|
| 8-Mop | 3 | | |
| A-Spas | 1 | | |
| A/B Otic | 1 | | |
| Aber-Fed | 1 | | |
| Aber-Tuss DR | 1 | | |
| Aber-Tuss HC | 1 | | |
| Abilify | 3PA | | |
| Abilify Disc | 3PA | | |
| Abstral | 3PA | | |
| Acanya | 3PA | | |
| Acarbose | 1 | | |
| Accolate* | 3 | 60 | |
| Accu-Chek Control Soln | 3 | | ST |
| Accu-Chek Lancet Device | 2 | | |
| Accu-Chek Test Strips | 3 | 150 | ST |
| Accuhist DM Pediatric* | 3 | | |
| Accuhist DM* | 3 | | |
| Accuhist LA* | 3 | | |
| Accuhist PDX* | 3 | | |
| Accuhist* | 3 | | |
| AccuNeb* | 3 | | |
| Accupril* | 3 | 30 | |
| Accuretic* | 3 | 30 | |
| Accusure Insulin Syringe | 2 | | |
| Accutane* | 3 | | |
| Accuzyme SE | 3 | | |
| Accuzyme* | 3 | | |
| Acebutolol HCl | 1 | | |
| Aceon | 3 | | |
| Acetaminophen-Codeine | 1 | | |
| Acetaminophen-Codeine #2 | 1 | | |
| Acetaminophen-Codeine #4 | 1 | | |
| Acetasol HC | 1 | | |
| AcetaZOLAMIDE | 1 | | |
| Acetic Acid | 1 | | |
| Acetic Acid-Aluminum Acetate | 1 | | |
| Acetylcysteine | 1 | | |
| Acid Jelly | 3 | | |
| Acidic Vaginal Jelly | 1 | | |
| Aciphex | 3PA | 30 | ST |
| Aclovate* | 3 | | |
| Acticin | 1 | | |
| Actigall* | 3 | | |
| Actiq* | 3PA | | |
| Active Test | 3 | 150 | |
| Activella | 3 | | |
| Actonel 150mg | 3 | 1 | |
| Actonel 35mg | 3 | 4 | |
| Actonel 5mg, 30mg | 3 | 30 | |
| Actonel 75mg | 3 | 2 | |
| Actonel with Calcium | 3 | | |
| ActoPlus Met | 2 | 60 | |
| ActoPlus Met XR | 2 | 30 | |
| Actos | 2 | 30 | |
| Acuflex | 3 | | |
| Acular | 3 | | |
| Acular LS | 3 | | |
| Acular PF | 3 | | |
| Acuvail 0.45% | 3 | | |
| Acyclovir | 1 | | |
| Aczone | 3PA | | |
| Adalat CC* | 3 | | |
| Adapalene | 1 | | |
| Adcirca | 3PA | | Specialty Pharmacy |
| Adderall XR* | 3 | 60 | |
| Adderall* | 3 | | |
| Adjustable Lancing Device | 2 | | |
| Adoxa Pak 1/100* | 3 | | |
| Adoxa Pak 1/150* | 3 | | |
| Adoxa Pak 2/100* | 3 | | |
| Adoxa* | 3 | | |
| Adrenaclick | 3 | | |
| Adrenalin | 3 | | |
| Advair Diskus | 3 | 60 | |
| Advair HFA | 3 | 1 | |
| Advance Control Solutions | 3 | | ST |
| Advance Test Strips | 3 | 150 | ST |
| Advicor | 3 | | |
| Aero Otic HC | 1 | | |
| Aerobid | 3 | | |
| Aerobid-M | 3 | | |
| Aerohist | 3 | | |
| Aerohist Plus | 1 | | |
| AeroKid* | 3 | | |
| Afeditab CR | 1 | 30 | |
| Afinitor | 3PA | | Specialty Pharmacy |
| Agenerase | 2 | | |
| Aggrenox | 3 | | |
| Agrylin* | 3PA | | |
| AH-Chew | 1 | | |
| AH-Chew D* | 3 | | |
| AH-Chew II | 3 | | |
| AH-Chew Susp | 3 | | |
| Aimsco Insulin Syringe | 2 | | |
| Aimsco Insulin Syringe Mx-Com | 2 | | |
| Aimsco Ultra Thin Lancets | 2 | | |
| Airet | 1 | | |
| AK-Con | 1 | | |
| AK-Dilate | 1 | | |
| AK-Pentolate | 1 | | |
| AK-Poly-Bac | 1 | | |
| AK-Pred | 1 | | |
| AK-Tob | 1 | | |
| Akineton | 3 | | |
| Akne-Mycin | 2 | | |
| Akorn Balanced Salt | 1 | | |
| Ala-Cort | 1 | | |
| Ala-Hist | 3 | | |
| Ala-Quin | 3 | | |
| Ala-Scalp | 3 | | |
| Alacol DM | 3 | | |
| Alamast | 3 | | |
| Alba-3 | 3 | | |
| Albalon* | 3 | | |
| Albatussin CF | 3 | | |
| Albatussin CF Pediatric | 3 | | |
| Albatussin DM Pediatric | 3 | | |
| Albatussin EX | 3 | | |
| Albatussin NN | 1 | | |
| Albatussin Pediatric Drops | 3 | | |
| Albatussin Pediatric Liqd | 1 | | |
| Albatussin Pediatric Syr | 3 | | |
| Albatussin SR | 3 | | |
| Albatussin SR F | 3 | | |
| Albenza | 3 | | |
| Albertsons Insulin Syringe | 2 | | |
| Albertsons Niacin | 1 | | |
| Albertsons Niacin SA | 1 | | |
| Albertsons Test Strip | 3 | 150 | ST |
| Albertsons Ultra Thin Lancets | 2 | | |
| Albuterol | 1 | | |
| Albuterol Sulfate | 1 | | |
| Albuterol/Ipratrop Nebs | 1 | | |
| Alcet | 3 | | |
| Alclometasone Dipropionate | 1 | | |
| Alcortin | 3 | | |
| Aldactazide* | 3 | | |
| Aldactone* | 3 | | |
| Aldara | 3 | | 48 pkt per year |
| Aldex G | 3 | | |
| Aldex* | 3 | | |
| Aldoclor | 3 | | |
| Aldoril D30 | 3 | | |
| Aldoril D50 | 3 | | |
| Aldoril-15* | 3 | | |
| Aldoril-25* | 3 | | |
| Alendronate 35mg, 70mg | 1 | 4 | |
| Alendronate 5, 10, 40 | 1 | 30 | |
| Alesse (28)* | 3 | | |
| Alferon N | 3PA | | |
| Alfuzosin | 1 | 30 | |
| Ali-flex | 1 | | |
| Alinia | 3 | | |
| Alkabel-SR | 1 | | |
| Alkeran | 3 | | |
| Allclenz | 3 | | |
| Allergen | 1 | | |
| AllerScript | 3 | | |
| Allersol | 1 | | |
| Allerx | 3 | | |
| Allerx DF | 3 | | |
| Allerx Dose Pack | 3 | | |
| Allerx-D* | 3 | | |
| Allfen | 3 | | |
| Allfen C | 3 | | |
| Allfen Jr* | 3 | | |
| Allfen-DM* | 3 | | |
| Allopurinol | 1 | | |
| Alocril | 3 | | |
| Alomide | 3 | | |
| Alora | 3 | 8 | |
| Alphagan P 0.1% | 2 | | |
| Alphagan P 0.15%* | 3 | | |
| AlphaTrex | 1 | | |
| Alprazolam | 1 | | |
| Alprazolam Intensol | 3 | | |
| Alprazolam XR* | 1 | 30 | |
| Alrex | 2 | | |
| Altabax | 3 | | |
| Altace | 3 | | |
| Altafrin | 1 | | |
| Altex-PSE | 1 | | |
| Altoprev | 3 | | |
| Aluminum Chloride Hexahydrate | 1 | | |
| Alupent | 3 | | |
| Alvesco | 3PA | | |
| Amantadine HCl | 1 | | |
| Amaryl* | 3 | | |
| Ambi 1000/55 | 1 | | |
| Ambi 45/800 | 1 | | |
| Ambi 45/800/30 | 1 | | |
| Ambi 5/15/100 | 3 | | |
| Ambi 60/580* | 3 | | |
| Ambi 60/580/30* | 3 | | |
| Ambi 80/700 | 1 | | |
| Ambi 80/700/40 | 1 | | |
| Ambi 80/780 | 1 | | |
| Ambi 80/780/40 | 1 | | |
| Ambien CR* | 3PA | 9 | |
| Ambien* | 3 | 30 | |
| Ambifed-G | 3 | | |
| Ambifed-G DM | 3 | | |
| Amcinonide Crm, Lotn | 1 | | |
| Amcinonide Oint | 3 | | |
| Amdry-C | 1 | | |
| Amdry-D | 1 | | |
| Amerge* | 3PA | 9 | |
| Americaine Anesthetic | 3 | | |
| Americet | 1 | | |
| Amerifed | 3 | | |
| Amerifed DM | 3 | | |
| Amerituss AD | 3 | | |
| Ames Gluco System | 2 | | |
| Ames Gluco System High Control | 3 | | |
| Ames Gluco System Low Control | 3 | | |
| Ames Gluco System Normal | 3 | | |
| Amethia | 1 | | 3 Copays |
| Amethia Lo | 1 | | 3 copays per Rx |
| Amethyst | 1 | | |
| Ami-Tex LA | 1 | | |
| Amibid DM | 1 | | |
| Amicar* | 3 | | |
| Amidal | 1 | | |
| Amidrine | 1 | | |
| Amigesic | 1 | | |
| Amiloride HCl | 1 | | |
| Amiloride-Hydrochlorothiazide | 1 | | |
| Amino Acid Cervical | 1 | | |
| Amino-Cerv* | 3 | | |
| Aminobenzoate Potassium | 1 | | |
| Aminocaproic Acid | 1 | | |
| Aminophylline | 1 | | |
| Amiodarone HCl | 1 | | |
| Amitex PSE | 1 | | |
| Amitiza | 3PA | | |
| Amitriptyline HCl | 1 | | |
| Amlodipine | 1 | 30 | |
| Amlodipine - atorvastatin | 2 | 30 | |
| Amlodipine - benazepril | 1 | | |
| Amnesteem | 1 | | |
| Amoclan | 1 | | |
| Amoxapine | 3 | | |
| Amoxicillin | 1 | | |
| Amoxicillin 400mg Chew | 3 | | |
| Amoxicillin-Pot Clavulanate | 1 | | |
| Amoxil* | 3 | | |
| Amphetamine Salt Combo | 1 | | |
| Ampicillin | 1 | | |
| Ampyra | 3PA | | |
| Amrix | 3PA | | |
| Amturnide | 3PA | | |
| Anabar | 3 | | |
| Anacaine | 3 | | |
| Anadrol | 3PA | | |
| Anafranil* | 3 | | |
| Anagrelide HCl | 1PA | | |
| Analpram-HC* | 3 | | |
| AnaMantle HC Forte | 3 | | |
| AnaMantle HC* | 3 | | |
| Anaplex DM* | 3 | | |
| Anaplex DMX | 3 | | |
| Anaplex HD* | 3 | | |
| Anaprox DS* | 3 | | |
| Anaprox* | 3 | | |
| Anaspaz* | 3 | | |
| Anastrozole | 1 | | |
| Ancobon* | 3 | | |
| Andehist DM NR | 1 | | |
| Andehist NR | 1 | | |
| Androderm | 3 | 30 | |
| AndroGel | 3 | | |
| AndroGel Pump | 3 | | |
| Android | 3 | | |
| Androxy | 3 | | |
| Anestacon | 1 | | |
| Anestafoam | 3 | | |
| Anexsia* | 3PA | | |
| Anextuss | 1 | | |
| Angeliq | 3 | | |
| Anolor 300 | 1 | | |
| Ansaid* | 3 | | |
| Antabuse* | 3 | | |
| Antara | 3 | | ST |
| Anthralin | 1 | | |
| Anti-Spas | 1 | | |
| Anti-Stick Insulin Syringe | 2 | | |
| Antiben | 1 | | |
| Antibiotic Ear | 1 | | |
| Antipyrine-Benzocaine | 1 | | |
| Antispasmodic | 1 | | |
| Antivert* | 3 | | |
| Anucort-HC | 1 | | |
| Anusol-HC* | 3 | | |
| Anzemet | 2 | 3 | |
| APAP Isomethheptene Caff | 1 | | |
| ApexiCon | 1 | | |
| Apexicon E Crm | 3 | | |
| ApexiCon E Oint | 1 | | |
| Aphrodyne | 1 | | |
| Aphthasol | 3 | | |
| Apidra Cartridge | 3PA | | |
| Apidra Vial | 3 | | |
| Aplenzin | 3PA | | |
| Apokyn | 3PA | | |
| Apraclonidine 0.5% | 1 | | |
| Apri | 1 | | |
| Apriso | 2 | | |
| Aptivus | 3 | | |
| Aquabid-DM | 1 | | |
| Aquachloral | 3 | | |
| Aquatab C* | 3 | | |
| Aquatab D* | 3 | | |
| Aquatab DM* | 3 | | |
| Aralen* | 3 | | |
| Aranelle | 1 | | |
| Aranesp | 3PA | | Specialty Pharmacy |
| Arava* | 3 | | |
| Arcalyst | 3PA | | Specialty Pharmacy |
| Aricept ODT | 3 | | |
| Aricept* | 3 | | |
| Arimidex* | 2 | | |
| Aristocort | 3 | | |
| Aristocort A* | 3 | | |
| Arixtra* | 3 | | Limit 14 day supply |
| Armour Thyroid* | 3 | | |
| Aromasin* | 3 | | |
| Arthrotec 50 | 3 | | |
| Arthrotec 75 | 3 | | |
| Asacol | 2 | | |
| Asacol HD | 2 | | |
| Ascensia Control Solns | 3 | | ST |
| Ascensia Lancets | 2 | | |
| Ascensia Test Strips | 3 | 150 | ST |
| Ascomp-Codeine | 1 | | |
| Asmanex 120 Metered Doses | 3 | | |
| Asmanex 14 Metered Doses | 3 | | |
| Asmanex 30 Metered Doses | 3 | | |
| Asmanex 60 Metered Doses | 3 | | |
| ASP 300/200/20 | 1 | | |
| Aspirin | 1 | | |
| Aspirin EC | 1 | | |
| Aspirin-Codeine #3 | 1 | | |
| Aspirin-Codeine #4 | 1 | | |
| Assure Control Solns | 3 | | ST |
| Assure Test Strips | 3 | 150 | ST |
| Astelin* | 3 | | |
| Astepro | 3 | | |
| At Last Control Solution | 3 | | ST |
| At Last Lancets | 2 | | |
| At Last Test Strips | 3 | 150 | ST |
| Atacand | 3 | | |
| Atacand HCT | 3 | | |
| Atamet | 1 | | |
| Atarax* | 3 | | |
| Atelvia | 3 | 4 | |
| Atenolol | 1 | | |
| Atenolol-Chlorthalidone | 1 | | |
| Ativan* | 3 | | |
| Atorvastatin | 2 | 30 | |
| Atovaquone/Proguanil | 1 | | |
| Atreza | 1 | | |
| Atripla | 3 | | |
| Atropine Sulfate | 1 | | |
| Atropine-Care | 1 | | |
| Atrovent Aer | 2 | | |
| Atrovent HFA Aer | 2 | | |
| Atrovent Soln* | 2 | | |
| Atuss DR* | 3 | | |
| Atuss G* | 3 | | |
| Atuss HC* | 3 | | |
| Atuss HD | 3 | | |
| Atuss MR* | 3 | | |
| Atuss MS* | 3 | | |
| Atuss NX* | 3 | | |
| Atuss-12 DM | 3 | | |
| Atuss-12 DX | 3 | | |
| Aug Betamethasone Dipropionate | 1 | | |
| Augmentin ES-600* | 3 | | |
| Augmentin XR | 3 | | |
| Augmentin* | 3 | | |
| Aurobiotic-HC | 1 | | |
| Aurodex | 1 | | |
| Auroguard | 1 | | |
| Aurora Healthcare Lancets | 2 | | |
| Auto-Lancet | 2 | | |
| Auto-Lancet Mini | 2 | | |
| Auto-Lancets | 2 | | |
| AutoLancet | 2 | | |
| Autolet | 2 | | |
| Autolet 2 | 2 | | |
| Autolet II Clinisafe | 2 | | |
| Autolet Lancing Device | 2 | | |
| Autolet Lite Clinisafe | 2 | | |
| Autolet Lite Starter Pack | 2 | | |
| Autolet Mini | 2 | | |
| Autopen | 2 | | |
| Avalide | 3 | | |
| Avandamet | 3 | | |
| Avandaryl | 3 | | |
| Avandia | 3 | | |
| Avapro | 3 | | |
| Avar | 3 | | |
| Avar Cleanser | 1 | | |
| Avar Green | 3 | | |
| AVAR-e Emollient | 1 | | |
| AVAR-e Green | 1 | | |
| AVC Vaginal | 3 | | |
| Avelox | 2 | | |
| Avelox ABC Pack | 2 | | |
| Aventyl* | 3 | | |
| Aviane | 1 | | |
| Avinza | 3 | | |
| Avita | 1PA | | PA if >26 eff 09/10 |
| Avodart | 3 | | |
| Avonex | 2 | | Specialty Pharmacy |
| Axert | 3 | 6 | |
| Axid* | 3 | | |
| Axiron | - | | New to Market Policy |
| Axocet | 1 | | |
| Aygestin* | 3 | | |
| Azasan | 3 | | |
| Azasite | 3 | | |
| Azathioprine | 1 | | |
| Azelastine Soln | 1 | | |
| Azelex | 3 | | |
| Azilect | 3 | | |
| Azithromycin | 1 | | |
| Azmacort | 3 | | |
| Azopt | 3 | | |
| Azor | 3 | 30 | |
| Azulfidine EN-tabs* | 3 | | |
| Azulfidine* | 3 | | |
| B & O 15-A Supprette* | 3 | | |
| B & O 16-A Supprette* | 3 | | |
| B-D Control Soln | 3 | | ST |
| B-D Disp Needle | 2 | | |
| B-D Insulin Syringe | 2 | | |
| B-D Lancet Device | 2 | | |
| B-D Lancets | 2 | | |
| B-D Pen Needle | 2 | | |
| B-D Test Strips | 3 | 150 | ST |
| B-Tuss* | 3 | | |
| Bacitra-Neomycin-Polymyxin-HC | 1 | | |
| Bacitracin | 1 | | |
| Bacitracin-Neomycin-Polymyxin | 1 | | |
| Bacitracin-Polymyxin B | 1 | | |
| Baclofen | 1 | | |
| Bactrim DS* | 3 | | |
| Bactrim* | 3 | | |
| Bactroban Nasal | 3 | 1 | |
| Bactroban* | 3 | | |
| Balagan | 1 | | |
| Balamine DM* | 3 | | |
| Balanced Salt | 1 | | |
| Baltussin | 3 | | |
| Baltussin HC | 1 | | |
| Balziva | 1 | | |
| Bancap-HC* | 3 | | |
| Banzel | 3PA | | |
| Baraclude | 3PA | | |
| BD Test | 3 | 150 | |
| Beconase AQ | 3 | | ST |
| Bel-Tabs | 1 | | |
| Belcomp-PB | 1 | | |
| Belladonna Alkaloids | 3 | | |
| Belladonna Alkaloids-Opium | 3 | | |
| Belladonna-Opium | 1 | | |
| Bellahist-D LA | 1 | | |
| Bellamine | 1 | | |
| Bellamine S | 1 | | |
| Bellaspas | 1 | | |
| Bellatal ER | 1 | | |
| Ben-Tann | 1 | | |
| Benazepril HCl | 1 | | |
| Benazepril-Hydrochlorothiazide | 1 | | |
| Benicar | 2 | | |
| Benicar HCT | 2 | | |
| Bensal HP | 3 | | |
| Bentyl* | 3 | | |
| Benzac AC Wash* | 3 | | |
| Benzac AC* | 3 | | |
| Benzac W Wash* | 3 | | |
| Benzac W* | 3 | | |
| Benzaclin | 3PA | | |
| Benzagel Wash | 1 | | |
| Benzagel-10* | 3 | | |
| Benzagel-5* | 3 | | |
| Benzamycin* | 3 | | |
| BenzamycinPak | 3 | | |
| Benzashave 10% | 1 | | |
| Benzashave 5% | 2 | | |
| Benzefoam* | 3PA | | |
| Benziq | 3 | | |
| Benziq LS Gel | 3 | | |
| Benziq Wash | 3 | | |
| Benzonatate | 1 | | |
| Benzotic | 1 | | |
| Benzoyl Peroxide | | | Tier will vary by product |
| Benzoyl Peroxide Wash | | | Tier will vary by product |
| Benzoyl Peroxide-Erythromycin | 1 | | |
| Benztropine Mesylate | 1 | | |
| Bepreve | 3 | | |
| Besivance | 3 | | |
| Beta-Val | 1 | | |
| Betagan without C Cap* | 3 | | |
| Betagan* | 3 | | |
| Betamethasone Dipropionate | 1 | | |
| Betamethasone Valerate | 1 | | |
| Betapace AF* | 3PA | | |
| Betapace* | 3 | | |
| Betaseron | 2 | | Specialty Pharmacy |
| BetaTan | 3 | | |
| BetaVent | 1 | | |
| Betaxolol HCl | 1 | | |
| Betaxolol Ophth | 1 | | |
| Bethanechol Chloride | 1 | | |
| Betimol | 2 | | |
| Betoptic-S | 2 | | |
| Bextra | 3PA | | |
| Beyaz | 3 | | |
| Biaxin XL | 3 | | |
| Biaxin XL Pac | 3 | | |
| Biaxin* | 3 | | |
| Bicalutamide | 1 | | |
| Bicitra* | 3 | | |
| Bidex-DM* | 3 | | |
| Bidhist | 1 | | |
| Bidhist-D | 1 | | |
| BiDil | 3PA | | |
| Biltricide | 3 | | |
| Binora Creamy Wash | 3PA | | |
| Bio-Statin | 3 | | |
| Bio-Throid | 3 | | |
| Biodec | 3 | | |
| Biodec-DM | 1 | | |
| Biohist LA* | 3 | | |
| Bioscanner Glucose Test Strip | 3 | 150 | ST |
| Biotussin AC | 1 | | |
| Biotussin DAC | 1 | | |
| Bisoprolol Fumarate | 1 | | |
| Bisoprolol-Hydrochlorothiazide | 1 | | |
| BL Insulin Syringe | 2 | | |
| BL Lancets | 2 | | |
| BL Lancing System Device | 2 | | |
| BL Miconazole 3 | 1 | | |
| BL Niacin TR | 1 | | |
| BL Test Strip | 3 | 150 | ST |
| Blanex-A | 1 | | |
| Bleph-10* | 3 | | |
| Blephamide | 2 | | |
| Blephamide S.O.P. | 2 | | |
| Blocadren* | 3 | | |
| Blood Glucose Test Strips | 3 | 150 | ST |
| Boniva 150mg | 3PA | 1 | ST |
| Boniva 2.5mg | 3PA | 30 | ST |
| Borofair | 1 | | |
| BPM | 1 | | |
| BPM Pseudo | 1 | | |
| Bravelle | 3PA | 20 | |
| Brethine* | 3 | | |
| Brevicon* | 3 | | |
| Brevoxyl Acne Wash Kit* | 3 | | |
| Brevoxyl Cleansing Lotion* | 3 | | |
| Brevoxyl Creamy Wash | 3 | | |
| Brevoxyl Creamy Wash Kit | 3 | | |
| Brevoxyl Gel* | 3 | | |
| Briellyn | 1 | | |
| Brilinta | 3PA | | |
| Brimonidine Tartrate | 1 | | |
| Brofed | 3 | | |
| Bromatan-DM | 1 | | |
| Bromatane DX | 1 | | |
| Bromaxefed DM RF | 1 | | |
| Bromaxefed RF | 1 | | |
| Bromday | 3 | | |
| Bromdec | 1 | | |
| Bromdec DM | 1 | | |
| Brometane DX | 1 | | |
| Bromfed DM | 1 | | |
| Bromfed* | 3 | | |
| Bromfed-PD* | 3 | | |
| Bromfenac Soln 0.09% | 1 | | |
| Bromfenex | 1 | | |
| Bromfenex PD | 1 | | |
| Bromfenex PE | 1 | | |
| Bromfenex PE Pediatric | 1 | | |
| Bromhist PDX | 1 | | |
| Bromhist Pediatric | 1 | | |
| Bromhist-DM | 1 | | |
| Bromhist-DM Pediatric | 1 | | |
| Bromhist-NR | 1 | | |
| Bromhist-PDX | 1 | | |
| Bromocriptine Mesylate | 1 | | |
