Upload
others
View
11
Download
0
Embed Size (px)
Citation preview
2014 Comprehensive Dual Preferred Drug List (List of Covered Drugs)
WellCare of New Jersey
00 9
Please read: This document contains information about the drugs we cover in this plan. Last updated (01/01/2014)
TESSALON 200 MG CAPSULE BENZONATATE 100 MG CAPSULE BENZONATATE 200 MG CAPSULE
DELSYM 30 MG/5 ML EXTENDED-RELEASE SUSPENSION
ROBITUSSIN PEDIATRIC COUGH SYP
DELSYM COUGH RELIEF PLUS LOZENGE
ALLANHIST PDX DROPS BROMHIST PDX DROPS BROTAPP DM LIQUID Q-TAPP DM ELIXIRBROMFED DM SYRUP ENDACOF-PD DROPS
COLD/COUGH CHILDRENS ELIXIRRYNEX DM DIMAPHEN DM ELIXIR
C-PHEN DM RONDEX-DM SYRUP DE-CHLOR DM LIQUID NOHIST-DM
PD-COF SYRUP SILDEC PE-DM SYRUP CORFEN DM TRI-DEX PE
PEDIATRIC COUGH-COLD LIQUID MESEHIST DMKIDKARE COUGH/COLD
VANACOF LIQUID
DIMETAPP LONG-ACTING COUGH LIQ ROBITUSSIN LONG ACTING LIQUID
PROMETHAZINE-DM SYRUP
DELSYM NIGHTTIME MULTI-SYMPTOM
DONATUSSIN DROPS PE-GUAI DROPS DESPEC LIQUID RESCON-GG LIQUID
Chlorpheniramine/Dextromethorphan HBr
Promethazine HCl/Dextromethorphan HBr
Guaifenesin/Phenylephrine HCl
EXPECTORANTS
NON-NARC ANTITUSS-1ST GEN. ANTIHIST-ANALGESIC COMBINATIONDextromethorphan HBr/Acetaminophen/Doxylamine
DECONGESTANT-EXPECTORANT COMBINATIONS
Dexchlorpheniramine/Pseudoephedrine HCl/Chlophedianol HCl
NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGESTBrompheniramine/Dextromethorphan HBr/Pseudoephedrine HCl
Brophenaramine/Dextromethorphan HBr/Phenylephrine HCl
Chlorpheniramine/Dextromethorphan HBr/Phenylephrine HCl
Chlorpheniramine/Dextromethorphan HBr/Pseudoephedrine HCl
WellCare of New Jersey Dual Eligible Medicaid Cough & Cold Drug List
Preferred Drugs
Benzonatate
Non-Preferred DrugsANTITUSSIVES,NON-NARCOTIC
Dextromethorphan HBr/Menthol
Dextromethorphan Polistirex
Dextromethorphan HBr
Last updated 01/01/14 Page 1 of 2
WellCare of New Jersey Dual Eligible Medicaid Cough & Cold Drug List
Preferred DrugsNon-Preferred Drugs
ROBAFEN CF SYRUP
DURATUSS DM ELIXIR SU-TUSS DM ELIXIR MUCUS RELIEF COUGH LIQUID DIABETIC TUSSIN DM LIQUIDSIMUC-DM ELIXIR GUAIFENESIN DM SYRUP Q-TUSSIN-DM SYRUP
EXTRA ACTION COUGH SILTUSSIN DM COUGH SYRUPREFENESEN DM SILTUSSIN DM DAS COUGH SYRUPMUCOSA DM
TUSSIONEX PENNKINETIC SUSP TUSSICAPS (min. age 6 years old) HYDROCODONE-CHLORPHENIRAMINE SUSPENSION (min. age 6 years old)
CYTUSS-HC NR SYRUP HC/PE/DBROM SYRUP PROMETH VC W/COD SYRUP PROMETHAZINE VC/COD SYRUPHC 2.5-PE 5-DBROM 1 MG SYRUP
PHENYLHISTINE DH
HYDROMET SYRUP HYDROCODONE-HOMATROPINE
HYDROCODONE-GUAIFENESIN SYRUP CHERATUSSIN AC SYRUPNARCOF SYRUP TUSSICLEAR DH SYRUP GUAIFENESIN-CODEINE SYRUP IOPHEN C-NR
CHERATUSSIN DAC SYRUP
NARCOTIC ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMBINATIONSCodeine Phosphate/Guaifenesin/Pseudoephedrine HCl
Dexbrompheniramine/Hydrocodone Bit/Phenylephrine HCl Codeine/Phenylephrine HCl/Promethazine
Pseudoephedrine HCl/Codeine/Chlorpheniramine
NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATIONHydrocodone Bit/Homatropine
Guaifenesin/Hydrocodone Bit Codeine Phosphate/Guaifenesin
Guaifenesin/Dextromethorphan HBr/Phenylephreine
NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB.Dextromethorphan HBr/Guaifenesin
ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID
NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE
Codeine Phosphate/Promethazine HCl
Chlorpheniramine/Hydrocodone Polistirex
NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT
NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION
NON-NARCOTIC DECONGESTANT-EXPECTORANT-ANTITUSSIVE
PROMETHAZINE-CODEINE SYRUP (min. age 6 years old)
Last updated 01/01/14 Page 2 of 2
UPPERCASE = Brand name drugs italics = Generic drugs
Preference DetailsP = PreferredDagger (†) = N/AAsterisk (*) = N/AAsterisk (**) = N/AAsterisk (***) = N/AXX = N/A
Coverage DetailsPA = Prior AuthorizationST = Step TherapyQL = Quantity LimitAL = Age LimitOTC = OTC- Covered w/Rx
Drug Name Preference Details Coverage Details
*Analgesics - Anti-Inflammatory*
*Nonsteroidal Anti-Inflammatory Agents (Nsaids)**
*Nonsteroidal Anti-Inflammatory Agents (Nsaids)***
Childrens Ibuprofen ORAL SUSPENSION 40 MG/ML
P OTC
Ibuprofen ORAL SUSPENSION 100 MG/5ML
P OTC
Ibuprofen ORAL TABLET 200 MG P OTC
*Analgesics - Nonnarcotic*
*Analgesics Other**
*Analgesics Other***
Acetaminophen ORAL SOLUTION 160 MG/5ML
P OTC
Acetaminophen ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s))
Acetaminophen ORAL TABLET 500 MG P OTC; QL (186 EA per 31 day(s))
Acetaminophen ORAL TABLET CHEWABLE80 MG
P OTC
APAP ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s))
APAP Drops ORAL SOLUTION 100 MG/ML P OTC
1
Drug Name Preference Details Coverage Details
APAP Extra Strength ORAL TABLET 500 MG
P OTC; QL (186 EA per 31 day(s))
Childrens Non-ASA Pain Relief ORAL TABLET CHEWABLE 80 MG
P OTC
Childrens Non-Aspirin ORAL TABLET CHEWABLE 80 MG
P OTC
Childrens Non-Aspirin Pain ORAL TABLET CHEWABLE 80 MG
P OTC
Childrens Pain Reliever ORAL TABLET CHEWABLE 80 MG
P OTC
Childrens Silapap ORAL LIQUID† 160 MG/5ML
P OTC
Childrens Tactinal ORAL TABLET CHEWABLE 80 MG
P OTC
Ed-APAP ORAL LIQUID† 160 MG/5ML P OTC
Mapap ORAL CAPSULE 500 MG P OTC; QL (186 EA per 31 day(s))
Mapap ORAL LIQUID† 160 MG/5ML P OTC
Mapap ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s))
Mapap ORAL TABLET 500 MG P OTC; QL (186 EA per 31 day(s))
Mapap ORAL TABLET CHEWABLE 80 MG P OTC
Mapap Arthritis Pain ORAL TABLET EXTENDEDRELEASE* 650 MG
P OTC; QL (93 EA per 31 day(s))
MAPAP CHILDRENS ORAL SUSPENSION 160 MG/5ML
P OTC
Maxapap Maximum Strength ORAL TABLET500 MG
P OTC; QL (186 EA per 31 day(s))
Maxapap Regular Strength ORAL TABLET325 MG
P OTC; QL (279 EA per 31 day(s))
Non-Aspirin ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s))
Non-Aspirin Extra Strength ORAL TABLET500 MG
P OTC; QL (186 EA per 31 day(s))
Non-Aspirin Pain Relief ORAL TABLET 325 MG
P OTC; QL (279 EA per 31 day(s))
Nortemp Infants ORAL SUSPENSION 80 MG/0.8ML
P OTC
Pain & Fever Childrens ORAL SOLUTION160 MG/5ML
P OTC
Pain Relief ORAL TABLET 500 MG P OTC; QL (186 EA per 31 day(s))
2
Drug Name Preference Details Coverage Details
Pain Relief Extra Strength ORAL TABLET500 MG
P OTC; QL (186 EA per 31 day(s))
PHARBETOL ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s))
PHARBETOL EXTRA STRENGTH ORAL TABLET 500 MG
P OTC; QL (186 EA per 31 day(s))
Q-PAP ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s))
Tactinal ORAL TABLET 325 MG P OTC; QL (279 EA per 31 day(s))
Tactinal Extra Strength ORAL TABLET 500 MG
P OTC; QL (186 EA per 31 day(s))
*Salicylates**
*Salicylate Combinations***
Tri-Buffered Aspirin ORAL TABLET 325 MG P OTC
*Salicylates***
Aspirin ORAL TABLET 325 MG, 81 MG P OTC
Aspirin ORAL TABLET CHEWABLE 81 MG P OTC
Aspirin ORAL TABLET DELAYED RELEASE 81 MG
P OTC
Aspirin RE SUPPOSITORY 300 MG, 600 MG P OTC
Aspirin Childrens ORAL TABLET CHEWABLE 81 MG
P OTC
Aspirin EC ORAL TABLET DELAYED RELEASE 325 MG, 81 MG
P OTC
Aspirin EC Low Dose ORAL TABLET DELAYED RELEASE 81 MG
P OTC
Aspirin Low Dose ORAL TABLET 81 MG P OTC
ECPIRIN ORAL TABLET DELAYED RELEASE 325 MG
P OTC
*Antacids*
*Antacid Combinations**
*Antacid & Simethicone***
Alamag Plus ORAL TABLET CHEWABLE200-200-25 MG
P OTC
ALMACONE ORAL SUSPENSION 200-200-20 MG/5ML
P OTC
Antacid ORAL SUSPENSION 200-200-20 MG/5ML
P OTC
Antacid Anti-Gas ORAL SUSPENSION200-200-20 MG/5ML
P OTC
3
Drug Name Preference Details Coverage Details
Antacid Anti-Gas Max Strength ORAL SUSPENSION 400-400-40 MG/5ML
P OTC
Antacid Extra Strength ORAL SUSPENSION400-400-40 MG/5ML
P OTC
Antacid I ORAL SUSPENSION 200-200-20 MG/5ML
P OTC
Antacid III ORAL SUSPENSION 400-400-40 MG/5ML
P OTC
Geri-Lanta ORAL SUSPENSION 200-200-20 MG/5ML
P OTC
MAALOX ADVANCED ORAL SUSPENSION 200-200-20 MG/5ML
P OTC
MAALOX ADVANCED MAX ST ORAL SUSPENSION 400-400-40 MG/5ML
P OTC
MAALOX MAX ORAL SUSPENSION 400-400-40 MG/5ML
P OTC
MAALOX MULTI SYMPTOM MAX ST ORAL SUSPENSION 400-400-40 MG/5ML
P OTC
MAALOX REGULAR STRENGTH ORAL SUSPENSION 200-200-20 MG/5ML
P OTC
Milantex ORAL SUSPENSION 200-200-20 MG/5ML
P OTC
Milantex Extra Strength ORAL SUSPENSION 400-400-40 MG/5ML
P OTC
MINTOX PLUS ORAL TABLET CHEWABLE 200-200-25 MG
P OTC
*Antacid Combinations***
ACID GONE ORAL TABLET CHEWABLE 160-105 MG, 80-20 MG
P OTC
MI-ACID ORAL TABLET CHEWABLE 700-300 MG
P OTC
*Antacids - Aluminum Salts**
*Antacids - Aluminum Salts***
Aluminum Hydroxide Gel ORAL SUSPENSION 320 MG/5ML
P OTC
*Antacids - Bicarbonate**
*Antacids - Bicarbonate***
Sodium Bicarbonate ORAL TABLET 325 MG, 650 MG
P OTC
*Antacids - Calcium Salts**
4
Drug Name Preference Details Coverage Details
*Antacids - Calcium Salts***
Alcalak ORAL TABLET CHEWABLE 420 MG
P OTC
Antacid ORAL TABLET CHEWABLE 420 MG, 500 MG
P OTC
CAL-GEST ANTACID ORAL TABLET CHEWABLE 500 MG
P OTC
Calcium Antacid ORAL TABLET CHEWABLE 500 MG
P OTC
Calcium Antacid Extra Strength ORAL TABLET CHEWABLE 750 MG
P OTC
Calcium Carbonate Antacid ORAL TABLET648 MG
P OTC
Calcium Carbonate Antacid ORAL TABLET CHEWABLE 500 MG
P OTC
MAALOX ORAL TABLET CHEWABLE 600 MG
P OTC
TITRALAC ORAL TABLET CHEWABLE 420 MG
P OTC
*Antacids - Magnesium Salts**
*Antacids - Magnesium Salts***
Magnesium Oxide ORAL TABLET 250 MG, 400 MG, 420 MG
P OTC
*Anthelmintics*
*Anthelmintics**
*Anthelmintics***
Reeses Pinworm Medicine ORAL SUSPENSION 144 MG/ML
P OTC
*Antidiabetics*
*Diabetic Other**
*Diabetic Other***
BD GLUCOSE ORAL TABLET CHEWABLE 5 GM
P OTC
Glucose ORAL TABLET CHEWABLE 4 GM P OTC
Ultilet Glucose ORAL TABLET CHEWABLE4 GM
P OTC
*Antidiarrheals*
*Antidiarrheal Agents - Misc.**
*Antidiarrheal Agents - Misc.***
5
Drug Name Preference Details Coverage Details
Bismatrol ORAL SUSPENSION 262 MG/15ML
P OTC
Bismatrol ORAL TABLET CHEWABLE 262 MG
P OTC
Bismuth ORAL TABLET CHEWABLE 262 MG
P OTC
Diotame ORAL TABLET CHEWABLE 262 MG
P OTC
Kao-Tin ORAL SUSPENSION 262 MG/15ML P OTC
KAOPECTATE ORAL SUSPENSION 262 MG/15ML
P OTC
KAOPECTATE EXTRA STRENGTH ORAL SUSPENSION 525 MG/15ML
P OTC
Pink Bismuth ORAL SUSPENSION 262 MG/15ML
P OTC
Pink Bismuth ORAL TABLET CHEWABLE262 MG
P OTC
Stomach Relief ORAL SUSPENSION 262 MG/15ML, 527 MG/30ML
P OTC
Stomach Relief ORAL TABLET CHEWABLE262 MG
P OTC
Stomach Relief Plus ORAL SUSPENSION525 MG/15ML
P OTC
*Antiperistaltic Agents**
*Antiperistaltic Agents***
Anti-Diarrheal ORAL LIQUID† 1 MG/5ML P OTC
LOPERAMIDE A-D ORAL TABLET 2 MG P OTC
Loperamide HCl ORAL LIQUID† 1 MG/5ML P OTC
*Antidotes*
*Antidotes**
*Antidotes***
Ipecac ORAL SYRUP P OTC
*Antiemetics*
*Antiemetics - Anticholinergic**
*Antiemetics - Anticholinergic***
Meclizine HCl ORAL TABLET 12.5 MG, 25 MG
P OTC
Travel Sickness ORAL TABLET CHEWABLE25 MG
P OTC
6
Drug Name Preference Details Coverage Details
*Antihistamines*
*Antihistamines - Alkylamines**
*Antihistamines - Alkylamines***
Aller-Chlor ORAL SYRUP 2 MG/5ML P OTC
Aller-Chlor ORAL TABLET 4 MG P OTC
Allergy ORAL TABLET 4 MG P OTC
Allergy Relief ORAL TABLET 4 MG P OTC
ChlorHist ORAL TABLET 4 MG P OTC
Chlorphen ORAL TABLET 4 MG P OTC
DIABETIC TUSSIN ALLERGY ORAL SYRUP 2 MG/5ML
P OTC
*Antihistamines - Ethanolamines**
*Antihistamines - Ethanolamines***
