F BD INSULIN SYRINGE RX/OTC 23GX1" MISC LUER-LOK/U-100/1ML (syringe/needle (disp) 3 MISC (insulin syringes F ml) (disposable)) BD 3ML RX/OTC BD INSULIN SYRINGE RX/OTC SYRINGE/SAFETYGLIDE MICROFINE IV/U- SHIELDING NEEDLE 100/0.5ML/28G X 1/2" 25GX5/8" MISC F F MISC (insulin (syringe/needle (disp) 3 ml) syringe/needle u-100) BD AUTOSHIELD 29G X BD INSULIN SYRINGE MICROFINE IV/U- 3/16" MISC ( insulin pen F 100/1ML/27G X 5/8" MISC ) F needle (insulin syringe/needle u-100)
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129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE RX/OTC BD INSULIN SYRINGE MICROFINE IV/U- ULTRA-FINE/1/2 100/1ML/28G X 1/2" MISC F UNIT/0.3ML/31G X 8MM F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) BD INSULIN SYRINGE RX/OTC BD INSULIN SYRINGE MICROFINE/U- ULTRA-FINE/1ML/30G X 100/0.5ML/28G X 1/2" F 12.7MM MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) BD INSULIN SYRINGE BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X MICROFINE/U- 8MM MISC (insulin F 100/1ML/27G X 5/8" MISC F syringe/needle u-100) (insulin syringe/needle BD INSULIN SYRINGE u-100) ULTRAFINE HALF- BD INSULIN SYRINGE RX/OTC UNIT/0.3ML/31G X 5/16" F MICROFINE/U- MISC (insulin 100/1ML/28G X 1/2" MISC F syringe/needle u-100) (insulin syringe/needle BD INSULIN SYRINGE u-100) ULTRAFINE/0.3ML/30G X BD INSULIN SYRINGE RX/OTC 1/2" MISC (insulin F SAFETYGLIDE/1ML/29G X F syringe/needle u-100) 1/2" MISC (insulin BD INSULIN SYRINGE syringe/needle u-100) ULTRAFINE/0.3ML/31G X BD INSULIN SYRINGE RX/OTC 5/16" MISC (insulin F SLIP TIP/U-100/1ML MISC F syringe/needle u-100) (insulin syringes BD INSULIN SYRINGE (disposable)) ULTRAFINE/0.5ML/30G X BD INSULIN SYRINGE 1/2" MISC (insulin F ULTRA-FINE/0.3ML/30G X F syringe/needle u-100) 12.7MM MISC (insulin BD INSULIN SYRINGE syringe/needle u-100) ULTRAFINE/0.5ML/31G X BD INSULIN SYRINGE 5/16" MISC (insulin F ULTRA-FINE/0.3ML/31G X F syringe/needle u-100) 8MM MISC (insulin BD INSULIN SYRINGE syringe/needle u-100) ULTRAFINE/1ML/30G X BD INSULIN SYRINGE 1/2" MISC (insulin F ULTRA-FINE/0.5ML/30G X F syringe/needle u-100) 12.7MM MISC (insulin BD INSULIN SYRINGE RX/OTC syringe/needle u-100) ULTRAFINE/U- BD INSULIN SYRINGE 100/0.3ML/29G X 1/2" F ULTRA-FINE/0.5ML/31G X MISC ( F insulin 8MM MISC (insulin syringe/needle u-100) syringe/needle u-100)
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130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE RX/OTC BD INSULIN SYRINGE/U- RX/OTC ULTRAFINE/U- 100/1ML/27G X 1/2" MISC 100/0.5ML/29G X 1/2" F (insulin syringe/needle F MISC (insulin u-100) syringe/needle u-100) BD INSULIN SYRINGE/U- BD INSULIN SYRINGE RX/OTC 100/2ML/27.5G X 5/8" ULTRAFINE/U- MISC (insulin F 100/1ML/29G X 1/2" MISC F syringe/needle u-100) (insulin syringe/needle BD INSULIN SYRINGE/U- u-100) 500/0.5ML/31G X 6MM BD INSULIN SYRINGE MISC (insulin F ULTRAFINE/U- syringe/needle u-500) 100/1ML/31G X 5/16" F BD INTEGRA 3ML RX/OTC MISC (insulin SYRINGE syringe/needle u-100) W/RETRACTING BD INSULIN RX/OTC NEEDLE/21G X 1-1/2" F SYRINGE/0.3ML/29G X MISC ( F syringe/needle 12.7MM MISC (insulin (disp) 3 ml) syringe/needle u-100) BD INTEGRA 3ML RX/OTC BD INSULIN RX/OTC SYRINGE SYRINGE/0.5ML/29G X W/RETRACTING F 12.7MM MISC (insulin F NEEDLE/25G X 1" MISC syringe/needle u-100) (syringe/needle (disp) 3 BD INSULIN RX/OTC ml) SYRINGE/1ML/27G X BD INTEGRA RX/OTC F SYRINGE/3ML/21G X 1" 12.7MM MISC (insulin F syringe/needle u-100) MISC (syringe/needle ) 3 ml) BD INSULIN RX/OTC (disp SYRINGE/1ML/29G X BD INTEGRA RX/OTC F SYRINGE/3ML/22G X 1.5" 12.7MM MISC (insulin F syringe/needle u-100) MISC (syringe/needle ) 3 ml) BD INSULIN (disp SYRINGE/DETACHABLE BD INTEGRA RX/OTC SYRINGE/3ML/23G X 1" NEEDLE/U-100/1ML/25G F F X 1" MISC (insulin MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) BD INSULIN BD INTEGRA RX/OTC SYRINGE/3ML/25G X 5/8 SYRINGE/DETACHABLE F NEEDLE/U-100/1ML/25G F MISC (syringe/needle X 5/8" MISC (insulin (disp) 3 ml) syringe/needle u-100) BD LUER-LOK SYRINGE/3ML/22G X 3/4" BD INSULIN F SYRINGE/DETACHABLE MISC (syringe/needle NEEDLE/U-100/1ML/26G F (disp) 3 ml) X 1/2" MISC (insulin syringe/needle u-100) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD PEN BD SAFETYGLIDE NEEDLE/MICRO/ULTRA- INSULIN F FINE/32G X 6MM MISC SYRINGE/0.3ML/31G X F (insulin pen needle) 5/16" MISC (insulin BD PEN RX/OTC syringe/needle u-100) NEEDLE/MINI/ULTRA- F BD SAFETYGLIDE FINE/31G X 5MM MISC INSULIN (insulin pen needle) SYRINGE/0.5ML/31G X F BD PEN NEEDLE/NANO RX/OTC 15/64" MISC (insulin 2ND GEN/32G X 5/32" syringe/needle u-100) F MISC (insulin pen BD SAFETYGLIDE needle) INSULIN BD PEN RX/OTC SYRINGE/1ML/31G X F NEEDLE/NANO/ULTRA- 15/64" MISC (insulin FINE/32G X 4MM MISC F syringe/needle u-100) (insulin pen needle) BD SAFETYGLIDE RX/OTC BD PEN INSULIN NEEDLE/ORIGINAL/ULTR SYSYRINGE/0.5ML/30G X F A-FINE/29G X 12.7MM F 5/16" MISC (insulin MISC (insulin pen syringe/needle u-100) needle) BD SAFETYGLIDE RX/OTC BD PEN RX/OTC SYRINGE 3ML/25GX1" NEEDLE/SHORT/ULTRA- MISC (syringe/needle F F FINE/31G X 8MM MISC (disp) 3 ml) (insulin pen needle) BD VEO INSULIN BD SAFETY-GLIDE RX/OTC SYRINGE ULTR-FINE/U- INSULIN 100/0.5ML/31G X 15/64" F SYRINGE/0.5ML/29G X F MISC (insulin 1/2" MISC (insulin syringe/needle u-100) syringe/needle u-100) BD VEO INSULIN RX/OTC BD SAFETY-LOK INSULIN RX/OTC SYRINGE ULTRA- SYRINGE/PERM AFINE/0.3ML/31G X 6MM F NEEDLE/UF/1ML/29G X F MISC (insulin 1/2" MISC (insulin syringe/needle u-100) syringe/needle u-100) BD VEO INSULIN RX/OTC BD SAFETYGLIDE RX/OTC SYRINGE ULTRA- INSULIN FINE/0.3ML/31G X 6MM F SYRINGE/0.3ML/29G X F MISC (insulin 1/2" MISC (insulin syringe/needle u-100) syringe/needle u-100) BD VEO INSULIN BD SAFETYGLIDE RX/OTC SYRINGE ULTRA- INSULIN FINE/0.5ML/31G X 6MM F SYRINGE/0.3ML/31G X F MISC (insulin 15/64" MISC (insulin syringe/needle u-100) syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD VEO INSULIN RX/OTC CAREFINE PEN SYRINGE ULTRA- NEEDLES 32GX6MM FINE/1/2 UNIT/0.3ML/31G F MISC (insulin pen F X 6MM MISC (insulin needle) syringe/needle u-100) CAREONE INSULIN BD VEO INSULIN SYRINGES/0.3ML/30G X SYRINGE ULTRA- 1/2" MISC (insulin F FINE/1ML/31G X 6MM F syringe/needle u-100) MISC (insulin CAREONE INSULIN syringe/needle u-100) SYRINGES/0.3ML/31G X BD VEO INSULIN RX/OTC 5/16" MISC (insulin F SYRINGE ULTRA-FINE/U- syringe/needle u-100) 100/0.3ML/31G X 15/64" F CAREONE INSULIN MISC (insulin SYRINGES/0.5ML/30G X syringe/needle u-100) 1/2" MISC (insulin F BD VEO INSULIN syringe/needle u-100) SYRINGE ULTRA-FINE/U- 100/1ML/31G X 15/64" CAREONE INSULIN F SYRINGES/0.5ML/31G X MISC (insulin 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) CAREFINE PEN NEEDLE RX/OTC CAREONE INSULIN 32GX4MM MISC (insulin F SYRINGES/1ML/30G X pen needle) 1/2" MISC (insulin F CAREFINE PEN RX/OTC syringe/needle u-100) NEEDLES 29GX1/2" MISC F CAREONE INSULIN (insulin pen needle) SYRINGES/1ML/31GX5/16 CAREFINE PEN RX/OTC " MISC (insulin F NEEDLES 30GX5/16" syringe/needle u-100) MISC (insulin pen F CAREONE UNIFINE RX/OTC needle) PENTIPS 29GX12MM CAREFINE PEN MISC (insulin pen F NEEDLES 31GX6MM needle) MISC (insulin pen F CAREONE UNIFINE RX/OTC needle) PENTIPS 31GX5MM MISC F CAREFINE PEN RX/OTC (insulin pen needle) NEEDLES 31GX8MM CAREONE UNIFINE MISC (insulin pen F PENTIPS 31GX6MM MISC F needle) (insulin pen needle) CAREFINE PEN RX/OTC CAREONE UNIFINE RX/OTC NEEDLES 32GX5MM F PENTIPS 31GX8MM MISC F MISC (insulin pen (insulin pen needle) needle) CAREONE UNIFINE RX/OTC PENTIPS PEN NEEDLES 32GX4MM MISC (insulin F pen needle) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAREONE UNIFINE RX/OTC CARETOUCH INSULIN PENTIPS PLUS PEN SYRINGE/U-100/1ML/28G NEEDLES 29GX12MM F X 5/16" MISC (insulin F MISC (insulin pen syringe/needle u-100) needle) CARETOUCH INSULIN CAREONE UNIFINE RX/OTC SYRINGE/U-100/1ML/29G PENTIPS PLUS PEN X 5/16" MISC (insulin F NEEDLES 31GX5MM F syringe/needle u-100) MISC (insulin pen CARETOUCH PEN needle) NEEDLES 31G X 6 MM CAREONE UNIFINE MISC (insulin pen F PENTIPS PLUS PEN needle) NEEDLES 31GX6MM F CARETOUCH PEN RX/OTC MISC (insulin pen NEEDLES 31GX 5MM needle) MISC (insulin pen F CAREONE UNIFINE RX/OTC needle) PENTIPS PLUS PEN NEEDLES 31GX8MM CARETOUCH PEN RX/OTC F NEEDLES 31GX 8MM MISC (insulin pen MISC (insulin pen F needle) needle) CAREONE UNIFINE RX/OTC PENTIPS PLUS PEN CARETOUCH PEN RX/OTC NEEDLES 32GX 4MM NEEDLES 32GX4MM F F MISC (insulin pen MISC (insulin pen needle) needle) CAREONE UNIFINE CARETOUCH PEN RX/OTC NEEDLES 32GX 5MM PENTIPS PLUS PEN F NEEDLES/33G X 5/32" F MISC (insulin pen MISC (insulin pen needle) needle) CLEVER CHOICE RX/OTC CAREPOINT SAFETY 1ST RX/OTC COMFORT EZINSULIN SYRINGE/NEEDLE PEN NEEDLES 31GX8MM F 3ML/23G X 1" MISC F MISC (insulin pen (syringe/needle (disp) 3 needle) ml) CLEVER CHOICE CAREPOINT SAFETY 1ST RX/OTC COMFORT EZINSULIN SYRINGE/NEEDLE PEN NEEDLES 33GX4MM F 3ML/25G X 1" MISC F MISC (insulin pen (syringe/needle (disp) 3 needle) ml) CLEVER CHOICE RX/OTC CAREPOINT SAFETY 1ST RX/OTC COMFORT EZINSULIN SYRINGE/NEEDLE SYRINGE/0.3ML/29G X F 3ML/25G X 5/8" MISC F 1/2" MISC (insulin (syringe/needle (disp) 3 syringe/needle u-100) ml)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE CLEVER CHOICE RX/OTC COMFORT EZINSULIN COMFORT EZINSULIN SYRINGE/0.3ML/30G X F SYRINGE/1ML/28G X 1/2" F 1/2" MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) CLEVER CHOICE RX/OTC CLEVER CHOICE RX/OTC COMFORT EZINSULIN COMFORT EZINSULIN SYRINGE/0.3ML/30G X F SYRINGE/1ML/29G X 1/2" F 5/16" MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) CLEVER CHOICE CLEVER CHOICE RX/OTC COMFORT EZINSULIN COMFORT EZINSULIN SYRINGE/0.3ML/31G X F SYRINGE/1ML/30G X F 5/16" MISC (insulin 5/16" MISC (insulin syringe/needle u-100) syringe/needle u-100) CLEVER CHOICE RX/OTC CLEVER CHOICE COMFORT EZINSULIN COMFORT EZINSULIN SYRINGE/0.5ML/28G X F SYRINGE/U- 1/2" MISC (insulin 100/1ML/31GX5/16" MISC F syringe/needle u-100) (insulin syringe/needle CLEVER CHOICE RX/OTC u-100) COMFORT EZINSULIN CLEVER CHOICE RX/OTC SYRINGE/0.5ML/29G X F COMFORT EZPEN 1/2" MISC (insulin NEEDLES 29GX12MM F syringe/needle u-100) MISC (insulin pen CLEVER CHOICE needle) COMFORT EZINSULIN CLEVER CHOICE RX/OTC SYRINGE/0.5ML/30G X F COMFORT EZPEN 1/2" MISC (insulin NEEDLES 31GX5MM F syringe/needle u-100) MISC (insulin pen CLEVER CHOICE RX/OTC needle) COMFORT EZINSULIN CLEVER CHOICE SYRINGE/0.5ML/30G X F COMFORT EZPEN 5/16" MISC (insulin NEEDLES 31GX6MM F syringe/needle u-100) MISC (insulin pen CLEVER CHOICE needle) COMFORT EZINSULIN CLEVER CHOICE RX/OTC SYRINGE/0.5ML/31G X F COMFORT EZPEN 5/16" MISC (insulin NEEDLES 31GX8MM F syringe/needle u-100) MISC (insulin pen CLEVER CHOICE needle) COMFORT EZINSULIN CLEVER CHOICE RX/OTC SYRINGE/1.0ML/30G X F COMFORT EZPEN 1/2" MISC (insulin NEEDLES 32GX4MM F syringe/needle u-100) MISC (insulin pen needle)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE RX/OTC CLICKFINE PEN COMFORT EZPEN NEEDLES 31G X 1/4" NEEDLES 32GX5MM F MISC (insulin pen F MISC (insulin pen needle) needle) CLICKFINE PEN RX/OTC CLEVER CHOICE NEEDLES 31G X 3/16" COMFORT EZPEN MISC (insulin pen F NEEDLES 32GX6MM F needle) MISC (insulin pen CLICKFINE PEN RX/OTC needle) NEEDLES 31G X 5/16" CLEVER CHOICE MISC (insulin pen F COMFORT EZPEN needle) NEEDLES 32GX8MM F CLICKFINE PEN RX/OTC MISC (insulin pen NEEDLES 31G X 8MM needle) MISC (insulin pen F CLEVER CHOICE needle) COMFORT EZPEN NEEDLES 33GX4MM CLICKFINE PEN RX/OTC F NEEDLES 32G X 5/32" MISC (insulin pen MISC (insulin pen F needle) needle) CLEVER CHOICE COMFORT EZPEN CLICKFINE PEN NEEDLES/31GX1/4" MISC NEEDLES 33GX5MM F F MISC (insulin pen (insulin pen needle) needle) CLICKFINE UNIVERSAL RX/OTC PEN NEEDLES 31GX5/16" CLEVER CHOICE F COMFORT EZPEN MISC (insulin pen NEEDLES 33GX6MM F needle) MISC (insulin pen COMFORT ASSIST RX/OTC needle) INSULIN SYRINGE 0.3ML/29G X 1/2" MISC CLEVER CHOICE F COMFORT EZPEN (insulin syringe/needle NEEDLES 33GX8MM F u-100) MISC (insulin pen COMFORT ASSIST RX/OTC needle) INSULIN SYRINGE/0.3ML/30G X CLICKFINE PEN NEEDLE RX/OTC F 5/16" MISC (insulin 32GX5/32" MISC (insulin F syringe/needle u-100) pen needle) COMFORT ASSIST CLICKFINE PEN NEEDLE INSULIN UNIVERSAL/31GX1/4" F SYRINGE/0.3ML/31G X F MISC (insulin pen 5/16" MISC (insulin needle) syringe/needle u-100) CLICKFINE PEN NEEDLE RX/OTC UNIVERSAL/31GX5/16" MISC (insulin pen F needle) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMFORT ASSIST RX/OTC COMFORT EZ/31G X 5MM RX/OTC INSULIN MISC (insulin pen F SYRINGE/0.5ML/29G X F needle) 1/2" MISC (insulin COMFORT EZ/31G X 6MM syringe/needle u-100) MISC (insulin pen F COMFORT ASSIST RX/OTC needle) INSULIN SYRINGE/0.5ML/30G X COMFORT TOUCH PEN F NEEDLES/31G X 4MM 5/16" MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) COMFORT ASSIST INSULIN COMFORT TOUCH PEN RX/OTC NEEDLES/31G X 5MM SYRINGE/0.5ML/31G X F F 5/16" MISC (insulin MISC (insulin pen syringe/needle u-100) needle) COMFORT ASSIST RX/OTC COMFORT TOUCH PEN NEEDLES/31G X 6 MM INSULIN F SYRINGE/1ML/29G X 1/2" F MISC (insulin pen MISC (insulin needle) syringe/needle u-100) COMFORT TOUCH PEN RX/OTC NEEDLES/31G X 8 MM COMFORT ASSIST RX/OTC F INSULIN MISC (insulin pen SYRINGE/1ML/30G X F needle) 5/16" MISC (insulin COMFORT TOUCH PEN RX/OTC syringe/needle u-100) NEEDLES/32G X 4MM F COMFORT ASSIST MISC (insulin pen INSULIN needle) SYRINGE/1ML/31G X F COMFORT TOUCH PEN RX/OTC 5/16" MISC (insulin NEEDLES/32G X 5MM syringe/needle u-100) MISC (insulin pen F COMFORT EZ INSULIN needle) SYRINGE/U- COMFORT TOUCH PEN 100/0.5ML/31G X 5/16" F NEEDLES/32G X 6MM MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) COMFORT EZ INSULIN COMFORT TOUCH PEN SYRINGE/U-100/1ML/31G F NEEDLES/32G X 8MM X 5/16" MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) COMFORT EZ RX/OTC COMFORT TOUCH PEN MICRO/32G X 4MM MISC F NEEDLES/33G X 5/32" (insulin pen needle) MISC (insulin pen F COMFORT EZ RX/OTC needle) SHORT/31G X 8MM MISC F (insulin pen needle)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMFORT TOUCH PEN DROPLET INSULIN NEEDLES/33GX 3/16" SYRINGE U- MISC (insulin pen F 100/0.3ML/30G X 1/2" F needle) MISC (insulin COMFORT TOUCH PEN syringe/needle u-100) NEEDLES/33GX1/4" MISC F DROPLET INSULIN RX/OTC (insulin pen needle) SYRINGE U- DIALYSIS SAFETY RX/OTC 100/0.3ML/30G X 5/16" F SYRINGES/LOW DEAD MISC (insulin SPACE 3ML/22GX1-1/2" F syringe/needle u-100) MISC (syringe/needle DROPLET INSULIN RX/OTC (disp) 3 ml) SYRINGE U- DIATHRIVE PEN 100/0.3ML/31G X 15/64" F NEEDLE/31 G X 6MM MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) DROPLET INSULIN DIATHRIVE PEN RX/OTC SYRINGE U- NEEDLE/31 GX 8MM 100/0.5ML/30G X 1/2" F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) DIATHRIVE PEN RX/OTC DROPLET INSULIN RX/OTC NEEDLE/31GX 5MM MISC SYRINGE U- F 100/0.5ML/30G X 5/16" (insulin pen needle) F MISC (insulin DIATHRIVE PEN RX/OTC syringe/needle u-100) NEEDLE/32GX 4MM MISC F ( ) DROPLET INSULIN insulin pen needle SYRINGE U- DROPLET INSULIN RX/OTC 100/0.5ML/31G X 5/16" F SYRINGE 0.3ML/29G X F MISC (insulin 1/2" MISC (insulin syringe/needle u-100) ) syringe/needle u-100 DROPLET INSULIN DROPLET INSULIN RX/OTC SYRINGE U-100/1ML/30G SYRINGE 0.5ML/29G X F F X 1/2" MISC (insulin 1/2" MISC (insulin syringe/needle u-100) ) syringe/needle u-100 DROPLET INSULIN RX/OTC DROPLET INSULIN RX/OTC SYRINGE U-100/1ML/30G SYRINGE 1ML/29G X 1/2" F F X 5/16" MISC (insulin MISC (insulin syringe/needle u-100) ) syringe/needle u-100 DROPLET INSULIN DROPLET INSULIN SYRINGE U-100/1ML/31G SYRINGE U-100/0.3/31G F F X 15/64" MISC (insulin X 5/16" MISC (insulin syringe/needle u-100) ) syringe/needle u-100 DROPLET INSULIN SYRINGE U-100/1ML/31G X 5/16" MISC (insulin F syringe/needle u-100) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET INSULIN RX/OTC DROPLET PEN NEEDLES RX/OTC SYRINGE/U- 29GX12MM MISC (insulin F 100/0.3ML/31G X 15/64" F pen needle) MISC (insulin DROPLET PEN NEEDLES RX/OTC syringe/needle u-100) 30G X 5/16" MISC F DROPLET INSULIN (insulin pen needle) SYRINGE/U- DROPLET PEN NEEDLES RX/OTC 100/0.3ML/31G X 5/16" F 31G X3/16" MISC (insulin F MISC (insulin pen needle) syringe/needle u-100) DROPLET PEN NEEDLES RX/OTC DROPLET INSULIN SYRINGE/U- 31G X5/16" MISC (insulin F 100/0.5ML/30G X 1/2" F pen needle) MISC (insulin DROPLET PEN NEEDLES RX/OTC syringe/needle u-100) 31GX5MM MISC (insulin F DROPLET INSULIN pen needle) SYRINGE/U- DROPLET PEN NEEDLES 100/0.5ML/31G X 15/64" F 31GX6MM MISC (insulin F MISC (insulin pen needle) syringe/needle u-100) DROPLET PEN NEEDLES RX/OTC DROPLET INSULIN 31GX8MM MISC (insulin F SYRINGE/U- pen needle) 100/0.5ML/31G X 5/16" F MISC (insulin DROPLET PEN NEEDLES syringe/needle u-100) 32G X 1/4" MISC (insulin F pen needle) DROPLET INSULIN SYRINGE/U-100/1ML/30G DROPLET PEN NEEDLES RX/OTC X 1/2" MISC (insulin F 32G X 3/16" MISC F syringe/needle u-100) (insulin pen needle) DROPLET INSULIN DROPLET PEN NEEDLES SYRINGE/U-100/1ML/31G 32G X 5/16" MISC F X 15/64" MISC (insulin F (insulin pen needle) syringe/needle u-100) DROPLET PEN NEEDLES RX/OTC 32G X 5/32" MISC DROPLET INSULIN F SYRINGE/U-100/1ML/31G (insulin pen needle) X 5/16" MISC (insulin F DROPLET PEN NEEDLES RX/OTC syringe/needle u-100) 32GX4MM MISC (insulin F DROPLET PEN NEEDLES RX/OTC pen needle) 29G X1/2" MISC (insulin F DROPLET PEN NEEDLES RX/OTC pen needle) 32GX5MM MISC (insulin F DROPLET PEN NEEDLES pen needle) 29GX10MM MISC F DROPLET PEN NEEDLES (insulin pen needle) 32GX6MM MISC (insulin F pen needle)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET PEN NEEDLES EASY COMFORT INSULIN 32GX8MM MISC ( SYRINGE/1ML/31G X insulin F F pen needle) 5/16" MISC (insulin DROPSAFE SAFETY PEN RX/OTC syringe/needle u-100) NEEDLES/31G X 5/16" EASY COMFORT INSULIN MISC (insulin pen F SYRINGE/U- needle) 100/0.5ML/30G X 1/2" F DROPSAFE SAFTEY PEN MISC (insulin NEEDLES/31G X 1/4" syringe/needle u-100) MISC (insulin pen F EASY COMFORT INSULIN SYRINGE/U-100/1ML/30G needle) F DRUG MART UNIFINE RX/OTC X 1/2" MISC (insulin PENTIPS 31GX5MM MISC F syringe/needle u-100) (insulin pen needle) EASY COMFORT PEN DRUG MART UNIFINE RX/OTC NEEDLES31GX1/4" MISC F PENTIPS29G X 12MM (insulin pen needle) MISC (insulin pen F EASY COMFORT PEN RX/OTC needle) NEEDLES31GX3/16" MISC F DRUG MART UNIFINE (insulin pen needle) PENTIPS31GX6MM MISC F EASY COMFORT PEN RX/OTC (insulin pen needle) NEEDLES31GX5/16" MISC F DRUG MART UNIFINE RX/OTC (insulin pen needle) PENTIPS31GX8MM MISC F EASY COMFORT PEN RX/OTC (insulin pen needle) NEEDLES32GX5/32" MISC F DRUG MART UNIFINE RX/OTC (insulin pen needle) PENTIPS32GX4MM MISC F EASY COMFORT PEN NEEDLES33G X 4MM (insulin pen needle) F DRUG MART UNIFINE RX/OTC MISC (insulin pen PENTIPSPLUS 32GX4MM needle) MISC (insulin pen F EASY COMFORT PEN NEEDLES33G X 5MM needle) F EASY COMFORT INSULIN RX/OTC MISC (insulin pen SYRINGE/0.5ML/30G X needle) 5/16" MISC (insulin F EASY COMFORT PEN NEEDLES33G X 6MM syringe/needle u-100) F EASY COMFORT INSULIN MISC (insulin pen SYRINGE/0.5ML/31G X needle) 5/16" MISC (insulin F EASY GLIDE PEN NEEDLES 33G X 5/32" syringe/needle u-100) F EASY COMFORT INSULIN RX/OTC MISC (insulin pen SYRINGE/1ML/30G X needle) 5/16" MISC (insulin F EASY TOUCH 32GX5MM RX/OTC syringe/needle u-100) MISC (insulin pen F needle)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH 32GX6MM EASY TOUCH FLIPLOCK RX/OTC MISC (insulin pen F SAFETY SYRINGE needle) 3ML/23GX1" MISC F EASY TOUCH FLIPLOCK RX/OTC (syringe/needle (disp) 3 SAFETTY SYRINGES ml) 3ML/18GX1-1/2" MISC F EASY TOUCH FLIPLOCK (syringe/needle (disp) 3 SAFETY SYRINGE ml) 3ML/23GX1-1/2" MISC F EASY TOUCH FLIPLOCK RX/OTC (syringe/needle (disp) 3 SAFETY INSULIN ml) SYRINGE 1ML/29GX1/2" F EASY TOUCH FLIPLOCK RX/OTC MISC (insulin SAFETY SYRINGE 3ML/25GX1" MISC syringe/needle u-100) F (syringe/needle (disp) 3 EASY TOUCH FLIPLOCK ml) SAFETY INSULIN SYRINGE 1ML/30GX1/2" EASY TOUCH FLIPLOCK RX/OTC F SAFETY SYRINGE MISC (insulin 3ML/25GX5/8" MISC F syringe/needle u-100) (syringe/needle (disp) 3 EASY TOUCH FLIPLOCK RX/OTC ml) SAFETY INSULIN EASY TOUCH FLIPLOCK RX/OTC SYRINGE 1ML/30GX5/16" F SAFETY SYRINGES MISC (insulin 3ML/18GX1" MISC F syringe/needle u-100) (syringe/needle (disp) 3 EASY TOUCH FLIPLOCK ml) SAFETY INSULIN EASY TOUCH FLIPLOCK RX/OTC SYRINGE 1ML/31GX5/16" F SAFETY SYRINGES MISC (insulin 3ML/20GX1" MISC F syringe/needle u-100) (syringe/needle (disp) 3 EASY TOUCH FLIPLOCK RX/OTC ml) SAFETY SYRINGE EASY TOUCH FLIPLOCK RX/OTC 3ML/21GX1" MISC F SAFETY SYRINGES (syringe/needle (disp) 3 3ML/20GX1-1/2" MISC F ml) (syringe/needle (disp) 3 EASY TOUCH FLIPLOCK ml) SAFETY SYRINGE EASY TOUCH FLIPLOCK RX/OTC 3ML/22GX1" MISC F SAFETY SYRINGES (syringe/needle (disp) 3 3ML/21GX1-1/2" MISC F ml) (syringe/needle (disp) 3 EASY TOUCH FLIPLOCK RX/OTC ml) SAFETY SYRINGE EASY TOUCH INSULIN RX/OTC 3ML/22GX1-1/2" MISC F SYRINGE/0.3ML/30G X F (syringe/needle (disp) 3 5/16" MISC (insulin ml) syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH INSULIN EASY TOUCH INSULIN RX/OTC SYRINGE/0.3ML/31G X SYRINGE/U- 5/16" MISC (insulin F 100/0.5ML/28G X 1/2" F syringe/needle u-100) MISC (insulin EASY TOUCH INSULIN RX/OTC syringe/needle u-100) SYRINGE/0.5ML/29G X EASY TOUCH INSULIN RX/OTC 1/2" MISC (insulin F SYRINGE/U- syringe/needle u-100) 100/0.5ML/29G X 1/2" F EASY TOUCH INSULIN RX/OTC MISC (insulin SYRINGE/0.5ML/30G X syringe/needle u-100) 5/16" MISC (insulin F EASY TOUCH INSULIN syringe/needle u-100) SYRINGE/U- 100/0.5ML/30G X 1/2" EASY TOUCH INSULIN RX/OTC F SYRINGE/1ML/30G X MISC (insulin 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) EASY TOUCH INSULIN SYRINGE/U- EASY TOUCH INSULIN RX/OTC 100/0.5ML/31G X 5/16" SYRINGE/SAFETY/U- F MISC (insulin 100/0.5ML/29G X 1/2" F MISC (insulin syringe/needle u-100) syringe/needle u-100) EASY TOUCH INSULIN RX/OTC SYRINGE/U-100/1ML/27G EASY TOUCH INSULIN RX/OTC F SYRINGE/SAFETY/U- X 1/2" MISC (insulin 100/0.5ML/30G X 5/16" F syringe/needle u-100) MISC (insulin EASY TOUCH INSULIN RX/OTC SYRINGE/U-100/1ML/28G syringe/needle u-100) F EASY TOUCH INSULIN RX/OTC X 1/2" MISC (insulin SYRINGE/SAFETY/U- syringe/needle u-100) 100/1ML/29G X 1/2" MISC F EASY TOUCH INSULIN RX/OTC ( SYRINGE/U-100/1ML/29G insulin syringe/needle F u-100) X 1/2" MISC (insulin EASY TOUCH INSULIN syringe/needle u-100) SYRINGE/SAFETY/U- EASY TOUCH INSULIN 100/1ML/30G X 1/2" MISC F SYRINGE/U-100/1ML/30G (insulin syringe/needle X 1/2" MISC (insulin F u-100) syringe/needle u-100) EASY TOUCH INSULIN EASY TOUCH INSULIN SYRINGE/U- SYRINGE/U-100/1ML/31G 100/0.3ML/30G X 1/2" F X 5/16" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) EASY TOUCH PEN RX/OTC EASY TOUCH INSULIN NEEDLE 30G X 5/16" SYRINGE/U- MISC (insulin pen F 100/0.5ML/27G X 1/2" F needle) MISC (insulin syringe/needle u-100) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH PEN EASY TOUCH SAFETY RX/OTC NEEDLE/30G X 3/16" SYRINGE/3ML/21G X 1" MISC (insulin pen F MISC (syringe/needle F needle) (disp) 3 ml) EASY TOUCH PEN RX/OTC EASY TOUCH SAFETY NEEDLES 29GX1/2" MISC F SYRINGE/3ML/22G X 1" (insulin pen needle) MISC (syringe/needle F EASY TOUCH PEN (disp) 3 ml) NEEDLES 31GX1/4" MISC F EASY TOUCH SAFETY RX/OTC (insulin pen needle) SYRINGE/3ML/22G X 1- EASY TOUCH PEN RX/OTC 1/2" MISC F NEEDLES 31GX5/16" (syringe/needle (disp) 3 MISC (insulin pen F ml) needle) EASY TOUCH SAFETY RX/OTC SYRINGE/3ML/23G X 1" EASY TOUCH PEN F NEEDLES 32GX1/4" MISC F MISC (syringe/needle (insulin pen needle) (disp) 3 ml) EASY TOUCH PEN RX/OTC EASY TOUCH SAFETY RX/OTC SYRINGE/3ML/25G X 1" NEEDLES 32GX3/16" F MISC (insulin pen F MISC (syringe/needle needle) (disp) 3 ml) EASY TOUCH PEN RX/OTC EASY TOUCH SAFETY RX/OTC SYRINGE/3ML/25G X 5/8" NEEDLES 32GX5/32" F MISC (insulin pen F MISC (syringe/needle needle) (disp) 3 ml) EASY TOUCH PEN RX/OTC EASY TOUCH RX/OTC NEEDLES/31G X 3/16" SHEATHLOCK SAFETY F INSULIN SYRINGE MISC (insulin pen 1ML/29GX1/2" MISC F needle) (insulin syringe/needle EASY TOUCH SAFETY u-100) PEN NEEDLES/29G X F EASY TOUCH RX/OTC 5MM MISC (insulin pen SHEATHLOCK SAFETY needle) INSULIN SYRINGE EASY TOUCH SAFETY 1ML/30GX5/16" MISC F PEN NEEDLES/29G X F (insulin syringe/needle 8MM MISC (insulin pen u-100) needle) EASY TOUCH EASY TOUCH SAFETY RX/OTC SHEATHLOCK SAFETY PEN NEEDLES/30G X INSULIN SYRINGE 5/16" MISC (insulin pen F 1ML/31GX5/16" MISC F needle) (insulin syringe/needle EASY TOUCH SAFETY RX/OTC u-100) SYRINGE/3ML/20G X 1" MISC (syringe/needle F (disp) 3 ml) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH EASYPOINT RX/OTC SHEATHLOCK SAFETY NEEDLE/SYRINGE SYRINGE 1ML/30GX1/2" F 3ML/18G X 1-1/2" MISC F MISC (insulin (syringe/needle (disp) 3 syringe/needle u-100) ml) EASY TOUCH RX/OTC EASYPOINT RX/OTC SHEATHLOCK SAFETY NEEDLE/SYRINGE SYRINGE 3ML/21GX1" F 3ML/23 G X 1" MISC F MISC (syringe/needle (syringe/needle (disp) 3 (disp) 3 ml) ml) EASY TOUCH RX/OTC EASYPOINT RX/OTC SHEATHLOCK SAFETY NEEDLE/SYRINGE 3ML/25G X 1" MISC F SYRINGE 3ML/21GX1-1/2" F MISC (syringe/needle (syringe/needle (disp) 3 ml) (disp) 3 ml) EASYPOINT RX/OTC EASY TOUCH NEEDLE/SYRINGE SHEATHLOCK SAFETY 3ML/25G X 5/8" MISC F SYRINGE 3ML/22GX1" F (syringe/needle (disp) 3 MISC (syringe/needle ml) (disp) 3 ml) ELITE-THIN INSULIN EASY TOUCH RX/OTC SYRINGE/0.3ML/31G X SHEATHLOCK SAFETY 5/16" MISC (insulin F SYRINGE 3ML/22GX1-1/2" F syringe/needle u-100) MISC (syringe/needle ELITE-THIN INSULIN RX/OTC (disp) 3 ml) SYRINGE/0.5ML/29G X EASY TOUCH RX/OTC 1/2" MISC (insulin F SHEATHLOCK SAFETY syringe/needle u-100) SYRINGE 3ML/23GX1" F MISC (syringe/needle ELITE-THIN INSULIN RX/OTC SYRINGE/0.5ML/30G X (disp) 3 ml) 5/16" MISC (insulin F EASY TOUCH RX/OTC SHEATHLOCK SAFETY syringe/needle u-100) SYRINGE 3ML/25GX1" F ELITE-THIN INSULIN SYRINGE/1ML/29G X MISC (syringe/needle F (disp) 3 ml) 5/16" MISC (insulin EASY TOUCH RX/OTC syringe/needle u-100) SHEATHLOCK SAFETY ELITE-THIN INSULIN RX/OTC SYRINGE/1ML/30G X SYRINGE 3ML/25GX5/8" F F MISC (syringe/needle 5/16" MISC (insulin (disp) 3 ml) syringe/needle u-100) EASYPOINT RX/OTC ELITE-THIN INSULIN RX/OTC NEEDLE/SYRINGE SYRINGE/U- 3ML/18G X 1" MISC F 100/0.5ML/28G X 1/2" F (syringe/needle (disp) 3 MISC (insulin ml) syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELITE-THIN INSULIN EQL INSULIN RX/OTC SYRINGE/U- SYRINGE/0.5ML/29G X 100/0.5ML/28G X 5/16" F 1/2" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) EQL INSULIN RX/OTC ELITE-THIN INSULIN SYRINGE/0.5ML/30G X SYRINGE/U- 5/16" MISC (insulin F 100/0.5ML/29G X 5/16" F syringe/needle u-100) MISC (insulin EQL INSULIN syringe/needle u-100) SYRINGE/0.5ML/31G X ELITE-THIN INSULIN 5/16" MISC (insulin F SYRINGE/U- syringe/needle u-100) 100/0.5ML/31G X 5/16" F EQL INSULIN RX/OTC MISC (insulin SYRINGE/1ML/29G X 1/2" syringe/needle u-100) MISC (insulin F ELITE-THIN INSULIN RX/OTC syringe/needle u-100) SYRINGE/U-100/1ML/28G F EQL INSULIN RX/OTC X 1/2" MISC (insulin SYRINGE/1ML/30G X syringe/needle u-100) 5/16" MISC (insulin F ELITE-THIN INSULIN syringe/needle u-100) SYRINGE/U-100/1ML/28G F EQL INSULIN X 5/16" MISC (insulin SYRINGE/1ML/31G X syringe/needle u-100) 5/16" MISC (insulin F ELITE-THIN INSULIN RX/OTC syringe/needle u-100) SYRINGE/U-100/1ML/29G F EXCEL COMFORT POINT X 1/2" MISC (insulin INSULIN PEN NEEDLES syringe/needle u-100) 31G X 4MM MISC (insulin F ELITE-THIN INSULIN pen needle) SYRINGE/U-100/1ML/31G F EXEL COMFORT POINT RX/OTC X 5/16" MISC (insulin INSULIN PEN NEEDLES syringe/needle u-100) 29G X 12MM MISC F EQL INSULIN RX/OTC (insulin pen needle) SYRINGE/0.3ML/29G X F EXEL COMFORT POINT 1/2" MISC (insulin INSULIN PEN NEEDLES syringe/needle u-100) 31G X 6MM MISC (insulin F EQL INSULIN RX/OTC pen needle) SYRINGE/0.3ML/30G X F EXEL COMFORT POINT RX/OTC 5/16" MISC (insulin INSULIN PEN NEEDLES syringe/needle u-100) 31G X 8MM MISC (insulin F EQL INSULIN pen needle) SYRINGE/0.3ML/31G X F EXEL COMFORT POINT RX/OTC 5/16" MISC (insulin INSULIN syringe/needle u-100) SYRINGE/0.3ML/29G X F 1/2" MISC (insulin syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
145 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXEL COMFORT POINT RX/OTC FIFTY50 PEN RX/OTC INSULIN NEEDLES/31GX8MM SYRINGE/0.3ML/30G X F MISC (insulin pen F 5/16" MISC (insulin needle) syringe/needle u-100) FIFTY50 PEN RX/OTC EXEL COMFORT POINT RX/OTC NEEDLES/32GX4MM INSULIN MISC (insulin pen F SYRINGE/0.5ML/28G X F needle) 1/2" MISC (insulin FIFTY50 PEN syringe/needle u-100) NEEDLES/32GX6MM EXEL COMFORT POINT RX/OTC MISC (insulin pen F INSULIN needle) SYRINGE/0.5ML/29G X F FIFTY50 SUPERIOR 1/2" MISC (insulin COMFORTINSULIN syringe/needle u-100) SYRINGE/0.3ML/31G X F EXEL COMFORT POINT RX/OTC 5/16" MISC (insulin INSULIN syringe/needle u-100) SYRINGE/0.5ML/30G X F FIFTY50 SUPERIOR 5/16" MISC (insulin COMFORTINSULIN syringe/needle u-100) SYRINGE/0.5ML/31G X F EXEL COMFORT POINT RX/OTC 5/16" MISC (insulin INSULIN syringe/needle u-100) SYRINGE/1ML/28G X 1/2" F FIFTY50 SUPERIOR MISC (insulin COMFORTINSULIN syringe/needle u-100) SYRINGE/1ML/31G X F EXEL COMFORT POINT RX/OTC 5/16" MISC (insulin INSULIN syringe/needle u-100) SYRINGE/1ML/29G X 1/2" F FREDS PHARMACY RX/OTC MISC (insulin UNIFINE PENTIPS PEN syringe/needle u-100) NEEDLES 32GX4MM F EXEL COMFORT POINT RX/OTC MISC (insulin pen INSULIN needle) SYRINGE/1ML/30G X F FREDS PHARMACY RX/OTC 5/16" MISC (insulin UNIFINE PENTIPS PLUS syringe/needle u-100) 31GX5MM MISC (insulin F FIFTY50 PEN NEEDLES RX/OTC pen needle) F 31G X3/16" (5MM) MISC FREDS PHARMACY RX/OTC (insulin pen needle) UNIFINE PENTIPS PLUS FIFTY50 PEN NEEDLES RX/OTC 31GX8MM MISC (insulin F 31G X5/16" (8MM) MISC F pen needle) (insulin pen needle) FREESTYLE PRECISION RX/OTC FIFTY50 PEN NEEDLES RX/OTC INSULIN SYRINGE/U- 31GX5MM MISC (insulin F 100/0.5ML/30G X 5/16" F pen needle) MISC (insulin syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
146 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FREESTYLE PRECISION GLOBAL EASY GLIDE INSULIN SYRINGE/U- INSULINSYRINGE/U- 100/0.5ML/31G X 5/16" F 100/0.3ML/31G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) FREESTYLE PRECISION GLOBAL EASY GLIDE RX/OTC INSULIN SYRINGE/U- PEN NEEDLES 32GX4MM 100/1ML/31G X 5/16" F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) GLOBAL INJECT EASE RX/OTC FREESTYLE PRECISION RX/OTC INSULIN SYRINGE/U- INSULIN SYRINGES/U- 100/0.3ML/29G X 1/2" F 100/1ML/30G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) GLOBAL INJECT EASE GLOBAL EASE INJECT RX/OTC INSULIN SYRINGE/U- PEN NEEDLES 100/0.3ML/30G X 1/2" F F 29GX12MM MISC MISC (insulin (insulin pen needle) syringe/needle u-100) GLOBAL EASE INJECT RX/OTC GLOBAL INJECT EASE RX/OTC PEN NEEDLES 31GX8MM INSULIN SYRINGE/U- F MISC (insulin pen 100/0.3ML/30G X 5/16" F needle) MISC (insulin GLOBAL EASE INJECT RX/OTC syringe/needle u-100) PEN NEEDLES 32GX4MM GLOBAL INJECT EASE MISC (insulin pen F INSULIN SYRINGE/U- needle) 100/0.3ML/31G X 5/16" F GLOBAL EASE INJECT RX/OTC MISC (insulin PEN NEEEDLES syringe/needle u-100) 31GX5MM MISC (insulin F GLOBAL INJECT EASE RX/OTC pen needle) INSULIN SYRINGE/U- GLOBAL EASY GLIDE RX/OTC 100/0.5ML/28G X 1/2" F INSULIN MISC (insulin SYRINGE/0.3ML/31G X F syringe/needle u-100) 15/64" MISC (insulin GLOBAL INJECT EASE RX/OTC syringe/needle u-100) INSULIN SYRINGE/U- GLOBAL EASY GLIDE 100/0.5ML/29G X 1/2" F INSULIN MISC (insulin SYRINGE/0.5ML/31G X F syringe/needle u-100) 15/64" MISC (insulin GLOBAL INJECT EASE syringe/needle u-100) INSULIN SYRINGE/U- GLOBAL EASY GLIDE 100/0.5ML/30G X 1/2" F INSULIN MISC (insulin SYRINGE/1ML/31G X F syringe/needle u-100) 15/64" MISC (insulin syringe/needle u-100) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
147 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLOBAL INJECT EASE RX/OTC GLUCOPRO INSULIN INSULIN SYRINGE/U- SYRINGE/U- 100/0.5ML/30G X 5/16" F 100/0.3ML/30G X 1/2" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) GLOBAL INJECT EASE GLUCOPRO INSULIN RX/OTC INSULIN SYRINGE/U- SYRINGE/U- 100/0.5ML/31G X 5/16" F 100/0.3ML/30G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) GLOBAL INJECT EASE RX/OTC GLUCOPRO INSULIN INSULIN SYRINGE/U- SYRINGE/U- 100/1ML/28G X 1/2" MISC F 100/0.3ML/31G X 5/16" F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) GLOBAL INJECT EASE RX/OTC GLUCOPRO INSULIN INSULIN SYRINGE/U- SYRINGE/U- 100/1ML/29G X 1/2" MISC F 100/0.5ML/30G X 1/2" F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) GLOBAL INJECT EASE GLUCOPRO INSULIN RX/OTC INSULIN SYRINGE/U- SYRINGE/U- 100/1ML/30G X 1/2" MISC F 100/0.5ML/30G X 5/16" F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) GLOBAL INJECT EASE RX/OTC GLUCOPRO INSULIN INSULIN SYRINGE/U- SYRINGE/U- 100/1ML/30G X 5/16" F 100/0.5ML/31G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) GLOBAL INJECT EASE GLUCOPRO INSULIN INSULIN SYRINGE/U- SYRINGE/U-100/1ML/30G 100/1ML/31G X 5/16" F X 1/2" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) GLUCOPRO INSULIN RX/OTC GLOBAL INSULIN SYRINGE/U-100/1ML/30G SYRINGE/U- X 5/16" MISC (insulin F 100/0.3ML/30G X 1/2" F syringe/needle u-100) MISC (insulin GLUCOPRO INSULIN syringe/needle u-100) SYRINGE/U-100/1ML/31G GLOBAL INSULIN RX/OTC X 5/16" MISC (insulin F SYRINGES/U- syringe/needle u-100) 100/0.3ML/30GX5/16" F GNP CLICKFINE MISC (insulin UNIVERSAL PEN syringe/needle u-100) NEEDLES 31GX1/4" MISC F (insulin pen needle) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
148 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP CLICKFINE RX/OTC GNP INSULIN UNIVERSAL PEN SYRINGE/1ML/31G X NEEDLES 31GX5/16" F 5/16" MISC (insulin F MISC (insulin pen syringe/needle u-100) needle) GNP ULTICARE PEN RX/OTC GNP INSULIN RX/OTC NEEDLES/31GX5/16" SYRINGE/0.3ML/29G X MISC ( F F insulin pen 1/2" MISC (insulin needle) syringe/needle u-100) GNP ULTICARE PEN RX/OTC GNP INSULIN RX/OTC NEEDLES/32GX 5/32" SYRINGE/0.3ML/30G X MISC ( F F insulin pen 5/16" MISC (insulin needle) syringe/needle u-100) GNP ULTICARE PEN GNP INSULIN NEEDLES/32GX1/4" MISC F SYRINGE/0.3ML/31G X ( ) F insulin pen needle 5/16" MISC (insulin GNP ULTICARE PEN RX/OTC syringe/needle u-100) NEEDLES31G X 5MM GNP INSULIN RX/OTC MISC (insulin pen F SYRINGE/0.5ML/28G X ) F needle 1/2" MISC (insulin GNP ULTRA COMFORT RX/OTC syringe/needle u-100) INSULIN GNP INSULIN RX/OTC SYRINGE/0.3ML/29G X F SYRINGE/0.5ML/29G X 1/2" MISC (insulin 1/2" MISC (insulin F syringe/needle u-100) syringe/needle u-100) GNP ULTRA COMFORT RX/OTC GNP INSULIN RX/OTC INSULIN SYRINGE/0.5ML/30G X SYRINGE/0.3ML/30G X F 5/16" MISC (insulin F 5/16" SHORT MISC syringe/needle u-100) (insulin syringe/needle GNP INSULIN u-100) SYRINGE/0.5ML/31G X GNP ULTRA COMFORT RX/OTC 5/16" MISC (insulin F INSULIN syringe/needle u-100) SYRINGE/0.5ML/28G X F 1/2" MISC (insulin GNP INSULIN RX/OTC SYRINGE/1ML/28G X 1/2" syringe/needle u-100) MISC (insulin F GNP ULTRA COMFORT RX/OTC syringe/needle u-100) INSULIN SYRINGE/0.5ML/29G X F GNP INSULIN RX/OTC 1/2" MISC (insulin SYRINGE/1ML/29G X 1/2" syringe/needle u-100) MISC (insulin F ) GNP ULTRA COMFORT RX/OTC syringe/needle u-100 INSULIN GNP INSULIN RX/OTC SYRINGE/1ML/28G X 1/2" F SYRINGE/1ML/30G X F MISC (insulin 5/16" MISC (insulin syringe/needle u-100) syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
149 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP ULTRA COMFORT RX/OTC H-E-B IN CONTROL PEN RX/OTC INSULIN NEEDLES/NANO/32GX4M SYRINGE/1ML/29G X 1/2" F M MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) H-E-B IN CONTROL GOODSENSE CLICKFINE RX/OTC UNIFINEPENTIPS PLUS SAFETY PEN 31GX1/4" MISC (insulin F NEEDLE/31G X 3/16" F pen needle) MISC (insulin pen H-E-B IN CONTROL RX/OTC needle) UNIFINEPENTIPS PLUS GOODSENSE PEN RX/OTC 31GX3/16" MISC (insulin F NEEDLE/PENFINE pen needle) CLASSIC/31G X 3/16" F H-E-B IN CONTROL RX/OTC MISC (insulin pen UNIFINEPENTIPS PLUS needle) 31GX5/16" MISC (insulin F GOODSENSE PEN RX/OTC pen needle) NEEDLE/PENFINE CLASSIC/31G X 5/16" H-E-B IN CONTROL RX/OTC F UNIFINEPENTIPS PLUS MISC (insulin pen 31GX5MM MISC (insulin F needle) pen needle) GOODSENSE PEN NEEDLE/PENFINE H-E-B IN CONTROL RX/OTC F UNIFINEPENTIPS PLUS CLASSIC/32G X 1/4" MISC F (insulin pen needle) 32GX4MM MISC (insulin ) GOODSENSE PEN RX/OTC pen needle NEEDLE/PENFINE H-E-B IN CONTROL RX/OTC UNIFINEPENTIPS PLUS CLASSIC/32G X 5/32" F F MISC (insulin pen 32GX5/32" MISC (insulin needle) pen needle) H-E-B IN CONTROL PEN RX/OTC H-E-B IN CONTROL UNIFINEPENTIPS PLUS NEEDLE 31GX3/16" MISC F F (insulin pen needle) 33GX5/32" MISC (insulin H-E-B IN CONTROL PEN RX/OTC pen needle) NEEDLES 31GX5MM H-E-B INCONTROL PEN RX/OTC F NEEDLES 29GX12MM MISC (insulin pen F needle) MISC (insulin pen H-E-B IN CONTROL PEN needle) NEEDLES 31GX6MM HEALTHWISE INSULIN RX/OTC MISC (insulin pen F SYRINGE/U- needle) 100/0.3ML/30G X 5/16" F MISC ( H-E-B IN CONTROL PEN RX/OTC insulin NEEDLES 31GX8MM syringe/needle u-100) MISC (insulin pen F needle)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
150 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEALTHWISE INSULIN HEALTHWISE SHORT RX/OTC SYRINGE/U- PEN NEEDLES/31G X 100/0.3ML/31G X 5/16" F 5/16" MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) HEALTHWISE UNIFINE RX/OTC HEALTHWISE INSULIN RX/OTC PENTIPS PEN NEEDLES SYRINGE/U- 32GX4MM MISC (insulin F 100/0.5ML/30G X 5/16" F pen needle) MISC (insulin HEALTHY ACCENTS RX/OTC syringe/needle u-100) UNIFINE PENTIPS PEN HEALTHWISE INSULIN NEEDLES 29GX12MM F SYRINGE/U- MISC (insulin pen 100/0.5ML/31G X 5/16" F needle) MISC (insulin HEALTHY ACCENTS RX/OTC syringe/needle u-100) UNIFINE PENTIPS PEN HEALTHWISE INSULIN RX/OTC NEEDLES 31GX5MM F SYRINGE/U-100/1ML/30G MISC ( F insulin pen X 5/16" MISC (insulin needle) syringe/needle u-100) HEALTHY ACCENTS HEALTHWISE INSULIN UNIFINE PENTIPS PEN SYRINGE/U-100/1ML/31G NEEDLES 31GX6MM F X 5/16" MISC (insulin F MISC (insulin pen syringe/needle u-100) needle) HEALTHWISE MICRON RX/OTC HEALTHY ACCENTS RX/OTC PEN NEEDLES/32G X UNIFINE PENTIPS PEN 5/32" MISC (insulin pen F NEEDLES 31GX8MM F needle) MISC (insulin pen HEALTHWISE MINI PEN needle) NEEDLES 31GX6MM HEALTHY ACCENTS RX/OTC MISC (insulin pen F UNIFINE PENTIPS PEN needle) NEEDLES 32GX4MM F HEALTHWISE PEN RX/OTC MISC (insulin pen NEEDLES 29GX12MM needle) MISC (insulin pen F HM ULTICARE INSULIN SYRINGE/1ML/30G X 1/2" needle) F HEALTHWISE SHORT RX/OTC MISC (insulin PEN NEEDLES 31GX8MM syringe/needle u-100) MISC (insulin pen F HM ULTICARE INSULIN needle) SYRINGE/U- 100/0.3ML/31G X 5/16" HEALTHWISE SHORT RX/OTC F PEN NEEDLES/31G X MISC (insulin 3/16" MISC (insulin pen F syringe/needle u-100) needle) HM ULTICARE MINI PEN RX/OTC NEEDLES/31G X 5MM F (3/16") MISC (insulin pen needle) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
151 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HM ULTICARE SHORT RX/OTC INSULIN RX/OTC PEN NEEDLES 31GX8MM SYRINGE/1ML/28G X 1/2" MISC (insulin pen F MISC (insulin F needle) syringe/needle u-100) INSULIN SYRINGE INSULIN RX/OTC 1ML/31G X1/4" MISC SYRINGE/1ML/29G X 1/2" (insulin syringe/needle F MISC (insulin F u-100) syringe/needle u-100) INSULIN INSULIN RX/OTC SYRINGE/0.3ML/29G X 1" SYRINGE/1ML/30G X MISC (insulin F 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) INSULIN RX/OTC INSULIN RX/OTC SYRINGE/0.3ML/29G X SYRINGE/NEEDLE 1/2" MISC (insulin F 0.3ML/30G X 5/16" MISC F syringe/needle u-100) (insulin syringe/needle INSULIN RX/OTC u-100) SYRINGE/0.3ML/30G X INSULIN 5/16" MISC (insulin F SYRINGE/NEEDLE syringe/needle u-100) 0.3ML/31G X 5/16" MISC F INSULIN (insulin syringe/needle SYRINGE/0.3ML/31G X u-100) 5/16" MISC (insulin F INSULIN RX/OTC syringe/needle u-100) SYRINGE/NEEDLE 0.5ML/29G X 1/2" MISC INSULIN F SYRINGE/0.5ML/27G X (insulin syringe/needle 1/2" MISC (insulin F u-100) syringe/needle u-100) INSULIN RX/OTC SYRINGE/NEEDLE INSULIN RX/OTC 0.5ML/30G X 5/16" MISC SYRINGE/0.5ML/28G X F (insulin syringe/needle 1/2" MISC (insulin F u-100) syringe/needle u-100) INSULIN INSULIN SYRINGE/NEEDLE SYRINGE/0.5ML/30G X F 0.5ML/31G X 5/16" MISC F 1/2" MISC (insulin (insulin syringe/needle syringe/needle u-100) u-100) INSULIN RX/OTC INSULIN RX/OTC SYRINGE/0.5ML/30G X F SYRINGE/NEEDLE 5/16" MISC (insulin 1ML/29G X 1/2" MISC F syringe/needle u-100) (insulin syringe/needle INSULIN u-100) SYRINGE/0.5ML/31G X 5/16" MISC (insulin F syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
152 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN RX/OTC INSULIN SYRINGE/NEEDLE SYRINGES/0.5ML/27GX1/ 1ML/30G X 5/16" MISC F 2" MISC (insulin F (insulin syringe/needle syringe/needle u-100) u-100) INSULIN RX/OTC INSULIN SYRINGES/0.5ML/28GX1/ SYRINGE/NEEDLE 2" MISC (insulin F 1ML/31G X 5/16" MISC F syringe/needle u-100) (insulin syringe/needle INSULIN RX/OTC u-100) SYRINGES/0.5ML/29GX1/ INSULIN SYRINGE/U- RX/OTC 2" MISC (insulin F 100/0.3ML/29G X 1/2" F syringe/needle u-100) MISC (insulin INSULIN RX/OTC syringe/needle u-100) SYRINGES/0.5ML/30GX5/ INSULIN SYRINGE/U- RX/OTC 16" MISC (insulin F 100/0.5ML/29G X 1/2" F syringe/needle u-100) MISC (insulin INSULIN syringe/needle u-100) SYRINGES/0.5ML/31GX INSULIN SYRINGE/U- RX/OTC 5/16" MISC (insulin F 100/1ML/29G X 1/2" MISC F syringe/needle u-100) (insulin syringe/needle INSULIN u-100) SYRINGES/0.5ML/31GX5/ INSULIN SYRINGE/U- RX/OTC 16" MISC (insulin F 100/1ML/30G X 5/16" F syringe/needle u-100) MISC (insulin INSULIN RX/OTC syringe/needle u-100) SYRINGES/1ML/27GX/1/2" INSULIN SYRINGE/U- MISC (insulin F 100/1ML/30G X 5/16" F syringe/needle u-100) MISC (insulin INSULIN RX/OTC syringe/needle u-100) SYRINGES/1ML/27GX1/2" INSULIN SYRINGE/U- MISC (insulin F 100/1ML/31G X 5/16" F syringe/needle u-100) MISC (insulin INSULIN RX/OTC syringe/needle u-100) SYRINGES/1ML/28GX1/2" INSULIN SYRINGES MISC (insulin F 0.3ML/31G X 1/4" MISC F syringe/needle u-100) (insulin syringe/needle INSULIN RX/OTC u-100) SYRINGES/1ML/29GX1/2" INSULIN SYRINGES MISC (insulin F 0.5ML/31G X 1/4" MISC F syringe/needle u-100) (insulin syringe/needle INSULIN u-100) SYRINGES/1ML/30GX1/2" MISC (insulin F syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
153 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN KINRAY INSULIN SYRINGES/1ML/31GX5/16 SYRINGE PREFERRED " MISC (insulin F PLUS/0.3ML/31G X 5/16" F syringe/needle u-100) MISC (insulin INSUPEN 29G X 12MM RX/OTC syringe/needle u-100) MISC (insulin pen F KINRAY INSULIN needle) SYRINGE PREFERRED PLUS/0.5ML/31G X 5/16" INSUPEN 31G X 5MM RX/OTC F MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) KINRAY INSULIN INSUPEN 31G X 8MM RX/OTC SYRINGE PREFERRED MISC (insulin pen F PLUS/1ML/31G X 5/16" F needle) MISC (insulin INSUPEN 32G X 4MM RX/OTC syringe/needle u-100) MISC (insulin pen F KINRAY INSULIN RX/OTC needle) SYRINGE/0.5ML/29G X F INSUPEN 33GX4MM MISC 1/2" MISC (insulin F (insulin pen needle) syringe/needle u-100) INSUPEN PEN NEEDLES RX/OTC KMART VALU PLUS 32G X4MM MISC (insulin F INSULIN pen needle) SYRINGE/0.3ML/30G F MISC (insulin syringes INSUPEN SENSITIVE (disposable)) 32GX6MM MISC (insulin F pen needle) KMART VALU PLUS INSULIN INSUPEN SENSITIVE SYRINGE/0.5ML/29G F 32GX8MM MISC (insulin F MISC (insulin syringes pen needle) (disposable)) INSUPEN ULTRAFIN RX/OTC KMART VALU PLUS 29GX12MM MISC F INSULIN (insulin pen needle) SYRINGE/0.5ML/30G F INSUPEN ULTRAFIN RX/OTC MISC (insulin syringes 30GX8MM MISC (insulin F (disposable)) pen needle) KMART VALU PLUS RX/OTC INSUPEN ULTRAFIN INSULIN 31GX6MM MISC (insulin F SYRINGE/1ML/29G MISC F pen needle) (insulin syringes (disposable)) INSUPEN ULTRAFIN RX/OTC 31GX8MM MISC (insulin F KMART VALU PLUS RX/OTC INSULIN pen needle) SYRINGE/1ML/30G MISC F (insulin syringes (disposable))
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
154 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KROGER INSULIN RX/OTC KROGER PEN NEEDLES SYRINGE/0.3ML/29G X 31GX1/4" MISC ( F insulin F 1/2" MISC (insulin pen needle) syringe/needle u-100) KROGER PEN KROGER INSULIN RX/OTC NEEDLES/31G X1/4" MISC F SYRINGE/0.3ML/30G X ( ) F insulin pen needle 5/16" MISC (insulin KROGER PEN RX/OTC syringe/needle u-100) NEEDLES/31G X3/16" KROGER INSULIN MISC (insulin pen F SYRINGE/0.3ML/31G X ) F needle 5/16" MISC (insulin KROGER PEN RX/OTC syringe/needle u-100) NEEDLES/31G X5/16" KROGER INSULIN RX/OTC MISC (insulin pen F SYRINGE/0.5ML/29G X ) F needle 1/2" MISC (insulin KROGER PEN RX/OTC syringe/needle u-100) NEEDLES/32G X5/32" KROGER INSULIN RX/OTC MISC (insulin pen F SYRINGE/0.5ML/30G X ) F needle 5/16" MISC (insulin KROGER PEN syringe/needle u-100) NEEDLES/33G X5/32" KROGER INSULIN MISC (insulin pen F SYRINGE/0.5ML/31G X ) F needle 5/16" MISC (insulin LEADER INSULIN RX/OTC syringe/needle u-100) SYRINGE/0.3ML/29G X KROGER INSULIN RX/OTC 1/2" MISC (insulin F SYRINGE/1ML/29G X 1/2" ) F syringe/needle u-100 MISC (insulin LEADER INSULIN RX/OTC syringe/needle u-100) SYRINGE/0.3ML/30G X KROGER INSULIN RX/OTC 5/16" MISC (insulin F SYRINGE/1ML/30G X ) F syringe/needle u-100 5/16" MISC (insulin LEADER INSULIN syringe/needle u-100) SYRINGE/0.3ML/31G X KROGER INSULIN 5/16" MISC (insulin F SYRINGE/1ML/31G X ) F syringe/needle u-100 5/16" MISC (insulin LEADER INSULIN RX/OTC syringe/needle u-100) SYRINGE/0.5ML/28G X KROGER PEN NEEDLES RX/OTC 1/2" MISC (insulin F 29G X12MM MISC F syringe/needle u-100) (insulin pen needle) LEADER INSULIN RX/OTC KROGER PEN NEEDLES RX/OTC SYRINGE/0.5ML/29G X 31G X8MM MISC (insulin F 1/2" MISC (insulin F pen needle) syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
155 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEADER INSULIN RX/OTC LEADER UNIFINE RX/OTC SYRINGE/0.5ML/30G X PENTIPS/PLUS/32GX5/32" 5/16" MISC (insulin F MISC (insulin pen F syringe/needle u-100) needle) LEADER INSULIN LITETOUCH INSULIN PEN RX/OTC SYRINGE/0.5ML/31G X NEEDLES/32G X 5/16" MISC (insulin F 4MM/MINI MISC (insulin F syringe/needle u-100) pen needle) LEADER INSULIN RX/OTC LITETOUCH INSULIN RX/OTC SYRINGE/1ML/28G X 1/2" SYRINGE/0.3ML/29G X MISC (insulin F 1/2" MISC (insulin F syringe/needle u-100) syringe/needle u-100) LEADER INSULIN RX/OTC LITETOUCH INSULIN RX/OTC SYRINGE/1ML/29G X 1/2" SYRINGE/0.3ML/30G X MISC (insulin F 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) LEADER INSULIN RX/OTC LITETOUCH INSULIN SYRINGE/1ML/30G X SYRINGE/0.3ML/31G X 5/16" MISC (insulin F 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) LEADER INSULIN LITETOUCH INSULIN RX/OTC SYRINGE/1ML/31G X SYRINGE/0.5ML/30G X 5/16" MISC (insulin F 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) LEADER UNIFINE RX/OTC LITETOUCH INSULIN PENTIPS SYRINGE/0.5ML/31G X PLUS/MINI/31GX3/16" F 5/16" MISC (insulin F MISC (insulin pen syringe/needle u-100) needle) LITETOUCH INSULIN RX/OTC LEADER UNIFINE RX/OTC SYRINGE/1ML/30G X PENTIPS 5/16" MISC (insulin F PLUS/SHORT/31GX5/16" F syringe/needle u-100) MISC (insulin pen LITETOUCH INSULIN RX/OTC needle) SYRINGE/U- LEADER UNIFINE RX/OTC 100/0.3ML/30G X 5/16" F PENTIPS/MINI/31GX3/16" MISC ( F insulin MISC (insulin pen syringe/needle u-100) needle) LITETOUCH INSULIN LEADER UNIFINE RX/OTC SYRINGE/U- PENTIPS/NANO/32GX5/32 100/0.3ML/31G X 5/16" F " MISC (insulin pen F MISC (insulin needle) syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
156 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITETOUCH INSULIN RX/OTC LITETOUCH PEN SYRINGE/U- NEEDLES 31G X 100/0.5ML/28G X 1/2" F 6MM/ULTRA SHORT F MISC (insulin MISC (insulin pen syringe/needle u-100) needle) LITETOUCH INSULIN RX/OTC LITETOUCH PEN RX/OTC SYRINGE/U- NEEDLES 31GX8MM 100/0.5ML/29G X 1/2" F SHORT MISC (insulin F MISC (insulin pen needle) syringe/needle u-100) LITETOUCH PEN RX/OTC LITETOUCH INSULIN RX/OTC NEEDLES/31G X 3/16" SYRINGE/U- MISC (insulin pen F 100/0.5ML/30G X 5/16" F needle) MISC (insulin LITETOUCH PEN RX/OTC syringe/needle u-100) NEEDLES/31G X LITETOUCH INSULIN 5MM/MINI MISC (insulin F SYRINGE/U- pen needle) 100/0.5ML/31G X 5/16" F LITETOUCH PEN RX/OTC MISC (insulin NEEDLES/31G X syringe/needle u-100) 8MM/SHORT MISC F LITETOUCH INSULIN RX/OTC (insulin pen needle) SYRINGE/U-100/1ML/28G F LONGS INSULIN X 1/2" MISC (insulin SYRINGE/0.5ML/31G X syringe/needle u-100) 5/16" MISC (insulin F LITETOUCH INSULIN RX/OTC syringe/needle u-100) SYRINGE/U-100/1ML/29G F MAGELLAN INSULIN RX/OTC X 1/2" MISC (insulin SAFETY SYRINGE/U- syringe/needle u-100) 100/0.3ML/29G X 1/2" F LITETOUCH INSULIN RX/OTC MISC (insulin SYRINGE/U-100/1ML/30G ) F syringe/needle u-100 X 5/16" MISC (insulin MAGELLAN INSULIN RX/OTC syringe/needle u-100) SAFETY SYRINGE/U- LITETOUCH INSULIN 100/0.3ML/30G X 5/16" F SYRINGE/U-100/1ML/31G MISC (insulin X 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) MAGELLAN INSULIN RX/OTC LITETOUCH PEN SAFETY SYRINGE/U- NEEDLES 29GX12.7MM 100/0.5ML/29G X 1/2" F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) LITETOUCH PEN MAGELLAN INSULIN RX/OTC NEEDLES 31G X 6MM SAFETY SYRINGE/U- MISC (insulin pen F 100/0.5ML/30G X 5/16" F needle) MISC (insulin syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
