ACTION: Original AMENDED DATE: 08/07/2013 1:34 …3-9-12...2012/03/09 · B3P-NON-NARC ANTITUS-1ST GEN ANTIHIST-DECON-ANALGES CB (cough suppressants may be covered for dual eligible)

5101:3-9-12 Appendix

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A1A-DIGITALIS GLYCOSIDESDIGOXIN 0.05MG/ML PED ELIXIR 0 NDIGOXIN 0.125MG, 0.25MG 0 NLANOXIN 0.05MG/ML PED ELIXIR 2 NLANOXIN 0.125MG, 0.25MG 2 N

A1B-XANTHINESAMINOPHYLLINE 100MG, 200MG TAB 0 NCAFFEINE CITRATE ORAL SOLN 20MG/ML 0 NDYLIX 100MG/15ML 2 NELIXOPHYLLIN ELIXIR 80MG/15ML 2 NTHEO-24 100MG, 200MG, 300MG, 400MG 2 NTHEOPHYLLINE LIQUID 80MG/15ML 0 NTHEOPHYLLINE SR TAB 100MG, 200MG, 300MG, 400MG, 450MG, 600MG 0 N

A1D-GENERAL BRONCHODILATOR AGENTS ATROVENT HFA 2 NDIFIL-G 400 400-200MG 2 NIPRATROPIUM 0.2MG/ML 0 NSPIRIVA INHALER 18MCG 2 N

A2A-ANTIARRHYTHMICSAMIODARONE 200MG 0 NDISOPYRAMIDE CR 150MG 0 NDISOPYRAMIDE PHOSPHATE 100MG, 150MG 0 NFLECAINIDE ACETATE 50MG, 100MG, 150MG 0 NMEXILITENE HCL 150MG, 200MG, 250MG 0 NNORPACE CR 100MG, 150MG 2 NPACERONE 200MG 0 NPROPAFENONE 150MG, 225MG, 300MG 0 NPROPAFENONE ER 225MG, 325MG, 425MG 0 NQUINIDINE GLUCONATE 324MG 0 NQUINIDINE SULFATE 200MG, 300MG 0 NQUINIDINE SULFATE SR 300MG 0 NTIKOSYN 0.125MG, 0.25MG, 0.5MG 2 N

A2C-ANTI-ANGINAL AND ANTI-ISCHEMIC AGENTS, NON-HEMODYNAMICRANEXA 500MG, 1000MG 2 N

A4A-ANTIHYPERTENSIVES, VASODILATORSHYDRALAZINE HCL 10MG, 25MG, 50MG, 100MG 0 NMINOXIDIL 2.5MG, 10MG 0 N

A4B-ANTIHYPERTENSIVES, SYMPATHOLYTICCATAPRES-TTS 0.1MG, 0.2MG, 0.3MG 0 NCLONIDINE HCL 0.1MG, 0.2MG, 0.3MG 0 NCLORPRES 0.2/15 2 NGUANABENZ 4MG, 8MG 0 NGUANFACINE 1MG, 2MG 0 NMETHYLDOPA 250MG, 500MG 0 NMETHYLDOPA/HCTZ 250/15, 250/25 0 N

Effective January 1, 2013 November 1, 2013

ACTION: Original DATE: 08/07/2013 1:34 PMAMENDEDAppendix

5101:3-9-12

APPENDIX p(107517) pa(188865) d(438141) ra(348072) print date: 08/07/2013 9:08 PM


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A4C-ANTIHYPERTENSIVES, GANGLIONIC BLOCKERSINVERSINE 2.5MG 2 NVECAMYL 2.5 MG TABLET 2 N

A4D-ANTIHYPERTENSIVES, ACE INHIBITORSBENAZEPRIL 5MG, 10MG, 20MG, 40MG 0 NCAPTOPRIL 12.5MG, 25MG, 50MG, 100MG 0 NENALAPRIL 2.5MG, 5MG, 10MG, 20MG 0 NFOSINOPRIL 10MG, 20MG, 40MG 0 NLISINOPRIL 2.5MG, 5MG, 10MG, 20MG, 30MG, 40MG 0 NMOEXIPRIL 7.5MG, 15MG 0 NPERINDOPRIL 2MG, 4MG, 8MG 0 NQUINAPRIL 5MG, 10MG, 20MG, 40MG 0 NRAMIPRIL 1.25MG, 2.5MG, 5MG, 10MG 0 NTRANDOLAPRIL 1MG, 2MG, 4MG 0 N

A4F-ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST AVAPRO 75MG, 150MG, 300MG 0 NIRBESARTAN 75MG, 150MG, 300MG 0 NLOSARTAN 25MG, 50MG, 100MG 0 N

A4I-ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMB AVALIDE 150-12.5MG, 150-25MG, 300-25MG 0 NDIOVAN HCT 80-12.5MG, 160-12.5MG, 160-25MG, 320-12.5MG, 320-25MG 0 NIRBESARTAN/HCTZ 150-12.5MG, 150-25MG, 300-25MG 0 NLOSARTAN/HCTZ 50-12.5MG, 100-12.5MG, 100-25MG 0 N

A4J-ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC BENAZEPRIL/HCTZ 5-6.25MG, 10-12.5MG, 20-12.5MG, 20-25MG 0 NCAPTOPRIL/HCTZ 25/15, 25/25, 50/15, 50/25 0 NENALAPRIL/HCTZ 5/12.5, 10/25 0 NFOSINOPRIL/HCTZ 10-12.5MG, 20-12.5MG 0 NLISINOPRIL/HCTZ 10/12.5, 20/12.5, 20/25 0 NMOEXIPRIL/HCTZ 7.5-12.5, 15-12.5, 15-25 0 NQUINAPRIL/HCTZ 10-12.5, 20-12.5, 20-25 0 N

A4K-ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION LOTREL 10/2.5, 10/5, 10/20, 20/5 0 NLOTREL 40/5, 40/10 0 NTARKA 2/180, 1/240, 2/240, 4/240 0 N

A4Y-ANTIHYPERTENSIVES, MISCELLANEOUSDEMSER 250MG 2 N

A7B-CORONARY VASODILATORSDILATRATE SR 40MG 2 NISORDIL 40MG 2 NISOSORBIDE DINITRATE ORAL 5MG, 10MG, 20MG, 30MG 0 NISOSORBIDE DINITRATE SL 2.5MG, 5MG 0 NISOSORBIDE DINITRATE SR 40MG 0 NISOSORBIDE MONONITRATE 10MG, 20MG, 30MG, 60MG, 120MG 0 NMINITRAN 0.1MG/HR, 0.2MG/HR, 0.4MG/HR, 0.6MG/HR 2 NNITROBID OINT 2% 2 N



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NITRO-DUR 0.1MG/HR, 0.2MG/HR, 0.3MG/HR, 0.4MG/HR, 0.6MG/HR, 0.8MG/HR 2 NNITROGLYCERIN PATCHES 0.1MG/HR, 0.2MG/HR, 0.4MG/HR, 0.6MG/HR 0 NNITROGLYCERIN SL 0.3, 0.4, 0.6 0 NNITROLINGUAL SPRAY 0.4MG/DOSE 2 NNITROQUICK 0.3MG, 0.4MG, 0.6MG 0 NNITROSTAT 0.3MG, 0.4MG, 0.6MG 2 N

A7C-PERIPHERAL VASODILATORSPAPAVERINE HCL 150MG 0 N

A9A-CALCIUM CHANNEL BLOCKERSAMLODIPINE 2.5MG, 5MG, 10MG 0 NDILTIAZEM 30MG, 60MG, 90MG, 120MG 0 NDILTIAZEM ER 24 HOUR 120MG, 180MG, 240MG, 300MG, 360MG, 420MG 0 NDILTIAZEM SR 12 HOUR 60MG, 90MG, 120MG 0 NFELODIPINE ER 2.5MG, 5MG, 10MG 0 NNICARDIPINE HCL 20MG, 30MG 0 NNIFEDIPINE 10MG, 20MG 0 NNIPEDIPINE ER 30MG, 60MG, 90MG 0 NTAZTIA XT 120MG, 180MG, 240MG, 300MG, 360MG 0 NVERAPAMIL HCL 40MG, 80MG, 120MG 0 NVERAPAMIL SR 120MG, 180MG, 240MG, 360MG 0 N

B0A-GENERAL INHALATION AGENTSSODIUM CHLORIDE FOR INHALATION 0.9%, 3%, 7%, 10% 0 N

B0B-CYSTIC FIB.TRANSMEMB CONDUCT.REG.(CFTR)POTENTIATOR KALYDECO 150MG 2 N

B3A-MUCOLYTICSACETYLCYSTEINE SOLN 10%, 20% 0 NPULMOZYME 2.5MG 2 N

B3J-EXPECTORANTS (guaifenesin may be covered for dual eligible)GUAIFENESIN 200MG, 400MG, 600MG 0 YGUAIFENESIN SYRUP 100MG/5ML, 200MG/5ML 0 YMUCINEX TABLET 600MG, 1200MG 2 Y

B3N-DECONGESTANT-ANALGESIC-EXPECTORANT COMBINATION MUCINEX COLD & SINUS LIQUID 10-650/20 2 NMUCINEX FAST-MAX COLD-SINUS 200-5-325 2 N

B3O-1ST GEN ANTIHISTAMINE-DECONGESTANT-ANALGESIC COMB DIPHENHYDRAMINE/PHENYLEPHRINE/ACETAMINOPHEN 25-650/30, 25-5-325MG 0 NPHENYLEPHRINE/ACETAMINOPHN/CP 5-325-2MG 0 NROBITUSSIN COUGH-COLD-FEVER 2 N

DELSYM MULTI-SYMPTOM 5-325/15ML 2 YDEXTROMETHOR/PHENYLEPHRINE/APAP/CHLORPHENIR 5-2.5-160, 10-5-325-2 0 YDEXTROMETHOR/PHENYLEPHRINE/APAP/DOXYLAMINE 5-325/15, 15-500/15 0 Y

B3P-NON-NARC ANTITUS-1ST GEN ANTIHIST-DECON-ANALGES CB (cough suppressants may be covered for dual eligible)



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BROMPHENIRAMINE/PSEUDOEPHEDRINE/CODEINE 1.3-10-6.3MG 0 YCHLORPHENIRAMINE/PE/CODEINE 2-5-10MG/5 0 YM-END PE 3.3-6.3/5ML 2 YPRO-RED AC 8.33-5-9/5ML 2 YPROMETHAZINE VC CODEINE SYRUP 0 YPSEUDOEPHEDRINE/CHLORPHENIRAMINE/CODEINE 30-10-2/5ML 0 YPSEUDOEPHEDRINE HCL/CODEINE/GUAIFENISEN 30-9-200/5 0 Y

DEXTROMETHORPHAN/PHENYLEPHRIN/BROMPHENIRAMINE 5-2.5-1/5, 2-5-10MG/5 0 YDEXTROMETHORPHAN/PHENYLEPHRINE/CHLORPHENIRAMINE 3-2-1MG/ML, 3-1.5-1/ML, 3-3.5-1/ML, 15-10-2/5ML, 15-6-2/5ML, 15-5-2/5ML, 15-10-4/5ML 0 YDEXTROMETHORPHAN/PSEUDOEPHRINE/BROMPHENIRAMINE 4-15-1/1ML, 5-12-1MG/MML, 5-15-1MG/5, 15-45-4/5, 10-30-2/5 0 YDEXTROMETHORPHAN/PSEUDOEPHRINE/CHLORPHENIRAMINE 5-15-1/5 0 YM-END DM 15-15-2/5ML 2 YPHENYLEPH/PYRIL/DM 5-8.33-10/5ML 0 YRESCON DM 10-30-2/5 2 Y

GUAIFENISEN/DEXTROMETHORPHAN/PHENYLEPHRINE/CHLORPHENERIMAINE 15-10-2/5 0 Y

GUAIFENESIN/DEXTROMETHORPHAN 100-5MG/5, 100-10/5, 200-10/5, 200-10/15, 300-20/5, 400-20MG TAB, 600-30MG, 1200-60MG 0 YMUCINEX DM TABLET 600-30MG, 1200-60MG 2 YROBITUSSIN DM 200-10MG/5ML 2 Y

B3X-1ST GEN ANTIHIST-DECONGEST-ANTICHOLINERGIC COMB CHLORPHENIRAMINE/PHENYLEPHRINE/METHSCOP 2-10-0.75/5 0 N

DEXTROMETHORPHAN/ACETAMINOPHEN 30-1000/30, 5-160/5 0 Y

HYDROCODONE/HOMATRO 5/1.5 TAB, SYRUP 0 Y

COTAB AX 4-20MG 2 YPRO-CLEAR AC 9-8.33MG/5ML 2 YPROMETHAZINE CODEINE SYRUP 10-6.25/5ML 0 Y

B4C-NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMB. (cough suppressants may be covered for dual eligible)

B4D-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE (cough suppressants may be covered for dual eligible)

B4A-NON-NARCOTIC ANTITUSSIVE-ANALGESIC COMBINATIONS (cough suppressants may be covered for dual eligible)

B3Q-NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST (cough suppressants may be covered for dual eligible)

B3R-NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST (cough suppressants may be covered for dual eligible)

B3S-NON-NARC ANTITUS-1ST GEN ANTIHIST-DECONGEST-EXPECT (cough suppressants may be covered for dual eligible)

B3T-NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB (cough suppressants may be covered for dual eligible)



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CAPRON DM 7.5-7.5/5ML 2 YDEXTROMETHORPHAN/CHLORPHENIRAMINE 7.5-1MG/5ML 0 YDEXTROMETHORPHAN HB/DOXYLAMINE 15-6.25/15 0 YPROMETHAZINE DM SYRUP 15-6.25/5 0 Y

DEXTROMETHROPHAN/ACETAMINOPHEN/DOXYLAMINE 30-12.5/30 0 YDEXTROMETHORPHAN/ACETAMINOPHEN/CHLORPHENIRAMINE 5-160-1/5 N Y

PSEUDOEPHEDRINE HCL/CODEINE 30-10MG/5 0 Y

DEXTROMETHORPHAN/PHENYLEPHRINE 5-2.5MG/5 0 Y

DEXTROMETHORPHAN/PE/ACETAMINOPHEN 5-325MG/15, 10-5-325 0 Y

CHILD'S MUCINEX COLD-FEVER 5-325/10 2 YMUCINEX COLD-FLU-SORETHROAT 10-650/20 2 YPHENYLEPHRINE/DM/ACETAMINOP/GG 5-325-200, 5-325MG/15 N Y

GUAIFENESIN/PSEUDOEPHEDRINE/CODEINE 100-30-10/5, 200-30-9/5 0 Y

CAPMIST DM 400-30-30, 400-15-60 2 YCHILD MUCINEX MULTI-SYMPTOM 5-2.5MG/5 2 YGUAIFENISEN/DEXTROMETHORPHAN/PHENYLEPHRINE 100-10-5/5ML 0 YGUAIFENESIN/DEXTROMETHORPHAN/PSEUDOEPHEDRINE 200-15-30/5 0 YTUSNEL PEDIATRIC LIQUID 50-5-15/5ML 2 Y

GUAIFENESIN/CODEINE CAPS 200-9 0 YGUAIFENESIN W/CODEINE SYRUP 100-6.3MG/5, 100-10MG/5, 200-10MG/5 0 Y

B4T-DECONGEST-ANALGESIC,NON-SALICYLATE COMB. PHENYLEPHRINE/ACETAMINOPHEN 5MG-325MG 0 N

B4W-DECONGESTANT-EXPECTORANT COMBINATIONSGUAIFENESIN/PHENYLEPHRINE 400-10MG 0 NGUAIFENESIN/PSEUDOEPHEDRINE HCL 400MG-40MG, 400MG-60MG 0 NMUCINEX COLD 100-2.5/5ML 2 N

B4E-NON-NARC ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB (cough suppressants may be covered for dual eligible)

B4G-NON-NARC ANTITUSS-1ST GEN ANTIHIST-ANALGESIC COMB (cough suppressants may be covered for dual eligible)

B4K-NARCOTIC ANTITUSSIVE-DECONGESTANT COMBINATIONS (cough suppressants may be covered for dual eligible)

B4L-NON-NARCOTIC ANTITUSSIVE-DECONGESTANT COMBINATIONS (cough suppressants may be covered for dual eligible)

B4M-NON-NARCOTIC ANTITUSSIVE-DECONGESTANT-ANALGESIC CB (cough suppressants may be covered for dual eligible)

B4P-NON-NARC ANTITUSS-DECONGESTANT-ANALGESIC-EXPECT CB (cough suppressants may be covered for dual eligible)

B4Q-NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT COMB (cough suppressants may be covered for dual eligible)

B4R-NON-NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT CMB (cough suppressants may be covered for dual eligible)

B4S-NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION (cough suppressants may be covered for dual eligible)



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MUCINEX D 600-60MG, 1200-120MG 2 NRESCON GG 100-5/5ML 2 NRESPAIRE-30 150MG-30MG 2 N

