Welcome to Nebraska Total Care
What is the Nebraska Total Care Recommended Drug List?
The drug list includes drugs used to treat common diseases or health problems. A team of
doctors and pharmacists meets regularly to decide which drugs should be on the drug list. The
team reviews new and existing drugs and chooses drugs that work best and are safe. The list of
drugs are in combination from the State Preferred Drug List and Nebraska Total Care
formulary.
How do I use the Nebraska Total Care Recommende d Drug List?
Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the
drug list. Both brand name drugs and generic drugs are listed in the index. Next to your drug,
you will see the page number where you can find your drug.
The table below tells you what the abbreviations on the Drug List mean.
Abbreviation
Term
What it means
AL
F
PA
Age Limit
Formulary
Prior
Some drugs are only covered for certain ages.
These drugs are covered on the Drug List.
Your doctor must ask for approval from Nebraska Total Care
before some drugs will be covered.
Authorization
QL
Quantity Limit
Some drugs are only covered for a certain amount.
NP
Non-preferred
These drugs are on formulary that may still need to meet prior
authorization/class criteria before they will be covered.
RX/OTC
Prescription and
OTC
Step Therapy
ST
These drugs are made in both prescription form and
Over-the-counter (OTC) form.
In some cases, you must first try certain drugs before
Nebraska Total Care covers another drug for your medical
condition.
For example, if Drug A and Drug B both treat your
medical condition, Nebraska Total Care may not cover
Drug B unless you try Drug A first.
What if my drug is not on the Nebraska Total Care Recommended Drug List?
If your drug is not on the drug list, call Member Services at 1-844-385-2192 and ask if your drug
is covered. If your drug is not covered, you can ask your doctor to prescribe a similar drug that is
covered. If your doctor feels you need to have the drug that is not covered, your doctor can ask
us to make an exception.
Can I go to any pharmacy?
Members must use pharmacies that are in the network. These pharmacies have a contract with
Nebraska Total Care. To find a pharmacy, call Member Services at 1-844-385-2192.
Are there any limits on my drug coverage?
Some drugs have limits on coverage. If a drug has limits, it will be noted in the
requirements/limits column on the Drug List.
How can I get an exception to the rules for drug coverage?
Your doctor can ask for an exception to our rules for drug cover.


Your doctor can ask us to cover your drug even if it is not on the drug list
Your doctor can ask us to make an exception for limits on your drug. For example, if
your drug has a quantity limit of 1 tablet per day, your doctor can ask us to cover more.
To request an exception, your doctor can fax a prior authorization form to us at 1-866-399-0929.
Once we receive your doctor’s request, we usually make our decision within one business day. If
we need more information, your doctor has five business days to give us that information before
we make our decision.
What if I’m a new member?
If you are a new member in our plan, you may be taking drugs that are not on our drug list. You
may also be taking a drug that is on our drug list, but the drug may have some limits. In these
cases, you should talk to your doctor to see if you should change to drugs that we cover. Your
doctor may request an exception so that we could cover the drug you have been taking. See the
section, “How do I get an exception to the rules for the drug coverage?” for more information.
What are over-the-counter drugs?
Over-the-counter (OTC) drugs are drugs you can buy without a prescription. The Nebraska
Total Care Recommended Drug List covers similar OTC drugs as those listed on the State
Nebraska Medicaid List of Contract Drugs. However, if you want Nebraska Total Care to cover
an OTC drug on the drug list, your doctor must write a prescription for that drug.
Are brand name drugs covered?
Your pharmacy benefit does not cover brand name drugs when generic drugs are available
unless the state requires use of the brand. Brand name drugs may be covered when generic
drugs are not available. If your doctor says the brand name drug is medically necessary or
preferred by the state formulary.
What is a generic drug?
A generic drug contains the same active ingredient and works the same way as the brand name
drug. Generic drugs must be safe and effective.
Will the pharmacist give me a generic drug if one is available?
Yes. Pharmacies may give you a generic drug, unless your doctor says that you must take the
brand name drug or preferred by the state.
Are there any excluded or carve-out drugs?
Excluded drugs
The Nebraska Total Care Recommended Drug List is similar to the State Nebraska Medicaid List
of Contract Drugs and does not include certain drugs. The following types of drugs are not
included on the drug list because they are excluded from coverage:

Drugs that do not have FDA approval

Experimental or investigational drugs

Drugs to help you get pregnant

Drugs used for weight loss

Cosmetic or hair-growth drugs

Drugs used to treat erectile problems

Drugs not on the OTC Drug Formulary
Need more information?
For more information about your pharmacy benefits, please review your Member Handbook or
call Member Services at 1-844-385-2192.
Nebraska Total Care complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex.
Nebraska Total Care does not exclude people or treat them differently because of
race, color, national origin, age, disability, or sex.
Nebraska Total Care:

Provides free aids and services to people with disabilities to
communicate effectively with us, such as qualified sign language
interpreters and written information in other formats (large print,
accessible electronic formats, other formats).

Provides free language services to people whose primary language is not
English, such as qualified interpreters and information written in other
languages.
If you need these services, contact Nebraska Total Care Contact Center at
1-844-385-2192, TTY: 1-844-307-0342, Relay 711.
If you believe that Nebraska Total Care has failed to provide these services or
discriminated in another way on the basis of race, color, national origin, age,
disability, or sex, you can file a grievance by calling the number above and telling
them you need help filing a grievance; Nebraska Total Care Member Service Center
is available to help you.
You can also use the member portal on our website at: www.NebraskaTotalCare.com
Give it to us in person or by mail:
Nebraska Total Care ATTN: Grievances:
2525 North 117th Ave
Omaha NE, 68164
When filing for a grievance be sure to include:





Your first and last name
Your Nebraska Medicaid ID number
Your address and telephone number
What you are unhappy with
What you would like to have happen
Drug Name
Drug Requirements/
Tier Limits
ADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS - Drugs to Treat
ADHD, Sleep and Eating Disorders
Amphetamines
ADDERALL TABS
1.25MG-1.25MG-1.25MG1.25MG (AmphetamineDextroamphetamine)
ADDERALL TABS
1.875MG-1.875MG1.875MG-1.875MG
(AmphetamineDextroamphetamine)
ADDERALL TABS 2.5MG2.5MG-2.5MG-2.5MG
(AmphetamineDextroamphetamine)
ADDERALL TABS
3.125MG-3.125MG3.125MG-3.125MG
(AmphetamineDextroamphetamine)
ADDERALL TABS
3.75MG-3.75MG-3.75MG3.75MG (AmphetamineDextroamphetamine)
ADDERALL TABS 5MG5MG-5MG-5MG
(AmphetamineDextroamphetamine)
ADDERALL TABS 7.5MG7.5MG-7.5MG-7.5MG
(AmphetamineDextroamphetamine)
ADDERALL XR CP24
1.25MG-1.25MG-1.25MG1.25MG (AmphetamineDextroamphetamine)
ADDERALL XR CP24
2.5MG-2.5MG-2.5MG2.5MG (AmphetamineDextroamphetamine)
ADDERALL XR CP24
3.75MG-3.75MG-3.75MG3.75MG (AmphetamineDextroamphetamine)
F
QL(12 ea
daily); AL
QL(8 ea daily);
AL
F
F
QL(6 ea daily);
AL
QL(4.8 ea
daily); AL
F
F
F
QL(4 ea daily);
AL
QL(3 ea daily);
AL
F
QL(2 ea daily);
AL
F
QL(12 ea
daily); AL
F
QL(6 ea daily);
AL
F
QL(4 ea daily);
AL
Nebraska Total Care Updated May 30, 2017
1
Drug Name
ADDERALL XR CP24
5MG-5MG-5MG-5MG
(AmphetamineDextroamphetamine)
ADDERALL XR CP24
6.25MG-6.25MG-6.25MG6.25MG (AmphetamineDextroamphetamine)
ADDERALL XR CP24
7.5MG-7.5MG-7.5MG7.5MG (AmphetamineDextroamphetamine)
Drug Requirements/
Tier Limits
QL(3 ea daily);
F AL
QL(2 ea daily)
F
F
QL(2 ea daily);
AL
ADZENYS XR-ODT TBED
NP
amphetaminedextroamphetamine cp24
1.25mg-1.25mg-1.25mg1.25mg
amphetaminedextroamphetamine cp24
2.5mg-2.5mg-2.5mg-2.5mg
amphetaminedextroamphetamine cp24
3.75mg-3.75mg-3.75mg3.75mg
amphetaminedextroamphetamine cp24
5mg-5mg-5mg-5mg
amphetaminedextroamphetamine cp24
6.25mg-6.25mg-6.25mg6.25mg
amphetaminedextroamphetamine cp24
7.5mg-7.5mg-7.5mg-7.5mg
amphetaminedextroamphetamine tabs
1.25mg-1.25mg-1.25mg1.25mg
amphetaminedextroamphetamine tabs
1.875mg-1.875mg1.875mg-1.875mg
amphetaminedextroamphetamine tabs
2.5mg-2.5mg-2.5mg-2.5mg
QL(12 ea
NP daily); AL
QL(6 ea daily);
NP AL
QL(4 ea daily);
NP AL
QL(3 ea daily);
NP AL
QL(2 ea daily)
NP
QL(2 ea daily);
NP AL
F
QL(12 ea
daily); AL
F
QL(8 ea daily);
AL
F
QL(6 ea daily);
AL
Drug Name
amphetaminedextroamphetamine tabs
3.125mg-3.125mg3.125mg-3.125mg
amphetaminedextroamphetamine tabs
3.75mg-3.75mg-3.75mg3.75mg
amphetaminedextroamphetamine tabs
5mg-5mg-5mg-5mg
amphetaminedextroamphetamine tabs
7.5mg-7.5mg-7.5mg-7.5mg
DESOXYN TABS
(Methamphetamine HCl)
DEXEDRINE CP24 10 MG
(Dextroamphetamine
Sulfate)
DEXEDRINE CP24 15 MG
(Dextroamphetamine
Sulfate)
DEXEDRINE CP24 5 MG
(Dextroamphetamine
Sulfate)
dextroamphetamine sulfate
cp24 10 mg
dextroamphetamine sulfate
cp24 15 mg
dextroamphetamine sulfate
cp24 5 mg
dextroamphetamine sulfate
soln
dextroamphetamine sulfate
tabs 10 mg
dextroamphetamine sulfate
tabs 5 mg
Drug Requirements/
Tier Limits
QL(4.8 ea
F daily); AL
Drug Name
VYVANSE CAPS
ZENZEDI TABS 15 MG
F
QL(4 ea daily);
AL
F
QL(3 ea daily);
AL
F
QL(2 ea daily);
AL
ZENZEDI TABS 2.5 MG
ZENZEDI TABS 20 MG
NP PA; QL(1 ea
daily); AL
PA; QL(6 ea
NP daily); AL
PA; QL(4 ea
NP daily); AL
PA; QL(12 ea
NP daily); AL
PA; QL(6 ea
daily); AL
F PA; QL(4 ea
daily); AL
F PA; QL(12 ea
daily); AL
F PA; QL(12 ml
daily); AL
NP QL(6 ea daily);
AL
NP QL(12 ea
daily); AL
F
ZENZEDI TABS 30 MG
ZENZEDI TABS 7.5 MG
Analeptics
CAFCIT SOLN (Caffeine
Citrate)
F
caffeine tabs
F
VIVARIN TABS (Caffeine)
NP
Attention-Deficit/Hyperactivity Disorder (ADHD)
F QL(2 ea daily);
clonidine hcl (adhd) tb12
AL
F PA; QL(1 ea
guanfacine hcl (adhd) tb24
daily); AL
INTUNIV TB24
NP PA; QL(1 ea
(Guanfacine HCl (ADHD))
daily); AL
KAPVAY TB12 (Clonidine
NP QL(2 ea daily);
HCl (ADHD))
AL
STRATTERA CAPS 18
F QL(2 ea daily);
MG, 10 MG, 40 MG, 25 MG
AL
STRATTERA CAPS 80
F QL(1 ea daily);
MG, 60 MG, 100 MG
AL
Stimulants - Misc.
NP
APTENSIO XR CP24
EVEKEO TABS
NP AL
armodafinil tabs
methamphetamine hcl tabs
PA; QL(1 ea
daily); AL
PA; QL(12 ml
NP daily); AL
CONCERTA TBCR
(Methylphenidate HCl)
PROCENTRA SOLN
(Dextroamphetamine
Sulfate)
NP
caffeine citrate soln
DYANAVEL XR SUER
F
Drug Requirements/
Tier Limits
F QL(1 ea daily);
AL
NP QL(4 ea daily);
AL
NP QL(24 ea
daily); AL
NP QL(3 ea daily);
AL
NP QL(2 ea daily);
AL
NP QL(8 ea daily);
AL
DAYTRANA PTCH
dexmethylphenidate hcl
cp24
NP QL(1 ea daily);
AL
NP QL(1 ea daily);
AL
NP PA
PA; QL(1 ea
daily); AL
NP QL(1 ea daily);
AL
F
Nebraska Total Care Updated May 30, 2017
2
Drug Name
dexmethylphenidate hcl
tabs 10 mg
dexmethylphenidate hcl
tabs 2.5 mg
dexmethylphenidate hcl
tabs 5 mg
FOCALIN TABS 10 MG
(Dexmethylphenidate HCl)
FOCALIN TABS 2.5 MG
(Dexmethylphenidate HCl)
FOCALIN TABS 5 MG
(Dexmethylphenidate HCl)
FOCALIN XR CP24
(Dexmethylphenidate HCl)
METADATE CD CPCR
(Methylphenidate HCl)
METHYLIN CHEW
(Methylphenidate HCl)
METHYLIN SOLN
(Methylphenidate HCl)
METHYLPHENIDATE HCL
CHEW
Drug Requirements/
Tier Limits
F QL(5 ea daily);
AL
F QL(20 ea
daily); AL
F QL(10 ea
daily); AL
NP QL(5 ea daily);
AL
NP QL(20 ea
daily); AL
NP QL(10 ea
daily); AL
F QL(1 ea daily);
AL
NP PA; QL(1 ea
daily)
F
F
PA; QL(1 ea
daily)
PA; QL(1 ea
daily)
ST; QL(1 ea
daily)
PA
F
PA
methylphenidate hcl cpcr
F
METHYLPHENIDATE HCL
ER (LA) CP24
METHYLPHENIDATE HCL
ER TB24
METHYLPHENIDATE HCL
ER TBCR
F
methylphenidate hcl soln
NP
methylphenidate hcl tabs
F
methylphenidate hcl tbcr 10
mg
methylphenidate hcl tbcr 20
mg
methylphenidate hcl tbcr 54
mg, 36 mg, 18 mg, 27 mg
modafinil tabs
NUVIGIL TABS
(Armodafinil)
F
F
F
NP
QUILLIVANT XR SUSR
F
RITALIN LA CP24 10 MG
RITALIN LA CP24 20 MG,
30 MG, 40 MG
(Methylphenidate HCl)
RITALIN LA CP24 60 MG
RITALIN TABS
(Methylphenidate HCl)
PA; QL(1 ea
daily)
PA; QL(1 ea
NP daily)
F
F
ST; QL(1 ea
daily)
NP
ALLERGENIC EXTRACTS/BIOLOGICALS MISC
ORALAIR ADULT SAMPLE
KIT SUBL
ORALAIR ADULT
STARTER PACK SUBL
ORALAIR
CHILDREN/ADOLESCENT
S STARTER PACK SUBL
QL(2 ea daily);
AL
QL(3 ea daily);
AL
PA
NP QL(2 ea daily);
AL
NP QL(1 ea daily);
AL
F
F
F
F
ORALAIR SUBL
F
RAGWITEK SUBL
F
ALTERNATIVE MEDICINES
Alternative Medicine - M's
melatonin tabs 5 mg, 10
mg, 3 mg, 1 mg
Nebraska Total Care Updated May 30, 2017
3
QUILLICHEW ER CHER
GRASTEK SUBL
NP
F
PROVIGIL TABS
(Modafinil)
Drug Requirements/
Tier Limits
NP QL(2 ea daily);
AL
Allergenic Extracts
NP
methylphenidate hcl cp24
Drug Name
F
Alternative Medicine Combinations
MELATONIN TABS 3MGF
10MG
AMINOGLYCOSIDES - Drugs to Treat Bacterial
Infections
Aminoglycosides
BETHKIS NEBU
F
KITABIS PAK NEBU
F
PA
Drug Name
Drug Requirements/
Tier Limits
neomycin sulfate tabs
F
TOBI NEBU (Tobramycin)
NP
TOBI PODHALER CAPS
F
Drug Name
OTREXUP SOAJ 7.5
MG/0.4ML
PA
RHEUMATREX TABS
tobramycin nebu
NP
Interleukin-1 Blockers
TOBRAMYCIN NEBU
NP
ARCALYST SOLR
Drug Requirements/
Tier Limits
PA; Limit 4ml
F per
month;QL(0.13
34 ml daily)
F
NP
Interleukin-1 Receptor Antagonist (IL-1Ra)
TOBRAMYCIN SULFATE
SOLN 40 MG/ML, 10
MG/ML
tobramycin sulfate soln 40
mg/ml, 10 mg/ml, 80
mg/2ml, 1.2 gm/30ml
F
F
tobramycin sulfate solr
F
ANALGESICS - ANTI-INFLAMMATORY - Drugs
to Treat Pain, Swelling, Muscle and Joint
Conditions
Anti-TNF-alpha - Monoclonal Antibodies
HUMIRA PEDIATRIC
QL(4 ea per fill
F retail)
CROHNS DISEASE
STARTER PACK PSKT
F QL(4 ea per fill
HUMIRA PEN PNKT
retail)
HUMIRA PEN-CROHNS
F QL(4 ea per fill
DISEASESTARTER PNKT
retail)
HUMIRA PEN-PSORIASIS
F QL(4 ea per fill
STARTER PNKT
retail)
HUMIRA PSKT 20
F QL(2 ea per fill
MG/0.4ML, 10 MG/0.2ML
retail)
HUMIRA PSKT 40
F QL(4 ea per fill
MG/0.8ML
retail)
SIMPONI SOAJ
NP
SIMPONI SOSY
NP
Antirheumatic - Enzyme Inhibitors
XELJANZ TABS
NP QL(2 ea daily)
XELJANZ XR TB24
NP
Antirheumatic Antimetabolites
KINERET SOSY
NP
Interleukin-6 Receptor Inhibitors
ACTEMRA SOSY
NP
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
ADVIL CAPS (Ibuprofen)
NP
ADVIL MIGRAINE CAPS
(Ibuprofen)
NP
ADVIL TABS (Ibuprofen)
NP
ALEVE ARTHRITIS TABS
(Naproxen Sodium)
ALEVE CAPS (Naproxen
Sodium)
ALEVE TABS (Naproxen
Sodium)
ANAPROX DS TABS
(Naproxen Sodium)
ARTHROTEC 50 TBEC
(Diclofenac w/ Misoprostol)
ARTHROTEC 75 TBEC
(Diclofenac w/ Misoprostol)
CELEBREX CAPS
(Celecoxib)
NP
NP
NP
NP
NP
NP
NP
celecoxib caps
NP
CHILDRENS ADVIL SUSP
(Ibuprofen)
CHILDRENS MOTRIN
SUSP (Ibuprofen)
DAYPRO TABS
(Oxaprozin)
NP RX/OTC
diclofenac potassium tabs
NP
NP RX/OTC
NP
Nebraska Total Care Updated May 30, 2017
4
Drug Name
Drug Requirements/
Tier Limits
Drug Name
diclofenac sodium tb24
F
KETOPROFEN ER CP24
diclofenac sodium tbec
F
ketorolac tromethamine
tabs
Drug Requirements/
Tier Limits
NP
F
diclofenac w/ misoprostol
tbec
NP
LODINE TABS (Etodolac)
NP
DUEXIS TABS
NP
MECLOFENAMATE
SODIUM CAPS
NP
EC-NAPROSYN TBEC
(Naproxen)
NP
mefenamic acid caps
NP
etodolac caps
NP
MELOXICAM SUSP
F
etodolac tabs
NP
meloxicam tabs
F
etodolac tb24
NP
MOBIC SUSP
F
FELDENE CAPS
(Piroxicam)
FENOPROFEN CALCIUM
CAPS 200 MG, 400 MG
FENOPROFEN CALCIUM
TABS
FENORTHO CAPS 200
MG, 400 MG
NP QL(1 ea daily)
MOBIC TABS (Meloxicam)
NP
NP
MOTRIN INFANTS
DROPS SUSP (Ibuprofen)
NP
NP
nabumetone tabs
NP
NALFON CAPS
NP
flurbiprofen tabs
NP
NAPRELAN TB24 375 MG,
500 MG (Naproxen
Sodium)
NP
ibuprofen caps
NP
NAPRELAN TB24 750 MG
NP
ibuprofen chew
F
ibuprofen susp 100 mg/5ml
F
ibuprofen susp 40 mg/ml,
50 mg/1.25ml
F
ibuprofen tabs
F
INDOCIN SUPP
NP
INDOCIN SUSP
NP
indomethacin caps
F
indomethacin cpcr
NP
INFANTS ADVIL SUSP
(Ibuprofen)
NP
ketoprofen caps
NP
RX/OTC
Nebraska Total Care Updated May 30, 2017
5
NAPROSYN SUSP
(Naproxen)
NAPROSYN TABS
(Naproxen)
naproxen sodium caps
naproxen sodium tabs 220
mg
naproxen sodium tabs 550
mg, 275 mg
naproxen sodium tb24
F
NP
NP
F
F
NP
NP
naproxen susp
F
NAPROXEN SUSP
F
naproxen tabs
F
QL(4 ea daily,5
day(s) limit)
PA; AL
PA; AL
Drug Name
naproxen tbec 375 mg, 500
mg
naproxen tbec 500 mg
Drug Requirements/
Tier Limits
NP
F
oxaprozin tabs
NP
piroxicam caps
NP QL(1 ea daily)
PONSTEL CAPS
(Mefenamic Acid)
NP
SPRIX SOLN
NP
sulindac tabs
F
Drug Name
Soluble Tumor Necrosis Factor Receptor Agents
F QL(8 ea per fill
ENBREL SOLR
retail)
ENBREL SOSY 25
F QL(4.08 ml per
MG/0.5ML
fill retail)
F QL(7.84 ml per
ENBREL SOSY 50 MG/ML
fill retail)
ENBREL SURECLICK
F QL(7.84 ml per
SOAJ
fill retail)
ANALGESICS - NonNarcotic - Drugs to Treat
Pain, Muscle and Joint Conditions
Pyrimidine Synthesis Inhibitors
ARAVA TABS
NP
(Leflunomide)
Analgesic Combinations
aspirin-acetaminophencaffeine tabs
butalbital-acetaminophen
tabs 325mg-50mg
butalbital-acetaminophencaffeine caps 325mg50mg-40mg
butalbital-acetaminophencaffeine tabs
butalbital-aspirin-caffeine
caps
ESGIC TABS (ButalbitalAcetaminophen-Caffeine)
EXCEDRIN EXTRA
STRENGTH TABS
(Aspirin-AcetaminophenCaffeine)
EXCEDRIN MENSTRUAL
COMPLETE TABS
(Aspirin-AcetaminophenCaffeine)
EXCEDRIN MIGRAINE
TABS (AspirinAcetaminophen-Caffeine)
FIORINAL CAPS
(Butalbital-Aspirin-Caffeine)
leflunomide tabs
TENCON TABS
TIVORBEX CAPS
NP
tolmetin sodium caps
NP
TOLMETIN SODIUM
CAPS
NP
TOLMETIN SODIUM TABS
NP
VIMOVO TBEC
NP
VIVLODEX CAPS
NP
VOLTAREN-XR TB24
(Diclofenac Sodium)
NP
ZIPSOR CAPS
NP
ZORVOLEX CAPS
NP
Phosphodiesterase 4 (PDE4) Inhibitors
NP QL(2 ea daily)
OTEZLA TABS
OTEZLA TBPK
NP
F
Selective Costimulation Modulators
ORENCIA CLICKJECT
NP
SOAJ
ORENCIA SOSY
NP
Drug Requirements/
Tier Limits
F
F
F
F
F
NP
NP
NP
NP
NP
F
Analgesics Other
acetaminophen caps
F
acetaminophen chew 80
mg
F
Nebraska Total Care Updated May 30, 2017
6
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
acetaminophen liqd
F
aspirin buffered (cal carbmag carb-mag oxide) tabs
F
acetaminophen soln
F
aspirin chew
F
acetaminophen supp
F
ASPIRIN LOW DOSE
TABS
F
acetaminophen susp
F
aspirin supp 300 mg
F
acetaminophen tabs
F
aspirin supp 600 mg
F
acetaminophen tbcr
F
aspirin tabs 325 mg
F
acetaminophen tbdp
F
FEVERALL INFANTS
SUPP
F
INFANTS SILAPAP SOLN
F
aspirin tbec 324 mg, 81
mg, 325 mg
BUFFERIN TABS (Aspirin
Buffered (Cal Carb-Mag
Carb-Mag Oxide))
TRIAMINIC FEVER
REDUCERPAIN
RELIEVER CHILDRENS
SYRP
TRIAMINIC FEVER
REDUCERPAIN
RELIEVER INFANTS
SYRP
TYLENOL 8 HOUR
ARTHRITISPAIN TBCR
(Acetaminophen)
TYLENOL 8 HOUR TBCR
(Acetaminophen)
TYLENOL CHILDRENS
SUSP (Acetaminophen)
TYLENOL EXTRA
STRENGTH TABS
(Acetaminophen)
TYLENOL INFANTS
PAIN+FEVER SUSP
(Acetaminophen)
TYLENOL INFANTS SUSP
(Acetaminophen)
TYLENOL SORE THROAT
DAYTIME LIQD
(Acetaminophen)
TYLENOL TABS
(Acetaminophen)
QL(0.4 ea
daily)
F
F
F
NP
diflunisal tabs
NP
ECOTRIN REGULAR
STRENGTH TBEC
(Aspirin)
NP
ANALGESICS - OPIOID - Drugs to Treat Pain,
Muscle and Joint Conditions
Opioid Agonists
NP
NP
NP
NP
NP
NP
NP
NP
Salicylates
Nebraska Total Care Updated May 30, 2017
7
QL(0.4 ea
daily)
ABSTRAL SUBL
ACTIQ LPOP (Fentanyl
Citrate)
AVINZA CP24 (Morphine
Sulfate Beads)
CODEINE SULFATE TABS
15 MG (Codeine Sulfate)
codeine sulfate tabs 30 mg,
15 mg, 60 mg
CODEINE SULFATE TABS
60 MG, 30 MG (Codeine
Sulfate)
NP
NP
NP QL(1 ea daily)
NP QL(5 ea daily)
F
QL(5 ea daily)
QL(5 ea daily)
F
CONZIP CP24
NP
DEMEROL TABS
(Meperidine HCl)
DILAUDID LIQD
(Hydromorphone HCl)
DILAUDID TABS
(Hydromorphone HCl)
NP QL(5 ea daily)
NP
NP QL(5 ea daily)
Drug Name
DOLOPHINE TABS
(Methadone HCl)
DURAGESIC PT72 12
MCG/HR (Fentanyl)
DURAGESIC PT72 75
MCG/HR, 25 MCG/HR, 50
MCG/HR, 100 MCG/HR
(Fentanyl)
EMBEDA CPCR
EXALGO T24A 12 MG, 8
MG, 16 MG
(Hydromorphone HCl)
EXALGO T24A 32 MG
(Hydromorphone HCl)
fentanyl citrate lpop
fentanyl pt72 12 mcg/hr
fentanyl pt72 25 mcg/hr,
100 mcg/hr, 75 mcg/hr, 50
mcg/hr
FENTANYL PT72 87.5
MCG/HR, 62.5 MCG/HR,
37.5 MCG/HR
Drug Requirements/
Tier Limits
KADIAN CP24 40 MG
NP PA; QL(0.5 ea
daily)
QL(0.5 ea
NP daily)
LAZANDA SOLN
NP
LEVORPHANOL
TARTRATE TABS
MEPERIDINE HCL SOLN
OR 50 MG/5ML
NP QL(5 ea daily)
NP QL(2 ea daily)
meperidine hcl tabs
NP QL(5 ea daily)
QL(1 ea daily)
methadone hcl conc
NP
NP
NP QL(2 ea daily)
NP
F
F
PA; QL(0.5 ea
daily)
QL(0.5 ea
daily)
QL(0.5 ea
NP daily)
NP
hydromorphone hcl liqd
NP
NP
NP QL(1 ea daily)
NP QL(2 ea daily)
hydromorphone hcl tabs
F
QL(5 ea daily)
HYSINGLA ER T24A
F
QL(1 ea daily)
KADIAN CP24 10 MG, 20
MG, 30 MG, 50 MG, 60
MG, 80 MG (Morphine
Sulfate)
KADIAN CP24 100 MG
(Morphine Sulfate)
KADIAN CP24 200 MG
Drug Requirements/
Tier Limits
NP
FENTORA TABS
HYDROMORPHONE HCL
SUPP
hydromorphone hcl t24a 12
mg, 8mg, 8 mg, 16 mg
hydromorphone hcl t24a 32
mg
Drug Name
F
METHADONE HCL SOLN
OR 10 MG/5ML, 5 MG/5ML
(Methadone HCl)
methadone hcl soln or 5
mg/5ml, 10 mg/5ml
QL(4 ea daily)
F
QL(4 ea daily)
NP
NP
NP
methadone hcl tabs
NP
methadone hcl tbso
QL(6 ea
NP daily,180
day(s) limit)
METHADOSE CONC
(Methadone HCl)
METHADOSE SUGARFREE CONC (Methadone
HCl)
morphine sulfate cp24 100
mg
morphine sulfate cp24 30
mg, 80 mg, 20 mg, 50 mg,
60 mg, 10 mg
MORPHINE SULFATE ER
CP24
morphine sulfate soln or 10
mg/5ml, 20 mg/5ml, 100
mg/5ml, 20 mg/ml
MORPHINE SULFATE
SUPP
MORPHINE SULFATE
TABS
morphine sulfate tbcr
F
F
NP
NP
NP QL(4 ea daily)
NP
NP QL(1 ea daily)
PA
F
NP
F
QL(5 ea daily)
F
MS CONTIN TBCR
(Morphine Sulfate)
NP
NUCYNTA ER TB12
NP
Nebraska Total Care Updated May 30, 2017
8
Drug Name
NUCYNTA TABS
Drug Requirements/
Tier Limits
NP QL(5 ea daily)
Drug Requirements/
Tier Limits
XTAMPZA ER C12A 36
NP QL(8 ea daily);
MG
AL
XTAMPZA ER C12A 9 MG, NP QL(3 ea daily);
13.5 MG, 18 MG, 27 MG
AL
Drug Name
OPANA ER (CRUSH
RESISTANT) T12A
OPANA TABS
(Oxymorphone HCl)
NP QL(3 ea daily)
NP QL(5 ea daily)
ZOHYDRO ER C12A
NP
OXAYDO TABA
NP
ZOHYDRO ER CP12 40
MG, 30 MG, 20 MG
NP
oxycodone hcl caps
NP QL(5 ea daily)
oxycodone hcl conc
NP
Opioid Combinations
acetaminophen w/ codeine
soln
acetaminophen w/ codeine
tabs
acetaminophen-caffdihydrocod caps
ASPIRIN-CAFFEINEDIHYDROCODEINE CAPS
butalbital-acetaminophencaffeine w/ codeine caps
325mg-50mg-40mg-30mg
butalbital-aspirin-caffeine
w/cod caps
OXYCODONE HCL ER
QL(3 ea daily)
NP
T12A 30 MG, 20 MG, 60
MG, 15 MG, 10 MG, 40 MG
OXYCODONE HCL ER
NP QL(4 ea daily)
T12A 80 MG
oxycodone hcl soln
F
oxycodone hcl tabs
F
OXYCONTIN T12A 15 MG,
10 MG, 60 MG, 20 MG, 40
MG, 30 MG
F
OXYCONTIN T12A 80 MG
F
QL(5 ea daily)
QL(3 ea daily)
QL(4 ea daily)
oxymorphone hcl tabs
NP QL(5 ea daily)
oxymorphone hcl tb12
NP QL(3 ea daily)
OXYMORPHONE
HYDROCHLORIDE ER
TB12
ROXICODONE TABS
(Oxycodone HCl)
QL(3 ea daily)
NP
NP QL(5 ea daily)
SUBSYS LIQD
NP
TRAMADOL HCL ER
CP24 300 MG, 100 MG,
200 MG
NP
tramadol hcl tabs
F
tramadol hcl tb24
NP
ULTRAM ER TB24
(Tramadol HCl)
ULTRAM TABS (Tramadol
HCl)
QL(8 ea daily)
NP
NP QL(8 ea daily)
Nebraska Total Care Updated May 30, 2017
9
CAPITAL/CODEINE SUSP
FIORINAL/CODEINE #3
CAPS (Butalbital-AspirinCaffeine w/Cod)
HYCET SOLN
(HydrocodoneAcetaminophen)
hydrocodoneacetaminophen soln
10mg/15ml-325mg/15ml
hydrocodoneacetaminophen soln
7.5mg/15ml-325mg/15ml,
5mg/10ml-217mg/10ml,
2.5mg/5ml-108mg/5ml
hydrocodoneacetaminophen tabs
hydrocodone-ibuprofen
tabs 200mg-2.5mg, 200mg5mg, 200mg-10mg
hydrocodone-ibuprofen
tabs 200mg-7.5mg, 200mg10mg, 200mg-5mg
F
F
QL(5 ea daily)
NP QL(5 ea daily)
NP QL(5 ea daily)
F
F
NP
NP
PA
NP
NP
PA
F
F
QL(5 ea daily)
QL(5 ea daily)
NP
QL(5 ea daily)
F
Drug Name
IBUDONE TABS
(Hydrocodone-Ibuprofen)
LORTAB ELIX
NORCO TABS
(HydrocodoneAcetaminophen)
oxycodone w/
acetaminophen tabs
Drug Requirements/
Tier Limits
NP QL(5 ea daily)
NP
QL(5 ea daily)
NP
F
QL(5 ea daily)
oxycodone-aspirin tabs
NP QL(5 ea daily)
OXYCODONE/IBUPROFE
N TABS
PERCOCET TABS
(Oxycodone w/
Acetaminophen)
NP QL(5 ea daily)
PRIMLEV TABS
NP QL(5 ea daily)
REPREXAIN TABS
(Hydrocodone-Ibuprofen)
NP QL(5 ea daily)
SYNALGOS-DC CAPS
NP QL(5 ea daily)
tramadol-acetaminophen
tabs
TREZIX CAPS
(Acetaminophen-CaffDihydrocod)
TYLENOL/CODEINE #3
TABS (Acetaminophen w/
Codeine)
TYLENOL/CODEINE #4
TABS (Acetaminophen w/
Codeine)
ULTRACET TABS
(Tramadol-Acetaminophen)
VICOPROFEN TABS
(Hydrocodone-Ibuprofen)
NP QL(5 ea daily)
XARTEMIS XR TBCR
NP QL(4 ea daily)
XODOL TABS
(HydrocodoneAcetaminophen)
ZAMICET SOLN
(HydrocodoneAcetaminophen)
QL(5 ea daily)
NP
QL(5 ea daily)
NP
QL(5 ea daily)
NP
QL(5 ea daily)
NP
NP QL(5 ea daily)
NP QL(5 ea daily)
QL(5 ea daily)
NP
NP
Opioid Partial Agonists
Drug Name
BELBUCA FILM
Drug Requirements/
Tier Limits
NP QL(2 ea daily);
AL
BUNAVAIL FILM
NP
buprenorphine hcl subl
NP
buprenorphine hclnaloxone hcl dihydrate subl NP
butorphanol tartrate soln na NP QL(0.334 ml
10 mg/ml
daily)
BUTRANS PTWK 10
Limit 4ea in 28
F days;QL(0.143
MCG/HR, 5 MCG/HR, 20
MCG/HR
ea daily)
BUTRANS PTWK 7.5
F QL(0.143 ea
MCG/HR, 15 MCG/HR
daily)
pentazocine w/ naloxone
NP QL(5 ea daily)
tabs
SUBOXONE FILM 12MGF PA; QL(2 ea
3MG
daily); AL
SUBOXONE FILM 4MGPA; AL
F
1MG, 8MG-2MG, 2MG0.5MG
ZUBSOLV SUBL 0.7MGNP
0.18MG
ZUBSOLV SUBL 11.4MGNP QL(1 ea daily);
2.9MG
AL
ZUBSOLV SUBL 2.9MGNP QL(2 ea daily);
0.71MG, 8.6MG-2.1MG
AL
ZUBSOLV SUBL 5.7MGNP AL
1.4MG, 1.4MG-0.36MG
ANDROGENS-ANABOLIC - Drugs to Regulate
Hormones
Androgens
ANDRODERM PT24
ANDROGEL GEL 20.25
MG/1.25GM, 40.5
MG/2.5GM
ANDROGEL GEL 50
MG/5GM, 25 MG/2.5GM
(Testosterone)
ANDROGEL PUMP GEL 1
% (Testosterone)
ANDROGEL PUMP GEL 1
% (Testosterone)
NP
F
F
NP
F
Nebraska Total Care Updated May 30, 2017
10
Drug Name
ANDROGEL PUMP GEL
1.62 %
Drug Requirements/
Tier Limits
F
AXIRON SOLN
NP
DEPO-TESTOSTERONE
SOLN (Testosterone
Cypionate)
NP
FORTESTA GEL
NP
NATESTO GEL
NP
TESTIM GEL
NP
TESTONE CIK KIT
F
testosterone cypionate soln
F
testosterone gel 25
mg/2.5gm, 50 mg/5gm, 1
%
TESTOSTERONE GEL 50
MG/5GM, 10 MG/ACT, 1
%, 25 MG/2.5GM
testosterone gel 50
mg/5gm, 25 mg/2.5gm
TESTOSTERONE PUMP
GEL
TESTOSTERONE SOLN
NP
NP
NP PA
NP
F
VOGELXO GEL
NP
VOGELXO PUMP GEL
NP
ANORECTAL AGENTS - Rectal Drugs to Treat
Pain, Swelling and Itching
Intrarectal Steroids
CORTENEMA ENEM
(Hydrocortisone
(Intrarectal))
hydrocortisone (intrarectal)
enem
UCERIS FOAM
NP
F
Drug Requirements/
Tier Limits
F
F
F
F
F
F
F
NP
NP
NP
NP
NP
dibucaine (rectal) oint
F
NUPERCAINAL OINT
(Dibucaine (Rectal))
NP
pramoxine hcl (rectal) foam
PROCTOFOAM FOAM
(Pramoxine HCl (Rectal))
F
Rectal Steroids
ANUSOL-HC CREA
(Hydrocortisone (Rectal))
Nebraska Total Care Updated May 30, 2017
11
phenylephrine in hard fat
supp
phenylephrine-cocoa butter
supp 88.44%-0.25%
phenylephrine-mineral oilpetrolatum oint 14%74.9%-0.25%
phenylephrine-shark liver
oil-cocoa butter supp
phenylephrine-shark liver
oil-mineral oil-petrolatum
oint
phenylephrine-witch hazel
gel
pramoxine-phenylephrineglycerin-petrolatum crea
PREPARATION H CREA
(Pramoxine-PhenylephrineGlycerin-Petrolatum)
PREPARATION H GEL
(Phenylephrine-Witch
Hazel)
PREPARATION H OINT
(Phenylephrine-Mineral OilPetrolatum)
PREPARATION H
TOTABLES BURN RELIEF
GEL (Phenylephrine-Witch
Hazel)
PREPARATION H
TOTABLES PAIN RELIEF
CREA (PramoxinePhenylephrine-GlycerinPetrolatum)
Rectal Local Anesthetics
NP
Rectal Combinations
ANALPRAM-HC LOTN
Drug Name
F
NP
F
Drug Name
hydrocortisone (rectal) crea
PROCTOCORT CREA
(Hydrocortisone (Rectal))
Drug Requirements/
Tier Limits
Antacids - Calcium Salts
calcium carbonate
(antacid) chew 500 mg
calcium carbonate
(antacid) tabs
TUMS CHEW (Calcium
Carbonate (Antacid))
TUMS LASTING EFFECTS
CHEW (Calcium Carbonate
(Antacid))
Drug Requirements/
Tier Limits
ANTI-INFECTIVE AGENTS - MISC. - Drugs to
Treat Bacterial Infections
F
NP
Anti-infective Agents - Misc.
ANTACIDS - Ulcer and Stomach Acid Drugs
Antacid Combinations
alum & mag hydroxsimethicone liqd
200mg/5ml-20mg/5ml200mg/5ml
alum & mag hydroxsimethicone liqd
400mg/5ml-40mg/5ml400mg/5ml
alum & mag hydroxsimethicone susp
200mg/5ml-200mg/5ml20mg/5ml-20mg/5ml200mg/5ml-200mg/5ml,
200mg/5ml-20mg/5ml200mg/5ml
alum & mag hydroxsimethicone susp
400mg/5ml-400mg/5ml40mg/5ml-40mg/5ml400mg/5ml-400mg/5ml,
400mg/5ml-40mg/5ml400mg/5ml
HYVEE ADVANCED
ANTACID MAXIMUM
STRENGTH SUSP (Alum
& Mag HydroxSimethicone)
Drug Name
QL(24 ml daily)
F
F
QL(24 ml daily)
F
F
CAYSTON SOLR
FLAGYL CAPS
(Metronidazole)
FLAGYL TABS
(Metronidazole)
F
F
NP
NP
NP
metronidazole tabs
F
TINDAMAX TABS
(Tinidazole)
NP
tinidazole tabs
NP
VANCOCIN HCL CAPS
(Vancomycin HCl)
NP
vancomycin hcl caps
NP
vancomycin hcl solr 1000
mg
vancomycin hcl solr 500
mg
F
QL(2 ea daily)
F
QL(4 ea daily)
NP
Anti-infective Misc. - Combinations
BACTRIM DS TABS
NP
(SulfamethoxazoleTrimethoprim)
BACTRIM TABS
NP
(SulfamethoxazoleTrimethoprim)
sulfamethoxazoleF
trimethoprim susp
sulfamethoxazoleF
trimethoprim tabs
Antiprotozoal Agents
ALINIA SUSR
NP QL(50 ml daily)
ALINIA TABS
NP QL(2 ea daily)
NP
Antacids - Magnesium Salts
magnesium oxide tabs 400
F
mg
NP
metronidazole caps
XIFAXAN TABS
NP
NP
Ketolides
KETEK TABS
NP
Nebraska Total Care Updated May 30, 2017
12
Drug Name
Drug Requirements/
Tier Limits
Leprostatics
dapsone tabs
Lincosamides
CLEOCIN CAPS 150 MG,
300 MG (Clindamycin HCl)
CLEOCIN PEDIATRIC
GRANULES SOLR
(Clindamycin Palmitate
Hydrochloride)
clindamycin hcl caps 300
mg, 150 mg
clindamycin palmitate
hydrochloride solr
buspirone hcl tabs
F
isosorbide dinitrate tabs
isosorbide mononitrate
tabs
isosorbide mononitrate
tb24
NITRO-BID OINT
NITRO-DUR PT24 0.2
MG/HR, 0.4 MG/HR, 0.1
MG/HR, 0.6 MG/HR
(Nitroglycerin)
F
NP
HYDROXYZINE
PAMOATE CAPS 100 MG
hydroxyzine pamoate caps
50 mg, 25 mg
NP
meprobamate tabs
NP
VISTARIL CAPS
(Hydroxyzine Pamoate)
NP
F
Benzodiazepines
ALPRAZOLAM INTENSOL
CONC
F
F
PA; QL(6 ea
per fill retail)
ANTIANGINAL AGENTS - Drugs to Treat Chest
Pain
Nitrates
ISORDIL TITRADOSE
TABS 5 MG (Isosorbide
Dinitrate)
ISOSORBIDE DINITRATE
ER TBCR
Drug Requirements/
Tier Limits
Antianxiety Agents - Misc.
Oxazolidinones
SIVEXTRO TABS
Drug Name
NP
F
F
NP
alprazolam tabs
F
alprazolam tb24
NP
alprazolam tbdp
NP
ATIVAN SOLN 2 MG/ML
(Lorazepam)
ATIVAN TABS
(Lorazepam)
NP
NP
F
chlordiazepoxide hcl caps
F
clorazepate dipotassium
tabs
NP
F
diazepam conc
NP
F
DIAZEPAM SOLN OR 1
MG/ML
F
F
diazepam tabs
F
lorazepam conc
F
lorazepam soln 2 mg/ml, 20
mg/10ml
F
NP
F
nitroglycerin pt24
F
lorazepam tabs
F
nitroglycerin subl
F
oxazepam caps
NP
TRANXENE T TABS
(Clorazepate Dipotassium)
NP
VALIUM TABS (Diazepam)
NP
NITROSTAT SUBL
(Nitroglycerin)
NP
ANTIANXIETY AGENTS - Drugs to Treat Anxiety
Nebraska Total Care Updated May 30, 2017
13
Drug Name
Drug Requirements/
Tier Limits
XANAX TABS (Alprazolam)
NP
XANAX XR TB24
(Alprazolam)
NP
ANTIARRHYTHMICS - Drugs to treat abnormal
heart rhythms
Antiarrhythmics Type I-A
disopyramide phosphate
caps
NORPACE CAPS
(Disopyramide Phosphate)
NORPACE CR CP12 150
MG
quinidine gluconate tbcr
QUINIDINE SULFATE ER
TBCR
QUINIDINE SULFATE
TABS 200 MG, 300 MG
quinidine sulfate tabs 300
mg
F
NP
F
F
F
F
Drug Name
Drug Requirements/
Tier Limits
Bronchodilators - Anticholinergics
ATROVENT HFA AERS
INCRUSE ELLIPTA AEPB
ipratropium bromide soln
SEEBRI NEOHALER
CAPS
SPIRIVA HANDIHALER
CAPS
SPIRIVA RESPIMAT
AERS
TUDORZA PRESSAIR
AEPB
Leukotriene Modulators
ACCOLATE TABS
(Zafirlukast)
montelukast sodium chew
F
montelukast sodium pack
Antiarrhythmics Type I-B
F
NP
F
NP
F
NP
NP
NP
QL(1 ea daily);
AL
NP QL(1 ea daily);
AL
F QL(1 ea daily)
F
F
montelukast sodium tabs
flecainide acetate tabs
F
propafenone hcl tabs
F
SINGULAIR CHEW
(Montelukast Sodium)
SINGULAIR PACK
(Montelukast Sodium)
SINGULAIR TABS
(Montelukast Sodium)
NP QL(1 ea daily);
AL
NP QL(1 ea daily);
AL
NP QL(1 ea daily)
zafirlukast tabs
NP
zileuton tb12
NP
ZYFLO CR TB12 (Zileuton)
NP
ZYFLO TABS
NP
mexiletine hcl caps
Antiarrhythmics Type I-C
RYTHMOL TABS
(Propafenone HCl)
Antiarrhythmics Type III
amiodarone hcl tabs 200
mg
CORDARONE TABS
(Amiodarone HCl)
dofetilide caps
TIKOSYN CAPS
(Dofetilide)
NP
F
NP
F
NP
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS - Drugs to Treat Lung Conditions
Anti-Inflammatory Agents
CROMOLYN SODIUM
NEBU
F
Selective Phosphodiesterase 4 (PDE4) Inhibitors
DALIRESP TABS
NP
Steroid Inhalants
AEROSPAN AERS
NP
ALVESCO AERS
NP AL
Nebraska Total Care Updated May 30, 2017
14
Drug Name
Drug Requirements/
Tier Limits
ARNUITY ELLIPTA AEPB
NP
ASMANEX HFA AERO
NP QL(3 gm per fill
retail); AL
QL(3 ea per fill
F retail); AL
ASMANEX TWISTHALER
120 METERED DOSES
AEPB
ASMANEX TWISTHALER
14 METERED DOSES
AEPB
ASMANEX TWISTHALER
30 METERED DOSES
AEPB
ASMANEX TWISTHALER
60 METERED DOSES
AEPB
ASMANEX TWISTHALER
7 METERED DOSES
AEPB
budesonide (inhalation)
susp
F
QL(3 ea per fill
retail); AL
F
QL(3 ea per fill
retail); AL
F
QL(3 ea per fill
retail); AL
F
QL(3 ea per fill
retail); AL
F
FLOVENT DISKUS AEPB
NP
FLOVENT HFA AERO
NP
PULMICORT FLEXHALER
AEPB
PULMICORT SUSP
(Budesonide (Inhalation))
QVAR AERS
AL
ADVAIR HFA AERO
albuterol sulfate nebu
0.083 %, 0.5 %
albuterol sulfate nebu 1.25
mg/3ml, 0.63 mg/3ml
ARCAPTA NEOHALER
CAPS
BEVESPI AEROSPHERE
AERO
NP AL
F
QL(2 ea daily)
NP
F
NP
NP
NP
BROVANA NEBU
NP
COMBIVENT RESPIMAT
AERS
F
DULERA AERO
F
FORADIL AEROLIZER
CAPS
F
ipratropium-albuterol soln
F
levalbuterol hcl nebu
LEVALBUTEROL
TARTRATE HFA AERO
METAPROTERENOL
SULFATE SYRP
METAPROTERENOL
SULFATE TABS
PROAIR HFA AERS
PROAIR RESPICLICK
AEPB
PROVENTIL HFA AERS
F
Drug Requirements/
Tier Limits
F ST
BREO ELLIPTA AEPB
PERFOROMIST NEBU
NP
Sympathomimetics
ADVAIR DISKUS AEPB
Drug Name
SEREVENT DISKUS
AEPB
STIOLTO RESPIMAT
AERS
STRIVERDI RESPIMAT
AERS
NP
NP
NP
NP
NP
F
NP
F
F
NP
NP
SYMBICORT AERO
F
albuterol sulfate syrp
F
terbutaline sulfate tabs
F
albuterol sulfate tabs
NP
UTIBRON NEOHALER
CAPS
NP
albuterol sulfate tb12
F
VENTOLIN HFA AERS
NP
VOSPIRE ER TB12
(Albuterol Sulfate)
NP
ANORO ELLIPTA AEPB
NP
Nebraska Total Care Updated May 30, 2017
15
ST
Drug Name
Drug Requirements/
Tier Limits
XOPENEX
CONCENTRATE NEBU
(Levalbuterol HCl)
NP
XOPENEX HFA AERO
NP
XOPENEX NEBU
(Levalbuterol HCl)
NP
enoxaparin sodium soln sc
30 mg/0.3ml
enoxaparin sodium soln sc
60 mg/0.6ml
enoxaparin sodium soln sc
80 mg/0.8ml
Xanthines
ELIXOPHYLLIN ELIX
F
THEO-24 CP24
F
theophylline soln
F
theophylline tb12
F
theophylline tb24
F
ANTICOAGULANTS - Blood Thinners
Coumarin Anticoagulants
COUMADIN TABS
(Warfarin Sodium)
warfarin sodium tabs
NP
F
Direct Factor Xa Inhibitors
ELIQUIS TABS
SAVAYSA TABS
XARELTO STARTER
PACK TBPK
F
NP QL(1 ea daily)
F
XARELTO TABS 10 MG
F
XARELTO TABS 15 MG
F
QL(35 ea per
fill retail)
QL(2 ea daily)
F
QL(1 ea daily)
XARELTO TABS 20 MG
Drug Name
Drug Requirements/
Tier Limits
F QL(18 ml per
fill retail)
F QL(36 ml per
fill retail)
F QL(48 ml per
fill retail)
fondaparinux sodium soln
NP
FRAGMIN SOLN
NP
heparin sodium (porcine)
soln
LOVENOX SOLN IJ 300
MG/3ML (Enoxaparin
Sodium)
LOVENOX SOLN SC 100
MG/ML, 150 MG/ML
(Enoxaparin Sodium)
LOVENOX SOLN SC 120
MG/0.8ML, 40 MG/0.4ML
(Enoxaparin Sodium)
LOVENOX SOLN SC 30
MG/0.3ML (Enoxaparin
Sodium)
LOVENOX SOLN SC 60
MG/0.6ML (Enoxaparin
Sodium)
LOVENOX SOLN SC 80
MG/0.8ML (Enoxaparin
Sodium)
Thrombin Inhibitors
PRADAXA CAPS
F
QL(15 ml per
NP fill retail)
QL(30 ml per
NP fill retail)
QL(24 ml per
NP fill retail)
QL(18 ml per
NP fill retail)
QL(36 ml per
NP fill retail)
QL(48 ml per
NP fill retail)
F
ANTICONVULSANTS - Drugs to Treat Seizures
AMPA Glutamate Receptor Antagonists
Heparins And Heparinoid-Like Agents
ARIXTRA SOLN
NP
(Fondaparinux Sodium)
enoxaparin sodium soln ij
F QL(15 ml per
300 mg/3ml
fill retail)
enoxaparin sodium soln sc
F QL(30 ml per
100 mg/ml, 150 mg/ml
fill retail)
enoxaparin sodium soln sc
QL(24 ml per
120 mg/0.8ml, 40 mg/0.4ml F fill retail)
FYCOMPA SUSP
F
FYCOMPA TABS
F
Anticonvulsants - Benzodiazepines
clonazepam tabs
F
clonazepam tbdp
F
DIASTAT ACUDIAL GEL
F
AL
Nebraska Total Care Updated May 30, 2017
16
Drug Requirements/
Tier Limits
F AL
DIASTAT PEDIATRIC GEL
Drug Name
Drug Name
Drug Requirements/
Tier Limits
BRIVIACT TABS
F
carbamazepine chew
F
PA; AL
carbamazepine cp12
F
AL
CARBAMAZEPINE POWD
F
PA; AL
KEPPRA SOLN OR 100
MG/ML (Levetiracetam)
KEPPRA TABS
(Levetiracetam)
KEPPRA XR TB24
(Levetiracetam)
LAMICTAL CHEWABLE
DISPERSIBLE CHEW 25
MG (Lamotrigine)
LAMICTAL CHEWABLE
DISPERSIBLE CHEW 5
MG (Lamotrigine)
LAMICTAL ODT KIT
(Lamotrigine)
LAMICTAL ODT TBDP
(Lamotrigine)
LAMICTAL STARTER/NOT
TAKING
CARBAMAZEPINE KIT
LAMICTAL
STARTER/TAKING
CARBAMAZEPINE/NOT
TAKING VALPROATE KIT
LAMICTAL
STARTER/TAKING
VALPROATE KIT
LAMICTAL TABS
(Lamotrigine)
carbamazepine susp
F
PA; AL
LAMICTAL XR KIT
carbamazepine tabs
F
PA; AL
LAMICTAL XR TB24
(Lamotrigine)
carbamazepine tb12
F
PA; AL
lamotrigine chew 25 mg
F
lamotrigine chew 5 mg
F
lamotrigine kit
F
DIAZEPAM GEL
KLONOPIN TABS
(Clonazepam)
F
AL
NP
ONFI SUSP
F
ONFI TABS
F
Anticonvulsants - Misc.
APTIOM TABS
F
BANZEL SUSP
F
BANZEL TABS
F
BRIVIACT SOLN IV 50
MG/5ML
BRIVIACT SOLN OR 10
MG/ML
CARBATROL CP12
(Carbamazepine)
FANATREX FUSEPAQ
SUSP
F
AL
PA; QL(3 ea
daily)
PA
F
NP AL
F
PA
NP
NP
NP
PA; QL(4 ea
NP daily)
PA; QL(4 ea
NP daily); AL
NP
NP
F
F
F
NP PA; QL(4 ea
daily)
F PA
NP PA
gabapentin caps
F
lamotrigine tabs
F
gabapentin soln
F
lamotrigine tb24
F
gabapentin tabs
F
lamotrigine tbdp
F
KEPPRA SOLN IV 500
MG/5ML (Levetiracetam)
NP PA
Nebraska Total Care Updated May 30, 2017
17
PA; QL(4 ea
daily)
PA; QL(4 ea
daily); AL
PA; QL(4 ea
daily)
PA
Drug Name
levetiracetam in sodium
chloride soln
1000mg/100ml750mg/100ml
levetiracetam in sodium
chloride soln
1500mg/100ml540mg/100ml,
500mg/100ml820mg/100ml
LEVETIRACETAM SOLN
IV 1000MG/100ML750MG/100ML
(Levetiracetam in Sodium
Chloride)
levetiracetam soln iv 500
mg/5ml
LEVETIRACETAM SOLN
IV 500MG/100ML820MG/100ML,
1500MG/100ML540MG/100ML
(Levetiracetam in Sodium
Chloride)
levetiracetam soln or 100
mg/ml, 500 mg/5ml
levetiracetam tabs
levetiracetam tb24
LYRICA CAPS 225 MG,
300 MG
LYRICA CAPS 25 MG, 150
MG, 50 MG, 200 MG, 75
MG, 100 MG
LYRICA SOLN
MYSOLINE TABS
(Primidone)
NEURONTIN CAPS
(Gabapentin)
NEURONTIN SOLN
(Gabapentin)
NEURONTIN TABS
(Gabapentin)
oxcarbazepine susp
Drug Requirements/
Tier Limits
oxcarbazepine tabs 150
mg, 300 mg
F
PA
F
NP
F
Drug Name
PA
PA
NP
F
F
Drug Requirements/
Tier Limits
F PA; AL
oxcarbazepine tabs 600 mg
F
AL
OXTELLAR XR TB24
F
PA
POTIGA TABS 200 MG,
400 MG, 300 MG
F
POTIGA TABS 50 MG
F
primidone tabs
F
QUDEXY XR CS24
F
SPRITAM TB3D
F
TEGRETOL SUSP
(Carbamazepine)
TEGRETOL TABS
(Carbamazepine)
TEGRETOL-XR TB12
(Carbamazepine)
TOPAMAX SPRINKLE
CPSP (Topiramate)
TOPAMAX TABS
(Topiramate)
QL(3 ea daily);
AL
QL(9 ea daily);
AL
NP PA; AL
NP PA; AL
NP PA; AL
NP AL
NP
topiramate cpsp
F
TOPIRAMATE ER CS24
F
topiramate tabs
F
AL
F
F
QL(2 ea daily)
QL(3 ea daily)
F
F
QL(30 ml daily)
NP
NP
NP
NP
F
PA
TRILEPTAL SUSP
(Oxcarbazepine)
TRILEPTAL TABS 150
MG, 300 MG
(Oxcarbazepine)
TRILEPTAL TABS 600 MG
(Oxcarbazepine)
NP PA
PA; AL
NP
NP AL
TROKENDI XR CP24
F
VIMPAT SOLN
F
PA
VIMPAT TABS
F
PA
ZONEGRAN CAPS
(Zonisamide)
NP
Nebraska Total Care Updated May 30, 2017
18
Drug Name
zonisamide caps
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
phenytoin susp
F
Carbamates
F
Succinimides
felbamate susp
F
CELONTIN CAPS
F
felbamate tabs
F
ethosuximide caps
F
NP
ethosuximide soln
F
FELBATOL SUSP
(Felbamate)
FELBATOL TABS
(Felbamate)
GABA Modulators
GABITRIL TABS 16 MG,
12 MG
GABITRIL TABS 2 MG, 4
MG (Tiagabine HCl)
F
NP
SABRIL PACK
F
SABRIL TABS
F
tiagabine hcl tabs
F
Hydantoins
CEREBYX SOLN
(Fosphenytoin Sodium)
DILANTIN CAPS 100 MG
(Phenytoin Sodium
Extended)
DILANTIN CAPS 30 MG
DILANTIN INFATABS
CHEW (Phenytoin)
DILANTIN-125 SUSP
(Phenytoin)
ZARONTIN CAPS
(Ethosuximide)
ZARONTIN SOLN
(Ethosuximide)
NP
QL(6 ea daily)
NP PA
NP
NP PA
NP
NP PA; AL
NP PA; AL
NP PA; AL
divalproex sodium csdr
F
PA; AL
NP
divalproex sodium tb24
F
PA; AL
F
divalproex sodium tbec
F
PA; AL
NP
valproate sodium soln
F
PA
NP
valproic acid caps
F
fosphenytoin sodium soln
F
PEGANONE TABS
F
PHENYTEK CAPS
(Phenytoin Sodium
Extended)
NP
phenytoin chew
F
phenytoin sodium extended
caps
F
phenytoin sodium soln
F
PA
ANTIDEPRESSANTS - Drugs to Treat Depression
Alpha-2 Receptor Antagonists (Tetracyclics)
F AL
mirtazapine tabs
mirtazapine tbdp
REMERON SOLTAB TBDP
(Mirtazapine)
REMERON TABS
(Mirtazapine)
PA
Nebraska Total Care Updated May 30, 2017
19
Valproic Acid
DEPACON SOLN
(Valproate Sodium)
DEPAKENE CAPS
(Valproic Acid)
DEPAKOTE ER TB24
(Divalproex Sodium)
DEPAKOTE SPRINKLES
CSDR (Divalproex Sodium)
DEPAKOTE TBEC
(Divalproex Sodium)
NP
F
AL
NP AL
NP AL
Antidepressant Combinations
Drug Name
PRAMLYTE THPK
Drug Requirements/
Tier Limits
FLUOXETINE DR CPDR
F
Antidepressants - Misc.
APLENZIN TB24
F
bupropion hcl tabs
F
QL(1 ea daily);
AL
AL
bupropion hcl tb12
F
AL
bupropion hcl tb24
F
FORFIVO XL TB24
F
MAPROTILINE HCL TABS
F
WELLBUTRIN SR TB12
(Bupropion HCl)
WELLBUTRIN TABS
(Bupropion HCl)
WELLBUTRIN XL TB24
(Bupropion HCl)
QL(1 ea daily);
AL
QL(1 ea daily);
AL
AL
NP AL
NP AL
NP QL(1 ea daily);
AL
Monoamine Oxidase Inhibitors (MAOIs)
F QL(1 ea daily);
EMSAM PT24
AL
F AL
MARPLAN TABS
NARDIL TABS (Phenelzine
Sulfate)
PARNATE TABS
(Tranylcypromine Sulfate)
phenelzine sulfate tabs
NP AL
NP AL
F
AL
tranylcypromine sulfate
F AL
tabs
Selective Serotonin Reuptake Inhibitors (SSRIs)
CELEXA TABS (Citalopram NP AL
Hydrobromide)
citalopram hydrobromide
F
soln
citalopram hydrobromide
F AL
tabs
F AL
escitalopram oxalate soln
escitalopram oxalate tabs
F
Drug Name
AL
Drug Requirements/
Tier Limits
F AL
fluoxetine hcl caps
F
fluoxetine hcl soln
F
fluoxetine hcl tabs 10 mg,
20 mg
FLUOXETINE HCL TABS
60 MG
F
AL
F
AL
fluvoxamine maleate cp24
F
fluvoxamine maleate tabs
F
LEXAPRO SOLN
(Escitalopram Oxalate)
LEXAPRO TABS
(Escitalopram Oxalate)
paroxetine hcl tabs
paroxetine hcl tb24 12.5
mg
paroxetine hcl tb24 37.5
mg, 25 mg
PAXIL CR TB24 12.5 MG
(Paroxetine HCl)
PAXIL CR TB24 25 MG,
37.5 MG (Paroxetine HCl)
PAXIL SUSP
PAXIL TABS (Paroxetine
HCl)
PEXEVA TABS
PROZAC CAPS
(Fluoxetine HCl)
PROZAC WEEKLY CPDR
(Fluoxetine HCl)
AL
NP AL
NP AL
F
AL
F
AL
F
NP AL
NP
F
NP AL
F
PA; AL
NP AL
NP AL
sertraline hcl conc
F
sertraline hcl tabs
F
ZOLOFT CONC (Sertraline
HCl)
ZOLOFT TABS (Sertraline
HCl)
AL
AL
NP
NP AL
Serotonin Modulators
Nebraska Total Care Updated May 30, 2017
20
Drug Requirements/
Tier Limits
F PA; QL(1 ea
BRINTELLIX TABS
daily); AL
NEFAZODONE HCL TABS
F AL
150 MG, 100 MG, 200 MG
nefazodone hcl tabs 250
F AL
mg, 50 mg
F QL(1 ea daily);
OLEPTRO TB24
AL
F QL(1 ea daily);
trazodone hcl tabs 150 mg
AL
F QL(2 ea daily);
trazodone hcl tabs 300 mg
AL
trazodone hcl tabs 50 mg,
F AL
100 mg
F PA; QL(1 ea
TRINTELLIX TABS
daily); AL
F PA; QL(1 ea
VIIBRYD KIT
daily); AL
VIIBRYD STARTER PACK
F PA; QL(1 ea
KIT
daily); AL
F PA; QL(1 ea
VIIBRYD TABS
daily); AL
Drug Name
Serotonin-Norepinephrine Reuptake Inhibitors
CYMBALTA CPEP
NP AL
(Duloxetine HCl)
DESVENLAFAXINE ER
F QL(1 ea daily);
TB24 50 MG, 100 MG
AL
desvenlafaxine succinate
F ST
tb24
duloxetine hcl cpep 30 mg,
F AL
60 mg, 20 mg
DULOXETINE HCL CPEP
F AL
40 MG
EFFEXOR XR CP24
NP AL
(Venlafaxine HCl)
F PA; AL
FETZIMA CP24
FETZIMA TITRATION
PACK C4PK
F
PA; AL
IRENKA CPEP
F
AL
KHEDEZLA TB24
PRISTIQ TB24
(Desvenlafaxine Succinate)
QL(1 ea daily);
AL
NP ST
F
Nebraska Total Care Updated May 30, 2017
21
Drug Name
venlafaxine hcl cp24
VENLAFAXINE HCL ER
TB24 150 MG, 75 MG, 37.5
MG (Venlafaxine HCl)
VENLAFAXINE HCL ER
TB24 225 MG
Drug Requirements/
Tier Limits
F AL
AL
NP
F
AL
venlafaxine hcl tabs
F
AL
venlafaxine hcl tb24
F
AL
amitriptyline hcl tabs
F
AL
AMOXAPINE TABS
F
AL
Tricyclic Agents
ANAFRANIL CAPS
(Clomipramine HCl)
NP AL
clomipramine hcl caps
F
AL
desipramine hcl tabs
F
AL
doxepin hcl caps 10 mg,
150 mg, 50 mg, 100 mg, 25
mg
DOXEPIN HCL CAPS 75
MG
doxepin hcl conc
ELAVIL TABS
(Amitriptyline HCl)
AL
F
F
AL
F
NP AL
imipramine hcl tabs
F
AL
imipramine pamoate caps
F
AL
NORPRAMIN TABS
(Desipramine HCl)
nortriptyline hcl caps
NORTRIPTYLINE HCL
SOLN
PAMELOR CAPS
(Nortriptyline HCl)
protriptyline hcl tabs
SURMONTIL CAPS
(Trimipramine Maleate)
NP AL
F
AL
F
NP AL
F
AL
NP AL
Drug Name
TOFRANIL TABS
(Imipramine HCl)
TOFRANIL-PM CAPS
(Imipramine Pamoate)
Drug Requirements/
Tier Limits
NP AL
trimipramine maleate caps
NP AL
F
AL
Drug Name
JANUMET TABS
JANUMET XR TB24
JENTADUETO TABS
Drug Requirements/
Tier Limits
F QL(2 ea daily);
AL
F QL(1 ea daily);
AL
F QL(2 ea daily);
AL
ANTIDIABETICS - Drugs to Regulate Blood Sugar
JENTADUETO XR TB24
NP
Alpha-Glucosidase Inhibitors
KAZANO TABS
NP QL(2 ea daily);
AL
NP QL(1 ea daily);
AL
NP QL(1 ea daily);
AL
acarbose tabs
F
GLYSET TABS (Miglitol)
F
KOMBIGLYZE XR TB24
miglitol tabs
NP
PRECOSE TABS
(Acarbose)
NP
Antidiabetic - Amylin Analogs
SYMLINPEN 120 SOPN
NP
SYMLINPEN 60 SOPN
NP
Antidiabetic Combinations
ACTOPLUS MET TABS
(Pioglitazone HClMetformin HCl)
OSENI TABS
pioglitazone hcl-glimepiride
tabs
pioglitazone hcl-metformin
hcl tabs
PRANDIMET TABS
(Repaglinide-Metformin
HCl)
REPAGLINIDE/METFORM
IN HYDROCHLORIDE
TABS
NP
NP
NP
NP
NP
SOLIQUA 100/33 SOPN
NP
ACTOPLUS MET XR TB24
NP
SYNJARDY TABS
ALOGLIPTIN/METFORMIN
HCL TABS
ALOGLIPTIN/PIOGLITAZO
NE TABS
DUETACT TABS
(Pioglitazone HClGlimepiride)
NP QL(2 ea daily);
AL
NP QL(1 ea daily);
AL
XIGDUO XR TB24 10MG500MG, 5MG-500MG,
10MG-1000MG
XIGDUO XR TB24 5MG1000MG
NP QL(2 ea daily);
AL
QL(1 ea daily)
NP
NP
XULTOPHY 100/3.6 SOPN
INVOKAMET TABS
NP QL(1 ea daily);
AL
F PA
Biguanides
FORTAMET TB24
(Metformin HCl)
GLUCOPHAGE TABS
(Metformin HCl)
GLUCOPHAGE XR TB24
(Metformin HCl)
GLUMETZA TB24
(Metformin HCl)
INVOKAMET XR TB24
NP
metformin hcl tabs
glipizide-metformin hcl tabs
GLUCOVANCE TABS
(Glyburide-Metformin)
glyburide-metformin tabs
GLYXAMBI TABS
F
NP
F
NP QL(2 ea daily)
F
NP
NP
NP
NP
F
Nebraska Total Care Updated May 30, 2017
22
Drug Name
metformin hcl tb24 1000
mg, 500 mg
metformin hcl tb24 750 mg,
500 mg
RIOMET SOLN
Diabetic Other
CVS GLUCOSE CHEW 4
GM
CVS GLUCOSE CHEW
4GM-6MG
Drug Requirements/
Tier Limits
F
NP
F
DEX4 FAST ACTING
GLUCOSE CHEW
F
DEX4 NATURALS CHEW
F
dextrose (diabetic use) gel
GLUCAGEN HYPOKIT
SOLR
GLUCAGON
EMERGENCY KIT KIT
GLUCOSE CHEW 4 GM
GLUCOSE CHEW 4GM4GM-6MG, 4GM-6MG
GLUCOSE INSTANT
ENERGY CHEW
GNP GLUCOSE CHEW 4
GM
GNP GLUCOSE CHEW
4GM-6MG
GNP QUICK DISSOLVE
GLUCOSE CHEW
GOODSENSE GLUCOSE
CHEW
QL(1.67 ea
daily)
F
DEX4 CHEW
DEX4 POUCH PACK
CHEW
DEX4 QUICK DISSOLVE
GLUCOSE CHEW
KROGER GLUCOSE
CHEW
LEADER GLUCOSE
CHEW
LEADER QUICK
DISSOLVE GLUCOSE
CHEW
NP
F
F
F
QL(1.67 ea
daily)
F
F
F
F
QL(1.67 ea
daily)
F
F
F
QL(1.67 ea
daily)
F
F
QL(1.67 ea
daily)
F
HM GLUCOSE CHEW
F
HY-VEE GLUCOSE CHEW
F
INSTA-GLUCOSE GEL
F
Nebraska Total Care Updated May 30, 2017
23
Drug Name
Drug Requirements/
Tier Limits
F
F
F
LONGS GLUCOSE CHEW
F
MEIJER GLUCOSE CHEW
F
PREFERRED PLUS
GLUCOSE CHEW
F
PX GLUCOSE CHEW
F
RA GLUCOSE CHEW
F
RELION GLUCOSE CHEW
F
SM GLUCOSE CHEW 4
GM
SM GLUCOSE CHEW
4GM-6MG
SMART SENSE
GLUCOSE CHEW
SMART SENSE
GLUCOSE TABLETS
CHEW
TGT GLUCOSE CHEW
UP & UP GLUCOSE
CHEW
VALUE PLUS GLUCOSE
CHEW
WALGREENS GLUCOSE
CHEW 4 GM
WALGREENS GLUCOSE
CHEW 4GM-6MG
F
QL(1.67 ea
daily)
QL(1.67 ea
daily)
F
F
F
F
F
F
F
QL(1.67 ea
daily)
F
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
NP QL(1 ea daily);
ALOGLIPTIN TABS
AL
F QL(1 ea daily);
JANUVIA TABS
AL
NP QL(1 ea daily);
NESINA TABS
AL
NP QL(1 ea daily);
ONGLYZA TABS
AL
Drug Name
TRADJENTA TABS
Drug Requirements/
Tier Limits
F QL(1 ea daily);
AL
Incretin Mimetic Agents (GLP-1 Receptor
ADLYXIN SOPN
NP
ADLYXIN STARTER PACK
PNKT
NP
BYDUREON PEN PEN
F
BYDUREON SRER
F
BYETTA SOPN
F
TANZEUM PEN
NP
TRULICITY SOPN
NP
VICTOZA SOPN
NP
Insulin Sensitizing Agents
ACTOS TABS
(Pioglitazone HCl)
AVANDIA TABS
pioglitazone hcl tabs
PA; QL(4 ea
per 28 days
retail); AL
PA; QL(4 ea
per 28 days
retail); AL
PA; AL
APIDRA SOLN
APIDRA SOLOSTAR
SOPN
BASAGLAR KWIKPEN
SOPN
HUMALOG KWIKPEN
SOPN 100 UNIT/ML
HUMALOG KWIKPEN
SOPN 200 UNIT/ML
HUMALOG MIX 50/50
KWIKPEN SUPN
HUMALOG MIX 50/50
SUSP
HUMALOG MIX 75/25
KWIKPEN SUPN
HUMALOG MIX 75/25
SUSP
NP
NP
F
HUMULIN 70/30 KWIKPEN
SUPN
F
HUMULIN N KWIKPEN
SUPN
NP
HUMULIN N SUSP
F
HUMULIN R SOLN
F
ST
LEVEMIR SOLN
F
ST
NOVOLIN 70/30 RELION
SUSP
NP
NOVOLIN 70/30 SUSP
F
NOVOLIN N RELION
SUSP
F
NOVOLIN N SUSP
F
NP
HUMULIN 70/30 SUSP
F
NP
F
HUMALOG SOLN
LANTUS SOLOSTAR
SOPN
LEVEMIR FLEXTOUCH
SOPN
NP
F
F
LANTUS SOLN
F
Drug Requirements/
Tier Limits
HUMALOG SOCT
HUMULIN R U-500
(CONCENTRATED) SOLN
HUMULIN R U-500
KWIKPEN SOPN
Insulin
AFREZZA POWD
Drug Name
Limit 40ml per
month;QL(1.33
4 ml daily)
Limit 40ml per
month;QL(1.33
4 ml daily)
Limit 40ml per
month;QL(1.33
4 ml daily)
F
NP
F
F
F
F
Limit 40ml per
NP month;QL(1.33
4 ml daily)
Limit 40ml per
NP month;QL(1.33
4 ml daily)
Limit 40ml per
NP month;QL(1.33
4 ml daily)
Limit 40ml per
NP month;QL(1.33
4 ml daily)
Nebraska Total Care Updated May 30, 2017
24
Drug Name
NOVOLIN R RELION
SOLN
NOVOLIN R SOLN
NOVOLOG FLEXPEN
SOPN
NOVOLOG MIX 70/30
PREFILLED FLEXPEN
SUPN
NOVOLOG MIX 70/30
SUSP
NOVOLOG PENFILL
SOCT
NOVOLOG SOLN
TOUJEO SOLOSTAR
SOPN
TRESIBA FLEXTOUCH
SOPN
Drug Requirements/
Tier Limits
Limit 40ml per
NP month;QL(1.33
4 ml daily)
Limit 40ml per
NP month;QL(1.33
4 ml daily)
F
F
F
F
F
NP
NP
Meglitinide Analogues
nateglinide tabs
NP
PRANDIN TABS
(Repaglinide)
NP
repaglinide tabs
F
STARLIX TABS
(Nateglinide)
NP
Sodium-Glucose Co-Transporter 2 (SGLT2)
FARXIGA TABS
NP
INVOKANA TABS
PA; QL(1 ea
daily); AL
NP QL(1 ea daily)
JARDIANCE TABS
Sulfonylureas
AMARYL TABS
(Glimepiride)
CHLORPROPAMIDE
TABS
F
NP
NP
DIABETA TABS
F
glimepiride tabs
F
Nebraska Total Care Updated May 30, 2017
25
Drug Name
Drug Requirements/
Tier Limits
glipizide tabs
F
glipizide tb24
F
GLUCOTROL TABS
(Glipizide)
GLUCOTROL XL TB24
(Glipizide)
NP
NP
glyburide micronized tabs
F
glyburide tabs
F
GLYNASE TABS
(Glyburide Micronized)
NP
tolazamide tabs 250 mg
NP
TOLAZAMIDE TABS 250
MG, 500 MG
NP
TOLBUTAMIDE TABS
NP
ANTIDIARRHEALS - Drugs to Treat Diarrhea
Antidiarrheal Agents - Misc.
