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Table of Contents
ANTI - INFECTIVES ........................................................................................................................................ 4
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ..................................................................... 13
AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ....................................................................... 18
CARDIOVASCULAR, HYPERTENSION & LIPIDS ................................................................................. 35
DERMATOLOGICALS/TOPICAL THERAPY .......................................................................................... 43
DIAGNOSTICS & MISCELLANEOUS AGENTS ...................................................................................... 52
EAR, NOSE & THROAT MEDICATIONS .................................................................................................. 54
ENDOCRINE/DIABETES .............................................................................................................................. 55
GASTROENTEROLOGY .............................................................................................................................. 72
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ............................................................................. 79
MUSCULOSKELETAL & RHEUMATOLOGY ......................................................................................... 82
OBSTETRICS & GYNECOLOGY ................................................................................................................ 83
OPHTHALMOLOGY ..................................................................................................................................... 89
RESPIRATORY, ALLERGY, COUGH & COLD ....................................................................................... 93
UROLOGICALS .............................................................................................................................................. 97
VITAMINS, HEMATINICS & ELECTROLYTES ..................................................................................... 99
Index ................................................................................................................................................................ 108
3
Please see the benefit schedule in your member certificate for member cost sharing associated with
Generic and Brand (Preferred and Non Preferred) drugs.
List of Abbreviations for the Prescription Drugs
Drug Category:
1: Generic Drug and Generic Specialty Drug
2: Preferred Drug and Non Preferred Generic Drug
3: Non Preferred Drug and Preferred Specialty Drug
4: Non Preferred Specialty Drug
5: Zero Cost Share Preventive Drug
6: Medical Service Drug
ACA*: Affordable Care Act is a zero cost share preventive drug.
M: Maintenance drug.
MSD: Medical Service Drug. This drug is only covered under the medical benefit.
OTC*: Over-the-Counter drug.
PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs.
This means that you will need to get approval before you fill your prescription. If you don’t get approval, your
plan may not cover the drug.
QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
S: Specialty drug.
SLA: Specialty Limited Availability. This prescription may be available only at certain pharmacies.
ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat
your medical condition, we may not cover Drug B unless you try Drug A first.
*Your plan has tobacco use coverage through the Routine Preventive Care benefit. Tobacco use includes two
tobacco cessation attempts per year (both prescription and over-the-counter medications) for a 90-day
treatment regimen when prescribed by an in-network health care provider without prior authorization.
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
4
Drug Name Drug
Category
Requirements
/ Limits
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
AMBISOME 6 MSD
amphotericin b 6 MSD
ANCOBON 3
CANCIDAS 6 MSD
caspofungin 6 MSD
clotrimazole 1
CRESEMBA
INTRAVENOUS
6 MSD
CRESEMBA ORAL 2
DIFLUCAN ORAL
SUSPENSION FOR
RECONSTITUTIO
N
3
DIFLUCAN ORAL
TABLET 100 MG,
200 MG, 50 MG
3
DIFLUCAN ORAL
TABLET 150 MG
3 QL
ERAXIS(WATER
DILUENT)
6 MSD
fluconazole in
dextrose(iso-o)
6 MSD
fluconazole in nacl
(iso-osm)
6 MSD
fluconazole oral
suspension for
reconstitution
1
fluconazole oral
tablet 100 mg, 200
mg, 50 mg
1
fluconazole oral
tablet 150 mg
1 QL
flucytosine 1
Drug Name Drug
Category
Requirements
/ Limits
griseofulvin
microsize
1
griseofulvin
ultramicrosize
1
itraconazole 1 QL
ketoconazole 1
NOXAFIL 2
nystatin 1
ONMEL 3 QL
ORAVIG 3
SPORANOX 2
SPORANOX
PULSEPAK
3 QL
terbinafine hcl 1
VFEND 3
VFEND IV 6 MSD
voriconazole
intravenous
6 MSD
voriconazole oral 1
ANTIVIRALS
abacavir 1 S; QL
abacavir-lamivudine 1 S; QL
abacavir-
lamivudine-
zidovudine
1 S; QL
acyclovir 1
adefovir 1
amantadine hcl 1 M
APTIVUS 3 S; QL
atazanavir 1 S
ATRIPLA 3 S; QL
BARACLUDE
ORAL SOLUTION
2
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
5
Drug Name Drug
Category
Requirements
/ Limits
BARACLUDE
ORAL TABLET
3
BIKTARVY 3 S
cidofovir 6 MSD
CIMDUO 4 S
COMBIVIR 4 S; QL
COMPLERA 3 S; QL
CRIXIVAN 3 S; QL
CYTOVENE 6 MSD
DAKLINZA 4 PA; ST; S;
SLA
DESCOVY 3 S
didanosine 1 S; QL
EDURANT 3 S; QL
efavirenz 1 S; QL
EMTRIVA 3 S; QL
entecavir 1
EPCLUSA 3 PA; S; SLA
EPIVIR 4 S; QL
EPIVIR HBV
ORAL SOLUTION
2
EPIVIR HBV
ORAL TABLET
3 QL
EPZICOM 4 S; QL
EVOTAZ 4 S; QL
famciclovir 1 QL
FLUMADINE 3
fosamprenavir 1 S; QL
FOSCAVIR 6 MSD
FUZEON 3 S; QL
GANCICLOVIR 6 MSD
ganciclovir sodium 6 MSD
GENVOYA 3 S
Drug Name Drug
Category
Requirements
/ Limits
HARVONI 3 PA; S; SLA;
QL
HEPSERA 3
INTELENCE 3 S; QL
INVIRASE 3 S; QL
ISENTRESS 3 S; QL
ISENTRESS HD 3 S
JULUCA 4 S
KALETRA ORAL
SOLUTION
4 S; QL
KALETRA ORAL
TABLET
3 S; QL
lamivudine oral
solution
1 S; QL
lamivudine oral
tablet 100 mg
1 QL
lamivudine oral
tablet 150 mg, 300
mg
1 S; QL
lamivudine-
zidovudine
1 S; QL
LEXIVA ORAL
SUSPENSION
3 S; QL
LEXIVA ORAL
TABLET
4 S; QL
lopinavir-ritonavir 1 S; QL
MAVYRET 3 S
nevirapine 1 S; QL
NORVIR ORAL
CAPSULE
3 S; QL
NORVIR ORAL
POWDER IN
PACKET
3 S
NORVIR ORAL
SOLUTION
3 S; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
6
Drug Name Drug
Category
Requirements
/ Limits
NORVIR ORAL
TABLET
4 S; QL
ODEFSEY 3 S
oseltamivir 1 QL
PREVYMIS
INTRAVENOUS
6 MSD
PREVYMIS ORAL 2
PREZCOBIX 4 S
PREZISTA 3 S; QL
RELENZA
DISKHALER
2 QL
RESCRIPTOR 3 S; QL
RETROVIR
INTRAVENOUS
6 MSD
RETROVIR ORAL 4 S; QL
REYATAZ ORAL
CAPSULE
4 S
REYATAZ ORAL
POWDER IN
PACKET
3 S
ribavirin 1 S; SLA
rimantadine 1
ritonavir 1 S; QL
SELZENTRY
ORAL SOLUTION
3 PA; S
SELZENTRY
ORAL TABLET
150 MG, 300 MG
3 PA; S; QL
SELZENTRY
ORAL TABLET 25
MG, 75 MG
3 PA; S
SOVALDI 4 PA; ST; S;
SLA; QL
stavudine 1 S; QL
STRIBILD 3 S; QL
Drug Name Drug
Category
Requirements
/ Limits
SUSTIVA 4 S; QL
SYMFI 4 S
SYMFI LO 4 S
SYNAGIS 6 MSD
TAMIFLU 2 QL
TECHNIVIE 3 PA; S; SLA
tenofovir disoproxil
fumarate
1 S; QL
TIVICAY ORAL
TABLET 10 MG, 25
MG
3 S
TIVICAY ORAL
TABLET 50 MG
3 S; QL
TRIUMEQ 3 S; QL
TRIZIVIR 4 S; QL
TROGARZO 6 MSD
TRUVADA ORAL
TABLET 100-150
MG, 133-200 MG,
167-250 MG
3 S
TRUVADA ORAL
TABLET 200-300
MG
3 S; QL
TYBOST 4 S; QL
valacyclovir 1 QL
VALCYTE 3
valganciclovir 1
VALTREX 3 ST; QL
VEMLIDY 2
VIDEX 2 GRAM
PEDIATRIC
3 S; QL
VIDEX EC 4 S; QL
VIEKIRA PAK 3 PA; S; SLA;
QL
VIEKIRA XR 3 PA; S; SLA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
7
Drug Name Drug
Category
Requirements
/ Limits
VIRACEPT 3 S; QL
VIRAMUNE 4 S; QL
VIRAMUNE XR 4 S; QL
VIRAZOLE 4 S; SLA
VIREAD ORAL
POWDER
3 S; QL
VIREAD ORAL
TABLET 150 MG,
200 MG, 250 MG
3 S; QL
VIREAD ORAL
TABLET 300 MG
4 S; QL
VOSEVI 3 S; SLA
ZEPATIER 4 PA; ST; S;
SLA
ZERIT 4 S; QL
ZIAGEN 4 S; QL
zidovudine 1 S; QL
ZOVIRAX 3
CEPHALOSPORINS
AVYCAZ 6 MSD
cefaclor 1
cefadroxil 1
cefazolin 6 MSD
CEFAZOLIN IN
0.9% SOD
CHLORIDE
6 MSD
cefazolin in dextrose
(iso-os) intravenous
piggyback 1 gram/50
ml, 2 gram/50 ml
6 MSD
CEFAZOLIN IN
DEXTROSE (ISO-
OS)
INTRAVENOUS
PIGGYBACK 2
GRAM/100 ML
6 MSD
Drug Name Drug
Category
Requirements
/ Limits
CEFAZOLIN IN
DEXTROSE 5 %
6 MSD
CEFAZOLIN IN
STERILE WATER
6 MSD
cefdinir 1
cefditoren pivoxil 1
cefepime 6 MSD
cefepime in
dextrose,iso-osm
6 MSD
cefixime 1
CEFOTAN 6 MSD
cefotaxime 6 MSD
cefotetan 6 MSD
cefoxitin 6 MSD
cefpodoxime 1
cefprozil 1
ceftriaxone in
dextrose,iso-os
6 MSD
ceftriaxone injection
recon soln 1 gram,
10 gram, 2 gram,
250 mg, 500 mg
6 MSD
CEFTRIAXONE
INJECTION
RECON SOLN 100
GRAM
6 MSD
cefuroxime axetil 1
cefuroxime sodium 6 MSD
cephalexin 1
CLAFORAN 6 MSD
DAXBIA 3
KEFLEX 3
MAXIPIME 6 MSD
SPECTRACEF 3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
8
Drug Name Drug
Category
Requirements
/ Limits
SUPRAX 3
TAZICEF 6 MSD
TEFLARO 6 MSD
ERYTHROMYCINS & OTHER
MACROLIDES
azithromycin
intravenous
6 MSD
azithromycin oral 1
clarithromycin 1
DIFICID 3
e.e.s. 400 1
E.E.S. GRANULES 3
ERYPED 200 3
ERYPED 400 3
ery-tab oral
tablet,delayed
release (dr/ec) 250
mg, 333 mg
1
ERY-TAB ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 500 MG
3
erythrocin (as
stearate)
1
erythromycin 1
erythromycin
ethylsuccinate
1
ZITHROMAX
INTRAVENOUS
6 MSD
ZITHROMAX
ORAL
3
ZITHROMAX TRI-
PAK
3
ZITHROMAX Z-
PAK
3
Drug Name Drug
Category
Requirements
/ Limits
MISCELLANEOUS
ANTIINFECTIVES
ALBENZA 2 QL
ALINIA 2 QL
amikacin 6 MSD
atovaquone 1
atovaquone-
proguanil
1 QL
BENZNIDAZOLE 2
BETHKIS 6 MSD
BILTRICIDE 2
CAPASTAT 6 MSD
CAYSTON 3 S; SLA; QL
chloramphenicol sod
succinate
6 MSD
chloroquine
phosphate
1
CLEOCIN HCL 3
CLEOCIN IN 5 %
DEXTROSE
6 MSD
CLEOCIN
INJECTION
6 MSD
cleocin intravenous
solution 300 mg/2 ml
6 MSD
CLEOCIN
INTRAVENOUS
SOLUTION 600
MG/4 ML, 900
MG/6 ML
6 MSD
CLEOCIN
PEDIATRIC
3
CLIN SINGLE USE 6 MSD
clindamycin hcl 1
CLINDAMYCIN IN
0.9 % SOD CHLOR
6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
9
Drug Name Drug
Category
Requirements
/ Limits
clindamycin in 5 %
dextrose
6 MSD
clindamycin
palmitate hcl
1
clindamycin
pediatric
1
clindamycin
phosphate
6 MSD
COARTEM 2 QL
colistin
(colistimethate na)
1
COLY-MYCIN M
PARENTERAL
3
CUBICIN 6 MSD
CUBICIN RF 6 MSD
CYCLOSERINE 3
dapsone 1 M
daptomycin 6 MSD
DARAPRIM 2 PA; SLA
DORIPENEM 6 MSD
EMVERM 2 QL
ethambutol 1
FLAGYL 3
gentamicin 6 MSD
gentamicin in nacl
(iso-osm)
intravenous
piggyback 100
mg/100 ml, 60 mg/50
ml, 70 mg/50 ml, 80
mg/100 ml, 80 mg/50
ml, 90 mg/100 ml
1
GENTAMICIN IN
NACL (ISO-OSM)
INTRAVENOUS
PIGGYBACK 100
MG/50 ML
2
Drug Name Drug
Category
Requirements
/ Limits
GENTAMICIN IN
NACL (ISO-OSM)
INTRAVENOUS
PIGGYBACK 120
MG/100 ML
3
gentamicin sulfate
(ped) (pf)
1
gentamicin sulfate
(pf) intravenous
solution 100 mg/10
ml
1
GENTAMICIN
SULFATE (PF)
INTRAVENOUS
SOLUTION 60
MG/6 ML
3
GENTAMICIN-
SODIUM CITRATE
6 MSD
hydroxychloroquine 1 M
imipenem-cilastatin 6 MSD
IMPAVIDO 3 S; QL
INVANZ 6 MSD
isoniazid 1
ivermectin 1 QL
KITABIS PAK 3 S; SLA
LINCOCIN 6 MSD
lincomycin 6 MSD
linezolid 1 PA
linezolid in dextrose
5%
6 MSD
MALARONE 3 QL
MALARONE
PEDIATRIC
3 QL
mefloquine 1 QL
MEPRON 3
meropenem 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
10
Drug Name Drug
Category
Requirements
/ Limits
MEROPENEM-
0.9% SODIUM
CHLORIDE
6 MSD
MERREM 6 MSD
metro i.v. 6 MSD
metronidazole 1
metronidazole in
nacl (iso-os)
6 MSD
MYAMBUTOL 3
MYCOBUTIN 3
NEBUPENT 2 QL
neomycin 1
paromomycin 1
PASER 3
PLAQUENIL 3 ST; M
polymyxin b sulfate 6 MSD
praziquantel 1
PRIFTIN 2
PRIMAQUINE 2 M; QL
PRIMAXIN IV 6 MSD
pyrazinamide 1
QUALAQUIN 3 QL
quinine sulfate 1 QL
rifabutin 1
RIFADIN
INTRAVENOUS
6 MSD
RIFADIN ORAL 3
RIFAMATE 3
rifampin intravenous 6 MSD
rifampin oral 1
RIFATER 3
RIMSO-50 3
SIRTURO 2 SLA
Drug Name Drug
Category
Requirements
/ Limits
SIVEXTRO 3 PA
SOLOSEC 3
STREPTOMYCIN 6 MSD
STROMECTOL 3 QL
SYNERCID 6 MSD
tigecycline 6
TINDAMAX 3 QL
tinidazole 1 QL
TOBI 3 ST; QL
TOBI PODHALER 2 QL
tobramycin in 0.225
% nacl
1 QL
tobramycin sulfate 6 MSD
TOBRAMYCIN
WITH NEBULIZER
4 S
TRECATOR 3
TYGACIL 6 MSD
VABOMERE 6 MSD
XIFAXAN 2
ZYVOX
INTRAVENOUS
6 MSD
ZYVOX ORAL 3 PA
PENICILLINS
amoxicillin 1
amoxicillin-pot
clavulanate
1
ampicillin 1
ampicillin sodium 6 MSD
ampicillin-sulbactam 6 MSD
AUGMENTIN ES-
600
3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
11
Drug Name Drug
Category
Requirements
/ Limits
AUGMENTIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N 125-31.25 MG/5
ML
2
AUGMENTIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N 250-62.5 MG/5
ML
3
AUGMENTIN
ORAL TABLET
3
AUGMENTIN XR 3
BICILLIN C-R 6 MSD
dicloxacillin 1
MOXATAG 3
nafcillin 6 MSD
oxacillin 6 MSD
oxacillin in
dextrose(iso-osm)
6 MSD
penicillin g
potassium
6 MSD
penicillin v
potassium
1
pfizerpen-g 6 MSD
PIPERACILLIN-
TAZOBACTAM
INTRAVENOUS
RECON SOLN 13.5
GRAM
6 MSD
piperacillin-
tazobactam
intravenous recon
soln 2.25 gram,
3.375 gram, 4.5
gram, 40.5 gram
6 MSD
UNASYN 6 MSD
Drug Name Drug
Category
Requirements
/ Limits
QUINOLONES
AVELOX 3
AVELOX IN NACL
(ISO-OSMOTIC)
6 MSD
BAXDELA
INTRAVENOUS
6 MSD
BAXDELA ORAL 3
CIPRO 3
CIPRO XR 3
ciprofloxacin 1
ciprofloxacin
(mixture)
1
ciprofloxacin hcl 1
FACTIVE 3
LEVAQUIN 3
levofloxacin in d5w 6 MSD
levofloxacin
intravenous
6 MSD
levofloxacin oral 1
moxifloxacin 1
moxifloxacin in nacl
(iso-osm)
6 MSD
ofloxacin 1
SULFA'S & RELATED AGENTS
BACTRIM 3
BACTRIM DS 3
sulfadiazine 1
sulfamethoxazole-
trimethoprim
intravenous
6
sulfamethoxazole-
trimethoprim oral
1
sulfatrim 1
TETRACYCLINES
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
12
Drug Name Drug
Category
Requirements
/ Limits
ACTICLATE 3 ST
avidoxy 1
coremino 1
demeclocycline 1
DORYX 3 ST
DORYX MPC 3 ST
doxycycline hyclate 1
doxycycline
monohydrate oral
capsule
1
DOXYCYCLINE
MONOHYDRATE
ORAL
CAPSULE,IR -
DELAY
REL,BIPHASE
3 ST
doxycycline
monohydrate oral
suspension for
reconstitution
1
doxycycline
monohydrate oral
tablet
1
MINOCIN 3 ST
minocycline 1
mondoxyne nl 1
MONODOX 3 ST
morgidox 1
ORACEA 2 ST
SOLODYN 2 ST
soloxide 1
TARGADOX 3 ST
tetracycline 1
VIBRAMYCIN 3 ST
XIMINO 3 ST
Drug Name Drug
Category
Requirements
/ Limits
URINARY TRACT AGENTS
FURADANTIN 3
HIPREX 3
MACROBID 3
MACRODANTIN 3
methenamine
hippurate
1
methenamine
mandelate
1
MONUROL 3
nitrofurantoin 1
nitrofurantoin
macrocrystal
1
nitrofurantoin
monohyd/m-cryst
1
PRIMSOL 3
trimethoprim 1
TRIMPEX 3
VANCOMYCIN
FIRVANQ 3
VANCOCIN 3
VANCOMYCIN IN
0.9 % SODIUM
CHL
6 MSD
VANCOMYCIN IN
DEXTROSE 5 %
6 MSD
VANCOMYCIN
INJECTION
6 MSD
vancomycin
intravenous
6 MSD
vancomycin oral 1
VIBATIV 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
13
Drug Name Drug
Category
Requirements
/ Limits
ANTINEOPLASTIC &
IMMUNOSUPPRESSANT
DRUGS
ADJUNCTIVE AGENTS
amifostine
crystalline
6 MSD
dexrazoxane hcl 6 MSD
ELITEK 6 MSD
ETHYOL 6 MSD
FUSILEV 6 MSD
KEPIVANCE 6 MSD
leucovorin calcium
injection
1 S
leucovorin calcium
oral
1
LEVOLEUCOVORI
N INTRAVENOUS
RECON SOLN 175
MG
6 MSD
levoleucovorin
intravenous recon
soln 50 mg
6 MSD
levoleucovorin
intravenous solution
6 MSD
mesna 6 MSD
MESNEX
INTRAVENOUS
6 MSD
MESNEX ORAL 2
TOTECT 6 MSD
VISTOGARD 2 SLA
VORAXAZE 6 MSD
XGEVA 6 MSD
ZINECARD (AS
HCL)
6 MSD
Drug Name Drug
Category
Requirements
/ Limits
ANTINEOPLASTIC &
IMMUNOSUPPRESSANT DRUGS
ABRAXANE 6 MSD
ADCETRIS 6 MSD
adriamycin 6 MSD
adrucil 6 MSD
AFINITOR 3 S; QL
AFINITOR
DISPERZ
3 S; QL
ALECENSA 3 S; SLA
ALIQOPA 6 MSD
ALKERAN
INTRAVENOUS
6 MSD
ALKERAN ORAL 3
ALUNBRIG 4 S
anastrozole 1
ARIMIDEX 3
AROMASIN 4 S
ARRANON 6 MSD
ARZERRA 6 MSD
ASTAGRAF XL 3 ST
AVASTIN 6 MSD
azacitidine 6 MSD
AZASAN 3
azathioprine 1
BAVENCIO 6 MSD
BELEODAQ 6 MSD
BENDEKA 6 MSD
BESPONSA 2
bexarotene 1 S
bicalutamide 1
BICNU 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
14
Drug Name Drug
Category
Requirements
/ Limits
bleomycin 6 MSD
BLINCYTO 6 MSD
BORTEZOMIB 6 MSD
BOSULIF 3 S; SLA
busulfan 6 MSD
BUSULFEX 6 MSD
CABOMETYX 3 S
CALQUENCE 3 SLA
CAMPTOSAR 6 MSD
capecitabine 1 S
CAPRELSA 2 S; SLA; QL
carboplatin 6 MSD
CASODEX 3
CELLCEPT 3
CELLCEPT
INTRAVENOUS
6 MSD
cisplatin 6 MSD
cladribine 6 MSD
clofarabine 6 MSD
CLOLAR 6 MSD
COMETRIQ 3 SLA; QL
COSMEGEN 6 MSD
COTELLIC 3 S; SLA
cyclophosphamide
intravenous
6 MSD
cyclophosphamide
oral
1
cyclosporine
intravenous
1 S
cyclosporine
modified
1
cyclosporine oral 1
CYRAMZA 6 MSD
Drug Name Drug
Category
Requirements
/ Limits
cytarabine 6 MSD
cytarabine (pf) 6 MSD
dacarbazine 6 MSD
DACOGEN 6 MSD
dactinomycin 6 MSD
DARZALEX 6 MSD
daunorubicin 6 MSD
decitabine 6 MSD
DOCEFREZ 6 MSD
docetaxel
intravenous solution
160 mg/16 ml (10
mg/ml), 160 mg/8 ml
(20 mg/ml), 20 mg/2
ml (10 mg/ml), 20
mg/ml (1 ml), 80
mg/4 ml (20 mg/ml),
80 mg/8 ml (10
mg/ml)
6 MSD
DOCETAXEL
INTRAVENOUS
SOLUTION 20
MG/ML
6 MSD
DOXIL 6 MSD
doxorubicin 6 MSD
doxorubicin, peg-
liposomal
6 MSD
DROXIA 3 S
ELIGARD 3 S
ELIGARD (3
MONTH)
3 S
ELIGARD (4
MONTH)
3 S
ELIGARD (6
MONTH)
3 S
ELLENCE 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
15
Drug Name Drug
Category
Requirements
/ Limits
EMCYT 3 S
EMPLICITI 6 MSD
ENVARSUS XR 3 ST
epirubicin 6 MSD
ERBITUX 6 MSD
ERIVEDGE 3 S; SLA
ERLEADA 2
ERWINAZE 6 MSD
etoposide
intravenous
6 MSD
etoposide oral 1 S
EVOMELA 6 MSD
exemestane 1 S
FARESTON 3 S
FARYDAK 4 S
FASLODEX 6 MSD
FEMARA 3
FIRMAGON KIT W
DILUENT
SYRINGE
3 S; SLA
floxuridine 6 MSD
fludarabine 6 MSD
fluorouracil 6 MSD
flutamide 1
FOLOTYN 6 MSD
GAZYVA 6 MSD
gemcitabine
intravenous recon
soln
6 MSD
Drug Name Drug
Category
Requirements
/ Limits
gemcitabine
intravenous solution
1 gram/26.3 ml (38
mg/ml), 2 gram/52.6
ml (38 mg/ml), 200
mg/5.26 ml (38
mg/ml)
6 MSD
GEMCITABINE
INTRAVENOUS
SOLUTION 100
MG/ML
6 MSD
GEMZAR 6 MSD
gengraf 1
GILOTRIF 3 S
GLEEVEC 4 S; QL
GLEOSTINE 3 S
GLIADEL WAFER 6
HALAVEN 6 MSD
HERCEPTIN 6 MSD
HEXALEN 3 S
HYCAMTIN
INTRAVENOUS
6 MSD
HYCAMTIN ORAL 3 S
HYDREA 3
hydroxyurea 1
IBRANCE 3 S
ICLUSIG 2 SLA
IDAMYCIN PFS 6 MSD
idarubicin 6 MSD
IDHIFA 3 S
IFEX 6 MSD
ifosfamide 6 MSD
ifosfamide-mesna 6 MSD
imatinib 1 S; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
16
Drug Name Drug
Category
Requirements
/ Limits
IMBRUVICA 2 SLA
IMFINZI 6 MSD
IMLYGIC 6 MSD
IMURAN 3
INLYTA 3 S; SLA; QL
IRESSA 3 S; SLA
irinotecan 6 MSD
ISTODAX 6 MSD
IXEMPRA 6 MSD
JAKAFI 3 S; SLA; QL
JEVTANA 6 MSD
KADCYLA 6 MSD
KISQALI 4 S
KISQALI FEMARA
CO-PACK
4 S
KYMRIAH 6 MSD
KYPROLIS 6 MSD
LARTRUVO 6 MSD
LENVIMA 3 S
letrozole 1
LEUKERAN 2
leuprolide 1 S
lipodox 6 MSD
lipodox 50 6 MSD
LONSURF 3 S
LUPRON DEPOT
(3 MONTH)
INTRAMUSCULA
R SYRINGE KIT
11.25 MG
3 S
Drug Name Drug
Category
Requirements
/ Limits
LUPRON DEPOT
(3 MONTH)
INTRAMUSCULA
R SYRINGE KIT
22.5 MG
4 S
LUPRON DEPOT
(4 MONTH)
4 S
LUPRON DEPOT
(6 MONTH)
4 S
LUPRON DEPOT
INTRAMUSCULA
R SYRINGE KIT
3.75 MG
3 S
LUPRON DEPOT
INTRAMUSCULA
R SYRINGE KIT
7.5 MG
4 S
LUPRON DEPOT-
PED
3 S
LYNPARZA 3 S; SLA
LYSODREN 3 S
MARQIBO 6 MSD
MATULANE 2 SLA
MEGACE ES 3
megestrol oral
suspension
1
megestrol oral tablet 1 S
MEKINIST 3 S
melphalan 1
melphalan hcl 6 MSD
mercaptopurine 1
methotrexate sodium 1
methotrexate sodium
(pf)
1
mitomycin 6 MSD
mitoxantrone 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
17
Drug Name Drug
Category
Requirements
/ Limits
MUSTARGEN 6 MSD
MUTAMYCIN 6 MSD
mycophenolate
mofetil
1
mycophenolate
mofetil hcl
6 MSD
mycophenolate
sodium
1
MYFORTIC 3
MYLERAN 3 S
MYLOTARG 6 MSD
NAVELBINE 6 MSD
NEORAL 3
NERLYNX 3 S
NEXAVAR 3 S; QL
NILANDRON 4 S
nilutamide 1 S
NINLARO 3 S; SLA
NIPENT 6 MSD
NULOJIX 6 MSD
octreotide acetate 1 S; SLA
ODOMZO 4 S
ONCASPAR 6 MSD
ONIVYDE 6 MSD
OPDIVO 6 MSD
oxaliplatin 6 MSD
paclitaxel 6 MSD
PERJETA 6 MSD
PORTRAZZA 6 MSD
PROGRAF 3
PURIXAN 2 SLA
RAPAMUNE
ORAL SOLUTION
2
Drug Name Drug
Category
Requirements
/ Limits
RAPAMUNE
ORAL TABLET
3
RITUXAN 6 MSD
RITUXAN
HYCELA
6 MSD
ROMIDEPSIN 6 MSD
RUBRACA 2 PA; SLA
RYDAPT 3 S
SANDIMMUNE
INTRAVENOUS
4 S
SANDIMMUNE
ORAL CAPSULE
3
SANDIMMUNE
ORAL SOLUTION
2
SANDOSTATIN 4 S; SLA
SANDOSTATIN
LAR DEPOT
6 MSD
SIGNIFOR 6 MSD
SIGNIFOR LAR 6 MSD
SIKLOS 4
SIMULECT 6 MSD
sirolimus 1
SOLTAMOX 3
SOMATULINE
DEPOT
3 S; SLA
SPRYCEL 3 S; QL
STIVARGA 3 S
SUPPRELIN LA 6 MSD
SUTENT 3 S; QL
SYLVANT 6 MSD
SYNRIBO 6 MSD
TABLOID 3 S
tacrolimus 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
18
Drug Name Drug
Category
Requirements
/ Limits
TAFINLAR 3 S
TAGRISSO 3 S
tamoxifen 1
TARCEVA 3 S; QL
TARGRETIN
ORAL
4 S
TARGRETIN
TOPICAL
2
TASIGNA 3 S; QL
TAXOTERE 6 MSD
TECENTRIQ 6 MSD
TEMODAR 4 S
temozolomide 1 S
TENIPOSIDE 6 MSD
TEPADINA 6 MSD
THALOMID 3 S
thiotepa 6 MSD
toposar 6 MSD
topotecan 6 MSD
TORISEL 6 MSD
TREANDA 6 MSD
TRELSTAR 6 MSD
tretinoin
(chemotherapy)
1 S
TREXALL 3
TRIPTODUR 6 MSD
TRISENOX 6 MSD
TYKERB 3 S; QL
UNITUXIN 6 MSD
VANTAS 6 MSD
VECTIBIX 6 MSD
VELCADE 6 MSD
Drug Name Drug
Category
Requirements
/ Limits
VENCLEXTA 2 SLA
VERZENIO 3 S
VIDAZA 6 MSD
vinblastine 6 MSD
vincasar pfs 6 MSD
vincristine 6 MSD
vinorelbine 6 MSD
VOTRIENT 3 S; QL
VYXEOS 6 MSD
XALKORI 3 S; QL
XATMEP 4 ST; S
XELODA 4 S
XERMELO 2 PA; SLA
XTANDI 3 S; QL
YERVOY 6 MSD
YONDELIS 6 MSD
YONSA 3
ZALTRAP 6 MSD
ZANOSAR 6 MSD
ZEJULA 2 SLA
ZELBORAF 3 S; QL
ZEVALIN (Y-90) 6 MSD
ZOLADEX 6 MSD
ZOLINZA 3 S; QL
ZORTRESS 2
ZYDELIG 2 SLA
ZYKADIA 3 S; SLA
ZYTIGA 3 S; QL
AUTONOMIC & CNS DRUGS,
NEUROLOGY & PSYCH
ANTICONVULSANTS
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
19
Drug Name Drug
Category
Requirements
/ Limits
APTIOM 3
BANZEL 2
BRIVIACT 3 ST
carbamazepine 1
CARBATROL 3
CELONTIN 2
clonazepam 1
DEPACON 6 MSD
DEPAKENE 3 ST
DEPAKOTE 3 ST
DEPAKOTE ER 3 ST
DEPAKOTE
SPRINKLES
3 ST
DIASTAT 3
DIASTAT
ACUDIAL
3
diazepam 1
DILANTIN 2
DILANTIN
EXTENDED
3
DILANTIN
INFATABS
3
DILANTIN-125 3
divalproex 1
epitol 1
EQUETRO 3
ethosuximide 1
felbamate 1
FELBATOL 3
fosphenytoin 6 MSD
FYCOMPA 2
gabapentin 1
GABITRIL 3
Drug Name Drug
Category
Requirements
/ Limits
GRALISE 2 ST; QL
GRALISE 30-DAY
STARTER PACK
2 ST; QL
KEPPRA
INTRAVENOUS
6 MSD
KEPPRA ORAL 3 ST
KEPPRA XR 3 ST
KLONOPIN 3
LAMICTAL 3 ST
LAMICTAL ODT 3 ST
LAMICTAL ODT
STARTER (BLUE)
3 ST
LAMICTAL ODT
STARTER
(GREEN)
3 ST
LAMICTAL ODT
STARTER
(ORANGE)
3 ST
LAMICTAL
STARTER (BLUE)
KIT
3 ST
LAMICTAL
STARTER
(GREEN) KIT
3 ST
LAMICTAL
STARTER
(ORANGE) KIT
3 ST
LAMICTAL XR 3 ST
LAMICTAL XR
STARTER (BLUE)
3 ST
LAMICTAL XR
STARTER
(GREEN)
3 ST
LAMICTAL XR
STARTER
(ORANGE)
3 ST
lamotrigine 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
20
Drug Name Drug
Category
Requirements
/ Limits
levetiracetam in nacl
(iso-os)
6 MSD
levetiracetam
intravenous
6 MSD
levetiracetam oral 1
LYRICA CR 3 ST
LYRICA ORAL
CAPSULE
2 ST
LYRICA ORAL
SOLUTION
2
MYSOLINE 3
NEURONTIN 3 ST
ONFI 2
oxcarbazepine 1
OXTELLAR XR 3 ST
PEGANONE 2
PHENYTEK 3
phenytoin 1
phenytoin sodium
extended
1
primidone 1
QUDEXY XR 2 ST
roweepra 1
roweepra xr 1
SABRIL 3 PA; S; SLA
subvenite 1
subvenite starter
(blue) kit
1
subvenite starter
(green) kit
1
subvenite starter
(orange) kit
1
TEGRETOL 3
TEGRETOL XR 3
Drug Name Drug
Category
Requirements
/ Limits
tiagabine 1
TOPAMAX 3 ST
topiramate oral
capsule, sprinkle
1 PA
TOPIRAMATE
ORAL
CAPSULE,SPRINK
LE,ER 24HR
3 ST
topiramate oral
tablet
1 PA
TRILEPTAL 3 ST
TROKENDI XR 3 ST
valproate sodium 6 MSD
valproic acid 1
valproic acid (as
sodium salt)
1
vigabatrin 1 PA; S; SLA
VIMPAT 2
ZARONTIN 3
ZONEGRAN ORAL
CAPSULE 100 MG
3 PA
ZONEGRAN ORAL
CAPSULE 25 MG
3
zonisamide 1 PA
ANTIPARKINSONISM AGENTS
APOKYN 3 S; SLA
AZILECT 3 M
benztropine 1
bromocriptine 1
carbidopa 1 M
carbidopa-levodopa 1 M
carbidopa-levodopa-
entacapone
1 M
COMTAN 3 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
21
Drug Name Drug
Category
Requirements
/ Limits
DUOPA 6 MSD
entacapone 1 M
GOCOVRI 3 PA; SLA
LODOSYN 3 M
MIRAPEX 3 M
MIRAPEX ER 3 M
NEUPRO 3 M
OSMOLEX ER 3 PA; M
PARLODEL 3
pramipexole 1 M
rasagiline 1 M
REQUIP 3 M
REQUIP XL 3 M
ropinirole 1 M
RYTARY 3 M
selegiline hcl 1 M
SINEMET 3 M
SINEMET CR 3 M
STALEVO 100 3 M
STALEVO 125 3 M
STALEVO 150 3 M
STALEVO 200 3 M
STALEVO 50 3 M
STALEVO 75 3 M
TASMAR 3 M
tolcapone 1 M
trihexyphenidyl 1
XADAGO 3 M
ZELAPAR 3 M
MIGRAINE & CLUSTER
HEADACHE THERAPY
Drug Name Drug
Category
Requirements
/ Limits
AIMOVIG
AUTOINJECTOR
2
AIMOVIG
AUTOINJECTOR
(2 PACK)
2
almotriptan malate 1 QL
AMERGE 3 ST; QL
AXERT 3 ST; QL
CAFERGOT 3
D.H.E.45 3
dihydroergotamine
injection
1
dihydroergotamine
nasal
1 QL
eletriptan 1 QL
ERGOMAR 3
ergotamine-caffeine 1
frovatriptan 1 QL
IMITREX 3 ST; QL
IMITREX
STATDOSE KIT
REFILL
3 ST; QL
IMITREX
STATDOSE PEN
3 ST; QL
isometh-dichloral-
acetaminophn
1
isomethepten-caf-
acetaminophen
1
MAXALT 3 ST; QL
MAXALT-MLT 3 ST; QL
migergot 1
MIGRANAL 3 QL
naratriptan 1 QL
ONZETRA XSAIL 3 QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
22
Drug Name Drug
Category
Requirements
/ Limits
PRODRIN 3
RELPAX 3 ST; QL
rizatriptan 1 QL
sumatriptan 1 QL
sumatriptan
succinate
1 QL
sumatriptan-
naproxen
1 QL
SUMAVEL
DOSEPRO
3 ST; QL
TREXIMET 3 ST; QL
ZEMBRACE
SYMTOUCH
3 QL
zolmitriptan 1 QL
ZOMIG NASAL 2 QL
ZOMIG ORAL 3 ST; QL
ZOMIG ZMT 3 ST; QL
MISCELLANEOUS
NEUROLOGICAL THERAPY
AMPYRA 3 PA; S; SLA;
QL
ARICEPT 3 ST; M
AUSTEDO 3 PA; SLA
donepezil oral tablet
10 mg, 5 mg
1 M
donepezil oral tablet
23 mg
1 ST; M
donepezil oral
tablet,disintegrating
1 M
EXELON 3 ST; M; QL
EXONDYS 51 6 MSD
galantamine oral
capsule,ext rel.
