FORMULARY (LIST OF COVERED DRUGS) Buckeye Health Plan - MyCare Ohio (MMP)

Transcription

1 2019 FORMULARY (LIST OF COVERED DRUGS) Buckeye Health Plan - MyCare Ohio (MMP) NOTE TO EXISTING MEMBERS: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. PLEASE READ: THIS DOCUMENT CONTAINS IORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN , Version 17 Updated 12/20/2017. For more recent information or other questions, please contact Buckeye Health Plan Member Services at , TTY:711. Member Service hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. Or visit: H0022_LOD17_Approved_

2 H0022_LOD17_Approved_ Buckeye Health Plan MyCare Ohio 2019 List of Covered s (Formulary) This is a list of drugs that members can get in Buckeye Health Plan MyCare Ohio (Buckeye). Buckeye Health Plan MyCare Ohio is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. The List of Covered s and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year. You can always check Buckeye s up-to-date List of Covered s online at Limitations and restrictions may apply. For more information, call Buckeye Member Services or read the Buckeye Member Handbook. You can get this information for free in other languages. Call Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. Puede obtener esta información en otros idiomas gratis. Llame al El horario de atención es de 8 a. m. a 8 p. m., de lunes a viernes. Luego del horario de atención, los fines de semana y los días feriado, es posible que se le pida que deje un mensaje. Le devolveremos la llamada el próximo día hábil. Los usuarios de TTY deben llamar al 711. La llamada es gratuita. You can get this information for free in other formats, such as large print, braille, or audio. Call from 8 a.m. to 8 p.m., Monday through Friday. TTY users call 711. The call is free. If you would like this information in a format other than English or in an alternate format, please call Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. You can also OH_MMP_ Requests@centene.com.? If you have questions, please call Buckeye at Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit

3 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered s. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered s? (We call the List of Covered s the List for short.) The drugs on the List of Covered s that starts on page 10 are the drugs covered by Buckeye. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. Buckeye will cover all medically necessary drugs on the List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at a Buckeye network pharmacy. Buckeye may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at (TTY: 711). 2. Does the List ever change? Yes. Buckeye may add or remove drugs on the List during the year. Generally, the List will only change if: a cheaper drug comes along that works as well as a drug on the List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from Buckeye before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page 3.) We will tell you when a drug you are taking is removed from the List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the List changes.? If you have questions, please call Buckeye at Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit

4 You can always check Buckeye s up to date List online at You can also call Member Services to check the current List at (TTY: 711). 3. What happens when a cheaper drug comes along that works as well as a drug on the List now? If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the List is made. We will mail you a notice if you are taking a drug, and we change our rules for covering it. You will receive the notice by mail at least 60 days before we remove the drug from our List of Covered s. Or, we have to tell you when you request a refill of the drug. If we tell you when you refill your drug, you will receive a 60 day supply of the drug. For more information on these drug rules, see below. If you have questions about the notice you receive from Buckeye, call Member Services at TTY Users should call 711. Hours are from 8 a.m. to 8 p.m., Monday through Friday. 4. What happens when we find out a drug is not safe? If the Food and Administration (FDA) says a drug you are taking is not safe, we will take it off the List right away. We will also send you a letter telling you that. If you have any questions after being notified of the change, you should contact the doctor who prescribed the drug for you. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Buckeye before you fill your prescription. If you don t get approval, Buckeye may not cover the drug. Quantity limits: Sometimes Buckeye limits the amount of a drug you can get. Step therapy: Sometimes Buckeye requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second.? If you have questions, please call Buckeye at Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit

5 You can find out if your drug has any additional requirements or limits by looking in the tables on pages 8. You can also get more information by visiting our web site at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Buckeye member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the List you can take instead or whether to ask for an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered s on page 10 has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60 day supply of the drug before the change to the List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it by reviewing the index of drugs that begins on page 147.? If you have questions, please call Buckeye at Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit

6 To search by medical condition, find the section labeled List of drugs by medical condition on page 10. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the List? If you don t see your drug on the List, call Member Services at (TTY: 711) and ask about it. If you learn that Buckeye will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. What if you are a new Buckeye member and can t find your drug on the List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Buckeye. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the List you can take instead or whether to ask for an exception. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by Buckeye, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 91 to 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to ones on the List or ask for an exception. Throughout the plan year, you may have a change in your treatment setting (the place where you get and take your medicine) because of the level of care you require. Such transitions may include, but are not limited to: Members who are discharged from a hospital or skilled-nursing facility to a home setting Members who are admitted to a hospital or skilled-nursing facility from a home setting? If you have questions, please call Buckeye at Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit

7 Members who transfer from one skilled-nursing facility to another and are served by a different pharmacy Members who end their skilled-nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who now need to use their Part D plan benefit Members who give up Hospice Status and go back to standard Medicare Part A and B coverage Members discharged from psychiatric hospitals with highly individualized drug regimens For these changes in treatment settings, Buckeye will cover as much as a 31-day temporary supply of a Part D-covered drug when you fill your prescription at a network pharmacy. If you change treatment settings multiple times within the same month, you may have to request an exception or prior authorization and get approval for continued coverage of your drug. We will review these requests for continuation of therapy on a case-by-case basis when you are on a stabilized drug regimen that, if changed, is known to have risks. To ask for a temporary supply of a drug, call Member Services. 11. Can you ask for an exception to cover your drug? Yes. You can ask Buckeye to make an exception to cover a drug that is not on the List. You can also ask us to change the rules on your drug. For example, Buckeye may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception.? If you have questions, please call Buckeye at Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit

8 4349 Easton Way, Suite 300 Columbus, OH TTY: 711 mmp.buckeyehealthplan.com 2019 Buckeye Health Plan

9 Name ALTERNATIVE MEDICINES Alternative Medicine - A's ALPHA LIPOIC ACID CAPS alpha-lipoic acid (thioctic acid) caps 100 mg, 200 mg, 600 mg ALPHA-LIPOIC ACID CAPS LIPOIC ACID CAPS Alternative Medicine - C's CHEW Q CHEW CO Q-10 CAPS 300 MG (Use Coenzyme Q10 (Ubidecarenone)) CO Q-10 CHEW 100 MG coenzyme q10 (ubidecarenone) caps 10 mg, 30 mg, 50 mg, 60 mg, 75 mg, 100 mg, 150 mg, 200 mg, 300 mg, 400 mg, 100mg-5unit NEOQ10 CAPS Q-GEL CAPS Alternative Medicine - U CYTO-Q LIQD CYTO-Q MAX LIQD CYTO-Q T/F LIQD Name QH LIQD Alternative Medicine Combinations CO Q-10 PLUS CAPS LIQ-10 SYRP ANALGESICS - ANTI-ILAMMATORY - s to Treat Pain, Swelling, Muscle and Joint Conditions Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL CAPS (Use Ibuprofen) ADVIL MIGRAINE CAPS (Use Ibuprofen) ADVIL TABS (Use Ibuprofen) ALEVE CAPS (Use Naproxen Sodium) ibuprofen caps ibuprofen chew ibuprofen susp ibuprofen tabs IANTS ADVIL SUSP (Use Ibuprofen) MOTRIN IANTS DROPS SUSP (Use Ibuprofen) naproxen sodium caps --non-formulary, -includes both Rx and OTC NDCs 1