157 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAGELLAN INSULIN RX/OTC MAXICOMFORT INSULIN RX/OTC SAFETY SYRINGE/U- SYRINGES 27G X 1/2" 100/1ML/29G X 1/2" MISC F MISC (insulin F (insulin syringe/needle syringe/needle u-100) u-100) MAXICOMFORT INSULIN MAGELLAN INSULIN RX/OTC SYRINGES 27G X 1/2" SAFETY SYRINGE/U- MISC (insulin F 100/1ML/30G X 5/16" F syringe/needle u-100) MISC (insulin MEDIC INSULIN RX/OTC syringe/needle u-100) SYRINGE/0.3ML/30G X MARATHON MEDICAL RX/OTC 5/16" MISC (insulin F PENTIPS29GX12MM F syringe/needle u-100) MISC (insulin pen MEDIC INSULIN RX/OTC needle) SYRINGE/0.5ML/30G X MARATHON MEDICAL RX/OTC 5/16" MISC (insulin F PENTIPS31GX5MM MISC F syringe/needle u-100) (insulin pen needle) MEDICINE SHOPPE PEN RX/OTC MARATHON MEDICAL RX/OTC NEEDLES 29G X 12MM PENTIPS31GX8MM MISC F MISC (insulin pen F (insulin pen needle) needle) MARATHON MEDICAL RX/OTC MEDICINE SHOPPE PEN PENTIPS32GX4MM MISC F NEEDLES 31G X 6MM (insulin pen needle) MISC (insulin pen F MAXI-COMFORT INSULIN RX/OTC needle) SYRINGE/U- MEDICINE SHOPPE PEN RX/OTC 100/0.5ML/28GX1/2" MISC F NEEDLES 31G X 8MM (insulin syringe/needle MISC (insulin pen F u-100) needle) MAXI-COMFORT INSULIN RX/OTC MEIJER PEN NEEDLES RX/OTC SYRINGE/U- 29G X12MM MISC 100/1ML/28GX1/2" MISC F F ) (insulin syringe/needle (insulin pen needle u-100) MEIJER PEN NEEDLES 31G X6MM MISC ( MAXI-COMFORT SAFETY insulin F PEN NEEDLE/29G X 3/16" pen needle) MISC (insulin pen F MEIJER PEN NEEDLES RX/OTC needle) 31G X8MM MISC (insulin F MAXI-COMFORT SAFETY pen needle) PEN NEEDLE/29G X 5/16" MICRODOT PEN F NEEDLE/31G X 6 MM MISC (insulin pen F needle) MISC (insulin pen MAXICOMFORT II PEN needle) NEEDLES/31G X 1/4" MISC (insulin pen F needle)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
158 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MICRODOT PEN RX/OTC MONOJECT 3ML RX/OTC NEEDLE/32G X 4 MM SYRINGE/STANDARD F HYPODERMIC MISC (insulin pen F needle) NEEDLE/21GX1-1/2" MISC MICRODOT PEN (syringe/needle (disp) 3 NEEDLE/33G X 4 MM ml) MISC (insulin pen F MONOJECT INSULIN RX/OTC SYRINGE/1ML MISC needle) (insulin syringes F MM INSULIN SYRINGE/U- RX/OTC ) 100/0.3ML/30G X 5/16" (disposable) MISC (insulin F MONOJECT INSULIN SYRINGE/1ML/31G X syringe/needle u-100) 5/16" MISC (insulin F MM INSULIN SYRINGE/U- ) 100/0.3ML/31G X 5/16" syringe/needle u-100 MISC (insulin F MONOJECT INSULIN SYRINGE/DETACH syringe/needle u-100) NEEDLE/1ML/25G X 5/8" F MM INSULIN SYRINGE/U- RX/OTC MISC (insulin 100/1/2ML/30G X 5/16" syringe/needle u-100) MISC (insulin F MONOJECT INSULIN RX/OTC syringe/needle u-100) SYRINGE/DETACH MM INSULIN SYRINGE/U- NEEDLE/1ML/27G X 1/2" F 100/1/2ML/31G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) MONOJECT INSULIN RX/OTC MM INSULIN SYRINGE/U- RX/OTC SYRINGE/PERM 100/1ML/30G X 5/16" NEEDLE/1ML/28G X 1/2" F F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) MM INSULIN SYRINGE/U- MONOJECT INSULIN RX/OTC 100/1ML/31G X 5/16" SYRINGE/PERM F MISC (insulin NEEDLE/U-100/0.5ML/28G F syringe/needle u-100) X 1/2" MISC (insulin MM PEN NEEDLES 31G X syringe/needle u-100) 1/4" MISC (insulin pen F MONOJECT INSULIN RX/OTC needle) SYRINGE/SAFETY/PERM MM PEN NEEDLES 31G X RX/OTC NEEDLE/0.3ML/29G X 1/2" F 3/16" MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) MM PEN NEEDLES 31G X RX/OTC MONOJECT INSULIN RX/OTC SYRINGE/SAFETY/PERM 5/16" MISC ( F insulin pen NEEDLE/0.3ML/29GX1/2" F needle) MISC (insulin MM PEN NEEDLES 32G X RX/OTC syringe/needle u-100) 5/32" MISC (insulin pen F needle)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
159 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT INSULIN RX/OTC MONOJECT LIFESHIELD RX/OTC SYRINGE/SAFETY/PERM BLUNTCANNULA/LUER NEEDLE/0.5ML/29G X 1/2" F LOCK SYR/3ML/18G X 1" F MISC (insulin MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) MONOJECT INSULIN RX/OTC MONOJECT MAGELLAN RX/OTC SYRINGE/SAFETY/PERM SYRINGE/SAFETY NEEDLE/1ML/29G X 1/2" F NEEDLE/3ML/20G X 1" F MISC (insulin MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) MONOJECT INSULIN RX/OTC MONOJECT MAGELLAN RX/OTC SYRINGE/SOFTPACK/1M SYRINGE/SAFETY L/27G X 1/2" MISC F NEEDLE/3ML/20G X 1-1/2" F (insulin syringe/needle MISC (syringe/needle u-100) (disp) 3 ml) MONOJECT INSULIN RX/OTC MONOJECT MAGELLAN RX/OTC SYRINGE/SOFTPACK/U- SYRINGE/SAFETY 100/0.5ML/28G X 1/2" F NEEDLE/3ML/21G X 1" F MISC (insulin MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) MONOJECT INSULIN RX/OTC MONOJECT MAGELLAN RX/OTC SYRINGE/U- SYRINGE/SAFETY 100/0.3ML/30G X 5/16" F NEEDLE/3ML/21G X 1-1/2" F MISC (insulin MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) MONOJECT INSULIN RX/OTC MONOJECT MAGELLAN SYRINGE/U- SYRINGE/SAFETY 100/0.5ML/30G X 5/16" F NEEDLE/3ML/22G X 1" F MISC (insulin MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) MONOJECT INSULIN RX/OTC MONOJECT MAGELLAN RX/OTC SYRINGE/U-100/1ML/28G SYRINGE/SAFETY X 1/2" MISC (insulin F NEEDLE/3ML/22G X 1-1/2" F syringe/needle u-100) MISC (syringe/needle MONOJECT INSULIN RX/OTC (disp) 3 ml) SYRINGE/U-100/1ML/30G MONOJECT MAGELLAN RX/OTC X 5/16" MISC (insulin F SYRINGE/SAFETY syringe/needle u-100) NEEDLE/3ML/23G X 1" F MONOJECT INSULIN RX/OTC MISC (syringe/needle SYRINGEREGULAR LUER (disp) 3 ml) TIP/SOFTPACK/1ML MISC F MONOJECT MAGELLAN RX/OTC (insulin syringes SYRINGE/SAFETY (disposable)) NEEDLE/3ML/25G X 1" F MISC (syringe/needle (disp) 3 ml)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
160 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT MAGELLAN RX/OTC MONOJECT RX/OTC SYRINGE/SAFETY SYRINGE/LUER NEEDLE/3ML/25G X 5/8" F LOCK/3ML/27G X 1-1/4" F MISC (syringe/needle MISC (syringe/needle (disp) 3 ml) (disp) 3 ml) MONOJECT RX/OTC MONOJECT RX/OTC SYRINGE/LUER SYRINGE/LUER- LOCK/3ML/20G X 1" MISC F LOCK/3ML/21G X 1" MISC F (syringe/needle (disp) 3 (syringe/needle (disp) 3 ml) ml) MONOJECT RX/OTC MONOJECT RX/OTC SYRINGE/LUER SYRINGE/LUER- LOCK/3ML/20G X 1-1/2" F LOCK/3ML/21G X 1-1/2" F MISC (syringe/needle MISC (syringe/needle (disp) 3 ml) (disp) 3 ml) MONOJECT MONOJECT RX/OTC SYRINGE/LUER SYRINGE/STANDARDHY LOCK/3ML/20G X 3/4" F PODERMIC MISC (syringe/needle NEEDLE/3ML/20GX1" F (disp) 3 ml) MISC (syringe/needle MONOJECT (disp) 3 ml) SYRINGE/LUER MONOJECT RX/OTC LOCK/3ML/22G X 1" MISC F SYRINGE/STANDARDHY (syringe/needle (disp) 3 PODERMIC ml) NEEDLE/3ML/20GX1-1/2" F MONOJECT RX/OTC MISC (syringe/needle SYRINGE/LUER (disp) 3 ml) LOCK/3ML/22G X 1-1/2" F MONOJECT RX/OTC MISC (syringe/needle SYRINGE/STANDARDHY (disp) 3 ml) PODERMIC F MONOJECT RX/OTC NEEDLE/3ML/21GX1" SYRINGE/LUER MISC (syringe/needle LOCK/3ML/23G X 1" MISC F (disp) 3 ml) (syringe/needle (disp) 3 MONOJECT ml) SYRINGE/STANDARDHY PODERMIC MONOJECT RX/OTC F SYRINGE/LUER NEEDLE/3ML/22GX1" LOCK/3ML/25G X 1" MISC F MISC (syringe/needle (syringe/needle (disp) 3 (disp) 3 ml) ml) MONOJECT RX/OTC MONOJECT RX/OTC SYRINGE/STANDARDHY SYRINGE/LUER PODERMIC F LOCK/3ML/25G X 5/8" F NEEDLE/3ML/22GX1-1/2" MISC (syringe/needle MISC (syringe/needle (disp) 3 ml) (disp) 3 ml)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
161 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT RX/OTC MONOJECT ULTRA RX/OTC SYRINGE/STANDARDHY COMFORT INSULIN PODERMIC SYRINGE/0.5ML/28G X F NEEDLE/3ML/23GX1" F 1/2" MISC (insulin MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) MONOJECT ULTRA RX/OTC MONOJECT RX/OTC COMFORT INSULIN SYRINGE/STANDARDHY SYRINGE/0.5ML/29G X F PODERMIC 1/2" MISC ( F insulin NEEDLE/3ML/25GX1" syringe/needle u-100) MISC (syringe/needle MONOJECT ULTRA RX/OTC (disp) 3 ml) COMFORT INSULIN MONOJECT SYRINGE/0.5ML/30G X F SYRINGE/STANDARDHY 5/16" MISC (insulin PODERMIC syringe/needle u-100) NEEDLE/3ML/25GX1-1/4" F MONOJECT ULTRA MISC (syringe/needle COMFORT INSULIN (disp) 3 ml) SYRINGE/0.5ML/31G X F MONOJECT RX/OTC 5/16" MISC (insulin SYRINGE/STANDARDHY syringe/needle u-100) PODERMIC NEEDLE/3ML/25GX5/8" F MONOJECT ULTRA RX/OTC COMFORT INSULIN MISC (syringe/needle SYRINGE/1ML/28G X 1/2" F (disp) 3 ml) MISC (insulin MONOJECT RX/OTC syringe/needle u-100) SYRINGE/STANDARDHY PODERMIC MONOJECT ULTRA RX/OTC NEEDLE/3ML/27GX1-1/4" F COMFORT INSULIN SYRINGE/1ML/29G X 1/2" MISC (syringe/needle F MISC (insulin (disp) 3 ml) syringe/needle u-100) MONOJECT ULTRA RX/OTC COMFORT INSULIN MS INSULIN SYRINGE/0.3ML/31G X SYRINGE/0.3ML/29G X F F 1/2" MISC (insulin 5/16" MISC (insulin syringe/needle u-100) syringe/needle u-100) MONOJECT ULTRA RX/OTC MS INSULIN SYRINGE/0.5ML/31G X COMFORT INSULIN F SYRINGE/0.3ML/30G X F 5/16" MISC (insulin 5/16" MISC (insulin syringe/needle u-100) syringe/needle u-100) MS INSULIN SYRINGE/1ML/31G X MONOJECT ULTRA F COMFORT INSULIN 5/16" MISC (insulin SYRINGE/0.3ML/31G X F syringe/needle u-100) 5/16" MISC (insulin NOVOFINE AUTOCOVER RX/OTC syringe/needle u-100) PEN NEEDLE 30G X 8MM MISC (insulin pen F needle) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
162 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NOVOFINE PEN NEEDLE PEN NEEDLES 31G X RX/OTC 32G X 4MM MISC F 3/16" MISC (insulin pen F (insulin pen needle) needle) NOVOFINE PLUS PEN RX/OTC PEN NEEDLES 31G X RX/OTC NEEDLE32G X 4MM MISC F 5MM MISC (insulin pen F (insulin pen needle) needle) NOVOTWIST PEN RX/OTC PEN NEEDLES 31G X NEEDLE 32GX 5MM MISC F 6MM MISC (insulin pen F (insulin pen needle) needle) PC UNIFINE PENTIPS RX/OTC PEN NEEDLES 31G X RX/OTC 29G X1/2" MISC ( insulin F 8MM MISC (insulin pen F pen needle) needle) PC UNIFINE PENTIPS RX/OTC PEN NEEDLES 31GX5/16" RX/OTC 31G X5MM MINI MISC F (insulin pen needle) MISC (insulin pen F needle) PC UNIFINE PENTIPS 31G X6MM ULTRA PEN NEEDLES 31GX6MM SHORT MISC (insulin F (1/4") MISC (insulin pen F pen needle) needle) PEN NEEDLES 31GX8MM RX/OTC PC UNIFINE PENTIPS RX/OTC F 31G X8MM SHORT MISC F (5/16") MISC (insulin pen needle) (insulin pen needle) PEN NEEDLES 31GX8MM RX/OTC PEN NEEDLES 29G X RX/OTC MISC (insulin pen F 12MM MISC (insulin pen F needle) needle) PEN NEEDLES 32G X RX/OTC PEN NEEDLES 29GX1/2" RX/OTC 4MM MISC (insulin pen F MISC (insulin pen F needle) needle) PEN NEEDLES 32G X RX/OTC PEN NEEDLES RX/OTC 5MM MISC ( 29GX12MM MISC F insulin pen F (insulin pen needle) needle) PEN NEEDLES 30GX5/16" RX/OTC PEN NEEDLES 32G X MISC (insulin pen F 6MM MISC (insulin pen F needle) needle) PEN NEEDLES 30GX5MM PEN NEEDLES 32GX4MM RX/OTC MISC (insulin pen F MISC (insulin pen F needle) needle) PEN NEEDLES 30GX8MM RX/OTC PEN NEEDLES 33G X MISC (insulin pen F 5/32" MISC (insulin pen F needle) needle) PEN NEEDLES 31G X 1/4" PEN NEEDLES/29G X 1/2" RX/OTC SHORT MISC (insulin F MISC (insulin pen F pen needle) needle)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
163 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEN NEEDLES/31G X 1/4" PRECISION SURE-DOSE RX/OTC MISC (insulin pen F INSULIN needle) SYRINGE/0.5ML/28G X F PEN NEEDLES/31G X RX/OTC 1/2" MISC (insulin 3/16" MISC (insulin pen F syringe/needle u-100) needle) PRECISION SURE-DOSE RX/OTC INSULIN PEN NEEDLES/31G X RX/OTC SYRINGE/0.5ML/29G X F 5/16" MISC (insulin pen F 1/2" MISC (insulin needle) syringe/needle u-100) PEN NEEDLES/31G X PRECISION SURE-DOSE 6MM MISC (insulin pen F INSULIN needle) SYRINGE/0.5ML/30G X F PEN NEEDLES/32G X RX/OTC 3/8" MISC (insulin 5/32" MISC (insulin pen F syringe/needle u-100) needle) PRECISION SURE-DOSE RX/OTC PENTIPS 29G X 12MM RX/OTC INSULIN MISC (insulin pen F SYRINGE/1ML/28G X 1/2" F needle) MISC (insulin syringe/needle u-100) PENTIPS 29GX12MM RX/OTC MISC (insulin pen F PRECISION SURE-DOSE RX/OTC PLUSINSULIN needle) SYRINGE/0.3ML/29G X F PENTIPS 31G X 5MM RX/OTC 1/2" MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) PRECISION SURE-DOSE RX/OTC PENTIPS 31G X 8MM RX/OTC PLUSINSULIN MISC (insulin pen F SYRINGE/1ML/29G X 1/2" F needle) MISC (insulin PENTIPS 31GX5MM MISC RX/OTC syringe/needle u-100) F (insulin pen needle) PREFERRED PLUS RX/OTC PENTIPS 31GX6MM MISC INSULIN SYRINGE/U- F 100/0.3ML/29G X 1/2" (insulin pen needle) F MISC (insulin PENTIPS 31GX8MM MISC RX/OTC F syringe/needle u-100) (insulin pen needle) PREFERRED PLUS RX/OTC PENTIPS 32G X 4MM RX/OTC INSULIN SYRINGE/U- MISC (insulin pen F 100/0.3ML/30G X 5/16" F needle) MISC (insulin PENTIPS 32GX4MM MISC RX/OTC syringe/needle u-100) F (insulin pen needle) PREFERRED PLUS RX/OTC PRECISION SURE-DOSE RX/OTC INSULIN SYRINGE/U- INSULIN 100/0.5ML/28G X 1/2" F SYRINGE/0.3ML/30G X F MISC (insulin 5/16" MISC (insulin syringe/needle u-100) syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
164 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREFERRED PLUS RX/OTC PREFERRED PLUS RX/OTC INSULIN SYRINGE/U- UNIFINE 100/0.5ML/29G X 1/2" F PENTIPS/MINI/31GX5MM F MISC (insulin MISC (insulin pen syringe/needle u-100) needle) PREFERRED PLUS RX/OTC PREVENT SAFETY PEN INSULIN SYRINGE/U- NEEDLES 31GX1/4" MISC F 100/0.5ML/30G X 5/16" F (insulin pen needle) MISC (insulin PREVENT SAFETY PEN RX/OTC syringe/needle u-100) NEEDLES 31GX5/16" PREFERRED PLUS RX/OTC MISC (insulin pen F INSULIN SYRINGE/U- needle) 100/1ML/28G X 1/2" MISC F PRO COMFORT INSULIN (insulin syringe/needle SYRINGES/0.5ML/30G X u-100) 1/2" MISC (insulin F PREFERRED PLUS RX/OTC syringe/needle u-100) INSULIN SYRINGE/U- PRO COMFORT INSULIN RX/OTC 100/1ML/29G X 1/2" MISC F SYRINGES/0.5ML/30G X (insulin syringe/needle 5/16" MISC (insulin F u-100) syringe/needle u-100) PREFERRED PLUS RX/OTC PRO COMFORT INSULIN INSULIN SYRINGE/U- SYRINGES/0.5ML/31G X 100/1ML/30G X 5/16" F 5/16" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) PRO COMFORT INSULIN PREFERRED PLUS RX/OTC SYRINGES/1ML/30G X UNIFINE PENTIPS 29G X F F 1/2" MISC (insulin 12MM MISC (insulin pen syringe/needle u-100) needle) PRO COMFORT INSULIN RX/OTC PREFERRED PLUS SYRINGES/1ML/30G X UNIFINE PENTIPS 31G X 5/16" MISC (insulin F 6MM ULTRA SHORT F MISC (insulin pen syringe/needle u-100) needle) PRO COMFORT INSULIN SYRINGES/1ML/31G X PREFERRED PLUS RX/OTC F UNIFINE PENTIPS 31G X 5/16" MISC (insulin 8MM SHORT MISC F syringe/needle u-100) (insulin pen needle) PRO COMFORT PEN RX/OTC NEEDLES/31G X 8MM PREFERRED PLUS RX/OTC F UNIFINE PENTIPS MISC (insulin pen 32GX4MM MISC (insulin F needle) pen needle) PRO COMFORT PEN RX/OTC NEEDLES/32G X 4MM MISC (insulin pen F needle)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
165 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRO COMFORT PEN RX/OTC PX PEN NEEDLE RX/OTC NEEDLES/32G X 5MM 29GX12MM MISC ( F insulin F MISC (insulin pen pen needle) needle) PX PEN NEEDLE RX/OTC PRO COMFORT PEN 31GX8MM MISC (insulin F NEEDLES/32G X 6MM F pen needle) MISC (insulin pen PX SHORTLENGTH PEN RX/OTC needle) NEEDLES/31GX8MM PRODIGY INSULIN MISC (insulin pen F SYRING/U-100/0.3ML/31G F needle) X 5/16" MISC (insulin QC PEN NEEDLES 29G X RX/OTC syringe/needle u-100) 12MM MISC (insulin pen F PRODIGY INSULIN needle) SYRINGE/1/2ML/31G X QC PEN NEEDLES 31G X 5/16" MISC (insulin F 6MM MISC (insulin pen F syringe/needle u-100) needle) PRODIGY INSULIN RX/OTC SYRINGE/1ML/28G X 1/2" QC PEN NEEDLES 31G X RX/OTC MISC (insulin F 8MM MISC (insulin pen F syringe/needle u-100) needle) PURE COMFORT PEN QC UNIFINE PENTIPS RX/OTC NEEDLE 32G X6MM MISC F 32GX4MM MISC (insulin F (insulin pen needle) pen needle) PURE COMFORT PEN RA INSULIN RX/OTC SYRINGE/0.5ML/29G X NEEDLE 32G X8MM MISC F F (insulin pen needle) 1/2" MISC (insulin PURE COMFORT PEN RX/OTC syringe/needle u-100) NEEDLE/32G X 5MM RA INSULIN RX/OTC F SYRINGE/1ML/29G X 1/2" MISC (insulin pen F needle) MISC (insulin PURE COMFORT PEN RX/OTC syringe/needle u-100) NEEDLE/32G X4MM MISC F RA INSULIN SYRINGE/U- RX/OTC 100/0.5ML/30G X 5/16" (insulin pen needle) F PX EXTRA SHORT PEN MISC (insulin NEEDLES 31GX6MM syringe/needle u-100) MISC (insulin pen F RA INSULIN SYRINGE/U- RX/OTC 100/1 ML/30G X 5/16" needle) F PX INSULIN SYRINGE/U- MISC (insulin 100/0.5ML/30G X 1/2" syringe/needle u-100) MISC (insulin F RA PEN NEEDLES 31G X RX/OTC syringe/needle u-100) 5MM3/16" MISC (insulin F PX MINI PEN NEEDLES RX/OTC pen needle) 31GX5MM MISC (insulin F RA PEN NEEDLES 31G X RX/OTC pen needle) 8MM5/16" MISC (insulin F pen needle) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
166 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REALITY INSULIN RX/OTC RELION INSULIN SYRINGE/U- SYRINGE/U- 100/0.5ML/28G X 1/2" F 100/0.5ML/31G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) REALITY INSULIN RX/OTC RELION INSULIN SYRINGE/U- SYRINGE/U-100/1ML/31G 100/0.5ML/29G X 1/2" F X 15/64" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) RELION INSULIN REALITY INSULIN RX/OTC SYRINGE/U-100/1ML/31G SYRINGE/U-100/1ML/28G X 5/16" MISC ( F F insulin X 1/2" MISC (insulin syringe/needle u-100) syringe/needle u-100) RELION MINI PEN REALITY INSULIN RX/OTC NEEDLES 31GX6MM SYRINGE/U-100/1ML/29G MISC ( F F insulin pen X 1/2" MISC (insulin needle) syringe/needle u-100) RELION PEN NEEDLES RX/OTC RELION INSULIN 29GX12MM MISC (insulin F SYRINGE 0.5ML/31G X F pen needle) 15/64" MISC (insulin RELION PEN NEEDLES syringe/needle u-100) 31G X6MM MISC (insulin F RELION INSULIN pen needle) SYRINGE RELION PEN NEEDLES RX/OTC 1ML/31GX15/64" MISC F (insulin syringe/needle 31G X8MM MISC (insulin F u-100) pen needle) RELION INSULIN RX/OTC RELION PEN NEEDLES RX/OTC SYRINGE/U- 31GX5/16" MISC (insulin F 100/0.3ML/31G X 15/64" F pen needle) MISC (insulin RELION PEN NEEDLES syringe/needle u-100) 31GX6MM MISC (insulin F RELION INSULIN pen needle) SYRINGE/U- RELION PEN NEEDLES RX/OTC 100/0.3ML/31G X 5/16" F 31GX8MM MISC (insulin F MISC (insulin pen needle) syringe/needle u-100) RELION PEN NEEDLES RX/OTC RELION INSULIN RX/OTC 32G X4MM MISC (insulin F SYRINGE/U- pen needle) 100/0.5ML/29G X 1/2" F MISC (insulin RELION PEN NEEDLES RX/OTC syringe/needle u-100) 32G X5/32" MISC (insulin F pen needle) RELION PEN NEEDLES RX/OTC 32GX4MM MISC (insulin F pen needle) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
167 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELION PEN SAFESNAP RX/OTC NEEDLES/31G X1/4" SYRINGE/NEEDLE/3ML/2 MISC (insulin pen F 1G X 1-1/2" MISC F needle) (syringe/needle (disp) 3 RELION SHORT PEN RX/OTC ml) NEEDLES31GX8MM MISC F SAFESNAP (insulin pen needle) SYRINGE/NEEDLE/3ML/2 2G X 1" MISC F SAFESNAP INSULIN RX/OTC (syringe/needle (disp) 3 SYRINGE/0.3ML/30G X ml) 5/16" MISC (insulin F SAFESNAP RX/OTC syringe/needle u-100) SYRINGE/NEEDLE/3ML/2 SAFESNAP INSULIN RX/OTC 2G X 1-1/2" MISC F SYRINGE/0.5ML/29G X F (syringe/needle (disp) 3 1/2" MISC (insulin ml) syringe/needle u-100) SAFESNAP RX/OTC SAFESNAP INSULIN RX/OTC SYRINGE/NEEDLE/3ML/2 SYRINGE/0.5ML/30G X 3G X 1" MISC F 5/16" MISC (insulin F (syringe/needle (disp) 3 syringe/needle u-100) ml) SAFESNAP INSULIN RX/OTC SAFESNAP SYRINGE/1ML/28G X 1/2" SYRINGE/NEEDLE/3ML/2 MISC (insulin F 3G X 1-1/2" MISC F syringe/needle u-100) (syringe/needle (disp) 3 ml) SAFESNAP INSULIN RX/OTC SAFESNAP RX/OTC SYRINGE/1ML/29G X 1/2" F SYRINGE/NEEDLE/3ML/2 MISC (insulin 5G X 1" MISC F syringe/needle u-100) (syringe/needle (disp) 3 SAFESNAP RX/OTC ml) SYRINGE/NEEDLE/3ML/2 SAFESNAP RX/OTC 0G X 1" MISC F SYRINGE/NEEDLE/3ML/2 (syringe/needle (disp) 3 5G X 5/8" MISC F ml) (syringe/needle (disp) 3 SAFESNAP RX/OTC ml) SYRINGE/NEEDLE/3ML/2 SAFETY INSULIN RX/OTC 0G X 1-1/2" MISC F SYRINGES (syringe/needle (disp) 3 0.5ML/29GX1/2" MISC F ml) (insulin syringe/needle SAFESNAP RX/OTC u-100) SYRINGE/NEEDLE/3ML/2 SAFETY INSULIN RX/OTC 1G X 1" MISC F SYRINGES (syringe/needle (disp) 3 0.5ML/30GX5/16" MISC ml) F (insulin syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
168 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFETY INSULIN RX/OTC SAFETY RX/OTC SYRINGES 1ML/27GX1/2" SYRINGES/NEEDLE MISC (insulin F 3ML/25GX5/8" MISC F syringe/needle u-100) (syringe/needle (disp) 3 SAFETY INSULIN RX/OTC ml) SYRINGES 1ML/29GX1/2" SAFETY-LOK RX/OTC MISC (insulin F SYRINGE/NEEDLE3ML LUER-LOK 21GX1-1/2" syringe/needle u-100) F MISC (syringe/needle SAFETY INSULIN ) 3 ml) SYRINGES 1ML/30GX1/2" (disp MISC (insulin F SAFETY-LOK SYRINGE/NEEDLE3ML syringe/needle u-100) LUER-LOK 22GX1" MISC F SAFETY RX/OTC (syringe/needle (disp) 3 SYRINGES/NEEDLE ml) 3ML/20GX1" MISC F SAFETY-LOK RX/OTC (syringe/needle (disp) 3 SYRINGE/NEEDLE3ML ml) LUER-LOK 22GX1-1/2" F SAFETY RX/OTC MISC (syringe/needle SYRINGES/NEEDLE (disp) 3 ml) 3ML/20GX1-1/2" MISC F (syringe/needle (disp) 3 SAFETY-LOK RX/OTC ml) SYRINGE/NEEDLE3ML LUER-LOK 23GX1" MISC F SAFETY RX/OTC SYRINGES/NEEDLE (syringe/needle (disp) 3 ml) 3ML/21GX1" MISC F (syringe/needle (disp) 3 SAFETY-LOK RX/OTC ml) SYRINGE/NEEDLE3ML LUER-LOK 25GX5/8" SAFETY RX/OTC F SYRINGES/NEEDLE MISC (syringe/needle 3ML/21GX1-1/2" MISC F (disp) 3 ml) (syringe/needle (disp) 3 SB INSULIN SYRINGE/U- RX/OTC ml) 100/0.5ML/29G X 1/2" F SAFETY MISC (insulin SYRINGES/NEEDLE syringe/needle u-100) 3ML/22GX1" MISC F SB INSULIN SYRINGE/U- RX/OTC (syringe/needle (disp) 3 100/0.5ML/30G X 5/16" ml) MISC (insulin F SAFETY RX/OTC syringe/needle u-100) SYRINGES/NEEDLE SB INSULIN SYRINGE/U- RX/OTC 3ML/22GX1-1/2" MISC F 100/1ML/29G X 1/2" MISC (syringe/needle (disp) 3 (insulin syringe/needle F ml) u-100) SAFETY RX/OTC SYRINGES/NEEDLE SB INSULIN SYRINGE/U- RX/OTC 100/1ML/30G X 5/16" 3ML/23GX1" MISC F F (syringe/needle (disp) 3 MISC (insulin ml) syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
169 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SB INSULIN SYRINGE/U- SECURESAFE RX/OTC 100/1ML/31G X 5/16" SYRINGE/NEEDLE/3ML/2 MISC (insulin F 2G X 1-1/2" MISC F syringe/needle u-100) (syringe/needle (disp) 3 SECURESAFE SAFETY RX/OTC ml) INSULIN SYRINGES/U- SECURESAFE RX/OTC 100/0.5ML/29GX1/2" MISC F SYRINGE/NEEDLE/3ML/2 (insulin syringe/needle 3G X 1" MISC F u-100) (syringe/needle (disp) 3 ml) SECURESAFE SAFETY RX/OTC INSULIN SYRINGES/U- SECURESAFE RX/OTC 100/1ML/29GX1/2" MISC SYRINGE/NEEDLE/3ML/2 F 5G X 5/8" MISC F (insulin syringe/needle (syringe/needle (disp) 3 u-100) ml) SECURESAFE SAFETY RX/OTC SHOPKO UNIFINE RX/OTC PEN NEEDLES/30G X F PENTIPS PEN 5/16" MISC (insulin pen NEEDLES/MICRO/32GX4 F needle) MM MISC (insulin pen SECURESAFE RX/OTC needle) SYRINGE/NEEDLE/3ML/2 SHOPKO UNIFINE RX/OTC 0G X 1" MISC F PENTIPS PEN (syringe/needle (disp) 3 NEEDLES/MINI/31GX5MM F ml) MISC (insulin pen SECURESAFE RX/OTC needle) SYRINGE/NEEDLE/3ML/2 0G X 1-1/2" MISC F SHOPKO UNIFINE RX/OTC PENTIPS PEN (syringe/needle (disp) 3 NEEDLES/ORIGINAL/29G ml) F X12MM MISC (insulin SECURESAFE RX/OTC ) SYRINGE/NEEDLE/3ML/2 pen needle 1G X 1" MISC F SHOPKO UNIFINE RX/OTC (syringe/needle (disp) 3 PENTIPS PEN ml) NEEDLES/SHORT/31GX8 F SECURESAFE RX/OTC MM MISC (insulin pen SYRINGE/NEEDLE/3ML/2 needle) 1G X 1-1/2" MISC F SHOPKO UNIFINE RX/OTC (syringe/needle (disp) 3 PENTIPS PLUS PEN ml) NEEDLES/MICRO/REMOV F SECURESAFE R/32GX4MM MISC SYRINGE/NEEDLE/3ML/2 (insulin pen needle) 2G X 1" MISC F SHOPKO UNIFINE RX/OTC (syringe/needle (disp) 3 PENTIPS PLUS PEN ml) NEEDLES/MINI/REMOVE F R/31GX5MM MISC (insulin pen needle)
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170 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SHOPKO UNIFINE RX/OTC SURE COMFORT RX/OTC PENTIPS PLUS PEN INSULIN SYRINGE/U- NEEDLES/REMOVER/29G F 100/0.5ML/29G X 1/2" F X12MM MISC (insulin MISC (insulin pen needle) syringe/needle u-100) SHOPKO UNIFINE RX/OTC SURE COMFORT PENTIPS PLUS PEN INSULIN SYRINGE/U- NEEDLES/SHORT/REMO F 100/0.5ML/30G X 1/2" F VR/31GX8MM MISC MISC (insulin (insulin pen needle) syringe/needle u-100) SURE COMFORT RX/OTC SURE COMFORT RX/OTC INSULIN SYRINGE/U- INSULIN SYRINGE/U- 100/0.3ML/29G X 1/2" F 100/0.5ML/30G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) SURE COMFORT SURE COMFORT INSULIN SYRINGE/U- INSULIN SYRINGE/U- 100/0.3ML/30G X 1/2" F 100/0.5ML/31G X 5/16 F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) SURE COMFORT RX/OTC SURE COMFORT RX/OTC INSULIN SYRINGE/U- INSULIN SYRINGE/U- 100/0.3ML/30G X 5/16" F 100/1ML/28G X 1/2" MISC F MISC (insulin (insulin syringe/needle syringe/needle u-100) u-100) SURE COMFORT SURE COMFORT RX/OTC INSULIN SYRINGE/U- INSULIN SYRINGE/U- 100/0.3ML/31G X 5/16 F 100/1ML/29G X 1/2" MISC F MISC (insulin (insulin syringe/needle syringe/needle u-100) u-100) SURE COMFORT SURE COMFORT INSULIN SYRINGE/U- INSULIN SYRINGE/U- 100/0.3ML/31G X 5/16" F 100/1ML/30G X 1/2" MISC F MISC (insulin (insulin syringe/needle syringe/needle u-100) u-100) SURE COMFORT SURE COMFORT RX/OTC INSULIN SYRINGE/U- INSULIN SYRINGE/U- 100/0.3ML/31GX1/4" MISC F 100/1ML/30G X 5/16" F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) SURE COMFORT RX/OTC SURE COMFORT INSULIN SYRINGE/U- INSULIN SYRINGE/U- 100/0.5ML/28G X 1/2" F 100/1ML/31G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100)
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171 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE COMFORT SURE-JECT INSULIN RX/OTC INSULIN SYRINGE/U- SYRINGES/0.5ML/31G X F 100/0.3ML/29G X 1/2" F 6MM MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) SURE COMFORT SURE-JECT INSULIN RX/OTC INSULIN SYRINGES/U- SYRINGE/U- 100/1ML/31GX6MM MISC F 100/0.3ML/30G X 5/16" F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) SURE COMFORT PEN SURE-JECT INSULIN NEEDLES29GX1/2" SYRINGE/U- 12.7MM MISC (insulin F 100/0.3ML/31G X 5/16" F pen needle) MISC (insulin SURE COMFORT PEN RX/OTC syringe/needle u-100) NEEDLES30GX5/16" SURE-JECT INSULIN RX/OTC SHORT MISC (insulin F SYRINGE/U- pen needle) 100/0.5ML/28G X 1/2" F SURE COMFORT PEN RX/OTC MISC (insulin NEEDLES31GX3/16" syringe/needle u-100) F (5MM) MISC (insulin pen SURE-JECT INSULIN RX/OTC needle) SYRINGE/U- SURE COMFORT PEN RX/OTC 100/0.5ML/29G X 1/2" F NEEDLES31GX5/16" MISC (insulin F (8MM) MISC (insulin pen syringe/needle u-100) needle) SURE-JECT INSULIN RX/OTC SURE COMFORT PEN RX/OTC SYRINGE/U- NEEDLES32GX5/32" 100/0.5ML/30G X 5/16" F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) SURE COMFORT PEN SURE-JECT INSULIN NEEDLES32GX6MM MISC F SYRINGE/U- (insulin pen needle) 100/0.5ML/31G X 5/16" F MISC (insulin SURE-FINE PEN NEEDLES 29GX1/2" syringe/needle u-100) 12.7MM MISC (insulin F SURE-JECT INSULIN RX/OTC pen needle) SYRINGE/U-100/1ML/28G X 1/2" MISC (insulin F SURE-FINE PEN RX/OTC NEEDLES 31GX3/16" syringe/needle u-100) 5MM MISC (insulin pen F SURE-JECT INSULIN RX/OTC needle) SYRINGE/U-100/1ML/29G X 1/2" MISC (insulin F SURE-FINE PEN RX/OTC NEEDLES 31GX5/16" syringe/needle u-100) 8MM MISC (insulin pen F needle)
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172 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE-JECT INSULIN RX/OTC SYRINGE/LUER SYRINGE/U-100/1ML/30G LOCK/3ML/22GX1" MISC F X 5/16" MISC (insulin F (syringe/needle (disp) 3 syringe/needle u-100) ml) SURE-JECT INSULIN SYRINGE/LUER RX/OTC LOCK/3ML/22GX1-1/2" SYRINGE/U-100/1ML/31G F X 5/16" MISC (insulin F MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) SYRINGE/LUER RX/OTC SYRINGE/LUER RX/OTC LOCK/3ML/20G X 1" MISC LOCK/3ML/23G X 1" MISC F F (syringe/needle (disp) 3 (syringe/needle (disp) 3 ml) ml) SYRINGE/LUER RX/OTC SYRINGE/LUER LOCK/3ML/23G X 1-1/2" LOCK/3ML/20G X 1-1/2" F MISC (syringe/needle F MISC (syringe/needle (disp) 3 ml) (disp) 3 ml) SYRINGE/LUER RX/OTC SYRINGE/LUER RX/OTC LOCK/3ML/23GX1" MISC LOCK/3ML/20GX1-1/2" F MISC (syringe/needle F (syringe/needle (disp) 3 (disp) 3 ml) ml) SYRINGE/LUER RX/OTC SYRINGE/LUER RX/OTC LOCK/3ML/21G X 1" MISC LOCK/3ML/25G X 1" MISC F F (syringe/needle (disp) 3 (syringe/needle (disp) 3 ml) ml) SYRINGE/LUER RX/OTC SYRINGE/LUER LOCK/3ML/25G X 1-1/2" LOCK/3ML/21G X 1-1/2" F MISC (syringe/needle F MISC (syringe/needle (disp) 3 ml) (disp) 3 ml) SYRINGE/LUER RX/OTC SYRINGE/LUER RX/OTC LOCK/3ML/21GX1" MISC LOCK/3ML/25G X 5/8" F F (syringe/needle (disp) 3 MISC (syringe/needle ml) (disp) 3 ml) SYRINGE/LUER RX/OTC SYRINGE/LUER RX/OTC LOCK/3ML/25GX1" MISC LOCK/3ML/21GX1-1/2" F MISC (syringe/needle F (syringe/needle (disp) 3 (disp) 3 ml) ml) SYRINGE/LUER SYRINGE/LUER RX/OTC LOCK/3ML/22G X 1" MISC LOCK/3ML/25GX5/8" MISC F F (syringe/needle (disp) 3 (syringe/needle (disp) 3 ml) ml) SYRINGE/LUER RX/OTC SYRINGES/LUER RX/OTC LOCK/1ML/20GX1" MISC LOCK/3ML/22G X 1-1/2" F MISC (syringe/needle F (syringe/needle (disp) 3 ml) (disp) 3 ml)
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173 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TECHLITE INSULIN RX/OTC TECHLITE INSULIN SYRINGEU- SYRINGEU- 100/0.3ML/29G X 1/2" F 100/0.5ML/31G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) TECHLITE INSULIN TECHLITE INSULIN RX/OTC SYRINGEU- SYRINGEU-100/1ML/29G 100/0.3ML/30G X 1/2" F X 1/2" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) TECHLITE INSULIN TECHLITE INSULIN RX/OTC SYRINGEU-100/1ML/30G SYRINGEU- X 1/2" MISC (insulin F 100/0.3ML/30G X 5/16" F syringe/needle u-100) MISC (insulin TECHLITE INSULIN RX/OTC syringe/needle u-100) SYRINGEU-100/1ML/30G TECHLITE INSULIN RX/OTC X 5/16" MISC (insulin F SYRINGEU- syringe/needle u-100) 100/0.3ML/31G X 15/64" F TECHLITE INSULIN MISC (insulin SYRINGEU-100/1ML/31G syringe/needle u-100) X 15/64" MISC (insulin F TECHLITE INSULIN syringe/needle u-100) SYRINGEU- 100/0.3ML/31G X 5/16" TECHLITE INSULIN F SYRINGEU-100/1ML/31G MISC (insulin X 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) TECHLITE INSULIN RX/OTC SYRINGEU- TECHLITE PEN NEEDLES 29GX 10MM MISC 100/0.5ML/29G X 1/2" F F MISC (insulin (insulin pen needle) syringe/needle u-100) TECHLITE PEN NEEDLES RX/OTC 29GX 12 MM MISC TECHLITE INSULIN F SYRINGEU- (insulin pen needle) 100/0.5ML/30G X 1/2" F TECHLITE PEN NEEDLES RX/OTC MISC (insulin 31GX 5MM MISC (insulin F syringe/needle u-100) pen needle) TECHLITE INSULIN RX/OTC TECHLITE PEN RX/OTC SYRINGEU- NEEDLES/31GX 5MM F 100/0.5ML/30G X 5/16" F MISC (insulin pen MISC (insulin needle) syringe/needle u-100) TECHLITE PEN TECHLITE INSULIN NEEDLES/31GX 6 MM SYRINGEU- MISC (insulin pen F 100/0.5ML/31G X 15/64" F needle) MISC (insulin syringe/needle u-100)
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174 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TECHLITE PEN RX/OTC TOPCARE ULTRA NEEDLES/31GX 8MM COMFORT INSULIN MISC (insulin pen F SYRINGE/0.3ML/31G X F needle) 5/16" MISC (insulin TECHLITE PEN RX/OTC syringe/needle u-100) NEEDLES/32GX 4MM TOPCARE ULTRA RX/OTC MISC (insulin pen F COMFORT INSULIN needle) SYRINGE/0.5ML/30G X F TECHLITE PEN 5/16" MISC (insulin NEEDLES/32GX 6MM syringe/needle u-100) MISC (insulin pen F TOPCARE ULTRA needle) COMFORT INSULIN SYRINGE/0.5ML/31G X TECHLITE PEN F NEEDLES/32GX 8MM 5/16" MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) TOPCARE ULTRA RX/OTC COMFORT INSULIN TODAYS HEALTH MINI SYRINGE/1ML/30G X PEN NEEDLES 31G X 1/4" F 5/16" MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) TOPCARE ULTRA TODAYS HEALTH RX/OTC COMFORT INSULIN ORIGINAL PEN NEEDLES F SYRINGE/1ML/31G X F 29G X 1/2" MISC (insulin 5/16" MISC (insulin pen needle) syringe/needle u-100) TODAYS HEALTH SHORT RX/OTC TOPCARE ULTRA RX/OTC PEN NEEDLES 31G X F COMFORT INSULIN 5/16" MISC (insulin pen SYRINGE/U- needle) 100/0.3ML/29G X 1/2" F TOPCARE CLICKFINE MISC (insulin UNIVERSAL PEN EEDLES syringe/needle u-100) F 31GX1/4" MISC (insulin TOPCARE ULTRA RX/OTC pen needle) COMFORT INSULIN SYRINGE/U- TOPCARE CLICKFINE RX/OTC F UNIVERSAL PEN EEDLES 100/0.5ML/29G X 1/2" 31GX5/16" MISC (insulin F MISC (insulin pen needle) syringe/needle u-100) TOPCARE ULTRA RX/OTC TOPCARE ULTRA RX/OTC COMFORT INSULIN COMFORT INSULIN SYRINGE/0.3ML/30G X F SYRINGE/U-100/1ML/29G F 5/16" MISC (insulin X 1/2" MISC (insulin syringe/needle u-100) syringe/needle u-100) TRUE COMFORT INSULIN SYRINGE/0.5ML/31G X 5/16" MISC (insulin F syringe/needle u-100)
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175 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUE COMFORT INSULIN TRUE COMFORT PRO RX/OTC SYRINGE/1ML/31G X PEN NEEDLES 31G X 5/16" MISC (insulin F 5MM MISC (insulin pen F syringe/needle u-100) needle) TRUE COMFORT PEN RX/OTC TRUE COMFORT PRO NEEDLES31G X 5MM PEN NEEDLES 31G X MISC (insulin pen F 6MM MISC (insulin pen F needle) needle) TRUE COMFORT PEN TRUE COMFORT PRO RX/OTC NEEDLES31G X 6MM PEN NEEDLES 31G X MISC (insulin pen F 8MM MISC (insulin pen F needle) needle) TRUE COMFORT PEN RX/OTC TRUE COMFORT PRO RX/OTC NEEDLES32G X 4MM PEN NEEDLES 32G X MISC (insulin pen F 4MM MISC (insulin pen F needle) needle) TRUE COMFORT PRO RX/OTC TRUE COMFORT PRO RX/OTC INSULINSYRINGE/0.5ML/ PEN NEEDLES 32G X 30G X 5/16" MISC F 5MM MISC (insulin pen F (insulin syringe/needle needle) u-100) TRUE COMFORT PRO TRUE COMFORT PRO PEN NEEDLES 32G X INSULINSYRINGE/0.5ML/ 6MM MISC (insulin pen F 31G X 5/16" MISC F needle) (insulin syringe/needle TRUE COMFORT PRO u-100) PEN NEEDLES 33G X TRUE COMFORT PRO RX/OTC 4MM MISC (insulin pen F INSULINSYRINGE/1ML/30 F needle) G X 5/16" MISC (insulin TRUE COMFORT PRO syringe/needle u-100) PEN NEEDLES 33G X TRUE COMFORT PRO 5MM MISC (insulin pen F INSULINSYRINGE/1ML/31 F needle) G X 5/16" MISC (insulin TRUE COMFORT PRO syringe/needle u-100) PEN NEEDLES 33G X TRUE COMFORT PRO 6MM MISC (insulin pen F INSULINSYRINGE/U- needle) 100/0.5ML/30G X 1/2" F TRUEPLUS 5-BEVEL PEN MISC (insulin NEEDLES 29GX12.7MM syringe/needle u-100) MISC (insulin pen F TRUE COMFORT PRO needle) INSULINSYRINGE/U- 100/1ML/30G X 1/2" MISC TRUEPLUS 5-BEVEL PEN RX/OTC F NEEDLES 31GX5MM (insulin syringe/needle MISC (insulin pen F u-100) needle)
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176 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUEPLUS 5-BEVEL PEN TRUEPLUS INSULIN NEEDLES 31GX6MM SYRINGE/U- MISC (insulin pen F 100/0.5ML/31G X 5/16" F needle) MISC (insulin TRUEPLUS 5-BEVEL PEN RX/OTC syringe/needle u-100) NEEDLES 31GX8MM TRUEPLUS INSULIN RX/OTC MISC ( F SYRINGE/U-100/1ML/28G insulin pen F needle) X 1/2" MISC (insulin TRUEPLUS 5-BEVEL PEN RX/OTC syringe/needle u-100) NEEDLES 32GX4MM TRUEPLUS INSULIN RX/OTC MISC ( F SYRINGE/U-100/1ML/29G insulin pen F needle) X 1/2" MISC (insulin TRUEPLUS INSULIN RX/OTC syringe/needle u-100) SYRINGE/U- TRUEPLUS INSULIN RX/OTC 100/0.3ML/29G X 1/2" F SYRINGE/U-100/1ML/30G MISC (insulin X 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) TRUEPLUS INSULIN RX/OTC TRUEPLUS INSULIN SYRINGE/U- SYRINGE/U-100/1ML/31G 100/0.3ML/30G X 5/16" F X 5/16" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) TRUEPLUS PEN RX/OTC TRUEPLUS INSULIN NEEDLES 29GX12MM SYRINGE/U- MISC (insulin pen F 100/0.3ML/31G X 5/16" F needle) MISC (insulin TRUEPLUS PEN RX/OTC syringe/needle u-100) NEEDLES 31GX5MM TRUEPLUS INSULIN RX/OTC MISC (insulin pen F SYRINGE/U- needle) 100/0.5ML/28G X 1/2" F TRUEPLUS PEN MISC (insulin NEEDLES 31GX6MM syringe/needle u-100) MISC (insulin pen F TRUEPLUS INSULIN RX/OTC needle) SYRINGE/U- 100/0.5ML/29G X 1/2" TRUEPLUS PEN RX/OTC F NEEDLES 31GX8MM MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) TRUEPLUS INSULIN RX/OTC SYRINGE/U- TRUEPLUS PEN RX/OTC NEEDLES 32GX4MM 100/0.5ML/30G X 5/16" F F MISC (insulin MISC (insulin pen syringe/needle u-100) needle)
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177 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN RX/OTC ULTICARE INSULIN RX/OTC SAFETY SYRINGE/1ML/29G X 1/2" SYRINGE/0.5ML/29G X F MISC (insulin F 1/2" MISC (insulin syringe/needle u-100) syringe/needle u-100) ULTICARE INSULIN ULTICARE INSULIN RX/OTC SYRINGE/1ML/30G X 1/2" SAFETY MISC (insulin F SYRINGE/1ML/29G X 1/2" F syringe/needle u-100) MISC (insulin ULTICARE INSULIN RX/OTC syringe/needle u-100) SYRINGE/1ML/30G X ULTICARE INSULIN RX/OTC 5/16" MISC (insulin F SYRINGE/0.3ML/29G X F syringe/needle u-100) 1/2" MISC (insulin ULTICARE INSULIN RX/OTC syringe/needle u-100) SYRINGE/SHORT/0.3ML/3 ULTICARE INSULIN 0G X 5/16" MISC (insulin F SYRINGE/0.3ML/30G X F syringe/needle u-100) 1/2" MISC (insulin ULTICARE INSULIN syringe/needle u-100) SYRINGE/SHORT/0.3ML/3 ULTICARE INSULIN RX/OTC 1G X 5/16" MISC (insulin F SYRINGE/0.3ML/30G X F syringe/needle u-100) 5/16" MISC (insulin ULTICARE INSULIN RX/OTC syringe/needle u-100) SYRINGE/SHORT/0.5ML/3 ULTICARE INSULIN RX/OTC 0G X 5/16" MISC (insulin F SYRINGE/0.5ML/28G X F syringe/needle u-100) 1/2" MISC (insulin ULTICARE INSULIN syringe/needle u-100) SYRINGE/SHORT/0.5ML/3 ULTICARE INSULIN RX/OTC 1G X 5/16" MISC (insulin F SYRINGE/0.5ML/29G X F syringe/needle u-100) 1/2" MISC (insulin ULTICARE INSULIN RX/OTC syringe/needle u-100) SYRINGE/SHORT/1ML/30 ULTICARE INSULIN G X 5/16" MISC (insulin F SYRINGE/0.5ML/30G X F syringe/needle u-100) 1/2" MISC (insulin ULTICARE INSULIN syringe/needle u-100) SYRINGE/SHORT/1ML/31 ULTICARE INSULIN RX/OTC G X 5/16" MISC (insulin F SYRINGE/0.5ML/30G X F syringe/needle u-100) 5/16" MISC (insulin ULTICARE INSULIN syringe/needle u-100) SYRINGE/U- ULTICARE INSULIN RX/OTC 100/0.3ML/30G X 1/2" F SYRINGE/1ML/28G X 1/2" MISC ( F insulin MISC (insulin syringe/needle u-100) syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
178 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN ULTICARE MICRO PEN SYRINGE/U- NEEDLES/31G X 1/4" 100/0.3ML/31G X 5/16" F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) ULTICARE MICRO PEN RX/OTC ULTICARE INSULIN NEEDLES/31G X 5/16" SYRINGE/U- MISC (insulin pen F 100/0.5ML/30G X 1/2" F needle) MISC (insulin ULTICARE MICRO PEN RX/OTC syringe/needle u-100) NEEDLES/32G X 4MM ULTICARE INSULIN MISC (insulin pen F SYRINGE/U- needle) 100/0.5ML/31G X 5/16" F ULTICARE MICRO PEN RX/OTC MISC (insulin NEEDLES/32G X 5/32" syringe/needle u-100) MISC (insulin pen F ULTICARE INSULIN needle) SYRINGE/U-100/1ML/30G F ULTICARE MINI PEN X 1/2" MISC (insulin NEEDLES 31GX6MM syringe/needle u-100) MISC (insulin pen F ULTICARE INSULIN needle) SYRINGE/U-100/1ML/31G F ULTICARE MINI PEN X 5/16" MISC (insulin NEEDLES ULTI-FINE IV syringe/needle u-100) MISC (insulin pen F ULTICARE INSULIN needle) SYRINGEULTRAFINE U- 100/0.3ML/31G X 5/16" ULTICARE MINI PEN F NEEDLES/31G X 6MM MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) ULTICARE INSULIN SYRINGEULTRAFINE U- ULTICARE MINI PEN NEEDLES/32G X 1/4" 100/0.5ML/31G X 5/16" F F MISC (insulin MISC (insulin pen syringe/needle u-100) needle) ULTICARE INSULIN ULTICARE MINI PEN SYRINGEULTRAFINE U- NEEDLES31GX6MM MISC F 100/1ML/31G X 5/16" F (insulin pen needle) MISC (insulin ULTICARE MINI SAFETY PENNEEDLES 30G X syringe/needle u-100) F ULTICARE MICRO PEN RX/OTC 3/16" MISC (insulin pen NEEDLES 31G X 8MM needle) MISC (insulin pen F ULTICARE ORIGINAL PEN NEEDLES ULTI-FINE needle) F ULTICARE MICRO PEN RX/OTC MISC (insulin pen NEEDLES 32G X 4MM needle) MISC (insulin pen F needle) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
179 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE PEN NEEDLES RX/OTC ULTIGUARD SAFEPACK 31GX 5MM/MINI MISC F INSULIN SYRINGE (insulin pen needle) 0.3ML/30G X 1/2"/SHARPS F ULTICARE PEN C MISC (insulin NEEDLES/29GX 12.7MM syringe/needle u-100) MISC (insulin pen F ULTIGUARD SAFEPACK needle) INSULIN SYRINGE 1/2ML ULTICARE SHORT PEN RX/OTC 30G X 1/2"/SHARPS C F NEEDLES 31GX8MM MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) ULTIGUARD SAFEPACK ULTICARE SHORT PEN RX/OTC INSULIN SYRINGE 1ML NEEDLES ULTI-FINE IV 30G X 1/2"/SHARPS CON F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) ULTICARE SHORT PEN RX/OTC ULTIGUARD SAFEPACK NEEDLES/31G X 8MM INSULIN SYRINGE 1ML 31G X 5/16"/SHARPS CO MISC (insulin pen F F MISC (insulin needle) syringe/needle u-100) ULTICARE SHORT RX/OTC SAFETY PEN NEEDLES ULTIGUARD SAFEPACK 30G X 5/16" MISC F INSULIN SYRINGE/0.3ML/30G X (insulin pen needle) 1/2"/SHARPS C MISC F ULTICARE SYRINGE/LOW RX/OTC (insulin syringe/needle DEADSPACE/3ML/22G u-100) X1-1/2" MISC F (syringe/needle (disp) 3 ULTIGUARD SAFEPACK ml) INSULIN SYRINGE/0.3ML/31G X ULTICARE U-100 INSULIN 5/16"/SHARPS MISC F SYRINGES/0.3ML/31G X F (insulin syringe/needle 1/4" MISC (insulin u-100) syringe/needle u-100) ULTIGUARD SAFEPACK ULTICARE U-100 INSULIN INSULIN SYRINGES/0.3ML/31G F SYRINGE/0.5ML/30G X X1/4" MISC (insulin 1/2"/SHARPS C MISC F syringe/needle u-100) (insulin syringe/needle ULTICARE U-100 INSULIN u-100) SYRINGES/0.5ML/31G X F ULTIGUARD SAFEPACK RX/OTC 1/4" MISC (insulin MINI PEN NEEDLE/31G X syringe/needle u-100) 3/16"/SHARPS CONTAI F ULTICARE U-100 INSULIN MISC (insulin pen SYRINGES/1ML/31G X needle) 1/4" MISC (insulin F syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
180 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTIGUARD SAFEPACK ULTILET INSULIN RX/OTC PEN NEEDLE/29G X SYRINGE 31X6MM MISC 1/2"/SHARPS F (insulin syringe/needle F CONTAINER MISC u-100) (insulin pen needle) ULTILET INSULIN ULTIGUARD RX/OTC SYRINGE 31X6MM MISC SAFEPACK/MICROPEN (insulin syringe/needle F NEEDLE/32G X 5/32" F u-100) MISC (insulin pen ULTILET INSULIN RX/OTC needle) SYRINGE/0.3ML/30G X ULTIGUARD RX/OTC 8MM MISC (insulin F SAFEPACK/MICROPEN ) NEEDLE/32G X syringe/needle u-100 5/32"/SHARPS CONTA F ULTILET INSULIN SYRINGE/0.3ML/31G X MISC (insulin pen F needle) 8MM MISC (insulin ) ULTIGUARD syringe/needle u-100 SAFEPACK/MINI PEN ULTILET INSULIN RX/OTC SYRINGE/0.5ML/30G X NEEDLE/31G X F 1/4"/SHARPS CONTAIN F 8MM MISC (insulin MISC (insulin pen syringe/needle u-100) needle) ULTILET INSULIN RX/OTC SYRINGE/1ML/30G X ULTIGUARD RX/OTC F SAFEPACK/MINI PEN 8MM MISC (insulin NEEDLE/31G X syringe/needle u-100) F 3/16"/SHARPS CONTAI ULTILET INSULIN MISC (insulin pen SYRINGE/1ML/31G X needle) 8MM MISC (insulin F ULTIGUARD syringe/needle u-100) SAFEPACK/MINI PEN ULTILET INSULIN NEEDLE/32G X SYRINGE/SHORT/0.3ML/3 1/4"/SHARPS CONTAIN F 0G X 12.7MM MISC F MISC (insulin pen (insulin syringe/needle needle) u-100) ULTIGUARD RX/OTC ULTILET INSULIN RX/OTC SAFEPACK/SHORTPEN SYRINGE/SHORT/0.3ML/3 NEEDLE/31G X F 5/16"/SHARPS CONTA F 0G X 5/16" MISC (insulin MISC (insulin pen syringe/needle u-100) needle) ULTILET INSULIN SYRINGE/SHORT/0.3ML/3 ULTIGUARD F SAFEPACK/SYRINGE/NE 1G X 5/16" MISC (insulin EDLE/31G X syringe/needle u-100) 5/16"/SHARPS CONTAIN F ULTILET INSULIN RX/OTC MISC (insulin SYRINGE/SHORT/0.5ML/3 F syringe/needle u-100) 0G X 5/16" MISC (insulin syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
181 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTILET INSULIN ULTILET SHORT PEN RX/OTC SYRINGE/SHORT/0.5ML/3 NEEDLES31GX3/16" MISC F 1G X 5/16" MISC (insulin F (insulin pen needle) syringe/needle u-100) ULTILET U-100 INSULIN ULTILET INSULIN RX/OTC SYRINGES/1ML/31G X SYRINGE/SHORT/1ML/30 6MM MISC (insulin F G X 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) ULTRA COMFORT RX/OTC ULTILET INSULIN INSULIN SYRINGE/U- SYRINGE/SHORT/1ML/31 100/0.3ML/30G X 5/16" F G X 5/16" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) ULTILET INSULIN ULTRA FLO INSULIN PEN RX/OTC SYRINGE/U- NEEDLE 31GX5MM MISC F 100/0.5ML/30G X 1/2" F (insulin pen needle) MISC (insulin ULTRA FLO INSULIN PEN RX/OTC syringe/needle u-100) NEEDLE 32GX4MM MISC F ULTILET INSULIN (insulin pen needle) SYRINGE/U- ULTRA FLO INSULIN PEN 100/0.5ML/31GX6MM F NEEDLE 33GX4MM MISC F MISC (insulin (insulin pen needle) syringe/needle u-100) ULTRA FLO INSULIN PEN RX/OTC ULTILET INSULIN NEEDLES MISC (insulin F SYRINGE/U-100/1ML/30G F pen needle) X 1/2" MISC (insulin ULTRA FLO INSULIN PEN RX/OTC syringe/needle u-100) NEELE 31GX8MM MISC F ULTILET PEN NEEDLE (insulin pen needle) 29GX12.7MM MISC F ULTRA FLO INSULIN RX/OTC (insulin pen needle) SYRINGE 0.3ML/29G X ULTILET PEN NEEDLE RX/OTC 1/2" MISC (insulin F 31GX5MM MISC (insulin F syringe/needle u-100) pen needle) ULTRA FLO INSULIN ULTILET PEN NEEDLE RX/OTC SYRINGE 0.3ML/30GX1/2" F 31GX8MM MISC (insulin F MISC (insulin pen needle) syringe/needle u-100) ULTILET PEN NEEDLE RX/OTC ULTRA FLO INSULIN RX/OTC 32GX4MM MISC (insulin F SYRINGE pen needle) 0.3ML/30GX5/16" MISC F ( ULTILET PEN NEEDLE RX/OTC insulin syringe/needle 32GX4MM/SHORT MISC F u-100) (insulin pen needle) ULTRA FLO INSULIN SYRINGE ULTILET SHORT PEN RX/OTC 0.3ML/31GX5/16" MISC NEEDLES 31GX5/16" F ( MISC (insulin pen F insulin syringe/needle needle) u-100) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
182 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA FLO INSULIN RX/OTC ULTRA FLO INSULIN SYRINGE 0.5ML/29GX1/2" SYRINGE 1ML/31GX5/16" MISC (insulin F MISC (insulin F syringe/needle u-100) syringe/needle u-100) ULTRA FLO INSULIN ULTRA THIN PEN RX/OTC SYRINGE 0.5ML/30GX1/2" NEEDLES 32G X 4MM MISC (insulin F MISC (insulin pen F syringe/needle u-100) needle) ULTRA FLO INSULIN RX/OTC ULTRA-COMFORT RX/OTC SYRINGE INSULIN SYRINGE/U- 0.5ML/30GX5/16" MISC F 100/0.3ML/29G X 1/2" F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) ULTRA FLO INSULIN ULTRA-COMFORT RX/OTC SYRINGE INSULIN SYRINGE/U- 0.5ML/31GX5/16" MISC F 100/0.3ML/30G X 5/16" F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) ULTRA FLO INSULIN ULTRA-COMFORT SYRINGE 1/2 INSULIN SYRINGE/U- UNIT/0.3ML/30GX1/2" F 100/0.3ML/31G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) ULTRA FLO INSULIN RX/OTC ULTRA-COMFORT RX/OTC SYRINGE 1/2 INSULIN SYRINGE/U- UNIT/0.3ML/30GX5/16" F 100/0.5ML/28G X 1/2" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) ULTRA FLO INSULIN ULTRA-COMFORT RX/OTC SYRINGE 1/2 INSULIN SYRINGE/U- UNIT/0.3ML/31GX5/16" F 100/0.5ML/29G X 1/2" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) ULTRA FLO INSULIN RX/OTC ULTRA-COMFORT RX/OTC SYRINGE 1M/29GX1/2" INSULIN SYRINGE/U- F MISC (insulin 100/0.5ML/30G X 5/16" F syringe/needle u-100) MISC (insulin ULTRA FLO INSULIN syringe/needle u-100) SYRINGE 1ML/30GX1/2" ULTRA-COMFORT MISC (insulin F INSULIN SYRINGE/U- syringe/needle u-100) 100/0.5ML/31G X 5/16" F ULTRA FLO INSULIN RX/OTC MISC (insulin SYRINGE 1ML/30GX5/16" syringe/needle u-100) MISC (insulin F syringe/needle u-100)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
183 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA-COMFORT RX/OTC ULTRA-THIN II INSULIN INSULIN SYRINGE/U- SYRINGE SHORT/U- 100/1ML/28G X 1/2" MISC F 100/1ML/31GX5/16" MISC F (insulin syringe/needle (insulin syringe/needle u-100) u-100) ULTRA-COMFORT RX/OTC ULTRA-THIN II INSULIN RX/OTC INSULIN SYRINGE/U- SYRINGE/U- 100/1ML/29G X 1/2" MISC F 100/0.5ML/29GX1/2" MISC F (insulin syringe/needle (insulin syringe/needle u-100) u-100) ULTRA-COMFORT RX/OTC ULTRA-THIN II INSULIN RX/OTC INSULIN SYRINGE/U- SYRINGE/U- 100/1ML/30G X 5/16" F 100/1ML/29GX1/2" MISC F MISC (insulin (insulin syringe/needle syringe/needle u-100) u-100) ULTRA-COMFORT ULTRA-THIN II MINI PEN RX/OTC INSULIN SYRINGE/U- NEEEDLES/31GX3/16" 100/1ML/31G X 5/16" F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) ULTRA-THIN II PEN ULTRA-THIN II INSULIN RX/OTC NEEDLES 29GX1/2" MISC F SYRINGE SHORT/U- (insulin pen needle) 100/0.3ML/30GX5/16" F ULTRA-THIN II PEN RX/OTC MISC (insulin NEEDLES/SHORT/31GX5/ syringe/needle u-100) 16" MISC (insulin pen F ULTRA-THIN II INSULIN needle) SYRINGE SHORT/U- ULTRACARE INSULIN RX/OTC 100/0.3ML/31GX5/16" F SYRINGE/U- MISC (insulin 100/0.3ML/30G X 5/16" F syringe/needle u-100) MISC (insulin ULTRA-THIN II INSULIN RX/OTC syringe/needle u-100) SYRINGE SHORT/U- ULTRACARE INSULIN 100/0.5ML/30GX5/16" F SYRINGE/U- MISC (insulin 100/0.3ML/31G X 5/16" F syringe/needle u-100) MISC (insulin ULTRA-THIN II INSULIN syringe/needle u-100) SYRINGE SHORT/U- ULTRACARE INSULIN 100/0.5ML/31GX5/16" F SYRINGE/U- MISC (insulin 100/0.5ML/30G X 1/2" F syringe/needle u-100) MISC (insulin ULTRA-THIN II INSULIN RX/OTC syringe/needle u-100) SYRINGE SHORT/U- ULTRACARE INSULIN RX/OTC 100/1ML/30GX5/16" MISC F SYRINGE/U- (insulin syringe/needle 100/0.5ML/30G X 5/16" F u-100) MISC (insulin syringe/needle u-100) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
