2019-01 ApprovedDrugs14730 PDF

CalOptima Approved Drug List
Pharmacy-dispensed injectable medications should be processed through the PBM.
All medications listed in the CalOptima Approved Drug List are Tier 1 drugs and are covered
(paid for) if there is no restriction or restrictions are met.
Brand names are representative only; please refer to the “Coverage” column to determine if
the brand formulation is available without prior authorization.
Step-Therapy: An enhanced utilization management process which requires a trial of a first-

line formulary medication prior to receiving the second-line medication. If it is medically
necessary for a member to use the medication as initial therapy, the prescriber can request
coverage by submitting a prior authorization request.
Contingent Therapy: Utilization management which restricts a drug to specific age, gender or
related drug therapy. If it is medically necessary for a member to use the medication and the
contingent therapy restriction cannot be met at the point-of-service, the prescriber can
request coverage by submitting a prior authorization request.
Please note that claims may reject at the pharmacy point of service for reasons not listed in
the Approved Drug List, such as for drug interactions and therapeutic duplication.
Certain medications such as drugs for treatment of substance use disorders, blood factors,
and anti-psychotics are “carved out” of the CalOptima plan and must be billed to Medi-Cal.
The carve out medication list can be found on the CalOptima website at
https://www.caloptima.org/en/Providers/Pharmacy/Medi-CalAndCalOptimaDirect.aspx
Intravenous solutions: Parenteral nutrition solutions (TPN), separately administered

intravenous lipids and other unlisted intravenous solutions may be covered for up to a 10-day
supply following inpatient discharge from an acute care hospital.
LEGEND
TYPE DESCRIPTION
There is a limit on the amount of this drug that is covered
QL Quantity Limit
per prescription, or within a specific time frame.
In some cases, you may be required to first try certain
Step Therapy
ST drugs to treat your medical condition before we will cover
another drug for that condition.
This prescription drug may only be covered for a single
GL Gender Limit
gender.
AL1 Age Limit This prescription drug may only be covered if you meet
the minimum or maximum age limit.
MFL There is a limit on the number of times this drug can be

Max Fill Limit
refilled.
FAL Female Age Limit This prescription drug may only be covered if you are a
female and meet the minimum or maximum age limit.
PAGE 2 LAST UPDATED 12/2018

LIST OF COVERED PRESCRIPTION MEDICATIONS
LIMITS &
BRAND NAME GENERIC DESCRIPTION COVERAGE
RESTRICTIONS
FIRST GENERATION ANTIHISTAMINES
ETHANOLAMINE DERIVATIVES
NIGHTTIME
diphenhydra/phenyleph/ace
SEVERE Brand
tamin 25-10-650 powd pack
COUGH-COLD
PHENOTHIAZINE DERIVATIVES
PROMETHAZINE phenylephrine QL 480 / 30 DAY(S)

Generic
VC hcl/promethazine hcl AL1 Up to 64 yrs old
promethazine hcl (12.5 mg
supp.rect, 25 mg supp.rect, Generic QL 12 / 30 DAY(S)
PHENADOZ
50 mg supp.rect) AL1 Up to 64 yrs old
promethazine hcl (12.5 mg

PROMETHAZINE QL 90 / 30 DAY(S)
tablet, 25 mg tablet, 50 mg Generic
HCL AL1 Up to 64 yrs old
tablet)
promethazine hcl (25 mg/ml
PHENERGAN vial, 25 mg/ml ampul, 50 Generic AL1 Up to 64 yrs old
mg/ml ampul, 50 mg/ml vial)
PROMETHAZINE promethazine hcl Generic QL 240 / 30 DAY(S)
HCL 6.25mg/5ml syrup AL1 Up to 64 yrs old
PROPYLAMINE DERIVATIVES
CHILD
brompheniramine/phenylep QL 480 / 30 DAY(S)
TRIAMINIC Brand
hrine 1-2.5 mg/5 solution AL1 3 to 20 yrs old
COLD-ALLERGY
WAL-PHED PE chlorpheniramine/phenylep Brand QL 60 / 30 DAY(S)
SINUS-ALLERGY hrine 4mg-10mg tablet AL1 3 to 20 yrs old
ANTIHISTAMINE DRUGS
SECOND GENERATION ANTIHISTAMINES
ALL DAY cetirizine hcl 1 mg/ml

Generic QL 300 / 30 DAY(S)
ALLERGY solution

LIMITS &
RESTRICTIONS
ALL DAY cetirizine hcl 1 mg/ml
Brand QL 300 / 30 DAY(S)
ALLERGY solution
WAL-ZYR cetirizine hcl 10 mg tablet Brand QL 30 / 30 DAY(S)
desloratadine (5 mg tablet, QL 30 / 30 DAY(S)
CLARINEX Generic
5 mg tab rapdis)
CHILDREN'S
fexofenadine hcl 30 mg/5 ml QL 450 / 30 DAY(S)
ALLEGRA Brand
oral susp ST
ALLERGY
fexofenadine hcl 30 mg/5 ml QL 450 / 30 DAY(S)
ALLEGRA Generic
oral susp ST
ALLEGRA fexofenadine hcl 60 mg Generic
tablet QL 60 / 30 day(s)
24HR ALLERGY levocetirizine

RELIEF dihydrochloride 5 mg tablet
ALAVERT loratadine 10 mg tab rapdis Generic QL 30 / 30 DAY(S)
ALLERGY loratadine 5 mg/5 ml Generic QL 240 / 30 DAY(S)
RELIEF solution
WAL-ITIN D 12 loratadine/pseudoephedrine
Brand
HOUR 5 mg-120mg tab er 12h
CEPHALOSPORIN ANTIBIOTICS
1ST GENERATION CEPHALOSPORIN ANTIBIOTICS
cefadroxil (1 g tablet, 250

mg/5ml susp recon, 500
CEFADROXIL Generic
mg/5ml susp recon, 500 mg
capsule)
CEFAZOLIN cefazolin sodium (1 g vial,
Generic
SODIUM 500 mg vial)
CEFAZOLIN Generic
cefazolin sodium 10 g vial QL 3 / 30 DAY(S)
SODIUM

LIMITS &
RESTRICTIONS
cephalexin (125 mg/5ml
susp recon, 250 mg/5ml
CEPHALEXIN susp recon, 250 mg Generic
capsule, 250 mg tablet, 500
mg tablet, 500 mg capsule,
750 mg capsule)
2ND GENERATION CEPHALOSPORIN ANTIBIOTICS
cefuroxime axetil (125 susp

CEFTIN Brand
recon, 250 susp recon)
cefuroxime axetil (250 mg
CEFTIN Generic
tablet, 500 mg tablet)
cefuroxime sodium (1.5 g Generic
ZINACEF vial, 7.5 g vial, 750 mg vial)
3RD GENERATION CEPHALOSPORIN ANTIBIOTICS
cefdinir (125 mg/5ml susp

CEFDINIR recon, 250 mg/5ml susp Generic
recon, 300 mg capsule)
cefotaxime sodium (1 g vial,
Generic
CLAFORAN 2 g vial, 10 g vial, 500 mg
vial)
ceftazidime (1 g vial, 2 g
TAZICEF Brand
vial, 6 g vial)
FORTAZ ceftazidime (2 g vial, 6 g

Generic
vial)
ceftriaxone sodium (1 g vial,
ROCEPHIN 10 g vial, 250 mg vial, 500 Generic
mg vial)
4TH GENERATION CEPHALOSPORIN ANTIBIOTICS
cefepime hcl (1 g vial, 2 g Generic

MAXIPIME
vial)

LIMITS &
RESTRICTIONS
MISC. BETA-LACTAM ANTIBIOTICS
CARBAPENEM ANTIBIOTICS
imipenem/cilastatin sodium
PRIMAXIN Generic
(250 mg vial, 500 mg vial)
MERREM meropenem (1 g vial, 500 Generic

mg vial)
CEPHAMYCIN ANTIBIOTICS
cefoxitin sodium (1 g vial, 2
CEFOXITIN Generic
g vial, 10 g vial)
MACROLIDE ANTIBIOTICS
OTHER MACROLIDE ANTIBIOTICS
azithromycin (500 mg vial

AZITHROMYCIN Generic QL 10 / 30 DAY(S)
port, 500 mg vial)
ZITHROMAX azithromycin 1 g packet Generic QL 1 / 30 DAY(S)
ZITHROMAX azithromycin 100 mg/5ml Generic QL 30 / 30 DAY(S)

susp recon
azithromycin 200 mg/5ml
ZITHROMAX Generic QL 60 / 30 DAY(S)
susp recon
ZITHROMAX Generic QL 6 / 1 FILL

azithromycin 250 mg tablet
MF 2 / 30 DAY(S)
QL 4 / 1 FILL
ZITHROMAX azithromycin 500 mg tablet Generic
MF 2 / 30 DAY(S)
ZITHROMAX azithromycin 600 mg tablet Generic QL 8 / 28 DAY(S)
BIAXIN clarithromycin (250 mg Generic QL 28 / 28 DAY(S)


LIMITS &
RESTRICTIONS
PENICILLIN ANTIBIOTICS
NATURAL PENICILLIN ANTIBIOTICS
penicillin g benzathine
BICILLIN L-A Brand QL 2 / 28 DAY(S)
1.2mm/2 ml syringe
BICILLIN L-A penicillin g benzathine Brand QL 4 / 30 DAY(S)

2.4mm/4ml syringe
penicillin g
benzathine/penicillin g
BICILLIN C-R procaine (pen g g 1.2mm/2 Brand QL 2 / 28 DAY(S)
ml syringe, pen g g 900-
300/2 syringe)
penicillin g
potassium/dextrose-water
PENICILLIN GK-
(pen g 1mm/50ml
ISO-OSM Generic
froz.piggy, pen g 2mm/50ml
DEXTROSE
froz.piggy, pen g 3mm/50ml
froz.piggy)
PENICILLIN G penicillin g procaine
PROCAINE 1.2mm/2 ml syringe
PENICILLIN G Generic
penicillin g sodium
SODIUM
penicillin v potassium (125
PENICILLIN V mg/5ml soln recon, 250 mg
Generic
POTASSIUM tablet, 250 mg/5ml soln
recon, 500 mg tablet)
AMINOPENICILLIN ANTIBIOTICS
amoxicillin (125 mg/5ml
susp recon, 125 mg tab
chew, 200 mg/5ml susp
recon, 250 mg capsule, 250
AMOXICILLIN Generic
mg/5ml susp recon, 250 mg
tab chew, 400 mg/5ml susp
recon, 500 mg tablet, 500
mg capsule, 875 mg tablet)

LIMITS &
RESTRICTIONS
amoxicillin/potassium
clavulanate (200-28.5/5
susp recon, 200-28.5mg tab
chew, 250-125 mg tablet, Generic
AMOXICILLIN-
250-62.5/5 susp recon,
CLAVULANATE
400-57mg/5 susp recon,
POTASS
400-57mg tab chew, 500-
125 mg tablet, 600-42.9/5
susp recon, 875-125 mg
tablet)
ampicillin sodium (1 g vial, 2
AMPICILLIN g vial, 2 g vial port, 10 g
Generic
SODIUM vial, 125 mg vial, 250 mg
vial, 500 mg vial)
ampicillin sodium/sulbactam Generic
UNASYN sodium (1.5 g vial, 3 g vial,
15 g vial)
ampicillin trihydrate (125
AMPICILLIN mg/5ml susp recon, 250 Generic
TRIHYDRATE mg/5ml susp recon, 250 mg
capsule, 500 mg capsule)
PENICILLINASE-RESISTANT PENICILLINS
DICLOXACILLIN dicloxacillin sodium (250 mg

SODIUM capsule, 500 mg capsule)
EXTENDED-SPECTRUM PENICILLINS
piperacillin
sodium/tazobactam sodium Generic
PIPERACILLIN- (2.25 g vial port, 2.25 g vial,
TAZOBACTAM 3.375 g vial, 3.375 g vial
port, 4.5 g vial, 4.5 g vial
port, 40.5 g vial)

LIMITS &
RESTRICTIONS
ANTIBACTERIALS, MISCELLANEOUS
GLYCOPEPTIDE ANTIBIOTICS
vancomycin hcl (1 g vial, 5

VANCOMYCIN g vial, 10 g vial, 500 mg vial
Generic
HCL port, 500 mg vial, 750 mg
vial port, 750 mg vial)
vancomycin hcl 125 mg QL 56 / 30 DAY(S)
VANCOCIN HCL Generic
capsule ST
vancomycin/0.9 % sod
VANCOMYCIN Generic
chloride 1.5g/500ml plast.
HCL-0.9% NACL
bag
LINCOMYCIN ANTIBIOTICS
clindamycin hcl (75 mg
CLEOCIN HCL capsule, 150 mg capsule, Generic
300 mg capsule)
CLEOCIN
clindamycin palmitate hcl Generic
PALMITATE
CLEOCIN clindamycin phosphate 150 Generic
PHOSPHATE mg/ml vial
ANTIBACTERIALS
AMINOGLYCOSIDE ANTIBIOTICS
amikacin sulfate (500

AMIKACIN
mg/2ml vial, 1000mg/4ml Generic
SULFATE
vial)
GENTAMICIN gentamicin sulfate 40 mg/ml
Generic
SULFATE vial
GENTAMICIN gentamicin sulfate/pf 20 Generic
SULFATE mg/2 ml vial
NEOMYCIN Generic
neomycin sulfate QL 90 / 30 DAY(S)
SULFATE

LIMITS &
RESTRICTIONS
TOBRAMYCIN tobramycin sulfate (10 Generic
SULFATE mg/ml vial, 40 mg/ml vial)
QUINOLONE ANTIBIOTICS
ciprofloxacin hcl (100 mg
CIPRO tablet, 250 mg tablet, 500 Generic QL 60 / 30 day(s)
mg tablet, 750 mg tablet)
ciprofloxacin lactate
Generic
CIPROFLOXACIN (200mg/20ml vial,
400mg/40ml vial)
levofloxacin (25 mg/ml vial,
LEVAQUIN Generic
250 mg tablet, 500 mg
levofloxacin/dextrose 5 % in
water (in 5 % 500mg/0.1l
LEVAQUIN piggyback, in 5 % Generic
750mg/.15l piggyback, in 5
% 250mg/50ml piggyback)
SULFONAMIDE ANTIBIOTICS (SYSTEMIC)
SULFADIAZINE sulfadiazine Generic QL 240 / 30 DAY(S)

sulfamethoxazole/trimethop
rim (80-16mg/ml vial, 200-
40mg/5 oral susp, 400mg- Generic
SULFATRIM
80mg tablet, 800-160/20
oral susp, 800-160 mg
tablet)
AZULFIDINE sulfasalazine 500 mg tablet Generic QL 240 / 60 DAY(S)
AZULFIDINE sulfasalazine 500 mg tablet Generic QL 240 / 60 DAY(S)

dr
TETRACYCLINE ANTIBIOTICS
doxycycline hyclate (50 mg
MORGIDOX capsule, 100 mg tablet, 100 Generic AL1 At least 8 yrs old
mg capsule, 100 mg vial)

LIMITS &
RESTRICTIONS
DOXY 100 doxycycline hyclate 100 mg Brand
vial AL1 At least 8 yrs old
doxycycline monohydrate
(50 mg tablet, 50 mg QL 60 / 30 DAY(S)
AVIDOXY Generic
capsule, 75 mg tablet, 100 AL1 At least 8 yrs old
mg capsule, 100 mg tablet)
doxycycline monohydrate
VIBRAMYCIN Generic AL1 9 to 16 yrs old
25 mg/5 ml susp recon
minocycline hcl (50 mg
MINOCIN Generic QL 60 / 30 day(s)
capsule, 75 mg capsule,
100 mg capsule) AL1 At least 8 yrs old
ANTIFUNGAL (SYSTEMIC)
ALLYLAMINE ANTIFUNGALS
terbinafine hcl 250 mg

LAMISIL Generic QL 168 / 28
tablet
AZOLE ANTIFUNGALS
fluconazole (10 mg/ml susp Generic QL 35 / 30 DAY(S)
DIFLUCAN recon, 40 mg/ml susp
recon) AL1 Up to 18 yrs old
fluconazole (100 mg tablet,

DIFLUCAN Generic
200 mg tablet)
DIFLUCAN Generic QL 4 / 30 DAY(S)

fluconazole 150 mg tablet
GL Female
DIFLUCAN fluconazole 50 mg tablet Generic QL 30 / 30 DAY(S)
KETOCONAZOLE ketoconazole 200 mg tablet Generic
POLYENE ANTIFUNGALS
amphotericin b lipid
ABELCET Brand
complex
NYSTATIN nystatin 100000/ml oral

susp

LIMITS &
RESTRICTIONS
NYSTATIN nystatin 500k unit tablet Generic QL 60 / 30 DAY(S)
ANTIFUNGALS, MISCELLANEOUS
griseofulvin ultramicrosize
QL 30 / 30 DAY(S)
GRIS-PEG (125 mg tablet, 250 mg Generic
tablet) AL1 Up to 12 yrs old
griseofulvin, microsize 125 QL 960 / 30 DAY(S)

GRISEOFULVIN Generic
mg/5ml oral susp AL1 Up to 12 yrs old
GRIFULVIN V griseofulvin, microsize 500 Generic QL 30 / 30 DAY(S)
mg tablet AL1 Up to 12 yrs old
ANTIMYCOBACTERIALS
ANTITUBERCULOSIS AGENTS
PASER aminosalicylic acid Brand QL 60 / 30 DAY(S)

SEROMYCIN cycloserine Generic QL 60 / 30 DAY(S)
ethambutol hcl 100 mg
MYAMBUTOL Generic QL 120 / 30 DAY(S)
tablet
MYAMBUTOL ethambutol hcl 400 mg Generic QL 90 / 30 DAY(S)

tablet
TRECATOR ethionamide Brand QL 90 / 30 DAY(S)
ISONIAZID isoniazid 100 mg tablet Generic QL 90 / 30 DAY(S)
ISONIAZID isoniazid 100 mg/ml vial Generic
ISONIAZID isoniazid 300 mg tablet Generic QL 30 / 30 DAY(S)
isoniazid 50 mg/5 ml QL 960 / 30 DAY(S)
ISONIAZID Generic
solution
PYRAZINAMIDE pyrazinamide Generic QL 120 / 30 DAY(S)
MYCOBUTIN rifabutin Generic QL 60 / 30 DAY(S)

ST
RIFADIN rifampin 150 mg capsule Generic QL 90 / 30 DAY(S)
RIFADIN rifampin 300 mg capsule Generic QL 60 / 30 DAY(S)

LIMITS &
RESTRICTIONS
RIFADIN rifampin 600 mg vial Generic
RIFAMATE rifampin/isoniazid Brand
rifampin/isoniazid/pyrazina
RIFATER Brand
mide
PRIFTIN rifapentine Brand
ANTIMYCOBACTERIALS, MISCELLANEOUS
dapsone (25 mg tablet, 100

DAPSONE Generic QL 30 / 30 DAY(S)
mg tablet)
ANTIRETROVIRALS
HIV ENTRY AND FUSION INHIBITORS
FUZEON enfuvirtide Brand

maraviroc (150 mg tablet, Brand QL 60 / 30 DAY(S)
SELZENTRY
300 mg tablet) ST
HIV PROTEASE INHIBITOR ANTIRETROVIRALS
atazanavir sulfate (150 mg

REYATAZ capsule, 200 mg capsule, Generic QL 60 / 30 DAY(S)
300 mg capsule)
atazanavir sulfate 50 mg QL 60 / 30 DAY(S)
REYATAZ Brand
powd pack
EVOTAZ atazanavir sulfate/cobicistat Brand QL 30 / 30 DAY(S)

ST
darunavir ethanolate (75 mg
PREZISTA tablet, 150 mg tablet, 600 Brand QL 60 / 30 DAY(S)
mg tablet) ST
darunavir ethanolate 100 QL 200 / 30 DAY(S)

PREZISTA Brand
mg/ml oral susp ST
PREZISTA darunavir ethanolate 800 Brand QL 30 / 30 DAY(S)
mg tablet ST
PREZCOBIX darunavir Brand QL 30 / 30 DAY(S)
ethanolate/cobicistat ST

LIMITS &
RESTRICTIONS
LEXIVA fosamprenavir calcium 50 Brand QL 840 / 30 day(s)
mg/ml oral susp ST
fosamprenavir calcium 700 QL 60 / 30 DAY(S)
LEXIVA Generic
mg tablet ST
indinavir sulfate 200 mg Brand
CRIXIVAN QL 360 / 30 day(s)
capsule
CRIXIVAN indinavir sulfate 400 mg QL 180 / 30 day(s)

Brand
capsule
lopinavir/ritonavir (100mg-
KALETRA 25mg tablet, 200mg-50mg Brand QL 180 / 30 DAY(S)
tablet) ST
lopinavir/ritonavir 400-100/5 QL 400 / 30 day(s)

KALETRA Generic
solution ST
VIRACEPT nelfinavir mesylate 250 mg Brand
tablet QL 270 / 30 DAY(S)
VIRACEPT nelfinavir mesylate 625 mg QL 120 / 30 DAY(S)

Brand
tablet
NORVIR ritonavir 100 mg capsule Brand QL 60 / 30 DAY(S)

ST
NORVIR ritonavir 100 mg tablet Generic QL 60 / 30 DAY(S)
NORVIR ritonavir 80 mg/ml solution Brand QL 90 / 30 DAY(S)

ST
saquinavir mesylate 200 mg
INVIRASE Brand QL 270 / 30 DAY(S)
capsule
INVIRASE saquinavir mesylate 500 mg Brand QL 120 / 30 DAY(S)

tablet
APTIVUS tipranavir Brand QL 120 / 30 DAY(S)
APTIVUS tipranavir/vitamin e tpgs Brand QL 300 / 30 DAY(S)
HIV INTEGRASE INHIBITOR ANTIRETROVIRALS
dolutegravir sodium (10 mg

TIVICAY tablet, 25 mg tablet, 50 mg Brand QL 30 / 30 day(s)
tablet)
PAGE 14
LAST UPDATED 12/2018
LIMITS &
RESTRICTIONS
VITEKTA elvitegravir (85 mg tablet, Brand
150 mg tablet) QL 1 / 1 DAY(S)
raltegravir potassium (25

ISENTRESS mg tab chew, 100 mg tab Brand QL 180 / 30 DAY(S)
chew)
raltegravir potassium 100
ISENTRESS Brand QL 60 / 30 DAY(S)
mg powd pack
ISENTRESS raltegravir potassium 400 Brand QL 60 / 365 day(s)

mg tablet
HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.
delavirdine mesylate 100

RESCRIPTOR Brand QL 360 / 30 DAY(S)
mg tab disper
delavirdine mesylate 200 Brand QL 180 / 30 DAY(S)
RESCRIPTOR
mg tablet
efavirenz (50 mg capsule,
SUSTIVA Brand QL 90 / 30 DAY(S)
200 mg capsule)
SUSTIVA efavirenz 600 mg tablet Generic QL 30 / 30 DAY(S)
HIV Nonnucleoside Reverse Transcriptase Inhibitors
efavirenz/lamivu/tenofov QL 30 / 30 day(s)
SYMFI Brand
disop 600-300mg tablet ST
HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.
etravirine (25 mg tablet, 200 QL 60 / 30 DAY(S)

INTELENCE Brand
mg tablet) ST
INTELENCE etravirine 100 mg tablet Brand QL 120 / 30 DAY(S)

ST
nevirapine (100 mg tab er
VIRAMUNE XR Generic QL 30 / 30 DAY(S)
24h, 400 mg tab er 24h)
VIRAMUNE nevirapine 200 mg tablet Generic QL 60 / 30 DAY(S)
nevirapine 50 mg/5 ml oral Generic QL 600 / 30 DAY(S)
VIRAMUNE
susp

LIMITS &
RESTRICTIONS
EDURANT rilpivirine hcl Brand QL 30 / 30 DAY(S)
ST
HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS
abacavir sulfate 20 mg/ml

ZIAGEN Brand QL 960 / 30 DAY(S)
solution
abacavir sulfate 300 mg QL 60 / 30 DAY(S)
ZIAGEN Generic
tablet
abacavir sulfate/dolutegravir QL 30 / 30 DAY(S)
TRIUMEQ Brand
sodium/lamivudine ST
EPZICOM abacavir sulfate/lamivudine Generic QL 30 / 30 DAY(S)
abacavir
TRIZIVIR sulfate/lamivudine/zidovudin Generic QL 60 / 30 DAY(S)
e
didanosine (125 mg capsule
dr, 200 mg capsule dr, 250 Generic
VIDEX EC QL 30 / 30 DAY(S)
mg capsule dr, 400 mg
capsule dr)
didanosine fnl10mg/ml soln QL 30 / 30 DAY(S)
VIDEX Brand
recon
efavirenz/emtricitabine/tenof Brand QL 30 / 30 DAY(S)
ATRIPLA
ovir disoproxil fumarate ST
elvitegravir/cobicistat/emtrici
GENVOYA tabine/tenofovir Brand QL 30 / 30 DAY(S)
alafenamide ST
elvitegravir/cobicistat/emtrici QL 30 / 30 DAY(S)
STRIBILD Brand
tabine/tenofovir disoproxil ST
EMTRIVA emtricitabine 10 mg/ml Brand
solution QL 60 / 30 DAY(S)
EMTRIVA emtricitabine 200 mg Brand QL 30 / 30 DAY(S)

capsule
emtricitabine/rilpivirine
ODEFSEY hcl/tenofovir alafenamide Brand QL 30 / 30 DAY(S)
fumarate ST

LIMITS &
RESTRICTIONS
emtricitabine/rilpivirine
COMPLERA hcl/tenofovir disoproxil Brand QL 30 / 30 DAY(S)
fumarate ST
emtricitabine/tenofovir (tdf)
TRUVADA Brand QL 30 / 30 day(s)
200-300 mg tablet
DESCOVY emtricitabine/tenofovir Brand QL 30 / 30 DAY(S)

alafenamide fumarate ST
emtricitabine/tenofovir
disoproxil fumarate (100-
TRUVADA Brand QL 30 / 30 DAY(S)
150 mg tablet, 133-200 mg
tablet, 167-250 mg tablet)
lamivudine 10 mg/ml QL 90 / 30 DAY(S)
EPIVIR Generic
solution ST
EPIVIR HBV lamivudine 100 mg tablet Generic
EPIVIR lamivudine 150 mg tablet Generic QL 60 / 30 DAY(S)

ST
EPIVIR lamivudine 300 mg tablet Generic QL 30 / 30 DAY(S)

ST
lamivudine/tenofovir QL 30 / 30 day(s)
CIMDUO Brand
disoproxil fumarate ST
COMBIVIR lamivudine/zidovudine Generic QL 60 / 30 DAY(S)
stavudine (15 mg capsule,
ZERIT 20 mg capsule, 30 mg Generic QL 60 / 30 DAY(S)
ZERIT stavudine 1 mg/ml soln Generic
recon QL 1800 / 30 day(s)
zidovudine (100 mg
RETROVIR Generic QL 60 / 30 DAY(S)
capsule, 300 mg tablet)
RETROVIR zidovudine 10 mg/ml syrup Generic QL 100 / 30 DAY(S)

LIMITS &
RESTRICTIONS
ANTIVIRALS (SYSTEMIC)
NEURAMINIDASE INHIBITOR ANTIVIRALS
oseltamivir phosphate (30

TAMIFLU Generic QL 10 / 365 DAY(S)
mg capsule, 45 mg capsule)
oseltamivir phosphate 6 Generic QL 120 / 365 DAY(S)
TAMIFLU mg/ml susp recon
oseltamivir phosphate 75
TAMIFLU Generic QL 125 / 365 DAY(S)
mg capsule
RELENZA zanamivir Brand QL 20 / 365 DAY(S)
NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS
acyclovir (200 mg capsule,

ZOVIRAX Generic QL 150 / 30 DAY(S)
800 mg tablet)
acyclovir 200 mg/5ml oral Generic QL 600 / 30 DAY(S)
ZOVIRAX
susp
valacyclovir hcl (500 mg Generic QL 60 / 30 DAY(S)
VALTREX tablet, 1000 mg tablet)
ANTIPROTOZOALS
AMEBICIDES
PAROMOMYCIN
paromomycin sulfate Generic QL 42 / 30 DAY(S)
SULFATE
ANTIMALARIALS
QL 120 / 30 DAY(S)
PLAQUENIL hydroxychloroquine sulfate Generic
PRIMAQUINE primaquine phosphate Generic
ANTIPROTOZOALS, MISCELLANEOUS
MEPRON atovaquone Generic ST
FLAGYL metronidazole (250 mg Generic


LIMITS &
RESTRICTIONS
METRO IV metronidazole in sodium Generic
chloride
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
pyrantel pamoate 250 mg

PIN-X Brand QL 4 / 30 day(s)
tab chew
PIN-X pyrantel pamoate 50 mg/ml Brand QL 30 / 30 day(s)

oral susp
URINARY ANTI-INFECTIVES
QL 280 / 365 DAY(S)

FURADANTIN nitrofurantoin Generic
AL1 Up to 18 yrs old
nitrofurantoin macrocrystal
MACRODANTIN (25 mg capsule, 50 mg
capsule, 100 mg capsule) AL1 Up to 64 yrs old
nitrofurantoin QL 30 / 30 DAY(S)
MACROBID Generic
monohydrate/macrocrystals AL1 Up to 64 yrs old
TRIMETHOPRIM trimethoprim 100 mg tablet Generic QL 28 / 30 DAY(S)
ANTICHOLINERGIC AGENTS
ANTIMUSCARINICS/ANTISPASMODICS
ATROPINE atropine sulfate (0.4 mg/ml

SULFATE vial, 0.8 mg/2ml syringe)
dicyclomine hcl 10 mg Generic QL 90 / 30 DAY(S)
BENTYL
capsule AL1 Up to 64 yrs old
DICYCLOMINE dicyclomine hcl 10 mg/5 ml Generic QL 960 / 30 DAY(S)
HCL solution AL1 Up to 64 yrs old
dicyclomine hcl 20 mg Generic QL 120 / 30 DAY(S)
BENTYL
tablet AL1 Up to 64 yrs old
glycopyrrolate (1 mg tablet, Generic QL 90 / 30 DAY(S)
ROBINUL FORTE
2 mg tablet) AL1 Up to 20 yrs old

LIMITS &
RESTRICTIONS
BEVESPI glycopyrrolate/formoterol Brand QL 10.7 / 30 day(s)
AEROSPHERE fumarate ST
IPRATROPIUM ipratropium bromide 0.2
BROMIDE mg/ml solution
ipratropium bromide 17mcg Brand QL 26 / 30 DAY(S)
ATROVENT HFA
hfa aer ad
DUONEB ipratropium/albuterol sulfate QL 360 / 30 DAY(S)

Generic
0.5-3mg/3 ampul-neb
COMBIVENT ipratropium/albuterol sulfate Brand QL 4 / 30 DAY(S)
RESPIMAT 20-100 mcg mist inhal
STIOLTO tiotropium QL 4 / 30 DAY(S)
Brand
RESPIMAT bromide/olodaterol hcl ST
INCRUSE
umeclidinium bromide Brand QL 30 / 30 DAY(S)
ELLIPTA
umeclidinium
ANORO ELLIPTA bromide/vilanterol Brand QL 60 / 30 DAY(S)
trifenatate ST
BETA-ADRENERGIC AGONISTS
SELECTIVE BETA-2-ADRENERGIC AGONISTS
albuterol sulfate
ACCUNEB (0.63mg/3ml vial-neb, 2.5 Generic QL 600 / 30 DAY(S)
mg/3ml vial-neb)
ACCUNEB albuterol sulfate
1.25mg/3ml vial-neb
ALBUTEROL albuterol sulfate 5 mg/ml Generic QL 80 / 30 DAY(S)
SULFATE solution
PROAIR albuterol sulfate 90 mcg aer Brand QL 2 / 60 DAY(S)
RESPICLICK pow ba
albuterol sulfate 90 mcg hfa QL 17 / 60 day(s)
PROAIR HFA Brand
aer ad
ARCAPTA QL 30 / 30 DAY(S)
indacaterol maleate Brand
NEOHALER

LIMITS &
RESTRICTIONS
UTIBRON indacaterol Brand QL 60 / 30 day(s)
NEOHALER maleate/glycopyrrolate ST
XOPENEX HFA levalbuterol tartrate Generic QL 15 / 30 DAY(S)

ST
METAPROTERE metaproterenol sulfate (10 Generic
NOL SULFATE mg tablet, 20 mg tablet) QL 30 / 30 DAY(S)
METAPROTERE metaproterenol sulfate 10 Generic QL 960 / 30 DAY(S)

NOL SULFATE mg/5 ml syrup
STRIVERDI Brand QL 4 / 30 DAY(S)
olodaterol hcl
RESPIMAT
TERBUTALINE terbutaline sulfate (2.5 mg QL 120 / 30 DAY(S)
Generic
SULFATE tablet, 5 mg tablet)
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ALPHA- AND BETA-ADRENERGIC AGONISTS
epinephrine (0.15/0.15 auto

AUVI-Q Brand QL 4 / 30 DAY(S)
injct, 0.3mg/0.3 auto injct)
epinephrine (0.15mg/0.3
ADRENACLICK auto injct, 0.15/0.15 auto Generic QL 4 / 30 DAY(S)
injct, 0.3mg/0.3 auto injct)
epinephrine (1 mg/ml vial, 1
ADRENALIN Brand QL 2 / 30 DAY(S)
mg/ml(1) vial)
EPINEPHRINE epinephrine 0.1 mg/ml QL 2 / 30 DAY(S)

Generic
syringe
SUDOGEST pseudoephedrine hcl (30 Generic QL 60 / 30 DAY(S)

ADULT NASAL
pseudoephedrine hcl 15
DECONGESTAN Brand QL 120 / 30 DAY(S)
mg/5 ml liquid
T
NASAL & SINUS
pseudoephedrine hcl 30 mg QL 60 / 30 DAY(S)
DECONGESTAN Brand
tablet
T
NASAL DECON
pseudoephedrine hcl 30
(PSEUDOEPHED Generic QL 118 / 30 DAY(S)
mg/5 ml liquid
RINE)

PAGE 21
LIMITS &
RESTRICTIONS
ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)
SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT
UROXATRAL alfuzosin hcl Generic QL 30 / 30 DAY(S)

RAPAFLO silodosin 4 mg capsule Generic
tamsulosin hcl (0.4 mg QL 60 / 30 DAY(S)

FLOMAX Generic
capsule, 0.4 mg cap er 24h)
SKELETAL MUSCLE RELAXANTS
CENTRALLY ACTING SKELETAL MUSCLE RELAXNT
QL 120 / 30 DAY(S)
SOMA carisoprodol 350 mg tablet Generic
cyclobenzaprine hcl 10 mg Generic QL 120 / 30 DAY(S)
FLEXERIL
FLEXERIL cyclobenzaprine hcl 5 mg Generic QL 90 / 30 DAY(S)
ROBAXIN-750 methocarbamol (500 mg Generic QL 120 / 30 DAY(S)
tablet, 750 mg tablet) AL1 Up to 64 yrs old
ROBAXIN methocarbamol 100 mg/ml Generic
vial AL1 Up to 64 yrs old
ZANAFLEX tizanidine hcl (2 mg tablet, 4 Generic QL 90 / 30 DAY(S)

mg tablet)
GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT
baclofen (10 mg tablet, 20

BACLOFEN Generic QL 120 / 30 DAY(S)
mg tablet)
AUTONOMIC DRUGS
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
donepezil hcl (5 mg tab QL 30 / 30 DAY(S)

ARICEPT ODT Generic
rapdis, 10 mg tab rapdis) AL1 At least 55 yrs old

LIMITS &
RESTRICTIONS
ARICEPT donepezil hcl (5 mg tablet, Generic QL 30 / 30 DAY(S)
10 mg tablet) AL1 At least 55 yrs old
galantamine hbr (16 mg
cap24h pel, 24 mg cap24h QL 30 / 30 DAY(S)
RAZADYNE ER Generic
pel) AL1 At least 55 yrs old
galantamine hbr (4 mg
RAZADYNE Generic QL 60 / 30 DAY(S)
tablet, 8 mg tablet, 12 mg
tablet) AL1 At least 55 yrs old
galantamine hbr 4 mg/ml QL 60 / 30 DAY(S)

RAZADYNE Generic
solution AL1 At least 55 yrs old
galantamine hbr 8 mg Generic QL 60 / 30 DAY(S)
RAZADYNE ER
cap24h pel AL1 At least 55 yrs old
rivastigmine tartrate (1.5 mg
capsule, 3 mg capsule, 4.5 QL 60 / 30 DAY(S)
EXELON Generic
mg capsule, 6 mg capsule) AL1 At least 55 yrs old
AUTONOMIC DRUGS, MISCELLANEOUS
nicotine (14mg/24hr patch

NICODERM CQ td24, 21 mg/24hr patch Generic QL 28 / 28 DAY(S)
td24)
NICOTROL nicotine 10 mg cartridge Brand QL 336 / 30 DAY(S)
NICOTROL NS nicotine 10 mg/ml spray Brand QL 120 / 30 DAY(S)
NICOTINE nicotine 21-14-7mg patch
PATCH dysq
nicotine polacrilex (2 mg Brand QL 360 / 30 DAY(S)
NICORELIEF
gum, 4 mg gum)
NICORETTE nicotine polacrilex 4 mg QL 360 / 30 DAY(S)

Generic
lozng mini
CHANTIX varenicline tartrate (0.5 mg Brand QL 56 / 28 DAY(S)

varenicline tartrate 0.5 (11)- QL 53 / 28 DAY(S)
CHANTIX Brand
1 tab ds pk

LIMITS &
RESTRICTIONS
ANTIANEMIA DRUGS
IRON PREPARATIONS
ferrous fumarate/folic
CENTRATEX acid/multivitamin-minerals Brand QL 30 / 30 DAY(S)
no.15 ST
ferrous fumarate/folic
acid/vitamin b comp and QL 30 / 30 day(s)
PARVLEX Brand
c/minerals AL1 Up to 5 yrs old
ferrous fumarate/liver
LIVER WITH
extract/vitamin b comp and Brand
IRON
c
ferrous gluconate
IRON (236(27)mg tablet, Generic QL 90 / 30 DAY(S)
256(28)mg tablet)
ferrous gluconate
FERATE (240(27)mg tablet,
324(38)mg tablet)
ferrous gluconate
FERGON Brand QL 90 / 30 DAY(S)
240(27)mg tablet
FERATE ferrous gluconate QL 90 / 30 DAY(S)

Brand
256(28)mg tablet
FERROUS ferrous gluconate 324(37.5)
Generic
GLUCONATE tablet
ferrous gluconate/lysine
APETIGEN-PLUS hcl/vit e/vit b cplex with Brand
c/zinc
ferrous sulfate (220 (44)/5
FERROUS
elixir, 220 (44)/5 solution, Generic QL 480 / 30 DAY(S)
SULFATE
300 mg/5ml liquid)
ferrous sulfate (47.5 iron
SLOW FE tablet er, 142(45)mg tablet Generic
er)
FEOSOL ferrous sulfate (mg tablet, Generic
mg tablet dr) QL 90 / 30 DAY(S)

LIMITS &
RESTRICTIONS
HIGH POTENCY ferrous sulfate 134 mg Brand
IRON tablet
FERROUS ferrous sulfate 140(45)mg
Generic
SULFATE tablet er
CHILDREN'S ferrous sulfate 15 mg/ml Generic
IRON drops QL 50 / 30 DAY(S)
ferrous sulfate 15 mg/ml Brand QL 50 / 30 DAY(S)

FER-IN-SOL
drops
MYKIDZ IRON 10 ferrous sulfate 15mg/1.5ml

Brand
oral susp
IRON ferrous sulfate 325(65) mg

Brand
capsule er
LYDIA PINKHAM ferrous sulfate/licorice root
Brand
HERBAL extract
IRON iron Generic QL 90 / 30 DAY(S)
iron amino acid
FERRACTIV
chelate/cyanocobalamin/foli Brand
IRON
c acid
iron bis-glycinate
Brand
MAXFE chelate/iron polysaccharide
cplx/b12/zinc
iron bisglycin/iron polysac
MAXFE Brand
complx/b12/biotin/magnesiu
m/zinc
iron fumarate-iron
FUSION Brand
polysaccharide combo
no.1/vit c/l. casei
iron fumarate/iron polysac
INTEGRA Brand
complex/vitamin
c/niacinamide
iron,carbonyl 15 mg tab
ICAR Generic QL 90 / 30 DAY(S)
chew
ICAR iron,carbonyl 15 mg tab Brand QL 90 / 30 DAY(S)

chew

LIMITS &
RESTRICTIONS
WEE CARE iron,carbonyl 15mg/1.25 Brand
oral susp
iron,carbonyl 18 mg tab
FERRETTS Brand
chew
PERFECT IRON iron,carbonyl 25 mg tablet Brand
FE C iron,carbonyl/ascorbic acid Brand

100-250 mg tablet
iron,carbonyl/ascorbic acid
VITRON-C Brand
65mg-125mg tablet dr
CHEWABLE iron,carbonyl/ascorbic
Generic
IRON acid/fructooligosaccharides
FERROCITE iron/folic ac/vit bcomp,c/min Brand QL 30 / 30 DAY(S)
PLUS 106 mg-1mg tablet ST
iron/folic acid/vit b complex
ABATRON no.16/mag sulfate/zinc Brand
sulfate
iron/folic acid/vit
ABATRON AF Brand
c/e/b12/biotin/cupric
sulf/docusate sod
iron/vit c/b12/b6/e/folic
IRO-PLEX Brand
acid/intrinsic factor/senna
leaf
iron/vit c/vit b12/calcium
Generic
CHROMAGEN threon/succinic
acid/stomach conc
ANTICOAGULANTS
COUMARIN DERIVATIVES
warfarin sodium (1 mg
tablet, 2 mg tablet, 2.5 mg
COUMADIN Brand QL 120 / 30 DAY(S)
tablet, 7.5 mg tablet, 10 mg
tablet)

LIMITS &
RESTRICTIONS
warfarin sodium (1 mg
COUMADIN tablet, 3 mg tablet, 4 mg Generic
tablet, 5 mg tablet, 6 mg QL 120 / 30 DAY(S)
tablet, 7.5 mg tablet, 10 mg
tablet)
HEPARINS
enoxaparin sodium (100

LOVENOX mg/ml syringe, 150 mg/ml Generic QL 20 / 10 DAY(S)
syringe)
enoxaparin sodium
LOVENOX (80mg/0.8ml syringe,
120mg/.8ml syringe)
enoxaparin sodium
LOVENOX Generic QL 21 / 10 DAY(S)
300mg/3ml vial
LOVENOX enoxaparin sodium Generic QL 6 / 10 DAY(S)

30mg/0.3ml syringe

40mg/0.4ml syringe

60mg/0.6ml syringe
heparin sodium,porcine
HEPARIN (1000/ml vial, 5000/ml vial,
SODIUM 10000/ml vial, 20000/ml
vial)
HEPARIN heparin sodium,porcine/pf
Generic
SODIUM (cartridge, vial)
MONOJECT heparin sodium,porcine/pf Brand
PREFILL 10 unit/ml syringe QL 2000 / 30 day(s)
MONOJECT heparin sodium,porcine/pf QL 2000 / 30 day(s)

Generic
PREFILL 10 unit/ml syringe
heparin sodium,porcine/pf Generic QL 2000 / 30 DAY(S)
HEPARIN FLUSH
10 unit/ml vial

LIMITS &
RESTRICTIONS
ANTITHROMBOTIC AGENTS
PLATELET-REDUCING AGENTS
anagrelide hcl 0.5 mg

AGRYLIN Generic QL 120 / 30 DAY(S)
capsule
ANAGRELIDE Generic QL 300 / 30 DAY(S)
anagrelide hcl 1 mg capsule
HCL
PLATELET-AGGREGATION INHIBITORS
cilostazol (50 mg tablet, 100

PLETAL Generic QL 60 / 30 DAY(S)
mg tablet)
PLAVIX clopidogrel bisulfate 75 mg Generic QL 30 / 30 DAY(S)

tablet
BLOOD FORMATION, COAGULATION, THROMBOSIS
HEMATOPOIETIC AGENTS
epoetin alfa (2000/ml vial,

3000/ml vial, 4000/ml vial,
EPOGEN Brand ST
10000/ml vial, 20000/2ml
vial, 20000/ml vial)
PROCRIT ST
epoetin alfa 40000/ml vial Brand
HEMORRHEOLOGIC AGENTS
TRENTAL pentoxifylline Generic QL 90 / 30 day(s)

ST
ANTIARRHYTHMIC AGENTS
CLASS IA ANTIARRHYTHMICS
disopyramide phosphate
QL 60 / 30 DAY(S)
NORPACE CR (100 mg capsule er, 150 mg Brand
capsule er) AL1 Up to 64 yrs old
disopyramide phosphate
NORPACE QL 120 / 30 DAY(S)
(100 mg capsule, 150 mg Generic
capsule) AL1 Up to 64 yrs old

LIMITS &
RESTRICTIONS
PROCAINAMIDE procainamide hcl 100 mg/ml Generic
HCL vial
QUINIDINE quinidine gluconate 324 mg
GLUCONATE tablet er
quinidine sulfate (200 mg
QUINIDINE QL 180 / 30 DAY(S)
tablet, 300 mg tablet er, 300 Generic
SULFATE
mg tablet)
CLASS IB ANTIARRHYTHMICS
lidocaine hcl/pf (50 mg/5 ml
LIDOCAINE HCL syringe, 100 mg/5ml Generic QL 50 / 30 day(s)
syringe)
mexiletine hcl (150 mg
MEXILETINE HCL capsule, 200 mg capsule,
250 mg capsule)
CLASS IC ANTIARRHYTHMICS
flecainide acetate (50 mg
TAMBOCOR tablet, 100 mg tablet, 150 Generic QL 60 / 30 DAY(S)
mg tablet)
propafenone hcl (150 mg
PROPAFENONE Generic QL 90 / 30 DAY(S)
tablet, 225 mg tablet, 300
HCL
mg tablet)
propafenone hcl (325 mg
RYTHMOL SR cap er 12h, 425 mg cap er Generic QL 60 / 30 DAY(S)
12h)
RYTHMOL SR propafenone hcl 225 mg Generic QL 30 / 30 DAY(S)
cap er 12h
CLASS III ANTIARRHYTHMICS
amiodarone hcl 100 mg

PACERONE Generic QL 60 / 30 DAY(S)
tablet
CORDARONE amiodarone hcl 200 mg Generic QL 90 / 30 DAY(S)

tablet
PACERONE amiodarone hcl 400 mg Generic QL 30 / 30 DAY(S)

tablet

LIMITS &
RESTRICTIONS
CARDIAC DRUGS
CARDIOTONIC AGENTS
digoxin (62.5 mcg tablet,
QL 30 / 30 DAY(S)
LANOXIN 187.5 mcg tablet, 250 mcg Brand
QL 60 / 30 DAY(S)
DIGITEK digoxin 125 mcg tablet Generic
LANOXIN digoxin 125 mcg tablet Brand QL 60 / 30 DAY(S)
DIGITEK digoxin 250 mcg tablet QL 30 / 30 DAY(S)
Generic
DIGOXIN digoxin 50 mcg/ml solution Generic QL 120 / 30 DAY(S)
ANTILIPEMIC AGENTS
BILE ACID SEQUESTRANTS
cholestyramine (with sugar)

QUESTRAN Generic QL 378 / 30 DAY(S)
4 g powd pack
PREVALITE cholestyramine/aspartame Generic QL 378 / 30 DAY(S)

4 g powd pack
COLESTID colestipol hcl 1 g tablet Generic QL 60 / 30 DAY(S)
COLESTID colestipol hcl 5 g packet Generic QL 120 / 30 DAY(S)
FIBRIC ACID DERIVATIVES
fenofibrate (54 mg tablet,

LOFIBRA Generic QL 30 / 30 DAY(S)
160 mg tablet)
TRICOR fenofibrate nanocrystallized Generic QL 30 / 30 DAY(S)

(48 mg tablet, 145mg tablet)
fenofibrate,micronized (43
mg capsule, 67 mg capsule,
LOFIBRA Generic QL 30 / 30 DAY(S)
134 mg capsule, 200 mg
capsule)
PAGE 30
LIMITS &
RESTRICTIONS
FIBRICOR fenofibric acid (35 mg Generic
tablet, 105 mg tablet) QL 30 / 30 DAY(S)
fenofibric acid (choline) 45

TRILIPIX Generic QL 30 / 30 DAY(S)
mg capsule dr
LOPID gemfibrozil Generic QL 60 / 30 DAY(S)
HMG-COA REDUCTASE INHIBITORS

atorvastatin calcium (10 mg
LIPITOR tablet, 20 mg tablet, 40 mg Generic QL 30 / 30 DAY(S)
lovastatin (10 mg tablet, 20
MEVACOR Generic QL 30 / 30 DAY(S)
mg tablet)
MEVACOR lovastatin 40 mg tablet Generic QL 60 / 30 DAY(S)
pravastatin sodium (10 mg
PRAVACHOL tablet, 20 mg tablet, 40 mg Generic QL 30 / 30 DAY(S)
rosuvastatin calcium (5 mg
CRESTOR Generic QL 30 / 30 DAY(S)
simvastatin (5 mg tablet, 10
ZOCOR Generic QL 30 / 30 DAY(S)
mg tablet, 20 mg tablet, 40
mg tablet)
ANTILIPEMIC AGENTS, MISCELLANEOUS
niacin (250 mg tablet er,

ENDUR-ACIN Brand QL 60 / 30 DAY(S)
500 mg tablet er)
NO FLUSH niacin (inositol niacinate) QL 120 / 30 DAY(S)
Generic
NIACIN 400(500mg) capsule
LOVAZA omega-3 acid ethyl esters Generic QL 120 / 30 day(s)

ST
omega-3 fatty
acids/dha/epa/other omega-
3s/fish oil (oil 300-1000mg QL 120 / 30 day(s)
FISH OIL Generic
capsule dr, oil 720-1200mg ST
capsule, oil 720-1200mg
capsule dr)

LIMITS &
RESTRICTIONS
omega-3 fatty
acids/docosahexanoic
FISH OIL acid/epa/fish oil (oil 60 mg- Generic QL 120 / 30 day(s)
90mg capsule dr, oil 300- ST
1000mg capsule dr, oil 900-
1400mg capsule dr)
omega-3 fatty acids/fish oil QL 120 / 30 day(s)
SEA-OMEGA 30 Generic
360-1200mg capsule ST
FISH OIL omega-3 fatty acids/fish oil Generic QL 120 / 30 day(s)
435-880mg capsule ST
FISH OIL omega-3s/dha/epa/fish oil Generic QL 120 / 30 day(s)
OMEGA-3 980-1400mg capsule dr ST
HYPOTENSIVE AGENTS
CENTRAL ALPHA-AGONISTS
clonidine hcl (0.1 mg tablet,

CATAPRES Generic QL 90 / 30 DAY(S)
0.2 mg tablet)
CATAPRES clonidine hcl 0.3 mg tablet Generic QL 120 / 30 DAY(S)
TENEX Generic QL 90 / 30 DAY(S)

guanfacine hcl 1 mg tablet
guanfacine hcl 2 mg tablet QL 30 / 30 DAY(S)
TENEX Generic
methyldopa 250 mg tablet Generic QL 90 / 30 DAY(S)
METHYLDOPA
METHYLDOPA methyldopa 500 mg tablet Generic QL 120 / 30 DAY(S)
METHYLDOPA- methyldopa/hydrochlorothia
HYDROCHLORO zide (250mg-25mg tablet, QL 30 / 30 DAY(S)
Generic
THIAZIDE 250mg-15mg tablet) AL1 Up to 64 yrs old
DIRECT VASODILATORS
hydralazine hcl (10 mg

