MCD-KY STAT 2 - MMIT

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2021Comprehensive Dual EligiblePreferred Drug List (List of Covered Drugs)WellCare of Kentucky009Please read: This document contains information about the drugs we cover in thisplan.Last updated (4/01/2021)

Drug NamePreference Details Coverage Details*Alternative Medicines**Alternative Medicine - Me's***melatonin maximum strength oral tablet 5 mgPmelatonin oral tablet 12 mg*Analgesics - Anti-Inflammatory*P*Nonsteroidal Anti-Inflammatory Agents(Nsaids)***childrens ibuprofen oral suspension 40 mg/mlPibuprofen oral suspension 100 mg/5mlPibuprofen oral tablet 200 mgPnaproxen sodium oral tablet 220 mg*Analgesics - Nonnarcotic*P*Analgesics Other***ACEPHEN RECTAL SUPPOSITORY 325MG, 650 MGPacetaminophen oral solution 160 mg/5mlPacetaminophen oral tablet 325 mgPQL (279 EA per 31 days)acetaminophen oral tablet 500 mgPQL (186 EA per 31 days)acetaminophen oral tablet chewable 325 mgPapap extra strength oral tablet 500 mgPQL (186 EA per 31 days)apap oral tablet 325 mgPQL (279 EA per 31 days)childrens non-asa pain relief oral tabletchewable 80 mgPchildrens non-aspirin oral tablet chewable 80mgPchildrens pain reliever oral tablet chewable80 mgPchildrens silapap oral liquid 160 mg/5mlPchildrens tactinal oral tablet chewable 80 mgPed-apap oral liquid 160 mg/5mlPinfants silapap oral solution 100 mg/mlPmapap arthritis pain oral tablet extendedrelease 650 mgPMAPAP CHILDRENS ORAL SUSPENSION160 MG/5MLPmapap oral capsule 500 mgPQL (186 EA per 31 days)mapap oral tablet 325 mgPQL (279 EA per 31 days)QL (93 EA per 31 days)P Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs1

Drug NamePreference Details Coverage Detailsmapap oral tablet 500 mgPmapap oral tablet chewable 80 mgPmaxapap maximum strength oral tablet 500mgPQL (186 EA per 31 days)maxapap regular strength oral tablet 325 mgPQL (279 EA per 31 days)non-aspirin extra strength oral tablet 500 mgPQL (186 EA per 31 days)non-aspirin oral tablet 325 mgPQL (279 EA per 31 days)non-aspirin pain relief oral tablet 325 mgPQL (279 EA per 31 days)nortemp infants oral suspension 80 mg/0.8mlPpain & fever childrens oral solution 160mg/5mlPpain relief extra strength oral tablet 500 mgPQL (186 EA per 31 days)pain relief oral tablet 500 mgPQL (186 EA per 31 days)PHARBETOL EXTRA STRENGTH ORALTABLET 500 MGPQL (186 EA per 31 days)PHARBETOL ORAL TABLET 325 MGPQL (279 EA per 31 days)q-pap oral tablet 325 mgPQL (279 EA per 31 days)tactinal extra strength oral tablet 500 mgPQL (186 EA per 31 days)tactinal oral tablet 325 mg*Salicylate Combinations***PQL (279 EA per 31 days)tri-buffered aspirin oral tablet 325 mg*Salicylates***Paspirin childrens oral tablet chewable 81 mgPaspirin ec low dose oral tablet delayedrelease 81 mgPaspirin ec oral tablet delayed release 325 mgPaspirin oral tablet 325 mg, 81 mgPaspirin oral tablet chewable 81 mgPaspirin rectal suppository 300 mg, 600 mgPECPIRIN ORAL TABLET DELAYEDRELEASE 325 MG*Anorectal And Related Products*QL (186 EA per 31 days)P*Rectal Combinations - Misc.***eq hemorrhoidal rectal suppository 0.2585.39 %Phemorrhoidal rectal suppository 0.25-3-85.5%, 0.25-85.39 %PP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs2

Drug NamePreference Details Coverage Details*Antacids**Antacid & Simethicone***antacid anti-gas max strength oralsuspension 400-400-40 mg/5mlPantacid anti-gas oral suspension 200-200-20mg/5mlPantacid extra strength oral suspension 400400-40 mg/5mlPantacid iii oral suspension 400-400-40mg/5mlPMAALOX ADVANCED MAX ST ORALSUSPENSION 400-400-40 MG/5MLPMAALOX MAX ORAL SUSPENSION 400400-40 MG/5MLPMAALOX MULTI SYMPTOM MAX ST ORALSUSPENSION 400-400-40 MG/5MLPmilantex extra strength oral suspension 400400-40 mg/5mlPMINTOX PLUS ORAL TABLET CHEWABLE200-200-25 MG*Antacid Combinations***PACID GONE ORAL TABLET CHEWABLE160-105 MGPgnp foaming antacid oral tablet chewable 8020 mgPMI-ACID ORAL TABLET CHEWABLE 700300 MG*Antacids - Aluminum Salts***aluminum hydroxide gel oral suspension 320mg/5ml*Antacids - Bicarbonate***sodium bicarbonate oral tablet 325 mg, 650mg*Antacids - Calcium Salts***PPPantacid oral tablet chewable 500 mgPcalcium antacid extra strength oral tabletchewable 750 mgPcalcium antacid oral tablet chewable 500 mgPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs3