184 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRACARE INSULIN UNIFINE PEN RX/OTC SYRINGE/U- NEEDLE/32G X4MM MISC F 100/0.5ML/31G X 5/16" F (insulin pen needle) MISC (insulin UNIFINE PENTIPS RX/OTC syringe/needle u-100) 29GX12MM MISC (insulin F ULTRACARE INSULIN pen needle) SYRINGE/U-100/1ML/30G F UNIFINE PENTIPS 31G X RX/OTC X 1/2" MISC (insulin 3/16" MISC (insulin pen F syringe/needle u-100) needle) ULTRACARE INSULIN RX/OTC UNIFINE PENTIPS RX/OTC SYRINGE/U-100/1ML/30G F 31GX5MM MISC (insulin F X 5/16" MISC (insulin pen needle) syringe/needle u-100) UNIFINE PENTIPS ULTRACARE INSULIN SYRINGE/U-100/1ML/31G 31GX6MM MISC (insulin F X 5/16" MISC (insulin F pen needle) syringe/needle u-100) UNIFINE PENTIPS RX/OTC ULTRACARE PEN 31GX8MM MISC (insulin F NEEDLES/31G X 1/4" pen needle) MISC (insulin pen F UNIFINE PENTIPS RX/OTC needle) 32GX4MM MISC (insulin F ULTRACARE PEN RX/OTC pen needle) NEEDLES/31G X 3/16" UNIFINE PENTIPS F MISC (insulin pen 32GX6MM MISC (insulin F needle) pen needle) ULTRACARE PEN RX/OTC UNIFINE PENTIPS NEEDLES/31G X 5/16" F 33GX4MM MISC (insulin F MISC (insulin pen pen needle) needle) UNIFINE PENTIPS PLUS RX/OTC ULTRACARE PEN 29GX12MM MISC (insulin F NEEDLES/32G X 1/14" pen needle) MISC (insulin pen F UNIFINE PENTIPS PLUS RX/OTC needle) 31GX5MM MISC (insulin F ULTRACARE PEN RX/OTC pen needle) NEEDLES/32G X 3/16" MISC (insulin pen F UNIFINE PENTIPS PLUS needle) 31GX6MM MISC (insulin F pen needle) ULTRACARE PEN RX/OTC NEEDLES/32G X 5/32" UNIFINE PENTIPS PLUS RX/OTC MISC (insulin pen F 31GX8MM MISC (insulin F needle) pen needle) ULTRACARE PEN UNIFINE PENTIPS PLUS RX/OTC NEEDLES/33G X 5/32" 32GX4MM MISC (insulin F MISC (insulin pen F pen needle) needle)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
185 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNIFINE PENTIPS PLUS VANISHPOINT INSULIN 33GX 5/32" MISC ( SYRINGE/0.5ML/30G X insulin F F pen needle) 1/2" MISC (insulin UNIFINE PENTIPS PLUS syringe/needle u-100) 33GX4MM MISC (insulin F VANISHPOINT INSULIN SYRINGE/0.5ML/30G X pen needle) F UNIFINE PENTIPS 3/16" MISC (insulin PLUS/30GX 3/16" MISC F syringe/needle u-100) (insulin pen needle) VANISHPOINT INSULIN RX/OTC SYRINGE/0.5ML/30G X UNIFINE PENTIPS/30G X F 3/16" MISC (insulin pen F 5/16" MISC (insulin needle) syringe/needle u-100) UNIFINE SAFECONTROL VANISHPOINT INSULIN RX/OTC SYRINGE/1ML/29G X 1/2" PEN NEEDLE/30G X 3/16" F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) UNIFINE SAFECONTROL RX/OTC VANISHPOINT INSULIN SYRINGE/1ML/29G X PEN NEEDLE/30G X 5/16" F MISC (insulin pen F 5/16" MISC (insulin needle) syringe/needle u-100) VALUE HEALTH INSULIN RX/OTC VANISHPOINT INSULIN SYRINGE/1ML/30G X SYRINGE/U- F 100/0.5ML/29G X 1/2" F 3/16" MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) VANISHPOINT INSULIN RX/OTC SYRINGE/1ML/30G X VALUE HEALTH INSULIN RX/OTC F SYRINGE/U-100/1ML/29G 5/16" MISC (insulin X 1/2" MISC (insulin F syringe/needle u-100) syringe/needle u-100) VANISHPOINT SAFETY RX/OTC SYRINGE/3ML/20GX1" VALUMARK PEN RX/OTC F NEEDLES 29GX12MM MISC (syringe/needle MISC (insulin pen F (disp) 3 ml) needle) VANISHPOINT SAFETY RX/OTC SYRINGE/3ML/20GX1-1/2" VALUMARK PEN F NEEDLES 31GX 6MM MISC (syringe/needle MISC (insulin pen F (disp) 3 ml) needle) VANISHPOINT SAFETY RX/OTC SYRINGE/3ML/21GX1" VALUMARK PEN RX/OTC F NEEDLES 31GX 8MM MISC (syringe/needle MISC (insulin pen F (disp) 3 ml) needle) VANISHPOINT SAFETY RX/OTC SYRINGE/3ML/21GX1-1/2" MISC (syringe/needle F (disp) 3 ml)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
186 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VANISHPOINT SAFETY VANISHPOINT RX/OTC SYRINGE/3ML/22GX1" SYRINGE/3ML/21G X 1- MISC (syringe/needle F 1/2" MISC F (disp) 3 ml) (syringe/needle (disp) 3 VANISHPOINT SAFETY RX/OTC ml) SYRINGE/3ML/22GX1-1/2" VANISHPOINT F SYRINGE/3ML/22G X 1" MISC (syringe/needle F (disp) 3 ml) MISC (syringe/needle ) 3 ml) VANISHPOINT SAFETY RX/OTC (disp SYRINGE/3ML/23GX1" VANISHPOINT RX/OTC MISC (syringe/needle F SYRINGE/3ML/22G X 1- 1/2" MISC (disp) 3 ml) F (syringe/needle (disp) 3 VANISHPOINT SAFETY ml) SYRINGE/3ML/23GX1-1/2" F VANISHPOINT RX/OTC MISC (syringe/needle SYRINGE/3ML/23G X 1" (disp) 3 ml) MISC (syringe/needle F VANISHPOINT SAFETY RX/OTC (disp) 3 ml) SYRINGE/3ML/25GX1" F VANISHPOINT MISC (syringe/needle SYRINGE/3ML/23G X 1- (disp) 3 ml) 1/2" MISC F VANISHPOINT SAFETY (syringe/needle (disp) 3 SYRINGE/3ML/25GX1-1/2" ml) F MISC (syringe/needle VANISHPOINT RX/OTC (disp) 3 ml) SYRINGE/3ML/25G X 1" F VANISHPOINT SAFETY RX/OTC MISC (syringe/needle SYRINGE/3ML/25GX5/8" (disp) 3 ml) F MISC (syringe/needle VANISHPOINT (disp) 3 ml) SYRINGE/3ML/25G X 1- VANISHPOINT SAFETY 1/2" MISC F SYRINGE/3ML/27GX1-1/2" (syringe/needle (disp) 3 MISC (syringe/needle F ml) (disp) 3 ml) VANISHPOINT RX/OTC SYRINGE/3ML/25G X 5/8" VANISHPOINT RX/OTC F SYRINGE/3ML/20G X 1" MISC (syringe/needle MISC (syringe/needle F (disp) 3 ml) (disp) 3 ml) VIDA MIA UNIFINE RX/OTC VANISHPOINT RX/OTC PENTIPS32GX4MM MISC F SYRINGE/3ML/20G X 1- (insulin pen needle) 1/2" MISC F VIDA MIA UNIFINE (syringe/needle (disp) 3 PENTIPSMINI 31GX6MM ml) MISC (insulin pen F VANISHPOINT RX/OTC needle) SYRINGE/3ML/21G X 1" MISC (syringe/needle F (disp) 3 ml)
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
187 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIDA MIA UNIFINE RX/OTC ZEVRX INSULIN RX/OTC PENTIPSORIGINAL SYRINGE/1ML/30G X F 29GX12MM MISC 5/16" MISC (insulin F (insulin pen needle) syringe/needle u-100) VIDA MIA UNIPFINE RX/OTC ZEVRX PEN NEEDLES RX/OTC PENTIPSSHORT F 31G X 5MM MISC (insulin F 31GX8MM MISC (insulin pen needle) pen needle) ZEVRX PEN NEEDLES VP INSULIN SYRINGE/U- RX/OTC 31G X 6MM MISC (insulin F 100/0.3ML/29G X 1/2" pen needle) MISC (insulin F ZEVRX PEN NEEDLES RX/OTC syringe/needle u-100) 31G X 8MM MISC (insulin F WEGMANS UNIFINE RX/OTC ) PENTIPS PLUS 32GX4MM pen needle MISC (insulin pen F ZEVRX PEN NEEDLES RX/OTC needle) 32G X 4MM MISC (insulin F ) WEGMANS UNIFINE RX/OTC pen needle PENTIPS Respiratory Therapy Supplies PLUS/MINI/31GX5MM F ACE AEROSOL CLOUD QL(1 ml per MISC (insulin pen ENHANCER MISC 360 days needle) (respiratory therapy F retail); RX/OTC WEGMANS UNIFINE RX/OTC supplies) PENTIPS ACTIVITY POUCH MISC QL(1 ml per PLUS/SHORT/31GX8MM F (respiratory therapy F 360 days MISC (insulin pen supplies) retail); RX/OTC needle) ADULT AEROSOL MASK QL(1 ml per WEGMANS UNIFINE MISC (respiratory F 360 days PENTIPS PLUS/ULTRA retail); RX/OTC SHORT/31GX6MM MISC F therapy supplies) (insulin pen needle) ADULT MASK LARGE QL(1 ml per MISC (respiratory F 360 days ZEVRX INSULIN retail); RX/OTC SYRINGE/0.5ML/30G X therapy supplies) 1/2" MISC (insulin F ADULT MASK MISC QL(1 ml per syringe/needle u-100) (respiratory therapy F 360 days retail); RX/OTC ZEVRX INSULIN RX/OTC supplies) SYRINGE/0.5ML/30G X AEROCHAMBER MINI RX/OTC 5/16" MISC (insulin F AEROSOLCHAMBER F syringe/needle u-100) DEVI (spacer/aerosol- ZEVRX INSULIN holding chambers) SYRINGE/1ML/30G X 1/2" AEROCHAMBER MV RX/OTC F MISC (insulin MISC (spacer/aerosol- F syringe/needle u-100) holding chambers)
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188 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AEROCHAMBER PLUS RX/OTC AEROCHAMBER/FLOWSI RX/OTC FLOW VU MISC GNAL MISC (spacer/aerosol-holding F (spacer/aerosol-holding F chambers) chambers) AEROCHAMBER PLUS RX/OTC AEROTRACH PLUS MISC QL(1 ml per FLOW-VU MISC ( 360 days F respiratory therapy F (spacer/aerosol-holding supplies) retail); RX/OTC chambers) AEROVENT PLUS RX/OTC AEROCHAMBER PLUS RX/OTC HOLDING FLOW-VU/LARGE MASK CHAMBER/COLLAPSIBLE F MISC (spacer/aerosol- F DEVI (spacer/aerosol- holding chambers) holding chambers) AEROCHAMBER PLUS RX/OTC AIRS PEDIATRIC QL(1 ml per FLOW-VU/MASK MISC AEROSOL MASK MISC 360 days (spacer/aerosol-holding F (respiratory therapy F retail); RX/OTC chambers) supplies) AEROCHAMBER PLUS RX/OTC AIRZONE PEAK FLOW QL(2 ea per FLOW-VU/MEDIUM MASK METER DEVI ( 365 days F peak flow F MISC (spacer/aerosol- meter) retail); RX/OTC holding chambers) ALL FLOW 1000 QL(1 ml per AEROCHAMBER PLUS RX/OTC PULMONARY FUNCTION 360 days FLOW-VU/SMALL MASK FILTER MISC F retail); RX/OTC MISC (spacer/aerosol- F (respiratory therapy holding chambers) supplies) AEROCHAMBER Z-STAT RX/OTC ARIAL CHAMBER DEVI RX/OTC PLUS VALVED HOLDING (spacer/aerosol-holding F CHAMBER W/FLOW VU F chambers) MISC (spacer/aerosol- ASSESS FULL RANGE QL(2 ea per holding chambers) PEAK FLOW METER DEVI F 365 days AEROCHAMBER Z-STAT RX/OTC (peak flow meter) retail); RX/OTC PLUS/FLOWSIGNAL MISC F ASSESS LOW RANGE QL(2 ea per (spacer/aerosol-holding PEAK FLOW METER DEVI F 365 days chambers) (peak flow meter) retail); RX/OTC AEROCHAMBER Z-STAT RX/OTC ASSESS PEAK FLOW QL(2 ea per PLUS/LARGE MASK MISC F METER FULL RANGE F 365 days (spacer/aerosol-holding DEVI (peak flow meter) retail); RX/OTC chambers) ASSESS PEAK FLOW QL(2 ea per AEROCHAMBER Z-STAT RX/OTC METER LOW RANGE F 365 days PLUS/MEDIUM MASK retail); RX/OTC F DEVI (peak flow meter) MISC (spacer/aerosol- ASTHMA CHECK METER- QL(2 ea per holding chambers) ZONE SYSTEM DEVI F 365 days AEROCHAMBER Z-STAT RX/OTC (peak flow meter) retail); RX/OTC PLUS/SMALL MASK MISC F ASTHMAMENTOR DEVI QL(2 ea per (spacer/aerosol-holding F 365 days chambers) (peak flow meter) retail); RX/OTC To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
189 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BREATHE EASE QL(1 ml per BREATHERITE RX/OTC NEBULIZER MASK/CHILD 360 days COLLAPSIBLESPACER MISC (respiratory F retail); RX/OTC W/ NEONATE MASK MISC F therapy supplies) (spacer/aerosol-holding BREATHE EASE QL(1 ml per chambers) NEBULIZER 360 days BREATHERITE MISC RX/OTC MASK/INFANT MISC F retail); RX/OTC (spacer/aerosol-holding F (respiratory therapy chambers) supplies) BREATHERITE RIGID RX/OTC BREATHE EASE PEAK QL(2 ea per SPACERW/MASK MISC FLOW METER DEVI F 365 days (spacer/aerosol-holding F (peak flow meter) retail); RX/OTC chambers) BREATHE EASE/LARGE RX/OTC BREATHERITE W/LARGE RX/OTC MASK DEVI MASK MISC F (spacer/aerosol-holding (spacer/aerosol-holding F chambers) chambers) BREATHE EASE/MEDIUM RX/OTC BREATHERITE RX/OTC MASK DEVI W/MEDIUM MASK MISC F (spacer/aerosol-holding (spacer/aerosol-holding F chambers) chambers) BREATHE EASE/SMALL RX/OTC BREATHERITE W/SMALL RX/OTC MASK DEVI MASK MISC F (spacer/aerosol-holding (spacer/aerosol-holding F chambers) chambers) BREATHERITE RX/OTC BUBBLES THE FISH II QL(1 ml per COLLAPSIBLEADULT PEDIATRIC MASK/PVC 360 days SPACER W/MASK MISC F MISC (respiratory F retail); RX/OTC (spacer/aerosol-holding therapy supplies) chambers) CARETOUCH 2 CPAP QL(1 ml per BREATHERITE RX/OTC HOSE HANGER MISC 360 days COLLAPSIBLECHILD (respiratory therapy F retail); RX/OTC SPACER W/MASK MISC F supplies) (spacer/aerosol-holding CARETOUCH CPAP & QL(1 ml per chambers) BIPAP HOSE/6FT MISC 360 days BREATHERITE RX/OTC (respiratory therapy F retail); RX/OTC COLLAPSIBLEINFANT supplies) SPACER W/MASK MISC F (spacer/aerosol-holding CARETOUCH CPAP QL(1 ml per MASK WIPES MISC 360 days chambers) (respiratory therapy F retail); RX/OTC BREATHERITE RX/OTC ) COLLAPSIBLESMALL supplies CHILD SPACER W/MASK F CARETOUCH CPAP QL(1 ml per MISC (spacer/aerosol- NEUTRALIZING PRE- 360 days F retail); RX/OTC holding chambers) WASH MISC (respiratory therapy supplies)
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190 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARETOUCH CPAP TUBE QL(1 ml per CO MONITOR QL(1 ml per CLEANING BRUSH MISC 360 days REPLACEMENT TPIECES 360 days (respiratory therapy F retail); RX/OTC MISC (respiratory F retail); RX/OTC supplies) therapy supplies) CARETOUCH UNIVERSAL QL(1 ml per COMPACT SPACE RX/OTC CPAPFILTERS MISC 360 days CHAMBER/ANTI-STATIC (respiratory therapy F retail); RX/OTC DEVI (spacer/aerosol- F supplies) holding chambers) CLEVER CHOICE ANTI- RX/OTC COMPACT SPACE RX/OTC STATICVALVED CHAMBER/ANTI- HOLDING STATIC/LARGE MASK F CHAMBER/ADULT LARGE F DEVI (spacer/aerosol- DEVI (spacer/aerosol- holding chambers) holding chambers) COMPACT SPACE RX/OTC CLEVER CHOICE ANTI- RX/OTC CHAMBER/ANTI- STATICVALVED STATIC/MEDIUM MASK F HOLDING DEVI ( F spacer/aerosol- CHAMBER/MEDIUM DEVI holding chambers) (spacer/aerosol-holding COMPACT SPACE RX/OTC chambers) CHAMBER/ANTI- CLEVER CHOICE ANTI- RX/OTC STATIC/SMALL MASK F STATICVALVED DEVI (spacer/aerosol- HOLDING holding chambers) CHAMBER/MEDIUM/3 F YEA DEVI EASIVENT MISC RX/OTC (spacer/aerosol-holding (spacer/aerosol-holding F chambers) chambers) CLEVER CHOICE ANTI- RX/OTC EASIVENT/MASK-LARGE RX/OTC STATICVALVED MISC (spacer/aerosol- F HOLDING holding chambers) F CHAMBER/SMALL DEVI EASIVENT/MASK- RX/OTC (spacer/aerosol-holding MEDIUM MISC chambers) (spacer/aerosol-holding F CLEVER CHOICE ANTI- RX/OTC chambers) STATICVALVED EASIVENT/MASK-SMALL RX/OTC HOLDING MISC (spacer/aerosol- F CHAMBER/SMALL F INFANT DEVI holding chambers) (spacer/aerosol-holding EASY FLOW 300 MM QL(1 ml per chambers) HOSE MISC (respiratory F 360 days retail); RX/OTC CLEVER CHOICE PEAK QL(2 ea per therapy supplies) FLOW METER DEVI F 365 days EASY FLOW 400 MM QL(1 ml per (peak flow meter) retail); RX/OTC HOSE MISC (respiratory F 360 days therapy supplies) retail); RX/OTC
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191 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY FLOW AIR NOZZLE QL(1 ml per FLYP HYPERSONIQ QL(1 ml per MISC ( 360 days CARTRIDGE MISC 360 days respiratory F F therapy supplies) retail); RX/OTC (respiratory therapy retail); RX/OTC EASY FLOW HEPA QL(1 ml per supplies) FILTER MISC 360 days FULL KIT NEBULIZER QL(1 ml per (respiratory therapy F retail); RX/OTC SET MISC (respiratory F 360 days supplies) therapy supplies) retail); RX/OTC EBASE CONTROLLER KIT QL(1 ml per HUDSON RCI SEE-THRU QL(1 ml per MISC (respiratory F 360 days AEROSOL MASK 360 days therapy supplies) retail); RX/OTC ELONGATED/ADULT F retail); RX/OTC EFLOW SCF AEROSOL QL(1 ml per MISC (respiratory HEAD MISC (respiratory F 360 days therapy supplies) therapy supplies) retail); RX/OTC INNOSPIRE QL(1 ml per REPLACEMENT FILTER 360 days ELITE DC AUTO QL(1 ml per F retail); RX/OTC ADAPTER MISC 360 days MISC (respiratory (respiratory therapy F retail); RX/OTC therapy supplies) supplies) INSPIRACHAMBER/ANTI- RX/OTC STATIC EQ SPACE CHAMBER RX/OTC VALVED/MOUTHPIECE ANTI-STATIC DEVI F DEVI (spacer/aerosol- (spacer/aerosol-holding F holding chambers) chambers) INSPIRACHAMBER/LARG RX/OTC EQ SPACE CHAMBER RX/OTC ANTI-STATIC/LARGE E DEVI (spacer/aerosol- F MASK DEVI F holding chambers) (spacer/aerosol-holding INSPIRACHAMBER/SOOT RX/OTC chambers) HERMASK/INSPIRAMASK /MEDIUM DEVI EQ SPACE CHAMBER RX/OTC F ANTI-STATIC/MEDIUM (spacer/aerosol-holding MASK DEVI F chambers) (spacer/aerosol-holding INSPIRACHAMBER/SOOT RX/OTC chambers) HERMASK/INSPIRAMASK /SMALL DEVI EQ SPACE CHAMBER RX/OTC F ANTI-STATIC/SMALL (spacer/aerosol-holding MASK DEVI F chambers) (spacer/aerosol-holding INSPIREASE DRUG RX/OTC DELIVERYSYSTEM MISC chambers) F FILTER AIR PP MISC QL(1 ml per (spacer/aerosol-holding (respiratory therapy F 360 days chambers) supplies) retail); RX/OTC INSPIREASE RESERVOIR QL(3 ea per BAGS MISC 180 days retail) FLEXICHAMBER DEVI RX/OTC (spacer/aerosol-holding F (spacer/aerosol-holding F chamber supplies - chambers) bags)
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192 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITEAIRE DEVI RX/OTC MINI WRIGHT PEAK QL(2 ea per (spacer/aerosol-holding F FLOW METER DEVI F 365 days chambers) (peak flow meter) retail); RX/OTC LITETOUCH MASK QL(1 ml per MINI WRIGHT PEAK QL(2 ea per FLOW METER 365 days LARGE MISC 360 days F (respiratory therapy F retail); RX/OTC STANDARD RANGE DEVI retail); RX/OTC supplies) (peak flow meter) LITETOUCH MASK QL(1 ml per MINIELITE FILTER QL(1 ml per MEDIUM MISC 360 days REPLACEMENTS MISC 360 days F retail); RX/OTC (respiratory therapy F retail); RX/OTC (respiratory therapy supplies) supplies) LITETOUCH MASK QL(1 ml per MINIELITE QL(1 ml per SMALL MISC 360 days RECHARGEABLE 360 days BATTERY MISC retail); RX/OTC (respiratory therapy F retail); RX/OTC F supplies) (respiratory therapy supplies) LUNG PERFORMANCE QL(2 ea per PEAK FLOW METER DEVI F 365 days NEBULIZER AIR QL(1 ml per TUBE/PLUGS MISC 360 days (peak flow meter) retail); RX/OTC (respiratory therapy F retail); RX/OTC MICROCHAMBER DEVI RX/OTC supplies) (spacer/aerosol-holding F chambers) NEBULIZER PEDIATRIC QL(1 ml per MASK MISC (respiratory F 360 days MICROCHAMBER MISC RX/OTC therapy supplies) retail); RX/OTC (spacer/aerosol-holding F chambers) NOSE CLIP MISC QL(1 ml per (respiratory therapy F 360 days MICROELITE FILTER QL(1 ml per retail); RX/OTC REPLACEMENTS MISC 360 days supplies) (respiratory therapy F retail); RX/OTC OPTICHAMBER RX/OTC supplies) ADVANTAGE/LARGE MASK MISC F MICROELITE QL(1 ml per (spacer/aerosol-holding RECHARGEABLE 360 days chambers) BATTERY MISC F retail); RX/OTC (respiratory therapy OPTICHAMBER RX/OTC supplies) ADVANTAGE/MEDIUM FACE MASK MISC F MICROLIFE DIGITAL QL(2 ea per (spacer/aerosol-holding PEAK FLOW METER DEVI 365 days F chambers) (peak flow meter) retail); RX/OTC OPTICHAMBER RX/OTC MICROSPACER MISC RX/OTC ADVANTAGE/SMALL (spacer/aerosol-holding F FACE MASK MISC F chambers) (spacer/aerosol-holding MINI WRIGHT AFS PEAK QL(2 ea per chambers) FLOWMETER LOW 365 days F OPTICHAMBER RX/OTC RANGE DEVI (peak flow retail); RX/OTC DIAMOND MISC meter) (spacer/aerosol-holding F chambers)
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193 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OPTICHAMBER RX/OTC PARI BABY CONVERSION QL(1 ml per DIAMOND/LARGEFACE KITSIZE 2 MISC 360 days MASK DEVI F (respiratory therapy F retail); RX/OTC (spacer/aerosol-holding supplies) chambers) PARI BABY CONVERSION QL(1 ml per OPTICHAMBER RX/OTC KITSIZE 3 MISC 360 days DIAMOND/MEDIUM FACE (respiratory therapy F retail); RX/OTC MASK MISC F supplies) (spacer/aerosol-holding PARI ERAPID NEBULIZER QL(1 ml per chambers) HANDSET MISC 360 days OPTICHAMBER RX/OTC (respiratory therapy F retail); RX/OTC DIAMOND/SMALLFACE supplies) MASK MISC F PARI EXPIRATORY QL(1 ml per (spacer/aerosol-holding FILTER VALVE SET DEVI 360 days chambers) (respiratory therapy F retail); RX/OTC OPTICHAMBER FACE RX/OTC supplies) MASK/LARGE MISC PARI MASK SET MISC QL(1 ml per (spacer/aerosol-holding F (respiratory therapy F 360 days chambers) supplies) retail); RX/OTC OPTICHAMBER FACE RX/OTC MASK/MEDIUM MISC PARI SOFT PLASTIC QL(1 ml per ADULT MASK MISC 360 days (spacer/aerosol-holding F (respiratory therapy F retail); RX/OTC chambers) supplies) OPTICHAMBER FACE RX/OTC MASK/SMALL MISC PARI SOFT PLASTIC QL(1 ml per PEDIATRIC MASK MISC 360 days (spacer/aerosol-holding F (respiratory therapy F retail); RX/OTC chambers) supplies) OPTIHALER MDI DRUG RX/OTC DELIVERY SYSTEM DEVI PARI VORTEX ADULT QL(1 ml per F MASK MISC (respiratory F 360 days (spacer/aerosol-holding retail); RX/OTC chambers) therapy supplies) OPTIHALER MISC RX/OTC PEAK A-I-R FLOW METER QL(2 ea per F 365 days (spacer/aerosol-holding F DEVI (peak flow meter) retail); RX/OTC chambers) PEAK AIR PEAK FLOW QL(2 ea per PARI ALTERA QL(1 ml per METERADULT/PEDIATRI 365 days NEBULIZER HANDSET 360 days C DEVI (peak flow F retail); RX/OTC F retail); RX/OTC MISC (respiratory meter) therapy supplies) PEDIATRIC QL(1 ml per PARI BABY CONVERSION QL(1 ml per MOUTHPIECE/DISPOSAB 360 days KITSIZE 1 MISC 360 days LE MISC (respiratory F retail); RX/OTC F retail); RX/OTC (respiratory therapy therapy supplies) supplies) PERSONAL BEST FULL QL(2 ea per RANGE DEVI (peak flow F 365 days meter) retail); RX/OTC
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194 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PERSONAL BEST LOW QL(2 ea per PRO COMFORT INHALER RX/OTC RANGE DEVI (peak flow F 365 days SPACER CHAMBER meter) retail); RX/OTC ADULT MISC F PFLEX MISC QL(1 ml per (spacer/aerosol-holding (respiratory therapy F 360 days chambers) supplies) retail); RX/OTC PRO COMFORT INHALER RX/OTC SPACER CHAMBER PHARMACIST CHOICE QL(1 ml per CHILD MISC NEBULIZER/CPAP/INHAL 360 days F ER CHAMBER MASK retail); RX/OTC (spacer/aerosol-holding WIPES MISC F chambers) (respiratory therapy PRO COMFORT INHALER RX/OTC supplies) SPACER CHAMBER INFANT DEVI F PIKO 1 ELECTRONIC QL(2 ea per F 365 days (spacer/aerosol-holding DEVI (peak flow meter) retail); RX/OTC chambers) PILLOW MASK/ADULT QL(1 ml per PROCARE SPACER RX/OTC MISC (respiratory F 360 days CHAMBER W/ADULT MASK DEVI therapy supplies) retail); RX/OTC F (spacer/aerosol-holding PILLOW MASK/CHILD QL(1 ml per chambers) MISC (respiratory F 360 days retail); RX/OTC PROCARE SPACER RX/OTC therapy supplies) CHAMBER W/CHILD PILLOW QL(1 ml per MASK DEVI F MASK/PEDIATRIC MISC 360 days F (spacer/aerosol-holding (respiratory therapy retail); RX/OTC chambers) supplies) PRONEB ULTRA FILTER QL(1 ml per POCKET CHAMBER DEVI RX/OTC SET MISC (respiratory F 360 days (spacer/aerosol-holding F therapy supplies) retail); RX/OTC chambers) PURE COMFORT PEAK QL(2 ea per POCKET PEAK FLOW QL(2 ea per FLOW METER ADULT F 365 days METER DEVI (peak flow F 365 days DEVI (peak flow meter) retail); RX/OTC retail); RX/OTC meter) PURE COMFORT PEAK QL(2 ea per POCKET SPACER DEVI RX/OTC FLOW METER CHILD F 365 days (spacer/aerosol-holding F DEVI (peak flow meter) retail); RX/OTC chambers) REPLACEMENT AIR QL(1 ml per FILTER MISC 360 days POCKETPEAK PEAK QL(2 ea per F FLOW METER LOW 365 days (respiratory therapy retail); RX/OTC RANGE DEVI (peak flow F retail); RX/OTC supplies) meter) REPLACEMENT FILTERS QL(1 ml per POCKETPEAK PEAK QL(2 ea per MISC (respiratory F 360 days FLOW 365 days therapy supplies) retail); RX/OTC METER/UNIVERSAL F retail); RX/OTC RITEFLO DEVI RX/OTC RANGE 50-720 LPM DEVI (spacer/aerosol-holding F (peak flow meter) chambers)
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195 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAMI THE SEAL QL(1 ml per SOOTHENEB NBL 100 QL(1 ml per REPLACEMENTFILTERS 360 days CHILD MASK MISC 360 days MISC (respiratory F retail); RX/OTC (respiratory therapy F retail); RX/OTC therapy supplies) supplies) SIDESTREAM ADULT QL(1 ml per SOOTHENEB NBL 100 QL(1 ml per FACE MASK MISC 360 days MEDICATION CUP MISC 360 days (respiratory therapy F retail); RX/OTC (respiratory therapy F retail); RX/OTC supplies) supplies) SIDESTREAM PEDIATRIC QL(1 ml per SOOTHENEB NBL 100 QL(1 ml per FACEMASK MISC 360 days MESH CAP MISC 360 days (respiratory therapy F retail); RX/OTC (respiratory therapy F retail); RX/OTC supplies) supplies) SIDESTREAM PEDIATRIC QL(1 ml per SOOTHENEB NBL100 QL(1 ml per FACEMASK/SAMI THE 360 days ADULT MASK MISC 360 days SEAL MISC (respiratory F retail); RX/OTC (respiratory therapy F retail); RX/OTC therapy supplies) supplies) SIDESTREAM PEDIATRIC QL(1 ml per THRESHOLD IMT MISC QL(1 ml per FACEMASK/TUCKER THE 360 days (respiratory therapy F 360 days TURTLE MISC F retail); RX/OTC supplies) retail); RX/OTC (respiratory therapy TRUZONE PEAK FLOW QL(2 ea per supplies) METER DEVI (peak flow F 365 days SIDESTREAM PLUS QL(1 ml per meter) retail); RX/OTC ADULT FACE MASK MISC 360 days TUBING/WING TIP MISC QL(1 ml per (respiratory therapy F retail); RX/OTC (respiratory therapy F 360 days supplies) supplies) retail); RX/OTC SILICONE MASK FOR QL(1 ml per BREATHERITE 360 days VALVED HOLDING RX/OTC CHAMBER DEVI CHAMBER/ADULT MISC F retail); RX/OTC F (respiratory therapy (spacer/aerosol-holding supplies) chambers) SILICONE MASK FOR QL(1 ml per VORTEX VALVED RX/OTC HOLDING CHAMBER BREATHERITE 360 days F CHAMBER/INFANT MISC F retail); RX/OTC DEVI (spacer/aerosol- (respiratory therapy holding chambers) supplies) WATCHHALER DEVI RX/OTC SILICONE MASK FOR QL(1 ml per (spacer/aerosol-holding F BREATHERITE 360 days chambers) CHAMBER/PEDIATRIC F retail); RX/OTC WINDMILL TRAINER QL(1 ml per MISC (respiratory MISC (respiratory F 360 days therapy supplies) therapy supplies) retail); RX/OTC SILICONE MASK FOR QL(1 ml per BREATHRITE 360 days MIGRAINE PRODUCTS - Drugs to Treat Migraine Headaches CHAMBER/ADULT MISC F retail); RX/OTC (respiratory therapy Calcitonin Gene-Related Peptide (CGRP) supplies)
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196 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AIMOVIG SOAJ PA; SP- Limit 2 per 7 F (erenumab-aooe) AcariaHealth sumatriptan succinate days;QL(0.29 F ml daily); AL(At Migraine Combinations soaj sc 4 mg/0.5ml least 12 yrs (Ergotamine W/ Caffeine) F old) MIGERGOT SUPP QL(2 ml per 7 sumatriptan succinate days retail); ergotamine w/ caffeine F F tabs soaj sc 6 mg/0.5ml AL(At least 12 yrs old) Migraine Products Limit 2 per 7 AL(At least 18 dihydroergotamine sumatriptan succinate days;QL(0.29 yrs old) F ml daily); AL(At mesylate soln ij 1 F soct sc 4 mg/0.5ml mg/ml least 12 yrs old) dihydroergotamine AL(At least 18 QL(2 ml per 7 mesylate soln na 4 F yrs old) sumatriptan succinate F days retail); mg/ml soct sc 6 mg/0.5ml AL(At least 12 ERGOMAR SUBL yrs old) F (ergotamine tartrate) QL(2.5 ml per MIGRANAL SOLN AL(At least 18 sumatriptan succinate F 30 days retail); (dihydroergotamine F yrs old) soln sc 6 mg/0.5ml AL(At least 12 yrs old) mesylate) QL(2 ml per 7 Serotonin Agonists sumatriptan succinate F days retail); QL(6 ea per 30 sosy sc 6 mg/0.5ml AL(At least 12 yrs old) almotriptan malate tabs F days retail); AL(At least 12 QL(9 ea per 30 yrs old) sumatriptan succinate tabs or 100 mg, 25 mg, F days retail); QL(6 ea per 30 AL(At least 12 50 mg yrs old) eletriptan hydrobromide F days retail); tabs AL(At least 18 QL(12 ea per yrs old) zolmitriptan soln na 5 F 30 days retail); QL(9 ea per 30 mg AL(At least 12 yrs old) naratriptan hcl tabs F days retail); AL(At least 18 QL(12 ea per yrs old) zolmitriptan tabs or 2.5 F 30 days retail); QL(12 ea per mg AL(At least 18 yrs old) rizatriptan benzoate F 30 days retail); tabs 10 mg, 5 mg AL(At least 6 QL(6 ea per 30 yrs old) zolmitriptan tabs or 5 F days retail); rizatriptan benzoate QL(0.4 ea mg AL(At least 18 F daily); AL(At yrs old) tbdp 10 mg, 5 mg least 6 yrs old) QL(12 ea per zolmitriptan tbdp or 2.5 30 days retail); F QL(6 ea per 30 F sumatriptan soln days retail) mg AL(At least 18 yrs old)
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197 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6 ea per 30 (Calcium Carbonate- zolmitriptan tbdp or 5 F days retail); Cholecalciferol) F mg AL(At least 18 CALCIUM+D3 TABS 15 yrs old) MCG-500 MG (Calcium Carbonate- MINERALS & ELECTROLYTES Cholecalciferol) Calcium CALCIUM/VITAMIN D-3, F OYSTER SHELL (Calcium Carbonate) CALCIUM 500+D CHEW CALCIUM 600 HIGH (Calcium Carbonate- POTENCY, CVS CALCIUM F CARBONATE, HIGH Cholecalciferol) KP F POTENCY CALCIUM CALCIUM 600+D3, LIQUID TABS CALCIUM/D3 CAPS (Calcium Carbonate) (Calcium Carbonate- CALCIUM 600 TABS 600 F Vitamin D) CALCIUM 500 + MG D, CALCIUM 500/D, CALCIUM 500/VITAMIN D, (Calcium Carbonate- CALCIUM 600+D HIGH Cholecalciferol) CALCIUM POTENCY, CALCIUM 500 + D, CALCIUM 500 HIGH POTENCY + +D3, CALCIUM EXTRA VITAMIN D, OYSTER D3, EQ CALCIUM 500+D, SHELL CALCIUM 500+ D, GNP CALCIUM 500 +D3, PX CALCIUM&D, RA F OS-CAL CALCIUM + D3, CALCIUM PLUS VITAMIN OS-CAL EXTRA D3, F D, RA HI CAL, SB OYSCO 500+D, OYSTER CALCIUM + D, SM CALCIUM/D3, OYSTER CALCIUM 600/VITAMIN D, SHELL CALCIUM SUPER CALCIUM 600 + PLUSVITAMIN D, D3, SUPER CALCIUM OYSTER SHELL 600+D 400, SUPER CALCIUM+D, SM CALCIUM 600+D3 400 CALCIUM /VITAMIN D TABS TABS (Calcium Carbonate- (Calcium Carbonate- Vitamin D) CALCIUM F Cholecalciferol) CALCIUM 500+D TABS 200 UNIT- 500+D, HM F 500 MG CALCIUM/VITAMIN D, SM CALCIUM/VITAMIN D (Calcium Carbonate- TABS 200 UNIT-500 MG Vitamin D) CALCIUM 600 + F D, CALCIUM 600+D3 (Calcium Carbonate- TABS 400 UNIT-600 MG Cholecalciferol) CALCIUM F PLUS VITAMIN D TABS 5 (Calcium Carbonate- MCG-500 MG Vitamin D) CALCIUM F 600+D TABS 200 UNIT- (Calcium Carbonate- 600 MG, 400 UNIT-600 MG Cholecalciferol) CALCIUM PLUS VITAMIN D3, KP F (Calcium Citrate) F CALCIUM 600+D CAPS CALCITRATE TABS 500 UNIT-600 MG
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198 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Calcium Citrate-Vitamin D) CALCIUM CHEW 100 CALCITRATE PLUS D, UNIT-500 MG (calcium CALCIUM CITRATE + D, carbonate- F CALCIUM CITRATE+ D, F ) RA CALCIUM CITRATE cholecalciferol CALCIUM CHEW 500 MG PLUS VITAMIN D, SM F CALCIUM CITRATE + D (calcium carbonate) TABS CALCIUM CITRATE (Calcium Citrate-Vitamin D) MALATE/VITAMIN D TABS CALCIUM CITRATE + D3 F (calcium citrate malate- F TABS 200 UNIT-250 MG cholecalciferol) (Calcium Citrate-Vitamin D) CALCIUM CITRATE + F calcium citrate tabs 200 F TABS 200 UNIT-315 MG mg (Calcium Citrate-Vitamin D) calcium citrate-vitamin CALCIUM CITRATE/D3 F d tabs 200 unit-315 mg, F TABS 5 MCG-315 MG 5 mcg-315 mg (Oyster Shell) OYSCO 500, CALCIUM LACTATE TABS OYSTERCAL, RA 648 MG, 750 MG (calcium F OYSTER SHELL F CALCIUM, SB OYSTER lactate) SHELL CALCIUM TABS CALCIUM TABS 200 UNIT- CALCIUM CARBONATE 600 MG (calcium w/ F CHEW 500 MG (calcium F vitamin d) carbonate) CALCIUM/VITAMIN D CAPS (calcium calcium carbonate tabs F 1250 mg, 500 mg, 600 F carbonate- mg cholecalciferol) calcium carbonate- CHEWABLE CALCIUM/D3 WAFR (calcium cholecalciferol caps F F 500 unit-600 mg carbonate- cholecalciferol) calcium carbonate- EQL CALCIUM/VITAMIN D cholecalciferol chew 10 F CAPS 100 UNIT-600 MG mcg-500 mg, 100 unit- (calcium carbonate- F 500 mg cholecalciferol) calcium carbonate- oyster shell tabs F cholecalciferol tabs 200 F unit-500 mg, 5 mcg- PARVA-CAL TABS F 500 mg (calcium-ergocalciferol) calcium carbonate- QC CALCIUM 500MG/D3 vitamin d tabs 125 unit- TABS (calcium- F cholecalciferol) 250 mg, 125 unit-500 F mg, 200 unit-500 mg, 200 unit-600 mg, 400 unit-600 mg
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199 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RA OYSTER SHELL CERALYTE 70 SOLN F CALCIUM/VITAMIN D (oral electrolytes) TABS (calcium F CERASPORT EX1 SOLN F carbonate- (oral electrolytes) ergocalciferol) CERASPORT SOLN 4 RISACAL-D TABS MEQ/L-6 MEQ/L-18 (calcium & phosphorus F MEQ/L-20 MEQ/L (oral F w/ vitamin d) electrolytes) Electrolyte Mixtures DEXTROSE PA (Oral Electrolytes) 5%/ELECTROLYTE #48 ADVANTAGE CARE ORAL VIAFLEX SOLN F ELECTROLYTE (electrolyte-48 in PEDIATRIC, CERALYTE dextrose) 70, CVS ELECTROLYTE DEXTROSE 10%/NACL PA SOLUTION, CVS 0.2% SOLN (dextrose w/ F PEDIATRIC ELECTROLYTE, CVS sodium chloride) PEDIATRIC DEXTROSE 5%/NACL PA ELECTROLYTE FREEZER 0.3% SOLN (dextrose w/ F POPS, GNP PEDIATRIC sodium chloride) ELECTROLYTE, H-E-B ORAL ELECTROLYTE dextrose w/ sodium PA SOLUTION, HM chloride soln 0.2 %-5 PEDIATRIC %, 0.225 %-5 %, 0.33 ELECTROLYTE, ORAL %-5 %, 0.45 %-10 %, F ELECTROLYTE 0.45 %-2.5 %, 0.45 %-5 SOLUTIONFREEZER %, 0.9 %-5 %, 5 %- POPS PEDIATRIC, F ORALYTE, ORALYTE 0.225 % FREEZER POPS, PEDIA DEXTROSE/SODIUM PA VANCE, PEDIATRIC CHLORIDE SOLN ELECTROLYTE, (dextrose w/ sodium F PEDIATRIC chloride) ELECTROLYTE FREEZE ENFAMIL ENFALYTE POPS, PEDIATRIC F ELECTROLYTE FREEZER SOLN (oral electrolytes) POPS, PEDIATRIC HYDRALYTE FREEZER ELECTROLYTE/WITH POPS SOLN (oral F ZINC, PEDIATRIC electrolytes) ELECTROLYTE/ZINC, RA PEDIATRIC HYDRALYTE SOLN 16 ELECTROLYTE, GM/L-20 MEQ/L-45 MEQ/L-45 MEQ/L-90 REHYDRALYTE, SB F PEDIATRIC MEQ/L, 210 MG/250ML- ELECTROLYTE, SM 270 MG/250ML (oral PEDIATRIC electrolytes) ELECTROLYTE SOLN BIOLYTE SOLN ( oral F electrolytes)
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200 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits IONOSOL-MB/DEXTROSE PA NORMOSOL-R SOLN PA F 5% SOLN 3 MEQ/L-3 (electrolyte-r (ph 7.4)) MEQ/L-5 %-20 MEQ/L-22 MEQ/L-23 MEQ/L-25 oral electrolytes soln F MEQ/L, 3 MEQ/L-3 F PLASMA-LYTE A SOLN PA MMOLE/L-5 %-20 MEQ/L- F 22 MEQ/L-23 MEQ/L-25 (electrolyte-a) PLASMA-LYTE-148 SOLN PA MEQ/L (electrolyte-mb F in dextrose) (electrolyte-148) ISOLYTE-P/DEXTROSE PA potassium chloride in PA 5% SOLN (electrolyte-p F dextrose & sodium F in dextrose) chloride soln ISOLYTE-S PH 7.4 SOLN PA PA F potassium chloride in F (electrolyte-s (ph 7.4)) dextrose soln ISOLYTE-S SOLN PA F potassium chloride in PA (electrolyte-s) nacl soln 0.15 %-0.9 %, KCL 0.15%/D5W/NACL PA 0.45 %-20 meq/l, 0.9 F 0.225% SOLN %-20 meq/l, 0.9 %-40 (potassium chloride in F meq/l, 20 meq/l-0.9 % dextrose & sodium POTASSIUM PA chloride) CHLORIDE/DEXTROSE KCL 0.3%/D5W/NACL PA SOLN (potassium F 0.9% SOLN (potassium ) F chloride in dextrose chloride in dextrose & POTASSIUM PA sodium chloride) CHLORIDE/DEXTROSE/L KINDERLYTE PREMAX ACTATED RINGERS F F SOLN (oral electrolytes) SOLN (potassium KINDERLYTE SOLN (oral chloride in d5w lactated F ) electrolytes) ringers POTASSIUM PA lactated ringer's soln PA CHLORIDE/LIDOCAINE 20 mg/100ml-30 HYDROCHLORIDE/SODIU mg/100ml-310 M CHLORIDE SOLN F mg/100ml-600 F (potassium chloride- mg/100ml, 3 meq/l-4 lidocaine-sodium meq/l-28 meq/l-109 chloride) meq/l-130 meq/l POTASSIUM PA NORMOSOL -R SOLN PA CHLORIDE/SODIUM F (electrolyte-r) CHLORIDE SOLN F NORMOSOL-M IN D5W PA (potassium chloride in SOLN (electrolyte-m in F nacl) dextrose) POTASSIUM PA CHLORIDE/SODIUMCHLO NORMOSOL-M/D5W PA RIDE SOLN (potassium F SOLN (electrolyte-m in F chloride in nacl) dextrose)
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201 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ringer's soln F PA (Pot Phosphate Monobasic W/ Sod Phosphate Dibasic Fluoride & Monobasic) PHOSPHA 250 NEUTRAL, F (Sodium Fluoride) PHOSPHO-TRIN 250 FLUORITAB, FLURA- F NEUTRAL, VIRT-PHOS DROPS, NAFRINSE 250 NEUTRAL TABS DROPS SOLN K-PHOS TABS (Sodium Fluoride) F NAFRINSE CHEW (potassium phosphate F ) MONOCAL TABS monobasic (sodium pot phosphate F monofluorophosphate- monobasic w/ sod F calcium carbonate) phosphate dibasic & sodium fluoride chew monobasic tabs 0.25 mg, 0.5 mg, 1 mg, F Potassium 2.2 mg (Potassium Bicarbonate) F RX/OTC EFFER-K TBEF 25 MEQ sodium fluoride soln F 0.5 mg/ml (Potassium Bicarbonate) K- PRIME, KLOR-CON/EF F sodium fluoride tabs F TBEF 0.5 mg, 1 mg (Potassium Chloride Magnesium Microencapsulated Crystals Er) KLOR-CON M10, F (Magnesium Chloride) F KLOR-CON M15, KLOR- MAGDELAY TBEC CON M20 TBCR MAGNESIUM CAPS 400 (Potassium Chloride) MG (magnesium oxide F KLOR-CON 10, KLOR- F (mg supplement)) CON 8 TBCR (Potassium Chloride) magnesium chloride F F tbec or 64 mg KLOR-CON PACK MAGNESIUM EXTRA (Potassium Chloride) STRENGTH CAPS KLOR-CON SPRINKLE F (magnesium oxide (mg F CPCR 10 MEQ supplement)) (Potassium Chloride) QL(1 ea daily) KLOR-CON SPRINKLE F magnesium oxide (mg CPCR 8 MEQ supplement) tabs 400 F K-TAB TBCR 8 MEQ F mg (potassium chloride) MAGNESIUM OXIDE CAPS 400 MG potassium chloride cpcr F (magnesium oxide (mg F or 10 meq QL(1 ea daily) supplement)) potassium chloride cpcr F or 8 meq Phosphate
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202 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits potassium chloride XIAFLEX SOLR PA; SP (collagenase microencapsulated F F crystals er tbcr 10 meq, clostridium 20 meq histolyticum) Immunomodulators potassium chloride F pack or 20 meq REVLIMID CAPS PA; SP- F POTASSIUM CHLORIDE PA (lenalidomide) Caremark;SP SOLN IV 0.4 MEQ/ML, 10 MEQ/100ML, 10 Immunosuppressive Agents MEQ/50ML, 20 (Cyclosporine Modified (For MEQ/100ML, 20 F Microemulsion)) F MEQ/50ML, 40 GENGRAF CAPS MEQ/100ML (potassium (Cyclosporine Modified (For chloride) Microemulsion)) F GENGRAF SOLN potassium chloride soln PA AZASAN TABS iv 10 meq/50ml, 2 F F (azathioprine) meq/ml, 20 meq/50ml, 40 meq/100ml azathioprine tabs or 50 F mg potassium chloride soln F or 10 %, 20 % cyclosporine caps F potassium chloride tbcr F cyclosporine modified or 10 meq, 8 meq (for microemulsion) F Sodium caps LIQUIVIDA HYDRATION PA cyclosporine modified KIT KIT (sodium F (for microemulsion) F chloride) soln PA AL(At least 21 sodium chloride soln ij F everolimus 0.9 %, 2.5 meq/ml (immunosuppressant) F yrs old) sodium chloride soln iv PA tabs 0.45 %, 0.9 %, 3 %, 4 F mycophenolate mofetil F meq/ml, 5 % caps or 250 mg Zinc mycophenolate mofetil F susr or 200 mg/ml (Zinc Sulfate) ORAZINC, F ZINC-220 CAPS mycophenolate mofetil F zinc sulfate caps or 220 F tabs or 500 mg mg mycophenolate sodium F MISCELLANEOUS THERAPEUTIC CLASSES tbec PROGRAF PACK 0.2 MG, PA F Chelating Agents 1 MG (tacrolimus) penicillamine tabs F SANDIMMUNE CAPS 100 MG, 25 MG F Enzymes (cyclosporine)
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203 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SANDIMMUNE SOLN 100 (Sodium Fluoride (Dental)) QL(112 ml per F MG/ML (cyclosporine) CAVAREST, DENTAGEL, F fill retail) SF GEL sirolimus soln F (Sodium Fluoride (Dental)) QL(102 gm per DENTA 5000 PLUS, SF fill retail) sirolimus tabs F 5000 PLUS, SODIUM F FLUORIDE 5000 PLUS, tacrolimus caps F SODIUM FLUORIDE 5000 PPM CREA Potassium Removing Agents (Stannous Fluoride) RX/OTC (Sodium Polystyrene FLUORIDEX DAILY F Sulfonate) KIONEX, SPS F RENEWAL, PERIOMED SUSP CONC sodium polystyrene QL(102 gm per F sodium fluoride (dental) F sulfonate powd crea dt 1.1 % fill retail) sodium polystyrene QL(112 ml per F sodium fluoride (dental) F sulfonate susp gel dt 1.1 % fill retail) Systemic Lupus Erythematosus Agents sodium fluoride (dental) F BENLYSTA SOLR IV 120 PA; SP- soln mt 0.2 % MG, 400 MG F AcariaHealth;S Steroids - Mouth/Throat/Dental (belimumab) P (Triamcinolone Acetonide MOUTH/THROAT/DENTAL AGENTS (Mouth)) ORALONE F DENTAL PASTE PSTE Anesthetics Topical Oral triamcinolone acetonide F FIRST-MOUTHWASH BLM (mouth) pste SUSP (diphenhydramine- Throat Products - Misc. F lidocaine-alum AQUORAL SOLN QL(900 ml per F fill retail); hydroxide-mg (artificial saliva) hydroxide-simeth) RX/OTC BIOTENE DRY MOUTH QL(900 ml per lidocaine hcl (mouth- F MOISTURIZING SPRAY F fill retail); throat) soln 2 % SOLN (artificial saliva) RX/OTC Anti-infectives - Throat CAPHOSOL SOLN QL(900 ml per F F fill retail); clotrimazole troc (artificial saliva) RX/OTC QL(900 ml per nystatin (mouth-throat) F CVS DRY MOUTH SPRAY susp F fill retail); SOLN (artificial saliva) RX/OTC Antiseptics - Mouth/Throat EQL DRY MOUTH ORAL QL(900 ml per (Chlorhexidine Gluconate RINSE SOLN (artificial F fill retail); (Mouth-Throat)) PAROEX, F RX/OTC PERIOGARD SOLN saliva) MOI-STIR SOLN QL(900 ml per chlorhexidine gluconate F F fill retail); (mouth-throat) soln (artificial saliva) RX/OTC Dental Products
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204 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MOUTH KOTE REMINT QL(900 ml per (B-Complex W/ C & Folic QL(1 ea daily); F fill retail); Acid) ACTIVITE, DAVITE, RX/OTC SOLN (artificial saliva) RX/OTC DIALYVITE, FOLIKA-NC, FOLIKA-T, GENICIN VITA- MOUTH KOTE SOLN QL(900 ml per F fill retail); S, LORID, NEPHRONEX, F (artificial saliva) RX/OTC RENA-VITE RX, TRONVITE, VITASURE, NUMOISYN LIQD QL(900 ml per VOL-CARE RX, VP-VITE F fill retail); RX, XVITE TABS (artificial saliva) RX/OTC (B-Complex W/ C & Folic RX/OTC ORAL RELIEF SPRAY QL(900 ml per Acid) MYNEPHROCAPS, FOR DRYMOUTH & fill retail); F MYNEPHRON, RENAL F DISCOMFORT SOLN RX/OTC CAPS, RENO CAPS, (artificial saliva) TRIPHROCAPS, VIRT- CAPS CAPS pilocarpine hcl (oral) F tabs Multiple Vitamins w/ Iron RA DRY MOUTH SOLN QL(900 ml per (Multiple Vitamins W/ Iron) F fill retail); (artificial saliva) DAILY MULTIPLE RX/OTC VITAMINS W/IRON, DAILY XEROSTOMIA RELIEF QL(900 ml per VITAMIN SPRAY SOLN (artificial F fill retail); FORMULA+IRON, DAILY saliva) RX/OTC VITE MULTIVITAMIN/IRON, MULTIVITAMINS DAILY-VITAMIN/IRON, DAILY-VITE/IRON/BETA- B-Complex Vitamins CAROTENE, GNP ONE (B-Complex Vitamins) RA DAILY PLUS IRON, HM ONE DAILY/IRON, MULTI B-COMPLEX, RA B- F COMPLEX WITH B-12 VITAMIN WITH IRON, TABS MULTI-DAYPLUS IRON, MULTI-VITAMINS/IRON, b-complex vitamins F MULTIVITAMIN PLUS caps IRON ADULT, NAT-RUL F b-complex vitamins DAILY-VITE + IRON, F ONCE DAILY/IRON, ONE tabs DAILY B-Complex w/ C MULTIVITAMIN/IRON, (B Complex W/ C) SUPER ONE DAILY B WITH C, VITAMIN B F MULTIVITAMIN/IRON COMPLEX-C CAPS ADULT, ONE-DAILY MULTI-VITAMIN/IRON, b complex w/ c caps F ONE-DAILY/IRON, QC DAILY B-Complex w/ Folic Acid MULTIVITAMINS/IRON, SM MULTIPLE VITAMINS/IRON, STRESS B COMPLEX/IRON, TAB- A-VITE MULTIVITAMIN/IRON, TAB-A-VITE/IRON TABS
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205 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Multiple Vitamins W/ Iron) (Multiple Vitamins W/ QL(1 ea daily); STRESS FORMULA/IRON Minerals) A THRU Z RX/OTC TABS 5 MG-10 MG-10 ADVANCED, A THRU Z MG-12 MCG-18 MG-20 ADVANCED ADULT MG-30 UNIT-45 MCG-100 F FORMULA, A THRU Z MG-400 MCG-500 MG, 5 HIGH POTENCY, A THRU MG-10 MG-12 MCG-15 Z SELECT, A THRU Z MG-20 MG-27 MG-30 SELECT 50+ ADVANCED UNIT-45 MCG-100 MG- FORMULA, A THRU Z 400 MCG-500 MG SELECT 50+ MENS, A THRU Z SELECT multiple vitamins w/ F iron tabs ADVANCED, A THRU Z SELECT TAB-A-VITE ULTIMATEWOMENS, A MULTIVITAMIN/IRON AND THRU Z ULTIMATE BETA-CAROTENE TABS F MENS, ABC PLUS, ABC (multiple vitamins w/ PLUS SENIOR, ABC PLUS iron) SENIOR ADULTS 50+, ANTIOXIDANT Multiple Vitamins w/ Minerals PROTECTION FORMULA, ANTIOXIDANT VITAMINS, B-PLEX PLUS, BIOCEL, BIOTIN PLUS/CALCIUM/VIT D3, CARRAVITE, CENTAVITE A-Z COMPLETE F MULTIVITAMIN/MINERAL S, CENTRAVITES, CENTURY, CENTURY MATURE, CEROVITE ADVANCED FORMULA, CEROVITE SENIOR, CERTA PLUS, COMPANION, COMPETE, COMPLETE, COMPLETE DAILY WITH LUTEIN, COMPLETE ENERGY, COMPLETE SENIOR, COMPLETE WOMENS, CORVITE FREE, CVS DAILY MULTIPLE FOR MEN, CVS DAILY MULTIPLE FOR WOMEN, CVS DAILY MULTIPLE FOR WOMEN 50+, CVS EYE HEALTH & LUTEIN, CVS ONE DAILY ESSENTIAL, CVS ONE DAILY MENS HEALTH FORMULA, CVS ONE DAILY WOMENS FORMULA, CVS To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
206 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPECTRAVITE CENTURY ADULT ADVANCEDFORMULA, FORMULA, GNP CVS SPECTRAVITE MEN, CENTURY ADULTS 50+ CVS SPECTRAVITE MEN SENIOR, GNP CENTURY 50+, CVS SPECTRAVITE CARDIO SENIOR, CVS HEALTHFORMULA, GNP SPECTRAVITE ULTRA CENTURY MATURE HEALTH MENS, CVS FORMULA/WOMEN'S 50+, SPECTRAVITE ULTRA GNP CENTURY WOMENS HEALTH ULTIMATE MENS SENIOR, CVS COMPLETE, GNP SPECTRAVITE WOMEN CENTURY ULTIMATE 50+, CVS WOMENS MENS SENIOR ACTIVE DAILY, DAILY FORMULA, GNP BETIC, DAILY COMBO CENTURY ULTIMATE MULTI VITAMIN, DAILY WOMENS COMPLETE, MENS HEALTH GNP CENTURY FORMULA, DAILY MULTI, ULTIMATE WOMENS DAILY MULTI 50+, DAILY SENIOR FORMULA, GNP MULTIPLE HAIR/SKIN/NAILS, GNP VITAMINS/MINERALS, HEALTHY EYES, GNP DAILY VITAMIN MEGA MULTI FOR MEN, FORMULA+MINERALS, GNP MEGA MULTI FOR DAILY WOMENS HEALTH WOMEN, GNP ONE DAILY FORMULA, DAILY- MAXIMUM, GNP ONE VITAMIN MAXIMUM DAILY MENS HEALTH FORMULA, DIABETES 50+, GNP ONE DAILY HEALTH FORMULA, MENS DIALYVITE 800/ULTRA D, HEALTH/LYCOPENE, DOCTORS CHOICE GNP ONE DAILY MULTIVITAMINS MEN, EQ WOMENS HEALTH 50+, COMPLETE GNP ONE DAILY MULTIVITAMINADULTS WOMENS METABOLISM 50+, EQ ONE DAILY SUPPORT, GNP WOMENS PRO-ACTIVE, THERAPEUTIC-M, HAIR EQL CENTURY, EQL FORMULA EXTRA CENTURY MATURE, EQL STRENGTH, HAIR SKIN CENTURY MATURE MEN AND NAILS FORMULA, 50+, EQL CENTURY HAIR VITAMINS, MATURE WOMEN50+, HAIR/SKIN/NAILS, EQL ONE DAILY MENS HEALTHY EYES, 50+ ADVANCED, EQL HEALTHY EYES/LUTEIN, ONE DAILY MENS HI-KOVITE 2-PART HEALTH FORMULA, EQL FORMULA, HI-POTENCY ONE DAILY WOMENS MULTI-VITAMIN/MINERAL 50+ADVANCED, EQL SUPPLEMENT, HM VISION FORMULA, ANTIOXIDANT VITAMINS, ESSENTIA, ESSENTIAL HM COMPLETE 50+, HM BALANCE, EYE-VITES, COMPLETE WOMEN, HM EYEPROTECT, GERIVITE MENS 50+ ADVANCED COMPLETE, GNP ONEDAILY, HM WOMENS CENTURY, GNP 50+ ADVANCED ONE To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
207 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DAILY, I-VITE, I-VITE MULTIVITAMIN WOMENS, PROTECT, ICAPS MV, KP MYAMULTI, NUTRIFAC ADULTS 50+ DAILY ZX, NUTRITIONAL FORMULA, KP ADULTS SUPPORT FOR YOUR DAILY FORMULA, KP SKIN/HAIR/NAILS, MENS 50+ DAILY OCUTABS, OCUTABS FORMULA, KP MENS VISION FORMULA, DAILY FORMULA, KP OCUTABS/LUTEIN, VISION FORMULA, KP OCUVITE EXTRA, VISION FORMULA OCUVITE EYE + MULTI, W/LUTEIN, KP WOMENS OCUVITE/LUTEIN, ONE 50+ DAILY FORMULA, KP DAILY 50 PLUS, ONE WOMENS DAILY DAILY ADULTS 50+, ONE FORMULA, LYSIPLEX DAILY COMPLETE, ONE PLUS, MACUVITE, DAILY COMPLETE FOR MACUVITE EYE CARE, MEN, ONE DAILY FOR MACUVITE/LUTEIN, MEN 50+ ADVANCED, MAXIMUM DAILY ONE DAILY FOR GREEN, MEDIPLEX MEN/LYCOPENE, ONE PLUS, MEGA VM-80, DAILY FOR WOMEN, ONE MEIJER ADVANCED DAILY FOR WOMEN FORMULA, MEIJER 50+ADVANCED, ONE ADVANCED FORMULA DAILY HEALTHY FOR ADULTS 50+, MENS WEIGHT, ONE DAILY HAIR FORMULA ULTRA HEALTHY MAN, MENS LIFE PACK, WEIGHTADVANCED, ONE MILLTRIUM ADVANCED DAILY MAXIMUM, ONE FORMULA WITH BETA DAILY MENS, ONE DAILY CAROTENE, MILLTRIUM MENS 50+ CARDIO, MILLTRIUM MULTIVITAMIN, ONE SENIOR, MULTI DAILY MENS COMPLETE/IRON, MULTI HEALTH/LYCOPENE, FOR HER, MULTI FOR ONE DAILY HER 50+, MULTI FOR MULTIVITAMIN MEN, ONE HIM, MULTI FOR HIM 50+, DAILY MULTIVITAMIN MULTI-DAY WEIGHT MENS 50+/LYCOPENE, TRIM, MULTI-DAYPLUS ONE DAILY MINERALS, MULTI-LEAN, MULTIVITAMIN WOMEN, MULTI- ONE DAILY VITAMIN/MENOPAUSALF MULTIVITAMIN/IRON- ORMULA, MULTI- FREE, ONE DAILY PLUS VITAMIN/MINERALS, IRON, ONE DAILY PLUS MULTIPLE MINERALS, ONE DAILY VITAMIN/MINERALS/NO WOMENS 50 PLUS, ONE IRON, MULTIPLE DAILY WOMENS 50+, VITAMINS/WOMENS, ONE MULTIVITAMIN ADULTS DAILY/IRON/CALCIUM, 50+, MULTIVITAMIN MEN ONE DAILY/MINERALS, 50+, MULTIVITAMIN ONE-A-DAY TEEN WOMEN 50+, ADVANTAGEFOR HER, MULTIVITAMIN WOMEN OPTIC-VITES, OPTIC- 50+ ADVANCED, VITES WITH LUTEIN, To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
208 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OPTIMUM PMS, ACTIVE ADULT 50+, OSTEOPRIME ULTRA, SUNVITE ADVANCED, PROSIGHT, PX SUPER ADVANCED FORMULA ANTIOXIDANT/A/C/E/SEL MULTIVITAMINS/LYCOPE ENIUM, SUPER AYTINAL NE, PX COMPLETE 50 PLUS, SUPER SENIOR MULTIVITAMINS, AYTINAL FOR PX MENS ACTIVEADULTS, SUPER MULTIVITAMINS, QC MULTIPLE, SUPER NU- HAIR SKIN & NAILS, QC THERA, SUPER THERA MAXIMUM DAILY VITE M, SUPER VITA- MULTIVITAMIN/MULTIMIN MINS, TGT ERAL, QC MENS DAILY MULTIVITAMIN/MULTIMIN MULTIVITAMIN, QC ERAL MULTI-VITE 50 & OVER, ADULTS/LYCOPENE, TGT QC THERIN-M, QC MULTIVITAMIN/MULTIMIN WOMENS DAILY ERAL/ADULT, THERA MULTIVITAMIN, RA VITAL M, THERA VITAL- CENTRAL-VITE MENS M, THERA-MILL M, MATURE, RA CENTRAL- THERABASIC-M, VITE WOMENS MATURE, THERADEX "M", RA ONE DAILY ENERGY THERADEX "M"/BETA FORMULA, RA ONE CAROTENE, DAILY MAXIMUM, RA THERAPEUTIC ONE DAILY MENS 50+ FORMULA/HEMATINICS, WITH VITAMIN D-3, RA THERAPEUTIC M, ONE DAILY MENS MULTI, THERAPEUTIC-M, RA ONE DAILY THERAPEUTIC- MENS/VITAMIND-3, RA M/LUTEIN, THERATRUM ONE DAILY COMPLETE, WOMENS/VITAMIN D-3, THERATRUM COMPLETE RENAPLEX, SAVISION, 50 PLUS, THERAVIM-M, SENIOR TABS, SENTRY THRIVE FOR LIFE ADULTS UNDER 50, SM WOMENS, ULTRA ANTIOXIDANT VITAMINS, ANTIOXIDANT FORMULA, SM COMPLETE, SM ULTRA FREEDA, ULTRA COMPLETE 50+, SM FREEDA/IRON, ULTRA COMPLETE 50+ VITA-TIME, ULTIMATEMENS, SM ULTRACHOICE COMPLETE 50+ ADVANCED FORMULA, ULTIMATEWOMENS, SM ULTRACHOICE COMPLETE ADVANCED ADVANCED FORMULA FORMULA, SM MATURE, VISION COMPLETE SENIOR FORMULA/LUTEIN, FORMULA, SM DAILY VISION VITAMINS, DIET SUPPORT, SM VISIVITES, HAIR/SKIN/NAILS, SM VISIVITES/LUTEIN, VITA OPTI-VITAMINS, STRESS HAIR, VITA S FORTE, B-COMPLEX/C/ZINC, VITABASIC COMPLETE, STRESS FORMULA/ZINC, VITABASIC SENIOR, STRESSTABS VITACEL, VITATRUM ADVANCED, SUNVITE COMPLETE, VITRUM To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