HYDRALAZINE
tablet, 25 mg tablet, 50 mg Generic QL 120 / 30 DAY(S)
HCL
tablet)

LIMITS &
RESTRICTIONS
HYDRALAZINE hydralazine hcl 100 mg Generic
HCL tablet QL 90 / 30 DAY(S)
MINOXIDIL minoxidil 10 mg tablet Generic QL 180 / 30 DAY(S)

MINOXIDIL minoxidil 2.5 mg tablet Generic QL 120 / 30 DAY(S)
PERIPHERAL ADRENERGIC INHIBITORS
reserpine (0.1 mg tablet,

RESERPINE Generic AL1 Up to 64 yrs old
0.25 mg tablet)
VASODILATING AGENTS
NITRATES AND NITRITES
isosorbide dinitrate (5 mg
ISOSORBIDE
DINITRATE
tablet)
ISOSORBIDE isosorbide dinitrate 20 mg
DINITRATE tablet
isosorbide dinitrate 40 mg Generic QL 120 / 30 DAY(S)
ISOCHRON
tablet er
MONOKET isosorbide mononitrate (10 Generic QL 30 / 30 DAY(S)

isosorbide mononitrate (30
IMDUR mg tab er 24h, 60 mg tab er Generic QL 30 / 30 DAY(S)
24h, 120 mg tab er 24h)
nitroglycerin (0.1mg/hr
patch td24, 0.2mg/hr patch
td24, 0.3 mg/hr patch td24, Brand 30 / 30 DAY(S)
NITRO-DUR
0.4mg/hr patch td24,
0.6mg/hr patch td24,
0.8mg/hr patch td24)
nitroglycerin (0.1mg/hr
patch td24, 0.2mg/hr patch
MINITRAN Generic QL 30 / 30 DAY(S)
td24, 0.4mg/hr patch td24,
0.6mg/hr patch td24)
nitroglycerin (0.3 mg tab Generic
NITROSTAT subl, 0.4 mg tab subl, 0.6 QL 150 / 30 DAY(S)
mg tab subl)
PAGE 33
LIMITS &
RESTRICTIONS
NITRO-BID nitroglycerin 2 % oint. (g) Brand QL 60 / 30 DAY(S)
VASODILATING AGENTS, MISCELLANEOUS
ALPROSTADIL alprostadil 500 mcg/ml vial Generic
AGGRENOX aspirin/dipyridamole Generic QL 60 / 30 DAY(S)

ST
dipyridamole (25 mg tablet, QL 120 / 30 DAY(S)
PERSANTINE Generic
75 mg tablet) AL1 Up to 64 yrs old
PERSANTINE Generic QL 240 / 30 DAY(S)
dipyridamole 50 mg tablet
CALCIUM-CHANNEL BLOCKING AGENTS
DIHYDROPYRIDINES
amlodipine besylate (2.5 mg

NORVASC tablet, 5 mg tablet, 10 mg Generic QL 30 / 30 DAY(S)
tablet)
amlodipine
besylate/benazepril hcl
(2.5mg-10mg capsule, 5
LOTREL Generic 30 / 30 DAY(S)
mg-40 mg capsule, 5 mg-20
mg capsule, 5 mg-10 mg
capsule, 10 mg-40mg
capsule, 10 mg-20mg
capsule)
amlodipine
besylate/valsartan (5 mg-
EXFORGE 160mg tablet, 5 mg-320mg Generic QL 30 / 30 DAY(S)
tablet, 10mg-160mg tablet,
10mg-320mg tablet)
felodipine (2.5 mg tab er QL 30 / 30 DAY(S)
FELODIPINE ER 24h, 5 mg tab er 24h, 10 Generic
mg tab er 24h)
ISRADIPINE isradipine (2.5 mg capsule, Generic QL 30 / 30 DAY(S)
5 mg capsule) ST

LIMITS &
RESTRICTIONS
nifedipine (30 mg tablet er,
NIFEDICAL XL 30 mg tab er 24, 60 mg Generic
tablet er, 60 mg tab er 24, QL 30 / 30 DAY(S)
90 mg tab er 24, 90 mg
tablet er)
PROCARDIA nifedipine 10 mg capsule Generic QL 120 / 30 DAY(S)
NIFEDIPINE nifedipine 20 mg capsule Generic QL 120 / 30 day(s)
CALCIUM-CHANNEL BLOCKING AGENTS, MISC.
diltiazem hcl (120 mg cap er

24h, 180 mg tab er 24h,
180 mg cap er 24h, 240 mg
tab er 24h, 240 mg cap er
CARDIZEM CD 24h, 300 mg cap er 24h, Generic QL 30 / 30 DAY(S)
300 mg tab er 24h, 360 mg
cap er 24h, 360 mg tab er
24h, 420 mg tab er 24h,
420 mg cap sa 24h)
diltiazem hcl (30 mg tablet,
CARDIZEM Generic QL 120 / 30 DAY(S)
60 mg tablet)
diltiazem hcl (60 mg cap er
DILTIAZEM 12HR Generic QL 60 / 30 DAY(S)
12h, 90 mg cap er 12h, 120
ER
mg cap er 12h)
diltiazem hcl (90 mg tablet, Generic QL 90 / 30 DAY(S)
CARDIZEM
120 mg tablet)
verapamil hcl (100 mg
cap24h pct, 200 mg cap24h Generic QL 30 / 30 DAY(S)
VERELAN PM
pct, 300 mg cap24h pct)
verapamil hcl (120 mg
cap24h pel, 180 mg tablet
CALAN SR er, 180 mg cap24h pel, 240 Generic QL 30 / 30 DAY(S)
mg cap24h pel, 240 mg
tablet er)
CALAN verapamil hcl (40 mg tablet, Generic QL 90 / 30 DAY(S)
80 mg tablet, 120 mg tablet)

LIMITS &
RESTRICTIONS
CALAN SR verapamil hcl 120 mg tablet Generic
er QL 90 / 30 DAY(S)
VERELAN verapamil hcl 360 mg QL 30 / 30 DAY(S)

Generic
cap24h pel
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
benazepril hcl (5 mg tablet,

LOTENSIN Generic QL 30 / 30 DAY(S)
LOTENSIN benazepril hcl 40 mg tablet Generic QL 60 / 30 DAY(S)
benazepril
hcl/hydrochlorothiazide (5-
LOTENSIN HCT Generic QL 30 / 30 DAY(S)
6.25mg tablet, 10-12.5mg
tablet, 20 mg-25mg tablet)
benazepril/hydrochlorothiazi Generic QL 60 / 30 DAY(S)
LOTENSIN HCT
de 20-12.5 mg tablet
captopril/hydrochlorothiazid
CAPTOPRIL- e (25 mg-25mg tablet, 25
HYDROCHLORO mg-15mg tablet, 50 mg- Generic QL 90 / 30 DAY(S)
THIAZIDE 15mg tablet, 50 mg-25mg
tablet)
enalapril maleate (2.5 mg
VASOTEC tablet, 5 mg tablet, 10 mg Generic QL 30 / 30 DAY(S)
tablet)
VASOTEC enalapril maleate 20 mg Generic QL 60 / 30 DAY(S)
tablet
enalapril
ENALAPRIL-
maleate/hydrochlorothiazide
HYDROCHLORO Generic QL 30 / 30 DAY(S)
(5mg-12.5mg tablet, 10 mg-
THIAZIDE
25mg tablet)
FOSINOPRIL fosinopril sodium (10 mg
SODIUM tablet, 20 mg tablet)
FOSINOPRIL fosinopril sodium 40 mg Generic QL 60 / 30 DAY(S)
SODIUM tablet

LIMITS &
RESTRICTIONS
lisinopril (2.5 mg tablet, 5
ZESTRIL mg tablet, 10 mg tablet, 20 Generic
mg tablet, 30 mg tablet, 40 QL 30 / 30 DAY(S)
mg tablet)
lisinopril/hydrochlorothiazid
e (10-12.5mg tablet, 20 mg-
PRINZIDE Generic QL 30 / 30 DAY(S)
25mg tablet, 20-12.5 mg
tablet)
UNIVASC moexipril hcl (7.5 mg tablet, Generic QL 30 / 30 DAY(S)
15 mg tablet)
moexipril
hcl/hydrochlorothiazide
UNIRETIC (7.5-12.5mg tablet, 15- Generic QL 30 / 30 day(s)
12.5mg tablet, 15-25mg
tablet)
perindopril erbumine (2 mg
ACEON tablet, 4 mg tablet, 8 mg Generic QL 30 / 30 DAY(S)
tablet)
quinapril hcl (5 mg tablet,
ACCUPRIL 10 mg tablet, 20 mg tablet,
40 mg tablet)
quinapril
hcl/hydrochlorothiazide (10-
ACCURETIC Generic QL 30 / 30 DAY(S)
12.5mg tablet, 20-12.5 mg
ALTACE ramipril (1.25 mg capsule, Generic QL 30 / 30 DAY(S)

2.5 mg capsule, 5 mg
trandolapril (1 mg tablet, 2
MAVIK Generic QL 30 / 30 DAY(S)
mg tablet)
MAVIK trandolapril 4 mg tablet Generic QL 60 / 30 DAY(S)
ANGIOTENSIN II RECEPTOR ANTAGONISTS
irbesartan (75 mg tablet,

AVAPRO 150 mg tablet, 300 mg Generic QL 30 / 30 DAY(S)
tablet)
PAGE 37
LIMITS &
RESTRICTIONS
irbesartan/hydrochlorothiazi
AVALIDE de (150-12.5mg tablet, 300- Generic
QL 30 / 30 DAY(S)
12.5mg tablet)
losartan potassium (25 mg
COZAAR tablet, 50 mg tablet, 100 mg Generic QL 30 / 30 DAY(S)
tablet)
losartan
HYZAAR potassium/hydrochlorothiazi Generic
de (50-12.5 mg tablet, QL 30 / 30 DAY(S)
100mg-25mg tablet, 100-
12.5mg tablet)
telmisartan (20 mg tablet, QL 30 / 30 DAY(S)
MICARDIS Generic
telmisartan/hydrochlorothiaz
ide (40-12.5 mg tablet, 80 Generic QL 30 / 30 DAY(S)
MICARDIS HCT
mg-25mg tablet, 80-12.5mg ST
tablet)
valsartan (40 mg tablet, 80
DIOVAN mg tablet, 160 mg tablet, Generic QL 30 / 30 DAY(S)
320 mg tablet)
valsartan/hydrochlorothiazid
e (80-12.5mg tablet, 160- Generic QL 30 / 30 DAY(S)
DIOVAN HCT 12.5mg tablet, 160-25mg
tablet, 320mg-25mg tablet,
320-12.5mg tablet)
MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS
INSPRA eplerenone 25 mg tablet Generic QL 30 / 30 day(s)

ST
INSPRA eplerenone 50 mg tablet Generic QL 60 / 30 day(s)

ST
spironolact/hydrochlorothiaz Generic
ALDACTAZIDE QL 30 / 30 DAY(S)
id 25 mg-25mg tablet
spironolactone (25 mg
ALDACTONE tablet, 50 mg tablet, 100 mg Generic QL 60 / 30 DAY(S)
tablet)

LIMITS &
RESTRICTIONS
CARDIOVASCULAR DRUGS
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate (1 mg
CARDURA tablet, 2 mg tablet, 4 mg Generic QL 90 / 30 DAY(S)
tablet)
doxazosin mesylate 8 mg Generic QL 60 / 30 DAY(S)
CARDURA
tablet
terazosin hcl (1 mg capsule,
2 mg capsule, 5 mg Generic QL 60 / 30 DAY(S)
TERAZOSIN HCL
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl (200 mg

SECTRAL Generic QL 90 / 30 DAY(S)
atenolol (25 mg tablet, 50 Generic QL 60 / 30 DAY(S)
TENORMIN mg tablet, 100 mg tablet)
atenolol/chlorthalidone (50
TENORETIC 100 mg-25mg tablet, 100mg- Generic QL 30 / 30 DAY(S)
25mg tablet)
betaxolol hcl (10 mg tablet,
KERLONE Generic QL 30 / 30 DAY(S)
20 mg tablet)
ZEBETA bisoprolol fumarate 10 mg Generic QL 60 / 30 DAY(S)

tablet
ZEBETA bisoprolol fumarate 5 mg Generic QL 30 / 30 DAY(S)

tablet
bisoprolol
fumarate/hydrochlorothiazid
ZIAC e (2.5-6.25mg tablet, 5- Generic QL 30 / 30 DAY(S)
6.25mg tablet, 10-6.25mg
tablet)
carvedilol (3.125 mg tablet, Generic QL 60 / 30 DAY(S)
COREG 6.25 mg tablet, 12.5 mg

LIMITS &
RESTRICTIONS
labetalol hcl (100 mg tablet,
TRANDATE 200 mg tablet, 300 mg Generic
QL 120 / 30 DAY(S)
tablet)
metoprolol succinate (25
TOPROL XL mg tab er 24h, 50 mg tab er Generic QL 30 / 30 DAY(S)
24h, 100 mg tab er 24h)
TOPROL XL metoprolol succinate 200 Generic QL 60 / 30 DAY(S)
mg tab er 24h
metoprolol tartrate (25 mg
METOPROLOL Generic QL 60 / 30 DAY(S)
tablet, 37.5 mg tablet, 50
TARTRATE
metoprolol tartrate 100 mg Generic QL 120 / 30 DAY(S)
LOPRESSOR
tablet
metoprolol
tartrate/hydrochlorothiazide
LOPRESSOR
(50 mg-25mg tablet, Generic QL 30 / 30 DAY(S)
HCT
100mg-25mg tablet,
100mg-50mg tablet)
nadolol (20 mg tablet, 40 QL 30 / 30 DAY(S)
CORGARD Generic
mg tablet, 80 mg tablet) ST
CORZIDE nadolol/bendroflumethiazide Generic
(40 mg tablet, 80 mg tablet) QL 30 / 30 DAY(S)
PINDOLOL pindolol 10 mg tablet Generic QL 180 / 30 day(s)

ST
PINDOLOL pindolol 5 mg tablet Generic QL 60 / 30 day(s)
ST
PROPRANOLOL propranolol hcl (10 mg Generic
HCL tablet, 80 mg tablet) QL 120 / 30 DAY(S)
propranolol hcl (20 mg

PROPRANOLOL
HCL
tablet)
PROPRANOLOL propranolol hcl (20 mg/5 ml
HCL solution, 40mg/5ml solution)
propranolol hcl (60 mg cap Generic QL 30 / 30 DAY(S)
INDERAL LA
sa 24h, 160 mg cap sa 24h)

LIMITS &
RESTRICTIONS
PROPRANOLOL- propranolol
HYDROCHLORO hcl/hydrochlorothiazide (40 Generic
QL 30 / 30 DAY(S)
THIAZID tablet, 80 tablet)
sotalol hcl (80 mg tablet,
BETAPACE 120 mg tablet, 160 mg Generic QL 60 / 30 DAY(S)
tablet)
BETAPACE sotalol hcl 240 mg tablet Generic QL 30 / 30 DAY(S)
TIMOLOL timolol maleate (5 mg Generic QL 60 / 30 DAY(S)
MALEATE tablet, 10 mg tablet)
TIMOLOL
timolol maleate 20 mg tablet Generic QL 90 / 30 DAY(S)
MALEATE
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
CYCLOOXYGENASE-2 (COX-2) INHIBITORS
celecoxib (100 mg capsule,

CELEBREX Generic QL 30 / 30 DAY(S)
200 mg capsule)
SALICYLATES
ASPIRIN aspirin 325 mg tablet Generic QL 100 / 30 DAY(S)

ASPIR-TRIN aspirin 325 mg tablet dr Generic QL 100 / 30 DAY(S)
ECPIRIN aspirin 325 mg tablet dr Brand QL 100 / 30 DAY(S)
ST. JOSEPH QL 30 / 30 DAY(S)
aspirin 81 mg tab chew Brand
ASPIRIN MF 100 / FILL
aspirin 81 mg tab chew QL 30 / 30 DAY(S)

BABY ASPIRIN Generic
MF 100 / FILL
MINIPRIN aspirin 81 mg tablet dr Brand QL 60 / 30 DAY(S)

MF 100 / FILL
aspirin 81 mg tablet dr QL 60 / 30 DAY(S)

ADULT ASPIRIN Generic
MF 100 / FILL
BUFFERIN aspirin/calcium Generic

carbonate/magnesium QL 100 / 30 DAY(S)
QL 60 / 30 day(s)
butalbital/aspirin/caffeine
FIORINAL Generic AL1 Up to 64 yrs old
50-325-40 capsule
MF 360 / 365 day(s)
PAGE 41
LIMITS &
RESTRICTIONS
choline
CHOLINE MAG Generic
salicylate/magnesium QL 240 / 30 DAY(S)
TRISALICYLATE
salicylate
PAIN RELIEVING methyl salicylate/menthol
Brand
CREAM 15 %-1 % cream (g)
trolamine salicylate 10 % Brand
ANALGESIC
cream (g)
ANALGESIC trolamine salicylate 10 % Generic

cream (g)
ASPERCREME trolamine salicylate 10 % Brand

lotion
OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS
DICLOFENAC diclofenac sodium (25 mg

SODIUM tablet dr, 75 mg tablet dr)
diclofenac sodium 1 % gel Generic QL 100 / 30 DAY(S)
VOLTAREN
(gram)
diclofenac sodium 100 mg Generic QL 60 / 30 day(s)
VOLTAREN-XR
tab er 24h
DICLOFENAC diclofenac sodium 50 mg Generic QL 90 / 30 DAY(S)
SODIUM tablet dr
etodolac (200 mg capsule,
ETODOLAC 300 mg capsule, 400 mg Generic QL 90 / 30 DAY(S)
tablet)
ETODOLAC etodolac 500 mg tablet Generic QL 60 / 30 DAY(S)
ANSAID flurbiprofen 100 mg tablet Generic QL 60 / 30 DAY(S)
ibuprofen (100 mg tab
ADVIL chew, 100 mg tablet, 200 Brand QL 120 / 30 DAY(S)
mg tablet)
ibuprofen (100 mg tab
chew, 100 mg tablet, 200
IBU mg tablet, 400 mg tablet, Generic QL 120 / 30 DAY(S)
tablet)

LIMITS &
RESTRICTIONS
ibuprofen (400 mg tablet,
IBU 600 mg tablet, 800 mg Brand
QL 120 / 30 DAY(S)
tablet)
CHILD ibuprofen 100 mg/5ml oral
IBUPROFEN susp
WAL-PROFEN ibuprofen 200 mg capsule Brand QL 120 / 30 DAY(S)
CHILDREN'S ibuprofen 50 mg/1.25 drops QL 30 / 30 DAY(S)
Generic
IBUPROFEN susp
ibuprofen 50 mg/1.25 drops
INFANTS' ADVIL Brand QL 30 / 30 DAY(S)
susp
INDOMETHACIN indomethacin (25 mg QL 90 / 30 DAY(S)

Generic
capsule, 50 mg capsule) AL1 Up to 64 yrs old
INDOMETHACIN indomethacin 75 mg
Generic AL1 Up to 64 yrs old
ER capsule er
INDOCIN I.V. indomethacin sodium Generic AL1 Up to 64 yrs old
ketoprofen (50 mg capsule, Generic QL 90 / 30 DAY(S)
KETOPROFEN
75 mg capsule)
meloxicam (7.5 mg tablet,
MOBIC Generic QL 30 / 30 DAY(S)
15 mg tablet)
NABUMETONE nabumetone 500 mg tablet Generic QL 60 / 30 DAY(S)
NABUMETONE nabumetone 750 mg tablet Generic QL 120 / 30 DAY(S)
naproxen (250 mg tablet,
NAPROSYN 375 mg tablet, 500 mg Generic QL 60 / 30 DAY(S)
tablet)
naproxen 125 mg/5ml oral
NAPROSYN Generic QL 480 / 30 DAY(S)
susp
FELDENE piroxicam (10 mg capsule, Generic QL 30 / 30 DAY(S)

20 mg capsule)
sulindac (150 mg tablet, Generic QL 60 / 30 DAY(S)
SULINDAC
200 mg tablet)

LIMITS &
RESTRICTIONS
ANALGESICS AND ANTIPYRETICS
OPIATE AGONISTS
acetaminophen with
ACETAMINOPHE QL 360 / 30 DAY(S)
codeine 120-12mg/5 Generic
N-CODEINE AL1 At least 13 yrs old
solution
acetaminophen with
ACETAMINOPHE codeine phosphate (300mg- Generic QL 120 / 30 day(s)
N-CODEINE 15mg tablet, 300mg-60mg AL1 At least 13 yrs old
tablet, 300mg-30mg tablet)
codeine sulfate (15 mg Generic
CODEINE QL 120 / 30 DAY(S)
SULFATE AL1 At least 13 yrs old
tablet)
fentanyl (12 mcg/hr patch
td72, 25 mcg/hr patch td72,
37.5mcg/hr patch td72,
50mcg/hr patch td72,
DURAGESIC Generic QL 10 / 30 DAY(S)
62.5mcg/hr patch td72,
75mcg/hr patch td72,
87.5mcg/hr patch td72, 100
mcg/hr patch td72)
hydrocodone
bitartrate/acetaminophen (5 Generic
LORCET PLUS mg-325mg tablet, 7.5-325 QL 60 / 30 day(s)
mg tablet, 10mg-325mg
tablet)
DILAUDID hydromorphone hcl (1

mg/ml liquid, 2 mg tablet, 4 Generic QL 240 / 30 DAY(S)
hydromorphone hcl (2
HYDROMORPHO mg/ml vial, 2 mg/ml syringe, Generic QL 60 / 30 DAY(S)
NE HCL 2 mg/ml ampul, 2 mg/ml
cartridge, 4 mg/ml ampul)
hydromorphone hcl/pf (2 Generic QL 60 / 30 DAY(S)
DILAUDID-HP mg/ml vial, 10 mg/ml vial,
10 mg/ml ampul)
PAGE 44
LIMITS &
RESTRICTIONS
LEVORPHANOL Generic
levorphanol tartrate QL 240 / 30 DAY(S)
TARTRATE
MORPHINE morphine sulfate (10 ml QL 960 / 30 DAY(S)
Generic
SULFATE solution, 20 ml solution)
morphine sulfate (15 mg QL 90 / 30 DAY(S)
MS CONTIN Generic
tablet er, 60 mg tablet er)
MORPHINE morphine sulfate (15 mg QL 360 / 30 DAY(S)
Generic
SULFATE tablet, 30 mg tablet)
morphine sulfate (4 mg/ml
MORPHINE cartridge, 5 mg/ml syringe,
SULFATE 8 mg/ml vial, 10 mg/ml
syringe)
morphine sulfate (5 mg
supp.rect, 10 mg supp.rect, Generic QL 120 / 30 DAY(S)
MORPHINE
20 mg supp.rect, 30 mg
SULFATE
supp.rect, 100 mg/5ml
solution)
morphine sulfate 30 mg
MS CONTIN Generic QL 120 / 30 DAY(S)
tablet er
MORPHINE morphine sulfate/pf Generic QL 60 / 30 DAY(S)
SULFATE 150mg/30ml pca vial
oxycodone hcl (10 mg tab
er 12h, 15 mg tab er 12h,
OXYCONTIN 20 mg tab er 12h, 30 mg Generic QL 60 / 30 DAY(S)
tab er 12h, 40 mg tab er
12h)
oxycodone hcl (5 mg
capsule, 5 mg tablet, 10 mg Generic 240 / 30 DAY(S)
ROXICODONE
OXYCODONE oxycodone hcl 20 mg/ml
HCL oral conc
OXYCODONE oxycodone hcl 5 mg/5 ml Generic QL 960 / 30 DAY(S)
HCL solution

LIMITS &
RESTRICTIONS
oxycodone
ENDOCET hcl/acetaminophen 5 mg- Generic
QL 60 / rx
325mg tablet
QL 120 / 30 DAY(S)
ULTRAM tramadol hcl 50 mg tablet Generic
AL1 At least 18 yrs old
tramadol Generic
ULTRACET QL 180 / 30 DAY(S)
hcl/acetaminophen
ANALGESICS AND ANTIPYRETICS, MISC.
acetaminophen (160
CHILDREN'S QL 240 / 30 DAY(S)
mg/5ml elixir, 650mg/20.3 Generic
NON-ASPIRIN AL1 Up to 20 yrs old
solution)
acetaminophen (325 mg Brand
PHARBETOL
acetaminophen (80 mg tab
JR PAIN & rapdis, 80 mg tab chew, QL 120 / 30 DAY(S)
Generic
FEVER 160 mg tab rapdis, 325 mg AL1 Up to 20 yrs old
capsule)
acetaminophen 120 mg QL 30 / 30 DAY(S)
ACEPHEN Generic
supp.rect AL1 Up to 20 yrs old
8 HOUR acetaminophen 650 mg Brand
tablet er
INFANT'S NON- acetaminophen 80mg/0.8ml QL 60 / 30 DAY(S)
Generic
ASPIRIN drops susp AL1 Up to 20 yrs old
acetaminophen/diphenhydr Generic QL 30 / 30 DAY(S)
ACETADRYL
amine 500mg-25mg tablet AL1 3 to 20 yrs old
QL 60 / 30 day(s)
ESGIC butalb/acetaminophen/caffe
Generic AL1 Up to 64 yrs old
ine 50-325-40 tablet
MF 360 / 365 day(s)
butalb/acetaminophen/caffe Generic QL 60 / 30 day(s)
ESGIC-PLUS
ine 50-500-40 tablet AL1 Up to 64 yrs old

LIMITS &
RESTRICTIONS
ANTICONVULSANTS
BARBITURATES (ANTICONVULSANTS)
primidone (50 mg tablet,

MYSOLINE Generic QL 180 / 30 DAY(S)
250 mg tablet)
BENZODIAZEPINES (ANTICONVULSANTS)
clonazepam (0.5 mg tablet, Generic QL 180 / 30 DAY(S)

KLONOPIN 1 mg tablet, 2 mg tablet)
HYDANTOINS
phenytoin 125 mg/5ml oral

DILANTIN-125 Generic QL 960 / 30 DAY(S)
susp
DILANTIN phenytoin 50 mg tab chew Generic QL 240 / 30 DAY(S)
phenytoin sodium extended
DILANTIN (100 mg capsule, 200 mg Generic QL 180 / 30 DAY(S)
phenytoin sodium extended Brand QL 180 / 30 DAY(S)
DILANTIN
30 mg capsule
SUCCINIMIDES
ZARONTIN ethosuximide 250 mg

capsule
ethosuximide 250 mg/5ml Generic QL 960 / 30 DAY(S)
ZARONTIN
solution
ANTICONVULSANTS, MISCELLANEOUS
carbamazepine (100 mg tab

EPITOL Generic QL 180 / 30 DAY(S)
chew, 200 mg tablet)
carbamazepine (200 mg
cpmp 12hr, 300 mg cpmp Generic QL 120 / 30 DAY(S)
CARBATROL
12hr)
CARBATROL carbamazepine 100 mg Generic QL 60 / 30 DAY(S)
cpmp 12hr

LIMITS &
RESTRICTIONS
TEGRETOL carbamazepine 100 mg/5ml Generic
oral susp QL 960 / 30 DAY(S)
carbamazepine 200 mg tab QL 180 / 30 DAY(S)

TEGRETOL XR Generic
er 12h
TEGRETOL XR carbamazepine 400 mg tab QL 90 / 30 DAY(S)

Generic
er 12h
divalproex sodium (125 mg
DEPAKOTE tablet dr, 125 mg cap dr spr, Generic QL 360 / 30 DAY(S)
250 mg tablet dr)
divalproex sodium 250 mg
DEPAKOTE ER Generic QL 90 / 30 DAY(S)
tab er 24h
DEPAKOTE ER divalproex sodium 500 mg Generic QL 240 / 30 DAY(S)

tab er 24h
DEPAKOTE divalproex sodium 500 mg Generic QL 240 / 30 DAY(S)

tablet dr
FELBATOL felbamate (400 mg tablet, Generic QL 360 / 30 DAY(S)

600 mg tablet)
felbamate 600 mg/5ml oral Generic QL 960 / 30 DAY(S)
FELBATOL
susp
gabapentin (100 mg
capsule, 300 mg capsule,
NEURONTIN Generic QL 180 / 30 DAY(S)
400 mg capsule, 600 mg
tablet)
gabapentin 250 mg/5ml QL 960 / 30 DAY(S)
NEURONTIN Generic
solution AL1 Up to 18 yrs old
NEURONTIN gabapentin 800 mg tablet Generic QL 120 / 30 DAY(S)
LAMICTAL lamotrigine (25 mg tablet, Generic QL 120 / 30 DAY(S)

200 mg tablet)
lamotrigine (5 mg tb chw
LAMICTAL Generic QL 180 / 30 DAY(S)
dsp, 25 mg tb chw dsp)
LAMICTAL lamotrigine 100 mg tablet Generic QL 60 / 30 DAY(S)
LAMICTAL lamotrigine 150 mg tablet Generic QL 150 / 30 DAY(S)

LIMITS &
RESTRICTIONS
LAMICTAL XR lamotrigine 25(21)-50 tb er Brand
(BLUE) dspk QL 1 / 30 DAY(S)
LAMICTAL ODT lamotrigine 25(21)-50 tb rd QL 28 / 35 DAY(S)

Generic
(BLUE) dspk
LAMICTAL lamotrigine 25(42)-100 tab Brand
(ORANGE) ds pk
LAMICTAL lamotrigine 25(84)-100 tab
Brand
(GREEN) ds pk
LAMICTAL XR lamotrigine 25-50-100 tb er
(ORANGE) dspk
LAMICTAL ODT lamotrigine 25-50-100 tb rd QL 35 / 35 DAY(S)
Generic
(ORANGE) dspk
LAMICTAL lamotrigine 25mg (35) tab Generic QL 1 / 30 DAY(S)
(BLUE) ds pk
LAMICTAL ODT lamotrigine 50(42)-100 tb rd Generic QL 56 / 35 DAY(S)
(GREEN) dspk
LAMICTAL XR lamotrigine 50-100-200 tb Brand QL 1 / 30 DAY(S)
(GREEN) er dspk
levetiracetam (250 mg
KEPPRA tablet, 500 mg tablet, 750 Generic QL 60 / 30 DAY(S)
levetiracetam (500 mg tab
KEPPRA XR Generic QL 60 / 30 DAY(S)
er 24h, 750 mg tab er 24h)
KEPPRA levetiracetam 100 mg/ml Generic QL 960 / 30 DAY(S)

solution
oxcarbazepine (150 mg Generic QL 90 / 30 DAY(S)
TRILEPTAL
TRILEPTAL oxcarbazepine 300 mg/5ml Generic QL 960 / 30 DAY(S)

oral susp
TRILEPTAL oxcarbazepine 600 mg Generic QL 120 / 30 DAY(S)

tablet
GABITRIL tiagabine hcl (2 mg tablet, 4 Generic QL 90 / 30 DAY(S)

mg tablet)

LIMITS &
RESTRICTIONS
topiramate (15 mg cap
TOPAMAX sprink, 25 mg tablet, 25 mg Generic
QL 180 / 30 DAY(S)
cap sprink)
topiramate (50 mg tablet,
TOPAMAX 100 mg tablet, 200 mg Generic QL 60 / 30 DAY(S)
tablet)
valproic acid (as sodium
DEPAKENE Generic QL 1920 / 30 DAY(S)
salt) 250 mg/5ml solution
DEPAKENE valproic acid 250 mg Generic QL 360 / 30 DAY(S)

capsule
zonisamide (25 mg capsule,
ZONISAMIDE Generic QL 60 / 30 DAY(S)
50 mg capsule)
ZONEGRAN zonisamide 100 mg capsule Generic QL 120 / 30 DAY(S)
ANTIDEPRESSANTS
SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR
desvenlafaxine succinate
(25 mg tab er 24h, 50 mg QL 30 / 30 day(s)
PRISTIQ Generic
tab er 24h, 100 mg tab er ST
24h)
duloxetine hcl (20 mg
CYMBALTA capsule dr, 30 mg capsule Generic QL 30 / 30 DAY(S)
dr, 60 mg capsule dr)
venlafaxine hcl (25 mg
VENLAFAXINE Generic QL 90 / 30 DAY(S)
HCL
tablet)
venlafaxine hcl (37.5 mg
EFFEXOR XR cap er 24h, 75 mg cap er
24h)
VENLAFAXINE venlafaxine hcl (37.5 mg
HCL tablet, 50 mg tablet)
venlafaxine hcl 150 mg cap Generic QL 60 / 30 DAY(S)
EFFEXOR XR
er 24h

LIMITS &
RESTRICTIONS
SELECTIVE-SEROTONIN REUPTAKE INHIBITORS
citalopram hydrobromide
CELEXA (10 mg tablet, 20 mg tablet, Generic QL 30 / 30 DAY(S)
40 mg tablet)
CITALOPRAM citalopram hydrobromide 10 Generic QL 225 / 30 DAY(S)
HBR mg/5 ml solution
escitalopram oxalate (5 mg
LEXAPRO
tablet)
fluoxetine hcl (10 mg tablet,
PROZAC Generic QL 30 / 30 DAY(S)
10 mg capsule)
PROZAC fluoxetine hcl (20 mg tablet, Generic QL 120 / 30 DAY(S)

20 mg capsule)
FLUOXETINE fluoxetine hcl 20 mg/5 ml Generic QL 600 / 30 DAY(S)
HCL solution
fluoxetine hcl 40 mg Generic QL 60 / 30 DAY(S)
PROZAC
capsule
FLUVOXAMINE fluvoxamine maleate (25 Generic QL 30 / 30 DAY(S)
MALEATE mg tablet, 50 mg tablet)
FLUVOXAMINE fluvoxamine maleate 100 Generic QL 90 / 30 DAY(S)
MALEATE mg tablet
paroxetine hcl (10 mg
QL 30 / 30 DAY(S)
PAXIL tablet, 20 mg tablet, 30 mg Generic
PAXIL paroxetine hcl 40 mg tablet Brand QL 30 / 30 DAY(S)

ZOLOFT sertraline hcl 100 mg tablet Generic QL 60 / 30 DAY(S)
sertraline hcl 20 mg/ml oral
ZOLOFT Generic QL 225 / 30 DAY(S)
conc

LIMITS &
RESTRICTIONS
SEROTONIN MODULATORS
nefazodone hcl (50 mg
NEFAZODONE Generic
tablet, 100 mg tablet, 150
HCL mg tablet, 200 mg tablet, QL 60 / 30 DAY(S)
250 mg tablet)
TRAZODONE trazodone hcl (100 mg
HCL tablet, 150 mg tablet)
TRAZODONE Generic QL 60 / 30 DAY(S)
trazodone hcl 50 mg tablet
HCL
TRICYCLICS, OTHER NOREPI-RU INHIBITORS
amitriptyline hcl (10 mg

AMITRIPTYLINE tablet, 25 mg tablet, 50 mg QL 90 / 30 DAY(S)
Generic
HCL tablet, 75 mg tablet, 100 mg AL1 Up to 64 yrs old
amoxapine (25 mg tablet,
AMOXAPINE 50 mg tablet, 100 mg tablet, Generic QL 60 / 30 DAY(S)
150 mg tablet)
doxepin hcl (10 mg capsule,
DOXEPIN HCL 25 mg capsule, 50 mg
doxepin hcl (75 mg capsule,

QL 30 / 30 DAY(S)
DOXEPIN HCL 100 mg capsule, 150 mg Generic
DOXEPIN HCL doxepin hcl 10 mg/ml oral Generic QL 120 / 30 DAY(S)

conc AL1 Up to 64 yrs old
imipramine hcl (10 mg
TOFRANIL Generic QL 60 / 30 DAY(S)
nortriptyline hcl (10 mg

QL 90 / 30 DAY(S)
PAMELOR capsule, 25 mg capsule, 50 Generic
mg capsule) AL1 Up to 64 yrs old
PAMELOR nortriptyline hcl 75 mg Generic QL 60 / 30 DAY(S)


LIMITS &
RESTRICTIONS
perphenazine/amitriptyline
PERPHENAZINE- hcl (2 mg-10 mg tablet, 2 Generic QL 120 / 30 DAY(S)
AMITRIPTYLINE mg-25 mg tablet, 4 mg-25 AL1 Up to 64 yrs old
mg tablet, 4mg-10mg tablet)
ANTIDEPRESSANTS, MISCELLANEOUS
bupropion hcl (100 mg tab

sr 12h, 100 mg tablet er,
100 mg tab er 12h, 150 mg
BUDEPRION SR tab sr 12h, 150 mg tab er Generic QL 60 / 30 DAY(S)
12h, 150 mg tablet er, 200
mg tab sr 12h, 200 mg tab
er 12h, 200 mg tablet er)
bupropion hcl (150 mg tab
BUDEPRION XL Generic QL 30 / 30 DAY(S)
er 24h, 300 mg tab er 24h)
WELLBUTRIN bupropion hcl (75 mg tablet, Generic QL 90 / 30 DAY(S)

100 mg tablet)
BUPROBAN bupropion hcl 150 mg tab er Brand QL 60 / 30 DAY(S)

12h
mirtazapine (7.5 mg tablet,
15 mg tab rapdis, 15 mg
REMERON tablet, 30 mg tablet, 30 mg Generic QL 30 / 30 DAY(S)
tab rapdis, 45 mg tablet, 45
mg tab rapdis)
ANOREXIGENICS;RESPIRATORY,CNS STIMULANTS
AMPHETAMINES
dextroamphetamine sulf-
saccharate/amphetamine
QL 60 / 30 DAY(S)
ADDERALL XR sulf-aspartate (20 mg cap er Generic
24h, 25 mg cap er 24h, 30 AL1 4 to 20 yrs old
mg cap er 24h)
ADDERALL XR saccharate/amphetamine Generic
sulf-aspartate (5 mg cap er QL 30 / 30 DAY(S)
24h, 10 mg cap er 24h, 15 AL1 4 to 20 yrs old
mg cap er 24h)

LIMITS &
RESTRICTIONS
saccharate/amphetamine
ADDERALL sulf-aspartate (5 mg tablet, Generic QL 60 / 30 DAY(S)
7.5 mg tablet, 10 mg tablet,
12.5 mg tablet, 15 mg AL1 4 to 20 yrs old
tablet)
dextroamphetamine sulfate QL 120 / 30 DAY(S)
DEXEDRINE Generic
(5 mg tablet, 10 mg tablet) AL1 4 to 20 yrs old
DEXEDRINE dextroamphetamine sulfate Generic QL 60 / 30 DAY(S)
10 mg capsule er AL1 4 to 20 yrs old
lisdexamfetamine
dimesylate (10 mg capsule,
20 mg capsule, 30 mg QL 30 / 30 DAY(S)
VYVANSE Brand
capsule, 40 mg capsule, 50 ST
mg capsule, 60 mg capsule,
70 mg capsule)
lisdexamfetamine
dimesylate (10 mg tab
chew, 20 mg tab chew, 30
VYVANSE Brand ST
mg tab chew, 40 mg tab
chew, 50 mg tab chew, 60
mg tab chew)
DESOXYN QL 90 / 30 DAY(S)
methamphetamine hcl Generic
AL1 4 to 20 yrs old
RESPIRATORY AND CNS STIMULANTS
ALERTNESS AID caffeine Generic

dexmethylphenidate hcl (2.5
FOCALIN mg tablet, 5 mg tablet, 10
mg tablet) AL1 4 to 20 yrs old

LIMITS &
RESTRICTIONS
dexmethylphenidate hcl (5
mg cpbp 50-50, 10 mg cpbp
FOCALIN XR 50-50, 15 mg cpbp 50-50, Generic
20 mg cpbp 50-50, 25 mg QL 30 / 30 DAY(S)
cpbp 50-50, 30 mg cpbp AL1 4 to 20 yrs old
50-50, 35 mg cpbp 50-50,
40 mg cpbp 50-50)
methylphenidate hcl (10 mg
cpbp 30-70, 20 mg cpbp
30-70, 30 mg cpbp 30-70, QL 30 / 30 DAY(S)
METADATE CD Generic
40 mg cpbp 30-70, 50 mg AL1 4 to 20 yrs old
cpbp 30-70, 60 mg cpbp
30-70)
methylphenidate hcl (10 mg QL 90 / 30 DAY(S)
METADATE ER Generic
tablet er, 20 mg tablet er) AL1 4 to 20 yrs old
CONCERTA tab er 24, 27 mg tab er 24, Generic QL 30 / 30 DAY(S)
36 mg tab er 24, 54 mg tab AL1 4 to 20 yrs old
er 24)
methylphenidate hcl (2.5
mg tab chew, 5 mg tab QL 1 / 1 DAY(S)
METHYLIN Generic
chew, 10 mg tab chew) AL1 4 to 20 yrs old

RITALIN LA cpbp 50-50, 40 mg cpbp
50-50) AL1 4 to 20 yrs old

QUILLICHEW ER Brand QL 30 / 30 DAY(S)
tab cbp24h, 40 mg tab
cbp24h) AL1 4 to 20 yrs old
METHYLIN QL 90 / 30 DAY(S)
tablet) AL1 4 to 20 yrs old
methylphenidate hcl (5 ml QL 600 / 30 DAY(S)

METHYLIN Generic
solution, 10 ml solution) AL1 4 to 20 yrs old
methylphenidate hcl 30 mg Brand QL 60 / 30 DAY(S)
QUILLICHEW ER
tab cbp24h AL1 4 to 20 yrs old

LIMITS &
RESTRICTIONS
ANXIOLYTICS, SEDATIVES AND HYPNOTICS
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
AMYTAL
amobarbital sodium Brand AL1 Up to 64 yrs old
SODIUM
BUTISOL butabarbital sodium 30 mg Brand AL1 Up to 64 yrs old
SODIUM tablet
phenobarbital (15 mg tablet,
16.2 mg tablet, 30 mg
PHENOBARBITA tablet, 32.4 mg tablet, 60 QL 90 / 30 DAY(S)
Generic
L mg tablet, 64.8 mg tablet, AL1 Up to 64 yrs old
97.2mg tablet, 100 mg
tablet)
PHENOBARBITA phenobarbital 20 mg/5 ml QL 960 / 30 DAY(S)
Generic
L elixir AL1 Up to 64 yrs old
PHENOBARBITA phenobarbital sodium (65 Generic
L SODIUM mg/ml vial, 130mg/ml vial) AL1 Up to 64 yrs old
BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)
alprazolam (0.25 mg tablet,

XANAX 0.5 mg tablet, 1 mg tablet, 2 Generic QL 120 / 30 DAY(S)
mg tablet)
chlordiazepoxide hcl (5 mg
CHLORDIAZEPO Generic QL 120 / 30 DAY(S)
capsule, 10 mg capsule, 25
XIDE HCL
mg capsule)
clorazepate dipotassium
TRANXENE T- Generic QL 120 / 30 DAY(S)
(3.75 mg tablet, 7.5 mg
TAB
diazepam (2 mg tablet, 10
VALIUM Generic QL 120 / 30 DAY(S)
mg tablet)
diazepam (5 mg/5 ml Generic QL 180 / 30 DAY(S)
DIAZEPAM
solution, 5 mg/ml oral conc)
VALIUM diazepam 5 mg tablet Generic QL 90 / 30 DAY(S)
DIAZEPAM diazepam 5 mg/ml vial Generic QL 40 / 30 DAY(S)

LIMITS &
RESTRICTIONS
FLURAZEPAM flurazepam hcl (15 mg Generic
HCL capsule, 30 mg capsule) QL 30 / 30 DAY(S)
lorazepam (0.5 mg tablet, 1

ATIVAN Generic QL 120 / 30 DAY(S)
ATIVAN lorazepam 2 mg/ml vial Generic QL 20 / 30 DAY(S)
lorazepam 4 mg/ml Generic
LORAZEPAM
cartridge
oxazepam (10 mg capsule,
OXAZEPAM 15 mg capsule, 30 mg Generic QL 30 / 30 DAY(S)
capsule)
temazepam (15 mg
RESTORIL Generic QL 30 / 30 DAY(S)
HALCION triazolam (0.125 mg tablet, Generic QL 30 / 30 DAY(S)

0.25 mg tablet)
ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC
buspirone hcl (5 mg tablet,

BUSPIRONE HCL Generic QL 90 / 30 DAY(S)
eszopiclone (1 mg tablet, 2 Generic QL 30 / 30 DAY(S)
LUNESTA mg tablet, 3 mg tablet) AL1 Up to 64 yrs old
HYDROXYZINE hydroxyzine hcl (10 mg Generic QL 90 / 30 DAY(S)
HCL tablet, 25 mg tablet) AL1 Up to 64 yrs old
HYDROXYZINE hydroxyzine hcl (25 mg/ml Generic
HCL vial, 50 mg/ml vial) AL1 Up to 64 yrs old
HYDROXYZINE hydroxyzine hcl 50 mg Generic QL 60 / 30 DAY(S)

HCL tablet AL1 Up to 64 yrs old
hydroxyzine pamoate (50
HYDROXYZINE QL 60 / 30 DAY(S)
mg capsule, 100 mg Generic
PAMOATE AL1 Up to 64 yrs old
capsule)
hydroxyzine pamoate 25 QL 90 / 30 DAY(S)
VISTARIL Generic
mg capsule AL1 Up to 64 yrs old
SONATA zaleplon (5 mg capsule, 10 Generic QL 30 / 30 DAY(S)
mg capsule) AL1 Up to 64 yrs old

LIMITS &
RESTRICTIONS
AMBIEN zolpidem tartrate (5 mg Generic QL 30 / 30 DAY(S)
ANTIMIGRAINE AGENTS
SELECTIVE SEROTONIN AGONISTS
naratriptan hcl (1 mg tablet,

AMERGE Generic QL 9 / 30 DAY(S)
2.5 mg tablet)
rizatriptan benzoate (5 mg
MAXALT tab rapdis, 5 mg tablet, 10 Generic QL 9 / 30 DAY(S)
mg tab rapdis, 10 mg tablet)
sumatriptan succinate (25
IMITREX mg tablet, 50 mg tablet, 100 Generic QL 9 / 30 DAY(S)
mg tablet)
zolmitriptan (2.5 mg tab QL 9 / 30 DAY(S)
ZOMIG ZMT Generic
rapdis, 5 mg tab rapdis) ST
ZOMIG zolmitriptan (2.5 mg tablet, Generic QL 9 / 30 DAY(S)
5 mg tablet) ST
DOPAMINE RECEPTOR AGONISTS
ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS
bromocriptine mesylate (2.5

PARLODEL Generic QL 90 / 30 DAY(S)
mg tablet, 5 mg capsule)
NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST
pramipexole di-hcl (0.125

mg tablet, 0.25 mg tablet,
MIRAPEX 0.5 mg tablet, 0.75 mg Generic QL 90 / 30 DAY(S)
tablet)
ropinirole hcl (0.25 mg
REQUIP tablet, 0.5 mg tablet, 1 mg Generic 90 / 30 DAY(S)
tablet)

LIMITS &
RESTRICTIONS
ANTIPARKINSONIAN AGENTS (CNS)
CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.
COMTAN entacapone Generic QL 120 / 30 DAY(S)

ST
DOPAMINE PRECURSORS
carbidopa/levodopa (10mg-
100mg tab rapdis, 10mg-
100mg tablet, 25mg-100mg
SINEMET 10-100 Generic QL 360 / 30 DAY(S)
tablet, 25mg-100mg tab
rapdis, 25mg-250mg tab
rapdis, 25mg-250mg tablet)
carbidopa/levodopa (25mg- Generic QL 120 / 30 DAY(S)
SINEMET CR 100mg tablet er, 50mg-
200mg tablet er)
MONOAMINE OXIDASE B INHIBITORS
selegiline hcl (5 mg Generic QL 60 / 30 DAY(S)

ELDEPRYL capsule, 5 mg tablet)
CENTRAL NERVOUS SYSTEM AGENTS
FIBROMYALGIA AGENTS
SAVELLA milnacipran hcl 50 mg tablet Brand QL 60 / 30 day(s)

ST
CENTRAL NERVOUS SYSTEM AGENTS, MISC.
atomoxetine hcl (10 mg

capsule, 18 mg capsule, 40
QL 30 / 30 DAY(S)
STRATTERA mg capsule, 60 mg capsule, Generic
80 mg capsule, 100 mg AL1 4 to 20 yrs old
capsule)
STRATTERA atomoxetine hcl 25 mg Generic QL 30 / 30 day(s)
capsule AL1 4 to 20 yrs old

LIMITS &
RESTRICTIONS
guanfacine hcl (1 mg tab er
INTUNIV Generic QL 30 / 30 DAY(S)
24h, 2 mg tab er 24h, 3 mg
tab er 24h, 4 mg tab er 24h) AL1 4 to 20 yrs old
memantine hcl (5 mg tablet, QL 60 / 30 DAY(S)

NAMENDA Generic
10 mg tablet) AL1 At least 55 yrs old
NAMENDA memantine hcl 2 mg/ml Generic QL 300 / 30 DAY(S)
solution AL1 At least 55 yrs old
memantine hcl/donepezil
hcl (/donepezil 7-10/14-10
cap24 dspk, /donepezil 7
mg-10 mg cap spr 24,
NAMZARIC /donepezil 14mg-10mg cap Brand QL 1 / 1 DAY(S)
spr 24, /donepezil 21 mg- ST
10mg cap spr 24,
/donepezil 28 mg-10mg cap
spr 24)
URINE AND FECES CONTENTS
SUGAR
DIASTIX
urine glucose test strip Generic ST
REAGENT
DIAGNOSTIC AGENTS
DIABETES MELLITUS
Generic
TRUETEST TEST QL 100 / 30 DAY(S)
blood sugar diagnostic
STRIPS ST
ION-REMOVING AGENTS
POTASSIUM-REMOVING AGENTS
SODIUM sodium polystyrene

POLYSTYRENE sulfonate (15 g/60 ml oral Generic QL 960 / 30 DAY(S)
SULFONATE susp, 30 g/120ml enema)

LIMITS &
RESTRICTIONS
PHOSPHATE-REMOVING AGENTS
calcium acetate 667 mg

CALPHRON Generic QL 360 / 30 DAY(S)
tablet
ELIPHOS calcium acetate 667 mg Brand QL 360 / 30 DAY(S)

tablet
calcium
MAGNEBIND 300 carbonate/magnesium Brand QL 270 / 30 DAY(S)
carbonate
DIURETICS
LOOP DIURETICS
BUMETANIDE bumetanide 0.5 mg tablet Generic QL 60 / 30 DAY(S)

BUMETANIDE bumetanide 1 mg tablet Generic QL 30 / 30 DAY(S)
BUMETANIDE bumetanide 2 mg tablet Generic QL 120 / 30 DAY(S)
furosemide (10 mg/ml vial,
FUROSEMIDE Generic QL 10 / 30 DAY(S)
10 mg/ml syringe)
LASIX furosemide (20 mg tablet, Generic QL 120 / 30 DAY(S)

40 mg tablet)
furosemide 10 mg/ml Generic QL 240 / 30 DAY(S)
FUROSEMIDE
solution
furosemide 40mg/5ml
FUROSEMIDE Generic QL 960 / 30 DAY(S)
solution
LASIX furosemide 80 mg tablet Generic QL 60 / 30 DAY(S)
torsemide (5 mg tablet, 10
DEMADEX mg tablet, 20 mg tablet, 100 Generic QL 60 / 30 DAY(S)
mg tablet)
OSMOTIC DIURETICS
MANNITOL mannitol 25 % vial Generic QL 250 / 30 DAY(S)