10 Name ANALGESICS - NonNarcotic - s to Treat Pain, Muscle and Joint Conditions Analgesic Combinations HISTAFLEX TABS Analgesics Other acetaminophen caps or 500 mg acetaminophen chew or 80 mg, 160 mg acetaminophen liqd or 160 mg/5ml, 500 mg/15ml, 1000 mg/30ml acetaminophen soln or 160 mg/5ml, 650 mg/20.3ml, 325 mg/10.15ml acetaminophen supp re 120 mg, 325 mg, 650 mg acetaminophen susp or 160 mg/5ml, 80 mg/0.8ml, 80 mg/2.5ml acetaminophen tabs or 325 mg, 500 mg acetaminophen tbcr or 650 mg acetaminophen tbdp or 80 mg, 160 mg FEVERALL IANTS SUPP NORTEMP IANTS SUSP TYLENOL 8 HOUR ARTHRITISPAIN TBCR (Use Acetaminophen) TYLENOL 8 HOUR TBCR (Use Acetaminophen) Name TYLENOL CHILDRENS CHEWABLES/PAIN + FEVER CHEW (Use Acetaminophen) TYLENOL CHILDRENS SUSP (Use Acetaminophen) TYLENOL EXTRA STRENGTH TABS (Use Acetaminophen) TYLENOL IANTS PAIN+FEVER SUSP (Use Acetaminophen) TYLENOL IANTS SUSP (Use Acetaminophen) TYLENOL SORE THROAT DAYTIME LIQD (Use Acetaminophen) TYLENOL TABS (Use Acetaminophen) Salicylates aspirin chew or 81 mg ASPIRIN SUPP RE 300 MG, 600 MG aspirin supp re 300 mg, 600 mg aspirin tabs or 325 mg aspirin tbec or 81 mg, 324 mg, 325 mg ECOTRIN REGULAR STRENGTH TBEC (Use Aspirin) ANORECTAL AGENTS - Rectal s to Treat Pain, Swelling and Itching Rectal Combinations phenylephrine in hard fat supp --non-formulary, -includes both Rx and OTC NDCs 2

11 Name phenylephrine-cocoa butter supp 88.44%-0.25% phenylephrine-mineral oilpetrolatum oint 14%- 74.9%-0.25% phenylephrine-shark liver oil-mineral oil-petrolatum oint PREPARATION H OINT 14%-74.9%-0.25% (Use Phenylephrine-Mineral Oil- Petrolatum) ANTACIDS Antacid Combinations alum & mag hydroxsimethicone chew alum & mag hydroxsimethicone liqd alum & mag hydroxsimethicone susp aluminum hydroxide-mag carb chew aluminum hydroxide-mag carb susp aluminum hydroxide-mag trisil chew calcium carbonate-mag hydrox chew 110mg- 550mg calcium carbonatesimethicone chew 60mg- 1000mg GAVISCON CHEW 14.2MG-80MG GAVISCON EXTRA STRENGTH CHEW (Use Aluminum Hydroxide-Mag Carb) Name GAVISCON EXTRA STRENGTH RELIEF FORMULA SUSP (Use Aluminum Hydroxide-Mag Carb) GAVISCON EXTRA STRENGTH SUSP (Use Aluminum Hydroxide-Mag Carb) GAVISCON SUSP 95MG/15ML-358MG/15ML, 95MG/15ML-95MG/15ML- 358MG/15ML- 358MG/15ML (Use Aluminum Hydroxide-Mag Carb) GELUSIL CHEW (Use Alum & Mag Hydrox- Simethicone) HYVEE ADVANCED ANTACID MAXIMUM STRENGTH SUSP (Use Alum & Mag Hydrox- Simethicone) MAALOX ADVANCED MAXIMUM STRENGTH CHEW (Use Calcium Carbonate-Simethicone) MAALOX MAX CHEW (Use Calcium Carbonate- Simethicone) MAG-AL LIQD MI-ACID CHEW Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUSP OR Antacids - Bicarbonate sodium bicarbonate (antacid) tabs Antacids - Calcium Salts --non-formulary, -includes both Rx and OTC NDCs 3

12 Name ANTACID CHEW ANTACID SOFT CHEWS CHEW calcium carbonate (antacid) chew 500 mg, 750 mg, 1000 mg calcium carbonate (antacid) susp 1250 mg/5ml calcium carbonate (antacid) tabs 648 mg CALCIUM CARBONATE TABS 648 MG TUMS CHEW (Use Calcium Carbonate (Antacid)) TUMS CHEWY BITES CHEW (Use Calcium Carbonate (Antacid)) TUMS CHEWY DELIGHTS CHEW TUMS E-X 750 CHEW (Use Calcium Carbonate (Antacid)) TUMS EXTRA STRENGTH 750 CHEW (Use Calcium Carbonate (Antacid)) TUMS KIDS CHEW (Use Calcium Carbonate (Antacid)) TUMS LASTING EFFECTS CHEW (Use Calcium Carbonate (Antacid)) TUMS SMOOTHIES CHEW (Use Calcium Carbonate (Antacid)) TUMS ULTRA 1000 CHEW (Use Calcium Carbonate (Antacid)) Antacids - Magnesium Salts Name magnesium oxide tabs 400 mg, 420 mg MAOX TABS ANTHELMINTICS - s to Treat Worm Infections Anthelmintics pyrantel pamoate susp REESES PINWORM MEDICINE TABS ANTIDIABETICS - s to Regulate Blood Sugar Diabetic Other BD GLUCOSE CHEW CVS GLUCOSE CHEW DEX4 CHEW DEX4 FAST ACTING GLUCOSE CHEW 4GM- 6MG DEX4 NATURALS CHEW DEX4 POUCH PACK CHEW DEX4 QUICK DISSOLVE GLUCOSE CHEW dextrose (diabetic use) gel 40 %, 15 gm/38gm GLUCOSE CHEW 4 GM --non-formulary, -includes both Rx and OTC NDCs 4

13 Name GLUCOSE CHEW 4GM- 6MG, 4GM-4GM-6MG GLUCOSE INSTANT ENERGY CHEW GNP GLUCOSE CHEW GNP QUICK DISSOLVE GLUCOSE CHEW GOODSENSE GLUCOSE CHEW HM GLUCOSE CHEW HY-VEE GLUCOSE CHEW INSTA-GLUCOSE GEL KROGER GLUCOSE CHEW LEADER GLUCOSE CHEW LEADER QUICK DISSOLVE GLUCOSE CHEW LONGS GLUCOSE CHEW MEIJER GLUCOSE CHEW PREFERRED PLUS GLUCOSE CHEW PX GLUCOSE CHEW RA GLUCOSE CHEW Name RELION GLUCOSE CHEW SM GLUCOSE CHEW SMART SENSE GLUCOSE CHEW SMART SENSE GLUCOSE TABLETS CHEW TGT GLUCOSE CHEW UP & UP GLUCOSE CHEW VALUE PLUS GLUCOSE CHEW WALGREENS GLUCOSE CHEW ANTIDIARRHEAL/PROBIOTIC AGENTS - s to Treat Diarrhea Antidiarrheal/Probiotic Agents - Misc. ACIDOPHILUS WAFR ACIDOPHILUS/BIFIDUS WAFR bismuth subsalicylate chew bismuth subsalicylate susp bismuth subsalicylate tabs FLORAJEN ACIDOPHILUS CAPS --non-formulary, -includes both Rx and OTC NDCs 5

