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Trusted Health Plan FormularyVersion 13; E�ective: 2/10/2018
2018
Introduction ...................................................................................................................................................................................................................................................................................................................................................................................................6The Trusted Health Plan Pharmacy and Therapeutics Committee (P&T) ......................................................................................................................................6Notice .........................................................................................................................................................................................................................................................................................................................................................................................................6Preface ........................................................................................................................................................................................................................................................................................................................................................................................................6Product Selection Criteria .............................................................................................................................................................................6Formulary Components ...................................................................................................................................................................................6Generic Substitution ...................................................................................................................................................................................6Covered Medications without Authorization ..............................................................................................................................................................6Non-Covered Benefits ...................................................................................................................................................................................7Prior Authorization ....................................................................................................................................................................................7Step Therapy ...........................................................................................................................................................................................7Specialty Medications ..................................................................................................................................................................................7Quantity Limits ........................................................................................................................................................................................7Benefit Exception ......................................................................................................................................................................................7Pharmacy Benefit Management ............................................................................................................................................................................7Prior Authorization Information ........................................................................................................................................................................8Acne Therapy ...........................................................................................................................................................................................16Agents for Narcotic Withdrawal .........................................................................................................................................................................17Alcoholism Treatment Agents ............................................................................................................................................................................17Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic .............................................................................................................................................17Analgesics - Narcotic ..................................................................................................................................................................................19Angina Therapy .........................................................................................................................................................................................22Anorectal - Glucocorticoids ............................................................................................................................................................................22Anorectal Combinations .................................................................................................................................................................................23Anterior Pituitary Hormones and Hormone Antagonists ....................................................................................................................................................23Anti-Infective - Immunologic Adjuvants .................................................................................................................................................................23Antianxiety Agents .....................................................................................................................................................................................23Antiarrhythmics ........................................................................................................................................................................................24Antibacterial Agents ...................................................................................................................................................................................26Anticoagulants .........................................................................................................................................................................................29Anticonvulsants ........................................................................................................................................................................................30Antidepressants ........................................................................................................................................................................................32Antidiarrheals .........................................................................................................................................................................................34Antiemetics ............................................................................................................................................................................................35Antifungals ............................................................................................................................................................................................35Antihemophilic Factor Agents ...........................................................................................................................................................................35Antihistamines .........................................................................................................................................................................................36Antihyperlipidemics ....................................................................................................................................................................................37Antihypertensive Therapy Agents ........................................................................................................................................................................38Antineoplastic - Alkylating Agents .....................................................................................................................................................................42Antineoplastic - Antibody/Antibody-Drug Complexes ......................................................................................................................................................42Antineoplastic - Antimetabolites .......................................................................................................................................................................42Antineoplastic - Hedgehog Pathway Inhibitor ............................................................................................................................................................43Antineoplastic - Hormone/Hormone Antagonist Agents .....................................................................................................................................................43Antineoplastic - Immunomodulators ......................................................................................................................................................................44Antineoplastic - Mast Cell Stabilizers .................................................................................................................................................................44Antineoplastic - Metal Complexes .......................................................................................................................................................................44Antineoplastic - Retinoids and Retinoid Receptor Agonists ..............................................................................................................................................44Antineoplastic - Systemic Enzyme Inhibitors ............................................................................................................................................................44Antineoplastic - Topoisomerase Inhibitors ..............................................................................................................................................................45Antiparasitics .........................................................................................................................................................................................45Antiparkinson Therapy ..................................................................................................................................................................................45Antiprotozoal-Antibacterial Agents .....................................................................................................................................................................47Antipsychotics (Neuroleptics) ..........................................................................................................................................................................47Antitussives ...........................................................................................................................................................................................49Antivirals .....................................................................................................................................................................................................................................................................................................................................................................................................49Appetite Stimulants ....................................................................................................................................................................................50Asthma/COPD Therapy Agents .............................................................................................................................................................................50Attention Deficit-Hyperact Disorder (ADHD) Therapy .....................................................................................................................................................52Beta Adrenergic Blockers ...............................................................................................................................................................................53Bipolar Therapy Agents .................................................................................................................................................................................54Blood Albumin and Plasma Proteins ......................................................................................................................................................................55Bradykinin B2 Receptor Antagonists .....................................................................................................................................................................55Calcium and Bone Metabolism Regulators .................................................................................................................................................................55Calcium Channel Blockers and Combinations ..............................................................................................................................................................55Cardiac Inotropes ......................................................................................................................................................................................56Cardiovascular Sympathomimetics and Combinations .......................................................................................................................................................56
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Chelating Agents .......................................................................................................................................................................................57Chemotherapy Rescue-Antidote Agents ....................................................................................................................................................................57CNS Stimulants .........................................................................................................................................................................................57Cognitive Disorder Therapy - Antidementia ..............................................................................................................................................................58Colonic Acidifier (Ammonia Inhibitor) ..................................................................................................................................................................58Contraceptives Implant .................................................................................................................................................................................58Contraceptives Injectable ..............................................................................................................................................................................58Contraceptives Intravaginal ............................................................................................................................................................................58Contraceptives Oral ....................................................................................................................................................................................58Contraceptives Transdermal .............................................................................................................................................................................62Corticosteroids ........................................................................................................................................................................................62Cystic Fibrosis Therapy Agents .........................................................................................................................................................................63Dental-Periodontal Products ............................................................................................................................................................................64Dermatological - Anti-infectives .......................................................................................................................................................................64Dermatological - Antineoplastic or Premalignant Lesions ................................................................................................................................................64Dermatological - Antiparasitics and Combinations .......................................................................................................................................................64Dermatological - Antipruritics .........................................................................................................................................................................64Dermatological - Antipsoriatics ........................................................................................................................................................................65Dermatological - Antiseborrheic Products and Combinations ..............................................................................................................................................65Dermatological - Burn Products .........................................................................................................................................................................65Dermatological - Emollients and Combinations ...........................................................................................................................................................65Dermatological - Glucocorticoids and Combinations ......................................................................................................................................................65Dermatological - Immunomodulating Agents ...............................................................................................................................................................67Dermatological - Immunosuppressive Agents ..............................................................................................................................................................67Dermatological - Keratolytics-Antimitotics .............................................................................................................................................................67Dermatological - NSAID’s ...............................................................................................................................................................................67Dermatological - Rosacea Therapy .......................................................................................................................................................................67Dermatological - Topical Local Anesthetics and Combinations ............................................................................................................................................67Diabetic Therapy .......................................................................................................................................................................................68Diagnostic Drugs - In Vivo .............................................................................................................................................................................70Digestive Aids .........................................................................................................................................................................................70Diuretics ......................................................................................................................................................................................................................................................................................................................................................................................................70Emergency Contraceptives and Combinations ..............................................................................................................................................................71Erectile Dysfunction (ED) Drugs-Sel.cGMP Phosphodiesterase Type5 Inhib .................................................................................................................................71Estrogens and Combinations .............................................................................................................................................................................71Gallstone Solubilizing (Litholysis) Agents and Combinations ............................................................................................................................................72Gastrointestinal Antispasmodics ........................................................................................................................................................................72Gastrointestinal Prokinetic Agents .....................................................................................................................................................................73General Anesthetics ....................................................................................................................................................................................73General Injectable Solutions and Diluents ..............................................................................................................................................................73Genitourinary Irrigants ................................................................................................................................................................................73Hematopoietic Agents ...................................................................................................................................................................................74Hepatic Hormones (Hormones Secreted by the Liver) ......................................................................................................................................................74Hyperuricemia Therapy ..................................................................................................................................................................................74Immunosuppressive - Calcineurin Inhibitors .............................................................................................................................................................75Immunosuppressive - Inosine Monophosphate Dehydrogenase Inhibitors .....................................................................................................................................75Immunosuppressive - Mammalian Target of Rapamycin (mTOR) Inhibitors ....................................................................................................................................75Immunosuppressive - Purine Analogs .....................................................................................................................................................................75Inflammatory Bowel Agents ..............................................................................................................................................................................75Interstitial Cystitis Agents ...........................................................................................................................................................................76Irrigation Solutions ...................................................................................................................................................................................76Irritable Bowel Syndrome (IBS) Agents ..................................................................................................................................................................76Laxatives ......................................................................................................................................................................................................................................................................................................................................................................................................76Local Anesthetics - Parenteral .........................................................................................................................................................................76Medical Supplies and DME - Diabetic Supplies ...........................................................................................................................................................77Medical Supplies and DME - Respiratory Therapy .........................................................................................................................................................78Metabolic Disease Enzyme Replacement, Gaucher’s Disease ................................................................................................................................................80Migraine Therapy .......................................................................................................................................................................................80Minerals and Electrolytes ..............................................................................................................................................................................81Mouth and Throat - Anti-infectives .....................................................................................................................................................................81Mouth and Throat - Glucocorticoids .....................................................................................................................................................................81Mouth and Throat - Local Anesthetics ...................................................................................................................................................................82Mouth and Throat - Xerostomia Therapy ..................................................................................................................................................................82Mucolytics .............................................................................................................................................................................................82Multiple Sclerosis Agent - Interferons .................................................................................................................................................................82Multiple Sclerosis Agent - Potassium Channel Blocker ...................................................................................................................................................82Musculoskeletal Therapy Agents .........................................................................................................................................................................82
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Narcolepsy and Cataplexy Therapy Agents ................................................................................................................................................................83Nasal Preparations .....................................................................................................................................................................................83Neuromuscular Therapy Agents ...........................................................................................................................................................................83Ophthalmic - Anti-allergy ..............................................................................................................................................................................83Ophthalmic - Anti-infectives ...........................................................................................................................................................................83Ophthalmic - Anti-inflammatory .........................................................................................................................................................................84Ophthalmic - Intraocular Pressure Reducing Agents ......................................................................................................................................................84Ophthalmic - Mydriatics and Cycloplegics ...............................................................................................................................................................85Ophthalmic Combinations ................................................................................................................................................................................85Opiate/Narcotic Reversal Agents - Opiate Antagonists ...................................................................................................................................................85Otic - Anti-infectives .................................................................................................................................................................................85Otic Combinations ......................................................................................................................................................................................85Passive Immunizing Agents ..............................................................................................................................................................................85Peptic Ulcer Therapy ...................................................................................................................................................................................86Pharmaceutical Adjuvants ...............................................................................................................................................................................86Phosphate Binders ......................................................................................................................................................................................87Platelet Aggregation Inhibitors and Combinations .......................................................................................................................................................87Posterior Pituitary Hormones ...........................................................................................................................................................................87Progestins .............................................................................................................................................................................................87Prostatic Hypertrophy Agents ...........................................................................................................................................................................87Pseudobulbar Affect (PBA) Agents .......................................................................................................................................................................88Respiratory Combinations ...............................................................................................................................................................................88Sedative-Hypnotics .....................................................................................................................................................................................88Sickle Cell Anemia Agents ..............................................................................................................................................................................89Smoking Deterrents and Combinations ....................................................................................................................................................................89Thyroid Therapy ........................................................................................................................................................................................89Urinary Analgesics .....................................................................................................................................................................................91Urinary Anti-infectives ................................................................................................................................................................................91Urinary Antispasmodics .................................................................................................................................................................................91Urinary pH Modifiers ...................................................................................................................................................................................91Urinary Retention Therapy ..............................................................................................................................................................................92Vaginal Anti-infectives ................................................................................................................................................................................92Vaginal Estrogens ......................................................................................................................................................................................92Vitamin Combinations ...................................................................................................................................................................................92Vitamins .......................................................................................................................................................................................................................................................................................................................................................................................................98Wound Care Therapy .....................................................................................................................................................................................98Acne Therapy ...........................................................................................................................................................................................99Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic .............................................................................................................................................99Anorectal - Hemorrhoidal Single Agents Other ...........................................................................................................................................................105Anorectal Combinations .................................................................................................................................................................................105Antacids and Combinations ..............................................................................................................................................................................105Antidiarrheals .........................................................................................................................................................................................108Antiemetics ............................................................................................................................................................................................111Antihistamines .........................................................................................................................................................................................112Antiseptic - Biguanides ................................................................................................................................................................................118Antitussives ...........................................................................................................................................................................................118Artificial Tears and Lubricants ........................................................................................................................................................................118Chemicals - Solvents ...................................................................................................................................................................................119Dermatological - Anti-infectives .......................................................................................................................................................................119Dermatological - Antiparasitics and Combinations .......................................................................................................................................................122Dermatological - Antipruritics .........................................................................................................................................................................123Dermatological - Astringents and Combinations ..........................................................................................................................................................123Dermatological - Emollients and Combinations ...........................................................................................................................................................123Dermatological - Glucocorticoids and Combinations ......................................................................................................................................................123Dermatological - Irritants-Counter-Irritants ...........................................................................................................................................................125Dermatological - Keratolytics-Antimitotics .............................................................................................................................................................125Diabetic Therapy .......................................................................................................................................................................................126Dietary Products .......................................................................................................................................................................................126Digestive Aids .........................................................................................................................................................................................126Emergency Contraceptives and Combinations ..............................................................................................................................................................127Expectorants ...........................................................................................................................................................................................127Gastrointestinal Antiflatulents and Combinations .......................................................................................................................................................128Irrigation Solutions ...................................................................................................................................................................................130Laxatives ..............................................................................................................................................................................................130Medical Supplies and DME - Diabetic Supplies ...........................................................................................................................................................136Medical Supplies and DME - GI-GU Ostomy and Irrigation Supplies ........................................................................................................................................158Medical Supplies and DME - Thermometers ................................................................................................................................................................158
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Minerals and Electrolytes ..............................................................................................................................................................................159Mouth and Throat - Non-Narcotic Antitussive - Local Anesthetic Combos ..................................................................................................................................164Nasal Preparations .....................................................................................................................................................................................164Nutritional Product - Nutritional Therapy ..............................................................................................................................................................165Ophthalmic - Anti-allergy ..............................................................................................................................................................................165Ophthalmic - Hyperosmolar Agents .......................................................................................................................................................................165Peptic Ulcer Therapy ...................................................................................................................................................................................165Respiratory Combinations ...............................................................................................................................................................................167Sedative-Hypnotics .....................................................................................................................................................................................170Smoking Deterrents and Combinations ....................................................................................................................................................................171Urinary Analgesics .....................................................................................................................................................................................173Vaginal Anti-infectives ................................................................................................................................................................................174Vitamin Combinations ...................................................................................................................................................................................175Vitamins ...............................................................................................................................................................................................182
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IntroductionTrusted Health Plan is pleased to provide an updated 2018 Medicaid Formulary as a referenceand informational tool for physicians, pharmacists and patients. The Trusted Health PlanFormulary is designed to assist practitioners in selecting clinically appropriate and cost-effectiveproducts for their patients.
The Trusted Health Plan Pharmacy and Therapeutics Committee (P&T)The medications on this formulary have been reviewed by the Trusted Health Plan PharmacyP&T Committee. The Committee includes physicians, pharmacists and health professionals. Theclinical information within the formulary is primarily derived from medical literature and isreviewed and approved by the P&T Committee.
NoticeThe information contained in this formulary is provided by Trusted Health Plan, solely for theconvenience of medical providers. This formulary is not intended to be a substitute for theknowledge, expertise, skill and judgment of the medical provider in their choice of prescriptiondrugs. Trusted Health Plan assumes no responsibility for the actions or omissions of any medicalprovider based upon reliance, in whole or in part, on the information contained herein. Themedical provider should consult the drug manufacturer’s product literature or standardreferences for more detailed information.
PrefaceThe Trusted Health Plan formulary is organized by sections. Each section includes therapeuticgroups identified by either drug class or disease state. Products are listed by generic name.Brand and common names are included as a reference to assist in product recognition. TrustedHealth Plan will not cover prescription drugs that are prescribed for experimental, investigationalor non FDA approved indications, dosages, or routes of administration. Trusted Health Plan doesnot cover any medication excluded by District of Columbia Medicaid (https://dc.fhsc.com/downloads/providers/dcrx_pdl_listing.pdf).
Product Selection CriteriaThe MeridianRx P&T Committee considers clinical information on new to market drugs that aretypically included in an outpatient pharmacy benefit. The primary goal of the MeridianRx P&TCommittee is to preserve and evaluate the Trusted Health Plan formulary based upon anobjective analysis of the safety, efficacy, approved indications, adverse effects, contraindications,patient administration/compliance considerations and cost effectiveness. When a new drug isconsidered for formulary inclusion, it will be reviewed relative to similar drugs currently includedin the Trusted Health Plan Formulary. Formulary decisions are communicated quarterly on theTrusted Health Plan website. Therapeutic substitution occurs when a preferred drug is approvedfor use because it has similar treatment effects but is not identical to a nonpreferred drug.
Formulary ComponentsThe Trusted Health Plan Formulary contains the following components: Covered medicationswithout authorization, medications that must meet Step Therapy Protocol, medications thatrequire Prior Authorization, Specialty medications and medications that are subject to QuantityLimits. Members will not be charged a co-pay when Trusted Health Plan covers a medication.
Generic SubstitutionTrusted Health Plan is a mandatory generic plan. The brand and common names listed in theformulary are for reference only. Generic medication will be dispensed where available.
Covered Medications without AuthorizationTrusted Health Plan covers many medications without any authorization required. Thesemedications include many prescription and over-the-counter medications (when ordered by aphysician).
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Non-Covered BenefitsThe following categories are not covered benefits: Medications used for cosmetic purposes, topromote fertility, for sexual dysfunction, for experimental or investigational purposes, ormedications that are not licensed for use in the United States.
Prior AuthorizationDrugs indicated with "PA" require Prior Authorization for coverage. Details of the PA criteria arelisted next to the drug name. Please call the MeridianRx Help Desk at 855-323-4588 or fax acompleted Prior Authorization form to 855-323-4586. All requests must be accompanied bypertinent clinical information and are reviewed within 72 hours.
Step TherapyDrugs indicated with a "ST" require Step Therapy for coverage. The required step is listed next tothe drug name. Step Therapy ensures clinically appropriate and cost-effective drugs are usedbefore other alternatives.
Specialty MedicationsAll specialty medications noted as "SP" are handled by MeridianRx. To order a specialtymedication by fax, send the prescription and a completed prior authorization form to 855-323-4586 or call MeridianRx’s Help Desk at 855-323-4588.
Quantity LimitsDrugs indicated with a "QL" have a set quantity limit imposed. These limits are based on FDArecommended dosing guidelines. The quantity limit is listed next to the drug name. Allmedications are subject to a maximum of 30 days per prescription.
Benefit ExceptionThe process for requesting non formulary medication(s) requires faxing of a completedFormulary Exception form indicating the request for an exception to the formulary. This requestwill need to include pertinent clinical documentation showing trial and failure of all formularyagents. It should also contain information showing the medication is the standard of care for theindication provided (Peer reviewed journal articles may be required). Please call the MeridianRxHelp Desk at 855-323-4588 or fax a completed Formulary Exception form to 855-323-4586.
Pharmacy Benefit ManagementTrusted Health Plan utilizes MeridianRx to manage each member’s pharmacy benefit.MeridianRx provides Trusted Health Plan with a pharmacy network, pharmacy claimsmanagement services, and claims adjudication. MeridianRx’s Help Desk can be contacted at855-323-4588.
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Prior Authorization Information
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Agents for Narcotic Withdrawal
Medication Info Common Name Drug Status Criteria
SUBOXONE 12 MG-3 MG SL FILM SUBOXONE PA
SUBOXONE 2 MG-0.5 MG SL FILM SUBOXONE PA
SUBOXONE 4 MG-1 MG SL FILM SUBOXONE PA
SUBOXONE 8 MG-2 MG SL FILM SUBOXONE PA
Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic
Medication Info Common Name Drug Status Criteria
BENLYSTA 120 MG VIAL BENLYSTA PA
BENLYSTA 400 MG VIAL BENLYSTA PA
ENBREL 25 MG KIT ENBREL PA
ENBREL 25 MG/0.5 ML SYRINGE ENBREL PA
ENBREL 50 MG/ML SURECLICK SYR ENBREL SURECLICK PA
ENBREL 50 MG/ML SYRINGE ENBREL PA
KINERET 100 MG/0.67 ML SYRINGE KINERET PA
Anterior Pituitary Hormones and Hormone Antagonists
Medication Info Common Name Drug Status Criteria
LUPRON DEPOT 11.25 MG(LUPANETA)
LUPRON DEPOT (LUPANETA) PA
LUPRON DEPOT 11.25 MG 3MO KIT LUPRON DEPOT PA
LUPRON DEPOT 3.75 MG (LUPANETA) LUPRON DEPOT (LUPANETA) PA
LUPRON DEPOT 3.75 MG KIT LUPRON DEPOT PA
LUPRON DEPOT-PED 11.25 MG 3MOKIT
LUPRON DEPOT-PED PA
LUPRON DEPOT-PED 11.25 MG KIT LUPRON DEPOT-PED PA
LUPRON DEPOT-PED 15 MG KIT LUPRON DEPOT-PED PA
LUPRON DEPOT-PED 30 MG 3MO KIT LUPRON DEPOT-PED PA
LUPRON DEPOT-PED 7.5 MG KIT LUPRON DEPOT-PED PA
Anti-Infective - Immunologic Adjuvants
Medication Info Common Name Drug Status Criteria
ACTIMMUNE 100 MCG/0.5 ML VIAL ACTIMMUNE PA,SP
Antibacterial Agents
Medication Info Common Name Drug Status Criteria
THALOMID 100 MG CAPSULE THALOMID PA
THALOMID 150 MG CAPSULE THALOMID PA
THALOMID 200 MG CAPSULE THALOMID PA
THALOMID 50 MG CAPSULE THALOMID PA
Anticonvulsants
Medication Info Common Name Drug Status Criteria
ONFI 10 MG TABLET ONFI PA
ONFI 20 MG TABLET ONFI PA
Antidepressants
Medication Info Common Name Drug Status Criteria
CYMBALTA 20 MG CAPSULE CYMBALTA PA,QL
CYMBALTA 30 MG CAPSULE CYMBALTA PA,QL
Prior Authorization Information
9
Antidepressants
Medication Info Common Name Drug Status Criteria
CYMBALTA 60 MG CAPSULE CYMBALTA PA,QL
Antihemophilic Factor Agents
Medication Info Common Name Drug Status Criteria
ADVATE 2,401-3,600 UNIT VIAL ADVATE PA
ALPHANATE 1,000-400 UNIT VIAL ALPHANATE PA
ALPHANATE 1,500-600 UNIT VIAL ALPHANATE PA
ALPHANATE 250-100 UNIT VIAL ALPHANATE PA
ALPHANATE 500-200 UNIT VIAL ALPHANATE PA
ALPHANINE SD 1,000 UNITS VIAL ALPHANINE SD PA
ALPHANINE SD 1,500 UNITS VIAL ALPHANINE SD PA
ALPHANINE SD 500 UNITS VIAL ALPHANINE SD PA
BENEFIX 1,000 UNIT RANGE BENEFIX PA
BENEFIX 2,000 UNIT RANGE BENEFIX PA
BENEFIX 250 UNIT RANGE BENEFIX PA
BENEFIX 3,000 UNIT RANGE BENEFIX PA
BENEFIX 500 UNIT RANGE BENEFIX PA
FEIBA NF 1,000 UNIT (NOMINAL) FEIBA NF PA
FEIBA NF 2,500 UNIT (NOMINAL) FEIBA NF PA
FEIBA NF 500 UNIT (NOMINAL) FEIBA NF PA
HELIXATE FS 3,000 UNITS VIAL HELIXATE FS PA
HEMOFIL M 1,000 UNIT NOMINAL HEMOFIL M PA
HEMOFIL M 1,700 UNIT NOMINAL HEMOFIL M PA
HEMOFIL M 250 UNIT NOMINAL HEMOFIL M PA
HEMOFIL M 500 UNIT NOMINAL HEMOFIL M PA
KOGENATE FS 3,000 UNIT-BIOSET KOGENATE FS PA
KOGENATE FS 3,000 UNITS VIAL KOGENATE FS PA
KOVALTRY 3,000 UNIT KIT KOVALTRY PA
KOVALTRY 3,000 UNIT VIAL KOVALTRY PA
MONONINE 1,000 UNIT VIAL MONONINE PA
NOVOSEVEN RT 1 MG VIAL NOVOSEVEN RT PA
NOVOSEVEN RT 2 MG VIAL NOVOSEVEN RT PA
NOVOSEVEN RT 5 MG VIAL NOVOSEVEN RT PA
NOVOSEVEN RT 8 MG VIAL NOVOSEVEN RT PA
RECOMBINATE 1,241-1,800 UNIT V RECOMBINATE PA
RECOMBINATE 1,801-2,400 UNIT V RECOMBINATE PA
RECOMBINATE 220-400 UNIT VIAL RECOMBINATE PA
RECOMBINATE 401-800 UNIT VIAL RECOMBINATE PA
RECOMBINATE 801-1,240 UNIT VL RECOMBINATE PA
RIXUBIS 1,000 UNIT NOMINAL RIXUBIS PA
RIXUBIS 2,000 UNIT NOMINAL RIXUBIS PA
RIXUBIS 250 UNIT NOMINAL RIXUBIS PA
RIXUBIS 3,000 UNIT NOMINAL RIXUBIS PA
RIXUBIS 500 UNIT NOMINAL RIXUBIS PA
Prior Authorization Information
10
Antihyperlipidemics
Medication Info Common Name Drug Status Criteria
JUXTAPID 10 MG CAPSULE JUXTAPID PA
JUXTAPID 20 MG CAPSULE JUXTAPID PA
JUXTAPID 5 MG CAPSULE JUXTAPID PA
Antihypertensive Therapy Agents
Medication Info Common Name Drug Status Criteria
LETAIRIS 10 MG TABLET LETAIRIS PA
LETAIRIS 5 MG TABLET LETAIRIS PA
Antineoplastic - Alkylating Agents
Medication Info Common Name Drug Status Criteria
TEMODAR 100 MG CAPSULE TEMODAR PA
TEMODAR 140 MG CAPSULE TEMODAR PA,QL
TEMODAR 180 MG CAPSULE TEMODAR PA,QL
TEMODAR 20 MG CAPSULE TEMODAR PA,QL
TEMODAR 250 MG CAPSULE TEMODAR PA,QL
TEMODAR 5 MG CAPSULE TEMODAR PA,QL
TEMOZOLOMIDE 100 MG CAPSULE TEMOZOLOMIDE PA
TEMOZOLOMIDE 140 MG CAPSULE TEMOZOLOMIDE PA
TEMOZOLOMIDE 180 MG CAPSULE TEMOZOLOMIDE PA
TEMOZOLOMIDE 20 MG CAPSULE TEMOZOLOMIDE PA
TEMOZOLOMIDE 250 MG CAPSULE TEMOZOLOMIDE PA
TEMOZOLOMIDE 5 MG CAPSULE TEMOZOLOMIDE PA
Antineoplastic - Antibody/Antibody-Drug Complexes
Medication Info Common Name Drug Status Criteria
PERJETA 420 MG/14 ML VIAL PERJETA PA
Antineoplastic - Antimetabolites
Medication Info Common Name Drug Status Criteria
CAPECITABINE 150 MG TABLET CAPECITABINE PA
CAPECITABINE 500 MG TABLET CAPECITABINE PA
XELODA 150 MG TABLET XELODA PA
XELODA 500 MG TABLET XELODA PA
Antineoplastic - Hedgehog Pathway Inhibitor
Medication Info Common Name Drug Status Criteria
ERIVEDGE 150 MG CAPSULE ERIVEDGE PA
Antineoplastic - Hormone/Hormone Antagonist Agents
Medication Info Common Name Drug Status Criteria
ELIGARD 22.5 MG SYRINGE B ELIGARD PA
ELIGARD 22.5 MG SYRINGE KIT ELIGARD PA
ELIGARD 30 MG SYRINGE B ELIGARD PA
ELIGARD 30 MG SYRINGE KIT ELIGARD PA
ELIGARD 45 MG SYRINGE B ELIGARD PA
ELIGARD 45 MG SYRINGE KIT ELIGARD PA
ELIGARD 7.5 MG SYRINGE B ELIGARD PA
ELIGARD 7.5 MG SYRINGE KIT ELIGARD PA
Prior Authorization Information
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Antineoplastic - Hormone/Hormone Antagonist Agents
Medication Info Common Name Drug Status Criteria
LEUPROLIDE 1 MG/0.2 ML VIAL LEUPROLIDE ACETATE PA
LEUPROLIDE 2WK 1 MG/0.2 ML KIT LEUPROLIDE ACETATE PA
LEUPROLIDE 2WK 14 MG/2.8 ML KT LEUPROLIDE ACETATE PA
LEUPROLIDE 2WK 14 MG/2.8 ML VL LEUPROLIDE ACETATE PA
LUPRON DEPOT 22.5 MG 3MO KIT LUPRON DEPOT PA
LUPRON DEPOT 45 MG 6MO KIT LUPRON DEPOT PA
LUPRON DEPOT 7.5 MG KIT LUPRON DEPOT PA
LUPRON DEPOT-4 MONTH KIT LUPRON DEPOT PA
TRELSTAR 11.25 MG SYRINGE TRELSTAR PA
TRELSTAR 11.25 MG VIAL TRELSTAR PA
TRELSTAR 22.5 MG SYRINGE TRELSTAR PA
TRELSTAR 22.5 MG VIAL TRELSTAR PA
TRELSTAR 3.75 MG SYRINGE TRELSTAR PA
TRELSTAR 3.75 MG VIAL TRELSTAR PA
XTANDI 40 MG CAPSULE XTANDI PA
ZOLADEX 10.8 MG IMPLANT SYRN ZOLADEX PA
ZOLADEX 3.6 MG IMPLANT SYRN ZOLADEX PA
Antineoplastic - Systemic Enzyme Inhibitors
Medication Info Common Name Drug Status Criteria
BOSULIF 100 MG TABLET BOSULIF PA
BOSULIF 500 MG TABLET BOSULIF PA
COMETRIQ 100 MG DAILY-DOSE PK COMETRIQ PA
COMETRIQ 140 MG DAILY-DOSE PK COMETRIQ PA
COMETRIQ 60 MG DAILY-DOSE PACK COMETRIQ PA
GLEEVEC 100 MG TABLET GLEEVEC PA,QL
GLEEVEC 400 MG TABLET GLEEVEC PA,QL
ICLUSIG 15 MG TABLET ICLUSIG PA
ICLUSIG 45 MG TABLET ICLUSIG PA
IMATINIB MESYLATE 100 MG TAB IMATINIB MESYLATE PA,QL
IMATINIB MESYLATE 400 MG TAB IMATINIB MESYLATE PA,QL
JAKAFI 10 MG TABLET JAKAFI PA
JAKAFI 15 MG TABLET JAKAFI PA
JAKAFI 20 MG TABLET JAKAFI PA
JAKAFI 25 MG TABLET JAKAFI PA
JAKAFI 5 MG TABLET JAKAFI PA
TARCEVA 100 MG TABLET TARCEVA PA,QL,SP Prior Authorization Required; Limited to30 tablets per 30 days.
TARCEVA 150 MG TABLET TARCEVA PA,QL,SP Prior Authorization Required; Limited to30 tablets per 30 days.
TARCEVA 25 MG TABLET TARCEVA PA,QL,SP Prior Authorization Required; Limited to90 tablets per 30 days.
XALKORI 200 MG CAPSULE XALKORI PA
XALKORI 250 MG CAPSULE XALKORI PA
ZELBORAF 240 MG TABLET ZELBORAF PA
Prior Authorization Information
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Antineoplastic - Topoisomerase Inhibitors
Medication Info Common Name Drug Status Criteria
HYCAMTIN 0.25 MG CAPSULE HYCAMTIN PA
HYCAMTIN 1 MG CAPSULE HYCAMTIN PA
Antivirals
Medication Info Common Name Drug Status Criteria
APTIVUS 100 MG/ML SOLUTION APTIVUS PA
APTIVUS 250 MG CAPSULE APTIVUS PA
EPCLUSA 400 MG-100 MG TABLET EPCLUSA PA,SP
HEPSERA 10 MG TABLET HEPSERA PA
MAVYRET 100-40 MG TABLET MAVYRET PA,SP Prior Authorization Required
PEGASYS 180 MCG/0.5 ML SYRINGE PEGASYS PA
PEGASYS 180 MCG/ML VIAL PEGASYS PA
PEGASYS PROCLICK 135 MCG/0.5 ML PEGASYS PROCLICK PA
PEGASYS PROCLICK 180 MCG/0.5 PEGASYS PROCLICK PA
PEGINTRON 50 MCG KIT PEGINTRON REDIPEN PA
PEGINTRON REDIPEN 120 MCG PEGINTRON REDIPEN PA
REBETOL 40 MG/ML SOLUTION REBETOL PA
RIBAVIRIN 200 MG CAPSULE RIBAVIRIN PA
RIBAVIRIN 200 MG TABLET RIBAVIRIN PA
RIBAVIRIN 6 GM INHALATION VIAL RIBAVIRIN PA
TRUVADA 100 MG-150 MG TABLET TRUVADA PA,SP Prior Authorization Required
TRUVADA 133 MG-200 MG TABLET TRUVADA PA,SP Prior Authorization Required
TRUVADA 167 MG-250 MG TABLET TRUVADA PA,SP Prior Authorization Required
TRUVADA 200 MG-300 MG TABLET TRUVADA PA,SP Prior Authorization Required
Asthma/COPD Therapy Agents
Medication Info Common Name Drug Status Criteria
XOLAIR 150 MG VIAL XOLAIR PA
Bipolar Therapy Agents
Medication Info Common Name Drug Status Criteria
ABILIFY 10 MG TABLET ABILIFY PA
ABILIFY 15 MG TABLET ABILIFY PA
ABILIFY 2 MG TABLET ABILIFY PA
ABILIFY 20 MG TABLET ABILIFY PA
ABILIFY 30 MG TABLET ABILIFY PA
ABILIFY 5 MG TABLET ABILIFY PA
Blood Albumin and Plasma Proteins
Medication Info Common Name Drug Status Criteria
CINRYZE 500 UNIT VIAL CINRYZE PA
Bradykinin B2 Receptor Antagonists
Medication Info Common Name Drug Status Criteria
FIRAZYR 30 MG/3 ML SYRINGE FIRAZYR PA
Prior Authorization Information
13
Calcium and Bone Metabolism Regulators
Medication Info Common Name Drug Status Criteria
FORTEO 600 MCG/2.4 ML PEN INJ FORTEO PA
Chelating Agents
Medication Info Common Name Drug Status Criteria
EXJADE 125 MG TABLET EXJADE PA
EXJADE 250 MG TABLET EXJADE PA
EXJADE 500 MG TABLET EXJADE PA
Cystic Fibrosis Therapy Agents
Medication Info Common Name Drug Status Criteria
KALYDECO 150 MG TABLET KALYDECO PA
TOBI 300 MG/5 ML SOLUTION TOBI PA
TOBI PODHALER 28 MG INHALE CAP TOBI PODHALER PA
Diabetic Therapy
Medication Info Common Name Drug Status Criteria
BYDUREON 2 MG VIAL BYDUREON PA
Hematopoietic Agents
Medication Info Common Name Drug Status Criteria
ARANESP 100 MCG/0.5 ML SYRINGE ARANESP PA
ARANESP 100 MCG/ML VIAL ARANESP PA
ARANESP 150 MCG/0.3 ML SYRINGE ARANESP PA
ARANESP 150 MCG/0.75 ML VIAL ARANESP PA
ARANESP 200 MCG/0.4 ML SYRINGE ARANESP PA
ARANESP 200 MCG/ML VIAL ARANESP PA
ARANESP 25 MCG/0.42 ML SYRING ARANESP PA
ARANESP 25 MCG/ML VIAL ARANESP PA
ARANESP 300 MCG/0.6 ML SYRINGE ARANESP PA
ARANESP 300 MCG/ML VIAL ARANESP PA
ARANESP 40 MCG/0.4 ML SYRINGE ARANESP PA
ARANESP 40 MCG/ML VIAL ARANESP PA
ARANESP 500 MCG/1 ML SYRINGE ARANESP PA
ARANESP 60 MCG/0.3 ML SYRINGE ARANESP PA
ARANESP 60 MCG/ML VIAL ARANESP PA
EPOGEN 10,000 UNITS/ML VIAL EPOGEN PA
EPOGEN 2,000 UNITS/ML VIAL EPOGEN PA
EPOGEN 20,000 UNITS/2 ML VIAL EPOGEN PA
EPOGEN 20,000 UNITS/ML VIAL EPOGEN PA
EPOGEN 3,000 UNITS/ML VIAL EPOGEN PA
EPOGEN 4,000 UNITS/ML VIAL EPOGEN PA
NEULASTA 6 MG/0.6 ML SYRINGE NEULASTA PA
NEUPOGEN 300 MCG/0.5 ML SYR NEUPOGEN PA
NEUPOGEN 300 MCG/ML VIAL NEUPOGEN PA
NEUPOGEN 480 MCG/0.8 ML SYR NEUPOGEN PA
NEUPOGEN 480 MCG/1.6 ML VIAL NEUPOGEN PA
NPLATE 250 MCG VIAL NPLATE PA
Prior Authorization Information
14
Hematopoietic Agents
Medication Info Common Name Drug Status Criteria
NPLATE 500 MCG VIAL NPLATE PA
PROCRIT 10,000 UNITS/ML VIAL PROCRIT PA
PROCRIT 2,000 UNITS/ML VIAL PROCRIT PA
PROCRIT 20,000 UNITS/ML VIAL PROCRIT PA
PROCRIT 3,000 UNITS/ML VIAL PROCRIT PA
PROCRIT 4,000 UNITS/ML VIAL PROCRIT PA
PROCRIT 40,000 UNITS/ML VIAL PROCRIT PA
Hepatic Hormones (Hormones Secreted by the Liver)
Medication Info Common Name Drug Status Criteria
INCRELEX 40 MG/4 ML VIAL INCRELEX PA
Inflammatory Bowel Agents
Medication Info Common Name Drug Status Criteria
HUMIRA 20 MG/0.4 ML SYRINGE HUMIRA PA
HUMIRA 40 MG/0.8 ML PEN HUMIRA PEN PA
HUMIRA 40 MG/0.8 ML SYRINGE HUMIRA PA
HUMIRA PEDIATRIC CROHN’S START HUMIRA PEDIATRIC CROHN’S PA
HUMIRA PEN CROHN-UC-HSSTARTER
HUMIRA PEN CROHN-UC-HSSTARTER
PA
HUMIRA PEN PSORIASIS-UVEITISSTARTER
HUMIRA PEN PSORIASIS-UVEITIS
PA
REMICADE 100 MG VIAL REMICADE PA
Metabolic Disease Enzyme Replacement, Gaucher’s Disease
Medication Info Common Name Drug Status Criteria
CEREZYME 400 UNITS VIAL CEREZYME PA
Mucolytics
Medication Info Common Name Drug Status Criteria
PULMOZYME 1 MG/ML AMPUL PULMOZYME PA
Multiple Sclerosis Agent - Interferons
Medication Info Common Name Drug Status Criteria
BETASERON 0.3 MG KIT BETASERON PA
BETASERON 0.3 MG VIAL BETASERON PA
EXTAVIA 0.3 MG KIT EXTAVIA PA
EXTAVIA 0.3 MG VIAL EXTAVIA PA
REBIF 22 MCG/0.5 ML SYRINGE REBIF PA
REBIF 44 MCG/0.5 ML SYRINGE REBIF PA
REBIF REBIDOSE 22 MCG/0.5 ML REBIF REBIDOSE PA
REBIF REBIDOSE 44 MCG/0.5 ML REBIF REBIDOSE PA
REBIF REBIDOSE TITRATION PACK REBIF REBIDOSE PA
REBIF TITRATION PACK REBIF PA
Multiple Sclerosis Agent - Potassium Channel Blocker
Medication Info Common Name Drug Status Criteria
AMPYRA ER 10 MG TABLET AMPYRA PA
Prior Authorization Information
15
Musculoskeletal Therapy Agents
Medication Info Common Name Drug Status Criteria
GENVISC 850 25 MG/2.5 ML SYR GENVISC 850 PA
HYALGAN 20 MG/2 ML SYRINGE HYALGAN PA
HYALGAN 20 MG/2 ML VIAL HYALGAN PA
SUPARTZ FX 25 MG/2.5 ML SYR SUPARTZ FX PA
SYNVISC SYRINGE SYNVISC PA
SYNVISC-ONE SYRINGE SYNVISC-ONE PA
VISCO-3 25 MG/2.5 ML SYR VISCO-3 PA
Passive Immunizing Agents
Medication Info Common Name Drug Status Criteria
CYTOGAM 2.5 GM/50 ML VIAL CYTOGAM PA
HYPERRHO S-D 1500 UNITS SYR HYPERRHO S-D PA
RHOGAM ULTRA-FILTERED PLUSSYR
RHOGAM ULTRA-FILTEREDPLUS
PA
SYNAGIS 100 MG/1 ML VIAL SYNAGIS PA
SYNAGIS 50 MG/0.5 ML VIAL SYNAGIS PA
Pseudobulbar Affect (PBA) Agents
Medication Info Common Name Drug Status Criteria
NUEDEXTA 20-10 MG CAPSULE NUEDEXTA PA
2018 Trusted Health Plan Medicaid Formulary
16
Acne Therapy