LIMITS &
RESTRICTIONS
POTASSIUM-SPARING DIURETICS
MIDAMOR amiloride hcl Generic QL 30 / 30 DAY(S)

AMILORIDE-
amiloride Generic QL 30 / 30 DAY(S)
HYDROCHLORO
hcl/hydrochlorothiazide
THIAZIDE
triamterene/hydrochlorothia
TRIAMTERENE- zide (37.5-25 mg capsule,
HYDROCHLORO 37.5-25 mg tablet, 50 mg- Generic QL 30 / 30 DAY(S)
THIAZID 25mg capsule, 75 mg-50mg
tablet)
THIAZIDE DIURETICS
hydrochlorothiazide (12.5
MICROZIDE mg capsule, 12.5 mg tablet, Generic QL 30 / 30 DAY(S)
METHYCLOTHIA Generic QL 30 / 30 DAY(S)
methyclothiazide
ZIDE
THIAZIDE-LIKE DIURETICS
CHLORTHALIDO chlorthalidone (25 mg

NE tablet, 50 mg tablet)
INDAPAMIDE indapamide 1.25 mg tablet Generic QL 30 / 30 DAY(S)
INDAPAMIDE indapamide 2.5 mg tablet Generic QL 60 / 30 DAY(S)
metolazone (2.5 mg tablet,
ZAROXOLYN Generic QL 30 / 30 DAY(S)
5 mg tablet)
METOLAZONE metolazone 10 mg tablet Generic QL 60 / 30 DAY(S)
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ACIDIFYING AGENTS
K-PHOS potassium
ORIGINAL phosphate,monobasic
sodium
PHOSPHA 250 phosphate,dibasic/pot Brand QL 240 / 30 DAY(S)
NEUTRAL phos,monob/sod phosphate
mono

LIMITS &
RESTRICTIONS
ALKALINIZING AGENTS
citric acid/sodium citrate

CYTRA-2 Generic QL 2700 / 30 DAY(S)
334-500mg solution
CYTRA-K potassium citrate/citric acid Generic QL 960 / 30 DAY(S)

1100-334/5 solution
AMMONIA DETOXICANTS
lactulose 10 g/15 ml
ENULOSE Generic QL 3800 / 60 DAY(S)
solution
REPLACEMENT PREPARATIONS
SODIUM 0.9 % sodium chloride 0.9

Generic
CHLORIDE % iv soln
MONOJECT 0.9%
0.9 % sodium chloride 0.9 Generic
SODIUM QL 2000 / 30 DAY(S)
% syringe
CHLORIDE
SODIUM 0.9 % sodium chloride 0.9 Generic QL 2000 / 30 DAY(S)
CHLORIDE % vial
ca/d3/mag
CALCIUM 600- Generic QL 120 / 30 DAY(S)
ox/zinc/cop/mang/bor 600
VIT D3-MINERAL
mg-400 tab chew
ca/d3/mag
CALTRATE
ox/zinc/cop/mang/bor 600 Brand QL 120 / 30 DAY(S)
600+D PLUS
mg-800 tab chew
ca/d3/mag
CALTRATE QL 120 / 30 DAY(S)
ox/zinc/cop/mang/bor 600 Generic
600+D PLUS
mg-800 tab chew
ca/d3/mag
CALCIUM 600-D3 Brand
ox/zinc/cop/mang/bor 600
PLUS
mg-800 tablet
cal cit/d3/k/mag ox/stron/bor
PROSTEON Brand
250 mg-500 tablet
THERACAL cal cit/d3/k/mag ox/stron/bor Brand

250mg-1000 tablet

LIMITS &
RESTRICTIONS
CALCIUM AMINO Generic
calcium amino acid chelate
ACID CHELATE
calcium carb, gluconate/vit
PARVA-CAL 500 Brand
d2 500 mg-200 tablet
calcium carb,citrate/vitamin
CITRACAL +
d3/mineral comb Brand
BONE DENSITY
no.34/genistein
calcium
Generic
CORAL CALCIUM carb/cholecalciferol/magnes
ium amino acid chelate
calcium carb/d3/mag
CALTRATE Brand
11/zinc/cupric
600+D PLUS
sulf/manganese/s.borate
calcium carb/d3/mag
CALTRATE + D3 Brand
oxide/cupric sulf/mang
PLUS MINERALS
sulf/zinc oxide
calcium carb/magnesium
CORAL CALCIUM oxid/d3 200 mg-100 Generic
capsule
CALCIUM calcium carb/magnesium Generic
MAGNESIUM + D oxid/d3 400mg-133 tablet
CALCIUM IN calcium carb/magnesium
PREMIUM oxid/d3 500-40-250 tab Generic
CHOCOLATE chew
CALTRATE 600- calcium carb/vit d3/mag
D3 PLUS ox/zinc/copper/manganese/ Brand QL 120 / 30 DAY(S)
MINERALS mg borate
calcium carb/vit d3/minerals QL 120 / 30 DAY(S)
CALCIUM Generic
600 mg-200 tab chew
CALTRATE-600 calcium carb/vit d3/minerals Generic
PLUS 600 mg-400 tablet
calcium carb/vit d3/vit k/folic Brand
ORTHO-TABS
acid/vit b12/vit c/minerals
VIACTIV calcium carb/vitamin d3/vit

k1 500-100-40 tab chew

LIMITS &
RESTRICTIONS
VIACTIV calcium carb/vitamin d3/vit Brand
k1 500-500-40 tab chew
calcium carb/vitamin d3/vit
VIACTIV Generic
k1 500-500-40 tab chew
calcium carb/vitamin d3/vit Generic
CITRACAL
k1 500mg-1000 tab chew
CITRACAL calcium carb/vitamin d3/vit Brand

k1 500mg-1000 tab chew
calcium carbonate
CALCIUM
(260mg(650) tab chew, 800 Generic
CARBONATE
mg/2 g powder)
calcium carbonate
Generic
CALCARB 600 (500(1250) tab chew, 600 QL 120 / 30 DAY(S)
mg tablet)
calcium carbonate
CAL-MINT Brand
260mg(650) tab chew
calcium carbonate
CORAL CALCIUM Generic
390(1000) tablet
CALCIUM calcium carbonate 500 Generic
CARBONATE mg/5ml oral susp QL 480 / 30 DAY(S)
calcium carbonate Brand

CALCI-MIX
500(1250) capsule
OYSCO-500 calcium carbonate

500(1250) tablet
OYSCO-500 calcium carbonate QL 120 / 30 DAY(S)

Generic
500(1250) tablet
calcium carbonate and
CITRACAL + D citrate/cholecalciferol (vit Generic
d3)
CITRACAL + D Brand
citrate/cholecalciferol (vit
d3)
LOCALNESIUM
citrate/magnesium citrate, Brand
glycinate

LIMITS &
RESTRICTIONS
calcium carbonate and Brand
CALMAG THINS
citrate/magnesium oxide
CITRACAL D +
citrate/vitamin Brand
HEART HEALTH
d3/phytosterol
calcium carbonate, calcium
CALCET Brand
lactate-cholecalciferol (vit
PETITES
d3)
calcium carbonate,
CALCIUM Brand
gluconate/magnesium
MAGNESIUM
oxide, gluconate
calcium
HEALTHY BONE
carbonate,citrate/magnesiu Generic
FORMULA
m oxide,aspartate/vit d3
CALCIUM WITH calcium carbonate/boron Generic
BORON gluconate
calcium
carbonate/cholecalciferol
CALCARB 600
(vitamin d3) (600 mg-400 Generic QL 120 / 30 DAY(S)
WITH VITAMIN D
tablet, 600 mg-200 tablet,
600 mg-800 tablet)
calcium
CALCIUM 600
carbonate/ergocalciferol (vit Generic
WITH SOY
d2)/soybean
OYSTER SHELL calcium
Generic
CALCIUM- carbonate/magnesium ox
MAGNESIUM 250-155 mg tablet
calcium
SUPER CAL- Brand
carbonate/magnesium ox
MAG
333-167 mg tablet
calcium
CAL-MAG carbonate/magnesium Brand
oxide, carbonate
calcium
LOCALNESIUM-C carbonate/magnesium Brand
oxide/ascorbic acid

LIMITS &
RESTRICTIONS
calcium
ACTICAL carbonate/magnesium Brand
oxide/vitamin
d2/bioflavonoids
CALCIUM- calcium carbonate/vit
MAGNESIUM- d3/magnesium Generic
ZINC-VIT D oxide,stearate/zinc sulf
calcium carbonate/vit
Brand
BIOCAL d3/magnesium oxide/folic
acid/vit k
OYSTER SHELL
calcium carbonate/vitamin
CALCIUM W-VIT Generic QL 120 / 30 DAY(S)
D
CALCIUM 1000 + calcium carbonate/vitamin
Generic
D3 d3 1000mg-800 tablet
calcium carbonate/vitamin Generic
OYSCO D QL 120 / 30 DAY(S)
calcium carbonate/vitamin Brand QL 120 / 30 DAY(S)
OYSCO D
calcium carbonate/vitamin
CALCIUM + VIT D Generic
d3 400-133.3 tablet
CALCIUM 500 + calcium carbonate/vitamin Generic
VITAMIN D d3 500 mg-125 tablet QL 120 / 30 DAY(S)
calcium carbonate/vitamin Brand QL 120 / 30 DAY(S)

HI-CAL
HI-CAL calcium carbonate/vitamin QL 120 / 30 DAY(S)

Generic
CALCIUM 500 + calcium carbonate/vitamin Generic QL 120 / 30 DAY(S)
VIT D d3 500 mg-400 tab chew
calcium carbonate/vitamin Generic QL 120 / 30 DAY(S)
OYSTERCAL-D
OYSTERCAL-D calcium carbonate/vitamin Brand QL 120 / 30 DAY(S)


LIMITS &
RESTRICTIONS
OS-CAL 500-VIT calcium carbonate/vitamin Brand
D3 d3 500 mg-600 tablet QL 120 / 30 DAY(S)
OS-CAL 500-VIT calcium carbonate/vitamin QL 120 / 30 DAY(S)

Generic
D3 d3 500 mg-600 tablet
calcium carbonate/vitamin Brand
CAL-QUICK
d3 500-400/5 liquid
CALCIUM 600 + calcium carbonate/vitamin
VIT D d3 600 mg-125 tablet
CALCIUM 600 + calcium carbonate/vitamin Generic
VIT D d3 600 mg-400 tab chew
CALCIUM 600- calcium carbonate/vitamin Generic
VIT D3 d3 600 mg-500 capsule
CALTRATE 600 + calcium carbonate/vitamin Brand
D d3 600 mg-800 tab chew
CALTRATE 600 calcium carbonate/vitamin
PLUS D3 d3 600 mg-800 tablet
OSTEO- calcium carbonate/vitamin
Brand
PORETICAL d3 600mg-1000 tablet
BONE DENSITY calcium carbonate/vitamin
Brand
CALCIUM + D d3/arginine/inositol/silicon
calcium
CALCIUM cit/magnesium/d3/zinc
Brand
CITRATE PLUS ox/copper gluc/manganese
gluc
calcium
CITRACAL-VIT D cit/magnesium/d3/zinc Brand
+ MAGNESIUM ox/copper
gluc/manganese/boron
calcium citrate (250 mg
CALCIUM
tablet, 760mg/3.5g Generic
CITRATE
granules)
CALCIUM calcium citrate
Generic
CITRATE malate/cholecalciferol
MALATE WITH D (vitamin d3)

LIMITS &
RESTRICTIONS
calcium
UPCAL D citrate/cholecalciferol Brand
(vitamin d3) (500 powder,
500 powd pack)
calcium citrate/magnesium
CALCIUM
ox,mag aspartate Generic QL 120 / 30 DAY(S)
CITRATE
hcl/vitamin d3
FEM-CAL Brand
ox/vit
CITRATE
d2/manganese/boron/silica
CALCIUM
oxide/vitamin Generic
CITRATE PLUS
d3/pyridoxine/min
calcium
ADVANCED Brand
citrate/minerals/vitamin
CALCIUM
d3/vit k2/silicon dioxide
CALCIUM
calcium citrate/vitamin d2
CITRATE- Generic QL 120 / 30 DAY(S)
1500mg-200 tablet
VITAMIN D
CAL-CITRATE Brand
250 mg-100 tablet
CITRACAL- calcium citrate/vitamin d3
Brand
VITAMIN D3 200 mg-250 tablet
Generic
VITAMIN D3 200 mg-250 tablet
CALCIUM
CITRATE- Generic QL 120 / 30 DAY(S)
200mg-125 tablet
VITAMIN D
Generic
VITAMIN D 250 mg-200 tablet
CITRACAL- calcium citrate/vitamin d3 Brand
VITAMIN D 250 mg-200 tablet
CALCITRATE + calcium citrate/vitamin d3
Generic
VIT D 315 mg-250 tablet

LIMITS &
RESTRICTIONS
CITRACAL + D calcium citrate/vitamin d3 Brand
MAXIMUM 315 mg-250 tablet
CALCET Brand
500 mg-400 tab chew
CALCIONATE calcium glubionate Brand QL 960 / 30 DAY(S)
calcium gluconate (45(500)
CALCIUM QL 120 / 30 DAY(S)
mg tablet, 50 mg tablet, Generic
GLUCONATE
60(650) mg tablet)
CALCIUM calcium gluconate 100 Generic
GLUCONATE mg/ml vial QL 50 / 30 DAY(S)
calcium
BONE Brand
hydroxyapatite/vitamin
ESSENTIALS
d3/vitamin c/vit k2/minerals
CALCIUM calcium lactate 100 mg
Generic
LACTATE tablet
calcium
phosphat/magnesium
PRO-CAL Brand
hydroxide/vit c/vit
d3/phosphorus
CALCIUM
calcium phosphate Generic
PHOSPHATE
FLINTSTONES calcium phosphate trib/vit Brand
BONE SUPPORT d3 125 mg-125 tab chew
YOGURT+CALCI calcium phosphate trib/vit
Brand
UM GUMMIES d3 250 mg-100 tab chew
CALCIUM + calcium phosphate trib/vit
Generic
VITAMIN D3 d3 250 mg-200 tab chew
calcium phosphate trib/vit Generic
CALCIUM ADULT
d3 250 mg-350 tab chew
CITRACAL + D3 calcium phosphate trib/vit Brand

d3 250 mg-500 tab chew QL 120 / 30 DAY(S)
CITRACAL + D3 calcium phosphate trib/vit QL 120 / 30 DAY(S)

Generic
d3 250 mg-500 tab chew

LIMITS &
RESTRICTIONS
CALTRATE calcium phosphate trib/vit Brand
GUMMY BITES d3 250mg-400 tab chew
CHILDREN'S calcium phosphate
CALCIUM tribasic/ergocalciferol Brand
GUMMIES (vitamin d2)
calcium phosphate,
Brand
RISACAL-D dibasic/cholecalciferol
(vitamin d3)
calcium phosphate,
tribasic/cholecalciferol
CALCIUM-
(vitamin d3) (200 mg-200 Generic
VITAMIN D3
tab chew, 250mg-400 tab
chew)
calcium/mag oxide/vitamin
CORAL CALCIUM Brand
d3 185-50-100 capsule
calcium/mag/d3/b12/fa/b6/b QL 30 / 30 day(s)
TL G-FOL OS Brand
oron 500-1.1mg tablet FAL Female - 12 to 44
yrs old
CALCIUM-
calcium/magnesium Generic
MAGNESIUM
calcium/multivitamin with Brand
FOSFREE
iron
MEN'S POTENT calcium/vitamin e/folic
Brand
FORMULA acid/pyridoxine/herbal drugs
DEXTROSE IN
dextrose 5 % in lactated
LACTATED Generic
ringers
RINGERS
DEXTROSE 5%- electrolyte-48
Generic
ELECTROLYTE solution/dextrose 5 % in
#48 water
IONOSOL B electrolyte-b
Brand
WITH solution/dextrose 5 % in
DEXTROSE 5% water
electrolyte-m
NORMOSOL-M
solution/dextrose 5 % in Brand
AND DEXTROSE
water

LIMITS &
RESTRICTIONS
electrolyte-mb
IONOSOL MB- Brand
solution/dextrose 5 % in
DEXTROSE 5%
water
electrolyte-p
ISOLYTE P WITH
solution/dextrose 5 % in Brand
DEXTROSE
water
electrolyte-r
NORMOSOL-R Brand
solution/dextrose 5 % in
AND DEXTROSE
water
ENFALYTE electrolytes/dextrose Brand AL1 Up to 5 yrs old
magnesium (200 mg tablet, QL 180 / 30 DAY(S)
MAGNESIUM Generic
250 mg tablet)
magnesium amino acid
MAGNESIUM Generic QL 180 / 30 DAY(S)
chelate 100 mg tablet
magnesium amino acid
MAGNESIUM Generic
chelate 27 mg tablet
MAGONATE magnesium carbonate Brand
MAG64 magnesium chloride 64 mg

Brand
tablet dr
magnesium chloride 70 mg
MAG DELAY Brand QL 360 / 30 DAY(S)
tablet dr
NU-MAG magnesium chloride 71.5 QL 180 / 30 DAY(S)

Brand
mg tablet dr
MAGNESIUM magnesium citrate 100 mg
Generic
CITRATE tablet
magnesium gluconate (27
MAGNESIUM
mg(500) tablet, 30 mg(550) Generic
GLUCONATE
tablet)
magnesium gluconate 27 Brand
MAG-G
mg(500) tablet
MAG GLYCINATE magnesium glycinate Brand
MAG-TAB SR magnesium l-lactate Brand QL 360 / 30 DAY(S)

LIMITS &
RESTRICTIONS
TRIPLE
magnesium oxide, Brand
MAGNESIUM QL 30 / 30 DAY(S)
aspartate, citrate
COMPLEX
magnesium
MAGNESIUM oxide/magnesium 300 mg Generic QL 360 / 30 DAY(S)
capsule
MAGNESIUM magnesium sulfate 100 mg
Generic
SULFATE capsule
K potassium bicarbonate/cit Brand
EFFERVESCENT ac 25 meq tablet eff QL 240 / 30 DAY(S)
potassium chloride (8 tablet

KLOR-CON er, 8 capsule er, 10 capsule QL 240 / 30 DAY(S)
Generic
SPRINKLE er, 10 tab er prt, 10 tablet
er, 20 tab er prt)
potassium chloride 10 meq
KLOR-CON M10 Brand QL 240 / 30 DAY(S)
tab er prt
KLOR-CON M20 potassium chloride 20 meq QL 240 / 30 DAY(S)

Brand
tab er prt
POTASSIUM potassium chloride in 0.45
Generic
CHLORIDE-NACL % sodium chloride
POTASSIUM potassium chloride in 0.9 %
CHL-NORMAL sodium chloride (in 20 iv Generic
SALINE soln, in 40 iv soln)
DEXTROSE 5%- potassium chloride in 5 %
Generic
POTASSIUM dextrose in water (in 20 iv
CHLORIDE soln, in 40 iv soln)
potassium chloride in
DEXTROSE 5%- dextrose 5 % and 0.9 %
Generic
NS-KCL sodium chloride (20 iv soln,
40 iv soln)
DEXTROSE 5%- dextrose 5 %-0.45 % Generic
1/2NS-KCL sodium chloride (10 iv soln,
30 iv soln, 40 iv soln)

LIMITS &
RESTRICTIONS
DEXTROSE 5%- Generic
dextrose 5% and 0.3 %
0.33% NACL-KCL
sodium chloride
POTASSIUM
potassium chloride in lr-d5
CHLORIDE IN Generic
20 meq/l iv soln
D5LR
DEXTROSE 5%- potassium chloride/d5-
Generic
0.2% NACL-KCL 0.2%nacl 20 meq/l iv soln
DEXTROSE 5%- potassium chloride/d5- Generic
0.45% NACL-KCL 0.45nacl 20 meq/l iv soln
potassium
POTASSIUM
chloride/potassium Generic QL 240 / 30 DAY(S)
CHLORIDE
bicarbonate/citric acid
LACTATED ringer's solution,lactated iv QL 1000 / 30 DAY(S)
Generic
RINGERS soln
SODIUM sodium chloride 0.45 % Generic
CHLORIDE 0.45 % iv soln
SODIUM sodium chloride 4 meq/ml Generic
CHLORIDE vial QL 1000 / 30 DAY(S)
SODIUM Generic
sodium chloride 5 %
CHLORIDE
sodium chloride for
HYPER-SAL inhalation (0.9 % vial-neb, 7 Generic QL 600 / 30 DAY(S)
% vial-neb)
sodium
phosphate/potassium Brand QL 120 / 30 DAY(S)
PHOS-NAK
phosphates, monobasic
and bibasic
ZINC CHLORIDE zinc chloride Generic
ZINC zinc gluconate 100 mg Generic
GLUCONATE tablet
CALORIC AGENTS

Generic
0.2% NACL sodium chloride

LIMITS &
RESTRICTIONS
DEXTROSE 10%- dextrose 10 % and 0.45 % Generic
DEXTROSE
dextrose 2.5 % and 0.45 %
2.5%-0.45% Generic
sodium chloride
NACL
Generic
dextrose 5 % in water (5 %
DEXTROSE IN
in 5 % iv soln, 5 % in 5 % Generic
WATER
vial)
medium chain triglycerides Brand QL 120 / 30 DAY(S)
MCT OIL
7.7kcal/ml oil AL1 Up to 5 yrs old
IRRIGATING SOLUTIONS
ACETIC ACID acetic acid 0.25 % irrig soln Generic QL 1000 / 30 DAY(S)
AMINOACETIC Generic
glycine urologic solution
ACID
RINGERS ringer's solution irrig soln Generic QL 1000 / 30 DAY(S)
IRRIGATION
LACTATED ringer's solution,lactated Generic QL 1000 / 30 DAY(S)
RINGERS irrig soln
AQUA CARE
sodium chloride irrigating
SODIUM Generic QL 4000 / 30 DAY(S)
solution
CHLORIDE
AQUA CARE
STERILE WATER water for irrigation,sterile
IRRIG

LIMITS &
RESTRICTIONS
URICOSURIC AGENTS
PROBENECID probenecid Generic QL 60 / 30 DAY(S)

PROBENECID- Generic QL 60 / 30 DAY(S)
probenecid/colchicine
COLCHICINE
CORTICOSTEROIDS (RESPIRATORY TRACT)
ORALLY INHALED PREPARATIONS (STEROIDS)
beclomethasone
dipropionate (40 mcg aer
QVAR Brand QL 8.7 / 30 DAY(S)
w/adap, 80 mcg aer
w/adap)
budesonide (0.25mg/2ml
QL 120 / 30 DAY(S)
PULMICORT ampul-neb, 0.5 mg/2ml Generic
ampul-neb) AL1 Up to 6 yrs old
PULMICORT budesonide 180 mcg aer

FLEXHALER pow ba
PULMICORT budesonide 90 mcg aer Brand QL 1 / 30 DAY(S)
FLEXHALER pow ba
budesonide/formoterol
fumarate (80-4.5 mcg hfa QL 11 / 30 DAY(S)
SYMBICORT Brand ST
aer ad, 160-4.5mcg hfa aer
ad) AL1 At least 6 yrs old
ciclesonide (80 mcg hfa aer

ALVESCO Brand QL 6.1 / 30 DAY(S)
ad, 160 mcg hfa aer ad)
flunisolide 80 mcg hfa aer Brand QL 17.8 / 30 DAY(S)
AEROSPAN
ad
fluticasone furoate (100
ARNUITY
mcg blst w/dev, 200 mcg Brand QL 30 / 30 DAY(S)
ELLIPTA
blst w/dev)
fluticasone furoate/vilanterol
trifenatate (100-25mcg blst Brand QL 60 / 30 DAY(S)
BREO ELLIPTA ST
w/dev, 200-25 mcg blst
w/dev) AL1 At least 18 yrs old

LIMITS &
RESTRICTIONS
fluticasone propionate (44
FLOVENT HFA mcg aer w/adap, 110 mcg Brand
aer w/adap, 220 mcg aer QL 12 / 30 DAY(S)
w/adap)
fluticasone propionate (50
FLOVENT mcg blst w/dev, 100 mcg QL 60 / 30 DAY(S)
Brand
DISKUS blst w/dev, 250 mcg blst
w/dev)
fluticasone
propionate/salmeterol
xinafoate (100-50 mcg blst Brand QL 60 / 30 DAY(S)
ADVAIR DISKUS ST
w/dev, 250-50 mcg blst
w/dev, 500-50 mcg blst AL1 At least 4 yrs old
w/dev)
fluticasone
ADVAIR HFA propionate/salmeterol QL 12 / 30 DAY(S)
xinafoate (45-21 mcg hfa Brand ST
aer ad, 115-21mcg hfa aer AL1 At least 12 yrs old
ad, 230-21mcg hfa aer ad)
fluticasone
propionate/salmeterol
xinafoate (55-14 mcg aer QL 1 / 30 day(s)
AIRDUO
Generic ST
RESPICLICK pow ba, 113-14 mcg aer
pow ba, 232-14 mcg aer AL1 At least 12 yrs old
pow ba)
mometasone furoate (100 Brand
ASMANEX HFA mcg hfa aer ad, 200 mcg QL 13 / 30 DAY(S)
hfa aer ad)
mometasone furoate
(110mcg(30) aer pow ba,
ASMANEX 110 mcg(7) aer pow ba, 1 / 30 DAY(S)
220mcg(30) aer pow ba, Brand
220mcg 120 aer pow ba,
220mcg(60) aer pow ba,
220mcg(14) aer pow ba)
mometasone
furoate/formoterol fumarate
DULERA ST
(100-5 mcg hfa aer ad, 200-
5 mcg hfa aer ad) AL1 At least 12 yrs old
PAGE 77
LIMITS &
RESTRICTIONS
ANTI-INFLAMMATORY AGENTS (RESPIRATORY)
LEUKOTRIENE MODIFIERS
montelukast sodium (4 mg
gran pack, 4 mg tab chew,
SINGULAIR Generic QL 30 / 30 DAY(S)
5 mg tab chew, 10 mg
tablet)
zafirlukast (10 mg tablet, 20 Generic QL 60 / 30 DAY(S)
ACCOLATE
mg tablet)
MAST-CELL STABILIZERS
CROMOLYN cromolyn sodium 20 mg/2

SODIUM ml ampul-neb
CROMOLYN Generic QL 10 / 30 DAY(S)
cromolyn sodium 4 % drops
SODIUM
NASAL ALLERGY cromolyn sodium 5.2 mg Generic QL 26 / 30 DAY(S)
SPRAY spray/pump
RESPIRATORY TRACT AGENTS
ANTITUSSIVES
benzonatate (100 mg
TESSALON Generic QL 30 / 30 DAY(S)
brompheniramine
ATUSS DA Brand QL 120 / 30 DAY(S)
maleate/pseudoephedrine
hcl/chlophedianol AL1 3 to 20 yrs old
brompheniramine/pseudoep QL 120 / 30 DAY(S)

BROMFED DM Generic
hed/dm 2-30-10/5 syrup AL1 3 to 20 yrs old
KIDKARE chlorpheniramin/pseudoeph Brand
ed/dm 1-15-5mg/5 liquid AL1 3 to 20 yrs old
chlorpheniramine/codeine AL1 18 to 64 yrs old

Z-TUSS AC Brand
phos 2 mg-9mg/5 liquid
PE-HIST DM chlorpheniramine/phenylep
Generic
h/dm 2-5-15mg/5 liquid

LIMITS &
RESTRICTIONS
codeine
CHERATUSSIN Brand QL 1920 / 365 DAY(S)
phosphate/guaifenesin 10-
AC AL1 18 to 64 yrs old
100mg/5 liquid
codeine
phosphate/guaifenesin 10- QL 1920 / 365 DAY(S)
AMBITUSSIN AC Generic
100mg/5 liquid AL1 18 to 64 yrs old
12-HOUR QL 240 / 30 DAY(S)

dextromethorphan polistirex Generic
COUGH RELIEF AL1 3 to 20 yrs old
ADULT TUSSIN guaifenesin/dextromethorph Generic QL 480 / 30 DAY(S)
DM an 100-10mg/5 syrup AL1 3 to 20 yrs old
guaifenesin/dextromethorph Brand
MUCUS DM AL1 3 to 20 yrs old
an 600mg-30mg tab er 12h
HYDROCODONE
hydrocodone bit/homatrop
-HOMATROPINE Generic AL1 At least 18 yrs old
me-br 5-1.5 mg/5 syrup
MBR
PROMETHAZINE QL 1920 / 365 DAY(S)
promethazine hcl/codeine Generic
-CODEINE AL1 18 to 64 yrs old
PROMETHAZINE promethazine Generic QL 1920 / 365 DAY(S)
-DM hcl/dextromethorphan hbr AL1 Up to 64 yrs old
CHERATUSSIN pseudoephed/codeine/guaif Brand QL 240 / 30 DAY(S)
DAC en 30-10-100 syrup AL1 18 to 64 yrs old
EXPECTORANTS
ADULT TUSSIN
guaifenesin 100 mg/5ml QL 1920 / 365 DAY(S)
CHEST Generic
liquid AL1 3 to 20 yrs old
CONGESTION
MUCOLYTIC AGENTS
ACETYLCYSTEIN acetylcysteine 200 mg/ml Generic

E vial

LIMITS &
RESTRICTIONS
ANTI-INFECTIVES (EENT)
ANTIBACTERIALS (EENT)
AZASITE azithromycin 1 % drops Brand QL 2.5 / 30 DAY(S)

bacitracin 500 unit/g oint. QL 30 / 30 DAY(S)
BACITRACIN Generic
(g)
bacitracin/polymyxin b
AK-POLY-BAC Generic QL 3.5 / 30 DAY(S)
sulfate 500-10k/g oint. (g)
BESIVANCE besifloxacin hcl Brand QL 5 / 30 DAY(S)
CILOXAN ciprofloxacin hcl 0.3 % QL 5 / 30 DAY(S)

Generic
drops
ciprofloxacin hcl 0.3 % oint.
CILOXAN Brand QL 3.5 / 30 DAY(S)
(g)
ciprofloxacin Brand QL 7.5 / 30 DAY(S)
CIPRODEX
hcl/dexamethasone AL1 Up to 21 yrs old
CIPRO HC ciprofloxacin Brand QL 10 / 30 DAY(S)
hcl/hydrocortisone AL1 Up to 21 yrs old
PERIOSTAT doxycycline hyclate 20 mg Generic
tablet AL1 At least 8 yrs old
erythromycin base (5 mg/g

ILOTYCIN oint. (g), 5 mg/gram oint. Generic QL 4 / 30 DAY(S)
(g))
ZYMAXID gatifloxacin Generic QL 3 / 30 DAY(S)
gentamicin
PRED-G sulf/prednisolone 0.3%-1% Brand QL 10 / 30 DAY(S)
drops susp
gentamicin
PRED-G sulf/prednisolone 0.3-0.6% Brand QL 3.5 / 30 DAY(S)
oint. (g)
gentamicin sulfate 0.3 %
GARAMYCIN Generic
drops
GARAMYCIN gentamicin sulfate 0.3 % Generic

oint. (g) QL 3.5 / 30 DAY(S)

LIMITS &
RESTRICTIONS
QUIXIN levofloxacin 0.5 % drops Generic QL 5 / 30 DAY(S)
moxifloxacin hcl 0.5 %
VIGAMOX Generic QL 3 / 30 DAY(S)
drops
moxifloxacin hcl 0.5 %
MOXEZA Brand QL 6 / 30 DAY(S)
drops visc
neomycin sulf/colistin
COLY-MYCIN S sul/hydrocortisone
ac/thonzonium brom AL1 Up to 20 yrs old
neomycin sulfate/bacitracin
CORTISPORIN zinc/polymyxin Generic QL 3.5 / 30 DAY(S)
b/hydrocortisone
neomycin
NEO-POLYCIN sulfate/bacitracin/polymyxin Generic QL 3.5 / 30 DAY(S)
b
NEOSPORIN neomycin sulfate/polymyxin Generic QL 10 / 30 DAY(S)
b sulfate/gramicidin d
neomycin/polymyxin
DEXASPORIN b/dexametha 0.1 % drops Generic QL 5 / 30 DAY(S)
susp
neomycin/polymyxin
AK-TROL b/dexametha 3.5-10k-.1 Generic QL 3.5 / 30 DAY(S)
oint. (g)
neomycin/polymyxin
ANTIBIOTIC EAR Generic QL 10 / 30 DAY(S)
b/hydrocort 3.5-10k-1 drops
SUSPENSION
susp
neomycin/polymyxin
ANTIBIOTIC EAR Generic QL 10 / 30 DAY(S)
b/hydrocort 3.5-10k-1
SOLUTION
solution
neomycin/polymyxin
NEOMYCIN- Generic QL 7.5 / 30 DAY(S)
b/hydrocort 3.5-10k-10
POLYMYXIN-HC
drops susp
QL 10 / 30 DAY(S)
FLOXIN ofloxacin 0.3 % drops Generic
polymyxin b Generic
POLYTRIM QL 10 / 30 DAY(S)
sulfate/trimethoprim

LIMITS &
RESTRICTIONS
BLEPH-10 sulfacetamide sodium 10 % Generic
drops QL 15 / 30 DAY(S)
SULFACETAMID sulfacetamide sodium 10 %

Generic
E SODIUM oint. (g)
SULFACETAMID sulfacetamide
E- sodium/prednisolone Generic QL 5 / 30 DAY(S)
PREDNISOLONE sodium phosphate
TOBRASOL tobramycin 0.3 % drops Generic
TOBRADEX tobramycin/dexamethasone Generic

0.3 %-0.1% drops susp QL 10 / 30 DAY(S)
tobramycin/dexamethasone QL 3.5 / 30 DAY(S)

TOBRADEX Brand
0.3 %-0.1% oint. (g)
TOBRADEX ST tobramycin/dexamethasone Brand QL 10 / 30 DAY(S)

0.3%-0.05% drops susp
ZYLET tobramycin/loteprednol Brand QL 5 / 30 DAY(S)

etabonate
ANTIFUNGALS (EENT)
NATACYN natamycin Brand QL 15 / 30 DAY(S)
ANTIVIRALS (EENT)
VIROPTIC trifluridine Generic QL 7.5 / 30 DAY(S)
EENT ANTI-INFECTIVES, MISCELLANEOUS
ACETIC ACID- acetic acid/aluminum QL 15 / 30 DAY(S)

Generic
ALUMINUM acetate AL1 Up to 20 yrs old
carbamide peroxide 6.5 % Brand QL 15 / 30 DAY(S)
AURAPHENE-B
drops AL1 Up to 20 yrs old
PAROEX chlorhexidine gluconate
0.12 % mouthwash
ACETASOL HC hydrocortisone/acetic acid

LIMITS &
RESTRICTIONS
ANTI-INFLAMMATORY AGENTS (EENT)
CORTICOSTEROIDS (EENT)
RHINOCORT budesonide 32mcg

Generic QL 8.6 / 30 day(s)
AQUA spray/pump
dexamethasone sodium
DEXASOL Generic QL 5 / 30 DAY(S)
phosphate 0.1 % drops
DUREZOL difluprednate Brand QL 5 / 30 DAY(S)
FLUNISOLIDE flunisolide 25 mcg spray Generic QL 25 / 30 DAY(S)

ST
QL 20 / 30 DAY(S)
DERMOTIC fluocinolone acetonide oil Generic
FML fluorometholone 0.1 % Generic
drops susp QL 15 / 30 DAY(S)
fluorometholone 0.1 % oint. Brand QL 3.5 / 30 DAY(S)

FML S.O.P.
(g)
FML FORTE fluorometholone 0.25 % QL 15 / 30 DAY(S)

Brand
drops susp
FLONASE fluticasone propionate 50 QL 16 / 30 day(s)

Generic
mcg spray susp
loteprednol etabonate (0.5
LOTEMAX % drops gel, 0.5 % drops Brand QL 5 / 30 DAY(S)
susp)
loteprednol etabonate 0.2
ALREX Brand QL 5 / 30 DAY(S)
% drops susp
prednisolone acetate 0.12 QL 10 / 30 DAY(S)
PRED MILD Brand
% drops susp
OMNIPRED prednisolone acetate 1 % QL 10 / 30 DAY(S)

Generic
drops susp
prednisolone sod
PREDNISOL Generic QL 10 / 30 DAY(S)
phosphate 1 % drops
VEXOL rimexolone Brand QL 10 / 30 DAY(S)

LIMITS &
RESTRICTIONS
NASACORT AQ triamcinolone acetonide 55 Generic
mcg spray QL 16.5 / 30 DAY(S)
CHILDREN'S triamcinolone acetonide 55

Brand QL 10.8 / 30 day(s)
NASACORT mcg spray
TRIESENCE triamcinolone acetonide/pf Brand QL 10 / 30 DAY(S)
EENT NONSTEROIDAL ANTI-INFLAM. AGENTS
bromfenac sodium (0.09 %

BROMDAY Generic QL 2.5 / 30 DAY(S)
drops, 0.09% drops)
diclofenac sodium 0.1 %
VOLTAREN Generic QL 5 / 30 DAY(S)
drops
OCUFEN flurbiprofen sodium Generic QL 2.5 / 30 DAY(S)
ketorolac tromethamine 0.4 Generic QL 5 / 30 DAY(S)
ACULAR LS
% drops
ketorolac tromethamine 0.5
ACULAR Generic QL 10 / 30 DAY(S)
% drops
ACUVAIL ketorolac tromethamine/pf Brand QL 30 / 30 DAY(S)
NEVANAC nepafenac 0.1 % drops QL 3 / 30 DAY(S)

Brand
susp
ANTIGLAUCOMA AGENTS
ALPHA-ADRENERGIC AGONISTS (EENT)
BRIMONIDINE brimonidine tartrate (0.15 %

TARTRATE drops, 0.2 % drops)
brimonidine tartrate 0.1 % Brand QL 10 / 30 DAY(S)
ALPHAGAN P
drops
COMBIGAN brimonidine tartrate/timolol QL 5 / 30 DAY(S)

Brand
maleate
BETA-ADRENERGIC BLOCKING AGENTS (EENT)
betaxolol hcl 0.25 % drops

BETOPTIC S Brand QL 15 / 30 DAY(S)
susp

LIMITS &
RESTRICTIONS
BETAXOLOL HCL betaxolol hcl 0.5 % drops Generic QL 5 / 30 DAY(S)
CARTEOLOL carteolol hcl Generic QL 15 / 30 DAY(S)
HCL
BETAGAN levobunolol hcl Generic QL 15 / 30 DAY(S)
OPTIPRANOLOL metipranolol Generic QL 15 / 30 DAY(S)
timolol (0.25 % drops, 0.5 %
BETIMOL Brand QL 5 / 30 DAY(S)
drops)
timolol maleate (0.25 % sol-
TIMOPTIC-XE gel, 0.25 % drops, 0.5 % Generic QL 5 / 30 DAY(S)
drops, 0.5 % sol-gel)
ISTALOL timolol maleate 0.5 % drop Brand QL 5 / 30 DAY(S)
daily
CARBONIC ANHYDRASE INHIBITORS (EENT)
ACETAZOLAMID acetazolamide (125 mg

E tablet, 250 mg tablet)
DIAMOX acetazolamide 500 mg Generic QL 60 / 30 DAY(S)
SEQUELS capsule er
AZOPT brinzolamide Brand QL 10 / 30 DAY(S)
TRUSOPT dorzolamide hcl Generic QL 10 / 30 DAY(S)
dorzolamide hcl/timolol
COSOPT Generic QL 10 / 30 DAY(S)
maleate
MIOTICS
MIOSTAT carbachol 0.01 % vial Brand QL 5 / 30 DAY(S)
PHOSPHOLINE echothiophate iodide Brand QL 5 / 30 DAY(S)
IODIDE
ISOPTO pilocarpine hcl (1 % drops,
CARPINE 2 % drops, 4 % drops)
PROSTAGLANDIN ANALOGS
LUMIGAN bimatoprost 0.03 % drops Generic QL 2.5 / 30 DAY(S)

ST
PAGE 85
LIMITS &
RESTRICTIONS
XALATAN latanoprost 0.005 % drops Generic QL 2.5 / 25 DAY(S)
EYE, EAR, NOSE AND THROAT (EENT) PREPS.
ANTIALLERGIC AGENTS
LASTACAFT alcaftadine Brand QL 3 / 30 DAY(S)

ST
OPTIVAR azelastine hcl 0.05 % drops Generic QL 6 / 30 DAY(S)
ST
azelastine hcl 137 mcg
ASTELIN Generic QL 30 / 30 DAY(S)
spray/pump
EMADINE emedastine difumarate Brand QL 5 / 30 DAY(S)
ELESTAT epinastine hcl Generic QL 5 / 30 DAY(S)

ST
ALAWAY ketotifen fumarate Generic QL 10 / 30 DAY(S)
ALAWAY ketotifen fumarate Brand QL 10 / 30 DAY(S)
PATANOL olopatadine hcl 0.1 % drops Generic QL 5 / 30 DAY(S)

ST
LOCAL ANESTHETICS (EENT)

LIDOCAINE HCL
lidocaine hcl 2 % solution Generic QL 100 / 30 DAY(S)
VISCOUS
MYDRIATICS
ATROPINE CARE atropine sulfate 1 % drops Generic QL 5 / 30 DAY(S)

cyclopentolate hcl (0.5 %
CYCLOGYL drops, 1 % drops, 2 % Generic QL 15 / 60 DAY(S)
drops)
HOMATROPAIRE homatropine hbr Generic QL 5 / 30 DAY(S)
ISOPTO scopolamine hydrobromide Brand QL 5 / 30 DAY(S)
HYOSCINE 0.25 % drops
MYDRAL tropicamide 1 % drops Generic QL 5 / 30 DAY(S)

LIMITS &
RESTRICTIONS
MOUTHWASHES AND GARGLES
ORAL hydrogen peroxide 1.5 % Brand

CLEANSER solution
VASOCONSTRICTORS
AK-CON naphazoline hcl Generic QL 15 / 30 DAY(S)

CLEAR EYES
naphazoline hcl/glycerin Brand QL 5 / 30 DAY(S)
REDNESS
0.012-0.2% drops
RELIEF
REDNESS naphazoline hcl/glycerin
RELIEF 0.012-0.25 drops
naphazoline
EYE ALLERGY Brand QL 5 / 30 DAY(S)
hcl/pheniramine .0268-.315
RELIEF
drops
naphazoline
VISINE-A hcl/pheniramine 0.025-0.3% Brand QL 15 / 30 DAY(S)
drops
phenylephrine hcl 0.125 %
LITTLE NOSES Brand QL 15 / 30 DAY(S)
drops
ALTAFRIN phenylephrine hcl 10 % QL 5 / 30 DAY(S)

Generic
drops
phenylephrine hcl 2.5 % Generic QL 15 / 30 DAY(S)
ALTAFRIN
drops
tetrahydrozoline hcl 0.05 % Brand
ALTAZINE
drops
tetrahydrozoline hcl/dextran
EYE DROPS Brand
70/peg 400/povidone
ASTRINGENT tetrahydrozoline hcl/zinc
EYE DROPS sulfate
EENT DRUGS, MISCELLANEOUS
0.9 % sodium chloride 0.9 QL 126 / 30 DAY(S)

NASAL MIST Brand
% spray

LIMITS &
RESTRICTIONS
IOPIDINE apraclonidine hcl 0.5 % Generic
drops QL 5 / 30 DAY(S)
apraclonidine hcl 1 % Brand QL 5 / 30 DAY(S)

IOPIDINE
droperette
REFRESH carboxymethylcellulos/glyce QL 15 / 30 DAY(S)
Brand
OPTIVE rin 0.5%-0.9% drops
carboxymethylcellulose QL 15 / 30 DAY(S)
THERA TEARS Brand
sodium 0.25 % drops
LUBRICANT GEL carboxymethylcellulose QL 15 / 30 DAY(S)
Brand
DROPS sodium/hypromellose
ARTIFICIAL dextran 70/hypromellose QL 15 / 30 DAY(S)
Brand
TEARS 0.1%-0.3% drops
GENTEAL dextran/hypromellose/glycer QL 15 / 30 DAY(S)
Brand
TEARS in
eucalyptus/menthol 6.1mg
MEDIKOFF Brand
lozenge
eye lubricant combination
FRESHKOTE Brand QL 15 / 30 DAY(S)
no.1
ARTIFICIAL glycerin/propylene glycol QL 15 / 30 DAY(S)
Brand
TEARS 0.3%-1% drops
hydroxypropyl cellulose 5 QL 60 / 30 DAY(S)
LACRISERT Brand
mg insert
EQ GENTLE hypromellose 0.3 % drops Brand QL 15 / 30 DAY(S)
ISOPTO TEARS hypromellose 0.5 % drops Brand QL 15 / 30 DAY(S)
GONAK hypromellose 2.5 % drops Brand QL 15 / 30 DAY(S)
RETAINE HPMC hypromellose/pf Brand
ipratropium bromide 21 mcg

ATROVENT Generic QL 30 / 30 DAY(S)
spray
ATROVENT ipratropium bromide 42 mcg Generic QL 15 / 30 DAY(S)

spray
peg
ARTIFICIAL
400/hypromellose/glycerin Brand QL 15 / 30 DAY(S)
TEARS
1-0.2-0.2% drops

LIMITS &
RESTRICTIONS
LUBRICANT EYE polyvinyl alcohol Brand
REFRESH polyvinyl
CLASSIC alcohol/povidone/pf
LUBRICANT EYE QL 15 / 30 DAY(S)
propylene glycol Brand
DROP
propylene glycol/peg 400 Brand QL 15 / 30 DAY(S)
LUBRICANT EYE
0.3 %-0.4% drops
ALTAMIST sodium chloride 0.65 % Brand QL 45 / 30 DAY(S)

spray AL1 Up to 5 yrs old
sodium chloride 0.65 % Generic QL 45 / 30 DAY(S)
ALTAMIST
spray AL1 Up to 5 yrs old
ANTIEMETICS
ANTIHISTAMINES (GI DRUGS)

dimenhydrinate 25 mg tab QL 90 / 30 DAY(S)
DRAMAMINE Brand
chew AL1 Up to 6 yrs old
DRAMAMINE dimenhydrinate 50 mg tab Brand QL 90 / 30 DAY(S)
chew AL1 Up to 64 yrs old
DRAMAMINE dimenhydrinate 50 mg Brand
ANTIVERT meclizine hcl (12.5 mg Generic QL 90 / 30 DAY(S)

TRAVEL meclizine hcl 25 mg tab
SICKNESS chew
COMPAZINE prochlorperazine Generic QL 24 / 30 DAY(S)
PROCHLORPER
prochlorperazine edisylate
AZINE Generic QL 20 / 30 DAY(S)
10 mg/2 ml vial
EDISYLATE
prochlorperazine maleate (5 QL 120 / 30 DAY(S)
COMPAZINE Generic
TIGAN trimethobenzamide hcl 300 Generic QL 120 / 30 DAY(S)

mg capsule AL1 Up to 64 yrs old

LIMITS &
RESTRICTIONS
5-HT3 RECEPTOR ANTAGONISTS
GRANISETRON granisetron hcl (1 mg/ml

HCL vial, 1 mg/ml(1) vial)
GRANISETRON Generic QL 6 / 30 DAY(S)
granisetron hcl 1 mg tablet
HCL
ondansetron (4 mg tab Generic QL 60 / 30 DAY(S)
ZOFRAN ODT
rapdis, 8 mg tab rapdis)
ZOFRAN ondansetron hcl (4 mg Generic QL 60 / 30 DAY(S)

ONDANSETRON ondansetron hcl 24 mg Generic QL 4 / 30 DAY(S)
HCL tablet
ondansetron hcl 4 mg/5 ml Generic
ZOFRAN
solution
ondansetron hcl/pf (4 ml
ONDANSETRON
syringe, 4 ml ampul, 4 ml Generic
HCL
vial)
NEUROKININ-1 RECEPTOR ANTAGONISTS
aprepitant (40 mg capsule,

EMEND 80 mg capsule, 125 mg Generic ST
capsule)
aprepitant 125 mg susp QL 3 / 30 DAY(S)
EMEND Brand
recon ST
EMEND aprepitant 125mg-80mg cap QL 3 / 30 DAY(S)
Generic
ds pk ST
ANTIEMETICS, MISCELLANEOUS
dronabinol (2.5 mg capsule, QL 90 / 30 DAY(S)

MARINOL Generic
5 mg capsule) ST
MARINOL dronabinol 10 mg capsule Generic QL 60 / 30 DAY(S)

ST
phosphorated carbohydrate Brand
NAUSEA RELIEF
(dextrose and fructose)

LIMITS &
RESTRICTIONS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
HISTAMINE H2-ANTAGONISTS
cimetidine (200 mg tablet,

ACID REDUCER 300 mg tablet, 400 mg Generic QL 60 / 30 DAY(S)
ACID famotidine (10 mg tablet, 40
CONTROLLER mg tablet)
FAMOTIDINE famotidine 10 mg/ml vial Generic QL 20 / 30 DAY(S)
PEPCID famotidine 40mg/5ml oral Generic QL 300 / 30 DAY(S)

susp
ranitidine hcl (75 mg tablet,
ACID CONTROL 150 mg capsule, 300 mg Generic QL 60 / 30 DAY(S)
tablet, 300 mg capsule)
ranitidine hcl 15 mg/ml QL 600 / 30 DAY(S)
ZANTAC Generic
syrup AL1 Up to 18 yrs old
ZANTAC ranitidine hcl 50 mg/2 ml Generic
vial QL 40 / 30 DAY(S)
PROSTAGLANDINS
CYTOTEC misoprostol (100 mcg

Generic ST
tablet, 200 mcg tablet)
PROTECTANTS
Generic
CARAFATE sucralfate 1 g tablet QL 120 / 30 DAY(S)
PROTON-PUMP INHIBITORS
esomeprazole magnesium
NEXIUM (20 mg capsule dr, 40 mg Generic QL 30 / 30 DAY(S)
capsule dr) ST
lansoprazole (15 mg
HEARTBURN Generic
capsule dr, 30 mg capsule QL 30 / 30 DAY(S)
RELIEF 24 HOUR
dr)

LIMITS &
RESTRICTIONS
omeprazole (10 mg capsule
PRILOSEC dr, 20 mg capsule dr, 40 mg Generic
QL 30 / 30 DAY(S)
capsule dr)
OMEPRAZOLE omeprazole 20 mg tablet dr Generic QL 60 / 30 DAY(S)
ACID REDUCER omeprazole magnesium 20 Generic QL 30 / 30 DAY(S)

mg capsule dr
omeprazole magnesium 20
PRILOSEC OTC Brand QL 30 / 30 DAY(S)
mg tablet dr
pantoprazole sodium (20
PROTONIX mg tablet dr, 40 mg tablet QL 30 / 30 DAY(S)
Generic
dr)
ACIPHEX rabeprazole sodium 20 mg Generic QL 30 / 30 DAY(S)
tablet dr ST
GASTROINTESTINAL DRUGS
ANTACIDS AND ADSORBENTS
mag hydrox/al
MILANTEX hydrox/simeth 200-200-20 Brand QL 480 / 30 DAY(S)
oral susp
mag hydrox/aluminum
ALMACONE hyd/simeth 200-200-20 oral
susp
mag hydrox/aluminum
ALMACONE Brand QL 100 / 30 DAY(S)
hyd/simeth 200-200-25 tab
chew
mag hydrox/aluminum
COMFORT GEL Brand QL 480 / 30 DAY(S)
hyd/simeth 400-400-40 oral
susp
ANTACID PLUS mag hydrox/aluminum
EXTRA hyd/simeth 450-500-40 oral
STRENGTH susp
magnesium
ACID GONE carbonate/aluminum
hydroxide

