Arizona Complete Health-Complete Care ... - Envolve Health

Arizona Complete Health-Complete Care Plan Behavioral Health Preferred Drug List The Arizona Complete Health-Complete Care Plan Behavioral Health Drug List includes all of the behavioral health drugs listed on the AHCCCS Behavioral Health Drug List (BHDL). This is not a complete list of all covered behavioral health drugs. If you need a drug that is not in the behavioral health drug list, your doctor may request prior authorization to cover the drug.

The drug list is updated often and may change. You can view the latest drug list at www.azcompletehealth.com/providers/pharmacy.html

www.azcompletehealth.com/providers/pharmacy.html

Pharmacy Program Arizona Complete Health-Complete Care Plan provides appropriate, high quality, and cost-effective drug therapy to all Arizona Complete Health-Complete Care Plan members. Arizona Complete Health-Complete Care Plan covers prescription drugs and certain over-the-counter (OTC) drugs when ordered by a doctor. Some drugs require prior authorization (PA) or have limits on age, dosage and maximum amounts.

Generic drugs have the same active ingredient as their brand name equivalents and should be used as the first line of treatment. This is unless a drug specifically notes brand is preferred. If there is no generic available, there may be more than one brand name drug that can be used in your treatment. The Arizona Complete Health-Complete Care Plan Behavioral Health PDL is reviewed often by our Arizona Complete Health Pharmacy and Therapeutics (P&T) Committee. This helps promote the appropriate and cost-effective use of medications.

Dispensing Limits You can get up to a maximum thirty (30) day supply for each new prescription or refill of most medications. You can get up to a ninety (90) day supply if:

• The medication is prescribed for chronic illness • You will be out of the service area for an extended period of time • The prescription is limited to the extended time period

A total of 85% of the 30 day supply must have elapsed before the prescription can be refilled for most drugs.

Prior Authorization and Other Limits

Some drugs listed on the Arizona Complete Health-Complete Care Plan Behavioral Health PDL may require prior authorization (PA). Your doctor or pharmacist will request a PA for you. The information should be submitted by the practitioner or pharmacist on the Medication Prior Authorization Form. This document is located on the Arizona Complete Health-Complete Care Plan website at https://www.azcompletehealth.com/providers/pharmacy.html. They may fax the PA form to1-855-554-5233 or your provider can send a PA request electronically to https://www.covermymeds.com/main/prior-authorization-forms/

https://www.azcompletehealth.com/providers/pharmacy.html

https://www.covermymeds.com/main/prior-authorization-forms/

Arizona Complete Health-Complete Care Plan will cover the medication if:

1. There is a behavioral health medical reason that requires the specific medication 2. Depending on the medication, other medications on the PDL have not worked Antipsychotic drugs and lithium on the drug list require a Prior Authorization if they are not prescribed by a behavioral health or other approved specialist.

If the request is approved, Arizona Complete Health-Complete Care Plan notifies your prescriber by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Arizona Complete Health-Complete Care Plan will review the request and notify you and your prescriber of our decision. We will also let you know about alternative medications if available and provide information about what you can do to appeal our decision if you do not agree with it.

Abbreviation What it means How it works

AL Age Limit Some drugs are only covered for certain ages.

F Formulary These drugs are covered by Arizona Complete Health-Complete Care Plan.

MP Maintenance Product

These drugs are used to treat long-term conditions or illnesses.

NF Non-Formulary These drugs require authorization to be covered by Arizona Complete Health-Complete Care Plan.

PA Prior Authorization

Your doctor must ask for approval from Arizona Complete Health-Complete Care Plan before some drugs will be covered.

QL Quantity Limit Some drugs are only covered for a certain amount.

SP Specialty Product

These drugs are used to treat complex or rare conditions such as hepatitis C or rheumatoid arthritis.

ST Step Therapy

In some cases, you must first try certain drugs before Arizona Complete Health-Complete Care Plan covers another drug for your medical condition.

For example, if Drug A and Drug B both treat your medical condition, Arizona Complete Health-Complete Care Plan may not cover Drug B unless you try Drug A first.

Medical Necessity Requests If an Arizona Complete Health-Complete Care Plan member requires a medication to treat a behavioral health condition that does not appear on the PDL, the member's doctor can make a medical necessity (MN) request for the medication.

Emergency Supply Policy State and Federal laws require that a pharmacy dispense up to a 4 day supply of medication to any member awaiting PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. Participating pharmacies are authorized to provide up to a 4 day supply of traditional behavioral health (non-specialty) medication. Have your Pharmacy call the Pharmacy Help Desk at 1-888-624-1131 for help filling a 4 day emergency supply.

Exclusions The Arizona Complete Health-Complete Care Plan Drug List does not include certain drugs. The following types of drugs are excluded from coverage. They are also not available for a 4 day emergency supply.

• Drugs that are considered experimental or investigational (Members who are enrolled may participate in experimental services; however, AHCCCS will not reimburse for the experimental service as per A.A.C. R9-22-203)

• Drug Efficacy Study and Implementation (DESI) drugs • Prosthesis, appliances and devices • Medications to treat physical health conditions • Oral vitamins and minerals or OTC drugs with the exception of those listed on the

PDL or if a member has a deficiency of a vitamin not listed on the PDL if it treats a behavioral health condition

• Nutritional supplements • Medical marijuana • Drugs eligible for coverage under Medicare Part D (for Medicare eligible

members); copayments and cost-sharing for behavioral health drugs are covered for SMI members who are also eligible for Medicare.

Newly Approved Products Arizona Complete Health-Complete Care Plan reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these drugs will be considered through the PA review process.

Filling a Prescription

You can have prescriptions filled at an Arizona Complete Health-Complete Care Plan network pharmacy. You can locate a pharmacy near you by contacting Arizona Complete Health-Complete Care Plan Member Services. When you pick a pharmacy, please bring your Arizona Complete Health-Complete Care Plan ID card with you. The pharmacy will need the information located on the card to fill your prescription.

For More information about your pharmacy benefits, please review your Member Handbook or call Member Services at 888-788-4408 (TTY/TDY 711).

Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating Disorders

Amphetamines ADDERALL TABS 1.25 MG-1.25 MG-1.25 MG-1.25 MG, 1.875 MG-1.875 MG-1.875 MG-1.875 MG, 2.5 MG-2.5 MG-2.5 MG-2.5 MG, 3.125 MG-3.125 MG-3.125 MG-3.125 MG, 5 MG-5 MG-5 MG-5 MG, 7.5 MG-7.5 MG-7.5 MG-7.5 MG (amphetamine-dextroamphetamine)

F

QL(2 ea daily);AL(At least 6yrs old)

ADDERALL TABS 3.75 MG-3.75 MG-3.75 MG-3.75 MG (amphetamine-dextroamphetamine)

F

QL(2 ea daily)

ADDERALL XR CP24 1.25 MG-1.25 MG-1.25 MG-1.25 MG, 2.5 MG-2.5 MG-2.5 MG-2.5 MG, 3.75 MG-3.75 MG-3.75 MG-3.75 MG, 6.25 MG-6.25 MG-6.25 MG-6.25 MG, 7.5 MG-7.5 MG-7.5 MG-7.5 MG (amphetamine-dextroamphetamine)

F


ADDERALL XR CP24 5 MG-5 MG-5 MG-5 MG (amphetamine-dextroamphetamine)

F


amphetamine-dextroamphetamine tabs1.25 mg-1.25 mg-1.25 mg-1.25 mg, 1.875 mg-1.875mg-1.875 mg-1.875 mg,2.5 mg-2.5 mg-2.5 mg-2.5mg, 3.125 mg-3.125 mg-3.125 mg-3.125 mg, 5 mg-5 mg-5 mg-5 mg, 7.5 mg-7.5 mg-7.5 mg-7.5 mg

F


amphetamine-dextroamphetamine tabs3.75 mg-3.75 mg-3.75 mg-3.75 mg

F

QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

VYVANSE CAPS 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

F QL(1 ea daily);AL(At least 6yrs old)

Attention-Deficit/Hyperactivity Disorder (ADHD)

atomoxetine hcl caps F QL(1 ea daily);AL(At least 6yrs old)

clonidine hcl (adhd) tb12 F QL(4 ea daily);AL(At least 6yrs old)

guanfacine hcl (adhd) tb24 F QL(1 ea daily);AL(At least 6yrs old)

INTUNIV TB24 (guanfacine hcl (adhd)) NF


KAPVAY TB12 (clonidine hcl (adhd)) NF


STRATTERA CAPS (atomoxetine hcl) NF


Stimulants - Misc. CONCERTA TBCR 18 MG, 27 MG, 36 MG (methylphenidate hcl)


CONCERTA TBCR 54 MG (methylphenidate hcl) F


DAYTRANA PTCH F QL(1 ea daily);AL(At least 6yrs old)

dexmethylphenidate hcltabs 2.5 mg, 10 mg, 5 mg F


FOCALIN TABS (dexmethylphenidate hcl) NF


FOCALIN XR CP24 10 MG, 15 MG, 20 MG, 5 MG (dexmethylphenidate hcl)


FOCALIN XR CP24 35 MG, 25 MG, 30 MG, 40 MG (dexmethylphenidate hcl)


METHYLIN SOLN (methylphenidate hcl) F

QL(10 mldaily); AL(Atleast 6 yrs old)

Arizona Complete Health - Complete Care Plan Behavioral HealthEffective April 1, 2022

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Drug Name DrugTier

Requirements/Limits

methylphenidate hcl cpcr or40 mg, 10 mg, 20 mg, 30mg, 50 mg, 60 mg


methylphenidate hcl tabs or10 mg, 20 mg, 5 mg F


RITALIN LA CP24 10 MG, 20 MG, 30 MG (methylphenidate hcl)


RITALIN LA CP24 40 MG (methylphenidate hcl) F


RITALIN TABS (methylphenidate hcl) NF


ALTERNATIVE MEDICINES

Alternative Medicine - M's

melatonin tabs or 5 mg F

Alternative Medicine Combinations

FLAX + DHA CAPS F

OMEGA 3-6-9 COMPLEX CAPS F

OMEGA-3-6-9 CAPS F

RA OMEGA 3-6-9 CAPS F

SM OMEGA-3 CAPS F

SM OMEGA-3-6-9 FATTY ACIDS CAPS F

SUPER OMEGA-3 CAPS F

TRIPLE OMEGA-3-6-9 CAPS F

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint Conditions

Opioid Partial Agonists

Drug Name DrugTier

Requirements/Limits

buprenorphine hcl subl sl 2 mg F

PA Req'dunless member is pregnant ornursing.Prescriber must note ICD-10 diagnosis codeon prescription.O09.91; O09.92; O09.93-Supervision ofhigh risk pregnancy, postpartumnursingmothers. First digit Letter, 2nddigit zeroQL(12ea daily)

buprenorphine hcl subl sl 8 mg F

PA Req'dunless member is pregnant ornursing.Prescriber must note ICD-10 diagnosis codeon prescription.O09.91; O09.92; O09.93-Supervision ofhigh risk pregnancy, postpartumnursingmothers. First digit Letter, 2nddigit zeroQL(3ea daily)

buprenorphine hcl-naloxone hcl dihydrate subl0.5 mg-2 mg

F QL(12 ea daily)

buprenorphine hcl-naloxone hcl dihydrate subl2 mg-8 mg

F QL(3 ea daily)

SUBLOCADE SOSY F PA

SUBOXONE FILM 0.5 MG-2 MG (buprenorphine hcl-naloxone hcl dihydrate)

F QL(12 eadaily); AL(Atleast 6 yrs old)


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Drug Name DrugTier

Requirements/Limits

SUBOXONE FILM 1 MG-4 MG (buprenorphine hcl-naloxone hcl dihydrate)






ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.