Medication Info Common Name Drug Status Criteria
ABSORICA 10 MG CAPSULE ABSORICA
ABSORICA 20 MG CAPSULE ABSORICA
ABSORICA 30 MG CAPSULE ABSORICA
ABSORICA 40 MG CAPSULE ABSORICA
ADAPALENE 0.1% CREAM ADAPALENE
ADAPALENE 0.1% GEL ADAPALENE
ADAPALENE 0.1% LOTION ADAPALENE
ADAPALENE 0.3% GEL ADAPALENE
ADAPALENE 0.3% GEL PUMP ADAPALENE
AMNESTEEM 10 MG CAPSULE AMNESTEEM
AMNESTEEM 20 MG CAPSULE AMNESTEEM
AMNESTEEM 40 MG CAPSULE AMNESTEEM
BENZOYL PEROX 4% CREAMY WASH BENZOYL PEROXIDE
CLARAVIS 10 MG CAPSULE CLARAVIS
CLARAVIS 20 MG CAPSULE CLARAVIS
CLARAVIS 30 MG CAPSULE CLARAVIS
CLARAVIS 40 MG CAPSULE CLARAVIS
CLINDAMYCIN PH 1% GEL CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PH 1% SOLUTION CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PHOS 1% PLEDGET CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PHOSP 1% LOTION CLINDAMYCIN PHOSPHATE
CLINDAMYCIN PHOSPHATE 1% FOAM CLINDAMYCIN PHOSPHATE
DAPSONE 5% GEL DAPSONE
ERYTHROMYCIN 2% GEL ERYTHROMYCIN
ERYTHROMYCIN 2% PLEDGETS ERYTHROMYCIN
ERYTHROMYCIN 2% SOLUTION ERYTHROMYCIN
METRONIDAZOLE 0.75% CREAM METRONIDAZOLE
METRONIDAZOLE 0.75% LOTION METRONIDAZOLE
MYORISAN 10 MG CAPSULE MYORISAN
MYORISAN 20 MG CAPSULE MYORISAN
MYORISAN 30 MG CAPSULE MYORISAN
MYORISAN 40 MG CAPSULE MYORISAN
NORITATE 1% CREAM NORITATE
SODIUM SULFACETAMIDE 10% LOTN SULFACETAMIDE SODIUM
SULFACETAMIDE SOD 10% TOPSUSP
SULFACETAMIDE SODIUM
SULFACETAMIDE-SULFUR 8-4%SUSP
SODIUM SULFACETAMIDE-SULFUR
TRETINOIN 0.01% GEL TRETINOIN
TRETINOIN 0.025% CREAM TRETINOIN
TRETINOIN 0.025% GEL TRETINOIN
TRETINOIN 0.05% CREAM TRETINOIN
TRETINOIN 0.05% GEL TRETINOIN
2018 Trusted Health Plan Medicaid Formulary
17
Acne Therapy
Medication Info Common Name Drug Status Criteria
TRETINOIN 0.1% CREAM TRETINOIN
ZENATANE 10 MG CAPSULE ZENATANE
ZENATANE 20 MG CAPSULE ZENATANE
ZENATANE 30 MG CAPSULE ZENATANE
ZENATANE 40 MG CAPSULE ZENATANE
Agents for Narcotic Withdrawal
Medication Info Common Name Drug Status Criteria
SUBOXONE 12 MG-3 MG SL FILM SUBOXONE PA
SUBOXONE 2 MG-0.5 MG SL FILM SUBOXONE PA
SUBOXONE 4 MG-1 MG SL FILM SUBOXONE PA
SUBOXONE 8 MG-2 MG SL FILM SUBOXONE PA
Alcoholism Treatment Agents
Medication Info Common Name Drug Status Criteria
DISULFIRAM 250 MG TABLET DISULFIRAM
DISULFIRAM 500 MG TABLET DISULFIRAM
Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic
Medication Info Common Name Drug Status Criteria
BENLYSTA 120 MG VIAL BENLYSTA PA
BENLYSTA 400 MG VIAL BENLYSTA PA
BUTALB-ACETAMIN-CAFF 50-300-40 BUTALBITAL-ACETAMINOPHEN-CAFFE
QL
BUTALB-ASPIRIN-CAFFE 50-325-40 BUTALBITAL-ASPIRIN-CAFFEINE
QL
CELEBREX 100 MG CAPSULE CELEBREX
CELEBREX 200 MG CAPSULE CELEBREX
CELEBREX 400 MG CAPSULE CELEBREX
CELEBREX 50 MG CAPSULE CELEBREX
CELECOXIB 100 MG CAPSULE CELECOXIB
CELECOXIB 200 MG CAPSULE CELECOXIB
CELECOXIB 400 MG CAPSULE CELECOXIB
CELECOXIB 50 MG CAPSULE CELECOXIB
DICLOFENAC SOD DR 25 MG TAB DICLOFENAC SODIUM
DICLOFENAC SOD DR 50 MG TAB DICLOFENAC SODIUM
DICLOFENAC SOD DR 75 MG TAB DICLOFENAC SODIUM
DICLOFENAC SOD EC 25 MG TAB DICLOFENAC SODIUM
DICLOFENAC SOD EC 50 MG TAB DICLOFENAC SODIUM
DICLOFENAC SOD EC 75 MG TAB DICLOFENAC SODIUM
DICLOFENAC SOD ER 100 MG TAB DICLOFENAC SODIUM ER
DIFLUNISAL 500 MG TABLET DIFLUNISAL
ENBREL 25 MG KIT ENBREL PA
ENBREL 25 MG/0.5 ML SYRINGE ENBREL PA
ENBREL 50 MG/ML SURECLICK SYR ENBREL SURECLICK PA
ENBREL 50 MG/ML SYRINGE ENBREL PA
2018 Trusted Health Plan Medicaid Formulary
18
Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic
Medication Info Common Name Drug Status Criteria
IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN
IBUPROFEN 400 MG TABLET IBUPROFEN
IBUPROFEN 600 MG TABLET IBUPROFEN
IBUPROFEN 800 MG TABLET IBUPROFEN
KETOPROFEN 50 MG CAPSULE KETOPROFEN
KETOPROFEN 75 MG CAPSULE KETOPROFEN
KETOPROFEN ER 200 MG CAPSULE KETOPROFEN
KETOROLAC 10 MG TABLET KETOROLAC TROMETHAMINE
KETOROLAC 15 MG/ML CARPUJECT KETOROLAC TROMETHAMINE
KETOROLAC 15 MG/ML ISECURE SYR KETOROLAC TROMETHAMINE
KETOROLAC 15 MG/ML SYRINGE KETOROLAC TROMETHAMINE
KETOROLAC 15 MG/ML VIAL KETOROLAC TROMETHAMINE
KETOROLAC 30 MG/ML CARPUJECT KETOROLAC TROMETHAMINE
KETOROLAC 30 MG/ML ISECURE SYR KETOROLAC TROMETHAMINE
KETOROLAC 30 MG/ML SYRINGE KETOROLAC TROMETHAMINE
KETOROLAC 30 MG/ML VIAL KETOROLAC TROMETHAMINE
KETOROLAC 300 MG/10 ML VIAL KETOROLAC TROMETHAMINE
KETOROLAC 60 MG/2 ML CARPUJECT KETOROLAC TROMETHAMINE
KETOROLAC 60 MG/2 ML SYRINGE KETOROLAC TROMETHAMINE
KETOROLAC 60 MG/2 ML VIAL KETOROLAC TROMETHAMINE
KINERET 100 MG/0.67 ML SYRINGE KINERET PA
LEFLUNOMIDE 10 MG TABLET LEFLUNOMIDE
LEFLUNOMIDE 20 MG TABLET LEFLUNOMIDE
MELOXICAM 15 MG TABLET MELOXICAM
MELOXICAM 7.5 MG TABLET MELOXICAM
MELOXICAM 7.5 MG/5 ML SUSP MELOXICAM
METHOTREXATE 2.5 MG TABLET METHOTREXATE
NABUMETONE 500 MG TABLET NABUMETONE
NABUMETONE 750 MG TABLET NABUMETONE
NAPROXEN 125 MG/5 ML SUSPEN NAPROXEN
NAPROXEN 250 MG TABLET NAPROXEN
NAPROXEN 375 MG TABLET NAPROXEN
NAPROXEN 500 MG KIT NAPROXEN
NAPROXEN 500 MG TABLET NAPROXEN
NAPROXEN DR 375 MG TABLET NAPROXEN
NAPROXEN DR 500 MG TABLET NAPROXEN
NAPROXEN EC 375 MG TABLET NAPROXEN
NAPROXEN EC 500 MG TABLET NAPROXEN
NAPROXEN SOD CR 375 MG TABLET NAPROXEN SODIUM CR
NAPROXEN SOD CR 500 MG TABLET NAPROXEN SODIUM CR
NAPROXEN SOD ER 375 MG TABLET NAPROXEN SODIUM ER
NAPROXEN SOD ER 500 MG TABLET NAPROXEN SODIUM ER
NAPROXEN SODIUM 275 MG TAB NAPROXEN SODIUM
2018 Trusted Health Plan Medicaid Formulary
19
Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic
Medication Info Common Name Drug Status Criteria
NAPROXEN SODIUM 550 MG TAB NAPROXEN SODIUM
NAPROXEN SODIUM DS 550 MG TAB NAPROXEN SODIUM DS
OXAPROZIN 600 MG CAPLET OXAPROZIN
OXAPROZIN 600 MG TABLET OXAPROZIN
SULINDAC 150 MG TABLET SULINDAC
SULINDAC 200 MG TABLET SULINDAC
Analgesics - Narcotic
Medication Info Common Name Drug Status Criteria
ACETAMINOPHEN-COD #2 TABLET ACETAMINOPHEN-CODEINE QL
ACETAMINOPHEN-COD #3 TABLET ACETAMINOPHEN-CODEINE QL
ACETAMINOPHEN-COD #4 TABLET ACETAMINOPHEN-CODEINE QL
ACETAMINOPHEN-CODEINE 120 MG-12 MG/5 ML SOLUTION
ACETAMINOPHEN-CODEINE QL
ACETAMINOPHEN-CODEINE 120-12MG/5 ML
ACETAMINOPHEN-CODEINE QL
ACETAMINOPHEN-CODEINE 240-24MG/10 ML
ACETAMINOPHEN-CODEINE QL
ACETAMINOPHEN-CODEINE 300-30MG/12.5 ML
ACETAMINOPHEN-CODEINE QL
ASCOMP WITH CODEINE CAPSULE ASCOMP WITH CODEINE QL
BUTALB-ACETAMINOPH-CAFF-CODEIN
BUTALB-ACETAMINOPH-CAFF-CODEIN
QL
FENTANYL 100 MCG/HR PATCH FENTANYL QL
FENTANYL 12 MCG/HR PATCH FENTANYL QL
FENTANYL 25 MCG/HR PATCH FENTANYL QL
FENTANYL 50 MCG/HR PATCH FENTANYL QL
FENTANYL 75 MCG/HR PATCH FENTANYL QL
FIORINAL WITH CODEINE #3 CAP FIORINAL WITH CODEINE #3 QL
FIORINAL-COD 30-50-325-40 CAP FIORINAL WITH CODEINE #3 QL
HYDROCODONE-ACETAMINOPHEN 5-300 MG TABLET
HYDROCODONE-ACETAMINOPHEN
QL
HYDROCODONE-ACETAMINOPHEN 5-325 MG TABLET
HYDROCODONE-ACETAMINOPHEN
QL
HYDROMORPHONE 0.5 MG/0.5 ML HYDROMORPHONE HCL
HYDROMORPHONE 1 MG/MLCARPUJCT
HYDROMORPHONE HCL
HYDROMORPHONE 1 MG/MLSOLUTION
HYDROMORPHONE HCL
HYDROMORPHONE 1 MG/MLSYRINGE
HYDROMORPHONE HCL
HYDROMORPHONE 110 MG/55 MLPCA SYRINGE (CMPD-RX)
HYDROMORPHONE HCL
HYDROMORPHONE 2 MG TABLET HYDROMORPHONE HCL
HYDROMORPHONE 2 MG/MLCARPUJCT
HYDROMORPHONE HCL
HYDROMORPHONE 2 MG/MLISECURE
HYDROMORPHONE HCL
2018 Trusted Health Plan Medicaid Formulary
20
Analgesics - Narcotic
Medication Info Common Name Drug Status Criteria
HYDROMORPHONE 2 MG/MLSYRINGE (CMPD-RX)
HYDROMORPHONE HCL
HYDROMORPHONE 2 MG/ML VIAL HYDROMORPHONE HCL
HYDROMORPHONE 3 MG SUPPOS HYDROMORPHONE HCL
HYDROMORPHONE 4 MG TABLET HYDROMORPHONE HCL
HYDROMORPHONE 4 MG/MLCARPUJCT
HYDROMORPHONE HCL
HYDROMORPHONE 5 MG/5 ML SOLN HYDROMORPHONE HCL
HYDROMORPHONE 8 MG TABLET HYDROMORPHONE HCL
HYDROMORPHONE HCL 110 MG/55ML
HYDROMORPHONE HCL
HYDROMORPHONE HCL 60 MG/30 ML HYDROMORPHONE HCL
HYDROMORPHONE HCL ER 12 MGTAB
HYDROMORPHONE ER
HYDROMORPHONE HCL ER 16 MGTAB
HYDROMORPHONE ER
HYDROMORPHONE HCL ER 32 MGTAB
HYDROMORPHONE ER
HYDROMORPHONE HCL ER 8 MGTAB
HYDROMORPHONE ER
LORCET 5-325 MG TABLET LORCET QL
MEPERIDINE 100 MG/ML VIAL MEPERIDINE HCL
MORPHINE 10 MG/0.7 ML AUTO-INJ MORPHINE SULFATE
MORPHINE 10 MG/ML CARPUJECT MORPHINE SULFATE
MORPHINE 10 MG/ML SYRINGE MORPHINE SULFATE
MORPHINE 15 MG/ML VIAL MORPHINE SULFATE
MORPHINE 2 MG/ML CARPUJECT MORPHINE SULFATE
MORPHINE 2 MG/ML SYRINGE MORPHINE SULFATE
MORPHINE 20 MG/ML ORAL SYRINGE MORPHINE SULFATE
MORPHINE 30 MG/30 ML SYRINGE MORPHINE SULFATE
MORPHINE 4 MG/ML CARPUJECT MORPHINE SULFATE
MORPHINE 4 MG/ML SYRINGE MORPHINE SULFATE
MORPHINE 5 MG/ML SYRINGE MORPHINE SULFATE
MORPHINE 8 MG/ML SYRINGE MORPHINE SULFATE
MORPHINE 8 MG/ML VIAL MORPHINE SULFATE
MORPHINE SULF 10 MG SUPPOS MORPHINE SULFATE
MORPHINE SULF 10 MG/5 ML SOLN MORPHINE SULFATE
MORPHINE SULF 100 MG/5 ML (20 MG/ML) SOLUTION
MORPHINE SULFATE
MORPHINE SULF 100 MG/5 ML SOLN MORPHINE SULFATE
MORPHINE SULF 20 MG SUPPOS MORPHINE SULFATE
MORPHINE SULF 20 MG/5 ML SOLN MORPHINE SULFATE
MORPHINE SULF 30 MG SUPPOS MORPHINE SULFATE
MORPHINE SULF 5 MG SUPPOS MORPHINE SULFATE
MORPHINE SULF CR 100 MG TABLET MORPHINE SULFATE CR
2018 Trusted Health Plan Medicaid Formulary
21
Analgesics - Narcotic
Medication Info Common Name Drug Status Criteria
MORPHINE SULF CR 60 MG TABLET MORPHINE SULFATE CR
MORPHINE SULF ER 100 MG TABLET MORPHINE SULFATE ER
MORPHINE SULF ER 15 MG TABLET MORPHINE SULFATE ER
MORPHINE SULF ER 200 MG TABLET MORPHINE SULFATE ER
MORPHINE SULF ER 30 MG TABLET MORPHINE SULFATE ER
MORPHINE SULF ER 60 MG TABLET MORPHINE SULFATE ER
MORPHINE SULFATE 10 MG/ML VIAL MORPHINE SULFATE
MORPHINE SULFATE 25 MG/ML VIAL MORPHINE SULFATE
MORPHINE SULFATE 25 MG/ML VL MORPHINE SULFATE
MORPHINE SULFATE 50 MG/ML VIAL MORPHINE SULFATE
MORPHINE SULFATE ER 10 MG CAP MORPHINE SULFATE ER
MORPHINE SULFATE ER 100 MG CAP MORPHINE SULFATE ER
MORPHINE SULFATE ER 120 MG CAP MORPHINE SULFATE ER
MORPHINE SULFATE ER 20 MG CAP MORPHINE SULFATE ER
MORPHINE SULFATE ER 30 MG CAP MORPHINE SULFATE ER
MORPHINE SULFATE ER 45 MG CAP MORPHINE SULFATE ER
MORPHINE SULFATE ER 50 MG CAP MORPHINE SULFATE ER
MORPHINE SULFATE ER 60 MG CAP MORPHINE SULFATE ER
MORPHINE SULFATE ER 75 MG CAP MORPHINE SULFATE ER
MORPHINE SULFATE ER 80 MG CAP MORPHINE SULFATE ER
MORPHINE SULFATE ER 90 MG CAP MORPHINE SULFATE ER
MORPHINE SULFATE IR 15 MG TAB MORPHINE SULFATE
MORPHINE SULFATE IR 30 MG TAB MORPHINE SULFATE
NORCO 5-325 TABLET NORCO QL
OXYCODONE HCL 10 MG TABLET OXYCODONE HCL QL
OXYCODONE HCL 100 MG/5 ML SOLN OXYCODONE HCL QL
OXYCODONE HCL 15 MG TABLET OXYCODONE HCL QL
OXYCODONE HCL 20 MG TABLET OXYCODONE HCL
OXYCODONE HCL 30 MG TABLET OXYCODONE HCL QL
OXYCODONE HCL 5 MG CAPSULE OXYCODONE HCL QL
OXYCODONE HCL 5 MG TABLET OXYCODONE HCL QL
OXYCODONE HCL 5 MG/5 ML SOLN OXYCODONE HCL QL
OXYCODONE-ACETAMINOPHEN 5-325 MG TAB
OXYCODONE-ACETAMINOPHEN
QL
OXYCODONE-ACETAMINOPHEN 5-325 MG TABLET
OXYCODONE-ACETAMINOPHEN
QL
OXYCODONE-ACETAMINOPHEN 5-325 MG/5 ML SOLUTION
OXYCODONE-ACETAMINOPHEN
OXYCODONE-ASPIRIN 4.8355-325 MGTABLET
OXYCODONE HCL-ASPIRIN
TRAMADOL ER 100 MG TABLET TRAMADOL HCL ER QL
TRAMADOL HCL 50 MG TABLET TRAMADOL HCL QL
TRAMADOL HCL ER 100 MG CAPSULE TRAMADOL HCL ER
TRAMADOL HCL ER 100 MG TABLET TRAMADOL HCL ER QL
2018 Trusted Health Plan Medicaid Formulary
22
Analgesics - Narcotic
Medication Info Common Name Drug Status Criteria
TRAMADOL HCL ER 200 MG TABLET TRAMADOL HCL ER QL
TRAMADOL HCL ER 300 MG TABLET TRAMADOL HCL ER QL
TRAMADOL-ACETAMINOPHEN 37.5-325 MG TAB
TRAMADOL HCL-ACETAMINOPHEN
QL
ULTRAM 50 MG TABLET ULTRAM QL
VICODIN 5-300 MG TABLET VICODIN QL
XODOL 5-300 TABLET XODOL 5-300 QL
Angina Therapy
Medication Info Common Name Drug Status Criteria
ISOSORBIDE DN 10 MG TABLET ISOSORBIDE DINITRATE
ISOSORBIDE DN 20 MG TABLET ISOSORBIDE DINITRATE
ISOSORBIDE DN 30 MG TABLET ISOSORBIDE DINITRATE
ISOSORBIDE DN 5 MG TABLET ISOSORBIDE DINITRATE
ISOSORBIDE DN ER 40 MG TABLET ISOSORBIDE DINITRATE
ISOSORBIDE MN 10 MG TABLET ISOSORBIDE MONONITRATE
ISOSORBIDE MN 20 MG TABLET ISOSORBIDE MONONITRATE
ISOSORBIDE MN ER 120 MG TAB ISOSORBIDE MONONITRATEER
ISOSORBIDE MN ER 30 MG TABLET ISOSORBIDE MONONITRATEER
ISOSORBIDE MN ER 60 MG TABLET ISOSORBIDE MONONITRATEER
NITROGLYCERIN 0.1 MG/HR PATCH NITROGLYCERIN PATCH
NITROGLYCERIN 0.2 MG/HR PATCH NITROGLYCERIN PATCH
NITROGLYCERIN 0.3 MG TABLET SL NITROGLYCERIN
NITROGLYCERIN 0.4 MG TABLET SL NITROGLYCERIN
NITROGLYCERIN 0.4 MG/HR PATCH NITROGLYCERIN PATCH
NITROGLYCERIN 0.6 MG TABLET SL NITROGLYCERIN
NITROGLYCERIN 0.6 MG/HR PATCH NITROGLYCERIN PATCH
NITROGLYCERIN 400 MCG SPRAY NITROGLYCERIN
NITROGLYCERIN 5 MG/ML VIAL NITROGLYCERIN
NITROGLYCERIN ER 2.5 MG CAP NITROGLYCERIN
NITROGLYCERIN ER 6.5 MG CAP NITROGLYCERIN
NITROGLYCERIN ER 9 MG CAPSULE NITROGLYCERIN
NITROGLYCERIN LINGUAL 0.4 MG NITROGLYCERIN
Anorectal - Glucocorticoids
Medication Info Common Name Drug Status Criteria
ANUCORT-HC 25 MG SUPPOSITORY ANUCORT-HC
ANUSOL-HC 25 MG SUPPOSITORY ANUSOL-HC
HEMMOREX-HC 25 MGSUPPOSITORY
HEMMOREX-HC
HYDROCORTISONE 1% CREAM HYDROCORTISONE
HYDROCORTISONE AC 25 MG SUPP HYDROCORTISONE ACETATE
HYDROCORTISONE AC 30 MG SUPP HYDROCORTISONE ACETATE
2018 Trusted Health Plan Medicaid Formulary
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Anorectal Combinations
Medication Info Common Name Drug Status Criteria
LIDOCAINE-HC 3-1% CREAM KIT LIDOCAINE-HYDROCORTISONE
Anterior Pituitary Hormones and Hormone Antagonists
Medication Info Common Name Drug Status Criteria
DANAZOL 100 MG CAPSULE DANAZOL
DANAZOL 200 MG CAPSULE DANAZOL
LUPRON DEPOT 11.25 MG(LUPANETA)
LUPRON DEPOT (LUPANETA) PA
LUPRON DEPOT 11.25 MG 3MO KIT LUPRON DEPOT PA
LUPRON DEPOT 3.75 MG (LUPANETA) LUPRON DEPOT (LUPANETA) PA
LUPRON DEPOT 3.75 MG KIT LUPRON DEPOT PA
LUPRON DEPOT-PED 11.25 MG 3MOKIT
LUPRON DEPOT-PED PA
LUPRON DEPOT-PED 11.25 MG KIT LUPRON DEPOT-PED PA
LUPRON DEPOT-PED 15 MG KIT LUPRON DEPOT-PED PA
LUPRON DEPOT-PED 30 MG 3MO KIT LUPRON DEPOT-PED PA
LUPRON DEPOT-PED 7.5 MG KIT LUPRON DEPOT-PED PA
OCTREOTIDE 1,000 MCG/5 ML VIAL OCTREOTIDE ACETATE
OCTREOTIDE 1,000 MCG/ML VIAL OCTREOTIDE ACETATE
OCTREOTIDE 5,000 MCG/5 ML VIAL OCTREOTIDE ACETATE
OCTREOTIDE ACET 100 MCG/ML AMP OCTREOTIDE ACETATE
OCTREOTIDE ACET 200 MCG/ML VL OCTREOTIDE ACETATE
OCTREOTIDE ACET 50 MCG/ML AMP OCTREOTIDE ACETATE
OCTREOTIDE ACET 500 MCG/ML AMP OCTREOTIDE ACETATE
SANDOSTATIN 0.05 MG/ML AMPUL SANDOSTATIN
SANDOSTATIN 0.1 MG/ML AMPUL SANDOSTATIN
SANDOSTATIN 0.2 MG/ML VIAL SANDOSTATIN
SANDOSTATIN 0.5 MG/ML AMPUL SANDOSTATIN
SANDOSTATIN 1 MG/ML VIAL SANDOSTATIN
Anti-Infective - Immunologic Adjuvants
Medication Info Common Name Drug Status Criteria
ACTIMMUNE 100 MCG/0.5 ML VIAL ACTIMMUNE PA,SP
Antianxiety Agents
Medication Info Common Name Drug Status Criteria
ALPRAZOLAM 0.25 MG TABLET ALPRAZOLAM
ALPRAZOLAM 0.5 MG TABLET ALPRAZOLAM
ALPRAZOLAM 1 MG TABLET ALPRAZOLAM
ALPRAZOLAM 2 MG TABLET ALPRAZOLAM
BUSPIRONE HCL 10 MG TABLET BUSPIRONE HCL
BUSPIRONE HCL 15 MG TABLET BUSPIRONE HCL
BUSPIRONE HCL 30 MG TABLET BUSPIRONE HCL
BUSPIRONE HCL 5 MG TABLET BUSPIRONE HCL
BUSPIRONE HCL 7.5 MG TABLET BUSPIRONE HCL
CHLORDIAZEPOXIDE 10 MGCAPSULE
CHLORDIAZEPOXIDE HCL
2018 Trusted Health Plan Medicaid Formulary
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Antianxiety Agents
Medication Info Common Name Drug Status Criteria
CHLORDIAZEPOXIDE 25 MGCAPSULE
CHLORDIAZEPOXIDE HCL
CHLORDIAZEPOXIDE 5 MG CAPSULE CHLORDIAZEPOXIDE HCL
CLONAZEPAM 0.125 MG DIS TAB CLONAZEPAM
CLONAZEPAM 0.125 MG ODT CLONAZEPAM
CLONAZEPAM 0.25 MG ODT CLONAZEPAM
CLONAZEPAM 0.5 MG DIS TABLET CLONAZEPAM
CLONAZEPAM 0.5 MG ODT CLONAZEPAM
CLONAZEPAM 0.5 MG TABLET CLONAZEPAM
CLONAZEPAM 1 MG DIS TABLET CLONAZEPAM
CLONAZEPAM 1 MG ODT CLONAZEPAM
CLONAZEPAM 1 MG TABLET CLONAZEPAM
CLONAZEPAM 2 MG ODT CLONAZEPAM
CLONAZEPAM 2 MG TABLET CLONAZEPAM
DIAZEPAM 10 MG TABLET DIAZEPAM
DIAZEPAM 10 MG/2 ML CARPUJECT DIAZEPAM
DIAZEPAM 10 MG/2 ML SYRINGE DIAZEPAM
DIAZEPAM 2 MG TABLET DIAZEPAM
DIAZEPAM 5 MG TABLET DIAZEPAM
DIAZEPAM 5 MG/5 ML ORAL SOLN DIAZEPAM
DIAZEPAM 5 MG/5 ML SOLUTION DIAZEPAM
DIAZEPAM 5 MG/ML ORAL CONC DIAZEPAM
DIAZEPAM 5 MG/ML VIAL DIAZEPAM
DIAZEPAM 50 MG/10 ML VIAL DIAZEPAM
HYDROXYZINE 10 MG/5 ML SOLN HYDROXYZINE HCL
HYDROXYZINE 10 MG/5 ML SYRUP HYDROXYZINE HCL SYRUP
HYDROXYZINE 100 MG/2 ML VIAL HYDROXYZINE HCL
HYDROXYZINE 25 MG/ML VIAL HYDROXYZINE HCL
HYDROXYZINE 50 MG/ML VIAL HYDROXYZINE HCL
HYDROXYZINE 500 MG/10 ML VIAL HYDROXYZINE HCL
HYDROXYZINE HCL 10 MG TABLET HYDROXYZINE HCL
HYDROXYZINE HCL 25 MG TABLET HYDROXYZINE HCL
HYDROXYZINE HCL 50 MG TABLET HYDROXYZINE HCL
LORAZEPAM 0.5 MG TABLET LORAZEPAM
LORAZEPAM 1 MG TABLET LORAZEPAM
LORAZEPAM 2 MG TABLET LORAZEPAM
OXAZEPAM 10 MG CAPSULE OXAZEPAM
OXAZEPAM 15 MG CAPSULE OXAZEPAM
OXAZEPAM 30 MG CAPSULE OXAZEPAM
Antiarrhythmics
Medication Info Common Name Drug Status Criteria
AMIODARONE HCL 200 MG TABLET AMIODARONE HCL
AMIODARONE HCL 400 MG TABLET AMIODARONE HCL
2018 Trusted Health Plan Medicaid Formulary
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Antiarrhythmics
Medication Info Common Name Drug Status Criteria
BETAPACE 120 MG TABLET BETAPACE
BETAPACE 160 MG TABLET BETAPACE
BETAPACE 240 MG TABLET BETAPACE
BETAPACE 80 MG TABLET BETAPACE
BETAPACE AF 120 MG TABLET BETAPACE AF
BETAPACE AF 160 MG TABLET BETAPACE AF
BETAPACE AF 80 MG TABLET BETAPACE AF
DILTIAZEM 125 MG/25 ML VIAL DILTIAZEM HCL
DILTIAZEM 25 MG/5 ML VIAL DILTIAZEM HCL
DILTIAZEM 50 MG/10 ML VIAL DILTIAZEM HCL
DILTIAZEM HCL 100 MG VIAL DILTIAZEM HCL
DISOPYRAMIDE 100 MG CAPSULE DISOPYRAMIDE PHOSPHATE
DISOPYRAMIDE 150 MG CAPSULE DISOPYRAMIDE PHOSPHATE
FLECAINIDE ACETATE 100 MG TAB FLECAINIDE ACETATE
FLECAINIDE ACETATE 150 MG TAB FLECAINIDE ACETATE
FLECAINIDE ACETATE 50 MG TAB FLECAINIDE ACETATE
LIDOCAINE HCL 1% ABBOJECT LIDOCAINE HCL
LIDOCAINE HCL 1% SYRINGE LIDOCAINE HCL
LIDOCAINE HCL 2% ABBOJECT LIDOCAINE HCL
LIDOCAINE HCL 2% LUER-JET LIDOCAINE HCL
LIDOCAINE HCL 2% SYRINGE LIDOCAINE HCL
LIDOCAINE HCL 2% VIAL LIDOCAINE HCL
PHENYTOIN 100 MG/2 ML VIAL PHENYTOIN SODIUM
PHENYTOIN 250 MG/5 ML VIAL PHENYTOIN SODIUM
PHENYTOIN 50 MG/ML VIAL PHENYTOIN SODIUM
PROPAFENONE HCL 150 MG TABLET PROPAFENONE HCL
PROPAFENONE HCL 225 MG TAB PROPAFENONE HCL
PROPAFENONE HCL 300 MG TAB PROPAFENONE HCL
PROPAFENONE HCL ER 225 MG CAP PROPAFENONE HCL ER
PROPAFENONE HCL ER 325 MG CAP PROPAFENONE HCL ER
PROPAFENONE HCL ER 425 MG CAP PROPAFENONE HCL ER
SORINE 120 MG TABLET SORINE
SORINE 160 MG TABLET SORINE
SORINE 240 MG TABLET SORINE
SORINE 80 MG TABLET SORINE
SOTALOL 120 MG TABLET SOTALOL
SOTALOL 160 MG TABLET SOTALOL
SOTALOL 240 MG TABLET SOTALOL
SOTALOL 80 MG TABLET SOTALOL
SOTALOL AF 120 MG TABLET SOTALOL AF
SOTALOL AF 160 MG TABLET SOTALOL AF
SOTALOL AF 80 MG TABLET SOTALOL AF
SOTALOL HCL 150 MG/10 ML VIAL SOTALOL HCL
2018 Trusted Health Plan Medicaid Formulary
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Antiarrhythmics
Medication Info Common Name Drug Status Criteria
VERAPAMIL 120 MG TABLET VERAPAMIL HCL
VERAPAMIL 2.5 MG/ML VIAL VERAPAMIL HCL
VERAPAMIL 40 MG TABLET VERAPAMIL HCL
VERAPAMIL 5 MG/2 ML VIAL VERAPAMIL HCL
VERAPAMIL 80 MG TABLET VERAPAMIL HCL
Antibacterial Agents
Medication Info Common Name Drug Status Criteria
AMOX-CLAV 200-28.5 MG TAB CHEW AMOXICILLIN-CLAVULANATEPOTASS
AMOX-CLAV 200-28.5 MG/5 ML SUS AMOXICILLIN-CLAVULANATEPOTASS
AMOX-CLAV 250-125 MG TABLET AMOXICILLIN-CLAVULANATEPOTASS
AMOX-CLAV 250-62.5 MG/5 ML SUS AMOXICILLIN-CLAVULANATEPOTASS
AMOX-CLAV 400-57 MG TAB CHEW AMOXICILLIN-CLAVULANATEPOTASS
AMOX-CLAV 400-57 MG/5 ML SUSP AMOXICILLIN-CLAVULANATEPOTASS
AMOX-CLAV 500-125 MG TABLET AMOXICILLIN-CLAVULANATEPOTASS
AMOX-CLAV 600-42.9 MG/5 ML SUS AMOXICILLIN-CLAVULANATEPOTASS
AMOX-CLAV 875-125 MG TABLET AMOXICILLIN-CLAVULANATEPOTASS
AMOXICILLIN 125 MG/5 ML SUSP AMOXICILLIN
AMOXICILLIN 200 MG/5 ML SUSP AMOXICILLIN
AMOXICILLIN 250 MG CAPSULE AMOXICILLIN
AMOXICILLIN 250 MG/5 ML SUSP AMOXICILLIN
AMOXICILLIN 400 MG/5 ML SUSP AMOXICILLIN
AMOXICILLIN 500 MG CAPSULE AMOXICILLIN
AMOXICILLIN 875 MG TABLET AMOXICILLIN
AMPICILLIN 125 MG/5 ML SUSP AMPICILLIN TRIHYDRATE
AMPICILLIN 250 MG CAPSULE AMPICILLIN TRIHYDRATE
AMPICILLIN 250 MG/5 ML SUSP AMPICILLIN TRIHYDRATE
AMPICILLIN 500 MG CAPSULE AMPICILLIN TRIHYDRATE
AZITHROMYCIN 1 GM PWD PACKET AZITHROMYCIN
AZITHROMYCIN 100 MG/5 ML SUSP AZITHROMYCIN
AZITHROMYCIN 200 MG/5 ML SUSP AZITHROMYCIN
AZITHROMYCIN 250 MG TABLET AZITHROMYCIN QL
AZITHROMYCIN 500 MG TABLET AZITHROMYCIN QL
AZITHROMYCIN 600 MG TABLET AZITHROMYCIN
AZITHROMYCIN I.V. 500 MG VIAL AZITHROMYCIN
BACITRACIN 50,000 UNIT VIAL BACITRACIN
CEFACLOR 125 MG/5 ML SUSP CEFACLOR
2018 Trusted Health Plan Medicaid Formulary
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Antibacterial Agents
Medication Info Common Name Drug Status Criteria
CEFACLOR 250 MG CAPSULE CEFACLOR
CEFACLOR 250 MG/5 ML SUSP CEFACLOR
CEFACLOR 375 MG/5 ML SUSPEN CEFACLOR
CEFACLOR 500 MG CAPSULE CEFACLOR
CEFADROXIL 1 GM TABLET CEFADROXIL
CEFADROXIL 250 MG/5 ML SUSP CEFADROXIL
CEFADROXIL 500 MG CAPSULE CEFADROXIL
CEFADROXIL 500 MG/5 ML SUSP CEFADROXIL
CEFDINIR 125 MG/5 ML SUSP CEFDINIR
CEFDINIR 250 MG/5 ML SUSP CEFDINIR
CEFDINIR 300 MG CAPSULE CEFDINIR
CEFPROZIL 125 MG/5 ML SUSP CEFPROZIL
CEFPROZIL 250 MG TABLET CEFPROZIL
CEFPROZIL 250 MG/5 ML SUSP CEFPROZIL
CEFPROZIL 500 MG TABLET CEFPROZIL
CEFUROXIME 125 MG/5 ML SUSP CEFUROXIME AXETIL
CEFUROXIME AXETIL 250 MG TAB CEFUROXIME
CEFUROXIME AXETIL 500 MG TAB CEFUROXIME
CEPHALEXIN 125 MG/5 ML SUSP CEPHALEXIN
CEPHALEXIN 250 MG CAPSULE CEPHALEXIN
CEPHALEXIN 250 MG/5 ML SUSP CEPHALEXIN
CEPHALEXIN 500 MG CAPSULE CEPHALEXIN
CIPRO 10% SUSPENSION CIPRO
CIPRO 5% SUSPENSION CIPRO
CIPROFLOXACIN HCL 100 MG TAB CIPROFLOXACIN HCL
CIPROFLOXACIN HCL 250 MG TAB CIPROFLOXACIN HCL
CIPROFLOXACIN HCL 500 MG TAB CIPROFLOXACIN HCL
CIPROFLOXACIN HCL 750 MG TAB CIPROFLOXACIN HCL
CLARITHROMYCIN 125 MG/5 ML SUS CLARITHROMYCIN
CLARITHROMYCIN 250 MG TABLET CLARITHROMYCIN
CLARITHROMYCIN 250 MG/5 ML SUS CLARITHROMYCIN
CLARITHROMYCIN 500 MG TABLET CLARITHROMYCIN
CLARITHROMYCIN ER 500 MG TAB CLARITHROMYCIN ER
CLINDAMYCIN 75 MG/5 ML SOLN CLINDAMYCIN PALMITATE HCL
CLINDAMYCIN HCL 150 MG CAPSULE CLINDAMYCIN HCL
CLINDAMYCIN HCL 300 MG CAPSULE CLINDAMYCIN HCL
CLINDAMYCIN HCL 75 MG CAPSULE CLINDAMYCIN HCL
CLINDAMYCIN PEDIATR 75 MG/5 ML CLINDAMYCIN PEDIATRIC
CLINDAMYCIN PEDIATRIC 75 MG/5 ML CLINDAMYCIN PEDIATRIC
DAPSONE 100 MG TABLET DAPSONE
DAPSONE 25 MG TABLET DAPSONE
DICLOXACILLIN 250 MG CAPSULE DICLOXACILLIN SODIUM
DOXYCYCLINE HYC 100 MG VIAL DOXYCYCLINE HYCLATE
2018 Trusted Health Plan Medicaid Formulary
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Antibacterial Agents
Medication Info Common Name Drug Status Criteria
DOXYCYCLINE HYC DR 100 MG TAB DOXYCYCLINE HYCLATE
DOXYCYCLINE HYC DR 150 MG TAB DOXYCYCLINE HYCLATE
DOXYCYCLINE HYC DR 200 MG TAB DOXYCYCLINE HYCLATE
DOXYCYCLINE HYC DR 75 MG TAB DOXYCYCLINE HYCLATE
DOXYCYCLINE HYCLATE 100 MG CAP DOXYCYCLINE HYCLATE
DOXYCYCLINE HYCLATE 100 MG TAB DOXYCYCLINE HYCLATE
DOXYCYCLINE HYCLATE 50 MG CAP DOXYCYCLINE HYCLATE
ERYTHROMYCIN 200 MG/5 ML GRAN ERYTHROMYCINETHYLSUCCINATE
ERYTHROMYCIN 250 MG FILMTAB ERYTHROMYCIN
ERYTHROMYCIN 500 MG FILMTAB ERYTHROMYCIN
ERYTHROMYCIN DR 250 MG CAP ERYTHROMYCIN
ERYTHROMYCIN EC 250 MG CAP ERYTHROMYCIN
ERYTHROMYCIN ES 400 MG TAB ERYTHROMYCINETHYLSUCCINATE
ERYTHROMYCIN ST 250 MG TAB ERYTHROMYCIN STEARATE
ETHAMBUTOL HCL 100 MG TABLET ETHAMBUTOL HCL
ETHAMBUTOL HCL 400 MG TABLET ETHAMBUTOL HCL
GENTAMICIN 10 MG/ML VIAL GENTAMICIN SULFATE
GENTAMICIN 20 MG/2 ML VIAL GENTAMICIN SULFATE
GENTAMICIN 40 MG/ML VIAL GENTAMICIN SULFATE
GENTAMICIN 80 MG/2 ML VIAL GENTAMICIN SULFATE
GENTAMICIN 800 MG/20 ML VIAL GENTAMICIN SULFATE
ISONIAZID 100 MG TABLET ISONIAZID
ISONIAZID 100 MG/ML VIAL ISONIAZID
ISONIAZID 300 MG TABLET ISONIAZID
ISONIAZID 50 MG/5 ML SOLUTION ISONIAZID
LEVOFLOXACIN 250 MG TABLET LEVOFLOXACIN
LEVOFLOXACIN 500 MG TABLET LEVOFLOXACIN
LEVOFLOXACIN 750 MG TABLET LEVOFLOXACIN
MINOCYCLINE 100 MG CAPSULE MINOCYCLINE HCL
MINOCYCLINE 50 MG CAPSULE MINOCYCLINE HCL
MINOCYCLINE 75 MG CAPSULE MINOCYCLINE HCL
MINOCYCLINE ER 135 MG TABLET MINOCYCLINE HCL ER
MINOCYCLINE ER 45 MG TABLET MINOCYCLINE HCL ER
MINOCYCLINE ER 90 MG TABLET MINOCYCLINE HCL ER
MINOCYCLINE HCL 100 MG TABLET MINOCYCLINE HCL
MINOCYCLINE HCL 50 MG TABLET MINOCYCLINE HCL
MINOCYCLINE HCL 75 MG TABLET MINOCYCLINE HCL
OFLOXACIN 300 MG TABLET OFLOXACIN
OFLOXACIN 400 MG TABLET OFLOXACIN
PEN G 1.2 MILLION UNIT/2 ML PENICILLIN G PROCAINE
PENICILLIN G 600,000 UNIT/1 ML PENICILLIN G PROCAINE
2018 Trusted Health Plan Medicaid Formulary
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Antibacterial Agents
Medication Info Common Name Drug Status Criteria
PENICILLIN G K 5 MILLION UNIT PENICILLIN G POTASSIUM
PENICILLIN G NA 5 MILLION UNIT PENICILLIN G SODIUM
PENICILLIN VK 125 MG/5 ML SOLN PENICILLIN V POTASSIUM
PENICILLIN VK 250 MG TABLET PENICILLIN V POTASSIUM
PENICILLIN VK 250 MG/5 ML SOLN PENICILLIN V POTASSIUM
PENICILLIN VK 250 MG/5 ML SUS PENICILLIN V POTASSIUM
PENICILLIN VK 500 MG TABLET PENICILLIN V POTASSIUM
PYRAZINAMIDE 500 MG TABLET PYRAZINAMIDE
RIFAMPIN 150 MG CAPSULE RIFAMPIN
RIFAMPIN 300 MG CAPSULE RIFAMPIN
RIFAMPIN IV 600 MG VIAL RIFAMPIN
SULFAMETHOXAZOLE-TMP DSTABLET
SULFAMETHOXAZOLE-TRIMETHOPRIM
SULFAMETHOXAZOLE-TMP INJ VIAL SULFAMETHOXAZOLE-TRIMETHOPRIM
SULFAMETHOXAZOLE-TMP SSTABLET
SULFAMETHOXAZOLE-TRIMETHOPRIM
SULFAMETHOXAZOLE-TMP SUSP SULFAMETHOXAZOLE-TRIMETHOPRIM
TETRACYCLINE 250 MG CAPSULE TETRACYCLINE HCL
TETRACYCLINE 500 MG CAPSULE TETRACYCLINE HCL
THALOMID 100 MG CAPSULE THALOMID PA
THALOMID 150 MG CAPSULE THALOMID PA
THALOMID 200 MG CAPSULE THALOMID PA
THALOMID 50 MG CAPSULE THALOMID PA
TRIMETHOPRIM 100 MG TABLET TRIMETHOPRIM
VANCOMYCIN 1 GM VIAL VANCOMYCIN HCL
VANCOMYCIN 125 MG/2.5 ML ORALSYRINGE (CMPD-RX)
VANCOMYCIN HCL
VANCOMYCIN 500 MG VIAL VANCOMYCIN HCL
ZITHROMAX 500 MG TABLET ZITHROMAX
ZITHROMAX TRI-PAK 500 MG TAB ZITHROMAX TRI-PAK
Anticoagulants
Medication Info Common Name Drug Status Criteria
ENOXAPARIN 100 MG/ML SYRINGE ENOXAPARIN SODIUM QL
ENOXAPARIN 120 MG/0.8 ML SYR ENOXAPARIN SODIUM QL
ENOXAPARIN 150 MG/ML SYRINGE ENOXAPARIN SODIUM QL
ENOXAPARIN 30 MG/0.3 ML SYR ENOXAPARIN SODIUM QL
ENOXAPARIN 300 MG/3 ML VIAL ENOXAPARIN SODIUM QL
ENOXAPARIN 40 MG/0.4 ML SYR ENOXAPARIN SODIUM QL
ENOXAPARIN 60 MG/0.6 ML SYR ENOXAPARIN SODIUM QL
ENOXAPARIN 80 MG/0.8 ML SYR ENOXAPARIN SODIUM QL
PRADAXA 150 MG CAPSULE PRADAXA
WARFARIN SODIUM 1 MG TABLET WARFARIN SODIUM
2018 Trusted Health Plan Medicaid Formulary
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Anticoagulants
Medication Info Common Name Drug Status Criteria
WARFARIN SODIUM 10 MG TABLET WARFARIN SODIUM
WARFARIN SODIUM 2 MG TABLET WARFARIN SODIUM
WARFARIN SODIUM 2.5 MG TABLET WARFARIN SODIUM
WARFARIN SODIUM 3 MG TABLET WARFARIN SODIUM
WARFARIN SODIUM 4 MG TABLET WARFARIN SODIUM
WARFARIN SODIUM 5 MG TABLET WARFARIN SODIUM
WARFARIN SODIUM 6 MG TABLET WARFARIN SODIUM
WARFARIN SODIUM 7.5 MG TABLET WARFARIN SODIUM
XARELTO 10 MG TABLET XARELTO QL
XARELTO 15 MG TABLET XARELTO QL
XARELTO 20 MG TABLET XARELTO QL
Anticonvulsants
Medication Info Common Name Drug Status Criteria
CARBAMAZEPINE 100 MG TAB CHEW CARBAMAZEPINE
CARBAMAZEPINE 100 MG/5 ML SUSP CARBAMAZEPINE
CARBAMAZEPINE 200 MG TABLET CARBAMAZEPINE
CARBAMAZEPINE ER 100 MG TABLET CARBAMAZEPINE ER
DIAZEPAM 10 MG RECTAL GEL SYST DIAZEPAM
DIAZEPAM 2.5 MG RECTAL GEL SYS DIAZEPAM
DIAZEPAM 20 MG RECTAL GEL SYST DIAZEPAM
DIVALPROEX DR 125 MG CAP SPRNK DIVALPROEX SODIUM
DIVALPROEX SOD DR 125 MG TAB DIVALPROEX SODIUM
DIVALPROEX SOD DR 250 MG TAB DIVALPROEX SODIUM
DIVALPROEX SOD DR 500 MG TAB DIVALPROEX SODIUM
DIVALPROEX SOD ER 250 MG TAB DIVALPROEX SODIUM ER
DIVALPROEX SOD ER 500 MG TAB DIVALPROEX SODIUM ER
ETHOSUXIMIDE 250 MG CAPSULE ETHOSUXIMIDE
ETHOSUXIMIDE 250 MG/5 ML SOLN ETHOSUXIMIDE
GABAPENTIN 100 MG CAPSULE GABAPENTIN
GABAPENTIN 250 MG/5 ML SOLN GABAPENTIN
GABAPENTIN 300 MG CAPSULE GABAPENTIN
GABAPENTIN 300 MG/6 ML SOLN GABAPENTIN
GABAPENTIN 400 MG CAPSULE GABAPENTIN
GABAPENTIN 600 MG TABLET GABAPENTIN
GABAPENTIN 800 MG TABLET GABAPENTIN
LAMOTRIGINE 100 MG TABLET LAMOTRIGINE
LAMOTRIGINE 150 MG TABLET LAMOTRIGINE
LAMOTRIGINE 200 MG TABLET LAMOTRIGINE
LAMOTRIGINE 25 MG DISPER TAB LAMOTRIGINE
LAMOTRIGINE 25 MG TABLET LAMOTRIGINE
LAMOTRIGINE 5 MG DISPER TABLET LAMOTRIGINE
LAMOTRIGINE ER 100 MG TABLET LAMOTRIGINE ER
LAMOTRIGINE ER 200 MG TABLET LAMOTRIGINE ER
2018 Trusted Health Plan Medicaid Formulary
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Anticonvulsants
Medication Info Common Name Drug Status Criteria
LAMOTRIGINE ER 25 MG TABLET LAMOTRIGINE ER
LAMOTRIGINE ER 250 MG TABLET LAMOTRIGINE ER
LAMOTRIGINE ER 300 MG TABLET LAMOTRIGINE ER
LAMOTRIGINE ER 50 MG TABLET LAMOTRIGINE ER
LAMOTRIGINE ODT 100 MG TABLET LAMOTRIGINE ODT
LAMOTRIGINE ODT 200 MG TABLET LAMOTRIGINE ODT
LAMOTRIGINE ODT 25 MG TABLET LAMOTRIGINE ODT
LAMOTRIGINE ODT 50 MG TABLET LAMOTRIGINE ODT
LAMOTRIGINE ODT KIT (BLUE) LAMOTRIGINE ODT (BLUE)
LAMOTRIGINE ODT KIT (GREEN) LAMOTRIGINE ODT (GREEN)
LAMOTRIGINE ODT KIT (ORANGE) LAMOTRIGINE ODT (ORANGE)
LAMOTRIGINE TAB START KIT-BLUE LAMOTRIGINE (BLUE)
LAMOTRIGINE TAB START KT-GREEN LAMOTRIGINE (GREEN)
LAMOTRIGINE TAB START KT-ORANG LAMOTRIGINE (ORANGE)
LEVETIRACETAM 1,000 MG TABLET LEVETIRACETAM
LEVETIRACETAM 100 MG/ML SOLN LEVETIRACETAM
LEVETIRACETAM 250 MG TABLET LEVETIRACETAM
LEVETIRACETAM 500 MG TABLET LEVETIRACETAM
LEVETIRACETAM 500 MG/5 ML SOLN LEVETIRACETAM
LEVETIRACETAM 750 MG TABLET LEVETIRACETAM
LEVETIRACETAM ER 500 MG TABLET LEVETIRACETAM ER
LEVETIRACETAM ER 750 MG TABLET LEVETIRACETAM ER
LYRICA 100 MG CAPSULE LYRICA QL
LYRICA 150 MG CAPSULE LYRICA QL
LYRICA 20 MG/ML ORAL SOLUTION LYRICA QL
LYRICA 200 MG CAPSULE LYRICA QL
LYRICA 225 MG CAPSULE LYRICA QL
LYRICA 25 MG CAPSULE LYRICA QL
LYRICA 300 MG CAPSULE LYRICA QL
LYRICA 50 MG CAPSULE LYRICA QL
LYRICA 75 MG CAPSULE LYRICA QL
ONFI 10 MG TABLET ONFI PA
ONFI 20 MG TABLET ONFI PA
OXCARBAZEPINE 150 MG TABLET OXCARBAZEPINE
OXCARBAZEPINE 300 MG TABLET OXCARBAZEPINE
OXCARBAZEPINE 300 MG/5 ML SUSP OXCARBAZEPINE
OXCARBAZEPINE 600 MG TABLET OXCARBAZEPINE
PHENYTOIN 100 MG/4 ML SUSP PHENYTOIN
PHENYTOIN 125 MG/5 ML SUSP PHENYTOIN
PHENYTOIN 50 MG INFATAB PHENYTOIN
PHENYTOIN 50 MG TABLET CHEW PHENYTOIN
PHENYTOIN SOD EXT 100 MG CAP PHENYTOIN SODIUMEXTENDED
2018 Trusted Health Plan Medicaid Formulary
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Anticonvulsants
Medication Info Common Name Drug Status Criteria
PHENYTOIN SOD EXT 200 MG CAP PHENYTOIN SODIUMEXTENDED
PHENYTOIN SOD EXT 300 MG CAP PHENYTOIN SODIUMEXTENDED
PRIMIDONE 250 MG TABLET PRIMIDONE
PRIMIDONE 50 MG TABLET PRIMIDONE
TIAGABINE HCL 2 MG TABLET TIAGABINE HCL
TIAGABINE HCL 4 MG TABLET TIAGABINE HCL
TOPIRAMATE 100 MG TABLET TOPIRAMATE
TOPIRAMATE 15 MG SPRINKLE CAP TOPIRAMATE
TOPIRAMATE 200 MG TABLET TOPIRAMATE
TOPIRAMATE 25 MG SPRINKLE CAP TOPIRAMATE
TOPIRAMATE 25 MG TABLET TOPIRAMATE
TOPIRAMATE 50 MG TABLET TOPIRAMATE
VALPROIC ACID 250 MG CAPSULE VALPROIC ACID
VALPROIC ACID 250 MG/5 ML ORAL VALPROIC ACID
VALPROIC ACID 250 MG/5 ML SOLN VALPROIC ACID
VALPROIC ACID 500 MG/10 ML SOL VALPROIC ACID
ZONISAMIDE 100 MG CAPSULE ZONISAMIDE
ZONISAMIDE 25 MG CAPSULE ZONISAMIDE
ZONISAMIDE 50 MG CAPSULE ZONISAMIDE
Antidepressants
Medication Info Common Name Drug Status Criteria
AMITRIPTYLINE HCL 10 MG TAB AMITRIPTYLINE HCL
AMITRIPTYLINE HCL 100 MG TAB AMITRIPTYLINE HCL
AMITRIPTYLINE HCL 150 MG TAB AMITRIPTYLINE HCL
AMITRIPTYLINE HCL 25 MG TAB AMITRIPTYLINE HCL
AMITRIPTYLINE HCL 50 MG TAB AMITRIPTYLINE HCL
AMITRIPTYLINE HCL 75 MG TAB AMITRIPTYLINE HCL
BUPROPION HCL 100 MG TABLET BUPROPION HCL
BUPROPION HCL 75 MG TABLET BUPROPION HCL
BUPROPION HCL SR 150 MG TABLET BUPROPION HCL SR
BUPROPION HCL XL 150 MG TABLET BUPROPION XL
BUPROPION HCL XL 300 MG TABLET BUPROPION XL
CITALOPRAM HBR 10 MG TABLET CITALOPRAM HBR
CITALOPRAM HBR 10 MG/5 ML SOLN CITALOPRAM HBR
CITALOPRAM HBR 20 MG TABLET CITALOPRAM HBR
CITALOPRAM HBR 20 MG/10 ML SOL CITALOPRAM HBR
CITALOPRAM HBR 40 MG TABLET CITALOPRAM HBR
CLOMIPRAMINE 25 MG CAPSULE CLOMIPRAMINE HCL
CLOMIPRAMINE 50 MG CAPSULE CLOMIPRAMINE HCL
CLOMIPRAMINE 75 MG CAPSULE CLOMIPRAMINE HCL
CYMBALTA 20 MG CAPSULE CYMBALTA PA,QL
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Antidepressants
Medication Info Common Name Drug Status Criteria
CYMBALTA 30 MG CAPSULE CYMBALTA PA,QL
CYMBALTA 60 MG CAPSULE CYMBALTA PA,QL
DOXEPIN 10 MG CAPSULE DOXEPIN HCL
DOXEPIN 10 MG/ML ORAL CONC DOXEPIN HCL
DOXEPIN 100 MG CAPSULE DOXEPIN HCL
DOXEPIN 150 MG CAPSULE DOXEPIN HCL
DOXEPIN 25 MG CAPSULE DOXEPIN HCL
DOXEPIN 50 MG CAPSULE DOXEPIN HCL
DOXEPIN 75 MG CAPSULE DOXEPIN HCL
DULOXETINE HCL DR 20 MG CAP DULOXETINE HCL QL
DULOXETINE HCL DR 30 MG CAP DULOXETINE HCL QL
DULOXETINE HCL DR 60 MG CAP DULOXETINE HCL QL
ESCITALOPRAM 10 MG TABLET ESCITALOPRAM OXALATE
ESCITALOPRAM 20 MG TABLET ESCITALOPRAM OXALATE
ESCITALOPRAM 5 MG TABLET ESCITALOPRAM OXALATE
ESCITALOPRAM OXALATE 5 MG/5 ML ESCITALOPRAM OXALATE
FLUOXETINE 20 MG/5 ML SOLUTION FLUOXETINE HCL
FLUOXETINE HCL 10 MG CAPSULE FLUOXETINE HCL
FLUOXETINE HCL 10 MG TABLET FLUOXETINE HCL
FLUOXETINE HCL 20 MG CAPSULE FLUOXETINE HCL
FLUOXETINE HCL 20 MG TABLET FLUOXETINE HCL
FLUOXETINE HCL 40 MG CAPSULE FLUOXETINE HCL
FLUVOXAMINE ER 100 MG CAPSULE FLUVOXAMINE MALEATE ER
FLUVOXAMINE ER 150 MG CAPSULE FLUVOXAMINE MALEATE ER
FLUVOXAMINE MALEATE 100 MG TAB FLUVOXAMINE MALEATE
FLUVOXAMINE MALEATE 25 MG TAB FLUVOXAMINE MALEATE
FLUVOXAMINE MALEATE 50 MG TAB FLUVOXAMINE MALEATE
IMIPRAMINE HCL 10 MG TABLET IMIPRAMINE HCL
IMIPRAMINE HCL 25 MG TABLET IMIPRAMINE HCL
IMIPRAMINE HCL 50 MG TABLET IMIPRAMINE HCL
IMIPRAMINE PAMOATE 100 MG CAP IMIPRAMINE PAMOATE
MIRTAZAPINE 15 MG ODT MIRTAZAPINE
MIRTAZAPINE 15 MG TABLET MIRTAZAPINE
MIRTAZAPINE 30 MG ODT MIRTAZAPINE
MIRTAZAPINE 30 MG TABLET MIRTAZAPINE
MIRTAZAPINE 45 MG ODT MIRTAZAPINE
MIRTAZAPINE 45 MG TABLET MIRTAZAPINE
MIRTAZAPINE 7.5 MG TABLET MIRTAZAPINE
NORTRIPTYLINE 10 MG/5 ML SOL NORTRIPTYLINE HCL
NORTRIPTYLINE HCL 10 MG CAP NORTRIPTYLINE HCL
NORTRIPTYLINE HCL 25 MG CAP NORTRIPTYLINE HCL
NORTRIPTYLINE HCL 50 MG CAP NORTRIPTYLINE HCL
NORTRIPTYLINE HCL 75 MG CAP NORTRIPTYLINE HCL
2018 Trusted Health Plan Medicaid Formulary
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Antidepressants
Medication Info Common Name Drug Status Criteria
PAROXETINE CR 12.5 MG TABLET PAROXETINE CR
PAROXETINE CR 25 MG TABLET PAROXETINE CR
PAROXETINE CR 37.5 MG TABLET PAROXETINE CR
PAROXETINE ER 12.5 MG TABLET PAROXETINE ER
PAROXETINE ER 25 MG TABLET PAROXETINE ER
PAROXETINE ER 37.5 MG TABLET PAROXETINE ER
PAROXETINE HCL 10 MG TABLET PAROXETINE HCL
PAROXETINE HCL 20 MG TABLET PAROXETINE HCL
PAROXETINE HCL 30 MG TABLET PAROXETINE HCL
PAROXETINE HCL 40 MG TABLET PAROXETINE HCL
PAXIL 10 MG/5 ML SUSPENSION PAXIL
PHENELZINE SULFATE 15 MG TAB PHENELZINE SULFATE
PROZAC 10 MG PULVULE PROZAC
PROZAC 20 MG PULVULE PROZAC
PROZAC 40 MG PULVULE PROZAC
SERTRALINE 20 MG/ML ORAL CONC SERTRALINE HCL
SERTRALINE HCL 100 MG TABLET SERTRALINE HCL
SERTRALINE HCL 25 MG TABLET SERTRALINE HCL
SERTRALINE HCL 50 MG TABLET SERTRALINE HCL
TRANYLCYPROMINE SULF 10 MGTAB
TRANYLCYPROMINE SULFATE
TRAZODONE 100 MG TABLET TRAZODONE HCL
TRAZODONE 150 MG TABLET TRAZODONE HCL
TRAZODONE 300 MG TABLET TRAZODONE HCL
TRAZODONE 50 MG TABLET TRAZODONE HCL
VENLAFAXINE HCL 100 MG TABLET VENLAFAXINE HCL
VENLAFAXINE HCL 25 MG TABLET VENLAFAXINE HCL
VENLAFAXINE HCL 37.5 MG TABLET VENLAFAXINE HCL
VENLAFAXINE HCL 50 MG TABLET VENLAFAXINE HCL
VENLAFAXINE HCL 75 MG TABLET VENLAFAXINE HCL
VENLAFAXINE HCL ER 150 MG CAP VENLAFAXINE HCL ER
VENLAFAXINE HCL ER 150 MG TAB VENLAFAXINE HCL ER
VENLAFAXINE HCL ER 225 MG TAB VENLAFAXINE HCL ER
VENLAFAXINE HCL ER 37.5 MG CAP VENLAFAXINE HCL ER
VENLAFAXINE HCL ER 37.5 MG TAB VENLAFAXINE HCL ER
VENLAFAXINE HCL ER 75 MG CAP VENLAFAXINE HCL ER
VENLAFAXINE HCL ER 75 MG TAB VENLAFAXINE HCL ER
Antidiarrheals
Medication Info Common Name Drug Status Criteria
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG TABLET
DIPHENOXYLATE-ATROPINE
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Antiemetics
Medication Info Common Name Drug Status Criteria
DRONABINOL 10 MG CAPSULE DRONABINOL
DRONABINOL 2.5 MG CAPSULE DRONABINOL
DRONABINOL 5 MG CAPSULE DRONABINOL
GRANISETRON HCL 1 MG TABLET GRANISETRON HCL
MECLIZINE 12.5 MG TABLET MECLIZINE HCL
MECLIZINE 25 MG TABLET MECLIZINE HCL
ONDANSETRON 4 MG/5 MLSOLUTION
ONDANSETRON HCL
ONDANSETRON HCL 24 MG TABLET ONDANSETRON HCL QL
ONDANSETRON HCL 4 MG TABLET ONDANSETRON HCL QL
ONDANSETRON HCL 8 MG TABLET ONDANSETRON HCL QL
PROCHLORPERAZINE 10 MG/2 ML VL PROCHLORPERAZINEEDISYLATE
PROCHLORPERAZINE 25 MG SUPP PROCHLORPERAZINE
PROCHLORPERAZINE 5 MG/ML VIAL PROCHLORPERAZINEEDISYLATE
TRIMETHOBENZAMIDE 300 MG CAP TRIMETHOBENZAMIDE HCL
Antifungals
Medication Info Common Name Drug Status Criteria
FLUCONAZOLE 10 MG/ML SUSP FLUCONAZOLE
FLUCONAZOLE 100 MG TABLET FLUCONAZOLE
FLUCONAZOLE 150 MG TABLET FLUCONAZOLE QL
FLUCONAZOLE 200 MG TABLET FLUCONAZOLE
FLUCONAZOLE 40 MG/ML SUSP FLUCONAZOLE
FLUCONAZOLE 50 MG TABLET FLUCONAZOLE
GRISEOFULVIN 125 MG/5 ML SUSP GRISEOFULVIN
GRISEOFULVIN MICRO 500 MG TAB GRISEOFULVIN
GRISEOFULVIN ULTRA 125 MG TAB GRISEOFULVINULTRAMICROSIZE
GRISEOFULVIN ULTRA 250 MG TAB GRISEOFULVINULTRAMICROSIZE
ITRACONAZOLE 100 MG CAPSULE ITRACONAZOLE
KETOCONAZOLE 200 MG TABLET KETOCONAZOLE
NYSTATIN 150,000,000 UNITS PWD NYSTATIN
NYSTATIN 500,000 UNIT ORAL TAB NYSTATIN
NYSTATIN 500,000,000 UNITS PWD NYSTATIN
TERBINAFINE HCL 250 MG TABLET TERBINAFINE HCL
Antihemophilic Factor Agents
Medication Info Common Name Drug Status Criteria
ADVATE 2,401-3,600 UNIT VIAL ADVATE PA
ALPHANATE 1,000-400 UNIT VIAL ALPHANATE PA
ALPHANATE 1,500-600 UNIT VIAL ALPHANATE PA
ALPHANATE 250-100 UNIT VIAL ALPHANATE PA
ALPHANATE 500-200 UNIT VIAL ALPHANATE PA
2018 Trusted Health Plan Medicaid Formulary
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Antihemophilic Factor Agents
Medication Info Common Name Drug Status Criteria
ALPHANINE SD 1,000 UNITS VIAL ALPHANINE SD PA
ALPHANINE SD 1,500 UNITS VIAL ALPHANINE SD PA
ALPHANINE SD 500 UNITS VIAL ALPHANINE SD PA
BENEFIX 1,000 UNIT RANGE BENEFIX PA
BENEFIX 2,000 UNIT RANGE BENEFIX PA
BENEFIX 250 UNIT RANGE BENEFIX PA
BENEFIX 3,000 UNIT RANGE BENEFIX PA
BENEFIX 500 UNIT RANGE BENEFIX PA
FEIBA NF 1,000 UNIT (NOMINAL) FEIBA NF PA
FEIBA NF 2,500 UNIT (NOMINAL) FEIBA NF PA
FEIBA NF 500 UNIT (NOMINAL) FEIBA NF PA
HELIXATE FS 3,000 UNITS VIAL HELIXATE FS PA
HEMOFIL M 1,000 UNIT NOMINAL HEMOFIL M PA
HEMOFIL M 1,700 UNIT NOMINAL HEMOFIL M PA
HEMOFIL M 250 UNIT NOMINAL HEMOFIL M PA
HEMOFIL M 500 UNIT NOMINAL HEMOFIL M PA
HUMATE-P 1,200 UNIT VWF:RCO HUMATE-P
HUMATE-P 2,400 UNIT VWF:RCO HUMATE-P
HUMATE-P 600 UNIT VWF:RCO HUMATE-P
KOGENATE FS 3,000 UNIT-BIOSET KOGENATE FS PA
KOGENATE FS 3,000 UNITS VIAL KOGENATE FS PA
KOVALTRY 3,000 UNIT KIT KOVALTRY PA
KOVALTRY 3,000 UNIT VIAL KOVALTRY PA
MONONINE 1,000 UNIT VIAL MONONINE PA
NOVOSEVEN RT 1 MG VIAL NOVOSEVEN RT PA
NOVOSEVEN RT 2 MG VIAL NOVOSEVEN RT PA
NOVOSEVEN RT 5 MG VIAL NOVOSEVEN RT PA
NOVOSEVEN RT 8 MG VIAL NOVOSEVEN RT PA
RECOMBINATE 1,241-1,800 UNIT V RECOMBINATE PA
RECOMBINATE 1,801-2,400 UNIT V RECOMBINATE PA
RECOMBINATE 220-400 UNIT VIAL RECOMBINATE PA
RECOMBINATE 401-800 UNIT VIAL RECOMBINATE PA
RECOMBINATE 801-1,240 UNIT VL RECOMBINATE PA
RIXUBIS 1,000 UNIT NOMINAL RIXUBIS PA
RIXUBIS 2,000 UNIT NOMINAL RIXUBIS PA
RIXUBIS 250 UNIT NOMINAL RIXUBIS PA
RIXUBIS 3,000 UNIT NOMINAL RIXUBIS PA
RIXUBIS 500 UNIT NOMINAL RIXUBIS PA
Antihistamines
Medication Info Common Name Drug Status Criteria
CETIRIZINE HCL 1 MG/ML SOLN CETIRIZINE HCL
CETIRIZINE HCL 1 MG/ML SYRUP CETIRIZINE HCL
CLEMASTINE FUM 2.68 MG TAB CLEMASTINE FUMARATE
2018 Trusted Health Plan Medicaid Formulary
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Antihistamines
Medication Info Common Name Drug Status Criteria
CYPROHEPTADINE 2 MG/5 ML SYRUP CYPROHEPTADINE HCL
CYPROHEPTADINE 4 MG TABLET CYPROHEPTADINE HCL
DIPHENHYDRAMINE 50 MG/MLSYRNG
DIPHENHYDRAMINE HCL
DIPHENHYDRAMINE 50 MG/ML VIAL DIPHENHYDRAMINE HCL
FEXOFENADINE HCL 180 MG TABLET FEXOFENADINE HCL
FEXOFENADINE HCL 60 MG TABLET FEXOFENADINE HCL
PROMETHAZINE 12.5 MG SUPPOS PROMETHAZINE HCL
PROMETHAZINE 12.5 MG TABLET PROMETHAZINE HCL
PROMETHAZINE 25 MGSUPPOSITORY
PROMETHAZINE HCL
PROMETHAZINE 25 MG TABLET PROMETHAZINE HCL
PROMETHAZINE 25 MG/ML AMPUL PROMETHAZINE HCL
PROMETHAZINE 25 MG/ML VIAL PROMETHAZINE HCL
PROMETHAZINE 50 MGSUPPOSITORY
PROMETHAZINE HCL
PROMETHAZINE 50 MG TABLET PROMETHAZINE HCL
PROMETHAZINE 50 MG/ML AMPUL PROMETHAZINE HCL
PROMETHAZINE 50 MG/ML VIAL PROMETHAZINE HCL
PROMETHAZINE 6.25 MG/5 ML SOLN PROMETHAZINE HCL
PROMETHAZINE 6.25 MG/5 ML SYRP PROMETHAZINE HCL
Antihyperlipidemics
Medication Info Common Name Drug Status Criteria
ATORVASTATIN 10 MG TABLET ATORVASTATIN CALCIUM
ATORVASTATIN 20 MG TABLET ATORVASTATIN CALCIUM
ATORVASTATIN 40 MG TABLET ATORVASTATIN CALCIUM
ATORVASTATIN 80 MG TABLET ATORVASTATIN CALCIUM
CHOLESTYRAMINE LIGHT PACKET CHOLESTYRAMINE LIGHT
CHOLESTYRAMINE LIGHT POWDER CHOLESTYRAMINE LIGHT
COLESTIPOL HCL 1 GM TABLET COLESTIPOL HCL
COLESTIPOL HCL GRANULES COLESTIPOL HCL
COLESTIPOL HCL GRANULESPACKET
COLESTIPOL HCL
COLESTIPOL MICRONIZED 1 GM TAB COLESTIPOL HCL
EZETIMIBE 10 MG TABLET EZETIMIBE
FENOFIBRATE 120 MG TABLET FENOFIBRATE
FENOFIBRATE 130 MG CAPSULE FENOFIBRATE
FENOFIBRATE 134 MG CAPSULE FENOFIBRATE
FENOFIBRATE 145 MG TABLET FENOFIBRATE
FENOFIBRATE 150 MG CAPSULE FENOFIBRATE
FENOFIBRATE 160 MG TABLET FENOFIBRATE
FENOFIBRATE 200 MG CAPSULE FENOFIBRATE
FENOFIBRATE 40 MG TABLET FENOFIBRATE
FENOFIBRATE 43 MG CAPSULE FENOFIBRATE
2018 Trusted Health Plan Medicaid Formulary
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Antihyperlipidemics
Medication Info Common Name Drug Status Criteria
FENOFIBRATE 48 MG TABLET FENOFIBRATE
FENOFIBRATE 50 MG CAPSULE FENOFIBRATE
FENOFIBRATE 54 MG TABLET FENOFIBRATE
FENOFIBRATE 67 MG CAPSULE FENOFIBRATE
GEMFIBROZIL 600 MG TABLET GEMFIBROZIL
JUXTAPID 10 MG CAPSULE JUXTAPID PA
JUXTAPID 20 MG CAPSULE JUXTAPID PA
JUXTAPID 5 MG CAPSULE JUXTAPID PA
LOVASTATIN 10 MG TABLET LOVASTATIN
LOVASTATIN 20 MG TABLET LOVASTATIN
LOVASTATIN 40 MG TABLET LOVASTATIN
NIACIN ER 1,000 MG TABLET NIACIN ER
NIACIN ER 500 MG TABLET NIACIN ER
NIACIN ER 750 MG TABLET NIACIN ER
PRAVASTATIN SODIUM 10 MG TAB PRAVASTATIN SODIUM
PRAVASTATIN SODIUM 20 MG TAB PRAVASTATIN SODIUM
PRAVASTATIN SODIUM 40 MG TAB PRAVASTATIN SODIUM
PRAVASTATIN SODIUM 80 MG TAB PRAVASTATIN SODIUM
ROSUVASTATIN CALCIUM 10 MG TAB ROSUVASTATIN CALCIUM
ROSUVASTATIN CALCIUM 20 MG TAB ROSUVASTATIN CALCIUM
ROSUVASTATIN CALCIUM 40 MG TAB ROSUVASTATIN CALCIUM
ROSUVASTATIN CALCIUM 5 MG TAB ROSUVASTATIN CALCIUM
SIMVASTATIN 10 MG TABLET SIMVASTATIN
SIMVASTATIN 20 MG TABLET SIMVASTATIN
SIMVASTATIN 40 MG TABLET SIMVASTATIN
SIMVASTATIN 5 MG TABLET SIMVASTATIN
SIMVASTATIN 80 MG TABLET SIMVASTATIN
ZETIA 10 MG TABLET ZETIA
Antihypertensive Therapy Agents
Medication Info Common Name Drug Status Criteria
AMLODIPINE-OLMESARTAN 10-20 MG AMLODIPINE-OLMESARTAN QL
AMLODIPINE-OLMESARTAN 10-40 MG AMLODIPINE-OLMESARTAN QL
AMLODIPINE-OLMESARTAN 5-20 MG AMLODIPINE-OLMESARTAN QL
AMLODIPINE-OLMESARTAN 5-40 MG AMLODIPINE-OLMESARTAN QL
ATENOLOL-CHLORTHALIDONE 100-25 ATENOLOL-CHLORTHALIDONE
ATENOLOL-CHLORTHALIDONE 50-25 ATENOLOL-CHLORTHALIDONE
AZOR 10-20 MG TABLET AZOR QL
AZOR 10-40 MG TABLET AZOR QL
AZOR 5-20 MG TABLET AZOR QL
AZOR 5-40 MG TABLET AZOR QL
BENAZEPRIL HCL 10 MG TABLET BENAZEPRIL HCL
BENAZEPRIL HCL 20 MG TABLET BENAZEPRIL HCL
BENAZEPRIL HCL 40 MG TABLET BENAZEPRIL HCL
2018 Trusted Health Plan Medicaid Formulary
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Antihypertensive Therapy Agents
Medication Info Common Name Drug Status Criteria
BENAZEPRIL HCL 5 MG TABLET BENAZEPRIL HCL
BENAZEPRIL-HYDROCHLOROTHIAZIDE 10-12.5 MGTAB
BENAZEPRIL-HYDROCHLOROTHIAZIDE
BENAZEPRIL-HYDROCHLOROTHIAZIDE 20-12.5 MGTAB
BENAZEPRIL-HYDROCHLOROTHIAZIDE
BENAZEPRIL-HYDROCHLOROTHIAZIDE 20-25 MGTAB
BENAZEPRIL-HYDROCHLOROTHIAZIDE
BENAZEPRIL-HYDROCHLOROTHIAZIDE 5-6.25 MGTAB
BENAZEPRIL-HYDROCHLOROTHIAZIDE
BIDIL TABLET BIDIL
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MGTAB
BISOPROLOL-HYDROCHLOROTHIAZIDE
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MGTB
BISOPROLOL-HYDROCHLOROTHIAZIDE
BISOPROLOL-HYDROCHLOROTHIAZIDE 5-6.25 MGTAB
BISOPROLOL-HYDROCHLOROTHIAZIDE
CAPTOPRIL 100 MG TABLET CAPTOPRIL
CAPTOPRIL 12.5 MG TABLET CAPTOPRIL
CAPTOPRIL 25 MG TABLET CAPTOPRIL
CAPTOPRIL 50 MG TABLET CAPTOPRIL
CAPTOPRIL-HYDROCHLOROTHIAZIDE 25-15 MGTABLET
CAPTOPRIL-HYDROCHLOROTHIAZIDE
CAPTOPRIL-HYDROCHLOROTHIAZIDE 25-25 MGTABLET
CAPTOPRIL-HYDROCHLOROTHIAZIDE
CAPTOPRIL-HYDROCHLOROTHIAZIDE 50-15 MGTABLET
CAPTOPRIL-HYDROCHLOROTHIAZIDE
CAPTOPRIL-HYDROCHLOROTHIAZIDE 50-25 MGTABLET
CAPTOPRIL-HYDROCHLOROTHIAZIDE
CLONIDINE 0.1 MG/DAY PATCH CLONIDINE QL
CLONIDINE 0.2 MG/DAY PATCH CLONIDINE QL
CLONIDINE 0.3 MG/DAY PATCH CLONIDINE QL
CLONIDINE HCL 0.1 MG TABLET CLONIDINE HCL
CLONIDINE HCL 0.2 MG TABLET CLONIDINE HCL
CLONIDINE HCL 0.3 MG TABLET CLONIDINE HCL
DOXAZOSIN MESYLATE 1 MG TAB DOXAZOSIN MESYLATE
DOXAZOSIN MESYLATE 2 MG TAB DOXAZOSIN MESYLATE
DOXAZOSIN MESYLATE 4 MG TAB DOXAZOSIN MESYLATE
DOXAZOSIN MESYLATE 8 MG TAB DOXAZOSIN MESYLATE
2018 Trusted Health Plan Medicaid Formulary
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Antihypertensive Therapy Agents
Medication Info Common Name Drug Status Criteria
ENALAPRIL MALEATE 10 MG TAB ENALAPRIL MALEATE
ENALAPRIL MALEATE 2.5 MG TAB ENALAPRIL MALEATE
ENALAPRIL MALEATE 20 MG TAB ENALAPRIL MALEATE
ENALAPRIL MALEATE 5 MG TABLET ENALAPRIL MALEATE
ENALAPRIL-HYDROCHLOROTHIAZIDE10-25 MG TABLET
ENALAPRIL-HYDROCHLOROTHIAZIDE
ENALAPRIL-HYDROCHLOROTHIAZIDE5-12.5 MG TAB
ENALAPRIL-HYDROCHLOROTHIAZIDE
EPOPROSTENOL SODIUM 0.5 MG VL EPOPROSTENOL SODIUM
EPOPROSTENOL SODIUM 1.5 MG VL EPOPROSTENOL SODIUM
FLOLAN 0.5 MG VIAL FLOLAN
FLOLAN 1.5 MG VIAL FLOLAN
FOSINOPRIL SODIUM 10 MG TAB FOSINOPRIL SODIUM
FOSINOPRIL SODIUM 20 MG TAB FOSINOPRIL SODIUM
FOSINOPRIL SODIUM 40 MG TAB FOSINOPRIL SODIUM
FOSINOPRIL-HYDROCHLOROTHIAZIDE 10-12.5 MGTAB
FOSINOPRIL-HYDROCHLOROTHIAZIDE
FOSINOPRIL-HYDROCHLOROTHIAZIDE 20-12.5 MGTAB
FOSINOPRIL-HYDROCHLOROTHIAZIDE
GUANFACINE 1 MG TABLET GUANFACINE HCL
GUANFACINE 2 MG TABLET GUANFACINE HCL
HYDRALAZINE 10 MG TABLET HYDRALAZINE HCL
HYDRALAZINE 100 MG TABLET HYDRALAZINE HCL
HYDRALAZINE 20 MG/ML VIAL HYDRALAZINE HCL
HYDRALAZINE 25 MG TABLET HYDRALAZINE HCL
HYDRALAZINE 50 MG TABLET HYDRALAZINE HCL
IRBESARTAN 150 MG TABLET IRBESARTAN QL
IRBESARTAN 300 MG TABLET IRBESARTAN QL
IRBESARTAN 75 MG TABLET IRBESARTAN QL
LETAIRIS 10 MG TABLET LETAIRIS PA
LETAIRIS 5 MG TABLET LETAIRIS PA
LISINOPRIL 10 MG TABLET LISINOPRIL
LISINOPRIL 2.5 MG TABLET LISINOPRIL
LISINOPRIL 20 MG TABLET LISINOPRIL
LISINOPRIL 30 MG TABLET LISINOPRIL
LISINOPRIL 40 MG TABLET LISINOPRIL
LISINOPRIL 5 MG TABLET LISINOPRIL
LISINOPRIL-HYDROCHLOROTHIAZIDE10-12.5 MG TAB
LISINOPRIL-HYDROCHLOROTHIAZIDE
LISINOPRIL-HYDROCHLOROTHIAZIDE20-12.5 MG TAB
LISINOPRIL-HYDROCHLOROTHIAZIDE
LISINOPRIL-HYDROCHLOROTHIAZIDE20-25 MG TAB
LISINOPRIL-HYDROCHLOROTHIAZIDE
2018 Trusted Health Plan Medicaid Formulary
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Antihypertensive Therapy Agents
Medication Info Common Name Drug Status Criteria
LOSARTAN POTASSIUM 100 MG TAB LOSARTAN POTASSIUM QL
LOSARTAN POTASSIUM 25 MG TAB LOSARTAN POTASSIUM QL
LOSARTAN POTASSIUM 50 MG TAB LOSARTAN POTASSIUM QL
LOSARTAN-HYDROCHLOROTHIAZIDE100-12.5 MG TAB
LOSARTAN-HYDROCHLOROTHIAZIDE
QL
LOSARTAN-HYDROCHLOROTHIAZIDE100-25 MG TAB
LOSARTAN-HYDROCHLOROTHIAZIDE
QL
LOSARTAN-HYDROCHLOROTHIAZIDE50-12.5 MG TAB
LOSARTAN-HYDROCHLOROTHIAZIDE
QL
METHYLDOPA 250 MG TABLET METHYLDOPA
METHYLDOPA 500 MG TABLET METHYLDOPA
METOPROLOL-HYDROCHLOROTHIAZIDE 100-25 MGTAB
METOPROLOL-HYDROCHLOROTHIAZIDE
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50 MGTAB
METOPROLOL-HYDROCHLOROTHIAZIDE
METOPROLOL-HYDROCHLOROTHIAZIDE 50-25 MGTAB
METOPROLOL-HYDROCHLOROTHIAZIDE
PRAZOSIN 1 MG CAPSULE PRAZOSIN HCL
PRAZOSIN 2 MG CAPSULE PRAZOSIN HCL
PRAZOSIN 5 MG CAPSULE PRAZOSIN HCL
PROPRANOLOL-HYDROCHLOROTHIAZIDE 40-25 MGTAB
PROPRANOLOL-HYDROCHLOROTHIAZID
PROPRANOLOL-HYDROCHLOROTHIAZIDE 80-25 MGTAB
PROPRANOLOL-HYDROCHLOROTHIAZID
QUINAPRIL 10 MG TABLET QUINAPRIL HCL
QUINAPRIL 20 MG TABLET QUINAPRIL HCL
QUINAPRIL 40 MG TABLET QUINAPRIL HCL
QUINAPRIL 5 MG TABLET QUINAPRIL HCL
QUINAPRIL-HYDROCHLOROTHIAZIDE10-12.5 MG TAB
QUINAPRIL-HYDROCHLOROTHIAZIDE
QUINAPRIL-HYDROCHLOROTHIAZIDE20-12.5 MG TAB
QUINAPRIL-HYDROCHLOROTHIAZIDE
QUINAPRIL-HYDROCHLOROTHIAZIDE20-25 MG TAB
QUINAPRIL-HYDROCHLOROTHIAZIDE
RAMIPRIL 1.25 MG CAPSULE RAMIPRIL
RAMIPRIL 10 MG CAPSULE RAMIPRIL
RAMIPRIL 2.5 MG CAPSULE RAMIPRIL
RAMIPRIL 5 MG CAPSULE RAMIPRIL
SILDENAFIL 10 MG/12.5 ML VIAL SILDENAFIL CITRATE QL
SILDENAFIL 20 MG TABLET SILDENAFIL QL
TEKTURNA 150 MG TABLET TEKTURNA
TEKTURNA 300 MG TABLET TEKTURNA
2018 Trusted Health Plan Medicaid Formulary
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Antihypertensive Therapy Agents
Medication Info Common Name Drug Status Criteria
TEKTURNA HCT 150-12.5 MG TAB TEKTURNA HCT
TEKTURNA HCT 150-25 MG TABLET TEKTURNA HCT
TEKTURNA HCT 300-12.5 MG TAB TEKTURNA HCT
TEKTURNA HCT 300-25 MG TABLET TEKTURNA HCT
TERAZOSIN 1 MG CAPSULE TERAZOSIN HCL
TERAZOSIN 10 MG CAPSULE TERAZOSIN HCL
TERAZOSIN 2 MG CAPSULE TERAZOSIN HCL
TERAZOSIN 5 MG CAPSULE TERAZOSIN HCL
Antineoplastic - Alkylating Agents
Medication Info Common Name Drug Status Criteria
ALKERAN 2 MG TABLET ALKERAN
CYCLOPHOSPHAMIDE 500 MG VIAL CYCLOPHOSPHAMIDE
GLEOSTINE 10 MG CAPSULE GLEOSTINE
GLEOSTINE 100 MG CAPSULE GLEOSTINE
GLEOSTINE 40 MG CAPSULE GLEOSTINE
HEXALEN 50 MG CAPSULE HEXALEN
LEUKERAN 2 MG TABLET LEUKERAN
MATULANE 50 MG CAPSULE MATULANE
MELPHALAN 2 MG TABLET MELPHALAN
MYLERAN 2 MG TABLET MYLERAN
TEMODAR 100 MG CAPSULE TEMODAR PA
TEMODAR 140 MG CAPSULE TEMODAR PA,QL
TEMODAR 180 MG CAPSULE TEMODAR PA,QL
TEMODAR 20 MG CAPSULE TEMODAR PA,QL
TEMODAR 250 MG CAPSULE TEMODAR PA,QL
TEMODAR 5 MG CAPSULE TEMODAR PA,QL
TEMOZOLOMIDE 100 MG CAPSULE TEMOZOLOMIDE PA
TEMOZOLOMIDE 140 MG CAPSULE TEMOZOLOMIDE PA
TEMOZOLOMIDE 180 MG CAPSULE TEMOZOLOMIDE PA
TEMOZOLOMIDE 20 MG CAPSULE TEMOZOLOMIDE PA
TEMOZOLOMIDE 250 MG CAPSULE TEMOZOLOMIDE PA
TEMOZOLOMIDE 5 MG CAPSULE TEMOZOLOMIDE PA
Antineoplastic - Antibody/Antibody-Drug Complexes
Medication Info Common Name Drug Status Criteria
PERJETA 420 MG/14 ML VIAL PERJETA PA
Antineoplastic - Antimetabolites
Medication Info Common Name Drug Status Criteria
CAPECITABINE 150 MG TABLET CAPECITABINE PA
CAPECITABINE 500 MG TABLET CAPECITABINE PA
FLUOROURACIL 1,000 MG/20 ML VL FLUOROURACIL
FLUOROURACIL 2,500 MG/50 ML VL FLUOROURACIL
FLUOROURACIL 2.5 GM/50 ML BTL FLUOROURACIL
FLUOROURACIL 2.5 GM/50 ML VIAL FLUOROURACIL
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Antineoplastic - Antimetabolites
Medication Info Common Name Drug Status Criteria
FLUOROURACIL 5 GM/100 ML BTL FLUOROURACIL
FLUOROURACIL 5 GM/100 ML VIAL FLUOROURACIL
FLUOROURACIL 5,000 MG/100 ML FLUOROURACIL
FLUOROURACIL 500 MG/10 ML VIAL FLUOROURACIL
HYDREA 500 MG CAPSULE HYDREA
HYDROXYUREA 500 MG CAPSULE HYDROXYUREA
MERCAPTOPURINE 50 MG TABLET MERCAPTOPURINE
TABLOID 40 MG TABLET TABLOID
XELODA 150 MG TABLET XELODA PA
XELODA 500 MG TABLET XELODA PA
Antineoplastic - Hedgehog Pathway Inhibitor
Medication Info Common Name Drug Status Criteria
ERIVEDGE 150 MG CAPSULE ERIVEDGE PA
Antineoplastic - Hormone/Hormone Antagonist Agents
Medication Info Common Name Drug Status Criteria
ANASTROZOLE 1 MG TABLET ANASTROZOLE
ARIMIDEX 1 MG TABLET ARIMIDEX
BICALUTAMIDE 50 MG TABLET BICALUTAMIDE
CASODEX 50 MG TABLET CASODEX
ELIGARD 22.5 MG SYRINGE B ELIGARD PA
ELIGARD 22.5 MG SYRINGE KIT ELIGARD PA
ELIGARD 30 MG SYRINGE B ELIGARD PA
ELIGARD 30 MG SYRINGE KIT ELIGARD PA
ELIGARD 45 MG SYRINGE B ELIGARD PA
ELIGARD 45 MG SYRINGE KIT ELIGARD PA
ELIGARD 7.5 MG SYRINGE B ELIGARD PA
ELIGARD 7.5 MG SYRINGE KIT ELIGARD PA
EMCYT 140 MG CAPSULE EMCYT
EXEMESTANE 25 MG TABLET EXEMESTANE
FARESTON 60 MG TABLET FARESTON
FLUTAMIDE 125 MG CAPSULE FLUTAMIDE
LETROZOLE 2.5 MG TABLET LETROZOLE
LEUPROLIDE 1 MG/0.2 ML VIAL LEUPROLIDE ACETATE PA
LEUPROLIDE 2WK 1 MG/0.2 ML KIT LEUPROLIDE ACETATE PA
LEUPROLIDE 2WK 14 MG/2.8 ML KT LEUPROLIDE ACETATE PA
LEUPROLIDE 2WK 14 MG/2.8 ML VL LEUPROLIDE ACETATE PA
LUPRON DEPOT 22.5 MG 3MO KIT LUPRON DEPOT PA
LUPRON DEPOT 45 MG 6MO KIT LUPRON DEPOT PA
LUPRON DEPOT 7.5 MG KIT LUPRON DEPOT PA
LUPRON DEPOT-4 MONTH KIT LUPRON DEPOT PA
LYSODREN 500 MG TABLET LYSODREN
MEGESTROL 20 MG TABLET MEGESTROL ACETATE
MEGESTROL 40 MG TABLET MEGESTROL ACETATE
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Antineoplastic - Hormone/Hormone Antagonist Agents
Medication Info Common Name Drug Status Criteria
NILUTAMIDE 150 MG TABLET NILUTAMIDE
TAMOXIFEN 10 MG TABLET TAMOXIFEN CITRATE
TAMOXIFEN 20 MG TABLET TAMOXIFEN CITRATE
TRELSTAR 11.25 MG SYRINGE TRELSTAR PA
TRELSTAR 11.25 MG VIAL TRELSTAR PA
TRELSTAR 22.5 MG SYRINGE TRELSTAR PA
TRELSTAR 22.5 MG VIAL TRELSTAR PA
TRELSTAR 3.75 MG SYRINGE TRELSTAR PA
TRELSTAR 3.75 MG VIAL TRELSTAR PA
XTANDI 40 MG CAPSULE XTANDI PA
ZOLADEX 10.8 MG IMPLANT SYRN ZOLADEX PA
ZOLADEX 3.6 MG IMPLANT SYRN ZOLADEX PA
Antineoplastic - Immunomodulators
Medication Info Common Name Drug Status Criteria
INTRON A 10 MILLION UNITS VIAL INTRON A
INTRON A 18 MILLION UNIT/3 ML INTRON A
INTRON A 18 MILLION UNITS VIAL INTRON A
INTRON A 25 MILLION UNIT/2.5 ML INTRON A
INTRON A 50 MILLION UNITS VIAL INTRON A
Antineoplastic - Mast Cell Stabilizers
Medication Info Common Name Drug Status Criteria
CROMOLYN 100 MG/5 ML ORALCONC
CROMOLYN SODIUM
Antineoplastic - Metal Complexes
Medication Info Common Name Drug Status Criteria
OXALIPLATIN 100 MG VIAL OXALIPLATIN
OXALIPLATIN 100 MG/20 ML VIAL OXALIPLATIN
Antineoplastic - Retinoids and Retinoid Receptor Agonists
Medication Info Common Name Drug Status Criteria
BEXAROTENE 75 MG CAPSULE BEXAROTENE
TARGRETIN 75 MG CAPSULE TARGRETIN
Antineoplastic - Systemic Enzyme Inhibitors
Medication Info Common Name Drug Status Criteria
BOSULIF 100 MG TABLET BOSULIF PA
BOSULIF 500 MG TABLET BOSULIF PA
COMETRIQ 100 MG DAILY-DOSE PK COMETRIQ PA
COMETRIQ 140 MG DAILY-DOSE PK COMETRIQ PA
COMETRIQ 60 MG DAILY-DOSE PACK COMETRIQ PA
GLEEVEC 100 MG TABLET GLEEVEC PA,QL
GLEEVEC 400 MG TABLET GLEEVEC PA,QL
ICLUSIG 15 MG TABLET ICLUSIG PA
ICLUSIG 45 MG TABLET ICLUSIG PA
IMATINIB MESYLATE 100 MG TAB IMATINIB MESYLATE PA,QL
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Antineoplastic - Systemic Enzyme Inhibitors
Medication Info Common Name Drug Status Criteria
IMATINIB MESYLATE 400 MG TAB IMATINIB MESYLATE PA,QL
JAKAFI 10 MG TABLET JAKAFI PA
JAKAFI 15 MG TABLET JAKAFI PA
JAKAFI 20 MG TABLET JAKAFI PA
JAKAFI 25 MG TABLET JAKAFI PA
JAKAFI 5 MG TABLET JAKAFI PA
TARCEVA 100 MG TABLET TARCEVA PA,QL,SP Prior Authorization Required; Limited to30 tablets per 30 days.
TARCEVA 150 MG TABLET TARCEVA PA,QL,SP Prior Authorization Required; Limited to30 tablets per 30 days.
TARCEVA 25 MG TABLET TARCEVA PA,QL,SP Prior Authorization Required; Limited to90 tablets per 30 days.
XALKORI 200 MG CAPSULE XALKORI PA
XALKORI 250 MG CAPSULE XALKORI PA
ZELBORAF 240 MG TABLET ZELBORAF PA
Antineoplastic - Topoisomerase Inhibitors
Medication Info Common Name Drug Status Criteria
ETOPOSIDE 50 MG CAPSULE ETOPOSIDE
HYCAMTIN 0.25 MG CAPSULE HYCAMTIN PA
HYCAMTIN 1 MG CAPSULE HYCAMTIN PA
Antiparasitics
Medication Info Common Name Drug Status Criteria
ATOVAQUONE-PROGUANIL 250-100MG TABLET
ATOVAQUONE-PROGUANILHCL
ATOVAQUONE-PROGUANIL 62.5-25 ATOVAQUONE-PROGUANILHCL
CHLOROQUINE PH 250 MG TABLET CHLOROQUINE PHOSPHATE
CHLOROQUINE PH 500 MG TABLET CHLOROQUINE PHOSPHATE
HYDROXYCHLOROQUINE 200 MGTAB
HYDROXYCHLOROQUINESULFATE
MEFLOQUINE HCL 250 MG TABLET MEFLOQUINE HCL
Antiparkinson Therapy
Medication Info Common Name Drug Status Criteria
AMANTADINE 100 MG CAPSULE AMANTADINE
BENZTROPINE MES 0.5 MG TAB BENZTROPINE MESYLATE
BENZTROPINE MES 1 MG TABLET BENZTROPINE MESYLATE
BENZTROPINE MES 2 MG TABLET BENZTROPINE MESYLATE
BROMOCRIPTINE 2.5 MG TABLET BROMOCRIPTINE MESYLATE
BROMOCRIPTINE 5 MG CAPSULE BROMOCRIPTINE MESYLATE
CARBIDOPA-LEVODOPA 10-100 TAB CARBIDOPA-LEVODOPA
CARBIDOPA-LEVODOPA 25-100 TAB CARBIDOPA-LEVODOPA
CARBIDOPA-LEVODOPA 25-250 TAB CARBIDOPA-LEVODOPA
CARBIDOPA-LEVODOPA-ENTA 100MG
CARBIDOPA-LEVODOPA-ENTACAPONE
CARBIDOPA-LEVODOPA-ENTA 125MG
CARBIDOPA-LEVODOPA-ENTACAPONE
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Antiparkinson Therapy
Medication Info Common Name Drug Status Criteria
CARBIDOPA-LEVODOPA-ENTA 150MG
CARBIDOPA-LEVODOPA-ENTACAPONE
CARBIDOPA-LEVODOPA-ENTA 200MG
CARBIDOPA-LEVODOPA-ENTACAPONE
CARBIDOPA-LEVODOPA-ENTA 50 MG CARBIDOPA-LEVODOPA-ENTACAPONE
CARBIDOPA-LEVODOPA-ENTA 75 MG CARBIDOPA-LEVODOPA-ENTACAPONE
ENTACAPONE 200 MG TABLET ENTACAPONE
PRAMIPEXOLE 0.125 MG TABLET PRAMIPEXOLEDIHYDROCHLORIDE
PRAMIPEXOLE 0.25 MG TABLET PRAMIPEXOLEDIHYDROCHLORIDE
PRAMIPEXOLE 0.5 MG TABLET PRAMIPEXOLEDIHYDROCHLORIDE
PRAMIPEXOLE 0.75 MG TABLET PRAMIPEXOLEDIHYDROCHLORIDE
PRAMIPEXOLE 1 MG TABLET PRAMIPEXOLEDIHYDROCHLORIDE
PRAMIPEXOLE 1.5 MG TABLET PRAMIPEXOLEDIHYDROCHLORIDE
PRAMIPEXOLE ER 0.375 MG TABLET PRAMIPEXOLE ER
PRAMIPEXOLE ER 0.75 MG TABLET PRAMIPEXOLE ER
PRAMIPEXOLE ER 1.5 MG TABLET PRAMIPEXOLE ER
PRAMIPEXOLE ER 2.25 MG TABLET PRAMIPEXOLE ER
PRAMIPEXOLE ER 3 MG TABLET PRAMIPEXOLE ER
PRAMIPEXOLE ER 3.75 MG TABLET PRAMIPEXOLE ER
PRAMIPEXOLE ER 4.5 MG TABLET PRAMIPEXOLE ER
ROPINIROLE HCL 0.25 MG TABLET ROPINIROLE HCL
ROPINIROLE HCL 0.5 MG TABLET ROPINIROLE HCL
ROPINIROLE HCL 1 MG TABLET ROPINIROLE HCL
ROPINIROLE HCL 2 MG TABLET ROPINIROLE HCL
ROPINIROLE HCL 3 MG TABLET ROPINIROLE HCL
ROPINIROLE HCL 4 MG TABLET ROPINIROLE HCL
ROPINIROLE HCL 5 MG TABLET ROPINIROLE HCL
ROPINIROLE HCL ER 12 MG TABLET ROPINIROLE ER
ROPINIROLE HCL ER 2 MG TABLET ROPINIROLE ER
ROPINIROLE HCL ER 4 MG TABLET ROPINIROLE ER
ROPINIROLE HCL ER 6 MG TABLET ROPINIROLE ER
ROPINIROLE HCL ER 8 MG TABLET ROPINIROLE ER
SELEGILINE HCL 5 MG CAPSULE SELEGILINE HCL
SELEGILINE HCL 5 MG TABLET SELEGILINE HCL
TRIHEXYPHENIDYL 2 MG TABLET TRIHEXYPHENIDYL HCL
TRIHEXYPHENIDYL 2 MG/5 ML ELX TRIHEXYPHENIDYL HCL
TRIHEXYPHENIDYL 5 MG TABLET TRIHEXYPHENIDYL HCL
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Antiprotozoal-Antibacterial Agents
Medication Info Common Name Drug Status Criteria
METRONIDAZOLE 250 MG TABLET METRONIDAZOLE
METRONIDAZOLE 375 MG CAPSULE METRONIDAZOLE
METRONIDAZOLE 500 MG TABLET METRONIDAZOLE
METRONIDAZOLE 500 MG/100 ML METRONIDAZOLE
Antipsychotics (Neuroleptics)
Medication Info Common Name Drug Status Criteria
CLOZAPINE 100 MG TABLET CLOZAPINE QL
CLOZAPINE 200 MG TABLET CLOZAPINE QL
CLOZAPINE 25 MG TABLET CLOZAPINE QL
CLOZAPINE 50 MG TABLET CLOZAPINE QL
CLOZAPINE ODT 100 MG TABLET CLOZAPINE ODT QL
CLOZAPINE ODT 12.5 MG TABLET CLOZAPINE ODT
CLOZAPINE ODT 150 MG TABLET CLOZAPINE ODT
CLOZAPINE ODT 200 MG TABLET CLOZAPINE ODT QL
CLOZAPINE ODT 25 MG TABLET CLOZAPINE ODT QL
FLUPHENAZINE 1 MG TABLET FLUPHENAZINE HCL
FLUPHENAZINE 10 MG TABLET FLUPHENAZINE HCL
FLUPHENAZINE 2.5 MG TABLET FLUPHENAZINE HCL
FLUPHENAZINE 2.5 MG/5 ML ELIX FLUPHENAZINE HCL
FLUPHENAZINE 2.5 MG/ML VIAL FLUPHENAZINE HCL
FLUPHENAZINE 5 MG TABLET FLUPHENAZINE HCL
FLUPHENAZINE 5 MG/ML CONC FLUPHENAZINE HCL
FLUPHENAZINE DEC 125 MG/5 ML FLUPHENAZINE DECANOATE
HALOPERIDOL 0.5 MG TABLET HALOPERIDOL
HALOPERIDOL 1 MG TABLET HALOPERIDOL
HALOPERIDOL 10 MG TABLET HALOPERIDOL
HALOPERIDOL 2 MG TABLET HALOPERIDOL
HALOPERIDOL 20 MG TABLET HALOPERIDOL
HALOPERIDOL 5 MG TABLET HALOPERIDOL
HALOPERIDOL 5 MG/ML AMPUL HALOPERIDOL
HALOPERIDOL DEC 100 MG/ML AMP HALOPERIDOL DECANOATE100
HALOPERIDOL DEC 100 MG/ML VIAL HALOPERIDOL DECANOATE
HALOPERIDOL DEC 50 MG/ML VIAL HALOPERIDOL DECANOATE
HALOPERIDOL DEC 500 MG/5 ML VL HALOPERIDOL DECANOATE
HALOPERIDOL DECAN 50 MG/ML AMP HALOPERIDOL DECANOATE
HALOPERIDOL LAC 2 MG/ML CONC HALOPERIDOL LACTATE
HALOPERIDOL LAC 5 MG/ML VIAL HALOPERIDOL LACTATE
HALOPERIDOL LAC 50 MG/10 ML VL HALOPERIDOL LACTATE
INVEGA SUSTENNA 117 MG/0.75 ML INVEGA SUSTENNA
INVEGA SUSTENNA 156 MG/ML SYRG INVEGA SUSTENNA
INVEGA SUSTENNA 234 MG/1.5 ML INVEGA SUSTENNA
INVEGA SUSTENNA 39 MG/0.25 ML INVEGA SUSTENNA
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Antipsychotics (Neuroleptics)
Medication Info Common Name Drug Status Criteria
INVEGA SUSTENNA 78 MG/0.5 ML INVEGA SUSTENNA
OLANZAPINE 10 MG TABLET OLANZAPINE
OLANZAPINE 10 MG VIAL OLANZAPINE QL
OLANZAPINE 15 MG TABLET OLANZAPINE
OLANZAPINE 2.5 MG TABLET OLANZAPINE
OLANZAPINE 20 MG TABLET OLANZAPINE
OLANZAPINE 5 MG TABLET OLANZAPINE
OLANZAPINE 7.5 MG TABLET OLANZAPINE
OLANZAPINE ODT 10 MG TABLET OLANZAPINE ODT QL
OLANZAPINE ODT 15 MG TABLET OLANZAPINE ODT QL
OLANZAPINE ODT 20 MG TABLET OLANZAPINE ODT QL
OLANZAPINE ODT 5 MG TABLET OLANZAPINE ODT QL
PERPHENAZINE 16 MG TABLET PERPHENAZINE
PERPHENAZINE 2 MG TABLET PERPHENAZINE
PERPHENAZINE 4 MG TABLET PERPHENAZINE
PERPHENAZINE 8 MG TABLET PERPHENAZINE
PROCHLORPERAZINE 10 MG TAB PROCHLORPERAZINEMALEATE
PROCHLORPERAZINE 5 MG TABLET PROCHLORPERAZINEMALEATE
QUETIAPINE ER 150 MG TABLET QUETIAPINE FUMARATE ER QL
QUETIAPINE ER 200 MG TABLET QUETIAPINE FUMARATE ER QL
QUETIAPINE ER 300 MG TABLET QUETIAPINE FUMARATE ER QL
QUETIAPINE ER 400 MG TABLET QUETIAPINE FUMARATE ER QL
QUETIAPINE ER 50 MG TABLET QUETIAPINE FUMARATE ER QL
QUETIAPINE FUMARATE 100 MG TAB QUETIAPINE FUMARATE QL
QUETIAPINE FUMARATE 200 MG TAB QUETIAPINE FUMARATE QL
QUETIAPINE FUMARATE 25 MG TAB QUETIAPINE FUMARATE QL
QUETIAPINE FUMARATE 300 MG TAB QUETIAPINE FUMARATE QL
QUETIAPINE FUMARATE 400 MG TAB QUETIAPINE FUMARATE QL
QUETIAPINE FUMARATE 50 MG TAB QUETIAPINE FUMARATE QL
RISPERIDONE 0.25 MG TABLET RISPERIDONE
RISPERIDONE 0.5 MG TABLET RISPERIDONE
RISPERIDONE 1 MG TABLET RISPERIDONE
RISPERIDONE 2 MG TABLET RISPERIDONE
RISPERIDONE 3 MG TABLET RISPERIDONE
RISPERIDONE 4 MG TABLET RISPERIDONE
THIOTHIXENE 1 MG CAPSULE THIOTHIXENE
THIOTHIXENE 10 MG CAPSULE THIOTHIXENE
THIOTHIXENE 2 MG CAPSULE THIOTHIXENE
THIOTHIXENE 5 MG CAPSULE THIOTHIXENE
TRIFLUOPERAZINE 1 MG TABLET TRIFLUOPERAZINE HCL
TRIFLUOPERAZINE 10 MG TABLET TRIFLUOPERAZINE HCL
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Antipsychotics (Neuroleptics)
Medication Info Common Name Drug Status Criteria
TRIFLUOPERAZINE 2 MG TABLET TRIFLUOPERAZINE HCL
TRIFLUOPERAZINE 5 MG TABLET TRIFLUOPERAZINE HCL
ZIPRASIDONE HCL 20 MG CAPSULE ZIPRASIDONE HCL
ZIPRASIDONE HCL 40 MG CAPSULE ZIPRASIDONE HCL
ZIPRASIDONE HCL 60 MG CAPSULE ZIPRASIDONE HCL
ZIPRASIDONE HCL 80 MG CAPSULE ZIPRASIDONE HCL
Antitussives
Medication Info Common Name Drug Status Criteria
BENZONATATE 100 MG CAPSULE BENZONATATE
BENZONATATE 150 MG CAPSULE BENZONATATE
BENZONATATE 200 MG CAPSULE BENZONATATE
Antivirals
Medication Info Common Name Drug Status Criteria
ACYCLOVIR 200 MG CAPSULE ACYCLOVIR
ACYCLOVIR 200 MG/5 ML SUSP ACYCLOVIR
ACYCLOVIR 400 MG TABLET ACYCLOVIR
ACYCLOVIR 800 MG TABLET ACYCLOVIR
ADEFOVIR DIPIVOXIL 10 MG TAB ADEFOVIR DIPIVOXIL
APTIVUS 100 MG/ML SOLUTION APTIVUS PA
APTIVUS 250 MG CAPSULE APTIVUS PA
EPCLUSA 400 MG-100 MG TABLET EPCLUSA PA,SP
EPIVIR HBV 100 MG TABLET EPIVIR HBV
EPIVIR HBV 25 MG/5 ML SOLN EPIVIR HBV
FAMCICLOVIR 125 MG TABLET FAMCICLOVIR
FAMCICLOVIR 250 MG TABLET FAMCICLOVIR
FAMCICLOVIR 500 MG TABLET FAMCICLOVIR
GANCICLOVIR 500 MG VIAL GANCICLOVIR SODIUM
HEPSERA 10 MG TABLET HEPSERA PA
MAVYRET 100-40 MG TABLET MAVYRET PA,SP Prior Authorization Required
OSELTAMIVIR PHOS 30 MG CAPSULE OSELTAMIVIR PHOSPHATE
OSELTAMIVIR PHOS 45 MG CAPSULE OSELTAMIVIR PHOSPHATE
OSELTAMIVIR PHOS 75 MG CAPSULE OSELTAMIVIR PHOSPHATE
PEGASYS 180 MCG/0.5 ML SYRINGE PEGASYS PA
PEGASYS 180 MCG/ML VIAL PEGASYS PA
PEGASYS PROCLICK 135 MCG/0.5 ML PEGASYS PROCLICK PA
PEGASYS PROCLICK 180 MCG/0.5 PEGASYS PROCLICK PA
PEGINTRON 50 MCG KIT PEGINTRON REDIPEN PA
PEGINTRON REDIPEN 120 MCG PEGINTRON REDIPEN PA
REBETOL 40 MG/ML SOLUTION REBETOL PA
RELENZA 5 MG DISKHALER RELENZA
RIBAVIRIN 200 MG CAPSULE RIBAVIRIN PA
RIBAVIRIN 200 MG TABLET RIBAVIRIN PA
RIBAVIRIN 6 GM INHALATION VIAL RIBAVIRIN PA
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Antivirals
Medication Info Common Name Drug Status Criteria
RIMANTADINE HCL 100 MG TABLET RIMANTADINE HCL
TAMIFLU 30 MG CAPSULE TAMIFLU
TAMIFLU 45 MG CAPSULE TAMIFLU
TAMIFLU 6 MG/ML SUSPENSION TAMIFLU
TAMIFLU 75 MG CAPSULE TAMIFLU
TRUVADA 100 MG-150 MG TABLET TRUVADA PA,SP Prior Authorization Required
TRUVADA 133 MG-200 MG TABLET TRUVADA PA,SP Prior Authorization Required
TRUVADA 167 MG-250 MG TABLET TRUVADA PA,SP Prior Authorization Required
TRUVADA 200 MG-300 MG TABLET TRUVADA PA,SP Prior Authorization Required
VALACYCLOVIR HCL 1 GRAM TABLET VALACYCLOVIR
VALACYCLOVIR HCL 500 MG TABLET VALACYCLOVIR
Appetite Stimulants
Medication Info Common Name Drug Status Criteria
MEGESTROL 800 MG/20 ML SUSP MEGESTROL ACETATE
MEGESTROL ACET 40 MG/ML SUSP MEGESTROL ACETATE
MEGESTROL ACET 400 MG/10 ML MEGESTROL ACETATE
MEGESTROL ACET 800 MG/20 ML MEGESTROL ACETATE
Asthma/COPD Therapy Agents
Medication Info Common Name Drug Status Criteria
ADVAIR 100-50 DISKUS ADVAIR DISKUS
ADVAIR 250-50 DISKUS ADVAIR DISKUS
ADVAIR 500-50 DISKUS ADVAIR DISKUS
ADVAIR HFA 115-21 MCG INHALER ADVAIR HFA
ADVAIR HFA 230-21 MCG INHALER ADVAIR HFA
ADVAIR HFA 45-21 MCG INHALER ADVAIR HFA
ALBUTEROL 15 MG/3 ML SOLUTION(CMPD-RX)
ALBUTEROL SULFATE Ventolin HFA is the preferred AlbuterolSulfate Inhaler.