LIMITS &
RESTRICTIONS
MAG-OXIDE magnesium oxide 200 mg Generic
MAGNESIUM tablet QL 180 / 30 DAY(S)
magnesium oxide 400 mg Generic

MAGNESIUM
capsule
MAGNESIUM magnesium oxide 400 mg Generic
OXIDE tablet QL 180 / 30 DAY(S)
magnesium oxide 400 mg Brand QL 180 / 30 DAY(S)

MGO
tablet
magnesium oxide 500 mg QL 360 / 30 DAY(S)
MAGNESIUM Generic
capsule
UROMAG magnesium oxide 84.5(140) Brand

capsule
SODIUM sodium bicarbonate (325
BICARBONATE mg tablet, 650 mg tablet)
ANTIDIARRHEA AGENTS
difenoxin hcl/atropine
MOTOFEN Brand QL 60 / 30 DAY(S)
sulfate
DIPHENOXYLAT diphenoxylate hcl/atropine QL 60 / 30 DAY(S)
Generic
E-ATROPINE 2.5-.025/5 liquid
diphenoxylate hcl/atropine Generic QL 30 / 30 DAY(S)
LOMOTIL
2.5-.025mg tablet
lactobacillus acidophilus Generic
DOFUS
capsule
lactobacillus acidophilus Generic
ACIDOPHILUS
100 mg capsule
ANTI- loperamide hcl (1mg/7.5ml
DIARRHEAL liquid, 1 mg/5 ml liquid)
DIAMODE loperamide hcl 2 mg tablet Brand QL 30 / 30 DAY(S)
CATHARTICS AND LAXATIVES
BISAC-EVAC bisacodyl 10 mg supp.rect Generic QL 30 / 30 DAY(S)

BISCOLAX bisacodyl 10 mg supp.rect Brand QL 30 / 30 DAY(S)

LIMITS &
RESTRICTIONS
ALOPHEN PILLS bisacodyl 5 mg tablet dr Generic QL 60 / 30 DAY(S)
ALOPHEN PILLS bisacodyl 5 mg tablet dr Brand QL 60 / 30 DAY(S)
calcium polycarbophil 625
FIBER Brand QL 180 / 30 DAY(S)
mg tablet
STOOL Brand QL 30 / 30 DAY(S)
docusate calcium
SOFTENER
docusate sodium 100 mg Brand QL 120 / 30 DAY(S)
DOK
capsule
docusate sodium 283 Brand QL 30 / 30 DAY(S)
ENEMEEZ
mg/5ml enema
COL-RITE docusate sodium 50 mg Brand QL 60 / 30 DAY(S)

capsule
docusate sodium 50 mg/5
DOCU LIQUID Brand QL 960 / 30 DAY(S)
ml liquid
SUPPOSITORY glycerin adult supp.rect Brand QL 12 / 30 DAY(S)
CHILD QL 12 / 30 DAY(S)
glycerin pediatric supp.rect Generic
SUPPOSITORY
CHILD
glycerin pediatric supp.rect Brand QL 12 / 30 DAY(S)
SUPPOSITORY
CITROMA magnesium citrate solution Generic QL 300 / 30 DAY(S)
CITROMA magnesium citrate solution Brand QL 300 / 30 DAY(S)
peg 3350/sod sulf/sod
bicarb/sod
GOLYTELY chloride/potassium chloride Brand QL 4000 / 30 DAY(S)
(227.1-21.5 powd pack,
236-22.74g soln recon)
peg3350/sod
MOVIPREP sul/nacl/kcl/asb/c 7.5- Brand QL 1 / 30 DAY(S)
2.691g powd pack
peg3350/sod
GAVILYTE-G sulf,bicarb,cl/kcl 236-22.74g Generic QL 4000 / 30 DAY(S)
soln recon

LIMITS &
RESTRICTIONS
COLYTE WITH peg3350/sod
FLAVOR sulf,bicarb,cl/kcl 240-22.72g Generic
QL 4000 / 30 DAY(S)
PACKETS soln recon
peg3350/sod
GAVILYTE-C sulf,bicarb,cl/kcl 240-22.72g Brand QL 4000 / 30 DAY(S)
soln recon
polyethylene glycol 3350
CLEARLAX Generic QL 28 / 28 DAY(S)
17g powd pack
CLEARLAX polyethylene glycol 3350 Generic QL 527 / 30 day(s)

17g/dose powder
psyllium husk (with sugar)
METAMUCIL (3.4 g/12 g powder, Brand QL 1400 / 30 DAY(S)
3.4g/11g powder)
psyllium husk/aspartame
WAL-MUCIL Brand QL 660 / 30 DAY(S)
3.4g/5.8g powder
FIBER SMOOTH psyllium seed powder Brand QL 660 / 30 DAY(S)
FIBER THERAPY psyllium seed (with sugar) Brand

powder
sennosides/docusate
DOK PLUS Brand QL 30 / 30 DAY(S)
sodium
sod phosphate mbas/sod Brand QL 40 / 30 DAY(S)
OSMOPREP
phos,di 1.5 g tablet
sodium chloride/sodium
GAVILYTE-N bicarbonate/potassium Generic QL 4000 / 30 DAY(S)
chloride/peg
TRILYTE WITH sodium chloride/sodium
FLAVOR bicarbonate/potassium Brand QL 4000 / 30 DAY(S)
PACKETS chloride/peg
sorbitol solution 70 % QL 960 / 30 DAY(S)
SORBITOL Generic
solution
CHOLELITHOLYTIC AGENTS
ursodiol (250 mg tablet, 300 QL 120 / 30 DAY(S)

ACTIGALL Generic
mg capsule) ST
PAGE 95
LIMITS &
RESTRICTIONS
URSO FORTE ursodiol 500 mg tablet Generic QL 60 / 30 DAY(S)
ST
DIGESTANTS
lipase/protease/amylase
(2.6 k-6.2k capsule dr, 4.2k-
14.2k capsule dr, 10.5- QL 270 / 30 DAY(S)
PANCREAZE Brand ST
35.5k capsule dr, 16.8-
56.8k capsule dr, 21 k- AL1 At least 21 yrs old
54.7k capsule dr)
lipase/protease/amylase (3-
9.5-15k capsule dr, 6k-19k- Brand
30k capsule dr, 12k-38k-60 QL 270 / 30 DAY(S)
CREON ST
capsule dr, 24-76-120k
capsule dr, 36k-114k AL1 At least 21 yrs old
capsule dr)
lipase/protease/amylase
(3k-10k-16k capsule dr, 10-
34-55k capsule dr, 15-51- QL 270 / 30 DAY(S)
ZENPEP 82k capsule dr, 20-68-109k Brand ST
capsule dr, 25-85-136k AL1 At least 21 yrs old
capsule dr, 40k-136k
capsule dr)
QL 270 / 30 DAY(S)
PANCRELIPASE lipase/protease/amylase 5k-
Brand ST
5,000 17k-27k capsule dr
LIPOTROPIC AGENTS
ALGAL OMEGA-3 docosahexanoic acid 200 QL 30 / 30 DAY(S)

Generic
FAL Female
DHA mg capsule - 12 to 44
yrs old
docosahexanoic acid 200 QL 30 / 30 DAY(S)

DHA PRENATAL Brand
mg capsule FAL Female - 12 to 44
yrs old
FISH OIL docosahexanoic acid/epa QL 120 / 30 day(s)
Generic
120-180 mg capsule ST

LIMITS &
RESTRICTIONS
PROKINETIC AGENTS
metoclopramide hcl (5 mg
REGLAN Generic QL 120 / 30 DAY(S)
metoclopramide hcl (5 mg/5
METOCLOPRAMI Generic QL 960 / 30 DAY(S)
ml solution, 10 mg/10ml
DE HCL
solution)
metoclopramide hcl 5 mg/ml Generic QL 60 / 30 DAY(S)
REGLAN
vial
GI DRUGS, MISCELLANEOUS
lactobac
RISA-BID acidophilus/l.bulgaricus/b.bif Brand
idium/s.thermophilus
ESTROGENS AND ANTIESTROGENS
ESTROGENS
drospirenone/estradiol
(0.25-0.5mg tablet, 0.5 mg- QL 30 / 30 DAY(S)
ANGELIQ Brand
1mg tablet) AL1 Up to 64 yrs old
estradiol (.025mg/24h patch

tdsw, .0375mg/24 patch
tdsw, 0.05mg/24h patch QL 8 / 28 day(s)
MINIVELLE Generic
tdsw, .075mg/24h patch AL1 Up to 64 yrs old
tdsw, 0.1mg/24hr patch
tdsw)
tdsw, 0.05mg/24h patch
QL 8 / 28 day(s)
ALORA tdsw, .075mg/24h patch Brand
tdsw, 0.1mg/24hr patch AL1 Up to 64 yrs old
tdsw)
tdwk, .0375mg/24 patch
tdwk, 0.05mg/24h patch QL 4 / 28 day(s)
CLIMARA Generic
tdwk, .075mg/24h patch AL1 Up to 64 yrs old
tdwk, 0.1mg/24hr patch
tdwk)

LIMITS &
RESTRICTIONS
ESTRACE estradiol (0.5 mg tablet, 1 Generic QL 30 / 30 DAY(S)
mg tablet, 2 mg tablet) AL1 Up to 64 yrs old
estradiol (4 mcg insert, 4
IMVEXXY mcg insr ds pk, 10 mcg insr Brand QL 18 / 28 day(s)
ds pk, 10 mcg insert)
estradiol .0375mg/24 patch QL 8 / 28 day(s)
MINIVELLE Brand
tdsw AL1 Up to 64 yrs old
CLIMARA estradiol 0.06mg/24h patch QL 4 / 28 DAY(S)
Generic
tdwk AL1 Up to 64 yrs old
estradiol 14mcg/24hr patch Brand QL 4 / 28 DAY(S)
MENOSTAR
tdwk AL1 Up to 64 yrs old
AMABELZ estradiol/norethindrone acet QL 28 / 28 day(s)
Brand
0.5-0.1 mg tablet AL1 Up to 64 yrs old
ACTIVELLA estradiol/norethindrone acet QL 28 / 28 day(s)
Generic
0.5-0.1 mg tablet AL1 Up to 64 yrs old
AMABELZ estradiol/norethindrone acet Brand QL 28 / 28 DAY(S)
1 mg-0.5mg tablet AL1 Up to 64 yrs old
ACTIVELLA estradiol/norethindrone acet QL 28 / 28 DAY(S)
Generic
1 mg-0.5mg tablet AL1 Up to 64 yrs old
estradiol/norethindrone
QL 8 / 28 DAY(S)
COMBIPATCH acetate (.05-.14/24 patch Brand
tdsw, .05-.25/24 patch tdsw) AL1 Up to 64 yrs old
QL 30 / 30 DAY(S)
PREFEST estradiol/norgestimate Brand
estrogen,con/m-progest Brand QL 30 / 30 DAY(S)
PREMPHASE
acet 0.625 (14) tablet AL1 Up to 64 yrs old
estrogens, conjugated (0.3
mg tablet, 0.45mg tablet, QL 30 / 30 DAY(S)
PREMARIN Brand
0.625 mg tablet, 0.9 mg AL1 Up to 64 yrs old
tablet, 1.25 mg tablet)
PREMARIN estrogens, conjugated Brand
0.625 mg/g cream/appl QL 42.5 / 30 DAY(S)

LIMITS &
RESTRICTIONS
PREMARIN estrogens, conjugated 25 Brand
mg vial QL 30 / 30 DAY(S)
estrogens, conjugated,
synthetic b (0.3 mg talet,
0.45mg talet, 0.625 mg QL 30 / 30 DAY(S)
ENJUVIA Brand
talet, 0.9 mg talet, 1.25 mg AL1 Up to 64 yrs old
talet)
DUAVEE estrogens, Brand

conjugated/bazedoxifene QL 30 / 30 DAY(S)
acetate ST
estrogens,
conjugated/medroxyprogest
erone acetate (0.3-1.5mg QL 30 / 30 DAY(S)
PREMPRO Brand
tablet, 0.45-1.5mg tablet, AL1 Up to 64 yrs old
0.625-2.5 tablet, 0.625-5
mg tablet)
estrogens,conj.,synthetic a
CENESTIN (0.45mg tblet, 0.625 mg Brand
QL 30 / 30 DAY(S)
tblet, 0.9 mg tblet, 1.25 mg AL1 Up to 64 yrs old
tblet)
estrogens,esterified (0.3 mg
QL 30 / 30 DAY(S)
MENEST tablet, 0.625 mg tablet, 1.25 Brand
mg tablet, 2.5 mg tablet) AL1 Up to 64 yrs old
OGEN estropipate (0.75 mg tablet, QL 30 / 30 DAY(S)

Generic
1.5 mg tablet, 3 mg tablet) AL1 Up to 64 yrs old
norethindrone acetate- QL 28 / 28 DAY(S)
Brand
FYAVOLV ethinyl estradiol (0.5mg-2.5 GL Female
tablet, 1mg-5mcg tablet) AL1 Up to 64 yrs old
norethindrone acetate- QL 28 / 28 DAY(S)
FEMHRT ethinyl estradiol (0.5mg-2.5 Generic GL Female
tablet, 1mg-5mcg tablet) AL1 Up to 64 yrs old
ESTROGEN AGONIST-ANTAGONISTS
EVISTA raloxifene hcl AL1 At least 70 yrs old
FAL Female - At least
70 yrs old

LIMITS &
RESTRICTIONS
TAMOXIFEN tamoxifen citrate 10 mg Generic QL 60 / 30 DAY(S)
CITRATE tablet GL Female
TAMOXIFEN tamoxifen citrate 20 mg QL 30 / 30 DAY(S)
Generic
CITRATE tablet GL Female
ANTIDIABETIC AGENTS
ALPHA-GLUCOSIDASE INHIBITORS
acarbose (25 mg tablet, 50

PRECOSE Generic QL 90 / 30 DAY(S)
BIGUANIDES
metformin hcl 1000 mg Generic QL 60 / 30 DAY(S)

GLUCOPHAGE
tablet
GLUCOPHAGE metformin hcl 500 mg tab er
XR 24h
GLUCOPHAGE metformin hcl 500 mg tablet Generic QL 150 / 30 DAY(S)
GLUCOPHAGE metformin hcl 750 mg tab er Generic QL 90 / 30 DAY(S)
XR 24h
GLUCOPHAGE metformin hcl 850 mg tablet Generic QL 90 / 30 DAY(S)
DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS
alogliptin benzoate (6.25

NESINA mg tablet, 12.5 mg tablet, Generic QL 30 / 30 DAY(S)
25 mg tablet) ST
alogliptin
benzoate/metformin hcl Generic QL 60 / 30 DAY(S)
KAZANO
(12.5-1000 tablet, 12.5- ST
500mg tablet)
alogliptin
benzoate/pioglitazone hcl
(12.5-45 mg tablet, 12.5-30
OSENI mg tablet, 12.5-15 mg Generic QL 30 / 30 DAY(S)
tablet, 25 mg-15mg tablet, ST
25 mg-30mg tablet, 25 mg-
45mg tablet)

LIMITS &
RESTRICTIONS
INCRETIN MIMETICS
albiglutide (30mg/0.5ml pen Brand

TANZEUM injctr, 50mg/0.5ml pen QL 4 / 28 day(s)
injctr) ST
exenatide 10mcg/0.04 pen QL 2.4 / 30 DAY(S)

BYETTA Brand
injctr ST
exenatide 5mcg/0.02 pen Brand QL 1.2 / 30 DAY(S)
BYETTA
injctr ST
exenatide microspheres 2 Brand QL 4 / 28 DAY(S)
BYDUREON
mg vial ST
BYDUREON PEN exenatide microspheres Brand QL 4 / 28 DAY(S)
2mg/0.65ml pen injctr ST
MEGLITINIDES
STARLIX nateglinide (60 mg tablet,

120 mg tablet)
repaglinide (0.5 mg tablet, 1
PRANDIN Generic QL 90 / 30 DAY(S)
mg tablet)
PRANDIN repaglinide 2 mg tablet Generic QL 180 / 30 DAY(S)
SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB
canagliflozin (100 mg tablet, QL 30 / 30 DAY(S)

INVOKANA Brand
300 mg tablet) ST
canagliflozin/metformin hcl
(50mg-500mg tab bp 24h, Brand
INVOKAMET XR 50-1000 mg tab bp 24h, QL 60 / 30 DAY(S)
150-500 mg tab bp 24h, ST
150-1000mg tab bp 24h)
canagliflozin/metformin hcl
(50mg-500mg tablet, 50-
INVOKAMET 1000 mg tablet, 150- Brand QL 60 / 30 DAY(S)
1000mg tablet, 150-500 mg ST
tablet)
JARDIANCE empagliflozin (10 mg tablet, Brand QL 30 / 30 day(s)
25 mg tablet) ST

LIMITS &
RESTRICTIONS
empagliflozin/metformin hcl
SYNJARDY (5mg-1000mg tablet, 12.5- Brand QL 60 / 30 day(s)
500mg tablet, 12.5-1000 ST
tablet)
ertugliflozin pidolate (5 mg QL 30 / 30 day(s)
STEGLATRO Brand
tablet, 15 mg tablet) ST
ertugliflozin
pidolate/metformin hcl (2.5-
SEGLUROMET 500 mg tablet, 2.5-1000mg Brand QL 60 / 30 day(s)
tablet, 7.5-500 mg tablet, ST
7.5-1000mg tablet)
ertugliflozin
pidolate/sitagliptin Brand
STEGLUJAN QL 30 / 30 day(s)
phosphate (5 mg-100mg ST
tablet, 15mg-100mg tablet)
SULFONYLUREAS
glimepiride (1 mg tablet, 2
AMARYL Generic QL 30 / 30 DAY(S)
mg tablet)
AMARYL glimepiride 4 mg tablet Generic QL 60 / 30 DAY(S)
glipizide (2.5 mg tab er 24, Generic QL 30 / 30 DAY(S)
GLUCOTROL XL
5 mg tab er 24)
GLUCOTROL XL glipizide 10 mg tab er 24 Generic QL 60 / 30 DAY(S)
GLUCOTROL glipizide 10 mg tablet Generic QL 120 / 30 DAY(S)
GLUCOTROL glipizide 5 mg tablet Generic QL 60 / 30 DAY(S)
glipizide/metformin hcl (2.5-
GLIPIZIDE-
250 mg tablet, 2.5-500 mg Generic QL 120 / 30 DAY(S)
METFORMIN
QL 30 / 30 DAY(S)
DIABETA glyburide 1.25 mg tablet Generic
DIABETA glyburide 2.5 mg tablet Generic QL 60 / 30 DAY(S)
DIABETA glyburide 5 mg tablet Generic QL 120 / 30 DAY(S)

LIMITS &
RESTRICTIONS
glyburide,micronized (1.5
GLYNASE Generic QL 60 / 30 DAY(S)
mg tablet, 3 mg tablet, 6 mg
glyburide/metformin hcl
(2.5-500 mg tablet, 5 mg- QL 120 / 30 DAY(S)
GLUCOVANCE Generic
500mg tablet) AL1 Up to 64 yrs old
GLYBURIDE-
glyburide/metformin hcl Generic QL 60 / 30 DAY(S)
METFORMIN
1.25-250mg tablet AL1 Up to 64 yrs old
HCL
tolazamide (250 mg tablet,
TOLAZAMIDE Generic QL 30 / 30 DAY(S)
500 mg tablet)
TOLBUTAMIDE tolbutamide Generic QL 30 / 30 DAY(S)
THIAZOLIDINEDIONES
pioglitazone hcl (15 mg

ACTOS tablet, 30 mg tablet, 45 mg Generic QL 30 / 30 DAY(S)
tablet)
ANTIHYPOGLYCEMIC AGENTS
GLYCOGENOLYTIC AGENTS
Brand
glucagon,human
GLUCAGEN QL 2 / 30 DAY(S)
recombinant 1 mg vial
PARATHYROID AND ANTIPARATHYROID AGENTS
ANTIPARATHYROID AGENTS
QL 4 / 28 DAY(S)
calcitonin,salmon,synthetic AL1 At least 70 yrs old
FORTICAL Generic
200/spray spray/pump
FAL Female - At least
70 yrs old
cinacalcet hcl (30 mg tablet, Brand QL 120 / 30 DAY(S)
SENSIPAR 60 mg tablet, 90 mg tablet) ST

LIMITS &
RESTRICTIONS
THYROID AND ANTITHYROID AGENTS
THYROID AGENTS
levothyroxine sodium (100

mcg tablet, 112 mcg tablet,
125 mcg tablet, 137 mcg
LEVOXYL Brand QL 30 / 30 DAY(S)
tablet, 150 mcg tablet,
175mcg tablet, 200 mcg
tablet)
30 / 30 DAY(S)
EUTHYROX Generic
tablet, 150 mcg tablet,
175mcg tablet, 200 mcg
tablet, 300 mcg tablet)
mcg capsule, 25 mcg
capsule, 50 mcg capsule,
75 mcg capsule, 88 mcg
TIROSINT Brand QL 28 / 28 DAY(S)
112 mcg capsule, 125 mcg
150 mcg capsule)
LEVOXYL Brand QL 60 / 30 DAY(S)
tablet)
mcg tablet, 50 mcg tablet, QL 60 / 30 DAY(S)
EUTHYROX Generic
tablet)
levothyroxine sodium 300
UNITHROID Brand QL 30 / 30 DAY(S)
mcg tablet
liothyronine sodium (5 mcg
CYTOMEL tablet, 25 mcg tablet, 50 QL 90 / 30 DAY(S)
Generic
mcg tablet)

LIMITS &
RESTRICTIONS
thyroid,pork (15 mg tablet,
30 mg tablet, 60 mg tablet, Brand
ARMOUR QL 30 / 30 DAY(S)
90 mg tablet, 120 mg tablet,
THYROID AL1 Up to 64 yrs old
thyroid,pork (16.25 mg
tablet, 32.5 mg tablet, 48.75
mg tablet, 65 mg tablet,
81.25 mg tablet, 97.5 mg
NATURE- QL 30 / 30 DAY(S)
tablet, 113.75 mg tablet, Brand
THROID AL1 Up to 64 yrs old
130 mg tablet, 146.25 mg
tablet, 162.5 mg tablet, 195
mg tablet, 260 mg tablet,
325 mg tablet)
ANTITHYROID AGENTS
methimazole (5 mg tablet,
TAPAZOLE Generic QL 90 / 30 DAY(S)
10 mg tablet)
PROPYLTHIOUR Generic QL 180 / 30 DAY(S)
propylthiouracil
ACIL
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
betamethasone acetate,sod
CELESTONE Generic QL 10 / 30 DAY(S)
phos 6 mg/ml vial
CORTISONE Generic QL 120 / 30 DAY(S)
cortisone acetate
ACETATE
dexamethasone (0.5 mg
DEXAMETHASO tablet, 0.75 mg tablet, 1 mg
NE tablet, 2 mg tablet, 4 mg
dexamethasone 0.5 mg/5ml
BAYCADRON Generic QL 480 / 30 DAY(S)
elixir
DEXAMETHASO dexamethasone 1 mg/ml Brand QL 480 / 30 DAY(S)
NE INTENSOL drops

LIMITS &
RESTRICTIONS
DEXAMETHASO dexamethasone 1.5 mg Generic
NE tablet
DEXAMETHASO
dexamethasone sodium
NE SODIUM Generic QL 10 / 30 DAY(S)
phosphate 10 mg/ml vial
PHOSPHATE
DEXAMETHASO
dexamethasone sodium Generic QL 25 / 30 DAY(S)
NE SODIUM
phosphate 4 mg/ml vial
PHOSPHATE
FLUDROCORTIS
fludrocortisone acetate Generic QL 60 / 30 DAY(S)
ONE ACETATE
hydrocortisone (5 mg tablet, Generic QL 270 / 30 DAY(S)
CORTEF
hydrocortisone sodium
succinate/pf (100 mg/2ml
SOLU-CORTEF vial, 250 mg/2ml vial, 500 Brand QL 10 / 30 DAY(S)
mg/4ml vial, 1000mg/8ml
vial)
methylprednisolone (4 mg
tablet, 4 mg tab ds pk, 8 mg QL 120 / 30 DAY(S)
MEDROL Generic
tablet)
methylprednisolone 2 mg
MEDROL Brand QL 120 / 30 DAY(S)
tablet
methylprednisolone acetate
DEPO-MEDROL (40 mg/ml vial, 80 mg/ml Generic QL 10 / 30 DAY(S)
vial)
SOLU-MEDROL methylprednisolone sod Brand QL 10 / 30 DAY(S)
succ 2 g vial
methylprednisolone sodium
SOLU-MEDROL succinate (40 mg vial, 125 Generic QL 10 / 30 DAY(S)
mg vial, 1000 mg vial)
MILLIPRED prednisolone 5 mg tablet Brand QL 120 / 30 DAY(S)
prednisolone sod
phosphate (5 ml solution,
PEDIAPRED Generic QL 360 / 30 DAY(S)
15 ml solution, 25 ml
solution)
PAGE 106
LIMITS &
RESTRICTIONS
prednisone (1 mg tablet, 2.5
mg tablet, 5 mg/5 ml
PREDNISONE solution, 5 mg tab ds pk, 5 Generic
mg tablet, 10 mg tab ds pk, QL 360 / 30 DAY(S)
10 mg tablet, 20 mg tablet,
50 mg tablet)
PREDNISONE prednisone 5 mg/ml oral
INTENSOL conc
triamcinolone acetonide (10 QL 5 / 30 DAY(S)
KENALOG-10 Generic
mg/ml vial, 40 mg/ml vial)
ARISTOSPAN triamcinolone hexacetonide Brand QL 5 / 30 DAY(S)

(5 mg/ml vial, 20 mg/ml vial)
ANDROGENS
ANDROXY QL 40 / 30 DAY(S)
fluoxymesterone Brand
GL Female
testosterone enanthate 200
DELATESTRYL Generic ST
mg/ml vial
CONTRACEPTIVES
CYRED desogestrel-ethinyl estradiol QL 28 / 28 DAY(S)

Brand
0.15-0.03 tablet GL Female
desogestrel-ethinyl estradiol QL 28 / 28 DAY(S)
APRI Generic
desogestrel-ethinyl estradiol Brand QL 28 / 28 DAY(S)
CAZIANT
7 days x 3 tablet GL Female
AZURETTE desogestrel-ethinyl QL 28 / 28 DAY(S)
Generic
estradiol/ethinyl estradiol GL Female
BEKYREE desogestrel-ethinyl Brand QL 28 / 28 DAY(S)
estradiol/ethinyl estradiol GL Female
RAJANI drospir/eth estra/levomefol QL 28 / 28 DAY(S)
Brand
ca 3-0.02(24) tablet GL Female
BEYAZ drospir/eth estra/levomefol QL 28 / 28 DAY(S)
Generic
ca 3-0.02(24) tablet GL Female

LIMITS &
RESTRICTIONS
NATAZIA Brand QL 28 / 28 DAY(S)
estradiol valerate/dienogest
GL Female
ethinyl
estradiol/drospirenone QL 28 / 28 DAY(S)
OCELLA Generic
(0.02-3(24) tablet, 0.03mg- GL Female
3mg tablet)
ethinyl
QL 28 / 28 DAY(S)
LORYNA estradiol/drospirenone 0.02- Brand
3(24) tablet GL Female
ethinyl
SYEDA Brand QL 28 / 28 DAY(S)
estradiol/drospirenone
0.03mg-3mg tablet GL Female
ethynodiol d-ethinyl QL 28 / 28 DAY(S)

KELNOR 1-35 Brand
estradiol 1 mg-35mcg tablet GL Female
ZOVIA 1-50E ethynodiol d-ethinyl Brand QL 28 / 28 DAY(S)
estradiol 1 mg-50mcg tablet GL Female
DEMULEN 1-50- ethynodiol d-ethinyl Generic QL 28 / 28 DAY(S)
28 estradiol 1 mg-50mcg tablet GL Female
etonogestrel/ethinyl Brand
NUVARING GL Female
estradiol
l-norgest/e.estradiol-
QL 91 / 91 DAY(S)
QUARTETTE e.estrad 0.15mg(84) tbdspk Brand
3mo GL Female
QL 28 / 28 DAY(S)
AMETHIA LO e.estrad 100-20(84) tbdspk Generic
3mo GL Female
CAMRESE LO Brand QL 28 / 28 DAY(S)
e.estrad 100-20(84) tbdspk
3mo GL Female
ASHLYNA QL 91 / 91 DAY(S)
e.estrad 150-30(84) tbdspk Brand
3mo GL Female
QL 91 / 91 DAY(S)
AMETHIA e.estrad 150-30(84) tbdspk Generic
3mo GL Female

LIMITS &
RESTRICTIONS
NEXT CHOICE levonorgestrel 0.75 mg Generic
QL 4 / 365 DAY(S)
AFTERA levonorgestrel 1.5 mg tablet Brand
GL Female
AUBRA levonorgestrel-ethin Brand QL 28 / 28 DAY(S)
estradiol 0.1-0.02mg tablet GL Female
levonorgestrel-ethin Brand QL 28 / 28 DAY(S)
ALTAVERA
estradiol 0.15-0.03 tablet GL Female
levonorgestrel-ethin
estradiol 0.15-0.03 tbdspk QL 28 / 28 DAY(S)
INTROVALE Brand
3mo GL Female
levonorgestrel-ethin
ENPRESSE Generic GL Female
estradiol 6-5-10 tablet
LEVONEST levonorgestrel-ethin Brand GL Female

estradiol 6-5-10 tablet
AMETHYST levonorgestrel-ethin QL 28 / 28 DAY(S)

Brand
estradiol 90-20 mcg tablet GL Female
levonorgestrel-ethinyl
estradiol (0.1-0.02mg tablet, QL 28 / 28 DAY(S)
AMETHYST Generic
0.15-0.03 tablet, 90-20 mcg GL Female
tablet)
norelgestromin/ethinyl QL 3 / 28 DAY(S)
ORTHO EVRA Brand
estradiol GL Female
FEMCON FE noreth-ethinyl estradiol/iron QL 28 / 28 DAY(S)
Brand
0.4-35(21) tab chew GL Female
GENERESS FE noreth-ethinyl estradiol/iron QL 28 / 28 DAY(S)
Brand
0.8-25(24) tab chew GL Female
DEBLITANE QL 30 / 30 DAY(S)
norethindrone Brand
GL Female
CAMILA norethindrone QL 30 / 30 DAY(S)
Generic
GL Female
norethindrone ac-eth Generic QL 28 / 28 DAY(S)
GILDESS
estradiol 1mg-20mcg tablet GL Female

LIMITS &
RESTRICTIONS
norethindrone acetate-
JUNEL ethinyl estradiol (1mg- Brand QL 28 / 28 DAY(S)
20mcg tablet, 1.5-0.03mg GL Female
tablet)
norethindrone acetate-
ethinyl estradiol/ferrous QL 28 / 28 DAY(S)
JUNEL FE Brand
fumarate (1mg-20(21) GL Female
tablet, 1.5-30(21) tablet)
norethindrone-e.estradiol- QL 28 / 28 DAY(S)
LO LOESTRIN FE Brand
iron 1mg-10(24) tablet GL Female
TAYTULLA norethindrone-e.estradiol- Brand QL 28 / 28 DAY(S)
iron 1mg-20(24) capsule GL Female
MINASTRIN 24 norethindrone-e.estradiol- Brand
FE iron 1mg-20(24) tab chew QL 28 / 28 DAY(S)
norethindrone-e.estradiol- Generic QL 28 / 28 DAY(S)

BLISOVI 24 FE
JUNEL FE 24 norethindrone-e.estradiol- Brand QL 28 / 28 DAY(S)
ESTROSTEP FE norethindrone-e.estradiol- Brand QL 28 / 28 DAY(S)
iron 5-7-9-7 tablet GL Female
BALZIVA norethindrone-ethinyl estrad Brand QL 28 / 28 DAY(S)
norethindrone-ethinyl estrad Brand QL 28 / 28 DAY(S)
BREVICON
NECON norethindrone-ethinyl estrad Brand QL 28 / 28 DAY(S)
10-11 tablet GL Female
norethindrone-ethinyl estrad Brand QL 28 / 28 DAY(S)
ARANELLE
7-9-5 tablet GL Female
norethindrone-ethinyl
QL 28 / 28 DAY(S)
ALYACEN estradiol (1 mg-35mcg Brand
tablet, 7 days x 3 tablet) GL Female
norethindrone-ethinyl
estradiol/ferrous fumarate QL 28 / 28 DAY(S)
FEMCON FE Generic
(0.4-35(21) tab chew, 0.8- GL Female
25(24) tab chew)

LIMITS &
RESTRICTIONS
NECON Brand QL 28 / 28 DAY(S)
norethindrone-mestranol
GL Female
norgestimate-ethinyl
estradiol (0.25-0.035 tablet, QL 28 / 28 DAY(S)
ESTARYLLA Generic
7daysx3 28 tablet) GL Female
norgestimate-ethinyl QL 28 / 28 DAY(S)
ESTARYLLA Brand
estradiol 0.25-0.035 tablet GL Female
norgestimate-ethinyl Brand QL 28 / 28 DAY(S)
TRI-ESTARYLLA
estradiol 7daysx3 28 tablet GL Female
TRI-LO- norgestimate-ethinyl Brand QL 28 / 28 DAY(S)
ESTARYLLA estradiol 7daysx3 lo tablet GL Female
norgestrel-ethinyl estradiol Brand QL 28 / 28 DAY(S)
CRYSELLE
0.3-0.03mg tablet GL Female
OGESTREL norgestrel-ethinyl estradiol QL 28 / 28 DAY(S)
Brand
0.5 mg-50 tablet GL Female
ELLA ulipristal acetate Brand QL 2 / 365 DAY(S)
PITUITARY
desmopressin acetate (0.1

DDAVP Generic QL 30 / 30 day(s)
mg tablet, 0.2 mg tablet)
PROGESTINS
medroxyprogesterone
DEPO-PROVERA acetate (150 mg/ml vial, Generic QL 1 / 84 DAY(S)
150 mg/ml syringe)
medroxyprogesterone
PROVERA Generic QL 30 / 30 DAY(S)
acetate (2.5 mg tablet, 5 mg
MEGESTROL megestrol acetate 20 mg
ACETATE tablet ST

MEGESTROL megestrol acetate 40 mg
ACETATE tablet ST

LIMITS &
RESTRICTIONS
QL 600 / 30 DAY(S)
megestrol acetate
MEGACE Generic ST
400mg/10ml oral susp
AYGESTIN norethindrone acetate Brand
QL 30 / 30 DAY(S)
progesterone, micronized QL 30 / 30 DAY(S)

PROMETRIUM (100 mg capsule, 200 mg Generic AL1 Up to 64 yrs old
FAL Female
capsule) - Up to 64
yrs old
ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES
TOXOIDS
diph,pertuss(acell),tet QL 0.5 / 365 DAY(S)

DAPTACEL DTAP Brand
ped/pf 15-10-5/.5 vial AL1 At least 19 yrs old
diph,pertuss(acell),tet Brand QL 0.5 / 365 DAY(S)
INFANRIX DTAP ped/pf 25-58-10 vial AL1 At least 19 yrs old
diphtheria,pertussis(acellula
r),tetanus vaccine (syringe, QL 0.5 / 365 DAY(S)
BOOSTRIX TDAP Brand
vial) AL1 At least 19 yrs old
diphtheria,pertussis(acellula
ADACEL TDAP QL 0.5 / 365 DAY(S)
r),tetanus vaccine/pf Brand
(syringe, vial) AL1 At least 19 yrs old
TETANUS
tetanus and diphtheria QL 1.5 / 365 DAY(S)
DIPHTHERIA Generic
toxoids, adult AL1 At least 19 yrs old
TOXOIDS
DIPHTHERIA-
tetanus,diphtheria toxoid QL 1.5 / 365 DAY(S)
TETANUS Generic
ped/pf AL1 At least 19 yrs old
TOXOIDS-PED
tetanus-diphtheria Brand QL 1.5 / 365 DAY(S)
TENIVAC
toxoids/pf 5-2/0.5ml syringe AL1 At least 19 yrs old
VACCINES
BIOTHRAX QL 1 / 365 DAY(S)

anthrax vaccine Brand

LIMITS &
RESTRICTIONS
VAXCHORA Brand QL 100 / 365 DAY(S)
cholera vaccine, live
VACCINE AL1 At least 19 yrs old
QUADRACEL diph,pertus(acel),tet,polio/pf QL 0.5 / 365 DAY(S)
Brand
DTAP-IPV 15-20-20 vial AL1 At least 19 yrs old
diphtheria,
QL 0.5 / 365 DAY(S)
KINRIX pertussis(acell),tetanus,poli Brand
o vaccine/pf (syringe, vial) AL1 At least 19 yrs old
diphtheria,pertussis(acell),te
PENTACEL tanus,polio/haemophilus
b/pf AL1 At least 19 yrs old
FLUZONE QUAD flu vacc qs2016-17 36mos QL 0.5 / 365 DAY(S)

Brand
2016-2017 up/pf 60mcg/.5ml syringe AL1 At least 19 yrs old
FLUZONE QUAD flu vacc qs2017-18 36mos Brand QL 1 / 365 day(s)
2017-2018 up/pf 60mcg/.5ml syringe AL1 At least 19 yrs old
haemophilus b conjugate
QL 1 / 365 DAY(S)
PEDVAXHIB vaccine (meningococcal Brand
prot.conj)/pf AL1 At least 19 yrs old
haemophilus b conjugate
ACTHIB Brand QL 1 / 365 DAY(S)
vaccine(tetanus toxoid
conjugate)/pf AL1 At least 19 yrs old
hep b
Brand QL 1.5 / 365 DAY(S)
PEDIARIX virus,rcmb/dipth,pertus(acell
),tet,polio vaccine/pf AL1 At least 19 yrs old
hepatitis a virus and

hepatitis b virus vaccine/pf
QL 4 / 365 DAY(S)
TWINRIX (heptitis nd vccine/pf Brand
syringe, heptitis nd AL1 At least 19 yrs old
vccine/pf vil)
hepatitis a virus vaccine/pf
VAQTA (heptitis vccine/pf 25/0.5ml Brand
vil, heptitis vccine/pf 50 QL 2 / 365 DAY(S)
unit/ml vil, heptitis vccine/pf AL1 At least 19 yrs old
50 unit/ml syringe)

LIMITS &
RESTRICTIONS
hepatitis a virus vaccine/pf
HAVRIX (heptitis vccine/pf 720/0.5ml Brand QL 2 / 365 DAY(S)
vil, heptitis vccine/pf
1440/ml vil, heptitis AL1 At least 19 yrs old
vccine/pf 1440/ml syringe)
hepatitis a virus vaccine/pf QL 1 / 365 DAY(S)
HAVRIX Brand
720/0.5ml syringe AL1 At least 19 yrs old
hepatitis b virus vaccine
RECOMBIVAX recombinant/pf (10 mcg/ml Brand QL 3 / 365 DAY(S)
HB vial, 10 mcg/ml syringe, 40 AL1 At least 19 yrs old
mcg/ml vial)
ENGERIX-B hepatitis b virus vaccine
QL 1.5 / 365 DAY(S)
PEDIATRIC- recombinant/pf (10 syringe, Brand
ADOLESCENT 10 vial) AL1 At least 19 yrs old
hepatitis b virus vaccine

ENGERIX-B Brand QL 3 / 365 DAY(S)
recombinant/pf (20 mcg/ml
ADULT AL1 At least 19 yrs old
vial, 20 mcg/ml syringe)
hepatitis b virus
COMVAX vaccine/haemoph b polysac
conj-mening/pf AL1 At least 19 yrs old
RECOMBIVAX hepatitis b virus vaccine/pf QL 1.5 / 365 DAY(S)

Brand
HB 5mcg/0.5ml syringe AL1 At least 19 yrs old
human papillomavirus Brand QL 1.5 / 365 DAY(S)
CERVARIX
vaccine, bivalent/pf AL1 At least 19 yrs old
human papillomavirus
GARDASIL QL 1.5 / 365 DAY(S)
vaccine, quadrivalent/pf Brand
influenza vaccine
FLUMIST QUAD Brand QL 1 / 365 DAY(S)
quadrivalent live 2016-2017
2016-2017 AL1 At least 19 yrs old
(2 yrs-49 yrs)
FLUZONE influenza virus vaccine
INTRADERM quadrivalent 2016-17(18yrs- QL 0.5 / 365 DAY(S)
Brand
QUAD 2016-17 64yrs)/pf AL1 At least 19 yrs old
FLUZONE HIGH- influenza virus vaccine trival Brand QL 0.5 / 365 DAY(S)
DOSE 2016-2017 split 2016-2017(65 yr up)/pf AL1 At least 19 yrs old

LIMITS &
RESTRICTIONS
IXIARO japanese encephalitis Brand QL 1 / 365 DAY(S)
vaccine/pf AL1 At least 19 yrs old
M-M-R II measles, mumps, and QL 1 / 365 DAY(S)
Brand
VACCINE rubella vaccine live/pf AL1 At least 19 yrs old
measles, mumps, rubella, QL 1 / 365 DAY(S)
PROQUAD Brand
and varicella vaccine live/pf AL1 At least 19 yrs old
MENACTRA mening vac a,c,y,w-135 QL 1 / 365 DAY(S)
Brand
dip/pf 4mcg/0.5ml vial AL1 At least 19 yrs old
BEXSERO meningococcal group b QL 1 / 365 DAY(S)
Brand
vaccine, 4-component AL1 At least 19 yrs old
meningococcal vaccine
QL 4 / 365 DAY(S)
MENHIBRIX c,y/haemophilus b conj- Brand
tetanus tox/pf AL1 At least 19 yrs old
neisseria meningitidis group

TRUMENBA Brand QL 1.5 / 365 DAY(S)
b, lipidated fhbp
recombinant AL1 At least 19 yrs old
pneumococcal 13-valent
PREVNAR 13 Brand QL 2 / 365 DAY(S)
conjugate vaccine
(diphtheria crm)/pf AL1 At least 19 yrs old
pneumococcal 23-valent
PNEUMOVAX 23 polysaccharide vaccine
IPOL QL 1.5 / 365 DAY(S)

poliomyelitis vaccine, killed Brand
IMOVAX RABIES rabies vaccine, human Brand QL 3 / 365 DAY(S)
VACCINE diploid cell/pf AL1 At least 19 yrs old
rabies vaccine, purified
QL 3 / 365 DAY(S)
RABAVERT chicken embryo cell Brand
(pcec)/pf AL1 At least 19 yrs old
rotavirus vaccine, live oral

QL 2 / 365 DAY(S)
ROTARIX attenuated,89-12 strain, Brand
g1p(8) AL1 At least 19 yrs old
ROTATEQ rotavirus vaccine, live oral Brand QL 6 / 365 DAY(S)

pentavalent AL1 At least 19 yrs old

LIMITS &
RESTRICTIONS
VIVOTIF Brand QL 4 / 365 DAY(S)
typhoid vacc,live,attenuated
typhoid vaccine vi capsular QL 0.5 / 365 DAY(S)
TYPHIM VI Brand
polysaccharide (al, syringe) AL1 At least 19 yrs old
VARIVAX varicella virus vaccine QL 2 / 365 DAY(S)
Brand
VACCINE live/pf AL1 At least 19 yrs old
varicella-zoster virus
QL 2 / 365 day(s)
SHINGRIX glycoprotein e,rec/as01b Brand
adjuvant/pf AL1 At least 50 yrs old
yellow fever vaccine live/pf QL 1 / 365 DAY(S)

YF-VAX Brand
10e4.74 vial AL1 At least 19 yrs old
ZOSTAVAX zoster vaccine live/pf
ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)
ALLYLAMINES (SKIN AND MUCOUS MEMBRANE)
terbinafine hcl 1 % cream

ANTIFUNGAL Generic QL 30 / 60 DAY(S)
(g)
AZOLES (SKIN AND MUCOUS MEMBRANE)
ANTIFUNGAL clotrimazole 1 % cream (g) Generic QL 30 / 14 DAY(S)

clotrimazole 1 % Generic QL 45 / 30 DAY(S)
GYNE-LOTRIMIN
cream/appl
LOTRIMIN clotrimazole 1 % solution Generic QL 30 / 60 DAY(S)
CLOTRIMAZOLE clotrimazole 10 mg troche Generic QL 150 / 30 DAY(S)
3-DAY VAGINAL clotrimazole 2 %
CREAM cream/appl
3-DAY VAGINAL clotrimazole 2 % QL 45 / 30 DAY(S)
Generic
CREAM cream/appl
clotrimazole/betamethasone Generic QL 45 / 30 DAY(S)
LOTRISONE
dip 1 %-0.05 % cream (g)
LOTRISONE clotrimazole/betamethasone Generic QL 30 / 30 DAY(S)

dip 1 %-0.05 % lotion

LIMITS &
RESTRICTIONS
NIZORAL A-D ketoconazole 1 % shampoo Brand QL 250 / 30 DAY(S)
KETOCONAZOLE ketoconazole 2 % cream (g) Generic QL 60 / 60 DAY(S)
NIZORAL ketoconazole 2 % shampoo Generic QL 240 / 60 DAY(S)
miconazole nitrate 100 mg
MONISTAT 7 Generic QL 7 / 30 DAY(S)
supp.vag
BAZA miconazole nitrate 2 % Brand QL 30 / 30 DAY(S)
ANTIFUNGAL cream (g)
miconazole nitrate 2 % QL 45 / 30 DAY(S)
MONISTAT 7 Brand
cream/appl
MONISTAT 7 miconazole nitrate 2 % QL 45 / 30 DAY(S)

Generic
cream/appl
MONISTAT 3 miconazole nitrate 200 mg Generic QL 3 / 30 DAY(S)

supp.vag
MONISTAT 3 miconazole nitrate 4 % Brand QL 25 / 30 DAY(S)

crm/pf app
TERAZOL 7 terconazole 0.4 % QL 45 / 30 DAY(S)

Generic
cream/appl
TERAZOL 3 terconazole 0.8 % Generic QL 20 / 30 DAY(S)

cream/appl
TERAZOL 3 terconazole 80 mg Generic QL 3 / 30 DAY(S)

supp.vag
HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)
CICLODAN ciclopirox 8 % solution Generic QL 6.6 / 30 DAY(S)
POLYENES (SKIN AND MUCOUS MEMBRANE)
nystatin (cream (g), oint.

NYSTATIN Generic QL 60 / 60 DAY(S)
(g))
MYCOSTATIN nystatin 100000/g powder Generic QL 60 / 30 DAY(S)
NYSTOP nystatin 100000/g powder Brand QL 60 / 30 DAY(S)

LIMITS &
RESTRICTIONS
THIOCARBAMATES(SKIN AND MUCOUS MEMBRANE)
BLIS-TO-SOL tolnaftate 1 % solution Generic QL 30 / 60 DAY(S)

BLIS-TO-SOL tolnaftate 1 % solution Brand QL 30 / 60 DAY(S)
ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)
ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)
BACITRAYCIN bacitracin 500 unit/g oint.