pellets 24 hr
1 M; QL
Drug Name Drug
Category
Requirements
/ Limits
galantamine oral
solution
1 M; QL
galantamine oral
tablet 12 mg
1 M
galantamine oral
tablet 4 mg, 8 mg
1 M; QL
HORIZANT 3 ST; QL
INGREZZA 3 PA; SLA
KEVEYIS 3 PA; SLA
memantine oral
capsule,sprinkle,er
24hr
1 M; QL
memantine oral
solution
1 M
memantine oral
tablet
1 M
MEMANTINE
ORAL
TABLETS,DOSE
PACK
3 M; QL
NAMENDA 3 ST; M
NAMENDA
TITRATION PAK
3 M; QL
NAMENDA XR
ORAL
CAP,SPRINKLE,ER
24HR DOSE PACK
2 M; QL
NAMENDA XR
ORAL
CAPSULE,SPRINK
LE,ER 24HR
2 ST; M; QL
NAMZARIC 2 ST
NUEDEXTA 2 PA
RADICAVA 6 MSD
RAZADYNE ER 3 ST; M; QL
RAZADYNE ORAL
TABLET 12 MG
3 ST; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
23
Drug Name Drug
Category
Requirements
/ Limits
RAZADYNE ORAL
TABLET 4 MG, 8
MG
3 ST; M; QL
rivastigmine 1 M; QL
rivastigmine tartrate 1 M; QL
tetrabenazine 1 PA
TYSABRI 6 MSD
XENAZINE 3 PA; ST
MUSCLE RELAXANTS &
ANTISPASMODIC THERAPY
AMRIX 3 ST
baclofen oral tablet
10 mg, 20 mg
1 M
BACLOFEN ORAL
TABLET 5 MG
3 M
BRIDION 6 MSD
carisoprodol 1
carisoprodol-asa-
codeine
1
carisoprodol-aspirin 1
chlorzoxazone 1
cyclobenzaprine 1
CYCLOTENS
REFILL
3
CYCLOTENS
STARTER
3
DANTRIUM 3 M
dantrolene 1 M
FEXMID 3 ST
LORZONE 3 ST
meprobamate 1
MESTINON ORAL
SYRUP
2 M
Drug Name Drug
Category
Requirements
/ Limits
MESTINON ORAL
TABLET
3 M
MESTINON
TIMESPAN
3 M
metaxall 1
metaxalone 1
methocarbamol
injection
6 MSD
methocarbamol oral 1
orphenadrine citrate 1
pyridostigmine
bromide
1 M
ROBAXIN
INJECTION
6 MSD
ROBAXIN ORAL 3
ROBAXIN-750 3
SKELAXIN 3
SOMA 3
tizanidine 1
ZANAFLEX 3
NARCOTIC ANALGESICS
ABSTRAL 3 ST; QL
acetaminophen-caff-
dihydrocod oral
capsule
1
ACETAMINOPHE
N-CAFF-
DIHYDROCOD
ORAL TABLET
3
acetaminophen-
codeine
1
ACTIQ 3 ST; QL
ALLZITAL 3 ST
ARYMO ER 3 ST; QL
ascomp with codeine 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
24
Drug Name Drug
Category
Requirements
/ Limits
BELBUCA 3 PA
BUPAP 3 ST
BUPRENEX 6 MSD
BUPRENORPHINE 3 ST
buprenorphine hcl
injection
6 MSD
buprenorphine hcl
sublingual
1
butalbital compound
w/codeine
1
butalbital-
acetaminop-caf-cod
1
butalbital-
acetaminophen
1
butalbital-
acetaminophen-caff
1
butalbital-aspirin-
caffeine
1
BUTRANS 3 ST
capacet 1
CAPITAL WITH
CODEINE
3
codeine sulfate 1
DEMEROL 3
DEMEROL (PF) 6 MSD
DILAUDID
INJECTION
6 MSD
DILAUDID ORAL 3
diskets 1
DOLOPHINE 3
DURAGESIC 3
EMBEDA 3 ST; QL
endocet 1
ESGIC 3 ST
Drug Name Drug
Category
Requirements
/ Limits
EXALGO ER 3 ST; QL
fentanyl 1
FENTANYL (PF)-
BUPIVACAINE-
NACL
6 MSD
fentanyl citrate 1 ST; QL
fentanyl citrate (pf)
intravenous syringe
100 mcg/2 ml (50
mcg/ml)
6 MSD
FENTANYL
CITRATE (PF)
INTRAVENOUS
SYRINGE 50
MCG/ML
6 MSD
FENTANYL
CITRATE (PF)-
0.9%NACL
INTRAVENOUS
SOLUTION 10
MCG/ML, 20
MCG/ML
6 MSD
fentanyl citrate (pf)-
0.9%nacl
intravenous solution
5 mcg/ml
6 MSD
FENTANYL-
ROPIVACAINE-
NACL (PF)
6 MSD
FENTORA 3 ST; QL
FIORICET 3 ST
FIORINAL 3 ST
FIORINAL-
CODEINE #3
3
hydrocodone-
acetaminophen
1
hydrocodone-
ibuprofen
1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
25
Drug Name Drug
Category
Requirements
/ Limits
HYDROMORPHO
NE IN 0.9 % NACL
INJECTION
6 MSD
HYDROMORPHO
NE IN 0.9 % NACL
INTRAVENOUS
PATIENT
CONTROL.ANALG
ESIA SOLN
6 MSD
HYDROMORPHO
NE IN 0.9 % NACL
INTRAVENOUS
PREFILLED PUMP
RESERVOIR
6 MSD
hydromorphone in
0.9 % nacl
intravenous pt
controlled analgesia
syring 15 mg/30 ml
(0.5 mg/ml)
6 MSD
HYDROMORPHO
NE IN 0.9 % NACL
INTRAVENOUS
PT CONTROLLED
ANALGESIA
SYRING 5 MG/25
ML (0.2 MG/ML), 6
MG/30 ML (0.2
MG/ML)
6 MSD
HYDROMORPHO
NE IN 0.9 % NACL
INTRAVENOUS
SOLUTION
6 MSD
HYDROMORPHO
NE IN 0.9 % NACL
INTRAVENOUS
SYRINGE
6 MSD
hydromorphone
injection solution
6 MSD
Drug Name Drug
Category
Requirements
/ Limits
HYDROMORPHO
NE INJECTION
SYRINGE 0.5
MG/0.5 ML
6 MSD
hydromorphone
injection syringe 1
mg/ml, 2 mg/ml, 4
mg/ml
6 MSD
HYDROMORPHO
NE
INTRAVENOUS
6 MSD
hydromorphone oral
liquid
1
hydromorphone oral
tablet
1
hydromorphone oral
tablet extended
release 24 hr
1 QL
hydromorphone
rectal
1
HYSINGLA ER 2 ST; QL
IBUDONE 3
ibuprofen-oxycodone 1
KADIAN 3 ST; QL
LAZANDA 3 ST; QL
levorphanol tartrate 1
lorcet (hydrocodone) 1
lorcet hd 1
lorcet plus 1
LORTAB ELIXIR 3
meperidine 1
methadone 1
methadose 1
MORPHABOND
ER
3 ST; QL
morphine (pf) 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
26
Drug Name Drug
Category
Requirements
/ Limits
MORPHINE (PF)
IN 0.9 % NACL
INTRAVENOUS
SOLUTION
6 MSD
morphine (pf) in 0.9
% nacl intravenous
syringe 0.5 mg/ml, 2
mg/2 ml (1 mg/ml)
6 MSD
MORPHINE (PF)
IN 0.9 % NACL
INTRAVENOUS
SYRINGE 5 MG/5
ML (1 MG/ML)
6 MSD
morphine
concentrate
1
MORPHINE IN 0.9
% SODIUM
CHLOR
6 MSD
morphine injection 6 MSD
MORPHINE
INTRAMUSCULA
R
6 MSD
morphine
intravenous
cartridge 10 mg/ml,
2 mg/ml, 4 mg/ml
6 MSD
MORPHINE
INTRAVENOUS
CARTRIDGE 8
MG/ML
6 MSD
morphine
intravenous pt
controlled analgesia
syring
6 MSD
morphine
intravenous solution
10 mg/ml, 100 mg/4
ml, 25 mg/ml, 250
mg/10 ml, 50 mg/ml
6 MSD
Drug Name Drug
Category
Requirements
/ Limits
MORPHINE
INTRAVENOUS
SOLUTION 4
MG/ML, 8 MG/ML
6 MSD
MORPHINE
INTRAVENOUS
SYRINGE 10
MG/ML, 8 MG/ML
6 MSD
morphine
intravenous syringe
2 mg/ml, 4 mg/ml
6 MSD
morphine oral
capsule, er
multiphase 24 hr
1 QL
morphine oral
capsule,extend.relea
se pellets
1 QL
morphine oral
solution
1
morphine oral tablet 1
morphine oral tablet
extended release
1 QL
morphine rectal 1
MS CONTIN 3 ST; QL
NALOCET 3
NORCO 3
OPANA 3
OXAYDO 3
oxycodone oral
capsule
1
oxycodone oral
concentrate
1
oxycodone oral
solution
1
oxycodone oral
tablet
1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
27
Drug Name Drug
Category
Requirements
/ Limits
OXYCODONE
ORAL
TABLET,ORAL
ONLY,EXT.REL.12
HR
3 ST; QL
oxycodone-
acetaminophen
1
oxycodone-aspirin 1
OXYCONTIN 2 ST; QL
oxymorphone oral
tablet
1
oxymorphone oral
tablet extended
release 12 hr
1 QL
panlor(acetam-caff-
dihydrocod)
1
PERCOCET 3
phrenilin forte(with
caffeine)
1
PRIMLEV 3
PROBUPHINE 6 MSD
ROXICODONE 3
ROXYBOND 3
SUBLOCADE 6 MSD
SUBSYS 3 ST; QL
tencon 1
TREZIX 3
TYLENOL-
CODEINE #3
3
TYLENOL-
CODEINE #4
3
VANATOL LQ 3 ST
VANATOL S 3 ST
verdrocet 1
vicodin 1
Drug Name Drug
Category
Requirements
/ Limits
vicodin es 1
vicodin hp 1
XTAMPZA ER 3 ST; QL
xylon 10 1
zebutal 1
ZOHYDRO ER 3 ST; QL
NON-NARCOTIC ANALGESICS
ANAPROX DS 3 ST; M
ARTHROTEC 50 3 ST; M
ARTHROTEC 75 3 ST; M
aspirin 5 ACA; OTC
aspir-trin 5 ACA; OTC
bayer aspirin 5 ACA; OTC
BUNAVAIL 3 QL
buprenorphine-
naloxone
1 QL
butorphanol tartrate
injection
6 MSD
butorphanol tartrate
nasal
1 QL
CAMBIA 3 ST; QL
CELEBREX 3 ST; M; QL
celecoxib 1 ST; M; QL
choline,magnesium
salicylate
1
CONZIP 3 ST; QL
DAYPRO 3 ST; M
DICLO GEL 3 ST; M
DICLO GEL-
XRYLIX SHEET
3 ST; M
diclofenac potassium 1
diclofenac sodium
oral
1 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
28
Drug Name Drug
Category
Requirements
/ Limits
diclofenac sodium
topical drops
1 M; QL
diclofenac sodium
topical gel
1 ST; M; QL
diclofenac-
misoprostol
1 M
DICLOPAK 3 ST; M
DICLOPR 3 ST; M
diflunisal 1 M
DISALCID 3
DITHOL 3 ST; M
DUEXIS 3 ST; M; QL
e.c. prin 5 ACA; OTC
EC-NAPROSYN 3 ST; M
ecotrin 5 ACA; OTC
etodolac 1 M
EUFLEXXA 6 MSD
EVZIO INJECTION
AUTO-INJECTOR
0.4 MG/0.4 ML
3 ST; QL
EVZIO INJECTION
AUTO-INJECTOR
2 MG/0.4 ML
3 ST
FELDENE 3 ST; M
FENOPROFEN
ORAL CAPSULE
3 ST; M
fenoprofen oral
tablet
1 M
FENORTHO 3 ST; M
FLECTOR 2 ST; QL
flurbiprofen 1 M
FROTEK 3 ST; M
ibu 1 M
ibuprofen 1 M
Drug Name Drug
Category
Requirements
/ Limits
INDOCIN 3 ST
indomethacin 1
ketoprofen 1 M
ketorolac injection 6 MSD
ketorolac
intramuscular
6 MSD
ketorolac oral 1 QL
LEXIXRYL 3 ST; M
lite coat aspirin 5 ACA; OTC
LODINE 3 ST; M
LUCEMYRA 3
meclofenamate 1 M
mefenamic acid 1
meloxicam oral
suspension
1 M
meloxicam oral
tablet 15 mg
1 M
meloxicam oral
tablet 7.5 mg
1 M; QL
MOBIC ORAL
TABLET 15 MG
3 ST; M
MOBIC ORAL
TABLET 7.5 MG
3 ST; M; QL
nabumetone 1 M
nalbuphine 6 MSD
NALFON 3 ST; M
naloxone 1
naltrexone 1
NAPRELAN CR 3 ST; M
NAPROSYN 3 ST; M
naproxen 1 M
naproxen sodium 1 M
NARCAN 2
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
29
Drug Name Drug
Category
Requirements
/ Limits
NUCYNTA 2 QL
NUCYNTA ER 2 ST; QL
oxaprozin 1 M
PENNSAID 3 ST; M; QL
pentazocine-
naloxone
1
piroxicam 1 M
profeno 1 M
READYSHARP
KETOROLAC
6 MSD
salsalate 1
SPRIX 3 ST; SLA; QL
SUBOXONE 2 QL
sulindac 1 M
TALWIN 6 MSD
TIVORBEX 3 ST; M
tolmetin 1 M
TORONOVA II
SUIK
6 MSD
TORONOVA SUIK 6 MSD
TRAMADOL
ORAL
CAPSULE,ER
BIPHASE 24 HR
17-83
3 ST; QL
TRAMADOL
ORAL
CAPSULE,ER
BIPHASE 24 HR
25-75
3 ST; QL
tramadol oral tablet 1 QL
tramadol oral tablet
extended release 24
hr
1 ST; QL
tramadol oral tablet,
er multiphase 24 hr
1 ST; QL
Drug Name Drug
Category
Requirements
/ Limits
tramadol-
acetaminophen
1 QL
ULTRACET 3 QL
ULTRAM 3 QL
VIMOVO 3 ST; M; QL
VIVITROL 6 MSD
VIVLODEX 3 ST; M
VOLTAREN 3 ST; M; QL
VOLTAREN-XR 3 ST; M
ZIPSOR 3 ST; QL
ZORVOLEX 3 ST; M; QL
ZUBSOLV 2 QL
PSYCHOTHERAPEUTIC DRUGS
ABILIFY 3 ST; QL
ABILIFY
MAINTENA
6 MSD
ADASUVE 3
ADDERALL 3 ST; QL
ADDERALL XR 3 ST; QL
ADDYI 3 PA
ADZENYS ER 3 ST
ADZENYS XR-
ODT
3 ST
alprazolam 1
alprazolam intensol 1
AMBIEN 3 ST; QL
AMBIEN CR 3 ST; QL
amitriptyline 1
amitriptyline-
chlordiazepoxide
1
amoxapine 1
ANAFRANIL 3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
30
Drug Name Drug
Category
Requirements
/ Limits
APLENZIN 3 ST; M; QL
APTENSIO XR 3 ST
aripiprazole oral
solution
1
aripiprazole oral
tablet
1 QL
aripiprazole oral
tablet,disintegrating
1 QL
ARISTADA 6 MSD
armodafinil 1 PA; QL
ATIVAN
INJECTION
6 MSD
ATIVAN ORAL 3
atomoxetine 1 QL
BELSOMRA 3 ST
BRISDELLE 2 ST; M; QL
bupropion hcl oral
tablet
1 M
bupropion hcl oral
tablet extended
release 12 hr
1 M; QL
bupropion hcl oral
tablet extended
release 24 hr 150 mg
1 M
bupropion hcl oral
tablet extended
release 24 hr 300 mg
1 M; QL
buspirone 1 M
CELEXA 3 ST; M; QL
chlordiazepoxide hcl 1
chlorpromazine 1
citalopram 1 M
clomipramine 1
clonidine hcl 1 QL
Drug Name Drug
Category
Requirements
/ Limits
clorazepate
dipotassium
1
clozapine oral tablet 1
clozapine oral
tablet,disintegrating
100 mg, 12.5 mg, 25
mg
1
CLOZAPINE
ORAL
TABLET,DISINTE
GRATING 150 MG,
200 MG
3
CLOZARIL 3
CONCERTA 3 ST; QL
COTEMPLA XR-
ODT
3 ST
CYMBALTA 3 ST; M; QL
DAYTRANA 2 ST; QL
desipramine 1
DESOXYN 3 QL
DESVENLAFAXIN
E
3 ST; M; QL
DESVENLAFAXIN
E FUMARATE
3 ST; M
desvenlafaxine
succinate oral tablet
extended release 24
hr 100 mg, 50 mg
1 M; QL
desvenlafaxine
succinate oral tablet
extended release 24
hr 25 mg
1 M
DEXEDRINE
SPANSULE
3 ST; QL
dexmethylphenidate 1 QL
dextroamphetamine 1 QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
31
Drug Name Drug
Category
Requirements
/ Limits
dextroamphetamine-
amphetamine
1 QL
diazepam injection 6 MSD
diazepam intensol 1
diazepam oral 1
DORAL 3
doxepin 1
duloxetine oral
capsule,delayed
release(dr/ec) 20
mg, 30 mg, 60 mg
1 M; QL
duloxetine oral
capsule,delayed
release(dr/ec) 40 mg
1 M
DYANAVEL XR 3 ST
EDLUAR 3 ST; QL
EFFEXOR XR 3 ST; M; QL
EMSAM 3 M; QL
ergoloid 1 M
escitalopram oxalate 1 M
estazolam 1
eszopiclone 1 QL
EVEKEO 2 PA
FANAPT 3 QL
FAZACLO 3
FETZIMA 2 ST; M; QL
flumazenil 6 MSD
fluoxetine oral
capsule 10 mg, 40
mg
1 M; QL
fluoxetine oral
capsule 20 mg
1 M
fluoxetine oral
capsule,delayed
release(dr/ec)
1 M; QL
Drug Name Drug
Category
Requirements
/ Limits
fluoxetine oral
solution
1 M
fluoxetine oral tablet
10 mg
1 M; QL
fluoxetine oral tablet
20 mg
1 M
fluoxetine oral tablet
60 mg
1
fluphenazine
decanoate
6 MSD
fluphenazine hcl 1
flurazepam 1
fluvoxamine 1 M; QL
FOCALIN 3 QL
FOCALIN XR 3 ST; QL
FORFIVO XL 3 ST; M; QL
GEODON
INTRAMUSCULA
R
6 MSD
GEODON ORAL 3 QL
guanfacine 1 QL
guanidine 1
HALCION 3
HALDOL 3
HALDOL
DECANOATE
3
haloperidol 1
haloperidol
decanoate
1
haloperidol lactate 1
HETLIOZ 4 S; SLA; QL
imipramine hcl 1
imipramine pamoate 1
INTERMEZZO 3 ST; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
32
Drug Name Drug
Category
Requirements
/ Limits
INTUNIV ER 3 ST; QL
INVEGA 3 QL
KAPVAY 3 ST; QL
KHEDEZLA 3 ST; M; QL
LATUDA 2 QL
LEXAPRO 3 ST; M; QL
lithium carbonate 1
lithium citrate 1
LITHOBID 3
LORAZEPAM IN
0.9% SOD
CHLORIDE
6 MSD
LORAZEPAM IN
DEXTROSE 5 %
6 MSD
lorazepam injection 6 MSD
lorazepam intensol 1
lorazepam oral 1
loxapine succinate 1
LUNESTA 3 ST; QL
maprotiline 1
MARPLAN 3 M
metadate er 1
methamphetamine 1 QL
METHYLIN 3 QL
methylphenidate hcl
oral capsule, er
biphasic 30-70
1
methylphenidate hcl
oral capsule,er
biphasic 50-50
1
methylphenidate hcl
oral solution
1 QL
methylphenidate hcl
oral tablet
1 QL
Drug Name Drug
Category
Requirements
/ Limits
methylphenidate hcl
oral tablet extended
release
1
methylphenidate hcl
oral tablet extended
release 24hr 18 mg,
27 mg, 36 mg, 54 mg
1 QL
METHYLPHENID
ATE HCL ORAL
TABLET
EXTENDED
RELEASE 24HR 72
MG
3 ST
methylphenidate hcl
oral tablet,chewable
1 QL
midazolam 6 MSD
midazolam (pf) in
0.9 % nacl
6 MSD
MIDAZOLAM IN
0.9 % SOD
CHLORID
6 MSD
MIDAZOLAM IN
DEXTROSE 5 %
6 MSD
mirtazapine 1 QL
modafinil 1 PA; QL
MYDAYIS 2 ST
NARDIL 3 M
nefazodone 1 M
NORPRAMIN 3
nortriptyline 1
NUPLAZID 4 S; SLA
NUVIGIL 3 PA; QL
olanzapine
intramuscular
6 MSD
olanzapine oral
tablet 10 mg, 15 mg,
2.5 mg, 5 mg, 7.5 mg
1 QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
33
Drug Name Drug
Category
Requirements
/ Limits
olanzapine oral
tablet 20 mg
1
olanzapine oral
tablet,disintegrating
1 QL
olanzapine-
fluoxetine
1
ORAP 3
oxazepam 1
paliperidone 1 QL
PAMELOR 3
PARNATE 3 M
paroxetine hcl 1 M; QL
paroxetine
mesylate(menop.sym
)
1 M; QL
PAXIL CR 3 ST; M; QL
PAXIL ORAL
SUSPENSION
3 ST; M
PAXIL ORAL
TABLET
3 ST; M; QL
perphenazine 1
perphenazine-
amitriptyline
1
PEXEVA 3 ST; M; QL
phenelzine 1 M
pimozide 1
PRISTIQ ORAL
TABLET
EXTENDED
RELEASE 24 HR
100 MG, 50 MG
3 ST; M; QL
PRISTIQ ORAL
TABLET
EXTENDED
RELEASE 24 HR
25 MG
3 ST; M
Drug Name Drug
Category
Requirements
/ Limits
procentra 1 QL
protriptyline 1
PROVIGIL 3 ST; QL
PROZAC ORAL
CAPSULE 10 MG,
40 MG
3 ST; M; QL
PROZAC ORAL
CAPSULE 20 MG
3 ST; M
quazepam 1
quetiapine oral
tablet 100 mg, 25
mg, 50 mg
1 PA; QL
quetiapine oral
tablet 200 mg, 300
mg, 400 mg
1 QL
quetiapine oral
tablet extended
release 24 hr
1 QL
QUILLICHEW ER 2 ST
QUILLIVANT XR 2 ST; QL
REMERON 3 QL
REMERON
SOLTAB
3 QL
RESTORIL 3
REXULTI 3
RISPERDAL ORAL
SOLUTION
3
RISPERDAL ORAL
TABLET
3 QL
risperidone oral
solution
1
risperidone oral
tablet
1 QL
risperidone oral
tablet,disintegrating
1 QL
RITALIN 3 QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
34
Drug Name Drug
Category
Requirements
/ Limits
RITALIN LA 3 ST
ROZEREM 2 ST; QL
SAPHRIS (BLACK
CHERRY)
SUBLINGUAL
TABLET 10 MG, 5
MG
3 QL
SAPHRIS (BLACK
CHERRY)
SUBLINGUAL
TABLET 2.5 MG
3
SARAFEM ORAL
TABLET 10 MG
3 ST; M; QL
SARAFEM ORAL
TABLET 20 MG
3 ST; M
SEROQUEL ORAL
TABLET 100 MG,
25 MG, 50 MG
3 PA; QL
SEROQUEL ORAL
TABLET 200 MG,
300 MG, 400 MG
3 ST; QL
SEROQUEL XR 3 ST; QL
sertraline oral
concentrate
1 M
sertraline oral tablet 1 M; QL
SILENOR 3 ST; QL
SONATA 3 ST; QL
STRATTERA 3 ST; QL
SURMONTIL 3
SYMBYAX 3
temazepam 1
thioridazine 1
thiothixene 1
TOFRANIL 3
TRANXENE T-
TAB
3
Drug Name Drug
Category
Requirements
/ Limits
tranylcypromine 1 M
trazodone 1
triazolam 1
trifluoperazine 1
trimipramine 1
TRINTELLIX 3 ST; QL
VALIUM 3 ST
venlafaxine oral
capsule,extended
release 24hr 150 mg
1 M
venlafaxine oral
capsule,extended
release 24hr 37.5
mg, 75 mg
1 M; QL
venlafaxine oral
tablet
1 M; QL
venlafaxine oral
tablet extended
release 24hr
1 ST; M; QL
VERSACLOZ 3
VIIBRYD ORAL
TABLET
2 ST; M; QL
VIIBRYD ORAL
TABLETS,DOSE
PACK
2 ST; QL
VRAYLAR 3
VYVANSE 2 ST; QL
WELLBUTRIN SR 3 ST; M; QL
WELLBUTRIN XL 3 ST; M; QL
XANAX 3 ST
XANAX XR 3 ST
XYREM 3 PA; S; SLA;
QL
zaleplon 1 QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
35
Drug Name Drug
Category
Requirements
/ Limits
zenzedi oral tablet
10 mg, 5 mg
1 QL
ZENZEDI ORAL
TABLET 15 MG
3 QL
ZENZEDI ORAL
TABLET 2.5 MG,
20 MG, 30 MG, 7.5
MG
3
ziprasidone hcl 1 QL
ZOLOFT ORAL
CONCENTRATE
3 ST; M
ZOLOFT ORAL
TABLET
3 ST; M; QL
zolpidem 1 QL
ZOLPIMIST 3 ST
ZYPREXA
INTRAMUSCULA
R
6 MSD
ZYPREXA ORAL
TABLET 10 MG, 15
MG, 2.5 MG, 5 MG,
7.5 MG
3 QL
ZYPREXA ORAL
TABLET 20 MG
3
ZYPREXA ZYDIS 3 QL
CARDIOVASCULAR,
HYPERTENSION & LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone 1 M
BETAPACE 3 M
BETAPACE AF 3 M
disopyramide
phosphate
1 M
dofetilide 1
flecainide 1 M
mexiletine 1 M
Drug Name Drug
Category
Requirements
/ Limits
MULTAQ 3 M
NORPACE 3 M
NORPACE CR 3 M
pacerone 1 M
procainamide 6 MSD
propafenone 1 M
quinidine gluconate 1 M
quinidine sulfate 1 M
RYTHMOL SR 3 M
sotalol 1 M
sotalol af 1 M
SOTYLIZE 2 M
TIKOSYN 3 ST
ANTIHYPERTENSIVE THERAPY
ACCUPRIL 3 M
ACCURETIC 3 M
acebutolol 1 M
ADALAT CC 3 ST; M
afeditab cr 1 M
ALDACTAZIDE 3 M
ALDACTONE 3 M
ALTACE 3 M
amiloride 1 M
amiloride-
hydrochlorothiazide
1 M
amlodipine 1 M
amlodipine-
benazepril
1 M
amlodipine-
olmesartan
1 M
amlodipine-
valsartan
1 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
36
Drug Name Drug
Category
Requirements
/ Limits
amlodipine-
valsartan-hcthiazid
1 M
ATACAND 3 ST; M
ATACAND HCT 3 ST; M
atenolol 1 M
atenolol-
chlorthalidone
1 M
AVALIDE 3 ST; M
AVAPRO 3 ST; M
AZOR 3 ST; M
benazepril 1 M
benazepril-
hydrochlorothiazide
1 M
BENICAR 3 ST; M
BENICAR HCT 3 ST; M
betaxolol 1 M
BIDIL 3 M
bisoprolol fumarate 1 M
bisoprolol-
hydrochlorothiazide
1 M
BREVIBLOC 6 MSD
BREVIBLOC IN
NACL (ISO-OSM)
6 MSD
bumetanide 1 M
BYSTOLIC 2 ST; M
BYVALSON 2 ST; M
CALAN 3 ST; M
CALAN SR 3 ST; M
candesartan 1 M
candesartan-
hydrochlorothiazid
1 M
captopril 1 M
Drug Name Drug
Category
Requirements
/ Limits
captopril-
hydrochlorothiazide
1 M
CARDIZEM 3 M
CARDIZEM CD 3 M
CARDIZEM LA 3 M
CARDURA 3 ST; M; QL
CARDURA XL 3 ST; M; QL
CAROSPIR 3 ST; M
cartia xt 1 M
carvedilol 1 M
carvedilol phosphate 1 M
CATAPRES 3 M
CATAPRES-TTS-1 3 M; QL
CATAPRES-TTS-2 3 M; QL
CATAPRES-TTS-3 3 M; QL
chlorothiazide 1 M
chlorothiazide
sodium
6 MSD
chlorthalidone 1 M
clonidine 1 M; QL
clonidine hcl 1 M
COREG 3 ST; M
COREG CR 3 ST; M
CORGARD 3 ST; M
CORZIDE 3 ST; M
COZAAR 3 ST; M
DEMADEX 3 M
DEMSER 2
DIBENZYLINE 3
diltiazem 1 M
dilt-xr 1 M
DIOVAN 3 ST; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
37
Drug Name Drug
Category
Requirements
/ Limits
DIOVAN HCT 3 ST; M
DIURIL 3 M
DIURIL IV 6 MSD
doxazosin 1 M; QL
DUTOPROL 3 ST; M
DYAZIDE 3 M
DYRENIUM 3 M
EDARBI 2 ST; M
EDARBYCLOR 2 ST; M
EDECRIN 3 M
enalapril maleate 1 M
enalaprilat 6 MSD
enalapril-
hydrochlorothiazide
1 M
EPANED 3 M
eplerenone 1 M
epoprostenol
(glycine)
6 MSD
eprosartan 1 M
esmolol 6 MSD
ethacrynate sodium 6 MSD
ethacrynic acid 1 M
EXFORGE 3 ST; M
EXFORGE HCT 3 ST; M
felodipine 1 M
FLOLAN 6 MSD
fosinopril 1 M
fosinopril-
hydrochlorothiazide
1 M
FUROSEMIDE IN
0.9 % NACL
6 MSD
furosemide injection 6 MSD
furosemide oral 1 M
Drug Name Drug
Category
Requirements
/ Limits
guanfacine 1 M
HEMANGEOL 3 SLA
hydralazine injection 6 MSD
hydralazine oral 1 M
hydrochlorothiazide 1 M
HYZAAR 3 ST; M
indapamide 1 M
INDERAL LA 3 ST; M
INDERAL XL 3 ST; M
INNOPRAN XL 3 ST; M
INSPRA 3 M
irbesartan 1 M
irbesartan-
hydrochlorothiazide
1 M
isradipine 1 M
labetalol
intravenous solution
6 MSD
labetalol
intravenous syringe
20 mg/4 ml (5
mg/ml), 25 mg/5 ml
(5 mg/ml)
6 MSD
LABETALOL
INTRAVENOUS
SYRINGE 50
MG/10 ML (5
MG/ML)
6 MSD
labetalol oral 1 M
LASIX 3 M
LEVATOL 3 ST; M
lisinopril 1 M
lisinopril-
hydrochlorothiazide
1 M
LOPRESSOR 3 ST; M
losartan 1 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
38
Drug Name Drug
Category
Requirements
/ Limits
losartan-
hydrochlorothiazide
1 M
LOTENSIN 3 M
LOTENSIN HCT 3 M
LOTREL 3 ST; M
matzim la 1 M
MAXZIDE 3 M
MAXZIDE-25MG 3 M
methyclothiazide 1 M
methyldopa 1 M
methyldopa-
hydrochlorothiazide
1 M
methyldopate 6 MSD
metolazone 1 M
metoprolol succinate 1 M
METOPROLOL
SU-
HYDROCHLOROT
HIAZ
3 ST; M
metoprolol ta-
hydrochlorothiaz
1 M
metoprolol tartrate
intravenous
6 MSD
metoprolol tartrate
oral
1 M
MICARDIS 3 ST; M
MICARDIS HCT 3 ST; M
MICROZIDE 3 M
MINIPRESS 3 M
minoxidil 1 M
moexipril 1 M
moexipril-
hydrochlorothiazide
1 M
nadolol 1 M
Drug Name Drug
Category
Requirements
/ Limits
nadolol-
bendroflumethiazide
1 M
nicardipine 1 M
nifedipine 1 M
nimodipine 1
nisoldipine 1 M
NORVASC 3 ST; M
NYMALIZE 3
olmesartan 1 M
olmesartan-
amlodipin-hcthiazid
1 M
olmesartan-
hydrochlorothiazide
1 M
ORENITRAM 4 PA; S; SLA
perindopril
erbumine
1 M
phenoxybenzamine 1
phentolamine 6 MSD
pindolol 1 M
prazosin 1 M
PRESTALIA 3 ST; M
PRINIVIL 3 M
PROCARDIA 3 ST; M
PROCARDIA XL 3 ST; M
propranolol 1 M
propranolol-
hydrochlorothiazid
1 M
QBRELIS 3 M
quinapril 1 M
quinapril-
hydrochlorothiazide
1 M
ramipril 1 M
REMODULIN 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
39
Drug Name Drug
Category
Requirements
/ Limits
SODIUM
EDECRIN
6 MSD
spironolactone 1 M
spironolacton-
hydrochlorothiaz
1 M
SULAR 3 ST; M
TARKA 3 M
taztia xt 1 M
TEKTURNA 2 M
TEKTURNA HCT 2 M
telmisartan 1 M
telmisartan-
amlodipine
1 M
telmisartan-
hydrochlorothiazid
1 M
TENORETIC 100 3 ST; M
TENORETIC 50 3 ST; M
TENORMIN 3 ST; M
terazosin 1 M; QL
TIAZAC 3 M
timolol maleate 1 M
TOPROL XL 3 ST; M
torsemide 1 M
trandolapril 1 M
trandolapril-
verapamil
1 M
triamterene-
hydrochlorothiazid
1 M
TRIBENZOR 3 ST; M
TWYNSTA 3 ST; M
UPTRAVI 3 PA; S; SLA
valsartan 1 M
Drug Name Drug
Category
Requirements
/ Limits
valsartan-
hydrochlorothiazide
1 M
VASERETIC 3 M
VASOTEC 3 M
veletri 6 MSD
verapamil 1 M
VERELAN 3 ST; M
VERELAN PM 3 ST; M
ZESTORETIC 3 M
ZESTRIL 3 M
ZIAC 3 ST; M
CARDIAC GLYCOSIDES
digitek 1 M
digox 1 M
digoxin injection 6 MSD
digoxin oral 1 M
LANOXIN
INJECTION
6 MSD
LANOXIN ORAL 3 M
LANOXIN
PEDIATRIC
6 MSD
COAGULATION THERAPY
ADVATE 6 MSD
ADYNOVATE 6 MSD
AFSTYLA 6 MSD
ALPHANATE 6 MSD
ALPHANINE SD 6 MSD
ALPROLIX 6 MSD
AMICAR 2
ANDEXXA 6 MSD
ANGIOMAX 6 MSD
ARGATROBAN 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
40
Drug Name Drug
Category
Requirements
/ Limits
ARGATROBAN IN
0.9 % SOD CHLOR
6 MSD
ARGATROBAN IN
NACL (ISO-OS)
6 MSD
ARIXTRA 3
BEBULIN 6 MSD
BENEFIX 6 MSD
BEVYXXA 3 QL
bivalirudin 6 MSD
BIVALIRUDIN-0.9
% SODIUM
CHLOR
6 MSD
CEPROTIN (BLUE
BAR)
6 MSD
CEPROTIN
(GREEN BAR)
6 MSD
COAGADEX 6 MSD
CORIFACT 6 MSD
COUMADIN 3
DEFITELIO 6 MSD
DOPTELET 3 PA
ELIQUIS 2 PA
ELOCTATE 6 MSD
enoxaparin
subcutaneous
solution
6 MSD
enoxaparin
subcutaneous
syringe
1
FEIBA NF 6 MSD
FIBRYGA 6 MSD
fondaparinux 1
FRAGMIN 2
HELIXATE FS 6 MSD
Drug Name Drug
Category
Requirements
/ Limits
HEMLIBRA 6 MSD
HEMOFIL M HIGH 6 MSD
HEMOFIL M LOW 6 MSD
HEMOFIL M MID 6 MSD
HEMOFIL M
SUPER HIGH
6 MSD
hep flush-10 (pf) 1
heparin (porcine) 1
HEPARIN
(PORCINE) IN
0.9% NACL
6 MSD
heparin (porcine) in
5 % dex
6 MSD
heparin (porcine) in
nacl (pf)
1
heparin
flush(porcine)-
0.9nacl
6 MSD
heparin lock flush 1
heparin lock flush
(porcine)
1
heparin
lockflush(porcine)(pf
)
1
HEPARIN(PORCIN
E) IN 0.45% NACL
6 MSD
heparin, porcine (pf) 1
HUMATE-P 6 MSD
IDELVION 6 MSD
IPRIVASK 6 MSD
IXINITY 6 MSD
jantoven 1
KOATE 6 MSD
KOGENATE FS 6 MSD
KOVALTRY 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
41
Drug Name Drug
Category
Requirements
/ Limits
LOVENOX
SUBCUTANEOUS
SOLUTION
6 MSD
LOVENOX
SUBCUTANEOUS
SYRINGE
3 ST
MEPHYTON 2
MONOCLATE-P 6 MSD
MONONINE 6 MSD
NOVOEIGHT 6 MSD
NOVOSEVEN RT 6 MSD
NPLATE 6 MSD
NUWIQ 6 MSD
OBIZUR 6 MSD
pentoxifylline 1 M
phytonadione
(vitamin k1)
1
PRADAXA 3 PA; M
PRAXBIND 6 MSD
PROFILNINE 6 MSD
PROMACTA 2 PA
REBINYN 6 MSD
RECOMBINATE 6 MSD
RIASTAP 6 MSD
RIXUBIS 6 MSD
SAVAYSA 3 PA
TAVALISSE 3 PA
tranexamic acid 6 MSD
TRETTEN 6 MSD
VONVENDI 6 MSD
warfarin 1
WILATE 6 MSD
XARELTO 2 PA
Drug Name Drug
Category
Requirements
/ Limits
XYNTHA 6 MSD
XYNTHA
SOLOFUSE
6 MSD
LIPID/CHOLESTEROL LOWERING
AGENTS
ALTOPREV 3 ST; M; QL
amlodipine-
atorvastatin
1 M; QL
ANTARA 3 ST; M; QL
atorvastatin oral
tablet 10 mg, 20 mg
5 M; ACA; QL
atorvastatin oral
tablet 40 mg, 80 mg
1 M; QL
CADUET 3 ST; M; QL
cholestyramine (with
sugar)
1 M
cholestyramine light 1 M
colesevelam 1 M
COLESTID 3 ST; M
COLESTID
FLAVORED
3 ST; M
colestipol 1 M
CRESTOR 3 ST; M; QL
ezetimibe 1 ST; M
ezetimibe-
simvastatin
1 M; QL
fenofibrate
micronized
1 M; QL
fenofibrate
nanocrystallized
1 M; QL
FENOFIBRATE
ORAL CAPSULE
3 ST; M; QL
fenofibrate oral
tablet
1 M; QL
fenofibric acid 1 M; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
42
Drug Name Drug
Category
Requirements
/ Limits
fenofibric acid
(choline)
1 M; QL
FENOGLIDE 3 ST; M; QL
FIBRICOR 3 ST; M; QL
FLOLIPID 3 ST; M
fluvastatin 5 M; ACA; QL
gemfibrozil 1 M; QL
JUXTAPID ORAL
CAPSULE 10 MG,
20 MG, 5 MG
3 PA; S; QL
JUXTAPID ORAL
CAPSULE 30 MG,
40 MG, 60 MG
3 PA; S
KYNAMRO 4 PA; S; SLA;
QL
LESCOL XL 3 ST; M; QL
LIPITOR 3 ST; M; QL
LIPOFEN 2 ST; M; QL
LIVALO 2 ST; M; QL
LOPID 3 M; QL
lovastatin 5 M; ACA; QL
LOVAZA 3 PA; M
niacin 1 M
NIACOR 3 M
NIASPAN
EXTENDED-
RELEASE
3 M
omega-3 acid ethyl
esters
1 PA; M
PRALUENT PEN 3 PA; S; SLA
PRAVACHOL 3 ST; M; QL
pravastatin 5 M; ACA; QL
prevalite 1 M
QUESTRAN 3 ST; M
Drug Name Drug
Category
Requirements
/ Limits
QUESTRAN
LIGHT
3 ST; M
REPATHA
PUSHTRONEX
3 PA; S; SLA
REPATHA
SURECLICK
3 PA; S; SLA
REPATHA
SYRINGE
3 PA; S; SLA
rosuvastatin oral
tablet 10 mg, 5 mg
5 M; ACA; QL
rosuvastatin oral
tablet 20 mg, 40 mg
1 M; QL
simvastatin oral
tablet 10 mg, 20 mg,
40 mg, 5 mg
5 M; ACA; QL
simvastatin oral
tablet 80 mg
1 M; QL
TRICOR 3 ST; M; QL
TRIGLIDE 3 ST; M; QL
triklo 1 PA; M
TRILIPIX 3 ST; M; QL
VASCEPA 2 PA; M
VYTORIN 10-10 3 ST; M; QL
VYTORIN 10-20 3 ST; M; QL
VYTORIN 10-40 3 ST; M; QL
VYTORIN 10-80 3 ST; M; QL
WELCHOL ORAL
POWDER IN
PACKET
2 ST; M
WELCHOL ORAL
TABLET
3 ST; M
ZETIA 3 ST; M
ZOCOR 3 ST; M; QL
MISCELLANEOUS
CARDIOVASCULAR AGENTS
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
43
Drug Name Drug
Category
Requirements
/ Limits
CORLANOR 2 PA; M
ENTRESTO 2 PA; M
GIAPREZA 6 MSD
NIPRIDE RTU 6 MSD
RANEXA 2 M
VECAMYL 3 SLA
NITRATES
DILATRATE-SR 2 M
GONITRO 3
ISOCHRON 3 M
ISORDIL 3 M
ISORDIL
TITRADOSE
3 M
isosorbide dinitrate 1 M
isosorbide
mononitrate
1 M
MINITRAN 3 M
nitro-bid 1 M
NITRO-DUR 3 M
nitroglycerin oral 1 M
nitroglycerin
sublingual
1
nitroglycerin
transdermal
1 M
nitroglycerin
translingual
1
NITROLINGUAL 3
NITROMIST 3
NITROSTAT 3
nitro-time 1 M
DERMATOLOGICALS/TOPICA
L THERAPY
Drug Name Drug
Category
Requirements
/ Limits
ANTIPSORIATIC /
ANTISEBORRHEIC
acitretin 1
ANALPRAM-HC 3 ST
calcipotriene 1 QL
calcipotriene-
betamethasone
1 QL
calcitrene 1 QL
calcitriol 1 QL
COAL TAR 2
COSENTYX 3 ST; S; SLA;
QL
COSENTYX (2
SYRINGES)
3 ST; S; SLA;
QL
COSENTYX PEN 3 ST; S; SLA;
QL
COSENTYX PEN
(2 PENS)
3 ST; S; SLA;
QL
DOVONEX 3 QL
drithocreme hp 1
ENSTILAR 2
EPIFOAM 3 ST
hydrocortisone-
pramoxine
1
OVACE 3
OVACE PLUS
SHAMPOO
3
OVACE PLUS
TOPICAL
CLEANSER
3
OVACE PLUS
TOPICAL CREAM
3 ST
OVACE PLUS
TOPICAL FOAM
3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
44
Drug Name Drug
Category
Requirements
/ Limits
OVACE PLUS
TOPICAL LOTION
3 ST
OVACE PLUS
WASH
3
PRAMOSONE 3 ST
PRAMOSONE E 3 ST
seb-prev 1
selenium sulfide 1
SELRX 3
SILIQ 4 ST; S
SORIATANE 3
SORILUX 3 QL
STELARA 6 MSD
sulfacetamide
sodium
1
TACLONEX
TOPICAL
OINTMENT
3 QL
TACLONEX
TOPICAL
SUSPENSION
2
TALTZ
AUTOINJECTOR
4 ST; S; SLA
TALTZ
AUTOINJECTOR
(2 PACK)
4 ST; S; SLA
TALTZ
AUTOINJECTOR
(3 PACK)
4 ST; S; SLA
TALTZ SYRINGE 4 ST; S; SLA
TERSI FOAM 3
TREMFYA 3 PA; ST; S
VECTICAL 3 QL
ZITHRANOL 3
BURN THERAPY
Drug Name Drug
Category
Requirements
/ Limits
SILVADENE 3
silver sulfadiazine 1
ssd 1
KERATOLYTICS
BENSAL HP 3
INOVA 4-1 3 ST
KERALYT RX 3
PODOCON 3
SALEX 3
salicylic acid 1
salimez 1
SALIMEZ FORTE 3
SALKERA 3
salvax 1
SALVAX DUO
PLUS
3
ULTRASAL-ER 3
VIRASAL 3
MISCELLANEOUS
DERMATOLOGICALS
ALEVICYN PLUS 3
AMELUZ 6 MSD
ATOPADERM 3
ATOPICLAIR 3
ATRAPRO CP 3
ATRAPRO
HYDROGEL
3
avo cream 1
BIAFINE
EMULSION
3
CARAC 2
celacyn 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
45
Drug Name Drug
Category
Requirements
/ Limits
CONDYLOX 3
CORTANE-B 3
DEXERYL 3
diclofenac sodium 1 PA
doxepin 1
DUPIXENT 3 PA; S
EFUDEX 3
eletone 1
ELIDEL 2 ST; QL
EPICERAM 3
ESKATA 3
EUCRISA 3 PA; ST; QL
FLUOROPLEX 3
FLUOROURACIL
TOPICAL CREAM
0.5 %
3 ST
fluorouracil topical
cream 5 %
1
fluorouracil topical
solution
1
hpr 1
hpr plus 1
hpr plus hydrogel 1
HPR PLUS-MB
HYDROGEL
3
HYDRO 35 3
HYDRO 40 3
HYLATOPIC 3
HYLATOPICPLUS 3
KERAFOAM 3
KERALAC 3
LEVICYN
ANTIPRURITIC
3
Drug Name Drug
Category
Requirements
/ Limits
LEVICYN
ANTIPRURITIC SG
3
LEVULAN 6 MSD
LOUTREX 3
LOYON 3
luxamend 1
methoxsalen 1
METOPIC 3
NEOCERA 3
NEOSALUS 3
nivatopic plus 1
NUTRASEB 3
OXSORALEN
ULTRA
3
PANRETIN 3
PICATO 2 QL
podofilox 1
PRESERA 3
PROMISEB 3
PROTOPIC 3 ST; QL
pruclair 1
prudoxin 1
prumyx 1
prutect 1
QUTENZA 6 MSD
