MAINTENANCE MEDICATION DRUG LIST - DRUG LEVEL_100952_UPDATED JULY 2014 - EXPRESS SCRIPTS
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Maintenance Medication Drug List
Drug Level_100952_Updated July 2014
1ST CHOICE
The Express ScriptsLANCETS
Maintenance Drug List contains medications that are generally taken on a long-term or
1ST TIER UNIFINE PENTIPS such as high blood pressure or high cholesterol. Through the Express
maintenance basis for conditions
1ST TIER UNILET
Scripts PharmacySM COMFORTOUCH
home delivery, you can get up to a 90-day supply of your medications for the same
2TEK30-day fills at a participating retail pharmacy.
cost as two
3M NEXCARE STOMASEAL
For the ACARBOSE
PPO Plan only: You may purchase maintenance medications from a participating retail pharmacy
three times, after which you must use the home delivery pharmacy for the medications to
be covered under the PPO Plan. If you continue to purchase your maintenance medications at a retail
pharmacy after the third fill, you will be responsible for the entire cost of the medication.
Note: This list (1) does not include all maintenance medications, (2) is subject to change, (3) may include
medications not covered by your health plan and (4) may include medications that are subject to additional
coverage rules as determined by your health plan.
1|PageMaintenance Medication Drug List
Drug Level_100952_Updated July 2014
ACTIVE LIFE UROSTOMY POUCH ADVOCATE REDI-CODE DUO
1ST CHOICE LANCETS
ACTIVE OB ADVOCATE REDI-CODE+ CTRL SOLN
1ST TIER UNIFINE PENTIPS
ACTIVELLA ADVOCATE SYRINGES
1ST TIER UNILET COMFORTOUCH
ACTONEL ADVOCATE TEST STRIP
2TEK
ACTOPLUS MET AEROSPAN
3M NEXCARE STOMASEAL
ACTOPLUS MET XR AFEDITAB CR
ACTOS AGAMATRIX AMP
A
ACURA CONTROL SOLUTION AGAMATRIX CONTROL
ACARBOSE
ACCESS SET ACURA CONTROL SOLUTION LOW AGGRASTAT
ACCOLATE ACURA CONTROL SOLUTION NORMAL AGGRENOX
ACCU-CHEK ACURA METER KIT AGRYLIN
ACCU-CHEK ACTIVE ACURA PLUS AIMSCO MINI ULTRA-THIN II
ACCU-CHEK AVIVA ACURA STARTER KIT AIMSCO ULTRA THIN II
ACCU-CHEK AVIVA PLUS ACURA TEST STRIPS AIRAVITE
ACCU-CHEK COMFORT CURVE ADALAT CC ALBUTEROL SULFATE
ACCU-CHEK COMPACT ADAPT ALCOHOL
ACCU-CHEK COMPACT BLUE CONTROL ADAPT BARRIER ALCOHOL PREP
ACCU-CHEK COMPACT PLUS CONTROL ADAPT BARRIER RING ALCOHOL PREP PAD
ACCU-CHEK FASTCLIX ADAPT CONVEX BARRIER ALCOHOL WIPES
ACCU-CHEK IIM MONITOR ADAPT PASTE ALDACTAZIDE
ACCU-CHEK NANO SMARTVIEW ADAPT STOMA POWDER ALDACTONE
ACCU-CHEK RAPID D ADEMPAS ALENDRONATE SODIUM
ACCU-CHEK SMARTVIEW ADENOCARD ALFUZOSIN HCL
ACCU-CHEK SOFTCLIX ADENOSINE ALKALINE BATTERIES
ACCU-CHEK SPIRIT ADHESIVE BARRIERS ALLKARE PROTECT BARRIER WIPE
ACCU-CHEK VOICEMATE ADJUSTABLE LANCING DEVICE ALORA
ACCUPRIL ADVAIR DISKUS ALPHAGAN P
ACCURETIC ADVAIR HFA ALPROSTADIL
ACCUTREND GLUCOSE ADVANCE ALTACE
ACEBUTOLOL HCL ADVANCE INTUITION ALTAVERA
ACEON ADVANCED AM/PM ALTERNATE SITE LANCET
ACETAZOLAMIDE ADVANCED LANCING DEVICE ALTERNATE SITE LANCING DEVICE
ACETEST REAGENT ADVANCED TRAVEL LANCETS ALTOPREV
ACIPHEX ADVICOR ALVESCO
ACIPHEX SPRINKLE ADVOCATE BLOOD GLUCOSE MONITOR ALYACEN
ACTIGALL ADVOCATE CONTROL SOLUTION ALZ-NAC
ACTI-LANCE ADVOCATE DUO AMANTADINE HCL
ACTIVE FE ADVOCATE LANCET AMARYL
ACTIVE LIFE CLOSED-END POUCH ADVOCATE LANCING DEVICE AMETHIA
ACTIVE LIFE CONVEX ADVOCATE PEN NEEDLES AMETHIA LO
ACTIVE LIFE DRAINABLE POUCH ADVOCATE RAPID-SAFE AMETHYST
ACTIVE LIFE STOMA CAP ADVOCATE REDI-CODE AMILORIDE HCL
2|PageMaintenance Medication Drug List
Drug Level_100952_Updated July 2014
AMILORIDE HCL W/HCTZ ASCORBIC ACID AUTOJECT 2
AMINOBENZOATE POTASSIUM ASMANEX AUTO-LANCET
AMINOPHYLLINE ASPIRIN E.C. AUTOLET IMPRESSION
AMIODARONE HCL ASSURA AUTOLET LANCING DEVICE
AMITRIPTYLINE HCL ASSURA 2PC DRAINABLE AUTOLET LITE CLINISAFE
AMITRIPTYLINE-PERPHENAZINE ASSURA 2PC IRRIGATION SLEEVE AUTOLET MINI
AMLODIPINE BESYLATE ASSURA AC AUTOLET MKII CLINISAFE
AMLODIPINE BESYLATE-BENAZEPRIL ASSURA CONVEX AUTOLET PLATFORMS
AMLODIPINE-ATORVASTATIN ASSURA CUT-TO-FIT AUTOPEN
AMOXAPINE ASSURA EASICLOSE DRAINABLE AVAPRO
AMTURNIDE ASSURA EXTRA AVIANE
AMYL NITRITE ASSURA FLANGE AVODART
ANAFRANIL ASSURA FLANGE CONVEX AXID ORAL SOLUTION
ANAGRELIDE HYDROCHLORIDE ASSURA IRRIGATION FACE PLATE AXID PULVULE
ANAPROX ASSURA LIGHT EASICLOSE DRAIN AYGESTIN
ANAPROX DS ASSURA NON-CONVEX DRAINABLE AZILECT
ANASTROZOLE ASSURA OSTOMY BELT AZOPT
ANIMI-3 ASSURA PEDIATRIC POUCH AZOR
ANIMI-3 WITH VITAMIN D ASSURA POUCH AZULFIDINE
ANORO ELLIPTA ASSURA STANDARD WEAR AZURETTE
ANSAID ASSURA TWO-PIECE URO MINICAP
ANTARA ASSURA WOUND MANAGER B
APIDRA ASSURE 4 BACMIN
APLENZIN ASSURE DOSE BAL-CARE DHA
APPBUTAMONE ASSURE HAEMOLANCE PLUS BAL-CARE DHA ESSENTIAL
APPBUTAMONE-D ASSURE ID INSULIN SAFETY BALZIVA
APPFORMIN ASSURE LANCE BANISH II
APPFORMIN-D ASSURE PLATINUM BANZEL
APRACLONIDINE HCL ASSURE PRO BARDIC ADAPTER-TUBING
APRI ATABEX EC B-D AUTO INJECTOR
APTIOM ATACAND BD AUTOSHIELD PEN NEEDLE
AQUA LANCE LANCING DEVICE ATACAND HCT BD ECLIPSE
AQUASOL A ATELVIA BD INSULIN PEN NEEDLE UF MINI
ARANELLE ATENOLOL B-D INSULIN SYRINGE