C0B-WATERSTERILE WATER FOR INJECTION 0 N

C0D-ANTI-ALCOHOLIC PREPARATIONSANTABUSE 250MG, 500MG 2 NCAMPRAL 333MG 2 NDISULFIRAM 250MG 0 NVIVITROL 380MG 0 N

C1A-ELECTROLYTE DEPLETERSCALCIUM ACETATE 667MG 0 NCALPHRON 667MG 0 NELIPHOS 667MG 0 NKAYEXALATE POWDER 2 NKIONEX PDR 0 NPHOSLO 667MG 2 NSODIUM POLYSTYRENE SULFONATE 15GM/60ML 0 N

C1B-SODIUM/SALINE PREPARATIONS NORMAL SALINE WASH 0 N

C1D POTASSIUM REPLACEMENTEFFER-K TABLETS 10MEQ, 20MEQ 2 NKLOR-CON 25 PACKETS 2 NKLOR-CON M15 2 NPOTASSIUM CHLORIDE 8MEQ, 10MEQ, 20MEQ 0 NPOTASSIUM CHLORIDE EFF TABS 25MEQ 0 NPOTASSIUM CHLORIDE ORAL LIQ 10%, 20% 0 NPOTASSIUM CHLORIDE PACKETS 20MEQ, 25MEQ 0 N

C1F-CALCIUM REPLACEMENT (may be covered for dual eligible)CALCIUM CITRATE-VITAMIN D 315-250 0 YCALCIUM CARBONATE 1.25 GM 0 YCALCIUM CARBONATE 10GR 0 YCALCIUM CARBONATE/VITAMIN D 153-100, 600-200, 600-400, 600-500 0 YCALCIUM CITRATE 950MG 0 YCALCIUM GLUBIONATE 1.8GM/5ML 0 YCALCIUM GLUCONATE 10GR 0 YCALCIUM LACTATE 10GR 0 YOYSTER SHELL CALC W/D 250MG/125U, 500MG/200U, 500MG/400U 0 YOYSTER SHELL CALCIUM 500MG 0 Y

C1H-MAGNESIUM SALTS REPLACEMENT (may be covered for dual eligible)MAG DELAY 64MG 0 YMAGNESIUM CARBONATE 64MG/5ML 0 YMAGNESIUM GLUCONATE 500MG 0 YMAGNESIUM OXIDE 400MG 0 YMAGTAB SR 84MG 2 YSLOW MAG 71.5MG 2 Y



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C1P-PHOSPHATE REPLACEMENT (may be covered for dual eligible)PHOS-NAK 2 Y

C1W-ELECTROLYTE MAINTENANCEORAL ELECTROLYTES 0 YPEDIALYTE SOLUTION 2 Y

C3B-IRON REPLACEMENT (may be covered for dual eligible)BIFERA 28MG 2 YCORVITE 150 2 YFEFUM/C/B12/IF/FA 0.5MG 0 YFERRALET 90 DUAL-IRON 90-1-50 MG 2 YFERRAPLUS 90-1-50MG 2 YFERROGELS FORTE 460/60MG 0 YFERROUS FUM/C/B-12 0 YFERROUS FUMARATE/FOLIC ACID 106 MG-1MG 0 YFERROUS FUMARATE/FA/MULTIVITAMIN/MINERAL COMB 10-MG-1MG 0 YFERROUS GLUCONATE 236MG 0 YFERROUS GLUCONATE EC 5GR 0 YFERROUS SULFATE 140MG, 5GR, SLOW RELEASE 160MG 0 YFERROUS SULFATE 220MG/5ML, 15MG/1ML 0 YFERROUS/FA/B&C 0 YHEMATOGEN 0 YHEMATOGEN FA 200-250MG 0 YHEMATOGEN FORTE 460-60MG 0 YIRON AG/C/B12/CA/SUC.ACID/STOM 70-150-10 0 YIRON,CARBONYL/FOLIC ACID 82MG-0.8MG 0 YIRON FUM & AG/C/B12/FA/CA/SUCC 151-60-1 0 YMULTIVITS,THERAP W-FE,HEMATIN 27-0.8MG 0 YMYKIDZ IRON 10 SUSPENSION 15MG/1.5ML 0 YNEPHRON FA 2 YPOLYSACCARIDE IRON 150 FORTE 0 YPOLYSACCARIDE IRON 150MG 0 YPOLYSACCARIDE IRON 150 PLUS 0 YPRO FE 180MG 2 YSE-TAN PLUS 106MG-1MG 0 YSTRESS FORMULA + IRON 0 Y

C3C-ZINC REPLACEMENT (may be covered for dual eligible)ZINC 50MG 2 YZINC SULFATE 220MG 2 Y

C3H-IODINE CONTAINING AGENTS (may be covered for dual eligible)POTASSIUM IODIDE 1GM/ML 0 Y

C4G-INSULINSHUMALOG 100U/ML 2 NHUMALOG MIX 50/50, 75/25 2 NHUMULIN 70/30 2 NHUMULIN N 2 NHUMULIN R 100U/ML, HUMULIN R-500 500U/ML 2 N



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LANTUS 100U/ML 2 NNOVOLIN 70/30 2 NNOVOLIN N 2 NNOVOLIN R 2 NNOVOLOG 2 NNOVOLOG MIX 70/30 2 NRELION 70/30 2 NRELION N 2 NRELION R 2 N

C4K-HYPOGLYCEMICS, INSULIN-RELEASE STIMULANT TYPE CHLORPROPAMIDE 100MG, 250MG 0 NGLIMEPIRIDE 1MG, 2MG, 4MG 0 NGLIPIZIDE 5MG, 10MG 0 NGLIPIZIDE-METFORMIN 2.5-500, 5-500 0 NGLIPIZIDE ER 2.5MG, 5MG, 10MG 0 NGLYBURIDE 1.25MG, 2.5MG, 5MG 0 NGLYBURIDE MICRONIZED 1.5MG, 3MG, 6MG 0 NSTARLIX 60MG, 120MG 0 NTOLAZAMIDE 250MG, 500MG 0 NTOLBUTAMIDE 500MG 0 N

C4L-HYPOGLYCEMICS, BIGUANIDE TYPE (NON-SULFONYLUREAS) METFORMIN 500MG, 850MG, 1000MG 0 NMETFORMIN HCL ER 500MG, 750MG 0 N

C4M-HYPOGLYCEM, ALPHA-GLUCOSIDASE INHIB TYPE (N-S)ACARBOSE 25MG, 50MG, 100MG 0 NGLYSET 25MG,50MG,100MG 2 N

C4N-HYPOGLYCEMICS, INSULIN-RESPONSE ENHANCER (N-S)ACTOS 15MG, 30MG, 45MG 0 NPIOGLITAZONE 15MG, 30MG, 45MG 0 N

C4S-HYPOGLY, INSULIN-REL STIM. & BIGUANIDE (N-S) COMB. GLYBURIDE-METFORMIN 1.25-250, 2.5-500, 5-500 0 N

C4T-ANTIHYPERGLYCEMIC,THIAZOLIDINEDIONE & BIGUANIDE ACTOPLUS MET 15-500MG, 15-850MG 0 N

C5B-PROTEIN REPLACEMENT (may be covered for dual eligible)ARGININE 500MG 0 Y

C5F-DIETARY SUPPLEMENTS, MISC (may be covered for dual eligible)CO ENZYME Q10 30MG, 100MG 0 YCYTO-Q MAX 100 MG/ML LIQUID 2 YLIQ10 50MG/5ML 0 YQ-GEL MEGA 100MG 0 Y

C5O-SOLNS MISCELLANEOUSDILUENT 2 N

C5U-NUTRITIONAL THERAPY, MED COND SPECIAL FORMULATION (may be covered for dual eligible)SLOESTEROL POWDER 2 Y



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C6B-VITAMIN B PREPARATIONS (may be covered for dual eligible)CEREFOLIN 1-6-50-5MG 2 YCEREFOLIN NAC 2 YDIALYVITE 3000 2 YDIALYVITE 5000 0 YDIALYVITE WITH ZINC TABLET 1-100MG 0 YFOLBEE 1-2.5-25MG 2 YFOLBEE PLUS 2 YFOLBIC 2-2.5-25MG 2 YFOLGARD RX 1-2.2-25 2 YFOLIC ACID/VITAMIN B COMP W-C 0 YFOLTX 2-2.5-25 2 YMETANX 2-2.8-25MG 2 YNEPHPLEX RX 2 YNEPHROCAPS QT 1MG-1750 0 YNEPHRONEX 1MG 2 YNEPHRO-VITE RX 2 YRENAL CAPS 1MG 2 YRENA-VITE 0 YRENA-VITE RX 0 YRENO CAPS 1MG 2 Y

C6C-VITAMIN C PREPARATIONS VITAMIN C 500MG 0 Y

C6D-VITAMIN D PREPARATIONS (may be covered for dual eligible)CALCIFEROL LIQ 8,000U/ML 2 YCALCITRIOL 0.25MCG, 0.5MCG, 1MCG/ML 0 YD-VI-SOL 400/ML 2 YDRISDOL 8000 IU/ML 2 YERGOCALCIFEROL 8000 IU/ML 0 YROCALTROL 0.25MCG, 0.5MCG 2 YROCALTROL 1MCG/ML 2 YVITAL-D RX 1750-60-1 0 YVITAMIN D2 50,000U 0 YVITAMIN D3 1000U, 2000U, 5000U, 10000U 0 Y

C6E-VITAMIN E PREPARATIONS (may be covered for dual eligible)AQUASOL E 50 UNIT/ML DROPS 2 YAQUA-E LIQUID 30-2MG/ML 2 Y

C6F-PRENATAL VITAMINS (family planning)CAVAN ONE OMEGA 27-1-330MG 0 NCAVAN-ALPHA KIT 27-1-300MG 0 NCAVAN-EC SOD DHA VITAMINS 30-1-440 0 NCAVAN-FOLATE DHA COMBO PACK 65-1-250 0 NCAVAN-FOLATE OB TABLET 65-1 0 NCAVAN-HEME OB TABLET 22-6-1 0 NCAVAN-HEME OMEGA COMBO PACK 22-6-1-200 0 NCITRANATAL 90 DHA 90-1-300MG 0 N



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CITRANATAL ASSURE 35-1-50MG 0 NCITRANATAL B-CALM 20-1-25MG 0 NCITRANATAL DHA 27-1-50MG 0 NCITRANATAL HARMONY 27-1-50MG 0 NCITRANATAL RX 27-1-50 0 NCOMPLETE NATAL DHA 29-1-250MG 0 NCOMPLETENATE 29MG-1MG 0 NCOMPLETE-RF PRENATAL 90-1-50MG 0 NCO-NATAL FA 0 NCONCEPT DHA 35-1-200MG 0 NCONCEPT OB 85MG-1MG 0 NCORENATE-DHA 35-1-50 0 NDUET DHA COMPLETE 27-1-300MG, 27-1-430MG, BALANCED 27-1-430 0 NED CYTE F TABLET 106-50-1 0 NEDGE OB 29MG-1MG 0 NELITE OB 400, DHA SOFTGEL 28-1.25 0 NEZFE FORTE 155-1 0 NFEMECAL OB 22-6-1MG, FEMECAL OB PLUS DHA 22-6-1-200 0 NFOLBECAL TABLET 200-12-1 0 NFOLCAL DHA 30-1.24-55, 27-1.25-55 0 NFOLCAPS CARE ONE 27-1-50MG 0 NFOLCAPS OMEGA-3 27-1-330MG 0 NFOLINATAL PLUS B 200-12-1 0 NFOLIVANE-EC CALCIUM DHA COM 27-1-250MG 0 NFOLIVANE-OB CAPSULE 85 MG-1 MG 0 NFOLIVANE-PRX DHA NF CAPSULE 30-1.24-55 0 NFOLTABS 27-1-50MG 0 NFOLTABS 90 PLUS DHA 0 NGENERIC PRENATALS 0 NGESTICARE DHA 0 NHIP PRENATAL 22-6-1 0 NINATAL ADVANCE 90-1MG 0 NINATAL GT 90-1MG 0 NINATAL ULTRA 90-1MG 0 NINFANATE BALANCE 29-1-50 DHA 28-1-250 0 NKOLNATAL DHA 27-1-250MG 0 NLACTOCAL-F TABLET 65-1 0 NMARNATAL-F 0 NMATERNITY VITAMIN 27-1 0 NMISSION PRENATAL, PRENATAL FA, PRENATAL HP 0 NMULTINATAL PLUS 30-1MG, 40-1MG 0 NMULTI-NATE 30 DHA 29-1-400, 29-1-430, DHA EXTRA 29-1-400, 29-1-430 0 NNATAFORT 60-1 0 NNATELLE-EZ 25-0.8 0 NNATELLE ONE CAPSULE 28-1-250 0 NNATELLE PLUS COMBO PACK 26-1-200MG 0 N



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NAVATAB + DHA 26-1-200MG 0 NNEEVO 29-0.5-1.4 0 NNEEVO DHA 27-1.13 0 NNESTABS ABC PRENATAL COMBO 32-1-120 0 NNEXA SELECT 29-1.25-55 0 NOB COMPLETE 400 35-5-1.2MG, 20-1-100, WITH DHA 30-10-1-200, PREMIER 30-20-1, ONE 40-10-1; PETITE 35-5-1-200 0 NO-CAL PRENATAL 0 NPAIRE OB PLUS DHA 22-6-1-200 0 NPNV-DHA 27-1, PNV-IRON 29-400-1, PNV-SELECT 27-1-300 0 NPNV OB+DHA 27-1-50-250, 27-1-50 0 NPNV-OMEGA 28-1-300 0 NPNV-TOTAL 35-5-1.2 0 NPOLY IRON PN FORTE 60-1MG 0 NPR NATAL 400, 430, 430 EC, 440 EC 0 NPREFERA-OB ONE 22-6-1-200, PREFERA-OB PLUS DHA 22-6-1-200 0 NPRENAFIRST 0 NPRENAPLUS 27MG-1MG 0 NPRENATABS FA 0 NPRENATABS RX 0 NPRENATAL 1 PLUS 1 TABLET 65-1 0 NPRENATAL 19 0 NPRENATAL LOW IRON 27-1MG 0 NPRENATAL MULTIVITAMIN WITH IRON 29MG-1MG 0 NPRENATAL PLUS IRON 27-1 0 NPRENATAL, PRENATAL RX 27-0.5 0 NPRENATAL-U 0 NPRENATE DHA SOFTGEL 27-1-300MG 0 NPRENATE ELITE TABLET 27 MG-1 MG 0 NPRENATE ESSENTIAL 28-1-300MG 0 NPRENEXA 27-1.25-55, PRENEXA PREMIER 27-1.25-55 0 NPREQUE 10 15-0.5-50 0 NPROFE FORTE 155-1 0 NPROVIDA OB CAPSULE 40-1.25 0 NPRUET DHA 29-1-430 0 NRE DUALVIT OB 0 NRE OB + DHA, RE OB 90 + DHA 0 NRE-NATA 29 OB 29MG-1MG 0 NRELNATE DHA 28-1-200 0 NRENATE DHA 0 NROVIN-A DHA 35-1-50-300, ROVIN-NV DHA 27-400-1 0 NSE-CARE 40-1, SE-CARE GESTURE 28-1 0 NSE-NATAL 19 29-1 0 NSE-PLETE DHA 0 NSE-TAN DHA 30-1-310.1 0 NSETONET, SETONET-EC 0 N



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STUART PRENATAL, STUART ONE 27-800-200 0 NTARON-BC 20-1-25 0 NTARON EC CALCIUM DHA 28-1-250 0 NTARON-C DHA CAPSULE 35-1-200 0 NTARON-DUO EC 29-1-400 0 NTARON-EC CAL 28-1, TARON PRENATAL 30-1.2-55, TARON A PRENATAL 35-1-50 0 NTARON-PREX PRENATAL DHA 30-1.2-55 0 NTL-ASSURE + DHA 29-1-250 0 NTL CARE DHA 27-1-500, TL SELECT DHA 29-1.25-55 0 NTRICARE PRENATAL DHA ONE 27-1-500MG, COMPLETE 27-1 0 NTRIMESIS RX 200-12-1 0 NTRINATAL GT, ULTRA 90-1-50 0 NTRINATAL RX 1 60MG-1MG 0 NTRINATE 0 NTRIVEEN-DUO DHA 29-1-400 0 NTRIVEEN-ONE 27-1-250MG, TRIVEEN-PRX RNF 26-1.2-55, TRIVEEN-U 106.5-1MG 0 NTRIVEEN-TEN 15-0.5-50 0 NULTIMATECARE COMBO 30-50-1MG, ULTIMATECARE ADVANTAGE 30-1-50 0 NULTIMATECARE ONE 27-1-330MG 0 NVEMAVITE-PRX 2 27-1.25-55 0 NVENATAL-FA 29-1 0 NVINACAL 27-1-50 0 NVINATE AZ 27-1 0 NVINATE AZ EXTRA 0 NVINATE C 30MG-1MG 0 NVINATE CALCIUM 27-1-50MG 0 NVINATE CARE 40-1MG 0 NVINATE GT 0 NVINATE II 29MG-1MG 0 NVINATE M 0 NVINATE ONE 0 NVINATE PN CARE 30-50-1MG 0 NVITAPHIL + DHA 0 NVITAPHIL 25-1MG 0 NVITAFOL-ONE 29-1-200 0 NVITASPIRE 29MG-1MG 0 NVOL-NATE 28-1, VOL-PLUS 27-1, VOL-TAB RX 29-1 0 NZATEAN-CH 27-1-50 0 NZATEAN-PN 27MG-1MG, ZATEAN-PN DHA 27-400-1 0 NZATEAN-PN PLUS 28-1-300MG 0 N