REGRANEX 2 QL
RESTIZAN 3
silver nitrate 1
silver nitrate
applicators
1
SOLARAZE 3 PA
sonafine 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
46
Drug Name Drug
Category
Requirements
/ Limits
sp antipruritic 1
sp scar management 1
tacrolimus 1 ST; QL
TOLAK 3
umecta 1
urea 1
urea nail stick 1
UTOPIC 3
VALCHLOR 3 S; SLA
VEREGEN 3
XCLAIR 3
ZONALON 3
THERAPY FOR ACNE
ABSORICA 2 QL
ACANYA 2 ST; QL
ACZONE 3 ST
adapalene topical
cream
1 QL
adapalene topical
gel
1 QL
adapalene topical
gel with pump
1 QL
ADAPALENE
TOPICAL LOTION
3 ST; QL
adapalene-benzoyl
peroxide
1 QL
AKTIPAK 3 ST
amnesteem 1 QL
ATRALIN 3 QL
AVAR LS 3 ST
avar topical cleanser 1
AVAR TOPICAL
FOAM
3 ST
Drug Name Drug
Category
Requirements
/ Limits
AVAR TOPICAL
PADS,
MEDICATED
3 ST
AVAR-E GREEN 3 ST
AVAR-E LS 3 ST
avita topical cream 1 QL
AVITA TOPICAL
GEL
3 QL
AZELEX 3 ST; QL
BENZACLIN 3 ST
BENZACLIN
PUMP
3 ST; QL
BENZAMYCIN 3 ST
BENZEFOAM 3 ST
BENZEFOAM
ULTRA
3 ST
benzepro 1
benzoyl peroxide 1
bp 10-1 1
bpo 1
claravis 1 QL
cleansing wash 1
CLEOCIN T 3 ST
CLINDACIN ETZ 3 ST
clindacin p 1
CLINDACIN PAC 3 ST
CLINDAGEL 3 ST
clindamycin
phosphate
1
clindamycin-benzoyl
peroxide topical gel
1.2 %(1 % base) -5
%
1 QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
47
Drug Name Drug
Category
Requirements
/ Limits
clindamycin-benzoyl
peroxide topical gel
1-5 %
1
clindamycin-benzoyl
peroxide topical gel
with pump
1 QL
clindamycin-
tretinoin
1
dapsone 1
DIFFERIN 3 ST; QL
DUAC 3 ST; QL
EPIDUO 3 ST; QL
EPIDUO FORTE 2 ST
ery pads 1
erygel 1
erythromycin with
ethanol
1
erythromycin-
benzoyl peroxide
1
EVOCLIN 3 ST
FABIOR 3 PA; QL
FINACEA 2 ST
INOVA 3 ST
isotretinoin 1 QL
METROCREAM 3 ST
METROGEL 3 ST
METROLOTION 3 ST
metronidazole 1
MIRVASO 2
neuac 1 QL
NEUAC KIT 3 ST
NORITATE 3 ST
NUOX 3 ST
Drug Name Drug
Category
Requirements
/ Limits
ONEXTON 2 ST; QL
PLEXION 3 ST
PLEXION
CLEANSING
CLOTHS
3 ST
RETIN-A MICRO 3
RETIN-A MICRO
PUMP
3
RETIN-A TOPICAL
CREAM 0.025 %
3 QL
RETIN-A TOPICAL
CREAM 0.05 %, 0.1
%
3
RETIN-A TOPICAL
GEL 0.01 %
3
RETIN-A TOPICAL
GEL 0.025 %
3 QL
RHOFADE 3
rosadan topical
cream
1
rosadan topical gel 1
ROSADAN
TOPICAL KIT,
CLEANSER AND
GEL
3 ST
ROSADAN
TOPICAL
KIT,CLEANSER
AND CREAM
3 ST
ROSANIL 3 ST
ROSULA 3 ST
rosula cleansing
cloths
1
SOOLANTRA 2 ST
sss 10-5 1
sulfacetamide
sodium-sulfur
1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
48
Drug Name Drug
Category
Requirements
/ Limits
sulfacetamide sod-
sulfur-urea
1
sulfacleanse 8-4 1
SUMADAN 3 ST
SUMAXIN 3 ST
SUMAXIN TS 3 ST
tazarotene 1 PA; QL
TAZORAC
TOPICAL CREAM
0.05 %
2 PA; QL
TAZORAC
TOPICAL CREAM
0.1 %
3 PA; QL
TAZORAC
TOPICAL GEL
2 PA; QL
tretinoin
microspheres
1
tretinoin topical
cream 0.025 %
1 QL
tretinoin topical
cream 0.05 %, 0.1 %
1
tretinoin topical gel
0.01 %
1
tretinoin topical gel
0.025 %, 0.05 %
1 QL
TRETIN-X 3
TRETIN-X CREAM
KIT
3
VANOXIDE-HC 3 ST
VELTIN 3 ST
zenatane 1 QL
ZIANA 3 ST
TOPICAL ANESTHETICS
AGONEAZE 3
ANASTIA 3
Drug Name Drug
Category
Requirements
/ Limits
ANODYNE LPT 3
ASTERO 3
BUCALSEP 3
DERMACINRX
EMPRICAINE
3
DOLOTRANZ 3
ethyl chloride 1
glydo 1
LDO PLUS 3
LEVA SET 3
lidocaine (pf)
injection solution
6 MSD
LIDOCAINE (PF)
INJECTION
SYRINGE
6 MSD
lidocaine hcl
injection solution
6 MSD
lidocaine hcl
injection syringe 10
mg/ml (1 %)
6 MSD
LIDOCAINE HCL
INJECTION
SYRINGE 100
MG/5 ML (2 %), 30
MG/3 ML (1%), 50
MG/5 ML (1 %)
6 MSD
lidocaine hcl
laryngotracheal
1
lidocaine hcl mucous
membrane
1
lidocaine hcl topical
cream 3 %
1
LIDOCAINE HCL
TOPICAL CREAM
3.88 %
3
lidocaine hcl topical
lotion
1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
49
Drug Name Drug
Category
Requirements
/ Limits
lidocaine hcl-
hydrocortison ac
1
lidocaine topical
adhesive
patch,medicated
1 PA
lidocaine topical
ointment
1
lidocaine viscous 1
lidocaine-prilocaine 1
LIDOCAINE-
TETRACAINE
3 ST
LIDODERM 3 PA; ST
LIDOPAC 3
lidopin topical
cream 3 %
1
LIDOPIN TOPICAL
CREAM 3.25 %
3
LIDO-PRILO
CAINE PACK
3
LIDORX 3
LIDOTRAL 3
lidozion 1
LIDTOPIC MAX 3
LIPROZONEPAK 3
lta pre-attached 1
MEDOLOR PAK 3
NUMBONEX 3
P-CARE X (PF) 6 MSD
PLIAGLIS 3
PRILOLID 3
READYSHARP
LIDOCAINE (PF)
6 MSD
relador pak 1
relador pak plus 1
Drug Name Drug
Category
Requirements
/ Limits
SYNERA 3
TRANZAREL 3
XYLOCAINE 6 MSD
XYLOCAINE-MPF 6 MSD
ZINGO 6 MSD
TOPICAL ANTIBACTERIALS
ALTABAX 3
BACTROBAN 3
CENTANY 3
CENTANY AT 3
CORTISPORIN 3
gentamicin 1
hydrocortisone-
iodoquinol-aloe
1
iodoquinol-hc 1
KLARON 3 ST
lugols 1
mafenide acetate 1
mupirocin 1
mupirocin calcium 1
NEO-SYNALAR 3
NEO-SYNALAR
KIT
3
SILVRSTAT 3
sulfacetamide
sodium (acne)
1
SULFAMYLON
TOPICAL CREAM
2
SULFAMYLON
TOPICAL PACKET
3
TOPICAL ANTIFUNGALS
ciclodan 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
50
Drug Name Drug
Category
Requirements
/ Limits
CICLODAN KIT
TOPICAL COMBO
PACK
3
CICLODAN KIT
TOPICAL
SOLUTION
3 ST
ciclopirox 1
clotrimazole-
betamethasone
1
econazole 1
ECOZA 3
ERTACZO 3
EXELDERM 3
EXODERM 3
EXTINA 3
JUBLIA 3 ST; QL
KERYDIN 3 ST; QL
ketoconazole 1
LOPROX 3
LOPROX (AS
OLAMINE)
3
LOPROX KIT 3
LOTRISONE 3
LUZU 3 QL
naftifine 1
NAFTIN 3
NIZORAL 3
nyamyc 1
nystatin 1
nystatin-
triamcinolone
1
nystop 1
oxiconazole 1
Drug Name Drug
Category
Requirements
/ Limits
OXISTAT 3
PENLAC 3 ST
TRIACETIN 2
TRIPLE DYE 3
VUSION 3
XOLEGEL 3
TOPICAL ANTIVIRALS
acyclovir 1 QL
DENAVIR 3
XERESE 3
ZOVIRAX
TOPICAL CREAM
2 QL
ZOVIRAX
TOPICAL
OINTMENT
3 QL
TOPICAL CORTICOSTEROIDS
ala-cort 1
ALA-SCALP 3 ST
alclometasone 1
amcinonide 1
apexicon e 1 QL
AQUA GLYCOLIC
HC
3 ST
betamethasone
dipropionate
1
betamethasone
valerate
1
betamethasone,
augmented
1
CAPEX 3 ST; QL
clobetasol 1
clobetasol-emollient 1
CLOBEX 3 ST
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
51
Drug Name Drug
Category
Requirements
/ Limits
CLOCORTOLONE
PIVALATE
3 ST; QL
clodan 1
CLODAN KIT 3 ST
CLODERM 3 ST; QL
CORDRAN 3 ST
CORDRAN TAPE
LARGE ROLL
3 ST
cormax 1
CUTIVATE 3 ST
DERMA-
SMOOTHE/FS
BODY OIL
3 ST; QL
DERMA-
SMOOTHE/FS
SCALP OIL
3 ST; QL
DERMATOP 3 ST
DESONATE 3 ST
desonide 1 QL
DESOWEN 3 ST; QL
desoximetasone 1 QL
diflorasone 1 QL
DIPROLENE 3 ST
ELLZIA PAK 3
ELOCON 3 ST
fluocinolone 1 QL
fluocinolone and
shower cap
1 QL
fluocinonide 1
fluocinonide-
emollient
1
flurandrenolide 1
fluticasone 1
Drug Name Drug
Category
Requirements
/ Limits
halobetasol
propionate
1 QL
HALOG 3 ST
hydrocortisone 1
hydrocortisone
butyrate
1
hydrocortisone
butyr-emollient
1
hydrocortisone
valerate
1
hydrocortisone-min
oil-wht pet
1
IMPOYZ 3 ST
KENALOG 3 ST
LOCOID 3 ST
LOCOID
LIPOCREAM
3 ST
LUXIQ 3 ST
mometasone 1
nolix 1
OLUX 3 ST
OLUX-E 3 ST
PANDEL 3 ST
prednicarbate 1
PSORCON 3 ST; QL
scalacort 1
SERNIVO 3 ST
SYNALAR 3 ST; QL
SYNALAR
CREAM KIT
3 ST
SYNALAR
OINTMENT KIT
3 ST
SYNALAR TS 3 ST
TEMOVATE 3 ST
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
52
Drug Name Drug
Category
Requirements
/ Limits
TEXACORT 3 ST
TOPICORT
TOPICAL CREAM
3 ST; QL
TOPICORT
TOPICAL GEL
3 ST; QL
TOPICORT
TOPICAL
OINTMENT
3 ST; QL
TOPICORT
TOPICAL
SPRAY,NON-
AEROSOL
3 ST
triamcinolone
acetonide
1
trianex 1
triderm 1
TRIDESILON 3 ST; QL
ULTRAVATE
TOPICAL CREAM
3 ST; QL
ULTRAVATE
TOPICAL LOTION
3 ST
ULTRAVATE
TOPICAL
OINTMENT
3 ST; QL
ULTRAVATE X 3 ST
VANOS 3 ST
VERDESO 3 ST
TOPICAL ENZYMES
SANTYL 2
TOPICAL SCABICIDES /
PEDICULICIDES
ELIMITE 3
EURAX 3
lindane 1
malathion 1
Drug Name Drug
Category
Requirements
/ Limits
NATROBA 3 QL
OVIDE 3
permethrin 1
SKLICE 3
spinosad 1 QL
ULESFIA 3
DIAGNOSTICS &
MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
lactated ringers 1
PHYSIOLYTE 3
PHYSIOSOL
IRRIGATION
3
ringer's 1
SORBITOL-
MANNITOL
3
tis-u-sol pentalyte 1
VASHE WOUND
THERAPY
6 MSD
MISCELLANEOUS AGENTS
acamprosate 1
ACTONEL 3 ST; QL
ADAGEN 6 MSD
AGRYLIN 3 M
alendronate 1 M; QL
AMMONUL 6 MSD
AMPHADASE 6 MSD
anagrelide 1 M
ANTABUSE 3
ARALAST NP 6 MSD
BUPHENYL 3
caffeine citrate 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
53
Drug Name Drug
Category
Requirements
/ Limits
CARBAGLU 3 PA; S; SLA
CARNITOR 3 M
CARNITOR
(SUGAR-FREE)
3 M
cevimeline 1 M
disulfiram 1
ENDARI 3 SLA
etidronate disodium 1 M
EVOXAC 3 M
FERRLECIT 6 MSD
GLASSIA 6 MSD
ic green 6 MSD
INCRELEX 3 PA; S; SLA
indocyanine green 6 MSD
INFASURF 6
KIT FOR TC 99M-
SESTAMIBI NO.1
6 MSD
KIT PREP OF TC-
99M-
MEBROFENIN
6 MSD
KIT PREP OF TC-
99M-SOD PYROPH
6 MSD
levocarnitine 1 M
levocarnitine (with
sugar)
1 M
LIPOCHOL PLUS 3
LITHOSTAT 3
METOPIRONE 3 SLA
midodrine 1
NITYR 2 SLA
NORTHERA 4 PA; S; SLA
NUTRESTORE 3
ORFADIN 2 SLA
Drug Name Drug
Category
Requirements
/ Limits
pilocarpine hcl 1
PROLASTIN-C 6 MSD
RAVICTI 3 S; SLA
RECLAST 6 MSD
RILUTEK 3
riluzole 1
risedronate 1 QL
SALAGEN
(PILOCARPINE)
3
sodium benzoate-sod
phenylacet
6 MSD
sodium chlor 0.9%
bacteriostat
6 MSD
sodium chloride 0.9
%
6 MSD
sodium ferric
gluconat-sucrose
6 MSD
sodium
phenylbutyrate
1
SOLIRIS 6 MSD
SURVANTA 6 MSD
THALLOUS
CHLORIDE TL-201
6
THIOLA 3 SLA
water for irrigation,
sterile
1
XURIDEN 2 SLA
ZEMAIRA 6 MSD
zoledronic acid-
mannitol-water
6 MSD
SMOKING DETERRENTS
bupropion hcl
(smoking deter)
5 M; ACA
CHANTIX 5 ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
54
Drug Name Drug
Category
Requirements
/ Limits
CHANTIX
CONTINUING
MONTH BOX
5 ACA
CHANTIX
STARTING
MONTH BOX
5 ACA
NICODERM CQ
TRANSDERMAL
PATCH 24 HOUR
14 MG/24 HR, 7
MG/24 HR
5 ACA; OTC
NICODERM CQ
TRANSDERMAL
PATCH 24 HOUR
21 MG/24 HR
5 M; ACA; OTC
nicorelief 5 ACA; OTC
NICORETTE
BUCCAL GUM 2
MG
5 ACA; OTC
nicorette buccal gum
4 mg
5 ACA; OTC
NICORETTE
BUCCAL
LOZENGE
5 ACA; OTC
NICORETTE
BUCCAL MINI
LOZENGE
5 ACA; OTC
nicotine (polacrilex) 5 ACA; OTC
nicotine transdermal
patch 24 hour 14
mg/24 hr, 7 mg/24
hr
5 ACA; OTC
nicotine transdermal
patch 24 hour 21
mg/24 hr
5 M; ACA; OTC
nicotine transdermal
patch, td daily,
sequential
5 ACA; OTC
NICOTROL 5 ACA
Drug Name Drug
Category
Requirements
/ Limits
NICOTROL NS 5 ACA
quit 2 buccal gum 5 ACA; OTC
QUIT 2 BUCCAL
LOZENGE
5 ACA; OTC
quit 4 buccal gum 5 ACA; OTC
QUIT 4 BUCCAL
LOZENGE
5 ACA; OTC
stop smoking aid 5 ACA; OTC
ZYBAN 5 M; ACA
EAR, NOSE & THROAT
MEDICATIONS
MISCELLANEOUS AGENTS
ARESTIN 6 MSD
ASTEPRO 3
azelastine nasal
aerosol,spray
1 QL
azelastine nasal
spray,non-aerosol
1
BACTROBAN
NASAL
3
chlorhexidine
gluconate
1
CLINPRO 5000 3 M
DEBACTEROL 3
denta 5000 plus 1 M
dentagel 1 M
EPISIL 3
FLUORIDEX
DAILY DEFENSE
3 M
GELCLAIR 3
ipratropium bromide 1 QL
MUGARD 3
olopatadine 1 QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
55
Drug Name Drug
Category
Requirements
/ Limits
oralone 1
ORAMAGICRX 3
paroex oral rinse 1
PATANASE 3 QL
PERIDEX 3
periogard 1
pilocarpine hcl 1
PREVIDENT 3 M
PREVIDENT 5000
BOOSTER PLUS
3 M
PREVIDENT 5000
DRY MOUTH
3 M
PREVIDENT 5000
ENAMEL
PROTECT
3 M
PREVIDENT 5000
PLUS
3 M
PREVIDENT 5000
SENSITIVE
3 M
Q-CARE RX Q4 3
SALAGEN
(PILOCARPINE)
3
sf 1 M
sf 5000 plus 1 M
triamcinolone
acetonide
1
TYZINE 3
MISCELLANEOUS OTIC
PREPARATIONS
acetic acid 1
CETRAXAL 3 ST
ciprofloxacin hcl 1
DERMOTIC OIL 3
Drug Name Drug
Category
Requirements
/ Limits
fluocinolone
acetonide oil
1
hydrocortisone-
acetic acid
1
ofloxacin 1
OTIPRIO 3
OTIC STEROID / ANTIBIOTIC
CIPRO HC 3
CIPRODEX 2
COLY-MYCIN S 3
neomycin-
polymyxin-hc
1
OTOVEL 2
ENDOCRINE/DIABETES
ADRENAL HORMONES
ACTHAR H.P. 6 MSD
betamethasone
acet,sod phos
6 MSD
BETAMETHASON
E SOD PHOSPH-
WATER
6 MSD
CELESTONE
SOLUSPAN
6 MSD
CORTEF 3 M
cortisone 1
CORTROSYN 6 MSD
cosyntropin 6 MSD
decadron 1
deltasone 1
dexamethasone 1
DEXAMETHASON
E ACE-NACL,ISO-
OSM
3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
56
Drug Name Drug
Category
Requirements
/ Limits
dexamethasone
intensol
1
dexamethasone
sodium phos (pf)
6 MSD
dexamethasone
sodium phosphate
6 MSD
DEXPAK 10 DAY 3 ST
DEXPAK 13 DAY 3 ST
DEXPAK 6 DAY 3 ST
EMFLAZA 3 PA; ST; SLA
fludrocortisone 1 M
hydrocortisone 1 M
KENALOG 6 MSD
MEDROL 3
MEDROL (PAK) 3
methylprednisolone 1
millipred 1
millipred dp 1
ORAPRED ODT 3
P-CARE K40 6 MSD
P-CARE K80 6 MSD
POD-CARE 100K 6 MSD
prednisolone 1
prednisolone sodium
phosphate
1
prednisone 1
prednisone intensol 1
PRO-C-DURE 5 6 MSD
PRO-C-DURE 6 6 MSD
RAYOS 3 ST
READYSHARP
DEXAMETHASON
E
6 MSD
Drug Name Drug
Category
Requirements
/ Limits
READYSHARP
TRIAMCINOLONE
6 MSD
TAPERDEX 3 ST
triamcinolone
acetonide
6 MSD
veripred 20 1
ANTITHYROID AGENTS
methimazole 1 M
propylthiouracil 1 M
SSKI 3 M
TAPAZOLE 3 M
BLOOD GLUCOSE MONITORING
DEVICES & SUPPLIES
ACCU-CHEK
AVIVA PLUS
TEST STRP
3 ST; OTC
ACCU-CHEK
COMPACT PLUS
TEST
3 ST; OTC
ACCU-CHEK
GUIDE
3 ST; OTC
ACCU-CHEK
SMARTVIEW
TEST STRIP
3 ST; OTC
ACCUTREND
GLUCOSE
3 ST; OTC
ADVANCED
GLUC METER
TEST STRIP
3 ST; OTC
ADVOCATE REDI-
CODE
3 ST; OTC
ADVOCATE TEST
STRIPS
3 ST; OTC
AGAMATRIX
AMP TEST STRIPS
3 ST; OTC
ASSURE 4 STRIPS 3 ST; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
57
Drug Name Drug
Category
Requirements
/ Limits
ASSURE
PLATINUM
3 ST; OTC
ASSURE PRISM
MULTI STRIP
3 ST; OTC
BIONIME
RIGHTEST TEST
STRIPS
3 ST; OTC
BLOOD GLUCOSE
TEST
3 ST; OTC
BREEZE 2 TEST
STRIPS
3 ST; OTC
CARESENS N
TEST STRIPS
3 ST; OTC
CARETOUCH
TEST STRIP
3 ST; OTC
CLEVER CHOICE
MICRO TEST
STRIP
3 ST; OTC
CLEVER CHOICE
PRO
3 ST; OTC
CLEVER CHOICE
TALK TEST
3 ST; OTC
CLEVER CHOICE
TEST STRIPS
3 ST; OTC
CLEVER CHOICE
VOICE+ TEST
3 ST; OTC
CONTOUR NEXT
TEST STRIPS
3 ST; OTC
CONTOUR TEST
STRIPS
3 ST; OTC
COOL GLUCOSE
TEST STRIP
3 ST; OTC
DIATRUE PLUS
TEST STRIP
3 ST; OTC
EASY PLUS II
TEST
3 ST; OTC
EASY STEP 3 ST; OTC
Drug Name Drug
Category
Requirements
/ Limits
EASY TALK
GLUCOSE TEST
3 ST; OTC
EASY TOUCH
TEST STRIP
3 ST; OTC
EASY TRAK
GLUCOSE TEST
3 ST; OTC
EASYGLUCO
PLUS
3 ST; OTC
EASYGLUCO
TEST
3 ST; OTC
EASYMAX 3 ST; OTC
ELEMENT
COMPACT TEST
STRIPS
3 ST; OTC
ELEMENT TEST
STRIPS
3 ST; OTC
EMBRACE
BLOOD GLUCOSE
SYSTEM
3 ST; OTC
EMBRACE EVO
TEST STRIPS
3 ST; OTC
EMBRACE PRO
TEST STRIPS
3 ST; OTC
EVENCARE G2 3 ST; OTC
EVENCARE G3
TEST
3 ST; OTC
EVENCARE MINI
GLUCOSE TEST
STR
3 ST; OTC
EVOLUTION TEST
STRIPS
3 ST; OTC
EZ SMART PLUS
TEST
3 ST; OTC
EZ SMART TEST 3 ST; OTC
FIFTY50 TEST
STRIP
3 ST; OTC
FORA D15G 3 ST; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
58
Drug Name Drug
Category
Requirements
/ Limits
FORA D20 3 ST; OTC
FORA D40-G31
TEST STRIPS
3 ST; OTC
FORA G20 3 ST; OTC
FORA G30-
PREMIUM V10
TEST STRP
3 ST; OTC
FORA GD50 TEST
STRIPS
3 ST; OTC
FORA TEST STRIP 3 ST; OTC
FORA TN'G VOICE
TEST STRIPS
3 ST; OTC
FORA V10 3 ST; OTC
FORA V10-V12-
D10-D20 STRIPS
3 ST; OTC
FORA V12
GLUCOSE
3 ST; OTC
FORA V20 3 ST; OTC
FORACARE GD20 3 ST; OTC
FORACARE GD40 3 ST; OTC
FORTISCARE
GLUCOSE TEST
STRIPS
3 ST; OTC
FREESTYLE
INSULINX
3 ST; OTC
FREESTYLE
INSULINX TEST
STRIPS
3 ST; OTC
FREESTYLE LITE
STRIPS
3 ST; OTC
FREESTYLE
PRECISION NEO
STRIPS
3 ST; OTC
FREESTYLE TEST 3 ST; OTC
GE100 BLOOD
GLUCOSE TEST
STRIP
3 ST; OTC
Drug Name Drug
Category
Requirements
/ Limits
GENSTRIP TEST
STRIP
3 ST; OTC
GLUCO NAVII
TEST STRIP
3 ST; OTC
GLUCOCARD 01
SENSOR PLUS
3 ST; OTC
GLUCOCARD
EXPRESSION
3 ST; OTC
GLUCOCARD
SHINE TEST
STRIPS
3 ST; OTC
GLUCOCARD
VITAL SENSOR
3 ST; OTC
GLUCOCARD
VITAL TEST
STRIPS
3 ST; OTC
GLUCOCOM
GLUCOSE
3 ST; OTC
GM100 3 ST; OTC
HEALTHPRO
TEST STRIPS
3 ST; OTC
IGLUCOSE TEST
STRIP
3 ST; OTC
INFINITY TEST
STRIPS
3 ST; OTC
INFINITY VOICE
TEST STRIP
3 ST; OTC
MICRO BLOOD
GLUCOSE
3 ST; OTC
MICRODOT
BLOOD GLUCOSE
SYSTEM
3 ST; OTC
MYGLUCOHEALT
H
3 ST; OTC
NEUTEK 2TEK
TEST STRIPS
3 ST; OTC
NOVA MAX
GLUCOSE TEST
3 ST; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
59
Drug Name Drug
Category
Requirements
/ Limits
ON CALL
EXPRESS TEST
STRIP
3 ST; OTC
ON CALL PLUS
TEST STRIP
3 ST; OTC
ON CALL VIVID
TEST STRIP
3 ST; OTC
ONETOUCH
ULTRA BLUE
TEST STRIP
2 ST; OTC
ONETOUCH
VERIO
2 ST; OTC
OPTIUM EZ 3 ST; OTC
OPTIUM TEST 3 ST; OTC
OPTUMRX 3 ST; OTC
PHARMACIST
CHOICE
3 ST; OTC
PRECISION PCX
PLUS TEST
3 ST; OTC
PRECISION PCX
TEST
3 ST; OTC
PRECISION POINT
OF CARE TEST
3 ST; OTC
PRECISION Q-I-D
TEST
3 ST; OTC
PRECISION XTRA
TEST
3 ST; OTC
PREMIER TEST
STRIP
3 ST; OTC
PREMIUM V10 3 ST; OTC
PRODIGY NO
CODING
3 ST; OTC
QUINTET AC 3 ST; OTC
REFUAH PLUS 3 ST; OTC
RELION
CONFIRM-MICRO
3 ST; OTC
Drug Name Drug
Category
Requirements
/ Limits
RELION PRIME
TEST STRIPS
3 ST; OTC
REVEAL TEST
STRIP
3 ST; OTC
RIGHTEST GS550
TEST STRIPS
3 ST; OTC
SMART SENSE
TEST STRIPS
3 ST; OTC
SMARTEST TEST 3 ST; OTC
SOLUS V2 TEST
STRIPS
3 ST; OTC
SURE-TEST
EASYPLUS MINI
3 ST; OTC
TELCARE TEST
STRIPS
3 ST; OTC
TEST N'GO TEST 3 ST; OTC
TRUE METRIX
GLUCOSE TEST
STRIP
3 ST; OTC
TRUETEST TEST
STRIPS
3 ST; OTC
TRUETRACK
TEST
3 ST; OTC
ULTIMA TEST
STRIPS
3 ST; OTC
ULTRATRAK 3 ST; OTC
ULTRATRAK
ULTIMATE
3 ST; OTC
UNISTRIP1 TEST
STRIP
3 ST; OTC
VERASENS TEST
STRIP
3 ST; OTC
WAVESENSE
JAZZ
3 ST; OTC
WAVESENSE
PRESTO
3 ST; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
60
Drug Name Drug
Category
Requirements
/ Limits
DIABETES, SUPPLIES, & DURABLE
MEDICAL EQUIPMENT
GLUCAGEN
DIAGNOSTIC KIT
2
GLUCAGON HCL 3
INSULIN
SYRINGE-
NEEDLE U-100
2 M
GLUCOSE ELEVATING AGENTS
GLUCAGEN
HYPOKIT
2
GLUCAGON
EMERGENCY KIT
(HUMAN)
2
PROGLYCEM 2 M
INSULIN
SYRINGES/MISCELLANEOUS
DURABLE MEDICAL EQU
2TEK
GLUCOSE/BLOOD
PRESSURE
3 OTC
ACCU-CHEK
AVIVA PLUS
METER
3 ST; OTC
ACCU-CHEK
COMPACT PLUS
CONTROL
3 OTC
ACCU-CHEK
GUIDE GLUCOSE
METER
3 ST; OTC
ACCU-CHEK
GUIDE L1-L2
CTRL SOL
3 OTC
ACCU-CHEK
NANO
3 ST; OTC
ACCU-CHEK
SMARTVIEW
CONTRL SOL
3 OTC
Drug Name Drug
Category
Requirements
/ Limits
ACCUTREND
GLUCOSE
CONTROL
3 OTC
ADVANCED
GLUCOSE METER
3 ST; OTC
ADVOCATE
BLOOD GLUCOSE
MONITOR
3 ST; OTC
ADVOCATE DUO 3 ST; OTC
ADVOCATE LOW
CONTROL
3 OTC
ADVOCATE REDI-
CODE DUO
METER
3 ST; OTC
ADVOCATE REDI-
CODE GLU
MONITOR
3 ST; OTC
ADVOCATE REDI-
CODE+ CTRL
LOW
3 OTC
AGAMATRIX
AMP GLUC
MONITOR SYS
3 ST; OTC
AGAMATRIX
CONTROL HIGH
3 OTC
ASSURE 4
CONTROL
SOLUTION
3 OTC
ASSURE DOSE
NORMAL
CONTROL
3 OTC
ASSURE
PLATINUM
3 ST; OTC
ASSURE PRISM
CONTROL 1-2
SOLN
3 OTC
ASSURE PRISM
MULTI METER
3 ST; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
61
Drug Name Drug
Category
Requirements
/ Limits
AUTOJECT 2
INJECTION
DEVICE
2 OTC
AUTOPEN 1 TO 21
UNITS
2 OTC
AUTOSOFT 30 6 MSD
AUTOSOFT 90 6 MSD
BIONIME
RIGHTEST GM300
SYSTEM
3 ST; OTC
BLOOD GLUCOSE
CONTROL,
NORMAL
3 OTC
BLOOD-GLUCOSE
METER
3 ST; OTC
BREEZE 2
CONTROL
SOLUTION,HIGH
3 OTC
CARESENS
CONTROL A
NORMAL
3 OTC
CARESENS N 3 ST; OTC
CARESENS N
VOICE
3 ST; OTC
CARETOUCH
GLUCOSE
MONITORING
3 ST; OTC
CLEVER CHEK
BLOOD GLUCOSE
3 ST; OTC
CLEVER CHOICE
GLUCOSE
MONITOR
3 ST; OTC
CLEVER CHOICE
LEVEL 2
CONTROL
3 OTC
CLEVER CHOICE
MICRO
3 ST; OTC
Drug Name Drug
Category
Requirements
/ Limits
CLEVER CHOICE
PRO
3 ST; OTC
CLEVER CHOICE
TALK GLUCOSE
SYS
3 ST; OTC
CONTOUR
CONTROL
SOLUTION, NML
3 OTC
CONTOUR LINK 3 ST; OTC
CONTOUR NEXT
EZ METER
3 ST; OTC
CONTOUR NEXT
LEV 2 CONTROL
SOL
3 OTC
CONTOUR NEXT
LINK
3 OTC
CONTOUR NEXT
LINK 2.4
3 OTC
CONTOUR NEXT
METER
3 ST; OTC
CONTOUR NEXT
ONE METER
3 ST; OTC
COOL BLOOD
GLUCOSE METER
3 ST; OTC
COOL CONTROL
A SOLUTION
3 OTC
DEXCOM G6
RECEIVER
6 MSD
DIATRUE
CONTROL SOLN
NORMAL
3 OTC
DIATRUE PLUS
BLOOD GLUCOSE
MET
3 ST; OTC
EASY PLUS II
BLOOD GLUCOSE
MET
3 ST; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
62
Drug Name Drug
Category
Requirements
/ Limits
EASY STEP
BLOOD GLUCOSE
METER
3 ST; OTC
EASY TALK
BLOOD GLUCOSE
METER
3 ST; OTC
EASY TOUCH
GLUCOSE
MONITOR
3 ST; OTC
EASY TRAK LOW
CONTROL
3 OTC
EASYGLUCO
MONITORING
SYSTEM
3 ST; OTC
EASYGLUCO
PLUS NORMAL
CONTROL
3 OTC
EASYMAX L
BLOOD GLUCOSE
METER
3 ST; OTC
EASYMAX LOW
CONTROL
3 OTC
EASYMAX NG 3 ST; OTC
EASYMAX
NORMAL
CONTROL
3 OTC
EASYMAX V
SPEAKING
GLUCOSE SYS
3 ST; OTC
EASYMAX V2
BLOOD GLUCOSE
METER
3 ST; OTC
ELEMENT
COMPACT
GLUCOSE METER
3 ST; OTC
ELEMENT
COMPACT
NORMAL
CONTROL
3 OTC
Drug Name Drug
Category
Requirements
/ Limits
ELEMENT
COMPACT V
GLUCOSE MTR
3 ST; OTC
ELEMENT
NORMAL
CONTROL
3 OTC
ELEMENT PLUS
BLOOD GLUCOSE
KIT
3 ST; OTC
EMBRACE
BLOOD GLUCOSE
SYSTEM
3 ST; OTC
EMBRACE EVO
LEVEL 1
3 OTC
EMBRACE
GLUCOSE
CONTROL LOW
3 OTC
EMBRACE PRO
GLUCOSE METER
3 ST; OTC
EVENCARE G2 3 ST; OTC
EVENCARE G3
GLUCOSE METER
3 ST; OTC
EVENCARE MINI
MONITOR
SYSTEM
3 ST; OTC
EVOLUTION
BLOOD GLUCOSE
METER
3 ST; OTC
EVOLUTION
NORMAL
CONTROL
3 OTC
EZ SMART PLUS
SYSTEM
3 ST; OTC
EZ SMART
SYSTEM
3 ST; OTC
FORA D10 3 OTC
FORA D20 3 ST; OTC
FORA G20 3 ST; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
63
Drug Name Drug
Category
Requirements
/ Limits
FORA G30A 3 ST; OTC
FORA GD50
BLOOD GLUCOSE
SYSTEM
3 ST; OTC
FORA NORMAL
CONTROL
3 OTC
FORA PREMIUM
V10 GLUCOSE
METER
3 ST; OTC
FORA TEST N'GO
VOICE METER
3 ST; OTC
FORA TN'G VOICE
METER
3 ST; OTC
FORA V10 3 ST; OTC
FORA V12 BLOOD
GLUCOSE
SYSTEM
3 ST; OTC
FORA V20 3 ST; OTC
FORA V30A 3 ST; OTC
FORACARE GD20
GLUCOSE METER
3 ST; OTC
FORACARE
GD40A GLUCOSE
METER
3 ST; OTC
FORACARE
GD40B GLUCOSE
METER
3 ST; OTC
FORACARE GDH
LOW CONTROL
3 OTC
FORTISCARE
BLOOD GLUCOSE
SYST
3 ST; OTC
FORTISCARE
NORMAL
3 OTC
FREESTYLE
CONTROL
3 OTC
FREESTYLE
FLASH SYSTEM
3 ST; OTC
Drug Name Drug
Category
Requirements
/ Limits
FREESTYLE
FREEDOM
3 ST; OTC
FREESTYLE
FREEDOM LITE
3 ST; OTC
FREESTYLE
INSULINX
3 ST; OTC
FREESTYLE
LIBRE READER
6
FREESTYLE
LIBRE SENSOR
6 MSD
FREESTYLE LITE
METER
3 ST; OTC
FREESTYLE
PRECISION NEO
METER
3 ST; OTC
FREESTYLE
SIDEKICK II
3 ST; OTC
FREESTYLE
SYSTEM KIT
3 ST; OTC
GE100 BLOOD
GLUCOSE
SYSTEM
3 ST; OTC
GE100 CONTROL
SOLUTION
NORMAL
3 OTC
GLUCO NAVII
GLUCOSE
MONITOR
3 ST; OTC
GLUCOCARD 01
METER
3 ST; OTC
GLUCOCARD 01
NORMAL
CONTROL
3 OTC
GLUCOCARD
EXPRESSION
3 ST; OTC
GLUCOCARD
SHINE METER
3 ST; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
64
Drug Name Drug
Category
Requirements
/ Limits
GLUCOCARD
SHINE XL METER
3 ST; OTC
GLUCOCARD
VITAL
3 ST; OTC
GLUCOCOM
BLOOD GLUCOSE
3 ST; OTC
GLUCOCOM
CONTROL
NORMAL
3 OTC
GLUCOSE
CONTROL
3 OTC
GM100 3 ST; OTC
HEALTHPRO
GLUCOSE
MONITOR
3 ST; OTC
HEALTHPRO
HIGH-LOW
CONTROL
3 OTC
HUMAPEN
LUXURA HD
2
IGLUCOSE
BLOOD GLUCOSE
MONITOR
3 ST; OTC
INFINITY
CONTROL
SOLUTION NORM
3 OTC
INFINITY
STARTER KIT
3 ST; OTC
INFINITY VOICE
CTRL SOLN-LVL 2
3 OTC
INFINITY VOICE
GLUCOSE
MONITOR
3 ST; OTC
JAZZ WIRELESS 2
METER KIT
3 ST; OTC
LANCETS 2 OTC
LANCING DEVICE 2 OTC
MEDISENSE 3 OTC
Drug Name Drug
Category
Requirements
/ Limits
MEDISENSE
GLUCOSE
KETONE
3 OTC
MICRODOT
BLOOD GLUCOSE
SYSTEM
3 ST; OTC
MYGLUCOHEALT
H
3 ST; OTC
MYGLUCOHEALT
H CONTROL
SOLUTION
3 OTC
NOVA MAX
BLOOD GLUCOSE
METER
3 ST; OTC
NOVA MAX
GLUCOSE
CONTROL
3 OTC
NOVAMAX PLUS
GLU-KET
3 OTC
NOVOPEN ECHO 3
ON CALL
EXPRESS
CONTROL
3 OTC
ON CALL
EXPRESS METER
3 ST; OTC
ON CALL PLUS
CONTROL
3 OTC
ON CALL PLUS
METER
3 ST; OTC
ON CALL VIVID
CONTROL
3 OTC
ON CALL VIVID
METER
3 ST; OTC
ON CALL VIVID
PAL METER
3 ST; OTC
ONETOUCH
ULTRA CONTROL
2 OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
65
Drug Name Drug
Category
Requirements
/ Limits
ONETOUCH
ULTRA2
2 ST; OTC
ONETOUCH
ULTRAMINI
2 ST; OTC
ONETOUCH
VERIO FLEX
2 ST; OTC
ONETOUCH
VERIO IQ METER
2 ST; OTC
ONETOUCH
VERIO SYSTEM
2 ST; OTC
OPTUMRX 3 ST; OTC
PEN NEEDLE 2 M; OTC
PHARMACIST
CHOICE
GLUCOSE SYS
3 ST; OTC
PRECISION XTRA
MONITOR
2 ST; OTC
PREMIER BLU
GLUCOSE METER
3 ST; OTC
PREMIER VOICE
GLUCOSE METER
3 ST; OTC
PREMIUM BLOOD
GLUCOSE
MONITOR
3 ST; OTC
PREMIUM V10 3 ST; OTC
PRESTO PRO
BLOOD GLUCOSE
METER
3 ST; OTC
PRODIGY
AUTOCODE
METER
3 ST; OTC
PRODIGY
AUTOCODE
MONITOR SYST
3 ST; OTC
PRODIGY
CONTROL
SOLUTION, LOW
3 OTC
Drug Name Drug
Category
Requirements
/ Limits
PRODIGY
CONTROL
SOLUTION,HIGH
3 OTC
PRODIGY
POCKET METER
3 ST; OTC
PRODIGY VOICE
GLUCOSE METER
3 ST; OTC
QUINTET BLOOD
GLUCOSE METER
3 ST; OTC
REFUAH PLUS
GLUCOSE
CONTROL
3 OTC
REFUAH PLUS
GLUCOSE
MONITOR
3 ST; OTC
RELION ALL-IN-
ONE METER
3 ST; OTC
RELION CONFIRM 3 ST; OTC
RELION MICRO
GLUCOSE
MONITOR
3 ST; OTC
RELION PRIME
METER
3 ST; OTC
REVEAL BLOOD
GLUCOSE METER
3 ST; OTC
RIGHTEST
CONTROL
SOLUTION HIGH
3 OTC
RIGHTEST GM550
SYSTEM
3 ST; OTC
SIDEKICK BLOOD
GLUCOSE
SYSTEM
3 OTC
SMART SENSE
MONITORING
SYSTEM
3 ST; OTC
SMARTEST
CONTROL
3 OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
66
Drug Name Drug
Category
Requirements
/ Limits
SMARTEST EJECT 3 ST; OTC
SMARTEST
PERSONA
STARTER
3 ST; OTC
SMARTEST
PRONTO
STARTER
3 ST; OTC
SMARTEST
PROTEGE
3 ST; OTC
SNAP INSULIN
PUMP
CONTROLLER
2
SOLUS V2
AUDIBLE METER
3 ST; OTC
SOLUS V2
CONTROL
SOLUTION,HIGH
3 OTC
SURE-TEST
EASYPLUS MINI
METER
3 ST; OTC
TELCARE BGM 3 ST; OTC
TELCARE BLOOD
GLUCOSE KIT
3 ST; OTC
TELCARE
CONTROL
3 OTC
TEST N'GO
BLOOD GLUCOSE
SYSTEM
3 ST; OTC
TRUE METRIX
AIR GLUCOSE
METER
3 ST; OTC
TRUE METRIX
GLUCOSE METER
3 ST; OTC
TRUE METRIX GO
GLUCOSE METER
3 ST; OTC
TRUE METRIX
LEVEL 1
3 OTC
Drug Name Drug
Category
Requirements
/ Limits
TRUE2GO BLOOD
GLUCOSE
SYSTEM
3 ST; OTC
TRUECONTROL
LEVEL 0
3 OTC
TRUERESULT
BLOOD GLUCOSE
SYSTM
3 ST; OTC
TRUETRACK
BLOOD GLUCOSE
SYSTEM
3 ST; OTC
TRUETRACK
SMART SYSTEM
3 ST; OTC
TRUSTEEL
INFUSION SET 32"
6 MSD
ULTIMA
MONITOR
3 ST; OTC
ULTRATRAK
GLUCOSE METER
3 ST; OTC
ULTRATRAK
ULTIMATE
3 ST; OTC
UNISTRIP LOW
CONTROL
3 OTC
VARISOFT
INFUSION SET 43"
6 MSD
VERASENS
BLOOD GLUCOSE
METER
3 ST; OTC
VGO 20 6 MSD
VGO 30 6 MSD
VGO 40 6 MSD
WAVESENSE AMP 3 ST; OTC
WAVESENSE
CONTROL
SOLUTION
3 OTC
WAVESENSE
PRESTO
3 ST; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
67
Drug Name Drug
Category
Requirements
/ Limits
INSULIN THERAPY
ADMELOG
SOLOSTAR U-100
INSULIN
3 M
ADMELOG U-100
INSULIN LISPRO
3 M
AFREZZA
INHALATION
CARTRIDGE
WITH INHALER 12
UNIT, 4 UNIT (90)/
8 UNIT (90), 4
UNIT/8 UNIT/ 12
UNIT (60), 8 UNIT
3 M
AFREZZA
INHALATION
CARTRIDGE
WITH INHALER 4
UNIT, 4 UNIT (60)/
8 UNIT (30)
3 M; QL
APIDRA
SOLOSTAR U-100
INSULIN
3 ST; M
APIDRA U-100
INSULIN
3 ST; M
BASAGLAR
KWIKPEN U-100
INSULIN
3 M
FIASP
FLEXTOUCH U-
100 INSULIN
3 ST; M
FIASP U-100
INSULIN
3 ST; M
HUMALOG
JUNIOR KWIKPEN
U-100
2 M
HUMALOG
KWIKPEN
INSULIN
2 M
Drug Name Drug
Category
Requirements
/ Limits
HUMALOG MIX
50-50 INSULN U-
100
2 M
HUMALOG MIX
50-50 KWIKPEN
2 M
HUMALOG MIX
75-25 KWIKPEN
2 M
HUMALOG MIX
75-25(U-
100)INSULN
2 M
HUMALOG U-100
INSULIN
2 M
HUMULIN 70/30
U-100 INSULIN
2 M; QL
HUMULIN 70/30
U-100 KWIKPEN
2 M; QL
HUMULIN N NPH
INSULIN
KWIKPEN
2 M
HUMULIN N NPH
U-100 INSULIN
2 M; QL
HUMULIN R
REGULAR U-100
INSULN
2 M; QL
HUMULIN R U-500
(CONC) INSULIN
2 M; QL
HUMULIN R U-500
(CONC) KWIKPEN
2 M
LANTUS
SOLOSTAR U-100
INSULIN
2 M
LANTUS U-100
INSULIN
2 M
LEVEMIR
FLEXTOUCH U-
100 INSULN
2 M
LEVEMIR U-100
INSULIN
2 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
68
Drug Name Drug
Category
Requirements
/ Limits
NOVOLOG
FLEXPEN U-100
INSULIN
3 ST; M
NOVOLOG MIX
70-30 U-100
INSULN
3 ST; M
NOVOLOG MIX
70-30FLEXPEN U-
100
3 ST; M
NOVOLOG
PENFILL U-100
INSULIN
3 ST; M
NOVOLOG U-100
INSULIN ASPART
3 ST; M
RELION NOVOLIN
70/30
3 ST; M; QL
RELION NOVOLIN
N
3 ST; M; QL
RELION NOVOLIN
R
3 ST; M; QL
SOLIQUA 100/33 2 ST; M
TOUJEO MAX
SOLOSTAR
2 M
TOUJEO
SOLOSTAR U-300
INSULIN
2 M
TRESIBA
FLEXTOUCH U-
100
2 M
TRESIBA
FLEXTOUCH U-
200
2 M
XULTOPHY
100/3.6
2 ST; M
MISCELLANEOUS HORMONES
ALDURAZYME 6 MSD
ANADROL-50 3
ANDRODERM 2 PA
Drug Name Drug
Category
Requirements
/ Limits
ANDROGEL
TRANSDERMAL
GEL IN
METERED-DOSE
PUMP
2 PA
ANDROGEL
TRANSDERMAL
GEL IN PACKET 1
% (25
MG/2.5GRAM), 1
% (50 MG/5
GRAM)
3 PA; ST
ANDROGEL
TRANSDERMAL
GEL IN PACKET
1.62 % (20.25
MG/1.25 GRAM),
1.62 % (40.5
MG/2.5 GRAM)
2 PA
ANDROID 3 ST
AVEED 6 MSD
AXIRON 3 PA
BRINEURA 6 MSD
cabergoline 1 M; QL
calcitonin (salmon) 1 M
calcitriol 1 M
CERDELGA 3 S; SLA
CEREZYME 6 MSD
CRYSVITA 2
danazol 1
DDAVP 3 M
DEPO-
TESTOSTERONE
3 PA
desmopressin 1 M
doxercalciferol
intravenous
6 MSD
doxercalciferol oral 1 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
69
Drug Name Drug
Category
Requirements
/ Limits
ELAPRASE 6 MSD
ELELYSO 6 MSD
FABRAZYME 6 MSD
FORTESTA 3 ST
HECTOROL 6 MSD
JYNARQUE 4 PA; S
KANUMA 6 MSD
KORLYM 3 PA; SLA
KUVAN 3 PA; S; SLA
LUMIZYME 6 MSD
MEPSEVII 6 MSD
METHITEST 2
methyltestosterone 1
MIACALCIN 6 MSD
miglustat 1 S
MYALEPT 3 PA; S; SLA
NAGLAZYME 6 MSD
NATESTO 3 ST
NATPARA 3 PA; S; SLA
NOCTIVA 3 M
OXANDRIN 3
oxandrolone 1
PALYNZIQ 3 PA
pamidronate 6 MSD
PARICALCITOL
HEMODIALYSIS
PORT INJECTION
6 MSD
paricalcitol
intravenous
6 MSD
paricalcitol oral 1 M
RAYALDEE 3 M
ROCALTROL 3 M
Drug Name Drug
Category
Requirements
/ Limits
SAMSCA 3 PA; S; QL
SENSIPAR 2 PA
SOMAVERT 3 S; SLA
STIMATE 2
STRENSIQ 2 SLA
STRIANT 3 PA
SYNAREL 2
TESTIM 3 ST
testosterone
cypionate
1 PA
testosterone
enanthate
1 PA
testosterone
transdermal gel
1
TESTOSTERONE
TRANSDERMAL
GEL IN
METERED-DOSE
PUMP 10 MG/0.5
GRAM
/ACTUATION
3 ST
testosterone
transdermal gel in
metered-dose pump
12.5 mg/ 1.25 gram
(1 %)
1
testosterone
transdermal gel in
packet
1
testosterone
transdermal solution
in metered pump
w/app
1
TESTRED 3 ST