209 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SENIOR, WOMENS DAILY (Multiple Vitamins W/ QL(1 ea daily); FORMULA, WOMENS Minerals) EQ ONE DAILY RX/OTC DAILY FORMULA/FOLIC WOMENS HEALTH TABS ACID/CALCIUM/IRON, 1.5 MG-1.7 MG-2 MG-2 WOMENS LIFE PACK, MG-2 MG-6 MCG-10 MG- F WOMENS MULTIVITAMIN, 15 MG-18 MG-20 MCG-20 WOMENS ONE DAILY, MG-22.5 UNIT-25 MCG-60 YOUR LIFE MULTI MENS MG-120 MCG-150 MCG- 50+, YOUR LIFE MULTI 300 MCG-400 MCG-500 WOMENS 50+ TABS MG-1000 UNIT-2500 UNIT (Multiple Vitamins W/ QL(1 ea daily); (Multiple Vitamins W/ QL(1 ea daily); Minerals) ANTIOXIDANT RX/OTC Minerals) MULTILEX TABS RX/OTC FORMULA TABS 17 MCG- F 0.15 MG-1 MG-1 MG-1.5 53 MG-133 UNIT-167 MG- MG-1.7 MG-3 MCG-5 MG- F 8333 UNIT 5 MG-5.5 UNIT-10 MG-10 (Multiple Vitamins W/ QL(1 ea daily); MG-15 MG-30 MG-100 Minerals) CENTRAVITES RX/OTC MG-400 UNIT-10000 UNIT 50 PLUS TABS 1.5 MG-1.7 (Multiple Vitamins W/ QL(1 ea daily); MG-2 MG-2 MG-3 MG-3.5 Minerals) MULTIVITAMIN RX/OTC MG-4 MG-5 MCG-10 ADULTS TABS 0.5 MG-1.5 MCG-10 MCG-10 MG-15 MG-1.7 MG-2 MG-2 MG- MG-20 MCG-20 MG-25 F 2.3 MG-5 MCG-6 MCG-10 MCG-30 MCG-45 UNIT-48 MCG-10 MCG-10 MCG-10 MG-60 MG-72 MG-80 MG- MG-11 MG-13.5 MG-18 100 MG-130 MCG-150 MG-20 MG-20 MG-25 MCG-150 MCG-160 MCG- MCG-30 MCG-35 MCG-45 200 MG-400 MCG-400 MCG-50 MG-55 MCG-60 UNIT-5000 UNIT MG-72 MG-75 MCG-80 (Multiple Vitamins W/ QL(1 ea daily); MG-150 MCG-200 MG-400 Minerals) RX/OTC MCG-1050 MCG, 0.5 MG- CERTAVITE/ANTIOXIDAN 1.5 MG-1.7 MG-2 MG-2 TS TABS 0.5 MG-1.5 MG- MG-2.3 MG-5 MCG-6 1.7 MG-2 MG-2 MG-2.3 MCG-10 MCG-10 MCG-10 MG-5 MCG-6 MCG-10 MG-11 MG-18 MG-20 MG- F 20 MG-25 MCG-30 MCG- MCG-10 MCG-10 MG-11 F MG-18 MG-20 MG-20 MG- 30 UNIT-35 MCG-45 MCG- 25 MCG-30 MCG-30 UNIT- 50 MG-55 MCG-60 MG-72 35 MCG-45 MCG-50 MG- MG-75 MCG-80 MG-150 55 MCG-60 MG-72 MG-75 MCG-200 MG-400 MCG- MCG-80 MG-150 MCG- 400 UNIT-3500 UNIT, 0.5 200 MG-400 MCG-400 MG-1.5 MG-1.7 MG-2 MG- UNIT-3500 UNIT 2 MG-2.3 MG-6 MCG-10 MCG-10 MCG-10 MG-11 MG-13.5 MG-18 MG-20 MG-20 MG-25 MCG-25 MCG-30 MCG-35 MCG-45 MCG-50 MG-55 MCG-60 MG-72 MG-80 MG-150 MCG-200 MG-400 MCG- 1050 MCG
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
210 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Multiple Vitamins W/ QL(1 ea daily); (Multiple Vitamins W/ QL(1 ea daily); Minerals) MULTIVITAMIN RX/OTC Minerals) QC MULTI-VITE RX/OTC WOMEN TABS 0.5 MG-1.1 TABS 0.9 MG-1.5 MG-1.7 MG-1.1 MG-1.8 MG-2 MG- MG-2 MG-2 MG-2.3 MG-5 6 MCG-8 MG-14 MG-15 MCG-6 MCG-10 MCG-10 MG-18 MCG-18 MG-20 MCG-10 MG-11 MG-18 MG-32 MCG-35 UNIT-40 MG-20 MG-20 MG-25 F MCG-50 MCG-50 MCG-72 MCG-30 MCG-30 UNIT-35 MG-75 MG-80 MG-100 MCG-45 MCG-50 MG-55 MG-150 MCG-200 MG-400 MCG-60 MG-72 MG-75 MCG-800 UNIT-3500 F MCG-80 MG-150 MCG-200 UNIT, 0.9 MG-1.1 MG-1.1 MG-400 MCG-400 UNIT- MG-1.8 MG-2 MG-2 MG-5 3500 UNIT MCG-6 MCG-8 MG-10 (Multiple Vitamins W/ QL(1 ea daily); MCG-10 MCG-14 MG-15 Minerals) QUINTABS-M RX/OTC MG-18 MG-20 MG-25 TABS 0.2 MG-2 MG-7.5 MCG-35 UNIT-40 MCG-50 MG-10 MG-15 MG-30 MCG-50 MCG-55 MCG-72 MCG-30 MCG-30 MG-30 F MG-75 MG-80 MG-100 MG-30 MG-30 MG-30 MG- MG-150 MCG-150 MCG- 35 MCG-50 UNIT-100 MG- 400 MCG-500 MG-800 150 MCG-300 MG-400 UNIT-3500 UNIT MCG-400 UNIT-5000 UNIT (Multiple Vitamins W/ QL(1 ea daily); (Multiple Vitamins W/ QL(1 ea daily); Minerals) ONE DAILY RX/OTC Minerals) SENTRY RX/OTC MULTIVITAMIN ADULT SENIOR TABS 0.5 MG-1.5 TABS 0.4 MG-1.5 MG-1.7 F MG-1.7 MG-2 MG-2.3 MG- MG-2 MG-6 MCG-10 3 MG-5 MCG-10 MCG-10 MCG-20 MG-30 UNIT-45 MG-11 MG-20 MG-20 MG- MG-60 MG-400 UNIT-3000 25 MCG-30 MCG-30 MCG- UNIT 45 MCG-45 MCG-50 MG- (Multiple Vitamins W/ QL(1 ea daily); 50 UNIT-55 MCG-60 MG- Minerals) ONE DAILY RX/OTC 72 MG-80 MG-150 MCG- WOMENS TABS 1.5 MG- 150 MCG-220 MG-250 1.7 MG-2 MG-2 MG-2 MG- MCG-300 MCG-400 MCG- F 6 MCG-10 MG-15 MG-18 500 UNIT-2500 UNIT, 0.9 MG-20 MCG-20 MG-22.5 MG-1.5 MG-1.7 MG-2 MG- UNIT-25 MCG-60 MG-120 2.3 MG-3 MG-5 MCG-10 MCG-150 MCG-300 MCG- F MCG-10 MG-11 MG-20 400 MCG-500 MG-1000 MG-25 MCG-30 MCG-30 UNIT-2500 UNIT, 1.5 MG- MCG-45 MCG-45 MCG-50 1.7 MG-2 MG-5 MG-6 MG-50 UNIT-55 MCG-72 MCG-10 MG-15 MG-18 MG-80 MG-90 MG-110 MG-30 UNIT-50 MG-60 MG-150 MCG-150 MCG- MG-400 MCG-400 UNIT- 220 MG-250 MCG-300 450 MG-2500 UNIT MCG-500 MCG-500 UNIT- 2500 UNIT
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
211 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Multiple Vitamins W/ QL(1 ea daily); (Multiple Vitamins W/ QL(1 ea daily); Minerals) SENTRY TABS RX/OTC Minerals) THERA-M TABS RX/OTC 0.9 MG-1.5 MG-1.7 MG-2 2 MG-2 MG-3 MG-3 MG- MG-2 MG-2.3 MG-5 MCG- 3.4 MG-3.5 MG-5 MCG-7.5 6 MCG-10 MCG-10 MCG- MG-7.5 MG-9 MCG-10 10 MG-11 MG-18 MG-20 MCG-10 MCG-10 MG-15 MG-25 MCG-30 MCG-30 F MG-18 MG-20 MG-21 UNIT-35 MCG-45 MCG-55 MCG-26 MCG-28 MCG-30 MCG-72 MG-80 MG-90 MCG-30 UNIT-31 MG-32 MG-100 MG-109 MG-150 MCG-40 MG-90 MG-100 MCG-150 MCG-200 MG- MG-150 MCG-150 MCG- F 250 MCG-300 MCG-400 400 MCG-400 UNIT-5000 UNIT-500 MCG-3500 UNIT UNIT, 2 MG-3 MG-3 MG- (Multiple Vitamins W/ QL(1 ea daily); 3.4 MG-5 MG-7.5 MG-7.5 Minerals) STRESS RX/OTC MG-9 MCG-10 MCG-10 FORMULA TABS 3 MG-5 MG-15 MCG-15 MCG-15 MG-10 MG-10 MG-12 MCG-15 MG-18 MG-30 MCG-20 MG-24 MG-30 MG-30 UNIT-31 MG-44 UNIT-45 MCG-77 MG-100 F MG-100 MG-120 MG-150 MG-400 MCG-500 MG, 5 MCG-400 MCG-400 UNIT- MG-10 MG-10 MG-12 5500 UNIT MCG-20 MG-30 UNIT-45 ABC COMPLETE SENIOR QL(1 ea daily); MCG-69 MG-100 MG-400 WOMENS 50+ TABS RX/OTC MCG-500 MG (multiple vitamins w/ F (Multiple Vitamins W/ QL(1 ea daily); minerals) Minerals) STRESS RX/OTC ADVANCED DIABETIC QL(1 ea daily); FORMULA/IRON TABS 5 MULTIVITAMIN FORMULA RX/OTC MG-10 MG-10 MG-12 F F MCG-18 MG-20 MG-30 TABS (multiple vitamins UNIT-45 MCG-100 MG- w/ minerals) 400 MCG-500 MG ALGAE BASED CALCIUM QL(1 ea daily); TABS (multiple vitamins F RX/OTC w/ minerals) ALIVE ENERGY 50+ TABS QL(1 ea daily); (multiple vitamins w/ F RX/OTC minerals) ALIVE MENS ENERGY QL(1 ea daily); TABS (multiple vitamins F RX/OTC w/ minerals) ALIVE ONCE DAILY QL(1 ea daily); WOMENS 50+ ULTRA RX/OTC POTENCY TABS F (multiple vitamins w/ minerals)
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212 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALIVE ONCE DAILY QL(1 ea daily); CENTRAVITES 50 PLUS QL(1 ea daily); WOMENS ULTRA RX/OTC TABS 0.5 MG-1.5 MG-1.7 RX/OTC POTENCY TABS F MG-2 MG-2.3 MG-3 MG-5 (multiple vitamins w/ MCG-10 MCG-10 MG-11 minerals) MG-19 MCG-20 MG-20 MG-25 MCG-30 MCG-30 ALIVE WOMENS 50+ QL(1 ea daily); MCG-45 MCG-50 MCG-50 F TABS (multiple vitamins F RX/OTC MG-50 UNIT-60 MG-80 w/ minerals) MG-150 MCG-220 MG-250 ALIVE WOMENS ENERGY QL(1 ea daily); MCG-300 MCG-400 MCG- TABS (multiple vitamins F RX/OTC 1000 UNIT-2500 UNIT w/ minerals) (multiple vitamins w/ minerals) ANTIOXIDANT FORMULA QL(1 ea daily); TABS 17 MCG-53 MG-61 RX/OTC CENTRAVITES ADULTS QL(1 ea daily); MG-167 MG-2492 MCG F TABS (multiple vitamins F RX/OTC (multiple vitamins w/ w/ minerals) minerals) CENTRUM CARDIO TABS QL(1 ea daily); AZO HORMONAL QL(1 ea daily); (multiple vitamins w/ F RX/OTC HEALTH CYCLE CARE & RX/OTC minerals) COMFORT TABS F CENTRUM MEN TABS 0.9 QL(1 ea daily); (multiple vitamins w/ MG-1.2 MG-1.3 MG-2 MG- RX/OTC minerals) 2 MG-2.3 MG-5 MCG-6 AZO HORMONAL QL(1 ea daily); MCG-8 MG-10 MCG-10 HEALTH HAPPY CYCLE RX/OTC MCG-11 MG-15 MG-16 TABS (multiple vitamins F MG-20 MG-35 MCG-40 MCG-45 UNIT-50 MCG-60 F w/ minerals) MCG-72 MG-80 MG-90 BACMIN TABS ( QL(1 ea daily); MG-100 MCG-100 MG-150 multiple F vitamins w/ minerals) RX/OTC MCG-200 MCG-210 MG- 600 MCG-1000 UNIT-3500 BASIC AM TABS QL(1 ea daily); UNIT (multiple vitamins (multiple vitamins w/ F RX/OTC ) minerals) w/ minerals CENTRUM SILVER QL(1 ea daily); BASIC PM TABS QL(1 ea daily); ULTRA WOMENS TABS RX/OTC RX/OTC (multiple vitamins w/ F (multiple vitamins w/ F minerals) minerals) CAL-DAY 1000 TABS QL(1 ea daily); CENTRUM SPECIALIST QL(1 ea daily); RX/OTC (multiple vitamins w/ F HEART TABS (multiple F RX/OTC minerals) vitamins w/ minerals) CENTRUM SPECIALIST QL(1 ea daily); IMMUNE SUPPORT TABS RX/OTC (multiple vitamins w/ F minerals) CENTRUM SPECIALIST QL(1 ea daily); VISION TABS (multiple F RX/OTC vitamins w/ minerals)
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213 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CENTRUM ULTRA QL(1 ea daily); CLINICAL NUTRIENTS QL(1 ea daily); WOMENS TABS RX/OTC FOR WOMEN TABS RX/OTC (multiple vitamins w/ F (multiple vitamins w/ F minerals) minerals) CERTAVITE SENIOR QL(1 ea daily); CVS ONE DAILY MENS QL(1 ea daily); TABS ( RX/OTC 50+ ADVANCED TABS RX/OTC multiple vitamins F F w/ minerals) (multiple vitamins w/ CERTAVITE QL(1 ea daily); minerals) SENIOR/ANTIOXIDANT RX/OTC CVS ONE DAILY QL(1 ea daily); NUTRIENTS TABS F WOMENS 50+ADVANCED RX/OTC (multiple vitamins w/ TABS (multiple vitamins F minerals) w/ minerals) CERTAVITE/ANTIOXIDAN QL(1 ea daily); CVS SPECTRAVITE QL(1 ea daily); TS TABS 0.5 MG-1.5 MG- RX/OTC ADULT 50+ TABS RX/OTC 1.7 MG-2 MG-2 MG-2.3 (multiple vitamins w/ F MG-5 MCG-6 MCG-10 minerals) MCG-10 MCG-10 MCG-10 MG-11 MG-13.5 MG-18 CVS SPECTRAVITE QL(1 ea daily); RX/OTC MG-20 MG-20 MG-25 F ADULTS TABS (multiple F MCG-30 MCG-35 MCG-45 vitamins w/ minerals) MCG-50 MG-55 MCG-60 CVS SPECTRAVITE QL(1 ea daily); MG-72 MG-75 MCG-80 ULTRA MEN50+ TABS RX/OTC MG-150 MCG-200 MG-400 (multiple vitamins w/ F MCG-1050 MCG (multiple minerals) vitamins w/ minerals) CVS SPECTRAVITE QL(1 ea daily); CLINICAL NUTRIENTS 45- QL(1 ea daily); ULTRA MENS HEALTH RX/OTC PLUS WOMEN TABS RX/OTC F F SENIOR TABS (multiple (multiple vitamins w/ vitamins w/ minerals) minerals) CVS SPECTRAVITE QL(1 ea daily); CLINICAL NUTRIENTS 50- QL(1 ea daily); ULTRA MENS HEALTH RX/OTC PLUS MEN TABS RX/OTC F F TABS (multiple vitamins (multiple vitamins w/ w/ minerals) minerals) CVS SPECTRAVITE QL(1 ea daily); CLINICAL NUTRIENTS QL(1 ea daily); ULTRA WOMEN TABS RX/OTC FOR FEMALE TEENS RX/OTC F F (multiple vitamins w/ TABS (multiple vitamins minerals) w/ minerals) CVS SPECTRAVITE QL(1 ea daily); CLINICAL NUTRIENTS QL(1 ea daily); ULTRA WOMENS RX/OTC FOR MALE TEENS TABS RX/OTC F HEALTH SENIOR TABS F (multiple vitamins w/ (multiple vitamins w/ minerals) minerals) CLINICAL NUTRIENTS QL(1 ea daily); CVS SPECTRAVITE QL(1 ea daily); FOR MEN TABS RX/OTC F ULTRA WOMENS RX/OTC (multiple vitamins w/ HEALTH TABS (multiple F minerals) vitamins w/ minerals)
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214 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DAYAVITE TABS QL(1 ea daily); EQL CENTURY WOMENS QL(1 ea daily); (multiple vitamins w/ F RX/OTC TABS (multiple vitamins F RX/OTC minerals) w/ minerals) DERMACINRX RIBOTIN-E QL(1 ea daily); EQL ONE DAILY MENS QL(1 ea daily); TABS (multiple vitamins F RX/OTC TABS (multiple vitamins F RX/OTC w/ minerals) w/ minerals) DERMACINRX QL(1 ea daily); ESTROVEN MENOPAUSE QL(1 ea daily); ZINTREXYL-C TABS RX/OTC SUPPLEMENT TABS RX/OTC (multiple vitamins w/ F (multiple vitamins w/ F minerals) minerals) DERMAVITE TABS QL(1 ea daily); EYE HEALTH/LUTEIN QL(1 ea daily); (multiple vitamins w/ F RX/OTC TABS (multiple vitamins F RX/OTC minerals) w/ minerals) EQ COMPLETE QL(1 ea daily); EYE QL(1 ea daily); MULTIVITAMINADULTS RX/OTC MULTIVITAMIN/LUTEIN RX/OTC UNDER 50 TABS F TABS (multiple vitamins F (multiple vitamins w/ w/ minerals) minerals) EYE QL(1 ea daily); EQ ONE DAILY MENS 50+ QL(1 ea daily); MULTIVITAMIN/SODIUM RX/OTC TABS (multiple vitamins F RX/OTC TABS (multiple vitamins F w/ minerals) w/ minerals) EQ ONE DAILY MENS QL(1 ea daily); FITNESS TABS FOR MEN QL(1 ea daily); HEALTH TABS ( RX/OTC AM/PM/LYCOPENE TABS RX/OTC multiple F F vitamins w/ minerals) (multiple vitamins w/ EQ ONE DAILY WOMENS QL(1 ea daily); minerals) 50+ TABS (multiple F RX/OTC FITNESS TABS FOR QL(1 ea daily); vitamins w/ minerals) WOMEN RX/OTC AM/PM/LYCOPENE TABS EQ ONE DAILY WOMENS QL(1 ea daily); F HEALTH TABS 1.5 MG-1.7 RX/OTC (multiple vitamins w/ MG-2 MG-2 MG-2 MG-5 minerals) MG-6 MCG-10 MG-15 MG- FOLIKA-CI TABS QL(1 ea daily); 18 MG-20 MCG-22.5 ( F RX/OTC F multiple vitamins w/ UNIT-25 MCG-30 MCG-50 minerals) MG-60 MG-120 MCG-400 MCG-500 MG-1000 UNIT- FOLIKA-MG TABS QL(1 ea daily); RX/OTC 2500 UNIT (multiple (multiple vitamins w/ F vitamins w/ minerals) minerals) EQL CENTURY MATURE QL(1 ea daily); FOLITIN-Z TABS QL(1 ea daily); ADULTS50+ TABS RX/OTC (multiple vitamins w/ F RX/OTC (multiple vitamins w/ F minerals) minerals) FREEDAVITE TABS QL(1 ea daily); EQL CENTURY MENS QL(1 ea daily); (multiple vitamins w/ F RX/OTC TABS (multiple vitamins F RX/OTC minerals) w/ minerals)
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215 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GERI-FREEDA SENIOR QL(1 ea daily); ICAPS AREDS FORMULA QL(1 ea daily); FORMULA TABS RX/OTC TABS ( RX/OTC F multiple vitamins F (multiple vitamins w/ w/ minerals) minerals) K-PAX IMMUNE QL(1 ea daily); HAIR SKIN & NAILS QL(1 ea daily); SUPPORT FORMULA RX/OTC ADVANCED FORMULA RX/OTC PROFESSIONAL TABS (multiple vitamins F STRENGTH TABS F w/ minerals) (multiple vitamins w/ HIGH POTENCY QL(1 ea daily); minerals) MULTIVITAMIN/BETA- RX/OTC LUTEIN QL(1 ea daily); CAROTENE TABS F PLUS/ZEAXANTHIN TABS RX/OTC (multiple vitamins w/ (multiple vitamins w/ F minerals) minerals) HIGH POTENCY QL(1 ea daily); MACULAR VITAMIN QL(1 ea daily); MULTIVITAMIN/FOLIC RX/OTC BENEFIT TABS ( RX/OTC F multiple F ACID TABS (multiple vitamins w/ minerals) vitamins w/ minerals) MEGA MULTI FOR MEN QL(1 ea daily); HM COMPLETE 50+ QL(1 ea daily); TABS (multiple vitamins F RX/OTC MENS ULTIMATE TABS RX/OTC F w/ minerals) (multiple vitamins w/ MEGA MULTI FOR QL(1 ea daily); minerals) WOMEN TABS (multiple F RX/OTC HM COMPLETE 50+ QL(1 ea daily); vitamins w/ minerals) WOMENS ULTIMATE RX/OTC F MEGA MULTIVITAMIN QL(1 ea daily); TABS (multiple vitamins FOR MEN TABS RX/OTC w/ minerals) (multiple vitamins w/ F HM COMPLETE MEN QL(1 ea daily); minerals) RX/OTC TABS (multiple vitamins F MEGA MULTIVITAMIN QL(1 ea daily); w/ minerals) FOR WOMEN TABS RX/OTC HM COMPLETE TABS QL(1 ea daily); (multiple vitamins w/ F (multiple vitamins w/ F RX/OTC minerals) minerals) MEGAVITE FRUITS & QL(1 ea daily); HM HAIR/SKIN/NAILS QL(1 ea daily); VEGGIES TABS (multiple F RX/OTC TABS (multiple vitamins F RX/OTC vitamins w/ minerals) w/ minerals) MEGAVITE GOLDEN QL(1 ea daily); HM ONE DAILY MENS QL(1 ea daily); YEARS 55+ TABS RX/OTC TABS (multiple vitamins F RX/OTC (multiple vitamins w/ F w/ minerals) minerals) HM ONE DAILY WOMENS QL(1 ea daily); MENS 50+ MULTI QL(1 ea daily); TABS (multiple vitamins F RX/OTC VITAMIN &MINERAL RX/OTC w/ minerals) FORMULA TABS F HYLAZINC TABS QL(1 ea daily); (multiple vitamins w/ (multiple vitamins w/ F RX/OTC minerals) minerals)
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216 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MENS MULTI VITAMIN & QL(1 ea daily); MULTIVITAMIN TABS 1 QL(1 ea daily); MINERAL FORMULA RX/OTC MG-1 MG-1.5 MG-2 MG- RX/OTC TABS (multiple vitamins F 2.5 MG-5 MG-7.5 MCG-10 w/ minerals) MCG-10 MG-10 MG-15 MG-15 MG-100 MG-150 F MENS MULTIVITAMIN QL(1 ea daily); MCG-150 MG-3000 MCG RX/OTC TABS (multiple vitamins F (multiple vitamins w/ w/ minerals) minerals) MULTI-BETIC DIABETES QL(1 ea daily); MULTIVITAMIN WOMEN QL(1 ea daily); TABS (multiple vitamins F RX/OTC TABS 0.5 MG-1.1 MG-1.1 RX/OTC w/ minerals) MG-1.8 MG-2 MG-2 MG-6 MULTI-VITAMIN QL(1 ea daily); MCG-8 MG-10 MCG-10 MONOCAPS TABS RX/OTC MCG-14 MG-15 MG-15.7 (multiple vitamins w/ F MG-18 MCG-18 MG-20 MG-25 MCG-32 MCG-40 F minerals) MCG-50 MCG-50 MCG-72 MULTILEX T&M TABS QL(1 ea daily); MG-75 MG-80 MG-100 (multiple vitamins w/ F RX/OTC MG-150 MCG-200 MG-400 minerals) MCG-1050 MCG (multiple MULTILEX TABS 1 MG-1 QL(1 ea daily); vitamins w/ minerals) MG-1.5 MG-1.7 MG-3 RX/OTC MULTIVITAMIN/ZINC QL(1 ea daily); MCG-5 MG-5 MG-5.5 STRESSFORMULA TABS RX/OTC UNIT-10 MG-10 MG-15 F F (multiple vitamins w/ MG-30 MG-100 MG-150 minerals) MCG-400 UNIT-10000 UNIT (multiple vitamins NAT-RUL THERAVITE- QL(1 ea daily); M/HIGHPOTENCY TABS RX/OTC w/ minerals) (multiple vitamins w/ F multiple vitamins w/ QL(1 ea daily); minerals) F RX/OTC minerals tabs NATRUL-VITES TABS QL(1 ea daily); MULTIVITAMIN ADULTS QL(1 ea daily); (multiple vitamins w/ F RX/OTC TABS 0.5 MG-1.5 MG-1.7 RX/OTC minerals) MG-2 MG-2 MG-2.3 MG-5 NEOVITE TABS ( QL(1 ea daily); MCG-6 MCG-10 MCG-10 multiple F MCG-10 MG-11 MG-18 vitamins w/ minerals) RX/OTC MG-20 MG-20 MG-25 NICADAN TABS (multiple QL(1 ea daily); MCG-30 MCG-30 UNIT-35 F F RX/OTC MCG-45 MCG-50 MG-55 vitamins w/ minerals) MCG-60 MG-72 MG-75 NICADAN ZX TABS QL(1 ea daily); MCG-80 MG-150 MCG- (multiple vitamins w/ F RX/OTC 200 MG-400 MCG-400 minerals) UNIT-3500 UNIT (multiple NICAZEL FORTE TABS QL(1 ea daily); vitamins w/ minerals) (multiple vitamins w/ F RX/OTC MULTIVITAMIN MEN QL(1 ea daily); minerals) TABS (multiple vitamins F RX/OTC NICAZEL TABS (multiple QL(1 ea daily); w/ minerals) F vitamins w/ minerals) RX/OTC
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217 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NO IRON MULTIPLE QL(1 ea daily); ONE-A-DAY MENS PRO QL(1 ea daily); VITAMIN/MINERALS RX/OTC EDGE TABS ( RX/OTC F multiple F TABS (multiple vitamins vitamins w/ minerals) w/ minerals) ONE-A-DAY MENS TABS QL(1 ea daily); NUTRICAP TABS QL(1 ea daily); 0.9 MG-1.32 MG-1.43 MG- RX/OTC (multiple vitamins w/ F RX/OTC 2.17 MG-2.3 MG-6.24 minerals) MCG-11 MG-15 MG-15.5 MG-17.6 MG-25 MCG-30 OCULAR VITAMINS TABS QL(1 ea daily); MCG-35 MCG-43 MCG-55 F (multiple vitamins w/ F RX/OTC MCG-99 MG-120 MG-150 minerals) MCG-210 MG-240 MCG- ONCOVITE TABS QL(1 ea daily); 300 MCG-900 MCG (multiple vitamins w/ F RX/OTC (multiple vitamins w/ minerals) minerals) ONE DAILY MENS QL(1 ea daily); ONE-A-DAY PROACTIVE QL(1 ea daily); FORMULA W/O IRON RX/OTC 65+ TABS (multiple F RX/OTC TABS (multiple vitamins F vitamins w/ minerals) w/ minerals) ONE-A-DAY TEEN QL(1 ea daily); ADVANTAGEFOR HIM RX/OTC ONE DAILY WOMENS QL(1 ea daily); F TABS 1.5 MG-1.7 MG-2 RX/OTC TABS (multiple vitamins MG-2 MG-2 MG-6 MCG-10 w/ minerals) MG-15 MG-18 MG-20 ONE-A-DAY WOMENS QL(1 ea daily); MCG-20 MG-22.5 UNIT-25 RX/OTC MCG-60 MG-120 MCG- F TABS (multiple vitamins F 150 MCG-300 MCG-400 w/ minerals) MCG-500 MG-1000 UNIT- ONEVITE TABS (multiple 2500 UNIT (multiple vitamins w/ minerals & F vitamins w/ minerals) folic acid) ONE-A-DAY ENERGY QL(1 ea daily); OPURITY TABS ( QL(1 ea daily); multiple F TABS (multiple vitamins F RX/OTC vitamins w/ minerals) RX/OTC w/ minerals) OSTEOPRIME QL(1 ea daily); ONE-A-DAY MENOPAUSE QL(1 ea daily); PLUS/CALCIUM & RX/OTC FORMULA TABS RX/OTC MAGNESIUM TABS F F (multiple vitamins w/ (multiple vitamins w/ minerals) minerals) ONE-A-DAY MENS 50+ QL(1 ea daily); PARVLEX TABS QL(1 ea daily); ADVANTAGE TABS RX/OTC RX/OTC F (multiple vitamins w/ F (multiple vitamins w/ minerals) minerals) PHYTOMULTI TABS QL(1 ea daily); ONE-A-DAY MENS 50+ QL(1 ea daily); (multiple vitamins w/ F RX/OTC TABS (multiple vitamins F RX/OTC minerals) w/ minerals) PRESERVISION AREDS QL(1 ea daily); ONE-A-DAY MENS QL(1 ea daily); TABS (multiple vitamins F RX/OTC HEALTH FORMULA TABS RX/OTC w/ minerals) (multiple vitamins w/ F minerals)
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218 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRO-CAL TABS 7.5 MG- QL(1 ea daily); SENTRY SENIOR TABS QL(1 ea daily); 40 MG-100 UNIT-145 MG- RX/OTC 0.5 MG-1.5 MG-1.7 MG-2 RX/OTC 187.5 MG (multiple F MG-2.3 MG-3 MG-5 MCG- vitamins w/ minerals) 10 MCG-10 MG-11 MG-20 MG-20 MG-25 MCG-30 PROCERV HP TABS QL(1 ea daily); MCG-30 MCG-45 MCG-45 RX/OTC (multiple vitamins w/ F MCG-50 MG-50 UNIT-55 F minerals) MCG-60 MG-72 MG-80 PRORENAL+D TABS QL(1 ea daily); MG-150 MCG-150 MCG- (multiple vitamins w/ F RX/OTC 220 MG-250 MCG-300 MCG-400 MCG-500 UNIT- minerals) 2500 UNIT (multiple PROVIT TABS (multiple QL(1 ea daily); vitamins w/ minerals) F RX/OTC vitamins w/ minerals) SENTRY SENIOR/LUTEIN QL(1 ea daily); QC MULTI-VITE TABS 0.5 QL(1 ea daily); TABS (multiple vitamins F RX/OTC MG-1.5 MG-1.7 MG-2 MG- RX/OTC w/ minerals) 2 MG-2.3 MG-5 MCG-6 MCG-10 MCG-10 MCG-10 SENTRY TABS 0.5 MG-1.5 QL(1 ea daily); MG-11 MG-18 MG-20 MG- MG-1.7 MG-2 MG-2 MG- RX/OTC 20 MG-25 MCG-30 MCG- 2.3 MG-5 MCG-6 MCG-10 30 UNIT-35 MCG-45 MCG- F MCG-10 MCG-10 MG-11 50 MG-55 MCG-60 MG-72 MG-18 MG-20 MG-20 MG- 25 MCG-30 MCG-30 UNIT- MG-75 MCG-80 MG-150 F MCG-200 MG-400 MCG- 35 MCG-45 MCG-50 MG- 400 UNIT-3500 UNIT 55 MCG-60 MG-72 MG-75 (multiple vitamins w/ MCG-80 MG-150 MCG-200 MG-400 MCG-400 UNIT- minerals) 3500 UNIT (multiple QUIN B STRONG TABS QL(1 ea daily); vitamins w/ minerals) (multiple vitamins w/ F RX/OTC SIDEROL TABS ( QL(1 ea daily); minerals) multiple F vitamins w/ minerals) RX/OTC QUINTABS-M TABS 0.2 QL(1 ea daily); MG-2 MG-7.5 MG-15 MG- RX/OTC SM ONE DAILY MENS QL(1 ea daily); 30 MCG-30 MCG-30 MG- TABS (multiple vitamins F RX/OTC 30 MG-30 MG-30 MG-30 w/ minerals) MG-35 MCG-50 UNIT-100 F SM ONE DAILY WOMENS QL(1 ea daily); MG-150 MCG-300 MG-400 RX/OTC MCG-400 UNIT-5000 UNIT TABS (multiple vitamins F (multiple vitamins w/ w/ minerals) minerals) SOLO TABS (multiple QL(1 ea daily); F RX/OTC RA CENTRAL-VITE TABS QL(1 ea daily); vitamins w/ minerals) (multiple vitamins w/ F RX/OTC SPECTRAVITE TABS QL(1 ea daily); minerals) (multiple vitamins w/ F RX/OTC RENAPLEX-D TABS QL(1 ea daily); minerals) (multiple vitamins w/ F RX/OTC STROVITE ONE TABS QL(1 ea daily); minerals) (multiple vitamins w/ F RX/OTC REQ 49+ TABS ( QL(1 ea daily); minerals) multiple F vitamins w/ minerals) RX/OTC
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219 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SYSTANE ICAPS AREDS2 QL(1 ea daily); THEREMS-H TABS QL(1 ea daily); TABS (multiple vitamins F RX/OTC (multiple vitamins w/ F RX/OTC w/ minerals) minerals) T-VITES TABS ( QL(1 ea daily); THEREMS-M TABS QL(1 ea daily); multiple F vitamins w/ minerals) RX/OTC (multiple vitamins w/ F RX/OTC THERA M PLUS TABS QL(1 ea daily); minerals) (multiple vitamins w/ F RX/OTC THRIVITE 19 TABS minerals) (multiple vitamins w/ F THERA-M TABS 2 MG-2 QL(1 ea daily); minerals & folic acid) MG-3 MG-3.4 MG-5 MCG- RX/OTC UDAMIN SP TABS 6 MG-6 MG-7 MG-7.5 MG- (multiple vitamins w/ F 9 MG-10 MCG-10 MCG-10 minerals & folic acid) MG-12 MCG-15 MG-20 MG-23 MG-28 MCG-30 UNICOMPLEX-M TABS QL(1 ea daily); MCG-30 MG-50 MCG-60 F (multiple vitamins w/ F RX/OTC UNIT-70 MCG-75 MCG-90 minerals) MG-100 MG-150 MCG-150 VENEXA FE TABS QL(1 ea daily); MCG-400 MCG-400 UNIT- (multiple vitamins w/ F RX/OTC 5000 UNIT (multiple minerals) vitamins w/ minerals) VENEXA TABS (multiple QL(1 ea daily); THERA-TABS M TABS QL(1 ea daily); F vitamins w/ minerals) RX/OTC (multiple vitamins w/ F RX/OTC minerals) VENTRIXYL FE TABS QL(1 ea daily); (multiple vitamins w/ F RX/OTC THERABETIC MULTI- QL(1 ea daily); minerals) VITAMIN TABS (multiple F RX/OTC vitamins w/ minerals) VENTRIXYL TABS (multiple vitamins w/ F THERAGRAN-M QL(1 ea daily); ADVANCED 50 PLUS RX/OTC minerals & folic acid) TABS (multiple vitamins F VITALINE TOTAL QL(1 ea daily); w/ minerals) FORMULA 2 TABS RX/OTC (multiple vitamins w/ F THERAGRAN-M QL(1 ea daily); ADVANCED TABS RX/OTC minerals) (multiple vitamins w/ F VITALINE TOTAL QL(1 ea daily); minerals) FORMULA 3 TABS RX/OTC (multiple vitamins w/ F THERAGRAN-M PREMIER QL(1 ea daily); minerals) 50 PLUS TABS (multiple F RX/OTC vitamins w/ minerals) VITAMIN D3 COMPLETE QL(1 ea daily); TABS (multiple vitamins F RX/OTC THERAGRAN-M PREMIER QL(1 ea daily); w/ minerals) TABS (multiple vitamins F RX/OTC w/ minerals) VITASANA TABS QL(1 ea daily); (multiple vitamins w/ F RX/OTC THERAGRAN-M TABS QL(1 ea daily); minerals) (multiple vitamins w/ F RX/OTC minerals) VITATRUM TABS QL(1 ea daily); (multiple vitamins w/ F RX/OTC minerals)
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220 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VITEYES CLASSIC QL(1 ea daily); WOMENS 50+ MULTI QL(1 ea daily); MULTIIVITAMIN TABS RX/OTC VITAMIN& MINERAL RX/OTC (multiple vitamins w/ F FORMULA TABS F minerals) (multiple vitamins w/ VITEYES CLASSIC QL(1 ea daily); minerals) MULTIVITAMIN TABS RX/OTC WOMENS BIOMULTIPLE QL(1 ea daily); (multiple vitamins w/ F TABS (multiple vitamins F RX/OTC minerals) w/ minerals) VITEYES OPTIC NERVE QL(1 ea daily); WOMENS MULTI VITAMIN QL(1 ea daily); SUPPORT TABS RX/OTC & MINERAL FORMULA RX/OTC (multiple vitamins w/ F TABS (multiple vitamins F minerals) w/ minerals) VITRANOL FE TABS QL(1 ea daily); YELETS TEENAGE QL(1 ea daily); ( F RX/OTC FORMULA TABS RX/OTC multiple vitamins w/ F minerals) (multiple vitamins w/ VITRANOL TABS QL(1 ea daily); minerals) (multiple vitamins w/ F RX/OTC Multivitamins minerals) VITREXATE FE TABS QL(1 ea daily); (multiple vitamins w/ F RX/OTC minerals) VITREXATE TABS QL(1 ea daily); (multiple vitamins w/ F RX/OTC minerals) VITREXYL TABS QL(1 ea daily); (multiple vitamins w/ F RX/OTC minerals) VITREXYL/IRON TABS QL(1 ea daily); (multiple vitamins w/ F RX/OTC minerals) VITRUM 50+ ADULT- QL(1 ea daily); MULTI IRON FREE TABS RX/OTC (multiple vitamins w/ F minerals) VITRUM 50+ SENIOR QL(1 ea daily); MULTI TABS (multiple F RX/OTC vitamins w/ minerals) WHOLE FOOD QL(1 ea daily); MULTIVITAMIN TABS RX/OTC (multiple vitamins w/ F minerals)
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221 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Multiple Vitamin) ANTI- (Multiple Vitamin) STRESS OXIDANT, DAILY FORMULA TABS 0.4 MG- MULTIPLE VITAMINS, 12 MCG-15 MG-20 MG-30 DAILY VALUE UNIT-45 MCG-100 MG-600 MULTIVITAMIN, DAILY MG, 3 MG-10 MG-10 MG- VITAMIN, DAILY 12 MCG-20 MG-30 UNIT- VITAMINS, DAILY VITE, 45 MCG-100 MG-400 DAILY-VITAMIN, DAILY- MCG-500 MG, 5 MG-10 F VITE, DAILY-VITE MG-10 MG-12 MCG-20 MULTIVITAMIN, GNP MG-30 UNIT-45 MCG-100 ESSENTIAL ONE DAILY, MG-400 MCG-500 MG, 5 HEALTHY HAIR SKIN & MG-10 MG-12 MCG-15 NAILS, MULTI VITAMIN MG-20 MG-30 UNIT-45 DAILY, MULTI-DAY, MCG-100 MG-400 MCG- MULTI-VITAMIN, MULTI- 500 MG VITAMIN DAILY, MULTI- (Multiple Vitamin) THERA VITAMINS, MULTIPLE TABS 3 MG-3 MG-3.4 MG- VITAMINS ESSENTIAL, F 9 MCG-10 MG-20 MG-30 F MULTIVITAMIN ADULT MCG-30 UNIT-90 MG-400 ONE DAILY, MCG-400 UNIT-5000 UNIT MULTIVITAMIN IRON- ESTROFACTORS TABS FREE, ONCE DAILY, ONE F DAILY, ONE-DAILY MULTI (multiple vitamin) VITAMINS, ONE-DAILY HIGH POTENCY MULTI-VITAMIN, QC MULTIVITAMIN TABS F ESSENTIALS, RA ONE (multiple vitamin) DAILY ESSENTIAL, MULTI VITAMIN TABS SIGTAB, SM MULTIPLE F VITAMINS ESSENTIAL, (multiple vitamin) STRESSTABS ENERGY, MULTI VITAMIN/D-3 TABS F TAB-A-VITE, TAB-A-VITE (multiple vitamin) W/BETA CAROTENE, THERA-MILL, THERA- multiple vitamin tabs F TABS, THEREMS, MULTIVITAMIN ADULT VITALEE TABS F TABS (multiple vitamin) (Multiple Vitamin) ONE DAILY ESSENTIAL TABS MULTIVITAMIN TABS 0.1 MG-1 MG-1.5 MG-2 MG-10 1.5 MG-1.7 MG-2 MG-6 F MCG-7.5 UNIT-10 MG-20 MCG-20 MG-28.5 MG-37.5 F MG-45 MG-60 MG-500 MG-1500 MCG (multiple MCG-800 UNIT-3000 UNIT vitamin) (Multiple Vitamin) ONE NEOMULTIVITE TABS F DAILY MULTIVITAMIN (multiple vitamin) ADULT TABS 0.4 MG-1.5 F OMNICAP TABS MG-1.7 MG-2 MG-6 MCG- F 20 MG-60 MG-400 UNIT- (multiple vitamin) 5000 UNIT
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222 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ONE DAILY ESSENTIAL (Pediatric Vitamins Acd W/ AL(Up to 13 yrs TABS 1.5 MG-1.7 MG-2 Fluoride) TRI- old ) MG-3.3 MG-6 MCG-10 VITE/FLUORIDE SOLN 0.5 F MG-20 MCG-20 MG-45 F MG/ML-35 MG/ML-400 MG-60 MG-500 MCG-900 UNIT/ML-1500 UNIT/ML MCG (multiple vitamin) FLORIVA PLUS SOLN AL(Up to 13 yrs QUINTABS TABS (pediatric multivitamins F old ); RX/OTC F (multiple vitamin) w/fl) THERA TABS 3 MG-3 MG- AL(Up to 13 yrs pediatric vitamins acd F 3.4 MG-9 MCG-10 MG-20 w/ fluoride soln old ) MG-30 MCG-30 UNIT-35 MG-45 MG-90 MG-400 POLY-VI-FLOR CHEW AL(Up to 5 yrs MCG-400 UNIT-5000 0.25 MG-15 UNIT-200 old ) MCG-400 UNIT, 0.5 MG-15 UNIT, 3 MG-3 MG-3.4 MG- F 9 MCG-10 MG-20 MG-30 UNIT-200 MCG-400 UNIT, F MCG-30 UNIT-45 MG-90 1 MG-15 UNIT-200 MCG- MG-400 MCG-400 UNIT- 400 UNIT (pediatric 5000 UNIT (multiple multivitamins w/fl) vitamin) QUFLORA PEDIATRIC AL(Up to 13 yrs THEREMS MULTIVITAMIN CHEW (pediatric F old ); RX/OTC F TABS (multiple vitamin) multivitamins w/fl) QUFLORA PEDIATRIC AL(Up to 13 yrs Ped MV w/ Fluoride SOLN (pediatric F old ); RX/OTC (Pediatric Multivitamins AL(Up to 13 yrs W/Fl) MULTI- old ); RX/OTC multivitamins w/fl) VITAMIN/FLUORIDE Ped MV w/ Iron DROPS, MULTIVITAMIN F BPROTECTED PEDIA WITH FLUORIDE, POLY-VITE/IRON SOLN MULTIVITAMIN/FLUORID F E SOLN (pediatric multiple vitamins w/ iron) (Pediatric Multivitamins AL(Up to 13 yrs W/Fl) old ); RX/OTC PC PEDIATRIC POLY- VITAMIN DROPS/IRON MULTIVITAMIN/FLUORID F E, SOLN (pediatric F MULTIVITAMINS/FLUORI multiple vitamins w/ DE CHEW iron) (Pediatric Vitamins Acd W/ AL(Up to 13 yrs POLY-VITA/IRON SOLN Fluoride) MULTIVITAMIN old ); RX/OTC (pediatric multiple F SELECT/FLUORIDE, F VITAMINS vitamins w/ iron) A/C/D/FLUORIDE SOLN Ped Multi Vitamins w/Fl & FE (Pediatric Vitamins Acd W/ AL(Up to 13 yrs (Ped Multivitamins W/Fl & AL(Up to 13 yrs Fluoride) TRI- old ); RX/OTC Iron) MULTI- old ); RX/OTC VITE/FLUORIDE SOLN F VIT/IRON/FLUORIDE, 0.25 MG/ML-35 MG/ML- MULTI- F 400 UNIT/ML-1500 VITAMIN/FLUORIDE/IRON UNIT/ML , MULTIVITAMIN/FLUORID E/IRON SOLN
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223 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POLY-VI-FLOR/IRON AL(Up to 5 yrs (Prenatal Vit W/ Docusate- RX/OTC CHEW 0.5 MG-10 MG-15 old ) Fe Fumarate-Folic Acid) UNIT-200 MCG-400 UNIT F PRENATAL 19 TABS 1 (ped multivitamins w/fl MG-3 MG-3 MG-7 MG-12 F & iron) MCG-15 MG-20 MG-20 MG-25 MG-29 MG-30 Pediatric Multiple Vitamins UNIT-100 MG-200 MG-400 (Pediatric Multiple Vitamin UNIT-1000 UNIT W/ C & Fa) ANIMAL (Prenatal Vit W/ Docusate- CHEWS, ANIMAL Iron Carbonyl-Folic Acid) F SHAPES, BITE-A-MINS, INATAL GT TABS BOUNTY BEARS/C, (Prenatal Vit W/ Ferrous CHEWABLE VITAMINS Fumarate-Folic Acid) CHILDRENS, CHEWABLE PRENATAL 19 CHEW 1 VITE CHILDRENS, MG-3 MG-3 MG-6 MG-7 F CHILDRENS CHEWABLE MG-12 MCG-20 MG-20 MULTIVITAMIN, MG-25 MG-29 MG-30 CHILDRENS CHEWABLE UNIT-100 MG-200 MG-400 VITAMIN, CHILDRENS UNIT-1000 UNIT CHEWABLE VITAMINS, CHILDRENS (Prenatal Vit W/ Ferrous Fumarate-Folic Acid) F MULTIVITAMIN, DINO- F LIFE, FLINTSTONES TRINATE TABS GUMMIES PLUSOMEGA-3 (Prenatal Vit W/ Iron DHA, FLINTSTONES Carbonyl-Folic Acid) F PLUS CALCIUM, PRENATABS RX TABS FLINTSTONES/MY FIRST, ALIVE PRENATAL MULTI- FRUITY CHEWS, VITAMIN/PLANT DHA GERBER GROW MIGHTY, CHEW (prenatal F GNP LITTLE ONES CHILDRENS, LITTLE multivitamins & ANIMALS, MULTIVITAMIN minerals w/fa-dha) CHILDRENS, POLY ATABEX EC TBEC VITAMIN, SM ANIMAL (prenatal vit w/ SHAPES KIDS FIRST, docusate-iron carbonyl- F ZOO FRIENDS GUMMIES CHEW folic acid) ATABEX OB TABS Pediatric Vitamins (prenatal vit w/ fe (Pediatric Vitamins Adc) AL(Up to 5 yrs bisglycinate chelate- F BPROTECTED PEDIA old ) folic acid) TRI-VITE, PC PEDIATRIC F TRI-VITAMIN DROPS, ATABEX PRENATAL TRI-VITE PEDIATRIC CHEW (prenatal without SOLN a vit w/ iron carbonyl- F Prenatal Vitamins folic acid) BRAINSTRONG PRENATAL MISC (prenatal mv & min w/fe F carbonyl-fa-dha)
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224 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CALNA TABS (prenatal CVS WOMENS F PRENATAL+DHA MISC vitamin) F CENTRUM SPECIALIST (prenatal mv & min w/fe PRENATAL MISC fumarate-fa-dha) (prenatal mv & min w/fe F ENFAMIL EXPECTA MISC fumarate-fa-dha) (prenatal mv & min w/fe F CLASSIC PRENATAL fumarate-fa-dha) TABS (prenatal vit w/ EQL PRENATAL F FORMULA TABS ferrous fumarate-folic F acid) (prenatal vit w/ ferrous CLINICAL NUTRIENTS fumarate-folic acid) PRENATAL FORMULA GNP PRENATAL TABS TABS (prenatal F (prenatal vit w/ ferrous F vitamins w/ ferrous fumarate-folic acid) succinate-folic acid) GOODSENSE PRENATAL VITAMINS TABS CO-NATAL FA TABS RX/OTC F (prenatal vit w/ ferrous F (prenatal vit w/ ferrous fumarate-folic acid) fumarate-folic acid) COMPLETE NATAL DHA HEALTHY MAMA BE MISC (prenatal mv & WELL ROUNDED THPK min w/fe bisglyc-fe prot F (prenatal vit w/ fe F succ-fa-ca-omega 3) bisglycinate-folic acid- omega 3 fatty acd) COMPLETENATE CHEW (prenatal vit w/ ferrous F HM ONE DAILY PRENATAL COMBO MISC fumarate-folic acid) (prenatal vit w/ ferrous F CVS PRENATAL fumarate-fa-omega 3 GUMMIES CHEW fatty acids) (prenatal multivitamins F & minerals w/fa-dha) HM PRENATAL TABS (prenatal vit w/ ferrous F CVS PRENATAL GUMMY/DHA/FOLIC ACID fumarate-folic acid) CHEW (prenatal JENLIVA F PRENATAL/POSTNATAL multivitamins & F minerals w/ folic acid- CAPS (prenatal multivit- fish oil) min w/fe-fa) CVS PRENATAL KP PRENATAL MULTIVITAMINS TABS MULTI+DHA CAPS F (prenatal mv & min w/fe F (prenatal vit w/ ferrous fumarate-fa-dha) fumarate-folic acid) CVS PRENATAL TABS KPN PRENATAL TABS (prenatal vit w/ ferrous F (prenatal multivit-min F fumarate-folic acid) w/fe-fa)
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225 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits M-NATAL PLUS TABS RX/OTC NEONATAL VITAMIN (prenatal vit w/ ferrous F TABS (prenatal vit w/ F fumarate-folic acid) ferrous fumarate-folic MARNATAL-F CAPS acid) (prenatal without vit a NIVA-PLUS TABS RX/OTC F w/ iron polysaccharide (prenatal vit w/ ferrous F complex-fa) fumarate-folic acid) MULTI PRENATAL TABS O-CAL FA TABS RX/OTC (prenatal vit w/ ferrous F (prenatal vit w/ ferrous F fumarate-folic acid) fumarate-folic acid) MYNATAL ADVANCE O-CAL PRENATAL TABS TABS (prenatal vit w/ (prenatal vit w/ ferrous F F docusate-iron carbonyl- fumarate-folic acid) folic acid) OBSTETRIX EC TABS RX/OTC MYNATAL CAPS (prenatal vit w/ F (prenatal multivit-min F docusate-iron carbonyl- w/fe-fa) folic acid) MYNATAL PLUS TABS OBTREX TABS (prenatal RX/OTC (prenatal vit w/ ferrous F vit w/ docusate-iron F fumarate-folic acid) carbonyl-folic acid) MYNATAL ULTRACAPLET ONE A DAY PRENATAL TABS (prenatal vit w/ F CHEW (prenatal docusate-iron carbonyl- multivitamins & F folic acid) minerals w/fa-dha) MYNATAL-Z TABS ONE A DAY WOMENS (prenatal vit w/ ferrous F PRENATAL/DHA MISC fumarate-folic acid) (prenatal vit w/ ferrous F MYNATE 90 PLUS TBCR fumarate-fa-omega 3 (prenatal vit w/ fatty acids) F docusate-fe fumarate- ONE A DAY WOMENS folic acid) PRENATAL1 CAPS NATALVIT TABS (prenatal vitamins w/ F (prenatal vit w/ ferrous F iron carbonyl-folic acid- fumarate-folic acid) omega 3) NEONATAL COMPLETE RX/OTC ONE VITE WOMENS RX/OTC PRENATALVITAMIN PLUS TABS (prenatal vit w/ ferrous fumarate-folic F TABS (prenatal vit w/ F acid) ferrous fumarate-folic acid) NEONATAL PLUS TABS RX/OTC ONE VITE WOMENS (prenatal vit w/ ferrous F PRENATALVITAMIN TABS fumarate-folic acid) (prenatal vit w/ ferrous F fumarate-folic acid)
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226 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ONE-A-DAY WOMENS PRENATAL COMPLETE PRENATAL MISC TABS (prenatal vit w/ (prenatal vit w/ ferrous F ferrous fumarate-folic F fumarate-fa-omega 3 acid) fatty acids) PRENATAL FORMULA A- PERRY PRENATAL CAPS FREE TABS (prenatal (prenatal vit w/ ferrous F without a vit w/ fe F fumarate-folic acid) fumarate-folic acid) PNV TABS 29-1 TABS PRENATAL FORMULA (prenatal vit w/ iron F CAPS (prenatal vit w/ carbonyl-folic acid) ferrous fumarate-fa- F PRE-NATAL FORMULA RX/OTC omega 3 fatty acids) TABS (prenatal multivit- F PRENATAL FORTE TABS RX/OTC min w/fe-fa) (prenatal multivit-min F PRENATABS FA TABS RX/OTC w/fe-fa) (prenatal vit w/ ferrous F PRENATAL fumarate-folic acid) GUMMIES/DHA & FOLIC PRENATAL 19 CHEW 1 ACID CHEW (prenatal MG-3 MG-3 MG-7 MG-12 multivitamins & F MCG-15 MG-20 MG-20 minerals w/fa-omega-3 MG-29 MG-30 UNIT-100 fatty acids) MG-200 MG-400 UNIT- F 1000 UNIT (prenatal vit PRENATAL LOW IRON TABS (prenatal vit w/ w/ ferrous fumarate- F folic acid) ferrous fumarate-folic acid) PRENATAL 19 TABS 1 RX/OTC MG-3 MG-3 MG-7 MG-12 PRENATAL MULTI + DHA CAPS (prenatal mv & MCG-15 MG-20 MG-20 F MG-25 MG-29 MG-30 min w/fe fumarate-fa- UNIT-100 MG-200 MG-400 F dha) UNIT-1000 UNIT PRENATAL MULTI +DHA (prenatal vit w/ CAPS (prenatal vit w/ docusate-fe fumarate- ferrous fumarate-fa- F folic acid) omega 3 fatty acids) PRENATAL ADULT PRENATAL GUMMY/DHA/FOLIC ACID MULTIVITAMIN + DHA CHEW (prenatal F MISC (prenatal mv & F multivitamins & min w/fe fumarate-fa- minerals w/fa-dha) dha) PRENATAL AND IRON RX/OTC PRENATAL TABS (prenatal multivit- F MULTIVITAMIN PLUS min w/fe-fa) DHA CAPS (prenatal mv F & min w/fe fumarate-fa- dha)
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227 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL PRENATAL TABS 0.8 MG- RX/OTC MULTIVITAMIN PLUS 1.7 MG-1.84 MG-2.6 MG-4 DHA MISC (prenatal mv F MCG-11 UNIT-18 MG-25 & min w/fe fumarate-fa- MG-27 MG-100 MG-200 F dha) MG-400 UNIT-4000 UNIT (prenatal multivit-min PRENATAL MULTIVITAMIN TABS w/fe-fa) (prenatal vit w/ ferrous F PRENATAL TABS 1 MG- RX/OTC ) 1.84 MG-2 MG-3 MG-10 fumarate-folic acid MCG-10 MG-10 MG-12 PRENATAL ONE DAILY MCG-20 MG-25 MG-27 TABS (prenatal vit w/ MG-120 MG-200 MG-1200 F F ferrous fumarate-folic MCG (prenatal vit w/ acid) ferrous fumarate-folic PRENATAL PLUS IRON acid) TABS (prenatal vit w/ F PRENATAL VITAMIN & iron carbonyl-folic acid) MINERAL TABS F PRENATAL TABS 0.5 MG- (prenatal vit w/ ferrous 0.5 MG-0.5 MG-0.75 MG- fumarate-folic acid) 0.75 MG-2.5 MCG-2.5 MG- PRENATAL VITAMIN 3.75 MG-3.75 UNIT-5 MG- TABS (prenatal vit w/ 6.75 MG-15 MG-25 MCG- F 25 MG-50 MG-100 UNIT- ferrous fumarate-folic 200 MCG-500 UNIT, 0.8 acid) MG-1.5 MG-1.7 MG-2.6 PRENATAL MG-4 MCG-11 UNIT-18 VITAMIN/IRON TABS MG-25 MG-27 MG-100 (prenatal vit w/ ferrous F MG-263 MG-400 UNIT- fumarate-folic acid) 4000 UNIT, 0.8 MG-1.7 MG-1.8 MG-2.6 MG-8 PRENATAL VITAMINS RX/OTC PLUS LOW IRON TABS MCG-20 MG-25 MG-28 F MG-30 UNIT-120 MG-200 (prenatal vit w/ ferrous MG-400 UNIT-4000 UNIT, fumarate-folic acid) F 1.5 MG-1.7 MG-2.6 MG-4 PRENATAL VITAMINS MCG-5 MG-10 MCG-18 TABS (prenatal vit w/ MG-25 MG-27 MG-100 F MG-200 MG-800 MCG- ferrous fumarate-folic 1200 MCG, 1.7 MG-1.8 acid) MG-2.6 MG-8 MCG-20 PRENATAL+DHA MISC MG-25 MG-28 MG-30 (prenatal mv & min w/fe F UNIT-120 MG-200 MG-400 fumarate-fa-dha) UNIT-800 MCG-4000 UNIT, 1.7 MG-1.84 MG-2.6 PRENATAL-U CAPS (prenatal without a vit MG-4 MCG-11 UNIT-18 F MG-25 MG-27 MG-100 w/ fe fumarate-folic MG-160 MG-200 MG-400 acid) UNIT-800 MCG-4000 UNIT (prenatal vit w/ ferrous fumarate-folic acid)
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228 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL/OMEGA- SE-NATAL 19 TABS RX/OTC 3/FOLIC ACID/IRON CAPS ( F prenatal vit w/ (prenatal vit w/ ferrous docusate-fe fumarate- F fumarate-fa-fish oil) folic acid) PRENATRIX TABS RX/OTC SIMILAC PRENATAL (prenatal vit w/ ferrous F EARLY SHIELD MISC fumarate-folic acid) (prenatal mv & min w/fe F PRENATRYL TABS RX/OTC fumarate-fa-dha) (prenatal vit w/ ferrous F SM ONE DAILY fumarate-folic acid) PRENATAL MISC PRENATVITE RX TABS RX/OTC (prenatal vit w/ ferrous F (prenatal multivit-min F fumarate-fa-omega 3 w/fe-fa) fatty acids) PREPLUS TABS RX/OTC SM PRENATAL VITAMINS TABS (prenatal vit w/ (prenatal vit w/ ferrous F F fumarate-folic acid) ferrous fumarate-folic acid) PRETAB TABS (prenatal RX/OTC vit w/ ferrous fumarate- F STUART ONE CAPS folic acid) (prenatal mv & min w/fe F carbonyl-fa-dha) PX PRENATAL MULTIVITAMINS TABS TARON-BC MISC F (prenatal without vit a (prenatal vit w/ ferrous F fumarate-folic acid) w/ iron carbonyl-folic QC PRENATAL TABS acid & vit b6) (prenatal vit w/ ferrous F THERANATAL fumarate-folic acid) COMPLETE MISC (prenatal mv & min w/fe F RA PRENATAL FORMULA/FOLICACID fumarate-fa-dha) TABS (prenatal vit w/ F THERANATAL CORE RX/OTC NUTRITION TABS ferrous fumarate-folic F acid) (prenatal vit w/ ferrous fumarate-folic acid) RA PRENATAL TABS (prenatal vit w/ ferrous F THRIVITE RX TABS fumarate-folic acid) (prenatal vit w/ iron F carbonyl-folic acid) RIGHT STEP PRENATAL TABS (prenatal vit w/ TL FOLATE TABS F (prenatal vit w/ ferrous ferrous fumarate-folic F acid) fumarate-l methylfolate- folic acid) SE-NATAL 19 CHEW (prenatal vit w/ ferrous F TRICARE TABS RX/OTC fumarate-folic acid) (prenatal vit w/ ferrous F fumarate-folic acid)
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229 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRINATAL RX 1 TABS MUSCULOSKELETAL THERAPY AGENTS - (prenatal vit w/ ferrous F Drugs to Treat Spasms fumarate-folic acid) Central Muscle Relaxants VINATE II TABS (Carisoprodol) VANADOM F (prenatal vit w/ fe TABS bisglycinate chelate- F baclofen tabs or 10 mg, F folic acid) 20 mg VINATE ONE TABS carisoprodol tabs 350 F (prenatal vit w/ ferrous F mg fumarate-folic acid) VITAFOL-OB TABS chlorzoxazone tabs F (prenatal vit w/ ferrous F 500 mg fumarate-folic acid) cyclobenzaprine hcl VITATHELY/GINGER RX/OTC tabs 10 mg, 5 mg, 7.5 F TABS (prenatal vit w/ mg F ferrous fumarate-folic methocarbamol tabs or F acid) 500 mg, 750 mg VOL-NATE TABS orphenadrine citrate F (prenatal vit w/ ferrous F tb12 or 100 mg fumarate-folic acid) tizanidine hcl tabs 2 F VOL-PLUS TABS RX/OTC mg, 4 mg (prenatal vit w/ ferrous F Direct Muscle Relaxants fumarate-folic acid) dantrolene sodium F VOL-TAB RX TABS caps (prenatal vit w/ iron F carbonyl-folic acid) NASAL AGENTS - SYSTEMIC AND TOPICAL - WEGMANS COMPLETE Drugs to treat the Nose or Sinus PRENATAL+DHA MISC Nasal Agents - Misc. (prenatal mv & min w/fe F fumarate-fa-dha) WESTAB PLUS TABS RX/OTC (prenatal vit w/ ferrous F fumarate-folic acid) YOUR LIFE MULTI PRENATAL CAPS (prenatal vit w/ ferrous F fumarate-fa-fish oil) Vitamins w/ Lipotropics (Vitamins W/ Lipotropics) B-STRESS, BALANCED B- 50 COMPLEX, F METHACHOLINE/LIVER, MULTI-VITAMIN HP/MINERALS CAPS To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
230 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Saline) AFRIN SALINE (Fluticasone Propionate RX/OTC NASAL MIST, ALTAMIST, (Nasal)) ALLERGY NASAL AYR, BABY AYR SALINE, SPRAY 24 HOUR, CVS SALINE NASAL ALLERGY RELIEF, EQ F SPRAY, DEEP SEA ALLERGY RELIEF, QC NASAL SPRAY, EQ ALLERGY RELIEF SUSP SALINE NASAL SPRAY, 50 MCG/ACT EQL SALINE NASAL (Fluticasone Propionate RX/OTC SPRAY, GNP NASAL (Nasal)) ALLERGY NASAL MOISTURIZING, HM SPRAY 24 HOUR, SALINE NASAL SPRAY, ALLERGY RELIEF, EQ F LITTLE NOSES SALINE, ALLERGY RELIEF, QC LITTLE NOSES STUFFY ALLERGY RELIEF SUSP NOSEKIT, MEIJER F NA 50 MCG/ACT SALINE NASAL SPRAY, NASAL MOIST, NASAL (Fluticasone Propionate RX/OTC MOISTURIZING SPRAY, (Nasal)) CLARISPRAY, OCEAN FOR KIDS, PX CVS FLUTICASONE SALINE NASAL SPRAY, PROPRIONATE NASAL QC SALINE NASAL SPRAY, EQL RELIEF, RA SALINE FLUTICASONE NASAL SPRAY, SALINE PROPIONATE, EQL MIST, SB SALINE NOSE, FLUTICASONE SM NASAL SPRAY PROPIONATE SALINE, TGT NASAL CHILDRENS, GNP SPRAY, TGT SALINE FLUTICASONE F NASAL SPRAY SOLN PROPIONATE, GNP FLUTICASONE saline soln F PROPIONATE CHILDRENS, HM Nasal Antiallergy ALLERGY RELIEF NASAL SPRAY 24HR, KLS azelastine hcl soln F ALLER-FLO, QC FLUTICASONE cromolyn sodium F PROPIONATE, SM (nasal) aers ALLERGY RELIEF NASAL Nasal Anticholinergics SPRAY SUSP (Triamcinolone Acetonide ipratropium bromide F (Nasal)) ALLERGY NASAL F (nasal) soln SPRAY 24 HOUR AERO Nasal Steroids 55 MCG/ACT (Budesonide (Nasal)) CVS BUDESONIDE NASAL SPRAY, EQ BUDESONIDE NASAL SPRAY, GNP BUDESONIDE NASAL F SPRAY, RA BUDESONIDE NASAL SPRAY, RHINOCORT ALLERGY SUSP
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231 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Triamcinolone Acetonide (Phenylephrine Hcl (Oral)) (Nasal)) CVS NASAL CVS NASAL ALLERGY SPRAY, EQ DECONGESTANT PE, NASAL ALLERGY SPRAY, CVS SINUS PE GNP 24 HOUR NASAL DECONGESTANT, EQL ALLERGY SPRAY, NASAL DECONGESTANT GOODSENSE NASAL F PE MAXIMUM ALLERGY SPRAY, NASAL STRENGTH, GNP NASAL ALLERGY 24 HOUR, DECONGESTANT PE NASAL ALLERGY 24 MAXIMUM STRENGTH, HOUR MULTI-SYMPTOM, HM NASAL RA NASAL ALLERGY DECONGESTANT PE, SPRAY AERO KLS SUPHEDRINE PE, budesonide (nasal) NASAL DECONGESTANT F PE, NASAL F susp DECONGESTANT PE flunisolide (nasal) soln F MAXIMUM STRENGTH, NON-PSEUDO SINUS RX/OTC DECONGESTANT, PX fluticasone propionate F (nasal) susp NASAL DECONGESTANT PE, QC NASAL triamcinolone F DECONGESTANT PE, RA acetonide (nasal) aero NASAL DECONGESTANT Sympathomimetic Decongestants PE, RA SINUS PRESSURE/CONGESTIO N RELIEF PE, SM NASAL DECONGESTANT PE, SUDOGEST PE, WAL- PHED PE TABS
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232 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pseudoephedrine Hcl) 12 (Pseudoephedrine Hcl) HOUR DECONGESTANT, CVS NASAL 12 HOUR NASAL DECONGESTANT, DECONGESTANT, CVS DECONGESTANT, EQL 12 HOUR NASAL NASAL DECONGESTANT, DECONGESTANT, GNP EQL NASAL PSEUDOEPHEDRINE DECONGESTANT HCL ER, GNP MAXIMUM STRENGTH, PSEUDOEPHEDRINE GENAPHED, GNP NASAL HCL12 HOUR, HM NASAL DECONGESTANT, GNP DECONGESTANT NASAL 12HOUR, NASAL DECONGESTANT/MAXIM DECONGESTANT 12 UM STRENGTH, HM HOUR SINUS, PX NASAL NASAL DECONGESTANT, DECONGESTANT, QC KP PSEUDOEPHEDRINE SUPHEDRINE MAXIMUM F HCL, MEIJER NASAL STRENGTH, RA DECONGESTANT, NASAL F SUPHEDRINE, SHOPKO DECONGESTANT NASAL DECONGESTANT, MAXIMUM STRENGTH, SINUS 12 HOUR, SM 12 PX NASAL HOUR SINUS DECONGESTANT, QC DECONGESTANT, SUPHEDRINE, RA SUDAFED 12 HOUR, SUPHEDRINE, SHOPKO SUDAFED SINUS NASAL CONGESTION12 HOUR, DECONGESTANTMAXIM SUDOGEST 12 HOUR, UM STRENGTH, SINUS SUPHEDRINE 12HOUR CONGESTION MAXIMUM STRENGTH, MAXIMUMSTRENGTH, TGT SINUS 12 HOUR, SM NASAL WAL-PHED 12 HOUR, DECONGESTANT WAL-PHED D TB12 MAXIMUM STRENGTH, SUDOGEST, SUDOGEST MAXIMUM STRENGTH, WAL-PHED TABS (Pseudoephedrine Hcl) F GNP SUPHEDRIN LIQD (Pseudoephedrine Hcl) NASAL DECONGESTANT F TABS OR 30 MG ADRENALIN SOLN (epinephrine hcl F (nasal)) epinephrine hcl (nasal) F soln phenylephrine hcl (oral) F tabs pseudoephedrine hcl F tabs
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233 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA pseudoephedrine hcl F dextrose soln 10 %, tb12 250 mg/ml, 5 %, 50 %, F SUDAFED CHILDRENS 70 % LIQD (pseudoephedrine F DEXTROSE SOLN 20 %, PA F hcl) 40 % (dextrose) SUDAFED PE POLYCOSE LIQD QL(124 ml per F CHILDRENS NASAL (glucose polymer) fill retail) DECONGESTANT SOLN F POLYCOSE POWD QL(350 gm per F (phenylephrine hcl (glucose polymer) fill retail) (oral)) Lipids NEUROMUSCULAR AGENTS - Drugs to CLINOLIPID EMUL ( PA Relax/Paralyze Muscles fat F emulsion plant based) ALS Agents INTRALIPID EMUL ( PA RADICAVA SOLN PA; SP- fat F F ) (edaravone) Caremark;SP emulsion plant based NUTRILIPID EMUL ( PA fat F riluzole tabs F emulsion plant based) Muscular Dystrophy Agents Misc. Nutritional Substances EXONDYS 51 SOLN PA; SP (Docosahexaenoic Acid) F (eteplirsen) ALGAL OMEGA-3 DHA, ATABEX DHA 200, DHA F Neuromuscular Blocking Agent - Neurotoxins COMPLETE, DHA BOTOX SOLR PA; SP- NATURAL OMEGA-3, F AcariaHealth;S PRENATAL DHA CAPS (onabotulinumtoxina) P (Omega-3 Fatty Acids) DYSPORT SOLR PA; SP- CVS FISH OIL CAPS 300 F AcariaHealth;S MG-1000 MG, 360 MG- F (abobotulinumtoxina) P 1200 MG, 360 MG-455 MG-900 MG-1000 MG MYOBLOC SOLN PA; SP- F AcariaHealth;S (rimabotulinumtoxinb) P XEOMIN SOLR PA; SP- F AcariaHealth;S (incobotulinumtoxina) P Spinal Muscular Atrophy Agents (SMA) SPINRAZA SOLN PA F (nusinersen) NUTRIENTS Carbohydrates DEXTROSE 20% SOLN PA F (dextrose)
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234 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Omega-3 Fatty Acids) (Omega-3 Fatty Acids) CVS NATURAL FISH OIL, FISH OIL MAXIMUM F EQL FISH OIL, EQL STRENGTH CAPS 1200 OMEGA 3 FISH OIL, MG ESKIMO PUREFA, FISH (Omega-3 Fatty Acids) OIL DOUBLE STRENGTH, GNP FISH OIL CAPS 300 F FISH OIL OMEGA-3, FISH MG-1000 MG OIL/SUPER POTENT/NOBURP, KP (Omega-3 Fatty Acids) HM FISH OIL, MAXEPA, FISH OIL CAPS 300 MG- F MAXIMUM EPA, 1000 MG, 360 MG-1200 NORWEGIAN SALMON MG OIL, OMEGA III EPA+DHA, (Omega-3 Fatty Acids) KP OMEGA-3 CF, OMEGA-3 F OMEGA-3 FISH OIL CAPS F PLUS, OMERA, PX FISH 600 MG-1200 MG OIL, QC FISH OIL, SB (Omega-3 Fatty Acids) RA OMEGA-3 FISH OIL, SEA- FISH OIL CAPS 100 MG- F OMEGA, SEA-OMEGA 30, 160 MG-1000 MG, 120 SM OMEGA-3 FISH OIL, MG-180 MG SUPER DHA GEMS, (Omega-3 Fatty Acids) SM SUPER OMEGA 3 FISH OIL CAPS 120 MG- EPA/DHA FORMULA, 180 MG-1000 MG, 300 F SUPER OMEGA-3, MG-1000 MG, 360 MG- THERAGRAN-M FISH OIL 1200 MG CONCENTRATE, THEROMEGA, ULTRA docosahexaenoic acid F OMEGA-3 CAPS caps (Omega-3 Fatty Acids) EQL OMEGA-3 FISH OIL CAPS 120 MG-180 MG- F 300 MG-1000 MG, 144 MG-216 MG-360 MG-1200 MG (Omega-3 Fatty Acids) FISH OIL BURP-LESS CAPS 300 MG-1000 MG, F 60 MG-120 MG-180 MG- 1200 MG, 60 MG-300 MG- 360 MG-1200 MG (Omega-3 Fatty Acids) FISH OIL CONCENTRATE F CAPS 120 MG-180 MG- 300 MG, 300 MG-1000 MG (Omega-3 Fatty Acids) FISH OIL EXTRA F STRENGTH CAPS 360 MG-1200 MG