CULTURELLE IMMUNITY
SUPPORT FORMULA
NF
CAPS (Lactobacillus
Rhamnosus (GG))
Antidiarrheal Combinations
lactobacillus acidophiluspectin caps
Antiperistaltic Agents
diphenoxylate w/ atropine
tabs
DIPHENOXYLATE/ATROP
INE LIQD
IMODIUM A-D CAPS
(Loperamide HCl)
IMODIUM A-D TABS
(Loperamide HCl)
LOMOTIL TABS
(Diphenoxylate w/ Atropine)
loperamide hcl caps
loperamide hcl caps
loperamide hcl tabs
F
F
F
NP RX/OTC
NP
NP
F
RX/OTC
NP RX/OTC
F
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
ANTIDOTES AND SPECIFIC ANTAGONISTS
dimenhydrinate tabs
F
Antidotes - Chelating Agents
DRAMAMINE TABS
(Dimenhydrinate)
NP
CHEMET CAPS
JADENU TABS
F
F
PA
Opioid Antagonists
EVZIO SOAJ
F
naloxone hcl soln
F
NALOXONE HCL SOSY
F
naltrexone hcl tabs
F
NARCAN LIQD
F
REVIA TABS (Naltrexone
HCl)
F
granisetron hcl tabs
NP
AL
AL
ondansetron hcl soln
F
QL(16 ml daily)
ondansetron hcl tabs 8 mg,
4 mg
F
QL(2 ea daily)
ondansetron tbdp
F
SANCUSO PTCH
ZOFRAN ODT TBDP
(Ondansetron)
ZOFRAN SOLN
(Ondansetron HCl)
ZOFRAN TABS
(Ondansetron HCl)
ZUPLENZ FILM
F
RX/OTC
NP
F
trimethobenzamide hcl
NP
caps
Antiemetics - Miscellaneous
5-HT3 Receptor Antagonists
NP
meclizine hcl tabs
TRANSDERM-SCOP PT72
ANTIEMETICS - Drugs to Treat Nausea and
Vomiting
ANZEMET TABS
F
TIGAN CAPS
(Trimethobenzamide HCl)
NP
NALOXONE HCL SOCT
meclizine hcl chew
AKYNZEO CAPS
NP
CESAMET CAPS
NP
DICLEGIS TBEC
F
dronabinol caps
F
EMETROL SOLN
(Fructose-DextrosePhosphoric Acid)
fructose-dextrosephosphoric acid liqd
fructose-dextrosephosphoric acid soln
MARINOL CAPS
(Dronabinol)
PA; QL(2 ea
daily)
AL
NP
F
F
NP AL
Substance P/Neurokinin 1 (NK1) Receptor
aprepitant caps
NP
NP
EMEND CAPS (Aprepitant)
NP
NP
EMEND SUSR
NP
NP QL(16 ml daily)
VARUBI TABS
NP
NP QL(2 ea daily)
ANTIFUNGALS - Drugs to Treat Fungal Infections
NP
Antiemetics - Anticholinergic
Antifungals
ANCOBON CAPS
(Flucytosine)
NP
Nebraska Total Care Updated May 30, 2017
26
Drug Name
flucytosine caps
GRIFULVIN V TABS
(Griseofulvin Microsize)
GRIS-PEG TABS
(Griseofulvin
Ultramicrosize)
Drug Requirements/
Tier Limits
NP
NP
NP
griseofulvin microsize susp
F
griseofulvin microsize tabs
NP
griseofulvin ultramicrosize
tabs
F
LAMISIL PACK
NP
LAMISIL TABS
(Terbinafine HCl)
NP
nystatin tabs
F
terbinafine hcl tabs
F
Imidazole-Related Antifungals
CRESEMBA CAPS
DIFLUCAN SUSR
(Fluconazole)
DIFLUCAN TABS
(Fluconazole)
NP
NP
NP
fluconazole susr
F
fluconazole tabs
F
itraconazole caps
NP
ketoconazole tabs
NP
NOXAFIL SUSP
NP
NOXAFIL TBEC
NP AL
ONMEL TABS
NP
SPORANOX CAPS
(Itraconazole)
SPORANOX PULSEPAK
CAPS (Itraconazole)
SPORANOX SOLN
NP
NP
NP
Nebraska Total Care Updated May 30, 2017
27
Drug Name
Drug Requirements/
Tier Limits
VFEND SUSR
(Voriconazole)
VFEND TABS
(Voriconazole)
NP
NP
voriconazole susr
NP
voriconazole tabs
NP
ANTIHISTAMINES - Drugs to Treat Allergies
Antihistamines - Alkylamines
CHLOR-TRIMETON
ALLERGY TBCR
(Chlorpheniramine
Maleate)
CHLOR-TRIMETON SYRP
(Chlorpheniramine
Maleate)
CHLOR-TRIMETON TABS
(Chlorpheniramine
Maleate)
chlorpheniramine maleate
syrp
chlorpheniramine maleate
tabs
chlorpheniramine maleate
tbcr
NP
NP
NP
F
F
F
Antihistamines - Ethanolamines
BENADRYL ALLERGY
NP
CAPS (Diphenhydramine
HCl)
BENADRYL ALLERGY
NP
CHILDRENS LIQD
(Diphenhydramine HCl)
BENADRYL ALLERGY
NP
TABS (Diphenhydramine
HCl)
BENADRYL DYE-FREE
ALLERGYLIQUID-GELS
NP
CAPS (Diphenhydramine
HCl)
clemastine fumarate tabs
F
1.34 mg
diphenhydramine hcl caps
F
25 mg
diphenhydramine hcl caps
F
50 mg
QL(4 ea daily)
QL(4 ea daily)
QL(4 ea daily)
QL(4 ea daily)
RX/OTC
Drug Name
diphenhydramine hcl elix
Drug Requirements/
Tier Limits
F RX/OTC
diphenhydramine hcl liqd
F
diphenhydramine hcl tabs
F
TAVIST ALLERGY TABS
(Clemastine Fumarate)
NP QL(4 ea daily)
Antihistamines - Non-Sedating
ALLEGRA ALLERGY
ST
NP
CHILDRENS SUSP
(Fexofenadine HCl)
ALLEGRA ALLERGY
QL(1 ea daily)
NP
TABS 180 MG
(Fexofenadine HCl)
ALLEGRA ALLERGY
NP
TABS 60 MG
(Fexofenadine HCl)
cetirizine hcl chew
NP
cetirizine hcl soln
F
cetirizine hcl syrp
F
cetirizine hcl tabs
F
QL(240 ml per
fill retail); AL;
RX/OTC
QL(240 ml per
fill retail); AL;
RX/OTC
QL(1 ea daily)
CLARINEX SYRP
F
ST
CLARINEX TABS
(Desloratadine)
CLARITIN REDITABS
TBDP 10 MG (Loratadine)
CLARITIN REDITABS
TBDP 5 MG
CLARITIN SYRP
(Loratadine)
CLARITIN TABS
(Loratadine)
DESLORATADINE ODT
TBDP
desloratadine tabs
fexofenadine hcl susp
NP
NP
F
NP
NP QL(1 ea daily)
NP
NP
F
ST
Drug Name
fexofenadine hcl tabs 180
mg
fexofenadine hcl tabs 60
mg
levocetirizine
dihydrochloride soln
levocetirizine
dihydrochloride tabs
Drug Requirements/
Tier Limits
NP QL(1 ea daily)
NP
NP RX/OTC
F
loratadine soln
F
loratadine syrp
F
loratadine tabs
F
loratadine tbdp
NP
XYZAL ALLERGY 24HR
CHILDRENS SOLN
(Levocetirizine
Dihydrochloride)
XYZAL ALLERGY 24HR
TABS (Levocetirizine
Dihydrochloride)
XYZAL SOLN
(Levocetirizine
Dihydrochloride)
XYZAL TABS
(Levocetirizine
Dihydrochloride)
ZYRTEC ALLERGY TABS
(Cetirizine HCl)
ZYRTEC CHILDRENS
ALLERGY SYRP
(Cetirizine HCl)
RX/OTC
QL(1 ea daily)
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
NP QL(1 ea daily)
QL(240 ml per
NP fill retail); AL;
RX/OTC
Antihistamines - Phenothiazines
promethazine hcl soln or
F
6.25 mg/5ml
promethazine hcl supp 25
F
mg, 12.5 mg, 50 mg
promethazine hcl supp 50
NP
mg
promethazine hcl syrp
F
promethazine hcl tabs
F
Antihistamines - Piperidines
Nebraska Total Care Updated May 30, 2017
28
Drug Name
Drug Requirements/
Tier Limits
cyproheptadine hcl syrp
F
cyproheptadine hcl tabs
F
Drug Name
QUESTRAN PACK
(Cholestyramine)
QUESTRAN POWD
(Cholestyramine)
Drug Requirements/
Tier Limits
NP
NP
ANTIHYPERLIPIDEMICS - Drugs to Treat High
Cholesterol
WELCHOL PACK
NP
Antihyperlipidemics - Combinations
WELCHOL TABS
NP
ezetimibe-simvastatin tabs
NP
Fibric Acid Derivatives
VYTORIN TABS
(Ezetimibe-Simvastatin)
NP
ANTARA CAPS
NP
choline fenofibrate cpdr
NP
NP
FENOFIBRATE CAPS
NP
NP
fenofibrate micronized caps
NP
NP
fenofibrate tabs 145 mg, 48
mg
fenofibrate tabs 160 mg,
120 mg, 54 mg, 40 mg
Antihyperlipidemics - Misc.
KYNAMRO SOSY
LOVAZA CAPS (Omega-3acid Ethyl Esters)
omega-3-acid ethyl esters
caps
VASCEPA CAPS
NP
Bile Acid Sequestrants
cholestyramine light pack
F
cholestyramine light powd
F
cholestyramine pack
F
cholestyramine powd
F
COLESTID FLAVORED
GRAN (Colestipol HCl)
COLESTID FLAVORED
PACK (Colestipol HCl)
COLESTID GRAN
(Colestipol HCl)
COLESTID PACK
(Colestipol HCl)
COLESTID TABS
(Colestipol HCl)
NP
NP
NP
NP
NP
colestipol hcl gran
NP
colestipol hcl pack
NP
colestipol hcl tabs
F
QUESTRAN LIGHT POWD
(Cholestyramine Light)
NP
Nebraska Total Care Updated May 30, 2017
29
F
NP
FENOFIBRIC ACID TABS
NP
FENOGLIDE TABS
(Fenofibrate)
NP
FIBRICOR TABS
NP
gemfibrozil tabs
F
LIPOFEN CAPS
NP
LOFIBRA CAPS
(Fenofibrate Micronized)
LOFIBRA TABS
(Fenofibrate)
NP
NP
LOPID TABS (Gemfibrozil)
NP
TRICOR TABS
(Fenofibrate)
NP
TRIGLIDE TABS
NP
TRILIPIX CPDR (Choline
Fenofibrate)
F
HMG CoA Reductase Inhibitors
ALTOPREV TB24
NP
Drug Name
Drug Requirements/
Tier Limits
atorvastatin calcium tabs
F
CRESTOR TABS
(Rosuvastatin Calcium)
F
fluvastatin sodium caps
NP
fluvastatin sodium tb24
NP
LESCOL CAPS
(Fluvastatin Sodium)
LESCOL XL TB24
(Fluvastatin Sodium)
LIPITOR TABS
(Atorvastatin Calcium)
REPATHA SOSY
NP
NP
REPATHA SURECLICK
SOAJ
NP QL(0.034 ml
daily); AL
NP
ANTIHYPERTENSIVES - Drugs to Treat High
Blood Pressure
NP
LIVALO TABS
NP
lovastatin tabs
F
MEVACOR TABS
(Lovastatin)
PRAVACHOL TABS
(Pravastatin Sodium)
pravastatin sodium tabs
rosuvastatin calcium tabs
simvastatin tabs
ZOCOR TABS
(Simvastatin)
ST
Drug Requirements/
Tier Limits
NP QL(0.0667 ml
PRALUENT SOPN
daily); AL
NP QL(0.0667 ml
PRALUENT SOSY
daily); AL
3.5ml per
REPATHA PUSHTRONEX NP Limit
month;QL(0.11
SYSTEM SOCT
7 ml daily); AL
Drug Name
NP
ACE Inhibitors
ACCUPRIL TABS
(Quinapril HCl)
ACEON TABS (Perindopril
Erbumine)
ALTACE CAPS (Ramipril)
NP
NP
NP
NP
benazepril hcl tabs
F
NP ST
F
NP
Intestinal Cholesterol Absorption Inhibitors
ezetimibe tabs
NP
ZETIA TABS (Ezetimibe)
NP
captopril tabs
enalapril maleate tabs
F
NP
F
EPANED SOLN
NP
EPANED SOLR
NP
fosinopril sodium tabs
NP
lisinopril tabs
F
Microsomal Triglyceride Transfer Protein (MTP)
LOTENSIN TABS
(Benazepril HCl)
NP
JUXTAPID CAPS
MAVIK TABS (Trandolapril)
NP
moexipril hcl tabs
NP
perindopril erbumine tabs
NP
Nicotinic Acid Derivatives
niacin (antihyperlipidemic)
tbcr
NP
F
NIACOR TABS
NP
PRINIVIL TABS (Lisinopril)
NP
NIASPAN TBCR (Niacin
(Antihyperlipidemic))
NP
QBRELIS SOLN
NP
quinapril hcl tabs
F
Proprotein Convertase Subtilisin/Kexin Type 9
Nebraska Total Care Updated May 30, 2017
30
Drug Name
ramipril caps
Drug Requirements/
Tier Limits
F
Drug Name
CATAPRES-TTS-3 PTWK
(Clonidine HCl)
Drug Requirements/
Tier Limits
F
trandolapril tabs
NP
clonidine hcl ptwk
NP
VASOTEC TABS (Enalapril
Maleate)
NP
clonidine hcl tabs
F
ZESTRIL TABS (Lisinopril)
NP
doxazosin mesylate tabs
F
Angiotensin II Receptor Antagonists
ATACAND TABS
NP
(Candesartan Cilexetil)
AVAPRO TABS
NP
(Irbesartan)
BENICAR TABS
NP
(Olmesartan Medoxomil)
guanfacine hcl tabs
F
methyldopa tabs
F
candesartan cilexetil tabs
NP
terazosin hcl caps
COZAAR TABS (Losartan
Potassium)
NP
DIOVAN TABS (Valsartan)
NP
EDARBI TABS
NP
EPROSARTAN
MESYLATE TABS
NP
Antihypertensive Combinations
ACCURETIC TABS
NP
(QuinaprilHydrochlorothiazide)
amlodipine besylateF
benazepril hcl caps
amlodipine besylateolmesartan medoxomil tabs NP
amlodipine besylateNP
valsartan tabs
amlodipine-valsartanNP
hydrochlorothiazide tabs
ATACAND HCT TABS
NP
(Candesartan CilexetilHydrochlorothiazide)
atenolol & chlorthalidone
F
tabs
AVALIDE TABS
NP
(IrbesartanHydrochlorothiazide)
AZOR TABS (Amlodipine
NP
Besylate-Olmesartan
Medoxomil)
benazepril &
F
hydrochlorothiazide tabs
BENICAR HCT TABS
NP
(Olmesartan MedoxomilHydrochlorothiazide)
irbesartan tabs
F
losartan potassium tabs
F
MICARDIS TABS
(Telmisartan)
NP
olmesartan medoxomil tabs NP
telmisartan tabs
valsartan tabs
NP
F
Antiadrenergic Antihypertensives
CARDURA TABS
NP
(Doxazosin Mesylate)
CATAPRES TABS
NP
(Clonidine HCl)
CATAPRES-TTS-1 PTWK
F
(Clonidine HCl)
CATAPRES-TTS-2 PTWK
F
(Clonidine HCl)
Nebraska Total Care Updated May 30, 2017
31
RESERPINE TABS
NP
TENEX TABS (Guanfacine
HCl)
NP
F
Drug Name
bisoprolol &
hydrochlorothiazide tabs
BYVALSON TABS
candesartan cilexetilhydrochlorothiazide tabs
CAPTOPRIL/HYDROCHL
OROTHIAZIDE TABS
CLORPRES TABS
CORZIDE TABS (Nadolol
& Bendroflumethiazide)
DIOVAN HCT TABS
(ValsartanHydrochlorothiazide)
Drug Requirements/
Tier Limits
F
NP QL(1 ea daily)
NP
NP
NP
NP
NP
DUTOPROL TB24
NP
EDARBYCLOR TABS
NP
enalapril maleate &
hydrochlorothiazide tabs
EXFORGE HCT TABS
(Amlodipine-ValsartanHydrochlorothiazide)
EXFORGE TABS
(Amlodipine BesylateValsartan)
fosinopril sodium &
hydrochlorothiazide tabs
HYZAAR TABS (Losartan
Potassium &
Hydrochlorothiazide)
irbesartanhydrochlorothiazide tabs
lisinopril &
hydrochlorothiazide tabs
LOPRESSOR HCT TABS
(Metoprolol &
Hydrochlorothiazide)
losartan potassium &
hydrochlorothiazide tabs
LOTENSIN HCT TABS
(Benazepril &
Hydrochlorothiazide)
LOTREL CAPS
(Amlodipine BesylateBenazepril HCl)
F
Drug Name
METHYLDOPA/HYDROCH
LOROTHIAZIDE TABS
metoprolol &
hydrochlorothiazide tabs
METOPROLOL
SUCCINATE
ER/HYDROCHLOROTHIA
ZIDE TB24
MICARDIS HCT TABS
(TelmisartanHydrochlorothiazide)
moexiprilhydrochlorothiazide tabs
nadolol &
bendroflumethiazide tabs
olmesartan medoxomilamlodipinehydrochlorothiazide tabs
olmesartan medoxomilhydrochlorothiazide tabs
PRESTALIA TABS
NP
NP
NP
NP
F
F
NP
F
NP
NP
PROPRANOLOL/HYDROC
HLOROTHIAZIDE TABS
quinaprilhydrochlorothiazide tabs
TARKA TBCR
(Trandolapril-Verapamil
HCl)
Drug Requirements/
Tier Limits
NP
NP
NP
NP
NP
NP
NP
NP
NP QL(1 ea daily)
NP
NP
NP
TEKTURNA HCT TABS
NP
telmisartan-amlodipine tabs
NP
telmisartanhydrochlorothiazide tabs
TENORETIC 100 TABS
(Atenolol & Chlorthalidone)
TENORETIC 50 TABS
(Atenolol & Chlorthalidone)
trandolapril-verapamil hcl
tbcr
TRIBENZOR TABS
(Olmesartan MedoxomilAmlodipineHydrochlorothiazide)
TWYNSTA TABS
(Telmisartan-Amlodipine)
NP
NP
NP
NP
NP
NP
Nebraska Total Care Updated May 30, 2017
32
Drug Name
valsartanhydrochlorothiazide tabs
VASERETIC TABS
(Enalapril Maleate &
Hydrochlorothiazide)
ZESTORETIC TABS
(Lisinopril &
Hydrochlorothiazide)
ZIAC TABS (Bisoprolol &
Hydrochlorothiazide)
Direct Renin Inhibitors
TEKTURNA TABS
Drug Requirements/
Tier Limits
Drug Name
MESTINON TIMESPAN
TBCR (Pyridostigmine
Bromide)
pyridostigmine bromide
tabs
F
NP
pyridostigmine bromide tbcr
NP
NP
NP QL(1 ea daily)
F
ISONIAZID SYRP
F
F
isoniazid tabs
minoxidil tabs
F
MYAMBUTOL TABS
(Ethambutol HCl)
ANTIMALARIALS - Drugs to Treat Malaria
(Parasitic Infections)
pyrazinamide tabs
Antimalarial Combinations
RIFADIN CAPS (Rifampin)
PLAQUENIL TABS
(Hydroxychloroquine
Sulfate)
PRIMAQUINE
PHOSPHATE TABS
F
QL(24 ea per
fill retail)
F
F
F
F
NP
F
ANTIMYASTHENIC/CHOLINERGIC AGENTS
Antimyasthenic/Cholinergic Agents
MESTINON TABS
NP
(Pyridostigmine Bromide)
Nebraska Total Care Updated May 30, 2017
NP
F
NP
rifampin caps
F
TRECATOR TABS
F
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES - Drugs to Treat Cancer
Alkylating Agents
ALKERAN TABS
F
CYCLOPHOSPHAMIDE
CAPS
F
GLEOSTINE CAPS
F
HEXALEN CAPS
NP
LEUKERAN TABS
F
LOMUSTINE CAPS
F
MYLERAN TABS
F
TEMODAR CAPS
(Temozolomide)
NP
temozolomide caps
33
F
ethambutol hcl tabs
F
mefloquine hcl tabs
F
Antimycobacterial Agents
hydralazine hcl tabs
Antimalarials
CHLOROQUINE
PHOSPHATE TABS 250
MG
chloroquine phosphate
tabs 500 mg, 250 mg
hydroxychloroquine sulfate
tabs
NP
ANTIMYCOBACTERIAL AGENTS - Drugs to
Treat Tuberculosis (Bacterial Infections)
Vasodilators
COARTEM TABS
Drug Requirements/
Tier Limits
F
Drug Name
Drug Requirements/
Tier Limits
Antimetabolites
exemestane tabs
capecitabine tabs
F
mercaptopurine tabs
F
METHOTREXATE
SODIUM SOLN 250
MG/10ML
methotrexate sodium soln
50 mg/2ml, 1 gm/40ml, 100
mg/4ml, 200 mg/8ml, 250
mg/10ml
PA
F
F
methotrexate sodium solr
F
methotrexate sodium tabs
F
Drug Requirements/
Tier Limits
F AL
FARESTON TABS
NP AL
FEMARA TABS (Letrozole)
NP AL
flutamide caps
F
AL
letrozole tabs
F
AL
MEGACE ORAL SUSP
(Megestrol Acetate)
NP
megestrol acetate susp
F
megestrol acetate tabs
F
NILANDRON TABS
(Nilutamide)
NP AL
F
nilutamide tabs
NP AL
F
tamoxifen citrate tabs
PURIXAN SUSP
NP
TABLOID TABS
TREXALL TABS
XELODA TABS
(Capecitabine)
Drug Name
NP PA
F
AL
XTANDI CAPS
NP QL(4 ea daily);
AL
ZYTIGA TABS
NP
Antineoplastic - BCL-2 Inhibitors
VENCLEXTA STARTING
F
PACK TBPK
PA
Antineoplastic - Immunomodulators
VENCLEXTA TABS
PA
POMALYST CAPS
F
Antineoplastic - Hedgehog Pathway Inhibitors
ERIVEDGE CAPS
F
ODOMZO CAPS
F
Antineoplastic Combinations
LONSURF TABS
AFINITOR DISPERZ TBSO
bicalutamide tabs
NP
Antineoplastic Enzyme Inhibitors
Antineoplastic - Hormonal and Related Agents
F AL
anastrozole tabs
ARIMIDEX TABS
(Anastrozole)
AROMASIN TABS
(Exemestane)
NP
NP
AFINITOR TABS
F
NP AL
ALECENSA CAPS
F
NP AL
BOSULIF TABS
F
AL
CASODEX TABS
(Bicalutamide)
NP AL
EMCYT CAPS
NP
NP
CABOMETYX TABS
F
CAPRELSA TABS
F
COMETRIQ KIT
PA
PA
NP
Nebraska Total Care Updated May 30, 2017
34
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
COTELLIC TABS
F
SPRYCEL TABS
F
FARYDAK CAPS
NP
STIVARGA TABS
NP
GILOTRIF TABS
F
GLEEVEC TABS 100 MG,
400 MG (Imatinib
Mesylate)
F
GLEEVEC TABS 400 MG
F
IBRANCE CAPS
NP QL(1 ea daily)
ICLUSIG TABS 15 MG
NP QL(2 ea daily)
ICLUSIG TABS 45 MG
NP QL(1 ea daily)
imatinib mesylate tabs
NP
IMBRUVICA CAPS
F
INLYTA TABS
F
IRESSA TABS
F
JAKAFI TABS
F
LENVIMA 10 MG DAILY
DOSE CPPK
LENVIMA 14 MG DAILY
DOSE CPPK
LENVIMA 18 MG DAILY
DOSE CPPK
LENVIMA 20 MG DAILY
DOSE CPPK
LENVIMA 24 MG DAILY
DOSE CPPK
LENVIMA 8 MG DAILY
DOSE CPPK
LYNPARZA CAPS
NP
F
TAFINLAR CAPS
F
TAGRISSO TABS
NP
TARCEVA TABS
F
TASIGNA CAPS
F
TYKERB TABS
NP
VOTRIENT TABS
F
XALKORI CAPS
F
ZELBORAF TABS
F
ZOLINZA CAPS
NP
ZYDELIG TABS
NP
ZYKADIA CAPS
NP
NP
Antineoplastics Misc.
HYDREA CAPS
(Hydroxyurea)
NP
hydroxyurea caps
F
NP
MATULANE CAPS
F
NP
NP
F
NEXAVAR TABS
F
NINLARO CAPS
F
RUBRACA TABS
NP
QL(4 ea daily)
NP
tretinoin (chemotherapy)
NP
caps
Chemotherapy Rescue/Antidote Agents
LEUCOVORIN CALCIUM
F
TABS 10 MG, 15 MG
leucovorin calcium tabs 25
F
mg, 5 mg
Topoisomerase I Inhibitors
NP
MEKINIST TABS
PA
Nebraska Total Care Updated May 30, 2017
35
SUTENT CAPS
HYCAMTIN CAPS
F
ANTIPARKINSON AGENTS - Drugs to Treat
Parkinson's Disease
Drug Name
Drug Requirements/
Tier Limits
Drug Name
carbidopa tabs
NP
MIRAPEX TABS
(Pramipexole
Dihydrochloride)
LODOSYN TABS
(Carbidopa)
NP
NEUPRO PT24
Antiparkinson Adjuvants
Antiparkinson Anticholinergics
benztropine mesylate tabs
F
trihexyphenidyl hcl elix
F
trihexyphenidyl hcl tabs
F
Antiparkinson COMT Inhibitors
COMTAN TABS
NP
(Entacapone)
entacapone tabs
NP
TASMAR TABS
(Tolcapone)
NP
tolcapone tabs
NP
PARLODEL CAPS
(Bromocriptine Mesylate)
PARLODEL TABS
(Bromocriptine Mesylate)
pramipexole
dihydrochloride tabs
pramipexole
dihydrochloride tb24
REQUIP TABS (Ropinirole
Hydrochloride)
REQUIP XL TB24
(Ropinirole Hydrochloride)
ropinirole hydrochloride
tabs
ropinirole hydrochloride
tb24
RYTARY CPCR
Antiparkinson Dopaminergics
amantadine hcl caps
F
amantadine hcl syrp
F
amantadine hcl tabs
NP
SINEMET CR TBCR
(Carbidopa-Levodopa)
SINEMET TABS
(Carbidopa-Levodopa)
Drug Requirements/
Tier Limits
NP
NP
NP
NP
F
NP
NP
NP
F
NP
NP
NP
NP
STALEVO 100 TABS
NP
STALEVO 125 TABS
NP
F
STALEVO 150 TABS
NP
carbidopa-levodopa tabs
F
STALEVO 200 TABS
NP
carbidopa-levodopa tbcr
F
STALEVO 50 TABS
NP
carbidopa-levodopa tbdp
NP
STALEVO 75 TABS
NP
bromocriptine mesylate
caps
bromocriptine mesylate
tabs
CARBIDOPA/LEVODOPA/
ENTACAPONE TABS
F
F
DUOPA SUSP
NP
MIRAPEX ER TB24
(Pramipexole
Dihydrochloride)
NP
Antiparkinson Monoamine Oxidase Inhibitors
AZILECT TABS (Rasagiline NP QL(1 ea daily)
Mesylate)
ELDEPRYL CAPS
NP
(Selegiline HCl)
NP QL(1 ea daily)
rasagiline mesylate tabs
Nebraska Total Care Updated May 30, 2017
36
Drug Name
Drug Requirements/
Tier Limits
selegiline hcl caps
NP
selegiline hcl tabs
F
ZELAPAR TBDP
NP
ANTIPSYCHOTICS/ANTIMANIC AGENTS Drugs to Treat Mood Disorders
Antimanic Agents
LITHIUM CARBONATE
CAPS 150 MG, 600 MG
(Lithium Carbonate)
lithium carbonate caps 300
mg, 600 mg, 150 mg
AL
NP
F
lithium carbonate tabs
F
AL
lithium carbonate tbcr
F
AL
LITHIUM SOLN
F
GEODON CAPS 20 MG
(Ziprasidone HCl)
GEODON CAPS 40 MG
(Ziprasidone HCl)
GEODON CAPS 60 MG
(Ziprasidone HCl)
GEODON CAPS 80 MG
(Ziprasidone HCl)
GEODON SOLR
LATUDA TABS
NP AL
paliperidone tb24 1.5 mg, 9
mg, 3 mg
paliperidone tb24 6 mg
F
PA
NP QL(8 ea daily);
AL
NP QL(4 ea daily);
AL
NP QL(3 ea daily);
AL
NP QL(2 ea daily);
AL
F PA; QL(6 ea
daily)
F PA; AL
NUPLAZID TABS
F
VRAYLAR CAPS
F
VRAYLAR CPPK
F
ziprasidone hcl caps 20 mg
F
QL(2 ea daily);
AL
PA; QL(1 ea
daily); AL
PA; QL(1 ea
daily); AL
QL(8 ea daily);
AL
Nebraska Total Care Updated May 30, 2017
37
FANAPT TITRATION
PACK TABS
INVEGA SUSTENNA
SUSP
INVEGA TB24 3 MG, 1.5
MG, 9 MG (Paliperidone)
INVEGA TB24 6 MG
(Paliperidone)
INVEGA TRINZA SUSP
Antipsychotics - Misc.
EQUETRO CP12
Benzisoxazoles
FANAPT TABS
AL
LITHOBID TBCR (Lithium
Carbonate)
Drug Requirements/
Tier Limits
F QL(4 ea daily);
ziprasidone hcl caps 40 mg
AL
F QL(3 ea daily);
ziprasidone hcl caps 60 mg
AL
F QL(2 ea daily);
ziprasidone hcl caps 80 mg
AL
Drug Name
RISPERDAL CONSTA
SUSR
RISPERDAL M-TAB TBDP
(Risperidone)
RISPERDAL SOLN
(Risperidone)
RISPERDAL TABS
(Risperidone)
F
PA; AL
F
PA; AL
F
PA
NP QL(1 ea daily);
AL
NP QL(2 ea daily);
AL
F PA
QL(1 ea daily);
AL
F QL(2 ea daily);
AL
F QL(1 ea per 14
days retail)
NP AL
F
NP AL
NP AL
risperidone soln
F
AL
risperidone tabs
F
AL
risperidone tbdp
F
AL
Butyrophenones
HALDOL DECANOATE
100 SOLN (Haloperidol
Decanoate)
HALDOL DECANOATE 50
SOLN (Haloperidol
Decanoate)
HALDOL SOLN
(Haloperidol Lactate)
NP
NP
NP
Drug Name
Drug Requirements/
Tier Limits
haloperidol decanoate soln
F
haloperidol lactate conc
F
haloperidol lactate soln
F
haloperidol tabs
F
SEROQUEL XR TB24 400
MG, 50 MG, 300 MG
(Quetiapine Fumarate)
VERSACLOZ SUSP
AL
Dibenzapines
ADASUVE AEPB
F
CLOZAPINE ODT TBDP
F
AL
clozapine tabs
F
AL
clozapine tbdp
F
AL
CLOZARIL TABS
(Clozapine)
FAZACLO TBDP 100 MG,
25 MG (Clozapine)
FAZACLO TBDP 12.5 MG,
200 MG, 150 MG
NP AL
NP AL
F
AL
loxapine succinate caps
F
AL
olanzapine solr
F
AL
F
AL
olanzapine tabs 20 mg, 10
mg, 15 mg
olanzapine tabs 7.5 mg, 5
mg, 2.5 mg
olanzapine tbdp
F
QL(1.5 ea
daily); AL
AL
quetiapine fumarate tabs
F
AL
quetiapine fumarate tb24
150 mg, 200 mg
quetiapine fumarate tb24
50 mg, 300 mg, 400 mg
SAPHRIS SUBL
SEROQUEL TABS
(Quetiapine Fumarate)
SEROQUEL XR TB24 200
MG, 150 MG (Quetiapine
Fumarate)
F
Drug Name
QL(1 ea daily);
AL
F QL(2 ea daily);
AL
F PA; QL(2 ea
daily)
NP AL
F
QL(1 ea daily);
NP AL
ZYPREXA RELPREVV
SUSR
ZYPREXA SOLR
(Olanzapine)
ZYPREXA TABS 10 MG,
15 MG, 20 MG
(Olanzapine)
ZYPREXA TABS 2.5 MG,
7.5 MG, 5 MG (Olanzapine)
ZYPREXA ZYDIS TBDP
(Olanzapine)
Dihydroindolones
MOLINDONE
HYDROCHLORIDE TABS
Phenothiazines
CHLORPROMAZINE HCL
SOLN
Drug Requirements/
Tier Limits
QL(2 ea daily);
NP AL
F
F
NP AL
AL
NP
NP QL(1.5 ea
daily); AL
NP AL
F
AL
F
F
AL
F
AL
F
AL
F
AL
F
AL
fluphenazine hcl tabs
F
AL
perphenazine tabs
F
QL(4 ea daily);
AL
chlorpromazine hcl tabs
fluphenazine decanoate
soln
FLUPHENAZINE HCL
CONC
FLUPHENAZINE HCL
ELIX
FLUPHENAZINE HCL
SOLN
prochlorperazine edisylate
soln
prochlorperazine maleate
tabs
F
F
prochlorperazine supp
F
AL
thioridazine hcl tabs
F
AL
trifluoperazine hcl tabs
F
AL
Nebraska Total Care Updated May 30, 2017
38
Drug Name
Drug Requirements/
Tier Limits
Quinolinone Derivatives
abacavir sulfate tabs
ABILIFY DISCMELT TBDP
F
ABILIFY MAINTENA SUSR
F
ABILIFY SOLN
F
ABILIFY TABS 2 MG
(Aripiprazole)
ABILIFY TABS 30 MG, 20
MG (Aripiprazole)
ABILIFY TABS 5 MG, 15
MG, 10 MG (Aripiprazole)
QL(1.5 ea
daily); AL
NP QL(2 ea daily);
AL
NP QL(1 ea daily);
AL
NP QL(1.5 ea
daily); AL
aripiprazole soln
F
aripiprazole tabs 10 mg, 15
mg, 5 mg
F
aripiprazole tabs 2 mg
F
aripiprazole tabs 20 mg, 30
mg
F
aripiprazole tbdp
F
ARISTADA PRSY
F
REXULTI TABS
F
QL(1.5 ea
daily); AL
QL(2 ea daily);
AL
QL(1 ea daily);
AL
QL(1.5 ea
daily); AL
QL(1 ea daily);
AL
Thioxanthenes
thiothixene caps
F
AL
ANTISEPTICS & DISINFECTANTS - Drugs to
Prevent Bacterial Skin Infections
Antiseptics & Disinfectants
formaldehyde soln 10%, 10
%
Chlorine Antiseptics
chlorhexidine gluconate
liqd 4 %
chlorhexidine gluconate
soln ex 4 %
HIBICLENS LIQD
(Chlorhexidine Gluconate)
F
F
F
NP
ANTIVIRALS - Drugs to Treat Viral Infections
Antiretrovirals
Nebraska Total Care Updated May 30, 2017
39
Drug Name
abacavir sulfate-lamivudine
tabs
abacavir sulfatelamivudine-zidovudine tabs
Drug Requirements/
Tier Limits
F QL(2 ea daily)
F
QL(1 ea daily)
F
QL(2 ea daily)
APTIVUS CAPS
F
QL(4 ea daily)
APTIVUS SOLN
F
QL(10 ml daily)
ATRIPLA TABS
F
QL(1 ea daily)
COMBIVIR TABS
(Lamivudine-Zidovudine)
NP QL(2 ea daily)
COMPLERA TABS
F
QL(1 ea daily)
CRIXIVAN CAPS 200 MG
F
QL(9 ea daily)
CRIXIVAN CAPS 400 MG
F
QL(6 ea daily)
DESCOVY TABS
F
QL(1 ea daily)
didanosine cpdr
F
QL(1 ea daily)
EDURANT TABS
F
QL(1 ea daily)
EMTRIVA CAPS
F
QL(1 ea daily)
EMTRIVA SOLN
F
QL(24 ml daily)
EPIVIR SOLN
(Lamivudine)
EPIVIR TABS 150 MG
(Lamivudine)
EPIVIR TABS 300 MG
(Lamivudine)
EPZICOM TABS (Abacavir
Sulfate-Lamivudine)
NP QL(30 ml daily)
NP QL(2 ea daily)
NP QL(1 ea daily)
NP QL(1 ea daily)
EVOTAZ TABS
F
GENVOYA TABS
F
INTELENCE TABS 100
MG, 25 MG
INTELENCE TABS 200
MG
INVIRASE CAPS
QL(1 ea daily)
F
QL(1 ea daily);
AL
QL(4 ea daily)
F
QL(2 ea daily)
F
QL(10 ea daily)
Drug Name
INVIRASE TABS
Drug Requirements/
Tier Limits
F QL(4 ea daily)
Drug Name
PREZISTA SUSP
Drug Requirements/
Tier Limits
F QL(12 ml daily)
ISENTRESS CHEW 100
MG
F
QL(6 ea daily)
PREZISTA TABS 150 MG
F
QL(3 ea daily)
ISENTRESS CHEW 25 MG
F
QL(12 ea daily)
PREZISTA TABS 600 MG,
75 MG
F
QL(2 ea daily)
ISENTRESS PACK
F
QL(2 ea daily)
PREZISTA TABS 800 MG
F
QL(1 ea daily)
ISENTRESS TABS
F
QL(2 ea daily)
RESCRIPTOR TABS 100
MG
RESCRIPTOR TABS 200
MG
RETROVIR CAPS
(Zidovudine)
RETROVIR SYRP
(Zidovudine)
REYATAZ CAPS 150 MG,
200 MG
F
QL(12 ea daily)
F
QL(6 ea daily)
KALETRA SOLN
(Lopinavir-Ritonavir)
KALETRA TABS 100MG25MG
KALETRA TABS 200MG50MG
NP QL(16 ml daily)
F
QL(4 ea daily)
F
QL(6 ea daily)
lamivudine soln
F
QL(30 ml daily)
lamivudine tabs 150 mg
F
QL(2 ea daily)
lamivudine tabs 300 mg
F
QL(1 ea daily)
lamivudine-zidovudine tabs
F
QL(2 ea daily)
LEXIVA SUSP
F
QL(56 ml daily)
LEXIVA TABS
F
QL(4 ea daily)
lopinavir-ritonavir soln
F
QL(16 ml daily)
NEVIRAPINE SUSP
F
QL(40 ml daily)
nevirapine tabs
F
QL(2 ea daily)
nevirapine tb24 100 mg
F
QL(3 ea daily)
nevirapine tb24 400 mg
F
QL(1 ea daily)
NORVIR CAPS
F
QL(12 ea daily)
NORVIR SOLN
F
QL(15 ml daily)
NORVIR TABS
F
QL(12 ea daily)
ODEFSEY TABS
PREZCOBIX TABS
NP QL(6 ea daily)
NP QL(60 ml daily)
F
REYATAZ CAPS 300 MG
F
REYATAZ PACK
F
QL(6 ea daily)
SELZENTRY TABS 150
MG, 75 MG
F
QL(2 ea daily)
SELZENTRY TABS 25 MG
F
QL(3 ea daily)
SELZENTRY TABS 300
MG
F
QL(4 ea daily)
stavudine caps
F
QL(2 ea daily)
stavudine solr
F
QL(80 ml daily)
STRIBILD TABS
F
QL(1 ea daily)
SUSTIVA CAPS 200 MG
F
QL(1 ea daily)
SUSTIVA CAPS 50 MG
F
QL(2 ea daily)
SUSTIVA TABS
F
QL(1 ea daily)
TIVICAY TABS 25 MG, 10
MG
F
TIVICAY TABS 50 MG
F
QL(2 ea daily)
TRIUMEQ TABS
F
QL(1 ea daily);
AL
F
F
QL(1 ea daily)
QL(2 ea daily)
Nebraska Total Care Updated May 30, 2017
40
Drug Name
TRIZIVIR TABS (Abacavir
Sulfate-LamivudineZidovudine)
TRUVADA TABS
TYBOST TABS
VIDEX EC CPDR
(Didanosine)
Drug Requirements/
Tier Limits
QL(2 ea daily)
NP
F
QL(1 ea daily)
QL(1 ea daily);
AL
NP QL(1 ea daily)
F
VIDEXPEDIATRIC SOLR
F
QL(20 ml daily)
VIRACEPT TABS 250 MG
F
QL(9 ea daily)
VIRACEPT TABS 625 MG
F
QL(4 ea daily)
VIRAMUNE SUSP
F
QL(40 ml daily)
VIRAMUNE TABS
(Nevirapine)
VIRAMUNE XR TB24 100
MG (Nevirapine)
VIRAMUNE XR TB24 400
MG (Nevirapine)
NP QL(2 ea daily)
NP QL(3 ea daily)
NP QL(1 ea daily)
VIREAD POWD
F
QL(8 gm daily)
VIREAD TABS
F
QL(1 ea daily)
VITEKTA TABS
ZERIT CAPS (Stavudine)
ZERIT SOLR
F
ZIAGEN SOLN
F
QL(30 ml daily)
NP QL(2 ea daily)
F
QL(6 ea daily)
zidovudine syrp
F
QL(60 ml daily)
zidovudine tabs
F
QL(2 ea daily)
zidovudine caps
CMV Agents
VALCYTE TABS
(Valganciclovir HCl)
valganciclovir hcl tabs
F
PA
BARACLUDE SOLN
F
PA
BARACLUDE TABS
(Entecavir)
COPEGUS TABS
(Ribavirin (Hepatitis C))
NP PA
NP PA
DAKLINZA TABS
F
entecavir tabs
F
EPCLUSA TABS
F
EPIVIR HBV SOLN
F
PA; QL(1 ea
daily)
PA
PA; QL(1 ea
daily); AL
PA
EPIVIR HBV TABS
(Lamivudine (HBV))
NP PA
HARVONI TABS
PA; QL(28 ea
per fill retail)
NP PA
HEPSERA TABS (Adefovir
Dipivoxil)
PEG-INTRON KIT
PEG-INTRON REDIPEN
KIT
PEG-INTRON REDIPEN
PAK 4 KIT
PEGASYS PROCLICK
SOLN
PEGASYS SOLN
PEGINTRON KIT
REBETOL CAPS (Ribavirin
(Hepatitis C))
REBETOL SOLN
F
F
PA
NP
F
PA; QL(0.143
ea daily)
PA; QL(0.143
ea daily)
PA; QL(0.143
ea daily)
PA
F
PA
F
F
F
PA; QL(0.143
ea daily)
NP PA
F
NP
NP QL(2 ea daily)
ribavirin (hepatitis c) caps
F
PA
QL(2 ea daily)
ribavirin (hepatitis c) tabs
F
PA
F
Nebraska Total Care Updated May 30, 2017
41
adefovir dipivoxil tabs
OLYSIO CAPS
F QL(1 ea daily);
AL
NP QL(2 ea daily)
Drug Requirements/
Tier Limits
Hepatitis Agents
lamivudine (hbv) tabs
QL(80 ml daily)
ZIAGEN TABS (Abacavir
Sulfate)
Drug Name
Drug Name
SOVALDI TABS
TECHNIVIE TABS
TYZEKA TABS
Drug Requirements/
Tier Limits
NP QL(28 ea per
fill retail)
F PA; QL(2 ea
daily)
F PA
VIEKIRA PAK TBPK
F
VIEKIRA XR TB24
F
ZEPATIER TABS
NP
PA; QL(4 ea
daily,28 day(s)
limit)
PA; QL(3 ea
daily); AL
Herpes Agents
Drug Requirements/
Tier Limits
Limit 10ea in
oseltamivir phosphate caps NP 180
30 mg, 45 mg
days;QL(12 ea
per fill retail)
oseltamivir phosphate caps NP QL(12 ea per
75 mg
fill retail)
RELENZA DISKHALER
F AL
AEPB
rimantadine hydrochloride
F
tabs
Limit 10ea in
TAMIFLU CAPS 30 MG, 45
F 180
MG (Oseltamivir
days;QL(12 ea
Phosphate)
per fill retail)
Drug Name
acyclovir caps
F
TAMIFLU CAPS 75 MG
(Oseltamivir Phosphate)
F
acyclovir susp
F
TAMIFLU SUSR
F
acyclovir tabs
F
BETA BLOCKERS - Drugs to Treat High Blood
Pressure
famciclovir tabs
F
Alpha-Beta Blockers
FAMVIR TABS
(Famciclovir)
NP
carvedilol tabs
SITAVIG TABS
NP
COREG CR CP24
NP
COREG TABS (Carvedilol)
NP
valacyclovir hcl tabs 1 gm,
1000 mg
F
valacyclovir hcl tabs 500
mg
F
VALTREX TABS 1 GM
(Valacyclovir HCl)
VALTREX TABS 500 MG
(Valacyclovir HCl)
ZOVIRAX CAPS
(Acyclovir)
ZOVIRAX SUSP
(Acyclovir)
ZOVIRAX TABS (Acyclovir)
Influenza Agents
FLUMADINE TABS
(Rimantadine
Hydrochloride)
QL(3 ea
daily,10 day(s)
limit)
QL(3 ea
NP daily,10 day(s)
limit)
NP
labetalol hcl tabs
F
F
Beta Blockers Cardio-Selective
acebutolol hcl caps
atenolol tabs
NP
F
betaxolol hcl tabs
NP
NP
bisoprolol fumarate tabs
NP
NP
BYSTOLIC TABS
NP
NP
LOPRESSOR TABS
(Metoprolol Tartrate)
NP
NP
QL(12 ea per
fill retail)
QL(120 ml per
fill retail)
metoprolol succinate tb24
F
metoprolol tartrate tabs 25
mg, 100 mg, 50 mg
F
Nebraska Total Care Updated May 30, 2017
42
Drug Name
METOPROLOL
TARTRATE TABS 75 MG,
37.5 MG
SECTRAL CAPS
(Acebutolol HCl)
TENORMIN TABS
(Atenolol)
TOPROL XL TB24
(Metoprolol Succinate)
ZEBETA TABS (Bisoprolol
Fumarate)
Drug Requirements/
Tier Limits
F
Drug Name
Calcium Channel Blockers
ADALAT CC TB24
(Nifedipine)
NP
amlodipine besylate tabs
NP
Drug Requirements/
Tier Limits
NP
F
HEMANGEOL SOLN
NP
INDERAL LA CP24
(Propranolol HCl)
NP
INDERAL XL CP24
NP
CALAN SR TBCR
(Verapamil HCl)
CALAN TABS (Verapamil
HCl)
CARDIZEM CD CP24
(Diltiazem HCl Coated
Beads)
CARDIZEM LA TB24 120
MG
CARDIZEM LA TB24 300
MG, 360 MG, 180 MG, 420
MG, 240 MG (Diltiazem
HCl Coated Beads)
CARDIZEM TABS
(Diltiazem HCl)
diltiazem hcl coated beads
cp24
diltiazem hcl coated beads
tb24
INNOPRAN XL CP24
NP
diltiazem hcl cp12
F
nadolol tabs
NP
diltiazem hcl cp24
F
pindolol tabs
NP
diltiazem hcl extended
release beads cp24
F
F
NP
NP
Beta Blockers Non-Selective
BETAPACE AF TABS
NP
(Sotalol HCl (AFIB/AFL))
BETAPACE TABS (Sotalol NP
HCl)
CORGARD TABS
NP
(Nadolol)
NP
NP
NP
NP
NP
NP
F
NP
propranolol hcl cp24
F
diltiazem hcl tabs
PROPRANOLOL HCL
SOLN OR 40 MG/5ML, 20
MG/5ML
F
felodipine tb24
NP
isradipine caps
NP
propranolol hcl tabs
F
nicardipine hcl caps
NP
sotalol hcl (afib/afl) tabs
F
sotalol hcl tabs
F
nifedipine tb24
F
F
SOTYLIZE SOLN
NP
TIMOLOL MALEATE TABS
NP
CALCIUM CHANNEL BLOCKERS - Drugs to
Treat High Blood Pressure
Nebraska Total Care Updated May 30, 2017
43
nifedipine caps
nimodipine caps
NP
NISOLDIPINE ER TB24
NP
nisoldipine tb24
NP
Drug Name
Drug Requirements/
Tier Limits
Drug Name
NORVASC TABS
(Amlodipine Besylate)
NP
inositol niacinate caps
NYMALIZE SOLN
NP
Prostaglandin Vasodilators
PROCARDIA CAPS
(Nifedipine)
PROCARDIA XL TB24
(Nifedipine)
SULAR TB24 (Nisoldipine)
TIAZAC CP24 (Diltiazem
HCl Extended Release
Beads)
verapamil hcl cp24 180 mg,
240 mg, 360 mg, 120 mg
verapamil hcl cp24 300 mg,
200 mg, 100 mg
NP
ORENITRAM TBCR
Drug Requirements/
Tier Limits
F
NP
F
QL(81.2 ml per
fill retail)
QL(81.2 ml per
fill retail)
QL(81.2 ml per
fill retail)
QL(5 ml daily)
F
QL(3 ml daily)
TYVASO REFILL SOLN
F
TYVASO SOLN
F
TYVASO STARTER SOLN
F
NP
NP
NP
NP
VENTAVIS SOLN 10
MCG/ML
VENTAVIS SOLN 20
MCG/ML
F
Pulmonary Hypertension - Endothelin Receptor
verapamil hcl tabs
F
LETAIRIS TABS
F
verapamil hcl tbcr
F
OPSUMIT TABS
NP
VERELAN CP24
(Verapamil HCl)
VERELAN PM CP24
(Verapamil HCl)
NP
NP
CARDIOTONICS - Drugs to Treat Heart Failure
and Abnormal Heart Rhythm
Cardiac Glycosides
DIGOXIN SOLN OR 0.05
MG/ML
digoxin tabs
LANOXIN TABS 250 MCG,
125 MCG (Digoxin)
F
F
NP
CARDIOVASCULAR AGENTS - MISC. - Drugs to
Treat Heart and Circulation Conditions
Cardiovascular Agents Misc. - Combinations
amlodipine besylateNP
atorvastatin calcium tabs
CADUET TABS
NP
(Amlodipine BesylateAtorvastatin Calcium)
F PA; QL(2 ea
ENTRESTO TABS
daily)
Peripheral Vasodilators
TRACLEER TABS
F
Pulmonary Hypertension - Phosphodiesterase
F PA; QL(3 ea
ADCIRCA TABS
daily)
F PA
REVATIO SUSR
REVATIO TABS (Sildenafil
Citrate (Pulmonary
Hypertension))
sildenafil citrate (pulmonary
hypertension) tabs
PA; QL(3 ea
NP daily)
F
PA; QL(3 ea
daily)
Pulmonary Hypertension - Prostacyclin Receptor
UPTRAVI TABS
NP
UPTRAVI TBPK
NP
Pulmonary Hypertension - Sol Guanylate Cyclase
ADEMPAS TABS
NP
CEPHALOSPORINS - Drugs to Treat Bacterial
Infections
Cephalosporins - 1st Generation
cefadroxil caps
F
Nebraska Total Care Updated May 30, 2017
44
Drug Name
Drug Requirements/
Tier Limits
cefadroxil susr
F
cefadroxil tabs
NP
Drug Name
ceftriaxone sodium solr ij
500 mg, 250 mg, 1 gm
ceftriaxone sodium solr iv 1
gm
Drug Requirements/
Tier Limits
F QL(10 ea per
fill retail)
F
cephalexin caps
F
SUPRAX CAPS
F
cephalexin susr
F
SUPRAX CHEW
NP
Cephalosporins - 2nd Generation
SUPRAX SUSR 200
MG/5ML, 100 MG/5ML
(Cefixime)
SUPRAX SUSR 500
MG/5ML
cefaclor caps
NP
CHEMICALS
CEFACLOR ER TB12
NP
Liquids
CEFACLOR SUSR
NP
CEPHALEXIN TABS
NP
KEFLEX CAPS
(Cephalexin)
NP
cefprozil susr
F
cefprozil tabs
F
NP
NP
GLYCERIN LIQD
F
RX/OTC
GLYCERINE LIQD
F
RX/OTC
GLYCEROL FORMAL
LIQD
F
RX/OTC
CEFTIN SUSR
NP
CONTRACEPTIVES - Drugs to Prevent
Pregnancy
CEFTIN TABS (Cefuroxime
Axetil)
NP
Combination Contraceptives - Oral
BREVICON-28 TABS
NP
(Norethindrone & Eth
Estradiol)
CYCLESSA TABS
NP
(Desogestrel-Ethinyl
Estradiol (Triphasic))
DESOGEN TABS
NP
(Desogestrel & Ethinyl
Estradiol)
desogestrel & ethinyl
F
estradiol tabs
desogestrel-ethinyl
F
estradiol (biphasic) tabs
desogestrel-ethinyl
F
estradiol (triphasic) tabs
drospirenone-ethinyl
F
estradiol tabs
ethynodiol diacet & eth
F
estrad tabs
levonorgestrel & eth
F
estradiol tabs
cefuroxime axetil tabs
F
Cephalosporins - 3rd Generation
CEDAX CAPS
NP
CEDAX SUSR
NP
cefdinir caps
F
cefdinir susr
F
cefixime susr
F
cefpodoxime proxetil susr
NP
cefpodoxime proxetil tabs
NP
CEFTIBUTEN CAPS
NP
CEFTIBUTEN SUSR
NP
Nebraska Total Care Updated May 30, 2017
45
Drug Name
LEVONORGESTREL AND
ETHINYL ESTRADIOL
TABS
levonorgestrel-eth estradiol
(triphasic) tabs
levonorgestrel-ethinyl
estradiol (91-day) tabs
levonorgestrel-ethinyl
estradiol (continuous) tabs
LOESTRIN 1.5/30-21
TABS (Norethindrone Acet
& Eth Estra)
LOESTRIN 1/20-21 TABS
(Norethindrone Acet & Eth
Estra)
LOESTRIN FE 1.5/30
TABS (Norethin Acet &
Estrad-Fe)
LOESTRIN FE 1/20 TABS
(Norethin Acet & EstradFe)
MIRCETTE TABS
(Desogestrel-Ethinyl
Estradiol (Biphasic))
MODICON TABS
(Norethindrone & Eth
Estradiol)
Drug Requirements/
Tier Limits
Drug Requirements/
Tier Limits
F
NORINYL 1+35 TABS
(Norethindrone & Eth
Estradiol)
NP
F
NORINYL 1+50 TABS
F
F
OGESTREL TABS
F
F
NP
NP
NP
NP
NP
NP
NATAZIA TABS
F
NECON 1/50-28 TABS
F
NECON 10/11-28 TABS
F
norethin acet & estrad-fe
tabs
norethindrone & eth
estradiol tabs
norethindrone acet & eth
estra tabs
norethindrone-eth estradiol
(triphasic) tabs
norgestimate-ethinyl
estradiol (triphasic) tabs
norgestimate-ethinyl
estradiol tabs
norgestrel & ethinyl
estradiol tabs
Drug Name
F
F
F
F
F
ORTHO TRI-CYCLEN LO
TABS (NorgestimateEthinyl Estradiol
(Triphasic))
ORTHO TRI-CYCLEN
TABS (NorgestimateEthinyl Estradiol
(Triphasic))
ORTHO-CEPT TABS
(Desogestrel & Ethinyl
Estradiol)
ORTHO-CYCLEN TABS
(Norgestimate-Ethinyl
Estradiol)
ORTHO-NOVUM 1/35
TABS (Norethindrone & Eth
Estradiol)
ORTHO-NOVUM 7/7/7
TABS (Norethindrone-Eth
Estradiol (Triphasic))
OVCON-35 TABS
(Norethindrone & Eth
Estradiol)
SEASONIQUE TABS
(Levonorgestrel-Ethinyl
Estradiol (91-Day))
TRI-NORINYL 28 TABS
(Norethindrone-Eth
Estradiol (Triphasic))
YASMIN 28 TABS
(Drospirenone-Ethinyl
Estradiol)
YAZ TABS (DrospirenoneEthinyl Estradiol)
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
Combination Contraceptives - Vaginal
NUVARING RING
F
Emergency Contraceptives
F
ELLA TABS
F
F
Nebraska Total Care Updated May 30, 2017
46
Drug Name
Drug Requirements/
Tier Limits
F QL(4 ea per
350 days retail)
QL(4 ea per
NP 350 days retail)
Drug Name
Drug Requirements/
Tier Limits
levonorgestrel (emergency
oc) tabs
PLAN B ONE-STEP TABS
(Levonorgestrel
(Emergency OC))
Progestin Contraceptives - Injectable
DEPO-PROVERA
QL(1 ml per fill
CONTRACEPTIVE SUSP
NP retail)
(Medroxyprogesterone
Acetate (Contraceptive))
medroxyprogesterone
QL(1 ml per fill
F retail)
acetate (contraceptive)
susp
Progestin Contraceptives - Oral
NOR-QD TABS
NP
(Norethindrone
(Contraceptive))
norethindrone
F
(contraceptive) tabs
ORTHO MICRONOR
NP
TABS (Norethindrone
(Contraceptive))
CORTICOSTEROIDS - Steroid Hormone Drugs to
Treat Systemic Swelling Conditions
Glucocorticosteroids
CORTEF TABS
NP
(Hydrocortisone)
CORTISONE ACETATE
F
TABS
MEDROL TABS 4 MG, 8
MG (Methylprednisolone)
methylprednisolone tabs 4
mg, 8 mg
UCERIS TB24
NP
dexamethasone elix
F
NP
dexamethasone sodium
phosphate soln ij 20
mg/5ml, 4 mg/ml, 120
mg/30ml
VERIPRED 20 SOLN
(Prednisolone Sodium
Phosphate)
F
Mineralocorticoids
DEXAMETHASONE SOLN
F
DEXAMETHASONE TABS
2 MG, 1 MG
dexamethasone tabs 4 mg,
1.5 mg, 0.5 mg, 0.75 mg, 6
mg
hydrocortisone tabs
F
F
MEDROL DOSEPAK TBPK NP
(Methylprednisolone)
Nebraska Total Care Updated May 30, 2017
47
F
methylprednisolone tbpk
F
MILLIPRED TABS
F
PEDIAPRED SOLN
(Prednisolone Sodium
Phosphate)
prednisolone sodium
phosphate soln or 20
mg/5ml, 6.7 mg/5ml, 15
mg/5ml, 5 mg/5ml
NP
F
prednisolone soln
F
prednisolone syrp
F
PREDNISONE INTENSOL
CONC
F
PREDNISONE SOLN
F
prednisone tabs 1 mg, 5
mg, 2.5 mg, 20 mg, 10 mg
PREDNISONE TABS 50
MG
PREDNISONE TBPK
fludrocortisone acetate tabs
F
NP
F
F
F
F
COUGH/COLD/ALLERGY - Drugs to Treat
Cough, Cold and Allergy Symptoms
Antitussives
benzonatate caps 100 mg
F
benzonatate caps 200 mg
F
hydrocodone w/
homatropine syrp
F
QL(1 ea daily)
Drug Name
TESSALON PERLES
CAPS (Benzonatate)
Drug Requirements/
Tier Limits
guaifenesin-codeine liqd
100mg/5ml-10mg/5ml
guaifenesin-codeine soln
100mg/5ml-10mg/5ml
NP
Cough/Cold/Allergy Combinations
brompheniramine &
F
phenyleph elix
brompheniramine &
F
pseudoeph elix
brompheniramine &
F
pseudoeph liqd
CHERACOL PLUS LIQD
NP
(DextromethorphanGuaifenesin)
CHERACOL-D COUGH
NP
LIQD (DextromethorphanGuaifenesin)
chlorpheniramine &
F
pseudoeph tabs
chlorpheniramineF
acetaminophen tabs
CLARITIN-D 24 HOUR
NP
TB24 (Loratadine &
Pseudoephedrine)
CORICIDIN HBP COLD &
FLU TABS
NP
(ChlorpheniramineAcetaminophen)
DECON-A ELIX
dextromethorphanguaifenesin liqd
20mg/10ml-200mg/10ml,
10mg/5ml-100mg/5ml,
10mg/5ml-10mg/5ml100mg/5ml-100mg/5ml,
15mg/7.5ml-150mg/7.5ml,
10mg/5ml-200mg/5ml
dextromethorphanguaifenesin soln
dextromethorphanguaifenesin syrp
dextromethorphanguaifenesin tb12 30mg600mg
DIMETAPP COLD &
ALLERGY ELIX
(Brompheniramine &
Phenyleph)
Drug Name
guaifenesin-codeine syrp
loratadine &
pseudoephedrine tb24
MUCINEX D TB12
(PseudoephedrineGuaifenesin)
MUCINEX DM TB12
(DextromethorphanGuaifenesin)
NEXAFED SINUS
PRESSURE +PAIN TABS
NORTUSS-EX LIQD
phenylephrine-chlorphendm liqd 15mg/5ml4mg/5ml-10mg/5ml
phenylephrine-dm-gg w/
apap tabs 10mg-325mg200mg-5mg, 10mg-10mg325mg-325mg-200mg200mg-5mg-5mg
promethazine &
phenylephrine syrp
promethazine w/codeine
syrp
F
promethazine-dm syrp
F
F
F
QL(2 ea daily)
F
NP
Drug Requirements/
Tier Limits
F
F
F
F
NP
QL(2 ea daily)
NP
F
F
F
F
F
AL
F
AL
F
AL
promethazinephenylephrine-codeine syrp F
PROMETHAZINE/PHENYL F AL
EPHRINE SYRP
pseudoephed-bromphenF
dm syrp
pseudoephedrine w/
F
codeine-gg soln
pseudoephedrineF
guaifenesin tb12 60mg600mg
ROBITUSSIN DM SYRP
NP
(DextromethorphanGuaifenesin)
Nebraska Total Care Updated May 30, 2017
48
Drug Name
ROBITUSSIN PEAK COLD
COUGH+ CHEST
CONGESTION DM MAX
STRENGTH LIQD
(DextromethorphanGuaifenesin)
ROBITUSSIN PEAK COLD
DM SYRP
(DextromethorphanGuaifenesin)
TRIAMINIC COLD &
ALLERGY SYRP
TUSNEL C SYRP
TYLENOL COLD & FLU
SEVERE TABS
(Phenylephrine-DM-GG w/
APAP)
Expectorants
guaifenesin liqd 400
mg/20ml, 100 mg/5ml
Drug Requirements/
Tier Limits
NP
NP
NP
VICKS VAPORUB OINT
F
Acne Products
ABSORICA CAPS 40 MG,
20 MG, 10 MG
ACANYA GEL
F
QL(40 ea per
fill retail)
NP QL(40 ea per
fill retail)
F
F
NP
F
F
Nebraska Total Care Updated May 30, 2017
49
F
DERMATOLOGICALS - Drugs to Treat Skin
Conditions
Misc. Respiratory Inhalants
camphor-eucalyptusF
menthol oint
camphor-eucalyptusF
menthol-turpentine oilwhite petrolatum oint
HYPER-SAL NEBU
NP
(Sodium Chloride
(Inhalant))
NEBUSAL NEBU
VAPORX BALM OINT
F
F
HYPERSAL NEBU 7 %
(Sodium Chloride
(Inhalant))
MEDICATED CHEST RUB
OINT
F
acetylcysteine soln
guaifenesin tabs 200 mg
HYPERSAL NEBU 3.5 %
F
F
F
MUCINEX TB12
(Guaifenesin)
sodium chloride (inhalant)
aers
sodium chloride (inhalant)
nebu
Drug Requirements/
Tier Limits
Mucolytics
guaifenesin soln
guaifenesin tb12 600 mg
Drug Name
ACNE MEDICATION 10
LOTN
ACNE MEDICATION 5
LOTN
F
F
NP
F
F
ACZONE GEL
NP
adapalene crea
NP
adapalene gel 0.1 %
NP RX/OTC
adapalene gel 0.3 %
NP
ADAPALENE LOTN
F
ATRALIN GEL (Tretinoin)
AVAR LS CLEANSER
LIQD (Sulfacetamide
Sodium w/ Sulfur)
AVAR-E LS CREA
(Sulfacetamide Sodium w/
Sulfur)
AZELEX CREA
BENZAC AC WASH LIQD
(Benzoyl Peroxide)
BENZACLIN GEL
(Clindamycin PhosphateBenzoyl Peroxide)
NP AL
NP
NP
F
AL
NP RX/OTC
NP
Drug Name
BENZACLIN WITH PUMP
GEL (Clindamycin
Phosphate-Benzoyl
Peroxide)
BENZAMYCIN GEL
(Benzoyl PeroxideErythromycin)
BENZEFOAM FOAM
(Benzoyl Peroxide)
BENZEFOAM ULTRA
FOAM (Benzoyl Peroxide)
BENZEFOAMULTRA
FOAM (Benzoyl Peroxide)
benzoyl peroxide foam 5.3
%
benzoyl peroxide foam 9.8
%
Drug Requirements/
Tier Limits
Limit 50ea per
F month;QL(1.66
7 gm daily)
NP
NP RX/OTC
NP
NP
NP RX/OTC
NP
benzoyl peroxide gel 10 %
F
BENZOYL PEROXIDE
GEL 2.5 %
F
benzoyl peroxide gel 5 %
F
CLEAN & CLEAR
ADVANTAGE 3-IN-1
EXFOLIATING CLEANSER
LOTN
CLEOCIN-T GEL
(Clindamycin Phosphate
(Topical))
CLEOCIN-T LOTN
(Clindamycin Phosphate
(Topical))
CLEOCIN-T SOLN
(Clindamycin Phosphate
(Topical))
CLEOCIN-T SWAB
(Clindamycin Phosphate
(Topical))
CLINDAGEL GEL
RX/OTC
benzoyl peroxide liqd 10 %,
5%
F
benzoyl peroxide liqd 4 %
F
benzoyl peroxide liqd 7 %
NP
benzoyl peroxide lotn
NP RX/OTC
benzoyl peroxide misc
NP
benzoyl peroxideerythromycin gel
BP CLEANSING WASH
EMUL
BPO 3% FOAMING
CLOTHS MISC
BPO 9% FOAMING
CLOTHS MISC
CLARIFOAM EF FOAM
(Sulfacetamide Sodium w/
Sulfur)
Drug Name
RX/OTC
NP
NP
NP
NP
NP
clindamycin phosphate
(topical) foam
clindamycin phosphate
(topical) gel
clindamycin phosphate
(topical) lotn
clindamycin phosphate
(topical) soln
clindamycin phosphate
(topical) swab
clindamycin phosphatebenzoyl peroxide
(refrigerate) gel
clindamycin phosphatebenzoyl peroxide gel
clindamycin phosphatetretinoin gel
DESQUAM-X WASH LIQD
(Benzoyl Peroxide)
DIFFERIN CREA
(Adapalene)
DIFFERIN GEL 0.1 %
(Adapalene)
DIFFERIN GEL 0.3 %
(Adapalene)
DIFFERIN LOTN
Drug Requirements/
Tier Limits
F
NP
NP
NP
NP
NP
NP
NP
F
F
NP
NP
Limit 50ea per
NP month;QL(1.66
7 gm daily)
NP
NP RX/OTC
F
F
RX/OTC
F
F
Nebraska Total Care Updated May 30, 2017
50
Drug Name
DUAC GEL (Clindamycin
Phosphate-Benzoyl
Peroxide (Refrigerate))
Drug Requirements/
Tier Limits
F
EPIDUO FORTE GEL
NP
EPIDUO GEL
NP
ERYGEL GEL
(Erythromycin (Acne Aid))
NP
erythromycin (acne aid) gel
NP
erythromycin (acne aid)
pads
erythromycin (acne aid)
soln
EVOCLIN FOAM
(Clindamycin Phosphate
(Topical))
FABIOR FOAM
isotretinoin caps 20 mg, 10
mg, 40 mg
KLARON LOTN
(Sulfacetamide Sodium
(Acne))
PANOXYL-4 CREAMY
WASH LIQD (Benzoyl
Peroxide)
RETIN-A CREA (Tretinoin)
RETIN-A GEL (Tretinoin)
RETIN-A MICRO GEL
(Tretinoin Microsphere)
RETIN-A MICRO PUMP
GEL 0.04 %, 0.1 %
(Tretinoin Microsphere)
RETIN-A MICRO PUMP
GEL 0.08 %
ROSULA PADS
Drug Name
SODIUM
SULFACETAMIDE/SULFU
R CLEANSER IN UREA
EMUL
SODIUM
SULFACETAMIDE/SULFU
R LOTN
SODIUM
SULFACETAMIDE/SULFU
R SUSP
SSS 10-5 FOAM
NP
F
NP
NP
F
NP
NP
PA; QL(20 gm
per fill retail);
AL
PA; QL(20 gm
F per fill retail);
AL
PA; QL(50 gm
NP per fill retail);
AL
PA; QL(50 gm
NP per fill retail);
AL
PA; QL(50 gm
F per fill retail);
AL
F
NP
sulfacetamide sodium
(acne) lotn
sulfacetamide sodium
(acne) susp
sulfacetamide sodium w/
sulfur crea 2%-10%
sulfacetamide sodium w/
sulfur emul
sulfacetamide sodium w/
sulfur liqd 4%-9%, 2%-2%10%-10%, 2%-10%, 4.5%9%
sulfacetamide sodium w/
sulfur lotn 5%-10%
sulfacetamide sodium w/
sulfur pads
sulfacetamide sodium w/
sulfur soln
sulfacetamide sodium w/
sulfur susp
SUMADAN WASH LIQD
(Sulfacetamide Sodium w/
Sulfur)
SUMAXIN PADS
(Sulfacetamide Sodium w/
Sulfur)
SUMAXIN TS SUSP
(Sulfacetamide Sodium w/
Sulfur)
SUMAXIN WASH LIQD
(Sulfacetamide Sodium w/
Sulfur)
tretinoin crea
Nebraska Total Care Updated May 30, 2017
51
Drug Requirements/
Tier Limits
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
PA; QL(20 gm
NP per fill retail);
AL
Drug Name
tretinoin gel 0.01 %, 0.025
%
tretinoin gel 0.05 %
tretinoin microsphere gel
Drug Requirements/
Tier Limits
PA; QL(20 gm
NP per fill retail);
AL
NP AL
F
VELTIN GEL
NP
ZIANA GEL (Clindamycin
Phosphate-Tretinoin)
NP
PA; QL(50 gm
per fill retail);
AL
Agents for Wrinkles/Lipoatrophy/Other Aesthetic
PA; QL(60 gm
F per fill retail);
REFISSA CREA
AL
PA; QL(60 gm
TRETINOIN EMOLLIENT
F per fill retail);
CREA
AL
Analgesics - Topical
menthol (topical analgesic)
gel 2 %
F
Anti-inflammatory Agents - Topical
diclofenac sodium (topical) NP
gel
diclofenac sodium (topical) NP
soln
FLECTOR PTCH
NP
LEXIXRYL THPK
NP
PENNSAID SOLN 1.5 %
(Diclofenac Sodium
(Topical))
NP
PENNSAID SOLN 2 %
NP
VOLTAREN GEL
(Diclofenac Sodium
(Topical))
NP
VOPAC MDS KIT
NP
XRYLIX THPK
NP
Drug Name
BACIGUENT OINT
(Bacitracin (Topical))
Drug Requirements/
Tier Limits
NP
bacitracin (topical) oint
F
bacitracin zinc oint
F
bacitracin-polymyxin b oint
F
BACTROBAN CREA
(Mupirocin Calcium
(Topical))
BACTROBAN OINT
(Mupirocin)
NP
NP
CENTANY AT KIT
NP
CENTANY OINT
NP
gentamicin sulfate (topical)
crea
GENTAMICIN SULFATE
OINT
mupirocin calcium (topical)
crea
mupirocin oint
neomycin-bacitracinpolymyxin oint
neomycin-bacitracinpolymyxin-pramoxine oint
neomycin-polymyxin w/
pramoxine crea
NEOSPORIN ORIGINAL
OINT (NeomycinBacitracin-Polymyxin)
NEOSPORIN PLUS PAIN
RELIEF MAXIMUM
STRENGTH CREA
(Neomycin-Polymyxin w/
Pramoxine)
POLYSPORIN OINT
(Bacitracin-Polymyxin B)
Antifungals - Topical
ALEVAZOL OINT
NP
NP
NP
F
F
F
F
NP
NP
NP
NP
Antibiotics - Topical
ALTABAX OINT
NP
Nebraska Total Care Updated May 30, 2017
52
Drug Name
ALOE VESTA
ANTIFUNGAL OINT
(Miconazole Nitrate
(Topical))
ALOE VESTA CLEAR
ANTIFUNGAL OINT
(Miconazole Nitrate
(Topical))
AZOLEN TINCTURE
SOLN
CICLODAN CREAM KIT
KIT
Drug Requirements/
Tier Limits
NP
F
ketoconazole (topical) foam
NP
F
ciclopirox sham
NP
ciclopirox soln
NP
F
LAMISIL AT CREA
(Terbinafine HCl (Topical))
LAMISIL AT JOCK ITCH
CREA (Terbinafine HCl
(Topical))
RX/OTC
QL(60 ml per
F fill retail);
RX/OTC
QL(60 ml per
NP fill retail);
RX/OTC
NP RX/OTC
F
NP
NP
ERTACZO CREA
NP
EXELDERM CREA
NP
EXELDERM SOLN
NP
EXTINA FOAM
(Ketoconazole (Topical))
NP
FUNGOID TINCTURE KIT
NP
Nebraska Total Care Updated May 30, 2017
53
ketoconazole (topical) crea
LAMISIL ADVANCED GEL
NP
econazole nitrate crea
NP
NP
ciclopirox olamine susp
clotrimazole w/
betamethasone crea
clotrimazole w/
betamethasone lotn
JUBLIA SOLN
F
NP
clotrimazole (topical) soln
NP
ketoconazole (topical)
sham
ciclopirox olamine crea
clotrimazole (topical) soln
FUNGOID TINCTURE
SOLN
NP
NP
clotrimazole (topical) soln
Drug Requirements/
Tier Limits
NP
ciclopirox gel
clotrimazole (topical) crea
Drug Name
F
F
LAMISIL AT SPRAY SOLN
F
LOPROX CREA (Ciclopirox
Olamine)
NP
LOPROX KIT
NP
LOPROX KIT KIT
NP
LOPROX SHAMPOO
SHAM (Ciclopirox)
LOPROX SUSP (Ciclopirox
Olamine)
LOTRIMIN AF AERO
NP
NP
F
LOTRIMIN AF CREA
(Clotrimazole (Topical))
LOTRIMIN AF FOR HER
CREA (Clotrimazole
(Topical))
LOTRIMIN AF JOCK ITCH
CREA (Clotrimazole
(Topical))
NP RX/OTC
LOTRIMIN ULTRA CREA
NP RX/OTC
LOTRISONE CREA
(Clotrimazole w/
Betamethasone)
NP
LUZU CREA
NP
MENTAX CREA
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
Drug Name
MICATIN CREA
(Miconazole Nitrate
(Topical))
miconazole nitrate (topical)
aero
miconazole nitrate (topical)
aerp
miconazole nitrate (topical)
crea
miconazole nitrate (topical)
oint
miconazole nitrate (topical)
powd
Drug Requirements/
Tier Limits
NP
F
F
F
Drug Name
TINACTIN DEODORANT
AERP (Tolnaftate)
TINACTIN JOCK ITCH
AERP (Tolnaftate)
TINACTIN JOCK ITCH
CREA (Tolnaftate)
TINACTIN POWD
(Tolnaftate)
Drug Requirements/
Tier Limits
NP
NP
NP
NP
tolnaftate aero
F
tolnaftate aerp
F
tolnaftate crea
F
tolnaftate liqd
F
tolnaftate powd
F
NP
F
naftifine hcl crea
NP
NAFTIN CREA (Naftifine
HCl)
NP
NAFTIN GEL
NP
tolnaftate soln
F
NIZORAL SHAM
(Ketoconazole (Topical))
NP
VUSION OINT
NP
nystatin (topical) crea
F
nystatin (topical) oint
F
nystatin (topical) powd
