Comprehensive PREFERRED DRUG LIST WSI PAGE 1 LAST UPDATED 02/2018 LEGEND TYPE DESCRIPTION There is a limit on the amount of drug covered per prescription, or QL Quantity Limit within a specific time frame. PA Prior Authorization Prior Authorization required before prescription can be filled. MDD Max Daily Dose A limit on the number of times the drug can be taken per day. C Custom This drug has unique restrictions. PAGE 2 LAST UPDATED 02/2018 LIST OF COVERED OVER-THE-COUNTER MEDICATIONS BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ANALGESICS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS ibuprofen tab 200 mg generic adult aspirin ec low strength 81 mg tab dr generic adult aspirin regimen 81 mg tab dr generic advil junior strength 100 mg chew tab generic ALKA-SELTZER EXTRA STRENGTH 500 MG EFFER TAB BRAND C Non-Formulary Drug aspirin effervescent anacin 81 mg tab dr generic ASCRIPTIN MS 500-33-33-237 MG TAB BRAND aspirin buffered (al hydrox-mg hydrox-ca carb) aspir-81 81 mg tab dr generic aspir-low 81 mg tab dr generic aspirin 300 mg suppos generic aspirin 81 mg tab generic aspirin 81 mg tab dr generic aspirin adult low dose 81 mg tab dr generic aspirin adult low strength 81 mg tab dr generic aspirin ec 81 mg tab dr generic aspirin ec adult low strength 81 mg tab dr generic aspirin ec lo-dose 81 mg tab dr generic aspirin ec low dose 81 mg tab dr generic aspirin ec low strength 81 mg tab dr generic aspirin low dose 81 mg tab dr generic aspirin regimen low dose adult 81 mg tab dr generic backache relief extra strength 580 mg tab generic C Non-Formulary Drug bayer aspirin ec low dose 81 mg tab dr generic bayer low dose 81 mg tab dr generic PAGE 3 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS bayer low strength 81 mg tab dr generic BC FAST PAIN RELIEF ARTHRITIS 742-222-38 MG PACKET BRAND C Non-Formulary Drug aspirin-salicylamide-caffeine child ibuprofen 100 mg/5ml suspension generic childrens ibuprofen 100 100 mg/5ml suspension generic childrens ibuprofen 100 mg/5ml suspension generic childrens medi-profen 100 mg/5ml suspension generic childs ibuprofen 100 mg/5ml suspension generic cope 400-32 mg tab generic C Non-Formulary Drug cvs aspirin 81 mg tab dr generic cvs aspirin adult low strength 81 mg tab dr generic cvs aspirin ec 81 mg tab dr generic cvs aspirin low dose 81 mg tab dr generic cvs aspirin low strength 81 mg tab dr generic cvs childrens ibuprofen 100 mg/5ml suspension generic cvs effervescent antacid 325-1000-1916 mg effer tab generic C Non-Formulary Drug ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic cvs ibuprofen childrens 100 mg/5ml suspension generic ibuprofen tab 200 mg generic cvs ibuprofen junior strength 100 mg chew tab generic doans extra strength 580 mg tab generic C Non-Formulary Drug ibuprofen tab 200 mg generic ec-81 aspirin 81 mg tab dr generic ecotrin low strength 81 mg tab dr generic effervescent antacid/pain rel 325-1000-1916 mg effer tab generic C Non-Formulary Drug effervescent pain relief 325 mg effer tab generic C Non-Formulary Drug effervescent pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug eq adult aspirin low strength 81 mg tab dr generic PAGE 4 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS eq antacid & pain relief 325 mg effer tab generic C Non-Formulary Drug eq aspirin adult low dose 81 mg tab dr generic eq aspirin low dose 81 mg tab dr generic eq childrens ibuprofen 100 mg/5ml suspension generic eq effervescent pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic eq ibuprofen junior 100 mg chew tab generic eql adult aspirin low strength 81 mg tab dr generic eql antacid/pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug eql aspirin ec 81 mg tab dr generic eql aspirin low dose 81 mg tab dr generic eql childrens ibuprofen 100 mg/5ml suspension generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic eql ibuprofen junior strength 100 mg chew tab generic ibuprofen tab 200 mg generic gnp adult aspirin low strength 81 mg tab dr generic gnp aspirin 81 mg tab dr generic gnp aspirin low dose 81 mg tab dr generic gnp childrens ibuprofen 100 mg/5ml suspension generic gnp effervescent antacid/pain 325-1000-1916 mg effer tab generic C Non-Formulary Drug ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic gnp ibuprofen junior strength 100 mg chew tab generic goodsense antacid/pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug goodsense aspirin low dose 81 mg tab dr generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic PAGE 5 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS goodsense ibuprofen childrens 100 mg/5ml suspension generic