C6G-GERIATRIC VITAMIN PREPARATIONS (may be covered for dual eligible)ELDERCAPS 2 YGERIATRIC VITAMINS (COMPARE TO GEVRABON) 0 YGERI-TONIC 0 YGERIATON 0 Y



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C6H-PEDIATRIC VITAMINS (may be covered for dual eligible)CHEWABLES AND LIQUID DROPS GENERICS 0 YCHEWABLES W/FLUORIDE AND LIQUID DROPS W/FLUORIDE 0 YCHEWABLES WITH IRON AND FLUORIDE GENERICS 0 YCHEWABLES WITH IRON AND LIQUID DROPS WITH IRON GENERICS 0 YLIQUID DROPS WITH IRON AND FLUORIDE GENERICS 0 YMYKIDZ IRON FL 10-0.25/2ML 2 Y

C6I-ANTIOXIDANT MULTIVITAMIN COMBINATIONS VIT A/VIT C/VIT E/ZINC/COPPER 0 Y

C6K-VITAMIN K PREPARATIONS (may be covered for dual eligible)MEPHYTON 5MG 2 Y

C6L-VITAMIN B-12 PREPARATIONS (may be covered for dual eligible)CYANOCOBALAMIN INJ 1000MG/ML 0 YFOLCAPS 0.5-2.2-25MG 2 YFOLPLEX 2.2MG 2 Y

C6M-FOLIC ACID PREPARATIONS (may be covered for dual eligible)DIALYVITE 0 YFOLIC ACID 0.8MG, 1MG 0 Y

C6N-NIACIN PREPARATIONS (may be covered for dual eligible)NIACIN SR 125MG, 250MG, 500MG 0 YSLO-NIACIN 250, 750MG 2 Y

C6Z-MULTIVITAMIN PREPARATIONS (may be covered for dual eligible)GENERIC EQUIVALENTS TO: ALLBEE C 0 Y BEROCCA PLUS 0 Y CENTRUM 0 Y OCUVITE 0 Y ONE-A-DAY & ONE-A-DAY W/IRON 0 Y STRESSTAB 600 FORMULA, WITH IRON AND WITH ZINC 0 Y THERAGRAN, THERAGRAN M & THERAGRAN H 0 Y UNICAP, UNICAP W/IRON, UNICAP M 0 Y VI-DAYLIN, VI-DAYLIN WITH IRON 0 YCENTRUM MULTIVITAMIN-MINERAL LIQUID 0 YCORVITE FREE 1.25-35 2 YDAILY MULTIVITAMIN WITH IRON 18MG-0.4MG 0 YDAILY VITAMIN FORMULA 0 YFOSFREE 175.5-14.5 0 YRENAX 35-2.5 2 YSTROVITE PLUS CAPLET 27-.8 2 Y

C7A-HYPERURICEMIA TX - PURINE INHIBITORSALLOPURINOL 100MG, 300MG 0 N

C7D-METABOLIC DEFICIENCY AGENTSCYSTADANE 1GM/1.7ML 2 N

C7F-APPETITE STIMULANTS FOR ANOREXIA, CACHEXIA, WASTING SYNDROMEMEGACE ES 625MG/5ML 2 N



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C7H-PKU TX AGENT-COFACTOR OF PHENYLALANINE HYDROXYLASE KUVAN 100MG 2 N

C8A-METALLIC POISON ANTIDOTESCHEMET 100MG 2 NEXJADE 125MG, 250MG, 500MG 2 NFERRIPROX 500MG 2 NGALZIN 25MG, 50MG 2 NSYPRINE 250MG 2 N

D1A-PERIODONTAL COLLAGENASE INHIBITORS DOXYCYCLINE HYCLATE 20MG 0 N

D1D-DENTAL AIDS & PREPARATIONSCHLORHEXIDINE GLUCONATE SOLN 0 NTRIAMCINOLONE DENTAL PASTE 0 N

D2A-FLUORIDE PREPARATIONSPREVIDENT 5000 1.1% DRY MOUTH 2 NSODIUM FLUORIDE 0.25MG, .5MG, 1MG 0 NSODIUM FLUORIDE CREAM 1.1% 0 NSODIUM FLUORIDE DROPS 0.5MG/ML, 2.5MG/ML 0 N

D4B-ANTACIDS (may be covered for dual eligible if available over the counter)GENERIC EQUIVALENTS OF: GAVISCON 358-95/15ML, 20-80 0 Y MAALOX 400-400-40, 450-500-40 0 Y MYLANTA 200-200-20, 400-400-40 0 Y RIOPAN 540MG/5ML 0 YALUMINUM HYDROXIDE 600MG/5ML, 320MG/5ML 0 YCALCIUM CARBONATE 500MG/5ML 0 YSODIUM BICARBONATE 5GR, 10GR 0 Y

D4D-ANTIDIARRHEAL MICROORGANISMS AGENTS ACIDOPHILUS W/PECTIN LIQ 0 Y

D4E-ANTIULCER PREPARATIONSCARAFATE 1GM/10ML 0 NMISOPROSTOL 100MCG, 200MCG 0 NSUCRALFATE 1GM 0 N

D4F-ANTI-ULCER-H.PYLORI AGENTS HELIDAC 2 N

D4G-GASTRIC ENZYMESLACTRASE 250MG 2 N

D4J-PROTON-PUMP INHIBITORS LANSOPRAZOLE 15MG, 30MG 0 NLANSOPRAZOLE ODT 15MG, 30MG (AGES 0-6) * NOMEPRAZOLE CAPS 10MG, 20MG, 40MG 0 NOMEPRAZOLE TABS 20MG 0 NPANTOPRAZOLE 20MG, 40MG 0 NPREVACID 24H 15MG 0 NPRILOSEC OTC 0 NZEGERID OTC 0 N



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D4N-ANTIFLATULENTS (may be covered for dual eligible if available over the counter)GAS-X 125MG 2 YSIMETHICONE 80MG TABS 0 YSIMETHICONE DROPS 40MG/0.6ML 0 Y

D6C-IRRITABLE BOWEL SYNDROME AGENT, 5HT-3 ANTAGONIST-TYPE LOTRONEX 0.5MG, 1MG 2 N

D6D-ANTIDIARRHEALS (may be covered for dual eligible if available over the counter)BISMUTH SUSPENSION 262MG/15ML, 525MG/15ML 0 YDIPHENOXYLATE/ATROPINE SULFATE TABS, LIQUID 0 NLOPERAMIDE HCL 2MG TABS, 1MG/5ML SOLN 0 NMOTOFEN TABS 2 N

D6F-DRUG TX-CHRONIC INFLAM. COLON DX, 5-AMINOSALICYLATEBALSALAZIDE DISODIUM 750 MG 0 N

D6S-LAXATIVES & CATHARTICS (may be covered for dual eligible if available over the counter)BISACODYL 5MG TABS 0 YCOLYTE 2 NDOCUSATE CALCIUM 240MG 0 YDOCUSATE SODIUM DROPS, LIQUID, SYRUP 150MG/15ML, 60MG/15ML 0 YDOCUSATE SODIUM CAPS 100MG, 250MG 0 YDOCUSATE SODIUM/CASANTHRANOL SYRUP, CAPS 300-100/5ML, 300-100 0 YFIBER LAXATIVE TABS 500MG, 625MG 0 YGLYCOLAX POWDER 2 YGOLYTELY SOLUTION 2 NLACTULOSE SYRUP 10GM/15ML 0 NMAGNESIUM CITRATE 0 YMILK OF MAGNESIA 400MG/5ML, 2400MG/10ML 0 YMIRALAX 2 YNULYTELY SOLUTION 2 NPEG-3350 0 NPOLYETHYLENE GLYCOL GRAN 0 YPSYLLIUM PREPARATIONS/VEGETABLE LAXATIVES 0 YSALINE-PHOSPHATE LAXATIVE ORAL LIQUID 0 YSENNA CONCENTRATES 8.6MG 0 YSENNA LIQUID 8.8MG/5ML 0 YSENNA W/DOCUSATE 8.6MG-50MG 0 YTRILYTE 2 N

D7A-BILE SALTSURSODIOL 250MG, 300MG, 500MG 0 N

D7L-BILE SALT SEQUESTRANTS CHOLESTYRAMINE LIGHT POWDER 0 NCHOLESTYRAMINE POWDER 0 NCOLESTIPOL 1G TABS 0 NPREVALITE POWDER 0 N



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D8A-PANCREATIC ENZYMESCREON 3K-9.5K-15K, 30K-6K-19K, 60K-12K-38K, 120K-24K-76K, 180K-36K-114K 2 NPANCREAZE 4200, 10500, 16800, 21000 2 NPANCRELIPASE 5K 2 NZENPEP 3K, 5K, 10K, 15K, 20K, 25K 2 N

D9A-AMMONIA INHIBITORBUPHENYL POWDER 500MG 2 NCARBAGLU 200MG 2 NLACTULOSE 10GM/15ML 0 NLITHOSTAT 250MG 2 N

E0G-PRENATAL VITAMINS WITHOUT IRON (family planning)PRENAISSANCE NEXT 1.2-40-100 0 N

F1A-ANDROGENIC AGENTSANDRODERM 2MG/24H, 2.5MG/24H, 4MG/24H, 5MG/24H 2 NANDROGEL 12.5MG, 25MG, 50MG 1%, 1.62% 2 NANDROID 10MG 2 NAXIRON 30MG 2 NFLUOXYMESTERONE 10MG 0 NFORTESTA 10MG (2%) 2 NMETHITEST 10MG 2 NTESTIM 1% (50MG) 2 NTESTRED 20MG 2 N

G1A-ESTROGENIC AGENTSALORA 0.025MG/24HR, 0.05MG/24HR, 0.075MG/24HR, 0.1MG/24HR 2 NCENESTIN 0.3MG, 0.45MG, 0.625MG, 0.9MG, 1.25MG 2 NCOMBIPATCH 0.05-0.14/24 HR, 0.05-0.25/24 HR 2 NENJUVIA TABLET 0.3MG, 0.45MG, 0.625MG, 0.9MG, 1.25MG 2 NESTRADIOL 0.5MG, 1MG, 2MG 0 NESTRADIOL PATCH 0.025MG, 0.0375MG, 0.05MG, 0.06MG, 0.075MG, 0.1MGESTROPIPATE 0.625MG, 1.25MG, 2.5MG 0 NFEMHRT 1-0.005MG, 2.5MCG-0.5 2 NMENEST 0.3MG, 0.625MG, 1.25MG, 2.5MG 2 NNORETHINDRONE-ETHINYL ESTRADIOL 1-5 0 NPREMARIN 0.3MG, 0.45MG, 0.625MG, 0.9MG, 1.25MG 2 NPREMPHASE 0.625/5 2 NPREMPRO 0.3-1.5MG, 0.625/2.5, 0.625/5 2 NPREMPRO LOW DOSE 0.45MG-1.5MG 2 N

G2A-PROGESTATIONAL AGENTSAYGESTIN 5MG 2 NCRINONE 4%, 8% 2 NMEDROXYPROGESTERONE ACETATE 2.5MG, 5MG, 10MG 0 NNORETHINDRONE ACETATE 5MG 0 NPROMETRIUM 100MG, 200MG 0 N

G3A-OXYTOCICS (family planning)METHERGINE 0.2MG 0 NMETHYLERGONOVINE 0.2MG 0 N



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G8A-CONTRACEPTIVES, ORAL (family planning)APRI 0.15-0.03 0 NARANELLE 7/9/5 0 NAVIANE 0.1-0.002 0 NAZURETTE 21-5 0 NBALZIVA 28 TABLET 0 NBEYAZ 3-0.02 0 NBREVICON 0.5-0.035MG 0 NCAMILA 0.35MG 0 NCAZIANT 7 DAYS X 3 0 NCESIA 7 DAYSX3 0 NCRYSELLE 0.3-0.03MG 0 NCYCLESSA 7-7-7 0 NDESOGEN 0.15/0.3 0 NELLA 30MG 0 NENPRESSE 6-5-10 0 NERRIN 0.35MG 0 NESTROSTEP 5-7-9-7 0 NETHINYL ESTRADIOL/DESOGESTREL 0.03/0.15 0 NETHINYL ESTRADIOL/DROSPIRENONE 0.03-3 0 NETHINYL ESTRADIOL/LEVONORGESTREL 0.03-0.15MG, 0.1-0.02, 90-20 0 NETHINYL ESTRADIOL/NORETHINDRONE 35MCG/0.5MG, 35MCG/0.4MG 0 NETHINYL ESTRADIOL/NORETHINDRONE 35MCG/1MG, 20MCG/3MG 0 NETHINYL ESTRADIOL/NORETHINDRONE/IRON 35MCG-0.4MG CHEW 0 NETHYNODIOL DIACETATA/ETHINYL ESTRADIOL 1/0.035 0 NGIANVI 0.02-3(24) 0 NJOLESSA 0.15 MG/0.03 MG TAB 0 NJOLIVETTE 0.35MG 0 NJUNEL 1-0.02MG, 1.5-0.03MG 0 NJUNEL FE 1.5-0.03MG, 1-0.02MG 0 NKARIVA 21-5 0 NLEENA 7-9-5 0 NLESSINA 0.1-0.02 0 NLEVONORGESTREL 0.75MG, 1.5MG 0 NLEVONORGESTROL/ETH ESTRADIOL 6-5-10 0 NLEVONORGESTROL/ETH ESTRADIOL 0.15/0.03MG-ETHINYL ESTRADIOL 0.01MG 0 NLEVORA 0.15/0.03 0 NLO/OVRAL 0.3/0.03 0 NLOESTRIN 1.5/0.03, 1/0.02 0 NLOESTRIN 24 FE 0 NLOESTRIN FE 1.5/30, 1/20 0 NLO LOESTRIN FE 1/10 0 NLOSEASONIQUE 0 NLUTERA 0.1-0.02 0 NLYBREL 90-20 MCG TABLET 0 NMESTRANOL/NORETHINDRONE 50MCG/1MG 0 N



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MICROGESTIN 1.0-02MG, 1.5-0.03MG 0 NMICROGESTIN FE 1.5-0.035, 1.0-0.02 0 NMICRONOR 0.35MG 0 NMINASTRIN 24 FE CHEWABLE 1MG-20(24) 0 NMIRCETTE 21-5 0 NNATAZIA 3-2-1(28) 0 NNECON 10/11 0 NNECON 7 DAYS X 3 0 NNORA-BE 0.35MG 0 NNORDETTE 0.15/0.03 0 NNORETHINDRONE 0.35 0 NNORETHINDRONE/ETHINYL ESTRADIOL/FE FUMARATE 1.5-0.03, 1-0.02 0 NNORETHINDRONE/ETHINYL ESTRADIOL 0.5-0.035 0 NNORGESTIMATE/ETHINYL ESTRADIOL 0.25/0.035, 0.18-0.035/0.215-0.035/0.25-0.035 0 NNORGESTREL/ETHINYL ESTRADIOL 0.3/0.03 0 NNORTREL 7 DAYS X 3 0 NNORTREL 0.5-0.035,1.0-0.035 0 NOCELLA 0.03-3MG 0 NOGESTREL 0.5-0.05MG 0 NORTHO NOVUM 1/35, 7/7/7 0 NORTHO-CEPT 0.15/30 0 NORTHO-CYCLEN 0.25-0.035 0 NORTHO-TRI-CYCLEN 0 NORTHO-TRI-CYCLEN LO 7-7-7-LOW 0 NOVCON 1/0.05, 0.4/0.035 0 NPLAN B, PLAN B ONE-STEP 0 NPORTIA 0.15-0.03 0 NQUARTETTE 0.15MG 0 NQUASENSE 0.15/0.03 MG 0 NRECLIPSEN 0 NSAFYRAL 3-0.03 0 NSEASONALE 0 NSEASONIQUE 0 NSOLIA 0.15-0.03 0 NSPRINTEC 0.25-0.035MG 0 NSRONYX 0 NTILIA FE 5-7-9-7 0 NTRINESSA 7DAYS X 3 0 NTRI-NORINYL 7-9-5 0 NTRI-LEGEST FE 5-7-9-7 0 NTRI-PREVIFEM 7 DAYS X 3 0 NTRI-SPRINTEC 7 DAYS X 3 0 NVELIVET 7 DAYS X 3 0 NYASMIN 28 0 N



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YAZ 0 NZENCHENT 0.4-0.035 0 NZOVIA 1/0.05MG, 1/0.035MG 0 N

G8F-CONTRACEPTIVE, TRANSDERMAL (family planning)ORTHO-EVRA 20-150/24HR 0 N

G9B- CONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC (family planning)NUVA RING 0.12-0.015 0 N