F
Antihistamines-Topical
BENADRYL EXTRA
STRENGTH CREA
(Diphenhydramine-Zinc
Acetate)
diphenhydramine-zinc
acetate crea 0.1%-2%,
0.1%-0.1%-2%-2%
NP
nystatin-triamcinolone crea
NP
nystatin-triamcinolone oint
NP
oxiconazole nitrate crea
NP
CARAC CREA
OXISTAT CREA
(Oxiconazole Nitrate)
NP
EFUDEX CREA
(Fluorouracil (Topical))
OXISTAT LOTN
NP
fluorouracil (topical) crea
F
NP
fluorouracil (topical) soln
F
F
FLUOROURACIL CREA
F
PENLAC NAIL LACQUER
SOLN (Ciclopirox)
terbinafine hcl (topical)
crea
TINACTIN AERO
(Tolnaftate)
TINACTIN AERP
(Tolnaftate)
TINACTIN CREA
(Tolnaftate)
NP
NP
NP
F
Antineoplastic or Premalignant Lesion Agents F
NP
Antipruritics - Topical
camphor & menthol lotn
SARNA LOTN (Camphor &
Menthol)
F
NP
Antipsoriatics
Nebraska Total Care Updated May 30, 2017
54
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
8-MOP CAPS
NP
salicylic acid & sulfur sham
F
acitretin caps
NP
SEBULEX SHAM (Salicylic
Acid & Sulfur)
NP
calcipotriene crea
F
selenium sulfide lotn 2.5 %
F
calcipotriene oint
NP
sulfacetamide sodium liqd
NP
calcipotriene soln
F
Antivirals - Topical
CALCITRIOL OINT
NP
ABREVA CREA
COSENTYX
SENSOREADY PEN SOAJ
NP
acyclovir topical oint
NP
COSENTYX SOSY
NP
DENAVIR CREA
NP
DOVONEX CREA
(Calcipotriene)
NP
XERESE CREA
NP
methoxsalen rapid caps
NP
ZOVIRAX CREA
NP
ZOVIRAX OINT (Acyclovir
Topical)
NP
OXSORALEN ULTRA
CAPS (Methoxsalen Rapid)
SORIATANE CAPS
(Acitretin)
NP
F
SORILUX FOAM
NP
TALTZ SOAJ
NP
tazarotene crea
NP
TAZORAC CREA 0.05 %
NP
TAZORAC CREA 0.1 %
(Tazarotene)
NP
TAZORAC GEL
NP
VECTICAL OINT
NP
Antiseborrheic Products
DHS ZINC SHAM
NP
(Pyrithione Zinc)
OVACE PLUS WASH LIQD NP
(Sulfacetamide Sodium)
OVACE WASH LIQD
NP
(Sulfacetamide Sodium)
pyrithione zinc sham 2 %,
F
Nebraska Total Care Updated May 30, 2017
55
Burn Products
SILVADENE CREA (Silver
Sulfadiazine)
silver sulfadiazine crea
Corticosteroids - Topical
ACLOVATE CREA
(Alclometasone
Dipropionate)
alclometasone dipropionate
crea
alclometasone dipropionate
oint
F
NP
F
NP
NP
NP
AMCINONIDE CREA
NP
AMCINONIDE LOTN
NP
AMCINONIDE OINT
NP
APEXICON E CREA
NP
betamethasone
dipropionate (topical) crea
betamethasone
dipropionate (topical) lotn
NP
NP
Drug Name
betamethasone
dipropionate (topical) oint
betamethasone
dipropionate augmented
crea
betamethasone
dipropionate augmented
gel
betamethasone
dipropionate augmented
lotn
betamethasone
dipropionate augmented
oint
betamethasone valerate
crea
betamethasone valerate
foam
betamethasone valerate
lotn
betamethasone valerate
oint
calcipotrienebetamethasone
dipropionate oint
Drug Requirements/
Tier Limits
Drug Name
CLOBEX LIQD (Clobetasol
Propionate)
CLOBEX LOTN
(Clobetasol Propionate)
CLOBEX SHAM
(Clobetasol Propionate)
CLOCORTOLONE
PIVALATE CREA
CLOCORTOLONE
PIVALATE PUMP CREA
NP
NP
NP
NP
NP
NP
F
F
AL
NP
NP
NP
clobetasol propionate gel
F
clobetasol propionate liqd
NP
clobetasol propionate lotn
NP
clobetasol propionate oint
F
F
NP
NP
NP
NP
CORDRAN TAPE
NP
CORDRAN TAPE TAPE
NP
DESONATE GEL
clobetasol propionate foam
F
NP
NP
clobetasol propionate soln
clobetasol propionate
emollient base crea
clobetasol propionate
emulsion foam
F
NP
CLODERM PUMP CREA
clobetasol propionate sham NP
clobetasol propionate crea
NP
NP
NP
CUTIVATE CREA
(Fluticasone Propionate)
CUTIVATE LOTN
(Fluticasone Propionate)
CVS HDYROCORTISONE
ACETATE CREA
DERMA-SMOOTHE/FS
BODY OIL (Fluocinolone
Acetonide)
DERMA-SMOOTHE/FS
SCALP OIL (Fluocinolone
Acetonide)
DERMACINRX SILAPAK
KIT (Triamcinolone
Acetonide-DimethiconeSilicone)
DERMATOP CREA
(Prednicarbate)
DERMATOP OINT
(Prednicarbate)
CAPEX SHAM
NP
CLODERM CREA
CORDRAN CREA
(Flurandrenolide)
CORDRAN LOTN
(Flurandrenolide)
CORDRAN OINT
(Flurandrenolide)
F
Drug Requirements/
Tier Limits
NP
NP
F
NP
NP
NP
NP
NP
NP
Nebraska Total Care Updated May 30, 2017
56
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
desonide crea
NP
fluocinonide crea
NP
desonide lotn
NP
fluocinonide emulsified
base crea
NP
desonide oint
NP
fluocinonide gel
NP
NP
fluocinonide oint
NP
NP
fluocinonide soln
NP
desoximetasone crea
NP
flurandrenolide crea
NP
desoximetasone gel
NP
flurandrenolide lotn
NP
desoximetasone oint
NP
flurandrenolide oint
NP
NP
fluticasone propionate crea
F
NP
fluticasone propionate lotn
NP
fluticasone propionate oint
F
halobetasol propionate
crea
F
halobetasol propionate oint
F
DESOWEN CREA
(Desonide)
DESOWEN LOTN
(Desonide)
DIFLORASONE
DIACETATE CREA
DIFLORASONE
DIACETATE OINT
DIPROLENE AF CREA
(Betamethasone
Dipropionate Augmented)
DIPROLENE LOTN
(Betamethasone
Dipropionate Augmented)
DIPROLENE OINT
(Betamethasone
Dipropionate Augmented)
ELOCON CREA
(Mometasone Furoate)
ELOCON LOTN
(Mometasone Furoate)
ELOCON OINT
(Mometasone Furoate)
NP
NP
NP
NP
NP
NP
ENSTILAR FOAM
NP
EPIFOAM FOAM
F
fluocinolone acetonide crea
NP
fluocinolone acetonide oil
NP
fluocinolone acetonide oint
NP
fluocinolone acetonide soln
NP
Nebraska Total Care Updated May 30, 2017
57
HALOG CREA
NP
HALOG OINT
NP
hydrocortisone (topical)
F
crea 0.5 %, 2.5 %
hydrocortisone (topical)
F RX/OTC
crea 1%, 1 %
hydrocortisone (topical) lotn F
2.5 %, 1 %
hydrocortisone (topical) oint F QL(2 gm daily);
1%
RX/OTC
hydrocortisone (topical) oint F
2.5 %, 0.5 %
hydrocortisone (topical)
F
soln
hydrocortisone acetate
F
(topical) crea
hydrocortisone butyrate
NP
crea
hydrocortisone butyrate
NP
hydrophilic lipo base crea
Drug Name
hydrocortisone butyrate
oint
hydrocortisone butyrate
soln
hydrocortisone valerate
crea
hydrocortisone valerate
oint
hydrocortisone-aloe vera
crea
KENALOG AERS
(Triamcinolone Acetonide
(Topical))
LOCOID CREA
(Hydrocortisone Butyrate)
LOCOID LIPOCREAM
CREA (Hydrocortisone
Butyrate Hydrophilic Lipo
Base)
LOCOID OINT
(Hydrocortisone Butyrate)
LOCOID SOLN
(Hydrocortisone Butyrate)
LUXIQ FOAM
(Betamethasone Valerate)
MICORT-HC CREA
Drug Requirements/
Tier Limits
Drug Name
SERNIVO EMUL
NP
SYNALAR CREA
(Fluocinolone Acetonide)
SYNALAR OINT
(Fluocinolone Acetonide)
SYNALAR SOLN
(Fluocinolone Acetonide)
TACLONEX OINT
(CalcipotrieneBetamethasone
Dipropionate)
NP
NP
NP
F
NP
TACLONEX SUSP
NP
NP
TEMOVATE CREA
(Clobetasol Propionate)
TEMOVATE E CREA
(Clobetasol Propionate
Emollient Base)
TEMOVATE GEL
(Clobetasol Propionate)
TEMOVATE OINT
(Clobetasol Propionate)
TEMOVATE SOLN
(Clobetasol Propionate)
NP
TEXACORT SOLN
NP
NP
NP
mometasone furoate crea
F
mometasone furoate oint
F
TOPICORT CREA
(Desoximetasone)
TOPICORT GEL
(Desoximetasone)
mometasone furoate soln
F
TOPICORT LIQD
MONISTAT SOOTHING
CARE ITCH RELIEF CREA
(Hydrocortisone (Topical))
OLUX FOAM (Clobetasol
Propionate)
OLUX-E FOAM (Clobetasol
Propionate Emulsion)
RX/OTC
PANDEL CREA
NP
prednicarbate crea
NP
prednicarbate oint
NP
TOPICORT OINT
(Desoximetasone)
triamcinolone acetonide
(topical) aers
triamcinolone acetonide
(topical) crea
triamcinolone acetonide
(topical) lotn
triamcinolone acetonide
(topical) oint
triamcinolone acetonidedimethicone-silicone kit
PSORCON CREA
NP
TRIANEX OINT
NP
NP
NP
Drug Requirements/
Tier Limits
NP
NP
NP
NP
AL
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
F
F
F
NP
NP
Nebraska Total Care Updated May 30, 2017
58
Drug Name
TRIDESILON CREA
(Desonide)
ULTRAVATE CREA
(Halobetasol Propionate)
ULTRAVATE LOTN
ULTRAVATE OINT
(Halobetasol Propionate)
VANOS CREA
(Fluocinonide)
WESTCORT OINT
(Hydrocortisone Valerate)
Drug Requirements/
Tier Limits
AQUAPHILIC OINT
NP
AQUAPHOR ADVANCED
THERAPY OINT
F
AL
NP
AQUAPHOR OINT
F
AL
NP
NP
NP
F
Emollient/Keratolytic Agents
CARMOL 20 CREA (Urea)
NP
urea crea 20 %, 40 %
F
urea lotn 40 %
F
Emollients
A + D PERSONAL CARE
LOTION LOTN
ALBOLENE CREA
ALOE AFTERSUN
LOTION LOTN
AMLACTIN CERAPEUTIC
LOTN
AMLACTIN ULTRA CREA
AQUA GLYCOLIC FACE
CREAM CREA
AQUA GLYCOLIC HAND &
BODYLOTION LOTN
AQUA LACTEN LOTN
AQUADERM CREA
F
AL; RX/OTC
F
AL
F
AL; RX/OTC
F
AL; RX/OTC
F
AL
F
AL
F
AL; RX/OTC
F
AL; RX/OTC
F
AL
AQUADERM
TREATMENT/MOISTURIZ
ER LOTN
F
AQUAMED LOTN
F
AL; RX/OTC
AL; RX/OTC
Nebraska Total Care Updated May 30, 2017
59
Drug Requirements/
Tier Limits
F AL
NP
Eczema Agents
DUPIXENT SOSY
Drug Name
AVEENO ACTIVE
NATURALS DAILY
MOISTURIZING BODY
YOGURT LOTN
AVEENO ACTIVE
NATURALS DAILY
MOISTURIZING BODY
YOGURT/APRICO LOTN
AVEENO ACTIVE
NATURALS SKIN RELIEF
HEALING OINT
AVEENO ACTIVE
NATURALS SKIN RELIEF
MOISTURE REPAIR
CREA
AVEENO DAILY
MOISTURIZINGSPF 15
LOTN
AVEENO INTENSE
RELIEF HAND CREA
AVEENO POSITIVELY
AGELESS LIFT & FIRM
EYE CREA
AVEENO POSITIVELY
AGELESS NIGHT CREA
AVEENO POSITIVELY
AGELESSFIRMING BODY
LOTN
AVEENO POSITIVELY
AGELESSSKIN
STRENGTHENING BODY
CREAM CREA
AVEENO POSITIVELY
AGELESSSKIN
STRENGTHENING HAND
CREAM CREA
AVEENO POSITIVELY
NOURISHING 24-HOUR
ULTRA-HYDRATING
CREA
AL; RX/OTC
F
AL; RX/OTC
F
AL
F
AL
F
AL; RX/OTC
F
F
AL
AL
F
F
AL
AL; RX/OTC
F
AL
F
AL
F
AL
F
Drug Name
AVEENO POSITIVELY
NOURISHING
ENERGIZING LOTN
AVEENO POSITIVELY
RADIANTINTENSIVE
NIGHT CREAM CREA
AVEENO SMART
ESSENTIALS NIGHTTIME
MOISTURE INFUSION
CREA
AVEENO STRESS RELIEF
MOISTURIZING LOTN
Drug Requirements/
Tier Limits
AL; RX/OTC
F
AL
F
AL
F
F
AL; RX/OTC
BASLE CREA
F
AL
BETA CARE CREA
F
AL
BETA CARE LOTN
F
AL; RX/OTC
BETA XMA CREA
F
AL
BOUDREAUXS BABY
BUTT SMOOTH DRY SKIN
OINT
F
AL
CAM LOTN
F
AL; RX/OTC
CARB-O-LAN 10 CREA
F
AL
CARB-O-LAN 20 CREA
F
AL
Drug Name
CETAPHIL DAILY
ADVANCE ULTRA
HYDRATING LOTN
CETAPHIL DAILY FACIAL
MOISTURIZER LOTN
CETAPHIL
DERMACONTROL
MOISTURIZER/SPF 30
LOTN
CETAPHIL
MOISTURIZING CREA
(Emollient)
CETAPHIL
MOISTURIZING LOTN
CETAPHIL
RESTORADERM LOTN
CETAPHIL THERAPEUTIC
HAND CREA
CLN FACIAL
MOISTURIZER
NOURISHING LOTN
COCOA BUTTER HAND &
BODYLOTION LOTN
COCOA BUTTER LOTN
F
AL
F
AL
CERAVE AM SPF 30
LOTN
F
AL; RX/OTC
COCONUT OIL BEAUTY
CREA
CVS DAILY ULTRA
MOISTURELOTION LOTN
DAILY CONDITIONING
TREATMENT OINT
DERMABASEOIL IN
WATER CREA
CERAVE CREA
F
AL
DERMAIDE ALOE CREA
CERAVE LOTN
F
AL; RX/OTC
CERAVE PM LOTN
F
AL; RX/OTC
CARB-O-PHILIC/20 CREA
CARB-O-SAL 5 CREA
CERAVE RENEWING SA
CREA
CERAVE SA RENEWING
LOTN
CETAPHIL CREA
F
AL
F
AL; RX/OTC
F
AL
DERMAL THERAPY
EXTRA STRENGTH BODY
LOTION LOTN
DERMAL THERAPY FACE
CAREMOISTURIZING
LOTION LOTN
DERMAL THERAPY FOOT
MASSAGE LOTN
DERMAL THERAPY HAND
ELBOW & KNEE CREAM
LOTN
Drug Requirements/
Tier Limits
AL; RX/OTC
F
F
AL; RX/OTC
AL; RX/OTC
F
AL
NP
F
AL; RX/OTC
F
AL; RX/OTC
F
AL
AL; RX/OTC
F
F
AL; RX/OTC
F
AL; RX/OTC
F
AL
F
AL; RX/OTC
F
AL
F
AL
F
AL
AL; RX/OTC
F
AL; RX/OTC
F
F
AL; RX/OTC
AL; RX/OTC
F
Nebraska Total Care Updated May 30, 2017
60
Drug Requirements/
Tier Limits
DERMAL THERAPY HEEL
F AL; RX/OTC
CARE LOTN
DERMALUBE DAILY
AL; RX/OTC
F
MOISTURIZING LOTION
LOTN
DERMEND
AL
F
MOISTURIZING BRUISE
FORMULA CREA
F AL
DHEA CREA
Drug Name
Drug Name
Drug Requirements/
Tier Limits
AL; RX/OTC
F
F
AL
F
AL
EQL ULTRA
MOISTURIZING DAILY
LOTION LOTN
EUCERIN CALMING
DAILY MOISTURIZER
CREA (Emollient)
EUCERIN DAILY
PROTECTION/SPF 30
LOTN
EUCERIN INTENSIVE
REPAIR LOTN
EUCERIN INTENSIVE
REPAIRHAND CREA
EUCERIN LOTN
F
F
AL; RX/OTC
DIABETIDERM LOTN
F
AL; RX/OTC
EUCERIN ORIGINAL
HEALINGSOOTHING
REPAIR LOTN
F
DMAE CREA
F
AL
EUCERIN PLUS CREA
F
DML FORTE CREA
F
AL
DROXY CREAM CREA
F
AL
EUCERIN PLUS
INTENSIVE REPAIR
CREA (Emollient)
F
AL
EUCERIN PLUS LOTN
ELTA CREA
F
AL
EMOLLIA-CREME CREA
F
AL
EMOLLIA-LOTION LOTN
F
AL; RX/OTC
emollient crea
F
AL
emollient lotn
F
AL; RX/OTC
emollient oint
F
AL
EPILYT LOTN
F
AL; RX/OTC
DIABETIDERM CREA
DIABETIDERM FOOT
REJUVENATING CREA
DIABETIDERM HAND &
BODY LOTN
ELON SKIN REPAIR
SYSTEM CREA
EQ THERAPEUTIC
MOISTURIZING CREAM
CREA
EQL ADVANCED
RECOVERY SKIN CARE
LOTN
EQL MOISTURIZING
CREAM CREA
AL
F
AL; RX/OTC
F
F
AL
Nebraska Total Care Updated May 30, 2017
61
EUCERIN SKIN CALMING
DAILY MOISTURIZING
CREA (Emollient)
EUCERIN SMOOTHING
REPAIRADVANCED
FORMULA LOTN
FORMULA 405
ENRICHED EYE CREA
FORMULA 405 FACE
CREAM CREA
FORMULA 405 LIGHT
TEXTURED
MOISTURIZER CREA
FORMULA 405
MOISTURIZING LOTN
AL
NP
AL; RX/OTC
F
F
AL; RX/OTC
F
AL
AL; RX/OTC
AL; RX/OTC
AL
AL
NP
F
AL; RX/OTC
AL
NP
AL; RX/OTC
F
F
AL
F
AL
AL
F
F
AL; RX/OTC
GENTLE CREA
F
AL
GERI-SOFT LOTN
F
AL; RX/OTC
glycerin (topical) liqd
F
GNP ADVANCED
RECOVERY LOTN
F
AL; RX/OTC
Drug Requirements/
Tier Limits
GOLD BOND MEDICATED
AL; RX/OTC
F
BODYLOTION EXTRA
STRENGTH LOTN
GOLD BOND MEDICATED F AL; RX/OTC
BODYLOTION LOTN
GOLD BOND ULTIMATE
AL; RX/OTC
F
DIABETICS' DRY RELIEF
LOTN
GOLD BOND ULTIMATE
F AL
HEALING CREA
GOLD BOND ULTIMATE
F AL; RX/OTC
HEALING LOTN
GOLD BOND ULTIMATE
F AL
HEALING OINT
GOLD BOND ULTIMATE
F AL; RX/OTC
LOTN
GOLD BOND ULTIMATE
F AL; RX/OTC
PROTECTION LOTN
GOLD BOND ULTIMATE
F AL; RX/OTC
RESTORING LOTN
GOLD BOND ULTIMATE
AL; RX/OTC
F
SHEERRIBBONS
PEARLRADIANCE LOTN
GOLD BOND ULTIMATE
AL; RX/OTC
F
SHEERRIBBONS
SILKSOFTNESS LOTN
GOLD BOND ULTIMATE
F AL; RX/OTC
SOFTENING LOTN
GOLD BOND ULTIMATE
F AL
SOOTHING CREA
GOLD BOND ULTIMATE
F AL; RX/OTC
SOOTHING LOTN
F AL; RX/OTC
GRX VITAMIN E LOTN
Drug Name
Drug Name
KERI LONG LASTING
CREA
KERI NOURISHING SHEA
BUTTER LOTN
Drug Requirements/
Tier Limits
F AL
F
AL; RX/OTC
KERI ORIGINAL LOTN
F
AL; RX/OTC
KERI OVERNIGHT LOTN
F
AL; RX/OTC
F
AL; RX/OTC
F
AL; RX/OTC
KERI RENEWAL MILK
BODY LOTN
KERI RENEWAL SKIN
FIRMING LOTN
KERI RENEWAL
STRETCH MARK
MINIMIZER LOTN
KERI SENSITIVE SKIN
LOTN
LAC-HYDRIN CREA
(Lactic Acid (Ammonium
Lactate))
LAC-HYDRIN LOTN (Lactic
Acid (Ammonium Lactate))
LAC-HYDRIN TWELVE
LOTN (Lactic Acid
(Ammonium Lactate))
lactic acid (ammonium
lactate) crea
lactic acid (ammonium
lactate) lotn 12 %
AL; RX/OTC
F
F
AL; RX/OTC
AL; RX/OTC
NP
NP AL; RX/OTC
AL; RX/OTC
NP
F
AL; RX/OTC
F
AL; RX/OTC
LACTINOL HX CREA
F
AL
LADY ESTHER 4
PURPOSE FACE CREAM
CREA
F
AL
HYDRASYN25 CREA
F
AL
LANAPHILIC OINT
F
AL
HYDRO-LAN CREA
F
AL
LANOLOR CREA
F
AL
J & J BURN CREAM CREA
F
AL
F
AL
KERADAN CREA
F
AL
LANTISEPTIC
THERAPEUTIC CREA
LEADER FINGER CREAM
CREA
LUBRIDERM ADVANCED
THERAPY LOTN
LUBRIDERM DAILY
MOISTURE/NORMAL TO
DRY SKIN LOTN
F
AL
F
AL; RX/OTC
KERI ADVANCED
MOISTURE THERAPY
LOTN
KERI BASIC ESSENTIALS
LOTN
AL; RX/OTC
F
F
AL; RX/OTC
AL; RX/OTC
F
Nebraska Total Care Updated May 30, 2017
62
Drug Name
LUBRIDERM DAILY
MOISTURESHEA +
CALMING LAVENDER
JASMINE LOTN
LUBRIDERM DAILY
MOISTUREWITH SPF 15
LOTN
LUBRIDERM INTENSE
SKIN REPAIR LOTN
LUBRIDERM LOTN
LUBRIDERM MENS 3-IN-1
LOTN
LUBRIDERM SERIOUSLY
SENSITIVE LOTN
LUBRIDERM SKIN
NOURISHINGWITH SHEA
AND COCOA BUTTERS
LOTN
LUBRIDERM SOOTHING
RELIEF/COOLING LOTN
Drug Requirements/
Tier Limits
AL; RX/OTC
F
AL; RX/OTC
F
F
AL; RX/OTC
F
AL; RX/OTC
F
AL; RX/OTC
F
AL; RX/OTC
AL; RX/OTC
Drug Name
NEUTROGENA
HAND/NORWEGIANFOR
MULA/FAST ABSORBING
CREA
NEUTROGENA HEALTHY
SKIN CREA
NEUTROGENA HEALTHY
SKIN FACE SPF 15 LOTN
NEUTROGENA
MOISTURE SENSITIVE
SKIN LOTN
NISEKO HYDRATING
FACIAL MOISTURIZER
CREA
NIVEA CREA
Drug Requirements/
Tier Limits
AL
F
F
AL
F
AL; RX/OTC
AL; RX/OTC
F
AL
F
F
AL
F
AL; RX/OTC
F
AL; RX/OTC
F
AL; RX/OTC
F
AL; RX/OTC
LUBRISOFT LOTN
F
AL; RX/OTC
NIVEA EXTRA ENRICHED
LOTION LOTN
NIVEA EXTRA ENRICHED
LOTN
NIVEA GENTLE BODY
EXFOLIATOR LOTN
F
AL; RX/OTC
NIVEA LIGHT CREA
F
AL
MAXAM LOTN
NIVEA LIGHT LOTN
F
AL; RX/OTC
F
AL
NIVEA LOTN
F
AL; RX/OTC
F
AL
NIVEA ORIGINAL LOTN
F
AL; RX/OTC
NIVEA ORIGINAL
MOISTURE LOTN
F
AL; RX/OTC
NIVEA SOFT CREA
F
AL
NIVEA VISAGE CREA
F
AL
F
MEDELA TENDER CARE
LANOLIN CREA
MEDERMA AG FACE
CREAM CREA
MEDERMA AG HAND &
BODY LOTION LOTN
MEDERMA STRETCH
MARKS THERAPY CREA
MOISTURIZING CREAM
CREA
MOTHERS FRIEND CREA
F
F
AL; RX/OTC
F
AL
F
AL
F
AL
MOTHERS FRIEND LOTN
F
AL; RX/OTC
NIVEA VISAGE INNER
BEAUTY NIGHTTIME
RENEWAL CREA
MSM SKIN LOTION LOTN
F
AL; RX/OTC
NIVEA VISAGE LOTN
F
AL; RX/OTC
NEOSALUS LOTN
F
AL; RX/OTC
NUTRADERM ADVANCED
FORMULA LOTN
F
AL; RX/OTC
AL; RX/OTC
NUTRADERM CREA
F
AL
NUTRADERM LOTN
F
AL; RX/OTC
NEUTROGENA BODY
LIGHT SESAME
FORMULA LOTN
NEUTROGENA HAND
CREA
F
F
AL
Nebraska Total Care Updated May 30, 2017
63
AL
Drug Name
OINTMENT BASE OINT
Drug Requirements/
Tier Limits
F AL
Drug Name
SKIN REPAIR LOTN
PEN-KERA CREA
F
AL
PENTRAVAN CREA
F
AL
PENTRAVAN PLUS CREA
F
AL
PETROLATUM OINT
F
AL
SOOTHE & COOL
MOISTURIZING BODY
LOTION WITH ALOE
LOTN
SOOTHE & COOL SKIN
CREAMWITH ALOE &
VITAMINS A, D & E CREA
F
AL
SORBOLENE CREA
F
AL
F
AL; RX/OTC
F
AL; RX/OTC
F
AL
PRETTY FEET & HANDS
CREA
RA GENTLE SKIN CREAM
CREA
RA RENEWAL DRY SKIN
THERAPY LOTN
RADIAGUARD
ADVANCED LOTN
RESTA CREA
RESTA LITE LOTN
RISABAL-PH CREA
ROC DEEP WRINKLE
SERUM LOTN
ROC MULTI CORREXION
5 IN1 RESTORING EYE
CREAM CREA
ROC MULTI CORREXION
5 IN1 RESTORING NIGHT
CREAM CREA
ROC MULTI CORREXION
LIFTANTI-GRAVITY
NIGHT CREA
ROC RETINOL
CORREXION CREA
ROC RETINOL
CORREXION NIGHT
CREA
ROC RETINOL
CORREXION SENSITIVE
EYE CREA
ROC RETINOL
CORREXION SENSITIVE
NIGHT CREA
ROSE MILK LOTN
F
AL
F
F
AL
F
AL
AL; RX/OTC
F
AL
F
F
AL
SWEEN CREAM CREA
F
AL
F
AL; RX/OTC
F
AL
F
AL; RX/OTC
TRIPLE CREAM CREA
F
AL
TROPAZONE LOTN
F
AL; RX/OTC
F
AL
F
AL
F
AL
VANICREAM CREA
F
AL
VANICREAM LITE LOTN
F
AL; RX/OTC
AL
VELVACHOL CREA
F
AL
F
AL
AL; RX/OTC
VITAMIN E WITH
PANTHENOL CREA
AL; RX/OTC
F
AL
F
AL; RX/OTC
AL
F
AL
F
AL
F
AL
AL
F
AL
F
F
F
AL; RX/OTC
SWEEN 24 CREA
F
F
SPECIAL CARE CREAM
CREA
ST IVES SWISS
FORMULA 24HOUR
MOISTURE LOTN
STUDIO 35
MOISTURIZING SKIN
CREA
Drug Requirements/
Tier Limits
F AL; RX/OTC
THERABETIC SKIN CARE
LOTN
THERAPEUTIC
MOISTURIZING CREA
THERAPLEX
HYDROLOTION LOTN
UDDERLY SMOOTH
CREA
UDDERLY SMOOTH
EXTRA CARE CREA
UDDERLY SMOOTH
EXTRA CARE20 CREA
Nebraska Total Care Updated May 30, 2017
64
Drug Requirements/
Tier Limits
F AL
vitamins a & d (topical) oint
Drug Name
Drug Name
WIBI LOTN
F
AL; RX/OTC
ZIMS CRACK CREME
DAYTIME CREA
F
AL
DERMAREST PSORIASIS
MEDICATED SHAMPOO
PLUS CONDITIONER
SHAM
NEUTROGENA T/SAL
SHAM
Enzymes - Topical
SANTYL OINT
F
Immunomodulating Agents - Topical
ALDARA CREA
NP QL(0.2667 ea
(Imiquimod)
daily)
F QL(0.2667 ea
imiquimod crea
daily)
ZYCLARA CREA
NP
ZYCLARA PUMP CREA
NP
Immunosuppressive Agents - Topical
F AL
ELIDEL CREA
PROTOPIC OINT
(Tacrolimus (Topical))
NP AL
tacrolimus (topical) oint
NP AL
Keratolytic/Antimitotic Agents
BENSAL HP OINT
BETASAL SHAM
NP
F
COMPOUND W LIQD
NP
(Salicylic Acid)
COMPOUND W MAXIMUM
STRENGTH GEL (Salicylic NP
Acid)
CONDYLOX SOLN
NP
(Podofilox)
CVS PSORIASIS
MEDICATED SHAMPOO
F
PLUS CONDITIONER
SHAM
CVS THERAPEUTIC
F
MAXIMUM STRENGTH
SHAM
DENOREX EXTRA
F
STRENGTH 2-IN-1 SHAM
Nebraska Total Care Updated May 30, 2017
65
Drug Requirements/
Tier Limits
F
F
P & S SHAM
F
podofilox soln
F
salicylic acid gel 17 %
F
salicylic acid liqd 17 %
F
salicylic acid soln 17 %
F
SELSUN BLUE DEEP
CLEANSING SHAM
SELSUN BLUE
NATURALS DRYSCALP
SHAM
SELSUN BLUE
NATURALS SHAM
THERAPEUTIC T+PLUS
MAXIMUM STRENGTH
SHAM
Liniments
ASPERCREME/ALOE
CREA (Trolamine
Salicylate)
BENGAY GREASELESS
CREA (Menthol-Methyl
Salicylate (Liniments))
BENGAY ULTRA
STRENGTH CREA
(Camphor-Menthol-Methyl
Salicylate)
BLUE-EMU SUPER
STRENGTH CREA
camphor-menthol-methyl
salicylate crea
liniments & rubs crea
menthol-methyl salicylate
(liniments) crea
menthol-methyl salicylate
(liniments) oint
F
F
F
F
NP
NP
NP
F
F
F
F
F
Drug Name
MOBISYL CREA
(Trolamine Salicylate)
MYOFLEX CREA
(Trolamine Salicylate)
SPORTSCREME CREA
(Trolamine Salicylate)
Drug Requirements/
Tier Limits
NP
trolamine salicylate crea
F
VICKS BABYRUB CREA
F
capsaicin crea
CAPZASIN-HP CREA
(Capsaicin)
dibucaine oint
EMLA CREA (LidocainePrilocaine)
F
F
F
F
lidocaine hcl gel 2 %
F
lidocaine oint
F
lidocaine ptch 5 %
F
lidocaine-prilocaine crea
F
pramoxine-zinc acetate lotn
RX/OTC
NP
F
RA ARTHRITIS PAIN
F
RELIEF CREA
ZOSTRIX ARTHRITIS
NP
PAIN RELIEF CREA
(Capsaicin)
ZOSTRIX DIABETIC FOOT NP
PAIN CREA (Capsaicin)
Misc. Topical
A+D FIRST AID OINT
F
F
F
F
F
AL; RX/OTC
BASIS OVERNIGHT CREA
F
AL; RX/OTC
BAZA CLEANSE &
PROTECT LOTN
F
BODI PROTECT OINT
F
CERAVE OINT
NP
Drug Requirements/
Tier Limits
F
CARRINGTON MOISTURE
BARRIER CREA
CARRINGTON MOISTURE
BARRIER/ZINC CREA
NP
lidocaine hcl crea
LIDODERM PTCH
(Lidocaine)
ALOE VESTA
PROTECTIVE OINT
AMERIDERM
PERISHIELD OINT
AQUAPHOR LIP REPAIR
OINT
BASIS FACIAL
MOISTURIZER CREA
NP
F
Local Anesthetics - Topical
ARTHRITIS PAIN
RELIEVING CREA
ABSORBASE OINT
NP
TRIXAICIN CREA
Drug Name
CHAPSTICK OVERNIGHT
OINT
CHAPSTICK ULTRA
MOISTUREDAYTIME
FORMULA OINT
CHAPSTICK
ULTRASMOOTH FORTIFY
OINT
CHAPSTICK
ULTRASMOOTH
NOURISH OINT
CHAPSTICK
ULTRASMOOTH
REJUVENATE OINT
CHAPSTICK
ULTRASMOOTH SOOTHE
OINT
CRITIC-AID CLEAR
MOISTUREBARRIER
OINT
DERMADROX OINT
DESITIN OINT (Zinc Oxide
(Topical))
F
AL; RX/OTC
F
AL; RX/OTC
F
F
F
F
F
F
F
F
F
NP
Nebraska Total Care Updated May 30, 2017
66
Drug Name
DR SMITHS DIAPER OINT
(Zinc Oxide (Topical))
DRYSOL SOLN
EUCERIN CREA (Skin
Protectants, Misc.)
Drug Requirements/
Tier Limits
NP
NP AL; RX/OTC
F
GOLD BOND EXTRA
STRENGTH POWD
F
GOLD BOND POWD
F
HYDROCERIN CREA
F
LANTISEPTIC SKIN
PROTECTANT OINT
F
lubricants gel
F
menthol-zinc oxide powd
skin protectants, misc. oint
F
GERI PROTECT OINT
Drug Requirements/
Tier Limits
F AL; RX/OTC
skin protectants, misc. crea
Drug Name
AL; RX/OTC
F
SOOTHE & COOL FREE
MEDSEPTIC OINT
SOOTHE & COOL FREE
MOISTURE BARRIER
OINT
SOOTHE & COOL FREE
SKIN PASTE OINT
SOOTHE & COOL
MOISTURE BARRIER
OINT
SOOTHE & COOL
PROTECT MOISTURE
BARRIER OINT
SORBIDON HYDRATE
CREA
witch hazel (hamamelis
virginiana) pads
F
F
F
F
F
F
F
AL; RX/OTC
F
NEOSPORIN LIP HEALTH
OVERNIGHT RENEWAL
THERAPY OINT
F
PALOMAR E OINT
F
PELEVERUS CLEAR OINT
F
PELEVERUS GOLD OINT
F
zinc oxide (topical) oint 10
F
%, 20 %, 40 %
Phosphodiesterase 4 (PDE4) Inhibitors - Topical
NP AL
EUCRISA OINT
PELEVERUS OINT
F
Rosacea Agents
PETROLEUM JELLY LIP
TREATMENT OINT
PROSHIELD
PROTECTIVE
HANDCREAM CREA
RA RENEWAL
ADVANCED HEALING
OINT
REMEDY CLEAR-AID
OINT
RESTORE CLEANSER &
MOISTURIZER LIQD
SENSI-CARE
MOISTURIZING CREA
SENSI-CARE
PROTECTIVE BARRIER
OINT
witch hazel-glycerin pads
DOXYCYCLINE CPDR
F
AL; RX/OTC
F
F
F
metronidazole (topical) lotn
F
F
AL; RX/OTC
F
Nebraska Total Care Updated May 30, 2017
67
METROCREAM CREA
(Metronidazole (Topical))
METROLOTION LOTN
(Metronidazole (Topical))
metronidazole (topical)
crea
metronidazole (topical) gel
0.75 %
ORACEA CPDR
Scabicides & Pediculicides
ELIMITE CREA
(Permethrin)
F
NP
NP
NP
F
F
F
NP
NP
Drug Name
Drug Requirements/
Tier Limits
EURAX CREA
NP
EURAX LOTN
NP
LINDANE LOTN
F
ST
lindane lotn
F
ST
lindane sham
NP
LINDANE SHAM
NP
malathion lotn
NP
NATROBA SUSP
F
NIX CREME RINSE LIQD
(Permethrin)
NP
OVIDE LOTN (Malathion)
NP
permethrin crea
F
permethrin liqd
F
permethrin lotn
F
pyrethrins-piperonyl
butoxide liqd 0.33%-4%
pyrethrins-piperonyl
butoxide sham
RID ESSENTIAL LICE
ELIMINATION KIT KIT
RID LIQD (PyrethrinsPiperonyl Butoxide)
SKLICE LOTN
SPINOSAD SUSP
Tar Products
coal tar extract sham 0.5
%, 1 %
DHS TAR GEL SHAM
(Coal Tar Extract)
DHS TAR SHAM (Coal Tar
Extract)
NEUTROGENA T/GEL
CONDITIONER LIQD
F
F
F
NP
F
NP
F
NP
NP
F
Drug Name
NEUTROGENA T/GEL
SHAM (Coal Tar Extract)
NEUTROGENA T/GEL
STUBBORN ITCH
CONTROL SHAM (Coal
Tar Extract)
THERAPLEX T SHAM
(Coal Tar Extract)
Wound Care Products
2ND SKIN MOIST BURN
PADS1.5"X2" PADS
2ND SKIN MOIST BURN
PADS2"X3" PADS
2ND SKIN MOIST BURN
PADS3"X4" PADS
2ND SKIN MOIST
DRESSING KIT PADS
2ND SKIN MOIST GEL
PADS 1"X1" PADS
2ND SKIN MOIST GEL
PADS 3" ROUND PADS
Drug Requirements/
Tier Limits
NP
NP
NP
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
ACTICOAT 7 2"X2" PADS
F
RX/OTC
ACTICOAT 7 4"X5" PADS
F
RX/OTC
ACTICOAT ABSORBENT
ANTIMICROBIAL
DRESSING 4"X5" PADS
ACTICOAT
ANTIMICROBIAL
DRESSING 2"X2" PADS
ACTICOAT
ANTIMICROBIAL
DRESSING 4"X4" PADS
ACTICOAT FLEX 3
BARRIER DRESSING
4"'X4" PADS
ADAPTIC NONADHERING DRESSING 3"
X 3" PADS
AGIE-GRX PADS
ALLEVYN ADHESIVE
PADS
ALLEVYN AG ADHESIVE
PADS
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
Nebraska Total Care Updated May 30, 2017
68
Drug Name
ALLEVYN AG GENTLE
BORDER PADS
ALLEVYN AG NONADHESIVE PADS
ALLEVYN AG SACRUM
PADS
ALLEVYN COMPRESSION
PADS
ALLEVYN GENTLE
BORDER HEEL PADS
ALLEVYN GENTLE
BORDER LITE PADS
ALLEVYN GENTLE
BORDER MULTISITE
PADS
ALLEVYN GENTLE
BORDER PADS
ALLEVYN GENTLE
BORDER SACRUM PADS
Drug Requirements/
Tier Limits
F RX/OTC
F
RX/OTC
F
RX/OTC
F
F
F
RX/OTC
RX/OTC
RX/OTC
RX/OTC
F
F
RX/OTC
F
RX/OTC
ALLEVYN GENTLE PADS
F
RX/OTC
ALLEVYN HEEL PADS
F
RX/OTC
ALLEVYN LIFE HEEL
PADS
F
RX/OTC
ALLEVYN LIFE PADS
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
ALLEVYN LIFE SACRUM
PADS
ALLEVYN NONADHESIVE PADS
ALLEVYN PLUS
ADHESIVE PADS
ALLEVYN PLUS CAVITY
PADS EX
ALLEVYN PLUS SACRUM
PADS
ALLEVYN SACRUM PADS
ALLEVYN
TRACHEOSTOMY 31/2"X3-1/2" PADS
AMERIGEL HYDROGEL
SATURATED GAUZE
DRESSING 2" X 2" PADS
F
F
RX/OTC
RX/OTC
RX/OTC
F
RX/OTC
F
Nebraska Total Care Updated May 30, 2017
69
Drug Name
AQUACEL
EXTRA/HYDROFIBER
PADS
AQUACEL FOAM
3.2"X3.2" PADS
AQUACEL FOAM 4"X4"
PADS
AQUACEL FOAM 5"X5"
PADS
AQUACEL FOAM 6"X6"
PADS
AQUACEL FOAM 6"X8"
PADS
AQUACEL FOAM 7"X7"
PADS
AQUACEL FOAM 8"X5.5"
PADS
AQUACEL FOAM 8"X7"
PADS
AQUASITE
IMPREGNATED
DRESSING 2"X2" PADS
AQUASITE
IMPREGNATED
DRESSING 4"X4" PADS
AQUASITE
IMPREGNATED
DRESSING 4"X8" PADS
AQUASITE
IMPREGNATED GAUZE
2"X2" PADS
AQUASITE
IMPREGNATED GAUZE
4"X4" PADS
AQUASITE SHEET
DRESSING 4"X4" PADS
ARGLAES FILM 2-3/8" X 31/8" PADS
ARGLAES FILM 3" X 14"
PADS
ARGLAES FILM 4" X 4-3/4"
PADS
ARGLAES FILM 4-3/4" X
10" PADS
ARGLAES ISLAND 2-3/8"
X 3-1/8" PADS
Drug Requirements/
Tier Limits
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
Drug Requirements/
Tier Limits
ARGLAES ISLAND 4" X 4F RX/OTC
3/4" PADS
ARGLAES ISLAND 4-3/4"
F RX/OTC
X 10" PADS
F RX/OTC
BIOBRANE 10"X15" PADS
Drug Name
F
RX/OTC
F
RX/OTC
DERMA-GEL 4" X 4" PADS
F
RX/OTC
F
RX/OTC
BIOBRANE 5"X15" PADS
F
RX/OTC
BIOBRANE 5"X5" PADS
F
RX/OTC
BIOBRANE-L 5"X5" PADS
CARBOFLEX ODOR
CONTROL DRESSING
PADS
CARRAGAUZE 2 X 2
PADS
CARRAGAUZE 4 X 4
PADS
COMFEEL PLUS
CLEARDRESSING PADS
COMFEEL PLUS
CONTOURDRESSING
PADS
COMFEEL PLUS
DRESSING PADS
COMFEEL PLUS
TRIANGLEDRESSING
PADS
COMFEEL PLUS ULCER
DRESSING PADS
COMFEEL PLUS
ULCERDRESSING PADS
COMFEEL ULCER
CAREDRESSING PADS
COMFORT-AID 1.5"X2.5"
PADS
CONTREET FOAM
CAVITY PADS
CONTREET FOAM HEEL
PADS
CONTREET FOAM PADS
CONTREET FOAM
SACRAL PADS
CONTREET
HYDROCOLLOID PADS
CURITY HEAVY
DRAINAGE PACK PADS
CURITY SALINE
DRESSING 8"X4" PADS
CURITY SODIUM
CHLORIDE DRESSING
6"X6-3/4" PADS
BIOBRANE 15"X20" PADS
BIOBRANE-L 10"X15"
PADS
BIOBRANE-L 5"X15"
PADS
Drug Name
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
RX/OTC
F
F
RX/OTC
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
DERMAGAUZE
DRESSING PADS
DERMAGRAN
HYDROPHILIC WOUND
DRESSING 2"X2" PADS
DERMAGRAN
HYDROPHILIC WOUND
DRESSING 4"X4" PADS
DERMAGRAN
HYDROPHILIC WOUND
DRESSING 8"X4" PADS
DOCTORS CHOICE
BURNS/SCALDS/ABRASI
ONS PADS
DOME-PASTE BANDAGE
PADS
DRAWTEX ADVANCED
WOUND CARE 2"X2"
PADS
DRAWTEX ADVANCED
WOUND CARE 3"X3"
PADS
DRAWTEX ADVANCED
WOUND CARE 4"X4"
PADS
DRAWTEX ADVANCED
WOUND CARE 6"X8"
PADS
DRAWTEX ADVANCED
WOUND CARE 8"X8"
PADS
Drug Requirements/
Tier Limits
F RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
RX/OTC
F
F
RX/OTC
F
RX/OTC
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
F
RX/OTC
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
Nebraska Total Care Updated May 30, 2017
70
Drug Requirements/
Tier Limits
F RX/OTC
EXU-DRY 4"X6" PADS
F
RX/OTC
EXU-DRY 6"X9" PADS
F
RX/OTC
F
RX/OTC
EXU-DRY 9"X15" PADS
F
RX/OTC
F
RX/OTC
F
RX/OTC
ELASTO-GEL 2"X3" PADS
ELASTO-GEL 3" ROUND
PADS
F
RX/OTC
ELASTO-GEL 4"X4" PADS
F
RX/OTC
ELASTO-GEL 5"X5" PADS
F
RX/OTC
ELASTO-GEL 6"X8" PADS
F
RX/OTC
F
RX/OTC
Drug Name
DUDRESS ISLAND
DRESSING 4"X4" PADS
DUDRESS ISLAND
DRESSING 6"X6" PADS
ELASTO-GEL 12"X12"
PADS
ELASTO-GEL 8"X16"
PADS
ELASTO-GEL
CAST/SPLINT 12"X12"
PADS
ELASTO-GEL
CAST/SPLINT 4"X4" PADS
ELASTO-GEL
CAST/SPLINT 6"X8" PADS
ELASTO-GEL
CAST/SPLINT 8"X16"
PADS
ELASTO-GEL FACE
MASK PADS
ELASTO-GEL PLUS 2"X3"
PADS
ELASTO-GEL PLUS 4"X4"
PADS
ELASTO-GEL PLUS 8"X8"
PADS
ELTA DERMAL WOUND
DRESSING PADS
RX/OTC
F
F
RX/OTC
F
RX/OTC
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
EXU-DRY 15"X24" PADS
F
RX/OTC
EXU-DRY 20"X28" PADS
F
RX/OTC
EXU-DRY 3"X4" PADS
F
RX/OTC
EXU-DRY 15"X18" PADS
Nebraska Total Care Updated May 30, 2017
71
Drug Name
EXU-DRY ARM 27"X31"
PADS
EXU-DRY
ARM/SHOULDER TIES
27"X31" PADS
EXU-DRY BURN JACKET
31"X32" PADS
EXU-DRY BURN JACKET
CHILD 17"X20" PADS
EXU-DRY BUTTOCKS
23"X53" PADS
EXU-DRY
ELBOW/KNEE/HEEL
10"X17" PADS
EXU-DRY FACE 9"X14"
PADS
EXU-DRY INCISION 3"X9"
PADS
EXU-DRY NONPERMEABLE PAD 24"X36"
PADS
EXU-DRY PADDED HAND
12"X13" PADS
EXU-DRY PADDED HAND
CHILD 8"X8" PADS
EXU-DRY PADDED NECK
6"X25" PADS
EXU-DRY PERMEABLE
PAD 24"X36" PADS
EXU-DRY SCALP 3"X14"
PADS
EXU-DRY SLIT TUBE
2"X3" PADS
FIBRACOL COLLAGENALGINATE WOUND
DRESSING/2" X 2" PADS
FIBRACOL COLLAGENALGINATE WOUND
DRESSING/4" X 8-3/4"
PADS
Drug Requirements/
Tier Limits
F RX/OTC
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
RX/OTC
F
F
RX/OTC
F
RX/OTC
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
RX/OTC
F
RX/OTC
F
Drug Name
FOAM DRESSING
BORDERED PADS
FOAM DRESSING
CIRCULAR BORDERED
PADS
FOAM DRESSING NONBORDERED PADS
GRX HYDROGEL GAUZE
2X2 PADS
GRX HYDROGEL GAUZE
4X4 PADS
Drug Requirements/
Tier Limits
F RX/OTC
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
HYCOLOID-GRX PADS
F
RX/OTC
HYDROCOL II PADS
F
RX/OTC
HYDROCOL II SACRAL
PADS
F
RX/OTC
HYDROCOL II THIN PADS
F
RX/OTC
F
RX/OTC
HYDROFERA BLUE 4"X4"
PADS
HYDROFERA BLUE
FOAM DRESSING 2"X2"
PADS
HYDROFERA BLUE
FOAM DRESSING 4"X4"
PADS
HYDROFERA BLUE
FOAM DRESSING 6"X6"
PADS
HYDROFERA BLUE
FOAM DRESSING PADS
HYDROFERA BLUE
FOAM
DRESSING/MOISTURE
RETENTIVE FILM PADS
HYDROFERA BLUE
FOAM
DRESSING/MOISTURE
RETENTIVE FILM/2-1/4X8
PADS
HYDROFERA BLUE
FOAM
DRESSING/MOISTURE
RETENTIVE FILM/4"X4"
PADS
RX/OTC
F
RX/OTC
F
RX/OTC
F
F
RX/OTC
RX/OTC
F
RX/OTC
F
RX/OTC
F
Drug Name
HYDROFERA BLUE
FOAM
DRESSING/MOISTURE
RETENTIVE FILM/ISLAND
PADS
HYDROFERA BLUE
FOAM
DRESSING/MOISTURE
RETENTIVE/OSTOMY/2.5"
PADS
HYDROFERA BLUE
FOAM
DRESSING/TUNNELING/9
MM PADS
HYDROFERA BLUE
HEAVY DRAINAGE 4"X4"
PADS
HYDROFERA BLUE
HEAVY DRAINAGE 6"X6"
PADS
HYDROFERA BLUE
READY FOAMDRESSING
2.5"X2.5" PADS
HYDROFERA BLUE
READY FOAMDRESSING
4"X5" PADS
HYDROFERA BLUE
READY FOAMDRESSING
8"X8" PADS
KALTOSTAT FORTEX
PADS
KALTOSTAT PADS
KALTOSTAT WOUND
DRESSING PADS
KENDALL ALGINATE
HYDROCOLLOID
DRESSING 4"X4" PADS
KENDALL ALGINATE
HYDROCOLLOID
DRESSING 4"X5" PADS
KENDALL ALGINATE
HYDROCOLLOID
DRESSING 6"X6" PADS
KENDALL ALGINATE
HYDROCOLLOID
DRESSING 6"X7" PADS
Drug Requirements/
Tier Limits
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
Nebraska Total Care Updated May 30, 2017
72
Drug Name
KENDALL ALGINATE
HYDROCOLLOID
DRESSING 8"X8" PADS
KENDALL ZINC CALCIUM
ALGINATE DRESSING
2"X2" PADS
KENDALL ZINC CALCIUM
ALGINATE DRESSING
4"X4" PADS
KENDALL ZINC CALCIUM
ALGINATE DRESSING
4"X8" PADS
KERAMATRIX REPLICINE
10CMX10CM PADS
KERAMATRIX REPLICINE
5CMX5CM PADS
KERLIX SUPER SPONGE
SALINE DRESSING PADS
MAXORB EXTRA AG+
PADS
MEDI-PAK
PERFORMANCE
PLUSCOMBINE ABD
PAD/8" X 7.5" PADS
MEDIHONEY CALCIUM
ALGINATE DRESSING
4"X5" PADS
MEDIHONEY CALCIUM
ALGINATE
DRESSING/2"X2" PADS
MEDIHONEY WOUND &
BURN DRESSING
3/4"X12" PADS
MEDIHONEY
WOUND/BURNDRESSING
4"X5" PADS
NU-GEL WOUND
DRESSING/3-3/4" X 3-3/4"
PADS
NU-GEL WOUND
DRESSING/6"X 8" PADS
POLYMEM ALGINATE
DRESSING/3" X 3" PADS
POLYMEM ALGINATE
DRESSING/4" X 4" PADS
POLYMEM ALGINATE
DRESSING/5" X 5" PADS
Drug Requirements/
Tier Limits
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
Nebraska Total Care Updated May 30, 2017
73
Drug Name
POLYMEM ALGINATE
DRESSING/6.5" X 7.5"
PADS
POLYMEM SILVER
DRESSING/4.25" X 4.25"
PADS
PRIMACOL BORDERED
DRESSING 2"X2" PADS
PRIMACOL BORDERED
DRESSING 4"X4" PADS
PRIMACOL BORDERED
DRESSING 6"X6" PADS
PRIMACOL DRESSING
4"X4" PADS
PRIMACOL DRESSING
6"X6" PADS
PRIMACOL DRESSING
8"X8" PADS
PRIMACOL SPECIALTY
DRESSING PADS
REPLICARE 1-1/2"X2-1/2"
PADS
Drug Requirements/
Tier Limits
RX/OTC
F
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
REPLICARE 4"X4" PADS
F
RX/OTC
REPLICARE 6"X6" PADS
F
RX/OTC
REPLICARE 8"X8" PADS
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
REPLICARE THIN
2"X2.75" PADS
REPLICARE THIN
3.5"X5.5" PADS
REPLICARE THIN 6"X8"
PADS
REPLICARE ULTRA 4"X4"
PADS
REPLICARE ULTRA 6"X6"
PADS
REPLICARE ULTRA
SACRUM 7"X8" PADS
RESTORE CX WOUND
CARE DRESSINGSTERILE PADS
RESTORE DRESSING
FOR PSORIASIS-STERILE
PADS
RX/OTC
F
RX/OTC
F
Drug Name
RESTORE EXTRA THIN
DRESSING 4"X4" PADS
RESTORE EXTRA THIN
DRESSING 6"X8" PADS
RESTORE EXTRA THIN
DRESSING 8"X8" PADS
RESTORE HYDROGEL
GAUZE PAD 4"X4" PADS
RESTORE PLUS WOUND
CARE DRESSING 4"X4"
PADS
RESTORE PLUS WOUND
CARE DRESSING 4"X4"
TAPERED EDGE PADS
RESTORE PLUS WOUND
CARE DRESSING 6"X6"
TAPERED EDGE PADS
RESTORE PLUS WOUND
CARE DRESSING 6"X8"
PADS
RESTORE PLUS WOUND
CARE DRESSING 6"X8"
TAPERED EDGE PADS
RESTORE PLUS WOUND
CARE DRESSING 8"X8"
PADS
RESTORE PLUS WOUND
CARE DRESSING 8"X8"
TAPERED EDGE PADS
RESTORE PLUS WOUND
CARE DRESSING
TRIANGLE PADS
RESTORE SILVER
DRESSING 2"X2" PADS
RESTORE SILVER
DRESSING 4"X4" NONADHESIVE PADS
RESTORE SILVER
DRESSING 4"X4.75"
PADS
RESTORE SILVER
DRESSING 4"X5"
CONTACT LAYER PADS
RESTORE SILVER
DRESSING 6"X8"
CONTACT LAYER PADS
Drug Requirements/
Tier Limits
F RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
F
RX/OTC
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
Drug Name
RESTORE SILVER
DRESSING 6"X8" NONADHESIVE PADS
RESTORE WOUND CARE
DRESSING 4"X4"
ADHESIVE PADS
RESTORE WOUND CARE
DRESSING 4"X4" NONADHESIVE PADS
RESTORE WOUND CARE
DRESSING 4"X4" PADS
RESTORE WOUND CARE
DRESSING 4"X5"
CONTACT LAYER PADS
RESTORE WOUND CARE
DRESSING 6"X6"
ADHESIVE PADS
RESTORE WOUND CARE
DRESSING 6"X8"
ADHESIVE PADS
RESTORE WOUND CARE
DRESSING 6"X8"
CONTACT LAYER PADS
RESTORE WOUND CARE
DRESSING 6"X8" NONADHESIVE PADS
RESTORE WOUND CARE
DRESSING 6"X8" PADS
RESTORE WOUND CARE
DRESSING 8"X8" PADS
RTD WOUND CARE
DRESSING2" X 2" PADS
RTD WOUND CARE
DRESSING4" X 4" PADS
RTD WOUND CARE
DRESSING4" X 5" PADS
SEASORB-AG PADS
SKINTEGRITY 2" X 2"
PADS
SKINTEGRITY 4" X 4"
PADS
SOLOSITE
CONFORMABLE WOUND
2"X2" PADS
Drug Requirements/
Tier Limits
RX/OTC
F
RX/OTC
F
RX/OTC
F
F
RX/OTC
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
RX/OTC
F
Nebraska Total Care Updated May 30, 2017
74
Drug Requirements/
Tier Limits
SOLOSITE
RX/OTC
F
CONFORMABLE WOUND
4"X4" PADS
SORBACELL FOAM
F RX/OTC
DRESSING 4"X4" PADS
SORBACELL FOAM
RX/OTC
F
DRESSINGSTRIP 1"X8"
PADS
SORBSAN TOPICAL
RX/OTC
F
WOUND DRESSING 12"
PADS
SORBSAN TOPICAL
RX/OTC
F
WOUND DRESSING 2" X
2" PADS
SORBSAN TOPICAL
RX/OTC
F
WOUND DRESSING 3 X 3
PADS
SORBSAN TOPICAL
RX/OTC
F
WOUND DRESSING 4 X 4
PADS
SORBSAN TOPICAL
RX/OTC
F
WOUND DRESSING 4" X
8" PADS
STRATASORB
RX/OTC
F
COMPOSITE ISLAND
DRESSING 4" X 4" PADS
TEGADERM AG MESH
RX/OTC
F
DRESSING WITH SILVER
2"X2" PADS
TEGADERM AG MESH
RX/OTC
F
DRESSING WITH SILVER
4"X5" PADS
TEGADERM AG MESH
RX/OTC
F
DRESSING WITH SILVER
4"X8" PADS
TEGADERM AG MESH
RX/OTC
F
DRESSING WITH SILVER
8"X8" PADS
TEGADERM ALGINATE
F RX/OTC
AG DRESSING PADS
TEGADERM HIGH
RX/OTC
F
GELLING ALGINATE
DRESSING 4"X4" PADS
TEGADERM HIGH
RX/OTC
F
INTEGRITY ALGINATE
DRESSING 4"X4" PADS
Drug Name
Nebraska Total Care Updated May 30, 2017
75
Drug Name
TEGADERM MATRIX
DRESSING PADS
TOE-AID PADS
TRIPLE HELIX
COLLAGEN 2"X2" PADS
ULTEC HYDROCOLLOID
DRESSING PADS
VASELINE PETROLATUM
GAUZE PADS
VASELINE PETROLATUM
GAUZECISION
DRESSING OVERWRAP
PADS
VASELINE PETROLATUM
GAUZECISION
DRESSING PADS
VASELINE PETROLATUM
GAUZEOVERWRAP PADS
VASELINE PETROLATUM
GAUZESTRIP
OVERWRAP PADS
VASELINE PETROLATUM
GAUZESTRIP PADS
VASELINE PETROLATUM
GAUZETUBE FOIL
OVERWRAP PADS
VIGILON PRIMARY
WOUND DRESSING/13" X
24" PADS
VIGILON PRIMARY
WOUND DRESSING/3" X
8" PADS
VIGILON PRIMARY
WOUND DRESSING/4" X
4" PADS
VIGILON PRIMARY
WOUND DRESSING/6" X
8" PADS
wound dressings pads
WOUNDGARD 2-1/2"X21/2" PADS
WOUNDGARD 4"X4-1/4"
PADS
WOUNDGARD 4"X6"
PADS
Drug Requirements/
Tier Limits
F RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
RX/OTC
F
RX/OTC
F
F
RX/OTC
RX/OTC
F
F
RX/OTC
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
Drug Name
XEROFLO DRESSING
1"X8" PADS
XEROFLO DRESSING
2"X2" PADS
XEROFLO DRESSING
5"X9" PADS
Drug Requirements/
Tier Limits
F RX/OTC
F
RX/OTC
F
RX/OTC
DIAGNOSTIC PRODUCTS
Diagnostic Drugs
GLUCAGEN DIAGNOSTIC
SOLR
Diagnostic Tests
ACCU-CHEK ACTIVE
STRIPS STRP
ACCU-CHEK AVIVA PLUS
STRP
F
NP RX/OTC
NP RX/OTC
ACCU-CHEK AVIVA STRP
NP RX/OTC
ACCU-CHEK COMPACT
PLUS STRP
ACCU-CHEK COMPACT
TEST DRUM STRP
ACCU-CHEK SMARTVIEW
STRIPS STRP
ACCUTREND GLUCOSE
STRP
ACURA BLOOD
GLUCOSE TESTSTRIPS
STRP
ADVANCE INTUITION
TEST STRIPS STRP
ADVANCE MICRO-DRAW
TEST STRIPS STRP
ADVOCATE REDI-CODE
STRP
ADVOCATE REDI-CODE+
TESTSTRIPS STRP
ADVOCATE TEST STRIPS
STRP
AGAMATRIX AMP NO
CODE TEST STRIPS
STRP
AGAMATRIX JAZZ TEST
STRIPS STRP
AGAMATRIX KEYNOTE
TEST STRIPS STRP
NP RX/OTC
NP RX/OTC
NP RX/OTC
NP RX/OTC
RX/OTC
NP
NP RX/OTC
NP RX/OTC
NP RX/OTC
NP RX/OTC
NP RX/OTC
RX/OTC
NP
NP RX/OTC
NP RX/OTC
Drug Name
AGAMATRIX PRESTO
TEST STRIPS STRP
ASSURE 3 TEST STRIPS
STRP
ASSURE 4 TEST STRIPS
STRP
ASSURE II CHECK STRIP
STRP
Drug Requirements/
Tier Limits
NP RX/OTC
NP RX/OTC
NP RX/OTC
NP RX/OTC
ASSURE II STRP
NP RX/OTC
ASSURE II TEST STRIPS
STRP
ASSURE PLATINUM TEST
STRIPS STRP
ASSURE PRISM MULTI
TEST STRIPS STRP
ASSURE PRO TEST
STRIPS STRP
AT LAST TEST STRIPS
STRP
BAYER CONTOUR
BLOOD GLUCOSE TEST
STRIPS STRP
BAYER CONTOUR NEXT
BLOODGLUCOSE TEST
STRP
BG STAR BLOOD
GLUCOSE TEST STRP
BIOSCANNER GLUCOSE
TEST STRIPS STRP
BLOOD GLUCOSE TEST
STRIPS PREMIUM STRP
BLOOD GLUCOSE TEST
STRIPS STRP
CAREONE BLOOD
GLUCOSE TEST
STRIPS/PREMIUM STRP
CAREONE BLOOD
GLUCOSE TEST
STRIPS/VALUE STRP
CARESENS N BLOOD
GLUCOSETEST STRIPS
STRP
CHEK-STIX COMBO PAK
URINALYSIS CONTROL
STRP
NP RX/OTC
NP RX/OTC
NP RX/OTC
NP RX/OTC
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
NP RX/OTC
NP RX/OTC
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
F
Nebraska Total Care Updated May 30, 2017
76
Drug Name
Drug Requirements/
Tier Limits
CHEK-STIX CONTROL
STRP
F
CHEMSTRIP-K STRP
F
Drug Name
EASY TRAK BLOOD
GLUCOSE TEST STRIPS
STRP
Drug Requirements/
Tier Limits
RX/OTC
NP
EASYGLUCO PLUS STRP
NP RX/OTC
EASYGLUCO STRP
NP RX/OTC
NP RX/OTC
NP RX/OTC
EASYMAX 15 TEST
STRIPS STRP
EASYMAX TEST STRIPS
STRP
EASYPLUS BLOOD
GLUCOSE TEST STRIP
STRP
EASYPRO BLOOD
GLUCOSE TEST STRIPS
STRP
CONTROL AST STRP
NP RX/OTC
EASYPRO PLUS STRP
NP RX/OTC
CONTROL TEST STRIPS
STRP
COOL BLOOD GLUCOSE
TEST STRIPS STRP
CVS ADVANCED
GLUCOSE METER TEST
STRIPS STRP
DIATRUE PLUS BLOOD
GLUCOSE TEST STRIPS
STRP
DUO-CARE TEST STRIPS
STRP
EASY PLUS BLOOD
GLUCOSE TEST STRIPS
STRP
EASY PLUS II BLOOD
GLUCOSE TEST STRP
EASY STEP TEST STRIPS
STRP
EASY TALK BLOOD
GLUCOSE TEST STRIPS
STRP
EASY TOUCH GLUCOSE
TEST STRIPS STRP
EASY TOUCH
HEALTHPRO GLUCOSE
TEST STRIPS STRP
NP RX/OTC
ELEMENT COMPACT
TEST STRIPS STRP
ELEMENT TEST STRIPS
STRP
EMBRACE BLOOD
GLUCOSE TEST STRIPS
STRP
EMBRACE EVO BLOOD
GLUCOSETEST STRIPS
STRP
EMBRACE PRO BLOOD
GLUCOSETEST STRIPS
STRP
EQ BLOOD GLUCOSE
TEST STRIPS STRP
EQL TRUETEST BLOOD
GLUCOSE TEST STRP
EQL TRUETRACK TEST
STRP
EVENCARE + BLOOD
GLUCOSETEST STRIP
STRP
EVENCARE BLOOD
GLUCOSE TEST STRIP
STRP
EVENCARE G2 TEST
STRIPS STRP
NP RX/OTC
CLEVER CHEK AUTOCODE TEST STRIPS
STRP
CLEVER CHEK AUTOCODE VOICE TEST
STRIPS STRP
CLEVER CHEK TEST
STRIPS STRP
CLEVER CHOICE AUTOCODE PRO TEST STRIPS
STRP
CLEVER CHOICE MICRO
TESTSTRIPS STRP
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
RX/OTC
NP
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
RX/OTC
NP
NP RX/OTC
NP RX/OTC
RX/OTC
NP
NP RX/OTC
RX/OTC
NP
Nebraska Total Care Updated May 30, 2017
77
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
NP RX/OTC
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
Drug Name
EVENCARE G3 TEST
STRIPS STRP
EVENCARE MINI BLOOD
GLUCOSE TEST STRIPS
STRP
EVOLUTION AUTOCODE
STRP
EXACTECH R-S-G TEST
STRIPS STRP
EXACTECH TEST STRIPS
STRP
EZ SMART BLOOD
GLUCOSE TEST STRIPS
STRP
EZ SMART PLUS BLOOD
GLUCOSE TEST STRIPS
STRP
FIFTY50 GLUCOSE TEST
STRIP 2.0 STRP
FORA BLOOD GLUCOSE
TEST STRIPS STRP
FORA D15G BLOOD
GLUCOSE TEST STRIPS
STRP
FORA D20 BLOOD
GLUCOSE TEST STRIPS
STRP
FORA D40/G31 BLOOD
GLUCOSE TEST STRIPS
STRP
FORA G20 BLOOD
GLUCOSE TEST STRIPS
STRP
FORA G30A BLOOD
GLUCOSE TEST STRIPS
STRP
FORA GD20 TEST
STRIPS STRP
FORA GD50 BLOOD
GLUCOSE TEST STRIPS
STRP
FORA TN'G/TN'G VOICE
BLOOD GLUCOSE TEST
STRIPS STRP
FORA V10 BLOOD
GLUCOSE TEST STRIPS
STRP
Drug Requirements/
Tier Limits
NP RX/OTC
Drug Name
Drug Requirements/
Tier Limits
RX/OTC
NP
NP RX/OTC
FORA V12 BLOOD
GLUCOSE TEST STRIPS
STRP
FORA V20 BLOOD
GLUCOSE TEST STRIPS
STRP
FORA V30A BLOOD
GLUCOSE TEST STRIPS
STRP
NP RX/OTC
FORACARE GD40 STRP
NP RX/OTC
FORACARE PREMIUM
V10 TESTSTRIPS STRP
FORACARE TEST N GO
TEST STRIPS STRP
FORTISCARE BLOOD
GLUCOSETEST STRIP
STRP
FREESTYLE INSULINX
BLOODGLUCOSE TEST
STRIPS STRP
FREESTYLE INSULINX
BLOODGLUCOSE TEST
STRP
FREESTYLE LITE TEST
STRIPS STRP
FREESTYLE PRECISION
NEO BLOOD GLUCOSE
TEST STRIPS STRP
FREESTYLE TEST
STRIPS STRP
GE100 BLOOD GLUCOSE
TESTSTRIPS STRP
NP RX/OTC
GENSTRIP 50 STRP
NP RX/OTC
GHT TEST STRIPS STRP
NP RX/OTC
GLUCO PERFECT 3 TEST
STRIPS STRP
GLUCOCARD 01 SENSOR
PLUS STRP
GLUCOCARD 01 SENSOR
PLUSTEST STRIPS STRP
GLUCOCARD
EXPRESSION BLOOD
GLUCOSE TEST STRIPS
STRP
NP RX/OTC
RX/OTC
NP
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
RX/OTC
NP
NP RX/OTC
NP RX/OTC
NP RX/OTC
NP RX/OTC
RX/OTC
NP
Nebraska Total Care Updated May 30, 2017
78
Drug Name
GLUCOCARD SHINE
TEST STRIPS STRP
GLUCOCARD VITAL TEST
STRIPS STRP
GLUCOCARD X-SENSOR
STRP
GLUCOCOM TEST
STRIPS STRP
GLUCONAVII BLOOD
GLUCOSETEST STRIPS
STRP
GLUCOSE METER TEST
STRIPS ADVANCED
STRP
GMATE BLOOD
GLUCOSE TESTSTRIPS
STRP
GNP EASY TOUCH
GLUCOSE TEST STRIPS
STRP
IN TOUCH BLOOD
GLUCOSE TEST STRIPS
STRP
INFINITY BLOOD
GLUCOSE TEST STRIPS
STRP
Drug Requirements/
Tier Limits
NP RX/OTC
NP RX/OTC
NP RX/OTC
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
KETOCARE STRP
F
KETONE TEST STRIPS
STRP
F
KETOSTIX STRP
F
KROGER BLOOD
GLUCOSE TESTSTRIPS
STRP
KROGER PREMIUM
BLOOD GLUCOSE TEST
STRIPS STRP
KROGER TEST STRIPS
STRP
LIBERTY NEXT
GENERATION BLOOD
GLUCOSE TEST STRIPS
STRP
LIBERTY TEST STRIPS
STRP
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
RX/OTC
NP
F
QL(3.34 ea
daily); RX/OTC
Nebraska Total Care Updated May 30, 2017
79
Drug Name
LIBERTY TEST STRIPS
STRP
MAXIMA BLOOD
GLUCOSE TESTSTRIPS
STRP
MEIJER BLOOD
GLUCOSE TESTSTRIPS
STRP
MEIJER ESSENTIAL
BLOOD GLUCOSE TEST
STRIPS STRP
MEIJER PREMIUM
BLOOD GLUCOSE TEST
STRIPS STRP
MEIJER TRUETEST
BLOOD GLUCOSE TEST
STRIPS STRP
MEIJER TRUETRACK
BLOOD GLUCOSE TEST
STRIPS STRP
MICRODOT TEST STRIPS
STRP
MYGLUCOHEALTH
BLOOD GLUCOSE TEST
STRP
NEUTEK 2TEK TEST
STRIPS STRP
NEXGEN TEST STRIPS
STRP
NOVA MAX GLUCOSE
TEST STRIPS STRP
NOVA MAX PLUS
KETONE TESTSTRIPS
STRP
ON CALL EXPRESS
BLOOD GLUCOSE TEST
STRIPS STRP
ON CALL PLUS BLOOD
GLUCOSE TEST STRP
ON CALL VIVID BLOOD
GLUCOSE TEST STRIPS
STRP
ON CALL VIVID BLOOD
GLUCOSE TEST STRP
ONETOUCH ULTRA BLUE
STRP
Drug Requirements/
Tier Limits
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
RX/OTC
NP
NP RX/OTC
NP RX/OTC
NP RX/OTC
F
RX/OTC
NP
NP RX/OTC
RX/OTC
NP
NP RX/OTC
NP RX/OTC
Drug Requirements/
Tier Limits
ONETOUCH VERIO TEST NP RX/OTC
STRIPS STRP
OPTIUM TEST STRIPS
NP RX/OTC
STRP
OPTIUMEZ TEST STRIPS NP RX/OTC
STRP
OPTUMRX BLOOD
NP RX/OTC
GLUCOSE TEST STRP
PHARMACIST CHOICE
RX/OTC
AUTOCODE BLOOD
NP
GLUCOSE TEST STRIPS
STRP
PHARMACIST CHOICE
RX/OTC
NO CODING BLOOD
NP
GLUCOSE TEST STRIPS
STRP
POCKETCHEM EZ
RX/OTC
NP
BLOOD GLUCOSE TEST
STRIPS STRP
PRECISION PCX PLUS
NP RX/OTC
TEST STRIPS STRP
NP RX/OTC
PRECISION PCX STRP
Drug Name
PRECISION POINT OF
CARE TEST STRIPS
STRP
PRECISION QID TEST
STRIPS STRP
PRECISION SOF-TACT
TEST STRIPS STRP
PRECISION XTRA BLOOD
GLUCOSE TEST STRIPS
STRP
PRECISION XTRA STRP
PREMIUM BLOOD
GLUCOSE TEST STRIPS
STRP
PRODIGY NO CODING
BLOOD GLUCOSE TEST
STRIPS STRP
PTS PANELS GLUCOSE
TEST STRP
PTS PANELS KETONE
TEST STRP
PTS PANELS KETONE
TEST STRP
RX/OTC
NP
NP RX/OTC
NP RX/OTC
RX/OTC
NP
F
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
F
NP
Drug Name
QUICKTEK TEST STRIPS
STRP
QUINTET AC BLOOD
GLUCOSETEST STRIPS
STRP
QUINTET BLOOD
GLUCOSE TEST STRIPS
STRP
RA TRUETEST STRIPS
STRP
REFUAH PLUS BLOOD
GLUCOSETEST STRIPS
STRP
RELION BLOOD
GLUCOSE TESTSTRIPS
STRP
RELION CONFIRM/MICRO
TEST STRIPS STRP
RELION KETONE STRP
RELION KETONE TEST
STRIPS STRP
RELION PRIME BLOOD
GLUCOSE TEST STRIPS
STRP
RELION ULTIMA BLOOD
GLUCOSE TEST STRIPS
STRP
RELION ULTIMA TEST
STRIPS STRP
REVEAL BLOOD
GLUCOSE TEST STRP
REXALL BLOOD
GLUCOSE TEST STRIPS
STRP
RIGHTEST GS100 BLOOD
GLUCOSE TEST STRIPS
STRP
RIGHTEST GS300 BLOOD
GLUCOSE TEST STRIPS
STRP
RIGHTEST GS550 BLOOD
GLUCOSE TEST STRIPS
STRP
SMART SENSE PREMIUM
BLOODGLUCOSE STRIPS
STRP
Drug Requirements/
Tier Limits
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
F
F
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
Nebraska Total Care Updated May 30, 2017
80
Drug Name
SMART SENSE VALUE
BLOOD GLUCOSE
STRIPS STRP
SMARTEST BLOOD
GLUCOSE TEST STRIPS
STRP
SOLUS V2 AUDIBLE TEST
STRP
SUPREME TEST STRIPS
STRP
SURE EDGE BLOOD
GLUCOSE TEST STRIPS
STRP
SURE-TEST EASYPLUS
MINI BLOOD GLUCOSE
TEST STRIPS STRP
SURECHEK BLOOD
GLUCOSE TEST STRIPS
STRP
TELCARE BLOOD
GLUCOSE TEST STRIPS
STRP
TGT BLOOD GLUCOSE
TEST STRIPS PREMIUM
STRP
TGT BLOOD GLUCOSE
TEST STRIPS STRP
TRUE METRIX BLOOD
GLUCOSETEST STRIPS
STRP
TRUE METRIX BLOOD
GLUCOSETEST STRIPS
STRP
TRUE METRIX SELF
MONITORING BLOOD
GLUCOSE STRIPS STRP
TRUE METRIX SELF
MONITORING BLOOD
GLUCOSE STRIPS STRP
TRUETEST BLOOD
GLUCOSE TEST STRIPS
STRP
TRUETEST BLOOD
GLUCOSE TEST STRP
TRUETEST STRIPS STRP
Drug Requirements/
Tier Limits
RX/OTC
NP
RX/OTC
TRUETRACK BLOOD
GLUCOSE TEST STRP
NP
TRUETRACK TEST STRP
NP RX/OTC
TRUETRACK TEST STRP
NP RX/OTC
ULTIMA TEST STRIPS
STRP
ULTRATRAK PRO TEST
STRIPS STRP
ULTRATRAK ULTIMATE
TEST STRIPS STRP
UNISTRIP1 GENERIC
STRP
VICTORY AGM-4000
TEST STRIPS STRP
VOCAL POINT BLOOD
GLUCOSE TEST STRIPS
STRP
WAVESENSE PRESTO
TEST STRIPS STRP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
NP RX/OTC
F
QL(3.34 ea
daily); RX/OTC
RX/OTC
NP
F
QL(3.34 ea
daily); RX/OTC
RX/OTC
NP
F
NP RX/OTC
NP RX/OTC
NP RX/OTC
NP RX/OTC
RX/OTC
NP
NP RX/OTC
Dietary Management Products
CARDIOTEK-RX TABS
F
FOLBEE AR TABS
F
Digestive Enzymes
QL(3.34 ea
daily); RX/OTC
LACTAID FAST ACT
CHEW (Lactase)
LACTAID FAST ACT TABS
(Lactase)
LACTAID TABS (Lactase)
F
QL(3.34 ea
daily); RX/OTC
NP RX/OTC
F
DIETARY PRODUCTS/DIETARY MANAGEMENT
PRODUCTS
CREON CPEP
F
QL(3.34 ea
daily); RX/OTC
NP RX/OTC
F
DIGESTIVE AIDS - Drugs to Treat Low Digestive
Enzymes
QL(3.34 ea
daily); RX/OTC
QL(3.34 ea
daily); RX/OTC
Nebraska Total Care Updated May 30, 2017
81
Drug Requirements/
Tier Limits
TRUETEST STRIPS STRP NP RX/OTC
Drug Name
F
NP
NP
NP
lactase chew
F
lactase tabs 9000 unit,
3000 unit
F
Drug Name
PANCREAZE CPEP
PANCRELIPASE CPEP
Drug Requirements/
Tier Limits
NP
Drug Name
TRIAMTERENE/HYDROC
HLOROTHIAZIDE CAPS
F
Loop Diuretics
PERTZYE CPEP
NP
bumetanide tabs
ULTRESA CPEP
NP PA
VIOKACE TABS
NP
BUMEX TABS
(Bumetanide)
DEMADEX TABS
(Torsemide)
ZENPEP CPEP
F
DIURETICS - Drugs to Treat Heart, Circulation
Conditions and Blood Pressure
Carbonic Anhydrase Inhibitors
furosemide soln ij 10 mg/ml
furosemide soln or 10
mg/ml
FUROSEMIDE SOLN OR 8
MG/ML
acetazolamide cp12
F
furosemide tabs
acetazolamide tabs
F
LASIX TABS (Furosemide)
DIAMOX CP12
(Acetazolamide)
NP
methazolamide tabs
F
NEPTAZANE TABS
(Methazolamide)
NP
Diuretic Combinations
ALDACTAZIDE TABS
25MG-25MG
(Spironolactone &
Hydrochlorothiazide)
amiloride &
hydrochlorothiazide tabs
DYAZIDE CAPS
(Triamterene &
Hydrochlorothiazide)
MAXZIDE TABS
(Triamterene &
Hydrochlorothiazide)
MAXZIDE-25 TABS
(Triamterene &
Hydrochlorothiazide)
spironolactone &
hydrochlorothiazide tabs
triamterene &
hydrochlorothiazide caps
triamterene &
hydrochlorothiazide tabs
NP
F
torsemide tabs
Drug Requirements/
Tier Limits
F
F
NP
NP
F
F
F
F
NP
F
Potassium Sparing Diuretics
ALDACTONE TABS
NP
(Spironolactone)
amiloride hcl tabs
F
spironolactone tabs
F
Thiazides and Thiazide-Like Diuretics
CHLOROTHIAZIDE TABS
F
250 MG
chlorothiazide tabs 500 mg
F
chlorthalidone tabs
F
hydrochlorothiazide caps
F
hydrochlorothiazide tabs 25
mg, 50 mg
F
indapamide tabs
F
F
metolazone tabs
F
F
MICROZIDE CAPS
(Hydrochlorothiazide)
NP
NP
NP
NP
F