AREDIA ATENOLOL W/CHLORTHALIDONE BD INSULIN SYRINGE MF
ARICEPT ATORVASTATIN CALCIUM BD INTEGRA NEEDLE
ARICEPT ODT ATROPEN BD INTEGRA SYRINGE
ARIMIDEX ATROVENT B-D MAGNI-GUIDE MAGNIFIER
ARMOUR THYROID ATROVENT HFA BD MICROTAINER LANCET
AROMASIN AUBRA BD NANO PEN NEEDLE
ARTHROTEC AURORA HEALTHCARE LANCETS B-D NEEDLES
ASCENSIA BREEZE 2 AURORA SUPER THIN LANCETS B-D PRECISIONGLIDE NEEDLE
3|PageMaintenance Medication Drug List
Drug Level_100952_Updated July 2014
B-D SAFE CLIP BROMOCRIPTINE MESYLATE CARDENE
B-D SAFETYGLIDE BRONCOMAR-1 CARDENE SR
B-D ULTRA FINE LANCETS BUDEPRION SR CARDIOTEK RX
BECONASE AQ BUDEPRION XL CARDIZEM
BENAZEPRIL HCL BUDESONIDE CARDIZEM CD
BENAZEPRIL HCL-HCTZ BULLSEYE MINI SAFETY LANCETS CARDIZEM LA
BENICAR BUMETANIDE CARDURA
BENICAR HCT BUPROPION HCL CARDURA XL
BENZTROPINE MESYLATE BUPROPION HCL XL CAREONE
BETAGAN BUPROPION SR CARESENS
BETAPACE BYDUREON CARESENS N
BETAPACE AF BYETTA CARESENS N VOICE
BETAXOLOL HCL BYSTOLIC CARTEOLOL HCL
BETIMOL CARTIA XT
BETOPTIC S C CARTRIDGE
BEYAZ CADUET CARTRIDGE PUMP
BG-STAR CAFFEINE & SODIUM BENZOATE CARTRIDGE STAMPED
BICALUTAMIDE CALAFOL RX CARVEDILOL
BIDIL CALAN CASODEX
BIFERA RX CALAN SR CATAFLAM
BINOSTO CALCIJEX CATAPRES
BISOPROLOL FUMARATE CALCITONIN-SALMON CATAPRES-TTS
BISOPROLOL FUMARATE/HCTZ CALCITRIOL CATHETER W-CAIR CLAMP NON-VENT
BLOOD GLUCOSE CALCIUM PNV CAVAN ONE OMEGA
BLOOD GLUCOSE MONITORING CALDOLOR CAVAN-ALPHA KIT
BLOOD GLUCOSE STRIPS CAMILA CAVAN-EC SOD DHA
BLOOD GLUCOSE TEST CAMRESE CAVAN-FOLATE DHA
BLOOD-GLUCOSE CONTROL CAMRESE LO CAVAN-FOLATE OB
BLOXIVERZ CANDESARTAN CILEXETIL CAVAN-HEME OB
B-NEXA CANDESARTAN-HYDROCHLOROTHIAZID CAVAN-HEME OMEGA
BONIVA CAPASTAT SULFATE CAVAN-X
B-PLEX CAPTOPRIL CAVERJECT
B-PLEX PLUS CAPTOPRIL/HYDROCHLOROTHIAZIDE CAZIANT
BREEZE 2 CARAFATE CELEBREX
BREO ELLIPTA CARBAMAZEPINE CELEXA
BREVIBLOC CARBAMAZEPINE ER CELONTIN
BREVICON CARBAMAZEPINE XR CENESTIN
BRIELLYN CARBATROL CENFOL
BRILINTA CARBIDOPA CENOLATE
BRIMONIDINE TARTRATE CARBIDOPA/LEVODOPA CENTRATEX
BRINTELLIX CARBIDOPA-LEVODOPA ER CEREBYX
BRISDELLE CARBIDOPA-LEVODOPA-ENTACAPONE CEREFOLIN
4|PageMaintenance Medication Drug List
Drug Level_100952_Updated July 2014
CEREFOLIN NAC CLEVER CHOICE MICRO CONTACT DETACH INFUSION SET
CETIRIZINE HCL CLEVER CHOICE MICRO TEST STRIP CONTOUR
CHATEAL CLEVER CHOICE PRO CONTOUR I
CHEK-STIX CLEVER CHOICE TEST STRIPS CONTOUR LINK
CHEMSTRIP CLEVIPREX CONTOUR NEXT
CHEMSTRIP 10 WITH SG CLICKFINE CONTOUR NEXT CONTROL SOLUTION
CHEMSTRIP 2 GP CLIMARA CONTOUR NEXT EZ
CHEMSTRIP 50B CLIMARA PRO CONTOUR NEXT LINK
CHEMSTRIP 7 CLINISTIX REAGENT CONTOUR NEXT USB
CHEMSTRIP 9 CLINITEST REAGENT CONTOUR USB
CHEMSTRIP BG DIARY CLINORIL CONTROL
CHEMSTRIP K CLOMIPRAMINE HCL CONTROL SOLUTION
CHEMSTRIP UGK CLONIDINE HCL CONVATEC NIGHT DRAIN CONTAINER
CHLOROTHIAZIDE CLOPIDOGREL CONVATEC NIGHT DRAINAGE TUBING
CHLORPROPAMIDE CLORPRES CONVEX SYN BARR W-FLOAT FLANGE
CHLORTHALIDONE CLOSED POUCH/DEODOR FILM/FLNG COPD
CHOICEDM G20 CLOSED-END POUCH CORDARONE
CHOICE-OB + DHA C-NATE DHA COREG
CHOICE-TABS COAGUCHEK COREG CR
CHOLESTYRAMINE COGENTIN CORENATE-DHA
CHOLESTYRAMINE LIGHT COLESTID CORGARD
CHOLINE MAG TRISALICYLATE COLESTIPOL HCL CORLOPAM
CHROMAGEN COLOPLAST CORVERT
CIALIS COLOPLAST PASTE CORVITA
CILOSTAZOL COLOPLAST RING CORVITE
CIMETIDINE COLOPLAST SKIN BARRIER CORVITE FE
CITALOPRAM HBR COLOR LANCETS CORZIDE
CITRANATAL 90 DHA COMBIGAN COSOPT
CITRANATAL ASSURE COMBIPATCH COSOPT PF
CITRANATAL B-CALM COMBISTIX REAGENT COVERA-HS
CITRANATAL DHA COMBIVENT COZAAR
CITRANATAL HARMONY COMBIVENT RESPIMAT CPL DRAINABLE POUCH
CITRANATAL RX COMFORT CREON
CLARINEX COMFORT EZ CRESTOR
CLARINEX-D 12 HOUR COMFORT LANCETS CRINONE
CLARINEX-D 24 HOUR COMFORT SHORT CROMOLYN SODIUM
CLEO 90 INFUSION SET COMPLETE NATAL DHA CUPRIMINE
CLEVER CHEK BLOOD GLUCOSE SYST COMPLETENATE CURITY ALCOHOL PREPS
CLEVER CHEK CONTROL SOLUTION COMPLETE-RF PRENATAL CYCLAFEM
CLEVER CHEK LANCETS COMTAN CYCLESSA
CLEVER CHEK TEST STRIPS CONCEPT DHA CYCLOSERINE
CLEVER CHOICE CONCEPT OB CYCLOSET
5|PageMaintenance Medication Drug List
Drug Level_100952_Updated July 2014
CYMBALTA DIALYVITE DILTZAC ER
CYSTOSCOPY-IRRIGATION SET DIALYVITE 800 WITH IRON DIOVAN
CYTOMEL DIALYVITE SUPREME D DIOVAN HCT
CYTOTEC DIAMOX SEQUELS DIPYRIDAMOLE
DIASCREEN 10 DISOPYRAMIDE PHOSPHATE
D DIASCREEN 1B REAGENT DITROPAN XL
DAILYVITE DIASCREEN 1G REAGENT DIURIL
DALIRESP DIASCREEN 1K REAGENT DIURIL SODIUM
DASETTA DIASCREEN 2GK REAGENT DIVALPROEX SODIUM
DAYPRO DIASCREEN 2GP DIVALPROEX SODIUM ER
DAYSEE DIASCREEN 3 REAGENT DIVIGEL
DELESTROGEN DIASCREEN 4NL REAGENT DOCOSAVIT
DEMADEX DIASCREEN 4OBL DONEPEZIL HCL
DEMSER DIASCREEN 4PH DORZOLAMIDE HCL
DEMULEN DIASCREEN 5 DORZOLAMIDE-TIMOLOL
DEPACON DIASCREEN 6 DOXAZOSIN MESYLATE
DEPAKENE DIASCREEN 7 DOXEPIN HCL
DEPAKOTE DIASCREEN 8 DRAIN POUCH/REPLACE DEODOR FLT
DEPAKOTE ER DIASCREEN 9 DRAINABLE MINI-POUCH W-FLANGE
DEPAKOTE SPRINKLE DIASTIX REAGENT DRAINABLE POUCH
DEPEN DIATRUE DRAINABLE POUCH CLAMP
DEPLIN DIATRUE PLUS DRAINABLE POUCH W/FILTR&FLANGE
DEPLIN-ALGAL OIL DIATX ZN DRAINABLE POUCH WITH FLANGE