Aler-Cap ORAL CAPSULE 25 MG P OTC
Aler-Dryl ORAL TABLET 50 MG P OTC
AlerTab ORAL TABLET 25 MG P OTC
Allergy Relief Childrens ORAL LIQUID† 12.5 MG/5ML
P OTC
Altaryl ORAL ELIXIR 12.5 MG/5ML P OTC
Altaryl ORAL SYRUP 12.5 MG/5ML P OTC
Anti-Hist ORAL CAPSULE 25 MG P OTC
Anti-Hist Allergy ORAL TABLET 25 MG P OTC
BANOPHEN ORAL CAPSULE 25 MG P OTC
BANOPHEN ORAL LIQUID† 12.5 MG/5ML
P OTC
BANOPHEN ORAL TABLET 25 MG P OTC
BENADRYL ALLERGY CHILDRENS ORAL LIQUID† 12.5 MG/5ML
P OTC
Complete Allergy Medication ORAL TABLET25 MG
P OTC
Complete Allergy Relief ORAL TABLET 25 MG
P OTC
Diphenhist ORAL CAPSULE 25 MG P OTC
Diphenhist ORAL LIQUID† 12.5 MG/5ML P OTC
Diphenhist ORAL TABLET 25 MG P OTC
DiphenhydrAMINE HCl ORAL CAPSULE 25 MG, 50 MG
P OTC
7
Drug Name Preference Details Coverage Details
DiphenhydrAMINE HCl ORAL TABLET 25 MG
P OTC
DORMIN ORAL CAPSULE 25 MG P OTC
Genahist ORAL CAPSULE 25 MG P OTC
Pharbedryl ORAL CAPSULE 25 MG, 50 MG P OTC
Q-Dryl ORAL CAPSULE 25 MG P OTC
Q-Dryl ORAL LIQUID† 12.5 MG/5ML P OTC
Quenalin ORAL SYRUP 12.5 MG/5ML P OTC
SCOT-TUSSIN ALLERGY RELIEF ORAL LIQUID† 12.5 MG/5ML
P OTC
Siladryl Allergy ORAL LIQUID† 12.5 MG/5ML
P OTC
Silphen Cough ORAL SYRUP 12.5 MG/5ML P OTC
SIMPLY ALLERGY ORAL TABLET 25 MG
P OTC
Total Allergy ORAL TABLET 25 MG P OTC
TOTAL ALLERGY MEDICINE ORAL LIQUID† 12.5 MG/5ML
P OTC
*Antihistamines - Non-Sedating**
*Antihistamines - Non-Sedating***
ALLEGRA ALLERGY CHILDRENS ORAL TABLET 30 MG
P OTC
Allergy ORAL TABLET DISPERSIBLE 10 MG
P OTC
Cetirizine HCl ORAL SYRUP 5 MG/5ML P OTC; QL (300 ML per 31 day(s))
Cetirizine HCl ORAL TABLET 10 MG, 5 MG P OTC
Cetirizine HCl Childrens ORAL SOLUTION 1 MG/ML
P OTC; QL (300 ML per 31 day(s))
Cetirizine HCl Childrens Alrgy ORAL SYRUP1 MG/ML
P OTC; QL (300 ML per 31 day(s))
Childrens Loratadine ORAL SYRUP 5 MG/5ML
P OTC; QL (300 ML per 31 day(s))
Fexofenadine HCl ORAL TABLET 180 MG, 60 MG
P OTC
Loratadine ORAL TABLET 10 MG P OTC
Loratadine Hives Relief ORAL SOLUTION 5 MG/5ML
P OTC; QL (300 ML per 31 day(s))
*Antiseptics & Disinfectants*
8
Drug Name Preference Details Coverage Details
*Chlorine Antiseptics**
*Chlorine Antiseptics***
Chlorhexidine Gluconate EXTERNAL LIQUID† 4 %
P OTC; QL (480 ML per 31 day(s))
*Iodine Antiseptics**
*Iodine Antiseptics***
OPERAND POVIDONE-IODINE EXTERNAL SOLUTION 10 %
P OTC
Povidone-Iodine EXTERNAL SOLUTION 10 %
P OTC
*Cough/Cold/Allergy*
*Cough/Cold/Allergy Combinations**
*Decongestant & Antihistamine***
ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG
P OTC
ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HR* 60-120 MG
P OTC
Allergy Relief/Nasal Decongest ORAL TABLET EXTENDED RELEASE 24 HR*10-240 MG
P OTC
Antihistamine Decongestant ORAL TABLET2.5-60 MG
P OTC
BROTAPP ORAL LIQUID† 1-15 MG/5ML P OTC
Cetirizine-Pseudoephedrine ER ORAL TABLET EXTENDED RELEASE 12 HR*5-120 MG
P OTC
Fexofenadine-Pseudoephed ER ORAL TABLET EXTENDED RELEASE 24 HR*180-240 MG
P OTC
Q-TAPP ORAL ELIXIR 1-15 MG/5ML P OTC
*Expectorants**
*Expectorants***
Chest Congestion Relief ORAL TABLET 400 MG
P OTC
Mucus Relief ORAL TABLET 400 MG P OTC
Refenesen ORAL TABLET 200 MG P OTC
Refenesen 400 ORAL TABLET 400 MG P OTC
9
Drug Name Preference Details Coverage Details
Robafen ORAL SYRUP 100 MG/5ML P OTC
*Misc. Respiratory Inhalants**
*Misc. Respiratory Inhalants***
BRONCHO SALINE INHALATION AEROSOL, SOLUTION 0.9 %
P OTC
Sodium Chloride INHALATION NEBULIZATION SOLUTION 0.9 %
P OTC
*Dermatologicals*
*Acne Products**
*Acne Products***
Acne Medication 5 EXTERNAL LOTION 5 % P OTC
Benzoyl Peroxide EXTERNAL GEL 10 %, 5 % P OTC
*Antibiotics - Topical**
*Antibiotic Mixtures Topical***
Bacitracin-Neomycin-Polymyxin EXTERNAL OINTMENT 400-5-5000
P OTC
Double Antibiotic EXTERNAL OINTMENT500-10000 UNIT/GM
P OTC
Triple Antibiotic EXTERNAL OINTMENT3.5-400-5000 , 5-400-5000
P OTC
*Antibiotics - Topical***
Bacitracin EXTERNAL OINTMENT 500 UNIT/GM
P OTC
Bacitracin Zinc EXTERNAL OINTMENT 500 UNIT/GM
P OTC
*Antifungals - Topical**
*Antifungals - Topical***
Terbinafine HCl EXTERNAL CREAM 1 % P OTC
*Imidazole-Related Antifungals - Topical***
Baza Antifungal EXTERNAL CREAM 2 % P OTC
Clotrimazole EXTERNAL CREAM 1 % P OTC
Clotrimazole EXTERNAL SOLUTION 1 % P OTC
*Antihistamines-Topical**
*Antihistamines - Topical***
Allergy EXTERNAL CREAM 2 % P OTC
Anti-Itch Maximum Strength EXTERNAL CREAM 2 %
P OTC
10
Drug Name Preference Details Coverage Details
BENADRYL ITCH STOPPING EXTERNAL GEL 2 %
P OTC
Itch Relief EXTERNAL CREAM 2 % P OTC
*Corticosteroids - Topical**
*Corticosteroids - Topical***
Hydrocortisone EXTERNAL CREAM 0.5 %, 1 %
P OTC
Hydrocortisone EXTERNAL LOTION 1 % P OTC
Hydrocortisone EXTERNAL OINTMENT 0.5 %, 1 %
P OTC
Hydrocortisone Max St EXTERNAL CREAM1 %
P OTC
Hydrocortisone Max St/12 Moist EXTERNAL CREAM 1 %
P OTC
HYDROSKIN EXTERNAL CREAM 1 % P OTC
PREPARATION H HYDROCORTISONE EXTERNAL CREAM 1 %
P OTC
*Topical Steroid Combinations***
Hydrocortisone-Aloe EXTERNAL CREAM 1 %
P OTC
*Emollients**
*Emollients***
AMLACTIN EXTERNAL LOTION 12 % POTC; QL (400 GM per 31 day(s))
Ammonium Lactate EXTERNAL CREAM 12 %
POTC; QL (400 GM per 31 day(s))
Ammonium Lactate EXTERNAL LOTION 12 %
POTC; QL (400 GM per 31 day(s))
*Keratolytic/Antimitotic Agents**
*Keratolytic/Antimitotic Agents***
CLEAR AWAY 1-STEP WART REMOVER EXTERNAL PAD 40 %
P OTC
COMPOUND W EXTERNAL LIQUID† 17 %
P OTC
COMPOUND W MAXIMUM STRENGTH EXTERNAL GEL 17 %
P OTC
FREEZONE EXTERNAL LIQUID† 17.6 % P OTC
SALACTIC FILM EXTERNAL SOLUTION 17 %
P OTC
11
Drug Name Preference Details Coverage Details
*Local Anesthetics - Topical**
*Local Anesthetics - Topical***
Capsaicin EXTERNAL CREAM 0.025 % P OTC
*Scabicides & Pediculicides**
*Scabicides & Pediculicides***
Permethrin EXTERNAL LOTION 1 % P OTC; QL (60 ML per 31 day(s))
*Diagnostic Products*
*Diagnostic Tests**
*Diagnostic Tests***
Pregnancy Test IN VITRO DIAGNOSTIC TEST†
P OTC
*Gastrointestinal Agents - Misc.*
*Antiflatulents**
*Antiflatulents***
Mi-Acid Gas Relief ORAL TABLET CHEWABLE 80 MG
P OTC
Mytab Gas ORAL TABLET CHEWABLE 80 MG
P OTC
Simethicone ORAL SUSPENSION 40 MG/0.6ML
P OTC
Simethicone ORAL TABLET CHEWABLE 80 MG
P OTC
*Genitourinary Agents - Miscellaneous*
*Alkalinizers**
*Citrates***
Sodium Citrate ORAL GRANULES P
*Hematopoietic Agents*
*Cobalamins**
*Cobalamins***
Cyanocobalamin INJECTION SOLUTION1000 MCG/ML
P
Vitamin B-12 ORAL TABLET 1000 MCG, 500 MCG
P OTC
Vitamin B-12 SUBLINGUAL TABLET SUBLINGUAL 1000 MCG
P OTC
Vitamin B-12 ER ORAL TABLET EXTENDEDRELEASE* 1000 MCG
P OTC
*Folic Acid/Folates**
12
Drug Name Preference Details Coverage Details
*Folic Acid/Folates***
Folic Acid ORAL TABLET 1 MG, 400 MCG, 800 MCG
P OTC
*Iron**
*Iron***
Ferro-Bob ORAL TABLET 325 (65 Fe) MG P OTC
Ferrous Sulfate ORAL ELIXIR 220 (44 Fe) MG/5ML
P OTC
Ferrous Sulfate ORAL TABLET 325 (65 Fe) MG
P OTC
Ferrous Sulfate ORAL TABLET DELAYED RELEASE 324 (65 Fe) MG, 325 (65 Fe) MG
P OTC
FerrouSul ORAL TABLET 325 (65 Fe) MG P OTC
Iron ORAL TABLET 325 (65 Fe) MG, 90 (18 Fe) MG
P OTC
POLY-IRON 150 ORAL CAPSULE 150 MG P OTC
Slow Release Iron ORAL TABLET EXTENDEDRELEASE* 160 (50 Fe) MG
P OTC
*Hypnotics*
*Antihistamine Hypnotics**
*Antihistamine Hypnotic Combinations***
Acetaminophen PM ORAL TABLET 500-25 MG
P OTC; QL (62 EA per 31 Day(s))
Headache PM ORAL TABLET 25-500 MG P OTC; QL (62 EA per 31 day(s))
Mapap PM ORAL TABLET 500-25 MG P OTC; QL (62 EA per 31 day(s))
Pain Relief PM Extra Strength ORAL TABLET 500-25 MG
P OTC; QL (62 EA per 31 day(s))
Pain Reliever PM ORAL TABLET 500-25 MG P OTC; QL (62 EA per 31 day(s))
*Antihistamine Hypnotics***
Compoz ORAL CAPSULE 50 MG P OTC
Compoz ORAL TABLET 50 MG P OTC
NYTOL ORAL TABLET 25 MG P OTC
SIMPLY SLEEP ORAL TABLET 25 MG P OTC
Sleep Tabs ORAL TABLET 25 MG P OTC
Sleep-Tabs ORAL TABLET 25 MG P OTC
SOMINEX ORAL TABLET 25 MG P OTC
SOMINEX MAXIMUM STRENGTH ORAL TABLET 50 MG
P OTC
13
Drug Name Preference Details Coverage Details
Tetra-Formula Nighttime Sleep ORAL TABLET 50 MG
P OTC
*Laxatives*
*Bulk Laxatives**
*Bulk Laxatives***
Fiber ORAL TABLET 625 MG P OTC
Fiber Laxative ORAL TABLET 625 MG P OTC
Fiber Therapy ORAL POWDER 58.6 % P OTC
Fiber-Lax ORAL TABLET 625 MG P OTC
FIBERGEN ORAL TABLET 625 MG P OTC
KONSYL ORAL PACKET 100 % P OTC
KONSYL FIBER ORAL TABLET 625 MG P OTC
METAMUCIL ORAL CAPSULE 0.52 GM P OTC
METAMUCIL ORAL POWDER 30.9 % P OTC
METAMUCIL ORAL WAFER P OTC
METAMUCIL MULTIHEALTH FIBER ORAL POWDER 58.6 %
P OTC
METAMUCIL SMOOTH TEXTURE ORAL PACKET 28 %
P OTC
METAMUCIL SMOOTH TEXTURE ORAL POWDER 28.3 %, 58.6 %
P OTC
Natural Fiber Therapy ORAL POWDER 30.9 %, 48.57 %
P OTC
Natural Vegetable Fiber ORAL POWDER48.57 %
P OTC
REGULOID ORAL CAPSULE 0.52 GM P OTC
*Laxative Combinations**
*Laxatives & Dss***
DOC-Q-LAX ORAL TABLET 8.6-50 MG P OTC
PERI-COLACE ORAL TABLET 8.6-50 MG P OTC
Senna Plus ORAL TABLET 8.6-50 MG P OTC
Senna S ORAL TABLET 8.6-50 MG P OTC
Senna-Docusate Sodium ORAL TABLET8.6-50 MG
P OTC
Senna-S ORAL TABLET 8.6-50 MG P OTC
Senna-Time S ORAL TABLET 8.6-50 MG P OTC
SENNALAX-S ORAL TABLET 8.6-50 MG P OTC
14
Drug Name Preference Details Coverage Details
Sennosides-Docusate Sodium ORAL TABLET8.6-50 MG
P OTC
*Laxatives - Miscellaneous**
*Laxatives - Miscellaneous***
Sorbitol ORAL SOLUTION 70 % P OTC
*Saline Laxatives**
*Saline Laxative Mixtures***
Enema RE ENEMA 7-19 GM/118ML P OTC
Phosphate Laxative ORAL SOLUTION0.9-2.4 GM/5ML
P OTC
*Saline Laxatives***
Citrate of Magnesia ORAL SOLUTION 1.745 GM/30ML
P OTC
CITROMA ORAL SOLUTION 1.745 GM/30ML
P OTC
DULCOLAX MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML
P OTC
Magnesium Citrate ORAL SOLUTION 1.745 GM/30ML
P OTC
Milk of Magnesia ORAL SUSPENSION 400 MG/5ML, 7.75 %
P OTC
*Stimulant Laxatives**
*Stimulant Laxatives***
BISAC-EVAC ORAL TABLET DELAYED RELEASE 5 MG
P OTC
BISAC-EVAC RE SUPPOSITORY 10 MG P OTC
Biscolax RE SUPPOSITORY 10 MG P OTC
CARTERS LITTLE PILLS ORAL TABLET DELAYED RELEASE 5 MG
P OTC
Correct ORAL TABLET DELAYED RELEASE 5 MG
P OTC
CORRECTOL ORAL TABLET DELAYED RELEASE 5 MG
P OTC
Ducodyl ORAL TABLET DELAYED RELEASE 5 MG
P OTC
EX-LAX ORAL TABLET CHEWABLE 15 MG
P OTC
EX-LAX ULTRA ORAL TABLET DELAYED RELEASE 5 MG
P OTC
15
Drug Name Preference Details Coverage Details
FEENAMINT ORAL TABLET DELAYED RELEASE 5 MG
P OTC
FLEET LAXATIVE ORAL TABLET DELAYED RELEASE 5 MG
P OTC
Gentle Laxative ORAL TABLET DELAYED RELEASE 5 MG
P OTC
Laxative RE SUPPOSITORY 10 MG P OTC
Magic Bullets RE SUPPOSITORY 10 MG P OTC
Natural Senna Laxative ORAL TABLET64.8-324 MG
P OTC
Senexon ORAL LIQUID† 8.8 MG/5ML P OTC
Senexon ORAL TABLET 8.6 MG P OTC
Senna ORAL SYRUP 8.8 MG/5ML P OTC
Senna ORAL TABLET 15 MG, 8.6 MG P OTC
Senna Lax ORAL TABLET 8.6 MG P OTC
Senna Laxative ORAL TABLET 8.6 MG P OTC
Senna Maximum Strength ORAL TABLET 25 MG
P OTC
SENNA SMOOTH ORAL TABLET 15 MG P OTC
Senna-Lax ORAL TABLET 8.6 MG P OTC
Senna-Tabs ORAL TABLET 8.6 MG P OTC
Senna-Time ORAL TABLET 8.6 MG P OTC
SENNACON ORAL TABLET 8.6 MG P OTC
SENNO ORAL TABLET 8.6 MG P OTC
Stimulant Laxative ORAL TABLET DELAYED RELEASE 5 MG
P OTC
Womens Laxative ORAL TABLET DELAYED RELEASE 5 MG
P OTC
*Surfactant Laxatives**
*Surfactant Laxatives***