Nebraska Total Care Updated May 30, 2017
82
Drug Name
Drug Requirements/
Tier Limits
Drug Name
ENDOCRINE AND METABOLIC AGENTS MISC. - Drugs to Treat Bone Disease and
Regulate Hormones
FOSAMAX TABS
(Alendronate Sodium)
Bone Density Regulators
ACTONEL TABS 150 MG
(Risedronate Sodium)
ACTONEL TABS 30 MG
(Risedronate Sodium)
ibandronate sodium tabs
ACTONEL TABS 35 MG
(Risedronate Sodium)
ACTONEL TABS 5 MG
(Risedronate Sodium)
ALENDRONATE SODIUM
SOLN
alendronate sodium tabs
10 mg, 5 mg
NP QL(0.034 ea
daily)
NP
Limit 4ea in 28
NP days;QL(0.143
ea daily)
NP QL(1 ea daily)
Limit 320ml per
NP month;QL(10.7
15 ml daily)
F QL(1 ea daily)
alendronate sodium tabs
35 mg, 70 mg
F
ALENDRONATE SODIUM
TABS 40 MG
F
Limit 4ea in 28
days;QL(0.143
ea daily)
ATELVIA TBEC
(Risedronate Sodium)
Limit 4ea in 28
NP days;QL(0.143
ea daily)
BINOSTO TBEF
NP
BONIVA TABS
(Ibandronate Sodium)
NP QL(0.034 ea
daily)
Limit 3.7ml per
F month;QL(0.12
4 ml daily)
NP QL(4 ea daily)
calcitonin (salmon) soln
ETIDRONATE DISODIUM
TABS 200 MG
ETIDRONATE DISODIUM
TABS 400 MG
FORTEO SOLN
FORTICAL SOLN
FOSAMAX PLUS D TABS
NP QL(1 ea daily)
NP
Limit 3.7ml per
NP month;QL(0.12
4 ml daily)
NP QL(0.143 ea
daily)
Nebraska Total Care Updated May 30, 2017
83
MIACALCIN SOLN IJ 200
UNIT/ML
MIACALCIN SOLN NA 200
UNIT/ACT (Calcitonin
(Salmon))
risedronate sodium tabs
150 mg
risedronate sodium tabs 30
mg
risedronate sodium tabs 35
mg
risedronate sodium tabs 5
mg
risedronate sodium tbec
Growth Hormones
GENOTROPIN MINIQUICK
SOLR
Drug Requirements/
Tier Limits
Limit 4ea in 28
NP days;QL(0.143
ea daily)
NP QL(0.034 ea
daily)
F
NP
NP QL(0.034 ea
daily)
NP
Limit 4ea in 28
NP days;QL(0.143
ea daily)
NP QL(1 ea daily)
Limit 4ea in 28
NP days;QL(0.143
ea daily)
NP
GENOTROPIN SOLR
NP
HUMATROPE COMBO
PACK SOLR
NP
HUMATROPE SOLR
NP
NORDITROPIN FLEXPRO
SOLN
NORDITROPIN
NORDIFLEX PEN SOLN
NUTROPIN AQ NUSPIN
10 SOLN
NUTROPIN AQ NUSPIN
20 SOLN
NUTROPIN AQ NUSPIN 5
SOLN
NUTROPIN AQ PEN SOLN
OMNITROPE SOLN 10
MG/1.5ML
F
PA
F
PA
F
PA
F
PA
F
PA
F
PA
NP
Drug Name
OMNITROPE SOLN 5
MG/1.5ML, 10 MG/1.5ML
OMNITROPE SOLR
Drug Requirements/
Tier Limits
NP PA
NP
SAIZEN CLICK.EASY
SOLR
F
PA
SAIZEN SOLR
F
PA
SAIZENPREP
RECONSTITUTIONKIT
SOLR
F
PA
SEROSTIM SOLR
NP
ZOMACTON SOLR
NP
ZORBTIVE SOLR
NP
desmopressin acetate tabs
Estrogen Combinations
ACTIVELLA TABS
(Estradiol & Norethindrone
Acetate)
Metabolic Modifiers
CARNITOR SF SOLN
(Levocarnitine (Metabolic
Modifiers))
CARNITOR SOLN OR 1
GM/10ML (Levocarnitine
(Metabolic Modifiers))
CARNITOR TABS
(Levocarnitine (Metabolic
Modifiers))
levocarnitine (metabolic
modifiers) soln
levocarnitine (metabolic
modifiers) tabs
ROCALTROL CAPS
(Calcitriol)
DDAVP TABS
(Desmopressin Acetate)
desmopressin acetate
refrigerated soln
desmopressin acetate
spray refrigerated soln
desmopressin acetate
spray soln
Drug Requirements/
Tier Limits
NP
F
F
PA
F
PA
F
ESTROGENS - Hormone Replacement/Modifying
Drugs
Hormone Receptor Modulators
EVISTA TABS (Raloxifene NP QL(1 ea daily)
HCl)
F QL(1 ea daily)
raloxifene hcl tabs
calcitriol caps
Drug Name
NP
COMBIPATCH PTTW
F
estradiol & norethindrone
acetate tabs
F
PREMPRO TABS
F
Estrogens
F
ALORA PTTW
CLIMARA PTWK
(Estradiol)
ESTRACE TABS
(Estradiol)
NP
NP
F
NP
NP
estradiol pttw
F
NP
estradiol ptwk
F
F
estradiol tabs
F
RX/OTC
F
RX/OTC
NP
Posterior Pituitary Hormones
DDAVP SOLN NA 0.01 %
NP
(Desmopressin Acetate
Refrigerated)
DDAVP SOLN NA 0.01 %
PA
NP
(Desmopressin Acetate
Spray)
estropipate tabs 0.75 mg,
1.5 mg
ESTROPIPATE TABS 0.75
MG, 3 MG, 1.5 MG
F
F
MINIVELLE PTTW
F
PREMARIN TABS
F
VIVELLE-DOT PTTW
(Estradiol)
NP
Nebraska Total Care Updated May 30, 2017
84
Drug Name
Drug Requirements/
Tier Limits
FLUOROQUINOLONES - Drugs to Treat Bacterial
Infections
Fluoroquinolones
AVELOX ABC PACK TABS
(Moxifloxacin HCl)
AVELOX TABS
(Moxifloxacin HCl)
CIPRO SUSR
(Ciprofloxacin)
CIPRO TABS
(Ciprofloxacin HCl)
CIPRO XR TB24
(Ciprofloxacin-Ciprofloxacin
HCl)
CIPROFLOXACIN HCL
TABS 100 MG
ciprofloxacin hcl tabs 750
mg, 500 mg, 250 mg
ciprofloxacin susr
ciprofloxacin-ciprofloxacin
hcl tb24
LEVAQUIN SOLN OR 25
MG/ML (Levofloxacin)
LEVAQUIN TABS
(Levofloxacin)
NP
NP
NP
NP
NP
F
NP
NP
NP
NP
simethicone caps
F
simethicone chew
F
simethicone susp
F
Bile Acid Synthesis Disorder Agents
CHOLBAM CAPS
NP
Farnesoid X Receptor (FXR) Agonists
NP QL(1 ea daily)
OCALIVA TABS
NP
NP
LEVOFLOXACIN SOLN
OR
NP
F
moxifloxacin hcl tabs
NP
OFLOXACIN TABS 300
MG
NP
ofloxacin tabs 400 mg
NP
GASTROINTESTINAL AGENTS - MISC. Miscellaneous Gastrointestinal Drugs
NP
NP
Nebraska Total Care Updated May 30, 2017
85
NP
NP
NP
Antiflatulents
GAS-X CHEW
(Simethicone)
GAS-X EXTRA
STRENGTH CHEW
(Simethicone)
MYLANTA GAS CHEW
(Simethicone)
MYLICON INFANTS GAS
RELIEF SUSP
(Simethicone)
MYLICON SUSP
(Simethicone)
PHAZYME CAPS
(Simethicone)
PHAZYME ULTRA
STRENGTH CAPS
(Simethicone)
Drug Requirements/
Tier Limits
F
levofloxacin soln or
levofloxacin tabs
Drug Name
NP
Gallstone Solubilizing Agents
ACTIGALL CAPS
NP
(Ursodiol)
CHENODAL TABS
URSO 250 TABS
(Ursodiol)
URSO FORTE TABS
(Ursodiol)
NP
NP
NP
ursodiol caps
NP
ursodiol tabs
F
Gastrointestinal Chloride Channel Activators
F AL
AMITIZA CAPS
Gastrointestinal Stimulants
metoclopramide hcl soln or
10 mg/10ml, 5 mg/5ml
metoclopramide hcl tabs
F
F
Drug Name
METOCLOPRAMIDE ODT
TBDP
METOZOLV ODT TBDP
(Metoclopramide HCl)
REGLAN TABS
(Metoclopramide HCl)
Drug Requirements/
Tier Limits
NP
sulfasalazine tbec
NP
Intestinal Acidifiers
lactulose (encephalopathy)
soln
NP
ASACOL HD TBEC
AZULFIDINE EN-TABS
TBEC (Sulfasalazine)
AZULFIDINE TABS
(Sulfasalazine)
alosetron hcl tabs
F
NP
NP
NP
balsalazide disodium caps
F
CANASA SUPP
F
CIMZIA KIT
CIMZIA STARTER KIT KIT
F
F
NP
DELZICOL CPDR
NP
DIPENTUM CAPS
NP
GIAZO TABS
NP
LIALDA TBEC
NP
MESALAMINE DR TBEC
NP
mesalamine enem
NP
mesalamine w/ cleanser kit
NP
F
NP
LINZESS CAPS 290 MCG,
145 MCG
F
LINZESS CAPS 72 MCG
F
LOTRONEX TABS
(Alosetron HCl)
NP
VIBERZI TABS
NP QL(2 ea daily)
RELISTOR TABS
Phosphate Binder Agents
AURYXIA TABS
calcium acetate (phosphate
binder) caps
calcium acetate (phosphate
binder) tabs
ELIPHOS TABS (Calcium
Acetate (Phosphate
Binder))
PA
NP QL(3 ea daily);
AL
NP
F
F
RX/OTC
RX/OTC
NP
FOSRENOL CHEW
NP
FOSRENOL PACK
NP
PHOSLO CAPS (Calcium
Acetate (Phosphate
Binder))
NP
PHOSLYRA SOLN
F
ROWASA KIT (Mesalamine NP
w/ Cleanser)
RENAGEL TABS
F
SFROWASA ENEM
NP
RENVELA PACK
NP
F
RENVELA TABS
NP
sulfasalazine tabs
QL(1 ea daily);
AL
Peripheral Opioid Receptor Antagonists
NP QL(1 ea daily)
MOVANTIK TABS
NP QL(1 ea per fill
retail)
NP QL(3 ea per fill
retail)
COLAZAL CAPS
(Balsalazide Disodium)
PENTASA CPCR
Drug Requirements/
Tier Limits
Irritable Bowel Syndrome (IBS) Agents
Inflammatory Bowel Agents
APRISO CP24
Drug Name
Nebraska Total Care Updated May 30, 2017
86
Drug Name
VELPHORO CHEW
Drug Requirements/
Tier Limits
NP
GENITOURINARY AGENTS - MISCELLANEOUS
- Miscellaneous Drugs to Treat Reproductive
Organs and Urinary System
Alkalinizers
potassium citrate
(alkalinizer) tbcr 1080 mg,
540 mg
SHOHLS SOLUTION
MODIFIED SOLN (Sodium
Citrate & Citric Acid)
sodium citrate & citric acid
soln
UROCIT-K 10 TBCR
(Potassium Citrate
(Alkalinizer))
UROCIT-K 5 TBCR
(Potassium Citrate
(Alkalinizer))
Genitourinary Irrigants
neomycin/polymyxin b gu
soln
NEOSPORIN GU
IRRIGANT SOLN
(Neomycin/Polymyxin B
GU)
sodium chloride (gu
irrigant) soln
RX/OTC
NP
RX/OTC
NP
NP
F
NP
F
Interstitial Cystitis Agents
ELMIRON CAPS
F
Prostatic Hypertrophy Agents
alfuzosin hcl tb24
F
AVODART CAPS
(Dutasteride)
NP
CARDURA XL TB24
NP
dutasteride caps
dutasteride-tamsulosin hcl
caps
finasteride tabs
FLOMAX CAPS
(Tamsulosin HCl)
JALYN CAPS (DutasterideTamsulosin HCl)
PROSCAR TABS
(Finasteride)
RAPAFLO CAPS
F
F
Drug Name
F
NP
F
87
NP
NP
NP
NP
tamsulosin hcl caps
F
UROXATRAL TB24
(Alfuzosin HCl)
NP
Urinary Analgesics
phenazopyridine hcl tabs
200 mg, 95 mg, 100 mg
PYRIDIUM TABS
(Phenazopyridine HCl)
F
NP
GOUT AGENTS - Drugs to Treat Gout
Gout Agent Combinations
colchicine w/ probenecid
tabs
Gout Agents
F
allopurinol tabs
F
COLCHICINE CAPS
NP
COLCHICINE TABS
NP
COLCRYS TABS
NP
MITIGARE CAPS
NP
ULORIC TABS
NP
ZURAMPIC TABS
NP QL(1 ea daily);
AL
ZYLOPRIM TABS
(Allopurinol)
NP
Uricosurics
probenecid tabs
F
HEMATOLOGICAL AGENTS - MISC. - Drugs to
Treat Blood Disorders
Hematorheologic Agents
Nebraska Total Care Updated May 30, 2017
Drug Requirements/
Tier Limits
Drug Name
pentoxifylline tbcr
Drug Requirements/
Tier Limits
FOLIC ACID SOLN
F
Plasma Kallikrein Inhibitors
KALBITOR SOLN
folic acid tabs 1 mg
F
PA
Platelet Aggregation Inhibitors
AGGRENOX CP12
F
(Aspirin-Dipyridamole)
aspirin-dipyridamole cp12
Drug Name
NP
Drug Requirements/
Tier Limits
F PA
F
folic acid tabs 400 mcg,
F
800 mcg
Hematopoietic Growth Factors
EPOGEN SOLN
F
GRANIX SOSY
NP
NP
BRILINTA TABS
F
cilostazol tabs
F
clopidogrel bisulfate tabs
F
MIRCERA SOSY 50
MCG/0.3ML, 200
MCG/0.3ML, 100
MCG/0.3ML, 75
MCG/0.3ML
dipyridamole tabs
F
NEUPOGEN SOLN
F
DURLAZA CP24
NP
NEUPOGEN SOSY
NP
EFFIENT TABS
F
PERSANTINE TABS
(Dipyridamole)
PLAVIX TABS (Clopidogrel
Bisulfate)
PROCRIT SOLN 10000
UNIT/ML, 40000 UNIT/ML,
4000 UNIT/ML, 3000
UNIT/ML, 2000 UNIT/ML,
20000 UNIT/ML
NP
NP
ZARXIO SOSY
PLETAL TABS (Cilostazol)
NP
ticlopidine hcl tabs
NP
YOSPRALA TBEC
NP MO
ZONTIVITY TABS
NP
Hematopoietic Mixtures
ferrous fumarate-fa-b
complex-c-zn-mg-mn-cu
tabs
folic acid-vitamin b6-vitamin
b12 tabs 115mcg-800mcg10mg
HEMATOPOIETIC AGENTS - Drugs to Treat
Blood Disorders
Cobalamins
B-12 DOTS TBDP
F
cyanocobalamin soln
F
cyanocobalamin tabs 100
mcg, 1000 mcg, 250 mcg,
500 mcg
cyanocobalamin tbcr 1000
mcg
Folic Acid/Folates
QL(1 ml per fill
retail)
F
F
RX/OTC
INTEGRA CAPS
iron polysaccharide
complex-vit b12-folic acid
caps
Iron
FEOSOL TABS 200 MG
(Ferrous Sulfate Dried)
FER-IN-SOL SOLN
(Ferrous Sulfate)
FERGON TABS (Ferrous
Gluconate)
F
NP
F
F
F
F
NP
NP
NP
Nebraska Total Care Updated May 30, 2017
88
Drug Name
ferrous fumarate tabs 324
mg
FERROUS GLUCONATE
TABS 225 MG
ferrous gluconate tabs 240
mg, 27 mg, 324 mg
Drug Requirements/
Tier Limits
F
F
F
ferrous sulfate dried tabs
F
ferrous sulfate elix
F
FERROUS SULFATE LIQD
F
ferrous sulfate soln
F
FERROUS SULFATE
SYRP
ferrous sulfate tabs 325
mg, 65 mg
FERROUS SULFATE
TBCR 140 MG
ferrous sulfate tbcr 142 mg,
45 mg
FERROUS SULFATE
TBEC 324 MG
HEMOCYTE TABS
(Ferrous Fumarate)
polysaccharide iron
complex caps 150 mg
SLOW FE TBCR (Ferrous
Sulfate)
F
F
F
F
F
NP
F
NP
HEMOSTATICS - Drugs to Stop Bleeding/Treat
Blood Disorders
Hemostatics - Systemic
AMICAR TABS 500 MG
F
PA
aminocaproic acid syrp
F
PA
F
PA
aminocaproic acid tabs 500
mg
LYSTEDA TABS
(Tranexamic Acid)
tranexamic acid tabs
NP Limit 1ea per
month
F Limit 1ea per
month
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
Antihistamine Hypnotics
Nebraska Total Care Updated May 30, 2017
89
Drug Name
diphenhydramine hcl
(sleep) caps 50 mg
diphenhydramine hcl
(sleep) tabs 25 mg
diphenhydramine hcl
(sleep) tabs 50 mg
diphenhydramineacetaminophen (sleep)
tabs 25mg-500mg, 30unit50mg-15mg-1.5mg-25mg18mg-2500unit-500mg10mg-1.7mg-6mcg400mcg-2mg, 25mg-25mg500mg-500mg
doxylamine succinate
(sleep) tabs
NYTOL MAXIMUM
STRENGTH TABS
(Diphenhydramine HCl
(Sleep))
TYLENOL PM EXTRA
STRENGTH TABS
(DiphenhydramineAcetaminophen (sleep))
UNISOM SLEEPGELS
CAPS (Diphenhydramine
HCl (Sleep))
UNISOM TABS
(Doxylamine Succinate
(Sleep))
Barbiturate Hypnotics
Drug Requirements/
Tier Limits
F
F
F
F
F
NP
NP
NP
NP
phenobarbital elix
F
phenobarbital soln
F
PHENOBARBITAL TABS
100 MG, 60 MG, 15 MG,
30 MG
phenobarbital tabs 64.8
mg, 97.2 mg, 16.2 mg, 32.4
mg
QL(1 ea daily)
F
F
Hypnotics - Tricyclic Agents
SILENOR TABS
NP
Non-Barbiturate Hypnotics
AMBIEN CR TBCR
(Zolpidem Tartrate)
NP ST
Drug Name
AMBIEN TABS (Zolpidem
Tartrate)
Drug Requirements/
Tier Limits
NP QL(1 ea daily)
EDLUAR SUBL
F
estazolam tabs
NP
eszopiclone tabs
F
FLURAZEPAM HCL CAPS
F
ST
PA; QL(1 ea
daily); AL
ST
HALCION TABS
(Triazolam)
INTERMEZZO SUBL
(Zolpidem Tartrate)
LUNESTA TABS
(Eszopiclone)
RESTORIL CAPS
(Temazepam)
NP ST
SONATA CAPS (Zaleplon)
NP
temazepam caps 22.5 mg,
7.5 mg
temazepam caps 30 mg,
15 mg
TRIAZOLAM TABS 0.125
MG
NP QL(1 ea daily)
NP PA; QL(1 ea
daily); AL
NP
NP
F
ST
triazolam tabs 0.25 mg
F
ST
zaleplon caps
F
NP QL(1 ea daily)
zolpidem tartrate tabs
F
QL(1 ea daily)
zolpidem tartrate tbcr
F
ST
ZOLPIMIST SOLN
NP
Orexin Receptor Antagonists
BELSOMRA TABS
NP QL(1 ea daily);
AL
Selective Melatonin Receptor Agonists
NP QL(1 ea daily)
HETLIOZ CAPS
ROZEREM TABS
F
PA; QL(1 ea
daily); AL
Drug Requirements/
Tier Limits
LAXATIVES - Bowel Treatment Drugs
Bulk Laxatives
calcium polycarbophil tabs
F
CITRUCEL FIBER
LAXATIVE POWD
(Methylcellulose (Laxative))
NP
EVAC POWD (Psyllium)
NP
FIBERCON TABS (Calcium
Polycarbophil)
HYDROCIL INSTANT
POWD (Psyllium)
KONSYL POWD 100 %
(Psyllium)
METAMUCIL CAPS
(Psyllium)
methylcellulose (laxative)
powd
psyllium caps
F
zolpidem tartrate subl
Drug Name
psyllium powd 95 %, 28.3
%, 100 %
Laxative Combinations
COLYTE-FLAVOR PACKS
SOLR 240GM-22.72GM5.84GM-2.98GM-6.72GM
(PEG 3350-KCl-Sod
Bicarb-Sod Chloride-Sod
Sulfate)
GOLYTELY SOLR 236GM22.74GM-5.86GM-2.97GM6.74GM (PEG 3350-KClSod Bicarb-Sod ChlorideSod Sulfate)
NULYTELY/FLAVOR
PACKS SOLR (PEG 3350Potassium Chloride-Sod
Bicarbonate-Sod Chloride)
peg 3350-kcl-sod bicarbsod chloride-sod sulfate
solr
peg 3350-potassium
chloride-sod bicarbonatesod chloride solr
NP
NP
NP
NP
F
F
F
NP
NP
NP
F
F
Nebraska Total Care Updated May 30, 2017
90
Drug Name
sennosides-docusate
sodium tabs
SENOKOT S TABS
(Sennosides-Docusate
Sodium)
Laxatives - Miscellaneous
glycerin (laxative) supp 1
gm, 80.7 %, 2 gm, 1.2 gm
GLYCERIN ADULT SUPP
(Glycerin (Laxative))
lactulose soln
MIRALAX POWD
(Polyethylene Glycol 3350)
PEDIA-LAX SUPP 1 GM
(Glycerin (Laxative))
polyethylene glycol 3350
powd or
Saline Laxatives
FLEET ENEMA ENEM
(Sodium Phosphates)
FLEET ENEMA SIX PACK
ENEM (Sodium
Phosphates)
FLEET PEDIATRIC ENEM
(Sodium Phosphates)
Drug Requirements/
Tier Limits
F QL(4 ea daily)
QL(4 ea daily)
NP
F
NP
F
NP QL(34 gm
daily); RX/OTC
NP
F
QL(34 gm
daily); RX/OTC
NP
NP
F
magnesium hydroxide susp
F
sodium phosphates enem
F
bisacodyl tbec
QL(32 ml daily)
DULCOLAX SUPP
(Bisacodyl)
DULCOLAX TBEC
(Bisacodyl)
EX-LAX MAXIMUM
STRENGTH TABS
(Sennosides)
sennosides liqd
F
F
QL(1 ea daily)
NP
NP QL(1 ea daily)
NP
F
Nebraska Total Care Updated May 30, 2017
91
sennosides tabs 8.6 mg, 25
mg
SENOKOT TABS
(Sennosides)
Surfactant Laxatives
COLACE CAPS (Docusate
Sodium)
F
F
NP
NP QL(3 ea daily)
docusate calcium caps
F
docusate sodium caps 100
mg
F
docusate sodium liqd
F
docusate sodium syrp
F
QL(3 ea daily)
MACROLIDES - Drugs to Treat Bacterial
Infections
AZITHROMYCIN PACK
F
azithromycin susr
F
azithromycin tabs
F
ZITHROMAX PACK
Stimulant Laxatives
bisacodyl supp
sennosides syrp
Drug Requirements/
Tier Limits
Azithromycin
NP
magnesium citrate soln
Drug Name
ZITHROMAX SUSR
(Azithromycin)
ZITHROMAX TABS
(Azithromycin)
ZITHROMAX TRI-PAK
TABS (Azithromycin)
ZITHROMAX Z-PAK TABS
(Azithromycin)
ZMAX SUSR
Clarithromycin
BIAXIN SUSR
(Clarithromycin)
BIAXIN TABS
(Clarithromycin)
clarithromycin susr
NP
NP
NP
NP
NP
NP QL(1 ea per fill
retail)
NP
NP
F
Drug Name
Drug Requirements/
Tier Limits
clarithromycin tabs
F
clarithromycin tb24
NP
Erythromycins
E.E.S. 400 TABS
NP
E.E.S. GRANULES SUSR
(Erythromycin
Ethylsuccinate)
F
ERY-TAB TBEC
F
ERYPED 200 SUSR
(Erythromycin
Ethylsuccinate)
NP
ERYPED 400 SUSR
F
ERYTHROCIN STEARATE
TABS
NP
erythromycin base cpep
NP
ERYTHROMYCIN BASE
TABS
erythromycin
ethylsuccinate susr
ERYTHROMYCIN
ETHYLSUCCINATE TABS
PCE TBEC
NP
F
NP
F
Fidaxomicin
DIFICID TABS
NP
MEDICAL DEVICES AND SUPPLIES
Contraceptives
AIMSCO LUBRICATED
MISC
ATLAS COLORED
LUBRICATEDCONDOM
DEVI
ATLAS LUBRICATED
CONDOM DEVI
ATLAS LUBRICATED
CONDOM/SPERMICIDE
DEVI
CLASS ACT LUBRICATED
MISC
F
F
F
F
Drug Name
DUREX EXTRA
SENSITIVE DEVI
ELEXA NATURAL FEEL
MISC
ELEXA STIMULATING
MISC
ELEXA ULTRA SENSITIVE
MISC
EXTRA SENSITIVE
SPERMICIDAL DEVI
FANTASY LUBRICATED
MISC
FANTASY
LUBRICATED/SPERMICID
E MISC
HIGH SENSATION
SPERMICIDAL DEVI
INTENSE SENSATION
DEVI
KAMELEON LUBRICATED
MISC
KIMONO COLORS DEVI
KIMONO LUBRICATED
MISC
KIMONO MICRO THIN
PLUS SPERMICIDE
LUBRICATED MISC
KIMONO PLUS
SPERMICIDE
LUBRICATED MISC
KIMONO PLUS
SPERMICIDE/LUBRICATE
D MISC
KIMONO PS LUBRICATED
MISC
KIMONO PS PLUS
SPERMICIDE/LUBRICATE
D MISC
KIMONO SENSATION
LUBRICATED MISC
KIMONO SENSATION
PLUS SPERMICIDE
LUBRICATED MISC
KIMONO SPECIAL DEVI
Drug Requirements/
Tier Limits
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
Nebraska Total Care Updated May 30, 2017
92
Drug Name
MAXX LUBRICATED MISC
MAXX PLUS SPERMICIDE
LUBRICATED MISC
PREMIUM CONDOMS
LUBRICATED MISC
REALITY LATEX
CONDOMS/LUBRICATED
MISC
REALITY LATEX/ULTRA
TEXTURED DEVI
REALITY LATEX/ULTRA
THIN DEVI
TROJAN EXTENDED
PLEASURE/LUBRICATED
DEVI
TROJAN MAGNUM MISC
TROJAN MAGNUM WARM
SENSATIONS DEVI
TROJAN MAGNUM XL
LUBRICATED DEVI
TROJAN PLEASURE
MESH/SPERMICIDAL
DEVI
TROJAN RIBBED
W/SPERMICIDAL MISC
TROJAN SHARED
SENSATION/LUBRICATE
D DEVI
TROJAN SUPRAS
SPERMICIDAL DEVI
TROJAN TWISTED
PLEASURE DEVI
TROJAN ULTRA
PLEASURE/LUBRICATED
DEVI
TROJAN VERY
SENSITIVE LUBRICATED
MISC
TROJAN VERY
SENSITIVE SPERMICIDAL
LUBRICANT MISC
TROJAN VERY THIN
LUBRICATED MISC
Drug Requirements/
Tier Limits
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
Nebraska Total Care Updated May 30, 2017
93
Drug Name
TROJAN VERY THIN
SPERMICIDAL
LUBRICANT MISC
TROJAN-ENZ LUBRICANT
MISC
TROJAN-ENZ
LUBRICATED MISC
TROJAN-ENZ
W/SPERMICIDAL MISC
TRUSTEX COLOR
CONDOMS + LUBE MISC
TRUSTEX LUBRICATED
EXTRALARGE MISC
TRUSTEX LUBRICATED
EXTRASTRENGTH MISC
TRUSTEX LUBRICATED
MISC
TRUSTEX
LUBRICATED/RIBBED/ST
UDDED MISC
TRUSTEX
LUBRICATED/SPERMICID
E EXTRA LARGE MISC
TRUSTEX
LUBRICATED/SPERMICID
E EXTRA STRENGTH
MISC
TRUSTEX
LUBRICATED/SPERMICID
E MISC
TRUSTEX NATURAL
CONDOMS
+LUBE/LUBRICATED
MISC
TRUSTEX WITH
NONOXYNOL9/RIBBED/STUDDED
MISC
TRUSTEX/RIA
LUBRICATED MISC
TRUSTEX/RIA
LUBRICATED
SPERMICIDE MISC
TRUSTEX/RIA
LUBRICATED/SPERMICID
E MISC
Drug Requirements/
Tier Limits
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
Drug Name
ULTIMATE FEELING DEVI
Diabetic Supplies
1ST CHOICE LANCETS
SUPERTHIN MISC
1ST CHOICE LANCETS
THIN MISC
1ST CHOICE LANCETS
ULTRATHIN MISC
1ST TIER UNILET
COMFORTOUCH
LANCETS 28G MISC
1ST TIER UNILET
COMFORTOUCH
LANCETS 30G MISC
ACCU-CHEK ACTIVE
GLUCOSECONTROL
SOLUTION LIQD
ACCU-CHEK AVIVA SOLN
ACCU-CHEK COMPACT
PLUS CLEAR CONTROL
SOLUTION (2 LEVELS)
SOLN
ACCU-CHEK FASTCLIX
LANCETS MISC
ACCU-CHEK MULTICLIX
LANCETS MISC
ACCU-CHEK SAFE-T-PRO
LANCETS MISC
ACCU-CHEK SAFE-T-PRO
PLUSLANCETS MISC
ACCU-CHEK SMARTVIEW
CONTROL LIQD
ACCU-CHEK SOFT
TOUCH LANCETS MISC
ACCU-CHEK SOFTCLIX
LANCETS MISC
ACCUTREND GLUCOSE
CONTROL SOLN
ACTI-LANCE LANCETS
28G MISC
ACTI-LANCE LITE
SAFETY LANCETS 28G
MISC
Drug Requirements/
Tier Limits
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
F
F
F
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
Drug Name
ACTI-LANCE SPECIAL
SAFETY LANCETS 17G
MISC
ACTI-LANCE SPECIAL
SAFETYLANCETS 17G
MISC
ACTI-LANCE UNIVERSAL
SAFETY LANCETS 23G
MISC
ACTIVE 1ST BLOOD
LANCETS30G/EASY
TWIST CAP MISC
ACURA CONTROL
SOLUTION HIGH SOLN
ACURA CONTROL
SOLUTION LOW SOLN
ACURA CONTROL
SOLUTION NORMAL
SOLN
ADJUSTABLE LANCING
DEVICE MISC
ADVANCE INTUITION
CONTROL SOLUTION
LIQD
ADVANCE MICRO-DRAW
CONTROL LEVEL 1-2
LIQD
ADVANCE MICRO-DRAW
NORMAL CONTROL LIQD
ADVOCATE CONTROL
SOLUTIONHIGH LIQD
ADVOCATE CONTROL
SOLUTIONLOW LIQD
ADVOCATE LANCETS
30G MISC
ADVOCATE LANCETS
MISC
ADVOCATE LANCING
DEVICE MISC
ADVOCATE RAPID-SAFE
LANCING DEVICE MISC
ADVOCATE REDI-CODE+
CONTROL SOLUTION
HIGH SOLN
ADVOCATE REDI-CODE+
CONTROL SOLUTION
LOW SOLN
Drug Requirements/
Tier Limits
NP
NP
NP
NP
NP
NP
NP
F
QL(1 ea per
160 days retail)
NP
NP
NP
NP
NP
NP
NP
F
F
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
NP
NP
Nebraska Total Care Updated May 30, 2017
94
Drug Name
ADVOCATE SAFETY
LANCETS 26G MISC
ADVOCATE SAFETY
LANCETS MISC
AGAMATRIX CONTROL
HIGH SOLN
AGAMATRIX CONTROL
NORMAL SOLN
AGAMATRIX CONTROL
NORMAL& HIGH SOLN
AGAMATRIX ULTRA-THIN
LANCETS 33G MISC
ALTERNATE SITE
LANCING DEVICE MISC
AQUA LANCE
ADJUSTABLE LANCING
DEVICE DEVI
ASSURE 3 CONTROL
LEVEL 1/2 LIQD
ASSURE 4 CONTROL
LEVEL 1/2 LIQD
ASSURE COMFORT
LANCETS ULTRA THIN
28G MISC
ASSURE COMFORT
LANCETS ULTRA THIN
30G MISC
ASSURE DOSE NORMAL
CONTROL SOLN
ASSURE DOSE
NORMAL/HIGH CONTROL
SOLN
ASSURE HAEMOLANCE
PLUS HIGH FLOW 18G
MISC
ASSURE HAEMOLANCE
PLUS LOW FLOW 25G
MISC
ASSURE HAEMOLANCE
PLUS MICRO FLOW 28G
MISC
ASSURE HAEMOLANCE
PLUS NORMAL FLOW
21G MISC
ASSURE HAEMOLANCE
PLUS PEDIATRIC BLADE
MISC
Drug Requirements/
Tier Limits
NP
NP
NP
NP
NP
F
F
F
QL(6.67 ea
daily)
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
NP
NP
NP
ASSURE II CONTROL
LEVEL 1 LIQD
ASSURE II CONTROL
LEVEL 1/2 LIQD
ASSURE LANCE
LANCETS 21G MISC
ASSURE LANCE
LANCETS MISC
ASSURE LANCE PLUS
SAFETYLANCETS 25G
MISC
ASSURE LANCE PLUS
SAFETYLANCETS 30G
MISC
ASSURE LANCETS MISC
ASSURE PRISM
CONTROL LEVEL 1/2
SOLN
ASSURE PRO CONTROL
LEVEL1/2 LIQD
AT LAST CONTROL
SOLUTION SOLN
AT LAST LANCETS MISC
NP
NP
NP
NP
NP
NP
NP
NP
Nebraska Total Care Updated May 30, 2017
95
Drug Name
AURORA LANCET SUPER
THIN30G MISC
AURORA LANCET THIN
23G MISC
Drug Requirements/
Tier Limits
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
F
F
AUTO-LANCET MINI MISC
F
AUTO-LANCET MISC
F
AUTOLET IMPRESSION
LANCING DEVICE MISC
AUTOLET LANCING
DEVICE MISC
F
F
AUTOLET MINI MISC
F
AUTOLET PLUS MISC
F
BAYER BREEZE 2 HIGH
CONTROL LIQD
BAYER BREEZE 2 LOW
CONTROL LIQD
NP
NP
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
Drug Name
BAYER BREEZE 2
NORMAL CONTROL LIQD
BAYER CONTOUR HIGH
CONTROL LIQD
BAYER CONTOUR LOW
CONTROL LIQD
BAYER CONTOUR NEXT
CONTROL LEVEL 1 SOLN
BAYER CONTOUR NEXT
CONTROL LEVEL 2 SOLN
BAYER CONTOUR
NORMAL CONTROL LIQD
BAYER MICROLET 2
LANCING DEVICE MISC
BAYER MICROLET
LANCETS MISC
BD LANCET DEVICE
MISC
BD LANCET ULTRAFINE
30G MISC
BD LANCET ULTRAFINE
30G MISC
BD LANCET ULTRAFINE
33G MISC
BD MICROTAINER
LANCETS MISC
BULLSEYE MINI SAFETY
LANCETS MISC
BULLSEYE SAFETY
LANCETS MISC
CARDIOCOM LANCING
DEVICE MISC
CAREONE ADVANCED
LANCINGDEVICE MISC
CAREONE LANCET THIN
MISC
CAREONE LANCET
ULTRA THIN MISC
CARESENS CONTROL A
SOLUTION SOLN
CARETOUCH LANCING
DEVICEWITH EJECTOR
MISC
CARETOUCH TWIST
LANCETS 30G MISC
Drug Requirements/
Tier Limits
NP
NP
NP
NP
NP
NP
F
QL(1 ea per
160 days retail)
NP
F
QL(1 ea per
160 days retail)
NP
F
QL(6.67 ea
daily)
NP
NP
NP
NP
F
F
F
F
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
F
QL(1 ea per
160 days retail)
NP
Drug Requirements/
Tier Limits
CLEANLET LANCETS 28G F QL(6.67 ea
MISC
daily)
CLEVER CHEK LANCETS NP
ULTRATHIN 30G MISC
CLEVER CHEK LANCETS NP
ULTRATHIN MISC
CLEVER CHOICE
NP
GLUCOSE CONTROL
HIGH LIQD
CLEVER CHOICE
NP
GLUCOSE CONTROL
LOW LIQD
F QL(1 ea per
CLOSERCARE MISC
160 days retail)
COAGUCHEK LANCETS
NP
MISC
COMFORT ASSURED
NP
LANCETS MICRO THIN
33G MISC
COMFORT ASSURED
QL(6.67 ea
F daily)
LANCETS SUPER THIN
28G MISC
COMFORT ASSURED
NP
LANCETS SUPER THIN
28G MISC
COMFORT LANCETS
F QL(6.67 ea
MISC
daily)
CONTROL SOLUTION
NP
NORMAL SOLN
COOL CONTROL
NP
SOLUTION A SOLN
COOL CONTROL
NP
SOLUTION B SOLN
F QL(6.67 ea
CVS LANCETS 21G MISC
daily)
CVS LANCETS MICRO
F QL(6.67 ea
THIN 33G MISC
daily)
CVS LANCETS MICROF QL(6.67 ea
THIN 33G MISC
daily)
CVS LANCETS ORIGINAL
F QL(6.67 ea
MISC
daily)
CVS LANCETS THIN 26G
F QL(6.67 ea
MISC
daily)
CVS LANCETS ULTRA
F QL(6.67 ea
THIN 30G MISC
daily)
Drug Name
Nebraska Total Care Updated May 30, 2017
96
Drug Name
CVS LANCETS ULTRATHIN 30G MISC
CVS LANCING DEVICE
MISC
CVS ULTRA THIN
LANCETS MISC
DIASTAR EASY TEST II
LANCETS 30G MISC
DIASTAR EASY TEST
LANCETS30G MISC
DIATRUE GLUCOSE
CONTROL SOLUTION
LEVEL 1 SOLN
DIATRUE GLUCOSE
CONTROL SOLUTION
LEVEL 2 SOLN
DIATRUE GLUCOSE
CONTROL SOLUTION
LEVEL 3 SOLN
DROPLET LANCETS
ULTRA THIN 30G MISC
DROPLET LANCING
DEVICE MISC
DRUG MART
ADJUSTABLE LANCING
DEVICE MISC
DRUG MART LANCETS
THIN MISC
DRUG MART ON-THE-GO
LANCETS GENTLE 30G
MISC
DRUG MART UNILET
LANCETSSUPER THIN
30G MISC
DRUG MART UNILET
LANCETSULTRA THIN
28G MISC
DUANE READE LANCET
ALTERNATE SITE 26G
MISC
DUANE READE LANCET
SUPERTHIN 30G MISC
DUANE READE LANCET
ULTRATHIN 28G MISC
DUO-CARE CONTROL
SOLUTION LIQD
Drug Requirements/
Tier Limits
F QL(6.67 ea
daily)
F QL(1 ea per
160 days retail)
F QL(6.67 ea
daily)
NP
NP
NP
NP
NP
F
F
F
F
QL(6.67 ea
daily)
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
QL(6.67 ea
daily)
NP
F
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
Nebraska Total Care Updated May 30, 2017
97
Drug Requirements/
Tier Limits
E-Z JECT LANCETS 21G
F QL(6.67 ea
MISC
daily)
E-Z JECT LANCETS
F QL(6.67 ea
COLOR MISC
daily)
F QL(6.67 ea
E-Z JECT LANCETS MISC
daily)
E-Z JECT LANCETS
F QL(6.67 ea
SUPER THIN 30G MISC
daily)
E-Z JECT LANCETS THIN
F QL(6.67 ea
26G MISC
daily)
E-ZJECT LANCETS
F QL(6.67 ea
MICRO-THIN 33G MISC
daily)
EASY COMFORT
LANCETS 30G/PULL TOP NP
MISC
EASY COMFORT
NP
LANCETS 30G/THIN TOP
MISC
EASY COMFORT
NP
LANCETS MISC
EASY MINI EJECT
F QL(1 ea per
LANCING DEVICE MISC
160 days retail)
EASY MINI LANCING
F QL(1 ea per
DEVICE MISC
160 days retail)
EASY PLUS II CONTROL
NP
SOLUTION HIGH SOLN
EASY PLUS II CONTROL
NP
SOLUTION LOW SOLN
EASY STEP CONTROL
NP
SOLUTION HIGH SOLN
EASY STEP CONTROL
NP
SOLUTION LOW SOLN
EASY STEP CONTROL
NP
SOLUTION NORMAL
SOLN
EASY TALK CONTROL
NP
SOLUTION HIGH SOLN
EASY TALK CONTROL
NP
SOLUTION LOW SOLN
EASY TALK CONTROL
NP
SOLUTION NORMAL
SOLN
EASY TOUCH CONTROL
NP
SOLUTION/HIGH & LOW
SOLN
Drug Name
Drug Name
EASY TOUCH
HEALTHPRO CONTROL
SOLUTION/HIGH & LOW
SOLN
EASY TOUCH LANCETS
21G/PRESSURE
ACTIVATED MISC
EASY TOUCH LANCETS
23G/PRESSURE
ACTIVATED MISC
EASY TOUCH LANCETS
26G/PRESSURE
ACTIVATED MISC
EASY TOUCH LANCETS
26G/PULL-TOP MISC
EASY TOUCH LANCETS
26G/TWIST MISC
EASY TOUCH LANCETS
28G/PRESSURE
ACTIVATED MISC
EASY TOUCH LANCETS
28G/PULL-TOP MISC
EASY TOUCH LANCETS
28G/TWIST MISC
EASY TOUCH LANCETS
30G/BUTTON-ACTIVATED
MISC
EASY TOUCH LANCETS
30G/PRESSURE
ACTIVATED MISC
EASY TOUCH LANCETS
30G/PULL-TOP MISC
EASY TOUCH LANCETS
30G/TWIST MISC
EASY TOUCH LANCETS
32G/PRESSURE
ACTIVATED MISC
EASY TOUCH LANCETS
32G/PULL-TOP MISC
EASY TOUCH LANCETS
32G/TWIST MISC
EASY TOUCH LANCETS
33G/TWIST MISC
EASY TOUCH LANCING
DEVICE/EJECTOR MISC
Drug Requirements/
Tier Limits
NP
NP
NP
NP
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
NP
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
F
F
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(1 ea per
160 days retail)
Drug Name
EASY TOUCH SAFETY
LANCETS21G/PRESSURE
ACTIVATED MISC
EASY TOUCH SAFETY
LANCETS23G/PRESSURE
ACTIVATED MISC
EASY TOUCH SAFETY
LANCETS26G/BUTTON
ACTIVATED MISC
EASY TOUCH SAFETY
LANCETS26G/PRESSURE
ACTIVATED MISC
EASY TOUCH SAFETY
LANCETS28G/BUTTON
ACTIVATED MISC
EASY TOUCH SAFETY
LANCETS28G/PRESSURE
ACTIVATED MISC
EASY TRAK GLUCOSE
CONTROLSOLUTION
HIGH SOLN
EASY TRAK GLUCOSE
CONTROLSOLUTION
LOW SOLN
EASY TRAK GLUCOSE
CONTROLSOLUTION
NORMAL SOLN
EASY TWIST & CAP
LANCETS MISC
EASYGLUCO CONTROL
SOLUTION HIGH SOLN
EASYGLUCO CONTROL
SOLUTION LOW SOLN
EASYGLUCO CONTROL
SOLUTION NORMAL
SOLN
EASYGLUCO PLUS
CONTROL SOLUTION
LEVEL 1 SOLN
EASYMAX 15 LEVEL 1
GLUCOSE CONTROL
SOLUTION SOLN
EASYMAX 15 LEVEL 2
GLUCOSE CONTROL
SOLUTION SOLN
EASYMAX CONTROL
SOLUTIONHIGH SOLN
Drug Requirements/
Tier Limits
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
Nebraska Total Care Updated May 30, 2017
98
Drug Name
EASYMAX CONTROL
SOLUTIONLOW SOLN
EASYMAX CONTROL
SOLUTIONNORMAL
SOLN
EASYTEST II LANCETS
MISC
EASYTEST LANCETS
MISC
ELEMENT COMPACT
CONTROL SOLUTION
LEVEL 2 SOLN
ELEMENT COMPACT
CONTROL SOLUTION
LEVEL 3 SOLN
ELEMENT HIGH
CONTROL LIQD
ELEMENT LOW
CONTROL LIQD
ELEMENT NORMAL
CONTROL LIQD
EMBRACE CONTROL
SOLUTIONLOW SOLN
EMBRACE EVO
GLUCOSE CONTROL
SOLUTION LEVEL 1 LIQD
EMBRACE EVO
GLUCOSE CONTROL
SOLUTION LEVEL 2 LIQD
EMBRACE GLUCOSE
CONTROL SOLUTION
HIGH LIQD
EMBRACE LANCETS
ULTRA THIN 30G MISC
EMBRACE PRO
GLUCOSE CONTROL
SOLUTION LIQD
EQL COLOR LANCETS
21G MISC
EQL COLOR LANCETS
MICRO THIN 33G MISC
EQL SUPER THIN
LANCETS 30G MISC
EQL THIN LANCETS 26G
MISC
EVENCARE CONTROL
SOLUTION LIQD
Drug Requirements/
Tier Limits
NP
NP
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
F
F
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
Nebraska Total Care Updated May 30, 2017
99
Drug Name
EVENCARE G2 GLUCOSE
CONTROL
SOLUTION/LOW-HIGH
SOLN
EVENCARE G3 GLUCOSE
CONTROL
SOLUTION/LOW-HIGH
SOLN
EVENCARE MINI
GLUCOSE CONTROL
SOLUTION NORMAL
SOLN
EVOLUTION CONTROL
SOLUTION NORMAL
SOLN
EZ SMART BLOOD
GLUCOSE LANCETS
MISC
EZ-LETS LANCETS 21G
MISC
EZ-LETS LANCETS 23G
MISC
EZ-LETS LANCETS 26G
SUPER-SOFT MISC
EZ-LETS LANCETS 28G
ULTRA-SOFT MISC
EZ-LETS LANCETS 30G
MISC
FIFTY50 CONTROL
SOLUTION2.0 SOLN
FIFTY50 LANCING
DEVICE MISC
FIFTY50 SAFETY SEAL
LANCETS 30G MISC
FIFTY50 SAFETY SEAL
LANCETS 32G MISC
FIFTY50 UNILET
LANCETS 33G MISC
FINE 30 MISC
FINGERSTIX LANCETS
MISC
FORA CONTROL
SOLUTION HIGH SOLN
FORA CONTROL
SOLUTION LOW SOLN
Drug Requirements/
Tier Limits
NP
NP
NP
NP
F
QL(6.67 ea
daily)
NP
F
F
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
F
NP
NP
NP
NP
NP
NP
NP
QL(1 ea per
160 days retail)
Drug Name
Drug Requirements/
Tier Limits
FORA CONTROL
SOLUTION NORMAL
SOLN
NP
FORA LANCETS MISC
NP
FORA LANCETS MISC
F
FORA LANCING DEVICE
MISC
FORA LANCING
DEVICE/CLEARCAP MISC
FORACARE GDH
CONTROL SOLUTION
HIGH SOLN
FORACARE GDH
CONTROL SOLUTION
LOW SOLN
FORACARE GDH
CONTROL SOLUTION
NORMAL SOLN
FORTISCARE CONTROL
SOLUTIONS HIGH SOLN
FORTISCARE CONTROL
SOLUTIONS LOW SOLN
FORTISCARE CONTROL
SOLUTIONS NORMAL
SOLN
FREDS PHARMACY
AUTOLET LANCING
DEVICE MISC
FREDS PHARMACY
UNILET LANCETS SUPER
THIN 30G MISC
FREDS PHARMACY
UNILET LANCETS ULTRA
THIN 28G MISC
FREESTYLE CONTROL
SOLUTION HIGH/LOW
LIQD
FREESTYLE CONTROL
SOLUTION LIQD
FREESTYLE LANCETS
MISC
FREESTYLE UNISTICK II
LANCETS MISC
F
F
QL(6.67 ea
daily)
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
NP
NP
NP
NP
NP
NP
F
QL(1 ea per
160 days retail)
F
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
NP
NP
NP
NP
Drug Name
GE100 CONTROL
SOLUTION NORMAL
SOLN
GENTLE-LET GP
LANCETS MISC
GENTLE-LET LANCETS
GENERAL PURPOSE
STYLE/FINE POINT MISC
GENTLE-LET LANCETS
GENERAL PURPOSE
STYLE/MEDIUM POINT
MISC
GENTLE-LET LANCETS
SAFETY STYLE/FINE
POINT MISC
GENTLE-LET LANCETS
SAFETY STYLE/MEDIUM
POINT MISC
GLOBAL INJECT EASE
LANCETS 28G MISC
GLOBAL INJECT EASE
LANCETS 30G MISC
GLOBAL LANCING
DEVICE MISC
GLUCOCARD 01
CONTROL SOLUTION
NORMAL/HIGH LIQD
GLUCOCARD 01
CONTROL
SOLUTION/NORMAL
SOLN
GLUCOCARD
EXPRESSION CONTROL
SOLUTION LEVEL 1
SOLN
GLUCOCARD SHINE
CONTROL SOLUTION
LEVEL 1 SOLN
GLUCOCARD X-METER
CONTROLSOLUTION/NO
RMAL SOLN
GLUCOCOM HIGH
CONTROL LIQD
GLUCOCOM LANCETS
28G MISC
GLUCOCOM LANCETS
30G MISC
Drug Requirements/
Tier Limits
NP
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
F
NP
NP
F
QL(1 ea per
160 days retail)
NP
NP
NP
NP
NP
NP
NP
NP
Nebraska Total Care Updated May 30, 2017
100
Drug Name
GLUCOCOM LANCETS
33G MISC
GLUCOCOM NORMAL
CONTROL LIQD
GLUCOLET 2
AUTOMATIC LANCING
DEVICE MISC
GLUCOSE CONTROL
NORMAL SOLN
GLUCOSE CONTROL
SOLUTION SOLN
GLUCOSOURCE LANCET
DEVICE MISC
GLUCOSOURCE
LANCETS MISC
GMATE CONTROL
SOLUTION LEVEL 2
SOLN
GMATE LANCETS 30G
MISC
GMATE LANCING DEVICE
MISC
GNP EASY TOUCH
CONTROL SOLUTION
HIGH/LOW SOLN
Drug Requirements/
Tier Limits
NP
NP
F
NP
NP
F
F
QL(1 ea per
160 days retail)
QL(6.67 ea
daily)
NP
NP
F
QL(1 ea per
160 days retail)
NP
GNP LANCETS 21G MISC
F
GNP LANCETS MICRO
THIN 33G MISC
F
GNP LANCETS MISC
F
GNP LANCETS SUPER
THIN 30G MISC
GNP LANCETS THIN 26G
MISC
GNP LANCETS THIN
MISC
GNP MICRO THIN
LANCETS 33G MISC
GNP SUPER THIN
LANCETS/30G MISC
GOODSENSE LANCING
DEVICE MISC
H-E-B INCONTROL
ADVANCEDLANCING
DEVICE MISC
QL(1 ea per
160 days retail)
F
F
F
F
F
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
Nebraska Total Care Updated May 30, 2017
101
Drug Name
H-E-B INCONTROL
LANCETS MICRO THIN
33G MISC
H-E-B INCONTROL
LANCETS SUPER THIN
30G MISC
H-E-B INCONTROL
LANCETS ULTRA THIN
28G MISC
HAEMOLANCE LOW
FLOW LANCETS MISC
HAEMOLANCE MISC
HAEMOLANCE PLUS
HIGH FLOW MISC
HAEMOLANCE PLUS
LOW FLOW MISC
HAEMOLANCE PLUS
MAX FLOW MISC
HAEMOLANCE PLUS
MISC
HAEMOLANCE PLUS
PEDIATRIC FLOW MISC
HEALTH CARE LANCING
DEVICE MISC
HEALTHWISE LANCETS
30G MISC
HEALTHWISE LANCING
PEN MISC
HEALTHY ACCENTS
AUTOLET IMPRESSION
LANCING DEVICE MISC
HEALTHY ACCENTS
UNILET LANCETS SUPER
THIN 30G MISC
HY-VEE LANCETS MISC
HY-VEE THIN LANCETS
MISC
IN TOUCH GLUCOSE
CONTROLSOLUTION
SOLN
IN TOUCH LANCING
DEVICE MISC
IN TOUCH STERILE
LANCETS30G MISC
Drug Requirements/
Tier Limits
QL(6.67 ea
F daily)
F
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
NP
NP
NP
NP
NP
NP
NP
F
QL(1 ea per
160 days retail)
NP
F
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
F
QL(6.67 ea
daily)
F
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
F
NP
QL(1 ea per
160 days retail)
Drug Name
INFINITY CONTROL
SOLUTION HIGH SOLN
INFINITY CONTROL
SOLUTION LOW SOLN
INFINITY CONTROL
SOLUTION NORMAL
SOLN
KINNEY LANCETS MISC
KINNEY THIN LANCETS
MISC
KROGER LANCETS 21G
MISC
KROGER LANCETS
MICRO THIN33G MISC
KROGER LANCETS MISC
KROGER LANCETS
SUPER THIN MISC
KROGER LANCETS THIN
26G MISC
KROGER LANCETS THIN
MISC
KROGER LANCETS
ULTRATHIN30G MISC
KROGER LANCING
DEVICE MISC
LANCET DEVICE
ADJUSTABLE MISC
LANCET DEVICE WITH
EJECTOR MISC
LANCETS 26G TWIST
TOP MISC
Drug Requirements/
Tier Limits
NP
NP
F
F
F
F
F
F
F
F
F
F
F
F
LANCETS 28G MISC
F
LANCETS 30G MISC
F
LANCETS 30G MISC
NP
LANCETS 30G TWIST
TOP MISC
LANCETS 30G/TWIST
TOP MISC
LANCETS 31G TWIST
TOP MISC
LANCETS 33G
UNIVERSAL DESIGN
MISC
LANCETS MICRO THIN
33G MISC
NP
F
Drug Name
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
NP
NP
Drug Requirements/
Tier Limits
NP
NP
LANCETS MISC
F
LANCETS MISC
NP
LANCETS SAFETY SEAL
21G MISC
LANCETS SAFETY SEAL
26G MISC
LANCETS SAFETY SEAL
28G MISC
LANCETS SAFETY SEAL
30G MISC
LANCETS SUPER THIN
28G MISC
LANCETS THIN MISC
LANCETS TWIST TOP
MISC
LANCETS ULTRA FINE
MISC
LANCETS ULTRA THIN
30G MISC
LANCETS ULTRA THIN
MISC
LANCETSBULLSEYE
SAFETY MISC
LANCING DEVICE
ADJUSTABLE MISC
F
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
NP
F
QL(6.67 ea
daily)
NP
NP
NP
F
QL(6.67 ea
daily)
NP
F
LANCING DEVICE MISC
F
LANZO MISC
F
LEADER ADVANCED
LANCING DEVICE MISC
LIBERTY CONTROL
SOLUTION HIGH SOLN
LIBERTY CONTROL
SOLUTIONNORMAL
SOLN
LIBERTY GLUCOSE
CONTROL LEVEL 1 SOLN
QL(6.67 ea
daily)
F
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
NP
NP
NP
Nebraska Total Care Updated May 30, 2017
102
Drug Name
LIBERTY GLUCOSE
CONTROL LEVEL 2 SOLN
LIBERTY GLUCOSE
CONTROL MID SOLN
LIBERTY GLUCOSE
CONTROL NORMAL LIQD
LIBERTY MEDICAL
LANCETS 30G MISC
LIBERTY MINI LANCING
DEVICE MISC
LIFESCAN UNISTIK 2
DEEP PENETRATION
MISC
LIFESCAN UNISTIK II
LANCETS MISC
LITE TOUCH LANCETS
MISC
LITE TOUCH LANCING
DEVICE MISC
LITE TOUCH LANCING
PEN MISC
LITETOUCH LANCETS
MICRO THIN 33G MISC
LIVE BETTER ADVANCED
LANCING DEVICE MISC
LIVE BETTER LANCET
SUPERTHIN 30G MISC
LIVE BETTER LANCET
ULTRATHIN 28G MISC
LONGS LANCETS
STANDARD MISC
LONGS LANCETS THIN
MISC
LONGS LANCETS ULTRA
THIN MISC
MAXIMA CONTROL
SOLUTION SOLN
MAXIMA CONTROL
SOLUTION/NORMAL
SOLN
MEDICHOICE PRE-SET
SAFETY LANCET DUAL
USE MISC
MEDICHOICE PRE-SET
SAFETY LANCET LOW
FLOW MISC
Drug Requirements/
Tier Limits
NP
NP
NP
NP
F
QL(1 ea per
160 days retail)
NP
NP
NP
F
F
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
NP
F
F
F
F
F
QL(1 ea per
160 days retail)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
NP
NP
NP
NP
Nebraska Total Care Updated May 30, 2017
103
Drug Name
MEDICHOICE PRE-SET
SAFETY LANCET
MEDIUM FLOW MISC
MEDICHOICE PRE-SET
SAFETY LANCET
MODERATE FLOW MISC
MEDICHOICE SAFETY
LANCETEXTRA MISC
MEDICHOICE SAFETY
LANCETNORMAL MISC
MEDISENSE GLUCOSE
KETONECONTROL
SOLUTION 1-LOW,1MED,1 HIGH LIQD
MEDISENSE GLUCOSE
KETONECONTROL
SOLUTION 1-NORMAL
LIQD
MEDISENSE HIGH/LOW
CONTROL SOLUTION
LIQD
MEDISENSE
HIGH/MID/LOW
CONTROL SOLUTION
LIQD
MEDISENSE MID
CONTROL SOLUTION
LIQD
MEDISENSE THIN
LANCETS MISC
MEDLANCE PLUS EXTRA
LANCETS 21G MISC
MEDLANCE PLUS
LANCETS LITE 25G MISC
MEDLANCE PLUS
LANCETS MISC
MEDLANCE PLUS LITE
LANCETS 25G MISC
MEDLANCE PLUS
SPECIAL LANCETS
0.8MM MISC
MEDLANCE PLUS
SUPERLITE 30G MISC
MEDLANCE PLUS
SUPERLITE
30G/COMFORT MAX
MISC
Drug Requirements/
Tier Limits
NP
NP
NP
NP
NP
NP
NP
NP
NP
F
NP
NP
NP
NP
NP
NP
NP
QL(6.67 ea
daily)
Drug Name
MEDLANCE PLUS
UNIVERSAL LANCETS
21G MISC
MEDLANCE PLUS/LITE
25G MISC
Drug Requirements/
Tier Limits
NP
NP
MEDLANCE/EXTRA MISC
NP
MEDLANCE/LITE MISC
NP
MEDLANCE/UNIVERSAL
MISC
MEIJER COLOR
LANCETS UNIVERSAL
33G MISC
MEIJER LANCETS MISC
MEIJER LANCETS THIN
MISC
MEIJER LANCETS
UNIVERSAL21G MISC
MEIJER LANCETS
UNIVERSAL30G MISC
MEIJER LANCETS
UNIVERSAL33G MISC
MEIJER SUPER THIN
LANCETS MISC
MICRODOT CONTROL
SOLUTIONHIGH/LOW
SOLN
MICROLET LANCETS
MISC
MICROLET NEXT MISC
NP
F
F
F
F
F
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
NP
F
QL(1 ea per
160 days retail)
MICROTAINER SAFETY
FLOW
NP
LANCET/STERILE/SINGL
E-USE MISC
MINI LANCING DEVICE
F QL(1 ea per
MISC
160 days retail)
MONOLET LANCETS
NP
MISC
MONOLET LANCETS
F QL(6.67 ea
MISC
daily)
MONOLET OPD LANCETS F QL(6.67 ea
MISC
daily)
MONOLETTOR SAFETY
NP
LANCETS MISC
Drug Name
MULTI-LANCET DEVICE
MISC
MYGLUCOHEALTH
CONTROL
LOW/NORMAL/HIGH
SOLN
MYGLUCOHEALTH MGH
SOFTLANCE LANCETS
30G MISC
NETGROUP LANCETS
MISC
NEUTEK 2TEK CONTROL
SOLUTIONS SOLN
NEXGEN NORMAL
CONTROL LIQD
NOVA MAX PLUS
GLU/KET CONTROL
SOLUTION-MID LIQD
NOVA SAFETY LANCETS
23G MISC
NOVA SAFETY LANCETS
28G MISC
NOVA SUREFLEX
LANCETS MISC
NOVA SUREFLEX
LANCETS MISC
NOVA SUREFLEX
LANCING DEVICE MISC
ON CALL EXPRESS
GLUCOSE CONTROL
SOLUTION SOLN
ON CALL LANCETS MISC
ON CALL LANCING
DEVICE MISC
ON CALL PLUS
GLUCOSE CONTROL
LEVEL 1/2 SOLN
ON CALL PLUS LANCETS
MISC
ON CALL PLUS LANCING
DEVICE MISC
ON CALL VIVID
GLUCOSE CONTROL
LEVEL 1/2 SOLN
Drug Requirements/
Tier Limits
F QL(1 ea per
160 days retail)
NP
NP
NP
NP
NP
NP
NP
NP
NP
F
F
QL(6.67 ea
daily)
QL(1 ea per
160 days retail)
NP
NP
F
QL(1 ea per
160 days retail)
NP
NP
F
QL(1 ea per
160 days retail)
NP
Nebraska Total Care Updated May 30, 2017
104
Drug Name
ONETOUCH CLUB
LANCETS FINE POINT
MISC
ONETOUCH COMBO
PACK MISC
ONETOUCH DELICA
LANCETS EXTRA FINE
33G MISC
ONETOUCH DELICA
LANCETS FINE 30G MISC
ONETOUCH DELICA
LANCING DEVICE MISC
ONETOUCH FINEPOINT
LANCETS MISC
ONETOUCH LANCETS
MISC
ONETOUCH ULTRA
CONTROL SOLN
ONETOUCH ULTRASOFT
LANCETS MISC
ONETOUCH VERIO
CONTROL SOLUTION
HIGH SOLN
ONETOUCH VERIO MID
CONTROL SOLUTION
SOLN
OPTUMRX GLUCOSE
CONTROL LEVEL 1/2
SOLN
PC LANCETS SUPER
THIN 30G MISC
PERFECT LANCETS 30G
MISC
PERFECT PRESSURE
ACTIVATED SAFETY
LANCETS 28G MISC
PHARMACIST CHOICE
ULTRA THIN LANCETS
28G MISC
PHARMACIST CHOICE
ULTRA THIN LANCETS
30G MISC
PHARMACIST CHOICE
ULTRA THIN LANCETS
31G MISC
Drug Requirements/
Tier Limits
NP
NP
NP
NP
F
QL(1 ea per
160 days retail)
NP
F
QL(6.67 ea
daily)
NP
NP
NP
NP
NP
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
NP
NP
NP
Nebraska Total Care Updated May 30, 2017
105
Drug Name
PHARMACIST CHOICE
ULTRA THIN LANCETS
33G MISC
PHARMACIST CHOICE
ULTRA THIN LANCETS
MISC
PHARMACY COUNTER
LANCETS MISC
POCKETCHEM EZ
CONTROL LEVEL 1 SOLN
PRECISION GLUCOSE
CONTROL LIQD
PRECISION GLUCOSE
CONTROLSOLUTION
(TRILEVEL/HI/LO/NORMAL)
SOLN
PRECISION GLUCOSE
KETONECONTROL
SOLUTION 1-LOW, 1HIGH LIQD
PRECISION
GLUCOSE/KETONECONT
ROL SOLUTIONS 1-HI 1LO LIQD
PRECISION THIN
LANCETS MISC
PRECISION THINS GP
LANCET MISC
PRECISION ULTRA
LANCET MISC
PREFERRED PLUS
LANCETS COLORED 21G
MISC
PREFERRED PLUS
LANCETS SUPER THIN
30G MISC
PREFERRED PLUS
LANCETS THIN 26G MISC
PRESSURE ACTIVATED
SAFETYLANCET 21G
MISC
PRO COMFORT
LANCETS 30G MISC
PRO COMFORT
LANCETS 31G MISC
Drug Requirements/
Tier Limits
NP
NP
F
QL(6.67 ea
daily)
NP
NP
NP
NP
NP
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
F
F
F
F
QL(6.67 ea
daily)
NP
NP
F
QL(6.67 ea
daily)
Drug Name
PRODIGY CONTROL
SOLUTIONHIGH SOLN
PRODIGY CONTROL
SOLUTIONLOW SOLN
PRODIGY LANCING
DEVICE MISC
PRODIGY PRESSURE
ACTIVATED SAFETY
LANCETS MISC
PRODIGY SAFETY
LANCETS MISC
PRODIGY TWIST TOP
LANCETS MISC
PRODIGY TWIST TOP
LANCETS MISC
PSS SELECT GP
LANCETS MISC
PSS SELECT SAFETY
LANCETS MISC
PUSH BUTTON SAFETY
LANCETS 21G MISC
PUSH BUTTON SAFETY
LANCETS 28G MISC
PX ADVANCED LANCING
DEVICE MISC
PX LANCET AUTO
INJECTOR MISC
PX LANCETS ULTRA
THIN MISC
QC ADVANCED LANCING
DEVICE MISC
QC LANCETS SUPER
THIN MISC
QC LANCETS ULTRA
THIN MISC
QC UNILET LANCETS
28G/ULTRA THIN MISC
QC UNILET LANCETS
33G/MICRO THIN MISC
QUICKTEK CONTROL
SOLUTION LIQD
QUINTET GLUCOSE
CONTROL/HIGH/NORMAL
SOLN
Drug Requirements/
Tier Limits
NP
NP
F
QL(1 ea per
160 days retail)
NP
NP
NP
F
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
NP
F
F
F
F
F
F
F
F
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
QL(6.67 ea
daily)
QL(1 ea per
160 days retail)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
NP
Drug Name
RA E-ZJECT COLOR
LANCETSMICRO-THIN
33G MISC
RA E-ZJECT LANCETS
28G MISC
RA E-ZJECT LANCETS
THIN 26G MISC
RA E-ZJECT LANCETS
THIN 28G MISC
RA E-ZJECT LANCETS
ULTRATHIN 30G MISC
RA LANCING DEVICE
MISC
READYLANCE SAFETY
LANCETS/30G/1.6MM
MISC
REALITY LANCETS MISC
REALITY TRIGGER
LANCETS MISC
REFUAH PLUS GLUCOSE
CONTROL SOLUTION
SOLN
RELION 2-IN-1 LANCING
DEVICE 25G MISC
RELION 2-IN-1 LANCING
DEVICE 30G MISC
RELION LANCETS
MICRO-THIN33G MISC
RELION LANCETS
STANDARD 21G MISC
RELION LANCETS THIN
26G MISC
RELION LANCETS
ULTRA-THIN30G MISC
RELION LANCING
DEVICE MISC
RELION ULTRA THIN
LANCETS30G MISC
RELION ULTRA THIN
PLUS LANCETS 32G
MISC
RELION ULTRA THIN
PLUS LANCETS 33G
MISC
Drug Requirements/
Tier Limits
QL(6.67 ea
F daily)
F
F
F
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(1 ea per
160 days retail)
NP
F
QL(6.67 ea
daily)
NP
NP
F
QL(1 ea per
160 days retail)
QL(1 ea per
160 days retail)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(1 ea per
160 days retail)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
F
F
F
F
F
F
F
F
Nebraska Total Care Updated May 30, 2017
106
Drug Requirements/
Tier Limits
REXALL LANCETS ULTRA F QL(6.67 ea
THIN MISC
daily)
RIGHTEST GC300 HIGH
NP
CONTROL LIQD
RIGHTEST GC300
NP
NORMAL CONTROL LIQD
RIGHTEST GD500
F QL(1 ea per
LANCING DEVICE MISC
160 days retail)
RIGHTEST GL300
F QL(6.67 ea
LANCETS MISC
daily)
SAFE-T-LANCE LOW
NP
FLOW 25G MISC
SAFE-T-LANCE NORMAL NP
FLOW21G MISC
SAFE-T-LANCE PLUS
NP
SAFETYLANCET HIGH
FLOW MISC
SAFE-T-LANCE PLUS
NP
SAFETYLANCET LOW
FLOW MISC
SAFE-T-LANCE PLUS
NP
SAFETYLANCET
NORMAL FLOW MISC
SAFETY LANCET
NP
21G/PRESSURE
ACTIVATED MISC
SAFETY LANCET
NP
28G/PRESSURE
ACTIVATED MISC
SAFETY LANCETS 21G
NP
MISC
SAFETY LANCETS 28G
NP
MISC
Drug Name
SAFETY LANCETS MISC
SAFETY LET LANCETS
MISC
SAFETY SEAL LANCETS
28G MISC
SAFETY SEAL LANCETS
30G MISC
SAPSCARE TWIST TOP
LANCETS 30G MISC
SB LANCETS THIN MISC
NP
NP
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
F
QL(6.67 ea
daily)
Nebraska Total Care Updated May 30, 2017
107
Drug Name
SB LANCETS ULTRA
THIN MISC
SELECT-LITE LANCING
DEVICE MISC
SHOPKO AUTOLET
LANCING DEVICE MISC
SHOPKO ON-THE-GO
COMFORTLANCETS 30G
MISC
SHOPKO UNILET
LANCETS SUPER THIN
30G MISC
SHOPKO UNILET
LANCETS ULTRA THIN
28G MISC
SIDE BUTTON SAFETY
LANCET21G MISC
SIMPLE DIAGNOSTICS
LANCING DEVICE MISC
SINGLE-LET MISC
SM MICRO THIN
LANCETS 33G MISC
SMART DIABETES
VANTAGE LANCING
DEVICE MISC
SMART SENSE COLOR
LANCETS UNIVERSAL
33G MISC
SMART SENSE
STANDARD LANCETS
UNIVERSAL 21G MISC
SMART SENSE SUPER
THIN LANCETS
UNIVERSAL 30G MISC
SMART SENSE THIN
LANCETSUNIVERSAL
26G MISC
SMARTEST CONTROL
SOLUTIONMEDIUM SOLN
SMARTEST LANCETS
28G MISC
SOLARTEK GLUCOSE
CONTROLSOLUTIONS
LIQD
SOLUS V2 CONTROL
HIGH SOLN
Drug Requirements/
Tier Limits
F QL(6.67 ea
daily)
F QL(1 ea per
160 days retail)
F QL(1 ea per
160 days retail)
NP
F
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
NP
F
QL(1 ea per
160 days retail)
NP
F
QL(6.67 ea
daily)
QL(1 ea per
160 days retail)
F
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
F
NP
NP
NP
NP
Drug Name
SOLUS V2 CONTROL
LOW SOLN
SOLUS V2 LANCING
DEVICE MISC
SOLUS V2 PRESSURE
ACTIVATED SAFETY
LANCETS 28G MISC
SOLUS V2 TWIST
LANCETS 30G MISC
STERILANCE TL MISC
SUPER THIN LANCETS
MISC
SUPREME II HIGH/LOW
CONTROL SOLUTION
LIQD
SURE COMFORT
LANCETS 28G MISC
SURE COMFORT
LANCETS 30G MISC
SURE COMFORT
LANCING PEN MISC
SURE-LANCE FLAT
LANCETS MISC
SURE-LANCE LANCETS
26G MISC
SURE-LANCE THIN
LANCETS 28G MISC
SURE-LANCE ULTRA
THIN LANCETS MISC
SURE-PEN MISC
SURE-TOUCH LANCETS
UNIVERSAL MISC
SURELITE LANCETS
MISC
SURESTEP GLUCOSE
CONTROL SOLN
SURESTEP GLUCOSE
CONTROLSOLUTION
SOLN
SURESTEP PRO HIGH
GLUCOSECONTROL
LIQD
Drug Requirements/
Tier Limits
NP
F
QL(1 ea per
160 days retail)
NP
Drug Name
SURESTEP PRO LOW
GLUCOSECONTROL
LIQD
SURESTEP PRO
NORMAL GLUCOSE
CONTROL LIQD
TAI DOC CONTROL SOLN
NP
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
NP
NP
F
QL(1 ea per
160 days retail)
NP
NP
NP
NP
F
QL(1 ea per
160 days retail)
NP
F
QL(6.67 ea
daily)
NP
NP
NP
TECHLITE AST LANCETS
MISC
TECHLITE LANCETS 30G
MISC
TECHLITE LANCETS
MISC
TELCARE GLUCOSE
CONTROL SOLUTION
LEVEL 1/2 SOLN
TGT ADVANCED
LANCING DEVICE MISC
TGT LANCET
ALTERNATE SITE MISC
TGT LANCET MICRO
THIN 33G MISC
TGT LANCET SUPER
THIN 30G MISC
TGT LANCET THIN 23G
MISC
TGT LANCET THIN 26G
MISC
TGT LANCET ULTRA
THIN 28G MISC
TGT LANCET ULTRA
THIN 30G MISC
TGT LANCING DEVICE
MISC
THINLETS GP LANCETS
MISC
THINLETS LANCET MISC
TODAYS HEALTH
ADVANCED LANCING
DEVICE MISC
TODAYS HEALTH SUPER
THINLANCETS 30G MISC
TODAYS HEALTH ULTRA
THINLANCETS 28G MISC
Drug Requirements/
Tier Limits
NP
NP
NP
F
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
F
F
F
F
F
F
F
F
F
F
F
F
F
F
QL(1 ea per
160 days retail)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(1 ea per
160 days retail)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(1 ea per
160 days retail)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
Nebraska Total Care Updated May 30, 2017
108
Drug Name
TRAVEL LANCETS 30G
MISC
TRUE METRIX CONTROL
SOLUTION LEVEL 1
SOLN
TRUE METRIX CONTROL
SOLUTION LEVEL 2
SOLN
TRUE METRIX CONTROL
SOLUTION LEVEL 3
SOLN
TRUECONTROL
GLUCOSE CONTROL
LEVEL 0 LIQD
TRUECONTROL
GLUCOSE CONTROL
LEVEL 1 LIQD
TRUEDRAW LANCING
DEVICE MISC
TRUEPLUS LANCETS
26G MISC
TRUEPLUS LANCETS
28G MISC
TRUEPLUS LANCETS
28G SUPER THIN MISC
TRUEPLUS LANCETS
28G SUPER THIN MISC
TRUEPLUS LANCETS
30G MISC
TRUEPLUS LANCETS
30G ULTRA THIN MISC
TRUEPLUS LANCETS
33G MICRO THIN MISC
TRUEPLUS LANCETS
33G MISC
TRUEPLUS SAFETY
LANCETS 28G MISC
TRUETEST GLUCOSE
CONTROLLEVEL 1 LIQD
TRUETEST GLUCOSE
CONTROLLEVEL 2 LIQD
TRUETEST GLUCOSE
CONTROLLEVEL 3 LIQD
ULTI-LANCE AUTOMATIC/
CLEAR TIP MISC
Drug Requirements/
Tier Limits
NP
F
F
QL(1 ea per 75
days retail)
F
QL(1 ea per 75
days retail)
F
QL(1 ea per 75
days retail)
F
QL(1 ea per 75
days retail)
F
F
F
QL(1 ea per
160 days retail)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
NP
F
QL(6.67 ea
daily)
NP
F
F
F
F
QL(1 ea per 75
days retail)
QL(1 ea per 75
days retail)
QL(1 ea per 75
days retail)
QL(1 ea per
160 days retail)
Nebraska Total Care Updated May 30, 2017
109
Drug Name
ULTICARE THIN
LANCETS 30G MISC
ULTILET CLASSIC
LANCETS MISC
ULTILET CLASSIC
LANCETS MISC
ULTILET LANCETS 33G
MISC
ULTILET LANCETS MISC
ULTILET SAFETY
LANCETS 23G MISC
ULTRA THIN LANCETS
28G MISC
ULTRA THIN LANCETS
30G MISC
ULTRA-THIN II AUTO
LANCET MISC
ULTRA-THIN II LANCETS
28G MISC
ULTRA-THIN II LANCETS
30G MISC
ULTRA-THIN II SAFETY
AUTOLANCETS 26G
MISC
ULTRATRAK PRO
CONTROL SOLUTION 2
LEVELS SOLN
ULTRATRAK PRO
NORMAL CONTROL
SOLN
ULTRATRAK ULTIMATE
CONTROL SOLUTION 2
LEVELS SOLN
UNILET COMFORTOUCH
LANCET MISC
Drug Requirements/
Tier Limits
NP
NP
F
NP
NP
NP
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
NP
NP
NP
NP
NP
NP
F
UNILET EXCELITE II MISC
F
UNILET EXCELITE MISC
F
UNILET G.P. LANCET
MISC
UNILET G.P. SUPERLITE
LANCET MISC
UNILET GP 28 ULTRA
THIN MISC
QL(6.67 ea
daily)
F
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
Drug Name
UNILET LANCET MISC
UNILET LANCETS
MICRO-THIN33G MISC
UNILET LANCETS
SUPER-THIN30G MISC
UNILET LANCETS
ULTRA-THIN 28G MISC
UNILET SUPERLITE