DEPO-ESTRADIOL DIBENZYLINE DRISDOL
DEPO-PROVERA DICLOFENAC POTASSIUM DROPLET LANCETS
DEPO-SUBQ PROVERA DICLOFENAC SODIUM DROPLET LANCING DEVICE
DESIPRAMINE HCL DICLOFENAC SODIUM-MISOPROSTOL DROSPIRENONE-ETHINYL ESTRADIOL
DESLORATADINE DIDGET DUALVIT F
DESOGEN DIDRONEL DUALVIT OB
DESOGESTREL-ETHINYL ESTRADIOL DIFIL-G DUALVIT PLUS
DESVENLAFAXINE ER DIFLUNISAL DUET DHA
DESVENLAFAXINE FUMARATE ER DIGOXIN DUET DHA BALANCED
DETROL DILACOR XR DUET DHA COMPLETE
DETROL LA DILANTIN DUET DHA EC
DEX4 GLUCOSE DILATRATE-SR DUETACT
DEX4 GLUCOSE BITS DILEX-G DUEXIS
DEXFERRUM DILT-CD DULEEK-DP 15
DEXILANT DILTIA XT DULEEK-DP 7.5
DEXTROSE-LACT RINGERS-KCL DILTIAZEM 24HR CD DULEEK-MET NEW
DIABETA DILTIAZEM ER DULERA
DIABETIC.COM STARTER DILTIAZEM HCL DULOXETINE HCL
DIAL-A-FLO MICRODRIP SET DILT-XR DUOLOCK CURVED TAIL CLOSURE
6|PageMaintenance Medication Drug List
Drug Level_100952_Updated July 2014
DUONEB EASYPLUS V ENSKYCE
DURAHESIVE MOLDABLE CONVEX ECLIPSE ENTACAPONE
DUTOPROL ECLIPSE CONTROL SOLUTION ENVISION
DYAZIDE EC-NAPROSYN EPANED
DY-G LIQUID ED CYTE F EPIFLUR
DYLIX EDARBI EPIKLOR
DYMISTA EDARBYCLOR EPITOL
DYNACIRC CR EDECRIN EPLERENONE
DY-O-DERM EDECRIN SODIUM EPROSARTAN MESYLATE
DYPHYLLINE-GG EDEX EQUETRO
DYRENIUM EFFER-K ERGOCALCIFEROL
EFFEXOR XR ERRIN
E EFFIENT ESCAVITE
EAKIN COHESIVE ELDEPRYL ESCAVITE D
EAKIN COHESIVE SEALS ELDERCAPS ESCAVITE LQ
EAKIN COHESIVE SLIMS ELEMENT BLOOD GLUCOSE METER ESCITALOPRAM OXALATE
EASICLOSE WIDE OUTLET ELEMENT COMPACT ESMOLOL HCL
EASY CHECK ELEMENT COMPACT CONTROL SOLN ESOMEPRAZOLE SODIUM
EASY CHECK TEST STRIP ELEMENT CONTROL SOLUTION ESOMEPRAZOLE STRONTIUM
EASY CLICK ELEMENT PLUS ESTARYLLA
EASY COMFORT ELEMENT PLUS CONTROL SOLUTION ESTEEM CLOSED POUCH
EASY COMFORT INSULIN SYRINGE ELEMENT TEST STRIPS ESTEEM DRAINABLE POUCH
EASY COMFORT PEN NEEDLES ELESTRIN ESTEEM SYNERGY
EASY PLUS II ELITE OB ESTEEM SYNERGY CLOSED POUCH
EASY PRO PLUS ELITE-OB ESTEEM SYNERGY DRAINABLE POUCH
EASY STEP ELITE-OB 400 ESTRACE
EASY TALK ELIXOPHYLLIN ESTRADERM
EASY TOUCH EMBRACE ESTRADIOL
EASY TOUCH ALCOHOL PREP PADS EMBRACE EVO ESTRADIOL VALERATE
EASY TOUCH INSULIN SAFETY EMBRACE GLUCOSE CONTROL LOW ESTRADIOL-NORETHINDRONE ACETAT
EASY TOUCH LANCING DEVICE EMBRACE PRO ESTRASORB
EASY TRAK EMOQUETTE ESTRING
EASYGLUCO ENABLEX ESTROGEL
EASYMAX ENALAPRIL MALEATE ESTROPIPATE
EASYMAX L ENALAPRIL MALEATE/HCTZ ESTROSTEP FE
EASYMAX N ENALAPRILAT ETHAMBUTOL HCL
EASYMAX NG ENJUVIA ETHOSUXIMIDE
EASYMAX SPEAKING ENLITE ETIDRONATE DISODIUM
EASYMAX V ENLITE GLUCOSE SENSOR ETODOLAC
EASYMAX V2 ENLITE SERTER ETODOLAC ER
EASYPLUS ENLYTE EVAMIST
EASYPLUS R13N ENPRESSE EVENCARE
7|PageMaintenance Medication Drug List
Drug Level_100952_Updated July 2014
EVENCARE G2 FEMRING FLOVENT DISKUS
EVENCARE G3 FEMTRACE FLOVENT HFA
EVISTA FENOFIBRATE FLOW-EZE
EVOLUTION BLOOD GLUCOSE METER FENOFIBRIC ACID FLUNISOLIDE
EVOLUTION CONTROL SOLUTION FENOGLIDE FLUOR-A-DAY
EVOLUTION TEST STRIPS FENOLDOPAM MESYLATE FLUORIDE
EXEL HUBER NEEDLE FENOPROFEN CALCIUM FLUOXETINE DR
EXEL HYPODERMIC NEEDLE FERAHEME FLUOXETINE HCL
EXEL INSULIN SYRINGE FERIVA FLURBIPROFEN
EXEL MTI DRAWING NEEDLE FERIVAFA FLUTAMIDE
EXELON FEROCON FLUTICASONE PROPIONATE
EXEMESTANE FEROTRIN FLUVASTATIN SODIUM
EXFORGE FEROTRINSIC FLUVOXAMINE MALEATE
EXFORGE HCT FERRALET 90 FOCALGIN-B
EXPRESS MED STARTER FERRAPLUS 90 FOLASTIN
EXTRA COLOSTOMY POUCH FERREX 150 FORTE FOLBALIN PLUS
EXTRA OPEN-END DRAIN FERREX 150 FORTE PLUS FOLBECAL
EXTRA SECURITY POUCH FERREX 28 FOLBEE
EXTRA-VIRT PLUS DHA FERRLECIT FOLBEE PLUS
E-Z JECT LANCETS FERROCITE PLUS FOLBIC
EZ SMART FERROGELS FORTE FOLBIC RF
EZ SMART LANCETS FETRIN FOLCAL DHA
EZ SMART PLUS FETZIMA FOLCAPS
EZ-VAC FIBRICOR FOLCAPS CARE ONE
FIFTY50 RESERVOIR FOLCAPS OMEGA-3
F FIFTY50 SAFETY SEAL LANCETS FOLGARD RX
FABB FIFTY50 TEST STRIP FOLIC ACID
FAC-X FILTER NEEDLE FOLIC ACID-CYANCOBAL-PYRIDOXIN
FALMINA FILTER REPLACEMENT FOLINATAL PLUS B
FAMOTIDINE FILTER SECURITY CLOSED POUCH FOLITAB
FARXIGA FILTRODOR POUCH FILTER FOLIVANE-F
FAST TAKE FINASTERIDE FOLIVANE-OB
FE 90 PLUS FINE 30 UNIVERSAL LANCETS FOLIVANE-PLUS
FE C FINGERSTIX FOLIVANE-PRX DHA NF
FECAL COLLECTOR FLAVOXATE HCL FOLPACE RX
FECAL COLLECTOR, DRAINABLE FLECAINIDE ACETATE FOLPLEX 2.2
FELDENE FLEXI-SEAL FMS FOLTANX
FELODIPINE ER FLEXI-TRAK ANCHORING DEVICE FOLTANX RF
FEMARA FLEXLINK PLUS INFUSION SET FOLTRATE
FEMCON FE FLEXTEND SKIN BARRIER FOLTRIN
FEMECAL OB FLOMAX FOLTX
FEMHRT FLONASE FORA D10
8|PageMaintenance Medication Drug List
Drug Level_100952_Updated July 2014
FORA D15 FREESTYLE SIDEKICK II GLUCOCARD VITAL
FORA D15C FREESTYLE SYSTEM GLUCOCARD VITAL SENSOR
FORA D15G FREESTYLE TEST STRIPS GLUCOCARD X-METER
FORA D15Z FREESTYLE UNISTIK 2 GLUCOCARD X-METER CONTROL
FORA D20 FUMATINIC GLUCOCARD X-SENSOR
FORA G20 FUROSEMIDE GLUCOCOM
FORA G30A FUSION PLUS GLUCOCOM AUTOLINK
FORA G71A GLUCOCOM BLOOD GLUCOSE
FORA G90 G GLUCOCOM CONTROL SOLUTION
FORA LANCETS G-4 GLUCOCOM GLUCOSE
FORA LANCING DEVICE GABAPENTIN GLUCOCOM LANCETS
FORA V10 GABITRIL GLUCOLAB