H0B-LOCAL ANESTHETICSLIDOCAINE GEL 2% 0 NLIDOCAINE VISCOUS 2% 0 N

H0E-AGENTS TO TREAT MULTIPLE SCLEROSISAVONEX 30MCG 2 NBETASERON 0.3MG 2 NCOPAXONE 20MG 2 NGILENYA 0.5MG 2 NREBIF 22MCG/0.5ML,44MCG/0.5ML, TITRATION PACK (8.8MCG AND 22MCG) 2 N

BUTISOL SODIUM ELIXIR 30MG/5ML 2 YBUTISOL SODIUM TABS 30MG, 50MG 2 YPHENOBARBITAL 1/4GR, 1/2GR, 1GR, 1-1/2GR 0 NPHENOBARBITAL ELIXIR 20MG/5ML 0 NSECONAL SODIUM 100MG 2 Y

H2E-NON-BARB SEDATIVE-HYPNOTICCHLORAL HYDRATE SYRUP 500MG/5ML 0 NESTAZOLAM 1MG, 2MG 0 NFLURAZEPAM 15MG, 30MG 0 NMIDAZOLAM HCL SYRUP 2MG/ML, VIAL 5MG/ML 0 NSOMNOTE 500MG 0 NTEMAZEPAM 15MG, 30MG 0 NTRIAZOLAM 0.125MG, 0.25MG 0 NZALEPLON 5MG, 10MG 0 NZOLPIDEM 5MG, 10MG 0 N

H2F-ANTI-ANXIETY DRUGSALPRAZOLAM 0.25MG, 0.5MG, 1MG, 2MG 0 NBUSPIRONE 5MG, 7.5MG, 10MG, 15MG, 30MG 0 NCHLORDIAZEPOXIDE HCL 5MG, 10MG, 25MG 0 NCLORAZEPATE 3.75MG, 7.5MG, 15MG 0 NDIAZEPAM 2MG, 5MG, 10MG 0 NDIAZEPAM ORAL SOLN 5MG/ML, 5MG/5ML 0 NLORAZEPAM 0.5MG, 1MG, 2MG 0 NLORAZEPAM INTENSOL SOLN 2MG/ML 0 NMEPROBAMATE 200MG, 400MG 0 NOXAZEPAM 10MG, 15MG, 30MG 0 N

H2D-BARBITURATES (may be covered for dual eligible unless used for treatment of treatment of epilepsy, cancer, or chronic mental health disorders)



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H2G-ANTI-PSYCHOTICS PHENOTHIAZINESCHLORPROMAZINE 10MG, 25MG, 50MG, 100MG, 200MG 0 NFLUPHENAZINE DECANOATE INJ 25MG/ML 0 NFLUPHENAZINE HCL 1MG, 2.5MG, 5MG, 10MG 0 NFLUPHENAZINE SOLN 2.5MG/5ML, 5MG/ML 0 NPERPHENAZINE 2MG, 4MG, 8MG, 16MG 0 NTHIORIDAZINE 10MG, 25MG, 50MG, 100MG 0 NTRIFLUOPERAZINE HCL 1MG, 2MG, 5MG, 10MG 0 N

H2M-ANTI-MANIA DRUGSEQUETRO 100MG, 200MG, 300MG 2 NLITHIUM CARBONATE 150MG, 300MG, 600MG 0 NLITHIUM CARBONATE SR 300MG, 450MG 0 NLITHIUM CITRATE SYRUP 8MEQ/5ML 0 NLITHOBID 300MG 2 N

H2S-SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) CITALOPRAM 10MG/5ML 0 NCITALOPRAM HBR 10MG, 20MG, 40MG 0 NFLUOXETINE 10MG, 20MG, 40MG TABS, CAPS, 20MG/5ML 0 NFLUVOXAMINE MALEATE 25MG, 50MG, 100MG 0 NLEXAPRO 5MG, 20MG, 5MG/5ML 2 NPAROXETINE HCL 10MG, 20MG, 30MG, 40MG, 10MG/5ML 0 NSERTRALINE 25MG, 50MG, 100MG, 20MG/ML 0 N

H2U-TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB AMITRIPTYLINE HCL 10MG, 25MG, 50MG, 75MG, 100MG, 150MG 0 NAMOXAPINE 25MG, 50MG, 100MG, 150MG 0 NCLOMIPRAMINE 25MG, 50MG, 75MG 0 NDESIPRAMINE 10MG, 25MG, 50MG, 75MG, 100MG, 150MG 0 NDOXEPIN HCL 10MG, 25MG, 50MG, 75MG, 100MG, 150MG, 10MG/ML 0 NIMIPRAMINE HCL 10MG, 25MG, 50MG 0 NIMIPRAMINE PAMOATE 75MG, 100MG, 125MG, 150MG 0 NMAPROTILINE 25MG, 50MG, 75MG 0 NNORTRIPTYLINE 10MG, 25MG, 50MG, 75MG, 10MG/5ML ORAL 0 NPROTRIPTYLINE 5MG, 10MG 0 NSURMONTIL 25MG, 50MG, 100MG 2 NVIVACTIL 5MG, 10MG 2 N

H2V-TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY FOCALIN 2.5MG, 5MG, 10MG (AGE 6 AND OVER) 0 NFOCALIN XR 5MG, 10MG, 15MG, 20MG, 25MG, 30MG, 35MG, 40MG (AGE 6 AND OVER) 2 NMETADATE CD 10MG, 20MG, 30MG, 40MG, 50MG, 60MG (AGE 5 AND OVER) 2 NMETHYLIN 5MG/5ML, 10MG/5ML (AGE 5 AND OVER) 2 NMETHYLIN ER 10MG (AGE 5 AND OVER) 2 N

METHYLPHENIDATE HCL 5MG, 10MG, 20MG, 5MG/ML, 10MG/ML (AGE 5 AND OVER) 0 NMETHYLPHENIDATE ER (24 HOUR) 18MG, 27MG, 36MG, 54MG (AGE 6 AND OVER) 0 NMETHYLPHENIDATE SR 20MG (AGE 5 AND OVER) 0 N



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H2W-TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNS AMITRIPTYLINE/PERPHENAZINE 10/2, 10/4, 25/2, 25/4, 50/4 0 N

H2X-TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNS AMITRIPTYLINE/CHLORDIAZEPOXIDE 12.5/5, 25/10 0 N

H3A-NARCOTIC ANALGESICSBELLADONNA/OPIUM SUPPS 30-16.2MG, 60-16.2 0 NBUTORPHANOL NS 10MG/ML 0 NFENTANYL PATCH 12MG, 25MCG, 50MCG, 75MCG, 100MCG 0 NHYDROCODONE/APAP 2.5-167/5ML, 2.5-500 0 NHYDROCODONE/APAP 5-325, 5-500 0 NHYDROCODONE/APAP 7.5-325, 7.5-500, 7.5-650, 7.5-750 0 NHYDROCODONE/APAP 10-325, 10-500, 10-650, 10-660, 10-750 0 NHYDROMORPHONE SUPPS 3MG 0 NMEPERIDINE SYRUP 50MG/5ML 0 NMETHADONE SOLN 5MG/5ML, 10MG/5ML, 10MG/ML CONC SOLN 0 NMETHADOSE 10MG/ML 0 NMORPHINE SULFATE ER 15MG, 30MG, 60MG, 100MG, 200MG 0 NMORPHINE SULFATE SOLN 10MG/5ML, 20MG/ML, 20MG/5ML 0 NMORPHINE SULFATE SUPPS 5MG, 10MG, 20MG, 30MG 0 NOXYCODONE HCL 5MG/5ML, 20MG/ML 0 NOXYCODONE HCL/ACETA 2.5-325, 5-325, 5-500, 7.5-325, 7.5-500, 10-325, 10-650 0 NOXYCODONE HCL/OXY T/ASA 4.5/0.38/325 0 NROXICET ORAL SOLN 5MG/325MG 0 NTRAMADOL 50MG 0 N

ASPIRIN EC 81MG, 325MG 0 YCHOLINE MAGNESIUM TRISALICYLATE 500MG, 750MG 0 NCHOLINE MAGNESIUM TRISALICYLATE LIQUID 500MG/5ML 0 NMAGNESIUM SALICYLATE 600MG 0 NSALSALATE 500MG, 750MG 0 N

ACETAMINOPHEN SUPPOSITORIES 120MG, 325MG, 650MG 0 YH3F-ANTIMIGRAINE PREPARATIONS

CAFERGOT 1-100MG 2 NCAFFEINE-ERGOTAMINE SUPPOSITORIES 0 NERGOTAMINE/CAFFEINE TABS 1-100MG 0 NIMITREX INJ 4MG/0.5ML, 6MG/0.5ML 0 NIMITREX NASAL 5MG, 20MG 0 NMAXALT-MLT 5MG, 10MG 0 NMIGRANAL NASAL 0.5MG/SPRAY 2 NNARATRIPTAN 1MG, 2.5MG 0 NRIZATRIPTAN 5MG, 10MG 0 NSUMATRIPTAN 25MG, 50MG, 100MG 0 N

H3D-ANALGESIC/ANTIPYRETICS, SALICYLATES (may be covered for dual eligible if available over the counter)

H3E-ANALGESIC, ANTIPYRETIC-NON-SAL (may be covered for dual eligible if available over the counter)



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ACETAMINOPHEN/BUTALBITAL 325MG/50MG, 650MG/50MG 0 YPHRENILIN FORTE 2 Y

BUTALBITAL/ACETAMINOPHEN/CAFFEINE 325/40/50 CAP, TAB 0 YBUTALBITAL/ACETAMINOPHEN/CAFFEINE 500-40-50 TAB 0 Y

H3T-NARCOTIC ANTAGONISTSNALTREXONE HCL 50MG 0 N

H3U-NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB ACETAMINOPHEN/CODEINE 15-300, 30-300, 60-300 0 NACETAMINOPHEN/CODEINE ELIXIR 120-12MG/5ML 0 N

H4B-ANTICONVULSANTSBANZEL 200MG, 400MG, 40MG/ML 2 NCARBAMAZEPINE 100MG, 200MG, 100MG/5ML 0 NCARBATROL 100MG, 200MG, 300MG 2 0 NCELONTIN 300MG 2 NCLONAZEPAM 0.5MG, 1MG, 2MG 0 NDEPAKENE 250MG (BMN ONLY) 2 NDEPAKENE SYRUP 250MG/5ML (BMN ONLY) 2 NDIASTAT ACUDIAL 2.5, 10, 20 2 0 NDILANTIN 30MG, 50MG CHEWABLE, 100MG 2 NDILANTIN SUSP 125MG/5ML 2 NDIVALPROEX SODIUM 125MG TAB, 125MG SPRINKLE CAP, 250MG, 500MG 0 NDIVALPROEX SODIUM ER 250MG, 500MG 0 NETHOSUXIMIDE 250MG, SYRUP 250MG/5ML 0 NFELBATOL 400MG, 600MG 2 NFELBATOL SUSP 600MG/5ML 2 NGABAPENTIN 100MG, 300MG, 400MG, 600MG, 800MG, 250MG/5ML 0 NGABITRIL 2MG, 4MG, 12MG, 16MG 2 NKEPPRA XR 500MG, 750MG 2 NLAMICTAL ODT 25MG, 50MG, 100MG, 200MG, 25(21)-50, 50(42)-100, 25-50-100 2 NLAMICTAL STARTER KIT ORANGE, BLUE, GREEN 2 NLAMICTAL XR 25MG, 50MG, 100MG, 200MG, 250MG, STARTER KIT ORANGE, BLUE, GREEN 2 NLAMOTRIGINE DISPER TAB 5MG, 25MG 0 NLAMOTRIGINE TAB 25MG, 100MG, 150MG, 200MG, STARTER KIT 0 NLEVETIRACETAM 250MG, 500MG, 750MG, 1000MG, 100MG/ML 0 NLYRICA 25MG, 50MG, 75MG, 100MG, 150MG, 200MG, 225MG, 300MG 2 NMEBARAL 32MG, 50MG, 100MG 2 NMEPHOBARBITAL 32MG, 50MG, 100MG 0 NMYSOLINE 250MG (BMN ONLY) 2 NMYSOLINE 50MG 2 NNEURONTIN 250MG/5ML 2 N

H3K-ANALGESIC, NON-SALICYLATE & BARBITURATE COMB. (barbiturates may be covered for dual eligible unless used for treatment of treatment of epilepsy, cancer, or chronic mental health disorders)

H3L-ANALGESIC,NON-SALICYLATE,BARBITURATE,&XANTHINE CMB (barbiturates may be covered for dual eligible unless used for treatment of treatment of epilepsy, cancer, or chronic mental health disorders)



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ONFI 5MG, 10MG, 20MG 2 NOXCARBAZEPINE 150MG, 300MG, 600MG, 300MG/5ML 0 NPEGANONE 250MG 2 NPHENYTEK 200MG, 300MG 2 NPHENYTOIN SODIUM 100MG, ER100MG 0 NPHENYTOIN SODIUM EXTENDED 200MG, 300MG 0 NPHENYTOIN SUSP 125MG/5ML 0 NPRIMIDONE 250MG 0 NPRIMIDONE 50MG 0 NSABRIL 500MG PACKETS, TABLETS 2 NTEGRETOL 100MG, 200MG (BMN ONLY) 2 NTEGRETOL SUSP 100MG/5ML (BMN ONLY) 2 NTEGRETOL XR 100MG, 200MG, 400MG 2 0 NTOPIRAMATE 25MG, 50MG, 100MG, 200MG 0 NTOPIRAMATE SPRINKLE 15MG, 25MG 0 NTRILEPTAL 300MG/5ML 2 NVALPROIC ACID 250MG 0 NVALPROIC ACID SYRUP 250MG/5ML 0 NVIMPAT 50MG, 100MG, 150MG, 200MG, 10 MG/ML 2 NZARONTIN 250MG 0 NZARONTIN SYRUP 250MG/5ML 2 NZONISAMIDE 25MG, 50MG, 100MG 0 N

H6A-ANTIPARKINSON DRUGS, OTHERAMANTADINE HCL 100MG 0 NAMANTADINE SYRUP 50MG/5ML 0 NBROMOCRIPTINE 2.5MG, 5MG 0 NCARBIDOPA/LEVODOPA 10/100, 25/100, 25/250 0 NCARBIDOPA/LEVODOPA CR 25/100, 50/200 0 NCOMTAN 200MG 2 NENTACAPONE 200MG 0 NPARLODEL 2.5MG, 5MG 2 NPRAMIPEXOLE 0.125MG, 0.25MG, 0.5MG, 0.75MG, 1MG, 1.5MG 0 NROPINIROLE 0.25MG, 0.5MG, 1MG, 2MG, 3MG, 4MG, 5MG 0 NSELEGILINE HCL 5MG 0 N

H6B-ANTIPARKINSONISM DRUGS, ANTICHOLINERGIC BENZTROPINE 0.5MG, 1MG, 2MG 0 NTRIHEXIPHENIDYL HCL 2MG, 5MG, 2MG/5ML 0 N

H6C-ANTITUSSIVE NON-NARC (may be covered for dual eligible)BENZONATATE 100MG, 200MG 0 YDELSYM 30MG/5ML 2 YDEXTROMETHORPHAN HBR 5MG/5ML, 15MG/5ML 0 YROBITUSSIN PEDIATRIC 7.5MG/5ML 2 Y

H6H-SKELETAL MUSCLE RELAXANTSBACLOFEN 10MG, 20MG 0 NCHLORZOXAZONE 250MG, 500MG 0 NCYCLOBENZAPRINE 5MG, 10MG 0 N



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DANTROLENE 25MG, 50MG, 100MG 0 NMETHOCARBAMOL 500MG, 750MG 0 NTIZANIDINE HCL 2MG, 4MG 0 N

H6J-ANTIEMETIC/ANTIVERTIGO AGENTSANTI-NAUSEA LIQUID 0 NCESAMET 1MG 2 NDIMENHYDRINATE 50MG 0 NEMEND 40MG, 80MG, 125MG, 125-80 2 NMARINOL 2.5MG, 5MG, 10MG 0 NMECLIZINE 12.5MG, 25MG CHEWABLE, 25MG 0 NONDANSETRON 4MG, 8MG, 24MG 0 NONDANSETRON ODT 4MG, 8MG 0 NONDANSETRON ORAL SOLUTION 4MG/5ML 0 NPROCHLORPERAZINE MALEATE 5MG, 10MG 0 NPROCHLORPERAZINE MALEATE SUPP 25MG 0 NPROMETHAZINE SUPPS, 12.5MG, 25MG, 50MG 0 NTRANSDERM SCOP PATCH 1.5MG/72HRS 2 NTRIMETHOBENZAMIDE HCL 300MG 0 N

H6L-MOVEMENT DISORDERS (DRUG THERAPY) XENAZINE 12.5MG, 25MG 2 N

H7B-ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS MIRTAZAPINE 7.5MG, 15MG, 30MG, 45MG 0 NMIRTAZAPINE RAPID DISSOLVE TABLET 15MG, 30MG, 45MG 0 N