CORRECTOL EXTRA GENTLE ORAL CAPSULE 100 MG
P OTC
D.O.S. ORAL CAPSULE 250 MG P OTC
Diocto ORAL LIQUID† 50 MG/5ML P OTC
Diocto ORAL SYRUP 60 MG/15ML P OTC
DocQLace ORAL CAPSULE 100 MG P OTC
Docu Soft ORAL CAPSULE 100 MG P OTC
16
Drug Name Preference Details Coverage Details
Docusate Calcium ORAL CAPSULE 240 MG P OTC
Docusate Sodium ORAL CAPSULE 250 MG P OTC
Docusate Sodium ORAL TABLET 100 MG P OTC
DOCUSIL ORAL CAPSULE 100 MG P OTC
DOK ORAL CAPSULE 100 MG, 250 MG P OTC
DOK ORAL TABLET 100 MG P OTC
DSS ORAL CAPSULE 100 MG, 250 MG P OTC
DULCOLAX STOOL SOFTENER ORAL CAPSULE 100 MG
P OTC
Kao-Tin ORAL CAPSULE 240 MG P OTC
Laxa Basic ORAL CAPSULE 100 MG, 250 MG
P OTC
Silace ORAL LIQUID† 150 MG/15ML P OTC
Silace ORAL SYRUP 60 MG/15ML P OTC
SOF-LAX ORAL CAPSULE 100 MG P OTC
Stool Softener ORAL CAPSULE 100 MG, 250 MG
P OTC
Stool Softener Laxative DC ORAL CAPSULE240 MG
P OTC
Sur-Q-Lax ORAL CAPSULE 240 MG P OTC
SURFAK ORAL CAPSULE 240 MG P OTC
*Medical Devices*
*Contraceptives**
*Condoms - Male***
TROJAN RIBBED XX MISC P OTC
*Contraceptive Sponge***
TODAY SPONGE VAGINAL MISC P OTC
*Respiratory Therapy Supplies**
*Peak Flow Meters***
Peak Flow Meter XX DEVICE P OTC; QL (2 EA per 365 day(s))
*Respiratory Therapy Supplies***
ACE AEROSOL CLOUD ENHANCER XX MISC
P QL (2 EA per 365 day(s))
IN-CHECK DIAL FLOW TRAINER XX DEVICE
P QL (2 EA per 365 day(s))
Inhaler Companions XX MISC P OTC; QL (2 EA per 365 day(s))
PFLEX XX MISC P QL (2 EA per 365 day(s))
17
Drug Name Preference Details Coverage Details
THRESHOLD IMT XX MISC P QL (2 EA per 365 day(s))
THRESHOLD PEP XX DEVICE P QL (2 EA per 365 day(s))
WINDMILL TRAINER XX MISC P QL (2 EA per 365 day(s))
*Spacer/Aerosol-Holding Chambers & Supplies***
AEROCHAMBER MV XX MISC P QL (2 EA per 365 day(s))
AEROCHAMBER PLUS FLO-VU XX MISC
P QL (2 EA per 365 day(s))
AEROCHAMBER PLUS FLO-VU LARGE XX MISC
P QL (2 EA per 365 day(s))
AEROCHAMBER PLUS FLO-VU SMALL XX MISC
P QL (2 EA per 365 day(s))
AEROCHAMBER PLUS FLO-VU W/MASK XX MISC
P QL (2 EA per 365 day(s))
AEROCHAMBER W/FLOWSIGNAL XX MISC
P QL (2 EA per 365 day(s))
AEROCHAMBER Z-STAT PLUS XX MISC P QL (2 EA per 365 day(s))
AEROCHAMBER Z-STAT PLUS CHAMBR XX MISC
P QL (2 EA per 365 day(s))
EASIVENT XX MISC P QL (2 EA per 365 day(s))
MICROCHAMBER XX MISC P QL (2 EA per 365 day(s))
MICROSPACER XX MISC P QL (2 EA per 365 day(s))
OPTICHAMBER ADVANTAGE XX MISC P QL (2 EA per 365 day(s))
OPTICHAMBER FACE MASK-LARGE XX MISC
P OTC; QL (2 EA per 365 day(s))
OPTICHAMBER FACE MASK-MEDIUM XX MISC
P OTC; QL (2 EA per 365 day(s))
OPTICHAMBER FACE MASK-SMALL XX MISC
P OTC; QL (2 EA per 365 day(s))
OPTIHALER XX DEVICE P QL (2 EA per 365 day(s))
OPTIHALER XX MISC P QL (2 EA per 365 day(s))
POCKET CHAMBER XX DEVICE P QL (2 EA per 365 day(s))
POCKET SPACER XX DEVICE P QL (2 EA per 365 day(s))
WATCHHALER XX DEVICE P QL (2 EA per 365 day(s))
*Minerals & Electrolytes*
*Calcium**
*Calcium Combinations***
Calcium ORAL TABLET 500-125 MG-UNIT P OTC
18
Drug Name Preference Details Coverage Details
Calcium + D3 ORAL TABLET 600-200 MG-UNIT
P OTC
Calcium 600-D ORAL TABLET 600-400 MG-UNIT
P OTC
Calcium Carbonate-Vitamin D ORAL TABLET 500-400 MG-UNIT, 600-400 MG-UNIT
P OTC
Calcium High Potency/Vitamin D ORAL TABLET 600-200 MG-UNIT
P OTC
Calcium-Carb 600 + D ORAL TABLET600-125 MG-UNIT
P OTC
Calcium-Vitamin D ORAL TABLET 500-125 MG-UNIT, 600-125 MG-UNIT, 600-200 MG-UNIT
P OTC
CALTRATE 600+D ORAL TABLET 600-800 MG-UNIT
P OTC
Liquid Calcium/Vitamin D ORAL CAPSULE600-200 MG-UNIT
P OTC
OS-CAL 500 + D ORAL TABLET 500-200 MG-UNIT
P OTC
OYSCO 500+D ORAL TABLET 500-200 MG-UNIT
P OTC
OYSCO D ORAL TABLET 250-125 MG-UNIT
P OTC
Oyst-Cal D ORAL TABLET 250-125 MG-UNIT
P OTC
Oyster Calcium + D ORAL TABLET 250-125 MG-UNIT
P OTC
Oyster Shell Calcium + D ORAL TABLET500-400 MG-UNIT
P OTC
Oyster Shell Calcium 500 + D ORAL TABLET500-125 MG-UNIT
P OTC
Oyster Shell Calcium/D ORAL TABLET250-125 MG-UNIT, 500-200 MG-UNIT
P OTC
Oyster Shell Calcium/Vitamin D ORAL TABLET 500-200 MG-UNIT
P OTC
Oyster Shell/Vitamin D ORAL TABLET600-125 MG-UNIT
P OTC
*Calcium***
CAL-CARB FORTE ORAL TABLET 1250 MG
P OTC
19
Drug Name Preference Details Coverage Details
Cal-Lac ORAL CAPSULE 500 MG P OTC
Calcarb 600 ORAL TABLET 1500 MG P OTC
CALCI-CHEW ORAL TABLET CHEWABLE 1250 MG
P OTC
Calcium 600 ORAL TABLET 600 MG P OTC
Calcium Carbonate ORAL SUSPENSION1250 MG/5ML
P OTC
Calcium Carbonate ORAL TABLET 1250 MG, 1500 MG, 600 MG
P OTC
Calcium High Potency ORAL TABLET 600 MG
P OTC
Calcium Lactate ORAL TABLET 648 MG P OTC
Calcium Oyster Shell ORAL TABLET 1250 MG
P OTC
Calcium-Carb 600 ORAL TABLET 600 MG P OTC
CALTRATE 600 ORAL TABLET 1500 MG P OTC
OS-CAL ORAL TABLET CHEWABLE 1250 MG
P OTC
OYSCO 500 ORAL TABLET 500 MG P OTC
OYSTERCAL ORAL TABLET 500 MG P OTC
*Electrolyte Mixtures**
*Electrolytes Oral***
ORALYTE ORAL SOLUTION POTC; QL (4000 ML per 31 day(s))
ORALYTE FREEZER POPS ORAL SOLUTION
POTC; QL (4000 ML per 31 day(s))
*Magnesium**
*Magnesium***
Mag-Delay ORAL TABLET EXTENDEDRELEASE* 535 (64 Mg) MG
P OTC
Mag-SR ORAL TABLET EXTENDEDRELEASE* 535 (64 Mg) MG
P OTC
MAG-TAB SR ORAL TABLET EXTENDEDRELEASE* 84 MG (7MEQ)
P OTC
MAG64 ORAL TABLET EXTENDEDRELEASE* 535 (64 MG) MG
P OTC
Magnacaps ORAL CAPSULE 100 MG P OTC
Magnesium ORAL TABLET 250 MG P OTC
20
Drug Name Preference Details Coverage Details
Magnesium Oxide ORAL TABLET 400 (240 Mg) MG
P OTC
MAGNESIUM-OXIDE ORAL TABLET 400 (241.3 MG) MG
P OTC
*Zinc**
*Zinc***
ORAZINC ORAL CAPSULE 220 MG P OTC
Zinc Sulfate ORAL CAPSULE 220 MG P OTC
Zinc Sulfate ORAL TABLET 220 (50 Zn) MG P OTC
Zinc-220 ORAL CAPSULE 220 MG P OTC
*Multivitamins*
*B-Complex W/ C**
*B-Complex W/ C***
Vitamin B Complex-C ORAL CAPSULE P OTC
*B-Complex W/ Folic Acid**
*B-Complex W/ C & Folic Acid***
NEPHRONEX ORAL TABLET P
Rena-Vite Rx ORAL TABLET 1 MG P
RENAL ORAL CAPSULE 1 MG P
Reno Caps ORAL CAPSULE 1 MG P
*Multiple Vitamins W/ Minerals**
*Multiple Vitamins W/ Minerals***
Centamin ORAL LIQUID† P OTC
CentaVite ORAL LIQUID† P OTC
Centavite A-Z Complete-Mineral ORAL TABLET
P OTC
CEROVITE ADVANCED FORMULA ORAL TABLET
P OTC
CERTAVITE/ANTIOXIDANTS ORAL LIQUID†
P OTC
Formula Twenty-One ORAL TABLET P OTC
Gerivite Complete ORAL TABLET P OTC
Golden Age Vitamin/Minerals ORAL LIQUID†
P OTC
Multivitamin & Mineral ORAL LIQUID† P OTC
SUPER NU-THERA ORAL TABLET P OTC
Thera Vital M ORAL TABLET P OTC
21
Drug Name Preference Details Coverage Details
Thera-M ORAL TABLET P OTC
Therabasic-M ORAL TABLET P OTC
Therapeutic Liquid ORAL SOLUTION P OTC
Therapeutic-M ORAL TABLET P OTC
TOTAL FORMULA 3 ORAL TABLET P OTC
*Multivitamins**
*Multivitamins***
Daily Multiple Vitamins ORAL TABLET P OTC
Daily Vite ORAL TABLET P OTC
Daily Vites ORAL TABLET P OTC
Multi-Day ORAL TABLET P OTC
Multi-Vitamin ORAL TABLET P OTC
Multi-Vitamins ORAL TABLET P OTC
Once Daily ORAL TABLET P OTC
One-Daily Multi Vitamins ORAL TABLET P OTC
THERA ORAL TABLET P OTC
Thera-Tabs ORAL TABLET P OTC
THERA/BETA-CAROTENE ORAL TABLET
P OTC
Therapeutic ORAL TABLET P OTC
*Ped Mv W/ Fluoride**
*Ped Mv W/ Fluoride***
Multi-Vit/Fluoride ORAL SOLUTION 0.25 MG/ML, 0.5 MG/ML
P
Multi-Vitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG
P
Multivitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG
P
Multivitamins/Fluoride ORAL TABLET CHEWABLE 0.25 MG
P
*Ped Mv W/ Iron**
*Ped Mv W/ Iron***
Poly-Vitamin/Iron ORAL SOLUTION 10 MG/ML
P OTC
*Pediatric Multiple Vitamins**
*Pediatric Multiple Vitamins W/ C***
Poly-Vitamin ORAL SOLUTION 35 MG/ML P OTC
22
Drug Name Preference Details Coverage Details
*Pediatric Vitamins**
*Pediatric Vitamins A & D W/ C***
Tri-Vitamin ORAL SOLUTION 1500-400-35 P OTC
*Prenatal Vitamins**
*Prenatal Mv & Min W/Fe-Fa***
Prenatal Low Iron ORAL TABLET 27-0.8 MG P OTC
*Specialty Vitamins Products**
*Specialty Vitamins Products***
Vitamins for Hair ORAL TABLET P OTC
*Nasal Agents - Systemic And Topical*
*Nasal Agents - Misc.**
*Nasal Agents - Misc.***
Altamist Spray NASAL SOLUTION 0.65 % P OTC
AYR NASAL SOLUTION 0.65 % P OTC
Deep Sea Nasal Spray NASAL SOLUTION0.65 %
P OTC
HUMIST NASAL SOLUTION 0.65 % P OTC
LITTLE NOSES SALINE NASAL SOLUTION 0.65 %
P OTC
Na-Zone NASAL SOLUTION 0.65 % P OTC
NASAL MOIST NASAL SOLUTION 0.65 % P OTC
OCEAN FOR KIDS NASAL SOLUTION 0.65 %
P OTC
Saline Mist Spray NASAL SOLUTION 0.65 % P OTC
Saline Nasal Spray NASAL SOLUTION 0.65 %
P OTC
Sea Soft Nasal Mist NASAL SOLUTION 0.65 %
P OTC
*Nasal Antiallergy**
*Nasal Mast Cell Stabilizers***
Cromolyn Sodium NASAL AEROSOL, SOLUTION 5.2 MG/ACT
P OTC
*Sympathomimetic Decongestants**
*Systemic Decongestants***
Pseudoephedrine HCl ORAL TABLET 30 MG, 60 MG
P OTC
*Ophthalmic Agents*
23
Drug Name Preference Details Coverage Details
*Artificial Tears And Lubricants**
*Artificial Tear And Lubricant Combinations***
Artificial Tears OPHTHALMIC OINTMENT83-15 %
P OTC
HYPOTEARS OPHTHALMIC SOLUTION 1-1 %
P OTC
*Artificial Tear Ointments***
Tears Again OPHTHALMIC OINTMENT P OTC
ULTRA FRESH PM OPHTHALMIC OINTMENT
P OTC
*Artificial Tear Solutions***
Tears Again OPHTHALMIC SOLUTION P OTC
*Artificial Tears And Lubricants***
Artificial Tears OPHTHALMIC SOLUTION1.4 %
P OTC; QL (15 ML per 31 day(s))
Liquitears OPHTHALMIC SOLUTION 1.4 % P OTC; QL (15 ML per 31 Day(s))
Polyvinyl Alcohol OPHTHALMIC SOLUTION 1.4 %
P OTC; QL (15 ML per 31 Day(s))
*Ophthalmics - Misc.**
*Ophthalmic Antiallergic***
ALAWAY OPHTHALMIC SOLUTION 0.025 %
P OTC
Ketotifen Fumarate OPHTHALMIC SOLUTION 0.025 %
P OTC
*Otic Agents*
*Otic Agents - Miscellaneous**
*Otic Agents - Miscellaneous***
Auraphene-B OTIC SOLUTION 6.5 % P OTC
AURO EARDROPS OTIC SOLUTION 6.5 %
P OTC
E-R-O EAR DROPS OTIC SOLUTION 6.5 %
P OTC
E-R-O EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 %
P OTC
Ear Drops Earwax Aid OTIC SOLUTION 6.5 %
P OTC
Earwax Treatment Drops OTIC SOLUTION6.5 %
P OTC
24
Drug Name Preference Details Coverage Details
MURINE EAR OTIC SOLUTION 6.5 % P OTC
MURINE EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 %
P OTC
OTIX OTIC SOLUTION 6.5 % P OTC
Thera-Ear OTIC SOLUTION 6.5 % P OTC
*Psychotherapeutic And Neurological Agents - Misc.*
*Smoking Deterrents**
*Smoking Deterrents***
Nicotine TRANSDERMAL PATCH 24 HR 14 MG/24HR, 21 MG/24HR, 7 MG/24HR
P OTC; QL (70 EA per 365 day(s))
Nicotine Polacrilex MOUTH/THROAT GUM2 MG, 4 MG
POTC; QL (4032 EA per 31 day(s))
*Ulcer Drugs*
*H-2 Antagonists**
*H-2 Antagonists***
Acid Reducer ORAL TABLET 75 MG P OTC
Cimetidine ORAL TABLET 200 MG P OTC
Famotidine ORAL TABLET 10 MG P OTC
*Proton Pump Inhibitors**
*Proton Pump Inhibitors***
Omeprazole ORAL TABLET DELAYED RELEASE 20 MG
P OTC
*Vaginal Products*
*Spermicides**
*Spermicides***
OPTIONS CONCEPTROL VAGINAL GEL 4 %
P OTC
VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM 12.5 %
P OTC
*Vaginal Anti-Infectives**
*Imidazole-Related Antifungals***
GYNE-LOTRIMIN 3 VAGINAL CREAM 2 %
P OTC
Miconazole 3 Combo Pack VAGINAL KIT200-2 MG-% (9GM)
P OTC
Miconazole Nitrate VAGINAL CREAM 2 % P OTC
25
Drug Name Preference Details Coverage Details
Miconazole Nitrate VAGINAL SUPPOSITORY 100 MG
P OTC
MONISTAT 3 VAGINAL CREAM 4 % P OTC
*Vitamins*
*Oil Soluble Vitamins**