FORA V12 GABOXETINE GLUCOLAB CONTROL
FORA V20 GALANTAMINE GLUCOLET 2
FORA V22 GANITE GLUCOPHAGE
FORA V30A GASTROCROM GLUCOPHAGE XR
FORACARE GE100 BLOOD GLUCOSE SYSTEM GLUCOPRO
FORACARE GD20 GE100 BLOOD GLUCOSE TEST STRIP GLUCOSE
FORACARE GD40 GE100 CONTROL SOLUTION NORMAL GLUCOSE BITS
FORACARE GD40A GELNIQUE GLUCOSE CONTROL
FORACARE GD40B GEMFIBROZIL GLUCOSE CONTROL SOLUTION
FORFIVO XL GENERESS FE GLUCOSE GEL
FORTAMET GENTLE DRAW GLUCOSE TEST STRIP
FORTAVIT GESTICARE GLUCOSOURCE
FORTICAL GESTICARE DHA GLUCOSTIX REAGENT
FOSAMAX GIANVI GLUCOTROL
FOSAMAX PLUS D GILDAGIA GLUCOTROL XL
FOSINOPRIL SODIUM GILDESS GLUCOVANCE
FOSINOPRIL-HYDROCHLOROTHIAZIDE GILDESS FE GLUMETZA
FOSPHENYTOIN SODIUM GLIMEPIRIDE GLUTOFAC-ZX
FREESTYLE CONTROL SOLUTION GLIPIZIDE GLUTOSE
FREESTYLE FLASH SYSTEM GLIPIZIDE ER GLYBURIDE
FREESTYLE FREEDOM GLIPIZIDE XL GLYBURIDE MICRONIZED
FREESTYLE FREEDOM LITE GLIPIZIDE-METFORMIN GLYBURIDE-METFORMIN HCL
FREESTYLE INSULINX GLUCO BURST GLYNASE
FREESTYLE INSULINX TEST STRIPS GLUCO NAVII GLYSET
FREESTYLE LANCETS GLUCO SHOT GMATE
FREESTYLE LITE METER GLUCOCARD 01 GMATE CONTROL SOLUTION
FREESTYLE LITE STRIPS GLUCOCARD 01 CONTROL GMATE LANCING DEVICE
FREESTYLE LITE TEST STRIPS GLUCOCARD 01 SENSOR GMATE TEST STRIPS
FREESTYLE NAVIGATOR GLUCOCARD 01-MINI GMATE VOICE METER
FREESTYLE PRECISION GLUCOCARD EXPRESSION GOLD SODIUM THIOMALATE
9|PageMaintenance Medication Drug List
Drug Level_100952_Updated July 2014
GOOD NEIGH STARTER HUMULIN 70/30 KWIKPEN INFANATE DHA
GUANABENZ ACETATE HUMULIN 70-30 INFED
GUANFACINE HCL HUMULIN N INFINITY
GUARDIAN REAL-TIME HUMULIN N KWIKPEN INFINITY CONTROL SOLUTION
GUARDIAN RT CHARGER HUMULIN R INFINITY TEST STRIPS
GUARDIAN RT STARTER KIT HYDRALAZINE HCL INFUSION SET
GUARDIAN RT SYSTEM HYDROCHLORIC ACID INFUVITE
GUARDIAN TEST PLUG HYDROCHLOROTHIAZIDE INFUVITE ADULT
GUARDIAN TRANSMITTER TAPE HYDROXOCOBALAMIN INJECT EASE LANCETS
HYDROXYCHLOROQUINE SULFATE INJECTAFER
H HYPERTENSOLOL INNOPRAN XL
HAEMOLANCE HYPODERMIC NEEDLE INNOVO
HAEMOLANCE PLUS HYPOLANCE INSET 30 TUBING
HAEMOLANCE, RETRACTABLE HYZAAR INSPRA
HEALTHPRO GLUCOSE CONTROL SOLN INSTACLEAN
HEALTHPRO GLUCOSE MONITOR I INSTA-GLUCOSE
HEALTHPRO TEST STRIPS IBANDRONATE SODIUM INSUL-CAP
HEALTHY ACCENTS AUTOLET IBG-STAR INSUL-EZE
HEALTHY ACCENTS UNIFINE PENTIP IBUPROFEN INSULIN CARTRIDGE
HEALTHY ACCENTS UNILET LANCET IBUTILIDE FUMARATE INSULIN PEN NEEDLE
HEATHER ICAR-C PLUS INSULIN- SYRINGE
HEMA-COMBISTIX ICAR-C PLUS SR INSUMED
HEMANGEOL IFEREX 150 FORTE INSUPEN
HEMATINIC PLUS ILE-SORB INTEGRA F
HEMATINIC WITH FOLIC ACID IMDUR INTEGRA PLUS
HEMATOGEN IMIPRAMINE HCL INTEGRILIN
HEMATOGEN FA IMIPRAMINE PAMOATE INTRAVENOUS,ARTERIAL & BLOOD
HEMATOGEN FORTE IN CONTROL PEN NEEDLE INTROVALE
HEMATRON INATAL ADVANCE INVACARE LANCETS
HEMATRON-AF INATAL GT INVOKANA
HEMAX INATAL ULTRA IODOPEN
HEMENATAL OB INCONTROL IOPIDINE
HEMENATAL OB + DHA INCONTROL LANCING DEVICE IPRATROPIUM BROMIDE
HEMETAB INCONTROL SUPER THIN LANCETS IPRATROPIUM-ALBUTEROL
HEMOCYTE PLUS INCONTROL ULTRA THIN LANCETS IRBESARTAN
HEMOCYTE-F INDAPAMIDE IRON
HOLLIHESIVE SKIN BARRIER INDERAL LA IROSPAN
HUMALOG INDERAL XL IRRIGATION SET
HUMALOG MIX 50-50 INDOCIN IRRIGATION SLEEVE
HUMALOG MIX 75-25 INDOCIN I.V. ISOCHRON
HUMAPEN LUXURA HD INDOMETHACIN ISONARIF
HUMAPEN MEMOIR INFANATE BALANCE ISONIAZID
10 | P a g eMaintenance Medication Drug List
Drug Level_100952_Updated July 2014
ISOPROPANOL KETOCARE LESSINA
ISOPROPYL ALCOHOL KETO-DIASTIX REAGENT LETAIRIS
ISOPTIN S.R. KETONE LETROZOLE
ISOPTO CARBACHOL KETOPROFEN LEVACET
ISOPTO CARPINE KETOSTIX REAGENT LEVATOL
ISORDIL KEYNOTE LEVEMIR
ISOSORBIDE DINITRATE KEYNOTE PRO LEVEMIR FLEXTOUCH
ISOSORBIDE MONONITRATE KHEDEZLA LEVETIRACETAM
ISOXSUPRINE HCL KINNEY BRAND LANCETS LEVETIRACETAM-NACL
ISRADIPINE KINRAY LEVITRA
ISTALOL KLOR-CON LEVOBUNOLOL HCL
IV ADMINISTRATION SET KLOR-CON M LEVOCETIRIZINE DIHYDROCHLORIDE
IV PREP WIPES KLOR-CON-EF LEVOMEFOLA-NAC-MECOBALM-AGAL
KOMBIGLYZE XR LEVOMEFOLATE CACLIUM-ALGAL
J K-TAB LEVOMEFOLATE CALCIUM-ALGAL
JALYN KURVELO LEVOMEFOLATE DHA
JANUMET LEVOMEFOLATEPNV
JANUMET XR L LEVOMEFOL-PYRIDOXAL-MEC-ALGAL
JANUVIA LABETALOL HCL LEVONEST
JAY-PHYL LABSTIX REAGENT STRIPS LEVONORGESTREL-ETH ESTRADIOL
JENCYCLA LACTOCAL-F LEVONORG-ETH ESTRAD ETH ESTRAD
JENTADUETO LAMICTAL LEVORA
JEVANTIQUE LAMICTAL ODT LEVOTHYROXINE SODIUM
JINTELI LAMICTAL XR LEVOXYL
JOLESSA LAMOTRIGINE LEXAPRO
JOLIVETTE LANCET LIBERTY CONTROL SOLUTION
JUNEL LANCET DEVICE LIBERTY LEV 1 GLUCOSE CONTROL
JUNEL FE LANCETS,THIN LIBERTY LEV 2 GLUCOSE CONTROL
JUVISYNC LANCING DEVICE LIBERTY MONITOR
LANCING SYSTEM LIBERTY TEST STRIP
K LANOXIN LIDOCAINE HCL
K EFFERVESCENT LANOXIN PEDIATRIC LIDOCAINE HCL IN DEXTROSE
KARAYA LANSOPRAZOLE LIFE MEDICAL STARTER
KARAYA DRAINABLE OSTOMY POUCH LANTUS LIFESCAN
KARAYA PASTE TUBE LANTUS SOLOSTAR LIFESHIELD BLUNT CANNULA
KARAYA SEAL CLOSED STOMA POUCH LARIN LIOTHYRONINE SODIUM
KARIVA LARIN FE LIPITOR
KAZANO LASIX LIPOFEN
KELNOR 1-35 LATANOPROST LIPTRUZET
KEPPRA LEENA LISINOPRIL
KEPPRA XR LESCOL LISINOPRIL-HCTZ