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
70
Drug Name Drug
Category
Requirements
/ Limits
VASOPRESSIN IN
0.9 % NACL
INTRAVENOUS
SOLUTION 40
UNIT/100 ML(0.4
UNIT/ML)
6 MSD
vasopressin in 0.9
% nacl intravenous
solution 60 unit/100
ml (0.6 unit/ml)
6 MSD
VASOPRESSIN IN
DEXTROSE 5 %
6 MSD
VASOSTRICT 6 MSD
VIMIZIM 6 MSD
VOGELXO 3 ST
VPRIV 6 MSD
ZAVESCA 3 S
ZEMPLAR
INTRAVENOUS
6 MSD
ZEMPLAR ORAL 3 M
zoledronic acid 6 MSD
ZOLEDRONIC AC-
MANNITOL-
0.9NACL
6 MSD
ZOMETA 6 MSD
NON-INSULIN HYPOGLYCEMIC
AGENTS
acarbose 1 M
ACTOPLUS MET 3 ST; M; QL
ACTOPLUS MET
XR
3 ST; M; QL
ACTOS 3 ST; M; QL
ADLYXIN 3 ST; M
ALOGLIPTIN 3 ST; M; QL
ALOGLIPTIN-
METFORMIN
3 ST; M; QL
Drug Name Drug
Category
Requirements
/ Limits
ALOGLIPTIN-
PIOGLITAZONE
3 M; QL
AMARYL 3 M
AVANDIA 3 ST; M; QL
BYDUREON
BCISE
2 ST; M
BYDUREON
SUBCUTANEOUS
PEN INJECTOR
2 ST; M
BYDUREON
SUBCUTANEOUS
SUSPENSION,EXT
ENDED REL
RECON
2 ST; M; QL
BYETTA 2 ST; M; QL
chlorpropamide 1 M
CYCLOSET 3 M; QL
DM2 3 M
DUETACT 3 ST; M; QL
FARXIGA 2 ST; M; QL
FORTAMET 3 ST; M
glimepiride 1 M
glipizide 1 M
glipizide-metformin 1 M
GLUCOPHAGE 3 ST; M
GLUCOPHAGE XR 3 ST; M
GLUCOTROL 3 M
GLUCOTROL XL 3 M
GLUCOVANCE 3 M
GLUMETZA 3 ST; M; QL
glyburide 1 M
glyburide
micronized
1 M
glyburide-metformin 1 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
71
Drug Name Drug
Category
Requirements
/ Limits
GLYNASE 3 M
GLYSET 3 M
GLYXAMBI 2 M
INVOKAMET 2 ST; M; QL
INVOKAMET XR 2 ST; M; QL
INVOKANA 2 ST; M; QL
JANUMET 2 ST; M; QL
JANUMET XR 2 ST; M; QL
JANUVIA 2 ST; M; QL
JARDIANCE 2 ST; M; QL
JENTADUETO 2 ST; M; QL
JENTADUETO XR 2 ST; M
KAZANO 3 ST; M; QL
KOMBIGLYZE XR 3 ST; M; QL
metformin oral
tablet
1 M
metformin oral
tablet extended
release 24 hr
1 M
metformin oral
tablet extended
release 24hr
1 ST; M
metformin oral
tablet,er
gast.retention 24 hr
1 M; QL
miglitol 1 M
nateglinide 1 M
NESINA 3 ST; M; QL
ONGLYZA 3 ST; M; QL
OSENI 3 M; QL
OZEMPIC 3 M
pioglitazone 1 M; QL
pioglitazone-
glimepiride
1 M; QL
Drug Name Drug
Category
Requirements
/ Limits
pioglitazone-
metformin
1 M; QL
PRANDIN 3 M
PRECOSE 3 M
QTERN 3 M
repaglinide 1 M
repaglinide-
metformin
1 M; QL
RIOMET 3 ST; M; QL
SEGLUROMET 2 ST; M
STARLIX 3 M
STEGLATRO 2 ST; M
STEGLUJAN 3 M
SYMLINPEN 120 2 ST; M; QL
SYMLINPEN 60 2 ST; M; QL
SYNJARDY 2 ST; M
SYNJARDY XR 2 ST; M
TANZEUM 3 ST; M; QL
tolazamide 1 M
tolbutamide 1 M
TRADJENTA 2 ST; QL
TRULICITY 2 ST; M; QL
VICTOZA 2-PAK 3 ST; M; QL
VICTOZA 3-PAK 3 ST; M; QL
XIGDUO XR
ORAL TABLET, IR
- ER, BIPHASIC
24HR 10-1,000 MG,
10-500 MG, 5-1,000
MG, 5-500 MG
2 ST; M; QL
XIGDUO XR
ORAL TABLET, IR
- ER, BIPHASIC
24HR 2.5-1,000 MG
2 ST; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
72
Drug Name Drug
Category
Requirements
/ Limits
THYROID HORMONES
ARMOUR
THYROID
2 M
CYTOMEL 3 ST; M
LEVO-T 3 M
LEVOTHYROXINE
INTRAVENOUS
RECON SOLN 100
MCG
6 MSD
levothyroxine
intravenous recon
soln 200 mcg, 500
mcg
6 MSD
levothyroxine oral 1 M
levoxyl 1 M
liothyronine 1 M
nature-throid 1 M
np thyroid 1 M
SYNTHROID 3 M
thyroid (pork) 1 M
THYROLAR-1 3 M
THYROLAR-1/2 3 M
THYROLAR-1/4 3 M
THYROLAR-2 3 M
THYROLAR-3 3 M
TIROSINT 3 M
unithroid 1 M
westhroid 1 M
WP THYROID 3 M
GASTROENTEROLOGY
ANTIDIARRHEALS &
ANTISPASMODICS
anaspaz 1
Drug Name Drug
Category
Requirements
/ Limits
atropine 6 MSD
atropine in 0.9 %
sod chloride
intravenous syringe
0.8 mg/2 ml (0.4
mg/ml)
6 MSD
ATROPINE IN 0.9
% SOD CHLORIDE
INTRAVENOUS
SYRINGE 1 MG/2.5
ML (0.4 MG/ML), 2
MG/5 ML (0.4
MG/ML)
6 MSD
belladonna
alkaloids-opium
1
belladonna-opium 1
BENTYL 6 MSD
chlordiazepoxide-
clidinium
1
CUVPOSA 3
dicyclomine
intramuscular
6 MSD
dicyclomine oral 1
diphenoxylate-
atropine
1
DONNATAL 3
ed-spaz 1
glycopyrrolate
injection
6 MSD
GLYCOPYRROLA
TE
INTRAVENOUS
6 MSD
glycopyrrolate oral 1
hyoscyamine sulfate 1
hyosyne 1
LEVBID 3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
73
Drug Name Drug
Category
Requirements
/ Limits
LEVSIN
INJECTION
6 MSD
LEVSIN ORAL 3
LEVSIN/SL 3
LIBRAX (WITH
CLIDINIUM)
3 ST
LOMOTIL 3
methscopolamine 1
MOTOFEN 3
MYTESI 3
NULEV 3
opium tincture 1
oscimin 1
oscimin sl 1
oscimin sr 1
paregoric 1
phenobarb-hyoscy-
atropine-scop
1
phenohytro 1
propantheline 1
ROBINUL FORTE 3
ROBINUL
INJECTION
6 MSD
ROBINUL ORAL 3
SYMAX DUOTAB 3
symax fastabs 1
symax-sl 1
symax-sr 1
MISCELLANEOUS
GASTROINTESTINAL AGENTS
ACTIGALL 3 M
Drug Name Drug
Category
Requirements
/ Limits
AKYNZEO
(FOSNETUPITANT
)
6 MSD
AKYNZEO
(NETUPITANT)
2 QL
alophen 5 ACA; OTC
alosetron 1
ALOXI 6 MSD
AMITIZA 2
ANALPRAM-HC 3
ANALPRAM-HC
SINGLES
3
anucort-hc 1
ANUSOL-HC 3 ST
ANZEMET 3 QL
aprepitant 1 QL
APRISO 2 M
ASACOL HD 3 ST; M
AURYXIA 3
AZULFIDINE 3 M
AZULFIDINE EN-
TABS
3 M
balsalazide 1
bisacodyl 5 ACA; OTC
bisa-lax 5 ACA; OTC
BONJESTA 3
budesonide 1
calcium acetate 1
CANASA 2
CESAMET 3 QL
CHENODAL 2 PA; SLA
CHOLBAM 2 PA; SLA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
74
Drug Name Drug
Category
Requirements
/ Limits
CIMZIA 4 PA; ST; S;
SLA
CIMZIA POWDER
FOR RECONST
4 PA; ST; S;
SLA
CINVANTI 6 MSD
citrate of magnesia 5 ACA; OTC
citroma 5 ACA; OTC
clearlax 5 ACA; OTC
CLENPIQ 5 ACA
COLAZAL 3
colocort 1
COLYTE WITH
FLAVOR PACKS
3
COMPAZINE 3
compro 1
constulose 1
CORTENEMA 3
CORTIFOAM 2
CREON 2
cromolyn 1
CYSTADANE 2 SLA
DELZICOL 3 ST; M
DICLEGIS 3
DIPENTUM 3 ST; M
dronabinol 1
ducodyl 5 ACA; OTC
eliphos 1
EMEND
(FOSAPREPITANT
)
6 MSD
EMEND ORAL
CAPSULE
3 QL
Drug Name Drug
Category
Requirements
/ Limits
EMEND ORAL
CAPSULE,DOSE
PACK
3 QL
EMEND ORAL
SUSPENSION FOR
RECONSTITUTIO
N
2
ENTOCORT EC 3
ENTYVIO 6 MSD
enulose 1
fleet laxative 5 ACA; OTC
FOSRENOL 3 ST
GASTROCROM 3
GATTEX 30-VIAL 4 S; SLA
gavilax 5 ACA; OTC
gavilyte-c 5 ACA
gavilyte-g 5 ACA
gavilyte-n 5 ACA
generlac 1
gentle laxative 5 ACA; OTC
gentlelax 5 ACA; OTC
GIALAX 5 ACA
GIAZO 3
glycolax 5 ACA; OTC
GOLYTELY ORAL
POWDER IN
PACKET
5 ACA
GOLYTELY ORAL
RECON SOLN
3
granisetron hcl 1 QL
healthylax 5 ACA; OTC
hemmorex-hc 1
hydrocortisone 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
75
Drug Name Drug
Category
Requirements
/ Limits
hydrocortisone
acetate
1
hydrocortisone-
pramoxine
1
INFLECTRA 6 MSD
kionex 1
kionex (with
sorbitol)
1
KRISTALOSE 3 M
lactulose 1
lanthanum 1
laxaclear 5 ACA; OTC
laxative (bisacodyl) 5 ACA; OTC
laxative feminine 5 ACA; OTC
laxative peg 3350 5 ACA; OTC
LIALDA 3 M
lidocaine hcl-
hydrocortison ac
1
LINZESS 2
LOTRONEX 3
MAGNEBIND 400 3
magnesium citrate 5 ACA; OTC
MARINOL 3
mesalamine oral
tablet,delayed
release (dr/ec) 1.2
gram
1 M
MESALAMINE
ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 800 MG
3 ST; M
mesalamine rectal 1
mesalamine with
cleansing wipe
1
Drug Name Drug
Category
Requirements
/ Limits
metoclopramide hcl
injection
6 MSD
metoclopramide hcl
oral
1
MICORT-HC 3 ST
milk of magnesia 5 ACA; OTC
milk of magnesia
concentrated
5 ACA; OTC
miralax 5 ACA; OTC
MOVANTIK 2
MOVIPREP 5 ACA
natura-lax 5 ACA; OTC
NULYTELY WITH
FLAVOR PACKS
3
OCALIVA 3 PA; S; SLA
ondansetron 1 QL
ondansetron hcl (pf) 6 MSD
ondansetron hcl
intravenous
6 MSD
ondansetron hcl oral 1 QL
oral saline laxative 5 ACA; OTC
OSMOPREP 5 ACA
PALONOSETRON
INTRAVENOUS
SOLUTION 0.25
MG/2 ML
6 MSD
palonosetron
intravenous solution
0.25 mg/5 ml
6 MSD
PANCREAZE 3 ST
peg 3350-
electrolytes
5 ACA
peg3350 5 ACA; OTC
peg-electrolyte soln 5 ACA
PENTASA 2 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
76
Drug Name Drug
Category
Requirements
/ Limits
PERTZYE 3 ST
PHOSLYRA 2
phosphate laxative 5 ACA; OTC
powderlax 5 ACA; OTC
pramcort 1
PREPOPIK 5 ACA
prochlorperazine 1
prochlorperazine
edisylate
6 MSD
prochlorperazine
maleate
1
PROCORT 3
PROCTOCORT 3
PROCTOFOAM HC 3
procto-med hc 1
proctosol hc 1
proctozone-hc 1
purelax 5 ACA; OTC
RECTIV 2
REGLAN 3
RELISTOR ORAL 3
RELISTOR
SUBCUTANEOUS
2
REMICADE 6 MSD
RENAGEL 3 ST
RENFLEXIS 6 PA; ST; MSD
RENVELA 3
ROWASA 3
SANCUSO 2 QL
scopolamine base 1
sevelamer carbonate 1
SFROWASA 3
Drug Name Drug
Category
Requirements
/ Limits
smoothlax 5 ACA; OTC
sodium polystyrene
(sorb free)
1
sodium polystyrene
sulfonate oral
1
sodium polystyrene
sulfonate rectal
enema 30 gram/120
ml
1
SODIUM
POLYSTYRENE
SULFONATE
RECTAL ENEMA
50 GRAM/200 ML
3
SOLESTA 6 MSD
sps (with sorbitol) 1
SUCRAID 3 S; SLA
sulfasalazine 1 M
SUPREP BOWEL
PREP KIT
5 ACA
SUSTOL 6 MSD
SYMPROIC 3
SYNDROS 3
TIGAN
INTRAMUSCULA
R
6 MSD
TIGAN ORAL 3
TRANSDERM-
SCOP
3
trilyte with flavor
packets
5 ACA
trimethobenzamide 1
TRULANCE 3 ST
UCERIS ORAL 2
UCERIS RECTAL 3
URSO 250 3 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
77
Drug Name Drug
Category
Requirements
/ Limits
URSO FORTE 3 M
ursodiol 1 M
VARUBI
INTRAVENOUS
6 MSD
VARUBI ORAL 2
VELPHORO 2
VELTASSA 3 S; SLA
VIBERZI 2
VIOKACE 2
woman's laxative 5 ACA; OTC
women's gentle
laxative(bisac)
5 ACA; OTC
women's laxative
(bisacodyl)
5 ACA; OTC
ZENPEP 2
ZOFRAN 3 QL
ZOFRAN ODT 3 QL
ZUPLENZ 3 QL
ULCER THERAPY
ACIPHEX 3 ST; M
ACIPHEX
SPRINKLE
3 ST; M; QL
amoxicil-
clarithromy-
lansopraz
1
CARAFATE ORAL
SUSPENSION
2 M
CARAFATE ORAL
TABLET
3 M
cimetidine 1 M
cimetidine hcl 1 M
CYTOTEC 3 M
DEXILANT 3 ST; M; QL
ESOMEP-EZS 3 ST; M
Drug Name Drug
Category
Requirements
/ Limits
esomeprazole
magnesium oral
capsule,delayed
release(dr/ec) 20 mg
1 M; QL
esomeprazole
magnesium oral
capsule,delayed
release(dr/ec) 40 mg
1 M
esomeprazole
sodium
6 MSD
ESOMEPRAZOLE
STRONTIUM
3 ST; M
famotidine (pf) 6 MSD
famotidine (pf)-nacl
(iso-os)
6 MSD
FAMOTIDINE IN
0.9 % NACL
6 MSD
famotidine
intravenous
6 MSD
famotidine oral 1 M
lansoprazole oral
capsule,delayed
release(dr/ec) 15 mg
1 M; QL
lansoprazole oral
capsule,delayed
release(dr/ec) 30 mg
1 M
lansoprazole oral
tablet,disintegrat,
delay rel 15 mg
1 M; QL
lansoprazole oral
tablet,disintegrat,
delay rel 30 mg
1 M
misoprostol 1 M
NEXIUM IV 6 MSD
NEXIUM ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
20 MG
3 ST; M; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
78
Drug Name Drug
Category
Requirements
/ Limits
NEXIUM ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
40 MG
3 ST; M
NEXIUM PACKET
ORAL GRANULES
DR FOR SUSP IN
PACKET 10 MG,
2.5 MG, 20 MG, 5
MG
2 ST; M; QL
NEXIUM PACKET
ORAL GRANULES
DR FOR SUSP IN
PACKET 40 MG
2 ST; M
nizatidine 1 M
OMECLAMOX-
PAK
3 QL
omeppi oral capsule
20-1.1 mg-gram
1 ST; M; QL
omeppi oral capsule
40-1.1 mg-gram
1 ST; M
omeprazole oral
capsule,delayed
release(dr/ec) 10 mg
1 M; QL
omeprazole oral
capsule,delayed
release(dr/ec) 20
mg, 40 mg
1 M
omeprazole-sodium
bicarbonate oral
capsule 20-1.1 mg-
gram
1 ST; M; QL
omeprazole-sodium
bicarbonate oral
capsule 40-1.1 mg-
gram
1 ST; M
omeprazole-sodium
bicarbonate oral
packet 20-1,680 mg
1 ST; QL
Drug Name Drug
Category
Requirements
/ Limits
omeprazole-sodium
bicarbonate oral
packet 40-1,680 mg
1 ST
pantoprazole oral
tablet,delayed
release (dr/ec) 20
mg
1 M; QL
pantoprazole oral
tablet,delayed
release (dr/ec) 40
mg
1 M
PEPCID 3 M
PREVACID ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
15 MG
3 ST; M; QL
PREVACID ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
30 MG
3 ST; M
PREVACID
SOLUTAB ORAL
TABLET,DISINTE
GRAT, DELAY
REL 15 MG
3 ST; M; QL
PREVACID
SOLUTAB ORAL
TABLET,DISINTE
GRAT, DELAY
REL 30 MG
3 ST; M
PRILOSEC 3 ST; M; QL
PROTONIX ORAL
GRANULES DR
FOR SUSP IN
PACKET
3 ST; M
PROTONIX ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 20 MG
3 ST; M; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
79
Drug Name Drug
Category
Requirements
/ Limits
PROTONIX ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 40 MG
3 ST; M
PYLERA 2
rabeprazole 1 M
ranitidine hcl
injection
6 MSD
ranitidine hcl oral 1 M
sucralfate 1 M
ZANTAC
INJECTION
6 MSD
ZANTAC ORAL 3 M
ZEGERID ORAL
CAPSULE 20-1.1
MG-GRAM
3 ST; M; QL
ZEGERID ORAL
CAPSULE 40-1.1
MG-GRAM
3 ST; M
ZEGERID ORAL
PACKET 20-1,680
MG
3 ST; QL
ZEGERID ORAL
PACKET 40-1,680
MG
3 ST
IMMUNOLOGY, VACCINES &
BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ARANESP (IN
POLYSORBATE)
6 MSD
EPOGEN 6 MSD
GRANIX 6 MSD
LEUKINE 6 MSD
MIRCERA 6 MSD
MOZOBIL 6 MSD
NEULASTA 6 MSD
Drug Name Drug
Category
Requirements
/ Limits
NEUPOGEN 6 MSD
PROCRIT 6 MSD
ZARXIO 6 MSD
GROWTH HORMONES
EGRIFTA 3 PA; S
GENOTROPIN 3 PA; S
GENOTROPIN
MINIQUICK
3 PA; S
HUMATROPE 3 PA; S
NORDITROPIN
FLEXPRO
3 PA; S
NUTROPIN AQ
NUSPIN
4 PA; ST; S
OMNITROPE 4 PA; ST; S
SAIZEN 4 PA; ST; S
SAIZEN
SAIZENPREP
4 PA; ST; S
SEROSTIM 3 PA; S
ZOMACTON 4 PA; ST; S
ZORBTIVE 4 PA; S; SLA
INTERFERONS
AUBAGIO 4 PA; S; SLA;
QL
AVONEX 3 PA; S; QL
AVONEX (WITH
ALBUMIN)
3 PA; S; QL
BETASERON 3 PA; ST; S; QL
COPAXONE
SUBCUTANEOUS
SYRINGE 20
MG/ML
4 ST; S; QL
COPAXONE
SUBCUTANEOUS
SYRINGE 40
MG/ML
3 PA; S; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
80
Drug Name Drug
Category
Requirements
/ Limits
EXTAVIA 3 PA; S; QL
GILENYA 3 PA; S; SLA
glatiramer 1 PA; S; QL
glatopa
subcutaneous
syringe 20 mg/ml
1 PA; S; QL
glatopa
subcutaneous
syringe 40 mg/ml
1 S; QL
LEMTRADA 6 MSD
moderiba 1 ST; S; SLA
moderiba dose pack 1 ST; S; SLA
OCREVUS 6 MSD
PEGASYS 3 PA; S; SLA;
QL
PEGASYS
PROCLICK
3 PA; S; SLA;
QL
PEGINTRON 4 PA; S; SLA;
QL
PLEGRIDY 3 ST; S; QL
POMALYST 3 S; QL
REBETOL 4 ST; S; SLA
REBIF (WITH
ALBUMIN)
3 PA; S; QL
REBIF REBIDOSE 3 PA; S; QL
REBIF TITRATION
PACK
3 PA; S; QL
REVLIMID 3 S
ribasphere 1 ST; S; SLA
ribasphere ribapak 1 ST; S; SLA
ribavirin 1 S; SLA
SYLATRON 3 PA; S; SLA;
QL
TECFIDERA 3 PA; S; SLA;
QL
Drug Name Drug
Category
Requirements
/ Limits
INTERLEUKINS
ACTIMMUNE 3 S; SLA
ALDARA 3 QL
ALFERON N 6 MSD
ARCALYST 3 PA; ST; S;
SLA
ILARIS (PF) 6 MSD
imiquimod 1 QL
INTRON A 3 S; SLA
KINERET 3 PA; ST; SLA;
QL
PROLEUKIN 6 MSD
ZYCLARA 3 ST; QL
VACCINES & MISCELLANEOUS
IMMUNOLOGICALS
ACTHIB (PF) 6 MSD
ADACEL(TDAP
ADOLESN/ADULT
)(PF)
6 MSD
ATGAM 6 MSD
BCG VACCINE,
LIVE (PF)
6 MSD
BEXSERO 6 MSD
BIVIGAM 6 MSD
BOOSTRIX TDAP 6 MSD
BOTOX 6 MSD
CARIMUNE NF
NANOFILTERED
6 MSD
CUVITRU 6 MSD
DAPTACEL (DTAP
PEDIATRIC) (PF)
6 MSD
DYSPORT 6 MSD
ENGERIX-B (PF) 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
81
Drug Name Drug
Category
Requirements
/ Limits
ENGERIX-B
PEDIATRIC (PF)
6 MSD
FLEBOGAMMA
DIF
6 MSD
GAMASTAN S/D 6 MSD
GAMMAGARD
LIQUID
6 MSD
GAMMAGARD S-
D (IGA < 1
MCG/ML)
6 MSD
GAMMAKED 6 MSD
GAMMAPLEX 6 MSD
GAMMAPLEX
(WITH SORBITOL)
6 MSD
GAMUNEX-C 6 MSD
HAVRIX (PF) 6 MSD
HEPAGAM B 6 MSD
HEPLISAV-B 6 MSD
HIBERIX (PF) 6 MSD
HIZENTRA 6 MSD
HYPERHEP B S/D 6 MSD
HYPERHEP B S-D
NEONATAL
6 MSD
HYPERRAB (PF) 6 MSD
HYPERRAB S/D
(PF)
6 MSD
HYPERTET S/D
(PF)
6 MSD
HYQVIA 6 MSD
IMOGAM RABIES-
HT (PF)
6 MSD
INFANRIX (DTAP)
(PF)
6 MSD
KINRIX (PF) 6 MSD
MENACTRA (PF) 6 MSD
Drug Name Drug
Category
Requirements
/ Limits
MENVEO A-C-Y-
W-135-DIP (PF)
6 MSD
M-M-R II (PF) 6 MSD
MYOBLOC 6 MSD
NABI-HB 6 MSD
OCTAGAM 6 MSD
PEDIARIX (PF) 6 MSD
PENTACEL
ACTHIB
COMPONENT (PF)
6 MSD
PNEUMOVAX 23 6 MSD
PRIVIGEN 6 MSD
PROQUAD (PF) 6 MSD
PROVENGE 6 MSD
QUADRACEL (PF) 6 MSD
RABAVERT (PF) 6 MSD
RECOMBIVAX HB
(PF)
6 MSD
ROTARIX 6 MSD
ROTATEQ
VACCINE
6 MSD
SHINGRIX (PF) 6 MSD
TENIVAC (PF) 6 MSD
TETANUS,DIPHTH
ERIA TOX
PED(PF)
6 MSD
TETANUS-
DIPHTHERIA
TOXOIDS-TD
6 MSD
THYMOGLOBULI
N
6 MSD
TICE BCG 6 MSD
TWINRIX (PF) 6 MSD
TYPHIM VI 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
82
Drug Name Drug
Category
Requirements
/ Limits
VAQTA (PF) 6 MSD
VARIZIG 6 MSD
VAXCHORA
VACCINE
6 MSD
VIVOTIF 6 MSD
XEOMIN 6 MSD
YF-VAX (PF) 6 MSD
ZINPLAVA 6 MSD
MUSCULOSKELETAL &
RHEUMATOLOGY
GOUT THERAPY
allopurinol 1 M
COLCHICINE 3 ST
COLCRYS 2
DUZALLO 3 ST
KRYSTEXXA 6 MSD
MITIGARE 2
probenecid 1 M
probenecid-
colchicine
1 M
ULORIC 2 ST; M
ZURAMPIC 3 ST; M
ZYLOPRIM 3 M
OSTEOPOROSIS THERAPY
ACTONEL 3 ST; M; QL
alendronate 1 M; QL
ATELVIA 3 ST; M; QL
BINOSTO 3 ST; M; QL
BONIVA
INTRAVENOUS
6 MSD
BONIVA ORAL 3 ST; M; QL
EVISTA 3 PA; M
Drug Name Drug
Category
Requirements
/ Limits
FORTEO 4 PA; ST; S;
SLA; QL
FOSAMAX 3 ST; M; QL
FOSAMAX PLUS
D
3 ST; M; QL
ibandronate
intravenous
6 MSD
ibandronate oral 1 M; QL
PROLIA 6 MSD
raloxifene 1 PA; M
risedronate 1 M; QL
TYMLOS 3 S
OTHER RHEUMATOLOGICALS
ACTEMRA
INTRAVENOUS
6 MSD
ACTEMRA
SUBCUTANEOUS
3 PA; ST; S;
SLA; QL
ARAVA 3 QL
BENLYSTA
INTRAVENOUS
6 MSD
BENLYSTA
SUBCUTANEOUS
3 S; SLA
CUPRIMINE 3 ST; M
DEPEN
TITRATABS
2 M
ENBREL 3 PA; ST; S; QL
ENBREL MINI 3 PA; ST; S; QL
ENBREL
SURECLICK
3 PA; ST; S; QL
HUMIRA 3 PA; ST; S; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
83
Drug Name Drug
Category
Requirements
/ Limits
HUMIRA
PEDIATRIC
CROHN'S START
SUBCUTANEOUS
SYRINGE KIT 40
MG/0.8 ML, 80
MG/0.8 ML-40
MG/0.4 ML
3 PA; ST; S; QL
HUMIRA
PEDIATRIC
CROHN'S START
SUBCUTANEOUS
SYRINGE KIT 80
MG/0.8 ML
3 PA; ST; S
HUMIRA PEN 3 PA; ST; S; QL
HUMIRA PEN
CROHN'S-UC-HS
START
3 PA; ST; S; QL
HUMIRA PEN
PSORIASIS-
UVEITIS
3 PA; ST; S; QL
KEVZARA
SUBCUTANEOUS
PEN INJECTOR
4 ST
KEVZARA
SUBCUTANEOUS
SYRINGE
4 ST; S
leflunomide 1 QL
OLUMIANT 3 ST
ORENCIA 4 PA; ST; S
ORENCIA (WITH
MALTOSE)
6 MSD
ORENCIA
CLICKJECT
4 PA; ST; S
OTEZLA 3 ST; S; SLA;
QL
OTEZLA
STARTER
3 ST; S; SLA;
QL
OTREXUP (PF) 3 S; QL
Drug Name Drug
Category
Requirements
/ Limits
RASUVO (PF) 3 S; QL
RIDAURA 2 M
SAVELLA ORAL
TABLET
2 ST; M; QL
SAVELLA ORAL
TABLETS,DOSE
PACK
2 ST; QL
SIMPONI ARIA 6 MSD
SIMPONI
SUBCUTANEOUS
PEN INJECTOR
100 MG/ML
3 PA; ST; S; QL
SIMPONI
SUBCUTANEOUS
PEN INJECTOR 50
MG/0.5 ML
4 PA; ST; S; QL
SIMPONI
SUBCUTANEOUS
SYRINGE 100
MG/ML
3 PA; ST; S; QL
SIMPONI
SUBCUTANEOUS
SYRINGE 50
MG/0.5 ML
4 PA; ST; S; QL
XELJANZ ORAL
TABLET 10 MG
3 ST; QL
XELJANZ ORAL
TABLET 5 MG
3 ST; S; QL
XELJANZ XR 3 ST; S; QL
OBSTETRICS &
GYNECOLOGY
DIAPHRAGMS AND OTHER NON-
ORAL CONTRACEPTIVES
CAYA
CONTOURED
5 ACA
FC2 FEMALE
CONDOM
5 ACA; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
84
Drug Name Drug
Category
Requirements
/ Limits
FEMCAP 5 ACA
KYLEENA 6 MSD
LILETTA 6 MSD
MIRENA 6 MSD
PARAGARD T
380A
6 MSD
SKYLA 6 MSD
WIDE-SEAL
DIAPHRAGM
5 ACA
ESTROGENS & PROGESTINS
ACTIVELLA 3 M
ALORA 3 M; QL
amabelz 1 M
ANGELIQ 3 M
AYGESTIN 3 M
camila 5 M; ACA
CLIMARA 3 M; QL
CLIMARA PRO 3 M; QL
COMBIPATCH 2 M
covaryx 1
covaryx h.s. 1
CRINONE 2
deblitane 5 M; ACA
DELESTROGEN 3
DEPO-ESTRADIOL 2
DEPO-PROVERA 5 ACA; QL
DEPO-SUBQ
PROVERA 104
5 ACA; QL
DIVIGEL 2 M; QL
DUAVEE 2
eemt 1
eemt hs 1
Drug Name Drug
Category
Requirements
/ Limits
ELESTRIN 3 M; QL
errin 5 M; ACA
ESTRACE 3 M
estradiol oral 1 M
estradiol
transdermal
1 M; QL
estradiol vaginal 1 M
estradiol valerate 1
estradiol-
norethindrone acet
1 M
ESTRING 2 M
ESTROGEL 3 ST; M; QL
estrogens-
methyltestosterone
1
estropipate 1 M
EVAMIST 3 QL
FEMHRT LOW
DOSE
3 M
FEMRING 3 ST; M
fyavolv 1 M
heather 5 M; ACA
hydroxyprogesterone
caproate
6 MSD
IMVEXXY 3
jencycla 5 M; ACA
jevantique lo 1 M
jinteli 1 M
jolivette 5 M; ACA
lopreeza 1 M
lyza 5 M; ACA
MAKENA 6 MSD
MAKENA (PF) 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
85
Drug Name Drug
Category
Requirements
/ Limits
medroxyprogesteron
e intramuscular
5 ACA; QL
medroxyprogesteron
e oral
1 M
MENEST 3 M
MENOSTAR 3 M; QL
mimvey 1 M
mimvey lo 1 M
MINIVELLE 2 M; QL
nora-be 5 M; ACA
norethindrone
(contraceptive)
5 M; ACA
norethindrone
acetate
1 M
norethindrone ac-eth
estradiol
1 M
norlyda 5 M; ACA
norlyroc 5 M; ACA
ORTHO
MICRONOR
5 ST; M; ACA
PREFEST 3 M
PREMARIN 2 M
PREMPHASE 2 M
PREMPRO 2 M
progesterone
micronized
1 M
PROMETRIUM 3 M
PROVERA 3 M
sharobel 5 M; ACA
tulana 5 M; ACA
VAGIFEM 3 M
VIVELLE-DOT 3 M; QL
yuvafem 1 M
Drug Name Drug
Category
Requirements
/ Limits
MISCELLANEOUS OB/GYN
AVC VAGINAL 3
CLEOCIN 3
clindamycin
phosphate
1
CLINDESSE 3
CONCEPTROL 5 ACA; OTC
fem ph 1
GYNAZOLE-1 3
gynol ii 5 ACA; OTC
INTRAROSA 3
isoxsuprine 1 M
LUPANETA PACK
(1 MONTH)
3
LUPANETA PACK
(3 MONTH)
3
LYSTEDA 3
METROGEL
VAGINAL
3
metronidazole 1
MIFEPREX 4 S; SLA
NEXPLANON 6 MSD
NUVARING 5 M; ACA
NUVESSA 3
OSPHENA 3
RELAGARD 3
terconazole 1
TODAY
CONTRACEPTIVE
SPONGE
5 ACA; OTC
tranexamic acid 1
vaginal
contraceptive foam
5 ACA; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
86
Drug Name Drug
Category
Requirements
/ Limits
vandazole 1
VCF
CONTRACEPTIVE
FILM
5 ACA; OTC
VCF
CONTRACEPTIVE
GEL
5 ACA; OTC
xulane 5 M; ACA
ORAL CONTRACEPTIVES &
RELATED AGENTS
AFTERA 5 ACA; OTC;
QL
altavera (28) 5 M; ACA
alyacen 1/35 (28) 5 M; ACA
alyacen 7/7/7 (28) 5 M; ACA
amethia 5 M; ACA
amethia lo 5 M; ACA
amethyst 5 M; ACA
apri 5 M; ACA
aranelle (28) 5 M; ACA
ashlyna 5 M; ACA
aubra 5 M; ACA
aviane 5 M; ACA
azurette (28) 5 M; ACA
BALCOLTRA 5 M; ACA
balziva (28) 5 M; ACA
bekyree (28) 5 M; ACA
BEYAZ 5 ST; M; ACA
blisovi 24 fe 5 M; ACA
blisovi fe 1.5/30 (28) 5 M; ACA
blisovi fe 1/20 (28) 5 M; ACA
BREVICON (28) 5 ST; M; ACA
briellyn 5 M; ACA
Drug Name Drug
Category
Requirements
/ Limits
camrese 5 M; ACA
camrese lo 5 M; ACA
caziant (28) 5 M; ACA
chateal 5 M; ACA
cryselle (28) 5 M; ACA
cyclafem 1/35 (28) 5 M; ACA
cyclafem 7/7/7 (28) 5 M; ACA
CYCLESSA (28) 5 ST; M; ACA
cyred 5 M; ACA
dasetta 1/35 (28) 5 M; ACA
dasetta 7/7/7 (28) 5 M; ACA
daysee 5 M; ACA
delyla (28) 5 M; ACA
desog-
e.estradiol/e.estradio
l
5 M; ACA
desogestrel-ethinyl
estradiol
5 M; ACA
drospirenone-
e.estradiol-lm.fa
5 M; ACA
drospirenone-ethinyl
estradiol
5 M; ACA
econtra ez 5 ACA; OTC;
QL
econtra one-step 5 ACA; OTC;
QL
elinest 5 M; ACA
ELLA 5 ACA; QL
emoquette 5 M; ACA
enpresse 5 M; ACA
enskyce 5 M; ACA
estarylla 5 M; ACA
ESTROSTEP FE-28 5 ST; M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
87
Drug Name Drug
Category
Requirements
/ Limits
ethynodiol diac-eth
estradiol
5 M; ACA
falmina (28) 5 M; ACA
fayosim 5 M; ACA
femynor 5 M; ACA
GENERESS FE 5 ST; M; ACA
gianvi (28) 5 M; ACA
introvale 5 M; ACA
isibloom 5 M; ACA
jolessa 5 M; ACA
juleber 5 M; ACA
junel 1.5/30 (21) 5 M; ACA
junel 1/20 (21) 5 M; ACA
junel fe 1.5/30 (28) 5 M; ACA
junel fe 1/20 (28) 5 M; ACA
junel fe 24 5 M; ACA
kaitlib fe 5 M; ACA
kariva (28) 5 M; ACA
kelnor 1/35 (28) 5 M; ACA
kelnor 1-50 5 M; ACA
kimidess (28) 5 M; ACA
kurvelo 5 M; ACA
l norgest/e.estradiol-
e.estrad
5 M; ACA
larin 1.5/30 (21) 5 M; ACA
larin 1/20 (21) 5 M; ACA
larin 24 fe 5 M; ACA
larin fe 1.5/30 (28) 5 M; ACA
larin fe 1/20 (28) 5 M; ACA
larissia 5 M; ACA
layolis fe 5 M; ACA
leena 28 5 M; ACA
Drug Name Drug
Category
Requirements
/ Limits
lessina 5 M; ACA
levonest (28) 5 M; ACA
levonorgestrel-
ethinyl estrad
5 M; ACA
levonorg-eth estrad
triphasic
5 M; ACA
levora-28 5 M; ACA
lillow 5 M; ACA
LO LOESTRIN FE 5 ST; M; ACA
LOESTRIN 1.5/30
(21)
5 ST; M; ACA
LOESTRIN 1/20
(21)
5 ST; M; ACA
LOESTRIN FE
1.5/30 (28-DAY)
5 ST; M; ACA
LOESTRIN FE 1/20
(28-DAY)
5 ST; M; ACA
loryna (28) 5 M; ACA
LOSEASONIQUE 5 ST; M; ACA
low-ogestrel (28) 5 M; ACA
lutera (28) 5 M; ACA
marlissa 5 M; ACA
melodetta 24 fe 5 M; ACA
mibelas 24 fe 5 M; ACA
microgestin 1.5/30
(21)
5 M; ACA
microgestin 1/20
(21)
5 M; ACA
MICROGESTIN 24
FE
5 ST; M; ACA
microgestin fe 1.5/30
(28)
5 M; ACA
microgestin fe 1/20
(28)
5 M; ACA
mili 5 M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
88
Drug Name Drug
Category
Requirements
/ Limits
MINASTRIN 24 FE 5 ST; M; ACA
MIRCETTE (28) 5 ST; M; ACA
mono-linyah 5 M; ACA
mononessa (28) 5 M; ACA
my choice 5 ACA; OTC;
QL
my way 5 ACA; OTC;
QL
myzilra 5 M; ACA
NATAZIA 5 ST; M; ACA
necon 0.5/35 (28) 5 M; ACA
necon 7/7/7 (28) 5 M; ACA
nikki (28) 5 M; ACA
noreth-ethinyl
estradiol-iron
5 M; ACA
norethindrone ac-eth
estradiol
5 M; ACA
norethindrone-
e.estradiol-iron
5 M; ACA
norgestimate-ethinyl
estradiol
5 M; ACA
nortrel 0.5/35 (28) 5 M; ACA
nortrel 1/35 (21) 5 M; ACA
nortrel 1/35 (28) 5 M; ACA
nortrel 7/7/7 (28) 5 M; ACA
ocella 5 M; ACA
ogestrel (28) 5 M; ACA
opcicon one-step 5 ACA; OTC;
QL
option-2 5 ACA; OTC;
QL
orsythia 5 M; ACA
ORTHO TRI-
CYCLEN (28)
5 ST; M; ACA
Drug Name Drug
Category
Requirements
/ Limits
ORTHO TRI-
CYCLEN LO (28)
5 ST; M; ACA
ORTHO-CYCLEN
(28)
5 M; ACA
ORTHO-NOVUM
1/35 (28)
5 ST; M; ACA
ORTHO-NOVUM
7/7/7 (28)
5 M; ACA
philith 5 M; ACA
pimtrea (28) 5 M; ACA
pirmella 5 M; ACA
PLAN B ONE-STEP 5 ACA; OTC;
QL
portia 5 M; ACA
previfem 5 M; ACA
QUARTETTE 5 ST; M; ACA
quasense 5 M; ACA
rajani 5 M; ACA
reclipsen (28) 5 M; ACA
rivelsa 5 M; ACA
SAFYRAL 5 ST; M; ACA
SEASONIQUE 5 ST; M; ACA
setlakin 5 M; ACA
sprintec (28) 5 M; ACA
sronyx 5 M; ACA
syeda 5 M; ACA
TAKE ACTION 5 ACA; OTC;
QL
tarina fe 1/20 (28) 5 M; ACA
TAYTULLA 5 ST; M; ACA
tilia fe 5 M; ACA
tri femynor 5 M; ACA
tri-estarylla 5 M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
89
Drug Name Drug
Category
Requirements
/ Limits
tri-legest fe 5 M; ACA
tri-linyah 5 M; ACA
tri-lo-estarylla 5 M; ACA
tri-lo-marzia 5 M; ACA
tri-lo-sprintec 5 M; ACA
tri-mili 5 M; ACA
trinessa (28) 5 M; ACA
trinessa lo 5 M; ACA
TRI-NORINYL (28) 5 ST; M; ACA
tri-previfem (28) 5 M; ACA
tri-sprintec (28) 5 M; ACA
trivora (28) 5 M; ACA
tri-vylibra 5 M; ACA
tydemy 5 M; ACA
velivet triphasic
regimen (28)
5 M; ACA
vienva 5 M; ACA
viorele (28) 5 M; ACA
vyfemla (28) 5 M; ACA
vylibra 5 M; ACA
wera (28) 5 M; ACA
wymzya fe 5 M; ACA
YASMIN (28) 5 ST; M; ACA
YAZ (28) 5 ST; M; ACA
zarah 5 M; ACA
zenchent (28) 5 M; ACA
zovia 1/35e (28) 5 M; ACA
OPHTHALMOLOGY
ANTIBIOTICS
ak-poly-bac 1
AZASITE 2
Drug Name Drug
Category
Requirements
/ Limits
bacitracin 1
bacitracin-
polymyxin b
1
BESIVANCE 3
BETADINE
OPHTHALMIC
PREP
3
CEFUROXIME
(PF) IN 0.9% NACL
6 MSD
CILOXAN 3
ciprofloxacin hcl 1
erythromycin 1
gatifloxacin 1
gentak 1
gentamicin 1
levofloxacin 1
MOXEZA 2
moxifloxacin 1
MOXIFLOXACIN
(PF)-BSS NO.2
6 MSD
MOXIFLOXACIN
IN NACL,ISO-
O(PF)
6 MSD
NATACYN 2
neomycin-
bacitracin-
polymyxin
1 M
neomycin-
polymyxin-
gramicidin
1
neo-polycin 1 M
OCUFLOX 3
ofloxacin 1
polycin 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
90
Drug Name Drug
Category
Requirements
/ Limits
polymyxin b sulf-
trimethoprim
1
POLYTRIM 3
tobramycin 1
TOBREX 3
VIGAMOX 3
ZYMAXID 3
ANTIVIRALS
trifluridine 1
VIROPTIC 3
ZIRGAN 3
BETA-BLOCKERS
BETAGAN 3 M
betaxolol 1 M
BETIMOL 3 M
BETOPTIC S 3 M
carteolol 1 M
ISTALOL 3 ST; M
levobunolol 1 M
metipranolol 1 M
timolol maleate 1 M
TIMOPTIC 3 M
TIMOPTIC
OCUDOSE (PF)
3 ST; M
TIMOPTIC-XE 3 M
CHOLINESTERASE INHIBITOR
MIOTICS
PHOSPHOLINE
IODIDE
2 M
CYCLOPLEGIC MYDRIATICS
atropine 1 M
ATROPINE IN 0.9
% SOD CHLORIDE
3 M
Drug Name Drug
Category
Requirements
/ Limits
CYCLOGYL 3 M
cyclopentolate 1 M
homatropaire 1 M
homatropine hbr 1 M
MYDRIACYL 3 M
PAREMYD 3
tropicamide 1 M
DIRECT ACTING MIOTICS
ISOPTO CARPINE 3 M
MIOCHOL-E 3
pilocarpine hcl 1 M
MISCELLANEOUS
OPHTHALMOLOGICS
acuicyn 1
AKTEN (PF) 3
ALOCRIL 3 ST
ALOMIDE 3 ST
altacaine 1
altafluor 1
azelastine 1
BEPREVE 2 ST
BEVACIZUMAB 6 MSD
cromolyn 1
CYSTARAN 2 PA; SLA
ELESTAT 3 ST
EMADINE 3 ST
epinastine 1
EYLEA 6 MSD
flucaine 1
fluorescein-
proparacaine
1
JETREA (PF) 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
91
Drug Name Drug
Category
Requirements
/ Limits
LACRISERT 3
LASTACAFT 3 ST
LIDOCAN-
PHENYLEPH-BSS
NO.2(PF)
6 MSD
LUCENTIS 6 MSD
LUXTURNA 6 MSD
MACUGEN 6 MSD
olopatadine 1
OMIDRIA 6 MSD
PATADAY 3 ST
PATANOL 3 ST
PAZEO 2 ST
PHOTREXA
CROSS-LINKING
KIT
6 MSD
PHOTREXA
VISCOUS
6 MSD
PREDNISOLON-
GATIFLOX-
BROMFENAC
3
proparacaine 1
RESTASIS 2 PA; M; QL
RESTASIS
MULTIDOSE
2 PA; M; QL
tetcaine 1
tetracaine hcl 1
TETRACAINE
HCL (PF)
3
TETRAVISC 3
TETRAVISC
FORTE
3
VISUDYNE 6 MSD
VITRASE 6 MSD
Drug Name Drug
Category
Requirements
/ Limits
XIIDRA 2 M; QL
NON-STEROIDAL ANTI-
INFLAMMATORY AGENTS
ACULAR 3
ACULAR LS 3
ACUVAIL (PF) 3 ST
bromfenac 1
BROMSITE 3
diclofenac sodium 1 QL
flurbiprofen sodium 1
ILEVRO 2
ketorolac 1
NEVANAC 3 ST
PROLENSA 2
ORAL DRUGS FOR GLAUCOMA
acetazolamide 1 M
acetazolamide
sodium
6 MSD
methazolamide 1 M
NEPTAZANE 3 M
OTHER GLAUCOMA DRUGS
AZOPT 3 M
bimatoprost 1 ST; M
COMBIGAN 2 M
COSOPT 3 M
COSOPT (PF) 3 M
dorzolamide 1 M
dorzolamide-timolol 1 M
latanoprost 1 ST; M
LUMIGAN 2 ST; M
MITOSOL 3
SIMBRINZA 3 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
92
Drug Name Drug
Category
Requirements
/ Limits
TRAVATAN Z 2 ST; M
TRUSOPT 3 M
VYZULTA 3 M
XALATAN 3 ST; M
ZIOPTAN (PF) 3 ST; M
STEROID-ANTIBIOTIC
COMBINATIONS
GATIFLOXACIN-
DEXAMETHASON
E
3
MAXITROL 3
neomycin-
bacitracin-poly-hc
1
neomycin-polymyxin
b-dexameth
1
neomycin-
polymyxin-hc
1
neo-polycin hc 1
PRED-G 3
PRED-G S.O.P. 3
PREDNISOLONE-
GATIFLOXACIN
3
TOBRADEX
OPHTHALMIC
(EYE)
DROPS,SUSPENSI
ON
3
TOBRADEX
OPHTHALMIC
(EYE) OINTMENT
2
TOBRADEX ST 2
tobramycin-
dexamethasone
1
ZYLET 2
STEROIDS
ALREX 2 ST
Drug Name Drug
Category
Requirements
/ Limits
dexamethasone
sodium phosphate
1
DUREZOL 3
FLAREX 3
fluorometholone 1
FML FORTE 3
FML LIQUIFILM 3
FML S.O.P. 3
ILUVIEN 6 MSD
LOTEMAX 2
MAXIDEX 3
OMNIPRED 3
OZURDEX 6 MSD
PRED FORTE 3
PRED MILD 3
prednisolone acetate 1
PREDNISOLONE
ACETATE (PF)
3
prednisolone sodium
phosphate
1
RETISERT 6 MSD
STEROID-SULFONAMIDE
COMBINATIONS
BLEPHAMIDE 3
BLEPHAMIDE
S.O.P.
