Over-the-Counter (OTC) Drugs Added

[Pages:4]Updated 05/2017

May 2017 Formulary Updates

Generics Added DESVENLAFAXINE ER 10MG, 25MG, 100MG TABS (generic Pristiq?)--PA, QL PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION 10 MG/5ML; 20MG/5ML TACROLIMUS OINT 0.03%; 0.1%--QL

Brands Added GLEOSTINE 10MG, 40MG, 100MG CAPS ILARIS INJ 150MG/ML--PA, QL KISQALI --PA, QL

Over-the-Counter (OTC) Drugs Added 4-WAY FAST ACTING A THRU Z ADVANCED A THRU Z HIGH POTENCY A THRU Z SELECT A THRU Z SELECT 50+ MENS A THRU Z SELECT ADVANCED A THRU Z SELECT ULTIMATE A THRU Z ULTIMATE MENS ABC PLUS ABC PLUS SENIOR ADULTS 50 ACETA-GESIC ACETAMINOPHEN ACETAMINOPHEN EXTRA STREN ACID REDUCER ACIDOPHILUS PLUS PECTIN ACIDOPHILUS/CITRUS PECTIN ACIDOPHILUS/PECTIN ACTICAL ADULT ONE DAILY GUMMIES AFRIN SALINE NASAL MIST AIRBORNE AIRBORNE GUMMIES ALAHIST DM ALA-HIST PE ALIVE WOMENS ENERGY ALIVE WOMENS GUMMY VITAMI ALL DAY ALLERGY CHILDRENS ALL DAY ALLERGY D ALL DAY PAIN RELIEF ALLERGY 24-HR ALLERGY RELIEF

Key: PA ? Prior Authorization; ST ? Step Therapy; QL ? Quantity Limit

Updated 05/2017

ALLERGY RELIEF CHILDRENS ALMACONE ALOE VESTA PROTECTIVE ALTAMIST AMERICERIN ANTACID FAST ACTING ANTACID MAXIMUM STRENGTH ANTACID PLUS ANTI-GAS REL ANTI-DIARRHEAL ANTIFUNGAL ANTIOXIDANT ANTI-OXIDANT ANTIOXIDANT FORMULA ANTIOXIDANT FORMULA SG ANTIOXIDANT VITAMINS APATATE FORTE AP-HIST DM AQUADEKS ASPIRIN ASPIRIN ADULT LOW STRENGT ASPIRIN EC ASPIRIN LOW STRENGTH ATHLETES FOOT SPRAY AYR AYR NASAL DROPS AYR NASAL MIST ALLERGY & AYR SALINE NASAL AYR SALINE NASAL NO-DRIP BABY AYR SALINE BABY DARLINGS PEDIATRIC E BACITRACIN BACITRACIN ZINC BACITRACIN/NEOMYCIN/POLYM BANOPHEN BENZONATATE BEROCCA BETADINE BETADINE SKIN CLEANSER BIO-35 GLUTEN-FREE BIOCAL BIOSUPP BIOTECT PLUS BIOTIN PLUS/CALCIUM/VIT D BISACODYL EC

Key: PA ? Prior Authorization; ST ? Step Therapy; QL ? Quantity Limit

Updated 05/2017

BISCOLAX BODY/HAIR/SKIN/NAILS CALCARB 600 CAL-CARB FORTE CALCET PLUS CALCI-CHEW CHERRY CALCIDOL CALCIFEROL CALCI-MIX CALCIONATE CALCITRATE CAL-CITRATE PLUS VITAMIN CALCIUM CALCIUM + D3 CALCIUM 1000 + D CALCIUM 1200 CALCIUM 500 + D CALCIUM 500 +D CALCIUM 500/D CALCIUM 500/VITAMIN D CALCIUM 500/VITAMIN D3 CALCIUM 500+D CALCIUM 500+D HIGH POTENC CALCIUM 600 CALCIUM 600 + D CALCIUM 600 HIGH POTENCY CALCIUM 600 WITH VITAMIN CALCIUM 600/VITAMIN D CALCIUM 600/VITAMIN D3 CALCIUM 600+D CALCIUM 600+D HIGH POTENC CALCIUM 600+D PLUS MINERA CALCIUM 600+D3 CALCIUM 600+D3 PLUS MINER CALCIUM 600-D CALCIUM CARBONATE CALCIUM CARBONATE/D3 CALCIUM CARBONATE/VITAMIN CALCIUM CITRATE CALCIUM CITRATE + D CALCIUM CITRATE + D3 CALCIUM CITRATE + D3 MAXI CALCIUM CITRATE +D CALCIUM CITRATE MAXIMUM/V