buspirone hcl tabs or 10mg, 5 mg, 7.5 mg, 15 mg F


buspirone hcl tabs or 30 mg F


hydroxyzine hcl soln im 25mg/ml, 50 mg/ml F PA

hydroxyzine hcl syrp or 10mg/5ml F QL(10 ml daily)

hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg F QL(8 ea daily)

hydroxyzine pamoate capsor 100 mg F


hydroxyzine pamoate capsor 25 mg, 50 mg F QL(4 ea daily)

VISTARIL CAPS (hydroxyzine pamoate) NF QL(4 ea daily)

Benzodiazepines

ALPRAZOLAM INTENSOL CONC F

Limit 1 anxiolytic per30 days;QL(60ml per 15 daysretail); AL(Atleast 6 yrs old)

alprazolam tabs or 0.25mg, 0.5 mg, 1 mg F

Limit 1 anxiolytic per30 days;QL(4ea daily); AL(Atleast 6 yrs old)

Drug Name DrugTier

Requirements/Limits

alprazolam tabs or 2 mg F


alprazolam tb24 or 0.5 mg,1 mg, 2 mg, 3 mg F


alprazolam tbdp or 0.25mg, 0.5 mg, 1 mg F


alprazolam tbdp or 2 mg F


ATIVAN SOLN IJ 4 MG/ML, 2 MG/ML(lorazepam)

NF PA

ATIVAN TABS OR 0.5 MG, 1 MG (lorazepam) NF


ATIVAN TABS OR 2 MG (lorazepam) NF


chlordiazepoxide hcl caps F QL(2 ea daily);AL(At least 6yrs old)

clorazepate dipotassiumtabs 15 mg F


clorazepate dipotassiumtabs 3.75 mg, 7.5 mg F


diazepam conc or 5 mg/ml F QL(2 ml daily);AL(At least 6yrs old)

DIAZEPAM SOAJ IM 10 MG/2ML F PA

diazepam soln ij 5 mg/ml F PA


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Drug Name DrugTier

Requirements/Limits

diazepam soln or 5 mg/5ml F QL(10 mldaily); AL(Atleast 6 yrs old)

diazepam tabs or 10 mg, 2mg, 5 mg F


lorazepam conc or 2 mg/ml F QL(2 ml daily);AL(At least 6yrs old)

lorazepam soln ij 4 mg/ml,2 mg/ml, 20 mg/10ml F PA

lorazepam tabs or 0.5 mg,1 mg F


lorazepam tabs or 2 mg F


oxazepam caps 10 mg, 15mg, 30 mg F


TRANXENE T TABS (clorazepate dipotassium) NF


VALIUM TABS (diazepam) NF QL(4 ea daily);AL(At least 6yrs old)

XANAX TABS 0.25 MG, 0.5 MG, 1 MG (alprazolam) NF


XANAX TABS 2 MG (alprazolam) NF


XANAX XR TB24 (alprazolam) NF


ANTICONVULSANTS - Drugs to Treat Seizures

Anticonvulsants - Benzodiazepines

Drug Name DrugTier

Requirements/Limits

clonazepam tabs or 0.5mg, 1 mg F


clonazepam tabs or 2 mg F QL(2 ea daily);AL(At least 6yrs old)

clonazepam tbdp or 0.125mg, 0.25 mg, 0.5 mg, 1 mg F QL(4 ea daily)

clonazepam tbdp or 2 mg F QL(2 ea daily)

DIASTAT ACUDIAL GEL (diazepam(anticonvulsant))

NF

DIASTAT PEDIATRIC GEL (diazepam(anticonvulsant))

NF

KLONOPIN TABS 0.5 MG, 1 MG (clonazepam) NF


KLONOPIN TABS 2 MG (clonazepam) NF


Anticonvulsants - Misc. carbamazepine chew or100 mg F

carbamazepine cp12 or100 mg, 200 mg, 300 mg F

carbamazepine susp or100 mg/5ml, 200 mg/10ml F

carbamazepine tabs or 200 mg F

carbamazepine tb12 or 100mg, 200 mg, 400 mg F

CARBATROL CP12 (carbamazepine) NF

gabapentin caps or 100mg, 300 mg, 400 mg F AL(At least 6

yrs old) gabapentin soln or 250mg/5ml, 300 mg/6ml F AL(At least 6

yrs old) gabapentin tabs or 600 mg,800 mg F AL(At least 6

yrs old) LAMICTAL CHEWABLE DISPERSIBLE CHEW (lamotrigine)

NF AL(At least 6yrs old)

LAMICTAL ODT TBDP 100 MG, 200 MG, 25 MG, 50 MG (lamotrigine)



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Drug Name DrugTier

Requirements/Limits

LAMICTAL TABS (lamotrigine) NF AL(At least 6

yrs old) LAMICTAL XR TB24 100 MG, 25 MG, 50 MG (lamotrigine)

NF QL(3 ea daily)

LAMICTAL XR TB24 200 MG, 250 MG, 300 MG (lamotrigine)

NF QL(2 ea daily)

lamotrigine chew or 25 mg,5 mg F AL(At least 6

yrs old) lamotrigine tabs or 150 mg,25 mg, 100 mg, 200 mg F AL(At least 6

yrs old) lamotrigine tb24 or 100 mg,25 mg, 50 mg F QL(3 ea daily)

lamotrigine tb24 or 200 mg,250 mg, 300 mg F QL(2 ea daily)

lamotrigine tbdp or 100 mg,200 mg, 25 mg, 50 mg F AL(At least 6

yrs old) NEURONTIN CAPS (gabapentin) NF AL(At least 6

yrs old) NEURONTIN SOLN (gabapentin) NF AL(At least 6

yrs old) NEURONTIN TABS (gabapentin) NF AL(At least 6

yrs old)

oxcarbazepine susp F AL(At least 6yrs old)

oxcarbazepine tabs F AL(At least 6yrs old)

QUDEXY XR CS24 (topiramate) NF

TEGRETOL SUSP (carbamazepine) NF

TEGRETOL TABS (carbamazepine) NF

TEGRETOL-XR TB12 (carbamazepine) NF

TOPAMAX SPRINKLE CPSP (topiramate) NF AL(At least 6

yrs old) TOPAMAX TABS (topiramate) NF AL(At least 6

yrs old) topiramate cpsp or 15 mg,25 mg F AL(At least 6

yrs old) topiramate tabs or 100 mg,200 mg, 25 mg, 50 mg F AL(At least 6

yrs old) TRILEPTAL SUSP (oxcarbazepine) NF AL(At least 6

yrs old)

Drug Name DrugTier

Requirements/Limits

TRILEPTAL TABS (oxcarbazepine) NF AL(At least 6

yrs old) Valproic Acid DEPAKOTE ER TB24 (divalproex sodium) NF

DEPAKOTE SPRINKLES CSDR (divalproex sodium) NF

DEPAKOTE TBEC (divalproex sodium) NF

divalproex sodium csdr or125 mg F

divalproex sodium tb24 or250 mg, 500 mg F

divalproex sodium tbec or125 mg, 250 mg, 500 mg F

valproate sodium soln or250 mg/5ml F

valproic acid caps or F

ANTIDEPRESSANTS - Drugs to Treat Depression

Alpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine tabs or 15 mg,30 mg, 45 mg, 7.5 mg F


mirtazapine tbdp or 15 mg,30 mg, 45 mg F


REMERON SOLTAB TBDP (mirtazapine) NF


REMERON TABS (mirtazapine) NF


Antidepressants - Misc.

bupropion hcl tabs or 100mg, 75 mg F


bupropion hcl tb12 or 100mg, 150 mg, 200 mg F


bupropion hcl tb24 or 300mg, 150 mg F


bupropion hcl tb24 or 450 mg F PA


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Drug Name DrugTier

Requirements/Limits

FORFIVO XL TB24 (bupropion hcl) F PA

maprotiline hcl tabs F AL(At least 6yrs old)

WELLBUTRIN SR TB12 (bupropion hcl) NF


WELLBUTRIN XL TB24 (bupropion hcl) NF


N-Methyl-D-aspartic acid (NMDA) Receptor SPRAVATO 56MG DOSE SOPK F PA; SP

SPRAVATO 84MG DOSE SOPK F PA; SP

Selective Serotonin Reuptake Inhibitors (SSRIs)

CELEXA TABS 10 MG (citalopram hydrobromide) NF


CELEXA TABS 20 MG, 40 MG (citalopramhydrobromide)

NF QL(1 ea daily);AL(At least 6yrs old)

citalopram hydrobromidesoln 10 mg/5ml F AL(Up to 12 yrs

old )

citalopram hydrobromidetabs 10 mg F


citalopram hydrobromidetabs 20 mg, 40 mg F


escitalopram oxalate tabsor 10 mg, 20 mg F


escitalopram oxalate tabsor 5 mg F


fluoxetine hcl caps or 10mg, 40 mg F


fluoxetine hcl caps or 20 mg F


fluoxetine hcl soln or 20 mg/5ml F AL(Up to 12 yrs

old )

Drug Name DrugTier

Requirements/Limits

fluvoxamine maleate tabs 100 mg F






LEXAPRO TABS 10 MG, 20 MG (escitalopram oxalate)


LEXAPRO TABS 5 MG (escitalopram oxalate) NF


paroxetine hcl tabs 10 mg,20 mg, 30 mg F


paroxetine hcl tabs 40 mg F QL(1.5 eadaily); AL(Atleast 6 yrs old)

PAXIL TABS 10 MG, 20 MG, 30 MG (paroxetine hcl)


PAXIL TABS 40 MG (paroxetine hcl) NF

QL(1.5 eadaily); AL(Atleast 6 yrs old)

PROZAC CAPS 10 MG, 40 MG (fluoxetine hcl) NF


PROZAC CAPS 20 MG (fluoxetine hcl) NF


sertraline hcl conc or 20 mg/ml F AL(Up to 12 yrs

old )

sertraline hcl tabs or 100 mg F


sertraline hcl tabs or 25 mg F QL(3 ea daily);AL(At least 6yrs old)

sertraline hcl tabs or 50 mg F QL(4 ea daily);AL(At least 6yrs old)

ZOLOFT CONC 20 MG/ML(sertraline hcl) NF AL(Up to 12 yrs

old )


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Drug Name DrugTier

Requirements/Limits

ZOLOFT TABS 100 MG (sertraline hcl) NF






Serotonin Modulators

trazodone hcl tabs or 100 mg F








Serotonin-Norepinephrine Reuptake Inhibitors

CYMBALTA CPEP 20 MG, 30 MG (duloxetine hcl) NF


CYMBALTA CPEP 60 MG (duloxetine hcl) NF


duloxetine hcl cpep or 20mg, 30 mg F


duloxetine hcl cpep or 60 mg F


EFFEXOR XR CP24 150 MG (venlafaxine hcl) NF


EFFEXOR XR CP24 75 MG, 37.5 MG (venlafaxine hcl)


venlafaxine hcl cp24 150 mg F


venlafaxine hcl cp24 75mg, 37.5 mg F


Drug Name DrugTier

Requirements/Limits

venlafaxine hcl tabs 100 mg, 37.5 mg, 50 mg F


venlafaxine hcl tabs 25 mg F QL(4 ea daily);AL(At least 6yrs old)

venlafaxine hcl tabs 75 mg F QL(5 ea daily);AL(At least 6yrs old)

Tricyclic Agents amitriptyline hcl tabs or 10mg, 50 mg, 100 mg, 150mg, 25 mg, 75 mg

F AL(At least 6yrs old)

amoxapine tabs F AL(At least 6yrs old)