3
sulfacetamide-
prednisolone
1
SULFONAMIDES
BLEPH-10 3
sulfacetamide
sodium
1
SYMPATHOMIMETICS
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
93
Drug Name Drug
Category
Requirements
/ Limits
ALPHAGAN P
OPHTHALMIC
(EYE) DROPS 0.1
%
2 M
ALPHAGAN P
OPHTHALMIC
(EYE) DROPS 0.15
%
3 M
apraclonidine 1 M
brimonidine 1 M
IOPIDINE 3 M
VASOCONSTRICTOR
DECONGESTANTS
CYCLOMYDRIL 3 M
phenylephrine hcl 1
RESPIRATORY, ALLERGY,
COUGH & COLD
ANTIHISTAMINE &
ANTIALLERGENIC AGENTS
ADYPHREN 3
ADYPHREN AMP 3
ADYPHREN AMP
II
3
ADYPHREN II 3
AUVI-Q
INJECTION AUTO-
INJECTOR 0.1
MG/0.1 ML
3 ST
AUVI-Q
INJECTION AUTO-
INJECTOR 0.15
MG/0.15 ML, 0.3
MG/0.3 ML
3 ST; QL
carbinoxamine
maleate
1
cetirizine 1
Drug Name Drug
Category
Requirements
/ Limits
CLARINEX ORAL
SYRUP
3
CLARINEX ORAL
TABLET
3 QL
clemastine 1
cyproheptadine 1
desloratadine 1 QL
diphenhydramine hcl 6 MSD
EPINEPHRINE
INJECTION AUTO-
INJECTOR 0.15
MG/0.15 ML, 0.3
MG/0.3 ML
3 ST; QL
EPINEPHRINE
INJECTION AUTO-
INJECTOR 0.15
MG/0.3 ML
2 ST; QL
EPINEPHRINESNA
P-V
3
EPIPEN 2-PAK 2 QL
EPIPEN JR 2-PAK 2 QL
EPISNAP 6 MSD
hydroxyzine hcl 1
hydroxyzine
pamoate
1
KARBINAL ER 3
phenadoz 1
PHENERGAN
INJECTION
6 MSD
phenergan rectal 1
promethazine
injection
6 MSD
promethazine oral 1
promethazine rectal 1
promethegan 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
94
Drug Name Drug
Category
Requirements
/ Limits
RYVENT 3
VISTARIL 3
COUGH & COLD THERAPY
benzonatate 1
BROMFED DM 3
brompheniramine-
pseudoeph-dm
1
CAPCOF 3
centergy 1
cheratussin ac 1
CLARINEX-D 12
HOUR
3 QL
codeine-guaifenesin 1
CODITUSSIN AC 3
CODITUSSIN DAC 3
g tussin ac 1
guaiatussin ac 1
guaifenesin ac 1
guaifenesin dac 1
HISTEX-AC 3
hydrocodone-
chlorpheniramine
1
hydrocodone-cpm-
pseudoephed
1
hydrocodone-
homatropine
1
hydromet 1
lortuss ex 1
MAR-COF CG 3
m-clear wc 1
M-END PE 3
NINJACOF-XG 3
OBREDON 3 ST
Drug Name Drug
Category
Requirements
/ Limits
POLY-TUSSIN AC 3
promethazine vc-
codeine
1
promethazine-
codeine
1
promethazine-dm 1
promethazine-
phenylephrine
1
PRO-RED AC (W/
DEXCHLORPHENI
R)
3
RESPA-AR 3
robafen ac 1
rydex 1
SEMPREX-D 3
TESSALON
PERLES
3
tusnel c 1
TUSNEL
PEDIATRIC
3
TUSSICAPS 3 ST
tussigon 1
TUSSIONEX
PENNKINETIC ER
3
TUZISTRA XR 3 ST
virtussin ac 1
virtussin dac 1
VITUZ 3 ST
ZODRYL AC 25 3
ZODRYL AC 30 3
ZODRYL AC 35 3
ZODRYL AC 40 3
ZODRYL AC 50 3
ZODRYL AC 60 3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
95
Drug Name Drug
Category
Requirements
/ Limits
ZODRYL AC 80 3
ZODRYL DAC 25 3
ZODRYL DAC 30 3
ZODRYL DAC 35 3
ZODRYL DAC 40 3
ZODRYL DAC 50 3
ZODRYL DAC 60 3
ZODRYL DAC 80 3
ZODRYL DEC 25 3
ZODRYL DEC 30 3
ZODRYL DEC 35 3
ZODRYL DEC 40 3
ZODRYL DEC 50 3
ZODRYL DEC 60 3
ZODRYL DEC 80 3
Z-TUSS AC 3
PULMONARY AGENTS
ACCOLATE 3 M; QL
acetylcysteine 1
ADCIRCA 3 PA; ST; S; QL
ADEMPAS 3 PA; S; SLA
ADRENALIN 3
ADVAIR DISKUS 2 ST; M; QL
ADVAIR HFA 2 ST; M; QL
AEROSPAN 3 M
AIRDUO
RESPICLICK
3 ST; M; QL
albuterol sulfate
inhalation
1
albuterol sulfate oral 1 M
ALVESCO 3 ST; M; QL
ANORO ELLIPTA 2 M; QL
Drug Name Drug
Category
Requirements
/ Limits
ARCAPTA
NEOHALER
2 M; QL
ARMONAIR
RESPICLICK
2 M; QL
ARNUITY
ELLIPTA
2 M
ASMANEX HFA 2 M
ASMANEX
TWISTHALER
2 M; QL
ATROVENT HFA 2 M; QL
BECONASE AQ 3 ST; QL
BERINERT 6 MSD
BEVESPI
AEROSPHERE
2 M
BREO ELLIPTA 2 ST; M; QL
BROVANA 3 M; QL
budesonide
inhalation
1 M; QL
budesonide nasal 1 QL
CINQAIR 6 MSD
CINRYZE 6 MSD
COMBIVENT
RESPIMAT
2 QL
cromolyn 1 M
CUROSURF 3
DALIRESP ORAL
TABLET 250 MCG
2 PA
DALIRESP ORAL
TABLET 500 MCG
2 PA; QL
DULERA 2 ST; M; QL
DYMISTA 2 ST; QL
ELIXOPHYLLIN 3 M
ESBRIET ORAL
CAPSULE
3 PA; S; SLA;
QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
96
Drug Name Drug
Category
Requirements
/ Limits
ESBRIET ORAL
TABLET
3 PA; S; SLA
FASENRA 6 MSD
FIRAZYR 3 PA; S; SLA
FLOVENT DISKUS 2 M; QL
FLOVENT HFA 2 M; QL
flunisolide 1 QL
fluticasone 1 QL
FLUTICASONE-
SALMETEROL
2 ST; M; QL
HAEGARDA 6 PA; MSD
HYPER-SAL 3
INCRUSE
ELLIPTA
2 M
ipratropium bromide 1 M
ipratropium-
albuterol
1 QL
KALBITOR 6 MSD
KALYDECO 3 PA; S; SLA
LETAIRIS 3 PA; ST; S
levalbuterol hcl 1
LEVALBUTEROL
TARTRATE
3 ST
LONHALA
MAGNAIR REFILL
3 M
LONHALA
MAGNAIR
STARTER
3 M
metaproterenol 1 M
mometasone 1 QL
montelukast oral
granules in packet
1 M
montelukast oral
tablet
1 M; QL
Drug Name Drug
Category
Requirements
/ Limits
montelukast oral
tablet,chewable
1 M; QL
NASONEX 3 ST; QL
nebusal inhalation
solution for
nebulization 3 %
1
NEBUSAL
INHALATION
SOLUTION FOR
NEBULIZATION 6
%
3
NUCALA 6 MSD
OFEV 3 PA; S; SLA;
QL
OMNARIS 3 ST; QL
OPSUMIT 3 PA; S
ORKAMBI 3 S; SLA
PERFOROMIST 2 M; QL
PROAIR HFA 2 QL
PROAIR
RESPICLICK
2
PROVENTIL HFA 3 ST; QL
PULMICORT 3 ST; M; QL
PULMICORT
FLEXHALER
2 M; QL
pulmosal 1
PULMOZYME 2
QNASL NASAL
HFA AEROSOL
INHALER 40
MCG/ACTUATION
2 ST
QNASL NASAL
HFA AEROSOL
INHALER 80
MCG/ACTUATION
2 ST; QL
QVAR
REDIHALER
2 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
97
Drug Name Drug
Category
Requirements
/ Limits
REVATIO
INTRAVENOUS
4 PA; S
REVATIO ORAL 4 PA; ST; S; QL
RUCONEST 6 MSD
SEEBRI
NEOHALER
3 M
SEREVENT
DISKUS
2 M; QL
sildenafil
(antihypertensive)
1 PA; S; QL
SINGULAIR ORAL
GRANULES IN
PACKET
3 ST; M
SINGULAIR ORAL
TABLET
3 ST; M; QL
SINGULAIR ORAL
TABLET,CHEWAB
LE
3 ST; M; QL
sodium chloride 1
SPIRIVA
RESPIMAT
2 M
SPIRIVA WITH
HANDIHALER
2 M; QL
STIOLTO
RESPIMAT
2 M
STRIVERDI
RESPIMAT
2 M
SURFAXIN 6
SYMBICORT 2 ST; M; QL
terbutaline oral 1 M
terbutaline
subcutaneous
1
THEO-24 3 M
theochron 1 M
theophylline 1 M
TICALAST 3 ST
Drug Name Drug
Category
Requirements
/ Limits
TRACLEER 3 PA; S; SLA
TRELEGY
ELLIPTA
2 M
TUDORZA
PRESSAIR
2 M; QL
TYVASO 6 MSD
TYVASO REFILL
KIT
6 MSD
TYVASO
STARTER KIT
6 MSD
UTIBRON
NEOHALER
3 M
VENTAVIS 3 ST; S
VENTOLIN HFA 2 QL
XHANCE 3 ST
XOLAIR 6 MSD
XOPENEX 3
XOPENEX
CONCENTRATE
3
XOPENEX HFA 3 ST
zafirlukast 1 M; QL
ZETONNA 3 ST; QL
zileuton 1 M; QL
ZYFLO 3 ST; M
ZYFLO CR 3 ST; M; QL
UROLOGICALS
ANTICHOLINERGICS &
ANTISPASMODICS
darifenacin 1 M
DETROL 3 ST; M
DETROL LA 3 ST; M
DITROPAN XL 3 ST; M
ENABLEX 3 ST; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
98
Drug Name Drug
Category
Requirements
/ Limits
flavoxate 1 M
GELNIQUE
TRANSDERMAL
GEL IN
METERED-DOSE
PUMP
2 ST
GELNIQUE
TRANSDERMAL
GEL IN PACKET
2 ST; M; QL
MYRBETRIQ 2 ST; M
oxybutynin chloride 1 M
OXYTROL 3 ST; M; QL
tolterodine 1 M
TOVIAZ 2 ST; M
trospium 1 M
VESICARE 2 ST; M
BENIGN PROSTATIC
HYPERPLASIA (BPH) THERAPY
alfuzosin 1 M
AVODART 3 ST; M
CIALIS 2 ST; QL
dutasteride 1 ST; M
dutasteride-
tamsulosin
1 ST; M
finasteride 1 M
FLOMAX 3 ST; M
JALYN 3 ST; M
PROSCAR 3 ST; M
RAPAFLO 2 ST; M
tamsulosin 1 M
UROXATRAL 3 ST; M
CHOLINERGIC STIMULANTS
bethanechol chloride 1
URECHOLINE 3
Drug Name Drug
Category
Requirements
/ Limits
MISCELLANEOUS UROLOGICALS
azuphen mb 1
CYSTAGON 2 PA; SLA
cytra k crystals 1
cytra-2 1
cytra-3 1
cytra-k 1
ELMIRON 2
hyolev mb 1
hyophen 1
INDIOMIN MB 3
K-PHOS NO 2 3
K-PHOS
ORIGINAL
2
methen-sod phos-
meth blue-hyos
1
ORACIT 3
phosphasal 1
pot,sodium citrate-
citric acid
1
potassium citrate 1 M
potassium citrate-
citric acid
1
PROCYSBI 4 PA; ST; S;
SLA
SHOHL'S
MODIFIED
3
sodium citrate-citric
acid
1
tricitrates 1
URELLE 3
uretron d-s 1
URIBEL 3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
99
Drug Name Drug
Category
Requirements
/ Limits
urimar-t 1
urin ds 1
uro-458 1
UROCIT-K 10 3 M
UROCIT-K 15 3 M
UROCIT-K 5 3 M
urogesic-blue 1
uro-mp 1
urophen mb 1
UROQID-ACID
NO.2
3
uryl 1
ustell 1
UTA 3
utira-c 1
virtrate-2 1
virtrate-3 1
virtrate-k 1
URINARY ANESTHETICS
phenazopyridine 1
PYRIDIUM 3
VITAMINS, HEMATINICS &
ELECTROLYTES
ELECTROLYTES
calcium 500 + d 5 ACA; OTC
calcium 500 with d 5 ACA; OTC
calcium 600 + d(3) 5 ACA; OTC
calcium 600 with
vitamin d3
5 ACA; OTC
calcium carb and
citrate-vitd3
5 ACA; OTC
Drug Name Drug
Category
Requirements
/ Limits
calcium carbonate-
vitamin d3
5 ACA; OTC
calcium citrate + d 5 ACA; OTC
calcium citrate-
vitamin d2
5 ACA; OTC
calcium citrate-
vitamin d3
5 ACA; OTC
calcium gluconate in
0.9% nacl
intravenous solution
1 gram/100 ml
6 MSD
CALCIUM
GLUCONATE IN
0.9% NACL
INTRAVENOUS
SOLUTION 1
GRAM/50 ML, 2
GRAM/100 ML, 2
GRAM/50 ML, 3
GRAM/100 ML
6 MSD
CALCIUM
GLUCONATE IN
0.9% NACL
INTRAVENOUS
SYRINGE
6 MSD
CALCIUM
GLUCONATE IN
D5W
6 MSD
citrus calcium 5 ACA; OTC
hi-cal plus vit d 5 ACA; OTC
k-phos-neutral 1
lugols 1
oysco 500/d 5 ACA; OTC
oyster shell + d3 5 ACA; OTC
oyster shell calcium-
vit d3
5 ACA; OTC
oystercal-d 5 ACA; OTC
phospha 250 neutral 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
100
Drug Name Drug
Category
Requirements
/ Limits
phosphorous 1
POTABA 3 M
sodium chloride 6 MSD
sodium chloride 0.45
%
6 MSD
sodium chloride 3 % 6 MSD
sodium chloride 5 % 6 MSD
strong iodine 1
virt-phos 250 neutral 1
MISCELLANEOUS VITAMINS,
HEMATINICS, & ELECTROLYTES
FORTAVIT 3
ISOLYTE-S 6 MSD
VITAMINS & HEMATINICS
ACTIVE FE 3
ANIMI-3 WITH
VITAMIN D
3
ATABEX EC 3
b complex-vitamin
b12
5 ACA; OTC
b complex-vitamin c-
folic acid
5 ACA; OTC
B-12
COMPLIANCE
6 MSD
BACMIN 3
balanced b-100 5 ACA; OTC
balanced b-100
complex
5 ACA; OTC
balanced b-50 5 ACA; OTC
bal-care dha 1
BAL-CARE DHA
ESSENTIAL
3
b-complex with
vitamin c oral tablet
5 ACA; OTC
Drug Name Drug
Category
Requirements
/ Limits
b-complex with
vitamin c oral tablet
400-500 mcg-mg
1 OTC
BIFERA RX 3
CADEAU DHA 3
calcium pnv 1
calcium-folic acid-
vitamin d
1
centratex 1
cholecalciferol
(vitamin d3)
5 ACA; OTC
ciferex 1 M
CITRANATAL
(DUAL-IRON)
3
CITRANATAL 90
DHA (ALGAL OIL)
3
CITRANATAL
ASSURE
3
CITRANATAL B-
CALM (FE GLUC)
3
CITRANATAL
BLOOM
3
CITRANATAL
DHA (ALGAL OIL)
3
CITRANATAL
HARMONY (IRON
FUM)
3
classic prenatal 5 ACA; OTC
c-nate dha 1
complete natal dha 1
completenate 1
complex b-100 1 OTC
CONCEPT DHA 3
CONCEPT OB 3
corvita 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
101
Drug Name Drug
Category
Requirements
/ Limits
corvita 150 1
CORVITE 3
CORVITE 150 3
CORVITE FE 3
CORVITE FREE 3
cyanocobalamin
(vitamin b-12)
1
delta d3 5 ACA; OTC
dialyvite 1
DIALYVITE 3000 3
DIALYVITE 5000 3
dialyvite 800 5 ACA; OTC
DIALYVITE 800
WITH IRON
3
DIALYVITE
SUPREME D
3
dothelle dha 1
DRISDOL 3
DUET DHA
BALANCED
3
DUET DHA WITH
OMEGA-3
3
d-vi-sol 5 ACA; OTC
ENBRACE HR 3
ergocalciferol
(vitamin d2) oral
capsule
1
ergocalciferol
(vitamin d2) oral
tablet
5 ACA; OTC
ESCAVITE 3
ESCAVITE D 3 M
ESCAVITE LQ 3 M
Drug Name Drug
Category
Requirements
/ Limits
EXTRA-VIRT
PLUS DHA
3
FERIVA 21-7
TABLET
3
ferocon 1
FERRALET 90
DUAL-IRON
DELIVERY
3
ferraplus 90 1
ferrocite plus 1
FLORIVA 3 M
FLORIVA
(FLUORIDE-
VITAMIN D3)
5 M; ACA
FLORIVA PLUS 3 M
FLORIVA PLUS
(WITH BIOTIN)
3 M
FLUORABON 5 M; ACA
fluoride (sodium)
oral drops
5 M; ACA
fluoride (sodium)
oral tablet,chewable
0.25 mg(0.55 mg
sod. fluoride), 0.5
mg (1.1 mg sodium
fluorid)
5 M; ACA
fluoride (sodium)
oral tablet,chewable
1 mg (2.2 mg sod.
fluoride)
1 M
fluoritab oral
tablet,chewable 0.5
mg (1.1 mg sodium
fluorid)
5 M; ACA
fluoritab oral
tablet,chewable 1
mg (2.2 mg sod.
fluoride)
1 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
102
Drug Name Drug
Category
Requirements
/ Limits
FLURA-DROPS 5 M; ACA
folbee 1
folbee plus 1
FOLET ONE 3
FOLGARD OS 3
FOLGARD RX 3
folic acid oral tablet
1 mg
1 M
folic acid oral tablet
400 mcg, 800 mcg
5 M; ACA; OTC
folic acid-vit b6-vit
b12
1
folivane-f 1
folivane-ob 1
folivane-plus 1
folplex 2.2 1
foltabs 800 1 OTC
FOLTRATE 3
full spectrum b-
vitamin c
5 ACA; OTC
FUSION PLUS 3
FUSION
SPRINKLES
3
hematinic plus
vit/minerals
1
hematinic/folic acid 1
hematogen 1
hematogen fa 1
hematogen forte 1
HEMATRON-AF 3
hemenatal ob 1
hemenatal ob + dha 1
hemetab 1
Drug Name Drug
Category
Requirements
/ Limits
HEMOCYTE-F 3
HEMOCYTE-PLUS 3
ICAR-C PLUS 3
INFUVITE ADULT 6 MSD
INFUVITE
PEDIATRIC
6 MSD
INJECTAFER 6 MSD
INTEGRA F 3
INTEGRA PLUS 3
IROSPAN 24/6 3
kobee 1 OTC
KOSHER
PRENATAL PLUS
IRON
3
kpn 1 OTC
ludent fluoride oral
tablet,chewable 0.25
mg(0.55 mg sod.
fluoride), 0.5 mg
(1.1 mg sodium
fluorid)
5 M; ACA
ludent fluoride oral
tablet,chewable 1
mg (2.2 mg sod.
fluoride)
1 M
m.v.i. adult 6 MSD
MARNATAL-F 3
MAXFE (FOLATE-
DOCUSATE)
3
multigen folic 1
multigen plus 1
multi-vit with
fluoride-iron
5 ACA
multi-vitamin with
fluoride oral drops
5 ACA
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affiliated companies.
103
Drug Name Drug
Category
Requirements
/ Limits
multi-vitamin with
fluoride oral
tablet,chewable 0.25
mg, 0.5 mg
5 ACA
multi-vitamin with
fluoride oral
tablet,chewable 1
mg
1
multivitamins with
fluoride oral
tablet,chewable 0.25
mg, 0.5 mg
5 ACA
multivitamins with
fluoride oral
tablet,chewable 1
mg
1
mvc-fluoride oral
tablet,chewable 0.25
mg, 0.5 mg
5 ACA
mvc-fluoride oral
tablet,chewable 1
mg
1
mynatal 1
mynatal advance 1
mynatal plus 1
mynatal-z 1
mynate 90 plus 1
mynephrocaps 1
mynephron 1
NATACHEW (FE
BIS-GLYCINATE)
3
natural b-100
complex
5 ACA; OTC
NEEVODHA
(WITH ALGAL
OIL)
3
nephplex rx 1
NEPHROCAPS 3
Drug Name Drug
Category
Requirements
/ Limits
NEPHROCAPS QT 3
NEPHRON FA 3
nephro-vite rx 1
NESTABS 3
NESTABS ABC 3
NESTABS DHA 3
NESTABS ONE 3
NEURIN-SL 3
newgen 1
NEXAVIR 3
NIVA-PLUS 3
NUTRICAP 3
OB COMPLETE
GOLD
3
OB COMPLETE
ONE
3
OB COMPLETE
PETITE
3
OB COMPLETE
PREMIER
3
OB COMPLETE
WITH DHA
3
obstetrix dha 1
OBSTETRIX EC 3
OBSTETRIX ONE 3
OBTREX DHA 3
O-CAL FA 3
O-CAL
PRENATAL
3
one daily prenatal 5 ACA; OTC
ortho d 1 M
ORTHO DF 3 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
104
Drug Name Drug
Category
Requirements
/ Limits
oyster shell calcium-
vit d2
5 ACA; OTC
perry prenatal 5 ACA; OTC
PHYSICIANS EZ
USE B-12
6 MSD
pnv 29-1 1
pnv ob+dha 1
pnv-dha 1
pnv-dha + docusate 1
pnv-ferrous
fumarate-docu-fa
1
pnv-omega 1
pnv-select 1
pnv-vp-u 1
POLY-VI-FLOR 3
POLY-VI-FLOR
WITH IRON
3
pr natal 400 1
pr natal 400 ec 1
pr natal 430 1
pr natal 430 ec 1
PREFERA-OB 3
PREFERA-OB ONE 3
PREFERA-OB
PLUS DHA
3
prena1 chew 1
prena1 pearl 1
prena1 true 1
prenaissance 1
prenaissance plus 1
PRENATA 3
prenatabs fa 1
prenatabs rx 1
Drug Name Drug
Category
Requirements
/ Limits
prenatal 5 ACA; OTC
prenatal complete 5 ACA; OTC
prenatal formula 5 ACA; OTC
prenatal multi-dha
(algal oil)
1 OTC
prenatal one daily 5 ACA; OTC
prenatal plus 1
prenatal plus
(calcium carb)
1
PRENATAL PLUS
DHA
3
prenatal vitamin 5 ACA; OTC
prenatal vitamin
plus low iron
1
prenatal vitamin
with minerals
5 ACA; OTC
prenatal vits96-iron
fum-folic
5 ACA; OTC
prenatal-u 1
PRENATE AM 3
PRENATE
CHEWABLE
3
PRENATE DHA
(FERR ASP
GLYCIN)
3
PRENATE ELITE
(IRON ASP GLYC)
3
PRENATE
ENHANCE
3
PRENATE
ESSENTIAL(IRON-
ASP-GL)
3
PRENATE MINI
(FERR ASP
GLYCIN)
3
PRENATE PIXIE 3
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105
Drug Name Drug
Category
Requirements
/ Limits
PRENATE
RESTORE
3
PRENATE STAR 3
preplus 1
pretab 1
PRIMACARE 3
PROFERRIN-
FORTE
3
PROTECT IRON 3
PROVIDA DHA 3
PROVIDA OB 3
PURALOR CI 3 M
PUREFE OB PLUS 3
PUREFE PLUS 3
purevit dualfe plus 1
QUFLORA 3 M
QUFLORA FE 3 M
QUFLORA FE
(FERROUS
SULFATE)
5 M; ACA
QUFLORA
PEDIATRIC
3 M
QUFLORA
PEDIATRIC
DROPS
3 M
relnate dha 1
renal caps 1
rena-vite 5 ACA; OTC
rena-vite rx 1
reno caps 1
risacal-d 5 ACA; OTC
R-NATAL OB 3
SELECT-OB 3
Drug Name Drug
Category
Requirements
/ Limits
SELECT-OB
(FOLIC ACID)
3
SELECT-OB +
DHA
3
se-natal 19 1
se-natal 19 (with
docusate)
1
se-tan plus 1
stress formula 5 ACA; OTC
stress formula with
iron
1 OTC
stress formula with
iron(sulf)
1 OTC
STROVITE FORTE 3
STROVITE ONE 3
super b complex-
vitamin c
1 OTC
super b maxi
complex
1 OTC
super b-50 complex
plus
1 OTC
super quints 1 OTC
super quints b-50 5 ACA; OTC
superplex-t 1 OTC
SUPERVITE 3
TANDEM PLUS 3
taron forte 1
taron-c dha 1
taron-prex prenatal-
dha
1
THRIVITE RX 3
thrivite-19 1
tl gard rx 1
tl g-fol os 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
106
Drug Name Drug
Category
Requirements
/ Limits
tl icon 1
total b/c 1 OTC
TRICARE 3
tricon 1
TRIFERIC 6 MSD
trigels-f forte 1
trinatal rx 1 1
trinate 1
triphrocaps 1
TRISTART DHA 3
triveen-duo dha 1
TRI-VI-FLOR 3
tri-vitamin with
fluoride
5 ACA
trust natal dha 1
UDAMIN SP 3
ultra b-100 complex 1 OTC
v-c forte 1
VENOFER 6 MSD
vic-forte 1
vinate care 1
VINATE DHA RF 3
vinate ii 1
vinate m 1
vinate one 1
virt-advance 1
virt-c dha 1
VIRT-CAPS 3
virt-gard 1
virt-nate 1
virt-nate dha 1
virt-pn 1
Drug Name Drug
Category
Requirements
/ Limits
virt-pn dha 1
virt-pn plus 1
VIRTPREX 3
virt-select 1
virt-vite 1
virt-vite gt 1
VIRT-VITE PLUS 3 M
vit 3 1
VITAFOL 3
VITAFOL FE+
(WITH
DOCUSATE)
3
VITAFOL
GUMMIES
3
VITAFOL NANO 3
VITAFOL ULTRA 3
VITAFOL-OB 3
VITAFOL-
OB+DHA
3
VITAFOL-ONE 3
vitajoy daily d 5 ACA; OTC
VITAL-D RX 3
VITAMED MD
ONE RX
3
VITAMEDMD
REDICHEW RX
3
vitamin b complex 5 ACA; OTC
vitamin b complex-
folic acid
5 ACA; OTC
vitamin d3 5 ACA; OTC
vitamins a,c,d and
fluoride
5 ACA
VITAPEARL 3
VITA-RESPA 3
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affiliated companies.
107
Drug Name Drug
Category
Requirements
/ Limits
VITATRUE 3
vol-nate 1
vol-plus 1
vol-tab rx 1
vp-ch plus 1
vp-ch-pnv 1
vp-ggr-b6 1
vp-heme ob 1
Drug Name Drug
Category
Requirements
/ Limits
vp-heme one 1
VP-PNV-DHA 3
vp-vite rx 1
zatean-pn dha 1
zatean-pn plus 1
zavara 1 M
zingiber 1
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affiliated companies.
108
Index 2 2TEK GLUCOSE/BLOOD
PRESSURE ...................... 59
A abacavir .................................. 3
abacavir-lamivudine ............... 3
abacavir-lamivudine-
zidovudine .......................... 3
ABILIFY .............................. 28
ABILIFY MAINTENA ........ 28
ABRAXANE ........................ 12
ABSORICA .......................... 45
ABSTRAL ............................ 22
acamprosate .......................... 51
ACANYA ............................. 45
acarbose ................................ 69
ACCOLATE......................... 94
ACCU-CHEK AVIVA PLUS
METER ............................ 59
ACCU-CHEK AVIVA PLUS
TEST STRP ...................... 55
ACCU-CHEK COMPACT
PLUS CONTROL ............ 59
ACCU-CHEK COMPACT
PLUS TEST ..................... 55
ACCU-CHEK GUIDE ......... 55
ACCU-CHEK GUIDE
GLUCOSE METER ......... 59
ACCU-CHEK GUIDE L1-L2
CTRL SOL ....................... 59
ACCU-CHEK NANO .......... 59
ACCU-CHEK SMARTVIEW
CONTRL SOL ................. 59
ACCU-CHEK SMARTVIEW
TEST STRIP .................... 55
ACCUPRIL .......................... 34
ACCURETIC ....................... 34
ACCUTREND GLUCOSE .. 55
ACCUTREND GLUCOSE
CONTROL ....................... 59
acebutolol ............................. 34
acetaminophen-caff-
dihydrocod ........................ 22
ACETAMINOPHEN-CAFF-
DIHYDROCOD ............... 22
acetaminophen-codeine ........ 22
acetazolamide ....................... 90
acetazolamide sodium .......... 90
acetic acid ............................. 54
acetylcysteine ....................... 94
ACIPHEX ............................. 76
ACIPHEX SPRINKLE ........ 76
acitretin ................................. 42
ACTEMRA .......................... 81
ACTHAR H.P. ..................... 54
ACTHIB (PF) ....................... 79
ACTICLATE ........................ 11
ACTIGALL .......................... 72
ACTIMMUNE ..................... 79
ACTIQ .................................. 22
ACTIVE FE .......................... 99
ACTIVELLA........................ 83
ACTONEL ..................... 51, 81
ACTOPLUS MET ................ 69
ACTOPLUS MET XR ......... 69
ACTOS ................................. 69
acuicyn.................................. 89
ACULAR.............................. 90
ACULAR LS ........................ 90
ACUVAIL (PF) .................... 90
acyclovir ........................... 3, 49
ACZONE .............................. 45
ADACEL(TDAP
ADOLESN/ADULT)(PF) 79
ADAGEN ............................. 51
ADALAT CC ....................... 34
adapalene .............................. 45
ADAPALENE ...................... 45
adapalene-benzoyl peroxide . 45
ADASUVE ........................... 28
ADCETRIS .......................... 12
ADCIRCA ............................ 94
ADDERALL ........................ 28
ADDERALL XR .................. 28
ADDYI ................................. 28
adefovir ................................... 3
ADEMPAS ........................... 94
ADLYXIN ............................ 69
ADMELOG SOLOSTAR U-
100 INSULIN ................... 66
ADMELOG U-100 INSULIN
LISPRO ............................ 66
ADRENALIN ....................... 94
adriamycin ............................ 12
adrucil ................................... 12
ADVAIR DISKUS ............... 94
ADVAIR HFA ...................... 94
ADVANCED GLUC METER
TEST STRIP ..................... 55
ADVANCED GLUCOSE
METER ............................. 59
ADVATE .............................. 38
ADVOCATE BLOOD
GLUCOSE MONITOR .... 59
ADVOCATE DUO .............. 59
ADVOCATE LOW
CONTROL ....................... 59
ADVOCATE REDI-CODE .. 55
ADVOCATE REDI-CODE
DUO METER ................... 59
ADVOCATE REDI-CODE
GLU MONITOR .............. 59
ADVOCATE REDI-CODE+
CTRL LOW ...................... 59
ADVOCATE TEST STRIPS 55
ADYNOVATE ..................... 38
ADYPHREN ........................ 92
ADYPHREN AMP ............... 92
ADYPHREN AMP II ........... 92
ADYPHREN II ..................... 92
ADZENYS ER ..................... 28
ADZENYS XR-ODT ........... 28
AEROSPAN ......................... 94
afeditab cr ............................. 34
AFINITOR ........................... 12
AFINITOR DISPERZ .......... 12
AFREZZA ............................ 66
AFSTYLA ............................ 38
AFTERA ............................... 85
AGAMATRIX AMP GLUC
MONITOR SYS ............... 59
AGAMATRIX AMP TEST
STRIPS ............................. 55
AGAMATRIX CONTROL
HIGH ................................ 59
AGONEAZE ........................ 47
AGRYLIN ............................ 51
AIMOVIG AUTOINJECTOR
.......................................... 20
AIMOVIG AUTOINJECTOR
(2 PACK) .......................... 20
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affiliated companies.
109
AIRDUO RESPICLICK ...... 94
ak-poly-bac ........................... 88
AKTEN (PF) ........................ 89
AKTIPAK ............................ 45
AKYNZEO
(FOSNETUPITANT) ....... 72
AKYNZEO (NETUPITANT)
.......................................... 72
ala-cort .................................. 49
ALA-SCALP ........................ 49
ALBENZA ............................. 7
albuterol sulfate .................... 94
alclometasone ....................... 49
ALDACTAZIDE .................. 34
ALDACTONE ..................... 34
ALDARA ............................. 79
ALDURAZYME .................. 67
ALECENSA ......................... 12
alendronate ..................... 51, 81
ALEVICYN PLUS ............... 43
ALFERON N........................ 79
alfuzosin ............................... 97
ALINIA .................................. 7
ALIQOPA ............................ 12
ALKERAN ........................... 12
allopurinol ............................ 81
ALLZITAL........................... 22
almotriptan malate ................ 20
ALOCRIL ............................ 89
ALOGLIPTIN ...................... 69
ALOGLIPTIN-METFORMIN
.......................................... 69
ALOGLIPTIN-
PIOGLITAZONE ............. 69
ALOMIDE ........................... 89
alophen ................................. 72
ALORA ................................ 83
alosetron ............................... 72
ALOXI ................................. 72
ALPHAGAN P ..................... 92
ALPHANATE ...................... 38
ALPHANINE SD ................. 38
alprazolam ............................ 28
alprazolam intensol .............. 28
ALPROLIX .......................... 38
ALREX ................................ 91
ALTABAX ........................... 48
altacaine ................................ 89
ALTACE .............................. 34
altafluor ................................ 89
altavera (28) .......................... 85
ALTOPREV ......................... 40
ALUNBRIG ......................... 12
ALVESCO............................ 94
alyacen 1/35 (28) .................. 85
alyacen 7/7/7 (28) ................. 85
amabelz ................................. 83
amantadine hcl ........................ 3
AMARYL ............................. 69
AMBIEN .............................. 28
AMBIEN CR ........................ 28
AMBISOME .......................... 3
amcinonide ........................... 49
AMELUZ ............................. 43
AMERGE ............................. 20
amethia ................................. 85
amethia lo ............................. 85
amethyst................................ 85
AMICAR .............................. 38
amifostine crystalline ........... 12
amikacin ................................. 7
amiloride ............................... 34
amiloride-hydrochlorothiazide
.......................................... 34
amiodarone ........................... 34
AMITIZA ............................. 72
amitriptyline ......................... 28
amitriptyline-chlordiazepoxide
.......................................... 28
amlodipine ............................ 34
amlodipine-atorvastatin ........ 40
amlodipine-benazepril .......... 34
amlodipine-olmesartan ......... 34
amlodipine-valsartan ............ 34
amlodipine-valsartan-hcthiazid
.......................................... 35
AMMONUL ......................... 51
amnesteem ............................ 45
amoxapine ............................ 28
amoxicil-clarithromy-lansopraz
.......................................... 76
amoxicillin .............................. 9
amoxicillin-pot clavulanate .... 9
AMPHADASE ..................... 51
amphotericin b ........................ 3
ampicillin ................................ 9
ampicillin sodium ................... 9
ampicillin-sulbactam .............. 9
AMPYRA ............................. 21
AMRIX ................................. 22
ANADROL-50 ..................... 67
ANAFRANIL ....................... 28
anagrelide ............................. 51
ANALPRAM-HC ........... 42, 72
ANALPRAM-HC SINGLES72
ANAPROX DS ..................... 26
anaspaz ................................. 71
ANASTIA ............................. 47
anastrozole ............................ 12
ANCOBON ............................ 3
ANDEXXA .......................... 38
ANDRODERM .................... 67
ANDROGEL ........................ 67
ANDROID ............................ 67
ANGELIQ ............................ 83
ANGIOMAX ........................ 38
ANIMI-3 WITH VITAMIN D
.......................................... 99
ANODYNE LPT .................. 47
ANORO ELLIPTA ............... 94
ANTABUSE ......................... 51
ANTARA ............................. 40
anucort-hc ............................. 72
ANUSOL-HC ....................... 72
ANZEMET ........................... 72
apexicon e ............................. 49
APIDRA SOLOSTAR U-100
INSULIN .......................... 66
APIDRA U-100 INSULIN ... 66
APLENZIN ........................... 29
APOKYN ............................. 19
apraclonidine ........................ 92
aprepitant .............................. 72
apri ........................................ 85
APRISO ................................ 72
APTENSIO XR .................... 29
APTIOM ............................... 18
APTIVUS ............................... 3
AQUA GLYCOLIC HC ....... 49
ARALAST NP ...................... 51
aranelle (28) .......................... 85
ARANESP (IN
POLYSORBATE) ............ 78
ARAVA ................................ 81
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affiliated companies.
110
ARCALYST ......................... 79
ARCAPTA NEOHALER ..... 94
ARESTIN ............................. 53
ARGATROBAN .................. 38
ARGATROBAN IN 0.9 %
SOD CHLOR ................... 39
ARGATROBAN IN NACL
(ISO-OS) .......................... 39
ARICEPT ............................. 21
ARIMIDEX .......................... 12
aripiprazole ........................... 29
ARISTADA .......................... 29
ARIXTRA ............................ 39
armodafinil ........................... 29
ARMONAIR RESPICLICK 94
ARMOUR THYROID ......... 71
ARNUITY ELLIPTA ........... 94
AROMASIN......................... 12
ARRANON .......................... 12
ARTHROTEC 50 ................. 26
ARTHROTEC 75 ................. 26
ARYMO ER ......................... 22
ARZERRA ........................... 12
ASACOL HD ....................... 72
ascomp with codeine ............ 22
ashlyna .................................. 85
ASMANEX HFA ................. 94
ASMANEX TWISTHALER 94
aspirin ................................... 26
aspir-trin ............................... 26
ASSURE 4 CONTROL
SOLUTION ...................... 59
ASSURE 4 STRIPS ............. 55
ASSURE DOSE NORMAL
CONTROL ....................... 59
ASSURE PLATINUM ... 56, 59
ASSURE PRISM CONTROL
1-2 SOLN ......................... 59
ASSURE PRISM MULTI
METER ............................ 59
ASSURE PRISM MULTI
STRIP ............................... 56
ASTAGRAF XL .................. 12
ASTEPRO ............................ 53
ASTERO .............................. 47
ATABEX EC........................ 99
ATACAND .......................... 35
ATACAND HCT ................. 35
atazanavir................................ 3
ATELVIA ............................. 81
atenolol ................................. 35
atenolol-chlorthalidone ......... 35
ATGAM ............................... 79
ATIVAN ............................... 29
atomoxetine .......................... 29
ATOPADERM ..................... 43
ATOPICLAIR ...................... 43
atorvastatin ........................... 40
atovaquone.............................. 7
atovaquone-proguanil ............. 7
ATRALIN ............................ 45
ATRAPRO CP ..................... 43
ATRAPRO HYDROGEL .... 43
ATRIPLA ............................... 3
atropine ........................... 71, 89
atropine in 0.9 % sod chloride
.......................................... 71
ATROPINE IN 0.9 % SOD
CHLORIDE ................ 71, 89
ATROVENT HFA ............... 94
AUBAGIO............................ 78
aubra ..................................... 85
AUGMENTIN ...................... 10
AUGMENTIN ES-600 ........... 9
AUGMENTIN XR ............... 10
AURYXIA............................ 72
AUSTEDO ........................... 21
AUTOJECT 2 INJECTION
DEVICE ........................... 60
AUTOPEN 1 TO 21 UNITS 60
AUTOSOFT 30 .................... 60
AUTOSOFT 90 .................... 60
AUVI-Q ................................ 92
AVALIDE ............................ 35
AVANDIA ........................... 69
AVAPRO.............................. 35
avar ....................................... 45
AVAR ................................... 45
AVAR LS ............................. 45
AVAR-E GREEN................. 45
AVAR-E LS ......................... 45
AVASTIN ............................ 12
AVC VAGINAL .................. 84
AVEED ................................ 67
AVELOX.............................. 10
AVELOX IN NACL (ISO-
OSMOTIC) ....................... 10
aviane .................................... 85
avidoxy ................................. 11
avita ...................................... 45
AVITA .................................. 45
avo cream .............................. 43
AVODART ........................... 97
AVONEX ............................. 78
AVONEX (WITH ALBUMIN)
.......................................... 78
AVYCAZ ............................... 6
AXERT ................................. 20
AXIRON ............................... 67
AYGESTIN .......................... 83
azacitidine ............................. 12
AZASAN .............................. 12
AZASITE ............................. 88
azathioprine .......................... 12
azelastine ........................ 53, 89
AZELEX ............................... 45
AZILECT ............................. 19
azithromycin ........................... 7
AZOPT ................................. 90
AZOR ................................... 35
AZULFIDINE ...................... 72
AZULFIDINE EN-TABS .... 72
azuphen mb ........................... 97
azurette (28) .......................... 85
B b complex-vitamin b12 ......... 99
b complex-vitamin c-folic acid
.......................................... 99
B-12 COMPLIANCE ........... 99
bacitracin .............................. 88
bacitracin-polymyxin b ......... 88
baclofen ................................ 22
BACLOFEN ......................... 22
BACMIN .............................. 99
BACTRIM ............................ 10
BACTRIM DS ...................... 10
BACTROBAN ..................... 48
BACTROBAN NASAL ....... 53
balanced b-100 ...................... 99
balanced b-100 complex ....... 99
balanced b-50 ........................ 99
bal-care dha .......................... 99
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
111
BAL-CARE DHA
ESSENTIAL..................... 99
BALCOLTRA ...................... 85
balsalazide ............................ 72
balziva (28) ........................... 85
BANZEL .............................. 18
BARACLUDE ................... 3, 4
BASAGLAR KWIKPEN U-
100 INSULIN ................... 66
BAVENCIO ......................... 12
BAXDELA ........................... 10
bayer aspirin ......................... 26
BCG VACCINE, LIVE (PF) 79
b-complex with vitamin c ..... 99
BEBULIN ............................ 39
BECONASE AQ .................. 94
bekyree (28).......................... 85
BELBUCA ........................... 23
BELEODAQ ........................ 12
belladonna alkaloids-opium . 71
belladonna-opium ................. 71
BELSOMRA ........................ 29
benazepril ............................. 35
benazepril-hydrochlorothiazide
.......................................... 35
BENDEKA ........................... 12
BENEFIX ............................. 39
BENICAR ............................ 35
BENICAR HCT ................... 35
BENLYSTA ......................... 81
BENSAL HP ........................ 43
BENTYL .............................. 71
BENZACLIN ....................... 45
BENZACLIN PUMP ........... 45
BENZAMYCIN ................... 45
BENZEFOAM ..................... 45
BENZEFOAM ULTRA ....... 45
benzepro ............................... 45
BENZNIDAZOLE ................. 7
benzonatate ........................... 93
benzoyl peroxide .................. 45
benztropine ........................... 19
BEPREVE ............................ 89
BERINERT .......................... 94
BESIVANCE ....................... 88
BESPONSA ......................... 12
BETADINE OPHTHALMIC
PREP ................................ 88
BETAGAN ........................... 89
betamethasone acet,sod phos 54
betamethasone dipropionate . 49
BETAMETHASONE SOD
PHOSPH-WATER ........... 54
betamethasone valerate......... 49
betamethasone, augmented ... 49
BETAPACE ......................... 34
BETAPACE AF ................... 34
BETASERON ...................... 78
betaxolol ......................... 35, 89
bethanechol chloride ............. 97
BETHKIS ............................... 7
BETIMOL ............................ 89
BETOPTIC S ........................ 89
BEVACIZUMAB ................. 89
BEVESPI AEROSPHERE ... 94
BEVYXXA .......................... 39
bexarotene ............................ 12
BEXSERO ............................ 79
BEYAZ ................................. 85
BIAFINE EMULSION......... 43
bicalutamide ......................... 12
BICILLIN C-R ..................... 10
BICNU.................................. 12
BIDIL ................................... 35
BIFERA RX ......................... 99
BIKTARVY ........................... 4
BILTRICIDE .......................... 7
bimatoprost ........................... 90
BINOSTO ............................. 81
BIONIME RIGHTEST
GM300 SYSTEM ............. 60
BIONIME RIGHTEST TEST
STRIPS ............................. 56
bisacodyl ............................... 72
bisa-lax ................................. 72
bisoprolol fumarate............... 35
bisoprolol-hydrochlorothiazide
.......................................... 35
bivalirudin ............................ 39
BIVALIRUDIN-0.9 %
SODIUM CHLOR ............ 39
BIVIGAM ............................ 79
bleomycin ............................. 13
BLEPH-10 ............................ 91
BLEPHAMIDE .................... 91
BLEPHAMIDE S.O.P. ......... 91
BLINCYTO .......................... 13
blisovi 24 fe .......................... 85
blisovi fe 1.5/30 (28) ............ 85
blisovi fe 1/20 (28) ............... 85
BLOOD GLUCOSE
CONTROL, NORMAL .... 60
BLOOD GLUCOSE TEST .. 56
BLOOD-GLUCOSE METER
.......................................... 60
BONIVA ............................... 81
BONJESTA .......................... 72
BOOSTRIX TDAP ............... 79
BORTEZOMIB .................... 13
BOSULIF ............................. 13
BOTOX ................................ 79
bp 10-1 .................................. 45
bpo ........................................ 45
BREEZE 2 CONTROL
SOLUTION,HIGH ........... 60
BREEZE 2 TEST STRIPS ... 56
BREO ELLIPTA .................. 94
BREVIBLOC ....................... 35
BREVIBLOC IN NACL (ISO-
OSM) ................................ 35
BREVICON (28) .................. 85
BRIDION ............................. 22
briellyn .................................. 85
brimonidine ........................... 92
BRINEURA .......................... 67
BRISDELLE ......................... 29
BRIVIACT ........................... 18
BROMFED DM ................... 93
bromfenac ............................. 90
bromocriptine ....................... 19
brompheniramine-pseudoeph-
dm ..................................... 93
BROMSITE .......................... 90
BROVANA .......................... 94
BUCALSEP .......................... 47
budesonide ...................... 72, 94
bumetanide ........................... 35
BUNAVAIL ......................... 26
BUPAP ................................. 23
BUPHENYL ......................... 51
BUPRENEX ......................... 23
BUPRENORPHINE ............. 23
buprenorphine hcl ................. 23
buprenorphine-naloxone ....... 26
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affiliated companies.
112
bupropion hcl........................ 29
bupropion hcl (smoking deter)
.......................................... 52
buspirone .............................. 29
busulfan ................................ 13
BUSULFEX ......................... 13
butalbital compound w/codeine
.......................................... 23
butalbital-acetaminop-caf-cod
.......................................... 23
butalbital-acetaminophen ..... 23
butalbital-acetaminophen-caff
.......................................... 23
butalbital-aspirin-caffeine .... 23
butorphanol tartrate .............. 26
BUTRANS ........................... 23
BYDUREON ........................ 69
BYDUREON BCISE ........... 69
BYETTA .............................. 69
BYSTOLIC .......................... 35
BYVALSON ........................ 35
C cabergoline ........................... 67
CABOMETYX .................... 13
CADEAU DHA.................... 99
CADUET .............................. 40
CAFERGOT ......................... 20
caffeine citrate ...................... 51
CALAN ................................ 35
CALAN SR .......................... 35
calcipotriene ......................... 42
calcipotriene-betamethasone 42
calcitonin (salmon) ............... 67
calcitrene .............................. 42
calcitriol .......................... 42, 67
calcium 500 + d .................... 98
calcium 500 with d ............... 98
calcium 600 + d(3) ............... 98
calcium 600 with vitamin d3 98
calcium acetate ..................... 72
calcium carb and citrate-vitd3
.......................................... 98
calcium carbonate-vitamin d3
.......................................... 98
calcium citrate + d ................ 98
calcium citrate-vitamin d2 .... 98
calcium citrate-vitamin d3 .... 98
calcium gluconate in 0.9% nacl
.......................................... 98
CALCIUM GLUCONATE IN
0.9% NACL ...................... 98
CALCIUM GLUCONATE IN
D5W ................................. 98
calcium pnv .......................... 99
calcium-folic acid-vitamin d 99
CALQUENCE ...................... 13
CAMBIA .............................. 26
camila ................................... 83
CAMPTOSAR ..................... 13
camrese ................................. 85
camrese lo ............................. 85
CANASA.............................. 72
CANCIDAS............................ 3
candesartan ........................... 35
candesartan-hydrochlorothiazid
.......................................... 35
capacet .................................. 23
CAPASTAT ........................... 7
CAPCOF .............................. 93
capecitabine .......................... 13
CAPEX ................................. 49
CAPITAL WITH CODEINE
.......................................... 23
CAPRELSA.......................... 13
captopril ................................ 35
captopril-hydrochlorothiazide
.......................................... 35
CARAC ................................ 43
CARAFATE ......................... 76
CARBAGLU ........................ 52
carbamazepine ...................... 18
CARBATROL ...................... 18
carbidopa .............................. 19
carbidopa-levodopa .............. 19
carbidopa-levodopa-
entacapone ........................ 19
carbinoxamine maleate ......... 92
carboplatin ............................ 13
CARDIZEM ......................... 35
CARDIZEM CD .................. 35
CARDIZEM LA ................... 35
CARDURA .......................... 35
CARDURA XL .................... 35
CARESENS CONTROL A
NORMAL ......................... 60
CARESENS N ...................... 60
CARESENS N TEST STRIPS
.......................................... 56
CARESENS N VOICE ......... 60
CARETOUCH GLUCOSE
MONITORING ................ 60
CARETOUCH TEST STRIP
.......................................... 56
CARIMUNE NF
NANOFILTERED ............ 79
carisoprodol .......................... 22
carisoprodol-asa-codeine ...... 22
carisoprodol-aspirin .............. 22
CARNITOR .......................... 52
CARNITOR (SUGAR-FREE)
.......................................... 52
CAROSPIR ........................... 35
carteolol ................................ 89
cartia xt ................................. 35
carvedilol .............................. 35
carvedilol phosphate ............. 35
CASODEX ........................... 13
caspofungin ............................. 3
CATAPRES .......................... 35
CATAPRES-TTS-1 .............. 35
CATAPRES-TTS-2 .............. 35
CATAPRES-TTS-3 .............. 35
CAYA CONTOURED ......... 82
CAYSTON ............................. 7
caziant (28) ........................... 85
cefaclor ................................... 6
cefadroxil ................................ 6
cefazolin ................................. 6
CEFAZOLIN IN 0.9% SOD
CHLORIDE ........................ 6
cefazolin in dextrose (iso-os) .. 6
CEFAZOLIN IN DEXTROSE
(ISO-OS) ............................. 6
CEFAZOLIN IN DEXTROSE
5 % ...................................... 6
CEFAZOLIN IN STERILE
WATER .............................. 6
cefdinir .................................... 6
cefditoren pivoxil .................... 6
cefepime ................................. 6
cefepime in dextrose,iso-osm . 6
cefixime .................................. 6
CEFOTAN .............................. 6
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affiliated companies.