ALBUTEROL 2.5 MG/0.5 ML SOL ALBUTEROL SULFATE Ventolin HFA is the preferred AlbuterolSulfate Inhaler.
ALBUTEROL 20 MG/4 ML SOLUTION(CMPD-RX)
ALBUTEROL SULFATE Ventolin HFA is the preferred AlbuterolSulfate Inhaler.
ALBUTEROL 5 MG/ML SOLUTION ALBUTEROL SULFATE Ventolin HFA is the preferred AlbuterolSulfate Inhaler.
ALBUTEROL SUL 0.63 MG/3 ML SOL ALBUTEROL SULFATE Ventolin HFA is the preferred AlbuterolSulfate Inhaler.
ALBUTEROL SUL 1.25 MG/3 ML SOL ALBUTEROL SULFATE Ventolin HFA is the preferred AlbuterolSulfate Inhaler.
ALBUTEROL SUL 2.5 MG/3 ML SOLN ALBUTEROL SULFATE Ventolin HFA is the preferred AlbuterolSulfate Inhaler.
ALBUTEROL SULF 2 MG/5 ML SYRUP ALBUTEROL SULFATE
ALBUTEROL SULFATE 2 MG TAB ALBUTEROL SULFATE
ALBUTEROL SULFATE 4 MG TAB ALBUTEROL SULFATE
ALBUTEROL SULFATE ER 4 MG TAB ALBUTEROL SULFATE
ALBUTEROL SULFATE ER 8 MG TAB ALBUTEROL SULFATE
ATROVENT HFA INHALER ATROVENT HFA
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Asthma/COPD Therapy Agents
Medication Info Common Name Drug Status Criteria
BUDESONIDE 0.25 MG/2 ML SUSP BUDESONIDE
BUDESONIDE 0.5 MG/2 ML SUSP BUDESONIDE
COMBIVENT RESPIMAT INHAL SPRAY COMBIVENT RESPIMAT
CROMOLYN 20 MG/2 ML NEB SOLN CROMOLYN SODIUM
DULERA 100 MCG/5 MCG INHALER DULERA
DULERA 200 MCG/5 MCG INHALER DULERA
FLOVENT 100 MCG DISKUS FLOVENT DISKUS
FLOVENT 250 MCG DISKUS FLOVENT DISKUS
FLOVENT 50 MCG DISKUS FLOVENT DISKUS
FLOVENT HFA 110 MCG INHALER FLOVENT HFA
FLOVENT HFA 220 MCG INHALER FLOVENT HFA
FLOVENT HFA 44 MCG INHALER FLOVENT HFA
FLUTICASONE-SALMETEROL 113-14 FLUTICASONE-SALMETEROL
FLUTICASONE-SALMETEROL 232-14 FLUTICASONE-SALMETEROL
FLUTICASONE-SALMETEROL 55-14 FLUTICASONE-SALMETEROL
FORADIL AEROLIZER 12 MCG CAP FORADIL
INCRUSE ELLIPTA 62.5 MCG INH INCRUSE ELLIPTA
IPRATROPIUM BR 0.02% SOLN IPRATROPIUM BROMIDE
LEVALBUTEROL 0.31 MG/3 ML SOL LEVALBUTEROL HCL
LEVALBUTEROL 0.63 MG/3 ML SOL LEVALBUTEROL HCL
LEVALBUTEROL 1.25 MG/3 ML SOL LEVALBUTEROL HCL
LEVALBUTEROL CONC 1.25 MG/0.5 LEVALBUTEROLCONCENTRATE
LEVALBUTEROL TAR HFA 45 MCGINH
LEVALBUTEROL TARTRATEHFA
MONTELUKAST SOD 10 MG TABLET MONTELUKAST SODIUM
MONTELUKAST SOD 4 MGGRANULES
MONTELUKAST SODIUM
MONTELUKAST SOD 4 MG TAB CHEW MONTELUKAST SODIUM
MONTELUKAST SOD 5 MG TAB CHEW MONTELUKAST SODIUM
PROAIR HFA 90 MCG INHALER PROAIR HFA Ventolin HFA is the preferred AlbuterolSulfate Inhaler.
PROVENTIL HFA 90 MCG INHALER PROVENTIL HFA Ventolin HFA is the preferred AlbuterolSulfate Inhaler.
PULMICORT 180 MCG FLEXHALER PULMICORT FLEXHALER
PULMICORT 90 MCG FLEXHALER PULMICORT FLEXHALER
SEREVENT DISKUS 50 MCG SEREVENT DISKUS
SPIRIVA 18 MCG CP-HANDIHALER SPIRIVA
SYMBICORT 160-4.5 MCG INHALER SYMBICORT
SYMBICORT 80-4.5 MCG INHALER SYMBICORT
TERBUTALINE SULF 1 MG/ML VIAL TERBUTALINE SULFATE
TERBUTALINE SULFATE 2.5 MG TAB TERBUTALINE SULFATE
TERBUTALINE SULFATE 5 MG TAB TERBUTALINE SULFATE
THEOPHYLLINE 200 MG/100 ML D5W THEOPHYLLINE IN 5%DEXTROSE
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Asthma/COPD Therapy Agents
Medication Info Common Name Drug Status Criteria
THEOPHYLLINE 200 MG/50 ML D5W THEOPHYLLINE IN 5%DEXTROSE
THEOPHYLLINE 400 MG/250 ML D5W THEOPHYLLINE IN 5%DEXTROSE
THEOPHYLLINE 400 MG/500 ML D5W THEOPHYLLINE IN 5%DEXTROSE
THEOPHYLLINE 80 MG/15 ML SOLN THEOPHYLLINE
THEOPHYLLINE 800 MG/250 ML D5W THEOPHYLLINE IN 5%DEXTROSE
THEOPHYLLINE ER 100 MG TABLET THEOPHYLLINE ANHYDROUS
THEOPHYLLINE ER 200 MG TABLET THEOPHYLLINE ANHYDROUS
THEOPHYLLINE ER 300 MG TAB THEOPHYLLINE ANHYDROUS
THEOPHYLLINE ER 400 MG TABLET THEOPHYLLINE
THEOPHYLLINE ER 450 MG TAB THEOPHYLLINE ANHYDROUS
THEOPHYLLINE ER 600 MG TABLET THEOPHYLLINE
VENTOLIN HFA 90 MCG INHALER VENTOLIN HFA Ventolin HFA is the preferred AlbuterolSulfate Inhaler.
XOLAIR 150 MG VIAL XOLAIR PA
XOPENEX 0.31 MG/3 ML SOLUTION XOPENEX Ventolin HFA is the preferred AlbuterolSulfate Inhaler.
XOPENEX 0.63 MG/3 ML SOLUTION XOPENEX
XOPENEX 1.25 MG/3 ML SOLUTION XOPENEX
XOPENEX CONC 1.25 MG/0.5 ML XOPENEX CONCENTRATE
XOPENEX HFA 45 MCG INHALER XOPENEX HFA
ZAFIRLUKAST 10 MG TABLET ZAFIRLUKAST
ZAFIRLUKAST 20 MG TABLET ZAFIRLUKAST
Attention Deficit-Hyperact Disorder (ADHD) Therapy
Medication Info Common Name Drug Status Criteria
CLONIDINE HCL ER 0.1 MG TABLET CLONIDINE HCL ER
DEXMETHYLPHENIDATE 10 MG TAB DEXMETHYLPHENIDATE HCL
DEXMETHYLPHENIDATE 2.5 MG TAB DEXMETHYLPHENIDATE HCL
DEXMETHYLPHENIDATE 5 MG TAB DEXMETHYLPHENIDATE HCL
DEXMETHYLPHENIDATE ER 10 MGCP
DEXMETHYLPHENIDATE HCLER
DEXMETHYLPHENIDATE ER 15 MGCP
DEXMETHYLPHENIDATE HCLER
DEXMETHYLPHENIDATE ER 20 MGCP
DEXMETHYLPHENIDATE HCLER
DEXMETHYLPHENIDATE ER 25 MGCP
DEXMETHYLPHENIDATE HCLER
DEXMETHYLPHENIDATE ER 30 MGCP
DEXMETHYLPHENIDATE HCLER
DEXMETHYLPHENIDATE ER 35 MGCP
DEXMETHYLPHENIDATE HCLER
DEXMETHYLPHENIDATE ER 40 MGCP
DEXMETHYLPHENIDATE HCLER
DEXMETHYLPHENIDATE ER 5 MGCAP
DEXMETHYLPHENIDATE HCLER
2018 Trusted Health Plan Medicaid Formulary
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Attention Deficit-Hyperact Disorder (ADHD) Therapy
Medication Info Common Name Drug Status Criteria
GUANFACINE HCL ER 1 MG TABLET GUANFACINE HCL ER
GUANFACINE HCL ER 2 MG TABLET GUANFACINE HCL ER
GUANFACINE HCL ER 3 MG TABLET GUANFACINE HCL ER
GUANFACINE HCL ER 4 MG TABLET GUANFACINE HCL ER
METHYLPHENIDATE 10 MG TABLET METHYLPHENIDATE HCL
METHYLPHENIDATE 20 MG TABLET METHYLPHENIDATE HCL
METHYLPHENIDATE 5 MG TABLET METHYLPHENIDATE HCL
METHYLPHENIDATE ER 10 MG TAB METHYLPHENIDATE ER
METHYLPHENIDATE ER 18 MG TAB METHYLPHENIDATE ER
METHYLPHENIDATE ER 20 MG CAP METHYLPHENIDATE ER
METHYLPHENIDATE ER 20 MG TAB METHYLPHENIDATE ER
METHYLPHENIDATE ER 27 MG TAB METHYLPHENIDATE ER
METHYLPHENIDATE ER 30 MG CAP METHYLPHENIDATE ER
METHYLPHENIDATE ER 36 MG TAB METHYLPHENIDATE ER
METHYLPHENIDATE ER 40 MG CAP METHYLPHENIDATE ER
METHYLPHENIDATE ER 54 MG TAB METHYLPHENIDATE ER
METHYLPHENIDATE LA 20 MG CAP METHYLPHENIDATE LA
METHYLPHENIDATE LA 30 MG CAP METHYLPHENIDATE LA
METHYLPHENIDATE LA 40 MG CAP METHYLPHENIDATE LA
RITALIN LA 20 MG CAPSULE RITALIN LA
Beta Adrenergic Blockers
Medication Info Common Name Drug Status Criteria
ATENOLOL 100 MG TABLET ATENOLOL
ATENOLOL 25 MG TABLET ATENOLOL
ATENOLOL 50 MG TABLET ATENOLOL
BISOPROLOL FUMARATE 10 MG TAB BISOPROLOL FUMARATE
BISOPROLOL FUMARATE 5 MG TAB BISOPROLOL FUMARATE
CARVEDILOL 12.5 MG TABLET CARVEDILOL QL
CARVEDILOL 25 MG TABLET CARVEDILOL QL
CARVEDILOL 3.125 MG TABLET CARVEDILOL QL
CARVEDILOL 6.25 MG TABLET CARVEDILOL QL
LABETALOL HCL 100 MG TABLET LABETALOL HCL
LABETALOL HCL 100 MG/20 ML VL LABETALOL HCL
LABETALOL HCL 20 MG/4 ML CRPJ LABETALOL HCL
LABETALOL HCL 20 MG/4 ML SYR LABETALOL HCL
LABETALOL HCL 20 MG/4 MLSYRINGE (CMPD-RX)
LABETALOL HCL
LABETALOL HCL 200 MG TABLET LABETALOL HCL
LABETALOL HCL 200 MG/40 ML VL LABETALOL HCL
LABETALOL HCL 25 MG/5 ML SYR LABETALOL HCL
LABETALOL HCL 25 MG/5 MLSYRINGE (CMPD-RX)
LABETALOL HCL
LABETALOL HCL 300 MG TABLET LABETALOL HCL
2018 Trusted Health Plan Medicaid Formulary
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Beta Adrenergic Blockers
Medication Info Common Name Drug Status Criteria
LABETALOL HCL 50 MG/10 MLSYRINGE (CMPD-RX)
LABETALOL HCL
LABETALOL HCL 50 MG/10 ML SYRN LABETALOL HCL
METOPROLOL SUCC ER 100 MG TAB METOPROLOL SUCCINATE
METOPROLOL SUCC ER 200 MG TAB METOPROLOL SUCCINATE
METOPROLOL SUCC ER 25 MG TAB METOPROLOL SUCCINATE
METOPROLOL SUCC ER 50 MG TAB METOPROLOL SUCCINATE
METOPROLOL TART 5 MG/5 ML AMP METOPROLOL TARTRATE
METOPROLOL TART 5 MG/5 ML VIAL METOPROLOL TARTRATE
METOPROLOL TARTRATE 100 MGTAB
METOPROLOL TARTRATE
METOPROLOL TARTRATE 25 MG TAB METOPROLOL TARTRATE
METOPROLOL TARTRATE 50 MG TAB METOPROLOL TARTRATE
NADOLOL 20 MG TABLET NADOLOL
NADOLOL 40 MG TABLET NADOLOL
NADOLOL 80 MG TABLET NADOLOL
PROPRANOLOL 1 MG/ML VIAL PROPRANOLOL HCL
PROPRANOLOL 10 MG TABLET PROPRANOLOL HCL
PROPRANOLOL 20 MG TABLET PROPRANOLOL HCL
PROPRANOLOL 20 MG/5 ML SOLN PROPRANOLOL HCL
PROPRANOLOL 40 MG TABLET PROPRANOLOL HCL
PROPRANOLOL 40 MG/5 ML SOLN PROPRANOLOL HCL
PROPRANOLOL 60 MG TABLET PROPRANOLOL HCL
PROPRANOLOL 80 MG TABLET PROPRANOLOL HCL
PROPRANOLOL ER 120 MG CAPSULE PROPRANOLOL HCL ER
PROPRANOLOL ER 160 MG CAPSULE PROPRANOLOL HCL ER
PROPRANOLOL ER 60 MG CAPSULE PROPRANOLOL HCL ER
PROPRANOLOL ER 80 MG CAPSULE PROPRANOLOL HCL ER
TIMOLOL MALEATE 10 MG TABLET TIMOLOL MALEATE
TIMOLOL MALEATE 20 MG TABLET TIMOLOL MALEATE
TIMOLOL MALEATE 5 MG TABLET TIMOLOL MALEATE
Bipolar Therapy Agents
Medication Info Common Name Drug Status Criteria
ABILIFY 10 MG TABLET ABILIFY PA
ABILIFY 15 MG TABLET ABILIFY PA
ABILIFY 2 MG TABLET ABILIFY PA
ABILIFY 20 MG TABLET ABILIFY PA
ABILIFY 30 MG TABLET ABILIFY PA
ABILIFY 5 MG TABLET ABILIFY PA
ARIPIPRAZOLE 10 MG TABLET ARIPIPRAZOLE
ARIPIPRAZOLE 15 MG TABLET ARIPIPRAZOLE
ARIPIPRAZOLE 2 MG TABLET ARIPIPRAZOLE
ARIPIPRAZOLE 20 MG TABLET ARIPIPRAZOLE
2018 Trusted Health Plan Medicaid Formulary
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Bipolar Therapy Agents
Medication Info Common Name Drug Status Criteria
ARIPIPRAZOLE 30 MG TABLET ARIPIPRAZOLE
ARIPIPRAZOLE 5 MG TABLET ARIPIPRAZOLE
LITHIUM CARBONATE 150 MG CAP LITHIUM CARBONATE
LITHIUM CARBONATE 300 MG CAP LITHIUM CARBONATE
LITHIUM CARBONATE 300 MG TAB LITHIUM CARBONATE
LITHIUM CARBONATE 600 MG CAP LITHIUM CARBONATE
LITHIUM CARBONATE ER 300 MG TB LITHIUM CARBONATE ER
LITHIUM CARBONATE ER 450 MG TB LITHIUM CARBONATE ER
Blood Albumin and Plasma Proteins
Medication Info Common Name Drug Status Criteria
CINRYZE 500 UNIT VIAL CINRYZE PA
Bradykinin B2 Receptor Antagonists
Medication Info Common Name Drug Status Criteria
FIRAZYR 30 MG/3 ML SYRINGE FIRAZYR PA
Calcium and Bone Metabolism Regulators
Medication Info Common Name Drug Status Criteria
ALENDRONATE SODIUM 10 MG TAB ALENDRONATE SODIUM QL
ALENDRONATE SODIUM 35 MG TAB ALENDRONATE SODIUM QL
ALENDRONATE SODIUM 40 MG TAB ALENDRONATE SODIUM QL
ALENDRONATE SODIUM 70 MG TAB ALENDRONATE SODIUM QL
CALCITONIN-SALMON 200 UNITS SP CALCITONIN-SALMON
EVISTA 60 MG TABLET EVISTA
FORTEO 600 MCG/2.4 ML PEN INJ FORTEO PA
MIACALCIN 200 UNIT NASAL SPRAY MIACALCIN
MIACALCIN 400 UNIT/2 ML VIAL MIACALCIN
RALOXIFENE HCL 60 MG TABLET RALOXIFENE HCL
Calcium Channel Blockers and Combinations
Medication Info Common Name Drug Status Criteria
AMLODIPINE BESYLATE 10 MG TAB AMLODIPINE BESYLATE QL
AMLODIPINE BESYLATE 2.5 MG TAB AMLODIPINE BESYLATE QL
AMLODIPINE BESYLATE 5 MG TAB AMLODIPINE BESYLATE QL
DILTIAZEM 120 MG TABLET DILTIAZEM HCL
DILTIAZEM 12HR ER 120 MG CAP DILTIAZEM 12HR ER
DILTIAZEM 12HR ER 60 MG CAP DILTIAZEM 12HR ER
DILTIAZEM 12HR ER 90 MG CAP DILTIAZEM 12HR ER
DILTIAZEM 24HR CD 120 MG CAP DILTIAZEM 24HR CD
DILTIAZEM 24HR CD 180 MG CAP DILTIAZEM 24HR CD
DILTIAZEM 24HR CD 240 MG CAP DILTIAZEM 24HR CD
DILTIAZEM 24HR CD 300 MG CAP DILTIAZEM 24HR CD
DILTIAZEM 24HR CD 360 MG CAP DILTIAZEM 24HR CD
DILTIAZEM 24HR ER 120 MG CAP DILTIAZEM 24HR ER
DILTIAZEM 24HR ER 180 MG CAP DILTIAZEM 24HR ER
DILTIAZEM 24HR ER 180 MG TAB DILTIAZEM 24HR ER
2018 Trusted Health Plan Medicaid Formulary
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Calcium Channel Blockers and Combinations
Medication Info Common Name Drug Status Criteria
DILTIAZEM 24HR ER 240 MG CAP DILTIAZEM 24HR ER
DILTIAZEM 24HR ER 240 MG TAB DILTIAZEM 24HR ER
DILTIAZEM 24HR ER 300 MG CAP DILTIAZEM 24HR ER
DILTIAZEM 24HR ER 300 MG TAB DILTIAZEM 24HR ER
DILTIAZEM 24HR ER 360 MG CAP DILTIAZEM 24HR ER
DILTIAZEM 24HR ER 360 MG TAB DILTIAZEM 24HR ER
DILTIAZEM 24HR ER 420 MG CAP DILTIAZEM 24HR ER
DILTIAZEM 24HR ER 420 MG TAB DILTIAZEM 24HR ER
DILTIAZEM 30 MG TABLET DILTIAZEM HCL
DILTIAZEM 60 MG TABLET DILTIAZEM HCL
DILTIAZEM 90 MG TABLET DILTIAZEM HCL
DILTIAZEM ER 120 MG CAPSULE DILTIAZEM ER
DILTIAZEM ER 180 MG CAPSULE DILTIAZEM ER
DILTIAZEM ER 240 MG CAPSULE DILTIAZEM ER
NIFEDIPINE 10 MG CAPSULE NIFEDIPINE
NIFEDIPINE 20 MG CAPSULE NIFEDIPINE
NIFEDIPINE ER 30 MG TABLET NIFEDIPINE ER
NIFEDIPINE ER 60 MG TABLET NIFEDIPINE ER
NIFEDIPINE ER 90 MG TABLET NIFEDIPINE ER
VERAPAMIL ER 120 MG CAPSULE VERAPAMIL ER
VERAPAMIL ER 120 MG TABLET VERAPAMIL ER
VERAPAMIL ER 180 MG CAPSULE VERAPAMIL ER
VERAPAMIL ER 180 MG TABLET VERAPAMIL ER
VERAPAMIL ER 240 MG TABLET VERAPAMIL ER
VERAPAMIL ER PM 300 MG CAPSULE VERAPAMIL ER PM
VERAPAMIL SR 120 MG CAPSULE VERAPAMIL SR
VERAPAMIL SR 180 MG CAPSULE VERAPAMIL SR
Cardiac Inotropes
Medication Info Common Name Drug Status Criteria
DIGOXIN 0.05 MG/ML SOLUTION DIGOXIN
DIGOXIN 0.125 MG TABLET DIGOXIN
DIGOXIN 0.125 MG/2.5 ML SOLN DIGOXIN
DIGOXIN 0.25 MG TABLET DIGOXIN
DIGOXIN 0.25 MG/5 ML SOLUTION DIGOXIN
DIGOXIN 0.25 MG/ML SYRINGE DIGOXIN
DIGOXIN 125 MCG TABLET DIGOXIN
DIGOXIN 250 MCG TABLET DIGOXIN
DIGOXIN 500 MCG/2 ML AMPULE DIGOXIN
Cardiovascular Sympathomimetics and Combinations
Medication Info Common Name Drug Status Criteria
EPINEPHRINE 0.15 MG AUTO-INJCT EPINEPHRINE
EPINEPHRINE 0.3 MG AUTO-INJECT EPINEPHRINE
MIDODRINE HCL 10 MG TABLET MIDODRINE HCL
2018 Trusted Health Plan Medicaid Formulary
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Cardiovascular Sympathomimetics and Combinations
Medication Info Common Name Drug Status Criteria
MIDODRINE HCL 2.5 MG TABLET MIDODRINE HCL
MIDODRINE HCL 5 MG TABLET MIDODRINE HCL
Chelating Agents
Medication Info Common Name Drug Status Criteria
EXJADE 125 MG TABLET EXJADE PA
EXJADE 250 MG TABLET EXJADE PA
EXJADE 500 MG TABLET EXJADE PA
Chemotherapy Rescue-Antidote Agents
Medication Info Common Name Drug Status Criteria
LEUCOVORIN CALCIUM 10 MG TAB LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 100 MG VIAL LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 15 MG TAB LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM 25 MG TAB LEUCOVORIN CALCIUM
MESNA 1 GRAM/10 ML VIAL MESNA
MESNA 100 MG/ML VIAL MESNA
CNS Stimulants
Medication Info Common Name Drug Status Criteria
DEXTROAMP-AMPHET ER 10 MG CAP DEXTROAMPHETAMINE-AMPHET ER
QL
DEXTROAMP-AMPHET ER 15 MG CAP DEXTROAMPHETAMINE-AMPHET ER
QL
DEXTROAMP-AMPHET ER 20 MG CAP DEXTROAMPHETAMINE-AMPHET ER
QL
DEXTROAMP-AMPHET ER 25 MG CAP DEXTROAMPHETAMINE-AMPHET ER
QL
DEXTROAMP-AMPHET ER 30 MG CAP DEXTROAMPHETAMINE-AMPHET ER
QL
DEXTROAMP-AMPHET ER 5 MG CAP DEXTROAMPHETAMINE-AMPHET ER
QL
DEXTROAMP-AMPHETAMIN 10 MGTAB
DEXTROAMPHETAMINE-AMPHETAMINE
DEXTROAMP-AMPHETAMIN 20 MGTAB
DEXTROAMPHETAMINE-AMPHETAMINE
DEXTROAMP-AMPHETAMIN 30 MGTAB
DEXTROAMPHETAMINE-AMPHETAMINE
DEXTROAMP-AMPHETAMINE 5 MGTAB
DEXTROAMPHETAMINE-AMPHETAMINE
DEXTROAMPHETAMINE 10 MG TAB DEXTROAMPHETAMINESULFATE
DEXTROAMPHETAMINE 5 MG TAB DEXTROAMPHETAMINESULFATE
DEXTROAMPHETAMINE 5 MG/5 ML DEXTROAMPHETAMINESULFATE
DEXTROAMPHETAMINE ER 10 MGCAP
DEXTROAMPHETAMINESULFATE ER
DEXTROAMPHETAMINE ER 15 MGCAP
DEXTROAMPHETAMINESULFATE ER
2018 Trusted Health Plan Medicaid Formulary
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CNS Stimulants
Medication Info Common Name Drug Status Criteria
DEXTROAMPHETAMINE ER 5 MG CAP DEXTROAMPHETAMINESULFATE ER
Cognitive Disorder Therapy - Antidementia
Medication Info Common Name Drug Status Criteria
DONEPEZIL HCL 10 MG TABLET DONEPEZIL HCL
DONEPEZIL HCL 5 MG TABLET DONEPEZIL HCL
GALANTAMINE 4 MG/ML ORAL SOLN GALANTAMINEHYDROBROMIDE
GALANTAMINE ER 16 MG CAPSULE GALANTAMINE ER
GALANTAMINE ER 24 MG CAPSULE GALANTAMINE ER
GALANTAMINE ER 8 MG CAPSULE GALANTAMINE ER
GALANTAMINE HBR 12 MG TABLET GALANTAMINE HBR
GALANTAMINE HBR 4 MG TABLET GALANTAMINE HBR
GALANTAMINE HBR 8 MG TABLET GALANTAMINE HBR
RIVASTIGMINE 1.5 MG CAPSULE RIVASTIGMINE
RIVASTIGMINE 13.3 MG/24HR PTCH RIVASTIGMINE
RIVASTIGMINE 3 MG CAPSULE RIVASTIGMINE
RIVASTIGMINE 4.5 MG CAPSULE RIVASTIGMINE
RIVASTIGMINE 4.6 MG/24HR PATCH RIVASTIGMINE
RIVASTIGMINE 6 MG CAPSULE RIVASTIGMINE
RIVASTIGMINE 9.5 MG/24HR PATCH RIVASTIGMINE
Colonic Acidifier (Ammonia Inhibitor)
Medication Info Common Name Drug Status Criteria
ENULOSE 10 GM/15 ML SOLUTION ENULOSE
GENERLAC 10 GM/15 ML SOLUTION GENERLAC
LACTULOSE 10 GM/15 ML SOLUTION LACTULOSE
Contraceptives Implant
Medication Info Common Name Drug Status Criteria
NEXPLANON 68 MG IMPLANT NEXPLANON
Contraceptives Injectable
Medication Info Common Name Drug Status Criteria
MEDROXYPROGESTERONE 150 MG/ML
DEPO-PROVERA
Contraceptives Intravaginal
Medication Info Common Name Drug Status Criteria
NUVARING VAGINAL RING NUVARING QL
Contraceptives Oral
Medication Info Common Name Drug Status Criteria
ALTAVERA-28 TABLET ALTAVERA
ALYACEN 1-35-28 TABLET ALYACEN
ALYACEN 7-7-7-28 TABLET ALYACEN
AMETHIA 0.15-0.03-0.01 MG TAB AMETHIA
AMETHIA LO TABLET AMETHIA LO
APRI 28 DAY TABLET APRI
2018 Trusted Health Plan Medicaid Formulary
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Contraceptives Oral
Medication Info Common Name Drug Status Criteria
ARANELLE 28 TABLET ARANELLE
ASHLYNA 0.15-0.03-0.01 MG TAB ASHLYNA
AUBRA-28 TABLET AUBRA
AVIANE-28 TABLET AVIANE
AZURETTE 28 DAY TABLET AZURETTE
BALZIVA 28 TABLET BALZIVA
BEKYREE 28 DAY TABLET BEKYREE
BLISOVI FE 1-20 TABLET BLISOVI FE
BLISOVI FE 1.5-30 TABLET BLISOVI FE
BREVICON 28 TABLET BREVICON
BRIELLYN TABLET BRIELLYN
CAMILA 0.35 MG TABLET CAMILA
CAMRESE 0.15-0.03-0.01 MG TAB CAMRESE
CAMRESE LO TABLET CAMRESE LO
CAZIANT 28 DAY TABLET CAZIANT
CHATEAL-28 TABLET CHATEAL
CRYSELLE-28 TABLET CRYSELLE
CYCLAFEM 1-35-28 TABLET CYCLAFEM
CYCLAFEM 7-7-7-28 TABLET CYCLAFEM
CYCLESSA 28 DAY TABLET CYCLESSA
CYRED 28 DAY TABLET CYRED
DASETTA 1-35-28 TABLET DASETTA
DASETTA 7/7/7-28 TABLET DASETTA
DAYSEE 0.15-0.03-0.01 MG TAB DAYSEE
DEBLITANE 0.35 MG TABLET DEBLITANE
DELYLA-28 TABLET DELYLA
DESOGEN 28 DAY TABLET DESOGEN
DESOGEST-ETH ESTRA 0.15-0.03 MG DESOGESTREL-ETHINYLESTRADIOL
DESOGESTREL-ETHINYL ESTRADTAB
DESOGESTREL-ETHINYLESTRADIOL
DROSPIRENONE-EE 3-0.02 MG TAB DROSPIRENONE-ETHINYLESTRADIOL
DROSPIRENONE-EE 3-0.03 MG TAB DROSPIRENONE-ETHINYLESTRADIOL
ELINEST-28 TABLET ELINEST
EMOQUETTE 28 DAY TABLET EMOQUETTE
ENPRESSE-28 TABLET ENPRESSE
ENSKYCE 28 TABLET ENSKYCE
ERRIN 0.35 MG TABLET ERRIN
ESTARYLLA 0.25 MG-0.035 MGTABLET
ESTARYLLA
ETHYNODIOL-ETH ESTRA 1 MG-35MCG
ETHYNODIOL-ETHINYLESTRADIOL
ETHYNODIOL-ETH ESTRA 1 MG-50MCG
ETHYNODIOL-ETHINYLESTRADIOL
2018 Trusted Health Plan Medicaid Formulary
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Contraceptives Oral
Medication Info Common Name Drug Status Criteria
FALMINA-28 TABLET FALMINA
FEMYNOR 28 TABLET FEMYNOR
GIANVI 3 MG-0.02 MG TABLET GIANVI
GILDAGIA 0.4 MG-0.035 MG TAB GILDAGIA
HEATHER TABLET HEATHER
ISIBLOOM 28 DAY TABLET ISIBLOOM
JENCYCLA 0.35 MG TABLET JENCYCLA
JOLIVETTE TABLET JOLIVETTE
JULEBER 28 DAY TABLET JULEBER
JUNEL 1 MG-20 MCG TABLET JUNEL
JUNEL 1.5 MG-30 MCG TABLET JUNEL
JUNEL FE 1 MG-20 MCG TABLET JUNEL FE
JUNEL FE 1.5 MG-30 MCG TABLET JUNEL FE
KARIVA 28 DAY TABLET KARIVA
KIMIDESS 28 DAY TABLET KIMIDESS
KURVELO TABLET KURVELO
LARIN 1.5 MG-30 MCG TABLET LARIN
LARIN 21 1-20 TABLET LARIN
LARIN FE 1-20 TABLET LARIN FE
LARIN FE 1.5-30 TABLET LARIN FE
LARISSIA-28 TABLET LARISSIA
LEENA 28 TABLET LEENA
LESSINA-28 TABLET LESSINA
LEVONEST-28 TABLET LEVONEST
LEVONO-E ESTRAD 0.10-0.02-0.01 LEVONORG-ETH ESTRAD ETHESTRAD
LEVONO-E ESTRAD 0.15-0.03-0.01 LEVONORG-ETH ESTRAD ETHESTRAD
LEVONOR-ETH ESTRAD 0.1-0.02 MG LEVONORGESTREL-ETHESTRADIOL
LEVONOR-ETH ESTRAD 0.15-0.03 LEVONORGESTREL-ETHESTRADIOL
LEVONOR-ETH ESTRAD TRIPHASIC LEVONORGESTREL-ETHESTRADIOL
LEVORA-28 TABLET LEVORA-28
LILLOW-28 TABLET LILLOW
LOESTRIN 21 1-20 TABLET LOESTRIN
LOESTRIN 21 1.5-30 TABLET LOESTRIN
LOESTRIN FE 1-20 TABLET LOESTRIN FE
LOESTRIN FE 1.5-30 TABLET LOESTRIN FE
LORYNA 3 MG-0.02 MG TABLET LORYNA
LOSEASONIQUE TABLET LOSEASONIQUE
LOW-OGESTREL-28 TABLET LOW-OGESTREL
LUTERA-28 TABLET LUTERA
2018 Trusted Health Plan Medicaid Formulary
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Contraceptives Oral
Medication Info Common Name Drug Status Criteria
LYZA 0.35 MG TABLET LYZA
MARLISSA-28 TABLET MARLISSA
MICROGESTIN 21 1-20 TABLET MICROGESTIN
MICROGESTIN 21 1.5-30 TAB MICROGESTIN
MICROGESTIN FE 1-20 TABLET MICROGESTIN FE
MICROGESTIN FE 1.5-30 TAB MICROGESTIN FE
MIRCETTE 28 DAY TABLET MIRCETTE
MONO-LINYAH 28 TABLET MONO-LINYAH
MONONESSA 28 TABLET MONONESSA
MYZILRA-28 TABLET MYZILRA
NECON 0.5-35-28 TABLET NECON
NECON 1-35-28 TABLET NECON
NECON 1-50-28 TABLET NECON
NECON 10-11-28 TABLET NECON
NECON 7-7-7-28 TABLET NECON
NIKKI 3 MG-0.02 MG TABLET NIKKI
NORA-BE TABLET NORA-BE
NORETH-ESTRAD-FE 1-0.02(21)-75 NORETHIN-ETH ESTRA-FERROUS FUM
NORETHIND-ETH ESTRAD 1-0.02 MG NORETHINDRON-ETHINYLESTRADIOL
NORETHINDRONE 0.35 MG TABLET NORETHINDRONE
NORG-EE 0.18-0.215-0.25/0.035 NORGESTIMATE-ETHINYLESTRADIOL
NORG-ETHIN ESTRA 0.25-0.035 MG NORGESTIMATE-ETHINYLESTRADIOL
NORINYL 1-35 28 TABLET NORINYL 1-35
NORLYDA 0.35 MG TABLET NORLYDA
NORLYROC 0.35 MG TABLET NORLYROC
NORTREL 0.5-35-28 TABLET NORTREL
NORTREL 1-35 21 TABLET NORTREL
NORTREL 1-35 28 TABLET NORTREL
NORTREL 7-7-7-28 TABLET NORTREL
OCELLA 3 MG-0.03 MG TABLET OCELLA
ORSYTHIA-28 TABLET ORSYTHIA
ORTHO MICRONOR 0.35 MG TABLET ORTHO MICRONOR
ORTHO TRI-CYCLEN 28 TABLET ORTHO TRI-CYCLEN
ORTHO-CYCLEN 28 TABLET ORTHO-CYCLEN
ORTHO-NOVUM 1-35-28 TABLET ORTHO-NOVUM
ORTHO-NOVUM 7-7-7-28 TABLET ORTHO-NOVUM
OVCON-35 28 TABLET OVCON-35
PHILITH 0.4-0.035 MG TABLET PHILITH
PIMTREA 28 DAY TABLET PIMTREA
PIRMELLA 1-35-28 TABLET PIRMELLA
2018 Trusted Health Plan Medicaid Formulary
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Contraceptives Oral
Medication Info Common Name Drug Status Criteria
PIRMELLA 7-7-7-28 TABLET PIRMELLA
PORTIA-28 TABLET PORTIA
PREVIFEM TABLET PREVIFEM
RECLIPSEN 28 DAY TABLET RECLIPSEN
SEASONIQUE 0.15-0.03-0.01 TAB SEASONIQUE
SHAROBEL 0.35 MG TABLET SHAROBEL
SPRINTEC 28 DAY TABLET SPRINTEC
SRONYX 0.10-0.02 MG TABLET SRONYX
SYEDA 28 TABLET SYEDA
TARINA FE 1-20 TABLET TARINA FE
TRI FEMYNOR 28 TABLET TRI FEMYNOR
TRI-ESTARYLLA TABLET TRI-ESTARYLLA
TRI-LEGEST FE-28 DAY TABLET TRI-LEGEST FE
TRI-LINYAH TABLET TRI-LINYAH
TRI-NORINYL 28 TABLET TRI-NORINYL
TRI-PREVIFEM TABLET TRI-PREVIFEM
TRI-SPRINTEC TABLET TRI-SPRINTEC
TRINESSA TABLET TRINESSA
TRIVORA-28 TABLET TRIVORA-28
VELIVET 28 DAY TABLET VELIVET
VESTURA 3 MG-0.02 MG TABLET VESTURA
VIENVA-28 TABLET VIENVA
VIORELE 28 DAY TABLET VIORELE
VYFEMLA 28 TABLET VYFEMLA
WERA 0.5/0.035 MG 28 TABLET WERA
YASMIN 28 TABLET YASMIN 28
YAZ 28 TABLET YAZ
ZARAH TABLET ZARAH
ZENCHENT 0.4 MG-35 MCG TABLET ZENCHENT
ZOVIA 1-50E TABLET ZOVIA 1-50E
Contraceptives Transdermal
Medication Info Common Name Drug Status Criteria
XULANE PATCH XULANE QL
Corticosteroids
Medication Info Common Name Drug Status Criteria
DEXAMETHASONE 0.5 MG TABLET DEXAMETHASONE
DEXAMETHASONE 0.5 MG/5 ML ELX DEXAMETHASONE
DEXAMETHASONE 0.5 MG/5 ML LIQ DEXAMETHASONE
DEXAMETHASONE 0.75 MG TABLET DEXAMETHASONE
DEXAMETHASONE 1 MG TABLET DEXAMETHASONE
DEXAMETHASONE 1.5 MG TABLET DEXAMETHASONE
DEXAMETHASONE 10 MG/ML VIAL DEXAMETHASONE SODIUMPHOSPHATE
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Corticosteroids
Medication Info Common Name Drug Status Criteria
DEXAMETHASONE 100 MG/10 ML VL DEXAMETHASONE SODIUMPHOSPHATE
DEXAMETHASONE 2 MG TABLET DEXAMETHASONE
DEXAMETHASONE 4 MG TABLET DEXAMETHASONE
DEXAMETHASONE 6 MG TABLET DEXAMETHASONE
FLUDROCORTISONE 0.1 MG TABLET FLUDROCORTISONE ACETATE
HYDROCORTISONE 10 MG TABLET HYDROCORTISONE
HYDROCORTISONE 20 MG TABLET HYDROCORTISONE
METHYLPREDNISOLONE 16 MG TAB METHYLPREDNISOLONE
METHYLPREDNISOLONE 32 MG TAB METHYLPREDNISOLONE
METHYLPREDNISOLONE 4 MGDOSEPK
METHYLPREDNISOLONE
METHYLPREDNISOLONE 4 MGTABLET
METHYLPREDNISOLONE
METHYLPREDNISOLONE 8 MG TAB METHYLPREDNISOLONE
PREDNISOLONE 10 MG/5 ML SOLN PREDNISOLONE SODIUMPHOSPHATE
PREDNISOLONE 15 MG/5 ML SOLN PREDNISOLONE SODIUMPHOSPHATE
PREDNISOLONE 20 MG/5 ML SOLN PREDNISOLONE SODIUMPHOSPHATE
PREDNISOLONE 5 MG/5 ML SOLN PREDNISOLONE SODIUMPHOSPHATE
PREDNISOLONE ODT 10 MG TABLET PREDNISOLONE SODIUMPHOS ODT
PREDNISOLONE ODT 15 MG TABLET PREDNISOLONE SODIUMPHOS ODT
PREDNISOLONE ODT 30 MG TABLET PREDNISOLONE SODIUMPHOS ODT
PREDNISOLONE SOD PH 25 MG/5 ML PREDNISOLONE SODIUMPHOSPHATE
PREDNISONE 1 MG TABLET PREDNISONE
PREDNISONE 10 MG TAB DOSE PACK PREDNISONE
PREDNISONE 10 MG TABLET PREDNISONE
PREDNISONE 2.5 MG TABLET PREDNISONE
PREDNISONE 20 MG TABLET PREDNISONE
PREDNISONE 5 MG TAB DOSE PACK PREDNISONE
PREDNISONE 5 MG TABLET PREDNISONE
PREDNISONE 5 MG/5 ML SOLUTION PREDNISONE
PREDNISONE 50 MG TABLET PREDNISONE
Cystic Fibrosis Therapy Agents
Medication Info Common Name Drug Status Criteria
KALYDECO 150 MG TABLET KALYDECO PA
TOBI 300 MG/5 ML SOLUTION TOBI PA
TOBI PODHALER 28 MG INHALE CAP TOBI PODHALER PA
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Dental-Periodontal Products
Medication Info Common Name Drug Status Criteria
DOXYCYCLINE HYCLATE 20 MG TAB DOXYCYCLINE HYCLATE
FLUORIDE 0.25 MG TABLET CHEW FLUORIDE
FLUORIDE 0.5 MG TABLET CHEW FLUORIDE
FLUORIDE 1 MG TABLET CHEWABLE FLUORIDE
SODIUM FLUORIDE 0.5 MG(1.1 MG) SODIUM FLUORIDE
SODIUM FLUORIDE 0.5 MG/ML DROP SODIUM FLUORIDE
SODIUM FLUORIDE 1 MG (2.2 MG) SODIUM FLUORIDE
Dermatological - Anti-infectives
Medication Info Common Name Drug Status Criteria
CICLOPIROX 0.77% CREAM CICLOPIROX
CICLOPIROX 0.77% GEL CICLOPIROX
CICLOPIROX 0.77% TOPICAL SUSP CICLOPIROX
CICLOPIROX 1% SHAMPOO CICLOPIROX
CICLOPIROX 8% SOLUTION CICLOPIROX
CICLOPIROX 8% TREATMENT KIT CICLOPIROX
ECONAZOLE NITRATE 1% CREAM ECONAZOLE NITRATE
GENTAMICIN 0.1% CREAM GENTAMICIN SULFATE
KETOCONAZOLE 2% CREAM KETOCONAZOLE
KETOCONAZOLE 2% FOAM KETOCONAZOLE
KETOCONAZOLE 2% SHAMPOO KETOCONAZOLE
MUPIROCIN 2% CREAM MUPIROCIN
MUPIROCIN 2% OINTMENT MUPIROCIN
NYSTATIN 100,000 UNIT/GM CREAM NYSTATIN
NYSTATIN 100,000 UNIT/GM POWD NYSTATIN
NYSTATIN 100,000 UNITS/GM OINT NYSTATIN
Dermatological - Antineoplastic or Premalignant Lesions
Medication Info Common Name Drug Status Criteria
DICLOFENAC SODIUM 3% GEL DICLOFENAC SODIUM
FLUOROURACIL 2% TOPICAL SOLN FLUOROURACIL
FLUOROURACIL 5% CREAM FLUOROURACIL
FLUOROURACIL 5% TOPICAL SOLN FLUOROURACIL
TARGRETIN 1% GEL TARGRETIN
Dermatological - Antiparasitics and Combinations
Medication Info Common Name Drug Status Criteria
MALATHION 0.5% LOTION MALATHION
PERMETHRIN 5% CREAM PERMETHRIN
SPINOSAD 0.9% TOPICAL SUSP SPINOSAD
Dermatological - Antipruritics
Medication Info Common Name Drug Status Criteria
DOXEPIN 5% CREAM DOXEPIN HCL
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Dermatological - Antipsoriatics
Medication Info Common Name Drug Status Criteria
CALCIPOTRIENE 0.005% CREAM CALCIPOTRIENE
CALCIPOTRIENE 0.005% OINTMENT CALCIPOTRIENE
CALCIPOTRIENE 0.005% SOLUTION CALCIPOTRIENE
CALCITRIOL 3 MCG/G OINTMENT CALCITRIOL
TAZORAC 0.05% CREAM TAZORAC
TAZORAC 0.05% GEL TAZORAC
TAZORAC 0.1% CREAM TAZORAC
TAZORAC 0.1% GEL TAZORAC
Dermatological - Antiseborrheic Products and Combinations
Medication Info Common Name Drug Status Criteria
SELENIUM SULFIDE 2.25% SHAMPOO SELENIUM SULFIDE
SOD SULFACETAMIDE 10%SHAMPOO
SODIUM SULFACETAMIDE
SODIUM SULFACETAMIDE 10% WASH SODIUM SULFACETAMIDE
Dermatological - Burn Products
Medication Info Common Name Drug Status Criteria
SILVER SULFADIAZINE 1% CREAM SILVER SULFADIAZINE
Dermatological - Emollients and Combinations
Medication Info Common Name Drug Status Criteria
AMMONIUM LACTATE 12% CREAM AMMONIUM LACTATE
Dermatological - Glucocorticoids and Combinations
Medication Info Common Name Drug Status Criteria
ALCLOMETASONE DIPR 0.05% OINT ALCLOMETASONEDIPROPIONATE
ALCLOMETASONE DIPRO 0.05% CRM ALCLOMETASONEDIPROPIONATE
BETAMETHASONE DP 0.05% CRM BETAMETHASONEDIPROPIONATE
BETAMETHASONE DP 0.05% LOT BETAMETHASONEDIPROPIONATE
BETAMETHASONE DP 0.05% OINT BETAMETHASONEDIPROPIONATE
BETAMETHASONE DP AUG 0.05%CRM
BETAMETHASONEDIPROPIONATE
BETAMETHASONE DP AUG 0.05%GEL
BETAMETHASONEDIPROPIONATE
BETAMETHASONE DP AUG 0.05%LOT
BETAMETHASONEDIPROPIONATE
BETAMETHASONE DP AUG 0.05% OIN BETAMETHASONEDIPROPIONATE
BETAMETHASONE VA 0.1% CREAM BETAMETHASONE VALERATE
BETAMETHASONE VA 0.1% LOTION BETAMETHASONE VALERATE
BETAMETHASONE VALER 0.1%OINTM
BETAMETHASONE VALERATE
BETAMETHASONE VALER 0.12%FOAM
BETAMETHASONE VALERATE
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Dermatological - Glucocorticoids and Combinations
Medication Info Common Name Drug Status Criteria
CLOBETASOL 0.05% CREAM CLOBETASOL PROPIONATE
CLOBETASOL 0.05% GEL CLOBETASOL PROPIONATE
CLOBETASOL 0.05% OINTMENT CLOBETASOL PROPIONATE
CLOBETASOL 0.05% SHAMPOO CLOBETASOL PROPIONATE
CLOBETASOL 0.05% SOLUTION CLOBETASOL PROPIONATE
CLOBETASOL 0.05% TOPICAL LOTN CLOBETASOL PROPIONATE
CLOBETASOL EMOLLIENT 0.05% CRM CLOBETASOL EMOLLIENT
CLOBETASOL EMOLLNT 0.05% FOAM CLOBETASOL EMOLLIENT
CLOBETASOL EMULSION 0.05%FOAM
CLOBETASOL EMULSION
CLOBETASOL PROP 0.05% FOAM CLOBETASOL PROPIONATE
CLOBETASOL PROP 0.05% SPRAY CLOBETASOL PROPIONATE
DESONIDE 0.05% CREAM DESONIDE
DESONIDE 0.05% LOTION DESONIDE
DESONIDE 0.05% OINTMENT DESONIDE
DESOXIMETASONE 0.05% CREAM DESOXIMETASONE
DESOXIMETASONE 0.05% GEL DESOXIMETASONE
DESOXIMETASONE 0.05% OINTMENT DESOXIMETASONE
DESOXIMETASONE 0.25% CREAM DESOXIMETASONE
DESOXIMETASONE 0.25% OINTMENT DESOXIMETASONE
DIFLORASONE 0.05% CREAM DIFLORASONE DIACETATE
DIFLORASONE 0.05% OINTMENT DIFLORASONE DIACETATE
FLUOCINOLONE 0.01% BODY OIL FLUOCINOLONE ACETONIDE
FLUOCINOLONE 0.01% CREAM FLUOCINOLONE ACETONIDE
FLUOCINOLONE 0.01% SCALP OIL FLUOCINOLONE ACETONIDE
FLUOCINOLONE 0.01% SOLUTION FLUOCINOLONE ACETONIDE
FLUOCINOLONE 0.025% CREAM FLUOCINOLONE ACETONIDE
FLUOCINOLONE 0.025% OINTMENT FLUOCINOLONE ACETONIDE
FLUOCINONIDE 0.05% CREAM FLUOCINONIDE
FLUOCINONIDE 0.05% GEL FLUOCINONIDE
FLUOCINONIDE 0.05% OINTMENT FLUOCINONIDE
FLUOCINONIDE 0.05% SOLUTION FLUOCINONIDE
FLUOCINONIDE 0.1% CREAM FLUOCINONIDE
FLUTICASONE PROP 0.005% OINT FLUTICASONE PROPIONATE
FLUTICASONE PROP 0.05% CREAM FLUTICASONE PROPIONATE
FLUTICASONE PROP 0.05% LOTION FLUTICASONE PROPIONATE
HALOBETASOL PROP 0.05% CREAM HALOBETASOL PROPIONATE
HALOBETASOL PROP 0.05%OINTMNT
HALOBETASOL PROPIONATE
HYDROCORTISONE 1% CREAM HYDROCORTISONE
HYDROCORTISONE 1% OINTMENT HYDROCORTISONE
HYDROCORTISONE 2.5% CREAM HYDROCORTISONE
HYDROCORTISONE 2.5% LOTION HYDROCORTISONE
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Dermatological - Glucocorticoids and Combinations
Medication Info Common Name Drug Status Criteria
HYDROCORTISONE 2.5% OINTMENT HYDROCORTISONE
HYDROCORTISONE BUTY 0.1%CREAM
HYDROCORTISONE BUTYRATE
HYDROCORTISONE BUTYR 0.1%OINT
HYDROCORTISONE BUTYRATE
HYDROCORTISONE BUTYR 0.1%SOLN
HYDROCORTISONE BUTYRATE
MOMETASONE FUROATE 0.1%CREAM
MOMETASONE FUROATE
MOMETASONE FUROATE 0.1% OINT MOMETASONE FUROATE
MOMETASONE FUROATE 0.1% SOLN MOMETASONE FUROATE
TRIAMCINOLONE 0.025% CREAM TRIAMCINOLONE ACETONIDE
TRIAMCINOLONE 0.025% LOTION TRIAMCINOLONE ACETONIDE
TRIAMCINOLONE 0.025% OINT TRIAMCINOLONE ACETONIDE
TRIAMCINOLONE 0.1% CREAM TRIAMCINOLONE ACETONIDE
TRIAMCINOLONE 0.1% LOTION TRIAMCINOLONE ACETONIDE
TRIAMCINOLONE 0.1% OINTMENT TRIAMCINOLONE ACETONIDE
Dermatological - Immunomodulating Agents
Medication Info Common Name Drug Status Criteria
IMIQUIMOD 5% CREAM PACKET IMIQUIMOD
Dermatological - Immunosuppressive Agents
Medication Info Common Name Drug Status Criteria
PROTOPIC 0.03% OINTMENT PROTOPIC
PROTOPIC 0.1% OINTMENT PROTOPIC
TACROLIMUS 0.03% OINTMENT TACROLIMUS
TACROLIMUS 0.1% OINTMENT TACROLIMUS
Dermatological - Keratolytics-Antimitotics
Medication Info Common Name Drug Status Criteria
PODOFILOX 0.5% TOPICAL SOLN PODOFILOX
Dermatological - NSAID’s
Medication Info Common Name Drug Status Criteria
DICLOFENAC 1.5% TOPICAL SOLN DICLOFENAC SODIUM
DICLOFENAC SODIUM 1% GEL DICLOFENAC SODIUM
Dermatological - Rosacea Therapy
Medication Info Common Name Drug Status Criteria
METRONIDAZOLE TOP 1% GEL PUMP METRONIDAZOLE
METRONIDAZOLE TOPICAL 0.75% GL METRONIDAZOLE
METRONIDAZOLE TOPICAL 1% GEL METRONIDAZOLE
Dermatological - Topical Local Anesthetics and Combinations
Medication Info Common Name Drug Status Criteria
LIDOCAINE 3% CREAM LIDOCAINE HCL
LIDOCAINE HCL 2% JELLY LIDOCAINE HCL
LIDOCAINE HCL 3% LOTION LIDOCAINE HCL
LIDOCAINE-PRILOCAINE CREAM LIDOCAINE-PRILOCAINE
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Diabetic Therapy
Medication Info Common Name Drug Status Criteria
ACARBOSE 100 MG TABLET ACARBOSE
ACARBOSE 25 MG TABLET ACARBOSE
ACARBOSE 50 MG TABLET ACARBOSE
APIDRA 100 UNITS/ML VIAL APIDRA
APIDRA SOLOSTAR 100 UNITS/ML APIDRA SOLOSTAR
BYDUREON 2 MG VIAL BYDUREON PA
BYETTA 10 MCG DOSE PEN INJ BYETTA QL
BYETTA 5 MCG DOSE PEN INJ BYETTA QL
GLIMEPIRIDE 1 MG TABLET GLIMEPIRIDE
GLIMEPIRIDE 2 MG TABLET GLIMEPIRIDE
GLIMEPIRIDE 4 MG TABLET GLIMEPIRIDE
GLIPIZIDE 10 MG TABLET GLIPIZIDE
GLIPIZIDE 5 MG TABLET GLIPIZIDE
GLIPIZIDE ER 10 MG TABLET GLIPIZIDE ER
GLIPIZIDE ER 2.5 MG TABLET GLIPIZIDE ER
GLIPIZIDE ER 5 MG TABLET GLIPIZIDE ER
GLIPIZIDE XL 10 MG TABLET GLIPIZIDE XL
GLIPIZIDE XL 2.5 MG TABLET GLIPIZIDE XL
GLIPIZIDE XL 5 MG TABLET GLIPIZIDE XL
GLIPIZIDE-METFORMIN 2.5-250 MG GLIPIZIDE-METFORMIN
GLIPIZIDE-METFORMIN 2.5-500 MG GLIPIZIDE-METFORMIN
GLIPIZIDE-METFORMIN 5-500 MG GLIPIZIDE-METFORMIN
GLUCAGON 1 MG EMERGENCY KIT GLUCAGON EMERGENCY KIT
GLYBURID-METFORMIN 1.25-250 MG GLYBURIDE-METFORMIN HCL
GLYBURIDE 1.25 MG TABLET GLYBURIDE
GLYBURIDE 2.5 MG TABLET GLYBURIDE
GLYBURIDE 5 MG TABLET GLYBURIDE
GLYBURIDE MICRO 1.5 MG TAB GLYBURIDE MICRONIZED
GLYBURIDE MICRO 3 MG TABLET GLYBURIDE MICRONIZED
GLYBURIDE MICRO 6 MG TABLET GLYBURIDE MICRONIZED
GLYBURIDE-METFORMIN 1.25 MG-250MG TABLET
GLYBURIDE-METFORMIN HCL
GLYBURIDE-METFORMIN 2.5-500 MG GLYBURIDE-METFORMIN HCL
GLYBURIDE-METFORMIN 5-500 MG GLYBURIDE-METFORMIN HCL
HUMALOG 100 UNITS/ML CARTRIDGE HUMALOG
HUMALOG 100 UNITS/ML KWIKPEN HUMALOG KWIKPEN U-100
HUMALOG 100 UNITS/ML VIAL HUMALOG
HUMALOG MIX 50-50 KWIKPEN HUMALOG MIX 50-50 KWIKPEN
HUMALOG MIX 50-50 VIAL HUMALOG MIX 50-50
HUMALOG MIX 75-25 KWIKPEN HUMALOG MIX 75-25 KWIKPEN
HUMALOG MIX 75-25 VIAL HUMALOG MIX 75-25
HUMULIN R 500 UNITS/ML VIAL HUMULIN R U-500
JANUMET 50-1,000 MG TABLET JANUMET
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Diabetic Therapy
Medication Info Common Name Drug Status Criteria
JANUMET 50-500 MG TABLET JANUMET
JANUMET XR 100-1,000 MG TABLET JANUMET XR
JANUMET XR 50-1,000 MG TABLET JANUMET XR
JANUMET XR 50-500 MG TABLET JANUMET XR
JANUVIA 100 MG TABLET JANUVIA
JANUVIA 25 MG TABLET JANUVIA
JANUVIA 50 MG TABLET JANUVIA
KORLYM 300 MG TABLET KORLYM
LANTUS 100 UNIT/ML VIAL LANTUS
LANTUS SOLOSTAR 100 UNIT/ML LANTUS SOLOSTAR
METFORMIN ER 1,000 MG OSM-TAB METFORMIN HCL ER
METFORMIN HCL 1,000 MG TABLET METFORMIN HCL
METFORMIN HCL 500 MG TABLET METFORMIN HCL
METFORMIN HCL 850 MG TABLET METFORMIN HCL
METFORMIN HCL ER 1,000 MG TAB METFORMIN HCL ER
METFORMIN HCL ER 500 MG OSM-TB METFORMIN HCL ER
METFORMIN HCL ER 500 MG TABLET METFORMIN HCL ER
METFORMIN HCL ER 750 MG TABLET METFORMIN HCL ER
NATEGLINIDE 120 MG TABLET NATEGLINIDE
NATEGLINIDE 60 MG TABLET NATEGLINIDE
NOVOLOG 100 UNIT/ML CARTRIDGE NOVOLOG
NOVOLOG 100 UNIT/ML VIAL NOVOLOG
NOVOLOG 100 UNITS/ML FLEXPEN NOVOLOG FLEXPEN
NOVOLOG MIX 70-30 FLEXPEN SYRN NOVOLOG MIX 70-30 FLEXPEN
NOVOLOG MIX 70-30 VIAL NOVOLOG MIX 70-30
ONGLYZA 2.5 MG TABLET ONGLYZA
ONGLYZA 5 MG TABLET ONGLYZA
PIOGLITAZONE HCL 15 MG TABLET PIOGLITAZONE HCL
PIOGLITAZONE HCL 30 MG TABLET PIOGLITAZONE HCL
PIOGLITAZONE HCL 45 MG TABLET PIOGLITAZONE HCL
PIOGLITAZONE-GLIMEPIRIDE 30-2 PIOGLITAZONE-GLIMEPIRIDE
PIOGLITAZONE-GLIMEPIRIDE 30-4 PIOGLITAZONE-GLIMEPIRIDE
PIOGLITAZONE-METFORMIN 15-500 PIOGLITAZONE-METFORMIN
PIOGLITAZONE-METFORMIN 15-850 PIOGLITAZONE-METFORMIN
PRANDIN 0.5 MG TABLET PRANDIN
PRANDIN 1 MG TABLET PRANDIN
PRANDIN 2 MG TABLET PRANDIN
REPAGLINIDE 0.5 MG TABLET REPAGLINIDE
REPAGLINIDE 1 MG TABLET REPAGLINIDE
REPAGLINIDE 2 MG TABLET REPAGLINIDE
SYMLINPEN 120 PEN INJECTOR SYMLINPEN 120
SYMLINPEN 60 PEN INJECTOR SYMLINPEN 60
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Diagnostic Drugs - In Vivo
Medication Info Common Name Drug Status Criteria
DIPYRIDAMOLE 5 MG/ML VIAL DIPYRIDAMOLE
Digestive Aids
Medication Info Common Name Drug Status Criteria
CREON DR 12,000 UNITS CAPSULE CREON
CREON DR 24,000 UNITS CAPSULE CREON
CREON DR 3,000 UNITS CAPSULE CREON
CREON DR 36,000 UNITS CAPSULE CREON
CREON DR 6,000 UNITS CAPSULE CREON
PANCREAZE DR 10,500 UNIT CAP PANCREAZE
PANCREAZE DR 16,800 UNIT CAP PANCREAZE
PANCREAZE DR 2,600 UNIT CAP PANCREAZE
PANCREAZE DR 21,000 UNIT CAP PANCREAZE
PANCREAZE DR 4,200 UNIT CAP PANCREAZE
ZENPEP DR 10,000 UNIT CAPSULE ZENPEP
ZENPEP DR 15,000 UNIT CAPSULE ZENPEP
ZENPEP DR 20,000 UNIT CAPSULE ZENPEP
ZENPEP DR 25,000 UNIT CAPSULE ZENPEP
ZENPEP DR 3,000 UNIT CAPSULE ZENPEP
ZENPEP DR 5,000 UNIT CAPSULE ZENPEP
Diuretics
Medication Info Common Name Drug Status Criteria
ACETAZOLAMIDE 125 MG TABLET ACETAZOLAMIDE
ACETAZOLAMIDE 250 MG TABLET ACETAZOLAMIDE
ACETAZOLAMIDE ER 500 MG CAP ACETAZOLAMIDE
AMILORIDE HCL 5 MG TABLET AMILORIDE HCL
AMILORIDE HCL-HYDROCHLOROTHIAZIDE 5-50 MGTAB
AMILORIDE-HYDROCHLOROTHIAZIDE
BUMETANIDE 0.5 MG TABLET BUMETANIDE
BUMETANIDE 1 MG TABLET BUMETANIDE
BUMETANIDE 2 MG TABLET BUMETANIDE
CHLORTHALIDONE 25 MG TABLET CHLORTHALIDONE
CHLORTHALIDONE 50 MG TABLET CHLORTHALIDONE
EPLERENONE 25 MG TABLET EPLERENONE
EPLERENONE 50 MG TABLET EPLERENONE
FUROSEMIDE 10 MG/ML SOLUTION FUROSEMIDE
FUROSEMIDE 10 MG/ML VIAL FUROSEMIDE
FUROSEMIDE 100 MG/10 ML SYRING FUROSEMIDE
FUROSEMIDE 100 MG/10 ML VIAL FUROSEMIDE
FUROSEMIDE 20 MG TABLET FUROSEMIDE
FUROSEMIDE 20 MG/2 ML VIAL FUROSEMIDE
FUROSEMIDE 40 MG TABLET FUROSEMIDE
FUROSEMIDE 40 MG/4 ML ORAL SOL FUROSEMIDE
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Diuretics
Medication Info Common Name Drug Status Criteria
FUROSEMIDE 40 MG/4 ML SYRINGE FUROSEMIDE
FUROSEMIDE 40 MG/4 ML VIAL FUROSEMIDE
FUROSEMIDE 40 MG/5 ML SOLN FUROSEMIDE
FUROSEMIDE 80 MG TABLET FUROSEMIDE
HYDROCHLOROTHIAZIDE 12.5 MG CP HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE 12.5 MG TB HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE 25 MG TAB HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE 50 MG TAB HYDROCHLOROTHIAZIDE
INDAPAMIDE 1.25 MG TABLET INDAPAMIDE
INDAPAMIDE 2.5 MG TABLET INDAPAMIDE
INSPRA 25 MG TABLET INSPRA
INSPRA 50 MG TABLET INSPRA
METHAZOLAMIDE 25 MG TABLET METHAZOLAMIDE
METHAZOLAMIDE 50 MG TABLET METHAZOLAMIDE
METOLAZONE 10 MG TABLET METOLAZONE
METOLAZONE 2.5 MG TABLET METOLAZONE
METOLAZONE 5 MG TABLET METOLAZONE
SPIRONOLACTONE 100 MG TABLET SPIRONOLACTONE
SPIRONOLACTONE 25 MG TABLET SPIRONOLACTONE
SPIRONOLACTONE 50 MG TABLET SPIRONOLACTONE
TORSEMIDE 10 MG TABLET TORSEMIDE
TORSEMIDE 100 MG TABLET TORSEMIDE
TORSEMIDE 20 MG TABLET TORSEMIDE
TORSEMIDE 5 MG TABLET TORSEMIDE
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5-25 MGCP
TRIAMTERENE-HYDROCHLOROTHIAZID
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5-25 MGTB
TRIAMTERENE-HYDROCHLOROTHIAZID
TRIAMTERENE-HYDROCHLOROTHIAZIDE 75-50 MGTAB
TRIAMTERENE-HYDROCHLOROTHIAZID
Emergency Contraceptives and Combinations
Medication Info Common Name Drug Status Criteria
ELLA 30 MG TABLET ELLA
Erectile Dysfunction (ED) Drugs-Sel.cGMP Phosphodiesterase Type5 Inhib
Medication Info Common Name Drug Status Criteria
SILDENAFIL 100 MG TABLET SILDENAFIL CITRATE QL
SILDENAFIL 25 MG TABLET SILDENAFIL CITRATE QL
SILDENAFIL 50 MG TABLET SILDENAFIL CITRATE QL
Estrogens and Combinations
Medication Info Common Name Drug Status Criteria
ESTRADIOL 0.025 MG PATCH ESTRADIOL
ESTRADIOL 0.0375 MG PATCH ESTRADIOL
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Estrogens and Combinations
Medication Info Common Name Drug Status Criteria
ESTRADIOL 0.0375 MG/DAY PATCH ESTRADIOL
ESTRADIOL 0.05 MG PATCH ESTRADIOL
ESTRADIOL 0.05 MG/DAY PATCH ESTRADIOL TRANSDERMALPATCH
ESTRADIOL 0.06 MG/DAY PATCH ESTRADIOL
ESTRADIOL 0.075 MG PATCH ESTRADIOL
ESTRADIOL 0.075 MG/DAY PATCH ESTRADIOL
ESTRADIOL 0.1 MG PATCH ESTRADIOL
ESTRADIOL 0.1 MG/DAY PATCH ESTRADIOL TRANSDERMALPATCH
ESTRADIOL 0.5 MG TABLET ESTRADIOL
ESTRADIOL 1 MG TABLET ESTRADIOL
ESTRADIOL 2 MG TABLET ESTRADIOL
ESTRADIOL TDS 0.025 MG/DAY ESTRADIOL
ESTRADIOL TDS 0.0375 MG/DAY ESTRADIOL
ESTRADIOL TDS 0.05 MG/DAY ESTRADIOL
ESTRADIOL TDS 0.06 MG/DAY ESTRADIOL
ESTRADIOL TDS 0.075 MG/DAY ESTRADIOL
ESTRADIOL TDS 0.1 MG/DAY ESTRADIOL
PREMARIN 0.3 MG TABLET PREMARIN
PREMARIN 0.45 MG TABLET PREMARIN
PREMARIN 0.625 MG TABLET PREMARIN
PREMARIN 0.9 MG TABLET PREMARIN
PREMARIN 1.25 MG TABLET PREMARIN
PREMPRO 0.3 MG-1.5 MG TABLET PREMPRO
PREMPRO 0.45-1.5 MG TABLET PREMPRO
PREMPRO 0.625-2.5 MG TABLET PREMPRO
PREMPRO 0.625-5 MG TABLET PREMPRO
Gallstone Solubilizing (Litholysis) Agents and Combinations
Medication Info Common Name Drug Status Criteria
URSODIOL 250 MG TABLET URSODIOL
URSODIOL 300 MG CAPSULE URSODIOL
URSODIOL 500 MG TABLET URSODIOL
Gastrointestinal Antispasmodics
Medication Info Common Name Drug Status Criteria
CHLORDIAZEPOXIDE-CLIDINIUM CAP CHLORDIAZEPOXIDE-CLIDINIUM
DICYCLOMINE 10 MG CAPSULE DICYCLOMINE HCL
DICYCLOMINE 10 MG/5 ML SOLN DICYCLOMINE HCL
DICYCLOMINE 20 MG TABLET DICYCLOMINE HCL
DICYCLOMINE 20 MG/2 ML VIAL DICYCLOMINE HCL
HYOSCYAMINE 0.125 MG ODT HYOSCYAMINE SULFATE
HYOSCYAMINE 0.125 MG TAB SL HYOSCYAMINE SULFATE
HYOSCYAMINE 0.125 MG/5 ML ELIX HYOSCYAMINE SULFATE
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Gastrointestinal Antispasmodics
Medication Info Common Name Drug Status Criteria
HYOSCYAMINE 0.125 MG/ML DROP HYOSCYAMINE SULFATE
HYOSCYAMINE ER 0.375 MG TAB HYOSCYAMINE SULFATE ER
HYOSCYAMINE SR 0.375 MG TAB HYOSCYAMINE SULFATE SR
HYOSCYAMINE SULF 0.125 MG TAB HYOSCYAMINE SULFATE
Gastrointestinal Prokinetic Agents
Medication Info Common Name Drug Status Criteria
METOCLOPRAMIDE 10 MG TABLET METOCLOPRAMIDE HCL
METOCLOPRAMIDE 10 MG/10 ML SOL METOCLOPRAMIDE HCL
METOCLOPRAMIDE 10 MG/2 ML VIAL METOCLOPRAMIDE HCL
METOCLOPRAMIDE 5 MG TABLET METOCLOPRAMIDE HCL
METOCLOPRAMIDE 5 MG/5 ML SOLN METOCLOPRAMIDE HCL
METOCLOPRAMIDE HCL 10 MG ODT METOCLOPRAMIDE HCL ODT
METOCLOPRAMIDE HCL 5 MG ODT METOCLOPRAMIDE HCL ODT
General Anesthetics
Medication Info Common Name Drug Status Criteria
METHOHEXITAL 100 MG/10 ML-WATER SYRINGE (CMPD-RX)