LANCET MISC
UNISTIK 3 GENTLE MISC
UNISTIK SAFETY
LANCETS 28G MISC
UNISTIK SAFETY
LANCETS 30G MISC
UNISTIK TOUCH SAFETY
LANCETS 21G MISC
UNISTIK TOUCH SAFETY
LANCETS 23G MISC
UNISTIK TOUCH SAFETY
LANCETS 28G MISC
UNISTIK TOUCH SAFETY
LANCETS 30G MISC
UNISTRIP CONTROL
SOLUTIONHIGH SOLN
UNISTRIP CONTROL
SOLUTIONLOW SOLN
UNIVERSAL 1 LANCETS
THIN26G MISC
UNIVERSAL 1 LANCETS
ULTRA THIN 30G MISC
UNIVERSAL 1
LANCETS/33G/MICROTHIN MISC
VALUE PLUS LANCETS
STANDARD 21G MISC
VALUE PLUS LANCETS
SUPERTHIN 30G MISC
VALUE PLUS LANCETS
THIN 26G MISC
VALUE PLUS LANCING
DEVICE MISC
VALUMARK LANCET
SUPER THIN 30G MISC
Drug Requirements/
Tier Limits
F QL(6.67 ea
daily)
F QL(6.67 ea
daily)
F QL(6.67 ea
daily)
F QL(6.67 ea
daily)
F QL(6.67 ea
daily)
Drug Name
NP
VALUMARK LANCET
ULTRA THIN 28G MISC
VICTORY CONTROL
LEVEL 1/2 SOLN
VIDA MIA AUTOLET
LANCINGDEVICE MISC
VIDA MIA UNILET
LANCETS SUPER THIN
30G MISC
VIDA MIA UNILET
LANCETS ULTRA THIN
28G MISC
VITALET PRO LANCETS
MISC
VITALET PRO PLUS
LANCETS MISC
NP
W&F LANCETS 26G MISC
NP
NP
NP
NP
NP
NP
NP
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
F
F
F
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(6.67 ea
daily)
QL(1 ea per
160 days retail)
QL(6.67 ea
daily)
W&F LANCETS
COLORED 21G MISC
WALGREENS ADVANCED
TRAVELLANCETS 28G
MISC
WALGREENS COMFORT
ASSUREDLANCETS
MICRO THIN/33G MISC
WALGREENS COMFORT
ASSUREDLANCETS
SUPER THIN/28G MISC
WALGREENS LANCETS
MISC
WALGREENS THIN
LANCETS MISC
WALGREENS THIN
LANCETS MISC
WALGREENS ULTRA
THIN LANCETS MISC
Misc. Devices
ALCOH-GLOVE
CONTOURED WIPE PADS
ALCOH-WIPE 12" X 12"
PADS
ALCOHOL PADS PADS
ALCOHOL PREP PADS
PADS
Drug Requirements/
Tier Limits
F QL(6.67 ea
daily)
NP
F
QL(1 ea per
160 days retail)
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
F
NP
NP
F
F
QL(6.67 ea
daily)
QL(6.67 ea
daily)
NP
F
QL(6.67 ea
daily)
F
QL(6.67 ea
daily)
NP
F
QL(6.67 ea
daily)
NP
NP
NP RX/OTC
NP RX/OTC
NP RX/OTC
F
QL(13.34 ea
daily); RX/OTC
Nebraska Total Care Updated May 30, 2017
110
Drug Name
ALCOHOL PREP PADS
PADS
ALCOHOL PREPS PADS
ALCOHOL SWABS PADS
ALCOHOL SWABS PADS
Drug Requirements/
Tier Limits
NP RX/OTC
QL(13.34 ea
daily); RX/OTC
F QL(13.34 ea
daily); RX/OTC
NP RX/OTC
F
ALCOHOL SWABSTICK
PADS
NP RX/OTC
ALCOHOL WIPES PADS
QL(13.34 ea
daily); RX/OTC
F QL(13.34 ea
daily); RX/OTC
F QL(13.34 ea
daily); RX/OTC
NP RX/OTC
BD SWABS SINGLE USE
BUTTERFLY PADS
BD SWABS SINGLE USE
PADS
CARETOUCH ALCOHOL
PREP PADS PADS
CURITY ALCOHOL
PREPS/MEDIUM 2 PLY
PADS
CURITY ALCOHOL
SWABS PADS
CVS ALCOHOL PREP
SWABS PADS
CVS ALCOHOL SWABS
PADS
CVS PREP PADS PADS
EASY TOUCH ALCOHOL
PREP PADS/MEDIUM
PADS
EQL ALCOHOL SWABS
PADS
FIFTY50 ALCOHOL PREP
PADS PADS
GLOBAL ALCOHOL PREP
EASEPADS PADS
GNP ALCOHOL SWABS
PADS
H-E-B INCONTROL
ALCOHOL PADS PADS
HEALTHWISE ALCOHOL
PREP PADS PADS
F
F
F
F
F
F
F
QL(13.34 ea
daily); RX/OTC
QL(13.34 ea
daily); RX/OTC
QL(13.34 ea
daily); RX/OTC
QL(13.34 ea
daily); RX/OTC
QL(13.34 ea
daily); RX/OTC
QL(13.34 ea
daily); RX/OTC
QL(13.34 ea
daily); RX/OTC
F QL(13.34 ea
daily); RX/OTC
NP RX/OTC
F
QL(13.34 ea
daily); RX/OTC
F QL(13.34 ea
daily); RX/OTC
NP RX/OTC
F
Nebraska Total Care Updated May 30, 2017
111
Drug Name
MEIJER ALCOHOL
SWABS EXTRA-THICK
PADS
PHARMACIST CHOICE
ALCOHOLPREP PADS
PADS
PRO COMFORT
ALCOHOL PADS PADS
QC ALCOHOL SWABS
PADS
RA ALCOHOL SWABS
PADS
REALITY SWABS PADS
RELION ALCOHOL
SWABS PADS
SAPS CARE ALCOHOL
PREP PADS PADS
SB ALCOHOL PREP
PADS PADS
SHOPKO ALCOHOL
SWABS PADS
SM ALCOHOL PREP
PADS PADS
SURE COMFORT
ALCOHOL PREP PADS
PADS
SURE-PREP ALCOHOL
PREP PADS PADS
TGT ALCOHOL SWABS
PADS
ULTICARE ALCOHOL
SWABS PADS
WEBCOL ALCOHOL
PREP LARGE 1 PLY
PADS
WEBCOL ALCOHOL
PREP LARGE 2 PLY
PADS
WEBCOL ALCOHOL
PREP MEDIUM 2 PLY
PADS
Drug Requirements/
Tier Limits
QL(13.34 ea
F daily); RX/OTC
RX/OTC
NP
NP RX/OTC
QL(13.34 ea
daily); RX/OTC
F QL(13.34 ea
daily); RX/OTC
F QL(13.34 ea
daily); RX/OTC
F QL(13.34 ea
daily); RX/OTC
NP RX/OTC
F
F
F
F
QL(13.34 ea
daily); RX/OTC
QL(13.34 ea
daily); RX/OTC
QL(13.34 ea
daily); RX/OTC
RX/OTC
NP
NP RX/OTC
F
QL(13.34 ea
daily); RX/OTC
QL(13.34 ea
daily); RX/OTC
QL(13.34 ea
daily); RX/OTC
F
QL(13.34 ea
daily); RX/OTC
F
QL(13.34 ea
daily); RX/OTC
F
F
Parenteral Therapy Supplies
1ST TIER UNIFINE
F
PENTIPS/MINI/31GX5MM
MISC
QL(5 ea daily)
Drug Name
1ST TIER UNIFINE
PENTIPS29GX12MM
MISC
1ST TIER UNIFINE
PENTIPS31GX6MM MISC
1ST TIER UNIFINE
PENTIPS31GX8MM MISC
1ST TIER UNIFINE
PENTIPS32GX4MM MISC
1ST TIER UNIFINE
PENTIPSPLUS 31GX8MM
MISC
1ST TIER UNIFINE
PENTIPSPLUS 32GX4MM
MISC
1ST TIER UNIFINE
PENTIPSPLUS/MINI/31GX
5MM MISC
1ST TIER UNIFINE
PENTIPSPLUS/ORIGINAL/
29GX12MM MISC
1ST TIER UNIFINE
PENTIPSPLUS/ULTRA
SHORT/31GX6MM MISC
ADVOCATE INSULIN PEN
NEEDLES 29GX12.7MM
MISC
ADVOCATE INSULIN PEN
NEEDLES 31GX5MM
MISC
ADVOCATE INSULIN PEN
NEEDLES 31GX8MM
MISC
ADVOCATE INSULIN
SYRINGE/U100/0.3ML/29GX1/2" MISC
ADVOCATE INSULIN
SYRINGE/U100/0.3ML/30GX5/16"
MISC
ADVOCATE INSULIN
SYRINGE/U100/0.3ML/31GX5/16"
MISC
ADVOCATE INSULIN
SYRINGE/U100/0.5ML/29GX1/2" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
F
F
F
F
F
QL(5 ea daily)
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
Drug Name
ADVOCATE INSULIN
SYRINGE/U100/0.5ML/30GX5/16"
MISC
ADVOCATE INSULIN
SYRINGE/U100/0.5ML/31GX5/16"
MISC
ADVOCATE INSULIN
SYRINGE/U100/1ML/29GX1/2" MISC
ADVOCATE INSULIN
SYRINGE/U100/1ML/30GX5/16" MISC
ADVOCATE INSULIN
SYRINGE/U100/1ML/31GX5/16" MISC
ANTI-STICK INSULIN
SYRINGE/U100/0.5ML/28G X 1/2"
MISC
ANTI-STICK INSULIN
SYRINGE/U100/0.5ML/29G X 1/2"
MISC
ANTI-STICK INSULIN
SYRINGE/U-100/1ML/29G
X 1/2" MISC
ASSURE ID INSULIN
SAFETYSYRINGE/U100/0.5ML/29G X 1/2"
MISC
ASSURE ID INSULIN
SAFETYSYRINGE/U100/1ML/29G X 1/2" MISC
AURORA PEN NEEDLES
29GX12MM MISC
AURORA PEN NEEDLES
31G X6MM MISC
AURORA PEN NEEDLES
31G X8MM MISC
AURORA UNIFINE
PENTIPS/32GX5/32" MISC
AURORA UNIFINE
PENTIPS/MINI/31GX3/16"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
Nebraska Total Care Updated May 30, 2017
112
Drug Name
B-D INSULIN SYRINGE
ULTRAFINE II/0.3ML/31G
X 5/16" MISC
B-D INSULIN SYRINGE
ULTRAFINE II/0.5ML/31G
X 5/16" MISC
B-D INSULIN SYRINGE
ULTRAFINE II/1ML/31G X
5/16" MISC
B-D INSULIN SYRINGE
ULTRAFINE/0.3ML/30G X
1/2" MISC
B-D INSULIN SYRINGE
ULTRAFINE/0.5ML/30G X
1/2" MISC
B-D INSULIN SYRINGE
ULTRAFINE/1ML/30G X
1/2" MISC
BD LO-DOSE INSULIN
SYRINGE MICROFINE
IV/0.5ML/28G X 1/2" MISC
BD AUTOSHIELD 29G X
5/16" MISC
BD INSULIN SYRINGE
LUER-LOK/U-100/1ML
MISC
BD INSULIN SYRINGE
MICROFINE IV/U100/0.3ML/28G X 1/2"
MISC
BD INSULIN SYRINGE
MICROFINE IV/U100/0.5ML/28G X 1/2"
MISC
BD INSULIN SYRINGE
MICROFINE IV/U100/1ML/27G X 5/8" MISC
BD INSULIN SYRINGE
MICROFINE IV/U100/1ML/28G X 1/2" MISC
BD INSULIN SYRINGE
MICROFINE/U100/0.3ML/28G X 1/2"
MISC
BD INSULIN SYRINGE
MICROFINE/U100/0.5ML/28G X 1/2"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
113
Drug Name
BD INSULIN SYRINGE
MICROFINE/U100/1ML/27G X 5/8" MISC
BD INSULIN SYRINGE
MICROFINE/U100/1ML/28G X 1/2" MISC
BD INSULIN SYRINGE
SAFETYGLIDE/0.5ML/29G
X 1/2" MISC
BD INSULIN SYRINGE
SAFETYGLIDE/1ML/29G X
1/2" MISC
BD INSULIN SYRINGE
SAFETYGLIDE/U100/0.3ML/31G X 5/16"
MISC
BD INSULIN SYRINGE
SLIP TIP/U-100/1ML MISC
BD INSULIN SYRINGE
ULTRAFINE HALFUNIT/0.3ML/31G X 5/16"
MISC
BD INSULIN SYRINGE
ULTRAFINE
II/SHORT/0.5ML/31G X
5/16" MISC
BD INSULIN SYRINGE
ULTRAFINE
II/SHORT/1ML/31G X 5/16"
MISC
BD INSULIN SYRINGE
ULTRAFINE/0.3ML/30G X
1/2" MISC
BD INSULIN SYRINGE
ULTRAFINE/0.3ML/31G X
5/16" MISC
BD INSULIN SYRINGE
ULTRAFINE/0.5ML/30G X
1/2" MISC
BD INSULIN SYRINGE
ULTRAFINE/0.5ML/31G X
5/16" MISC
BD INSULIN SYRINGE
ULTRAFINE/1ML/30G X
1/2" MISC
BD INSULIN SYRINGE
ULTRAFINE/1ML/31G X
5/16" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
Drug Name
BD INSULIN SYRINGE
ULTRAFINE/U100/0.3ML/29G X 1/2"
MISC
BD INSULIN SYRINGE
ULTRAFINE/U100/0.3ML/30G X 1/2"
MISC
BD INSULIN SYRINGE
ULTRAFINE/U100/0.3ML/31G X 5/16"
MISC
BD INSULIN SYRINGE
ULTRAFINE/U100/0.5ML/29G X 1/2"
MISC
BD INSULIN SYRINGE
ULTRAFINE/U100/0.5ML/30G X 1/2"
MISC
BD INSULIN SYRINGE
ULTRAFINE/U100/0.5ML/31G X 5/16"
MISC
BD INSULIN SYRINGE
ULTRAFINE/U100/1ML/29G X 1/2" MISC
BD INSULIN SYRINGE
ULTRAFINE/U100/1ML/30G X 1/2" MISC
BD INSULIN SYRINGE
ULTRAFINE/U100/1ML/31G X 15/64"
MISC
BD INSULIN SYRINGE
ULTRAFINE/U100/1ML/31G X 5/16"
MISC
BD INSULIN
SYRINGE/DETACHABLE
NEEDLE/U-100/1ML/25G
X 1" MISC
BD INSULIN
SYRINGE/DETACHABLE
NEEDLE/U-100/1ML/25G
X 5/8" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
Drug Name
BD INSULIN
SYRINGE/DETACHABLE
NEEDLE/U-100/1ML/26G
X 1/2" MISC
BD INSULIN SYRINGE/U100/0.5ML/30G X 1/2"
MISC
BD INSULIN SYRINGE/U100/1ML/27G X 1/2" MISC
BD INSULIN SYRINGE/U100/1ML/28G X 1/2" MISC
BD INTEGRA INSULIN
SYRINGE/U-100/1ML/29G
X 1/2" MISC
BD INTEGRA
SYRINGE/RETRACTING
NEEDLE/1ML/25G X 1"
MISC
BD PEN
NEEDLE/MINI/ULTRAFINE
/31G X 3/16" MISC
BD PEN
NEEDLE/NANO/ULTRAFI
NE/32G X 4MM MISC
BD PEN
NEEDLE/SHORT/ULTRAFI
NE/31G X 5/16" MISC
BD PEN
NEEDLE/ULTRAFINE/29G
X 12.7MM MISC
BD PEN
NEEDLE/ULTRAFINE/29G
X1/2" 12.7MM MISC
BD PEN NEEDLES
SHORT/ULTRAFINE/31G
X 5/16" MISC
BD SAFETY-GLIDE
INSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
BD SAFETY-LOK INSULIN
SYRINGE/PERM
NEEDLE/UF/1ML/29G X
1/2" MISC
BD SAFETYGLIDE
INSULIN
SYSYRINGE/0.5ML/30G X
5/16" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
QL(5 ea daily)
F
F
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
114
Drug Name
CAREFINE PEN NEEDLE
32GX4MM MISC
CAREFINE PEN
NEEDLES 29GX1/2" MISC
CAREFINE PEN
NEEDLES 30GX5/16"
MISC
CAREFINE PEN
NEEDLES 31GX6MM
MISC
CAREFINE PEN
NEEDLES 31GX8MM
MISC
CAREFINE PEN
NEEDLES 32GX5MM
MISC
CAREFINE PEN
NEEDLES 32GX6MM
MISC
CAREONE INSULIN
SYRINGES/0.3ML/30G X
1/2" MISC
CAREONE INSULIN
SYRINGES/0.3ML/31G X
5/16" MISC
CAREONE INSULIN
SYRINGES/0.5ML/30G X
1/2" MISC
CAREONE INSULIN
SYRINGES/0.5ML/31G X
5/16" MISC
CAREONE INSULIN
SYRINGES/1ML/30G X
1/2" MISC
CAREONE INSULIN
SYRINGES/1ML/31GX5/16
" MISC
CAREONE UNIFINE
PENTIPS 29GX12MM
MISC
CAREONE UNIFINE
PENTIPS 31GX5MM MISC
CAREONE UNIFINE
PENTIPS 31GX6MM MISC
CAREONE UNIFINE
PENTIPS 31GX8MM MISC
Drug Requirements/
Tier Limits
F QL(5 ea daily);
RX/OTC
F QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
115
Drug Name
CAREONE UNIFINE
PENTIPS PEN NEEDLES
32GX4MM MISC
CAREONE UNIFINE
PENTIPS PLUS PEN
NEEDLES 29GX12MM
MISC
CAREONE UNIFINE
PENTIPS PLUS PEN
NEEDLES 31GX5MM
MISC
CAREONE UNIFINE
PENTIPS PLUS PEN
NEEDLES 31GX6MM
MISC
CAREONE UNIFINE
PENTIPS PLUS PEN
NEEDLES 31GX8MM
MISC
CAREONE UNIFINE
PENTIPS PLUS PEN
NEEDLES 32GX4MM
MISC
CARETOUCH PEN
NEEDLES 31G X 6 MM
MISC
CARETOUCH PEN
NEEDLES 31GX 5MM
MISC
CARETOUCH PEN
NEEDLES 31GX 8MM
MISC
CARETOUCH PEN
NEEDLES 32GX 4MM
MISC
CARETOUCH PEN
NEEDLES 32GX 5MM
MISC
CLEVER CHOICE
COMFORT EZINSULIN
PEN NEEDLES 31GX8MM
MISC
CLEVER CHOICE
COMFORT EZINSULIN
SYRINGE/0.3ML/29G X
1/2" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Drug Name
CLEVER CHOICE
COMFORT EZINSULIN
SYRINGE/0.3ML/30G X
1/2" MISC
CLEVER CHOICE
COMFORT EZINSULIN
SYRINGE/0.3ML/30G X
5/16" MISC
CLEVER CHOICE
COMFORT EZINSULIN
SYRINGE/0.3ML/31G X
5/16" MISC
CLEVER CHOICE
COMFORT EZINSULIN
SYRINGE/0.5ML/28G X
1/2" MISC
CLEVER CHOICE
COMFORT EZINSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
CLEVER CHOICE
COMFORT EZINSULIN
SYRINGE/0.5ML/30G X
1/2" MISC
CLEVER CHOICE
COMFORT EZINSULIN
SYRINGE/0.5ML/30G X
5/16" MISC
CLEVER CHOICE
COMFORT EZINSULIN
SYRINGE/0.5ML/31G X
5/16" MISC
CLEVER CHOICE
COMFORT EZINSULIN
SYRINGE/1.0ML/30G X
1/2" MISC
CLEVER CHOICE
COMFORT EZINSULIN
SYRINGE/1ML/28G X 1/2"
MISC
CLEVER CHOICE
COMFORT EZINSULIN
SYRINGE/1ML/29G X 1/2"
MISC
CLEVER CHOICE
COMFORT EZINSULIN
SYRINGE/1ML/30G X
5/16" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Drug Name
CLEVER CHOICE
COMFORT EZINSULIN
SYRINGE/U100/1ML/31GX5/16" MISC
CLEVER CHOICE
COMFORT EZPEN
NEEDLES 29GX12MM
MISC
CLEVER CHOICE
COMFORT EZPEN
NEEDLES 31GX5MM
MISC
CLEVER CHOICE
COMFORT EZPEN
NEEDLES 31GX6MM
MISC
CLEVER CHOICE
COMFORT EZPEN
NEEDLES 31GX8MM
MISC
CLEVER CHOICE
COMFORT EZPEN
NEEDLES 32GX4MM
MISC
CLEVER CHOICE
COMFORT EZPEN
NEEDLES 32GX5MM
MISC
CLEVER CHOICE
COMFORT EZPEN
NEEDLES 32GX6MM
MISC
CLICKFINE PEN NEEDLE
32GX5/32" MISC
CLICKFINE PEN NEEDLE
UNIVERSAL/31GX1/4"
MISC
CLICKFINE PEN NEEDLE
UNIVERSAL/31GX5/16"
MISC
CLICKFINE PEN
NEEDLES/31GX1/4" MISC
CLICKFINE PEN
NEEDLES/31GX5/16"
MISC
CLICKFINE UNIVERSAL
PEN NEEDLES 31GX5/16"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
116
Drug Name
COMFORT ASSIST
INSULIN SYRINGE
0.3ML/29G X 1/2" MISC
COMFORT ASSIST
INSULIN
SYRINGE/0.3ML/30G X
5/16" MISC
COMFORT ASSIST
INSULIN
SYRINGE/0.3ML/31G X
5/16" MISC
COMFORT ASSIST
INSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
COMFORT ASSIST
INSULIN
SYRINGE/0.5ML/30G X
5/16" MISC
COMFORT ASSIST
INSULIN
SYRINGE/0.5ML/31G X
5/16" MISC
COMFORT ASSIST
INSULIN
SYRINGE/1ML/29G X 1/2"
MISC
COMFORT ASSIST
INSULIN
SYRINGE/1ML/30G X
5/16" MISC
COMFORT ASSIST
INSULIN
SYRINGE/1ML/31G X
5/16" MISC
DROPLET PEN NEEDLES
29GX12MM MISC
DROPLET PEN NEEDLES
31GX5MM MISC
DROPLET PEN NEEDLES
31GX6MM MISC
DROPLET PEN NEEDLES
31GX8MM MISC
DROPLET PEN NEEDLES
32GX4MM MISC
DROPLET PEN NEEDLES
32GX5MM MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
117
Drug Requirements/
Tier Limits
DROPLET PEN NEEDLES
F QL(5 ea daily)
32GX6MM MISC
DRUG MART UNIFINE
F QL(5 ea daily)
PENTIPS 31GX5MM MISC
DRUG MART UNIFINE
QL(5 ea daily)
F
PENTIPS29G X 12MM
MISC
DRUG MART UNIFINE
F QL(5 ea daily)
PENTIPS31GX6MM MISC
DRUG MART UNIFINE
F QL(5 ea daily);
PENTIPS31GX8MM MISC
RX/OTC
DRUG MART UNIFINE
F QL(5 ea daily);
PENTIPS32GX4MM MISC
RX/OTC
DRUG MART UNIFINE
QL(5 ea daily);
F RX/OTC
PENTIPSPLUS 32GX4MM
MISC
DUANE READE UNIFINE
QL(5 ea daily)
F
PENTIPS 29G X 12MM
MISC
DUANE READE UNIFINE
QL(5 ea daily)
F
PENTIPS 31G X 6MM
ULTRA SHORT MISC
DUANE READE UNIFINE
QL(5 ea daily);
F RX/OTC
PENTIPS 31G X 8MM
SHORT MISC
EASY COMFORT INSULIN
QL(5 ea daily);
F RX/OTC
SYRINGE/0.3ML/30G X
5/16" MISC
EASY COMFORT INSULIN
QL(5 ea daily);
F RX/OTC
SYRINGE/0.5ML/30G X
5/16" MISC
EASY COMFORT INSULIN
QL(5 ea daily)
F
SYRINGE/0.5ML/31G X
5/16" MISC
EASY COMFORT INSULIN
QL(5 ea daily);
F RX/OTC
SYRINGE/1ML/30G X
5/16" MISC
EASY COMFORT INSULIN
QL(5 ea daily)
F
SYRINGE/1ML/31G X
5/16" MISC
EASY COMFORT INSULIN
QL(5 ea daily)
SYRINGE/UF
100/0.5ML/30G X 1/2"
MISC
EASY COMFORT INSULIN
QL(5 ea daily)
F
SYRINGE/U-100/1ML/30G
X 1/2" MISC
Drug Name
Drug Name
EASY COMFORT PEN
NEEDLES31GX1/4" MISC
EASY COMFORT PEN
NEEDLES31GX3/16"
MISC
EASY COMFORT PEN
NEEDLES31GX5/16"
MISC
EASY COMFORT PEN
NEEDLES32GX5/32"
MISC
EASY TOUCH 32GX5MM
MISC
EASY TOUCH 32GX6MM
MISC
EASY TOUCH FLIPLOCK
SAFETY INSULIN
SYRINGE 1ML/29GX1/2"
MISC
EASY TOUCH FLIPLOCK
SAFETY INSULIN
SYRINGE 1ML/30GX1/2"
MISC
EASY TOUCH FLIPLOCK
SAFETY INSULIN
SYRINGE 1ML/30GX5/16"
MISC
EASY TOUCH FLIPLOCK
SAFETY INSULIN
SYRINGE 1ML/31GX5/16"
MISC
EASY TOUCH INSULIN
SYRINGE/0.3ML/30G X
5/16" MISC
EASY TOUCH INSULIN
SYRINGE/0.3ML/31G X
5/16" MISC
EASY TOUCH INSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
EASY TOUCH INSULIN
SYRINGE/0.5ML/30G X
5/16" MISC
EASY TOUCH INSULIN
SYRINGE/1ML/30G X
5/16" MISC
Drug Requirements/
Tier Limits
F QL(5 ea daily)
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Drug Name
EASY TOUCH INSULIN
SYRINGE/SAFETY/U100/0.5ML/29G X 1/2"
MISC
EASY TOUCH INSULIN
SYRINGE/SAFETY/U100/0.5ML/30G X 5/16"
MISC
EASY TOUCH INSULIN
SYRINGE/SAFETY/U100/1ML/29G X 1/2" MISC
EASY TOUCH INSULIN
SYRINGE/SAFETY/U100/1ML/30G X 1/2" MISC
EASY TOUCH INSULIN
SYRINGE/U100/0.3ML/30G X 1/2"
MISC
EASY TOUCH INSULIN
SYRINGE/U100/0.5ML/27G X 1/2"
MISC
EASY TOUCH INSULIN
SYRINGE/U100/0.5ML/28G X 1/2"
MISC
EASY TOUCH INSULIN
SYRINGE/U100/0.5ML/30G X 1/2"
MISC
EASY TOUCH INSULIN
SYRINGE/U100/0.5ML/31G X 5/16"
MISC
EASY TOUCH INSULIN
SYRINGE/U-100/1ML/27G
X 1/2" MISC
EASY TOUCH INSULIN
SYRINGE/U-100/1ML/28G
X 1/2" MISC
EASY TOUCH INSULIN
SYRINGE/U-100/1ML/29G
X 1/2" MISC
EASY TOUCH INSULIN
SYRINGE/U-100/1ML/30G
X 1/2" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
Nebraska Total Care Updated May 30, 2017
118
Drug Requirements/
Tier Limits
EASY TOUCH INSULIN
QL(5 ea daily)
F
SYRINGE/U-100/1ML/31G
X 5/16" MISC
EASY TOUCH PEN
F QL(5 ea daily)
NEEDLES 29GX1/2" MISC
EASY TOUCH PEN
F QL(5 ea daily)
NEEDLES 31GX1/4" MISC
EASY TOUCH PEN
QL(5 ea daily);
F RX/OTC
NEEDLES 31GX5/16"
MISC
EASY TOUCH PEN
F QL(5 ea daily)
NEEDLES 32GX1/4" MISC
EASY TOUCH PEN
QL(5 ea daily);
F RX/OTC
NEEDLES 32GX3/16"
MISC
EASY TOUCH PEN
QL(5 ea daily);
F RX/OTC
NEEDLES 32GX5/32"
MISC
EASY TOUCH PEN
QL(5 ea daily)
F
NEEDLES/31G X 3/16"
MISC
EASY TOUCH
QL(5 ea daily);
SHEATHLOCK SAFETY
F RX/OTC
INSULIN SYRINGE
1ML/29GX1/2" MISC
EASY TOUCH
QL(5 ea daily);
SHEATHLOCK SAFETY
F RX/OTC
INSULIN SYRINGE
1ML/30GX5/16" MISC
EASY TOUCH
QL(5 ea daily)
SHEATHLOCK SAFETY
F
INSULIN SYRINGE
1ML/31GX5/16" MISC
EASY TOUCH
QL(5 ea daily)
SHEATHLOCK SAFETY
F
SYRINGE 1ML/30GX1/2"
MISC
ELITE-THIN INSULIN
QL(5 ea daily)
F
SYRINGE/0.3ML/31G X
5/16" MISC
ELITE-THIN INSULIN
QL(5 ea daily);
F RX/OTC
SYRINGE/0.5ML/29G X
1/2" MISC
ELITE-THIN INSULIN
QL(5 ea daily);
F RX/OTC
SYRINGE/0.5ML/30G X
5/16" MISC
Drug Name
Nebraska Total Care Updated May 30, 2017
119
Drug Name
ELITE-THIN INSULIN
SYRINGE/1ML/30G X
5/16" MISC
ELITE-THIN INSULIN
SYRINGE/U100/0.5ML/28G X 1/2"
MISC
ELITE-THIN INSULIN
SYRINGE/U100/0.5ML/31G X 5/16"
MISC
ELITE-THIN INSULIN
SYRINGE/U-100/1ML/28G
X 1/2" MISC
ELITE-THIN INSULIN
SYRINGE/U-100/1ML/29G
X 1/2" MISC
ELITE-THIN INSULIN
SYRINGE/U-100/1ML/31G
X 5/16" MISC
EQL INSULIN
SYRINGE/0.3ML/29G X
1/2" MISC
EQL INSULIN
SYRINGE/0.3ML/30G X
5/16" MISC
EQL INSULIN
SYRINGE/0.3ML/31G X
5/16" MISC
EQL INSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
EQL INSULIN
SYRINGE/0.5ML/30G X
5/16" MISC
EQL INSULIN
SYRINGE/0.5ML/31G X
5/16" MISC
EQL INSULIN
SYRINGE/1ML/29G X 1/2"
MISC
EQL INSULIN
SYRINGE/1ML/30G X
5/16" MISC
EQL INSULIN
SYRINGE/1ML/31G X
5/16" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
Drug Name
EQL INSULIN
SYRINGE/U100/0.3ML/29G X 1/2"
MISC
EQL INSULIN
SYRINGE/U100/0.5ML/29G X 1/2"
MISC
EQL INSULIN
SYRINGE/U-100/1ML/29G
X 1/2" MISC
EQL SHORT PEN
NEEDLES 31G X 8MM
MISC
EQL ULTRA COMFORT
INSULINSYRINGE/0.3ML/
31G X 5/16" MISC
EQL ULTRA COMFORT
INSULINSYRINGE/1ML/30
G X 5/16" MISC
EQL ULTRA SHORT PEN
NEEDLES 31G X 6MM
MISC
EXEL COMFORT POINT
INSULIN PEN NEEDLES
29G X 12MM MISC
EXEL COMFORT POINT
INSULIN PEN NEEDLES
31G X 6MM MISC
EXEL COMFORT POINT
INSULIN PEN NEEDLES
31G X 8MM MISC
EXEL COMFORT POINT
INSULIN
SYRINGE/0.3ML/29G X
1/2" MISC
EXEL COMFORT POINT
INSULIN
SYRINGE/0.3ML/30G X
5/16" MISC
EXEL COMFORT POINT
INSULIN
SYRINGE/0.5ML/28G X
1/2" MISC
EXEL COMFORT POINT
INSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Drug Name
EXEL COMFORT POINT
INSULIN
SYRINGE/0.5ML/30G X
5/16" MISC
EXEL COMFORT POINT
INSULIN
SYRINGE/1ML/28G X 1/2"
MISC
EXEL COMFORT POINT
INSULIN
SYRINGE/1ML/29G X 1/2"
MISC
EXEL COMFORT POINT
INSULIN
SYRINGE/1ML/30G X
5/16" MISC
FIFTY50 PEN NEEDLES
31G X3/16" (5MM) MISC
FIFTY50 PEN NEEDLES
31G X5/16" (8MM) MISC
FIFTY50 PEN NEEDLES
31GX5MM MISC
FIFTY50 PEN
NEEDLES/31GX8MM
MISC
FIFTY50 PEN
NEEDLES/32GX4MM
MISC
FIFTY50 PEN
NEEDLES/32GX6MM
MISC
FIFTY50 SUPERIOR
COMFORTINSULIN
SYRINGE/0.3ML/31G X
5/16" MISC
FIFTY50 SUPERIOR
COMFORTINSULIN
SYRINGE/0.5ML/31G X
5/16" MISC
FIFTY50 SUPERIOR
COMFORTINSULIN
SYRINGE/1ML/31G X
5/16" MISC
FREDS PHARMACY
UNIFINE PENTIPS PEN
NEEDLES 32GX4MM
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
120
Drug Name
FREDS PHARMACY
UNIFINE PENTIPS PLUS
31GX5MM MISC
FREDS PHARMACY
UNIFINE PENTIPS PLUS
31GX8MM MISC
FREESTYLE PRECISION
INSULIN SYRINGE/U100/0.5ML/30G X 5/16"
MISC
FREESTYLE PRECISION
INSULIN SYRINGE/U100/0.5ML/31G X 5/16"
MISC
FREESTYLE PRECISION
INSULIN SYRINGE/U100/1ML/31G X 5/16"
MISC
FREESTYLE PRECISION
INSULIN SYRINGES/U100/1ML/30G X 5/16"
MISC
GLOBAL EASE INJECT
PEN NEEDLES
29GX12MM MISC
GLOBAL EASE INJECT
PEN NEEDLES 31GX8MM
MISC
GLOBAL EASE INJECT
PEN NEEDLES 32GX4MM
MISC
GLOBAL EASE INJECT
PEN NEEEDLES
31GX5MM MISC
GLOBAL EASY GLIDE
INSULINSYRINGE/U100/0.3ML/31G X 5/16"
MISC
GLOBAL EASY GLIDE
PEN NEEDLES 32GX4MM
MISC
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/0.3ML/29G X 1/2"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
121
Drug Name
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/0.3ML/30G X 1/2"
MISC
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/0.3ML/30G X 5/16"
MISC
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/0.3ML/31G X 5/16"
MISC
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/0.5ML/28G X 1/2"
MISC
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/0.5ML/29G X 1/2"
MISC
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/0.5ML/30G X 1/2"
MISC
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/0.5ML/30G X 5/16"
MISC
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/0.5ML/31G X 5/16"
MISC
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/1ML/28G X 1/2" MISC
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/1ML/29G X 1/2" MISC
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/1ML/30G X 1/2" MISC
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/1ML/30G X 5/16"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
Drug Name
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/1ML/31G X 5/16"
MISC
GLOBAL INSULIN
SYRINGE/U100/0.3ML/30G X 1/2"
MISC
GLOBAL INSULIN
SYRINGES/U100/0.3ML/30GX5/16"
MISC
GLUCOPRO INSULIN
SYRINGE/U100/0.3ML/30G X 1/2"
MISC
GLUCOPRO INSULIN
SYRINGE/U100/0.3ML/30G X 5/16"
MISC
GLUCOPRO INSULIN
SYRINGE/U100/0.3ML/31G X 5/16"
MISC
GLUCOPRO INSULIN
SYRINGE/U100/0.5ML/30G X 1/2"
MISC
GLUCOPRO INSULIN
SYRINGE/U100/0.5ML/30G X 5/16"
MISC
GLUCOPRO INSULIN
SYRINGE/U100/0.5ML/31G X 5/16"
MISC
GLUCOPRO INSULIN
SYRINGE/U-100/1ML/30G
X 1/2" MISC
GLUCOPRO INSULIN
SYRINGE/U-100/1ML/30G
X 5/16" MISC
GLUCOPRO INSULIN
SYRINGE/U-100/1ML/31G
X 5/16" MISC
GNP CLICKFINE PEN
NEEDLEUNIVERSAL/31G
X5/16" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
Drug Name
GNP CLICKFINE
UNIVERSAL PEN
NEEDLES 31GX1/4" MISC
GNP CLICKFINE
UNIVERSAL PEN
NEEDLES 31GX5/16"
MISC
GNP INSULIN
SYRINGE/0.3ML/29G X
1/2" MISC
GNP INSULIN
SYRINGE/0.3ML/30G X
5/16" MISC
GNP INSULIN
SYRINGE/0.3ML/31G X
5/16" MISC
GNP INSULIN
SYRINGE/0.5ML/28G X
1/2" MISC
GNP INSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
GNP INSULIN
SYRINGE/0.5ML/30G X
5/16" MISC
GNP INSULIN
SYRINGE/0.5ML/31G X
5/16" MISC
GNP INSULIN
SYRINGE/1ML/28G X 1/2"
MISC
GNP INSULIN
SYRINGE/1ML/29G X 1/2"
MISC
GNP INSULIN
SYRINGE/1ML/30G X
5/16" MISC
GNP INSULIN
SYRINGE/1ML/31G X
5/16" MISC
GNP ULTRA COMFORT
INSULIN
SYRINGE/0.3ML/29G X
1/2" MISC
GNP ULTRA COMFORT
INSULIN
SYRINGE/0.3ML/30G X
5/16" SHORT MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
122
Drug Name
GNP ULTRA COMFORT
INSULIN
SYRINGE/0.3ML/31G X
5/16" SHORT MISC
GNP ULTRA COMFORT
INSULIN
SYRINGE/0.5ML/28G X
1/2" MISC
GNP ULTRA COMFORT
INSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
GNP ULTRA COMFORT
INSULIN
SYRINGE/0.5ML/30G X
5/16" SHORT MISC
GNP ULTRA COMFORT
INSULIN
SYRINGE/0.5ML/31G X
5/16" SHORT MISC
GNP ULTRA COMFORT
INSULIN
SYRINGE/1ML/28G X 1/2"
MISC
GNP ULTRA COMFORT
INSULIN
SYRINGE/1ML/29G X 1/2"
MISC
GNP ULTRA COMFORT
INSULIN
SYRINGE/1ML/30G X
5/16" SHORT MISC
GNP ULTRA COMFORT
INSULIN
SYRINGE/1ML/31G X
5/16" SHORT MISC
H-E-B IN CONTROL PEN
NEEDLES 31GX5MM
MISC
H-E-B IN CONTROL PEN
NEEDLES 31GX6MM
MISC
H-E-B IN CONTROL PEN
NEEDLES 31GX8MM
MISC
H-E-B IN CONTROL PEN
NEEDLES/NANO/32GX4M
M MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
123
Drug Name
H-E-B IN CONTROL
UNIFINEPENTIPS PLUS
31GX5MM MISC
H-E-B IN CONTROL
UNIFINEPENTIPS PLUS
32GX4MM MISC
H-E-B INCONTROL PEN
NEEDLES 29GX12MM
MISC
HEALTHWISE MINI PEN
NEEDLES 31GX6MM
MISC
HEALTHWISE PEN
NEEDLES 29GX12MM
MISC
HEALTHWISE SHORT
PEN NEEDLES 31GX8MM
MISC
HEALTHWISE UNIFINE
PENTIPS PEN NEEDLES
32GX4MM MISC
HEALTHY ACCENTS
UNIFINE PENTIPS PEN
NEEDLES 29GX12MM
MISC
HEALTHY ACCENTS
UNIFINE PENTIPS PEN
NEEDLES 31GX5MM
MISC
HEALTHY ACCENTS
UNIFINE PENTIPS PEN
NEEDLES 31GX6MM
MISC
HEALTHY ACCENTS
UNIFINE PENTIPS PEN
NEEDLES 31GX8MM
MISC
HEALTHY ACCENTS
UNIFINE PENTIPS PEN
NEEDLES 32GX4MM
MISC
INSULIN
SYRINGE/0.3ML/29G X 1"
MISC
INSULIN
SYRINGE/0.3ML/29G X
1/2" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
Drug Name
INSULIN
SYRINGE/0.3ML/30G X
5/16" MISC
INSULIN
SYRINGE/0.3ML/31G X
5/16" MISC
INSULIN
SYRINGE/0.5ML/27G X
1/2" MISC
INSULIN
SYRINGE/0.5ML/28G X
1/2" MISC
INSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
INSULIN
SYRINGE/0.5ML/30G X
1/2" MISC
INSULIN
SYRINGE/0.5ML/30G X
5/16" MISC
INSULIN
SYRINGE/0.5ML/31G X
5/16" MISC
INSULIN
SYRINGE/1ML/28G X 1/2"
MISC
INSULIN
SYRINGE/1ML/29G X 1/2"
MISC
INSULIN
SYRINGE/1ML/30G X
5/16" MISC
INSULIN
SYRINGE/1ML/31G X
5/16" MISC
INSULIN SYRINGE/U100/0.3ML/29G X 1/2"
MISC
INSULIN SYRINGE/U100/0.5ML/28G X 1/2"
MISC
INSULIN SYRINGE/U100/0.5ML/29G X 1/2"
MISC
INSULIN SYRINGE/U100/1ML/28G X 1/2" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Drug Name
INSULIN SYRINGE/U100/1ML/29G X 1/2" MISC
INSULIN SYRINGE/U100/1ML/30G X 5/16"
MISC
INSULIN SYRINGE/U100/1ML/31G X 5/16"
MISC
INSULIN
SYRINGES/0.5ML/27GX1/
2" MISC
INSULIN
SYRINGES/0.5ML/28GX1/
2" MISC
INSULIN
SYRINGES/0.5ML/29GX1/
2" MISC
INSULIN
SYRINGES/0.5ML/30GX5/
16" MISC
INSULIN
SYRINGES/0.5ML/31GX
5/16" MISC
INSULIN
SYRINGES/0.5ML/31GX5/
16" MISC
INSULIN
SYRINGES/1ML/27GX/1/2"
MISC
INSULIN
SYRINGES/1ML/27GX1/2"
MISC
INSULIN
SYRINGES/1ML/28GX1/2"
MISC
INSULIN
SYRINGES/1ML/29GX1/2"
MISC
INSULIN
SYRINGES/1ML/30GX1/2"
MISC
INSULIN
SYRINGES/1ML/31GX5/16
" MISC
INSUPEN PEN NEEDLES
32G X4MM MISC
Drug Requirements/
Tier Limits
F QL(5 ea daily);
RX/OTC
QL(5 ea daily);
F RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
124
Drug Name
INSUPEN SENSITIVE
32GX6MM MISC
INSUPEN ULTRAFIN
29GX12MM MISC
INSUPEN ULTRAFIN
30GX8MM MISC
INSUPEN ULTRAFIN
31GX6MM MISC
INSUPEN ULTRAFIN
31GX8MM MISC
KINRAY INSULIN
SYRINGE PREFERRED
PLUS/0.3ML/31G X 5/16"
MISC
KINRAY INSULIN
SYRINGE PREFERRED
PLUS/0.5ML/31G X 5/16"
MISC
KINRAY INSULIN
SYRINGE PREFERRED
PLUS/1ML/31G X 5/16"
MISC
KINRAY INSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
KMART VALU PLUS
INSULIN
SYRINGE/1ML/29G MISC
KMART VALU PLUS
INSULIN
SYRINGE/1ML/30G MISC
KROGER INSULIN
SYRINGE/0.3ML/29G X
1/2" MISC
KROGER INSULIN
SYRINGE/0.3ML/30G X
5/16" MISC
KROGER INSULIN
SYRINGE/0.3ML/31G X
5/16" MISC
KROGER INSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
KROGER INSULIN
SYRINGE/0.5ML/30G X
5/16" MISC
Drug Requirements/
Tier Limits
F QL(5 ea daily)
F
F
F
F
QL(5 ea daily)
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
125
Drug Name
KROGER INSULIN
SYRINGE/0.5ML/31G X
5/16" MISC
KROGER INSULIN
SYRINGE/1ML/29G X 1/2"
MISC
KROGER INSULIN
SYRINGE/1ML/30G X
5/16" MISC
KROGER INSULIN
SYRINGE/1ML/31G X
5/16" MISC
KROGER PEN NEEDLES
29G X12MM MISC
KROGER PEN NEEDLES
31G X8MM MISC
KROGER PEN NEEDLES
31GX1/4" MISC
LEADER INSULIN
SYRINGE/0.3ML/29G X
1/2" MISC
LEADER INSULIN
SYRINGE/0.3ML/30G X
5/16" MISC
LEADER INSULIN
SYRINGE/0.3ML/31G X
5/16" MISC
LEADER INSULIN
SYRINGE/0.5ML/28G X
1/2" MISC
LEADER INSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
LEADER INSULIN
SYRINGE/0.5ML/30G X
5/16" MISC
LEADER INSULIN
SYRINGE/0.5ML/31G X
5/16" MISC
LEADER INSULIN
SYRINGE/1ML/28G X 1/2"
MISC
LEADER INSULIN
SYRINGE/1ML/29G X 1/2"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Drug Name
LEADER INSULIN
SYRINGE/1ML/30G X
5/16" MISC
LEADER INSULIN
SYRINGE/1ML/31G X
5/16" MISC
LEADER UNIFINE
PENTIPS
PLUS/MINI/31GX3/16"
MISC
LEADER UNIFINE
PENTIPS
PLUS/SHORT/31GX5/16"
MISC
LEADER UNIFINE
PENTIPS/MINI/31GX3/16"
MISC
LEADER UNIFINE
PENTIPS/NANO/32GX5/32
" MISC
LEADER UNIFINE
PENTIPS/PLUS/32GX5/32
" MISC
LITE TOUCH PEN
NEEDLES/31G X 3/16"
MISC
LITETOUCH INSULIN
SYRINGE/0.3ML/29G X
1/2" MISC
LITETOUCH INSULIN
SYRINGE/0.3ML/30G X
5/16" MISC
LITETOUCH INSULIN
SYRINGE/0.3ML/31G X
5/16" MISC
LITETOUCH INSULIN
SYRINGE/0.5ML/30G X
5/16" MISC
LITETOUCH INSULIN
SYRINGE/0.5ML/31G X
5/16" MISC
LITETOUCH INSULIN
SYRINGE/1ML/30G X
5/16" MISC
LITETOUCH INSULIN
SYRINGE/U100/0.5ML/28G X 1/2"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Drug Name
LITETOUCH INSULIN
SYRINGE/U100/0.5ML/29G X 1/2"
MISC
LITETOUCH INSULIN
SYRINGE/U-100/1ML/28G
X 1/2" MISC
LITETOUCH INSULIN
SYRINGE/U-100/1ML/29G
X 1/2" MISC
LITETOUCH INSULIN
SYRINGE/U-100/1ML/31G
X 5/16" MISC
LITETOUCH PEN
NEEDLES 29GX12.7MM
MISC
LITETOUCH PEN
NEEDLES 31G X 6MM
MISC
LITETOUCH PEN
NEEDLES 31GX8MM
SHORT MISC
LIVE BETTER PEN
NEEDLES 29G X 12MM
MISC
LIVE BETTER PEN
NEEDLES 31G X 12MM
MISC
LIVE BETTER PEN
NEEDLES 31G X 6MM
MISC
LONGS INSULIN
SYRINGE/0.5ML/31G X
5/16" MISC
MAGELLAN INSULIN
SAFETY SYRINGE/U100/0.3ML/29G X 1/2"
MISC
MAGELLAN INSULIN
SAFETY SYRINGE/U100/0.3ML/30G X 5/16"
MISC
MAGELLAN INSULIN
SAFETY SYRINGE/U100/0.5ML/29G X 1/2"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
126
Drug Name
MAGELLAN INSULIN
SAFETY SYRINGE/U100/0.5ML/30G X 5/16"
MISC
MAGELLAN INSULIN
SAFETY SYRINGE/U100/1ML/29G X 1/2" MISC
MAGELLAN INSULIN
SAFETY SYRINGE/U100/1ML/30G X 5/16"
MISC
MAXI-COMFORT INSULIN
SYRINGE/U100/0.5ML/28GX1/2" MISC
MAXI-COMFORT INSULIN
SYRINGE/U100/1ML/28GX1/2" MISC
MEDIC INSULIN
SYRINGE/0.3ML/30G X
5/16" MISC
MEDIC INSULIN
SYRINGE/0.5ML/30G X
5/16" MISC
MEDICINE SHOPPE PEN
NEEDLES 29G X 12MM
MISC
MEDICINE SHOPPE PEN
NEEDLES 31G X 6MM
MISC
MEDICINE SHOPPE PEN
NEEDLES 31G X 8MM
MISC
MEIJER PEN NEEDLES
29G X12MM MISC
MEIJER PEN NEEDLES
31G X6MM MISC
MEIJER PEN NEEDLES
31G X8MM MISC
MONOJECT INSULIN
SYRINGE/1ML MISC
MONOJECT INSULIN
SYRINGE/1ML/31G X
5/16" MISC
MONOJECT INSULIN
SYRINGE/DETACH
NEEDLE/1ML/25G X 5/8"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
Nebraska Total Care Updated May 30, 2017
127
Drug Name
MONOJECT INSULIN
SYRINGE/DETACH
NEEDLE/1ML/27G X 1/2"
MISC
MONOJECT INSULIN
SYRINGE/PERM
NEEDLE/1ML/28G X 1/2"
MISC
MONOJECT INSULIN
SYRINGE/PERM
NEEDLE/U-100/0.5ML/28G
X 1/2" MISC
MONOJECT INSULIN
SYRINGE/SAFETY/PERM
NEEDLE/0.3ML/29G X 1/2"
MISC
MONOJECT INSULIN
SYRINGE/SAFETY/PERM
NEEDLE/0.3ML/29GX1/2"
MISC
MONOJECT INSULIN
SYRINGE/SAFETY/PERM
NEEDLE/0.5ML/29G X 1/2"
MISC
MONOJECT INSULIN
SYRINGE/SAFETY/PERM
NEEDLE/1ML/29G X 1/2"
MISC
MONOJECT INSULIN
SYRINGE/SOFTPACK/1M
L/27G X 1/2" MISC
MONOJECT INSULIN
SYRINGE/SOFTPACK/U100/0.5ML/28G X 1/2"
MISC
MONOJECT INSULIN
SYRINGE/U100/0.3ML/30G X 5/16"
MISC
MONOJECT INSULIN
SYRINGE/U100/0.5ML/28G X 1/2"
MISC
MONOJECT INSULIN
SYRINGE/U100/0.5ML/30G X 5/16"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Drug Requirements/
Tier Limits
MONOJECT INSULIN
QL(5 ea daily);
F RX/OTC
SYRINGE/U-100/1ML/28G
X 1/2" MISC
MONOJECT INSULIN
QL(5 ea daily);
F RX/OTC
SYRINGE/U-100/1ML/30G
X 5/16" MISC
MONOJECT INSULIN
QL(5 ea daily);
SYRINGEREGULAR LUER F RX/OTC
TIP/SOFTPACK/1ML MISC
MONOJECT ULTRA
QL(5 ea daily);
COMFORT INSULIN
F RX/OTC
SYRINGE/0.3ML/29G X
1/2" MISC
MONOJECT ULTRA
QL(5 ea daily);
COMFORT INSULIN
F RX/OTC
SYRINGE/0.3ML/30G X
5/16" MISC
MONOJECT ULTRA
QL(5 ea daily)
COMFORT INSULIN
F
SYRINGE/0.3ML/31G X
5/16" MISC
MONOJECT ULTRA
QL(5 ea daily);
COMFORT INSULIN
F RX/OTC
SYRINGE/0.5ML/28G X
1/2" MISC
MONOJECT ULTRA
QL(5 ea daily);
COMFORT INSULIN
F RX/OTC
SYRINGE/0.5ML/29G X
1/2" MISC
MONOJECT ULTRA
QL(5 ea daily);
COMFORT INSULIN
F RX/OTC
SYRINGE/0.5ML/30G X
5/16" MISC
MONOJECT ULTRA
QL(5 ea daily)
COMFORT INSULIN
F
SYRINGE/0.5ML/31G X
5/16" MISC
MONOJECT ULTRA
QL(5 ea daily);
COMFORT INSULIN
F RX/OTC
SYRINGE/1ML/28G X 1/2"
MISC
MONOJECT ULTRA
QL(5 ea daily);
COMFORT INSULIN
F RX/OTC
SYRINGE/1ML/29G X 1/2"
MISC
Drug Name
Drug Name
MONOJECT ULTRA
COMFORT INSULIN
SYRINGE/1ML/30G X
5/16" MISC
MOORE MED MONOJECT
INSULIN SYRINGE/U100/0.5ML/28G X 1/2"
MISC
MOORE MED MONOJECT
INSULIN SYRINGE/U100/0.5ML/29G X 1/2"
MISC
MOORE MED MONOJECT
INSULIN SYRINGE/U100/1ML/28G X 1/2" MISC
MOORE MED MONOJECT
INSULIN SYRINGE/U100/1ML/29G X 1/2" MISC
MS INSULIN
SYRINGE/0.3ML/31G X
5/16" MISC
MS INSULIN
SYRINGE/0.5ML/31G X
5/16" MISC
MS INSULIN
SYRINGE/1ML/31G X
5/16" MISC
NOVOFINE 30GX8MM
MISC
NOVOFINE 32GX6MM
MISC
NOVOFINE AUTOCOVER
30GX8MM MISC
NOVOFINE PLUS
32GX4MM MISC
NOVOTWIST 30GX8MM
MISC
NOVOTWIST 32GX5MM
MISC
PC UNIFINE PENTIPS
29G X1/2" MISC
PC UNIFINE PENTIPS
31G X5MM MINI MISC
PC UNIFINE PENTIPS
31G X6MM ULTRA
SHORT MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
F
F
QL(5 ea daily)
F
Nebraska Total Care Updated May 30, 2017
128
Drug Name
PC UNIFINE PENTIPS
31G X8MM SHORT MISC
PEN NEEDLES 29G X
12MM MISC
PEN NEEDLES 29GX1/2"
MISC
PEN NEEDLES 30GX5/16"
MISC
PEN NEEDLES 30GX8MM
MISC
PEN NEEDLES 31G X 1/4"
SHORT MISC
PEN NEEDLES 31G X
3/16" MISC
PEN NEEDLES 31G X
5MM MISC
PEN NEEDLES 31G X
6MM MISC
PEN NEEDLES 31GX5/16"
MISC
PEN NEEDLES 31GX6MM
(1/4") MISC
PEN NEEDLES 31GX8MM
(5/16") MISC
PEN NEEDLES 31GX8MM
MISC
PEN NEEDLES 32GX4MM
MISC
PENTIPS 29GX12MM
MISC
Drug Requirements/
Tier Limits
F QL(5 ea daily);
RX/OTC
F QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
PENTIPS 31GX5MM MISC
F
QL(5 ea daily)
PENTIPS 31GX6MM MISC
F
QL(5 ea daily)
PENTIPS 31GX8MM MISC
F
PENTIPS 32GX4MM MISC
F
PRECISION SURE-DOSE
INSULIN
SYRINGE/0.3ML/30G X
5/16" MISC
PRECISION SURE-DOSE
INSULIN
SYRINGE/0.5ML/28G X
1/2" MISC
F
F
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
129
Drug Name
PRECISION SURE-DOSE
INSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
PRECISION SURE-DOSE
INSULIN
SYRINGE/0.5ML/30G X
3/8" MISC
PRECISION SURE-DOSE
INSULIN
SYRINGE/1ML/28G X 1/2"
MISC
PRECISION SURE-DOSE
PLUSINSULIN
SYRINGE/0.3ML/29G X
1/2" MISC
PRECISION SURE-DOSE
PLUSINSULIN
SYRINGE/1ML/29G X 1/2"
MISC
PREFERRED PLUS
INSULIN SYRINGE/U100/0.3ML/29G X 1/2"
MISC
PREFERRED PLUS
INSULIN SYRINGE/U100/0.3ML/30G X 5/16"
MISC
PREFERRED PLUS
INSULIN SYRINGE/U100/0.5ML/28G X 1/2"
MISC
PREFERRED PLUS
INSULIN SYRINGE/U100/0.5ML/29G X 1/2"
MISC
PREFERRED PLUS
INSULIN SYRINGE/U100/0.5ML/30G X 5/16"
MISC
PREFERRED PLUS
INSULIN SYRINGE/U100/1ML/28G X 1/2" MISC
PREFERRED PLUS
INSULIN SYRINGE/U100/1ML/29G X 1/2" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Drug Name
PREFERRED PLUS
INSULIN SYRINGE/U100/1ML/30G X 5/16"
MISC
PREFERRED PLUS
UNIFINE PENTIPS 29G X
12MM MISC
PREFERRED PLUS
UNIFINE PENTIPS 31G X
6MM ULTRA SHORT
MISC
PREFERRED PLUS
UNIFINE PENTIPS 31G X
8MM SHORT MISC
PREFERRED PLUS
UNIFINE PENTIPS
32GX4MM MISC
PREFERRED PLUS
UNIFINE
PENTIPS/MINI/31GX5MM
MISC
PRO COMFORT PEN
NEEDLES/31G X 8MM
MISC
PRO COMFORT PEN
NEEDLES/32G X 4MM
MISC
PRO COMFORT PEN
NEEDLES/32G X 5MM
MISC
PRO COMFORT PEN
NEEDLES/32G X 6MM
MISC
PRODIGY INSULIN
SYRING/U-100/0.3ML/31G
X 5/16" MISC
PRODIGY INSULIN
SYRINGE/1/2ML/31G X
5/16" MISC
PRODIGY INSULIN
SYRINGE/1ML/28G X 1/2"
MISC
PX EXTRA SHORT PEN
NEEDLES 31GX6MM
MISC
PX INSULIN SYRINGE/U100/0.3ML/30G X 1/2"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
Drug Name
PX INSULIN SYRINGE/U100/0.3ML/31G X 5/16"
MISC
PX INSULIN SYRINGE/U100/0.5ML/30G X 1/2"
MISC
PX INSULIN SYRINGE/U100/0.5ML/31G X 5/16"
MISC
PX INSULIN SYRINGE/U100/1ML/30G X 1/2" MISC
PX INSULIN SYRINGE/U100/1ML/31G X 5/16"
MISC
PX MINI PEN NEEDLES
31GX5MM MISC
PX PEN NEEDLE
29GX12MM MISC
PX PEN NEEDLE
31GX8MM MISC
PX SHORTLENGTH PEN
NEEDLES/31GX8MM
MISC
QC PEN NEEDLES 29G X
12MM MISC
QC PEN NEEDLES 31G X
6MM MISC
QC PEN NEEDLES 31G X
8MM MISC
QC UNIFINE PENTIPS
32GX4MM MISC
RA INSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
RA INSULIN
SYRINGE/1ML/29G X 1/2"
MISC
RA INSULIN SYRINGE/U100/0.5ML/30G X 5/16"
MISC
RA INSULIN SYRINGE/U100/1 ML/30G X 5/16"
MISC
RA PEN NEEDLES 31G X
5MM3/16" MISC
RA PEN NEEDLES 31G X
8MM5/16" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily)
QL(5 ea daily)
F
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily)
F
F
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
130
Drug Name
REALITY INSULIN
SYRINGE/U100/0.5ML/28G X 1/2"
MISC
REALITY INSULIN
SYRINGE/U100/0.5ML/29G X 1/2"
MISC
REALITY INSULIN
SYRINGE/U-100/1ML/28G
X 1/2" MISC
REALITY INSULIN
SYRINGE/U-100/1ML/29G
X 1/2" MISC
RELION INSULIN
SYRINGE
1ML/31GX15/64" MISC
RELION INSULIN
SYRINGE/U-00/1ML/29G
X 1/2" MISC
RELION INSULIN
SYRINGE/U100/0.3ML/29G X 1/2"
MISC
RELION INSULIN
SYRINGE/U100/0.3ML/30G X 5/16"
MISC
RELION INSULIN
SYRINGE/U100/0.3ML/31G X 5/16"
MISC
RELION INSULIN
SYRINGE/U100/0.5ML/29G X 1/2"
MISC
RELION INSULIN
SYRINGE/U100/0.5ML/30G X 5/16"
MISC
RELION INSULIN
SYRINGE/U100/0.5ML/31G X 5/16"
MISC
RELION INSULIN
SYRINGE/U-100/1ML/30G
X 5/16" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
131
Drug Name
RELION INSULIN
SYRINGE/U-100/1ML/31G
X 5/16" MISC
RELION MINI PEN
NEEDLES 31GX6MM
MISC
RELION PEN NEEDLES
29GX12MM MISC
RELION PEN NEEDLES
31GX6MM MISC
RELION PEN NEEDLES
31GX8MM MISC
RELION PEN NEEDLES
32GX4MM MISC
RELION SHORT PEN
NEEDLES31GX8MM MISC
SAFESNAP INSULIN
SYRINGE/0.3ML/30G X
5/16" MISC
SAFESNAP INSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
SAFESNAP INSULIN
SYRINGE/0.5ML/30G X
5/16" MISC
SAFESNAP INSULIN
SYRINGE/1ML/28G X 1/2"
MISC
SAFESNAP INSULIN
SYRINGE/1ML/29G X 1/2"
MISC
SAFETY INSULIN
SYRINGES
0.5ML/29GX1/2" MISC
SAFETY INSULIN
SYRINGES
0.5ML/30GX5/16" MISC
SAFETY INSULIN
SYRINGES 1ML/27GX1/2"
MISC
SAFETY INSULIN
SYRINGES 1ML/29GX1/2"
MISC
SAFETY INSULIN
SYRINGES 1ML/30GX1/2"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
F
F
QL(5 ea daily)
F
Drug Name
SAFETY-GLIDE INSULIN
SYRINGE/0.3ML/29G X
1/2" MISC
SB INSULIN SYRINGE/U100/0.5ML/29G X 1/2"
MISC
SB INSULIN SYRINGE/U100/0.5ML/30G X 5/16"
MISC
SB INSULIN SYRINGE/U100/1ML/29G X 1/2" MISC
SB INSULIN SYRINGE/U100/1ML/30G X 5/16"
MISC
SB INSULIN SYRINGE/U100/1ML/31G X 5/16"
MISC
SCHNUCKS INSULIN
SYRINGEULTI-FINE/U100/0.5ML/29G X 1/2"
MISC
SCHNUCKS INSULIN
SYRINGEULTI-FINE/U100/0.5ML/30G X 5/16"
MISC
SHOPKO UNIFINE
PENTIPS PEN
NEEDLES/MICRO/32GX4
MM MISC
SHOPKO UNIFINE
PENTIPS PEN
NEEDLES/MINI/31GX5MM
MISC
SHOPKO UNIFINE
PENTIPS PEN
NEEDLES/ORIGINAL/29G
X12MM MISC
SHOPKO UNIFINE
PENTIPS PEN
NEEDLES/SHORT/31GX8
MM MISC
SHOPKO UNIFINE
PENTIPS PLUS PEN
NEEDLES/MICRO/REMOV
R/32GX4MM MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
Drug Name
SHOPKO UNIFINE
PENTIPS PLUS PEN
NEEDLES/MINI/REMOVE
R/31GX5MM MISC
SHOPKO UNIFINE
PENTIPS PLUS PEN
NEEDLES/REMOVER/29G
X12MM MISC
SHOPKO UNIFINE
PENTIPS PLUS PEN
NEEDLES/SHORT/REMO
VR/31GX8MM MISC
SM INSULIN
SYRINGE/1ML/31G X
5/16" MISC
SURE COMFORT
INSULIN SYRINGE/U100/0.3ML/29G X 1/2"
MISC
SURE COMFORT
INSULIN SYRINGE/U100/0.3ML/30G X 1/2"
MISC
SURE COMFORT
INSULIN SYRINGE/U100/0.3ML/30G X 5/16"
MISC
SURE COMFORT
INSULIN SYRINGE/U100/0.3ML/31G X 5/16
MISC
SURE COMFORT
INSULIN SYRINGE/U100/0.3ML/31G X 5/16"
MISC
SURE COMFORT
INSULIN SYRINGE/U100/0.5ML/28G X 1/2"
MISC
SURE COMFORT
INSULIN SYRINGE/U100/0.5ML/29G X 1/2"
MISC
SURE COMFORT
INSULIN SYRINGE/U100/0.5ML/30G X 1/2"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
Nebraska Total Care Updated May 30, 2017
132
Drug Name
SURE COMFORT
INSULIN SYRINGE/U100/0.5ML/30G X 5/16"
MISC
SURE COMFORT
INSULIN SYRINGE/U100/0.5ML/31G X 5/16
MISC
SURE COMFORT
INSULIN SYRINGE/U100/1ML/28G X 1/2" MISC
SURE COMFORT
INSULIN SYRINGE/U100/1ML/29G X 1/2" MISC
SURE COMFORT
INSULIN SYRINGE/U100/1ML/30G X 1/2" MISC
SURE COMFORT
INSULIN SYRINGE/U100/1ML/30G X 5/16"
MISC
SURE COMFORT
INSULIN SYRINGE/U100/1ML/31G X 5/16"
MISC
SURE COMFORT PEN
NEEDLES29GX1/2"
12.7MM MISC
SURE COMFORT PEN
NEEDLES30GX5/16"
SHORT MISC
SURE COMFORT PEN
NEEDLES31GX3/16"
(5MM) MISC
SURE COMFORT PEN
NEEDLES31GX5/16"
(8MM) MISC
SURE COMFORT PEN
NEEDLES32GX5/32"
MISC
SURE COMFORT PEN
NEEDLES32GX6MM MISC
SURE-FINE PEN
NEEDLES 29GX1/2"
12.7MM MISC
SURE-FINE PEN
NEEDLES 31GX3/16"
5MM MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily)
QL(5 ea daily)
F
QL(5 ea daily)
F
Nebraska Total Care Updated May 30, 2017
133
Drug Requirements/
Tier Limits
SURE-FINE PEN
QL(5 ea daily);
NEEDLES 31GX5/16" 8MM F RX/OTC
MISC
SURE-JECT INSULIN
QL(5 ea daily);
SYRINGE/UF RX/OTC
100/0.3ML/29G X 1/2"
MISC
SURE-JECT INSULIN
QL(5 ea daily);
SYRINGE/UF RX/OTC
100/0.3ML/30G X 5/16"
MISC
SURE-JECT INSULIN
QL(5 ea daily)
SYRINGE/UF
100/0.3ML/31G X 5/16"
MISC
SURE-JECT INSULIN
QL(5 ea daily);
SYRINGE/UF RX/OTC
100/0.5ML/28G X 1/2"
MISC
SURE-JECT INSULIN
QL(5 ea daily);
SYRINGE/UF RX/OTC
100/0.5ML/29G X 1/2"
MISC
SURE-JECT INSULIN
QL(5 ea daily);
SYRINGE/UF RX/OTC
100/0.5ML/30G X 5/16"
MISC
SURE-JECT INSULIN
QL(5 ea daily)
SYRINGE/UF
100/0.5ML/31G X 5/16"
MISC
SURE-JECT INSULIN
QL(5 ea daily);
F RX/OTC
SYRINGE/U-100/1ML/28G
X 1/2" MISC
SURE-JECT INSULIN
QL(5 ea daily);
F RX/OTC
SYRINGE/U-100/1ML/29G
X 1/2" MISC
SURE-JECT INSULIN
QL(5 ea daily);
F RX/OTC
SYRINGE/U-100/1ML/30G
X 5/16" MISC
SURE-JECT INSULIN
QL(5 ea daily)
F
SYRINGE/U-100/1ML/31G
X 5/16" MISC
TECHLITE PEN
QL(5 ea daily)
F
NEEDLES/31GX 5MM
MISC
Drug Name
Drug Name
TECHLITE PEN
NEEDLES/31GX 6 MM
MISC
TECHLITE PEN
NEEDLES/31GX 8MM
MISC
TECHLITE PEN
NEEDLES/32GX 4MM
MISC
TECHLITE PEN
NEEDLES/32GX 6MM
MISC
TODAYS HEALTH MINI
PEN NEEDLES 31G X 1/4"
MISC
TODAYS HEALTH
ORIGINAL PEN NEEDLES
29G X 1/2" MISC
TODAYS HEALTH SHORT
PEN NEEDLES 31G X
5/16" MISC
TOPCARE CLICKFINE
UNIVERSAL PEN EEDLES
31GX1/4" MISC
TOPCARE CLICKFINE
UNIVERSAL PEN EEDLES
31GX5/16" MISC
TOPCARE ULTRA
COMFORT INSULIN
SYRINGE/0.3ML/30G X
5/16" MISC
TOPCARE ULTRA
COMFORT INSULIN
SYRINGE/0.3ML/31G X
5/16" MISC
TOPCARE ULTRA
COMFORT INSULIN
SYRINGE/0.5ML/30G X
5/16" MISC
TOPCARE ULTRA
COMFORT INSULIN
SYRINGE/0.5ML/31G X
5/16" MISC
TOPCARE ULTRA
COMFORT INSULIN
SYRINGE/1ML/30G X
5/16" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
Drug Name
TOPCARE ULTRA
COMFORT INSULIN
SYRINGE/1ML/31G X
5/16" MISC
TOPCARE ULTRA
COMFORT INSULIN
SYRINGE/U100/0.3ML/29G X 1/2"
MISC
TOPCARE ULTRA
COMFORT INSULIN
SYRINGE/U100/0.5ML/29G X 1/2"
MISC
TOPCARE ULTRA
COMFORT INSULIN
SYRINGE/U-100/1ML/29G
X 1/2" MISC
TOPCO INSULIN
SYRINGE/U100/0.3ML/29G X 1/2"
MISC
TOPCO INSULIN
SYRINGE/U100/0.5ML/28G X 1/2"
MISC
TOPCO INSULIN
SYRINGE/U100/0.5ML/29G X 1/2"
MISC
TOPCO INSULIN
SYRINGE/U-100/1ML/28G
X 1/2" MISC
TOPCO INSULIN
SYRINGE/U-100/1ML/29G
X 1/2" MISC
TRUEPLUS INSULIN
SYRINGE/U100/0.3ML/29G X 1/2"
MISC
TRUEPLUS INSULIN
SYRINGE/U100/0.3ML/30G X 5/16"
MISC
TRUEPLUS INSULIN
SYRINGE/U100/0.3ML/31G X 5/16"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
Nebraska Total Care Updated May 30, 2017
134
Drug Name
TRUEPLUS INSULIN
SYRINGE/U100/0.5ML/28G X 1/2"
MISC
TRUEPLUS INSULIN
SYRINGE/U100/0.5ML/29G X 1/2"
MISC
TRUEPLUS INSULIN
SYRINGE/U100/0.5ML/30G X 5/16"
MISC
TRUEPLUS INSULIN
SYRINGE/U100/0.5ML/31G X 5/16"
MISC
TRUEPLUS INSULIN
SYRINGE/U-100/1ML/28G
X 1/2" MISC
TRUEPLUS INSULIN
SYRINGE/U-100/1ML/29G
X 1/2" MISC
TRUEPLUS INSULIN
SYRINGE/U-100/1ML/30G
X 5/16" MISC
TRUEPLUS INSULIN
SYRINGE/U-100/1ML/31G
X 5/16" MISC
TRUEPLUS PEN
NEEDLES 29GX12MM
MISC
TRUEPLUS PEN
NEEDLES 31GX5MM
MISC
TRUEPLUS PEN
NEEDLES 31GX6MM
MISC
TRUEPLUS PEN
NEEDLES 31GX8MM
MISC
TRUEPLUS PEN
NEEDLES 32GX4MM
MISC
ULTICARE INSULIN
SAFETY
SYRINGE/0.5ML/29G X
1/2" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
135
Drug Name
ULTICARE INSULIN
SAFETY
SYRINGE/1ML/29G X 1/2"
MISC
ULTICARE INSULIN
SYRINGE/0.3ML/29G X
1/2" MISC
ULTICARE INSULIN
SYRINGE/0.3ML/30G X
1/2" MISC
ULTICARE INSULIN
SYRINGE/0.3ML/30G X
5/16" MISC
ULTICARE INSULIN
SYRINGE/0.5ML/28G X
1/2" MISC
ULTICARE INSULIN
SYRINGE/0.5ML/29G X
1/2" MISC
ULTICARE INSULIN
SYRINGE/0.5ML/30G X
1/2" MISC
ULTICARE INSULIN
SYRINGE/0.5ML/30G X
5/16" MISC
ULTICARE INSULIN
SYRINGE/1ML/28G X 1/2"
MISC
ULTICARE INSULIN
SYRINGE/1ML/29G X 1/2"
MISC
ULTICARE INSULIN
SYRINGE/1ML/30G X 1/2"
MISC
ULTICARE INSULIN
SYRINGE/1ML/30G X
5/16" MISC
ULTICARE INSULIN
SYRINGE/SHORT/0.3ML/3
0G X 5/16" MISC
ULTICARE INSULIN
SYRINGE/SHORT/0.3ML/3
1G X 5/16" MISC
ULTICARE INSULIN
SYRINGE/SHORT/0.5ML/3
0G X 5/16" MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
Drug Requirements/
Tier Limits
ULTICARE INSULIN
QL(5 ea daily)
SYRINGE/SHORT/0.5ML/3 F
1G X 5/16" MISC
ULTICARE INSULIN
QL(5 ea daily);
F RX/OTC
SYRINGE/SHORT/1ML/30
G X 5/16" MISC
ULTICARE INSULIN
QL(5 ea daily)
F
SYRINGE/SHORT/1ML/31
G X 5/16" MISC
ULTICARE INSULIN
QL(5 ea daily);
SYRINGE/UF RX/OTC
100/0.3ML/29G X 1/2"
MISC
ULTICARE INSULIN
QL(5 ea daily)
SYRINGE/UF
100/0.3ML/30G X 1/2"
MISC
ULTICARE INSULIN
QL(5 ea daily);
SYRINGE/UF RX/OTC
100/0.3ML/30G X 5/16"
MISC
ULTICARE INSULIN
QL(5 ea daily)
SYRINGE/UF
100/0.3ML/31G X 5/16"
MISC
ULTICARE INSULIN
QL(5 ea daily);
SYRINGE/UF RX/OTC
100/0.5ML/29G X 1/2"
MISC
ULTICARE INSULIN
QL(5 ea daily)
SYRINGE/UF
100/0.5ML/30G X 1/2"
MISC
ULTICARE INSULIN
QL(5 ea daily);
SYRINGE/UF RX/OTC
100/0.5ML/30G X 5/16"
MISC
ULTICARE INSULIN
QL(5 ea daily)
SYRINGE/UF
100/0.5ML/31G X 5/16"
MISC
ULTICARE INSULIN
QL(5 ea daily);
F RX/OTC
SYRINGE/U-100/1ML/29G
X 1/2" MISC
ULTICARE INSULIN
QL(5 ea daily)
F
SYRINGE/U-100/1ML/30G
X 1/2" MISC
Drug Name
Drug Name
ULTICARE INSULIN
SYRINGE/U-100/1ML/30G
X 5/16" MISC
ULTICARE INSULIN
SYRINGE/U-100/1ML/31G
X 5/16" MISC
ULTICARE INSULIN
SYRINGEULTRAFINE U100/0.3ML/31G X 5/16"
MISC
ULTICARE INSULIN
SYRINGEULTRAFINE U100/0.5ML/31G X 5/16"
MISC
ULTICARE INSULIN
SYRINGEULTRAFINE U100/1ML/31G X 5/16"
MISC
ULTICARE MICRO PEN
NEEDLES 31G X 8MM
MISC
ULTICARE MICRO PEN
NEEDLES 32G X 4MM
MISC
ULTICARE MICRO PEN
NEEDLES/32G X 4MM
MISC
ULTICARE MINI PEN
NEEDLES 31GX6MM
MISC
ULTICARE MINI PEN
NEEDLES ULTI-FINE IV
MISC
ULTICARE MINI PEN
NEEDLES/31G X 6MM
MISC
ULTICARE MINI PEN
NEEDLES31GX6MM MISC
ULTICARE ORIGINAL
PEN NEEDLES ULTI-FINE
MISC
ULTICARE PEN
NEEDLES/29GX 12.7MM
MISC
ULTICARE SHORT PEN
NEEDLES 31GX8MM
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily)
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
136
Drug Name
ULTICARE SHORT PEN
NEEDLES ULTI-FINE IV
MISC
ULTICARE SHORT PEN
NEEDLES/31G X 8MM
MISC
ULTILET INSULIN
SYRINGE/SHORT/0.3ML/3
0G X 5/16" MISC
ULTILET INSULIN
SYRINGE/SHORT/0.3ML/3
1G X 5/16" MISC
ULTILET INSULIN
SYRINGE/SHORT/0.5ML/3
0G X 5/16" MISC
ULTILET INSULIN
SYRINGE/SHORT/0.5ML/3
1G X 5/16" MISC
ULTILET INSULIN
SYRINGE/SHORT/1ML/30
G X 5/16" MISC
ULTILET INSULIN
SYRINGE/SHORT/1ML/31
G X 5/16" MISC
ULTILET PEN NEEDLE
32GX4MM/SHORT MISC
ULTILET SHORT PEN
NEEDLES 31GX5/16"
MISC
ULTILET SHORT PEN
NEEDLES31GX3/16"
MISC
ULTRA COMFORT
INSULIN SYRINGE/U100/0.3ML/30G X 5/16"
MISC
ULTRA COMFORT
INSULIN SYRINGE/U100/0.5ML/28G X 1/2"
MISC
ULTRA-COMFORT
INSULIN SYRINGE/U100/0.3ML/29G X 1/2"
MISC
ULTRA-COMFORT
INSULIN SYRINGE/U100/0.3ML/30G X 5/16"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily);
F RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
F
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
137
Drug Name
ULTRA-COMFORT
INSULIN SYRINGE/U100/0.3ML/31G X 5/16"
MISC
ULTRA-COMFORT
INSULIN SYRINGE/U100/0.5ML/28G X 1/2"
MISC
ULTRA-COMFORT
INSULIN SYRINGE/U100/0.5ML/29G X 1/2"
MISC
ULTRA-COMFORT
INSULIN SYRINGE/U100/0.5ML/30G X 5/16"
MISC
ULTRA-COMFORT
INSULIN SYRINGE/U100/0.5ML/31G X 5/16"
MISC
ULTRA-COMFORT
INSULIN SYRINGE/U100/1ML/28G X 1/2" MISC
ULTRA-COMFORT
INSULIN SYRINGE/U100/1ML/29G X 1/2" MISC
ULTRA-COMFORT
INSULIN SYRINGE/U100/1ML/30G X 5/16"
MISC
ULTRA-COMFORT
INSULIN SYRINGE/U100/1ML/31G X 5/16"
MISC
ULTRA-THIN II INSULIN
SYRINGE SHORT/U100/0.3ML/30GX5/16"
MISC
ULTRA-THIN II INSULIN
SYRINGE SHORT/U100/0.3ML/31GX5/16"
MISC
ULTRA-THIN II INSULIN
SYRINGE SHORT/U100/0.5ML/30GX5/16"
MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
Drug Name
ULTRA-THIN II INSULIN
SYRINGE SHORT/U100/0.5ML/31GX5/16"
MISC
ULTRA-THIN II INSULIN
SYRINGE SHORT/U100/1ML/30GX5/16" MISC
ULTRA-THIN II INSULIN
SYRINGE SHORT/U100/1ML/31GX5/16" MISC
ULTRA-THIN II INSULIN
SYRINGE/U100/0.3ML/29GX1/2" MISC
ULTRA-THIN II INSULIN
SYRINGE/U100/0.5ML/29GX1/2" MISC
ULTRA-THIN II INSULIN
SYRINGE/U100/1ML/29GX1/2" MISC
ULTRA-THIN II MINI PEN
NEEEDLES/31GX3/16"
MISC
ULTRA-THIN II PEN
NEEDLES 29GX1/2" MISC
ULTRA-THIN II PEN
NEEDLES/SHORT/31GX5/
16" MISC
UNIFINE PENTIPS
29GX12MM MISC
UNIFINE PENTIPS 31G X
3/16" MISC
UNIFINE PENTIPS
31GX5MM MISC
UNIFINE PENTIPS
31GX6MM MISC
UNIFINE PENTIPS
31GX8MM MISC
UNIFINE PENTIPS
32GX4MM MISC
UNIFINE PENTIPS PLUS
29GX12MM MISC
UNIFINE PENTIPS PLUS
31GX5MM MISC
UNIFINE PENTIPS PLUS
31GX6MM MISC
UNIFINE PENTIPS PLUS
31GX8MM MISC
Drug Requirements/
Tier Limits
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
QL(5 ea daily)
F
F
F