KERR STARTER LESCOL XL LITE TOUCH
11 | P a g eMaintenance Medication Drug List
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LITTLE ONES ACTIVE LIFE POUCH LUER-LOK SYRINGE MEDISENSE GLUCOSE KETONE CONTR
LITTLE ONES CLOSED-END POUCH LUFYLLIN MEDISENSE THIN LANCETS
LITTLE ONES DRAINABLE POUCH LUFYLLIN-GG MEDLANCE PLUS
LITTLE ONES SKIN BARRIER LUMIGAN MEDLANCE PLUS SPECIAL BLADE
LITTLE ONES UROSTOMY POUCH LUTERA MEDROXYPROGESTERONE ACETATE
LIVALO LUVOX CR MEDTRONIC REMOTE CONTROL
L-MEFOLATE-PYRIDOX-MECOBALAMIN LYBREL MEFENAMIC ACID
L-METHYL-B6-B12 LYTENSOPRIL MEIJER STARTER
L-METHYLFOLATE CA P-5-P ME-CBL LYZA MELOXICAM
L-METHYLFOLATE CALCIUM MEMANTINE HCL
L-METHYLFOLATE FORMULA M MENEST
L-METHYLFOLATE FORTE M.V.I. ADULT MENOSTAR
L-METHYLFOLATE PNV DHA M.V.I. PEDIATRIC MEPHYTON
L-METHYLFOLATE-MECOBALAMIN-NAC M.V.I.-12 MESTINON
L-METHYL-MC M9CLEANER-DECRYSTALLIZER METAFOLBIC
LMTHF-PYRIDOXINE-CYANOCOBAL MACNATAL CN DHA METAFOLBIC PLUS
LO LOESTRIN FE MACUTEK METAFOLBIC PLUS RF
LO MINASTRIN FE MAGELLAN INSULIN SAFETY SYRNG METANX
LODOSYN MAGELLAN INSULIN SYRINGE METAPROTERENOL SULFATE
LOESTRIN MAJOR COMFORT METFORMIN HCL
LOESTRIN 24 FE MANIFOLD 111-SL METFORMIN HCL ER
LOESTRIN FE MANNITOL METHAZOLAMIDE
LOFIBRA MAPROTILINE HCL METHIMAZOLE
LOMEDIA 24 FE MARLISSA METHYCLOTHIAZIDE
LONG STARTER MARNATAL-F METHYL SALICYLATE
LOOP OSTOMY BRIDGE, STERILE MARTINIC METHYLDOPA
LOPID MATERNITY METHYLDOPA/HYDROCHLOROTHIAZIDE
LOPRESSOR MATZIM LA METHYLDOPATE HCL
LOPRESSOR HCT MAVIK METIPRANOLOL
LO-PROFILE UROSTOMY POUCH MAX BLOOD GLUCOSE METER METOLAZONE
LORYNA MAX GLUCOSE CONTROL SOLUTION METOPROLOL SUCCINATE
LOSARTAN POTASSIUM MAX GLUCOSE TEST STRIPS METOPROLOL TARTRATE
LOSARTAN-HYDROCHLOROTHIAZIDE MAXARON FORTE METOPROLOL-HYDROCHLOROTHIAZIDE
LOSEASONIQUE MAXI-COMFORT MEVACOR
LOTENSIN MAXIMA MEXILETINE HCL
LOTENSIN HCT MAXINATE MIACALCIN
LOTREL MAXZIDE MICARDIS
LOVASTATIN MECLOFENAMATE SODIUM MICARDIS HCT
LOVAZA MEDICAL ADHESIVE MICRO
LOZI-FLUR MEDI-JECTOR VISION MICRO THIN LANCETS
LS PLUM PRIMARY SET-OL MEDI-LANCE MICRODERM
LUDENT FLUORIDE MEDISENSE MICRODERM PLUS
12 | P a g eMaintenance Medication Drug List
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MICRODOT MONTELUKAST SODIUM MYZILRA
MICROGESTIN MOTRIN
MICROGESTIN FE MST 600 N
MICROHESIVE STOMA PASTE MULTAQ NABUMETONE
MICRO-K MULTI-B-PLUS NADOLOL
MICROLET MULTICHEW NADOLOL-BENDROFLUMETHIAZIDE
MICROZIDE MULTIGEN NALFON
MIDAMOR MULTIGEN FOLIC NAMENDA
MIMVEY MULTIGEN PLUS NAMENDA XR
MIMVEY LO MULTI-LANCET DEVICE NAPRELAN
MINASTRIN 24 FE MULTINATAL PLUS NAPRELAN CR DOSEPAK
MINI LANCING DEVICE MULTI-NATE 30 DHA NAPROSYN
MINI ULTRA-THIN II MULTI-NATE DHA EXTRA NAPROXEN
MINI UROSTOMY POUCH MULTISTIX NAPROXEN SODIUM
MINILINK REAL-TIME TRANSMITTER MULTISTIX 10 SG NASACORT AQ
MINIMED MULTISTIX 5 NASCOBAL
MINIMED RESERVOIR MULTISTIX 7 NASONEX
MINIPRESS MULTISTIX 8 SG NATA KOMPLETE
MINIVELLE MULTISTIX 9 NATACHEW
MINOXIDIL MULTISTIX 9 SG NATAFORT
MIO INFUSION SET MULTIVITAMIN W/FLUORIDE & IRON NATAL-V RX
MIOCHOL-E MULTIVITAMIN WITH FLUORIDE NATALVIRT 90 DHA
MI-OMEGA NF MULTIVITAMINS NATALVIRT CA
MIOSTAT MULTIVITAMINS-A,B,D,E,K,ZN NATALVIRT FLT
MIRAPEX MUSE NATALVIT
MIRAPEX ER MVC-FLUORIDE NATAZIA
MIRCETTE M-VIT NATELLE ONE
MIRTAZAPINE MYAMBUTOL NATELLE-EZ
MISOPROSTOL MYCOBUTIN NATRECOR
MOBIC MYFERON-150 FORTE NATURA CLOSED POUCH
MODICON MYGLUCOHEALTH NATURA DRAINABLE POUCH
MOEXIPRIL HCL MYGLUCOHEALTH CONTROL SOLUTION NATURA DURAHESIVE SKIN BARRIER
MOEXIPRIL-HYDROCHLOROTHIAZIDE MYGLUCOHEALTH LANCETS NATURA STOMAHESIVE SKN BARRIER
MONOJECT MYKIDZ IRON FL NATURE-THROID
MONOJECT BLOOD COLLECTION MYNATAL NAVARRO STARTER
MONOJECT INSULIN SYRINGE MYNATAL ADVANCE NAVATAB + DHA
MONOJECTOR LANCET DEVICE MYNATAL PLUS NECON
MONOKET MYNATAL-Z NEEDLES
MONOLET LANCETS MYNATE 90 PLUS NEEVO
MONOLET THIN LANCETS MYNEPHROCAPS NEEVO DHA
MONO-LINYAH MYOCHRYSINE NEFAZODONE HCL
MONONESSA MYSOLINE NEOPROFEN
13 | P a g eMaintenance Medication Drug List
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NEOSTIGMINE BROMIDE NIASPAN NOVOFINE AUTOCOVER
NEOSTIGMINE METHYLSULFATE NICARDIPINE HCL NOVOLIN 70-30
NEO-SYNEPHRINE NICOMIDE NOVOLIN N
NEPHPLEX RX NICOTINAMIDE NOVOLIN R
NEPHROCAPS NICOTINAMIDE ZCF NOVOLOG
NEPHROCAPS QT NIFEDIAC CC NOVOLOG FLEXPEN
NEPHRON FA NIFEDICAL XL NOVOLOG MIX 70-30
NEPHRO-VITE RX NIFEDIPINE NOVOPEN 3
NEPTAZANE NIFEDIPINE ER NOVOPEN ECHO
NESINA NIFEREX-150 FORTE NOVOPEN JR
NESTABS NIGHT DRAIN ADAPTER NOVOTWIST
NESTABS ABC NILANDRON NP THYROID
NESTABS DHA NIMODIPINE NULECIT
NEUPRO NIRON KOMPLETE NUTRICAP
NEURIN-SL NISOLDIPINE NUTRIPORT BALLOON
NEURONTIN NITROPRESS NUTRI-TAB OB
NEUTEK 2TEK TEST STRIPS NIZATIDINE NUTRI-TAB OB + DHA
NEW IMAGE NO STING SKIN PREP NUVARING
NEW IMAGE CLOSED MINI-POUCH NOKOR ADMIX NEEDLE NYMALIZE
NEW IMAGE CLOSED POUCH NOKOR NEEDLE
NEW IMAGE COLOSTOMY-ILEO KIT NONVENTED T-U-R SET
NEW IMAGE DRAINABLE KIT NORA-BE
NEW IMAGE DRAINABLE MINI-POUCH NORDETTE
NEW IMAGE DRAINABLE POUCH NORETHINDRONE ACETATE O
NEW IMAGE FLEXTEND NORETHINDRONE-ETHIN ESTRADIOL O.A.D.