Key: PA ? Prior Authorization; ST ? Step Therapy; QL ? Quantity Limit

Updated 05/2017

CALCIUM CITRATE PETITE/VI CALCIUM CITRATE W/D CALCIUM CITRATE/VITAMIN D CALCIUM CITRATE+ D CALCIUM CITRATE+D CALCIUM CITRATE+D3 CALCIUM CITRATE+D3 PETITE CALCIUM GUMMIES CALCIUM HIGH POTENCY CALCIUM HIGH POTENCY + VI CALCIUM LACTATE CALCIUM OYSTER SHELL CALCIUM PLUS VITAMIN D3 CALCIUM POLYCARBOPHIL CALCIUM/D CALCIUM/D3 LIQUID CALCIUM/VITAMIN D CALCIUM/VITAMIN D/MINERAL CALCIUM/VITAMIN D3 CALCIUM+D3 CAL-MINT CAL-QUICK CALTRATE 600 CALTRATE 600+D CALTRATE 600+D PLUS MINER CALTRATE 600+D SOFT CHEWS CALTRATE 600+D3 SOFT CHEW CALTRATE MINIS PLUS MIN CAPSAICIN CARDENZ CARRAVITE CARRINGTON MOISTURE BARRI CASTOR OIL STIMULANT LAXA CENTAMIN CENTAVITE CENTAVITE A-Z COMPLETE MU CENTRAVITES CENTRAVITES 50 PLUS CENTRUM CENTRUM ADULTS CENTRUM CARDIO CENTRUM FLAVOR BURST ADUL CENTRUM FLAVOR BURST KIDS CENTRUM SILVER

Key: PA ? Prior Authorization; ST ? Step Therapy; QL ? Quantity Limit

Updated 05/2017

CENTRUM SILVER ADULT 50+ CENTRUM SILVER ULTRA MENS CENTRUM SILVER ULTRA WOME CENTRUM SPECIALIST HEART CENTRUM SPECIALIST VISION CENTRUM ULTRA MENS CENTRUM ULTRA WOMENS CENTURY CENTURY MATURE CERALYTE 70 CEROVITE ADVANCED FORMULA CEROVITE SENIOR CERTA PLUS CERTAGEN CERTA-VITE CERTAVITE SENIOR/ANTIOXID CERTAVITE/ANTIOXIDANTS CHEST CONGESTION RELIEF P CHEWABLE CALCIUM CHILDRENS ALLERGY CHILDRENS COLD & ALLERGY CHILDRENS IBUPROFEN CHLORPHENIRAMINE MALEATE CITRACAL + D3 MAXIMUM CITRACAL CALCIUM GUMMIES CITRACAL MAXIMUM CITRACAL PETITES/VITAMIN CITRACAL/VITAMIN D CITRACAL+D3 CITRUCEL CITRUS CALCIUM +D CITRUS CALCIUM/VITAMIN D CLEARLAX COLACE COLACE CLEAR COLD & ALLERGY COMPANION COMPETE COMPLETE COMPLETE FORMULATION MULT COMPLETE MULTIVITAMIN/MUL COMPLETE SENIOR CONCEPTIONXR MOTILITY SUP CONEX COLD/ALLERGY