ANAFRANIL CAPS (clomipramine hcl) NF AL(At least 6

yrs old) clomipramine hcl caps or25 mg, 50 mg, 75 mg F AL(At least 6

yrs old) desipramine hcl tabs or 10mg, 100 mg, 150 mg, 25mg, 75 mg, 50 mg


doxepin hcl caps or 150mg, 25 mg, 75 mg, 10 mg,100 mg, 50 mg


doxepin hcl conc or 10mg/ml F

QL(6 ml daily);AL(At least 6yrs old)

imipramine hcl tabs or 10mg, 25 mg, 50 mg F AL(At least 6

yrs old)

imipramine pamoate caps F AL(At least 6yrs old)

NORPRAMIN TABS (desipramine hcl) NF AL(At least 6

yrs old) nortriptyline hcl caps or 10mg, 50 mg, 25 mg, 75 mg F AL(At least 6

yrs old) nortriptyline hcl soln or 10mg/5ml F AL(At least 6

yrs old) PAMELOR CAPS (nortriptyline hcl) NF AL(At least 6

yrs old)

protriptyline hcl tabs F AL(At least 6yrs old)

trimipramine maleate capsor 100 mg, 25 mg, 50 mg F AL(At least 6

yrs old)

ANTIDOTES AND SPECIFIC ANTAGONISTS


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Drug Name DrugTier

Requirements/Limits

Opioid Antagonists

KLOXXADO LIQD F

naloxone hcl liqd na 4mg/0.1ml F AL(At least 6

yrs old) naloxone hcl soct ij 0.4mg/ml F AL(At least 6

yrs old) naloxone hcl soln ij 0.4mg/ml, 4 mg/10ml F AL(At least 6

yrs old) naloxone hcl sosy ij 2mg/2ml F AL(At least 6

yrs old)

naltrexone hcl tabs or F AL(At least 6yrs old)

NARCAN LIQD (naloxone hcl) NF AL(At least 6

yrs old)

VIVITROL SUSR F AL(At least 6yrs old); SP

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Ethanolamines

ALER-DRYL TABS F AL(At least 6yrs old)

BENADRYL ALLERGY CAPS (diphenhydramine hcl)


BENADRYL ALLERGY CHILDRENS CHEW (diphenhydramine hcl)


BENADRYL ALLERGY CHILDRENS LIQD (diphenhydramine hcl)


BENADRYL ALLERGY TABS (diphenhydramine hcl)


BENADRYL ALLERGY ULTRATABS TABS (diphenhydramine hcl)


diphenhydramine hcl capsor 50 mg, 25 mg F AL(At least 6

yrs old) diphenhydramine hcl chewor 12.5 mg F AL(At least 6

yrs old) diphenhydramine hcl elix or12.5 mg/5ml F AL(At least 6

yrs old) diphenhydramine hcl liqd or6.25 mg/ml, 12.5 mg/5ml,25 mg/10ml, 50 mg/20ml


Drug Name DrugTier

Requirements/Limits

diphenhydramine hcl tabsor 25 mg F AL(At least 6

yrs old) DIPHENHYDRAMINE HYDROCHLORIDE LIQD F AL(At least 6

yrs old) VANAMINE PD LIQD (diphenhydramine hcl) NF AL(At least 6

yrs old) Antihistamines - Piperidines cyproheptadine hcl tabs or4 mg F AL(At least 6

yrs old) ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Fibric Acid Derivatives

LIPOFEN CAPS NF

ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure

Antiadrenergic Antihypertensives CATAPRES TABS (clonidine hcl) NF AL(At least 6

yrs old)

CATAPRES-TTS-1 PTWK (clonidine) NF






clonidine hcl tabs or 0.1 mg, 0.2 mg, 0.3 mg F AL(At least 6

yrs old)

clonidine ptwk F QL(0.15 eadaily); AL(Atleast 6 yrs old)

guanfacine hcl tabs F AL(At least 6yrs old)

MINIPRESS CAPS (prazosin hcl) NF AL(At least 6

yrs old)

prazosin hcl caps F AL(At least 6yrs old)

ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinson's Disease

Antiparkinson Anticholinergics benztropine mesylate solnij 1 mg/ml F PA


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Drug Name DrugTier

Requirements/Limits

benztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg F AL(At least 6

yrs old) COGENTIN SOLN (benztropine mesylate) NF PA

trihexyphenidyl hcl soln 0.4mg/ml F

trihexyphenidyl hcl tabs 2mg, 5 mg F AL(At least 6

yrs old) Antiparkinson Dopaminergics

amantadine hcl caps or F

STALEVO 100 TABS (carbidopa-levodopa-entacapone)

NF


NF


NF


NF


NF


NF

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood Disorders

Antimanic Agents lithium carbonate caps or150 mg, 300 mg, 600 mg F

lithium carbonate tabs or 300 mg F

lithium carbonate tbcr or 300 mg, 450 mg F

LITHIUM SOLN F

LITHOBID TBCR (lithium carbonate) NF

Antipsychotics - Misc. GEODON CAPS OR 20 MG, 40 MG, 60 MG (ziprasidone hcl)


Drug Name DrugTier

Requirements/Limits

GEODON CAPS OR 80 MG (ziprasidone hcl) NF


LATUDA TABS F QL(1 ea daily);AL(At least 6yrs old)

ziprasidone hcl caps 20mg, 40 mg, 60 mg F


ziprasidone hcl caps 80 mg F QL(2 ea daily);AL(At least 6yrs old)

Benzisoxazoles

INVEGA HAFYERA SUSY F PA; SP

INVEGA SUSTENNA SUSY F

Limit 1 per 4weeks;;1 rtl pack lmtamt,28 rtl packlmt day(s),;AL(At least 18yrs old); SP

INVEGA TRINZA SUSY 273 MG/0.88ML, 410MG/1.32ML, 546MG/1.75ML

F

PA; Try InvegaSustenna first; Limit 1 per 3months;1 rtl pack lmtamt,90 rtl packlmt day(s),;AL(At least 18yrs old); SP

INVEGA TRINZA SUSY 819 MG/2.63ML F

PA; Try InvegaSustenna first; Limit 1 per 3months

PERSERIS PRSY F

Limit 1 per 28days;QL(0.036ea daily); AL(Atleast 18 yrsold); SP

RISPERDAL CONSTA SRER F

Limit 2 per 4weeks;;2 rtl MAX fill,28 rtl day(s) supply,;AL(At least 18yrs old); SP


9

Drug Name DrugTier

Requirements/Limits

RISPERDAL SOLN 1 MG/ML (risperidone) NF

QL(8 mldaily,240 mlper 30 daysretail); AL(Atleast 6 yrs old)

RISPERDAL TABS 0.5 MG (risperidone) NF


RISPERDAL TABS 1 MG, 2 MG (risperidone) NF


RISPERDAL TABS 3 MG, 4 MG (risperidone) NF


risperidone soln 1 mg/ml F

QL(8 mldaily,240 mlper 30 daysretail); AL(Atleast 6 yrs old)

risperidone tabs 0.25 mg,0.5 mg F


risperidone tabs 1 mg, 2 mg F


risperidone tabs 3 mg, 4 mg F


risperidone tbdp 0.25 mg,0.5 mg, 1 mg, 2 mg, 3 mg,4 mg


Butyrophenones HALDOL DECANOATE 100 SOLN (haloperidol decanoate)


HALDOL DECANOATE 50 SOLN (haloperidoldecanoate)


HALDOL SOLN (haloperidol lactate) NF AL(At least 6

yrs old) haloperidol decanoate solnim 100 mg/ml, 50 mg/ml F AL(At least 18

yrs old)

haloperidol lactate conc F AL(At least 6yrs old)

haloperidol lactate soln F AL(At least 6yrs old)

Drug Name DrugTier

Requirements/Limits

haloperidol tabs or 0.5 mg,1 mg, 10 mg, 2 mg, 20 mg,5 mg


Dibenzapines

CLOZAPINE ODT TBDP (clozapine) F


clozapine tabs 200 mg, 50mg, 100 mg, 25 mg F


clozapine tbdp 100 mg,12.5 mg, 25 mg, 200 mg,150 mg


CLOZARIL TABS 100 MG, 25 MG (clozapine) NF

CLOZARIL TABS 200 MG, 50 MG (clozapine) NF


loxapine succinate caps F AL(At least 6yrs old)

olanzapine solr im 10 mg F PA

olanzapine tabs or 10 mg,5 mg F


olanzapine tabs or 15 mg,20 mg F


olanzapine tabs or 2.5 mg,7.5 mg F

QL(1 eadaily,30 day(s)limit); AL(Atleast 6 yrs old)

olanzapine tbdp or 10 mg,5 mg F


olanzapine tbdp or 15 mg,20 mg F


quetiapine fumarate tabs100 mg, 200 mg, 25 mg, 50 mg


quetiapine fumarate tabs300 mg, 400 mg F


SEROQUEL TABS 100 MG, 200 MG, 25 MG, 50 MG (quetiapine fumarate)



10

Drug Name DrugTier

Requirements/Limits

SEROQUEL TABS 300 MG, 400 MG (quetiapine fumarate)


ZYPREXA SOLR IM 10 MG (olanzapine) NF PA

ZYPREXA TABS OR 10 MG, 5 MG (olanzapine) NF


ZYPREXA TABS OR 15 MG, 20 MG (olanzapine) NF


ZYPREXA TABS OR 2.5 MG, 7.5 MG (olanzapine) NF

QL(1 eadaily,30 day(s)limit); AL(Atleast 6 yrs old)

ZYPREXA ZYDIS TBDP 10 MG, 5 MG (olanzapine) NF


ZYPREXA ZYDIS TBDP 15 MG, 20 MG (olanzapine) NF


Dihydroindolones

molindone hcl tabs F PA

Phenothiazines chlorpromazine hcl soln ij25 mg/ml, 50 mg/2ml F PA

chlorpromazine hcl tabs or10 mg, 100 mg, 200 mg, 25mg, 50 mg


fluphenazine decanoatesoln ij F AL(At least 18

yrs old) fluphenazine hcl conc or 5mg/ml F AL(At least 6

yrs old) fluphenazine hcl elix or 2.5mg/5ml F AL(At least 6

yrs old) fluphenazine hcl soln ij 2.5mg/ml F PA; AL(At least

18 yrs old) fluphenazine hcl tabs or 1mg, 10 mg, 2.5 mg, 5 mg F AL(At least 6

yrs old) perphenazine tabs or 16mg, 2 mg, 4 mg, 8 mg F AL(At least 6

yrs old) thioridazine hcl tabs or 10 mg, 100 mg, 25 mg, 50 mg F AL(At least 6

yrs old)

trifluoperazine hcl tabs F AL(At least 6yrs old)

Drug Name DrugTier

Requirements/Limits

Quinolinone Derivatives

ABILIFY MAINTENA PRSY F


ABILIFY MAINTENA SRER F


ABILIFY TABS (aripiprazole) NF


aripiprazole tabs F QL(1 ea daily);AL(At least 6yrs old)

ARISTADA INITIO PRSY F

Limit 2 doses per 365Days;;2 rtl MAXfill,365 rtl day(s) supply,;AL(At least 18yrs old); SP

ARISTADA PRSY 1064 MG/3.9ML F

Limit 1 per 8weeks;1 rtl pack lmtamt,56 rtl packlmt day(s),;AL(At least 18yrs old); SP

ARISTADA PRSY 441 MG/1.6ML, 662 MG/2.4ML,882 MG/3.2ML

F


Thioxanthenes

thiothixene caps F AL(At least 6yrs old)