QL(5 ea daily);
RX/OTC
Drug Name
UNIFINE PENTIPS PLUS
32GX4MM MISC
V-R MONOJECT INSULIN
SYRINGE/U100/0.3ML/29G X 1/2"
MISC
V-R MONOJECT INSULIN
SYRINGE/U100/0.5ML/28G X 1/2"
MISC
V-R MONOJECT INSULIN
SYRINGE/U100/0.5ML/29G X 1/2"
MISC
V-R MONOJECT INSULIN
SYRINGE/U-100/1ML/28G
X 1/2" MISC
V-R MONOJECT INSULIN
SYRINGE/U-100/1ML/29G
X 1/2" MISC
VALUE HEALTH INSULIN
SYRINGE/U100/0.5ML/29G X 1/2"
MISC
VALUE HEALTH INSULIN
SYRINGE/U-100/1ML/29G
X 1/2" MISC
VALUMARK PEN
NEEDLES 29GX12MM
MISC
VALUMARK PEN
NEEDLES 31GX 6MM
MISC
VALUMARK PEN
NEEDLES 31GX 8MM
MISC
VANISHPOINT INSULIN
SYRINGE/0.5ML/30G X
1/2" MISC
VANISHPOINT INSULIN
SYRINGE/0.5ML/30G X
5/16" MISC
VANISHPOINT INSULIN
SYRINGE/1ML/29G X 1/2"
MISC
VANISHPOINT INSULIN
SYRINGE/1ML/30G X
5/16" MISC
Drug Requirements/
Tier Limits
F QL(5 ea daily);
RX/OTC
QL(5 ea daily);
F RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
Nebraska Total Care Updated May 30, 2017
138
Drug Name
VIDA MIA UNIFINE
PENTIPS32GX4MM MISC
VIDA MIA UNIFINE
PENTIPSMINI 31GX6MM
MISC
VIDA MIA UNIFINE
PENTIPSORIGINAL
29GX12MM MISC
VIDA MIA UNIPFINE
PENTIPSSHORT
31GX8MM MISC
VP INSULIN SYRINGE/U100/0.3ML/29G X 1/2"
MISC
WEGMANS UNIFINE
PENTIPS PLUS 32GX4MM
MISC
WEGMANS UNIFINE
PENTIPS
PLUS/MINI/31GX5MM
MISC
WEGMANS UNIFINE
PENTIPS
PLUS/SHORT/31GX8MM
MISC
WEGMANS UNIFINE
PENTIPS PLUS/ULTRA
SHORT/31GX6MM MISC
Drug Requirements/
Tier Limits
F QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
F
QL(5 ea daily);
RX/OTC
QL(5 ea daily)
F
Respiratory Therapy Supplies
ACE AEROSOL CLOUD
ENHANCER MISC
ACTIVITY POUCH MISC
ADULT AEROSOL MASK
MISC
ADULT MASK LARGE
MISC
F
F
F
F
ADULT MASK MISC
F
AEROCHAMBER MINI
AEROSOLCHAMBER
DEVI
F
QL(1 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
Nebraska Total Care Updated May 30, 2017
139
Drug Requirements/
Tier Limits
QL(2 ea per
AEROCHAMBER MV
F 350 days
MISC
retail); RX/OTC
QL(2 ea per
AEROCHAMBER PLUS
F 350 days
FLOW VU MISC
retail); RX/OTC
QL(2 ea per
AEROCHAMBER PLUS
F 350 days
FLOW-VU MISC
retail); RX/OTC
AEROCHAMBER PLUS
QL(2 ea per
F 350 days
FLOW-VU/LARGE MASK
MISC
retail); RX/OTC
QL(2 ea per
AEROCHAMBER PLUS
F 350 days
FLOW-VU/MASK MISC
retail); RX/OTC
AEROCHAMBER PLUS
QL(2 ea per
F 350 days
FLOW-VU/MEDIUM MASK
MISC
retail); RX/OTC
AEROCHAMBER PLUS
QL(2 ea per
F 350 days
FLOW-VU/SMALL MASK
MISC
retail); RX/OTC
AEROCHAMBER Z-STAT
QL(2 ea per
PLUS VALVED HOLDING
F 350 days
CHAMBER W/FLOW VU
retail); RX/OTC
MISC
QL(2 ea per
AEROCHAMBER Z-STAT
F 350 days
PLUS/FLOWSIGNAL MISC
retail); RX/OTC
Drug Name
AEROCHAMBER Z-STAT
PLUS/LARGE MASK MISC
F
AEROCHAMBER Z-STAT
PLUS/MEDIUM MASK
MISC
F
AEROCHAMBER Z-STAT
PLUS/SMALL MASK MISC
F
AEROCHAMBER/FLOWSI
GNAL MISC
F
AEROTRACH PLUS MISC
F
AEROVENT PLUS
HOLDING
CHAMBER/COLLAPSIBLE
DEVI
F
QL(2 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
Drug Name
AIRS PEDIATRIC
AEROSOL MASK MISC
ALL FLOW 1000
PULMONARY FUNCTION
FILTER MISC
ARIAL CHAMBER DEVI
BREATHERITE
COLLAPSIBLEADULT
SPACER W/MASK MISC
BREATHERITE
COLLAPSIBLECHILD
SPACER W/MASK MISC
BREATHERITE
COLLAPSIBLEINFANT
SPACER W/MASK MISC
BREATHERITE
COLLAPSIBLESMALL
CHILD SPACER W/MASK
MISC
BREATHERITE
COLLAPSIBLESPACER
W/ NEONATE MASK MISC
Drug Requirements/
Tier Limits
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(2 ea per
F 350 days
retail); RX/OTC
QL(2 ea per
F 350 days
retail); RX/OTC
QL(2 ea per
F 350 days
retail); RX/OTC
QL(2 ea per
F 350 days
retail); RX/OTC
QL(2 ea per
F 350 days
retail); RX/OTC
F
BREATHERITE MISC
F
BREATHERITE RIGID
SPACERW/MASK MISC
F
BREATHERITE W/LARGE
MASK MISC
F
BREATHERITE
W/MEDIUM MASK MISC
F
BREATHERITE W/SMALL
MASK MISC
F
BUBBLES THE FISH II
PEDIATRIC MASK/PVC
MISC
CLEVER CHOICE ANTISTATICVALVED
HOLDING
CHAMBER/ADULT LARGE
DEVI
F
F
QL(2 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
Drug Name
CLEVER CHOICE ANTISTATICVALVED
HOLDING
CHAMBER/MEDIUM DEVI
CLEVER CHOICE ANTISTATICVALVED
HOLDING
CHAMBER/SMALL DEVI
CO MONITOR
REPLACEMENT TPIECES
MISC
COMPACT SPACE
CHAMBER/ANTI-STATIC
DEVI
COMPACT SPACE
CHAMBER/ANTISTATIC/LARGE MASK
DEVI
COMPACT SPACE
CHAMBER/ANTISTATIC/MEDIUM MASK
DEVI
COMPACT SPACE
CHAMBER/ANTISTATIC/SMALL MASK
DEVI
Drug Requirements/
Tier Limits
QL(2 ea per
F 350 days
retail); RX/OTC
F
F
F
F
F
F
CONE MASK MISC
F
E-Z SPACER DEVI
F
E-Z SPACER THE BODY
GUARDS PACK DEVI
F
EARLOOP MASK MISC
F
EASIVENT MISC
F
EASIVENT/MASK-LARGE
MISC
F
EASIVENT/MASKMEDIUM MISC
F
QL(2 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
Nebraska Total Care Updated May 30, 2017
140
Drug Requirements/
Tier Limits
QL(2 ea per
EASIVENT/MASK-SMALL
F 350 days
MISC
retail); RX/OTC
ea per
EBASE CONTROLLER KIT F QL(1
350
days
MISC
retail); RX/OTC
QL(1 ea per
EFLOW SCF AEROSOL
F 350 days
HEAD MISC
retail); RX/OTC
QL(1 ea per
ELITE DC AUTO
F 350 days
ADAPTER MISC
retail); RX/OTC
QL(1 ea per
F 350 days
FILTER AIR PP MISC
retail); RX/OTC
QL(2 ea per
F 350 days
FLEXICHAMBER DEVI
retail); RX/OTC
QL(1 ea per
FULL KIT NEBULIZER
F 350 days
SET MISC
retail); RX/OTC
HEALTHY LIVING
QL(1 ea per
F 350 days
REPLACEMENT FILTERS
MISC
retail); RX/OTC
HEALTHY LIVING
QL(1 ea per
F 350 days
REPLACEMENT KIT FOR
NEBULIZER MISC
retail); RX/OTC
HEALTHY LIVING
QL(1 ea per
F 350 days
REPLACEMENT MASKS
MISC
retail); RX/OTC
HUDSON RCI SEE-THRU
QL(1 ea per
AEROSOL MASK
F 350 days
ELONGATED/ADULT
retail); RX/OTC
MISC
INNOSPIRE
QL(1 ea per
F 350 days
REPLACEMENT FILTER
MISC
retail); RX/OTC
INSPIRACHAMBER/ANTIQL(2 ea per
STATIC
F 350 days
VALVED/MOUTHPIECE
retail); RX/OTC
DEVI
QL(2 ea per
INSPIRACHAMBER/LARG
F 350 days
E DEVI
retail); RX/OTC
Drug Name
INSPIRACHAMBER/SOOT
HERMASK/INSPIRAMASK
/MEDIUM DEVI
F
QL(2 ea per
350 days
retail); RX/OTC
Nebraska Total Care Updated May 30, 2017
141
Drug Requirements/
Tier Limits
INSPIRACHAMBER/SOOT
QL(2 ea per
F 350 days
HERMASK/INSPIRAMASK
/SMALL DEVI
retail); RX/OTC
Drug Name
INSPIREASE BAGS MISC
F
INSPIREASE DRUG
DELIVERYSYSTEM MISC
F
INSPIREASE RESERVOIR
BAGS MISC
F
LITEAIRE DEVI
F
LITETOUCH MASK
LARGE MISC
F
LITETOUCH MASK
MEDIUM MISC
F
LITETOUCH MASK
SMALL MISC
F
MICROCHAMBER MISC
F
MICROELITE FILTER
REPLACEMENTS MISC
F
MICROELITE
RECHARGEABLE
BATTERY MISC
F
MICROSPACER MISC
F
MINIELITE FILTER
REPLACEMENTS MISC
F
MINIELITE
RECHARGEABLE
BATTERY MISC
F
NEBULIZER AIR
TUBE/PLUGS MISC
F
NEBULIZER PEDIATRIC
MASK MISC
F
QL(2 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(2 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
Drug Requirements/
Tier Limits
QL(1 ea per
F 350 days
NOSE CLIP MISC
retail); RX/OTC
QL(2 ea per
OPTICHAMBER
F 350 days
ADVANTAGE MISC
retail); RX/OTC
OPTICHAMBER
QL(2 ea per
F 350 days
ADVANTAGE/LARGE
MASK MISC
retail); RX/OTC
OPTICHAMBER
QL(2 ea per
F 350 days
ADVANTAGE/MEDIUM
FACE MASK MISC
retail); RX/OTC
OPTICHAMBER
QL(2 ea per
F 350 days
ADVANTAGE/SMALL
FACE MASK MISC
retail); RX/OTC
QL(2 ea per
OPTICHAMBER
F 350 days
DIAMOND DEVI
retail); RX/OTC
QL(2 ea per
OPTICHAMBER
F 350 days
DIAMOND MISC
retail); RX/OTC
OPTICHAMBER
QL(2 ea per
F 350 days
DIAMOND/LARGEFACE
MASK DEVI
retail); RX/OTC
OPTICHAMBER
QL(2 ea per
F 350 days
DIAMOND/MEDIUM FACE
MASK MISC
retail); RX/OTC
OPTICHAMBER
QL(2 ea per
F 350 days
DIAMOND/SMALLFACE
MASK MISC
retail); RX/OTC
QL(2 ea per
OPTICHAMBER FACE
F 350 days
MASK/LARGE MISC
retail); RX/OTC
QL(2 ea per
OPTICHAMBER FACE
F 350 days
MASK/MEDIUM MISC
retail); RX/OTC
QL(2 ea per
OPTICHAMBER FACE
F 350 days
MASK/SMALL MISC
retail); RX/OTC
QL(2 ea per
OPTIHALER MDI DRUG
F 350 days
DELIVERY SYSTEM DEVI
retail); RX/OTC
QL(2 ea per
F 350 days
OPTIHALER MISC
retail); RX/OTC
PARI ALTERA
QL(1 ea per
F 350 days
NEBULIZER HANDSET
MISC
retail); RX/OTC
Drug Name
Drug Name
PARI BABY CONVERSION
KITSIZE 1 MISC
PARI BABY CONVERSION
KITSIZE 2 MISC
PARI BABY CONVERSION
KITSIZE 3 MISC
PARI ERAPID NEBULIZER
HANDSET MISC
PARI EXPIRATORY
FILTER VALVE SET DEVI
PARI MASK SET MISC
PARI SOFT PLASTIC
ADULT MASK MISC
PARI SOFT PLASTIC
PEDIATRIC MASK MISC
PEDIATRIC AEROSOL
MASK MISC
PEDIATRIC
MOUTHPIECE/DISPOSAB
LE MISC
PFLEX MISC
PILLOW MASK/ADULT
MISC
PILLOW MASK/CHILD
MISC
PILLOW
MASK/PEDIATRIC MISC
POCKET CHAMBER DEVI
POCKET SPACER DEVI
Drug Requirements/
Tier Limits
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(2 ea per
F 350 days
retail); RX/OTC
QL(2 ea per
F 350 days
retail); RX/OTC
Nebraska Total Care Updated May 30, 2017
142
Drug Name
REPLACEMENT AIR
FILTER MISC
REPLACEMENT FILTERS
MISC
RITEFLO DEVI
SAMI THE SEAL
REPLACEMENTFILTERS
MISC
SIDESTREAM ADULT
FACE MASK MISC
SIDESTREAM PEDIATRIC
FACEMASK MISC
SIDESTREAM PEDIATRIC
FACEMASK/SAMI THE
SEAL MISC
SIDESTREAM PEDIATRIC
FACEMASK/TUCKER THE
TURTLE MISC
SIDESTREAM PLUS
ADULT FACE MASK MISC
SILICONE MASK FOR
BREATHERITE
CHAMBER/ADULT MISC
SILICONE MASK FOR
BREATHERITE
CHAMBER/INFANT MISC
SILICONE MASK FOR
BREATHERITE
CHAMBER/PEDIATRIC
MISC
SILICONE MASK FOR
BREATHRITE
CHAMBER/ADULT MISC
Drug Requirements/
Tier Limits
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(2 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
F
SOOTHENEB NBL 100
CHILD MASK MISC
F
SOOTHENEB NBL 100
MEDICATION CUP MISC
F
QL(1 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
QL(1 ea per
350 days
retail); RX/OTC
Nebraska Total Care Updated May 30, 2017
143
Drug Name
SOOTHENEB NBL 100
MESH CAP MISC
SOOTHENEB NBL100
ADULT MASK MISC
THRESHOLD IMT MISC
TUBING/WING TIP MISC
VALVED HOLDING
CHAMBER DEVI
VORTEX VALVED
HOLDING CHAMBER
DEVI
WATCHHALER DEVI
WINDMILL TRAINER
MISC
Drug Requirements/
Tier Limits
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
QL(2 ea per
F 350 days
retail); RX/OTC
QL(2 ea per
F 350 days
retail); RX/OTC
QL(2 ea per
F 350 days
retail); RX/OTC
QL(1 ea per
F 350 days
retail); RX/OTC
MIGRAINE PRODUCTS - Drugs to Treat Migraine
Headaches
Migraine Combinations
CAFERGOT TABS
(Ergotamine w/ Caffeine)
ergotamine w/ caffeine tabs
isometheptene-caffeineacetaminophen tabs
isometheptenedichloralphenazoneacetaminophen caps
NP
NP
NP
NP
MIGERGOT SUPP
NP
MIGRANOW THPK
NP
PRODRIN TABS
(Isometheptene-CaffeineAcetaminophen)
TREXIMET TABS 10MG60MG
TREXIMET TABS 85MG500MG
NP
NP
NP QL(0.62 ea
daily)
Drug Name
Drug Requirements/
Tier Limits
Migraine Products - NSAIDs
CAMBIA PACK
Migraine Products
DIHYDROERGOTAMINE
MESYLATE SOLN NA 4
MG/ML
MIGRANAL SOLN
NP
NP
NP
Serotonin Agonists
NP QL(0.62 ea
daily)
Limit 18ea per
AMERGE TABS
NP month;QL(0.6
(Naratriptan HCl)
ea daily)
AXERT TABS (Almotriptan NP QL(0.62 ea
Malate)
daily)
FROVA TABS (Frovatriptan NP QL(0.62 ea
Succinate)
daily)
NP QL(0.62 ea
frovatriptan succinate tabs
daily)
Limit 6ea per
IMITREX SOLN NA 20
F month;QL(0.2
MG/ACT (Sumatriptan)
ea daily); AL
IMITREX SOLN NA 5
F QL(0.2 ea
MG/ACT (Sumatriptan)
daily); AL
IMITREX SOLN SC 6
Limit 18ml per
NP month;QL(0.6
MG/0.5ML (Sumatriptan
Succinate)
ml daily)
IMITREX STATDOSE
QL(0.6 ml
F daily)
REFILL SOCT
(Sumatriptan Succinate)
IMITREX STATDOSE
QL(0.3 ml
SYSTEM SOAJ 4
F daily); AL
MG/0.5ML (Sumatriptan
Succinate)
IMITREX STATDOSE
Limit 9ml (18
SYSTEM SOAJ 6
F doses) per
MG/0.5ML (Sumatriptan
month;QL(0.3
Succinate)
ml daily); AL
Limit 18ea per
IMITREX TABS
NP month;QL(0.6
(Sumatriptan Succinate)
ea daily)
almotriptan malate tabs
18ea per
MAXALT TABS (Rizatriptan NP Limit
month;QL(0.6
Benzoate)
ea daily)
Drug Requirements/
Tier Limits
MAXALT-MLT TBDP
NP QL(0.6 ea
(Rizatriptan Benzoate)
daily)
Limit 18ea per
NP month;QL(0.6
naratriptan hcl tabs
ea daily)
NP QL(0.62 ea
ONZETRA XSAIL EXHP
daily)
F QL(0.62 ea
RELPAX TABS
daily)
Limit 18ea per
F month;QL(0.6
rizatriptan benzoate tabs
ea daily)
F QL(0.6 ea
rizatriptan benzoate tbdp
daily)
Limit 6ea per
sumatriptan soln 20 mg/act NP month;QL(0.2
ea daily); AL
NP QL(0.2 ea
sumatriptan soln 5 mg/act
daily); AL
sumatriptan succinate soaj NP QL(0.3 ml
4 mg/0.5ml
daily); AL
Limit 9ml (18
sumatriptan succinate soaj NP doses) per
6 mg/0.5ml
month;QL(0.3
ml daily); AL
ml
sumatriptan succinate soct NP QL(0.6
daily)
Limit 18ml per
F month;QL(0.6
sumatriptan succinate soln
ml daily)
Limit 18ml per
SUMATRIPTAN
NP month;QL(0.6
SUCCINATE SOSY
ml daily)
Limit 18ea per
F month;QL(0.6
sumatriptan succinate tabs
ea daily)
SUMAVEL DOSEPRO
NP QL(0.62 ml
SOTJ
daily)
NP QL(0.62 ea
ZECUITY PTCH
daily)
ZEMBRACE SYMTOUCH
NP
SOAJ
NP QL(0.62 ea
zolmitriptan tabs
daily)
Drug Name
zolmitriptan tbdp
NP
Nebraska Total Care Updated May 30, 2017
144
Drug Name
Drug Requirements/
Tier Limits
ZOMIG SOLN
NP
ZOMIG TABS
(Zolmitriptan)
ZOMIG ZMT TBDP
(Zolmitriptan)
NP QL(0.62 ea
daily)
NP
MINERALS & ELECTROLYTES
Calcium
calcium carbonate tabs
calcium carbonatecholecalciferol chew
500mg-400unit, 500mg100unit
calcium carbonatecholecalciferol tabs
calcium carbonateergocalciferol tabs
calcium carbonate-vitamin
d tabs 125unit-500mg,
600mg-400unit, 200unit500mg, 500mg-200unit,
500mg-500mg-200unit200unit, 600mg-200unit,
125unit-250mg, 500mg125unit, 200unit-600mg,
500mg-400unit, 250mg125unit, 400unit-600mg
calcium citrate tabs 200
mg, 950 mg
calcium citrate-vitamin d
tabs 315mg-250unit,
315mg-200unit
CALCIUM GLUCONATE
TABS 500 MG
F
F
F
F
F
calcium-magnesium-zinc
tabs 333mg-5mg-133mg,
5mg-133.333mg333.333mg, 5mg-134mg334mg, 5mg-133.33mg333.33mg, 5mg-133mg333mg
CALTRATE 600+D PLUS
MINERALS CHEW
(Calcium CarbonateVitamin D w/ Minerals)
CALTRATE 600+D TABS
(Calcium CarbonateCholecalciferol)
CITRACAL + D3
MAXIMUM TABS (Calcium
Citrate-Vitamin D)
CITRACAL MAXIMUM
TABS (Calcium CitrateVitamin D)
GNP VITAMIN D-400
TABS
Drug Requirements/
Tier Limits
F
NF
NP
NP
NP
F
oyster shell tabs
F
RA OYSTER SHELL
CALCIUM/VITAMIN D
TABS
F
Electrolyte Mixtures
F
CERALYTE 70 SOLN
CERASPORT EX1 SOLN
F
F
calcium tabs 500 mg
F
CALCIUM TABS 600MG200UNIT
F
calcium w/ vitamin d tabs
F
Nebraska Total Care Updated May 30, 2017
145
Drug Name
CERASPORT SOLN
ENFAMIL ENFALYTE
SOLN
EQUALYTE SOLN (Oral
Electrolytes)
oral electrolytes soln
PEDIALYTE ADVANCED
CARE SOLN (Oral
Electrolytes)
PEDIALYTE FREEZER
POPS SOLN (Oral
Electrolytes)
QL(6084 ml per
fill retail)
F QL(6084 ml per
fill retail)
F QL(6084 ml per
fill retail)
F QL(6084 ml per
fill retail)
NP QL(6084 ml per
fill retail)
F QL(6084 ml per
fill retail)
QL(6084 ml per
NP fill retail)
F
QL(6084 ml per
NP fill retail)
Drug Name
PEDIALYTE SINGLES
SOLN (Oral Electrolytes)
PEDIALYTE SOLN (Oral
Electrolytes)
Fluoride
LURIDE SOLN (Sodium
Fluoride)
Drug Requirements/
Tier Limits
NP QL(6084 ml per
fill retail)
NP QL(6084 ml per
fill retail)
NP QL(50 ml per
fill retail)
sodium fluoride chew
F
sodium fluoride soln
F
QL(50 ml per
fill retail)
Iodine Products
SSKI SOLN
F
Magnesium
MAG64 TBCR
MAGNESIUM
GLUCONATE TABS 500
MG
magnesium gluconate tabs
500 mg
magnesium oxide (mg
supplement) tabs 400 mg,
241.3 mg
MAGONATE LIQD
MAGOX 400 TABS
(Magnesium Oxide (Mg
Supplement))
F
F
F
F
F
NP
NU-MAG TBEC
F
SLOW-MAG TBEC
F
Manganese
MANGANESE
GLUCONATE TABS
Mineral Combinations
ADVANCED
CALCIUM/VITAMIND/MAG
NESIUM TABS
BONE DENSITY BUILDER
TABS
CAL MAG ZINC +D3 TABS
NP
F
Drug Name
Drug Requirements/
Tier Limits
CAL-MAG-ZINC-D TABS
F
CAL-MAG-ZINC-D3 TABS
F
CALCIUM/MAGNESIUM/ZI
NC TABS 5MG-133MG333MG-200UNIT
CALCIUM/MAGNESIUM/ZI
NC/VITAMIN D3 TABS
F
F
CITRACAL PLUS TABS
F
FEM-CAL CITRATE TABS
F
MULTI MEGA MINERALS
TABS
multiple minerals w/
vitamins tabs
MULTISOURCE CALCIUM
MAGNESIUM & D
FORMULA TABS
F
F
F
NATRUL-CAL TABS
F
PROSTEON TABS
F
THERACAL D2000 TABS
F
THERACAL D4000 TABS
F
THERACAL RAPID
REPLETION TABS
F
Phosphate
K-PHOS NEUTRAL TABS
(Pot Phosphate Monobasic
w/ Sod Phosphate Dibasic
& Monobasic)
pot phosphate monobasic
w/ sod phosphate dibasic &
monobasic tabs
Potassium
K-TAB TBCR 10 MEQ
(Potassium Chloride)
NP
F
NP
K-TAB TBCR 8 MEQ
F
F
KLOR-CON M15 TBCR
F
F
MICRO-K CPCR
(Potassium Chloride)
NP
Nebraska Total Care Updated May 30, 2017
146
Drug Name
Drug Requirements/
Tier Limits
Drug Name
potassium bicarbonate tbef
F
CUPRIMINE CAPS
potassium chloride cpcr
F
Immunomodulators
POTASSIUM CHLORIDE
ER TBCR 8 MEQ
potassium chloride
microencapsulated crystals
cr tbcr
potassium chloride pack
potassium chloride soln or
10 %, 20 %
POTASSIUM CHLORIDE
SOLN OR 20 %
F
F
F
F
F
potassium chloride tbcr
F
POTASSIUM
GLUCONATE TABS 2.5
MEQ
F
potassium tabs 99 mg
F
Sodium
sodium chloride soln ij 0.9
%
sodium chloride soln iv 0.9
%
sodium chloride tabs
Trace Minerals
SE PLUS PROTEIN TABS
(Selenium)
F
F
NP
F
REVLIMID CAPS
F
THALOMID CAPS
NP
Immunosuppressive Agents
AZASAN TABS
F
azathioprine tabs
F
CELLCEPT CAPS
(Mycophenolate Mofetil)
CELLCEPT SUSR
(Mycophenolate Mofetil)
CELLCEPT TABS
(Mycophenolate Mofetil)
cyclosporine caps
F
Drug Requirements/
Tier Limits
NP
NP
NP
F
cyclosporine modified (for
F
microemulsion) caps
cyclosporine modified (for
F
microemulsion) soln
CYCLOSPORINE
MODIFIED CAPS
NP
(Cyclosporine Modified (For
Microemulsion))
IMURAN TABS
NP
(Azathioprine)
mycophenolate mofetil
F
caps
selenium tabs 200 mcg
F
mycophenolate mofetil susr
F
SELENIUM TBCR
F
mycophenolate mofetil tabs
F
Zinc
zinc gluconate tabs 50 mg
F
zinc sulfate caps
F
zinc tabs 50 mg
F
MISCELLANEOUS THERAPEUTIC CLASSES
Chelating Agents
Nebraska Total Care Updated May 30, 2017
147
mycophenolate sodium
F
tbec
MYFORTIC TBEC
NP
(Mycophenolate Sodium)
NEORAL CAPS
(Cyclosporine Modified (For NP
Microemulsion))
NEORAL SOLN
(Cyclosporine Modified (For NP
Microemulsion))
Drug Name
PROGRAF CAPS
(Tacrolimus)
RAPAMUNE SOLN
RAPAMUNE TABS
(Sirolimus)
SANDIMMUNE CAPS
(Cyclosporine)
Drug Requirements/
Tier Limits
NP
F
NP
NP
sirolimus tabs
F
tacrolimus caps
F
Potassium Removing Agents
KAYEXALATE POWD
NP
(Sodium Polystyrene
Sulfonate)
sodium polystyrene
F
sulfonate powd
sodium polystyrene
F
sulfonate susp or 15
gm/60ml
MOUTH/THROAT/DENTAL AGENTS
Anesthetics Topical Oral
ANBESOL MAXIMUM
STRENGTH LIQD
(Benzocaine (Dental))
benzocaine (dental) liqd
Drug Name
lidocaine hcl (mouth-throat)
soln
Anti-infectives - Throat
F
benzocaine-menthol
F
(mouth-throat) lozg 3.6mg15mg, 2.6mg-15mg
CEPACOL SORE THROAT
EXTRA STRENGTH LOZG NP
(Benzocaine-Menthol
(Mouth-Throat))
CEPACOL SORE THROAT
EXTRASTRENGTH LOZG NP
(Benzocaine-Menthol
(Mouth-Throat))
CEPACOL SORE THROAT
LOZG 2.6MG-15MG,
NP
3.6MG-15MG (BenzocaineMenthol (Mouth-Throat))
CEPACOL SORE THROAT
F
MAXIMUM NUMBING
LOZG
F
clotrimazole lozg
F
clotrimazole troc
F
nystatin (mouth-throat)
susp
F
ORAVIG TABS
Antiseptics - Mouth/Throat
CHERACOL SORE
THROAT LIQD (Phenol
(Antiseptic))
chlorhexidine gluconate
(mouth-throat) soln
PAIN-A-LAY LIQD (Phenol
(Antiseptic))
PERIDEX SOLN
(Chlorhexidine Gluconate
(Mouth-Throat))
phenol (antiseptic) liqd
NP
Drug Requirements/
Tier Limits
Dental Products
PREVIDENT 5000 DRY
MOUTH GEL (Sodium
Fluoride (Dental))
PREVIDENT 5000 PLUS
CREA (Sodium Fluoride
(Dental))
PREVIDENT FLUORIDE
GEL (Sodium Fluoride
(Dental))
sodium fluoride (dental)
crea
NP
NP
F
NP
NP
F
NP
NP
NP
F
sodium fluoride (dental) gel
F
THERA-FLUR-N GEL
(Sodium Fluoride (Dental))
NP
Lozenges
CEPASTAT LOZG
F
DENTIVA LOZG
F
Nebraska Total Care Updated May 30, 2017
148
Drug Name
Drug Requirements/
Tier Limits
DIABETIC TUSSIN
COUGH DROPS LOZG
F
SALESE LOZG
F
throat lozenges lozg
F
ZINC W/A&C LOZG
F
Steroids - Mouth/Throat
triamcinolone acetonide
(mouth) pste
Throat Products - Misc.
F
BIOTENE DRY MOUTH
MOISTURIZING SPRAY
SOLN
F
RX/OTC
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
MOI-STIR SOLN
F
RX/OTC
MOUTHKOTE SOLN
F
RX/OTC
NUMOISYN LIQD
F
RX/OTC
CAPHOSOL SOLN
CVS DRY MOUTH SPRAY
SOLN
DRY MOUTH SPRAY
SOLN
EQL DRY MOUTH ORAL
RINSE SOLN
ORAL RELIEF SPRAY
FOR DRYMOUTH &
DISCOMFORT SOLN
pilocarpine hcl (oral) tabs 5
mg
RX/OTC
F
F
RA DRY MOUTH SOLN
F
SALAGEN TABS 5 MG
(Pilocarpine HCl (Oral))
NP
RX/OTC
MULTIVITAMINS
B-Complex Vitamins
b-complex vitamins caps
F
b-complex vitamins tabs
F
Nebraska Total Care Updated May 30, 2017
149
Drug Requirements/
Tier Limits
B-Complex w/ C
F
AQUORAL SOLN
Drug Name
b complex w/ c caps
F
b complex w/ c tabs
F
b-complex w/ c & calcium
tabs
b-complex w/ c & e + zn
tabs
PRONUTRIENTS SUPER
BCOMPLEX+ANTIOXIDANT
S TABS
B-Complex w/ Folic Acid
F
F
F
B-100 COMPLEX TABS
F
b-complex w/ c & folic acid
caps
F
Drug Name
b-complex w/ c & folic acid
tabs 5mg-25mg-20mg15mcg-100mg-400mcg30mcg-2mg-150mg, 50mg50mg-50mg-50mg-50mcg400mcg-50mcg-50mg500mg, 30unit-10mg100mg-10mg-20mg12mcg-400mcg-45mcg5mg-500mg, 18mg-5mg45mg-10mg-10mcg400mcg-5mg-250mg,
25mg-5mg-10mg-250mcg5mg-400mcg-300mcg5mg-120mg, 15mg-50mg10.2mg-10mg-400mcg300mcg-5mg-300mg,
30unit-100mg-10mg-1mg20mg-1mg-1mg-10mg12mcg-400mcg-45mcg5mg-500mg, 5mg-25mg50mg-5mg-37.5mcg200mcg-15mcg-5mg150mg, 100mg-100mg5.5mg-25mg-20mg-30mcg400mcg-45mcg-5mg180mg, 50mg-50mg-50mg50mg-50mcg-50mg400mcg-50mcg-500mg,
25mg-5.5mg-25mg-20mg100mcg-400mcg-1000mcg5mg-60mg, 15mg-50mg10.2mg-10mg-6mcg400mcg-5mg-300mg,
30unit-10mg-20mg-100mg10mg-12mcg-400mcg45mcg-5mg-500mg, 15mg100mg-15mg-18mg-5mcg0.5mg-4mg-500mg,
100mg-5.5mg-25mg-20mg15mcg-400mcg-30mcg2mg-150mg
b-complex w/ folic acid tabs
b-complex w/biotin & folic
acid tabs
MILCO-B-FORTE TABS
(B-Complex w/ C & Folic
Acid)
NEPHROCAPS CAPS (BComplex w/ C & Folic Acid)
Drug Requirements/
Tier Limits
RX/OTC
Drug Requirements/
Tier Limits
SM B-COMPLEX/VITAMIN
F RX/OTC
C TABS
Drug Name
B-Complex w/ Minerals
b-complex w/ minerals liqd
Bioflavonoid Products
ADRENAL C FORMULA
TABS
ADVANCED C PLUS
TABS
F
RX/OTC
NP
NP
RX/OTC
F
RX/OTC
F
ASCOCID-500-D TBCR
F
bioflavonoid products tabs
F
bioflavonoid products tbcr
F
CEMILL PLUS TABS
F
DAFLONEX-XL TBCR
F
ESTER-C TABS 200MG60MG-500MG
F
FRUIT C 200 CHEW
F
VITAMIN C CHEW
F
F
ASCOCID-1000 TBCR
NAT-RUL C-COMPLEX
TABS
NAT-RUL C-COMPLEX TR
TBCR
PERIDIN-C TABS
(Bioflavonoid Products)
SUPER C-500 COMPLEX
TBCR
F
F
Multiple Vitamins w/ Calcium
HM ONE DAILY
ESSENTIAL TABS
multiple vitamins w/
calcium tabs
ONE-A-DAY WOMENS
FORMULA TABS (Multiple
Vitamins w/ Calcium)
SM ONE DAILY
ESSENTIAL TABS
F
RX/OTC
RX/OTC
RX/OTC
RX/OTC
F
NP RX/OTC
F
F
F
F
NP
F
Nebraska Total Care Updated May 30, 2017
150
Drug Name
Multiple Vitamins w/ Iron
DAILY MULTIPLE
VITAMIN PLUS IRON
TABS
multiple vitamins w/ iron
tabs
Drug Requirements/
Tier Limits
BASIC PM TABS
F
F
Multiple Vitamins w/ Minerals
ADULT ONE DAILY
F
GUMMIES CHEW
ADVANCED DIABETIC
MULTIVITAMIN FORMULA F
TABS
AIRBORNE LOZG
ALIVE MENS ENERGY
TABS
ALIVE ONCE DAILY
WOMENS 50+ ULTRA
POTENCY TABS
ALIVE ONCE DAILY
WOMENS ULTRA
POTENCY TABS
ALIVE WOMENS 50+
TABS
ALIVE WOMENS ENERGY
TABS
ALIVE WOMENS GUMMY
VITAMINS CHEW
ANTIOXIDANT FORMULA
SG CPCR
ANTIOXIDANT FORTE
TABS
RX/OTC
F
F
RX/OTC
RX/OTC
F
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
F
F
RX/OTC
AP-ZEL TABS
F
RX/OTC
APATATE FORTE LIQD
F
RX/OTC
AQUADEKS CAPS
F
RX/OTC
AQUADEKS CHEW
F
BACMIN TABS
F
BARIATRIC FUSION
CHEW
F
BASIC AM TABS
F
RX/OTC
RX/OTC
Drug Requirements/
Tier Limits
F RX/OTC
BIO-35 GLUTEN-FREE
CAPS
F
RX/OTC
BIO-35 IRON FREE CAPS
F
RX/OTC
BIOCAL CAPS
F
RX/OTC
BIOSUPP LIQD
F
RX/OTC
BIOTECT PLUS CAPS
F
RX/OTC
BIOTECT PLUS LIQD
F
RX/OTC
BIOVOL SYRP
F
BURIED TREASURE
ACTIVE 55PLUS SENIOR
COMPLEX LIQD
F
C-BUFF POWD
F
CAL-DAY 1000 TABS
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
CELLULAR SECURITY
CAPS
CENTRAVITES 50 PLUS
TABS
CENTRAVITES ADULTS
TABS
CENTRUM ADULTS TABS
(Multiple Vitamins w/
Minerals)
RX/OTC
RX/OTC
NP
CENTRUM CARDIO TABS
F
CENTRUM CHEW
F
CENTRUM FLAVOR
BURST ADULT CHEW
CENTRUM FLAVOR
BURST CHEW
CENTRUM FLAVOR
BURST KIDS CHEW
CENTRUM LIQD (Multiple
Vitamins w/ Minerals)
CENTRUM MEN TABS
Nebraska Total Care Updated May 30, 2017
151
Drug Name
RX/OTC
F
F
F
NP RX/OTC
F
RX/OTC
Drug Name
CENTRUM
MULTIGUMMIES ADULTS
CHEW
CENTRUM
MULTIGUMMIES MEN
CHEW
CENTRUM
MULTIGUMMIES WOMEN
CHEW
CENTRUM
MULTIVITAMIN FLAVOR
BURST DRINK PACK
CENTRUM SILVER
50+MEN TABS (Multiple
Vitamins w/ Minerals)
CENTRUM SILVER
50+WOMEN TABS
(Multiple Vitamins w/
Minerals)
CENTRUM SILVER
ADULT 50+ TABS (Multiple
Vitamins w/ Minerals)
CENTRUM SILVER CHEW
CENTRUM SILVER TABS
(Multiple Vitamins w/
Minerals)
CENTRUM SILVER
ULTRA MENS TABS
CENTRUM SILVER
ULTRA WOMENS TABS
CENTRUM SPECIALIST
HEART TABS
CENTRUM SPECIALIST
IMMUNE SUPPORT TABS
CENTRUM SPECIALIST
VISION TABS
CENTRUM TABS (Multiple
Vitamins w/ Minerals)
CENTRUM ULTRA MENS
TABS (Multiple Vitamins w/
Minerals)
CENTRUM ULTRA
WOMENS TABS
CENTRUM VITAMINTS
CHEW
Drug Requirements/
Tier Limits
F
F
F
F
RX/OTC
NP
RX/OTC
NP
RX/OTC
NP
F
RX/OTC
NP
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
NP RX/OTC
RX/OTC
NP
F
RX/OTC
F
Drug Requirements/
Tier Limits
CENTRUM WOMEN TABS
RX/OTC
NP
(Multiple Vitamins w/
Minerals)
CEROVITE ADVANCED
F RX/OTC
FORMULA LIQD
CERTAVITE
RX/OTC
F
SENIOR/ANTIOXIDANT
NUTRIENTS TABS
CHOICEFUL
F RX/OTC
MULTIVITAMIN CAPS
CHOICEFUL
F
MULTIVITAMIN CHEW
CLINICAL NUTRIENTS 45- F RX/OTC
PLUS WOMEN TABS
CLINICAL NUTRIENTS 50- F RX/OTC
PLUS MEN TABS
CLINICAL NUTRIENTS
F RX/OTC
ANTIOXIDANT CAPS
CLINICAL NUTRIENTS
RX/OTC
F
FOR FEMALE TEENS
TABS
CLINICAL NUTRIENTS
F RX/OTC
FOR MALE TEENS TABS
CLINICAL NUTRIENTS
F RX/OTC
FOR MEN TABS
CLINICAL NUTRIENTS
F RX/OTC
FOR WOMEN TABS
COMPLETE
RX/OTC
F
FORMULATION D3000
CAPS
COMPLETE
RX/OTC
FORMULATION
F
MULTIVITAMIN
SUPPLEMENT CAPS
CONCEPTIONXR
F
MOTILITY SUPPORT
FORMULA MISC
CORVITE TABS (Multiple
NP
Vitamins w/ Minerals &
Folic Acid)
CVS AIRSHIELD
F
IMMUNITY SUPPORT
CHEW
CVS DIABETES HEALTH
F
SUPPORT MISC
CVS ONE DAILY MENS
F RX/OTC
50+ ADVANCED TABS
Drug Name
Nebraska Total Care Updated May 30, 2017
152
Drug Name
CVS SPECTRAVITE
ADULT 50+ CHEW
CVS SPECTRAVITE
ADULT 50+ TABS
CVS SPECTRAVITE
ADULT GUMMIES CHEW
CVS SPECTRAVITE
ULTRA MEN50+ TABS
CVS SPECTRAVITE
ULTRA MENS HEALTH
SENIOR TABS
CVS SPECTRAVITE
ULTRA MENS HEALTH
TABS
CVS SPECTRAVITE
ULTRA WOMEN TABS
CVS SPECTRAVITE
ULTRA WOMENS
HEALTH SENIOR TABS
CVS SPECTRAVITE
ULTRA WOMENS
HEALTH TABS
DAILY HEART HEALTH
SUPPORT MISC
DAILY PAK MAXIMUM
MULTIVITAMIN/ASIAN
GINSENG EXTRACT
MISC
Drug Requirements/
Tier Limits
F
F
RX/OTC
F
F
RX/OTC
RX/OTC
F
RX/OTC
F
F
F
F
DEKAS PLUS CAPS
F
RX/OTC
DEKAS PLUS CHEW
F
DERMAVITE TABS
F
RX/OTC
F
F
F
F
Nebraska Total Care Updated May 30, 2017
153
F
EMERGEN-C PINK PACK
F
F
F
RX/OTC
F
EMERGEN-C FIVE PACK
F
F
RX/OTC
F
F
EMERGEN-C MSM LITE
PACK
F
EMERGEN-C BLUE PACK
F
RX/OTC
RX/OTC
ELLIS TONIC ELIX
F
F
F
ELDERTONIC ELIX
EMERGEN-C HEART
HEALTH PACK
EMERGEN-C IMMUNE
PACK
EMERGEN-C IMMUNE
PLUS PACK
EMERGEN-C IMMUNE
PLUS/VITAMIN D CHEW
EMERGEN-C IMMUNE+
WARMERS PACK
EMERGEN-C JOINT
HEALTH PACK
Drug Requirements/
Tier Limits
EMERGEN-C KIDZ PACK
DECUBI-VITE CAPS
DIABETES HEALTH PACK
MISC
DIABETES SUPPORT
PACK MISC
Drug Name
EMERGEN-C SUPER
FRUIT PACK
EMERGEN-C VITAMIN C
CHEW
EMERGEN-C VITAMIN C
LITE PACK
EMERGEN-C VITAMIN C
PACK
EMERGEN-C VITAMIN D
& CALCIUM PACK
END FATIGUE DAILY
ENERGYENFUSION
POWD
ENERGY BOOSTER
PACK
EQ COMPLETE
MULTIVITAMINADULTS
UNDER 50 TABS
EQ ONE DAILY MENS
HEALTH TABS
EQ ONE DAILY WOMENS
HEALTH TABS
EQL CENTURY MATURE
ADULTS50+ TABS
EQL CENTURY MENS
TABS
EQL CENTURY WOMENS
TABS
F
F
F
F
F
F
F
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
Drug Name
EQL MEGA SELECT
MENS TABS
EQL MEGA SELECT
WOMENS TABS
EQL ONE DAILY ADULT
GUMMIES CHEW
EQL ONE DAILY DIET
SUPPORT TABS
EQL ONE DAILY MENS
50+ ADVANCED TABS
EQL ONE DAILY MENS
TABS
EQL PROTECTAVISION
CAPS
EQL SUPER ENERGY
BOOSTER PACK
EYE HEALTH CAPS
FITNESS TABS FOR MEN
AM/PM/LYCOPENE TABS
FITNESS TABS FOR
WOMEN
AM/PM/LYCOPENE TABS
Drug Requirements/
Tier Limits
F RX/OTC
F
RX/OTC
F
F
RX/OTC
HYALEX TABS
F
RX/OTC
RX/OTC
ICAPS AREDS FORMULA
TABS
F
RX/OTC
F
RX/OTC
ICAPS PLUS TABS
F
RX/OTC
F
RX/OTC
F
RX/OTC
IMMUNE SUPPORT
CHEW
IMMUNE SUPPORT
VITAMIN C PACK
K-PAX IMMUNE
SUPPORT FORMULA
DOUBLE STRENGTH
CAPS
K-PAX IMMUNE
SUPPORT FORMULA
PROFESSIONAL
STRENGTH TABS
K-PAX IMMUNE
SUPPORT FORMULA
SINGLE STRENGTH
CAPS
KP WOMENS DAILY
PACK MISC
F
F
RX/OTC
F
RX/OTC
RX/OTC
F
F
RX/OTC
FORTAVIT LIQD
F
RX/OTC
NP RX/OTC
FREEDAVITE TABS
F
RX/OTC
GERI-FREEDA SENIOR
FORMULA TABS
F
RX/OTC
HAIR-VITES TABS
F
RX/OTC
HAIR/SKIN/NAILS TABS
F
RX/OTC
F
RX/OTC
HM COMPLETE 50+
MENS ULTIMATE TABS
HM COMPLETE 50+
WOMENS ULTIMATE
TABS
HM ONE DAILY MENS
TABS
HM ONE DAILY WOMENS
TABS
Drug Requirements/
Tier Limits
F RX/OTC
F
FORTAVIT CAPS
FOSFREE TABS (Multiple
Vitamins w/ Minerals)
Drug Name
RX/OTC
F
HM COMPLETE TABS
F
RX/OTC
HM HAIR/SKIN/NAILS
TABS
F
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
F
LIFE PACK MENS MISC
F
LIFE PACK WOMENS
MISC
F
M2 B-60 TBCR
F
MACULAR VITAMIN
BENEFIT TABS
F
MAXIMIN PACK PACK
F
MEGA MULTI MEN TBCR
F
MEGA MULTI WOMEN
TBCR
MEGA MULTIVITAMIN
FOR MEN TABS
MEGA MULTIVITAMIN
FOR WOMEN TABS
RX/OTC
F
F
RX/OTC
F
RX/OTC
Nebraska Total Care Updated May 30, 2017
154
Drug Name
MEGA MULTIVITAMIN
POWD
MEGAVITE FRUITS &
VEGGIES TABS
MEGAVITE GOLDEN
YEARS 55+ TABS
MENS 50+ ADVANCED
CAPS
MENS 50+ MULTI
VITAMIN &MINERAL
FORMULA TABS
MENS MULTI VITAMIN &
MINERAL FORMULA
TABS
Drug Requirements/
Tier Limits
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
Drug Name
MULTIVITAMIN MEN
TABS
MVW COMPLETE
FORMULATIONCHEWABL
ES MULTIVITAMIN CHEW
Drug Requirements/
Tier Limits
F RX/OTC
F
NATRUL-100 TBCR
F
NATRUL-CHEWS CHEW
F
NATRUL-MEGA-75 TABS
F
RX/OTC
NATRUL-VITES TABS
F
RX/OTC
NICADAN TABS
F
RX/OTC
RX/OTC
F
RX/OTC
F
MENS PACK MISC
F
NICADAN ZX TABS
F
RX/OTC
MH MACULAR HEALTH
MISC
F
NICAZEL FORTE TABS
F
RX/OTC
MULTI FOR HER PACK
F
NICAZEL TABS
F
RX/OTC
MULTI FOR HIM PACK
F
NO IRON MULTIPLE
VITAMIN/MINERALS
TABS
F
NUTRICAP TABS
F
RX/OTC
F
RX/OTC
F
RX/OTC
OCUVITE LUTEIN CAPS
F
RX/OTC
ONCOVITE TABS
F
RX/OTC
MULTI-BETIC DIABETES
TABS
MULTI-VITAMIN
MONOCAPS TABS
multiple vitamins w/
minerals & folic acid tabs
multiple vitamins w/
minerals caps
multiple vitamins w/
minerals chew
multiple vitamins w/
minerals liqd
multiple vitamins w/
minerals tabs
multiple vitamins w/
minerals tbcr
MULTIVITAL PLATINUM
TABS
MULTIVITAMIN ADULT
CHEW
MULTIVITAMIN ADULT
EXTRAVITAMIN C CHEW
MULTIVITAMIN ADULTS
TABS
F
RX/OTC
F
RX/OTC
F
F
RX/OTC
F
F
F
RX/OTC
RX/OTC
F
F
RX/OTC
F
F
F
RX/OTC
Nebraska Total Care Updated May 30, 2017
155
OCUVITE ADULT 50+
CAPS
OCUVITE ADULT
FORMULA CAPS
ONE DAILY MENS
FORMULA W/O IRON
TABS
ONE DAILY PLUS IRON
TABS
ONE-A-DAY ENERGY
TABS
ONE-A-DAY FOR HER
VITACRAVES TEEN
MULTI GUMMIES CHEW
ONE-A-DAY FOR
HIM/VITACRAVES TEEN
MULTI GUMMIES CHEW
RX/OTC
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
F
Drug Requirements/
Tier Limits
ONE-A-DAY MENOPAUSE F RX/OTC
FORMULA TABS
ONE-A-DAY MENS 50+
F RX/OTC
ADVANTAGE TABS
ONE-A-DAY MENS
F RX/OTC
HEALTH FORMULA TABS
ONE-A-DAY MENS PRO
F RX/OTC
EDGE TABS
ONE-A-DAY MENS
F
VITACRAVES GUMMIES
CHEW
ONE-A-DAY TEEN
RX/OTC
F
ADVANTAGEFOR HIM
TABS
ONE-A-DAY VITACRAVES F
CHEW
ONE-A-DAY VITACRAVES
F
GUMMIES/IMMUNITY
SUPPORT CHEW
ONE-A-DAY VITACRAVES F
SOURGUMMIES CHEW
ONE-A-DAY VITACRAVES F
WOMENS MULTI CHEW
ONE-A-DAY WEIGHT
RX/OTC
SMART ADVANCED TABS NP
(Multiple Vitamins w/
Minerals)
ONE-A-DAY WOMENS
RX/OTC
50+ ADVANTAGE TABS
NP
(Multiple Vitamins w/
Minerals)
ONE-A-DAY WOMENS
RX/OTC
ACTIVE MIND & BODY
NP
TABS (Multiple Vitamins w/
Minerals)
ONE-A-DAY WOMENS
RX/OTC
NP
PETITES TABS (Multiple
Vitamins w/ Minerals)
ONE-A-DAY WOMENS
RX/OTC
PLUS HEALTHY SKIN
NP
SUPPORT TABS (Multiple
Vitamins w/ Minerals)
ONE-A-DAY WOMENS
F
VITACRAVES GUMMIES
CHEW
F RX/OTC
OPTI-WOMAN TABS
Drug Name
Drug Name
OPTIMUM AIRVITES
CHEW
OPTISOURCE POST
BARIATRIC SURGERY
CHEW
OPTIVITE P.M.T. TABS
(Multiple Vitamins w/
Minerals)
OPURITY TABS
OPURITY/BYPASS
OPTIMIZED CHEW
PA MENS 50 PLUS
VITAPAK MISC
PA MENS VITAPAK MISC
PA WOMENS 50 PLUS
VITAPAK MISC
PA WOMENS VITAPAK
MISC
Drug Requirements/
Tier Limits
F
F
RX/OTC
NP
F
F
F
F
F
F
PARVLEX TABS
F
PHLEXY-VITS POWD
F
PHYTOMULTI TABS
F
PREMIUM PACKETS
MISC
PRESCRIPTIVE
FORMULAS OPTIMAL
VITAMIN PACKS MENS
MISC
PRESCRIPTIVE
FORMULAS OPTIMAL
VITAMIN PACKS
WOMENS MISC
PRESERVISION AREDS 2
+ MULTI VITAMIN CAPS
PRESERVISION AREDS 2
CAPS
PRESERVISION AREDS
CAPS
PRESERVISION AREDS
TABS
PRESERVISION/LUTEIN
CAPS
RX/OTC
RX/OTC
RX/OTC
F
F
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
Nebraska Total Care Updated May 30, 2017
156
Drug Name
PRO-CAL TABS
Drug Requirements/
Tier Limits
F RX/OTC
PROCERV HP TABS
F
RX/OTC
PRORENAL+D TABS
F
RX/OTC
F
RX/OTC
F
RX/OTC
PROTECT PLUS CAPS
F
RX/OTC
PROTECT PLUS NF LIQD
F
PROTECT PLUS SO
CAPS
Drug Name
SKIN BEAUTY &
WELLNESS PACK
SM ONE DAILY MENS
TABS
SM ONE DAILY WOMENS
TABS
Drug Requirements/
Tier Limits
F
F
RX/OTC
F
RX/OTC
SOLO TABS
F
RX/OTC
STROVITE FORTE SYRP
F
RX/OTC
STROVITE FORTE TABS
(Multiple Vitamins w/
Minerals)
NP
RX/OTC
STROVITE ONE TABS
F
RX/OTC
F
F
SUPER ANTIOXIDANT
CAPS
F
RX/OTC
QUENCH TABS
RX/OTC
QUIN B STRONG TABS
F
RX/OTC
SUPER NU-THERA POWD
F
QUINTABS-M TABS
F
RX/OTC
SUPERB NAILS TABS
F
F
RX/OTC
SUPERVITE EC TBEC
F
RX/OTC
SUPPORT LIQD
F
SYNAGEX CAPS
F
SYNATEK CAPS
F
T-VITES TABS
F
RX/OTC
PRORENAL+D/OMEGA-3
CAPS
PROTECT CARDIO AF
CAPS
RA CENTRAL-VITE
UNDER 50MENS TABS
RA CENTRAL-VITE
UNDER 50WOMENS
TABS
RA ESSENCE-C PACK
RAGUS TABS (Multiple
Vitamins w/ Minerals)
F
F
NP RX/OTC
RX/OTC
RX/OTC
RX/OTC
RENAPLEX-D TABS
F
RX/OTC
THERA M PLUS TABS
F
RX/OTC
REPLACE CAPS
F
RX/OTC
THERA-M TABS
F
RX/OTC
REQ 49+ TABS
F
RX/OTC
THERA-TABS M TABS
F
RX/OTC
SAVISION CAPS
F
RX/OTC
F
RX/OTC
SENIOR VITES TBCR
F
SENTRY SENIOR/LUTEIN
TABS
F
RX/OTC
SENTRY TABS
F
RX/OTC
SIDEROL TABS
F
RX/OTC
THERABETIC MULTIVITAMIN TABS
THERAGRAN-M
ADVANCED 50 PLUS
TABS
THERAGRAN-M
ADVANCED TABS
THERAGRAN-M PREMIER
50 PLUS TABS
THERAGRAN-M PREMIER
TABS
Nebraska Total Care Updated May 30, 2017
157
RX/OTC
F
F
RX/OTC
F
RX/OTC
F
RX/OTC
Drug Name
THERAGRAN-M TABS
Drug Requirements/
Tier Limits
F RX/OTC
THERAMILL FORTE CAPS
RX/OTC
NP
(Multiple Vitamins w/
Minerals)
THERANATAL
F
LACTATION COMPLETE
MISC
THERANATAL
F RX/OTC
LACTATION ONE CAPS
THERANATAL
F
LACTATION SUPPORT
MISC
F RX/OTC
THEREMS-H TABS
THEREMS-M TABS
F
ULTRA MEGA GOLD
TBCR
F
ULTRA MEGA TBCR
F
RX/OTC
ULTRA MEGA TWO TBCR
F
ULTRA MENS PACK MISC
F
ULTRA WOMENS PACK
MISC
F
UNICOMPLEX-M TABS
F
RX/OTC
VITA-BOB CAPS
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
VITABEX CAPS
VITALINE TOTAL
FORMULA 2 TABS
VITALINE TOTAL
FORMULA 3 TABS
VITAMENT PACK
VITAMIN C
EFFERVESCENT BLEND
PACK
VITAMIN
C/ELECTROLYTES PACK
VITAMIN D3 COMPLETE
TABS
VITAMINS TO GO
MAXIMUM MISC
VITAMINS TO GO MEN
MISC
VITAMINS TO GO
WOMEN MISC
VITAROCA PLUS TABS
(Multiple Vitamins w/
Minerals)
F
RX/OTC
F
F
F
RX/OTC
NP
F
RX/OTC
VITATRUM TABS
F
RX/OTC
VITRUM 50+ SENIOR
MULTI TABS
F
RX/OTC
VP-ZEL TABS
F
RX/OTC
F
RX/OTC
WHOLE FOOD
MULTIVITAMIN TABS
WOMENS 50+ MULTI
VITAMIN& MINERAL
FORMULA TABS
WOMENS BIOMULTIPLE
TABS
WOMENS MULTI VITAMIN
& MINERAL FORMULA
TABS
YELETS TEENAGE
FORMULA TABS
YOUR LIFE MULTI ADULT
GUMMIES CHEW
YOUR LIFE TEEN
MULTIVITAMIN GUMMIES
CHEW
ZINC LOZG OR 50MG15MG-10MG-500UNIT100MG, 50MG-15MG500UNIT-100MG, 10MG5MG-10MG-10MG-15MG500UNIT-60MG
Multivitamins
CARDENZ TABS (Multiple
Vitamin)
F
Drug Requirements/
Tier Limits
VITASANA TABS
WOMENS PACK MISC
F
F
Drug Name
RX/OTC
F
F
RX/OTC
RX/OTC
F
F
F
RX/OTC
F
F
F
NP
DEKAS ESSENTIAL CAPS
F
multiple vitamin caps
F
Nebraska Total Care Updated May 30, 2017
158
Drug Name
Drug Requirements/
Tier Limits
multiple vitamin tabs
F
OMNICAP TABS
F
ONE-A-DAY ESSENTIAL
TABS (Multiple Vitamin)
ONE-A-DAY MENS TABS
(Multiple Vitamin)
QUINTABS TABS
THERA/BETA-CAROTENE
TABS
ZE-PLUS CAPS (Multiple
Vitamin)
NP
NP
F
F
NP
Ped MV w/ Fluoride
FLORIVA PLUS SOLN
MULTIVITAMIN/FLUORID
E CHEW 0.5MG2500UNIT-13.5MG-1.2MG4.5MCG-400UNIT1.05MG-0.3MG-15UNIT1.05MG-60MG
pediatric multivitamins w/fl
chew 15unit-0.5mg2500unit-13.5mg-1.2mg4.5mcg-400unit-1.05mg0.3mg-1.05mg-60mg,
0.5mg-15unit-1.2mg2500unit-4.5mcg-400unit1.05mg-13.5mg-1.05mg0.3mg-60mg, 0.5mg15unit-400unit-2500unit1.2mg-4.5mcg-13.5mg1.05mg-0.3mg-1.05mg60mg, 0.5mg-2500unit13.5mg-1.2mg-4.5mcg400unit-1.05mg-0.3mg15unit-1.05mg-60mg,
15unit-0.5mg-1.05mg13.5mg-1.2mg-2500unit4.5mcg-400unit-0.3mg1.05mg-60mg
pediatric multivitamins w/fl
soln
pediatric vitamins acd w/
fluoride soln
F
Drug Requirements/
Tier Limits
QUFLORA PEDIATRIC
CHEW 108MCG-1MG15UNIT-0.5MG-15MG1200UNIT-5MG-1.3MG4MCG-400UNIT-1.2MG100MCG-1.5MG-60MG
QUFLORA PEDIATRIC
SOLN
Ped MV w/ Iron
pediatric multiple vitamins
w/ iron chew
pediatric multiple vitamins
w/ iron liqd
pediatric multiple vitamins
w/ iron soln
POLY-VI-SOL/IRON SOLN
(Pediatric Multiple Vitamins
w/ Iron)
F
F
F
F
F
NP
Ped Multi Vitamins w/Fl & FE
F
F
F
F
Nebraska Total Care Updated May 30, 2017
159
Drug Name
ESCAVITE LQ LIQD
F
ped multivitamins w/fl &
F
iron soln
TRI-VIT/FLUORIDE/IRON
F
SOLN
Ped Multiple Vitamins w/ Minerals
FLINTSTONES GUMMIES
NP
CHEW (Pediatric Multiple
Vitamin w/ Minerals & C)
FLINTSTONES GUMMIES
COMPLETE CHEW
1.25MG-15MCG-2.5MG1000UNIT-1.5MCGNP
300UNIT-100MCG-9UNIT37.5MCG-0.5MG-15MG
(Pediatric Multiple Vitamin
w/ Minerals & C)
FLINTSTONES GUMMIES
COMPLETE CHEW
1.25MG-15MCG-2.5MGF
1000UNIT-1.5MG300UNIT-100MCG-9UNIT37.5MCG-0.5MG-15MG
Drug Name
FLINTSTONES GUMMIES
PLUSIMMUNITY
SUPPORT/EXTRA C
CHEW (Pediatric Multiple
Vitamin w/ Minerals & C)
FLINTSTONES SOUR
GUMMIES CHEW
(Pediatric Multiple Vitamin
w/ Minerals & C)
FLINTSTONES
TODDLER/TASTISMOOTH
CHEW
GNP CHILDRENS
COMPLETE CHEWABLES
CHEW
HEALTHY KIDS GUMMIES
CHEW
NF FORMULAS
CHILDRENS CHEWABLE
CHEW
ONE-A-DAY SCOOBYDOO GUMMIES CHEW
(Pediatric Multiple Vitamin
w/ Minerals & C)
ONE-A-DAY/JOLLY
RANCHER CHEW
(Pediatric Multiple Vitamin
w/ Minerals & C)
pediatric multiple vitamin w/
minerals & c chew
pediatric multiple vitamin w/
minerals & c liqd
pediatric multiple vitamin w/
minerals & c soln
Drug Requirements/
Tier Limits
Drug Name
pediatric multiple vitamin w/
c & fa chew
pediatric multiple vitamin w/
c soln
pediatric multiple vitamin w/
extra c & fa chew
pediatric multiple vitamins
liqd
POLY-VI-SOL SOLN
(Pediatric Multiple Vitamin
w/ C)
Pediatric Vitamins
NP
NP
F
Drug Requirements/
Tier Limits
F
F
F
F
NP
F
HONEY BEARS CHEW
F
F
pediatric vitamins adc soln
F
Prenatal Vitamins
F
NP
ACTIVE OB CAPS
F
BAL-CARE DHA MISC
F
BP FOLINATAL PLUS B
TABS
BP MULTINATAL PLUS
CHEW
BP MULTINATAL PLUS
TABS
NP
F
F
RX/OTC
F
RX/OTC
F
F
F
C-NATE DHA CAPS
F
CALCIUM PNV CAPS
F
CITRANATAL 90 DHA
MISC
CITRANATAL ASSURE
MISC
CITRANATAL B-CALM
MISC
RX/OTC
F
VITALETS CHEW
F
VITALETS CHILDRENS
CHEW
F
VITAMAX CHEW
F
CITRANATAL DHA MISC
F
ZOO FRIENDS
COMPLETE CHEW
F
CITRANATAL HARMONY
CAPS
F
CITRANATAL RX TABS
F
CLASSIC PRENATAL
TABS
F
AL
CO-NATAL FA TABS
F
AL
Pediatric Multiple Vitamins
ONE-A-DAY VITACRAVES
GUMMIES+OMEGA-3
DHA CHEW (Pediatric
Multiple Vitamin w/ C & FA)
NP
F
F
Nebraska Total Care Updated May 30, 2017
160
Drug Name
Drug Requirements/
Tier Limits
COMPLETE NATAL DHA
MISC
F
COMPLETENATE CHEW
F
CONCEPT DHA CAPS
Drug Name
Drug Requirements/
Tier Limits
INATAL ADVANCE TABS
F
INATAL GT TABS
F
F
INATAL ULTRA TABS
F
CONCEPT OB CAPS
F
INFANATE BALANCE
CAPS
F
CVS PRENATAL TABS
F
INFANATE PLUS CAPS
F
DOTHELLE DHA CAPS
F
KP PRENATAL
MULTIVITAMINS TABS
F
ELITE-OB TABS
F
KPN PRENATAL TABS
F
ENBRACE HR CAPS
F
M-VIT TABS
F
ENFAMIL EXPECTA MISC
F
MACNATAL CN DHA
CAPS
F
MARNATAL-F CAPS
F
F
MTERYTI FOLIC 5 TBPK
F
EZFE FORTE CAPS
F
MTERYTI TBPK
F
FOCALGIN 90 DHA MISC
F
MULTI PRENATAL TABS
F
FOCALGIN CA MISC
F
MYNATAL ADVANCE
TABS
F
FOLCAL DHA CAPS
F
MYNATAL PLUS TABS
F
FOLCAPS OMEGA 3
CAPS
F
MYNATAL ULTRACAPLET
TABS
F
FOLIVANE-OB CAPS
F
MYNATAL-Z TABS
F
AL
GNP DAILY PRENATAL
MISC
F
NAT-RUL PRENATAL
VITAMINS TABS
F
AL
GNP PRENATAL TABS
F
AL
NATALVIT TABS
F
F
AL
NATELLE ONE CAPS
F
F
NEEVO DHA CAPS
F
HEMENATAL OB TABS
F
NESTABS ABC MISC
F
HM ONE DAILY
PRENATAL COMBO MISC
F
NESTABS DHA MISC
F
HM PRENATAL TABS
F
NESTABS TABS
F
EQL PRENATAL
FORMULA TABS
EXTRA-VIRT PLUS DHA
CAPS
GOODSENSE PRENATAL
VITAMINS TABS
HEMENATAL OB + DHA
MISC
F
AL
AL
AL
AL
Nebraska Total Care Updated May 30, 2017
161
AL
AL; RX/OTC
AL
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
F AL
NEWGEN TABS
F
PNV-VP-U CAPS
NEXA PLUS CAPS
F
PR NATAL 400 EC MISC
F
NIVA-PLUS TABS
F
AL; RX/OTC
PR NATAL 400 MISC
F
O-CAL FA TABS
F
AL; RX/OTC
PR NATAL 430 EC MISC
F
O-CAL PRENATAL TABS
F
AL
PR NATAL 430 MISC
F
F
PREFERA OB TABS
F
F
PREFERAOB +DHA MISC
F
F
PREFERAOB ONE CAPS
F
OB COMPLETE GOLD
CAPS
OB COMPLETE ONE
CAPS
OB COMPLETE PETITE
CAPS
OB COMPLETE PREMIER
TABS
OB COMPLETE TABS
OB COMPLETE/DHA
CAPS
ONE-A-DAY WOMENS
PRENATAL MISC
PAIRE OB MISC
PNV FERROUS
FUMARATE/DOCUSATE/F
OLIC ACID TABS
PNV FOLIC ACID + IRON
MULTIVITAMIN TABS
PNV OB+DHA MISC
F
PRENAISSANCE 90 DHA
MISC
PRENAISSANCE
BALANCE CAPS
F
PRENAISSANCE CAPS
F
F
F
F
F
AL; RX/OTC
F
PNV PRENATAL PLUS
MULTIVITAMIN TABS
F
PNV TABS 29-1 TABS
F
PNV-DHA CAPS
F
PNV-DHA+DOCUSATE
CAPS
F
PNV-OMEGA CAPS
F
PNV-SELECT TABS
F
PNV-TOTAL CAPS
F
AL; RX/OTC
PRENAISSANCE DHA
MISC
PRENAISSANCE
HARMONY DHA MISC
PRENAISSANCE NEXT
TABS
PRENAISSANCE NEXT-B
TABS
PRENAISSANCE PLUS
CAPS
PRENAISSANCE
PROMISE MISC
F
F
F
F
F
F
F
F
F
PRENATA CHEW
F
PRENATABS FA TABS
F
PRENATABS RX TABS
F
PRENATAL 19 CHEW
F
PRENATAL 19 TABS
F
PRENATAL FORMULA AFREE TABS
PRENATAL FORMULA
TABS
AL
AL
F
F
AL
Nebraska Total Care Updated May 30, 2017
162
Drug Name
PRENATAL LOW IRON
TABS
PRENATAL
MULTIVITAMIN + DHA
MISC
PRENATAL
MULTIVITAMIN TABS
PRENATAL ONE DAILY
TABS
PRENATAL PLUS IRON
TABS
PRENATAL PLUS TABS
PRENATAL TABS 22MG2MG-25MG-1.84MG200MG-27MG-4000UNIT20MG-3MG-12MCG400UNIT-1MG-10MG120MG
PRENATAL TABS
3.75UNIT-0.5MG-50MG0.5MG-25MG-15MG3.75MG-6.75MG-2.5MG5MG-0.75MG-500UNIT2.5MCG-0.5MG-200MCG25MCG-0.75MG-100UNIT,
11UNIT-263MG-25MG1.5MG-27MG-4000UNIT18MG-1.7MG-4MCG400UNIT-0.8MG-2.6MG100MG, 160MG-11UNIT200MG-25MG-1.84MG27MG-4000UNIT-18MG1.7MG-4MCG-400UNIT800MCG-2.6MG-100MG
Drug Requirements/
Tier Limits
F
F
F
AL
F
F
F
AL; RX/OTC
AL; RX/OTC
F
F
Nebraska Total Care Updated May 30, 2017
163
Drug Requirements/
Tier Limits
PRENATAL TABS 30UNITAL
4000UNIT-25MG-1.8MG200MG-28MG-20MG1.7MG-8MCG-400UNIT0.8MG-2.6MG-120MG,
30UNIT-25MG-1.8MG200MG-28MG-20MG1.7MG-4000UNIT-8MCG400UNIT-800MCG-2.6MG120MG, 4000UNIT30UNIT-25MG-1.8MGF
200MG-28MG-20MG1.7MG-8MCG-400UNIT800MCG-2.6MG-120MG,
30UNIT-4000UNIT-25MG1.8MG-200MG-28MG20MG-1.7MG-8MCG400UNIT-800MCG-2.6MG120MG, 4000UNIT30UNIT-200MG-25MG1.8MG-28MG-20MG1.7MG-8MCG-400UNIT800MCG-2.6MG-120MG
PRENATAL VITAMIN
F
TABS
PRENATAL
F AL
VITAMIN/IRON TABS
PRENATAL VITAMINS
F AL; RX/OTC
PLUS LOW IRON TABS
PRENATAL VITAMINS
AL
TABS 30UNIT-4000UNIT25MG-1.8MG-200MGF
28MG-20MG-1.7MG8MCG-400UNIT-800MCG2.6MG-120MG
F AL
PRENATAL-U CAPS
Drug Name
PRENATE AM TABS
F
PRENATE CHEW
F
PRENATE DHA CAPS
F
Drug Name
PRENATE ELITE TABS
600MCG-10UNIT150MCG-2600UNIT1.5MG-15MG-15MG25MG-3MG-100MG-26MG6MG-21MG-3.5MG13MCG-450UNIT400MCG-330MCG-21MG75MG, 600MCG-10UNIT150MCG-2600UNIT1.5MG-15MG-25MG-3MG100MG-26MG-6MG-21MG3.5MG-13MCG-450UNIT400MCG-330MCG-21MG75MG
PRENATE ENHANCE
CAPS
PRENATE ESSENTIAL
CAPS
Drug Requirements/
Tier Limits
Drug Name
RA PRENATAL
FORMULA/FOLICACID
TABS
Drug Requirements/
Tier Limits
AL
F
RA PRENATAL TABS
F
RELNATE DHA CAPS
F
RIGHT STEP PRENATAL
TABS
F
RULAVITE DHA CAPS
F
SE-NATAL 19 CHEW
F
SE-NATAL 19 TABS
F
SE-TAN DHA CAPS
F
F
SELECT-OB CHEW
F
PRENATE MINI CAPS
F
SELECT-OB+DHA MISC
F
PRENATE PIXIE CAPS
F
PRENATE RESTORE
CAPS
F
SM ONE DAILY
PRENATAL MISC
SM PRENATAL VITAMINS
TABS
PREPLUS TABS
F
PREQUE 10 TABS
F
PRETAB TABS
F
PROFE FORTE CAPS
F
F
AL; RX/OTC
F
F
TARON-BC MISC
F
TARON-C DHA CAPS
F
F
TARON-PREX CAPS
F
PROVIDA DHA CAPS
F
PROVIDA OB CAPS
F
PUREFE OB PLUS CAPS
F
TH PRENATAL VITAMINS
TABS
THERANATAL CORE
NUTRITION TABS
PX PRENATAL
MULTIVITAMINS TABS
F
AL
QC PRENATAL TABS
F
AL
R-NATAL OB CAPS
F
RA ONE DAILY MISC
F
AL
F
STUART ONE CAPS
AL
AL
AL
F
AL
F
AL; RX/OTC
THRIVITE 19 TABS
F
THRIVITE RX TABS
F
TL FOLATE TABS
F
TL-CARE DHA CAPS
F
TL-SELECT CAPS
F
TRI-TABS DHA MISC
F
Nebraska Total Care Updated May 30, 2017
164
Drug Name
TRIADVANCE TABS
TRICARE PRENATAL 1
CHEW
TRICARE PRENATAL
CHEW
TRICARE PRENATAL
COMPLEAT MISC
TRICARE PRENATAL
DHA ONE CAPS
TRICARE PRENATAL
THPK
Drug Requirements/
Tier Limits
VINATE II TABS
F
F
VINATE M TABS
F
F
VINATE ONE TABS
F
F
VIRT NATE TABS
F
VIRT-ADVANCE TABS
F
VIRT-C DHA CAPS
F
VIRT-CARE ONE CAPS
F
VIRT-NATE DHA CAPS
F
VIRT-PN DHA CAPS
F
VIRT-PN PLUS CAPS
F
VIRT-PN TABS
F
VIRT-SELECT CAPS
F
VIRT-VITE GT TABS
F
VIRTPREX CAPS
F
VITAFOL FE+ CPPK
F
VITAFOL GUMMIES
CHEW
F
VITAFOL ULTRA CAPS
F
VITAFOL-NANO TABS
F
VITAFOL-OB TABS
F
VITAFOL-OB+DHA MISC
F
VITAFOL-ONE CAPS
F
VIVA DHA CAPS
F
VOL-NATE TABS
F
VOL-PLUS TABS
F
VOL-TAB RX TABS
F
F
F
F
TRINATAL GT TABS
F
TRINATAL RX 1 TABS
F
TRINATE TABS
F
TRISTART DHA CAPS
F
TRIVEEN-DUO DHA MISC
F
TRIVEEN-PRX RNF CAPS
F
AL; RX/OTC
F
F
VENA-BAL DHA MISC
F
VINACAL B MISC
F
F
VINATE CALCIUM TABS
F
AL
VINATE CARE CHEW
F
RX/OTC
VINATE DHA RF CAPS
F
F
Nebraska Total Care Updated May 30, 2017
165
AL
F
VINATE C TABS
VINATE IC CAPS
AL
F
VEMAVITE-PRX 2 CAPS
VINATE AZ EXTRA TABS
Drug Requirements/
Tier Limits
F
TRICARE TABS
ULTIMATECARE ONE
CAPS
ULTIMATECARE ONE NF
CAPS
Drug Name
AL; RX/OTC
Drug Name
Drug Requirements/
Tier Limits
VP-CH PLUS CAPS
F
VP-CH-PNV CAPS
F
VP-GGR-B6 PRENATAL
TABS
VP-HEME OB + DHA
MISC
Drug Name
ELON MATRIX 5000
TABS
ELON MATRIX PLUS
TABS
ELON MATRIX 5000
COMPLETE TABS
ELON MATRIX
COMPLETE TABS
F
F
Drug Requirements/
Tier Limits
F RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
VP-HEME OB TABS
F
ELON R3 TABS
F
RX/OTC
VP-HEME ONE CAPS
F
GREEN SOURCE TABS
F
RX/OTC
VP-PNV-DHA CAPS
F
HAIR FARE TABS
F
RX/OTC
ZATEAN-CH CAPS
F
F
RX/OTC
ZATEAN-PN DHA CAPS
F
F
RX/OTC
ZATEAN-PN PLUS CAPS
F
HAIR NOURISHING
SUPPLEMENT TABS
HEALTHY HEART
COMPLEX TABS
HEART TABS
F
RX/OTC
ZATEAN-PN TABS
F
HM ESTROPLUS TABS
F
RX/OTC
KIDNEY TABS
F
RX/OTC
LIPIDSHIELD PLUS TABS
F
RX/OTC
LUNG TABS
F
RX/OTC
LYMPH TABS
F
RX/OTC
M2 CALCIUM TABS
F
RX/OTC
M2 CHROMIUM TABS
F
RX/OTC
MAMMARY TABS
F
RX/OTC
MENOPAUSE RELIEF
TABS
F
RX/OTC
MG-PLUS PROTEIN TABS
F
RX/OTC
MIL ADREGEN TABS
F
RX/OTC
MILADRENE FORTE
TABS
F
RX/OTC
MILPAN TABS
F
RX/OTC
MULTI-GLAN TABS
F
RX/OTC
Specialty Vitamins Products
ADRENAL STRESS CALM
TABS
ADVANCED COLLAGEN
TABS
ALLERWELL ALLERGY
FORMULA TABS
BIOTIN PLUS KERATIN
TABS
BRAIN MIGHT/DHA & CO
Q10 TABS
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
F
RX/OTC
BRAIN TABS
F
RX/OTC
CA-PLUS TABS
F
RX/OTC
CARDIO TONE TABS
F
RX/OTC
F
RX/OTC
F
RX/OTC
CU-PLUS TABS
F
RX/OTC
CVS HAIR/SKIN/NAILS
TABS
F
RX/OTC
CENTRUM
PERFORMANCE TABS
CENTRUM SPECIALIST
ENERGY TABS
Nebraska Total Care Updated May 30, 2017
166
Drug Name
NEW LIFE HAIR TABS
Drug Requirements/
Tier Limits
F RX/OTC
Drug Name
vitamins a & d caps
Drug Requirements/
Tier Limits
F
ORCHIC TABS
F
RX/OTC
OVARY TABS
F
RX/OTC
PARATHYROID TABS
F
RX/OTC
PITUITARY TABS
F
RX/OTC
vitamins w/ lipotropics tabs
PROSTATE TABS
F
RX/OTC
MUSCULOSKELETAL THERAPY AGENTS Drugs to Treat Spasms
RA EAR CARE TABS
F
RX/OTC
Central Muscle Relaxants
specialty vitamins products
tabs
F
RX/OTC
AMRIX CP24
NP
SPLEEN TABS
F
RX/OTC
baclofen tabs
F
STOMACH TABS
F
RX/OTC
carisoprodol tabs 250 mg
NP
F
RX/OTC
carisoprodol tabs 350 mg
NP QL(4 ea daily)
F
RX/OTC
chlorzoxazone tabs
F
F
RX/OTC
cyclobenzaprine hcl tabs
F
UTERUS TABS
F
RX/OTC
FEXMID TABS
(Cyclobenzaprine HCl)
NP
VITAMINS FOR THE HAIR
TABS
F
RX/OTC
LORZONE TABS
NP
F
RX/OTC
METAXALONE TABS 400
MG
NP
metaxalone tabs 800 mg
NP
TAB-A-VITE WOMENS
TABS
THERABETIC EYE
HEALTH TABS
THYMUS TABS
ZN-PLUS TABS
Vitamin Mixtures
Vitamins w/ Lipotropics
ACTIFLOVIT EAR
HEALTH TABS
LIPOTRIAD TABS
(Vitamins w/ Lipotropics)
methocarbamol tabs
cod liver oil caps
F
COD LIVER OIL FOR KIDS
OIL
F
RX/OTC
orphenadrine citrate tb12
COD LIVER OIL OIL
F
RX/OTC
CVS COD LIVER OIL OIL
F
RX/OTC
NORWEGIAN COD LIVER
OIL OIL
F
RX/OTC
QC COD LIVER OIL OIL
F
RX/OTC
RA COD LIVER OIL OIL
F
RX/OTC
PARAFON FORTE DSC
TABS (Chlorzoxazone)
ROBAXIN TABS
(Methocarbamol)
ROBAXIN-750 TABS
(Methocarbamol)
SKELAXIN TABS
(Metaxalone)
SOMA TABS 250 MG
(Carisoprodol)
Nebraska Total Care Updated May 30, 2017
167
F
NP
F
F
NP
NP
NP
NP
NP
NP
Drug Name
SOMA TABS 350 MG
(Carisoprodol)
Drug Requirements/
Tier Limits
NP QL(4 ea daily)
tizanidine hcl caps
NP
tizanidine hcl tabs
F
ZANAFLEX CAPS
(Tizanidine HCl)
ZANAFLEX TABS
(Tizanidine HCl)
Direct Muscle Relaxants
DANTRIUM CAPS
(Dantrolene Sodium)
dantrolene sodium caps
NP
NP
saline gel
saline soln na 0.65%0.002%, 0.65%, 0.65 %
Nasal Antiallergy
ASTEPRO SOLN
(Azelastine HCl)
NP
F
Nasal Steroids
NP
budesonide (nasal) susp
NP RX/OTC
NP
FLONASE ALLERGY
RELIEF CHILDRENS
SUSP (Fluticasone
Propionate (Nasal))
FLONASE ALLERGY
RELIEF SUSP (Fluticasone
Propionate (Nasal))
FLONASE SENSIMIST
SUSP
QL(0.534 ml
NP daily); RX/OTC
flunisolide (nasal) soln
NP
NP
Nasal Agent Combinations
Nasal Agents - Misc.