NEW IMAGE FLEXWEAR NORGESTIMATE-ETHINYL ESTRADIOL OB + DHA
NEW IMAGE IRRIGATION SLEEVE NORGESTREL-ETHINY ESTRA OB COMPLETE
NEW IMAGE KIT NORINYL OB COMPLETE DHA
NEW IMAGE SKIN BARRIER NORPACE OB COMPLETE ONE
NEW IMAGE SKIN BARRIER-FLANGE NORPACE CR OB COMPLETE PETITE
NEW IMAGE UROSTOMY NORPRAMIN OB COMPLETE PREMIER
NEW IMAGE UROSTOMY KIT NOR-Q-D OB-NATAL ONE
NEW IMAGE UROSTOMY POUCH NORTREL OBSTETRIX DHA
NEWGEN NORTRIPTYLINE HCL OBSTETRIX EC
NEWTEK NORVASC OBTREX
NEXA PLUS NOVA MAX BLOOD GLUCOSE METER OBTREX DHA
NEXA SELECT NOVA SAFETY LANCETS O-CAL FA
NEXICLON XR NOVA SUREFLEX O-CAL PRENATAL
NEXIUM RX NOVAFERRUM OCELLA
NEXTERONE NOVAMAX PLUS ODOR ELIMINATOR
NIACIN ER NOVAMAX PLUS GLU-KET OGEN
NIACOR NOVOFINE OGESTREL
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OLEPTRO ER OPTUMRX PAROXETINE HCL
OMEPRAZOLE ORENITRAM ER PASER
OMEPRAZOLE-SODIUM BICARBONATE ORSINI INSULIN SYRINGE PAXIL
OMNARIS ORSYTHIA PAXIL CR
OMNIPOD ORTHO EVRA PCA CONT INF MINI-BORE
ON CALL EXPRESS CONTROL SOLN ORTHO MICRONOR PCA MINI-BORE
ON CALL EXPRESS METER ORTHO TRI-CYCLEN PCA SET
ON CALL EXPRESS TEST STRIP ORTHO TRI-CYCLEN LO PEGANONE
ON CALL LANCET ORTHO-CEPT PEN- NEEDLE
ON CALL LANCING DEVICE ORTHO-CYCLEN PENICILLAMINE(D-)
ON CALL PLUS CONTROL ORTHO-NOVUM PENLET PLUS BLOOD SAMPLER
ON CALL PLUS LANCET ORTHO-PREFEST PEPCID
ON CALL PLUS LANCING DEVICE OSENI PERINDOPRIL ERBUMINE
ON CALL PLUS METER OSMITROL PERSANTINE
ON CALL PLUS TEST STRIP OSPHENA PERTZYE
ON CALL VIVID CONTROL OSTOMY BELT PEXEVA
ON CALL VIVID METER OSTOMY PASTE PHARMACIST CHOICE
ON CALL VIVID PAL OSTOMY PROTECTIVE POWDER PHENOXYBENZAMINE HCL
ON CALL VIVID TEST STRIP OVCON PHENYLEPHRINE HCL
ONE TOUCH BASIC SYSTEM OXAPROZIN PHENYTEK
ONE TOUCH DELICA OXCARBAZEPINE PHENYTOIN
ONE TOUCH GLUCOSE CONTROL SOLN OXTELLAR XR PHENYTOIN SODIUM
ONE TOUCH LANCETS OXYBUTYNIN CHLORIDE PHILITH
ONE TOUCH SURESOFT OXYBUTYNIN CHLORIDE ER PHLUORIVIT
ONE TOUCH TEST STRIPS OXYTROL PHLUORIVIT + FE
ONE TOUCH ULTRA PHYSICIANS EZ USE B-12
ONE TOUCH ULTRA 2 P PHYTONADIONE
ONE TOUCH ULTRA CONTROL SOLN PACERONE PILOCARPINE HCL
ONE TOUCH ULTRA SMART PAIRE OB PLUS DHA PILOPINE HS
ONE TOUCH ULTRA SYSTEM PAMELOR PIMTREA
ONE TOUCH ULTRA TEST STRIPS PAMIDRONATE DISODIUM PINDOLOL
ONE TOUCH ULTRALINK PANCREAZE PIOGLITAZONE HCL
ONE TOUCH ULTRAMINI PANCRELIPASE PIOGLITAZONE-GLIMEPIRIDE
ONE TOUCH VERIO PANTOPRAZOLE SODIUM PIOGLITAZONE-METFORMIN
ONE TOUCH VERIO IQ PAPAVERINE HCL PIRMELLA
ONE TOUCH VERIO SYNC PARADIGM PIROXICAM
ONGLYZA PARADIGM INFUSION PLAQUENIL
ON-THE-GO PARADIGM REAL-TIME PLAVIX
OPSUMIT PARADIGM REMOTE CONTROL PLETAL
OPTIPRANOLOL PARADIGM SILHOUETTE PLUMSET MICRODRIP PUMP SET-OL
OPTIUM PARCOPA PLUMSET PRIMARY SET-OL
OPTIUM EZ PARLODEL PNV FOLIC ACID + IRON
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PNV OB+DHA PR NATAL 430 PRENA1
PNV-DHA PR NATAL 430 EC PRENA1 CHEW
PNV-DHA + DOCUSATE PR NATAL 440 EC PRENA1 PEARL
PNV-DHA PLUS PRAMIPEXOLE DI-HCL PRENA1 PLUS
PNV-FERROUS FUMARATE-DOCU-FA PRANDIMET PRENACARE
PNV-FIRST PRANDIN PRENAFIRST
PNV-IRON PRAVACHOL PRENAISSANCE
PNV-OMEGA PRAVASTATIN SODIUM PRENAISSANCE 90 DHA
PNV-SELECT PRAZOSIN HCL PRENAISSANCE BALANCE
PNV-TOTAL PRECISION PRENAISSANCE DHA
POCKETCHEM EZ PRECISION PCX PRENAISSANCE HARMONY DHA
PODIAPN PRECISION PCX PLUS PRENAISSANCE NEXT
POLY HUB NEEDLE PRECISION POINT OF CARE PRENAISSANCE NEXT-B
POLY IRON PN PRECISION Q-I-D PRENAISSANCE PLUS
POLY IRON PN FORTE PRECISION XTRA PRENAISSANCE PROMISE
POLYFIN PRECISIONGLIDE PRENAPLUS
POLYFIN QR PRECOSE PRENATA
POLY-IRON 150 FORTE PREFERA-OB PRENATABS FA
POLYSACCHARIDE IRON FORTE PREFERA-OB ONE PRENATABS RX
POLY-VI-FLOR PREFERA-OB PLUS DHA PRENATAL
POLY-VI-FLOR W/IRON PREFEST PRENATAL 19
POLY-VITAMIN WITH FLUORIDE PREFOL-DHA PRENATAL AD
POLYVITAMIN WITH IRON-FLUORIDE PREMARIN PRENATAL LOW IRON
PONSTEL PREMESIS RX PRENATAL MULTIVITAMIN W-IRON
PORTIA PREMIER CLOSED MINI-POUCH PRENATAL MV & MIN
POT CHLORIDE/DEXTROSE/NS PREMIER CLOSED POUCH PRENATAL PLUS
POTABA PREMIER COLOSTOMY-ILEOSTOMY PRENATAL-U
POTASSIUM ACETATE PREMIER DRAINABLE MINI-POUCH PRENATE
POTASSIUM BICARBONATE PREMIER DRAINABLE POUCH PRENATE AM
POTASSIUM CHL-NORMAL SALINE PREMIER LOCK N ROLL PRENATE DHA
POTASSIUM CHLORIDE PREMIER PRE-SIZED MINI-POUCH PRENATE ELITE
POTASSIUM CHLORIDE/DEXTROSE PREMIER SKN BARR W-FLOAT FLANG PRENATE ENHANCE
POTASSIUM CHLORIDE-DW5-LR PREMIER UROSTOMY PRENATE ESSENTIAL
POUCH CLAMP PREMIER UROSTOMY POUCH PRENATE MINI
POUCHKINS DRAIN TUBE PREMIER UROSTOMY POUCH/FLANGE PRENATE PLUS
POUCHKINS DRAINABLE POUCH PREMIUM BLOOD GLUCOSE PRENATE RESTORE
POUCHKINS PEDIATRIC BELT PREMIUM BLOOD GLUCOSE TEST PRENATE STAR
POUCHKINS PREMIE POUCH PREMIUM DRAINABLE POUCH PRENEXA
POUCHKINS SKIN BARRIER PREMIUM SKIN BARRIER PRENEXA PREMIER
POUCHKINS UROSTOMY POUCH PREMIUM V10 PREPLUS
PR NATAL 400 PREMPHASE PREQUE 10
PR NATAL 400 EC PREMPRO PRESSURE ACTIVATED LANCETS
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PRESTIGE PROTECT BONE R
PRESTIGE METER PROTECT CARDIO RABEPRAZOLE SODIUM
PRESTIGE SMART SYSTEM PROTECT IRON RALOXIFENE HCL
PRESTIGE SMART SYSTEM IQ PROTECT NATAL RAMIPRIL
PRESTO PRO PROTECT PLUS RANEXA
PREVACID RX PROTECT PLUS NR RANITIDINE HCL
PREVALITE PROTECTIVE BARRIER FILM RAPAFLO
PREVIFEM PROTECTIVE BARRIER WIPES RAZADYNE
PRIFTIN PROTONIX RAZADYNE ER
PRILOSEC RX PROTONIX IV REAPHIRM