PLUS (g)
clindamycin phos/benzoyl QL 50 / 30 DAY(S)
BENZACLIN Generic
perox 1 %-5 % gel (gram)
clindamycin phosphate (1 %
CLEOCIN T solution, 1 % lotion, 1 % Generic QL 60 / 30 DAY(S)
med. swab, 1 % gel (gram))
CLEOCIN clindamycin phosphate 2 % Generic QL 40 / 30 DAY(S)
cream/appl
erythromycin base in
ethanol (in 2 % med. swab,
ERY Generic QL 60 / 30 DAY(S)
in 2 % gel (gram), in 2 %
solution)
erythromycin/benzoyl
BENZAMYCIN peroxide 3 %-5 % gel Generic QL 50 / 30 DAY(S)
(gram)
GENTAMICIN gentamicin sulfate (0.1 % Generic QL 30 / 30 DAY(S)
SULFATE oint. (g), 0.1 % cream (g))
metronidazole (0.75 % gel
(gram), 0.75 % cream (g), Generic QL 45 / 30 DAY(S)
METROCREAM
0.75 % lotion)
METROGEL- metronidazole 0.75 % gel
VAGINAL w/appl
BACTROBAN mupirocin 2 % oint. (g) Generic QL 22 / 30 DAY(S)
TRIPLE neomycin sulf/bacitracin
ANTIBIOTIC zinc/polymyxin b Brand QL 30 / 30 DAY(S)
PLUS sulf/pramoxine hcl

LIMITS &
RESTRICTIONS
ANTIBIOTIC + neomycin sulfate/polymyxin Brand
PAIN RELIEF b sulfate/pramoxine QL 30 / 60 DAY(S)
SCABICIDES AND PEDICULICIDES
lindane (1 % lotion, 1 %
LINDANE Generic QL 120 / 180 DAY(S)
shampoo)
OVIDE malathion Generic QL 59 / 30 DAY(S)

ST
LICE CREAM Brand
permethrin 1 % liquid QL 118 / 30 DAY(S)
RINSE
LICE CREAM
permethrin 1 % liquid Generic QL 118 / 30 DAY(S)
RINSE
ACTICIN permethrin 5 % cream (g) Generic QL 60 / 30 DAY(S)
piperonyl
RID butoxide/pyrethrins 4%- Brand QL 1 / 30 DAY(S)
0.33% shampoo
NATROBA spinosad Generic QL 120 / 30 DAY(S)

ST
LOCAL ANTI-INFECTIVES, MISCELLANEOUS
ALCOHOL PREP
alcohol antiseptic pads Generic QL 200 / 30 DAY(S)
PADS
SELENIUM selenium sulfide 2.5 %
SULFIDE lotion
SILVADENE silver sulfadiazine Generic QL 400 / 30 DAY(S)
KLARON sulfacetamide sodium 10 % Generic QL 120 / 30 DAY(S)

suspension
ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)
CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE)
alclometasone dipropionate
ACLOVATE Generic QL 60 / 30 DAY(S)
0.05 % oint. (g)
amcinonide (0.1 % oint. (g), Generic QL 60 / 30 DAY(S)
AMCINONIDE
0.1 % lotion)

LIMITS &
RESTRICTIONS
BETAMETHASO betamethasone
NE dipropionate (0.05 % oint. Generic
QL 45 / 30 DAY(S)
DIPROPIONATE (g), 0.05 % cream (g))
BETAMETHASO betamethasone
NE DIPROP dipropionate 0.05 % gel Generic QL 60 / 30 DAY(S)
AUGMENTED (gram)
BETAMETHASO
betamethasone Generic QL 60 / 30 DAY(S)
NE
dipropionate 0.05 % lotion
DIPROPIONATE
betamethasone
dipropionate/propylene
DIPROLENE AF Generic QL 50 / 30 DAY(S)
glycol (0.05 % oint. (g), 0.05
% cream (g))
betamethasone valerate Generic
BETAMETHASO QL 60 / 30 DAY(S)
(0.1 % cream (g), 0.1 %
NE VALERATE
lotion)
BETAMETHASO betamethasone valerate 0.1
NE VALERATE % oint. (g)
betamethasone/propylene Generic QL 60 / 30 DAY(S)
DIPROLENE
glyc 0.05 % lotion
TEMOVATE clobetasol propionate 0.05 Generic QL 60 / 30 DAY(S)

% cream (g)
CORMAX clobetasol propionate 0.05 Generic QL 50 / 30 DAY(S)

% solution
desoximetasone 0.25 % Generic QL 60 / 30 DAY(S)
TOPICORT
cream (g)
fluocinolone acetonide
(0.01 % solution, 0.01 %
SYNALAR Generic QL 60 / 30 DAY(S)
cream (g), 0.025 % oint. (g),
0.025 % cream (g))
fluocinonide (0.05 % oint.
(g), 0.05 % cream (g), 0.05 Generic QL 60 / 30 DAY(S)
FLUOCINONIDE
% gel (gram), 0.05 %
solution)

LIMITS &
RESTRICTIONS
FLUOCINONIDE- Generic
fluocinonide/emollient base QL 60 / 30 DAY(S)
E
fluticasone propionate
CUTIVATE (0.005 % oint. (g), 0.05 % Generic QL 60 / 30 DAY(S)
cream (g))
halobetasol propionate 0.05 Generic QL 50 / 30 DAY(S)
ULTRAVATE
% cream (g)
hydrocortisone (0.5 % oint.
(g), 0.5 % cream (g), 1 %
HYDROCORTISO
oint. (g), 1 % cream (g), 2.5 Generic QL 60 / 30 DAY(S)
NE
% cream (g), 2.5 % oint.
(g))
hydrocortisone (1 % oint.
CORTIZONE-10 Brand QL 60 / 30 DAY(S)
(g), 1 % cream (g))
DERMAREST QL 118 / 30 DAY(S)
hydrocortisone 1 % lotion Brand
ECZEMA
hydrocortisone 100mg/60ml QL 1680 / 30 DAY(S)
COLOCORT Generic
enema
hydrocortisone 2.5 % Brand QL 30 / 30 DAY(S)
PROCTOSOL-HC
crm/pe app
HYDROCORTISO QL 59 / 30 DAY(S)
hydrocortisone 2.5 % lotion Generic
NE
hydrocortisone butyrate 0.1 Generic QL 60 / 30 DAY(S)
LOCOID
% oint. (g) ST
hydrocortisone valerate (0.2
HYDROCORTISO QL 60 / 30 DAY(S)
% cream (g), 0.2 % oint. Generic
NE VALERATE ST
(g))
hydrocortisone/aloe vera 1
CORTISONE Generic QL 60 / 30 DAY(S)
% cream (g)
LIDAMANTLE HC lidocaine/hydrocortisone ac Generic QL 100 / 30 DAY(S)

3 %-0.5 % cream (g)
ELOCON mometasone furoate (0.1 % Generic QL 45 / 30 DAY(S)

oint. (g), 0.1 % cream (g))

LIMITS &
RESTRICTIONS
ELOCON mometasone furoate 0.1 % Generic
solution QL 60 / 30 DAY(S)
triamcinolone acetonide
TRIAMCINOLON
(0.025 % cream (g), 0.1 % Generic QL 60 / 30 DAY(S)
E ACETONIDE
oint. (g), 0.1 % lotion)
TRIAMCINOLON Generic
(0.025 % oint. (g), 0.025 % QL 80 / 30 DAY(S)
E ACETONIDE
lotion)
TRIAMCINOLON
(0.5 % oint. (g), 0.5 % Generic QL 45 / 30 DAY(S)
E ACETONIDE
cream (g))
triamcinolone acetonide 0.1 Generic QL 240 / 30 DAY(S)
TRIDERM
% cream (g)
EMOLLIENTS, DEMULCENTS, AND PROTECTANTS
BASIC LOTIONS AND LINIMENTS
EUCALYPTUS
eucalyptus oil oil Generic
OIL
SENSITIVE SKIN Brand
glycerin/dimethicone QL 100 / 30 DAY(S)
MOISTURE
BASIC OINTMENTS AND PROTECTANTS
cold cream/zinc
DERMACLOUD Brand
oxide/starch/lanolin
SKIN AND MUCOUS MEMBRANE AGENTS
ANTIPRURITICS AND LOCAL ANESTHETICS
phenazopyridine hcl (100

PYRIDIUM Generic QL 12 / 30 DAY(S)

LIMITS &
RESTRICTIONS
CELL STIMULANTS AND PROLIFERANTS
tretinoin (0.01 % gel (gram),

0.025 % gel (gram), 0.025 QL 45 / 30 DAY(S)
RETIN-A Generic
% cream (g), 0.05 % cream AL1 Up to 34 yrs old
(g), 0.1 % cream (g))
tretinoin 0.0375 % cream Brand QL 45 / 30 DAY(S)
TRETIN-X
(g) AL1 Up to 34 yrs old
KERATOLYTIC AGENTS
benzoyl peroxide (4 % gel

BPO Brand QL 60 / 30 DAY(S)
(gram), 8 % gel (gram))
ACNE benzoyl peroxide (5 % Brand QL 120 / 30 DAY(S)
MEDICATION lotion, 10 % gel (gram))
ACNE FOAMING benzoyl peroxide 10 % Brand QL 240 / 30 DAY(S)
FACE WASH cleanser
ACNE &
benzoyl peroxide 2.5 % gel
BLACKHEAD Brand QL 60 / 30 DAY(S)
(gram)
TERMINATOR
ACNE benzoyl peroxide 5 % gel Brand QL 60 / 30 DAY(S)
MEDICATION (gram)
SKIN AND MUCOUS MEMBRANE AGENTS, MISC.
adapalene (0.1 % cream QL 45 / 30 DAY(S)

DIFFERIN Generic
(g), 0.1 % gel (gram)) AL1 Up to 34 yrs old
ARTHRITIS PAIN Generic
capsaicin 0.1 % cream (g)
RELIEF
ICY HOT PAIN Brand
menthol 2.5 % gel (gram)
RELIEVING
HAIR
minoxidil 5 % solution Generic
REGROWTH
ELIDEL pimecrolimus
AL1 2 to 12 yrs old
tacrolimus (0.03 % oint. (g), QL 30 / 30 DAY(S)
PROTOPIC Generic
0.1 % oint. (g)) AL1 2 to 12 yrs old

LIMITS &
RESTRICTIONS
GENITOURINARY SMOOTH MUSCLE RELAXANTS
ANTIMUSCARINICS
oxybutynin chloride (10 mg

DITROPAN XL Generic QL 60 / 30 DAY(S)
tab er 24, 15 mg tab er 24)
oxybutynin chloride 10 % Brand QL 30 / 30 DAY(S)
GELNIQUE
gel packet
oxybutynin chloride 5 mg QL 30 / 30 DAY(S)
DITROPAN XL Generic
tab er 24
OXYBUTYNIN oxybutynin chloride 5 mg Generic QL 120 / 30 DAY(S)
CHLORIDE tablet
OXYBUTYNIN oxybutynin chloride 5 mg/5 Generic QL 360 / 30 DAY(S)
CHLORIDE ml syrup
tolterodine tartrate (1 mg Generic QL 60 / 30 DAY(S)
DETROL
tablet, 2 mg tablet) ST
tolterodine tartrate (2 mg
DETROL LA cap er 24h, 4 mg cap er Generic QL 30 / 30 DAY(S)
24h) ST
trospium chloride 20 mg QL 60 / 30 DAY(S)

SANCTURA Generic
tablet ST
trospium chloride 60 mg Generic QL 30 / 30 DAY(S)
SANCTURA XR
cap er 24h ST
SMOOTH MUSCLE RELAXANTS
RESPIRATORY SMOOTH MUSCLE RELAXANTS
theophylline anhydrous
(100 mg tab er 12h, 200 mg
THEOCHRON Generic QL 90 / 30 DAY(S)
tab er 12h, 300 mg tab er
12h)
theophylline anhydrous 400
THEOPHYLLINE Generic QL 60 / 30 DAY(S)
mg tab er 24h
THEOPHYLLINE theophylline anhydrous 450 Generic QL 60 / 30 DAY(S)
ANHYDROUS mg tab er 12h

LIMITS &
RESTRICTIONS
THEOPHYLLINE theophylline anhydrous 600 Generic
mg tab er 24h QL 30 / 30 DAY(S)
ELIXOPHYLLIN theophylline anhydrous 80 QL 960 / 30 DAY(S)

Brand
mg/15ml elixir
VITAMINS
VITAMIN A
vit a and d3 in cod liver oil

COD LIVER OIL Generic
1250-135 capsule
CHILD'S OMEGA-
vit a palm/vit c/vitamin d3/vit Brand
3 DHA
e acetate/omega-3/ala/dha
MULTIVITAM
VITAMIN B COMPLEX
METAFOLBIC acetylcysteine/mecobalamin
Brand
PLUS /levomefolate calcium
b-complex with vitamin c Brand QL 30 / 30 DAY(S)
SUPPORT-500
capsule ST
SUPER B
b-complex with vitamin c
COMPLEX WITH Generic QL 30 / 30 DAY(S)
capsule
C
SUPER B
b-complex with vitamin c Brand QL 30 / 30 DAY(S)
COMPLEX-
tablet ST
VITAMIN C
b-complex with vitamin c QL 30 / 30 DAY(S)
FARBEE W-C Generic
tablet ST
VITAMIN B- b-complex with vitamin c Generic
COMPLEX & C tablet er
calcium carbonate/vitamin b Brand
COMPLEX B-50
complex/folic acid
cholecalciferol/folic
FOLGARD acid/riboflavin/pyridoxine Brand
hcl/vit b12

LIMITS &
RESTRICTIONS
cyanocobalamin (vitamin b-
VITAMIN B-12 12) (250 mcg tab chew, 500 Generic
mcg tab subl, 1000mcg/ml
drops, 2000 mcg tablet)
cyanocobalamin (vitamin b- QL 30 / 30 DAY(S)
12) (250 mcg tablet, 500 AL1 12 to 44 yrs old
VITAMIN B-12 Generic
mcg tablet, 1000 mcg
tablet) FAL Female - 12 to 45
yrs old
12) (50 mcg lozenge, 250 QL 30 / 30 DAY(S)
VITAMIN B-12 Generic
mcg lozenge, 500 mcg AL1 12 to 44 yrs old
lozenge, 3000 mcg FAL Female - 12 to 44
lozenge) yrs old
12) (500 mcg tab rapdis,
VITAMELTS
1500mcg tab rapdis, 2500 Generic
ENERGY
mcg lozenge, 3000 mcg tab
subl, 5000mcg/ml drops)
LIQUID B-12 Generic
12) 1000mcg/15 liquid
VITAMELTS cyanocobalamin (vitamin b- Brand
ENERGY 12) 1500mcg tab rapdis
RAPID B-12 cyanocobalamin (vitamin b-
Brand
ENERGY 12) 200 mcg spray susp
QL 30 / 30 DAY(S)
cyanocobalamin (vitamin b- AL1 12 to 44 yrs old
VITAMIN B12 Generic
12) 2500 mcg tab chew
FAL Female - 12 to 44
yrs old
QL 30 / 30 DAY(S)
cyanocobalamin (vitamin b- AL1 12 to 44 yrs old
B-12 Generic
12) 2500 mcg tab subl Female - 12 to 45
FAL yrs old
cyanocobalamin (vitamin b- Generic

VITAMIN B12
12) 2500 mcg tablet

LIMITS &
RESTRICTIONS
QL 30 / 30 DAY(S)
B-12 DUAL cyanocobalamin (vitamin b- Generic AL1 12 to 44 yrs old
SPECTRUM 12) 5000 mcg tab ir er
yrs old
cyanocobalamin/cobamami
B-12 de (mcg lozenge, mcg tab Brand
subl)
B COMPLEX- cyanocobalamin/folic ac/vit
Generic
FOLIC ACID b6 0.2-.5-5mg tablet
HOMOCYSTEINE cyanocobalamin/folic ac/vit Brand
FORMULA b6 100-0.8-50 tablet
cyanocobalamin/folic ac/vit Brand
FOLTABS 800
b6 115-0.8-10 tablet
cyanocobalamin/folic acid Brand
MTX SUPPORT
0.5 mg-1mg tablet
QL 30 / 30 DAY(S)
cyanocobalamin/folic acid AL1 12 to 44 yrs old
B-12 Generic
1mg-400mcg tab subl
yrs old
VITAMIN B12- cyanocobalamin/folic acid
Generic
FOLIC ACID 500-400mcg tablet
cyanocobalamin/intrinsic
INTRINSI B12- Brand
factor/folic acid,
FOLATE
levomefolate
cyanocobalamin/levomefola
FOLBIC RF te calcium/pyridoxine hcl Generic
(b6)
cyanocobalamin/levomefola
FOLBIC RF te calcium/pyridoxine hcl Brand
(b6)
ABANEU-SL cyanocobalamin/mecobala
Brand
min
folic acid (0.4 mg tablet, 0.8 QL 30 / 30 DAY(S)

FOLIC ACID Generic
mg tablet, 1 mg tablet) FAL Female - 12 to 44
yrs old

LIMITS &
RESTRICTIONS
FA-8 folic acid 0.8 mg capsule Brand
FOLIC ACID folic acid 20 mg capsule Generic
folic acid/vit b complex and QL 30 / 30 DAY(S)
DIALYVITE 800 Brand
c 0.8 mg tablet ST
DIALYVITE folic acid/vit b complex and Brand QL 30 / 30 DAY(S)
c 1 mg-100mg tablet ST
B-COMPLEX folic acid/vit b complex and Generic
WITH VITAMIN C c 400 mcg tablet er
folic acid/vit b complex and Brand QL 30 / 30 DAY(S)
FOLBEE PLUS
c 5 mg tablet ST
FOLBEE PLUS folic acid/vitamin b comp Brand QL 30 / 30 DAY(S)
CZ and c/copper/zinc oxide ST
folic acid/vitamin b comp
DIALYVITE 3000 and Brand QL 30 / 30 DAY(S)
c/selenium/minerals/zinc ST
DIALYVITE 800- folic acid/vitamin b comp

Brand
ULTRA D and c/zinc/vitamin d3
VITAMIN B-
folic acid/vitamin b complex QL 30 / 30 DAY(S)
COMPLEX WITH Generic
and c/rice bran ST
VIT C
leucovorin calcium/pyridoxal Brand
FOLINIC-PLUS
phosphate/mecobalamin
levomefolate
CEREFOLIN NAC cal/acetylcysteine/mecobala Generic
min/schiz.algal oil
levomefolate
METAFOLBIC
cal/acetylcysteine/mecobala Brand
PLUS RF
min/schiz.algal oil
levomefolate calc/pyridoxal
FOLTANX RF phos/mecobalamin/schiz.al Generic
gal oil
SUPERVITE lysine/b comp/folic acid/zinc Brand QL 30 / 30 DAY(S)
1000-1-75 liquid ST

LIMITS &
RESTRICTIONS
mecobalamin (1000 mcg
B-12 tab rapdis, 5000 mcg tab Generic
rapdis)
OPURITY mecobalamin/folic acid Brand
FALESSA methyltetrahydrofolate Brand

glucosa 1 mg tablet
multivitamins with minerals QL 30 / 30 DAY(S)
DIALYVITE 5000 Brand
no.11/folic acid ST
pyridoxine hcl (vitamin b6)
PYRIDOXINE
HCL
(100 mg/ml vial, 500 mg Generic FAL Female - 12 to 44
tablet) yrs old
pyridoxine hcl (vitamin b6)

B-NATAL (25 mg lozenge hd, 25 mg Brand Female - 12 to 44
FAL
lozenge) yrs old
pyridoxine hcl (vitamin b6) QL 100 / 30 DAY(S)

VITAMIN B-6 (25 mg tablet, 50 mg tablet, Generic AL1 12 to 44 yrs old
100 mg tablet) FAL Female - 12 to 44
yrs old
VITAMIN B-6 pyridoxine hcl (vitamin b6) Brand

(50 mg capsule, 200 mg Female - 12 to 44
FAL
tablet er) yrs old
QL 100 / 30 DAY(S)
PYRIDOXINE pyridoxine hcl (vitamin b6) AL1 12 to 44 yrs old
Generic
HCL 250 mg tablet Female - 12 to 44
FAL yrs old
QL 100 / 30 DAY(S)
VITAMIN B-6 pyridoxine hcl 200 mg tablet Generic AL1 12 to 44 yrs old
yrs old
CHROMIUM
pyridoxine/chromium
PICOLINATE Brand
picolinate
KLB6
riboflavin (vitamin b2) 343 Brand
CYTO B-2
mg/g powder

LIMITS &
RESTRICTIONS
thiamine hcl (100 mg tablet, QL 30 / 30 DAY(S)

THIAMINE HCL Generic
250 mg tablet) FAL Female - 12 to 45
yrs old
thiamine
B-COMPLEX
hcl/riboflavin/niacinamide/cy Brand
WITH B-12
anocobalamin/protease
thiamine
B COMPLEX
m.nit/riboflavin/niacin/ca Generic
WITH VITAMIN C
pantothenate/b6/b12/c/fa
NATURAL
vit b complex 100 QL 30 / 30 DAY(S)
BALANCED B- Brand
combination no.2/herbs ST
100
BALANCED B- vit b complex 100 combo Brand QL 30 / 30 DAY(S)
100 no.3/herbs ST
vit b complex no.4/vit
d3/ascorbic acid/folic Brand
VITAL-D RX QL 30 / 30 DAY(S)
acid/zinc oxid
STRESS vit b complex/vit c/folic
FORMULA WITH acid/ferrous fumarate/vit e Generic QL 30 / 30 DAY(S)
IRON acet ST

Brand
FORMULA WITH acid/ferrous fumarate/vit e QL 30 / 30 DAY(S)
IRON acet
Brand
FORMULA WITH acid/ferrous sulfate/vit e
IRON acet
vit b cplx with c/ferrous
Brand
PRORENAL fumarate/folic acid/vit
d3/zinc ox
vit b12/pyridoxine/thiamine
APATATE Brand
liquid
vit b12/pyridoxine/thiamine Brand
NEURO VITE
tablet
vit
B COMPLEX b2/niacinamide/pyridoxine
Generic
WITH B-12 hcl (b6)/vit
b12/dexpanthenol

LIMITS &
RESTRICTIONS
vitamin b comp and c/folic Brand
QUIN B STRONG
acid/zinc
FATIGUE RELIEF vitamin b comp and c/st.jhn
Brand
COMPLEX wrt/siberian ginseng/p.ginsg
SUPER B-50
vitamin b complex capsule Generic
COMPLEX
SUPER B-50 vitamin b complex capsule Brand
COMPLEX
B COMPLETE vitamin b complex tablet Brand QL 30 / 30 DAY(S)

ST
B COMPLETE vitamin b complex tablet Generic QL 30 / 30 DAY(S)

ST
B-50 COMPLEX vitamin b complex tablet er Brand
B-100 COMPLEX vitamin b complex 100

Brand
combination no.2
vitamin b complex and
RENAL CAPS Brand ST
vitamin c no.20/folic acid
B-COMPLEX vitamin b complex and
Generic
PLUS VITAMIN C vitamin c/calcium carbonate
RABANO vitamin b complex Brand
YODADO no.12/niacinamide (vit b3)
vitamin b complex no.3/folic
NEPHRO-VITE QL 30 / 30 DAY(S)
acid/ascorbic Brand
RX ST
acid(vitc)/biotin
B COMPLEX vitamin b complex vit c no.3
Generic
WITH VITAMIN C 15-10-300 capsule
BALANCED B vitamin b complex vit c no.3 Brand
COMPLEX-VIT C 15-10-300 tablet er
vitamin b complex with
DIALYVITE 800
c/folic acid/cholecalciferol Brand
PLUS D
(vit d3)
SUPER B vitamin b complex with Brand
COMPLEX vitamin c combination no.4

LIMITS &
RESTRICTIONS
NEPHRONEX vitamin b complex with Brand
vitamin c no.10/folic acid QL 30 / 30 DAY(S)

NEPHRONEX-SL vitamin c no.19/folic Brand
acid/vitamin d3
DIALYVITE 800 vitamin c/folic acid/zinc Brand
WITH ZINC citrate (0.8mg-15mg talet,
0.8mg-50mg talet)
vitamin b complex/ferrous
APETIGEN PLUS Brand
gluconate/zinc oxide/lysine
BALANCED B- vitamin b complex/folic acid QL 30 / 30 DAY(S)
Brand
100 0.4 mg tablet ST
BALANCED B- vitamin b complex/folic acid QL 30 / 30 DAY(S)
Generic
100 0.4 mg tablet ST
BALANCED B- vitamin b complex/folic acid Generic
100 0.4 mg tablet er
vitamin b complex/folic acid Brand
B-STRESS
2000 mcg capsule
MEDTYCHOLL-B
vitamin b complex/liver
COMPLEX W- Brand
extract
LIVER
BIOPETIT vitamin b complex/lysine Brand QL 30 / 30 DAY(S)

ST
STRESS Brand
vitamin b complex/minerals
FORMULA
BREWER'S yeast,dried (s. cerevisiae) Brand
YEAST 680 mg tablet
VITAMIN D
QL 30 / 30 DAY(S)
ROCALTROL calcitriol 0.25 mcg capsule Generic
calcitriol 0.5 mcg capsule Generic QL 60 / 30 DAY(S)
ROCALTROL
PAGE 132
LIMITS &
RESTRICTIONS
ISO D3 cholecalciferol (vit d3)/soy Brand
isoflavone
cholecalciferol (vit
K2 PLUS D3 Generic
d3)/vitamin k2 (mk4)
cholecalciferol (vitamin d3)
DDROPS (1000/drop drops, Brand QL 90 / 30 DAY(S)
2000/drop drops)
D3-2000 (400 capsule, 400 tablet, QL 90 / 30 DAY(S)
1000 capsule, 1000 tablet, Generic
2000 capsule, 2000 tablet,
5000 capsule)
(400 unit/5 liquid, 1000 unit
tab chew, 1000/spray spray
VITAMIN D3 Generic
susp, 3000 unit tablet, 4000
unit capsule, 5000/ml drops,
10000 unit tablet)
DECARA Generic QL 8 / 28 DAY(S)
10000 unit capsule
cholecalciferol (vitamin d3) Brand QL 8 / 28 DAY(S)
MAXIMUM D3
10000 unit capsule
OPTIMAL D3 M cholecalciferol (vitamin d3) Brand QL 4 / 28 DAY(S)

14000 unit capsule
CHILDREN'S cholecalciferol (vitamin d3) Brand
REPLESTA 14000 unit wafer
cholecalciferol (vitamin d3) Brand
THERA-D QL 90 / 30 DAY(S)
2000 unit tablet
cholecalciferol (vitamin d3) Brand
DECARA
25000 unit capsule
cholecalciferol (vitamin d3) Generic
KIDS VITAMIN D3
400 unit tab chew
DELTA D3 cholecalciferol (vitamin d3) Brand

400 unit tablet QL 90 / 30 DAY(S)

LIMITS &
RESTRICTIONS
BABY DDROPS cholecalciferol (vitamin d3) Generic QL 50 / 30 DAY(S)
400/drop drops AL1 Up to 5 yrs old
BABY DDROPS cholecalciferol (vitamin d3) Brand QL 50 / 30 DAY(S)
400/drop drops AL1 Up to 5 yrs old
JUST D cholecalciferol (vitamin d3)
400/ml drops
THERA-D Brand
4000 unit tablet
D3-50 Generic QL 4 / 28 DAY(S)
50000 unit capsule
cholecalciferol (vitamin d3) Brand QL 4 / 28 DAY(S)
DECARA
50000 unit capsule
DIALYVITE cholecalciferol (vitamin d3)
Brand
VITAMIN D3 MAX 50000 unit tablet
cholecalciferol (vitd3)/vit k2
D3 + K2 DOTS Brand
1000-90 tab rapdis
VITAMIN D2 ergocalciferol (vitamin d2)

Generic
2000 unit tablet
VITAMIN D ergocalciferol (vitamin d2) Generic

400 unit tablet
DRISDOL ergocalciferol (vitamin d2) Generic

50000 unit capsule QL 4 / 28 DAY(S)
ergocalciferol (vitamin d2) Brand QL 60 / 30 DAY(S)

CALCIDOL
8000/ml drops AL1 Up to 5 yrs old
VITAMIN K ACTIVITY
VITAMIN K phytonadione (vit k1) 100

Generic QL 20 / 30 day(s)
mcg tablet
phytonadione (vit k1) 5 mg Generic
MEPHYTON
tablet
MULTIVITAMIN PREPARATIONS
alpha lipoic acid/folic

DIABETES
acid/multivit with Brand
HEALTH
minerals/lutein

LIMITS &
RESTRICTIONS
amino
BIOTECT PLUS acids/multivitamin,therapeut Brand
ic,iron,other minerals
EYE HEALTH beta-carotene(a) w-c and
Brand
PLUS LUTEIN e/lutein/minerals
beta-carotene(a)-vits Brand
ANTIOXIDANT
c,e/mins capsule
OCUTABS beta-carotene(a)-vits Brand

c,e/mins tablet
beta-carotene/vit c/e
MACUVITE EYE
acetate/zinc oxide/cupric Brand
CARE
oxide/lutein
bioflavonoids/multivitamin
LIFE-PACK Brand
with iron and other minerals
FLINTSTONES calcium Brand
PLUS CALCIUM carbonate/multivitamin
calcium no.1/vit
HEARTBURN &
d3/pyridoxine/folic acid/vit Brand
ACID REFLUX
b12/aloe vera
calcium no.1/vit
HEARTBURN &
d3/pyridoxine/folic acid/vit Generic
ACID REFLUX
b12/aloe vera
FOLIC ACID-VIT calcium/cyanocobalamin/foli Brand
B-6-VIT B-12 c acid/pyridoxine
calcium/magnesium/vit b
WOMEN'S Brand
comp/vitamin d3/herbal
COMPLEX
complex no.61
DIALYVITE 800 ferrous fumarate/folic Brand QL 30 / 30 DAY(S)
WITH IRON acid/vitamin b comp and c ST
ferrous sulfate/vitamin a
MYKIDZ IRON palmitate/ascorbic
acid/vitamin d3 AL1 Up to 5 yrs old
CERTA PLUS folic acid/multivit with iron, Brand

minerals/lutein

LIMITS &
RESTRICTIONS
folic
CENTRAVITES acid/multivit,calcium,iron,oth Brand
er mins/lycopene/lutein
folic acid/multivit,iron,miner
CENTRUM Brand
.4-18-3500 tab chew
CENTURY folic acid/multivit,iron,miner Brand

0.4mg-18mg tablet
MEN'S DAILY folic acid/multivit-min/lutein Brand
PACK 0.4mg-250 combo. pkg
ESSENTIAL folic acid/multivit-min/lutein Brand
WOMAN 50+ 0.4mg-250 tablet
folic acid/multivit-min/lutein Brand
MAXIMIN
0.8mg-250 combo. pkg
ADULT
folic acid/multivit-min/lutein
MULTIVITAMIN Generic
200-137.5 tab chew
GUMMIES
ADULT
folic acid/multivit-min/lutein Brand
MULTIVITAMIN
200-137.5 tab chew
GUMMIES
DIABETES
folic acid/multivit-min/lutein
HEALTH Brand
500-250mcg tablet
FORMULA
OPURITY iron,carbonyl/folic acid/mv-
Brand
MULTIVITAMIN mn 30-0.8mg tab chew
iron/lysine/vitamin b Brand QL 30 / 30 DAY(S)
NUTRIVIT
complex/folic acid ST
iron/vitamin b
I.L.X. B-12 complex/cyanocobalamin/liv Brand
er extract
ONE DAILY WITH multivit with
Brand
CALCIUM-IRON calcium,iron,min tablet
ONE DAILY WITH multivit with
Generic
CALCIUM-IRON calcium,iron,min tablet

LIMITS &
RESTRICTIONS
multivit with
ESSENTIAL Brand
calcium,iron,min 18mg-
DAILY
0.4mg tablet
multivit with
ONE DAILY
calcium,iron,min 27mg- Brand QL 30 / 30 DAY(S)
WOMEN'S
0.4mg tablet
CENTRUM multivit with
Brand
SPECIALIST calcium,iron,minerals/folic
HEART acid/phytosterol
DIABETES multivit with
Brand
HEALTH calcium,minerals/folic
SUPPORT acid/bioflavonoids no.4
multivit with
Brand
MEGA MULTI calcium,mins/iron/folic
acid/lutein/herbal 179
multivit with iron,
Brand
CENTRAL VITE minerals/ginkgo biloba
ext/panax ginseng
CENTRAL-VITE multivit with iron,hematinic
Brand
tablet
CENTAVITE A-Z multivit with iron,hematinic Brand
WITH MINERALS 27mg-0.4mg tablet
multivit with iron,minerals Brand QL 30 / 30 DAY(S)
LYSIPLEX PLUS
liquid AL1 Up to 5 yrs old
CHILD VITAMIN multivit with iron,minerals Brand
WITH MINERALS tab chew QL 30 / 30 DAY(S)
multivit with iron,minerals Brand

MULTILEX
tablet
multivit with iron,minerals Brand
SUPERIOR 35
tablet er
LIFE-PACK multivit with iron,minerals Brand

0.8 mg combo. pkg
SUPER multivit with
MULTIPLE-LOW iron,minerals/folic Brand
IRON acid/dietary supp. no.24

LIMITS &
RESTRICTIONS
VITAMINS FOR multivit with iron,mins/folic Brand
HAIR acid/inositol/choline bit/paba
ONE DAILY multivit with minerals/folic
WOMEN'S 50 acid/calcium carbonate/vit Brand
PLUS ADV k1
multivit with minerals/folic AL1 12 to 44 yrs old
DAILY MULTIPLE acid/ginkgo biloba leaf Brand
extract yrs old
BEROCCA multivit with minerals/folic Brand
acid/guarana/caffeine
multivit with minerals/folic
acid/lycopene/lutein/herbal Brand
MEGA MULTI
178
SUPER
multivit with
GINSENG Brand
minerals/ginseng
MULTIVITAMIN
multivit with
OXI-FREEDA minerals/glutathione/cystein Brand
e
MEN'S multivit with minerals/herbal Brand
BIOMULTIPLE drugs
ONE DAILY multivit, calcium,
HEALTHY iron,minerals/folic acid/herb Brand
WEIGHT complex 145
multivit,calc,mins/folic acid
ULTRA FREEDA Brand
267 mcg tablet
QUINTABS-M multivit,calc,mins/iron/folic Brand

10mg-0.4mg tablet
multivit,calc,mins/iron/folic Brand
THERA-TABS M
27mg-400 tablet
ONE DAILY multivit,calc,mins/iron/folic Brand
WOMEN'S 450-18-0.4 tablet
CENTRAL-VITE QL 30 / 30 DAY(S)
multivit,calc,mins/iron/folic AL1 12 to 44 yrs old
WOMEN'S Brand
500-18-0.4 tablet
FAL Female
UNDER 50 - 12 to 44
yrs old

LIMITS &
RESTRICTIONS
ULTRA FREEDA
6mg-267mcg tablet
ONE-A-DAY
multivit,calc,mins/iron/folic
WOMEN'S Brand
9mg-200mcg tablet
PETITES
ONE-A-DAY
TEEN
9mg-400mcg tablet
ADVANTAGE
multivit,calc,mins/vit k/omg-
DIABETES
3/vit Brand
HEALTH PACK
d3/mag/c/gr.tea/chromium
BODY, HAIR, multivit,calcium,iron,min/foli Brand
SKIN AND NAILS c acid/choline/inositol/paba
multivit,calcium,iron,mineral
s/folic acid/guarana, Brand
DAILY ENERGY
caffeine
BIO-35 multivit,calcium,iron,mineral
Brand
s/folic acid/lutein/herbal 153
ONE DAILY DIET multivit,calcium,min/iron/foli Brand
SUPPORT c acid/epigallocatechin/caff
HAIR, SKIN AND multivit,calcium,minerals/fer Brand
NAILS rous glucon/folic acid/biotin
multivit,calcium,minerals/iro Brand
COMPLETE
n/folic acid/lycopene/lutein
ALIVE WOMEN'S multivit,calcium,minerals/iro Brand
ENERGY n/folic acid/vit k/herb no.244
multivit,calcium,mins/iron/fol
BIO-35 ic Brand
acid/lutein/lycopen/herb175
multivit,iron,min/green tea xt AL1 12 to 44 yrs old

DAILY MULTIPLE Brand
FAL Female
18-0.4-27 tablet - 12 to 44
yrs old
ONE DAILY multivit,iron,min/green tea xt Brand
18-0.4-32 tablet

LIMITS &
RESTRICTIONS
multivit,iron,minerals/folic
PRORENAL QD acid/d3/omeg- Brand
3/dha/epa/fish oil
multivit,therapeutic with
THERA-M calcium,iron,minerals/folic Brand
acid
COMPLETE multivit,tx with iron,minerals
Brand
MULTIVITAMIN tablet
multivit,tx with iron,minerals Brand
THEREMS-H
27-0.33mg tablet
THEREMS-M multivit,tx with iron,minerals Brand

27mg-0.4mg tablet
multivit-
MACULAR
min/fa/lutein/zeaxant Brand
VITAMIN
500mcg-5-1 tablet
multivit-
Brand
ESSENTIAL MAN min/fa/lycopen/lutein 0.4-2-
250 tablet
WOMEN'S
multivit-min/folic acid/biotin
MULTIVITAMIN Brand
200-300mcg tab chew
W-BIOTIN
HAIR, SKIN AND multivit-min/folic acid/biotin Brand
NAILS 66.7-1000 tablet
multivit-min/folic
THERAMILL Brand
acid/inositol/choline
FORTE
bit/bioflav,citrus
MULTI FOR HER multivit-min/folic acid/vit k1
Brand
50 PLUS 400-80 mcg capsule
multivit-min/folic acid/vit k1 Brand
SOLO
400-80 mcg tablet
TRUEPLUS multivit-min/folic acid/vit k1 Brand
MULTIVITAMIN 500-10 mcg tablet
MEN 50 PLUS
multivit-min/folic/vit k/lycop
ADVANCED ONE Brand
400-20-370 tablet
DAILY

LIMITS &
RESTRICTIONS
MEN'S DAILY multivit-min/folic/vit k/lycop Brand
FORMULA 400-300mcg tablet
multivit-min/iron fum/folic ac
FREEDAVITE Brand
1.8mg-400 tablet
MONOCAPS multivit-min/iron fum/folic ac

Brand
14 mg-400 tablet
MULTI-VITAMIN multivit-min/iron fum/folic ac
Generic
WITH MINERALS 7.5 mg-400 tablet
MULTI-DAY multivit-min/iron/folic acid/k Brand
PLUS MINERALS 18-400-25 tablet
multivit-min/methylfolate
PROTECT PLUS
glucos/coenzyme Brand
AF
q10/dietary no.26
multivit-
PROTECT Brand
min/methyltetrahydrofolate
CARDIO AF
gl/co-q10/dha/epa/diet27
multivit-
PROTECT PLUS Brand
min/methyltetrahydrofolate
SO
glucos/co-q10/dietary 26
multivit-
MEN'S DAILY Brand
minerals/fa/lycopene 0.4
FORMULA
mg-600 capsule
multivit-
Brand
ONE DAILY minerals/fa/lycopene 0.4
mg-600 tablet
multivit-minerals/folic acid AL1 12 to 44 yrs old

COMPANION Brand
FAL Female
0.4 mg tablet - 12 to 44
yrs old
ADULT MULTI multivit-minerals/folic acid Brand
GUMMIES 200 mcg tab chew
multivit-minerals/folic
DAILY Brand
acid/vit k/lycopene/lutein/co
MULTIVITAMIN
q10
multivit-minerals/folic
OCUVITE EYE
acid/vit Brand
PLUS MULTI
k/lycopene/lutein/zeaxanth

LIMITS &
RESTRICTIONS
multivit-minerals/iron
PROCERV HP fumarate/folic acid/vit Brand
k/green tea
multivit-minerals/iron
K-PAX IMMUNE
picolin/folic/calcium/d3/amin Brand
SUPPORT
o acid
THERANATAL
multivit-minerals/iron/folic Brand
LACTATION
acid/k/d3/choline/dha/fish oil
SUPPORT
multivit-mins/iron
Brand
SUNVITE fumarate/folic acid/vit
k/lycopene/lutein
MY FAVORITE
multivitamin liquid Brand
MULTIPLE
multivitamin tab chew QL 30 / 30 DAY(S)

ANIMAL CHEWS Generic
AL1 Up to 5 yrs old
ANIMAL CHEWS multivitamin tab chew Brand QL 30 / 30 DAY(S)
AL1 Up to 5 yrs old
DAILY MULTIPLE multivitamin tablet Brand
VITAMIN
CENTRAL-VITE multivitamin tablet Generic
HP
CENTRUM
multivitamin and minerals
FLAVOR BURST Brand
combination no.55
ADULT
ONE-A-DAY multivitamin with calcium,
Brand
MENOPAUSE mineral/folic acid/soy
FORMULA isoflavone
ONE-A-DAY multivitamin with calcium,
Brand
WOMEN'S minerals/iron/folic
HEALTHY SKIN acid/lutein
ONE DAILY
multivitamin with folic acid Brand
MULTIVITAMIN
ANIMAL SHAPES multivitamin with iron tab Brand
PLUS IRON chew

LIMITS &
RESTRICTIONS
DAILY VITAMIN + Brand
multivitamin with iron tablet
IRON
A THRU Z multivitamin with iron and
Brand
SELECT other minerals/lutein
multivitamin with minerals
MYVITALIFE Brand
capsule
APATATE FORTE multivitamin with minerals

Brand
liquid
BIOVOL multivitamin with minerals

Brand
syrup
ANTIOXIDANT multivitamin with minerals
Brand
VITAMIN tablet
ANTIOXIDANT multivitamin with minerals
Generic
VITAMIN tablet
TOTALDAY multivitamin with minerals Brand
MULTIPLE tablet er
multivitamin with minerals
PROTECT PLUS
no.49/ferrous sulfate/folic Brand
NF
acid
COMPLETE
multivitamin with
MULTIVITAMIN- Generic
minerals/ferrous fumarate
MINERAL
multivitamin with
CENTAMIN Generic
minerals/ferrous gluconate
CENTAMIN multivitamin with Brand

minerals/ferrous gluconate
ONE-A-DAY
multivitamin with
VITACRAVES Brand
minerals/folic acid/caffeine
ENERGY
multivitamin with
SUPER Brand
minerals/folic acid/dietary
MULTIPLE
suppl no.19
multivitamin with AL1 12 to 44 yrs old
WOMEN'S 50+ Brand
minerals/folic acid/ginkgo
DAILY FORMULA
leaf extract FAL Female - 12 to 44
yrs old

LIMITS &
RESTRICTIONS
ALIVE WOMEN'S multivitamin with
GUMMY minerals/folic acid/herbal Brand
VITAMINS complex no.245
multivitamin with
BLADDER 2.2 minerals/folic Brand
acid/lycopene/boron
multivitamin with
minerals/folic
A THRU Z acid/lycopene/lutein (.4- Brand
SELECT 300-250 tablet, 300-
600mcg tablet, 500-300mcg
tablet)
multivitamin with mins
AQUADEKS no.52/folic acid/vit Brand
k1/ubidecarenone
multivitamin, minerals
AQUADEKS Brand
no.51/folic acid/vit
k1/ubidecarenone
multivitamin,ca,min/folic
CENTURY Brand
acid/vitamin
MATURE
k/lycopene/lutein
STRESS 500 multivitamin,stress formula Brand
STRESS 500 multivitamin,stress Brand
PLUS ZINC formula/zinc
THERAMILL multivitamin,ther and
Brand
FORTE minerals capsule
THERAMILL multivitamin,ther and
Generic
FORTE minerals capsule
SUPER multivitamin,ther and Generic
THERAVITE-M minerals tablet
SUPER multivitamin,ther and Brand
THERAVITE-M minerals tablet
KENWOOD multivitamin,therapeutic
Brand
THERAPEUTIC liquid

LIMITS &
RESTRICTIONS
ONCOVITE multivitamin,therapeutic Brand
tablet
multivitamin-minerals QL 30 / 30 DAY(S)
SUPERVITE EC Brand
no.21/folic acid AL1 Up to 5 yrs old
CENTRAL-VITE multivitamin-
Brand
WOMEN'S minerals/ferrous
MATURE fumarate/folic acid/lutein
THERAGRAN-M
multivitamin-minerals/folic
PREMIER 50 Brand
acid/co q10/lycopene/lutein
PLUS
multivitamin-minerals/iron
ONE-A-DAY Brand
fum/folic acid/calcium
WOMEN'S
carb/vit k
CENTRUM multivitamin-minerals/iron
Brand
SPECIALIST fumarate/fa/vit k/korean
ENERGY ginseng
multivitamin-minerals/iron
CENTRAL-VITE Brand
fumarate/folic acid/panax
ENERGY
ginseng
BIOTIN PLUS- multivitamin-
Generic
CALCIUM & VIT mins/calcium/biotin/cholecal
D3 ciferol/folic acid
A THRU Z AL1 12 to 44 yrs old
multivitamin/ferrous
ADVANCED Brand
FAL Female
fumarate/folic acid - 12 to 44
FORMULA yrs old
multivitamin/ferrous Brand
MULTI-DELYN
gluconate
ONE-DAILY
MULTI-VITAMIN- Brand
multivitamin/ferrous sulfate
IRON
ONE-A-DAY
multivitamin/folic
VITACRAVES Brand
acid/docosahexanoic acid
OMEGA-3
multivitamin/folic acid/zinc Brand
DECUBI VITE
sulfate/ascorbic acid

LIMITS &
RESTRICTIONS
multivits with calcium and
A THRU Z minerals/iron/folic Brand
acid/lycopene
ONE-A-DAY mv,ca,min/iron/fa/guarana/c
Brand
WOMEN'S aff 18mg-0.4mg tablet
ONE DAILY mv,ca,min/iron/fa/guarana/c Brand
ENERGY aff 9-400-200 tablet
mv,calcium,min/iron/folic/vit Brand
MULTI FOR HER
k 18-600-80 tablet
OPTISOURCE mv,calcium,min/iron/folic/vit Brand

k 9-200-40 tab chew
mv,iron,mins/folic acid/biotin Brand
HAIR FORMULA
400-100mcg tablet
HAIR, SKIN AND mv,iron,mins/folic acid/biotin Brand
NAILS 66.7 mcg capsule
mv-min/fa/d3/om-
CARDIAMIN 3/dha/epa/fish 200mcg-500 Brand
capsule
ELON MATRIX mv-min/folic ac/biotin/lutein Brand
COMPLETE 33-3000mcg tablet
mv-
MEN'S 50+ DAILY Brand
mins/folic/lycopene/ginkgo
FORMULA
400-300mcg tablet
mv- AL1 12 to 44 yrs old
DAILY MULTIPLE mins/folic/lycopene/ginkgo Brand
400-600mcg tablet yrs old
SOURCECF pedi multivit 22/vit d3/vit k QL 30 / 30 DAY(S)
Generic
1000-800 tab chew AL1 Up to 5 yrs old
MVW COMPLETE
pedi multivit 22/vit d3/vit k Brand
FORMULTN
1500-1000 tab chew
MULTIVIT
MVW COMPLETE
pedi multivit 22/vit d3/vit k QL 30 / 30 DAY(S)
FORMULATION Brand
3000-1000 tab chew AL1 Up to 5 yrs old
D3000

LIMITS &
RESTRICTIONS
pedi multivit
MULTIVITAMINS- Generic
65/cholecalciferol(vit AL1 Up to 5 yrs old
A,B,D,E,K,ZN
d3)/phytonadione(vit k)
MULTIVITAMIN pedi multivit no.17 w- QL 50 / 30 DAY(S)
Generic
WITH FLUORIDE fluoride 0.5 mg tab chew AL1 Up to 5 yrs old
MVW COMPLETE
pediatric multivit 61/d3/vit k Brand
FORMULTN
1500-800 capsule
MULTIVIT
MVW COMPLETE
pediatric multivit 61/d3/vit k
FORMULATION Brand AL1 Up to 5 yrs old
3000-800 capsule
D3000
MVW COMPLETE
pediatric multivit 61/d3/vit k Brand QL 30 / 30 DAY(S)
FORMULATION
5000-800 capsule AL1 Up to 5 yrs old
D5000
pediatric multivit
CHOICEFUL Brand
no.62/cholecalciferol(d3)/ph
VITAMINS
ytonadione(k)
pediatric multivit
CHOICEFUL Brand
no.64/cholecalciferol(d3)/ph
VITAMINS
ytonadione(k)
MVW COMPLETE pediatric multivit
FORMLTN no.77/cholecalciferol(d3)/ph Brand AL1 Up to 5 yrs old
PEDIATRIC ytonadione(k)
pediatric multivit no.8/folic Brand QL 30 / 30 DAY(S)
KIDS VITAMINS
acid AL1 Up to 5 yrs old
ONE-A-DAY pediatric multivit
Brand
TEEN HIM no.89/cholecalciferol(d3)/ph
VITACRAVES ytonadione(k)
pediatric multivit
KIDS VITAMINS
no.9/ferrous fumarate/folic Brand
COMPLETE
acid
ONE-A-DAY pediatric multivit
Brand
TEEN HER no.99/cholecalciferol(d3)/ph
VITACRAVES ytonadione(k)

LIMITS &
RESTRICTIONS
TRI-VITA pediatric multivitamin Brand QL 50 / 30 DAY(S)
a,c,and d3 no.21 AL1 Up to 5 yrs old
pediatric multivitamin QL 50 / 30 DAY(S)
TRI-VITA Generic
a,c,and d3 no.21 AL1 Up to 5 yrs old
pediatric multivitamin Brand
GUMMY
no.101
pediatric multivitamin
TEXAVITE LQ no.108/iron Brand AL1 Up to 5 yrs old
fumarate/sodium fluoride
GUMMY DINOS Brand
ZOO FRIENDS pediatric multivitamin Brand
no.111
CHILDREN'S
CHEW VITAMIN- Brand
no.114/ferrous fumarate
IRON
TROPICAL
LIQUID
no.118
NUTRITION
KIDSTART Brand QL 30 / 30 DAY(S)
no.121
EMERGEN-C pediatric multivitamin
Brand
KIDZ no.127
CHILDREN pediatric multivitamin QL 30 / 30 DAY(S)
Generic
MULTIVITAMIN no.136 AL1 Up to 5 yrs old
NANO VM 1-3 no.14/ferrous fumarate/folic Brand
acid
KIDS
pediatric multivitamin Brand QL 30 / 30 DAY(S)
MULTIVITAMIN
no.140/ferrous fumarate AL1 Up to 5 yrs old
COMPLETE
CHILDREN'S
CHEWABLE
no.144 AL1 Up to 5 yrs old
VITAMIN

LIMITS &
RESTRICTIONS
NANO VM 4-8 no.15/ferrous fumarate/folic Brand
acid
POLYVITAMIN pediatric multivitamin
WITH IRON no.156/ferrous fumarate
DINO-LIFE
no.159/ferrous sulfate
KID'S VITAMINS pediatric multivitamin Brand
+ IRON no.17/ferrous fumarate
CHILDREN'S pediatric multivitamin Brand
CHEWABLES no.17/ferrous sulfate
CHILDREN'S
MULTI-VIT Brand
GUMMIES
POLY-VITA pediatric multivitamin no.20
AL1 Up to 5 yrs old
SOURCECF Brand QL 30 / 30 DAY(S)
no.22/cholecalciferol/phyton
adione AL1 Up to 5 yrs old
CHILDREN'S pediatric multivitamin Brand

CHEWABLES no.23/folic acid
CHILDREN'S
CHEWABLE
no.25/folic acid
MULTIVITMN
FLINTSTONES pediatric multivitamin
Brand
WITH EXTRA C no.27/folic acid
CHILD Brand
pediatric multivitamin no.28
MULTIVITAMINS
LITTLE ANIMALS pediatric multivitamin Brand
PLUS IRON no.28/ferrous fumarate
GUMMIES
GIRLS' pediatric multivitamin no.29 Brand
MULTIVITAMINS

LIMITS &
RESTRICTIONS
GUMMIES
CHILDREN pediatric multivitamin no.30 Brand
MULTIVITAMIN
CHILDREN'S QL 30 / 30 DAY(S)
no.31/ferrous sulfate/folic Brand
CHEWABLE AL1 Up to 5 yrs old
acid
VITALETS Brand
no.36/ferrous fumarate AL1 Up to 5 yrs old
ANIMAL SHAPES pediatric multivitamin Brand
COMPLETE no.38/ferrous fumarate
AQUADEKS
no.40/phytonadione (vit k1) AL1 Up to 5 yrs old
CHILD'S GUMMY
VITAMIN- pediatric multivitamin no.42 Brand
MINERAL
ANIMAL SHAPES pediatric multivitamin
Brand
COMPLETE no.43/ferrous fumarate
POLY-VITA WITH pediatric multivitamin Brand QL 50 / 30 DAY(S)
IRON no.46/ferrous sulfate AL1 Up to 5 yrs old
ONE-A-DAY Brand
KID'S
FLINTSTONES pediatric multivitamin no.49 Brand
GUMMIES
FLINTSTONES
no.50/docosahexanoic acid
CHILD
COMPLETE Brand
MULTIVITAMIN
CENTRUM KIDS Brand
no.68/iron carbonyl
FLINTSTONES pediatric multivitamin Brand QL 30 / 30 DAY(S)

FLINTSTONES Brand QL 30 / 30 DAY(S)
COMPLETE AL1 Up to 5 yrs old

LIMITS &
RESTRICTIONS
ESCAVITE D with iron and sodium Brand
AL1 Up to 5 yrs old
fluoride
FLINTSTONES pediatric multivitamin
Brand
WITH IRON no.79/ferrous fumarate
POLY-VI-SOL pediatric multivitamin
Brand AL1 Up to 6 yrs old
WITH IRON no.80/ferrous sulfate
POLY-VI-SOL pediatric multivitamin no.81 Brand
CHILDREN'S
CHEW MULTIVIT- Brand
IRON
NANOVM T/F Brand
no.93/ferrous sulfate
NANOVM 9-18 pediatric multivitamin Brand

ONE A DAY QL 30 / 30 DAY(S)

prenatal vit 75/iron/folic/om3 AL1 12 to 44 yrs old
WOMEN'S Brand
28-800-223 combo. pkg
PRENATAL DHA FAL Female - 12 to 44
yrs old
QL 30 / 30 DAY(S)
DAILY prenatal vit 75/iron/folic/om3 Brand AL1 12 to 44 yrs old
PRENATAL 28-800-440 combo. pkg
yrs old
prenatal vit no.71/iron fum- QL 30 / 30 DAY(S)
PRENA1 PEARL sodium feredetate/folic Brand
acid/dha yrs old
prenatal vit with calcium QL 30 / 30 DAY(S)
PRENATAL
95/ferrous fumarate/folic Generic
VITAMIN + DHA
acid/dha FAL Female - 12 to 44
yrs old
PRENATAL Generic
no.122/ferrous
MULTI
fumarate/folic acid FAL Female - 12 to 44
yrs old

CLASSIC AL1 12 to 44 yrs old
no.126/ferrous Brand
PRENATAL
FAL Female
fumarate/folic acid - 12 to 44
yrs old

LIMITS &
RESTRICTIONS

PRENATAL Generic AL1 12 to 44 yrs old
no.128/ferrous
VITAMIN
yrs old
PRENATAL
no.130/ferrous Generic
VITAMINS
yrs old

no.131/ferrous
FORMULA Female - 12 to 44
fumarate/folic acid FAL
yrs old
WOMEN'S prenatal vit with calcium QL 30 / 30 DAY(S)