| Bromophed DX | 1 | | |
| Bromphenex DM | 1 | | |
| Bromphenex HD | 3 | | |
| Bromplex DM | 1 | | |
| Bromplex HD | 1 | | |
| Broncap | 3 | | |
| Broncholate | 3 | | |
| Broncodur | 3 | | |
| Broncomar-1 | 3 | | |
| Broncopectol | 3 | | |
| Broncotron-D | 3 | | |
| Brondil | 3 | | |
| Brontex* | 3 | | |
| Brontuss SF | 3 | | |
| Brooks Insulin Syringe | 2 | | |
| Brovana | 3PA | | |
| Brovex CT* | 3 | | |
| Brovex HC | 3 | | |
| Brovex* | 3 | | |
| BroveX-D | 3 | | |
| Bubbli-Pred | 1 | | |
| Bucalcide | 3 | | |
| Budeprion SR | 1 | | |
| Budeprion XL | 1 | 30 | |
| Budesonide SR Cap | 1 | 90 | |
| Budesonide Susp | 1PA | | |
| Bumetanide | 1 | | |
| Bumex* | 3 | | |
| Bupap | 1 | | |
| Buphenyl | 3 | | |
| Buprenorphine SL | 1PA | | |
| Buproban | 1 | | |
| Bupropion HCl | 1 | | |
| Bupropion HCl (Smoking Deter) | 1 | | |
| BuSpar* | 3 | | |
| Buspirone HCl | 1 | | |
| Butal-ASA-Caff-Cod | 1 | | |
| Butalbital Compound/ASA | 1 | | |
| Butalbital-APAP | 1 | | |
| Butalbital-APAP-Caff-Cod | 1 | | |
| Butalbital-APAP-Caffeine | 1 | | |
| Butalbital-ASA-Caff-Codeine | 1 | | |
| Butalbital-Aspirin-Caffeine | 1 | | |
| Butisol Sodium | 2 | | |
| Butorphanol Tartrate | 1PA | | |
| Butrans | 3PA | | |
| Bydureon | - | | New to Market Policy |
| Byetta | 3PA | | ST |
| Bystolic | 3 | 30 | ST |
| C-Hist SR | 3 | | |
| C-Phed Tannate | 1 | | |
| C-Tanna 12 | 1 | | |
| C-Tanna 12D | 1 | | |
| Cabergoline | 1 | 8 | |
| Caduet* | 3 | 30 | |
| Cafcit | 3PA | | |
| Cafergot* | 3 | | |
| Calan SR* | 3 | | |
| Calan* | 3 | | |
| Calcibind | 3 | | |
| Calcipotriene | 1 | | |
| Calcitonin-Salmon | 1 | | |
| Calcitriol | 1 | | |
| Calcium Acetate | 1 | | |
| Calomist | 3PA | | |
| Cambia | 3PA | | |
| Camila | 1 | | |
| Campral | 3PA | | |
| Camrese | 1 | | 3 Copays |
| Camrese Lo | 1 | | 3 copays per Rx |
| Canasa | 2 | | |
| Cantil | 3 | | |
| Capex | 3 | | |
| Capital/Codeine | 3 | | |
| Capoten* | 3 | | |
| Capozide* | 3 | | |
| Caprelsa | 3PA | | |
| Captopril | 1 | | |
| Captopril-Hydrochlorothiazide | 1 | | |
| Carac | 3 | | |
| Carafate* | 3 | | |
| Carba-XP* | 3 | | |
| Carbaglu | 3PA | | |
| Carbamazepine | 1 | | |
| Carbaphen 12 | 3 | | |
| Carbaphen 12 Ped | 3 | | |
| Carbatrol | 3 | | |
| Carbatuss* | 3 | | |
| Carbatuss-CL | 3 | | |
| Carbaxefed DM RF | 1 | | |
| Carbaxefed RF | 1 | | |
| Carbetaplex | 1 | | |
| Carbic DS | 1 | | |
| Carbidopa-Levodopa | 1 | | |
| Carbidopa-Levodopa CR | 1 | | |
| Carbihist | 1 | | |
| Carbinoxamine PD | 1 | | |
| Carbinoxamine-Pseudoephedrine | 1 | | |
| Carbiset TR | 3 | | |
| Carbodex DM | 1 | | |
| Carbofed DM | 1 | | |
| Carboptic | 1 | | |
| Carboxine | 1 | | |
| Carboxine-PSE | 3 | | |
| Cardec | 1 | | |
| Cardec DM | 1 | | |
| Cardene SR | 3 | | |
| Cardene* | 3 | | |
| Cardizem CD* | 3 | | |
| Cardizem LA* | 3 | | |
| Cardizem* | 3 | | |
| Cardura XL | 3 | 30 | |
| Cardura* | 3 | 30 | |
| CareOne Lancet 26G | 2 | | |
| CareOne Lancet 30G | 2 | | |
| CareOne Lancet Ultra Thin | 2 | | |
| Carisoprodol | 1 | | |
| Carisoprodol-Aspirin | 1 | | |
| Carisoprodol-Aspirin-Codeine | 1 | | |
| Carmol 40* | 3 | | |
| Carmol Scalp Treatment* | 3 | | |
| Carmol-HC* | 3 | | |
| Carnitor* | 3 | | |
| Carteolol HCl | 1 | | |
| Cartia XT | 1 | | |
| Cartrol | 3 | | |
| Carvedilol | 1PA | | ST |
| Casodex* | 3 | | |
| Cataflam* | 3 | | |
| Catapres* | 3 | | |
| Catapres-TTS-1 | 3 | | |
| Catapres-TTS-2 | 3 | | |
| Catapres-TTS-3 | 3 | | |
| Caverject | 3 | 4 | |
| Caverject Impulse | 3 | 4 | |
| Cayston | 3PA | | |
| Ceclor* | 3 | | |
| Cedax | 3PA | | |
| CeeNU | 3 | | |
| Cefaclor | 1 | | |
| Cefaclor CR | 3 | | |
| Cefadroxil Hemihydrate | 1 | | |
| Cefadroxil Monohydrate | 1 | | |
| Cefdinir | 1 | | |
| Cefpodoxime Proxetil | 1 | | |
| Cefprozil | 1 | | |
| Ceftin* | 3 | | |
| Cefuroxime Axetil | 1 | | |
| Cefzil* | 3 | | |
| Celebrex | 2PA | | |
| Celestone | 3 | | |
| Celexa* | 3 | | |
| CellCept* | 3 | | |
| Celontin | 3 | | |
| Cenestin | 3 | | |
| Centany | 1 | | |
| Cephadyn | 1 | | |
| Cephalexin Monohydrate | 1 | | |
| Cephalexin Tabs | 1 | | |
| Certuss-D* | 3 | | |
| Cerumenex | 2 | | |
| Cervical Amino Acid | 1 | | |
| Cesamet | 3PA | | |
| Cesia | 1 | | |
| Ceta Plus | 1 | | |
| Cetacaine* | 3 | | |
| Cetacort | 1 | | |
| Cetraxal Otic | 3 | | |
| Chantix Pak | 3 | 25 Week Supply | |
| Chemet | 2 | | |
| Chemstrip bG | 3 | 150 | |
| Chemstrip uG | 3 | | |
| Cheracol Cough | 1 | | |
| Cheratussin AC | 1 | | |
| Cheratussin DAC | 1 | | |
| Chlor-Mes D | 1 | | |
| Chloral Hydrate | 1 | | |
| ChlorDex GP | 1 | | |
| Chlordiazepoxide HCl | 1 | | |
| Chlordiazepoxide-Amitriptyline | 1 | | |
| Chlorex-A | 1 | | |
| Chlorex-A 12 | 1 | | |
| Chlorhexidine Gluconate | 1 | | |
| Chloroptic | 3 | | |
| Chloroquine 250mg | 1 | | |
| Chloroquine 500mg | 1 | | |
| Chlorothiazide | 1 | | |
| Chlorphen HD | 1 | | |
| Chlorphen Tan-Carbetapent Tan | 1 | | |
| Chlorphen Tan-Pseudoeph Tan | 1 | | |
| Chlorphen-Phenyleph-Methscop | 1 | | |
| Chlorphen-Phenyltolox-PE | 1 | | |
| Chlorphen-Pseudoeph-Methscop | 1 | | |
| Chlorpheniramine Maleate CR | 1 | | |
| Chlorpheniramine-Pseudoeph | 1 | | |
| ChlorproMAZINE HCl | 1 | | |
| ChlorproPAMIDE | 1 | | |
| Chlorthalidone | 1 | | |
| Chlorthalidone 100mg | 1 | | |
| Chlorzoxazone | 1 | | |
| Cholestyramine | 1 | | |
| Cholestyramine Light | 1 | | |
| Choline & Mag Trisalicylate | 1 | | |
| Choline-Mag Trisalicylate | 1 | | |
| Chorex-10 | 1PA | 1 | |
| Chorionic Gonadotropin | 1PA | 1 | |
| Cialis | 3 | 4 | |
| Ciclopirox Olamine | 1 | | |
| Cilostazol | 1 | | |
| Ciloxan* | 3 | | |
| Cimetidine | 1 | | |
| Cimetidine HCl | 1 | | |
| Cimzia | 3PA | | Specialty Pharmacy |
| Cipro HC | 3 | | |
| Cipro Susp | 2 | | |
| Cipro XR | 2 | 3 per Rx | |
| Cipro* | 3 | | |
| Ciprodex | 3 | | |
| Ciprofloxacin HCl | 1 | | |
| Ciprofloxacin Ophth | 1 | | |
| Citalopram Hydrobromide | 1 | | |
| Citric Acid-Sodium Citrate | 1 | | |
| Citrolith | 3 | | |
| Claravis | 1 | | |
| Clarifoam EF | 3 | | |
| Clearplex X | 1 | | |
| Clemastine Fumarate | 1 | | |
| Clenia | 1 | | |
| Clenia Foaming Wash | 1 | | |
| Cleocin Soln | 3 | | |
| Cleocin Vag Crm* | 2 | | |
| Cleocin* | 3 | | |
| Cleocin-T* | 3 | | |
| Clidinium-Chlordiazepoxide | 1 | | |
| Climara Pro | 3 | | |
| Climara* | 3 | 4 | |
| Clinac BPO | 3 | | |
| Clinda-Derm | 1 | | |
| Clindagel | 3 | | |
| ClindaMax | 1 | | |
| Clindamycin HCl | 1 | | |
| Clindamycin Phosphate | 1 | | |
| Clindesse | 3 | | |
| Clindets | 1 | | |
| Clinistix | 3 | | |
| Clinoril* | 3 | | |
| Clioquinol-HC | 1 | | |
| Clobetasol Foam | 1PA | | ST |
| Clobetasol Lotion | 1PA | | ST |
| Clobetasol Propionate | 1 | | |
| Clobetasol Propionate E | 1 | | |
| Clobetasol Shampoo | 1PA | | ST |
| Clobevate | 1 | | |
| Clobex Lotion* | 3PA | | ST |
| Clobex Shampoo* | 3PA | | ST |
| Clobex Spray | 3PA | | ST |
| Cloderm | 3 | | |
| Clomid* | 3 | | |
| ClomiPHENE Citrate | 1 | | |
| ClomiPRAMINE HCl | 1 | | |
| Clonazepam | 1 | | |
| Clonidine HCl | 1 | | |
| Clopidogrel | 1 | | |
| Clorazepate Dipotassium | 1 | | |
| Clorfed | 3 | | |
| Clorpres | 3 | | |
| Clotrimazole | 1 | | |
| Clotrimazole-Betamethasone | 1 | | |
| Clozapine | 1 | | |
| Clozaril* | 3 | | |
| CNL8 Nail Kit* | 3 | 1 | 1 Kit = 3 copays |
| Co-Gesic | 1 | | |
| Coal Tar | 3 | | |
| Coartem | 3 | | |
| Cocaine HCl | 1 | | |
| Cocet | 3 | | |
| Cocet Plus | 3 | | |
| Codafed Expectorant | 1 | | |
| Codafed Pediatric Expectorant | 1 | | |
| Codal-DH | 1 | | |
| Codal-DM | 1 | | |
| Codeine Phosphate | 3 | | |
| Codeine Phosphate Soluble | 1 | | |
| Codeine Sulfate | 3 | | |
| Codeine-Guaifenesin | 1 | | |
| Codiclear DH | 1 | | |
| Codimal DH* | 3 | | |
| Codimal PH | 3 | | |
| Codituss DH | 1 | | |
| Cognex | 3PA | | |
| Colazal* | 3 | | |
| Colchicine | 1 | | |
| Colchicine-Probenecid | 1 | | |
| Colcrys | 3 | | |
| Coldamine | 1 | | |
| Coldcough | 1 | | |
| Coldcough EXP | 1 | | |
| ColdCough HC | 1 | | |
| Coldcough PD | 1 | | |
| ColdCough XP | 1 | | |
| Coldec | 1 | | |
| Coldec D | 3 | | |
| Coldec D 12 Hour | 1 | | |
| Coldec DS 2-15 | 3 | | |
| Coldec DS 2-25 | 1 | | |
| Coldec-DM | 1 | | |
| Coldec-TR | 1 | | |
| Coldex-A SR | 1 | | |
| Coldmist DM | 1 | | |
| Coldmist JR | 1 | | |
| Coldmist LA | 1 | | |
| Coldmist S | 1 | | |
| Coldtuss | 1 | | |
| ColdTuss-DR | 1 | | |
| Colestid Flavored* | 3 | | |
| Colestid* | 3 | | |
| Colestipol HCl | 1 | | |
| Colfed-A | 1 | | |
| Colidrops | 1 | | |
| Colocort | 1 | | |
| Color Lancets | 2 | | |
| Colrex Compound | 3 | | |
| Coly-Mycin S | 3 | | |
| Colyte with Flavor Packs* | 3 | | |
| Colyte* | 3 | | |
| Colyte-Flavored* | 3 | | |
| Colytrol | 3 | | |
| Colytrol Pediatric | 3 | | |
| Combigan | 3 | | |
| CombiPatch | 3 | | |
| Combivent | 2 | | |
| Combivir* | 3 | | |
| Combunox | 3 | | |
| Comfort Lancets | 2 | | |
| Comhist | 3 | | |
| Compact Test | 3 | 150 | ST |
| Compazine | 3 | | |
| Complera | 3 | | |
| Compro | 1 | | |
| Comtan | 3 | | |
| Concerta 18, 27, 54mg | 3 | 30 | |
| Concerta 36mg | 3 | 60 | |
| Condylox* | 3 | | |
| Conex | 3 | | |
| Conpec | 3 | | |
| Conpec LA NR | 1 | | |
| Constulose | 1 | | |
| Conzip | - | | New to Market Policy |
| Copaxone | 2 | | Specialty Pharmacy |
| COPD | 1 | | |
| Cophene #2 | 1 | | |
| Cordarone* | 3 | | |
| Cordran | 3 | | |
| Cordran SP | 3 | | |
| Cordron-D | 3 | | |
| Cordron-DM | 3 | | |
| Cordron-HC | 3 | | |
| Coreg CR | 2PA | 30 | ST |
| Coreg* | 3PA | | ST |
| Corfen-DM | 1 | | |
| Corgard* | 3 | | |
| Cormax | 1 | | |
| Cortane-B Aqueous* | 3 | | |
| Cortane-B* | 3 | | |
| Cortef* | 3 | | |
| Cortic | 1 | | |
| Cortic-ND | 1 | | |
| Cortifoam | 2 | | |
| Cortisone Acetate | 1 | | |
| Cortisporin* | 3 | | |
| Cortisporin-TC | 3 | | |
| Cortomycin | 1 | | |
| Corzide | 3 | | |
| Cosopt* | 3 | | |
| Cotuss EX | 1 | | |
| Cotuss HD | 1 | | |
| Cotuss MS | 1 | | |
| Cotuss-V | 1 | | |
| Coughtuss | 1 | | |
| Coumadin* | 3 | | |
| Covera-HS | 3 | | |
| Cozaar* | 3 | | |
| CPM 8/PE 20/MSC 1.25 | 1 | | |
| CPM-PSE CR | 1 | | |
| Crantex | 1 | | |
| Crantex ER | 1 | | |
| Crantex HC | 1 | | |
| Crantex LA | 1 | | |
| Crantex LAC | 1 | | |
| Creon | 2 | | |
| Crestor | 3 | 30 | ST |
| Cresylate | 3 | | |
| Crinone | 3PA | 60 | |
| Crixivan | 2 | | |
| Crolom* | 3 | | |
| Cromolyn Sodium | 1 | | |
| Cryselle-28 | 1 | | |
| Cuprimine | 2 | | |
| Cutivate* | 3 | | |
| Cuvposa | 3PA | | |
| CVS Blood Glucose Test | 3 | 150 | ST |
| CVS Insulin Syringe | 2 | | |
| CVS Lancets | 2 | | |
| Cyanide Antidote | 3 | | |
| Cyclafem 1/35 | 1 | | |
| Cyclafem 7/7/7 | 1 | | |
| Cyclessa* | 3 | | |
| Cyclobenzaprine HCl | 1 | | |
| Cyclocort* | 3 | | |
| Cyclogyl* | 3 | | |
| Cyclomydril | 3 | | |
| Cyclopentolate HCl | 1 | | |
| Cyclophosphamide | 3 | | |
| Cycloset | 3PA | | |
| Cyclosporine | 1 | | |
| Cyclosporine Modified | 1 | | |
| Cylate | 1 | | |
| Cylert* | 3 | | |
| Cymbalta | 3PA | | ST |
| Cyotic | 1 | | |
| Cyproheptadine Syrup | 1 | | |
| Cyproheptadine Tab | 1 | | |
| Cystadane | 3 | | |
| Cystagon | 3 | | Specialty as of 07/01/11 |
| Cystex | 3 | | |
| Cystospaz* | 3 | | |
| Cystospaz-M* | 3 | | |
| Cytadren | 3 | | |
| Cytomel* | 3 | | |
| Cytotec* | 3 | | |
| Cytovene* | 3 | | |
| Cytra K Crystals | 1 | | |
| Cytra-2 | 1 | | |
| Cytra-3 | 1 | | |
| Cytra-K | 1 | | |
| D 1000 | 3 | | |
| D&K Insulin Syringe | 2 | | |
| D-Amine-SR | 1 | | |
| D-Feda II | 1 | | |
| D-Tal | 1 | | |
| D-Tann | 1 | | |
| D-Tann CT | 1 | | |
| D.H.E. 45* | 2 | | |
| Dacex-A | 1 | | |
| Dacex-DM | 1 | | |
| Dacex-PE | 1 | | |
| Daliresp | - | | New to Market Policy |
| Dallergy JR | 3 | | |
| Dallergy Syr | 1 | | |
| Dallergy Tab* | 3 | | |
| Dallergy-JR | 3 | | |
| Dalmane* | 3 | | |
| Danazol | 1 | | |
| Dantrium* | 3 | | |
| Dantrolene Sodium | 1 | | |
| Dapsone | 3 | | |
| Daraprim | 3 | | |
| Daypro* | 3 | | |
| Daytrana | 3PA | | |
| Dazidox | 3 | | |
| DD Lancets | 2 | | |
| DDAVP (Refrigerated)* | 3 | | |
| DDAVP Nasal Spry* | 3 | | |
| DDAVP Tabs* | 3 | | |
| DE Lancets | 2 | | |
| De-Chlor DM | 1 | | |
| De-Chlor DR | 1 | | |
| De-Chlor G | 1 | | |
| De-Chlor HC | 1 | | |
| De-Chlor HD | 1 | | |
| De-Chlor MR | 1 | | |
| De-Chlor NX | 1 | | |
| Debacterol | 3 | | |
| Decadron Dose Pack* | 3 | | |
| Decadron* | 3 | | |
| Decahist-DM | 3 | | |
| Declomycin* | 2 | | |
| Decon DM | 1 | | |
| Decon-A | 3 | | |
| Decon-E | 3 | | |
| Decon-G | 3 | | |
| Deconamine SR* | 3 | | |
| Deconamine* | 3 | | |
| Deconex | 3 | | |
| Decongest II | 1 | | |
| Decongestine TR | 1 | | |
| Deconsal II | 3 | | |
| Dehistine | 1 | | |
| Deka | 3 | | |
| Deka Pediatric | 3 | | |
| Del-Aqua | 1 | | |
| Del-Beta | 1 | | |
| Delos | 3 | | |
| Deltuss DMX | 3 | | |
| Demadex* | 3 | | |
| Demeclocycline HCl | 1 | | |
| Demerol* | 3 | | |
| Demser | 3 | | |
| Demulen 1/35 (28)* | 2 | | |
| Demulen 1/50 (28)* | 2 | | |
| Denavir | 3 | | |
| Denaze | 1 | | |
| Depade | 1 | | |
| Depakene* | 3 | | |
| Depakote ER | 3 | | |
| Depakote Sprinkles* | 3 | | |
| Depakote* | 3 | | |
| Depen Titratabs | 3 | | |
| Depo-Provera* | 3 | 1 | 3 Copays |
| Depo-SubQ Provera 104 | 2 | 1 per 90 days | 3 Copays |
| Derma-Smoothe/FS | 2 | | |
| Dermatop* | 3 | | |
| Dermazene | 1 | | |
| Dermotic | 3 | | |
| Desal-II | 1 | | |
| Desipramine HCl | 1 | | |
| Desmopressin Ace Spray Refrig | 1 | | |
| Desmopressin Acetate (Refrig) | 1 | | |
| Desmopressin Acetate Spray | 1 | | |
| Desogen* | 3 | | |
| Desonate | 3PA | | |
| Desonide | 1 | | |
| DesOwen* | 3 | | |
| Desoximetasone | 1 | | |
| Desoxyn* | 3 | | |
| Despec | 3 | | |
| Despec (5-100) | 1 | | |
| Despec DM | 3 | | |
| Despec SR | 3 | | |
| Desquam-E* | 3 | | |
| Desquam-X* | 3 | | |
| Desyrel* | 3 | | |
| Detrol | 3 | | |
| Detrol LA | 3 | | |
| Detuss | 1 | | |
| Dex PC | 1 | | |
| Dexacidin | 1 | | |
| Dexamethasone (Brand) | 1 | | |
| Dexamethasone (Generic) | 1 | | |
| Dexamethasone (Pak) | 1 | | |
| Dexamethasone Intensol | 3 | | |
| Dexamethasone Sodium Phosphate | 1 | | |
| Dexaphen SA | 1 | | |
| Dexasol | 1 | | |
| Dexasporin | 1 | | |
| Dexchlor | 1 | | |
| Dexchlorpheniramine Syr | 1 | | |
| Dexchlorpheniramine Tab | 1 | | |
| Dexcon-DM | 1 | | |
| Dexcon-PE | 1 | | |
| Dexedrine* | 3 | | |
| Dexilant | 3 | 30 | |
| Dexmethylphenidate | 1 | | |
| DexPak | 3 | | |
| Dextroamphetamine Sulfate | 1 | | |
| Dextroamphetamine Sulfate CR | 1 | | |
| DextroStat 10mg* | 3 | | |
| DextroStat 5mg | 1 | | |
| DG 200 | 1 | | |
| DHE* | 3 | | |
| Diabeta* | 3 | | |
| Diabetic Automatic Lance | 2 | | |
| Diabetic Tussin C | 3 | | |
| Diabetic.com Test Strips | 3 | 150 | ST |
| Diabinese* | 3 | | |
| Diamox Sequels | 3 | | |
| Diastat | 3 | | |
| Diastat Adult | 3 | | |
| Diastat Pediatric | 3 | | |
| Diastat Universal | 3 | | |
| Diastix | 3 | | |
| Diazepam Intensol | 3 | | |
| Diazepam Soln | 1 | | |
| Diazepam Tab | 1 | | |
| Dibenzyline | 3 | | |
| Diclofenac Potassium | 1 | | |
| Diclofenac Sodium | 1 | | |
| Diclofenac Sodium CR | 1 | | |
| Dicloxacillin Sodium | 1 | | |
| Dicyclomine | 1 | | |
| Dicyclomine HCl | 1 | | |
| Didanosine | 1 | | |
| Didronel* | 3 | | |
| Differin Crm | 3 | | |
| Differin Gel 0.1% | 3 | | |
| Differin Gel 0.3% | 2 | | |
| Differin Lotion | 3 | | |
| Dificid | 3PA | | |
| Difil G Forte | 1 | | |
| Difil-G | 3 | | |
| Diflorasone Diacetate | 1 | | |
| Diflucan 150mg Tab* | 3 | 1 per Rx | |
| Diflucan 50, 100, 200mg Tab* | 3 | 15 | |
| Diflucan Susp* | 3 | 75 | |
| Diflunisal | 1 | | |
| Digesplen Plus | 1 | | |
| Digex | 1 | | |
| Digitek | 1 | | |
| Digoxin | 1 | | |
| Dihistine DH | 1 | | |