Drug NamePreference Details Coverage Detailscalcium carbonate antacid oral suspension1250 mg/5mlPcalcium carbonate antacid oral tablet 648 mgPcalcium carbonate antacid oral tabletchewable 500 mgPCAL-GEST ANTACID ORAL TABLETCHEWABLE 500 MGPMAALOX ORAL TABLET CHEWABLE 600MGPTITRALAC ORAL TABLET CHEWABLE 420MG*Antacids - Magnesium Salts***magnesium oxide oral tablet 250 mg, 400mg, 420 mg*Anthelmintics*PP*Anthelmintics***reeses pinworm medicine oral suspension144 (50 base) mg/ml*Antidiabetics*P*Diabetic Other***BD GLUCOSE ORAL TABLET CHEWABLE5 GMglucose oral tablet chewable 4 gm*Antidiarrheal/Probiotic Agents*PP*Antidiarrheal/Probiotic Agents - Misc.***bismatrol oral suspension 262 mg/15mlPbismatrol oral tablet chewable 262 mgPbismuth oral tablet chewable 262 mgPdiotame oral tablet chewable 262 mgPKAOPECTATE EXTRA STRENGTH ORALSUSPENSION 525 MG/15MLPKAOPECTATE ORAL SUSPENSION 262MG/15MLPKAO-TIN ORAL SUSPENSION 262MG/15MLPpink bismuth oral suspension 262 mg/15mlPpink bismuth oral tablet chewable 262 mgPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs4

Drug NamePreference Details Coverage Detailsstomach relief oral suspension 262 mg/15ml,527 mg/30mlPstomach relief oral tablet chewable 262 mgPstomach relief plus oral suspension 525mg/15ml*Antiperistaltic Agents***Panti-diarrheal oral liquid 1 mg/5mlPLOPERAMIDE A-D ORAL TABLET 2 MGPloperamide hcl oral liquid 1 mg/5ml*Antidotes And Specific Antagonists*P*Antidotes And Specific Antagonists***ipecac oral syrupPsm ipecac syrup oral syrup*Antiemetics*P*Antiemetics - Anticholinergic***meclizine hcl oral tablet 12.5 mg, 25 mgPtravel sickness oral tablet chewable 25 mg*Antihistamines*P*Antihistamines - Alkylamines***aller-chlor oral syrup 2 mg/5mlPaller-chlor oral tablet 4 mgPallergy oral tablet 4 mgPallergy relief oral tablet 4 mgPchlorhist oral tablet 4 mgPDIABETIC TUSSIN ALLERGY ORALSYRUP 2 MG/5ML*Antihistamines - Ethanolamines***Paler-cap oral capsule 25 mgPaler-dryl oral tablet 50 mgPalertab oral tablet 25 mgPallergy relief childrens oral liquid 12.5 mg/5mlPaltaryl oral elixir 12.5 mg/5mlPaltaryl oral syrup 12.5 mg/5mlPanti-hist allergy oral tablet 25 mgPBANOPHEN ORAL CAPSULE 25 MGPBANOPHEN ORAL LIQUID 12.5 MG/5MLPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs5