METHOHEXITAL-STERILEWATER
METHOHEXITAL-WATER 100 MG/10ML
METHOHEXITAL-STERILEWATER
MIDAZOLAM 100 MG/100 ML-0.9%NACL BAG (CMPD-RX)
MIDAZOLAM HCL-0.9% NACL
MIDAZOLAM 250 MG/250 ML-0.9%NACL BAG (CMPD-RX)
MIDAZOLAM HCL-0.9% NACL
MIDAZOLAM 50 MG/50 ML-0.9% NACLBAG (CMPD-RX)
MIDAZOLAM HCL-0.9% NACL
MIDAZOLAM-0.9% NACL 100 MG/100 MIDAZOLAM HCL-0.9% NACL
MIDAZOLAM-0.9% NACL 250 MG/250 MIDAZOLAM HCL-0.9% NACL
MIDAZOLAM-0.9% NACL 50 MG/100 MIDAZOLAM HCL-0.9% NACL
MIDAZOLAM-0.9% NACL 50 MG/50 MIDAZOLAM HCL-0.9% NACL
General Injectable Solutions and Diluents
Medication Info Common Name Drug Status Criteria
SALINE 0.45% SOLN-EXCEL CON SODIUM CHLORIDE
SODIUM CHLORIDE 0.45% SOLN SODIUM CHLORIDE
SODIUM CHLORIDE 0.45% SOLUTION SODIUM CHLORIDE
SODIUM CHLORIDE 100 MEQ/40 ML SODIUM CHLORIDE
SODIUM CHLORIDE 3% IV SOLN SODIUM CHLORIDE
SODIUM CHLORIDE 4 MEQ/ML VL SODIUM CHLORIDE
SODIUM CHLORIDE 5% IV SOLN SODIUM CHLORIDE
SODIUM CHLORIDE 50 MEQ/20 ML SODIUM CHLORIDE
Genitourinary Irrigants
Medication Info Common Name Drug Status Criteria
ACETIC ACID 0.25% IRRIG SOLN ACETIC ACID
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Hematopoietic Agents
Medication Info Common Name Drug Status Criteria
ARANESP 100 MCG/0.5 ML SYRINGE ARANESP PA
ARANESP 100 MCG/ML VIAL ARANESP PA
ARANESP 150 MCG/0.3 ML SYRINGE ARANESP PA
ARANESP 150 MCG/0.75 ML VIAL ARANESP PA
ARANESP 200 MCG/0.4 ML SYRINGE ARANESP PA
ARANESP 200 MCG/ML VIAL ARANESP PA
ARANESP 25 MCG/0.42 ML SYRING ARANESP PA
ARANESP 25 MCG/ML VIAL ARANESP PA
ARANESP 300 MCG/0.6 ML SYRINGE ARANESP PA
ARANESP 300 MCG/ML VIAL ARANESP PA
ARANESP 40 MCG/0.4 ML SYRINGE ARANESP PA
ARANESP 40 MCG/ML VIAL ARANESP PA
ARANESP 500 MCG/1 ML SYRINGE ARANESP PA
ARANESP 60 MCG/0.3 ML SYRINGE ARANESP PA
ARANESP 60 MCG/ML VIAL ARANESP PA
EPOGEN 10,000 UNITS/ML VIAL EPOGEN PA
EPOGEN 2,000 UNITS/ML VIAL EPOGEN PA
EPOGEN 20,000 UNITS/2 ML VIAL EPOGEN PA
EPOGEN 20,000 UNITS/ML VIAL EPOGEN PA
EPOGEN 3,000 UNITS/ML VIAL EPOGEN PA
EPOGEN 4,000 UNITS/ML VIAL EPOGEN PA
LEUKINE 250 MCG VIAL LEUKINE
NEULASTA 6 MG/0.6 ML SYRINGE NEULASTA PA
NEUPOGEN 300 MCG/0.5 ML SYR NEUPOGEN PA
NEUPOGEN 300 MCG/ML VIAL NEUPOGEN PA
NEUPOGEN 480 MCG/0.8 ML SYR NEUPOGEN PA
NEUPOGEN 480 MCG/1.6 ML VIAL NEUPOGEN PA
NPLATE 250 MCG VIAL NPLATE PA
NPLATE 500 MCG VIAL NPLATE PA
PROCRIT 10,000 UNITS/ML VIAL PROCRIT PA
PROCRIT 2,000 UNITS/ML VIAL PROCRIT PA
PROCRIT 20,000 UNITS/ML VIAL PROCRIT PA
PROCRIT 3,000 UNITS/ML VIAL PROCRIT PA
PROCRIT 4,000 UNITS/ML VIAL PROCRIT PA
PROCRIT 40,000 UNITS/ML VIAL PROCRIT PA
Hepatic Hormones (Hormones Secreted by the Liver)
Medication Info Common Name Drug Status Criteria
INCRELEX 40 MG/4 ML VIAL INCRELEX PA
Hyperuricemia Therapy
Medication Info Common Name Drug Status Criteria
ALLOPURINOL 100 MG TABLET ALLOPURINOL
ALLOPURINOL 300 MG TABLET ALLOPURINOL
PROBENECID 500 MG TABLET PROBENECID
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Immunosuppressive - Calcineurin Inhibitors
Medication Info Common Name Drug Status Criteria
CYCLOSPORINE 100 MG CAPSULE CYCLOSPORINE
CYCLOSPORINE 100 MG/ML SOLN CYCLOSPORINE
CYCLOSPORINE 25 MG CAPSULE CYCLOSPORINE
CYCLOSPORINE 50 MG/ML AMPUL CYCLOSPORINE
CYCLOSPORINE MODIFIED 100 MG CYCLOSPORINE MODIFIED
CYCLOSPORINE MODIFIED 25 MG CYCLOSPORINE MODIFIED
CYCLOSPORINE MODIFIED 50 MG CYCLOSPORINE MODIFIED
TACROLIMUS 0.5 MG CAPSULE TACROLIMUS
TACROLIMUS 1 MG CAPSULE TACROLIMUS
TACROLIMUS 5 MG CAPSULE TACROLIMUS
Immunosuppressive - Inosine Monophosphate Dehydrogenase Inhibitors
Medication Info Common Name Drug Status Criteria
MYCOPHENOLATE 200 MG/ML SUSP MYCOPHENOLATE MOFETIL
MYCOPHENOLATE 250 MG CAPSULE MYCOPHENOLATE MOFETIL
MYCOPHENOLATE 500 MG TABLET MYCOPHENOLATE MOFETIL
Immunosuppressive - Mammalian Target of Rapamycin (mTOR) Inhibitors
Medication Info Common Name Drug Status Criteria
RAPAMUNE 0.5 MG TABLET RAPAMUNE
RAPAMUNE 1 MG TABLET RAPAMUNE
RAPAMUNE 1 MG/ML ORAL SOLN RAPAMUNE
RAPAMUNE 2 MG TABLET RAPAMUNE
SIROLIMUS 0.5 MG TABLET SIROLIMUS
SIROLIMUS 1 MG TABLET SIROLIMUS
SIROLIMUS 2 MG TABLET SIROLIMUS
Immunosuppressive - Purine Analogs
Medication Info Common Name Drug Status Criteria
AZASAN 100 MG TABLET AZASAN
AZASAN 75 MG TABLET AZASAN
AZATHIOPRINE 50 MG TABLET AZATHIOPRINE
Inflammatory Bowel Agents
Medication Info Common Name Drug Status Criteria
BUDESONIDE EC 3 MG CAPSULE BUDESONIDE EC
CANASA 1,000 MG SUPPOSITORY CANASA
CORTIFOAM 10% AEROSOL CORTIFOAM
HUMIRA 20 MG/0.4 ML SYRINGE HUMIRA PA
HUMIRA 40 MG/0.8 ML PEN HUMIRA PEN PA
HUMIRA 40 MG/0.8 ML SYRINGE HUMIRA PA
HUMIRA PEDIATRIC CROHN’S START HUMIRA PEDIATRIC CROHN’S PA
HUMIRA PEN CROHN-UC-HSSTARTER
HUMIRA PEN CROHN-UC-HSSTARTER
PA
HUMIRA PEN PSORIASIS-UVEITISSTARTER
HUMIRA PEN PSORIASIS-UVEITIS
PA
HYDROCORTISONE 100 MG/60 ML HYDROCORTISONE
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Inflammatory Bowel Agents
Medication Info Common Name Drug Status Criteria
REMICADE 100 MG VIAL REMICADE PA
SULFASALAZINE 500 MG TABLET SULFASALAZINE
SULFASALAZINE DR 500 MG TAB SULFASALAZINE DR
Interstitial Cystitis Agents
Medication Info Common Name Drug Status Criteria
ELMIRON 100 MG CAPSULE ELMIRON
Irrigation Solutions
Medication Info Common Name Drug Status Criteria
SODIUM CHLORIDE 0.9% IRRIG. SODIUM CHLORIDE
Irritable Bowel Syndrome (IBS) Agents
Medication Info Common Name Drug Status Criteria
AMITIZA 24 MCG CAPSULES AMITIZA
AMITIZA 8 MCG CAPSULE AMITIZA
Laxatives
Medication Info Common Name Drug Status Criteria
COLYTE WITH FLAVOR PACKETS COLYTE WITH FLAVORPACKETS
GAVILYTE-C SOLUTION GAVILYTE-C
LACTULOSE 10 GM/15 ML SOLUTION LACTULOSE
PEG 3350 ELECTROLYTE SOLN PEG 3350-ELECTROLYTE
PEG 3350-ELECTROLYTE SOLUTION PEG 3350-ELECTROLYTE
POLYETHYLENE GLYCOL 3350 POWD POLYETHYLENE GLYCOL 3350
Local Anesthetics - Parenteral
Medication Info Common Name Drug Status Criteria
LIDOCAINE 1%-0.9% NACL SYRINGE(CMPD-RX)
LIDOCAINE HCL-0.9% NACL
LIDOCAINE 10 MG/ML (1%)-0.9% NACLSYRINGE (CMPD-RX)
LIDOCAINE HCL-0.9% NACL
LIDOCAINE 100 MG/5 ML (2%)SYRINGE (CMPD-RX)
LIDOCAINE HCL
LIDOCAINE 200 MG/10 ML (2%)SYRINGE (CMPD-RX)
LIDOCAINE HCL
LIDOCAINE 200 MG/20 ML (1%)SYRINGE (CMPD-RX)
LIDOCAINE HCL
LIDOCAINE 40 MG/2 ML (2%)SYRINGE (CMPD-RX)
LIDOCAINE HCL
LIDOCAINE HCL 0.5% VIAL LIDOCAINE HCL
LIDOCAINE HCL 1% 20 MG/2 MLAMPULE
LIDOCAINE HCL
LIDOCAINE HCL 1% 20 MG/2 ML VL LIDOCAINE HCL
LIDOCAINE HCL 1% 300 MG/30 ML LIDOCAINE HCL
LIDOCAINE HCL 1% 50 MG/5 MLAMPULE
LIDOCAINE HCL
LIDOCAINE HCL 1% 50 MG/5 ML VIAL LIDOCAINE HCL
LIDOCAINE HCL 1% AMPUL LIDOCAINE HCL
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Local Anesthetics - Parenteral
Medication Info Common Name Drug Status Criteria
LIDOCAINE HCL 1% SYRINGE LIDOCAINE HCL
LIDOCAINE HCL 1% SYRINGE (CMPD-RX)
LIDOCAINE HCL
LIDOCAINE HCL 1% VIAL LIDOCAINE HCL
LIDOCAINE HCL 1.5% AMPUL LIDOCAINE HCL
LIDOCAINE HCL 10 MG/ML SYRINGE(CMPD-RX)
LIDOCAINE HCL
LIDOCAINE HCL 100 MG/10 MLSYRINGE (CMPD-RX)
LIDOCAINE HCL
LIDOCAINE HCL 100 MG/5 ML SYR LIDOCAINE HCL
LIDOCAINE HCL 100 MG/5 MLSYRINGE (CMPD-RX)
LIDOCAINE HCL
LIDOCAINE HCL 2% 100 MG/5 ML LIDOCAINE HCL
LIDOCAINE HCL 2% 40 MG/2 ML VL LIDOCAINE HCL
LIDOCAINE HCL 2% SYRINGE LIDOCAINE HCL
LIDOCAINE HCL 2% VIAL LIDOCAINE HCL
LIDOCAINE HCL 200 MG/10 ML SYR LIDOCAINE HCL
LIDOCAINE HCL 200 MG/10 MLSYRINGE (CMPD-RX)
LIDOCAINE HCL
LIDOCAINE HCL 200 MG/20 ML SYR LIDOCAINE HCL
LIDOCAINE HCL 30 MG/3 ML SYRINGE(CMPD-RX)
LIDOCAINE HCL
LIDOCAINE HCL 4% AMPUL LIDOCAINE HCL
LIDOCAINE HCL 4% SOLUTION LIDOCAINE HCL
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
BD INS SYRINGE 1/2 ML 31GX6MM(ONLY FOR 500 UNIT/ML INSULIN)
INSULIN SYRINGE U-500
FIFTY50 1.8 ML RESERVOIR FIFTY50 RESERVOIR
FIFTY50 3 ML RESERVOIR FIFTY50 RESERVOIR
HUMAPEN LUXURA HD HUMAPEN LUXURA HD
INPEN (FOR HUMALOG) INPEN (FOR HUMALOG)
INPEN (FOR NOVOLOG) INPEN (FOR NOVOLOG)
INSULIN SYRIN 0.5 ML 30GX1/2" INSULIN SYRINGE
INSULIN SYRIN 0.5 ML 30GX5/16" INSULIN SYRINGE
INSULIN SYRINGE 1 ML 30GX1/2" INSULIN SYRINGE
INSULIN SYRINGE 1 ML 30GX5/16" INSULIN SYRINGE
MAGELLAN INSUL SYRINGE 0.3 ML MAGELLAN INSULIN SYRINGE
MAGELLAN INSUL SYRINGE 0.5 ML MAGELLAN INSULIN SYRINGE
MAGELLAN INSULIN SYR 0.3 ML MAGELLAN INSULIN SAFETYSYRNG
MAGELLAN INSULIN SYR 0.5 ML MAGELLAN INSULIN SAFETYSYRNG
MAGELLAN INSULIN SYRINGE 1 ML MAGELLAN INSULIN SAFETYSYRNG
MINIMED RESERVOIR 1.8 ML MINIMED RESERVOIR
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Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
MINIMED RESERVOIR 3 ML MINIMED RESERVOIR
MONOJECT 0.5 ML SYRN 28GX1/2" MONOJECT
MONOJECT 1 ML SYRN 28GX1/2" MONOJECT INSULIN SYRINGE
MONOJECT INSULIN SYR 0.3 ML MONOJECT INSULIN SYRINGE
MONOJECT INSULIN SYR 0.5 ML MONOJECT INSULIN SYRINGE
MONOJECT INSULIN SYR 1 ML MONOJECT INSULIN SYRINGE
MONOJECT INSULIN SYR U-100 MONOJECT INSULIN SYRINGE
MONOJECT SYRINGE 1 ML MONOJECT INSULIN SYRINGE
NOVOPEN ECHO INSULIN DEVICE NOVOPEN ECHO
PARADIGM RESERVOIR 1.8 ML PARADIGM
PARADIGM RESERVOIR 3 ML PARADIGM
PEN NEEDLE 30G X 5/16" PEN NEEDLE
PEN NEEDLE 31G X 3/16" PEN NEEDLE
PEN NEEDLE 31G X 5/16" PEN NEEDLE
SNAP INSULIN PUMP CONTROLLER SNAP INSULIN PUMPCONTROLLER
THINSET 1.8 ML RESERVOIR THINSET
THINSET 3 ML RESERVOIR THINSET
ULTICARE INS SAFETY 1 ML 29X1/2 INSULIN SYRINGE
ULTICARE SAFETY 0.5 ML 29GX1/2 INSULIN SYRINGE
Medical Supplies and DME - Respiratory Therapy
Medication Info Common Name Drug Status Criteria
ACE AEROSOL CLOUD ENHANCER ACE AEROSOL CLOUDENHANCER
AEROCHAMBER MINI AEROCHAMBER MINI
AEROCHAMBER MV HOLD CHAMBER AEROCHAMBER MV
AEROCHAMBER PLUS FLOW-VU AEROCHAMBER PLUS FLOW-VU
AEROCHAMBER PLUS FLOW-VULARGE
AEROCHAMBER PLUS FLOW-VU
AEROCHAMBER PLUS FLOW-VU MED AEROCHAMBER PLUS FLOW-VU
AEROCHAMBER PLUS FLOW-VUSMALL
AEROCHAMBER PLUS FLOW-VU
AEROCHAMBER PLUS W-FLOWSIGNAL
AEROCHAMBER WITHFLOWSIGNAL
AEROCHAMBER PLUS Z STAT AEROCHAMBER PLUS Z STAT
AEROCHAMBER PLUS Z STAT LARGE AEROCHAMBER PLUS Z STAT
AEROCHAMBER PLUS Z STATMEDIUM
AEROCHAMBER PLUS Z STAT
AEROCHAMBER PLUS Z STAT SMALL AEROCHAMBER PLUS Z STAT
AEROCHAMBER Z-STAT PLUS LARGE AEROCHAMBER Z-STAT PLUS
AEROCHAMBER Z-STAT PLUS W-FLOW
AEROCHAMBER Z-STAT PLUS
AEROCHAMBER Z-STAT PLUS-MED AEROCHAMBER Z-STAT PLUS
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Medical Supplies and DME - Respiratory Therapy
Medication Info Common Name Drug Status Criteria
AEROCHAMBER Z-STAT PLUS-SMALL AEROCHAMBER Z-STAT PLUS
AEROTRACH HOLDING CHAMBER AEROTRACH PLUS
AEROVENT PLUS HOLDINGCHAMBER
AEROVENT PLUS
BREATHERITE MDI SPACER BREATHERITE
BREATHRITE VALVED MDI CHAMBER BREATHRITE
BREATHRITE VALVED MDI SPACER BREATHRITE
CLEVER CHOICE CHAMBER-LRGMASK
CLEVER CHOICE HOLDINGCHAMBER
CLEVER CHOICE CHAMBER-MEDMASK
CLEVER CHOICE HOLDINGCHAMBER
CLEVER CHOICE CHAMBER-SMMASK
CLEVER CHOICE HOLDINGCHAMBER
COMPACT SPACE CHAMBER COMPACT SPACE CHAMBER
COMPACT SPACE CHAMBER PLUS COMPACT SPACE CHAMBERPLUS
COMPACT SPACE CHAMBER-LRGMASK
COMPACT SPACE CHAMBER
COMPACT SPACE CHAMBER-MEDMASK
COMPACT SPACE CHAMBER
COMPACT SPACE CHAMBER-SMMASK
COMPACT SPACE CHAMBER
E-Z SPACER E-Z SPACER
EASIVENT HOLDING CHAMBER EASIVENT
FLEXICHAMBER FLEXICHAMBER
INSPIRACHAMBER INSPIRACHAMBER
INSPIRACHAMBER WITH MASK-LARGE
INSPIRACHAMBER
INSPIRACHAMBER WITH MASK-MED INSPIRACHAMBER
INSPIRACHAMBER WITH MASK-SMALL
INSPIRACHAMBER
LITEAIRE MDI CHAMBER LITEAIRE
MICROCHAMBER MICROCHAMBER
MICROSPACER FOR AEROSOLDEVICE
MICROSPACER
MONAGHAN Z STAT CHAMBER MONAGHAN Z STAT
MONAGHAN Z STAT CHAMBER-LGMSK
MONAGHAN Z STAT
MONAGHAN Z STAT CHAMBER-MDMSK
MONAGHAN Z STAT
MONAGHAN Z STAT CHAMBER-SMMSK
MONAGHAN Z STAT
OPTICHAMBER DIAMOND VHC OPTICHAMBER DIAMOND
OPTICHAMBER DIAMOND W-LRGMASK
OPTICHAMBER DIAMOND
OPTICHAMBER DIAMOND W-MEDMASK
OPTICHAMBER DIAMOND
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Medical Supplies and DME - Respiratory Therapy
Medication Info Common Name Drug Status Criteria
OPTICHAMBER DIAMOND W-SMLMASK
OPTICHAMBER DIAMOND
POCKET CHAMBER POCKET CHAMBER
PRIMEAIRE CHAMBER PRIMEAIRE
PROCHAMBER HOLDING CHAMBER PROCHAMBER
RITEFLO SPACER RITEFLO
SPACE CHAMBER PLUS SPACE CHAMBER PLUS
VORTEX HOLDING CHAMBER VORTEX
VORTEX VHC FROG CHILD MASK VORTEX VHC FROG MASK
VORTEX VHC LADYBUG TODDLERMSK
VORTEX VHC LADYBUG MASK
Metabolic Disease Enzyme Replacement, Gaucher’s Disease
Medication Info Common Name Drug Status Criteria
CEREZYME 400 UNITS VIAL CEREZYME PA
Migraine Therapy
Medication Info Common Name Drug Status Criteria
DIHYDROERGOTAMINE 1 MG/ML AMP DIHYDROERGOTAMINEMESYLATE
DIHYDROERGOTAMINE 1 MG/ML VL DIHYDROERGOTAMINEMESYLATE
DIHYDROERGOTAMINE MESYLATE 4MG/ML NASAL SPRAY
DIHYDROERGOTAMINEMESYLATE
ERGOTAMINE-CAFFEINE 1-100 MG TB ERGOTAMINE-CAFFEINE
RIZATRIPTAN 10 MG ODT RIZATRIPTAN QL
RIZATRIPTAN 10 MG TABLET RIZATRIPTAN QL
RIZATRIPTAN 5 MG ODT RIZATRIPTAN QL
RIZATRIPTAN 5 MG TABLET RIZATRIPTAN QL
SUMATRIPTAN 20 MG NASAL SPRAY SUMATRIPTAN
SUMATRIPTAN 4 MG/0.5 ML CART SUMATRIPTAN SUCCINATE QL
SUMATRIPTAN 4 MG/0.5 ML INJECT SUMATRIPTAN SUCCINATE QL
SUMATRIPTAN 5 MG NASAL SPRAY SUMATRIPTAN
SUMATRIPTAN 6 MG/0.5 ML INJECT SUMATRIPTAN SUCCINATE QL
SUMATRIPTAN 6 MG/0.5 ML REFILL SUMATRIPTAN SUCCINATE QL
SUMATRIPTAN 6 MG/0.5 ML SYRNG SUMATRIPTAN SUCCINATE QL
SUMATRIPTAN 6 MG/0.5 ML VIAL SUMATRIPTAN SUCCINATE QL
SUMATRIPTAN SUCC 100 MG TABLET SUMATRIPTAN SUCCINATE QL
SUMATRIPTAN SUCC 25 MG TABLET SUMATRIPTAN SUCCINATE QL
SUMATRIPTAN SUCC 50 MG TABLET SUMATRIPTAN SUCCINATE QL
ZOLMITRIPTAN 2.5 MG ODT ZOLMITRIPTAN ODT
ZOLMITRIPTAN 2.5 MG TABLET ZOLMITRIPTAN QL
ZOLMITRIPTAN 5 MG ODT ZOLMITRIPTAN ODT QL
ZOLMITRIPTAN 5 MG TABLET ZOLMITRIPTAN QL
ZOMIG 2.5 MG TABLET ZOMIG QL
ZOMIG 5 MG NASAL SPRAY ZOMIG QL
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Migraine Therapy
Medication Info Common Name Drug Status Criteria
ZOMIG 5 MG TABLET ZOMIG QL
ZOMIG ZMT 2.5 MG TABLET ZOMIG ZMT QL
ZOMIG ZMT 5 MG TABLET ZOMIG ZMT QL
Minerals and Electrolytes
Medication Info Common Name Drug Status Criteria
EFFER-K 25 MEQ TABLET EFF EFFER-K QL
K EFFERVESCENT 25 MEQ TABLET K EFFERVESCENT QL
KLOR-CON M20 TABLET KLOR-CON M20
KLOR-CON-EF 25 MEQ TAB EFF KLOR-CON-EF QL
POTASSIUM 25 MEQ TABLET EFF POTASSIUM BICARBONATE QL
POTASSIUM CL 10 MEQ/100 ML SOL POTASSIUM CHLORIDE
POTASSIUM CL 10 MEQ/5 ML CONC POTASSIUM CHLORIDE
POTASSIUM CL 10 MEQ/50 ML SOL POTASSIUM CHLORIDE
POTASSIUM CL 10% (20 MEQ/15 ML)LIQUID
POTASSIUM CHLORIDE
POTASSIUM CL 10% (40 MEQ/30 ML)LIQUID
POTASSIUM CHLORIDE
POTASSIUM CL 2 MEQ/ML VIAL POTASSIUM CHLORIDE
POTASSIUM CL 20 MEQ PACKET POTASSIUM CHLORIDE
POTASSIUM CL 20 MEQ/10 ML CONC POTASSIUM CHLORIDE
POTASSIUM CL 20 MEQ/100 ML SOL POTASSIUM CHLORIDE
POTASSIUM CL 20 MEQ/50 ML SOL POTASSIUM CHLORIDE
POTASSIUM CL 20% (40 MEQ/15 ML)LIQUID
POTASSIUM CHLORIDE
POTASSIUM CL 30 MEQ/100 ML SOL POTASSIUM CHLORIDE
POTASSIUM CL 40 MEQ/100 ML SOL POTASSIUM CHLORIDE
POTASSIUM CL 40 MEQ/20 ML CONC POTASSIUM CHLORIDE
POTASSIUM CL ER 10 MEQ CAPSULE POTASSIUM CHLORIDE
POTASSIUM CL ER 10 MEQ TABLET POTASSIUM CHLORIDE
POTASSIUM CL ER 20 MEQ TABLET POTASSIUM CHLORIDE
POTASSIUM CL ER 8 MEQ CAPSULE POTASSIUM CHLORIDE
POTASSIUM CL ER 8 MEQ TABLET POTASSIUM CHLORIDE
Mouth and Throat - Anti-infectives
Medication Info Common Name Drug Status Criteria
CHLORHEXIDINE 0.12% RINSE CHLORHEXIDINE GLUCONATE
CLOTRIMAZOLE 10 MG TROCHE CLOTRIMAZOLE
NYSTATIN 100,000 UNIT/ML SUSP NYSTATIN
NYSTATIN 500,000 UNIT/5 ML SUS NYSTATIN
Mouth and Throat - Glucocorticoids
Medication Info Common Name Drug Status Criteria
TRIAMCINOLONE 0.1% PASTE TRIAMCINOLONE ACETONIDE
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Mouth and Throat - Local Anesthetics
Medication Info Common Name Drug Status Criteria
LIDOCAINE HCL 4% SOLUTION LIDOCAINE HCL
Mouth and Throat - Xerostomia Therapy
Medication Info Common Name Drug Status Criteria
AQUORAL SPRAY AQUORAL
PILOCARPINE HCL 5 MG TABLET PILOCARPINE HCL
PILOCARPINE HCL 7.5 MG TABLET PILOCARPINE HCL
Mucolytics
Medication Info Common Name Drug Status Criteria
PULMOZYME 1 MG/ML AMPUL PULMOZYME PA
Multiple Sclerosis Agent - Interferons
Medication Info Common Name Drug Status Criteria
AVONEX 30 MCG VIAL KIT AVONEX
AVONEX PREFILLED SYR 30 MCG AVONEX
AVONEX PREFILLED SYR 30 MCG KIT AVONEX
BETASERON 0.3 MG KIT BETASERON PA
BETASERON 0.3 MG VIAL BETASERON PA
EXTAVIA 0.3 MG KIT EXTAVIA PA
EXTAVIA 0.3 MG VIAL EXTAVIA PA
REBIF 22 MCG/0.5 ML SYRINGE REBIF PA
REBIF 44 MCG/0.5 ML SYRINGE REBIF PA
REBIF REBIDOSE 22 MCG/0.5 ML REBIF REBIDOSE PA
REBIF REBIDOSE 44 MCG/0.5 ML REBIF REBIDOSE PA
REBIF REBIDOSE TITRATION PACK REBIF REBIDOSE PA
REBIF TITRATION PACK REBIF PA
Multiple Sclerosis Agent - Potassium Channel Blocker
Medication Info Common Name Drug Status Criteria
AMPYRA ER 10 MG TABLET AMPYRA PA
Musculoskeletal Therapy Agents
Medication Info Common Name Drug Status Criteria
BACLOFEN 10 MG TABLET BACLOFEN
BACLOFEN 20 MG TABLET BACLOFEN
CARISOPRODOL 250 MG TABLET CARISOPRODOL
CARISOPRODOL 350 MG TABLET CARISOPRODOL
CYCLOBENZAPRINE 10 MG TABLET CYCLOBENZAPRINE HCL
CYCLOBENZAPRINE 5 MG TABLET CYCLOBENZAPRINE HCL QL
CYCLOBENZAPRINE 7.5 MG TABLET CYCLOBENZAPRINE HCL QL
DANTROLENE SODIUM 100 MG CAP DANTROLENE SODIUM
DANTROLENE SODIUM 25 MG CAP DANTROLENE SODIUM
DANTROLENE SODIUM 50 MG CAP DANTROLENE SODIUM
GENVISC 850 25 MG/2.5 ML SYR GENVISC 850 PA
HYALGAN 20 MG/2 ML SYRINGE HYALGAN PA
HYALGAN 20 MG/2 ML VIAL HYALGAN PA
METAXALONE 400 MG TABLET METAXALONE
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Musculoskeletal Therapy Agents
Medication Info Common Name Drug Status Criteria
METAXALONE 800 MG TABLET METAXALONE
METHOCARBAMOL 1,000 MG/10 ML METHOCARBAMOL
METHOCARBAMOL 500 MG TABLET METHOCARBAMOL
METHOCARBAMOL 750 MG TABLET METHOCARBAMOL
ORPHENADRINE ER 100 MG TABLET ORPHENADRINE CITRATE
SUPARTZ FX 25 MG/2.5 ML SYR SUPARTZ FX PA
SYNVISC SYRINGE SYNVISC PA
SYNVISC-ONE SYRINGE SYNVISC-ONE PA
TIZANIDINE HCL 2 MG CAPSULE TIZANIDINE HCL
TIZANIDINE HCL 2 MG TABLET TIZANIDINE HCL
TIZANIDINE HCL 4 MG CAPSULE TIZANIDINE HCL
TIZANIDINE HCL 4 MG TABLET TIZANIDINE HCL
TIZANIDINE HCL 6 MG CAPSULE TIZANIDINE HCL
VISCO-3 25 MG/2.5 ML SYR VISCO-3 PA
Narcolepsy and Cataplexy Therapy Agents
Medication Info Common Name Drug Status Criteria
MODAFINIL 100 MG TABLET MODAFINIL
MODAFINIL 200 MG TABLET MODAFINIL
Nasal Preparations
Medication Info Common Name Drug Status Criteria
AZELASTINE 0.1% (137 MCG) SPRY AZELASTINE HCL
AZELASTINE 0.15% NASAL SPRAY AZELASTINE HCL
FLUNISOLIDE 0.025% SPRAY FLUNISOLIDE
FLUTICASONE PROP 50 MCG SPRAY FLUTICASONE PROPIONATE
IPRATROPIUM 0.03% SPRAY IPRATROPIUM BROMIDE
IPRATROPIUM 0.06% SPRAY IPRATROPIUM BROMIDE
Neuromuscular Therapy Agents
Medication Info Common Name Drug Status Criteria
PYRIDOSTIGMINE BR 60 MG TABLET PYRIDOSTIGMINE BROMIDE
PYRIDOSTIGMINE ER 180 MG TAB PYRIDOSTIGMINE BROMIDE ER
Ophthalmic - Anti-allergy
Medication Info Common Name Drug Status Criteria
AZELASTINE HCL 0.05% DROPS AZELASTINE HCL
CROMOLYN 4% EYE DROPS CROMOLYN SODIUM
Ophthalmic - Anti-infectives
Medication Info Common Name Drug Status Criteria
BACITRACIN 500 UNIT/GMOPHTHALMIC OINTMENT
BACITRACIN
BACITRACIN-POLYMYXIN EYE OINT BACITRACIN-POLYMYXIN
CIPROFLOXACIN 0.3% EYE DROP CIPROFLOXACIN HCL
ERYTHROMYCIN 0.5% EYEOINTMENT
ERYTHROMYCIN
GENTAMICIN 0.3% EYE DROPS GENTAMICIN SULFATE
2018 Trusted Health Plan Medicaid Formulary
84
Ophthalmic - Anti-infectives
Medication Info Common Name Drug Status Criteria
GENTAMICIN 0.3% EYE OINTMENT GENTAMICIN SULFATE
GENTAMICIN 3 MG/GM EYE OINT GENTAMICIN SULFATE
GENTAMICIN 3 MG/ML EYE DROPS GENTAMICIN SULFATE
LEVOFLOXACIN 0.5% EYE DROPS LEVOFLOXACIN
NEO-POLYCIN EYE OINTMENT NEO-POLYCIN
NEOMYC-BACIT-POLYMIX EYE OINT NEOMYCIN-BACITRACIN-POLYMYXIN
NEOMYC-POLYM-GRAMICID EYEDROP
NEOMYCIN-POLYMYXIN-GRAMICIDIN
OFLOXACIN 0.3% EYE DROPS OFLOXACIN
POLYMYXIN B-TMP EYE DROPS POLYMYXIN B SUL-TRIMETHOPRIM
SULFACETAMIDE 10% EYE DROPS SULFACETAMIDE SODIUM
SULFACETAMIDE 10% EYEOINTMENT
SULFACETAMIDE SODIUM
TOBRAMYCIN 0.3% EYE DROPS TOBRAMYCIN
TRIFLURIDINE 1% EYE DROPS TRIFLURIDINE
VIROPTIC 1% EYE DROPS VIROPTIC
Ophthalmic - Anti-inflammatory
Medication Info Common Name Drug Status Criteria
DICLOFENAC 0.1% EYE DROPS DICLOFENAC SODIUM
FLUOROMETHOLONE 0.1% DROPS FLUOROMETHOLONE
FML FORTE 0.25% EYE DROPS FML FORTE
KETOROLAC 0.4% OPHTH SOLUTION KETOROLAC TROMETHAMINE
KETOROLAC 0.5% OPHTH SOLUTION KETOROLAC TROMETHAMINE
LOTEMAX 0.5% EYE DROPS LOTEMAX
LOTEMAX 0.5% EYE OINTMENT LOTEMAX
LOTEMAX 0.5% OPHTHALMIC GEL LOTEMAX
PREDNISOLONE AC 1% EYE DROP PREDNISOLONE ACETATE
PREDNISOLONE SOD 1% EYE DROP PREDNISOLONE SODIUMPHOSPHATE
Ophthalmic - Intraocular Pressure Reducing Agents
Medication Info Common Name Drug Status Criteria
ALPHAGAN P 0.1% DROPS ALPHAGAN P
ALPHAGAN P 0.15% EYE DROPS ALPHAGAN P
AZOPT 1% EYE DROPS AZOPT
BIMATOPROST 0.03% EYE DROPS BIMATOPROST
BRIMONIDINE 0.2% EYE DROP BRIMONIDINE TARTRATE
BRIMONIDINE TARTRATE 0.15% DRP BRIMONIDINE TARTRATE
DORZOLAMIDE HCL 2% EYE DROPS DORZOLAMIDE HCL
DORZOLAMIDE-TIMOLOL EYE DROPS DORZOLAMIDE-TIMOLOL
LATANOPROST 0.005% EYE DROPS LATANOPROST
LEVOBUNOLOL 0.5% EYE DROPS LEVOBUNOLOL HCL
METIPRANOLOL 0.3% EYE DROPS METIPRANOLOL
2018 Trusted Health Plan Medicaid Formulary
85
Ophthalmic - Intraocular Pressure Reducing Agents
Medication Info Common Name Drug Status Criteria
PILOCARPINE 1% EYE DROPS PILOCARPINE HCL
PILOCARPINE 2% EYE DROPS PILOCARPINE HCL
PILOCARPINE 4% EYE DROPS PILOCARPINE HCL
TIMOLOL 0.25% GEL-SOLUTION TIMOLOL MALEATE
TIMOLOL 0.25% GFS GEL-SOLUTION TIMOLOL MALEATE
TIMOLOL 0.5% EYE DROPS TIMOLOL MALEATE
TIMOLOL 0.5% GEL-SOLUTION TIMOLOL MALEATE
TIMOLOL 0.5% GFS GEL-SOLUTION TIMOLOL MALEATE
TIMOLOL MALEATE 0.25% EYE DROP TIMOLOL MALEATE
TIMOLOL MALEATE 0.5% EYE DROPS TIMOLOL MALEATE
Ophthalmic - Mydriatics and Cycloplegics
Medication Info Common Name Drug Status Criteria
ATROPINE 1% EYE DROPS ATROPINE SULFATE
Ophthalmic Combinations
Medication Info Common Name Drug Status Criteria
NEO-BACIT-POLY-HC EYE OINTMENT NEOMYCIN-BACITRACIN-POLY-HC
NEO-POLYCIN HC EYE OINTMENT NEO-POLYCIN HC
NEOMYC-POLYM-DEXAMET EYEOINTM
NEOMYCIN-POLYMYXIN-DEXAMETH
NEOMYC-POLYM-DEXAMETH EYEDROP
NEOMYCIN-POLYMYXIN-DEXAMETH
NEOMYCIN-POLY-HC EYE DROPS NEOMYCIN-POLYMYXIN-HC
TOBRAMYCIN-DEXAMETH OPHTHSUSP
TOBRAMYCIN-DEXAMETHASONE
Opiate/Narcotic Reversal Agents - Opiate Antagonists
Medication Info Common Name Drug Status Criteria
NARCAN 4 MG NASAL SPRAY NARCAN
Otic - Anti-infectives
Medication Info Common Name Drug Status Criteria
ACETIC ACID 2% EAR SOLUTION ACETIC ACID
OFLOXACIN 0.3% EAR DROPS OFLOXACIN
Otic Combinations
Medication Info Common Name Drug Status Criteria
ACETIC ACID-ALUMINUM DROPS ACETIC ACID-ALUMINUM
NEOMYCIN-POLYMYXIN-HC EARSOLN
NEOMYCIN-POLYMYXIN-HYDROCORT
NEOMYCIN-POLYMYXIN-HC EARSUSP
NEOMYCIN-POLYMYXIN-HC
Passive Immunizing Agents
Medication Info Common Name Drug Status Criteria
CYTOGAM 2.5 GM/50 ML VIAL CYTOGAM PA
GAMMAKED 1 GRAM/10 ML VIAL GAMMAKED
GAMMAKED 10 GRAM/100 ML VIAL GAMMAKED
GAMMAKED 2.5 GRAM/25 ML VIAL GAMMAKED
2018 Trusted Health Plan Medicaid Formulary
86
Passive Immunizing Agents
Medication Info Common Name Drug Status Criteria
GAMMAKED 20 GRAM/200 ML VIAL GAMMAKED
GAMMAKED 5 GRAM/50 ML VIAL GAMMAKED
GAMUNEX-C 1 GRAM/10 ML VIAL GAMUNEX-C
GAMUNEX-C 10 GRAM/100 ML VIAL GAMUNEX-C
GAMUNEX-C 2.5 GRAM/25 ML VIAL GAMUNEX-C
GAMUNEX-C 20 GRAM/200 ML VIAL GAMUNEX-C
GAMUNEX-C 5 GRAM/50 ML VIAL GAMUNEX-C
HYPERRHO S-D 1500 UNITS SYR HYPERRHO S-D PA
RHOGAM ULTRA-FILTERED PLUSSYR
RHOGAM ULTRA-FILTEREDPLUS
PA
SYNAGIS 100 MG/1 ML VIAL SYNAGIS PA
SYNAGIS 50 MG/0.5 ML VIAL SYNAGIS PA
Peptic Ulcer Therapy
Medication Info Common Name Drug Status Criteria
CIMETIDINE 300 MG TABLET CIMETIDINE
CIMETIDINE 300 MG/5 ML SOLN CIMETIDINE
CIMETIDINE 400 MG TABLET CIMETIDINE
CIMETIDINE 800 MG TABLET CIMETIDINE
ESOMEPRAZOLE MAG DR 20 MG CAP ESOMEPRAZOLE MAGNESIUM
ESOMEPRAZOLE MAG DR 40 MG CAP ESOMEPRAZOLE MAGNESIUM
LANSOPRAZOLE DR 30 MG CAPSULE LANSOPRAZOLE
MISOPROSTOL 100 MCG TABLET MISOPROSTOL
MISOPROSTOL 200 MCG TABLET MISOPROSTOL
OMEPRAZOLE DR 10 MG CAPSULE OMEPRAZOLE
OMEPRAZOLE DR 20 MG CAPSULE OMEPRAZOLE
OMEPRAZOLE DR 40 MG CAPSULE OMEPRAZOLE
PANTOPRAZOLE SOD DR 20 MG TAB PANTOPRAZOLE SODIUM
PANTOPRAZOLE SOD DR 40 MG TAB PANTOPRAZOLE SODIUM
RANITIDINE 15 MG/ML SYRUP RANITIDINE HCL
RANITIDINE 150 MG CAPSULE RANITIDINE HCL
RANITIDINE 150 MG/10 ML SYRUP RANITIDINE HCL
RANITIDINE 300 MG CAPSULE RANITIDINE HCL
RANITIDINE 300 MG TABLET RANITIDINE HCL
SUCRALFATE 1 GM TABLET SUCRALFATE
SUCRALFATE 1 GM/10 ML SUSP SUCRALFATE
Pharmaceutical Adjuvants
Medication Info Common Name Drug Status Criteria
SODIUM CHLORIDE 10% VIAL SODIUM CHLORIDE
SODIUM CHLORIDE 3% VIAL SODIUM CHLORIDE
SODIUM CHLORIDE 7% VIAL SODIUM CHLORIDE
2018 Trusted Health Plan Medicaid Formulary
87
Phosphate Binders
Medication Info Common Name Drug Status Criteria
CALCIUM ACETATE 667 MG CAPSULE CALCIUM ACETATE
CALCIUM ACETATE 667 MG GELCAP CALCIUM ACETATE
CALCIUM ACETATE 667 MG TABLET CALCIUM ACETATE
Platelet Aggregation Inhibitors and Combinations
Medication Info Common Name Drug Status Criteria
ANAGRELIDE HCL 0.5 MG CAPSULE ANAGRELIDE HCL
ANAGRELIDE HCL 1 MG CAPSULE ANAGRELIDE HCL
CILOSTAZOL 100 MG TABLET CILOSTAZOL
CILOSTAZOL 50 MG TABLET CILOSTAZOL
CLOPIDOGREL 300 MG TABLET CLOPIDOGREL
CLOPIDOGREL 75 MG TABLET CLOPIDOGREL
DIPYRIDAMOLE 25 MG TABLET DIPYRIDAMOLE
DIPYRIDAMOLE 50 MG TABLET DIPYRIDAMOLE
DIPYRIDAMOLE 75 MG TABLET DIPYRIDAMOLE
Posterior Pituitary Hormones
Medication Info Common Name Drug Status Criteria
DESMOPRESSIN 0.01% SOLUTION DESMOPRESSIN ACETATE
DESMOPRESSIN 0.01% SPRAY DESMOPRESSIN ACETATE
DESMOPRESSIN 0.1 MG/ML SOL DESMOPRESSIN ACETATE
DESMOPRESSIN 10 MCG/0.1 ML SPR DESMOPRESSIN ACETATE
DESMOPRESSIN 40 MCG/10 ML VIAL DESMOPRESSIN ACETATE
DESMOPRESSIN AC 4 MCG/MLAMPUL
DESMOPRESSIN ACETATE
DESMOPRESSIN AC 4 MCG/ML VIAL DESMOPRESSIN ACETATE
DESMOPRESSIN ACETATE 0.1 MG TB DESMOPRESSIN ACETATE
DESMOPRESSIN ACETATE 0.2 MG TB DESMOPRESSIN ACETATE
Progestins
Medication Info Common Name Drug Status Criteria
MEDROXYPROGESTERONE 10 MGTAB
DEPO-PROVERA
MEDROXYPROGESTERONE 2.5 MGTAB
DEPO-PROVERA
MEDROXYPROGESTERONE 5 MGTAB
DEPO-PROVERA
NORETHINDRN 5 MG TB (LUPANETA) NORETHINDRONE AC(LUPANETA)
NORETHINDRONE 5 MG TABLET NORETHINDRONE ACETATE
Prostatic Hypertrophy Agents
Medication Info Common Name Drug Status Criteria
ALFUZOSIN HCL ER 10 MG TABLET ALFUZOSIN HCL ER
AVODART 0.5 MG SOFTGEL AVODART
DUTASTERIDE 0.5 MG CAPSULE DUTASTERIDE
FINASTERIDE 5 MG TABLET FINASTERIDE
TAMSULOSIN HCL 0.4 MG CAPSULE TAMSULOSIN HCL
2018 Trusted Health Plan Medicaid Formulary
88
Pseudobulbar Affect (PBA) Agents
Medication Info Common Name Drug Status Criteria
NUEDEXTA 20-10 MG CAPSULE NUEDEXTA PA
Respiratory Combinations
Medication Info Common Name Drug Status Criteria
BROMFED DM COUGH SYRUP BROMFED DM
BROMPHENIR-PSEUDOEPHED-DMSYR
BROMPHENIRAMINE-PSEUDOEPHED-DM
FEXOFENADINE-PSE ER 60-120 TAB FEXOFENADINE-PSE ER QL
HYDROCODONE-HOMATROPINESYRUP
HYDROCODONE-HOMATROPINE MBR
PROMETHAZINE VC-CODEINE SYRUP PROMETHAZINE VC-CODEINE
PROMETHAZINE-CODEINE SYRUP PROMETHAZINE-CODEINE
PROMETHAZINE-DM SYRUP PROMETHAZINE-DM
PROMETHAZINE-PE-CODEINE SYRUP PROMETHAZINE-PHENYLEPH-CODEINE
ZYRTEC-D TABLET ZYRTEC-D
Sedative-Hypnotics
Medication Info Common Name Drug Status Criteria
FLURAZEPAM 15 MG CAPSULE FLURAZEPAM HCL
FLURAZEPAM 30 MG CAPSULE FLURAZEPAM HCL
LORAZEPAM 4 MG/ML CARPUJECT LORAZEPAM
LORAZEPAM 4 MG/ML VIAL LORAZEPAM
LORAZEPAM 40 MG/10 ML VIAL LORAZEPAM
PHENOBARBITAL 100 MG TABLET PHENOBARBITAL
PHENOBARBITAL 15 MG TABLET PHENOBARBITAL
PHENOBARBITAL 16.2 MG TABLET PHENOBARBITAL
PHENOBARBITAL 20 MG/5 ML ELIX PHENOBARBITAL
PHENOBARBITAL 20 MG/5 ML SOLN PHENOBARBITAL
PHENOBARBITAL 30 MG TABLET PHENOBARBITAL
PHENOBARBITAL 32.4 MG TABLET PHENOBARBITAL
PHENOBARBITAL 60 MG TABLET PHENOBARBITAL
PHENOBARBITAL 64.8 MG TABLET PHENOBARBITAL
PHENOBARBITAL 97.2 MG TABLET PHENOBARBITAL
TEMAZEPAM 15 MG CAPSULE TEMAZEPAM
TEMAZEPAM 22.5 MG CAPSULE TEMAZEPAM
TEMAZEPAM 30 MG CAPSULE TEMAZEPAM
TEMAZEPAM 7.5 MG CAPSULE TEMAZEPAM
ZOLPIDEM TART 1.75 MG TAB SL ZOLPIDEM TARTRATE QL
ZOLPIDEM TART 3.5 MG TABLET SL ZOLPIDEM TARTRATE QL
ZOLPIDEM TART ER 12.5 MG TAB ZOLPIDEM TARTRATE ER QL
ZOLPIDEM TART ER 6.25 MG TAB ZOLPIDEM TARTRATE ER QL
ZOLPIDEM TARTRATE 10 MG TABLET ZOLPIDEM TARTRATE QL
ZOLPIDEM TARTRATE 5 MG TABLET ZOLPIDEM TARTRATE QL
2018 Trusted Health Plan Medicaid Formulary
89
Sickle Cell Anemia Agents
Medication Info Common Name Drug Status Criteria
DROXIA 200 MG CAPSULE DROXIA
DROXIA 300 MG CAPSULE DROXIA
DROXIA 400 MG CAPSULE DROXIA
Smoking Deterrents and Combinations
Medication Info Common Name Drug Status Criteria
CHANTIX 1 MG CONT MONTH BOX CHANTIX QL
CHANTIX 1 MG TABLET CHANTIX QL
CHANTIX STARTING MONTH BOX CHANTIX QL
Thyroid Therapy
Medication Info Common Name Drug Status Criteria
LEVO-T 100 MCG TABLET LEVO-T
LEVO-T 112 MCG TABLET LEVO-T
LEVO-T 125 MCG TABLET LEVO-T
LEVO-T 137 MCG TABLET LEVO-T
LEVO-T 150 MCG TABLET LEVO-T
LEVO-T 175 MCG TABLET LEVO-T
LEVO-T 200 MCG TABLET LEVO-T
LEVO-T 25 MCG TABLET LEVO-T
LEVO-T 300 MCG TABLET LEVO-T
LEVO-T 50 MCG TABLET LEVO-T
LEVO-T 75 MCG TABLET LEVO-T
LEVO-T 88 MCG TABLET LEVO-T
LEVOTHYROXINE 0.025 MG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 0.05 MG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 0.075 MG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 0.088 MG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 0.1 MG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 0.112 MG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 0.125 MG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 0.137 MG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 0.15 MG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 0.175 MG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 100 MCG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 100 MCG VIAL LEVOTHYROXINE SODIUM
LEVOTHYROXINE 112 MCG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 125 MCG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 137 MCG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 150 MCG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 175 MCG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 200 MCG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 200 MCG VIAL LEVOTHYROXINE SODIUM
LEVOTHYROXINE 25 MCG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 300 MCG TABLET LEVOTHYROXINE SODIUM
2018 Trusted Health Plan Medicaid Formulary
90
Thyroid Therapy
Medication Info Common Name Drug Status Criteria
LEVOTHYROXINE 50 MCG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 500 MCG VIAL LEVOTHYROXINE SODIUM
LEVOTHYROXINE 75 MCG TABLET LEVOTHYROXINE SODIUM
LEVOTHYROXINE 88 MCG TABLET LEVOTHYROXINE SODIUM
LEVOXYL 100 MCG TABLET LEVOXYL
LEVOXYL 112 MCG TABLET LEVOXYL
LEVOXYL 125 MCG TABLET LEVOXYL
LEVOXYL 137 MCG TABLET LEVOXYL
LEVOXYL 150 MCG TABLET LEVOXYL
LEVOXYL 175 MCG TABLET LEVOXYL
LEVOXYL 200 MCG TABLET LEVOXYL
LEVOXYL 25 MCG TABLET LEVOXYL
LEVOXYL 50 MCG TABLET LEVOXYL
LEVOXYL 75 MCG TABLET LEVOXYL
LEVOXYL 88 MCG TABLET LEVOXYL
LIOTHYRONINE SOD 10 MCG/ML VL LIOTHYRONINE SODIUM
LIOTHYRONINE SOD 25 MCG TAB LIOTHYRONINE SODIUM
LIOTHYRONINE SOD 5 MCG TAB LIOTHYRONINE SODIUM
LIOTHYRONINE SOD 50 MCG TAB LIOTHYRONINE SODIUM
METHIMAZOLE 10 MG TABLET METHIMAZOLE
METHIMAZOLE 5 MG TABLET METHIMAZOLE
PROPYLTHIOURACIL 50 MG TABLET PROPYLTHIOURACIL
SYNTHROID 0.137 MG TABLET SYNTHROID
SYNTHROID 100 MCG TABLET SYNTHROID
SYNTHROID 112 MCG TABLET SYNTHROID
SYNTHROID 125 MCG TABLET SYNTHROID
SYNTHROID 137 MCG TABLET SYNTHROID
SYNTHROID 150 MCG TABLET SYNTHROID
SYNTHROID 175 MCG TABLET SYNTHROID
SYNTHROID 200 MCG TABLET SYNTHROID
SYNTHROID 25 MCG TABLET SYNTHROID
SYNTHROID 300 MCG TABLET SYNTHROID
SYNTHROID 50 MCG TABLET SYNTHROID
SYNTHROID 75 MCG TABLET SYNTHROID
SYNTHROID 88 MCG TABLET SYNTHROID
UNITHROID 100 MCG TABLET UNITHROID
UNITHROID 112 MCG TABLET UNITHROID
UNITHROID 125 MCG TABLET UNITHROID
UNITHROID 137 MCG TABLET UNITHROID
UNITHROID 150 MCG TABLET UNITHROID
UNITHROID 175 MCG TABLET UNITHROID
UNITHROID 200 MCG TABLET UNITHROID
UNITHROID 25 MCG TABLET UNITHROID
2018 Trusted Health Plan Medicaid Formulary
91
Thyroid Therapy
Medication Info Common Name Drug Status Criteria
UNITHROID 300 MCG TABLET UNITHROID
UNITHROID 50 MCG TABLET UNITHROID
UNITHROID 75 MCG TABLET UNITHROID
UNITHROID 88 MCG TABLET UNITHROID
Urinary Analgesics
Medication Info Common Name Drug Status Criteria
PHENAZOPYRIDINE 100 MG TAB PHENAZOPYRIDINE HCL
PHENAZOPYRIDINE 200 MG TAB PHENAZOPYRIDINE HCL
Urinary Anti-infectives
Medication Info Common Name Drug Status Criteria
CIPRO XR 1,000 MG TABLET CIPRO XR
CIPROFLOXACIN ER 1,000 MG TAB CIPROFLOXACIN ER
CIPROFLOXACIN ER 500 MG TABLET CIPROFLOXACIN ER QL
NITROFURANTOIN 25 MG/5 ML SUSP NITROFURANTOIN
NITROFURANTOIN MCR 100 MG CAP NITROFURANTOIN
NITROFURANTOIN MCR 25 MG CAP NITROFURANTOIN
NITROFURANTOIN MCR 50 MG CAP NITROFURANTOIN
NITROFURANTOIN MONO-MCR 100MG
NITROFURANTOIN MONO-MACRO
Urinary Antispasmodics
Medication Info Common Name Drug Status Criteria
DARIFENACIN ER 15 MG TABLET DARIFENACIN ER
DARIFENACIN ER 7.5 MG TABLET DARIFENACIN ER
DETROL LA 2 MG CAPSULE DETROL LA
DETROL LA 4 MG CAPSULE DETROL LA
ENABLEX 15 MG TABLET ENABLEX
ENABLEX 7.5 MG TABLET ENABLEX
OXYBUTYNIN 5 MG TABLET OXYBUTYNIN CHLORIDE
OXYBUTYNIN 5 MG/5 ML SYRUP OXYBUTYNIN CHLORIDE
OXYBUTYNIN CL ER 10 MG TABLET OXYBUTYNIN CHLORIDE ER
OXYBUTYNIN CL ER 15 MG TABLET OXYBUTYNIN CHLORIDE ER
OXYBUTYNIN CL ER 5 MG TABLET OXYBUTYNIN CHLORIDE ER
TOLTERODINE TART ER 2 MG CAP TOLTERODINE TARTRATE ER
TOLTERODINE TART ER 4 MG CAP TOLTERODINE TARTRATE ER
TOLTERODINE TARTRATE 1 MG TAB TOLTERODINE TARTRATE
TOLTERODINE TARTRATE 2 MG TAB TOLTERODINE TARTRATE
TROSPIUM CHLORIDE 20 MG TABLET TROSPIUM CHLORIDE
TROSPIUM CHLORIDE ER 60 MG CAP TROSPIUM CHLORIDE ER
Urinary pH Modifiers
Medication Info Common Name Drug Status Criteria
POTASSIUM CIT-CITRIC ACID SOLN POTASSIUM CITRATE-CITRICACID
POTASSIUM CITRATE ER 10 MEQ TB POTASSIUM CITRATE ER
2018 Trusted Health Plan Medicaid Formulary
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Urinary pH Modifiers
Medication Info Common Name Drug Status Criteria
POTASSIUM CITRATE ER 15 MEQ TB POTASSIUM CITRATE ER
POTASSIUM CITRATE ER 5 MEQ TAB POTASSIUM CITRATE ER
SOD CITRATE-CITRIC ACID SOLN SODIUM CITRATE-CITRIC ACID
Urinary Retention Therapy
Medication Info Common Name Drug Status Criteria
BETHANECHOL 10 MG TABLET BETHANECHOL CHLORIDE
BETHANECHOL 25 MG TABLET BETHANECHOL CHLORIDE
BETHANECHOL 5 MG TABLET BETHANECHOL CHLORIDE
BETHANECHOL 50 MG TABLET BETHANECHOL CHLORIDE
Vaginal Anti-infectives
Medication Info Common Name Drug Status Criteria
CLEOCIN 100 MG VAGINAL OVULE CLEOCIN
CLINDAMYCIN 2% VAGINAL CREAM CLINDAMYCIN PHOSPHATE
METRONIDAZOLE VAGINAL 0.75% GL METRONIDAZOLE
TERCONAZOLE 0.4% CREAM TERCONAZOLE
TERCONAZOLE 0.8% CREAM TERCONAZOLE
TERCONAZOLE 80 MG SUPPOSITORY TERCONAZOLE
Vaginal Estrogens
Medication Info Common Name Drug Status Criteria
ESTRADIOL 10 MCG VAGINAL INSRT ESTRADIOL
PREMARIN VAGINAL CREAM-APPL PREMARIN
Vitamin Combinations
Medication Info Common Name Drug Status Criteria
ACTIVE OB SOFTGEL ACTIVE OB
ATABEX EC CAPLET ATABEX EC
BAL-CARE DHA COMBO PACK BAL-CARE DHA
BAL-CARE DHA ESSENTIAL PACK BAL-CARE DHA ESSENTIAL
C-NATE DHA SOFTGEL C-NATE DHA
CADEAU DHA SOFTGEL CADEAU DHA
CALCIUM-PNV 28-1-250 MG SFTGL CALCIUM PNV
CITRANATAL 90 DHA COMBO PACK CITRANATAL 90 DHA
CITRANATAL ASSURE COMBO PACK CITRANATAL ASSURE
CITRANATAL B-CALM COMBO PACK CITRANATAL B-CALM
CITRANATAL DHA PACK CITRANATAL DHA
CITRANATAL HARMONY CAPSULE CITRANATAL HARMONY
CITRANATAL RX TABLET CITRANATAL RX
COMPLETE NATAL DHA COMPLETE NATAL DHA
COMPLETENATE TABLET CHEW COMPLETENATE
CONCEPT DHA CAPSULE CONCEPT DHA
CONCEPT OB CAPSULE CONCEPT OB
DOTHELLE DHA SOFTGEL DOTHELLE DHA
DUET DHA 400 COMBO PACK DUET DHA 400
DUET DHA BALANCED (25 MG IRON) DUET DHA BALANCED
2018 Trusted Health Plan Medicaid Formulary
93
Vitamin Combinations
Medication Info Common Name Drug Status Criteria
ELITE OB DHA SOFTGEL ELITE OB DHA
ELITE-OB 400 CAPSULE ELITE-OB 400
ELITE-OB CAPLET ELITE-OB
ESCAVITE D TABLET CHEWABLE ESCAVITE D
ESCAVITE LQ DROPS ESCAVITE LQ
ESCAVITE TABLET CHEWABLE ESCAVITE
EXTRA-VIRT PLUS DHA SOFTGEL EXTRA-VIRT PLUS DHA
FLORIVA 0.25 MG CHEW TABLET FLORIVA
FLORIVA 0.5 MG CHEWABLE TABLET FLORIVA
FLORIVA 1 MG CHEWABLE TABLET FLORIVA
FLORIVA PLUS 0.25 MG/ML DROPS FLORIVA PLUS
FOCALGIN 90 DHA COMBO PACK FOCALGIN 90 DHA
FOCALGIN CA COMBO PACK FOCALGIN CA
FOLET ONE SOFTGEL FOLET ONE
FOLIVANE-OB CAPSULE FOLIVANE-OB
HEMENATAL OB + DHA COMBO PACK HEMENATAL OB + DHA
HEMENATAL OB TABLET HEMENATAL OB
INFUVITE PEDIATRIC BULK VIAL INFUVITE PEDIATRIC
INFUVITE PEDIATRIC BULK VIAL 1 INFUVITE PEDIATRIC VIAL 1
INFUVITE PEDIATRIC BULK VIAL 2 INFUVITE PEDIATRIC VIAL 2
INFUVITE PEDIATRIC VIAL INFUVITE PEDIATRIC
INFUVITE PEDIATRIC VIAL 1 INFUVITE PEDIATRIC VIAL 1
INFUVITE PEDIATRIC VIAL 2 INFUVITE PEDIATRIC VIAL 2
KOSHER PRENATAL PLUS IRON TAB KOSHER PRENATAL PLUSIRON
LEVOMEFOLATE DHA CAPSULE LEVOMEFOLATE DHA
M.V.I. PEDIATRIC VIAL M.V.I. PEDIATRIC
MACNATAL CN DHA SOFTGEL MACNATAL CN DHA
MARNATAL-F CAPSULE MARNATAL-F
MAXINATE TABLET MAXINATE
MULTI-VIT W-FLUOR 0.25 MG/ML MULTI-VITAMIN W-FLUORIDE
MULTI-VIT W-FLUOR 0.5 MG/ML MULTI-VITAMIN W-FLUORIDE
MULTIVIT-FLUOR 0.25 MG TAB CHW MULTIVITAMIN WITH FLUORIDE
MULTIVIT-FLUOR 0.25 MG/ML DROP MULTIVITAMINS WITHFLUORIDE
MULTIVIT-FLUOR 0.5 MG TAB CHEW MULTIVITAMIN WITH FLUORIDE
MULTIVIT-FLUOR 0.5 MG TAB CHW MULTI-VITAMIN WITHFLUORIDE
MULTIVIT-FLUOR 0.5 MG/ML DROP MULTIVITAMINS WITHFLUORIDE
MULTIVIT-FLUOR-IRON 0.25 MG/ML MULTI-VITAMIN W-FLUORIDE-IRON
MULTIVIT-FLUORIDE 1 MG TAB CHW MULTIVITAMIN WITH FLUORIDE
MULTIVIT-IRON-FL 0.25 MG/ML MULTIVITAMINS W-FLUORIDE-IRON
2018 Trusted Health Plan Medicaid Formulary
94
Vitamin Combinations
Medication Info Common Name Drug Status Criteria
MULTIVIT-IRON-FLUOR 0.25 MG/ML MULTIVITAMIN-IRON-FLUORIDE
MVC-FLUORIDE 0.25 MG TAB CHEW MVC-FLUORIDE
MVC-FLUORIDE 0.5 MG TAB CHEW MVC-FLUORIDE
MVC-FLUORIDE 1 MG TAB CHEW MVC-FLUORIDE
MYNATAL ADVANCE TABLET MYNATAL ADVANCE
MYNATAL CAPSULE MYNATAL
MYNATAL PLUS CAPTAB MYNATAL PLUS
MYNATAL ULTRACAPLET MYNATAL
MYNATAL-Z CAPTAB MYNATAL-Z
MYNATE 90 PLUS CAPLET SA MYNATE 90 PLUS
NATACHEW TABLET NATACHEW
NATELLE ONE CAPSULE NATELLE ONE
NEEVODHA CAPSULE NEEVODHA
NESTABS ABC PRENATAL COMBO PK NESTABS ABC
NESTABS DHA COMBO PACK NESTABS DHA
NESTABS ONE SOFTGEL NESTABS ONE
NESTABS TABLET NESTABS
NEWGEN TABLET NEWGEN
NEXA PLUS SOFTGEL NEXA PLUS
NIVA-PLUS TABLET NIVA-PLUS
O-CAL FA TABLET O-CAL FA
O-CAL PRENATAL TABLET O-CAL PRENATAL
OB COMPLETE CAPLET OB COMPLETE
OB COMPLETE GOLD SOFTGEL OB COMPLETE GOLD
OB COMPLETE ONE SOFTGEL OB COMPLETE ONE
OB COMPLETE PETITE SOFTGEL OB COMPLETE PETITE
OB COMPLETE WITH DHA SOFTGEL OB COMPLETE WITH DHA
OBSTETRIX DHA COMBO PAK OBSTETRIX DHA
OBSTETRIX EC CAPLET OBSTETRIX EC
OBSTETRIX ONE SOFTGEL OBSTETRIX ONE
OBTREX DHA PRENATAL VITAMIN OBTREX DHA
PNV 29-1 TABLET PNV 29-1
PNV OB+DHA COMBO PACK PNV OB+DHA
PNV PRENATAL PLUS MULTIVIT TAB PRENATAL PLUS
PNV-DHA + DOCUSATE SOFTGEL PNV-DHA + DOCUSATE
PNV-DHA SOFTGEL PNV-DHA
PNV-FERROUS FUMARATE-DOCU-FA PNV-FERROUS FUMARATE-DOCU-FA
PNV-OMEGA SOFTGEL PNV-OMEGA
PNV-SELECT TABLET PNV-SELECT
PNV-VP-U CAPSULE PNV-VP-U
POLY-VI-FLOR 0.25 MG DROPS POLY-VI-FLOR
POLY-VI-FLOR 0.25 MG TAB CHEW POLY-VI-FLOR
2018 Trusted Health Plan Medicaid Formulary
95
Vitamin Combinations
Medication Info Common Name Drug Status Criteria
POLY-VI-FLOR 0.5 MG TAB CHEW POLY-VI-FLOR
POLY-VI-FLOR 1 MG TAB CHEW POLY-VI-FLOR
POLY-VI-FLOR WITH IRON 0.25 MG POLY-VI-FLOR WITH IRON
POLY-VI-FLOR WITH IRON 0.5 MG POLY-VI-FLOR WITH IRON
POLYVIT-FLUOR 0.25 MG/ML DROP POLYVITAMINS-FLUORIDE
PR NATAL 400 COMBO PACK PR NATAL 400
PR NATAL 400 EC COMBO PACK PR NATAL 400 EC
PR NATAL 430 COMBO PACK PR NATAL 430
PR NATAL 430 EC COMBO PACK PR NATAL 430 EC
PREFERA OB TABLET PREFERA OB
PREFERA-OB ONE SOFTGEL PREFERA-OB ONE
PREFERA-OB PLUS DHA COMBOPACK
PREFERA-OB PLUS DHA
PRENA1 CHEW TABLET PRENA1 CHEW
PRENA1 PEARL SOFTGEL PRENA1 PEARL
PRENA1 TRUE COMBO PACK PRENA1 TRUE
PRENAISSANCE CAPSULE PRENAISSANCE
PRENAISSANCE PLUS SOFTGEL PRENAISSANCE PLUS
PRENATA CHEWABLE TABLET PRENATA
PRENATABS FA TABLET PRENATABS FA
PRENATABS RX TABLET PRENATABS RX
PRENATAL 19 CHEWABLE TABLET PRENATAL 19
PRENATAL 19 TABLET PRENATAL 19
PRENATAL LOW IRON TABLET PRENATAL LOW IRON
PRENATAL PLUS IRON TABLET PRENATAL PLUS
PRENATAL PLUS TABLET PRENATAL PLUS
PRENATAL PLUS-DHA COMBO PACK PRENATAL PLUS-DHA
PRENATAL VITAMIN PLUS LOW IRON PRENATAL VITAMIN PLUS LOWIRON
PRENATAL-U CAPSULE PRENATAL-U
PRENATE AM TABLET PRENATE AM
PRENATE CHEWABLE TABLET PRENATE CHEWABLE
PRENATE DHA SOFTGEL PRENATE DHA
PRENATE ELITE TABLET PRENATE ELITE
PRENATE ENHANCE SOFTGEL PRENATE ENHANCE
PRENATE ESSENTIAL SOFTGEL PRENATE ESSENTIAL
PRENATE MINI SOFTGEL PRENATE MINI
PRENATE PIXIE SOFTGEL PRENATE PIXIE
PRENATE RESTORE SOFTGEL PRENATE RESTORE
PRENATE STAR TABLET PRENATE STAR
PREPLUS CA-FE 27 MG-FA 1 MG TB PREPLUS
PREQUE 10 TABLET PREQUE 10
PRETAB 29 MG-1 MG TABLET PRETAB
2018 Trusted Health Plan Medicaid Formulary
96
Vitamin Combinations
Medication Info Common Name Drug Status Criteria
PRIMACARE SOFTGEL PRIMACARE
PROVIDA DHA CAPSULE PROVIDA DHA
PROVIDA OB CAPSULE PROVIDA OB
PUREFE OB PLUS CAPSULE PUREFE OB PLUS
PUREFE PLUS CAPSULE PUREFE PLUS
QUFLORA FE 0.25 MG CHEW TABLET QUFLORA FE
QUFLORA FE PED 0.25 MG/ML DROP QUFLORA FE
QUFLORA PED 0.25 MG CHEW TAB QUFLORA
QUFLORA PED 0.25 MG/ML DROP QUFLORA
QUFLORA PED 0.5 MG CHEW TAB QUFLORA
QUFLORA PED 0.5 MG/ML DROP QUFLORA
QUFLORA PED 1 MG CHEW TAB QUFLORA
R-NATAL OB SOFTGEL R-NATAL OB
RELNATE DHA PRENATAL SOFTGEL RELNATE DHA
RULAVITE DHA SOFTGEL RULAVITE DHA
SE-NATAL 19 CHEWABLE TABLET SE-NATAL 19
SE-NATAL 19 TABLET SE-NATAL 19
SELECT-OB + DHA PACK SELECT-OB + DHA
SELECT-OB CHEWABLE CAPLET SELECT-OB