goodsense ibuprofen junior st 100 mg chew tab generic GOODYS EXTRA STRENGTH 520-260-32.5 MG PACKET BRAND C Non-Formulary Drug aspirin-acetaminophen-caffeine h-e-b aspirin 81 mg tab dr generic halfprin 81 mg tab dr generic hm aspirin ec low dose 81 mg tab dr generic hm ibuprofen 100 mg chew tab generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic hm ibuprofen childrens 100 mg/5ml suspension generic ibuprofen tab 200 mg generic hyvee ibuprofen childrens 100 mg/5ml suspension generic ibuprofen tab 200 mg generic ibuprofen tab 200 mg generic ibuprofen 100 junior strength 100 mg chew tab generic ibuprofen 100 mg/5ml suspension generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic ibuprofen childrens 100 mg/5ml suspension generic ibuprofen junior strength 100 mg chew tab generic kls aspirin low dose 81 mg tab dr generic ibuprofen tab 200 mg generic ibuprofen tab 200 mg generic kp aspirin 81 mg tab dr generic ibuprofen cap 200 mg generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic medi-seltzer 325 mg effer tab generic C Non-Formulary Drug ibuprofen tab 200 mg generic PAGE 6 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ibuprofen cap 200 mg generic miniprin low dose 81 mg tab dr generic ibuprofen tab 200 mg generic neutralin 325-1000-1916 mg effer tab generic C Non-Formulary Drug p-a-c 400-32 mg tab generic C Non-Formulary Drug ibuprofen tab 200 mg generic px childrens profen ib 100 mg/5ml suspension generic px effervescent 325-1000-1916 mg effer tab generic C Non-Formulary Drug px enteric aspirin 81 mg tab dr generic ibuprofen tab 200 mg generic px ibuprofen junior strength 100 mg chew tab generic qc aspirin low dose 81 mg tab dr generic qc childrens ibuprofen 100 mg/5ml suspension generic qc effervescent antacid/pain 325-1000-1916 mg effer tab generic C Non-Formulary Drug ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic ibuprofen tab 200 mg generic ra antacid pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug ra aspirin adult low strength 81 mg tab dr generic ra aspirin ec 81 mg tab dr generic ra aspirin ec adult low st 81 mg tab dr generic ra backache relief 580 mg tab generic C Non-Formulary Drug ra ibuprofen 100 mg/5ml suspension generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic ra ibuprofen childrens 100 mg/5ml suspension generic ra ibuprofen junior strength 100 mg chew tab generic sb aspirin 81 mg tab dr generic sb aspirin adult low strength 81 mg tab dr generic PAGE 7 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS sb childrens ibuprofen 100 mg/5ml suspension generic sb effervescent pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug ibuprofen tab 200 mg generic sb low dose asa ec 81 mg tab dr generic sm aspirin adult low strength 81 mg tab dr generic sm aspirin ec low strength 81 mg tab dr generic sm aspirin low dose 81 mg tab dr generic sm childrens ibuprofen 100 mg/5ml suspension generic sm effervescent pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic sm ibuprofen ib 100 mg chew tab generic ibuprofen tab 200 mg generic st joseph aspirin 81 mg tab dr generic tgt aspirin 81 mg tab dr generic tgt aspirin low dose 81 mg tab dr generic tgt childrens ibuprofen 100 mg/5ml suspension generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic tgt ibuprofen childrens 100 mg/5ml suspension generic tgt ibuprofen junior strength 100 mg chew tab generic th aspirin low dose 81 mg tab dr generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic VANQUISH 227-194-33 MG TAB BRAND C Non-Formulary Drug aspirin-acetaminophen-caffeine (buffered) ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic zee-zeltzer 325-1000-1916 mg tbef generic C Non-Formulary Drug PAGE 8 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ANESTHETICS LOCAL ANESTHETICS anesthetic maximum strength 20 % gel generic PA benz-o-sthetic 20 % gel generic PA cvs oral anesthetic max str 20 % gel generic PA cvs oral pain reliever 20 % cream generic hurricaine 20 % gel generic PA intense toothache pain relief 20 % gel generic PA orabase maximum strength 20 % gel generic PA oral analgesic max st 20 % gel generic PA oral pain relief max st 20 % gel generic PA orastat maximum strength 20 % gel generic PA ra anesthetic oral 20 % gel generic PA ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS SMOKING CESSATION AGENTS cvs nicotine polacrilex 2 mg gum generic PA cvs nicotine polacrilex 4 mg gum generic cvs nicotine polacrilex 4 mg lozenge generic PA eq nicotine 2 mg gum generic PA eq nicotine 4 mg gum generic eq nicotine 4 mg lozenge generic PA eq nicotine polacrilex 2 mg gum generic PA eq nicotine polacrilex