PRIMIDONE PROTRIPTYLINE HCL RECLIPSEN
PRINIVIL PROVERA REFUAH PLUS
PRINZIDE PROVIDA OB REFUAH PLUS GLUCOSE CONTROL
PRISTIQ ER PROZAC REGONOL
PROBARIMIN QT PROZAC WEEKLY RELIAMED
PROCAINAMIDE HCL PSV SET RELIAMED MINI LANCING DEVICE
PROCARDIA PULMICORT RELIAMED SAFETY SEAL LANCETS
PROCARDIA XL PULMICORT FLEXHALER RELIASEAL DISC
PRODIGY PULMOPHYLLINE RELION
PRODIGY AUTOCODE PUREFE OB PLUS RELION CONFIRM
PRODIGY AUTOCODE PRO PUREFE PLUS RELION CONFIRM-MICRO
PRODIGY CONTROL SOLUTION PUREVIT DUALFE PLUS RELION MICRO
PRODIGY INSULIN SYRINGE PYRAZINAMIDE RELION PEN NEEDLES
PRODIGY LANCETS PYRIDOSTIGMINE BROMIDE RELION PRIME
PRODIGY LANCING DEVICE PYRIDOXINE HCL RELION THIN
PRODIGY NO CODING Q RELION ULTRA THIN PLUS
PRODIGY PEN NEEDLE QNASL RELNATE DHA
PRODIGY POCKET Q-TABS REMERON
PRODIGY PREFERRED QUARTETTE RENAL CAPS
PRODIGY TWIST TOP LANCET QUASENSE RENALPREN
PRODIGY VOICE QUDEXY XR RE-NATA 29 OB
PROFERRIN-FORTE QUESTRAN RENA-VITE RX
PROGESTERONE QUESTRAN LIGHT RENAX
PROMAR QUFLORA RENEW ADVANCED LANCING SYSTEM
PROMETRIUM QUICK-SET PARADIGM RENEW ADVANCED MICRO-LANCETS
PROPAFENONE HCL QUINAPRIL RENO CAPS
PROPRANOLOL HCL QUINAPRIL-HYDROCHLOROTHIAZIDE REOCYTE PLUS
PROPRANOLOL HCL-HCTZ QUINIDINE GLUCONATE REOPRO
PROPYLTHIOURACIL QUINIDINE SULFATE REPAGLINIDE
PROSCAR QVAR REPLACEMENT PEDIATRIC MONITOR
PROSTIGMIN REQ49+
PROSTIN VR PEDIATRIC REQUIP
17 | P a g eMaintenance Medication Drug List
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REQUIP XL SARAFEM SINGULAIR
RESCULA SEASONALE SIRTURO
RESECTISOL SEASONIQUE SKELID
RESERPINE SE-CARE SKIN BARRIER W-FLOATING FLANGE
RESTASIS SE-CARE CONCEIVE SKIN GEL PROTECTIVE DRESSING
REVEAL BLOOD GLUCOSE METER SE-CARE GESTURE SKIN-PREP
REVEAL TEST STRIP SECONDARY IRRIGATION SET SMART SENSE
RHINOCORT AQUA SECTRAL SMART SENSE LANCETS
RIDAURA SELECT-OB SMART SENSE MONITORING SYSTEM
RIFABUTIN SELECT-OB + DHA SMART SENSE TEST STRIPS
RIFADIN SELEGILINE HCL SMARTDIABETES VANTAGE
RIFAMATE SELFEMRA SMARTDIABETES XPRES
RIFAMPIN SE-NATAL 19 SMARTEST
RIFATER SE-NATAL 90 SMARTEST EJECT
RIGHTEST CONTROL SOLUTION SE-NATAL ONE SMARTEST LANCET
RIGHTEST GD500 SENOPHYLLINE SMARTEST PERSONA
RIGHTEST GL300 LANCETS SEN-SERTER SMARTEST PRONTO
RIGHTEST GM100 SYSTEM SENSURA CLICK OSTOMY POUCH SMARTEST PROTEGE
RIGHTEST GM300 SYSTEM SENSURA EASICLOSE WIDE OUTLET SMARTEST TEST
RIGHTEST GM550 SYSTEM SENSURA OSTOMY BASE PLATE SMS GLUCOSE CONTROL
RIGHTEST GS100 TEST STRIPS SENTROXATINE SNAP INSULIN PUMP-INFUSION SET
RIGHTEST GS300 TEST STRIPS SE-PLETE DHA SOD FERRIC GLUCONATE COMPLEX
RIGHTEST GS550 TEST STRIPS SEROMYCIN SOF-SENSOR
RIGHTSOURCE SERTRALINE HCL SOF-SERTER
RIOMET SE-TAN DHA SOFT TOUCH
RISEDRONATE SODIUM SE-TAN PLUS SOFTCLIX
RIVASTIGMINE SETONET SOFTFLEX SKIN BARRIER
R-NATAL OB SETONET-EC SOLIA
ROCALTROL SEVEN PLUS SOLO V2
ROPINIROLE HCL SEVEN SYSTEM SENSOR SOLO V2 CONTROL SOLUTION
RYTHMOL SHOPRITE VALUE PACK SOLO V2 LANCETS
RYTHMOL SR SIDEKICK SOLO V2 LANCING DEVICE
SIDEROL SOLO V2 TEST STRIPS
S SILHOUETTE SOLTAMOX
SAFESNAP INSULIN SYRINGE SIL-SERTER SOLUS V2
SAFETY LANCETS SIMBRINZA SOLUSET 150X15 I.V. SET-SL
SAFETY SEAL LANCETS SIMCOR SOLUSET IV PUMP SET
SAFETY-LET SIMVASTATIN SORINE
SAFYRAL SINEMET SOTALOL
SALSALATE SINEMET CR SOTALOL AF
SANCTURA SINGLE USE SWAB SOTALOL HCL
SANCTURA XR SINGLE-LET SPECIAL NEEDLE
18 | P a g eMaintenance Medication Drug List
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SPIRIVA SURE EDGE GLUCOSE CONTROL SOLN SYMLINPEN 120
SPIRONOLACTONE SURE EDGE TEST STRIPS SYMLINPEN 60
SPIRONOLACTONE W/HCTZ SURECHEK GLUCOSE CONTROL SYNAGEX
SPRINTEC SURECHEK TEST STRIPS SYNTHROID
SRONYX SURE-FINE PEN NEEDLES
STALEVO SUREFLEX T
STARLIX SURE-JECT INSULIN SYRINGE T:SLIM
STARTER KIT SURE-LANCE TAMBOCOR
STAVZOR SURE-PEN TAMSULOSIN HCL
STAXYN SURE-PREP ALCOHOL PREP PADS TANDEM DHA
STENDRA SURESTEP TANDEM F
STERILANCE TL SURESTEP PRO TANDEM OB
STERILE TWO-FER NEEDLE SURE-T TANDEM PLUS
STOMA CAP W-DEODOR FLTR-FLANGE SURE-T PARADIGM TANZEUM
STOMA CAP W-MICROPORE ADHESIVE SURE-TEST EASYPLUS MINI TAPAZOLE
STOMA CONE W-CONNECTOR UNIT SURE-TOUCH TARKA
STOMA IRRIGATOR DRAIN W-FLANGE SUR-FIT AUTOLOCK TARON FORTE
STOMA LUBRICANT SUR-FIT AUTOLOCK DRAIN POUCH TARON PRENATAL
STOMA URINE BAG SUR-FIT AUTOLOCK DURAHESIVE TARON-BC
STOMAHESIVE SUR-FIT AUTOLOCK INSERTS TARON-C DHA
STOMAHESIVE PROTECTIVE SUR-FIT AUTOLOCK POUCH TARON-DUO EC
STOMAHESIVE SKIN BARRIER SUR-FIT AUTOLOCK STOMAHESIVE TAZTIA XT
STROVITE SUR-FIT NAT IRRIG FACEPLATE TECHLITE BLOOD LANCET
STROVITE ADVANCE SUR-FIT NATURA TEGRETOL
STROVITE FORTE SUR-FIT NATURA ADAPTOR TEGRETOL XR
STROVITE ONE SUR-FIT NATURA CLOSED-END PCH TEKAMLO
STROVITE PLUS SUR-FIT NATURA CONVEX INSERTS TEKTURNA
SUCRALFATE SUR-FIT NATURA DRAINABLE POUCH TEKTURNA HCT
SULAR SUR-FIT NATURA DURAHESIVE TELCARE
SULFASALAZINE SUR-FIT NATURA FLANGE CAP TELCARE CONTROL SOLUTION
SULFASALAZINE DR SUR-FIT NATURA HIGH OUTPUT TELMISARTAN
SULFAZINE SUR-FIT NATURA LITTLE ONES TELMISARTAN-AMLODIPINE
SULFAZINE EC SUR-FIT NATURA LOW-PRESSURE TELMISARTAN-HYDROCHLOROTHIAZID
SULINDAC SUR-FIT NATURA MINI-POUCH TENEX
SUPER THIN LANCETS SUR-FIT NATURA POUCH TENORETIC
SUPERVITE SUR-FIT NATURA STOMAHESIVE TENORMIN
SUPPORT SUR-FIT NATURA UROSTOMY POUCH TERAZOSIN HCL
SURE COMFORT SUR-FIT-ACT LIFE-TAIL CLOSURES TERBUTALINE SULFATE