H7C-SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) VENLAFAXINE HCL 25MG, 37.5MG, 50MG, 75MG, 100MG TABS 0 NVENLAFAXINE ER CAPSULE 37.5MG, 75GM, 150MG 0 N

H7D-NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION HCL 75MG, 100MG 0 NBUPROPION SR 100MG, 150MG, 200MG 0 NBUPROPION XL 150MG, 300MG 0 N

H7E-SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) NEFAZODONE HCL 50MG, 100MG, 150MG, 200MG, 250MG 0 NTRAZODONE HCL 50MG, 100MG, 150MG 0 N

H7J-MAOIS - NON-SELECTIVE & IRREVERSIBLE H7N-SMOKING DETERRENTS, OTHER

BUPROPION SR 150MG 0 NH7O-ANTIPSYCHOTICS, DOPAMINE ANTAGONISTS, BUTYROPHENONES

HALDOL DECANOATE 50MG/ML, 100MG/ML 2 NHALOPERIDOL 0.5MG, 1MG, 2MG, 5MG, 10MG, 20MG 0 NHALOPERIDOL DECANOATE 50MG/ML, 100MG/ML 0 NHALOPERIDOL LACTATE CONC LIQUID 2MG/ML 0 N

H7P-ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENES NAVANE 20MG 2 NTHIOTHIXENE 1MG, 2MG, 5MG, 10MG 0 N

H7R-ANTIPSYCH, DOPAMINE ANTAGONIST, DIPHENYLBUTYLPIPERIDINES ORAP 1MG, 2MG 2 N



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H7S-ANTIPSYCHOTICS, DOPAMINE ANTAGONIST, DIHYDROINDOLONES MOBAN 10MG, 25MG, 50MG 2 N

H7T-ANTIPSYCHOTICS, ATYPICAL,DOPAMINE, & SEROTONIN ANTAG INVEGA SUSTENNA 39MG, 78MG, 117MG, 156MG, 234MG 0 NQUETIAPINE 25MG, 50MG, 100MG, 200MG, 300MG, 400MG 0 NRISPERDAL CONSTA 12.5MG, 25MG, 37.5MG, 50MG 0 NRISPERIDONE 0.25MG, 0.5MG, 1MG, 2MG, 3MG, 4MG, 1MG/ML 0 NRISPERIDONE ODT 0.25MG, 0.5MG, 1MG, 2MG, 3MG, 4MG 0 NZIPRASIDONE 20MG, 40MG, 60MG, 80MG 2 NZYPREXA RELPREVV 210MG, 300MG, 405MG 0 N

H7U-ANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTS LOXAPINE SUCCINATE 5MG, 10MG, 25MG, 50MG 0 N

H7X-ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED ABILIFY MAINTENA 300MG, 400MG 0 N

H7Y-TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE STRATTERA 10MG, 18MG, 25MG, 40MG, 60MG, 80MG, 100MG (AGE 6 AND OLDER) 2 N

H7Z-SSRI &ANTIPSYCH, ATYP, DOPAMINE & SEROTONIN ANTAG COMB H8M-TX FOR ADHD - SELECTIVE ALPHA-2 RECEPTOR AGONIST

INTUNIV ER 1MG, 2MG, 3MG, 4MG 2 NH8O-PSEUDOBULBAR AFFECT (PBA) AGENTS, NMDA ANTAGONISTS

NUEDEXTA 20-10 2 NH8P-SSRI & SEROTONIN PARTIAL AGONIST ANTIDEPRESSANT J1A-PARASYMPATHETIC AGENTS

BETHANECHOL CHLORIDE 5MG, 10MG, 25MG, 50MG 0 NEVOXAC 30MG 2 NGUANIDINE HCL 125MG 2 NPILOCARPINE HCL 5MG, 7.5MG 0 NSALAGEN 5MG 2 N

J1B-CHOLINESTERASE INHIBITORSDONEPEZIL 5MG, 10MG 0 NDONEPEZIL ODT 5MG, 10MG 0 NEXELON 1.5MG, 3MG, 4.5MG, 6MG, 2MG/ML 0 NGALANTAMINE 4MG, 8MG, 12MG, 4MG/ML 0 NGALANTAMINE ER 8MG, 16MG, 24MG 0 NMESTINON 180MG 2 NMESTINON 60MG/5ML LIQUID 2 NMYTELASE 10MG 2 NPROSTIGMIN 15MG 2 NPYRIDOSTIGMINE BROMIDE 60MG 0 N

J2A-BELLADONNA ALKALOIDSHYOMAX-FT 0.125MG 2 NHYOMAX-SL 0.125MG 2 NHYOSCYAMINE 0.125MG 0 NHYOSCYAMINE 0.125MG, 0.25MG RAPID DISSOLVE 0 NHYOSCYAMINE 0.125MG/ML, 0.125MG/5ML 0 NHYOSCYAMINE SR 0.375MG 0 N



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METHSCOPOLAMINE BROMIDE 2.5MG 0 NNULEV 0.125MG 2 NSYMAX 0.125MG 2 N

J2B-ANTICHOLINERGIC, QUATERNARY AMMONIUM CUVPOSA 1MG/5ML 2 NCANTIL 25MG 2 NGLYCOPYRROLATE 1MG, 2MG 0 NPROPANTHELINE 15MG 0 N

J2D-ANTICHOLINERGIC ANTISPASMODICSDICYCLOMINE HCL 10MG, 20MG, 10MG/5ML 0 N

J3A-SMOKING DETERRENT AGENTS (GANGLIONIC STIM, OTHERS) COMMIT 2MG, 4MG 2 NNICODERM CQ PATCH 7MG/24HR, 14MG/24HR, 21MG/24HR 0 NNICORETTE GUM 2MG, 4MG 2 NNICOTINE GUM 2MG, 4MG 0 NNICOTINE LOZENGE 2MG, 4MG 0 NNICOTINE PATCH 7MG/24HR, 14MG/24HR, 21MG/24HR 0 NNICOTROL INHALER 2 NNICOTROL NASAL SPRAY 2 N

J3C-SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONISTCHANTIX 0.5MG, 1MG, MONTH PAK 2 N

J5B-ADRENERGICS, AROMATIC, NON-CATECHOLAMINE ADDERALL XR 5MG, 10MG, 15MG, 20MG, 25MG, 30MG 0 NAMPHETAMINE SALT COMBO 5MG, 7.5MG, 10MG, 12.5MG, 15MG, 20MG, 30MG 0 NVYVANSE 20MG, 30MG, 40MG, 50MG, 60MG, 70MG 2 N

J5D-BETA ADRENERGIC AGENTSACCUNEB (AGE 0 TO 12 ONLY) 0.21MG/ML, 0.42MG/ML * NALBUTEROL (AGE 0 TO 12 ONLY) 0.21MG/ML, 0.42MG/ML * NALBUTEROL 0.83MG/ML SOLN FOR INH 0 NALBUTEROL 2MG, 4MG 0 NALBUTEROL 2MG/5ML SYRUP 0 NALBUTEROL 5MG/ML SOLN FOR INH 0 NALBUTEROL ER 4MG, 8MG 0 NMETAPROTERENOL 10MG, 20MG 0 NMETAPROTERENOL 10MG/5ML SYRUP 0 NPROAIR HFA 0 NPROVENTIL HFA 2 NTERBUTALINE SO4 2.5MG, 5MG 0 NVENTOLIN HFA 2 N

J5E-SYMPATHOMIMETIC AGENTSEPHEDRINE SULFATE 25MG 0 NPHENYLEPHRINE HCL 10MG 0 NPSEUDOEPHEDRINE HCL 30MG, 60MG 0 NPSEUDOEPHEDRINE HCL 15MG/5ML, 30MG/5ML 0 N



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J5F-ANAPHYLAXIS THERAPY AGENTS ADRENACLICK 0.15MG, 0.3MG 2 NAUVI-Q 0.15MG, 0.3MG 2 NEPINEPHRINE AUTO-INJECTOR 0.15MG, 0.3MG 0 NEPIPEN, EPIPEN JR 0.15MG 2 NTWINJECT 0.15MG/0.15ML, 0.3MG/0.3ML 2 N

J5H-ADRENERGIC VASOPRESSOR AGENTS MIDODRINE HCL 2.5MG, 5MG, 10MG 0 N

J5J-BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS COMBIVENT 103-18MCG 2 NIPRATROPIUM - ALBUTEROL NEBULIZER SOLUTION 0.5MG-3MG/3ML 0 N

J7A-ALPHA/BETA-ADRENERGIC BLOCKING AGENTSCARVEDILOL TABLETS 3.125MG, 6.25MG, 12.5MG, 25MG 0 NLABETALOL 100MG, 200MG, 300MG 0 N

J7B-ALPHA-ADRENERGIC BLOCKING AGENTS DOXAZOSIN MESYLATE 1MG, 2MG, 4MG, 8MG 0 NPRAZOSIN HCL 1MG, 2MG, 5MG 0 NTERAZOSIN HCL 1MG, 2MG, 5MG, 10MG 0 N

J7C-BETA ADRENERGIC BLOCKERSACEBUTOLOL 200MG, 400MG 0 NATENOLOL 25MG, 50MG, 100MG 0 NBETAXOLOL HCL 10MG, 20MG 0 NBISOPROLOL FUM 5MG, 10MG 0 NMETOPROLOL SUCCINATE 25MG, 50MG, 100MG, 200MG 0 NMETOPROLOL TARTRATE 25MG, 50MG, 100MG 0 NNADOLOL 20MG, 40MG, 80MG 0 NPINDOLOL 5MG, 10MG 0 NPROPRANOLOL 20MG/5ML, 40MG/5ML SOLN 2 NPROPRANOLOL HCL 10MG, 20MG, 40MG, 60MG, 80MG 0 NPROPRANOLOL LA 60MG, 80MG, 120MG, 160MG 0 NSOTALOL 80MG, 120MG, 160MG, 240MG 0 NTIMOLOL MALEATE 5MG, 10MG, 20MG 0 N

J7H-BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & RELATED ATENOLOL/CHLORTHALIDONE 25/50, 25/100 0 NBISOPROLOL FUMARATE/HCTZ 6.25/2.5, 6.25/5, 6.25/10 0 NDUTOPROL 25/12.5MG, 50/12.5MG, 100/12.5MG 2 NMETOPROLOL/HCTZ 50/25, 100/25, 100/50 0 NNADOLOL/BENDROFLUMETHIAZIDE 40-5MGMG, 80-5MG 0 NPROPRANOL/HCTZ 25/40, 25/80 0 N

J9A-INTESTINAL MOTILITY STIMULANTSMETOCLOPRAMIDE HCL 5MG, 10MG 0 NMETOCLOPRAMIDE HCL 5MG/5ML ORAL SOLN 0 N

L0B-TOPICAL/MUCOUS MEMBRANE/SUBCUTANEOUS ENZYMESANTYL 2 N

L1A-ANTIPSORIATIC AGENTS, SYSTEMIC SORIATANE 10MG, 17.5MG, 22.5MG, 25MG 2 N



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L2A-EMOLLIENTSAMERIPHOR MOIST OINTMENT 0 NAMMONIUM LACTATE 12% CREAM, LOTION 0 NATRAC-TAIN 10% 2 NDERMAPHOR OINTMENT 0 NKERI ORIGINAL MOIST THERAPY LOTION, SENSITIVE SKIN LOTION 2 NMINERIN CREME 0 NNOURIVA REPAIR CREAM 0 NPETROLATUM BASE OINTMENT 0 N

L3A-PROTECTIVES (may be covered for dual eligible if available over the counter)ALOE VESTA 2 YBAZA PROTECT 2 YDERMAPHOR 44% 2 YDERMAGRAN OINT, SPRAY 2 YDERMAMED OINT 2 YPELEVERUS, PELEVERUS CLEAR, PELEVERUS WOUND SPRAY 2 YREMEDY SKIN REPAIR CREAM 1.5% 2 YSENSI-CARE MOIST BARRIER OINT, PROTECT BARRIER OINT 2 Y

L3P-ANTIPRURITICS TOPICALDIPHENHYDRAMINE 2% CREAM 0 NPRUDOXIN 5% 2 NZONALON 5% 2 N

L5A-KERATOLYTICSBENZOYL PEROXIDE CLEANSER 6%, 9% 0 NBENZOYL PEROXIDE CREAMY WASH 4%, 8% 0 NBENZOYL PEROXIDE GEL 2.5%, 4%, 5%, 8%, 10% 0 NBENZOYL PEROXIDE LOTION 4%, 5%, 10% 0 NBENZOYL PEROXIDE WASH 2.5%, 5%, 10% 0 NCARMOL 40% CREAM, LOTION, GEL 2 NCONDYLOX GEL 0.5% 2 NCONDYLOX TOP SOLN 0.5% 0 NHYDRISALIC GEL 2 NKEROL 50%, AD 45% EMULSION 2 NPANOXYL 10% 2 NREMEVEN 50% CREAM 2 NSAL-PLANT GEL 17% 2 NSALACTIC FILM 16.7% 2 NSALICYLIC ACID 3%, 6% SHAMPOO 0 NSALICYLIC ACID 6% CREAM KIT 0 NSALICYLIC ACID 6% LOTION KIT 0 NSEBULEX SHAMPOO 2%-2% 2 NUREA CLOTHS 42% 0 NUREA CREAM, GEL 40% 0 NUREA EMULSION 50% 0 N



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UREA LOTION 35% 0 NUREA NAILSTICK 50% 2 NUREA TOPICAL SUSPENSION 50% 0 N

L5E-ANTISEBORRHEIC AGENTS SELENIUM SULFIDE 1% SHAMPOO, 2.5% LOTION, SHAMPOO 0 N

L5F-ANTIPSORIATICSCALCIPOTRIENE 0.005% OINTMENT, SOLUTION 0 NDOVONEX CREAM, SOLN 0.005% 2 NTAZORAC GEL 0.05%, 0.1%(AGES 0-23) 2 N

L5G-ROSACEA AGENTS, TOPICAL METROGEL 1% 2 NMETROLOTION 0.75% 2 NMETRONIDAZOLE 0.75% TOPICAL CREAM, GEL 0 NNORITATE 1% 2 N

L5H-ACNE AGENTS, TOPICALAZELEX 20% CREAM 2 NBENZACLIN 1-5% PUMP 2 NCLINDAMYCIN /BENZOYL PEROXIDE GEL 1%-5% 0 NKLARON LOTION 10% 0 N

L6A-IRRITANTS/COUNTER-IRRITANTS BETATAR SHAMPOO 2.5% 0 NCAPSAICIN 0.025%, 0.075%, 0.1% CREAM 0 NZIKS OINT 2 N

L9A-MISC TOPICAL AGENTSUREA CREAM, LOTION 10% 0 NUREA LOTION 40% 0 NWOUN'DRES 2 N

L9B-VITAMIN A DERIVATIVES RETIN A MICRO 0.04%, 0.1% (AGES 0-23) 2 NTRETINOIN CREAM 0.025%, 0.05%, 0.1% (AGES 0-23) 0 NTRETINOIN GEL 0.01%, 0.025% (AGES 0-23) 0 N

M0C-BLOOD FACTORS,MISCELLANEOUS CORIFACT KIT 2 N

M0E-ANTIHEMOPHILIC FACTORS ADVATE 2 NALPHANATE 2 NBIOCLATE 2 NFEIBA NF 2 NFEIBA VH IMMUNO 2 NHELIXATE FS 2 NHEMOFIL-M 2 NHEMOFIL-T 2 NHUMATE-P 2 NKOATE-DVI 2 NKOGENATE FS 2 NMONOCLATE-P 2 N



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NOVOSEVEN RT 2 NRECOMBINATE 2 NXYNTHA KIT, SOLOFUSE 2 N

M0F-FACTOR IX PREPARATIONS BEBULIN VH IMMUNO 2 NBENEFIX 2 NMONONINE 2 NPROFILNINE SD 2 NPROPLEX SX 2 N

M4D-ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS ATORVASTATIN 10MG, 20MG, 40MG, 80MG 0 NLOVASTATIN 10MG, 20MG, 40MG 0 NPRAVASTATIN 10MG, 20MG, 40MG, 80MG 0 NSIMVASTATIN 5MG, 10MG, 20MG, 40MG, 80MG 0 N

M4E-LIPOTROPICSANTARA 43MG, 130MG 2 NFISH OIL 340-1000, 360-1200, 435-880, 500-1000, 1000 0 NGEMFIBROZIL 600MG 0 NNIASPAN 500MG, 750MG, 1000MG 2 NTRICOR 48MG, 145MG 2 0 NTRILIPIX 45MG, 135MG 2 N

M4G-HYPERGLYCEMICSGLUCACON 1MG, EMERGENCY KIT 1MG 2 NGLUCOSE 4G CHEWABLE 0 NPROGLYCEM 50MG/ML 2 N

M4L-ANTIHYPERLIPIDEMIC-HMG COA REDUCTASE INHIB.&NIACIN SIMCOR 500-20, 500-40, 750-20, 1000-20, 1000-40 2 N

M9D-ANTIFIBRINOLYTIC AGENTSAMICAR 250MG/ML SYRUP 0 NAMICAR 500MG, 1000MG 2 NLYSTEDA 650MG 2 N

M9K-HEPARIN AND RELATED PREPARATIONSFRAGMIN 2500U, 5000U 2 NFRAGMIN 7500U, 10000U, 12500U, 15000U, 18000U, 25000U 2 NHEPARIN 10U/ML, 100U/ML 0 NLOVENOX 30MG, 40MG, 60MG, 80MG, 100MG, 120MG, 150MG INJ 2 N