Drug NamePreference Details Coverage DetailsBANOPHEN ORAL TABLET 25 MGPBENADRYL ALLERGY CHILDRENS ORALLIQUID 12.5 MG/5MLPcomplete allergy medication oral tablet 25 mgPcomplete allergy relief oral tablet 25 mgPdiphenhist oral capsule 25 mgPdiphenhist oral liquid 12.5 mg/5mlPdiphenhist oral tablet 25 mgPdiphenhydramine hcl oral capsule 25 mg, 50mgPdiphenhydramine hcl oral tablet 25 mgPgenahist oral capsule 25 mgPpharbedryl oral capsule 25 mg, 50 mgPq-dryl oral capsule 25 mgPq-dryl oral liquid 12.5 mg/5mlPSCOT-TUSSIN ALLERGY RELIEF ORALLIQUID 12.5 MG/5MLPsiladryl allergy oral liquid 12.5 mg/5mlPsilphen cough oral syrup 12.5 mg/5mlPTOTAL ALLERGY MEDICINE ORAL LIQUID12.5 MG/5MLPtotal allergy oral tablet 25 mg*Antihistamines - Non-Sedating***Pallergy oral tablet dispersible 10 mgPcetirizine hcl childrens alrgy oral syrup 1mg/mlPQL (300 ML per 31 days)cetirizine hcl childrens oral solution 1 mg/mlPQL (300 ML per 31 days)cetirizine hcl oral tablet 10 mg, 5 mgPchildrens loratadine oral syrup 5 mg/5mlPfexofenadine hcl oral tablet 180 mg, 60 mgPloratadine hives relief oral solution 5 mg/5mlPloratadine oral tablet 10 mg*Antiseptics & Disinfectants*PQL (310 ML per 31 days)QL (300 ML per 31 days)*Chlorine Antiseptic Combinations***dakins external solution 0.4-0.5 %*Chlorine Antiseptics***Pchlorhexidine gluconate external liquid 4 %PQL (480 ML per 31 days)P Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs6

Drug Namedakins (1/2 strength) external solution 0.25 %dakins (1/4 strength) external solution 0.125%*Iodine Antiseptics***OPERAND POVIDONE-IODINE EXTERNALSOLUTION 10 %povidone-iodine external solution 10 %*Cough/Cold/Allergy*Preference Details Coverage DetailsPPPP*Antitussive - Nonnarcotic***benzonatate oral capsule 100 mg, 200 mgPdextromethorphan polistirex er oralsuspension extended release 30 mg/5mlPROBITUSSIN CHILDRENS COUGH LAORAL SYRUP 7.5 MG/5ML*Antitussive - Opioid***hydrocodone-homatropine oral syrup 5-1.5mg/5mlhydrocodone-homatropine oral tablet YM NIGHT TIME MULTI-SYMPTORAL LIQUID 15-6.25-325 MG/15ML*Antitussive-Expectorant***PPPPcheratussin ac oral syrup 100-10 mg/5mlPdiabetic siltussin-dm oral liquid 100-10mg/5mlPDIABETIC TUSSIN MAX ST ORAL LIQUID10-200 MG/5MLPextra action cough oral syrup 100-10 mg/5mlPMUCINEX FAST-MAX DM MAX ORALLIQUID 20-400 MG/20MLPmucus relief dm cough oral tablet 20-400 ssin dac oral solution 30-10-100mg/5mlProbafen cf cough/cold oral syrup 5-10-100mg/5mlPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs7

Drug NamePreference Details Coverage Details*Decongestant & Antihistamine***ALAVERT ALLERGY/SINUS ORAL TABLETEXTENDED RELEASE 12 HOUR 5-120 MGPALLEGRA-D ALLERGY & CONGESTIONORAL TABLET EXTENDED RELEASE 12HOUR 60-120 MGPallergy relief/nasal decongest oral tabletextended release 24 hour 10-240 mgPBROTAPP ORAL LIQUID 1-15 MG/5MLPcetirizine-pseudoephedrine er oral tabletextended release 12 hour 5-120 mgPfexofenadine-pseudoephed er oral tabletextended release 24 hour 180-240 mgPmaxifed tr oral tablet 1.25-30 mgPQ-TAPP ORAL ELIXIR 1-15 MG/5MLPtriprolidine-pse oral tablet 2.5-60 mg*Decongestant W/ Expectorant***Ptussin pe oral liquid 5-100 mg/5ml*Expectorants***Pdiabetic siltussin das-na oral liquid 100mg/5mlPmucus relief oral tablet 400 mgPrefenesen 400 oral tablet 400 mgPrefenesen oral tablet 200 mgProbafen oral syrup 100 mg/5ml*Misc. Respiratory Inhalants***PBRONCHO SALINE INHALATIONAEROSOL SOLUTION 0.9 %sodium chloride inhalation nebulizationsolution 0.9 %*Non-Narc Antitussive-Antihistamine***PPDIMETAPP LONG ACT COUGH/COLDORAL SYRUP 1-7.5 MG/5MLPpromethazine-dm oral syrup 6.25-15 mg/5mlPROBITUSSIN CHILD COUGH/COLD LAORAL LIQUID 1-7.5 MG/5MLPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs8