14 Name LACTINEX PACK (Use Lactobacillus) lactobacillus caps lactobacillus chew lactobacillus pack lactobacillus tabs MORE-DOPHILUS ACIDOPHILUS POWD PEPTO BISMOL TABS (Use Bismuth Subsalicylate) PEPTO-BISMOL CHEW 262 MG (Use Bismuth Subsalicylate) PEPTO-BISMOL INSTACOOL CHEW (Use Bismuth Subsalicylate) PEPTO-BISMOL MAX STRENGTH SUSP (Use Bismuth Subsalicylate) PEPTO-BISMOL SUSP 262 MG/15ML, 524 MG/30ML (Use Bismuth Subsalicylate) PEPTO-BISMOL TO-GO CHEW (Use Bismuth Subsalicylate) PROBIOTIC CAPS PROBIOTIC GOLD EXTRA STRENGTH CAPS REPHRESH PRO-B CAPS Antidiarrheal/Probiotic Combinations Name ACIDOPHILUS/CITRUS PECTIN TABS KALA TABS lactobacillus acidophiluspectin caps Antiperistaltic Agents IMODIUM A-D CAPS 2 MG (Use Loperamide HCl) IMODIUM A-D LIQD 1 MG/7.5ML (Use Loperamide HCl) IMODIUM A-D TABS 2 MG (Use Loperamide HCl) loperamide hcl caps 2 mg loperamide hcl caps 2 mg loperamide hcl caps 2 mg loperamide hcl liqd 1 mg/5ml, 1 mg/7.5ml loperamide hcl susp 1 mg/7.5ml loperamide hcl tabs 2 mg Over-thecounter;RX/OT C ; NT ANTIEMETICS - s to Treat Nausea and Vomiting Antiemetics - Anticholinergic dimenhydrinate tabs DRAMAMINE TABS (Use Dimenhydrinate) meclizine hcl chew 25 mg --non-formulary, -includes both Rx and OTC NDCs 6

15 Name meclizine hcl tabs 12.5 mg meclizine hcl tabs 25 mg, 12.5 mg meclizine hcl tabs 25 mg, 12.5 mg Antiemetics - Miscellaneous EMETROL SOLN (Use Fructose-Dextrose- Phosphoric Acid) fructose-dextrosephosphoric acid liqd fructose-dextrosephosphoric acid soln ; NT Over-thecounter;RX/OT C ANTIHISTAMINES - s to Treat Allergies Antihistamines - Alkylamines ALA-HIST IR TABS CHLOR-TRIMETON ALLERGY TBCR (Use Chlorpheniramine Maleate) CHLOR-TRIMETON SYRP 2 MG/5ML (Use Chlorpheniramine Maleate) CHLOR-TRIMETON TABS 4 MG (Use Chlorpheniramine Maleate) chlorpheniramine maleate syrp chlorpheniramine maleate tabs chlorpheniramine maleate tbcr ED CHLORPED LIQD Name HISTEX PD LIQD HISTEX SYRP 2.5 MG/5ML triprolidine hcl liqd VANACLEAR PD LIQD (Use Triprolidine HCl) VANAHIST PD LIQD (Use Triprolidine HCl) Antihistamines - Ethanolamines BENADRYL ALLERGY CHILDRENS LIQD 12.5 MG/5ML (Use Diphenhydramine HCl) BENADRYL ALLERGY TABS (Use Diphenhydramine HCl) clemastine fumarate tabs diphenhydramine hcl caps 50 mg diphenhydramine hcl liqd 25 mg/10ml, 50 mg/20ml, 6.25 mg/ml, 12.5 mg/5ml diphenhydramine hcl tabs 25 mg SILPHEN COUGH SYRP TAVIST ALLERGY TABS (Use Clemastine Fumarate) VANAMINE PD LIQD (Use Diphenhydramine HCl) Antihistamines - Non-Sedating --non-formulary, -includes both Rx and OTC NDCs 7

16 Name ALLEGRA ALLERGY CHILDRENS SUSP 30 MG/5ML (Use Fexofenadine HCl) ALLEGRA ALLERGY TABS (Use Fexofenadine HCl) cetirizine hcl chew 5 mg, 10 mg cetirizine hcl soln 1 mg/ml, 5 mg/5ml cetirizine hcl soln 1 mg/ml, 5 mg/5ml cetirizine hcl syrp 1 mg/ml, 5 mg/5ml cetirizine hcl tabs 5 mg, 10 mg CLARITIN ALLERGY CHILDRENS SYRP (Use Loratadine) CLARITIN CAPS 10 MG (Use Loratadine) CLARITIN CHEW 5 MG CLARITIN CHEW 5 MG (Use Loratadine) CLARITIN CHILDRENS CHEW (Use Loratadine) CLARITIN REDITABS TBDP 10 MG (Use Loratadine) CLARITIN REDITABS TBDP 5 MG CLARITIN SYRP 5 MG/5ML (Use Loratadine) CLARITIN TABS 10 MG (Use Loratadine) fexofenadine hcl susp Over-thecounter;RX/OT C Name fexofenadine hcl tabs loratadine caps loratadine chew loratadine soln loratadine syrp loratadine tabs loratadine tbdp ZYRTEC ALLERGY TABS (Use Cetirizine HCl) ZYRTEC CHILDRENS ALLERGY SOLN 1 MG/ML, 5 MG/5ML (Use Cetirizine HCl) ZYRTEC CHILDRENS ALLERGY SOLN 5 MG/5ML (Use Cetirizine HCl) ANTISEPTICS & DISIECTANTS Iodine Antiseptics BETADINE SKIN CLEANSER SOLN (Use Povidone-Iodine) BETADINE SOLN 10 % (Use Povidone-Iodine) BETADINE SOLN 5 % BETADINE SURGICAL SCRUB SOLN (Use Povidone-Iodine) ; NT --non-formulary, -includes both Rx and OTC NDCs 8

17 Name BETADINE SWAB AID SWAB (Use Povidone- Iodine) BETADINE SWABSTICKS SWAB (Use Povidone- Iodine) NUPREP 5% POVIDONE- IODINE SOLN povidone-iodine oint povidone-iodine soln povidone-iodine swab CARDIOVASCULAR AGENTS - MISC. - s to Treat Heart and Circulation Conditions Peripheral Vasodilators inositol niacinate caps CHEMICALS Bulk Chemicals - B's BIOTIN POWD XX BIOTIN-D POWD Bulk Chemicals - C's CITRULLINE(L) POWD L-CITRULLINE POWD XX Bulk Chemicals - S's SALICYLIC ACID POWD XX Liquids Name CASTOR OIL OIL XX CVS CASTOR OIL OIL GLYCERIN LIQD GLYCERINE LIQD GLYCEROL FORMAL LIQD HM CASTOR OIL OIL QC CASTOR OIL OIL SESAME OIL OIL CONTRACEPTIVES - s to Prevent Pregnancy Emergency Contraceptives levonorgestrel (emergency oc) tabs PLAN B ONE-STEP TABS (Use Levonorgestrel (Emergency OC)) COUGH/COLD/ALLERGY - s to Treat Cough, Cold and Allergy Symptoms Antitussives benzonatate caps DELSYM COUGH CHILDRENS SUER (Use Dextromethorphan Polistirex) DELSYM SUER (Use Dextromethorphan Polistirex) --non-formulary, -includes both Rx and OTC NDCs 9