BETA BLOCKERS - Drugs to Treat High BloodPressure

Beta Blockers Non-Selective


11

Drug Name DrugTier

Requirements/Limits

CORGARD TABS (nadolol) NF

PA req age 19and up or usealternative;AL(Up to 18 yrs old)

nadolol tabs or 20 mg, 40mg, 80 mg F

PA req age 19and up or usealternative;AL(Up to 18 yrs old)

propranolol hcl tabs or 10mg, 20 mg, 80 mg, 40 mg,60 mg


CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation Conditions

Peripheral Vasodilators

inositol niacinate caps F

NIACIN FLUSH FREE CAPS F

NIACIN FLUSH-FREE EXTRA STRENGTH CAPS F

NO FLUSH NIACIN TABS F

DERMATOLOGICALS - Drugs to Treat SkinConditions

Corticosteroids - Topical PSORCON CREA (diflorasone diacetate) NF

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders

Cobalamins

B-12 TABS F AL(At least 6yrs old)

cyanocobalamin tabs or 50mcg, 250 mcg, 1000 mcg,100 mcg, 500 mcg


Folic Acid/Folates

folic acid tabs F AL(At least 6yrs old);RX/OTC

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTS

Antihistamine Hypnotics

Drug Name DrugTier

Requirements/Limits

diphenhydramine hcl(sleep) caps 25 mg F QL(2 ea daily)

diphenhydramine hcl(sleep) caps 50 mg F QL(1 ea daily)

diphenhydramine hcl(sleep) liqd 50 mg/30ml F QL(30 ml daily)

diphenhydramine hcl(sleep) tabs 25 mg F QL(2 ea daily)

diphenhydramine hcl(sleep) tabs 50 mg F QL(1 ea daily)

diphenhydramine hcl(sleep) tbdp 25 mg F QL(2 ea daily)

NYTOL MAXIMUM STRENGTH TABS (diphenhydramine hcl(sleep))

NF

QL(1 ea daily)

UNISOM SLEEPGELS CAPS (diphenhydraminehcl (sleep))

NF QL(1 ea daily)

UNISOM SLEEPMELTS TBDP (diphenhydraminehcl (sleep))

NF QL(2 ea daily)

WAL-SLEEP Z LIQUID SHOTS LIQD F QL(50 ml daily)

ZZZQUIL CAPS 25 MG (diphenhydramine hcl(sleep))

NF QL(2 ea daily)

ZZZQUIL LIQD 50 MG/30ML(diphenhydramine hcl(sleep))

NF

QL(30 ml daily)

Non-Barbiturate Hypnotics

AMBIEN TABS 10 MG (zolpidem tartrate) NF


AMBIEN TABS 5 MG (zolpidem tartrate) NF


DORAL TABS (quazepam) NF

eszopiclone tabs F QL(1 ea daily);AL(At least 6yrs old)

LUNESTA TABS (eszopiclone) NF



12

Drug Name DrugTier

Requirements/Limits

RESTORIL CAPS (temazepam) NF


temazepam caps F QL(1 ea daily);AL(At least 6yrs old)

zolpidem tartrate tabs or 10 mg F


zolpidem tartrate tabs or 5 mg F


Selective Melatonin Receptor Agonists

HETLIOZ CAPS F PA

HETLIOZ LQ SUSP F PA; SP

ROZEREM TABS (ramelteon) F

ST; Try 2: temazepam,zolpidem,eszopiclone;QL(1 ea daily);AL(At least 6yrs old)

LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives ADVANCED FIBER COMPLEX/ACIDOPHILUSCAPS

F

calcium polycarbophil tabs F

CITRUCEL FIBER LAXATIVE POWD (methylcellulose (laxative))

NF

CITRUCEL TABS (methylcellulose (laxative)) NF

corn dextrin powd F

CVS DAILY FIBER PACK F

CVS NATURAL FIBER SUPPLEMENT PACK F

DAILY FIBER PACK F

EQUALACTIN CHEW F

Drug Name DrugTier

Requirements/Limits

EVAC POWD (psyllium) NF

fiber chew F

FIBER COMPLETE TABS F

FIBER DIET TABS F

FIBER FORMULA CAPS F

FIBERCEL POWD F

FIBERCON TABS (calcium polycarbophil) NF

FIBEREX F15 LIQD F

HYDROCIL INSTANT PACK F

HYDROCIL INSTANT POWD (psyllium) NF

KONSYL DAILY FIBER PACK 100 %, 28.3 %, 60.3 %

F

KONSYL DAILY FIBER POWD 100 % (psyllium) NF

KONSYL DAILY FIBER POWD 60.3 % F

KONSYL ORIGINAL DAILY FIBER PACK F

KONSYL POWD F

KONSYL-D POWD F

METAMUCIL CAPS 0.52 GM (psyllium) NF

METAMUCIL FIBER PACK F

METAMUCIL FREE & NATURAL POWD (psyllium)

NF

METAMUCIL MULTIHEALTH FIBER POWD

F

METAMUCIL MULTIHEALTH FIBER SINGLES PACK

F


13

Drug Name DrugTier

Requirements/Limits

METAMUCIL ORIGINAL TEXTURE POWD (psyllium)

NF

METAMUCIL PACK 28 % F

METAMUCIL POWD 48.57 % (psyllium) NF

METAMUCIL WAFR F

methylcellulose (laxative)powd F

methylcellulose (laxative)tabs F

NATURAL FIBER LAXATIVE POWD F

PROFIBER LIQD F

psyllium caps F

psyllium powd F

SM FIBER POWDER POWD F

SOLFIBER POWD F

UNIFIBER POWD F

Laxatives - Miscellaneous lactulose soln 10 gm/15ml,20 gm/30ml F

Saline Laxatives FLEET ENEMA ENEM (sodium phosphates) NF

FLEET ENEMA SIX PACK ENEM (sodium phosphates)

NF

FLEET PEDIATRIC ENEM (sodium phosphates) NF

magnesium citrate soln or1.745 gm/30ml, F

magnesium oxide (laxative)tabs F

PEDIA-LAX CHEW OR 400 MG F

PHILLIPS MILK OF MAGNESIA CHEWABLE CHEW

F

Drug Name DrugTier

Requirements/Limits

PHILLIPS TABS (magnesium oxide(laxative))

NF

sodium phosphates enem F

Stimulant Laxatives

bisacodyl supp re 10 mg F

bisacodyl tbec or 5 mg F

BLACK DRAUGHT CHEW 10 MG F

cascara sagrada caps 450 mg F

CASCARA SAGRADA EXTR 1 GM/ML F

DULCOLAX SUPP (bisacodyl) NF

DULCOLAX TBEC (bisacodyl) NF

EVAC-U-GEN CHEW F

EX-LAX CHEW (sennosides) NF

FLEET BISACODYL ENEM F

LITTLE TUMMYS LAXATIVE LIQD F

SENNA LEAVES LEAV F

SENNA SYRP OR F

sennosides caps F

sennosides chew F

sennosides liqd F

sennosides syrp F

sennosides tabs F

SENOKOT TABS (sennosides) NF

Surfactant Laxatives COLACE CAPS (docusate sodium) NF AL(At least 6

yrs old)


14

Drug Name DrugTier

Requirements/Limits

docusate sodium caps or250 mg, 100 mg F AL(At least 6

yrs old) docusate sodium liqd or100 mg/10ml, 150mg/15ml, 50 mg/5ml

F

docusate sodium syrp or60 mg/15ml F

docusate sodium tabs or 100 mg F

PEDIA-LAX LIQD OR 50 MG/15ML F

MINERALS & ELECTROLYTES

Electrolyte Mixtures DEXTROSE/SODIUMCHLORIDE SOLN (dextrose w/ sodiumchloride)

NF

POTASSIUM CHLORIDE/SODIUMCHLORIDE SOLN 0.9 %-40 MEQ/L (potassiumchloride in nacl)

NF

Potassium POTASSIUM CHLORIDE SOLN IV 10 MEQ/100ML,20 MEQ/100ML (potassium chloride)

NF

MOUTH/THROAT/DENTAL AGENTS

Throat Products - Misc. AQUORAL SOLN F RX/OTC

artificial saliva lozg F RX/OTC

BIOTENE DRY MOUTH GUM GUM F

BIOTENE DRY MOUTH MOISTURIZING SPRAY SOLN

F RX/OTC

BIOTENE ORALBALANCE DRY MOUTH MOISTURIZING GEL

F

BIOTENE PBF DRY MOUTH GUM GUM F

BOCASAL PACK F

Drug Name DrugTier

Requirements/Limits

CAPHOSOL SOLN F RX/OTC

CAPHOSOL TBEF F

CVS DRY MOUTH SPRAY SOLN F RX/OTC

EQL DRY MOUTH ORAL RINSE SOLN F RX/OTC

MIGHTEAFLOW GUM F

MOI-STIR SOLN F RX/OTC

MOUTH KOTE REMINT SOLN F RX/OTC

MOUTH KOTE SOLN F RX/OTC

MUCOSITISRX PACK F

NEUTRASAL PACK F

NUMOISYN LIQD F RX/OTC

NUMOISYN LOZG (artificial saliva) NF RX/OTC

ORAL RELIEF FOR DRY MOUTH& DISCOMFORT GEL

F

ORAL RELIEF FOR DRY MOUTH& DISCOMFORT KIT

F

ORAL RELIEF SPRAY FOR DRYMOUTH & DISCOMFORT SOLN

F RX/OTC

RA DRY MOUTH SOLN F RX/OTC

SALIVAMAX PACK F

XEROSTOMIA RELIEF SPRAY SOLN F RX/OTC

MULTIVITAMINS

Multiple Vitamins w/ Iron multiple vitamins w/ irontabs F AL(At least 6

yrs old) TAB-A-VITE MULTIVITAMIN/IRON ANDBETA-CAROTENE TABS



15

Drug Name DrugTier

Requirements/Limits

Multiple Vitamins w/ Minerals

ABC COMPLETE SENIOR WOMENS 50+ TABS F

AL(At least 6yrs old);RX/OTC

ACTIVNUTRIENTS CAPS F AL(At least 6yrs old);RX/OTC

ADVANCED DIABETIC MULTIVITAMIN FORMULA TABS

F AL(At least 6yrs old);RX/OTC

ALGAE BASED CALCIUM TABS F


ALIVE ENERGY 50+ TABS F AL(At least 6yrs old);RX/OTC

ALIVE MENS ENERGY TABS F


ALIVE ONCE DAILY WOMENS 50+ ULTRA POTENCY TABS


ALIVE ONCE DAILY WOMENS ULTRA POTENCY TABS


ALIVE WOMENS 50+ TABS F


ALIVE WOMENS ENERGY TABS F


ANTIOXIDANT FORMULA TABS F


AZO HORMONAL HEALTH CYCLE CARE & COMFORT TABS


AZO HORMONAL HEALTH HAPPY CYCLE TABS


BACMIN TABS F AL(At least 6yrs old);RX/OTC

BARIATRIC MULTIVITAMINS/IRONCAPS


Drug Name DrugTier

Requirements/Limits

BASIC AM TABS F AL(At least 6yrs old);RX/OTC

BASIC PM TABS F AL(At least 6yrs old);RX/OTC

BIO-35 GLUTEN-FREE CAPS F


BIO-35 IRON FREE CAPS F AL(At least 6yrs old);RX/OTC

BIOCAL CAPS F AL(At least 6yrs old);RX/OTC

CAL-DAY 1000 TABS F AL(At least 6yrs old);RX/OTC

CELEBRATE MULTI-COMPLETE18 CAPS F








CELLULAR SECURITY CAPS F


CENTRAVITES 50 PLUS TABS F


CENTRAVITES ADULTS TABS F


CENTRUM ADULTS TABS (multiple vitamins w/minerals)

NF AL(At least 6yrs old);RX/OTC

CENTRUM CARDIO TABS F AL(At least 6yrs old);RX/OTC


16

Drug Name DrugTier

Requirements/Limits

CENTRUM MEN TABS 0.9 MG-1.2 MG-1.3 MG-2 MG-2 MG-2.3 MG-5 MCG-6 MCG-8 MG-10 MCG-10 MCG-11 MG-15 MG-16 MG-20 MG-35 MCG-40 MCG-45 UNIT-50 MCG-60 MCG-72 MG-80 MG-90 MG-100 MCG-100 MG-150 MCG-200 MCG-210 MG-600 MCG-1000 UNIT-3500 UNIT