TARON-C DHA CAPSULE TARON-C DHA
TARON-PREX PRENATAL DHA CAP TARON-PREX PRENATAL
TEXAVITE LQ DROPS TEXAVITE LQ
THRIVITE 19 TABLET THRIVITE 19
THRIVITE RX TABLET THRIVITE RX
TL-SELECT CAPSULE TL-SELECT
TRI-TABS DHA COMBO PACK TRI-TABS DHA
TRI-VI-FLOR 0.25 MG DROPS TRI-VI-FLOR
TRI-VI-FLOR 0.5 MG DROPS TRI-VI-FLOR
TRI-VIT-FLUOR 0.25 MG/ML DROP TRI-VITAMIN WITH FLUORIDE
TRI-VIT-FLUOR 0.5 MG/ML DROP TRI-VITAMIN WITH FLUORIDE
TRI-VIT-FLUOR-IRON 0.25 MG/ML TRI-VIT WITH FLUORIDE-IRON
TRIADVANCE TABLET TRIADVANCE
TRICARE PRENATAL CHEWABLE TAB TRICARE PRENATAL
TRICARE PRENATAL DHA ONE SFTGL TRICARE PRENATAL DHA ONE
TRICARE PRENATAL TABLET TRICARE
TRICARE PRENATAL WITH DHA PACK TRICARE PRENATAL WITH DHA
TRINATAL GT TABLET TRINATAL GT
TRINATAL RX 1 TABLET TRINATAL RX 1
TRINATE TABLET TRINATE
TRIPLE-VIT W-FLUOR 0.25 MG/ML TRIPLE-VITAMIN W-FLUORIDE
TRISTART DHA SOFTGEL TRISTART DHA
TRIVEEN-DUO DHA COMBO PACK TRIVEEN-DUO DHA
TRIVEEN-ONE CAPSULE TRIVEEN-ONE
2018 Trusted Health Plan Medicaid Formulary
97
Vitamin Combinations
Medication Info Common Name Drug Status Criteria
TRIVEEN-PRX RNF CAPSULE TRIVEEN-PRX RNF
TRUST NATAL DHA TRUST NATAL DHA
ULTIMATECARE ONE CAPSULE ULTIMATECARE ONE
ULTIMATECARE ONE NF CAPSULE ULTIMATECARE ONE NF
VEMAVITE-PRX 2 CAPSULE VEMAVITE-PRX 2
VENA-BAL DHA COMBO PACK VENA-BAL DHA
VINATE CARE CHEWABLE TABLET VINATE CARE
VINATE DHA RF GELCAP VINATE DHA RF
VINATE ONE TABLET VINATE ONE
VINATE-M TABLET VINATE-M
VIRT-ADVANCE TABLET VIRT-ADVANCE
VIRT-C DHA SOFTGEL VIRT-C DHA
VIRT-NATE DHA SOFTGEL VIRT-NATE DHA
VIRT-NATE TABLET VIRT-NATE
VIRT-PN DHA SOFTGEL VIRT-PN DHA
VIRT-PN PLUS SOFTGEL VIRT-PN PLUS
VIRT-PN TABLET VIRT-PN
VIRT-SELECT CAPSULE VIRT-SELECT
VIRT-VITE GT TABLET VIRT-VITE GT
VIRTPREX CAPSULE VIRTPREX
VIT A,C,D-FLUORIDE 0.25 MG/ML VITAMINS A,C,D ANDFLUORIDE
VIT A,D,C-FLUORIDE 0.25 MG/ML VITAMINS A,D,C ANDFLUORIDE
VITAFOL FE+ DOCUSATE COMBOPCK
VITAFOL FE+
VITAFOL GUMMIES VITAFOL GUMMIES
VITAFOL NANO TABLET VITAFOL NANO
VITAFOL ULTRA SOFTGEL VITAFOL ULTRA
VITAFOL-OB CAPLET VITAFOL-OB
VITAFOL-OB+DHA COMBO PACK VITAFOL-OB+DHA
VITAFOL-ONE CAPSULE VITAFOL-ONE
VITAMEDMD ONE RX SOFTGEL VITAMEDMD ONE RX
VITAMEDMD REDICHEW RX TABCHEW
VITAMEDMD REDICHEW RX
VITAPEARL SOFTGEL VITAPEARL
VITATRUE COMBO PACK VITATRUE
VOL-NATE TABLET VOL-NATE
VOL-PLUS TABLET VOL-PLUS
VOL-TAB RX TABLET VOL-TAB RX
VP-CH PLUS SOFTGEL VP-CH PLUS
VP-CH-PNV PRENATAL SOFTGEL VP-CH-PNV
VP-GGR-B6 TABLET VP-GGR-B6
VP-HEME OB TABLET VP-HEME OB
2018 Trusted Health Plan Medicaid Formulary
98
Vitamin Combinations
Medication Info Common Name Drug Status Criteria
VP-HEME ONE SOFTGEL VP-HEME ONE
VP-PNV-DHA SOFTGEL VP-PNV-DHA
ZATEAN-CH CAPSULE ZATEAN-CH
ZATEAN-PN DHA CAPSULE ZATEAN-PN DHA
ZATEAN-PN PLUS SOFTGEL ZATEAN-PN PLUS
ZINGIBER TABLET ZINGIBER
Vitamins
Medication Info Common Name Drug Status Criteria
CALCITRIOL 0.25 MCG CAPSULE CALCITRIOL
CALCITRIOL 0.5 MCG CAPSULE CALCITRIOL
CALCITRIOL 1 MCG/ML AMPUL CALCITRIOL
CALCITRIOL 1 MCG/ML SOLUTION CALCITRIOL
CYANOCOBALAMIN 1,000 MCG/ML CYANOCOBALAMIN INJECTION
CYANOCOBALAMIN 10,000 MCG/10 CYANOCOBALAMIN INJECTION
CYANOCOBALAMIN 30,000 MCG/30 CYANOCOBALAMIN INJECTION
FOLIC ACID 1 MG TABLET FOLIC ACID
FOLIC ACID 1,000 MCG TABLET FOLIC ACID
PYRIDOXINE 100 MG/ML VIAL PYRIDOXINE HCL
THIAMINE 200 MG/2 ML VIAL THIAMINE HCL
VIT D2 1.25 MG (50,000 UNIT) VITAMIN D2
Wound Care Therapy
Medication Info Common Name Drug Status Criteria
REGRANEX 0.01% GEL REGRANEX
2018 Trusted Health Plan Medicaid OTC Formulary
99
Acne Therapy
Medication Info Common Name Drug Status Criteria
ACNE FOAMING 10% WASH ACNE FOAMING WASH
ACNE TREATMENT 10% GEL ACNE TREATMENT
BENZOYL PEROXIDE 10% GEL BENZOYL PEROXIDE
BENZOYL PEROXIDE 10% WASH BENZOYL PEROXIDE
BENZOYL PEROXIDE 2.5% GEL BENZOYL PEROXIDE
BENZOYL PEROXIDE 5% GEL BENZOYL PEROXIDE
BENZOYL PEROXIDE 5% WASH BENZOYL PEROXIDE
CVS ACNE SPOT TRTMENT 2.5% CRM ACNE SPOT TREATMENT
CVS ACNE TREATMENT 10% GEL ACNE TREATMENT
CVS ADV EXFOLIATING 5% CLEANSR ADVANCED EXFOLIATINGCLEANSER
CVS FOAMING ACNE FACE 10%WASH
FOAMING ACNE FACE WASH
Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic
Medication Info Common Name Drug Status Criteria
ADULT ASPIRIN REGIMEN EC 81 MG ADULT ASPIRIN REGIMEN
ALL DAY PAIN RELIEF 220 MG TAB ALL DAY PAIN RELIEF
ALL DAY PAIN RLF 220 MG CAPLET ALL DAY PAIN RELIEF
ANALGESIC TABLET ANALGESIC
ASPIR EC 81 MG TABLET ASPIR 81
ASPIRIN 325 MG COATED TABLET ASPIRIN
ASPIRIN 325 MG LITE-COAT TAB ASPIRIN
ASPIRIN 325 MG TABLET ASPIRIN
ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN
ASPIRIN EC 325 MG TABLET ASPIRIN EC
ASPIRIN EC 500 MG TABLET ASPIRIN EC
ASPIRIN EC 650 MG TABLET ASPIRIN EC
ASPIRIN EC 81 MG TABLET ASPIRIN EC
BAYER ASPIRIN 325 MG TABLET ASPIRIN
CHILD ASPIRIN 81 MG CHEW TAB CHILDREN’S ASPIRIN
CHILD ASPIRIN 81 MG TAB CHEW CHILDREN’S ASPIRIN
CHILD IBU-DROPS 50 MG/1.25 ML CHILDREN’S IBUPROFEN
CHILD IBUPROFEN 100 MG/5 ML CHILD IBUPROFEN
CHILDREN IBUPROFEN 100 MG/5 ML CHILDREN’S IBUPROFEN
CVS ALL DAY PAIN RLF 220 MG TB ALL DAY PAIN RELIEF
CVS ASPIRIN 325 MG CAPLET ASPIRIN
CVS ASPIRIN 325 MG TABLET ASPIRIN
CVS ASPIRIN 81 MG CHEWABLE TAB ASPIRIN
CVS ASPIRIN EC 325 MG TABLET ASPIRIN EC
CVS ASPIRIN EC 81 MG TABLET ASPIRIN EC
CVS CHILD ASPIRIN CHEW TAB CHILDREN’S ASPIRIN
CVS CHLD IBUPROFEN 100 MG/5 ML CHILDREN’S IBUPROFEN
CVS HEADACHE RELIEF CAPLET HEADACHE RELIEF
2018 Trusted Health Plan Medicaid OTC Formulary
100
Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic
Medication Info Common Name Drug Status Criteria
CVS HEADACHE RELIEF GELCAP HEADACHE RELIEF
CVS HEADACHE RELIEF TABLET HEADACHE RELIEF
CVS IBUPROFEN 200 MG CAPLET IBUPROFEN
CVS IBUPROFEN 200 MG CAPSULE IBUPROFEN
CVS IBUPROFEN 200 MG SOFTGEL IBUPROFEN
CVS IBUPROFEN 200 MG TAB IBUPROFEN
CVS IBUPROFEN 200 MG TABLET IBUPROFEN
CVS IBUPROFEN IB 200 MG CPLT IBUPROFEN IB
CVS IBUPROFEN IB 200 MG TAB IBUPROFEN IB
CVS IBUPROFEN IB 200 MG TABLET IBUPROFEN
CVS IBUPROFEN JR STR 100 MG TB IBUPROFEN
CVS INF IBUPROFEN 50 MG/1.25 ML INFANTS’ IBUPROFEN
CVS INFANT IBUPROFEN SUSP DROP INFANT’S IBUPROFEN
CVS MIGRAINE RELIEF CAPLET MIGRAINE RELIEF
CVS NAPROXEN SOD 220 MGCAPLET
NAPROXEN SODIUM
CVS NAPROXEN SOD 220 MG TABLET NAPROXEN SODIUM
CVS NAPROXEN SODIUM 220 MGCAP
NAPROXEN SODIUM
CVS SUPER PAIN RELIEF SUPER PAIN RELIEF
CVS SUPER PAIN RELIEF TAB SUPER PAIN RELIEF
ECPIRIN EC 325 MG TABLET ECPIRIN
EQ ASPIRIN 325 MG TABLET ASPIRIN
EQ ASPIRIN 81 MG CHEWABLE TAB ASPIRIN
EQ ASPIRIN EC 325 MG TABLET ASPIRIN EC
EQ ASPIRIN EC 81 MG TABLET ASPIRIN EC
EQ CHILD IBUPROFEN 100 MG/5 ML CHILDREN’S IBUPROFEN
EQ IBUPROFEN 200 MG CAPLET IBUPROFEN
EQ IBUPROFEN 200 MG SOFTGEL IBUPROFEN
EQ IBUPROFEN 200 MG TABLET IBUPROFEN
EQ IBUPROFEN JR STR 100 MG TAB IBUPROFEN
EQ INF IBUPROFEN 50 MG/1.25 ML INFANTS’ IBUPROFEN
EQ NAPROXEN SOD 220 MG CAPLET NAPROXEN SODIUM
EQ NAPROXEN SOD 220 MG TABLET NAPROXEN SODIUM
EQ NAPROXEN SODIUM 220 MG CAP NAPROXEN SODIUM
EQL ASPIRIN 325 MG TABLET ASPIRIN
EQL ASPIRIN 81 MG CHEWABLE TAB ASPIRIN
EQL ASPIRIN EC 325 MG TABLET ASPIRIN EC
EQL ASPIRIN EC 81 MG TABLET ASPIRIN EC
EQL CHLD IBUPROFEN 100 MG/5 ML CHILDREN’S IBUPROFEN
EQL HEADACHE RELIEF TABLET HEADACHE RELIEF
EQL IBUPROFEN 200 MG CAPLET IBUPROFEN
EQL IBUPROFEN 200 MG SOFTGEL IBUPROFEN
2018 Trusted Health Plan Medicaid OTC Formulary
101
Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic
Medication Info Common Name Drug Status Criteria
EQL IBUPROFEN 200 MG TABLET IBUPROFEN
EQL IBUPROFEN JR 100 MG TB CHW IBUPROFEN
EQL INF IBUPROFEN 50 MG/1.25 ML INFANTS IBUPROFEN
EQL MIGRAINE FORMULA CAPLET MIGRAINE FORMULA
EQL NAPROXEN SOD 220 MGCAPLET
NAPROXEN SODIUM
EQL NAPROXEN SODIUM 220 MGCAP
NAPROXEN SODIUM
EQL NAPROXEN SODIUM 220 MG TAB NAPROXEN SODIUM
GNP ALL DAY PAIN RLF 220 MG TB ALL DAY PAIN RELIEF
GNP ASPIRIN 325 MG TABLET ASPIRIN
GNP ASPIRIN 81 MG CHEWABLE TAB ASPIRIN
GNP ASPIRIN EC 325 MG TABLET ASPIRIN EC
GNP ASPIRIN EC 81 MG TABLET ASPIRIN EC
GNP CHILD ASPIRIN 81 MG CHW TB CHILDREN’S ASPIRIN
GNP CHLD IBUPROFEN 100 MG/5 ML CHILDREN’S IBUPROFEN
GNP HEADACHE RELIEF CAPLET HEADACHE RELIEF
GNP IBUPROFEN 200 MG CAPLET IBUPROFEN
GNP IBUPROFEN 200 MG SOFTGEL IBUPROFEN
GNP IBUPROFEN 200 MG TABLET IBUPROFEN
GNP IBUPROFEN JR STR 100 MG TB IBUPROFEN
GNP INFANT IBUPROFEN SUSPDROP
INFANT’S IBUPROFEN
GNP LITE COAT ASA 325 MG TAB LITE COAT ASPIRIN
GNP MIGRAINE FORMULA CAPLET MIGRAINE FORMULA
GNP MIGRAINE RELIEF CAPLET MIGRAINE RELIEF
GNP NAPROXEN SOD 220 MGCAPLET
NAPROXEN SODIUM
GNP NAPROXEN SOD 220 MGTABLET
NAPROXEN SODIUM
GNP NAPROXEN SODIUM 220 MGCAP
NAPROXEN SODIUM
GS CHILD IBUPROFEN 100 MG/5 ML CHILDREN’S IBUPROFEN
GS IBUPROFEN 200 MG SOFTGEL IBUPROFEN
GS NAPROXEN SOD 220 MG CAPLET NAPROXEN SODIUM
HEADACHE RELIEF CAPLET HEADACHE RELIEF
HEADACHE RELIEF GELCAP HEADACHE RELIEF
HEADACHE RELIEF TABLET HEADACHE RELIEF
HM ASPIRIN 325 MG TABLET ASPIRIN
HM ASPIRIN 81 MG CHEWABLE TAB ASPIRIN
HM ASPIRIN EC 325 MG TABLET ASPIRIN EC
HM ASPIRIN EC 81 MG TABLET ASPIRIN EC
HM CHILD IBUPROFEN 100 MG/5 ML CHILDREN’S IBUPROFEN
HM IBUPROFEN 200 MG CAPLET IBUPROFEN
HM IBUPROFEN 200 MG CAPSULE IBUPROFEN
2018 Trusted Health Plan Medicaid OTC Formulary
102
Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic
Medication Info Common Name Drug Status Criteria
HM IBUPROFEN 200 MG TABLET IBUPROFEN
HM IBUPROFEN IB 200 MG CAPLET IBUPROFEN IB
HM IBUPROFEN IB 200 MG TABLET IBUPROFEN IB
HM INF IBUPROFEN 50 MG/1.25 ML INFANTS’ IBUPROFEN
HM LOW DOSE ASPIRIN EC 81 MG LOW DOSE ASPIRIN EC
HM MIGRAINE FORMULA CAPLET MIGRAINE FORMULA
HM NAPROXEN SOD 220 MG CAPLET NAPROXEN SODIUM
HM NAPROXEN SODIUM 220 MG CAP NAPROXEN SODIUM
IBU-DROPS 40 MG/ML SUSP DRPS IBU-DROPS
IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN
IBUPROFEN 200 MG CAPLET IBUPROFEN
IBUPROFEN 200 MG CAPSULE IBUPROFEN
IBUPROFEN 200 MG SOFTGEL IBUPROFEN
IBUPROFEN 200 MG TABLET IBUPROFEN
IBUPROFEN 200 MG/10 ML SUSP IBUPROFEN
IBUPROFEN 50 MG/1.25 ML SUSP IBUPROFEN
IBUPROFEN IB 200 MG CAPLET IBUPROFEN IB
IBUPROFEN JR STR 100 MG CHEW IBUPROFEN
IBUPROFEN JR STR 100 MG TB CHW IBUPROFEN
INFANT IBUPROFEN 50 MG/1.25 ML INFANT’S IBUPROFEN
INFANTS IBU-DROPS SUSPENSION INFANTS IBU-DROPS
KRO ALL DAY RLF 220 MG CAPLET ALL DAY RELIEF
KRO ASPIRIN 325 MG TABLET ASPIRIN
KRO ASPIRIN 81 MG CHEWABLE TAB ASPIRIN
KRO ASPIRIN EC 325 MG TABLET ASPIRIN EC
KRO ASPIRIN EC 81 MG TABLET ASPIRIN EC
KRO CHLD IBUPROFEN 100 MG/5 ML CHILDREN’S IBUPROFEN
KRO IBUPROFEN 200 MG CAPLET IBUPROFEN
KRO IBUPROFEN 200 MG SOFTGEL IBUPROFEN
KRO IBUPROFEN 200 MG TABLET IBUPROFEN
KRO IBUPROFEN JR STR 100 MG TB IBUPROFEN
KRO MIGRAINE FORMULA CAPLET MIGRAINE FORMULA
KRO NAPROXEN SOD 220 MGCAPLET
NAPROXEN SODIUM
KRO NAPROXEN SODIUM 220 MGTAB
NAPROXEN SODIUM
LITE COAT ASPIRIN 325 MG TAB LITE COAT ASPIRIN
LOW DOSE ASPIRIN EC 81 MG TAB LOW DOSE ASPIRIN EC
MIGRAINE FORMULA CAPLET MIGRAINE FORMULA
MIGRAINE RELIEF CAPLET MIGRAINE RELIEF
NAPROXEN SODIUM 220 MG CAPLET NAPROXEN SODIUM
NAPROXEN SODIUM 220 MGCAPSULE
NAPROXEN SODIUM
NAPROXEN SODIUM 220 MG TABLET NAPROXEN SODIUM
2018 Trusted Health Plan Medicaid OTC Formulary
103
Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic
Medication Info Common Name Drug Status Criteria
PAIN RELIEVER TABLET PAIN RELIEVER
PROVIL 200 MG TABLET PROVIL
PUB ALL DAY RELIEF 220 MG TAB ALL DAY RELIEF
PUB ALL DAY RLF 220 MG CAPLET ALL DAY RELIEF
PUB ASPIRIN 325 MG TABLET ASPIRIN
PUB ASPIRIN 81 MG CHEWABLE TAB ASPIRIN
PUB CHILDREN’S PROFEN IB SUSP CHILDREN’S PROFEN IB
PUB CHILDREN’S PROFENIB SUSP CHILDREN’S PROFENIB
PUB IBUPROFEN 200 MG TABLET IBUPROFEN
PUB IBUPROFEN JR 100 MG CHEW IBUPROFEN
PUB INFANTS PROFENIB DROPS INFANTS PROFENIB
PUB MIGRAINE RELIEF CAPLET MIGRAINE RELIEF
PUB NAPROXEN SOD 220 MG TABLET NAPROXEN SODIUM
QC ASPIRIN 325 MG TABLET ASPIRIN
QC ASPIRIN 81 MG CHEWABLE TAB ASPIRIN
QC ASPIRIN EC 325 MG TABLET ASPIRIN EC
QC ASPIRIN EC 81 MG TABLET ASPIRIN EC
QC CHILD IBUPROFEN 100 MG/5 ML CHILDREN’S IBUPROFEN
QC HEADACHE RELIEF TABLET HEADACHE RELIEF
QC IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN
QC IBUPROFEN 200 MG CAPLET IBUPROFEN
QC IBUPROFEN 200 MG SOFTGEL IBUPROFEN
QC IBUPROFEN 200 MG TABLET IBUPROFEN
QC IBUPROFEN IB 200 MG CAPLET IBUPROFEN IB
QC IBUPROFEN IB 200 MG TABLET IBUPROFEN IB
QC INF IBUPROFEN 50 MG/1.25 ML INFANTS’ IBUPROFEN
QC LO-DOSE ASPIRIN EC 81 MG TB LO-DOSE ASPIRIN EC
QC NAPROXEN SOD 220 MG TABLET NAPROXEN SODIUM
RA ASPIRIN 325 MG TABLET ASPIRIN
RA ASPIRIN 81 MG CHEWABLE TAB ASPIRIN
RA ASPIRIN EC 325 MG TABLET ASPIRIN EC
RA ASPIRIN EC 81 MG TABLET ASPIRIN EC
RA CHILD ASPIRIN 81 MG CHW TAB CHILDREN’S ASPIRIN
RA CHILD IBUPROFEN 100 MG/5 ML CHILDREN’S IBUPROFEN
RA IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN
RA IBUPROFEN 200 MG CAPLET IBUPROFEN
RA IBUPROFEN 200 MG LIQUID GEL IBUPROFEN
RA IBUPROFEN 200 MG SOFTGEL IBUPROFEN
RA IBUPROFEN 200 MG TABLET IBUPROFEN
RA IBUPROFEN JR STR 100 MG CHW IBUPROFEN
RA INFANT IBUPROFEN SUSP DROP INFANT’S IBUPROFEN
RA MIGRAINE RELIEF CAPLET MIGRAINE RELIEF
RA NAPROXEN SOD 220 MG TABLET NAPROXEN SODIUM
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Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic
Medication Info Common Name Drug Status Criteria
RA NAPROXEN SODIUM 220 MG CAP NAPROXEN SODIUM
RA PAIN RELIEVER TABLET PAIN RELIEVER
SB ASPIRIN 325 MG TABLET ASPIRIN
SB ASPIRIN EC 81 MG TABLET ASPIRIN EC
SB CHILD ASPIRIN 81 MG CHW TAB CHILDREN’S ASPIRIN
SB CHILD IBUPROFEN 100 MG/5 ML CHILDREN’S IBUPROFEN
SB IBUPROFEN 200 MG CAPLET IBUPROFEN
SB IBUPROFEN 200 MG TABLET IBUPROFEN
SB INF IBUPROFEN 50 MG/1.25 ML INFANTS’ IBUPROFEN
SB NAPROXEN SOD 220 MG CAPLET NAPROXEN SODIUM
SB NAPROXEN SOD 220 MG TABLET NAPROXEN SODIUM
SB PAIN RELIEF E-S TABLET PAIN RELIEF EXTRASTRENGTH
SM ADDED STRENGTH HEADACHETAB
ADDED STRENGTH HEADACHE
SM ALL DAY RELIEF 220 MG CAPLT ALL DAY PAIN RELIEF
SM ALL DAY RELIEF 220 MG TAB ALL DAY PAIN RELIEF
SM ASPIRIN 325 MG TABLET ASPIRIN
SM ASPIRIN 81 MG CHEWABLE TAB ASPIRIN
SM ASPIRIN EC 325 MG TABLET ASPIRIN EC
SM ASPIRIN EC 81 MG TABLET ASPIRIN EC
SM CHILD ASPIRIN 81 MG CHW TAB CHILDREN’S ASPIRIN
SM IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN
SM IBUPROFEN 200 MG CAPLET IBUPROFEN
SM IBUPROFEN 200 MG SOFTGEL IBUPROFEN
SM IBUPROFEN 200 MG TABLET IBUPROFEN
SM IBUPROFEN IB 100 MG CHEW TAB IBUPROFEN IB
SM IBUPROFEN IB 100 MG TABLET IBUPROFEN
SM IBUPROFEN IB 200 MG CAPLET IBUPROFEN IB
SM IBUPROFEN IB 200 MG TABLET IBUPROFEN IB
SM INFANT IBUPROFEN SUSP DROP INFANT’S IBUPROFEN
SM MIGRAINE RELIEF CAPLET MIGRAINE RELIEF
SM NAPROXEN SOD 220 MG CAPLET NAPROXEN SODIUM
SM NAPROXEN SOD 220 MG TABLET NAPROXEN SODIUM
SM NAPROXEN SODIUM 220 MG CAP NAPROXEN SODIUM
V-R ASPIRIN EC 325 MG TABLET ASPIRIN EC
V-R ASPIRIN EC 81 MG TABLET ASPIRIN EC
V-R IBUPROFEN 200 MG TABLET IBUPROFEN
V-R NAPROXEN SOD 220 MG TABLET NAPROXEN SODIUM
VR ADD-STR PAIN RELIEF CAPLET ADDED STRENGTH PAINRELIEVER
WAL-PROFEN 200 MG CAPLET WAL-PROFEN
WAL-PROFEN 200 MG CAPSULE WAL-PROFEN
WAL-PROFEN 200 MG SOFTGEL WAL-PROFEN
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Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic
Medication Info Common Name Drug Status Criteria
WAL-PROFEN 200 MG TABLET WAL-PROFEN
WAL-PROXEN 220 MG CAPLET WAL-PROXEN
WAL-PROXEN 220 MG TABLET WAL-PROXEN
Anorectal - Hemorrhoidal Single Agents Other
Medication Info Common Name Drug Status Criteria
EQ HEMORRHOIDAL 50% PADS HEMORRHOIDAL PADS
EQ HEMORRHOIDAL MED 50% WIPES HEMORRHOIDAL MEDICATEDWIPES
HEMORRHOIDAL HYGIENE PADS HEMORRHOIDAL HYGIENE
KRO MEDICATED 50% WIPES MEDICATED WIPES
MEDICATED 50% PADS MEDICATED PADS
MEDICATED 50% WIPES MEDICATED WIPES
PREPARATION H MEDICATED WIPES PREPARATION H
PREPARATION H TOTABLES WIPES PREPARATION H TOTABLES
TUCKS 50% MEDICATED PADS TUCKS
Anorectal Combinations
Medication Info Common Name Drug Status Criteria
CVS HEMORRHOIDAL CREAM HEMORRHOIDAL CREAM
CVS HEMORRHOIDAL OINTMENT HEMORRHOIDAL OINTMENT
EQ HEMORRHOIDAL CREAM HEMORRHOIDAL CREAM
EQL HEMORRHOIDAL CREAM HEMORRHOIDAL CREAM
HEMORRHOIDAL COOLING GEL HEMORRHOIDAL COOLINGGEL
HEMORRHOIDAL CREAM HEMORRHOIDAL CREAM
HEMORRHOIDAL OINTMENT HEMORRHOIDAL OINTMENT
HEMORRHOIDAL SUPPOSITORIES HEMORRHOIDAL
PREPARATION H COOLING GEL PREPARATION H
PREPARATION H CREAM PREPARATION H
PUB HEMORRHOIDAL CREAM HEMORRHOIDAL CREAM
PUB HEMORRHOIDAL OINTMENT HEMORRHOIDAL OINTMENT
PUB HEMORRHOIDALSUPPOSITORIES
HEMORRHOIDALSUPPOSITORIES
RA HEMORRHOIDAL CREAM HEMORRHOIDAL CREAM
RA HEMORRHOIDAL H SUPP HEMORRHOIDAL H
RA HEMORRHOIDAL OINTMENT HEMORRHOIDAL OINTMENT
SM HEMORRHOIDAL COOLING GEL HEMORRHOIDAL COOLINGGEL
SM HEMORRHOIDAL CREAM HEMORRHOIDAL CREAM
V-R HEMORRHOIDAL CREAM HEMORRHOIDAL CREAM
Antacids and Combinations
Medication Info Common Name Drug Status Criteria
ADV ANTACID-ANTIGAS LIQUID ADVANCED ANTACID-ANTIGAS
ADVANCED ANTACID LIQUID ADVANCED ANTACID
ALUM-MAG HYDROXIDE-SIMETH LIQ ALUM-MAG HYDROXIDE-SIMETHICONE
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Antacids and Combinations
Medication Info Common Name Drug Status Criteria
ALUMINUM HYDROXIDE GEL ALUMINUM HYDROXIDE
ANTACID 500 MG CHEW TABLET ANTACID
ANTACID 500 MG CHEWABLE TABLET ANTACID
ANTACID 750 MG CHEW TB ANTACID
ANTACID ANTI-GAS LIQUID ANTACID-ANTIGAS
ANTACID EX-STR 750 MG TAB CHEW ANTACID EXTRA STRENGTH
ANTACID EX-STR TABLET CHEW CALCIUM ANTACID
ANTACID LIQUID ANTACID
ANTACID M LIQUID ANTACID M
ANTACID MAXIMUM STRENGTH LIQ ANTACID MAXIMUM STRENGTH
ANTACID PLUS ANTI-GAS LIQUID ANTACID PLUS ANTI-GAS
ANTACID PLUS ANTI-GAS RELF LIQ ANTACID PLUS ANTI-GAS
ANTACID PLUS ANTI-GAS SUSP ANTACID PLUS ANTI-GAS
ANTACID SUSPENSION ANTACID
ANTACID ULTRA STR 1,000 MG CHW ANTACID ULTRA STRENGTH
ANTACID ULTRA STR TABCHEWABLE
ANTACID ULTRA STRENGTH
ANTACID ULTRA TABLET CHEW ULTRA STRENGTH ANTACID
ANTACID XTRA STRENGTH CHEWTAB
ANTACID EXTRA STRENGTH
ANTACID-ANTIGAS LIQUID ANTACID-ANTIGAS
ANTACID-ANTIGAS TAB CHEW ANTACID-ANTIGAS
ANTACID-SIMETHICONE LIQUID ANTACID WITH SIMETHICONE
CALCIUM ANTACID 1,000 MG TAB CALCIUM ANTACID
CALCIUM ANTACID 500 MG CHW TAB CALCIUM ANTACID
CALCIUM ANTACID EX-STR CHEW CALCIUM ANTACID
CALCIUM ANTACID EX-STR TABLET CALCIUM ANTACID
CALCIUM ANTACID ULTRA-STRCHEW
CALCIUM ANTACID
CALCIUM CARB 1,250 MG/5 ML SUS CALCIUM CARBONATE
CALCIUM CARB 500 MG TAB CHEW CALCIUM CARBONATE
CALCIUM CARBONATE 10 GRAIN TAB CALCIUM CARBONATE
CALCIUM CARBONATE 648 MG TAB CALCIUM CARBONATE
CALCIUM CARBONATE 750 MG CHEW CALCIUM CARBONATE
CHILD SOOTHE 400 MG TAB CHEW CHILDREN’S SOOTHE
COMFORT GEL EX-STRENGTHLIQUID
COMFORT GEL
COMFORT GEL EXTRA STR SUSP COMFORT GEL
COMFORT GEL MAX STR SUSP COMFORT GEL
COMFORT GEL SUSPENSION COMFORT GEL
CVS ANTACID 750 MG CHEW TABLET ANTACID
CVS ANTACID LIQUID ANTACID
CVS ANTACID PLUS ANTI-GAS LIQ ANTACID PLUS ANTI-GAS
CVS ANTACID ULTRA TAB CHEW ANTACID ULTRA STRENGTH
2018 Trusted Health Plan Medicaid OTC Formulary
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Antacids and Combinations
Medication Info Common Name Drug Status Criteria
CVS ANTACID XTRA STR CHEW TAB ANTACID EXTRA STRENGTH
CVS ANTACID-ANTIGAS LIQUID ANTACID-ANTIGAS
CVS ANTACID-ANTIGAS MAX STR LQ ANTACID-ANTIGAS
CVS ANTACID-ANTIGAS TAB CHEW ANTACID-ANTIGAS
CVS ANTACID-SIMETHICONE LIQUID ANTACID WITH SIMETHICONE
CVS CALCIUM ANTACID 1,000 MG CALCIUM ANTACID
CVS FLAVOR CHEW ANTACID 750 MG FLAVOR CHEWS ANTACID
CVS KIDS ANTACID 750 MG CHEW ANTACID
CVS SMOOTH ANTACID 750 MGCHEW
SMOOTH ANTACID
EQ ANTACID 500 MG CHEW TABLET ANTACID
EQ ANTACID EXTRA STR CHEW TAB ANTACID EXTRA STRENGTH
EQ ANTACID LIQUID ANTACID
EQ ANTACID ULTRA STR TAB CHEW ANTACID ULTRA STRENGTH
EQ ANTACID-ANTIGAS TAB CHEW ANTACID-ANTIGAS
EQ LIQUID ANTACID SUSP LIQUID ANTACID
EQ LIQUID ANTACID SUSPENSION LIQUID ANTACID
EQL ADV ANTACID-ANTIGAS LIQUID ADVANCED ANTACID-ANTIGAS
EQL ANTACID 500 MG CHEW TABLET ANTACID
EQL ANTACID EXTRA STR CHEW TAB ANTACID EXTRA STRENGTH
EQL ANTACID LIQUID ANTACID
EQL ANTACID SUSPENSION ANTACID
EQL ANTACID ULTRA STR TAB CHEW ANTACID ULTRA STRENGTH
GNP ANTACID 500 MG CHEW TABLET ANTACID
GNP ANTACID 750 MG TAB CHEW ANTACID
GNP ANTACID ANTI-GAS LIQUID ANTACID-ANTIGAS
GNP ANTACID SUSPENSION ANTACID
GNP ANTACID ULTRA TAB CHEW ULTRA STRENGTH ANTACID
GNP ANTACID XTRA STR CHEW TAB ANTACID EXTRA STRENGTH
GNP ANTACID-ANTIGAS TAB CHEW ANTACID-ANTIGAS
GNP LIQUID ANTACID SUSPENSION LIQUID ANTACID
GNP MASANTI LIQUID MASANTI
HM ADV ANTACID-ANTIGAS SUSP ADVANCED ANTACID-ANTIGAS
HM ANTACID ANTI-GAS SUSPENSION ANTACID-ANTIGAS
HM ANTACID-ANTIGAS SUSPENSION ANTACID-ANTIGAS
HM CAL ANTACID 500 MG CHEW TAB CALCIUM ANTACID
HM CAL ANTACID 750 MG CHEW TAB CALCIUM ANTACID
HV ANTACID MAX STRENGTH LIQUID ANTACID MAXIMUM STRENGTH
KRO ADV ANTACID-ANTIGAS LIQUID ADVANCED ANTACID-ANTIGAS
KRO ANTACID-ANTIGAS LIQUID ANTACID-ANTIGAS
LIQUID ANTACID SUSPENSION LIQUID ANTACID
MAGNESIUM-ALUMINUMSUSPENSION
ALUM-MAG HYDROXIDE-SIMETHICONE
2018 Trusted Health Plan Medicaid OTC Formulary
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Antacids and Combinations
Medication Info Common Name Drug Status Criteria
MASANTI LIQUID MASANTI
PUB ANTACID 500 MG CHEW TABLET ANTACID
PUB ANTACID-ANTI GAS SUSP ANTACID-ANTIGAS
PUB CALCIUM CARB 1,000 MG TAB CALCIUM CARBONATE
QC ANTACID 500 MG CHEW TABLET ANTACID
QC ANTACID SUSPENSION ANTACID
QC ANTACID XTRA STR CHEW TAB ANTACID EXTRA STRENGTH
QC ANTACID-ANTIGAS MAX STR ANTACID-ANTIGAS
QC ANTACID-ANTIGAS SUSPENSION ANTACID-ANTIGAS
RA ANTACID & ANTIGAS LIQUID ANTACID & ANTIGAS
RA ANTACID & GAS RELIEF LIQUID ANTACID & GAS RELIEF
RA ANTACID-ANTIGAS LIQUID ANTACID-ANTIGAS
SB ANTACID 500 MG CHEW TABLET ANTACID
SB ANTACID ANTI-GAS D-S LIQ ANTACID ANTI-GAS DOUBLESTR
SB ANTACID SUSPENSION ANTACID
SB ANTACID XTRA STR CHEW TAB ANTACID EXTRA STRENGTH
SB ANTACID-ANTIGAS LIQUID ANTACID-ANTIGAS
SM ADV ANTACID-ANTIGAS LIQUID ADVANCED ANTACID
SM ADV ANTACID-ANTIGAS SUSP ADVANCED ANTACID-ANTIGAS
SM ANTACID 500 MG CHEW TABLET ANTACID
SM ANTACID ANTI-GAS LIQUID ANTACID-ANTIGAS
SM ANTACID MAX STRENGTH SUSP ANTACID MAXIMUM STRENGTH
SM ANTACID SUSPENSION ANTACID MAXIMUM STRENGTH
SM ANTACID XTRA STR CHEW TAB ANTACID EXTRA STRENGTH
SM ANTACID-ANTIGAS LIQUID ANTACID-ANTIGAS
SM CAL ANTACID 500 MG CHEW TAB CALCIUM ANTACID
SM CAL ANTACID 500 MG CHW TAB CALCIUM ANTACID
SM CAL ANTACID 750 MG CHEW TAB CALCIUM ANTACID
SM CALCIUM ANTACID TAB CHEW ULTRA STRENGTH ANTACID
SM SMOOTH ANTACID TAB CHEW SMOOTH ANTACID
SMOOTH DISSOLVE ANTACID CHEW SMOOTH DISSOLVINGANTACID
V-R ANTACID XTRA STR CHEW TAB ANTACID EXTRA STRENGTH
Antidiarrheals
Medication Info Common Name Drug Status Criteria
ANTI-DIARRHEAL 1 MG/5 ML LIQ ANTI-DIARRHEAL
ANTI-DIARRHEAL 1 MG/7.5 ML SUS ANTI-DIARRHEAL
ANTI-DIARRHEAL 2 MG CAPLET ANTI-DIARRHEAL
ANTI-DIARRHEAL 2 MG SOFTGEL ANTI-DIARRHEAL
ANTI-DIARRHEAL 2 MG TABLET ANTI-DIARRHEAL
BISMUTH 262 MG TABLET CHEW BISMUTH
BISMUTH 262 MG/15 ML SUSP BISMUTH SUBSALICYLATE
2018 Trusted Health Plan Medicaid OTC Formulary
109
Antidiarrheals
Medication Info Common Name Drug Status Criteria
BISMUTH 524 MG/30 ML SUSP BISMUTH SUBSALICYLATE
CVS ANTI-DIARRHEAL 2 MG CAPLET ANTI-DIARRHEAL
CVS ANTI-DIARRHEAL 2 MG SFTGEL ANTI-DIARRHEAL
CVS ANTI-DIARRHEAL SUSPENSION ANTI-DIARRHEAL
CVS BISMUTH 262 MG CAPLET BISMUTH
CVS BISMUTH CHEWABLE TABLET BISMUTH
CVS BISMUTH MAX-STRENGTH LIQ BISMUTH MAXIMUMSTRENGTH
CVS BISMUTH REGULAR LIQUID BISMUTH
CVS LOPERAMIDE 1 MG/7.5 ML LIQ LOPERAMIDE
CVS STOMACH RELF 525 MG/30 ML STOMACH RELIEF
CVS STOMACH RELIEF MAX STR LIQ STOMACH RELIEF
CVS STOMACH RLF 262 MG CHEW TB STOMACH RELIEF
DIAMODE 2 MG TABLET DIAMODE
DIARRHEA RELIEF 262 MG/15 ML DIARRHEA RELIEF
DIARRHEA RELIEF SUSPENSION DIARRHEA RELIEF
DIGESTIVE RELIEF 262 MG CHW TB DIGESTIVE RELIEF
DIGESTIVE RELIEF CAPLET DIGESTIVE RELIEF
DIGESTIVE RELIEF SUSPENSION DIGESTIVE RELIEF
EQ ANTI-DIARRHEAL 2 MG CAPLET ANTI-DIARRHEAL
EQ LOPERAMIDE 1 MG/7.5 ML SUSP LOPERAMIDE
EQ STOMACH RELIEF 262 MG/15 ML STOMACH RELIEF
EQ STOMACH RELIEF 525 MG/15 ML STOMACH RELIEF
EQ STOMACH RLF 262 MG CHEW TAB STOMACH RELIEF
EQL ANTI-DIARRHEAL 2 MG CAPLET ANTI-DIARRHEAL
EQL LOPERAMIDE 1 MG/7.5 ML SUS LOPERAMIDE
EQL STOMACH RELIEF LIQUID STOMACH RELIEF
EQL STOMACH RLF 262 MG CHEW TB STOMACH RELIEF
EQL STOMACH RLF 262 MG/15 ML STOMACH RELIEF
EQL STOMACH RLF 525 MG/15 ML STOMACH RELIEF
EQL STOMACH RLF 525 MG/30 ML STOMACH RELIEF
GNP ANTI-DIARRHEAL 2 MG CAPLET ANTI-DIARRHEAL
GNP ANTI-DIARRHEAL 2 MG SFTGEL ANTI-DIARRHEAL
GNP K-PEC SUSPENSION K-PEC
GNP LOPERAMIDE 1 MG/7.5 ML LIQ LOPERAMIDE
GNP PINK BISMUTH 262 MG/15 ML PINK BISMUTH
GNP PINK BISMUTH CAPLET PINK BISMUTH
GNP PINK BISMUTH MAX-STR SUSP PINK BISMUTH
GNP PINK BISMUTH TABLET CHEW PINK BISMUTH
GNP STOMACH RLF 262 MG/15 ML STOMACH RELIEF
GS STOMACH RLF 262 MG CHEW TAB STOMACH RELIEF
HM ANTI-DIARRHEAL 2 MG CAPLET ANTI-DIARRHEAL
HM LOPERAMIDE 1 MG/7.5 ML LIQ LOPERAMIDE
2018 Trusted Health Plan Medicaid OTC Formulary
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Antidiarrheals
Medication Info Common Name Drug Status Criteria
HM LOPERAMIDE 2 MG SOFTGEL LOPERAMIDE
HM STOMACH RELIEF 262 MG/15 ML STOMACH RELIEF
HM STOMACH RELIEF 525 MG/15 ML STOMACH RELIEF
HM STOMACH RLF 262 MG CHEWTAB
STOMACH RELIEF
IMODIUM A-D 2 MG CAPLET IMODIUM A-D
K-PEC SUSPENSION K-PEC
KRO ANTI-DIARRHEAL 2 MG CAPLET ANTI-DIARRHEAL
KRO LOPERAMIDE 1 MG/7.5 ML SUS LOPERAMIDE
KRO STOMACH RELIEF 1,050 MG/30 STOMACH RELIEF
KRO STOMACH RLF 262 MG CHEWTB
STOMACH RELIEF
KRO STOMACH RLF 262 MG/15 ML STOMACH RELIEF
LOPERAMIDE 1 MG/5 ML LIQUID LOPERAMIDE
LOPERAMIDE 1 MG/5 ML SOLUTION LOPERAMIDE
LOPERAMIDE 1 MG/7.5 ML LIQUID LOPERAMIDE
LOPERAMIDE 1 MG/7.5 ML SOLN LOPERAMIDE
LOPERAMIDE 1 MG/7.5 ML SUSP LOPERAMIDE
LOPERAMIDE 2 MG CAPLET LOPERAMIDE
LOPERAMIDE 2 MG TABLET LOPERAMIDE
LOPERAMIDE 2 MG/10 ML SOLUTION LOPERAMIDE
LOPERAMIDE 2 MG/15 ML SUSP LOPERAMIDE
PINK BISMUTH 262 MG/15 ML SUSP PINK BISMUTH
PINK BISMUTH CAPLET PINK BISMUTH
PINK BISMUTH MAX-STR SUSP PINK BISMUTH
PINK BISMUTH TABLET CHEW PINK BISMUTH
PUB PINK BISMUTH MAX STR LIQ PINK BISMUTH
PUB STOMACH RLF 262 MG CHEW TB STOMACH RELIEF
PUB STOMACH RLF 262 MG/15 ML STOMACH RELIEF ORIGINAL
QC ANTI-DIARRHEAL 2 MG CAPLET ANTI-DIARRHEAL
QC DIARRHEA RLF 262 MG/15 ML DIARRHEA RELIEF
QC PINK BISMUTH 262 MG CAPLET PINK BISMUTH
QC PINK BISMUTH TABLET CHEW PINK BISMUTH
RA ANTI DIARRHEAL 2 MG CAPLET ANTI-DIARRHEAL
RA ANTI-DIARRHEAL 2 MG CAPLET ANTI-DIARRHEAL
RA ANTI-DIARRHEAL 2 MG SOFTGEL ANTI-DIARRHEAL
RA LOPERAMIDE 1 MG/7.5 ML SUSP LOPERAMIDE
RA PINK BISMUTH 262 MG/15 ML PINK BISMUTH
RA PINK BISMUTH CAPLET PINK BISMUTH
RA PINK BISMUTH TABLET CHEW PINK BISMUTH
RA STOMACH RELIEF 262 MG/15 ML STOMACH RELIEF
RA STOMACH RELIEF MAX STR LIQ STOMACH RELIEF
SB ANTI-DIARRHEA 2 MG CAPLET ANTI-DIARRHEA
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111
Antidiarrheals
Medication Info Common Name Drug Status Criteria
SB BISMUTH CHEWABLE TABLET BISMUTH
SB BISMUTH MAX-STRENGTH LIQ BISMUTH MAXIMUMSTRENGTH
SB BISMUTH REGULAR LIQUID BISMUTH
SB PEPTIC RELIEF 262 MG/15 ML PEPTIC RELIEF
SM ANTI-DIARRHEAL 1 MG/5 ML ANTI-DIARRHEAL
SM ANTI-DIARRHEAL 2 MG CAPLET ANTI-DIARRHEAL
SM ANTI-DIARRHEAL 2 MG SOFTGEL ANTI-DIARRHEAL
SM LOPERAMIDE 1 MG/7.5 ML LIQ LOPERAMIDE
SM STOMACH RELIEF 262 MG/15 ML STOMACH RELIEF
SM STOMACH RELIEF CAPLET STOMACH RELIEF
SM STOMACH RELIEF LIQUID STOMACH RELIEF
SM STOMACH RELIEF MAX STR LIQ STOMACH RELIEF
SM STOMACH RLF 262 MG CHEWTAB
STOMACH RELIEF
SOOTHE 262 MG CAPLET SOOTHE
SOOTHE 262 MG CHEWABLE TABLET SOOTHE
SOOTHE 262 MG/15 ML SUSPENSION SOOTHE
SOOTHE REGULAR STRENGTH SUSP SOOTHE
SOOTHE SUSPENSION SOOTHE
STOMACH RELIEF 262 MG CHEW TAB STOMACH RELIEF
STOMACH RELIEF 262 MG/15 ML STOMACH RELIEF
STOMACH RELIEF MAX STR LIQUID STOMACH RELIEF
STOMACH RLF 262 MG/15 ML SUSP STOMACH RELIEF
STOMACH RLF 525 MG/30 ML SUSP STOMACH RELIEF
ULTRA A-D 2 MG CAPLET ULTRA A-D
V-R ANTI-DIARRHEAL 2 MG CAPLET ANTI-DIARRHEAL
Antiemetics
Medication Info Common Name Drug Status Criteria
ANTI-NAUSEA LIQUID ANTI-NAUSEA
CVS MOTION SICKNESS 50 MG TAB MOTION SICKNESS
CVS MOTION SICKNESS II TABLET MOTION SICKNESS II
CVS MOTION SICKNESS RELIEF TAB MOTION SICKNESS RELIEF
CVS NAUSEA RELIEF LIQUID NAUSEA RELIEF
DIMENHYDRINATE 50 MG TABLET DIMENHYDRINATE
DRAMAMINE 25 MG TABLET CHEW DRAMAMINE
EQ ANTI-NAUSEA LIQUID ANTI-NAUSEA
EQ MOTION SICKNESS 25 MG TAB MOTION SICKNESS RELIEF
EQL ANTI-NAUSEA LIQUID ANTI-NAUSEA
EQL MOTION SICKNESS 25 MG TAB MOTION SICKNESS RELIEF
GNP ANTI-NAUSEA LIQUID ANTI-NAUSEA
GNP MOTION SICKNES 25 MG TAB MOTION SICKNESS
GNP MOTION SICKNESS 50 MG TAB MOTION SICKNESS RELIEF
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112
Antiemetics
Medication Info Common Name Drug Status Criteria
GNP NAUSEA RELIEF LIQUID NAUSEA RELIEF
HM ANTI-NAUSEA LIQUID ANTI-NAUSEA
HM MOTION RELIEF 25 MG TABLET MOTION RELIEF
HM MOTION SICKNESS 50 MG TAB MOTION SICKNESS RELIEF
KRO MOTION SICKNESS II TABLET MOTION SICKNESS II
MECLIZINE 12.5 MG CAPLET MECLIZINE HCL
MECLIZINE 12.5 MG TABLET MECLIZINE HCL
MECLIZINE 25 MG TABLET MECLIZINE HCL
MECLIZINE 25 MG TABLET CHEW MECLIZINE HCL
MOTION RELIEF 25 MG TABLET MOTION RELIEF
MOTION SICKNESS 25 MG TABLET MOTION SICKNESS
MOTION SICKNESS 50 MG TABLET MOTION SICKNESS RELIEF
MOTION SICKNESS RELIEF TB CHEW MOTION SICKNESS RELIEF
NAUSEA CONTROL LIQUID NAUSEA CONTROL
NAUSEA CONTROL SOLUTION NAUSEA CONTROL
NAUSEA RELIEF LIQUID NAUSEA RELIEF
RA ANTI-NAUSEA LIQUID ANTI-NAUSEA
RA MOTION SICKNESS 50 MG TAB MOTION SICKNESS RELIEF
RA MOTION SICKNESS RLF TB CHEW MOTION SICKNESS RELIEF
RA TRAVEL SICKNESS 50 MG TAB TRAVEL SICKNESS
SB MOTION SICKNESS 50 MG TAB MOTION SICKNESS
SM ANTI-NAUSEA LIQUID ANTI-NAUSEA
SM MOTION SICKNES 25 MG TABLET MOTION SICKNESS
SM MOTION SICKNESS 25 MG TAB MOTION SICKNESS
SM MOTION SICKNESS 50 MG TAB MOTION SICKNESS RELIEF
TRAVEL SICKNESS 50 MG TABLET TRAVEL SICKNESS
WAL-DRAM 50 MG TABLET WAL-DRAM
Antihistamines
Medication Info Common Name Drug Status Criteria
24HOUR ALLERGY 10 MG TABLET 24HOUR ALLERGY
ALL DAY ALLERGY 10 MG TABLET ALL DAY ALLERGY
ALL DAY ALLERGY RLF 10 MG TAB ALL DAY ALLERGY RELIEF
ALLER-EASE 180 MG TABLET ALLER-EASE QL
ALLER-EASE 30 MG/5 ML SUSP ALLER-EASE QL
ALLER-FEX 180 MG TABLET ALLER-FEX QL
ALLER-TEC 10 MG TABLET ALLER-TEC
ALLERCLEAR 10 MG TABLET ALLERCLEAR
ALLERGY 12.5 MG/5 ML ELIXIR CHILDREN’S ALLERGY
ALLERGY 25 MG CAPSULE ALLERGY
ALLERGY 25 MG SOFTGEL ALLERGY
ALLERGY 25 MG TABLET ALLERGY
ALLERGY 4 MG TABLET ALLERGY
ALLERGY MEDICINE 25 MG TABLET ALLERGY MEDICINE
2018 Trusted Health Plan Medicaid OTC Formulary
113
Antihistamines
Medication Info Common Name Drug Status Criteria
ALLERGY RELIEF 10 MG ODT ALLERGY RELIEF
ALLERGY RELIEF 10 MG TABLET ALLERGY RELIEF
ALLERGY RELIEF 180 MG TABLET ALLERGY RELIEF QL
ALLERGY RELIEF 25 MG CAPSULE ALLERGY RELIEF
ALLERGY RELIEF 25 MG SOFTGEL ALLERGY RELIEF
ALLERGY RELIEF 25 MG TABLET ALLERGY RELIEF
ALLERGY RELIEF 5 MG/5 ML SOLN ALLERGY RELIEF
ALLERGY RELIEF ER 12 MG TABLET ALLERGY RELIEF
ALLERGY RELIEF SYRUP ALLERGY RELIEF
ALLERHIST-1 1.34 MG TABLET ALLERHIST-1
ANTIHIST 12.5 MG/5 ML ELIXIR ANTIHIST
ANTIHISTAMINE 25 MG CAPSULE ANTIHISTAMINE
ANTIHISTAMINE 25 MG TABLET ANTIHISTAMINE
CETIRIZINE HCL 1 MG/ML SOLN CETIRIZINE HCL
CETIRIZINE HCL 1 MG/ML SYRUP CETIRIZINE HCL
CETIRIZINE HCL 10 MG CHEW TAB CETIRIZINE HCL
CETIRIZINE HCL 10 MG TABLET CETIRIZINE HCL
CETIRIZINE HCL 5 MG CHEW TAB CETIRIZINE HCL
CETIRIZINE HCL 5 MG TABLET CETIRIZINE HCL
CETIRIZINE HCL 5 MG/5 ML SOLN CETIRIZINE HCL
CETIRIZINE HCL 5 MG/5 ML SYRUP CETIRIZINE HCL
CHILD ALL DAY ALLERGY 1 MG/ML CHILDREN’S ALL DAY ALLERGY
CHILD ALLEGRA ALLERGY 30 MG/5ML SUSPENSION
CHILDREN’S ALLEGRAALLERGY
QL
CHILD ALLERGY 5 MG/5 ML SOLN CHILDREN’S ALLERGY
CHILD ALLERGY REL 12.5 MG/5 ML CHILDREN’S ALLERGY RELIEF
CHILD ALLERGY RELIEF 1 MG/ML CHILDREN’S ALLERGY RELIEF
CHILD ALLERGY RLF 12.5 MG/5 ML CHILDREN’S ALLERGY RELIEF
CHILD CETIRIZINE 10 MG CHEW TB CHILDREN’S CETIRIZINE HCL
CHILD CETIRIZINE 5 MG CHEW TAB CHILDREN’S CETIRIZINE HCL
CHILD CETIRIZINE HCL 1 MG/ML CHILDREN’S CETIRIZINE HCL
CHILD LORATADINE 5 MG/5 ML SYR CHILDREN’S LORATADINE
CHILD WAL-ITIN 5 MG/5 ML SOLN WAL-ITIN
CHILD WAL-ITIN 5 MG/5 ML SYRUP WAL-ITIN
CHILD WAL-ZYR 1 MG/ML SOLUTION CHILDREN’S WAL-ZYR
CHILD’S ALLER-TEC 1 MG/ML SOLN CHILDREN’S ALLER-TEC
CHILD’S ALLERGY 12.5 MG/5 ML CHILDREN’S ALLERGY RELIEF
CHILD’S WAL-DRYL 12.5 MG/5 ML CHILDREN’S WAL-DRYLALLERGY
CHILD’S WAL-ZYR 10 MG CHEW TAB CHILDREN’S WAL-ZYR
CHILDREN’S WAL-FEX 30 MG/5 ML CHILDREN’S WAL-FEX QL
CHLORPHENIRAMINE 4 MG TABLET CHLORPHENIRAMINEMALEATE
CHLORPHENIRAMINE ER 12 MG TAB CHLORPHENIRAMINEMALEATE
2018 Trusted Health Plan Medicaid OTC Formulary
114
Antihistamines
Medication Info Common Name Drug Status Criteria
COMPLETE ALLERGY 12.5 MG/5 ML COMPLETE ALLERGY
CVS ALLERGY 12.5 MG/5 ML LIQ ALLERGY
CVS ALLERGY 25 MG CAPSULE ALLERGY
CVS ALLERGY 25 MG SOFTGEL ALLERGY
CVS ALLERGY 25 MG TABLET ALLERGY
CVS ALLERGY 50 MG/20 ML LIQ ALLERGY RELIEF
CVS ALLERGY RELIEF 10 MG SFTGL ALLERGY RELIEF
CVS ALLERGY RELIEF 10 MG TAB ALLERGY RELIEF
CVS ALLERGY RELIEF 180 MG TAB ALLERGY RELIEF QL
CVS ALLERGY RELIEF 25 MG CAP ALLERGY RELIEF
CVS ALLERGY RELIEF 25 MG TAB ALLERGY RELIEF
CVS ALLERGY RELIEF 4 MG TABLET ALLERGY RELIEF
CVS ALLERGY RELIEF 5 MG/5 ML CHILDREN’S ALLERGY RELIEF
CVS ALLERGY RELIEF ER 12 MG TB ALLERGY RELIEF
CVS CHILD ALLERGY 10 MG CHW TB CHILDREN’S ALLERGY RELIEF
CVS CHILD ALLERGY 12.5 MG/5 ML CHILDREN’S ALLERGY
CVS CHILD ALLERGY RELF 1 MG/ML CHILDREN’S ALLERGY RELIEF
CVS CHILD ALLERGY RLF 30 MG/5 CHILDREN’S ALLERGY RELIEF QL
CVS LORATADINE 10 MG TABLET LORATADINE
CVS NIGHTTIME ALLERGY 25 MG NIGHTTIME ALLERGY RELIEF
DAILYHIST-1 1.34 MG TABLET DAILYHIST-1
DAYHIST ALLERGY 1.34 MG TABLET DAYHIST ALLERGY
DAYHIST TABLET DAYHIST
DIPHEDRYL 12.5 MG/5 ML ELIXIR DIPHEDRYL
DIPHEDRYL 25 MG TABLET DIPHEDRYL
DIPHEDRYL ALLERGY CAPSULE DIPHEDRYL
DIPHENHYDRAMINE 12.5 MG/5 ML DIPHENHYDRAMINE HCL
DIPHENHYDRAMINE 25 MG CAPLET DIPHENHYDRAMINE HCL
DIPHENHYDRAMINE 25 MG CAPSULE DIPHENHYDRAMINE HCL
DIPHENHYDRAMINE 50 MG CAPSULE DIPHENHYDRAMINE HCL
DIPHENHYDRAMINE COUGH SYRUP DIPHENHYDRAMINE HCL
EQ ALLERGY RELIEF 1 MG/ML SOLN ALLERGY RELIEF
EQ ALLERGY RELIEF 10 MG TABLET ALLERGY RELIEF
EQ ALLERGY RELIEF 180 MG TAB ALLERGY RELIEF QL
EQ ALLERGY RELIEF 25 MG CAP ALLERGY RELIEF
EQ ALLERGY RELIEF 25 MG TABLET ALLERGY RELIEF
EQ CHILD ALLERGY 12.5 MG/5 ML CHILDREN’S ALLERGY RELIEF
EQ CHILD ALLERGY RELF 1 MG/ML CHILDREN’S ALLERGY RELIEF
EQ CHILD ALLERGY RELIEF SOLN CHILDREN’S ALLERGY RELIEF
EQ CHLORTABS 4 MG TABLET CHLORTABS
EQL ALL DAY ALLERGY 10 MG TAB ALL DAY ALLERGY
EQL ALLER-EASE 180 MG TABLET ALLER-EASE QL
EQL ALLERGY 25 MG TABLET ALLERGY
2018 Trusted Health Plan Medicaid OTC Formulary
115
Antihistamines
Medication Info Common Name Drug Status Criteria
EQL ALLERGY 4 MG TABLET ALLERGY
EQL ALLERGY RELIEF 10 MG TAB ALLERGY RELIEF
EQL ALLERGY RELIEF 25 MG CAP ALLERGY RELIEF
EQL CHILD ALLERGY 12.5 MG/5 ML CHILDREN’S ALLERGY
EQL CHLD ALL DAY ALLER 1 MG/ML CHILDREN’S ALL DAY ALLERGY
FEXOFENADINE HCL 180 MG TABLET FEXOFENADINE HCL QL
FEXOFENADINE HCL 30 MG/5 ML FEXOFENADINE HCL QL
GNP ALL DAY ALLERGY 10 MG TAB ALL DAY ALLERGY
GNP ALLERGY 25 MG CAPSULE ALLERGY
GNP ALLERGY 25 MG SOFTGEL ALLERGY
GNP ALLERGY 25 MG TABLET ALLERGY
GNP ALLERGY 4 MG TABLET ALLERGY
GNP ALLERGY RELF 5 MG/5 ML SLN ALLERGY RELIEF
GNP ALLERGY RELIEF 180 MG TAB ALLERGY RELIEF QL
GNP CHILD ALLERGY 12.5 MG/5 ML CHILDREN’S ALLERGY
GNP CHLD ALL DAY ALLER 1 MG/ML CHILDREN’S ALL DAY ALLERGY
GNP CHLD LORATADINE 5 MG/5 ML CHILDREN’S LORATADINE
GNP DAYHIST ALLERGY 1.34 MG TB DAYHIST ALLERGY
GNP DIPHEDRYL 12.5 MG/5 ML ELX DIPHEDRYL
GNP DIPHEDRYL 25 MG TABLET DIPHEDRYL
GNP DIPHEDRYL ALLERGY CAP DIPHEDRYL
GNP LORATADINE 10 MG TABLET LORATADINE
GNP LORATADINE 5 MG/5 ML SYRUP LORATADINE
GS ALLER-EASE 180 MG TABLET ALLER-EASE QL
GS ALLERGY RELIEF 10 MG TABLET ALLERGY RELIEF
GS CHILD ALLERGY 12.5 MG/5 ML CHILDREN’S ALLERGY
HM ALL DAY ALLERGY 10 MG TAB ALL DAY ALLERGY
HM ALLERGY 25 MG CAPSULE ALLERGY
HM ALLERGY 25 MG TABLET ALLERGY
HM ALLERGY RELIEF 10 MG ODT ALLERGY RELIEF
HM ALLERGY RELIEF 10 MG TABLET ALLERGY RELIEF
HM ALLERGY RELIEF 25 MG CAP ALLERGY RELIEF
HM ALLERGY RELIEF 4 MG TABLET ALLERGY RELIEF
HM CHILD ALL DAY ALLER 1 MG/ML CHILDREN’S ALL DAY ALLERGY
HM CHILD ALLERGY 12.5 MG/5 ML CHILDREN’S ALLERGY
HM CHILD CETIRIZINE 1 MG/ML CHILDREN’S CETIRIZINE HCL
HM CHILD LORATADINE 5 MG/5 ML CHILDREN’S LORATADINE
HM CHLD ALLER COMPLETE 1 MG/ML CHILDREN’S ALLERGYCOMPLETE
HM FEXOFENADINE HCL 180 MG TAB FEXOFENADINE HCL QL
HM LORATADINE 10 MG TABLET LORATADINE
KRO ALL DAY ALLERGY 10 MG SFGL ALL DAY ALLERGY
KRO ALL DAY ALLERGY 10 MG TAB ALL DAY ALLERGY
2018 Trusted Health Plan Medicaid OTC Formulary
116
Antihistamines
Medication Info Common Name Drug Status Criteria
KRO ALLERGY 25 MG CAPSULE ALLERGY
KRO ALLERGY 25 MG TABLET ALLERGY
KRO ALLERGY 4 MG TABLET ALLERGY
KRO ALLERGY RELIEF 10 MG TAB ALLERGY RELIEF
KRO ALLERGY RELIEF 180 MG TAB ALLERGY RELIEF QL
KRO CHILD ALLERGY 12.5 MG/5 ML CHILDREN’S ALLERGY RELIEF
KRO CHILD ALLERGY RELIEF SOLN CHILDREN’S ALLERGY RELIEF
KRO CHLD ALL DAY ALLER 1 MG/ML CHILDREN’S ALL DAY ALLERGY
LORATADINE 10 MG ODT LORATADINE
LORATADINE 10 MG TABLET LORATADINE
LORATADINE 5 MG/5 ML SOLN LORATADINE
LORATADINE 5 MG/5 ML SYRUP LORATADINE
LORATADINE ALLERGY 5 MG/5 ML LORATADINE ALLERGY
LORATADINE HIVES 5 MG/5 ML LORATADINE HIVES RELIEF
NIGHT ALLERGY RLF 25 MG CAPLET NIGHTTIME ALLERGY RELIEF
PUB ALLERGY 12.5 MG/5 ML LIQ ALLERGY
PUB ALLERGY 25 MG CAPSULE ALLERGY
PUB ALLERGY 25 MG TABLET ALLERGY
PUB ALLERGY RELIEF 10 MG TAB ALLERGY RELIEF
PUB ALLERGY RELIEF 180 MG TAB ALLERGY RELIEF QL
PUB CHILDREN’S ALLERGY 1 MG/ML CHILDREN’S ALLERGY
PUB DAYHIST ALLERGY 1.34 MG TB DAYHIST ALLERGY
QC ALL DAY ALLERGY 10 MG TAB ALL DAY ALLERGY
QC ALLERGY RELIEF 10 MG ODT ALLERGY RELIEF
QC CHILD ALLERGY 12.5 MG/5 ML CHILDREN’S ALLERGY
QC CHLORPHENIRAMINE 4 MG TAB CHLORPHENIRAMINEMALEATE
QC COMPLETE ALLERGY 25 MG CAP COMPLETE ALLERGY
QC COMPLETE ALLERGY 25 MG CPLT COMPLETE ALLERGY
QC FEXOFENADINE HCL 180 MG TAB FEXOFENADINE HCL QL
QC LORATADINE 10 MG TABLET LORATADINE
RA ALLERGY 25 MG TABLET ALLERGY
RA ALLERGY MED 25 MG CAPSULE ALLERGY MEDICATION
RA ALLERGY MED 25 MG TABLET ALLERGY MEDICATION
RA ALLERGY MED CAPSULE ALLERGY MEDICATION
RA ALLERGY RELIEF 10 MG TABLET ALLERGY RELIEF
RA ALLERGY RELIEF 180 MG TAB ALLERGY RELIEF QL
RA ALLERGY RELIEF 25 MG CAP ALLERGY RELIEF
RA CETIRIZINE HCL 10 MG TABLET CETIRIZINE HCL
RA CHILD ALLERGY 12.5 MG/5 ML CHILDREN’S ALLERGY RELIEF
RA CHILD ALLERGY 5 MG/5 ML SOL CHILDREN’S ALLERGY
RA CHILD ALLERGY RELF 1 MG/ML CHILDREN’S ALLERGY RELIEF
RA CHILD CETIRIZINE 10 MG CHEW CHILDREN’S CETIRIZINE HCL
2018 Trusted Health Plan Medicaid OTC Formulary
117
Antihistamines
Medication Info Common Name Drug Status Criteria
RA CHLORPHENIRAMINE 4 MG TAB CHLORPHENIRAMINEMALEATE
RA COMPLETE ALLERGY MED CPT COMPLETE ALLERGY
RA COMPLETE ALLERGY SOFTGEL COMPLETE ALLERGY
RA DIPHEDRYL 12.5 MG/5 ML ELIX DIPHEDRYL
RA DIPHEDRYL 12.5 MG/5 ML LIQ DIPHEDRYL ALLERGY
RA LORATADINE 10 MG TABLET LORATADINE
RA LORATADINE 5 MG/5 ML SYRUP LORATADINE
SB ALLERGY 10 MG TABLET ALLERGY
SB ALLERGY 12.5 MG/5 ML ELIXIR ALLERGY MEDICINE
SB ALLERGY MED 25 MG TABLET ALLERGY MEDICINE
SB ALLERGY MEDICINE 25 MG CAP ALLERGY MEDICINE
SB CHLORPHENIRAMINE 4 MG TAB CHLORPHENIRAMINEMALEATE
SB LORATADINE 10 MG TABLET LORATADINE
SM ALL DAY ALLERGY 1 MG/ML SYR ALL DAY ALLERGY
SM ALL DAY ALLERGY 10 MG TAB ALL DAY ALLERGY
SM ALLERGY 4 MG TABLET ALLERGY
SM ALLERGY 4-HR 4 MG TABLET ALLERGY 4-HOUR
SM ALLERGY RELIEF 1.34 MG TAB ALLERGY RELIEF
SM ALLERGY RELIEF 10 MG ODT ALLERGY RELIEF
SM ALLERGY RELIEF 12.5 MG/5 ML ALLERGY RELIEF
SM ALLERGY RELIEF 25 MG CAP ALLERGY RELIEF
SM ALLERGY RELIEF 25 MG TABLET ALLERGY RELIEF
SM CHILD ALL DAY ALLER 1 MG/ML CHILDREN’S ALL DAY ALLERGY
SM CHILD ALLERGY 12.5 MG/5 ML CHILDREN’S ALLERGY RELIEF
SM CHILD LORATADINE 5 MG/5 ML CHILDREN’S LORATADINE
SM FEXOFENADINE HCL 180 MG TAB FEXOFENADINE HCL QL
SM LORATADINE 10 MG ODT LORATADINE
SM LORATADINE 10 MG TABLET LORATADINE
SM LORATADINE 5 MG/5 ML SYRUP LORATADINE
SW ALLERGY RELIEF 10 MG TAB ALLERGY RELIEF
TOTAL ALLERGY 25 MG TABLET TOTAL ALLERGY
V-R VALUDRYL 12.5 MG/5 ML ELX VALU-DRYL
VALU-DRYL ALLERGY MED TAB VALU-DRYL ALLERGYMEDICINE
WAL-DRYL ALLERGY 12.5 MG/5 ML WAL-DRYL ALLERGY
WAL-DRYL ALLERGY 25 MG CAPSULE WAL-DRYL
WAL-DRYL ALLERGY 25 MG MINITAB WAL-DRYL
WAL-DRYL ALLERGY 25 MG SOFTGEL WAL-DRYL
WAL-FEX ALLERGY 180 MG TABLET WAL-FEX ALLERGY QL
WAL-FINATE 4 MG TABLET WAL-FINATE
WAL-ITIN 10 MG ODT WAL-ITIN
WAL-ITIN 10 MG TABLET WAL-ITIN
2018 Trusted Health Plan Medicaid OTC Formulary
118
Antihistamines
Medication Info Common Name Drug Status Criteria
WAL-ITIN 5 MG/5 ML SYRUP WAL-ITIN
WAL-ZYR 10 MG SOFTGEL WAL-ZYR
WAL-ZYR 10 MG TABLET WAL-ZYR
WAL-ZYR SOLUTION WAL-ZYR
Antiseptic - Biguanides
Medication Info Common Name Drug Status Criteria
CHLORHEXIDINE 2% SOLUTION CHLORHEXIDINE GLUCONATE
CHLORHEXIDINE GLUC 2% CLOTH CHLORHEXIDINE GLUCONATE
CVS HAND WASH 2% SOLUTION HAND WASH
Antitussives
Medication Info Common Name Drug Status Criteria
12-HR COUGH RELIEF 30 MG/5 ML 12-HOUR COUGH RELIEF
CHILD COUGH DM ER 30 MG/5 ML CHILDREN’S COUGH DM ER
COUGH DM ER 30 MG/5 ML SUSP COUGH DM ER
CVS CHILD COUGH DM ER 30 MG/5 CHILDREN’S COUGH DM ER
CVS COUGH DM ER 30 MG/5 ML SUS COUGH DM ER
DEXTROMETHORPHAN ER 30 MG/5ML
DEXTROMETHORPHANPOLISTIREX
EQ COUGH DM ER 30 MG/5 ML SUSP COUGH DM ER
GNP COUGH DM ER 30 MG/5 ML SUS COUGH DM ER
HM COUGH DM ER 30 MG/5 ML SUSP COUGH DM ER
KRO COUGH DM ER 30 MG/5 ML SUS COUGH DM ER
RA COUGH DM ER 30 MG/5 ML SUSP COUGH DM ER
Artificial Tears and Lubricants
Medication Info Common Name Drug Status Criteria
ARTIFICIAL TEARS ARTIFICIAL TEARS
ARTIFICIAL TEARS 1.4 % DROPS ARTIFICIAL TEARS
ARTIFICIAL TEARS 1.4% DROPS ARTIFICIAL TEARS
ARTIFICIAL TEARS DROPS ARTIFICIAL TEARS
ARTIFICIAL TEARS EYE DROPS ARTIFICIAL TEARS