*Vitamin A***
Vitamin A ORAL CAPSULE 10000 UNIT, 8000 UNIT
P OTC
*Vitamin D***
CALCIFEROL ORAL SOLUTION 8000 UNIT/ML
P OTC
Vitamin D ORAL CAPSULE 400 UNIT P OTC
Vitamin D ORAL TABLET 400 UNIT P OTC
Vitamin D (Ergocalciferol) ORAL CAPSULE50000 UNIT
P QL (4 EA per 31 day(s))
Vitamin D-400 ORAL TABLET 400 UNIT P OTC
Vitamin D3 ORAL CAPSULE 2000 UNIT P OTC
Vitamin D3 ORAL TABLET 1000 UNIT, 400 UNIT
P OTC
Vitamin D3 ORAL TABLET CHEWABLE400 UNIT
P OTC
*Vitamin E***
Vitamin E ORAL CAPSULE 400 UNIT P OTC
Vitamin E ORAL TABLET CHEWABLE 400 UNIT
P OTC
*Vitamin K***
Vitamin K (Phytonadione) ORAL TABLET100 MCG
P OTC
*Water Soluble Vitamins**
*Vitamin B-1***
Vitamin B-1 ORAL TABLET 100 MG, 250 MG, 50 MG
P OTC
*Vitamin B-2***
Vitamin B-2 ORAL TABLET 100 MG P OTC
*Vitamin B-3***
Niacin ORAL TABLET 100 MG, 250 MG, 50 MG, 500 MG
P OTC
26
Drug Name Preference Details Coverage Details
Niacin ER ORAL CAPSULE EXTENDED RELEASE* 250 MG
P OTC
Niacin ER ORAL TABLET EXTENDEDRELEASE* 250 MG
P OTC
*Vitamin B-6***
Vitamin B-6 ORAL TABLET 100 MG, 25 MG, 250 MG, 50 MG, 500 MG
P OTC
Vitamin B-6 ER ORAL TABLET EXTENDEDRELEASE* 200 MG
P OTC
*Vitamin C***
Ascorbic Acid ORAL TABLET 1000 MG, 250 MG, 500 MG
P OTC
Ascorbic Acid ORAL TABLET CHEWABLE250 MG
P OTC
C-500 ORAL TABLET CHEWABLE 500 MG P OTC
Vitamin C ORAL SYRUP 500 MG/5ML P OTC
Vitamin C ORAL TABLET 100 MG, 1000 MG, 250 MG, 500 MG
P OTC
Vitamin C ORAL TABLET CHEWABLE 100 MG, 250 MG
P OTC
27
28
Index
29
Acetaminophen ORAL SOLUTION 160 MG/5ML .............. 1Acetaminophen ORAL TABLET325 MG .......................................................................... 1Acetaminophen ORAL TABLET500 MG .......................................................................... 1Acetaminophen ORAL TABLET CHEWABLE 80 MG ................................ 1
APAP ORAL TABLET 325 MG.................................................................................................... 1
APAP Drops ORAL SOLUTION100 MG/ML ........................................................... 1APAP Extra Strength ORAL TABLET 500 MG .......................................... 2
Aspirin Childrens ORAL TABLET CHEWABLE 81 MG.................................................................................................... 3Aspirin EC Low Dose ORAL TABLET DELAYED RELEASE81 MG ............................................................................. 3
Alamag Plus ORAL TABLET CHEWABLE 200-200-25 MG.................................................................................................... 3
ALMACONE ORAL SUSPENSION 200-200-20 MG/5ML .................................................................... 3
Antacid ORAL SUSPENSION200-200-20 MG/5ML ................................ 3
Antacid Anti-Gas ORAL SUSPENSION 200-200-20 MG/5ML ..................................................................... 3
Antacid Anti-Gas Max Strength ORAL SUSPENSION400-400-40 MG/5ML ................................ 4
Antacid Extra Strength ORAL SUSPENSION 400-400-40 MG/5ML ..................................................................... 4Antacid I ORAL SUSPENSION200-200-20 MG/5ML ................................ 4Antacid III ORAL SUSPENSION 400-400-40 MG/5ML ..................................................................... 4
ACID GONE ORAL TABLET CHEWABLE 160-105 MG, 80-20 MG ................................................................... 4
Aluminum Hydroxide Gel ORAL SUSPENSION 320 MG/5ML.................................................................................................... 4
Alcalak ORAL TABLET CHEWABLE 420 MG ............................ 5
Antacid ORAL TABLET CHEWABLE 420 MG, 500 MG.................................................................................................... 5Anti-Diarrheal ORAL LIQUID†1 MG/5ML ............................................................... 6
Aller-Chlor ORAL SYRUP 2 MG/5ML ..................................................................... 7Aller-Chlor ORAL TABLET 4 MG ....................................................................................... 7
Allergy ORAL TABLET 4 MG.................................................................................................... 7
Allergy Relief ORAL TABLET 4 MG ....................................................................................... 7
Aler-Cap ORAL CAPSULE 25 MG ....................................................................................... 7Aler-Dryl ORAL TABLET 50 MG ....................................................................................... 7AlerTab ORAL TABLET 25 MG.................................................................................................... 7
Allergy Relief Childrens ORAL LIQUID† 12.5 MG/5ML .................... 7
Altaryl ORAL ELIXIR 12.5 MG/5ML ..................................................................... 7Altaryl ORAL SYRUP 12.5 MG/5ML ..................................................................... 7
Anti-Hist ORAL CAPSULE 25 MG ....................................................................................... 7
Anti-Hist Allergy ORAL TABLET 25 MG .............................................. 7
ALLEGRA ALLERGY CHILDRENS ORAL TABLET 30 MG ............................................................................. 8
Allergy ORAL TABLET DISPERSIBLE 10 MG ......................... 8
ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG.................................................................................................... 9
ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HR* 60-120 MG.................................................................................................... 9
Allergy Relief/Nasal Decongest ORAL TABLET EXTENDED RELEASE 24 HR* 10-240 MG.................................................................................................... 9
Antihistamine Decongestant ORAL TABLET 2.5-60 MG.................................................................................................... 9
Acne Medication 5 EXTERNAL LOTION 5 % .................................................... 10 Allergy EXTERNAL CREAM 2
% ......................................................................................... 10
Anti-Itch Maximum Strength EXTERNAL CREAM 2 % ........... 10
AMLACTIN EXTERNAL LOTION 12 % ................................................ 11Ammonium Lactate EXTERNAL CREAM 12 % .................................................. 11Ammonium Lactate EXTERNAL LOTION 12 % ................................................. 11
Acetaminophen PM ORAL TABLET 500-25 MG ............................ 13
ACE AEROSOL CLOUD ENHANCER XX MISC ................ 17
AEROCHAMBER MV XX MISC ............................................................................ 18
AEROCHAMBER PLUS FLO-VU XX MISC ................................ 18
AEROCHAMBER PLUS FLO-VU LARGE XX MISC................................................................................................ 18AEROCHAMBER PLUS FLO-VU SMALL XX MISC................................................................................................ 18AEROCHAMBER PLUS FLO-VU W/MASK XX MISC................................................................................................ 18
AEROCHAMBER W/FLOWSIGNAL XX MISC................................................................................................ 18
AEROCHAMBER Z-STAT PLUS XX MISC ......................................... 18
AEROCHAMBER Z-STAT PLUS CHAMBR XX MISC................................................................................................ 18
Altamist Spray NASAL SOLUTION 0.65 % ................................. 23 Artificial Tears OPHTHALMIC
OINTMENT 83-15 % ........................... 24Artificial Tears OPHTHALMIC SOLUTION 1.4 % .................................... 24
ALAWAY OPHTHALMIC SOLUTION 0.025 % ............................. 24
Acid Reducer ORAL TABLET 75 MG ................................................................................... 25
Ascorbic Acid ORAL TABLET1000 MG, 250 MG, 500 MG................................................................................................ 27Ascorbic Acid ORAL TABLET CHEWABLE 250 MG ........................ 27
30
Aspirin ORAL TABLET 325 MG, 81 MG ............................................................. 3Aspirin ORAL TABLET CHEWABLE 81 MG ................................ 3Aspirin ORAL TABLET DELAYED RELEASE 81 MG.................................................................................................... 3Aspirin RE SUPPOSITORY 300 MG, 600 MG ......................................................... 3
Aspirin EC ORAL TABLET DELAYED RELEASE 325 MG, 81 MG ............................................................................. 3Aspirin Low Dose ORAL TABLET 81 MG .............................................. 3
CAL-GEST ANTACID ORAL TABLET CHEWABLE 500 MG.................................................................................................... 5
Calcium Antacid ORAL TABLET CHEWABLE 500 MG.................................................................................................... 5
Calcium Antacid Extra Strength ORAL TABLET CHEWABLE750 MG .......................................................................... 5
Calcium Carbonate Antacid ORAL TABLET 648 MG ................... 5Calcium Carbonate Antacid ORAL TABLET CHEWABLE500 MG .......................................................................... 5
BD GLUCOSE ORAL TABLET CHEWABLE 5 GM .................................. 5
Bismatrol ORAL SUSPENSION262 MG/15ML .................................................... 6Bismatrol ORAL TABLET CHEWABLE 262 MG ............................ 6Bismuth ORAL TABLET CHEWABLE 262 MG ............................ 6
BANOPHEN ORAL CAPSULE 25 MG ............................................................................. 7BANOPHEN ORAL LIQUID† 12.5 MG/5ML ..................................................... 7BANOPHEN ORAL TABLET 25 MG ............................................................................. 7
BENADRYL ALLERGY CHILDRENS ORAL LIQUID† 12.5 MG/5ML ..................................................... 7
Cetirizine HCl ORAL SYRUP 5 MG/5ML ..................................................................... 8Cetirizine HCl ORAL TABLET10 MG, 5 MG ....................................................... 8
Cetirizine HCl Childrens ORAL SOLUTION 1 MG/ML ......................... 8
Cetirizine HCl Childrens Alrgy ORAL SYRUP 1 MG/ML ................ 8
BROTAPP ORAL LIQUID† 1-15 MG/5ML .................................................... 9
Cetirizine-Pseudoephedrine ER ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG.................................................................................................... 9
BRONCHO SALINE INHALATION AEROSOL, SOLUTION 0.9 % .................................... 10
Benzoyl Peroxide EXTERNAL GEL 10 %, 5 % ................................................ 10