F


CENTRUM MEN TABS 0.9 MG-1.2 MG-1.3 MG-2 MG-2.3 MG-6 MCG-8 MG-11 MG-15 MG-16 MG-20 MG-20.3 MG-25 MCG-35 MCG-40 MCG-50 MCG-60 MCG-72 MG-80 MG-90 MG-100 MCG-100 MG-150 MCG-200 MCG-210 MG-600 MCG-1050 MCG (multiple vitamins w/minerals)

NF


CENTRUM SILVER 50+MEN TABS (multiplevitamins w/ minerals)


CENTRUM SILVER 50+WOMEN TABS (multiple vitamins w/minerals)

NF


CENTRUM SILVER ADULT 50+ TABS (multiplevitamins w/ minerals)


CENTRUM SILVER TABS (multiple vitamins w/minerals)


CENTRUM SILVER ULTRA WOMENS TABS F


CENTRUM SPECIALIST HEART TABS F


CENTRUM SPECIALIST IMMUNE SUPPORT TABS F


CENTRUM SPECIALIST VISION TABS F


Drug Name DrugTier

Requirements/Limits

CENTRUM TABS (multiplevitamins w/ minerals) NF


CENTRUM ULTRA WOMENS TABS F


CENTRUM WOMEN TABS (multiple vitamins w/minerals)


CERTAVITE SENIOR TABS F


CERTAVITE SENIOR/ANTIOXIDANTNUTRIENTS TABS


CERTAVITE/ANTIOXIDANTS TABS F


CHOICEFUL MULTIVITAMIN CAPS F


CLINICAL NUTRIENTS 45-PLUS WOMEN TABS F


CLINICAL NUTRIENTS 50-PLUS MEN TABS F


CLINICAL NUTRIENTS ANTIOXIDANT CAPS F


CLINICAL NUTRIENTS FOR FEMALE TEENS TABS


CLINICAL NUTRIENTS FOR MALE TEENS TABS F


CLINICAL NUTRIENTS FOR MEN TABS F


CLINICAL NUTRIENTS FOR WOMEN TABS F


CVS ADULT 50+ EYE HEALTH CAPS F


CVS EYE HEALTH ADULT 50+ CAPS F



17

Drug Name DrugTier

Requirements/Limits

CVS ONE DAILY MENS 50+ ADVANCED TABS F


CVS ONE DAILY WOMENS 50+ADVANCED TABS


CVS SPECTRAVITE ADULT 50+ TABS F


CVS SPECTRAVITE ADULTS TABS F


CVS SPECTRAVITE ULTRA MEN50+ TABS F


CVS SPECTRAVITE ULTRA MENS HEALTH SENIOR TABS


CVS SPECTRAVITE ULTRA MENS HEALTH TABS


CVS SPECTRAVITE ULTRA WOMEN TABS F


CVS SPECTRAVITE ULTRA WOMENS HEALTH SENIOR TABS


CVS SPECTRAVITE ULTRA WOMENS HEALTH TABS


CVS VISION HEALTH CAPS F


DAYAVITE TABS F AL(At least 6yrs old);RX/OTC

DECUBI-VITE CAPS F AL(At least 6yrs old);RX/OTC

DEKAS PLUS CAPS F AL(At least 6yrs old);RX/OTC

DEKAS PLUS OCEAN CAPS F


DERMACINRX RIBOTIN-E TABS F


Drug Name DrugTier

Requirements/Limits

DERMACINRX ZINTREXYL-C TABS F


DERMAVITE TABS F AL(At least 6yrs old);RX/OTC

EQ COMPLETE MULTIVITAMINADULTS UNDER 50 TABS


EQ ONE DAILY MENS 50+ TABS F


EQ ONE DAILY MENS HEALTH TABS F


EQ ONE DAILY WOMENS 50+ TABS F


EQ ONE DAILY WOMENS HEALTH TABS F


EQL CENTURY MATURE ADULTS50+ TABS F


EQL CENTURY MENS TABS F


EQL CENTURY WOMENS TABS F


EQL ONE DAILY MENS TABS F


ESTROVEN MENOPAUSE SUPPLEMENT TABS F


EYE HEALTH CAPS F AL(At least 6yrs old);RX/OTC

EYE HEALTH/LUTEINTABS F


EYE MULTIVITAMIN CAPS F


EYE MULTIVITAMIN/LUTEINCAPS



18

Drug Name DrugTier

Requirements/Limits

EYE MULTIVITAMIN/LUTEINTABS


EYE MULTIVITAMIN/SODIUMTABS


FITNESS TABS FOR MEN AM/PM/LYCOPENE TABS F


FITNESS TABS FOR WOMEN AM/PM/LYCOPENE TABS


FOLAMAX TABS F AL(At least 6yrs old);RX/OTC

FOLIFLEX TABS F AL(At least 6yrs old);RX/OTC

FOLIKA-CI TABS F AL(At least 6yrs old);RX/OTC

FOLIKA-MG TABS F AL(At least 6yrs old);RX/OTC

FOLITIN-Z TABS F AL(At least 6yrs old);RX/OTC

FORTAVIT CAPS F AL(At least 6yrs old);RX/OTC

FOSFREE TABS (multiplevitamins w/ minerals) NF


FREEDAVITE TABS F AL(At least 6yrs old);RX/OTC

GENADEK STEP 1 CAPS F AL(At least 6yrs old);RX/OTC

GENADEK STEP 2 CAPS F AL(At least 6yrs old);RX/OTC

GERI-FREEDA SENIOR FORMULA TABS F


HAIR SKIN & NAILS ADVANCED FORMULA TABS


Drug Name DrugTier

Requirements/Limits

HAIR/SKIN/NAILS CAPS F AL(At least 6yrs old);RX/OTC

HEALTHY EYES SUPERVISION2 CAPS F


HIGH POTENCY MULTIVITAMIN/BETA-CAROTENE TABS


HIGH POTENCY MULTIVITAMIN/FOLICACID TABS


HM COMPLETE 50+ MENS ULTIMATE TABS F


HM COMPLETE 50+ WOMENS ULTIMATE TABS


HM COMPLETE MEN TABS F


HM COMPLETE TABS F AL(At least 6yrs old);RX/OTC

HM HAIR/SKIN/NAILSTABS F


HM ONE DAILY MENS TABS F


HM ONE DAILY WOMENS TABS F


HYLAZINC TABS F AL(At least 6yrs old);RX/OTC

ICAPS AREDS FORMULA TABS F


K-PAX IMMUNE SUPPORT FORMULA PROFESSIONAL STRENGTH TABS

F


LUTEIN PLUS/ZEAXANTHIN TABS F



19

Drug Name DrugTier

Requirements/Limits

MACULAR VITAMIN BENEFIT TABS F


MEGA MULTI FOR MEN TABS F


MEGA MULTI FOR WOMEN TABS F


MEGA MULTIVITAMIN FOR MEN TABS F


MEGAVITE FRUITS & VEGGIES TABS F


MEGAVITE GOLDEN YEARS 55+ TABS F


MENS 50+ ADVANCED CAPS F


MENS 50+ MULTI VITAMIN &MINERAL FORMULA TABS


MENS MULTI VITAMIN & MINERAL FORMULA TABS


MENS MULTIVITAMIN TABS F


MULTI-BETIC DIABETES SUPPORT TABS F


MULTI-BETIC DIABETES TABS F


MULTI-VITAMIN MONOCAPS TABS F


MULTILEX T&M TABS F AL(At least 6yrs old);RX/OTC

MULTILEX TABS F AL(At least 6yrs old);RX/OTC

multiple vitamins w/minerals caps F


Drug Name DrugTier

Requirements/Limits

multiple vitamins w/minerals tabs F


MULTIVITAMIN ADULTS TABS F


MULTIVITAMIN MEN TABS F


MULTIVITAMIN TABS 1 MG-1 MG-1.5 MG-2 MG-2.5 MG-5 MG-7.5 MCG-10 MCG-10 MG-10 MG-15 MG-15 MG-100 MG-150 MCG-150 MG-3000 MCG

F


MULTIVITAMIN WOMEN TABS F


MULTIVITAMIN/ZINCSTRESSFORMULA TABS F


MVW COMPLETE FORMULATION CAPS F


MVW COMPLETE FORMULATIOND3000 CAPS


MVW COMPLETE FORMULATIOND500 CAPS


MVW COMPLETE FORMULATIONMINIS CAPS


NAT-RUL THERAVITE-M/HIGHPOTENCY TABS F


NATRUL-VITES TABS F AL(At least 6yrs old);RX/OTC

NEOVITE TABS F AL(At least 6yrs old);RX/OTC

NICADAN TABS F AL(At least 6yrs old);RX/OTC

NICADAN ZX TABS F AL(At least 6yrs old);RX/OTC


20

Drug Name DrugTier

Requirements/Limits

NICAZEL FORTE TABS F AL(At least 6yrs old);RX/OTC

NICAZEL TABS F AL(At least 6yrs old);RX/OTC

NO IRON MULTIPLE VITAMIN/MINERALSTABS


NUTRICAP TABS F AL(At least 6yrs old);RX/OTC

OCULAR VITAMINS TABS F AL(At least 6yrs old);RX/OTC

OCUVITE ADULT 50+ CAPS F


OCUVITE ADULT FORMULA CAPS F


OCUVITE LUTEIN CAPS F AL(At least 6yrs old);RX/OTC

ONCOVITE TABS F AL(At least 6yrs old);RX/OTC

ONE DAILY MENS 50+ MULTIVITAMIN TABS F


ONE DAILY MENS FORMULA W/O IRONTABS


ONE DAILY WOMENS TABS F


ONE DIALY MULTIVITAMIN WOMENS TABS


ONE-A-DAY ENERGY TABS F


ONE-A-DAY MENOPAUSE FORMULA TABS F


ONE-A-DAY MENS 50+ ADVANTAGE TABS F


Drug Name DrugTier

Requirements/Limits

ONE-A-DAY MENS 50+ TABS F


ONE-A-DAY MENS HEALTH FORMULA TABS F


ONE-A-DAY MENS PRO EDGE TABS F


ONE-A-DAY MENS TABS 0.9 MG-1.07 MG-1.43 MG-2.17 MG-2.3 MG-6.24 MCG-11 MG-15 MG-15.5 MG-17.6 MG-25 MCG-30 MCG-35 MCG-43 MCG-55 MCG-99 MG-120 MG-150 MCG-210 MG-240 MCG-300 MCG-900 MCG, 0.9 MG-1.32 MG-1.43 MG-2.17 MG-2.3 MG-6.24 MCG-11 MG-15 MG-15.5 MG-17.6 MG-25 MCG-30 MCG-35 MCG-43 MCG-55 MCG-99 MG-120 MG-150 MCG-210 MG-240 MCG-300 MCG-900 MCG

F


ONE-A-DAY PROACTIVE 65+ TABS F


ONE-A-DAY TEEN ADVANTAGEFOR HIM TABS


ONE-A-DAY WEIGHT SMART ADVANCED TABS (multiple vitamins w/minerals)

NF


ONE-A-DAY WOMENS 50+ ADVANTAGE TABS (multiple vitamins w/minerals)

NF


ONE-A-DAY WOMENS 50+ HEALTHY ADVANTAGE TABS (multiple vitamins w/minerals)

NF


ONE-A-DAY WOMENS 50+ TABS F



21

Drug Name DrugTier

Requirements/Limits

ONE-A-DAY WOMENS ACTIVE MIND & BODY TABS (multiple vitamins w/minerals)

NF


ONE-A-DAY WOMENS PETITES TABS (multiplevitamins w/ minerals)


ONE-A-DAY WOMENS PLUS HEALTHY SKIN SUPPORT TABS (multiplevitamins w/ minerals)