113
cefotaxime .............................. 6
cefotetan ................................. 6
cefoxitin .................................. 6
cefpodoxime ........................... 6
cefprozil .................................. 6
ceftriaxone .............................. 6
CEFTRIAXONE .................... 6
ceftriaxone in dextrose,iso-os . 6
CEFUROXIME (PF) IN 0.9%
NACL ............................... 88
cefuroxime axetil .................... 6
cefuroxime sodium ................. 6
celacyn .................................. 43
CELEBREX ......................... 26
celecoxib............................... 26
CELESTONE SOLUSPAN . 54
CELEXA .............................. 29
CELLCEPT .......................... 13
CELLCEPT INTRAVENOUS
.......................................... 13
CELONTIN .......................... 18
CENTANY ........................... 48
CENTANY AT .................... 48
centergy ................................ 93
centratex ............................... 99
cephalexin............................... 6
CEPROTIN (BLUE BAR) ... 39
CEPROTIN (GREEN BAR) 39
CERDELGA......................... 67
CEREZYME ........................ 67
CESAMET ........................... 72
cetirizine ............................... 92
CETRAXAL......................... 54
cevimeline ............................ 52
CHANTIX ............................ 52
CHANTIX CONTINUING
MONTH BOX .................. 53
CHANTIX STARTING
MONTH BOX .................. 53
chateal................................... 85
CHENODAL ........................ 72
cheratussin ac ....................... 93
chloramphenicol sod succinate
............................................ 7
chlordiazepoxide hcl ............ 29
chlordiazepoxide-clidinium .. 71
chlorhexidine gluconate ....... 53
chloroquine phosphate............ 7
chlorothiazide ....................... 35
chlorothiazide sodium .......... 35
chlorpromazine ..................... 29
chlorpropamide ..................... 69
chlorthalidone ....................... 35
chlorzoxazone ....................... 22
CHOLBAM .......................... 72
cholecalciferol (vitamin d3) . 99
cholestyramine (with sugar) . 40
cholestyramine light ............. 40
choline,magnesium salicylate
.......................................... 26
CIALIS ................................. 97
ciclodan ................................ 48
CICLODAN KIT .................. 49
ciclopirox .............................. 49
cidofovir ................................. 4
ciferex ................................... 99
CILOXAN ............................ 88
CIMDUO ................................ 4
cimetidine ............................. 76
cimetidine hcl ....................... 76
CIMZIA ................................ 73
CIMZIA POWDER FOR
RECONST ........................ 73
CINQAIR ............................. 94
CINRYZE ............................. 94
CINVANTI ........................... 73
CIPRO .................................. 10
CIPRO HC ............................ 54
CIPRO XR ............................ 10
CIPRODEX .......................... 54
ciprofloxacin ......................... 10
ciprofloxacin (mixture) ......... 10
ciprofloxacin hcl ....... 10, 54, 88
cisplatin ................................ 13
citalopram ............................. 29
CITRANATAL (DUAL-
IRON) ............................... 99
CITRANATAL 90 DHA
(ALGAL OIL) .................. 99
CITRANATAL ASSURE .... 99
CITRANATAL B-CALM (FE
GLUC) .............................. 99
CITRANATAL BLOOM ..... 99
CITRANATAL DHA
(ALGAL OIL) .................. 99
CITRANATAL HARMONY
(IRON FUM) .................... 99
citrate of magnesia ................ 73
citroma .................................. 73
citrus calcium ........................ 98
cladribine .............................. 13
CLAFORAN ........................... 6
claravis .................................. 45
CLARINEX .......................... 92
CLARINEX-D 12 HOUR .... 93
clarithromycin ......................... 7
classic prenatal ...................... 99
cleansing wash ...................... 45
clearlax ................................. 73
clemastine ............................. 92
CLENPIQ ............................. 73
cleocin ..................................... 7
CLEOCIN ......................... 7, 84
CLEOCIN HCL ...................... 7
CLEOCIN IN 5 %
DEXTROSE ....................... 7
CLEOCIN PEDIATRIC ......... 7
CLEOCIN T ......................... 45
CLEVER CHEK BLOOD
GLUCOSE ........................ 60
CLEVER CHOICE
GLUCOSE MONITOR .... 60
CLEVER CHOICE LEVEL 2
CONTROL ....................... 60
CLEVER CHOICE MICRO . 60
CLEVER CHOICE MICRO
TEST STRIP ..................... 56
CLEVER CHOICE PRO 56, 60
CLEVER CHOICE TALK
GLUCOSE SYS ............... 60
CLEVER CHOICE TALK
TEST ................................. 56
CLEVER CHOICE TEST
STRIPS ............................. 56
CLEVER CHOICE VOICE+
TEST ................................. 56
CLIMARA ............................ 83
CLIMARA PRO ................... 83
CLIN SINGLE USE ............... 7
CLINDACIN ETZ ................ 45
clindacin p ............................ 45
CLINDACIN PAC ............... 45
CLINDAGEL ....................... 45
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affiliated companies.
114
clindamycin hcl ...................... 7
CLINDAMYCIN IN 0.9 %
SOD CHLOR ..................... 7
clindamycin in 5 % dextrose .. 8
clindamycin palmitate hcl ...... 8
clindamycin pediatric ............. 8
clindamycin phosphate .... 8, 45,
84
clindamycin-benzoyl peroxide
.................................... 45, 46
clindamycin-tretinoin ........... 46
CLINDESSE ........................ 84
CLINPRO 5000 .................... 53
clobetasol .............................. 49
clobetasol-emollient ............. 49
CLOBEX .............................. 49
CLOCORTOLONE
PIVALATE ...................... 50
clodan ................................... 50
CLODAN KIT...................... 50
CLODERM .......................... 50
clofarabine ............................ 13
CLOLAR .............................. 13
clomipramine ........................ 29
clonazepam ........................... 18
clonidine ............................... 35
clonidine hcl ................... 29, 35
clorazepate dipotassium ....... 29
clotrimazole ............................ 3
clotrimazole-betamethasone . 49
clozapine............................... 29
CLOZAPINE ........................ 29
CLOZARIL .......................... 29
c-nate dha ............................. 99
COAGADEX ....................... 39
COAL TAR .......................... 42
COARTEM ............................ 8
codeine sulfate ...................... 23
codeine-guaifenesin .............. 93
CODITUSSIN AC ............... 93
CODITUSSIN DAC ............. 93
COLAZAL ........................... 73
COLCHICINE ...................... 81
COLCRYS ........................... 81
colesevelam .......................... 40
COLESTID .......................... 40
COLESTID FLAVORED .... 40
colestipol .............................. 40
colistin (colistimethate na) ..... 8
colocort ................................. 73
COLY-MYCIN M
PARENTERAL .................. 8
COLY-MYCIN S ................. 54
COLYTE WITH FLAVOR
PACKS ............................. 73
COMBIGAN ........................ 90
COMBIPATCH .................... 83
COMBIVENT RESPIMAT . 94
COMBIVIR ............................ 4
COMETRIQ ......................... 13
COMPAZINE ....................... 73
COMPLERA .......................... 4
complete natal dha ................ 99
completenate ......................... 99
complex b-100 ...................... 99
compro .................................. 73
COMTAN ............................. 19
CONCEPT DHA .................. 99
CONCEPT OB ..................... 99
CONCEPTROL .................... 84
CONCERTA ........................ 29
CONDYLOX........................ 44
constulose ............................. 73
CONTOUR CONTROL
SOLUTION, NML ........... 60
CONTOUR LINK ................ 60
CONTOUR NEXT EZ
METER ............................ 60
CONTOUR NEXT LEV 2
CONTROL SOL............... 60
CONTOUR NEXT LINK .... 60
CONTOUR NEXT LINK 2.4
.......................................... 60
CONTOUR NEXT METER 60
CONTOUR NEXT ONE
METER ............................ 60
CONTOUR NEXT TEST
STRIPS ............................. 56
CONTOUR TEST STRIPS .. 56
CONZIP................................ 26
COOL BLOOD GLUCOSE
METER ............................ 60
COOL CONTROL A
SOLUTION ...................... 60
COOL GLUCOSE TEST
STRIP ............................... 56
COPAXONE ........................ 78
CORDRAN ........................... 50
CORDRAN TAPE LARGE
ROLL ................................ 50
COREG ................................. 35
COREG CR .......................... 35
coremino ............................... 11
CORGARD ........................... 35
CORIFACT .......................... 39
CORLANOR ........................ 42
cormax .................................. 50
CORTANE-B ....................... 44
CORTEF ............................... 54
CORTENEMA ..................... 73
CORTIFOAM ....................... 73
cortisone ............................... 54
CORTISPORIN .................... 48
CORTROSYN ...................... 54
corvita ................................... 99
corvita 150 .......................... 100
CORVITE ........................... 100
CORVITE 150 .................... 100
CORVITE FE ..................... 100
CORVITE FREE ................ 100
CORZIDE ............................. 35
COSENTYX ......................... 42
COSENTYX (2 SYRINGES)
.......................................... 42
COSENTYX PEN ................ 42
COSENTYX PEN (2 PENS) 42
COSMEGEN ........................ 13
COSOPT ............................... 90
COSOPT (PF) ....................... 90
cosyntropin ........................... 54
COTELLIC ........................... 13
COTEMPLA XR-ODT ........ 29
COUMADIN ........................ 39
covaryx ................................. 83
covaryx h.s. ........................... 83
COZAAR .............................. 35
CREON ................................. 73
CRESEMBA ........................... 3
CRESTOR ............................ 40
CRINONE ............................ 83
CRIXIVAN ............................. 4
cromolyn ................... 73, 89, 94
cryselle (28) .......................... 85
CRYSVITA .......................... 67
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affiliated companies.
115
CUBICIN ............................... 8
CUBICIN RF ......................... 8
CUPRIMINE ........................ 81
CUROSURF ......................... 94
CUTIVATE .......................... 50
CUVITRU ............................ 79
CUVPOSA ........................... 71
cyanocobalamin (vitamin b-12)
........................................ 100
cyclafem 1/35 (28) ............... 85
cyclafem 7/7/7 (28) .............. 85
CYCLESSA (28) .................. 85
cyclobenzaprine .................... 22
CYCLOGYL ........................ 89
CYCLOMYDRIL ................ 92
cyclopentolate....................... 89
cyclophosphamide ................ 13
CYCLOSERINE .................... 8
CYCLOSET ......................... 69
cyclosporine ......................... 13
cyclosporine modified .......... 13
CYCLOTENS REFILL ........ 22
CYCLOTENS STARTER ... 22
CYMBALTA ....................... 29
cyproheptadine ..................... 92
CYRAMZA .......................... 13
cyred ..................................... 85
CYSTADANE ...................... 73
CYSTAGON ........................ 97
CYSTARAN ........................ 89
cytarabine ............................. 13
cytarabine (pf) ...................... 13
CYTOMEL .......................... 71
CYTOTEC ........................... 76
CYTOVENE .......................... 4
cytra k crystals ...................... 97
cytra-2................................... 97
cytra-3................................... 97
cytra-k................................... 97
D D.H.E.45 ............................... 20
dacarbazine ........................... 13
DACOGEN .......................... 13
dactinomycin ........................ 13
DAKLINZA ........................... 4
DALIRESP ........................... 94
danazol ................................. 67
DANTRIUM ........................ 22
dantrolene ............................. 22
dapsone ............................. 8, 46
DAPTACEL (DTAP
PEDIATRIC) (PF) ............ 79
daptomycin ............................. 8
DARAPRIM ........................... 8
darifenacin ............................ 96
DARZALEX ........................ 13
dasetta 1/35 (28) ................... 85
dasetta 7/7/7 (28) .................. 85
daunorubicin ......................... 13
DAXBIA ................................ 6
DAYPRO.............................. 26
daysee ................................... 85
DAYTRANA........................ 29
DDAVP ................................ 67
DEBACTEROL.................... 53
deblitane ............................... 83
decadron ............................... 54
decitabine.............................. 13
DEFITELIO.......................... 39
DELESTROGEN ................. 83
delta d3 ............................... 100
deltasone ............................... 54
delyla (28)............................. 85
DELZICOL .......................... 73
DEMADEX .......................... 35
demeclocycline ..................... 11
DEMEROL ........................... 23
DEMEROL (PF) .................. 23
DEMSER .............................. 35
DENAVIR ............................ 49
denta 5000 plus ..................... 53
dentagel ................................ 53
DEPACON ........................... 18
DEPAKENE ......................... 18
DEPAKOTE ......................... 18
DEPAKOTE ER ................... 18
DEPAKOTE SPRINKLES... 18
DEPEN TITRATABS .......... 81
DEPO-ESTRADIOL ............ 83
DEPO-PROVERA................ 83
DEPO-SUBQ PROVERA 104
.......................................... 83
DEPO-TESTOSTERONE .... 67
DERMACINRX
EMPRICAINE ................. 47
DERMA-SMOOTHE/FS
BODY OIL ....................... 50
DERMA-SMOOTHE/FS
SCALP OIL ...................... 50
DERMATOP ........................ 50
DERMOTIC OIL .................. 54
DESCOVY ............................. 4
desipramine ........................... 29
desloratadine ......................... 92
desmopressin ........................ 67
desog-e.estradiol/e.estradiol . 85
desogestrel-ethinyl estradiol . 85
DESONATE ......................... 50
desonide ................................ 50
DESOWEN ........................... 50
desoximetasone ..................... 50
DESOXYN ........................... 29
DESVENLAFAXINE .......... 29
DESVENLAFAXINE
FUMARATE .................... 29
desvenlafaxine succinate ...... 29
DETROL .............................. 96
DETROL LA ........................ 96
dexamethasone ..................... 54
DEXAMETHASONE ACE-
NACL,ISO-OSM .............. 54
dexamethasone intensol ........ 55
dexamethasone sodium phos
(pf) .................................... 55
dexamethasone sodium
phosphate .................... 55, 91
DEXCOM G6 RECEIVER .. 60
DEXEDRINE SPANSULE .. 29
DEXERYL ........................... 44
DEXILANT .......................... 76
dexmethylphenidate .............. 29
DEXPAK 10 DAY ............... 55
DEXPAK 13 DAY ............... 55
DEXPAK 6 DAY ................. 55
dexrazoxane hcl .................... 12
dextroamphetamine .............. 29
dextroamphetamine-
amphetamine ..................... 30
dialyvite .............................. 100
DIALYVITE 3000 .............. 100
DIALYVITE 5000 .............. 100
dialyvite 800 ....................... 100
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
116
DIALYVITE 800 WITH IRON
........................................ 100
DIALYVITE SUPREME D
........................................ 100
DIASTAT ............................. 18
DIASTAT ACUDIAL .......... 18
DIATRUE CONTROL SOLN
NORMAL ........................ 60
DIATRUE PLUS BLOOD
GLUCOSE MET .............. 60
DIATRUE PLUS TEST STRIP
.......................................... 56
diazepam......................... 18, 30
diazepam intensol ................. 30
DIBENZYLINE ................... 35
DICLEGIS ............................ 73
DICLO GEL ......................... 26
DICLO GEL-XRYLIX
SHEET ............................. 26
diclofenac potassium ............ 26
diclofenac sodium ... 26, 27, 44,
90
diclofenac-misoprostol ......... 27
DICLOPAK .......................... 27
DICLOPR ............................. 27
dicloxacillin .......................... 10
dicyclomine .......................... 71
didanosine............................... 4
DIFFERIN ............................ 46
DIFICID ................................. 7
diflorasone ............................ 50
DIFLUCAN ............................ 3
diflunisal ............................... 27
digitek ................................... 38
digox ..................................... 38
digoxin .................................. 38
dihydroergotamine ............... 20
DILANTIN ........................... 18
DILANTIN EXTENDED .... 18
DILANTIN INFATABS ...... 18
DILANTIN-125 ................... 18
DILATRATE-SR ................. 42
DILAUDID .......................... 23
diltiazem ............................... 35
dilt-xr .................................... 35
DIOVAN .............................. 35
DIOVAN HCT ..................... 36
DIPENTUM ......................... 73
diphenhydramine hcl ............ 92
diphenoxylate-atropine ......... 71
DIPROLENE ........................ 50
DISALCID ........................... 27
diskets ................................... 23
disopyramide phosphate ....... 34
disulfiram.............................. 52
DITHOL ............................... 27
DITROPAN XL ................... 96
DIURIL ................................ 36
DIURIL IV ........................... 36
divalproex ............................. 18
DIVIGEL .............................. 83
DM2...................................... 69
DOCEFREZ ......................... 13
docetaxel ............................... 13
DOCETAXEL ...................... 13
dofetilide ............................... 34
DOLOPHINE ....................... 23
DOLOTRANZ...................... 47
donepezil .............................. 21
DONNATAL ........................ 71
DOPTELET .......................... 39
DORAL ................................ 30
DORIPENEM ......................... 8
DORYX ................................ 11
DORYX MPC ...................... 11
dorzolamide .......................... 90
dorzolamide-timolol ............. 90
dothelle dha ........................ 100
DOVONEX .......................... 42
doxazosin .............................. 36
doxepin ........................... 30, 44
doxercalciferol ...................... 67
DOXIL.................................. 13
doxorubicin ........................... 13
doxorubicin, peg-liposomal .. 13
doxycycline hyclate .............. 11
doxycycline monohydrate .... 11
DOXYCYCLINE
MONOHYDRATE ........... 11
DRISDOL ........................... 100
drithocreme hp ...................... 42
dronabinol ............................. 73
drospirenone-e.estradiol-lm.fa
.......................................... 85
drospirenone-ethinyl estradiol
.......................................... 85
DROXIA ............................... 13
DUAC ................................... 46
DUAVEE .............................. 83
ducodyl ................................. 73
DUET DHA BALANCED . 100
DUET DHA WITH OMEGA-3
........................................ 100
DUETACT ........................... 69
DUEXIS ............................... 27
DULERA .............................. 94
duloxetine ............................. 30
DUOPA ................................ 20
DUPIXENT .......................... 44
DURAGESIC ....................... 23
DUREZOL ........................... 91
dutasteride ............................. 97
dutasteride-tamsulosin .......... 97
DUTOPROL ......................... 36
DUZALLO ........................... 81
d-vi-sol ................................ 100
DYANAVEL XR ................. 30
DYAZIDE ............................ 36
DYMISTA ............................ 94
DYRENIUM ......................... 36
DYSPORT ............................ 79
E e.c. prin ................................. 27
e.e.s. 400 ................................. 7
E.E.S. GRANULES ................ 7
EASY PLUS II BLOOD
GLUCOSE MET .............. 60
EASY PLUS II TEST ........... 56
EASY STEP ......................... 56
EASY STEP BLOOD
GLUCOSE METER ......... 61
EASY TALK BLOOD
GLUCOSE METER ......... 61
EASY TALK GLUCOSE
TEST ................................. 56
EASY TOUCH GLUCOSE
MONITOR ....................... 61
EASY TOUCH TEST STRIP
.......................................... 56
EASY TRAK GLUCOSE
TEST ................................. 56
EASY TRAK LOW
CONTROL ....................... 61
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affiliated companies.
117
EASYGLUCO
MONITORING SYSTEM 61
EASYGLUCO PLUS ........... 56
EASYGLUCO PLUS
NORMAL CONTROL ..... 61
EASYGLUCO TEST ........... 56
EASYMAX .......................... 56
EASYMAX L BLOOD
GLUCOSE METER ......... 61
EASYMAX LOW CONTROL
.......................................... 61
EASYMAX NG ................... 61
EASYMAX NORMAL
CONTROL ....................... 61
EASYMAX V SPEAKING
GLUCOSE SYS ............... 61
EASYMAX V2 BLOOD
GLUCOSE METER ......... 61
EC-NAPROSYN .................. 27
econazole .............................. 49
econtra ez.............................. 85
econtra one-step.................... 85
ecotrin ................................... 27
ECOZA ................................ 49
EDARBI ............................... 36
EDARBYCLOR ................... 36
EDECRIN ............................ 36
EDLUAR .............................. 30
ed-spaz .................................. 71
EDURANT ............................. 4
eemt ...................................... 83
eemt hs.................................. 83
efavirenz ................................. 4
EFFEXOR XR ..................... 30
EFUDEX .............................. 44
EGRIFTA ............................. 78
ELAPRASE .......................... 68
ELELYSO ............................ 68
ELEMENT COMPACT
GLUCOSE METER ......... 61
ELEMENT COMPACT
NORMAL CONTROL ..... 61
ELEMENT COMPACT TEST
STRIPS ............................. 56
ELEMENT COMPACT V
GLUCOSE MTR .............. 61
ELEMENT NORMAL
CONTROL ....................... 61
ELEMENT PLUS BLOOD
GLUCOSE KIT ................ 61
ELEMENT TEST STRIPS ... 56
ELESTAT ............................. 89
ELESTRIN ........................... 83
eletone .................................. 44
eletriptan ............................... 20
ELIDEL ................................ 44
ELIGARD ............................ 13
ELIGARD (3 MONTH) ....... 13
ELIGARD (4 MONTH) ....... 13
ELIGARD (6 MONTH) ....... 13
ELIMITE .............................. 51
elinest.................................... 85
eliphos .................................. 73
ELIQUIS .............................. 39
ELITEK ................................ 12
ELIXOPHYLLIN ................. 94
ELLA .................................... 85
ELLENCE ............................ 13
ELLZIA PAK ....................... 50
ELMIRON ............................ 97
ELOCON .............................. 50
ELOCTATE ......................... 39
EMADINE............................ 89
EMBEDA ............................. 23
EMBRACE BLOOD
GLUCOSE SYSTEM . 56, 61
EMBRACE EVO LEVEL 1 . 61
EMBRACE EVO TEST
STRIPS ............................. 56
EMBRACE GLUCOSE
CONTROL LOW ............. 61
EMBRACE PRO GLUCOSE
METER ............................ 61
EMBRACE PRO TEST
STRIPS ............................. 56
EMCYT ................................ 14
EMEND ................................ 73
EMEND (FOSAPREPITANT)
.......................................... 73
EMFLAZA ........................... 55
emoquette ............................. 85
EMPLICITI .......................... 14
EMSAM ............................... 30
EMTRIVA .............................. 4
EMVERM .............................. 8
ENABLEX ........................... 96
enalapril maleate ................... 36
enalaprilat ............................. 36
enalapril-hydrochlorothiazide
.......................................... 36
ENBRACE HR ................... 100
ENBREL ............................... 81
ENBREL MINI .................... 81
ENBREL SURECLICK ....... 81
ENDARI ............................... 52
endocet .................................. 23
ENGERIX-B (PF) ................ 79
ENGERIX-B PEDIATRIC
(PF) ................................... 80
enoxaparin ............................ 39
enpresse ................................ 85
enskyce ................................. 85
ENSTILAR ........................... 42
entacapone ............................ 20
entecavir ................................. 4
ENTOCORT EC ................... 73
ENTRESTO .......................... 42
ENTYVIO ............................ 73
enulose .................................. 73
ENVARSUS XR .................. 14
EPANED .............................. 36
EPCLUSA .............................. 4
EPICERAM .......................... 44
EPIDUO ............................... 46
EPIDUO FORTE .................. 46
EPIFOAM ............................. 42
epinastine .............................. 89
EPINEPHRINE .................... 92
EPINEPHRINESNAP-V ...... 92
EPIPEN 2-PAK .................... 92
EPIPEN JR 2-PAK ............... 92
epirubicin .............................. 14
EPISIL .................................. 53
EPISNAP .............................. 92
epitol ..................................... 18
EPIVIR ................................... 4
EPIVIR HBV .......................... 4
eplerenone ............................. 36
EPOGEN .............................. 78
epoprostenol (glycine) .......... 36
eprosartan ............................. 36
EPZICOM ............................... 4
EQUETRO ........................... 18
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affiliated companies.
118
ERAXIS(WATER DILUENT)
............................................ 3
ERBITUX ............................ 14
ergocalciferol (vitamin d2) . 100
ergoloid................................. 30
ERGOMAR .......................... 20
ergotamine-caffeine .............. 20
ERIVEDGE .......................... 14
ERLEADA ........................... 14
errin ...................................... 83
ERTACZO ........................... 49
ERWINAZE ......................... 14
ery pads ................................ 46
erygel .................................... 46
ERYPED 200 ......................... 7
ERYPED 400 ......................... 7
ery-tab..................................... 7
ERY-TAB .............................. 7
erythrocin (as stearate) ........... 7
erythromycin .................... 7, 88
erythromycin ethylsuccinate .. 7
erythromycin with ethanol ... 46
erythromycin-benzoyl peroxide
.......................................... 46
ESBRIET ........................ 94, 95
ESCAVITE ........................ 100
ESCAVITE D ..................... 100
ESCAVITE LQ .................. 100
escitalopram oxalate ............. 30
ESGIC .................................. 23
ESKATA .............................. 44
esmolol ................................. 36
ESOMEP-EZS ...................... 76
esomeprazole magnesium .... 76
esomeprazole sodium ........... 76
ESOMEPRAZOLE
STRONTIUM .................. 76
estarylla ................................ 85
estazolam .............................. 30
ESTRACE ............................ 83
estradiol ................................ 83
estradiol valerate .................. 83
estradiol-norethindrone acet . 83
ESTRING ............................. 83
ESTROGEL ......................... 83
estrogens-methyltestosterone 83
estropipate ............................ 83
ESTROSTEP FE-28 ............. 85
eszopiclone ........................... 30
ethacrynate sodium ............... 36
ethacrynic acid ...................... 36
ethambutol .............................. 8
ethosuximide ........................ 18
ethyl chloride ........................ 47
ethynodiol diac-eth estradiol 86
ETHYOL .............................. 12
etidronate disodium .............. 52
etodolac ................................ 27
etoposide ............................... 14
EUCRISA ............................. 44
EUFLEXXA ......................... 27
EURAX ................................ 51
EVAMIST ............................ 83
EVEKEO .............................. 30
EVENCARE G2 ............. 56, 61
EVENCARE G3 GLUCOSE
METER ............................ 61
EVENCARE G3 TEST ........ 56
EVENCARE MINI
GLUCOSE TEST STR ..... 56
EVENCARE MINI
MONITOR SYSTEM....... 61
EVISTA ................................ 81
EVOCLIN ............................ 46
EVOLUTION BLOOD
GLUCOSE METER ......... 61
EVOLUTION NORMAL
CONTROL ....................... 61
EVOLUTION TEST STRIPS
.......................................... 56
EVOMELA .......................... 14
EVOTAZ ................................ 4
EVOXAC ............................. 52
EVZIO .................................. 27
EXALGO ER ....................... 23
EXELDERM ........................ 49
EXELON .............................. 21
exemestane ........................... 14
EXFORGE............................ 36
EXFORGE HCT................... 36
EXODERM .......................... 49
EXONDYS 51 ...................... 21
EXTAVIA ............................ 79
EXTINA ............................... 49
EXTRA-VIRT PLUS DHA 100
EYLEA ................................. 89
EZ SMART PLUS SYSTEM
.......................................... 61
EZ SMART PLUS TEST ..... 56
EZ SMART SYSTEM .......... 61
EZ SMART TEST ................ 56
ezetimibe ............................... 40
ezetimibe-simvastatin ........... 40
F FABIOR ............................... 46
FABRAZYME ..................... 68
FACTIVE ............................. 10
falmina (28) .......................... 86
famciclovir .............................. 4
famotidine ............................. 76
famotidine (pf) ...................... 76
famotidine (pf)-nacl (iso-os) 76
FAMOTIDINE IN 0.9 %
NACL ............................... 76
FANAPT ............................... 30
FARESTON ......................... 14
FARXIGA ............................ 69
FARYDAK ........................... 14
FASENRA ............................ 95
FASLODEX ......................... 14
fayosim ................................. 86
FAZACLO ............................ 30
FC2 FEMALE CONDOM ... 82
FEIBA NF ............................ 39
felbamate .............................. 18
FELBATOL .......................... 18
FELDENE ............................ 27
felodipine .............................. 36
fem ph ................................... 84
FEMARA ............................. 14
FEMCAP .............................. 83
FEMHRT LOW DOSE ........ 83
FEMRING ............................ 83
femynor ................................. 86
fenofibrate ............................. 40
FENOFIBRATE ................... 40
fenofibrate micronized .......... 40
fenofibrate nanocrystallized . 40
fenofibric acid ....................... 40
fenofibric acid (choline) ....... 41
FENOGLIDE ........................ 41
fenoprofen ............................. 27
FENOPROFEN .................... 27
FENORTHO ......................... 27
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affiliated companies.
119
fentanyl ................................. 23
FENTANYL (PF)-
BUPIVACAINE-NACL... 23
fentanyl citrate ...................... 23
fentanyl citrate (pf) ............... 23
FENTANYL CITRATE (PF)
.......................................... 23
fentanyl citrate (pf)-0.9%nacl
.......................................... 23
FENTANYL CITRATE (PF)-
0.9%NACL ....................... 23
FENTANYL-
ROPIVACAINE-NACL
(PF) ................................... 23
FENTORA ........................... 23
FERIVA 21-7 TABLET ..... 100
ferocon ................................ 100
FERRALET 90 DUAL-IRON
DELIVERY .................... 100
ferraplus 90 ......................... 100
FERRLECIT......................... 52
ferrocite plus ....................... 100
FETZIMA ............................ 30
FEXMID .............................. 22
FIASP FLEXTOUCH U-100
INSULIN .......................... 66
FIASP U-100 INSULIN ....... 66
FIBRICOR ........................... 41
FIBRYGA ............................ 39
FIFTY50 TEST STRIP ........ 56
FINACEA ............................ 46
finasteride ............................. 97
FIORICET ............................ 23
FIORINAL ........................... 23
FIORINAL-CODEINE #3 ... 23
FIRAZYR ............................. 95
FIRMAGON KIT W
DILUENT SYRINGE ...... 14
FIRVANQ ............................ 11
FLAGYL ................................ 8
FLAREX .............................. 91
flavoxate ............................... 97
FLEBOGAMMA DIF .......... 80
flecainide .............................. 34
FLECTOR ............................ 27
fleet laxative ......................... 73
FLOLAN .............................. 36
FLOLIPID ............................ 41
FLOMAX ............................. 97
FLORIVA ........................... 100
FLORIVA (FLUORIDE-
VITAMIN D3) ............... 100
FLORIVA PLUS ................ 100
FLORIVA PLUS (WITH
BIOTIN) ......................... 100
FLOVENT DISKUS ............ 95
FLOVENT HFA ................... 95
floxuridine ............................ 14
flucaine ................................. 89
fluconazole ............................. 3
fluconazole in dextrose(iso-o) 3
fluconazole in nacl (iso-osm) . 3
flucytosine .............................. 3
fludarabine ............................ 14
fludrocortisone...................... 55
FLUMADINE ........................ 4
flumazenil ............................. 30
flunisolide ............................. 95
fluocinolone .......................... 50
fluocinolone acetonide oil .... 54
fluocinolone and shower cap 50
fluocinonide .......................... 50
fluocinonide-emollient ......... 50
FLUORABON.................... 100
fluorescein-proparacaine ...... 89
fluoride (sodium) ................ 100
FLUORIDEX DAILY
DEFENSE ........................ 53
fluoritab .............................. 100
fluorometholone ................... 91
FLUOROPLEX .................... 44
fluorouracil ..................... 14, 44
FLUOROURACIL ............... 44
fluoxetine .............................. 30
fluphenazine decanoate ........ 30
fluphenazine hcl ................... 30
FLURA-DROPS ................. 101
flurandrenolide ..................... 50
flurazepam ............................ 30
flurbiprofen ........................... 27
flurbiprofen sodium .............. 90
flutamide ............................... 14
fluticasone ...................... 50, 95
FLUTICASONE-
SALMETEROL................ 95
fluvastatin ............................. 41
fluvoxamine .......................... 30
FML FORTE ........................ 91
FML LIQUIFILM ................ 91
FML S.O.P. ........................... 91
FOCALIN ............................. 30
FOCALIN XR ...................... 30
folbee .................................. 101
folbee plus .......................... 101
FOLET ONE ...................... 101
FOLGARD OS ................... 101
FOLGARD RX ................... 101
folic acid ............................. 101
folic acid-vit b6-vit b12 ...... 101
folivane-f ............................ 101
folivane-ob .......................... 101
folivane-plus ....................... 101
FOLOTYN ........................... 14
folplex 2.2 ........................... 101
foltabs 800 .......................... 101
FOLTRATE ........................ 101
fondaparinux ......................... 39
FORA D10 ............................ 61
FORA D15G ......................... 56
FORA D20 ...................... 57, 61
FORA D40-G31 TEST
STRIPS ............................. 57
FORA G20 ...................... 57, 61
FORA G30A ......................... 62
FORA G30-PREMIUM V10
TEST STRP ...................... 57
FORA GD50 BLOOD
GLUCOSE SYSTEM ....... 62
FORA GD50 TEST STRIPS 57
FORA NORMAL CONTROL
.......................................... 62
FORA PREMIUM V10
GLUCOSE METER ......... 62
FORA TEST N'GO VOICE
METER ............................. 62
FORA TEST STRIP ............. 57
FORA TN'G VOICE METER
.......................................... 62
FORA TN'G VOICE TEST
STRIPS ............................. 57
FORA V10 ...................... 57, 62
FORA V10-V12-D10-D20
STRIPS ............................. 57
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affiliated companies.
120
FORA V12 BLOOD
GLUCOSE SYSTEM ....... 62
FORA V12 GLUCOSE ........ 57
FORA V20 ..................... 57, 62
FORA V30A ........................ 62
FORACARE GD20 .............. 57
FORACARE GD20
GLUCOSE METER ......... 62
FORACARE GD40 .............. 57
FORACARE GD40A
GLUCOSE METER ......... 62
FORACARE GD40B
GLUCOSE METER ......... 62
FORACARE GDH LOW
CONTROL ....................... 62
FORFIVO XL ...................... 30
FORTAMET ........................ 69
FORTAVIT .......................... 99
FORTEO .............................. 81
FORTESTA .......................... 68
FORTISCARE BLOOD
GLUCOSE SYST ............. 62
FORTISCARE GLUCOSE
TEST STRIPS .................. 57
FORTISCARE NORMAL ... 62
FOSAMAX .......................... 81
FOSAMAX PLUS D ............ 81
fosamprenavir ......................... 4
FOSCAVIR ............................ 4
fosinopril .............................. 36
fosinopril-hydrochlorothiazide
.......................................... 36
fosphenytoin ......................... 18
FOSRENOL ......................... 73
FRAGMIN ........................... 39
FREESTYLE CONTROL .... 62
FREESTYLE FLASH
SYSTEM .......................... 62
FREESTYLE FREEDOM ... 62
FREESTYLE FREEDOM
LITE ................................. 62
FREESTYLE INSULINX ... 57,
62
FREESTYLE INSULINX
TEST STRIPS .................. 57
FREESTYLE LIBRE
READER .......................... 62
FREESTYLE LIBRE
SENSOR ........................... 62
FREESTYLE LITE METER 62
FREESTYLE LITE STRIPS 57
FREESTYLE PRECISION
NEO METER ................... 62
FREESTYLE PRECISION
NEO STRIPS .................... 57
FREESTYLE SIDEKICK II 62
FREESTYLE SYSTEM KIT 62
FREESTYLE TEST ............. 57
FROTEK .............................. 27
frovatriptan ........................... 20
full spectrum b-vitamin c ... 101
FURADANTIN .................... 11
furosemide ............................ 36
FUROSEMIDE IN 0.9 %
NACL ............................... 36
FUSILEV.............................. 12
FUSION PLUS ................... 101
FUSION SPRINKLES ....... 101
FUZEON ................................ 4
fyavolv .................................. 83
FYCOMPA ........................... 18
G g tussin ac ............................. 93
gabapentin ............................ 18
GABITRIL ........................... 18
galantamine .......................... 21
GAMASTAN S/D ................ 80
GAMMAGARD LIQUID .... 80
GAMMAGARD S-D (IGA < 1
MCG/ML) ........................ 80
GAMMAKED ...................... 80
GAMMAPLEX .................... 80
GAMMAPLEX (WITH
SORBITOL) ..................... 80
GAMUNEX-C...................... 80
GANCICLOVIR .................... 4
ganciclovir sodium ................. 4
GASTROCROM .................. 73
gatifloxacin ........................... 88
GATIFLOXACIN-
DEXAMETHASONE ...... 91
GATTEX 30-VIAL .............. 73
gavilax .................................. 73
gavilyte-c .............................. 73
gavilyte-g .............................. 73
gavilyte-n .............................. 73
GAZYVA ............................. 14
GE100 BLOOD GLUCOSE
SYSTEM .......................... 62
GE100 BLOOD GLUCOSE
TEST STRIP ..................... 57
GE100 CONTROL
SOLUTION NORMAL .... 62
GELCLAIR .......................... 53
GELNIQUE .......................... 97
gemcitabine ........................... 14
GEMCITABINE ................... 14
gemfibrozil ........................... 41
GEMZAR ............................. 14
GENERESS FE .................... 86
generlac ................................. 73
gengraf .................................. 14
GENOTROPIN ..................... 78
GENOTROPIN MINIQUICK
.......................................... 78
GENSTRIP TEST STRIP ..... 57
gentak ................................... 88
gentamicin .................. 8, 48, 88
gentamicin in nacl (iso-osm) .. 8
GENTAMICIN IN NACL
(ISO-OSM) ......................... 8
gentamicin sulfate (ped) (pf) .. 8
gentamicin sulfate (pf) ............ 8
GENTAMICIN SULFATE
(PF) ..................................... 8
GENTAMICIN-SODIUM
CITRATE ........................... 8
gentle laxative ....................... 73
gentlelax ............................... 73
GENVOYA ............................ 4
GEODON ............................. 30
GIALAX ............................... 73
gianvi (28) ............................ 86
GIAPREZA .......................... 42
GIAZO .................................. 73
GILENYA ............................ 79
GILOTRIF ............................ 14
GLASSIA ............................. 52
glatiramer .............................. 79
glatopa .................................. 79
GLEEVEC ............................ 14
GLEOSTINE ........................ 14
GLIADEL WAFER .............. 14
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affiliated companies.
121
glimepiride ........................... 69
glipizide ................................ 69
glipizide-metformin .............. 69
GLUCAGEN DIAGNOSTIC
KIT ................................... 59
GLUCAGEN HYPOKIT ..... 59
GLUCAGON EMERGENCY
KIT (HUMAN) ................ 59
GLUCAGON HCL .............. 59
GLUCO NAVII GLUCOSE
MONITOR ....................... 62
GLUCO NAVII TEST STRIP
.......................................... 57
GLUCOCARD 01 METER . 62
GLUCOCARD 01 NORMAL
CONTROL ....................... 62
GLUCOCARD 01 SENSOR
PLUS ................................ 57
GLUCOCARD EXPRESSION
.................................... 57, 62
GLUCOCARD SHINE
METER ............................ 62
GLUCOCARD SHINE TEST
STRIPS ............................. 57
GLUCOCARD SHINE XL
METER ............................ 63
GLUCOCARD VITAL ........ 63
GLUCOCARD VITAL
SENSOR .......................... 57
GLUCOCARD VITAL TEST
STRIPS ............................. 57
GLUCOCOM BLOOD
GLUCOSE ....................... 63
GLUCOCOM CONTROL
NORMAL ........................ 63
GLUCOCOM GLUCOSE ... 57
GLUCOPHAGE ................... 69
GLUCOPHAGE XR ............ 69
GLUCOSE CONTROL........ 63
GLUCOTROL ...................... 69
GLUCOTROL XL ............... 69
GLUCOVANCE .................. 69
GLUMETZA ........................ 69
glyburide............................... 69
glyburide micronized............ 69
glyburide-metformin ............ 69
glycolax ................................ 73
glycopyrrolate....................... 71
GLYCOPYRROLATE ......... 71
glydo ..................................... 47
GLYNASE ........................... 70
GLYSET ............................... 70
GLYXAMBI ........................ 70
GM100............................ 57, 63
GOCOVRI ............................ 20
GOLYTELY ......................... 73
GONITRO ............................ 42
GRALISE ............................. 18
GRALISE 30-DAY STARTER
PACK ............................... 18
granisetron hcl ...................... 73
GRANIX .............................. 78
griseofulvin microsize ............ 3
griseofulvin ultramicrosize ..... 3
guaiatussin ac ....................... 93
guaifenesin ac ....................... 93
guaifenesin dac ..................... 93
guanfacine ...................... 30, 36
guanidine .............................. 30
GYNAZOLE-1 ..................... 84
gynol ii .................................. 84
H HAEGARDA........................ 95
HALAVEN ........................... 14
HALCION ............................ 30
HALDOL.............................. 30
HALDOL DECANOATE .... 30
halobetasol propionate .......... 50
HALOG ................................ 50
haloperidol ............................ 30
haloperidol decanoate ........... 30
haloperidol lactate ................ 30
HARVONI.............................. 4
HAVRIX (PF) ...................... 80
HEALTHPRO GLUCOSE
MONITOR ....................... 63
HEALTHPRO HIGH-LOW
CONTROL ....................... 63
HEALTHPRO TEST STRIPS
.......................................... 57
healthylax ............................. 73
heather .................................. 83
HECTOROL ......................... 68
HELIXATE FS ..................... 39
HEMANGEOL ..................... 36
hematinic plus vit/minerals 101
hematinic/folic acid ............ 101
hematogen ........................... 101
hematogen fa ...................... 101
hematogen forte .................. 101
HEMATRON-AF ............... 101
hemenatal ob ....................... 101
hemenatal ob + dha ............. 101
hemetab ............................... 101
HEMLIBRA ......................... 39
hemmorex-hc ........................ 73
HEMOCYTE-F .................. 101
HEMOCYTE-PLUS ........... 101
HEMOFIL M HIGH ............. 39
HEMOFIL M LOW .............. 39
HEMOFIL M MID ............... 39
HEMOFIL M SUPER HIGH39
hep flush-10 (pf) ................... 39
HEPAGAM B ....................... 80
heparin (porcine) .................. 39
HEPARIN (PORCINE) IN
0.9% NACL ...................... 39
heparin (porcine) in 5 % dex 39
heparin (porcine) in nacl (pf) 39
heparin flush(porcine)-0.9nacl
.......................................... 39
heparin lock flush ................. 39
heparin lock flush (porcine) .. 39
heparin lockflush(porcine)(pf)
.......................................... 39
HEPARIN(PORCINE) IN
0.45% NACL .................... 39
heparin, porcine (pf) ............. 39
HEPLISAV-B ....................... 80
HEPSERA .............................. 4
HERCEPTIN ........................ 14
HETLIOZ ............................. 30
HEXALEN ........................... 14
HIBERIX (PF) ...................... 80
hi-cal plus vit d ..................... 98
HIPREX ................................ 11
HISTEX-AC ......................... 93
HIZENTRA .......................... 80
homatropaire ......................... 89
homatropine hbr .................... 89
HORIZANT .......................... 21
hpr ......................................... 44
hpr plus ................................. 44
hpr plus hydrogel .................. 44
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affiliated companies.
122
HPR PLUS-MB HYDROGEL
.......................................... 44
HUMALOG JUNIOR
KWIKPEN U-100 ............ 66
HUMALOG KWIKPEN
INSULIN .......................... 66
HUMALOG MIX 50-50
INSULN U-100 ................ 66
HUMALOG MIX 50-50
KWIKPEN ....................... 66
HUMALOG MIX 75-25
KWIKPEN ....................... 66
HUMALOG MIX 75-25(U-
100)INSULN .................... 66
HUMALOG U-100 INSULIN
.......................................... 66
HUMAPEN LUXURA HD .. 63
HUMATE-P ......................... 39
HUMATROPE ..................... 78
HUMIRA .............................. 81
HUMIRA PEDIATRIC
CROHN'S START ........... 82
HUMIRA PEN ..................... 82
HUMIRA PEN CROHN'S-
UC-HS START ................ 82
HUMIRA PEN PSORIASIS-
UVEITIS .......................... 82
HUMULIN 70/30 U-100
INSULIN .......................... 66
HUMULIN 70/30 U-100
KWIKPEN ....................... 66
HUMULIN N NPH INSULIN
KWIKPEN ....................... 66
HUMULIN N NPH U-100
INSULIN .......................... 66
HUMULIN R REGULAR U-
100 INSULN .................... 66
HUMULIN R U-500 (CONC)
INSULIN .......................... 66
HUMULIN R U-500 (CONC)
KWIKPEN ....................... 66
HYCAMTIN ........................ 14
hydralazine ........................... 36
HYDREA ............................. 14
HYDRO 35 ........................... 44
HYDRO 40 ........................... 44
hydrochlorothiazide .............. 36
hydrocodone-acetaminophen 23
hydrocodone-chlorpheniramine
.......................................... 93
hydrocodone-cpm-
pseudoephed ..................... 93
hydrocodone-homatropine .... 93
hydrocodone-ibuprofen ........ 23
hydrocortisone .......... 50, 55, 73
hydrocortisone acetate .......... 74
hydrocortisone butyrate ........ 50
hydrocortisone butyr-emollient
.......................................... 50
hydrocortisone valerate ........ 50
hydrocortisone-acetic acid .... 54
hydrocortisone-iodoquinol-aloe
.......................................... 48
hydrocortisone-min oil-wht pet
.......................................... 50
hydrocortisone-pramoxine... 42,
74
hydromet ............................... 93
hydromorphone .................... 24
HYDROMORPHONE ......... 24
hydromorphone in 0.9 % nacl
.......................................... 24
HYDROMORPHONE IN 0.9
% NACL ........................... 24
hydroxychloroquine................ 8
hydroxyprogesterone caproate
.......................................... 83
hydroxyurea .......................... 14
hydroxyzine hcl .................... 92
hydroxyzine pamoate ........... 92
HYLATOPIC ....................... 44
HYLATOPICPLUS.............. 44
hyolev mb ............................. 97
hyophen ................................ 97
hyoscyamine sulfate ............. 71
hyosyne ................................. 71
HYPERHEP B S/D .............. 80
HYPERHEP B S-D
NEONATAL .................... 80
HYPERRAB (PF)................. 80
HYPERRAB S/D (PF) ......... 80
HYPER-SAL ........................ 95
HYPERTET S/D (PF) .......... 80
HYQVIA .............................. 80
HYSINGLA ER ................... 24
HYZAAR ............................. 36
I ibandronate ........................... 81
IBRANCE ............................. 14
ibu ......................................... 27
IBUDONE ............................ 24
ibuprofen ............................... 27
ibuprofen-oxycodone ............ 24
ic green ................................. 52
ICAR-C PLUS .................... 101
ICLUSIG .............................. 14
IDAMYCIN PFS .................. 14
idarubicin .............................. 14
IDELVION ........................... 39
IDHIFA ................................. 14
IFEX ..................................... 14
ifosfamide ............................. 14
ifosfamide-mesna ................. 14
IGLUCOSE BLOOD
GLUCOSE MONITOR .... 63
IGLUCOSE TEST STRIP .... 57
ILARIS (PF) ......................... 79
ILEVRO ............................... 90
ILUVIEN .............................. 91
imatinib ................................. 14
IMBRUVICA ....................... 15
IMFINZI ............................... 15
imipenem-cilastatin ................ 8
imipramine hcl ...................... 30
imipramine pamoate ............. 30
imiquimod ............................. 79
IMITREX ............................. 20
IMITREX STATDOSE KIT
REFILL ............................. 20
IMITREX STATDOSE PEN 20
IMLYGIC ............................. 15
IMOGAM RABIES-HT (PF)
.......................................... 80
IMPAVIDO ............................ 8
IMPOYZ ............................... 50
IMURAN .............................. 15
IMVEXXY ........................... 83
INCRELEX .......................... 52
INCRUSE ELLIPTA ............ 95
indapamide ........................... 36
INDERAL LA ...................... 36
INDERAL XL ...................... 36
INDIOMIN MB .................... 97
INDOCIN ............................. 27
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affiliated companies.