Bacitracin-Neomycin-Polymyxin EXTERNAL OINTMENT400-5-5000 ........................................................... 10
Bacitracin EXTERNAL OINTMENT 500 UNIT/GM................................................................................................ 10Bacitracin Zinc EXTERNAL OINTMENT 500 UNIT/GM................................................................................................ 10
Baza Antifungal EXTERNAL CREAM 2 % ...................................................... 10
BENADRYL ITCH STOPPING EXTERNAL GEL 2 % ..................... 11
Capsaicin EXTERNAL CREAM0.025 % ....................................................................... 12
BISAC-EVAC ORAL TABLET DELAYED RELEASE 5 MG................................................................................................ 15BISAC-EVAC RE SUPPOSITORY 10 MG ................. 15Biscolax RE SUPPOSITORY 10 MG ................................................................................... 15
CARTERS LITTLE PILLS ORAL TABLET DELAYED RELEASE 5 MG ........................................ 15
Calcium ORAL TABLET500-125 MG-UNIT ................................... 18
Calcium + D3 ORAL TABLET600-200 MG-UNIT ................................... 19
Calcium 600-D ORAL TABLET600-400 MG-UNIT ................................... 19
Calcium Carbonate-Vitamin D ORAL TABLET 500-400 MG-UNIT, 600-400 MG-UNIT................................................................................................ 19
Calcium High Potency/Vitamin D ORAL TABLET 600-200 MG-UNIT ............................................................. 19
Calcium-Carb 600 + D ORAL TABLET 600-125 MG-UNIT................................................................................................ 19
Calcium-Vitamin D ORAL TABLET 500-125 MG-UNIT, 600-125 MG-UNIT, 600-200 MG-UNIT ............................................................. 19
CALTRATE 600+D ORAL TABLET 600-800 MG-UNIT................................................................................................ 19
CAL-CARB FORTE ORAL TABLET 1250 MG ................................. 19
Cal-Lac ORAL CAPSULE 500 MG ................................................................................... 20
Calcarb 600 ORAL TABLET1500 MG .................................................................. 20
CALCI-CHEW ORAL TABLET CHEWABLE 1250 MG .................... 20
Calcium 600 ORAL TABLET600 MG ...................................................................... 20
Calcium Carbonate ORAL SUSPENSION 1250 MG/5ML................................................................................................ 20Calcium Carbonate ORAL TABLET 1250 MG, 1500 MG, 600 MG ...................................................................... 20
Calcium High Potency ORAL TABLET 600 MG ...................................... 20
Calcium Lactate ORAL TABLET648 MG ...................................................................... 20
Calcium Oyster Shell ORAL TABLET 1250 MG ................................... 20
Calcium-Carb 600 ORAL TABLET 600 MG ...................................... 20
CALTRATE 600 ORAL TABLET 1500 MG ................................. 20
Centamin ORAL LIQUID†................................................................................................ 21
CentaVite ORAL LIQUID†................................................................................................ 21
Centavite A-Z Complete-Mineral ORAL TABLET ....................................... 21
CEROVITE ADVANCED FORMULA ORAL TABLET................................................................................................ 21CERTAVITE/ANTIOXIDANTS ORAL LIQUID† .................................. 21
AYR NASAL SOLUTION 0.65 % ......................................................................................... 23
Auraphene-B OTIC SOLUTION6.5 % .............................................................................. 24AURO EARDROPS OTIC SOLUTION 6.5 % .................................... 24
CALCIFEROL ORAL SOLUTION 8000 UNIT/ML................................................................................................ 26
C-500 ORAL TABLET CHEWABLE 500 MG ........................ 27
31
Childrens Ibuprofen ORAL SUSPENSION 40 MG/ML.................................................................................................... 1
Childrens Non-ASA Pain Relief ORAL TABLET CHEWABLE80 MG ............................................................................. 2Childrens Non-Aspirin ORAL TABLET CHEWABLE 80 MG.................................................................................................... 2Childrens Non-Aspirin Pain ORAL TABLET CHEWABLE80 MG ............................................................................. 2Childrens Pain Reliever ORAL TABLET CHEWABLE 80 MG.................................................................................................... 2Childrens Silapap ORAL LIQUID† 160 MG/5ML ...................... 2Childrens Tactinal ORAL TABLET CHEWABLE 80 MG.................................................................................................... 2
Ed-APAP ORAL LIQUID† 160 MG/5ML ..................................................................... 2
ECPIRIN ORAL TABLET DELAYED RELEASE 325 MG.................................................................................................... 3Diotame ORAL TABLET
CHEWABLE 262 MG ............................ 6
ChlorHist ORAL TABLET 4 MG.................................................................................................... 7Chlorphen ORAL TABLET 4 MG ....................................................................................... 7
DIABETIC TUSSIN ALLERGY ORAL SYRUP 2 MG/5ML .................................................................... 7
Complete Allergy Medication ORAL TABLET 25 MG ....................... 7Complete Allergy Relief ORAL TABLET 25 MG .............................................. 7
Diphenhist ORAL CAPSULE 25 MG ....................................................................................... 7Diphenhist ORAL LIQUID† 12.5 MG/5ML ..................................................................... 7Diphenhist ORAL TABLET 25 MG ....................................................................................... 7DiphenhydrAMINE HCl ORAL CAPSULE 25 MG, 50 MG .............. 7DiphenhydrAMINE HCl ORAL TABLET 25 MG .............................................. 8
DORMIN ORAL CAPSULE 25 MG ...................................................................................... 8
Childrens Loratadine ORAL SYRUP 5 MG/5ML .................................... 8
Chlorhexidine Gluconate EXTERNAL LIQUID† 4 %.................................................................................................... 9
Chest Congestion Relief ORAL TABLET 400 MG .......................................... 9
Double Antibiotic EXTERNAL OINTMENT 500-10000 UNIT/GM .............................................................. 10
Clotrimazole EXTERNAL CREAM 1 % ...................................................... 10Clotrimazole EXTERNAL SOLUTION 1 % .......................................... 10
CLEAR AWAY 1-STEP WART REMOVER EXTERNAL PAD 40 % ................................................................................ 11
COMPOUND W EXTERNAL LIQUID† 17 % .............................................. 11COMPOUND W MAXIMUM STRENGTH EXTERNAL GEL 17 % ................................................................................ 11
Cyanocobalamin INJECTION SOLUTION 1000 MCG/ML................................................................................................ 12
Compoz ORAL CAPSULE 50 MG ................................................................................... 13Compoz ORAL TABLET 50 MG................................................................................................ 13
DOC-Q-LAX ORAL TABLET 8.6-50 MG ............................................................. 14
Enema RE ENEMA 7-19 GM/118ML .......................................................... 15
Citrate of Magnesia ORAL SOLUTION 1.745 GM/30ML................................................................................................ 15CITROMA ORAL SOLUTION 1.745 GM/30ML .......................................... 15
DULCOLAX MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML................................................................................................ 15
Correct ORAL TABLET DELAYED RELEASE 5 MG................................................................................................ 15
CORRECTOL ORAL TABLET DELAYED RELEASE 5 MG................................................................................................ 15
Ducodyl ORAL TABLET DELAYED RELEASE 5 MG................................................................................................ 15
EX-LAX ORAL TABLET CHEWABLE 15 MG ........................... 15EX-LAX ULTRA ORAL TABLET DELAYED RELEASE 5 MG ........................................ 15
CORRECTOL EXTRA GENTLE ORAL CAPSULE 100 MG .................................................................................. 16
D.O.S. ORAL CAPSULE 250 MG ................................................................................... 16
Diocto ORAL LIQUID† 50 MG/5ML ................................................................. 16Diocto ORAL SYRUP 60 MG/15ML ............................................................. 16
DocQLace ORAL CAPSULE100 MG ...................................................................... 16
Docu Soft ORAL CAPSULE 100 MG ................................................................................... 16
Docusate Calcium ORAL CAPSULE 240 MG ................................. 17Docusate Sodium ORAL CAPSULE 250 MG ................................. 17Docusate Sodium ORAL TABLET 100 MG ...................................... 17DOCUSIL ORAL CAPSULE 100 MG ..................................................................... 17DOK ORAL CAPSULE 100 MG, 250 MG ...................................................... 17DOK ORAL TABLET 100 MG................................................................................................ 17
DSS ORAL CAPSULE 100 MG, 250 MG ...................................................................... 17
DULCOLAX STOOL SOFTENER ORAL CAPSULE 100 MG ..................................................................... 17
EASIVENT XX MISC ...................... 18
Daily Multiple Vitamins ORAL TABLET .............................................................. 22Daily Vite ORAL TABLET................................................................................................ 22Daily Vites ORAL TABLET................................................................................................ 22Deep Sea Nasal Spray NASAL SOLUTION 0.65 % ................................. 23