| DiHydro-CP | 1 | | |
| DiHydro-GP | 1 | | |
| Dihydroergotamine Mesylate | 1 | | |
| Dilacor XR* | 3 | | |
| Dilantin Infatabs | 2 | | |
| Dilantin* | 2 | | |
| Dilatrate-SR | 2 | | |
| Dilaudid* | 3 | | |
| Dilaudid-5* | 3 | | |
| Dilex-G | 1 | | |
| Dilex-G 200 | 3 | | |
| Dilex-G 400 | 3 | | |
| Dilor | 1 | | |
| Dilor-G | 1 | | |
| Dilt-CD | 1 | | |
| Dilt-XR | 1 | | |
| Diltia XT | 1 | | |
| Diltiazem HCl | 1 | | |
| Diltiazem HCl Coated Beads | 1 | | |
| Diltiazem HCl CR | 1 | | |
| Diltiazem HCl ER Beads | 1 | | |
| Diovan | 2 | | |
| Diovan HCT | 2 | | |
| Dipentum | 2 | | |
| DiphenhydrAMINE HCl | 1 | | |
| Diphenoxylate-Atropine | 1 | | |
| Diphentann-D | 1 | | |
| Dipivefrin HCl | 1 | | |
| Diprolene AF* | 3 | | |
| Diprolene Gel* | 3 | | |
| Diprolene Lotn* | 3 | | |
| Diprolene Oint* | 3 | | |
| Diprosone* | 3 | | |
| Dipyridamole | 1 | | |
| Discount Drug Mart Test Strips | 3 | 150 | ST |
| Disopyramide Phosphate | 1 | | |
| DisperMox | 3 | | |
| Ditropan XL* | 3 | | |
| Ditropan* | 3 | | |
| Diuril* | 3 | | |
| Divalproex | 1 | | |
| Divigel | 3 | | |
| DM | 1 | | |
| DM-Phenylephrine-Chlorphen | 1 | | |
| DM-Pot Guaiacolsulfonate | 1 | | |
| DMax | 3 | | |
| DMax Pediatric | 3 | | |
| Dolacet | 1 | | |
| Dolagesic | 1 | | |
| Dolgic LQ | 3 | | |
| Dolgic Plus | 3 | | |
| Dolobid* | 3 | | |
| Dolophine* | 3 | | |
| Dolorex | 1 | | |
| Dolorex Forte | 1 | | |
| Dolotic | 1 | | |
| Domeboro* | 3 | | |
| Dometuss Cough/Cold | 1 | | |
| Dometuss DM | 1 | | |
| Donatussin | 3 | | |
| Donatussin Pediatric | 1 | | |
| Donatussin-DC | 1 | | |
| Donepezil | 1 | | |
| Donnaphen | 1 | | |
| Donnatal Extentabs* | 3 | | |
| Donnatal* | 3 | | |
| Doral | 3 | | |
| Doryx | 3 | | |
| Dostinex* | 3 | 8 | |
| Dovonex* | 3 | | |
| Doxazosin Mesylate | 1 | 30 | |
| Doxepin HCl | 1 | | |
| Doxy-Caps | 1 | | |
| Doxycycline Hyclate 75,100mg | 1 | | |
| Doxycycline Monohydrate | 1 | | |
| DR Lancets | 2 | | |
| DR Thin Lancets | 2 | | |
| Drexophed SR | 1 | | |
| DriHist SR | 1 | | |
| Drisdol* | 3 | | |
| Dritho-Creme | 3 | | |
| Dritho-Scalp | 2 | | |
| Drituss DM | 1 | | |
| Drituss GP | 1 | | |
| Drituss HD | 1 | | |
| Drixomed | 1 | | |
| Drize-R | 1 | | |
| Drocon-CS | 1 | | |
| Dronabinol | 1 | 3 | |
| Droxia | 3 | | |
| Drug Emporium Insulin Syringe | 2 | | |
| Drug Emporium Test Strip | 3 | 150 | ST |
| Drysec | 1 | | |
| Drysol* | 3 | | |
| Duac | 3PA | | |
| Duetact | 2 | 30 | |
| Duexis | - | | New to Market Policy |
| Dulera | 3 | | |
| Duonate-12 | 1 | | |
| DuoNeb* | 3 | | |
| Duotan | 1 | | |
| Duotan DM | 1 | | |
| Duotan PD | 1 | | |
| Durabac Forte | 3 | | |
| Durabac* | 3 | | |
| DuraDal HD | 1 | | |
| DuraDal HD Plus | 1 | | |
| DuraDEX | 3 | | |
| Duradrin | 1 | | |
| Duradryl | 1 | | |
| Durafed | 1 | | |
| Duraflu | 3 | | |
| DuraGanidin DM | 1 | | |
| Duragesic* | 3 | | |
| Durahist PE* | 3 | | |
| DURAHIST* | 3 | | |
| Duraphen DM* | 3 | | |
| Duraphen Forte | 3 | | |
| Duraphen II DM | 3 | | |
| Duraphen II* | 3 | | |
| Durasal II | 1 | | |
| DuraTan DM* | 3 | | |
| Duratuss | 3 | | |
| Duratuss DM | 3 | | |
| Duratuss GP | 3 | | |
| Duratuss HD | 3 | | |
| Duraxin | 3 | | |
| Durezol | 3 | | |
| Duricef* | 3 | | |
| Dutoprol | 3 | 30 | |
| Dy-G | 1 | | |
| Dyazide* | 3 | | |
| Dyflex-G | 1 | | |
| Dygase | 3 | | |
| Dyline-GG | 1 | | |
| Dylix | 3 | | |
| Dynabac D5-Pak | 3 | | |
| Dynacin | 3 | | |
| DynaCirc | 3 | | |
| DynaCirc CR | 3 | | |
| Dynahist ER | 1 | | |
| Dynatuss | 1 | | |
| Dynatuss DF | 1 | | |
| Dynatuss EX | 1 | | |
| Dynatuss HC | 1 | | |
| Dynatuss HCG | 3 | | |
| Dynex* | 3 | | |
| Dyphyl-G | 1 | | |
| Dyphylline-Guaifenesin | 1 | | |
| Dyrenium | 3 | | |
| Dytan* | 3 | | |
| Dytan-CS* | 3 | | |
| Dytan-D* | 3 | | |
| Dytuss | 1 | | |
| E-Z Ject Blood Lancets | 2 | | |
| E-Z Ject Lancets | 2 | | |
| E-Z Ject Lancets Super Thin | 2 | | |
| E-Z Ject Thin | 2 | | |
| E-Z Ject XL Blood Lancets | 2 | | |
| E.E.S. 200 | 1 | | |
| E.E.S. 400 | 1 | | |
| E.E.S. Granules* | 3 | | |
| Ear-Gesic | 1 | | |
| Easprin* | 3 | | |
| EasyGluco Test Strips | 3 | 150 | ST |
| EasyTest Lancets | 2 | | |
| EC-Naprosyn* | 3 | | |
| ECK Blood Glucose Test Strips | 3 | 150 | ST |
| ECK Insulin Syringe | 2 | | |
| ECK Lancets | 2 | | |
| ECK Niacin | 1 | | |
| ECK Night time Sleep-Aid | 1 | | |
| Econazole Nitrate | 1 | | |
| Econopred Plus* | 3 | | |
| Ed A-Hist* | 3 | | |
| ED DM | 3 | | |
| ED K+10 | 1 | | |
| Ed-A-Hist DM | 3 | | |
| Ed-Bron G | 3 | | |
| Ed-Chlor-Tan | 3 | | |
| Ed-Flex | 1 | | |
| ED-TLC | 1 | | |
| Ed-Tuss HC | 1 | | |
| Edarbi | 3 | 30 | |
| Edarbyclor | 3 | 30 | |
| Edecrin | 2 | | |
| Edex | 3 | 4 | |
| Edluar | 3PA | | |
| Edurant | 3 | | |
| Effer-K | 3 | | Some products generic |
| Effervescent Pot Chloride | 1 | | |
| Effexor XR* | 3 | | ST |
| Effexor* | 3 | | |
| Effient | 3PA | | |
| Efudex Occlusion Pack | 3 | | |
| Efudex* | 3 | | |
| Egrifta | - | | New to Market Policy |
| Elavil* | 3 | | |
| Eldepryl* | 3 | | |
| Elestat* | 3 | | |
| Elestrin Gel | 3 | | 2 Copays per container |
| Elidel | 3 | | |
| Elimite* | 3 | | |
| Eliphos* | 3 | | |
| Elite-Thin Insulin Syringe | 2 | | |
| Elixophyllin | 3 | | |
| Elixophyllin GG | 3 | | |
| Elixophyllin-KI | 3 | | |
| Ella | 3 | 1 | Limit 1 per Rx |
| Elmiron | 2 | | |
| Elocon* | 3 | | |
| Emadine | 3 | | |
| Embeda | 3PA | | |
| Embeline | 1 | | |
| Embeline E | 1 | | |
| Emcyt | 2 | | |
| Emend | 3PA | | |
| Emend Tri-fold | 3PA | | |
| Emgel | 1 | | |
| EMLA* | 3 | | |
| EMLA/Tegaderm | 3 | | |
| Emoquette | 1 | | |
| Emsam | 3PA | 30 | |
| Emtriva | 3 | | |
| Enablex | 3 | 30 | |
| Enalapril Maleate | 1 | | |
| Enalapril-Hydrochlorothiazide | 1 | | |
| Enbrel 25mg | 3 | 8 | Specialty Pharmacy |
| Enbrel 50mg | 3 | 4 | Specialty Pharmacy |
| Encort | 1 | | |
| EndaCof-DM | 1 | | |
| EndaCof-HC | 1 | | |
| EndaCof-PD | 1 | | |
| EndaCof-Plus | 1 | | |
| EndaCof-XP | 1 | | |
| Endagen-HD | 1 | | |
| Endal-HD Plus* | 3 | | |
| Endal-HD* | 3 | | |
| Endocet | 1 | | |
| Endodan | 1 | | |
| Endometrin | 3PA | | |
| Endur-Acin | 1 | | |
| Enduronyl Forte | 3 | | |
| Enjuvia | 3 | | |
| Enplus-HD | 1 | | |
| Enpresse-28 | 1 | | |
| Entab-DM | 1 | | |
| Entereg | 3PA | | |
| Entex ER* | 3 | | |
| Entex HC* | 3 | | |
| Entex LA* | 3 | | |
| Entex PSE* | 3 | | |
| Entex* | 3 | | |
| Entocort EC* | 3 | 90 | |
| Entuss* | 3 | | |
| Enulose | 1 | | |
| Enzycap | 3 | | |
| Enzymax | 3 | | |
| Eperbel-S | 1 | | |
| Epidrin | 1 | | |
| EpiDuo | 3PA | | |
| Epifoam | 3 | | |
| Epinastine Oph | 1 | | |
| EpiPen | 2 | | |
| EpiPen Jr | 2 | | |
| Epitol | 1 | | |
| Epivir HBV | 2 | | |
| Epivir* | 3 | | |
| Epogen | 3PA | | Specialty Pharmacy |
| Eprosartan | 1 | | |
| Epzicom | 3 | | |
| Equagesic | 3 | | |
| Equate Regular Lancets | 2 | | |
| Equate Thin Lancets | 2 | | |
| Equetro | 3 | | |
| Ergocaff-PB | 1 | | |
| Ergoloid Mesylates | 1 | | |
| Ergoloid Mesylates SL | 3 | | |
| Ergomar | 2 | | |
| Ergotamine-Caffeine | 1 | | |
| Erivedge | - | | New to Market Policy |
| Errin | 1 | | |
| Ertaczo | 3 | | |
| Ery-Tab | 2 | | |
| Eryc* | 3 | | |
| Erycette* | 3 | | |
| Eryderm | 1 | | |
| Erygel* | 3 | | |
| EryPed | 2 | | |
| EryPed 200* | 2 | | |
| EryPed 400 | 2 | | |
| Erythrocin Stearate | 1 | | |
| Erythromycin | 1 | | |
| Erythromycin Base Cap | 1 | | |
| Erythromycin Base Tab | 1 | | |
| Erythromycin Ethylsuccinate | 1 | | |
| Erythromycin-Sulfisoxazole | 1 | | |
| Esclim | 2 | 8 | |
| Esgic* | 3 | | |
| Esgic-Plus* | 3 | | |
| Estazolam | 1 | 9 | |
| Estrace Vag Crm | 2 | | |
| Estrace* | 3 | | |
| Estraderm | 2 | 8 | |
| Estradiol | 1 | | |
| Estradiol Patch | 1 | 4 | |
| Estrasorb | 3 | | |
| Estratest H.S.* | 2 | | |
| Estratest* | 2 | | |
| Estring | 3 | 1 | 3 Copays per Rx |
| Estrogel | 3 | | 2 Copays per container |
| Estropipate | 1 | | |
| Estrostep* | 3 | | |
| Ethambutol HCl | 1 | | |
| EtheDent | 1 | | |
| EthexDERM BPW-10 | 1 | | |
| EthexDERM BPW-5 | 1 | | |
| Ethezyme | 3 | | |
| Ethezyme 830 | 1 | | |
| Ethmozine | 3 | | |
| Ethosuximide | 1 | | |
| Ethyl Chloride | 3 | | |
| Etidronate | 1 | | |
| Etodolac | 1 | | |
| Etodolac CR | 1 | | |
| Etoposide | 3 | | |
| Eudal-SR* | 3 | | |
| Eulexin* | 3 | | |
| Eurax | 3 | | |
| Evamist | 3 | | |
| EvenCare Blood Glucose Test | 3 | 150 | ST |
| EvenCare Control Soln | 3 | | ST |
| Evista | 3 | | |
| Evoclin | 3PA | | |
| Evoxac | 2 | | |
| Ex-Dec-TR | 1 | | |
| ExacTech Test Strips | 3 | 150 | ST |
| Exalgo | 3PA | | |
| Excel G Test Strips | 3 | 150 | ST |
| ExeFen-DM | 1 | | |
| ExeFen-PD | 1 | | |
| Exel Insulin Syringe | 2 | | |
| Exel Pen Needles | 2 | | |
| Exelderm | 2 | | |
| Exelon Cap* | 3 | | |
| Exelon Patch | 3 | 30 | |
| Exelon Soln | 3 | | |
| Exemestane | 1 | | |
| Exforge | 3 | 30 | |
| Exforge HCT | 3 | 30 | |
| Exjade | 3 | | Specialty Pharmacy |
| Exoderm | 1 | | |
| Exotic-HC | 1 | | |
| Express Med Test Strip | 3 | 150 | ST |
| Exratuss | 1 | | |
| Extavia | 3 | | |
| Extendryl JR | 3 | | |
| Extendryl SR | 3 | | |
| Extendryl* | 3 | | |
| Extina* | 3PA | | |
| Extuss LA | 1 | | |
| Exubera Comb Pow Pack | 3PA | | |
| Exubera Pow Kit | 3PA | | |
| EZ-Lets Lancets | 2 | | |
| Ezol | 1 | | |
| Factive | 3PA | | |
| Famciclovir | 1 | | |
| Famotidine 40mg only | 1 | | |
| Famvir* | 3 | | |
| Fanapt | 3PA | | |
| Fansidar | 3 | | |
| Fareston | 3 | | |
| FastTake Test Strips | 2 | 150 | |
| FazaClo | 3 | | |
| Felbamate Tabs | 1 | | |
| Felbatol* | 3 | | |
| Feldene* | 3 | | |
| Felodipine | 1 | | |
| Fem pH | 3 | | |
| Femara* | 3 | | |
| Femhrt 1/5* | 3 | | |
| FemHRT Low Dose | 3 | | |
| Femring | 3 | 1 per Rx | |
| FemTrace | 3 | | |
| Fenofibrate | 1 | | |
| Fenoglide | 3 | | |
| Fenoprofen 600mg | 3 | | |
| Fentanyl | 1 | | |
| Fentanyl Citrate | 3PA | | |
| Fentanyl LPOP | 1PA | | |
| Fentora | 3PA | | |
| Ferriprox | - | | New to Market Policy |
| Fertinex | 3PA | | |
| Fibricor | 3 | | |
| Finacea | 3 | | |
| Finasteride | 1 | 30 | |
| Fioricet* | 3 | | |
| Fioricet/Codeine* | 3 | | |
| Fiorinal* | 3 | | |
| Fiorinal/Codeine #3* | 3 | | |
| Firazyr | - | | New to Market Policy |
| First Choice Insulin Syringe | 2 | | |
| First Choice Lancets Colored | 2 | | |
| First Choice Lancets Thin | 2 | | |
| First-Hydrocortisone | 2PA | | |
| First-Mouthwash BLM | 3 | | |
| First-Progesterone MC 10 | 3 | | |
| First-Progesterone MC 5 | 3 | | |
| First-Progesterone VGS | 3 | | |
| First-Testosterone | 2 | | |
| First-Testosterone MC | 2 | | |
| Flagyl ER* | 3 | | |
| Flagyl* | 3 | | |
| Flarex | 3 | | |
| Flavoxate HCl | 1 | | |
| Flecainide Acetate | 1 | | |
| Flector | 3PA | | |
| Flexeril* | 3 | | |
| Flextra | 3 | | |
| Flextra DS* | 3 | | |
| Flextra-650* | 3 | | |
| Flo-Pred | 3 | | |
| Flomax* | 3 | | |
| Flonase* | 3 | | ST |
| Florinef* | 3 | | |
| Flovent Diskus | 2 | 60 | |
| Flovent HFA | 2 | 12 | |
| Floxin Otic* | 3 | | |
| Floxin* | 3 | | |
| Fluconazole 150mg Tab | 1 | 1 per Rx | |
| Fluconazole 50, 100, 200mg Tab | 1 | 15 | |
| Fluconazole Susp | 1 | 75 | |
| Flucytosine | 1 | | |
| Fludrocortisone Acetate | 1 | | |
| Flumadine* | 3PA | | |
| Flunisolide | 1 | | |
| Fluocinolone Acetonide | 1 | | |
| Fluocinonide | 1 | | |
| Fluocinonide-E | 1 | | |
| Fluor-a-day | 1 | | |
| Fluor-Op | 1 | | |
| Fluorabon Soln* | 3 | | |
| Fluorabon Tab | 1 | | |
| Fluoride | 1 | | |
| Fluoritab | 1 | | |
| Fluorometholone | 1 | | |
| Fluoroplex | 3 | | |
| Fluorouracil | 1 | | |
| Fluoxetine 60mg | 3 | | Not a generic |
| Fluoxetine DR 40mg | 1PA | 4 | Prozac Weekly Generic |
| Fluoxetine HCl 10, 20mg | 1 | | |
| Fluoxetine HCl 40mg | 1PA | | |
| Fluphenazine HCl Conc | 1 | | |
| Fluphenazine HCl Elx | 1 | | |
| Fluphenazine HCl Tab | 1 | | |
| Flura-Drops | 1 | | |
| Flurazepam HCl | 1 | | |
| Flurbiprofen | 1 | | |
| Flurbiprofen Sodium | 1 | | |
| Flutamide | 1 | | |
| Fluticasone | 1 | | |
| Fluticasone Propionate | 1 | | |
| FluTuss HC | 3 | | |
| Fluvoxamine Maleate | 1 | | |
| FML Forte | 2 | | |
| FML Liquifilm* | 3 | | |
| FML S.O.P. | 2 | | |
| FML-S Liquifilm | 2 | | |
| Focalin | 3* | | |
| Focalin XR | 3 | 30 | |
| Folic Acid | 1 | | |
| Follistim AQ 150 | 3PA | 10 | |
| Follistim AQ 300 | 3PA | 5 | |
| Follistim AQ 600 | 3PA | 3 | |
| Follistim AQ 75 | 3PA | 20 | |
| Follistim AQ 900 | 3PA | 2 | |
| Fondaparinux | 1 | | Limit 14 day supply |
| Foradil Aerolizer | 2 | | |
| Fortabs | 1 | | |
| Fortamet | 3 | 30 | ST |
| Forteo | 3PA | | Specialty Pharmacy |
| Fortesta | 3PA | | |
| Fortical | 3 | | |
| Fosamax 70mg Tab* | 3 | 4 | |
| Fosamax Plus D | 2 | 4 | |
| Fosamax* | 3 | | |
| Fosinopril Sodium | 1 | | |
| Fosinopril Sodium-HCTZ | 1 | | |
| Fosrenol | 3PA | | |
| FP Blood Glucose Test Strips | 3 | 150 | ST |
| FP Insulin Syringe | 2 | | |
| FP Lancets | 2 | | |
| Fragmin | 2 | 14 Day Supply | |
| FreeStyle Control Solution | 3 | | ST |
| FreeStyle Lancets | 2 | | |
| FreeStyle Test Strips | 3 | 150 | ST |
| Frenadol | 3 | | |
| Freshkote | 3 | | |
| Frova | 3 | 9 | |
| Furadantin* | 3 | | |
| Furosemide Soln 10mg/ml | 1 | | |
| Furosemide Soln 8mg/ml | 3 | | |
| Furosemide Tab | 1 | | |
| Furoxone | 3 | | |
| G P Tex | 1 | | |
| G-Bid DM | 1 | | |
| G-Phed | 1 | | |
| G-Phed-PD | 1 | | |
| G-Tuss | 1 | | |
| G/P | 1 | | |
| G/P 1200/60 | 1 | | |
| Gabapentin | 1 | | |
| Gabarone* | 3 | | |
| Gabitril | 3 | | |
| Galantamine | 1 | | |
| Galantamine ER | 1 | | |
| Ganciclovir | 1 | | |
| Gani-Tuss DM NR | 1 | | |
| Gani-Tuss NR | 1 | | |
| Ganidin NR | 1 | | |
| Ganirelix Acetate | 3PA | | |
| Gantrisin Pediatric | 3 | | |
| Garamycin Oph Oint | 1 | | |
| Garamycin Oph Soln | 3 | | |
| Gastrinex | 3 | | |
| Gastrocrom* | 3 | | |
| GDP-EX | 1 | | |
| Gebauers Spray and Stretch | 3 | | |
| Gelclair | 3 | | |
| Gelnique | 3PA | | |
| Gemfibrozil | 1 | | |
| Genantuss | 1 | | |
| Genebrom DM | 1 | | |
| GeneBronco-D | 3 | | |
| Genecar | 1 | | |
| Genecof-HC 15-2-2.5 | 3 | | |
| Genecof-HC 15-2-3 | 1 | | |
| Genecof-XP 15-2.5-100 | 3 | | |
| Genecof-XP 15-3-100 | 1 | | |
| Genedel | 3 | | |
| Genedotuss-DM | 1 | | |
| Genelan* | 3 | | |
| GenePatuss | 3 | | |
| Generlac | 1 | | |
| Genetuss | 1 | | |
| Genetuss-2 | 1 | | |
| Genexotic-HC | 1 | | |
| Genexpect DM | 3 | | |
| Genexpect-PE | 3 | | |
| Genexpect-SF | 3 | | |
| Gengraf | 1 | | |
| Genoptic | 1 | | |
| Genotropin | 3PA | | Specialty Pharmacy |
| Gentacidin | 1 | | |
| Gentafair | 1 | | |
| Gentak | 1 | | |
| Gentamicin Sulfate | 1 | | |
| Gentasol | 1 | | |
| Gentle Touch Insulin Syringe | 2 | | |
| Gentle-Let GP Lancets | 2 | | |
| Gentle-Let Lancets | 2 | | |
| Geocillin | 2 | | |
| Geodon | 2 | | |
| Geone (G-1) | 1 | | |
| Geref | 3PA | | |
| GFN 1000/DM 50 | 3 | | |
| GFN 1000/DM 60 | 1 | | |
| GFN 1200/DM 20/PE 40 | 1 | | |
| GFN 1200/DM 60 | 1 | | |
| GFN 1200/DM 60/PSE 120 | 1 | | |
| GFN 1200/Phenylephrine 40 | 1 | | |
| GFN 1200/PSE 50 | 1 | | |
| GFN 500/DM 30 | 1 | | |
| GFN 550/PSE 60 | 3 | | |
| GFN 550/PSE 60/DM 30 | 3 | | |
| GFN 595/PSE 48 | 1 | | |
| GFN 595/PSE 48/DM 32 | 1 | | |
| GFN 600/Phenylephrine 20 | 1 | | |
| GFN 600/Phenylephrine 40 | 1 | | |
| GFN 795/PSE 85 | 1 | | |
| GFN 800/DM 30 | 1 | | |
| GFN 800/PE 25 | 1 | | |
| GFN 800/PSE 60 | 1 | | |
| GFN 800/PSE 60/DM 30 | 1 | | |
| GFN/DM/PSE | 1 | | |
| GFN/PSE | 1 | | |
| GFN600/PSE60/DM30 | 1 | | |
| GG 200 NR | 1 | | |
| Giant Eagle Lancets | 2 | | |
| Giant Eagle Pharm Test Strips | 3 | 150 | ST |
| Gianvi | 1 | | |
| Gilchew IR | 1 | | |
| Gilenya | 3PA | | |
| Gilphex TR | 3 | | |
| Giltuss CR | 3 | | |
| Giltuss HC | 3 | | |