18 Name dextromethorphan hbr caps dextromethorphan hbr liqd DEXTROMETHORPHAN HBR MONOHYDRATE CRYS dextromethorphan hbr syrp dextromethorphan polistirex suer hydrocodone w/ homatropine syrp hydrocodone w/ homatropine tabs ROBITUSSIN CHILDRENS COUGH LONG-ACTING SYRP ROBITUSSIN LINGERING COLDLONG-ACTING COUGHGELS CAPS (Use Dextromethorphan HBr) TESSALON PERLES CAPS (Use Benzonatate) Cough/Cold/Allergy Combinations acetaminophen w/ dm liqd acetaminophen w/ dm susp ACTICON SOLN ACTICON TABS ACTINEL LIQD Name ACTINEL PEDIATRIC LIQD ADVIL COLD & SINUS TABS (Use Pseudoephedrine- Ibuprofen) ALA-HIST PE TABS ALAHIST DM LIQD 2MG/5ML-15MG/5ML- 7.5MG/5ML ALAHIST DM LIQD 4MG/5ML-15MG/5ML- 7.5MG/5ML (Use Phenylephrine- Brompheniramine-DM) ALEVE-D SINUS & COLD TB12 (Use Pseudoephedrine- Naproxen Sodium) ALEVE-D SINUS & HEADACHE TB12 (Use Pseudoephedrine- Naproxen Sodium) ALKA-SELTZER PLUS COLD TBEF (Use Chlorpheniramine- Phenylephrine-ASA) ALLEGRA-D 12 HOUR ALLERGY & CONGESTION TB12 (Use Fexofenadine- Pseudoephedrine) AMBI 60PSE/400GFN TABS AP-HIST DM LIQD AQUANAZ TABS ATUSS DA LIQD --non-formulary, -includes both Rx and OTC NDCs 10

19 Name BIONEL LIQD BIONEL PEDIATRIC LIQD BROHIST D TABS brompheniramine & phenyleph elix 1mg/5ml- 2.5mg/5ml, 1mg/5ml- 1mg/5ml-2.5mg/5ml- 2.5mg/5ml brompheniramine & pseudoeph elix brompheniramine & pseudoeph liqd BROTAPP DM LIQD CAPCOF SYRP CAPMIST DM TABS CAPRON DM LIQD cetirizine-pseudoephedrine tb12 CHERACOL PLUS LIQD (Use Dextromethorphan- Guaifenesin) CHERACOL-D COUGH LIQD (Use Dextromethorphan- Guaifenesin) CHLO HIST SOLN CHLO TUSS LIQD Name chlorpheniramine & phenylephrine liqd chlorpheniramine & phenylephrine tabs chlorpheniramine & pseudoeph tabs chlorpheniramine-dm tabs chlorpheniraminephenylephrineacetaminophen misc chlorpheniraminephenylephrineacetaminophen tabs chlorpheniraminephenylephrine-asa tbef CLARITIN-D 12 HOUR TB12 (Use Loratadine & Pseudoephedrine) CLARITIN-D 24 HOUR TB24 (Use Loratadine & Pseudoephedrine) CLEAR COUGH PM MULTI-SYMPTOM LIQD (Use Dextromethorphan- Doxylamine- Acetaminophen) COMTREX COLD & COUGH DAY/NIGHT MAXIMUM STRENGTH MISC (Use Phenylephrine- Chlorpheniramine-DM w/ APAP) COMTREX COLD & COUGH MAXIMUM STRENGTH TABS (Use Dextromethorphan- Phenylephrine- Acetaminophen) --non-formulary, -includes both Rx and OTC NDCs 11

20 Name COMTREX COLD & COUGH NIGHTTIME MAXIMUM STRENGTH TABS (Use Phenylephrine- Chlorpheniramine-DM w/ APAP) CONEX COLD/ALLERGY SOLN CONEX COLD/ALLERGY TABS CONGESTAC TABS (Use Pseudoephedrine- Guaifenesin) CORICIDIN HBP COUGH & COLD TABS (Use Chlorpheniramine-DM) CORICIDIN HBP FLU TABS (Use Dextromethorphan- Acetaminophen- Chlorpheniramine) DALLERGY LIQD DALLERGY SYRP DALLERGY TABS DAY TIME MULTI- SYMPTOM COLD/FLU RELIEF CAPS (Use Dextromethorphan- Phenylephrine- Acetaminophen) DECONEX DMX TABS 15MG-380MG-10MG (Use Phenylephrine w/ DM-GG) DECONEX DMX TABS 17.5MG-385MG-10MG DECONEX IR TABS 380MG-10MG (Use Phenylephrine- Guaifenesin) Name DECONEX IR TABS 385MG-10MG dextromethorphanacetaminophenchlorpheniramine tabs dextromethorphandoxylamine-acetaminophen caps dextromethorphandoxylamine-acetaminophen liqd dextromethorphanguaifenesin liqd dextromethorphanguaifenesin soln dextromethorphanguaifenesin syrp dextromethorphanguaifenesin tabs dextromethorphanguaifenesin tb12 dextromethorphanphenylephrineacetaminophen caps dextromethorphanphenylephrineacetaminophen liqd dextromethorphanphenylephrineacetaminophen pack dextromethorphanphenylephrineacetaminophen tabs DIMETAPP COLD & ALLERGY ELIX 1MG/5ML- 2.5MG/5ML (Use Brompheniramine & Phenyleph) DIMETAPP DM COLD & COUGH LIQD (Use Phenylephrine- Brompheniramine-DM) --non-formulary, -includes both Rx and OTC NDCs 12