M9L-ANTICOAGULANTS, COUMARIN TYPE WARFARIN SODIUM 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 0 N

M9P-PLATELET AGGREGATE INHIBAGGRENOX 25-200MG 2 NBRILINTA 90MG 2 NCILOSTAZOL 50MG, 100MG 0 NCLOPIDOGREL 75MG 0 NDIPYRIDAMOLE 25MG, 50MG, 75MG 0 NEFFIENT 5MG, 10MG 2 NTICLOPIDINE 250MG 0 N



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M9S-HEMORRHEOLOGIC AGENTSPENTOXIFYLLINE 400MG 0 N

M9V-DIRECT FACTOR XA INHIBITORS XARELTO 10MG, 15MG, 25MG 2 N

N1C-LEUKOCYTE STIMULANTSLEUKINE 250MCG, 500MCG INJ 2 NNEULASTA 6MG/0.6ML 2 NNEUPOGEN 300MCG/ML, 600MCG/ML INJ 2 N

N1D-PLATELET REDUCING AGENTS ANAGRELIDE HCL 0.5MG, 1MG 0 N

N1E-PLATELET PROLIFERATION STIMULANTS NEUMEGA 5MG INJ 2 N

NIF-THROMBOPOIETIN RECEPTOR AGONISTS PROMACTA 25MG, 50MG, 75MG 2 N

P1B-SOMATOSTATIC AGENTSOCTREOTIDE 0.05MG/ML, 0.1MG/ML, 0.2MG/ML, 0.5MG/ML, 1MG/ML 0 N

P1F-PITUITARY SUPPRESSIVE AGENTSCABERGOLINE 0.5MG 0 NDANAZOL 50MG, 100MG, 200MG 0 NDANOCRINE 50MG, 100MG, 200MG 2 N

P1M-LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS SYNAREL 2MG/ML NASAL SOLN 2 N

P2B-ANTIDIURETIC AND VASOPRESSOR HORMONESDDAVP 0.1MG, 0.2MG 2 NDDAVP 4MCG/ML INJ 2 NDDAVP NASAL 0.01%, SPRAY PUMP 10MCG/DOSE 2 NDESMOPRESSIN ACETATE INJ 4MCG/ML 0 NDESMOPRESSIN ACETATE 0.1MG, 0.2MG TABS, NASAL 0.1MG/ML 0 N

P3A-THYROID HORMONESARMOUR THYROID 15MG, 30MG, 60MG, 100MG, 120MG, 180MG, 240MG, 300MG 2 NCYTOMEL 5MCG, 25MCG, 50MCG 0 NLEVOTHROID 0.0137 0 NLEVOTHYROXINE SODIUM 0.025, 0.05, 0.075, 0.88, 0.1, 0.112, 0.125MG 0 NLEVOTHYROXINE SODIUM 0.137, 0.15, 0.175, 0.2, 0.3MG 0 NTHYROID 30MG, 60MG, 120MG 0 NTHYROLAR 1/4, 1/2, 1, 2, 3 STRENGTH 2 N

P3L-ANTITHYROIDSMETHIMAZOLE 5MG, 10MG 0 NPROPYLTHIOURACIL 50MG 0 N

P4D-HYPERPARATHYROID VITAMIN D ANALOGHECTOROL 0.5MG, 1MG, 2.5MG 2 NZEMPLAR 1MCG, 2MCG, 4MCG 2 N



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P4L-BONE RESORPTION INHIBITORS ALENDRONATE 5MG, 10MG, 35MG, 40MG, 70MG 0 NEVISTA 60MG 2 NFORTICAL 0 NMIACALCIN NASAL SOLN 200U/DOSE 0 N

P4M-CALCIMIMETIC,PARATHYROID CALCIUM ENHANCER SENSIPAR 30MG, 60MG, 90MG 2 N

P5A-GLUCOCORTICOIDSASMANEX 2 NBUDESONIDE EC 3MG 0 NCELESTONE 0.6MG/5ML SOLN 2 NCORTEF 5MG, 10MG 2 NCORTISONE ACETATE 25MG 0 NDEXAMETHASONE 0.5MG, 0.75MG, 1MG, 1.5MG, 2MG, 4MG, 6MG 0 NDEXAMETHASONE 1MG/ML, 0.5MG/5ML 0 NDEXPAK 1.5MG 2 NENTOCORT EC 3MG 2 NFLOVENT DISKUS 50MCG, 100MCG, 250MCG 2 NFLOVENT HFA SPRAY 44MCG, 110MCG, 220MCG 2 NHYDROCORTISONE 5MG, 10MG, 20MG 0 NMEDROL 2MG, 16MG 2 NMEDROL 8MG 0 NMETHYLPREDNISOLONE TABLET 4MG, 16MG, 32MG 0 NMILLIPRED 10MG/5ML 2 NMILLIPRED 5MG 2 NORAPRED ODT TAB 10MG, 15MG, 30MG 2 NPEDIAPRED LIQUID 6.7MG/5ML 2 NPREDNISOLONE ORAL SOLN 15MG/5ML, 5MG/5ML 0 NPREDNISONE 1MG, 2.5MG, 5MG, 10MG, 20MG, 50MG, 5MG/5ML, 5MG/ML 0 NPULMICORT 0.25MG/2ML, 0.5MG/2ML, 1MG/2ML (AGES 0-8) * NQVAR INH 0.04MG, 0.08MG PER ACTUATION 2 NVERIPRED 20MG/5ML 2 NZEMA-PAK 1.5MG 2 N

P5S-MINERALOCORTICOIDSFLUDROCORTISONE 0.1MG 0 N

Q2C-OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPE RESTASIS 0.05% 2 N

Q3A-RECTAL PREPSANUSOL HC 2.5% CREAM 2 NHYDROCORTISONE CREAM 2.5% 0 NPROCTOCORT 1% 2 NPROCTOCREAM HC 2.5% 2 NPROCTOSOL HC 2.5% 2 NPROCTOZONE HC 2.5% 2 N

Q3B-RECTAL/LOWER BOWEL PREP., GLUCOCORTICOID (NON-HEMORRHOID)HYDROCORTISONE ENEMA 100MG 0 N



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Q3D-HEMORRHOIDAL PREPSHEMORRHOIDAL OINT, SUPP 0 N

Q3E-CHRONIC INFLAMMATORY COLON DX, 5-A-SALICYLAT, RECTAL TX CANASA 1000MG 2 NMESALAMINE ENEMA 4G/60ML 0 N

Q3S-LAXATIVES, LOCAL/RECTAL (may be covered for dual eligible if available over the counter)BISACODYL 10MG SUPPOSITORY 0 YDOCUSOL MINI ENEMA 2 YENEMEEZ MINI ENEMA 2 YENEMEEZ PLUS MINI ENEMA 2 YFLEET BISACODYL 10MG, MINERAL OIL, PEDIALAX, SODIUM PHOSPHATE ENEMA 2 YMINERAL OIL ENEMA 0 YSODIUM PHOSPHATE ENEMA 0 Y

Q4F-VAGINAL ANTIFUNGALSCLOTRIMAZOLE VAG CREAM, SUPPS 0 NGYNAZOLE-1 2 NGYNE-LOTRIMIN 3 DAY 2% CRM 2 NMICONAZOLE NITRATE VAG CREAM 2% 0 NMICONAZOLE VAG SUPPS 100MG, 200MG 0 NMICONAZOLE VAGINAL COMBO PAK 200MG-2%, 1200-2% CREAM 0 NNYSTATIN 100000U VAG TABS 0 NTERAZOL 3 VAG CREAM 0.8% 2 NTERAZOL 3 VAG TABS 2 NTERAZOL 7 VAG CREAM 0.4% 2 NTERCONAZOLE VAG CREAM 0.4%, 0.8% 0 NTERCONAZOLE VAG SUPPOSITORY 80MG 0 NTICONAZOLE-1 6.5% 0 N

Q4K-VAGINAL ESTROGENS ESTRING 7.5MCG/24HR 2 N

PREMARIN VAG CREAM 0.625MG/GM 2 NQ4S-VAGINAL SULFONAMIDES

AVC 15% VAG CREAM 2 NQ4W-VAGINAL ANTIBIOTICS

CLEOCIN VAG TAB 100MG 2 NCLINDAMYCIN VAG CREAM 2% 0 NCLINDESSE 2% 2 NMETROGEL VAGINAL 0.75% 2 NMETRONIDAZOLE VAGINAL GEL 0.75% 0 N

Q5A-TOPICAL PREPS, MISC (may be covered for dual eligible if available over the counter)ALUMINUM ACETATE ASTRINGENT PAD 0 YNAIL SCRUB 2 Y

Q5B-TOPICAL ANTIBACTERIALSPHISOHEX 3% 2 NPOVIDONE-IODINE OINT, SCRUB, SOLN 0 N



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Q5F-TOPICAL ANTIFUNGALSCLOTRIM/BETAMETH CRM, LOTION 0 NCLOTRIMAZOLE CREAM 1%, AF CREAM, SOLUTION 0 NCICLOPIROX 0.77% CREAM, SHAMPOO, SUSPENSION 0 NCICLOPIROX 8% SOLUTION 0 NECONAZOLE NITRATE 1% CREAM 0 NFUNGOID TR 2 NKETOCONAZOLE 2% CREAM 0 NKETOCONAZOLE SHAMPOO 2% 0 NLOPROX GEL 0.77% 0 NMICONAZOLE NITRATE CREAM 2% 0 NNYSTATIN CREAM, OINT, PDR 100000U/GM 0 NNYSTATIN TRIAMCINOLONE CREAM, OINT 0 NTERBINAFINE 1% CREAM 0 NTOLNAFTATE CREAM, POWDER, SOLN 1% 0 N

Q5H-TOPICAL LOCAL ANESTHETICSEMLA CREAM 2.5%/2.5% 2 NL.M.X.4 4% 2 NL.M.X.4 PLUS 4% 2 NLIDOCAINE OINT 5% 0 NLIDOCAINE-HC 0.5-3% 0 NLIDOCAINE-PRILOCAINE 2.5-2.5% 0 NLIDOCAINE 3%, CREAM 0 NMPM REGENECARE 2 N

Q5N-TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGENTS CARAC 0.5% 2 NFLUOROPLEX CREAM 1% 2 NFLUOROURACIL CREAM 5%, SOLUTION 2%, 5% 0 NSOLARAZE 3% 2 N

Q5P-TOPICAL ANTI-INFLAMMATORY STEROIDALAMCINONIDE 0.1% LOTION, CREAM, OINTMENT 0 NBETAMETHASONE VALERATE CREAM, OINT, LOT 0.1% 0 NDERMA-SMOOTHE/FS OIL 0.01% 2 NDESONIDE CREAM, OINT 0.05% 0 NDIFLORASONE DIACETATE CREAM, OINT 0.05% 0 NFLUOCINOLONE ACETONIDE CREAM, OINT 0.025% 0 NFLUOCINOLONE ACETONIDE CREAM, SOLN 0.01% 0 NFLUOCINOLONE BODY OIL, SCALP OIL 0.01% 0 NFLUOCINONIDE CREAM, OINT, SOLN, GEL 0.05% 0 NFLUOCINONIDE E CREAM 0.05% 0 NFLUTICASONE PROPIONATE CRM 0.05% 0 NFLUTICASONE PROPIONATE OINT 0.005% 0 NHYDROCORTISONE CREAM, OINT, 0.5%, 1%, 2.5% 0 NHYDROCORTISONE LOT 1%, 2.5% 0 N



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HYDROCORTISONE SOLUTION 0.1% 0 NMOMETASONE FUROATE CREAM, LOTION, OINT 0.1% 0 NTRIAMCINOLONE CREAM, OINT 0.025%, 0.1%, 0.5% 0 N

Q5R-TOPICAL ANTIPARISITICSEURAX CREAM 10% 2 NNATROBA 0.9% TOPICAL SUSPENSION 0 NPERMETHRIN 1% LIQUID, 5% CREAM 0 NPIPERONYL BUTOXIDE/PYRETHRINS SHAMPOO, LOTION 0 NSKLICE 0.5% 2 N

Q5S-TOPICAL SULFONAMIDESSILVER SULFADIAZINE 1% 0 NSODIUM SULFACETAMIDE-SULFUR WASH 10-5% (W/W) 0 NSULFAMYLON 8.5% 2 N

Q5V-TOPICAL ANTIVIRALSDENAVIR CREAM 1% 2 NZOVIRAX CREAM, OINT 5% 2 N

Q5W-TOPICAL ANTIBIOTICS (may be covered for dual eligible if available over the counter)BACITRACIN TOPICAL 500U/GM 0 YBACITRACIN/POLYMYXIN OINT 500U/GM/10MU/GM 0 YBACTROBAN CREAM 2% 2 NCENTANY 2% 0 NCLINDAMYCIN TOP GEL, LOTION, SOLN 1% 0 NERYTHROMYCIN GEL, SOLN 2% 0 NERYTHROMYCIN-BENZOYL PEROXIDE GEL 3%-5% 0 NGENTAMICIN SULFATE CREAM, OINT 0.1% 0 NMUPIROCIN OINT 2% 0 NTRIPLE ANTIBIOTIC OINT 0 Y

Q5X-TOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDAL CORTISPORIN OINT 1% 2 N

Q6A-EYE PREPS MISCMURO 128 SOLN, OINT 5% 2 NSODIUM CHLORIDE SOLN, OINT 5% 0 N

Q6C-EYE VASOCONSTRICTORS RXPHENYLEPHRINE SOLN 2.5%, 10% 0 N

Q6D-EYE VASOCONSTRICTORS OTCTETRAHYDROZOLINE/ZINC 0.5-0.25% 0 N

Q6G-MIOTICS/OTHER INTRAOC. PRESSURE REDUCERS ALPHAGAN P SOLN 0.1% 2 NALPHAGAN P SOLN 0.15% 0 NAZOPT SOLN 1% 2 NBETAXOLOL HCL 0.5% 0 NBRIMONIDINE TARTRATE 0.2% 0 NCARTEOLOL HCL 1% 0 NCOMBIGAN 0.2-0.5% 2 NDORZOLAMIDE 2% 0 NDORZOLAMIDE/TIMOLOL 2%-0.5% 0 N



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ISOPTO CARBACHOL SOLN 1.5%, 3% 2 NISOPTO CARPINE 2% 2 NLATANOPROST 0.005% 0 NLEVOBUNOLOL SOLN 0.25%, 0.5% 0 NMETIPRANOLOL 0.3% 0 NPHOSPHOLINE IODIDE SOLN 0.125% 2 NPILOCARPINE SOLN 0.5%, 1%, 2%, 3%, 4%, 6% 0 NPILOPINE HS GEL 4% 2 NTIMOLOL MALEATE SOL 0.25%, 0.5% 0 NTIMOLOL MALEATE SOLN XE 0.25%, 0.5% 0 N

Q6H-EYE LOCAL ANESTHETICSPROPARICAINE HCL SOLN 0.5% 0 NTETRACAINE HCL SOLN 0.5% 0 N

Q6I-EYE ANTIBIOTIC-CORTICOID COMBINATIONS BACITRACIN/NEOMYCIN/POLYMYXIN/HC OINT 0 NDEXAMETHASONE/NEOMYCIN/POLYMYXIN OINT, SOLN 0 NTOBRADEX SUSP 0.3%/0.1% 0 N

Q6J-MYDRIATICSAK-PENTOLATE SOLN 2% 0 NATROPINE SULFATE SOLN, OINT 1% 0 NCYCLOGYL 0.5%, 1%, 2% 2 NCYCLOMYDRIL SOLN 0.2%/1% 2 NCYCLOPENTOLATE SOLN 1% 0 NISOPTO ATROPINE SOLN 1% 0 NISOPTO HOMATROPINE SOLN 2%, 5% 2 NISOPTO HYOSCINE SOLN 0.25% 2 NTROPICAMIDE SOLN 0.5%, 1% 0 N

Q6P-EYE ANTIINFLAMMATORY AGENTSALREX SOLN 0.2% 2 NDEXAMETHASONE SOD PHOSPHATE SOLN 0.1% 0 NDICLOFENAC SODIUM 0.1% 0 NDUREZOL 0.05% 2 NFLUOROMETHOLONE SOLN 0.1% 0 NFLURBIPROFEN SODIUM 0.03% 0 NFML FORTE SOLN 0.25% 2 NFML SOP OINT 0.1% 2 NKETOROLAC 0.4%, 0.5% 0 NLOTEMAX OINT, SOLN, GEL 0.5% 2 NMAXIDEX SOLN 0.1% 2 NPRED MILD SOLN 0.12% 2 NPREDNISOLONE ACETATE SOLN 1% 0 NPREDNISOLONE SOD PHOSPHATE SOLN 0.125%, 1% 0 NVEXOL SOLN 1% 2 N