| Giltuss Ped-C | 3 | | |
| Giltuss Pediatric* | 3 | | |
| Giltuss* | 3 | | |
| Gladase | 1 | | |
| Gladase-C | 1 | | |
| Gleevec | 3 | | Specialty Pharmacy |
| Glimepiride | 1 | | |
| GlipiZIDE | 1 | | |
| GlipiZIDE XL | 1 | | |
| GlucaGen | 2 | | |
| Glucagon Emergency | 2 | | |
| Glucofilm Control Soln | 3 | | ST |
| Glucofilm Test Strips | 3 | 150 | ST |
| Glucolet Lancing Dev | 2 | | |
| Glucometer Control Soln | 3 | | ST |
| Glucometer Dex Glucose Sensors | 3 | 150 | ST |
| Glucometer Test Strips | 3 | 150 | ST |
| Glucophage XR* | 3 | | |
| Glucophage* | 3 | | |
| Glucosource Lancet Device | 2 | | |
| Glucosource Lancets | 2 | | |
| Glucostix | 3 | 150 | ST |
| Glucotrol XL* | 3 | | |
| Glucotrol* | 3 | | |
| Glucovance* | 3 | 120 | |
| Glumetza | 3 | | |
| GlyBURIDE | 1 | | |
| GlyBURIDE Micronized | 1 | | |
| Glyburide-Metformin | 1 | 120 | |
| GlycoLax | 1 | | |
| Glycopyrrolate | 1 | | |
| Glycron | 1 | | |
| Glycron (4.5mg) | 3 | | |
| Glynase* | 3 | | |
| Glyset | 3 | | |
| GNP Insulin Syringe | 2 | | |
| GNP Lancets | 2 | | |
| GNP Lancing Device | 2 | | |
| GNP Niacin TR | 1 | | |
| GNP Test Strip | 3 | 150 | ST |
| Golytely | 3 | | |
| Gonal-f 1050 | 2PA | | |
| Gonal-f 450 | 2PA | 1 | |
| Gonal-f 600 Kit | 2PA | 3 | |
| Gonal-f RFF 75 | 2PA | 20 | |
| Gonal-f RFF Pen 300 | 2PA | 5 | |
| Gonal-f RFF Pen 450 | 2PA | 4 | |
| Gonal-f RFF Pen 900 | 2PA | 2 | |
| Goniosol* | 3 | | |
| Gordofilm | 3 | | |
| Gordons Urea | 3 | | |
| GP-1200 | 1 | | |
| GP500 | 1 | | |
| Gralise | - | | New to Market Policy |
| Granisetron Tab | 1 | 3 | |
| Granulderm | 1 | | |
| Granulex* | 3 | | |
| Grifulvin V* | 2 | | |
| Gripex PE Pediatric | 1 | | |
| Gris-PEG | 3 | | |
| Griseofulvin Microsize | 1 | | |
| Gua C | 1 | | |
| Gua PC | 1 | | |
| Guacol DM Pediatric | 3 | | |
| Guai-Co | 1 | | |
| Guai-Dex | 1 | | |
| Guaiatussin AC | 1 | | |
| Guaidex-TR | 1 | | |
| Guaifed* | 3 | | |
| Guaifed-PD* | 3 | | |
| Guaifen PSE | 1 | | |
| Guaifenesin | 1 | | |
| Guaifenesin 600/PSE 120 | 1 | | |
| Guaifenesin AC | 1 | | |
| Guaifenesin DM | 1 | | |
| Guaifenesin DM NR | 1 | | |
| Guaifenesin NR | 1 | | |
| Guaifenesin PSE | 1 | | |
| Guaifenesin PSE SR | 1 | | |
| Guaifenesin-Codeine | 1 | | |
| Guaifenesin-DM | 1 | | |
| Guaifenesin-DM CR | 1 | | |
| Guaifenesin-DM LA | 1 | | |
| Guaifenesin-Phenylephrine CR | 1 | | |
| Guaifenesin-PSE CR | 1 | | |
| Guaifenesin-PSE-Hydrocodone | 1 | | |
| Guaifenesin-Pseudoephedrine CR | 1 | | |
| Guaifenesin-Pseudoephedrine SR | 1 | | |
| Guaifenex DM | 1 | | |
| Guaifenex GP | 1 | | |
| Guaifenex PSE 120 | 1 | | |
| Guaifenex PSE 60 | 1 | | |
| Guaifenex PSE 80 | 1 | | |
| GuaiMAX-D | 1 | | |
| Guaimist DM | 1 | | |
| Guaimist S | 1 | | |
| Guaiphen-D | 1 | | |
| Guaiphen-D 1200 | 1 | | |
| Guaiphen-PD | 1 | | |
| Guaitussin AC | 1 | | |
| Guaitussin DAC | 1 | | |
| Guanabenz Acetate | 1 | | |
| Guanfacine HCl | 1 | | |
| Guanidine HCl | 3 | | |
| Guapetex | 1 | | |
| Guapetex HC | 1 | | |
| Guia-D | 1 | | |
| Guiadex D | 1 | | |
| Guiadex DH | 1 | | |
| Guiadex DM | 1 | | |
| Guiadex PD | 1 | | |
| Guiadrine DM | 1 | | |
| Guiadrine GP | 1 | | |
| Guiatuss AC | 1 | | |
| Guiatuss DAC | 1 | | |
| Gynazole-1 | 3 | | |
| Gynodiol | 1 | | |
| Gynodiol (1.5mg) | 3 | | |
| H&H Lancets | 2 | | |
| Halcion* | 3PA | | |
| Halfan | 3 | | |
| HalfLytely Bowel Prep | 3 | | |
| Halobetasol Propionate | 1 | | |
| Halog | 2 | | |
| Haloperidol | 1 | | |
| Haloperidol (10mg) | 1 | | |
| Haloperidol (20mg) | 1 | | |
| Haloperidol Lactate Conc | 1 | | |
| Haponal | 1 | | |
| HC Cream | 1 | | |
| HC Pramoxine | 3 | | |
| HC Tussive | 1 | | |
| HC Tussive-D | 1 | | |
| HCA Allergy Relief | 1 | | |
| HCA Cold/Cough | 1 | | |
| HCA Insulin Syringe | 2 | | |
| HCA Lancets | 2 | | |
| HCA Lancing Device | 2 | | |
| HCA Niacin | 1 | | |
| HCA Niacin CR | 1 | | |
| HCA Niacin TR | 1 | | |
| HCA Test Strips | 3 | 150 | ST |
| HCTZ / Losartan | 1 | 30 | |
| Health Alliance Test Strip | 3 | 150 | ST |
| Hectorol | 3 | | |
| Helidac | 3PA | | |
| Hemorrhoidal-HC | 1 | | |
| Hemril-30 | 1 | | |
| Hemril-HC | 1 | | |
| Hepsera | 3PA | | |
| Hexafed | 3 | | |
| Hexaflu | 3 | | |
| Hexalen | 3 | | |
| Hiprex* | 3 | | |
| Hisdec | 1 | | |
| Hist-HC | 1 | | |
| Hist-Plus | 1 | | |
| Hista-Vent DA | 1 | | |
| Hista-Vent PSE | 1 | | |
| Histacol DM | 1 | | |
| Histacol DM Pediatric | 1 | | |
| Histacol LA | 1 | | |
| Histade CR | 1 | | |
| Histade MX | 1 | | |
| Histalet | 3 | | |
| Histex CT* | 3 | | |
| Histex HC* | 3 | | |
| Histex IE* | 3 | | |
| Histex PD 12 | 3 | | |
| Histex PD* | 3 | | |
| Histex SR* | 3 | | |
| Histex* | 3 | | |
| Histinex HC | 1 | | |
| Histinex PV | 1 | | |
| Histuss | 1 | | |
| Histuss HC | 1 | | |
| Histuss PD | 1 | | |
| Histussin D | 1 | | |
| Histussin HC | 1 | | |
| Hivid | 3 | | |
| HM Mono Insulin Syringe | 2 | | |
| HMS Liquifilm | 3 | | |
| Homapin-10 | 3 | | |
| Homatropaire | 1 | | |
| Horizant | 3PA | | |
| HT-Tuss DM | 1 | | |
| Humalog | 2 | | |
| Humalog Mix | 3 | | |
| Humalog Mix Pen or Cart | 3PA | | |
| Humalog Pen | 3PA | | |
| Humatin* | 3 | | |
| Humatrope | 3PA | | Specialty Pharmacy |
| Humibid DM | 3 | | |
| Humibid LA | 3 | | |
| Humira | 3 | 2 | Specialty Pharmacy |
| Humira Pen | 3 | 2 | Specialty Pharmacy |
| Humira Starter Kit | 3 | 6 | Crohn's Only |
| Humulin 50/50 | 2 | | |
| Humulin 70/30 | 2 | | |
| Humulin 70/30 Pen | 3PA | | |
| Humulin L | 2 | | |
| Humulin N | 2 | | |
| Humulin N Pen | 3PA | | |
| Humulin R | 2 | | |
| Humulin U | 2 | | |
| Hy-KXP | 1 | | |
| Hy-Vee Insulin Syringe | 2 | | |
| Hy-Vee Lancets | 2 | | |
| Hy-Vee Thin Lancets | 2 | | |
| Hycamtin (oral) | 3PA | | Specialty Pharmacy |
| Hycet* | 3 | | |
| Hycodan* | 3 | | |
| Hycofed | 3 | | |
| Hycomal DH | 1 | | |
| Hycotuss Expectorant* | 3 | | |
| Hydergine* | 3 | | |
| Hydex PD | 1 | | |
| Hydone | 1 | | |
| HydrALAZINE HCl | 1 | | |
| Hydralazine-HCTZ | 1 | | |
| Hydrea* | 3 | | |
| Hydro GP | 1 | | |
| Hydro Pro | 1 | | |
| Hydro Pro D | 1 | | |
| Hydro Pro DM | 1 | | |
| Hydro-DP | 1 | | |
| Hydro-PC II | 1 | | |
| Hydro-PC II Plus | 1 | | |
| Hydro-Tussin CBX | 1 | | |
| Hydro-Tussin DHC | 1 | | |
| Hydro-Tussin DM | 1 | | |
| Hydro-Tussin EXP | 1 | | |
| Hydro-Tussin HC | 1 | | |
| Hydro-Tussin HD | 1 | | |
| Hydro-Tussin XP | 1 | | |
| Hydrocet | 1 | | |
| Hydrochlorothiazide | 1 | | |
| Hydrochlorothiazide Soln | 1 | | |
| Hydrocodone-Acetaminophen | 1 | | |
| Hydrocodone-GG Expectorant | 1 | | |
| Hydrocodone-Guaifenesin | 1 | | |
| Hydrocodone-Homatropine | 1 | | |
| Hydrocodone-Ibuprofen | 1 | | |
| Hydrocodone-PE-Chlorpheniramin | 1 | | |
| Hydrocodone-Potassium Guaiaco | 1 | | |
| Hydrocodone-Potassium Guaico | 1 | | |
| Hydrocof-HC | 1 | | |
| Hydrocortisone | 1 | | |
| Hydrocortisone Acetate Cream | 1 | | |
| Hydrocortisone Acetate Supp | 1 | | |
| Hydrocortisone Butyrate | 1 | | |
| Hydrocortisone Valerate | 1 | | |
| Hydrocortisone-Acetic Acid | 1 | | |
| Hydrocortisone-Iodoquinol | 1 | | |
| Hydrocortone | 3 | | |
| Hydromet | 1 | | |
| Hydromorphone 3mg Supp | 3 | | |
| Hydromorphone HCl | 1 | | |
| Hydron CP | 1 | | |
| Hydron EX | 1 | | |
| Hydron KGS | 1 | | |
| Hydron PSC | 1 | | |
| Hydropramox | 3 | | |
| Hydroxychloroquine Sulfate | 1 | | |
| Hydroxyurea | 1 | | |
| HydrOXYzine HCl | 1 | | |
| HydrOXYzine Pamoate | 1 | | |
| Hyflex-650 | 1 | | |
| Hyflex-DS | 1 | | |
| Hylira* | 3 | | |
| Hyomax | 1 | | |
| Hyoscyamine | 1 | | |
| Hyoscyamine Sulfate | 1 | | |
| Hyoscyamine Sulfate CR | 1 | | |
| Hyoscyamine Sulfate SL | 1 | | |
| Hyospaz | 1 | | |
| Hyosyne | 1 | | |
| Hypercare | 1 | | |
| Hyphed | 1 | | |
| Hyphen-HD | 1 | | |
| Hypodermic Needle | 2 | | |
| Hytakerol | 3 | | |
| Hytone* | 3 | | |
| Hytrin* | 3 | | |
| Hyzaar* | 3 | 30 | |
| IB-Stat | 3 | | |
| IBU | 1 | | |
| Ibuprofen | 1 | | |
| Iletin II Lente (Pork) | 2 | | |
| Iletin II NPH (Pork) | 2 | | |
| Iletin II Regular (Pork) | 2 | | |
| Imdur* | 3 | | |
| Imipramine HCl | 1 | | |
| Imitrex Inj* | 3 | 2 | |
| Imitrex Nasal Soln* | 3 | 6 | |
| Imitrex STATdose* | 3 | 2 | |
| Imitrex Tabs* | 3 | 9 | |
| Imuran* | 3 | | |
| Incivek | 3PA | | |
| Increlex | 3PA | | Specialty Pharmacy |
| Indapamide | 1 | | |
| Inderal LA | 3 | | |
| Inderal* | 3 | | |
| Inderide* | 3 | | |
| Indocin SR* | 3 | | |
| Indocin* | 3 | | |
| Indomethacin | 1 | | |
| Indomethacin CR | 1 | | |
| Infergen | 3PA | | Specialty Pharmacy |
| Inflamase Forte* | 3 | | |
| Inflamase Mild | 3 | | |
| Inlyta | - | | New to Market Policy |
| Innohep | 3PA | 21 Day Supply | |
| InnoPran XL | 3 | | |
| Inova | 3 | | |
| Ins Syr Ul Thin Shrt 0.5ml/30G | 2 | | |
| Inspra* | 3PA | | |
| Insulin Sringe Ult Thin Short | 2 | | |
| Insulin Syringe | 2 | | |
| Insulin Syringe/Needle | 2 | | |
| Intal* | 3 | | |
| Intelence | 3 | | |
| Intestinex | 3 | | |
| Introl | 3 | | |
| Intron-A | 3PA | | |
| Introvale | 1 | | 3 copays per pack |
| Intuniv | 3PA | | |
| Invega | 3PA | | |
| Inversine | 3 | | |
| Invirase | 2 | | |
| Iobid DM | 1 | | |
| Iodine Strong | 3 | | |
| Iophen C-NR | 1 | | |
| Iophen DM-NR | 1 | | |
| Iophen-NR | 1 | | |
| Iopidine 0.5%* | 3 | | |
| Iopidine 1% | 2 | | |
| Iosal II | 1 | | |
| Iotex PSE | 1 | | |
| Iplex | 3PA | | |
| Ipratropium Bromide | 1 | | |
| Ipratropium/albuterol Neb | 1 | | |
| Iprivask | - | | New to Market Policy |
| Iquix | 3 | | |
| Iressa | 3 | | |
| Isentress | 3 | | |
| Ismo* | 3 | | |
| Ismotic | 3 | | |
| Isochron | 1 | | |
| Isoetharine HCl 0.2% | 3 | | |
| Isoetharine HCl 1% | 1 | | |
| Isometheptene-APAP-Dichloral | 1 | | |
| Isoniazid Syrup | 3 | | |
| Isoniazid Tab | 1 | | |
| Isoptin SR* | 3 | | |
| Isopto Atropine* | 3 | | |
| Isopto Carbachol* | 2 | | |
| Isopto Carpine* | 3 | | |
| Isopto Homatropine* | 3 | | |
| Isopto Hyoscine | 2 | | |
| Isordil Titradose* | 3 | | |
| Isosorbide Dinitrate | 1 | | |
| Isosorbide Dinitrate CR | 1 | | |
| Isosorbide Mononitrate | 1 | | |
| Isosorbide Mononitrate CR | 1 | | |
| Isovate | 1 | | |
| Isoxsuprine HCl | 3 | | |
| Istalol | 3 | | |
| Itraconazole | 1PA | | |
| J-Max | 3 | | |
| Jakafi | - | | New to Market Policy |
| Jalyn | 3 | 30 | |
| Jantoven | 1 | | |
| Janumet | 3 | | ST |
| Januvia | 3 | 30 | ST |
| Jay-Gic DS | 3 | | |
| Jay-Phyl | 3 | | |
| Jay-Rx | 3 | | |
| Jay-Rx PD | 3 | | |
| Jaycof | 1 | | |
| Jaycof-HC* | 3 | | |
| Jaycof-XP* | 3 | | |
| Jentadueto | 3 | 60 | |
| Jevantique | 1 | | |
| Jinteli | 1 | | |
| Jolessa | 1 | | 3 copays |
| Jolivette | 1 | | |
| Junel 1.5/30 | 1 | | |
| Junel 1/20 | 1 | | |
| Junel FE 1.5/30 | 1 | | |
| Junel FE 1/20 | 1 | | |
| Juvisync | - | | New to Market Policy |
| K+ Potassium | 1 | | |
| K-Bicarb | 3 | | |
| K-Dur* | 3 | | |
| K-Effervescent | 1 | | |
| K-Lor* | 3 | | |
| K-Lyte DS | 3 | | |
| K-Lyte* | 3 | | |
| K-Lyte/Cl 25* | 3 | | |
| K-Lyte/Cl 50 | 3 | | |
| K-Phos | 2 | | |
| K-Phos MF | 2 | | |
| K-Phos No 2 | 2 | | |
| K-Phos-Neutral* | 3 | | |
| K-Tabs* | 3 | | |
| K-Tan | 1 | | |
| K-Tan 4 | 1 | | |
| K-Vescent | 1 | | |
| Kadian | 3PA | | |
| Kaletra | 2 | | |
| Kalydeco | - | | New to Market Policy |
| Kaochlor | 1 | | |
| Kaon | 3 | | |
| Kaon-Cl* | 3 | | |
| Kaon-Cl-10 | 1 | | |
| Kapidex | 3 | 30 | |
| Kapvay | 3PA | | |
| Karidium | 1 | | |
| Kariva | 1 | | |
| Kay Ciel | 1 | | |
| Kayexalate* | 3 | | |
| KCl-20 | 1 | | |
| KCl-40 | 1 | | |
| Keflex* | 3 | | |
| Kemadrin | 3 | | |
| Kenalog in Orabase* | 3 | | |
| Kenalog* | 3 | | |
| Keppra XR* | 3 | | |
| Keppra* | 3 | | |
| Keralac* | 3 | | |
| Keratol 40 | 1 | | |
| Kerlone* | 3 | | |
| Kerr Drug Test Strip | 3 | 150 | ST |
| Ketek | 3 | | |
| Ketek Pak | 3 | | |
| Ketoconazole | 1 | | |
| Ketoprofen | 1 | | |
| Ketoprofen CR | 1 | | |
| Ketorolac Tromethamine | 1PA | 5 Day Supply | |
| KGS-PE | 1 | | |
| KIE | 3 | | |
| Kineret | 3 | | |
| Kinray Insulin Syringe | 2 | | |
| Kinray Test Strips | 3 | 150 | ST |
| Kionex | 1 | | |
| Klaron* | 3 | | |
| Klerist-D | 1 | | |
| Klonopin Wafer* | 3 | | |
| Klonopin* | 3 | | |
| Klor-Con | 1 | | |
| Klor-Con (25meq) | 3 | | |
| Klor-Con 10 | 1 | | |
| Klor-Con M10 | 1 | | |
| Klor-Con M15* | 3 | | |
| Klor-Con M20 | 1 | | |
| Klor-Con/EF | 1 | | |
| Klotrix | 1 | | |
| Kmart Valu Insulin Syringe 29G | 2 | | |
| Kmart Valu Insulin Syringe 30G | 2 | | |
| Kombiglyze | 3 | 30 | ST |
| Kovia | 1 | | |
| Kristalose | 2 | | |
| Kroger Insulin Syringe | 2 | | |
| Kroger Lancets | 2 | | |
| Kroger Lancets Super Thin | 2 | | |
| Kroger Lancets Thin | 2 | | |
| Kroger Lancing Device | 2 | | |
| Kroger Pen Needles 29G | 2 | | |
| Kroger Pen Needles 31G | 2 | | |
| Kroger Test Strips | 3 | 150 | ST |
| Kronofed-A | 1 | | |
| Kronofed-A-Jr | 1 | | |
| Ku-Zyme | 3 | | |
| Ku-Zyme HP | 3 | | |
| Kutrase | 3 | | |
| Kuvan | 3PA | | Specialty Pharmacy |
| Kwelcof | 1 | | |
| Kytril Soln | 2 | 15 | |
| Kytril Tab* | 2 | 3 | |
| Labetalol HCl | 1 | | |
| Lacrisert | 3 | | |
| Lactic Acid E | 1 | | |
| LactiCare-HC | 1 | | |
| Lactinol-E* | 3 | | |
| Lady Lite Lancets | 2 | | |
| Lahey Mixture #3 | 1 | | |
| Lamictal XR | 3 | | |
| Lamictal* | 3 | | |
| Lamisil Granules | 3PA | | 6 week limit |
| Lamisil Tab* | 3 | | 84 tabs per year |
| Lamivudine | 1 | | |
| Lamivudine-Zidovudine | 1 | | |
| Lamotrigine | 1 | | |
| Lancets | 2 | | |
| Lancets Super Thin | 2 | | |
| Lancets Thin | 2 | | |
| Lancets Thin 23G | 2 | | |
| Lancing Device | 2 | | |
| Lanoxicaps | 2 | | |
| Lanoxin* | 3 | | |
| Lantus Opticlik | 3PA | | |
| Lantus Solostar | 3PA | | |
| Lantus Vial | 2 | | |
| Lanzatuss-NF | 1 | | |
| Lapase | 3 | | |
| Lariam* | 3 | | |
| Larodopa | 3 | | |
| Lartus | 3 | | |
| Lasix* | 3 | | |
| Lastacaft | 3 | | |
| Latanoprost | 1 | | |
| Latuda | 3PA | | |
| Lazanda | - | | New to Market Policy |
| Leader Insulin Syringe | 2 | | |
| Leader Lancets Colored | 2 | | |
| Leader Super Thin Lancet | 2 | | |
| Leader Thin Lancets | 2 | | |
| Leena | 1 | | |
| Lemohist Plus | 3 | | |
| Lemotussin-DM | 3 | | |
| Lescol | 2 | 30 | |
| Lescol XL | 2 | 30 | |
| Lessina-28 | 1 | | |
| Letairis | 3PA | | Specialty Pharmacy |
| Letrozole | 1 | | |
| Leucovorin Calcium | 1 | | |
| Leucovorin Calcium (10mg) | 3 | | |
| Leucovorin Calcium (15mg) | 3 | | |
| Leukeran | 2 | | |
| Leuprolide Acetate 5mg/ml | 1 | | |
| LEV/PSE/GG | 1 | | |
| Levacet | 3 | | |
| Levall 5.0* | 3 | | |
| Levall G* | 3 | | |
| Levall* | 3 | | |
| Levall-12 | 3 | | |
| Levaquin LEVA-pak | 3 | | |
| Levaquin* | 3 | | |
| Levatol | 3PA | | |
| Levbid* | 3 | | |
| Levemir | 3 | | |
| Levemir Flexpen | 3PA | | |
| Levitra | 3 | 4 | |
| Levlen (28)* | 2 | | |
| Levlite (28)* | 2 | | |
| Levobunolol HCl | 1 | | |
| Levocarnitine | 1 | | |
| Levofloxacin | 1 | | |
| Levofloxacin Oph | 1 | | |
| Levora 0.15/30 (28) | 1 | | |
| Levorphanol Tartrate | 1 | | |
| Levothroid | 1 | | |
| Levothyroxine Sodium | 1 | | |
| Levoxyl | 1 | | |
| Levsin* | 3 | | |
| Levsin/SL* | 3 | | |
| Levsinex* | 3 | | |
| Lexapro | 3 | | ST |
| Lexiva | 3 | | |
| Lialda | 3PA | | |
| Liberty Test Strips | 3 | 150 | ST |
| Librax (Reformulation) | 3 | | |
| Librium* | 3 | | |
| LidaMantle HC* | 3 | | |
| LidaMantle* | 3 | | |
| LidaZone HC | 1 | | |
| Lidex* | 3 | | |
| Lidex-E* | 3 | | |
| Lidocaine HCl | 1 | | |
| Lidocaine HCl (Oint) | 1 | | |
| Lidocaine Viscous | 1 | | |
| Lidocaine-Hydrocortisone Ace | 1 | | |
| Lidocaine-Prilocaine | 1 | | |
| Lidoderm | 3 | 30 | |
| Lidomar Viscous | 1 | | |
| Life Medical Test Strips | 3 | 150 | ST |
| Limbitrol DS* | 3 | | |
| Limbitrol* | 3 | | |
| Lindane Lotn | 1 | | |