AYR NASAL DROPS
SOLN
DERMACINRX TICANASE
PAK THPK
OCEAN NASAL SPRAY
SOLN (Saline)
Nasal Anticholinergics
ATROVENT SOLN
(Ipratropium Bromide
(Nasal))
ipratropium bromide (nasal)
soln
F
NP
NASAL AGENTS - SYSTEMIC AND TOPICAL Drugs to treat the Nose or Sinus
DYMISTA SUSP
PATANASE SOLN
(Olopatadine HCl (Nasal))
Drug Requirements/
Tier Limits
BECONASE AQ SUSP
Muscle Relaxant Combinations
carisoprodol w/ aspirin tabs
Drug Name
NP
F
NP
NP
F
F
NP
azelastine hcl soln
NP
cromolyn sodium (nasal)
aers
NASALCROM AERS
(Cromolyn Sodium (Nasal))
QL(0.867 ml
daily)
NP QL(0.867 ml
daily)
olopatadine hcl (nasal) soln
NP
F
fluticasone propionate
(nasal) susp
mometasone furoate
(nasal) susp
NASACORT ALLERGY
24HR AERO
NASACORT ALLERGY
24HR AERO
(Triamcinolone Acetonide
(Nasal))
NASACORT ALLERGY
24HR CHILDRENS AERO
(Triamcinolone Acetonide
(Nasal))
NASONEX SUSP
(Mometasone Furoate
(Nasal))
QL(0.534 ml
NP daily); RX/OTC
NP RX/OTC
F
F
QL(0.534 ml
daily); RX/OTC
AL
NP RX/OTC
RX/OTC
NP
RX/OTC
NP
AL
NP
OMNARIS SUSP
NP
QNASL AERS
NP
QNASL CHILDRENS
AERS
NP
Nebraska Total Care Updated May 30, 2017
168
Drug Requirements/
Tier Limits
RHINOCORT AQUA SUSP NP RX/OTC
(Budesonide (Nasal))
triamcinolone acetonide
NP RX/OTC
(nasal) aero
triamcinolone acetonide
F RX/OTC
(nasal) aero
NP RX/OTC
VERAMYST SUSP
Drug Name
ZETONNA AERS
NP
Sympathomimetic Decongestants
AFRIN 12 HOUR SOLN
NP
(Oxymetazoline HCl)
AFRIN ALL NIGHT
NP
NODRIP SOLN
(Oxymetazoline HCl)
AFRIN NASAL SPRAY
NP
SOLN (Oxymetazoline HCl)
AFRIN NODRIP EXTRA
NP
MOISTURIZING SOLN
(Oxymetazoline HCl)
AFRIN NODRIP ORIGINAL NP
SOLN (Oxymetazoline HCl)
AFRIN NODRIP SEVERE
NP
CONGESTION SOLN
(Oxymetazoline HCl)
AFRIN NODRIP SINUS
NP
SOLN (Oxymetazoline HCl)
AFRIN SINUS SOLN
NP
(Oxymetazoline HCl)
AFRIN SOLN
NP
(Oxymetazoline HCl)
DRISTAN SPRAY SOLN
NP
(Oxymetazoline HCl)
DURATION 12 HOUR
NP
SOLN (Oxymetazoline HCl)
DURATION SPRAY SOLN NP
(Oxymetazoline HCl)
NASAL DECONGESTANT
F
SYRP
NEO-SYNEPHRINE 12
HOUR EXTRA
NP
MOISTURIZING SOLN
(Oxymetazoline HCl)
oxymetazoline hcl soln
F
Nebraska Total Care Updated May 30, 2017
169
Drug Name
Drug Requirements/
Tier Limits
phenylephrine hcl (oral)
tabs
F
pseudoephedrine hcl liqd
F
pseudoephedrine hcl tabs
F
pseudoephedrine hcl tb12
F
SUDAFED CHILDRENS
LIQD (Pseudoephedrine
HCl)
SUDAFED CONGESTION
TABS (Pseudoephedrine
HCl)
SUDAFED NASAL
DECONGESTANT
MAXIMUM STRENGTH
TABS (Pseudoephedrine
HCl)
SUDAFED PE
CONGESTION TABS
(Phenylephrine HCl (Oral))
SUDAFED TABS
(Pseudoephedrine HCl)
VICKS SINEX 12 HOUR
DECONGESTANT SOLN
(Oxymetazoline HCl)
VICKS SINEX 12 HOUR
DECONGESTANT ULTRA
FINE MIST SOLN
(Oxymetazoline HCl)
VICKS SINEX 12 HOUR
DECONGESTANT ULTRA
FINE MIST/MOISTURIZNG
SOLN (Oxymetazoline HCl)
VICKS SINEX
MOISTURIZING SOLN
(Oxymetazoline HCl)
VICKS SINEX SEVERE
NASALDECONGESTANT
SOLN (Oxymetazoline HCl)
VICKS SINEX SOLN
(Oxymetazoline HCl)
NUTRIENTS
Misc. Nutritional Substances
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
NP
Drug Name
Drug Requirements/
Tier Limits
omega-3 fatty acids caps
210mg-1000mg-75mg90mg, 300mg-180mg1000mg-120mg-1unit,
300mg-200mg-1unit,
300mg-180mg-120mg,
300mg-1000mg-1unit,
400mg-1000mg-300mg,
180mg-120mg-1.8unit,
300mg-1000mg-200mg,
180mg-1unit-1000mg120mg, 180mg-1000mg120mg-1unit, 350mg1000mg-250mg, 300mg1000mg, 1000mg,
1000mg-180mg-120mg,
300mg-180mg-1000mg120mg, 1000mg-180mg120mg-1unit, 300mg1000mg-200mg-1unit,
600mg-1000mg, 100mg1000mg-500mg-10unit,
500mg-1000mg-250mg,
300mg-1unit-1000mg,
1000mg-180mg-120mg1mg, 160mg-1000mg100mg, 40mg-340mg180mg-1000mg-120mg5unit, 100mg-300mg1000mg-200mg, 270mg1000mg-180mg, 300mg180mg-1gm-120mg,
700mg-350mg-1000mg250mg, 180mg-1000mg120mg, 1000 mg, 350mg1000mg, 180mg-120mg5unit, 340mg-180mg1000mg-120mg-5unit,
180mg-120mg, 340mg180mg-1unit-1000mg120mg
Drug Name
carboxymethylcellulose
sodium (ophth) soln
carboxymethylcelluloseglycerin soln
carboxymethylcellulosehypromellose gel
GENTEAL GEL
(CarboxymethylcelluloseHypromellose)
OPHTHALMIC AGENTS - Drugs to Treat the Eye
Artificial Tears and Lubricants
artificial tear ointment oint
F
artificial tear solution soln
F
ARTIFICIAL TEARS SOLN
F
F
F
F
NP
GENTEAL MILD SOLN
F
GENTEAL MILD TO
MODERATE SOLN
(Hypromellose (Ophth))
NP
GENTEAL SEVERE GEL
F
Drug Requirements/
Tier Limits
GENTEAL TEARS
MODERATEPF SOLN
GONAK SOLN
(Hypromellose
(Gonioscopic))
GONIOSOL SOLN
(Hypromellose
(Gonioscopic))
F
F
NP
NP
HYPOTEARS SOLN
F
hypromellose (gonioscopic)
soln
F
hypromellose (ophth) soln
F
ISOPTO TEARS SOLN
F
polyethylene glycolpropylene glycol (ophth)
soln
F
polyvinyl alcohol soln
F
polyvinyl alcohol-povidone
(ophth) soln
REFRESH CELLUVISC
SOLN
REFRESH LIQUIGEL
SOLN
REFRESH OPTIVE
ADVANCED SENSITIVE
SOLN
F
F
F
F
Nebraska Total Care Updated May 30, 2017
170
Drug Name
REFRESH OPTIVE
ADVANCED SOLN
REFRESH OPTIVE
SENSITIVE SOLN
REFRESH OPTIVE SOLN
(CarboxymethylcelluloseGlycerin)
REFRESH PLUS SOLN
(Carboxymethylcellulose
Sodium (Ophth))
REFRESH SOLN
(Polyvinyl AlcoholPovidone (Ophth))
REFRESH TEARS SOLN
(Carboxymethylcellulose
Sodium (Ophth))
SYSTANE OVERNIGHT
THERAPY LUBRICANT
EYE GEL
SYSTANE SOLN
(Polyethylene GlycolPropylene Glycol (Ophth))
SYSTANE ULTRA HOME
& AWAY PACK SOLN
(Polyethylene GlycolPropylene Glycol (Ophth))
SYSTANE ULTRA SOLN
(Polyethylene GlycolPropylene Glycol (Ophth))
TEARS NATURALE PM
OINT (White PetrolatumMineral Oil)
white petrolatum-mineral oil
oint
Drug Requirements/
Tier Limits
F
F
NP
NP
NP
NP
F
NP
NP
NP
COSOPT PF SOLN
COSOPT SOLN
(Dorzolamide HCl-Timolol
Maleate)
dorzolamide hcl-timolol
maleate soln
ISTALOL SOLN
NP
F
betaxolol hcl (ophth) soln
NP
BETIMOL SOLN 0.5 %
NP
BETOPTIC-S SUSP
NP
carteolol hcl (ophth) soln
F
COMBIGAN SOLN
F
Nebraska Total Care Updated May 30, 2017
Drug Requirements/
Tier Limits
NP
NP
F
NP
levobunolol hcl soln
F
timolol maleate (ophth) solg
F
timolol maleate (ophth) soln
F
TIMOPTIC OCUDOSE
SOLN
TIMOPTIC SOLN (Timolol
Maleate (Ophth))
TIMOPTIC-XE SOLG
(Timolol Maleate (Ophth))
Cycloplegic Mydriatics
atropine sulfate
(ophthalmic) soln
ATROPINE SULFATE
SOLN OP 1 %
CYCLOGYL SOLN
(Cyclopentolate HCl)
cyclopentolate hcl soln
Beta-blockers - Ophthalmic
BETAGAN SOLN
NP
(Levobunolol HCl)
171
Drug Name
ISOPTO ATROPINE SOLN
(Atropine Sulfate
(Ophthalmic))
MYDRIACYL SOLN
(Tropicamide)
tropicamide soln
Miotics
ISOPTO CARPINE SOLN
(Pilocarpine HCl)
PHOSPHOLINE IODIDE
SOLR
pilocarpine hcl soln
NP
NP
NP
F
F
NP
F
NP
NP
F
F
NP
F
Ophthalmic Adrenergic Agents
Drug Name
ALPHAGAN P SOLN 0.1 %
ALPHAGAN P SOLN 0.15
% (Brimonidine Tartrate)
apraclonidine hcl soln
brimonidine tartrate soln
0.15 %
brimonidine tartrate soln
0.2 %
IOPIDINE SOLN 0.5 %
(Apraclonidine HCl)
IOPIDINE SOLN 1 %
SIMBRINZA SUSP
Drug Requirements/
Tier Limits
NP
F
NP
NP
F
NP
Drug Name
NATACYN SUSP
neomycin-bacitracin znpolymyxin oint
neomycin-polymyxingramicidin soln
NEOSPORIN SOLN
(Neomycin-PolymyxinGramicidin)
OCUFLOX SOLN
(Ofloxacin (Ophth))
ofloxacin (ophth) soln
NP
F
Ophthalmic Anti-infectives
AZASITE SOLN
NP QL(2.5 ml per
fill retail)
BACITRACIN OINT
NP
polymyxin b-trimethoprim
soln
POLYTRIM SOLN
(Polymyxin BTrimethoprim)
sulfacetamide sodium
(ophth) soln
SULFACETAMIDE
SODIUM OINT
Drug Requirements/
Tier Limits
NP
NP
NP QL(10 ml per
fill retail)
QL(10 ml per
F fill retail)
NP
F
F
NP
NP
NP
bacitracin-polymyxin b
(ophth) oint
NP
BESIVANCE SUSP
NP
BLEPH-10 SOLN
(Sulfacetamide Sodium
(Ophth))
NP
TOBREX SOLN
(Tobramycin (Ophth))
CILOXAN OINT
NP
trifluridine soln
F
NP
VIGAMOX SOLN
F
CILOXAN SOLN
(Ciprofloxacin HCl (Ophth))
ciprofloxacin hcl (ophth)
soln
F
erythromycin (ophth) oint
F
gatifloxacin (ophth) soln
NP
gentamicin sulfate (ophth)
oint
gentamicin sulfate (ophth)
soln
levofloxacin (ophth) soln
MOXEZA SOLN
F
F
NP
F
tobramycin (ophth) soln
F
TOBREX OINT
F
VIROPTIC SOLN
(Trifluridine)
ZYMAXID SOLN
(Gatifloxacin (Ophth))
Ophthalmic Decongestants
NAPHAZOLINE HCL
SOLN
phenylephrine hcl (ophth)
soln 2.5 %
tetrahydrozoline hcl (ophth)
soln
tetrahydrozoline w/
polyethylene glycol soln
NP
NP
NP
F
F
F
F
Nebraska Total Care Updated May 30, 2017
172
Drug Name
Drug Requirements/
Tier Limits
tetrahydrozoline-dextranF
polyethylene glycolpovidone soln
VISINE ADVANCED
RELIEF SOLN
(Tetrahydrozoline-Dextran- NP
Polyethylene GlycolPovidone)
VISINE EXTRA SOLN
NP
(Tetrahydrozoline HCl
(Ophth))
VISINE SOLN
NP
(Tetrahydrozoline HCl
(Ophth))
Ophthalmic Immunomodulators
RESTASIS EMUL
RESTASIS MULTIDOSE
EMUL
F
NP
Ophthalmic Integrin Antagonists
XIIDRA SOLN
NP
Ophthalmic Steroids
ALREX SUSP
bacitracin-poly-neomycinhc oint
BLEPHAMIDE S.O.P.
OINT
BLEPHAMIDE SUSP
dexamethasone sodium
phosphate (ophth) soln
DEXAMETHASONE
SODIUM PHOSPHATE
SOLN OP 0.1 %
F
NP
NP
NP
F
F
DUREZOL EMUL
F
FLAREX SUSP
F
fluorometholone (ophth)
susp
F
FML FORTE SUSP
NP
FML LIQUIFILM SUSP
(Fluorometholone (Ophth))
NP
Nebraska Total Care Updated May 30, 2017
173
Drug Name
Drug Requirements/
Tier Limits
FML OINT
NP
LOTEMAX GEL
NP
LOTEMAX OINT
NP
LOTEMAX SUSP
F
MAXIDEX SUSP
F
MAXITROL OINT
(Neomycin-PolymyDexameth)
MAXITROL SUSP
(Neomycin-PolymyDexameth)
neomycin-polymydexameth oint
neomycin-polymydexameth susp
NEOMYCIN/POLYMYXIN/
HYDROCORTISONE
SUSP
OMNIPRED SUSP
(Prednisolone Acetate
(Ophth))
PRED FORTE SUSP
(Prednisolone Acetate
(Ophth))
NP
NP
F
F
NP
NP
NP
PRED MILD SUSP
F
PRED-G S.O.P. OINT
F
PRED-G SUSP
F
prednisolone acetate
(ophth) susp
PREDNISOLONE SODIUM
PHOSPHATE SOLN OP 1
%
sulfacetamide sodprednisolone soln
TOBRADEX OINT
TOBRADEX ST SUSP
NP
NP
F
F
NP
Drug Name
TOBRADEX SUSP
(TobramycinDexamethasone)
tobramycindexamethasone susp
Drug Requirements/
Tier Limits
F
NP
VEXOL SUSP
NP
ZYLET SUSP
NP
Ophthalmics - Misc.
ACULAR LS SOLN
(Ketorolac Tromethamine
(Ophth))
ACULAR SOLN (Ketorolac
Tromethamine (Ophth))
NP
NP
ACUVAIL SOLN
NP
ALOCRIL SOLN
NP
ALOMIDE SOLN
azelastine hcl (ophth) soln
AZOPT SUSP
Drug Name
EYEAID IRRIGATING
SOLUTION SOLN
(Ophthalmic Irrigation
Solution)
flurbiprofen sodium soln
ILEVRO SUSP
ketorolac tromethamine
(ophth) soln
ketotifen fumarate (ophth)
soln
Drug Requirements/
Tier Limits
NP
F
NP
NP
F
LASTACAFT SOLN
NP
MURO 128 OINT (Sodium
Chloride Hypertonic)
NP
MURO 128 SOLN 2 %
F
NP
MURO 128 SOLN 5 %
(Sodium Chloride
Hypertonic)
NP
NP
NEVANAC SUSP
NP
OCUFEN SOLN
(Flurbiprofen Sodium)
NP
F
BEPREVE SOLN
NP
olopatadine hcl soln
NP
bromfenac sodium (ophth)
soln
NP
ophthalmic irrigation
solution soln
F
BROMFENAC SOLN
NP
PATADAY SOLN
F
BROMSITE SOLN
NP
PATANOL SOLN
(Olopatadine HCl)
NP
cromolyn sodium (ophth)
soln
diclofenac sodium (ophth)
soln
dorzolamide hcl soln
F
PAZEO SOLN
F
PROLENSA SOLN
F
ELESTAT SOLN
(Epinastine HCl (Ophth))
NP
EMADINE SOLN
NP
epinastine hcl (ophth) soln
NP
sodium chloride hypertonic
oint
sodium chloride hypertonic
soln
TRUSOPT SOLN
(Dorzolamide HCl)
ZADITOR SOLN (Ketotifen
Fumarate (Ophth))
Prostaglandins - Ophthalmic
F
NP
F
F
NP
NP
Nebraska Total Care Updated May 30, 2017
174
Drug Name
BIMATOPROST SOLN
Drug Requirements/
Tier Limits
NP
latanoprost soln
F
LUMIGAN SOLN
NP
TRAVATAN Z SOLN
F
TRAVOPROST SOLN
NP
XALATAN SOLN
(Latanoprost)
NP
ZIOPTAN SOLN
NP
OTIC AGENTS - Drugs to Treat the Ear
Otic Agents - Miscellaneous
acetic acid (otic) soln
ACETIC ACID/ALUMINUM
ACETATE SOLN
carbamide peroxide (otic)
soln
DEBROX SOLN
(Carbamide Peroxide
(Otic))
F
NP
F
NP
CIPROFLOXACIN SOLN
OT 0.2 %
FLOXIN OTIC SOLN
(Ofloxacin (Otic))
ofloxacin (otic) soln
F
F
OTOVEL SOLN
F
PRAMOTIC LIQD
F
Otic Steroids
DERMOTIC OIL
(Fluocinolone Acetonide
(Otic))
fluocinolone acetonide
(otic) oil
hydrocortisone w/acetic
acid soln
NP
F
NP
OXYTOCICS - Drugs to Prevent/Control Uterine
Bleeding
Oxytocics
METHERGINE TABS
F
methylergonovine maleate
tabs
F
Aminopenicillins
F
amoxicillin caps
F
F
AMOXICILLIN CHEW
F
F
AMOXICILLIN ER TB24
F
amoxicillin susr
F
amoxicillin tabs
F
ampicillin caps
F
AMPICILLIN SUSR
F
Otic Combinations
antipyrine-benzocaine soln
neomycin-polymyxin-hc
(otic) soln
neomycin-polymyxin-hc
(otic) susp
Drug Requirements/
Tier Limits
PENICILLINS - Drugs to Treat Bacterial Infections
Otic Anti-infectives
CETRAXAL SOLN
Drug Name
F
CIPRO HC SUSP
NP
CIPRODEX SUSP
F
MOXATAG TB24
NP
NP
COLY-MYCIN S SUSP
NP
Natural Penicillins
CORTISPORIN-TC SUSP
NP
penicillin v potassium solr
F
penicillin v potassium tabs
F
Nebraska Total Care Updated May 30, 2017
175
Drug Name
Drug Requirements/
Tier Limits
Penicillin Combinations
amoxicillin & pot
F
clavulanate susr
amoxicillin & pot
F
clavulanate tabs
amoxicillin & pot
NP
clavulanate tb12
AMOXICILLIN/CLAVULAN
F
ATE POTASSIUM CHEW
AUGMENTIN ES-600
NP
SUSR (Amoxicillin & Pot
Clavulanate)
AUGMENTIN SUSR
F
125MG/5ML-31.25MG/5ML
AUGMENTIN SUSR
250MG/5ML-62.5MG/5ML
NP
(Amoxicillin & Pot
Clavulanate)
AUGMENTIN TABS
NP
(Amoxicillin & Pot
Clavulanate)
AUGMENTIN XR TB12
NP
(Amoxicillin & Pot
Clavulanate)
Penicillinase-Resistant Penicillins
dicloxacillin sodium caps
MAKENA OIL
Agents for Chemical Dependency
ANTABUSE TABS 250 MG NP
(Disulfiram)
disulfiram tabs 250 mg
XYREM SOLN
NP
medroxyprogesterone
acetate tabs
F
norethindrone acetate tabs
F
progesterone micronized
caps
PROMETRIUM CAPS
(Progesterone Micronized)
PROVERA TABS
(Medroxyprogesterone
Acetate)
F
Anti-Cataplectic Agents
F
F
Drug Requirements/
Tier Limits
PSYCHOTHERAPEUTIC AND NEUROLOGICAL
AGENTS - MISC. - Drugs to Treat Mental and
Emotional Conditions
PROGESTINS - Hormone Replacement/Modifying
Drugs
Progestins
AYGESTIN TABS
(Norethindrone Acetate)
Drug Name
PA
F
NP
NP
Antidementia Agents
ARICEPT TABS (Donepezil
Hydrochloride)
donepezil hydrochloride
tabs 23 mg, 10 mg
donepezil hydrochloride
tabs 5 mg, 10 mg
donepezil hydrochloride
tbdp
EXELON CAPS
(Rivastigmine Tartrate)
EXELON PT24 13.3
MG/24HR (Rivastigmine)
EXELON PT24 4.6
MG/24HR, 9.5 MG/24HR
(Rivastigmine)
galantamine hydrobromide
cp24
GALANTAMINE
HYDROBROMIDE SOLN
galantamine hydrobromide
tabs
memantine hcl soln
memantine hcl tabs
NAMENDA SOLN
(Memantine HCl)
NAMENDA TABS
(Memantine HCl)
NAMENDA TITRATION
PAK TABS (Memantine
HCl)
NAMENDA XR CP24
F
PA
NP
NP
F
F
NP
F
QL(1 ea daily)
F
NP
NP
NP
NP QL(10 ml daily)
F
F
QL(10 ml daily)
NP
NP
NP
Nebraska Total Care Updated May 30, 2017
176
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
Limit 15ea per
NP month;QL(0.5
ea daily)
QL(1 ml daily)
F
NAMENDA XR TITRATION
PACK CP24
NP
NAMZARIC C4PK
NP
NAMZARIC CP24
NP
COPAXONE SOSY 20
MG/ML (Glatiramer
Acetate)
NP
COPAXONE SOSY 40
MG/ML
NP
EXTAVIA KIT
NP
GILENYA CAPS
Limit 12ml in 28
NP days;QL(0.43
ml daily)
Limit 15ea per
NP month;QL(0.5
ea daily)
F QL(1 ea daily)
NP QL(1 ea daily)
glatiramer acetate sosy
NP QL(1 ml daily)
NP
PLEGRIDY SOPN
RAZADYNE ER CP24
(Galantamine
Hydrobromide)
RAZADYNE TABS
(Galantamine
Hydrobromide)
rivastigmine pt24 13.3
mg/24hr
rivastigmine pt24 4.6
mg/24hr, 9.5 mg/24hr
rivastigmine tartrate caps
BETASERON KIT
Combination Psychotherapeutics
olanzapine-fluoxetine hcl
F AL
caps
PERPHENAZINE/AMITRIP
F AL
TYLINE TABS
SYMBYAX CAPS
AL
NP
(Olanzapine-Fluoxetine
HCl)
Fibromyalgia Agents
SAVELLA TABS
F
SAVELLA TITRATION
PACK MISC
F
PA; QL(2 ea
daily); AL
PA; QL(2 ea
daily); AL
Multiple Sclerosis Agents
AMPYRA TB12
AUBAGIO TABS
NP QL(1 ea daily)
AVONEX KIT
F
AVONEX PEN AJKT
F
AVONEX PSKT
F
F
Limit 4ea in 28
days;QL(0.143
ea daily)
QL(0.1429 ea
daily)
QL(0.1429 ea
daily)
Limit 15ea per
month;QL(0.5
ea daily)
Nebraska Total Care Updated May 30, 2017
177
TECFIDERA CPDR
NP
TECFIDERA STARTER
PACK MISC
NP
ZINBRYTA SOSY
NP
PLEGRIDY SOSY
PLEGRIDY STARTER
PACK SOPN
PLEGRIDY STARTER
PACK SOSY
REBIF REBIDOSE SOAJ
REBIF REBIDOSE
TITRATIONPACK SOAJ
REBIF SOSY
NP QL(2 ea daily)
BETASERON KIT
REBIF TITRATION PACK
SOSY
Limit 1ml in 28
NP days;QL(0.036
ml daily)
Limit 1ml in 28
NP days;QL(0.036
ml daily)
Limit 1ml in 28
NP days;QL(0.036
ml daily)
Limit 1ml in 28
NP days;QL(0.036
ml daily)
F PA; QL(0.2 ml
daily)
F PA; QL(0.2 ml
daily)
F PA; QL(0.2 ml
daily)
F PA; QL(0.2 ml
daily)
Premenstrual Dysphoric Disorder (PMDD) Agents
FLUOXETINE CAPS
F
Psychotherapeutic and Neurological Agents -
Drug Name
Drug Requirements/
Tier Limits
Drug Name
ERGOLOID MESYLATES
TABS
F
NICOTROL INHALER
INHA
ergoloid mesylates tabs
F
NICOTROL NS SOLN
ORAP TABS 1 MG
(Pimozide)
ORAP TABS 2 MG
(Pimozide)
pimozide tabs 1 mg
pimozide tabs 2 mg
Smoking Deterrents
bupropion hcl (smoking
deterrent) tb12
CHANTIX CONTINUING
MONTHPAK TABS
CHANTIX STARTING
MONTH PAK TABS
CHANTIX TABS
NICODERM CQ PT24 21
MG/24HR, 14 MG/24HR
(Nicotine)
NICODERM CQ PT24 7
MG/24HR (Nicotine)
NICORETTE GUM
(Nicotine Polacrilex)
NICORETTE LOZG
(Nicotine Polacrilex)
NICORETTE MINI LOZG
(Nicotine Polacrilex)
NICORETTE STARTER
KIT GUM (Nicotine
Polacrilex)
NP QL(10 ea
daily); AL
NP QL(5 ea daily);
AL
F QL(10 ea
daily); AL
F QL(5 ea daily);
AL
F
F
F
F
PA; QL(2 ea
daily); AL
PA; QL(2 ea
daily); AL
PA; QL(2 ea
daily); AL
PA; QL(2 ea
daily); AL
PA; AL
Drug Requirements/
Tier Limits
F PA; AL
ZYBAN TB12 (Bupropion
HCl (Smoking Deterrent))
F
NP PA; QL(2 ea
daily); AL
Vasomotor Symptom Agents
BRISDELLE CAPS
F
RESPIRATORY AGENTS - MISC. - Drugs to
Treat Lung Conditions
Cystic Fibrosis Agents
KALYDECO PACK
F
KALYDECO TABS
F
ORKAMBI TABS
F
PULMOZYME SOLN
F
ESBRIET CAPS
NP
NP PA; QL(1 ea
daily); AL
NP PA; AL
OFEV CAPS
NP
NP PA; AL
Tetracyclines
ADOXA CAPS
(Doxycycline
(Monohydrate))
ADOXA PAK 1/100 TABS
(Doxycycline
(Monohydrate))
ADOXA PAK 1/150 TABS
(Doxycycline
(Monohydrate))
ADOXA PAK 2/100 TABS
(Doxycycline
(Monohydrate))
ADOXA TABS
(Doxycycline
(Monohydrate))
PA; AL
NP
nicotine polacrilex gum
F
PA; AL
nicotine polacrilex lozg
F
PA; AL
nicotine pt24 14 mg/24hr,
21 mg/24hr
F
PA; AL
nicotine pt24 7 mg/24hr
F
NICOTINE
TRANSDERMAL SYSTEM
KIT
F
PA; QL(1 ea
daily); AL
PA; AL
PA; QL(2 ea
daily)
PA
PA; QL(4 ea
daily); AL
PA
Pulmonary Fibrosis Agents
NP
NP PA; AL
PA; AL
TETRACYCLINES - Drugs to Treat Bacterial
Infections
demeclocycline hcl tabs
NP
NP
NP
NP
NP
F
PA
Nebraska Total Care Updated May 30, 2017
178
Drug Name
DORYX MPC TBEC
DORYX TBEC
(Doxycycline Hyclate)
doxycycline (monohydrate)
caps 100 mg, 50 mg
doxycycline (monohydrate)
caps 75 mg, 150 mg
doxycycline (monohydrate)
susr
doxycycline (monohydrate)
tabs
Drug Requirements/
Tier Limits
NP
NP
F
NP
Drug Name
Drug Requirements/
Tier Limits
VIBRAMYCIN SUSR
(Doxycycline
(Monohydrate))
NP
VIBRAMYCIN SYRP
NP
THYROID AGENTS - Drugs to Regulate Thyroid
Hormones
Antithyroid Agents
NP
methimazole tabs
F
NP
propylthiouracil tabs
F
doxycycline hyclate caps
F
TAPAZOLE TABS
(Methimazole)
doxycycline hyclate tabs
F
doxycycline hyclate tbec
NP
MINOCIN CAPS
(Minocycline HCl)
NP
NP
MINOCYCLINE HCL ER
TB24
NP
Thyroid Hormones
ARMOUR THYROID TABS
300 MG, 120 MG, 240 MG,
180 MG
ARMOUR THYROID TABS
90 MG, 30 MG, 60 MG, 15
MG (Thyroid)
CYTOMEL TABS
(Liothyronine Sodium)
minocycline hcl tabs
NP
levothyroxine sodium tabs
F
minocycline hcl tb24
NP
liothyronine sodium tabs
F
MONODOX CAPS
(Doxycycline
(Monohydrate))
NP
SYNTHROID TABS
(Levothyroxine Sodium)
NP
MORGIDOX 1X100MG KIT
NP
MORGIDOX 1X50MG KIT
KIT
NP
MORGIDOX 2X100MG KIT
NP
SOLODYN TB24
NP
minocycline hcl caps
tetracycline hcl caps 250
mg, 500 mg
TETRACYCLINE HCL
CAPS 500 MG, 250 MG
(Tetracycline HCl)
VIBRAMYCIN CAPS
(Doxycycline Hyclate)
F
NP
NP
NP
thyroid tabs
F
THYROLAR-1 TABS
F
THYROLAR-1/2 TABS
F
THYROLAR-1/4 TABS
F
THYROLAR-2 TABS
F
THYROLAR-3 TABS
F
NP
ULCER DRUGS - Drugs to Treat Bowel, Intestine
and Stomach Conditions
NP
Antispasmodics
ANASPAZ TBDP
(Hyoscyamine Sulfate)
Nebraska Total Care Updated May 30, 2017
179
F
NP
Drug Name
BENTYL CAPS
(Dicyclomine HCl)
BENTYL TABS
(Dicyclomine HCl)
Drug Requirements/
Tier Limits
Drug Requirements/
Tier Limits
NP
nizatidine caps
NP
NP
NIZATIDINE SOLN
NP
dicyclomine hcl caps
F
dicyclomine hcl soln or 10
mg/5ml
F
dicyclomine hcl tabs
F
glycopyrrolate tabs
F
hyoscyamine sulfate elix
F
hyoscyamine sulfate soln
F
hyoscyamine sulfate subl
F
hyoscyamine sulfate tabs
F
hyoscyamine sulfate tb12
F
hyoscyamine sulfate tbdp
F
LEVBID TB12
(Hyoscyamine Sulfate)
LEVSIN TABS
(Hyoscyamine Sulfate)
LEVSIN/SL SUBL
(Hyoscyamine Sulfate)
ROBINUL FORTE TABS
(Glycopyrrolate)
ROBINUL TABS
(Glycopyrrolate)
Drug Name
PEPCID AC MAXIMUM
STRENGTH TABS
(Famotidine)
PEPCID AC TABS
(Famotidine)
PEPCID SUSR
(Famotidine)
PEPCID TABS 20 MG
(Famotidine)
PEPCID TABS 40 MG
(Famotidine)
NP
NP
NP
NP
H-2 Antagonists
NP
NP
NP RX/OTC
NP
ranitidine hcl caps
NP
ranitidine hcl syrp
F
ranitidine hcl tabs 150 mg
F
ranitidine hcl tabs 75 mg,
300 mg
TAGAMET HB TABS
(Cimetidine)
ZANTAC 150 MAXIMUM
STRENGTH TABS
(Ranitidine HCl)
ZANTAC 75 TABS
(Ranitidine HCl)
ZANTAC TABS 150 MG
(Ranitidine HCl)
ZANTAC TABS 300 MG
(Ranitidine HCl)
Misc. Anti-Ulcer
NP
RX/OTC
NP
F
NP RX/OTC
RX/OTC
NP
NP
NP RX/OTC
NP
cimetidine hcl soln
NP
CARAFATE SUSP
F
cimetidine tabs 200 mg
NP RX/OTC
NP
cimetidine tabs 800 mg,
300 mg, 400 mg
CARAFATE TABS
(Sucralfate)
NP
famotidine susr
NP
famotidine tabs 20 mg
F
famotidine tabs 40 mg, 10
mg
F
sucralfate tabs
RX/OTC
Proton Pump Inhibitors
ACIPHEX SPRINKLE
CPSP
ACIPHEX TBEC
(Rabeprazole Sodium)
RX/OTC
AL
F
NP
NP QL(1 ea daily)
Nebraska Total Care Updated May 30, 2017
180
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
DEXILANT CPDR
NP
PRILOSEC PACK
NP
esomeprazole magnesium
cpdr 20 mg
esomeprazole magnesium
cpdr 40 mg
ESOMEPRAZOLE
STRONTIUM CPDR
NP QL(1 ea daily);
RX/OTC
NP QL(1 ea daily)
PROTONIX PACK
NP QL(2 ea daily)
PROTONIX TBEC
(Pantoprazole Sodium)
NP QL(2 ea daily)
NP
rabeprazole sodium tbec
NP QL(1 ea daily)
lansoprazole cpdr 15 mg
NP QL(1 ea daily);
RX/OTC
NP QL(1 ea daily)
Ulcer Drugs - Prostaglandins
CYTOTEC TABS
NP
(Misoprostol)
lansoprazole cpdr 30 mg
NEXIUM 24HR CLEAR
MINIS CPDR
NEXIUM 24HR CPDR
NEXIUM CPDR 20 MG
(Esomeprazole
Magnesium)
NEXIUM CPDR 40 MG
(Esomeprazole
Magnesium)
NP QL(1 ea daily);
RX/OTC
NP QL(1 ea daily);
RX/OTC
QL(1 ea daily);
NP RX/OTC
misoprostol tabs
Ulcer Therapy Combinations
amoxicillin-clarithromycin
NP
w/ lansoprazole misc
OMECLAMOX-PAK MISC
NP
QL(1 ea daily);
NP RX/OTC
omeprazole cpdr 20 mg
F
QL(4 ea daily)
omeprazole cpdr 40 mg
F
QL(2 ea daily)
omeprazole-sodium
bicarbonate caps 20mg1100mg
omeprazole-sodium
bicarbonate caps 40mg1100mg
omeprazole-sodium
bicarbonate pack
PREVPAC MISC
(Amoxicillin-Clarithromycin
w/ Lansoprazole)
pantoprazole sodium tbec
F
QL(2 ea daily)
PYLERA CAPS
NEXIUM PACK
omeprazole cpdr 10 mg
PREVACID 24HR CPDR
(Lansoprazole)
PREVACID CPDR 15 MG
(Lansoprazole)
PREVACID CPDR 30 MG
(Lansoprazole)
PREVACID SOLUTAB
TBDP
PRILOSEC CPDR 10 MG
(Omeprazole)
PRILOSEC CPDR 20 MG
(Omeprazole)
PRILOSEC CPDR 40 MG
(Omeprazole)
QL(1 ea daily)
NP
NP QL(1 ea daily)
F
QL(1 ea daily)
NP
NP
NP
F
NP QL(4 ea daily)
ZEGERID CAPS 20MG1100MG (OmeprazoleSodium Bicarbonate)
ZEGERID CAPS 40MG1100MG (OmeprazoleSodium Bicarbonate)
ZEGERID OTC CAPS
(Omeprazole-Sodium
Bicarbonate)
ZEGERID PACK
(Omeprazole-Sodium
Bicarbonate)
NP QL(2 ea daily)
URINARY ANTI-INFECTIVES - Drugs to Treat
Bladder/Kidney Infections
NP QL(1 ea daily);
RX/OTC
NP QL(1 ea daily);
RX/OTC
NP QL(1 ea daily)
NP QL(1 ea daily)
NP
Nebraska Total Care Updated May 30, 2017
181
F
QL(1 ea daily);
NP RX/OTC
QL(1 ea daily)
NP
QL(1 ea daily);
NP RX/OTC
NP
Urinary Anti-infective Combinations
Drug Name
methenamine-hyoscmethylene blue-sod phosphenyl sal tabs 40.8mg0.12mg-36.2mg-81.6mg10.8mg, 40.8mg-36.2mg0.12mg-81.6mg-10.8mg
Urinary Anti-infectives
FURADANTIN SUSP
(Nitrofurantoin)
MACROBID CAPS
(Nitrofurantoin Monohyd
Macro)
MACRODANTIN CAPS 50
MG, 100 MG
(Nitrofurantoin
Macrocrystal)
METHENAMINE
MANDELATE TABS 0.5
GM
methenamine mandelate
tabs 1 gm
nitrofurantoin macrocrystal
caps 50 mg, 100 mg
nitrofurantoin monohyd
macro caps
nitrofurantoin susp
Drug Requirements/
Tier Limits
F
NP
NP
Drug Name
oxybutynin chloride tabs
F
oxybutynin chloride tb24
F
OXYTROL FOR WOMEN
PTTW
NP RX/OTC
OXYTROL PTTW
NP RX/OTC
tolterodine tartrate cp24
NP
tolterodine tartrate tabs
NP
TOVIAZ TB24
NP
F
F
F
Drug Requirements/
Tier Limits
F
trospium chloride cp24
NP
trospium chloride tabs
NP
VESICARE TABS
F
Urinary Antispasmodics - Beta-3 Adrenergic
MYRBETRIQ TB24
NP
Urinary Antispasmodics - Cholinergic Agonists
F
F
URINARY ANTISPASMODICS - Drugs to Treat
Miscellaneous Bladder Spasms
Urinary Antispasmodic - Antimuscarinics
darifenacin hydrobromide
NP QL(1 ea daily)
tb24
DETROL LA CP24
NP
(Tolterodine Tartrate)
DETROL TABS
NP
(Tolterodine Tartrate)
DITROPAN XL TB24
NP
(Oxybutynin Chloride)
ENABLEX TB24
QL(1 ea daily)
NP
(Darifenacin
Hydrobromide)
GELNIQUE GEL
NP
GELNIQUE PUMP GEL
NP
oxybutynin chloride syrp
F
bethanechol chloride tabs
URECHOLINE TABS
(Bethanechol Chloride)
F
NP
Urinary Antispasmodics - Direct Muscle Relaxants
flavoxate hcl tabs
F
VACCINES
Bacterial Vaccines
BEXSERO SUSY
F
MENACTRA INJ
F
QL(1 ml per
350 days
retail,1 ml per
350 days mail);
AL
QL(1 ml per
350 days
retail,1 ml per
350 days mail);
AL
Nebraska Total Care Updated May 30, 2017
182
Drug Requirements/
Tier Limits
QL(1 ea per
350 days
MENOMUNE-A/C/Y/W-135
F retail,1 ea per
INJ
350 days mail);
AL
QL(1 ea per
350 days
F retail,1 ea per
MENVEO SOLR
350 days mail);
AL
F QL(0.5 ml per
PNEUMOVAX 23 INJ
fill retail); AL
PNEUMOVAX 23/1 DOSE
F QL(0.5 ml per
INJ
fill retail); AL
F QL(0.5 ml per
PREVNAR 13 SUSP
fill retail); AL
QL(1 ml per
350 days
F retail,1 ml per
TRUMENBA SUSY
350 days mail);
AL
Drug Name
Viral Vaccines
AFLURIA 2014-2015
SUSP
AFLURIA 2015-2016
SUSP
AFLURIA 2016-2017
SUSP
AFLURIA PF 2014-2015
SUSY
AFLURIA PF 2015-2016
SUSY
AFLURIA PF 2016-2017
SUSY
AFLURIA QUADRIVALENT
2016-2017 SUSY
FLUAD 2016-2017 SUSY
NP
NP
F
QL(0.5 ml per
fill retail); AL
NP
NP
F
QL(0.5 ml per
fill retail); AL
NP
F
QL(0.5 ml per
fill retail); AL
FLUARIX 2014-2015
NP
SUSY
FLUARIX QUADRIVALENT NP
2014-2015 SUSY
FLUARIX QUADRIVALENT NP
2015-2016 SUSY
FLUARIX QUADRIVALENT F QL(0.5 ml per
2016-2017 SUSY
fill retail); AL
Nebraska Total Care Updated May 30, 2017
183
Drug Name
FLUBLOK 2014-2015
SOLN
FLUBLOK 2015-2016
SOLN
FLUBLOK 2016-2017
SOLN
FLUCELVAX
QUADRIVALENT 20162017 SUSY
FLULAVAL 2014-2015
SUSP
FLULAVAL
QUADRIVALENT 20142015 SUSP
FLULAVAL
QUADRIVALENT 20142015 SUSY
FLULAVAL
QUADRIVALENT 20152016 SUSP
FLULAVAL
QUADRIVALENT 20162017 SUSP
FLULAVAL
QUADRIVALENT 20162017 SUSY
FLUVIRIN 2014-2015
SUSP
FLUVIRIN 2015-2016
SUSP
FLUVIRIN 2015-2016
SUSY
FLUVIRIN 2016-2017
SUSP
FLUVIRIN 2016-2017
SUSY
FLUZONE HIGH-DOSE PF
2014-2015 SUSY
FLUZONE HIGH-DOSE PF
2015-2016 SUSY
FLUZONE HIGH-DOSE PF
2016-2017 SUSY
FLUZONE INTRADERMAL
QUADRIVALENT 20152016 SUPN
Drug Requirements/
Tier Limits
NP
NP
F
F
QL(0.5 ml per
fill retail); AL
QL(0.5 ml per
fill retail); AL
NP
NP
NP
NP
F
QL(0.5 ml per
fill retail); AL
F
QL(0.5 ml per
fill retail); AL
NP
NP
NP
F
F
QL(0.5 ml per
fill retail); AL
QL(0.5 ml per
fill retail); AL
NP
NP
F
NP
QL(0.5 ml per
fill retail); AL
Drug Requirements/
Tier Limits
FLUZONE INTRADERMAL
QL(0.5 ml per
F fill retail); AL
QUADRIVALENT 20162017 SUPN
FLUZONE PF 2014-2015
NP
SUSY
FLUZONE
NP
QUADRIVALENT 20142015 SUSP
FLUZONE
NP
QUADRIVALENT 20142015 SUSY
FLUZONE
NP
QUADRIVALENT 20152016 SUSP
FLUZONE
NP
QUADRIVALENT 20152016 SUSY
FLUZONE
QL(0.5 ml per
F fill retail); AL
QUADRIVALENT 20162017 SUSP
FLUZONE
QL(0.5 ml per
F fill retail); AL
QUADRIVALENT 20162017 SUSY
FLUZONE SPLIT 2014NP
2015 SUSP
FLUZONE SPLIT 2015NP
2016 SUSP
QL(1 ea per
F 350 days
ZOSTAVAX SUSR
retail); AL
Drug Name
Drug Name
Drug Requirements/
Tier Limits
GYNE-LOTRIMIN 3 CREA
(Clotrimazole Vaginal)
GYNE-LOTRIMIN CREA
(Clotrimazole Vaginal)
METROGEL-VAGINAL
GEL (Metronidazole
Vaginal)
NP
NP
NP
metronidazole vaginal gel
NP
metronidazole vaginal gel
F
miconazole nitrate vaginal
crea 2 %
miconazole nitrate vaginal
kit
miconazole nitrate vaginal
supp
MONISTAT 3
COMBINATION PACK KIT
(Miconazole Nitrate
Vaginal)
MONISTAT 7 SIMPLY
CURE CREA (Miconazole
Nitrate Vaginal)
NUVESSA GEL
TERAZOL 3 CREA
(Terconazole Vaginal)
TERAZOL 7 CREA
(Terconazole Vaginal)
F
F
F
NP
NP
NP
NP
NP
VAGINAL PRODUCTS - Drugs to Treat Vaginal
Infections and Low Hormones
terconazole vaginal crea
F
Vaginal Anti-infectives
CLEOCIN CREA
(Clindamycin Phosphate
Vaginal)
terconazole vaginal supp
F
NP
Vaginal Estrogens
ESTRACE CREA
F
F
CLEOCIN SUPP
F
PREMARIN CREA
clindamycin phosphate
vaginal crea
F
Vaginal Progestins
CLINDESSE CREA
NP
CRINONE GEL
F
clotrimazole vaginal crea
F
VASOPRESSORS - Drugs to Treat Heart and
Circulation Conditions
GYNAZOLE-1 CREA
F
Anaphylaxis Therapy Agents
Nebraska Total Care Updated May 30, 2017
184
Drug Name
ADRENACLICK SOAJ 0.15
MG/0.15ML
ADRENACLICK SOAJ 0.3
MG/0.3ML
AUVI-Q SOAJ 0.3
MG/0.3ML
AUVI-Q SOAJ 0.3
MG/0.3ML, 0.15
MG/0.15ML
EPINEPHRINE SOAJ 0.15
MG/0.15ML
EPINEPHRINE SOAJ 0.15
MG/0.3ML
EPINEPHRINE SOAJ 0.3
MG/0.3ML
EPINEPHRINE SOAJ 0.3
MG/0.3ML
Drug Requirements/
Tier Limits
NP
DECARA CAPS
NP QL(4 ea per fill
retail)
NP QL(4 ea per fill
retail)
DRISDOL CAPS
(Ergocalciferol)
DRISDOL SOLN
(Ergocalciferol)
NP
F
NP
F
EPIPEN-JR 2-PAK SOAJ
F
QL(4 ea per fill
retail)
Limit 2 per
month;QL(0.06
7 ea daily)
Vasopressors
ergocalciferol soln
F
QL(2 ml daily)
MEPHYTON TABS
F
vitamin a caps 8000 unit,
10000 unit
F
vitamin a tabs 10000 unit
F
vitamin e caps 100 unit,
1000 unit, 400 unit, 200
unit
F
vitamin e soln
F
Water Soluble Vitamins
ascorbic acid chew 500
mg, 7.5mg-500mg, 250 mg,
500mg, 250mg
F
F
F
F
F
F
F
F
B-1 TABS
F
biotin caps 5 mg, 5000 mcg
F
biotin tabs 300 mcg
F
niacin cpcr
F
niacin tabs 50 mg, 500 mg
F
niacin tbcr 250 mg, 500 mg
F
QL(2 ea daily)
QL(0.267 ea
daily)
F
F
NP
Nebraska Total Care Updated May 30, 2017
185
NP QL(2 ml daily)
AL
ascorbic acid tabs 10mg500mg, 14mg-25mg500mg, 500 mg, 250 mg,
500mg, 37mg-500mg
ascorbic acid tabs 37mg1000mg, 1000mg, 1000 mg
ascorbic acid tbcr 1000 mg,
500mg, 500 mg
F
NP AL
F
ascorbic acid liqd
F
F
ergocalciferol caps
F
VITAMINS
Oil Soluble Vitamins
BETA CAROTENE CAPS
10000 UNIT
beta carotene caps 25000
unit
cholecalciferol caps 2000
unit, 1000 unit
cholecalciferol caps 5000
unit
cholecalciferol caps 50000
unit
cholecalciferol liqd 400
unit/ml
cholecalciferol tabs 400
unit, 1000 unit, 50000 unit,
2000 unit
D-VI-SOL LIQD
(Cholecalciferol)
Drug Requirements/
Tier Limits
PA
Limit 2 per
NP month;QL(0.06
7 ea daily)
F QL(4 ea per fill
retail)
EPIPEN 2-PAK SOAJ
midodrine hcl tabs
Drug Name
QL(3.34 ea
daily)
Drug Name
Drug Requirements/
Tier Limits
niacinamide tabs 500 mg
F
pyridoxine hcl tabs 100 mg,
25 mg, 50 mg
F
riboflavin tabs 100 mg
F
SLO-NIACIN TBCR 500
MG (Niacin)
thiamine hcl tabs 100 mg,
50 mg
QL(3.34 ea
daily)
NP
F
thiamine mononitrate tabs
F
VITAMIN C SYRP
F
QL(3.34 ea
daily)
QL(3.34 ea
daily)
Nebraska Total Care Updated May 30, 2017
186
Index
1ST CHOICE LANCETS
SUPERTHIN
94
1ST CHOICE LANCETS THIN
94
1ST CHOICE LANCETS
ULTRATHIN
94
1ST TIER UNIFINE
PENTIPS/MINI/31GX5MM 111
1ST TIER UNIFINE
PENTIPS29GX12MM
112
1ST TIER UNIFINE
PENTIPS31GX6MM
112
1ST TIER UNIFINE
PENTIPS31GX8MM
112
1ST TIER UNIFINE
PENTIPS32GX4MM
112
1ST TIER UNIFINE
PENTIPSPLUS 31GX8MM 112
1ST TIER UNIFINE
PENTIPSPLUS 32GX4MM 112
1ST TIER UNIFINE
PENTIPSPLUS/MINI/31GX5MM
112
1ST TIER UNIFINE
PENTIPSPLUS/ORIGINAL/29GX
12MM
112
1ST TIER UNIFINE
PENTIPSPLUS/ULTRA
SHORT/31GX6MM
112
1ST TIER UNILET
COMFORTOUCH LANCETS
28G
94
1ST TIER UNILET
COMFORTOUCH LANCETS
30G
94
2ND SKIN MOIST BURN
PADS1.5"X2"
68
2ND SKIN MOIST BURN
PADS2"X3"
68
2ND SKIN MOIST BURN
PADS3"X4"
68
2ND SKIN MOIST DRESSING
KIT
68
2ND SKIN MOIST GEL PADS
1"X1"
68
2ND SKIN MOIST GEL PADS 3"
ROUND
68
8-MOP
55
A + D PERSONAL CARE
LOTION
59
A+D FIRST AID
66
abacavir sulfate
39
abacavir sulfate-lamivudine 39
abacavir sulfate-lamivudinezidovudine
39
ABILIFY
39
ABILIFY 2 MG
39
Index 1
ABILIFY 30 MG, 20 MG
39
ABILIFY 5 MG, 15 MG, 10
MG
39
ABILIFY DISCMELT
39
ABILIFY MAINTENA
39
ABREVA
55
ABSORBASE
66
ABSORICA 40 MG, 20 MG, 10
MG
49
ABSTRAL
7
ACANYA
49
acarbose
22
ACCOLATE
14
ACCU-CHEK ACTIVE
GLUCOSECONTROL
SOLUTION
94
ACCU-CHEK ACTIVE
STRIPS
76
ACCU-CHEK AVIVA
76
ACCU-CHEK AVIVA PLUS76
ACCU-CHEK COMPACT
PLUS
76
ACCU-CHEK COMPACT PLUS
CLEAR CONTROL SOLUTION
(2 LEVELS)
94
ACCU-CHEK COMPACT TEST
DRUM
76
ACCU-CHEK FASTCLIX
LANCETS
94
ACCU-CHEK MULTICLIX
LANCETS
94
ACCU-CHEK SAFE-T-PRO
LANCETS
94
ACCU-CHEK SAFE-T-PRO
PLUSLANCETS
94
ACCU-CHEK SMARTVIEW
CONTROL
94
ACCU-CHEK SMARTVIEW
STRIPS
76
ACCU-CHEK SOFT TOUCH
LANCETS
94
ACCU-CHEK SOFTCLIX
LANCETS
94
ACCUPRIL
30
ACCURETIC
31
ACCUTREND GLUCOSE 76
ACCUTREND GLUCOSE
CONTROL
94
ACE AEROSOL CLOUD
ENHANCER
139
acebutolol hcl
42
ACEON
30
acetaminophen
6
acetaminophen 80 mg
6
acetaminophen w/ codeine
9
acetaminophen-caffdihydrocod
9
acetazolamide
82
acetic acid (otic)
175
ACETIC ACID/ALUMINUM
ACETATE
175
acetylcysteine
49
ACIPHEX
180
ACIPHEX SPRINKLE
180
acitretin
55
ACLOVATE
55
ACNE MEDICATION 10
49
ACNE MEDICATION 5
49
ACTEMRA
4
ACTI-LANCE LANCETS
28G
94
ACTI-LANCE LITE SAFETY
LANCETS 28G
94
ACTI-LANCE SPECIAL SAFETY
LANCETS 17G
94
ACTI-LANCE SPECIAL
SAFETYLANCETS 17G
94
ACTI-LANCE UNIVERSAL
SAFETY LANCETS 23G
94
ACTICOAT 7 2"X2"
68
ACTICOAT 7 4"X5"
68
ACTICOAT ABSORBENT
ANTIMICROBIAL DRESSING
4"X5"
68
ACTICOAT ANTIMICROBIAL
DRESSING 2"X2"
68
ACTICOAT ANTIMICROBIAL
DRESSING 4"X4"
68
ACTICOAT FLEX 3 BARRIER
DRESSING 4"'X4"
68
ACTIFLOVIT EAR HEALTH167
ACTIGALL
85
ACTIQ
7
ACTIVE 1ST BLOOD
LANCETS30G/EASY TWIST
CAP
94
ACTIVE OB
160
ACTIVELLA
84
ACTIVITY POUCH
139
ACTONEL 150 MG
83
ACTONEL 30 MG
83
ACTONEL 35 MG
83
ACTONEL 5 MG
83
ACTOPLUS MET
22
ACTOPLUS MET XR
22
ACTOS
24
ACULAR
174
ACULAR LS
174
ACURA BLOOD GLUCOSE
TESTSTRIPS
76
ACURA CONTROL SOLUTION
HIGH
94
ACURA CONTROL SOLUTION
LOW
94
ACURA CONTROL SOLUTION
NORMAL
94
ACUVAIL
174
acyclovir
42
acyclovir topical
55
ACZONE
49
ADALAT CC
43
adapalene
49
ADAPALENE
49
adapalene 0.1 %
49
adapalene 0.3 %
49
ADAPTIC NON-ADHERING
DRESSING 3" X 3"
68
ADASUVE
38
ADCIRCA
44
ADDERALL 1.25MG-1.25MG1.25MG-1.25MG
1
ADDERALL 1.875MG-1.875MG1.875MG-1.875MG
1
ADDERALL 2.5MG-2.5MG2.5MG-2.5MG
1
ADDERALL 3.125MG-3.125MG3.125MG-3.125MG
1
ADDERALL 3.75MG-3.75MG3.75MG-3.75MG
1
ADDERALL 5MG-5MG-5MG5MG
1
ADDERALL 7.5MG-7.5MG7.5MG-7.5MG
1
ADDERALL XR 1.25MG-1.25MG1.25MG-1.25MG
1
ADDERALL XR 2.5MG-2.5MG2.5MG-2.5MG
1
ADDERALL XR 3.75MG-3.75MG3.75MG-3.75MG
1
ADDERALL XR 5MG-5MG-5MG5MG
1
ADDERALL XR 6.25MG-6.25MG6.25MG-6.25MG
1
ADDERALL XR 7.5MG-7.5MG7.5MG-7.5MG
1
adefovir dipivoxil
41
ADEMPAS
44
ADJUSTABLE LANCING
DEVICE
94
ADLYXIN
24
ADLYXIN STARTER PACK 24
ADOXA
178
ADOXA PAK 1/100
178
ADOXA PAK 1/150
178
ADOXA PAK 2/100
178
ADRENACLICK 0.15
MG/0.15ML
185
ADRENACLICK 0.3
MG/0.3ML
185
ADRENAL C FORMULA 150
ADRENAL STRESS
CALM
166
ADULT AEROSOL MASK139
ADULT MASK
139
ADULT MASK LARGE 139
ADULT ONE DAILY
GUMMIES
151
ADVAIR DISKUS
15
ADVAIR HFA
15
ADVANCE INTUITION
CONTROL SOLUTION
94
ADVANCE INTUITION TEST
STRIPS
76
ADVANCE MICRO-DRAW
CONTROL LEVEL 1-2
94
ADVANCE MICRO-DRAW
NORMAL CONTROL
94
ADVANCE MICRO-DRAW
TEST STRIPS
76
ADVANCED C PLUS
150
ADVANCED
CALCIUM/VITAMIND/MAGNES
IUM
146
ADVANCED COLLAGEN 166
ADVANCED DIABETIC
MULTIVITAMIN
FORMULA
151
ADVIL
4
ADVIL MIGRAINE
4
ADVOCATE CONTROL
SOLUTIONHIGH
94
ADVOCATE CONTROL
SOLUTIONLOW
94
ADVOCATE INSULIN PEN
NEEDLES 29GX12.7MM 112
ADVOCATE INSULIN PEN
NEEDLES 31GX5MM
112
ADVOCATE INSULIN PEN
NEEDLES 31GX8MM
112
ADVOCATE INSULIN
SYRINGE/U100/0.3ML/29GX1/2"
112
ADVOCATE INSULIN
SYRINGE/U100/0.3ML/30GX5/16"
112
ADVOCATE INSULIN
SYRINGE/U100/0.3ML/31GX5/16"
112
ADVOCATE INSULIN
SYRINGE/U100/0.5ML/29GX1/2"
112
ADVOCATE INSULIN
SYRINGE/U100/0.5ML/30GX5/16"
112
ADVOCATE INSULIN
SYRINGE/U100/0.5ML/31GX5/16"
112
ADVOCATE INSULIN
SYRINGE/U-100/1ML/29GX1/2"
112
ADVOCATE INSULIN
SYRINGE/U-100/1ML/30GX5/16"
112
ADVOCATE INSULIN
SYRINGE/U-100/1ML/31GX5/16"
112
ADVOCATE LANCETS
94
ADVOCATE LANCETS 30G 94
ADVOCATE LANCING
DEVICE
94
ADVOCATE RAPID-SAFE
LANCING DEVICE
94
ADVOCATE REDI-CODE
76
ADVOCATE REDI-CODE+
CONTROL SOLUTION
HIGH
94
ADVOCATE REDI-CODE+
CONTROL SOLUTION LOW94
ADVOCATE REDI-CODE+
TESTSTRIPS
76
ADVOCATE SAFETY
LANCETS
95
ADVOCATE SAFETY LANCETS
26G
95
ADVOCATE TEST STRIPS 76
ADZENYS XR-ODT
1
AEROCHAMBER MINI
AEROSOLCHAMBER
139
AEROCHAMBER MV
139
AEROCHAMBER PLUS FLOW
VU
139
AEROCHAMBER PLUS FLOWVU
139
AEROCHAMBER PLUS FLOWVU/LARGE MASK
139
AEROCHAMBER PLUS FLOWVU/MASK
139
AEROCHAMBER PLUS FLOWVU/MEDIUM MASK
139
AEROCHAMBER PLUS FLOWVU/SMALL MASK
139
Index 2
AEROCHAMBER Z-STAT PLUS
VALVED HOLDING CHAMBER
W/FLOW VU
139
AEROCHAMBER Z-STAT
PLUS/FLOWSIGNAL
139
AEROCHAMBER Z-STAT
PLUS/LARGE MASK
139
AEROCHAMBER Z-STAT
PLUS/MEDIUM MASK
139
AEROCHAMBER Z-STAT
PLUS/SMALL MASK
139
AEROCHAMBER/FLOWSIGNAL
139
AEROSPAN
14
AEROTRACH PLUS
139
AEROVENT PLUS HOLDING
CHAMBER/COLLAPSIBLE 139
AFINITOR
34
AFINITOR DISPERZ
34
AFLURIA 2014-2015
183
AFLURIA 2015-2016
183
AFLURIA 2016-2017
183
AFLURIA PF 2014-2015
183
AFLURIA PF 2015-2016
183
AFLURIA PF 2016-2017
183
AFLURIA QUADRIVALENT
2016-2017
183
AFREZZA
24
AFRIN
169
AFRIN 12 HOUR
169
AFRIN ALL NIGHT
NODRIP
169
AFRIN NASAL SPRAY
169
AFRIN NODRIP EXTRA
MOISTURIZING
169
AFRIN NODRIP ORIGINAL 169
AFRIN NODRIP SEVERE
CONGESTION
169
AFRIN NODRIP SINUS
169
AFRIN SINUS
169
AGAMATRIX AMP NO CODE
TEST STRIPS
76
AGAMATRIX CONTROL
HIGH
95
AGAMATRIX CONTROL
NORMAL
95
AGAMATRIX CONTROL
NORMAL& HIGH
95
AGAMATRIX JAZZ TEST
STRIPS
76
AGAMATRIX KEYNOTE TEST
STRIPS
76
AGAMATRIX PRESTO TEST
STRIPS
76
Index 3
AGAMATRIX ULTRA-THIN
LANCETS 33G
95
AGGRENOX
88
AGIE-GRX
68
AIMSCO LUBRICATED
92
AIRBORNE
151
AIRS PEDIATRIC AEROSOL
MASK
140
AKYNZEO
26
ALBOLENE
59
albuterol sulfate
15
albuterol sulfate 0.083 %, 0.5
%
15
albuterol sulfate 1.25 mg/3ml,
0.63 mg/3ml
15
alclometasone
dipropionate
55
ALCOH-GLOVE CONTOURED
WIPE
110
ALCOH-WIPE 12" X 12" 110
ALCOHOL PADS
110
ALCOHOL PREP PADS 110
ALCOHOL PREPS
111
ALCOHOL SWABS
111
ALCOHOL SWABSTICK 111
ALCOHOL WIPES
111
ALDACTAZIDE 25MG25MG
82
ALDACTONE
82
ALDARA
65
ALECENSA
34
ALENDRONATE SODIUM 83
alendronate sodium 10 mg, 5
mg
83
alendronate sodium 35 mg, 70
mg
83
ALENDRONATE SODIUM 40
MG
83
ALEVAZOL
52
ALEVE
4
ALEVE ARTHRITIS
4
alfuzosin hcl
87
ALINIA
12
ALIVE MENS ENERGY 151
ALIVE ONCE DAILY WOMENS
50+ ULTRA POTENCY 151
ALIVE ONCE DAILY WOMENS
ULTRA POTENCY
151
ALIVE WOMENS 50+
151
ALIVE WOMENS
ENERGY
151
ALIVE WOMENS GUMMY
VITAMINS
151
ALKERAN
33
ALL FLOW 1000 PULMONARY
FUNCTION FILTER
140
ALLEGRA ALLERGY 180
MG
28
ALLEGRA ALLERGY 60 MG 28
ALLEGRA ALLERGY
CHILDRENS
28
ALLERWELL ALLERGY
FORMULA
166
ALLEVYN ADHESIVE
68
ALLEVYN AG ADHESIVE 68
ALLEVYN AG GENTLE
BORDER
69
ALLEVYN AG NONADHESIVE
69
ALLEVYN AG SACRUM
69
ALLEVYN COMPRESSION 69
ALLEVYN GENTLE
69
ALLEVYN GENTLE
BORDER
69
ALLEVYN GENTLE BORDER
HEEL
69
ALLEVYN GENTLE BORDER
LITE
69
ALLEVYN GENTLE BORDER
MULTISITE
69
ALLEVYN GENTLE BORDER
SACRUM
69
ALLEVYN HEEL
69
ALLEVYN LIFE
69
ALLEVYN LIFE HEEL
69
ALLEVYN LIFE SACRUM 69
ALLEVYN NON-ADHESIVE 69
ALLEVYN PLUS ADHESIVE 69
ALLEVYN PLUS CAVITY
69
ALLEVYN PLUS SACRUM 69
ALLEVYN SACRUM
69
ALLEVYN TRACHEOSTOMY 31/2"X3-1/2"
69
allopurinol
87
almotriptan malate
144
ALOCRIL
174
ALOE AFTERSUN LOTION 59
ALOE VESTA ANTIFUNGAL53
ALOE VESTA CLEAR
ANTIFUNGAL
53
ALOE VESTA PROTECTIVE66
ALOGLIPTIN
23
ALOGLIPTIN/METFORMIN
HCL
22
ALOGLIPTIN/PIOGLITAZONE
22
ALOMIDE
174
ALORA
84
alosetron hcl
86
ALPHAGAN P 0.1 %
172
ALPHAGAN P 0.15 %
172
alprazolam
13
ALPRAZOLAM INTENSOL 13
ALREX
173
ALTABAX
52
ALTACE
30
ALTERNATE SITE LANCING
DEVICE
95
ALTOPREV
29
alum & mag hydrox-simethicone
200mg/5ml-200mg/5ml20mg/5ml-20mg/5ml-200mg/5ml200mg/5ml, 200mg/5ml20mg/5ml-200mg/5ml
12
alum & mag hydrox-simethicone
200mg/5ml-20mg/5ml-200mg/5ml
12
alum & mag hydrox-simethicone
400mg/5ml-400mg/5ml40mg/5ml-40mg/5ml-400mg/5ml400mg/5ml, 400mg/5ml40mg/5ml-400mg/5ml
12
alum & mag hydrox-simethicone
400mg/5ml-40mg/5ml-400mg/5ml
12
ALVESCO
14
amantadine hcl
36
AMARYL
25
AMBIEN
90
AMBIEN CR
89
AMCINONIDE
55
AMERGE
144
AMERIDERM PERISHIELD 66
AMERIGEL HYDROGEL
SATURATED GAUZE
DRESSING 2" X 2"
69
AMICAR 500 MG
89
amiloride &
hydrochlorothiazide
82
amiloride hcl
82
aminocaproic acid
89
aminocaproic acid 500 mg 89
amiodarone hcl 200 mg
14
AMITIZA
85
amitriptyline hcl
21
AMLACTIN CERAPEUTIC 59
AMLACTIN ULTRA
59
amlodipine besylate
43
amlodipine besylateatorvastatin calcium
44
amlodipine besylate-benazepril
hcl
31
amlodipine besylate-olmesartan
medoxomil
31
amlodipine besylatevalsartan
31
amlodipine-valsartanhydrochlorothiazide
31
AMOXAPINE
21
amoxicillin
175
AMOXICILLIN
175
amoxicillin & pot
clavulanate
176
AMOXICILLIN ER
175
amoxicillin-clarithromycin w/
lansoprazole
181
AMOXICILLIN/CLAVULANATE
POTASSIUM
176
amphetaminedextroamphetamine 1.25mg1.25mg-1.25mg-1.25mg
1
amphetaminedextroamphetamine 1.875mg1.875mg-1.875mg-1.875mg 1
amphetaminedextroamphetamine 2.5mg2.5mg-2.5mg-2.5mg
1
amphetaminedextroamphetamine 3.125mg3.125mg-3.125mg-3.125mg 2
amphetaminedextroamphetamine 3.75mg3.75mg-3.75mg-3.75mg
1
amphetaminedextroamphetamine 5mg-5mg5mg-5mg
1
amphetaminedextroamphetamine 6.25mg6.25mg-6.25mg-6.25mg
1
amphetaminedextroamphetamine 7.5mg7.5mg-7.5mg-7.5mg
1
ampicillin
175
AMPICILLIN
175
AMPYRA
177
AMRIX
167
ANAFRANIL
21
ANALPRAM-HC
11
ANAPROX DS
4
ANASPAZ
179
anastrozole
34
ANBESOL MAXIMUM
STRENGTH
148
ANCOBON
26
ANDRODERM
10
ANDROGEL 20.25 MG/1.25GM,
40.5 MG/2.5GM
10
ANDROGEL 50 MG/5GM, 25
MG/2.5GM
10
ANDROGEL PUMP 1 %
10
ANDROGEL PUMP 1.62 % 11
ANORO ELLIPTA
15
ANTABUSE 250 MG
176
ANTARA
29
ANTI-STICK INSULIN
SYRINGE/U-100/0.5ML/28G X
1/2"
112
ANTI-STICK INSULIN
SYRINGE/U-100/0.5ML/29G X
1/2"
112
ANTI-STICK INSULIN
SYRINGE/U-100/1ML/29G X
1/2"
112
ANTIOXIDANT FORMULA
SG
151
ANTIOXIDANT FORTE
151
antipyrine-benzocaine
175
ANUSOL-HC
11
ANZEMET
26
AP-ZEL
151
APATATE FORTE
151
APEXICON E
55
APIDRA
24
APIDRA SOLOSTAR
24
APLENZIN
20
apraclonidine hcl
172
aprepitant
26
APRISO
86
APTENSIO XR
2
APTIOM
17
APTIVUS
39
AQUA GLYCOLIC FACE
CREAM
59
AQUA GLYCOLIC HAND &
BODYLOTION
59
AQUA LACTEN
59
AQUA LANCE ADJUSTABLE
LANCING DEVICE
95
AQUACEL
EXTRA/HYDROFIBER
69
AQUACEL FOAM 3.2"X3.2" 69
AQUACEL FOAM 4"X4"
69
Index 4
AQUACEL FOAM 5"X5"
69
AQUACEL FOAM 6"X6"
69
AQUACEL FOAM 6"X8"
69
AQUACEL FOAM 7"X7"
69
AQUACEL FOAM 8"X5.5" 69
AQUACEL FOAM 8"X7"
69
AQUADEKS
151
AQUADERM
59
AQUADERM
TREATMENT/MOISTURIZER
59
AQUAMED
59
AQUAPHILIC
59
AQUAPHOR
59
AQUAPHOR ADVANCED
THERAPY
59
AQUAPHOR LIP REPAIR 66
AQUASITE IMPREGNATED
DRESSING 2"X2"
69
AQUASITE IMPREGNATED
DRESSING 4"X4"
69
AQUASITE IMPREGNATED
DRESSING 4"X8"
69
AQUASITE IMPREGNATED