PRENATAL + no.61/iron fumarate/folic Brand AL1 12 to 44 yrs old
DHA acid/dha FAL Female - 12 to 44
yrs old
ONE-A-DAY prenatal vit,calcium QL 30 / 30 DAY(S)

Brand AL1 12 to 44 yrs old
WOMEN'S no.123/iron/folic
PRENATAL 1 acid/omega-3/dha/epa FAL Female - 12 to 44
yrs old
RIGHT STEP QL 30 / 30 DAY(S)
prenatal vit/iron fum/folic ac
PRENATAL Brand
FAL Female
27mg-0.8mg tablet - 12 to 44
VITAMINS yrs old
STUART prenatal vit/iron fum/folic ac QL 30 / 30 DAY(S)

Brand
FAL Female
PRENATAL 28mg-0.8mg tablet - 12 to 44
yrs old
prenatal vitamin QL 30 / 30 DAY(S)
KPN calcium,iron,folic acid (less Brand
than 1 mg) yrs old
KPN calcium,iron,folic acid (less Generic
than 1 mg) yrs old
prenatal vitamin no.103/folic Generic QL 30 / 30 DAY(S)

PRENATAL Female - 12 to 44
acid/omega-3s/dha/fish oil FAL
yrs old
PRENATAL ONE prenatal vitamin no.108/iron Generic QL 30 / 30 DAY(S)

amino acid chelate/folic acid Female - 12 to 44
FAL
yrs old

LIMITS &
RESTRICTIONS

VINACAL B Brand AL1 12 to 44 yrs old
no.48/iron,carbonyl,glucona
te/folic acid/b6 FAL Female - 12 to 44
yrs old
prenatal vitamin with
calcium QL 30 / 30 DAY(S)
THRIVITE RX Brand
no.76/iron,carbonyl/folic FAL Female - 12 to 44
acid yrs old
prenatal vitamins QL 30 / 30 DAY(S)

THERANATAL Brand AL1 12 to 44 yrs old
no.100/iron fumarate/folic
ONE
acid/dha/epa FAL Female - 12 to 44
yrs old
PRENATAL
no.116/iron fumarate/folic Brand
FAL Female
FORMULA-DHA - 12 to 44
acid/dha yrs old
PRENATAL
no.121/ferrous Generic
FAL Female
MULTIVITAMIN - 12 to 44
fumarate/folic acid yrs old
prenatal vitamins no.23/iron QL 30 / 30 DAY(S)

EZFE FORTE polysacchar. complex/folic Brand AL1 12 to 44 yrs old
acid FAL Female - 12 to 44
yrs old
PRENATAL-1 prenatal vitamins QL 30 / 30 DAY(S)

no.25/ferrous fumarate/folic Generic
yrs old

THERANATAL Brand AL1 12 to 44 yrs old
no.28/ferrous fumarate/folic
yrs old

THERANATAL AL1 12 to 44 yrs old
COMPLETE
FAL Female
acid/dha - 12 to 44
yrs old
PRENATAL
FAL Female
MULTI-DHA - 12 to 44
acid/dha yrs old

LIMITS &
RESTRICTIONS

MINI PRENATAL no.49/ferrous fumarate/folic
yrs old
prenatal vitamins no.62/folic QL 30 / 30 DAY(S)

PRENATAL acid/omega-3s/dha/epa/fish Generic AL1 12 to 44 yrs old
oil FAL Female - 12 to 44
yrs old

STUART ONE no.63/iron,carbonyl/folic
yrs old

OVAVITE
FAL Female
acid/coq10 - 12 to 44
yrs old

PLUS
yrs old
prenatal vitamins no.79/iron Brand QL 30 / 30 DAY(S)
VINATE DHA fum/folic
acid/levomefolate/dha FAL Female - 12 to 44
yrs old
prenatal vitamins with
calcium/ferrous QL 30 / 30 DAY(S)
STUART
fumarate/folic acid (27mg- Generic
FAL Female
PRENATAL - 12 to 44
0.8mg tablet, 28mg-0.8mg yrs old
tablet)
prenatal vits no.102/iron QL 30 / 30 DAY(S)
VITAFOL FE+ polysacch/folate Brand
no.1/docusate/dha yrs old
prenatal vits no.51/iron QL 30 / 30 DAY(S)
PRENATAL
fumarate/folic acid/omega- Generic
MULTI + DHA
3/dha/epa FAL Female - 12 to 44
yrs old
prenatal vits with calcium QL 60 / 30 DAY(S)
Generic
PREPLUS #72/ferrous fumarate/folic
yrs old
PAGE 154
LIMITS &
RESTRICTIONS

133/ferrous fumarate/folic
VITAMINS
yrs old
prenatal vits with calcium
PRENATAL
137/ferrous fumarate/folic Generic
VITAMIN
acid

PERRY Brand AL1 12 to 44 yrs old
acid FAL
yrs old
PREPLUS 72/ferrous fumarate/folic Generic
yrs old
PRENATAL Generic
MULTIVITAMINS
yrs old
CENTRUM prenatal vits with calcium QL 30 / 30 DAY(S)

SPECIALIST no.101/ferrous fum/folic Brand AL1 12 to 44 yrs old
PRENATAL acid/dha FAL Female - 12 to 44
yrs old

EXPECTA Brand AL1 12 to 44 yrs old
no.116/ferrous fum/folic
PRENATAL
yrs old
PRENATAL
no.124/ferrous fumarat/folic Generic
VITAMIN
yrs old
Generic
PREPLUS no.72/ferrous fumarate/folic
yrs old
PRENATAL Generic
FORMULA
yrs old
PRENATAL Generic
FORMULA
yrs old

LIMITS &
RESTRICTIONS
PRENATAL no.96/ferrous fumarate/folic Generic
yrs old

KPN no.98/ferrous fumarate/folic Brand AL1 12 to 44 yrs old
FAL Female
acid - 12 to 44
yrs old
prenatal vits, calcium QL 30 / 30 DAY(S)

SIMILAC AL1 12 to 44 yrs old
no.102/ferrous fum/folic Brand
acid/dha/lut FAL yrs old
prenatal vits, calcium QL 30 / 30 DAY(S)

PRENATAL +
DHA
yrs old
prenatl QL 30 / 30 DAY(S)
MTERYTI FOLIC Brand AL1 12 to 44 yrs old
vit6/iron/fa/b12/ca/d3 35
5
mg-5 mg tablet seq FAL Female - 12 to 44
yrs old
prenatl QL 30 / 30 DAY(S)
MTERYTI vit6/iron/fa/b12/ca/d3 35mg- Brand AL1 12 to 44 yrs old
FAL Female
1.1mg tablet seq - 12 to 44
yrs old
riboflavin/beta-carotene(a)
ICAPS w-c and Brand
e/lutein/zeaxanthin/min
vit a palmitate/vit c/vit d3 Brand QL 50 / 30 DAY(S)
TRI-VI-SOL
750-35/ml drops AL1 Up to 5 yrs old
vit a/c/e acetate/zinc
PROSIGHT Brand
oxide/sodium
selenate/cupric oxide
vitamin a palmitate/beta-
VITAMINS A-D-E carotene/vit d2/vit Generic
e/selenium
vitamin a/ascorbic
KIDS COD LIVER Brand
acid/cholecalciferol (vit
OIL +D
d3)/cod liver

LIMITS &
RESTRICTIONS
MISCELLANEOUS THERAPEUTIC AGENTS
ALCOHOL DETERRENTS
ANTABUSE disulfiram 250 mg tablet Generic QL 60 / 30 day(s)

ANTABUSE disulfiram 500 mg tablet Generic QL 30 / 30 day(s)
5-ALPHA-REDUCTASE INHIBITORS
QL 30 / 30 DAY(S)
AVODART dutasteride Generic
GL Male
QL 30 / 30 DAY(S)
Generic
PROSCAR finasteride 5 mg tablet ST
GL Male
ANTIDOTES
leucovorin calcium (5 mg
LEUCOVORIN
CALCIUM
vial, 200 mg vial, 350 mg
vial)
ANTIGOUT AGENTS
ZYLOPRIM allopurinol 100 mg tablet Generic QL 90 / 30 DAY(S)

ZYLOPRIM allopurinol 300 mg tablet Brand QL 60 / 30 DAY(S)
ZYLOPRIM allopurinol 300 mg tablet Generic QL 60 / 30 DAY(S)
COLCRYS colchicine 0.6 mg tablet Generic QL 60 / 30 DAY(S)
IMMUNOMODULATORY AGENTS
thalidomide (50 mg capsule,
QL 30 / 30 day(s)
THALOMID 100 mg capsule, 150 mg Brand
capsule, 200 mg capsule) GL Male
BONE RESORPTION INHIBITORS
alendronate sodium (35 mg QL 4 / 28 DAY(S)

FOSAMAX Generic
tablet, 70 mg tablet) AL1 At least 50 yrs old
PAGE 157
LIMITS &
RESTRICTIONS
FOSAMAX alendronate sodium (5 mg Generic QL 30 / 30 DAY(S)
tablet, 10 mg tablet) AL1 At least 50 yrs old
ALENDRONATE alendronate sodium 40 mg
SODIUM tablet
QL 1 / 30 DAY(S)
ibandronate sodium 150 mg
BONIVA Generic GL Female
tablet
QL 1 / 30 DAY(S)
risedronate sodium 150 mg
ACTONEL Generic ST
tablet
GL Female
ACTONEL risedronate sodium 30 mg Generic QL 4 / 28 DAY(S)
tablet ST
QL 4 / 28 DAY(S)
ACTONEL risedronate sodium 35 mg Generic
tablet ST
GL Female
ATELVIA risedronate sodium 35 mg Generic QL 4 / 28 DAY(S)
tablet dr ST
risedronate sodium 5 mg QL 30 / 30 DAY(S)

Generic
ACTONEL ST
tablet
GL Female
CARIOSTATIC AGENTS
fluoride (sodium) 0.5 mg/ml QL 50 / 30 day(s)
SODIPHLUOR Generic
drops AL1 Up to 5 yrs old
DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
leflunomide (10 mg tablet, Generic QL 30 / 30 DAY(S)

ARAVA
20 mg tablet) ST
IMMUNOSUPPRESSIVE AGENTS
IMURAN azathioprine 50 mg tablet Generic QL 240 / 30 DAY(S)

cyclosporine (25 mg Generic
SANDIMMUNE

LIMITS &
RESTRICTIONS
cyclosporine, modified (25
GENGRAF mg capsule, 50 mg capsule, Generic
100 mg capsule, 100 mg/ml
solution)
everolimus (0.25 mg tablet,
ZORTRESS 0.5 mg tablet, 0.75 mg Brand
tablet)
mycophenolate mofetil (200
CELLCEPT mg/ml susp recon, 250 mg Generic
CELLCEPT mycophenolate mofetil hcl Generic
mycophenolate sodium
MYFORTIC (180 mg tablet dr, 360 mg Generic
tablet dr)
sirolimus (0.5 mg tablet, 1
RAPAMUNE Generic
tacrolimus (0.5 mg capsule,
HECORIA 1 mg capsule, 5 mg Generic
capsule)
tacrolimus (0.75 mg tab er
ENVARSUS XR 24h, 1 mg tab er 24h, 4 mg Brand QL 30 / 30 DAY(S)
tab er 24h)
PROTECTIVE AGENTS
ETHYOL amifostine crystalline Generic

MESNEX mesna 100 mg/ml vial Generic
MESNEX mesna 400 mg tablet Brand
OTHER MISCELLANEOUS THERAPEUTIC AGENTS
5-hydroxytryptophan (5-htp)
5-HTP Generic
100 mg capsule
ALPHA-LIPOIC alpha lipoic acid 50 mg Generic
ACID capsule
bioflav,lemon/vit bcomp,c Brand QL 30 / 30 DAY(S)
RISANOID PLUS
200-100 mg tablet ST

LIMITS &
RESTRICTIONS
calcium
SOY FORMULA carbonate/cholecalciferol Brand
(vit d3)/soybean
CINNAMON cinnamon bark Generic
TYBOST cobicistat Brand QL 1 / 1 DAY(S)

ST
HYPROST dietary supplement capsule Brand
ECHINACEA echinacea 400 mg capsule Generic
flaxseed oil 1000 mg
FLAXSEED OIL Generic
capsule
GARLIC garlic 500 mg capsule Generic
GINKGO BILOBA ginkgo biloba 40 mg tablet Generic
GLUCOSAMINE gluc su/chondro su a/vit

Generic
CHONDROITIN c/mn 750-600-55 tablet
GLUCOSAMINE- glucosam sul na/chondr Generic
CHONDROITIN 750-600 mg tablet
GLUCOSAMINE- glucosam/chon-
CHONDROITIN- msm1/c/mang/bosw 750- Generic
MSM 625mg tablet
glucosam/chon-
Brand
OSTEO BI-FLEX msm1/c/mang/bosw 750-
644 mg tablet
glucosamine sulfate 500 mg
CIDATRINE Brand
tablet
CIDATRINE glucosamine sulfate 500 mg

Generic
tablet
GLUCOSAMINE- glucosamine/chondroitin-
CHONDROITIN msm no.7/vit Brand
COMPLX c/manganese/boron citr
KELP-LECITHIN- lecithin/pyridoxine/kelp
Brand
VIT B-6 capsule
KELP-LECITHIN- lecithin/pyridoxine/kelp Brand
B-6-VINEGAR tablet

LIMITS &
RESTRICTIONS
CARNITOR levocarnitine (with sugar) Generic QL 960 / 30 DAY(S)
CARNITOR levocarnitine 200 mg/ml vial Generic QL 10 / 30 DAY(S)
CARNITOR levocarnitine 330 mg tablet Generic QL 240 / 30 DAY(S)
CYTO-Q liposomal ubiquinol 80 Brand
mg/10ml ampul
LUTEIN lutein 6 mg capsule Generic
MELATONIN melatonin 5 mg tab subl Generic
melatonin/pyridoxine 5 mg-
MELATONIN Generic
1 mg tablet
MILK THISTLE milk thistle 175 mg tablet Generic
PAPAYA papaya tab chew Generic
plant stanol ester 450 mg

CHOLEST OFF Brand
tablet
DHEA prasterone (dhea) (50 mg

Generic
RED YEAST red yeast rice 600 mg
Generic
RICE capsule
RESVERATROL resveratrol 100 mg capsule Generic
LIQ-10 ubidecarenone/vitamin e 50 Brand

mg-15/5 syrup
vit a/vit c/vit e/zinc/copper
ICAPS Brand
7160-113 tablet dr
yohimbe bark 500 mg
YOHIMBE Generic
capsule
UNCATEGORIZED
Ethanolamine Derivatives
diphenhydramine hcl QL 240 / 30 DAY(S)

BANOPHEN Brand
12.5mg/5ml liquid AL1 Up to 64 yrs old

LIMITS &
RESTRICTIONS
WAL-DRYL diphenhydramine hcl 25 mg Brand QL 120 / 30 DAY(S)
diphenhydramine hcl 25 mg QL 120 / 30 DAY(S)
ALER-CAPS Generic
NIGHTTIME diphenhydramine hcl 50 mg QL 90 / 30 day(s)
Brand
SLEEP AID capsule AL1 Up to 64 yrs old
MEDI-SLEEP doxylamine succinate Brand QL 30 / 30 DAY(S)
Propylamine Derivatives
chlorpheniramine maleate 4 QL 90 / 30 DAY(S)
ALLERGY Brand
mg tablet AL1 Up to 64 yrs old
Derivatives, Miscellaneous
CYPROHEPTADI cyproheptadine hcl 4 mg QL 90 / 30 DAY(S)

Generic
NE HCL tablet AL1 Up to 64 yrs old
Second Generation Antihistamines

24HOUR
cetirizine hcl 10 mg tablet Generic QL 30 / 30 DAY(S)
ALLERGY
Nucleosides and Nucleotides

ZOVIRAX acyclovir 400 mg tablet
Antivirals, Miscellaneous
baloxavir marboxil (20 mg Brand QL 2 / 30 day(s)

XOFLUZA
ANTINEOPLASTIC AGENTS
HEXALEN altretamine Brand
ARIMIDEX QL 30 / 30 DAY(S)
anastrozole Generic
GL Female
CASODEX bicalutamide Generic QL 30 / 30 DAY(S)
BLEO 15K bleomycin sulfate (15 vial, Generic

30 vial)

LIMITS &
RESTRICTIONS
MYLERAN busulfan 2 mg tablet Brand
JEVTANA cabazitaxel Brand GL Male
CARBOPLATIN carboplatin 10 mg/ml vial Generic
BICNU carmustine Generic
LEUKERAN chlorambucil Brand QL 90 / 30 DAY(S)

CISPLATIN cisplatin Generic
LEUSTATIN cladribine Generic
CYCLOPHOSPH cyclophosphamide (1 g vial,

Generic
AMIDE 2 g vial, 500 mg vial)
cyclophosphamide (25 mg
CYCLOPHOSPH Generic
tablet, 25 mg capsule, 50 QL 60 / 30 DAY(S)
AMIDE
mg tablet, 50 mg capsule)
cytarabine/pf (2 g/20 ml vial, Generic
CYTARABINE
100 mg/5ml vial)
dacarbazine (100 mg vial,
DACARBAZINE Generic
200 mg vial)
COSMEGEN dactinomycin Brand
daunorubicin citrate
DAUNOXOME Brand
liposomal
DAUNORUBICIN daunorubicin hcl 5 mg/ml
Generic
HCL vial
docetaxel (20 mg/2 ml vial, Generic
TAXOTERE
80 mg/4 ml vial)
ADRIAMYCIN doxorubicin hcl (2 mg/ml Generic

vial, 10 mg vial, 50 mg vial)
IMFINZI durvalumab (120 mg/2.4 Brand

vial, 500mg/10ml vial)
epirubicin hcl (50 mg/25ml
EPIRUBICIN HCL vial, 50 mg vial, 200mg/0.1l Generic
vial)
EMCYT estramustine phosphate Brand QL 210 / 30 DAY(S)

sodium GL Male

LIMITS &
RESTRICTIONS
TOPOSAR etoposide 20 mg/ml vial Generic
exemestane QL 30 / 30 DAY(S)
AROMASIN Generic
GL Female
FLOXURIDINE floxuridine Generic
FLUDARABINE fludarabine phosphate 50
Generic
PHOSPHATE mg/2 ml vial
fluorouracil (1 g/20 ml vial, 5
ADRUCIL g/100 ml vial, 500mg/10ml Generic
vial)
FLUTAMIDE flutamide Generic
QL 180 / 30 DAY(S)
gemcitabine hcl (1 g/26.3ml
GEMCITABINE vial, 1 g vial, 2 g vial, 2
Generic
HCL g/52.6ml vial, 200mg/5.26
vial, 200 mg vial)
hydroxyurea (200 mg
DROXIA capsule, 300 mg capsule, Brand QL 30 / 30 day(s)
400 mg capsule)
HYDREA hydroxyurea 500 mg
Generic
capsule
IDAMYCIN PFS idarubicin hcl Generic
IFEX ifosfamide 1 g vial Generic
IFOSFAMIDE-
ifosfamide/mesna 1g-1g kit Generic
MESNA
irinotecan hcl (40 mg/2 ml
vial, 100 mg/5ml vial, Generic
CAMPTOSAR
500mg/25ml vial)
irinotecan hcl 300mg/15ml
CAMPTOSAR Brand
vial
FEMARA QL 30 / 30 DAY(S)
letrozole Generic
GL Female
lomustine (10 mg capsule,
CEENU 40 mg capsule, 100 mg Generic
capsule)

LIMITS &
RESTRICTIONS
GLEOSTINE lomustine 5 mg capsule Brand
MUSTARGEN mechlorethamine hcl 10 mg

Brand
vial
ALKERAN melphalan hcl Generic
mercaptopurine 50 mg Generic
PURINETHOL
tablet
methotrexate sodium (2.5
METHOTREXATE Generic
mg tablet, 25 mg/ml vial)
METHOTREXATE methotrexate sodium/pf 1 g Generic

vial
METHOTREXATE methotrexate sodium/pf 25 Generic
SODIUM mg/ml vial
mitomycin (5 mg vial, 20 mg Generic
MUTAMYCIN
vial, 40 mg vial)
LYSODREN mitotane Brand
NOVANTRONE mitoxantrone hcl Generic
ARRANON nelarabine Brand
NILANDRON nilutamide Generic

oxaliplatin (50 mg/10ml vial,
ELOXATIN 50 mg vial, 100mg/20ml Generic QL 80 / 28 DAY(S)
vial, 100 mg vial)
ONXOL paclitaxel Generic
ONCASPAR pegaspargase Brand
NIPENT pentostatin Brand
FOLOTYN pralatrexate 20mg/ml(1) vial Brand

MATULANE procarbazine hcl Brand
ZANOSAR streptozocin Brand
TABLOID thioguanine Brand
TEPADINA thiotepa 15 mg vial Generic

LIMITS &
RESTRICTIONS
HYCAMTIN topotecan hcl (0.25 mg Brand
HYCAMTIN topotecan hcl 4 mg vial Generic
TRETINOIN tretinoin 10 mg capsule Generic QL 240 / 30 day(s)
VALSTAR valrubicin Brand
VINBLASTINE vinblastine sulfate 1 mg/ml

Generic
SULFATE vial
vincristine sulfate 2 mg/2 ml Generic
VINCASAR PFS
vial
NAVELBINE vinorelbine tartrate (10 Generic

mg/ml vial, 50 mg/5 ml vial)
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
FEMCAP cervical cap 22mm each Generic QL 2 / 365 DAY(S)

CONDOMS condoms, latex, lubricated Generic QL 24 / 30 DAY(S)
WIDE SEAL diaphragms, wide seal QL 1 / 365 DAY(S)
Generic
DIAPHRAGM 65mm diaphragm GL Female
GOLD COMPOUNDS
RIDAURA auranofin Brand QL 60 / 30 DAY(S)

ST
HEAVY METAL ANTAGONISTS
CHEMET succimer Brand QL 172 / 19 DAY(S)

ST
LOCAL ANESTHETICS (PARENTERAL)
MARCAINE bupivacaine hcl in

SPINAL dextrose/pf
SENSORCAINE- bupivacaine
MPF hcl/epinephrine/pf 0.5- Brand QL 50 / 30 DAY(S)
EPINEPHRINE 1:200k vial

LIMITS &
RESTRICTIONS
bupivacaine hcl/pf (2.5
MARCAINE mg/ml ampul, 2.5 mg/ml Generic
vial, 7.5 mg/ml vial, 7.5 QL 50 / 30 DAY(S)
mg/ml ampul)
lidocaine hcl (5 mg/ml vial,
QL 50 / 30 DAY(S)
XYLOCAINE 10 mg/ml vial, 100mg/10ml Generic
syringe)
lidocaine hcl in sodium Generic
LIDOCAINE HCL
chloride, iso-osmotic/pf
lidocaine hcl/epinephrine
LIDOCAINE HCL- (0.5-1:200k vial, 1%-1:100k
EPINEPHRINE vial, 1.5-1:200k ampul, 1.5-
1:200k vial, 2%-1:200k vial)
lidocaine hcl/pf (5 mg/ml
LIDOCAINE HCL Generic QL 50 / 30 DAY(S)
vial, 10 mg/ml syringe)
POLOCAINE- mepivacaine hcl/pf 20 Brand QL 50 / 30 DAY(S)
MPF mg/ml vial
OXYTOCICS
QL 12 / 30 day(s)
methylergonovine maleate
METHERGINE Generic GL Female
0.2 mg tablet
AL1 12 to 44 yrs old
RADIOACTIVE AGENTS
samarium sm 153 Brand

QUADRAMET
lexidronam
DEVICES
aloe vera/lactic
acid/ceramides
SILICONE SCAR Brand
no.3/silicones/adhesive
tape
BLOOD
GLUCOSE blood-glucose meter kit Generic
MONITORING

LIMITS &
RESTRICTIONS
ENEMA BOTTLE container,empty bottle Generic
SHARPSAFETY container,empty each Generic

CONTAINER
AMBER GLASS
container,empty 30ml each Generic
SERUM BOTTLE
PLASTIC WHITE container,empty 90ml each Generic
HDPE BOTTLE
CAPRI BLADDER incontinence pad,liner,disp Generic
CONTROL PADS
AEROCHAMBER inhaler, assist devices Generic
PLUS FLOW-VU QL 1 / 365 DAY(S)
PEDIATRIC inhaler, assist devices, Generic QL 1 / 365 DAY(S)

MASK accessories
BREATHERITE
inhaler,assist device with
SPACER-ADULT Generic QL 1 / 365 DAY(S)
large mask
MASK
AEROCHAMBER inhaler,assist device with Generic QL 1 / 365 DAY(S)
PLUS FLOW-VU medium mask
BREATHERITE
inhaler,assist device with Generic QL 1 / 365 DAY(S)
SPACER-
small mask
NEONATE MSK
FINGERSTIX lancets each Generic QL 100 / 30 DAY(S)
MEDLANCE Generic QL 100 / 30 DAY(S)
lancets (21 each, 25 each)
PLUS
ULTRA THIN
lancets (31 each, 33 each) Generic QL 100 / 30 DAY(S)
LANCETS
ACTI-LANCE lancets 17 gauge each Generic QL 100 / 30 DAY(S)
ASSURE
HAEMOLANCE lancets 18 gauge each Generic QL 100 / 30 DAY(S)
PLUS
KINNEY BRAND lancets 23 gauge each Generic QL 100 / 30 DAY(S)
LANCETS

LIMITS &
RESTRICTIONS
ALTERNATE Generic
lancets 26 gauge each QL 100 / 30 DAY(S)
SITE LANCETS
THIN LANCETS lancets 28 gauge each Generic QL 100 / 30 DAY(S)
ON-THE-GO lancets 30 gauge each Generic QL 100 / 30 DAY(S)
EASY TOUCH lancets 32 gauge each Generic QL 100 / 30 DAY(S)
medical supply,
TABLET CUTTER Generic QL 1 / 365 DAY(S)
miscellaneous each
NASAL Generic QL 1 / 365 DAY(S)
nasal syringe
ASPIRATOR AL1 Up to 6 yrs old
TRUZONE PEAK Generic
peak flow meter QL 1 / 365 DAY(S)
FLOW METER
AEROGEAR
peak flow meter/inhaler, QL 1 / 365 DAY(S)
ASTHMA ACTION Generic
assist devices
KIT
ULTRA-FINE
pen needle, diabetic 32gx
NANO PEN Generic QL 100 / 30 DAY(S)
5/32" dis needle
NEEDLE
INSULIN syring-needl,disp,insul,0.3 Generic QL 100 / 30 DAY(S)
SYRINGE ml 31 gx5/16" disp syrin
syringe and
INSULIN Generic QL 100 / 30 DAY(S)
needle,insulin,1ml 31
SYRINGE
gx5/16" disp syrin
VEO INSULIN syringe-needle,insulin,0.5 Generic QL 100 / 30 DAY(S)
SYRINGE ml 31gx15/64" disp syrin
PHARMACEUTICAL AIDS
diluent for live yellow fever

DILUENT FOR
vacc,sd(0.9 % sodium Brand
YF-VAX
chloride)
AQUA GLYCOLIC emollient base cream (g) Generic QL 100 / 30 DAY(S)
piperonyl
LICIDE butoxide/pyrethrins 1 %-0.2 Brand QL 60 / 30 DAY(S)
% spray

LIMITS &
RESTRICTIONS
STERILE WATER water for injection,sterile Generic
FOR KCENTRA (ampul, vial) QL 1000 / 30 DAY(S)
Uncategorized
A-B OTIC antipyrine/benzocaine (5.4 QL 15 / 30 DAY(S)

Generic
drops, 5.5 drops) AL1 Up to 20 yrs old
antipyrine/benzocaine 5.4 QL 15 / 30 DAY(S)
OTIC CARE Brand
%-1.4% drops AL1 Up to 20 yrs old
ELSPAR asparaginase Brand
BUTISOL butabarbital sodium (30 Brand

SODIUM mg/5 ml elixir, 50 mg tablet) AL1 Up to 64 yrs old
CALCIUM WITH calcium carbonate/vitamin QL 120 / 30 DAY(S)

Generic
VITAMIN D d2 600 mg-125 tablet
CITRACAL- calcium phosphate trib/vit Brand
VITAMIN D d3 250 mg-250 tab chew
carbinoxamine maleate 4
ARBINOXA Generic QL 30 / 30 DAY(S)
mg tablet
ED CHLORPED chlorpheniramine maleate 2 Brand QL 240 / 30 DAY(S)
JR mg/5 ml syrup AL1 Up to 64 yrs old
cranberry fruit 475 mg
CRANBERRY Generic
capsule
CYPROHEPTADI cyproheptadine hcl (2 mg/5 Generic QL 473 / 30 DAY(S)
NE HCL ml syrup, 4 mg/10 ml syrup) AL1 Up to 64 yrs old
darunavir
SYMTUZA eth/cobicistat/emtricitabine/t Brand QL 180 / 30 day(s)
enofovir alafenamide ST
diphenhydramine hcl (50

DIPHENHYDRAM QL 30 / 30 DAY(S)
mg/ml syringe, 50 mg/ml Generic
INE HCL AL1 Up to 64 yrs old
vial, 50 mg/ml cartridge)
COMPLETE diphenhydramine hcl 25 mg QL 30 / 30 DAY(S)
Brand
ALLERGY tablet AL1 Up to 64 yrs old
diphenhydramine hcl 50 mg QL 90 / 30 day(s)
BANOPHEN Generic

LIMITS &
RESTRICTIONS
TAXOTERE docetaxel (20mg/2 vial, Generic
80mg/8 vial)
LUFYLLIN dyphylline 200 mg tablet Brand QL 60 / 30 DAY(S)
LUFYLLIN dyphylline 400 mg tablet Brand QL 30 / 30 DAY(S)
efavirenz/lamivu/tenofov QL 30 / 30 day(s)
SYMFI LO Brand
disop 400-300 mg tablet ST
IRON PLUS ferrous fumarate/ascorbic Generic
VITAMIN C acid/ascorbate sodium
insulin aspart (cartridge, Brand
NOVOLOG QL 40 / 30 DAY(S)
vial)
FIASP insulin aspart (niacinamide) Brand QL 15 / 30 day(s)
FLEXTOUCH 100/ml (3) insuln pen
insulin aspart (niacinamide) Brand QL 20 / 30 day(s)
FIASP
100/ml vial
NOVOLOG insulin aspart 100/ml insuln Brand QL 15 / 30 DAY(S)
FLEXPEN pen
NOVOLOG MIX insulin aspart prot/insuln Brand QL 90 / 60 DAY(S)
70-30 FLEXPEN asp 70-30/ml insuln pen
NOVOLOG MIX insulin aspart prot/insuln Brand QL 40 / 30 DAY(S)
70-30 asp 70-30/ml vial
LEVEMIR insulin detemir 100/ml (3)
FLEXTOUCH insuln pen
LEVEMIR insulin detemir 100/ml vial Brand QL 20 / 30 DAY(S)
insulin
BASAGLAR
glargine,hum.rec.anlog Brand QL 30 / 30 DAY(S)
KWIKPEN U-100
100/ml (3) insuln pen
insulin
LANTUS glargine,hum.rec.anlog
100/ml vial
APIDRA insulin glulisine 100/ml
SOLOSTAR insuln pen
APIDRA insulin glulisine 100/ml vial Brand QL 40 / 30 DAY(S)

LIMITS &
RESTRICTIONS
HUMALOG insulin lispro 100/ml Brand
cartridge QL 9 / 30 DAY(S)
ADMELOG insulin lispro 100/ml insuln

SOLOSTAR pen
ADMELOG insulin lispro 100/ml vial Brand QL 20 / 30 day(s)
HUMALOG insulin lispro 200/ml (3) Brand QL 15 / 30 DAY(S)
KWIKPEN U-200 insuln pen
HUMALOG MIX insulin lispro protamin/lispro
50-50 KWIKPEN 50-50/ml insuln pen
HUMALOG MIX insulin lispro protamin/lispro Brand QL 40 / 30 DAY(S)
50-50 50-50/ml vial
75-25 KWIKPEN 75-25/ml insuln pen
75-25 75-25/ml vial
HUMULIN 70/30 insulin nph hum/reg insulin Brand QL 40 / 30 DAY(S)
KWIKPEN hm 70-30/ml insuln pen
insulin nph hum/reg insulin Brand QL 40 / 30 DAY(S)
HUMULIN 70-30
hm 70-30/ml vial
HUMULIN N insulin nph human isophane Brand QL 15 / 30 DAY(S)
KWIKPEN 100/ml (3) insuln pen
insulin nph human isophane Brand QL 40 / 30 DAY(S)
HUMULIN N
100/ml vial
HUMULIN R insulin regular, human Brand QL 40 / 30 DAY(S)

100/ml vial
MORPHINE morphine sulfate 15 mg/ml Generic QL 60 / 30 DAY(S)
SULFATE cartridge
multivit with iron-minerals Brand QL 30 / 30 DAY(S)
SPECTRAVITE
liquid AL1 Up to 5 yrs old
CENTRUM multivitamin with
SPECIALIST minerals/folic Brand
VISION acid/lutein/zeaxanthin

LIMITS &
RESTRICTIONS
SOURCECF multivitamin/folic acid/zinc Brand
ascorbate
QL 30 / 30 DAY(S)
SOURCECF multivitamin/zinc gluconate Brand
AL1 Up to 5 yrs old
multivits,ca,minerals/iron/foli
SPECTRAVITE Brand
c
CARDIO HEALTH
acid/lycopene/lut/phytoster
NANO VM 1-3 combination no.4/iron/folic Brand
acid
NANO VM 4-8 combination no.5/iron/folic Brand
acid
ZOO FRIENDS pediatric multivitamin Brand
combination no.53
NANO VM T/F no.18/ferrous Brand
gluconate/folic acid
AKEDAMINS Brand
no.32/folic acid/zinc oxide
VANACOF DX pseudoeph/chlophedianol/g Brand QL 240 / 30 DAY(S)

g 30-12.5/5 liquid AL1 3 to 20 yrs old
EXELON rivastigmine tartrate 2 Brand QL 60 / 30 DAY(S)
mg/ml solution AL1 At least 55 yrs old
ticarcillin
disodium/potassium
TIMENTIN clavulanate (3.1g/0.1l Brand
froz.piggy, 3.1g vial, 31g
vial)
vit a/c/e acetate/zinc
MACUVITE oxide/sodium Brand
selenite/cupric sulfate
STRESS vit b comp c/ferrous
Brand
FORMULA fumarate/folic acid/vit
ENERGY e/amino acid 16

Index of covered drugs
ACNE & BLACKHEAD TERMINATOR 123
0 ACNE FOAMING FACE WASH 123
0.9 % SODIUM CHLORIDE 63,87 ACNE MEDICATION 123
ACTHIB 113
3 ACTICAL 67
116
3-DAY VAGINAL CREAM ACUVAIL 84
ACYCLOVIR 18,162
5 ADACEL TDAP 112
159
5-HYDROXYTRYPTOPHAN (5-HTP) ADAPALENE 123
ADMELOG 172
8 ADMELOG SOLOSTAR 172
46
8 HOUR ADRENALIN 21
ADULT MULTI GUMMIES 141
A ADULT MULTIVITAMIN GUMMIES 136
A THRU Z 146 ADULT NASAL DECONGESTANT 21
A THRU Z ADVANCED FORMULA 145 ADVAIR DISKUS 77
A THRU Z SELECT 143,144 ADVAIR HFA 77
ABACAVIR SULFATE 16 ADVANCED CALCIUM 69
ABACAVIR SULFATE/DOLUTEGRAVIR ADVIL 42
SODIUM/LAMIVUDINE 16 AEROSPAN 76
ABACAVIR SULFATE/LAMIVUDINE 16 AFTERA 109
ABACAVIR AKEDAMINS 173
SULFATE/LAMIVUDINE/ZIDOVUDINE 16 ALAWAY 86
ABANEU-SL 127 ALBIGLUTIDE 101
ABATRON 26 ALBUTEROL SULFATE 20
ABATRON AF 26 ALCAFTADINE 86
ABELCET 11 ALCLOMETASONE DIPROPIONATE 119
ACARBOSE 100 ALCOHOL ANTISEPTIC PADS 119
ACEBUTOLOL HCL 39 ALENDRONATE SODIUM 157,158
ACETAMINOPHEN 46 ALFUZOSIN HCL 22
ACETAMINOPHEN WITH CODEINE ALIVE WOMEN'S ENERGY 139
PHOSPHATE 44 ALIVE WOMEN'S GUMMY VITAMINS 144
ACETAMINOPHEN/DIPHENHYDRAMINE ALL DAY ALLERGY 4
HCL 46 ALLERGY 162
ACETAZOLAMIDE 85 ALLOPURINOL 157
ACETIC ACID 75 ALMACONE 92
ACETIC ACID/ALUMINUM ACETATE 82 ALOE VERA/LACTIC ACID/CERAMIDES
ACETYLCYSTEINE 79 NO.3/SILICONES/ADHESIVE TAPE 167
ACETYLCYSTEINE/MECOBALAMIN/LEVOM ALOGLIPTIN BENZOATE 100
EFOLATE CALCIUM 125 ALOGLIPTIN BENZOATE/METFORMIN
ACID GONE 92 HCL 100

ALOGLIPTIN BENZOATE/PIOGLITAZONE AMPICILLIN SODIUM 8
HCL 100 AMPICILLIN SODIUM/SULBACTAM
ALOPHEN PILLS 94 SODIUM 8
ALORA 97 AMPICILLIN TRIHYDRATE 8
ALPHA LIPOIC ACID 159 AMYTAL SODIUM 56
ALPHA LIPOIC ACID/FOLIC ACID/MULTIVIT ANAGRELIDE HCL 28
WITH MINERALS/LUTEIN 134 ANALGESIC 42
ALPHAGAN P 84 ANASTROZOLE 162
ALPRAZOLAM 56 ANDROXY 107
ALPROSTADIL 34 ANGELIQ 97
ALREX 83 ANIMAL CHEWS 142
ALTAMIST 89 ANIMAL SHAPES COMPLETE 150
ALTAVERA 109 ANIMAL SHAPES PLUS IRON 142
ALTAZINE 87 ANORO ELLIPTA 20
ALTRETAMINE 162 ANTACID PLUS EXTRA STRENGTH 92
ALVESCO 76 ANTHRAX VACCINE 112
ALYACEN 110 ANTIBIOTIC + PAIN RELIEF 119
AMABELZ 98 ANTIOXIDANT 135
AMCINONIDE 119 ANTIOXIDANT VITAMIN 143
AMETHYST 109 ANTIPYRINE/BENZOCAINE 170
AMIFOSTINE CRYSTALLINE 159 APATATE 130
AMIKACIN SULFATE 9 APATATE FORTE 143
AMILORIDE HCL 62 APETIGEN PLUS 132
AMILORIDE APETIGEN-PLUS 24
HCL/HYDROCHLOROTHIAZIDE 62 APIDRA 171
AMINO APIDRA SOLOSTAR 171
ACIDS/MULTIVITAMIN,THERAPEUTIC,IRO APRACLONIDINE HCL 88
N,OTHER MINERALS 135 APREPITANT 90
AMINOSALICYLIC ACID 12 APTIVUS 14
AMIODARONE HCL 29 AQUADEKS 144,150
AMITRIPTYLINE HCL 52 ARANELLE 110
AMLODIPINE BESYLATE 34 ARCAPTA NEOHALER 20
AMLODIPINE BESYLATE/BENAZEPRIL ARISTOSPAN 107
HCL 34 ARMOUR THYROID 105
AMLODIPINE BESYLATE/VALSARTAN 34 ARNUITY ELLIPTA 76
AMOBARBITAL SODIUM 56 ARRANON 165
AMOXAPINE 52 ARTIFICIAL TEARS 88
AMOXICILLIN 7 ASHLYNA 108
AMOXICILLIN/POTASSIUM ASMANEX 77
CLAVULANATE 8 ASMANEX HFA 77
AMPHOTERICIN B LIPID COMPLEX 11 ASPARAGINASE 170

ASPERCREME 42 BACITRAYCIN PLUS 118
ASPIRIN 41 BACLOFEN 22
ASPIRIN/CALCIUM BALANCED B COMPLEX-VIT C 131
CARBONATE/MAGNESIUM 41 BALANCED B-100 130,132
ASPIRIN/DIPYRIDAMOLE 34 BALOXAVIR MARBOXIL 162
ASTRINGENT EYE DROPS 87 BALZIVA 110
ATAZANAVIR SULFATE 13 BANOPHEN 161
ATAZANAVIR SULFATE/COBICISTAT 13 BASAGLAR KWIKPEN U-100 171
ATENOLOL 39 BAZA ANTIFUNGAL 117
ATENOLOL/CHLORTHALIDONE 39 BECLOMETHASONE DIPROPIONATE 76
ATOMOXETINE HCL 59 BEKYREE 107
ATORVASTATIN CALCIUM 31 BENAZEPRIL HCL 36
ATOVAQUONE 18 BENAZEPRIL
ATRIPLA 16 HCL/HYDROCHLOROTHIAZIDE 36
ATROPINE SULFATE 19,86 BENZONATATE 78
ATROVENT HFA 20 BENZOYL PEROXIDE 123
ATUSS DA 78 BEROCCA 138
AUBRA 109 BESIFLOXACIN HCL 80
AURANOFIN 166 BESIVANCE 80
AURAPHENE-B 82 BETA-CAROTENE (VITAMIN A) WITH
AUVI-Q 21 VITAMINS C AND E/MINERALS 135
AYGESTIN 112 BETA-CAROTENE(A) W-C AND
AZASITE 80 E/LUTEIN/MINERALS 135
AZATHIOPRINE 158 BETA-CAROTENE/ASCORBIC ACID/VITE
AZELASTINE HCL 86 AC/ZINC OXIDE/CUPRIC OXIDE 161
AZITHROMYCIN 6,80 BETA-CAROTENE/VIT C/E ACETATE/ZINC
AZOPT 85 OXIDE/CUPRIC OXIDE/LUTEIN 135
BETAMETHASONE
B ACETATE/BETAMETHASONE SODIUM
B COMPLETE 131 PHOSPHATE 105
B-100 COMPLEX 131 BETAMETHASONE DIPROPIONATE 120
B-12 127 BETAMETHASONE
B-12 DOTS 126 DIPROPIONATE/PROPYLENE GLYCOL 120
B-50 COMPLEX 131 BETAMETHASONE VALERATE 120
B-COMPLEX WITH B-12 130 BETAXOLOL HCL 39,84,85
B-COMPLEX WITH VITAMIN C 125 BETIMOL 85
B-NATAL 129 BETOPTIC S 84
B-STRESS 132 BEVESPI AEROSPHERE 20
BABY DDROPS 134 BEXSERO 115
BACITRACIN 80,118 BICALUTAMIDE 162
BACITRACIN/POLYMYXIN B SULFATE 80 BICILLIN C-R 7

BICILLIN L-A 7 BROMPHENIRAMINE
BIMATOPROST 85 MALEATE/PSEUDOEPHEDRINE
BIO-35 139 HCL/DEXTROMETHORPHAN 78
BIOCAL 67 BUDESONIDE 76,83
BIOFLAVONOID, LEMON/VITAMIN B COMP BUDESONIDE/FORMOTEROL
AND C 159 FUMARATE 76
BIOFLAVONOIDS/MULTIVITAMIN WITH BUMETANIDE 61
IRON AND OTHER MINERALS 135 BUPIVACAINE HCL IN DEXTROSE/PF 166
BIOPETIT 132 BUPIVACAINE HCL/EPINEPHRINE/PF 166
BIOTECT PLUS 135 BUPIVACAINE HCL/PF 167
BIOTHRAX 112 BUPROBAN 53
BIOVOL 143 BUPROPION HCL 53
BISACODYL 93,94 BUSPIRONE HCL 57
BISCOLAX 93 BUSULFAN 163
BISOPROLOL FUMARATE 39 BUTABARBITAL SODIUM 56,170
BISOPROLOL BUTALBITAL/ACETAMINOPHEN/CAFFEINE
FUMARATE/HYDROCHLOROTHIAZIDE 39 46
BLADDER 2.2 144 BUTALBITAL/ASPIRIN/CAFFEINE 41
BLEOMYCIN SULFATE 162 BUTISOL SODIUM 56,170
BLIS-TO-SOL 118 BYDUREON 101
BLOOD SUGAR DIAGNOSTIC 60 BYDUREON PEN 101
BLOOD-GLUCOSE METER 167 BYETTA 101
BODY, HAIR, SKIN AND NAILS 139
BONE DENSITY CALCIUM + D 68 C
BONE ESSENTIALS 70 CABAZITAXEL 163
BOOSTRIX TDAP 112 CAFFEINE 54
BPO 123 CAL-CITRATE 69
BREO ELLIPTA 76 CAL-MAG 66
BREVICON 110 CAL-MINT 65
BREWER'S YEAST 132 CAL-QUICK 68
BRIMONIDINE TARTRATE 84 CALCET 70
BRIMONIDINE TARTRATE/TIMOLOL CALCET PETITES 66
MALEATE 84 CALCI-MIX 65
BRINZOLAMIDE 85 CALCIDOL 134
BROMFENAC SODIUM 84 CALCIONATE 70
BROMOCRIPTINE MESYLATE 58 CALCITONIN,SALMON,SYNTHETIC 103
BROMPHENIRAMINE CALCITRIOL 132
MALEATE/PHENYLEPHRINE HCL 3 CALCIUM 600-D3 PLUS 63
BROMPHENIRAMINE CALCIUM ACETATE 61
MALEATE/PSEUDOEPHEDRINE CALCIUM AMINO ACID CHELATE 64
HCL/CHLOPHEDIANOL 78

CALCIUM CARB,CITRATE/VITAMIN CALCIUM
D3/MINERAL COMB NO.34/GENISTEIN 64 CARBONATE/CHOLECALCIFEROL (VIT
CALCIUM D3)/MINERALS 64
CARB/CHOLECALCIFEROL/MAGNESIUM CALCIUM
64
AMINO ACID CHELATE CARBONATE/CHOLECALCIFEROL (VIT
CALCIUM CARB/D3/MAG 11/ZINC/CUPRIC D3)/SOYBEAN 160
SULF/MANGANESE/S.BORATE 64 CALCIUM
CALCIUM CARB/D3/MAG OXIDE/CUPRIC CARBONATE/CHOLECALCIFEROL (VIT
SULF/MANG SULF/ZINC OXIDE 64 D3)/VIT K1 64,65
CALCIUM CARB/MAG OXIDE/VITAMIN CALCIUM
D3/VIT B12/FA/VIT B6/BORON 71 CARBONATE/CHOLECALCIFEROL
CALCIUM CARB/VIT D3/MAG (VITAMIN D3) 66,67,68
OX/ZINC/COPPER/MANGANESE/MG CALCIUM
BORATE 64 CARBONATE/ERGOCALCIFEROL (VIT
CALCIUM CARB/VIT D3/VIT K/FOLIC D2)/SOYBEAN 66
ACID/VIT B12/VIT C/MINERALS 64 CALCIUM
CALCIUM CARBONATE 65 CARBONATE/ERGOCALCIFEROL (VITAMIN
CALCIUM CARBONATE AND D2) 67,170
CITRATE/CHOLECALCIFEROL (VIT D3) 65 CALCIUM CARBONATE/MAGNESIUM
CALCIUM CARBONATE AND CARBONATE 61
CITRATE/MAGNESIUM CITRATE, CALCIUM CARBONATE/MAGNESIUM
GLYCINATE 65 OXIDE 66
CALCIUM CARBONATE AND CALCIUM CARBONATE/MAGNESIUM
CITRATE/MAGNESIUM OXIDE 66 OXIDE, CARBONATE 66
CALCIUM CARBONATE AND CALCIUM CARBONATE/MAGNESIUM
CITRATE/VITAMIN D3/PHYTOSTEROL 66 OXIDE/ASCORBIC ACID 66
CALCIUM CARBONATE, CALCIUM CALCIUM CARBONATE/MAGNESIUM
LACTATE-CHOLECALCIFEROL (VIT D3) 66 OXIDE/CHOLECALCIFEROL (VIT D3) 64
CALCIUM CARBONATE, CALCIUM CARBONATE/MAGNESIUM
GLUCONATE/MAGNESIUM OXIDE, OXIDE/VITAMIN D2/BIOFLAVONOIDS 67
GLUCONATE 66 CALCIUM CARBONATE/MULTIVITAMIN 135
CALCIUM CARBONATE,CALCIUM CALCIUM CARBONATE/VIT D3/MAG
GLUCONATE/ERGOCALCIFEROL (VIT OX/ZINC/COPPER/MANGANESE/BORON63
64
D2) CALCIUM CARBONATE/VIT
CALCIUM D3/MAGNESIUM OXIDE,STEARATE/ZINC
CARBONATE,CITRATE/MAGNESIUM SULF 67
OXIDE,ASPARTATE/VIT D3 66 CALCIUM CARBONATE/VIT
CALCIUM CARBONATE/BORON D3/MAGNESIUM OXIDE/FOLIC ACID/VIT
66 67
GLUCONATE K
CALCIUM CARBONATE/VITAMIN B
COMPLEX/FOLIC ACID 125

CALCIUM CARBONATE/VITAMIN CALCIUM PHOSPHATE,
D3/ARGININE/INOSITOL/SILICON 68 DIBASIC/CHOLECALCIFEROL (VITAMIN
CALCIUM CIT/MAGNESIUM/D3/ZINC D3) 71
OX/COPPER GLUC/MANGANESE GLUC 68 CALCIUM PHOSPHATE,
CALCIUM CIT/MAGNESIUM/D3/ZINC TRIBASIC/CHOLECALCIFEROL (VITAMIN
OX/COPPER D3) 70,71,170
GLUC/MANGANESE/BORON 68 CALCIUM POLYCARBOPHIL 94
CALCIUM CIT/VIT D3/VIT K/MAG CALCIUM/CYANOCOBALAMIN/FOLIC
OX/STRONTIUM CIT/SODIUM BORATE 63 ACID/PYRIDOXINE 135
CALCIUM CITRATE 68 CALCIUM/MAGNESIUM 71
CALCIUM CITRATE CALCIUM/MAGNESIUM
MALATE/CHOLECALCIFEROL (VITAMIN OXIDE/CHOLECALCIFEROL (VITAMIN
D3) 68 D3) 71
CALCIUM CITRATE PLUS 68 CALCIUM/MAGNESIUM/VIT B
CALCIUM CITRATE/CHOLECALCIFEROL COMP/VITAMIN D3/HERBAL COMPLEX
(VITAMIN D3) 69,70 NO.61 135
CALCIUM CITRATE/ERGOCALCIFEROL CALCIUM/MULTIVITAMIN WITH IRON 71
(VITAMIN D2) 69 CALCIUM/VITAMIN E/FOLIC
CALCIUM CITRATE/MAGNESIUM OX,MAG ACID/PYRIDOXINE/HERBAL DRUGS 71
ASPARTATE HCL/VITAMIN D3 69 CALMAG THINS 66
CALCIUM CITRATE/MAGNESIUM OX/VIT CALTRATE + D3 PLUS MINERALS 64
D2/MANGANESE/BORON/SILICA 69 CALTRATE 600 + D 68
CALCIUM CITRATE/MAGNESIUM CALTRATE 600 PLUS D3 68
OXIDE/VITAMIN D3/PYRIDOXINE/MIN 69 CALTRATE 600+D PLUS 63,64
CALCIUM CITRATE/MINERALS/VITAMIN CALTRATE 600-D3 PLUS MINERALS 64
D3/VIT K2/SILICON DIOXIDE 69 CALTRATE GUMMY BITES 71
CALCIUM GLUBIONATE 70 CAMPTOSAR 164
CALCIUM GLUCONATE 70 CAMRESE LO 108
CALCIUM HYDROXYAPATITE/VITAMIN CANAGLIFLOZIN 101
D3/VITAMIN C/VIT K2/MINERALS 70 CANAGLIFLOZIN/METFORMIN HCL 101
CALCIUM LACTATE 70 CAPSAICIN 123
CALCIUM MAGNESIUM 66 CAPTOPRIL/HYDROCHLOROTHIAZIDE 36
CALCIUM NO.1/VIT D3/PYRIDOXINE/FOLIC CARBACHOL 85
ACID/VIT B12/ALOE VERA 135 CARBAMAZEPINE 47,48
CALCIUM PHOSPHAT/MAGNESIUM CARBAMIDE PEROXIDE 82
HYDROXIDE/VIT C/VIT CARBIDOPA/LEVODOPA 59
D3/PHOSPHORUS 70 CARBINOXAMINE MALEATE 170
CALCIUM PHOSPHATE 70 CARBOPLATIN 163
CALCIUM PHOSPHATE CARBOXYMETHYLCELLULOSE SODIUM 88
TRIBASIC/ERGOCALCIFEROL (VITAMIN CARBOXYMETHYLCELLULOSE
D2) 71 SODIUM/GLYCERIN 88