| Lindane Sham | 1 | | |
| Liothyronine | 1 | | |
| Lipex | 3 | | |
| Lipitor | 3 | 30 | |
| Lipofen | 3 | | |
| Lipram 4500 | 3 | | |
| Lipram-CR10 | 3 | | |
| Lipram-CR20 | 3 | | |
| Lipram-CR5 | 3 | | |
| Lipram-PN10 | 3 | | |
| Lipram-PN16 | 3 | | |
| Lipram-PN20 | 3 | | |
| Lipram-UL12 | 3 | | |
| Lipram-UL18 | 3 | | |
| Lipram-UL20 | 3 | | |
| Liquadd | 3 | | |
| Liquibid | 1 | | |
| Liquibid-D 1200* | 3 | | |
| Liquibid-D* | 3 | | |
| Liquibid-PD* | 3 | | |
| Liquicet | 3 | | |
| Lisinopril | 1 | | |
| Lisinopril-Hydrochlorothiazide | 1 | | |
| Lite Touch Insulin Syringe | 2 | | |
| Lite Touch Lancets | 2 | | |
| Lite Touch Lancing Device | 2 | | |
| Lithium Carbonate | 1 | | |
| Lithium Carbonate | 1 | | |
| Lithium Citrate | 3 | | |
| Lithobid* | 3 | | |
| Lithostat | 3 | | |
| Livalo | 3PA | 30 | ST |
| Lo Loestrin | 3 | | |
| Lo/Ovral (28)* | 3 | | |
| Lobac Cap* | 3 | | |
| Lobac Tab | 1 | | |
| Locoid | 3 | | |
| Locoid Lipocream | 3 | | |
| Lodine XL* | 3 | | |
| Lodine* | 3 | | |
| Lodosyn | 3 | | |
| Lodrane 12 Hour* | 3 | | |
| Lodrane 12D* | 3 | | |
| Lodrane 24 | 3 | | |
| Lodrane D | 3 | | |
| Lodrane LD | 1 | | |
| Lodrane XR | 3 | | |
| Lodrane* | 3 | | |
| Loestrin 1.5/30 (21)* | 3 | | |
| Loestrin 1/20 (21)* | 3 | | |
| Loestrin 24 | 3 | | |
| Loestrin Fe 1.5/30* | 3 | | |
| Loestrin Fe 1/20* | 3 | | |
| Lofene | 1 | | |
| Lofibra* | 3 | | |
| LoHist-12 | 1 | | |
| LoHist-12D | 1 | | |
| LoHist-D | 1 | | |
| LoHist-LQ | 1 | | |
| LoKara | 1 | | |
| Lomotil* | 3 | | |
| Long Test Strip | 3 | 150 | ST |
| Longs Clotrimazole | 1 | | |
| Longs Insulin Syringe | 2 | | |
| Longs Lancets | 2 | | |
| Lonox | 1 | | |
| Loperamide HCl | 1 | | |
| Lopid* | 3 | | |
| Lopressor HCT* | 3 | | |
| Lopressor* | 3 | | |
| Loprox* | 3 | | |
| Lorazepam | 1 | | |
| Lorazepam Intensol* | 3 | | Not considered generic |
| Lorcet 10/650* | 3 | | |
| Lorcet Plus* | 3 | | |
| Lorcet-HD* | 3 | | |
| Lortab 10* | 3 | | |
| Lortab 2.5* | 3 | | |
| Lortab 5* | 3 | | |
| Lortab 7.5* | 3 | | |
| Lortab* | 3 | | |
| Lortuss DM* | 3 | | |
| Lortuss HC* | 3 | | |
| Loryna | 1 | | |
| Losartan | 1 | | |
| LoSeasonique | 3 | | 3 copays |
| Lotemax | 3 | | |
| Lotensin HCT* | 3 | | |
| Lotensin* | 3 | | |
| Lotrel* | 3 | | |
| Lotrisone* | 3 | | |
| Lotronex | 3PA | 60 | |
| Lovastatin | 1 | | |
| Lovaza | 3PA | | |
| Lovenox | 3 | | Limit 21 day supply |
| Low-Ogestrel | 1 | | |
| Loxapine Succinate | 1 | | |
| Loxitane* | 3 | | |
| Lozi-Flur | 3 | | |
| Lozol* | 3 | | |
| Lufyllin* | 3 | | |
| Lufyllin-GG* | 3 | | |
| Lumigan | 3 | | |
| Lunesta | 3PA | | ST |
| Lupron Depot | - | | MEDICAL BENEFIT ONLY |
| Luride* | 3 | | |
| Lusonal | 3 | | |
| Lusonex | 3 | | |
| Lutera | 1 | | |
| Lutrepulse | 3 | | |
| Luveris | 3PA | 20 | Specialty Pharmacy |
| Luvox CR | 3 | 30 | |
| Luxiq | 3PA | | ST |
| Lybrel* | 3 | | |
| Lynox | 3 | | |
| Lyrica | 3PA | | |
| Lysodren | 2 | | |
| Lysteda | 3 | 30 | |
| M-Clear Jr | 3 | | |
| M-Clear* | 3 | | |
| M-Zole 3 Combo Pack | 1 | | |
| Macrobid* | 3 | | |
| Macrodantin (25mg) | 2 | | |
| Macrodantin* | 3 | | |
| Mag-Phen | 1 | | |
| Magan | 3 | | |
| Magnacet | 3 | | |
| Magsal* | 3 | | |
| Major Comfort Lancets | 2 | | |
| Major Insulin Syringe | 2 | | |
| Malarone* | 3 | | |
| Maldemar | 1 | | |
| Mandelamine* | 3 | | |
| Maprotiline HCl | 1 | | |
| Maprotiline HCl (25mg) | 1 | | |
| Mar-Spas* | 3 | | |
| Marcof Expectorant | 1 | | |
| Margesic | 1 | | |
| Margesic-H | 1 | | |
| Marinol* | 3 | 3 | |
| Marplan | 2 | | |
| Marten-Tab | 1 | | |
| Matulane | 2 | | |
| Matzim LA | 1 | | |
| Mavik | 3 | | |
| Max HC | 3 | | |
| Maxair Autohaler | 2 | | |
| Maxalt | 3 | 9 | |
| Maxalt-MLT | 3 | 9 | |
| Maxaquin | 3PA | | |
| Maxi-Tuss DM | 1 | | |
| Maxi-Tuss HC | 1 | | |
| Maxi-Tuss HCG | 3 | | |
| Maxi-Tuss HCX | 3 | | |
| Maxidex | 2 | | |
| Maxidone* | 3 | | |
| Maxifed DM | 1 | | |
| Maxifed DMX* | 3 | | |
| Maxifed* | 3 | | |
| Maxifed-G | 1 | | |
| Maxiflor* | 3 | | |
| Maxiphen | 3 | | |
| Maxiphen ADT | 3 | | |
| Maxiphen DM | 3 | | |
| Maxiphen-G | 3 | | |
| Maxiphen-G DM | 3 | | |
| Maxitrol* | 3 | | |
| Maxzide* | 3 | | |
| Maxzide-25* | 3 | | |
| Mebaral* | 3 | | |
| Mebendazole | 1 | | |
| Meclizine HCl | 1 | | |
| Meclofenamate Sodium | 1 | | |
| Med-Fast Mono Insulin Syringe | 2 | | |
| Medent DM* | 3 | | |
| Medent LD* | 3 | | |
| Medi-Lance Lancets | 2 | | |
| Medic Insulin Syringe | 2 | | |
| Medic Ult Com Insulin Syringe | 2 | | |
| Medicine Shoppe Lancets | 2 | | |
| Medicine Shoppe Lancets Thin | 2 | | |
| Medigesic | 1 | | |
| Mediotic-HC | 1 | | |
| MediSense Glucose Ketone Contr | 3 | | |
| Medisense Hi/Mid/Low Control | 3 | | |
| Medisense High/Low Control | 3 | | |
| Medisense Mid Control | 3 | | |
| MediSense Thin Lancets | 2 | | |
| Medrol* | 3 | | |
| MedroxyPROGESTERone Acetate Susp | 1 | 1 per 90 days | |
| MedroxyPROGESTERone Acetate Tab | 1 | | |
| Mefanamic Acid | 1 | | |
| Mefenamic Acid | 1 | | |
| Mefloquine HCl | 1 | | |
| Megace ES | 3 | | |
| Megace Oral* | 3 | | |
| Megestrol Acetate | 1 | | |
| Meijer Lancets | 2 | | |
| Meijer Pen Needles | 2 | | |
| Meijer Test Strips | 3 | 150 | ST |
| Meloxicam | 1 | | |
| Menest | 2 | | |
| Meni-D | 3 | | |
| Menopur | 3PA | 20 | |
| Menostar | 3 | 4 | |
| Mentax | 2 | | |
| Meperidine HCl | 1 | | |
| Meperidine-Promethazine | 1 | | |
| Meperitab | 1 | | |
| Mephyton | 2 | | |
| Meprobamate | 1 | | |
| Mepron | 2 | | |
| Meprozine | 1 | | |
| Mercaptopurine | 1 | | |
| Mesalamine | 1 | | |
| Mesnex | 3 | | |
| Mestinon Syr | 2 | | |
| Mestinon Tab* | 3 | | |
| Mestinon TimeSpan | 2 | | |
| Metadate CD | 3 | | |
| Metadate ER 10mg* | 3 | | |
| Metadate ER 20mg | 1 | | |
| Metaglip* | 3 | | |
| Metaproterenol Sulfate Neb | 1 | | |
| Metaproterenol Sulfate Syr | 1 | | |
| Metaproterenol Sulfate Tab | 1 | | |
| Metaxolone | 1 | | |
| Metformin HCl | 1 | | |
| Methadone HCl | 1 | | |
| Methadone HCl Intensol* | 3 | | |
| Methadone HCl Soln | 3 | | |
| Methadose | 1 | | |
| Methadose Sugar-Free | 1 | | |
| Methamphetamine HCl | 1 | | |
| Methazolamide | 1 | | |
| Methenamine Hippurate | 1 | | |
| Methenamine Mandelate | 1 | | |
| Methergine* | 3 | | |
| Methimazole | 1 | | |
| Methimazole (20mg) | 1 | | |
| Methitest | 3 | | |
| Methocarbamol | 1 | | |
| Methotrexate | 1 | | |
| Methyclothiazide | 1 | | |
| Methyldopa | 1 | | |
| Methyldopa-Hydrochlorothiazide | 1 | | |
| Methylergonovine | 1 | | |
| Methylin Chew | 3 | | |
| Methylin ER | 1 | | |
| Methylin Soln | 3 | | |
| Methylin Tab | 1 | | |
| Methylphenidate ER 18, 27, 54mg | 1 | 30 | Concerta generic |
| Methylphenidate ER 36mg | 1 | 60 | Concerta generic |
| Methylphenidate HCl | 1 | | |
| Methylphenidate HCl CR | 1 | | |
| Methylphenidate HCl LA | 1 | | |
| Methylphenidate HCl SR | 1 | | |
| MethylPREDNISolone | 1 | | |
| MethylPREDNISolone (Pak) | 1 | | |
| Metipranolol | 1 | | |
| Metoclopramide HCl | 1 | | |
| Metolazone | 1 | | |
| Metoprolol Succ ER | 1 | 30 | |
| Metoprolol Tartrate | 1 | | |
| Metoprolol-Hydrochlorothiazide | 1 | | |
| Metozolv | 3PA | | |
| MetroCream* | 3 | | |
| Metrogel Kit | 3 | | |
| Metrogel Topical Gel | 2 | | |
| Metrogel Vaginal* | 3 | | |
| MetroLotion* | 3 | | |
| Metronidazole | 1 | | |
| Metronidazole Vaginal | 1 | | |
| Mevacor* | 3 | | |
| Mexar Wash | 1 | | |
| Mexiletine HCl | 1 | | |
| MHP-A | 1 | | |
| Miacalcin Inj | 2 | | |
| Miacalcin Nasal* | 2 | | |
| Micardis | 3 | | |
| Micardis HCT | 3 | | |
| Miconazole 3 | 1 | | |
| Miconazole 3 Combo Pack | 1 | | |
| Micro-K* | 3 | | |
| Microgestin | 1 | | |
| Microgestin FE 1.5/30 | 1 | | |
| Microgestin FE 1/20 | 1 | | |
| Microlet Auto Lancing Device | 2 | | |
| Microlet Vaculance Device | 2 | | |
| Micronase* | 3 | | |
| Microzide* | 3 | | |
| Midamor* | 3 | | |
| Midazolam HCl | 1 | | |
| Midodrine HCl | 1PA | | |
| Midrin* | 3 | | |
| Mifeprex | 3 | 8 | |
| Migergot | 3 | | |
| Migquin | 1 | | |
| Migral | 3 | | |
| MigraLam | 3 | | |
| Migranal | 3 | 8 | |
| Migratine | 1 | | |
| Migrazone | 1 | | |
| Migrin-A | 1 | | |
| Millipred | 3 | | |
| Miltown* | 3 | | |
| Mindal | 1 | | |
| Mindal DM | 1 | | |
| Minipress* | 3 | | |
| Minirin | 1 | | |
| Minitran | 1 | | |
| Minizide | 3 | | |
| Minocin* | 3 | | |
| Minocycline HCl | 1 | | |
| Minoxidil | 1 | | |
| Mintab C | 1 | | |
| Mintab D | 1 | | |
| Mintab DM | 1 | | |
| Mintex | 1 | | |
| Mintex CT | 1 | | |
| Mintex HC | 1 | | |
| Mintex PD | 1 | | |
| Mintezol | 3 | | |
| Mintuss DM | 1 | | |
| Mintuss DR | 1 | | |
| Mintuss EX | 1 | | |
| Mintuss G | 1 | | |
| Mintuss HC | 1 | | |
| Mintuss HD | 1 | | |
| Mintuss MR | 1 | | |
| Mintuss MS | 1 | | |
| Mintuss NX | 1 | | |
| MiraLax* | 3 | | |
| Mirapex ER | 3 | 30 | |
| Mirapex* | 3 | | |
| Miraphen PE | 1 | | |
| Miraphen PSE | 1 | | |
| Mircette* | 3 | | |
| Mirtazapine | 1 | | |
| Mirtazapine (7.5mg) | 1 | | |
| Misoprostol | 1 | | |
| Moban | 2 | | |
| Mobic* | 3 | | |
| Modicon (28)* | 3 | | |
| Moduretic* | 3 | | |
| Mometasone Furoate | 1 | | |
| Monoject Insulin Safety Syr | 2 | | |
| Monoject Insulin Syringe | 2 | | |
| Monoject Ultra Comfort Syringe | 2 | | |
| Monojector Lancet Device | 2 | | |
| Monoket* | 3 | | |
| Monolet Lancets | 2 | | |
| Monolet Thin Lancets | 2 | | |
| Mononessa | 1 | | |
| Monopril HCT* | 3 | | |
| Monopril* | 3 | | |
| Monurol | 3PA | | |
| Moore Mono Ins Syr 1cc/28G | 2 | | |
| Moore Mono Insulin Syringe | 2 | | |
| Morphine Sulfate | 1 | | |
| Morphine Sulfate Conc | 1 | | |
| Morphine Sulfate CR | 1 | | |
| Morphine Sulfate Soln* | 3 | | |
| Morphine Sulfate Supp | 3 | | |
| Morphine Sulfate Tab | 1 | | |
| Motofen | 3 | | |
| Motrin* | 3 | | |
| Moviprep | 3 | | |
| Moxatag | 3PA | | |
| Moxeza | 3 | | |
| Mozobil | 3PA | | Specialty Pharmacy |
| MS Contin* | 3 | | |
| MS Insulin Syringe | 2 | | |
| MS/L | 1 | | |
| MSIR | 1 | | |
| MST 600 | 3 | | |
| Muco-Fen DM* | 3 | | |
| Mucomyst* | 3 | | |
| Mucomyst-10* | 3 | | |
| Mucotrol | 3 | | |
| Multaq | 3PA | | |
| Mupirocin | 1 | | |
| Murocoll-2 | 3 | | |
| Muse | 3 | 6 | |
| Myambutol* | 3 | | |
| Mycelex* | 2 | | |
| Mycobutin | 2 | | |
| Mycophenolate | 1 | | |
| Mycostatin* | 3 | | |
| Mydfrin* | 3 | | |
| Mydral | 1 | | |
| Mydriacyl* | 3 | | |
| Myfortic | 3 | | ST |
| Myleran | 3 | | |
| Mylocel | 3 | | |
| Myogesic | 1 | | |
| Myphetane DX | 1 | | |
| Myrac | 1 | | |
| Mysoline* | 3 | | |
| Mytelase | 2 | | |
| Mytrex | 1 | | |
| Mytussin AC | 1 | | |
| N D Clear* | 3 | | |
| Nabumetone | 1 | | |
| Nacon | 1 | | |
| Nadolol | 1 | | |
| Nadolol-Bendroflumethiazide | 1 | | |
| Naftin | 3 | | |
| Nalex DH* | 3 | | |
| Nalex Expectorant | 1 | | |
| Nalex-A 12 | 1 | | |
| Nalex-A* | 3 | | |
| Nalex-CR | 1 | | |
| Nalfon | 3 | | |
| Naltrexone HCl | 1 | | |
| Namenda | 3 | | |
| Namenda Titration Pak | 3 | | |
| Naphazole | 1 | | |
| Naphazoline HCl | 1 | | |
| Naprelan* | 3PA | | |
| Naproderm | - | | New to Market Policy |
| Naprosyn* | 3 | | |
| Naproxen | 1 | | |
| Naproxen DR | 1 | | |
| Naproxen Sodium | 1 | | |
| Naratriptan | 1PA | 9 | |
| Nardil* | 3 | | |
| Narvox | 1 | | |
| Nasacort AQ | 3 | | ST |
| Nasarel | 2 | | ST |
| Nasatab LA | 1 | | |
| Nascobal | 3PA | | |
| Nascobal Spray | 3PA | | |
| Nasex | 1 | | |
| Nasofed | 3 | | |
| Nasonex | 2 | | |
| Nasop | 3 | | |
| Natacyn | 3 | | |
| Natazia | 3 | | |
| Natroba | 3PA | | |
| Nature-Throid | 3 | | |
| Naturetin | 3 | | |
| Navane* | 3 | | |
| Navarro Lancets | 2 | | |
| Navarro Test Strips | 3 | 150 | ST |
| ND-Gesic | 3 | | |
| Nebupent | 3 | | |
| Necon 0.5/35 (28) | 1 | | |
| Necon 1/35 (28) | 1 | | |
| Necon 1/50 (28) | 1 | | |
| Necon 10/11 (28) | 3 | | |
| Necon 7/7/7 | 1 | | |
| Nefazodone HCl | 1 | | |
| NegGram | 3 | | |
| Neo-Fradin | 3 | | |
| Neo-Synephrine | 1 | | |
| Neobenz Micro | 3 | | |
| Neocin | 1 | | |
| Neocin-PG | 1 | | |
| Neofrin | 1 | | |
| Neomycin Sulfate | 1 | | |
| Neomycin-Bacitracin Zn-Polymyx | 1 | | |
| Neomycin-Bacitracin-Polymyxin | 1 | | |
| Neomycin-Polymyxin-Dexameth | 1 | | |
| Neomycin-Polymyxin-Gramicidin | 1 | | |
| Neomycin-Polymyxin-HC | 1 | | |
| Neoral* | 3 | | |
| Neosol | 1 | | |
| Neosporin* | 3 | | |
| Neotic Drop | 3 | | |
| NeoTuss-D | 3 | | |
| Nescon-PD | 1 | | |
| Neumega | 3PA | | Specialty Pharmacy |
| Neupogen | 2 | | Specialty Pharmacy |
| Neupro | 3PA | | |
| Neurontin Cap* | 3 | | |
| Neurontin Soln* | 3 | | |
| Neurontin Tab* | 3 | | |
| Neutra-Phos* | 2 | | |
| Neutra-Phos-K | 2 | | |
| Nevanac | 3 | | |
| Nexavar | 3PA | | Specialty Pharmacy |
| NexGen Control | 3 | | |
| NexGen Test | 3 | 150 | ST |
| Nexiclon XR | 3PA | | |
| Nexium | 3PA | 30 | ST |
| Nexium Gra | 3PA | 30 | ST |
| Niacin | 1 | | |
| Niacin CR | 1 | | |
| Niacin CR (1000mg) | 1 | | |
| Niacin TR 1000 | 3 | | |
| Niacor | 1 | | |
| NiaDelay | 1 | | |
| Niaspan | 3 | | |
| NiCARdipine HCl | 1 | | |
| Nicotinic Acid | 1 | | |
| Nicotinic Acid CR | 1 | | |
| Nifediac CC | 1 | 30 | |
| Nifedical XL | 1 | 30 | |
| NIFEdipine | 1 | 30 | |
| NIFEdipine CR Osmotic | 1 | 30 | |
| Nilandron | 3PA | | |
| Nimotop | 3 | | |
| Niravam | 3 | | |
| Nisoldipine | 1 | | |
| Nitrek | 1 | | |
| Nitro-Bid | 3 | | |
| Nitro-Dur* | 3 | | |
| Nitro-Time | 1 | | |
| Nitrofurantoin | 1 | | |
| Nitrogard | 3 | | |
| Nitroglycerin | 1 | | |
| Nitroglycerin CR | 1 | | |
| Nitrolingual | 3 | | |
| NitroMist | 3 | | |
| NitroQuick | 1 | | |
| Nitrostat* | 2 | | |
| NitroTab | 1 | | |
| Nizatidine | 1 | | |
| Nizoral* | 3 | | |
| Nolvadex* | 3 | | |
| Nor-QD* | 3 | | |
| Nora-BE | 1 | | |
| Norco* | 3 | | |
| Nordette (28)* | 3 | | |
| Norditropin | 3PA | | Specialty Pharmacy |
| Norditropin NordiFlex | 3PA | | Specialty Pharmacy |
| Norditropin NordiFlex Pen | 3PA | | Specialty Pharmacy |
| Norel DM* | 3 | | |
| Norel LA | 3 | | |
| Norel SD | 1 | | |
| Norel SR | 3 | | |
| Norethindrone Acetate | 1 | | |
| Norgesic Forte* | 3 | | |
| Norgesic* | 3 | | |
| Norinyl 1 35* | 3 | | |
| Norinyl 1 50 | 2 | | |
| Noritate | 3 | | |
| Noroxin | 2 | | |
| Norpace CR | 2 | | |
| Norpace* | 3 | | |
| Norpramin* | 3 | | |
| Northyx | 3 | | |
| Nortrel 0.5/35 (28) | 1 | | |
| Nortrel 1/35 (21) | 1 | | |
| Nortrel 1/35 (28) | 1 | | |
| Nortrel 7/7/7 | 1 | | |
| Nortriptyline HCl | 1 | | |
| Nortuss-DE | 1 | | |
| Nortuss-Ex | 1 | | |
| Norvasc* | 3 | 30 | |
| Norvir | 2 | | |
| Notuss PD* | 3 | | |
| Notuss* | 3 | | |
| Novacort | 3 | | |
| Novagesic | 1 | | |
| Novagest Expectorant/Codeine | 1 | | |
| Novahistine DH* | 3 | | |
| Novahistine Expectorant* | 3 | | |
| Novarel | 1PA | 1 | |
| Novasal* | 3 | | |
| NovoFine 30 | 2 | | |
| Novofine 31 | 2 | | |
| Novolin 70/30 | 3 | | |
| Novolin 70/30 Innolet | 3PA | | |
| Novolin 70/30 PenFill | 3PA | | |
| Novolin N | 3 | | |
| Novolin N Innolet | 3PA | | |
| Novolin N PenFill | 3PA | | |
| Novolin R | 3 | | |
| Novolin R InnoLet | 3PA | | |
| Novolin R PenFill | 3PA | | |
| NovoLog | 3PA | | |
| NovoLog Flexpen | 3PA | | |
| NovoLog Mix 70/30 Flexpen | 3PA | | |
| NovoLog Mix 70/30 PenFill | 3PA | | |
| NovoLog Mix 70/30 vial | 3PA | | |
| NovoLog PenFill | 3PA | | |
| Novopen 3 | 2 | | Device |
| Novopen 3 Penmate | 2 | | Device |
| Novopen Jr (Green) | 2 | | Device |
| Novopen Jr (Yellow) | 2 | | Device |
| Noxafil | 3PA | | |
| Nucofed | 3 | | |
| Nucofed Expectorant* | 3 | | |
| Nucofed Pediatric Expectorant* | 3 | | |
| Nucort Lotion | 3 | | |
| Nucynta | 3PA | | |
| NuDal HD | 3 | | |
| Nuedexta | 3PA | | |
| Nuhist Pediatric | 1 | | |
| NuLev* | 3 | | |
| Nulytely* | 3 | | |