21 Name DIMETAPP LONG ACTING COUGH PLUS COLD SYRP DIMETAPP MULTI- SYMPTOM COLD & FLU LIQD (Use Phenylephrine- Chlorpheniramine-DM w/ APAP) diphenhydramineacetaminophen tabs diphenhydraminephenylephrine liqd 6.25mg/5ml-2.5mg/5ml diphenhydraminephenylephrineacetaminophen liqd diphenhydraminephenylephrineacetaminophen pack diphenhydraminephenylephrineacetaminophen tabs DONATUSSIN SYRP DOUBLE-TUSSIN DM LIQD (Use Dextromethorphan- Guaifenesin) doxylamine-dm liqd 12.5mg/30ml-30mg/30ml, 6.25mg/15ml-15mg/15ml, 6.25mg/15ml-6.25mg/15ml- 15mg/15ml-15mg/15ml- 10% doxylamine-phenylephrineacetaminophen caps 6.25mg-325mg-5mg, 6.25mg-6.25mg-325mg- 325mg-5mg-5mg DURAFLU TABS DURAVENT DM TABS Name ED A-HIST DM TABS ED A-HIST LIQD (Use Chlorpheniramine & Phenylephrine) ED BRON GP LIQD ED CHLORPED D LIQD fexofenadinepseudoephedrine tb12 60mg-120mg FLOWTUSS SOLN FLU & SORE THROAT PACK GLENMAX PEB LIQD GNP COLD RELIEF PLUS TBEF GNP DAY TIME MUCUS RELIEFDM LIQD (Use Dextromethorphan- Guaifenesin) GNP FLU & SORE THROAT PACK guaifenesin-codeine liqd guaifenesin-codeine soln guaifenesin-codeine syrp HISTEX-AC SYRP --non-formulary, -includes both Rx and OTC NDCs 13

22 Name HISTEX-DM SYRP HISTEX-PE SYRP HYCOFENIX SOLN HYDROCODONE BITARTRATE/CHLORPHE NIRAMINE MALEATE/PSE SOLN HYDROCODONE BITARTRATE/GUAIFENES IN SOLN hydrocodone polistirexchlorpheniramine polistirex suer LODRANE D CAPS LOHIST-D LIQD LOHIST-DM SYRP loratadine & pseudoephedrine tb12 loratadine & pseudoephedrine tb24 LORTUSS DM LIQD (Use Pseudoephedrine- Doxylamine- Dextromethorphan) LORTUSS EX LIQD LORTUSS LQ LIQD M-CLEAR WC SOLN Name M-END DMX LIQD M-END PE LIQD MAR-COF BP LIQD MAR-COF CG EXPECTORANT LIQD (Use Guaifenesin-Codeine) MUCINEX CHILDRENS COLD COUGH & SORE THROAT LIQD (Use Phenylephrine-DM-GG w/ APAP) MUCINEX CHILDRENS MULTI-SYMPTOM COLD & FEVER LIQD (Use Phenylephrine-DM-GG w/ APAP) MUCINEX CHILDRENS MULTI-SYMPTOM COLD LIQD (Use Phenylephrine w/ DM-GG) MUCINEX CONGESTION & COUGH CHILDRENS LIQD (Use Phenylephrine w/ DM-GG) MUCINEX COUGH FOR KIDS PACK MUCINEX D MAXIMUM STRENGTH TB12 (Use Pseudoephedrine- Guaifenesin) MUCINEX D TB12 (Use Pseudoephedrine- Guaifenesin) MUCINEX DM MAXIMUM STRENGTH TB12 (Use Dextromethorphan- Guaifenesin) MUCINEX DM TB12 (Use Dextromethorphan- Guaifenesin) --non-formulary, -includes both Rx and OTC NDCs 14

23 Name MUCINEX FAST-MAX COLD & SINUS LIQD (Use Phenylephrine- Acetaminophen- Guaifenesin) MUCINEX FAST-MAX COLD FLU& SORE THROAT CLEAR & COOL LIQD (Use Phenylephrine- DM-GG w/ APAP) MUCINEX FAST-MAX COLD FLU& SORE THROAT LIQD (Use Phenylephrine-DM-GG w/ APAP) MUCINEX FAST-MAX COLD/FLU/SORE THROAT CAPS (Use Phenylephrine-DM-GG w/ APAP) MUCINEX FAST-MAX DAY TIME/NIGHT TIME MISC MUCINEX FAST-MAX DAY TIME/NIGHT TIME MISC (Use Phenylephrine- Diphenhydramine-DM- Guaifenesin-APAP) MUCINEX FAST-MAX DAY/NIGHT CPPK (Use Phenylephrine- Doxylamine-DM- Guaifenesin-APAP) MUCINEX FAST-MAX DAY/NIGHT MAXIMUM STRENGTH MISC MUCINEX FAST-MAX DAY/NITE M/S MISC MUCINEX FAST-MAX SEVERE COLD LIQD (Use Phenylephrine-DM-GG w/ APAP) MUCINEX FAST-MAX SEVERE CONGESTION & COUGH CLEAR & COOL LIQD (Use Phenylephrine w/ DM-GG) Name MUCINEX FAST-MAX SEVERE CONGESTION & COUGH LIQD 20MG/20ML-400MG/20ML- 10MG/20ML (Use Phenylephrine w/ DM-GG) MUCINEX FAST-MAX SEVERE CONGESTION & COUGH TABS 10MG- 200MG-5MG MUCINEX MULTI- SYMPTOM COLD DAY/NIGHT PACK MISC MUCINEX SINUS-MAX DAY/NIGHT CPPK (Use Phenylephrine-Doxylamine- DM-Guaifenesin-APAP) MUCINEX SINUS-MAX SEVERECONGESTION RELIEF CAPS (Use Phenylephrine-DM-GG w/ APAP) MUCINEX STUFFY NOSE & COLD CHILDRENS LIQD (Use Phenylephrine- Guaifenesin) MULTI-SYMPTOM COLD DAYTIME/NIGHTTIME CHILDRENS MISC NASOPEN PE LIQD NINJACOF LIQD NINJACOF-A LIQD NINJACOF-XG LIQD NIVANEX DMX TABS NOREL AD TABS --non-formulary, -includes both Rx and OTC NDCs 15

24 Name OBREDON SOLN PERCOGESIC TABS (Use Diphenhydramine- Acetaminophen) PHENYLEPHRINE HCL/PYRILAMINE MALEATE TABS phenylephrine w/ acetaminophen caps 325mg-5mg, 325mg- 325mg-5mg-5mg phenylephrine w/ acetaminophen tabs 325mg-5mg, 325mg- 325mg-5mg-5mg phenylephrine w/ dm-gg liqd 10mg/5ml-100mg/5ml- 5mg/5ml, 10mg/5ml- 200mg/5ml-5mg/5ml, 5mg/5ml-100mg/5ml- 2.5mg/5ml, 18mg/15ml- 200mg/15ml-10mg/15ml, 20mg/20ml-400mg/20ml- 10mg/20ml, 10mg/5ml- 10mg/5ml-100mg/5ml- 100mg/5ml-5mg/5ml- 5mg/5ml phenylephrine w/ dm-gg syrp 10mg/5ml-100mg/5ml- 5mg/5ml phenylephrine w/ dm-gg tabs 15mg-380mg-10mg phenylephrineacetaminophenguaifenesin liqd phenylephrineacetaminophenguaifenesin tabs phenylephrinebrompheniramine-dm elix phenylephrinebrompheniramine-dm liqd Name phenylephrine-chlorphendm liqd phenylephrinechlorpheniramine-dm w/ apap liqd phenylephrinechlorpheniramine-dm w/ apap misc phenylephrinechlorpheniramine-dm w/ apap susp phenylephrinechlorpheniramine-dm w/ apap tabs phenylephrinediphenhydramine-dmguaifenesin-apap misc phenylephrinediphenhydramine-gg w/ apap misc phenylephrine-dm liqd phenylephrine-dm soln phenylephrine-dm-gg w/ apap caps phenylephrine-dm-gg w/ apap liqd phenylephrine-dm-gg w/ apap tabs phenylephrine-doxylaminedextromethorphanacetaminophen caps phenylephrine-doxylaminedextromethorphanacetaminophen liqd phenylephrine-doxylaminedm-guaifenesin-apap cppk phenylephrine-guaifenesin liqd --non-formulary, -includes both Rx and OTC NDCs 16