CARBOXYMETHYLCELLULOSE CERVARIX 114
SODIUM/HYPROMELLOSE 88 CERVICAL CAP 166
CARDIAMIN 146 CETIRIZINE HCL 3,4,162
CARISOPRODOL 22 CHANTIX 23
CARMUSTINE 163 CHEMET 166
CARTEOLOL HCL 85 CHERATUSSIN AC 79
CARVEDILOL 39 CHERATUSSIN DAC 79
CAZIANT 107 CHILD COMPLETE MULTIVITAMIN 150
CEFADROXIL 4 CHILD MULTIVITAMINS 149
CEFAZOLIN SODIUM 4 CHILD SUPPOSITORY 94
CEFDINIR 5 CHILD TRIAMINIC COLD-ALLERGY 3
CEFEPIME HCL 5 CHILD VITAMIN WITH MINERALS 137
CEFOTAXIME SODIUM 5 CHILD'S GUMMY VITAMIN-MINERAL 150
CEFOXITIN SODIUM 6 CHILD'S OMEGA-3 DHA MULTIVITAM 125
CEFTAZIDIME 5 CHILDREN'S ALLEGRA ALLERGY 4
CEFTIN 5 CHILDREN'S CALCIUM GUMMIES 71
CEFTRIAXONE SODIUM 5 CHILDREN'S CHEW MULTIVIT-IRON 151
CEFUROXIME AXETIL 5 CHILDREN'S CHEW VITAMIN-IRON 148
CEFUROXIME SODIUM 5 CHILDREN'S CHEWABLE 150
CELECOXIB 41 CHILDREN'S CHEWABLE MULTIVITMN 149
CENESTIN 99 CHILDREN'S CHEWABLE VITAMIN 148
CENTAMIN 143 CHILDREN'S CHEWABLES 149
CENTAVITE A-Z WITH MINERALS 137 CHILDREN'S MULTI-VIT GUMMIES 149
CENTRAL VITE 137 CHILDREN'S NASACORT 84
CENTRAL-VITE 137 CHILDREN'S REPLESTA 133
CENTRAL-VITE ENERGY 145 CHLORAMBUCIL 163
CENTRAL-VITE WOMEN'S MATURE 145 CHLORDIAZEPOXIDE HCL 56
CENTRAL-VITE WOMEN'S UNDER 50 138 CHLORHEXIDINE GLUCONATE 82
CENTRATEX 24 CHLORPHENIRAMINE MALEATE 162,170
CENTRAVITES 136 CHLORPHENIRAMINE MALEATE/CODEINE
CENTRUM 136 PHOSPHATE 78
CENTRUM FLAVOR BURST ADULT 142 CHLORPHENIRAMINE
CENTRUM KIDS 150 MALEATE/PHENYLEPHRINE HCL 3
CENTRUM SPECIALIST ENERGY 145 CHLORPHENIRAMINE
CENTRUM SPECIALIST HEART 137 MALEATE/PHENYLEPHRINE
CENTRUM SPECIALIST PRENATAL 155 HCL/DEXTROMETHORPHAN 78
CENTRUM SPECIALIST VISION 172 CHLORPHENIRAMINE
CENTURY 136 MALEATE/PSEUDOEPHEDRINE/DEXTROM
CENTURY MATURE 144 ETHORPHAN 78
CEPHALEXIN 5 CHLORTHALIDONE 62
CERTA PLUS 135 CHOICEFUL VITAMINS 147

CHOLECALCIFEROL (VIT D3)/SOY CITRACAL D + HEART HEALTH 66
ISOFLAVONE 133 CITRACAL-VIT D + MAGNESIUM 68
CHOLECALCIFEROL (VIT D3)/VITAMIN CITRACAL-VITAMIN D 69,170
K2 134 CITRACAL-VITAMIN D3 69
CHOLECALCIFEROL (VIT D3)/VITAMIN K2 CITRIC ACID/SODIUM CITRATE 63
(MK4) 133 CITROMA 94
CHOLECALCIFEROL (VITAMIN D3) 133,134 CLADRIBINE 163
CHOLECALCIFEROL/FOLIC CLARITHROMYCIN 6
ACID/RIBOFLAVIN/PYRIDOXINE HCL/VIT CLASSIC PRENATAL 151
B12 125 CLEAR EYES REDNESS RELIEF 87
CHOLERA VACCINE, LIVE 113 CLINDAMYCIN HCL 9
CHOLEST OFF 161 CLINDAMYCIN PALMITATE HCL 9
CHOLESTYRAMINE (WITH SUGAR) 30 CLINDAMYCIN PHOSPHATE 9,118
CHOLESTYRAMINE/ASPARTAME 30 CLINDAMYCIN PHOSPHATE/BENZOYL
CHOLINE SALICYLATE/MAGNESIUM PEROXIDE 118
SALICYLATE 42 CLOBETASOL PROPIONATE 120
CHROMIUM PICOLINATE KLB6 129 CLONAZEPAM 47
CICLESONIDE 76 CLONIDINE HCL 32
CICLOPIROX 117 CLOPIDOGREL BISULFATE 28
CIDATRINE 160 CLORAZEPATE DIPOTASSIUM 56
CILOSTAZOL 28 CLOTRIMAZOLE 116
CILOXAN 80 CLOTRIMAZOLE/BETAMETHASONE
CIMDUO 17 DIPROPIONATE 116
CIMETIDINE 91 COBICISTAT 160
CINACALCET HCL 103 CODEINE PHOSPHATE/GUAIFENESIN 79
CINNAMON BARK 160 CODEINE SULFATE 44
CIPRO HC 80 COL-RITE 94
CIPRODEX 80 COLCHICINE 157
CIPROFLOXACIN HCL 10,80 COLD CREAM/ZINC
CIPROFLOXACIN OXIDE/STARCH/LANOLIN 122
HCL/DEXAMETHASONE 80 COLESTIPOL HCL 30
CIPROFLOXACIN COLY-MYCIN S 81
HCL/HYDROCORTISONE 80 COMBIGAN 84
CIPROFLOXACIN LACTATE 10 COMBIPATCH 98
CISPLATIN 163 COMBIVENT RESPIMAT 20
CITALOPRAM HYDROBROMIDE 51 COMFORT GEL 92
CITRACAL 65 COMPANION 141
CITRACAL + BONE DENSITY 64 COMPLERA 17
CITRACAL + D 65 COMPLETE 139
CITRACAL + D MAXIMUM 70 COMPLETE ALLERGY 170
CITRACAL + D3 70 COMPLETE MULTIVITAMIN 140

COMPLEX B-50 125 DACARBAZINE 163
COMVAX 114 DACTINOMYCIN 163
CONDOMS, LATEX, LUBRICATED 166 DAILY ENERGY 139
CONTAINER,EMPTY 168 DAILY MULTIPLE 138,139,146
CORAL CALCIUM 71 DAILY MULTIPLE VITAMIN 142
CORTISONE ACETATE 105 DAILY MULTIVITAMIN 141
CORTIZONE-10 121 DAILY PRENATAL 151
COSMEGEN 163 DAILY VITAMIN + IRON 143
COUMADIN 26 DAPSONE 13
CRANBERRY FRUIT 170 DAPTACEL DTAP 112
CREON 96 DARUNAVIR
CRIXIVAN 14 ETH/COBICISTAT/EMTRICITABINE/TENOF
CROMOLYN SODIUM 78 OVIR ALAFENAMIDE 170
CRYSELLE 111 DARUNAVIR ETHANOLATE 13
CYANOCOBALAMIN (VITAMIN B- DARUNAVIR ETHANOLATE/COBICISTAT 13
12) 126,127 DAUNORUBICIN CITRATE LIPOSOMAL 163
CYANOCOBALAMIN/COBAMAMIDE 127 DAUNORUBICIN HCL 163
CYANOCOBALAMIN/FOLIC ACID 127 DAUNOXOME 163
CYANOCOBALAMIN/FOLIC DDROPS 133
ACID/PYRIDOXINE 127 DEBLITANE 109
CYANOCOBALAMIN/INTRINSIC DECARA 133,134
FACTOR/FOLIC ACID, LEVOMEFOLATE127 DECUBI VITE 145
CYANOCOBALAMIN/LEVOMEFOLATE DELAVIRDINE MESYLATE 15
CALCIUM/PYRIDOXINE HCL (B6) 127 DELTA D3 133
CYANOCOBALAMIN/MECOBALAMIN 127 DERMACLOUD 122
CYANOCOBALAMIN/PYRIDOXINE HCL DERMAREST ECZEMA 121
(B6)/THIAMINE 130 DESCOVY 17
CYCLOBENZAPRINE HCL 22 DESLORATADINE 4
CYCLOPENTOLATE HCL 86 DESMOPRESSIN ACETATE 111
CYCLOPHOSPHAMIDE 163 DESOGESTREL-ETHINYL ESTRADIOL 107
CYCLOSERINE 12 DESOGESTREL-ETHINYL
CYCLOSPORINE 158 ESTRADIOL/ETHINYL ESTRADIOL 107
CYCLOSPORINE, MODIFIED 158,159 DESOXIMETASONE 120
CYPROHEPTADINE HCL 162,170 DESVENLAFAXINE SUCCINATE 50
CYRED 107 DEXAMETHASONE 105,106
CYTARABINE/PF 163 DEXAMETHASONE INTENSOL 105
CYTO B-2 129 DEXAMETHASONE SODIUM
CYTO-Q 161 PHOSPHATE 83,106
DEXMETHYLPHENIDATE HCL 54,55
D DEXTRAN 70/HYPROMELLOSE 88
D3 + K2 DOTS 134 DEXTRAN/HYPROMELLOSE/GLYCERIN 88

DEXTROAMPHETAMINE SULF- DIDANOSINE 16
SACCHARATE/AMPHETAMINE SULF- DIETARY SUPPLEMENT 160
ASPARTATE 53,54 DIFENOXIN HCL/ATROPINE SULFATE 93
DEXTROAMPHETAMINE SULFATE 54 DIFLUPREDNATE 83
DEXTROMETHORPHAN POLISTIREX 79 DIGOXIN 30
DEXTROSE 10 % AND 0.2 % SODIUM DILANTIN 47
CHLORIDE 74 DILTIAZEM HCL 35
DEXTROSE 10 % AND 0.45 % SODIUM DILUENT FOR LIVE YELLOW FEVER
CHLORIDE 75 VACC,SD(0.9 % SODIUM CHLORIDE) 169
DEXTROSE 2.5 % AND 0.45 % SODIUM DILUENT FOR YF-VAX 169
CHLORIDE 75 DIMENHYDRINATE 89
DEXTROSE 5 % AND 0.2 % SODIUM DINO-LIFE 149
CHLORIDE 75 DIPHENHYDRAMINE HCL 161,162,170
DEXTROSE 5 % AND 0.3 % SODIUM DIPHENHYDRAMINE
CHLORIDE 75 HCL/PHENYLEPHRINE
DEXTROSE 5 % AND 0.45 % SODIUM HCL/ACETAMINOPHEN 3
CHLORIDE 75 DIPHENOXYLATE HCL/ATROPINE
DEXTROSE 5 % AND 0.9 % SODIUM SULFATE 93
CHLORIDE 75 DIPHTHERIA, PERTUSSIS (ACELL),
DEXTROSE 5 % IN LACTATED RINGERS 71 TETANUS PEDIATRIC VACCINE/PF 112
DEXTROSE 5 % IN WATER 75 DIPHTHERIA,
DHA PRENATAL 96 PERTUSSIS(ACELL),TETANUS,POLIO
DIABETES HEALTH 134 VACCINE/PF 113
DIABETES HEALTH FORMULA 136 DIPHTHERIA,PERTUSSIS(ACELL),TETANU
DIABETES HEALTH PACK 139 S,POLIO/HAEMOPHILUS B/PF 113
DIABETES HEALTH SUPPORT 137 DIPHTHERIA,PERTUSSIS(ACELLULAR),TE
DIALYVITE 128 TANUS VACCINE 112
DIALYVITE 3000 128 DIPHTHERIA,PERTUSSIS(ACELLULAR),TE
DIALYVITE 5000 129 TANUS VACCINE/PF 112
DIALYVITE 800 128 DIPYRIDAMOLE 34
DIALYVITE 800 PLUS D 131 DISOPYRAMIDE PHOSPHATE 28
DIALYVITE 800 WITH IRON 135 DISULFIRAM 157
DIALYVITE 800 WITH ZINC 132 DIVALPROEX SODIUM 48
DIALYVITE 800-ULTRA D 128 DOCETAXEL 163,171
DIALYVITE VITAMIN D3 MAX 134 DOCOSAHEXANOIC ACID 96
DIAMODE 93 DOCOSAHEXANOIC
DIAPHRAGMS, WIDE SEAL 166 ACID/EICOSAPENTAENOIC ACID 96
DIAZEPAM 56 DOCU LIQUID 94
DICLOFENAC SODIUM 42,84 DOCUSATE CALCIUM 94
DICLOXACILLIN SODIUM 8 DOCUSATE SODIUM 94
DICYCLOMINE HCL 19 DOK 94

DOK PLUS 95 ELECTROLYTE-B SOLUTION/DEXTROSE 5
DOLUTEGRAVIR SODIUM 14 % IN WATER 71
DONEPEZIL HCL 22,23 ELECTROLYTE-M SOLUTION/DEXTROSE 5
DORZOLAMIDE HCL 85 % IN WATER 71
DORZOLAMIDE HCL/TIMOLOL MALEATE85 ELECTROLYTE-MB SOLUTION/DEXTROSE
DOXAZOSIN MESYLATE 39 5 % IN WATER 72
DOXEPIN HCL 52 ELECTROLYTE-P SOLUTION/DEXTROSE 5
DOXORUBICIN HCL 163 % IN WATER 72
DOXY 100 11 ELECTROLYTE-R SOLUTION/DEXTROSE 5
DOXYCYCLINE HYCLATE 10,11,80 % IN WATER 72
DOXYCYCLINE MONOHYDRATE 11 ELECTROLYTES/DEXTROSE 72
DOXYLAMINE SUCCINATE 162 ELIDEL 123
DRAMAMINE 89 ELIPHOS 61
DRONABINOL 90 ELIXOPHYLLIN 125
DROSPIRENONE/ESTRADIOL 97 ELLA 111
DROSPIRENONE/ETHINYL ELON MATRIX COMPLETE 146
ESTRADIOL/LEVOMEFOLATE ELSPAR 170
CALCIUM 107 ELVITEGRAVIR 15
DROXIA 164 ELVITEGRAVIR/COBICISTAT/EMTRICITABI
DUAVEE 99 NE/TENOFOVIR ALAFENAMIDE 16
DULERA 77 ELVITEGRAVIR/COBICISTAT/EMTRICITABI
DULOXETINE HCL 50 NE/TENOFOVIR DISOPROXIL 16
DUREZOL 83 EMADINE 86
DURVALUMAB 163 EMCYT 163
DUTASTERIDE 157 EMEDASTINE DIFUMARATE 86
DYPHYLLINE 171 EMEND 90
EMERGEN-C KIDZ 148
E EMOLLIENT BASE 169
ECHINACEA 160 EMPAGLIFLOZIN 101
ECHOTHIOPHATE IODIDE 85 EMPAGLIFLOZIN/METFORMIN HCL 102
ECPIRIN 41 EMTRICITABINE 16
ED CHLORPED JR 170 EMTRICITABINE/RILPIVIRINE
EDURANT 16 HCL/TENOFOVIR ALAFENAMIDE
EFAVIRENZ 15 FUMARATE 16
EFAVIRENZ/EMTRICITABINE/TENOFOVIR EMTRICITABINE/RILPIVIRINE
DISOPROXIL FUMARATE 16 HCL/TENOFOVIR DISOPROXIL
EFAVIRENZ/LAMIVUDINE/TENOFOVIR FUMARATE 17
DISOPROXIL FUMARATE 15,171 EMTRICITABINE/TENOFOVIR
ELECTROLYTE-48 SOLUTION/DEXTROSE ALAFENAMIDE FUMARATE 17
5 % IN WATER 71 EMTRICITABINE/TENOFOVIR DISOPROXIL
FUMARATE 17

EMTRIVA 16 ESTRADIOL/NORETHINDRONE
ENALAPRIL MALEATE 36 ACETATE 98
ENALAPRIL ESTRADIOL/NORGESTIMATE 98
MALEATE/HYDROCHLOROTHIAZIDE 36 ESTRAMUSTINE PHOSPHATE SODIUM 163
ENDUR-ACIN 31 ESTROGENS, CONJUGATED 98,99
ENEMEEZ 94 ESTROGENS, CONJUGATED, SYNTHETIC
ENFALYTE 72 B 99
ENFUVIRTIDE 13 ESTROGENS,
ENGERIX-B ADULT 114 CONJUGATED/BAZEDOXIFENE
ENGERIX-B PEDIATRIC-ADOLESCENT 114 ACETATE 99
ENJUVIA 99 ESTROGENS,
ENOXAPARIN SODIUM 27 CONJUGATED/MEDROXYPROGESTERON
ENTACAPONE 59 E ACETATE 98,99
ENVARSUS XR 159 ESTROGENS,CONJ.,SYNTHETIC A 99
EPINASTINE HCL 86 ESTROGENS,ESTERIFIED 99
EPINEPHRINE 21 ESTROPIPATE 99
EPIRUBICIN HCL 163 ESTROSTEP FE 110
EPLERENONE 38 ESZOPICLONE 57
EPOETIN ALFA 28 ETHAMBUTOL HCL 12
EPOGEN 28 ETHINYL ESTRADIOL/DROSPIRENONE 108
EQ GENTLE 88 ETHIONAMIDE 12
ERGOCALCIFEROL (VITAMIN D2) 134 ETHOSUXIMIDE 47
ERTUGLIFLOZIN PIDOLATE 102 ETHYNODIOL DIACETATE-ETHINYL
ERTUGLIFLOZIN PIDOLATE/METFORMIN ESTRADIOL 108
HCL 102 ETODOLAC 42
ERTUGLIFLOZIN PIDOLATE/SITAGLIPTIN ETONOGESTREL/ETHINYL ESTRADIOL108
PHOSPHATE 102 ETOPOSIDE 164
ERYTHROMYCIN BASE 80 ETRAVIRINE 15
ERYTHROMYCIN BASE IN ETHANOL 118 EUCALYPTUS OIL 122
ERYTHROMYCIN BASE/BENZOYL EUCALYPTUS/MENTHOL 88
PEROXIDE 118 EVEROLIMUS 159
ESCAVITE D 151 EVOTAZ 13
ESCITALOPRAM OXALATE 51 EXELON 173
ESOMEPRAZOLE MAGNESIUM 91 EXEMESTANE 164
ESSENTIAL DAILY 137 EXENATIDE 101
ESSENTIAL MAN 140 EXENATIDE MICROSPHERES 101
ESSENTIAL WOMAN 50+ 136 EXPECTA PRENATAL 155
ESTARYLLA 111 EYE ALLERGY RELIEF 87
ESTRADIOL 97,98 EYE DROPS 87
ESTRADIOL VALERATE/DIENOGEST 108 EYE HEALTH PLUS LUTEIN 135
EYE LUBRICANT COMBINATION NO.1 88

EZFE FORTE 153 FERROUS SULFATE/VITAMIN A
PALMITATE/ASCORBIC ACID/VITAMIN
F D3 135
FA-8 128 FEXOFENADINE HCL 4
FALESSA 129 FIASP 171
FAMOTIDINE 91 FIASP FLEXTOUCH 171
FATIGUE RELIEF COMPLEX 131 FIBER 94
FE C 26 FIBER SMOOTH 95
FELBAMATE 48 FIBER THERAPY 95
FELODIPINE 34 FINASTERIDE 157
FEM-CAL CITRATE 69 FLAXSEED OIL 160
FEMCON FE 109 FLECAINIDE ACETATE 29
FENOFIBRATE 30 FLINTSTONES 150
FENOFIBRATE NANOCRYSTALLIZED 30 FLINTSTONES BONE SUPPORT 70
FENOFIBRATE,MICRONIZED 30 FLINTSTONES COMPLETE 150
FENOFIBRIC ACID 31 FLINTSTONES GUMMIES 150
FENOFIBRIC ACID (CHOLINE) 31 FLINTSTONES PLUS CALCIUM 135
FENTANYL 44 FLINTSTONES WITH EXTRA C 149
FER-IN-SOL 25 FLINTSTONES WITH IRON 151
FERATE 24 FLOVENT DISKUS 77
FERGON 24 FLOVENT HFA 77
FERRACTIV IRON 25 FLOXURIDINE 164
FERRETTS 26 FLUCONAZOLE 11
FERROCITE PLUS 26 FLUDARABINE PHOSPHATE 164
FERROUS FUMARATE/ASCORBIC FLUDROCORTISONE ACETATE 106
ACID/ASCORBATE SODIUM 171 FLUMIST QUAD 2016-2017 114
FERROUS FUMARATE/FOLIC FLUNISOLIDE 76,83
ACID/MULTIVITAMIN-MINERALS NO.15 24 FLUOCINOLONE ACETONIDE 120
FERROUS FUMARATE/FOLIC FLUOCINOLONE ACETONIDE OIL 83
ACID/VITAMIN B COMP AND C 135 FLUOCINONIDE 120
FERROUS FUMARATE/FOLIC FLUOCINONIDE/EMOLLIENT BASE 121
ACID/VITAMIN B COMP AND FLUORIDE (SODIUM) 158
C/MINERALS 24 FLUOROMETHOLONE 83
FERROUS FUMARATE/LIVER FLUOROURACIL 164
EXTRACT/VITAMIN B COMP AND C 24 FLUOXETINE HCL 51
FERROUS GLUCONATE 24 FLUOXYMESTERONE 107
FERROUS GLUCONATE/LYSINE HCL/VIT FLURAZEPAM HCL 57
E/VIT B CPLEX WITH C/ZINC 24 FLURBIPROFEN 42
FERROUS SULFATE 24,25 FLURBIPROFEN SODIUM 84
FERROUS SULFATE/LICORICE ROOT FLUTAMIDE 164
EXTRACT 25 FLUTICASONE FUROATE 76

FLUTICASONE FUROATE/VILANTEROL FOSAMPRENAVIR CALCIUM 14
TRIFENATATE 76 FOSFREE 71
FLUTICASONE PROPIONATE 77,83,121 FOSINOPRIL SODIUM 36
FLUTICASONE FREEDAVITE 141
PROPIONATE/SALMETEROL FRESHKOTE 88
XINAFOATE 77 FUROSEMIDE 61
FLUVOXAMINE MALEATE 51 FUSION 25
FLUZONE HIGH-DOSE 2016-2017 114 FUZEON 13
FLUZONE INTRADERM QUAD 2016-17 114 FYAVOLV 99
FLUZONE QUAD 2016-2017 113
FLUZONE QUAD 2017-2018 113 G
FML FORTE 83 GABAPENTIN 48
FML S.O.P. 83 GALANTAMINE HBR 23
FOLBEE PLUS 128 GARDASIL 114
FOLBEE PLUS CZ 128 GARLIC 160
FOLBIC RF 127 GATIFLOXACIN 80
FOLGARD 125 GAVILYTE-C 95
FOLIC ACID 127,128 GELNIQUE 124
FOLIC ACID-VIT B-6-VIT B-12 135 GEMCITABINE HCL 164
FOLIC ACID/MULTIVIT WITH IRON, GEMFIBROZIL 31
MINERALS/LUTEIN 135 GENERESS FE 109
FOLIC ACID/MULTIVIT WITH GENTAMICIN SULFATE 9,80,118
MINERALS/LUTEIN 136 GENTAMICIN SULFATE/PF 9
FOLIC GENTAMICIN SULFATE/PREDNISOLONE
ACID/MULTIVIT,CALCIUM,IRON,OTHER ACETATE 80
MINS/LYCOPENE/LUTEIN 136 GENTEAL TEARS 88
FOLIC ACID/MULTIVITAMIN WITH IRON, GENVOYA 16
MINERALS 136 GINKGO BILOBA 160
FOLIC ACID/VITAMIN B COMP AND GLEOSTINE 165
C/COPPER/ZINC OXIDE 128 GLIMEPIRIDE 102
FOLIC ACID/VITAMIN B COMP AND GLIPIZIDE 102
C/SELENIUM/MINERALS/ZINC 128 GLIPIZIDE/METFORMIN HCL 102
FOLIC ACID/VITAMIN B COMP AND GLUCAGEN 103
C/ZINC/VITAMIN D3 128 GLUCAGON,HUMAN RECOMBINANT 103
FOLIC ACID/VITAMIN B COMPLEX AND GLUCOSAMINE SULFATE 160
C/RICE BRAN 128 GLUCOSAMINE SULFATE SODIUM
FOLIC ACID/VITAMIN B COMPLEX AND CL/CHONDROITIN SULFATE A SODIUM160
VITAMIN C 128 GLUCOSAMINE SULFATE/CHONDROITIN
FOLINIC-PLUS 128 SULFATE A/ASCORBIC ACID/MANG 160
FOLOTYN 165 GLUCOSAMINE-CHONDROITIN
FOLTABS 800 127 COMPLX 160

GLUCOSAMINE/CHONDROIT-MSM HEP B
NO.1/C/MANGANESE/BOSWELLIA VIRUS,RCMB/DIPTH,PERTUS(ACELL),TET,
SERRATA 160 POLIO VACCINE/PF 113
GLUCOSAMINE/CHONDROITIN-MSM HEPARIN SODIUM,PORCINE 27
NO.7/VIT C/MANGANESE/BORON CITR 160 HEPARIN SODIUM,PORCINE/PF 27
GLYBURIDE 102 HEPATITIS A VIRUS AND HEPATITIS B
GLYBURIDE,MICRONIZED 103 VIRUS VACCINE/PF 113
GLYBURIDE/METFORMIN HCL 103 HEPATITIS A VIRUS VACCINE/PF 113,114
GLYCERIN 94 HEPATITIS B VIRUS VACCINE
GLYCERIN/DIMETHICONE 122 RECOMBINANT/PF 114
GLYCERIN/PROPYLENE GLYCOL 88 HEPATITIS B VIRUS VACCINE/HAEMOPH
GLYCINE UROLOGIC SOLUTION 75 B POLYSAC CONJ-MENING/PF 114
GLYCOPYRROLATE 19 HEXALEN 162
GLYCOPYRROLATE/FORMOTEROL HI-CAL 67
FUMARATE 20 HIGH POTENCY IRON 25
GOLYTELY 94 HOMATROPINE HBR 86
GONAK 88 HOMOCYSTEINE FORMULA 127
GRANISETRON HCL 90 HUMALOG 172
GRISEOFULVIN ULTRAMICROSIZE 12 HUMALOG KWIKPEN U-200 172
GRISEOFULVIN, MICROSIZE 12 HUMALOG MIX 50-50 172
GUAIFENESIN 79 HUMALOG MIX 50-50 KWIKPEN 172
GUAIFENESIN/DEXTROMETHORPHAN HUMALOG MIX 75-25 172
HBR 79 HUMALOG MIX 75-25 KWIKPEN 172
GUANFACINE HCL 32,60 HUMAN PAPILLOMAVIRUS VACCINE,
GUMMIES CHILDREN MULTIVITAMIN 150 BIVALENT/PF 114
GUMMIES GIRLS' MULTIVITAMINS 149 HUMAN PAPILLOMAVIRUS VACCINE,
GUMMY 148 QUADRIVALENT/PF 114
GUMMY DINOS 148 HUMULIN 70-30 172
HUMULIN 70/30 KWIKPEN 172
H HUMULIN N 172
HAEMOPHILUS B CONJUGATE VACCINE HUMULIN N KWIKPEN 172
(MENINGOCOCCAL PROT.CONJ)/PF 113 HUMULIN R 172
HAEMOPHILUS B CONJUGATE HYCAMTIN 166
VACCINE(TETANUS TOXOID HYDRALAZINE HCL 32,33
CONJUGATE)/PF 113 HYDROCHLOROTHIAZIDE 62
HAIR FORMULA 146 HYDROCODONE
HAIR, SKIN AND NAILS 139,140,146 BITARTRATE/ACETAMINOPHEN 44
HALOBETASOL PROPIONATE 121 HYDROCODONE
HAVRIX 114 BITARTRATE/HOMATROPINE
HEARTBURN & ACID REFLUX 135 METHYLBROMIDE 79
HYDROCORTISONE 106,121

HYDROCORTISONE BUTYRATE 121 INDOMETHACIN 43
HYDROCORTISONE SODIUM INDOMETHACIN SODIUM 43
SUCCINATE/PF 106 INFANRIX DTAP 112
HYDROCORTISONE VALERATE 121 INFANTS' ADVIL 43
HYDROCORTISONE/ACETIC ACID 82 INFLUENZA VACCINE QUADRIVALENT
HYDROCORTISONE/ALOE VERA 121 LIVE 2016-2017 (2 YRS-49 YRS) 114
HYDROGEN PEROXIDE 87 INFLUENZA VIRUS VACCINE
HYDROMORPHONE HCL 44 QUADRIVALENT 2016-17(18YRS-
114
HYDROMORPHONE HCL/PF 44 64YRS)/PF
HYDROXYCHLOROQUINE SULFATE 18 INFLUENZA VIRUS VACCINE
HYDROXYPROPYL CELLULOSE 88 QUADRIVALENT 2017-18 (36 MOS
HYDROXYUREA 164 UP)/PF 113
HYDROXYZINE HCL 57 INFLUENZA VIRUS VACCINE QUADVAL
HYDROXYZINE PAMOATE 57 SPLIT 2016-17(36 MOS UP)/PF 113
HYPROMELLOSE 88 INFLUENZA VIRUS VACCINE TRIVAL
HYPROMELLOSE/PF 88 SPLIT 2016-2017(65 YR UP)/PF 114
HYPROST 160 INHALER, ASSIST DEVICES 168
INHALER, ASSIST DEVICES,
I ACCESSORIES 168
I.L.X. B-12 136 INHALER,ASSIST DEVICE WITH LARGE
IBANDRONATE SODIUM 158 MASK 168
IBU 43 INHALER,ASSIST DEVICE WITH MEDIUM
IBUPROFEN 42,43 MASK 168
ICAPS 156,161 INHALER,ASSIST DEVICE WITH SMALL
ICAR 25 MASK 168
ICY HOT PAIN RELIEVING 123 INSULIN ASPART 171
IDARUBICIN HCL 164 INSULIN ASPART (NIACINAMIDE) 171
IFOSFAMIDE 164 INSULIN ASPART PROTAMINE
IFOSFAMIDE/MESNA 164 HUMAN/INSULIN ASPART 171
IMFINZI 163 INSULIN DETEMIR 171
IMIPENEM/CILASTATIN SODIUM 6 INSULIN GLARGINE,HUMAN
IMIPRAMINE HCL 52 RECOMBINANT ANALOG 171
IMOVAX RABIES VACCINE 115 INSULIN GLULISINE 171
IMVEXXY 98 INSULIN LISPRO 172
INCONTINENCE PAD,LINER,DISP 168 INSULIN LISPRO PROTAMINE AND
INCRUSE ELLIPTA 20 INSULIN LISPRO 172
INDACATEROL MALEATE 20 INSULIN NPH HUMAN ISOPHANE 172
INDACATEROL INSULIN NPH HUMAN ISOPHANE/INSULIN
MALEATE/GLYCOPYRROLATE 21 REGULAR, HUMAN 172
INDAPAMIDE 62 INSULIN REGULAR, HUMAN 172
INDINAVIR SULFATE 14 INTEGRA 25

INTELENCE 15 IRON/FOLIC ACID/VIT
INTRINSI B12-FOLATE 127 C/E/B12/BIOTIN/CUPRIC SULF/DOCUSATE
INTROVALE 109 SOD 26
INVIRASE 14 IRON/FOLIC ACID/VITAMIN B COMP AND
INVOKAMET 101 C/MINERALS 26
INVOKAMET XR 101 IRON/LYSINE/VITAMIN B COMPLEX/FOLIC
INVOKANA 101 ACID 136
IONOSOL B WITH DEXTROSE 5% 71 IRON/VIT C/B12/B6/E/FOLIC
IONOSOL MB-DEXTROSE 5% 72 ACID/INTRINSIC FACTOR/SENNA LEAF 26
IOPIDINE 88 IRON/VIT C/VIT B12/CALCIUM
IPOL 115 THREON/SUCCINIC ACID/STOMACH
IPRATROPIUM BROMIDE 20,88 CONC 26
IPRATROPIUM BROMIDE/ALBUTEROL IRON/VITAMIN B
SULFATE 20 COMPLEX/CYANOCOBALAMIN/LIVER
IRBESARTAN 37 EXTRACT 136
IRBESARTAN/HYDROCHLOROTHIAZIDE 38 ISENTRESS 15
IRINOTECAN HCL 164 ISO D3 133
IRO-PLEX 26 ISOLYTE P WITH DEXTROSE 72
IRON 25 ISONIAZID 12
IRON AMINO ACID ISOPTO HYOSCINE 86
CHELATE/CYANOCOBALAMIN/FOLIC ISOPTO TEARS 88
ACID 25 ISOSORBIDE DINITRATE 33
IRON BIS-GLYCINATE CHELATE/IRON ISOSORBIDE MONONITRATE 33
POLYSACCHARIDE CPLX/B12/ZINC 25 ISRADIPINE 34
IRON BISGLYCIN/IRON POLYSAC ISTALOL 85
COMPLX/B12/BIOTIN/MAGNESIUM/ZINC 25 IXIARO 115
IRON FUMARATE-IRON
POLYSACCHARIDE COMBO NO.1/VIT C/L. J
CASEI 25 JAPANESE ENCEPHALITIS
IRON FUMARATE/IRON POLYSAC VACCINE/PF 115
COMPLEX/VITAMIN C/NIACINAMIDE 25 JARDIANCE 101
IRON,CARBONYL 25,26 JEVTANA 163
IRON,CARBONYL/ASCORBIC ACID 26 JUNEL 110
IRON,CARBONYL/ASCORBIC JUNEL FE 110
ACID/FRUCTOOLIGOSACCHARIDES 26 JUNEL FE 24 110
IRON,CARBONYL/FOLIC ACID/MULTIVIT JUST D 134
WITH MINERALS 136
IRON/FOLIC ACID/VIT B COMPLEX K
NO.16/MAG SULFATE/ZINC SULFATE 26 K EFFERVESCENT 73
K-PAX IMMUNE SUPPORT 142
K-PHOS ORIGINAL 62

KALETRA 14 LANOXIN 30
KELNOR 1-35 108 LANSOPRAZOLE 91
KELP-LECITHIN-B-6-VINEGAR 160 LANTUS 171
KELP-LECITHIN-VIT B-6 160 LASTACAFT 86
KENWOOD THERAPEUTIC 144 LATANOPROST 86
KETOCONAZOLE 11,117 LECITHIN/PYRIDOXINE/KELP 160
KETOPROFEN 43 LEFLUNOMIDE 158
KETOROLAC TROMETHAMINE 84 LETROZOLE 164
KETOROLAC TROMETHAMINE/PF 84 LEUCOVORIN CALCIUM 157
KETOTIFEN FUMARATE 86 LEUCOVORIN CALCIUM/PYRIDOXAL
KID'S VITAMINS + IRON 149 PHOSPHATE/MECOBALAMIN 128
KIDKARE 78 LEUKERAN 163
KIDS COD LIVER OIL +D 156 LEVALBUTEROL TARTRATE 21
KIDS MULTIVITAMIN COMPLETE 148 LEVEMIR 171
KIDS VITAMINS 147 LEVEMIR FLEXTOUCH 171
KIDS VITAMINS COMPLETE 147 LEVETIRACETAM 49
KIDSTART 148 LEVOBUNOLOL HCL 85
KINRIX 113 LEVOCARNITINE 161
KLOR-CON M10 73 LEVOCARNITINE (WITH SUGAR) 161
KLOR-CON M20 73 LEVOCETIRIZINE DIHYDROCHLORIDE 4
KPN 152,156 LEVOFLOXACIN 10,81
LEVOFLOXACIN/DEXTROSE 5 % IN
L WATER 10
LABETALOL HCL 40 LEVOMEFOLATE
LACRISERT 88 CAL/ACETYLCYSTEINE/MECOBALAMIN/S
LACTOBAC CHIZ.ALGAL OIL 128
ACIDOPHILUS/L.BULGARICUS/B.BIFIDIUM/ LEVOMEFOLATE CALC/PYRIDOXAL
S.THERMOPHILUS 97 PHOS/MECOBALAMIN/SCHIZ.ALGAL
LACTOBACILLUS ACIDOPHILUS 93 OIL 128
LACTULOSE 63 LEVONEST 109
LAMICTAL (GREEN) 49 LEVONORGESTREL 109
LAMICTAL (ORANGE) 49 LEVONORGESTREL-ETHINYL
LAMICTAL XR (BLUE) 49 ESTRADIOL 109
LAMICTAL XR (GREEN) 49 LEVONORGESTREL/ETHINYL ESTRADIOL
LAMICTAL XR (ORANGE) 49 AND ETHINYL ESTRADIOL 108
LAMIVUDINE 17 LEVORPHANOL TARTRATE 45
LAMIVUDINE/TENOFOVIR DISOPROXIL LEVOTHYROXINE SODIUM 104
FUMARATE 17 LEVOXYL 104
LAMIVUDINE/ZIDOVUDINE 17 LEXIVA 14
LAMOTRIGINE 48,49 LICE CREAM RINSE 119
LANCETS 168,169 LICIDE 169

LIDOCAINE HCL 86,167 LYDIA PINKHAM HERBAL 25
LIDOCAINE HCL IN SODIUM CHLORIDE, LYSINE HCL/VITAMIN B COMPLEX/FOLIC
ISO-OSMOTIC/PF 167 ACID/ZINC 128
LIDOCAINE HCL/EPINEPHRINE 167 LYSIPLEX PLUS 137
LIDOCAINE HCL/HYDROCORTISONE LYSODREN 165
ACETATE 121
LIDOCAINE HCL/PF 29,167 M
LIFE-PACK 135,137 M-M-R II VACCINE 115
LINDANE 119 MACULAR VITAMIN 140
LIOTHYRONINE SODIUM 104 MACUVITE 173
LIPASE/PROTEASE/AMYLASE 96 MACUVITE EYE CARE 135
LIPOSOMAL UBIQUINOL 161 MAG DELAY 72
LIQ-10 161 MAG GLYCINATE 72
LISDEXAMFETAMINE DIMESYLATE 54 MAG-G 72
LISINOPRIL 37 MAG-TAB SR 72
LISINOPRIL/HYDROCHLOROTHIAZIDE 37 MAG64 72
LITTLE ANIMALS PLUS IRON 149 MAGNEBIND 300 61
LITTLE NOSES 87 MAGNESIUM 72
LIVER WITH IRON 24 MAGNESIUM AMINO ACID CHELATE 72
LO LOESTRIN FE 110 MAGNESIUM CARBONATE 72
LOCALNESIUM 65 MAGNESIUM CARBONATE/ALUMINUM
LOCALNESIUM-C 66 HYDROXIDE 92
LOMUSTINE 164,165 MAGNESIUM CHLORIDE 72
LOPERAMIDE HCL 93 MAGNESIUM CITRATE 72,94
LOPINAVIR/RITONAVIR 14 MAGNESIUM GLUCONATE 72
LORATADINE 4 MAGNESIUM GLYCINATE 72
LORATADINE/PSEUDOEPHEDRINE MAGNESIUM HYDROXIDE/ALUMINUM
SULFATE 4 HYDROXIDE/SIMETHICONE 92
LORAZEPAM 57 MAGNESIUM L-LACTATE 72
LORYNA 108 MAGNESIUM OXIDE 93
LOSARTAN POTASSIUM 38 MAGNESIUM OXIDE, ASPARTATE,
LOSARTAN CITRATE 73
POTASSIUM/HYDROCHLOROTHIAZIDE 38 MAGNESIUM OXIDE/MAGNESIUM AMINO
LOTEMAX 83 ACID CHELATE 73
LOTEPREDNOL ETABONATE 83 MAGNESIUM SULFATE 73
LOVASTATIN 31 MAGONATE 72
LUBRICANT EYE 89 MALATHION 119
LUBRICANT EYE DROP 89 MANNITOL 61
LUBRICANT GEL DROPS 88 MARAVIROC 13
LUFYLLIN 171 MATULANE 165
LUTEIN 161 MAXFE 25

MAXIMIN 136 MENINGOCOCCALVACCINE A,C,Y,W-
MAXIMUM D3 133 135,DIPHTHERIA TOXOID CONJ/PF 115
MCT OIL 75 MENOSTAR 98
MEASLES, MUMPS, AND RUBELLA MENTHOL 123
VACCINE LIVE/PF 115 MEPIVACAINE HCL/PF 167
MEASLES, MUMPS, RUBELLA, AND MERCAPTOPURINE 165
VARICELLA VACCINE LIVE/PF 115 MEROPENEM 6
MECHLORETHAMINE HCL 165 MESNA 159
MECLIZINE HCL 89 MESNEX 159
MECOBALAMIN 129 METAFOLBIC PLUS 125
MECOBALAMIN/FOLIC ACID 129 METAFOLBIC PLUS RF 128
MEDI-SLEEP 162 METAMUCIL 95
MEDICAL SUPPLY, MISCELLANEOUS 169 METAPROTERENOL SULFATE 21
MEDIKOFF 88 METFORMIN HCL 100
MEDIUM CHAIN TRIGLYCERIDES 75 METHAMPHETAMINE HCL 54
MEDROL 106 METHIMAZOLE 105
MEDROXYPROGESTERONE ACETATE 111 METHOCARBAMOL 22
MEDTYCHOLL-B COMPLEX W-LIVER 132 METHOTREXATE SODIUM 165
MEGA MULTI 137,138 METHOTREXATE SODIUM/PF 165
MEGESTROL ACETATE 111,112 METHYCLOTHIAZIDE 62
MELATONIN 161 METHYL SALICYLATE/MENTHOL 42
MELATONIN/PYRIDOXINE 161 METHYLDOPA 32
MELOXICAM 43 METHYLDOPA/HYDROCHLOROTHIAZIDE 3
MELPHALAN HCL 165 2
MEMANTINE HCL 60 METHYLERGONOVINE MALEATE 167
MEMANTINE HCL/DONEPEZIL HCL 60 METHYLPHENIDATE HCL 55
MEN 50 PLUS ADVANCED ONE DAILY 140 METHYLPREDNISOLONE 106
MEN'S 50+ DAILY FORMULA 146 METHYLPREDNISOLONE ACETATE 106
MEN'S BIOMULTIPLE 138 METHYLPREDNISOLONE SODIUM
MEN'S DAILY FORMULA 141 SUCCINATE 106
MEN'S DAILY PACK 136 METHYLTETRAHYDROFOLATE
MEN'S POTENT FORMULA 71 GLUCOSAMINE 129
MENACTRA 115 METIPRANOLOL 85
MENEST 99 METOCLOPRAMIDE HCL 97
MENHIBRIX 115 METOLAZONE 62
MENINGOCOCCAL GROUP B VACCINE, 4- METOPROLOL SUCCINATE 40
COMPONENT 115 METOPROLOL TARTRATE 40
MENINGOCOCCAL VACCINE METOPROLOL
C,Y/HAEMOPHILUS B CONJ-TETANUS TARTRATE/HYDROCHLOROTHIAZIDE 40
TOX/PF 115 METRONIDAZOLE 18,118

METRONIDAZOLE IN SODIUM MUCUS DM 79
CHLORIDE 19 MULTI FOR HER 146
MEXILETINE HCL 29 MULTI FOR HER 50 PLUS 140
MGO 93 MULTI-DAY PLUS MINERALS 141
MICONAZOLE NITRATE 117 MULTI-DELYN 145
MILANTEX 92 MULTILEX 137
MILK THISTLE 161 MULTIVIT WITH CALCIUM, IRON, AND
MILLIPRED 106 OTHER MINERALS 136,137
MILNACIPRAN HCL 59 MULTIVIT WITH
MINASTRIN 24 FE 110 CALCIUM,IRON,MINERALS/FOLIC
MINI PRENATAL 154 ACID/PHYTOSTEROL 137
MINIPRIN 41 MULTIVIT WITH
MINIVELLE 98 CALCIUM,MINERALS/FOLIC
MINOCYCLINE HCL 11 ACID/BIOFLAVONOIDS NO.4 137
MINOXIDIL 33,123 MULTIVIT WITH
MIOSTAT 85 CALCIUM,MINS/IRON/FOLIC
MIRTAZAPINE 53 ACID/LUTEIN/HERBAL 179 137
MISOPROSTOL 91 MULTIVIT WITH CALCIUM-MINS/IRON
MITOMYCIN 165 FUMARATE/FOLIC ACID/VIT K 146
MITOTANE 165 MULTIVIT WITH IRON, MINERALS/GINKGO
MITOXANTRONE HCL 165 BILOBA EXT/PANAX GINSENG 137
MOEXIPRIL HCL 37 MULTIVIT WITH IRON,MINERALS/FOLIC
MOEXIPRIL ACID/DIETARY SUPP. NO.24 137
HCL/HYDROCHLOROTHIAZIDE 37 MULTIVIT WITH IRON,MINS/FOLIC
MOMETASONE FUROATE 77,121,122 ACID/INOSITOL/CHOLINE BIT/PABA 138
MOMETASONE FUROATE/FORMOTEROL MULTIVIT WITH MINERALS/FOLIC
FUMARATE 77 ACID/BIOTIN/LUTEIN 146
MONISTAT 3 117 MULTIVIT WITH MINERALS/FOLIC
MONISTAT 7 117 ACID/CALCIUM CARBONATE/VIT K1 138
MONOCAPS 141 MULTIVIT WITH MINERALS/FOLIC
MONOJECT PREFILL 27 ACID/GINKGO BILOBA LEAF EXTRACT 138
MONTELUKAST SODIUM 78 MULTIVIT WITH MINERALS/FOLIC
MORPHINE SULFATE 45,172 ACID/GUARANA/CAFFEINE 138
MORPHINE SULFATE/PF 45 MULTIVIT WITH MINERALS/FOLIC
MOTOFEN 93 ACID/LUTEIN/ZEAXANTHIN 140
MOVIPREP 94 MULTIVIT WITH MINERALS/FOLIC
MOXEZA 81 ACID/LYCOPENE/LUTEIN/HERBAL 178 138
MOXIFLOXACIN HCL 81 MULTIVIT WITH MINERALS/GINSENG 138
MTERYTI 156 MULTIVIT WITH
MTERYTI FOLIC 5 156 MINERALS/GLUTATHIONE/CYSTEINE 138
MTX SUPPORT 127

MULTIVIT WITH MINERALS/HERBAL MULTIVIT-MINERALS/FOLIC
DRUGS 138 ACID/LYCOPENE/GINKGO LEAF
MULTIVIT, CALCIUM, EXTRACT 146
IRON,MINERALS/FOLIC ACID/HERB MULTIVIT-MINERALS/FOLIC ACID/VIT
COMPLEX 145 138 K/LYCOPENE/LUTEIN/CO Q10 141
MULTIVIT,CALC,MINS/VIT K/OMG-3/VIT MULTIVIT-MINERALS/FOLIC ACID/VIT
D3/MAG/C/GR.TEA/CHROMIUM 139 K/LYCOPENE/LUTEIN/ZEAXANTH 141
MULTIVIT,CALCIUM,IRON,MIN/FOLIC MULTIVIT-MINERALS/IRON
ACID/CHOLINE/INOSITOL/PABA 139 FUMARATE/FOLIC ACID/VIT K/GREEN
MULTIVIT,CALCIUM,IRON,MINERALS/FOLI TEA 142
C ACID/GUARANA, CAFFEINE 139 MULTIVIT-MINERALS/IRON
MULTIVIT,CALCIUM,IRON,MINERALS/FOLI PICOLIN/FOLIC/CALCIUM/D3/AMINO
C ACID/LUTEIN/HERBAL 153 139 ACID 142
MULTIVIT,CALCIUM,MIN/FERROUS MULTIVIT-MINERALS/IRON/FOLIC
FUM/FOLIC ACID/GUARANA/CAFFEINE 146 ACID/K/D3/CHOLINE/DHA/FISH OIL 142
MULTIVIT,CALCIUM,MIN/IRON/FOLIC MULTIVIT-MINS/IRON FUMARATE/FOLIC
ACID/EPIGALLOCATECHIN/CAFF 139 ACID/VIT K/LYCOPENE/LUTEIN 142
MULTIVIT,CALCIUM,MINERALS/FERROUS MULTIVITAMIN 142
GLUCON/FOLIC ACID/BIOTIN 139 MULTIVITAMIN AND MINERALS
MULTIVIT,CALCIUM,MINERALS/IRON/FOLI COMBINATION NO.55 142
C ACID/LYCOPENE/LUTEIN 139 MULTIVITAMIN WITH CALCIUM AND
MULTIVIT,CALCIUM,MINERALS/IRON/FOLI MINERALS/FOLIC ACID 138
C ACID/VIT K/HERB NO.244 139 MULTIVITAMIN WITH CALCIUM,
MULTIVIT,CALCIUM,MINS/IRON/FOLIC MINERAL/FOLIC ACID/SOY
ACID/LUTEIN/LYCOPEN/HERB175 139 ISOFLAVONE 142
MULTIVIT,IRON,MINERALS/FOLIC MULTIVITAMIN WITH CALCIUM,
ACID/D3/OMEG-3/DHA/EPA/FISH OIL 140 MINERALS/IRON/FOLIC ACID/LUTEIN 142
MULTIVIT,THERAPEUTIC WITH MULTIVITAMIN WITH FOLIC ACID 142
CALCIUM,IRON,MINERALS/FOLIC ACID 140 MULTIVITAMIN WITH IRON 142,143
MULTIVIT-MIN/FOLIC MULTIVITAMIN WITH IRON AND
ACID/INOSITOL/CHOLINE MINERALS/FOLIC ACID/BIOTIN 146
BIT/BIOFLAV,CITRUS 140 MULTIVITAMIN WITH IRON AND OTHER
MULTIVIT-MIN/METHYLFOLATE MINERALS 137,172
GLUCOS/COENZYME Q10/DIETARY MULTIVITAMIN WITH IRON AND OTHER
141
NO.26 MINERALS/LUTEIN 143
MULTIVIT- MULTIVITAMIN WITH IRON,HEMATINIC 137
MIN/METHYLTETRAHYDROFOLATE MULTIVITAMIN WITH IRON,OTHER
141
GL/CO-Q10/DHA/EPA/DIET27 MINERAL/GREEN TEA LEAF EXTRACT 139
MULTIVIT- MULTIVITAMIN WITH MIN/FOLIC
MIN/METHYLTETRAHYDROFOLATE ACID/D3/OMEGA-3/DHA/EPA/FISH OIL 146
141
GLUCOS/CO-Q10/DIETARY 26 MULTIVITAMIN WITH MINERALS 143