| Numobid | 3 | | |
| Numobid DX | 3 | | |
| Numonyl | 1 | | |
| Numonyl DX | 3 | | |
| Numonyl DX Pediatric | 3 | | |
| Numonyl Pediatric | 1 | | |
| Numonyl SR | 1 | | |
| Numorphan | 3 | | |
| Nuox | 3 | | |
| Nutracort | 1 | | |
| Nutropin | 3PA | | Specialty Pharmacy |
| Nutropin AQ | 3PA | | Specialty Pharmacy |
| Nutropin AQ Pen | 3PA | | Specialty Pharmacy |
| NuvaRing | 3 | | |
| Nuvigil | 3PA | 30 | |
| Nuzon | 3 | | |
| Nystatin Oral Pwdr | 3 | | |
| Nystatin Oral Tab | 1 | | |
| Nystatin Top Pwdr | 1 | | |
| Nystatin Vag Tab | 1/3 | | |
| Nystatin-Triamcinolone | 1 | | |
| Nystop | 1 | | |
| Ocella | 1 | | |
| OCL | 3 | | |
| Octreotide | 1PA | 8 | Specialty Pharmacy |
| Ocufen* | 3 | | |
| Ocuflox* | 3 | | |
| Ocusulf-10 | 1 | | |
| Ocutricin | 1 | | |
| Ofloxacin | 1 | | |
| Ogen 0.625* | 3 | | |
| Ogen 1.25* | 3 | | |
| Ogen 2.5* | 3 | | |
| Ogestrel | 1 | | |
| Olanzapine | 2 | | |
| Oleptro | 3PA | | |
| Olux Foam* | 3PA | | ST |
| Olux-E | 3PA | | ST |
| Omedia Otic | 1 | | |
| Omeprazole OTC only | | | $5 copay per 42 |
| Omnaris | 3 | | ST |
| Omnicef | 3 | | |
| Omniflex Diaphragm | 3 | | |
| OMNIhist II LA | 3 | | |
| Omnihist L.A. | 1 | | |
| Ondansetrol Oral Soln | 1 | 60 | |
| Ondansetron Tab 4 & 8mg | 1PA | 9 | |
| One Touch Control Solns | 2 | | |
| One Touch Lancets | 2 | | |
| One Touch Test Strips | 2 | 150 | |
| Onfi | - | | New to Market Policy |
| Onglyza | 3 | 30 | ST |
| Onsolis | 3PA | | |
| Opana | 3PA | | |
| Opana ER | 3PA | 60 | |
| Opium | 3 | | |
| Optipranolol* | 3 | | |
| Optium Test Strips | 3 | 150 | ST |
| Optivar | 3 | | |
| Oracea | 3PA | | |
| Oracit | 3 | | |
| OraMagicRx | 3 | | |
| Oramorph SR* | 3 | | |
| Orap | 2 | | |
| Orapred ODT | 3 | | |
| Orapred* | 3 | | |
| Orasep | 3 | | |
| Oratuss | 3 | | |
| Oravig | 3PA | | |
| Orbivan | 3 | | |
| Orencia SC | 3PA | | |
| Orfadin | 3PA | | |
| Organ-I NR | 1 | | |
| Organidin NR Liq* | 3 | | |
| Organidin NR Tab | 1 | | |
| Orphenadrine Citrate CR | 1 | | |
| Orphenadrine Compound | 3 | | |
| Orphenadrine-ASA-Caffeine | 3 | | |
| Orphengesic | 1 | | |
| Orphengesic Forte | 1 | | |
| Ortho Diaphragm All-Flex | 3 | | |
| Ortho Diaphragm Coil | 3 | | |
| Ortho Diaphragm Flat | 3 | | |
| Ortho Evra | 3 | | |
| Ortho Micronor* | 3 | | |
| Ortho Tri-Cyclen (28)* | 3 | | |
| Ortho Tri-Cyclen Lo | 3 | | |
| Ortho-Cept (28)* | 3 | | |
| Ortho-Cyclen (28)* | 3 | | |
| Ortho-Est 0.625 | 1 | | |
| Ortho-Est 1.25 | 1 | | |
| Ortho-Novum 1/35 (28)* | 3 | | |
| Ortho-Novum 1/50 (28)* | 3 | | |
| Ortho-Novum 10/11 (28)* | 3 | | |
| Ortho-Novum 7/7/7 (28)* | 3 | | |
| Oruvail* | 3 | | |
| Osmoglyn | 3 | | |
| Oticaine Otic | 1 | | |
| Oticin HC Drop* | 3 | | |
| Oticin HC Soln | 1 | | |
| Oticin HC Susp | 1 | | |
| OtiLam | 3 | | |
| Otimar | 1 | | |
| OtiRx | 1 | | |
| Otix Drops | 3 | | |
| Otocain | 1 | | |
| Otogesic | 1 | | |
| Otogesic Otic | 1 | | |
| Otomar-HC | 1 | | |
| Otozone | 1 | | |
| Otra NR | 1 | | |
| Ovace | 3 | | |
| Ovace Wash* | 3 | | |
| Ovcon 35 | 3 | | |
| Ovcon-35 (28) | 3 | | |
| Ovcon-50 | 3 | | |
| Ovide | 3PA | | |
| Ovidrel | 2PA | 1 | |
| Ovral (28)* | 3 | | |
| Ovrette | 3 | | |
| Oxandrin* | 3PA | | |
| Oxandrolone | 1PA | | |
| Oxaprozin | 1 | | |
| Oxazepam | 1 | | |
| Oxcarbazepine | 1 | | |
| Oxecta | - | | New to Market Policy |
| Oxistat | 2 | | |
| Oxsoralen Ultra | 3 | | |
| Oxybutynin Chloride | 1 | | |
| Oxybutynin ER | 1 | | |
| Oxycodone Caps | 3 | | Not considered generic |
| Oxycodone Soln | 3 | | Not considered generic |
| Oxycodone Tab | 1 | | |
| Oxycodone-Acetaminophen | 1 | | |
| Oxycodone-Aspirin | 1 | | |
| OxyContin | 3PA | 60 | |
| Oxydose | 1 | | |
| Oxyfast | 1PA | | |
| OxyIR* | 3 | | |
| P Chlor GG | 1 | | |
| P-Tuss | 1 | | |
| P-Tuss D | 1 | | |
| P-Tuss DM | 1 | | |
| P-V Tussin* | 3 | | |
| Pacerone* | 3 | | |
| Pacnex MX | 3PA | | |
| Palcaps 10 | 3 | | |
| Palcaps 20 | 3 | | |
| Palgic D* | 3 | | |
| Palgic DS* | 3 | | |
| Palgic Liqd | 1 | | |
| Palgic Tab | 3 | | |
| Palipase | 3 | | |
| Palipase MT 16 | 3 | | |
| Palipase MT 20 | 3 | | |
| Palpeon DR 10 | 3 | | |
| Palpeon DR 20 | 3 | | |
| Palpeon MT 20 | 3 | | |
| Paltrase V8 | 3 | | |
| Pamelor* | 3 | | |
| Pamine | 3PA | | |
| Pamine Forte | 3PA | | |
| Panafil SE | 3 | | |
| Panafil* | 3 | | |
| Panafil-White | 3 | | |
| Panatuss DXP | 3 | | |
| Panatuss DXP Pediatric | 3 | | |
| Pancof EXP* | 3 | | |
| Pancof HC | 3 | | |
| Pancof PD* | 3 | | |
| Pancof XP | 3 | | |
| Pancof* | 3 | | |
| Pancrease | 3 | | |
| Pancrease MT 10 | 3 | | |
| Pancrease MT 16 | 3 | | |
| Pancrease MT 20 | 3 | | |
| Pancrease MT 4 | 3 | | |
| Pancreatin | 3 | | |
| Pancreaze | 3 | | |
| Pancrecarb MS-16 | 3 | | |
| Pancrecarb MS-4 | 3 | | |
| Pancrecarb MS-8 | 3 | | |
| Pancrelipase | 3 | | |
| Pancrelipase MST-16 | 3 | | |
| Pancron 10 | 3 | | |
| Pancron 20 | 3 | | |
| Pandel | 3 | | |
| Panfil-G* | 3 | | |
| Pangestyme CN 10 | 3 | | |
| Pangestyme CN 20 | 3 | | |
| Pangestyme EC | 3 | | |
| Pangestyme MT 16 | 3 | | |
| Pangestyme UL 12 | 3 | | |
| Pangestyme UL 18 | 3 | | |
| Pangestyme UL 20 | 3 | | |
| Panixine DisperDose | 3 | | |
| Panlor DC | 3 | | |
| Panlor SS | 3 | | |
| PanMist DM* | 3 | | |
| PanMist JR* | 3 | | |
| PanMist LA* | 3 | | |
| PanMist S* | 3 | | |
| Pannaz S* | 3 | | |
| Panocaps | 3 | | |
| Panocaps MT 16 | 3 | | |
| Panocaps MT 20 | 3 | | |
| Panokase | 3 | | |
| Panokase-16 | 3 | | |
| Panretin | 3 | | |
| Papain-Urea-Chlorophyllin | 1 | | |
| Papaverine HCl CR | 1 | | |
| Papfyll | 3 | | |
| Paptase | 3 | | |
| Para-Time | 1 | | |
| Parafon Forte DSC* | 3 | | |
| Parcopa | 3 | | |
| Paregoric | 1 | | |
| Parlodel* | 3 | | |
| Parnate* | 3 | | |
| Paromomycin Sulfate | 1 | | |
| Paroxetine HCl | 1 | | |
| Paser | 3 | | |
| Pataday | 3 | | |
| Patanase | 3 | | |
| Patanol | 3 | | |
| Paxil CR* | 3 | | |
| Paxil* | 3 | | |
| Paxipam | 3 | | |
| PCE | 3 | | |
| PCM | 1 | | |
| PCM Allergy | 1 | | |
| PCM LA | 1 | | |
| PDM GG | 1 | | |
| Pedi-Dri | 1 | | |
| Pediaflor* | 3 | | |
| PediaHist DM | 1 | | |
| Pediapred* | 3 | | |
| Pediatex | 3 | | |
| Pediatex 12 | 3 | | |
| Pediatex 12D | 3 | | |
| Pediatex 12DM | 3 | | |
| Pediatex DM | 3 | | |
| Pediatex HC | 3 | | |
| Pediatex-D | 3 | | |
| Pediazole* | 3 | | |
| Pediotic* | 3 | | |
| Pediox Chew* | 3 | | |
| Pediox Liq | 1 | | |
| PEG 3350/Electrolytes | 1 | | |
| Peg-Intron | 3PA | | Specialty Pharmacy |
| Peg-Intron Redipen | 3PA | | Specialty Pharmacy |
| Peg-Intron Redipen Pak 4 | 3PA | | Specialty Pharmacy |
| Peganone | 3 | | |
| Pegasys | 3PA | | Specialty Pharmacy |
| Pemoline | 1 | | |
| Pen Needles | 2PA | | |
| Pendex | 1 | | |
| Penicillin V Potassium | 1 | | |
| Penlac | 3PA | | |
| Penlet II Blood Sampler | 2 | | |
| Pennsaid | 3 | | |
| Pentasa | 3 | | |
| Pentazocine-APAP | 1 | | |
| Pentazocine-Naloxone HCl | 1 | | |
| Pentetate Calcium Trisodium | 3PA | | |
| Pentetate Zinc Trisodium | 3PA | | |
| PentoPAK | 1 | | |
| Pentoxifylline CR | 1 | | |
| Pentoxil | 1 | | |
| Pentuss | 1 | | |
| Pepcid* | 3PA | | |
| Peranex HC | 3PA | | |
| Percocet* | 3 | | |
| Percodan* | 3 | | |
| Percolone | 1 | | |
| Perforomist | 3PA | | |
| Pergolide Mesylate | 1 | | |
| Peridex* | 3 | | |
| Periogard | 1 | | |
| Perisol | 1 | | |
| Permax* | 3 | | |
| Permethrin | 1 | | |
| Perphenazine Conc | 1 | | |
| Perphenazine Tab | 1 | | |
| Perphenazine-Amitriptyline | 1 | | |
| Perphenazine-Amitriptyline (2-10 & 4-50) | 1 | | |
| Persantine* | 3 | | |
| Pexeva | 3 | | |
| Phanasin | 3 | | |
| Phanatuss HC | 3 | | |
| Pharm Mono Insulin Syringe | 2 | | |
| Pharmaflur | 1 | | |
| Phena-HC | 3 | | |
| Phena-Plus | 3 | | |
| Phena-S | 3 | | |
| Phenabid | 1 | | |
| Phenabid DM | 3 | | |
| Phenadoz | 1 | | |
| PhenaVent | 1 | | |
| PhenaVent D | 1 | | |
| PhenaVent LA | 1 | | |
| PhenaVent PED | 1 | | |
| Phenazopyridine HCl | 1 | | |
| Phenazopyridine Plus | 1 | | |
| Phencarb GG | 1 | | |
| Phenclor Tannate Pediatric | 1 | | |
| Phenergan* | 3 | | |
| Phenobarbital | 1 | | |
| Phenobarbital-Belladonna Alk | 1 | | |
| Phenoptic | 1 | | |
| Phenydex | 3 | | |
| Phenydex Pediatric 2.5-5-50 | 3 | | |
| Phenydex Pediatric 5-50 | 1 | | |
| Phenydryl | 1 | | |
| Phenyl Chlor-Tan | 1 | | |
| Phenyleph-Carbetapentane-GG | 1 | | |
| Phenyleph-Chlorphen-Hydrocod | 1 | | |
| Phenyleph-Pot Guaiacolsulf | 1 | | |
| Phenylephrine HCl | 1 | | |
| Phenylephrine HCl (Refrig) | 1 | | |
| Phenylephrine HD | 1 | | |
| Phenylephrine-Chlorphen-DM | 1 | | |
| Phenylephrine-GG CR | 1 | | |
| Phenylephrine-Guaifenesin | 1 | | |
| Phenylephrine-Hydrocodone-GG | 1 | | |
| Phenylhistine DH | 1 | | |
| Phenylhistine Expectorant | 1 | | |
| Phenytek | 3 | | |
| Phenytoin | 1 | | |
| Phenytoin Sodium Extended | 1 | | |
| Phenytoin Sodium Prompt | 1 | | |
| Phisohex | 2 | | |
| Phos-NaK | 3 | | |
| PhosLo* | 3 | | |
| Phoslyra | 3 | | |
| Phospha 250 Neutral | 1 | | |
| Phospholine Iodide | 3 | | |
| Phrenilin Forte | 3 | | |
| Phrenilin w/Caffeine-Codeine | 1 | | |
| Phrenilin* | 3 | | |
| Picato | - | | New to Market Policy |
| Pilocar | 1 | | |
| Pilocarpine 0.5% 3% | 3 | | |
| Pilocarpine 1% 2% 4% 6% | 1 | | |
| Pilocarpine Tab | 1 | | |
| Pilopine HS | 2 | | |
| Piloptic-1 | 1 | | |
| Piloptic-1/2 | 1 | | |
| Piloptic-2 | 1 | | |
| Piloptic-3 | 1 | | |
| Piloptic-4 | 1 | | |
| Piloptic-6 | 1 | | |
| Pima | 3 | | |
| Pindolol | 1 | | |
| Piroxicam | 1 | | |
| Placidyl | 3 | | |
| Plan B | 3 | 2 | Females under age 17 |
| Plan B One Step | 3 | 1 | Females under age 17 |
| Plaquenil* | 3 | | |
| Plaretase 8000 | 3 | | |
| Plavix 300mg | 2 | 1 | |
| Plavix* | 2 | | |
| Plendil* | 3 | | |
| Pletal* | 3 | | |
| Plexion Cleansing Cloth* | 3 | | |
| Plexion SCT* | 3 | | |
| Plexion TS* | 3 | | |
| Plexion* | 3 | | |
| Pneumotussin* | 3 | | |
| Podocon | 1 | | |
| Podofilox | 1 | | |
| Poly Hist DM | 3 | | |
| Poly Hist Forte | 3 | | |
| Poly Hist PD | 3 | | |
| Poly-Dex | 1 | | |
| Poly-Histine* | 3 | | |
| Poly-Pred | 3 | | |
| Poly-Tussin Cough* | 3 | | |
| Poly-Tussin DM* | 3 | | |
| Poly-Tussin HD | 1 | | |
| Poly-Tussin XP Expectorant | 1 | | |
| Poly-Vent | 3 | | |
| Poly-Vent Jr | 3 | | |
| Polycin B | 1 | | |
| Polycitra* | 3 | | |
| Polycitra-K* | 3 | | |
| Polycitra-LC* | 3 | | |
| Polyethylene Glycol 3350 | 1 | | |
| Polymyxin B-Trimethoprim | 1 | | |
| Polysporin* | 3 | | |
| Polytrim* | 3 | | |
| Ponstel* | 3 | | |
| Pontocaine* | 3 | | |
| Portia-28 | 1 | | |
| Pot Bicarb-Pot Chloride | 1 | | |
| Potaba* | 2 | | |
| Potassium Bicarbonate | 1 | | |
| Potassium Chloride | 1 | | |
| Potassium Chloride CR | 1 | | |
| Potassium Chloride Crys CR | 1 | | |
| Potassium Citrate-Citric Acid | 1 | | |
| Potassium Effervescent | 1 | | |
| PP Ultra Com Insulin Sryinge | 2 | | |
| PP Ultra Com Insulin Syringe | 2 | | |
| Pradaxa | 3PA | | |
| Pramipexole | 1 | | |
| Pramipexole | 1 | | |
| Pramosone* | 3 | | |
| PramOtic* | 3 | | |
| Prandimet | 2 | 90 | |
| Prandin | 2 | 90 | |
| Prascion | 1 | | |
| Pravachol* | 3 | 30 | |
| Pravastatin | 1 | 30 | |
| Pravigard Pac | 3 | 30 | |
| Prazosin HCl | 1 | | |
| Pre-hist-D | 1 | | |
| Precision Control Solns | 3 | | ST |
| Precision Insulin Syringe | 2 | | |
| Precision Lancets | 2 | | |
| Precision Test Strips | 3 | 150 | ST |
| Precose | 3* | 90 | |
| Pred Forte* | 3 | | |
| Pred Mild | 3 | | |
| Pred-G | 2 | | |
| Pred-G S.O.P. | 2 | | |
| Prednicarbate | 1 | | |
| Prednisol | 1 | | |
| PrednisoLONE | 1 | | |
| PrednisoLONE Acetate | 1 | | |
| PrednisoLONE Sodium Phosphate | 3 | | |
| PredniSONE | 1 | | |
| PredniSONE (50mg) | 1 | | |
| PredniSONE (Pak) | 1 | | |
| PredniSONE Intensol | 3 | | |
| PredniSONE Soln | 1 | | |
| Preferred Plus Insulin Syringe | 2 | | |
| Preferred Plus Lancets Colored | 2 | | |
| Preferred Plus Lancets Thin | 2 | | |
| Prefest | 3 | | |
| Pregnyl | 1PA | 1 | |
| Prelone* | 3 | | |
| Premarin Tab | 3 | | |
| Premarin Vag Crm | 2 | | |
| Premphase | 3 | | |
| Prempro | 3 | | |
| Prentif Cavity-Rim Cerv Cap | 3 | | |
| Prestige Control Solns | 3 | | ST |
| Prestige Lancets | 2 | | |
| Prestige Test Strips | 3 | 150 | ST |
| Prevacid 24 OTC | | | $5 copay per 42 |
| Prevalite | 1 | | |
| Previfem | 1 | | |
| Prezista | 3 | | |
| Priftin | 3 | | |
| Prilosec OTC | | | $5 copay for 42 |
| Primaquine Phosphate | 3 | | |
| Primidone | 1 | | |
| Primsol | 3 | | |
| Principen | 1 | | |
| Prinivil* | 3 | 30 | |
| Prinzide* | 3 | 30 | |
| Pristiq | 3PA | 30 | |
| Pro-Banthine | 3 | | |
| Pro-Clear | 3 | | |
| Pro-Cof | 1 | | |
| Pro-Cof D | 1 | | |
| Pro-Otic | 1 | | |
| Pro-Red | 3 | | |
| Pro-Tannate Pediatric | 1 | | |
| ProAir HFA | 2 | 2 | |
| ProAmatine* | 2PA | | |
| Probenecid | 1 | | |
| Procainamide HCl 250mg cap | 1 | | |
| Procainamide HCl 500mg cap | 1 | | |
| Procainamide HCl CR | 1 | | |
| Procainamide HCl CR (500mg) | 1 | | |
| Procanbid | 2 | | |
| Procardia XL* | 3 | 30 | |
| Procardia* | 3 | 30 | |
| Prochieve | 3PA | 60 | |
| Prochlorperazine Maleate | 1 | | |
| Prochlorperazine Supp | 1 | | |
| Prochlorperazine Supp (25mg) | 1 | | |
| Procrit | 2PA | | Specialty Pharmacy |
| Procto-Kit | 1 | | |
| Procto-Pak | 1 | | |
| Proctocort* | 3 | | |
| ProctoCream-HC | 1 | | |
| Proctofoam HC | 2 | | |
| Proctosert HC | 1 | | |
| Proctosol | 1 | | |
| Proctosol HC | 1 | | |
| Proctozone-HC | 1 | | |
| Prodec-DM | 1 | | |
| Prodrin* | 3 | | |
| Profasi | 1PA | 1 | |
| Profasi HP | 3PA | 1 | |
| Profen Forte DM* | 3 | | |
| Profen Forte* | 3 | | |
| Profen II DM* | 3 | | |
| Profen II* | 3 | | |
| Progesterone | 1 | | |
| Progesterone VGS | 3 | | |
| Proglycem | 3 | | |
| Prograf* | 3 | | |
| Prolex D* | 3 | | |
| Prolex DH Soln | 1 | | |
| Prolex DH Syr* | 3 | | |
| Prolex DM* | 3 | | |
| Prolex PD* | 3 | | |
| Prolixin* | 3 | | |
| Proloprim* | 3 | | |
| Promacet | 1 | | |
| Promacta | 3PA | | Specialty Pharmacy |
| Promethazine HCl | 1 | | |
| Promethazine HCl (12.5mg) | 1 | | |
| Promethazine HCl Supp | 1 | | |
| Promethazine Plain/Codeine | 1 | | |
| Promethazine VC | 3 | | |
| Promethazine VC/Codeine | 3 | | |
| Promethazine-Codeine | 1 | | |
| Promethazine-DM | 1 | | |
| Promethegan | 1 | | |
| Prometrium | 2 | | |
| Pronestyl* | 3 | | |
| Pronestyl-SR* | 3 | | |
| Propafenone HCl | 1 | | |
| Propantheline Bromide | 1 | | |
| Propine* | 3 | | |
| Propranolol HCl Intensol | 3 | | |
| Propranolol HCl Soln | 1 | | |
| Propranolol HCl Tab | 1 | | |
| Propranolol-HCTZ | 1 | | |
| Propylthiouracil | 1 | | |
| Proquin XR | 3 | 3 per Rx | |
| Proscar* | 3 | 30 | |
| Prosed EC | 3 | | |
| Prosed/DS* | 3 | | |
| Proset D | 1 | | |
| Prosom* | 3 | 9 | |
| Prostaphlin | 3 | | |
| Prostigmin | 3 | | |
| Protex | 1 | | |
| Protex D | 1 | | |
| Protid | 3 | | |
| Protopic | 2 | | |
| Protriptyline | 1 | | |
| Proventil HFA | 3 | 2 | |
| Proventil* | 3 | | |
| Provera* | 3 | | |
| Provigil | 2PA | 30 | |
| Prozac Weekly | 3PA | 4 | |
| Prozac* | 3 | | |
| Prudoxin | 3 | | |
| PSE 15/CPM 2 | 1 | | |
| PSE BPM | 1 | | |
| PSE BPM HD | 1 | | |
| Pse Brom DM | 1 | | |
| PSE CPM | 1 | | |
| PSE-Carbinoxamine-DM | 1 | | |
| PSE-CPM-Methscopolamine | 1 | | |
| PSE-GG CR | 1 | | |
| Pseubrom | 1 | | |
| Pseubrom-PD | 1 | | |
| Pseudatex | 1 | | |
| Pseudo CM | 1 | | |
| Pseudo GG TR | 1 | | |
| Pseudo Max | 1 | | |
| Pseudo Max DMX | 1 | | |
| Pseudoeph-Carbinox-Hydrocod | 1 | | |
| Pseudoephedrine-Codeine-GG | 1 | | |
| Pseudoephedrine-DM-GG | 1 | | |
| Pseudoephedrine-GG CR | 1 | | |
| Pseudoephedrine-Guaifenesin | 1 | | |
| Pseudoephedrine-Guaifenesin CR | 1 | | |