Drug NamePreference Details Coverage Details*Non-Narc Antitussive-DecongestantAntihistamine***brotapp dm oral liquid 15-1-5 mg/5mlPcold/cough childrens oral elixir 2.5-1-5mg/5mlPkidkare cough/cold oral liquid 15-1-5 mg/5mlPm-end dm oral liquid 15-2-15 mg/5mlPnohist-dm oral liquid 10-4-15 mg/5mlPrynex dm oral liquid 2.5-1-5 mg/5mlPVANACOF ORAL LIQUID 30-1-12.5 MG/5ML*Opioid Antitussive-Antihistamine***Phydrocod polst-cpm polst er oral suspensionextended release 10-8 mg/5mlPpromethazine-codeine oral syrup 6.25-10mg/5mlPTUSSICAPS ORAL CAPSULE EXTENDEDRELEASE 12 HOUR 10-8 MG, 5-4 MG*Opioid ine dh oral liquid 30-2-10 mg/5mlpromethazine vc/codeine oral syrup 6.25-510 mg/5ml*Dermatologicals*PPP*Acne Products***acne medication 5 external lotion 5 %Pbenzoyl peroxide cleanser external liquid 6 %Pbenzoyl peroxide external gel 10 %, 5 %PPANOXYL WASH EXTERNAL LIQUID 10 %*Antibiotic Mixtures Topical***Pbacitracin-neomycin-polymyxin externalointment 400-5-5000Pdouble antibiotic external ointment 50010000 unit/gmPtriple antibiotic external ointment 3.5-4005000 , 5-400-5000*Antibiotics - Topical***Pbacitracin external ointment 500 unit/gmPbacitracin zinc external ointment 500 unit/gmPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs9

Drug NamePreference Details Coverage Details*Antifungals - Topical***anti-fungal external powder 1 %Pterbinafine hcl external cream 1 %*Antihistamines - Topical***Panti-itch maximum strength external cream 2%PBENADRYL ITCH STOPPING EXTERNALGEL 2 %Pitch relief external cream 2 %*Corticosteroids - Topical***PAVEENO ANTI-ITCH MAX ST EXTERNALCREAM 1 %Phydrocortisone external cream 0.5 %, 1 %Phydrocortisone external lotion 1 %Phydrocortisone external ointment 0.5 %, 1 %Phydrocortisone max st external cream 1 %Phydrocortisone max st/12 moist externalcream 1 %PHYDROSKIN EXTERNAL CREAM 1 %Pkp hydrocortisone external cream 1 %PPREPARATION H EXTERNAL CREAM 1 %Ptgt anti-itch/aloe/vit e external cream 1 %*Emollients***PAMLACTIN EXTERNAL LOTION 12 %PQL (400 GM per 31 days)ammonium lactate external cream 12 %PQL (400 GM per 31 days)ammonium lactate external lotion 12 %*Imidazole-Related Antifungals Topical***PQL (400 GM per 31 days)clotrimazole external cream 1 %Pclotrimazole external solution 1 %*Keratolytic/Antimitotic Agents***PCLEAR AWAY 1-STEP WART REMOVEREXTERNAL PAD 40 %PCOMPOUND W EXTERNAL LIQUID 17 %PCOMPOUND W MAXIMUM STRENGTHEXTERNAL GEL 17 %PFREEZONE EXTERNAL LIQUID 17.6 %PP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs10

Drug NameSALACTIC FILM EXTERNAL SOLUTION 17%*Local Anesthetics - Topical***Preference Details Coverage DetailsPcapsaicin external cream 0.025 %*Scabicides & Pediculicides***Ppermethrin external lotion 1 %*Tar Products***PTERA-GEL TAR EXTERNAL SHAMPOO 0.5%*Topical Steroid Combinations***QL (60 GM per 30 days)Phydrocortisone-aloe external cream 1 %Psm hydrocortisone plus external cream 1 %*Gastrointestinal Agents - Misc.*P*Antiflatulents***mi-acid gas relief oral tablet chewable 80 mgPmytab gas oral tablet chewable 80 mgPsimethicone oral suspension 40 mg/0.6mlPsimethicone oral tablet chewable 80 mg*Genitourinary Agents - Miscellaneous*P*Urinary Analgesics***AZO URINARY PAIN RELIEF ORALTABLET 99.5 MGPphenazopyridine hcl oral tablet 95 mgPurinary pain relief max st oral tablet 97.5 mg*Hematopoietic Agents*P*Cobalamins***cyanocobalamin injection solution 1000mcg/mlPvitamin b-12 er oral tablet extended release1000 mcgPvitamin b-12 oral tablet 1000 mcg, 250 mcg,500 mcgPvitamin b-12 sublingual tablet sublingual1000 mcg*Folic Acid/Folates***folic acid oral tablet 1 mg, 400 mcg, 800 mcgPPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs11