ARTIFICIAL TEARS EYE OINTMENT ARTIFICIAL TEARS
ARTIFICIALS TEARS DROPS ARTIFICIAL TEARS
BION TEARS EYE DROPS BION TEARS
CVS ARTIFICIAL TEARS DROPS ARTIFICIAL TEARS
CVS DRY EYE RELIEF EYE DROPS DRY EYE RELIEF
CVS NATURAL TEARS DROPS NATURAL TEARS
EQ ARTIFICIAL TEARS DROPS ARTIFICIAL TEARS
EYE DROP TEARS EYE DROP TEARS
GENTEAL TEARS 0.1%-0.2%-0.3% GENTEAL TEARS
GENTEAL TEARS 0.1%-0.3% DROP GENTEAL TEARS
GNP ARTIFICIAL TEARS DROPS ARTIFICIAL TEARS
GS ARTIFICIAL TEARS EYE DROPS ARTIFICIAL TEARS
HM ARTIFICIAL TEARS EYE DROPS ARTIFICIAL TEARS
2018 Trusted Health Plan Medicaid OTC Formulary
119
Artificial Tears and Lubricants
Medication Info Common Name Drug Status Criteria
LIQUITEARS 1.4 % DROPS LIQUITEARS
LUBRICANT EYE DROPS LUBRICANT EYE
LUBRICANT EYE OINTMENT LUBRICANT EYE
LUBRIFRESH PM EYE OINTMENT LUBRIFRESH PM
NATURAL BALANCE TEARS EYEDROP
NATURAL BALANCE TEARS
NATURE’S TEARS EYE DROPS NATURE’S TEARS
POLYVINYL ALCOHL 1.4 % EYEDROP POLYVINYL ALCOHOL
PUB ARTIFICIAL TEARS ARTIFICIAL TEARS
RA ARTIFICIAL TEARS DROPS ARTIFICIAL TEARS
SM ARTIFICIAL TEARS ARTIFICIAL TEARS
TEARFAIR 1.4 % DROPS TEARFAIR
TEARS AGAIN 1.4 % DROPS TEARS AGAIN
TEARS NATURALE FREE DROPS TEARS NATURALE FREE
ULTRA FRESH PM OINTMENT ULTRA FRESH PM
VISINE DRY EYE RELIEF DROP VISINE DRY EYE RELIEF
VISINE TEARS DROPS VISINE
Chemicals - Solvents
Medication Info Common Name Drug Status Criteria
GNP MINERAL OIL MINERAL OIL
MINERAL OIL MINERAL OIL
Dermatological - Anti-infectives
Medication Info Common Name Drug Status Criteria
ANTIBIOTIC OINTMENT ANTIBIOTIC
ANTIBIOTIC PLUS PAIN RELIEF CR ANTIBIOTIC PLUS PAIN RELIEF
ANTIFUNGAL 1% CREAM ANTIFUNGAL CREAM
ANTIFUNGAL 1% POWDER SPRAY ANTIFUNGAL
ANTIFUNGAL 1% SPRAY POWDER ANTIFUNGAL
ATHLETE’S 1% FOOT CREAM ATHLETE’S FOOT
ATHLETE’S FOOT 1% CREAM ATHLETE’S FOOT
ATHLETE’S FOOT 2% POWDER ATHLETE’S FOOT
ATHLETE’S FOOT 2% POWDERSPRAY
ATHLETE’S FOOT SPRAY
ATHLETE’S FOOT AF 1% CREAM ATHLETE’S FOOT AF
ATHLETES FOOT 1% CREAM ATHLETE’S FOOT
BACITRACIN 500 UNIT/GM OINTMNT BACITRACIN
BACITRACIN ZN 500 UNIT/GM OINT BACITRACIN ZINC
BACITRACIN-POLYMYXIN OINTMENT BACITRACIN-POLYMYXIN
CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM GRX CLOTRIMAZOLE
CVS AF 1% SPRAY POWDER AF
CVS ANTI-FUNGAL 2% POWDER ANTI-FUNGAL
CVS ANTIBIOTIC OINTMENT ANTIBIOTIC
2018 Trusted Health Plan Medicaid OTC Formulary
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Dermatological - Anti-infectives
Medication Info Common Name Drug Status Criteria
CVS ANTIBIOTIC PLUS CREAM ANTIBIOTIC PLUS
CVS ANTIFUNGAL 1% CREAM ANTIFUNGAL CREAM
CVS ATHLETE’S FOOT 1% CREAM ATHLETE’S FOOT
CVS ATHLETE’S FOOT 2% PWD SPRY ATHLETE’S FOOT SPRAY
CVS ATHLETE’S FOOT POWD SPRAY ATHLETE’S FOOT SPRAY
CVS BACITRACIN ZN 500 UNIT/GM BACITRACIN ZINC
CVS CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE
CVS FOOT & SNEAKER SPRAY PWD FOOT & SNEAKER
CVS ITCH RELIEF 1% CREAM ITCH RELIEF
CVS JOCK ITCH 1% CREAM JOCK ITCH
CVS POLY BACITRACIN OINTMNT POLY BACITRACIN
CVS POVIDONE-IODINE 10% SOLN POVIDONE-IODINE
CVS RINGWORM 1% CREAM RINGWORM
CVS TRIPLE ANTIBIOTIC OINTMENT TRIPLE ANTIBIOTIC
DOUBLE ANTIBIOTIC OINTMENT DOUBLE ANTIBIOTIC
DOUBLE ANTIBIOTIC-PAIN RLF CRM DOUBLE ANTIBIOTIC-PAINRELIEF
EQ ANTIBIOTIC +PAIN RELIEF CRM ANTIBIOTIC + PAIN RELIEF
EQ ATHLETE’S FOOT 1% CREAM ATHLETE’S FOOT
EQ ATHLETE’S FOOT 1% PWD SPRAY ATHLETE’S FOOT
EQ ATHLETE’S FOOT 2% PWD SPRAY ATHLETE’S FOOT SPRAY
EQ FIRST AID ANTISEPTIC SOLN FIRST AID ANTISEPTIC
EQ JOCK ITCH 1% CREAM JOCK ITCH
EQ TERBINAFINE 1% CREAM TERBINAFINE
EQ TRIPLE ANTIBIOTIC OINTMENT TRIPLE ANTIBIOTIC
EQL ANTIFUNGAL 1% CREAM ANTIFUNGAL CREAM
EQL ATHLETE’S FOOT 1% CREAM ATHLETE’S FOOT
EQL BACITRACIN ZN 500 UNIT/GM BACITRACIN ZINC
EQL FIRST AID ANTIBIOTIC OINT FIRST AID ANTIBIOTIC
EQL FIRST AID ANTIBIOTIC-PAIN FIRST AID ANTIBIOTIC-PAINRLF
FIRST AID ABX PAIN RELIEF CRM FIRST AID ABX PAIN RELIEF
FIRST AID BACITRACIN OINTMENT BACITRACIN
GNP ANTIFUNGAL 1% CREAM ANTIFUNGAL
GNP BACITRACIN ZN 500 UNIT/GM BACITRACIN ZINC
GNP MICONAZOLE 2% SPRAYPOWDER
MICONAZOLE NITRATE
GNP MICONAZORB AF 2% POWDER MICONAZORB AF
GNP TERBINAFINE 1% CREAM TERBINAFINE
GNP TOLNAFTATE 1% CREAM TOLNAFTATE
GNP TRIPLE ANTIBIOTIC OINTMENT TRIPLE ANTIBIOTIC
HM BACITRACIN ZN 500 UNIT/GM BACITRACIN ZINC
HM DOUBLE ANTIBIOTIC OINTMENT DOUBLE ANTIBIOTIC
HM POVIDONE-IODINE 10% SOLN POVIDONE-IODINE
2018 Trusted Health Plan Medicaid OTC Formulary
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Dermatological - Anti-infectives
Medication Info Common Name Drug Status Criteria
HM TRIPLE ANTIBIOTIC OINTMENT TRIPLE ANTIBIOTIC
HOSPITAL ANTISEPTIC SOLN HOSPITAL ANTISEPTIC
JOCK ITCH 1% CREAM JOCK ITCH
JOCK ITCH 1% POWDER SPRAY JOCK ITCH
JOCK ITCH RELIEF 1% CREAM JOCK ITCH RELIEF
KRO ANTIBIOTIC-PAIN RELIEF CRM ANTIBIOTIC PLUS PAIN RELIEF
KRO TRIPLE ANTIBIOTIC OINTMENT TRIPLE ANTIBIOTIC
MICONAZOLE 2% SPRAY POWDER MICONAZOLE NITRATE
MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE
MICONAZORB AF 2% POWDER MICONAZORB AF
MULTI ANTIBIOTIC PLUS CREAM MULTI ANTIBIOTIC PLUS
NEOSPORIN ANTIBIOTIC OINTMENT NEOSPORIN
NEOSPORIN OINTMENT NEOSPORIN
ODOR CTRL FOOT-SNEAKER 1%POWD
ODOR CONTROL FOOT-SNEAKER
POLY BACITRACIN OINTMENT POLY BACITRACIN
POLYSPORIN OINTMENT POLYSPORIN
POVIDONE-IODINE 10% OINTMENT POVIDONE-IODINE
POVIDONE-IODINE 10% PREP PAD POVIDONE-IODINE
POVIDONE-IODINE 10% SOLUTION POVIDONE-IODINE
POVIDONE-IODINE 10% SWAB AMPUL POVIDONE-IODINE
POVIDONE-IODINE 10% SWABSTICK POVIDONE-IODINE
POVIDONE-IODINE 7.5% SCRUB POVIDONE-IODINE
POVIDONE-IODINE 7.5% SWABST POVIDONE-IODINE
POVIDONE-IODINE SPONGE STICKS POVIDONE-IODINE
POVIDONE-IODINE WINGED SPONGE POVIDONE-IODINE
PUB ATHLETIC FOOT 1% CREAM ATHLETIC FOOT CREAM
PUB TRIPLE ANTIBIOTIC OINTMENT TRIPLE ANTIBIOTIC
QC BACITRACIN 500 UNIT/GM OINT BACITRACIN
QC POVIDONE-IODINE 10% SOLN POVIDONE-IODINE
QC TOLNAFTATE 1% CREAM TOLNAFTATE
RA ANTIBIOTIC PLUS CREAM ANTIBIOTIC PLUS
RA ANTIFUNGAL 1% CREAM ANTIFUNGAL
RA ANTISEPTIC 10% SOLUTION ANTISEPTIC
RA ATHLETE’S FOOT 2% PWD SPRAY ATHLETE’S FOOT SPRAY
RA BACITRACIN ZN 500 UNIT/GM BACITRACIN ZINC
RA CLOTRIMAZOLE AF 1% CREAM CLOTRIMAZOLE AF
RA DOUBLE ANTIBIOTIC OINT DOUBLE ANTIBIOTIC
RA JOCK ITCH 1% POWDER SPRAY JOCK ITCH
RA JOCK ITCH CREAM JOCK ITCH RELIEF
RA TRIPLE ANTIBIOTIC OINTMENT TRIPLE ANTIBIOTIC
SB POVIDONE-IODINE 10% SOLN POVIDONE-IODINE
SB TRIPLE ANTIBIOTIC OINTMENT TRIPLE ANTIBIOTIC
2018 Trusted Health Plan Medicaid OTC Formulary
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Dermatological - Anti-infectives
Medication Info Common Name Drug Status Criteria
SM ANTIBIOTIC 500 UNIT/GM OINT ANTIBIOTIC
SM ANTIBIOTIC PLUS CREAM ANTIBIOTIC PLUS
SM ANTIFUNGAL 1% CREAM ANTIFUNGAL CREAM
SM ATHLETE’S 1% FOOT CREAM ATHLETE’S FOOT
SM CLOTRIMAZOLE AF 1% CREAM CLOTRIMAZOLE
SM DOUBLE ANTIBIOTIC OINT DOUBLE ANTIBIOTIC
SM MICONAZOLE NITRATE 2%CREAM
MICONAZOLE NITRATE
SM POVIDONE-IODINE 10% SOLN POVIDONE-IODINE
SM TRIPLE ANTIBIOTIC OINTMENT TRIPLE ANTIBIOTIC
TERBINAFINE 1% CREAM TERBINAFINE
TOLNAFTATE 1% CREAM TOLNAFTATE
TOLNAFTATE 1% POWDER TOLNAFTATE
TOLNAFTATE 1% SOLUTION TOLNAFTATE
TOLNAFTATE 1% SPRAY POWDER TOLNAFTATE
TOLNAFTATE AF 1% CREAM TOLNAFTATE
TRIPLE ANTIBIOTIC OINTMENT TRIPLE ANTIBIOTIC
V-R DOUBLE ANTIBIOTIC OINT DOUBLE ANTIBIOTIC
WAL-SPORIN FIRST AID OINTMENT WAL-SPORIN
Dermatological - Antiparasitics and Combinations
Medication Info Common Name Drug Status Criteria
BEDDING 0.5% SPRAY BEDDING SPRAY
CVS LICE BEDDING SPRAY LICE BEDDING
CVS LICE KILLING SHAMPOO LICE KILLING
CVS PERMETHRIN 1% LOTION PERMETHRIN
EQ LICE KILLING SHAMPOO LICE KILLING
EQL LICE KILLING SHAMPOO LICE KILLING
GNP LICE BEDDING SPRAY LICE BEDDING
GNP LICE TREATMENT 1% CRM RINS LICE TREATMENT
GNP LICE TREATMENT SHAMPOO LICE TREATMENT
GS LICE KILLING SHAMPOO LICE KILLING
HM LICE KILLING SHAMPOO LICE KILLING
HM LICE TREATMENT 1% CRM RINSE LICE TREATMENT
KRO LICE KILLING SHAMPOO LICE KILLING
LICE BEDDING SPRAY LICE BEDDING
LICE KILLING SHAMPOO LICE KILLING
LICE TREATMENT 1% CREME RINSE LICE TREATMENT
LICE TREATMENT SHAMPOO LICE TREATMENT
RA LICE PYRINYL SHAMPOO LICE PYRINYL SHAMPOO
RA LICE TREATMENT 1% CRM RINSE LICE TREATMENT
RID ESSENTIAL LICE KIT RID
RID LICE KILLING SHAMPOO RID
SB LICE KILLING SHAMPOO LICE KILLING
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Dermatological - Antiparasitics and Combinations
Medication Info Common Name Drug Status Criteria
SM LICE BEDDING SPRAY LICE BEDDING
SM LICE KILLING SHAMPOO LICE KILLING
SM LICE TREATMENT 1% CRM RINSE LICE TREATMENT
SM LICE TREATMENT PERMETHRIN LICE TREATMENT
STOP LICE 0.5% SPRAY STOP LICE
V-R LICE CREAM RINSE LICE CREAM RINSE
V-R LICE KILLING SHAMPOO LICE KILLING
Dermatological - Antipruritics
Medication Info Common Name Drug Status Criteria
CVS ITCH RELIEF 2% GEL ITCH RELIEF
CVS ITCH RELIEF GEL ITCH RELIEF
RA ANTI-ITCH GEL ANTI-ITCH
RA DIPHENHYDRAMINE 2% CREAM DIPHENHYDRAMINE HCL
Dermatological - Astringents and Combinations
Medication Info Common Name Drug Status Criteria
PRE-MOISTENED MEDICATED WIPES PRE-MOISTENED MEDICATEDWIPES
Dermatological - Emollients and Combinations
Medication Info Common Name Drug Status Criteria
AMMONIUM LACTATE 12% CREAM AMMONIUM LACTATE
AMMONIUM LACTATE 12% LOTION AMMONIUM LACTATE
CVS PURE GLYCERIN 99.5% LIQUID GLYCERIN
CVS SKIN TREATMENT BODY LOTION SKIN TREATMENT
CVS VITAMIN E 28,000 UNITS OIL VITAMIN E
E-CREAM E-CREAM
GLYCERIN 99.5% LIQUID GLYCERIN
GLYCERIN 99.5% SKIN PROTECT LQ GLYCERIN
GLYCERIN LIQUID GLYCERIN
GLYCERIN SKIN PROTECTANT LIQ GLYCERIN
GNP GLYCERIN 99.5% LIQUID GLYCERIN
HM GLYCERIN 99.5% LIQUID GLYCERIN
LAC-HYDRIN FIVE 5% LOTION LAC-HYDRIN FIVE
SM GLYCERIN LIQUID GLYCERIN
TOPICAL LIGHT MINERAL OIL TOPICAL LIGHT MINERAL OIL
VITAMIN E 56,000 UNITS OIL VITAMIN E
VITAMIN E 6,000 UNITS CREAM VITAMIN E
VITAMIN E 70,000 UNITS OIL VITAMIN E
VITAMIN E OIL VITAMIN E
Dermatological - Glucocorticoids and Combinations
Medication Info Common Name Drug Status Criteria
ANTI-ITCH 1% CREAM ANTI-ITCH
ANTI-ITCH 1% LOTION ANTI-ITCH
ANTI-ITCH 1% OINTMENT ANTI-ITCH
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Dermatological - Glucocorticoids and Combinations
Medication Info Common Name Drug Status Criteria
CORTAID 1% CREAM CORTAID
CORTIZONE-10 1% CREME CORTIZONE-10
CORTIZONE-10 PLUS 1% CREME CORTIZONE-10 PLUS
CORTIZONE-10 PLUS CREME CORTIZONE-10 PLUS
CVS ANTI-ITCH 1% CREAM ANTI-ITCH
CVS CORTISONE + COOLING RLF GL CORTISONE + COOLINGRELIEF
CVS CORTISONE 1% CREAM CORTISONE
CVS CORTISONE 1% HEALING LOT CORTISONE
CVS CORTISONE 1% OINTMENT CORTISONE
CVS ECZEMA ANTI-ITCH 1% CREAM ECZEMA ANTI-ITCH
CVS HYDROCORTISONE 0.5% CRM HYDROCORTISONE ACETATE
CVS HYDROCORTISONE 1% CREAM HYDROCORTISONE
CVS HYDROCORTISONE 1% OINT HYDROCORTISONE
EQ HYDROCORTISONE 1% CREAM HYDROCORTISONE
EQL ANTI-ITCH 1% CREAM ANTI-ITCH
EQL ANTI-ITCH 1% OINTMENT ANTI-ITCH
GNP HYDROCORT ACETATE 1% CR HYDROCORTISONE ACETATE
GNP HYDROCORTISONE 0.5% CRM HYDROCORTISONE ACETATE
GNP HYDROCORTISONE 1% CREAM HYDROCORTISONE
GNP HYDROCORTISONE 1%OINTMENT
HYDROCORTISONE
HM HYDROCORTISONE 1% CREAM HYDROCORTISONE
HYDROCORTISONE 0.5% CREAM HYDROCORTISONE
HYDROCORTISONE 0.5% OINTMENT HYDROCORTISONE
HYDROCORTISONE 1% CREAM HYDROCORTISONE
HYDROCORTISONE 1% LOTION HYDROCORTISONE
HYDROCORTISONE 1% OINTMENT HYDROCORTISONE
HYDROCORTISONE PLUS 1% CREAM HYDROCORTISONE
KRO HYDROCORTISONE 1% CREAM HYDROCORTISONE
NEOSPORIN 1% ANTI-ITCH CREAM NEOSPORIN
NOBLE FORMULA HC 1% CREAM NOBLE FORMULA HC
PREPARATION H HC 1% CREAM PREPARATION H
PUB HYDROCREAM 1% HYDROCREAM
RA ANTI-ITCH 1% CREAM ANTI-ITCH
RA ANTI-ITCH 1% OINTMENT ANTI-ITCH
RA HYDROCORTISONE 1% CREAM HYDROCORTISONE
RECORT PLUS 1% CREAM RECORT PLUS
SB HYDROCORTISONE 1% CREAM HYDROCORTISONE
SB HYDROCORTISONE 1%OINTMENT
HYDROCORTISONE
SCALP RELIEF LIQUID SCALP RELIEF
SM HYDROCORTISONE 0.5% CREAM HYDROCORTISONE
SM HYDROCORTISONE 0.5%OINTMNT
HYDROCORTISONE
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Dermatological - Glucocorticoids and Combinations
Medication Info Common Name Drug Status Criteria
SM HYDROCORTISONE 1% CREAM HYDROCORTISONE
SM HYDROCORTISONE 1%OINTMENT
HYDROCORTISONE
SOOTHING CARE 1% CREAM SOOTHING CARE
Dermatological - Irritants-Counter-Irritants
Medication Info Common Name Drug Status Criteria
CAPSAICIN 0.025% CREAM CAPSAICIN
Dermatological - Keratolytics-Antimitotics
Medication Info Common Name Drug Status Criteria
CALLUS REMOVERS PADS CALLUS REMOVERS
CALLUS REMOVERS PATCH CALLUS REMOVERS
CLEAR AWAY MEDICATED DISC CLEAR AWAY
COMPOUND W 17% GEL COMPOUND W
COMPOUND W INVISIBLE STRIPS COMPOUND W
COMPOUND W PADS COMPOUND W
CORN REMOVER 40% PATCH CORN REMOVER
CORN REMOVER STRIPS CORN REMOVER
CVS CALLUS REMOVER PAD CALLUS REMOVER
CVS CORN REMOVER PAD CORN REMOVER
CVS PLANTAR WART REMOVER PLANTAR WART REMOVER
CVS WART REMOVER WART REMOVER
CVS WART REMOVER 17% GEL PEN WART REMOVER
CVS WART REMOVER LIQUID WART REMOVER
CVS WART REMOVER STRIPS WART REMOVER
DR SCHOLL’S CLEAR AWAY STRIPS DR SCHOLL’S CLEAR AWAY
GEL CALLUS REMOVERS CUSHION CALLUS REMOVERS
GNP LIQUID WART REMOVER 17% LQ WART REMOVER
GNP WART REMOVER SOLUTION WART REMOVER
GS CORN-CALLUS REMOVER CORN-CALLUS REMOVER
GS WART REMOVER 17% LIQUID WART REMOVER
LIQUID CORN-CALLUS REMOVER LIQUID CORN-CALLUSREMOVER
LIQUID WART REMOVER 17% LIQUID WART REMOVER
MEDIPLAST CORN-CALLUS-WARTPAD
MEDIPLAST CORN-CALLUS-WART
MOSCO 40% CORN REMOVER PADS MOSCO CORN REMOVER
RA CORN REMOVER 40% PATCH CORN REMOVER
RA CORN REMOVERS PATCH CORN REMOVER
RA WART REMOVER 17% GEL WART REMOVER
SAL-PLANT 17% GEL SAL-PLANT
SM MAX STRENGTH WART REMOVER WART REMOVER
SM MEDICATED CORN REMOVERS MEDICATED CORN REMOVERS
WART REMOVER 17% GEL WART REMOVER
WART REMOVER 17% GEL PEN WART REMOVER
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Dermatological - Keratolytics-Antimitotics
Medication Info Common Name Drug Status Criteria
WART REMOVER 17% LIQUID WART REMOVER
WART REMOVER 40% PATCH WART REMOVER
WART REMOVER LIQUID WART REMOVER
WART REMOVER SOLUTION WART REMOVER
WART REMOVER STRIPS WART REMOVER
Diabetic Therapy
Medication Info Common Name Drug Status Criteria
HUMULIN 70-30 VIAL HUMULIN 70-30
HUMULIN 70/30 KWIKPEN HUMULIN 70/30 KWIKPEN
HUMULIN N 100 UNITS/ML KWIKPEN HUMULIN N KWIKPEN
HUMULIN N 100 UNITS/ML VIAL HUMULIN N
HUMULIN R 100 UNITS/ML VIAL HUMULIN R
NOVOLIN 70-30 100 UNIT/ML VIAL NOVOLIN 70-30
NOVOLIN N 100 UNITS/ML VIAL NOVOLIN N
NOVOLIN R 100 UNITS/ML VIAL NOVOLIN R
RELION NOVOLIN 70-30 VIAL NOVOLIN 70-30
RELION NOVOLIN N 100 UNIT/ML NOVOLIN N
RELION NOVOLIN R 100 UNIT/ML NOVOLIN R
Dietary Products
Medication Info Common Name Drug Status Criteria
ENFAMIL PROSOBEE LIPIL LIQ ENFAMIL PROSOBEE LIPIL
EO28 SPLASH DRINK EO28 SPLASH
HI-CAL LIQUID HI-CAL
NUTRAMENT LIQUID NUTRAMENT
PEDIATRIC BALANCED NUTRITN LIQ PEDIATRIC BALANCEDNUTRITION
PEDIATRIC DRINK WITH FIBER LIQ PEDIATRIC DRINK WITH FIBER
PREGESTIMIL LIPIL NURSETTE PREGESTIMIL
RCF SOY FORMULA W-IRON LIQUID RCF SOY FORMULA
RE-GEN LIQUID RE-GEN
RESOURCE 2.0 LIQUID RESOURCE 2.0
SIMILAC ADVANCE FORMULA SIMILAC ADVANCE
SIMILAC ADVANCE LIQ CONC SIMILAC ADVANCE
SIMILAC EXPERT CARE NEOSURE LQ SIMILAC EXPERT CARENEOSURE
SIMILAC LOW-IRON FORMULA SIMILAC
SIMILAC NEOSURE INFANT FORMULA SIMILAC NEOSURE
Digestive Aids
Medication Info Common Name Drug Status Criteria
CVS DAIRY RELIEF 9,000 UNIT DAIRY RELIEF
CVS DAIRY RELIEF 9,000 UNITS DAIRY RELIEF
CVS DAIRY RLF 9,000 UNIT CHEW DAIRY RELIEF
CVS LACTASE 3,000 UNIT CAPLET LACTASE
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Digestive Aids
Medication Info Common Name Drug Status Criteria
DAIRY DIGESTIVE 9,000 UNIT DAIRY DIGESTIVE
DAIRY DIGESTIVE AID 9,000 UNIT DAIRY DIGESTIVE
DAIRY RELIEF 3,000 UNIT CAPLET DAIRY RELIEF
DAIRY RLF 9,000 UNIT TAB CHEW DAIRY RELIEF
EQ DAIRY DIGESTIVE 9,000 UNIT DAIRY DIGESTIVE
EQL DAIRY RELIEF 9,000 UNIT DAIRY RELIEF
FAST ACTING LACTASE 9,000 UNIT FAST ACTING LACTASE
GNP DAIRY RELIEF 3,000 UNIT CP DAIRY RELIEF
GNP DAIRY RLF 9,000 UNIT CHEW DAIRY RELIEF
LACTASE 3,000 UNIT CAPLET LACTASE
LACTASE FAST ACTING 9,000 UNIT LACTASE FAST ACTING
LACTOSE FAST ACTING 9,000 UNIT LACTOSE FAST ACTING
LACTOSE FAST ACTING RLF 9,000 LACTOSE FAST ACTINGRELIEF
PUB DAIRY DIGESTIVE 9,000 UNIT DAIRY DIGESTIVE
RA DAIRY RELIEF 9,000 UNIT DAIRY RELIEF
RA DAIRY RLF 9,000 UNIT CHEW DAIRY RELIEF
SB DAIRY RELIEF CAPLET DAIRY RELIEF
SM DAIRY DIGESTIVE CAPLET DAIRY DIGEST
SM ULTRA DAIRY DIGESTIVE CPLT ULTRA DAIRY DIGESTIVE
ULTRA DAIRY DIGESTIVE CPLET ULTRA DAIRY DIGESTIVE
Emergency Contraceptives and Combinations
Medication Info Common Name Drug Status Criteria
AFTERA 1.5 MG TABLET AFTERA
ECONTRA EZ 1.5 MG TABLET ECONTRA EZ
FALLBACK SOLO 1.5 MG TABLET FALLBACK SOLO
LEVONORGESTREL 1.5 MG TABLET LEVONORGESTREL
MY WAY 1.5 MG TABLET MY WAY
NEXT CHOICE ONE DOSE 1.5 MG TB NEXT CHOICE ONE DOSE
OPCICON ONE-STEP 1.5 MG TABLET OPCICON ONE-STEP
OPTION 2 1.5 MG TABLET OPTION 2
PLAN B ONE-STEP 1.5 MG TABLET PLAN B ONE-STEP
TAKE ACTION 1.5 MG TABLET TAKE ACTION
Expectorants
Medication Info Common Name Drug Status Criteria
ADULT WAL-TUSSIN LIQUID ADULT WAL-TUSSIN
CHILDREN’S CHEST CONGEST LIQ CHILDREN’S CHESTCONGESTION
CHILDREN’S MUCUS RELIEF LIQ CHILDREN’S MUCUS RELIEF
COUGH SYRUP 100 MG/5 ML COUGH SYRUP
CVS CHILD’S CHEST CONGEST LIQ CHILDREN’S CHESTCONGESTION
CVS TUSSIN 100 MG/5 ML LIQUID TUSSIN
EQL TUSSIN CHEST CONGESTSYRUP
TUSSIN CHEST CONGESTION
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Expectorants
Medication Info Common Name Drug Status Criteria
EQL TUSSIN MUCUS-CHESTCONGEST
TUSSIN MUCUS-CHESTCONGESTION
EXPECTORANT 100 MG/5 ML SYRUP EXPECTORANT
GNP TUSSIN 100 MG/5 ML SYRUP TUSSIN
GNP TUSSIN MUCUS-CON 200 MG/10 TUSSIN MUCUS-CHESTCONGESTION
GUAIFENESIN 100 MG/5 ML LIQUID GUAIFENESIN
GUAIFENESIN 100 MG/5 ML SOLN GUAIFENESIN
GUAIFENESIN 100 MG/5 ML SYRUP GUAIFENESIN
GUAIFENESIN 200 MG/10 ML SOLN GUAIFENESIN
GUAIFENESIN 300 MG/15 ML SOLN GUAIFENESIN
HM ADULT TUSSIN CHEST CONG LIQ ADULT TUSSIN CHESTCONGESTION
HV TUSSIN MUCUS-CONG 200 MG/10 TUSSIN MUCUS-CHESTCONGESTION
KRO TUSSIN 200 MG/10 ML SYRUP TUSSIN
PEDIATRIC COUGH-COLD SYRUP PEDIATRIC COUGH-COLD
PUB TUSSIN 100 MG/5 ML SYRUP TUSSIN
RA EXPECTORANT COUGH SYRUP EXPECTORANT
RA TUSSIN 100 MG/5 ML SYRUP TUSSIN
RA TUSSIN CHEST CONGESTIONSYR
TUSSIN CHEST CONGESTION
SB COUGH CONTROL SYRUP COUGH CONTROL
SM TUSSIN 100 MG/5 ML LIQUID TUSSIN
SM TUSSIN MUCUS-CONG 200 MG/10 TUSSIN MUCUS-CHESTCONGESTION
TUSSIN 100 MG/5 ML SYRUP TUSSIN
TUSSIN CHEST CONGESTION LIQUID TUSSIN CHEST CONGESTION
TUSSIN HONEY SYRUP TUSSIN HONEY
TUSSIN MUCUS-CONG 200 MG/10 TUSSIN MUCUS-CHESTCONGESTION
TUSSIN MUCUS-CONGEST 100 MG/5 TUSSIN MUCUS-CHESTCONGESTION
WAL-TUSSIN SYRUP WAL-TUSSIN
Gastrointestinal Antiflatulents and Combinations
Medication Info Common Name Drug Status Criteria
CVS ANTI-GAS 180 MG SOFTGEL ANTI-GAS
CVS GAS RELIEF 125 MG CHEW TAB GAS RELIEF
CVS GAS RELIEF 125 MG SOFTGEL GAS RELIEF
CVS GAS RELIEF 80 MG TAB CHEW GAS RELIEF
CVS GAS RELIEF EX-STR DROPS GAS RELIEF
CVS INFT GAS RLF 20 MG/0.3 DRP INFANTS’ GAS RELIEF
CVS INFT GAS RLF 20 MG/0.3 ML INFANTS’ GAS RELIEF
EQ GAS RELIEF 125 MG SOFTGEL GAS RELIEF
EQ INF GAS RELIEF 20 MG/0.3 ML INFANTS’ GAS RELIEF
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Gastrointestinal Antiflatulents and Combinations
Medication Info Common Name Drug Status Criteria
EQL GAS RELIEF 125 MG CHEW TAB GAS RELIEF
EQL GAS RELIEF 125 MG SOFTGEL GAS RELIEF
EQL GAS RELIEF 180 MG SOFTGEL GAS RELIEF
EQL GAS RELIEF DROPS GAS RELIEF
GAS RELIEF 125 MG CHEW TABLET GAS RELIEF
GAS RELIEF 125 MG SOFTGEL GAS RELIEF
GAS RELIEF 180 MG SOFTGEL GAS RELIEF
GAS RELIEF 40 MG/0.6 ML DROPS GAS RELIEF
GAS RELIEF 80 MG TABLET CHEW GAS RELIEF
GAS RELIEF 80 TABLET CHEW GAS RELIEF 80
GAS RELIEF DROPS GAS RELIEF
GAS RELIEF DROPS 20 MG/0.3 ML INFANTS’ GAS RELIEF
GNP GAS RELIEF 125 MG CHEW TAB GAS RELIEF
GNP GAS RELIEF 125 MG SOFTGEL GAS RELIEF
GNP GAS RELIEF 80 TAB CHEW GAS RELIEF 80
GNP INFANT GAS RELIEF DROPS INFANT GAS RELIEF
GNP SIMETHICONE 180 MG SOFTGEL SIMETHICONE
GS GAS RELIEF 125 MG SOFTGEL GAS RELIEF
HM GAS RELIEF 80 MG TAB CHEW GAS RELIEF
HM INF GAS RELIEF 20 MG/0.3 ML INFANTS’ GAS RELIEF
INFANT GAS RELIEF DROPS INFANT GAS RELIEF
INFANTS’ GAS RLF 20 MG/0.3 ML INFANTS’ GAS RELIEF
KRO GAS RELIEF 180 MG SOFTGEL GAS RELIEF
KRO INFT GAS RLF 20 MG/0.3 ML INFANTS’ GAS RELIEF
PUB GAS RELIEF 125 MG SOFTGEL GAS RELIEF
PUB GAS RELIEF 180 MG SOFTGEL GAS RELIEF
PUB INFANTS’ GAS RELIEF DROPS INFANTS’ GAS RELIEF
QC ANTI-GAS 180 MG SOFTGEL ANTI-GAS
QC GAS RELIEF 125 MG TAB CHEW GAS RELIEF
RA GAS RELIEF 125 MG SOFTGEL GAS RELIEF
RA GAS RELIEF 125 MG TAB CHEW GAS RELIEF
SIMETHICONE 125 MG SOFTGEL SIMETHICONE
SIMETHICONE 125 MG TAB CHEW SIMETHICONE
SIMETHICONE 180 MG SOFTGEL SIMETHICONE
SIMETHICONE 40 MG/0.6 ML DROP SIMETHICONE
SIMETHICONE 80 MG TAB CHEW SIMETHICONE
SM GAS REL ANTIFLATUENT 180 MG GAS RELIEF
SM GAS RELIEF 125 MG SOFTGEL GAS RELIEF
SM GAS RELIEF 80 MG TAB CHEW GAS RELIEF
SM INF GAS RELIEF 20 MG/0.3 ML INFANTS’ GAS RELIEF
V-R GAS RELIEF 80 MG TAB CHEW GAS RELIEF
V-R GAS RELIEF INFANT DROPS INFANTS’ GAS RELIEF
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Irrigation Solutions
Medication Info Common Name Drug Status Criteria
SODIUM CHLORIDE 1,000 MG TAB SODIUM CHLORIDE
Laxatives
Medication Info Common Name Drug Status Criteria
BISA-LAX EC 5 MG TABLET BISA-LAX
BISACODYL 10 MG SUPPOSITORY BISACODYL
BISACODYL EC 5 MG TABLET BISACODYL
CHOCOLATED LAXATIVE CHOCOLATED LAXATIVE
CITRATE OF MAGNESIA SOLN CITRATE OF MAGNESIA
CLEARLAX POWDER CLEARLAX
CLEARLAX POWDER PACKET CLEARLAX
COL-RITE 250 MG SOFTGEL COL-RITE
CVS BISACODYL 10 MG SUPPOS BISACODYL
CVS BISACODYL EC 5 MG TABLET BISACODYL
CVS CITRATE OF MAGNESIA SOLN MAGNESIUM CITRATE
CVS ENEMA DISPOSABLE ENEMA DISPOSABLE
CVS ENEMA DISPOSABLE TWINPACK
ENEMA DISPOSABLE
CVS GENTLE LAXATIVE 10 MG SUPP GENTLE LAXATIVE
CVS GENTLE LAXATIVE EC 5 MG TB GENTLE LAXATIVE
CVS GLYCERIN SUPPOSITORY GLYCERIN
CVS LAXATIVE 15 MG PILLS LAXATIVE
CVS LAXATIVE PILLS LAXATIVE
CVS MAGNESIUM CITRATE SOLN MAGNESIUM CITRATE
CVS MILK OF MAGNESIA SUSP MILK OF MAGNESIA
CVS MINERAL OIL MINERAL OIL
CVS MINERAL OIL ENEMA MINERAL OIL
CVS PHOSPHATE ORAL SALINE LAX PHOSPHATE LAXATIVE
CVS PURELAX POWDER PURELAX
CVS PURELAX POWDER PACKET PURELAX
CVS SENNA LAXATIVE 8.6 MG TAB SENNA LAXATIVE
CVS SENNA PLUS TABLET SENNA PLUS
CVS SENNA-EXTRA 17.2 MG TABLET SENNA-EXTRA
CVS STOOL SOFTENER 100 MG CAP STOOL SOFTENER
CVS STOOL SOFTENER 100 MG SFTG STOOL SOFTENER
CVS STOOL SOFTENER 250 MG SFGL STOOL SOFTENER
CVS STOOL SOFTENER 250 MGSFTGL
STOOL SOFTENER
CVS STOOL SOFTENER 50 MGSOFTGEL
STOOL SOFTENER
CVS STOOL SOFTENER SOFTGEL STOOL SOFTENER
CVS STOOL SOFTENER-LAXATIVE TB STOOL SOFTENER-LAXATIVE
CVS SUPPOSITORY SUPPOSITORY
CVS SUPPOSITORY ADULT SUPPOSITORY
CVS WOMEN’S GENTLE LAX EC 5 MG WOMEN’S GENTLE LAXATIVE
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Laxatives
Medication Info Common Name Drug Status Criteria
DOCUSATE CAL 240 MG CAPSULE DOCUSATE CALCIUM
DOCUSATE CAL 240 MG SOFTGEL DOCUSATE CALCIUM
DOCUSATE SOD 20 MG/5 ML SYRUP DOCUSATE SODIUM
DOCUSATE SOD 60 MG/15 ML SYRP DOCUSATE SODIUM
DOCUSATE SODIUM 100 MGCAPSULE
DOCUSATE SODIUM
DOCUSATE SODIUM 100 MGSOFTGEL
DOCUSATE SODIUM
DOCUSATE SODIUM 100 MG TABLET DOCUSATE SODIUM
DOCUSATE SODIUM 250 MGCAPSULE
DOCUSATE SODIUM
DOCUSATE SODIUM 250 MGSOFTGEL
DOCUSATE SODIUM
DOCUSATE SODIUM 50 MG/5 ML LIQ DOCUSATE SODIUM
DOCUSATE SODIUM-SENNA TABLET DOCUSATE SODIUM-SENNA
DOCUSIL 100 MG SOFTGEL DOCUSIL
DUCODYL EC 5 MG TABLET DUCODYL
ENEMA READY TO USE ENEMA
ENEMA READY-TO-USE ENEMA
EQ CHOCOLATED LAXATIVE CHOCOLATED LAXATIVE
EQ CLEARLAX POWDER CLEARLAX
EQ FIBER THERAPY POWDER FIBER THERAPY
EQ GENTLE LAXATIVE DR 5 MG TAB GENTLE LAXATIVE
EQ LAXATIVE 25 MG TABLET LAXATIVE
EQ MAGNESIUM CITRATE SOLUTION MAGNESIUM CITRATE
EQ MAX STR LAXATIVE PILLS LAXATIVE
EQ MILK OF MAGNESIA SUSPENSION MILK OF MAGNESIA
EQ MINERAL OIL MINERAL OIL
EQ NATURAL LAXATIVE 8.6 MG TAB NATURAL LAXATIVE
EQ SENNA-S TAB 8.6-50MG EQ SENNA-S
EQ SENNA-S TABLET SENNA-S
EQ STOOL SOFTENER 100 MG SFTGL STOOL SOFTENER
EQ STOOL SOFTENER-LAXATIVE TAB STOOL SOFTENER-LAXATIVE
EQ VEGETABLE LAXATIVE TABLET VEGETABLE LAXATIVE
EQ WOMEN’S LAXATIVE 5 MG TAB WOMEN’S LAXATIVE
EQ WOMEN’S LAXATIVE EC 5 MG TB WOMEN’S LAXATIVE
EQL CHOCOLATED LAXATIVE CHOCOLATED LAXATIVE
EQL CLEARLAX POWDER CLEARLAX
EQL ENEMA READY TO USE ENEMA
EQL GENTLE LAXATIVE EC 5 MG TB GENTLE LAXATIVE
EQL LAXATIVE 25 MG TABLET LAXATIVE
EQL MAGNESIUM CITRATESOLUTION
MAGNESIUM CITRATE
EQL MILK OF MAGNESIA SUSP MILK OF MAGNESIA
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Laxatives
Medication Info Common Name Drug Status Criteria
EQL SENNA LAXATIVE 8.6 MG TAB SENNA LAXATIVE
EQL SENNA-S TABLET SENNA-S
EQL STOOL SOFTENER 100 MG SFGL STOOL SOFTENER
EQL STOOL SOFTENER-STIM LAX TB STOOL SOFTENER-STIMULANTLAX
EVAC-U-GEN 8.6 MG TABLET EVAC-U-GEN
GENTLE LAXATIVE 10 MG SUPPOSIT GENTLE LAXATIVE
GENTLE LAXATIVE 5 MG TABLET GENTLE LAXATIVE
GENTLE LAXATIVE EC 5 MG TABLET GENTLE LAXATIVE
GENTLELAX POWDER GENTLELAX
GERI-KOT 8.6 MG TABLET GERI-KOT
GLYCERIN ADULT SUPPOSITORY ADULT GLYCERIN
GLYCERIN PEDIATRIC SUPPOS GLYCERIN
GLYCERIN PEDIATRIC SUPPOSITORY GLYCERIN
GLYCERIN SUPPOSITORY GLYCERIN
GNP BISA-LAX EC 5 MG TABLET BISA-LAX
GNP CITRATE OF MAGNESIA SOLN CITRATE OF MAGNESIA
GNP CLEARLAX POWDER CLEARLAX
GNP CLEARLAX POWDER PACKET CLEARLAX
GNP ENEMA READY TO USE ENEMA
GNP GLYCERIN SUPPOSITORY GLYCERIN
GNP LAXATIVE 25 MG PILL LAXATIVE
GNP LAXATIVE EC 5 MG TABLET LAXATIVE
GNP MILK OF MAGNESIA SUSP MILK OF MAGNESIA
GNP MINERAL OIL ENEMA MINERAL OIL
GNP NATURAL FIBER POWDER NATURAL FIBER POWDER
GNP SENNA LAX 8.6 MG TABLET SENNA LAX
GNP SENNA PLUS TABLET SENNA PLUS
GNP SENNA-LAX 8.6 MG TABLET SENNA LAX
GNP STOOL SOFT-STIMULANT LAX T STOOL SOFTENER-STIMULANTLAX
GNP STOOL SOFTENER 100 MG SFGL STOOL SOFTENER
GNP STOOL SOFTENER 250 MG SFGL STOOL SOFTENER
GNP STOOL SOFTENER 50 MG/5 ML STOOL SOFTENER
GNP STOOL SOFTENER SYRUP STOOL SOFTENER
GNP STOOL SOFTENER-LAXATIVE TB STOOL SOFTENER-LAXATIVE
GNP STOOL SOFTENER-STIM LAX TB STOOL SOFTENER-STIMULANTLAX
HM CLEARLAX POWDER CLEARLAX
HM ENEMA READY TO USE ENEMA
HM ENEMA READY TO USE TWIN PAK ENEMA
HM LAXATIVE EC 5 MG TABLET LAXATIVE
HM MAGNESIUM CITRATE SOLUTION MAGNESIUM CITRATE
HM MILK OF MAGNESIA SUSPENSION MILK OF MAGNESIA
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Laxatives
Medication Info Common Name Drug Status Criteria
HM MINERAL OIL MINERAL OIL
HM MINERAL OIL ENEMA MINERAL OIL
HM READY TO USE MIN OIL ENEMA READY TO USE ENEMA
HM SENNA 8.6 MG TABLET SENNA
HM SENNA-S TABLET SENNA-S
HM STOOL SOFTENER 100 MG SFTGL STOOL SOFTENER
HM STOOL SOFTENER 100 MG TAB STOOL SOFTENER
HM STOOL SOFTENER 250 MG SFTGL STOOL SOFTENER
HM STOOL SOFTENER-LAXATIVE TAB STOOL SOFTENER-LAXATIVE
HV MILK OF MAGNESIA SUSPENSION MILK OF MAGNESIA
INFANT & CHILD GLYCERIN SUPPOS GLYCERIN
KRO GENTLELAX 17 GRAM POWDER GENTLELAX
KRO MILK OF MAGNESIA SUSP MILK OF MAGNESIA
LAX STOOL SOFTENER-SENNA TAB LAX STOOL SOFTENER WITHSENNA
LAXACLEAR POWDER LAXACLEAR
LAXATIVE 15 MG PILLS LAXATIVE PILLS
LAXATIVE 25 MG PILL LAXATIVE
LAXATIVE 25 MG PILLS LAXATIVE PILLS
LAXATIVE 5 MG TABLET LAXATIVE
LAXATIVE EC 5 MG TABLET LAXATIVE
LAXATIVE FEMININE 5 MG TAB LAXATIVE FEMININE
LAXATIVE MAX STRENGTH PILLS LAXATIVE MAXIMUMSTRENGTH
MAGNESIUM CITRATE SOLUTION MAGNESIUM CITRATE
MILK OF MAGNESIA CONCENTRATED MILK OF MAGNESIA
MILK OF MAGNESIA SUSPENSION MILK OF MAGNESIA
MINERAL OIL MINERAL OIL
MINERAL OIL ENEMA MINERAL OIL
MINERAL OIL, HEAVY MINERAL OIL
NATURAL FIBER POWDER NATURAL FIBER POWDER
NATURAL LAXATIVE TABLET NATURAL LAXATIVE
NATURAL SENNA LAXATIVE TAB NATURAL SENNA LAXATIVE
NATURAL VEGETABLE POWDER NATURAL VEGETABLEPOWDER
ORAL SALINE LAXATIVE LIQUID ORAL SALINE LAXATIVE
PEDIATRIC GLYCERIN SUPPOSITORY GLYCERIN
PHOSPHATE ORAL SALINE LAXATIVE PHOSPHATE LAXATIVE
POLYETHYLENE GLYCOL 3350 POWD POLYETHYLENE GLYCOL 3350
POWDERLAX POWDER POWDERLAX
PSYLLIUM SEED POWDER PSYLLIUM SEED
PUB DOCUSATE SODIUM 100 MGCAP
DOCUSATE SODIUM
PUB LAXATIVE EC 5 MG TABLET LAXATIVE
2018 Trusted Health Plan Medicaid OTC Formulary
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Laxatives
Medication Info Common Name Drug Status Criteria
PUB MILK OF MAGNESIA SUSP MILK OF MAGNESIA
QC GENTLE LAXATIVE 10 MG SUPP GENTLE LAXATIVE
QC LAXATIVE 25 MG TABLET LAXATIVE
QC MAGNESIUM CITRATE SOLUTION MAGNESIUM CITRATE
QC MILK OF MAGNESIA SUSPENSION MILK OF MAGNESIA
QC MINERAL OIL HEAVY MINERAL OIL
QC NATURA-LAX 17 GM POWDER NATURA-LAX
QC NATURAL VEG LAXATIVE TABLET NATURAL VEGETABLELAXATIVE
QC NATURAL VEGETABLE POWDER NATURAL VEGETABLEPOWDER
QC READY TO USE ENEMA ENEMA
QC STOOL SOFTENER-LAX TABLET STOOL SOFTENER
RA BISACODYL EC 5 MG TABLET BISACODYL
RA CITRATE OF MAGNESIA SOLN CITRATE OF MAGNESIA
RA COL-RITE 100 MG CAPSULE COL-RITE
RA COL-RITE 250 MG SOFTGEL COL-RITE
RA ENEMA TWIN PACK ENEMA
RA FAST RELIEF LAX 10 MG SUPP FAST RELIEF LAXATIVE
RA GLYCERIN ADULT SUPPOSITORY ADULT GLYCERIN
RA GLYCERIN PEDIATRIC SUPP GLYCERIN
RA LAXATIVE 25 MG PILL LAXATIVE
RA LAXATIVE EC 5 MG TABLET LAXATIVE
RA LAXATIVE PEG 3350 POWDER LAXATIVE PEG 3350
RA MILK OF MAGNESIA SUSPENSION MILK OF MAGNESIA
RA MINERAL OIL EXTRA-HEAVY MINERAL OIL EXTRA HEAVY
RA P-COL RITE TABLET P-COL RITE
RA SALINE ENEMA SALINE ENEMA
RA SENNA 8.6 MG TABLET SENNA
RA SENNA PLUS TABLET SENNA PLUS
RA SENNA-LAX 8.6 MG TABLET SENNA LAX
RA STOOL SOFTENER 100 MG CAP STOOL SOFTENER
RA WOMEN’S LAXATIVE TABLET WOMEN’S LAXATIVE
READY TO USE ENEMA READY TO USE ENEMA
SB BISACODYL EC 5 MG TABLET BISACODYL
SB DOCUSATE SOD 100 MGCAPSULE
DOCUSATE SODIUM
SB WOMEN’S GENTLE LAX EC 5 MG WOMEN’S GENTLE LAXATIVE
SEN-O-TAB SEN-O-TAB
SENEXON TABLET SENEXON
SENNA 8.6 MG TABLET SENNA
SENNA 8.8 MG/5 ML SYRUP SENNA
SENNA 8.8 MG/5 ML SYRUP GRX SENNA
SENNA CONCENTRATE TABLET SENNA CONCENTRATE
2018 Trusted Health Plan Medicaid OTC Formulary
135
Laxatives
Medication Info Common Name Drug Status Criteria
SENNA LAX 8.6 MG TABLET SENNA LAX
SENNA LAXATIVE 8.6 MG TAB SENNA
SENNA LAXATIVE 8.6 MG TABLET SENNA LAXATIVE
SENNA LAXATIVE TABLET SENNA LAXATIVE
SENNA PLUS TABLET SENNA PLUS
SENNA-DOCUSATE SODIUM TABLET SENNA-DOCUSATE SODIUM
SENNA-GEN NF TABLET SENNA-GEN
SENNA-LAX 8.6 MG TABLET SENNA LAX
SENNA-S TABLET SENNA-S
SENNA-TIME 8.6 MG TABLET SENNA
SENNO TABLET SENNO
SENNOSIDES 8.6 MG TABLET SENNOSIDES
SENNOSIDES-DOCUSATE SODIUMTAB
SENNOSIDES-DOCUSATESODIUM
SENOKOT 8.6 MG TABLET SENOKOT
SM CLEARLAX POWDER CLEARLAX
SM DOCUSATE CAL 240 MGSOFTGEL
DOCUSATE CALCIUM
SM ENEMA READY TO USE ENEMA
SM ENEMA READY TO USE TWIN PAK ENEMA
SM FIBER POWDER FIBER
SM FIBER SMOOTH POWDER FIBER SMOOTH
SM FIBER SMOOTH TEXTURE PWD FIBER SMOOTH
SM GENTLE LAXATIVE EC 5 MG TAB GENTLE LAXATIVE
SM GLYCERIN ADULT SUPPOSITORY ADULT GLYCERIN
SM GLYCERIN PEDIATRIC SUPPO GLYCERIN
SM LAXATIVE 10 MG SUPPOSITORY LAXATIVE SUPPOSITORY
SM LAXATIVE 25 MG TABLET LAXATIVE
SM LAXATIVE PEDIATRIC SUPPOS LAXATIVE SUPPOSITORY
SM LAXATIVE TABLET LAXATIVE
SM MAGNESIUM CITRATE SOLUTION MAGNESIUM CITRATE
SM MILK OF MAGNESIA SUSPENSION MILK OF MAGNESIA
SM MINERAL OIL MINERAL OIL
SM MINERAL OIL HEAVY MINERAL OIL
SM NAT LAX PLUS STOOL SOFTENER STOOL SOFTENER
SM READY TO USE ENEMA READY TO USE ENEMA
SM SENNA LAXATIVE 8.6 MG TAB SENNA LAXATIVE
SM SENNA LAXATIVE PILLS SENNA LAXATIVE
SM SENNA-S TABLET SENNA-S
SM STOOL SOFTENER 100 MG SFTGL STOOL SOFTENER
SM STOOL SOFTENER 240 MG SFTGL STOOL SOFTENER
SM STOOL SOFTENER 250 MG SFTGL STOOL SOFTENER
SM STOOL SOFTENER TABLET STOOL SOFTENER
2018 Trusted Health Plan Medicaid OTC Formulary
136
Laxatives
Medication Info Common Name Drug Status Criteria
SM STOOL SOFTENER-LAXATIVE TAB STOOL SOFTENER-LAXATIVE
SM WOMAN’S LAXATIVE 5 MG TAB WOMAN’S LAXATIVE
SMOOTHLAX POWDER SMOOTHLAX
SMOOTHLAX POWDER PACKET SMOOTHLAX
STIMULANT LAXATIVE PLUS TABLET STIMULANT LAXATIVE PLUS
STOOL SOFT-STIMULANT LAX TAB STOOL SOFTENER-STIMULANTLAX
STOOL SOFTENER 100 MG CAPSULE STOOL SOFTENER
STOOL SOFTENER 100 MG SOFTGEL STOOL SOFTENER
STOOL SOFTENER 240 MG SOFTGEL STOOL SOFTENER
STOOL SOFTENER 250 MG SOFTGEL STOOL SOFTENER
STOOL SOFTENER 50 MG/5 ML LIQ STOOL SOFTENER
STOOL SOFTENER SYRUP STOOL SOFTENER
STOOL SOFTENER TABLET STOOL SOFTENER
STOOL SOFTENER-LAXATIVE TABLET STOOL SOFTENER-LAXATIVE
STOOL SOFTENER-STIMULANT LAX STOOL SOFTENER-STIMULANTLAX
SW CLEARLAX POWDER CLEARLAX
V-R LAXATIVE CHOCOLATE LAXATIVE
V-R LAXATIVE PILLS REG TAB LAXATIVE PILLS
V-R MILK OF MAGNESIA SUSP MILK OF MAGNESIA
V-R STOOL SOFTENER TABLET STOOL SOFTENER
VR LAXATIVE MAX-STR PILLS LAXATIVE MAXIMUMSTRENGTH
WOMAN’S LAXATIVE TABLET WOMAN’S LAXATIVE
WOMANS LAXATIVE TABLET WOMEN’S LAXATIVE
WOMEN’S LAXATIVE 5 MG TABLET WOMEN’S LAXATIVE
WOMEN’S LAXATIVE EC 5 MB TAB WOMEN’S LAXATIVE
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
1ST TIER COMFORTOUCH 28GLANCT
1ST TIER UNILETCOMFORTOUCH
QL
1ST TIER COMFORTOUCH 30GLANCT
1ST TIER UNILETCOMFORTOUCH
QL
1ST TIER UNIFINE PENTP 5MM 31G 1ST TIER UNIFINE PENTIPS
1ST TIER UNIFINE PNTIP 4MM 32G 1ST TIER UNIFINE PENTIPS
1ST TIER UNIFINE PNTIP 6MM 31G 1ST TIER UNIFINE PENTIPS
1ST TIER UNIFINE PNTIP 8MM 31G 1ST TIER UNIFINE PENTIPS
1ST TIER UNIFINE PNTP 12MM 29G 1ST TIER UNIFINE PENTIPS
1ST TIER UNIFINE PNTP 29GX1/2" 1ST TIER UNIFINE PENTIPS
1ST TIER UNIFINE PNTP 31GX1/4" 1ST TIER UNIFINE PENTIPS
1ST TIER UNIFINE PNTP 31GX3/16 1ST TIER UNIFINE PENTIPSPLUS
1ST TIER UNIFINE PNTP 31GX5/16 1ST TIER UNIFINE PENTIPSPLUS
2018 Trusted Health Plan Medicaid OTC Formulary
137
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
1ST TIER UNIFINE PNTP 32GX5/32 1ST TIER UNIFINE PENTIPSPLUS
ACTI-LANCE LITE 28G LANCETS ACTI-LANCE QL
ACTI-LANCE SPECIAL 17G LANCETS ACTI-LANCE QL
ACTI-LANCE UNIVERS 23G LANCETS ACTI-LANCE QL
ADJUSTABLE LANCING DEVICE ADJUSTABLE LANCING DEVICE QL
ADVANCED LANCING DEVICE LANCING DEVICE QL
ADVANCED TRAVEL 28G LANCETS ADVANCED TRAVEL LANCETS QL
ADVANCED TRAVEL 30G LANCETS ADVANCED TRAVEL LANCETS QL
ADVOCATE 26G LANCETS ADVOCATE LANCETS QL
ADVOCATE 30G LANCETS ADVOCATE LANCET QL
ADVOCATE INS 0.3 ML 30GX5/16" ADVOCATE SYRINGES
ADVOCATE INS 0.3 ML 31GX5/16" ADVOCATE SYRINGES
ADVOCATE INS 0.5 ML 30GX5/16" ADVOCATE SYRINGES
ADVOCATE INS 0.5 ML 31GX5/16" ADVOCATE SYRINGES
ADVOCATE INS 1 ML 31GX5/16" ADVOCATE SYRINGES
ADVOCATE INS SYR 0.3 ML 29GX1/2 ADVOCATE SYRINGES
ADVOCATE INS SYR 0.5 ML 29GX1/2 ADVOCATE SYRINGES
ADVOCATE INS SYR 1 ML 29GX1/2" ADVOCATE SYRINGES
ADVOCATE INS SYR 1 ML 30GX5/16 ADVOCATE SYRINGES
ADVOCATE PEN NDL 12.7MM 29G ADVOCATE PEN NEEDLES
ADVOCATE PEN NEEDLE 4MM 33G ADVOCATE PEN NEEDLE
ADVOCATE PEN NEEDLES 5MM 31G ADVOCATE PEN NEEDLES
ADVOCATE PEN NEEDLES 8MM 31G ADVOCATE PEN NEEDLES
ALTERNATE SITE 26G LANCETS ALTERNATE SITE LANCETS QL
ASSURE COMFORT 28G LANCETS LANCETS QL
ASSURE COMFORT 30G LANCETS LANCETS QL
ASSURE HAEMOLANCE PLUS 28G ASSURE HAEMOLANCE PLUS QL
ASSURE ID SYR 0.5 ML 29GX1/2" ASSURE ID INSULIN SAFETY
ASSURE ID SYR 1 ML 29GX1/2" ASSURE ID INSULIN SAFETY
ASSURE LANCE 28G LANCETS ASSURE LANCE QL
ASSURE LANCE PLUS 30G LANCETS ASSURE LANCE PLUS QL
AUTOJECT 2 INJECTION DEVICE AUTOJECT 2
AUTOLET LANCING DEVICE AUTOLET LANCING DEVICE QL
AUTOPEN 1 TO 21 UNITS AUTOPEN
AUTOPEN 2 TO 42 UNITS AUTOPEN
BD AUTOSHIELD DUO NDL 5MMX30G AUTOSHIELD DUO PENNEEDLE
BD AUTOSHIELD NEEDLE 5MMX29G AUTOSHIELD PEN NEEDLE
BD AUTOSHIELD NEEDLE 8MMX29G AUTOSHIELD PEN NEEDLE
BD ECLIPSE 30GX1/2" SYRINGE ECLIPSE SYRINGE
BD INSUL SYR 0.3 ML 31GX15/64" INSULIN SYRINGE
BD INSUL SYR 0.5 ML 31GX15/64" INSULIN SYRINGE
2018 Trusted Health Plan Medicaid OTC Formulary
138
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
BD INSULIN SYR 0.3 ML 28GX1/2" INSULIN SYRINGE
BD INSULIN SYR 0.3 ML 29GX1/2" INSULIN SYRINGE
BD INSULIN SYR 0.3 ML 30GX1/2" INSULIN SYRINGE
BD INSULIN SYR 0.3 ML 31GX5/16 INSULIN SYRINGE
BD INSULIN SYR 0.3 ML 31GX5/16" INSULIN SYRINGE
BD INSULIN SYR 0.3 ML 6MMX31G INSULIN SYRINGE
BD INSULIN SYR 0.3 ML 8MMX31G INSULIN SYRINGE
BD INSULIN SYR 0.5 ML 28GX1/2" INSULIN SYRINGE
BD INSULIN SYR 0.5 ML 29GX1/2" INSULIN SYRINGE
BD INSULIN SYR 0.5 ML 30GX1/2" INSULIN SYRINGE
BD INSULIN SYR 0.5 ML 31GX5/16" INSULIN SYRINGE
BD INSULIN SYR 0.5 ML 6MMX31G INSULIN SYRINGE
BD INSULIN SYR 0.5 ML 8MMX31G INSULIN SYRINGE
BD INSULIN SYR 1 ML 12.7MMX30G INSULIN SYRINGE
BD INSULIN SYR 1 ML 25GX1" INSULIN SYRINGE
BD INSULIN SYR 1 ML 25GX5/8" INSULIN SYRINGE
BD INSULIN SYR 1 ML 26GX1/2" INSULIN SYRINGE
BD INSULIN SYR 1 ML 27GX5/8" INSULIN SYRINGE
BD INSULIN SYR 1 ML 28GX1/2" INSULIN SYRINGE
BD INSULIN SYR 1 ML 29GX1/2" INSULIN SYRINGE
BD INSULIN SYR 1 ML 30GX1/2" INSULIN SYRINGE
BD INSULIN SYR 1 ML 31GX15/64" INSULIN SYRINGE
BD INSULIN SYR 1 ML 31GX5/16" INSULIN SYRINGE
BD INSULIN SYR 1 ML 6MMX31G INSULIN SYRINGE
BD INSULIN SYR 1 ML 8MMX31G INSULIN SYRINGE
BD INSULIN SYRINGE 1 ML INSULIN SYRINGE
BD INSULIN U100-3/10 ML SYR INSULIN SYRINGE
BD INTEGRA SYR 1 ML 29GX1/2" INTEGRA SYRINGE
BD LANCETS 33G LANCETS QL
BD LUER-LOK SYRINGE 1 ML LUER-LOK SYRINGE
BD MICROTAINER 30G LANCETS BD MICROTAINER LANCETS QL
BD SAFETY-G INS 0.3 ML 31GX5/16 SAFETYGLIDE INSULINSYRINGE
BD SAFETYGLIDE SYRINGE 27GX5/8 SAFETYGLIDE SYRINGE
BD SAFTGLD INS SYR 0.3 ML 29G SAFETYGLIDE INSULINSYRINGE
BD SAFTGLD INS SYR 0.5 ML 30G SAFETYGLIDE INSULINSYRINGE
BD SYR 0.3 ML 6MMX31G (1/2) INSULIN SYRINGE
BD SYR 0.3 ML 8MMX31G (1/2) INSULIN SYRINGE
BD SYRINGE 0.3 ML 12.7MMX30G INSULIN SYRINGE
BD SYRINGE 0.5 ML 12.7MMX30G INSULIN SYRINGE
BD ULTRA-FINE 33G LANCETS BD ULTRA-FINE QL
BD ULTRA-FINE II 30G LANCETS BD ULTRA-FINE II QL
2018 Trusted Health Plan Medicaid OTC Formulary
139
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
BD ULTRA-FINE NDL 12.7MMX29G BD ULTRA-FINE PEN NEEDLE
BD ULTRA-FINE PEN NDL 32GX1/4" BD ULTRA-FINE PEN NEEDLE
BD ULTRA-FINE PEN NDL 4MMX32G BD ULTRA-FINE PEN NEEDLE
BD ULTRA-FINE PEN NDL 5MMX31G BD ULTRA-FINE PEN NEEDLE
BD ULTRA-FINE PEN NDL 8MMX31G BD ULTRA-FINE PEN NEEDLE
BLOOD LANCETS 30G BLOOD LANCETS QL
BREEZE 2 DISC TEST STRIP BREEZE 2 QL
BULLSEYE MINI SAFETY 28G LANCT BULLSEYE MINI SAFETYLANCETS
QL
CA INS SYR 0.3 ML 30GX5/16" INSULIN SYRINGE
CA INS SYR 0.3 ML 31GX5/16" INSULIN SYRINGE
CA INS SYR 0.5 ML 30GX5/16" INSULIN SYRINGE
CA INS SYR 0.5 ML 31GX5/16" INSULIN SYRINGE
CA INSULIN SYR 0.3 ML 29GX1/2" INSULIN SYRINGE
CA INSULIN SYR 0.5 ML 29GX1/2" INSULIN SYRINGE
CA INSULIN SYR 1 ML 29GX1/2" INSULIN SYRINGE
CA INSULIN SYR 1 ML 30GX5/16" INSULIN SYRINGE
CA INSULIN SYR 1 ML 31GX5/16" INSULIN SYRINGE
CAREFINE PEN NEEDLE 12.7MM 29G CAREFINE PEN NEEDLE
CAREFINE PEN NEEDLE 4MM 32G CAREFINE PEN NEEDLE
CAREFINE PEN NEEDLE 5MM 32G CAREFINE PEN NEEDLE
CAREFINE PEN NEEDLE 6MM 31G CAREFINE PEN NEEDLE
CAREFINE PEN NEEDLE 8MM 30G CAREFINE PEN NEEDLE
CAREFINE PEN NEEDLES 6MM 32G CAREFINE PEN NEEDLE
CAREFINE PEN NEEDLES 8MM 31G CAREFINE PEN NEEDLE
CAREONE LANCING DEVICE CAREONE QL
CAREONE SYR 0.3 ML 30GX1/2" INSULIN SYRINGE
CAREONE SYR 0.3 ML 31GX5/16" INSULIN SYRINGE
CAREONE SYR 0.5 ML 30GX1/2" INSULIN SYRINGE
CAREONE SYR 0.5 ML 31GX5/16" INSULIN SYRINGE
CAREONE SYR 1 ML 30GX1/2" INSULIN SYRINGE
CAREONE SYR 1 ML 31GX5/16" INSULIN SYRINGE
CAREONE THIN LANCET CAREONE QL
CAREONE ULTRA THIN LANCET CAREONE QL
CAREONE UNIFINE PENTIP 4MM 32G UNIFINE PENTIPS
CAREONE UNIFINE PENTIP 5MM 31G UNIFINE PENTIPS
CAREONE UNIFINE PENTIP 6MM 31G UNIFINE PENTIPS
CAREONE UNIFINE PENTIP 8MM 31G UNIFINE PENTIPS
CAREONE UNIFINE PENTP 29GX1/2" UNIFINE PENTIPS PLUS
CAREONE UNIFINE PENTP 31GX1/4" UNIFINE PENTIPS PLUS
CAREONE UNIFINE PNTP 12MM 29G UNIFINE PENTIPS
CAREONE UNIFINE PNTP 31GX3/16" UNIFINE PENTIPS PLUS
CAREONE UNIFINE PNTP 31GX5/16" UNIFINE PENTIPS PLUS
2018 Trusted Health Plan Medicaid OTC Formulary
140
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
CAREONE UNIFINE PNTP 32GX5/32" UNIFINE PENTIPS PLUS
CARESENS ULTRA THIN 30G LANCET CARESENS QL
CARETOUCH PEN NEEDLE 31GX1/4" CARETOUCH PEN NEEDLE
CARETOUCH PEN NEEDLE 31GX3/16" CARETOUCH PEN NEEDLE
CARETOUCH PEN NEEDLE 31GX5/16" CARETOUCH PEN NEEDLE
CARETOUCH PEN NEEDLE 32GX3/16" CARETOUCH PEN NEEDLE
CARETOUCH PEN NEEDLE 32GX5/32" CARETOUCH PEN NEEDLE
CARETOUCH SYR 0.3 ML 31GX5/16" CARETOUCH INSULINSYRINGE
CARETOUCH SYR 0.5 ML 30GX5/16" CARETOUCH INSULINSYRINGE
CARETOUCH SYR 0.5 ML 31GX5/16" CARETOUCH INSULINSYRINGE
CARETOUCH SYR 1 ML 30GX5/16" CARETOUCH INSULINSYRINGE
CARETOUCH SYR 1 ML 31GX5/16" CARETOUCH INSULINSYRINGE
CARETOUCH TWIST 28G LANCET CARETOUCH TWIST LANCET QL
CARETOUCH TWIST 30G LANCET CARETOUCH TWIST LANCET QL
CARETOUCH TWIST 33G LANCET CARETOUCH TWIST LANCET QL
CLEVER CHEK ULTRA THIN 30G CLEVER CHEK LANCETS QL
CLICKFINE 31G X 1/4" NEEDLES CLICKFINE
CLICKFINE 31G X 5/16" NEEDLES CLICKFINE
CLICKFINE PEN NEEDLE 32GX5/32" CLICKFINE
CLICKFINE UNIVERSAL 31G X 1/4" CLICKFINE
CLICKFINE UNIVERSAL 31GX5/16" CLICKFINE
COAGUCHEK LANCETS COAGUCHEK QL
COMFORT EZ INS 0.3 ML 30GX1/2" COMFORT EZ
COMFORT EZ INS 0.3 ML 30GX5/16" COMFORT EZ
COMFORT EZ INSULIN SYR 0.3 ML COMFORT EZ
COMFORT EZ INSULIN SYR 0.5 ML COMFORT EZ
COMFORT EZ PEN NEEDLE 12MM29G
COMFORT EZ
COMFORT EZ PEN NEEDLES 4MM32G
COMFORT EZ
COMFORT EZ PEN NEEDLES 4MM33G
COMFORT EZ
COMFORT EZ PEN NEEDLES 5MM31G
COMFORT EZ
COMFORT EZ PEN NEEDLES 5MM32G
COMFORT EZ
COMFORT EZ PEN NEEDLES 5MM33G
COMFORT EZ
COMFORT EZ PEN NEEDLES 6MM31G
COMFORT EZ
COMFORT EZ PEN NEEDLES 6MM32G
COMFORT EZ
2018 Trusted Health Plan Medicaid OTC Formulary
141
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
COMFORT EZ PEN NEEDLES 6MM33G
COMFORT EZ
COMFORT EZ PEN NEEDLES 8MM31G
COMFORT EZ
COMFORT EZ PEN NEEDLES 8MM32G
COMFORT EZ
COMFORT EZ PEN NEEDLES 8MM33G
COMFORT EZ
COMFORT EZ SAFETY 28G LANCETS COMFORT EZ QL
COMFORT EZ SYR 0.3 ML 29GX1/2" COMFORT EZ
COMFORT EZ SYR 0.5 ML 28GX1/2" COMFORT EZ
COMFORT EZ SYR 0.5 ML 29GX1/2" COMFORT EZ
COMFORT EZ SYR 0.5 ML 30GX1/2" COMFORT EZ
COMFORT EZ SYR 1 ML 28GX1/2" COMFORT EZ