| Pseudoephedrine-Methscopolamin | 1 | | |
| Pseudovent | 1 | | |
| Pseudovent 400 | 1 | | |
| Pseudovent DM | 1 | | |
| Pseudovent Ped | 1 | | |
| Pseudox M | 1 | | |
| Psorcon E* | 3 | | |
| Psorcon* | 3 | | |
| Psoriatec* | 3 | | |
| PSS Select GP Lancets | 2 | | |
| PSS Select Safety Lancets | 2 | | |
| PTS Test Strips | 3 | 150 | ST |
| Publix Lancet Auto Injector | 2 | | |
| Pulexn DM | 1 | | |
| Pulmicort Flexhaler | 2 | 1 | |
| Pulmicort Susp* | 3PA | | |
| Pulmicort Turbuhaler | 2 | 1 | |
| Pulmozyme | 2 | | Specialty Pharmacy |
| Purinethol* | 3 | | |
| PX Niacin | 1 | | |
| Pylera | 3PA | | |
| Pyrazinamide | 1 | | |
| Pyridium Plus* | 3 | | |
| Pyridium* | 3 | | |
| Pyridostigmine Bromide | 1 | | |
| Pyrilafen Tannate-12 | 1 | | |
| Q-V Tussin | 1 | | |
| QC Allergy Relief | 1 | | |
| QC Insulin Syringe | 2 | | |
| QC Lancets | 2 | | |
| QC Lancets Thin | 2 | | |
| Qdall | 3 | | |
| Quad Tann | 1 | | |
| Quad Tann Pediatric | 1 | | |
| Quad-Tuss | 1 | | |
| Quadratuss | 1 | | |
| Quadratuss Pediatric | 1 | | |
| Qual-Tussin | 1 | | |
| Qual-Tussin DC | 1 | | |
| Qual-Tussin Pediatric | 1 | | |
| Quala-Cet | 1 | | |
| Quala-HC | 1 | | |
| Quala-TLA | 1 | | |
| Qualaquin | 3PA | | |
| Quarzan | 3 | | |
| Quasense | 1 | 1 Pkg per 91 days | 3 Copays |
| Questran Light* | 3 | | |
| Questran* | 3 | | |
| Quibron | 3 | | |
| Quibron-300 | 3 | | |
| Quibron-T | 3 | | |
| Quibron-T/SR* | 3 | | |
| Quick-K | 3 | | |
| QuickTek Control Solution | 3 | | |
| QuickTek Test Strips | 3 | 150 | ST |
| Quinapril HCl | 1 | 30 | |
| Quinaretic | 1 | 30 | |
| Quindal CR | 1 | | |
| Quinerva | 1 | | |
| Quinidine Gluconate CR | 1 | | |
| Quinidine Sulfate | 1 | | |
| Quinidine Sulfate CR | 1 | | |
| Quinine Sulfate (200mg) | 1PA | | |
| Quinine Sulfate 260mg Tab | 1PA | | |
| Quinine Sulfate 325mg Cap | 1PA | | |
| Quinine Sulfate 325mg Tab | 3PA | | |
| Quintex | 1 | | |
| Quintex HC | 1 | | |
| Quixin* | 3 | | |
| QV-Allergy | 1 | | |
| Qvar | 2 | | |
| R-Tanna | 1 | | |
| R-Tanna Pediatric | 1 | | |
| R-Tanna S | 1 | | |
| R-Tannamine Pediatric | 1 | | |
| RA Anti Diarrheal | 1 | | |
| RA Blood Glucose Test Strips | 3 | 150 | ST |
| RA Insulin Syringe | 2 | | |
| RA Lancets | 2 | | |
| RA Miconazole 3 Combo Pack | 1 | | |
| Ralix | 1 | | |
| Ramipril | 1 | | |
| Ranexa | 3PA | | |
| Raniclor | 3 | | |
| Ranitidine HCl | 1 | | |
| Rapaflo | 3PA | | |
| Rapamune | 2 | | |
| Rapiflux* | 3 | | |
| Raptiva | 3PA | | |
| Rauwolfia-Bendroflumethiazide | 1 | | |
| Razadyne ER* | 3 | | |
| Razadyne* | 3 | | |
| RE 10 Wash | 1 | | |
| RE 40 | 1 | | |
| RE2+30 | 1 | | |
| Reality Insulin Syringe | 2 | | |
| Reality Lancets | 2 | | |
| Reality Trigger Lancets | 2 | | |
| Rebetol* | 3PA | | Specialty Pharmacy |
| Rebif | 3PA | | Specialty Pharmacy |
| Rebif Titration Pack | 3PA | | |
| Reclipsen | 1 | | |
| Rectagel-HC | 3 | | |
| Rectasol-HC | 1 | | |
| Rectiv | - | | New to Market Policy |
| Regenecare Wound | 3 | | |
| Reglan* | 3 | | |
| Regranex | 3PA | | |
| Relacon-DM | 3 | | |
| Relacon-HC | 3 | | |
| Relafen* | 3 | | |
| Relagard | 3 | | |
| Relagesic* | 3 | | |
| Relenza Diskhaler | 3PA | | |
| Reli On Standard Lancets | 2 | | |
| Reli-On Insulin Syringe | 2 | | |
| ReliOn 70/30 | 3PA | | |
| ReliOn 70/30 Innolet | 3PA | | |
| ReliOn Insulin Syringe | 2 | | |
| ReliOn Lancets | 2 | | |
| ReliOn Lancing Device | 2 | | |
| ReliOn N | 3PA | | |
| ReliOn N Innolet | 3PA | | |
| ReliOn Pen Needle | 2 | | |
| ReliOn R | 3PA | | |
| ReliOn Test Strips | 3 | 150 | ST |
| ReliOn Thin Lancets | 2 | | |
| ReliOn Ultra Comfort Syringe | 2 | | |
| Relistor | 3PA | | |
| Relpax | 2 | 6 | |
| Remeron SolTab* | 3 | | |
| Remeron* | 3 | | |
| Reminyl | 3 | | |
| Renagel | 2 | | |
| Rentamine Pediatric | 1 | | |
| Renvela | 2 | | |
| Repan | 1 | | |
| Repan-CF | 1 | | |
| Reprexain | 3 | | |
| Repronex | 3PA | 20 | |
| Requip XL | 3 | | |
| Requip* | 3 | | |
| Requip* | 3 | | |
| Rescon-ED | 1 | | |
| Rescon-Jr | 3 | | |
| Rescon-MX* | 3 | | |
| Rescriptor | 3 | | |
| Reserpine | 1 | | |
| Respa DM | 3 | | |
| Respa-1st | 3 | | |
| Respa-AR* | 3 | | |
| Respa-PE | 3 | | |
| Respahist | 1 | | |
| Respaire-120 | 1 | | |
| Respaire-60 | 3 | | |
| Respi-Tann | 3 | | |
| Restasis | 3PA | 64 | |
| Restoril* | 3 | | |
| Retin-A Micro | 3PA | | PA if > 26 Eff 09/10 |
| Retin-A* | 3PA | | PA if > 26 Eff 09/10 |
| Retrovir* | 3 | | |
| Rev-Eyes | 3 | | |
| Revatio | 3PA | | Specialty Pharmacy |
| ReVia* | 3 | | |
| Revlimid | 3PA | | Specialty Pharmacy |
| Reyataz | 3 | | |
| Rheumatrex* | 3 | | |
| Rhinabid | 1 | | |
| Rhinabid PD | 1 | | |
| Rhinacon A | 1 | | |
| Rhinacon DH | 1 | | |
| Rhinocort Aqua | 2 | | ST |
| Rhinoflex | 1 | | |
| Rhinoflex-650 | 1 | | |
| Ribasphere | 1PA | | Specialty Pharmacy |
| Ribatab | 1PA | | Specialty Pharmacy |
| Ribatab Pak | 1PA | | Specialty Pharmacy |
| Ribavirin | 1PA | | Specialty Pharmacy |
| Ricobid | 3 | | |
| Ricobid NR | 3 | | |
| Ricobid-D | 3 | | |
| Ricobid-H | 3 | | |
| Ricotuss 30-4-5 Susp | 1 | | |
| Ricotuss 60-8-10 Susp | 3 | | |
| Ricotuss 7.5-2-15 Susp | 3 | | |
| Ricotuss Tab | 1 | | |
| Rid-A-Pain | 3 | | |
| Ridaura | 2 | | |
| Rifadin* | 3 | | |
| Rifamate* | 3 | | |
| Rifampin | 1 | | |
| Rifater | 3 | | |
| Rilutek | 2 | | |
| Rimantadine HCl | 1PA | | |
| Rindal HD | 1 | | |
| Rindal HD Plus | 1 | | |
| Rindal HPD | 1 | | |
| Riomet | 3 | | |
| Risperdal M-TAB* | 3 | 60 | |
| Risperdal* | 3 | 60 | |
| Risperidone | 1 | 60 | |
| Ritalin LA* | 3 | | |
| Ritalin SR* | 3 | | |
| Ritalin* | 3 | | |
| Rivastigmine Cap | 1 | | |
| RMS* | 3 | | |
| Robafen AC | 1 | | |
| Robaxin* | 3 | | |
| Robaxin-750* | 3 | | |
| Robinul* | 3 | | |
| Robinul-Forte* | 3 | | |
| Rocaltrol* | 3 | | |
| Roferon-A | 3PA | | |
| Romilar AC | 1 | | |
| Romycin | 1 | | |
| Rondamine | 1 | | |
| Ropinirole | 1 | | |
| Rosac Wash | 3 | | |
| Rosac* | 3 | | |
| Rosaderm | 1 | | |
| Rosanil Cleanser | 1 | | |
| Rosula NS | 3 | | |
| Rosula* | 3 | | |
| Rowasa Kit | 3 | | |
| Rowasa* | 2 | | |
| Roxanol* | 3 | | |
| Roxanol-T* | 3 | | |
| Roxicet 5-325 | 1 | | |
| Roxicet 5-500 | 3 | | |
| Roxicet Soln | 3 | | |
| Roxicodone* | 3 | | |
| Rozerem | 3PA | | |
| Rozex | 3 | | |
| Ru-Tuss | 1 | | |
| Ru-Tuss 800 DM | 3 | | |
| Ru-Tuss A | 1 | | |
| Ru-Tuss DM | 3 | | |
| Ru-Tuss Jr | 1 | | |
| Rum-K-SF | 3 | | |
| Ry-T-12 | 1 | | |
| Ryna-12 S* | 3 | | |
| Ryna-12* | 3 | | |
| Ryna-12X | 3 | | |
| Rynatan Pediatric* | 3 | | |
| Rynatan* | 3 | | |
| Rynatuss Pediatric* | 3 | | |
| Rynatuss* | 3 | | |
| Rythmol SR | 3PA | | |
| Rythmol* | 3 | | |
| Ryzolt* | 3PA | | |
| S-T Forte 2 | 3 | | |
| Sabril | 3PA | | Specialty Pharmacy |
| SAFETY-LOK Insulin Syringe | 2 | | |
| Safyral | 3 | | |
| Saizen | 3PA | | Specialty Pharmacy |
| Sal-Tropine* | 3 | | |
| Salagen* | 3 | | |
| Salflex | 1 | | |
| SaliCept | 1 | | |
| Salkera | 3 | | |
| Salsalate | 1 | | |
| Samsca | 3PA | | |
| Sanctura | 3 | | |
| Sancuso | 3PA | | |
| Sandimmune* | 3 | | |
| Sandostatin* | 2PA | | Specialty Pharmacy |
| Santyl | 2 | | |
| Saphris | 3PA | | |
| Sarafem | 3PA | | |
| Savella | 3PA | | |
| SB Clotrimazole Foot | 1 | | |
| SB Lancets Thin | 2 | | |
| SB Lancets Ultra Thin | 2 | | |
| SB Miconazole 3-Day Combo | 1 | | |
| Schnucks Insulin Syringe | 2 | | |
| Scopace* | 3 | | |
| Seasonale* | 3 | | 3 Copays |
| Seasonique* | 3 | | 3 Copays |
| Seba-Gel | 1 | | |
| Sebizon* | 3 | | |
| Seconal | 2 | | |
| Sectral* | 3 | | |
| Sedapap* | 3 | | |
| Select Brand Insulin Syringe | 2 | | |
| Select GT Control Solutions | 3 | | ST |
| Select GT Test Strips | 3 | 150 | ST |
| Select-Lite Lancet Device | 2 | | |
| Selegiline HCl | 1 | | |
| Selenium Sulfide | 1 | | |
| Selseb* | 3 | | |
| Selsun* | 3 | | |
| Selzentry | 3PA | | |
| Semprex-D | 2 | | |
| Sensipar | 3PA | | Specialty Pharmacy |
| Sentry Test Strips | 3 | 150 | ST |
| Septra DS* | 3 | | |
| Septra* | 3 | | |
| Serax* | 3 | | |
| Serevent Diskus | 3 | | |
| Seromycin | 3 | | |
| Serophene | 1 | | |
| Seroquel | 3 | | |
| Seroquel XR | 3 | 30 | |
| Serostim | 3PA | | Specialty Pharmacy |
| Sertraline | 1 | | |
| Servira | 1 | | |
| Shohls Modified* | 3 | | |
| Shoprite Test Strips | 3 | 150 | ST |
| Sil-Tex | 1 | | |
| Sildec | 1 | | |
| Sildec DM | 1 | | |
| Silenor | 3PA | | |
| Silvadene* | 3 | | |
| Silver Sulfadiazine | 1 | | |
| Simcor | 3 | 30 | |
| Simetyl | 3 | | |
| Simponi | 3PA | | Specialty Pharmacy |
| Simvastatin | 1 | 30 | |
| Sina-12X | 3 | | |
| Sinemet CR* | 3 | | |
| Sinemet* | 3 | | |
| Sinequan* | 3 | | |
| Singulair | 2 | | Asthma Treatment |
| Singulair | 2PA | | Allergy Treatment |
| SINUtuss DM | 3 | | |
| Sinuvent PE* | 3 | | |
| Sitrex | 3 | | |
| Skelaxin* | 3 | | |
| Skelid | 3 | | |
| Slo-Niacin (250mg) | 1 | | |
| Slo-Niacin* | 3 | | |
| SM Clotrimazole | 1 | | |
| SM Glucose Test Strips | 3 | 150 | ST |
| SM Insulin Syringe | 2 | | |
| SM Lancets | 2 | | |
| SM Niacin CR | 1 | | |
| SOBA Anti-Diarrheal | 1 | | |
| SOBA Insulin Syringe | 2 | | |
| SOBA Lancets Colored | 2 | | |
| SOBA Thin Lancets | 2 | | |
| Sodium Chloride Nebu | 1/3 | | |
| Sodium Fluoride Chw | 1 | | |
| Sodium Fluoride Gel | 3 | | |
| Sodium Fluoride Oral Tab | 1 | | |
| Sodium Fluoride Soln | 1 | | |
| Sodium Polystyrene Sulfonate | 1 | | |
| Soft Touch Lancet Device | 2 | | |
| Soft Touch Lancets | 2 | | |
| Softclix Lancets | 2 | | |
| Solaraze | 3PA | | |
| Solartek Glucose Control | 3 | | |
| Solia | 1 | | |
| Solodyn | 3PA | | |
| Solotuss | 3 | | |
| Soltamox | 3 | | |
| Soma Compound* | 3 | | |
| Soma Compound/Codeine* | 3 | | |
| Soma* | 3 | | |
| Somatuline | 3PA | | Specialty Pharmacy |
| Somavert | 3PA | | Specialty Pharmacy |
| Somnote | 3 | | |
| Sonata | 3 | 9 | |
| Sorbutuss | 3 | | |
| Soriatane | 2 | | |
| Sorine | 1 | | |
| Sotalol HCl | 1 | | |
| Sotalol HCl (AF) | 1PA | | |
| Sotret | 1 | | |
| Spacol T/S | 1 | | |
| Spasdel | 1 | | |
| Spastrin | 1 | | |
| Spectazole* | 3 | | |
| Spectracef* | 3PA | | |
| Spiriva HandiHaler | 3 | | |
| Spironolactone | 1 | | |
| Spironolactone-HCTZ | 1 | | |
| Sporanox Pulsepak* | 3PA | | |
| Sporanox* | 3PA | | |
| Sprintec 28 | 1 | | |
| Sprix | 3PA | | |
| Sprycel | 3PA | | Specialty Pharmacy |
| SPS | 3 | | |
| SSD | 1 | | |
| SSD AF | 1 | | |
| SSKI | 3 | | |
| STA-D | 3 | | |
| Staflex* | 3 | | |
| Stagesic | 1 | | |
| Stagesic-10 | 3 | | |
| Stahist | 3 | | |
| Stalevo | 3PA | | |
| Stamoist E | 1 | | |
| Starlix | 3 | | |
| Statuss DM | 1 | | |
| Statuss Green | 3 | | |
| Stavudine | 1 | | |
| Stavzor | 3PA | | |
| Staxyn | 3 | 4 | |
| Sterapred DS* | 3 | | |
| Sterapred* | 3 | | |
| Sterile Water | 1 | | |
| Stimate | 3 | | Specialty Pharmacy |
| Strattera | 3PA | | |
| Striant | 3PA | | |
| Stromectol | 3 | | |
| Strong Iodine | 3 | | |
| Su-Tuss DM | 1 | | |
| Su-Tuss HD | 1 | | |
| Suboxone SL Film | 3PA | | |
| Suboxone SL Tab | 3PA | | |
| Subutex* | 3PA | | |
| Suclor | 1 | | |
| Sucraid | 3 | | |
| Sucralfate Susp | 3 | | |
| Sucralfate Tab | 1 | | |
| Sudal 12 | 3 | | |
| Sudal DM* | 3 | | |
| Sudal SR* | 3 | | |
| Sudal* | 3 | | |
| SudaTex | 1 | | |
| Sudatuss DM | 1 | | |
| Sudatuss-2 | 1 | | |
| Sudatuss-SF | 1 | | |
| Sular* | 3 | | |
| Sulf-10 | 1 | | |
| Sulfac | 1 | | |
| Sulfacet-R* | 3 | | |
| Sulfacetamide Sodium Oint | 3 | | |
| Sulfacetamide Sodium Soln | 1 | | |
| Sulfacetamide Sodium-Sulfur | 1 | | |
| Sulfacetamide-Prednisolone | 1 | | |
| SulfADIAZINE | 1 | | |
| Sulfamethoxazole-TMP DS | 1 | | |
| Sulfamethoxazole-Trimethoprim | 1 | | |
| Sulfasalazine | 1 | | |
| Sulfatrim | 1 | | |
| Sulfazine | 1 | | |
| Sulfazine EC | 1 | | |
| Sulfinpyrazone | 1 | | |
| SulfiSOXAZOLE | 1 | | |
| Sulfoam | 3 | | |
| Sulfoxyl Regular | 2 | | |
| Sulfoxyl Strong | 2 | | |
| Sulfurated Lime | 3 | | |
| Sulindac | 1 | | |
| Sumatriptan Inj | 1 | 2 | |
| Sumatriptan Nasal Soln | 21 | 6 | |
| Sumatriptan Tabs | 1 | 9 | |
| Sumavel | 3 | 2 | |
| Sumaxin | 3 | | |
| Sumycin | 3 | | |
| Super Thin Lancets | 2 | | |
| Suphera | 1 | | |
| Suprax | 3 | | |
| Supreme Control Solns | 3 | | ST |
| Supreme Test Strips | 3 | 150 | ST |
| Suprep | 3 | | |
| Supress-DX Pediatric | 1 | | |
| Sure Comfort Insulin Syringe | 2 | | |
| Sure One Insulin Syringe | 2 | | |
| Surelite Lancets | 2 | | |
| SureStep Control Soln | 2 | | |
| SureStep Test Strips | 2 | 150 | |
| Surmontil* | 3 | | |
| Sustiva | 2 | | |
| Sutent | 3PA | | Specialty Pharmacy |
| Suttar-2 | 3 | | |
| Suttar-SF | 3 | | |
| Syeda | 1 | | |
| Sylatron | 3PA | | |
| Symax Duotab | 3 | | |
| Symax FasTabs | 1 | | |
| Symax-SL | 1 | | |
| Symax-SR | 1 | | |
| Symbicort | 3 | | |
| Symbyax | 3PA | | |
| Symlin | 3PA | | |
| SymlinPen | 3PA | | |
| Synalar* | 3 | | |
| Synalgos-DC | 3 | | |
| Synarel | 2 | | |
| Synera Dis | 3 | | |
| Syntest DS | 1 | | |
| Syntest HS | 1 | | |
| Synthroid* | 3 | | |
| Syprine | 3 | | |
| T-Tanna DM | 1 | | |
| Taclonex | 3PA | | |
| Tacrolimus Caps | 1 | | |
| Tagamet* | 3 | | |
| Talacen* | 3 | | |
| Taladine* | 3 | | |
| Talwin NX* | 3 | | |
| Tambocor* | 3 | | |
| Tamiflu Cap | 3 | | 10 per Rx |
| Tamiflu Susp | 3 | | 75 per Rx |
| Tamoxifen Citrate | 1 | | |
| Tamsulosin | 1 | | |
| Tana DM | 1 | | |
| Tana PSE | 1 | | |
| Tana R-12 | 1 | | |
| Tana T-12 | 1 | | |
| TanaCof-A 12 | 1 | | |
| Tanafed DMX* | 3 | | |
| Tanafed DP* | 3 | | |
| Tanatan RF | 1 | | |
| Tanatuss Pediatric | 1 | | |
| Tanavan | 1 | | |
| Tannate DMP-DEX | 1 | | |
| Tannate-12 | 1 | | |
| Tannate-12 S | 1 | | |
| Tannate-12D S | 1 | | |
| Tannate-V-DM | 1 | | |
| Tannic-12 | 1 | | |
| Tannic-12 S | 1 | | |
| Tannihist-12 RF | 1 | | |
| Tapazole* | 3 | | |
| Tarceva | 3PA | | Specialty Pharmacy |
| Targretin Cap | 3 | | Specialty Pharmacy |
| Targretin Gel | 3 | | Specialty Pharmacy |
| Tarka* | 3 | | |
| Tasigna | 3PA | | Specialty Pharmacy |
| Tasmar | 3 | | |
| Tazorac | 2 | | |
| Taztia XT | 1 | | |
| TBC | 1 | | |
| Tebamide | 1 | | |
| Techlite Lancets | 2 | | |
| Tegretol XR* | 3 | | |
| Tegretol* | 3 | | |
| Tekamlo | 3PA | | |
| Tekturna | 3PA | | |
| Tekturna HCT | 3PA | | |
| Temazepam | 1 | | |
| Temodar | 2 | | Specialty Pharmacy |
| Temovate E* | 3 | | |
| Temovate* | 3 | | |
| Tenake | 1 | | |
| Tencet | 1 | | |
| Tencon | 3 | | |
| Tenex* | 3 | | |
| Tenoretic 100* | 3 | | |
| Tenoretic 50* | 3 | | |
| Tenormin* | 3 | | |
| Tequin | 3 | | |
| Terak | 1 | | |
| Terazol 3* | 3 | | |
| Terazol 7* | 3 | | |
| Terazosin HCl | 1 | | |
| Terbinafine Tab | 1 | | Limit 84 per year |
| Terbutaline Sulfate | 1 | | |
| Terconazole | 1 | | |
| Terramycin* | 3 | | |
| Tersi Foam | 3PA | | |
| Terumo Insulin Syringe | 2 | | |
| Teslac | 3 | | |
| Tessalon Perles* | 3 | | |
| Tessalon* | 3 | | |
| Testim | 3PA | | |
| Testomar | 1 | | |
| Testred | 3 | | |
| Tetra Tannate Pediatric | 1 | | |
| Tetra-Mag | 1 | | |
| Tetracycline HCl | 1 | | |
| Tev-Tropin | 2PA | | Specialty Pharmacy |
| Teveten HCT | 3 | | |
| Teveten* | 3 | | |
| Texacort 1% | 1 | | |
| Texacort 2.5% | 3 | | |
| Thalitone | 3 | | |
| Thalomid | 2PA | | Specialty Pharmacy |
| Theo-24 | 2 | | |
| TheoCap | 1 | | |
| Theochron | 1 | | |
| Theomar GG | 3 | | |
| Theophylline CR | 1 | | |
| Theophylline Soln | 1 | | |
| Theophylline Tab | 1 | | |
| Thermazene | 1 | | |
| Thin Lancets | 2 | | |
| Thinlets GP Lancets | 2 | | |
| Thinlets Lancet | 2 | | |
| Thioguanine | 3 | | |
| Thiola | 3 | | |
| Thioridazine HCl (10mg,25mg,50mg,100mg) | 1 | | |
| Thioridazine HCl (15mg,150mg,200mg) | 1 | | |
| Thioridazine HCl Conc | 1 | | |
| Thiothixene | 1 | | |