Key: PA ? Prior Authorization; ST ? Step Therapy; QL ? Quantity Limit

Updated 05/2017

COUGH & COLD COUGH DM CRITIC-AID CLEAR AF CRITIC-AID CLEAR MOISTURE CVS CALCIUM CVS CALCIUM 600 & VITAMIN CVS CALCIUM 600 + D/MINER CVS CALCIUM 600+D CVS CALCIUM CARBONATE CVS CALCIUM CITRATE CVS CALCIUM CITRATE + D CVS CALCIUM CITRATE +D3 M CVS D3 CVS DAILY ENERGY CVS DAILY GUMMIES CVS DAILY MULTIPLE CVS DAILY MULTIPLE FOR ME CVS DAILY MULTIPLE FOR WO CVS DAILY MULTIPLE PLUS I CVS DIABETES HEALTH SUPPO CVS ELECTROLYTE SOLUTION CVS FISH OIL CVS FOLIC ACID CVS GLUCOSE CVS IRON CVS MAGNESIUM CVS MENS DAILY GUMMIES CVS NASAL MIST CVS NATURAL FISH OIL CVS OMEGA-3 GUMMY FISH/DH CVS OYSTER SHELL CALCIUM CVS PEDIATRIC ELECTROLYTE CVS SALINE NASAL SPRAY CVS SALINE NOSE SPRAY CVS SLOW RELEASE IRON CVS SPECTRAVITE ADULT 50+ CVS SPECTRAVITE ADULT GUM CVS SPECTRAVITE ADVANCED CVS SPECTRAVITE PERFORMAN CVS SPECTRAVITE SENIOR CVS SPECTRAVITE ULTRA HEA CVS SPECTRAVITE ULTRA MEN CVS SPECTRAVITE ULTRA WOM CVS VISION FORMULA

Key: PA ? Prior Authorization; ST ? Step Therapy; QL ? Quantity Limit

Updated 05/2017

CVS VITAMIN D 5000 HIGH-P CVS VITAMIN D3 CVS WOMENS ACTIVE DAILY CVS WOMENS DAILY GUMMIES D 1000 D 10000 D 2000 D 400 D 5000 D-1000 EXTRA STRENGTH D-1000 MAXIMUM ST D-2000 MAXIMUM STRENGTH D2000 ULTRA STRENGTH D3 D3 ADULT D3 HIGH POTENCY D3 KIDS D3 SUPER STRENGTH D3 ULTRA STRENGTH D3-1000 D-3-5 D3-50 D-400 D-5000 DAILY COMBO MULTI VITAMIN DAILY MULTI DAILY MULTIPLE VITAMIN DAILY MULTIPLE VITAMIN/IR DAILY MULTIPLE VITAMINS DAILY MULTIPLE VITAMINS W DAILY MULTIPLE VITAMINS/I DAILY MULTIPLE VITAMINS/M DAILY MULTIPLE WEIGHT LOS DAILY MULTIVITAMIN DAILY VALUE MULTIVITAMIN DAILY VITAMIN DAILY VITAMIN FORMULA+IR DAILY VITAMIN FORMULA+IRO DAILY VITAMIN FORMULA+MIN DAILY VITAMINS DAILY VITE DAILY-VITE DAILY-VITE/IRON/BETA-CARO DALLERGY

Key: PA ? Prior Authorization; ST ? Step Therapy; QL ? Quantity Limit

Updated 05/2017

DAY TIME COLD/FLU RELIEF DAY TIME COUGH DAYHIST ALLERGY 12 HOUR R DAYTIME PE MULTI-SYMPTOM DECARA DECONEX DMX DECONEX IR DECUBI-VITE DEKAS ESSENTIAL DEKAS PLUS DELSYM DELSYM COUGH CHILDRENS DELTA D3 DERMACERIN DERMAGRAN DERMAGRAN BC DERMAMED DEX4 QUICK DISSOLVE GLUCO DIABETES HEALTH FORMULA DIABETES HEALTH PACK DIALYVITE 800/ULTRA D DIALYVITE VITAMIN D 5000 DIALYVITE VITAMIN D3 MAX DIMAPHEN CHILDRENS DIPHENHYDRAMINE HCL DISNEY CALCIUM + VITAMIN DOCUSATE SODIUM DOCUSATE SODIUM & SENNA S DOCUSOL KIDS DOCUSOL PLUS MINI-ENEMA DONATUSSIN DOUBLE ANTIBIOTIC DRISDOL DURAVENT DM ED A-HIST ED A-HIST DM ED-APAP ELDERTONIC ENDUR-ACIN ENFAMIL ENFALYTE ENVIRO-STRESS EPA EQ ASPIRIN EC EQ CALCIUM 500+D

Key: PA ? Prior Authorization; ST ? Step Therapy; QL ? Quantity Limit

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