NF


ONE-A-DAY WOMENS TABS F


ONE-DAILY MULTI CAPS CAPS F


OPTIVITE P.M.T. TABS (multiple vitamins w/minerals)


OPURITY TABS F AL(At least 6yrs old);RX/OTC

OSTEOPRIME PLUS/CALCIUM &MAGNESIUM TABS


PARVLEX TABS F AL(At least 6yrs old);RX/OTC

PHYTOMULTI TABS F AL(At least 6yrs old);RX/OTC

PRESERVISION AREDS 2 + MULTI VITAMIN CAPS F


PRESERVISION AREDS 2 CAPS F


PRESERVISION AREDS CAPS F


PRESERVISION AREDS TABS F


PRESERVISION/LUTEINCAPS F


Drug Name DrugTier

Requirements/Limits

PRO-CAL TABS F AL(At least 6yrs old);RX/OTC

PROCERV HP TABS F AL(At least 6yrs old);RX/OTC

PROFOLA TABS F AL(At least 6yrs old);RX/OTC

PRORENAL+D TABS F AL(At least 6yrs old);RX/OTC

PRORENAL+D/OMEGA-3CAPS F


PROTECT CARDIO AF CAPS F


PROTECT PLUS SO CAPS F


PROTEGRA CAPS F AL(At least 6yrs old);RX/OTC

PROVIT TABS F AL(At least 6yrs old);RX/OTC

QC MULTI-VITE TABS F AL(At least 6yrs old);RX/OTC

QC OCUHEALTH VISION SUPPORT 2 CAPS F


QUIN B STRONG TABS F AL(At least 6yrs old);RX/OTC

QUINTABS-M TABS F AL(At least 6yrs old);RX/OTC

RA CENTRAL-VITE TABS F AL(At least 6yrs old);RX/OTC

RENAPLEX-D TABS F AL(At least 6yrs old);RX/OTC

REPLACE CAPS F AL(At least 6yrs old);RX/OTC


22

Drug Name DrugTier

Requirements/Limits

REQ 49+ TABS F AL(At least 6yrs old);RX/OTC

SENTRY SENIOR TABS F AL(At least 6yrs old);RX/OTC

SENTRY SENIOR/LUTEINTABS F


SENTRY TABS F AL(At least 6yrs old);RX/OTC

SIDEROL TABS F AL(At least 6yrs old);RX/OTC

SM ONE DAILY MENS TABS F


SM ONE DAILY WOMENS TABS F


SOLO TABS F AL(At least 6yrs old);RX/OTC

SPECTRAVITE TABS F AL(At least 6yrs old);RX/OTC

STROVITE FORTE TABS (multiple vitamins w/minerals)


STROVITE ONE TABS F AL(At least 6yrs old);RX/OTC

SUPER ANTIOXIDANT CAPS F


SYSTANE ICAPS AREDS2 TABS F


T-VITES TABS F AL(At least 6yrs old);RX/OTC

THERA M PLUS TABS F AL(At least 6yrs old);RX/OTC

THERA-M TABS F AL(At least 6yrs old);RX/OTC

Drug Name DrugTier

Requirements/Limits

THERA-TABS M TABS F AL(At least 6yrs old);RX/OTC

THERABETIC MULTI-VITAMIN TABS F


THERAGRAN-M ADVANCED 50 PLUS TABS


THERAGRAN-M ADVANCED TABS F


THERAGRAN-M PREMIER 50 PLUS TABS F


THERAGRAN-M PREMIER TABS F


THERAGRAN-M TABS F AL(At least 6yrs old);RX/OTC

THERAMILL FORTE CAPS F AL(At least 6yrs old);RX/OTC

THERANATAL LACTATION ONE CAPS F


THEREMS-M TABS F AL(At least 6yrs old);RX/OTC

UNICOMPLEX-M TABS F AL(At least 6yrs old);RX/OTC

VENEXA FE TABS F AL(At least 6yrs old);RX/OTC

VENEXA TABS F AL(At least 6yrs old);RX/OTC

VENTRIXYL FE TABS F AL(At least 6yrs old);RX/OTC

VISTA ADVANCED AREDS2 FORMULA CAPS F


VISTA ADVANCED DRY EYE FORMULA CAPS F



23

Drug Name DrugTier

Requirements/Limits

VITABEX CAPS F AL(At least 6yrs old);RX/OTC

VITABEX PLUS CAPS F AL(At least 6yrs old);RX/OTC

VITALINE TOTAL FORMULA 2 TABS F


VITALINE TOTAL FORMULA 3 TABS F


VITAMIN D3 COMPLETE TABS F


VITAROCA PLUS TABS (multiple vitamins w/minerals)


VITASANA TABS F AL(At least 6yrs old);RX/OTC

VITATRUM TABS F AL(At least 6yrs old);RX/OTC

VITEYES CLASSIC ADVANCED CAPS F


VITEYES CLASSIC CAPS F AL(At least 6yrs old);RX/OTC

VITEYES CLASSIC MACULAR SUPPORT CAPS


VITEYES CLASSIC MULTIIVITAMIN TABS F


VITEYES CLASSIC MULTIVITAMIN TABS F


VITEYES CLASSIC+OMEGA-3 CAPS


VITEYES CLASSIC/OMEGA-3 CAPS F


VITEYES OPTIC NERVE SUPPORT TABS F


Drug Name DrugTier

Requirements/Limits

VITRAMYN TABS F AL(At least 6yrs old);RX/OTC

VITRANOL FE TABS F AL(At least 6yrs old);RX/OTC

VITRANOL TABS F AL(At least 6yrs old);RX/OTC

VITREXATE FE TABS F AL(At least 6yrs old);RX/OTC

VITREXATE TABS F AL(At least 6yrs old);RX/OTC

VITREXYL TABS F AL(At least 6yrs old);RX/OTC

VITREXYL/IRON TABS F AL(At least 6yrs old);RX/OTC

VITRUM 50+ ADULT-MULTI IRON FREE TABS F


VITRUM 50+ SENIOR MULTI TABS F


WHOLE FOOD MULTIVITAMIN TABS F


WOMENS 50+ MULTI VITAMIN& MINERAL FORMULA TABS


WOMENS BIOMULTIPLE TABS F


WOMENS MULTI VITAMIN & MINERAL FORMULA TABS


YELETS TEENAGE FORMULA TABS F


ZYVANA CAPS F AL(At least 6yrs old);RX/OTC

Multivitamins


24

Drug Name DrugTier

Requirements/Limits

AMLADEX TABS F AL(At least 6yrs old)

DAILY MULTIPLE VITAMINS TABS F AL(At least 6

yrs old)

ESTROFACTORS TABS F AL(At least 6yrs old)

HIGH POTENCY MULTIVITAMIN TABS F AL(At least 6

yrs old)

MULTI VITAMIN TABS F AL(At least 6yrs old)

MULTI VITAMIN/D-3 TABS F AL(At least 6yrs old)

multiple vitamin tabs F AL(At least 6yrs old)

MULTIVITAMIN ADULT TABS F AL(At least 6

yrs old) MULTIVITAMIN TABS 0.1 MG-1 MG-1.5 MG-2 MG-10 MCG-20 MG-28.5 MG-37.5 MG-1500 MCG

F

AL(At least 6yrs old)

NEOMULTIVITE TABS F AL(At least 6yrs old)

OMNICAP TABS F AL(At least 6yrs old)

ONE DAILY ESSENTIAL TABS F AL(At least 6

yrs old) ONE-A-DAY ESSENTIAL TABS (multiple vitamin) NF AL(At least 6

yrs old) ONE-A-DAY MENS TABS 0.4 MG-2.25 MG-2.55 MG-3 MG-9 MCG-10 MG-20 MG-45 UNIT-200 MG-400 UNIT-5000 UNIT (multiple vitamin)

NF


QUINTABS TABS F AL(At least 6yrs old)

THERA TABS F AL(At least 6yrs old)

THEREMS MULTIVITAMIN TABS F AL(At least 6

yrs old)

NUTRIENTS

Misc. Nutritional Substances

FISH OIL CAPS F AL(At least 6yrs old)

Drug Name DrugTier

Requirements/Limits

FISH OIL CHEW F AL(At least 6yrs old)

FISH OIL PEARLS CAPS F AL(At least 6yrs old)

FISH OIL TRIPLE STRENGTH CAPS F AL(At least 6

yrs old)

FISH OIL ULTRA CAPS F AL(At least 6yrs old)

OCEAN BLUE MINICAPS OMEGA-3 CAPS F AL(At least 6

yrs old)

OMEGA-3 CAPS F AL(At least 6yrs old)

OMEGA-3 EPA FISH OIL CAPS F AL(At least 6

yrs old)

omega-3 fatty acids caps F AL(At least 6yrs old)

omega-3 fatty acids chew F AL(At least 6yrs old)

OMEGA-3 FISH OIL EXTRA STRENGTH CAPS F AL(At least 6

yrs old)

SALMON CAPS F AL(At least 6yrs old)

SALMON OIL CAPS F AL(At least 6yrs old)

SALMON OIL-1000 CAPS F AL(At least 6yrs old)

SM FISH OIL CAPS F AL(At least 6yrs old)

SUPER TWIN EPA/DHACAPS F AL(At least 6

yrs old)

ULTRA OMEGA 3 CAPS F AL(At least 6yrs old)

ULTRA OMEGA-3 FISH OIL BURP-LESS CAPS F AL(At least 6

yrs old) PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental andEmotional Conditions

Agents for Chemical Dependency

acamprosate calcium tbec F AL(At least 6yrs old)

ANTABUSE TABS (disulfiram) NF AL(At least 6

yrs old) disulfiram tabs or 250 mg,500 mg F AL(At least 6

yrs old) Movement Disorder Drug Therapy


25

Drug Name DrugTier

Requirements/Limits

AUSTEDO TABS F PA; SP

INGREZZA CAPS F PA; SP

Psychotherapeutic and Neurological Agents -

pimozide tabs F AL(At least 12yrs old)

THYROID AGENTS - Drugs to Regulate ThyroidHormones

Thyroid Hormones ARMOUR THYROID TABS 120 MG, 30 MG, 60 MG, 90 MG (thyroid)


CYTOMEL TABS (liothyronine sodium) NF AL(At least 6

yrs old) LEVOTHYROXINE SODIUM SOLR IV 100 MCG, 500 MCG (levothyroxine sodium)

NF

levothyroxine sodium tabsor 300 mcg, 100 mcg, 112mcg, 125 mcg, 137 mcg,150 mcg, 175 mcg, 200mcg, 25 mcg, 50 mcg, 75mcg, 88 mcg

F


liothyronine sodium tabs or25 mcg, 5 mcg, 50 mcg F AL(At least 6

yrs old) NATURE-THROID TABS 130 MG, 195 MG, 32.5 MG, 65 MG


SYNTHROID TABS (levothyroxine sodium) NF AL(At least 6

yrs old) thyroid tabs or 120 mg, 30mg, 60 mg, 90 mg F AL(At least 6

yrs old) WESTHROID TABS 130 MG, 195 MG, 32.5 MG, 65 MG


WP THYROID TABS 130 MG, 32.5 MG, 65 MG F AL(At least 6

yrs old) ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach Conditions

Antispasmodics ATROPINE SULFATE SOSY IJ 0.25 MG/5ML, 0.5MG/5ML (atropine sulfate)

NF

Drug Name DrugTier

Requirements/Limits

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms

Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride tabs or 10 mg, 25 mg, 5 mg, 50 mg


URECHOLINE TABS (bethanechol chloride) NF AL(At least 6

yrs old)

VITAMINS

Oil Soluble Vitamins vitamin e caps or 100 unit,200 unit, 400 unit, 180 mg F AL(At least 6

yrs old) VITAMIN E CHEW OR 400 UNIT F AL(At least 6

yrs old) Water Soluble Vitamins

B-1 TABS F AL(At least 6yrs old)

niacin cpcr F

niacin tbcr F

pyridoxine hcl tabs F AL(At least 6yrs old)