Drug NamePreference Details Coverage Details*Iron***ferro-bob oral tablet 325 (65 fe) mgPferrous sulfate oral elixir 220 (44 fe) mg/5mlPferrous sulfate oral tablet 325 (65 fe) mgPferrous sulfate oral tablet delayed release324 (65 fe) mg, 325 (65 fe) mgPferrousul oral tablet 325 (65 fe) mgPiron oral tablet 325 (65 fe) mg, 90 (18 fe) mgPPOLY-IRON 150 ORAL CAPSULE 150 MGPslow release iron oral tablet extended release160 (50 fe) mg*Hypnotics/Sedatives/Sleep DisorderAgents*P*Antihistamine Hypnotic Combinations***headache pm oral tablet 25-500 mgPQL (62 EA per 31 days)mapap pm oral tablet 500-25 mgPQL (62 EA per 31 days)pain relief pm extra strength oral tablet 50025 mgPQL (62 EA per 31 days)pain reliever pm oral tablet 500-25 mg*Antihistamine Hypnotics***PQL (62 EA per 31 days)compoz oral capsule 50 mgPcompoz oral tablet 50 mgPdiphenhydramine hcl (sleep) oral tablet 50mgPNYTOL ORAL TABLET 25 MGPSIMPLY SLEEP ORAL TABLET 25 MGPsleep tabs oral tablet 25 mgPsleep-tabs oral tablet 25 mgPSOMINEX ORAL TABLET 25 MGPtetra-formula nighttime sleep oral tablet 50mg*Laxatives*P*Bulk Laxatives***fiber laxative oral tablet 625 mgPfiber oral tablet 625 mgPFIBERGEN ORAL TABLET 625 MGPfiber-lax oral tablet 625 mgPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs12

Drug NamePreference Details Coverage Detailskonsyl daily fiber oral packet 100 %PKONSYL FIBER ORAL TABLET 625 MGPMETAMUCIL ORAL CAPSULE 0.36 GMPMETAMUCIL ORAL WAFERPMETAMUCIL SMOOTH TEXTURE ORALPACKET 28 %PMETAMUCIL SMOOTH TEXTURE ORALPOWDER 28.3 %, 58.6 %Pnatural fiber therapy oral powder 30.9 %,48.57 %Pnatural vegetable fiber oral powder 48.57 %PREGULOID ORAL CAPSULE 0.52 GM*Laxatives - Miscellaneous***Pcvs glycerin adult rectal suppository 2 gmPsorbitol oral solution 70 %*Laxatives & Dss***PDOC-Q-LAX ORAL TABLET 8.6-50 MGPPERI-COLACE ORAL TABLET 8.6-50 MGPsenna plus oral tablet 8.6-50 mgPsenna s oral tablet 8.6-50 mgPsenna-docusate sodium oral tablet 8.6-50 mgPSENNALAX-S ORAL TABLET 8.6-50 MGPsenna-s oral tablet 8.6-50 mgPsenna-time s oral tablet 8.6-50 mgPsennosides-docusate sodium oral tablet 8.650 mg*Saline Laxative Mixtures***enema rectal enema 7-19 gm/118mlsm oral saline laxative oral solution 2.7-7.2gm/5ml*Saline Laxatives***PPPcitrate of magnesia oral solution 1.745gm/30mlPCITROMA ORAL SOLUTION 1.745GM/30MLPDULCOLAX MILK OF MAGNESIA ORALSUSPENSION 400 MG/5MLPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs13

Drug Namemagnesium citrate oral solution 1.745gm/30mlmilk of magnesia oral suspension 400mg/5ml, 7.75 %*Stimulant Laxatives***Preference Details Coverage DetailsPPBISAC-EVAC RECTAL SUPPOSITORY 10MGPbiscolax rectal suppository 10 mgPCARTERS LITTLE PILLS ORAL TABLETDELAYED RELEASE 5 MGPcorrect oral tablet delayed release 5 mgPCORRECTOL ORAL TABLET DELAYEDRELEASE 5 MGPducodyl oral tablet delayed release 5 mgPEX-LAX ORAL TABLET CHEWABLE 15 MGPEX-LAX ULTRA ORAL TABLET DELAYEDRELEASE 5 MGPFEENAMINT ORAL TABLET DELAYEDRELEASE 5 MGPFLEET LAXATIVE ORAL TABLETDELAYED RELEASE 5 MGPgentle laxative oral tablet delayed release 5mgPlaxative rectal suppository 10 mgPnatural senna laxative oral tablet 64.8-324mgPsenexon oral liquid 8.8 mg/5mlPsenexon oral tablet 8.6 mgPsenna lax oral tablet 8.6 mgPsenna laxative oral tablet 25 mg, 8.6 mgPsenna oral syrup 8.8 mg/5mlPsenna oral tablet 8.6 mgPSENNA SMOOTH ORAL TABLET 15 MGPSENNACON ORAL TABLET 8.6 MGPsenna-lax oral tablet 8.6 mgPsenna-tabs oral tablet 8.6 mgPsenna-time oral tablet 8.6 mgPSENNO ORAL TABLET 8.6 MGPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs14