SURE COMFORT ALCOHOL PREP PADS SURMONTIL TERUMO INSULIN SYRINGE
SURE COMFORT LANCETS SYEDA TERUMO SURGUARD
SURE COMFORT LANCING PEN SYMBICORT TEST N'GO
SURE EDGE BLOOD GLUCOSE METER SYMLIN TEST STRIPS
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TEVETEN TOLTERODINE TARTRATE ER TRINATAL GT
TEVETEN HCT TOPAMAX TRINATAL RX 1
THALASET TOPCARE ULTRA COMFORT TRINATAL ULTRA
THALITONE TOPCARE UNIVERSAL1 THIN LANCET TRINATE
THEO-24 TOPIRAGEN TRINESSA
THEOCHRON TOPIRAMATE TRI-NORINYL
THEOPHYLLINE ANHYDROUS TOPIRAMATE ER TRIOSTAT
THEOPHYLLINE IN 5% DEXTROSE TOPROL XL TRIPHLUORIVIT
THERAPEUTIC HEMATINIC TORSEMIDE TRIPHROCAPS
THERAPEUTIC VITAMIN W-MINERALS TOVIAZ TRIPLE-VITAMIN W-FLUORIDE
THEROBEC TRADE NAME DESCRIPTION TRI-PREVIFEM
THEROBEC PLUS TRADJENTA TRI-SPRINTEC
THIAMINE HCL TRANDATE TRI-TABS DHA
THIN LANCETS TRANDOLAPRIL TRIVEEN-DUO DHA
THINPRO INSULIN SYRINGE TRANDOLAPRIL-VERAPAMIL TRIVEEN-ONE
THINSET TRANSFER NEEDLE TRIVEEN-PRX RNF
TIAGABINE HCL TRAVATAN Z TRIVEEN-TEN
TIAZAC TRAVOPROST TRIVEEN-U
TICLOPIDINE HCL TRAZAMINE TRI-VI-FLOR
TIKOSYN TRAZODONE HCL TRI-VI-FLORO
TILIA FE TRECATOR TRI-VITAMIN WITH FLUORIDE
TIMOLOL MALEATE TRI RX TRI-VITAMIN WITH IRON-FLUORIDE
TIMOPTIC TRIADVANCE TRIVORA
TIMOPTIC-XE TRIAMCINOLONE ACETONIDE TROKENDI XR
TIROSINT TRIAMTERENE W/HCTZ TROSPIUM CHLORIDE
TL GARD RX TRIBENZOR TRUE CARE STARTER
TL ICON TRICARE TRUE2GO BLOOD GLUCOSE SYSTEM
TL NICOTINAMIDE TRICARE DHA TRUECONTROL
TL-ASSURE + DHA TRICARE PRENATAL COMPLEAT TRUEPLUS
TL-ASSURE ONE TRICARE PRENATAL DHA ONE TRUEPLUS INSULIN SYRINGE
TL-CARE DHA TRICON TRUEPLUS LANCETS
TL-FLUORIVITE TRICOR TRUERESULT BLOOD GLUCOSE SYSTM
TL-FOL 500 TRI-ESTARYLLA TRUETEST GLUCOSE CONTROL
TL-HEM 150 TRIGELS-F FORTE TRUETEST TEST STRIPS
TL-SELECT TRIGLIDE TRUETRACK
TL-SELECT DHA TRIHEXYPHENIDYL HCL TRUETRACK BLOOD GLUCOSE SYSTEM
TOFRANIL TRI-LEGEST FE TRUETRACK SMART SYSTEM
TOFRANIL-PM TRILEPTAL TRUSOPT
TOLAZAMIDE TRI-LINYAH TRUST NATAL DHA
TOLBUTAMIDE TRILIPIX TUDORZA PRESSAIR
TOLMETIN SODIUM TRIMESIS RX T-U-R SYSTEM W-FLOW POUCH
TOLTERODINE TARTRATE TRIMIPRAMINE MALEATE TWYNSTA
20 | P a g eMaintenance Medication Drug List
Drug Level_100952_Updated July 2014
UNISTIK 3 EXTRA VENOFER
U UNISTIK CZT VENOSET
UDAMIN UNISTRIP VERAMYST
UDAMIN SP UNISTRIP1 VERAPAMIL ER
ULTICARE UNITHROID VERAPAMIL ER PM
ULTICARE INSULIN SYRINGE UNIVASC VERAPAMIL HCL
ULTI-LANCE UNIVERSAL 1 VERELAN
ULTILET URISTIX 4 VERELAN PM
ULTILET ALCOHOL SWAB URISTIX REAGENT VESICARE
ULTILET BASIC UROSTOMY DRAIN TUBE ADAPTER VESTURA
ULTILET CLASSIC UROSTOMY MICRO-POUCH VGO 20
ULTILET INSULIN SYRINGE UROSTOMY MULTI-CHAMBER VGO 30
ULTILET LANCETS UROSTOMY MULTI-CHAMBER POUCH VGO 40
ULTILET PEN NEEDLE UROSTOMY POUCH VIAGRA
ULTILET SAFETY UROSTOMY POUCH WITH FLANGE VI-C FORTE
ULTIMA UROXATRAL VICA-FORTE
ULTIMATE OB DHA URSO VICAP FORTE
ULTIMATECARE ONE URSO FORTE VICTORY
ULTIMATECARE ONE NF URSODIOL VICTOZA
ULTRA COMFORT VIIBRYD
V
ULTRA THIN LANCETS VIMOVO
ULTRA THIN PLUS LANCETS VAGIFEM VINACAL
ULTRALANCE VALPROATE SODIUM VINATE
ULTRA-THIN II VALPROIC ACID VINATE AZ
ULTRATHIN LANCETS VALSARTAN VINATE C
ULTRATLC LANCETS VALSARTAN-HYDROCHLOROTHIAZIDE VINATE CALCIUM
ULTRATRAK PRO VALTURNA VINATE DHA
ULTRATRAK ULTIMATE VANISHPOINT VINATE DHA RF
ULTRESA VASCULERA VINATE GT
UNIFINE PENTIPS VASERETIC VINATE IC
UNIFINE PENTIPS PLUS VASOTEC VINATE II
UNILET COMFORTOUCH VAYAROL VINATE ONE
UNILET EXCELITE V-C FORTE VINATE ULTRA
UNILET EXCELITE II VECAMYL VINATE-M
UNILET GP LANCET VELIVET VIOKACE
UNILET LANCET VEMAVITE-PRX 2 VIORELE
UNILET LANCETS VENA-BAL DHA VIRT-BAL DHA
UNIRETIC VENATAL COMPLETE DHA VIRT-BAL DHA PLUS
UNISTIK VENATAL-FA VIRT-CAPS
UNISTIK 2 VENLAFAXINE HCL VIRT-PN
UNISTIK 2 NORMAL VENLAFAXINE HCL ER VIRT-PN DHA
UNISTIK 3 VENLAFAXINE HCL ER BRAND VIRT-PN PLUS
21 | P a g eMaintenance Medication Drug List
Drug Level_100952_Updated July 2014
VIRT-SELECT VOL-NATE YASMIN
VIRT-VITE VOL-PLUS YAZ
VIRT-VITE FORTE VOL-TAB RX YOHIMBINE HCL
VIRT-VITE PLUS VOLTAREN-XR
VISI-FLOW IRRIG STARTER SET VOSPIRE ER Z
VISI-FLOW IRRIGATION SLEEVE VP CH ULTRA ZAFIRLUKAST
VISI-FLOW IRRIGATOR STOMA CONE VP-CH PLUS ZANTAC RX
VISI-FLOW SLEEVE TAIL CLOSURES VP-CH-PNV ZARAH
VISI-FLOW STOMA CONE VP-ERA OB PLUS ZARONTIN
VIT 3 VP-GGR-B6 ZAROXOLYN
VITA S FORTE VP-HEME OB ZATEAN-CH
VITACIRC-B VP-HEME OB + DHA ZATEAN-PN
VITAFOL VP-HEME ONE ZATEAN-PN DHA
VITAFOL NANO VP-PNV-DHA ZATEAN-PN PLUS
VITAFOL ULTRA VYFEMLA ZEBETA
VITAFOL-OB VYNATAL-FA ZEGERID RX
VITAFOL-OB+DHA VYTORIN ZELAPAR
VITAFOL-ONE W ZENCHENT
VITAFOL-PLUS WAVESENSE AMP ZENCHENT FE
VITAFOL-PN WAVESENSE CONTROL SOLUTION ZENPEP
VITAL-D RX WAVESENSE JAZZ ZEOSA
VITAMAX WAVESENSE PRESTO ZESTORETIC
VITAMED MD ONE RX W-D STARTER ZESTRIL
VITAMED MD PLUS RX WEBCOL ALCOHOL PREPS ZETIA
VITAMEDMD REDICHEW RX WELCHOL ZETONNA
VITAMIN B COMPLEX WELLBUTRIN ZIAC
VITAMIN D2 WELLBUTRIN SR ZINGIBER
VITAMIN K WELLBUTRIN XL ZIOPTAN
VITAMINS A,C,D & FLUORIDE WERA ZIPSOR
VITAPEARL WESTHROID ZOCOR
VITA-RESPA WESTHROID-P ZOLOFT
VITASPIRE WINN DIXIE MEDIC ZONEGRAN
VIVA CT WP THYROID ZONISAMIDE
VIVA DHA WYMZYA FE ZONTIVITY
VIVACTIL ZORVOLEX
VIVELLE X ZOVIA
VIVELLE- DOT XALATAN ZYFLO
V-NATAL XPRES ZYFLO CR
V-NATAL DHA XULANE ZYRTEC RX
VOCAL POINT XYLOCAINE ZYRTEC-D RX
VOCALPOINT GLUCOSE CONTROL XYZAL
VOL-CARE RX YALE NEEDLE
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