25 Name phenylephrine-guaifenesin tabs PHENYLHISTINE DH LIQD POLY HIST FORTE TABS POLY-HIST DM LIQD POLY-HIST PD LIQD POLY-TUSSIN AC LIQD POLY-VENT DM TABS POLY-VENT IR TABS PRO-RED AC SYRP promethazine w/codeine soln promethazine w/codeine syrp promethazine-dm syrp promethazinephenylephrine-codeine syrp PROMETHAZINE/PHENYL EPHRINE/CODEINE SYRP pseudoephed-bromphendm syrp pseudoephed-cpm w/ hydrocod soln Name pseudoephedrine w/ codeine-gg soln pseudoephedrinebrompheniramine-codeine liqd pseudoephedrinechlorphen-dm liqd pseudoephedrinedexchlorpheniraminechlophedianol liqd pseudoephedrinedoxylaminedextromethorphan liqd pseudoephedrineguaifenesin tb12 pseudoephedrine-ibuprofen tabs pseudoephedrine-naproxen sodium tb12 QC MEDIFIN PE TABS (Use Phenylephrine- Guaifenesin) RELHIST BP TABS RESCON TABS RESPAIRE-30 CAPS REZIRA SOLN ROBITUSSIN CHILDRENS COUGH & COLD CF LIQD ROBITUSSIN CHILDRENS COUGH/COLD LONG- ACTING LIQD ROBITUSSIN NIGHTTIME COUGH LONG-ACTING DM CHILDRENS LIQD --non-formulary, -includes both Rx and OTC NDCs 17

26 Name ROBITUSSIN PEAK COLD COUGH+ CHEST CONGESTION DM MAX STRENGTH LIQD (Use Dextromethorphan- Guaifenesin) ROBITUSSIN PEAK COLD DAY/NIGHT PACK MAXIMUM STRENGTH MISC ROBITUSSIN PEAK COLD DM SYRP (Use Dextromethorphan- Guaifenesin) ROBITUSSIN PEAK COLD MULTI-SYMPTOM COLD LIQD (Use Phenylephrine w/ DM-GG) ROBITUSSIN TO GO COUGH &COLD CF LIQD (Use Phenylephrine w/ DM- GG) RU-HIST D TABS RYDEX LIQD RYMED TABS SM COUGH & SORE THROAT DAYTIME PAIN RELIEVER LIQD STAFLEX TABS STAHIST AD LIQD STAHIST AD TABS THERAFLU FLU & SORE THROAT PACK Name THERAFLU SEVERE COLD & COUGH DAYTIME PACK (Use Dextromethorphan- Phenylephrine- Acetaminophen) THERAFLU SEVERE COLD & COUGH NIGHTTIME PACK (Use Diphenhydramine- Phenylephrine- Acetaminophen) THERAFLU SEVERE COLD NIGHTTIME TABS (Use Phenylephrine- Chlorpheniramine-DM w/ APAP) TRIAMINIC COLD & ALLERGY SYRP TRIAMINIC COLD & COUGH DAY TIME CHILDRENS SOLN TRIAMINIC COLD & COUGH DAY TIME CHILDRENS SYRP TRIAMINIC COUGH & CONGESTION CHILDRENS SYRP TRIAMINIC COUGH & SORE THROAT SUSP TRIAMINIC NIGHT TIME COLD & COUGH SYRP triprolidine & pseudoephedrine tabs TUSNEL C SYRP TUSNEL LIQD TUSNEL PEDIATRIC LIQD --non-formulary, -includes both Rx and OTC NDCs 18

27 Name TUSNEL-DM PEDIATRIC LIQD TUSSICAPS CP12 TUSSIONEX PENNKINETIC EXTENDED RELEASE SUER (Use Hydrocodone Polistirex- Chlorpheniramine Polistirex) TYLENOL CHILDRENS PLUS FLU SUSP (Use Phenylephrine- Chlorpheniramine-DM w/ APAP) TYLENOL CHILDRENS PLUS MULTI-SYMPTOM COLD SUSP (Use Phenylephrine- Chlorpheniramine-DM w/ APAP) TYLENOL COLD & FLU SEVERE TABS (Use Phenylephrine-DM-GG w/ APAP) TYLENOL COLD & HEAD SEVERE CONGESTION TABS (Use Phenylephrine- Acetaminophen- Guaifenesin) TYLENOL COLD MAX LIQD (Use Dextromethorphan- Phenylephrine- Acetaminophen) TYLENOL COLD MULTI- SYMPTOM NIGHTTIME LIQD (Use Phenylephrine- Doxylamine- Dextromethorphan- Acetaminophen) TYLENOL COLD MULTI- SYMPTOM SEVERE DAYTIME LIQD (Use Phenylephrine-DM-GG w/ APAP) Name TYLENOL COLD/COUGH/SORE THROAT CHILDRENS SUSP (Use Acetaminophen w/ DM) TYLENOL SINUS SEVERE TABS (Use Phenylephrine- Acetaminophen- Guaifenesin) TYLENOL WARMING COUGH & SEVER CONGESTION DAYTIME LIQD (Use Phenylephrine- DM-GG w/ APAP) VANACOF DM LIQD (Use Phenylephrine w/ DM-GG) VANACOF LIQD (Use Pseudoephedrine- Dexchlorpheniramine- Chlophedianol) VANACOF-8 LIQD VICKS DAYQUIL MUCUS CONTROL DM LIQD VICKS NYQUIL COLD & FLU LIQD (Use Dextromethorphan- Doxylamine- Acetaminophen) VICKS NYQUIL COLD & FLU NIGHTTIME RELIEF LIQD (Use Dextromethorphan- Doxylamine- Acetaminophen) VICKS NYQUIL COUGH LIQD (Use Doxylamine- DM) VICKS NYQUIL HBP COLD & FLU LIQD (Use Dextromethorphan- Doxylamine- Acetaminophen) WAL-FLU SEVERE COLD NIGHT TIME PACK --non-formulary, -includes both Rx and OTC NDCs 19