| Thorazine* | 3 | | |
| Thyroid | 1 | | |
| Thyrolar-1 | 2 | | |
| Thyrolar-1/2 | 2 | | |
| Thyrolar-1/4 | 2 | | |
| Thyrolar-2 | 2 | | |
| Thyrolar-3 | 2 | | |
| Tiazac* | 3 | | |
| Ticlid* | 3 | | |
| Ticlopidine HCl | 1 | | |
| Tigan* | 3 | | |
| Tikosyn | 3 | | |
| Tilade | 2 | | |
| Time-Hist | 1 | | |
| Timolide | 3 | | |
| Timolol Maleate | 1 | | |
| Timoptic Ocudose | 3 | | |
| Timoptic* | 3 | | |
| Timoptic-XE* | 3 | | |
| Tindamax | 3 | 3 Day Supply | |
| Tirosint | 3 | 30 | |
| Tizanidine HCl | 1PA | | |
| Tobi | 3 | | Specialty Pharmacy |
| TobraDex | 2 | | |
| Tobradex ST | 3 | | |
| Tobramy/Dexameth | 1 | | |
| Tobramycin Sulfate | 1 | | |
| Tobrasol | 1 | | |
| Tobrex Oint | 2 | | |
| Tobrex Soln* | 3 | | |
| Tofranil* | 3 | | |
| Tofranil-PM | 3 | | |
| TOLAZamide | 1 | | |
| TOLBUTamide | 1 | | |
| Tolectin* | 3 | | |
| Tolinase* | 3 | | |
| Tolmetin Sodium | 1 | | |
| Topamax* | 3 | | |
| Topco Insulin Syringe | 2 | | |
| Topicort LP* | 3 | | |
| Topicort* | 3 | | |
| Topiramate | 1 | | |
| Toprol XL* | 3 | 30 | |
| Toradol Oral* | 3PA | 5 Day Supply | |
| Torsemide | 1 | | |
| Touro Allergy | 3 | | |
| Touro CC | 3 | | |
| Touro CC-LD | 3 | | |
| Touro DM | 3 | | |
| Touro HC | 3 | | |
| Touro LA | 3 | | |
| Touro LA-LD | 3 | | |
| Toviaz | 3PA | | |
| Trac | 3 | | |
| Tracer Glucose Control | 3 | | |
| Tracleer | 3PA | | Specialty Pharmacy |
| Tradjenta | 3 | 30 | ST |
| Tramadol ER | 1 | | |
| Tramadol ER Biphasic | 1PA | | Ryzolt generic |
| Tramadol HCl | 1 | | |
| Trandate* | 3 | | |
| Trandolapril/Verapamil | 1 | | |
| Transderm-Scop | 2 | 4 | |
| Tranxene-SD | 3 | | |
| Tranxene-T* | 3 | | |
| Tranylcypromine | 1 | | |
| Travatan | 2 | | |
| Travatan Z | 2 | | |
| Travel-Ease | 1 | | |
| Trazodone HCl | 1 | | |
| Trecator | 3 | | |
| Trecator-SC | 3 | | |
| Trental* | 3 | | |
| Tretin-X Crm | 3PA | | PA if > 26 Eff 09/10 |
| Tretin-X Gel | 3PA | | PA if > 26 Eff 09/10 |
| Tretinoin Caps | 3 | | |
| Tretinoin Topical | 1PA | | PA if > 26 Eff 09/10 |
| Trexall | 3PA | | |
| Treximet | 3PA | 9 | |
| Tri Tann Pediatric | 1 | | |
| Tri-Gestan S | 1 | | |
| Tri-Histine | 1 | | |
| Tri-K | 3 | | |
| Tri-Norinyl (28)* | 3 | | |
| Tri-Otic | 1 | | |
| Tri-Previfem | 1 | | |
| Tri-Sprintec | 1 | | |
| Tri-Vent DM | 1 | | |
| Tri-Vent DPC | 1 | | |
| Tri-Vent HC | 1 | | |
| Triacetin | 3 | | |
| Triad | 1 | | |
| Triamcinolone Acetonide | 1 | | |
| Triamcinolone in Absorbase | 3 | | |
| Triamterene-HCTZ | 1 | | |
| Trianex | 3 | | |
| Triant-HC* | 3 | | |
| Triaz | 3 | | |
| Triazolam | 1 | | |
| Tribenzor | 3 | 30 | |
| Tricitrates | 1 | | |
| Tricof | 1 | | |
| Tricof EXP | 1 | | |
| Tricof PD | 1 | | |
| Tricor | 3 | | ST |
| Tricosal | 1 | | |
| Tridal | 3 | | |
| Tridal HD | 1 | | |
| Tridal HD Plus | 1 | | |
| Triderm | 1 | | |
| Tridesilon* | 3 | | |
| Trifluoperazine HCl | 1 | | |
| Trifluridine | 1 | | |
| Triglide | 3 | | |
| Trihexyphenidyl HCl | 1 | | |
| Trikof-D | 3 | | |
| Trileptal* | 3 | | |
| Trilipix | 3PA | | ST |
| TriLyte | 1 | | |
| Trimethobenzamide HCl | 1 | | |
| Trimethobenzamide-Benzocaine | 1 | | |
| Trimethoprim | 1 | | |
| Trimethoprim-SMZ DS | 1 | | |
| Trimipramine Maleate | 1 | | |
| Trimox | 1 | | |
| TriNessa (28) | 1 | | |
| Trionate | 1 | | |
| Trionate NF | 1 | | |
| Triotann Pediatric | 1 | | |
| Triotann-S Pediatric | 1 | | |
| Triphasil (28)* | 3 | | |
| Triple Antibiotic | 1 | | |
| Triple Tannate Pediatric | 1 | | |
| Trispec DMX | 3 | | |
| Trispec DMX Pediatric | 3 | | |
| Trispec PSE | 3 | | |
| Trispec PSE Pediatric | 3 | | |
| Trispec SFX | 3 | | |
| Trital DM | 1 | | |
| Trituss DM | 1 | | |
| TriTuss* | 3 | | |
| Trituss-A* | 3 | | |
| TriTuss-ER* | 3 | | |
| Tritussin | 1 | | |
| Trivora (28) | 1 | | |
| Trizivir | 3 | | |
| Tropicacyl | 1 | | |
| Tropicamide | 1 | | |
| Trospium | 1 | | |
| True Care Test Strips | 3 | 150 | ST |
| TrueTest Test Strips | 3 | 150 | ST |
| TrueTrack Control Solns | 3 | | ST |
| TrueTrack Test Strips | 3 | 150 | ST |
| Trusopt* | 3 | | |
| Truvada | 3 | | |
| Tusdec-DM | 1 | | |
| Tusdec-HC | 1 | | |
| Tusnel | 3 | | |
| Tusnel Ped-C | 3 | | |
| Tusnel Pediatric* | 3 | | |
| Tusnel-DM Pediatric | 3 | | |
| Tusnel-HC | 3 | | |
| Tuss-AX | 1 | | |
| Tuss-DA NR | 3 | | |
| Tuss-DM | 3 | | |
| Tuss-DS | 1 | | |
| Tuss-ES* | 3 | | |
| Tuss-HC | 1 | | |
| Tuss-PD | 1 | | |
| Tuss-S | 3 | | |
| Tussadur-HD | 1 | | |
| Tussafed | 1 | | |
| Tussafed EX 10-30-200 Liq | 1 | | |
| Tussafed EX 2.5-5-50 Liq | 1 | | |
| Tussafed EX Syr* | 3 | | |
| Tussafed HC | 1 | | |
| Tussafed-HCG | 3 | | |
| Tussafed-LA | 1 | | |
| Tussall | 3 | | |
| Tussall-ER | 3 | | |
| Tussbid | 1 | | |
| Tussend Expectorant* | 3 | | |
| Tussend* | 3 | | |
| Tussi-12 S* | 3 | | |
| Tussi-12* | 3 | | |
| Tussi-12D | 3 | | |
| Tussi-12D S* | 3 | | |
| Tussi-bid | 1 | | |
| Tussi-Organidin DM-S NR | 1 | | |
| Tussi-Organidin NR DM | 1 | | |
| Tussi-Organidin NR* | 3 | | |
| Tussi-Pres | 3 | | |
| Tussi-Pres Pediatric | 3 | | |
| Tussidex* | 3 | | |
| Tussigon | 3 | | |
| Tussin-V | 1 | | |
| TussiNATE | 3 | | |
| Tussionex Pennkinetic ER | 3 | | |
| Tussirex | 3 | | |
| Tussirex Sugar Free | 3 | | |
| Tussitab | 1 | | |
| Tussizone-12 RF | 1 | | |
| Tusso-DF* | 3 | | |
| Twinject | 3 | | |
| Twynsta | 3 | | |
| Tykerb | 3PA | | Specialty Pharmacy |
| Tylenol/Codeine #3* | 3 | | |
| Tylenol/Codeine #4* | 3 | | |
| Tylox* | 3 | | |
| Tympagesic* | 3 | | |
| Tyvaso | 3PA | | |
| Tyzeka | 3PA | 30 | |
| Tyzine | 3 | | |
| U-Cort | 1 | | |
| Ulesfia | 3 | | |
| Uloric | 3PA | | |
| Ulti-Lance Auto-Adjust Device | 2 | | |
| Ulti-Lance Automatic | 2 | | |
| Ulti-Lance Mini Adjustable | 2 | | |
| UltiCare Insulin Syringe | 2 | | |
| UltiCare Thin Lancets | 2 | | |
| UltiCare Thin Lancets 30G | 2 | | |
| UltiGuard Insulin Syringe | 2 | | |
| Ultilet Classic Lancets | 2 | | |
| Ultilet Insulin Syringe | 2 | | |
| Ultilet Insulin Syringe Short | 2 | | |
| Ultilet Lancets | 2 | | |
| Ultilet Operating Device | 2 | | |
| Ultilet Pen Needle | 2 | | |
| Ultilet Ulti-Lance ADJ Device | 2 | | |
| Ultima Test Strips | 3 | 150 | ST |
| Ultra Comfort Insulin Syringe | 2 | | |
| Ultra Insulin Syringe | 2 | | |
| Ultra Thin Lancets | 2 | | |
| Ultrabrom | 1 | | |
| Ultrabrom PD | 1 | | |
| Ultracaps MT 20 | 3 | | |
| Ultracet | 3PA | | |
| UltraLytic 2 | 3 | | |
| Ultram ER* | 3 | | |
| Ultram* | 3 | | |
| Ultrase | 3 | | |
| Ultrase MT 12 | 3 | | |
| Ultrase MT 18 | 3 | | |
| Ultrase MT 20 | 3 | | |
| Ultratuss 12 S | 1 | | |
| Ultravate* | 3 | | |
| Umecta | 3 | | |
| Uni-Cof | 1 | | |
| Uni-Cof EXP | 1 | | |
| Uni-Hist | 1 | | |
| Uni-Hist DM Pediatric | 1 | | |
| Uni-Hist PDX | 1 | | |
| Uni-Lev 5.0 | 1 | | |
| Uni-Otic | 1 | | |
| Uni-Serp | 3 | | |
| Uni-Tex 120/10 ER | 1 | | |
| Uni-Tricof HC | 1 | | |
| Uni-Tuss DM | 1 | | |
| Uni-Tuss HC | 1 | | |
| Unifine Pentips | 2PA | | |
| Unilet ComforTouch Lancet | 2 | | |
| Unilet Excelite | 2 | | |
| Unilet Excelite II | 2 | | |
| Unilet G.P. Lancet | 2 | | |
| Unilet G.P. Superlite Lancet | 2 | | |
| Unilet GP 28 | 2 | | |
| Unilet Lancet | 2 | | |
| Unilet Superlite Lancet | 2 | | |
| Uniphyl* | 3 | | |
| Uniretic | 3 | | |
| Unistik 1 | 2 | | |
| Unistik 2 | 2 | | |
| Unistik 2 Extra | 2 | | |
| Unistik 2 Neonatal | 2 | | |
| Unistik 2 Normal | 2 | | |
| Unistik 2 Super | 2 | | |
| Unistik 3 | 2 | | |
| Unistik 3 Comfort | 2 | | |
| Unistik 3 Neonatal | 2 | | |
| Unistik 3 Normal | 2 | | |
| Unithroid | 1 | | |
| Univasc | 3 | | |
| Uramaxin | 3 | | |
| Urea | 1 | | |
| Urea Nail | 1 | | |
| Urealac | 1 | | |
| Urealac Nail | 1 | | |
| Urecholine* | 3 | | |
| Urelief Plus | 1 | | |
| Urelle | 3 | | |
| Uretron D/S* | 3 | | |
| Urex* | 3 | | |
| Uribel | 3 | | |
| Urimar T | 1 | | |
| Urimar-T | 1 | | |
| Urimax* | 2 | | |
| Urin DS | 1 | | |
| Urised* | 3 | | |
| Uriseptic | 1 | | |
| Urispas* | 2 | | |
| UriSym | 3 | | |
| Uritact DS | 1 | | |
| Uro-Kp-Neutral | 3 | | |
| Uroblue | 1 | | |
| Urocit-K 10* | 3 | | |
| Urocit-K 15 | 2 | | |
| Urocit-K 5* | 3 | | |
| Urogesic-Blue | 1 | | |
| Urolene Blue | 3 | | |
| Uroqid #2 | 3 | | |
| Uroxatral* | 3 | 30 | |
| Urso 250 | 3 | | |
| Urso Forte | 3 | | |
| Ursodiol | 1 | | |
| Usept | 1 | | |
| UTA | 3 | | |
| Utira | 3 | | |
| V-Dec-M | 1 | | |
| V-R Mono Insulin Syringe | 2 | | |
| V-Tann B.I.D | 1 | | |
| Vagifem | 3 | | |
| Vagistat-1* | 3 | | |
| Vagistat-3 | 1 | | |
| Valacyclovir | 1 | | |
| Valcyte | 2PA | | |
| Valium* | 3 | | |
| Valproate Sodium | 1 | | |
| Valproic Acid | 1 | | |
| Valtrex* | 3 | | |
| Valturna | 3PA | | |
| Value Health Insulin Syringe | 2 | | |
| Value Plus Thin Lancets | 2 | | |
| Vanacet | 1 | | |
| Vanacon | 1 | | |
| Vanamide | 1 | | |
| Vanatrip | 1 | | |
| Vancocin HCl | 3PA | | |
| Vandetanib | - | | New to Market Policy |
| Vanex-HD | 1 | | |
| Vanos | 3 | | |
| Vanoxide-HC | 3 | | |
| Vanspar* | 3 | | |
| Vantin* | 2 | | |
| Vaseretic* | 3 | | |
| Vasodilan* | 3 | | |
| Vasotec* | 3 | | |
| VaZol | 3 | | |
| VaZol-D | 3 | | |
| Vectical | 3PA | | |
| Veetids | 1 | | |
| Velivet | 1 | | |
| Velosef | 3 | | |
| Veltin Gel | 3PA | | |
| Venlafaxine SR | 1 | | ST |
| Venlafaxine Tab | 1 | | |
| Venlafaxine XR | 1 | | ST |
| Ventavis | 3PA | | Specialty Pharmacy |
| Ventolin HFA | 3 | 2 | |
| VePesid* | 3 | | |
| Veramyst | 3 | | ST |
| Verapamil HCl | 1 | | |
| Verapamil HCl CR | 1 | | |
| Verapamil SR 24H | 1PA | | |
| Verdeso | 3PA | | |
| Veregen | 3PA | | |
| Verelan PM* | 3PA | | |
| Verelan* | 3 | | |
| Vermox* | 3 | | |
| Versacaps | 1 | | |
| Versiclear | 1 | | |
| Vertin-32 | 1 | | |
| Vesanoid* | 3 | | |
| VESIcare | 3 | 30 | |
| Vexol | 2 | | |
| Vfend* | 3PA | | |
| Vi-Q-Tuss | 1 | | |
| Viagra | 3 | 4 | |
| Vibra-Tabs* | 3 | | |
| Vibramycin* | 3 | | |
| Vicoclear | 1 | | |
| Vicodin ES* | 3 | | |
| Vicodin HP | 1 | | |
| Vicodin* | 3 | | |
| Vicoprofen* | 3 | | |
| Victoza | 3PA | | |
| Victrelis | 3PA | | |
| Vidaza | 3PA | | |
| Videx EC* | 3 | | |
| Videx Pediatric | 2 | | |
| Vigamox | 3 | 3 per Rx | |
| Viibryd | 3PA | | |
| Vimovo | 3PA | | |
| Vimpat | 3PA | | |
| Viokase | 2 | | |
| Viokase 16 | 2 | | |
| Viokase 8 | 2 | | |
| Viracept | 2 | | |
| Viramune | 2 | | |
| Viramune XR | 2 | | |
| Viravan DM* | 3 | | |
| Viravan-S* | 3 | | |
| Viravan-T | 3 | | |
| Viread | 2 | | |
| Viroptic* | 3 | | |
| Visicol | 3 | | |
| Vistaril* | 3 | | |
| Vita-Numonyl | 3 | | |
| Vita-Numonyl AD | 1 | | |
| Vita-Numonyl DM | 3 | | |
| Vita-Numonyl EX | 3 | | |
| Vita-Numonyl NR | 1 | | |
| Vita-Numonyl Pediatric | 1 | | |
| Vitalet 23 Gauge Lancet | 2 | | |
| Vitalet 26 Gauge Lancet | 2 | | |
| Vitamin D 50000u | 1 | | |
| Vitamin D3 | 3 | | |
| Vitussin | 1 | | |
| Vivactil* | 3 | | |
| Vivelle | 3 | 8 | |
| Vivelle-Dot | 3 | 8 | |
| Vivotif Berna Vaccine | 3 | | |
| Voltaren Gel | 3 | | |
| Voltaren Ophth* | 2 | | |
| Voltaren Tab* | 3 | | |
| Voltaren-XR* | 3 | | |
| Vopac | 3 | | |
| Voriconazole | 1PA | | |
| VoSpire ER | 3 | | |
| VP Insulin Syringe | 2 | | |
| Vytone* | 3 | | |
| Vytorin | 3 | | |
| Vyvanse | 3PA | | |
| W&F Color Lancets | 2 | | |
| W&F Lancets 26G | 2 | | |
| W&F Lancets Colored 21G | 2 | | |
| W&F Lancets Ultra Thin | 2 | | |
| Walgreens Insulin Syringe | 2 | | |
| Walgreens Lancets | 2 | | |
| Walgreens Lancing Device | 2 | | |
| Walgreens Thin Lancets | 2 | | |
| Walgreens Ultra Thin Lancets | 2 | | |
| Warfarin Sodium | 1 | | |
| WaveSense Test Strips | 3 | 150 | ST |
| WD Lancets | 2 | | |
| WD Lancets Thin | 2 | | |
| WD Thin Lancets | 2 | | |
| WE Allergy | 1 | | |
| We Mist II LA | 1 | | |
| WelChol | 3 | | |
| Well-Tuss HD | 1 | | |
| WellBid-D | 1 | | |
| WellBid-D 1200 | 1 | | |
| Wellbutrin SR* | 3 | | |
| Wellbutrin XL* | 3 | 30 | |
| Wellbutrin* | 3 | | |
| WellTuss EXP | 1 | | |
| WellTuss HC | 1 | | |
| Westcort* | 3 | | |
| Westhroid | 3 | | |
| Wide-Seal Diaphragm 60 | 3 | | |
| Wide-Seal Diaphragm 65 | 3 | | |
| Wide-Seal Diaphragm 70 | 3 | | |
| Wide-Seal Diaphragm 75 | 3 | | |
| Wide-Seal Diaphragm 80 | 3 | | |
| Wide-Seal Diaphragm 85 | 3 | | |
| Wide-Seal Diaphragm 90 | 3 | | |
| Wide-Seal Diaphragm 95 | 3 | | |
| Winn Dixie Medic Test Strips | 3 | 150 | ST |
| X-Viate | 1 | | |
| Xalatan* | 3 | | |
| Xalkori | 3PA | | Specialty Pharmacy |
| Xanax XR* | 3 | 30 | |
| Xanax* | 3 | | |
| Xarelto 10mg | 3 | | 35 tab limit per yr |
| Xarelto 15mg 20mg | 3PA | | |
| Xeloda | 3 | | Specialty Pharmacy |
| Xenaderm | 3 | | |
| Xenazine | 3PA | | Specialty Pharmacy |
| Xenical | 3PA | | |
| Xerac AC | 3 | | |
| Xerese | - | | New to Market Policy |
| Xibrom* | 3 | | |
| Xifaxin 200mg | 3 | 9 | 9 tabs per Rx limit |
| Xifaxin 550mg | 3PA | | |
| Xiral SR | 1 | | |
| Xiratuss Susp* | 3 | | |
| Xiratuss Tab | 1 | | |
| Xodol* | 3 | | |
| Xolegel | 3 | | |
| Xopenex HFA Inhaler | 3PA | | |
| Xopenex Nebs | 3PA | | |
| Xopenex Nebs Concentrate | 3PA | | |
| Xpect-AT | 3 | | |
| Xpect-HC | 3 | | |
| Xylocaine Jelly* | 3 | | |
| Xylocaine Viscous* | 3 | | |
| Xylocaine* | 3 | | |
| Xyrem | 3PA | | |
| Yale Disp Needles | 2 | | |
| Yasmin* | 3 | | |
| Yaz* | 3 | | |
| Yocon* | 3 | | |
| Yodefan | 3 | | |
| Yodefan-NF | 3 | | |
| Yodoxin | 3 | | |
| Yohimbine HCl | 1 | | |
| Z-Clinz 10 | 3 | | |
| Z-Clinz 5 | 3 | | |
| Z-Cof DM | 3 | | |
| Z-Cof DMX | 3 | | |
| Z-Cof HC | 3 | | |
| Z-Cof LA* | 3 | | |
| Z-Cof LAX | 3 | | |
| Zaclir Cleansing | 1 | | |
| Zafirlucast | 1 | 60 | |
| Zanaflex* | 3PA | | |
| Zantac EFFERdose | 3 | | |
| Zantac* | 3 | | |
| Zarah | 1 | | |
| Zarontin* | 3 | | |
| Zaroxolyn* | 3 | | |
| Zavesca | 3PA | | |
| Zazole | 1 | | |
| Zazole 0.4% Crm | 1 | | |
| Zazole 0.8% Crm | 1 | | |
| Zebeta* | 3 | | |
| Zebutal | 1 | | |
| Zelapar | 3 | | |
| Zelboraf | 3PA | | Specialty Pharmacy |
| Zemplar | 3PA | | |
| Zenchant | 1 | | |
| Zenpep | 3 | | |
| Zephrex | 1 | | |
| Zephrex LA* | 3 | | |
| Zerit | 2 | | |
| Zero-Order Release Aspirin | 1 | | |
| Zestoretic* | 3 | | |
| Zestril* | 3 | | |
| Zetacet | 1 | | |
| Zetia | 3 | | |
| Ziac* | 3 | | |
| Ziagen | 2 | | |
| Ziana | 3PA | | |
| Zidovudine | 1 | | |
| Zinotic Drop | 3 | | |
| Zinotic ES Drop | 3 | | |
| Zinotic* | 3 | | |
| Ziox | 1 | | |
| Zipsor | - | | New to Market Policy |
| Zirgan | 3 | | |
| Zithromax Susp* | 3 | | |
| Zithromax Tab | 3 | | |
| Zithromax Tri-Pak* | 3 | | |
| Zithromax Z-Pak* | 3 | | |
| Zmax | 3 | | |
| Zocor* | 3 | 30 | ST |
| Zoderm Cleanser* | 3 | | |
| Zoderm* | 3 | | |
| Zofran 24mg Tab | 3 | 1 | |
| Zofran ODT* | 3 | 9 | |
| Zofran Soln | 3 | 60 | |
| Zofran Tab* 4 & 8mg | 3 | 9 | |
| Zolene HC | 1 | | |
| Zolinza | 3PA | | Specialty Pharmacy |
| Zoloft* | 3 | | |
| Zolpidem | 1 | 30 | |
| Zolpidem ER | 3PA | 9 | |
| Zomig | 2 | 6 | |
| Zomig ZMT | 2 | 6 | |
| Zonalon* | 3 | | |
| Zonegran* | 3 | | |
| Zonisamide | 1 | | |
| Zorbtive | 3PA | | Specialty Pharmacy |
| Zorprin* | 3 | | |
| Zortress | 3PA | | |
| Zotane HC | 1 | | |
| Zotex Pediatric | 3 | | |
| Zotex* | 3 | | |
| Zotex-G | 3 | | |
| Zotex-GP | 3 | | |
| Zotex-LA* | 3 | | |
| Zoto-HC | 1 | | |
| Zovia 1/35E (28) | 1 | | |
| Zovia 1/50E (28) | 3 | | |
| Zovirax* | 3 | | |
| Ztuss | 3 | | |
| Ztuss Expectorant | 3 | | |
| Ztuss ZT | 3 | | |
| Zyban* | 3 | | |
| Zyclara | 3 | | |
| Zydone | 3 | | |
| Zyflo | 3PA | | |
| Zyflo CR | 3PA | | |
| Zylet | 3 | | |
| Zyloprim* | 3 | | |
| Zymar | 3 | 5 per Rx | |
| Zymaxid | 3 | | QL 2.5ml per Rx |
| Zymine | 3 | | |
| Zymine-D | 3 | | |
| Zyprexa Zydis | 3 | | |
| Zyprexa* | 3 | | |
| Zytiga | 3PA | | |
| Zyvox | 3PA | | |