COMFORT EZ SYR 1 ML 29GX1/2" COMFORT EZ
COMFORT EZ SYR 1 ML 30GX1/2" COMFORT EZ
COMFORT EZ SYR 1 ML 30GX5/16" COMFORT EZ
COMFORT EZ SYR 1 ML 31GX5/16" COMFORT EZ
COMFORT LANCETS COMFORT LANCETS QL
COMFORT POINT PEN NDL 29GX1/2" INSULIN PEN NEEDLE
COMFORT POINT PEN NDL 31GX1/3" INSULIN PEN NEEDLE
COMFORT POINT PEN NDL 31GX1/4" INSULIN PEN NEEDLE
COMFORT POINT PEN NDL 31GX1/6" INSULIN PEN NEEDLE
CONTOUR METER CONTOUR QL
CONTOUR METER SYSTEM CONTOUR QL
CONTOUR NEXT EZ METER CONTOUR NEXT EZ QL
CONTOUR NEXT EZ METER SYSTEM CONTOUR NEXT EZ QL
CONTOUR NEXT LINK 2.4 METER KT CONTOUR NEXT LINK 2.4 QL
CONTOUR NEXT LINK METER CONTOUR NEXT LINK QL
CONTOUR NEXT METER CONTOUR NEXT QL
CONTOUR NEXT STRIPS CONTOUR NEXT QL
CONTOUR TEST STRIPS CONTOUR QL
CVS MICRO THIN 33G LANCETS MICRO THIN LANCETS QL
CVS THIN 26G LANCETS LANCETS QL
CVS ULTRA THIN 30G LANCETS ULTRA THIN LANCETS QL
DARIO 100 STERILE LANCETS LANCETS QL
DROPLET 30G LANCETS DROPLET LANCETS QL
DROPLET LANCING DEVICE DROPLET LANCING DEVICE QL
DROPLET PEN NEEDLE 29GX1/2" DROPLET PEN NEEDLE
DROPLET PEN NEEDLE 29GX3/8" DROPLET PEN NEEDLE
DROPLET PEN NEEDLE 31GX1/4" DROPLET PEN NEEDLE
DROPLET PEN NEEDLE 31GX3/16" DROPLET PEN NEEDLE
DROPLET PEN NEEDLE 31GX5/16" DROPLET PEN NEEDLE
DROPLET PEN NEEDLE 32GX1/4" DROPLET PEN NEEDLE
2018 Trusted Health Plan Medicaid OTC Formulary
142
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
DROPLET PEN NEEDLE 32GX3/16" DROPLET PEN NEEDLE
DROPLET PEN NEEDLE 32GX5/16" DROPLET PEN NEEDLE
DROPLET PEN NEEDLE 32GX5/32" DROPLET PEN NEEDLE
DRUG MART ULTRA COMFORT SYR ULTRA COMFORT
E-Z JECT COLORED LANCETS E-Z JECT LANCETS QL
E-Z JECT LANCETS E-Z JECT LANCETS QL
E-ZJECT COLOR 32G LANCETS E-ZJECT LANCETS QL
E-ZJECT COLOR 33G LANCETS E-ZJECT LANCETS QL
E-ZJECT SUPER THIN 30G LANCETS E-ZJECT LANCETS QL
E-ZJECT THIN LANCETS LANCETS QL
EASY COMFORT 0.3 ML SYRINGE EASY COMFORT INSULINSYRINGE
EASY COMFORT 0.5 ML 30GX1/2" EASY COMFORT INSULINSYRINGE
EASY COMFORT 0.5 ML 31GX5/16" EASY COMFORT INSULINSYRINGE
EASY COMFORT 0.5 ML SYRINGE EASY COMFORT INSULINSYRINGE
EASY COMFORT 1 ML 31GX5/16" EASY COMFORT INSULINSYRINGE
EASY COMFORT 30G LANCETS EASY COMFORT QL
EASY COMFORT INSULIN 1 ML SYR EASY COMFORT INSULINSYRINGE
EASY COMFORT PEN NDL 31GX1/4" EASY COMFORT PEN NEEDLES
EASY COMFORT PEN NDL 31GX3/16" EASY COMFORT PEN NEEDLES
EASY COMFORT PEN NDL 31GX5/16" EASY COMFORT PEN NEEDLES
EASY COMFORT PEN NDL 32GX5/32" EASY COMFORT PEN NEEDLES
EASY COMFORT SYR 1 ML 30GX1/2" EASY COMFORT INSULINSYRINGE
EASY TOUCH 0.3 ML SYR 30GX1/2" EASY TOUCH INSULINSYRINGE
EASY TOUCH 0.5 ML SYR 27GX1/2" EASY TOUCH INSULINSYRINGE
EASY TOUCH 0.5 ML SYR 29GX1/2" EASY TOUCH INSULIN SAFETY
EASY TOUCH 0.5 ML SYR 30GX1/2" EASY TOUCH INSULINSYRINGE
EASY TOUCH 0.5 ML SYR 30GX5/16 EASY TOUCH INSULIN SAFETY
EASY TOUCH 1 ML SYR 27GX1/2" EASY TOUCH INSULINSYRINGE
EASY TOUCH 1 ML SYR 29GX1/2" EASY TOUCH INSULIN SAFETY
EASY TOUCH 1 ML SYR 30GX1/2" EASY TOUCH INSULIN SAFETY
EASY TOUCH 28G LANCETS EASY TOUCH LANCETS QL
EASY TOUCH BUTTON 30G LANCETS EASY TOUCH QL
EASY TOUCH INSULIN 1 ML 29GX1/2 EASY TOUCH SHEATHLOCKINSULIN
EASY TOUCH INSULIN 1 ML 30GX1/2 EASY TOUCH SHEATHLOCKINSULIN
2018 Trusted Health Plan Medicaid OTC Formulary
143
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
EASY TOUCH INSULIN SYR 0.3 ML EASY TOUCH
EASY TOUCH INSULIN SYR 0.5 ML EASY TOUCH
EASY TOUCH INSULIN SYR 1 ML EASY TOUCH
EASY TOUCH INSULN 1 ML 29GX1/2" EASY TOUCH FLIPLOCKINSULIN
EASY TOUCH INSULN 1 ML 30GX1/2" EASY TOUCH FLIPLOCKINSULIN
EASY TOUCH INSULN 1 ML 30GX5/16 EASY TOUCH FLIPLOCKINSULIN
EASY TOUCH INSULN 1 ML 31GX5/16 EASY TOUCH FLIPLOCKINSULIN
EASY TOUCH LUER LOK INSUL 1 ML EASY TOUCH LUER LOCKINSULIN
EASY TOUCH PEN NEEDLE 29GX1/2" EASY TOUCH PEN NEEDLE
EASY TOUCH PEN NEEDLE 31GX1/4" EASY TOUCH PEN NEEDLE
EASY TOUCH PEN NEEDLE 31GX3/16 EASY TOUCH PEN NEEDLE
EASY TOUCH PEN NEEDLE 31GX5/16 EASY TOUCH PEN NEEDLE
EASY TOUCH PEN NEEDLE 32GX1/4" EASY TOUCH PEN NEEDLE
EASY TOUCH PEN NEEDLE 32GX3/16 EASY TOUCH PEN NEEDLE
EASY TOUCH PEN NEEDLE 32GX5/32 EASY TOUCH PEN NEEDLE
EASY TOUCH PRESSURE 30GLANCET
EASY TOUCH QL
EASY TOUCH PULL-TOP 26G LANCET EASY TOUCH QL
EASY TOUCH PULL-TOP 28G LANCET EASY TOUCH QL
EASY TOUCH PULL-TOP 30G LANCET EASY TOUCH QL
EASY TOUCH SAFETY 26G LANCETS EASY TOUCH QL
EASY TOUCH SAFETY 28G LANCETS EASY TOUCH QL
EASY TOUCH TWIST 26G LANCETS EASY TOUCH QL
EASY TOUCH TWIST 28G LANCETS EASY TOUCH QL
EASY TOUCH TWIST 30G LANCETS EASY TOUCH QL
EASY TOUCH TWIST 33G LANCETS EASY TOUCH QL
EASY TOUCH UNI-SLIP SYR 1 ML EASY TOUCH UNI-SLIP
EASY TWIST & CAP 28G LANCETS EASY TWIST & CAP LANCETS QL
EASY-TOUCH INS 1 ML 31GX5/16" EASY-TOUCH INSULINSYRINGE
EMBRACE 30G LANCETS EMBRACE QL
EQL 33G LANCETS LANCETS QL
EQL INS SYR 1 ML 29GX1/2" INSULIN SYRINGE
EQL INSUL SYR 0.3 ML 31GX5/16" INSULIN SYRINGE
EQL INSUL SYR 0.5 ML 31GX5/16" INSULIN SYRINGE
EQL INSULIN 0.3 ML SYRINGE INSULIN SYRINGE
EQL INSULIN 0.5 ML SYRINGE INSULIN SYRINGE
EQL INSULIN 1 ML SYRINGE INSULIN SYRINGE
EQL INSULIN SYR 1 ML 31GX5/16" INSULIN SYRINGE
EQL MICRO THIN 33G LANCETS MICRO THIN LANCETS QL
2018 Trusted Health Plan Medicaid OTC Formulary
144
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
EXEL INS SYR U100 1 ML 28GX1/2 INSULIN SYRINGE
EXEL U100 0.3 ML 29GX1/2" INSULIN SYRINGE
EXEL U100 0.3 ML 30GX5/16" INSULIN SYRINGE
EXEL U100 0.5 ML 28GX1/2" INSULIN SYRINGE
EXEL U100 0.5 ML 29GX1/2" INSULIN SYRINGE
EXEL U100 0.5 ML 30GX5/16" INSULIN SYRINGE
EXEL U100 1 ML 30GX5/16" INSULIN SYRINGE
EXEL U100 INS SYR 1 ML 29GX1/2 INSULIN SYRINGE
EZ SMART 28G LANCETS EZ SMART LANCETS QL
FIFTY50 INS 0.3 ML 31GX5/16" INSULIN SYRINGE
FIFTY50 INS 0.5 ML 31GX5/16" INSULIN SYRINGE
FIFTY50 INS SYR 1 ML 31GX5/16" INSULIN SYRINGE
FIFTY50 PEN 31G X 3/16" NEEDLE PEN NEEDLE
FIFTY50 PEN 31G X 5/16" NEEDLE PEN NEEDLE
FIFTY50 PEN NEEDLE 32G X 1/4" PEN NEEDLE
FIFTY50 PEN NEEDLE 32G X 5/32" PEN NEEDLE
FIFTY50 SAFETY SEAL 30G LANCET FIFTY50 SAFETY SEALLANCETS
QL
FIFTY50 UNILET 33G LANCETS UNILET LANCETS QL
FINE 30 UNIVERSAL 30G LANCETS FINE 30 UNIVERSAL LANCETS QL
FINGERSTIX LANCETS FINGERSTIX QL
FORA 30G LANCETS FORA LANCETS QL
FORACARE 30G LANCETS FORACARE LANCETS QL
FREESTYLE 28G LANCETS FREESTYLE LANCETS QL
FREESTYLE PREC 0.5 ML 30GX5/16 FREESTYLE PRECISION
FREESTYLE PREC 0.5 ML 31GX5/16 FREESTYLE PRECISION
FREESTYLE PREC 1 ML 30GX5/16" FREESTYLE PRECISION
FREESTYLE PREC 1 ML 31GX5/16" FREESTYLE PRECISION
FREESTYLE UNISTIK 2 LANCETS FREESTYLE UNISTIK 2 QL
GLUCOCOM 28G LANCETS GLUCOCOM LANCETS QL
GLUCOCOM 30G LANCETS GLUCOCOM LANCETS QL
GLUCOCOM 33G LANCETS GLUCOCOM QL
GMATE 30G LANCETS GMATE QL
GNP CLICKFINE 31G X 1/4" NDL CLICKFINE
GNP CLICKFINE 31G X 5/16" NDL CLICKFINE
GNP CLICKFINE PEN NDL 31GX1/4" PEN NEEDLE
GNP CLICKFINE PEN NDL 31GX5/16 PEN NEEDLE
GNP INS SYR 0.3 ML 29GX1/2" INSULIN SYRINGE
GNP INSUL SYR 0.3 ML 31GX5/16" INSULIN SYRINGE
GNP INSUL SYR 0.5 ML 31GX5/16" INSULIN SYRINGE
GNP INSULIN SYR 1 ML 31GX5/16" INSULIN SYRINGE
GNP LANCING SYSTEM DEVICE LANCING SYSTEM QL
GNP MICRO THIN 33G LANCETS MICRO THIN LANCETS QL
2018 Trusted Health Plan Medicaid OTC Formulary
145
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
GNP ULT C 0.3 ML 29GX1/2" (1/2) ULTRA COMFORT
GNP ULT CMFRT 0.5 ML 29GX1/2" ULTRA COMFORT
GNP ULTR CMFRT 0.5 ML 28GX1/2" ULTRA COMFORT
GNP ULTR CMFRT 0.5 ML 30GX5/16 ULTRA COMFORT
GNP ULTR COMFORT 1 ML 29GX1/2" ULTRA COMFORT
GNP ULTRA COMFORT 0.5 ML SYR ULTRA COMFORT
GNP ULTRA COMFORT 1 MLSYRINGE
ULTRA COMFORT
GNP ULTRA COMFORT 3/10 ML SYR ULTRA COMFORT
GNP ULTRA COMFRT 1 ML 28GX1/2" ULTRA COMFORT
GNP UNIVERSAL 1 STANDARD 21G UNIVERSAL 1 QL
GNP UNIVERSAL 1 SUPER THIN 30G UNIVERSAL 1 QL
GNP UNIVERSAL 1 THIN 26G LANCT UNIVERSAL 1 QL
GS UNIVERSAL 1 MICRO THIN 33G UNIVERSAL 1 QL
GS UNIVERSAL 1 THIN 26G LANCET UNIVERSAL 1 QL
GS UNIVERSAL 1 ULTRA THIN 30G UNIVERSAL 1 QL
HEALTHY ACCENTS AUTOLETDEVICE
HEALTHY ACCENTS AUTOLET QL
HEALTHY ACCENTS PENTIP 4MM 32G HEALTHY ACCENTS UNIFINEPENTIP
HEALTHY ACCENTS PENTIP 5MM 31G HEALTHY ACCENTS UNIFINEPENTIP
HEALTHY ACCENTS PENTIP 6MM 31G HEALTHY ACCENTS UNIFINEPENTIP
HEALTHY ACCENTS PENTIP 8MM 31G HEALTHY ACCENTS UNIFINEPENTIP
HEALTHY ACCENTS PENTP 12MM29G
HEALTHY ACCENTS UNIFINEPENTIP
HEALTHY ACCENTS UNILET 30G HEALTHY ACCENTS UNILETLANCET
QL
HEB MICRO THIN 33G LANCETS MICRO THIN LANCETS QL
HEB UNIFINE PNTP PLUS 31GX3/16 UNIFINE PENTIPS PLUS
HEB UNIFINE PNTP PLUS 32GX5/32 UNIFINE PENTIPS PLUS
INCONTROL LANCING DEVICE INCONTROL LANCING DEVICE QL
INCONTROL PEN NEEDLE 12MM 29G INCONTROL PEN NEEDLE
INCONTROL PEN NEEDLE 4MM 32G INCONTROL PEN NEEDLE
INCONTROL PEN NEEDLE 5MM 31G INCONTROL PEN NEEDLE
INCONTROL PEN NEEDLE 6MM 31G INCONTROL PEN NEEDLE
INCONTROL PEN NEEDLE 8MM 31G INCONTROL PEN NEEDLE
INCONTROL SUPER THIN 30G LANCT INCONTROL SUPER THINLANCETS
QL
INCONTROL ULTRA THIN 28G LANCT INCONTROL ULTRA THINLANCETS
QL
INJECT EASE 28G LANCETS INJECT EASE LANCETS QL
INJECT EASE 30G LANCETS INJECT EASE LANCETS QL
INSUL SYR 0.3 ML 8MMX31G (1/2) INSULIN SYRINGE
2018 Trusted Health Plan Medicaid OTC Formulary
146
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
INSULIN 1 ML SYRINGE INSULIN SYRINGE
INSULIN 1/2 ML SYRINGE INSULIN SYRINGE
INSULIN 3/10 ML SYRINGE INSULIN SYRINGE
INSULIN SYR 0.3 ML 30GX5/16" INSULIN SYRINGE
INSULIN SYR 0.3 ML 31GX1/4(1/2) INSULIN SYRINGE
INSULIN SYRIN 0.3 ML 29GX1/2" INSULIN SYRINGE
INSULIN SYRIN 0.3 ML 30GX1/2" INSULIN SYRINGE
INSULIN SYRIN 0.3 ML 30GX5/16" INSULIN SYRINGE
INSULIN SYRIN 0.3 ML 31GX5/16" INSULIN SYRINGE
INSULIN SYRIN 0.5 ML 28GX1/2" INSULIN SYRINGE
INSULIN SYRIN 0.5 ML 29GX1/2" INSULIN SYRINGE
INSULIN SYRIN 0.5 ML 30GX1/2" INSULIN SYRINGE
INSULIN SYRIN 0.5 ML 30GX5/16" INSULIN SYRINGE
INSULIN SYRIN 0.5 ML 31GX5/16" INSULIN SYRINGE
INSULIN SYRIN 1 ML 29GX1/2" INSULIN SYRINGE
INSULIN SYRING 0.5 ML 29GX1/2" INSULIN SYRINGE
INSULIN SYRINGE 0.3 ML ULTILET INSULIN SYRINGE
INSULIN SYRINGE 0.3 ML 31GX1/4 INSULIN SYRINGE
INSULIN SYRINGE 0.5 ML ULTILET INSULIN SYRINGE
INSULIN SYRINGE 0.5 ML 31GX1/4 INSULIN SYRINGE
INSULIN SYRINGE 1 ML ULTILET INSULIN SYRINGE
INSULIN SYRINGE 1 ML 28GX1/2" INSULIN SYRINGE
INSULIN SYRINGE 1 ML 29GX1/2" INSULIN SYRINGE
INSULIN SYRINGE 1 ML 30GX1/2" INSULIN SYRINGE
INSULIN SYRINGE 1 ML 30GX5/16" INSULIN SYRINGE
INSULIN SYRINGE 1 ML 31GX1/4" INSULIN SYRINGE
INSULIN SYRINGE 1 ML 31GX5/16" INSULIN SYRINGE
INSULIN SYRINGE U100 1 ML INSULIN SYRINGE
INSUPEN 29G ULTRAFIN NEEDLE INSUPEN
INSUPEN 30G ULTRAFIN NEEDLE INSUPEN
INSUPEN 31G ULTRAFIN NEEDLE INSUPEN
INSUPEN 32G 6MM PEN NEEDLE INSUPEN
INSUPEN 32G 8MM PEN NEEDLE INSUPEN
INSUPEN PEN NEEDLE 29GX1/2" INSUPEN
INSUPEN PEN NEEDLE 31GX3/16" INSUPEN
INSUPEN PEN NEEDLE 31GX5/16" INSUPEN
INSUPEN PEN NEEDLE 32GX5/32" INSUPEN
INSUPEN PEN NEEDLE 33GX5/32" INSUPEN
INVACARE 30G LANCETS INVACARE LANCETS QL
KINRAY INS SYR 1 ML 31GX5/16" INSULIN SYRINGE
KINRAY SYRING 0.3 ML 31GX5/16" INSULIN SYRINGE
KINRAY SYRING 0.5 ML 31GX5/16" INSULIN SYRINGE
KMART VALU PLUS SYR 1/2 ML INSULIN SYRINGE
2018 Trusted Health Plan Medicaid OTC Formulary
147
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
KMART VALU PLUS SYRINGE 1 ML INSULIN SYRINGE
KRO INS SYR 0.3 ML 29GX1/2" INSULIN SYRINGE
KRO INSULIN SYR 1 ML 30GX5/16" INSULIN SYRINGE
KRO UNIVERSAL 1 THIN 26G LANCT UNIVERSAL 1 QL
KROGER INS SYR 0.3 ML 30GX5/16 INSULIN SYRINGE
KROGER INS SYR 0.5 ML 29GX1/2" INSULIN SYRINGE
KROGER INS SYR 1 ML 29GX1/2" INSULIN SYRINGE
KROGER INS SYR 1 ML 31GX5/16" INSULIN SYRINGE
KROGER LANCETS LANCETS QL
KROGER LANCING DEVICE LANCING DEVICE QL
KROGER PEN NEEDLES 31G X 5/16" PEN NEEDLE
KROGER SUPER THIN LANCETS SUPER THIN LANCETS QL
KROGER SYR 0.5 ML 30GX5/16" INSULIN SYRINGE
KROGER SYRING 0.3 ML 31GX5/16" INSULIN SYRINGE
KROGER SYRING 0.5 ML 31GX5/16" INSULIN SYRINGE
LANCETS 26G LANCETS QL
LANCETS 26G X 1.8MM LANCETS QL
LANCETS 28G LANCETS LANCETS QL
LANCETS 28G X 1.8MM LANCETS QL
LANCETS 30G LANCETS QL
LANCETS 33G LANCETS QL
LANCETS ULTRA FINE 28G LANCETS QL
LANCETS ULTRA THIN 26G LANCETS ULTRA THIN QL
LANCING DEVICE LANCING DEVICE QL
LEADER INS SYR 0.3 ML 29GX1/2" INSULIN SYRINGE
LEADER INS SYR 0.5 ML 28GX1/2" INSULIN SYRINGE
LEADER INS SYR 0.5 ML 29GX1/2" INSULIN SYRINGE
LEADER INS SYR 0.5 ML 30GX1/2" INSULIN SYRINGE
LEADER INS SYR 1 ML 28GX1/2" INSULIN SYRINGE
LEADER INS SYR 1 ML 29GX1/2" INSULIN SYRINGE
LEADER INS SYR 1 ML 30GX5/16" INSULIN SYRINGE
LEADER INS SYR 1 ML 31GX5/16" INSULIN SYRINGE
LEADER INSULIN SYRINGE 0.3 ML INSULIN SYRINGE
LEADER PEN NEEDLE 6MM 31G PEN NEEDLE
LEADER PEN NEEDLES 12MM 29G PEN NEEDLES
LEADER PEN NEEDLES 31G PEN NEEDLES
LEADER SYRING 0.3 ML 31GX5/16" INSULIN SYRINGE
LEADER SYRING 0.5 ML 31GX5/16" INSULIN SYRINGE
LITE TOUCH 30G LANCETS LITE TOUCH QL
LITE TOUCH 31GX1/4" PEN NEEDLE LITE TOUCH
LITE TOUCH 33G LANCETS LITE TOUCH QL
LITE TOUCH INSULIN 0.5 ML SYR LITE TOUCH
LITE TOUCH INSULIN 1 ML SYR LITE TOUCH
2018 Trusted Health Plan Medicaid OTC Formulary
148
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
LITE TOUCH INSULIN SYR 0.3 ML LITE TOUCH
LITE TOUCH INSULIN SYR 0.5 ML LITE TOUCH
LITE TOUCH INSULIN SYR 1 ML LITE TOUCH
LITE TOUCH PEN NEEDLE 29G LITE TOUCH
LITE TOUCH PEN NEEDLE 31G LITE TOUCH
LITETOUCH INS 0.3 ML 29GX1/2" LITETOUCH INSULIN SYRINGE
LITETOUCH INS 0.3 ML 30GX5/16" LITETOUCH INSULIN SYRINGE
LITETOUCH INS 0.3 ML 31GX5/16" LITETOUCH INSULIN SYRINGE
LITETOUCH INS 0.5 ML 31GX5/16" LITETOUCH INSULIN SYRINGE
LITETOUCH SYR 0.5 ML 28GX1/2" LITETOUCH INSULIN SYRINGE
LITETOUCH SYR 0.5 ML 29GX1/2" LITETOUCH INSULIN SYRINGE
LITETOUCH SYR 0.5 ML 30GX5/16" LITETOUCH INSULIN SYRINGE
LITETOUCH SYRIN 1 ML 28GX1/2" LITETOUCH INSULIN SYRINGE
LITETOUCH SYRIN 1 ML 29GX1/2" LITETOUCH INSULIN SYRINGE
LITETOUCH SYRIN 1 ML 30GX5/16" LITETOUCH INSULIN SYRINGE
LIVE BETTER PEN NEEDLES 8MM PEN NEEDLE
LIVE BETTER SUPER THIN LANCET SUPER THIN LANCETS QL
LIVE BETTER ULTRA THIN LANCET ULTRA THIN LANCETS QL
LONGS THIN LANCETS 26G THIN LANCETS QL
LONGS THIN LANCETS 30G THIN LANCETS QL
MAXI-COMFORT INS 0.5 ML 28G MAXI-COMFORT
MAXI-COMFORT INS 1 ML 28GX1/2" MAXI-COMFORT
MEDISENSE THIN 28G LANCETS MEDISENSE THIN LANCETS QL
MEDISENSE THIN LANCETS LANCETS QL
MEDLANCE PLUS 21G LANCETS MEDLANCE PLUS QL
MEDLANCE PLUS 30G LANCETS MEDLANCE PLUS QL
MEDLANCE PLUS EXTRA 21GLANCET
MEDLANCE PLUS QL
MEDLANCE PLUS LITE 25G LANCETS MEDLANCE PLUS QL
MEIJER LANCETS LANCETS QL
MEIJER UNIVERSAL 1 26G LANCETS UNIVERSAL 1 QL
MICRO THIN 33G LANCETS MICRO THIN LANCETS QL
MICROLET LANCETS MICROLET QL
MINI ULTRA-THIN II PEN NDL 31G MINI ULTRA-THIN II
MONOJECT 1 ML SYRN 27X1/2" MONOJECT INSULIN SYRINGE
MONOJECT 1 ML SYRN 28GX1/2" MONOJECT INSULIN SYRINGE
MONOJECT INSUL SYR U100 MONOJECT INSULIN SYRINGE
MONOJECT INSUL SYR U100 0.5 ML MONOJECT INSULIN SYRINGE
MONOJECT INSUL SYR U100 1 ML MONOJECT INSULIN SYRINGE
MONOJECT INSULIN SYR 0.3 ML MONOJECT INSULIN SYRINGE
MONOJECT INSULIN SYR 0.5 ML MONOJECT INSULIN SYRINGE
MONOJECT INSULIN SYR 1 ML MONOJECT INSULIN SYRINGE
MONOJECT INSULIN SYR U-100 MONOJECT INSULIN SAFETYSYRNG
2018 Trusted Health Plan Medicaid OTC Formulary
149
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
MONOJECT INSULIN SYRN 3/10 ML MONOJECT INSULIN SYRINGE
MONOJECT SYRINGE 0.3 ML MONOJECT INSULIN SYRINGE
MONOJECT SYRINGE 0.5 ML MONOJECT INSULIN SYRINGE
MONOJECT SYRINGE 1 ML MONOJECT INSULIN SYRINGE
MONOLET THIN 28G LANCETS MONOLET THIN LANCETS QL
MS INS SYR 0.5 ML 29GX1/2" INSULIN SYRINGE
MS INS SYR 1 ML 29GX1/2" INSULIN SYRINGE
MS INS SYRINGE 1 ML 30GX1/2" INSULIN SYRINGE
MS INSUL SYR 0.3 ML 31GX5/16" INSULIN SYRINGE
MS INSUL SYR 0.5 ML 30GX1/2" INSULIN SYRINGE
MS INSUL SYR 0.5 ML 31GX5/16" INSULIN SYRINGE
MS INSULIN SYR 0.3 ML 29GX1/2" INSULIN SYRINGE
MS INSULIN SYR 1 ML 31GX5/16" INSULIN SYRINGE
MS INSULIN SYRINGE 0.3 ML INSULIN SYRINGE
MS PEN NEEDLE 6MM 31G PEN NEEDLE
MYGLUCOHEALTH 30G LANCETS MYGLUCOHEALTH LANCETS QL
NOVA SAFETY 28G LANCETS NOVA SAFETY LANCETS QL
NOVA SUREFLEX THIN LANCETS NOVA SUREFLEX QL
NOVOFINE 30G X 1/3" NEEDLES NOVOFINE
NOVOFINE 32G NEEDLES NOVOFINE 32
NOVOFINE AUTOCOVER 30G NEEDLE NOVOFINE AUTOCOVER
NOVOFINE PLUS PEN NDL 32GX1/6" NOVOFINE PLUS
NOVOTWIST NEEDLE 32G 5MM NOVOTWIST
ON CALL 30G LANCET ON CALL LANCET QL
ON CALL PLUS 30G LANCET ON CALL PLUS LANCET QL
ON-THE-GO 30G LANCETS ON-THE-GO QL
ONETOUCH DELICA 30G LANCETS ONETOUCH DELICA QL
ONETOUCH DELICA 33G LANCETS ONETOUCH DELICA QL
ONETOUCH SURESOFT LANCINGDEV
ONETOUCH SURESOFT QL
ONETOUCH ULTRASOFT LANCETS ONETOUCH LANCETS QL
PC SUPER THIN 30G LANCETS SUPER THIN LANCETS QL
PC UNIFINE PENTIPS 12MM NEEDLE UNIFINE PENTIPS
PC UNIFINE PENTIPS 6MM NEEDLE UNIFINE PENTIPS
PC UNIFINE PENTIPS 8MM NEEDLE UNIFINE PENTIPS
PEN NEEDLE 12MM 29G PEN NEEDLE
PEN NEEDLE 31G X 1/4" PEN NEEDLE
PEN NEEDLE 31G X 3/16" PEN NEEDLE
PEN NEEDLE 31G X 5/16" PEN NEEDLE
PEN NEEDLE 32G X 1/4" PEN NEEDLE
PEN NEEDLE 32G X 3/16" PEN NEEDLE
PEN NEEDLE 32G X 5/32" PEN NEEDLE
PEN NEEDLE 4MM 32G PEN NEEDLE
2018 Trusted Health Plan Medicaid OTC Formulary
150
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
PEN NEEDLE 5MM 31G PEN NEEDLE
PEN NEEDLE 6MM 31G PEN NEEDLE
PEN NEEDLE 8MM 31G PEN NEEDLE
PEN NEEDLES 12MM 29G PEN NEEDLES
PEN NEEDLES 4MM 32G PEN NEEDLES
PEN NEEDLES 5MM 31G PEN NEEDLES
PEN NEEDLES 6MM 31G PEN NEEDLES
PEN NEEDLES 8MM 31G PEN NEEDLES
PENTIPS PEN NEEDLE 29GX1/2" PENTIPS
PENTIPS PEN NEEDLE 31GX1/4" PENTIPS
PENTIPS PEN NEEDLE 31GX3/16" PENTIPS
PENTIPS PEN NEEDLE 31GX5/16" PENTIPS
PENTIPS PEN NEEDLE 32GX5/32" PENTIPS
PENTIPS PEN NEEDLE 6MM 31G PENTIPS
PHARMACIST CHOICE 28G LANCETS ULTRA THIN LANCETS QL
PHARMACIST CHOICE 30G LANCETS LANCETS QL
PHARMACIST CHOICE 33G LANCETS LANCETS QL
PREF PLUS INS 0.3 ML 29GX1/2" INSULIN SYRINGE
PREF PLUS SYR 0.5 ML 30GX5/16" INSULIN SYRINGE
PREF PLUS SYRING 1 ML 29GX1/2" INSULIN SYRINGE
PREFERRED PLUS 0.3 ML 30GX5/16 INSULIN SYRINGE
PREFERRED PLUS 0.5 ML 29GX1/2" INSULIN SYRINGE
PREFERRED PLUS LANCETS LANCETS QL
PREFERRED PLUS SYRINGE 0.5 ML INSULIN SYRINGE
PREFERRED PLUS SYRINGE 1 ML INSULIN SYRINGE
PREFERRED PLUS THIN LANCETS LANCETS QL
PREFPLS INS SYR 1 ML 30GX5/16" INSULIN SYRINGE
PRESSURE ACTIVATED 28GLANCETS
PRESSURE ACTIVATEDLANCETS
QL
PRO COMFORT 30G LANCETS PRO COMFORT LANCETS QL
PRO COMFORT 31G LANCET PRO COMFORT LANCET QL
PRO COMFORT PEN NDL 32G X 1/4" PRO COMFORT PEN NEEDLE
PRO COMFORT PEN NDL 5MM 32G PRO COMFORT PEN NEEDLE
PRODIGY INS SYR 1 ML 28GX1/2" PRODIGY INSULIN SYRINGE
PRODIGY PRESSURE ACTIVATED28G
PRODIGY LANCETS QL
PRODIGY SAFETY 26G LANCETS PRODIGY LANCETS QL
PRODIGY SYRNG 0.5 ML 31GX5/16" PRODIGY INSULIN SYRINGE
PRODIGY SYRNGE 0.3 ML 31GX5/16" PRODIGY INSULIN SYRINGE
PRODIGY TWIST TOP 28G LANCET PRODIGY TWIST TOP LANCET QL
PUB 28G LANCETS LANCETS QL
PUB INS SYRIN 0.3 ML 30GX1/2" INSULIN SYRINGE
PUB INS SYRINGE 1 ML 30GX1/2" INSULIN SYRINGE
2018 Trusted Health Plan Medicaid OTC Formulary
151
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
PUB INSUL SYR 0.3 ML 31GX5/16" INSULIN SYRINGE
PUB INSUL SYR 0.5 ML 30GX1/2" INSULIN SYRINGE
PUB INSUL SYR 0.5 ML 31GX5/16" INSULIN SYRINGE
PUB INSULIN SYR 1 ML 31GX5/16" INSULIN SYRINGE
PUB PEN 12MM 29G NEEDLES PEN NEEDLE
PUB PEN 8MM 31G NEEDLES PEN NEEDLE
PUB PEN NEEDLE 6MM 31G PEN NEEDLE
PUB UNIFINE PNTP PLUS 31GX3/16 UNIFINE PENTIPS PLUS
PUSH BUTTON SAFETY 28G LANCET PUSH BUTTON SAFETYLANCETS
QL
QC UNIFINE PENTIPS 32GX5/32" UNIFINE PENTIPS
QC UNIFINE PENTIPS 4MM 32G UNIFINE PENTIPS
QC UNILET SUPER THIN 30G LANCT UNILET LANCETS QL
QC UNILET ULTRA THIN 28G LANCT UNILET LANCETS QL
RA E-ZJECT 26G LANCETS E-ZJECT LANCETS QL
RA E-ZJECT 28G LANCETS E-ZJECT LANCETS QL
RA E-ZJECT 30G LANCETS E-ZJECT LANCETS QL
RA E-ZJECT COLOR 33G LANCETS E-ZJECT LANCETS QL
RA INS SYR 0.5 ML 29GX1/2" INSULIN SYRINGE
RA INS SYR 0.5 ML 30GX5/16" INSULIN SYRINGE
RA INS SYR 1 ML 29GX1/2" INSULIN SYRINGE
RA INS SYRINGE 1 ML 30GX5/16" INSULIN SYRINGE
RA PEN NEEDLE 31GX3/16" PEN NEEDLE
RA PEN NEEDLE 31GX5/16" PEN NEEDLE
READYLANCE 26G SAFETY LANCETS READYLANCE SAFETYLANCETS
QL
READYLANCE 28G SAFETY LANCETS READYLANCE SAFETYLANCETS
QL
READYLANCE 30G SAFETY LANCETS READYLANCE SAFETYLANCETS
QL
RELI ON 31G X 1/4" NEEDLES NEEDLES
RELI-ON INSULIN 0.3 ML SYR INSULIN SYRINGE
RELI-ON INSULIN 0.5 ML SYR INSULIN SYRINGE
RELI-ON INSULIN 1 ML SYR INSULIN SYRINGE
RELIAMED 28G LANCETS RELIAMED QL
RELIAMED 30G LANCETS RELIAMED QL
RELIAMED LANCING DEVICE ADJUSTABLE LANCING DEVICE QL
RELIAMED MINI LANCING DEVICE RELIAMED MINI LANCINGDEVICE
QL
RELIAMED SAFETY 23G LANCETS RELIAMED QL
RELIAMED SAFETY 28G LANCETS RELIAMED QL
RELIAMED SAFETY SEAL 28G LANCT RELIAMED SAFETY SEALLANCETS
QL
RELIAMED SAFETY SEAL 30G LANCT RELIAMED SAFETY SEALLANCETS
QL
2018 Trusted Health Plan Medicaid OTC Formulary
152
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
RELIAMED TWIST&CAP 28G LANCETS RELIAMED QL
RELION INS SYR 0.3 ML 29GX1/2" INSULIN SYRINGE
RELION INS SYR 0.3 ML 30GX5/16 INSULIN SYRINGE
RELION INS SYR 0.3 ML 31GX6MM INSULIN SYRINGE
RELION INS SYR 0.5 ML 29GX1/2" INSULIN SYRINGE
RELION INS SYR 0.5 ML 31GX6MM INSULIN SYRINGE
RELION INS SYR 1 ML 29GX1/2" INSULIN SYRINGE
RELION INS SYR 1 ML 30GX5/16" INSULIN SYRINGE
RELION INS SYR 1 ML 31GX15/64" INSULIN SYRINGE
RELION INS SYR 1 ML 31GX5/16" INSULIN SYRINGE
RELION INSULIN SYR 0.5 ML INSULIN SYRINGE
RELION LANCING DEVICE LANCING DEVICE QL
RELION MINI PEN 31G X 1/4" NDL PEN NEEDLE
RELION PEN 29G NEEDLE PEN NEEDLE
RELION PEN 31G NEEDLE PEN NEEDLE
RELION PEN NEEDLE 29GX1/2" PEN NEEDLE
RELION PEN NEEDLE 31GX1/4" PEN NEEDLE
RELION PEN NEEDLE 31GX5/16" PEN NEEDLE
RELION PEN NEEDLE 32GX5/32" PEN NEEDLE
RELION PEN NEEDLES 32GX5/32" RELION PEN NEEDLES
RELION SYR 0.5 ML 30GX5/16" INSULIN SYRINGE
RELION SYRING 0.3 ML 31GX5/16" INSULIN SYRINGE
RELION SYRING 0.5 ML 31GX5/16" INSULIN SYRINGE
RELION THIN 26G LANCETS RELION THIN QL
RELION ULTRA THIN 30G LANCETS ULTRA THIN LANCETS QL
RELION ULTRA THIN PLUS 33G ULTRA THIN PLUS LANCETS QL
RELION ULTRA THIN PLUS LANCETS ULTRA THIN PLUS QL
REXALL UNIVERSAL 1 30G LANCETS UNIVERSAL 1 QL
RIGHTEST GL300 30G LANCETS RIGHTEST GL300 LANCETS QL
SAFESNAP INS SYR UNITS-100 0.3 ML SAFESNAP INSULIN SYRINGE
SAFESNAP INS SYR UNITS-100 0.5 ML SAFESNAP INSULIN SYRINGE
SAFESNAP INS SYR UNITS-100 1 ML SAFESNAP INSULIN SYRINGE
SAFETY 28G LANCETS SAFETY LANCETS QL
SAFETY LANCETS 26G SAFETY LANCETS QL
SAFETY SEAL 28G LANCETS SAFETY SEAL LANCETS QL
SAFETY SEAL 30G LANCETS SAFETY SEAL LANCETS QL
SAFETY-LET 30G LANCETS SAFETY-LET QL
SAPS CARE 30G LANCETS LANCETS QL
SCHNUCKS SYR 0.5 ML 29GX1/2" INSULIN SYRINGE
SCHNUCKS SYR 0.5 ML 30GX5/16" INSULIN SYRINGE
SHOPKO AUTOLET LANCING DEVICE AUTOLET LANCING DEVICE QL
SHOPKO ON-THE-GO 30G LANCETS ON-THE-GO QL
SHOPKO UNIFINE PENTIPS 4MM 32G UNIFINE PENTIPS
2018 Trusted Health Plan Medicaid OTC Formulary
153
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
SHOPKO UNIFINE PENTIPS 5MM 31G UNIFINE PENTIPS
SHOPKO UNIFINE PENTIPS 8MM 31G UNIFINE PENTIPS
SHOPKO UNIFINE PNTIPS 12MM 29G UNIFINE PENTIPS
SHOPKO UNILET SUPER THIN 30G UNILET LANCETS QL
SHOPKO UNILET ULTRA THIN 28G UNILET LANCETS QL
SINGLE-LET LANCETS SINGLE-LET QL
SM COLOR LANCETS 21G COLOR LANCETS QL
SM INS SYR 0.5 ML 29GX1/2" INSULIN SYRINGE
SM INS SYR 0.5 ML 30GX5/16" INSULIN SYRINGE
SM INS SYR 1 ML 29GX1/2" INSULIN SYRINGE
SM INS SYRING 0.3 ML 30GX5/16" INSULIN SYRINGE
SM INS SYRINGE 1 ML 28GX1/2" INSULIN SYRINGE
SM INS SYRINGE 1 ML 30GX5/16" INSULIN SYRINGE
SM INSUL SYR 0.3 ML 31GX5/16" INSULIN SYRINGE
SM INSUL SYR 0.5 ML 31GX5/16" INSULIN SYRINGE
SM INSULIN SYR 0.3 ML 29GX1/2" INSULIN SYRINGE
SM INSULIN SYR 0.5 ML 28GX1/2" INSULIN SYRINGE
SM INSULIN SYR 1 ML 31GX5/16" INSULIN SYRINGE
SM LANCETS 21G LANCETS QL
SM MICRO THIN 33G LANCETS MICRO THIN LANCETS QL
SM SUPER THIN 30G LANCETS SUPER THIN LANCETS QL
SM THIN LANCETS 26G THIN LANCETS QL
SM ULT CFT 0.3 ML 30GX5/16(1/2) ULTRA COMFORT
SM ULT CFT 0.3 ML 31GX5/16(1/2) ULTRA COMFORT
SMART SENSE COLOR 33G LANCETS SMART SENSE QL
SMART SENSE STANDARD 21G SMART SENSE LANCETS QL
SMART SENSE SUPER THIN 30G SUPER THIN LANCETS QL
SMART SENSE THIN 26G LANCETS SMART SENSE LANCETS QL
SMARTEST LANCET SMARTEST LANCET QL
SOFT TOUCH LANCETS SOFT TOUCH QL
SOLUS V2 28G LANCETS SOLUS V2 QL
SOLUS V2 30G TWIST LANCETS SOLUS V2 LANCETS QL
STERILANCE TL TWIST 30G LANCET STERILANCE TL QL
SUPER THIN 28G LANCETS SUPER THIN LANCETS QL
SUPER THIN 30G LANCETS SUPER THIN LANCETS QL
SURE COMFORT 0.3 ML SYRINGE SURE COMFORT
SURE COMFORT 0.5 ML SYRINGE SURE COMFORT
SURE COMFORT 1 ML SYRINGE SURE COMFORT
SURE COMFORT 28G LANCETS SURE COMFORT LANCETS QL
SURE COMFORT 3/10 ML SYRINGE SURE COMFORT
SURE COMFORT 30G LANCETS SURE COMFORT LANCETS QL
SURE COMFORT 30G PEN NEEDLE SURE COMFORT
SURE COMFORT 31G PEN NEEDLE SURE COMFORT
2018 Trusted Health Plan Medicaid OTC Formulary
154
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
SURE COMFORT INS 0.3 ML 31GX1/4 SURE COMFORT INSULINSYRINGE
SURE COMFORT INS 0.5 ML 31GX1/4 SURE COMFORT INSULINSYRINGE
SURE COMFORT INS 1 ML 31GX1/4" SURE COMFORT INSULINSYRINGE
SURE COMFORT PEN NDL 29GX1/2" SURE COMFORT
SURE COMFORT PEN NDL 31GX3/16" SURE COMFORT
SURE COMFORT PEN NDL 32GX1/4" SURE COMFORT
SURE COMFORT PEN NDL 32GX5/32" SURE COMFORT
SURE-FINE PEN NEEDLES 12.7MM SURE-FINE PEN NEEDLES
SURE-FINE PEN NEEDLES 5MM SURE-FINE PEN NEEDLES
SURE-FINE PEN NEEDLES 8MM SURE-FINE PEN NEEDLES
SURE-JECT INS 0.3 ML 31GX5/16" INSULIN SYRINGE
SURE-JECT INS 0.5 ML 31GX5/16" INSULIN SYRINGE
SURE-JECT INSU SYR U100 0.3 ML SURE-JECT INSULIN SYRINGE
SURE-JECT INSU SYR U100 0.5 ML SURE-JECT INSULIN SYRINGE
SURE-JECT INSU SYR U100 1 ML SURE-JECT INSULIN SYRINGE
SURE-JECT INSUL SYR U100 1 ML SURE-JECT INSULIN SYRINGE
SURE-JECT INSULIN SYRINGE 1 ML SURE-JECT INSULIN SYRINGE
SURE-LANCE 26G LANCETS SURE-LANCE QL
SURE-LANCE FLAT LANCETS SURE-LANCE QL
SURE-LANCE THIN 28G LANCETS SURE-LANCE QL
SURE-LANCE ULTRA THIN 30G SURE-LANCE QL
SURE-TOUCH LANCET SURE-TOUCH QL
TECHLITE 28G LANCETS TECHLITE LANCETS QL
TECHLITE 30G LANCETS TECHLITE LANCETS QL
TECHLITE PEN NEEDLE 29GX1/2" TECHLITE PEN NEEDLE
TECHLITE PEN NEEDLE 29GX3/8" TECHLITE PEN NEEDLE
TECHLITE PEN NEEDLE 31GX1/4" TECHLITE PEN NEEDLE
TECHLITE PEN NEEDLE 31GX3/16" TECHLITE PEN NEEDLE
TECHLITE PEN NEEDLE 31GX5/16" TECHLITE PEN NEEDLE
TECHLITE PEN NEEDLE 32GX1/4" TECHLITE PEN NEEDLE
TECHLITE PEN NEEDLE 32GX5/16" TECHLITE PEN NEEDLE
TECHLITE PEN NEEDLE 32GX5/32" TECHLITE PEN NEEDLE
TELCARE BGM BLOOD GLUCOSE KIT TELCARE BGM
TELCARE CONTROL SOLUTION TELCARE CONTROL SOLUTION
TELCARE TEST STRIPS TELCARE
TELCARE ULTRA THIN 30G LANCETS TELCARE QL
TERUMO INS SYR 0.3 ML 29GX1/2" INSULIN SYRINGE
TERUMO INS SYRINGE U100-1 ML TERUMO INSULIN SYRINGE
TERUMO INS SYRINGE U100-1/2 ML TERUMO INSULIN SYRINGE
TERUMO INS SYRINGE U100-1/3 ML TERUMO INSULIN SYRINGE
TERUMO INS SYRNG U100-1/2 ML TERUMO INSULIN SYRINGE
2018 Trusted Health Plan Medicaid OTC Formulary
155
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
THIN 26G LANCETS THIN LANCETS QL
THIN LANCETS 28G THIN LANCETS QL
THINPRO INS SYRIN U100-0.3 ML THINPRO INSULIN SYRINGE
THINPRO INS SYRIN U100-0.5 ML THINPRO INSULIN SYRINGE
THINPRO INS SYRIN U100-1 ML THINPRO INSULIN SYRINGE
TODAY’S HLTH PN NEEDLE 6MM 31G PEN NEEDLE
TOPCARE CLICKFINE 31G X 1/4" TOPCARE CLICKFINE
TOPCARE CLICKFINE 31G X 5/16" TOPCARE CLICKFINE
TOPCARE ULTRA COMFORTSYRINGE
TOPCARE ULTRA COMFORT
TOPCARE UNIVERSAL1 33GLANCETS
TOPCARE UNIVERSAL1LANCET
QL
TOPCARE UNIVERSAL1 THIN LANCET TOPCARE UNIVERSAL1 THINLANCET
QL
TRUEDRAW LANCING DEVICE TRUEDRAW QL
TRUEPLUS 26G LANCETS TRUEPLUS LANCETS QL
TRUEPLUS 30G LANCETS TRUEPLUS LANCETS QL
TRUEPLUS 33G LANCETS TRUEPLUS LANCETS QL
TRUEPLUS PEN NEEDLE 29GX1/2" TRUEPLUS PEN NEEDLE
TRUEPLUS PEN NEEDLE 31G X 1/4" TRUEPLUS PEN NEEDLE
TRUEPLUS PEN NEEDLE 31GX3/16" TRUEPLUS PEN NEEDLE
TRUEPLUS PEN NEEDLE 31GX5/16" TRUEPLUS PEN NEEDLE
TRUEPLUS PEN NEEDLE 32GX5/32" TRUEPLUS PEN NEEDLE
TRUEPLUS SAFETY 28G LANCETS TRUEPLUS LANCETS QL
TRUEPLUS SUPER THIN 28G LANCET TRUEPLUS LANCETS QL
TRUEPLUS SYR 0.3 ML 29GX1/2" TRUEPLUS INSULIN SYRINGE
TRUEPLUS SYR 0.3 ML 30GX5/16" TRUEPLUS INSULIN SYRINGE
TRUEPLUS SYR 0.3 ML 31GX5/16" TRUEPLUS INSULIN SYRINGE
TRUEPLUS SYR 0.5 ML 28GX1/2" TRUEPLUS INSULIN SYRINGE
TRUEPLUS SYR 0.5 ML 29GX1/2" TRUEPLUS INSULIN SYRINGE
TRUEPLUS SYR 0.5 ML 30GX5/16" TRUEPLUS INSULIN SYRINGE
TRUEPLUS SYR 0.5 ML 31GX5/16" TRUEPLUS INSULIN SYRINGE
TRUEPLUS SYR 1 ML 28GX1/2" TRUEPLUS INSULIN SYRINGE
TRUEPLUS SYR 1 ML 29GX1/2" TRUEPLUS INSULIN SYRINGE
TRUEPLUS SYR 1 ML 30GX5/16" TRUEPLUS INSULIN SYRINGE
TRUEPLUS SYR 1 ML 31GX5/16" TRUEPLUS INSULIN SYRINGE
TRUEPLUS ULTRA THIN 30G LANCET TRUEPLUS LANCETS QL
TWIST LANCETS LANCETS QL
ULT CFT 0.3 ML 29GX1/2" (1/2) ULTRA COMFORT
ULT CFT 0.3 ML 30GX5/16" (1/2) ULTRA COMFORT
ULT CFT 0.3 ML 31GX5/16" (1/2) ULTRA COMFORT
ULTCARE INS SYR 1 ML 31GX5/16" INSULIN SYRINGE
ULTICAR INS 0.3 ML 31GX1/4(1/2) ULTICARE INSULIN SYRINGE
ULTICARE INS 0.3 ML 30GX1/2" ULTICARE
2018 Trusted Health Plan Medicaid OTC Formulary
156
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
ULTICARE INS 0.3 ML 31GX1/4" ULTICARE INSULIN SYRINGE
ULTICARE INS 0.5 ML 30GX1/2" ULTICARE
ULTICARE INS 0.5 ML 31GX1/4" ULTICARE INSULIN SYRINGE
ULTICARE INS 1 ML 31GX1/4" ULTICARE INSULIN SYRINGE
ULTICARE INS SYR 1 ML 28GX1/2" INSULIN SYRINGE
ULTICARE INS SYR 1 ML 29GX1/2" INSULIN SYRINGE
ULTICARE INS SYR 1 ML 30GX1/2" ULTICARE
ULTICARE PEN NDL 12.7 MM 29G ULTICARE PEN NEEDLE
ULTICARE PEN NEEDLE 31GX3/16" ULTICARE PEN NEEDLE
ULTICARE PEN NEEDLE 4MM 32G ULTICARE PEN NEEDLE
ULTICARE PEN NEEDLE 6MM 31G ULTICARE PEN NEEDLE
ULTICARE PEN NEEDLE 8MM 31G ULTICARE PEN NEEDLE
ULTICARE PEN NEEDLES 12MM 29G ULTICARE PEN NEEDLE
ULTICARE PEN NEEDLES 4MM 32G ULTICARE PEN NEEDLE
ULTICARE PEN NEEDLES 6 MM 31 G ULTICARE PEN NEEDLE
ULTICARE PEN NEEDLES 6MM 31G ULTICARE PEN NEEDLE
ULTICARE PEN NEEDLES 8 MM 31 G ULTICARE PEN NEEDLE
ULTICARE PEN NEEDLES 8MM 31G ULTICARE PEN NEEDLE
ULTICARE SYR 0.3 ML 29GX1/2" ULTICARE
ULTICARE SYR 0.3 ML 30GX1/2" ULTICARE
ULTICARE SYR 0.3 ML 30GX5/16" ULTICARE
ULTICARE SYR 0.3 ML 31GX5/16" ULTICARE
ULTICARE SYR 0.5 ML 29GX1/2" ULTICARE
ULTICARE SYR 0.5 ML 30GX1/2" ULTICARE
ULTICARE SYR 0.5 ML 30GX5/16" ULTICARE
ULTICARE SYR 0.5 ML 31GX5/16" ULTICARE
ULTICARE SYR 1 ML 30GX5/16" ULTICARE
ULTICARE SYR 1 ML 31GX5/16" ULTICARE
ULTICARE SYRIN 0.3 ML 29GX1/2" INSULIN SYRINGE
ULTICARE SYRIN 0.5 ML 28GX1/2" INSULIN SYRINGE
ULTICARE SYRINGE 1 ML 29GX1/2" ULTICARE
ULTICARE SYRINGE 1 ML 30GX1/2" ULTICARE
ULTILET 28G LANCETS ULTILET LANCETS QL
ULTILET 30G LANCETS ULTILET LANCETS QL
ULTILET 33G LANCETS ULTILET LANCETS QL
ULTILET BASIC 30G LANCETS ULTILET BASIC QL
ULTILET CLASSIC 26G LANCETS ULTILET CLASSIC QL
ULTILET CLASSIC 28G LANCETS ULTILET CLASSIC QL
ULTILET CLASSIC 30G LANCETS ULTILET CLASSIC QL
ULTILET CLASSIC 33G LANCETS ULTILET CLASSIC QL
ULTILET INSULIN SYRINGE 0.3 ML ULTILET INSULIN SYRINGE
ULTILET INSULIN SYRINGE 0.5 ML ULTILET INSULIN SYRINGE
ULTILET INSULIN SYRINGE 1 ML ULTILET INSULIN SYRINGE
2018 Trusted Health Plan Medicaid OTC Formulary
157
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
ULTILET PEN NEEDLE ULTILET PEN NEEDLE
ULTILET PEN NEEDLE 4MM 32G ULTILET PEN NEEDLE
ULTRA COMFORT 0.3 ML 29GX1/2" ULTRA COMFORT
ULTRA COMFORT 0.3 ML SYRINGE ULTRA COMFORT
ULTRA COMFORT 0.5 ML 28GX1/2" ULTRA COMFORT
ULTRA COMFORT 0.5 ML 29GX1/2" ULTRA COMFORT
ULTRA COMFORT 0.5 ML 30GX5/16" ULTRA COMFORT
ULTRA COMFORT 0.5 ML 31GX5/16" ULTRA COMFORT
ULTRA COMFORT 0.5 ML SYRINGE ULTRA COMFORT
ULTRA COMFORT 1 ML 28GX1/2" ULTRA COMFORT
ULTRA COMFORT 1 ML 29GX1/2" ULTRA COMFORT
ULTRA COMFORT 1 ML 30GX5/16" ULTRA COMFORT
ULTRA COMFORT 1 ML 31GX5/16" ULTRA COMFORT
ULTRA COMFORT 1 ML SYRINGE ULTRA COMFORT
ULTRA THIN 28G LANCETS ULTRA THIN LANCETS QL
ULTRA THIN 30G LANCETS ULTRA THIN LANCETS QL
ULTRA THIN 31G LANCETS ULTRA THIN LANCETS QL
ULTRA THIN 33G LANCETS ULTRA THIN LANCETS QL
ULTRA-THIN II 1 ML 31GX5/16" ULTRA-THIN II
ULTRA-THIN II 26G LANCET ULTRA-THIN II QL
ULTRA-THIN II 28G LANCETS ULTRA-THIN II QL
ULTRA-THIN II 30G LANCETS ULTRA-THIN II QL
ULTRA-THIN II INS 0.3 ML 29G ULTRA-THIN II
ULTRA-THIN II INS 0.3 ML 30G ULTRA-THIN II
ULTRA-THIN II INS 0.3 ML 31G ULTRA-THIN II
ULTRA-THIN II INS 0.5 ML 29G ULTRA-THIN II
ULTRA-THIN II INS 0.5 ML 30G ULTRA-THIN II
ULTRA-THIN II INS 0.5 ML 31G ULTRA-THIN II
ULTRA-THIN II INS SYR 1 ML 29G ULTRA-THIN II
ULTRA-THIN II INS SYR 1 ML 30G ULTRA-THIN II
ULTRA-THIN II PEN NDL 29GX1/2" ULTRA-THIN II
ULTRA-THIN II PEN NDL 31GX5/16 ULTRA-THIN II
ULTRALANCE 26G LANCETS ULTRALANCE QL
ULTRALANCE 28G LANCETS ULTRALANCE QL
ULTRATLC LANCETS ULTRATLC LANCETS QL
UNIFINE PENTIPS 12MM 29G UNIFINE PENTIPS
UNIFINE PENTIPS 31GX3/16" UNIFINE PENTIPS
UNIFINE PENTIPS 32GX5/32" UNIFINE PENTIPS
UNIFINE PENTIPS 6MM 31G UNIFINE PENTIPS
UNIFINE PENTIPS 6MM NEEDLE UNIFINE PENTIPS
UNIFINE PENTIPS 8MM 31G UNIFINE PENTIPS
UNIFINE PENTIPS 8MM NEEDLE UNIFINE PENTIPS
UNIFINE PENTIPS NEEDLES 29G UNIFINE PENTIPS
2018 Trusted Health Plan Medicaid OTC Formulary
158
Medical Supplies and DME - Diabetic Supplies
Medication Info Common Name Drug Status Criteria
UNIFINE PENTIPS PLUS 29GX1/2" UNIFINE PENTIPS PLUS
UNIFINE PENTIPS PLUS 31GX1/4" UNIFINE PENTIPS PLUS
UNIFINE PENTIPS PLUS 31GX3/16" UNIFINE PENTIPS PLUS
UNIFINE PENTIPS PLUS 31GX5/16" UNIFINE PENTIPS PLUS
UNIFINE PENTIPS PLUS 32GX5/32" UNIFINE PENTIPS PLUS
UNILET COMFORTOUCH 26GLANCETS
UNILET COMFORTOUCH QL
UNILET COMFORTOUCH LANCET UNILET COMFORTOUCH QL
UNILET EXCELITE II LANCET UNILET EXCELITE II QL
UNILET EXCELITE LANCET UNILET EXCELITE QL
UNILET GP LANCET UNILET GP LANCET QL
UNILET GP LANCET SUPERLITE UNILET GP LANCET QL
UNILET MICRO THIN 33G LANCETS UNILET LANCETS QL
UNILET SUPER THIN 30G LANCETS UNILET LANCETS QL
UNILET ULTRA THIN 28G LANCETS UNILET LANCETS QL
UNISTIK 3 COMFORT LANCET UNISTIK 3 QL
UNISTIK 3 GENTLE 30G LANCETS UNISTIK 3 QL
UNISTIK 3 GENTLE ON-THE-GO 30G UNISTIK 3 QL
UNISTIK CZT COMFORT 28G LANCET UNISTIK CZT QL
UNISTIK SAFETY 28G LANCET UNISTIK SAFETY QL
UNISTIK SAFETY 30G LANCETS UNISTIK SAFETY QL
UNISTIK TOUCH 28G LANCETS UNISTIK TOUCH QL
UNISTIK TOUCH 30G LANCETS UNISTIK TOUCH QL
UNIVERSAL 1 33G LANCETS UNIVERSAL 1 QL
VALUE PLUS LANCING DEVICE LANCING DEVICE QL
VANISHPOINT 0.5 ML 30GX1/2" SY VANISHPOINT
VANISHPOINT U-100 29X1/2 SYR VANISHPOINT
WALGREENS THIN LANCETS THIN LANCETS QL
WALGREENS ULTRA THIN LANCETS ULTRA THIN LANCETS QL
WM UNIFINE PENTIP PLUS 4MM 32G UNIFINE PENTIPS PLUS
WM UNIFINE PENTIP PLUS 5MM 31G UNIFINE PENTIPS PLUS
WM UNIFINE PENTIP PLUS 6MM 31G UNIFINE PENTIPS PLUS
WM UNIFINE PENTIP PLUS 8MM 31G UNIFINE PENTIPS PLUS
Medical Supplies and DME - GI-GU Ostomy and Irrigation Supplies
Medication Info Common Name Drug Status Criteria
RELIAMED PROTECT BARRIERWIPES
PROTECTIVE BARRIER WIPES
Medical Supplies and DME - Thermometers
Medication Info Common Name Drug Status Criteria
THERMOMETER UNIVERSAL GLASS THERMOMETER
2018 Trusted Health Plan Medicaid OTC Formulary
159
Minerals and Electrolytes
Medication Info Common Name Drug Status Criteria
CAL-CITRATE PLUS VITAMIN D TAB CAL-CITRATE
CAL-QUICK LIQUID CAL-QUICK
CALCET CITRATE CREAMY BITES CALCET
CALCET PETITES TABLET CALCET PETITES
CALCITRATE + VIT D CAPLET CALCITRATE + VIT D
CALCIUM + D3 ER TABLET CALCIUM + D3
CALCIUM + VITAMIN D3 GUMMIES CALCIUM + VITAMIN D3
CALCIUM 1,000 + D3 CAPLET CALCIUM 1000 + D3
CALCIUM 250+D TABLET OYSTER SHELL + D
CALCIUM 250-VIT D3 125 TABLET CALCIUM 250-VIT D3
CALCIUM 500 + VIT D CAPLET CALCIUM 500 + VITAMIN D
CALCIUM 500 MG CHEWABLE TABLET CALCIUM
CALCIUM 500 MG TABLET CALCIUM CARBONATE
CALCIUM 500+D TABLET CHEW CALCIUM 500 + VIT D
CALCIUM 500-VIT D3 200 CAPLET CALCIUM 500-VIT D3
CALCIUM 500-VIT D3 200 TABLET CALCIUM 500-VIT D3
CALCIUM 500-VIT D3 400 TABLET CALCIUM 500-VIT D3
CALCIUM 500-VIT D3 600 CAPLET CALCIUM 500-VIT D3
CALCIUM 500-VIT D3 600 TABLET CALCIUM 500-VIT D3
CALCIUM 600 + VIT D 400 SOFTGL CALCIUM 600 + VIT D
CALCIUM 600 + VIT D TABLET CALCIUM 600 + VIT D
CALCIUM 600 MG TABLET CALCIUM
CALCIUM 600 WITH VIT D CHEW TB CALCIUM 600 + VIT D
CALCIUM 600+D SOFTGEL CALCIUM CARBONATE/VITAMIN D3
CALCIUM 600-VIT D3 2,500 SFTGL CALCIUM 600-VIT D3
CALCIUM 600-VIT D3 200 TABLET CALCIUM 600-VIT D3
CALCIUM 600-VIT D3 400 CAPLET CALCIUM 600-VIT D3
CALCIUM 600-VIT D3 400 TABLET CALCIUM 600-VIT D3
CALCIUM 600-VIT D3 500 SOFTGEL CALCIUM 600-VIT D3
CALCIUM 600-VIT D3 800 CAPLET CALCIUM 600-VIT D3
CALCIUM 600-VIT D3 800 TAB CALCIUM 600-VIT D3
CALCIUM 600-VIT D3 800 TABLET CALCIUM 600-VIT D3
CALCIUM ADULT GUMMIES CALCIUM ADULT
CALCIUM CARB 260 MG TAB CHEW CALCIUM CARBONATE
CALCIUM CARB 500 (1,250) MG TB CALCIUM CARBONATE
CALCIUM CARBONATE 1.25 GM TAB CALCIUM CARBONATE
CALCIUM CARBONATE 1.5 GM TAB CALCIUM CARBONATE
CALCIUM CARBONATE 650 MG TAB CALCIUM CARBONATE
CALCIUM CARBONATE POWDER CALCIUM CARBONATE
CALCIUM CIT 200-VIT D3 250 TAB CALCIUM CITRATE-VIT D3
CALCIUM CIT 315-VIT D3 250 TAB CALCIUM CITRATE-VIT D3
CALCIUM CIT-VIT D 250-200 TAB CALCIUM CITRATE-VITAMIN D
2018 Trusted Health Plan Medicaid OTC Formulary
160
Minerals and Electrolytes
Medication Info Common Name Drug Status Criteria
CALCIUM CIT-VIT D 315-200 TAB CALCIUM CITRATE - VITAMIN D
CALCIUM CITRATE - VIT D CAPLET CALCIUM CITRATE - VITAMIN D
CALCIUM CITRATE - VIT D TABLET CALCIUM CITRATE - VITAMIN D
CALCIUM CITRATE - VIT D3 TAB CALCIUM CITRATE - VITAMIND3
CALCIUM CITRATE 200 MG CAPLET CALCIUM CITRATE
CALCIUM CITRATE 200 MG TABLET CALCIUM CITRATE
CALCIUM CITRATE 250 MG CAPLET CALCIUM CITRATE
CALCIUM CITRATE 250 MG TABLET CALCIUM CITRATE
CALCIUM CITRATE GRANULES CALCIUM CITRATE
CALCIUM CITRATE MALATE WITH D CALCIUM CITRATE MALATEWITH D
CALCIUM CITRATE WITH D TABLET CALCIUM CITRATE-VITAMIN D
CALCIUM CITRATE-VIT D CAPLET CALCIUM CITRATE - VITAMIN D
CALCIUM CITRATE-VIT D3 CAPLET CALCIUM CITRATE-VITAMIN D3
CALCIUM CITRATE-VIT D3 TABLET CALCIUM CITRATE-VIT D3
CALCIUM GUMMIES CALCIUM
CALCIUM LACTATE 100 MG TABLET CALCIUM LACTATE
CALCIUM OYS SHELL 250 MG TAB OYSTER SHELL CALCIUM W-VIT D
CALCIUM PETITES SOFTGEL CALCIUM PETITES
CALCIUM WITH VIT D TABLET CALCIUM CITRATE-VITAMIN D
CALCIUM-500 MG TABLETCHEWABLE
CALCIUM
CALCIUM-VITAMIN D3 GUMMIES CALCIUM-VITAMIN D3
CALTRATE 600 + D SOFT CHEW TAB CALTRATE 600 + D
CALTRATE 600 PLUS D3 TABLET CALTRATE 600 PLUS D3
CALTRATE GUMMY BITES CALTRATE GUMMY BITES
CHILD FERROUS SULFATE 15 MG/ML CHILDREN’S FERROUSSULFATE
CITRACAL + D ER TABLET CITRACAL + D
CITRACAL + D MAXIMUM CAPLET CITRACAL + D MAXIMUM
CITRACAL + D3 GUMMIES CITRACAL + D3
CITRACAL-VIT D 250 MG-200 TAB CITRACAL-VITAMIN D
CITRACAL-VIT D3 200 MG-250 TAB CITRACAL-VITAMIN D3
CITRUS CALCIUM + D TABLET CITRUS CALCIUM + D
CITRUS CALCIUM 200-VIT D3 250 CITRUS CALCIUM-VITAMIN D3
CVS CALCIUM 250-D3 400 GUMMY CALCIUM-VITAMIN D3
CVS CALCIUM 500 + VIT D TABLET CALCIUM 500 + VITAMIN D
CVS CALCIUM 600 MG TABLET CALCIUM
CVS CALCIUM 600-VIT D3 800 TAB CALCIUM 600-VIT D3
CVS CALCIUM CITRATE-VIT D TAB CALCIUM CITRATE-VITAMIN D
CVS CALCIUM CITRATE-VIT D3 TAB CALCIUM CITRATE-VIT D3
CVS IRON 27 MG TABLET IRON
2018 Trusted Health Plan Medicaid OTC Formulary
161
Minerals and Electrolytes
Medication Info Common Name Drug Status Criteria
CVS IRON 65 MG TABLET IRON
CVS LAX DIETARY 500 MG CAPLET LAXATIVE DIETARYSUPPLEMENT
CVS MAGNESIUM 500 MG TABLET MAGNESIUM OXIDE
CVS PEDIATRIC ELECTROLYTE POPS PEDIATRIC ELECTROLYTE
CVS PEDIATRIC ELECTROLYTE SOLN PEDIATRIC ELECTROLYTE
CVS SLOW RELEASE IRON TABLET SLOW RELEASE IRON
CVS YOGURT+CALCIUM GUMMIES YOGURT+CALCIUM GUMMIES
ENFAMIL ENFALYTE SOLUTION ENFAMIL ENFALYTE
EQ CALCIUM 500-VIT D3 400 TAB CALCIUM 500-VIT D3
EQ CALCIUM 600-VIT D3 400 TAB CALCIUM 600-VIT D3
EQ CALCIUM CITRATE-D TABLET CALCIUM CITRATE-D
EQ SLOW RELEASE IRON 45 MG TAB SLOW RELEASE IRON
EQL CALCIUM 250-D3 400 GUMMY CALCIUM-VITAMIN D3
EQL CALCIUM 600-VIT D3 800 TAB CALCIUM 600-VIT D3
EQL CALCIUM CITRATE-VIT D3 CPT CALCIUM CITRATE-VITAMIN D3
FERROUS GLUCONATE 240 MG TAB FERROUS GLUCONATE
FERROUS GLUCONATE 324 MG TAB FERROUS GLUCONATE
FERROUS SULF 15 MG (IRON)/MLORAL SYRINGE
FERROUS SULFATE
FERROUS SULF 15 MG IRON/ML DRP FERROUS SULFATE
FERROUS SULF 220 MG/5 ML ELIX FERROUS SULFATE
FERROUS SULF 220 MG/5 ML LIQ FERROUS SULFATE
FERROUS SULF 300 MG/5 ML LIQ FERROUS SULFATE
FERROUS SULF EC 324 MG TABLET FERROUS SULFATE
FERROUS SULF EC 325 MG TABLET FERROUS SULFATE
FERROUS SULFATE 325 MG TABLET FERROUS SULFATE
FERROUS SULFATE ER 140 MG TAB FERROUS SULFATE
FERROUSUL 325 MG TABLET FERROUSUL
FLINTSTONES BONE SUPPRTGUMMIE
FLINTSTONES BONE SUPPORT
GNP CALCIUM 500-VIT D3 600 TAB CALCIUM 500-VIT D3
GNP CALCIUM 600 MG TABLET CALCIUM
GNP CALCIUM 600-VIT D3 800 TAB CALCIUM 600-VIT D3
GNP CALCIUM CITRATE-VIT D3 TAB CALCIUM CITRATE - VITAMIND3
GNP IRON 65 MG TABLET IRON
GNP MAGNESIUM 250 MG TABLET MAGNESIUM
GNP PEDIATRIC ELECTROLYTE SOLN PEDIATRIC ELECTROLYTE
HEB PEDIATRIC ELECTROLYTE SOLN PEDIATRIC ELECTROLYTE
HM CALCIUM 500-VIT D3 200 CPLT CALCIUM 500-VIT D3
HM CALCIUM 600-VIT D3 400 TAB CALCIUM 600-VIT D3
HM CALCIUM 600-VIT D3 800 TAB CALCIUM 600-VIT D3
HM CALCIUM CITRATE-VIT D CPLT CALCIUM CITRATE-VIT D
2018 Trusted Health Plan Medicaid OTC Formulary
162
Minerals and Electrolytes
Medication Info Common Name Drug Status Criteria
HM CALCIUM CITRATE-VIT D3 TAB CALCIUM CITRATE-VIT D3
HM IRON 65 MG TABLET IRON
HM MAGNESIUM 400 MG CAPLET MAGNESIUM
HM PEDIATRIC ELECTROLYTE SOLN PEDIATRIC ELECTROLYTE
HM SLOW RELEASE IRON 45 MG TAB SLOW RELEASE IRON
HM SLOW RELEASE IRON TABLET SLOW RELEASE IRON
IRON 100-VITAMIN C TABLET IRON 100-VITAMIN C
IRON 27 MG TABLET IRON
IRON 28 MG TABLET IRON
IRON 325 MG TABLET IRON
IRON 65 MG TABLET IRON
KRO SLOW RLS IRON 45 MG TABLET SLOW RELEASE IRON
LIQUID CALCIUM 600-VIT D3 SFGL LIQUID CALCIUM 600-VIT D3
LIQUID CALCIUM WITH VITAMIN D LIQUID CALCIUM + VITAMIN D
LIQUID CALCIUM-VIT D SOFTGEL LIQUID CALCIUM-VIT D
MAGNESIUM 250 MG TABLET MAGNESIUM