Drug Namestimulant laxative oral tablet delayed release5 mgwomens laxative oral tablet delayed release5 mg*Surfactant Laxatives***Preference Details Coverage DetailsPPCORRECTOL EXTRA GENTLE ORALCAPSULE 100 MGPdiocto oral liquid 50 mg/5mlPdiocto oral syrup 60 mg/15mlPdocqlace oral capsule 100 mgPdocu soft oral capsule 100 mgPdocusate calcium oral capsule 240 mgPdocusate sodium oral tablet 100 mgPDOCUSIL ORAL CAPSULE 100 MGPDOK ORAL CAPSULE 100 MG, 250 MGPDOK ORAL TABLET 100 MGPdss oral capsule 100 mg, 250 mgPDULCOLAX STOOL SOFTENER ORALCAPSULE 100 MGPKAO-TIN ORAL CAPSULE 240 MGPlaxa basic oral capsule 100 mgPsilace oral liquid 150 mg/15mlPsilace oral syrup 60 mg/15mlPSOF-LAX ORAL CAPSULE 100 MGPstool softener oral capsule 100 mg, 250 mgPSURFAK ORAL CAPSULE 240 MG*Medical Devices And Supplies*P*Respiratory Therapy Supplies***ACE AEROSOL CLOUD ENHANCERPQL (2 EA per 365 days)IN-CHECK DIAL FLOW TRAINER DEVICEPQL (2 EA per 365 days)PFLEXPQL (2 EA per 365 days)THRESHOLD IMTPQL (2 EA per 365 days)THRESHOLD PEP DEVICEPQL (2 EA per 365 days)WINDMILL TRAINER*Spacer/Aerosol-Holding Chambers &Supplies***PQL (2 EA per 365 days)AEROCHAMBER MVPQL (2 EA per 365 days)P Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs15

Drug NamePreference Details Coverage DetailsAEROCHAMBER PLUS FLO-VUPQL (2 EA per 365 days)AEROCHAMBER PLUS FLO-VU LARGEPQL (2 EA per 365 days)AEROCHAMBER PLUS FLO-VU SMALLPQL (2 EA per 365 days)AEROCHAMBER PLUS FLO-VU W/MASKPQL (2 EA per 365 days)AEROCHAMBER W/FLOWSIGNALPQL (2 EA per 365 days)AEROCHAMBER Z-STAT PLUSPQL (2 EA per 365 days)AEROCHAMBER Z-STAT PLUS CHAMBRPQL (2 EA per 365 days)EASIVENTPQL (2 EA per 365 days)MICROCHAMBERPQL (2 EA per 365 days)MICROSPACERPQL (2 EA per 365 days)OPTICHAMBER ADVANTAGEPQL (2 EA per 365 days)OPTIHALERPQL (2 EA per 365 days)OPTIHALER DEVICEPQL (2 EA per 365 days)POCKET CHAMBER DEVICEPQL (2 EA per 365 days)POCKET SPACER DEVICEPQL (2 EA per 365 days)WATCHHALER DEVICE*Minerals & Electrolytes*PQL (2 EA per 365 days)*Calcium Combinations***calcium d3 oral tablet 600-200 mg-unitPcalcium 600-d oral tablet 600-400 mg-unitPcalcium carb-cholecalciferol oral tablet 500125 mg-unit, 600-400 mg-unitPcalcium carbonate-vitamin d oral tablet 500400 mg-unit, 600-400 mg-unitPcalcium high potency/vitamin d oral tablet600-200 mg-unitPcalcium oral tablet 500-125 mg-unitPcalcium-carb 600 d oral tablet 600-125 mgunitPcalcium-vitamin d oral tablet 500-125 mgunit, 600-125 mg-unit, 600-200 mg-unitPCALTRATE 600 D ORAL TABLET 600-800MG-UNITPCELEBRATE CALCIUM PLUS 500 ORALTABLET CHEWABLE 500-333 MG-UNITPliquid calcium/vitamin d oral capsule 600-200mg-unitPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs16