123
indocyanine green ................ 52
indomethacin ........................ 27
INFANRIX (DTAP) (PF) .... 80
INFASURF .......................... 52
INFINITY CONTROL
SOLUTION NORM ......... 63
INFINITY STARTER KIT .. 63
INFINITY TEST STRIPS .... 57
INFINITY VOICE CTRL
SOLN-LVL 2 ................... 63
INFINITY VOICE GLUCOSE
MONITOR ....................... 63
INFINITY VOICE TEST
STRIP ............................... 57
INFLECTRA ........................ 74
INFUVITE ADULT ........... 101
INFUVITE PEDIATRIC.... 101
INGREZZA .......................... 21
INJECTAFER .................... 101
INLYTA ............................... 15
INNOPRAN XL ................... 36
INOVA ................................. 46
INOVA 4-1 ........................... 43
INSPRA ................................ 36
INSULIN SYRINGE-
NEEDLE U-100 ............... 59
INTEGRA F ....................... 101
INTEGRA PLUS ............... 101
INTELENCE .......................... 4
INTERMEZZO .................... 30
INTRAROSA ....................... 84
INTRON A ........................... 79
introvale ................................ 86
INTUNIV ER ....................... 31
INVANZ................................. 8
INVEGA............................... 31
INVIRASE ............................. 4
INVOKAMET ...................... 70
INVOKAMET XR ............... 70
INVOKANA ........................ 70
iodoquinol-hc ....................... 48
IOPIDINE............................. 92
ipratropium bromide ....... 53, 95
ipratropium-albuterol ........... 95
IPRIVASK ........................... 39
irbesartan .............................. 36
irbesartan-hydrochlorothiazide
.......................................... 36
IRESSA ................................ 15
irinotecan .............................. 15
IROSPAN 24/6 ................... 101
ISENTRESS ........................... 4
ISENTRESS HD .................... 4
isibloom ................................ 86
ISOCHRON.......................... 42
ISOLYTE-S .......................... 99
isometh-dichloral-
acetaminophn.................... 20
isomethepten-caf-
acetaminophen .................. 20
isoniazid.................................. 8
ISOPTO CARPINE .............. 89
ISORDIL .............................. 42
ISORDIL TITRADOSE ....... 42
isosorbide dinitrate ............... 42
isosorbide mononitrate ......... 42
isotretinoin ............................ 46
isoxsuprine............................ 84
isradipine .............................. 36
ISTALOL ............................. 89
ISTODAX ............................ 15
itraconazole ............................ 3
ivermectin ............................... 8
IXEMPRA ............................ 15
IXINITY ............................... 39
J JAKAFI ................................ 15
JALYN ................................. 97
jantoven ................................ 39
JANUMET ........................... 70
JANUMET XR ..................... 70
JANUVIA ............................. 70
JARDIANCE ........................ 70
JAZZ WIRELESS 2 METER
KIT ................................... 63
jencycla ................................. 83
JENTADUETO .................... 70
JENTADUETO XR .............. 70
JETREA (PF) ....................... 89
jevantique lo ......................... 83
JEVTANA ............................ 15
jinteli ..................................... 83
jolessa ................................... 86
jolivette ................................. 83
JUBLIA ................................ 49
juleber ................................... 86
JULUCA ................................. 4
junel 1.5/30 (21) ................... 86
junel 1/20 (21) ...................... 86
junel fe 1.5/30 (28) ............... 86
junel fe 1/20 (28) .................. 86
junel fe 24 ............................. 86
JUXTAPID ........................... 41
JYNARQUE ......................... 68
K KADCYLA ........................... 15
KADIAN .............................. 24
kaitlib fe ................................ 86
KALBITOR .......................... 95
KALETRA ............................. 4
KALYDECO ........................ 95
KANUMA ............................ 68
KAPVAY ............................. 31
KARBINAL ER ................... 92
kariva (28) ............................ 86
KAZANO ............................. 70
KEFLEX ................................. 6
kelnor 1/35 (28) .................... 86
kelnor 1-50 ............................ 86
KENALOG ..................... 50, 55
KEPIVANCE ....................... 12
KEPPRA ............................... 18
KEPPRA XR ........................ 18
KERAFOAM ........................ 44
KERALAC ........................... 44
KERALYT RX ..................... 43
KERYDIN ............................ 49
ketoconazole ..................... 3, 49
ketoprofen ............................. 27
ketorolac ......................... 27, 90
KEVEYIS ............................. 21
KEVZARA ........................... 82
KHEDEZLA ......................... 31
kimidess (28) ........................ 86
KINERET ............................. 79
KINRIX (PF) ........................ 80
kionex ................................... 74
kionex (with sorbitol) ........... 74
KISQALI .............................. 15
KISQALI FEMARA CO-
PACK ............................... 15
KIT FOR TC 99M-
SESTAMIBI NO.1 ........... 52
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affiliated companies.
124
KIT PREP OF TC-99M-
MEBROFENIN ................ 52
KIT PREP OF TC-99M-SOD
PYROPH .......................... 52
KITABIS PAK ....................... 8
KLARON ............................. 48
KLONOPIN ......................... 18
KOATE ................................ 39
kobee .................................. 101
KOGENATE FS ................... 39
KOMBIGLYZE XR ............. 70
KORLYM ............................ 68
KOSHER PRENATAL PLUS
IRON .............................. 101
KOVALTRY ........................ 39
K-PHOS NO 2 ...................... 97
K-PHOS ORIGINAL ........... 97
k-phos-neutral....................... 98
kpn ...................................... 101
KRISTALOSE ..................... 74
KRYSTEXXA ...................... 81
kurvelo .................................. 86
KUVAN ............................... 68
KYLEENA ........................... 83
KYMRIAH ........................... 15
KYNAMRO ......................... 41
KYPROLIS .......................... 15
L l norgest/e.estradiol-e.estrad . 86
labetalol ................................ 36
LABETALOL ...................... 36
LACRISERT ........................ 90
lactated ringers ..................... 51
lactulose ................................ 74
LAMICTAL ......................... 18
LAMICTAL ODT ................ 18
LAMICTAL ODT STARTER
(BLUE) ............................. 18
LAMICTAL ODT STARTER
(GREEN) .......................... 18
LAMICTAL ODT STARTER
(ORANGE)....................... 18
LAMICTAL STARTER
(BLUE) KIT ..................... 18
LAMICTAL STARTER
(GREEN) KIT .................. 18
LAMICTAL STARTER
(ORANGE) KIT ............... 18
LAMICTAL XR ................... 18
LAMICTAL XR STARTER
(BLUE) ............................. 18
LAMICTAL XR STARTER
(GREEN) .......................... 18
LAMICTAL XR STARTER
(ORANGE) ....................... 18
lamivudine .............................. 4
lamivudine-zidovudine ........... 4
lamotrigine............................ 18
LANCETS ............................ 63
LANCING DEVICE ............ 63
LANOXIN ............................ 38
LANOXIN PEDIATRIC ...... 38
lansoprazole .......................... 76
lanthanum ............................. 74
LANTUS SOLOSTAR U-100
INSULIN .......................... 66
LANTUS U-100 INSULIN .. 66
larin 1.5/30 (21) .................... 86
larin 1/20 (21) ....................... 86
larin 24 fe.............................. 86
larin fe 1.5/30 (28) ................ 86
larin fe 1/20 (28) ................... 86
larissia ................................... 86
LARTRUVO ........................ 15
LASIX .................................. 36
LASTACAFT ....................... 90
latanoprost ............................ 90
LATUDA.............................. 31
laxaclear................................ 74
laxative (bisacodyl) .............. 74
laxative feminine .................. 74
laxative peg 3350.................. 74
layolis fe ............................... 86
LAZANDA ........................... 24
LDO PLUS ........................... 47
leena 28................................. 86
leflunomide ........................... 82
LEMTRADA ........................ 79
LENVIMA............................ 15
LESCOL XL......................... 41
lessina ................................... 86
LETAIRIS ............................ 95
letrozole ................................ 15
leucovorin calcium ............... 12
LEUKERAN ........................ 15
LEUKINE ............................. 78
leuprolide .............................. 15
LEVA SET ........................... 47
levalbuterol hcl ..................... 95
LEVALBUTEROL
TARTRATE ..................... 95
LEVAQUIN ......................... 10
LEVATOL ............................ 36
LEVBID ............................... 71
LEVEMIR FLEXTOUCH U-
100 INSULN .................... 66
LEVEMIR U-100 INSULIN 66
levetiracetam ......................... 19
levetiracetam in nacl (iso-os) 19
LEVICYN ANTIPRURITIC 44
LEVICYN ANTIPRURITIC
SG ..................................... 44
levobunolol ........................... 89
levocarnitine ......................... 52
levocarnitine (with sugar) ..... 52
levofloxacin .................... 10, 88
levofloxacin in d5w .............. 10
levoleucovorin ...................... 12
LEVOLEUCOVORIN ......... 12
levonest (28) ......................... 86
levonorgestrel-ethinyl estrad 86
levonorg-eth estrad triphasic 86
levora-28 ............................... 86
levorphanol tartrate ............... 24
LEVO-T ................................ 71
levothyroxine ........................ 71
LEVOTHYROXINE ............ 71
levoxyl .................................. 71
LEVSIN ................................ 72
LEVSIN/SL .......................... 72
LEVULAN ........................... 44
LEXAPRO ............................ 31
LEXIVA ................................. 4
LEXIXRYL .......................... 27
LIALDA ............................... 74
LIBRAX (WITH
CLIDINIUM) ................... 72
lidocaine ............................... 48
lidocaine (pf) ........................ 47
LIDOCAINE (PF) ................ 47
lidocaine hcl .......................... 47
LIDOCAINE HCL ............... 47
lidocaine hcl-hydrocortison ac
.................................... 48, 74
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affiliated companies.
125
lidocaine viscous .................. 48
lidocaine-prilocaine .............. 48
LIDOCAINE-TETRACAINE
.......................................... 48
LIDOCAN-PHENYLEPH-
BSS NO.2(PF) .................. 90
LIDODERM ......................... 48
LIDOPAC ............................ 48
lidopin .................................. 48
LIDOPIN .............................. 48
LIDO-PRILO CAINE PACK
.......................................... 48
LIDORX ............................... 48
LIDOTRAL .......................... 48
lidozion ................................. 48
LIDTOPIC MAX ................. 48
LILETTA ............................. 83
lillow .................................... 86
LINCOCIN ............................. 8
lincomycin .............................. 8
lindane .................................. 51
linezolid .................................. 8
linezolid in dextrose 5% ......... 8
LINZESS .............................. 74
liothyronine .......................... 71
LIPITOR .............................. 41
LIPOCHOL PLUS ............... 52
lipodox .................................. 15
lipodox 50 ............................. 15
LIPOFEN ............................. 41
LIPROZONEPAK ................ 48
lisinopril ............................... 36
lisinopril-hydrochlorothiazide
.......................................... 36
lite coat aspirin ..................... 27
lithium carbonate .................. 31
lithium citrate ....................... 31
LITHOBID ........................... 31
LITHOSTAT ........................ 52
LIVALO ............................... 41
LO LOESTRIN FE .............. 86
LOCOID ............................... 50
LOCOID LIPOCREAM ....... 50
LODINE ............................... 27
LODOSYN ........................... 20
LOESTRIN 1.5/30 (21) ........ 86
LOESTRIN 1/20 (21) ........... 86
LOESTRIN FE 1.5/30 (28-
DAY) ................................ 86
LOESTRIN FE 1/20 (28-DAY)
.......................................... 86
LOMOTIL ............................ 72
LONHALA MAGNAIR
REFILL ............................ 95
LONHALA MAGNAIR
STARTER ........................ 95
LONSURF ............................ 15
LOPID .................................. 41
lopinavir-ritonavir .................. 4
lopreeza ................................ 83
LOPRESSOR ....................... 36
LOPROX .............................. 49
LOPROX (AS OLAMINE) .. 49
LOPROX KIT ...................... 49
lorazepam ............................. 31
LORAZEPAM IN 0.9% SOD
CHLORIDE ...................... 31
LORAZEPAM IN
DEXTROSE 5 % .............. 31
lorazepam intensol ................ 31
lorcet (hydrocodone) ............ 24
lorcet hd ................................ 24
lorcet plus ............................. 24
LORTAB ELIXIR ................ 24
lortuss ex............................... 93
loryna (28) ............................ 86
LORZONE ........................... 22
losartan ................................. 36
losartan-hydrochlorothiazide 37
LOSEASONIQUE................ 86
LOTEMAX .......................... 91
LOTENSIN .......................... 37
LOTENSIN HCT ................. 37
LOTREL ............................... 37
LOTRISONE ........................ 49
LOTRONEX ........................ 74
LOUTREX ........................... 44
lovastatin .............................. 41
LOVAZA.............................. 41
LOVENOX ........................... 40
low-ogestrel (28) .................. 86
loxapine succinate ................ 31
LOYON ................................ 44
lta pre-attached ..................... 48
LUCEMYRA........................ 27
LUCENTIS ........................... 90
ludent fluoride .................... 101
lugols .............................. 48, 98
LUMIGAN ........................... 90
LUMIZYME ......................... 68
LUNESTA ............................ 31
LUPANETA PACK (1
MONTH) .......................... 84
LUPANETA PACK (3
MONTH) .......................... 84
LUPRON DEPOT ................ 15
LUPRON DEPOT (3
MONTH) .......................... 15
LUPRON DEPOT (4
MONTH) .......................... 15
LUPRON DEPOT (6
MONTH) .......................... 15
LUPRON DEPOT-PED ....... 15
lutera (28) ............................. 86
luxamend .............................. 44
LUXIQ .................................. 50
LUXTURNA ........................ 90
LUZU ................................... 49
LYNPARZA ......................... 15
LYRICA ............................... 19
LYRICA CR ......................... 19
LYSODREN ......................... 15
LYSTEDA ............................ 84
lyza ....................................... 83
M m.v.i. adult .......................... 101
MACROBID ......................... 11
MACRODANTIN ................ 11
MACUGEN .......................... 90
mafenide acetate ................... 48
MAGNEBIND 400 ............... 74
magnesium citrate ................. 74
MAKENA ............................. 83
MAKENA (PF) .................... 83
MALARONE ......................... 8
MALARONE PEDIATRIC .... 8
malathion .............................. 51
maprotiline ............................ 31
MAR-COF CG ..................... 93
MARINOL ........................... 74
marlissa ................................. 86
MARNATAL-F .................. 101
MARPLAN ........................... 31
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affiliated companies.
126
MARQIBO ........................... 15
MATULANE ....................... 15
matzim la .............................. 37
MAVYRET ............................ 4
MAXALT ............................. 20
MAXALT-MLT ................... 20
MAXFE (FOLATE-
DOCUSATE) ................. 101
MAXIDEX ........................... 91
MAXIPIME ............................ 6
MAXITROL ......................... 91
MAXZIDE ........................... 37
MAXZIDE-25MG ................ 37
m-clear wc ............................ 93
meclofenamate ..................... 27
MEDISENSE ....................... 63
MEDISENSE GLUCOSE
KETONE .......................... 63
MEDOLOR PAK ................. 48
MEDROL ............................. 55
MEDROL (PAK) ................. 55
medroxyprogesterone ........... 84
mefenamic acid .................... 27
mefloquine .............................. 8
MEGACE ES ....................... 15
megestrol .............................. 15
MEKINIST ........................... 15
melodetta 24 fe ..................... 86
meloxicam ............................ 27
melphalan ............................. 15
melphalan hcl ....................... 15
memantine ............................ 21
MEMANTINE ..................... 21
MENACTRA (PF) ............... 80
M-END PE ........................... 93
MENEST .............................. 84
MENOSTAR ........................ 84
MENVEO A-C-Y-W-135-DIP
(PF) ................................... 80
meperidine ............................ 24
MEPHYTON ........................ 40
meprobamate ........................ 22
MEPRON ............................... 8
MEPSEVII ........................... 68
mercaptopurine ..................... 15
meropenem ............................. 8
MEROPENEM-0.9%
SODIUM CHLORIDE ....... 9
MERREM ............................... 9
mesalamine ........................... 74
MESALAMINE ................... 74
mesalamine with cleansing
wipe .................................. 74
mesna .................................... 12
MESNEX.............................. 12
MESTINON ......................... 22
MESTINON TIMESPAN .... 22
metadate er ........................... 31
metaproterenol ...................... 95
metaxall ................................ 22
metaxalone............................ 22
metformin ............................. 70
methadone ............................ 24
methadose ............................. 24
methamphetamine ................ 31
methazolamide ...................... 90
methenamine hippurate ........ 11
methenamine mandelate ....... 11
methen-sod phos-meth blue-
hyos .................................. 97
methimazole ......................... 55
METHITEST ........................ 68
methocarbamol ..................... 22
methotrexate sodium ............ 15
methotrexate sodium (pf) ..... 15
methoxsalen .......................... 44
methscopolamine .................. 72
methyclothiazide .................. 37
methyldopa ........................... 37
methyldopa-
hydrochlorothiazide .......... 37
methyldopate ........................ 37
METHYLIN ......................... 31
methylphenidate hcl ............. 31
METHYLPHENIDATE HCL
.......................................... 31
methylprednisolone .............. 55
methyltestosterone ................ 68
metipranolol.......................... 89
metoclopramide hcl .............. 74
metolazone............................ 37
METOPIC ............................ 44
METOPIRONE .................... 52
metoprolol succinate ............. 37
METOPROLOL SU-
HYDROCHLOROTHIAZ 37
metoprolol ta-hydrochlorothiaz
.......................................... 37
metoprolol tartrate ................ 37
metro i.v. ................................. 9
METROCREAM .................. 46
METROGEL ........................ 46
METROGEL VAGINAL ..... 84
METROLOTION ................. 46
metronidazole ............. 9, 46, 84
metronidazole in nacl (iso-os) 9
mexiletine ............................. 34
MIACALCIN ....................... 68
mibelas 24 fe ......................... 86
MICARDIS ........................... 37
MICARDIS HCT .................. 37
MICORT-HC ........................ 74
MICRO BLOOD GLUCOSE
.......................................... 57
MICRODOT BLOOD
GLUCOSE SYSTEM . 57, 63
microgestin 1.5/30 (21) ........ 86
microgestin 1/20 (21) ........... 86
MICROGESTIN 24 FE ........ 86
microgestin fe 1.5/30 (28) .... 86
microgestin fe 1/20 (28) ....... 86
MICROZIDE ........................ 37
midazolam ............................ 31
midazolam (pf) in 0.9 % nacl
.......................................... 31
MIDAZOLAM IN 0.9 % SOD
CHLORID ........................ 31
MIDAZOLAM IN
DEXTROSE 5 % .............. 31
midodrine .............................. 52
MIFEPREX .......................... 84
migergot ................................ 20
miglitol ................................. 70
miglustat ............................... 68
MIGRANAL ......................... 20
mili ........................................ 86
milk of magnesia .................. 74
milk of magnesia concentrated
.......................................... 74
millipred ............................... 55
millipred dp .......................... 55
mimvey ................................. 84
mimvey lo ............................. 84
MINASTRIN 24 FE ............. 87
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
127
MINIPRESS ......................... 37
MINITRAN .......................... 42
MINIVELLE ........................ 84
MINOCIN ............................ 11
minocycline .......................... 11
minoxidil .............................. 37
MIOCHOL-E ....................... 89
miralax .................................. 74
MIRAPEX ............................ 20
MIRAPEX ER ...................... 20
MIRCERA ............................ 78
MIRCETTE (28) .................. 87
MIRENA .............................. 83
mirtazapine ........................... 31
MIRVASO ........................... 46
misoprostol ........................... 76
MITIGARE .......................... 81
mitomycin ............................ 15
MITOSOL ............................ 90
mitoxantrone ........................ 15
M-M-R II (PF) ...................... 80
MOBIC ................................. 27
modafinil .............................. 31
moderiba ............................... 79
moderiba dose pack .............. 79
moexipril .............................. 37
moexipril-hydrochlorothiazide
.......................................... 37
mometasone .................... 50, 95
mondoxyne nl ....................... 11
MONOCLATE-P ................. 40
MONODOX ......................... 11
mono-linyah ......................... 87
mononessa (28) .................... 87
MONONINE ........................ 40
montelukast .......................... 95
MONUROL .......................... 11
morgidox .............................. 11
MORPHABOND ER ........... 24
morphine............................... 25
MORPHINE ......................... 25
morphine (pf)........................ 24
morphine (pf) in 0.9 % nacl . 25
MORPHINE (PF) IN 0.9 %
NACL ............................... 25
morphine concentrate ........... 25
MORPHINE IN 0.9 %
SODIUM CHLOR............ 25
MOTOFEN ........................... 72
MOVANTIK ........................ 74
MOVIPREP .......................... 74
MOXATAG.......................... 10
MOXEZA ............................. 88
moxifloxacin ................... 10, 88
MOXIFLOXACIN (PF)-BSS
NO.2 ................................. 88
moxifloxacin in nacl (iso-osm)
.......................................... 10
MOXIFLOXACIN IN
NACL,ISO-O(PF) ............ 88
MOZOBIL ............................ 78
MS CONTIN ........................ 25
MUGARD ............................ 53
MULTAQ ............................. 34
multigen folic ..................... 101
multigen plus ...................... 101
multi-vit with fluoride-iron 101
multi-vitamin with fluoride101,
102
multivitamins with fluoride 102
mupirocin.............................. 48
mupirocin calcium ................ 48
MUSTARGEN ..................... 16
MUTAMYCIN ..................... 16
mvc-fluoride ....................... 102
my choice ............................. 87
my way ................................. 87
MYALEPT ........................... 68
MYAMBUTOL ...................... 9
MYCOBUTIN ........................ 9
mycophenolate mofetil ......... 16
mycophenolate mofetil hcl ... 16
mycophenolate sodium ......... 16
MYDAYIS ........................... 31
MYDRIACYL ...................... 89
MYFORTIC ......................... 16
MYGLUCOHEALTH .... 57, 63
MYGLUCOHEALTH
CONTROL SOLUTION .. 63
MYLERAN .......................... 16
MYLOTARG ....................... 16
mynatal ............................... 102
mynatal advance ................. 102
mynatal plus ....................... 102
mynatal-z ............................ 102
mynate 90 plus.................... 102
mynephrocaps ..................... 102
mynephron .......................... 102
MYOBLOC .......................... 80
MYRBETRIQ ....................... 97
MYSOLINE ......................... 19
MYTESI ............................... 72
myzilra .................................. 87
N NABI-HB ............................. 80
nabumetone ........................... 27
nadolol .................................. 37
nadolol-bendroflumethiazide 37
nafcillin ................................. 10
naftifine ................................. 49
NAFTIN ............................... 49
NAGLAZYME ..................... 68
nalbuphine ............................ 27
NALFON .............................. 27
NALOCET ........................... 25
naloxone ............................... 27
naltrexone ............................. 27
NAMENDA .......................... 21
NAMENDA TITRATION
PAK .................................. 21
NAMENDA XR ................... 21
NAMZARIC ......................... 21
NAPRELAN CR .................. 27
NAPROSYN ......................... 27
naproxen ............................... 27
naproxen sodium .................. 27
naratriptan ............................. 20
NARCAN ............................. 27
NARDIL ............................... 31
NASONEX ........................... 95
NATACHEW (FE BIS-
GLYCINATE) ................ 102
NATACYN ........................... 88
NATAZIA ............................ 87
nateglinide ............................ 70
NATESTO ............................ 68
NATPARA ........................... 68
NATROBA ........................... 51
natural b-100 complex ........ 102
natura-lax .............................. 74
nature-throid ......................... 71
NAVELBINE ....................... 16
NEBUPENT ........................... 9
nebusal .................................. 95
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affiliated companies.
128
NEBUSAL ........................... 95
necon 0.5/35 (28).................. 87
necon 7/7/7 (28) ................... 87
NEEVODHA (WITH ALGAL
OIL) ................................ 102
nefazodone ........................... 31
NEOCERA ........................... 44
neomycin ................................ 9
neomycin-bacitracin-poly-hc 91
neomycin-bacitracin-
polymyxin ........................ 88
neomycin-polymyxin b-
dexameth .......................... 91
neomycin-polymyxin-
gramicidin......................... 88
neomycin-polymyxin-hc 54, 91
neo-polycin ........................... 88
neo-polycin hc ...................... 91
NEORAL .............................. 16
NEOSALUS ......................... 44
NEO-SYNALAR ................. 48
NEO-SYNALAR KIT .......... 48
nephplex rx ......................... 102
NEPHROCAPS .................. 102
NEPHROCAPS QT............ 102
NEPHRON FA ................... 102
nephro-vite rx ..................... 102
NEPTAZANE ...................... 90
NERLYNX ........................... 16
NESINA ............................... 70
NESTABS .......................... 102
NESTABS ABC ................. 102
NESTABS DHA ................ 102
NESTABS ONE ................. 102
neuac..................................... 46
NEUAC KIT ........................ 46
NEULASTA ......................... 78
NEUPOGEN ........................ 78
NEUPRO .............................. 20
NEURIN-SL ....................... 102
NEURONTIN....................... 19
NEUTEK 2TEK TEST
STRIPS ............................. 57
NEVANAC .......................... 90
nevirapine ............................... 4
newgen ............................... 102
NEXAVAR .......................... 16
NEXAVIR .......................... 102
NEXIUM ........................ 76, 77
NEXIUM IV ......................... 76
NEXIUM PACKET ............. 77
NEXPLANON...................... 84
niacin .................................... 41
NIACOR ............................... 41
NIASPAN EXTENDED-
RELEASE ........................ 41
nicardipine ............................ 37
NICODERM CQ .................. 53
nicorelief ............................... 53
nicorette ................................ 53
NICORETTE ........................ 53
nicotine ................................. 53
nicotine (polacrilex) ............. 53
NICOTROL .......................... 53
NICOTROL NS .................... 53
nifedipine .............................. 37
nikki (28) .............................. 87
NILANDRON ...................... 16
nilutamide ............................. 16
nimodipine ............................ 37
NINJACOF-XG.................... 93
NINLARO ............................ 16
NIPENT ................................ 16
NIPRIDE RTU ..................... 42
nisoldipine ............................ 37
nitro-bid ................................ 42
NITRO-DUR ........................ 42
nitrofurantoin ........................ 11
nitrofurantoin macrocrystal .. 11
nitrofurantoin monohyd/m-
cryst .................................. 11
nitroglycerin ......................... 42
NITROLINGUAL ................ 42
NITROMIST ........................ 42
NITROSTAT ........................ 42
nitro-time .............................. 42
NITYR .................................. 52
NIVA-PLUS ....................... 102
nivatopic plus ....................... 44
nizatidine .............................. 77
NIZORAL ............................ 49
NOCTIVA ............................ 68
nolix ...................................... 50
nora-be .................................. 84
NORCO ................................ 25
NORDITROPIN FLEXPRO 78
noreth-ethinyl estradiol-iron . 87
norethindrone (contraceptive)
.......................................... 84
norethindrone acetate ............ 84
norethindrone ac-eth estradiol
.................................... 84, 87
norethindrone-e.estradiol-iron
.......................................... 87
norgestimate-ethinyl estradiol
.......................................... 87
NORITATE .......................... 46
norlyda .................................. 84
norlyroc ................................. 84
NORPACE ........................... 34
NORPACE CR ..................... 34
NORPRAMIN ...................... 31
NORTHERA ........................ 52
nortrel 0.5/35 (28) ................. 87
nortrel 1/35 (21) .................... 87
nortrel 1/35 (28) .................... 87
nortrel 7/7/7 (28) ................... 87
nortriptyline .......................... 31
NORVASC ........................... 37
NORVIR ............................. 4, 5
NOVA MAX BLOOD
GLUCOSE METER ......... 63
NOVA MAX GLUCOSE
CONTROL ....................... 63
NOVA MAX GLUCOSE
TEST ................................. 57
NOVAMAX PLUS GLU-KET
.......................................... 63
NOVOEIGHT ....................... 40
NOVOLOG FLEXPEN U-100
INSULIN .......................... 67
NOVOLOG MIX 70-30 U-100
INSULN ........................... 67
NOVOLOG MIX 70-
30FLEXPEN U-100 ......... 67
NOVOLOG PENFILL U-100
INSULIN .......................... 67
NOVOLOG U-100 INSULIN
ASPART ........................... 67
NOVOPEN ECHO ............... 63
NOVOSEVEN RT ................ 40
NOXAFIL ............................... 3
np thyroid .............................. 71
NPLATE ............................... 40
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affiliated companies.
129
NUCALA ............................. 95
NUCYNTA .......................... 28
NUCYNTA ER .................... 28
NUEDEXTA ........................ 21
NULEV ................................ 72
NULOJIX ............................. 16
NULYTELY WITH FLAVOR
PACKS ............................. 74
NUMBONEX ....................... 48
NUOX .................................. 46
NUPLAZID .......................... 31
NUTRASEB ......................... 44
NUTRESTORE .................... 52
NUTRICAP ........................ 102
NUTROPIN AQ NUSPIN ... 78
NUVARING......................... 84
NUVESSA ........................... 84
NUVIGIL ............................. 31
NUWIQ ................................ 40
nyamyc ................................. 49
NYMALIZE ......................... 37
nystatin ............................. 3, 49
nystatin-triamcinolone .......... 49
nystop ................................... 49
O OB COMPLETE GOLD .... 102
OB COMPLETE ONE ....... 102
OB COMPLETE PETITE .. 102
OB COMPLETE PREMIER
........................................ 102
OB COMPLETE WITH DHA
........................................ 102
OBIZUR ............................... 40
OBREDON .......................... 93
obstetrix dha ....................... 102
OBSTETRIX EC ................ 102
OBSTETRIX ONE ............. 102
OBTREX DHA .................. 102
O-CAL FA ......................... 102
O-CAL PRENATAL .......... 102
OCALIVA ............................ 74
ocella .................................... 87
OCREVUS ........................... 79
OCTAGAM .......................... 80
octreotide acetate .................. 16
OCUFLOX ........................... 88
ODEFSEY .............................. 5
ODOMZO ............................ 16
OFEV.................................... 95
ofloxacin ................... 10, 54, 88
ogestrel (28) .......................... 87
olanzapine ....................... 31, 32
olanzapine-fluoxetine ........... 32
olmesartan ............................ 37
olmesartan-amlodipin-
hcthiazid ........................... 37
olmesartan-
hydrochlorothiazide .......... 37
olopatadine ..................... 53, 90
OLUMIANT ......................... 82
OLUX ................................... 50
OLUX-E ............................... 50
OMECLAMOX-PAK .......... 77
omega-3 acid ethyl esters ..... 41
omeppi .................................. 77
omeprazole ........................... 77
omeprazole-sodium
bicarbonate ....................... 77
OMIDRIA ............................ 90
OMNARIS............................ 95
OMNIPRED ......................... 91
OMNITROPE ....................... 78
ON CALL EXPRESS
CONTROL ....................... 63
ON CALL EXPRESS METER
.......................................... 63
ON CALL EXPRESS TEST
STRIP ............................... 58
ON CALL PLUS CONTROL
.......................................... 63
ON CALL PLUS METER ... 63
ON CALL PLUS TEST STRIP
.......................................... 58
ON CALL VIVID CONTROL
.......................................... 63
ON CALL VIVID METER .. 63
ON CALL VIVID PAL
METER ............................ 63
ON CALL VIVID TEST
STRIP ............................... 58
ONCASPAR ......................... 16
ondansetron .......................... 74
ondansetron hcl..................... 74
ondansetron hcl (pf).............. 74
one daily prenatal ............... 102
ONETOUCH ULTRA BLUE
TEST STRIP ..................... 58
ONETOUCH ULTRA
CONTROL ....................... 63
ONETOUCH ULTRA2 ........ 64
ONETOUCH ULTRAMINI . 64
ONETOUCH VERIO ........... 58
ONETOUCH VERIO FLEX 64
ONETOUCH VERIO IQ
METER ............................. 64
ONETOUCH VERIO
SYSTEM .......................... 64
ONEXTON ........................... 46
ONFI ..................................... 19
ONGLYZA ........................... 70
ONIVYDE ............................ 16
ONMEL .................................. 3
ONZETRA XSAIL ............... 20
OPANA ................................ 25
opcicon one-step ................... 87
OPDIVO ............................... 16
opium tincture ....................... 72
OPSUMIT ............................. 95
option-2 ................................. 87
OPTIUM EZ ......................... 58
OPTIUM TEST .................... 58
OPTUMRX ..................... 58, 64
ORACEA .............................. 11
ORACIT ............................... 97
oral saline laxative ................ 74
oralone .................................. 54
ORAMAGICRX ................... 54
ORAP ................................... 32
ORAPRED ODT .................. 55
ORAVIG ................................. 3
ORENCIA ............................ 82
ORENCIA (WITH
MALTOSE) ...................... 82
ORENCIA CLICKJECT ...... 82
ORENITRAM ...................... 37
ORFADIN ............................ 52
ORKAMBI ........................... 95
orphenadrine citrate .............. 22
orsythia ................................. 87
ortho d ................................. 102
ORTHO DF ........................ 102
ORTHO MICRONOR .......... 84
ORTHO TRI-CYCLEN (28) 87
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affiliated companies.
130
ORTHO TRI-CYCLEN LO
(28) ................................... 87
ORTHO-CYCLEN (28) ....... 87
ORTHO-NOVUM 1/35 (28) 87
ORTHO-NOVUM 7/7/7 (28)
.......................................... 87
oscimin ................................. 72
oscimin sl ............................. 72
oscimin sr ............................. 72
oseltamivir .............................. 5
OSENI .................................. 70
OSMOLEX ER .................... 20
OSMOPREP ......................... 74
OSPHENA ........................... 84
OTEZLA .............................. 82
OTEZLA STARTER ........... 82
OTIPRIO .............................. 54
OTOVEL .............................. 54
OTREXUP (PF) ................... 82
OVACE ................................ 42
OVACE PLUS ............... 42, 43
OVACE PLUS SHAMPOO . 42
OVACE PLUS WASH......... 43
OVIDE ................................. 51
oxacillin ................................ 10
oxacillin in dextrose(iso-osm)
.......................................... 10
oxaliplatin ............................. 16
OXANDRIN......................... 68
oxandrolone .......................... 68
oxaprozin .............................. 28
OXAYDO ............................ 25
oxazepam .............................. 32
oxcarbazepine ....................... 19
oxiconazole........................... 49
OXISTAT ............................. 49
OXSORALEN ULTRA ....... 44
OXTELLAR XR .................. 19
oxybutynin chloride.............. 97
oxycodone ............................ 25
OXYCODONE .................... 26
oxycodone-acetaminophen ... 26
oxycodone-aspirin ................ 26
OXYCONTIN ...................... 26
oxymorphone ........................ 26
OXYTROL ........................... 97
oysco 500/d .......................... 98
oyster shell + d3 ................... 98
oyster shell calcium-vit d2 . 103
oyster shell calcium-vit d3 ... 98
oystercal-d ............................ 98
OZEMPIC ............................ 70
OZURDEX ........................... 91
P pacerone................................ 34
paclitaxel .............................. 16
paliperidone .......................... 32
palonosetron ......................... 74
PALONOSETRON .............. 74
PALYNZIQ .......................... 68
PAMELOR ........................... 32
pamidronate .......................... 68
PANCREAZE ...................... 74
PANDEL .............................. 50
panlor(acetam-caff-
dihydrocod) ...................... 26
PANRETIN .......................... 44
pantoprazole ......................... 77
PARAGARD T 380A ........... 83
paregoric ............................... 72
PAREMYD .......................... 89
paricalcitol ............................ 68
PARICALCITOL ................. 68
PARLODEL ......................... 20
PARNATE............................ 32
paroex oral rinse ................... 54
paromomycin .......................... 9
paroxetine hcl ....................... 32
paroxetine
mesylate(menop.sym)....... 32
PASER.................................... 9
PATADAY ........................... 90
PATANASE ......................... 54
PATANOL ........................... 90
PAXIL .................................. 32
PAXIL CR ............................ 32
PAZEO ................................. 90
P-CARE K40 ........................ 55
P-CARE K80 ........................ 55
P-CARE X (PF) .................... 48
PEDIARIX (PF) ................... 80
peg 3350-electrolytes ........... 74
peg3350 ................................ 74
PEGANONE ........................ 19
PEGASYS ............................ 79
PEGASYS PROCLICK ....... 79
peg-electrolyte soln .............. 74
PEGINTRON ....................... 79
PEN NEEDLE ...................... 64
penicillin g potassium ........... 10
penicillin v potassium ........... 10
PENLAC ............................... 49
PENNSAID .......................... 28
PENTACEL ACTHIB
COMPONENT (PF) ......... 80
PENTASA ............................ 74
pentazocine-naloxone ........... 28
pentoxifylline ........................ 40
PEPCID ................................ 77
PERCOCET .......................... 26
PERFOROMIST ................... 95
PERIDEX ............................. 54
perindopril erbumine ............ 37
periogard ............................... 54
PERJETA ............................. 16
permethrin ............................. 51
perphenazine ......................... 32
perphenazine-amitriptyline ... 32
perry prenatal ...................... 103
PERTZYE ............................. 75
PEXEVA .............................. 32
pfizerpen-g ............................ 10
PHARMACIST CHOICE .... 58
PHARMACIST CHOICE
GLUCOSE SYS ............... 64
phenadoz ............................... 92
phenazopyridine ................... 98
phenelzine ............................. 32
phenergan ............................. 92
PHENERGAN ...................... 92
phenobarb-hyoscy-atropine-
scop ................................... 72
phenohytro ............................ 72
phenoxybenzamine ............... 37
phentolamine ........................ 37
phenylephrine hcl ................. 92
PHENYTEK ......................... 19
phenytoin .............................. 19
phenytoin sodium extended .. 19
philith .................................... 87
PHOSLYRA ......................... 75
phospha 250 neutral .............. 98
phosphasal ............................ 97
phosphate laxative ................ 75
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affiliated companies.
131
PHOSPHOLINE IODIDE .... 89
phosphorous ......................... 99
PHOTREXA CROSS-
LINKING KIT.................. 90
PHOTREXA VISCOUS ...... 90
phrenilin forte(with caffeine) 26
PHYSICIANS EZ USE B-12
........................................ 103
PHYSIOLYTE ..................... 51
PHYSIOSOL IRRIGATION 51
phytonadione (vitamin k1) ... 40
PICATO ............................... 44
pilocarpine hcl .......... 52, 54, 89
pimozide ............................... 32
pimtrea (28) .......................... 87
pindolol ................................ 37
pioglitazone .......................... 70
pioglitazone-glimepiride ...... 70
pioglitazone-metformin ........ 70
piperacillin-tazobactam ........ 10
PIPERACILLIN-
TAZOBACTAM .............. 10
pirmella................................. 87
piroxicam .............................. 28
PLAN B ONE-STEP ............ 87
PLAQUENIL ......................... 9
PLEGRIDY .......................... 79
PLEXION ............................. 46
PLEXION CLEANSING
CLOTHS .......................... 46
PLIAGLIS ............................ 48
PNEUMOVAX 23 ............... 80
pnv 29-1 ............................. 103
pnv ob+dha ......................... 103
pnv-dha ............................... 103
pnv-dha + docusate ............ 103
pnv-ferrous fumarate-docu-fa
........................................ 103
pnv-omega .......................... 103
pnv-select ........................... 103
pnv-vp-u ............................. 103
POD-CARE 100K ................ 55
PODOCON .......................... 43
podofilox .............................. 44
polycin .................................. 88
polymyxin b sulfate ................ 9
polymyxin b sulf-trimethoprim
.......................................... 89
POLYTRIM.......................... 89
POLY-TUSSIN AC .............. 93
POLY-VI-FLOR ................ 103
POLY-VI-FLOR WITH IRON
........................................ 103
POMALYST ........................ 79
portia ..................................... 87
PORTRAZZA ...................... 16
pot,sodium citrate-citric acid 97
POTABA .............................. 99
potassium citrate ................... 97
potassium citrate-citric acid .. 97
powderlax ............................. 75
pr natal 400 ......................... 103
pr natal 400 ec .................... 103
pr natal 430 ......................... 103
pr natal 430 ec .................... 103
PRADAXA ........................... 40
PRALUENT PEN................. 41
pramcort................................ 75
pramipexole .......................... 20
PRAMOSONE ..................... 43
PRAMOSONE E .................. 43
PRANDIN ............................ 70
PRAVACHOL ..................... 41
pravastatin ............................ 41
PRAXBIND.......................... 40
praziquantel ............................ 9
prazosin ................................ 37
PRECISION PCX PLUS TEST
.......................................... 58
PRECISION PCX TEST ...... 58
PRECISION POINT OF
CARE TEST ..................... 58
PRECISION Q-I-D TEST .... 58
PRECISION XTRA
MONITOR ....................... 64
PRECISION XTRA TEST ... 58
PRECOSE ............................ 70
PRED FORTE ...................... 91
PRED MILD......................... 91
PRED-G................................ 91
PRED-G S.O.P. .................... 91
prednicarbate ........................ 50
prednisolone ......................... 55
prednisolone acetate ............. 91
PREDNISOLONE ACETATE
(PF) ................................... 91
prednisolone sodium phosphate
.................................... 55, 91
PREDNISOLONE-
GATIFLOXACIN ............ 91
PREDNISOLON-GATIFLOX-
BROMFENAC ................. 90
prednisone ............................. 55
prednisone intensol ............... 55
PREFERA-OB .................... 103
PREFERA-OB ONE .......... 103
PREFERA-OB PLUS DHA
........................................ 103
PREFEST ............................. 84
PREMARIN ......................... 84
PREMIER BLU GLUCOSE
METER ............................. 64
PREMIER TEST STRIP ...... 58
PREMIER VOICE GLUCOSE
METER ............................. 64
PREMIUM BLOOD
GLUCOSE MONITOR .... 64
PREMIUM V10 .............. 58, 64
PREMPHASE ....................... 84
PREMPRO ........................... 84
prena1 chew ........................ 103
prena1 pearl ........................ 103
prena1 true .......................... 103
prenaissance ........................ 103
prenaissance plus ................ 103
PRENATA .......................... 103
prenatabs fa ......................... 103
prenatabs rx ........................ 103
prenatal ............................... 103
prenatal complete ................ 103
prenatal formula .................. 103
prenatal multi-dha (algal oil)
........................................ 103
prenatal one daily ............... 103
prenatal plus ........................ 103
prenatal plus (calcium carb)103
PRENATAL PLUS DHA ... 103
prenatal vitamin .................. 103
prenatal vitamin plus low iron
........................................ 103
prenatal vitamin with minerals
........................................ 103
prenatal vits96-iron fum-folic
........................................ 103
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affiliated companies.
132
prenatal-u ............................ 103
PRENATE AM .................. 103
PRENATE CHEWABLE ... 103
PRENATE DHA (FERR ASP
GLYCIN) ....................... 103
PRENATE ELITE (IRON ASP
GLYC) ............................ 103
PRENATE ENHANCE ...... 103
PRENATE
ESSENTIAL(IRON-ASP-
GL) ................................. 103
PRENATE MINI (FERR ASP
GLYCIN) ....................... 103
PRENATE PIXIE ............... 103
PRENATE RESTORE ....... 104
PRENATE STAR ............... 104
preplus ................................ 104
PREPOPIK ........................... 75
PRESERA ............................ 44
PRESTALIA ........................ 37
PRESTO PRO BLOOD
GLUCOSE METER ......... 64
pretab .................................. 104
PREVACID .......................... 77
PREVACID SOLUTAB ...... 77
prevalite ................................ 41
PREVIDENT ........................ 54
PREVIDENT 5000 BOOSTER
PLUS ................................ 54
PREVIDENT 5000 DRY
MOUTH ........................... 54
PREVIDENT 5000 ENAMEL
PROTECT ........................ 54
PREVIDENT 5000 PLUS .... 54
PREVIDENT 5000
SENSITIVE ...................... 54
previfem ............................... 87
PREVYMIS ............................ 5
PREZCOBIX .......................... 5
PREZISTA ............................. 5
PRIFTIN ................................. 9
PRILOLID ............................ 48
PRILOSEC ........................... 77
PRIMACARE .................... 104
PRIMAQUINE ....................... 9
PRIMAXIN IV ....................... 9
primidone ............................. 19
PRIMLEV ............................ 26
PRIMSOL ............................. 11
PRINIVIL ............................. 37
PRISTIQ ............................... 32
PRIVIGEN ........................... 80
PROAIR HFA ...................... 95
PROAIR RESPICLICK ....... 95
probenecid ............................ 81
probenecid-colchicine .......... 81
PROBUPHINE ..................... 26
procainamide ........................ 34
PROCARDIA ....................... 37
PROCARDIA XL................. 37
PRO-C-DURE 5 ................... 55
PRO-C-DURE 6 ................... 55
procentra ............................... 32
prochlorperazine ................... 75
prochlorperazine edisylate .... 75
prochlorperazine maleate ..... 75
PROCORT............................ 75
PROCRIT ............................. 78
PROCTOCORT.................... 75
PROCTOFOAM HC ............ 75
procto-med hc ....................... 75
proctosol hc .......................... 75
proctozone-hc ....................... 75
PROCYSBI .......................... 97
PRODIGY AUTOCODE
METER ............................ 64
PRODIGY AUTOCODE
MONITOR SYST............. 64
PRODIGY CONTROL
SOLUTION, LOW ........... 64
PRODIGY CONTROL
SOLUTION,HIGH ........... 64
PRODIGY NO CODING ..... 58
PRODIGY POCKET METER
.......................................... 64
PRODIGY VOICE GLUCOSE
METER ............................ 64
PRODRIN ............................ 21
profeno.................................. 28
PROFERRIN-FORTE ........ 104
PROFILNINE ....................... 40
progesterone micronized ...... 84
PROGLYCEM ..................... 59
PROGRAF ........................... 16
PROLASTIN-C .................... 52
PROLENSA ......................... 90
PROLEUKIN ....................... 79
PROLIA ................................ 81
PROMACTA ........................ 40
promethazine ........................ 92
promethazine vc-codeine ...... 93
promethazine-codeine ........... 93
promethazine-dm .................. 93
promethazine-phenylephrine 93
promethegan ......................... 92
PROMETRIUM ................... 84
PROMISEB .......................... 44
propafenone .......................... 34
propantheline ........................ 72
proparacaine ......................... 90
propranolol ........................... 37
propranolol-hydrochlorothiazid
.......................................... 37
propylthiouracil .................... 55
PROQUAD (PF) ................... 80
PRO-RED AC (W/
DEXCHLORPHENIR) ..... 93
PROSCAR ............................ 97
PROTECT IRON ................ 104
PROTONIX .................... 77, 78
PROTOPIC ........................... 44
protriptyline .......................... 32
PROVENGE ......................... 80
PROVENTIL HFA ............... 95
PROVERA ........................... 84
PROVIDA DHA ................. 104
PROVIDA OB .................... 104
PROVIGIL ........................... 32
PROZAC .............................. 32
pruclair .................................. 44
prudoxin ................................ 44
prumyx .................................. 44
prutect ................................... 44
PSORCON ............................ 50
PULMICORT ....................... 95
PULMICORT FLEXHALER
.......................................... 95
pulmosal ............................... 95
PULMOZYME ..................... 95
PURALOR CI .................... 104
PUREFE OB PLUS ............ 104
PUREFE PLUS .................. 104
purelax .................................. 75
purevit dualfe plus .............. 104
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affiliated companies.