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235 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits omega-3 fatty acids (Amino Acid Infusion) PA caps 1 unit-120 mg-180 CLINISOL SF 15%, F mg-1000 mg, 1 unit- HEPATAMINE, 120 mg-180 mg-340 PLENAMINE SOLN AMINOSYN II SOLN 172 PA mg-1000 mg, 1 unit- MG/100ML-200 300 mg-1000 mg, 1 MG/100ML-270 unit-300 mg-1000 mg- MG/100ML-298 1000 mg, 100 mg-150 MG/100ML-300 mg-300 mg-1000 mg, MG/100ML-400 1000 mg, 108 mg-180 MG/100ML-500 MG/100ML-500 mg-360 mg-1200 mg, MG/100ML-530 12 mg-360 mg-360 mg- MG/100ML-660 1200 mg, 120 mg-180 MG/100ML-700 mg, 120 mg-180 mg- MG/100ML-722 1000 mg, 120 mg-180 MG/100ML-738 mg-300 mg, 120 mg- MG/100ML-993 MG/100ML-1000 180 mg-300 mg-1000 F MG/100ML-1018 mg, 1200 mg, 144 mg- MG/100ML-1050 180 mg-1200 mg, 144 MG/100ML, 38 MEQ/L-71.8 mg-216 mg-1200 mg, MEQ/L-172 MG/100ML- F 144 mg-216 mg-360 200 MG/100ML-270 mg-1200 mg, 15 unit- MG/100ML-298 MG/100ML-300 144 mg-216 mg-1200 MG/100ML-400 mg, 180 mg-270 mg- MG/100ML-500 1000 mg, 3 mg-108 MG/100ML-500 mg-162 mg-1000 mg, MG/100ML-530 300 mg-1000 mg, 350 MG/100ML-660 mg-1000 mg, 360 mg- MG/100ML-700 MG/100ML-722 1200 mg, 5 unit-120 MG/100ML-738 mg-180 mg, 60 mg-120 MG/100ML-993 mg-180 mg-1200 mg, MG/100ML-1000 60 mg-300 mg-360 mg- MG/100ML-1018 1200 mg, 600 mg-1000 MG/100ML-1050 mg, 600 mg-1200 mg MG/100ML (amino acid infusion) Protein-Carbohydrate-Lipid Combinations AMINOSYN-PF 7% SOLN PA KABIVEN EMUL (amino PA F (amino acid infusion) acids-dextrose-lipids F AMINOSYN-PF SOLN PA with electrolytes) F (amino acid infusion) PERIKABIVEN EMUL PA ( CLINIMIX PA amino acids-dextrose- F 4.25%/DEXTROSE 10% ) lipids with electrolytes SOLN (amino acid F Proteins infusion in d10w)
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236 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLINIMIX PA FREAMINE III SOLN PA F 4.25%/DEXTROSE 25% ( ) F amino acid infusion SOLN (amino acid NEPHRAMINE SOLN PA F infusion in d25w) (amino acid infusion) CLINIMIX PA PREMASOL SOLN PA F 4.25%/DEXTROSE 5% (amino acid infusion) SOLN (amino acid F PROSOL SOLN ( PA infusion in d5w) amino F acid infusion) CLINIMIX 5%/DEXTROSE PA SYNTHAMIN 17 SOLN PA 15% SOLN (amino acid F F infusion in d15w) (amino acid infusion) TRAVASOL SOLN PA CLINIMIX 5%/DEXTROSE PA F 20% SOLN (amino acid F (amino acid infusion) TROPHAMINE SOLN PA infusion in d20w) F CLINIMIX 5%/DEXTROSE PA (amino acid infusion) 25% SOLN (amino acid F OPHTHALMIC AGENTS - Drugs to Treat the Eye infusion in d25w) CLINIMIX E PA Artificial Tears and Lubricants 2.75%/DEXTROSE 10% (Polyvinyl Alcohol) SOLN (amino acid F ARTIFICIAL TEARS SOLN F electrolyte w/ calcium 1.4 % infusion in d10w) (Polyvinyl Alcohol) TEARS F AGAIN SOLN CLINIMIX E PA 2.75%/DEXTROSE 5% SOLN (amino acid F electrolyte w/ calcium infusion in d5w) CLINIMIX E PA 4.25%/DEXTROSE 10% SOLN (amino acid F electrolyte w/ calcium infusion in d10w) CLINIMIX E PA 4.25%/DEXTROSE 5% SOLN (amino acid F electrolyte w/ calcium infusion in d5w) CLINIMIX N9G20E SOLN PA (amino acid electrolyte w/ calcium infusion in F d10w) FREAMINE HBC 6.9% PA SOLN (amino acid F infusion)
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237 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (White Petrolatum-Mineral QL(42 gm per carteolol hcl (ophth) F Oil) ALTALUBE, fill retail) soln ARTIFICAL EYE, CVS DRY-EYE RELIEF dorzolamide hcl-timolol NIGHTTIME, CVS EYE maleate soln 0.5 %-2 F LUBRICANT, CVS %, 5 mg/ml-20 mg/ml, LUBRICATING EYE 6.8 mg/ml-22.3 mg/ml OINTMENT/OVERNIGHT, CVS NIGHTTIME DRY- levobunolol hcl soln F EYE RELIEF, EQ RESTORE PM, EYE timolol maleate (ophth) F LUBRICANT, FOR STY solg 0.25 %, 0.5 % RELIEF, GENTEAL timolol maleate (ophth) TEARS NIGHT-TIME, GNP F LUBRICANT PM, soln 0.25 %, 0.5 % timolol maleate (ophth) QL(60 ea per HYPOTEARS, F F LUBRICANT EYE, soln 0.5 % fill retail) LUBRICANT EYE FAST TIMOPTIC OCUDOSE ACTING, LUBRICANT EYE NIGHTTIME, LUBRICANT SOLN 0.25 % (timolol F EYE PM, LUBRICANT PM, maleate (ophth)) LUBRIFRESH P.M., TIMOPTIC-XE SOLG PURALUBE, REFRESH (timolol maleate F LACRI-LUBE, REFRESH (ophth)) P.M., RETAINE PM, SOOTHE NIGHTTIME Cycloplegic Mydriatics DRY EYETHERAPY, (Homatropine Hbr) F STYE, SYSTANE HOMATROPAIRE SOLN NIGHTTIME, TEARS (Phenylephrine Hcl AGAIN, TGT LUBRICANT (Mydriatic)) ALTAFRIN F EYE NIGHTTIME, ULTRA SOLN 2.5 % FRESH PM OINT (White Petrolatum-Mineral QL(42 gm per atropine sulfate F Oil) ARTIFICIAL TEARS F fill retail) (ophthalmic) oint OINT 15 %-83 %-83 % ATROPINE SULFATE NUTRATEAR SOLN SOLN OP 1 % (atropine F F (polyvinyl alcohol) sulfate (ophthalmic)) polyvinyl alcohol soln F CYCLOMYDRIL SOLN (cyclopentolate w/ F Beta-blockers - Ophthalmic phenylephrine) (Timolol Maleate (Ophth)) QL(60 ea per cyclopentolate hcl soln F TIMOLOL MALEATE IN F fill retail) OCUDOSE SOLN homatropine hbr soln F betaxolol hcl (ophth) F soln ISOPTO ATROPINE SOLN (atropine sulfate F BETOPTIC-S SUSP F (ophthalmic)) (betaxolol hcl (ophth)) phenylephrine hcl F (mydriatic) soln 2.5 %
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238 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tropicamide soln F erythromycin (ophth) F oint Miotics gatifloxacin (ophth) soln F PHOSPHOLINE IODIDE SOLR (echothiophate F gentamicin sulfate F iodide) (ophth) soln QL(3 ml per fill pilocarpine hcl soln F moxifloxacin hcl (ophth) F soln retail) Ophthalmic - Angiogenesis Inhibitors NATACYN SUSP F LUCENTIS SOLN 0.3 PA; SP- (natamycin) MG/0.05ML, 0.5 AcariaHealth;S F MG/0.05ML P neomycin-bacitracin zn- F (ranibizumab) polymyxin oint LUCENTIS SOSY 0.5 PA; SP- neomycin-polymyxin- F MG/0.05ML F AcariaHealth;S gramicidin soln P (ranibizumab) ofloxacin (ophth) soln F Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 0.1 % polymyxin b- F F trimethoprim soln (brimonidine tartrate) sulfacetamide sodium F apraclonidine hcl soln F (ophth) oint sulfacetamide sodium brimonidine tartrate F F soln (ophth) soln IOPIDINE SOLN F tobramycin (ophth) soln F (apraclonidine hcl) TOBREX OINT Ophthalmic Anti-infectives F (tobramycin (ophth)) (Bacitracin-Polymyxin B (Ophth)) AK-POLY-BAC, F trifluridine soln F POLYCIN OINT Ophthalmic Decongestants (Gentamicin Sulfate F (Ophth)) GENTAK OINT (Naphazoline W/ (Neomycin-Bacitracin Zn- Pheniramine) ALLERGY Polymyxin) NEO-POLYCIN F EYE DROPS, CVS EYE OINT ALLERGY RELIEF, EQ EYE ALLERGY RELIEF, F bacitracin (ophthalmic) F EYE ALLERGY RELIEF, oint RA EYE ALLERGY RELIEF, TGT EYE bacitracin-polymyxin b F (ophth) oint ALLERGY RELIEF SOLN (Naphazoline W/ CILOXAN OINT Pheniramine) VISINE F (ciprofloxacin hcl F SOLN 0.025 %-0.3 % (ophth)) ciprofloxacin hcl F (ophth) soln
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239 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Tetrahydrozoline Hcl QL(30 ml per dexamethasone (Ophth)) CVS EYE DROPS fill retail) sodium phosphate F ORIGINAL, EQ EYE (ophth) soln DROPS, EQL EYE fluorometholone DROPS, EYE DROPS, HM F F EYE DROPS, PX STERILE (ophth) susp EYE DROPS, QC EYE FML FORTE SUSP DROPS, REDNESS RELIEVER EYE DROPS, (fluorometholone F SM EYE DROPS SOLN (ophth)) (Tetrahydrozoline Hcl QL(30 ml per FML OINT (fluorometholone F (Ophth)) GNP EYE F fill retail) DROPS, GOODSENSE (ophth)) EYE DROPS SOLN 0.05 % MAXIDEX SUSP Ophthalmic Immunomodulators (dexamethasone F RESTASIS EMUL PA (ophth)) F (cyclosporine (ophth)) neomycin-polymy- F RESTASIS MULTIDOSE PA dexameth oint EMUL (cyclosporine F neomycin-polymy- F (ophth)) dexameth susp Ophthalmic Kinase Inhibitors neomycin-polymyxin-hc F RHOPRESSA SOLN PA F (ophth) susp (netarsudil dimesylate) PRED MILD SUSP Ophthalmic Local Anesthetics (prednisolone acetate F (Tetracaine Hcl (Ophth)) (ophth)) ALTACAINE, TETCAINE, F PRED-G S.O.P. OINT TETRAVISC, TETRAVISC (gentamicin- F FORTE SOLN prednisolone acetate) proparacaine hcl soln F PA PRED-G SUSP (gentamicin- F tetracaine hcl (ophth) F prednisolone acetate) soln prednisolone acetate F Ophthalmic Steroids (ophth) susp (Bacitracin-Poly-Neomycin- PREDNISOLONE Hc) NEO-POLYCIN HC F ACETATE P-F SUSP OINT (prednisolone acetate F bacitracin-poly- F (ophth)) neomycin-hc oint PREDNISOLONE SODIUM BLEPHAMIDE S.O.P. PHOSPHATE SOLN OP 1 OINT (sulfacetamide F % (prednisolone sodium F sod-prednisolone) phosphate (ophth)) BLEPHAMIDE SUSP sulfacetamide sod- F (sulfacetamide sod- F prednisolone soln prednisolone)
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240 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOBRADEX OINT QL(4 gm per fill QL(10 ml per cromolyn sodium F (tobramycin- F retail) (ophth) soln fill retail) dexamethasone) Limit 4 bottles CYSTARAN SOLN per tobramycin- F F dexamethasone susp (cysteamine hcl) month;QL(2.15 ml daily) Ophthalmics - Misc. QL(5 ml per fill diclofenac sodium F (Ketotifen Fumarate (ophth) soln retail) (Ophth)) ALAWAY, ALAWAY CHILDRENS dorzolamide hcl soln F ALLERGYEYE ITCH DORZOLAMIDE HCL RELIEF, ALLERGY EYE F DROPS, CLARITIN EYE, SOLN (dorzolamide hcl) CVS ALLERGY EYE flurbiprofen sodium DROPS, CVS EYE ITCH F RELIEF, EYE ITCH F soln RELIEF, GNP EYE ITCH ketorolac tromethamine F RELIEF, GNP ITCHY EYE, (ophth) soln HM EYE ITCH RELIEF, KP KETOTIFEN FUMARATE, ketotifen fumarate F RA EYE ITCH RELIEF, SM (ophth) soln EYE ITCH RELIEF, MURO 128 SOLN 2 % THERATEARS ALLERGY (sodium chloride F EYE ITCH RELIEF SOLN hypertonic) (Sodium Chloride Hypertonic) sodium chloride F hypertonic oint ALTACHLORE, CVS F SODIUM CHLORIDE, CVS sodium chloride F SODIUM CHLORIDE hypertonic soln HYPERTONICITY OINT (Sodium Chloride Prostaglandins - Ophthalmic Hypertonic) Limit 2.5mls ALTACHLORE, CVS F bimatoprost soln F per SODIUM CHLORIDE, month;QL(0.09 SOCHLOR SOLN ml daily) ALOCRIL SOLN QL(5 ml per fill latanoprost soln F (nedocromil sodium F retail) ) Limit 2.5mls (ophth) LUMIGAN SOLN F per ALOMIDE SOLN QL(10 ml per (bimatoprost) month;QL(0.09 (lodoxamide F fill retail) ml daily) tromethamine) OTIC AGENTS - Drugs to Treat the Ear azelastine hcl (ophth) F soln Otic Agents - Miscellaneous F QL(15 ml per brinzolamide susp fill retail) bromfenac sodium F (ophth) soln
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241 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Carbamide Peroxide neomycin-polymyxin-hc F (Otic)) CLEARCANAL (otic) susp EARWAX SOFTENER, CVS EAR DROPS, CVS Otic Steroids EARWAX REMOVAL KIT, (Fluocinolone Acetonide F QL(20 ml per CVS EARWAX REMOVAL (Otic)) FLAC OIL fill retail) SYSTEM, EAR DROPS, fluocinolone acetonide QL(20 ml per EAR DROPS EARWAX F fill retail) REMOVALAID, EAR WAX (otic) oil REMOVAL DROPS, EAR QL(10 ml per hydrocortisone w/acetic F WAX REMOVAL KIT, EAR acid soln fill retail) WAX REMOVAL SYSTEM, EARWAX REMOVAL, OXYTOCICS - Drugs to Prevent/Control Uterine EARWAX REMOVAL KIT, Bleeding EQ EAR DROPS, EQ EAR Oxytocics WAX REMOVAL AID, GNP EAR DROPS, GNP EAR F (Methylergonovine SYSTEMS, GNP EARWAX Maleate) METHERGINE F REMOVAL DROPS, GNP TABS EARWAX REMOVAL KIT, methylergonovine F GOODSENSE EAR WAX maleate tabs or 0.2 mg REMOVAL DROPS, GOODSENSE EAR WAX PASSIVE IMMUNIZING AND TREATMENT REMOVAL KIT, MURINE AGENTS - Antibody Drugs to Treat Low Immune EAR, MURINE FOR EAR System WAX REMOVAL SYSTEM, Immune Serums OTIX, QC EAR WAX HYPERRHO S/D SOSY SP- REMOVAL DROPS, QC (rho d immune globulin F AcariaHealth;S EARWAX REMOVAL, QC P EARWAX REMOVAL KIT, (human)) RA EAR DROPS, RA RHOGAM ULTRA- SP- EARWAX REMOVAL KIT, FILTERED PLUS SOSY AcariaHealth;S SM EAR DROPS SOLN (rho d immune globulin F P acetic acid (otic) soln F (human)) Monoclonal Antibodies Otic Anti-infectives SYNAGIS SOLN PA; SP- ciprofloxacin hcl (otic) F F AcariaHealth;S soln (palivizumab) P ofloxacin (otic) soln F PENICILLINS - Drugs to Treat Bacterial Infections Otic Combinations Aminopenicillins (Pramoxine-Hc- QL(15 ml per F Chloroxylenol) CORTIC- F fill retail) amoxicillin caps ND, EXOTIC-HC SOLN amoxicillin chew F QL(7.5 ml per ciprofloxacin- F dexamethasone susp 30 days retail) amoxicillin susr F neomycin-polymyxin-hc F (otic) soln amoxicillin tabs F
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242 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ampicillin caps F SIMPLYTHICK GEL (xanthan gum F Natural Penicillins (thickening)) penicillin v potassium F Semi Solid Vehicles solr (Lanolin) HPA LANOLIN F RX/OTC OINT penicillin v potassium F tabs lanolin oint F RX/OTC Penicillin Combinations PROGESTINS - Hormone Replacement/Modifying amoxicillin & pot F Drugs clavulanate chew Progestins amoxicillin & pot F hydroxyprogesterone PA; SP- clavulanate susr F caproate oil AcariaHealth amoxicillin & pot F MAKENA SOAJ SC 275 PA; SP- clavulanate tabs MG/1.1ML AcariaHealth F amoxicillin & pot F (hydroxyprogesterone clavulanate tb12 caproate) AUGMENTIN SUSR 31.25 medroxyprogesterone F MG/5ML-125 MG/5ML acetate tabs (amoxicillin & pot F norethindrone acetate clavulanate) F tabs Penicillinase-Resistant Penicillins QL(1 ea daily) progesterone caps 100 F dicloxacillin sodium F mg caps progesterone caps 200 PA F nafcillin sodium solr ij 1 F mg gm, 2 gm PSYCHOTHERAPEUTIC AND NEUROLOGICAL PA nafcillin sodium solr iv F AGENTS - MISC. - Drugs to Treat Mental and 1 gm, 10 gm, 2 gm Emotional Conditions NAFCILLIN SODIUM PA Agents for Chemical Dependency SOLR IV 10 GM (nafcillin F acamprosate calcium CO sodium) tbec PHARMACEUTICAL ADJUVANTS ANTABUSE TABS CO (disulfiram) Internal Vehicle Ingredients/Agents SIMPLYTHICK EASY MIX disulfiram tabs CO GEL (xanthan gum F LUCEMYRA TABS CO (thickening)) (lofexidine hcl) SIMPLYTHICK EASYMIX Antidementia Agents GEL (xanthan gum F (thickening)) donepezil F hydrochloride tabs donepezil F hydrochloride tbdp To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
243 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits galantamine F Multiple Sclerosis Agents hydrobromide cp24 (Glatiramer Acetate) PA; SP- F AcariaHealth;S galantamine F GLATOPA SOSY hydrobromide soln P AUBAGIO TABS PA; SP- galantamine F F AcariaHealth;S hydrobromide tabs (teriflunomide) P memantine hcl cp24 14 PA AVONEX PEN AJKT PA; SP- mg, 21 mg, 28 mg, 7 F F AcariaHealth;S (interferon beta-1a) mg P memantine hcl soln 10 AVONEX PSKT PA; SP- F F AcariaHealth;S mg/5ml, 2 mg/ml (interferon beta-1a) P memantine hcl tabs 10 F BETASERON KIT PA; SP- mg, 5 mg, F AcariaHealth;S (interferon beta-1b) NAMENDA XR TITRATION PA P PACK CP24 (memantine F dalfampridine tb12 F PA; SP hcl) PA; SP rivastigmine pt24 F PA dimethyl fumarate cpdr F PA dimethyl fumarate misc F PA; SP rivastigmine tartrate F caps EXTAVIA KIT (interferon PA; SP- Combination Psychotherapeutics F AcariaHealth;S beta-1b) P chlordiazepoxide- F amitriptyline tabs GILENYA CAPS 0.5 MG PA; SP- F AcariaHealth;S (fingolimod hcl) olanzapine-fluoxetine CO P hcl caps PA; SP- glatiramer acetate sosy F AcariaHealth;S perphenazine- F amitriptyline tabs P SYMBYAX CAPS LEMTRADA SOLN PA; SP- F Caremark;SP (olanzapine-fluoxetine CO (alemtuzumab (ms)) hcl) OCREVUS SOLN PA; SP- F AcariaHealth;S Fibromyalgia Agents (ocrelizumab) P SAVELLA TABS PA PLEGRIDY SOPN SC PA; SP F F (milnacipran hcl) (peginterferon beta-1a) SAVELLA TITRATION PA; QL(55 ea PLEGRIDY SOSY SC PA; SP F PACK MISC F per 365 days (peginterferon beta-1a) ( ) retail) milnacipran hcl PLEGRIDY STARTER PA; SP Movement Disorder Drug Therapy PACK SOPN F AL(At least 21 (peginterferon beta-1a) tetrabenazine tabs 12.5 F mg yrs old) PLEGRIDY STARTER PA; SP AL(At least 21 PACK SOSY F tetrabenazine tabs 25 F mg yrs old); SP (peginterferon beta-1a) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
244 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REBIF REBIDOSE SOAJ PA; SP- (Nicotine Polacrilex) CVS F AcariaHealth;S NICOTINE LOZENGE, (interferon beta-1a) P CVS NICOTINE REBIF REBIDOSE PA; SP- POLACRILEX, EQ TITRATIONPACK SOAJ F AcariaHealth;S NICOTINE LOZENGES, (interferon beta-1a) P EQ NICOTINE POLACRILEX, EQL REBIF SOSY (interferon PA; SP- NICOTINE POLACRILEX, F AcariaHealth;S beta-1a) GNP NICOTINE MINI P LOZENGE, GNP REBIF TITRATION PACK PA; SP- NICOTINE POLACRILEX, SOSY (interferon beta- F AcariaHealth;S GNP NICOTINE 1a) P POLACRILEX MINI, GOODSENSE NICOTINE, F TYSABRI CONC PA; SP- GOODSENSE NICOTINE F AcariaHealth;S (natalizumab) POLACRILEX, HM P NICOTINE POLACRILEX, Premenstrual Dysphoric Disorder (PMDD) Agents KLS QUIT2, KLS QUIT4, QL(1 ea NICOTINE MINI LOZENGE, NICOTINE fluoxetine hcl (pmdd) F daily,270 ea caps 10 mg per 9999 days POLACRILEX MINI, PX retail) STOP SMOKING AID, RA MINI NICOTINE, RA QL(2 ea daily) fluoxetine hcl (pmdd) F NICOTINE POLACRILEX, caps 20 mg SM NICOTINE, SM NICOTINE POLACRILEX, Psychotherapeutic and Neurological Agents - TGT NICOTINE ergoloid mesylates tabs F POLACRILEX LOZG pimozide tabs CO Smoking Deterrents
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
245 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine Polacrilex) CVS (Nicotine) CVS NICOTINE NICOTINE, CVS TRANSDERMALSYSTEM, NICOTINE POLACRILEX, CVS NICOTINE CVS NICOTINE TRANSDERMALSYSTEM POLACRILEX STARTER, STEP 1, CVS NICOTINE EQ NICOTINE TRANSDERMALSYSTEM POLACRILEX, EQL STEP 2, CVS NICOTINE NICOTINE POLACRILEX, TRANSDERMALSYSTEM/ EQL NICOTINE STEP 3, EQ NICOTINE, POLACRILEX REFILL, EQ NICOTINE STEP 3, EQL NICOTINE GNP NICOTINE POLACRILEX STARTER, TRANSDERMALSYSTEM, GNP NICOTINE GUM, GNP NICOTINE GNP NICOTINE F TRANSDERMALSYSTEM POLACRILEX, STEP 2, HABITROL, HM GOODSENSE NICOTINE NICOTINE GUM, GOODSENSE TRANSDERMAL SYSTEM, NICOTINE POLACRILEX HM NICOTINE GUM, HM NICOTINE TRANSDERMAL SYSTEM POLACRILEX, KLS QUIT2, STEP 1, HM NICOTINE KLS QUIT4, PX STOP TRANSDERMAL SYSTEM SMOKING AID, RA STEP 2, HM NICOTINE NICOTINE, RA NICOTINE TRANSDERMAL SYSTEM GUM, SM NICOTINE, SM STEP 3, HM NICOTINE NICOTINE POLACRILEX, TRANSDERMALSYSTEM, TGT NICOTINE GUM, TGT NICOTINE STEP 1, F NICOTINE POLACRILEX, NICOTINE STEP 3, THRIVE GUM NICOTINE TRANSDERMAL SYSTEM STEP 1, NICOTINE TRANSDERMAL SYSTEM STEP 1/CLEAR, NICOTINE TRANSDERMAL SYSTEM STEP 2, NICOTINE TRANSDERMAL SYSTEM STEP 2/CLEAR, NICOTINE TRANSDERMAL SYSTEM STEP 3, NICOTINE TRANSDERMAL SYSTSTEM STEP 3/CLEAR, QC NICOTINE TRANSDERMAL SYSTEM/STEP 1, QC NICOTINE TRANSDERMAL SYSTEM/STEP 2, RA NICOTINE, RA NICOTINE TRANSDERMAL SYSTEM, SM NICOTINE TRANSDERMAL SYSTEM, To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
246 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SM NICOTINE ARALAST NP SOLR 1000 PA; SP TRANSDERMAL MG (alpha1-proteinase F SYSTEM/STEP 1/CLEAR, inhibitor (human)) SM NICOTINE TRANSDERMAL ARALAST NP SOLR 500 PA; SP- SYSTEM/STEP 2/CLEAR, MG (alpha1-proteinase F Caremark;SP SM NICOTINE inhibitor (human)) TRANSDERMAL GLASSIA SOLN (alpha1- PA; SP- SYSTEM/STEP 3/CLEAR, Caremark;SP TGT NICOTINE STEP proteinase inhibitor F ONE, TGT NICOTINE (human)) STEP THREE, TGT PROLASTIN-C SOLN PA; SP NICOTINE STEP TWO (alpha1-proteinase F PT24 inhibitor (human)) APO-VARENICLINE TABS QL(2 ea daily) F PROLASTIN-C SOLR PA; SP (varenicline tartrate) (alpha1-proteinase F QL(2 ea daily) bupropion hcl (smoking F inhibitor (human)) deterrent) tb12 ZEMAIRA SOLR (alpha1- PA; SP CHANTIX CONTINUING QL(2 ea daily) proteinase inhibitor F MONTHPAK TABS F (human)) (varenicline tartrate) CHANTIX STARTING Cystic Fibrosis Agents KALYDECO PACK PA; SP MONTH PAK TABS F F (varenicline tartrate) (ivacaftor) CHANTIX TABS QL(2 ea daily) KALYDECO TABS PA; SP F F (varenicline tartrate) (ivacaftor) ORKAMBI PACK PA; SP- Acaria F F nicotine polacrilex gum (lumacaftor-ivacaftor) Health;SP ORKAMBI TABS PA; SP- Acaria nicotine polacrilex lozg F F (lumacaftor-ivacaftor) Health;SP F nicotine pt24 PULMOZYME SOLN SP- F AcariaHealth;S NICOTINE (dornase alfa) P TRANSDERMAL SYSTEM F SYMDEKO TBPK PA KIT (nicotine) F (tezacaftor-ivacaftor) QL(16.8 ea NICOTROL INHALER SULFONAMIDES - Drugs to Treat Bacterial F daily,1512 ea INHA (nicotine) per 90 days Infections retail) Sulfonamides NICOTROL NS SOLN QL(360 ml per SULFADIAZINE TABS F 90 days retail) F (nicotine) (sulfadiazine) RESPIRATORY AGENTS - MISC. - Drugs to TETRACYCLINES - Drugs to Treat Bacterial Treat Lung Conditions Infections Alpha-Proteinase Inhibitor (Human) Tetracyclines
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
247 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Doxycycline (Thyroid) NP THYROID (Monohydrate)) AVIDOXY F 120, NP THYROID 15, NP TABS THYROID 30, NP F (Doxycycline THYROID 60, NP THYROID 90 TABS (Monohydrate)) F MONDOXYNE NL CAPS ARMOUR THYROID TABS 100 MG 120 MG, 15 MG, 30 MG, F (Doxycycline Hyclate) 60 MG, 90 MG (thyroid) MORGIDOX 1X100MG, ARMOUR THYROID TABS MORGIDOX 1X50MG, F 180 MG, 240 MG, 300 MG F MORGIDOX 2X100MG (thyroid) CAPS CYTOMEL TABS 5 MCG F doxycycline (liothyronine sodium) (monohydrate) caps F 100 mg, 50 mg levothyroxine sodium tabs or 100 mcg, 112 doxycycline mcg, 125 mcg, 137 (monohydrate) susr 25 F mcg, 150 mcg, 175 F mg/5ml mcg, 200 mcg, 25 mcg, doxycycline 300 mcg, 50 mcg, 75 (monohydrate) tabs F mcg, 88 mcg 100 mg, 50 mg liothyronine sodium F doxycycline hyclate F tabs caps 100 mg, 50 mg NATURE-THROID NT-2.5 F doxycycline hyclate F TABS (thyroid) tabs 100 mg, 20 mg NATURE-THROID TABS 130 MG, 16.25 MG, 195 minocycline hcl caps F F 100 mg, 50 mg, 75 mg MG, 32.5 MG, 65 MG (thyroid) tetracycline hcl caps F SYNTHROID TABS F VIBRAMYCIN SYRP 50 (levothyroxine sodium) MG/5ML (doxycycline F thyroid tabs F calcium) WESTHROID TABS 130 THYROID AGENTS - Drugs to Regulate Thyroid MG, 195 MG, 32.5 MG, 65 F Hormones MG (thyroid) Antithyroid Agents WP THYROID TABS 130 methimazole tabs F MG, 16.25 MG, 32.5 MG, F 65 MG (thyroid) propylthiouracil tabs F TOXOIDS Thyroid Hormones Toxoid Combinations (Levothyroxine Sodium) EUTHYROX, LEVO-T, F LEVOXYL, UNITHROID TABS
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
248 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 dose CUVPOSA SOLN F ADACEL SUSP (tetanus per 10 years;1 (glycopyrrolate) toxoid-diphtheria- rtl MAX fill,999 F rtl day(s) dicyclomine hcl caps F acellular pertussis supply,; AL(At adsorb (tdap)) least 19 yrs dicyclomine hcl soln F old) Limit 1 dose dicyclomine hcl tabs F BOOSTRIX SUSP per 10 years;1 rtl MAX fill,999 glycopyrrolate tabs or 1 F (tetanus toxoid- mg, 2 mg diphtheria-acellular F rtl day(s) supply,; AL(At hyoscyamine sulfate pertussis adsorb (tdap)) F least 19 yrs elix or 0.125 mg/5ml old) Limit 1 dose hyoscyamine sulfate F per 10 years;1 soln or 0.125 mg/ml rtl MAX fill,999 TDVAX SUSP (tetanus- hyoscyamine sulfate F F rtl day(s) subl sl 0.125 mg diphtheria toxoids (td)) supply,; AL(At least 19 yrs hyoscyamine sulfate F old) tabs or 0.125 mg Limit 1 dose hyoscyamine sulfate F per 10 years;1 tb12 or 0.375 mg TENIVAC INJ (tetanus- rtl MAX fill,999 F rtl day(s) hyoscyamine sulfate F diphtheria toxoids (td)) supply,; AL(At tbdp or 0.125 mg least 19 yrs propantheline bromide F old) tabs Limit 1 dose SYMAX DUOTAB TBCR per 10 years;1 F TETANUS/DIPHTHERIA (hyoscyamine sulfate) TOXOIDS-ADSORBED rtl MAX fill,999 ADULT SUSP ( F rtl day(s) H-2 Antagonists tetanus- supply,; AL(At diphtheria toxoids (td)) (Cimetidine) CIMETIDINE RX/OTC least 19 yrs 200, CIMETIDINE ACID old) REDUCER, EQ ULCER DRUGS - Drugs to Treat Bowel, Intestine CIMETIDINE ACID F and Stomach Conditions REDUCER, GNP HEARTBURN RELIEF, SB Antispasmodics CIMETIDINE TABS (Hyoscyamine Sulfate) ED- (Cimetidine) CVS RX/OTC SPAZ, NULEV, OSCIMIN F HEARTBURN RELIEF, EQ TBDP ACID REDUCER, (Hyoscyamine Sulfate) HEARTBURN RELIEF, PX F OSCIMIN SR, SYMAX-SR F ACID REDUCER, SM TB12 ACID REDUCER TABS 200 MG (Hyoscyamine Sulfate) F OSCIMIN SUBL (Hyoscyamine Sulfate) F OSCIMIN TABS
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
249 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Famotidine) ACID RX/OTC (Famotidine) ACID CONTROL MAXIMUM CONTROL MAXIMUM STRENGTH, ACID STRENGTH, ACID CONTROLLER, ACID CONTROLLER, ACID CONTROLLER MAXIMUM CONTROLLER MAXIMUM STRENGTH, ACID STRENGTH, ACID REDUCER MAXIMUM REDUCER MAXIMUM STRENGTH, ACID STRENGTH, ACID REDUCER ORIGINAL REDUCER ORIGINAL STRENGTH, CVS ACID STRENGTH, CVS ACID CONTROLLER, CVS ACID CONTROLLER, CVS ACID CONTROLLER MAXIMUM CONTROLLER MAXIMUM STRENGTH, EQ STRENGTH, EQ FAMOTIDINE MAXIMUM FAMOTIDINE MAXIMUM STRENGTH, EQL STRENGTH, EQL HEARTBURN HEARTBURN PREVENTION, EQL PREVENTION, EQL HEARTBURN HEARTBURN PREVENTION/MAXIMUM PREVENTION/MAXIMUM STRENGTH, FAMOTIDINE STRENGTH, FAMOTIDINE MAXIMUM STRENGTH, MAXIMUM STRENGTH, FAMOTIDINE ORIGINAL FAMOTIDINE ORIGINAL STRENGTH, GNP ACID STRENGTH, GNP ACID REDUCER, GNP ACID F REDUCER, GNP ACID F REDUCER REDUCER MAXIMUMSTRENGTH, MAXIMUMSTRENGTH, HEARTBURN RELIEF HEARTBURN RELIEF MAXIMUMSTRENGTH, MAXIMUMSTRENGTH, KLS ACID CONTROLLER KLS ACID CONTROLLER MAXIMUM STRENGTH, MAXIMUM STRENGTH, MM ACID-PEP MAXIMUM MM ACID-PEP MAXIMUM STRENGTH, MM STRENGTH, MM FAMOTIDINE, PX ACID FAMOTIDINE, PX ACID REDUCER MAXIMUM REDUCER MAXIMUM STRENGTH, QC ACID STRENGTH, QC ACID CONTROLLER, QC ACID CONTROLLER, QC ACID CONTROLLER MAXIMUM CONTROLLER MAXIMUM STRENGTH, RA ACID STRENGTH, RA ACID REDUCER, RA ACID REDUCER, RA ACID REDUCER MAXIMUM REDUCER MAXIMUM STRENGTH, SB ACID STRENGTH, SB ACID CONTROLLER, SB ACID CONTROLLER, SB ACID CONTROLLER MAXIMUM CONTROLLER MAXIMUM STRENGTH, SM ACID STRENGTH, SM ACID REDUCER MAXIMUM REDUCER MAXIMUM STRENGTH, ZANTAC 360, STRENGTH, ZANTAC 360, ZANTAC 360 MAXIMUM ZANTAC 360 MAXIMUM STRENGTH TABS STRENGTH TABS
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
250 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Famotidine) ACID (Ranitidine Hcl) ACID RX/OTC REDUCER, EQ ACID CONTROL MAXIMUM REDUCER, HEARTBURN STRENGTH, ACID RELIEF, HM F REDUCER MAXIMUM FAMOTIDINE, PX ACID STRENGTH, CVS ACID REDUCER, SB ACID REDUCER, CVS ACID REDUCER, SM ACID REDUCER REDUCER TABS 10 MG MAXIMUMSTRENGTH, (Famotidine) HM RX/OTC CVS RANITIDINE, EQ FAMOTIDINE TABS 20 F RANITIDINE, EQL ACID MG REDUCER, EQL ACID REDUCER MAXIMUMSTRENGTH, EQL HEARTBURN RELIEF MAXIMUM STRENGTH, GNP ACID CONTROL 150 MAXIMUM STRENGTH, GNP ACID REDUCER, HEARTBURN RELIEF 150 MAXIMUM STRENGTH, HM ACID REDUCER F MAXIMUM STRENGTH, KLS ACID REDUCER, KLS ACID REDUCER MAXIMUMSTRENGTH, PX ACID REDUCER MAXIMUM STRENGTH, PX RANITIDINE, RA ACID REDUCER, RA ACID REDUCER MAXIMUM STRENGTH, RANITIDINE 150 MAXIMUM STRENGTH, RANITIDINE ACID REDUCER, SB ACID REDUCER RANITIDINE 75, SM ACID REDUCER MAXIMUM STRENGTH, TGT ACID REDUCER, WAL-ZAN 150 MAXIMUM STRENGTH, WAL-ZAN 75 TABS
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
251 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Ranitidine Hcl) ACID (Ranitidine Hcl) ACID RX/OTC CONTROL MAXIMUM REDUCER, EQ ACID STRENGTH, ACID REDUCER, GOODSENSE F REDUCER MAXIMUM ACID REDUCER, HM STRENGTH, CVS ACID ACID REDUCER, SB ACID REDUCER, CVS ACID REDUCER TABS 150 MG REDUCER cimetidine hcl soln 300 MAXIMUMSTRENGTH, F CVS RANITIDINE, EQ mg/5ml RANITIDINE, EQL ACID cimetidine tabs 200 mg F RX/OTC REDUCER, EQL ACID REDUCER cimetidine tabs 300 mg, F MAXIMUMSTRENGTH, 400 mg, 800 mg EQL HEARTBURN RELIEF MAXIMUM STRENGTH, famotidine susr 40 F GNP ACID CONTROL 150 mg/5ml MAXIMUM STRENGTH, famotidine tabs 10 mg, F GNP ACID REDUCER, 40 mg HEARTBURN RELIEF 150 MAXIMUM STRENGTH, famotidine tabs 20 mg F RX/OTC HM ACID REDUCER F MAXIMUM STRENGTH, GNP ACID CONTROL 150 RX/OTC KLS ACID REDUCER, KLS MAXIMUM STRENGTH F ACID REDUCER TABS (ranitidine hcl) MAXIMUMSTRENGTH, PX ranitidine hcl caps or QL(2 ea daily) ACID REDUCER F MAXIMUM STRENGTH, 150 mg, 300 mg PX RANITIDINE, RA ACID ranitidine hcl syrp or 15 REDUCER, RA ACID mg/ml, 150 mg/10ml, F REDUCER MAXIMUM 75 mg/5ml STRENGTH, RANITIDINE RX/OTC 150 MAXIMUM ranitidine hcl tabs or F STRENGTH, RANITIDINE 150 mg ACID REDUCER, SB ACID ranitidine hcl tabs or REDUCER RANITIDINE F 75, SM ACID REDUCER 300 mg, 75 mg MAXIMUM STRENGTH, Misc. Anti-Ulcer TGT ACID REDUCER, WAL-ZAN 150 MAXIMUM sucralfate susp F STRENGTH, WAL-ZAN 75 TABS sucralfate tabs F (Ranitidine Hcl) ACID Proton Pump Inhibitors REDUCER, EQ ACID REDUCER, GOODSENSE ACID REDUCER, HM F ACID REDUCER, PX ACID REDUCER, SM ACID REDUCER TABS 75 MG
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
252 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Esomeprazole QL(2 ea daily); QL(2 ea daily); lansoprazole cpdr 15 F Magnesium) CVS RX/OTC mg RX/OTC ESOMEPRAZOLE QL(2 ea daily) MAGNESIUM, GNP lansoprazole cpdr 30 F ESOMEPRAZOLE mg MAGNESIUM, lansoprazole tbdd 15 QL(1 ea daily); GOODSENSE F RX/OTC ESOMEPRAZOLE mg F QL(1 ea daily) MAGNESIUM, HM lansoprazole tbdd 30 F ESOMEPRAZOLE mg MAGNESIUM DELAYED QL(2 ea daily) RELEASE, KLS omeprazole cpdr 10 F ESOMEPRAZOLE mg, 40 mg MAGNESIUM, SM F QL(2 ea daily); ESOMEPRAZOLE omeprazole cpdr 20 mg RX/OTC MAGNESIUM CPDR QL(1 ea daily) omeprazole F (Lansoprazole) CVS F QL(1 ea daily); magnesium tbec 20 mg LANSOPRAZOLE TBDD RX/OTC QL(1 ea daily) (Lansoprazole) CVS QL(2 ea daily); omeprazole tbec 20 mg F LANSOPRAZOLE, EQ RX/OTC QL(1 ea daily) LANSOPRAZOLE, GNP pantoprazole sodium F LANSOPRAZOLE, tbec 20 mg GOODSENSE QL(2 ea daily) pantoprazole sodium F LANSOPRAZOLE, tbec 40 mg HEARTBURN F TREATMENT 24 HOUR, Ulcer Drugs - Prostaglandins HM LANSOPRAZOLE, F KLS LANSOPRAZOLE, QC misoprostol tabs LANSOPRAZOLE, RA Ulcer Therapy Combinations LANSOPRAZOLE, SM LANSOPRAZOLE CPDR amoxicillin- QL(112 ea per fill retail) (Omeprazole Magnesium) QL(1 ea daily) clarithromycin w/ F ACID REDUCER TBEC 20 F lansoprazole misc MG URINARY ANTISPASMODICS - Drugs to Treat (Omeprazole) CVS QL(1 ea daily) Miscellaneous Bladder Spasms OMEPRAZOLE TBEC 20 F MG Urinary Antispasmodic - Antimuscarinics (Omeprazole) EQ QL(1 ea daily) oxybutynin chloride F OMEPRAZOLE, EQL syrp OMEPRAZOLE, GNP oxybutynin chloride OMEPRAZOLE, HM F OMEPRAZOLE, KLS tabs OMEPRAZOLE, PX F oxybutynin chloride F OMEPRAZOLE, RA tb24 OMEPRAZOLE, SB QL(1 ea daily) OMEPRAZOLE, SM tolterodine tartrate cp24 F OMEPRAZOLE, TGT 2 mg, 4 mg OMEPRAZOLE TBEC tolterodine tartrate tabs F QL(2 ea daily); 1 mg, 2 mg esomeprazole F magnesium cpdr 20 mg RX/OTC To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
253 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits trospium chloride cp24 F Limit 5 per PNEUMOVAX 23/1 DOSE lifetime;5 rtl F INJ ( F MAX fill,999 rtl trospium chloride tabs pneumococcal vac day(s) supply,; polyvalent) Urinary Antispasmodics - Cholinergic Agonists AL(At least 19 yrs old) bethanechol chloride F Limit 1 dose tabs PREVNAR 13 SUSP per lifetime;1 rtl (pneumococcal 13- Urinary Antispasmodics - Direct Muscle Relaxants F MAX fill,999 rtl valent conjugate day(s) supply,; flavoxate hcl tabs F vaccine) AL(At least 19 yrs old) VACCINES Limit 3 doses TRUMENBA SUSY per lifetime;3 rtl Bacterial Vaccines (meningococcal group F MAX fill,999 rtl ACTHIB SOLR AL(At least 19 b vaccine day(s) supply,; (haemophilus b polysac F yrs old) (recombinant)) AL(At least 19 conj vac) yrs old) Limit 2 fills per TYPHIM VI SOLN PA BEXSERO SUSY Lifetime;2 rtl (typhoid vi (meningococcal vac F F MAX fill,999 rtl polysaccharide group b (recombant day(s) supply,; vaccine) omv adjuvanted)) AL(At least 19 yrs old) VAXCHORA SUSR PA (cholera vaccine live F HIBERIX SOLR AL(At least 19 attenuated) (haemophilus b polysac F yrs old) VIVOTIF CPDR ( PA conj vac) typhoid F MENACTRA INJ AL(At least 19 vaccine) (meningococcal yrs old) Viral Vaccines (a,c,y&w-135) F AFLURIA QUADRIVALENT Limit 1 fill per polysaccharide conjugate 2019-2020 SUSP 180 days;AL(At vaccine) (influenza virus vaccine F least 19 yrs MENQUADFI INJ AL(At least 19 split quadrivalent) old) (meningococcal yrs old) AFLURIA QUADRIVALENT Limit 1 fill per (a,c,y&w-135) F 2019-2020 SUSY 180 days;AL(At polysaccharide conjugate (influenza virus vaccine F least 19 yrs vaccine) split quadrivalent) old) MENVEO SOLR AL(At least 19 AFLURIA QUADRIVALENT Limit 1 fill per (meningococcal yrs old) 2020-2021 SUSP 180 days;AL(At (a,c,y&w-135) F (influenza virus vaccine F least 19 yrs oligosaccharide conjugate split quadrivalent) old) vac) AFLURIA QUADRIVALENT Limit 1 fill per Limit 5 per 2020-2021 SUSY 180 days;AL(At lifetime;5 rtl PNEUMOVAX 23 INJ (influenza virus vaccine F least 19 yrs ( F MAX fill,999 rtl old) pneumococcal vac day(s) supply,; split quadrivalent) polyvalent) AL(At least 19 yrs old)
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254 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AFLURIA QUADRIVALENT Limit 1 fill per FLUARIX QUADRIVALENT Limit 1 fill per 2021-2022 SUSP 180 days;AL(At 2019-2020 SUSY 180 days;AL(At (influenza virus vaccine F least 19 yrs (influenza virus vaccine F least 19 yrs split quadrivalent) old) split quadrivalent) old) AFLURIA QUADRIVALENT Limit 1 fill per FLUARIX QUADRIVALENT Limit 1 fill per 2021-2022 SUSY 180 days;AL(At 2020-2021 SUSY 180 days;AL(At (influenza virus vaccine F least 19 yrs (influenza virus vaccine F least 19 yrs split quadrivalent) old) split quadrivalent) old) ASTRAZENECA COVID-19 FLUARIX QUADRIVALENT Limit 1 fill per VACCINE SUSP ( 2021-2022 SUSY 180 days;AL(At covid- CO F 19 (sars-cov-2) (influenza virus vaccine least 19 yrs adenovirus vaccine) split quadrivalent) old) Limit 3 per FLUBLOK Limit 1 fill per ENGERIX-B INJ lifetime;3 rtl QUADRIVALENT 2019- 180 days;AL(At (hepatitis b vaccine F MAX fill,999 rtl 2020 SOSY (influenza least 19 yrs day(s) supply,; virus vac recomb F old) (recomb)) AL(At least 19 yrs old) hemagglutinin (ha) quadrivalent) Limit 3 per FLUBLOK Limit 1 fill per ENGERIX-B SUSP lifetime;3 rtl MAX fill,999 rtl QUADRIVALENT 2020- 180 days;AL(At (hepatitis b vaccine F 2021 SOSY (influenza least 19 yrs day(s) supply,; F (recomb)) AL(At least 19 virus vac recomb old) yrs old) hemagglutinin (ha) FLUAD 2019-2020 SUSY Limit 1 fill per quadrivalent) (influenza virus vaccine 180 days;AL(At FLUBLOK Limit 1 fill per types a & b surface F least 19 yrs QUADRIVALENT 2021- 180 days;AL(At antigen adjuvant) old) 2022 SOSY (influenza least 19 yrs F old) FLUAD 2020-2021 SUSY Limit 1 fill per virus vac recomb (influenza virus vaccine 180 days;AL(At hemagglutinin (ha) types a & b surface F least 19 yrs quadrivalent) old) FLUCELVAX Limit 1 fill per antigen adjuvant) QUADRIVALENT 2019- 180 days;AL(At FLUAD QUADRIVALENT Limit 1 fill every 2020 SUSP (influenza least 19 yrs 2021-2022 PRSY 180 days;AL(At F old) least 19 yrs virus vaccine tissue- (influenza virus vacc F cultured subunit types a & b surf antigen old) quadrivalent) adjuvant quad) FLUCELVAX Limit 1 fill per FLUAD QUADRIVALENT Limit 1 fill every QUADRIVALENT 2019- 180 days;AL(At INFLUENZA VACCINE 180 days;AL(At 2020 SUSY (influenza least 19 yrs FOR ADULTS PRSY least 19 yrs F old) (influenza virus vacc F old) virus vaccine tissue- types a & b surf antigen cultured subunit adjuvant quad) quadrivalent)
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255 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUCELVAX Limit 1 fill per FLUMIST Limit 1 fill per QUADRIVALENT 2020- 180 days;AL(At QUADRIVALENT SUSP 180 days;AL(At 2021 SUSP (influenza least 19 yrs (influenza virus vaccine F least 19 yrs virus vaccine tissue- F old) live quadrivalent) old) cultured subunit FLUZONE HIGH-DOSE PF Limit 1 fill per quadrivalent) 2019-2020 SUSY 180 days;AL(At FLUCELVAX Limit 1 fill per (influenza virus vaccine F least 19 yrs QUADRIVALENT 2020- 180 days;AL(At split high-dose old) 2021 SUSY (influenza least 19 yrs preservative free) F virus vaccine tissue- old) FLUZONE HIGH-DOSE PF Limit 1 fill every cultured subunit 2020-2021 SUSY 180 days;AL(At quadrivalent) (influenza virus vac F least 19 yrs old) FLUCELVAX Limit 1 fill per split high-dose quad QUADRIVALENT 2021- 180 days;AL(At preservative free) 2022 SUSP (influenza least 19 yrs FLUZONE HIGH-DOSE PF Limit 1 fill every virus vaccine tissue- F old) 2021-2022 SUSY 180 days;AL(At cultured subunit (influenza virus vac F least 19 yrs quadrivalent) split high-dose quad old) FLUCELVAX Limit 1 fill per preservative free) QUADRIVALENT 2021- 180 days;AL(At FLUZONE Limit 1 fill per 2022 SUSY (influenza least 19 yrs QUADRIVALENT 2019- 180 days;AL(At F virus vaccine tissue- old) 2020 SUSP (influenza F least 19 yrs cultured subunit virus vaccine split old) quadrivalent) quadrivalent) FLULAVAL Limit 1 fill per FLUZONE Limit 1 fill per QUADRIVALENT 2019- 180 days;AL(At QUADRIVALENT 2019- 180 days;AL(At 2020 SUSP (influenza F least 19 yrs 2020 SUSY (influenza F least 19 yrs virus vaccine split old) virus vaccine split old) quadrivalent) quadrivalent) FLULAVAL Limit 1 fill per FLUZONE Limit 1 fill per QUADRIVALENT 2019- 180 days;AL(At QUADRIVALENT 2020- 180 days;AL(At 2020 SUSY (influenza F least 19 yrs 2021 SUSP (influenza F least 19 yrs virus vaccine split old) virus vaccine split old) quadrivalent) quadrivalent) FLULAVAL Limit 1 fill per FLUZONE Limit 1 fill per QUADRIVALENT 2020- 180 days;AL(At QUADRIVALENT 2020- 180 days;AL(At 2021 SUSY (influenza F least 19 yrs 2021 SUSY (influenza F least 19 yrs virus vaccine split old) virus vaccine split old) quadrivalent) quadrivalent) FLULAVAL Limit 1 fill per FLUZONE Limit 1 fill per QUADRIVALENT 2021- 180 days;AL(At QUADRIVALENT 2021- 180 days;AL(At 2022 SUSY (influenza F least 19 yrs 2022 SUSP (influenza F least 19 yrs virus vaccine split old) virus vaccine split old) quadrivalent) quadrivalent)
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256 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUZONE Limit 1 fill per Limit 2 fills per QUADRIVALENT 2021- 180 days;AL(At M-M-R II SOLR Lifetime;2 rtl 2022 SUSY (influenza F least 19 yrs ( F MAX fill,999 rtl old) measles, mumps & day(s) supply,; virus vaccine split rubella virus vaccines) ) AL(At least 19 quadrivalent yrs old) Limit 3 per MODERNA COVID-19 GARDASIL 9 SUSP lifetime;3 rtl VACCINE SUSP (covid- (human papillomavirus F MAX fill,999 rtl CO (hpv) 9-valent recombinant day(s) supply,; 19 (sars-cov-2) mrna vaccine) AL(At least 19 virus vaccine) yrs old) NOVAVAX COVID-19 Limit 3 per VACCINE SUSP (covid- GARDASIL 9 SUSY lifetime;3 rtl 19 (sars-cov-2) subunit CO (human papillomavirus F MAX fill,999 rtl (spike) protein virus (hpv) 9-valent recombinant day(s) supply,; vaccine) vaccine) AL(At least 19 PFIZER-BIONTECH yrs old) COVID-19VACCINE SUSP CO Limit 2 fills per (covid-19 (sars-cov-2) Lifetime;2 rtl mrna virus vaccine) HAVRIX SUSP (hepatitis MAX fill,999 rtl F RABAVERT SUSR a vaccine) day(s) supply,; F AL(At least 19 (rabies vaccine, pcec) yrs old) Limit 3 per Limit 2 fills per RECOMBIVAX HB SUSP lifetime;3 rtl HEPLISAV-B SOLN Lifetime;2 rtl (hepatitis b vaccine F MAX fill,999 rtl (hepatitis b vaccine day(s) supply,; F MAX fill,999 rtl (recomb)) recombinant day(s) supply,; AL(At least 19 adjuvanted) AL(At least 19 yrs old) yrs old) Limit 2 doses Limit 2 fills per SHINGRIX SUSR (zoster per lifetime;2 rtl HEPLISAV-B SOSY Lifetime;2 rtl vaccine recombinant F MAX fill,999 rtl (hepatitis b vaccine day(s) supply,; F MAX fill,999 rtl adjuvanted) recombinant day(s) supply,; AL(At least 50 adjuvanted) AL(At least 19 yrs old) yrs old) STAMARIL SUSR ( PA yellow F IMOVAX RABIES fever vaccine) (H.D.C.V.) INJ (rabies F Limit 5 per virus vaccine, hdc) TWINRIX SUSY lifetime;5 rtl IXIARO SUSP (japanese PA (hepatitis a F MAX fill,999 rtl encephalitis vaccine F (inactivated)-hepatitis b day(s) supply,; (recombinant) vaccines) AL(At least 19 inactivated adsorbed) yrs old) JANSSEN COVID-19 Limit 2 fills per VACCINE SUSP (covid- CO Lifetime;2 rtl 19 (sars-cov-2) VAQTA SUSP ( hepatitis F MAX fill,999 rtl adenovirus vaccine) a vaccine) day(s) supply,; AL(At least 19 yrs old)
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257 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 fills per (Clotrimazole Vaginal) 3 Lifetime;2 rtl DAY VAGINAL, VARIVAX INJ ( varicella F MAX fill,999 rtl CLOTRIMAZOLE 3, virus vaccine live) day(s) supply,; CLOTRIMAZOLE-7, CVS AL(At least 19 CLOTRIMAZOLE 3, GNP F yrs old) CLOTRIMAZOLE 3, RA YF-VAX INJ (yellow PA CLOTRIMAZOLE 7, SM 3- F DAY VAGINAL, SM fever vaccine) CLOTRIMAZOLE Limit 1 dose VAGINAL CREA per lifetime;1 rtl (Metronidazole Vaginal) ZOSTAVAX SUSR F F MAX fill,999 rtl VANDAZOLE GEL (zoster vaccine live) day(s) supply,; AL(At least 50 (Miconazole Nitrate yrs old) Vaginal) CVS MICONAZOLE 3 VAGINAL AND RELATED PRODUCTS COMBINATION PACK, EQL MICONAZOLE 3, Spermicides GNP MICONAZOLE 3, ENCARE SUPP MICONAZOLE 3 F (nonoxynol-9) COMBINATIONPACK, MICONAZOLE 3 COMBO F OPTIONS GYNOL II PACK, PX MICONAZOLE VAGINALCONTRACEPTIV F 3-DAY COMBO PACK, RA E GEL (nonoxynol-9) MICONAZOLE 3 SHUR-SEAL GEL COMBINATION PACK, SM F (nonoxynol-9) MICONAZOLE 3, TGT MICONAZOLE 3 TODAY SPONGE MISC F COMBINATION PACK, (nonoxynol-9) VAGISTAT-3 KIT VCF VAGINAL (Miconazole Nitrate CONTRACEPTIVE FILM F Vaginal) CVS FILM (nonoxynol-9) MICONAZOLE 7, EQ VCF VAGINAL MICONAZOLE 7 DAY CONTRACEPTIVE FOAM F TREATMENT, EQL FOAM (nonoxynol-9) MICONAZOLE 7, GNP MICONAZOLE 7, F VCF VAGINAL MICONAZOLE 7, QC 3 CONTRACEPTIVEGEL F DAY VAGINAL CREAM, GEL (nonoxynol-9) QC MICONAZOLE 7, RA Vaginal Anti-infectives MICONAZOLE 7, SM MICONAZOLE 7, TGT (Clotrimazole Vaginal) 3 QL(21 gm per MICONAZOLE 7 CREA DAY VAGINAL, fill retail) CLOTRIMAZOLE 3, (Miconazole Nitrate CLOTRIMAZOLE-7, CVS Vaginal) MICONAZOLE 3 F CREA 4 % CLOTRIMAZOLE 3, GNP F CLOTRIMAZOLE 3, RA (Miconazole Nitrate QL(3 ea per fill CLOTRIMAZOLE 7, SM 3- Vaginal) MICONAZOLE 3 F retail) DAY VAGINAL, SM SUPP 200 MG CLOTRIMAZOLE VAGINAL CREA
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258 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Miconazole Nitrate VASOPRESSORS - Drugs to Treat Heart and Vaginal) MICONAZOLE 7, F Circulation Conditions SM MICONAZOLE 7 SUPP (Tioconazole Vaginal) CVS Anaphylaxis Therapy Agents TIOCONAZOLE 1, EQ epinephrine QL(2 ea per fill TIOCONAZOLE 1, EQL retail) (anaphylaxis) soaj 0.15 F TIOCONAZOLE-1, GNP mg/0.15ml, 0.15 TIOCONAZOLE 1, mg/0.3ml, 0.3 mg/0.3ml MONISTAT 1-DAY, RA F TIOCONAZOLE 1, SM Vasopressors TIOCONAZOLE-1, TGT TIOCONAZOLE 1, TGT midodrine hcl tabs F TIOCONAZOLE 1DAY, TIOCONAZOLE 1, VITAMINS TIOCONAZOLE-1 OINT Oil Soluble Vitamins AVC CREA F (Cholecalciferol) (sulfanilamide vaginal) AQUEOUS VITAMIN D INFANTS, BABY SUPER clindamycin phosphate F vaginal crea DAILY D3, BABY VITAMIN CLINDESSE CREA D3 DROPS, BPROTECTED PEDIA D- (clindamycin phosphate F VITE, D-VITE PEDIATRIC, F (one dose)) D3 MAXIMUM STRENGTH, JUST D, clotrimazole vaginal F crea PHARMACIST CHOICE D- VITAMIN PEDIATRIC GYNAZOLE-1 CREA DROPS, VITAMIN D (butoconazole nitrate F INFANT LIQD (one dose)) (Cholecalciferol) CVS D3, EQL VITAMIN D3 CAPS metronidazole vaginal F F gel 1000 UNIT, 2000 UNIT, 5000 UNIT miconazole nitrate F vaginal crea QL(45 gm per terconazole vaginal F crea 0.4 % fill retail) QL(20 gm per terconazole vaginal F crea 0.8 % fill retail) QL(3 ea per fill terconazole vaginal F supp 80 mg retail) Vaginal Estrogens estradiol vaginal crea F 0.1 mg/gm PREMARIN CREA VA 0.625 MG/GM (estrogens, conjugated F vaginal) To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
259 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Cholecalciferol) D 1000, D (Cholecalciferol) HM 400, D 5000, D-1000, D- VITAMIN D3 CAPS 2000 F 1000 EXTRA STRENGTH, UNIT D-400, D-5000, D3, D3 (Cholecalciferol) HM HIGH POTENCY, D3-1000, VITAMIN D3 TABS 25 F DELTA D3, GNP VITAMIN MCG D MAXIMUM STRENGTH, GNP VITAMIN D SUPER (Cholecalciferol) KP STRENGTH, GNP VITAMIN D CAPS 1000 F VITAMIN D-400, GNP UNIT, 2000 UNIT VITAMIN D3 EXTRA (Cholecalciferol) SM VITAMIN D3 MAXIMUM STRENGTH, HM VITAMIN F F D, NAT-RUL VITAMIN D, STRENGTH CAPS 5000 NATURAL VITAMIN D-3, UNIT QC VITAMIN D3, RA (Cholecalciferol) VITAMIN F VITAMIN D-3, RADIANCE D3 TABS OR 2000 UNIT PLATINUM VITAMIN D3, (Ergocalciferol) CALCIDOL, F SM VITAMIN D, SM CALCIFEROL SOLN VITAMIN D3, THERA-D 2000, THERA-D RAPID (Phytonadione) K 100 F REPLETION, VITAMIN D- TABS 1000 MAXIMUM (Vitamin E) ALPH-E, STRENGTH, VITAMIN D- ALPH-E-MIXED, CVS E, E- 400 TABS 200, E-400, E-400-CLEAR, (Cholecalciferol) D 1000, D E200, E400, EQL VITAMIN 5000, D-3-5, D2000 E, GNP VITAMIN E ULTRA STRENGTH, D3 WATER DISPERSIBLE, HIGH POTENCY, D3 HM E VITAMIN, KP MAXIMUM STRENGTH, VITAMIN E, PX VITAMIN F D3 SUPER STRENGTH, E, QC VITAMIN E, RA D3-1000, D3-50, NATURAL VITAMIN E, RA DIALYVITE VITAMIN D VITAMIN E, VITAMIN E 5000, GNP D 1000, KLS BLEND, VITAMIN E HIGH POTENCY, VITAMIN E- D3, KP VITAMIN D3, F OPTIMAL-D, OPTIMAL-D 200, VITAMIN E/D-ALPHA PACK, PRONUTRIENTS NATURAL CAPS VITAMIN D3, QC VITAMIN (Vitamin E) CVS VITAMIN D3, RA VITAMIN D-3, SM E CAPS OR 180 MG, 400 F VITAMIN D3, VITAMIN D UNIT HIGH POTENCY, VITAMIN (Vitamin E) GNP VITAMIN D3 HIGH POTENCY, E, HM VITAMIN E, SM F VITAMIN D3 MAXIMUM VITAMIN E CAPS 200 STRENGTH, WEEKLY-D UNIT, 400 UNIT CAPS (Vitamin E) NATURAL (Cholecalciferol) DECARA F VITAMIN E CAPS 100 F CAPS 50000 UNIT UNIT, 400 UNIT (Cholecalciferol) GNP BABY DDROPS LIQD 400 VITAMIN D TABS 1000 F UNT/0.03ML F UNIT (cholecalciferol)
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260 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cholecalciferol caps (Ascorbic Acid) ASCO- 1.25 mg, 1000 unit, 125 TABS-1000, C 1000, C mcg, 2000 unit, 25 F 250, C 500, C 500/ROSE HIPS, C-1000, C- mcg, 50 mcg, 5000 1000/ROSE HIPS, C-250, unit, 50000 unit C-500, C-500/ROSE HIPS, CVS VITAMIN C, CVS cholecalciferol liqd 400 F unit/ml, 5000 unit/ml VITAMIN C/ROSE HIPS, EQL VITAMIN C, EQL cholecalciferol tabs VITAMIN C/ROSE HIPS, GNP VITAMIN C W/ROSE 1000 unit, 125 mcg, F 2000 unit, 25 mcg, 400 HIPS, GNP VITAMIN unit, 50 mcg, 5000 unit C/ROSE HIPS, MEIJER C, NATURAL C/ROSE HIPS, F ergocalciferol caps F PUREWAY-C, PX VITAMIN C, QC C WITH ergocalciferol soln F ROSE HIPS, RA VITAMIN C/ROSE HIPS, SB KEY-E CHEW (vitamin e) F VITAMIN C, SM VIT C/ROSE HIPS, SM VITAMIN C/ROSE HIPS, phytonadione tabs or F 100 mcg, 5 mg VITAMIN C PLUS BIOFLAVONOIDS/WILD vitamin e caps or 100 ROSE HIPS, VITAMIN unit, 180 mg, 200 unit, F C/NATURAL ROSE HIPS, 400 unit, 45 mg, 90 mg YL VITAMIN C, YL VITAMIN E CHEW OR 400 VITAMIN C/ROSE HIPS F UNIT (vitamin e) TABS (Ascorbic Acid) GNP Water Soluble Vitamins VITAMIN C, SM VITAMIN F C TABS 1000 MG, 250 MG, 500 MG (Ascorbic Acid) HM VITAMIN C, QC VITAMIN F C TABS 1000 MG, 500 MG (Ascorbic Acid) RA VITAMIN C TABS 250 MG, F 500 MG (Niacin) ENDUR-ACIN, HM NIACIN, HM NIACIN TR, F SM NIACIN CR TBCR (Niacin) KP NIACIN, NIACIN-50, PX NIACIN, F RA NIACIN, RA NO FLUSH NIACIN 500 TABS
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261 Drug Requirements/ Drug Name Tier Limits (Pyridoxine Hcl) B6 NATURAL, CVS B6, EQL B-6, GNP VITAMIN B-6, KP VITAMIN B-6, NEURO- F K-50, QC VITAMIN B6, RA VITAMIN B-6, SM VITAMIN B-6, SM VITAMIN B6, YL VITAMIN B-6 TABS (Riboflavin) CVS VITAMIN F B-2 TABS (Thiamine Hcl) B1 HIGH POTENCY, CVS B-1, CVS F B1, GNP VITAMIN B-1, QC VITAMIN B1 TABS (Thiamine Mononitrate) HM VITAMIN B1, RA VITAMIN F B-1, SM VITAMIN B1 TABS ascorbic acid tabs or 10 mg-500 mg, 1000 F mg, 250 mg, 500 mg B-1 TABS (thiamine hcl) F niacin cpcr 250 mg, F 500 mg niacin tabs 100 mg, 50 F mg, 500 mg niacin tbcr 250 mg, 500 F mg, 750 mg NIACIN TR TBCR (niacin) F pyridoxine hcl tabs or F 100 mg, 25 mg, 50 mg riboflavin tabs 100 mg, F 25 mg, 50 mg thiamine hcl soln F thiamine hcl tabs F thiamine mononitrate F tabs
To learn what the symbols and abbreviations on this table mean, go to page iii Last Updated: September 1, 2021 www.calvivahealth.org