Drug NamePreference Details Coverage DetailsOYSCO 500 D ORAL TABLET 500-200 MGUNITPoyst-cal d oral tablet 250-125 mg-unitPoyster calcium d oral tablet 250-125 mgunitPoyster shell calcium d oral tablet 500-400mg-unitPoyster shell calcium 500 d oral tablet 500125 mg-unitPoyster shell calcium/d oral tablet 250-125mg-unit, 500-200 mg-unitPoyster shell calcium/vitamin d oral packet500-200 mg-unitPoyster shell calcium/vitamin d oral tablet 250125 mg-unit, 500-200 mg-unitPoyster shell/vitamin d oral tablet 600-125 mgunit*Calcium***PCAL-CARB FORTE ORAL TABLET 1250(500 CA) MGPCALCI-CHEW ORAL TABLET CHEWABLE1250 (500 CA) MGPcalcium 600 oral tablet 600 mgPcalcium carbonate oral suspension 1250(500 ca) mg/5mlPcalcium carbonate oral tablet 1250 (500 ca)mg, 1500 (600 ca) mg, 600 mgPcalcium high potency oral tablet 600 mgPcalcium lactate oral tablet 648 mgPcalcium oral tablet 600 mgPcalcium oyster shell oral tablet 1250 (500 ca)mgPcalcium-carb 600 oral tablet 600 mgPcal-lac oral capsule 500 mgPCALTRATE 600 ORAL TABLET 1500 (600CA) MGPOYSCO 500 ORAL TABLET 500 MGPOYSTERCAL ORAL TABLET 500 MGPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs17

Drug NamePreference Details Coverage Details*Electrolytes Oral***ORALYTE ORAL SOLUTION*Magnesium***PMAG64 ORAL TABLET EXTENDEDRELEASE 535 (64 MG) MGPmag-delay oral tablet extended release 535(64 mg) mgPmagnacaps oral capsule 100 mgPmagnesium oral tablet 250 mgPmagnesium oxide 400 oral packet 240 mgPmagnesium oxide oral tablet 400 (240 mg)mg, 400 (241.3 mg) mg, 420 (252 mg) mgPMAGNESIUM-OXIDE ORAL TABLET 400(241.3 MG) MGPMAG-TAB SR ORAL TABLET EXTENDEDRELEASE 84 MG (7MEQ)*Sodium***QL (4000 ML per 31 days)Psodium chloride oral tablet 1 gm*Zinc***PORAZINC ORAL CAPSULE 220 (50 ZN) MGPzinc gluconate oral tablet 50 mgPzinc oral tablet 50 mgPzinc sulfate oral capsule 220 (50 zn) mgPzinc sulfate oral tablet 220 (50 zn) mgPzinc-220 oral capsule 220 (50 zn) mg*Mouth/Throat/Dental Agents*P*Lozenge - Combinations***DELSYM COUGH RELIEFMOUTH/THROAT LOZENGE 5-5 MG*Multivitamins*P*B-Complex W/ C & Folic Acid***NEPHRONEX ORAL TABLETPRENAL ORAL CAPSULE 1 MGPrena-vite rx oral tablet 1 mgPreno caps oral capsule 1 mg*B-Complex W/ C***Pvitamin b complex-c oral capsulePP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs18

Drug NamePreference Details Coverage Details*Multiple Vitamins W/ Minerals***centamin oral liquidPcentavite a-z complete-mineral oral tabletPcentavite oral liquidPCEROVITE ADVANCED FORMULA ORALTABLETPCERTAVITE/ANTIOXIDANTS ORAL LIQUIDPgerivite complete oral tabletPmultivitamin & mineral oral liquidPSUPER NU-THERA ORAL TABLETPthera vital m oral tabletPtherabasic-m oral tabletPtherapeutic liquid oral solutionPtherapeutic-m oral tabletPTOTAL FORMULA 3 ORAL TABLETPvitamins a-d-e/selenium oral tablet*Multivitamins***Pdaily multiple vitamins oral tabletPdaily vite oral tabletPdaily vites oral tabletPmulti-day oral tabletPmulti-vitamin oral tabletPmulti-vitamins oral tabletPonce daily oral tabletPone-daily multi vitamins oral tabletPTHERA ORAL TABLETPTHERA/BETA-CAROTENE ORAL TABLETPtherapeutic oral tabletPthera-tabs oral tablet*Ped Mv W/ Fluoride***Pmultivitamin/fluoride oral tablet chewable 0.5mg*Ped Mv W/ Iron***polyvitamin/iron oral solution 10 mg/mlPPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs19