SLO-NIACIN TBCR (niacin) NF

thiamine hcl tabs F AL(At least 6yrs old)

thiamine mononitrate tabs F AL(At least 6yrs old)


26

Index ABC COMPLETE SENIOR BACMIN 16 CELLULAR SECURITY 16 WOMENS 50+ 16 BARIATRIC CENTRAVITES 50 PLUS 16 ABILIFY 11 MULTIVITAMINS/IRON 16 CENTRAVITES ADULTS 16 ABILIFY MAINTENA 11 BASIC AM 16 CENTRUM 17 acamprosate calcium 25 BASIC PM 16 CENTRUM ADULTS 16 ACTIVNUTRIENTS 16 BENADRYL ALLERGY 8 CENTRUM CARDIO 16 ADDERALL 1 BENADRYL ALLERGY

CENTRUM MEN 17 CHILDRENS 8 ADDERALL XR 1 BENADRYL ALLERGY CENTRUM SILVER 17 ADVANCED DIABETIC ULTRATABS 8 CENTRUM SILVER MULTIVITAMIN FORMULA 16 benztropine mesylate 8,9 50+MEN 17 ADVANCED FIBER CENTRUM SILVER COMPLEX/ACIDOPHILUS 13 bethanechol chloride 26 50+WOMEN 17 ALER-DRYL 8 BIO-35 GLUTEN-FREE 16 CENTRUM SILVER ADULT

ALGAE BASED CALCIUM 16 BIO-35 IRON FREE 16 50+ 17 ALIVE ENERGY 50+ 16 BIOCAL 16 CENTRUM SILVER ULTRA

WOMENS 17 ALIVE MENS ENERGY 16 BIOTENE DRY MOUTH CENTRUM SPECIALIST GUM 15 ALIVE ONCE DAILY WOMENS HEART 17 BIOTENE DRY MOUTH 50+ ULTRA POTENCY 16 CENTRUM SPECIALIST MOISTURIZING SPRAY 15 ALIVE ONCE DAILY WOMENS IMMUNE SUPPORT 17 BIOTENE ORALBALANCE ULTRA POTENCY 16 CENTRUM SPECIALIST DRY MOUTH ALIVE WOMENS 50+ 16 VISION 17 MOISTURIZING 15 ALIVE WOMENS ENERGY 16 CENTRUM ULTRA BIOTENE PBF DRY MOUTH WOMENS 17 alprazolam 3 GUM 15 CENTRUM WOMEN 17 ALPRAZOLAM INTENSOL 3 bisacodyl 14 CERTAVITE SENIOR 17 amantadine hcl 9 BLACK DRAUGHT 14 CERTAVITE AMBIEN 12 BOCASAL 15 SENIOR/ANTIOXIDANT

amitriptyline hcl 7 buprenorphine hcl 2 NUTRIENTS 17 AMLADEX 25 buprenorphine hcl-naloxone hcl CERTAVITE/ANTIOXIDANTS

dihydrate 2 17 amoxapine 7 bupropion hcl 5 chlordiazepoxide hcl 3 amphetamine-dextroamphetamine 1 buspirone hcl 3 chlorpromazine hcl 11 ANAFRANIL 7 CAL-DAY 1000 16 CHOICEFUL

MULTIVITAMIN 17 ANTABUSE 25 calcium polycarbophil 13 citalopram hydrobromide 6 ANTIOXIDANT FORMULA 16 CAPHOSOL 15 CITRUCEL 13 AQUORAL 15 carbamazepine 4 CITRUCEL FIBER

aripiprazole 11 CARBATROL 4 LAXATIVE 13 ARISTADA 11 cascara sagrada 14 CLINICAL NUTRIENTS 45-PLUS ARISTADA INITIO 11 CASCARA SAGRADA 14 WOMEN 17

CLINICAL NUTRIENTS 50-PLUS ARMOUR THYROID 26 CATAPRES 8 MEN 17 artificial saliva 15 CATAPRES-TTS-1 8 CLINICAL NUTRIENTS ATIVAN 3 CATAPRES-TTS-2 8 ANTIOXIDANT 17

CLINICAL NUTRIENTS FOR atomoxetine hcl 1 CATAPRES-TTS-3 8 FEMALE TEENS 17 CELEBRATE MULTI-ATROPINE SULFATE 26 CLINICAL NUTRIENTS FOR COMPLETE18 16 AUSTEDO 26 MALE TEENS 17 CELEBRATE MULTI-AZO HORMONAL HEALTH CLINICAL NUTRIENTS FOR COMPLETE36 16 CYCLE CARE & COMFORT 16 MEN 17 CELEBRATE MULTI-AZO HORMONAL HEALTH CLINICAL NUTRIENTS FOR COMPLETE45 16 HAPPY CYCLE 16 WOMEN 17 CELEBRATE MULTI- clomipramine hcl 7 B-1 26 COMPLETE60 16 B-12 12 CELEXA 6 clonazepam 4

Index 1

clonidine 8 DEKAS PLUS 18 ESTROFACTORS 25 clonidine hcl 8 DEKAS PLUS OCEAN 18 ESTROVEN MENOPAUSE

SUPPLEMENT 18 clonidine hcl (adhd) 1 DEPAKOTE 5 eszopiclone 12 clorazepate dipotassium 3 DEPAKOTE ER 5 EVAC 13 clozapine 10 DEPAKOTE SPRINKLES 5 EVAC-U-GEN 14 CLOZAPINE ODT 10 DERMACINRX RIBOTIN-E18 EX-LAX 14 CLOZARIL 10 DERMACINRX ZINTREXYL-

C 18 EYE HEALTH 18 COGENTIN 9 DERMAVITE 18 EYE HEALTH/LUTEIN 18 COLACE 14 desipramine hcl 7 EYE MULTIVITAMIN 18 CONCERTA 1 dexmethylphenidate hcl 1 EYE MULTIVITAMIN/LUTEIN

CORGARD 12 DEXTROSE/SODIUM 18 corn dextrin 13 EYE MULTIVITAMIN/SODIUMCHLORIDE 15 CVS ADULT 50+ EYE 19 DIASTAT ACUDIAL 4 HEALTH 17 fiber 13 DIASTAT PEDIATRIC 4 CVS DAILY FIBER 13 FIBER COMPLETE 13 diazepam 3 CVS DRY MOUTH SPRAY 15 FIBER DIET 13 DIAZEPAM 3 CVS EYE HEALTH ADULT FIBER FORMULA 13 50+ 17 diazepam 4

FIBERCEL 13 CVS NATURAL FIBER diphenhydramine hcl 8 SUPPLEMENT 13 diphenhydramine hcl FIBERCON 13 CVS ONE DAILY MENS 50+ FIBEREX F15 13 (sleep) 12 ADVANCED 18 DIPHENHYDRAMINE FISH OIL 25 CVS ONE DAILY WOMENS HYDROCHLORIDE 8 FISH OIL PEARLS 25 50+ADVANCED 18 disulfiram 25 CVS SPECTRAVITE ADULT FISH OIL TRIPLE

divalproex sodium STRENGTH 50+ 18 5 25 CVS SPECTRAVITE docusate sodium 15 FISH OIL ULTRA 25 ADULTS 18 DORAL 12 FITNESS TABS FOR MEN CVS SPECTRAVITE ULTRA AM/PM/LYCOPENE 19 doxepin hcl 7 MEN50+ 18 FITNESS TABS FOR WOMEN CVS SPECTRAVITE ULTRA DULCOLAX 14 AM/PM/LYCOPENE 19 MENS HEALTH 18 duloxetine hcl 7 FLAX + DHA 2 CVS SPECTRAVITE ULTRA EFFEXOR XR 7 FLEET BISACODYL 14 MENS HEALTH SENIOR 18 EQ COMPLETE CVS SPECTRAVITE ULTRA FLEET ENEMA 14

MULTIVITAMINADULTS WOMEN 18 FLEET ENEMA SIX PACK 14 UNDER 50 18 CVS SPECTRAVITE ULTRA EQ ONE DAILY MENS FLEET PEDIATRIC 14 WOMENS HEALTH 18 50+ 18 fluoxetine hcl 6 CVS SPECTRAVITE ULTRA EQ ONE DAILY MENS WOMENS HEALTH fluphenazine decanoate 11 HEALTH 18 SENIOR 18 fluphenazine hcl 11 EQ ONE DAILY WOMENS CVS VISION HEALTH 18 50+ 18 fluvoxamine maleate 6 cyanocobalamin 12 EQ ONE DAILY WOMENS FOCALIN 1 CYMBALTA 7 HEALTH 18 FOCALIN XR 1 EQL CENTURY MATURE cyproheptadine hcl 8 ADULTS50+ 18 FOLAMAX 19 CYTOMEL 26 EQL CENTURY MENS 18 folic acid 12 DAILY FIBER 13 EQL CENTURY WOMENS18 FOLIFLEX 19 DAILY MULTIPLE EQL DRY MOUTH ORAL FOLIKA-CI 19 VITAMINS 25 RINSE 15 FOLIKA-MG 19 DAYAVITE 18 EQL ONE DAILY MENS 18 FOLITIN-Z 19 DAYTRANA 1 EQUALACTIN 13 FORFIVO XL 6 DECUBI-VITE 18 escitalopram oxalate 6 FORTAVIT 19

Index 2

FOSFREE 19 INVEGA HAFYERA 9 MEGAVITE GOLDEN YEARS

FREEDAVITE gabapentin GENADEK STEP 1 GENADEK STEP 2 GEODON GERI-FREEDA SENIOR FORMULA

19 4

19 19

9

19

INVEGA SUSTENNA 9 INVEGA TRINZA 9 K-PAX IMMUNE SUPPORT FORMULA PROFESSIONAL STRENGTH 19 KAPVAY 1 KLONOPIN 4

55+ 20 melatonin 2 MENS 50+ ADVANCED 20 MENS 50+ MULTI VITAMIN &MINERAL FORMULA 20 MENS MULTI VITAMIN & MINERAL FORMULA 20 MENS MULTIVITAMIN 20

guanfacine hcl 8 guanfacine hcl (adhd) 1 HAIR SKIN & NAILS ADVANCED

KLOXXADO KONSYL KONSYL DAILY FIBER

8 13 13

METAMUCIL METAMUCIL FIBER METAMUCIL FREE &

13,14 13

FORMULA 19 KONSYL ORIGINAL DAILY NATURAL 13 HAIR/SKIN/NAILS 19 HALDOL 10 HALDOL DECANOATE 100 10 HALDOL DECANOATE 50 10 haloperidol 10 haloperidol decanoate 10 haloperidol lactate 10 HEALTHY EYES SUPERVISION2 19 HETLIOZ 13 HETLIOZ LQ 13 HIGH POTENCY MULTIVITAMIN 25 HIGH POTENCY

FIBER KONSYL-D lactulose LAMICTAL LAMICTAL CHEWABLE DISPERSIBLE LAMICTAL ODT LAMICTAL XR lamotrigine LATUDA LEVOTHYROXINE SODIUM levothyroxine sodium LEXAPRO

13 13 14

5

4 4 5 5 9

26 26

6

METAMUCIL MULTIHEALTH FIBER 13 METAMUCIL MULTIHEALTH FIBER SINGLES 13 METAMUCIL ORIGINAL TEXTURE 14 methylcellulose (laxative) 14 METHYLIN 1 methylphenidate hcl 2 MIGHTEAFLOW 15 MINIPRESS 8 mirtazapine 5 MOI-STIR 15 molindone hcl 11