262 Index 12 hour allergy-d 65 3ML LUER-LOK SYRINGE21G ABILIFY MAINTENA 49 12 hour decongestant 233 X 1-1/2" 126 ABILIFY MYCITE 49 3ML LUER-LOK SYRINGE22G 1ST TIER UNIFINE X 1" 126 abiraterone acetate 43 PENTIPS/MINI/31GX5MM 125 3ML LUER-LOK SYRINGE25G ABOUTTIME PEN NEEDLE 1ST TIER UNIFINE X 5/8" 126 32GX 5/32" 127 PENTIPS29GX12MM 125 3ML LUER-LOK TIP ABOUTTIME PEN NEEDLES 1ST TIER UNIFINE SYRINGE25G X 1-1/2" 126 30GX 5/16" 127 PENTIPS31GX6MM 125 3ML SYRINGE/18G X 1- ABOUTTIME PEN NEEDLES 1ST TIER UNIFINE 1/2"/LUER LOCK TIP 126 31G X 3/16" 127 PENTIPS31GX8MM 125 3ML SYRINGE/20G X 1"/LUER ABOUTTIME PEN NEEDLES 1ST TIER UNIFINE LOCK TIP 126 31G X 5/16" 127 PENTIPS32GX4MM 125 3ML SYRINGE/20G X 1"/LUER acamprosate calcium 243 1ST TIER UNIFINE SLIP TIP 126 acarbose 26 PENTIPS32GX6MM 125 3ML SYRINGE/20G X 1- 1ST TIER UNIFINE ACCU-CHEK FASTCLIX 1/2"/LUER LOCK TIP 126 LANCETDEVICE KIT 112 PENTIPS33GX4MM 125 3ML SYRINGE/21G X 1"/LUER 1ST TIER UNIFINE ACCU-CHEK MULTICLIX LOCK TIP 126 LANCET DEVICE KIT 112 PENTIPSPLUS 31GX8MM 125 3ML SYRINGE/21G X 1"/LUER 1ST TIER UNIFINE ACCU-CHEK SOFTCLIX SLIP TIP 126 LANCETDEVICE KIT 112 PENTIPSPLUS 32GX4MM 125 3ML SYRINGE/21G X 1- 1ST TIER UNIFINE 1/2"/LUER LOCK TIP 126 accutane 69 PENTIPSPLUS 33GX4MM 125 3ML SYRINGE/21G X 1- ACE AEROSOL CLOUD 1ST TIER UNIFINE 1/4"/LUER LOCK TIP 126 ENHANCER 188 PENTIPSPLUS/MINI/31GX5MM 3ML SYRINGE/22G 1- acebutolol hcl 59 125 1/2"/LUER LOCK TIP 126 1ST TIER UNIFINE acetaminophen 9 3ML SYRINGE/22G X 1"/LUER acetaminophen junior PENTIPSPLUS/ORIGINAL/29GX LOCK TIP 126 12MM 125 strength 7 3ML SYRINGE/22G X 1- acetaminophen w/ codeine 13 1ST TIER UNIFINE 1/4"/LUER LOCK TIP 126 PENTIPSPLUS/ULTRA 3ML SYRINGE/22G X acetazolamide 85 SHORT/31GX6MM 125 3/4"/LUER LOCK TIP 126 acetic acid 90 1ST TIER UNILET 3ML SYRINGE/22G X acetic acid (otic) 242 COMFORTOUCH LANCETS 3/4"/LUER SLIP TIP 126 28G 112 3ML SYRINGE/25G X 1"/LUER acetylcysteine 68 1ST TIER UNILET LOCK TIP 126 acid control maximum COMFORTOUCH LANCETS 3ML SYRINGE/27G X 1- strength 250 30G 112 1/4"/LUER LOCK TIP 126 acid controller 250 24hr allergy relief 37 3ML SYRINGE/LUER LOCK acid reducer 252,253 3 day vaginal 258 TIP 127 3ML SYRINGE/LUER LOCK acne foaming wash 69 3ML LUER LOCK SAFETY acne medication 10 69 SYRINGES 3ML/22G X 1 1/2" TIP23GX1" 127 125 3ML SYRINGE/LUER LOCK ACNE MEDICATION 10 69 3ML LUER LOCK SAFETY TIP25G X 1-1/2" 127 ACNE MEDICATION 5 69 SYRINGES/3ML/21G X 1 1/2" 3ML SYRINGE/LUER SLIP acne treatment cleansingbar 125 TIP23GX1" 127 3ML SYRINGE/NEEDLE maximum strength 69 3ML LUER LOCK SAFETY ACTEMRA 3 SYRINGES/3ML/22G X 1" 125 REGULAR WALL LUER-LOK 3ML LUER LOCK SAFETY 25GX5/8" SUB-Q 127 ACTHAR 86 SYRINGES/3ML/23G X 1" 125 7t lido gel 80 ACTHIB 254 3ML LUER LOCK SAFETY abacavir sulfate 55 ACTIMMUNE 46 SYRINGES/3ML/25G X 1" 125 abacavir sulfate- activite 205 3ML LUER LOCK SAFETY lamivudine 55 SYRINGES/3ML/25G X 5/8" abacavir sulfate-lamivudine- ACTIVITY POUCH 188 126 zidovudine 55 acyclovir 58 3ML LUER-LOK SYRINGE 22GX ABC COMPLETE SENIOR acyclovir topical 74 1-1/2" 126 WOMENS 50+ 212 ADACEL 249 3ML LUER-LOK SYRINGE21G X ABILIFY 49 1" 126 adapalene 70
Index 1 adapalene treatment 68 ADVOCATE INSULIN AFLURIA QUADRIVALENT ADASUVE 48 SYRINGE/U- 2019-2020 254 100/0.5ML/30GX5/16" 127 AFLURIA QUADRIVALENT addaprin 3 ADVOCATE INSULIN 2020-2021 254 adefovir dipivoxil 58 SYRINGE/U- AFLURIA QUADRIVALENT ADHESIVE 100/0.5ML/31GX5/16" 127 2021-2022 255 PADS/LARGE/3"X4" 103 ADVOCATE INSULIN afrin saline nasal mist 231 ADHESIVE SYRINGE/U- AFSTYLA 91 PADS/MEDIUM/2"X3" 103 100/1ML/29GX1/2" 127 ADJUSTABLE LANCING ADVOCATE INSULIN aftera 63 DEVICE 112 SYRINGE/U- AGAMATRIX ULTRA-THIN ADLYXIN 27 100/1ML/30GX5/16" 128 LANCETS 33G 112 AIMOVIG 197 ADLYXIN STARTER PACK 28 ADVOCATE INSULIN SYRINGE/U- AIMSCO LUBRICATED 110 ADMELOG 28 100/1ML/31GX5/16" 128 AIRS PEDIATRIC AEROSOL ADMELOG SOLOSTAR 28 ADVOCATE LANCING MASK 189 ADRENALIN 233 DEVICE 112 AIRZONE PEAK FLOW ADVOCATE RAPID-SAFE adriamycin 44 METER 189 LANCING DEVICE 112 ak-poly-bac 239 ADULT AEROSOL MASK 188 ADYNOVATE 91 al12 80 adult aspirin regimen 10 AEROCHAMBER MINI ADULT MASK 188 AEROSOLCHAMBER 188 ala-cort 74,75 ADULT MASK LARGE 188 AEROCHAMBER MV 188 alavert 37 ADVAIR HFA 21 AEROCHAMBER PLUS FLOW alavert allergy/sinus 67 VU 189 alaway 241 ADVANCED DIABETIC AEROCHAMBER PLUS MULTIVITAMIN FORMULA 212 FLOW-VU 189 albendazole 18 advantage care oral electrolyte AEROCHAMBER PLUS albuterol sulfate 21 pediatric 200 FLOW-VU/LARGE MASK 189 ALBUTEROL SULFATE 21 ADVATE 91 AEROCHAMBER PLUS albuterol sulfate 21 ADVIL ALLERGY & FLOW-VU/MASK 189 CONGESTION 68 AEROCHAMBER PLUS ALCOH-WIPE 12" X 12" 124 advil junior strength 4 FLOW-VU/MEDIUM ALCOHOL PREP PADS 124 advil liqui-gels minis 4 MASK 189 ALCOHOL SWABS 124 ADVIL MULTI-SYMPTOM AEROCHAMBER PLUS FLOW-VU/SMALL MASK 189 ALCOHOL SWABSTICK 124 COLD& FLU 68 ALDURAZYME 86 ADVOCATE INSULIN PEN AEROCHAMBER Z-STAT NEEDLES 127 PLUS VALVED HOLDING ALECENSA 45 ADVOCATE INSULIN PEN CHAMBER W/FLOW VU 189 alendronate sodium 85,86 AEROCHAMBER Z-STAT NEEDLES 29GX12.7MM 127 aler-cap 33 ADVOCATE INSULIN PEN PLUS/FLOWSIGNAL 189 NEEDLES 31GX5MM 127 AEROCHAMBER Z-STAT ALER-DRYL 35 ADVOCATE INSULIN PEN PLUS/LARGE MASK 189 alertab 34 NEEDLES 31GX8MM 127 AEROCHAMBER Z-STAT PLUS/MEDIUM MASK 189 ALEVAZOL 73 ADVOCATE INSULIN alfuzosin hcl 90 SYRINGE/U- AEROCHAMBER Z-STAT 100/0.3ML/29GX1/2" 127 PLUS/SMALL MASK 189 ALGAE BASED CALCIUM 212 ADVOCATE INSULIN AEROCHAMBER/FLOWSIGNA algal omega-3 dha 234 L 189 SYRINGE/U- ALIVE ENERGY 50+ 212 100/0.3ML/30GX5/16" 127 AEROTRACH PLUS 189 ADVOCATE INSULIN AEROVENT PLUS HOLDING ALIVE MENS ENERGY 212 SYRINGE/U- CHAMBER/COLLAPSIBLE ALIVE ONCE DAILY WOMENS 100/0.3ML/31GX5/16" 127 189 50+ ULTRA POTENCY 212 ADVOCATE INSULIN AFINITOR 45 ALIVE ONCE DAILY WOMENS ULTRA POTENCY 213 SYRINGE/U- AFINITOR DISPERZ 45 100/0.5ML/29GX1/2" 127 ALIVE PRENATAL MULTI- afirmelle 61 VITAMIN/PLANT DHA 224 ALIVE WOMENS 50+ 213
Index 2 ALIVE WOMENS ENERGY 213 alyacen 7/7/7 62 ANTABUSE 243 all day allergy 36 alyq 60 antacid 16,17 all day allergy childrens 35 amabelz 87 antacid calcium extra all day pain relief 5 amantadine hcl 47 strength 17 antacid extra strength 17 ALL FLOW 1000 PULMONARY ambrisentan 60 FUNCTION FILTER 189 AMD FOAM DRESSING anti-dandruff shampoo 74 aller-chlor 33 4"X4" 103 anti-diarrheal 31 allergy 35,38 AMD FOAM ANTI-DIARRHEAL 31 allergy childrens 34 DRESSING/TOPSHEET anti-fungal 72 4"X4" 103 allergy eye drops 239 ameda triple zero lanolin 81 anti-itch 74 allergy nasal spray 24 hour 231 AMERIWASH 51 anti-oxidant 222 allergy relief 37,231 amethia 61 antibacterial liquid soap 51 allergy relief 24hr 37 amiloride & antibiotic ointment 70 allergy relief childrens 36,38 hydrochlorothiazide 85 antifungal 72 allergy relief d 67 amiloride hcl 85 antioxidant formula 210 allergy relief loratadine 38 aminocaproic acid 95 ANTIOXIDANT FORMULA 213 ALLI 1 aminophylline 22 antiseptic skin cleanser 51 allopurinol 91 AMINOSYN II 236 ANTISEPTIC WOUND & SKIN almacone 15 AMINOSYN-PF 236 CLEANSER 51 APEXICON E 78 almotriptan malate 197 AMINOSYN-PF 7% 236 APLICARE ALCOHOL ALOCRIL 241 amiodarone hcl 20 SWABSTICK 124 alogliptin benzoate 27 amitriptyline hcl 26 aplicare povidone- alogliptin-metformin hcl 26 amlodipine besylate 59 iodinescrub 53 APLICARE alogliptin-pioglitazone 26 amlodipine besylate-benazepril hcl 40 POVIDONE/IODINE 53 ALOMIDE 241 amlodipine besylate-olmesartan APO-VARENICLINE 247 ALORA 88 medoxomil 40 apra 7 alph-e 260 amlodipine besylate- apraclonidine hcl 239 ALPHAGAN P 239 valsartan 40 amlodipine-valsartan- aprepitant 32 ALPHANATE 91 hydrochlorothiazide 40 apri 61 ALPHANATE/VON amoxapine 26 aprodine 67 WILLEBRANDFACTOR COMPLEX/HUMAN 91 amoxicillin 242 APTIVUS 55 ALPHANINE SD 91 amoxicillin & pot AQUA LANCE ADJUSTABLE clavulanate 243 LANCING DEVICE 112 alprazolam 19 amoxicillin-clarithromycin w/ AQUALANCE LANCETS ULTRA ALPROLIX 91 lansoprazole 253 THIN 30G 112 altacaine 240 amphetamine- aquanil hc 75 dextroamphetamine 1 altachlore 241 aquaphor itch relief maximum ampicillin 243 altafrin 238 strength 75 anagrelide hcl 93 aqueous vitamin d infants 259 altalube 238 ANALPRAM-HC 14 ALTERNATE SITE LANCING AQUORAL 204 DEVICE 112 ANASEPT 51 ARALAST NP 247 alum & mag hydrox- ANASEPT ANTIMICROBIAL ARANESP ALBUMIN FREE 93 SKIN & WOUND GEL 51 simethicone 16 argyle sterile saline 90 ALUMINUM HYDROXIDE 16 anastrozole 43 ARIAL CHAMBER 189 aluminum sulfate & calcium ANDRODERM 14 ARIKAYCE 2 acetate 82 anecream 81 aripiprazole 49 ALUNBRIG 45 animal chews 224 ARISTADA 49 alyacen 1/35 62 ANORO ELLIPTA 22 ARISTADA INITIO 49
Index 3 armodafinil 2 ASSURE ID INSULIN AURORA UNIFINE ARMOUR THYROID 248 SAFETYSYRINGE/U- PENTIPS/32GX5/32" 128 100/1ML/29G X 1/2" 128 AURORA UNIFINE ARNUITY ELLIPTA 21 ASSURE ID SAFETY PEN PENTIPS/MINI/31GX3/16" 128 arthritis pain reliever 70 NEEDLES 30G X 3/16" 128 aurovela 1.5/30 62 ARTHRITIS PAIN ASSURE ID SAFETY PEN aurovela 1/20 62 RELIEVING 81 NEEDLES 30G X 5/16" 128 aurovela 24 fe 62 artificial tears 237,238 ASSURE ID SAFETY PEN NEEDLES 31G X 3/16" 128 AUTO-LANCET 113 asco-tabs-1000 261 ASSURE LANCE AUTO-LANCET MINI 113 ascomp/codeine 13 LANCETS 112 AUTOLET II CLINISAFE 113 ascorbic acid 262 ASSURE LANCE LANCETS AUTOLET IMPRESSION asenapine maleate 48 21G 112 ASSURE LANCE PLUS LANCING DEVICE 113 ASMANEX HFA 21 SAFETYLANCETS 25G 112 AUTOLET LANCING ASMANEX TWISTHALER 120 ASSURE LANCE PLUS DEVICE 113 METERED DOSES 21 SAFETYLANCETS 30G 113 AUTOLET LITE ASMANEX TWISTHALER 14 ASSURE PLATINUM TEST CLINISAFE 113 METERED DOSES 21 STRIPS 83 AUTOLET LITE STARTER ASMANEX TWISTHALER 30 ASTHMA CHECK METER- PACK 113 METERED DOSES 21 ZONE SYSTEM 189 AUTOLET MINI 113 ASMANEX TWISTHALER 60 ASTHMAMENTOR 189 AUTOLET PLATFORMS 113 METERED DOSES 21 ASTRAZENECA COVID-19 AUTOLET PLUS 113 ASMANEX TWISTHALER 7 VACCINE 255 METERED DOSES 21 AVANDIA 28 ATABEX EC 224 aspercreme w/lidocaine 81 AVASTIN 42 ATABEX OB 224 aspirin 11 AVC 259 ATABEX PRENATAL 224 ASPIRIN 11 avedana glycerin (adult) 99 atazanavir sulfate 55 aspirin 11 aveeno anti-itch atenolol 59 aspirin 81 low dose 10 maximumstrength 76 atenolol & chlorthalidone 40 avidoxy 248 aspirin adult 11 aspirin buffered (cal carb-mag athletes foot 72 avita 69 carb-mag oxide) 11 athletes foot af cream 72 AVONEX 244 ASSESS FULL RANGE PEAK atomoxetine hcl 1 AVONEX PEN 244 FLOW METER 189 atorvastatin calcium 39 AZASAN 203 ASSESS LOW RANGE PEAK FLOW METER 189 atovaquone 18 azathioprine 203 ASSESS PEAK FLOW METER atovaquone-proguanil hcl 41 azelaic acid 82 FULL RANGE 189 ATRIPLA 55 azelastine hcl 231 ASSESS PEAK FLOW METER LOW RANGE 189 ATROPINE SULFATE 238 azelastine hcl (ophth) 241 ASSURE COMFORT LANCETS atropine sulfate azithromycin 102 ULTRA THIN 28G 112 (ophthalmic) 238 AZO HORMONAL HEALTH ASSURE HAEMOLANCE PLUS ATROVENT HFA 20 CYCLE CARE & HIGH FLOW 18G 112 AUBAGIO 244 COMFORT 213 ASSURE HAEMOLANCE PLUS AUGMENTIN 243 AZO HORMONAL HEALTH LOW FLOW 25G 112 HAPPY CYCLE 213 ASSURE HAEMOLANCE PLUS aurophen childrens 8 azurette 61 MICRO FLOW 28G 112 AURORA LANCET SUPER ASSURE HAEMOLANCE PLUS THIN30G 113 b complex w/ c 205 NORMAL FLOW 21G 112 AURORA LANCET THIN B-1 262 ASSURE HAEMOLANCE PLUS 23G 113 b-complex vitamins 205 PEDIATRIC BLADE 112 AURORA PEN NEEDLES B-D INSULIN SYRINGE ASSURE ID INSULIN 29GX12MM 128 ULTRAFINE II/0.3ML/31G X SAFETYSYRINGE/U- AURORA PEN NEEDLES 31G 5/16" 128 100/0.5ML/29G X 1/2" 128 X6MM 128 B-D INSULIN SYRINGE AURORA PEN NEEDLES 31G ULTRAFINE II/0.5ML/31G X X8MM 128 5/16" 128
Index 4 B-D INSULIN SYRINGE BASIC PM 213 BD INSULIN SYRINGE ULTRAFINE II/1ML/31G X BD LO-DOSE INSULIN MICROFINE IV/U- 5/16" 128 SYRINGE MICROFINE 100/0.5ML/28G X 1/2" 129 B-D INSULIN SYRINGE IV/0.5ML/28G X 1/2" 128 BD INSULIN SYRINGE ULTRAFINE/0.3ML/30G X BD 3ML LUER-LOCK MICROFINE IV/U-100/1ML/27G 1/2" 128 SYRINGE18G X 1 1/2" 128 X 5/8" 129 B-D INSULIN SYRINGE BD 3ML LUER-LOK SYRINGE BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 18G X 1 1/2" 128 MICROFINE IV/U-100/1ML/28G 1/2" 128 BD 3ML LUER-LOK SYRINGE X 1/2" 130 b-stress 230 20G X 1-1/2" 128 BD INSULIN SYRINGE b1 high potency 262 BD 3ML LUER-LOK MICROFINE/U-100/0.5ML/28G X SYRINGE/20G X 1" 128 1/2" 130 b6 natural 262 BD 3ML LUER-LOK BD INSULIN SYRINGE BABY DDROPS 260 SYRINGE/21G X 1" 129 MICROFINE/U-100/1ML/27G X bac 7 BD 3ML LUER-LOK 5/8" 130 BD INSULIN SYRINGE bacitracin (ophthalmic) 239 SYRINGE/21G X 1-1/2" 129 BD 3ML LUER-LOK MICROFINE/U-100/1ML/28G X bacitracin (topical) 71 SYRINGE/23G X 1" 129 1/2" 130 bacitracin zinc 71 BD 3ML LUER-LOK BD INSULIN SYRINGE bacitracin-poly-neomycin-hc SYRINGE/23G X 1-1/2" 129 SAFETYGLIDE/1ML/29G X 240 BD 3ML LUER-LOK 1/2" 130 bacitracin-polymyxin b SYRINGE/25G X 1" 129 BD INSULIN SYRINGE SLIP (ophth) 239 BD 3ML LUER-LOK TIP/U-100/1ML 130 bacitraycin plus 70 SYRINGE/26G X 5/8" 129 BD INSULIN SYRINGE ULTRA- BD 3ML FINE/0.3ML/30G X 12.7MM130 baclofen 230 SYRINGE/SAFETYGLIDE BD INSULIN SYRINGE ULTRA- BACMIN 213 SHIELDING IM NEEDLE FINE/0.3ML/31G X 8MM 130 balsalazide disodium 90 22GX1-1/2" 129 BD INSULIN SYRINGE ULTRA- BAND-AID ALL-IN-ONE BD 3ML FINE/0.5ML/30G X 12.7MM130 ADHESIVE GAUZE SYRINGE/SAFETYGLIDE BD INSULIN SYRINGE ULTRA- PAD/LARGE 103 SHIELDING IM NEEDLE FINE/0.5ML/31G X 8MM 130 BAND-AID ALL-IN-ONE 23GX1" 129 BD INSULIN SYRINGE ULTRA- ADHESIVE GAUZE BD 3ML FINE/1/2 UNIT/0.3ML/31G X PAD/MEDIUM 103 SYRINGE/SAFETYGLIDE 8MM 130 BAND-AID GAUZE PADS SHIELDING NEEDLE BD INSULIN SYRINGE ULTRA- LARGE4" X 4" 103 25GX5/8" 129 FINE/1ML/30G X 12.7MM 130 BAND-AID GAUZE PADS BD AUTOSHIELD 29G X BD INSULIN SYRINGE ULTRA- MEDIUM 3" X 3" 103 3/16" 129 FINE/1ML/31G X 8MM 130 BAND-AID GAUZE PADS BD AUTOSHIELD 29G X BD INSULIN SYRINGE SMALL2" X 2" 103 5/16" 129 ULTRAFINE HALF- BAND-AID HURT-FREE NON- BD AUTOSHIELD DUO 30G X UNIT/0.3ML/31G X 5/16" 130 STICK PADS LARGE 3" X 5MM 129 BD INSULIN SYRINGE 4" 103 BD ECLIPSE SYRINGE ULTRAFINE/0.3ML/30G X BAND-AID HURT-FREE NON- 3ML/21G X 1" 129 1/2" 130 STICK PADS MEDIUM 2" X BD ECLIPSE SYRINGE LUER- BD INSULIN SYRINGE 3" 103 LOK/3ML/22G X 1" 129 ULTRAFINE/0.3ML/31G X BAND-AID MIRASORB GAUZE BD ECLIPSE SYRINGE LUER- 5/16" 130 SPONGES LARGE 4" X 4" 103 LOK/3ML/25G X 1" 129 BD INSULIN SYRINGE BAND-AID QUILTVENT BD ECLIPSE ULTRAFINE/0.5ML/30G X WATERPROOF PAD LARGE SYRINGE/3ML/23G X 1" 129 1/2" 130 2.875" X 4" 103 BD ECLIPSE BD INSULIN SYRINGE banophen 35 SYRINGE/3ML/25GX5/8" ULTRAFINE/0.5ML/31G X 129 5/16" 130 BAQSIMI ONE PACK 27 BD ECLIPSE SYRINGE/LUER- BD INSULIN SYRINGE BAQSIMI TWO PACK 27 LOK/3ML/22G X 1-1/2" 129 ULTRAFINE/1ML/30G X BARACLUDE 58 BD GLUCOSE 27 1/2" 130 BD INSULIN SYRINGE BASAGLAR KWIKPEN 28 BD INSULIN SYRINGE LUER- LOK/U-100/1ML 129 ULTRAFINE/U-100/0.3ML/29G X BASIC AM 213 1/2" 130
Index 5 BD INSULIN SYRINGE BD PEN BD VEO INSULIN SYRINGE ULTRAFINE/U-100/0.5ML/29G X NEEDLE/MINI/ULTRA- ULTRA-FINE/1/2 1/2" 131 FINE/31G X 5MM 132 UNIT/0.3ML/31G X 6MM 133 BD INSULIN SYRINGE BD PEN NEEDLE/NANO 2ND BD VEO INSULIN SYRINGE ULTRAFINE/U-100/1ML/29G X GEN/32G X 5/32" 132 ULTRA-FINE/1ML/31G X 1/2" 131 BD PEN 6MM 133 BD INSULIN SYRINGE NEEDLE/NANO/ULTRA- BD VEO INSULIN SYRINGE ULTRAFINE/U-100/1ML/31G X FINE/32G X 4MM 132 ULTRA-FINE/U-100/0.3ML/31G 5/16" 131 BD PEN X 15/64" 133 BD INSULIN NEEDLE/ORIGINAL/ULTRA- BD VEO INSULIN SYRINGE SYRINGE/0.3ML/29G X FINE/29G X 12.7MM 132 ULTRA-FINE/U-100/1ML/31G X 12.7MM 131 BD PEN 15/64" 133 BD INSULIN NEEDLE/SHORT/ULTRA- BD VERITOR SYSTEM FOR SYRINGE/0.5ML/29G X FINE/31G X 8MM 132 RAPID DETECTION OF SARS- 12.7MM 131 BD SAFETY-GLIDE INSULIN COV-2 83 BD INSULIN SYRINGE/1ML/27G SYRINGE/0.5ML/29G X bedding spray lice treatment step X 12.7MM 131 1/2" 132 3 82 BD INSULIN SYRINGE/1ML/29G BD SAFETY-LOK INSULIN BELBUCA 13 X 12.7MM 131 SYRINGE/PERM BELVIQ 1 BD INSULIN NEEDLE/UF/1ML/29G X SYRINGE/DETACHABLE 1/2" 132 BELVIQ XR 1 NEEDLE/U-100/1ML/25G X BD SAFETYGLIDE INSULIN benadryl allergy plus congestion 1" 131 SYRINGE/0.3ML/29G X ultratabs 66 BD INSULIN 1/2" 132 benazepril & SYRINGE/DETACHABLE BD SAFETYGLIDE INSULIN hydrochlorothiazide 40 NEEDLE/U-100/1ML/25G X SYRINGE/0.3ML/31G X benazepril hcl 39 5/8" 131 15/64" 132 BENAZEPRIL BD INSULIN BD SAFETYGLIDE INSULIN HCL/HYDROCHLOROTHIAZIDE SYRINGE/DETACHABLE SYRINGE/0.3ML/31G X 40 NEEDLE/U-100/1ML/26G X 5/16" 132 BENEFIX 91 1/2" 131 BD SAFETYGLIDE INSULIN BENLYSTA 204 BD INSULIN SYRINGE/U- SYRINGE/0.5ML/31G X 100/1ML/27G X 1/2" 131 15/64" 132 BENZALKONIUM BD INSULIN SYRINGE/U- BD SAFETYGLIDE INSULIN CHLORIDE 51 100/2ML/27.5G X 5/8" 131 SYRINGE/1ML/31G X benzalkonium chloride 51 BD INSULIN SYRINGE/U- 15/64" 132 BENZALKONIUM 500/0.5ML/31G X 6MM 131 BD SAFETYGLIDE INSULIN CHLORIDE 51 BD INTEGRA 3ML SYRINGE SYSYRINGE/0.5ML/30G X benzonatate 64 W/RETRACTING NEEDLE/21G 5/16" 132 benzoyl peroxide 70 X 1-1/2" 131 BD SAFETYGLIDE SYRINGE BENZOYL PEROXIDE BD INTEGRA 3ML SYRINGE 3ML/25GX1" 132 CLEANSER 70 W/RETRACTING NEEDLE/25G BD SWABS SINGLE X 1" 131 USE 124 benzoyl peroxide wash 69 BD INTEGRA BD SWABS SINGLE USE benzoyl peroxide- SYRINGE/3ML/21G X 1" 131 BUTTERFLY 124 erythromycin 70 BD INTEGRA BD VEO INSULIN SYRINGE benzphetamine hcl 1 SYRINGE/3ML/22G X 1.5" 131 ULTR-FINE/U-100/0.5ML/31G benztropine mesylate 47 BD INTEGRA X 15/64" 132 BETADINE 53 SYRINGE/3ML/23G X 1" 131 BD VEO INSULIN SYRINGE BETADINE SURGICAL BD INTEGRA ULTRA-AFINE/0.3ML/31G X SCRUB 53 SYRINGE/3ML/25G X 5/8 131 6MM 132 BD LANCET ULTRAFINE betamethasone dipropionate BD VEO INSULIN SYRINGE (topical) 78 30G 113 ULTRA-FINE/0.3ML/31G X BD LUER-LOK betamethasone dipropionate 6MM 132 augmented 78 SYRINGE/3ML/22G X 3/4" 131 BD VEO INSULIN SYRINGE BD PEN ULTRA-FINE/0.5ML/31G X betamethasone valerate 78 NEEDLE/MICRO/ULTRA- 6MM 132 betasept surgical scrub 51 FINE/32G X 6MM 132 BETASERON 244
Index 6 betaxolol hcl (ophth) 238 BOTOX 234 budesonide (nasal) 232 bethanechol chloride 254 bp wash 69 budesonide-formoterol fumarate BETOPTIC-S 238 bprotected pedia iron 94 dihydrate 22 BUFFERIN EXTRA BEVESPI AEROSPHERE 22 BPROTECTED PEDIA POLY- STRENGTH 11 VITE/IRON 223 BEVYXXA 22 bumetanide 85 bprotected pedia tri-vite 224 bexarotene 46 BUNAVAIL 13 BRAFTOVI 45 BEXSERO 254 BRAINSTRONG BUPRENEX 13 bicalutamide 43 PRENATAL 224 buprenorphine 13 BIKTARVY 55 BREATHE EASE NEBULIZER buprenorphine hcl 13 bimatoprost 241 MASK/CHILD 190 buprenorphine hcl-naloxone hcl BINAXNOW COVID-19 AG BREATHE EASE NEBULIZER dihydrate 13 CARD 84 MASK/INFANT 190 bupropion hcl 25 BREATHE EASE PEAK FLOW BINAXNOW COVID-19 AG bupropion hcl (smoking CARD HOME TEST 83 METER 190 BREATHE EASE/LARGE deterrent) 247 biocotron 66 MASK 190 buspirone hcl 19 BIOGUARD GAUZE SPONGE BREATHE EASE/MEDIUM butalbital-acetaminophen 7 2"X2" 8 PLY 103 MASK 190 butalbital-acetaminophen- BIOGUARD GAUZE SPONGES BREATHE EASE/SMALL caffeine 7 4"X4" 12 PLY 103 MASK 190 butalbital-acetaminophen- BIOLYTE 200 BREATHERITE 190 caffeine w/ codeine 13 BIOPATCH ANTIMICROBIAL BREATHERITE butalbital-aspirin-caffeine 7 DRESSING/1" DISK/4MM COLLAPSIBLEADULT butalbital-aspirin-caffeine HOLE 51 SPACER W/MASK 190 w/cod 13 BIOPATCH ANTIMICROBIAL BREATHERITE BUTALBITAL/ASPIRIN/CAFFEIN DRESSING/1" DISK/7MM COLLAPSIBLECHILD SPACER E 7 HOLE 51 W/MASK 190 BUTRANS 14 BIOPATCH ANTIMICROBIAL BREATHERITE DRESSING/3/4" DISK/1.5MM COLLAPSIBLEINFANT BYDUREON BCISE 28 HOLE 51 SPACER W/MASK 190 BYDUREON PEN 28 BIOPATCH PROTECTIVE BREATHERITE BYETTA 28 DISKWITH CHG/1"DISK/4MM COLLAPSIBLESMALL CHILD bzk antiseptic towelettes 50 HOLE 51 SPACER W/MASK 190 BIOTENE DRY MOUTH BREATHERITE CA-REZZ 51 MOISTURIZING SPRAY 204 COLLAPSIBLESPACER W/ CA-REZZ GENTLE 51 bisacodyl 101 NEONATE MASK 190 CA-REZZ MOISTURE bismatrol 30 BREATHERITE RIGID BARRIER 51 bismuth subsalicylate 30 SPACERW/MASK 190 CA-REZZ NORISC 52 BREATHERITE W/LARGE CA-REZZ NORISC CREAM 51 bisoprolol & MASK 190 hydrochlorothiazide 40 BREATHERITE W/MEDIUM cabergoline 87 bisoprolol fumarate 59 MASK 190 CABOMETYX 45 bleomycin sulfate 44 BREATHERITE W/SMALL caffeine citrate 1 MASK 190 BLEPHAMIDE 240 CAL-DAY 1000 213 BREO ELLIPTA 22 BLEPHAMIDE S.O.P. 240 CALAMINE 82 BRILINTA 93 blis-to-sol 72 CALAMINE PHENOLATED 82 brimonidine tartrate 239 bonine 32 calcidol 260 BONJESTA 32 brinzolamide 241 bromfenac sodium calcipotriene 74 BOOSTRIX 249 (ophth) 241 calcitonin (salmon) 86 BORDERED GAUZE 104 bromocriptine mesylate 47 calcitrate 198 boro-packs 81 BUBBLES THE FISH II calcitrate plus d 199 bosentan 60 PEDIATRIC MASK/PVC 190 calcitrene 74 budesonide 64 BOSULIF 45 calcitriol 86 budesonide (inhalation) 21
Index 7 calcitriol (topical) 74 CARAC 73 CAREONE UNIFINE PENTIPS CALCIUM 199 CARBAGLU 86 PLUS PEN NEEDLES 29GX12MM 134 calcium 500 + d 198 carbamazepine 23 CAREONE UNIFINE PENTIPS calcium 500+d 198 carbidopa 47 PLUS PEN NEEDLES calcium 600 198 carbidopa-levodopa 47 31GX5MM 134 CARDIOCOM LANCING CAREONE UNIFINE PENTIPS calcium 600 + d 198 PLUS PEN NEEDLES calcium 600 high potency 198 DEVICE 113 CAREFINE PEN NEEDLE 31GX6MM 134 calcium 600+d 198 32GX4MM 133 CAREONE UNIFINE PENTIPS calcium acetate (phosphate CAREFINE PEN NEEDLES PLUS PEN NEEDLES binder) 90 29GX1/2" 133 31GX8MM 134 CALCIUM CAREFINE PEN NEEDLES CAREONE UNIFINE PENTIPS CARBONATE 17,199 30GX5/16" 133 PLUS PEN NEEDLES calcium carbonate 199 CAREFINE PEN NEEDLES 32GX4MM 134 CAREONE UNIFINE PENTIPS calcium carbonate (antacid) 17 31GX6MM 133 CAREFINE PEN NEEDLES PLUS PEN NEEDLES/33G X calcium carbonate- 5/32" 134 cholecalciferol 199 31GX8MM 133 CAREFINE PEN NEEDLES CAREPOINT SAFETY 1ST calcium carbonate-vitamin SYRINGE/NEEDLE 3ML/23G X d 199 32GX5MM 133 CAREFINE PEN NEEDLES 1" 134 calcium citrate 199 32GX6MM 133 CAREPOINT SAFETY 1ST calcium citrate + 199 CAREONE ADVANCED SYRINGE/NEEDLE 3ML/25G X calcium citrate + d3 199 LANCINGDEVICE 113 1" 134 CALCIUM CITRATE CAREONE INSULIN CAREPOINT SAFETY 1ST SYRINGE/NEEDLE 3ML/25G X MALATE/VITAMIN D 199 SYRINGES/0.3ML/30G X 5/8" 134 calcium citrate-vitamin d 199 1/2" 133 CAREONE INSULIN CARETOUCH 2 CPAP HOSE calcium citrate/d3 199 SYRINGES/0.3ML/31G X HANGER 190 CALCIUM LACTATE 199 5/16" 133 CARETOUCH ALCOHOL PREP calcium plus vitamin d 198 CAREONE INSULIN PADS 124 SYRINGES/0.5ML/30G X CARETOUCH CPAP & BIPAP calcium plus vitamin d3 198 1/2" 133 HOSE/6FT 190 calcium polycarbophil 97 CAREONE INSULIN CARETOUCH CPAP MASK calcium+d3 198 SYRINGES/0.5ML/31G X WIPES 190 CARETOUCH CPAP CALCIUM/VITAMIN D 199 5/16" 133 CAREONE INSULIN NEUTRALIZING PRE- calcium/vitamin d-3 198 SYRINGES/1ML/30G X WASH 190 CALNA 225 1/2" 133 CARETOUCH CPAP TUBE CAREONE INSULIN CLEANING BRUSH 191 CALQUENCE 45 CARETOUCH INSULIN camila 63 SYRINGES/1ML/31GX5/16" 133 SYRINGE/U-100/1ML/28G X candesartan cilexetil 40 CAREONE LANCET SUPER 5/16" 134 candesartan cilexetil- THIN/30G 113 CARETOUCH INSULIN hydrochlorothiazide 40 CAREONE LANCET SYRINGE/U-100/1ML/29G X capecitabine 42 THIN 113 5/16" 134 CARETOUCH LANCING CAPEX 78 CAREONE UNIFINE PENTIPS 29GX12MM 133 DEVICEWITH EJECTOR 113 CAPHOSOL 204 CAREONE UNIFINE PENTIPS CARETOUCH PEN NEEDLES CAPLYTA 47 31GX5MM 133 31G X 6 MM 134 CAPRELSA 45 CAREONE UNIFINE PENTIPS CARETOUCH PEN NEEDLES 31GX6MM 133 31GX 5MM 134 capsaicin 81 CAREONE UNIFINE PENTIPS CARETOUCH PEN NEEDLES capsaicin hp 80 31GX8MM 133 31GX 8MM 134 captopril 40 CAREONE UNIFINE PENTIPS CARETOUCH PEN NEEDLES captopril & PEN NEEDLES 32GX 4MM 134 hydrochlorothiazide 40 32GX4MM 133 CARETOUCH PEN NEEDLES 32GX 5MM 134 CAPZASIN-P 81
Index 8 CARETOUCH TWIST LANCETS CERALYTE 70 200 CHLORHEXIDINE 30G 113 CERASPORT 200 GLUCONATE 52 CARETOUCH UNIVERSAL chlorhexidine gluconate (mouth- CPAPFILTERS 191 CERASPORT EX1 200 throat) 204 carisoprodol 230 CEREZYME 93 CHLORHEXIDINE GLUCONATE CARRASMART 104 CEROVEL 80 CLOTH 52 chloroquine phosphate 41 CARRASMART FOAM 104 certa plus 206 chlorothiazide 85 carrington antifungal 72 CERTAVITE SENIOR 214 chlorpheniramine maleate 33 carteolol hcl (ophth) 238 CERTAVITE SENIOR/ANTIOXIDANT chlorpromazine hcl 49 cartia xt 59 NUTRIENTS 214 chlorthalidone 85 carvedilol 58 certavite/antioxidants 210 chlorzoxazone 230 carvedilol phosphate 58 CERTAVITE/ANTIOXIDANTS CHOLBAM 89 cataflam 3 214 cholecalciferol 261 cavarest 204 cetirizine hcl 38 cholestyramine 39 CAVILON SKIN CLEANSER 52 cetirizine hcl childrens 36 cholestyramine light 39 CAYA 110 cetirizine-pseudoephedrine 68 chromagen 94 caziant 61 CETYLCIDE II 53 cidofovir 57 cefaclor 60 CETYLCIDE-G 50 cilostazol 93 cefadroxil 60 CHANTIX 247 CEFAZOLIN SODIUM/SODIUM CILOXAN 239 CHANTIX CONTINUING CIMDUO 55 CHLORIDE 60 MONTHPAK 247 CEFAZOLIN/SODIUM CHANTIX STARTING MONTH cimetidine 252 CHLORIDE 60 PAK 247 cimetidine 200 249 cefdinir 60 CHEMET 31 cimetidine hcl 252 cefpodoxime proxetil 61 CHEMSTRIP -10 WITH cinacalcet hcl 86 cefprozil 60 SG 84 CINQAIR 20 ceftriaxone sodium 61 CHEMSTRIP 10 MD 84 CINRYZE 93 CEFTRIAXONE SODIUM 61 CHEMSTRIP 2 GP STRIPS 84 CIPRO 88 ceftriaxone sodium 61 CHEMSTRIP 5 OB 84 ciprofloxacin 88 cefuroxime axetil 60 CHEMSTRIP 7 84 ciprofloxacin hcl 88 celecoxib 6 CHEMSTRIP 9 STRIPS 84 ciprofloxacin hcl (ophth) 239 CELONTIN 24 CHEMSTRIP-K 84 ciprofloxacin hcl (otic) 242 centravites 50 plus 210 CHEWABLE ciprofloxacin-dexamethasone CENTRAVITES 50 PLUS 213 CALCIUM/D3 199 242 CENTRAVITES ADULTS 213 childrens acetaminophen 8 citalopram hydrobromide 25 CENTRUM CARDIO 213 childrens apap 9 citroma 100 CENTRUM MEN 213 childrens ibuprofen 4 clarispray 231 CENTRUM SILVER ULTRA childrens loratadine 38 clarithromycin 103 WOMENS 213 childrens non-aspirin 9 CLARITIN REDITABS 38 CENTRUM SPECIALIST HEART 213 childrens silapap 9 CLASSIC PRENATAL 225 CENTRUM SPECIALIST chloramphenicol sodium CLEANLET LANCETS 28G 113 IMMUNE SUPPORT 213 succinate 18 clearcanal earwax softener 242 CENTRUM SPECIALIST chlordiazepoxide hcl 19 clearlax 99 PRENATAL 225 chlordiazepoxide-amitriptyline CENTRUM SPECIALIST 244 clemastine fumarate 35 VISION 213 chlorhexidine gluconate 51 CLEOCIN PHOSPHATE 19 CENTRUM ULTRA CHLORHEXIDINE CLEVER CHOICE ANTI- WOMENS 214 GLUCONATE 52 STATICVALVED HOLDING cephalexin 60 chlorhexidine gluconate 52 CHAMBER/ADULT LARGE 191
Index 9 CLEVER CHOICE ANTI- CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLE STATICVALVED HOLDING EZINSULIN UNIVERSAL/31GX1/4" 136 CHAMBER/MEDIUM 191 SYRINGE/1.0ML/30G X CLICKFINE PEN NEEDLE CLEVER CHOICE ANTI- 1/2" 135 UNIVERSAL/31GX5/16" 136 STATICVALVED HOLDING CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLES 31G CHAMBER/MEDIUM/3 EZINSULIN X 1/4" 136 YEA 191 SYRINGE/1ML/28G X CLICKFINE PEN NEEDLES 31G CLEVER CHOICE ANTI- 1/2" 135 X 3/16" 136 STATICVALVED HOLDING CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLES 31G CHAMBER/SMALL 191 EZINSULIN X 5/16" 136 CLEVER CHOICE ANTI- SYRINGE/1ML/29G X CLICKFINE PEN NEEDLES 31G STATICVALVED HOLDING 1/2" 135 X 8MM 136 CHAMBER/SMALL CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLES 32G INFANT 191 EZINSULIN X 5/32" 136 CLEVER CHOICE COMFORT SYRINGE/1ML/30G X CLICKFINE PEN EZINSULIN PEN NEEDLES 5/16" 135 NEEDLES/31GX1/4" 136 31GX8MM 134 CLEVER CHOICE COMFORT CLICKFINE UNIVERSAL PEN CLEVER CHOICE COMFORT EZINSULIN SYRINGE/U- NEEDLES 31GX5/16" 136 EZINSULIN PEN NEEDLES 100/1ML/31GX5/16" 135 CLIMARA PRO 87 33GX4MM 134 CLEVER CHOICE COMFORT clindamycin hcl 19 CLEVER CHOICE COMFORT EZPEN NEEDLES clindamycin palmitate EZINSULIN 29GX12MM 135 hydrochloride 19 SYRINGE/0.3ML/29G X CLEVER CHOICE COMFORT clindamycin phosphate 19 1/2" 134 EZPEN NEEDLES clindamycin phosphate CLEVER CHOICE COMFORT 31GX5MM 135 EZINSULIN CLEVER CHOICE COMFORT (topical) 70 SYRINGE/0.3ML/30G X EZPEN NEEDLES clindamycin phosphate vaginal 259 1/2" 135 31GX6MM 135 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT CLINDESSE 259 EZINSULIN EZPEN NEEDLES CLINICAL NUTRIENTS 45-PLUS SYRINGE/0.3ML/30G X 31GX8MM 135 WOMEN 214 5/16" 135 CLEVER CHOICE COMFORT CLINICAL NUTRIENTS 50-PLUS CLEVER CHOICE COMFORT EZPEN NEEDLES MEN 214 EZINSULIN 32GX4MM 135 CLINICAL NUTRIENTS FOR SYRINGE/0.3ML/31G X CLEVER CHOICE COMFORT FEMALE TEENS 214 5/16" 135 EZPEN NEEDLES CLINICAL NUTRIENTS FOR CLEVER CHOICE COMFORT 32GX5MM 136 MALE TEENS 214 EZINSULIN CLEVER CHOICE COMFORT CLINICAL NUTRIENTS FOR SYRINGE/0.5ML/28G X EZPEN NEEDLES MEN 214 1/2" 135 32GX6MM 136 CLINICAL NUTRIENTS FOR CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT WOMEN 214 EZINSULIN EZPEN NEEDLES CLINICAL NUTRIENTS SYRINGE/0.5ML/29G X 32GX8MM 136 PRENATAL FORMULA 225 1/2" 135 CLEVER CHOICE COMFORT CLINIMIX 4.25%/DEXTROSE CLEVER CHOICE COMFORT EZPEN NEEDLES 10% 236 EZINSULIN 33GX4MM 136 CLINIMIX 4.25%/DEXTROSE SYRINGE/0.5ML/30G X CLEVER CHOICE COMFORT 25% 237 EZPEN NEEDLES CLINIMIX 4.25%/DEXTROSE 1/2" 135 237 CLEVER CHOICE COMFORT 33GX5MM 136 5% CLEVER CHOICE COMFORT CLINIMIX 5%/DEXTROSE EZINSULIN 15% 237 SYRINGE/0.5ML/30G X EZPEN NEEDLES 33GX6MM 136 CLINIMIX 5%/DEXTROSE 5/16" 135 20% 237 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT EZPEN NEEDLES CLINIMIX 5%/DEXTROSE EZINSULIN 25% 237 SYRINGE/0.5ML/31G X 33GX8MM 136 CLEVER CHOICE PEAK CLINIMIX E 2.75%/DEXTROSE 5/16" 135 237 FLOW METER 191 10% CLICKFINE PEN NEEDLE CLINIMIX E 2.75%/DEXTROSE 237 32GX5/32" 136 5%
Index 10 CLINIMIX E 4.25%/DEXTROSE COMFORT ASSIST INSULIN COMFORT TOUCH PEN 10% 237 SYRINGE 0.3ML/29G X NEEDLES/32G X 8MM 137 CLINIMIX E 4.25%/DEXTROSE 1/2" 136 COMFORT TOUCH PEN 5% 237 COMFORT ASSIST INSULIN NEEDLES/33G X 5/32" 137 CLINIMIX N9G20E 237 SYRINGE/0.3ML/30G X COMFORT TOUCH PEN clinisol sf 15% 236 5/16" 136 NEEDLES/33GX 3/16" 138 COMFORT ASSIST INSULIN COMFORT TOUCH PEN CLINOLIPID 234 SYRINGE/0.3ML/31G X NEEDLES/33GX1/4" 138 clobetasol propionate 78 5/16" 136 COMPACT SPACE clobetasol propionate e 74 COMFORT ASSIST INSULIN CHAMBER/ANTI-STATIC 191 clobetasol propionate emollient SYRINGE/0.5ML/29G X COMPACT SPACE base 78 1/2" 137 CHAMBER/ANTI- STATIC/LARGE MASK 191 clomipramine hcl 26 COMFORT ASSIST INSULIN SYRINGE/0.5ML/30G X COMPACT SPACE clonazepam 23 5/16" 137 CHAMBER/ANTI- clonidine hcl 40 COMFORT ASSIST INSULIN STATIC/MEDIUM MASK 191 clonidine hcl (adhd) 1 SYRINGE/0.5ML/31G X COMPACT SPACE 5/16" 137 CHAMBER/ANTI-STATIC/SMALL clopidogrel bisulfate 93 COMFORT ASSIST INSULIN MASK 191 clorazepate dipotassium 19 SYRINGE/1ML/29G X COMPLERA 55 clorox nasal antiseptic 1/2" 137 COMPLETE NATAL DHA 225 swabs 53 COMFORT ASSIST INSULIN COMPLETENATE 225 CLORPACTIN WCS-90 52 SYRINGE/1ML/30G X compoz 95 clotrimazole 204 5/16" 137 COMFORT ASSIST INSULIN compro 49 clotrimazole (topical) 73 SYRINGE/1ML/31G X CONDYLOX 80 clotrimazole vaginal 259 5/16" 137 clotrimazole w/ COMFORT ASSURED constulose 99 betamethasone 73 LANCETS SUPER THIN CONTRAVE 1 clotrimazole-7 258 28G 113 COPA ISLAND BORDERED clozapine 48 COMFORT EZ INSULIN FOAM DRESSING 4"X4" 104 SYRINGE/U-100/0.5ML/31G X COPA PLUS HYDROPHILIC CLOZARIL 48 5/16" 137 FOAM DRESSING 4"X4" 104 CO MONITOR REPLACEMENT COMFORT EZ INSULIN COPIKTRA 45 TPIECES 191 SYRINGE/U-100/1ML/31G X CORIFACT 91 CO-NATAL FA 225 5/16" 137 correctol extra gentle 102 COAGADEX 91 COMFORT EZ MICRO/32G X 4MM 137 cortic-nd 242 coal tar extract 83 COMFORT EZ SHORT/31G X CORTIFOAM 14 COARTEM 41 8MM 137 cortisone acetate 64 CODEINE SULFATE 11 COMFORT EZ/31G X cortizone-10 intensive codeine sulfate 11 5MM 137 COMFORT EZ/31G X healing 78 COGENTIN 47 6MM 137 COSENTYX 74 colace 2-in-1 98 COMFORT LANCETS 113 COSENTYX SENSOREADY colchicine 91 COMFORT TOUCH PEN PEN 74 colchicine w/ probenecid 91 NEEDLES/31G X 4MM 137 COTELLIC 45 COMFORT TOUCH PEN cold/allergy childrens 64 COUMADIN 22 NEEDLES/31G X 5MM 137 COVRSITE COVER colestipol hcl 39 COMFORT TOUCH PEN DRESSING 104 colocort 14 NEEDLES/31G X 6 MM 137 COVRSITE PLUS COMPOSITE COMBIPATCH 87 COMFORT TOUCH PEN DRESSING 104 NEEDLES/31G X 8 MM 137 COMBIVENT RESPIMAT 22 COMFORT TOUCH PEN CREOLIN 53 COMBIVIR 55 NEEDLES/32G X 4MM 137 CREON 85 COMETRIQ 45 COMFORT TOUCH PEN CRIXIVAN 55 NEEDLES/32G X 5MM 137 cromolyn sodium 20 COMFORT TOUCH PEN NEEDLES/32G X 6MM 137
Index 11 cromolyn sodium CURITY GAUZE SPONGE cvs daily fiber 96 (mastocytosis) 89 3"X3" 12 PLY 105 CVS DAILY FIBER 97 cromolyn sodium (nasal) 231 CURITY GAUZE SPONGE CVS DRY MOUTH SPRAY 204 cromolyn sodium (ophth) 241 4"X4" 12 PLY 105 CURITY GAUZE SPONGE cvs enema disposable 100 crotan 82 4"X4" 16 PLY 105 cvs esomeprazole CRUAD GAUZE PADS 4" X CURITY GAUZE SPONGE magnesium 253 4" 104 4"X4" 8 PLY 105 cvs eye drops original 240 cryselle-28 62 CURITY GAUZE SPONGE cvs fever reducing childrens 9 CURAD NON-STICK PADS 4"X4"16 PLY 105 WITHADHESIVE TABS CURITY GAUZE SPONGES cvs fiber 96 3"X4" 104 4"X4" 12 PLY 105 cvs fiber laxative 96 curad triple antibiotic 71 CURITY GAUZE SPONGES cvs fish oil 234 4"X4" 8 PLY 105 CURECHROME 52 CURITY NON-ADHERENT cvs folic acid 93 CURITY ALCOHOL STRIPS 3"X3" 105 cvs gas relief 89 PREPS/MEDIUM 2 PLY 124 CURITY cvs gas relief drops extra CURITY ALCOHOL SPONGES/CELLULOSEFILLE strength 88 SWABS 124 D/2"X2" 105 cvs gas relief infants 88 CURITY ALL PURPOSE CURITY SPONGES 2"X2" 104 SPONGES/CELLULOSEFILLE CVS GAUZE PAD 3"X3" 105 CURITY ALL PURPOSE D/4"X4" 105 CVS GAUZE PADS 2"X2" 12- SPONGES 2"X2" 4PLY 104 CURX ANTIMICROBIAL 52 PLY 105 CURITY ALL PURPOSE CVS GAUZE PADS 4"X4" 12- SPONGES 3"X3" 4PLY 104 CUVPOSA 249 PLY 105 CURITY ALL PURPOSE cvs acid reducer 252 CVS GAUZE PADS STERILE SPONGES 4 PLY 104 CVS ADHESIVE PAD 4"X4" 12-PLY 106 CURITY ALL PURPOSE 4"X4" 105 CVS GLUCOSE 27 SPONGES 4"X4" 104 CVS ADHESIVE PAD cvs glycerin adult 99 CURITY ALL PURPOSE 6"X6" 105 SPONGES 4"X4" 4PLY 104 CVS ADHESIVE PADS cvs heartburn relief 249 CURITY ALL PURPOSE 2.25"X3" 105 cvs hemorrhoidal & topical SPONGES 4"X4" 4PLY/SOFT cvs advanced 3-in-1 exfoliating analgesic 80 POUCH 104 cleanser 69 cvs hydrocortisone anti-itch 77 CURITY AMD CVS ALCOHOL PREP cvs hydrogen peroxide 50 ANTIMICROBIALGAUZE PADS 124 cvs ibuprofen infants 5 SPONGES 2"X2" 8 PLY 104 cvs allergy relief 36,37 CURITY AMD CVS IODINE TINCTURE 53 cvs allergy relief childrens 36 ANTIMICROBIALGAUZE cvs iron 94 cvs allergy/congestion SPONGES 4"X4" 12 PLY 104 CVS LANCETS 21G 113 CURITY COVER SPONGE childrens 66 cvs anti-dandruff 74 CVS LANCETS MICRO THIN 4"X4" 104 33G 113 CURITY COVER SPONGES cvs anti-diarrheal 30 CVS LANCETS MICRO-THIN 3"X3" 104 cvs anti-itch 74 CURITY COVER SPONGES 33G 113 4"X4" 104 cvs antibiotic plus 71 CVS LANCETS ORIGINAL 113 CURITY DRESSING SPONGES cvs antifungal 73 CVS LANCETS THIN 26G 113 4"X4" 6 PLY 105 cvs bacitracin 70 CVS LANCETS ULTRA THIN CURITY GAUZE PADS cvs bismuth 30 30G 113 2"X2" 105 CVS LANCETS ULTRA-THIN CURITY GAUZE PADS 2"X2" 12 cvs budesonide nasal 30G 113 spray 231 PLY 105 CVS LANCING DEVICE 113 CURITY GAUZE PADS cvs buffered aspirin 9 3"X3" 105 cvs clotrimazole cvs lansoprazole 253 CURITY GAUZE PADS 4"X4" 12 maximumstrength 72 cvs lice killing 83 PLY 105 cvs cold & allergy childrens65 cvs lice solution kit 83 CURITY GAUZE SPONGE 2"X2" cvs cold & sinus relief 67 CVS LICE SOLUTION KIT 3- 8 PLY 105 cvs d3 259 STEP 83 CURITY GAUZE SPONGE cvs lice treatment 82 2"X2"12 PLY 105
Index 12 cvs merthiolate 50 CVS SPECTRAVITE ULTRA deferasirox 31 cvs miconazole 3 combination MENS HEALTH SENIOR 214 DELSTRIGO 55 CVS SPECTRAVITE ULTRA pack 258 denta 5000 plus 204 cvs miconazole 7 258 WOMEN 214 CVS SPECTRAVITE ULTRA DEPAKENE 24 cvs milk of magnesia 100 WOMENS HEALTH 214 DEPO-SUBQ PROVERA cvs mini enema kids 102 CVS SPECTRAVITE ULTRA 104 63 cvs motion sickness 32 WOMENS HEALTH DERMA CIDOL 2000 50 SENIOR 214 cvs motion sickness ii 32 DERMACEA DRAIN SPONGES cvs stool softener 102 cvs naproxen sodium 5 4"X4" 106 cvs therapeutic 83 DERMACEA GAUZE SPONGE cvs nasal allergy spray 232 cvs tioconazole 1 259 2"X2" 12 PLY 106 cvs nasal decongestant 233 DERMACEA GAUZE SPONGE cvs ultra sleep 96 cvs nasal decongestant pe 232 2"X2" 8 PLY 106 CVS ULTRA THIN DERMACEA GAUZE SPONGE cvs natural daily fiber 97 LANCETS 113 3"X3" 12 PLY 106 cvs natural fiber supplement 97 cvs vitamin b-2 262 DERMACEA GAUZE SPONGE CVS NATURAL FIBER cvs vitamin e 260 3"X3" 8 PLY 106 SUPPLEMENT 97 CVS WOMENS DERMACEA GAUZE SPONGE cvs natural fish oil 235 PRENATAL+DHA 225 4"X4" 12 PLY 106 cvs nicotine 246 cvs zinc oxide 81 DERMACEA GAUZE SPONGE 4"X4" 16 PLY 106 cvs nicotine lozenge 245 cyanocobalamin 93 DERMACEA GAUZE SPONGE cvs nicotine cyclobenzaprine hcl 230 4"X4" 8 PLY 106 transdermalsystem 246 CYCLOMYDRIL 238 DERMACEA I.V. DRAIN cvs omeprazole 253 SPONGES 2"X2" 106 cyclopentolate hcl 238 CVS ONE DAILY MENS 50+ DERMACEA I.V. DRAIN ADVANCED 214 CYCLOSET 27 SPONGES 4"X4" 106 CVS ONE DAILY WOMENS cyclosporine 203 DERMACEA I.V. SPONGES 50+ADVANCED 214 cyclosporine modified (for 2"X2" 106 cvs pain relief childrens 9 microemulsion) 203 DERMACEA NON-WOVEN SPONGES 2"X2" 4 PLY 106 cvs pinworm treatment 17 cyproheptadine hcl 39 DERMACEA NON-WOVEN cvs poly bacitracin 71 CYRAMZA 42 SPONGES 3"X3" 4 PLY 106 CVS PRENATAL 225 CYSTARAN 241 DERMACEA NON-WOVEN CVS PRENATAL CYTOMEL 248 SPONGES 4"X4" 4 PLY 106 DERMACEA NON-WOVEN GUMMIES 225 cytra k crystals 90 CVS PRENATAL SPONGES 4"X4" 6 PLY 106 GUMMY/DHA/FOLIC ACID 225 d 1000 260 DERMACEA TYPE VII GAUZE CVS PRENATAL DAILY FIBER 97 2"X2" 12 PLY 106 MULTI+DHA 225 daily multiple vitamins DERMACEA TYPE VII GAUZE w/iron 205 2"X2" 8 PLY 106 CVS PREP PADS 124 DERMACEA TYPE VII GAUZE cvs purelax 99 dalfampridine 244 3"X3" 12 PLY 106 cvs senna 101 danazol 14 DERMACEA TYPE VII GAUZE cvs sinus & allergy maximum dantrolene sodium 230 3"X3" 12PLY 106 strength 65 dapsone 18 DERMACEA TYPE VII GAUZE cvs sleep-aid nighttime 95,96 4"X4" 12 PLY 106 DARZALEX 43 DERMACEA TYPE VII GAUZE CVS SOFT GLUCOSE 27 DAYAVITE 215 4"X4" 16 PLY 106 CVS SPECTRAVITE ADULT dayhist allergy 12 hour DERMACEA TYPE VII GAUZE 50+ 214 relief 33 4"X4" 8 PLY 107 CVS SPECTRAVITE DDAVP 87 DERMACEA X-RAY SPONGES ADULTS 214 4"X4" 16 PLY 107 decadron 63 CVS SPECTRAVITE ULTRA dermacinrx penetral 80 MEN50+ 214 decara 260 DERMACINRX RIBOTIN-E 215 CVS SPECTRAVITE ULTRA decitabine 42 MENS HEALTH 214 DERMACINRX ZINTREXYL- DECOLORIZED IODINE 53 C 215
Index 13 DERMALEVIN ADHESIVE DIABET-X DAILY dimethyl fumarate 244 FOAMDRESSING 4"X4" 107 PREVENTIONSKIN diocto 102 DERMAVITE 215 THERAPY 52 diphenhydramine hcl 35 DESCOVY 55 DIABETIC BASICS HEALTHY FOOT 52 diphenhydramine hcl (sleep) 96 desipramine hcl 26 diabetic tussin allergy 33 diphenoxylate w/ atropine 31 DESMOPRESSIN DIALYSIS SAFETY dipyridamole 93 ACETATE 87 SYRINGES/LOW DEAD desmopressin acetate 87 SPACE 3ML/22GX1-1/2" 138 disopyramide phosphate 20 desmopressin acetate spray 87 diamode 31 disulfiram 243 desmopressin acetate spray DIASTIX 84 divalproex sodium 25 refrigerated 87 DOCETAXEL 46 desogestrel & ethinyl DIATHRIVE LANCETS 113 estradiol 62 DIATHRIVE LANCETS ULTRA docetaxel 46 desogestrel-ethinyl estradiol THIN 30G 113 DOCETAXEL 46 (biphasic) 62 DIATHRIVE LANCING docetaxel 46 desonide 78 DEVICE 113 DIATHRIVE PEN NEEDLE/31 DOCETAXEL 46 desoximetasone 78 G X 6MM 138 docosahexaenoic acid 235 desvenlafaxine 26 DIATHRIVE PEN NEEDLE/31 docusate calcium 102 DESVENLAFAXINE ER 26 GX 8MM 138 DIATHRIVE PEN docusate sodium 102 desvenlafaxine succinate 26 NEEDLE/31GX 5MM 138 DOCUSOL PLUS MINI- DEX4 QUICK DISSOLVE DIATHRIVE PEN ENEMA 102 GLUCOSE 27 NEEDLE/32GX 4MM 138 dofetilide 20 dexamethasone 64 diazepam 19 dok 102 DEXAMETHASONE diazepam (anticonvulsant) 23 donepezil hydrochloride 243 INTENSOL 64 dexamethasone sodium dibucaine 81 dorzolamide hcl 241 phosphate 64 diclofenac potassium 6 DORZOLAMIDE HCL 241 DEXAMETHASONE SODIUM diclofenac sodium 6 dorzolamide hcl-timolol PHOSPHATE 64 diclofenac sodium (ophth)241 maleate 238 dexamethasone sodium dotti 87 phosphate (ophth) 240 diclofenac sodium (topical) 70 DOVATO 55 dexchlorpheniramine dicloxacillin sodium 243 doxazosin mesylate 40 maleate 33 dicyclomine hcl 249 dexmethylphenidate hcl 2 doxepin hcl 26 didanosine 55 dextroamphetamine sulfate 1 doxorubicin hcl 44 diethylpropion hcl 1 dextromethorphan-guaifenesin doxycycline (monohydrate) 248 difil-g forte 20 68 doxycycline hyclate 248 dextrose 234 diflorasone diacetate 78 doxylamine-pyridoxine 32 DEXTROSE 234 diflunisal 11 dr gs clear nail 73 DEXTROSE 5%/ELECTROLYTE digitek 60 DRAMAMINE 32 #48 VIAFLEX 200 digoxin 60 DEXTROSE 10%/NACL dihydroergotamine DRITHO-CREME HP 74 0.2% 200 mesylate 197 DRIXORAL DEXTROSE 20% 234 DILANTIN 24 COLD/ALLERGY 68 DEXTROSE 5%/NACL dronabinol 32 DILANTIN INFATABS 24 0.3% 200 DROPLET GENTEEL LANCING dextrose w/ sodium DILANTIN-125 24 DEVICE 114 chloride 200 DILATRATE SR 19 DROPLET INSULIN SYRINGE DEXTROSE/SODIUM dilt-xr 59 0.3ML/29G X 1/2" 138 CHLORIDE 200 DROPLET INSULIN SYRINGE DI-DAK-SOL 52 diltiazem hcl 59 0.5ML/29G X 1/2" 138 di-phen 35 diltiazem hcl coated beads 59 DROPLET INSULIN SYRINGE diltiazem hcl extended release 1ML/29G X 1/2" 138 beads 59 DROPLET INSULIN SYRINGE U-100/0.3/31G X 5/16" 138
Index 14 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES 31G DULERA 22 U-100/0.3ML/30G X 1/2" 138 X5/16" 139 duloxetine hcl 26 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES U-100/0.3ML/30G X 5/16" 138 31GX5MM 139 DUPIXENT 79 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES duramorph 11 U-100/0.3ML/31G X 15/64" 138 31GX6MM 139 DUREX EXTRA DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES SENSITIVE 110 U-100/0.5ML/30G X 1/2" 138 31GX8MM 139 dutasteride-tamsulosin hcl 90 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES 32G U-100/0.5ML/30G X 5/16" 138 X 1/4" 139 DUTOPROL 40 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES 32G DYSPORT 234 U-100/0.5ML/31G X 5/16" 138 X 3/16" 139 E-Z JECT LANCETS 114 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES 32G E-Z JECT LANCETS 21G 114 U-100/1ML/30G X 1/2" 138 X 5/16" 139 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES 32G E-Z JECT LANCETS U-100/1ML/30G X 5/16" 138 X 5/32" 139 COLOR 114 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES E-Z JECT LANCETS SUPER U-100/1ML/31G X 15/64" 138 32GX4MM 139 THIN 30G 114 DROPLET INSULIN SYRINGE DROPLET PEN NEEDLES E-Z JECT LANCETS THIN U-100/1ML/31G X 5/16" 138 32GX5MM 139 26G 114 DROPLET INSULIN DROPLET PEN NEEDLES E-ZJECT LANCETS MICRO- SYRINGE/U-100/0.3ML/31G X 32GX6MM 139 THIN 33G 114 15/64" 139 DROPLET PEN NEEDLES e.e.s. 400 103 DROPLET INSULIN 32GX8MM 140 EASIVENT 191 SYRINGE/U-100/0.3ML/31G X DROPSAFE SAFETY PEN EASIVENT/MASK-LARGE 191 5/16" 139 NEEDLES/31G X 5/16" 140 EASIVENT/MASK-MEDIUM DROPLET INSULIN DROPSAFE SAFTEY PEN 191 SYRINGE/U-100/0.5ML/30G X NEEDLES/31G X 1/4" 140 1/2" 139 drospirenone-ethinyl EASIVENT/MASK-SMALL 191 DROPLET INSULIN estradiol 62 EASY COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X DROXIA 93 SYRINGE/0.5ML/30G X 15/64" 139 5/16" 140 DRUG MART ADJUSTABLE EASY COMFORT INSULIN DROPLET INSULIN LANCING DEVICE 114 SYRINGE/U-100/0.5ML/31G X DRUG MART LANCETS SYRINGE/0.5ML/31G X 5/16" 139 THIN 114 5/16" 140 DROPLET INSULIN DRUG MART UNIFINE EASY COMFORT INSULIN SYRINGE/U-100/1ML/30G X PENTIPS 31GX5MM 140 SYRINGE/1ML/30G X 1/2" 139 DRUG MART UNIFINE 5/16" 140 DROPLET INSULIN PENTIPS29G X 12MM 140 EASY COMFORT INSULIN SYRINGE/U-100/1ML/31G X DRUG MART UNIFINE SYRINGE/1ML/31G X 15/64" 139 PENTIPS31GX6MM 140 5/16" 140 DROPLET INSULIN DRUG MART UNIFINE EASY COMFORT INSULIN SYRINGE/U-100/1ML/31G X PENTIPS31GX8MM 140 SYRINGE/U-100/0.5ML/30G X 5/16" 139 DRUG MART UNIFINE 1/2" 140 DROPLET LANCETS ULTRA PENTIPS32GX4MM 140 EASY COMFORT INSULIN THIN 30G 114 DRUG MART UNIFINE SYRINGE/U-100/1ML/30G X DROPLET LANCING PENTIPSPLUS 1/2" 140 DEVICE 114 32GX4MM 140 EASY COMFORT PEN DROPLET PEN NEEDLES 29G DRUG MART UNILET NEEDLES31GX1/4" 140 X1/2" 139 LANCETSSUPER THIN EASY COMFORT PEN DROPLET PEN NEEDLES 30G 114 NEEDLES31GX3/16" 140 29GX10MM 139 DRUG MART UNILET EASY COMFORT PEN DROPLET PEN NEEDLES LANCETSULTRA THIN NEEDLES31GX5/16" 140 29GX12MM 139 28G 114 EASY COMFORT PEN DROPLET PEN NEEDLES 30G DRUG MART UNILET MICRO NEEDLES32GX5/32" 140 X 5/16" 139 THIN LANCETS 33G 114 EASY COMFORT PEN NEEDLES33G X 4MM 140 DROPLET PEN NEEDLES 31G DRYMAX EXTRA 107 X3/16" 139 EASY COMFORT PEN DRYSOL 82 NEEDLES33G X 5MM 140
Index 15 EASY COMFORT PEN EASY TOUCH FLIPLOCK EASY TOUCH INSULIN NEEDLES33G X 6MM 140 SAFETY SYRINGES SYRINGE/U-100/1ML/28G X EASY FLOW 300 MM 3ML/20GX1" 141 1/2" 142 HOSE 191 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY FLOW 400 MM SAFETY SYRINGES SYRINGE/U-100/1ML/29G X HOSE 191 3ML/20GX1-1/2" 141 1/2" 142 EASY FLOW AIR NOZZLE 192 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY FLOW HEPA SAFETY SYRINGES SYRINGE/U-100/1ML/30G X FILTER 192 3ML/21GX1-1/2" 141 1/2" 142 EASY GLIDE PEN NEEDLES EASY TOUCH INSULIN EASY TOUCH INSULIN 33G X 5/32" 140 SYRINGE/0.3ML/30G X SYRINGE/U-100/1ML/31G X EASY MINI EJECT LANCING 5/16" 141 5/16" 142 DEVICE 114 EASY TOUCH INSULIN EASY TOUCH LANCETS EASY MINI LANCING SYRINGE/0.3ML/31G X 26G/PULL-TOP 114 DEVICE 114 5/16" 142 EASY TOUCH LANCETS EASY TOUCH 32GX5MM 140 EASY TOUCH INSULIN 28G/PULL-TOP 114 SYRINGE/0.5ML/29G X EASY TOUCH LANCETS EASY TOUCH 32GX6MM 141 1/2" 142 28G/TWIST 114 EASY TOUCH ALCOHOL PREP EASY TOUCH INSULIN EASY TOUCH LANCETS PADS/MEDIUM 124 SYRINGE/0.5ML/30G X 30G/PULL-TOP 114 EASY TOUCH FLIPLOCK 5/16" 142 EASY TOUCH LANCETS SAFETTY SYRINGES EASY TOUCH INSULIN 30G/TWIST 114 3ML/18GX1-1/2" 141 SYRINGE/1ML/30G X EASY TOUCH LANCETS EASY TOUCH FLIPLOCK 5/16" 142 32G/PULL-TOP 114 SAFETY INSULIN SYRINGE EASY TOUCH INSULIN EASY TOUCH LANCETS 1ML/29GX1/2" 141 SYRINGE/SAFETY/U- 32G/TWIST 114 EASY TOUCH FLIPLOCK 100/0.5ML/29G X 1/2" 142 EASY TOUCH LANCETS SAFETY INSULIN SYRINGE EASY TOUCH INSULIN 33G/TWIST 114 1ML/30GX1/2" 141 SYRINGE/SAFETY/U- EASY TOUCH LANCING EASY TOUCH FLIPLOCK 100/0.5ML/30G X 5/16" 142 DEVICE/EJECTOR 114 SAFETY INSULIN SYRINGE EASY TOUCH INSULIN EASY TOUCH PEN NEEDLE 1ML/30GX5/16" 141 SYRINGE/SAFETY/U- 30G X 5/16" 142 EASY TOUCH FLIPLOCK 100/1ML/29G X 1/2" 142 EASY TOUCH PEN SAFETY INSULIN SYRINGE EASY TOUCH INSULIN NEEDLE/30G X 3/16" 143 1ML/31GX5/16" 141 SYRINGE/SAFETY/U- EASY TOUCH PEN NEEDLES EASY TOUCH FLIPLOCK 100/1ML/30G X 1/2" 142 29GX1/2" 143 SAFETY SYRINGE EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES 3ML/21GX1" 141 SYRINGE/U-100/0.3ML/30G X 31GX1/4" 143 EASY TOUCH FLIPLOCK 1/2" 142 EASY TOUCH PEN NEEDLES SAFETY SYRINGE EASY TOUCH INSULIN 31GX5/16" 143 3ML/22GX1" 141 SYRINGE/U-100/0.5ML/27G X EASY TOUCH PEN NEEDLES EASY TOUCH FLIPLOCK 1/2" 142 32GX1/4" 143 SAFETY SYRINGE 3ML/22GX1- EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES 1/2" 141 SYRINGE/U-100/0.5ML/28G X 32GX3/16" 143 EASY TOUCH FLIPLOCK 1/2" 142 EASY TOUCH PEN NEEDLES SAFETY SYRINGE EASY TOUCH INSULIN 32GX5/32" 143 3ML/23GX1" 141 SYRINGE/U-100/0.5ML/29G X EASY TOUCH PEN EASY TOUCH FLIPLOCK 1/2" 142 NEEDLES/31G X 3/16" 143 SAFETY SYRINGE 3ML/23GX1- EASY TOUCH INSULIN EASY TOUCH SAFETY PEN 1/2" 141 SYRINGE/U-100/0.5ML/30G X NEEDLES/29G X 5MM 143 EASY TOUCH FLIPLOCK 1/2" 142 EASY TOUCH SAFETY PEN SAFETY SYRINGE EASY TOUCH INSULIN NEEDLES/29G X 8MM 143 3ML/25GX1" 141 SYRINGE/U-100/0.5ML/31G X EASY TOUCH SAFETY PEN EASY TOUCH FLIPLOCK 5/16" 142 NEEDLES/30G X 5/16" 143 SAFETY SYRINGE EASY TOUCH INSULIN EASY TOUCH SAFETY 3ML/25GX5/8" 141 SYRINGE/U-100/1ML/27G X SYRINGE/3ML/20G X 1" 143 EASY TOUCH FLIPLOCK 1/2" 142 EASY TOUCH SAFETY SAFETY SYRINGES SYRINGE/3ML/21G X 1" 143 3ML/18GX1" 141
Index 16 EASY TOUCH SAFETY EDURANT 55 ELLA 63 SYRINGE/3ML/22G X 1" 143 efavirenz 55 ELMIRON 90 EASY TOUCH SAFETY SYRINGE/3ML/22G X 1- efavirenz-emtricitabine- ELOCTATE 91 1/2" 143 tenofovir disoproxil eluryng 63 fumarate 55 EASY TOUCH SAFETY EMBRACE LANCING DEVICE SYRINGE/3ML/23G X 1" 143 efavirenz-lamivudine-tenofovir disoproxil fumarate 55 WITH EJECTOR 114 EASY TOUCH SAFETY EMCYT 44 SYRINGE/3ML/25G X 1" 143 effer-k 202 EASY TOUCH SAFETY EFLOW SCF AEROSOL EMPLICITI 43 SYRINGE/3ML/25G X 5/8" 143 HEAD 192 EMSAM 25 EASY TOUCH SHEATHLOCK eletriptan hydrobromide 197 emtricitabine 55 SAFETY INSULIN SYRINGE ELIGARD 43 emtricitabine-tenofovir disoproxil 1ML/29GX1/2" 143 ELIQUIS 23 fumarate 55 EASY TOUCH SHEATHLOCK EMTRIVA 55 SAFETY INSULIN SYRINGE ELIQUIS STARTER PACK 22 1ML/30GX5/16" 143 ELITE DC AUTO EMVERM 18 EASY TOUCH SHEATHLOCK ADAPTER 192 enalapril maleate 40 SAFETY INSULIN SYRINGE ELITE-THIN INSULIN enalapril maleate & 1ML/31GX5/16" 143 SYRINGE/0.3ML/31G X hydrochlorothiazide 40 EASY TOUCH SHEATHLOCK 5/16" 144 ENBREL 7 ELITE-THIN INSULIN SAFETY SYRINGE ENBREL MINI 7 1ML/30GX1/2" 144 SYRINGE/0.5ML/29G X EASY TOUCH SHEATHLOCK 1/2" 144 ENBREL SURECLICK 7 SAFETY SYRINGE ELITE-THIN INSULIN ENCARE 258 3ML/21GX1" 144 SYRINGE/0.5ML/30G X endocet 13 EASY TOUCH SHEATHLOCK 5/16" 144 SAFETY SYRINGE 3ML/21GX1- ELITE-THIN INSULIN endur-acin 261 1/2" 144 SYRINGE/1ML/29G X ENEMEEZ PLUS 102 EASY TOUCH SHEATHLOCK 5/16" 144 ENFAMIL ENFALYTE 200 SAFETY SYRINGE ELITE-THIN INSULIN ENFAMIL EXPECTA 225 3ML/22GX1" 144 SYRINGE/1ML/30G X EASY TOUCH SHEATHLOCK 5/16" 144 ENGERIX-B 255 SAFETY SYRINGE 3ML/22GX1- ELITE-THIN INSULIN enoxaparin sodium 23 1/2" 144 SYRINGE/U-100/0.5ML/28G X enpresse-28 61 EASY TOUCH SHEATHLOCK 1/2" 144 SAFETY SYRINGE ELITE-THIN INSULIN entacapone 47 3ML/23GX1" 144 SYRINGE/U-100/0.5ML/28G X entecavir 58 EASY TOUCH SHEATHLOCK 5/16" 145 ENTYVIO 90 SAFETY SYRINGE ELITE-THIN INSULIN enulose 90 3ML/25GX1" 144 SYRINGE/U-100/0.5ML/29G X EASY TOUCH SHEATHLOCK 5/16" 145 EPIFOAM 79 SAFETY SYRINGE ELITE-THIN INSULIN epinephrine (anaphylaxis) 259 3ML/25GX5/8" 144 SYRINGE/U-100/0.5ML/31G X epinephrine hcl (nasal) 233 EASYPOINT NEEDLE/SYRINGE 5/16" 145 epitol 23 3ML/18G X 1" 144 ELITE-THIN INSULIN EASYPOINT NEEDLE/SYRINGE SYRINGE/U-100/1ML/28G X EPIVIR 55 3ML/18G X 1-1/2" 144 1/2" 145 EPIVIR HBV 58 EASYPOINT NEEDLE/SYRINGE ELITE-THIN INSULIN EPZICOM 55 3ML/23 G X 1" 144 SYRINGE/U-100/1ML/28G X EASYPOINT NEEDLE/SYRINGE 5/16" 145 eq allergy relief 36,37 3ML/25G X 1" 144 ELITE-THIN INSULIN eq anti-diarrheal 31 EASYPOINT NEEDLE/SYRINGE SYRINGE/U-100/1ML/29G X eq cetirizine hydrochloride 3ML/25G X 5/8" 144 1/2" 145 childrens 36 EBASE CONTROLLER KIT192 ELITE-THIN INSULIN EQ COMPLETE ec-naproxen 6 SYRINGE/U-100/1ML/31G X MULTIVITAMINADULTS UNDER 5/16" 145 50 215 econazole nitrate 73 ELIXOPHYLLIN 22 eq daily fiber 97 ED CHLORPED D 68