Cromolyn Sodium NASAL AEROSOL, SOLUTION 5.2 MG/ACT ................................................................. 23
E-R-O EAR DROPS OTIC SOLUTION 6.5 % .................................... 24E-R-O EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % ......................................................................................... 24
Ear Drops Earwax Aid OTIC SOLUTION 6.5 % .................................... 24Earwax Treatment Drops OTIC SOLUTION 6.5 % .................................... 24
Cimetidine ORAL TABLET 200 MG ................................................................................... 25
Famotidine ORAL TABLET 10 MG ................................................................................... 25
32
Ibuprofen ORAL SUSPENSION100 MG/5ML ........................................................ 1Ibuprofen ORAL TABLET 200 MG ....................................................................................... 1
Geri-Lanta ORAL SUSPENSION 200-200-20 MG/5ML ..................................................................... 4
MAALOX ADVANCED ORAL SUSPENSION 200-200-20 MG/5ML .................................................................... 4
MAALOX ADVANCED MAX ST ORAL SUSPENSION 400-400-40 MG/5ML ................................ 4
MAALOX MAX ORAL SUSPENSION 400-400-40 MG/5ML .................................................................... 4MAALOX MULTI SYMPTOM MAX ST ORAL SUSPENSION 400-400-40 MG/5ML ................................ 4
MAALOX REGULAR STRENGTH ORAL SUSPENSION 200-200-20 MG/5ML .................................................................... 4
MAALOX ORAL TABLET CHEWABLE 600 MG ........................... 5
Glucose ORAL TABLET CHEWABLE 4 GM .................................... 5
Kao-Tin ORAL SUSPENSION262 MG/15ML .................................................... 6
KAOPECTATE ORAL SUSPENSION 262 MG/15ML.................................................................................................... 6
KAOPECTATE EXTRA STRENGTH ORAL SUSPENSION 525 MG/15ML.................................................................................................... 6
LOPERAMIDE A-D ORAL TABLET 2 MG ................................................ 6Loperamide HCl ORAL LIQUID† 1 MG/5ML ............................. 6
Ipecac ORAL SYRUP ......................... 6
Genahist ORAL CAPSULE 25 MG ....................................................................................... 8
Fexofenadine HCl ORAL TABLET 180 MG, 60 MG ................ 8
Loratadine ORAL TABLET 10 MG ....................................................................................... 8
Loratadine Hives Relief ORAL SOLUTION 5 MG/5ML ..................... 8
Fexofenadine-Pseudoephed ER ORAL TABLET EXTENDED RELEASE 24 HR* 180-240 MG.................................................................................................... 9
Itch Relief EXTERNAL CREAM2 % .................................................................................... 11
Hydrocortisone EXTERNAL CREAM 0.5 %, 1 % ................................. 11Hydrocortisone EXTERNAL LOTION 1 % .................................................... 11Hydrocortisone EXTERNAL OINTMENT 0.5 %, 1 % ................... 11Hydrocortisone Max St EXTERNAL CREAM 1 % ........... 11Hydrocortisone Max St/12 Moist EXTERNAL CREAM 1 % ........... 11
HYDROSKIN EXTERNAL CREAM 1 % ..................................................... 11
Hydrocortisone-Aloe EXTERNAL CREAM 1 % ........... 11
FREEZONE EXTERNAL LIQUID† 17.6 % ......................................... 11
Folic Acid ORAL TABLET 1 MG, 400 MCG, 800 MCG .............. 13
Ferro-Bob ORAL TABLET 325 (65 Fe) MG ......................................................... 13Ferrous Sulfate ORAL ELIXIR220 (44 Fe) MG/5ML .......................... 13Ferrous Sulfate ORAL TABLET325 (65 Fe) MG ............................................ 13Ferrous Sulfate ORAL TABLET DELAYED RELEASE 324 (65 Fe) MG, 325 (65 Fe) MG .............. 13FerrouSul ORAL TABLET 325 (65 Fe) MG ......................................................... 13
Iron ORAL TABLET 325 (65 Fe) MG, 90 (18 Fe) MG .................. 13
Headache PM ORAL TABLET25-500 MG ............................................................ 13
Fiber ORAL TABLET 625 MG................................................................................................ 14
Fiber Laxative ORAL TABLET625 MG ...................................................................... 14
Fiber Therapy ORAL POWDER58.6 % ........................................................................... 14
Fiber-Lax ORAL TABLET 625 MG ................................................................................... 14
FIBERGEN ORAL TABLET 625 MG ..................................................................... 14
KONSYL ORAL PACKET 100 % ......................................................................................... 14
KONSYL FIBER ORAL TABLET 625 MG ..................................... 14
Magnesium Citrate ORAL SOLUTION 1.745 GM/30ML................................................................................................ 15
FEENAMINT ORAL TABLET DELAYED RELEASE 5 MG................................................................................................ 16
FLEET LAXATIVE ORAL TABLET DELAYED RELEASE 5 MG ........................................ 16
Gentle Laxative ORAL TABLET DELAYED RELEASE 5 MG................................................................................................ 16
Laxative RE SUPPOSITORY 10 MG ................................................................................... 16
Magic Bullets RE SUPPOSITORY 10 MG .................. 16
Kao-Tin ORAL CAPSULE 240 MG ................................................................................... 17
Laxa Basic ORAL CAPSULE100 MG, 250 MG ......................................... 17
IN-CHECK DIAL FLOW TRAINER XX DEVICE ............... 17Inhaler Companions XX MISC................................................................................................ 17
Liquid Calcium/Vitamin D ORAL CAPSULE 600-200 MG-UNIT................................................................................................ 19
Mag-Delay ORAL TABLET EXTENDEDRELEASE* 535 (64 Mg) MG ..................................................... 20
MAG64 ORAL TABLET EXTENDEDRELEASE* 535 (64 MG) MG ..................................................... 20
Magnacaps ORAL CAPSULE100 MG ...................................................................... 20
Magnesium ORAL TABLET 250 MG ................................................................................... 20
Formula Twenty-One ORAL TABLET .............................................................. 21
Gerivite Complete ORAL TABLET .............................................................. 21
Golden Age Vitamin/Minerals ORAL LIQUID† ..................................... 21
HUMIST NASAL SOLUTION 0.65 % ........................................................................... 23
LITTLE NOSES SALINE NASAL SOLUTION 0.65 %................................................................................................ 23
HYPOTEARS OPHTHALMIC SOLUTION 1-1 % .................................... 24
Liquitears OPHTHALMIC SOLUTION 1.4 % .................................... 24
Ketotifen Fumarate OPHTHALMIC SOLUTION0.025 % ....................................................................... 24
GYNE-LOTRIMIN 3 VAGINAL CREAM 2 % ............... 25
33
Mapap ORAL CAPSULE 500 MG ....................................................................................... 2Mapap ORAL LIQUID† 160 MG/5ML ..................................................................... 2Mapap ORAL TABLET 325 MG.................................................................................................... 2Mapap ORAL TABLET 500 MG.................................................................................................... 2Mapap ORAL TABLET CHEWABLE 80 MG ................................ 2
Mapap Arthritis Pain ORAL TABLET EXTENDEDRELEASE* 650 MG ....................................................................................... 2MAPAP CHILDRENS ORAL SUSPENSION 160 MG/5ML.................................................................................................... 2
Maxapap Maximum Strength ORAL TABLET 500 MG ................... 2Maxapap Regular Strength ORAL TABLET 325 MG ................... 2
Non-Aspirin ORAL TABLET 325 MG ....................................................................................... 2
Non-Aspirin Extra Strength ORAL TABLET 500 MG ................... 2
Non-Aspirin Pain Relief ORAL TABLET 325 MG .......................................... 2Nortemp Infants ORAL SUSPENSION 80 MG/0.8ML.................................................................................................... 2
Milantex ORAL SUSPENSION200-200-20 MG/5ML ................................ 4
Milantex Extra Strength ORAL SUSPENSION 400-400-40 MG/5ML ..................................................................... 4
MINTOX PLUS ORAL TABLET CHEWABLE 200-200-25 MG .................................................. 4
MI-ACID ORAL TABLET CHEWABLE 700-300 MG.................................................................................................... 4
Magnesium Oxide ORAL TABLET 250 MG, 400 MG, 420 MG ....................................................................................... 5
Meclizine HCl ORAL TABLET12.5 MG, 25 MG .............................................. 6
Mucus Relief ORAL TABLET400 MG .......................................................................... 9
Mi-Acid Gas Relief ORAL TABLET CHEWABLE 80 MG................................................................................................ 12
Mytab Gas ORAL TABLET CHEWABLE 80 MG ............................ 12
Mapap PM ORAL TABLET500-25 MG ............................................................ 13
NYTOL ORAL TABLET 25 MG .................................................................................. 13
METAMUCIL ORAL CAPSULE 0.52 GM .............................. 14METAMUCIL ORAL POWDER 30.9 % ....................................... 14METAMUCIL ORAL WAFER................................................................................................ 14
METAMUCIL MULTIHEALTH FIBER ORAL POWDER 58.6 % ............... 14
METAMUCIL SMOOTH TEXTURE ORAL PACKET 28 % ......................................................................................... 14
METAMUCIL SMOOTH TEXTURE ORAL POWDER 28.3 %, 58.6 % .................................................. 14
Natural Fiber Therapy ORAL POWDER 30.9 %, 48.57 % .......... 14
Natural Vegetable Fiber ORAL POWDER 48.57 % ................................... 14
Milk of Magnesia ORAL SUSPENSION 400 MG/5ML, 7.75 % ........................................................................... 15
Natural Senna Laxative ORAL TABLET 64.8-324 MG ....................... 16