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Q6R-EYE ANTIHISTAMINEALAWAY 0.025% 0 NBEPREVE 1.5% 2 NKETOTIFEN 0.025% 0 NOPTIVAR 0.05% 0 NPATADAY 0.2% 2 NZADITOR 0.025% 0 N

Q6S-EYE SULFONAMIDESPREDNISOLONE/SULFACETAMIDE SOLN 0.25%-10% 0 NSULFACETAMIDE SODIUM, SOLN 10% 0 N

Q6T-EYE LUBRICANTS/TEARS (may be covered for dual eligible if available over the counter)ARTIFICIAL TEARS 0.5%, 1.4%, 0.3%/0.4%, 0.5%/0.6% 0 YCARBOXYMETHYLCELLULOSE SODIUM 0.5% 0 NFRESHKOTE 2 NGENTEAL MILD 2%, MILD TO MODERATE 0.30%, SEVERE 0.30% 2 YHYPOTEARS SOLN 2 YSYSTANE, SYSTANE ULTRA 0.3%-0.4%, SYSTANE BALANCE 0.6% 2 YSYSTANE GEL 0.3%-0.4% 2 YTEARS NATURALE FORTE 2 Y

Q6U-EYE MAST CELL STABILIZERSCROMOLYN SODIUM SOLN 4% 0 N

Q6V-EYE ANTIVIRALSTRIFLURIDINE SOLN 1% 0 NVIROPTIC SOLN 1% 2 N

Q6W-EYE ANTIBIOTICSBACITRACIN OINT 500U/GM 0 NBACITRACIN/POLYMYXIN OINT 0 NCIPROFLOXACIN 0.3% DROPS 0 NERYTHROMYCIN OINT 5MG/GM 0 NGENTAMICIN SOLN 3MG/ML, OINT 3MG/GM 0 NNATACYN 5% 2 NNEOMYCIN/POLYMYXIN/BACITRACIN OINT 0 NNEOMYCIN/POLYMYXIN/GRAMICIDIN SOLN 0 NOFLOXACIN 0.3% DROPS 0 NPOLYMYXIN/TRIMETHOPRIM SOLN 0 NTOBRAMYCIN SOLN 0.3% 0 N

Q6Y-EYE PREP, MISC (may be covered for dual eligible)EYE LUBRICANT OINTMENT 0 YSYSTANE NIGHTTIME EYE OINT 3%-94% 2 Y

Q7A-NOSE PREPARATIONS, MISCELLANEOUS (RX) IPRATROPIUM BR 21MCG, 42MCG NS 0 N

Q7C-NASAL VASOCONSTRICTORS RXADRENALIN NASAL SOLUTION 2 NTYZINE 0.05%, 0.1% 2 N



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Q7D-NASAL VASOCONSTRICTORS OTCOXYMETAZOLINE HCL 0.05% 0 NPHENYLEPHRINE HCL1% 0 N

Q7E-NASAL ANTIHISTAMINEASTELIN NASAL SPRAY 137MCG 0 NASTEPRO NASAL SPRAY 137MCG 2 NPATANASE 0.6% NASAL SPRAY 2 N

CROMOLYN SODIUM 40MG/ML 0 YQ7P-NASAL, ANTI-INFLAMMATORY STEROIDS

FLUNISOLIDE 0.025% 0 NFLUTICASONE 0.05% 0 NNASACORT AQ 0 N

Q7Q-NASAL MOISTURIZER (may be covered for dual eligible if available over the counter)RHINARIS 0.2% NASAL GEL 2 Y

Q7W-NASAL ANTIBIOTICSBACTROBAN NASAL 2% 2 N

Q7Y-NASAL OTC MISC (may be covered for dual eligible if available over the counter)SODIUM CHLORIDE (SALINE) NASAL SPRAY 0.65% 0 Y

Q8B-EAR PREPS, MISC ANTI-INFECTIVEACETIC ACID HC OTIC 2% 0 NACETIC ACID OTIC 2% 0 NACETIC ACID/ ALUMINUM ACETATE 0 N

Q8F-OTIC PREPARATIONS, ANTI-INFLAMMATORY-ANTIBIOTICS CIPRODEX 0.3-0.1% 2 N

Q8H-EAR PREPS, LOCAL ANESTHETICANTIPYRINE/BENZOCAINE 0 NBENZOCAINE 20% 0 NPHENYLEPHRINE/ANTIPY/B-CAINE 0.25-5-5% 0 N

Q8P-EAR PREPARATIONS ANTI-INFLAMMATORY DERMOTIC OIL 0.01% EAR DROP 2 NFLUOCINOLONE OIL 0.01% EAR DROP 0 N

Q8R-EAR WAX REMOVAL PREPS (may be covered for dual eligible if available over the counter)CARBAMIDE PEROXIDE 6.5% 0 Y

Q8W-EAR ANTIBIOTICSNEOMYCIN/POLYMYXIN/HC SUSP, SOLN 0 NOFLOXACIN OTIC 0 N

Q9B-BPH/MICTURITION AGENTSFINASTERIDE 5MG 0 NTAMSULOSIN 0.4MG 0 N

RIA-URINARY TRACT ANTISPASMODICS/ANTIINCONTINENCE AGENT FLAVOXATE 100MG 0 NOXYBUTYNIN CHLORIDE 5MG 0 NOXYBUTYNIN CHLORIDE 5MG/5ML 0 N

Q7H-NASAL MAST CELL STABILIZERS AGENTS (may be covered for dual eligible if available over the counter)



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OXYBUTYNIN ER 5MG, 10MG, 15MG 0 NSANCTURA 20MG 0 NSANCTURA XR 60MG 0 N

R1E-CARBONIC ANHYDRASE INHIBITORSACETAZOLAMIDE 125MG, 250MG 0 NDIAMOX SEQUELS 500MG 0 NMETHAZOLAMIDE 25MG, 50MG 0 N

R1F-THIAZIDE DIURETIC & RELCHLOROTHIAZIDE 250MG, 500MG 0 NCHLORTHALIDONE 25MG, 50MG 0 NDIURIL 250MG/5ML 2 NHYDROCHLOROTHIAZIDE 12.5MG, 25MG, 50MG 0 NINDAPAMIDE 1.25MG, 2.5MG 0 NMETHYCLOTHIAZIDE 5MG 0 NMETOLAZONE 2.5MG, 5MG, 10MG 0 N

R1H-POTASSIUM SPARING DIURETICS (SEE ALSO P5T) AMILORIDE HCL 5MG 0 N

EPLERENONE 25MG, 50MG 0 NSPIRONOLACTONE 25MG, 50MG, 100MG 0 N

R1L-POTASSIUM SPARING DIURETICS IN COMBINATION AMILORIDE/HCTZ 5/50 0 NSPIRONOLACTONE/HCTZ 25/25 0 NTRIAMTERENE HCTZ 25/50, 25/37.5, 50/75 0 N

R1M-LOOP DIURETICS BUMETANIDE 0.5MG, 1MG, 2MG 0 NEDECRIN 25MG 2 NFUROSEMIDE 10MG/ML ORAL, 40MG/5ML ORAL 0 NFUROSEMIDE 20MG, 40MG, 80MG 0 NTORSEMIDE 5MG, 10MG, 20MG, 100MG 0 N

R1N-ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS SAMSCA 15MG, 30MG 2 N

R1R-URICOSURIC AGENTSPROBENECID 500MG 0 N

R1S-URINARY PH MODIFIERSCITRIC ACID/SODIUM CITRATE 334-500MG 0 NCYTRA-2 SOLN 0 NCYTRA-3 SOLN 0 NCYTRA-K SOLN, CRYSTALS PACKET 0 NK-PHOS M.F., #2 2 NK-PHOS NEUTRAL 250MG 2 NK-PHOS ORIGINAL 2 NPHOSPHA 250 NEUTRAL 250 MG 2 NPOTASSIUM CITRATE 5 MEQ, 10 MEQ 0 NPOTASSIUM CITRATE/CITRIC ACID 0 N



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RENACIDIN SOLN 0 NUROCIT-K 5MEQ, 10MEQ, 15MEQ 2 NUROQID-ACID NO.2 2 N

R4A-KIDNEY STONE AGENTSCYSTAGON 50MG, 150MG 2 NTHIOLA 2 N

R5A-URINARY TRACT ANESTHETIC/ANALGESIC AGENTSAZO 95MG 2 NPHENAZOPYRIDINE 100MG, 200MG 0 NPHENAZOPYRIDINE PLUS 150-0.3-15 0 N

R5B-URINARY ANALGESICSELMIRON 100MG 2 N

S2A-COLCHICINESPROBENECID W/ COLCHICINE 500MG/0.5MG 0 N

S2B-NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ADVIL 40MG/ML, 100MG/5ML 0 NCELEBREX 50MG, 100MG, 200MG, 400MG (AGE 60+) 2 NDICLOFENAC POTASSIUM 50MG 0 NDICLOFENAC SODIUM 25MG, 50MG, 75MG, 100MG 0 NETODOLAC 200MG, 300MG, 400MG, 500MG 0 NETODOLAC XL 400MG, 500MG, 600MG 0 NFENOPROFEN CALCIUM 600MG 0 NFLURBIPROFEN 50MG, 100MG 0 NIBUPROFEN 100MG, 200MG, 400MG, 600MG, 800MG 0 NIBUPROFEN 100MG/5ML SUSP, 40MG/ML DROPS 0 NINDOCIN SUPP 50MG 2 NINDOCIN SUSP 25MG/5ML 2 NINDOMETHACIN 25MG, 50MG 0 NKETOPROFEN 200MG SR 0 NKETOPROFEN 50MG, 75MG 0 NKETOROLAC TROMETHAMINE 10MG 0 NMECLOFENAMATE SODIUM 50MG, 100MG 0 NMELOXICAM 7.5MG, 15MG 0 NMOTRIN 40MG/ML, 100MG/5ML 0 NNABUMETONE 500MG, 750MG 0 NNAPROSYN 125MG/5ML 2 NNAPROXEN 250MG, 375MG, 500MG, 125MG/5ML 0 NNAPROXEN EC 375MG, 500MG 0 NNAPROXEN SODIUM 220MG, 275MG, 550MG 0 NOXAPROZIN 600MG 0 NPIROXICAM 10MG, 20MG 0 NSULINDAC 150MG, 200MG 0 N

S2C-GOLD SALTSRIDAURA 3MG 2 N

S2I-ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR LEFLUNOMIDE 10MG, 20MG 0 N



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S2K-ANTI-ARTHRITIC AND CHELATING AGENTS CUPRIMINE 250MG 2 NDEPEN 250MG 2 N

S2M-ANTI-INFLAM. INTERLEUKIN-1 RECEPTOR ANTAGONIST ARCALYST 220 MG INJECTION 2 N

T0C-TOPICAL GENITAL WART-HPV TREATMENT AGENTS VEREGEN 15% OINTMENT 2 N

U6E-OINTMENT-CREAM BASESHYDROPHILIC PETROLATUM 2 N

U6F-HYDROPHILIC CREAM/OINTMENT BASESHYDROPHILIC 2 NTRIAD 2 N

U6N-VEHICLESORA-BLEND 2 NORA-BLEND SF 2 NORA-PLUS 2 NORA-SWEET 2 NORA-SWEET SF 2 NSORBITOL 70% 0 N

U6W-BULK CHEMICALSARGININE-L POWDER 0 NCLORPACTIN WCS-90 2 NHYDROUS EMULSIFIED BASE 0 NL-CITRULLINE POWDER 0 NL-GLUTAMINE PDR 2 NL-ISOLEUCINE POWDER 0 NSODIUM BENZOATE POWDER 0 NZINC SULFATE PDR 2 N

V1A-ALKYLATING AGENTSALKERAN 2MG 2 NCEENU 10MG, 40MG, 100MG 2 NCYCLOPHOSPHAMIDE 25MG, 50MG TAB 0 NDROXIA 200MG, 300MG, 400MG 2 NHEXALEN 50MG 2 NHYDROXYUREA 500MG 0 NLEUKERAN 2MG 2 NMYLERAN 2MG 2 NTEMODAR 5MG, 20MG, 100MG, 140MG, 180MG, 250MG 2 N

V1B-ANTIMETABOLITESMERCAPTOPURINE 50MG 0 NMETHOTREXATE TAB 2.5MG 0 NOFORTA 10MG 2 NPURINETHOL 50MG 2 NTABLOID 40MG 2 NTHIOGUANINE 40MG 2 NXELODA 150MG, 500MG 2 N



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V1E-STEROID ANTINEOPLASTICSEMCYT 140MG 2 NMEGESTROL ACETATE 20MG, 40MG, 40MG/ML 0 N

V1F-MISC ANTINEOPLASTICSETOPOSIDE 50MG 0 NLYSODREN 500MG 2 NMATULANE 50MG 2 NTRETINOIN 10MG 0 N

V1I-CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS LEUCOVORIN CALCIUM TABS 5MG, 25MG 0 N

V1J-ANTIANDROGENIC AGENTS BICALUTAMIDE 50MG 0 NFLUTAMIDE 125MG 0 NNILANDRON 150MG 2 N

V1M-ANTINEOPLASTIC IMMUNOMODULATOR AGENTS SYLATRON 296MCG 2 N

V1Q-ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPRELSA 300MG 2 NCOMETRIQ 60, 100, 140MG DAILY DOSE 2 NGLEEVEC 100MG, 400MG 2 NINLYTA 1MG, 5MG 2 NIRESSA 250MG 2 NMEKINIST 0.5, 2 MG 2 NNEXAVAR 200MG 2 NSUTENT 12.5MG, 25MG, 50MG 2 NTAFINLAR 50, 75 MG 2 NTARCEVA 25MG, 100MG, 150MG 2 NTASIGNA 150MG, 200MG 2 NTYKERB 250MG 2 NVANDETANIB 100MG 2 NVOTRIENT 200MG 2 NXALKORI 250MG 2 NZELBORAF 240MG 2 N

V1T-SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM) FARESTON 60MG 2 NTAMOXIFEN CITRATE 10MG, 20MG 0 N

V3C-ANTINEOPLASTIC - MTOR KINASE INHIBITORS AFINITOR 2.5MG, 5MG, 7.5MG, 10MG 2 NAFINITOR DISPERZ 2MG, 3MG, 5MG 2 N

V3E-ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS HYCAMTIN 0.25MG, 1MG 2 N

V3F-ANTINEOPLASTIC - AROMATASE INHIBITORS ANASTROZOLE 1MG 0 NEXEMESTANE 25MG 0 NFEMARA 2.5MG 2 NLETROZOLE 2.5MG 0 N



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V3L-ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS JAKAFI 5MG, 10MG, 15MG, 20MG, 25MG 2 N

V3M-ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITOR ERIVEDGE 150MG 2 N

W1A-PENICILLINSAMOX TR/POTASSIUM CLAV 200-28.5/5, 250-62.5/5, 400-57/5, 600-42.9/5ML 0 NAMOX TR/POTASSIUM CLAV 250-125MG, 500-125MG, 875-125MG, 1000-62.5 0 NAMOX TR/POTASSIUM CLAV CHEW TAB 200-28.5, 400-57 0 NAMOXICILLIN 250MG, 500MG, 875MG, 125MG/5ML, 250MG/5ML 0 NAMOXICILLIN 200MG/5ML, 400MG/5ML 0 NAMOXICILLIN CHEWABLE 125MG, 200MG, 250MG, 400MG 0 NAMPICILLIN 250MG, 500MG 0 NAMPICILLIN SUSP 125MG/5ML, 250MG/5ML 0 NAUGMENTIN CHEWABLES 250/62.5 0 NAUGMENTIN SUSP 125-31.25/5ML 0 NAUGMENTIN SUSP 250-62.5/5ML 0 NAUGMENTIN XR 1000-62.5 2 NDICLOXACILLIN 250MG, 500MG 0 NPENICILLIN VK 250MG, 500MG, 125MG/5ML, 250MG/5ML 0 N

W1C-TETRACYCLINESDOXYCYCLINE HYCLATE 50MG, 100MG 0 NMINOCYCLINE HCL 50MG, 75MG, 100MG 0 NTETRACYCLINE HCL 250MG, 500MG 0 NVIBRAMYCIN 25MG/5ML SUSP 2 NVIBRAMYCIN CALCIUM 50MG/5ML SYRUP 2 N

W1D-MACROLIDESAZITHROMYCIN 250MG, 500MG, 600MG 0 NAZITHROMYCIN PACKETS 1GM 0 NAZITHROMYCIN SUSP 100MG/5ML, 200MG/5ML 0 NCLARITHROMYCIN 250MG, 500MG 0 NCLARITHROMYCIN ER 500MG 0 NCLARITHROMYCIN SUSP 125MG/5ML, 250MG/5ML 0 NDIFICID 200MG 2 NERYTHROMYCIN 250MG 0 NERYTHROMYCIN 333MG 0 NERYTHROMYCIN 500MG 0 NERYTHROMYCIN ETHYLSUCCINATE 400MG, 200MG/5ML, 400MG/5ML 0 NERYTHROMYCIN STEARATE 250MG, 500MG 0 NERYTHROMYCIN W/ SULFISOXAZOLE 200/600 SUSP 0 N