Index 17 eq fiber therapy 96 EQL INSULIN ESTROVEN MENOPAUSE eq omeprazole 253 SYRINGE/0.5ML/30G X SUPPLEMENT 215 5/16" 145 eszopiclone 96 EQ ONE DAILY MENS 50+ 215 EQL INSULIN ethambutol hcl 42 EQ ONE DAILY MENS SYRINGE/0.5ML/31G X HEALTH 215 5/16" 145 ethosuximide 24 EQ ONE DAILY WOMENS EQL INSULIN ethyl chloride 81 50+ 215 SYRINGE/1ML/29G X ETHYL CHLORIDE/FINE eq one daily womens 1/2" 145 STREAM 81 health 210 EQL INSULIN ETHYL CHLORIDE/MEDIUM EQ ONE DAILY WOMENS SYRINGE/1ML/30G X STREAM 81 HEALTH 215 5/16" 145 ethynodiol diacet & eth EQ SPACE CHAMBER ANTI- EQL INSULIN estrad 63 STATIC 192 SYRINGE/1ML/31G X etidronate disodium 86 EQ SPACE CHAMBER ANTI- 5/16" 145 etodolac 6 STATIC/LARGE MASK 192 eql omega-3 fish oil 235 EQ SPACE CHAMBER ANTI- etonogestrel-ethinyl estradiol63 EQL ONE DAILY MENS 215 STATIC/MEDIUM MASK 192 etoposide 46 EQ SPACE CHAMBER ANTI- EQL PRENATAL STATIC/SMALL MASK 192 FORMULA 225 etravirine 55 EQL ALCOHOL SWABS 124 eql slow release iron 94 EURAX 83 EQL ANTIBACTERIAL EQL SUPER THIN LANCETS euthyrox 248 DEODORANT SOAP 52 30G 114 evac-u-gen 101 EQL THIN LANCETS EQL ANTIBACTERIAL everolimus 45 FOAMINGHAND WASH 52 26G 114 EQUALACTIN 97 everolimus EQL CALCIUM/VITAMIN D 199 (immunosuppressant) 203 EQL CENTURY MATURE ergocalciferol 261 EVOTAZ 55 ADULTS50+ 215 ergoloid mesylates 245 EQL CENTURY MENS 215 EVZIO 31 ERGOMAR 197 EXCEL AP 50 EQL CENTURY WOMENS 215 ergotamine w/ caffeine 197 EQL COLOR LANCETS EXCEL COMFORT POINT 21G 114 ERIVEDGE 43 INSULIN PEN NEEDLES 31G X EQL COLOR LANCETS MICRO ERLEADA 44 4MM 145 THIN 33G 114 EXCILON AMD erlotinib hcl 43 ANTIMICROBIALDRAIN EQL DRY MOUTH ORAL ery 69 RINSE 204 SPONGES 4"X4" 6 PLY 107 eql fiber therapy 97 ery-tab 103 EXCILON AMD erythrocin stearate 103 ANTIMICROBIALNON-WOVEN eql gas relief 89 SPONGES 4"X4" 6 PLY 107 EQL GAUZE PADS erythromycin (acne aid) 70 EXCILON DRAIN SPONGE 2"X2"/SMALL 107 erythromycin (ophth) 239 4"X4" 107 EQL GAUZE PADS erythromycin base 103 EXCILON DRAIN SPONGES 4"X4"/LARGE 107 erythromycin 4"X4" 6 PLY 107 EQL GAUZE STERILE PADS ethylsuccinate 103 EXCILON I.V. SPONGES 2"X2" 6 3"X3" 107 PLY 107 EQL INSULIN escitalopram oxalate 25 EXEL COMFORT POINT SYRINGE/0.3ML/29G X esgic 7 INSULIN PEN NEEDLES 29G X 1/2" 145 esomeprazole 12MM 145 EQL INSULIN magnesium 253 EXEL COMFORT POINT SYRINGE/0.3ML/30G X estarylla 62 INSULIN PEN NEEDLES 31G X 5/16" 145 estazolam 96 6MM 145 EQL INSULIN EXEL COMFORT POINT SYRINGE/0.3ML/31G X estradiol 88 INSULIN PEN NEEDLES 31G X 5/16" 145 estradiol & norethindrone 8MM 145 EQL INSULIN acetate 87 EXEL COMFORT POINT SYRINGE/0.5ML/29G X estradiol vaginal 259 INSULIN SYRINGE/0.3ML/29G X 1/2" 145 ESTROFACTORS 222 1/2" 145
Index 18 EXEL COMFORT POINT fe tabs 94 FIFTY50 SUPERIOR INSULIN SYRINGE/0.3ML/30G X FEIBA 91 COMFORTINSULIN 5/16" 146 SYRINGE/1ML/31G X EXEL COMFORT POINT felbamate 24 5/16" 146 INSULIN SYRINGE/0.5ML/28G X felodipine 59 FILTER AIR PP 192 1/2" 146 FEMCAP 110 finasteride 90 EXEL COMFORT POINT INSULIN SYRINGE/0.5ML/29G X fenofibrate 39 FIRMAGON 44 1/2" 146 FENOFIBRATE 39 first aid antibiotic 71 EXEL COMFORT POINT fenofibrate 39 FIRST AID ANTISEPTIC INSULIN SYRINGE/0.5ML/30G X fenofibrate micronized 39 OINTMENT 53 5/16" 146 FIRST-MOUTHWASH BLM 204 EXEL COMFORT POINT fenoprofen calcium 6 INSULIN SYRINGE/1ML/28G X FENSOLVI 86 FIRVANQ 18 1/2" 146 fentanyl 11 fish oil burp-less 235 EXEL COMFORT POINT FERRETTS 94 fish oil concentrate 235 INSULIN SYRINGE/1ML/29G X fish oil extra strength 235 1/2" 146 ferrex 150 94 EXEL COMFORT POINT ferrocite 94 fish oil maximum strength 235 FITNESS TABS FOR MEN INSULIN SYRINGE/1ML/30G X ferrocite plus 94 5/16" 146 AM/PM/LYCOPENE 215 ferrous fumarate 94 EXELDERM 73 FITNESS TABS FOR WOMEN ferrous gluconate 94 AM/PM/LYCOPENE 215 exemestane 44 FERROUS GLUCONATE 94 flac 242 EXFORGE HCT 41 ferrous sulfate 94 flavoxate hcl 254 EXONDYS 51 234 FERROUS SULFATE 94 flecainide acetate 20 EXTAVIA 244 ferrous sulfate 95 FLEET BISACODYL 101 EYE HEALTH/LUTEIN 215 FERROUS SULFATE 95 FLEET LIQUID GLYCERIN EYE MULTIVITAMIN/LUTEIN SUPPOSITORIES 99 215 ferrous sulfate 95 FLEXICHAMBER 192 EYE MULTIVITAMIN/SODIUM FEVERALL INFANTS 9 FLORIVA PLUS 223 215 fexofenadine hcl 38 EZ-LETS LANCETS 26G FLOVENT DISKUS 21 SUPER-SOFT 114 fiber therapy 97 FLOVENT HFA 21 EZ-LETS LANCETS 28G FIBRYGA 91 FLUAD 2019-2020 255 ULTRA-SOFT 115 FIFTY50 ALCOHOL PREP EZ-LETS LANCETS 30G 115 PADS 124 FLUAD 2020-2021 255 FLUAD QUADRIVALENT 2021- ezetimibe 39 FIFTY50 PEN NEEDLES 31G X3/16" (5MM) 146 2022 255 ezetimibe-simvastatin 39 FIFTY50 PEN NEEDLES 31G FLUAD QUADRIVALENT fa-8 93 X5/16" (8MM) 146 INFLUENZA VACCINE FOR FABRAZYME 87 FIFTY50 PEN NEEDLES ADULTS 255 FLUARIX QUADRIVALENT famciclovir 58 31GX5MM 146 FIFTY50 PEN 2019-2020 255 famotidine 252 NEEDLES/31GX8MM 146 FLUARIX QUADRIVALENT FANAPT 48 FIFTY50 PEN 2020-2021 255 FLUARIX QUADRIVALENT FANAPT TITRATION PACK 48 NEEDLES/32GX4MM 146 FIFTY50 PEN 2021-2022 255 FANTASY LUBRICATED 110 NEEDLES/32GX6MM 146 FLUBLOK QUADRIVALENT FANTASY FIFTY50 SUPERIOR 2019-2020 255 LUBRICATED/SPERMICIDE COMFORTINSULIN FLUBLOK QUADRIVALENT 110 SYRINGE/0.3ML/31G X 2020-2021 255 FARYDAK 45 5/16" 146 FLUBLOK QUADRIVALENT FASENRA 20 FIFTY50 SUPERIOR 2021-2022 255 FLUCELVAX QUADRIVALENT FAZACLO 48 COMFORTINSULIN SYRINGE/0.5ML/31G X 2019-2020 255 FC FEMALE CONDOM 110 5/16" 146 FLUCELVAX QUADRIVALENT FC2 FEMALE CONDOM 110 2020-2021 256
Index 19 FLUCELVAX QUADRIVALENT FOLIC ACID 93 FREESTYLE LITE BLOOD 2021-2022 256 folic acid 93 GLUCOSE MONITORING fluconazole 33 SYSTEM 115 FOLIKA-CI 215 fludrocortisone acetate 64 FREESTYLE LITE TEST FOLIKA-MG 215 STRIPS 84 FLULAVAL QUADRIVALENT FOLITIN-Z 215 FREESTYLE PRECISION 2019-2020 256 INSULIN SYRINGE/U- FLULAVAL QUADRIVALENT FORA GTEL BLOOD KETONE TEST STRIPS 84 100/0.5ML/30G X 5/16" 146 2020-2021 256 FREESTYLE PRECISION FLULAVAL QUADRIVALENT FORA LANCETS 115 INSULIN SYRINGE/U- 2021-2022 256 FORA LANCING DEVICE115 100/0.5ML/31G X 5/16" 147 FLUMIST QUADRIVALENT256 FORA LANCING FREESTYLE PRECISION flunisolide (nasal) 232 DEVICE/CLEARCAP 115 INSULIN SYRINGE/U- fluocinolone acetonide 79 formaldehyde 50 100/1ML/31G X 5/16" 147 fluocinolone acetonide FORMALDEHYDE 50 FREESTYLE PRECISION INSULIN SYRINGES/U- (otic) 242 FOSAMAX PLUS D 86 fluocinonide 79 100/1ML/30G X 5/16" 147 fosamprenavir calcium 55 FREESTYLE PRECISION NEO fluocinonide emulsified base 79 fosinopril sodium 40 BLOOD GLUCOSE fluoridex daily renewal 204 fosinopril sodium & MONITORING SYSTEM 115 fluoritab 202 hydrochlorothiazide 41 FREESTYLE PRECISION NEO FREAMINE HBC 6.9% 237 BLOOD GLUCOSE TEST fluorometholone (ophth) 240 STRIPS 84 FLUOROPLEX 73 FREAMINE III 237 FREESTYLE TEST STRIPS 84 fluorouracil (topical) 73,74 FREDS PHARMACY FREESTYLE UNISTICK II AUTOLET LANCING LANCETS 115 fluoxetine hcl 25 DEVICE 115 fluoxetine hcl (pmdd) 245 FULL KIT NEBULIZER FREDS PHARMACY UNIFINE SET 192 PENTIPS PEN NEEDLES fluphenazine decanoate 49 furosemide 85 fluphenazine hcl 49 32GX4MM 146 FREDS PHARMACY UNIFINE FUZEON 55 flurazepam hcl 96 PENTIPS PLUS fyavolv 87 flurbiprofen 6 31GX5MM 146 FYCOMPA 23 FREDS PHARMACY UNIFINE flurbiprofen sodium 241 g tussin ac 66 flutamide 44 PENTIPS PLUS 31GX8MM 146 gabapentin 23 fluticasone propionate 79 FREDS PHARMACY UNILET GABITRIL 24 fluticasone propionate LANCETS SUPER THIN galantamine hydrobromide 244 (nasal) 232 30G 115 fluticasone-salmeterol 22 FREDS PHARMACY UNILET GARDASIL 9 257 fluvastatin sodium 39 LANCETS ULTRA THIN gas relief 89 28G 115 fluvoxamine maleate 25 gatifloxacin (ophth) 239 FREEDAVITE 215 FLUZONE HIGH-DOSE PF 2019- GAUZE DRESSING 4"X4" 107 2020 256 FREESTYLE CONTROL SOLUTION 115 GAUZE PADS 2"X2" 107 FLUZONE HIGH-DOSE PF 2020- GAUZE PADS 3"X3" 107 2021 256 FREESTYLE CONTROL FLUZONE HIGH-DOSE PF 2021- SOLUTION HIGH/LOW 115 GAUZE PADS 4"X4" 107 2022 256 FREESTYLE FREEDOM GAUZE SPONGE TYPE VII FLUZONE QUADRIVALENT LITE 115 MEDI-PAK 2"X2" 8PLY 107 2019-2020 256 FREESTYLE INSULINX GAUZE SPONGES 4"X4" 12 FLUZONE QUADRIVALENT BLOODGLUCOSE PLY 107 2020-2021 256 MONITORING SYSTEM 115 gavilyte-c 98 FREESTYLE INSULINX FLUZONE QUADRIVALENT gavilyte-n/flavor pack 98 2021-2022 256 BLOODGLUCOSE TEST 84 FLYP HYPERSONIQ FREESTYLE INSULINX gemfibrozil 39 CARTRIDGE 192 BLOODGLUCOSE TEST gengraf 203 STRIPS 84 FML 240 GENOTROPIN 86 FREESTYLE LANCETS 115 FML FORTE 240 gentak 239
Index 20 gentamicin in saline 2 GENVOYA 56 GLOBAL INJECT EASE INSULIN gentamicin sulfate (ophth) 239 GEODON 48 SYRINGE/U-100/0.5ML/28G X 1/2" 147 gentamicin sulfate (topical) 71 GERI-FREEDA SENIOR GLOBAL INJECT EASE INSULIN GENTEEL CONTACT FORMULA 216 SYRINGE/U-100/0.5ML/29G X TIPS/BLUE 115 geri-hydrolac 12 80 1/2" 147 GENTEEL CONTACT GERMBLOC HEALTH 52 GLOBAL INJECT EASE INSULIN TIPS/CLEAR 115 GERMBLOC HEALTH HAND SYRINGE/U-100/0.5ML/30G X GENTEEL CONTACT SANITIZER 52 1/2" 147 TIPS/GREEN 115 gianvi 61 GLOBAL INJECT EASE INSULIN GENTEEL CONTACT GILENYA 244 SYRINGE/U-100/0.5ML/30G X TIPS/ORANGE 115 5/16" 148 GENTEEL CONTACT GILOTRIF 43 GLOBAL INJECT EASE INSULIN TIPS/RAINBOW 115 GLASSIA 247 SYRINGE/U-100/0.5ML/31G X GENTEEL CONTACT glatiramer acetate 244 5/16" 148 TIPS/VIOLET 115 GLOBAL INJECT EASE INSULIN GENTEEL CONTACT glatopa 244 SYRINGE/U-100/1ML/28G X TIPS/YELLOW 115 GLEOSTINE 42 1/2" 148 GENTEEL LANCING glimepiride 29 GLOBAL INJECT EASE INSULIN DEVICE/GLORIOUS glipizide 29 SYRINGE/U-100/1ML/29G X GOLD 115 1/2" 148 GENTEEL LANCING glipizide xl 29 GLOBAL INJECT EASE INSULIN DEVICE/PRECIOUS glipizide-metformin hcl 26 SYRINGE/U-100/1ML/30G X PLATINUM 115 GLOBAL EASE INJECT PEN 1/2" 148 GENTEEL LANCING NEEDLES 29GX12MM 147 GLOBAL INJECT EASE INSULIN DEVICE/STATELY SILVER115 GLOBAL EASE INJECT PEN SYRINGE/U-100/1ML/30G X GENTEEL LANCING NEEDLES 31GX8MM 147 5/16" 148 KIT/BUTTERFLY BLUE 115 GLOBAL EASE INJECT PEN GLOBAL INJECT EASE INSULIN GENTEEL NOZZLES 115 NEEDLES 32GX4MM 147 SYRINGE/U-100/1ML/31G X GENTEEL PLUS LANCING GLOBAL EASE INJECT PEN 5/16" 148 DEVICE/BUFF BLACK 116 NEEEDLES 31GX5MM 147 GLOBAL INSULIN SYRINGE/U- GENTEEL PLUS LANCING GLOBAL EASY GLIDE 100/0.3ML/30G X 1/2" 148 DEVICE/BUTTERFLY INSULIN SYRINGE/0.3ML/31G GLOBAL INSULIN SYRINGES/U- BLUE 116 X 15/64" 147 100/0.3ML/30GX5/16" 148 GENTEEL PLUS LANCING GLOBAL EASY GLIDE GLOBAL LANCING DEVICE/PLAYFUL INSULIN SYRINGE/0.5ML/31G DEVICE 116 PURPLE 116 X 15/64" 147 GLUCAGEN HYPOKIT 27 GENTEEL PLUS LANCING GLOBAL EASY GLIDE glucagon (rdna) 27 DEVICE/PRINCESS PINK 116 INSULIN SYRINGE/1ML/31G X GENTEEL PLUS LANCING GLUCOPRO INSULIN 15/64" 147 SYRINGE/U-100/0.3ML/30G X DEVICE/WILLOWY WHITE 116 GLOBAL EASY GLIDE GENTLE-LET GP INSULINSYRINGE/U- 1/2" 148 LANCETS 116 GLUCOPRO INSULIN 100/0.3ML/31G X 5/16" 147 SYRINGE/U-100/0.3ML/30G X GENTLE-LET LANCETS GLOBAL EASY GLIDE PEN GENERAL PURPOSE 5/16" 148 NEEDLES 32GX4MM 147 GLUCOPRO INSULIN STYLE/FINE POINT 116 GLOBAL INJECT EASE GENTLE-LET LANCETS INSULIN SYRINGE/U- SYRINGE/U-100/0.3ML/31G X 5/16" 148 GENERAL PURPOSE 100/0.3ML/29G X 1/2" 147 STYLE/MEDIUM POINT 116 GLOBAL INJECT EASE GLUCOPRO INSULIN SYRINGE/U-100/0.5ML/30G X GENTLE-LET LANCETS INSULIN SYRINGE/U- SAFETY STYLE/FINE 1/2" 148 100/0.3ML/30G X 1/2" 147 GLUCOPRO INSULIN POINT 116 GLOBAL INJECT EASE GENTLE-LET LANCETS INSULIN SYRINGE/U- SYRINGE/U-100/0.5ML/30G X SAFETY STYLE/MEDIUM 5/16" 148 100/0.3ML/30G X 5/16" 147 GLUCOPRO INSULIN POINT 116 GLOBAL INJECT EASE GENTLE-LET PLATFORMS INSULIN SYRINGE/U- SYRINGE/U-100/0.5ML/31G X 5/16" 148 2.4MM 116 100/0.3ML/31G X 5/16" 147 GENTLE-LET PLATFORMS 3.0MM 116
Index 21 GLUCOPRO INSULIN GNP INSULIN GNP ULTRA COMFORT SYRINGE/U-100/1ML/30G X SYRINGE/0.5ML/30G X INSULIN SYRINGE/1ML/28G X 1/2" 148 5/16" 149 1/2" 149 GLUCOPRO INSULIN GNP INSULIN GNP ULTRA COMFORT SYRINGE/U-100/1ML/30G X SYRINGE/0.5ML/31G X INSULIN SYRINGE/1ML/29G X 5/16" 148 5/16" 149 1/2" 150 GLUCOPRO INSULIN GNP INSULIN gnp vitamin c 261 SYRINGE/U-100/1ML/31G X SYRINGE/1ML/28G X gnp vitamin d 260 5/16" 148 1/2" 149 GLUCOSE 27 GNP INSULIN gnp vitamin e 260 GLUTARALDEHYDE 50 SYRINGE/1ML/29G X GOCOVRI 47 1/2" 149 GOJJI BLOOD KETONE TEST glyburide 29 GNP INSULIN STRIPS 84 glyburide micronized 29 SYRINGE/1ML/30G X GOJJI LANCING glyburide-metformin 26 5/16" 149 DEVICE/CLEAR CAP 116 GNP INSULIN glycerin (laxative) 99 GOLD BOND FIRST AID QUICK SYRINGE/1ML/31G X SPRAY 52 glycopyrrolate 249 5/16" 149 GOLD BOND ULTIMATE HAND glydo 81 GNP IODIDES TINCTURE 53 SANITIZER SHEER GNP ACID CONTROL 150 GNP IODINE TINCTURE 53 MOISTURE 52 MAXIMUM STRENGTH 252 GOLD BOND ULTIMATE HAND GNP LANCETS 21G 116 SANITIZER/MOISTURIZER 52 GNP ALCOHOL SWABS 124 GNP LANCETS MICRO THIN gnp allergy plus sinus GOLYTELY 99 33G 116 GOODSENSE CLICKFINE headache 66 GNP LANCETS SUPER THIN gnp allergy relief 35 30G 116 SAFETY PEN NEEDLE/31G X 3/16" 150 gnp allergy relief 24 hour 37 GNP LANCETS THIN 116 GOODSENSE COLOR GNP CALAMINE 82 GNP LANCETS THIN LANCETS MICRO-THIN 33G GNP CALAMINE 26G 116 UNIVERSAL 116 PHENOLATED 82 gnp motion sickness relief 32 GOODSENSE IODINE 53 gnp clearlax 99 GNP PRENATAL 225 GOODSENSE LANCETS GNP CLICKFINE UNIVERSAL GNP QUICK DISSOLVE MICRO-THIN 33G 116 PEN NEEDLES 31GX1/4" 148 GLUCOSE 27 GOODSENSE LANCETS GNP CLICKFINE UNIVERSAL GNP STERILE GAUZE PADS MICRO-THIN 33G PEN NEEDLES 31GX5/16" 149 2"X2" 107 UNIVERSAL 116 gnp eye drops 240 GNP STERILE GAUZE PADS GOODSENSE LANCETS gnp fish oil 235 3"X3" 107 ULTRA-THIN 26G gnp suphedrin 233 UNIVERSAL 116 GNP GLUCOSE 27 GNP ULTICARE PEN GOODSENSE LANCETS gnp hydrocortisone 77 NEEDLES/31GX5/16" 149 ULTRA-THIN 30G 116 GNP HYDROGEN PEROXIDE GNP ULTICARE PEN GOODSENSE LANCETS WIPES 50 NEEDLES/32GX 5/32" 149 ULTRA-THIN 30G GNP INSULIN GNP ULTICARE PEN UNIVERSAL 116 SYRINGE/0.3ML/29G X NEEDLES/32GX1/4" 149 GOODSENSE LANCING 1/2" 149 GNP ULTICARE PEN DEVICE 116 GNP INSULIN NEEDLES31G X 5MM 149 GOODSENSE PEN SYRINGE/0.3ML/30G X GNP ULTRA COMFORT NEEDLE/PENFINE 5/16" 149 INSULIN SYRINGE/0.3ML/29G CLASSIC/31G X 3/16" 150 GNP INSULIN X 1/2" 149 GOODSENSE PEN SYRINGE/0.3ML/31G X GNP ULTRA COMFORT NEEDLE/PENFINE 5/16" 149 INSULIN SYRINGE/0.3ML/30G CLASSIC/31G X 5/16" 150 GNP INSULIN X 5/16" SHORT 149 GOODSENSE PEN SYRINGE/0.5ML/28G X GNP ULTRA COMFORT NEEDLE/PENFINE 1/2" 149 INSULIN SYRINGE/0.5ML/28G CLASSIC/32G X 1/4" 150 GNP INSULIN X 1/2" 149 GOODSENSE PEN SYRINGE/0.5ML/29G X GNP ULTRA COMFORT NEEDLE/PENFINE 1/2" 149 INSULIN SYRINGE/0.5ML/29G CLASSIC/32G X 5/32" 150 X 1/2" 149
Index 22 GOODSENSE PRENATAL H-E-B INCONTROL LANCETS HEALTHWISE MINI PEN VITAMINS 225 MICRO THIN 33G 116 NEEDLES 31GX6MM 151 goodsense womens H-E-B INCONTROL LANCETS HEALTHWISE PEN NEEDLES laxative 101 SUPER THIN 30G 117 29GX12MM 151 gordons urea 80 H-E-B INCONTROL LANCETS HEALTHWISE SHORT PEN granisetron hcl 31 ULTRA THIN 28G 117 NEEDLES 31GX8MM 151 H-E-B INCONTROL PEN HEALTHWISE SHORT PEN griseofulvin microsize 32 NEEDLES 29GX12MM 150 NEEDLES/31G X 3/16" 151 griseofulvin ultramicrosize 32 HAEMOLANCE 117 HEALTHWISE SHORT PEN guaiatussin ac 66 HAEMOLANCE LOW FLOW NEEDLES/31G X 5/16" 151 HEALTHWISE UNIFINE guaifenesin-codeine 68 LANCETS 117 HAEMOLANCE PLUS 117 PENTIPS PEN NEEDLES guanfacine hcl 40 32GX4MM 151 HAEMOLANCE PLUS HIGH guanfacine hcl (adhd) 2 HEALTHY ACCENTS AUTOLET FLOW 117 IMPRESSION LANCING GVOKE PFS 27 HAEMOLANCE PLUS LOW DEVICE 117 GYNAZOLE-1 259 FLOW 117 HEALTHY ACCENTS UNIFINE HAEMOLANCE PLUS MAX gynecort 10 77 PENTIPS PEN NEEDLES FLOW 117 h-chlor 12 51 29GX12MM 151 HAEMOLANCE PLUS HEALTHY ACCENTS UNIFINE PEDIATRIC FLOW 117 H-CHLOR 6 52 PENTIPS PEN NEEDLES H-CHLOR WOUND 52 HAIR SKIN & NAILS ADVANCED FORMULA 216 31GX5MM 151 H-E-B IN CONTROL PEN HEALTHY ACCENTS UNIFINE NEEDLE 31GX3/16" 150 HALAVEN 46 PENTIPS PEN NEEDLES H-E-B IN CONTROL PEN HALDOL 48 31GX6MM 151 NEEDLES 31GX5MM 150 HALDOL DECANOATE HEALTHY ACCENTS UNIFINE H-E-B IN CONTROL PEN 100 48 PENTIPS PEN NEEDLES NEEDLES 31GX6MM 150 HALDOL DECANOATE 50 48 31GX8MM 151 H-E-B IN CONTROL PEN halobetasol propionate 79 HEALTHY ACCENTS UNIFINE NEEDLES 31GX8MM 150 PENTIPS PEN NEEDLES H-E-B IN CONTROL PEN haloperidol 48 32GX4MM 151 NEEDLES/NANO/32GX4MM HALOPERIDOL 61 HEALTHY ACCENTS UNILET 150 haloperidol decanoate 48 LANCETS SUPER THIN H-E-B IN CONTROL 30G 117 UNIFINEPENTIPS PLUS haloperidol lactate 48 HEALTHY MAMA BE WELL 31GX1/4" 150 HAVRIX 257 ROUNDED 225 H-E-B IN CONTROL HEALTH CARE LANCING healthylax 99 UNIFINEPENTIPS PLUS DEVICE 117 31GX3/16" 150 HEALTHWISE INSULIN HELIXATE FS 91 H-E-B IN CONTROL SYRINGE/U-100/0.3ML/30G X HEMANGEOL 59 UNIFINEPENTIPS PLUS 5/16" 150 HEMLIBRA 91 31GX5/16" 150 HEALTHWISE INSULIN HEMOFIL M 92 H-E-B IN CONTROL SYRINGE/U-100/0.3ML/31G X UNIFINEPENTIPS PLUS 5/16" 151 hemorrhoidal suppositories 14 31GX5MM 150 HEALTHWISE INSULIN heparin sod (porcine) in d5w 23 H-E-B IN CONTROL SYRINGE/U-100/0.5ML/30G X heparin sodium (porcine) 23 UNIFINEPENTIPS PLUS 5/16" 151 HEPARIN 32GX4MM 150 HEALTHWISE INSULIN SODIUM/DEXTROSE 23 H-E-B IN CONTROL SYRINGE/U-100/0.5ML/31G X HEPLISAV-B 257 UNIFINEPENTIPS PLUS 5/16" 151 32GX5/32" 150 HEALTHWISE INSULIN HERCEPTIN 43 H-E-B IN CONTROL SYRINGE/U-100/1ML/30G X HIBERIX 254 UNIFINEPENTIPS PLUS 5/16" 151 HIGH POTENCY 33GX5/32" 150 HEALTHWISE INSULIN MULTIVITAMIN 222 H-E-B INCONTROL SYRINGE/U-100/1ML/31G X HIGH POTENCY ADVANCEDLANCING 5/16" 151 MULTIVITAMIN/BETA- DEVICE 116 HEALTHWISE MICRON PEN CAROTENE 216 H-E-B INCONTROL ALCOHOL NEEDLES/32G X 5/32" 151 PADS 124
Index 23 HIGH POTENCY HUMATE-P 92 hydrocortisone valerate 79 MULTIVITAMIN/FOLIC HUMATROPE 86 hydrocortisone w/acetic ACID 216 HUMATROPE COMBO acid 242 HM ADHESIVE PADS hydrocortisone-aloe vera 79 ANTIBACTERIAL/SHEER 107 PACK 86 HM CALAMINE 82 HUMIRA 2 hydrogen peroxide 50 HUMIRA PEDIATRIC CROHNS HM COMPLETE 216 HYDROGEN PEROXIDE 50 DISEASE STARTER PACK 2 hydrogen peroxide 50 HM COMPLETE 50+ MENS HUMIRA PEN 2 216 hydromet 64 ULTIMATE HUMIRA PEN-CD/UC/HS HM COMPLETE 50+ WOMENS hydromorphone hcl 11 ULTIMATE 216 STARTER 2 HUMIRA PEN-PEDIATRIC UC HYDROMORPHONE HCL 11 HM COMPLETE MEN 216 STARTER PACK 2 hydromorphone hcl 11 hm famotidine 251 HUMIRA PEN-PS/UV hydroxychloroquine sulfate 41 hm fiber 97 STARTER 2 HUMULIN 70/30 28 hydroxyprogesterone hm fish oil 235 caproate 243 HM HAIR/SKIN/NAILS 216 HUMULIN 70/30 hydroxyprogesterone caproate KWIKPEN 28 (antineoplastic) 44 HM IODIDES TINCTURE 53 HUMULIN N 28 HM IODINE TINCTURE 54 hydroxyurea 46 HUMULIN N KWIKPEN 28 hydroxyzine hcl 19 hm laxative 101 HUMULIN R 28 hm magnesium 17 hydroxyzine pamoate 19 HUMULIN R U-500 HYLAMEND FIRST AID HM ONE DAILY MENS 216 (CONCENTRATED) 28 ANTISEPTIC 50 HUMULIN R U-500 HM ONE DAILY PRENATAL HYLAZINC 216 COMBO 225 KWIKPEN 28 HM ONE DAILY WOMENS 216 HY-VEE LANCETS 117 hyoscyamine sulfate 249 HM PRENATAL 225 HY-VEE THIN LANCETS 117 HYPERRHO S/D 242 HM STERILE PADS 107 HYCAMTIN 46 HYPERSAL 68 hydralazine hcl 41 HYPOLANCE AST LANCING HM STERILE PADS 2"X2" 107 KIT 117 HM ULTICARE INSULIN HYDRALYTE 200 IBRANCE 45 SYRINGE/1ML/30G X 1/2" 151 HYDRALYTE FREEZER HM ULTICARE INSULIN POPS 200 ibuprofen 6 SYRINGE/U-100/0.3ML/31G X HYDRO-LAN 82 ICAPS AREDS FORMULA 216 5/16" 151 HYDROCELL ADHESIVE iclevia 61 HM ULTICARE MINI PEN DRESSING 4"X4" 108 NEEDLES/31G X 5MM ICLUSIG 45 HYDROCELL DRESSING ID NOW COVID-19 84 (3/16") 151 4"X4" 108 ID NOW COVID-19 CONTROL HM ULTICARE SHORT PEN hydrochlorothiazide 85 NEEDLES 31GX8MM 152 SWAB KIT 84 hm vitamin b1 262 HYDROCIL INSTANT 97 IDELVION 92 hydrocodone polistirex- IDHIFA 45 hm vitamin c 261 chlorpheniramine polistirex 68 hm vitamin d3 260 hydrocodone w/ ILARIS 3 homatropaire 238 homatropine 64 imatinib mesylate 45 homatropine hbr 238 hydrocodone- IMBRUVICA 45 acetaminophen 13 imipramine hcl 26 hpa lanolin 243 hydrocortisone 64 HUDSON RCI SEE-THRU imiquimod 80 hydrocortisone (intrarectal) 14 AEROSOL MASK IMOVAX RABIES ELONGATED/ADULT 192 hydrocortisone (rectal) 15 (H.D.C.V.) 257 HUMALOG MIX 50/50 28 hydrocortisone (topical) 79 IMPAVIDO 18 HUMALOG MIX 50/50 hydrocortisone acetate IN TOUCH LANCING KWIKPEN 28 (topical) 79 DEVICE 117 HUMALOG MIX 75/25 28 hydrocortisone acetate w/ inatal gt 224 pramoxine 15 HUMALOG MIX 75/25 INCRUSE ELLIPTA 20 KWIKPEN 28 hydrocortisone butyrate 79 indapamide 85
Index 24 INDOCIN 6 INSULIN SYRINGE/NEEDLE INSULIN indomethacin 6 0.3ML/31G X 5/16" 152 SYRINGES/1ML/30GX1/2" 153 INSULIN SYRINGE/NEEDLE INSULIN INFLECTRA 90 0.5ML/29G X 1/2" 152 SYRINGES/1ML/31GX5/16" INLYTA 42 INSULIN SYRINGE/NEEDLE 154 INNOSPIRE REPLACEMENT 0.5ML/30G X 5/16" 152 INSUPEN 29G X 12MM 154 FILTER 192 INSULIN SYRINGE/NEEDLE INSUPEN 31G X 5MM 154 INSPIRACHAMBER/ANTI- 0.5ML/31G X 5/16" 152 STATIC INSULIN SYRINGE/NEEDLE INSUPEN 31G X 8MM 154 VALVED/MOUTHPIECE 192 1ML/29G X 1/2" 152 INSUPEN 32G X 4MM 154 INSPIRACHAMBER/LARGE INSULIN SYRINGE/NEEDLE INSUPEN 33GX4MM 154 192 1ML/30G X 5/16" 153 INSUPEN PEN NEEDLES 32G INSPIRACHAMBER/SOOTHER INSULIN SYRINGE/NEEDLE X4MM 154 MASK/INSPIRAMASK/MEDIUM 1ML/31G X 5/16" 153 INSUPEN SENSITIVE 192 INSULIN SYRINGE/U- 32GX6MM 154 INSPIRACHAMBER/SOOTHER 100/0.3ML/29G X 1/2" 153 INSUPEN SENSITIVE MASK/INSPIRAMASK/SMALL INSULIN SYRINGE/U- 32GX8MM 154 192 100/0.5ML/29G X 1/2" 153 INSUPEN ULTRAFIN INSPIREASE DRUG INSULIN SYRINGE/U- 29GX12MM 154 DELIVERYSYSTEM 192 100/1ML/29G X 1/2" 153 INSUPEN ULTRAFIN INSPIREASE RESERVOIR INSULIN SYRINGE/U- 30GX8MM 154 BAGS 192 100/1ML/30G X 5/16" 153 INSUPEN ULTRAFIN INSULIN ASPART INSULIN SYRINGE/U- 31GX6MM 154 PROTAMINE/INSULIN 100/1ML/31G X 5/16" 153 INSUPEN ULTRAFIN ASPART 28 INSULIN SYRINGES 31GX8MM 154 0.3ML/31G X 1/4" 153 INSULIN ASPART INTELENCE 56 PROTAMINE/INSULIN ASPART INSULIN SYRINGES FLEXPEN 28 0.5ML/31G X 1/4" 153 INTRALIPID 234 INSULIN LISPRO INSULIN INVEGA 48 PROTAMINE/INSULIN LISPRO SYRINGES/0.5ML/27GX1/2" INVEGA SUSTENNA 48 153 KWIKPEN 28 INVEGA TRINZA 48 INSULIN SYRINGE 1ML/31G INSULIN X1/4" 152 SYRINGES/0.5ML/28GX1/2" INVIRASE 56 INSULIN SYRINGE/0.3ML/29G X 153 INVOKAMET 26 INSULIN 1" 152 INVOKAMET XR 26 INSULIN SYRINGE/0.3ML/29G X SYRINGES/0.5ML/29GX1/2" 1/2" 152 153 INVOKANA 29 INSULIN SYRINGE/0.3ML/30G X INSULIN IODEX 54 5/16" 152 SYRINGES/0.5ML/30GX5/16" IODEX/METHYL INSULIN SYRINGE/0.3ML/31G X 153 SALICYLATE 54 5/16" 152 INSULIN IODINE TINCTURE 54 SYRINGES/0.5ML/31GX INSULIN SYRINGE/0.5ML/27G X IODINE TINCTURE MILD 54 1/2" 152 5/16" 153 INSULIN SYRINGE/0.5ML/28G X INSULIN IODINE TINCTURE 1/2" 152 SYRINGES/0.5ML/31GX5/16" STRONG 54 INSULIN SYRINGE/0.5ML/30G X 153 IODINE TINCTURE STRONG 1/2" 152 INSULIN DECOLORIZED 54 INSULIN SYRINGE/0.5ML/30G X SYRINGES/1ML/27GX/1/2" IODOFLEX 54 5/16" 152 153 IODOSORB 54 INSULIN SYRINGE/0.5ML/31G X INSULIN IONOSOL-MB/DEXTROSE 5/16" 152 SYRINGES/1ML/27GX1/2" 5% 201 INSULIN SYRINGE/1ML/28G X 153 IOPIDINE 239 1/2" 152 INSULIN INSULIN SYRINGE/1ML/29G X SYRINGES/1ML/28GX1/2" ipratropium bromide 20 1/2" 152 153 ipratropium bromide (nasal)231 INSULIN SYRINGE/1ML/30G X INSULIN ipratropium-albuterol 22 5/16" 152 SYRINGES/1ML/29GX1/2" INSULIN SYRINGE/NEEDLE 153 irbesartan 40 0.3ML/30G X 5/16" 152
Index 25 irbesartan-hydrochlorothiazide K-PAX IMMUNE SUPPORT ketoconazole 33 41 FORMULA PROFESSIONAL ketoconazole (topical) 73 IRESSA 43 STRENGTH 216 KETONE 84 irinotecan hcl 47 K-PHOS 202 KETONE TEST STRIPS 84 IRON CHEWS PEDIATRIC 95 k-prime 202 ketoprofen 6 iron supplement 94 K-TAB 202 ketorolac tromethamine 6 ISENTRESS 56 K-Y ME & YOU EXTRA LUBRICATED 110 ketorolac tromethamine ISENTRESS HD 56 K-Y ME & YOU INTENSE110 (ophth) 241 ISOLYTE-P/DEXTROSE KABIVEN 236 KETOSTIX 84 5% 201 ketotifen fumarate (ophth) 241 ISOLYTE-S 201 KADCYLA 43 KEVZARA 3 ISOLYTE-S PH 7.4 201 KADIAN 11 KEY-E 261 isoniazid 42 kaitlib fe 62 KHEDEZLA 26 ISOPTO ATROPINE 238 KALETRA 56 KIMONO COLORS 110 isosorbide dinitrate 19 KALYDECO 247 KIMONO LUBRICATED 110 isosorbide mononitrate 19 KAMELEON LUBRICATED 110 KIMONO MICRO THIN 110 isotretinoin 70 KCENTRA 92 KIMONO MICRO THIN PLUS ITCH RELIEF 73 KCL 0.15%/D5W/NACL SPERMICIDE itraconazole 33 0.225% 201 LUBRICATED 110 IV PREP WIPES 50 KCL 0.3%/D5W/NACL KIMONO PLUS SPERMICIDE 0.9% 201 LUBRICATED 110 IXEMPRA KIT 46 kelnor 1/35 61 KIMONO PLUS IXIARO 257 KENDALL GEL SKIN SCRUB SPERMICIDE/LUBRICATED IXINITY 92 PACK/LARGE WINGED 111 J & J ADHESIVE LARGE 108 SPONGES 54 KIMONO PS LUBRICATED111 KIMONO PS PLUS J & J GAUZE 2"X2" 8 PLY 108 KENDALL GEL SKIN SCRUB PACK/SMALL WINGED SPERMICIDE/LUBRICATED J & J GAUZE 4"X4" 12 PLY108 SPONGES 54 111 J & J GAUZE 4"X4" 8 PLY 108 KENDALL HYDROPHILIC KIMONO SENSATION J & J GAUZE SPONGES 12-PLY FOAMDRESSING 2"X2" 108 LUBRICATED 111 4" X 4" 108 KENDALL HYDROPHILIC KIMONO SENSATION PLUS J & J GAUZE SPONGES 16-PLY FOAMDRESSING 3"X3" 108 SPERMICIDE 4" X 4" 108 KENDALL HYDROPHILIC LUBRICATED 111 J & J GAUZE SPONGES 8- FOAMDRESSING 4"X4" 108 KIMONO SPECIAL 111 PLY4" X 4" 108 KENDALL HYDROPHILIC KINDERLYTE 201 J & J NON-STICK PADS FOAMPLUS DRESSING 100LARGE 108 2"X2" 108 KINDERLYTE PREMAX 201 JAKAFI 45 KENDALL HYDROPHILIC KINNEY LANCETS 117 JANSSEN COVID-19 FOAMPLUS DRESSING KINNEY THIN LANCETS 117 VACCINE 257 3"X3" 108 KINRAY INSULIN SYRINGE jantoven 22 KENDALL MINOR WET SKIN PREFERRED PLUS/0.3ML/31G SCRUB PACK 54 JANUMET 26 X 5/16" 154 KENDALL SPONGE KINRAY INSULIN SYRINGE JANUMET XR 26 STICK/PVP 54 PREFERRED PLUS/0.5ML/31G JANUVIA 27 KENDALL VAGINAL PREP X 5/16" 154 PACK 54 JARDIANCE 29 KINRAY INSULIN SYRINGE KENDALL VAGINAL PREP PREFERRED PLUS/1ML/31G X JENLIVA TRAY 54 PRENATAL/POSTNATAL 225 5/16" 154 KENDALL WET SKIN SCRUB KINRAY INSULIN JENTADUETO 26 PACK 54 SYRINGE/0.5ML/29G X JIVI 92 KERLIX SPONGES 4" X 4" 12 1/2" 154 PLY 108 JULUCA 56 KERLIX SPONGES 4" X 4" 16 kionex 204 JYNARQUE 87 PLY 108 KISQALI 45 k 100 260 KERR TRIPLE DYE 50
Index 26 KISQALI FEMARA 200 KROGER INSULIN LACTIC ACID E 80 DOSE 44 SYRINGE/0.3ML/31G X lactulose 99 KISQALI FEMARA 400 5/16" 155 DOSE 45 KROGER INSULIN lactulose (encephalopathy) 90 KISQALI FEMARA 600 SYRINGE/0.5ML/29G X LAMISIL AT SPRAY 73 DOSE 45 1/2" 155 lamivudine 56 KROGER INSULIN KITABIS PAK 2 lamivudine (hbv) 58 klor-con 202 SYRINGE/0.5ML/30G X 5/16" 155 lamivudine-zidovudine 56 klor-con 10 202 KROGER INSULIN lamotrigine 23,24 klor-con m10 202 SYRINGE/0.5ML/31G X LANCET DEVICE klor-con sprinkle 202 5/16" 155 ADJUSTABLE 117 KMART VALU PLUS INSULIN KROGER INSULIN LANCET DEVICE WITH SYRINGE/0.3ML/30G 154 SYRINGE/1ML/29G X EJECTOR 117 KMART VALU PLUS INSULIN 1/2" 155 LANCET TRANSPORTER SYRINGE/0.5ML/29G 154 KROGER INSULIN CASE 117 KMART VALU PLUS INSULIN SYRINGE/1ML/30G X LANCETS 118 SYRINGE/0.5ML/30G 154 5/16" 155 LANCETS 26G TWIST KMART VALU PLUS INSULIN KROGER INSULIN TOP 118 SYRINGE/1ML/31G X SYRINGE/1ML/29G 154 LANCETS 28G 118 KMART VALU PLUS INSULIN 5/16" 155 SYRINGE/1ML/30G 154 KROGER LANCETS 117 LANCETS 30G 118 KOATE 92 KROGER LANCETS 21G 117 LANCETS SAFETY SEAL 21G 118 KOATE-DVI 92 KROGER LANCETS MICRO LANCETS SAFETY SEAL KOGENATE FS 92 THIN33G 117 26G 118 KROGER LANCETS SUPER KOMBIGLYZE XR 26 LANCETS SAFETY SEAL THIN 117 28G 118 konsyl 97 KROGER LANCETS LANCETS SUPER THIN KONSYL 97 THIN 117 28G 118 KROGER LANCETS THIN konsyl daily fiber 97 26G 117 LANCETS THIN 118 KONSYL DAILY FIBER 97 KROGER LANCETS LANCETS ULTRA THIN 118 KONSYL ORIGINAL DAILY ULTRATHIN30G 117 LANCING DEVICE 118 FIBER 97 KROGER LANCING LANCING DEVICE KONSYL-D 97 DEVICE 117 ADJUSTABLE 118 KORLYM 27 KROGER PEN NEEDLES 29G lanolin 243 X12MM 155 KOVALTRY 92 KROGER PEN NEEDLES 31G lanolin (topical) 82 kp calcium 600+d3 198 X8MM 155 LANOLOR 82 kp folic acid 93 KROGER PEN NEEDLES LANOXIN 60 31GX1/4" 155 kp niacin 261 KROGER PEN NEEDLES/31G lansoprazole 253 kp omega-3 fish oil 235 X1/4" 155 LANZO 118 KP PRENATAL KROGER PEN NEEDLES/31G lapatinib ditosylate 45 MULTIVITAMINS 225 X3/16" 155 LARTRUVO 44 kp vitamin d 260 KROGER PEN NEEDLES/31G latanoprost 241 KPN PRENATAL 225 X5/16" 155 KROGER PEN NEEDLES/32G LATUDA 48 KRINTAFEL 41 X5/32" 155 laxative 101 KROGER AUTOLET LANCING KROGER PEN NEEDLES/33G DEVICE 117 LEADER ADVANCED LANCING X5/32" 155 DEVICE 118 KROGER HEALTHPRO TWIST KRYSTEXXA 91 LANCETS/26G 117 LEADER INSULIN KROGER INSULIN KYMRIAH 43 SYRINGE/0.3ML/29G X SYRINGE/0.3ML/29G X labetalol hcl 58 1/2" 155 LEADER INSULIN 1/2" 155 lactated ringer's 201 KROGER INSULIN SYRINGE/0.3ML/30G X lactic acid (ammonium 5/16" 155 SYRINGE/0.3ML/30G X lactate) 80 5/16" 155
Index 27 LEADER INSULIN levetiracetam 24 LITETOUCH INSULIN SYRINGE/0.3ML/31G X levobunolol hcl 238 SYRINGE/0.5ML/31G X 5/16" 155 5/16" 156 LEADER INSULIN levocarnitine (metabolic LITETOUCH INSULIN modifiers) 87 SYRINGE/1ML/30G X SYRINGE/0.5ML/28G X levocetirizine 1/2" 155 5/16" 156 LEADER INSULIN dihydrochloride 38 LITETOUCH INSULIN SYRINGE/0.5ML/29G X levofloxacin 88 SYRINGE/U-100/0.3ML/30G X 1/2" 155 levonorgestrel & eth 5/16" 156 LEADER INSULIN estradiol 63 LITETOUCH INSULIN SYRINGE/0.5ML/30G X levonorgestrel (emergency SYRINGE/U-100/0.3ML/31G X 5/16" 156 oc) 63 5/16" 156 LEADER INSULIN levonorgestrel-eth estradiol LITETOUCH INSULIN SYRINGE/0.5ML/31G X (triphasic) 63 SYRINGE/U-100/0.5ML/28G X 5/16" 156 levonorgestrel-ethinyl estradiol 1/2" 157 LEADER INSULIN (91-day) 63 LITETOUCH INSULIN SYRINGE/1ML/28G X 1/2" 156 levothyroxine sodium 248 SYRINGE/U-100/0.5ML/29G X LEADER INSULIN LEXIVA 56 1/2" 157 SYRINGE/1ML/29G X 1/2" 156 LIBERTY MINI LANCING LITETOUCH INSULIN LEADER INSULIN DEVICE 118 SYRINGE/U-100/0.5ML/30G X SYRINGE/1ML/30G X LICE B GONE 83 5/16" 157 5/16" 156 LITETOUCH INSULIN LEADER INSULIN lice treatment 82 SYRINGE/U-100/0.5ML/31G X SYRINGE/1ML/31G X LICEMD 83 5/16" 157 5/16" 156 lidocaine 81 LITETOUCH INSULIN LEADER QUICK DISSOLVE lidocaine hcl 81 SYRINGE/U-100/1ML/28G X GLUCOSE 27 1/2" 157 LEADER UNIFINE PENTIPS lidocaine hcl (mouth- LITETOUCH INSULIN PLUS/MINI/31GX3/16" 156 throat) 204 SYRINGE/U-100/1ML/29G X LEADER UNIFINE PENTIPS lidocaine-hydrocortisone 1/2" 157 PLUS/SHORT/31GX5/16" 156 acetate (rectal) 15 LITETOUCH INSULIN LEADER UNIFINE lidocaine-prilocaine 81 SYRINGE/U-100/1ML/30G X PENTIPS/MINI/31GX3/16" 156 lidocort 14 5/16" 157 LEADER UNIFINE lidopin 81 LITETOUCH INSULIN PENTIPS/NANO/32GX5/32" SYRINGE/U-100/1ML/31G X 156 liothyronine sodium 248 5/16" 157 LEADER UNIFINE LIQUIVIDA HYDRATION LITETOUCH MASK PENTIPS/PLUS/32GX5/32" KIT 203 LARGE 193 156 lisinopril 40 LITETOUCH MASK leflunomide 6 lisinopril & MEDIUM 193 LEMTRADA 244 hydrochlorothiazide 41 LITETOUCH MASK SMALL193 LITE TOUCH LANCING LITETOUCH PEN NEEDLES LENVIMA 10 MG DAILY PEN 118 DOSE 42 29GX12.7MM 157 LENVIMA 14 MG DAILY LITEAIRE 193 LITETOUCH PEN NEEDLES DOSE 42 LITETOUCH INSULIN PEN 31G X 6MM 157 LENVIMA 18 MG DAILY NEEDLES/32G X LITETOUCH PEN NEEDLES DOSE 43 4MM/MINI 156 31G X 6MM/ULTRA LENVIMA 20 MG DAILY LITETOUCH INSULIN SHORT 157 DOSE 43 SYRINGE/0.3ML/29G X LITETOUCH PEN NEEDLES LENVIMA 24 MG DAILY 1/2" 156 31GX8MM SHORT 157 DOSE 43 LITETOUCH INSULIN LITETOUCH PEN LENVIMA 8 MG DAILY SYRINGE/0.3ML/30G X NEEDLES/31G X 3/16" 157 DOSE 43 5/16" 156 LITETOUCH PEN letrozole 44 LITETOUCH INSULIN NEEDLES/31G X SYRINGE/0.3ML/31G X 5MM/MINI 157 leucovorin calcium 46 5/16" 156 LITETOUCH PEN LEUKERAN 42 LITETOUCH INSULIN NEEDLES/31G X leuprolide acetate 44 SYRINGE/0.5ML/30G X 8MM/SHORT 157 5/16" 156
Index 28 LITHIUM 47 LYRA DIRECT SARS-COV-2 MAXI-COMFORT INSULIN lithium carbonate 47 ASSAY 84 SYRINGE/U- LYRA SARS-COV-2 100/0.5ML/28GX1/2" 158 LITHOBID 47 ASSAY 84 MAXI-COMFORT INSULIN LIVE BETTER ADVANCED LYSODREN 44 SYRINGE/U-100/1ML/28GX1/2" LANCING DEVICE 118 M-M-R II 257 158 LIVE BETTER LANCET MAXI-COMFORT SAFETY PEN SUPERTHIN 30G 118 M-NATAL PLUS 226 NEEDLE/29G X 3/16" 158 LIVE BETTER LANCET MAALOX 17 MAXI-COMFORT SAFETY PEN ULTRATHIN 28G 118 maalox max 16 NEEDLE/29G X 5/16" 158 LOMAIRA 1 MACULAR VITAMIN MAXI-TUSS PE 68 LONGS INSULIN BENEFIT 216 MAXICOMFORT II PEN SYRINGE/0.5ML/31G X mag-al plus 16 NEEDLES/31G X 1/4" 158 5/16" 157 MAXICOMFORT INSULIN LONGS LANCETS magdelay 202 SYRINGES 27G X 1/2" 158 STANDARD 118 MAGELLAN INSULIN SAFETY MAXIDEX 240 LONGS LANCETS THIN 118 SYRINGE/U-100/0.3ML/29G X 1/2" 157 MAXX LUBRICATED 111 LONSURF 45 MAGELLAN INSULIN SAFETY MAXX PLUS SPERMICIDE loperamide hcl 31 SYRINGE/U-100/0.3ML/30G X LUBRICATED 111 lopinavir-ritonavir 56 5/16" 157 meclizine hcl 32 loratadine 38 MAGELLAN INSULIN SAFETY meclofenamate sodium 6 SYRINGE/U-100/0.5ML/29G X lorazepam 19 MEDIC INSULIN 1/2" 157 SYRINGE/0.3ML/30G X lorazepam intensol 19 MAGELLAN INSULIN SAFETY 5/16" 158 lorcet 13 SYRINGE/U-100/0.5ML/30G X MEDIC INSULIN 5/16" 157 SYRINGE/0.5ML/30G X losartan potassium 40 MAGELLAN INSULIN SAFETY losartan potassium & 5/16" 158 SYRINGE/U-100/1ML/29G X MEDICINE SHOPPE PEN hydrochlorothiazide 41 1/2" 158 lovastatin 39 NEEDLES 29G X 12MM 158 MAGELLAN INSULIN SAFETY MEDICINE SHOPPE PEN loxapine succinate 48 SYRINGE/U-100/1ML/30G X NEEDLES 31G X 6MM 158 lubiprostone 89 5/16" 158 MEDICINE SHOPPE PEN LUCEMYRA 243 MAGNESIUM 202 NEEDLES 31G X 8MM 158 MEDISENSE THIN LUCENTIS 239 magnesium chloride 202 magnesium citrate 100 LANCETS 118 LUCIRA COVID-19 ALL-IN-ONE MEDROL 64 TEST KIT 84 MAGNESIUM EXTRA medroxyprogesterone LUGOLS STRONG IODINE 54 STRENGTH 202 magnesium oxide 17 acetate 243 LUMIGAN 241 medroxyprogesterone acetate LUMIZYME 87 MAGNESIUM OXIDE 202 (contraceptive) 63 LUNG PERFORMANCE PEAK magnesium oxide (mg mefloquine hcl 41 supplement) 202 FLOW METER 193 MEGA MULTI FOR MEN 216 MAKENA 243 LUPRON DEPOT (1- MEGA MULTI FOR MONTH) 44 malathion 83 WOMEN 216 LUPRON DEPOT (3- maprotiline hcl 25 MEGA MULTIVITAMIN FOR MONTH) 44 MARATHON MEDICAL MEN 216 LUPRON DEPOT (4- PENTIPS29GX12MM 158 MEGA MULTIVITAMIN FOR MONTH) 44 MARATHON MEDICAL WOMEN 216 LUPRON DEPOT (6- PENTIPS31GX5MM 158 MEGAVITE FRUITS & MONTH) 44 MARATHON MEDICAL VEGGIES 216 LUPRON DEPOT-PED (1- PENTIPS31GX8MM 158 MEGAVITE GOLDEN YEARS MONTH) 86 MARATHON MEDICAL 55+ 216 LUPRON DEPOT-PED (3- PENTIPS32GX4MM 158 megestrol acetate 44 MONTH) 86 LUTEIN MARNATAL-F 226 MEIJER ALCOHOL SWABS PLUS/ZEAXANTHIN 216 MARPLAN 25 EXTRA-THICK 124 LYNPARZA 45 MATULANE 46 MEIJER CALAMINE 82
Index 29 MEIJER COLOR LANCETS METHOTREXATE 3 midodrine hcl 259 UNIVERSAL 33G 118 methotrexate sodium 42 migergot 197 MEIJER LANCETS 118 methyldopa 40 MIGRANAL 197 MEIJER LANCETS THIN 118 methyldopa & MILLIPRED 64 MEIJER LANCETS hydrochlorothiazide 41 MINI LANCING DEVICE 118 UNIVERSAL21G 118 methylergonovine MEIJER LANCETS maleate 242 MINI WRIGHT AFS PEAK FLOWMETER LOW UNIVERSAL30G 118 methylphenidate hcl 2 MEIJER LANCETS RANGE 193 UNIVERSAL33G 118 methylprednisolone 64 MINI WRIGHT PEAK FLOW MEIJER PEN NEEDLES 29G methyltestosterone 14 METER 193 X12MM 158 metoclopramide hcl 89 MINI WRIGHT PEAK FLOW MEIJER PEN NEEDLES 31G METER STANDARD X6MM 158 metolazone 85 RANGE 193 MEIJER PEN NEEDLES 31G metoprolol & MINIELITE FILTER X8MM 158 hydrochlorothiazide 41 REPLACEMENTS 193 MEIJER SUPER THIN metoprolol succinate 59 MINIELITE RECHARGEABLE LANCETS 118 METOPROLOL SUCCINATE BATTERY 193 MEKINIST 45 ER/HYDROCHLOROTHIAZIDE minitran 19 MEKTOVI 45 41 minocycline hcl 248 metoprolol tartrate 59 meloxicam 6 minoxidil 41 metronidazole 18 melphalan 42 mintox plus 16 METRONIDAZOLE 18 memantine hcl 244 MIRASORB SPONGES 2" X metronidazole 18 MENACTRA 254 2" 108 metronidazole (topical) 82 MIRASORB SPONGES 4" X MENEST 88 4" 108 metronidazole in nacl 18 MENQUADFI 254 mirtazapine 25 metronidazole vaginal 259 MENS 50+ MULTI VITAMIN misoprostol 253 &MINERAL FORMULA 216 metyrosine 40 MENS MULTI VITAMIN & mitoxantrone hcl 44 mexiletine hcl 20 MM INSULIN SYRINGE/U- MINERAL FORMULA 217 miconazole 3 258 MENS MULTIVITAMIN 217 100/0.3ML/30G X 5/16" 159 miconazole 7 259 MM INSULIN SYRINGE/U- MENVEO 254 miconazole nitrate (topical)73 100/0.3ML/31G X 5/16" 159 MM INSULIN SYRINGE/U- meperidine hcl 11 miconazole nitrate meprobamate 19 100/1/2ML/30G X 5/16" 159 vaginal 259 MM INSULIN SYRINGE/U- mercaptopurine 42 MICROCHAMBER 193 100/1/2ML/31G X 5/16" 159 MERTHIOLATE TINCTURE 52 MICROCLENS WIPES 50 MM INSULIN SYRINGE/U- mesalamine 90 MICRODOT PEN 100/1ML/30G X 5/16" 159 MM INSULIN SYRINGE/U- mesalamine w/ cleanser 90 NEEDLE/31G X 6 MM 158 MICRODOT PEN 100/1ML/31G X 5/16" 159 METAMUCIL 97 NEEDLE/32G X 4 MM 159 MM LANCING DEVICE 118 METAMUCIL FIBER 97 MICRODOT PEN MM PEN NEEDLES 31G X metformin hcl 27 NEEDLE/33G X 4 MM 159 1/4" 159 MICROELITE FILTER methadone hcl 11,12 MM PEN NEEDLES 31G X REPLACEMENTS 193 3/16" 159 methadone hydrochloride MICROELITE MM PEN NEEDLES 31G X intensol 11 RECHARGEABLE 5/16" 159 methadose 11 BATTERY 193 MM PEN NEEDLES 32G X methazolamide 85 microklenz 50 5/32" 159 methenamine mandelate 19 MICROLET NEXT 118 modafinil 2 methergine 242 MICROLIFE DIGITAL PEAK MODERNA COVID-19 VACCINE 257 methimazole 248 FLOW METER 193 MICROSPACER 193 moexipril hcl 40 METHITEST 14 midazolam hcl 96 MOI-STIR 204 methocarbamol 230
Index 30 MOLESKIN FOAM MONOJECT INSULIN MONOJECT PADDING 108 SYRINGEREGULAR LUER SYRINGE/STANDARDHYPODE molindone hcl 49 TIP/SOFTPACK/1ML 160 RMIC mometasone furoate 79 MONOJECT LIFESHIELD NEEDLE/3ML/20GX1" 161 BLUNTCANNULA/LUER LOCK MONOJECT mondoxyne nl 248 SYR/3ML/18G X 1" 160 SYRINGE/STANDARDHYPODE MONOCAL 202 MONOJECT MAGELLAN RMIC NEEDLE/3ML/20GX1-1/2" MONOJECT 3ML SYRINGE/SAFETY 161 SYRINGE/STANDARD NEEDLE/3ML/20G X 1" 160 MONOJECT HYPODERMIC NEEDLE/21GX1- MONOJECT MAGELLAN SYRINGE/STANDARDHYPODE 1/2" 159 SYRINGE/SAFETY RMIC MONOJECT INSULIN NEEDLE/3ML/20G X 1- NEEDLE/3ML/21GX1" 161 SYRINGE/1ML 159 1/2" 160 MONOJECT MONOJECT INSULIN MONOJECT MAGELLAN SYRINGE/STANDARDHYPODE SYRINGE/1ML/31G X SYRINGE/SAFETY RMIC 5/16" 159 NEEDLE/3ML/21G X 1" 160 NEEDLE/3ML/22GX1" 161 MONOJECT INSULIN MONOJECT MAGELLAN MONOJECT SYRINGE/DETACH SYRINGE/SAFETY SYRINGE/STANDARDHYPODE NEEDLE/1ML/25G X 5/8" 159 NEEDLE/3ML/21G X 1- RMIC NEEDLE/3ML/22GX1-1/2" MONOJECT INSULIN 1/2" 160 161 SYRINGE/DETACH MONOJECT MAGELLAN MONOJECT NEEDLE/1ML/27G X 1/2" 159 SYRINGE/SAFETY SYRINGE/STANDARDHYPODE MONOJECT INSULIN NEEDLE/3ML/22G X 1" 160 RMIC SYRINGE/PERM MONOJECT MAGELLAN NEEDLE/3ML/23GX1" 162 NEEDLE/1ML/28G X 1/2" 159 SYRINGE/SAFETY MONOJECT MONOJECT INSULIN NEEDLE/3ML/22G X 1- SYRINGE/STANDARDHYPODE SYRINGE/PERM NEEDLE/U- 1/2" 160 RMIC 100/0.5ML/28G X 1/2" 159 MONOJECT MAGELLAN NEEDLE/3ML/25GX1" 162 MONOJECT INSULIN SYRINGE/SAFETY MONOJECT SYRINGE/SAFETY/PERM NEEDLE/3ML/23G X 1" 160 SYRINGE/STANDARDHYPODE NEEDLE/0.3ML/29G X 1/2" 159 MONOJECT MAGELLAN RMIC NEEDLE/3ML/25GX1-1/4" MONOJECT INSULIN SYRINGE/SAFETY 162 SYRINGE/SAFETY/PERM NEEDLE/3ML/25G X 1" 160 MONOJECT NEEDLE/0.3ML/29GX1/2" 159 MONOJECT MAGELLAN SYRINGE/STANDARDHYPODE MONOJECT INSULIN SYRINGE/SAFETY RMIC NEEDLE/3ML/25GX5/8" SYRINGE/SAFETY/PERM NEEDLE/3ML/25G X 5/8" 161 162 NEEDLE/0.5ML/29G X 1/2" 160 MONOJECT SYRINGE/LUER MONOJECT MONOJECT INSULIN LOCK/3ML/20G X 1" 161 SYRINGE/STANDARDHYPODE SYRINGE/SAFETY/PERM MONOJECT SYRINGE/LUER RMIC NEEDLE/3ML/27GX1-1/4" NEEDLE/1ML/29G X 1/2" 160 LOCK/3ML/20G X 1-1/2" 161 162 MONOJECT INSULIN MONOJECT SYRINGE/LUER MONOJECT ULTRA COMFORT SYRINGE/SOFTPACK/1ML/27G LOCK/3ML/20G X 3/4" 161 INSULIN SYRINGE/0.3ML/29G X X 1/2" 160 MONOJECT SYRINGE/LUER 1/2" 162 MONOJECT INSULIN LOCK/3ML/22G X 1" 161 MONOJECT ULTRA COMFORT SYRINGE/SOFTPACK/U- MONOJECT SYRINGE/LUER INSULIN SYRINGE/0.3ML/30G X 100/0.5ML/28G X 1/2" 160 LOCK/3ML/22G X 1-1/2" 161 5/16" 162 MONOJECT INSULIN MONOJECT SYRINGE/LUER MONOJECT ULTRA COMFORT SYRINGE/U-100/0.3ML/30G X LOCK/3ML/23G X 1" 161 INSULIN SYRINGE/0.3ML/31G X 5/16" 160 MONOJECT SYRINGE/LUER 5/16" 162 MONOJECT INSULIN LOCK/3ML/25G X 1" 161 MONOJECT ULTRA COMFORT SYRINGE/U-100/0.5ML/30G X MONOJECT SYRINGE/LUER INSULIN SYRINGE/0.5ML/28G X 5/16" 160 LOCK/3ML/25G X 5/8" 161 1/2" 162 MONOJECT INSULIN MONOJECT SYRINGE/LUER MONOJECT ULTRA COMFORT SYRINGE/U-100/1ML/28G X LOCK/3ML/27G X 1-1/4" 161 INSULIN SYRINGE/0.5ML/29G X 1/2" 160 MONOJECT SYRINGE/LUER- 1/2" 162 MONOJECT INSULIN LOCK/3ML/21G X 1" 161 MONOJECT ULTRA COMFORT SYRINGE/U-100/1ML/30G X MONOJECT SYRINGE/LUER- INSULIN SYRINGE/0.5ML/30G X 5/16" 160 LOCK/3ML/21G X 1-1/2" 161 5/16" 162
Index 31 MONOJECT ULTRA COMFORT multilex 210 naproxen sodium 6 INSULIN SYRINGE/0.5ML/31G X MULTILEX 217 naratriptan hcl 197 5/16" 162 MONOJECT ULTRA COMFORT MULTILEX T&M 217 NARCAN 31 INSULIN SYRINGE/1ML/28G X multiple vitamin 222 NARDIL 25 1/2" 162 multiple vitamins w/ iron 206 nasal decongestant 233 MONOJECT ULTRA COMFORT multiple vitamins w/ NAT-RUL THERAVITE- INSULIN SYRINGE/1ML/29G X minerals 217 M/HIGHPOTENCY 217 1/2" 162 MULTIVITAMIN 217,222 NATACYN 239 MONOLET LANCETS 118 MULTIVITAMIN ADULT 222 NATALVIT 226 MONOLET OPD LANCETS118 multivitamin adults 210 nateglinide 29 MONONINE 92 MULTIVITAMIN ADULTS 217 NATRUL-VITES 217 montelukast sodium 20 MULTIVITAMIN MEN 217 natural vitamin e 260 morgidox 1x100mg 248 multivitamin NATURE-THROID 248 morphine sulfate 12 select/fluoride 223 NATURE-THROID NT-2.5 248 MORPHINE SULFATE 12 multivitamin women 211 NAYZILAM 23 morphine sulfate 12 MULTIVITAMIN WOMEN 217 NEBULIZER AIR MORPHINE SULFATE 12 multivitamin/fluoride 223 TUBE/PLUGS 193 morphine sulfate 12 MULTIVITAMIN/ZINC NEBULIZER PEDIATRIC MORPHINE SULFATE 12 STRESSFORMULA 217 MASK 193 mupirocin 71 nebusal 68 morphine sulfate 12 mupirocin calcium (topical) 71 nefazodone hcl 25 MORPHINE SULFATE 12 MURO 128 241 neo-polycin 239 morphine sulfate 12 mycophenolate mofetil 203 neo-polycin hc 240 MORPHINE SULFATE 12 mycophenolate sodium 203 NEOMULTIVITE 222 morphine sulfate 12 MYLERAN 42 neomycin sulfate 2 morphine sulfate beads 12 MYNATAL 226 neomycin-bacitracin zn- motion sickness relief 32 MYNATAL ADVANCE 226 polymyxin 239 MOUTH KOTE 205 neomycin-polymy- MYNATAL PLUS 226 MOUTH KOTE REMINT 205 dexameth 240 MYNATAL neomycin-polymyxin-gramicidin MOVANTIK 90 ULTRACAPLET 226 239 moxifloxacin hcl (ophth) 239 MYNATAL-Z 226 neomycin-polymyxin-hc MS INSULIN MYNATE 90 PLUS 226 (ophth) 240 SYRINGE/0.3ML/31G X neomycin-polymyxin-hc 5/16" 162 mynephrocaps 205 (otic) 242 MS INSULIN MYOBLOC 234 NEONATAL COMPLETE 226 SYRINGE/0.5ML/31G X nabumetone 6 NEONATAL PLUS 226 5/16" 162 nadolol 59 MS INSULIN SYRINGE/1ML/31G NEONATAL VITAMIN 226 X 5/16" 162 nafcillin sodium 243 NEOVITE 217 MULTAQ 20 NAFCILLIN SODIUM 243 NEPHRAMINE 237 MULTI PRENATAL 226 nafrinse 202 NERLYNX 45 MULTI VITAMIN 222 naftifine hcl 73 nevirapine 56 MULTI VITAMIN/D-3 222 NAFTIN 73 NEXAFED SINUS PRESSURE MULTI-BETIC DIABETES 217 NAGLAZYME 87 +PAIN 68 MULTI-LANCET DEVICE 118 naloxone hcl 31 NEXAVAR 46 NALTREXONE 31 NEXCARE ABSOLUTE MULTI-LANCET DEVICE 2 118 WATERPROOF PAD 108 multi-vit/iron/fluoride 223 naltrexone hcl 31 niacin 262 NAMENDA XR TITRATION MULTI-VITAMIN niacin (antihyperlipidemic) 39 MONOCAPS 217 PACK 244 multi-vitamin/fluoride drops 223 naproxen 6 NIACIN TR 262
Index 32 niacor 39 NORPACE CR 20 NUPLAZID 48 NICADAN 217 NORTEMP INFANTS 9 NUTRATEAR 238 NICADAN ZX 217 nortriptyline hcl 26 NUTRICAP 218 nicardipine hcl 59 NORVIR 56 NUTRILIPID 234 NICAZEL 217 NOSE CLIP 193 NUWIQ 92 NICAZEL FORTE 217 NOVA MAX PLUS KETONE nyamyc 72 nicotine 247 TESTSTRIPS 84 NYMALIZE 59 NOVA SUREFLEX nicotine polacrilex 247 LANCETS 119 nystatin 32 NICOTINE TRANSDERMAL NOVA SUREFLEX LANCING nystatin (mouth-throat) 204 SYSTEM 247 DEVICE 119 nystatin (topical) 73 NICOTROL INHALER 247 NOVAVAX COVID-19 nystatin-triamcinolone 73 NICOTROL NS 247 VACCINE 257 O-CAL FA 226 nifedipine 59 NOVOEIGHT 92 NOVOFINE AUTOCOVER PEN O-CAL PRENATAL 226 nimodipine 59 NEEDLE 30G X 8MM 162 OBIZUR 92 NINLARO 46 NOVOFINE PEN NEEDLE 32G OBSTETRIX EC 226 nisoldipine 59 X 4MM 163 OBTREX 226 NITRO-BID 19 NOVOFINE PLUS PEN NEEDLE32G X 4MM 163 OCREVUS 244 NITRO-DUR 19 NOVOLIN 70/30 29 OCULAR VITAMINS 218 nitro-time 19 NOVOLIN 70/30 ODEFSEY 56 nitrofurantoin 19 FLEXPEN 29 ODOMZO 43 nitrofurantoin macrocrystal 19 NOVOLIN 70/30 FLEXPEN OFF DEEP WOODS 82 nitrofurantoin monohyd RELION 28 macro 19 NOVOLIN 70/30 RELION 29 OFF DEEP WOODS DRY 82 nitroglycerin 19 NOVOLIN N 29 ofloxacin 88 NIVA-PLUS 226 NOVOLIN N FLEXPEN 29 ofloxacin (ophth) 239 nizoral a-d 72 NOVOLIN N FLEXPEN ofloxacin (otic) 242 RELION 29 NIZORAL A-D 73 olanzapine 48 NOVOLIN N RELION 29 NO IRON MULTIPLE olanzapine-fluoxetine hcl 244 NOVOLIN R 29 VITAMIN/MINERALS 218 olmesartan medoxomil 40 noble formula hc 77 NOVOLIN R RELION 29 olmesartan medoxomil- NORDITROPIN FLEXPRO 86 NOVOLOG MIX 70/30 29 amlodipine-hydrochlorothiazide norethin acet & estrad-fe 63 NOVOLOG MIX 70/30 41 norethindrone & ethinyl estradiol- PREFILLED FLEXPEN 29 olmesartan medoxomil- fe 63 NOVOLOG MIX 70/30 hydrochlorothiazide 41 norethindrone PREFILLED FLEXPEN omega-3 fatty acids 236 (contraceptive) 63 RELION 29 NOVOLOG MIX 70/30 omeprazole 253 norethindrone acet & eth omeprazole magnesium 253 estra 63 RELION 29 OMNICAP 222 norethindrone acetate 243 NOVOSEVEN RT 92 norethindrone acetate-ethinyl NOVOTWIST PEN NEEDLE OMNIFLEX DIAPHRAGM 111 estradiol 87 32GX 5MM 163 OMNITROPE 86 norgestimate-ethinyl np thyroid 120 248 ON CALL LANCING estradiol 63 NPLATE 93 DEVICE 119 norgestimate-ethinyl estradiol NU GAUZE 4PLY 4"X4" 108 ON CALL PLUS LANCING (triphasic) 63 NU GAUZE GENERAL-USE DEVICE 119 NORMOSOL -R 201 SPONGES 4"X4" 4 PLY 108 ONCOVITE 218 NORMOSOL-M IN D5W 201 NUCALA 20 ondansetron 32 NORMOSOL-M/D5W 201 NUCYNTA ER 12 ondansetron hcl 31 NORMOSOL-R 201 nulev 249 ONE A DAY PRENATAL 226 NORPACE 20 NUMOISYN 205
Index 33 ONE A DAY WOMENS OPTICHAMBER oxycodone hcl 12,13 PRENATAL/DHA 226 ADVANTAGE/SMALL FACE oxycodone w/ ONE A DAY WOMENS MASK 193 acetaminophen 13 PRENATAL1 226 OPTICHAMBER oxycodone-aspirin 13 one daily essential 222 DIAMOND 193 OXYZAL WET DRESSING 52 ONE DAILY ESSENTIAL 223 OPTICHAMBER DIAMOND/LARGEFACE oysco 500 199 ONE DAILY MENS FORMULA MASK 194 oyster shell 199 W/O IRON 218 OPTICHAMBER one daily multivitamin pacerone 20 adult 211,222 DIAMOND/MEDIUM FACE MASK 194 paliperidone 48 one daily womens 211 OPTICHAMBER PANCREAZE 85 ONE DAILY WOMENS 218 DIAMOND/SMALLFACE PANRETIN 74 ONE VITE WOMENS MASK 194 PRENATALVITAMIN 226 OPTICHAMBER FACE pantoprazole sodium 253 ONE VITE WOMENS MASK/LARGE 194 paregoric 31 PRENATALVITAMIN PLUS 226 OPTICHAMBER FACE PARI ALTERA NEBULIZER ONE-A-DAY ENERGY 218 MASK/MEDIUM 194 HANDSET 194 ONE-A-DAY MENOPAUSE OPTICHAMBER FACE PARI BABY CONVERSION FORMULA 218 MASK/SMALL 194 KITSIZE 1 194 ONE-A-DAY MENS 218 OPTIFOAM 108 PARI BABY CONVERSION OPTIHALER 194 KITSIZE 2 194 ONE-A-DAY MENS 50+ 218 PARI BABY CONVERSION OPTIHALER MDI DRUG ONE-A-DAY MENS 50+ KITSIZE 3 194 ADVANTAGE 218 DELIVERY SYSTEM 194 PARI ERAPID NEBULIZER OPTIONS GYNOL II ONE-A-DAY MENS HEALTH HANDSET 194 FORMULA 218 VAGINALCONTRACEPTIVE PARI EXPIRATORY FILTER ONE-A-DAY MENS PRO 258 VALVE SET 194 EDGE 218 OPURITY 218 PARI MASK SET 194 ONE-A-DAY PROACTIVE ORACIT 90 PARI SOFT PLASTIC ADULT 65+ 218 oral electrolytes 201 MASK 194 ONE-A-DAY TEEN PARI SOFT PLASTIC ADVANTAGEFOR HIM 218 ORAL RELIEF SPRAY FOR DRYMOUTH & PEDIATRIC MASK 194 ONE-A-DAY WOMENS 218 DISCOMFORT 205 PARI VORTEX ADULT ONE-A-DAY WOMENS oralone dental paste 204 MASK 194 PRENATAL 227 paricalcitol 87 ONETOUCH DELICA LANCING orazinc 203 DEVICE 119 ORENCIA 6 PARNATE 25 ONETOUCH DELICA PLUS ORENCIA CLICKJECT 6 paroex 204 LANCING DEVICE 119 ORKAMBI 247 paromomycin sulfate 2 ONETOUCH DELICA SAFETY paroxetine hcl 25 LACING DEVICE 119 orphenadrine citrate 230 ONETOUCH SURESOFT oscimin 249 PARVA-CAL 199 LANCING DEVICE/18G 119 PARVLEX 218 ONETOUCH SURESOFT oscimin sr 249 oseltamivir phosphate 58 PAXIL 25 LANCING DEVICE/21G 119 PC LANCETS SUPER THIN ONETOUCH SURESOFT OSMOLEX ER 47 30G 119 LANCING DEVICE/28G 119 OSTEOPRIME PC PEDIATRIC POLY-VITAMIN ONEVITE 218 PLUS/CALCIUM & DROPS/IRON 223 ONGLYZA 27 MAGNESIUM 218 PC UNIFINE PENTIPS 29G OPDIVO 43 OTEZLA 6 X1/2" 163 OPTICHAMBER oxandrolone 14 PC UNIFINE PENTIPS 31G ADVANTAGE/LARGE X5MM MINI 163 oxaprozin 6 PC UNIFINE PENTIPS 31G MASK 193 OXAYDO 12 OPTICHAMBER X6MM ULTRA SHORT 163 ADVANTAGE/MEDIUM FACE oxazepam 19 PC UNIFINE PENTIPS 31G MASK 193 oxcarbazepine 24 X8MM SHORT 163 PEAK A-I-R FLOW METER194 oxybutynin chloride 253