133
PURIXAN ............................ 16
PYLERA .............................. 78
pyrazinamide .......................... 9
PYRIDIUM .......................... 98
pyridostigmine bromide ....... 22
Q QBRELIS ............................. 37
Q-CARE RX Q4 .................. 54
QNASL ................................ 95
QTERN ................................ 70
QUADRACEL (PF) ............. 80
QUALAQUIN ........................ 9
QUARTETTE ...................... 87
quasense ............................... 87
quazepam .............................. 32
QUDEXY XR ...................... 19
QUESTRAN......................... 41
QUESTRAN LIGHT............ 41
quetiapine ............................. 32
QUFLORA ......................... 104
QUFLORA FE ................... 104
QUFLORA FE (FERROUS
SULFATE) ..................... 104
QUFLORA PEDIATRIC ... 104
QUFLORA PEDIATRIC
DROPS ........................... 104
QUILLICHEW ER ............... 32
QUILLIVANT XR ............... 32
quinapril ............................... 37
quinapril-hydrochlorothiazide
.......................................... 37
quinidine gluconate .............. 34
quinidine sulfate ................... 34
quinine sulfate ........................ 9
QUINTET AC ...................... 58
QUINTET BLOOD
GLUCOSE METER ......... 64
quit 2 ..................................... 53
QUIT 2 ................................. 53
quit 4 ..................................... 53
QUIT 4 ................................. 53
QUTENZA ........................... 44
QVAR REDIHALER ........... 95
R RABAVERT (PF) ................ 80
rabeprazole ........................... 78
RADICAVA ......................... 21
rajani ..................................... 87
raloxifene .............................. 81
ramipril ................................. 37
RANEXA ............................. 42
ranitidine hcl ......................... 78
RAPAFLO ............................ 97
RAPAMUNE........................ 16
rasagiline .............................. 20
RASUVO (PF) ..................... 82
RAVICTI .............................. 52
RAYALDEE ........................ 68
RAYOS ................................ 55
RAZADYNE .................. 21, 22
RAZADYNE ER .................. 21
READYSHARP
DEXAMETHASONE ...... 55
READYSHARP
KETOROLAC .................. 28
READYSHARP LIDOCAINE
(PF) ................................... 48
READYSHARP
TRIAMCINOLONE ......... 55
REBETOL ............................ 79
REBIF (WITH ALBUMIN) . 79
REBIF REBIDOSE .............. 79
REBIF TITRATION PACK . 79
REBINYN ............................ 40
RECLAST ............................ 52
reclipsen (28) ........................ 87
RECOMBINATE ................. 40
RECOMBIVAX HB (PF) .... 80
RECTIV................................ 75
REFUAH PLUS ................... 58
REFUAH PLUS GLUCOSE
CONTROL ....................... 64
REFUAH PLUS GLUCOSE
MONITOR ....................... 64
REGLAN .............................. 75
REGRANEX ........................ 44
relador pak ............................ 48
relador pak plus .................... 48
RELAGARD ........................ 84
RELENZA DISKHALER ...... 5
RELION ALL-IN-ONE
METER ............................ 64
RELION CONFIRM ............ 64
RELION CONFIRM-MICRO
.......................................... 58
RELION MICRO GLUCOSE
MONITOR ....................... 64
RELION NOVOLIN 70/30 .. 67
RELION NOVOLIN N ........ 67
RELION NOVOLIN R ......... 67
RELION PRIME METER .... 64
RELION PRIME TEST
STRIPS ............................. 58
RELISTOR ........................... 75
relnate dha .......................... 104
RELPAX ............................... 21
REMERON ........................... 32
REMERON SOLTAB .......... 32
REMICADE ......................... 75
REMODULIN ...................... 37
RENAGEL ........................... 75
renal caps ............................ 104
rena-vite .............................. 104
rena-vite rx .......................... 104
RENFLEXIS ......................... 75
reno caps ............................. 104
RENVELA ........................... 75
repaglinide ............................ 70
repaglinide-metformin .......... 70
REPATHA PUSHTRONEX 41
REPATHA SURECLICK .... 41
REPATHA SYRINGE ......... 41
REQUIP ................................ 20
REQUIP XL ......................... 20
RESCRIPTOR ........................ 5
RESPA-AR ........................... 93
RESTASIS ............................ 90
RESTASIS MULTIDOSE .... 90
RESTIZAN ........................... 44
RESTORIL ........................... 32
RETIN-A .............................. 46
RETIN-A MICRO ................ 46
RETIN-A MICRO PUMP .... 46
RETISERT ........................... 91
RETROVIR ............................ 5
REVATIO ............................. 96
REVEAL BLOOD GLUCOSE
METER ............................. 64
REVEAL TEST STRIP ........ 58
REVLIMID ........................... 79
REXULTI ............................. 32
REYATAZ ............................. 5
RHOFADE ........................... 46
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affiliated companies.
134
RIASTAP ............................. 40
ribasphere ............................. 79
ribasphere ribapak ................ 79
ribavirin ............................ 5, 79
RIDAURA ............................ 82
rifabutin .................................. 9
RIFADIN ................................ 9
RIFAMATE ........................... 9
rifampin .................................. 9
RIFATER ............................... 9
RIGHTEST CONTROL
SOLUTION HIGH ........... 64
RIGHTEST GM550 SYSTEM
.......................................... 64
RIGHTEST GS550 TEST
STRIPS ............................. 58
RILUTEK ............................. 52
riluzole .................................. 52
rimantadine ............................. 5
RIMSO-50 .............................. 9
ringer's .................................. 51
RIOMET .............................. 70
risacal-d .............................. 104
risedronate ...................... 52, 81
RISPERDAL ........................ 32
risperidone ............................ 32
RITALIN .............................. 32
RITALIN LA........................ 33
ritonavir .................................. 5
RITUXAN ............................ 16
RITUXAN HYCELA ........... 16
rivastigmine .......................... 22
rivastigmine tartrate.............. 22
rivelsa ................................... 87
RIXUBIS .............................. 40
rizatriptan ............................. 21
R-NATAL OB .................... 104
robafen ac ............................. 93
ROBAXIN ............................ 22
ROBAXIN-750 .................... 22
ROBINUL ............................ 72
ROBINUL FORTE .............. 72
ROCALTROL ...................... 68
ROMIDEPSIN ..................... 16
ropinirole .............................. 20
rosadan ................................. 46
ROSADAN .......................... 46
ROSANIL ............................ 46
ROSULA .............................. 46
rosula cleansing cloths.......... 46
rosuvastatin ........................... 41
ROTARIX ............................ 80
ROTATEQ VACCINE......... 80
ROWASA ............................. 75
roweepra ............................... 19
roweepra xr ........................... 19
ROXICODONE.................... 26
ROXYBOND ....................... 26
ROZEREM ........................... 33
RUBRACA ........................... 16
RUCONEST ......................... 96
RYDAPT .............................. 16
rydex ..................................... 93
RYTARY.............................. 20
RYTHMOL SR .................... 34
RYVENT .............................. 93
S SABRIL ................................ 19
SAFYRAL ............................ 87
SAIZEN ................................ 78
SAIZEN SAIZENPREP ....... 78
SALAGEN (PILOCARPINE)
.................................... 52, 54
SALEX ................................. 43
salicylic acid ......................... 43
salimez .................................. 43
SALIMEZ FORTE ............... 43
SALKERA............................ 43
salsalate ................................ 28
salvax .................................... 43
SALVAX DUO PLUS ......... 43
SAMSCA ............................. 68
SANCUSO ........................... 75
SANDIMMUNE .................. 16
SANDOSTATIN .................. 16
SANDOSTATIN LAR
DEPOT ............................. 16
SANTYL .............................. 51
SAPHRIS (BLACK
CHERRY) ........................ 33
SARAFEM ........................... 33
SAVAYSA ........................... 40
SAVELLA ............................ 82
scalacort ................................ 50
scopolamine base .................. 75
SEASONIQUE ..................... 87
seb-prev ................................ 43
SEEBRI NEOHALER .......... 96
SEGLUROMET ................... 70
SELECT-OB ....................... 104
SELECT-OB (FOLIC ACID)
........................................ 104
SELECT-OB + DHA .......... 104
selegiline hcl ......................... 20
selenium sulfide .................... 43
SELRX ................................. 43
SELZENTRY ......................... 5
SEMPREX-D ....................... 93
se-natal 19 ........................... 104
se-natal 19 (with docusate) . 104
SENSIPAR ........................... 68
SEREVENT DISKUS .......... 96
SERNIVO ............................. 50
SEROQUEL ......................... 33
SEROQUEL XR ................... 33
SEROSTIM .......................... 78
sertraline ............................... 33
se-tan plus ........................... 104
setlakin .................................. 87
sevelamer carbonate ............. 75
sf 54
sf 5000 plus ........................... 54
SFROWASA ........................ 75
sharobel ................................. 84
SHINGRIX (PF) ................... 80
SHOHL'S MODIFIED ......... 97
SIDEKICK BLOOD
GLUCOSE SYSTEM ....... 64
SIGNIFOR ............................ 16
SIGNIFOR LAR ................... 16
SIKLOS ................................ 16
sildenafil (antihypertensive) . 96
SILENOR ............................. 33
SILIQ .................................... 43
SILVADENE ........................ 43
silver nitrate .......................... 44
silver nitrate applicators ....... 44
silver sulfadiazine ................. 43
SILVRSTAT ......................... 48
SIMBRINZA ........................ 90
SIMPONI .............................. 82
SIMPONI ARIA ................... 82
SIMULECT .......................... 16
simvastatin ............................ 41
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affiliated companies.
135
SINEMET ............................ 20
SINEMET CR ...................... 20
SINGULAIR ........................ 96
sirolimus ............................... 16
SIRTURO ............................... 9
SIVEXTRO ............................ 9
SKELAXIN .......................... 22
SKLICE ................................ 51
SKYLA ................................ 83
SMART SENSE
MONITORING SYSTEM 64
SMART SENSE TEST
STRIPS ............................. 58
SMARTEST CONTROL ..... 64
SMARTEST EJECT ............ 65
SMARTEST PERSONA
STARTER ........................ 65
SMARTEST PRONTO
STARTER ........................ 65
SMARTEST PROTEGE ...... 65
SMARTEST TEST .............. 58
smoothlax ............................. 75
SNAP INSULIN PUMP
CONTROLLER ............... 65
sodium benzoate-sod
phenylacet......................... 52
sodium chlor 0.9% bacteriostat
.......................................... 52
sodium chloride .............. 96, 99
sodium chloride 0.45 % ........ 99
sodium chloride 0.9 % .......... 52
sodium chloride 3 % ............. 99
sodium chloride 5 % ............. 99
sodium citrate-citric acid ...... 97
SODIUM EDECRIN ............ 38
sodium ferric gluconat-sucrose
.......................................... 52
sodium phenylbutyrate ......... 52
sodium polystyrene (sorb free)
.......................................... 75
sodium polystyrene sulfonate
.......................................... 75
SODIUM POLYSTYRENE
SULFONATE................... 75
SOLARAZE ......................... 44
SOLESTA ............................ 75
SOLIQUA 100/33 ................ 67
SOLIRIS ............................... 52
SOLODYN ........................... 11
SOLOSEC .............................. 9
soloxide ................................ 11
SOLTAMOX ........................ 16
SOLUS V2 AUDIBLE
METER ............................ 65
SOLUS V2 CONTROL
SOLUTION,HIGH ........... 65
SOLUS V2 TEST STRIPS ... 58
SOMA .................................. 22
SOMATULINE DEPOT ...... 16
SOMAVERT ........................ 68
sonafine ................................ 44
SONATA .............................. 33
SOOLANTRA ...................... 46
SORBITOL-MANNITOL .... 51
SORIATANE ....................... 43
SORILUX ............................. 43
sotalol ................................... 34
sotalol af ............................... 34
SOTYLIZE ........................... 34
SOVALDI .............................. 5
sp antipruritic ........................ 45
sp scar management .............. 45
SPECTRACEF ....................... 6
spinosad ................................ 51
SPIRIVA RESPIMAT .......... 96
SPIRIVA WITH
HANDIHALER ................ 96
spironolactone ...................... 38
spironolacton-hydrochlorothiaz
.......................................... 38
SPORANOX .......................... 3
SPORANOX PULSEPAK ..... 3
sprintec (28) .......................... 87
SPRIX ................................... 28
SPRYCEL ............................ 16
sps (with sorbitol) ................. 75
sronyx ................................... 87
ssd ......................................... 43
SSKI ..................................... 55
sss 10-5 ................................. 46
STALEVO 100 ..................... 20
STALEVO 125 ..................... 20
STALEVO 150 ..................... 20
STALEVO 200 ..................... 20
STALEVO 50 ....................... 20
STALEVO 75 ....................... 20
STARLIX ............................. 70
stavudine ................................. 5
STEGLATRO ....................... 70
STEGLUJAN ....................... 70
STELARA ............................ 43
STIMATE ............................. 68
STIOLTO RESPIMAT ......... 96
STIVARGA .......................... 16
stop smoking aid ................... 53
STRATTERA ....................... 33
STRENSIQ ........................... 68
STREPTOMYCIN ................. 9
stress formula ...................... 104
stress formula with iron ...... 104
stress formula with iron(sulf)
........................................ 104
STRIANT ............................. 68
STRIBILD .............................. 5
STRIVERDI RESPIMAT .... 96
STROMECTOL ..................... 9
strong iodine ......................... 99
STROVITE FORTE ........... 104
STROVITE ONE ................ 104
SUBLOCADE ...................... 26
SUBOXONE ........................ 28
SUBSYS ............................... 26
subvenite ............................... 19
subvenite starter (blue) kit .... 19
subvenite starter (green) kit .. 19
subvenite starter (orange) kit 19
SUCRAID ............................. 75
sucralfate ............................... 78
SULAR ................................. 38
sulfacetamide sodium ..... 43, 91
sulfacetamide sodium (acne) 48
sulfacetamide sodium-sulfur 46
sulfacetamide sod-sulfur-urea
.......................................... 47
sulfacetamide-prednisolone .. 91
sulfacleanse 8-4 .................... 47
sulfadiazine ........................... 10
sulfamethoxazole-trimethoprim
.......................................... 10
SULFAMYLON ................... 48
sulfasalazine ......................... 75
sulfatrim ................................ 10
sulindac ................................. 28
SUMADAN .......................... 47
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affiliated companies.
136
sumatriptan ........................... 21
sumatriptan succinate ........... 21
sumatriptan-naproxen ........... 21
SUMAVEL DOSEPRO ....... 21
SUMAXIN ........................... 47
SUMAXIN TS...................... 47
super b complex-vitamin c . 104
super b maxi complex ........ 104
super b-50 complex plus .... 104
super quints ........................ 104
super quints b-50 ................ 104
superplex-t .......................... 104
SUPERVITE ...................... 104
SUPPRELIN LA .................. 16
SUPRAX ................................ 7
SUPREP BOWEL PREP KIT
.......................................... 75
SURE-TEST EASYPLUS
MINI ................................. 58
SURE-TEST EASYPLUS
MINI METER .................. 65
SURFAXIN .......................... 96
SURMONTIL ...................... 33
SURVANTA ........................ 52
SUSTIVA ............................... 5
SUSTOL ............................... 75
SUTENT .............................. 16
syeda ..................................... 87
SYLATRON......................... 79
SYLVANT ........................... 16
SYMAX DUOTAB .............. 72
symax fastabs ....................... 72
symax-sl ............................... 72
symax-sr ............................... 72
SYMBICORT ...................... 96
SYMBYAX .......................... 33
SYMFI .................................... 5
SYMFI LO ............................. 5
SYMLINPEN 120 ................ 70
SYMLINPEN 60 .................. 70
SYMPROIC ......................... 75
SYNAGIS .............................. 5
SYNALAR ........................... 50
SYNALAR CREAM KIT .... 50
SYNALAR OINTMENT KIT
.......................................... 50
SYNALAR TS ..................... 50
SYNAREL ........................... 68
SYNDROS ........................... 75
SYNERA .............................. 48
SYNERCID ............................ 9
SYNJARDY ......................... 70
SYNJARDY XR................... 70
SYNRIBO ............................ 16
SYNTHROID ....................... 71
T TABLOID ............................ 16
TACLONEX ........................ 43
tacrolimus ....................... 16, 45
TAFINLAR .......................... 17
TAGRISSO .......................... 17
TAKE ACTION ................... 87
TALTZ AUTOINJECTOR .. 43
TALTZ AUTOINJECTOR (2
PACK) .............................. 43
TALTZ AUTOINJECTOR (3
PACK) .............................. 43
TALTZ SYRINGE ............... 43
TALWIN .............................. 28
TAMIFLU .............................. 5
tamoxifen .............................. 17
tamsulosin ............................. 97
TANDEM PLUS ................ 104
TANZEUM .......................... 70
TAPAZOLE ......................... 55
TAPERDEX ......................... 55
TARCEVA ........................... 17
TARGADOX........................ 11
TARGRETIN ....................... 17
tarina fe 1/20 (28) ................. 87
TARKA ................................ 38
taron forte ........................... 104
taron-c dha .......................... 104
taron-prex prenatal-dha ...... 104
TASIGNA ............................ 17
TASMAR ............................. 20
TAVALISSE ........................ 40
TAXOTERE ......................... 17
TAYTULLA ......................... 87
tazarotene.............................. 47
TAZICEF................................ 7
TAZORAC ........................... 47
taztia xt ................................. 38
TECENTRIQ ........................ 17
TECFIDERA ........................ 79
TECHNIVIE ........................... 5
TEFLARO .............................. 7
TEGRETOL ......................... 19
TEGRETOL XR ................... 19
TEKTURNA ......................... 38
TEKTURNA HCT ................ 38
TELCARE BGM .................. 65
TELCARE BLOOD
GLUCOSE KIT ................ 65
TELCARE CONTROL ........ 65
TELCARE TEST STRIPS ... 58
telmisartan ............................ 38
telmisartan-amlodipine ......... 38
telmisartan-hydrochlorothiazid
.......................................... 38
temazepam ............................ 33
TEMODAR .......................... 17
TEMOVATE ........................ 50
temozolomide ....................... 17
tencon ................................... 26
TENIPOSIDE ....................... 17
TENIVAC (PF) .................... 80
tenofovir disoproxil fumarate . 5
TENORETIC 100 ................. 38
TENORETIC 50 ................... 38
TENORMIN ......................... 38
TEPADINA .......................... 17
terazosin ................................ 38
terbinafine hcl ......................... 3
terbutaline ............................. 96
terconazole ............................ 84
TERSI FOAM ...................... 43
TESSALON PERLES .......... 93
TEST N'GO BLOOD
GLUCOSE SYSTEM ....... 65
TEST N'GO TEST ................ 58
TESTIM ................................ 68
testosterone ........................... 68
TESTOSTERONE ................ 68
testosterone cypionate .......... 68
testosterone enanthate ........... 68
TESTRED ............................. 68
TETANUS,DIPHTHERIA
TOX PED(PF) .................. 80
TETANUS-DIPHTHERIA
TOXOIDS-TD .................. 80
tetcaine .................................. 90
tetrabenazine ......................... 22
tetracaine hcl ......................... 90
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affiliated companies.
137
TETRACAINE HCL (PF) .... 90
tetracycline ........................... 11
TETRAVISC ........................ 90
TETRAVISC FORTE .......... 90
TEXACORT......................... 51
THALLOUS CHLORIDE TL-
201 .................................... 52
THALOMID......................... 17
THEO-24 .............................. 96
theochron .............................. 96
theophylline .......................... 96
THIOLA ............................... 52
thioridazine ........................... 33
thiotepa ................................. 17
thiothixene ............................ 33
THRIVITE RX ................... 104
thrivite-19 ........................... 104
THYMOGLOBULIN ........... 80
thyroid (pork) ....................... 71
THYROLAR-1 ..................... 71
THYROLAR-1/2 .................. 71
THYROLAR-1/4 .................. 71
THYROLAR-2 ..................... 71
THYROLAR-3 ..................... 71
tiagabine ............................... 19
TIAZAC ............................... 38
TICALAST .......................... 96
TICE BCG ............................ 80
TIGAN ................................. 75
tigecycline .............................. 9
TIKOSYN ............................ 34
tilia fe.................................... 87
timolol maleate ............... 38, 89
TIMOPTIC ........................... 89
TIMOPTIC OCUDOSE (PF)
.......................................... 89
TIMOPTIC-XE .................... 89
TINDAMAX .......................... 9
tinidazole ................................ 9
TIROSINT ............................ 71
tis-u-sol pentalyte ................. 51
TIVICAY ............................... 5
TIVORBEX .......................... 28
tizanidine .............................. 22
tl gard rx ............................. 104
tl g-fol os ............................ 104
tl icon .................................. 105
TOBI ...................................... 9
TOBI PODHALER ................ 9
TOBRADEX ........................ 91
TOBRADEX ST................... 91
tobramycin ............................ 89
tobramycin in 0.225 % nacl .... 9
tobramycin sulfate .................. 9
TOBRAMYCIN WITH
NEBULIZER ...................... 9
tobramycin-dexamethasone .. 91
TOBREX .............................. 89
TODAY CONTRACEPTIVE
SPONGE .......................... 84
TOFRANIL .......................... 33
TOLAK ................................ 45
tolazamide ............................ 70
tolbutamide ........................... 70
tolcapone .............................. 20
tolmetin ................................. 28
tolterodine ............................. 97
TOPAMAX .......................... 19
TOPICORT .......................... 51
topiramate ............................. 19
TOPIRAMATE .................... 19
toposar .................................. 17
topotecan .............................. 17
TOPROL XL ........................ 38
TORISEL.............................. 17
TORONOVA II SUIK.......... 28
TORONOVA SUIK ............. 28
torsemide .............................. 38
total b/c ............................... 105
TOTECT ............................... 12
TOUJEO MAX SOLOSTAR
.......................................... 67
TOUJEO SOLOSTAR U-300
INSULIN .......................... 67
TOVIAZ ............................... 97
TRACLEER ......................... 96
TRADJENTA ....................... 70
tramadol ................................ 28
TRAMADOL ....................... 28
tramadol-acetaminophen ...... 28
trandolapril ........................... 38
trandolapril-verapamil .......... 38
tranexamic acid ............... 40, 84
TRANSDERM-SCOP .......... 75
TRANXENE T-TAB ............ 33
tranylcypromine.................... 33
TRANZAREL ...................... 48
TRAVATAN Z ..................... 91
trazodone .............................. 33
TREANDA ........................... 17
TRECATOR ........................... 9
TRELEGY ELLIPTA ........... 96
TRELSTAR .......................... 17
TREMFYA ........................... 43
TRESIBA FLEXTOUCH U-
100 .................................... 67
TRESIBA FLEXTOUCH U-
200 .................................... 67
tretinoin ................................. 47
tretinoin (chemotherapy) ...... 17
tretinoin microspheres .......... 47
TRETIN-X ............................ 47
TRETIN-X CREAM KIT ..... 47
TRETTEN ............................ 40
TREXALL ............................ 17
TREXIMET .......................... 21
TREZIX ................................ 26
tri femynor ............................ 87
TRIACETIN ......................... 49
triamcinolone acetonide . 51, 54,
55
triamterene-hydrochlorothiazid
.......................................... 38
trianex ................................... 51
triazolam ............................... 33
TRIBENZOR ........................ 38
TRICARE ........................... 105
tricitrates ............................... 97
tricon ................................... 105
TRICOR ............................... 41
triderm .................................. 51
TRIDESILON ....................... 51
tri-estarylla ............................ 87
TRIFERIC .......................... 105
trifluoperazine ....................... 33
trifluridine ............................. 89
trigels-f forte ....................... 105
TRIGLIDE ............................ 41
trihexyphenidyl ..................... 20
triklo ..................................... 41
tri-legest fe ............................ 88
TRILEPTAL ......................... 19
tri-linyah ............................... 88
TRILIPIX ............................. 41
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affiliated companies.
138
tri-lo-estarylla ....................... 88
tri-lo-marzia .......................... 88
tri-lo-sprintec ........................ 88
trilyte with flavor packets ..... 75
trimethobenzamide ............... 75
trimethoprim ......................... 11
tri-mili .................................. 88
trimipramine ......................... 33
TRIMPEX ............................ 11
trinatal rx 1 ......................... 105
trinate .................................. 105
trinessa (28) .......................... 88
trinessa lo.............................. 88
TRI-NORINYL (28) ............ 88
TRINTELLIX....................... 33
triphrocaps .......................... 105
TRIPLE DYE ....................... 49
tri-previfem (28) ................... 88
TRIPTODUR ....................... 17
TRISENOX .......................... 17
tri-sprintec (28) ..................... 88
TRISTART DHA ............... 105
TRIUMEQ .............................. 5
triveen-duo dha ................... 105
TRI-VI-FLOR .................... 105
tri-vitamin with fluoride ..... 105
trivora (28)............................ 88
tri-vylibra .............................. 88
TRIZIVIR ............................... 5
TROGARZO .......................... 5
TROKENDI XR ................... 19
tropicamide ........................... 89
trospium ................................ 97
TRUE METRIX AIR
GLUCOSE METER ......... 65
TRUE METRIX GLUCOSE
METER ............................ 65
TRUE METRIX GLUCOSE
TEST STRIP .................... 58
TRUE METRIX GO
GLUCOSE METER ......... 65
TRUE METRIX LEVEL 1 .. 65
TRUE2GO BLOOD
GLUCOSE SYSTEM ....... 65
TRUECONTROL LEVEL 0 65
TRUERESULT BLOOD
GLUCOSE SYSTM ......... 65
TRUETEST TEST STRIPS . 58
TRUETRACK BLOOD
GLUCOSE SYSTEM ....... 65
TRUETRACK SMART
SYSTEM .......................... 65
TRUETRACK TEST ........... 58
TRULANCE ......................... 75
TRULICITY ......................... 70
TRUSOPT ............................ 91
trust natal dha ..................... 105
TRUSTEEL INFUSION SET
32 ...................................... 65
TRUVADA ............................ 5
TUDORZA PRESSAIR ....... 96
tulana .................................... 84
tusnel c .................................. 93
TUSNEL PEDIATRIC ......... 93
TUSSICAPS ......................... 93
tussigon ................................. 93
TUSSIONEX PENNKINETIC
ER ..................................... 93
TUZISTRA XR .................... 93
TWINRIX (PF)..................... 80
TWYNSTA .......................... 38
TYBOST ................................ 5
tydemy .................................. 88
TYGACIL .............................. 9
TYKERB .............................. 17
TYLENOL-CODEINE #3 .... 26
TYLENOL-CODEINE #4 .... 26
TYMLOS.............................. 81
TYPHIM VI ......................... 80
TYSABRI ............................. 22
TYVASO .............................. 96
TYVASO REFILL KIT........ 96
TYVASO STARTER KIT ... 96
TYZINE................................ 54
U UCERIS ................................ 75
UDAMIN SP ...................... 105
ULESFIA.............................. 51
ULORIC ............................... 81
ULTIMA MONITOR ........... 65
ULTIMA TEST STRIPS ...... 58
ultra b-100 complex............ 105
ULTRACET ......................... 28
ULTRAM ............................. 28
ULTRASAL-ER ................... 43
ULTRATRAK ...................... 58
ULTRATRAK GLUCOSE
METER ............................. 65
ULTRATRAK ULTIMATE 58,
65
ULTRAVATE ...................... 51
ULTRAVATE X .................. 51
umecta ................................... 45
UNASYN ............................. 10
UNISTRIP LOW CONTROL
.......................................... 65
UNISTRIP1 TEST STRIP .... 58
unithroid ............................... 71
UNITUXIN ........................... 17
UPTRAVI ............................. 38
urea ....................................... 45
urea nail stick ........................ 45
URECHOLINE ..................... 97
URELLE ............................... 97
uretron d-s ............................. 97
URIBEL ................................ 97
urimar-t ................................. 98
urin ds ................................... 98
uro-458 ................................. 98
UROCIT-K 10 ...................... 98
UROCIT-K 15 ...................... 98
UROCIT-K 5 ........................ 98
urogesic-blue ........................ 98
uro-mp .................................. 98
urophen mb ........................... 98
UROQID-ACID NO.2 .......... 98
UROXATRAL ..................... 97
URSO 250 ............................ 75
URSO FORTE ...................... 76
ursodiol ................................. 76
uryl ........................................ 98
ustell ..................................... 98
UTA ...................................... 98
UTIBRON NEOHALER ...... 96
utira-c .................................... 98
UTOPIC ................................ 45
V VABOMERE .......................... 9
VAGIFEM ............................ 84
vaginal contraceptive foam ... 84
valacyclovir ............................ 5
VALCHLOR ........................ 45
VALCYTE ............................. 5
valganciclovir ......................... 5
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
139
VALIUM .............................. 33
valproate sodium .................. 19
valproic acid ......................... 19
valproic acid (as sodium salt)
.......................................... 19
valsartan ............................... 38
valsartan-hydrochlorothiazide
.......................................... 38
VALTREX ............................. 5
VANATOL LQ .................... 26
VANATOL S ....................... 26
VANCOCIN ......................... 11
vancomycin .......................... 11
VANCOMYCIN .................. 11
VANCOMYCIN IN 0.9 %
SODIUM CHL ................. 11
VANCOMYCIN IN
DEXTROSE 5 % .............. 11
vandazole .............................. 85
VANOS ................................ 51
VANOXIDE-HC .................. 47
VANTAS .............................. 17
VAQTA (PF) ........................ 81
VARISOFT INFUSION SET
43 ...................................... 65
VARIZIG ............................. 81
VARUBI .............................. 76
VASCEPA ............................ 41
VASERETIC ........................ 38
VASHE WOUND THERAPY
.......................................... 51
vasopressin in 0.9 % nacl .... 69
VASOPRESSIN IN 0.9 %
NACL ............................... 69
VASOPRESSIN IN
DEXTROSE 5 % .............. 69
VASOSTRICT ..................... 69
VASOTEC ........................... 38
VAXCHORA VACCINE .... 81
v-c forte .............................. 105
VCF CONTRACEPTIVE
FILM ................................ 85
VCF CONTRACEPTIVE GEL
.......................................... 85
VECAMYL .......................... 42
VECTIBIX ........................... 17
VECTICAL .......................... 43
VELCADE ........................... 17
veletri .................................... 38
velivet triphasic regimen (28)
.......................................... 88
VELPHORO ......................... 76
VELTASSA.......................... 76
VELTIN................................ 47
VEMLIDY.............................. 5
VENCLEXTA ...................... 17
venlafaxine ........................... 33
VENOFER.......................... 105
VENTAVIS .......................... 96
VENTOLIN HFA ................. 96
verapamil .............................. 38
VERASENS BLOOD
GLUCOSE METER ......... 65
VERASENS TEST STRIP ... 58
VERDESO............................ 51
verdrocet ............................... 26
VEREGEN ........................... 45
VERELAN ........................... 38
VERELAN PM..................... 38
veripred 20 ............................ 55
VERSACLOZ ...................... 33
VERZENIO .......................... 17
VESICARE .......................... 97
VFEND ................................... 3
VFEND IV ............................. 3
VGO 20 ................................ 65
VGO 30 ................................ 65
VGO 40 ................................ 65
VIBATIV.............................. 11
VIBERZI .............................. 76
VIBRAMYCIN .................... 11
vic-forte .............................. 105
vicodin .................................. 26
vicodin es .............................. 26
vicodin hp ............................. 26
VICTOZA 2-PAK ................ 70
VICTOZA 3-PAK ................ 70
VIDAZA ............................... 17
VIDEX 2 GRAM PEDIATRIC
............................................ 5
VIDEX EC ............................. 5
VIEKIRA PAK....................... 5
VIEKIRA XR ......................... 5
vienva ................................... 88
vigabatrin .............................. 19
VIGAMOX ........................... 89
VIIBRYD ............................. 33
VIMIZIM .............................. 69
VIMOVO .............................. 28
VIMPAT ............................... 19
vinate care ........................... 105
VINATE DHA RF .............. 105
vinate ii ............................... 105
vinate m .............................. 105
vinate one ............................ 105
vinblastine ............................. 17
vincasar pfs ........................... 17
vincristine ............................. 17
vinorelbine ............................ 17
VIOKACE ............................ 76
viorele (28) ........................... 88
VIRACEPT ............................. 6
VIRAMUNE ........................... 6
VIRAMUNE XR .................... 6
VIRASAL ............................. 43
VIRAZOLE ............................ 6
VIREAD ................................. 6
VIROPTIC ............................ 89
virt-advance ........................ 105
virt-c dha ............................. 105
VIRT-CAPS ....................... 105
virt-gard .............................. 105
virt-nate ............................... 105
virt-nate dha ........................ 105
virt-phos 250 neutral ............. 99
virt-pn ................................. 105
virt-pn dha .......................... 105
virt-pn plus .......................... 105
VIRTPREX ......................... 105
virtrate-2 ............................... 98
virtrate-3 ............................... 98
virtrate-k ............................... 98
virt-select ............................ 105
virtussin ac ............................ 93
virtussin dac .......................... 93
virt-vite ............................... 105
virt-vite gt ........................... 105
VIRT-VITE PLUS .............. 105
VISTARIL ............................ 93
VISTOGARD ....................... 12
VISUDYNE .......................... 90
vit 3 ..................................... 105
VITAFOL ........................... 105
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affiliated companies.
140
VITAFOL FE+ (WITH
DOCUSATE) ................. 105
VITAFOL GUMMIES ....... 105
VITAFOL NANO .............. 105
VITAFOL ULTRA ............ 105
VITAFOL-OB .................... 105
VITAFOL-OB+DHA ......... 105
VITAFOL-ONE ................. 105
vitajoy daily d ..................... 105
VITAL-D RX ..................... 105
VITAMED MD ONE RX .. 105
VITAMEDMD REDICHEW
RX .................................. 105
vitamin b complex .............. 105
vitamin b complex-folic acid
........................................ 105
vitamin d3 ........................... 105
vitamins a,c,d and fluoride . 105
VITAPEARL ...................... 105
VITA-RESPA..................... 105
VITATRUE ........................ 106
VITRASE ............................. 90
VITUZ .................................. 93
VIVELLE-DOT ................... 84
VIVITROL ........................... 28
VIVLODEX ......................... 28
VIVOTIF .............................. 81
VOGELXO........................... 69
vol-nate ............................... 106
vol-plus ............................... 106
vol-tab rx ............................ 106
VOLTAREN ........................ 28
VOLTAREN-XR ................. 28
VONVENDI ......................... 40
VORAXAZE ........................ 12
voriconazole ........................... 3
VOSEVI ................................. 6
VOTRIENT .......................... 17
vp-ch plus ........................... 106
vp-ch-pnv ........................... 106
vp-ggr-b6 ............................ 106
vp-heme ob ......................... 106
vp-heme one ....................... 106
VP-PNV-DHA ................... 106
VPRIV .................................. 69
vp-vite rx ............................ 106
VRAYLAR .......................... 33
VUSION ............................... 49
vyfemla (28) ......................... 88
vylibra ................................... 88
VYTORIN 10-10 .................. 41
VYTORIN 10-20 .................. 41
VYTORIN 10-40 .................. 41
VYTORIN 10-80 .................. 41
VYVANSE ........................... 33
VYXEOS .............................. 17
VYZULTA ........................... 91
W warfarin ................................ 40
water for irrigation, sterile .... 52
WAVESENSE AMP ............ 65
WAVESENSE CONTROL
SOLUTION ...................... 65
WAVESENSE JAZZ ........... 58
WAVESENSE PRESTO 58, 65
WELCHOL .......................... 41
WELLBUTRIN SR .............. 33
WELLBUTRIN XL .............. 33
wera (28)............................... 88
westhroid .............................. 71
WIDE-SEAL DIAPHRAGM
.......................................... 83
WILATE ............................... 40
woman's laxative .................. 76
women's gentle laxative(bisac)
.......................................... 76
women's laxative (bisacodyl)76
WP THYROID ..................... 71
wymzya fe ............................ 88
X XADAGO ............................. 20
XALATAN ........................... 91
XALKORI ............................ 17
XANAX................................ 33
XANAX XR ......................... 33
XARELTO ........................... 40
XATMEP.............................. 17
XCLAIR ............................... 45
XELJANZ ............................ 82
XELJANZ XR ...................... 82
XELODA.............................. 17
XENAZINE .......................... 22
XEOMIN .............................. 81
XERESE ............................... 49
XERMELO ........................... 17
XGEVA ................................ 12
XHANCE ............................. 96
XIFAXAN .............................. 9
XIGDUO XR ........................ 70
XIIDRA ................................ 90
XIMINO ............................... 11
XOLAIR ............................... 96
XOLEGEL ............................ 49
XOPENEX ........................... 96
XOPENEX CONCENTRATE
.......................................... 96
XOPENEX HFA .................. 96
XTAMPZA ER ..................... 26
XTANDI ............................... 17
xulane ................................... 85
XULTOPHY 100/3.6 ........... 67
XURIDEN ............................ 52
XYLOCAINE ....................... 48
XYLOCAINE-MPF ............. 48
xylon 10 ................................ 26
XYNTHA ............................. 40
XYNTHA SOLOFUSE ........ 40
XYREM ................................ 33
Y YASMIN (28) ....................... 88
YAZ (28) .............................. 88
YERVOY ............................. 17
YF-VAX (PF) ....................... 81
YONDELIS .......................... 17
YONSA ................................ 17
yuvafem ................................ 84
Z zafirlukast ............................. 96
zaleplon ................................. 33
ZALTRAP ............................ 17
ZANAFLEX ......................... 22
ZANOSAR ........................... 17
ZANTAC .............................. 78
zarah ..................................... 88
ZARONTIN .......................... 19
ZARXIO ............................... 78
zatean-pn dha ...................... 106
zatean-pn plus ..................... 106
zavara .................................. 106
ZAVESCA ............................ 69
zebutal ................................... 26
ZEGERID ............................. 78
ZEJULA ............................... 17
ZELAPAR ............................ 20
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affiliated companies.
141
ZELBORAF ......................... 17
ZEMAIRA ............................ 52
ZEMBRACE SYMTOUCH . 21
ZEMPLAR ........................... 69
zenatane ................................ 47
zenchent (28) ........................ 88
ZENPEP ............................... 76
zenzedi .................................. 34
ZENZEDI ............................. 34
ZEPATIER ............................. 6
ZERIT..................................... 6
ZESTORETIC ...................... 38
ZESTRIL .............................. 38
ZETIA .................................. 41
ZETONNA ........................... 96
ZEVALIN (Y-90) ................. 17
ZIAC .................................... 38
ZIAGEN ................................. 6
ZIANA ................................. 47
zidovudine .............................. 6
zileuton ................................. 96
ZINECARD (AS HCL) ........ 12
zingiber ............................... 106
ZINGO ................................. 48
ZINPLAVA .......................... 81
ZIOPTAN (PF) ..................... 91
ziprasidone hcl...................... 34
ZIPSOR ................................ 28
ZIRGAN ............................... 89
ZITHRANOL ....................... 43
ZITHROMAX ........................ 7
ZITHROMAX TRI-PAK ....... 7
ZITHROMAX Z-PAK ........... 7
ZOCOR ................................ 41
ZODRYL AC 25 .................. 93
ZODRYL AC 30 .................. 93
ZODRYL AC 35 .................. 93
ZODRYL AC 40 .................. 93
ZODRYL AC 50 .................. 93
ZODRYL AC 60 .................. 93
ZODRYL AC 80 .................. 94
ZODRYL DAC 25 ............... 94
ZODRYL DAC 30 ............... 94
ZODRYL DAC 35 ............... 94
ZODRYL DAC 40 ............... 94
ZODRYL DAC 50 ............... 94
ZODRYL DAC 60 ............... 94
ZODRYL DAC 80 ............... 94
ZODRYL DEC 25 ................ 94
ZODRYL DEC 30 ................ 94
ZODRYL DEC 35 ................ 94
ZODRYL DEC 40 ................ 94
ZODRYL DEC 50 ................ 94
ZODRYL DEC 60 ................ 94
ZODRYL DEC 80 ................ 94
ZOFRAN .............................. 76
ZOFRAN ODT ..................... 76
ZOHYDRO ER .................... 26
ZOLADEX ........................... 17
zoledronic acid ..................... 69
zoledronic acid-mannitol-water
.......................................... 52
ZOLEDRONIC AC-
MANNITOL-0.9NACL ... 69
ZOLINZA ............................. 17
zolmitriptan .......................... 21
ZOLOFT ............................... 34
zolpidem ............................... 34
ZOLPIMIST ......................... 34
ZOMACTON ....................... 78
ZOMETA ............................. 69
ZOMIG ................................. 21
ZOMIG ZMT ........................ 21
ZONALON ........................... 45
ZONEGRAN ........................ 19
zonisamide ............................ 19
ZORBTIVE .......................... 78
ZORTRESS .......................... 17
ZORVOLEX ......................... 28
zovia 1/35e (28) .................... 88
ZOVIRAX ........................ 6, 49
Z-TUSS AC .......................... 94
ZUBSOLV ............................ 28
ZUPLENZ ............................ 76
ZURAMPIC ......................... 81
ZYBAN ................................ 53
ZYCLARA ........................... 79
ZYDELIG ............................. 17
ZYFLO ................................. 96
ZYFLO CR ........................... 96
ZYKADIA ............................ 17
ZYLET ................................. 91
ZYLOPRIM .......................... 81
ZYMAXID ........................... 89
ZYPREXA ............................ 34
ZYPREXA ZYDIS ............... 34
ZYTIGA ............................... 17
ZYVOX .................................. 9
Insured/CP-10.14.2016
Discrimination is Against the Law Blue KC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue KC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue KC:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
○ Qualified sign language interpreters ○ Written information in other formats (large print, audio, accessible electronic
formats, other formats) • Provides free language services to people whose primary language is not English, such
as: ○ Qualified interpreters ○ Information written in other languages
If you need these services, contact Customer Service, 844-395-7126 (Toll free), [email protected]. If you believe that Blue KC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Appeals Department, PO Box 419169, Kansas City, MO 64141-6169, 816-395-3537, TTY: 816-842-5607, [email protected]. You can file a grievance in person or by mail, or email. If you need help filing a grievance, the Appeals Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. If you, or someone you’re helping, has questions about Blue KC, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-844-395-7126. Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue KC, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-395-7126. Chinese: 如果您,或是您正在協助的對象,有關於 Blue KC方面的問題,您 有權利免費以您的母語得到幫
助和訊息。洽詢一位翻譯員,請撥電話1-844-395-7126。 Vietnamese: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Blue KC, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-395-7126. German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Blue KC haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-844-395-7126 an.
Insured/CP-10.14.2016
Korean: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 [Blue KC]에 관해서 질문이 있다면 귀하는 그러한
도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기
위해서는 1-844-395-7126 로 전화하십시오. Serbo-Croatian: Ukoliko Vi ili neko kome Vi pomažete ima pitanje o Blue KC, imate pravo da besplatno dobijete pomoć i informacije na Vašem jeziku. Da biste razgovarali sa prevodiocem, nazovite 1-844-395-7126. Arabic:
الضرورية بلغتك من دون اية تكلفة. ، فلديك الحق في الحصول على المساعدة والمعلومات Blue KC إن كان لديك أو لدى شخص تساعده أسئلة بخصوص .7126-395-844-1. للتحدث مع مترجم اتصل بـ
Russian: Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Blue KC, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону1-844-395-7126. French: Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Blue KC, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-844-395-7126. Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue KC, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa1-844-395-7126. Laotian: ຖ້ າທ່ ານ, ຫຼື ຄົນ ◌່ ທທ່ ານກໍ າລັງຊ່ ວຍເຫືຼ ອ, ມ ◌ໍ ຄາຖາມກ່ ຽວກັບ Blue KC, ທ່ ານມ ◌ິ ສດ ◌່ ທຈະໄດ້ຮັບການຊ່ ວຍເຫືຼ ອແລະ◌ໍ ຂ້ ມູ ນຂ່ າວສານ ◌່ ທເປັ ນພາສາຂອງທ່ ານໍ ◌່ ບມ ຄ່ າໃຊ້ຈ່ າຍ. ການໂອ້ລົມກັບນາຍພາສາ, ໃຫ້ ໂທຫາ 1-844-395-7126. Pennsylvanian Dutch: Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut Blue KC, hoscht du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du 1-844-395-7126 uffrufe. Persian:
زبان خود را به طور ، داشته باشيد حق اين را داريد که کمکو اطالعات به Blue KC اگر شما، يا کسی که شما به او کمک ميکنيد ، سوال در مورد .تماس حاصل نماييد 7126-395-844-1.رايگان دريافت نماييد
Cushite: Isin yookan namni biraa isin deeggartan Blue KC irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa 1-844-395-7126 tiin bilbilaa. Portuguese: Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Blue KC, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-844-395-7126. For TTY services, please call 1-816-842-5607.