W1F-AMINOGLYCOSIDESNEO-FRADIN 125MG/5ML 2 NNEOMYCIN SULFATE 500MG 0 NTOBI 300MG/5ML, PODHALER 28MG 2 N



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W1G-ANTITUBERCULAR ANTIBIOTICSRIFAMPIN 150MG, 300MG 0 NRIFATER 120/50/300 2 NSEROMYCIN 250MG 2 N

W1J-VANCOMYCIN AND DERIVATIVES VANCOCIN 125MG, 250MG 2 NVANCOMYCIN 125MG, 250MG 0 N

W1K-LINCOSAMIDESCLEOCIN 75MG, 75MG/5ML 2 NCLINDAMYCIN HCL 150MG, 300MG, 75MG/5ML 0 N

W1N-POLYMYXIN AND DERIVATIVESCOLISTIMETHATE NA 150MG 0 NCOLY-MYCIN M INJ 150MG 2 N

W1P-BETALACTAMSCAYSTON 75 MG/ML 2 N

W1Q-QUINOLONESCIPRO SUSP (AGES 0-12) * NCIPROFLOXACIN 250MG, 500MG, 750MG 0 NLEVOFLOXACIN 250MG, 500MG, 750MG, 250MG/10ML 0 NOFLOXACIN 200MG, 300MG, 400MG 0 N

W1W-CEPHALOSPORINS - 1ST GENERATION CEFADROXIL MONOHYDRATE 500MG, 1G, 250MG/5ML, 500MG/5ML 0 NCEPHALEXIN 250MG, 500MG, 125MG/5ML, 250MG/5ML 0 N

W1X-CEPHALOSPORINS - 2ND GENERATION CEFACLOR 250MG, 500MG 0 NCEFACLOR ER 500MG 0 NCEFACLOR SUSP 125/5, 250/5, 375/5ML (AGE 0 THROUGH 12) 0 NCEFPROZIL 250MG, 500MG 0 NCEFTIN SUSPENSION (AGE 0 THROUGH 12) * NCEFUROXIME 250MG, 500MG 0 NCEFUROXIME SUSPENSION (AGE 0 THROUGH 12) * N

W1Y-CEPHALOSPORINS - 3RD GENERATION CEFDINIR 300MG, 125MG/5ML, 250MG/5ML 0 N

W2A-ABSORBABLE SULFONAMIDESSULFADIAZINE 500MG 0 NSULFAMETHOXAZOLE/TRIMETHOPRIM SUSP 200-40/5 0 NSULFAMETHOXAZOLE/TRIMETHOPRIM TAB 400/80, 800/160 0 NSULFASALAZINE 500MG, EC500MG 0 N

W2E-ANTI-MYCOBACTERIUM AGENTSETHAMBUTOL HCL 100MG, 400MG 0 NISONIAZID 100MG, 300MG, 50MG/5ML 0 NMYAMBUTOL 100MG, 400MG 2 NMYCOBUTIN 150MG 2 NPASER 4GM 2 NPYRAZINAMIDE 500MG 0 NTRECATOR-SC 250MG 2 N



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W2F-NITROFURAN DERIVATIVESFURADANTIN 25MG/5ML ORAL SUSP (AGES 0-12) * NMACRODANTIN 25MG, 50MG, 100MG 2 NNITROFURANTOIN MACROCRYSTAL 50MG, 100MG 0 NNITROFURANTOIN MONOHYDRATE MACRO 100MG 0 N

W2G-CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC. HIPREX 1GM 2 NMETHENAMINE HIPPURATE 1GM 0 NMETHENAMINE MANDELATE 500MG, 1GM 0 NMONUROL 3GM 2 NMTH/ME BLUE/SALICY/NA PHOS/HYO 81.6-0.12MG 81.6-10.8MG, 120-0.12MG 0 NPRIMSOL 50MG/5ML 2 NPROSED DS 2 NTRIMETHOPRIM 100MG 0 NUREX 1GM 2 NUTA 120-0.12MG 2 NUTIRA-C 81.6-10.8MG 2 N

W3A-ANTIFUNGAL ANTIBIOTICSGRIFULVIN V 500MG 2 NGRISEOFULVIN 125MG/5ML 0 NGRIS-PEG 125MG, 250MG 2 NNYSTATIN SUSP 100000U/ML, TAB 500,000U 0 N

W3B-ANTIFUNGALSANCOBON 250MG, 500MG 2 NCLOTRIMAZOLE TROCHE 10MG 0 NFLUCONAZOLE 50MG, 100MG, 150MG, 200MG, 50MG/5ML, 200MG/5ML 0 NKETOCONAZOLE 200MG 0 NTERBINAFINE HCL 250MG TABLET 0 N

W4A-ANTIMALARIALSCHLOROQUINE PHOSPHATE 250MG, 500MG 0 NCOARTEM 20MG-120MG 2 NDARAPRIM 25MG 2 NHYDROXYCHLOROQUINE SULFATE 200MG 0 NMALARONE 62.5/25MG, 250/100MG 2 NMEFLOQUINE 250MG 0 NPRIMAQUINE PHOSPHATE 26.3MG 2 NQUALAQUIN 324MG 2 N

W4C-AMEBACIDESPAROMOMYCIN 250 MG 0 N

W4E-ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS FLAGYL ER 750MG 2 NMETRONIDAZOLE 250MG, 500MG 0 N

W4G-2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL TINDAMAX 250MG, 500MG 2 N



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W4K-MISC ANTI-PROTOZOALSMEPRON 750MG/5ML 2 NNEBUPENT AEROSOL 2 N

W4L-ANTHELMINTICSALBENZA 200MG 2 NBILTRICIDE 600MG 2 NMEBENDAZOLE 100MG 0 NSTROMECTOL 3MG 2 N

W4M-ANTIPARASITICS ALINIA 100MG/5ML 2 NALINIA 500MG 2 N

W4P-ANTI-LEPROTICSDAPSONE 25MG, 100MG 2 N

W5A-ANTIVIRALS, GENERALACYCLOVIR 200MG, 400MG, 800MG, 200MG/5ML 0 NGANCICLOVIR 250MG, 500MG 0 NRELENZA 5MG 2 NRIMANTADINE 100MG 0 NTAMIFLU 6MG/ML, 12MG/ML 2 NTAMIFLU 30MG, 45MG, 75MG 2 NVALACYCLOVIR 500MG, 1000MG 0 NVALCYTE 450MG, 50MG/ML 2 NVALTREX 500MG, 1000MG 2 N

W5C-ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORSCRIXIVAN 100MG, 200MG, 400MG 2 NINVIRASE 200MG, 500MG 2 NLEXIVA 700MG TABLET, 50MG/ML SUSPENSION 2 NNORVIR 100MG, 80MG/ML SOLN 2 NREYATAZ 100MG, 150MG, 200MG, 300MG 2 NVIRACEPT 250MG, 625MG, PED ORAL PDR 50MG/GM 2 N

W5F-HEPATITIS B TREATMENT AGENTS BARACLUDE 0.05MG/ML 2 NBARACLUDE 0.5MG, 1MG 2 NEPIVIR HBV 100MG, 25MG/5ML 2 NHEPSERA 10MG 2 NTYZEKA 600MG 2 N

W5G-HEPATITIS C TREATMENTSINFERGEN 9MCG/0.3ML, 15MCG/0.5ML 2 NPEGASYS 180MCG/ML 2 NPEGASYS PROCLICK 135MCG/0.5ML, 180MCG/0.5ML 2 NPEGASYS SYRINGE 180MCG/0.5ML 2 NPEG-INTRON 100MCG, 160MCG, 240MCG 2 NPEG-INTRON REDIPEN 120MCG/0.5, 150MCG/0.5 2 NPEG-INTRON REDIPEN 50MCG/0.5, 80MCG/0.5 2 NREBETOL 40MG/ML 2 NRIBAVIRIN 200MG TAB, CAP 0 N



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W5I-ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI VIREAD 150MG, 200MG, 250MG, 300MG, 40MG/GRAM 2 N

W5J-ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI ABACAVIR 300MG 0 NDIDANOSINE 125MG, 200MG, 250MG, 400MG 0 NEMTRIVA 200MG 2 NEPIVIR 150MG, 300MG, 10MG/ML ORAL SOLN 2 NLAMIVUDINE 150MG, 300MG 0 NRETROVIR 100MG, 10MG/ML SYRUP 2 NSTAVUDINE 15MG, 20MG, 30MG, 40MG, 1MG/ML 0 NVIDEX EC 125MG, 200MG, 250MG, 400MG 2 NVIDEX PED SUSP 2GM/120MG, 4GM/240ML 10MG/ML 2 NZERIT 1MG/ML ORAL 2 NZIAGEN 20MG/ML 2 NZIAGEN 300MG 2 NZIDOVUDINE 100MG, 300MG, 10MG/ML 0 N

W5K-ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI INTELENCE 100MG, 200MG 2 NNEVIRAPINE 200MG, 50MG/5ML 0 NRESCRIPTOR 100MG, 200MG 2 NSUSTIVA 50MG, 200MG, 600MG 2 NVIRAMUNE 200MG, 50ML/5ML 2 NVIRAMUNE XR 100MG, 400MG 2 N

W5L-ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMBO COMBIVIR 150MG/300MG 2 0 NEPZICOM 600-300MG 2 NTRIZIVIR 300-150MG 2 N

W5M-ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMBOKALETRA 25-100, 50-200 2 NKALETRA 400-100/5ML 2 N

W5N-ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORSFUZEON 90MG/ML 2 N

W5O-ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG TRUVADA 200MG-300MG 2 N

W5P-ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIBAPTIVUS 250MG, 100MG/ML 2 NPREZISTA 75MG, 150MG, 400MG, 600MG, 100MG/ML 2 N

W5Q-ANTIRETROVIRAL COMB NUCLEOSIDE, NUCLEOTIDE, & NON-NUCLEOSIDE RTI ATRIPLA 600-200 2 NCOMPLERA 200-25-300MG 2 N

W5T-ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAGONITSTSSELZENTRY TABLET 150MG, 300MG 2 N

W5U-ANTIVIRALS, HIV-1 INTEGRASE STRAND TRANSFER INHIBITOR ISENTRESS 400MG 2 N

W5X-ARV CMB-NRTI,N(T)RTI, INTEGRASE INHIBITORSTRIBILD 150/150/200/300 2 N



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W7C-INFLUENZA VIRUS VACCINES (COVERED DURING INFLUENZA SEASON)AFLURIA 0 NFLUARIX 0 NFLULAVAL 0 NFLUMIST NASAL 0 NFLUVIRIN 0 NFLUZONE 0 N

W8F-IRRIGANTSACETIC ACID SOLN 0.25% 0 NLACTATED RINGERS IRRIGATION 0 NNEOSPORIN G.U. IRRIGANT 2 NSEA-CLENS 2 NSODIUM CHLORIDE SOLN 0.45%,0.9% 0 NSORBITOL UROLOGIC IRRIGATION 3%, 3.3% 0 NWATER FOR IRRIGATION, STERILE 0 N

W8J-MISC ANTIBACTERIAL IRRIGANTSAMINOACETIC ACID IRRIGATION 1.5% 0 NGLYCINE 0 N

W9A-KETOLIDESKETEK 300MG, 400MG 2 N

ZIE-ANTIOXIDANT AGENTS (MAY BE COVERED FOR DUAL ELIGIBLE)ALPHA LIPOIC ACID 100MG, 300MG 0 Y

Z2D-HISTAMINE 2 INHIBITORSCIMETIDINE 200MG, 300MG, 400MG, 800MG, 300MG/5ML 0 NFAMOTIDINE 10MG 0 NFAMOTIDINE 20MG, 40MG 0 NRANITIDINE 150MG, 300MG 0 NRANITIDINE 150MG/10ML SYRUP, 15MG/ML ORAL SOLN (0-12 YRS) * N

Z2E-IMMUNOSUPPRESSIVESAZASAN 75MG, 100MG 2 NAZATHIOPRINE 50MG 0 NCELLCEPT 200MG/ML 2 NCYCLOSPORINE 25MG, 50MG, 100MG, 100MG/ML 0 NGENGRAF 25MG, 100MG, 100MG/ML 2 NMYCOPHENOLATE MOFETIL 250MG, 500MG 0 NMYFORTIC 180MG, 360MG 2 NNEORAL 100MG/ML ORAL 2 NNEORAL 25MG, 100MG 2 NPROGRAF 0.5MG, 1MG, 5MG 2 NRAPAMUNE 0.5MG, 1MG, 2MG 2 NRAPAMUNE 1MG/ML 2 NSANDIMMUNE 100MG/ML SOLUTION 2 NSANDIMMUNE 25MG, 100MG 2 NZORTRESS 0.25MG, 0.5MG, 0.75MG 2 N



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Z2F-MAST CELL STABILIZERS CROMOLYN SODIUM 10MG/ML INH SOLN 0 NGASTROCOM 20MG/ML 2 N

Z2G-IMMUNOMODULATORSINTRON A 6MMU, 10MMU, 18MMU, 50MMU 2 NINTRON A PEN DELIVERY SYSTEMS 3MMU, 5MMU, 10MMU 2 N

Z2N-1ST GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS CHILD DELSYM COUGH-COLD 5-12.5/5ML 2 NPHENYLEPHRINE/BROMPHENIRAMINE 2.5-1MG/5 0 NPHENYLEPHRINE/CHLORPHENIRAMINE 3.5-1MG/ML, 2MG-1MG/ML, 9-0.8MG/ML 0 NPHENYLEPHRINE/CHLORPHENIRAMINE MAL 10MG-3MG, 10MG-4MG, 20MG-8MG, 5MG-2MG/ML 0 NPHENYLEPHRINE/CHLORPHENIRAMINE TAN 60-2/1MG 0 NPHENYLEPHRINE/DIPHENHYDRAMINE 2.5-6.25MG/5ML 0 NPROMETHAZINE VC SYRUP 0 NPSEUDOEPHEDRINE/BROMPHENIRAMINE 7.5-1/1ML, 15-1/5ML 0 NPSEUDOEPHENDRIN/CHLORPHENIRAMINE SYRUP 2MG-30MG/5ML 0 NPSEUDOEPHEDRINE HCL/CHLOR-MAL 60MG-4MG, 90-0.8MG/ML, 120MG-8MG 0 NPSEUDOEPHEDRINE/TRIPROLIDINE LIQUID 60-2.5, 30-1.25/5ML 0 NSONAHIST 2MG-1MG/ML 2 N

Z2O-2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS ALLERGY RELIEF D 240-10MG 0 NCETIRIZINE/PSEUDOEPHRINE 5/120MG 0 NLORATADINE D 240-10MG 0 NSEMPREX-D 60/8 2 N

Z2P-ANTIHISTAMINES - 1ST GENERATION (oral diphenhydramine may be available for dual eligible)BROMPHENIRAMINE 6MG 0 NCARBINOXAMINE SYRUP 4MG/5ML 0 NCHLORPHENIRAMINE 4MG, 12MG 0 NCHLORPHENIRAMINE 2MG/5ML, 2MG/ML 0 NCLEMASTINE 1.34MG, 2.68MG, 0.67MG/5ML 0 NCYPROHEPTADINE 4MG 0 NCYPROHEPTADINE SYRUP 2MG/5ML 0 NDEXCHLORPHENIRAMINE MALEATE 2MG/5ML 0 NDIPHENHYDRAMINE 25MG, 50MG, 12.5MG/5ML 0 YHYDROXYZINE HCL 10MG, 25MG, 50MG 0 NHYDROXYZINE HCL SYRUP 10MG/5ML 0 NHYDROXYZINE PAMOATE 25MG, 50MG, 100MG 0 NPALGIC 4MG, 4MG/5ML 2 NPROMETHAZINE HCL 12.5MG, 25MG, 50MG TAB 0 NPROMETHAZINE SYRUP 6.25MG/5ML 0 NVANAHIST PD 0.625 MG/ML 2 N

Z2Q-ANTIHISTAMINES - 2ND GENERATION ALLERGY RELIEF 5MG/5ML (LORATADINE) 0 NCETIRIZINE HCL CHEWABLE TABS 5MG, 10MG (AGES 0-6) * N



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CETIRIZINE HCL 5MG, 10MG 0 NCETIRIZINE HCL 1MG/1ML (AGES 0-6) * NLORATADINE 10MG, 10MG RAPID DISSOLVE, 5MG/5ML 0 N

Z4B-LEUKOTRIENE RECEPTOR ANTAGONISTS ACCOLATE 10MG, 20MG 2 NMONTELUKAST 4MG, 5MG, 10MG 0 NSINGULAIR ORAL GRANULES 4MG 0 NZAFIRLUKAST 10MG, 20MG 0 N


Documents

ACTION: Original AMENDED DATE: 08/07/2013 1:34 …3-9-12...2012/03/09 · B3P-NON-NARC ANTITUS-1ST GEN ANTIHIST-DECON-ANALGES CB (cough suppressants may be covered for dual eligible)