28 Name Z-TUSS AC LIQD ZUTRIPRO SOLN (Use Pseudoephed-CPM w/ Hydrocod) ZYRTEC-D ALLERGY/CONGESTION TB12 (Use Cetirizine- Pseudoephedrine) Expectorants guaifenesin liqd guaifenesin soln guaifenesin syrp guaifenesin tabs guaifenesin tb12 MUCINEX FOR KIDS PACK MUCINEX MAXIMUM STRENGTH TB12 (Use Guaifenesin) MUCINEX TB12 (Use Guaifenesin) Misc. Respiratory Inhalants sodium chloride (inhalant) aers DERMATOLOGICALS - s to Treat Skin Conditions Acne Products ACNE MEDICATION 10 LOTN Name ACNE MEDICATION 5 LOTN ACNEFREE 24 HOUR ACNE CLEARING SYSTEM KIT BENZAC AC WASH LIQD (Use Benzoyl Peroxide) BENZEFOAM FOAM (Use Benzoyl Peroxide) BENZEFOAM ULTRA FOAM (Use Benzoyl Peroxide) benzoyl peroxide bar 10 % BENZOYL PEROXIDE CLEANSER LOTN benzoyl peroxide foam 5.3 % benzoyl peroxide foam 9.8 % benzoyl peroxide gel 10 % BENZOYL PEROXIDE GEL 2.5 % benzoyl peroxide gel 5 % benzoyl peroxide liqd 4 % benzoyl peroxide liqd 5 %, 10 % benzoyl peroxide lotn 6 % BPO CREAMY WASH COMPLETEPACK KIT --non-formulary, -includes both Rx and OTC NDCs 20

29 Name CLEAN & CLEAR ADVANTAGE 3-IN-1 EXFOLIATING CLEANSER LOTN DESQUAM-X WASH LIQD (Use Benzoyl Peroxide) PANOXYL-4 CREAMY WASH LIQD (Use Benzoyl Peroxide) Antibiotics - Topical BACIGUENT OINT (Use Bacitracin (Topical)) bacitracin (topical) oint bacitracin zinc oint bacitracin-polymyxin b oint neomycin-bacitracinpolymyxin oint neomycin-bacitracinpolymyxin-pramoxine oint neomycin-polymyxin w/ pramoxine crea ALEVAZOL OINT Name ALOE VESTA ANTIFUNGAL OINT (Use Miconazole Nitrate (Topical)) ALOE VESTA CLEAR ANTIFUNGAL OINT (Use Miconazole Nitrate (Topical)) AZOLEN TINCTURE SOLN castellani paint liqd clotrimazole (topical) crea clotrimazole (topical) crea clotrimazole (topical) crea clotrimazole (topical) soln clotrimazole (topical) soln FUNGOID TINCTURE KIT FUNGOID TINCTURE SOLN LAMISIL ADVANCED GEL LAMISIL AT CREA (Use Terbinafine HCl (Topical)) LAMISIL AT JOCK ITCH CREA (Use Terbinafine HCl (Topical)) LAMISIL AT SPRAY SOLN ; NT NEOSPORIN ORIGINAL OINT (Use Neomycin- Bacitracin-Polymyxin) NEOSPORIN PLUS PAIN RELIEF MAXIMUM STRENGTH CREA (Use Neomycin-Polymyxin w/ Pramoxine) POLYSPORIN OINT (Use Bacitracin-Polymyxin B) Antifungals - Topical Over-thecounter;RX/OT C Over-thecounter;RX/OT C --non-formulary, -includes both Rx and OTC NDCs 21

30 Name LOTRIMIN AF CREA 1 % (Use Clotrimazole (Topical)) LOTRIMIN AF FOR HER CREA (Use Clotrimazole (Topical)) LOTRIMIN AF JOCK ITCH CREA (Use Clotrimazole (Topical)) MICATIN CREA (Use Miconazole Nitrate (Topical)) miconazole nitrate (topical) aerp miconazole nitrate (topical) crea miconazole nitrate (topical) oint miconazole nitrate (topical) powd terbinafine hcl (topical) crea TINACTIN AERO (Use Tolnaftate) TINACTIN AERP (Use Tolnaftate) TINACTIN CREA (Use Tolnaftate) TINACTIN DEODORANT AERP (Use Tolnaftate) TINACTIN JOCK ITCH AERP (Use Tolnaftate) TINACTIN JOCK ITCH CREA (Use Tolnaftate) TINACTIN POWD (Use Tolnaftate) tolnaftate aero tolnaftate aerp Name tolnaftate crea tolnaftate liqd tolnaftate powd tolnaftate soln Antihistamines-Topical BENADRYL EXTRA STRENGTH CREA (Use Diphenhydramine-Zinc Acetate) diphenhydramine hcl (topical) soln diphenhydramine-zinc acetate crea 0.1%-0.1%- 2%-2%, 0.1%-2% diphenhydramine-zinc acetate liqd 0.1%-2% Antiseborrheic Products DHS ZINC SHAM (Use Pyrithione Zinc) pyrithione zinc sham 2 % salicylic acid & sulfur sham SEBULEX SHAM (Use Salicylic Acid & Sulfur) selenium sulfide lotn selenium sulfide sham SELSUN BLUE DAILY LOTN (Use Selenium Sulfide) --non-formulary, -includes both Rx and OTC NDCs 22

31 Name SELSUN BLUE LOTN (Use Selenium Sulfide) SELSUN BLUE MEDICATED LOTN (Use Selenium Sulfide) SELSUN BLUE MOISTURIZING LOTN (Use Selenium Sulfide) Corticosteroids - Topical hydrocortisone (topical) crea 0.5 % hydrocortisone (topical) crea 1 % hydrocortisone (topical) crea 1 % hydrocortisone (topical) crea 1%, 1 % hydrocortisone (topical) lotn 1 % hydrocortisone (topical) oint 0.5 % hydrocortisone (topical) soln 1 % hydrocortisone-aloe vera crea MONISTAT SOOTHING CARE ITCH RELIEF CREA (Use Hydrocortisone (Topical)) Emollient/Keratolytic Agents ATRAC-TAIN CREA (Use Urea) CARMOL 10 LOTN (Use Urea) urea crea 10 % Over-thecounter;RX/OT C ; NT Name urea lotn 10 % Emollients ALBOLENE CREA AMLACTIN ULTRA CREA AQUA GLYCOLIC FACE CREAM CREA AQUAPHILIC OINT AQUAPHOR ADVANCED THERAPY OINT AQUAPHOR OINT AVEENO ACTIVE NATURALS SKIN RELIEF MOISTURE REPAIR CREA AVEENO INTENSE RELIEF HAND CREA AVEENO POSITIVELY AGELESSSKIN STRENGTHENING BODY CREAM CREA AVEENO POSITIVELY AGELESSSKIN STRENGTHENING HAND CREAM CREA AVEENO POSITIVELY NOURISHING 24-HOUR ULTRA-HYDRATING CREA AVEENO POSITIVELY RADIANTOVERNIGHT HYDRATING FACIAL MOISTURI CREA BASLE CREA --non-formulary, -includes both Rx and OTC NDCs 23

32 Name BETA CARE CREA BETA XMA CREA BOUDREAUXS BABY BUTT SMOOTH DRY SKIN OINT CERAVE CREA CERAVE RENEWING SA CREA CETAPHIL CREA CETAPHIL MOISTURIZING CREA (Use Emollient) CETAPHIL THERAPEUTIC HAND CREA COCONUT OIL BEAUTY CREA CVS MOISTURIZING CREAM CREA DAILY CONDITIONING TREATMENT OINT DERMABASEOIL IN WATER CREA DERMAIDE ALOE CREA DERMEND MOISTURIZING BRUISE FORMULA CREA DHEA CREA EX 1% DIABETIDERM CREA Name DIABETIDERM FOOT REJUVENATING CREA DMAE CREA DML FORTE CREA DROXY CREAM CREA ELON SKIN REPAIR SYSTEM CREA EMOLLIA-CREME CREA emollient crea emollient oint EQ THERAPEUTIC DRY SKIN CREA EQ THERAPEUTIC MOISTURIZING CREAM CREA EQL MOISTURIZING CREAM CREA EUCERIN CALMING DAILY MOISTURIZER CREA (Use Emollient) EUCERIN INTENSIVE REPAIRHAND CREA EUCERIN PLUS CREA EUCERIN PLUS INTENSIVE REPAIR CREA (Use Emollient) EUCERIN SKIN CALMING DAILY MOISTURIZING CREA (Use Emollient) --non-formulary, -includes both Rx and OTC NDCs 24