MICROCHAMBER XX MISC................................................................................................ 18MICROSPACER XX MISC................................................................................................ 18
Mag-SR ORAL TABLET EXTENDEDRELEASE* 535 (64 Mg) MG ..................................................... 20MAG-TAB SR ORAL TABLET EXTENDEDRELEASE* 84 MG (7MEQ) ...................................................... 20
Magnesium Oxide ORAL TABLET 400 (240 Mg) MG................................................................................................ 21MAGNESIUM-OXIDE ORAL TABLET 400 (241.3 MG) MG................................................................................................ 21
NEPHRONEX ORAL TABLET................................................................................................ 21
Multivitamin & Mineral ORAL LIQUID† ............................................................ 21
Multi-Day ORAL TABLET................................................................................................ 22
Multi-Vitamin ORAL TABLET................................................................................................ 22
Multi-Vitamins ORAL TABLET................................................................................................ 22
Once Daily ORAL TABLET................................................................................................ 22
Multi-Vit/Fluoride ORAL SOLUTION 0.25 MG/ML, 0.5 MG/ML ..................................................................... 22
Multi-Vitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG ................................. 22
Multivitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG ................................. 22
Multivitamins/Fluoride ORAL TABLET CHEWABLE 0.25 MG................................................................................................ 22
Na-Zone NASAL SOLUTION0.65 % ........................................................................... 23
NASAL MOIST NASAL SOLUTION 0.65 % ................................ 23
OCEAN FOR KIDS NASAL SOLUTION 0.65 % ................................ 23
MURINE EAR OTIC SOLUTION 6.5 % .................................... 25MURINE EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % .................................... 25
Nicotine TRANSDERMAL PATCH 24 HR 14 MG/24HR, 21 MG/24HR, 7 MG/24HR ................... 25
Nicotine Polacrilex MOUTH/THROAT GUM 2 MG, 4 MG ............................................................................. 25
Omeprazole ORAL TABLET DELAYED RELEASE 20 MG................................................................................................ 25
Miconazole 3 Combo Pack VAGINAL KIT 200-2 MG-% (9GM) ........................................................................ 25Miconazole Nitrate VAGINAL CREAM 2 % ...................................................... 25Miconazole Nitrate VAGINAL SUPPOSITORY 100 MG .............. 26
MONISTAT 3 VAGINAL CREAM 4 % ..................................................... 26
Niacin ORAL TABLET 100 MG, 250 MG, 50 MG, 500 MG ............... 26
Niacin ER ORAL CAPSULE EXTENDED RELEASE* 250 MG ................................................................................... 27Niacin ER ORAL TABLET EXTENDEDRELEASE* 250 MG ................................................................................... 27
34
Pain & Fever Childrens ORAL SOLUTION 160 MG/5ML .............. 2
Pain Relief ORAL TABLET 500 MG ....................................................................................... 2
Pain Relief Extra Strength ORAL TABLET 500 MG .......................................... 3
PHARBETOL ORAL TABLET 325 MG ......................................................................... 3
PHARBETOL EXTRA STRENGTH ORAL TABLET 500 MG ......................................................................... 3
Q-PAP ORAL TABLET 325 MG.................................................................................................... 3
Reeses Pinworm Medicine ORAL SUSPENSION 144 MG/ML.................................................................................................... 5
Pink Bismuth ORAL SUSPENSION 262 MG/15ML.................................................................................................... 6Pink Bismuth ORAL TABLET CHEWABLE 262 MG ............................ 6
Pharbedryl ORAL CAPSULE 25 MG, 50 MG ............................................................. 8
Q-Dryl ORAL CAPSULE 25 MG ....................................................................................... 8Q-Dryl ORAL LIQUID† 12.5 MG/5ML ..................................................................... 8
Quenalin ORAL SYRUP 12.5 MG/5ML ..................................................................... 8
SCOT-TUSSIN ALLERGY RELIEF ORAL LIQUID† 12.5 MG/5ML .................................................................... 8
OPERAND POVIDONE-IODINE EXTERNAL SOLUTION 10 %.................................................................................................... 9
Povidone-Iodine EXTERNAL SOLUTION 10 % .......................................... 9
Q-TAPP ORAL ELIXIR 1-15 MG/5ML .................................................................... 9
Refenesen ORAL TABLET 200 MG ....................................................................................... 9
Refenesen 400 ORAL TABLET400 MG .......................................................................... 9
Robafen ORAL SYRUP 100 MG/5ML ................................................................. 10
PREPARATION H HYDROCORTISONE EXTERNAL CREAM 1 %................................................................................................ 11
SALACTIC FILM EXTERNAL SOLUTION 17 % ...................................... 11
Permethrin EXTERNAL LOTION 1 % .................................................... 12
Pregnancy Test IN VITRO DIAGNOSTIC TEST† .................. 12
POLY-IRON 150 ORAL CAPSULE 150 MG ................................ 13
Pain Relief PM Extra Strength ORAL TABLET 500-25 MG................................................................................................ 13Pain Reliever PM ORAL TABLET 500-25 MG ............................ 13
REGULOID ORAL CAPSULE 0.52 GM ................................................................... 14
PERI-COLACE ORAL TABLET 8.6-50 MG ............................. 14
Phosphate Laxative ORAL SOLUTION 0.9-2.4 GM/5ML................................................................................................ 15
Peak Flow Meter XX DEVICE................................................................................................ 17
PFLEX XX MISC .................................... 17
OPTICHAMBER ADVANTAGE XX MISC ........... 18OPTICHAMBER FACE MASK-LARGE XX MISC................................................................................................ 18OPTICHAMBER FACE MASK-MEDIUM XX MISC................................................................................................ 18OPTICHAMBER FACE MASK-SMALL XX MISC................................................................................................ 18OPTIHALER XX DEVICE................................................................................................ 18OPTIHALER XX MISC ................ 18
POCKET CHAMBER XX DEVICE .................................................................. 18POCKET SPACER XX DEVICE .................................................................. 18
OS-CAL 500 + D ORAL TABLET 500-200 MG-UNIT................................................................................................ 19
OYSCO 500+D ORAL TABLET 500-200 MG-UNIT................................................................................................ 19OYSCO D ORAL TABLET 250-125 MG-UNIT ................................. 19Oyst-Cal D ORAL TABLET250-125 MG-UNIT ................................... 19Oyster Calcium + D ORAL TABLET 250-125 MG-UNIT................................................................................................ 19Oyster Shell Calcium + D ORAL TABLET 500-400 MG-UNIT................................................................................................ 19Oyster Shell Calcium 500 + D ORAL TABLET 500-125 MG-UNIT ............................................................. 19
Oyster Shell Calcium/D ORAL TABLET 250-125 MG-UNIT, 500-200 MG-UNIT ................................... 19Oyster Shell Calcium/Vitamin D ORAL TABLET 500-200 MG-UNIT ............................................................. 19Oyster Shell/Vitamin D ORAL TABLET 600-125 MG-UNIT................................................................................................ 19
OS-CAL ORAL TABLET CHEWABLE 1250 MG .................... 20
OYSCO 500 ORAL TABLET 500 MG ..................................................................... 20
OYSTERCAL ORAL TABLET 500 MG ..................................................................... 20
ORALYTE ORAL SOLUTION................................................................................................ 20
ORALYTE FREEZER POPS ORAL SOLUTION ............................... 20
ORAZINC ORAL CAPSULE 220 MG ..................................................................... 21
Rena-Vite Rx ORAL TABLET 1 MG ................................................................................... 21
RENAL ORAL CAPSULE 1 MG .................................................................................. 21
Reno Caps ORAL CAPSULE 1 MG ................................................................................... 21
One-Daily Multi Vitamins ORAL TABLET .............................................................. 22
Poly-Vitamin/Iron ORAL SOLUTION 10 MG/ML .................. 22
Poly-Vitamin ORAL SOLUTION 35 MG/ML .................. 22
Prenatal Low Iron ORAL TABLET 27-0.8 MG .............................. 23
Saline Mist Spray NASAL SOLUTION 0.65 % ................................. 23Saline Nasal Spray NASAL SOLUTION 0.65 % ................................. 23
Sea Soft Nasal Mist NASAL SOLUTION 0.65 % ................................. 23
Pseudoephedrine HCl ORAL TABLET 30 MG, 60 MG ................ 23
Polyvinyl Alcohol OPHTHALMIC SOLUTION1.4 % .............................................................................. 24
OTIX OTIC SOLUTION 6.5 %................................................................................................ 25
OPTIONS CONCEPTROL VAGINAL GEL 4 % ............................ 25
35
Tactinal ORAL TABLET 325 MG ....................................................................................... 3
Tactinal Extra Strength ORAL TABLET 500 MG .......................................... 3
Tri-Buffered Aspirin ORAL TABLET 325 MG .......................................... 3