MULTIVITAMIN WITH MINERALS MULTIVITAMIN,CA,MIN/FOLIC
NO.49/FERROUS SULFATE/FOLIC ACID143 ACID/VITAMIN K/LYCOPENE/LUTEIN 144
MULTIVITAMIN WITH MULTIVITAMIN,STRESS FORMULA 144
MINERALS/FERROUS FUMARATE 143 MULTIVITAMIN,STRESS
MULTIVITAMIN WITH FORMULA/ZINC 144
MINERALS/FERROUS FUMARATE/FOLIC MULTIVITAMIN,THERAPEUTIC 144,145
ACID 141 MULTIVITAMIN,THERAPEUTIC WITH IRON
MULTIVITAMIN WITH AND MINERALS 140
MINERALS/FERROUS FUMARATE/FOLIC MULTIVITAMIN,THERAPEUTIC WITH
ACID/VIT K 141 MINERALS 144
MULTIVITAMIN WITH MULTIVITAMIN-MINERALS NO.21/FOLIC
MINERALS/FERROUS GLUCONATE 143 ACID 145
MULTIVITAMIN WITH MINERALS/FOLIC MULTIVITAMIN-MINERALS/FERROUS
ACID 141 FUMARATE/FOLIC ACID/LUTEIN 145
MULTIVITAMIN WITH MINERALS/FOLIC MULTIVITAMIN-MINERALS/FOLIC ACID/CO
ACID/BIOTIN 140 Q10/LYCOPENE/LUTEIN 145
MULTIVITAMIN WITH MINERALS/FOLIC MULTIVITAMIN-MINERALS/IRON
ACID/CAFFEINE 143 FUM/FOLIC ACID/CALCIUM CARB/VIT K145
MULTIVITAMIN WITH MINERALS/FOLIC MULTIVITAMIN-MINERALS/IRON
ACID/DIETARY SUPPL NO.19 143 FUMARATE/FA/VIT K/KOREAN
MULTIVITAMIN WITH MINERALS/FOLIC GINSENG 145
ACID/GINKGO LEAF EXTRACT 143 MULTIVITAMIN-MINERALS/IRON
MULTIVITAMIN WITH MINERALS/FOLIC FUMARATE/FOLIC ACID/PANAX
ACID/HERBAL COMPLEX NO.245 144 GINSENG 145
MULTIVITAMIN WITH MINERALS/FOLIC MULTIVITAMIN-
ACID/LUTEIN/ZEAXANTHIN 172 MINS/CALCIUM/BIOTIN/CHOLECALCIFERO
MULTIVITAMIN WITH MINERALS/FOLIC L/FOLIC ACID 145
ACID/LYCOPENE 141 MULTIVITAMIN/FERROUS
MULTIVITAMIN WITH MINERALS/FOLIC FUMARATE/FOLIC ACID 145
ACID/LYCOPENE/BORON 144 MULTIVITAMIN/FERROUS GLUCONATE145
MULTIVITAMIN WITH MINERALS/FOLIC MULTIVITAMIN/FERROUS SULFATE 145
ACID/LYCOPENE/LUTEIN 140,144 MULTIVITAMIN/FOLIC
MULTIVITAMIN WITH MINERALS/FOLIC ACID/DOCOSAHEXANOIC ACID 145
ACID/PHYTONADIONE 140 MULTIVITAMIN/FOLIC ACID/ZINC
MULTIVITAMIN WITH MINERALS/FOLIC ASCORBATE 173
ACID/VITAMIN K1/LYCOPENE 140,141 MULTIVITAMIN/FOLIC ACID/ZINC
MULTIVITAMIN WITH MINS NO.52/FOLIC SULFATE/ASCORBIC ACID 145
ACID/VIT K1/UBIDECARENONE 144 MULTIVITAMIN/ZINC GLUCONATE 173
MULTIVITAMIN, MINERALS NO.51/FOLIC MULTIVITAMINS WITH MINERALS
ACID/VIT K1/UBIDECARENONE 144 NO.11/FOLIC ACID 129

MULTIVITS WITH CALCIUM AND NAPROXEN 43
MINERALS/IRON FUMARATE/FOLIC NARATRIPTAN HCL 58
ACID 138,139 NASAL & SINUS DECONGESTANT 21
MULTIVITS WITH CALCIUM AND NASAL MIST 87
MINERALS/IRON/FOLIC NASAL SYRINGE 169
ACID/LYCOPENE 146 NATACYN 82
MULTIVITS,CA,MINERALS/IRON/FOLIC NATAMYCIN 82
ACID/LYCOPENE/LUT/PHYTOSTER 173 NATAZIA 108
MUPIROCIN 118 NATEGLINIDE 101
MUSTARGEN 165 NATURAL BALANCED B-100 130
MVW COMPLETE FORMLTN NATURE-THROID 105
PEDIATRIC 147 NAUSEA RELIEF 90
MVW COMPLETE FORMULATION NECON 110,111
D3000 146,147 NEFAZODONE HCL 52
MVW COMPLETE FORMULATION NEISSERIA MENINGITIDIS GROUP B,
D5000 147 LIPIDATED FHBP RECOMBINANT 115
MVW COMPLETE FORMULTN NELARABINE 165
MULTIVIT 146,147 NELFINAVIR MESYLATE 14
MY FAVORITE MULTIPLE 142 NEOMYCIN SULF/BACITRACIN
MYCOPHENOLATE MOFETIL 159 ZINC/POLYMYXIN B SULF/PRAMOXINE
MYCOPHENOLATE MOFETIL HCL 159 HCL 118
MYCOPHENOLATE SODIUM 159 NEOMYCIN SULF/COLISTIN
MYKIDZ IRON 135 SUL/HYDROCORTISONE
MYKIDZ IRON 10 25 AC/THONZONIUM BROM 81
MYLERAN 163 NEOMYCIN SULFATE 9
MYVITALIFE 143 NEOMYCIN SULFATE/BACITRACIN
ZINC/POLYMYXIN B/HYDROCORTISONE81
N NEOMYCIN
NABUMETONE 43 SULFATE/BACITRACIN/POLYMYXIN B 81
NADOLOL 40 NEOMYCIN SULFATE/POLYMYXIN B
NADOLOL/BENDROFLUMETHIAZIDE 40 SULFATE/GRAMICIDIN D 81
NAMZARIC 60 NEOMYCIN SULFATE/POLYMYXIN B
NANO VM 1-3 148,173 SULFATE/HYDROCORTISONE 81
NANO VM 4-8 149,173 NEOMYCIN SULFATE/POLYMYXIN B
NANO VM T/F 173 SULFATE/PRAMOXINE 119
NANOVM 9-18 151 NEOMYCIN/POLYMYXIN B
NANOVM T/F 151 SULFATE/DEXAMETHASONE 81
NAPHAZOLINE HCL 87 NEORAL 158
NAPHAZOLINE HCL/GLYCERIN 87 NEPAFENAC 84
NAPHAZOLINE HCL/PHENIRAMINE NEPHRO-VITE RX 131
MALEATE 87 NEPHRONEX 132

NEPHRONEX-SL 132 NORPACE CR 28
NEURO VITE 130 NORTRIPTYLINE HCL 52
NEVANAC 84 NORVIR 14
NEVIRAPINE 15 NOVOLOG 171
NIACIN 31 NOVOLOG FLEXPEN 171
NIACIN (INOSITOL NIACINATE) 31 NOVOLOG MIX 70-30 171
NICORELIEF 23 NOVOLOG MIX 70-30 FLEXPEN 171
NICOTINE 23 NU-MAG 72
NICOTINE POLACRILEX 23 NUTRIVIT 136
NICOTROL 23 NUVARING 108
NICOTROL NS 23 NYSTATIN 11,12,117
NIFEDIPINE 35 NYSTOP 117
NIGHTTIME SEVERE COUGH-COLD 3
NIGHTTIME SLEEP AID 162 O
NILUTAMIDE 165 OCUTABS 135
NIPENT 165 OCUVITE EYE PLUS MULTI 141
NITRO-BID 34 ODEFSEY 16
NITRO-DUR 33 OFLOXACIN 81
NITROFURANTOIN 19 OGESTREL 111
NITROFURANTOIN MACROCRYSTAL 19 OLODATEROL HCL 21
NITROFURANTOIN OLOPATADINE HCL 86
MONOHYDRATE/MACROCRYSTALS 19 OMEGA-3 ACID ETHYL ESTERS 31
NITROGLYCERIN 33,34 OMEGA-3 FATTY ACIDS/DHA/EPA/OTHER
NIZORAL A-D 117 OMEGA-3S/FISH OIL 31,32
NORELGESTROMIN/ETHINYL OMEGA-3 FATTY
ESTRADIOL 109 ACIDS/DOCOSAHEXANOIC ACID/EPA/FISH
NORETHINDRONE 109 OIL 32
NORETHINDRONE ACETATE 112 OMEGA-3 FATTY ACIDS/FISH OIL 32
NORETHINDRONE ACETATE-ETHINYL OMEPRAZOLE 92
ESTRADIOL 99,109,110 OMEPRAZOLE MAGNESIUM 92
NORETHINDRONE ACETATE-ETHINYL ONCASPAR 165
ESTRADIOL/FERROUS FUMARATE 110 ONCOVITE 145
NORETHINDRONE-ETHINYL ONDANSETRON 90
ESTRADIOL 110 ONDANSETRON HCL 90
NORETHINDRONE-ETHINYL ONDANSETRON HCL/PF 90
ESTRADIOL/FERROUS FUMARATE 109,110 ONE A DAY WOMEN'S PRENATAL DHA 151
NORETHINDRONE-MESTRANOL 111 ONE DAILY 139,141
NORGESTIMATE-ETHINYL ESTRADIOL 111 ONE DAILY DIET SUPPORT 139
NORGESTREL-ETHINYL ESTRADIOL 111 ONE DAILY ENERGY 146
NORMOSOL-M AND DEXTROSE 71 ONE DAILY HEALTHY WEIGHT 138
NORMOSOL-R AND DEXTROSE 72 ONE DAILY MULTIVITAMIN 142

ONE DAILY WITH CALCIUM-IRON 136 PAIN RELIEVING CREAM 42
ONE DAILY WOMEN'S 137,138 PANCREAZE 96
ONE DAILY WOMEN'S 50 PLUS ADV 138 PANCRELIPASE 5,000 96
ONE-A-DAY KID'S 150 PANTOPRAZOLE SODIUM 92
ONE-A-DAY MENOPAUSE FORMULA 142 PAPAYA 161
ONE-A-DAY TEEN ADVANTAGE 139 PAROMOMYCIN SULFATE 18
ONE-A-DAY TEEN HER VITACRAVES 147 PAROXETINE HCL 51
ONE-A-DAY TEEN HIM VITACRAVES 147 PARVA-CAL 500 64
ONE-A-DAY VITACRAVES ENERGY 143 PARVLEX 24
ONE-A-DAY VITACRAVES OMEGA-3 145 PASER 12
ONE-A-DAY WOMEN'S 145,146 PAXIL 51
ONE-A-DAY WOMEN'S HEALTHY SKIN 142 PEAK FLOW METER 169
ONE-A-DAY WOMEN'S PETITES 139 PEAK FLOW METER/INHALER, ASSIST
ONE-A-DAY WOMEN'S PRENATAL 1 152 DEVICES 169
ONE-DAILY MULTI-VITAMIN-IRON 145 PEDI MULTIVIT
OPTIMAL D3 M 133 65/CHOLECALCIFEROL(VIT
OPTISOURCE 146 D3)/PHYTONADIONE(VIT K) 147
OPURITY 129 PEDIARIX 113
OPURITY MULTIVITAMIN 136 PEDIATRIC MULTIVIT
ORAL CLEANSER 87 NO.22/CHOLECALCIFEROL(D3)/PHYTONA
ORTHO EVRA 109 DIONE(K) 146
ORTHO-TABS 64 PEDIATRIC MULTIVIT
OS-CAL 500-VIT D3 68 NO.61/CHOLECALCIFEROL(D3)/PHYTONA
OSELTAMIVIR PHOSPHATE 18 DIONE(K) 147
OSMOPREP 95 PEDIATRIC MULTIVIT
OSTEO BI-FLEX 160 NO.62/CHOLECALCIFEROL(D3)/PHYTONA
OSTEO-PORETICAL 68 DIONE(K) 147
OTIC CARE 170 PEDIATRIC MULTIVIT
OXALIPLATIN 165 NO.64/CHOLECALCIFEROL(D3)/PHYTONA
OXAZEPAM 57 DIONE(K) 147
OXCARBAZEPINE 49 PEDIATRIC MULTIVIT
OXI-FREEDA 138 NO.77/CHOLECALCIFEROL(D3)/PHYTONA
OXYBUTYNIN CHLORIDE 124 DIONE(K) 147
OXYCODONE HCL 45 PEDIATRIC MULTIVIT NO.8/FOLIC ACID147
OXYCODONE HCL/ACETAMINOPHEN 46 PEDIATRIC MULTIVIT
OYSCO D 67 NO.89/CHOLECALCIFEROL(D3)/PHYTONA
OYSCO-500 65 DIONE(K) 147
OYSTERCAL-D 67 PEDIATRIC MULTIVIT NO.9/FERROUS
FUMARATE/FOLIC ACID 147
P
PACLITAXEL 165

PEDIATRIC MULTIVIT PEDIATRIC MULTIVITAMIN
NO.99/CHOLECALCIFEROL(D3)/PHYTONA NO.18/FERROUS GLUCONATE/FOLIC
DIONE(K) 147 ACID 173
PEDIATRIC MULTIVITAMIN A,C,AND D3 PEDIATRIC MULTIVITAMIN NO.19/FOLIC
NO.21 148 ACID 149
PEDIATRIC MULTIVITAMIN COMBINATION PEDIATRIC MULTIVITAMIN NO.20 149
NO.4/IRON/FOLIC ACID 173 PEDIATRIC MULTIVITAMIN
PEDIATRIC MULTIVITAMIN COMBINATION NO.22/CHOLECALCIFEROL/PHYTONADIO
NO.5/IRON/FOLIC ACID 173 NE 149
PEDIATRIC MULTIVITAMIN COMBINATION PEDIATRIC MULTIVITAMIN NO.23/FOLIC
NO.53 173 ACID 149
PEDIATRIC MULTIVITAMIN NO.101 148 PEDIATRIC MULTIVITAMIN NO.25/FOLIC
PEDIATRIC MULTIVITAMIN NO.108/IRON ACID 149
FUMARATE/SODIUM FLUORIDE 148 PEDIATRIC MULTIVITAMIN NO.27/FOLIC
PEDIATRIC MULTIVITAMIN NO.11/FOLIC ACID 149
ACID 148 PEDIATRIC MULTIVITAMIN NO.28 149
PEDIATRIC MULTIVITAMIN NO.111 148 PEDIATRIC MULTIVITAMIN
PEDIATRIC MULTIVITAMIN NO.28/FERROUS FUMARATE 149
NO.114/FERROUS FUMARATE 148 PEDIATRIC MULTIVITAMIN NO.29 149
PEDIATRIC MULTIVITAMIN NO.118 148 PEDIATRIC MULTIVITAMIN NO.30 150
PEDIATRIC MULTIVITAMIN NO.127 148 NO.31/FERROUS SULFATE/FOLIC ACID150
PEDIATRIC MULTIVITAMIN NO.136 148 PEDIATRIC MULTIVITAMIN NO.32/FOLIC
PEDIATRIC MULTIVITAMIN ACID/ZINC OXIDE 173
NO.14/FERROUS FUMARATE/FOLIC PEDIATRIC MULTIVITAMIN
ACID 148 NO.36/FERROUS FUMARATE 150
PEDIATRIC MULTIVITAMIN PEDIATRIC MULTIVITAMIN
NO.140/FERROUS FUMARATE 148 NO.38/FERROUS FUMARATE 150
PEDIATRIC MULTIVITAMIN NO.40/PHYTONADIONE (VIT K1) 150
NO.15/FERROUS FUMARATE/FOLIC PEDIATRIC MULTIVITAMIN NO.42 150
ACID 149 PEDIATRIC MULTIVITAMIN
PEDIATRIC MULTIVITAMIN NO.43/FERROUS FUMARATE 150
NO.156/FERROUS FUMARATE 149 PEDIATRIC MULTIVITAMIN
PEDIATRIC MULTIVITAMIN NO.46/FERROUS SULFATE 150
NO.159/FERROUS SULFATE 149 PEDIATRIC MULTIVITAMIN NO.48 150
PEDIATRIC MULTIVITAMIN PEDIATRIC MULTIVITAMIN NO.49 150
NO.17/FERROUS FUMARATE 149 PEDIATRIC MULTIVITAMIN
PEDIATRIC MULTIVITAMIN NO.50/DOCOSAHEXANOIC ACID 150
NO.17/FERROUS SULFATE 149 PEDIATRIC MULTIVITAMIN
NO.58/FERROUS FUMARATE 150

PEDIATRIC MULTIVITAMIN NO.68/IRON PERPHENAZINE/AMITRIPTYLINE HCL 53
CARBONYL 150 PERRY PRENATAL 155
PEDIATRIC MULTIVITAMIN NO.7/FOLIC PHARBETOL 46
ACID 150 PHENAZOPYRIDINE HCL 122
PEDIATRIC MULTIVITAMIN NO.76 150 PHENOBARBITAL 56
PEDIATRIC MULTIVITAMIN NO.78 WITH PHENOBARBITAL SODIUM 56
IRON AND SODIUM FLUORIDE 151 PHENYLEPHRINE HCL 87
PEDIATRIC MULTIVITAMIN PHENYLEPHRINE HCL/PROMETHAZINE
NO.79/FERROUS FUMARATE 151 HCL 3
PEDIATRIC MULTIVITAMIN PHENYTOIN 47
NO.80/FERROUS SULFATE 151 PHENYTOIN SODIUM EXTENDED 47
PEDIATRIC MULTIVITAMIN NO.81 151 PHOS-NAK 74
PEDIATRIC MULTIVITAMIN PHOSPHA 250 NEUTRAL 62
NO.91/FERROUS FUMARATE 151 PHOSPHOLINE IODIDE 85
PEDIATRIC MULTIVITAMIN PHOSPHORATED CARBOHYDRATE
NO.93/FERROUS SULFATE 151 (DEXTROSE AND FRUCTOSE) 90
PEDIATRIC MULTIVITAMIN PHYTONADIONE (VIT K1) 134
NO.94/FERROUS FUMARATE 151 PILOCARPINE HCL 85
PEDIATRIC MULTIVITAMINS NO.17 WITH PIMECROLIMUS 123
SODIUM FLUORIDE 147 PIN-X 19
PEDVAXHIB 113 PINDOLOL 40
PEG 3350/SOD SULF/SOD BICARB/SOD PIOGLITAZONE HCL 103
CHLORIDE/POTASSIUM CHLORIDE 94,95 PIPERACILLIN SODIUM/TAZOBACTAM
PEG 3350/SODIUM SULFATE/SOD SODIUM 8
CHLORIDE/KCL/ASCORBATE SOD/VIT C 94 PIPERONYL
PEGASPARGASE 165 BUTOXIDE/PYRETHRINS 119,169
PEN NEEDLE, DIABETIC 169 PIROXICAM 43
PENICILLIN G BENZATHINE 7 PLANT STANOL ESTER 161
PENICILLIN G BENZATHINE/PENICILLIN G PNEUMOCOCCAL 13-VALENT
PROCAINE 7 CONJUGATE VACCINE (DIPHTHERIA
PENICILLIN G POTASSIUM/DEXTROSE- CRM)/PF 115
WATER 7 PNEUMOCOCCAL 23-VALENT
PENICILLIN G PROCAINE 7 POLYSACCHARIDE VACCINE 115
PENICILLIN G SODIUM 7 PNEUMOVAX 23 115
PENICILLIN V POTASSIUM 7 POLIOMYELITIS VACCINE, KILLED 115
PENTACEL 113 POLOCAINE-MPF 167
PENTOSTATIN 165 POLY-VI-SOL 151
PENTOXIFYLLINE 28 POLY-VI-SOL WITH IRON 151
PERFECT IRON 26 POLY-VITA 149
PERINDOPRIL ERBUMINE 37 POLY-VITA WITH IRON 150
PERMETHRIN 119 POLYETHYLENE GLYCOL 3350 95

POLYETHYLENE GLYCOL PREFEST 98
400/HYPROMELLOSE/GLYCERIN 88 PREMARIN 98,99
POLYMYXIN B PREMPHASE 98
SULFATE/TRIMETHOPRIM 81 PREMPRO 99
POLYVINYL ALCOHOL 89 PRENA1 PEARL 151
POLYVINYL ALCOHOL/POVIDONE/PF 89 PRENATAL FORMULA-DHA 153
POLYVITAMIN WITH IRON 149 PRENATAL VIT NO.6/IRON FUM/FOLIC
POTASSIUM BICARBONATE/CITRIC ACID/VIT B12/CALCIUM/VIT D3 156
ACID 73 PRENATAL VIT NO.71/IRON FUM-SODIUM
POTASSIUM CHLORIDE 73 FEREDETATE/FOLIC ACID/DHA 151
POTASSIUM CHLORIDE IN 0.45 % SODIUM PRENATAL VIT WITH CALCIUM
CHLORIDE 73 75/IRON/FOLIC ACID/OMEGA-
POTASSIUM CHLORIDE IN 0.9 % SODIUM 3/DHA/EPA 151
CHLORIDE 73 PRENATAL VIT WITH CALCIUM
POTASSIUM CHLORIDE IN 5 % DEXTROSE 95/FERROUS FUMARATE/FOLIC
151
IN WATER 73 ACID/DHA
POTASSIUM CHLORIDE IN DEXTROSE 5 % PRENATAL VIT WITH CALCIUM
AND 0.9 % SODIUM CHLORIDE 73 NO.122/FERROUS FUMARATE/FOLIC
151
POTASSIUM CHLORIDE IN DEXTROSE 5 ACID
%-0.2 % SODIUM CHLORIDE 74 PRENATAL VIT WITH CALCIUM
POTASSIUM CHLORIDE IN DEXTROSE 5 NO.126/FERROUS FUMARATE/FOLIC
151
%-0.45 % SODIUM CHLORIDE 73,74 ACID
POTASSIUM CHLORIDE IN DEXTROSE 5% PRENATAL VIT WITH CALCIUM
AND 0.3 % SODIUM CHLORIDE 74 NO.128/FERROUS FUMARATE/FOLIC
152
POTASSIUM CHLORIDE IN LACTATED ACID
RINGERS AND 5 % DEXTROSE 74 PRENATAL VIT WITH CALCIUM
POTASSIUM CHLORIDE/POTASSIUM NO.130/FERROUS FUMARATE/FOLIC
152
BICARBONATE/CITRIC ACID 74 ACID
POTASSIUM CITRATE/CITRIC ACID 63 PRENATAL VIT WITH CALCIUM
POTASSIUM PHOSPHATE,MONOBASIC 62 NO.131/FERROUS FUMARATE/FOLIC
152
PRALATREXATE 165 ACID
PRAMIPEXOLE DI-HCL 58 PRENATAL VIT WITH CALCIUM
PRASTERONE (DHEA) 161 NO.61/IRON FUMARATE/FOLIC
152
PRAVASTATIN SODIUM 31 ACID/DHA
PRED MILD 83 PRENATAL VIT,CALCIUM
PRED-G 80 NO.123/IRON/FOLIC ACID/OMEGA-
152
PREDNISOLONE 106 3/DHA/EPA
PREDNISOLONE ACETATE 83 PRENATAL VITAMIN CALCIUM,IRON,FOLIC
PREDNISOLONE SOD PHOSPHATE 83,106 ACID (LESS THAN 1 MG) 152
PREDNISONE 107 PRENATAL VITAMIN NO.103/FOLIC
PREDNISONE INTENSOL 107 ACID/OMEGA-3S/DHA/FISH OIL 152

PRENATAL VITAMIN NO.108/IRON AMINO PRENATAL VITS NO.102/IRON
ACID CHELATE/FOLIC ACID 152 POLYSACCH/FOLATE
PRENATAL VITAMIN NO.1/DOCUSATE/DHA 154
NO.48/IRON,CARBONYL,GLUCONATE/FOL PRENATAL VITS NO.51/IRON
IC ACID/B6 153 FUMARATE/FOLIC ACID/OMEGA-
154
PRENATAL VITAMIN WITH CALCIUM 3/DHA/EPA
NO.76/IRON,CARBONYL/FOLIC ACID 153 PRENATAL VITS WITH CALCIUM
PRENATAL VITAMINS NO.100/IRON #72/FERROUS FUMARATE/FOLIC ACID 154
FUMARATE/FOLIC ACID/DHA/EPA 153 PRENATAL VITS WITH CALCIUM
PRENATAL VITAMINS NO.116/IRON 133/FERROUS FUMARATE/FOLIC ACID 155
FUMARATE/FOLIC ACID/DHA 153 PRENATAL VITS WITH CALCIUM
PRENATAL VITAMINS NO.121/FERROUS 137/FERROUS FUMARATE/FOLIC ACID 155
FUMARATE/FOLIC ACID 153 PRENATAL VITS WITH CALCIUM
PRENATAL VITAMINS NO.23/IRON 36/FERROUS FUMARATE/FOLIC ACID 155
POLYSACCHAR. COMPLEX/FOLIC PRENATAL VITS WITH CALCIUM
ACID 153 72/FERROUS FUMARATE/FOLIC ACID 155
PRENATAL VITAMINS NO.25/FERROUS PRENATAL VITS WITH CALCIUM
FUMARATE/FOLIC ACID/DHA 153 95/FERROUS FUMARATE/FOLIC ACID 155
FUMARATE/FOLIC ACID 153 NO.101/FERROUS FUM/FOLIC
PRENATAL VITAMINS NO.32/FERROUS ACID/DHA 155
FUMARATE/FOLIC ACID/DHA 153 PRENATAL VITS WITH CALCIUM
PRENATAL VITAMINS NO.40/FERROUS NO.116/FERROUS FUM/FOLIC
153 155
FUMARATE/FOLIC ACID/DHA ACID/DHA
FUMARATE/FOLIC ACID 154 NO.124/FERROUS FUMARAT/FOLIC
155
PRENATAL VITAMINS NO.62/FOLIC ACID
ACID/OMEGA-3S/DHA/EPA/FISH OIL 154 PRENATAL VITS WITH CALCIUM
PRENATAL VITAMINS NO.72/FERROUS FUMARATE/FOLIC
155
NO.63/IRON,CARBONYL/FOLIC ACID
ACID/DHA 154 PRENATAL VITS WITH CALCIUM
PRENATAL VITAMINS NO.74/FERROUS NO.90/FERROUS FUMARATE/FOLIC
154 155
FUMARATE/FOLIC ACID/COQ10 ACID
FUMARATE/FOLIC ACID/DHA 154 NO.93/FERROUS FUMARATE/FOLIC
155
PRENATAL VITAMINS NO.79/IRON ACID
FUM/FOLIC PRENATAL VITS WITH CALCIUM
ACID/LEVOMEFOLATE/DHA 154 NO.96/FERROUS FUMARATE/FOLIC
156
PRENATAL VITAMINS WITH ACID
CALCIUM/FERROUS FUMARATE/FOLIC
ACID 152,154

PRENATAL VITS WITH CALCIUM PROPYLTHIOURACIL 105
NO.98/FERROUS FUMARATE/FOLIC PROQUAD 115
ACID 156 PRORENAL 130
PRENATAL VITS, CALCIUM PRORENAL QD 140
NO.102/FERROUS FUM/FOLIC PROSIGHT 156
156
ACID/DHA/LUT PROSTEON 63
PRENATAL VITS, CALCIUM PROTECT CARDIO AF 141
NO.91/FERROUS FUMARATE/FOLIC PROTECT PLUS AF 141
ACID/DHA 156 PROTECT PLUS NF 143
PREVNAR 13 115 PROTECT PLUS SO 141
PREZCOBIX 13 PSEUDOEPHEDRINE HCL 21
PREZISTA 13 PSEUDOEPHEDRINE
PRIFTIN 13 HCL/CHLOPHEDIANOL
PRILOSEC OTC 92 HCL/GUAIFENESIN 173
PRIMAQUINE PHOSPHATE 18 PSEUDOEPHEDRINE HCL/CODEINE
PRIMIDONE 47 PHOSPHATE/GUAIFENESIN 79
PRO-CAL 70 PSYLLIUM HUSK (WITH SUGAR) 95
PROAIR HFA 20 PSYLLIUM HUSK/ASPARTAME 95
PROAIR RESPICLICK 20 PSYLLIUM SEED 95
PROBENECID 76 PSYLLIUM SEED (WITH SUGAR) 95
PROBENECID/COLCHICINE 76 PULMICORT FLEXHALER 76
PROCAINAMIDE HCL 29 PYRANTEL PAMOATE 19
PROCARBAZINE HCL 165 PYRAZINAMIDE 12
PROCERV HP 142 PYRIDOXINE HCL 129
PROCHLORPERAZINE 89 PYRIDOXINE HCL (VITAMIN B6) 129
PROCHLORPERAZINE EDISYLATE 89 PYRIDOXINE/CHROMIUM PICOLINATE 129
PROCHLORPERAZINE MALEATE 89
PROCRIT 28 Q
PROCTOSOL-HC 121 QUADRACEL DTAP-IPV 113
PROGESTERONE, MICRONIZED 112 QUADRAMET 167
PROMETHAZINE HCL 3 QUARTETTE 108
PROMETHAZINE HCL/CODEINE 79 QUILLICHEW ER 55
PROMETHAZINE QUIN B STRONG 131
HCL/DEXTROMETHORPHAN HBR 79 QUINAPRIL HCL 37
PROPAFENONE HCL 29 QUINAPRIL
PROPRANOLOL HCL 40 HCL/HYDROCHLOROTHIAZIDE 37
PROPRANOLOL QUINIDINE GLUCONATE 29
HCL/HYDROCHLOROTHIAZIDE 41 QUINIDINE SULFATE 29
PROPYLENE GLYCOL 89 QUINTABS-M 138
PROPYLENE GLYCOL/POLYETHYLENE QVAR 76
GLYCOL 400 89

RILPIVIRINE HCL 16
R RIMEXOLONE 83
RABANO YODADO 131 RINGER'S SOLUTION 75
RABAVERT 115 RINGER'S SOLUTION,LACTATED 74,75
RABEPRAZOLE SODIUM 92 RISA-BID 97
RABIES VACCINE, HUMAN DIPLOID RISACAL-D 71
CELL/PF 115 RISANOID PLUS 159
RABIES VACCINE, PURIFIED CHICKEN RISEDRONATE SODIUM 158
EMBRYO CELL (PCEC)/PF 115 RITONAVIR 14
RAJANI 107 RIVASTIGMINE TARTRATE 23,173
RALOXIFENE HCL 99 RIZATRIPTAN BENZOATE 58
RALTEGRAVIR POTASSIUM 15 ROPINIROLE HCL 58
RAMIPRIL 37 ROSUVASTATIN CALCIUM 31
RANITIDINE HCL 91 ROTARIX 115
RAPID B-12 ENERGY 126 ROTATEQ 115
RECOMBIVAX HB 114 ROTAVIRUS VACCINE, LIVE ORAL
RED YEAST RICE 161 ATTENUATED,89-12 STRAIN, G1P(8) 115
REDNESS RELIEF 87 ROTAVIRUS VACCINE, LIVE ORAL
REFRESH CLASSIC 89 PENTAVALENT 115
REFRESH OPTIVE 88
RELENZA 18 S
RENAL CAPS 131 SAMARIUM SM 153 LEXIDRONAM 167
REPAGLINIDE 101 SAQUINAVIR MESYLATE 14
RESCRIPTOR 15 SAVELLA 59
RESERPINE 33 SCOPOLAMINE HYDROBROMIDE 86
RESVERATROL 161 SEGLUROMET 102
RETAINE HPMC 88 SELEGILINE HCL 59
REYATAZ 13 SELENIUM SULFIDE 119
RIBOFLAVIN (VITAMIN B2) 129 SELZENTRY 13
RIBOFLAVIN/BETA-CAROTENE(A) W-C SENNOSIDES/DOCUSATE SODIUM 95
AND E/LUTEIN/ZEAXANTHIN/MIN 156 SENSIPAR 103
RID 119 SENSITIVE SKIN MOISTURE 122
RIDAURA 166 SENSORCAINE-MPF EPINEPHRINE 166
RIFABUTIN 12 SERTRALINE HCL 51
RIFAMATE 13 SHINGRIX 116
RIFAMPIN 12,13 SILICONE SCAR 167
RIFAMPIN/ISONIAZID 13 SILODOSIN 22
RIFAMPIN/ISONIAZID/PYRAZINAMIDE 13 SILVER SULFADIAZINE 119
RIFAPENTINE 13 SIMILAC PRENATAL 156
RIFATER 13 SIMVASTATIN 31
RIGHT STEP PRENATAL VITAMINS 152 SIROLIMUS 159

SODIUM BICARBONATE 93 STRESS FORMULA 132
SODIUM CHLORIDE 74,89 STRESS FORMULA ENERGY 173
SODIUM CHLORIDE 0.45 % 74 STRESS FORMULA WITH IRON 130
SODIUM CHLORIDE 5 % 74 STRIBILD 16
SODIUM CHLORIDE FOR INHALATION 74 STRIVERDI RESPIMAT 21
SODIUM CHLORIDE IRRIGATING STUART ONE 154
SOLUTION 75 STUART PRENATAL 152
SODIUM CHLORIDE/SODIUM SUCCIMER 166
BICARBONATE/POTASSIUM SUCRALFATE 91
CHLORIDE/PEG 95 SULFACETAMIDE SODIUM 82,119
SODIUM PHOSPHATE,DIBASIC/POT SULFACETAMIDE
PHOS,MONOB/SOD PHOSPHATE MONO62 SODIUM/PREDNISOLONE SODIUM
SODIUM PHOSPHATE 82
PHOSPHATE,MONOBASIC/SODIUM SULFADIAZINE 10
PHOSPHATE,DIBASIC 95 SULFAMETHOXAZOLE/TRIMETHOPRIM 10
SODIUM PHOSPHATE/POTASSIUM SULFASALAZINE 10
PHOSPHATES, MONOBASIC AND SULINDAC 43
BIBASIC 74 SUMATRIPTAN SUCCINATE 58
SODIUM POLYSTYRENE SULFONATE 60 SUNVITE 142
SOLO 140 SUPER B COMPLEX 131
SOLU-CORTEF 106 SUPER B COMPLEX-VITAMIN C 125
SOLU-MEDROL 106 SUPER B-50 COMPLEX 131
SORBITOL SOLUTION 95 SUPER CAL-MAG 66
SOTALOL HCL 41 SUPER GINSENG MULTIVITAMIN 138
SOURCECF 149,173 SUPER MULTIPLE 143
SOY FORMULA 160 SUPER MULTIPLE-LOW IRON 137
SPECTRAVITE 172 SUPER THERAVITE-M 144
SPECTRAVITE CARDIO HEALTH 173 SUPERIOR 35 137
SPINOSAD 119 SUPERVITE 128
SPIRONOLACTONE 38 SUPERVITE EC 145
SPIRONOLACTONE/HYDROCHLOROTHIAZ SUPPORT-500 125
IDE 38 SUPPOSITORY 94
ST. JOSEPH ASPIRIN 41 SUSTIVA 15
STAVUDINE 17 SYEDA 108
STEGLATRO 102 SYMBICORT 76
STEGLUJAN 102 SYMFI 15
STIOLTO RESPIMAT 20 SYMFI LO 171
STOOL SOFTENER 94 SYMTUZA 170
STREPTOZOCIN 165 SYNJARDY 102
STRESS 500 144 SYRINGE WITH
STRESS 500 PLUS ZINC 144 NEEDLE,DISPOSABLE,INSULIN 1 ML 169

SYRINGE WITH NEEDLE,INSULIN,0.3 THERA-TABS M 138
ML 169 THERACAL 63
SYRINGE WITH NEEDLE,INSULIN,0.5 THERAGRAN-M PREMIER 50 PLUS 145
ML 169 THERAMILL FORTE 140,144
THERANATAL 153
T THERANATAL COMPLETE 153
TABLOID 165 THERANATAL LACTATION SUPPORT 142
TACROLIMUS 123,159 THERANATAL ONE 153
TAMOXIFEN CITRATE 100 THERANATAL OVAVITE 154
TAMSULOSIN HCL 22 THERANATAL PLUS 154
TANZEUM 101 THEREMS-H 140
TAYTULLA 110 THEREMS-M 140
TAZICEF 5 THIAMINE HCL 130
TELMISARTAN 38 THIAMINE
TELMISARTAN/HYDROCHLOROTHIAZIDE3 HCL/RIBOFLAVIN/NIACINAMIDE/CYANOCO
8 BALAMIN/PROTEASE 130
TEMAZEPAM 57 THIAMINE M.NIT/RIBOFLAVIN/NIACIN/CA
TENIVAC 112 PANTOTHENATE/B6/B12/C/FA 130
TERAZOSIN HCL 39 THIOGUANINE 165
TERBINAFINE HCL 11,116 THIOTEPA 165
TERBUTALINE SULFATE 21 THRIVITE RX 153
TERCONAZOLE 117 THYROID,PORK 105
TESTOSTERONE ENANTHATE 107 TIAGABINE HCL 49
TETANUS AND DIPHTHERIA TOXOIDS, TICARCILLIN DISODIUM/POTASSIUM
ADSORBED, ADULT/PF 112 CLAVULANATE 173
TETANUS AND DIPHTHERIA TOXOIDS, TIMENTIN 173
ADULT 112 TIMOLOL 85
TETANUS,DIPHTHERIA TOXOID TIMOLOL MALEATE 41,85
PED/PF 112 TIOTROPIUM BROMIDE/OLODATEROL
TETRAHYDROZOLINE HCL 87 HCL 20
TETRAHYDROZOLINE HCL/DEXTRAN TIPRANAVIR 14
70/PEG 400/POVIDONE 87 TIPRANAVIR/VITAMIN E TPGS 14
TETRAHYDROZOLINE HCL/ZINC TIROSINT 104
SULFATE 87 TIVICAY 14
TEXAVITE LQ 148 TIZANIDINE HCL 22
THALIDOMIDE 157 TL G-FOL OS 71
THALOMID 157 TOBRADEX 82
THEOPHYLLINE ANHYDROUS 124,125 TOBRADEX ST 82
THERA TEARS 88 TOBRAMYCIN 82
THERA-D 133,134 TOBRAMYCIN SULFATE 10
THERA-M 140 TOBRAMYCIN/DEXAMETHASONE 82

TOBRAMYCIN/LOTEPREDNOL TRUMENBA 115
ETABONATE 82 TRUVADA 17
TOLAZAMIDE 103 TWINRIX 113
TOLBUTAMIDE 103 TYBOST 160
TOLNAFTATE 118 TYPHIM VI 116
TOLTERODINE TARTRATE 124 TYPHOID VACC,LIVE,ATTENUATED 116
TOPIRAMATE 50 TYPHOID VACCINE VI CAPSULAR
TOPOTECAN HCL 166 POLYSACCHARIDE 116
TORSEMIDE 61
TOTALDAY MULTIPLE 143 U
TRAMADOL HCL 46 UBIDECARENONE/VITAMIN E 161
TRAMADOL HCL/ACETAMINOPHEN 46 ULIPRISTAL ACETATE 111
TRANDOLAPRIL 37 ULTRA FREEDA 138,139
TRAVEL SICKNESS 89 UMECLIDINIUM BROMIDE 20
TRAZODONE HCL 52 UMECLIDINIUM BROMIDE/VILANTEROL
TRECATOR 12 TRIFENATATE 20
TRETIN-X 123 UNITHROID 104
TRETINOIN 123,166 UPCAL D 69
TRI-ESTARYLLA 111 URINE GLUCOSE TEST STRIP 60
TRI-LO-ESTARYLLA 111 UROMAG 93
TRI-VI-SOL 156 URSODIOL 95,96
TRI-VITA 148 UTIBRON NEOHALER 21
TRIAMCINOLONE ACETONIDE 84,107,122
TRIAMCINOLONE ACETONIDE/PF 84 V
TRIAMCINOLONE HEXACETONIDE 107 VALACYCLOVIR HCL 18
TRIAMTERENE/HYDROCHLOROTHIAZIDE VALPROIC ACID 50
62 VALPROIC ACID (AS SODIUM SALT)
TRIAZOLAM 57 (VALPROATE SODIUM) 50
TRIESENCE 84 VALRUBICIN 166
TRIFLURIDINE 82 VALSARTAN 38
TRILYTE WITH FLAVOR PACKETS 95 VALSARTAN/HYDROCHLOROTHIAZIDE 38
TRIMETHOBENZAMIDE HCL 89 VALSTAR 166
TRIMETHOPRIM 19 VANACOF DX 173
TRIPLE ANTIBIOTIC PLUS 118 VANCOMYCIN HCL 9
TRIPLE MAGNESIUM COMPLEX 73 VANCOMYCIN IN 0.9 % SODIUM
TRIUMEQ 16 CHLORIDE 9
TROLAMINE SALICYLATE 42 VAQTA 113
TROPICAL LIQUID NUTRITION 148 VARENICLINE TARTRATE 23
TROPICAMIDE 86 VARICELLA VIRUS VACCINE LIVE/PF 116
TROSPIUM CHLORIDE 124
TRUEPLUS MULTIVITAMIN 140

VARICELLA-ZOSTER VIRUS VIT B2/NIACINAMIDE/PYRIDOXINE HCL
GLYCOPROTEIN E,REC/AS01B (B6)/VIT B12/DEXPANTHENOL 130
ADJUVANT/PF 116 VITAFOL FE+ 154
VARIVAX VACCINE 116 VITAL-D RX 130
VAXCHORA VACCINE 113 VITALETS 150
VENLAFAXINE HCL 50 VITAMELTS ENERGY 126
VERAPAMIL HCL 35,36 VITAMIN A AND CHOLECALCIFEROL (VIT
VEXOL 83 D3) IN COD LIVER OIL 125
VIACTIV 65 VITAMIN A PALMITATE/ASCORBIC
VIDEX 16 ACID/CHOLECALCIFEROL (VIT D3) 156
VINACAL B 153 VITAMIN A PALMITATE/BETA-
VINATE DHA 154 CAROTENE/VIT D2/VIT E/SELENIUM 156
VINBLASTINE SULFATE 166 VITAMIN A/ASCORBIC
VINCRISTINE SULFATE 166 ACID/CHOLECALCIFEROL (VIT D3)/COD
VINORELBINE TARTRATE 166 LIVER 156
VIRACEPT 14 VITAMIN B COMP AND C/FOLIC
VISINE-A 87 ACID/ZINC 131
VIT A PALM/VIT C/VITAMIN D3/VIT E VITAMIN B COMP AND C/ST.JHN
ACETATE/OMEGA-3/ALA/DHA 125 WRT/SIBERIAN GINSENG/P.GINSG 131
VIT A/C/E ACETATE/ZINC OXIDE/SODIUM VITAMIN B COMPLEX 131
SELENATE/CUPRIC OXIDE 156 VITAMIN B COMPLEX 100 COMBINATION
VIT A/C/E ACETATE/ZINC OXIDE/SODIUM NO.2 131
SELENITE/CUPRIC SULFATE 173 VITAMIN B COMPLEX AND VITAMIN C
VIT B COMP C/FERROUS NO.20/FOLIC ACID 131
FUMARATE/FOLIC ACID/VIT E/AMINO ACID VITAMIN B COMPLEX AND VITAMIN
16 173 C/CALCIUM CARBONATE 131
VIT B COMPLEX 100 COMBINATION VITAMIN B COMPLEX NO.12/NIACINAMIDE
NO.2/HERBS 130 (VIT B3) 131
VIT B COMPLEX 100 COMBO VITAMIN B COMPLEX NO.3/FOLIC
NO.3/HERBS 130 ACID/ASCORBIC ACID(VITC)/BIOTIN 131
VIT B COMPLEX NO.4/VIT D3/ASCORBIC VITAMIN B COMPLEX WITH C/FOLIC
ACID/FOLIC ACID/ZINC OXID 130 ACID/CHOLECALCIFEROL (VIT D3) 131
VIT B COMPLEX/VIT C/FOLIC VITAMIN B COMPLEX WITH VITAMIN C
ACID/FERROUS FUMARATE/VIT E COMBINATION NO.3 131
ACET 130 VITAMIN B COMPLEX WITH VITAMIN C
VIT B COMPLEX/VIT C/FOLIC COMBINATION NO.4 131
ACID/FERROUS SULFATE/VIT E ACET 130 VITAMIN B COMPLEX WITH VITAMIN C
VIT B CPLX WITH C/FERROUS NO.10/FOLIC ACID 132
FUMARATE/FOLIC ACID/VIT D3/ZINC VITAMIN B COMPLEX WITH VITAMIN C
OX 130 NO.19/FOLIC ACID/VITAMIN D3 132

VITAMIN B COMPLEX WITH VITAMIN
C/FOLIC ACID/ZINC CITRATE 132 Z
VITAMIN B COMPLEX/FERROUS Z-TUSS AC 78
GLUCONATE/ZINC OXIDE/LYSINE 132 ZAFIRLUKAST 78
VITAMIN B COMPLEX/FOLIC ACID 132 ZALEPLON 57
VITAMIN B COMPLEX/LIVER EXTRACT 132 ZANAMIVIR 18
VITAMIN B COMPLEX/LYSINE 132 ZANOSAR 165
VITAMIN B COMPLEX/MINERALS 132 ZENPEP 96
VITAMIN B-6 129 ZIAGEN 16
VITAMINS FOR HAIR 138 ZIDOVUDINE 17
VITEKTA 15 ZINC CHLORIDE 74
VITRON-C 26 ZINC GLUCONATE 74
VIVOTIF 116 ZOLMITRIPTAN 58
VYVANSE 54 ZOLPIDEM TARTRATE 58
ZONISAMIDE 50
W ZOO FRIENDS 148,173
WAL-DRYL 162 ZORTRESS 159
WAL-ITIN D 12 HOUR 4 ZOSTAVAX 116
WAL-MUCIL 95 ZOSTER VACCINE LIVE/PF 116
WAL-PHED PE SINUS-ALLERGY 3 ZOVIA 1-50E 108
WAL-PROFEN 43 ZYLET 82
WAL-ZYR 4 ZYLOPRIM 157
WARFARIN SODIUM 26,27
WATER FOR INJECTION,STERILE 170
WATER FOR IRRIGATION,STERILE 75
WEE CARE 26
WOMEN'S 50+ DAILY FORMULA 143
WOMEN'S COMPLEX 135
WOMEN'S MULTIVITAMIN W-BIOTIN 140
WOMEN'S PRENATAL + DHA 152
X
XOFLUZA 162
Y
YEAST, DRIED (SACCHAROMYCES
CEREVISIAE) 132
YELLOW FEVER VACCINE LIVE/PF 116
YF-VAX 116
YOGURT+CALCIUM GUMMIES 70
YOHIMBE BARK 161

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CalOptima Approved Drug List

Pharmacy-dispensed injectable medications should be processed through the PBM.

Step-Therapy: An enhanced utilization management process which requires a trial of a first-

Intravenous solutions: Parenteral nutrition solutions (TPN), separately administered

MFL There is a limit on the number of times this drug can be

PAGE 2 LAST UPDATED 12/2018

PROMETHAZINE phenylephrine QL 480 / 30 DAY(S)

promethazine hcl (12.5 mg

SECOND GENERATION ANTIHISTAMINES

ALL DAY cetirizine hcl 1 mg/ml

PAGE 3 LAST UPDATED 12/2018

24HR ALLERGY levocetirizine

1ST GENERATION CEPHALOSPORIN ANTIBIOTICS

cefadroxil (1 g tablet, 250

PAGE 4 LAST UPDATED 12/2018

2ND GENERATION CEPHALOSPORIN ANTIBIOTICS

cefuroxime axetil (125 susp

3RD GENERATION CEPHALOSPORIN ANTIBIOTICS

cefdinir (125 mg/5ml susp

FORTAZ ceftazidime (2 g vial, 6 g

4TH GENERATION CEPHALOSPORIN ANTIBIOTICS

cefepime hcl (1 g vial, 2 g Generic

PAGE 5 LAST UPDATED 12/2018

MISC. BETA-LACTAM ANTIBIOTICS

MERREM meropenem (1 g vial, 500 Generic

OTHER MACROLIDE ANTIBIOTICS

azithromycin (500 mg vial

ZITHROMAX azithromycin 100 mg/5ml Generic QL 30 / 30 DAY(S)

ZITHROMAX Generic QL 6 / 1 FILL

BIAXIN clarithromycin (250 mg Generic QL 28 / 28 DAY(S)

PAGE 6 LAST UPDATED 12/2018

NATURAL PENICILLIN ANTIBIOTICS

BICILLIN L-A penicillin g benzathine Brand QL 4 / 30 DAY(S)

PAGE 7 LAST UPDATED 12/2018

DICLOXACILLIN dicloxacillin sodium (250 mg

PAGE 8 LAST UPDATED 12/2018

vancomycin hcl (1 g vial, 5

amikacin sulfate (500

PAGE 9 LAST UPDATED 12/2018

SULFONAMIDE ANTIBIOTICS (SYSTEMIC)

SULFADIAZINE sulfadiazine Generic QL 240 / 30 DAY(S)

AZULFIDINE sulfasalazine 500 mg tablet Generic QL 240 / 60 DAY(S)

PAGE 10 LAST UPDATED 12/2018

terbinafine hcl 250 mg

fluconazole (100 mg tablet,

DIFLUCAN Generic QL 4 / 30 DAY(S)

NYSTATIN nystatin 100000/ml oral

PAGE 11 LAST UPDATED 12/2018

griseofulvin, microsize 125 QL 960 / 30 DAY(S)

PASER aminosalicylic acid Brand QL 60 / 30 DAY(S)

MYAMBUTOL ethambutol hcl 400 mg Generic QL 90 / 30 DAY(S)

MYCOBUTIN rifabutin Generic QL 60 / 30 DAY(S)

PAGE 12 LAST UPDATED 12/2018

dapsone (25 mg tablet, 100

HIV ENTRY AND FUSION INHIBITORS

FUZEON enfuvirtide Brand

HIV PROTEASE INHIBITOR ANTIRETROVIRALS

atazanavir sulfate (150 mg

EVOTAZ atazanavir sulfate/cobicistat Brand QL 30 / 30 DAY(S)

darunavir ethanolate 100 QL 200 / 30 DAY(S)

PAGE 13 LAST UPDATED 12/2018

CRIXIVAN indinavir sulfate 400 mg QL 180 / 30 day(s)

lopinavir/ritonavir 400-100/5 QL 400 / 30 day(s)