33 Name FORMULA 405 ENRICHED EYE CREA FORMULA 405 FACE CREAM CREA FORMULA 405 LIGHT TEXTURED MOISTURIZER CREA GENTLE CREA GOLD BOND ULTIMATE HEALING CREA GOLD BOND ULTIMATE HEALING OINT GOLD BOND ULTIMATE SOOTHING CREA HYDRASYN25 CREA HYDRO-LAN CREA J & J BURN CREAM CREA KERADAN CREA KERI LONG LASTING CREA LAC-HYDRIN TWELVE LOTN (Use Lactic Acid (Ammonium Lactate)) lactic acid (ammonium lactate) crea 12 % lactic acid (ammonium lactate) lotn 12 % lactic acid (ammonium lactate) lotn 12 % Over-thecounter;RX/OT C Over-thecounter;RX/OT C Name LACTINOL HX CREA LADY ESTHER 4 PURPOSE FACE CREAM CREA LANAPHILIC OINT LANOLOR CREA LEADER FINGER CREAM CREA MEDELA TENDER CARE LANOLIN CREA MEDERMA AG FACE CREAM CREA MEDERMA STRETCH MARKS THERAPY CREA MOISTURIZING CREAM CREA MOTHERS FRIEND CREA NEUTROGENA HAND CREA NEUTROGENA HAND/NORWEGIAOR MULA/FAST ABSORBING CREA NEUTROGENA HEALTHY SKIN CREA NISEKO HYDRATING FACIAL MOISTURIZER CREA NIVEA CREA --non-formulary, -includes both Rx and OTC NDCs 25

34 Name NIVEA LIGHT CREA NIVEA SOFT CREA NIVEA VISAGE CREA NIVEA VISAGE INNER BEAUTY NIGHTTIME RENEWAL CREA NUTRADERM CREA OINTMENT BASE OINT PEN-KERA CREA PENTRAVAN CREA PENTRAVAN PLUS CREA PETROLATUM OINT PRETTY FEET & HANDS CREA RA ADVANCED HEALING OINT RA GENTLE SKIN CREAM CREA RESTA CREA RISABAL-PH CREA ROC MULTI CORREXION 5 IN1 RESTORING EYE CREAM CREA Name ROC MULTI CORREXION 5 IN1 RESTORING NIGHT CREAM CREA ROC RETINOL CORREXION CREA ROC RETINOL CORREXION MAX CREA ROC RETINOL CORREXION NIGHT CREA ROC RETINOL CORREXION SENSITIVE EYE CREA ROC RETINOL CORREXION SENSITIVE NIGHT CREA SOOTHE & COOL SKIN CREAMWITH ALOE & VITAMINS A, D & E CREA SORBOLENE CREA SPECIAL CARE CREAM CREA STUDIO 35 MOISTURIZING SKIN CREA THERAPEUTIC MOISTURIZING CREA UDDERLY SMOOTH CREA UDDERLY SMOOTH EXTRA CARE CREA UDDERLY SMOOTH EXTRA CARE20 CREA VANICREAM CREA VELVACHOL CREA --non-formulary, -includes both Rx and OTC NDCs 26

35 Name VITAMIN E WITH PANTHENOL CREA ZIMS CRACK CREME DAYTIME CREA Keratolytic/Antimitotic Agents COMPOUND W LIQD (Use Salicylic Acid) COMPOUND W MAXIMUM STRENGTH GEL (Use Salicylic Acid) salicylic acid gel ex 17 % salicylic acid liqd ex 3 %, 17 % salicylic acid soln ex 17 % Liniments ZIKS ARTHRITIS PAIN RELIEF CREA Local Anesthetics - Topical ARTHRITIS PAIN RELIEVING CREA capsaicin crea %, 0.1 % CAPZASIN LIQD CAPZASIN-HP CREA (Use Capsaicin) CVS CAPSAICIN LIQD GNP CAPSAICIN LIQD GOODSENSE CAPSAICIN ARTHRITIS PAIN RELIEF LIQD Name LENZAPATCH PTCH (Use Lidocaine-Menthol) lidocaine crea lidocaine-transparent dressing kit LMX 4 CREA (Use Lidocaine) LMX 4 PLUS KIT (Use Lidocaine-Transparent Dressing) Misc. Dermatological Products 5 DAY LIQD dermatological products, misc. liqd DIABETIDERM MASSAGE STIMULATOR LIQD GENADUR LIQD JOBST IT STAYS/ROLL- ON LIQD KERASAL FUNGAL NAIL RENEWAL LIQD NAIL SCRUB LIQD REMOVE ADHESIVE REMOVER LIQD THUM LIQD Misc. Topical 4-N-1 CREA --non-formulary, -includes both Rx and OTC NDCs 27

36 Name A+D FIRST AID OINT ABSORBASE OINT ALOE VESTA DAILY MOISTURIZER LOTN (Use Dimethicone (Topical)) ALOE VESTA PROTECTIVE OINT ALOE VESTA SKIN CONDITIONER LOTN (Use Dimethicone (Topical)) aluminum hydroxide oint ex aluminum sulfate & calcium acetate pack AMERIDERM PERISHIELD OINT AQUAPHOR LIP REPAIR OINT BASIS FACIAL MOISTURIZER CREA BASIS OVERNIGHT CREA benzoin compound tinc BENZOIN TINCTURE PLAIN TINC BENZOIN TINCTURE TINC CARRINGTON MOISTURE BARRIER CREA Name CARRINGTON MOISTURE BARRIER/ZINC CREA CERAVE OINT CHAPSTICK OVERNIGHT OINT CHAPSTICK ULTRA MOISTUREDAYTIME FORMULA OINT CHAPSTICK ULTRASMOOTH FORTIFY OINT CHAPSTICK ULTRASMOOTH NOURISH OINT CHAPSTICK ULTRASMOOTH REJUVENATE OINT CHAPSTICK ULTRASMOOTH SOOTHE OINT COOL BOTTOMS CREA CRITIC-AID CLEAR MOISTUREBARRIER OINT DERMADROX OINT DERMAGRAN OINT (Use Aluminum Hydroxide) DERMAGRAN SKIN PROTECTANT OINT (Use Aluminum Hydroxide) dimethicone (topical) lotn 3 % DOMEBORO PACK (Use Aluminum Sulfate & Calcium Acetate) EUCERIN CREA (Use Skin Protectants, Misc.) --non-formulary, -includes both Rx and OTC NDCs 28