Sodium Bicarbonate ORAL TABLET 325 MG, 650 MG.................................................................................................... 4
TITRALAC ORAL TABLET CHEWABLE 420 MG ........................... 5
Stomach Relief ORAL SUSPENSION 262 MG/15ML, 527 MG/30ML .................................................... 6Stomach Relief ORAL TABLET CHEWABLE 262 MG ............................ 6Stomach Relief Plus ORAL SUSPENSION 525 MG/15ML.................................................................................................... 6
Travel Sickness ORAL TABLET CHEWABLE 25 MG ................................ 6Siladryl Allergy ORAL LIQUID†
12.5 MG/5ML ...................................................... 8Silphen Cough ORAL SYRUP12.5 MG/5ML ...................................................... 8
SIMPLY ALLERGY ORAL TABLET 25 MG ............................................ 8
Total Allergy ORAL TABLET 25 MG ....................................................................................... 8
TOTAL ALLERGY MEDICINE ORAL LIQUID† 12.5 MG/5ML ..................................................... 8
Sodium Chloride INHALATION NEBULIZATION SOLUTION0.9 % .............................................................................. 10
Triple Antibiotic EXTERNAL OINTMENT 3.5-400-5000 , 5-400-5000 ........................................................... 10
Terbinafine HCl EXTERNAL CREAM 1 % ...................................................... 10
Simethicone ORAL SUSPENSION 40 MG/0.6ML................................................................................................ 12Simethicone ORAL TABLET CHEWABLE 80 MG ............................ 12
Sodium Citrate ORAL GRANULES .................................................. 12
Slow Release Iron ORAL TABLET EXTENDEDRELEASE* 160 (50 Fe) MG ......................................................... 13
SIMPLY SLEEP ORAL TABLET 25 MG ......................................... 13Sleep Tabs ORAL TABLET 25 MG ................................................................................... 13Sleep-Tabs ORAL TABLET 25 MG ................................................................................... 13
SOMINEX ORAL TABLET 25 MG .................................................................................. 13
SOMINEX MAXIMUM STRENGTH ORAL TABLET 50 MG ......................................................................... 13
Tetra-Formula Nighttime Sleep ORAL TABLET 50 MG ................... 14
Senna Plus ORAL TABLET8.6-50 MG .............................................................. 14Senna S ORAL TABLET 8.6-50 MG ................................................................................... 14
Senna-Docusate Sodium ORAL TABLET 8.6-50 MG .............................. 14
Senna-S ORAL TABLET 8.6-50 MG ................................................................................... 14
Senna-Time S ORAL TABLET8.6-50 MG .............................................................. 14
SENNALAX-S ORAL TABLET 8.6-50 MG ............................................................. 14
Sennosides-Docusate Sodium ORAL TABLET 8.6-50 MG................................................................................................ 15
Sorbitol ORAL SOLUTION 70 % ......................................................................................... 15
Senexon ORAL LIQUID† 8.8 MG/5ML ................................................................. 16Senexon ORAL TABLET 8.6 MG ................................................................................... 16
Senna ORAL SYRUP 8.8 MG/5ML ................................................................. 16Senna ORAL TABLET 15 MG, 8.6 MG ........................................................................ 16
Senna Lax ORAL TABLET 8.6 MG ................................................................................... 16Senna Laxative ORAL TABLET8.6 MG ........................................................................ 16Senna Maximum Strength ORAL TABLET 25 MG .......................................... 16
SENNA SMOOTH ORAL TABLET 15 MG ......................................... 16
Senna-Lax ORAL TABLET 8.6 MG ................................................................................... 16
Senna-Tabs ORAL TABLET 8.6 MG ................................................................................... 16Senna-Time ORAL TABLET 8.6 MG ................................................................................... 16
SENNACON ORAL TABLET 8.6 MG ....................................................................... 16
SENNO ORAL TABLET 8.6 MG .................................................................................. 16
Stimulant Laxative ORAL TABLET DELAYED RELEASE5 MG ............................................................................. 16
Silace ORAL LIQUID† 150 MG/15ML ............................................................. 17Silace ORAL SYRUP 60 MG/15ML ............................................................. 17
SOF-LAX ORAL CAPSULE 100 MG ..................................................................... 17
Stool Softener ORAL CAPSULE100 MG, 250 MG ......................................... 17
Stool Softener Laxative DC ORAL CAPSULE 240 MG................................................................................................ 17
Sur-Q-Lax ORAL CAPSULE240 MG ...................................................................... 17
SURFAK ORAL CAPSULE 240 MG ..................................................................... 17
TODAY SPONGE VAGINAL MISC ............................................................................ 17
THRESHOLD IMT XX MISC................................................................................................ 18THRESHOLD PEP XX DEVICE .................................................................. 18
SUPER NU-THERA ORAL TABLET ................................................................. 21
Thera Vital M ORAL TABLET................................................................................................ 21
Thera-M ORAL TABLET................................................................................................ 22
Therabasic-M ORAL TABLET................................................................................................ 22
Therapeutic Liquid ORAL SOLUTION .................................................... 22
Therapeutic-M ORAL TABLET................................................................................................ 22
TOTAL FORMULA 3 ORAL TABLET ................................................................. 22
THERA ORAL TABLET ............ 22
Thera-Tabs ORAL TABLET................................................................................................ 22
THERA/BETA-CAROTENE ORAL TABLET ......................................... 22
Therapeutic ORAL TABLET................................................................................................ 22
Tri-Vitamin ORAL SOLUTION1500-400-35 ........................................................ 23
Tears Again OPHTHALMIC OINTMENT .................................................. 24Tears Again OPHTHALMIC SOLUTION .................................................... 24
Thera-Ear OTIC SOLUTION 6.5 % ......................................................................................... 25
36
Ultilet Glucose ORAL TABLET CHEWABLE 4 GM .................................... 5
Vitamin B-12 ORAL TABLET1000 MCG, 500 MCG .......................... 12Vitamin B-12 SUBLINGUAL TABLET SUBLINGUAL 1000 MCG .............................................................................. 12
Vitamin B-12 ER ORAL TABLET EXTENDEDRELEASE* 1000 MCG .............................................................................. 12
Womens Laxative ORAL TABLET DELAYED RELEASE5 MG ............................................................................. 16
TROJAN RIBBED XX MISC................................................................................................ 17
WINDMILL TRAINER XX MISC ............................................................................ 18
WATCHHALER XX DEVICE................................................................................................ 18
Zinc Sulfate ORAL CAPSULE220 MG ...................................................................... 21Zinc Sulfate ORAL TABLET 220 (50 Zn) MG ....................................................... 21Zinc-220 ORAL CAPSULE 220 MG ................................................................................... 21
Vitamin B Complex-C ORAL CAPSULE ........................................................ 21
Vitamins for Hair ORAL TABLET .............................................................. 23
ULTRA FRESH PM OPHTHALMIC OINTMENT................................................................................................ 24VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM 12.5 % ................................................. 25Vitamin A ORAL CAPSULE10000 UNIT, 8000 UNIT ................. 26
Vitamin D ORAL CAPSULE 400 UNIT ............................................................................ 26Vitamin D ORAL TABLET 400 UNIT ............................................................................ 26
Vitamin D (Ergocalciferol) ORAL CAPSULE 50000 UNIT................................................................................................ 26
Vitamin D-400 ORAL TABLET400 UNIT ............................................................... 26
Vitamin D3 ORAL CAPSULE2000 UNIT ............................................................ 26Vitamin D3 ORAL TABLET1000 UNIT, 400 UNIT ........................ 26Vitamin D3 ORAL TABLET CHEWABLE 400 UNIT .................. 26
Vitamin E ORAL CAPSULE 400 UNIT ............................................................................ 26Vitamin E ORAL TABLET CHEWABLE 400 UNIT .................. 26Vitamin K (Phytonadione) ORAL TABLET 100 MCG................................................................................................ 26
Vitamin B-1 ORAL TABLET 100 MG, 250 MG, 50 MG ............................ 26
Vitamin B-2 ORAL TABLET 100 MG ................................................................................... 26
Vitamin B-6 ORAL TABLET 100 MG, 25 MG, 250 MG, 50 MG, 500 MG ...................................................................... 27
Vitamin B-6 ER ORAL TABLET EXTENDEDRELEASE* 200 MG ................................................................................... 27
Vitamin C ORAL SYRUP 500 MG/5ML ................................................................. 27Vitamin C ORAL TABLET 100 MG, 1000 MG, 250 MG, 500 MG................................................................................................ 27Vitamin C ORAL TABLET CHEWABLE 100 MG, 250 MG................................................................................................ 27