MAGNESIUM 400 MG CAPS MAGNESIUM
MAGNESIUM 400 MG SOFTGEL MAGNESIUM
MAGNESIUM 400 MG TABLET MAGNESIUM
MAGNESIUM 500 MG SOFTGEL MAGNESIUM
MAGNESIUM 500 MG TABLET MAGNESIUM OXIDE
MAGNESIUM CHELATED 100 MG TAB MAGNESIUM
MAGNESIUM CITRATE 100 MG TAB MAGNESIUM CITRATE
MAGNESIUM OXIDE 250 MG CAPLET MAGNESIUM OXIDE
MAGNESIUM OXIDE 250 MG TABLET MAGNESIUM OXIDE
MAGNESIUM OXIDE 400 MG TABLET MAGNESIUM OXIDE
MAGNESIUM OXIDE 420 MG TABLET MAGNESIUM OXIDE
MAGNESIUM OXIDE 500 MGCAPSULE
MAGNESIUM OXIDE
MAGNESIUM OXIDE 500 MG TABLET MAGNESIUM OXIDE
MAGNESIUM-OXIDE 400 MG TABLET MAGNESIUM OXIDE
NATURAL CALCIUM 500 MG TABLET NATURAL CALCIUM
ORALYTE ELECTROLYTE SOLN ORALYTE
ORALYTE FREEZER POPS ORALYTE
ORALYTE SOLUTION ORALYTE
OS-CAL 500-VIT D3 200 CAPLET OS-CAL 500-VIT D3
OS-CAL 500-VIT D3 600 CAPLET OS-CAL 500-VIT D3
OSTEO-PORETICAL TABLET OSTEO-PORETICAL
OYSCO 500-VIT D3 200 TABLET OYSCO 500-VIT D3
OYSTER SHELL 250 MG + VIT D TB OYSTER SHELL CALCIUM W-VIT D
OYSTER SHELL 500-VIT D3 200 TB OYSTER SHELL CALCIUM-VITD3
OYSTER SHELL CALCIUM 500 MG OYSTER SHELL CALCIUM
2018 Trusted Health Plan Medicaid OTC Formulary
163
Minerals and Electrolytes
Medication Info Common Name Drug Status Criteria
OYSTER SHELL CALCIUM 500 MG TB OYSTER SHELL CALCIUM
OYSTER SHELL CALCIUM TABLET OYSTER SHELL CALCIUM
OYSTER SHELL CALCIUM-VIT D TAB OYSTER SHELL CALCIUM W-VIT D
OYSTER SHELL+D 250 MG TABLET OYSTER SHELL + D
OYSTERCAL-D 500 MG-400 UNIT TB OYSTERCAL-D
PARVA-CAL 250 TABLET PARVA-CAL 250
PARVA-CAL 500 TABLET PARVA-CAL 500
PEDI ELECTROLYTE FREEZER POP PEDIATRIC ELECTROLYTE
PEDIALYTE ADVANCED CARE SOLN PEDIALYTE ADVANCED CARE
PEDIALYTE ELECTROLYTE SINGLES PEDIALYTE ELECTROLYTESINGLES
PEDIALYTE FREEZER POPS PEDIALYTE
PEDIALYTE SOLUTION PEDIALYTE
PEDIATRIC ELECTROLYTE PWDPACK
PEDIATRIC ELECTROLYTE
PEDIATRIC ELECTROLYTE SOLUTION PEDIATRIC ELECTROLYTE
POLYSACC IRON 150 COMPLEX C POLYSACCHARIDE IRON 150
POSTURE-D CAPLET POSTURE-D
PROSTEON TABLET PROSTEON
QC CALCIUM 600-VIT D3 400 TAB CALCIUM 600-VIT D3
RA CALCIUM 600 MG TABLET CALCIUM
RA CALCIUM 600-VIT D3 400 TAB CALCIUM 600-VIT D3
RA CALCIUM CITRATE - VIT D TAB CALCIUM CITRATE - VITAMIN D
RA CALCIUM CITRATE-VIT D3 TAB CALCIUM CITRATE-VIT D3
RA HI-CAL PLUS VITAMIN D TAB HI-CAL
RA IRON 65 MG TABLET IRON
RA MAGNESIUM 500 MG CAPSULE MAGNESIUM
RA OYSTER SHELL 500-VIT D3 200 OYSTER SHELL CALCIUM-VITD3
RA PEDIATRIC ELECTROLYTE SOLN PEDIATRIC ELECTROLYTE
RA PEDIATRIC FREEZER POPS PEDIATRIC FREEZER POPS
RISACAL-D TABLET RISACAL-D
SLOW RELEASE IRON 45 MG TAB SLOW RELEASE IRON
SLOW RELEASE IRON 45 MG TABLET SLOW RELEASE IRON
SM CALCIUM 500 MG TABLET CALCIUM
SM CALCIUM 500-VIT D3 200 CPLT CALCIUM 500-VIT D3
SM CALCIUM 500-VIT D3 400 TAB CALCIUM 500-VIT D3
SM CALCIUM 600 MG TABLET CALCIUM
SM CALCIUM 600 TABLET CALCIUM
SM CALCIUM 600-VIT D3 400 TAB CALCIUM 600-VIT D3
SM CALCIUM 600-VIT D3 800 TAB CALCIUM 600-VIT D3
SM CALCIUM CITRATE-VIT D CPLT CALCIUM CITRATE - VITAMIN D
SM CALCIUM CITRATE-VIT D3 TAB CALCIUM CITRATE-VIT D3
2018 Trusted Health Plan Medicaid OTC Formulary
164
Minerals and Electrolytes
Medication Info Common Name Drug Status Criteria
SM CORAL CALCIUM 1,000 MG TAB CORAL CALCIUM
SM IRON 325 MG TABLET IRON
SM IRON 65 MG TABLET IRON
SM PEDIATRIC ELECTROLYTE SOLN PEDIATRIC ELECTROLYTE
SM SLOW RELEASE IRON 45 MG TAB SLOW RELEASE IRON
SODIUM CHLORIDE 1 GM TABLET SODIUM CHLORIDE
SUPER CALCIUM 600-VIT D3 400 SUPER CALCIUM 600-VIT D3
SV CALCIUM 600 MG TABLET CALCIUM
SV CALCIUM 600-VIT D3 400 TAB CALCIUM 600-VIT D3
SV CALCIUM CITRATE-VIT D3 TAB CALCIUM CITRATE - VITAMIND3
SV IRON 65 MG TABLET IRON
SV MAGNESIUM OXIDE 400 MG TAB MAGNESIUM OXIDE
SV SLOW RELEASE IRON 45 MG TAB SLOW RELEASE IRON
THERACAL D2000 TABLET THERACAL
THERACAL D4000 TABLET THERACAL
THERACAL RAPID REPLETION TAB THERACAL
UPCAL D POWDER UPCAL D
UPCAL D POWDER PACKET UPCAL D
V-R CALCIUM 400 + D 133 CAPLET CALCIUM + VIT D
V-R FERROUS SULFATE 325 MG TAB FERROUS SULFATE
Mouth and Throat - Non-Narcotic Antitussive - Local Anesthetic Combos
Medication Info Common Name Drug Status Criteria
CEPACOL SORETHROAT-COUGH LOZ CEPACOL SORETHROAT-COUGH
Nasal Preparations
Medication Info Common Name Drug Status Criteria
CHILD SALINE 0.65% NASAL SPRAY CHILDREN’S SALINE NASALSPRAY
CROMOLYN SODIUM NASAL SPRAY CROMOLYN SODIUM
CVS SALINE 0.65% NASAL SPRAY SALINE NASAL SPRAY
CVS SALINE 0.65% NOSE SPRAY SALINE NOSE SPRAY
EQ NASAL 0.65% SPRAY NASAL SPRAY
EQL SALINE 0.65% NASAL SPRAY SALINE NASAL SPRAY
GNP NASAL MOIST 0.65% SPRAY NASAL MOISTURIZING
GNP SALINE 0.65% NOSE SPRAY SALINE NASAL SPRAY
HM SALINE 0.65% NASAL SPRAY SALINE NASAL SPRAY
NASAL 0.65% SPRAY NASAL SPRAY
NASAL MOISTURIZING 0.65% SPRAY NASAL MOISTURIZING
PUB SALINE 0.65% NASAL SPRAY SALINE NASAL SPRAY
RA NASAL RLF SINUS WASH REFILL NASAL RELIEF SINUS WASH
RA SALINE 0.65% NASAL SPRAY SALINE NASAL SPRAY
RA SALINE 0.65% NOSE SPRAY SALINE NOSE SPRAY
SALINE 0.65% NASAL SPRAY SALINE NASAL SPRAY
2018 Trusted Health Plan Medicaid OTC Formulary
165
Nasal Preparations
Medication Info Common Name Drug Status Criteria
SALINE 0.65% NOSE SPRAY SALINE NASAL SPRAY
SALINE MIST 0.65% NOSE SPRY SALINE MIST
SB SALINE 0.65% NOSE SPRAY SALINE NOSE SPRAY
SM SALINE 0.65% NASAL SPRAY SALINE NASAL SPRAY
SOD. CHLORIDE 0.65% MIST SODIUM CHLORIDE
ULTRA SALINE 0.65% NASAL SPRAY ULTRA SALINE
V-R NASAL ALLERGY SYM SPRAY NASAL ALLERGY SPRAY
V-R SALINE 0.65% NOSE SPRAY SALINE NASAL SPRAY
Nutritional Product - Nutritional Therapy
Medication Info Common Name Drug Status Criteria
NUTREN 1 CAL LIQUID NUTREN 1 CAL
NUTREN 1.5 LIQUID NUTREN 1.5
NUTREN 2.0 LIQUID NUTREN 2.0
PROMOTE LIQUID PROMOTE
REPLETE 1 CAL LIQUID REPLETE
Ophthalmic - Anti-allergy
Medication Info Common Name Drug Status Criteria
ALLERGY 0.025% EYE DROPS ALLERGY EYE DROPS
CVS ALLERGY 0.025% EYE DROPS ALLERGY EYE DROPS
CVS EYE ITCH RELIEF 0.025% DRP EYE ITCH RELIEF
EQ EYE ITCH RELIEF 0.025% DROP EYE ITCH RELIEF
EQ ITCHY EYE 0.025% DROPS ITCHY EYE
EYE ITCH RELIEF 0.025% DROPS EYE ITCH RELIEF
HM EYE ITCH RELIEF 0.025% DROP EYE ITCH RELIEF
KETOTIFEN FUM 0.025% EYE DROPS KETOTIFEN FUMARATE
KRO EYE ITCH RLF 0.025% DROPS EYE ITCH RELIEF
KRO ITCHY EYE 0.025% DROPS ITCHY EYE
RA EYE ITCH RELIEF 0.025% DROP EYE ITCH RELIEF
SM EYE ITCH RELIEF 0.025% DROP EYE ITCH RELIEF
WAL-ZYR 0.025% EYE DROPS WAL-ZYR
Ophthalmic - Hyperosmolar Agents
Medication Info Common Name Drug Status Criteria
CVS SODIUM CHLORIDE 5% EYE DRP SODIUM CHLORIDE
CVS SODIUM CHLORIDE 5% OINT SODIUM CHLORIDE
RA SODIUM CHLORIDE 5% EYE DROP SODIUM CHLORIDE
SOCHLOR 5% EYE OINTMENT SOCHLOR
SODIUM CHLORIDE 5% EYE DROP SODIUM CHLORIDE
SODIUM CHLORIDE 5% EYE OINT SODIUM CHLORIDE
SODIUM CHLORIDE 5% OPHT SOLN SODIUM CHLORIDE
Peptic Ulcer Therapy
Medication Info Common Name Drug Status Criteria
ACID CONTROL 150 MG TABLET ACID CONTROL
ACID REDUCER 150 MG TABLET ACID REDUCER
2018 Trusted Health Plan Medicaid OTC Formulary
166
Peptic Ulcer Therapy
Medication Info Common Name Drug Status Criteria
ACID REDUCER 200 MG TABLET ACID REDUCER
ACID REDUCER DR 20 MG CAP ACID REDUCER
CIMETIDINE 200 MG TABLET CIMETIDINE
CVS ACID REDUCER 150 MG TABLET ACID REDUCER
CVS CIMETIDINE 200 MG TABLET CIMETIDINE
CVS LANSOPRAZOLE DR 15 MG CAP LANSOPRAZOLE
CVS OMEPRAZOLE DR 20 MGTABLET
OMEPRAZOLE
CVS OMEPRAZOLE MAG DR 20.6 MG OMEPRAZOLE MAGNESIUM
EQ ACID REDUCER 150 MG TABLET ACID REDUCER
EQ ACID REDUCER 200 MG TABLET ACID REDUCER
EQ LANSOPRAZOLE DR 15 MG CAP LANSOPRAZOLE
EQ OMEPRAZOLE DR 20 MG TABLET OMEPRAZOLE
EQ OMEPRAZOLE MAG DR 20.6 MG OMEPRAZOLE MAGNESIUM
EQ RANITIDINE 150 MG TABLET RANITIDINE HCL
EQL ACID REDUCER 150 MG TABLET ACID REDUCER
EQL LANSOPRAZOLE DR 15 MG CAP LANSOPRAZOLE
EQL OMEPRAZOLE DR 20 MG TABLET OMEPRAZOLE
GNP ACID CONTROL 150 MG TABLET ACID CONTROL
GNP CIMETIDINE 200 MG TABLET CIMETIDINE
GNP LANSOPRAZOLE DR 15 MG CAP LANSOPRAZOLE
GNP OMEPRAZOLE DR 20 MGTABLET
OMEPRAZOLE
GS OMEPRAZOLE DR 20 MG TABLET OMEPRAZOLE
HEARTBURN RELIEF 150 MG TAB HEARTBURN RELIEF 150
HEARTBURN RELIEF 150 MG TABLET HEARTBURN RELIEF 150
HEARTBURN RELIEF 200 MG TABLET HEARTBURN RELIEF
HM ACID REDUCER 150 MG TABLET ACID REDUCER
HM LANSOPRAZOLE DR 15 MG CAP LANSOPRAZOLE
HM OMEPRAZOLE DR 20 MG TABLET OMEPRAZOLE
KRO ACID REDUCER 200 MG TABLET ACID REDUCER
KRO HEARTBURN RELIEF 150 MG TB HEARTBURN RELIEF
KRO LANSOPRAZOLE DR 15 MG CAP LANSOPRAZOLE
KRO OMEPRAZOLE DR 20 MGTABLET
OMEPRAZOLE
KRO OMEPRAZOLE MAG DR 20.6 MG OMEPRAZOLE MAGNESIUM
LANSOPRAZOLE DR 15 MG CAPSULE LANSOPRAZOLE
OMEPRAZOLE DR 20 MG TABLET OMEPRAZOLE
OMEPRAZOLE MAG DR 20.6 MG CAP OMEPRAZOLE MAGNESIUM
PUB OMEPRAZOLE DR 20 MGTABLET
OMEPRAZOLE
PUB RANITIDINE 150 MG TABLET RANITIDINE HCL
QC OMEPRAZOLE MAG DR 20.6 MG OMEPRAZOLE MAGNESIUM
RA ACID REDUCER 150 MG TABLET ACID REDUCER
2018 Trusted Health Plan Medicaid OTC Formulary
167
Peptic Ulcer Therapy
Medication Info Common Name Drug Status Criteria
RA LANSOPRAZOLE DR 15 MG CAP LANSOPRAZOLE
RA OMEPRAZOLE DR 20 MG TABLET OMEPRAZOLE
RANITIDINE 150 MG TABLET RANITIDINE HCL
SB ACID REDUCER 150 MG TABLET ACID REDUCER
SB OMEPRAZOLE DR 20 MG TABLET OMEPRAZOLE
SM ACID REDUCER 150 MG TABLET ACID REDUCER
SM ACID REDUCER 200 MG TABLET ACID REDUCER
SM HEARTBURN RELIEF 200 MG TAB HEARTBURN RELIEF
SM LANSOPRAZOLE DR 15 MG CAP LANSOPRAZOLE
SM OMEPRAZOLE DR 20 MG TABLET OMEPRAZOLE
SW ACID REDUCER 150 MG TABLET ACID REDUCER 150
SW OMEPRAZOLE DR 20 MG TABLET OMEPRAZOLE
V-R HEARTBURN RELF 200 MG TB HEARTBURN RELIEF
WAL-ZAN 150 MG TABLET WAL-ZAN 150
Respiratory Combinations
Medication Info Common Name Drug Status Criteria
ADULT WAL-TUSSIN DM SYRUP ADULT WAL-TUSSIN DM
ALL DAY ALLERGY-D TABLET ALL DAY ALLERGY-D
ALL-NITE COLD-FLU RELIEF LIQ ALL-NITE COLD-FLU RELIEF
ALLER-TEC D 5-120 MG TABLET ALLER-TEC D
ALLERCLEAR D-12HR TABLET ALLERCLEAR D-12HR
ALLERCLEAR D-24HR ER TABLET ALLERCLEAR D-24HR QL
ALLERGY CONGESTION RELIEF TAB ALLERGY-CONGESTIONRELIEF
QL
ALLERGY D-12 TABLET ALLERGY D-12
ALLERGY RELIEF D 12-HOUR TAB ALLERGY RELIEF D
ALLERGY RELIEF D-24 TABLET ALLERGY RELIEF D-24 QL
ALLERGY RELIEF-D 12 HOUR TAB ALLERGY RELIEF-D
ALLERGY RELIEF-NASAL DECONG TB ALLERGY RELIEF-NASALDECONGEST
QL
ALLERGY+CONGESTION RELF-D TAB ALLERGY+CONGESTIONRELIEF-D
QL
ALLERGY-CONGES RELF ER TABLET ALLERGY-CONGESTIONRELIEF
QL
ALLERGY-CONGEST RELIEF ER TAB ALLERGY-CONGESTIONRELIEF
QL
ALLERGY-CONGEST RLF-D 24HR TAB ALLERGY-CONGESTIONRELIEF-D
QL
ALLERGY-CONGESTION RLF 12H TAB ALLERGY-CONGESTIONRELIEF 12HR
ALLERGY-CONGESTION RLF-D 12HR ALLERGY-CONGESTIONRELIEF-D
CETIRIZINE-PSE ER 5-120 MG TAB CETIRIZINE-PSEUDOEPHEDRINE ER
CHERATUSSIN AC SYRUP CHERATUSSIN AC
2018 Trusted Health Plan Medicaid OTC Formulary
168
Respiratory Combinations
Medication Info Common Name Drug Status Criteria
CHILDS TRIACTING COLD & COUGH CHILDS TRIACTING COLD &COUGH
CODEINE-GUAIFEN 10-100 MG/5 ML CODEINE-GUAIFENESIN
COLD MULTI-SYMPTOM NIGHT LIQ COLD MULTI-SYMPTOMNIGHTTIME
COLD-FLU RELIEF LIQUID COLD-FLU RELIEF
CONTAC COLD-FLU NIGHT LIQUID CONTAC COLD-FLU NIGHT
CORICIDIN HBP COLD-MULTI SYMPT CORICIDIN HBP COLD-MULTISYMPT
COUGH & SORE THROAT LIQUID COUGH & SORE THROAT
COUGH SYRUP DM COUGH SYRUP DM
CVS ALLERGY RELIEF D-24 TABLET ALLERGY RELIEF D-24 QL
CVS ALLERGY RELIEF-D TABLET ALLERGY RELIEF-D QL
CVS ALLERGY RELIEF-D12 TABLET ALLERGY RELIEF-D12
CVS COLD & COUGH NIGHTTIME LIQ COLD & COUGH NIGHTTIME
CVS LORATADINE-D 24HR TABLET LORATADINE-D QL
CVS NIGHTTIME COLD-FLU RLF LIQ NIGHTTIME COLD-FLU RELIEF
DIMETAPP COLD & CONGEST LIQUID DIMETAPP COLD &CONGESTION
EQ CHILD NIGHT TIME COLD-COUGHLIQUID
CHILD NIGHT TIME COLD &COUGH
EQ NIGHTTIME COLD-FLU RLF LIQ NIGHTTIME COLD-FLU RELIEF
EQ NITETIME COLD & FLU LIQUID NITETIME COLD & FLU
EQ TUSSIN DM COUGH-CHEST SYR TUSSIN DM
EQL ALL DAY ALLERGY-D TABLET ALL DAY ALLERGY-D
EQL ALLERGY-CONGEST RLF ER TAB ALLERGY-CONGESTIONRELIEF
QL
EQL ALLERGY-CONGESTION 12H TAB ALLERGY-CONGESTIONRELIEF 12HR
EQL NIGHT SEVERE COLD-FLU LIQ NIGHTTIME SEVERE COLD-FLU
EQL NIGHTTIME COLD-FLU RLF LIQ NIGHTTIME COLD-FLU RELIEF
EQL TUSSIN DM COUGH-CHEST SYR TUSSIN DM
EXPECTORANT DM COUGH SYRUP EXPECTORANT DM
FEXOFENADINE-PSE ER 60-120 TAB FEXOFENADINE-PSE ER QL
GNP ALL DAY ALLERGY-D TABLET ALL DAY ALLERGY-D
GNP ALLERGY-CONGES RELF ERTAB
ALLERGY-CONGESTIONRELIEF
QL
GNP COLD MULTI-SYMPTOM NIGHT COLD MULTI-SYMPTOMNIGHTTIME
GNP LORATADINE-D 12 HOUR TAB LORATADINE-D
GNP LORATADINE-D 24HR TABLET LORATADINE-D QL
GNP NIGHT TIME COLD & FLU LIQ NIGHT TIME COLD & FLU
GNP TUSSIN DM CLEAR SYRUP TUSSIN DM CLEAR
GNP TUSSIN DM SYRUP TUSSIN DM
GS NIGHTTIME COLD-FLU LIQUID NIGHTTIME COLD-FLU
2018 Trusted Health Plan Medicaid OTC Formulary
169
Respiratory Combinations
Medication Info Common Name Drug Status Criteria
GUAIFEN-CODEINE 100-10 MG/5 ML GUAIFENESIN-CODEINE
GUAIFEN-CODEINE 200-20 MG/10 ML GUAIFENESIN-CODEINE
GUAIFENESIN DM SYRUP GUAIFENESIN-DEXTROMETHORPHAN
GUAIFENESIN-CODEINE SYRUP GUAIFENESIN-CODEINE
HM ADULT TUSSIN DM SYRUP ADULT TUSSIN DM
HM ALLERGY COMPLETE-D TABLET ALLERGY COMPLETE-D
HM ALLERGY RLF-NASAL DECONGTB
ALLERGY RELIEF-NASALDECONGEST
QL
HM ALLERGY-CONGESTION 12HRTAB
ALLERGY-CONGESTION 12HR
HM NIGHT TIME COLD & FLU LIQ NIGHT TIME COLD & FLU
HV ALLERGY-CONGEST RLF ER TAB ALLERGY-CONGESTIONRELIEF
QL
KRO ALLERGY RELIEF-D TABLET ALLERGY RELIEF-D QL
KRO ALLERGY-CONGEST RLF ERTAB
ALLERGY-CONGESTIONRELIEF
QL
KRO ALLERGY-CONGESTION 12HTAB
ALLERGY-CONGESTIONRELIEF 12HR
KRO CHILD NITE TIME COLD & CGH CHILD NITE TIME COLD &COUGH
KRO NITETIME COLD & FLU LIQUID NITETIME COLD & FLU
KRO NITETIME COLD-FLU LIQUID NITETIME COLD-FLU
KRO NITETIME SEVERE COLD-FLU NITETIME SEVERE COLD & FLU
LORATADINE-D 12 HOUR TABLET LORATADINE-D QL
LORATADINE-D 24HR TABLET LORATADINE-D QL
LORATADINE-PSEUDOEPHED 10-240 LORATADINE-PSEUDOEPHED QL
MEIJER ALL DAY ALLERGY-D TAB ALL DAY ALLERGY-D
NIGHT TIME COLD & FLU LIQ NIGHT TIME COLD & FLU
NIGHT TIME COLD & FLU LIQUID NIGHT TIME COLD & FLU
NIGHTTIME COLD-FLU LIQUID NIGHTTIME COLD-FLU
NIGHTTIME SEVERE COLD-FLU LIQ NIGHTTIME SEVERE COLD-FLU
NITE TIME COLD-FLU LIQUID NITE TIME COLD-FLU
NITE-TIME COLD & FLU LIQUID NITE-TIME COLD & FLU
PUB ALLERGY RELIEF D TABLET ALLERGY RELIEF D QL
PUB ALLERGY RELIEF-D TABLET ALLERGY RELIEF-D
PUB NITETIME MULTI-SYMPTOM LIQ NITETIME MULTI-SYMPTOM
PUB TUSSIN DM LIQUID TUSSIN DM
QC LORATADINE-D 24HR TABLET LORATADINE-D QL
RA ALLERGY-CONGESTION 12HRTAB
ALLERGY-CONGESTIONRELIEF 12HR
RA ANTI-TUSSIVE DM SYRUP ANTITUSSIVE DM
RA CETIRI-D ER TABLET CETIRI-D
RA LORATA-D 24-HOUR TABLET LORATA-D QL
RA NIGHTTIME COLD-FLU RLF LIQ NIGHTTIME COLD-FLU RELIEF
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Respiratory Combinations
Medication Info Common Name Drug Status Criteria
RA TUSSIN DM COUGH-CHESTSYRUP
TUSSIN DM COUGH-CHESTCONGEST
RA TUSSIN DM SYRUP TUSSIN DM
SB COUGH CONTROL DM SYRUP COUGH CONTROL DM
SEVERE COLD-FLU NIGHTTIME LIQ SEVERE COLD-FLU NIGHTTIME
SM ALL DAY ALLERGY-D TABLET ALL DAY ALLERGY-D
SM LORATA-DINE D 24HR TABLET LORATA-DINE D QL
SM LORATADINE D 12 HOUR TABLET LORATADINE D
SM NITE TIME COLD & FLU RELIEF NIGHT TIME COLD-FLU RELIEF
SM NITE TIME COLD-FLU LIQUID NITE TIME COLD-FLU
SM TUSSIN CLEAR SYRUP TUSSIN DM CLEAR
SM TUSSIN DM SYRUP TUSSIN DM
SW ALLERGY RELIEF-D TABLET ALLERGY RELIEF-D
TRIAMINIC NIGHTTIME COLD-COUGH TRIAMINIC NIGHTTIME COLD-COUGH
TUSSIN DM CLEAR LIQUID TUSSIN DM
TUSSIN DM CLEAR SYRUP TUSSIN DM CLEAR
TUSSIN DM COUGH & CHEST LIQUID TUSSIN DM COUGH & CHEST
TUSSIN DM COUGH SYRUP TUSSIN DM
TUSSIN DM SYRUP TUSSIN DM
TYLENOL COLD MAX NIGHT LIQUID TYLENOL COLD MAX
VICKS NYQUIL COLD & FLU LIQUID VICKS NYQUIL
VICKS NYQUIL SEVERE COLD-FLU VICKS NYQUIL SEVERE COLD-FLU
WAL-FEX D 12 HOUR 60-120 TAB WAL-FEX D 12 HOUR QL
WAL-FEX D 24 HOUR 180-240 TAB WAL-FEX D 24 HOUR QL
WAL-ITIN D 12 HOUR TABLET WAL-ITIN D 12 HOUR
WAL-ITIN D 24 HOUR TABLET WAL-ITIN D QL
WAL-TUSSIN DM CLEAR SYRUP WAL-TUSSIN DM
WAL-TUSSIN DM SYRUP WAL-TUSSIN DM
WAL-ZYR D TABLET WAL-ZYR D
Sedative-Hypnotics
Medication Info Common Name Drug Status Criteria
CVS NIGHTTIME SLEEP 25 MG CPLT NIGHTTIME SLEEP AID
CVS NIGHTTIME SLEEP AID 50 MG NIGHTTIME SLEEP AID
CVS SLEEP AID 25 MG TABLET SLEEP AID
CVS SLEEP AID 50 MG SOFTGEL SLEEP AID
CVS SLEEP AID CAPLET SLEEP AID
CVS SLEEP AID SOFTGEL SLEEP AID
DIPHENHYDRAMINE 25 MG CAPLET DIPHENHYDRAMINE HCL
EQ NIGHTTIME SLEEP 25 MG CPLT NIGHTTIME SLEEP AID
EQ NIGHTTIME SLEEP AID 50 MG NIGHTTIME SLEEP AID
EQL NIGHTTIME SLEEP 25 MG CPLT NIGHTTIME SLEEP AID
EQL SLEEP AID 50 MG SOFTGEL SLEEP AID
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Sedative-Hypnotics
Medication Info Common Name Drug Status Criteria
EQL SLEEP AID 50 MG/30 ML LIQ SLEEP AID
GNP NIGHTTIME SLEEP 25 MG CPLT NIGHTTIME SLEEP AID
GNP SLEEP TIME 50 MG/30 ML LIQ SLEEP TIME
HM NIGHTTIME SLEEP AID 50 MG NIGHTTIME SLEEP AID
HM Z-SLEEP 25 MG SOFTGEL Z-SLEEP
KRO EZ NITE SLEEP 25 MG SFTGL EZ NITE SLEEP
KRO NIGHTTIME SLEEP 25 MG CPLT NIGHTTIME SLEEP AID
KRO SLEEP AID 50 MG SOFTGEL SLEEP AID
NIGHT SLEEP AID 50 MG/30 ML LQ NIGHTTIME SLEEP AID
NIGHTTIME SLEEP AID 25 MG CPLT SLEEP AID
NIGHTTIME SLEEP AID 25 MG SFGL NIGHTTIME SLEEP AID
ORMIR 50 MG CAPSULE ORMIR
QC NIGHTTIME SLEEP 25 MG TAB NIGHTTIME SLEEP AID
QC SLEEP AID 50 MG SOFTGEL SLEEP AID
RA NIGHTTIME SLEEP 25 MG CPLT NIGHTTIME SLEEP AID
RA NIGHTTIME SLEEP GEL NIGHTTIME SLEEP GEL
RA SLEEP AID 25 MG CAPLET SLEEP AID
RA SLEEP TABLET SLEEP TABLET
RA SLEEP-AID SOFTGEL SLEEP-AID
RESTFULLY SLEEP 25 MG CAPLET RESTFULLY SLEEP
SB SLEEP TABLET SLEEP TABS
SLEEP AID 25 MG CAPLET SLEEP AID
SLEEP AID 25 MG LIQUID GEL SLEEP AID
SLEEP AID 50 MG SOFTGEL SLEEP AID
SLEEP AID TABLET SLEEP AID
SLEEP II 25 MG TABLET SLEEP II
SLEEP TIME 50 MG/30 ML LIQUID SLEEP TIME
SLEEPGELS 50 MG SLEEPGELS
SLEEPING 50 MG CAPSULE SLEEPING
SM NIGHTTIME SLEEP 25 MG CPLT NIGHTTIME SLEEP AID
SM SLEEP AID NIGHT TIME CAPLET SLEEP AID
SM SLEEP AID SOFTGEL SLEEP AID
SM Z-SLEEP 50 MG/30 ML LIQUID Z-SLEEP
WAL-SLEEP Z 25 MG SOFTGEL WAL-SLEEP Z
WAL-SLEEP Z 50 MG/30 ML LIQUID WAL-SLEEP Z
WAL-SOM 50 MG SOFTGEL WAL-SOM
Smoking Deterrents and Combinations
Medication Info Common Name Drug Status Criteria
CVS NICOTINE 14 MG/24HR PATCH NICOTINE PATCH
CVS NICOTINE 2 MG CHEWING GUM NICOTINE GUM
CVS NICOTINE 2 MG LOZENGE NICOTINE LOZENGE
CVS NICOTINE 2 MG MINI LOZENGE NICOTINE LOZENGE
CVS NICOTINE 21 MG/24HR PATCH NICOTINE PATCH
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Smoking Deterrents and Combinations
Medication Info Common Name Drug Status Criteria
CVS NICOTINE 4 MG CHEWING GUM NICOTINE GUM
CVS NICOTINE 4 MG LOZENGE NICOTINE LOZENGE
CVS NICOTINE 4 MG MINI LOZENGE NICOTINE LOZENGE
CVS NICOTINE 7 MG/24HR PATCH NICOTINE PATCH
CVS NTS 21 MG/24HR PATCH NTS
EQ NICOTINE 14 MG/24HR PATCH NICOTINE PATCH
EQ NICOTINE 2 MG CHEWING GUM NICOTINE GUM
EQ NICOTINE 2 MG LOZENGE NICOTINE LOZENGE
EQ NICOTINE 21 MG/24HR PATCH NICOTINE PATCH
EQ NICOTINE 4 MG CHEWING GUM NICOTINE GUM
EQ NICOTINE 4 MG LOZENGE NICOTINE LOZENGE
EQ NICOTINE 7 MG/24HR PATCH NICOTINE PATCH
EQL NICOTINE 2 MG CHEWING GUM NICOTINE GUM
EQL NICOTINE 2 MG LOZENGE NICOTINE LOZENGE
EQL NICOTINE 4 MG CHEWING GUM NICOTINE GUM
EQL NICOTINE 4 MG LOZENGE NICOTINE LOZENGE
GNP NICOTINE 2 MG CHEWING GUM NICOTINE GUM
GNP NICOTINE 2 MG LOZENGE NICOTINE LOZENGE
GNP NICOTINE 2 MG MINI LOZENGE NICOTINE LOZENGE
GNP NICOTINE 21 MG/24HR PATCH NICOTINE PATCH
GNP NICOTINE 4 MG CHEWING GUM NICOTINE GUM
GNP NICOTINE 4 MG LOZENGE NICOTINE LOZENGE
GNP NICOTINE 4 MG MINI LOZENGE NICOTINE LOZENGE
HM NICOTINE 14 MG/24HR PATCH NICOTINE PATCH
HM NICOTINE 2 MG CHEWING GUM NICOTINE GUM
HM NICOTINE 2 MG LOZENGE NICOTINE LOZENGE
HM NICOTINE 21 MG/24HR PATCH NICOTINE PATCH
HM NICOTINE 4 MG CHEWING GUM NICOTINE GUM
HM NICOTINE 4 MG LOZENGE NICOTINE LOZENGE
HM NICOTINE 7 MG/24HR PATCH NICOTINE PATCH
KRO NICOTINE 14 MG/24HR PATCH NICOTINE PATCH
KRO NICOTINE 2 MG CHEWING GUM NICOTINE GUM
KRO NICOTINE 2 MG LOZENGE NICOTINE LOZENGE
KRO NICOTINE 2 MG MINI LOZENGE NICOTINE LOZENGE
KRO NICOTINE 21 MG/24HR PATCH NICOTINE PATCH
KRO NICOTINE 4 MG CHEWING GUM NICOTINE GUM
KRO NICOTINE 4 MG LOZENGE NICOTINE LOZENGE
KRO NICOTINE 4 MG MINI LOZENGE NICOTINE LOZENGE
KRO NICOTINE 7 MG/24HR PATCH NICOTINE PATCH
LDR NICOTINE 2 MG CHEWING GUM NICOTINE GUM
LDR NICOTINE 4 MG CHEWING GUM NICOTINE GUM
NICOTINE 14 MG/24 HR PATCH NICOTINE PATCH
NICOTINE 14 MG/24HR PATCH NICOTINE PATCH
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Smoking Deterrents and Combinations
Medication Info Common Name Drug Status Criteria
NICOTINE 2 MG CHEWING GUM NICOTINE GUM
NICOTINE 2 MG LOZENGE NICOTINE LOZENGE
NICOTINE 2 MG MINI LOZENGE NICOTINE LOZENGE
NICOTINE 21 MG/24 HR PATCH NICOTINE PATCH
NICOTINE 21 MG/24HR PATCH NICOTINE PATCH
NICOTINE 22 MG/24HR PATCH NICOTINE PATCH
NICOTINE 4 MG CHEWING GUM NICOTINE GUM
NICOTINE 4 MG LOZENGE NICOTINE LOZENGE
NICOTINE 4 MG MINI LOZENGE NICOTINE LOZENGE
NICOTINE 7 MG/24HR PATCH NICOTINE PATCH
NICOTINE TRANSDERMAL SYSTEM NICOTINE PATCH
PUB STOP SMOKING AID 2 MG LOZG STOP SMOKING AID
PUB STOP SMOKING AID 4 MG LOZG STOP SMOKING AID
QUIT 2 MG CHEWING GUM QUIT 2
QUIT 2 MG LOZENGE QUIT 2
QUIT 4 MG CHEWING GUM QUIT 4
QUIT 4 MG LOZENGE QUIT 4
RA NICOTINE 14 MG/24HR PATCH NICOTINE PATCH
RA NICOTINE 2 MG CHEWING GUM NICOTINE GUM
RA NICOTINE 2 MG LOZENGE NICOTINE LOZENGE
RA NICOTINE 2 MG MINI LOZENGE NICOTINE LOZENGE
RA NICOTINE 21 MG/24HR PATCH NICOTINE PATCH
RA NICOTINE 4 MG CHEWING GUM NICOTINE GUM
RA NICOTINE 4 MG LOZENGE NICOTINE LOZENGE
RA NICOTINE 4 MG MINI LOZENGE NICOTINE LOZENGE
RA NICOTINE 7 MG/24HR PATCH NICOTINE PATCH
SM NICOTINE 14 MG/24HR PATCH NICOTINE PATCH
SM NICOTINE 2 MG CHEWING GUM NICOTINE GUM
SM NICOTINE 2 MG LOZENGE NICOTINE LOZENGE
SM NICOTINE 21 MG/24HR PATCH NICOTINE PATCH
SM NICOTINE 4 MG CHEWING GUM NICOTINE GUM
SM NICOTINE 4 MG LOZENGE NICOTINE LOZENGE
SM NICOTINE 7 MG/24HR PATCH NICOTINE PATCH
SW NICOTINE 2 MG CHEWING GUM NICOTINE GUM
SW NICOTINE 2 MG LOZENGE NICOTINE LOZENGE
SW NICOTINE 4 MG CHEWING GUM NICOTINE GUM
SW NICOTINE 4 MG LOZENGE NICOTINE LOZENGE
Urinary Analgesics
Medication Info Common Name Drug Status Criteria
CVS URINARY PAIN RLF 95 MG TAB URINARY PAIN RELIEF
EQ URINARY PAIN RLF 95 MG TAB URINARY PAIN RELIEF
PHENAZOPYRIDINE 95 MG TABLET PHENAZOPYRIDINE HCL
RA URINARY PAIN RLF 95 MG TAB URINARY PAIN RELIEF
2018 Trusted Health Plan Medicaid OTC Formulary
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Urinary Analgesics
Medication Info Common Name Drug Status Criteria
SB URINARY PAIN RLF 97.5 MG TB URINARY PAIN RELIEF
SM URINARY PAIN REL 97.5 MG TB URINARY PAIN RELIEF
SM URINARY PAIN RLF 95 MG TAB URINARY PAIN RELIEF
URINARY PAIN RELIEF 95 MG TAB URINARY PAIN RELIEF
URINARY PAIN RELIEF 97.5 MG TB URINARY PAIN RELIEF
V-R URINARY PAIN RLF 95 MG TAB URINARY PAIN RELIEF
Vaginal Anti-infectives
Medication Info Common Name Drug Status Criteria
3-DAY VAGINAL CREAM 3-DAY VAGINAL CREAM
CLOTRIM 1% VAGINAL CREAM CLOTRIMAZOLE
CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE
CLOTRIMAZOLE 3 2% CREAM CLOTRIMAZOLE-3
CLOTRIMAZOLE INSERT CLOTRIMAZOLE
CLOTRIMAZOLE-3 CREAM CLOTRIMAZOLE-3
CLOTRIMAZOLE-7 CREAM CLOTRIMAZOLE-7
CVS 3-DAY VAGINAL CREAM 3-DAY VAGINAL CREAM
CVS MEDICATE DISPOSABLEDOUCHE
MEDICATED DOUCHE
CVS MICONAZOLE 7 CREAM MICONAZOLE 7
EQ MICONAZOLE 7 CREAM MICONAZOLE 7
EQ MICONAZOLE NITRATE 2% CRM MICONAZOLE NITRATE
EQL MICONAZOLE 7 CREAM MICONAZOLE 7
GNP CLOTRIMAZOLE-3 CREAM CLOTRIMAZOLE-3
GNP MICONAZOLE 7 CREAM MICONAZOLE 7
GYNE-LOTRIMIN 3 DAY 2% CRM GYNE-LOTRIMIN
GYNE-LOTRIMIN-7 1% CREAM GYNE-LOTRIMIN-7
KRO MICONAZOLE 7 CREAM MICONAZOLE 7
MICONAZOLE 100 MG VAG SUPP MICONAZOLE NITRATE
MICONAZOLE 7 100 MG VAG SUPP MICONAZOLE 7
MICONAZOLE 7 CREAM MICONAZOLE 7
MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE
MONISTAT 7 CREAM MONISTAT 7
POVIDONE-IODINE DOUCHE POVIDONE-IODINE
QC MICONAZOLE 7 CREAM MICONAZOLE 7
RA CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE
RA FEMININE CARE DOUCHE FEMININE CARE DOUCHE
RA MICONAZOLE 7 CREAM MICONAZOLE 7
SB DISP DOUCHE EXTRA CLNS V&W DISP DOUCHE EXTRA CLNSV&W
SM 3-DAY VAGINAL CREAM 3-DAY VAGINAL CREAM
SM CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE
SM MICONAZOLE 7 100 MG VAG SUP MICONAZOLE 7
SM MICONAZOLE 7 CREAM MICONAZOLE 7
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Vaginal Anti-infectives
Medication Info Common Name Drug Status Criteria
SM MICONAZOLE NITRATE 2%CREAM
MICONAZOLE NITRATE
Vitamin Combinations
Medication Info Common Name Drug Status Criteria
A THRU Z ADVANCED FORMULA TAB A THRU Z
A THRU Z SELECT MULTIVIT TAB A THRU Z SELECT
A THRU Z SELECT TABLET A THRU Z SELECT
ANIMAL CHEWS TABLET ANIMAL CHEWS
ANIMAL SHAPES TABLET CHEW ANIMAL SHAPES
AQUADEKS PEDIATRIC LIQUID AQUADEKS
B COMPLEX FORMULA #1 TABLET B COMPLEX # 1
B COMPLEX TABLET VITAMIN B COMPLEX
B-COMPLEX WITH B12 TABLET VITAMIN B COMPLEX
BABY IRON-MULTIVITAMIN DROP BABY IRON-MULTIVITAMIN
BALANCED B-100 TABLET BALANCED B-100
BALANCED B-50 TABLET SA BALANCED B-50
CENTRUM KIDS CHEW TAB CENTRUM KIDS
CENTRUM SPECIALIST PRENATAL CENTRUM SPECIALISTPRENATAL
CENTURY TABLET CENTURY
CENTURY ULTIMATE WOMEN’S TAB CENTURY ULTIMATE WOMEN’S
CEROVITE JR TABLET CEROVITE JR
CEROVITE JR TABLET CHEW CEROVITE JR
CEROVITE SENIOR TABLET CEROVITE SENIOR
CHEW-VITES-IRON TABLET CHEW CHEWABLE-VITE WITH IRON
CHILD CHEW + IRON TAB CHEW CHILD CHEW + IRON
CHILD CHEW VITAMIN TABLET CHILD CHEW VITAMIN
CHILD MULTIVITAMIN PLUS IRON CHILD MULTIVITAMIN PLUSIRON
CHILD MULTIVITAMINS TAB CHEW CHILD MULTIVITAMINS
CHILD VITAMIN-IRON TAB CHEW CHILDREN’S VITAMINS WITHIRON
CHILD’S CHEW MULTIVIT W/IRON CHILDREN’S CHEW MULTIVIT-IRON
CHILD’S CHEW VITAMIN-IRON TAB CHILDREN’S CHEW VITAMIN-IRON
CHILD’S CHEWABLE MULTIVIT TAB CHILDREN’S CHEWABLEMULTIVITMN
CHILD’S CHEWABLE VITAMIN TAB CHILDREN’S CHEWABLEVITAMIN
CHILD’S OMEGA-3 DHA MULTIVITAM CHILD’S OMEGA-3 DHAMULTIVITAM
CHILDREN MULTIVITAMIN GUMMIES CHILDREN’S MULTIVITAMIN
CHILDREN’S CHEWABLE VITAMIN CHILDREN’S CHEWABLEVITAMIN
CHILDREN’S CHEWABLES CHILDREN’S CHEWABLE
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Vitamin Combinations
Medication Info Common Name Drug Status Criteria
CHILDREN’S MULTI-VIT GUMMIES CHILDREN’S MULTI-VITGUMMIES
CHILDRENS CHEW VITAMIN TAB CHILDREN’S CHEWABLEVITAMIN
CHILDRENS MULTIVIT TAB CHEW CHILDREN’S CHEWABLEVITAMIN
CHILDRENS VIT-IRON TAB CHEW CHILDREN’S VITAMINS WITHIRON
CHOICEFUL VITAMINS CHEW TABLET CHOICEFUL VITAMINS
CHOICEFUL VITAMINS SOFTGEL CHOICEFUL VITAMINS
CLASSIC PRENATAL TABLET CLASSIC PRENATAL
COMPLETE MULTI 50+ TABLET COMPLETE MULTI 50+
COMPLETE MULTI TABLET COMPLETE MULTI
COMPLETE MULTIVITAMIN TAB COMPLETE MULTIVITAMIN
CVS BAL B-100 TABLET BAL B-100
CVS BAL B-50 TABLET BAL B-50
CVS CHILD VIT-MINERAL TAB CHILD VITAMIN WITHMINERALS
CVS CHILD’S VITAMIN-IRON TB CHILD’S VITAMIN WITH IRON
CVS DAILY MULTIPLE TABLET DAILY MULTIPLE VITAMIN
CVS DAILY VIT-IRON-CAL TAB MULTIVITAMINS W-CALCIUM-IRON
CVS GUMMY DINOS GUMMIES GUMMY DINOS
CVS GUMMY DINOS VITAMIN GUMMY DINOS
CVS HAIR, SKIN AND NAILS CPLT HAIR, SKIN AND NAILS
CVS KIDS’ MULTIVITAMIN GUMMY GUMMY
CVS MEN’S MULTI-VIT TABLET MEN’S MULTI-VITAMIN
CVS PRENATAL GUMMY VITAMINS PRENATAL
CVS PRENATAL MULTI-DHA SOFTGEL PRENATAL MULTI-DHA
CVS PRENATAL VITAMIN TABLET PRENATAL VITAMINS
CVS SPECTRAVITE ADVANCED TAB SPECTRAVITE ADVANCEDFORMULA
CVS SPECTRAVITE SENIOR TABLET SPECTRAVITE SENIOR
CVS SPECTRAVITE ULTRA WOMENTB
SPECTRAVITE ULTRA WOMEN
CVS WOMEN’S PRENATAL + DHA WOMEN’S PRENATAL + DHA
DAILY MULTI VITAMIN-IRON TAB MULTIVITAMINS WITH IRON
DAILY MULTIPLE TABLET DAILY MULTIPLE
DAILY MULTIPLE VITAMIN TABLET DAILY MULTIPLE VITAMIN
DAILY MULTIVIT-MINERALS TAB MULTIVITAMINS WITHMINERALS
DAILY MULTIVITAMIN-IRON TABLET DAILY MULTIVITAMIN-IRON
DAILY PRENATAL COMBO PACK DAILY PRENATAL
DEKAS PLUS LIQUID DEKAS PLUS
DINO-LIFE EXTRA C TAB CHEW DINO-LIFE WITH EXTRA C
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Vitamin Combinations
Medication Info Common Name Drug Status Criteria
DINO-LIFE IRON-ZINC TB CHEW DINO-LIFE
DINO-LIFE TABLET CHEWABLE DINO-LIFE
EMERGEN-C KIDZ 250 MG PACKET EMERGEN-C KIDZ
EQ CHILD COMPLETE CHEW TABLET CHILD COMPLETEMULTIVITAMIN
EQ CHILD MULTIVITAMIN GUMMIES CHILDREN’S MULTIVITAMIN
EQ COMPLETE MULTIVITAMIN TAB COMPLETE MULTIVITAMIN
EQL B COMPLEX 50 TABLET VITAMIN B COMPLEX
EQL ONE DAILY MEN’S TABLET MEN’S ONE DAILY
EXPECTA PRENATAL COMBO PACK EXPECTA PRENATAL
FLINTSTONES + CALCIUM TAB FLINTSTONES PLUS CALCIUM
FLINTSTONES COMPLETE CHEW TAB FLINTSTONES COMPLETE
FLINTSTONES COMPLETE GUMMIES FLINTSTONES COMPLETE
FLINTSTONES COMPLETE TABLET FLINTSTONES COMPLETE
FLINTSTONES EXTRA C GUMMIES FLINTSTONES WITH EXTRA C
FLINTSTONES EXTRA C TAB CHEW FLINTSTONES WITH EXTRA C
FLINTSTONES GUMMIES CHEW TAB FLINTSTONES GUMMIES
FLINTSTONES MULTI-VIT GUMMIES FLINTSTONES MULTI-VITGUMMIES
FLINTSTONES MULTIVIT CHEW TAB FLINTSTONES
FLINTSTONES SOUR-GUM CHEW TAB FLINTSTONES
FLINTSTONES TAB CHEW FLINTSTONES
FLINTSTONES TABLET CHEWABLE FLINTSTONES
FLINTSTONES WITH IRON TAB CHEW FLINTSTONES WITH IRON
FRUITY VITAMINS TABLET CHEW FRUITY VITAMIN
GNP ANIMAL SHAPES TABLET CHEW ANIMAL SHAPES
GNP CENTURY TABLET CENTURY
GNP CENTURY ULTIMATE WOMENTAB
CENTURY ULTIMATE WOMEN’S
GNP CHILDREN’S CHEWABLES CHILDREN’S CHEWABLES
GNP DAILY PRENATAL COMBO PACK DAILY PRENATAL
GNP ONE DAILY ESSENTIAL TABLET ONE DAILY ESSENTIAL
GNP ONE DAILY MAXIMUM TABLET ONE DAILY MAXIMUM
GNP ONE DAILY PLUS IRON TABLET ONE DAILY PLUS IRON
GNP PRENATAL VITAMINS TABLET PRENATAL VITAMINS
GNP ZOO CHEWS GUMMIE TABLET ZOO CHEWS
GS PRENATAL VITAMINS TABLET PRENATAL VITAMINS
GUMMI BEAR MULTIVIT TAB CHEW GUMMI BEAR MULTIVITAMIN
GUMMIES CHILDREN MULTIVITAMIN GUMMIES CHILDRENMULTIVITAMIN
GUMMIES GIRLS’ MULTIVITAMINS GUMMIES GIRLS’MULTIVITAMINS
HI-B COMPLEX TABLET HI B COMPLEX
HM ANIMAL SHAPES COMPLETECHEW
ANIMAL SHAPES COMPLETE
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Vitamin Combinations
Medication Info Common Name Drug Status Criteria
HM COMPLETE MULTI-VIT-MINERAL COMPLETE MULTI-VIT-MINERAL
HM COMPLETE WOMEN TABLET COMPLETE WOMEN
HM HAIR, SKIN AND NAILS CAPLET HAIR, SKIN AND NAILS
HM ONE DAILY ESSENTIAL TABLET ONE DAILY ESSENTIAL
HM ONE DAILY PRENATAL COMBOPK
ONE DAILY PRENATAL
HM ONE DAILY WITH IRON TABLET ONE DAILY WITH IRON
HM PRENATAL TABLET PRENATAL
HONEY BEARS CHEW TAB HONEY BEARS
HONEY BEARS-IRON-ZINC TAB CHEW HONEY BEARS
KIDS COD LIVER OIL +D TAB CHEW KIDS COD LIVER OIL +D
KIDS MULTIVIT-MINERALS GUMMIES KIDS MULTIVITAMIN-MINERALS
KIDS MULTIVITAMIN COMPLETE TAB KIDS MULTIVITAMINCOMPLETE
KIDSTART CHEWABLE TABLET KIDSTART
KPN PRENATAL TABLET KPN
KPN TABLET KPN
KRO PRENATAL VITAMINS TABLET PRENATAL VITAMINS
LITTLE ANIMALS CHILD TB CHW CHILD LITTLE ANIMALSVITAMINS
LITTLE ANIMALS-IRON TAB CHEW LITTLE ANIMALS PLUS IRON
LYSIPLEX PLUS LIQUID LYSIPLEX PLUS
MEGA MULTIVITAMIN-MINERAL TAB MEGA MULTIVITAMIN WITHMINERAL
MILLTRIUM SENIOR MULTIVIT TAB MILLTRIUM SENIOR
MINI PRENATAL TABLET MINI PRENATAL
MTERYTI COMBO PACK MTERYTI
MTERYTI FOLIC 5 COMBO PACK MTERYTI FOLIC 5
MULTI-DAY VITAMIN TABLET MULTI-DAY VITAMINS
MULTI-VITAMIN GUMMIES MULTI-VITAMIN
MULTIPLE VITAMIN PLAIN TAB MULTIPLE VITAMINS
MULTIPLE VITAMIN TABLET MULTIPLE VITAMINS
MULTIPLE VITAMIN W-MINERALS TB MULTIPLE VITAMIN
MULTIPLE VITAMIN WITH IRON TAB MULTIVITAMINS WITH IRON
MULTIPLE VITAMINS TABLET MULTIPLE VITAMINS
MULTIVIT WITH IRON TAB CHEW MULTIVITAMINS WITH IRON
MULTIVIT-A,B,D,E,K,ZN CHEW TAB MULTIVITAMIN-A,B,D,E,K,ZN
MULTIVIT-FLUOR 0.25 MG/ML DROP MULTIVITAMIN WITH FLUORIDE
MULTIVIT-FLUOR 0.5 MG/ML DROP MULTIVITAMIN WITH FLUORIDE
MULTIVIT-FLUOR-IRON 0.25 MG/ML MULTI-VITAMIN W-FLUORIDE-IRON
MULTIVIT-IRON CHILD TAB CHEW CHILDREN’S MULTIVITAMIN-IRON
MULTIVIT-MINERALS TABLET MULTIVITAMINS WITHMINERALS
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Vitamin Combinations
Medication Info Common Name Drug Status Criteria
MULTIVITAMIN CHILD TAB CHEW CHILDREN’S MULTIVITAMINS
MULTIVITAMIN-A,B,D,E,K,ZN DROP MULTIVITAMIN-A,B,D,E,K,ZN
MULTIVITAMIN-CALCIUM-IRON TAB MULTIVITAMINS W-CALCIUM-IRON
MULTIVITAMINS TABLET MULTIVITAMINS
MULTIVITAMINS-IRON TABLET MULTIVITAMINS WITH IRON
MVW COMPLETE FORM MULTIVISFGL
MVW COMPLETE FORMULTNMULTIVIT
MVW COMPLETE FORM MULTIVITCHW
MVW COMPLETE FORMULTNMULTIVIT
MVW COMPLETE FORMUL D3000CHEW
MVW COMPLETEFORMULATION D3000
MVW COMPLETE FORMUL D3000SFGL
MVW COMPLETEFORMULATION D3000
MVW COMPLETE FORMUL D5000SFGL
MVW COMPLETEFORMULATION D5000
MVW COMPLETE FORMUL PEDIADRPS
MVW COMPLETE FORMLTNPEDIATRIC
NANO VM 1-3 POWDER NANO VM 1-3
NANO VM 4-8 POWDER NANO VM 4-8
NANO VM T/F POWDER NANOVM T/F
NANOVM 9-18 POWDER NANOVM 9-18
NOVAFERRUM PED MULTIVIT-IRON NOVAFERRUM PEDIATRIC
ONCE DAILY TABLET ONCE DAILY
ONCE DAILY WITH IRON TABLET ONE DAILY WITH IRON
ONE A DAY PRENATAL DHA PACK ONE A DAY WOMEN’SPRENATAL DHA
ONE DAILY ESSENTIAL TABLET ONE DAILY ESSENTIAL
ONE DAILY FOR WOMEN TABLET ONE DAILY FOR WOMEN
ONE DAILY MAXIMUM TABLET ONE DAILY MAXIMUM
ONE DAILY MULTIVITAMIN-IRON TB ONE DAILY MULTIVITAMIN-IRON
ONE DAILY PLUS IRON TABLET ONE DAILY PLUS IRON
ONE DAILY TABLET ONE DAILY
ONE DAILY WOMEN’S TABLET ONE DAILY WOMEN’S
ONE DAILY WOMENS 50 PLUS TAB ONE DAILY WOMENS 50 PLUS
ONE-A-DAY KID’S GUMMIES ONE-A-DAY KID’S
ONE-A-DAY PRENATAL 1 DHA SFGL ONE-A-DAY WOMEN’SPRENATAL 1
ONE-A-DAY TEEN HIM VITACRAVES ONE-A-DAY TEEN HIMVITACRAVES
P-D NATAL PLUS-FOLIC ACID TAB P-D NATAL PLUS WITH FOLICACID
PERRY PRENATAL CAPSULE PERRY PRENATAL
PHARMACIST MULTI-VITE TAB PHARMACIST FAVORITE MULTI-VITE
POLY-VI-SOL DROPS POLY-VI-SOL
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Vitamin Combinations
Medication Info Common Name Drug Status Criteria
POLY-VI-SOL WITH IRON DROPS POLY-VI-SOL WITH IRON
POLY-VITA DROPS POLY-VITA
POLY-VITA WITH IRON DROPS POLY-VITA WITH IRON
POLY-VITAMIN DROPS POLY-VITAMIN
POLY-VITAMIN TAB CHEW POLY-VITAMIN
POLYVITAMIN W-IRON DROPS POLYVITAMIN WITH IRON
POLYVITAMIN WITH IRON TAB CHEW POLYVITAMIN WITH IRON
PRENATAL + DHA COMBO PACK PRENATAL + DHA
PRENATAL 19 CHEWABLE TABLET PRENATAL 19
PRENATAL 19 TABLET PRENATAL 19
PRENATAL COMPLETE CAPLET PRENATAL COMPLETE
PRENATAL DHA+COMPLETEPRENATAL
PRENATAL DHA+COMPLETEPRENATAL
PRENATAL FORMULA TABLET PRENATAL FORMULA
PRENATAL FORMULA-DHA SOFTGEL PRENATAL FORMULA-DHA
PRENATAL GUMMIES PRENATAL
PRENATAL MULTI + DHA SOFTGEL PRENATAL MULTI + DHA
PRENATAL MULTI-DHA SOFTGEL PRENATAL MULTI-DHA
PRENATAL MULTIVITAMIN TABLET PRENATAL MULTIVITAMIN
PRENATAL MULTIVITAMIN-DHA SFGL PRENATAL MULTIVITAMIN-DHA
PRENATAL ONE DAILY TABLET PRENATAL ONE DAILY
PRENATAL ONE TABLET PRENATAL ONE
PRENATAL PLUS-DHA COMBO PACK PRENATAL PLUS-DHA
PRENATAL TABLET PRENATAL
PRENATAL VITAMIN FORMULA TB PRENATAL VITAMINS
PRENATAL VITAMIN TABLET PRENATAL VITAMIN
PRENATAL VITAMINS TABLET PRENATAL VITAMINS
PRENATAL-1 CAPSULE PRENATAL-1
PUB MULTIVITAMIN 50 PLUS TAB MULTIVITAMIN 50 PLUS
QC PRENATAL TABLET PRENATAL
QUFLORA 0.125 MG GUMMIES QUFLORA
RA B-COMPLEX TABLET B COMPLEX
RA B-COMPLEX-VITAMIN B-12 TAB VITAMIN B COMPLEX
RA BALANCED B-50 TABLET BALANCED B-50
RA CENTRAL-VITE TABLET CENTRAL-VITE
RA ONE DAILY ENERGY TABLET ONE DAILY ENERGY
RA ONE DAILY ESSENTIAL TABLET ONE DAILY ESSENTIAL
RA ONE DAILY MAXIMUM TABLET ONE DAILY MAXIMUM
RA ONE DAILY PRENATAL DHA PACK ONE DAILY PRENATAL
RA PRENATAL FORMULA TABLET PRENATAL FORMULA
RA PRENATAL TABLET PRENATAL VITAMINS
RIGHT STEP PRENATAL VIT TAB RIGHT STEP PRENATALVITAMINS
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Vitamin Combinations
Medication Info Common Name Drug Status Criteria
SCOOBY-DOO ONE A DAY GUMMIES SCOOBY-DOO
SCOOBY-DOO ONE A DAY TABLET SCOOBY-DOO
SENTRY MULTIVIT & MINERAL CPLT SENTRY
SENTRY SENIOR MULTIVIT CAPLET SENTRY SENIOR
SIMILAC PRENATAL COMBO PACK SIMILAC PRENATAL
SM ANIMAL SHAPES COMPLETECHEW
ANIMAL SHAPES COMPLETE
SM ANIMAL SHAPES TAB CHEW MULTIVITAMINS
SM ANIMAL SHAPES W-IRON TAB ANIMAL SHAPES PLUS IRON
SM BALANCED B-50 TABLET BALANCED B-50
SM COMPLETE ADVANCED TABLET COMPLETE
SM COMPLETE MULTI-VIT-MINERAL COMPLETE MULTI-VIT-MINERAL
SM HAIR, SKIN AND NAILS CAPLET HAIR, SKIN AND NAILS
SM MULTIPLE VITAMIN WOMENS TAB MULTIPLE VITAMINS FORWOMEN
SM MULTIVITAMIN W-IRON TAB MULTIVITAMINS WITH IRON
SM MULTIVITAMINS TABLET MULTIVITAMINS
SM ONE DAILY PRENATAL COMBOPK
ONE DAILY PRENATAL
SM PRENATAL TABLET PRENATAL
SM PRENATAL VITAMINS TABLET PRENATAL VITAMINS
SM THERAPEUTIC M TABLET THERAPEUTIC M
STRESS B TABLET STRESS B
STUART ONE CAPSULE STUART ONE
SV PRENATAL TABLET PRENATAL
THERA-M CAPLET THERA-M
THERANATAL COMPLETE COMBO THERANATAL COMPLETE
THERANATAL CORE NUTRITION TAB THERANATAL
THERANATAL ONE SOFTGEL THERANATAL ONE
THERANATAL OVAVITE COMBO PACK THERANATAL OVAVITE
THERANATAL PLUS COMBO PACK THERANATAL PLUS
THERAPEUTIC M TABLET THERAPEUTIC M
THERATRUM COMP 50 PLUS TAB THERATRUM COMPLETE 50PLUS
THERATRUM COMPL 50 PLUS TAB THERATRUM COMPLETE 50PLUS
TRI-VI-SOL DROPS TRI-VI-SOL
TRI-VITA DROPS TRI-VITA
TRI-VITAMIN DROPS TRI-VITAMIN
TROPICAL LIQUID NUTRITION TROPICAL LIQUID NUTRITION
V-R BALANCED B-50 TABLET BALANCED B-50
V-R NATURAL B-100 TABLET NATURAL B-100
VINACAL B PRENATAL COMBO PACK VINACAL B
VISION PLUS LUTEIN VITAMIN TAB VISION PLUS LUTEIN
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Vitamin Combinations
Medication Info Common Name Drug Status Criteria
VITALETS TABLET CHEWABLE VITALETS
VITAMIN B COMPLEX TABLET VITAMIN B COMPLEX
VITAMIN B COMPLEX-VIT C CAP VITAMIN B-COMPLEX WITH VITC
VITRUM SENIOR TABLET VITRUM SENIOR
ZOO CHEWS GUMMIE TABLET ZOO CHEWS
ZOO FRIENDS COMPLETE TAB CHEW ZOO FRIENDS COMPLETE
ZOO FRIENDS ORIGINAL TAB CHEW ZOO FRIENDS ORIGINAL
ZOO FRIENDS TABLET CHEWABLE ZOO FRIENDS
Vitamins
Medication Info Common Name Drug Status Criteria
B-1 100 MG TABLET B-1
BABY DDROPS 400 UNIT/DROP BABY DDROPS
BABY VITAMIN D3 400 UNIT/DROP BABY VITAMIN D3
BIO-D-MULSION 400 UNIT/DROP BIO-D-MULSION
CVS B-1 100 MG TABLET B-1
CVS FOLIC ACID 800 MCG TABLET FOLIC ACID
CVS VITAMIN A 8,000 UNIT SFTGL VITAMIN A
CVS VITAMIN B-6 100 MG TABLET VITAMIN B-6
CVS VITAMIN D3 400 UNIT/DROP VITAMIN D3
CVS VITAMIN E 1,000 UNITS CAP VITAMIN E
CVS VITAMIN E 400 UNIT CAPSULE VITAMIN E
CVS VITAMIN E 400 UNIT SOFTGEL VITAMIN E
D-VI-SOL 400 UNITS/ML DROP D-VI-SOL
D-VITA 400 UNIT/ML DROP D-VITA
EQL VITAMIN B-6 100 MG TABLET VITAMIN B-6
EQL VITAMIN E 1,000 UNIT SFTGL VITAMIN E
EQL VITAMIN E 400 UNIT SOFTGEL VITAMIN E
FNP VITAMIN E 400 UNIT TABLET VITAMIN E
FOLIC ACID 0.4 MG TABLET FOLIC ACID
FOLIC ACID 0.8 MG TABLET FOLIC ACID
FOLIC ACID 400 MCG TABLET FOLIC ACID
FOLIC ACID 800 MCG TABLET FOLIC ACID
GNP FOLIC ACID 400 MCG TABLET FOLIC ACID
GNP NIACIN 250 MG TABLET NIACIN
GNP VITAMIN A 10,000 UNIT SFGL VITAMIN A
GNP VITAMIN B-1 100 MG TABLET VITAMIN B-1
GNP VITAMIN B-6 100 MG TABLET VITAMIN B-6
GNP VITAMIN E 200 UNIT SOFTGEL VITAMIN E
GNP VITAMIN E 400 UNIT SOFTGEL VITAMIN E
HM FOLIC ACID 400 MCG TABLET FOLIC ACID
HM NIACIN TR 250 MG TABLET NIACIN
HM VITAMIN B-1 100 MG TABLET VITAMIN B-1
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Vitamins
Medication Info Common Name Drug Status Criteria
HM VITAMIN B-6 100 MG TABLET VITAMIN B-6
HM VITAMIN E 400 UNIT SOFTGEL VITAMIN E
JUST D 400 UNITS/ML DROP JUST D
NIACIN 100 MG TABLET NIACIN
NIACIN 125 MG CAPSULE SA NIACIN
NIACIN 250 MG TABLET NIACIN
NIACIN 250 MG TABLET SA NIACIN
NIACIN 50 MG TABLET NIACIN
NIACIN 500 MG CAPSULE SA NIACIN
NIACIN 500 MG TABLET NIACIN
NIACIN 750 MG TABLET SA NIACIN
NIACIN ER 1,000 MG CAPLET NIACIN
NIACIN ER 1,000 MG TABLET NIACIN
NIACIN ER 250 MG CAPSULE NIACIN
NIACIN ER 250 MG TABLET NIACIN
NIACIN ER 500 MG CAPLET NIACIN
NIACIN ER 500 MG TABLET NIACIN
NIACIN SA 250 MG CAPSULE NIACIN
NIACIN TR 250 MG CAPSULE NIACIN
NIACIN TR 500 MG CAPLET NIACIN
NIACIN TR 500 MG CAPSULE NIACIN
NIACIN TR 500 MG TABLET NIACIN
PLAIN NIACIN 250 MG TABLET PLAIN NIACIN
PLAIN NIACIN 500 MG TABLET PLAIN NIACIN
PYRIDOXINE 100 MG TABLET PYRIDOXINE HCL
RA FOLIC ACID 0.4 MG TABLET FOLIC ACID
RA FOLIC ACID 800 MCG TABLET FOLIC ACID
RA NIACIN 100 MG TABLET NIACIN
RA NIACIN 500 MG TABLET NIACIN
RA VITAMIN A 10,000 UNIT SFTGL VITAMIN A
RA VITAMIN B-1 100 MG TABLET VITAMIN B-1
RA VITAMIN B-6 100 MG TABLET VITAMIN B-6
RA VITAMIN E 400 UNIT SOFTGEL VITAMIN E
SM FOLIC ACID 0.4 MG TABLET FOLIC ACID
SM FOLIC ACID 400 MCG TABLET FOLIC ACID
SM NIACIN TR 250 MG TABLET NIACIN
SM VITAMIN B-1 100 MG TABLET VITAMIN B-1
SM VITAMIN B-6 100 MG TABLET VITAMIN B-6
SM VITAMIN E 1,000 UNIT SFTGEL VITAMIN E
SM VITAMIN E 200 UNIT SOFTGEL VITAMIN E
SM VITAMIN E 400 UNIT CAPSULE VITAMIN E
SM VITAMIN E 400 UNIT SOFTGEL VITAMIN E
SV FOLIC ACID 800 MCG TABLET FOLIC ACID
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Vitamins
Medication Info Common Name Drug Status Criteria
SV VITAMIN B-6 100 MG TABLET VITAMIN B-6
SV VITAMIN E 1,000 UNIT SFTGEL VITAMIN E
SV VITAMIN E 200 UNIT SOFTGEL VITAMIN E
SV VITAMIN E 400 UNIT SOFTGEL VITAMIN E
THIAMINE 100 MG TABLET THIAMINE HCL
V-R VITAMIN B-6 100 MG TABLET VITAMIN B-6
V-R VITAMIN E 1,000 UNITS SFTG VITAMIN E
V-R VITAMIN E 400 UNIT CAPSULE VITAMIN E
V-R VITAMIN E 400 UNIT SOFTGEL VITAMIN E
VITAMIN A 10,000 UNIT CAPSULE VITAMIN A
VITAMIN A 10,000 UNIT SOFTGEL VITAMIN A
VITAMIN A 10,000 UNITS SOFTGEL VITAMIN A
VITAMIN A 25,000 UNITS CAPSULE VITAMIN A
VITAMIN A 8,000 UNIT CAPSULE VITAMIN A
VITAMIN A 8,000 UNITS SOFTGEL VITAMIN A
VITAMIN A PALM 15,000 UNIT TAB VITAMIN A PALMITATE
VITAMIN B-1 100 MG TABLET VITAMIN B-1
VITAMIN B-6 100 MG TABLET VITAMIN B-6
VITAMIN D2 400 UNIT TABLET VITAMIN D2
VITAMIN D3 400 UNIT/ML DROP VITAMIN D3
VITAMIN E 1,000 UNIT SOFTGEL VITAMIN E
VITAMIN E 1,000 UNITS CAPSULE VITAMIN E
VITAMIN E 1,000 UNITS SOFTGEL VITAMIN E
VITAMIN E 100 UNIT CAPSULE VITAMIN E
VITAMIN E 200 UNIT CAPSULE VITAMIN E
VITAMIN E 200 UNIT SOFTGEL VITAMIN E
VITAMIN E 200 UNITS CAPSULE VITAMIN E
VITAMIN E 400 UNIT CAPSULE VITAMIN E
VITAMIN E 400 UNIT MIXED SFTGL VITAMIN E
VITAMIN E 400 UNIT SOFTGEL VITAMIN E
VITAMIN E 50 UNIT/ML DROPS VITAMIN E
VITAMIN E 600 UNIT CAPSULE VITAMIN E