Drug NamePreference Details Coverage Details*Pediatric Multiple Vitamins W/ C & Fa***childrens chewable multi vits oral tabletchewable*Pediatric Multiple Vitamins W/ C***Ppolyvitamin oral solution 35 mg/ml*Pediatric Vitamins A & D W/ C***Ptri-vitamin oral solution 1500-400-35*Prenatal Mv & Min W/Fe-Fa***Ppnv prenatal plus multivit dha oral 27-1 &312 mgPprenatal low iron oral tablet 27-0.8 mg*Specialty Vitamins Products***Pvitamins for hair oral tablet*Nasal Agents - Systemic And Topical*P*Nasal Agents - Misc.***altamist spray nasal solution 0.65 %PAYR NASAL SOLUTION 0.65 %Pdeep sea nasal spray nasal solution 0.65 %PHUMIST NASAL SOLUTION 0.65 %PLITTLE NOSES SALINE NASAL SOLUTION0.65 %PNASAL MOIST NASAL SOLUTION 0.65 %Pna-zone nasal solution 0.65 %POCEAN FOR KIDS NASAL SOLUTION 0.65%Psaline mist spray nasal solution 0.65 %Psaline nasal spray nasal solution 0.65 %Psea soft nasal mist nasal solution 0.65 %*Nasal Mast Cell Stabilizers***Pcromolyn sodium nasal aerosol solution 5.2mg/act*Systemic Decongestants***Ppseudoephedrine hcl oral tablet 30 mg, 60mgPSUDAFED 12 HOUR ORAL TABLETEXTENDED RELEASE 12 HOUR 120 MGPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs20

Drug NamePreference Details Coverage Details*Ophthalmic Agents**Artificial Tear And LubricantCombinations***artificial tears ophthalmic ointment 83-15 %PHYPOTEARS OPHTHALMIC SOLUTION 1-1%PTEARS AGAIN OPHTHALMIC OINTMENTPULTRA FRESH PM OPHTHALMICOINTMENT*Artificial Tear Solutions***Ptears again ophthalmic solution*Artificial Tears And Lubricants***Partificial tears ophthalmic solution 1.4 %PQL (15 ML per 31 days)liquitears ophthalmic solution 1.4 %PQL (15 ML per 31 Days)polyvinyl alcohol ophthalmic solution 1.4 %*Ophthalmic Antiallergic***PQL (15 ML per 31 Days)ALAWAY OPHTHALMIC SOLUTION 0.025%ketotifen fumarate ophthalmic solution 0.025%*Otic Agents*PP*Otic Agents - Miscellaneous***auraphene-b otic solution 6.5 %Pear drops earwax aid otic solution 6.5 %Pearwax treatment drops otic solution 6.5 %PE-R-O EAR DROPS OTIC SOLUTION 6.5 %PE-R-O EAR WAX REMOVAL SYSTEM OTICSOLUTION 6.5 %PMURINE EAR OTIC SOLUTION 6.5 %PMURINE EAR WAX REMOVAL SYSTEMOTIC SOLUTION 6.5 %POTIX OTIC SOLUTION 6.5 %*Psychotherapeutic And NeurologicalAgents - Misc.*P*Smoking Deterrents***nicotine polacrilex mouth/throat gum 2 mg, 4mgPQL (4032 EA per 365 days)P Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs21

Drug Namenicotine transdermal patch 24 hour 14mg/24hr, 21 mg/24hr, 7 *Preference Details Coverage DetailsPQL (70 EA per 365 days)*H-2 Antagonists***cimetidine oral tablet 200 mgPfamotidine oral tablet 10 mg*Proton Pump Inhibitors***Pomeprazole oral tablet delayed release 20mg*Vaginal And Related Products*P*Imidazole-Related Antifungals***GYNE-LOTRIMIN 3 VAGINAL CREAM 2 %Pmiconazole 3 applicator vaginal kit 200 & 2mg-% (9gm)Pmiconazole 3 combo pack vaginal kit 200 & 2mg-% (9gm)Pmiconazole nitrate vaginal cream 2 %Pmiconazole nitrate vaginal suppository 100mgPMONISTAT 3 VAGINAL CREAM 4 %*Vitamins*P*Vitamin A***vitamin a oral capsule 10000 unit, 8000 unit*Vitamin B-1***vitamin b-1 oral tablet 100 mg, 250 mg, 50mg*Vitamin B-2***vitamin b-2 oral tablet 100 mg*Vitamin B-3***PPPENDUR-ACIN ORAL TABLET EXTENDEDRELEASE 500 MGPniacin er oral capsule extended release 250mg, 500 mgPniacin er oral tablet extended release 250 mgPniacin oral tablet 100 mg, 250 mg, 50 mg,500 mgPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs22

Drug NamePrefe

ORAL LIQUID 15-6.25-325 MG/15ML: P *Antitussive-Expectorant*** cheratussin ac oral syrup 100-10 mg/5ml. P: diabetic siltussin-dm oral liquid 100-10 mg/5ml. P: DIABETIC TUSSIN MAX ST ORAL LIQUID 10-200 MG/5ML. P: extra action cough oral syrup 100-10 mg/5ml. P: MUCINEX FAST-MAX DM MAX ORAL LIQUID 20-400 MG/20ML. P: mucus relief dm cough oral .

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