Index 34 PEAK AIR PEAK FLOW PEN NEEDLES/32G X PHENOL EZ SWABS 50 METERADULT/PEDIATRIC 5/32" 164 phenoxybenzamine hcl 40 194 penicillamine 203 phentermine hcl 1 PEDIATRIC penicillin v potassium 243 MOUTHPIECE/DISPOSABLE phenylephrine hcl 194 PENLET II AUTOMATIC (mydriatic) 238 pediatric vitamins acd w/ BLOODSAMPLER 119 phenylephrine hcl (oral) 233 PENLET II REPLACEMENT fluoride 223 phenytoin 24 peg 3350-kcl-sod bicarb-sod CAPS 119 PENLET II REPLACEMENT chloride-sod sulfate 99 phenytoin infatabs 24 CAPS-DEEP 119 phenytoin sodium extended 24 peg 3350-potassium chloride-sod PENLET II REPLACEMENT bicarbonate-sod chloride 99 CAPS-REGULAR 119 phillips milk of magnesia 100 PEGASYS 58 PENTIPS 29G X 12MM 164 PHILLIPS MILK OF PEGASYS PROCLICK 58 MAGNESIA 100 PENTIPS 29GX12MM 164 PEGINTRON 58 PHILLIPS MILK OF MAGNESIA PENTIPS 31G X 5MM 164 CHEWABLE 100 PEN NEEDLES 29G X PENTIPS 31G X 8MM 164 PHILLIPS MILK OF MAGNESIA 12MM 163 CONCENTRATED 100 PENTIPS 31GX5MM 164 PEN NEEDLES 29GX1/2" 163 phospha 250 neutral 202 PEN NEEDLES PENTIPS 31GX6MM 164 phosphasal 18 29GX12MM 163 PENTIPS 31GX8MM 164 PHOSPHOLINE IODIDE 239 PEN NEEDLES 30GX5/16" 163 PENTIPS 32G X 4MM 164 PHYTOMULTI 218 PEN NEEDLES 30GX5MM 163 PENTIPS 32GX4MM 164 phytonadione 261 PEN NEEDLES 30GX8MM 163 pentoxifylline 93 PICATO 74 PEN NEEDLES 31G X 1/4" PERFECT LANCETS SHORT 163 30G 119 PIFELTRO 56 PEN NEEDLES 31G X PIKO 1 ELECTRONIC 195 3/16" 163 PERIKABIVEN 236 PEN NEEDLES 31G X PERJETA 43 PILLOW MASK/ADULT 195 5MM 163 permethrin 83 PILLOW MASK/CHILD 195 PEN NEEDLES 31G X perphenazine 49 PILLOW 6MM 163 perphenazine-amitriptyline MASK/PEDIATRIC 195 PEN NEEDLES 31G X pilocarpine hcl 239 8MM 163 244 pilocarpine hcl (oral) 205 PEN NEEDLES 31GX5/16" 163 PERRY PRENATAL 227 PEN NEEDLES 31GX6MM PERSERIS 48 pimecrolimus 80 (1/4") 163 PERSONAL BEST FULL pimozide 245 PEN NEEDLES 31GX8MM 163 RANGE 194 pindolol 59 PEN NEEDLES 31GX8MM PERSONAL BEST LOW RANGE 195 pioglitazone hcl 28 (5/16") 163 pioglitazone hcl-glimepiride 26 PEN NEEDLES 32G X PFIZER-BIONTECH COVID- 4MM 163 19VACCINE 257 pioglitazone hcl-metformin PEN NEEDLES 32G X PFLEX 195 hcl 26 5MM 163 PHARMACIST CHOICE piroxicam 6 PEN NEEDLES 32G X NEBULIZER/CPAP/INHALER PLASMA-LYTE A 201 6MM 163 CHAMBER MASK PLASMA-LYTE-148 201 WIPES 195 PEN NEEDLES 32GX4MM 163 PLEGRIDY 244 PEN NEEDLES 33G X PHARMACY COUNTER LANCETS 119 PLEGRIDY STARTER 5/32" 163 PACK 244 PEN NEEDLES/29G X 1/2" 163 phazyme 89 phenadoz 38 PNEUMOVAX 23 254 PEN NEEDLES/31G X 1/4" 164 PNEUMOVAX 23/1 DOSE 254 PEN NEEDLES/31G X phenazo 91 3/16" 164 phenazopyridine hcl 91 PNV TABS 29-1 227 PEN NEEDLES/31G X phenelzine sulfate 25 POCKET CHAMBER 195 5/16" 164 POCKET PEAK FLOW PEN NEEDLES/31G X phenobarbital 96 METER 195 6MM 164 PHENOL 50 POCKET SPACER 195
Index 35 POCKETPEAK PEAK FLOW POVIDONE-IODINE PREP PRECISION XTRA 84 METER LOW RANGE 195 PADS 54 PRECISION XTRA BLOOD POCKETPEAK PEAK FLOW POVIDONE-IODINE SCRUB GLUCOSE TEST STRIPS 84 METER/UNIVERSAL RANGE 50- LARGE WINGED PRED MILD 240 720 LPM 195 SPONGE 54 podofilox 80 POVIDONE-IODINE SCRUB PRED-G 240 POLY-VI-FLOR 223 SMALL WINGED PRED-G S.O.P. 240 SPONGE 54 prednicarbate 79 POLY-VI-FLOR/IRON 224 POVIDONE-IODINE SCRUB POLY-VITA/IRON 223 SPONGE STICKS 54 prednisolone 64 PRADAXA 23 prednisolone acetate POLYCOSE 234 (ophth) 240 polyethylene glycol 3350 99 pramipexole PREDNISOLONE ACETATE P- dihydrochloride 47 POLYMEM FILM DOT 108 F 240 PRAMOSONE 79 POLYMEM NON-ADHESIVE prednisolone sodium PAD 109 pramoxine hcl (rectal) 15 phosphate 64 polymyxin b-trimethoprim 239 prasugrel hcl 93 PREDNISOLONE SODIUM PHOSPHATE 240 pravastatin sodium 39 polysaccharide iron complex 95 prednisone 64 praziquantel 18 polyvinyl alcohol 238 PREDNISONE INTENSOL 64 POMALYST 44 prazosin hcl 40 PREFERRED PLUS INSULIN pot phosphate monobasic w/ sod PRE-NATAL FORMULA 227 SYRINGE/U-100/0.3ML/29G X phosphate dibasic & PRECISION GLUCOSE 1/2" 164 monobasic 202 CONTROL 119 PREFERRED PLUS INSULIN potassium chloride 202,203 PRECISION GLUCOSE SYRINGE/U-100/0.3ML/30G X POTASSIUM CHLORIDE 203 CONTROLSOLUTION (TRI- 5/16" 164 LEVEL/HI/LO/NORMAL) 119 PREFERRED PLUS INSULIN potassium chloride 203 PRECISION GLUCOSE SYRINGE/U-100/0.5ML/28G X potassium chloride in KETONECONTROL 1/2" 164 dextrose 201 SOLUTION 1-LOW, 1- PREFERRED PLUS INSULIN potassium chloride in dextrose & HIGH 119 SYRINGE/U-100/0.5ML/29G X sodium chloride 201 PRECISION 1/2" 165 potassium chloride in nacl 201 GLUCOSE/KETONECONTROL PREFERRED PLUS INSULIN potassium chloride SOLUTIONS 1-HI 1-LO 119 SYRINGE/U-100/0.5ML/30G X microencapsulated crystals PRECISION SURE-DOSE 5/16" 165 er 203 INSULIN SYRINGE/0.3ML/30G PREFERRED PLUS INSULIN POTASSIUM X 5/16" 164 SYRINGE/U-100/1ML/28G X CHLORIDE/DEXTROSE 201 PRECISION SURE-DOSE 1/2" 165 POTASSIUM INSULIN SYRINGE/0.5ML/28G PREFERRED PLUS INSULIN CHLORIDE/DEXTROSE/LACTA X 1/2" 164 SYRINGE/U-100/1ML/29G X TED RINGERS 201 PRECISION SURE-DOSE 1/2" 165 POTASSIUM INSULIN SYRINGE/0.5ML/29G PREFERRED PLUS INSULIN CHLORIDE/LIDOCAINE X 1/2" 164 SYRINGE/U-100/1ML/30G X HYDROCHLORIDE/SODIUM PRECISION SURE-DOSE 5/16" 165 CHLORIDE 201 INSULIN SYRINGE/0.5ML/30G PREFERRED PLUS LANCETS POTASSIUM X 3/8" 164 COLORED 21G 119 CHLORIDE/SODIUM PRECISION SURE-DOSE PREFERRED PLUS LANCETS CHLORIDE 201 INSULIN SYRINGE/1ML/28G X SUPER THIN 30G 119 POTASSIUM 1/2" 164 PREFERRED PLUS LANCETS CHLORIDE/SODIUMCHLORIDE PRECISION SURE-DOSE THIN 26G 119 201 PLUSINSULIN PREFERRED PLUS UNIFINE potassium citrate SYRINGE/0.3ML/29G X PENTIPS 29G X 12MM 165 (alkalinizer) 90 1/2" 164 PREFERRED PLUS UNIFINE povidone-iodine 54 PRECISION SURE-DOSE PENTIPS 31G X 6MM ULTRA POVIDONE-IODINE 54 PLUSINSULIN SHORT 165 SYRINGE/1ML/29G X PREFERRED PLUS UNIFINE POVIDONE-IODINE PREP PENTIPS 31G X 8MM PAD 54 1/2" 164 PRECISION THINS GP SHORT 165 LANCET 119
Index 36 PREFERRED PLUS UNIFINE PREPLUS 229 PROCARE SPACER CHAMBER PENTIPS 32GX4MM 165 PRESERVISION AREDS 218 W/CHILD MASK 195 PREFERRED PLUS UNIFINE PROCERV HP 219 PRETAB 229 PENTIPS/MINI/31GX5MM 165 prochlorperazine 49 PREMARIN 88,259 prevalite 39 prochlorperazine maleate 49 PREMASOL 237 PREVENT SAFETY PEN procto-med hc 15 PREMIUM CONDOMS NEEDLES 31GX1/4" 165 LUBRICATED 111 PREVENT SAFETY PEN PROCTOFOAM HC 15 NEEDLES 31GX5/16" 165 PREMPHASE 87 PRODIGY INSULIN SYRING/U- PREVNAR 13 254 100/0.3ML/31G X 5/16" 166 PREMPRO 87 PREZCOBIX 56 PRODIGY INSULIN PRENATABS FA 227 PREZISTA 56 SYRINGE/1/2ML/31G X prenatabs rx 224 5/16" 166 PRIFTIN 42 PRENATAL 228 PRODIGY INSULIN primidone 24 SYRINGE/1ML/28G X 1/2" 166 prenatal 19 224 PRO COMFORT INHALER PRODIGY LANCING PRENATAL 19 227 SPACER CHAMBER DEVICE 120 PRENATAL ADULT ADULT 195 PRODIGY TWIST TOP GUMMY/DHA/FOLIC ACID 227 PRO COMFORT INHALER LANCETS 120 PRENATAL AND IRON 227 SPACER CHAMBER PROFILNINE 92 PRENATAL COMPLETE 227 CHILD 195 PROFILNINE SD 92 PRO COMFORT INHALER PRENATAL FORMULA 227 SPACER CHAMBER progesterone 243 PRENATAL FORMULA A- INFANT 195 PROGRAF 203 FREE 227 PRO COMFORT INSULIN PROLASTIN-C 247 PRENATAL FORTE 227 SYRINGES/0.5ML/30G X PROMACTA 93,94 PRENATAL GUMMIES/DHA & 1/2" 165 promethazine & FOLIC ACID 227 PRO COMFORT INSULIN phenylephrine 68 SYRINGES/0.5ML/30G X PRENATAL LOW IRON 227 promethazine hcl 38 PRENATAL MULTI + DHA 227 5/16" 165 PRO COMFORT INSULIN promethazine w/codeine 68 PRENATAL MULTI +DHA 227 SYRINGES/0.5ML/31G X promethazine-dm 68 PRENATAL 5/16" 165 promethazine-phenylephrine- MULTIVITAMIN 228 PRO COMFORT INSULIN codeine 68 PRENATAL MULTIVITAMIN + SYRINGES/1ML/30G X PRONEB ULTRA FILTER DHA 227 1/2" 165 SET 195 PRENATAL MULTIVITAMIN PRO COMFORT INSULIN propafenone hcl 20 PLUS DHA 227 SYRINGES/1ML/30G X PRENATAL ONE DAILY 228 5/16" 165 propantheline bromide 249 PRENATAL PLUS IRON 228 PRO COMFORT INSULIN proparacaine hcl 240 PRENATAL VITAMIN 228 SYRINGES/1ML/31G X propranolol & 5/16" 165 hydrochlorothiazide 41 PRENATAL VITAMIN & PRO COMFORT PEN propranolol hcl 59 MINERAL 228 NEEDLES/31G X 8MM 165 PRENATAL PRO COMFORT PEN propylthiouracil 248 VITAMIN/IRON 228 NEEDLES/32G X 4MM 165 PRORENAL+D 219 PRENATAL VITAMINS 228 PRO COMFORT PEN PROSOL 237 PRENATAL VITAMINS PLUS NEEDLES/32G X 5MM 166 protriptyline hcl 26 LOW IRON 228 PRO COMFORT PEN PRENATAL+DHA 228 NEEDLES/32G X 6MM 166 PROVENGE 43 PRENATAL-U 228 PRO-CAL 219 PROVIT 219 PRENATAL/OMEGA-3/FOLIC probenecid 91 pseudoephedrine hcl 233 ACID/IRON 229 PROBUPHINE IMPLANT PSORCON 79 PRENATRIX 229 KIT 14 PSS SELECT GP PRENATRYL 229 procainamide hcl 20 LANCETS 120 PSS SELECT PRENATVITE RX 229 PROCARE SPACER CHAMBER W/ADULT PLATFORMS 120 preparation h 75 MASK 195
Index 37 PSS SELECT SAFETY QC CALCIUM 500MG/D3 199 RA E-ZJECT LANCETS LANCETS 120 QC IODIDES TINCTURE 54 ULTRATHIN 30G 120 psyllium 98 RA FIRST AID IODINE 54 QC IODINE TINCTURE 54 PTS PANELS KETONE RA FIRST AID NON-STICK TEST 84 QC LANCETS SUPER PADS 109 THIN 120 PULMICORT FLEXHALER 21 QC LANCETS ULTRA ra fish oil 235 PULMOZYME 247 THIN 120 ra ibuprofen 5 PURE COMFORT PEAK FLOW qc multi-vite 211 RA INSULIN METER ADULT 195 QC MULTI-VITE 219 SYRINGE/0.5ML/29G X PURE COMFORT PEAK FLOW 1/2" 166 METER CHILD 195 QC PEN NEEDLES 29G X RA INSULIN SYRINGE/1ML/29G PURE COMFORT PEN NEEDLE 12MM 166 X 1/2" 166 32G X6MM 166 QC PEN NEEDLES 31G X RA INSULIN SYRINGE/U- PURE COMFORT PEN NEEDLE 6MM 166 100/0.5ML/30G X 5/16" 166 32G X8MM 166 QC PEN NEEDLES 31G X RA INSULIN SYRINGE/U-100/1 PURE COMFORT PEN 8MM 166 ML/30G X 5/16" 166 NEEDLE/32G X 5MM 166 QC PRENATAL 229 ra iron 94 PURE COMFORT PEN QC STERILE PADS 109 ra laxative 101 NEEDLE/32G X4MM 166 QC UNIFINE PENTIPS RA OYSTER SHELL PURIXAN 42 32GX4MM 166 CALCIUM/VITAMIN D 200 PX ADVANCED LANCING QC UNILET LANCETS RA PEN NEEDLES 31G X DEVICE 120 28G/ULTRA THIN 120 5MM3/16" 166 PX CALAMINE 82 QC UNILET LANCETS RA PEN NEEDLES 31G X PX EXTRA SHORT PEN 33G/MICRO THIN 120 8MM5/16" 166 NEEDLES 31GX6MM 166 QSYMIA 1 RA PRENATAL 229 px hemorrhoidal 14 quetiapine fumarate 49 RA PRENATAL PX INSULIN SYRINGE/U- QUFLORA PEDIATRIC 223 FORMULA/FOLICACID 229 100/0.5ML/30G X 1/2" 166 QUICKVUE AT-HOME COVID- RA SHEER ADHESIVE PX LANCET AUTO 19 TEST 84 LARGE 109 INJECTOR 120 QUICKVUE SARS ANTIGEN RA STERILE PADS 2"X2" 109 PX LANCETS ULTRA TEST 85 RA STERILE PADS 3"X3" 109 THIN 120 QUIN B STRONG 219 PX LANCETS ULTRA THIN RA STERILE PADS 4"X4" 109 28G 120 quinapril hcl 40 ra vitamin c 261 quinapril-hydrochlorothiazide PX MINI PEN NEEDLES RABAVERT 257 31GX5MM 166 41 PX PEN NEEDLE quinidine gluconate 20 RADICAVA 234 29GX12MM 166 quinidine sulfate 20 raloxifene hcl 86 PX PEN NEEDLE QUINTABS 223 ramipril 40 31GX8MM 166 PX PRENATAL quintabs-m 211 ranitidine hcl 252 MULTIVITAMINS 229 QUINTABS-M 219 RAY-TEC X-RAY DETECTABLESPONGES 4" X 4" PX SHORTLENGTH PEN QVAR REDIHALER 21 NEEDLES/31GX8MM 166 16 PLY 109 RA ALCOHOL SWABS 124 pyrazinamide 42 READYLANCE SAFETY ra allergy relief childrens 36 LANCETS/30G/1.6MM 120 pyridostigmine bromide 42 REALITY INSULIN SYRINGE/U- ra arthritis pain relief 80 pyridoxine hcl 262 100/0.5ML/28G X 1/2" 167 QC ADVANCED LANCING ra b-complex 205 REALITY INSULIN SYRINGE/U- DEVICE 120 RA CENTRAL-VITE 219 100/0.5ML/29G X 1/2" 167 QC ALCOHOL SWABS 124 RA DRY MOUTH 205 REALITY INSULIN SYRINGE/U- 100/1ML/28G X 1/2" 167 QC ALL PURPOSE RA E-ZJECT LANCETS REALITY INSULIN SYRINGE/U- 109 DRESSINGS4"X4" 28G 120 100/1ML/29G X 1/2" 167 qc allergy relief childrens 36 RA E-ZJECT LANCETS THIN 26G 120 REALITY LANCETS 120 QC BORDER ISLAND GAUZE REALITY LATEX 109 RA E-ZJECT LANCETS THIN PAD 2"X2" CONDOMS/LUBRICATED 111 QC CALAMINE 82 28G 120
Index 38 REALITY LATEX/ULTRA RELION PEN NEEDLES 31G REYATAZ 56 TEXTURED 111 X6MM 167 RHOGAM ULTRA-FILTERED REALITY LATEX/ULTRA RELION PEN NEEDLES 31G PLUS 242 THIN 111 X8MM 167 RHOPRESSA 240 REALITY SWABS 124 RELION PEN NEEDLES RIASTAP 92 REBIF 245 31GX5/16" 167 RELION PEN NEEDLES ribasphere 58 REBIF REBIDOSE 245 31GX6MM 167 RIBASPHERE 58 REBIF REBIDOSE RELION PEN NEEDLES TITRATIONPACK 245 31GX8MM 167 RIBASPHERE RIBAPAK 58 REBIF TITRATION PACK 245 RELION PEN NEEDLES 32G ribavirin (hepatitis c) 58 REBINYN 92 X4MM 167 riboflavin 262 RELION PEN NEEDLES 32G RECOMBINATE 92 RID ESSENTIAL LICE X5/32" 167 ELIMINATION KIT 83 RECOMBIVAX HB 257 RELION PEN NEEDLES RIDAURA 3 RECTIV 15 32GX4MM 167 rifabutin 42 REGENECARE HA 81 RELION PEN NEEDLES/31G X1/4" 168 rifampin 42 reguloid 97 RELION SHORT PEN RIGHT STEP PRENATAL 229 relafen 5 NEEDLES31GX8MM 168 RIGHTEST GD-L500 RELENZA DISKHALER 58 RELION ULTRA THIN ALTERNATE SITE LANCETS30G 120 RELION 2-IN-1 LANCET ADAPTER 121 DEVICES 30G 120 RELION ULTRA THIN PLUS RIGHTEST GD500 LANCING 120 RELION 2-IN-1 LANCING LANCETS 32G DEVICE 121 DEVICE 25G 120 RELION ULTRA THIN PLUS RIGHTEST GL300 120 RELION 2-IN-1 LANCING LANCETS 33G LANCETS 121 DEVICE 30G 120 REMEDY ANTIMICROBIAL CLEANSER 52 riluzole 234 RELION ALCOHOL rimantadine hydrochloride 58 SWABS 124 REMICADE 90 RELION INSULIN SYRINGE RENAPLEX-D 219 ringer's 202 0.5ML/31G X 15/64" 167 RENFLEXIS 90 RISACAL-D 200 RELION INSULIN SYRINGE REPLACEMENT AIR risedronate sodium 86 1ML/31GX15/64" 167 FILTER 195 RISPERDAL 48 RELION INSULIN SYRINGE/U- REPLACEMENT 100/0.3ML/31G X 15/64" 167 FILTERS 195 RISPERDAL CONSTA 48 RELION INSULIN SYRINGE/U- risperidone 48 100/0.3ML/31G X 5/16" 167 REQ 49+ 219 RELION INSULIN SYRINGE/U- RESCRIPTOR 56 RITEFLO 195 100/0.5ML/29G X 1/2" 167 RESTASIS 240 ritonavir 56 RELION INSULIN SYRINGE/U- RESTASIS MULTIDOSE 240 RITUXAN 43 100/0.5ML/31G X 5/16" 167 RITUXAN HYCELA 45 RELION INSULIN SYRINGE/U- RESTORE CONTACT 100/1ML/31G X 15/64" 167 LAYER/NON-ADHERENT rivastigmine 244 RELION INSULIN SYRINGE/U- 2"X2" 109 rivastigmine tartrate 244 RESTORE FOAM DRESSING 100/1ML/31G X 5/16" 167 RIXUBIS 92 RELION KETONE TEST BORDERED 4"X4" 109 STRIPS 85 RESTORE FOAM DRESSING rizatriptan benzoate 197 RELION LANCETS MICRO- NON-BORDERED 4"X4" 109 ropinirole hydrochloride 47 RESTORE ODOR THIN33G 120 82 ABSORBING DRESSING rosadan RELION LANCETS THIN rosuvastatin calcium 39 26G 120 4"X4" 109 RELION LANCETS ULTRA- RESTORE TRIO ABSORBENT roweepra 23 THIN30G 120 DRESSING 3"X3" 109 roweepra xr 23 RELION LANCING RETACRIT 94 RUBRACA 46 DEVICE 120 REVLIMID 203 rufinamide 24 RELION MINI PEN NEEDLES REXALL LANCETS ULTRA 31GX6MM 167 THIN 120 ryclora 33 RELION PEN NEEDLES REXULTI 49 RYDAPT 46 29GX12MM 167
Index 39 RYMED 68 SAFETY SEAL LANCETS SB INSULIN SYRINGE/U- rynex pse 65 30G 121 100/0.5ML/30G X 5/16" 169 SAFETY SYRINGES/NEEDLE SB INSULIN SYRINGE/U- SAFESNAP INSULIN 3ML/20GX1" 169 100/1ML/29G X 1/2" 169 SYRINGE/0.3ML/30G X SAFETY SYRINGES/NEEDLE SB INSULIN SYRINGE/U- 5/16" 168 3ML/20GX1-1/2" 169 100/1ML/30G X 5/16" 169 SAFESNAP INSULIN SAFETY SYRINGES/NEEDLE SB INSULIN SYRINGE/U- SYRINGE/0.5ML/29G X 3ML/21GX1" 169 100/1ML/31G X 5/16" 170 1/2" 168 SAFETY SYRINGES/NEEDLE SAFESNAP INSULIN SB LANCETS THIN 121 3ML/21GX1-1/2" 169 SB LANCETS ULTRA SYRINGE/0.5ML/30G X SAFETY SYRINGES/NEEDLE 5/16" 168 THIN 121 3ML/22GX1" 169 sb lice treatment 83 SAFESNAP INSULIN SAFETY SYRINGES/NEEDLE SYRINGE/1ML/28G X 1/2" 168 3ML/22GX1-1/2" 169 sb triple antibiotic 71 SAFESNAP INSULIN SAFETY SYRINGES/NEEDLE SCHOOLTIME SHAMPOO 83 SYRINGE/1ML/29G X 1/2" 168 3ML/23GX1" 169 SE-NATAL 19 229 SAFESNAP SAFETY SYRINGES/NEEDLE SYRINGE/NEEDLE/3ML/20G X 3ML/25GX5/8" 169 SECUADO 49 1" 168 SAFETY-LOK SECURESAFE SAFETY SAFESNAP SYRINGE/NEEDLE3ML LUER- INSULIN SYRINGES/U- SYRINGE/NEEDLE/3ML/20G X LOK 21GX1-1/2" 169 100/0.5ML/29GX1/2" 170 1-1/2" 168 SAFETY-LOK SECURESAFE SAFETY SAFESNAP SYRINGE/NEEDLE3ML LUER- INSULIN SYRINGES/U- SYRINGE/NEEDLE/3ML/21G X LOK 22GX1" 169 100/1ML/29GX1/2" 170 1" 168 SAFETY-LOK SECURESAFE SAFETY PEN SAFESNAP SYRINGE/NEEDLE3ML LUER- NEEDLES/30G X 5/16" 170 SYRINGE/NEEDLE/3ML/21G X LOK 22GX1-1/2" 169 SECURESAFE 1-1/2" 168 SAFETY-LOK SYRINGE/NEEDLE/3ML/20G X SAFESNAP SYRINGE/NEEDLE3ML LUER- 1" 170 SYRINGE/NEEDLE/3ML/22G X LOK 23GX1" 169 SECURESAFE 1" 168 SAFETY-LOK SYRINGE/NEEDLE/3ML/20G X SAFESNAP SYRINGE/NEEDLE3ML LUER- 1-1/2" 170 SYRINGE/NEEDLE/3ML/22G X LOK 25GX5/8" 169 SECURESAFE 1-1/2" 168 salicylic acid 80 SYRINGE/NEEDLE/3ML/21G X SAFESNAP 1" 170 SYRINGE/NEEDLE/3ML/23G X saline 231 SECURESAFE 1" 168 salsalate 11 SYRINGE/NEEDLE/3ML/21G X SAFESNAP SAMI THE SEAL 1-1/2" 170 SYRINGE/NEEDLE/3ML/23G X REPLACEMENTFILTERS 19 SECURESAFE 1-1/2" 168 6 SYRINGE/NEEDLE/3ML/22G X SAFESNAP SANDIMMUNE 203,204 1" 170 SYRINGE/NEEDLE/3ML/25G X SECURESAFE 1" 168 SANTYL 80 SYRINGE/NEEDLE/3ML/22G X SAFESNAP SAPHRIS 49 1-1/2" 170 SYRINGE/NEEDLE/3ML/25G X sapropterin SECURESAFE 5/8" 168 dihydrochloride 87 SYRINGE/NEEDLE/3ML/23G X SAFETY INSULIN SYRINGES SAPS HEALTH TWIST TOP 1" 170 0.5ML/29GX1/2" 168 LANCETS 30G 121 SECURESAFE SAFETY INSULIN SYRINGES SAVELLA 244 SYRINGE/NEEDLE/3ML/25G X 0.5ML/30GX5/16" 168 SAVELLA TITRATION 5/8" 170 SAFETY INSULIN SYRINGES PACK 244 SEGLUROMET 27 1ML/27GX1/2" 169 SAXENDA 1 SELECT-LITE SAFETY INSULIN SYRINGES SB ALCOHOL PREP DEVICE/LANCETS 121 1ML/29GX1/2" 169 SELECT-LITE LANCING SAFETY INSULIN SYRINGES PADS 124 sb gas relief 89 DEVICE 121 1ML/30GX1/2" 169 selegiline hcl 47 SAFETY LANCETS 28G 121 sb hemorrhoid 14 SAFETY SEAL LANCETS SB INSULIN SYRINGE/U- selenium sulfide 74 28G 121 100/0.5ML/29G X 1/2" 169 SELZENTRY 56
Index 40 sennosides 101 SIDEROL 219 SM FOAMING ANTACID 16 sennosides-docusate SIDESTREAM ADULT FACE sm gas relief 89 sodium 99 MASK 196 SM GAUZE PADS 2"X2" 109 sentry 212 SIDESTREAM PEDIATRIC SM GAUZE PADS 3"X3" 109 SENTRY 219 FACEMASK 196 SIDESTREAM PEDIATRIC SM GAUZE PADS 4"X4" 109 sentry senior 211 FACEMASK/SAMI THE SM GLUCOSE 27 SENTRY SENIOR 219 SEAL 196 sm hydrocortisone 77 SENTRY SENIOR/LUTEIN 219 SIDESTREAM PEDIATRIC FACEMASK/TUCKER THE SM IODIDES TINCTURE 54 SEREVENT DISKUS 22 TURTLE 196 SM IODINE TINCTURE 54 SEROQUEL 49 SIDESTREAM PLUS ADULT SM MICRO THIN LANCETS SEROQUEL XR 49 FACE MASK 196 33G 121 sertraline hcl 25 SILICONE MASK FOR SM ONE DAILY MENS 219 BREATHERITE SM ONE DAILY SEVENFACT 92 CHAMBER/ADULT 196 SFROWASA 90 SILICONE MASK FOR PRENATAL 229 SM ONE DAILY WOMENS 219 SHINGRIX 257 BREATHERITE SHOPKO ALCOHOL CHAMBER/INFANT 196 SM PRENATAL VITAMINS 229 SWABS 124 SILICONE MASK FOR SM STERILE PADS 109 SHOPKO AUTOLET LANCING BREATHERITE SM STERILE PADS 2"X2" 109 DEVICE 121 CHAMBER/PEDIATRIC 196 SILICONE MASK FOR SM TRUEDRAW LANCING SHOPKO UNIFINE PENTIPS DEVICE 121 PEN BREATHRITE CHAMBER/ADULT 196 sm vitamin d3 maximum NEEDLES/MICRO/32GX4MM strength 260 170 silver sulfadiazine 74 SMART DIABETES VANTAGE SHOPKO UNIFINE PENTIPS simethicone 89 LANCING DEVICE 121 PEN NEEDLES/MINI/31GX5MM SIMILAC PRENATAL EARLY SMART SENSE COLOR 170 SHIELD 229 LANCETS UNIVERSAL SHOPKO UNIFINE PENTIPS SIMPLE DIAGNOSTICS 33G 121 PEN LANCING DEVICE 121 SMART SENSE STANDARD NEEDLES/ORIGINAL/29GX12M simply saline baby 68 LANCETS UNIVERSAL M 170 SIMPLYTHICK 243 21G 121 SHOPKO UNIFINE PENTIPS SMART SENSE SUPER THIN PEN SIMPLYTHICK EASY LANCETS UNIVERSAL 243 NEEDLES/SHORT/31GX8MM MIX 30G 121 170 SIMPLYTHICK EASYMIX 243 SMART SENSE THIN SHOPKO UNIFINE PENTIPS SIMPONI ARIA 2 LANCETSUNIVERSAL PLUS PEN simvastatin 39 26G 121 NEEDLES/MICRO/REMOVR/32 sirolimus 204 sodium bicarbonate GX4MM 170 (antacid) 16 SHOPKO UNIFINE PENTIPS SIVEXTRO 19 sodium chloride 203 PLUS PEN slow release iron 94 sodium chloride (gu irrigant) 90 NEEDLES/MINI/REMOVER/31G SM ADHESIVE PADS X5MM 170 2"X3" 109 sodium chloride (inhalant) 68 SHOPKO UNIFINE PENTIPS SM ADHESIVE PADS sodium chloride hypertonic 241 PLUS PEN 3"X4" 109 sodium citrate & citric acid 90 NEEDLES/REMOVER/29GX12M SM ALCOHOL PREP sodium fluoride 202 M 171 PADS 124 SHOPKO UNIFINE PENTIPS SM CALAMINE 82 sodium fluoride (dental) 204 PLUS PEN SM CALAMINE sodium phosphates 100 NEEDLES/SHORT/REMOVR/31 PHENOLATED 82 sodium polystyrene GX8MM 171 sm cold & allergy childrens 65 sulfonate 204 SHOPKO UNILET LANCETS sodium sulfacetamide wash 74 121 sm fiber 97 SUPER THIN 30G SODIUM SHOPKO UNILET LANCETS SM FIBER POWDER 98 ULTRA THIN 28G 121 SULFACETAMIDE/SULFUR sm fish oil 235 70 SHUR-SEAL 258
Index 41 SOF-SET ADHESIVE STERILE PADS 4"X4" 110 SURE COMFORT INSULIN PATCH 109 STIMATE 87 SYRINGE/U-100/0.3ML/31G X SOF-WICK 4"X4" 109 5/16 171 STIOLTO RESPIMAT 22 SOFIA SARS ANTIGEN FIA 85 SURE COMFORT INSULIN STIVARGA 46 SYRINGE/U-100/0.3ML/31G X SOFIA2 SARS ANTIGEN stress formula 212,222 5/16" 171 FIA 85 SURE COMFORT INSULIN sofosbuvir-velpatasvir 58 stress formula/iron 206,212 SYRINGE/U- SOLIQUA 100/33 27 STRIBILD 57 100/0.3ML/31GX1/4" 171 SOLIRIS 93 STRIVERDI RESPIMAT 22 SURE COMFORT INSULIN SOLO 219 STROVITE ONE 219 SYRINGE/U-100/0.5ML/28G X 1/2" 171 soluble fiber 96 STUART ONE 229 SURE COMFORT INSULIN SOLUS V2 LANCING SUBLOCADE 14 SYRINGE/U-100/0.5ML/29G X DEVICE 121 SUBOXONE 14 1/2" 171 soothe 30 subvenite 23 SURE COMFORT INSULIN SOOTHENEB NBL 100 CHILD SYRINGE/U-100/0.5ML/30G X MASK 196 sucralfate 252 1/2" 171 SOOTHENEB NBL 100 SUDAFED CHILDRENS 234 SURE COMFORT INSULIN MEDICATION CUP 196 SUDAFED PE CHILDRENS SYRINGE/U-100/0.5ML/30G X SOOTHENEB NBL 100 MESH NASAL 5/16" 171 CAP 196 DECONGESTANT 234 SURE COMFORT INSULIN SOOTHENEB NBL100 ADULT sulconazole nitrate 73 SYRINGE/U-100/0.5ML/31G X MASK 196 sulfacetamide sod- 5/16 171 SORBITOL 99 prednisolone 240 SURE COMFORT INSULIN sorine 59 SYRINGE/U-100/1ML/28G X sulfacetamide sodium 74 1/2" 171 sotalol hcl 59 sulfacetamide sodium SURE COMFORT INSULIN sotalol hcl (afib/afl) 59 (acne) 70 SYRINGE/U-100/1ML/29G X sulfacetamide sodium SOTYLIZE 59 1/2" 171 (ophth) 239 SURE COMFORT INSULIN SPECTRAVITE 219 sulfacetamide sodium w/ SYRINGE/U-100/1ML/30G X spinosad 83 sulfur 70 1/2" 171 SPINRAZA 234 SULFADIAZINE 247 SURE COMFORT INSULIN sulfamethoxazole-trimethoprim SPIRIVA HANDIHALER 20 SYRINGE/U-100/1ML/30G X 18 5/16" 171 SPIRIVA RESPIMAT 20 SULFAMYLON 74 SURE COMFORT INSULIN spironolactone 85 sulfasalazine 90 SYRINGE/U-100/1ML/31G X 5/16" 171 spironolactone & sulfatrim pediatric 18 hydrochlorothiazide 85 SURE COMFORT INSULIN SPRYCEL 46 sulindac 6 SYRINGES/0.5ML/31G X ssd 74 sumatriptan 197 6MM 172 sumatriptan succinate 197 SURE COMFORT INSULIN STAMARIL 257 SYRINGES/U- stavudine 56 sunitinib malate 46 100/1ML/31GX6MM 172 STAVUDINE 56 super b with c 205 SURE COMFORT LANCETS SUPER THIN LANCETS 121 18G 121 STEGLATRO 29 SURE COMFORT LANCETS STELARA 74 SUPPRELIN LA 86 21G 121 SURE COMFORT INSULIN STERILANCE PA 121 SURE COMFORT LANCETS SYRINGE/U-100/0.3ML/29G X 23G 121 STERILANCE TL 121 1/2" 171 SURE COMFORT LANCETS STERILE GAUZE PADS SURE COMFORT INSULIN 30G 121 2"X2" 110 SYRINGE/U-100/0.3ML/30G X SURE COMFORT LANCING STERILE GAUZE PADS 1/2" 171 PEN 122 3"X3" 110 SURE COMFORT INSULIN SURE COMFORT PEN STERILE PADS 2"X2" 110 SYRINGE/U-100/0.3ML/30G X NEEDLES29GX1/2" STERILE PADS 3"X3" 110 5/16" 171 12.7MM 172
Index 42 SURE COMFORT PEN SYMAX DUOTAB 249 SYSTANE ICAPS AREDS2 220 NEEDLES30GX5/16" SYMBYAX 244 T-VITES 220 SHORT 172 SURE COMFORT PEN SYMDEKO 247 TAB-A-VITE NEEDLES31GX3/16" SYMFI 57 MULTIVITAMIN/IRON AND BETA-CAROTENE 206 (5MM) 172 SYMFI LO 57 SURE COMFORT PEN TABLOID 42 NEEDLES31GX5/16" SYMLINPEN 120 26 tacrolimus 204 (8MM) 172 SYMLINPEN 60 26 tadalafil (pulmonary SURE COMFORT PEN SYMTUZA 57 hypertension) 60 NEEDLES32GX5/32" 172 SYNAGIS 242 TAFINLAR 46 SURE COMFORT PEN NEEDLES32GX6MM 172 SYNAREL 86 TAGRISSO 43 SURE-FINE PEN NEEDLES SYNJARDY 27 TALTZ 74 29GX1/2" 12.7MM 172 SYNJARDY XR 27 TAMIFLU 58 SURE-FINE PEN NEEDLES tamoxifen citrate 44 31GX3/16" 5MM 172 SYNTHAMIN 17 237 SURE-FINE PEN NEEDLES SYNTHROID 248 tamsulosin hcl 91 31GX5/16" 8MM 172 SYRINGE/LUER TARON-BC 229 SURE-JECT INSULIN LOCK/3ML/20G X 1" 173 TASIGNA 46 SYRINGE/U-100/0.3ML/29G X SYRINGE/LUER 1/2" 172 LOCK/3ML/20G X 1-1/2" 173 tazarotene 74 SURE-JECT INSULIN SYRINGE/LUER TAZORAC 74 SYRINGE/U-100/0.3ML/30G X LOCK/3ML/20GX1-1/2" 173 taztia xt 59 5/16" 172 SYRINGE/LUER TDVAX 249 SURE-JECT INSULIN LOCK/3ML/21G X 1" 173 SYRINGE/U-100/0.3ML/31G X SYRINGE/LUER tears again 237 5/16" 172 LOCK/3ML/21G X 1-1/2" 173 TECHLITE AST LANCETS 122 SURE-JECT INSULIN SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.5ML/28G X LOCK/3ML/21GX1" 173 100/0.3ML/29G X 1/2" 174 1/2" 172 SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SURE-JECT INSULIN LOCK/3ML/21GX1-1/2" 173 100/0.3ML/30G X 1/2" 174 SYRINGE/U-100/0.5ML/29G X SYRINGE/LUER TECHLITE INSULIN SYRINGEU- 1/2" 172 LOCK/3ML/22G X 1" 173 100/0.3ML/30G X 5/16" 174 SURE-JECT INSULIN SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.5ML/30G X LOCK/3ML/22G X 1-1/2" 173 100/0.3ML/31G X 15/64" 174 5/16" 172 SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SURE-JECT INSULIN LOCK/3ML/22GX1" 173 100/0.3ML/31G X 5/16" 174 SYRINGE/U-100/0.5ML/31G X SYRINGE/LUER TECHLITE INSULIN SYRINGEU- 5/16" 172 LOCK/3ML/22GX1-1/2" 173 100/0.5ML/29G X 1/2" 174 SURE-JECT INSULIN SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/1ML/28G X LOCK/3ML/23G X 1" 173 100/0.5ML/30G X 1/2" 174 1/2" 172 SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SURE-JECT INSULIN LOCK/3ML/23G X 1-1/2" 173 100/0.5ML/30G X 5/16" 174 SYRINGE/U-100/1ML/29G X SYRINGE/LUER TECHLITE INSULIN SYRINGEU- 1/2" 172 LOCK/3ML/23GX1" 173 100/0.5ML/31G X 15/64" 174 SURE-JECT INSULIN SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/1ML/30G X LOCK/3ML/25G X 1" 173 100/0.5ML/31G X 5/16" 174 5/16" 173 SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SURE-JECT INSULIN LOCK/3ML/25G X 1-1/2" 173 100/1ML/29G X 1/2" 174 SYRINGE/U-100/1ML/31G X SYRINGE/LUER TECHLITE INSULIN SYRINGEU- 5/16" 173 LOCK/3ML/25G X 5/8" 173 100/1ML/30G X 1/2" 174 SYRINGE/LUER SURE-PEN 122 TECHLITE INSULIN SYRINGEU- LOCK/3ML/25GX1" 173 100/1ML/30G X 5/16" 174 SURELITE LANCETS 122 SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SURGICAL GAUZE LOCK/3ML/25GX5/8" 173 100/1ML/31G X 15/64" 174 SPONGE 110 SYRINGES/LUER TECHLITE INSULIN SYRINGEU- SUSTIVA 57 LOCK/1ML/20GX1" 173 100/1ML/31G X 5/16" 174 SYLATRON 46 TECHLITE LANCETS 122
Index 43 TECHLITE LANCETS 30G 122 TETANUS/DIPHTHERIA tiagabine hcl 24 TECHLITE PEN NEEDLES 29GX TOXOIDS-ADSORBED TIBSOVO 46 ADULT 249 10MM 174 tilia fe 62 TECHLITE PEN NEEDLES 29GX tetrabenazine 244 12 MM 174 tetracaine hcl (ophth) 240 timolol maleate 59 TECHLITE PEN NEEDLES 31GX tetracycline hcl 248 timolol maleate (ophth) 238 5MM 174 timolol maleate in ocudose 238 TECHLITE PEN NEEDLES/31GX TGT ALCOHOL SWABS 125 5MM 174 tgt allergy+ congestion relief- TIMOPTIC OCUDOSE 238 TECHLITE PEN NEEDLES/31GX d 65 TIMOPTIC-XE 238 6 MM 174 TGT LANCET MICRO THIN tiopronin 91 33G 122 TECHLITE PEN NEEDLES/31GX TIVICAY 57 8MM 175 TGT LANCET THIN 26G 122 TECHLITE PEN NEEDLES/32GX TGT LANCET ULTRA THIN TIVICAY PD 57 4MM 175 30G 122 tizanidine hcl 230 TECHLITE PEN NEEDLES/32GX TGT LANCING DEVICE 122 TL FOLATE 229 6MM 175 TECHLITE PEN NEEDLES/32GX THEO-24 22 TOBI PODHALER 2 8MM 175 theophylline 22 TOBRADEX 241 TEGADERM CHG DRESSING/2- thera 222 tobramycin 2 3/4"X3-3/8" 52 TEGADERM CHG DRESSING/3- THERA 223 tobramycin (ophth) 239 1/2"X4-1/2" 53 THERA M PLUS 220 tobramycin sulfate 2 TEGADERM CHG thera-m 212 tobramycin- DRESSING/4"X4-3/4" 53 THERA-M 220 dexamethasone 241 TEGADERM CHG TOBREX 239 DRESSING/4"X6-1/8" 53 THERA-TABS M 220 THERABETIC MULTI- TODAY SPONGE 258 TEGADERM FOAM DRESSING TODAYS HEALTH ADVANCED 2"X2" 110 VITAMIN 220 THERAGAUZE 110 LANCING DEVICE 122 TEGADERM FOAM DRESSING TODAYS HEALTH MINI PEN 4"X4" 110 THERAGRAN-M 220 NEEDLES 31G X 1/4" 175 TEGRETOL 24 THERAGRAN-M TODAYS HEALTH ORIGINAL TEGRETOL-XR 24 ADVANCED 220 PEN NEEDLES 29G X 1/2" 175 telmisartan 40 THERAGRAN-M ADVANCED TODAYS HEALTH SHORT PEN 50 PLUS 220 NEEDLES 31G X 5/16" 175 telmisartan-amlodipine 41 THERAGRAN-M TODAYS HEALTH SUPER telmisartan-hydrochlorothiazide PREMIER 220 THINLANCETS 30G 122 41 THERAGRAN-M PREMIER 50 TODAYS HEALTH ULTRA temazepam 96 PLUS 220 THINLANCETS 28G 122 TEMIXYS 57 THERANATAL tolbutamide 29 COMPLETE 229 temozolomide 42 THERANATAL CORE tolmetin sodium 6 tencon 7 NUTRITION 229 tolnaftate 73 TENIVAC 249 THEREMS tolterodine tartrate 253 tenofovir disoproxil fumarate 57 MULTIVITAMIN 223 tolvaptan 87 THEREMS-H 220 terazosin hcl 40 TOPCARE CLICKFINE THEREMS-M 220 terbinafine hcl 32 UNIVERSAL PEN EEDLES thiamine hcl 262 31GX1/4" 175 terbinafine hcl (topical) 73 thiamine mononitrate 262 TOPCARE CLICKFINE terbutaline sulfate 22 UNIVERSAL PEN EEDLES THINLETS GP LANCETS122 terconazole vaginal 259 31GX5/16" 175 thioridazine hcl 49 testosterone 14 TOPCARE LANCETS MICRO- thiothixene 49 THIN 33G 122 testosterone cypionate 14 TOPCARE ULTRA COMFORT TESTOSTERONE THRESHOLD IMT 196 INSULIN SYRINGE/0.3ML/30G X CYPIONATE 14 THRIVITE 19 220 5/16" 175 testosterone cypionate 14 THRIVITE RX 229 thyroid 248
Index 44 TOPCARE ULTRA COMFORT tri-vite/fluoride 223 TRUE COMFORT PRO INSULIN SYRINGE/0.3ML/31G X triamcinolone acetonide INSULINSYRINGE/U- 5/16" 175 (mouth) 204 100/1ML/30G X 1/2" 176 TOPCARE ULTRA COMFORT triamcinolone acetonide TRUE COMFORT PRO PEN INSULIN SYRINGE/0.5ML/30G X (nasal) 232 NEEDLES 31G X 5MM 176 5/16" 175 triamcinolone acetonide TRUE COMFORT PRO PEN TOPCARE ULTRA COMFORT (topical) 79 NEEDLES 31G X 6MM 176 INSULIN SYRINGE/0.5ML/31G X triamterene & TRUE COMFORT PRO PEN 5/16" 175 hydrochlorothiazide 85 NEEDLES 31G X 8MM 176 TOPCARE ULTRA COMFORT triazolam 96 TRUE COMFORT PRO PEN INSULIN SYRINGE/1ML/30G X NEEDLES 32G X 4MM 176 5/16" 175 TRICARE 229 TRUE COMFORT PRO PEN TOPCARE ULTRA COMFORT triclosan 53 NEEDLES 32G X 5MM 176 INSULIN SYRINGE/1ML/31G X triderm 78 TRUE COMFORT PRO PEN NEEDLES 32G X 6MM 176 5/16" 175 trifluoperazine hcl 49 TOPCARE ULTRA COMFORT TRUE COMFORT PRO PEN INSULIN SYRINGE/U- trifluridine 239 NEEDLES 33G X 4MM 176 100/0.3ML/29G X 1/2" 175 TRIGLIDE 39 TRUE COMFORT PRO PEN TOPCARE ULTRA COMFORT trihexyphenidyl hcl 47 NEEDLES 33G X 5MM 176 INSULIN SYRINGE/U- TRUE COMFORT PRO PEN 100/0.5ML/29G X 1/2" 175 trimethobenzamide hcl 32 NEEDLES 33G X 6MM 176 TOPCARE ULTRA COMFORT trimethoprim 18 TRUE METRIX CONTROL INSULIN SYRINGE/U- TRINATAL RX 1 230 SOLUTION LEVEL 1 122 TRUE METRIX CONTROL 100/1ML/29G X 1/2" 175 trinate 224 topiramate 24 SOLUTION LEVEL 2 122 TRIUMEQ 57 TRUE METRIX CONTROL topotecan hcl 47 TRIZIVIR 57 SOLUTION LEVEL 3 122 TOPOTECAN HCL 47 TROGARZO 57 TRUECONTROL GLUCOSE topotecan hcl 47 CONTROL LEVEL 0 122 TROPHAMINE 237 TOPPER DRESSING SPONGES TRUECONTROL GLUCOSE 4"X4" 110 tropicamide 239 CONTROL LEVEL 1 122 trospium chloride 254 TRUEDRAW LANCING toremifene citrate 44 DEVICE 122 torsemide 85 TRUE COMFORT INSULIN SYRINGE/0.5ML/31G X TRUEPLUS 5-BEVEL PEN TRACLEER 60 5/16" 175 NEEDLES 29GX12.7MM 176 TRADJENTA 27 TRUE COMFORT INSULIN TRUEPLUS 5-BEVEL PEN NEEDLES 31GX5MM 176 tramadol hcl 13 SYRINGE/1ML/31G X TRUEPLUS 5-BEVEL PEN tramadol-acetaminophen 13 5/16" 176 TRUE COMFORT PEN NEEDLES 31GX6MM 177 trandolapril 40 TRUEPLUS 5-BEVEL PEN NEEDLES31G X 5MM 176 NEEDLES 31GX8MM 177 trandolapril-verapamil hcl 41 TRUE COMFORT PEN TRUEPLUS 5-BEVEL PEN tranexamic acid 95 NEEDLES31G X 6MM 176 NEEDLES 32GX4MM 177 TRUE COMFORT PEN TRUEPLUS INSULIN tranylcypromine sulfate 25 NEEDLES32G X 4MM 176 TRAVASOL 237 TRUE COMFORT PRO SYRINGE/U-100/0.3ML/29G X 1/2" 177 trazodone hcl 25 INSULINSYRINGE/0.5ML/30G TRUEPLUS INSULIN TRECATOR 42 X 5/16" 176 TRUE COMFORT PRO SYRINGE/U-100/0.3ML/30G X TRELEGY ELLIPTA 22 5/16" 177 INSULINSYRINGE/0.5ML/31G TRUEPLUS INSULIN TRELSTAR MIXJECT 44 X 5/16" 176 TRUE COMFORT PRO SYRINGE/U-100/0.3ML/31G X treprostinil 60 5/16" 177 INSULINSYRINGE/1ML/30G X TRUEPLUS INSULIN tretinoin 70 5/16" 176 tretinoin (chemotherapy) 46 TRUE COMFORT PRO SYRINGE/U-100/0.5ML/28G X 1/2" 177 tretinoin microsphere 70 INSULINSYRINGE/1ML/31G X TRUEPLUS INSULIN TRETTEN 92 5/16" 176 TRUE COMFORT PRO SYRINGE/U-100/0.5ML/29G X TREXALL 42 INSULINSYRINGE/U- 1/2" 177 tri femynor 62 100/0.5ML/30G X 1/2" 176
Index 45 TRUEPLUS INSULIN TRUSTEX ULTICARE INSULIN SYRINGE/U-100/0.5ML/30G X LUBRICATED/SPERMICIDE SYRINGE/0.5ML/30G X 5/16" 177 EXTRA STRENGTH 111 1/2" 178 TRUEPLUS INSULIN TRUSTEX NATURAL ULTICARE INSULIN SYRINGE/U-100/0.5ML/31G X CONDOMS SYRINGE/0.5ML/30G X 5/16" 177 +LUBE/LUBRICATED 111 5/16" 178 TRUEPLUS INSULIN TRUSTEX NON- ULTICARE INSULIN SYRINGE/U-100/1ML/28G X LUBRICATED 111 SYRINGE/1ML/28G X 1/2" 178 1/2" 177 TRUSTEX WITH ULTICARE INSULIN TRUEPLUS INSULIN NONOXYNOL- SYRINGE/1ML/29G X 1/2" 178 SYRINGE/U-100/1ML/29G X 9/RIBBED/STUDDED 112 ULTICARE INSULIN 1/2" 177 TRUSTEX/RIA SYRINGE/1ML/30G X 1/2" 178 TRUEPLUS INSULIN LUBRICATED 112 ULTICARE INSULIN SYRINGE/U-100/1ML/30G X TRUSTEX/RIA LUBRICATED SYRINGE/1ML/30G X 5/16" 177 SPERMICIDE 112 5/16" 178 TRUEPLUS INSULIN TRUSTEX/RIA ULTICARE INSULIN SYRINGE/U-100/1ML/31G X LUBRICATED/SPERMICIDE SYRINGE/SHORT/0.3ML/30G X 5/16" 177 112 5/16" 178 TRUEPLUS LANCETS TRUSTEX/RIA NON- ULTICARE INSULIN 26G 122 LUBRICATED 112 SYRINGE/SHORT/0.3ML/31G X TRUEPLUS LANCETS TRUVADA 57 5/16" 178 28G 122 TRUZONE PEAK FLOW ULTICARE INSULIN TRUEPLUS LANCETS 28G METER 196 SYRINGE/SHORT/0.5ML/30G X SUPER THIN 122 TUBING/WING TIP 196 5/16" 178 TRUEPLUS LANCETS ULTICARE INSULIN 30G 122 TUDORZA PRESSAIR 20 SYRINGE/SHORT/0.5ML/31G X TRUEPLUS LANCETS 30G TWINRIX 257 5/16" 178 ULTRA THIN 122 TYBLUME 63 ULTICARE INSULIN TRUEPLUS LANCETS TYBOST 57 SYRINGE/SHORT/1ML/30G X 33G 122 5/16" 178 TRUEPLUS PEN NEEDLES TYPHIM VI 254 ULTICARE INSULIN 29GX12MM 177 TYSABRI 245 SYRINGE/SHORT/1ML/31G X TRUEPLUS PEN NEEDLES UDAMIN SP 220 5/16" 178 31GX5MM 177 ULTI-LANCE AUTOMATIC/ ULTICARE INSULIN TRUEPLUS PEN NEEDLES SYRINGE/U-100/0.3ML/30G X 31GX6MM 177 CLEAR TIP 122 ULTICARE ALCOHOL 1/2" 178 TRUEPLUS PEN NEEDLES ULTICARE INSULIN 31GX8MM 177 SWABS 125 ULTICARE INSULIN SAFETY SYRINGE/U-100/0.3ML/31G X TRUEPLUS PEN NEEDLES 5/16" 179 32GX4MM 177 SYRINGE/0.5ML/29G X 1/2" 178 ULTICARE INSULIN TRULICITY 28 ULTICARE INSULIN SAFETY SYRINGE/U-100/0.5ML/30G X TRUMENBA 254 SYRINGE/1ML/29G X 1/2" 179 TRUSTEX COLOR CONDOMS + 1/2" 178 ULTICARE INSULIN LUBE 111 ULTICARE INSULIN SYRINGE/U-100/0.5ML/31G X TRUSTEX LUBRICATED 111 SYRINGE/0.3ML/29G X 5/16" 179 1/2" 178 ULTICARE INSULIN TRUSTEX LUBRICATED SYRINGE/U-100/1ML/30G X EXTRALARGE 111 ULTICARE INSULIN SYRINGE/0.3ML/30G X 1/2" 179 TRUSTEX LUBRICATED ULTICARE INSULIN EXTRASTRENGTH 111 1/2" 178 ULTICARE INSULIN SYRINGE/U-100/1ML/31G X TRUSTEX 5/16" 179 LUBRICATED/RIBBED/STUDDE SYRINGE/0.3ML/30G X 5/16" 178 ULTICARE INSULIN D 111 SYRINGEULTRAFINE U- TRUSTEX ULTICARE INSULIN SYRINGE/0.5ML/28G X 100/0.3ML/31G X 5/16" 179 LUBRICATED/SPERMICIDE ULTICARE INSULIN 111 1/2" 178 ULTICARE INSULIN SYRINGEULTRAFINE U- TRUSTEX 100/0.5ML/31G X 5/16" 179 LUBRICATED/SPERMICIDE SYRINGE/0.5ML/29G X EXTRA LARGE 111 1/2" 178
Index 46 ULTICARE INSULIN ULTIGUARD SAFEPACK ULTILET INSULIN SYRINGEULTRAFINE U- INSULIN SYRINGE 0.3ML/30G SYRINGE/0.3ML/31G X 100/1ML/31G X 5/16" 179 X 1/2"/SHARPS C 180 8MM 181 ULTICARE MICRO PEN ULTIGUARD SAFEPACK ULTILET INSULIN NEEDLES 31G X 8MM 179 INSULIN SYRINGE 1/2ML 30G SYRINGE/0.5ML/30G X ULTICARE MICRO PEN X 1/2"/SHARPS C 180 8MM 181 NEEDLES 32G X 4MM 179 ULTIGUARD SAFEPACK ULTILET INSULIN ULTICARE MICRO PEN INSULIN SYRINGE 1ML 30G X SYRINGE/1ML/30G X 8MM181 NEEDLES/31G X 1/4" 179 1/2"/SHARPS CON 180 ULTILET INSULIN ULTICARE MICRO PEN ULTIGUARD SAFEPACK SYRINGE/1ML/31G X 8MM181 NEEDLES/31G X 5/16" 179 INSULIN SYRINGE 1ML 31G X ULTILET INSULIN ULTICARE MICRO PEN 5/16"/SHARPS CO 180 SYRINGE/SHORT/0.3ML/30G X NEEDLES/32G X 4MM 179 ULTIGUARD SAFEPACK 12.7MM 181 ULTICARE MICRO PEN INSULIN SYRINGE/0.3ML/30G ULTILET INSULIN NEEDLES/32G X 5/32" 179 X 1/2"/SHARPS C 180 SYRINGE/SHORT/0.3ML/30G X ULTICARE MINI PEN NEEDLES ULTIGUARD SAFEPACK 5/16" 181 31GX6MM 179 INSULIN SYRINGE/0.3ML/31G ULTILET INSULIN ULTICARE MINI PEN NEEDLES X 5/16"/SHARPS 180 SYRINGE/SHORT/0.3ML/31G X ULTI-FINE IV 179 ULTIGUARD SAFEPACK 5/16" 181 ULTICARE MINI PEN INSULIN SYRINGE/0.5ML/30G ULTILET INSULIN NEEDLES/31G X 6MM 179 X 1/2"/SHARPS C 180 SYRINGE/SHORT/0.5ML/30G X ULTICARE MINI PEN ULTIGUARD SAFEPACK MINI 5/16" 181 NEEDLES/32G X 1/4" 179 PEN NEEDLE/31G X ULTILET INSULIN ULTICARE MINI PEN 3/16"/SHARPS CONTAI 180 SYRINGE/SHORT/0.5ML/31G X NEEDLES31GX6MM 179 ULTIGUARD SAFEPACK PEN 5/16" 182 ULTICARE MINI SAFETY NEEDLE/29G X 1/2"/SHARPS ULTILET INSULIN PENNEEDLES 30G X CONTAINER 181 SYRINGE/SHORT/1ML/30G X 3/16" 179 ULTIGUARD 5/16" 182 ULTICARE ORIGINAL PEN SAFEPACK/MICROPEN ULTILET INSULIN NEEDLES ULTI-FINE 179 NEEDLE/32G X 5/32" 181 SYRINGE/SHORT/1ML/31G X ULTICARE PEN NEEDLES ULTIGUARD 5/16" 182 31GX 5MM/MINI 180 SAFEPACK/MICROPEN ULTILET INSULIN SYRINGE/U- ULTICARE PEN NEEDLE/32G X 5/32"/SHARPS 100/0.5ML/30G X 1/2" 182 NEEDLES/29GX 12.7MM 180 CONTA 181 ULTILET INSULIN SYRINGE/U- ULTICARE SHORT PEN ULTIGUARD SAFEPACK/MINI 100/0.5ML/31GX6MM 182 NEEDLES 31GX8MM 180 PEN NEEDLE/31G X ULTILET INSULIN SYRINGE/U- ULTICARE SHORT PEN 1/4"/SHARPS CONTAIN 181 100/1ML/30G X 1/2" 182 NEEDLES ULTI-FINE IV 180 ULTIGUARD SAFEPACK/MINI ULTILET PEN NEEDLE ULTICARE SHORT PEN PEN NEEDLE/31G X 29GX12.7MM 182 NEEDLES/31G X 8MM 180 3/16"/SHARPS CONTAI 181 ULTILET PEN NEEDLE ULTICARE SHORT SAFETY ULTIGUARD SAFEPACK/MINI 31GX5MM 182 PEN NEEDLES 30G X PEN NEEDLE/32G X ULTILET PEN NEEDLE 5/16" 180 1/4"/SHARPS CONTAIN 181 31GX8MM 182 ULTICARE SYRINGE/LOW ULTIGUARD ULTILET PEN NEEDLE DEADSPACE/3ML/22G X1- SAFEPACK/SHORTPEN 32GX4MM 182 1/2" 180 NEEDLE/31G X 5/16"/SHARPS ULTILET PEN NEEDLE ULTICARE U-100 INSULIN CONTA 181 32GX4MM/SHORT 182 SYRINGES/0.3ML/31G X ULTIGUARD ULTILET SHORT PEN 1/4" 180 SAFEPACK/SYRINGE/NEEDL NEEDLES 31GX5/16" 182 ULTICARE U-100 INSULIN E/31G X 5/16"/SHARPS ULTILET SHORT PEN SYRINGES/0.3ML/31G CONTAIN 181 NEEDLES31GX3/16" 182 X1/4" 180 ULTILET CLASSIC ULTILET U-100 INSULIN ULTICARE U-100 INSULIN LANCETS 122 SYRINGES/1ML/31G X SYRINGES/0.5ML/31G X ULTILET INSULIN SYRINGE 6MM 182 1/4" 180 31X6MM 181 ULTRA COMFORT INSULIN ULTICARE U-100 INSULIN ULTILET INSULIN SYRINGE/U-100/0.3ML/30G X SYRINGES/1ML/31G X SYRINGE/0.3ML/30G X 5/16" 182 1/4" 180 8MM 181 ULTRA FLO INSULIN PEN NEEDLE 31GX5MM 182
Index 47 ULTRA FLO INSULIN PEN ULTRA-COMFORT INSULIN ULTRACARE INSULIN NEEDLE 32GX4MM 182 SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/0.5ML/30G X ULTRA FLO INSULIN PEN 5/16" 183 5/16" 184 NEEDLE 33GX4MM 182 ULTRA-COMFORT INSULIN ULTRACARE INSULIN ULTRA FLO INSULIN PEN SYRINGE/U-100/0.5ML/31G X SYRINGE/U-100/0.5ML/31G X NEEDLES 182 5/16" 183 5/16" 185 ULTRA FLO INSULIN PEN ULTRA-COMFORT INSULIN ULTRACARE INSULIN NEELE 31GX8MM 182 SYRINGE/U-100/1ML/28G X SYRINGE/U-100/1ML/30G X ULTRA FLO INSULIN SYRINGE 1/2" 184 1/2" 185 0.3ML/29G X 1/2" 182 ULTRA-COMFORT INSULIN ULTRACARE INSULIN ULTRA FLO INSULIN SYRINGE SYRINGE/U-100/1ML/29G X SYRINGE/U-100/1ML/30G X 0.3ML/30GX1/2" 182 1/2" 184 5/16" 185 ULTRA FLO INSULIN SYRINGE ULTRA-COMFORT INSULIN ULTRACARE INSULIN 0.3ML/30GX5/16" 182 SYRINGE/U-100/1ML/30G X SYRINGE/U-100/1ML/31G X ULTRA FLO INSULIN SYRINGE 5/16" 184 5/16" 185 0.3ML/31GX5/16" 182 ULTRA-COMFORT INSULIN ULTRACARE PEN ULTRA FLO INSULIN SYRINGE SYRINGE/U-100/1ML/31G X NEEDLES/31G X 1/4" 185 0.5ML/29GX1/2" 183 5/16" 184 ULTRACARE PEN ULTRA FLO INSULIN SYRINGE ULTRA-THIN II INSULIN NEEDLES/31G X 3/16" 185 0.5ML/30GX1/2" 183 SYRINGE SHORT/U- ULTRACARE PEN ULTRA FLO INSULIN SYRINGE 100/0.3ML/30GX5/16" 184 NEEDLES/31G X 5/16" 185 0.5ML/30GX5/16" 183 ULTRA-THIN II INSULIN ULTRACARE PEN ULTRA FLO INSULIN SYRINGE SYRINGE SHORT/U- NEEDLES/32G X 1/14" 185 0.5ML/31GX5/16" 183 100/0.3ML/31GX5/16" 184 ULTRACARE PEN ULTRA FLO INSULIN SYRINGE ULTRA-THIN II INSULIN NEEDLES/32G X 3/16" 185 1/2 UNIT/0.3ML/30GX1/2" 183 SYRINGE SHORT/U- ULTRACARE PEN ULTRA FLO INSULIN SYRINGE 100/0.5ML/30GX5/16" 184 NEEDLES/32G X 5/32" 185 1/2 UNIT/0.3ML/30GX5/16" ULTRA-THIN II INSULIN ULTRACARE PEN 183 SYRINGE SHORT/U- NEEDLES/33G X 5/32" 185 ULTRA FLO INSULIN SYRINGE 100/0.5ML/31GX5/16" 184 ULTRALANCE 122 1/2 UNIT/0.3ML/31GX5/16" ULTRA-THIN II INSULIN ULTRATHON INSECT 183 SYRINGE SHORT/U- REPELLENT 8 82 ULTRA FLO INSULIN SYRINGE 100/1ML/30GX5/16" 184 UNI-SOLVE 50 1M/29GX1/2" 183 ULTRA-THIN II INSULIN ULTRA FLO INSULIN SYRINGE SYRINGE SHORT/U- UNICOMPLEX-M 220 1ML/30GX1/2" 183 100/1ML/31GX5/16" 184 UNIFIBER 98 ULTRA FLO INSULIN SYRINGE ULTRA-THIN II INSULIN UNIFINE PEN NEEDLE/32G 1ML/30GX5/16" 183 SYRINGE/U- X4MM 185 ULTRA FLO INSULIN SYRINGE 100/0.5ML/29GX1/2" 184 UNIFINE PENTIPS 1ML/31GX5/16" 183 ULTRA-THIN II INSULIN 29GX12MM 185 ULTRA THIN PEN NEEDLES SYRINGE/U- UNIFINE PENTIPS 31G X 32G X 4MM 183 100/1ML/29GX1/2" 184 3/16" 185 ULTRA-COMFORT INSULIN ULTRA-THIN II MINI PEN UNIFINE PENTIPS SYRINGE/U-100/0.3ML/29G X NEEEDLES/31GX3/16" 184 31GX5MM 185 1/2" 183 ULTRA-THIN II PEN NEEDLES UNIFINE PENTIPS ULTRA-COMFORT INSULIN 29GX1/2" 184 31GX6MM 185 SYRINGE/U-100/0.3ML/30G X ULTRA-THIN II PEN UNIFINE PENTIPS 5/16" 183 NEEDLES/SHORT/31GX5/16" 31GX8MM 185 ULTRA-COMFORT INSULIN 184 UNIFINE PENTIPS SYRINGE/U-100/0.3ML/31G X ULTRACARE INSULIN 32GX4MM 185 5/16" 183 SYRINGE/U-100/0.3ML/30G X UNIFINE PENTIPS ULTRA-COMFORT INSULIN 5/16" 184 32GX6MM 185 SYRINGE/U-100/0.5ML/28G X ULTRACARE INSULIN UNIFINE PENTIPS 1/2" 183 SYRINGE/U-100/0.3ML/31G X 33GX4MM 185 ULTRA-COMFORT INSULIN 5/16" 184 UNIFINE PENTIPS PLUS SYRINGE/U-100/0.5ML/29G X ULTRACARE INSULIN 29GX12MM 185 1/2" 183 SYRINGE/U-100/0.5ML/30G X UNIFINE PENTIPS PLUS 1/2" 184 31GX5MM 185
Index 48 UNIFINE PENTIPS PLUS UNIVERSAL 1 LANCETS VANISHPOINT INSULIN 31GX6MM 185 THIN26G 123 SYRINGE/0.5ML/30G X UNIFINE PENTIPS PLUS UNIVERSAL 1 LANCETS 5/16" 186 31GX8MM 185 ULTRA THIN 30G 123 VANISHPOINT INSULIN UNIFINE PENTIPS PLUS UNIVERSAL 1 SYRINGE/1ML/29G X 1/2" 186 32GX4MM 185 LANCETS/33G/MICRO-THIN VANISHPOINT INSULIN UNIFINE PENTIPS PLUS 33GX 123 SYRINGE/1ML/29G X 5/32" 186 urea 80 5/16" 186 UNIFINE PENTIPS PLUS urea-c40 80 VANISHPOINT INSULIN 33GX4MM 186 SYRINGE/1ML/30G X UNIFINE PENTIPS PLUS/30GX ursodiol 89 3/16" 186 3/16" 186 vagisil 77 VANISHPOINT INSULIN UNIFINE PENTIPS/30G X valacyclovir hcl 58 SYRINGE/1ML/30G X 3/16" 186 5/16" 186 UNIFINE SAFECONTROL PEN valganciclovir hcl 57 VANISHPOINT SAFETY NEEDLE/30G X 3/16" 186 valproate sodium 25 SYRINGE/3ML/20GX1" 186 UNIFINE SAFECONTROL PEN valproic acid 25 VANISHPOINT SAFETY NEEDLE/30G X 5/16" 186 valsartan 40 SYRINGE/3ML/20GX1-1/2" UNILET COMFORTOUCH 186 LANCET 122 valsartan-hydrochlorothiazide 41 VANISHPOINT SAFETY UNILET EXCELITE 123 SYRINGE/3ML/21GX1" 186 VALUE HEALTH INSULIN VANISHPOINT SAFETY UNILET EXCELITE II 123 SYRINGE/U-100/0.5ML/29G X SYRINGE/3ML/21GX1-1/2" UNILET G.P. LANCET 123 1/2" 186 186 UNILET G.P. SUPERLITE VALUE HEALTH INSULIN VANISHPOINT SAFETY SYRINGE/U-100/1ML/29G X LANCET 123 SYRINGE/3ML/22GX1" 187 UNILET GP 28 ULTRA 1/2" 186 VANISHPOINT SAFETY VALUE PLUS LANCETS THIN 123 SYRINGE/3ML/22GX1-1/2" UNILET LANCET 123 STANDARD 21G 123 VALUE PLUS LANCETS 187 UNILET LANCETS MICRO- VANISHPOINT SAFETY SUPERTHIN 30G 123 THIN33G 123 VALUE PLUS LANCETS THIN SYRINGE/3ML/23GX1" 187 UNILET LANCETS SUPER- VANISHPOINT SAFETY 123 26G 123 THIN30G VALUE PLUS LANCING SYRINGE/3ML/23GX1-1/2" UNILET LANCETS ULTRA-THIN 187 123 DEVICE 123 28G VALUMARK LANCET SUPER VANISHPOINT SAFETY UNILET SUPERLITE SYRINGE/3ML/25GX1" 187 123 THIN 30G 123 LANCET VALUMARK LANCET ULTRA VANISHPOINT SAFETY UNISTIK 1 123 THIN 28G 123 SYRINGE/3ML/25GX1-1/2" UNISTIK 2 123 VALUMARK PEN NEEDLES 187 29GX12MM 186 VANISHPOINT SAFETY UNISTIK 2 COMFORT 123 SYRINGE/3ML/25GX5/8" 187 UNISTIK 2 EXTRA 123 VALUMARK PEN NEEDLES 31GX 6MM 186 VANISHPOINT SAFETY UNISTIK 2 NEONATAL 123 VALUMARK PEN NEEDLES SYRINGE/3ML/27GX1-1/2" UNISTIK 2 NORMAL 123 31GX 8MM 186 187 VANISHPOINT UNISTIK 2 SUPER 123 VALVED HOLDING CHAMBER 196 SYRINGE/3ML/20G X 1" 187 UNISTIK 3 123 VANISHPOINT vanadom 230 UNISTIK 3 COMFORT 123 SYRINGE/3ML/20G X 1- vancomycin hcl 18 1/2" 187 UNISTIK 3 EXTRA 123 VANCOMYCIN VANISHPOINT UNISTIK 3 EXTRA SINGLE USE HYDROCHLORIDE 18 SYRINGE/3ML/21G X 1" 187 SAFETY LANCETS/21G 123 vandazole 258 VANISHPOINT UNISTIK 3 NEONATAL 123 VANISHPOINT INSULIN SYRINGE/3ML/21G X 1- UNISTIK 3 NORMAL 123 SYRINGE/0.5ML/30G X 1/2" 187 UNISTIK CZT COMFORT 123 1/2" 186 VANISHPOINT SYRINGE/3ML/22G X 1" 187 UNISTIK CZT NORMAL 123 VANISHPOINT INSULIN SYRINGE/0.5ML/30G X VANISHPOINT UNISTIK NORMAL 123 3/16" 186 SYRINGE/3ML/22G X 1- 1/2" 187
Index 49 VANISHPOINT VIDEX EC 57 VOL-NATE 230 SYRINGE/3ML/23G X 1" 187 VIDEXPEDIATRIC 57 VOL-PLUS 230 VANISHPOINT SYRINGE/3ML/23G X 1- vigabatrin 24 VOL-TAB RX 230 1/2" 187 vigadrone 24 VONVENDI 92 VANISHPOINT VIIBRYD 26 voriconazole 33 SYRINGE/3ML/25G X 1" 187 VIMPAT 24 VORTEX VALVED HOLDING VANISHPOINT CHAMBER 196 SYRINGE/3ML/25G X 1- VINATE II 230 VOTRIENT 46 1/2" 187 VINATE ONE 230 VP INSULIN SYRINGE/U- VANISHPOINT vincristine sulfate 46 SYRINGE/3ML/25G X 5/8" 187 100/0.3ML/29G X 1/2" 188 VANTAS 44 VIRACEPT 57 VPRIV 93 VAQTA 257 VIRAMUNE 57 VRAYLAR 48 VARIVAX 258 VIRAMUNE XR 57 VYVANSE 1 VAXCHORA 254 VIREAD 57 WALGREENS COMFORT virtussin ac/alc 66 ASSUREDLANCETS MICRO VCF VAGINAL THIN/33G 124 CONTRACEPTIVE FILM 258 visine 239 WALGREENS COMFORT VCF VAGINAL VISTOGARD 31 ASSUREDLANCETS SUPER CONTRACEPTIVE FOAM 258 THIN/28G 124 VCF VAGINAL VITAFOL-OB 230 CONTRACEPTIVEGEL 258 VITALINE TOTAL FORMULA WALGREENS GLUCOSE 27 VEMLIDY 58 2 220 WALGREENS THIN VITALINE TOTAL FORMULA LANCETS 124 VENCLEXTA 43 3 220 WALTZ FREE HAND VENCLEXTA STARTING vitamin d3 260 SANITIZER 53 PACK 43 VITAMIN D3 COMPLETE 220 WALTZ FREE HAND VENEXA 220 SANITZER 53 vitamin e 261 VENEXA FE 220 warfarin sodium 22 VITAMIN E 261 venlafaxine hcl 26 WATCHHALER 196 VITASANA 220 VENTAVIS 60 WEBCOL ALCOHOL PREP VITATHELY/GINGER 230 LARGE 1 PLY 125 VENTRIXYL 220 VITATRUM 220 WEBCOL ALCOHOL PREP VENTRIXYL FE 220 VITEYES CLASSIC LARGE 2 PLY 125 verapamil hcl 60 MULTIIVITAMIN 221 WEBCOL ALCOHOL PREP VERELAN 60 VITEYES CLASSIC MEDIUM 2 PLY 125 WEGMANS COMPLETE VERELAN PM 60 MULTIVITAMIN 221 VITEYES OPTIC NERVE PRENATAL+DHA 230 VERSACLOZ 49 SUPPORT 221 WEGMANS UNIFINE PENTIPS VIBRAMYCIN 248 PLUS 32GX4MM 188 VITRANOL 221 WEGMANS UNIFINE PENTIPS VICTOZA 28 VITRANOL FE 221 PLUS/MINI/31GX5MM 188 VIDA MIA AUTOLET VITREXATE 221 WEGMANS UNIFINE PENTIPS LANCINGDEVICE 123 VITREXATE FE 221 PLUS/SHORT/31GX8MM 188 VIDA MIA UNIFINE WEGMANS UNIFINE PENTIPS PENTIPS32GX4MM 187 VITREXYL 221 PLUS/ULTRA VIDA MIA UNIFINE VITREXYL/IRON 221 SHORT/31GX6MM 188 PENTIPSMINI 31GX6MM 187 VITRUM 50+ ADULT-MULTI WESTAB PLUS 230 VIDA MIA UNIFINE IRON FREE 221 WESTHROID 248 PENTIPSORIGINAL VITRUM 50+ SENIOR 29GX12MM 188 WHOLE FOOD MULTI 221 MULTIVITAMIN 221 VIDA MIA UNILET LANCETS VIVAGUARD LANCING SUPER THIN 30G 124 DEVICE 124 WILATE 92 VIDA MIA UNILET LANCETS WINDMILL TRAINER 196 ULTRA THIN 28G 124 VIVITROL 31 VIDA MIA UNIPFINE VIVOTIF 254 wixela inhub 21 PENTIPSSHORT VOGELXO 14 WOMENS 50+ MULTI VITAMIN& MINERAL FORMULA 221 31GX8MM 188 VOGELXO PUMP 14
Index 50 WOMENS BIOMULTIPLE 221 ZEVRX PEN NEEDLES 31G X WOMENS MULTI VITAMIN & 5MM 188 MINERAL FORMULA 221 ZEVRX PEN NEEDLES 31G X WP THYROID 248 6MM 188 ZEVRX PEN NEEDLES 31G X XALKORI 46 8MM 188 XARELTO 23 ZEVRX PEN NEEDLES 32G X XARELTO STARTER PACK 23 4MM 188 XATMEP 42 ZIAGEN 57 XELJANZ 2 zidovudine 57 XELJANZ XR 2,3 zinc oxide (topical) 82 XENICAL 1 zinc sulfate 203 XEOMIN 234 ziprasidone hcl 48 XEROSTOMIA RELIEF ziprasidone mesylate 48 SPRAY 205 ZOLADEX 44 XIAFLEX 203 zoledronic acid 86 XOLAIR 20 ZOLEDRONIC ACID 86 XPERT XPRESS SARS-COV- zoledronic acid 86 2 85 ZOLEDRONIC ACID 86 XTANDI 44 ZOLINZA 46 xulane 63 zolmitriptan 197 XULTOPHY 100/3.6 27 zolpidem tartrate 96 XURIDEN 87 ZOMACTON 86 XYNTHA 93 zonisamide 24 XYNTHA SOLOFUSE 93 YELETS TEENAGE ZONTIVITY 93 FORMULA 221 ZOSTAVAX 258 YF-VAX 258 ZUBSOLV 14 YONDELIS 42 ZYDELIG 46 YONSA 44 ZYPREXA 49 YOUR LIFE MULTI ZYPREXA RELPREVV 49 PRENATAL 230 ZYPREXA ZYDIS 49 zafirlukast 20 zaleplon 96 ZALTRAP 43 ZARONTIN 24 ZARXIO 94 ZEJULA 46 ZELBORAF 46 ZEMAIRA 247 zenzedi 1 ZEVRX INSULIN SYRINGE/0.5ML/30G X 1/2" 188 ZEVRX INSULIN SYRINGE/0.5ML/30G X 5/16" 188 ZEVRX INSULIN SYRINGE/1ML/30G X 1/2" 188 ZEVRX INSULIN SYRINGE/1ML/30G X 5/16" 188
Index 51