MULTIVITAMIN/BETA-CAROTENE HIGH POTENCY MULTIVITAMIN/FOLICACID

19

19

liothyronine sodium LIPOFEN LITHIUM lithium carbonate

26 8 9 9

MOUTH KOTE MOUTH KOTE REMINT MUCOSITISRX MULTI VITAMIN

15 15 15 25

HM COMPLETE 19 LITHOBID 9 MULTI VITAMIN/D-3 25 HM COMPLETE 50+ MENS LITTLE TUMMYS MULTI-BETIC DIABETES 20 ULTIMATE 19 HM COMPLETE 50+ WOMENS ULTIMATE 19 HM COMPLETE MEN 19 HM HAIR/SKIN/NAILS 19 HM ONE DAILY MENS 19 HM ONE DAILY WOMENS 19 HYDROCIL INSTANT 13 hydroxyzine hcl 3 hydroxyzine pamoate 3 HYLAZINC 19 ICAPS AREDS FORMULA 19

LAXATIVE lorazepam loxapine succinate LUNESTA LUTEIN PLUS/ZEAXANTHIN MACULAR VITAMIN BENEFIT magnesium citrate magnesium oxide(laxative) maprotiline hcl MEGA MULTI FOR MEN

14 4

10 12

19

20 14

14 6

20

MULTI-BETIC DIABETES SUPPORT 20 MULTI-VITAMIN MONOCAPS 20 MULTILEX 20 MULTILEX T&M 20 multiple vitamin 25 multiple vitamins w/ iron 15 multiple vitamins w/ minerals 20 MULTIVITAMIN 20,25 MULTIVITAMIN ADULT 25 MULTIVITAMIN ADULTS 20

imipramine hcl imipramine pamoate INGREZZA inositol niacinate INTUNIV

7 7

26 12

1

MEGA MULTI FOR WOMEN 20 MEGA MULTIVITAMIN FOR MEN 20 MEGAVITE FRUITS & VEGGIES 20

MULTIVITAMIN MEN MULTIVITAMIN WOMEN MULTIVITAMIN/ZINCSTRESSFORMULA MVW COMPLETE FORMULATION

20 20

20

20

Index 3

MVW COMPLETE OMEGA-3-6-9 2 oxcarbazepine 5 FORMULATIOND3000 20 OMNICAP 25 PAMELOR 7 MVW COMPLETE

ONCOVITE 21 paroxetine hcl 6 FORMULATIOND500 20 MVW COMPLETE ONE DAILY ESSENTIAL 25 PARVLEX 22 FORMULATIONMINIS 20 ONE DAILY MENS 50+ PAXIL 6 nadolol 12 MULTIVITAMIN 21 PEDIA-LAX 14,15 ONE DAILY MENS FORMULA naloxone hcl 8 perphenazine 11 W/O IRON 21 naltrexone hcl 8 ONE DAILY WOMENS 21 PERSERIS 9 NARCAN 8 ONE DIALY MULTIVITAMIN PHILLIPS 14 NAT-RUL THERAVITE- WOMENS 21 PHILLIPS MILK OF MAGNESIA M/HIGHPOTENCY 20 ONE-A-DAY ENERGY 21 CHEWABLE 14 NATRUL-VITES 20 ONE-A-DAY ESSENTIAL 25 PHYTOMULTI 22 NATURAL FIBER ONE-A-DAY MENOPAUSE pimozide 26 LAXATIVE 14 FORMULA 21 POTASSIUM CHLORIDE 15 NATURE-THROID 26 ONE-A-DAY MENS 21,25 POTASSIUM NEOMULTIVITE 25 ONE-A-DAY MENS 50+ 21 CHLORIDE/SODIUMNEOVITE 20 ONE-A-DAY MENS 50+ CHLORIDE 15 NEURONTIN 5 ADVANTAGE 21 prazosin hcl 8 NEUTRASAL 15 ONE-A-DAY MENS HEALTH PRESERVISION AREDS 22 FORMULA 21 niacin 26 PRESERVISION AREDS 2 22 ONE-A-DAY MENS PRO NIACIN FLUSH FREE 12 PRESERVISION AREDS 2 + EDGE 21 NIACIN FLUSH-FREE EXTRA ONE-A-DAY PROACTIVE MULTI VITAMIN 22 STRENGTH 12 65+ 21 PRESERVISION/LUTEIN 22 NICADAN 20 ONE-A-DAY TEEN PRO-CAL 22

ADVANTAGEFOR HIM 21 NICADAN ZX 20 PROCERV HP 22 ONE-A-DAY WEIGHT SMART NICAZEL 21 PROFIBER 14 ADVANCED 21 NICAZEL FORTE 21 ONE-A-DAY WOMENS 22 PROFOLA 22 NO FLUSH NIACIN 12 ONE-A-DAY WOMENS propranolol hcl 12 NO IRON MULTIPLE 50+ 21 PRORENAL+D 22 VITAMIN/MINERALS 21 ONE-A-DAY WOMENS 50+ PRORENAL+D/OMEGA-3 22 NORPRAMIN 7 ADVANTAGE 21

ONE-A-DAY WOMENS 50+ PROTECT CARDIO AF 22 nortriptyline hcl 7 HEALTHY ADVANTAGE 21 PROTECT PLUS SO 22 NUMOISYN 15 ONE-A-DAY WOMENS PROTEGRA 22 NUTRICAP 21 ACTIVE MIND & BODY 22 NYTOL MAXIMUM ONE-A-DAY WOMENS protriptyline hcl 7 STRENGTH 12 PETITES 22 PROVIT 22 OCEAN BLUE MINICAPS ONE-A-DAY WOMENS PLUS PROZAC 6 OMEGA-3 25 HEALTHY SKIN PSORCON 12 SUPPORT 22 OCULAR VITAMINS 21

ONE-DAILY MULTI CAPS 22 psyllium 14 OCUVITE ADULT 50+ 21 OPTIVITE P.M.T. 22 pyridoxine hcl 26 OCUVITE ADULT

FORMULA 21 OPURITY 22 QC MULTI-VITE 22 OCUVITE LUTEIN 21 ORAL RELIEF FOR DRY QC OCUHEALTH VISION

SUPPORT 2 22 olanzapine 10 MOUTH& DISCOMFORT 15 ORAL RELIEF SPRAY FOR QUDEXY XR 5 OMEGA 3-6-9 COMPLEX 2 DRYMOUTH & quetiapine fumarate 10 OMEGA-3 25 DISCOMFORT 15 QUIN B STRONG 22 OMEGA-3 EPA FISH OIL 25 OSTEOPRIME PLUS/CALCIUM & QUINTABS 25 omega-3 fatty acids 25 MAGNESIUM 22 QUINTABS-M 22 OMEGA-3 FISH OIL EXTRA oxazepam 4 RA CENTRAL-VITE 22 STRENGTH 25

Index 4

RA DRY MOUTH 15 STALEVO 50 9 trazodone hcl 7 RA OMEGA 3-6-9 2 STALEVO 75 9 trifluoperazine hcl 11 REMERON 5 STRATTERA 1 trihexyphenidyl hcl 9 REMERON SOLTAB 5 STROVITE FORTE 23 TRILEPTAL 5 RENAPLEX-D 22 STROVITE ONE 23 trimipramine maleate 7 REPLACE 22 SUBLOCADE 2 TRIPLE OMEGA-3-6-9 2 REQ 49+ 23 SUBOXONE 2,3 ULTRA OMEGA 3 25 RESTORIL 13 SUPER ANTIOXIDANT 23 ULTRA OMEGA-3 FISH OIL

BURP-LESS 25 RISPERDAL 10 SUPER OMEGA-3 2 UNICOMPLEX-M 23 RISPERDAL CONSTA 9 SUPER TWIN EPA/DHA 25 UNIFIBER 14 risperidone 10 SYNTHROID 26 UNISOM SLEEPGELS 12 RITALIN 2 SYSTANE ICAPS

AREDS2 23 UNISOM SLEEPMELTS 12 RITALIN LA 2 T-VITES 23 URECHOLINE 26 ROZEREM 13 TAB-A-VITE VALIUM 4 SALIVAMAX 15 MULTIVITAMIN/IRON AND valproate sodium 5 SALMON 25 BETA-CAROTENE 15 valproic acid 5 SALMON OIL 25 TEGRETOL 5

VANAMINE PD 8 SALMON OIL-1000 25 TEGRETOL-XR 5 VENEXA 23 SENNA 14 temazepam 13 VENEXA FE 23 SENNA LEAVES 14 THERA 25 venlafaxine hcl 7 sennosides 14 THERA M PLUS 23 VENTRIXYL FE 23 SENOKOT 14 THERA-M 23 VISTA ADVANCED AREDS2

SENTRY 23 THERA-TABS M 23 FORMULA 23 THERABETIC MULTI-SENTRY SENIOR 23 VISTA ADVANCED DRY EYE VITAMIN 23 FORMULA 23 SENTRY SENIOR/LUTEIN 23 THERAGRAN-M 23 VISTARIL 3 SEROQUEL 10,11 THERAGRAN-M VITABEX 24 sertraline hcl 6 ADVANCED 23 VITABEX PLUS 24 SIDEROL 23 THERAGRAN-M ADVANCED 50 PLUS 23 VITALINE TOTAL FORMULA SLO-NIACIN 26 THERAGRAN-M 2 24

SM FIBER POWDER 14 PREMIER 23 VITALINE TOTAL FORMULA SM FISH OIL 25 THERAGRAN-M PREMIER 50 3 24

PLUS 23 VITAMIN D3 COMPLETE 24 SM OMEGA-3 2 23 26 SM OMEGA-3-6-9 FATTY THERAMILL FORTE vitamin e

ACIDS 2 THERANATAL LACTATION VITAMIN E 26 ONE 23 SM ONE DAILY MENS 23 VITAROCA PLUS 24 THEREMS SM ONE DAILY WOMENS 23 MULTIVITAMIN 25 VITASANA 24

sodium phosphates 14 THEREMS-M 23 VITATRUM 24 SOLFIBER 14 thiamine hcl 26 VITEYES CLASSIC 24 SOLO 23 thiamine mononitrate 26 VITEYES CLASSIC SPECTRAVITE 23 ADVANCED 24 thioridazine hcl 11 VITEYES CLASSIC MACULAR SPRAVATO 56MG DOSE 6 thiothixene 11 SUPPORT 24 SPRAVATO 84MG DOSE 6 thyroid 26 VITEYES CLASSIC STALEVO 100 9 MULTIIVITAMIN 24 TOPAMAX 5 VITEYES CLASSIC STALEVO 125 9 TOPAMAX SPRINKLE 5 MULTIVITAMIN 24 STALEVO 150 9 topiramate 5 VITEYES CLASSIC+OMEGA-STALEVO 200 9 TRANXENE T 4 3 24

Index 5

VITEYES CLASSIC/OMEGA-3 24 VITEYES OPTIC NERVE

VITRUM 50+ ADULT-MULTI

VITRUM 50+ SENIOR

WAL-SLEEP Z LIQUID

WHOLE FOOD

WOMENS 50+ MULTI VITAMIN&

WOMENS MULTI VITAMIN &

XEROSTOMIA RELIEF

YELETS TEENAGE

ZOLOFT 6,7

SUPPORT 24 VITRAMYN 24 VITRANOL 24 VITRANOL FE 24 VITREXATE 24 VITREXATE FE 24 VITREXYL 24 VITREXYL/IRON 24

IRON FREE 24

MULTI 24 VIVITROL 8 VYVANSE 1

SHOTS 12 WELLBUTRIN SR 6 WELLBUTRIN XL 6 WESTHROID 26

MULTIVITAMIN 24

MINERAL FORMULA 24 WOMENS BIOMULTIPLE 24

MINERAL FORMULA 24 WP THYROID 26 XANAX 4 XANAX XR 4

SPRAY 15

FORMULA 24 ziprasidone hcl 9

zolpidem tartrate 13 ZYPREXA 11 ZYPREXA ZYDIS 11 ZYVANA 24 ZZZQUIL 12

Index 6

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