GAUZE 2"X2"
69
AQUASITE IMPREGNATED
GAUZE 4"X4"
69
AQUASITE SHEET DRESSING
4"X4"
69
AQUORAL
149
ARAVA
6
ARCALYST
4
ARCAPTA NEOHALER
15
ARGLAES FILM 2-3/8" X 31/8"
69
ARGLAES FILM 3" X 14"
69
ARGLAES FILM 4" X 4-3/4" 69
ARGLAES FILM 4-3/4" X 10"69
ARGLAES ISLAND 2-3/8" X 31/8"
69
ARGLAES ISLAND 4" X 43/4"
70
ARGLAES ISLAND 4-3/4" X
10"
70
ARIAL CHAMBER
140
ARICEPT
176
ARIMIDEX
34
aripiprazole
39
aripiprazole 10 mg, 15 mg, 5
mg
39
aripiprazole 2 mg
39
aripiprazole 20 mg, 30 mg 39
Index 5
ARISTADA
39
ARIXTRA
16
armodafinil
2
ARMOUR THYROID 300 MG,
120 MG, 240 MG, 180
MG
179
ARMOUR THYROID 90 MG, 30
MG, 60 MG, 15 MG
179
ARNUITY ELLIPTA
15
AROMASIN
34
ARTHRITIS PAIN
RELIEVING
66
ARTHROTEC 50
4
ARTHROTEC 75
4
artificial tear ointment
170
artificial tear solution
170
ARTIFICIAL TEARS
170
ASACOL HD
86
ASCOCID-1000
150
ASCOCID-500-D
150
ascorbic acid
185
ascorbic acid 1000 mg, 500mg,
500 mg
185
ascorbic acid 10mg-500mg,
14mg-25mg-500mg, 500 mg,
250 mg, 500mg, 37mg500mg
185
ascorbic acid 37mg-1000mg,
1000mg, 1000 mg
185
ascorbic acid 500 mg, 7.5mg500mg, 250 mg, 500mg,
250mg
185
ASMANEX HFA
15
ASMANEX TWISTHALER 120
METERED DOSES
15
ASMANEX TWISTHALER 14
METERED DOSES
15
ASMANEX TWISTHALER 30
METERED DOSES
15
ASMANEX TWISTHALER 60
METERED DOSES
15
ASMANEX TWISTHALER 7
METERED DOSES
15
ASPERCREME/ALOE
65
aspirin
7
aspirin 300 mg
7
aspirin 324 mg, 81 mg, 325
mg
7
aspirin 325 mg
7
aspirin 600 mg
7
aspirin buffered (cal carb-mag
carb-mag oxide)
7
ASPIRIN LOW DOSE
7
aspirin-acetaminophencaffeine
6
ASPIRIN-CAFFEINEDIHYDROCODEINE
9
aspirin-dipyridamole
88
ASSURE 3 CONTROL LEVEL
1/2
95
ASSURE 3 TEST STRIPS 76
ASSURE 4 CONTROL LEVEL
1/2
95
ASSURE 4 TEST STRIPS 76
ASSURE COMFORT LANCETS
ULTRA THIN 28G
95
ASSURE COMFORT LANCETS
ULTRA THIN 30G
95
ASSURE DOSE NORMAL
CONTROL
95
ASSURE DOSE NORMAL/HIGH
CONTROL
95
ASSURE HAEMOLANCE PLUS
HIGH FLOW 18G
95
ASSURE HAEMOLANCE PLUS
LOW FLOW 25G
95
ASSURE HAEMOLANCE PLUS
MICRO FLOW 28G
95
ASSURE HAEMOLANCE PLUS
NORMAL FLOW 21G
95
ASSURE HAEMOLANCE PLUS
PEDIATRIC BLADE
95
ASSURE ID INSULIN
SAFETYSYRINGE/U100/0.5ML/29G X 1/2"
112
ASSURE ID INSULIN
SAFETYSYRINGE/U100/1ML/29G X 1/2"
112
ASSURE II
76
ASSURE II CHECK STRIP 76
ASSURE II CONTROL LEVEL
1
95
ASSURE II CONTROL LEVEL
1/2
95
ASSURE II TEST STRIPS 76
ASSURE LANCE LANCETS 95
ASSURE LANCE LANCETS
21G
95
ASSURE LANCE PLUS
SAFETYLANCETS 25G
95
ASSURE LANCE PLUS
SAFETYLANCETS 30G
95
ASSURE LANCETS
95
ASSURE PLATINUM TEST
STRIPS
76
ASSURE PRISM CONTROL
LEVEL 1/2
95
ASSURE PRISM MULTI TEST
STRIPS
76
ASSURE PRO CONTROL
LEVEL1/2
95
ASSURE PRO TEST
STRIPS
76
ASTEPRO
168
AT LAST CONTROL
SOLUTION
95
AT LAST LANCETS
95
AT LAST TEST STRIPS
76
ATACAND
31
ATACAND HCT
31
ATELVIA
83
atenolol
42
atenolol & chlorthalidone
31
ATIVAN
13
ATIVAN 2 MG/ML
13
ATLAS COLORED
LUBRICATEDCONDOM
92
ATLAS LUBRICATED
CONDOM
92
ATLAS LUBRICATED
CONDOM/SPERMICIDE
92
atorvastatin calcium
30
ATRALIN
49
ATRIPLA
39
atropine sulfate
(ophthalmic)
171
ATROPINE SULFATE 1 % 171
ATROVENT
168
ATROVENT HFA
14
AUBAGIO
177
AUGMENTIN
176
AUGMENTIN 125MG/5ML31.25MG/5ML
176
AUGMENTIN 250MG/5ML62.5MG/5ML
176
AUGMENTIN ES-600
176
AUGMENTIN XR
176
AURORA LANCET SUPER
THIN30G
95
AURORA LANCET THIN
23G
95
AURORA PEN NEEDLES
29GX12MM
112
AURORA PEN NEEDLES 31G
X6MM
112
AURORA PEN NEEDLES 31G
X8MM
112
AURORA UNIFINE
PENTIPS/32GX5/32"
112
AURORA UNIFINE
PENTIPS/MINI/31GX3/16" 112
AURYXIA
86
AUTO-LANCET
95
AUTO-LANCET MINI
95
AUTOLET IMPRESSION
LANCING DEVICE
95
AUTOLET LANCING
DEVICE
95
AUTOLET MINI
95
AUTOLET PLUS
95
AUVI-Q 0.3 MG/0.3ML 185
AUVI-Q 0.3 MG/0.3ML, 0.15
MG/0.15ML
185
AVALIDE
31
AVANDIA
24
AVAPRO
31
AVAR LS CLEANSER
49
AVAR-E LS
49
AVEENO ACTIVE NATURALS
DAILY MOISTURIZING BODY
YOGURT
59
AVEENO ACTIVE NATURALS
DAILY MOISTURIZING BODY
YOGURT/APRICO
59
AVEENO ACTIVE NATURALS
SKIN RELIEF HEALING 59
AVEENO ACTIVE NATURALS
SKIN RELIEF MOISTURE
REPAIR
59
AVEENO DAILY
MOISTURIZINGSPF 15 59
AVEENO INTENSE RELIEF
HAND
59
AVEENO POSITIVELY
AGELESS LIFT & FIRM
EYE
59
AVEENO POSITIVELY
AGELESS NIGHT
59
AVEENO POSITIVELY
AGELESSFIRMING BODY59
AVEENO POSITIVELY
AGELESSSKIN
STRENGTHENING BODY
CREAM
59
AVEENO POSITIVELY
AGELESSSKIN
STRENGTHENING HAND
CREAM
59
AVEENO POSITIVELY
NOURISHING 24-HOUR
ULTRA-HYDRATING
59
AVEENO POSITIVELY
NOURISHING
ENERGIZING
60
AVEENO POSITIVELY
RADIANTINTENSIVE NIGHT
CREAM
60
AVEENO SMART ESSENTIALS
NIGHTTIME MOISTURE
INFUSION
60
AVEENO STRESS RELIEF
MOISTURIZING
60
AVELOX
85
AVELOX ABC PACK
85
AVINZA
7
AVODART
87
AVONEX
177
AVONEX PEN
177
AXERT
144
AXIRON
11
AYGESTIN
176
AYR NASAL DROPS
168
AZASAN
147
AZASITE
172
azathioprine
147
azelastine hcl
168
azelastine hcl (ophth)
174
AZELEX
49
AZILECT
36
AZITHROMYCIN
91
azithromycin
91
AZOLEN TINCTURE
53
AZOPT
174
AZOR
31
AZULFIDINE
86
AZULFIDINE EN-TABS
86
b complex w/ c
149
B-1
185
B-100 COMPLEX
149
B-12 DOTS
88
b-complex vitamins
149
b-complex w/ c & calcium 149
b-complex w/ c & e + zn
149
b-complex w/ c & folic acid 149
Index 6
b-complex w/ c & folic acid 5mg25mg-20mg-15mcg-100mg400mcg-30mcg-2mg-150mg,
50mg-50mg-50mg-50mg-50mcg400mcg-50mcg-50mg-500mg,
30unit-10mg-100mg-10mg-20mg12mcg-400mcg-45mcg-5mg500mg, 18mg-5mg-45mg-10mg10mcg-400mcg-5mg-250mg,
25mg-5mg-10mg-250mcg-5mg400mcg-300mcg-5mg-120mg,
15mg-50mg-10.2mg-10mg400mcg-300mcg-5mg-300mg,
30unit-100mg-10mg-1mg-20mg1mg-1mg-10mg-12mcg-400mcg45mcg-5mg-500mg, 5mg-25mg50mg-5mg-37.5mcg-200mcg15mcg-5mg-150mg, 100mg100mg-5.5mg-25mg-20mg30mcg-400mcg-45mcg-5mg180mg, 50mg-50mg-50mg-50mg50mcg-50mg-400mcg-50mcg500mg, 25mg-5.5mg-25mg20mg-100mcg-400mcg1000mcg-5mg-60mg, 15mg50mg-10.2mg-10mg-6mcg400mcg-5mg-300mg, 30unit10mg-20mg-100mg-10mg12mcg-400mcg-45mcg-5mg500mg, 15mg-100mg-15mg18mg-5mcg-0.5mg-4mg-500mg,
100mg-5.5mg-25mg-20mg15mcg-400mcg-30mcg-2mg150mg
150
b-complex w/ folic acid
150
b-complex w/ minerals
150
b-complex w/biotin & folic
acid
150
B-D INSULIN SYRINGE
ULTRAFINE II/0.3ML/31G X
5/16"
113
B-D INSULIN SYRINGE
ULTRAFINE II/0.5ML/31G X
5/16"
113
B-D INSULIN SYRINGE
ULTRAFINE II/1ML/31G X
5/16"
113
B-D INSULIN SYRINGE
ULTRAFINE/0.3ML/30G X
1/2"
113
B-D INSULIN SYRINGE
ULTRAFINE/0.5ML/30G X
1/2"
113
B-D INSULIN SYRINGE
ULTRAFINE/1ML/30G X
1/2"
113
BACIGUENT
52
Index 7
BACITRACIN
172
bacitracin (topical)
52
bacitracin zinc
52
bacitracin-poly-neomycin-hc
173
bacitracin-polymyxin b
52
bacitracin-polymyxin b
(ophth)
172
baclofen
167
BACMIN
151
BACTRIM
12
BACTRIM DS
12
BACTROBAN
52
BAL-CARE DHA
160
balsalazide disodium
86
BANZEL
17
BARACLUDE
41
BARIATRIC FUSION
151
BASAGLAR KWIKPEN
24
BASIC AM
151
BASIC PM
151
BASIS FACIAL
MOISTURIZER
66
BASIS OVERNIGHT
66
BASLE
60
BAYER BREEZE 2 HIGH
CONTROL
95
BAYER BREEZE 2 LOW
CONTROL
95
BAYER BREEZE 2 NORMAL
CONTROL
96
BAYER CONTOUR BLOOD
GLUCOSE TEST STRIPS 76
BAYER CONTOUR HIGH
CONTROL
96
BAYER CONTOUR LOW
CONTROL
96
BAYER CONTOUR NEXT
BLOODGLUCOSE TEST 76
BAYER CONTOUR NEXT
CONTROL LEVEL 1
96
BAYER CONTOUR NEXT
CONTROL LEVEL 2
96
BAYER CONTOUR NORMAL
CONTROL
96
BAYER MICROLET 2
LANCING DEVICE
96
BAYER MICROLET
LANCETS
96
BAZA CLEANSE &
PROTECT
66
BD LO-DOSE INSULIN
SYRINGE MICROFINE
IV/0.5ML/28G X 1/2"
113
BD AUTOSHIELD 29G X
5/16"
113
BD INSULIN SYRINGE LUERLOK/U-100/1ML
113
BD INSULIN SYRINGE
MICROFINE IV/U100/0.3ML/28G X 1/2"
113
BD INSULIN SYRINGE
MICROFINE IV/U100/0.5ML/28G X 1/2"
113
BD INSULIN SYRINGE
MICROFINE IV/U-100/1ML/27G
X 5/8"
113
BD INSULIN SYRINGE
MICROFINE IV/U-100/1ML/28G
X 1/2"
113
BD INSULIN SYRINGE
MICROFINE/U-100/0.3ML/28G X
1/2"
113
BD INSULIN SYRINGE
MICROFINE/U-100/0.5ML/28G X
1/2"
113
BD INSULIN SYRINGE
MICROFINE/U-100/1ML/27G X
5/8"
113
BD INSULIN SYRINGE
MICROFINE/U-100/1ML/28G X
1/2"
113
BD INSULIN SYRINGE
SAFETYGLIDE/0.5ML/29G X
1/2"
113
BD INSULIN SYRINGE
SAFETYGLIDE/1ML/29G X
1/2"
113
BD INSULIN SYRINGE
SAFETYGLIDE/U100/0.3ML/31G X 5/16"
113
BD INSULIN SYRINGE SLIP
TIP/U-100/1ML
113
BD INSULIN SYRINGE
ULTRAFINE HALFUNIT/0.3ML/31G X 5/16" 113
BD INSULIN SYRINGE
ULTRAFINE
II/SHORT/0.5ML/31G X
5/16"
113
BD INSULIN SYRINGE
ULTRAFINE II/SHORT/1ML/31G
X 5/16"
113
BD INSULIN SYRINGE
ULTRAFINE/0.3ML/30G X
1/2"
113
BD INSULIN SYRINGE
ULTRAFINE/0.3ML/31G X
5/16"
113
BD INSULIN SYRINGE
ULTRAFINE/0.5ML/30G X
1/2"
113
BD INSULIN SYRINGE
ULTRAFINE/0.5ML/31G X
5/16"
113
BD INSULIN SYRINGE
ULTRAFINE/1ML/30G X
1/2"
113
BD INSULIN SYRINGE
ULTRAFINE/1ML/31G X
5/16"
113
BD INSULIN SYRINGE
ULTRAFINE/U-100/0.3ML/29G X
1/2"
114
BD INSULIN SYRINGE
ULTRAFINE/U-100/0.3ML/30G X
1/2"
114
BD INSULIN SYRINGE
ULTRAFINE/U-100/0.3ML/31G X
5/16"
114
BD INSULIN SYRINGE
ULTRAFINE/U-100/0.5ML/29G X
1/2"
114
BD INSULIN SYRINGE
ULTRAFINE/U-100/0.5ML/30G X
1/2"
114
BD INSULIN SYRINGE
ULTRAFINE/U-100/0.5ML/31G X
5/16"
114
BD INSULIN SYRINGE
ULTRAFINE/U-100/1ML/29G X
1/2"
114
BD INSULIN SYRINGE
ULTRAFINE/U-100/1ML/30G X
1/2"
114
BD INSULIN SYRINGE
ULTRAFINE/U-100/1ML/31G X
15/64"
114
BD INSULIN SYRINGE
ULTRAFINE/U-100/1ML/31G X
5/16"
114
BD INSULIN
SYRINGE/DETACHABLE
NEEDLE/U-100/1ML/25G X
1"
114
BD INSULIN
SYRINGE/DETACHABLE
NEEDLE/U-100/1ML/25G X
5/8"
114
BD INSULIN
SYRINGE/DETACHABLE
NEEDLE/U-100/1ML/26G X
1/2"
114
BD INSULIN SYRINGE/U100/0.5ML/30G X 1/2"
114
BD INSULIN SYRINGE/U100/1ML/27G X 1/2"
114
BD INSULIN SYRINGE/U100/1ML/28G X 1/2"
114
BD INTEGRA INSULIN
SYRINGE/U-100/1ML/29G X
1/2"
114
BD INTEGRA
SYRINGE/RETRACTING
NEEDLE/1ML/25G X 1" 114
BD LANCET DEVICE
96
BD LANCET ULTRAFINE
30G
96
BD LANCET ULTRAFINE
33G
96
BD MICROTAINER
LANCETS
96
BD PEN
NEEDLE/MINI/ULTRAFINE/31
G X 3/16"
114
BD PEN
NEEDLE/NANO/ULTRAFINE/3
2G X 4MM
114
BD PEN
NEEDLE/SHORT/ULTRAFINE/
31G X 5/16"
114
BD PEN
NEEDLE/ULTRAFINE/29G X
12.7MM
114
BD PEN
NEEDLE/ULTRAFINE/29GX1/2
" 12.7MM
114
BD PEN NEEDLES
SHORT/ULTRAFINE/31G X
5/16"
114
BD SAFETY-GLIDE INSULIN
SYRINGE/0.5ML/29G X
1/2"
114
BD SAFETY-LOK INSULIN
SYRINGE/PERM
NEEDLE/UF/1ML/29G X
1/2"
114
BD SAFETYGLIDE INSULIN
SYSYRINGE/0.5ML/30G X
5/16"
114
BD SWABS SINGLE
USE
111
BD SWABS SINGLE USE
BUTTERFLY
111
BECONASE AQ
168
BELBUCA
10
BELSOMRA
90
BENADRYL ALLERGY
27
BENADRYL ALLERGY
CHILDRENS
27
BENADRYL DYE-FREE
ALLERGYLIQUID-GELS 27
BENADRYL EXTRA
STRENGTH
54
benazepril &
hydrochlorothiazide
31
benazepril hcl
30
BENGAY GREASELESS
65
BENGAY ULTRA
STRENGTH
65
BENICAR
31
BENICAR HCT
31
BENSAL HP
65
BENTYL
180
BENZAC AC WASH
49
BENZACLIN
49
BENZACLIN WITH PUMP 50
BENZAMYCIN
50
BENZEFOAM
50
BENZEFOAM ULTRA
50
BENZEFOAMULTRA
50
benzocaine (dental)
148
benzocaine-menthol (mouththroat) 3.6mg-15mg, 2.6mg15mg
148
benzonatate 100 mg
47
benzonatate 200 mg
47
benzoyl peroxide
50
benzoyl peroxide 10 %
50
benzoyl peroxide 10 %, 5 % 50
BENZOYL PEROXIDE 2.5
%
50
benzoyl peroxide 4 %
50
benzoyl peroxide 5 %
50
benzoyl peroxide 5.3 %
50
benzoyl peroxide 7 %
50
benzoyl peroxide 9.8 %
50
benzoyl peroxideerythromycin
50
benztropine mesylate
36
BEPREVE
174
BESIVANCE
172
BETA CARE
60
BETA CAROTENE 10000
UNIT
185
beta carotene 25000 unit 185
BETA XMA
60
BETAGAN
171
betamethasone dipropionate
(topical)
55
betamethasone dipropionate
augmented
56
betamethasone valerate
56
BETAPACE
43
BETAPACE AF
43
Index 8
BETASAL
65
BETASERON
177
betaxolol hcl
42
betaxolol hcl (ophth)
171
bethanechol chloride
182
BETHKIS
3
BETIMOL 0.5 %
171
BETOPTIC-S
171
BEVESPI AEROSPHERE 15
BEXSERO
182
BG STAR BLOOD GLUCOSE
TEST
76
BIAXIN
91
bicalutamide
34
BIMATOPROST
175
BINOSTO
83
BIO-35 GLUTEN-FREE
151
BIO-35 IRON FREE
151
BIOBRANE 10"X15"
70
BIOBRANE 15"X20"
70
BIOBRANE 5"X15"
70
BIOBRANE 5"X5"
70
BIOBRANE-L 10"X15"
70
BIOBRANE-L 5"X15"
70
BIOBRANE-L 5"X5"
70
BIOCAL
151
bioflavonoid products
150
BIOSCANNER GLUCOSE TEST
STRIPS
76
BIOSUPP
151
BIOTECT PLUS
151
BIOTENE DRY MOUTH
MOISTURIZING SPRAY 149
biotin 300 mcg
185
biotin 5 mg, 5000 mcg
185
BIOTIN PLUS KERATIN
166
BIOVOL
151
bisacodyl
91
bisoprolol &
hydrochlorothiazide
32
bisoprolol fumarate
42
BLEPH-10
172
BLEPHAMIDE
173
BLEPHAMIDE S.O.P.
173
BLOOD GLUCOSE TEST
STRIPS
76
BLOOD GLUCOSE TEST
STRIPS PREMIUM
76
Index 9
BLUE-EMU SUPER
STRENGTH
65
BODI PROTECT
66
BONE DENSITY
BUILDER
146
BONIVA
83
BOSULIF
34
BOUDREAUXS BABY BUTT
SMOOTH DRY SKIN
60
BP CLEANSING WASH 50
BP FOLINATAL PLUS B 160
BP MULTINATAL PLUS 160
BPO 3% FOAMING
CLOTHS
50
BPO 9% FOAMING
CLOTHS
50
BRAIN
166
BRAIN MIGHT/DHA & CO
Q10
166
BREATHERITE
140
BREATHERITE
COLLAPSIBLEADULT
SPACER W/MASK
140
BREATHERITE
COLLAPSIBLECHILD SPACER
W/MASK
140
BREATHERITE
COLLAPSIBLEINFANT
SPACER W/MASK
140
BREATHERITE
COLLAPSIBLESMALL CHILD
SPACER W/MASK
140
BREATHERITE
COLLAPSIBLESPACER W/
NEONATE MASK
140
BREATHERITE RIGID
SPACERW/MASK
140
BREATHERITE W/LARGE
MASK
140
BREATHERITE W/MEDIUM
MASK
140
BREATHERITE W/SMALL
MASK
140
BREO ELLIPTA
15
BREVICON-28
45
BRILINTA
88
brimonidine tartrate 0.15
%
172
brimonidine tartrate 0.2 %172
BRINTELLIX
21
BRISDELLE
178
BRIVIACT
17
BRIVIACT 10 MG/ML
17
BRIVIACT 50 MG/5ML
17
BROMFENAC
174
bromfenac sodium (ophth) 174
bromocriptine mesylate
36
brompheniramine &
phenyleph
48
brompheniramine &
pseudoeph
48
BROMSITE
174
BROVANA
15
BUBBLES THE FISH II
PEDIATRIC MASK/PVC
140
budesonide (inhalation)
15
budesonide (nasal)
168
BUFFERIN
7
BULLSEYE MINI SAFETY
LANCETS
96
BULLSEYE SAFETY
LANCETS
96
bumetanide
82
BUMEX
82
BUNAVAIL
10
buprenorphine hcl
10
buprenorphine hcl-naloxone hcl
dihydrate
10
bupropion hcl
20
bupropion hcl (smoking
deterrent)
178
BURIED TREASURE ACTIVE
55PLUS SENIOR
COMPLEX
151
buspirone hcl
13
butalbital-acetaminophen 325mg50mg
6
butalbital-acetaminophencaffeine
6
butalbital-acetaminophencaffeine 325mg-50mg-40mg 6
butalbital-acetaminophencaffeine w/ codeine 325mg50mg-40mg-30mg
9
butalbital-aspirin-caffeine
6
butalbital-aspirin-caffeine
w/cod
9
butorphanol tartrate 10
mg/ml
10
BUTRANS 10 MCG/HR, 5
MCG/HR, 20 MCG/HR
10
BUTRANS 7.5 MCG/HR, 15
MCG/HR
10
BYDUREON
24
BYDUREON PEN
24
BYETTA
24
BYSTOLIC
42
BYVALSON
32
C-BUFF
151
C-NATE DHA
160
CA-PLUS
166
CABOMETYX
34
CADUET
44
CAFCIT
2
CAFERGOT
143
caffeine
2
caffeine citrate
2
CAL MAG ZINC +D3
146
CAL-DAY 1000
151
CAL-MAG-ZINC-D
146
CAL-MAG-ZINC-D3
146
CALAN
43
CALAN SR
43
calcipotriene
55
calcipotriene-betamethasone
dipropionate
56
calcitonin (salmon)
83
CALCITRIOL
55
calcitriol
84
calcium 500 mg
145
CALCIUM 600MG200UNIT
145
calcium acetate (phosphate
binder)
86
calcium carbonate
145
calcium carbonate (antacid) 12
calcium carbonate (antacid) 500
mg
12
calcium carbonatecholecalciferol
145
calcium carbonate-cholecalciferol
500mg-400unit, 500mg100unit
145
calcium carbonateergocalciferol
145
calcium carbonate-vitamin d
125unit-500mg, 600mg-400unit,
200unit-500mg, 500mg-200unit,
500mg-500mg-200unit-200unit,
600mg-200unit, 125unit-250mg,
500mg-125unit, 200unit-600mg,
500mg-400unit, 250mg-125unit,
400unit-600mg
145
calcium citrate 200 mg, 950
mg
145
calcium citrate-vitamin d 315mg250unit, 315mg-200unit
145
CALCIUM GLUCONATE 500
MG
145
CALCIUM PNV
160
calcium polycarbophil
90
calcium w/ vitamin d
145
calcium-magnesium-zinc
333mg-5mg-133mg, 5mg133.333mg-333.333mg, 5mg134mg-334mg, 5mg-133.33mg333.33mg, 5mg-133mg333mg
145
CALCIUM/MAGNESIUM/ZINC
5MG-133MG-333MG-200UNIT
146
CALCIUM/MAGNESIUM/ZINC/
VITAMIN D3
146
CALTRATE 600+D
145
CALTRATE 600+D PLUS
MINERALS
145
CAM
60
CAMBIA
144
camphor & menthol
54
camphor-eucalyptus-menthol
49
camphor-eucalyptus-mentholturpentine oil-white
petrolatum
49
camphor-menthol-methyl
salicylate
65
CANASA
86
candesartan cilexetil
31
candesartan cilexetilhydrochlorothiazide
32
capecitabine
34
CAPEX
56
CAPHOSOL
149
CAPITAL/CODEINE
9
CAPRELSA
34
capsaicin
66
captopril
30
CAPTOPRIL/HYDROCHLORO
THIAZIDE
32
CAPZASIN-HP
66
CARAC
54
CARAFATE
180
CARB-O-LAN 10
60
CARB-O-LAN 20
60
CARB-O-PHILIC/20
60
CARB-O-SAL 5
60
carbamazepine
17
CARBAMAZEPINE
17
carbamide peroxide (otic) 175
CARBATROL
17
carbidopa
36
carbidopa-levodopa
36
CARBIDOPA/LEVODOPA/ENTA
CAPONE
36
CARBOFLEX ODOR CONTROL
DRESSING
70
carboxymethylcellulose sodium
(ophth)
170
carboxymethylcellulose-glycerin
170
carboxymethylcellulosehypromellose
170
CARDENZ
158
CARDIO TONE
166
CARDIOCOM LANCING
DEVICE
96
CARDIOTEK-RX
81
CARDIZEM
43
CARDIZEM CD
43
CARDIZEM LA 120 MG
43
CARDIZEM LA 300 MG, 360 MG,
180 MG, 420 MG, 240 MG 43
CARDURA
31
CARDURA XL
87
CAREFINE PEN NEEDLE
32GX4MM
115
CAREFINE PEN NEEDLES
29GX1/2"
115
CAREFINE PEN NEEDLES
30GX5/16"
115
CAREFINE PEN NEEDLES
31GX6MM
115
CAREFINE PEN NEEDLES
31GX8MM
115
CAREFINE PEN NEEDLES
32GX5MM
115
CAREFINE PEN NEEDLES
32GX6MM
115
CAREONE ADVANCED
LANCINGDEVICE
96
CAREONE BLOOD GLUCOSE
TEST STRIPS/PREMIUM 76
CAREONE BLOOD GLUCOSE
TEST STRIPS/VALUE
76
CAREONE INSULIN
SYRINGES/0.3ML/30G X
1/2"
115
CAREONE INSULIN
SYRINGES/0.3ML/31G X
5/16"
115
CAREONE INSULIN
SYRINGES/0.5ML/30G X
1/2"
115
CAREONE INSULIN
SYRINGES/0.5ML/31G X
5/16"
115
Index 10
CAREONE INSULIN
SYRINGES/1ML/30G X
1/2"
115
CAREONE INSULIN
SYRINGES/1ML/31GX5/16"
115
CAREONE LANCET THIN 96
CAREONE LANCET ULTRA
THIN
96
CAREONE UNIFINE PENTIPS
29GX12MM
115
CAREONE UNIFINE PENTIPS
31GX5MM
115
CAREONE UNIFINE PENTIPS
31GX6MM
115
CAREONE UNIFINE PENTIPS
31GX8MM
115
CAREONE UNIFINE PENTIPS
PEN NEEDLES 32GX4MM 115
CAREONE UNIFINE PENTIPS
PLUS PEN NEEDLES
29GX12MM
115
CAREONE UNIFINE PENTIPS
PLUS PEN NEEDLES
31GX5MM
115
CAREONE UNIFINE PENTIPS
PLUS PEN NEEDLES
31GX6MM
115
CAREONE UNIFINE PENTIPS
PLUS PEN NEEDLES
31GX8MM
115
CAREONE UNIFINE PENTIPS
PLUS PEN NEEDLES
32GX4MM
115
CARESENS CONTROL A
SOLUTION
96
CARESENS N BLOOD
GLUCOSETEST STRIPS
76
CARETOUCH ALCOHOL PREP
PADS
111
CARETOUCH LANCING
DEVICEWITH EJECTOR
96
CARETOUCH PEN NEEDLES
31G X 6 MM
115
CARETOUCH PEN NEEDLES
31GX 5MM
115
CARETOUCH PEN NEEDLES
31GX 8MM
115
CARETOUCH PEN NEEDLES
32GX 4MM
115
CARETOUCH PEN NEEDLES
32GX 5MM
115
CARETOUCH TWIST LANCETS
30G
96
carisoprodol 250 mg
167
carisoprodol 350 mg
167
carisoprodol w/ aspirin
168
CARMOL 20
59
Index 11
CARNITOR
84
CARNITOR 1 GM/10ML 84
CARNITOR SF
84
CARRAGAUZE 2 X 2
70
CARRAGAUZE 4 X 4
70
CARRINGTON MOISTURE
BARRIER
66
CARRINGTON MOISTURE
BARRIER/ZINC
66
carteolol hcl (ophth)
171
carvedilol
42
CASODEX
34
CATAPRES
31
CATAPRES-TTS-1
31
CATAPRES-TTS-2
31
CATAPRES-TTS-3
31
CAYSTON
12
CEDAX
45
cefaclor
45
CEFACLOR
45
CEFACLOR ER
45
cefadroxil
44
cefdinir
45
cefixime
45
cefpodoxime proxetil
45
cefprozil
45
CEFTIBUTEN
45
CEFTIN
45
ceftriaxone sodium 1 gm 45
ceftriaxone sodium 500 mg,
250 mg, 1 gm
45
cefuroxime axetil
45
CELEBREX
4
celecoxib
4
CELEXA
20
CELLCEPT
147
CELLULAR SECURITY 151
CELONTIN
19
CEMILL PLUS
150
CENTANY
52
CENTANY AT
52
CENTRAVITES 50 PLUS 151
CENTRAVITES ADULTS 151
CENTRUM
151
CENTRUM ADULTS
151
CENTRUM CARDIO
151
CENTRUM FLAVOR
BURST
151
CENTRUM FLAVOR BURST
ADULT
151
CENTRUM FLAVOR BURST
KIDS
151
CENTRUM MEN
151
CENTRUM MULTIGUMMIES
ADULTS
152
CENTRUM MULTIGUMMIES
MEN
152
CENTRUM MULTIGUMMIES
WOMEN
152
CENTRUM MULTIVITAMIN
FLAVOR BURST DRINK 152
CENTRUM
PERFORMANCE
166
CENTRUM SILVER
152
CENTRUM SILVER
50+MEN
152
CENTRUM SILVER
50+WOMEN
152
CENTRUM SILVER ADULT
50+
152
CENTRUM SILVER ULTRA
MENS
152
CENTRUM SILVER ULTRA
WOMENS
152
CENTRUM SPECIALIST
ENERGY
166
CENTRUM SPECIALIST
HEART
152
CENTRUM SPECIALIST
IMMUNE SUPPORT
152
CENTRUM SPECIALIST
VISION
152
CENTRUM ULTRA MENS 152
CENTRUM ULTRA
WOMENS
152
CENTRUM VITAMINTS
152
CENTRUM WOMEN
152
CEPACOL SORE THROAT
2.6MG-15MG, 3.6MG15MG
148
CEPACOL SORE THROAT
EXTRA STRENGTH
148
CEPACOL SORE THROAT
EXTRASTRENGTH
148
CEPACOL SORE THROAT
MAXIMUM NUMBING
148
CEPASTAT
148
cephalexin
45
CEPHALEXIN
45
CERALYTE 70
145
CERASPORT
145
CERASPORT EX1
145
CERAVE
60
CERAVE AM SPF 30
60
CERAVE PM
60
CERAVE RENEWING SA 60
CERAVE SA RENEWING 60
CEREBYX
19
CEROVITE ADVANCED
FORMULA
152
CERTAVITE
SENIOR/ANTIOXIDANT
NUTRIENTS
152
CESAMET
26
CETAPHIL
60
CETAPHIL DAILY ADVANCE
ULTRA HYDRATING
60
CETAPHIL DAILY FACIAL
MOISTURIZER
60
CETAPHIL DERMACONTROL
MOISTURIZER/SPF 30
60
CETAPHIL MOISTURIZING 60
CETAPHIL
RESTORADERM
60
CETAPHIL THERAPEUTIC
HAND
60
cetirizine hcl
28
CETRAXAL
175
CHANTIX
178
CHANTIX CONTINUING
MONTHPAK
178
CHANTIX STARTING MONTH
PAK
178
CHAPSTICK OVERNIGHT 66
CHAPSTICK ULTRA
MOISTUREDAYTIME
FORMULA
66
CHAPSTICK ULTRASMOOTH
FORTIFY
66
CHAPSTICK ULTRASMOOTH
NOURISH
66
CHAPSTICK ULTRASMOOTH
REJUVENATE
66
CHAPSTICK ULTRASMOOTH
SOOTHE
66
CHEK-STIX COMBO PAK
URINALYSIS CONTROL
76
CHEK-STIX CONTROL
77
CHEMET
26
CHEMSTRIP-K
77
CHENODAL
85
CHERACOL PLUS
48
CHERACOL SORE
THROAT
148
CHERACOL-D COUGH
48
CHILDRENS ADVIL
4
CHILDRENS MOTRIN
4
CHLOR-TRIMETON
27
CHLOR-TRIMETON
ALLERGY
27
chlordiazepoxide hcl
13
chlorhexidine gluconate
(mouth-throat)
148
chlorhexidine gluconate 4
%
39
CHLOROQUINE PHOSPHATE
250 MG
33
chloroquine phosphate 500 mg,
250 mg
33
CHLOROTHIAZIDE 250
MG
82
chlorothiazide 500 mg
82
chlorpheniramine &
pseudoeph
48
chlorpheniramine maleate 27
chlorpheniramineacetaminophen
48
CHLORPROMAZINE HCL 38
chlorpromazine hcl
38
CHLORPROPAMIDE
25
chlorthalidone
82
chlorzoxazone
167
CHOICEFUL
MULTIVITAMIN
152
CHOLBAM
85
cholecalciferol 2000 unit, 1000
unit
185
cholecalciferol 400 unit, 1000
unit, 50000 unit, 2000
unit
185
cholecalciferol 400
unit/ml
185
cholecalciferol 5000 unit 185
cholecalciferol 50000 unit 185
cholestyramine
29
cholestyramine light
29
choline fenofibrate
29
CICLODAN CREAM KIT 53
ciclopirox
53
ciclopirox olamine
53
cilostazol
88
CILOXAN
172
cimetidine 200 mg
180
cimetidine 800 mg, 300 mg,
400 mg
180
cimetidine hcl
180
CIMZIA
86
CIMZIA STARTER KIT
86
CIPRO
85
CIPRO HC
175
CIPRO XR
85
CIPRODEX
175
ciprofloxacin
85
CIPROFLOXACIN 0.2 % 175
ciprofloxacin hcl (ophth)
172
CIPROFLOXACIN HCL 100
MG
85
ciprofloxacin hcl 750 mg, 500 mg,
250 mg
85
ciprofloxacin-ciprofloxacin
hcl
85
citalopram hydrobromide
20
CITRACAL + D3
MAXIMUM
145
CITRACAL MAXIMUM
145
CITRACAL PLUS
146
CITRANATAL 90 DHA
160
CITRANATAL ASSURE
160
CITRANATAL B-CALM
160
CITRANATAL DHA
160
CITRANATAL HARMONY 160
CITRANATAL RX
160
CITRUCEL FIBER
LAXATIVE
90
CLARIFOAM EF
50
CLARINEX
28
clarithromycin
91
CLARITIN
28
CLARITIN REDITABS 10
MG
28
CLARITIN REDITABS 5 MG 28
CLARITIN-D 24 HOUR
48
CLASS ACT LUBRICATED 92
CLASSIC PRENATAL
160
CLEAN & CLEAR ADVANTAGE
3-IN-1 EXFOLIATING
CLEANSER
50
CLEANLET LANCETS 28G 96
clemastine fumarate 1.34 mg27
CLEOCIN
184
CLEOCIN 150 MG, 300 MG 13
CLEOCIN PEDIATRIC
GRANULES
13
CLEOCIN-T
50
CLEVER CHEK AUTO-CODE
TEST STRIPS
77
CLEVER CHEK AUTO-CODE
VOICE TEST STRIPS
77
CLEVER CHEK LANCETS
ULTRATHIN
96
CLEVER CHEK LANCETS
ULTRATHIN 30G
96
Index 12
CLEVER CHEK TEST
STRIPS
77
CLEVER CHOICE ANTISTATICVALVED HOLDING
CHAMBER/ADULT LARGE 140
CLEVER CHOICE ANTISTATICVALVED HOLDING
CHAMBER/MEDIUM
140
CLEVER CHOICE ANTISTATICVALVED HOLDING
CHAMBER/SMALL
140
CLEVER CHOICE AUTO-CODE
PRO TEST STRIPS
77
CLEVER CHOICE COMFORT
EZINSULIN PEN NEEDLES
31GX8MM
115
CLEVER CHOICE COMFORT
EZINSULIN
SYRINGE/0.3ML/29G X
1/2"
115
CLEVER CHOICE COMFORT
EZINSULIN
SYRINGE/0.3ML/30G X
1/2"
116
CLEVER CHOICE COMFORT
EZINSULIN
SYRINGE/0.3ML/30G X
5/16"
116
CLEVER CHOICE COMFORT
EZINSULIN
SYRINGE/0.3ML/31G X
5/16"
116
CLEVER CHOICE COMFORT
EZINSULIN
SYRINGE/0.5ML/28G X
1/2"
116
CLEVER CHOICE COMFORT
EZINSULIN
SYRINGE/0.5ML/29G X
1/2"
116
CLEVER CHOICE COMFORT
EZINSULIN
SYRINGE/0.5ML/30G X
1/2"
116
CLEVER CHOICE COMFORT
EZINSULIN
SYRINGE/0.5ML/30G X
5/16"
116
CLEVER CHOICE COMFORT
EZINSULIN
SYRINGE/0.5ML/31G X
5/16"
116
CLEVER CHOICE COMFORT
EZINSULIN
SYRINGE/1.0ML/30G X
1/2"
116
CLEVER CHOICE COMFORT
EZINSULIN SYRINGE/1ML/28G
X 1/2"
116
Index 13
CLEVER CHOICE COMFORT
EZINSULIN
SYRINGE/1ML/29G X
1/2"
116
CLEVER CHOICE COMFORT
EZINSULIN
SYRINGE/1ML/30G X
5/16"
116
CLEVER CHOICE COMFORT
EZINSULIN SYRINGE/U100/1ML/31GX5/16"
116
CLEVER CHOICE COMFORT
EZPEN NEEDLES
29GX12MM
116
CLEVER CHOICE COMFORT
EZPEN NEEDLES
31GX5MM
116
CLEVER CHOICE COMFORT
EZPEN NEEDLES
31GX6MM
116
CLEVER CHOICE COMFORT
EZPEN NEEDLES
31GX8MM
116
CLEVER CHOICE COMFORT
EZPEN NEEDLES
32GX4MM
116
CLEVER CHOICE COMFORT
EZPEN NEEDLES
32GX5MM
116
CLEVER CHOICE COMFORT
EZPEN NEEDLES
32GX6MM
116
CLEVER CHOICE GLUCOSE
CONTROL HIGH
96
CLEVER CHOICE GLUCOSE
CONTROL LOW
96
CLEVER CHOICE MICRO
TESTSTRIPS
77
CLICKFINE PEN NEEDLE
32GX5/32"
116
CLICKFINE PEN NEEDLE
UNIVERSAL/31GX1/4" 116
CLICKFINE PEN NEEDLE
UNIVERSAL/31GX5/16" 116
CLICKFINE PEN
NEEDLES/31GX1/4"
116
CLICKFINE PEN
NEEDLES/31GX5/16"
116
CLICKFINE UNIVERSAL PEN
NEEDLES 31GX5/16"
116
CLIMARA
84
CLINDAGEL
50
clindamycin hcl 300 mg, 150
mg
13
clindamycin palmitate
hydrochloride
13
clindamycin phosphate
(topical)
50
clindamycin phosphate
vaginal
184
clindamycin phosphate-benzoyl
peroxide
50
clindamycin phosphate-benzoyl
peroxide (refrigerate)
50
clindamycin phosphatetretinoin
50
CLINDESSE
184
CLINICAL NUTRIENTS 45-PLUS
WOMEN
152
CLINICAL NUTRIENTS 50-PLUS
MEN
152
CLINICAL NUTRIENTS
ANTIOXIDANT
152
CLINICAL NUTRIENTS FOR
FEMALE TEENS
152
CLINICAL NUTRIENTS FOR
MALE TEENS
152
CLINICAL NUTRIENTS FOR
MEN
152
CLINICAL NUTRIENTS FOR
WOMEN
152
CLN FACIAL MOISTURIZER
NOURISHING
60
clobetasol propionate
56
clobetasol propionate emollient
base
56
clobetasol propionate
emulsion
56
CLOBEX
56
CLOCORTOLONE
PIVALATE
56
CLOCORTOLONE PIVALATE
PUMP
56
CLODERM
56
CLODERM PUMP
56
clomipramine hcl
21
clonazepam
16
clonidine hcl
31
clonidine hcl (adhd)
2
clopidogrel bisulfate
88
clorazepate dipotassium
13
CLORPRES
32
CLOSERCARE
96
clotrimazole
148
clotrimazole (topical)
53
clotrimazole vaginal
184
clotrimazole w/
betamethasone
53
clozapine
38
CLOZAPINE ODT
38
CLOZARIL
38
CO MONITOR REPLACEMENT
TPIECES
140
CO-NATAL FA
160
COAGUCHEK LANCETS
96
coal tar extract 0.5 %, 1 % 68
COARTEM
33
COCOA BUTTER
60
COCOA BUTTER HAND &
BODYLOTION
60
COCONUT OIL BEAUTY
60
cod liver oil
167
COD LIVER OIL
167
COD LIVER OIL FOR KIDS167
CODEINE SULFATE 15 MG 7
codeine sulfate 30 mg, 15 mg, 60
mg
7
CODEINE SULFATE 60 MG, 30
MG
7
COLACE
91
COLAZAL
86
COLCHICINE
87
colchicine w/ probenecid
87
COLCRYS
87
COLESTID
29
COLESTID FLAVORED
29
colestipol hcl
29
COLY-MYCIN S
175
COLYTE-FLAVOR PACKS
240GM-22.72GM-5.84GM2.98GM-6.72GM
90
COMBIGAN
171
COMBIPATCH
84
COMBIVENT RESPIMAT
15
COMBIVIR
39
COMETRIQ
34
COMFEEL PLUS
CLEARDRESSING
70
COMFEEL PLUS
CONTOURDRESSING
70
COMFEEL PLUS
DRESSING
70
COMFEEL PLUS
TRIANGLEDRESSING
70
COMFEEL PLUS ULCER
DRESSING
70
COMFEEL PLUS
ULCERDRESSING
70
COMFEEL ULCER
CAREDRESSING
70
COMFORT ASSIST INSULIN
SYRINGE 0.3ML/29G X
1/2"
117
COMFORT ASSIST INSULIN
SYRINGE/0.3ML/30G X
5/16"
117
COMFORT ASSIST INSULIN
SYRINGE/0.3ML/31G X
5/16"
117
COMFORT ASSIST INSULIN
SYRINGE/0.5ML/29G X
1/2"
117
COMFORT ASSIST INSULIN
SYRINGE/0.5ML/30G X
5/16"
117
COMFORT ASSIST INSULIN
SYRINGE/0.5ML/31G X
5/16"
117
COMFORT ASSIST INSULIN
SYRINGE/1ML/29G X
1/2"
117
COMFORT ASSIST INSULIN
SYRINGE/1ML/30G X
5/16"
117
COMFORT ASSIST INSULIN
SYRINGE/1ML/31G X
5/16"
117
COMFORT ASSURED
LANCETS MICRO THIN
33G
96
COMFORT ASSURED
LANCETS SUPER THIN
28G
96
COMFORT LANCETS
96
COMFORT-AID 1.5"X2.5" 70
COMPACT SPACE
CHAMBER/ANTI-STATIC
140
COMPACT SPACE
CHAMBER/ANTISTATIC/LARGE MASK 140
COMPACT SPACE
CHAMBER/ANTISTATIC/MEDIUM MASK 140
COMPACT SPACE
CHAMBER/ANTISTATIC/SMALL MASK 140
COMPLERA
39
COMPLETE FORMULATION
D3000
152
COMPLETE FORMULATION
MULTIVITAMIN
SUPPLEMENT
152
COMPLETE NATAL DHA 161
COMPLETENATE
161
COMPOUND W
65
COMPOUND W MAXIMUM
STRENGTH
65
COMTAN
36
CONCEPT DHA
161
CONCEPT OB
161
CONCEPTIONXR MOTILITY
SUPPORT FORMULA
152
CONCERTA
2
CONDYLOX
65
CONE MASK
140
CONTREET FOAM
70
CONTREET FOAM CAVITY 70
CONTREET FOAM HEEL 70
CONTREET FOAM
SACRAL
70
CONTREET
HYDROCOLLOID
70
CONTROL AST
77
CONTROL SOLUTION
NORMAL
96
CONTROL TEST STRIPS 77
CONZIP
7
COOL BLOOD GLUCOSE TEST
STRIPS
77
COOL CONTROL SOLUTION
A
96
COOL CONTROL SOLUTION
B
96
COPAXONE 20 MG/ML
177
COPAXONE 40 MG/ML
177
COPEGUS
41
CORDARONE
14
CORDRAN
56
CORDRAN TAPE
56
COREG
42
COREG CR
42
CORGARD
43
CORICIDIN HBP COLD &
FLU
48
CORTEF
47
CORTENEMA
11
CORTISONE ACETATE
47
CORTISPORIN-TC
175
CORVITE
152
CORZIDE
32
COSENTYX
55
COSENTYX SENSOREADY
PEN
55
COSOPT
171
COSOPT PF
171
COTELLIC
35
COUMADIN
16
COZAAR
31
CREON
81
Index 14
CRESEMBA
27
CRESTOR
30
CRINONE
184
CRITIC-AID CLEAR
MOISTUREBARRIER
66
CRIXIVAN 200 MG
39
CRIXIVAN 400 MG
39
CROMOLYN SODIUM
14
cromolyn sodium (nasal) 168
cromolyn sodium (ophth) 174
CU-PLUS
166
CULTURELLE IMMUNITY
SUPPORT FORMULA
25
CUPRIMINE
147
CURITY ALCOHOL
PREPS/MEDIUM 2 PLY
111
CURITY ALCOHOL
SWABS
111
CURITY HEAVY DRAINAGE
PACK
70
CURITY SALINE DRESSING
8"X4"
70
CURITY SODIUM CHLORIDE
DRESSING 6"X6-3/4"
70
CUTIVATE
56
CVS ADVANCED GLUCOSE
METER TEST STRIPS
77
CVS AIRSHIELD IMMUNITY
SUPPORT
152
CVS ALCOHOL PREP
SWABS
111
CVS ALCOHOL SWABS 111
CVS COD LIVER OIL
167
CVS DAILY ULTRA
MOISTURELOTION
60
CVS DIABETES HEALTH
SUPPORT
152
CVS DRY MOUTH SPRAY 149
CVS GLUCOSE 4 GM
23
CVS GLUCOSE 4GM-6MG 23
CVS HAIR/SKIN/NAILS
166
CVS HDYROCORTISONE
ACETATE
56
CVS LANCETS 21G
96
CVS LANCETS MICRO THIN
33G
96
CVS LANCETS MICRO-THIN
33G
96
CVS LANCETS ORIGINAL 96
CVS LANCETS THIN 26G 96
CVS LANCETS ULTRA THIN
30G
96
CVS LANCETS ULTRA-THIN
30G
97
Index 15
CVS LANCING DEVICE 97
CVS ONE DAILY MENS 50+
ADVANCED
152
CVS PRENATAL
161
CVS PREP PADS
111
CVS PSORIASIS MEDICATED
SHAMPOO PLUS
CONDITIONER
65
CVS SPECTRAVITE ADULT
50+
153
CVS SPECTRAVITE ADULT
GUMMIES
153
CVS SPECTRAVITE ULTRA
MEN50+
153
CVS SPECTRAVITE ULTRA
MENS HEALTH
153
CVS SPECTRAVITE ULTRA
MENS HEALTH SENIOR 153
CVS SPECTRAVITE ULTRA
WOMEN
153
CVS SPECTRAVITE ULTRA
WOMENS HEALTH
153
CVS SPECTRAVITE ULTRA
WOMENS HEALTH
SENIOR
153
CVS THERAPEUTIC
MAXIMUM STRENGTH 65
CVS ULTRA THIN
LANCETS
97
cyanocobalamin
88
cyanocobalamin 100 mcg, 1000
mcg, 250 mcg, 500 mcg 88
cyanocobalamin 1000 mcg 88
CYCLESSA
45
cyclobenzaprine hcl
167
CYCLOGYL
171
cyclopentolate hcl
171
CYCLOPHOSPHAMIDE 33
cyclosporine
147
CYCLOSPORINE
MODIFIED
147
cyclosporine modified (for
microemulsion)
147
CYMBALTA
21
cyproheptadine hcl
29
CYTOMEL
179
CYTOTEC
181
D-VI-SOL
185
DAFLONEX-XL
150
DAILY CONDITIONING
TREATMENT
60
DAILY HEART HEALTH
SUPPORT
153
DAILY MULTIPLE VITAMIN
PLUS IRON
151
DAILY PAK MAXIMUM
MULTIVITAMIN/ASIAN
GINSENG EXTRACT
153
DAKLINZA
41
DALIRESP
14
DANTRIUM
168
dantrolene sodium
168
dapsone
13
darifenacin hydrobromide 182
DAYPRO
4
DAYTRANA
2
DDAVP
84
DDAVP 0.01 %
84
DEBROX
175
DECARA
185
DECON-A
48
DECUBI-VITE
153
DEKAS ESSENTIAL
158
DEKAS PLUS
153
DELZICOL
86
DEMADEX
82
demeclocycline hcl
178
DEMEROL
7
DENAVIR
55
DENOREX EXTRA STRENGTH
2-IN-1
65
DENTIVA
148
DEPACON
19
DEPAKENE
19
DEPAKOTE
19
DEPAKOTE ER
19
DEPAKOTE SPRINKLES
19
DEPO-PROVERA
CONTRACEPTIVE
47
DEPO-TESTOSTERONE
11
DERMA-GEL 4" X 4"
70
DERMA-SMOOTHE/FS
BODY
56
DERMA-SMOOTHE/FS
SCALP
56
DERMABASEOIL IN
WATER
60
DERMACINRX SILAPAK
56
DERMACINRX TICANASE
PAK
168
DERMADROX
66
DERMAGAUZE DRESSING 70
DERMAGRAN HYDROPHILIC
WOUND DRESSING 2"X2" 70
DERMAGRAN HYDROPHILIC
WOUND DRESSING 4"X4" 70
DERMAGRAN HYDROPHILIC
WOUND DRESSING 8"X4" 70
DERMAIDE ALOE
60
DERMAL THERAPY EXTRA
STRENGTH BODY LOTION 60
DERMAL THERAPY FACE
CAREMOISTURIZING
LOTION
60
DERMAL THERAPY FOOT
MASSAGE
60
DERMAL THERAPY HAND
ELBOW & KNEE CREAM 60
DERMAL THERAPY HEEL
CARE
61
DERMALUBE DAILY
MOISTURIZING LOTION
61
DERMAREST PSORIASIS
MEDICATED SHAMPOO PLUS
CONDITIONER
65
DERMATOP
56
DERMAVITE
153
DERMEND MOISTURIZING
BRUISE FORMULA
61
DERMOTIC
175
DESCOVY
39
desipramine hcl
21
DESITIN
66
desloratadine
28
DESLORATADINE ODT
28
desmopressin acetate
84
desmopressin acetate
refrigerated
84
desmopressin acetate spray 84
desmopressin acetate spray
refrigerated
84
DESOGEN
45
desogestrel & ethinyl
estradiol
45
desogestrel-ethinyl estradiol
(biphasic)
45
desogestrel-ethinyl estradiol
(triphasic)
45
DESONATE
56
desonide
57
DESOWEN
57
desoximetasone
57
DESOXYN
2
DESQUAM-X WASH
50
DESVENLAFAXINE ER 50 MG,
100 MG
21
desvenlafaxine succinate 21
DETROL
182
DETROL LA
182
DEX4
23
DEX4 FAST ACTING
GLUCOSE
23
DEX4 NATURALS
23
DEX4 POUCH PACK
23
DEX4 QUICK DISSOLVE
GLUCOSE
23
dexamethasone
47
DEXAMETHASONE
47
DEXAMETHASONE 2 MG, 1
MG
47
dexamethasone 4 mg, 1.5 mg,
0.5 mg, 0.75 mg, 6 mg
47
dexamethasone sodium
phosphate (ophth)
173
DEXAMETHASONE SODIUM
PHOSPHATE 0.1 %
173
dexamethasone sodium
phosphate 20 mg/5ml, 4 mg/ml,
120 mg/30ml
47
DEXEDRINE 10 MG
2
DEXEDRINE 15 MG
2
DEXEDRINE 5 MG
2
DEXILANT
181
dexmethylphenidate hcl
2
dexmethylphenidate hcl 10
mg
3
dexmethylphenidate hcl 2.5
mg
3
dexmethylphenidate hcl 5
mg
3
dextroamphetamine sulfate 2
dextroamphetamine sulfate 10
mg
2
dextroamphetamine sulfate 15
mg
2
dextroamphetamine sulfate 5
mg
2
dextromethorphan-guaifenesin
48
dextromethorphan-guaifenesin
20mg/10ml-200mg/10ml,
10mg/5ml-100mg/5ml,
10mg/5ml-10mg/5ml100mg/5ml-100mg/5ml,
15mg/7.5ml-150mg/7.5ml,
10mg/5ml-200mg/5ml
48
dextromethorphan-guaifenesin
30mg-600mg
48
dextrose (diabetic use)
23
DHEA
61
DHS TAR
68
DHS TAR GEL
68
DHS ZINC
55
DIABETA
25
DIABETES HEALTH PACK 153
DIABETES SUPPORT
PACK
153
DIABETIC TUSSIN COUGH
DROPS
149
DIABETIDERM
61
DIABETIDERM FOOT
REJUVENATING
61
DIABETIDERM HAND &
BODY
61
DIAMOX
82
DIASTAR EASY TEST II
LANCETS 30G
97
DIASTAR EASY TEST
LANCETS30G
97
DIASTAT ACUDIAL
16
DIASTAT PEDIATRIC
17
DIATRUE GLUCOSE CONTROL
SOLUTION LEVEL 1
97
DIATRUE GLUCOSE CONTROL
SOLUTION LEVEL 2
97
DIATRUE GLUCOSE CONTROL
SOLUTION LEVEL 3
97
DIATRUE PLUS BLOOD
GLUCOSE TEST STRIPS 77
diazepam
13
DIAZEPAM
17
DIAZEPAM 1 MG/ML
13
dibucaine
66
dibucaine (rectal)
11
DICLEGIS
26
diclofenac potassium
4
diclofenac sodium
5
diclofenac sodium (ophth) 174
diclofenac sodium (topical) 52
diclofenac w/ misoprostol
5
dicloxacillin sodium
176
dicyclomine hcl
180
dicyclomine hcl 10 mg/5ml 180
didanosine
39
DIFFERIN
50
DIFFERIN 0.1 %
50
DIFFERIN 0.3 %
50
DIFICID
92
DIFLORASONE
DIACETATE
57
DIFLUCAN
27
Index 16
diflunisal
7
digoxin
44
DIGOXIN 0.05 MG/ML
44
DIHYDROERGOTAMINE
MESYLATE 4 MG/ML
144
DILANTIN 100 MG
19
DILANTIN 30 MG
19
DILANTIN INFATABS
19
DILANTIN-125
19
DILAUDID
7
diltiazem hcl
43
diltiazem hcl coated beads 43
diltiazem hcl extended release
beads
43
dimenhydrinate
26
DIMETAPP COLD &
ALLERGY
48
DIOVAN
31
DIOVAN HCT
32
DIPENTUM
86
diphenhydramine hcl
28
diphenhydramine hcl (sleep) 25
mg
89
diphenhydramine hcl (sleep) 50
mg
89
diphenhydramine hcl 25 mg 27
diphenhydramine hcl 50 mg 27
diphenhydramine-acetaminophen
(sleep) 25mg-500mg, 30unit50mg-15mg-1.5mg-25mg-18mg2500unit-500mg-10mg-1.7mg6mcg-400mcg-2mg, 25mg-25mg500mg-500mg
89
diphenhydramine-zinc acetate
0.1%-2%, 0.1%-0.1%-2%2%
54
diphenoxylate w/ atropine
25
DIPHENOXYLATE/ATROPINE
25
DIPROLENE
57
DIPROLENE AF
57
dipyridamole
88
disopyramide phosphate
14
disulfiram 250 mg
176
DITROPAN XL
182
divalproex sodium
19
DMAE
61
DML FORTE
61
DOCTORS CHOICE
BURNS/SCALDS/ABRASIONS
70
Index 17
docusate calcium
91
docusate sodium
91
docusate sodium 100 mg 91
dofetilide
14
DOLOPHINE
8
DOME-PASTE BANDAGE 70
donepezil hydrochloride 176
donepezil hydrochloride 23 mg,
10 mg
176
donepezil hydrochloride 5 mg,
10 mg
176
DORYX
179
DORYX MPC
179
dorzolamide hcl
174
dorzolamide hcl-timolol
maleate
171
DOTHELLE DHA
161
DOVONEX
55
doxazosin mesylate
31
doxepin hcl
21
doxepin hcl 10 mg, 150 mg, 50
mg, 100 mg, 25 mg
21
DOXEPIN HCL 75 MG
21
DOXYCYCLINE
67
doxycycline
(monohydrate)
179
doxycycline (monohydrate) 100
mg, 50 mg
179
doxycycline (monohydrate) 75
mg, 150 mg
179
doxycycline hyclate
179
doxylamine succinate
(sleep)
89
DR SMITHS DIAPER
67
DRAMAMINE
26
DRAWTEX ADVANCED
WOUND CARE 2"X2"
70
DRAWTEX ADVANCED
WOUND CARE 3"X3"
70
DRAWTEX ADVANCED
WOUND CARE 4"X4"
70
DRAWTEX ADVANCED
WOUND CARE 6"X8"
70
DRAWTEX ADVANCED
WOUND CARE 8"X8"
70
DRISDOL
185
DRISTAN SPRAY
169
dronabinol
26
DROPLET LANCETS ULTRA
THIN 30G
97
DROPLET LANCING
DEVICE
97
DROPLET PEN NEEDLES
29GX12MM
117
DROPLET PEN NEEDLES
31GX5MM
117
DROPLET PEN NEEDLES
31GX6MM
117
DROPLET PEN NEEDLES
31GX8MM
117
DROPLET PEN NEEDLES
32GX4MM
117
DROPLET PEN NEEDLES
32GX5MM
117
DROPLET PEN NEEDLES
32GX6MM
117
drospirenone-ethinyl
estradiol
45
DROXY CREAM
61
DRUG MART ADJUSTABLE
LANCING DEVICE
97
DRUG MART LANCETS
THIN
97
DRUG MART ON-THE-GO
LANCETS GENTLE 30G
97
DRUG MART UNIFINE PENTIPS
31GX5MM
117
DRUG MART UNIFINE
PENTIPS29G X 12MM
117
DRUG MART UNIFINE
PENTIPS31GX6MM
117
DRUG MART UNIFINE
PENTIPS31GX8MM
117
DRUG MART UNIFINE
PENTIPS32GX4MM
117
DRUG MART UNIFINE
PENTIPSPLUS 32GX4MM 117
DRUG MART UNILET
LANCETSSUPER THIN 30G97
DRUG MART UNILET
LANCETSULTRA THIN 28G 97
DRY MOUTH SPRAY
149
DRYSOL
67
DUAC
51
DUANE READE LANCET
ALTERNATE SITE 26G
97
DUANE READE LANCET
SUPERTHIN 30G
97
DUANE READE LANCET
ULTRATHIN 28G
97
DUANE READE UNIFINE
PENTIPS 29G X 12MM
117
DUANE READE UNIFINE
PENTIPS 31G X 6MM ULTRA
SHORT
117
DUANE READE UNIFINE
PENTIPS 31G X 8MM
SHORT
117
DUDRESS ISLAND DRESSING
4"X4"
71
DUDRESS ISLAND DRESSING
6"X6"
71
DUETACT
22
DUEXIS
5
DULCOLAX
91
DULERA
15
duloxetine hcl 30 mg, 60 mg, 20
mg
21
DULOXETINE HCL 40 MG 21
DUO-CARE CONTROL
SOLUTION
97
DUO-CARE TEST STRIPS 77
DUOPA
36
DUPIXENT
59
DURAGESIC 12 MCG/HR
8
DURAGESIC 75 MCG/HR, 25
MCG/HR, 50 MCG/HR, 100
MCG/HR
8
DURATION 12 HOUR
169
DURATION SPRAY
169
DUREX EXTRA SENSITIVE 92
DUREZOL
173
DURLAZA
88
dutasteride
87
dutasteride-tamsulosin hcl 87
DUTOPROL
32
DYANAVEL XR
2
DYAZIDE
82
DYMISTA
168
E-Z JECT LANCETS
97
E-Z JECT LANCETS 21G 97
E-Z JECT LANCETS
COLOR
97
E-Z JECT LANCETS SUPER
THIN 30G
97
E-Z JECT LANCETS THIN
26G
97
E-Z SPACER
140
E-Z SPACER THE BODY
GUARDS PACK
140
E-ZJECT LANCETS MICROTHIN 33G
97
E.E.S. 400
92
E.E.S. GRANULES
92
EARLOOP MASK
140
EASIVENT
140
EASIVENT/MASK-LARGE 140
EASIVENT/MASK-MEDIUM
140
EASIVENT/MASK-SMALL 141
EASY COMFORT INSULIN
SYRINGE/0.3ML/30G X
5/16"
117
EASY COMFORT INSULIN
SYRINGE/0.5ML/30G X
5/16"
117
EASY COMFORT INSULIN
SYRINGE/0.5ML/31G X
5/16"
117
EASY COMFORT INSULIN
SYRINGE/1ML/30G X
5/16"
117
EASY COMFORT INSULIN
SYRINGE/1ML/31G X
5/16"
117
EASY COMFORT INSULIN
SYRINGE/U-100/0.5ML/30G X
1/2"
117
EASY COMFORT INSULIN
SYRINGE/U-100/1ML/30G X
1/2"
117
EASY COMFORT
LANCETS
97
EASY COMFORT LANCETS
30G/PULL TOP
97
EASY COMFORT LANCETS
30G/THIN TOP
97
EASY COMFORT PEN
NEEDLES31GX1/4"
118
EASY COMFORT PEN
NEEDLES31GX3/16"
118
EASY COMFORT PEN
NEEDLES31GX5/16"
118
EASY COMFORT PEN
NEEDLES32GX5/32"
118
EASY MINI EJECT LANCING
DEVICE
97
EASY MINI LANCING
DEVICE
97
EASY PLUS BLOOD
GLUCOSE TEST STRIPS 77
EASY PLUS II BLOOD
GLUCOSE TEST
77
EASY PLUS II CONTROL
SOLUTION HIGH
97
EASY PLUS II CONTROL
SOLUTION LOW
97
EASY STEP CONTROL
SOLUTION HIGH
97
EASY STEP CONTROL
SOLUTION LOW
97
EASY STEP CONTROL
SOLUTION NORMAL
97
EASY STEP TEST
STRIPS
77
EASY TALK BLOOD
GLUCOSE TEST STRIPS 77
EASY TALK CONTROL
SOLUTION HIGH
97
EASY TALK CONTROL
SOLUTION LOW
97
EASY TALK CONTROL
SOLUTION NORMAL
97
EASY TOUCH 32GX5MM 118
EASY TOUCH 32GX6MM 118
EASY TOUCH ALCOHOL PREP
PADS/MEDIUM
111
EASY TOUCH CONTROL
SOLUTION/HIGH & LOW
97
EASY TOUCH FLIPLOCK
SAFETY INSULIN SYRINGE
1ML/29GX1/2"
118
EASY TOUCH FLIPLOCK
SAFETY INSULIN SYRINGE
1ML/30GX1/2"
118
EASY TOUCH FLIPLOCK
SAFETY INSULIN SYRINGE
1ML/30GX5/16"
118
EASY TOUCH FLIPLOCK
SAFETY INSULIN SYRINGE
1ML/31GX5/16"
118
EASY TOUCH GLUCOSE TEST
STRIPS
77
EASY TOUCH HEALTHPRO
CONTROL SOLUTION/HIGH &
LOW
98
EASY TOUCH HEALTHPRO
GLUCOSE TEST STRIPS 77
EASY TOUCH INSULIN
SYRINGE/0.3ML/30G X
5/16"
118
EASY TOUCH INSULIN
SYRINGE/0.3ML/31G X
5/16"
118
EASY TOUCH INSULIN
SYRINGE/0.5ML/29G X
1/2"
118
EASY TOUCH INSULIN
SYRINGE/0.5ML/30G X
5/16"
118
EASY TOUCH INSULIN
SYRINGE/1ML/30G X
5/16"
118
EASY TOUCH INSULIN
SYRINGE/SAFETY/U100/0.5ML/29G X 1/2"
118
EASY TOUCH INSULIN
SYRINGE/SAFETY/U100/0.5ML/30G X 5/16"
118
EASY TOUCH INSULIN
SYRINGE/SAFETY/U100/1ML/29G X 1/2"
118
EASY TOUCH INSULIN
SYRINGE/SAFETY/U100/1ML/30G X 1/2"
118
Index 18
EASY TOUCH INSULIN
SYRINGE/U-100/0.3ML/30G X
1/2"
118
EASY TOUCH INSULIN
SYRINGE/U-100/0.5ML/27G X
1/2"
118
EASY TOUCH INSULIN
SYRINGE/U-100/0.5ML/28G X
1/2"
118
EASY TOUCH INSULIN
SYRINGE/U-100/0.5ML/30G X
1/2"
118
EASY TOUCH INSULIN
SYRINGE/U-100/0.5ML/31G X
5/16"
118
EASY TOUCH INSULIN
SYRINGE/U-100/1ML/27G X
1/2"
118
EASY TOUCH INSULIN
SYRINGE/U-100/1ML/28G X
1/2"
118
EASY TOUCH INSULIN
SYRINGE/U-100/1ML/29G X
1/2"
118
EASY TOUCH INSULIN
SYRINGE/U-100/1ML/30G X
1/2"
118
EASY TOUCH INSULIN
SYRINGE/U-100/1ML/31G X
5/16"
119
EASY TOUCH LANCETS
21G/PRESSURE
ACTIVATED
98
EASY TOUCH LANCETS
23G/PRESSURE
ACTIVATED
98
EASY TOUCH LANCETS
26G/PRESSURE
ACTIVATED
98
EASY TOUCH LANCETS
26G/PULL-TOP
98
EASY TOUCH LANCETS
26G/TWIST
98
EASY TOUCH LANCETS
28G/PRESSURE
ACTIVATED
98
EASY TOUCH LANCETS
28G/PULL-TOP
98
EASY TOUCH LANCETS
28G/TWIST
98
EASY TOUCH LANCETS
30G/BUTTON-ACTIVATED 98
EASY TOUCH LANCETS
30G/PRESSURE
ACTIVATED
98
EASY TOUCH LANCETS
30G/PULL-TOP
98
EASY TOUCH LANCETS
30G/TWIST
98
Index 19
EASY TOUCH LANCETS
32G/PRESSURE
ACTIVATED
98
EASY TOUCH LANCETS
32G/PULL-TOP
98
EASY TOUCH LANCETS
32G/TWIST
98
EASY TOUCH LANCETS
33G/TWIST
98
EASY TOUCH LANCING
DEVICE/EJECTOR
98
EASY TOUCH PEN NEEDLES
29GX1/2"
119
EASY TOUCH PEN NEEDLES
31GX1/4"
119
EASY TOUCH PEN NEEDLES
31GX5/16"
119
EASY TOUCH PEN NEEDLES
32GX1/4"
119
EASY TOUCH PEN NEEDLES
32GX3/16"
119
EASY TOUCH PEN NEEDLES
32GX5/32"
119
EASY TOUCH PEN
NEEDLES/31G X 3/16" 119
EASY TOUCH SAFETY
LANCETS21G/PRESSURE
ACTIVATED
98
EASY TOUCH SAFETY
LANCETS23G/PRESSURE
ACTIVATED
98
EASY TOUCH SAFETY
LANCETS26G/BUTTON
ACTIVATED
98
EASY TOUCH SAFETY
LANCETS26G/PRESSURE
ACTIVATED
98
EASY TOUCH SAFETY
LANCETS28G/BUTTON
ACTIVATED
98
EASY TOUCH SAFETY
LANCETS28G/PRESSURE
ACTIVATED
98
EASY TOUCH SHEATHLOCK
SAFETY INSULIN SYRINGE
1ML/29GX1/2"
119
EASY TOUCH SHEATHLOCK
SAFETY INSULIN SYRINGE
1ML/30GX5/16"
119
EASY TOUCH SHEATHLOCK
SAFETY INSULIN SYRINGE
1ML/31GX5/16"
119
EASY TOUCH SHEATHLOCK
SAFETY SYRINGE
1ML/30GX1/2"
119
EASY TRAK BLOOD
GLUCOSE TEST STRIPS 77
EASY TRAK GLUCOSE
CONTROLSOLUTION HIGH 98
EASY TRAK GLUCOSE
CONTROLSOLUTION LOW 98
EASY TRAK GLUCOSE
CONTROLSOLUTION
NORMAL
98
EASY TWIST & CAP
LANCETS
98
EASYGLUCO
77
EASYGLUCO CONTROL
SOLUTION HIGH
98
EASYGLUCO CONTROL
SOLUTION LOW
98
EASYGLUCO CONTROL
SOLUTION NORMAL
98
EASYGLUCO PLUS
77
EASYGLUCO PLUS CONTROL
SOLUTION LEVEL 1
98
EASYMAX 15 LEVEL 1
GLUCOSE CONTROL
SOLUTION
98
EASYMAX 15 LEVEL 2
GLUCOSE CONTROL
SOLUTION
98
EASYMAX 15 TEST
STRIPS
77
EASYMAX CONTROL
SOLUTIONHIGH
98
EASYMAX CONTROL
SOLUTIONLOW
99
EASYMAX CONTROL
SOLUTIONNORMAL
99
EASYMAX TEST STRIPS 77
EASYPLUS BLOOD GLUCOSE
TEST STRIP
77
EASYPRO BLOOD GLUCOSE
TEST STRIPS
77
EASYPRO PLUS
77
EASYTEST II LANCETS
99
EASYTEST LANCETS
99
EBASE CONTROLLER KIT141
EC-NAPROSYN
5
econazole nitrate
53
ECOTRIN REGULAR
STRENGTH
7
EDARBI
31
EDARBYCLOR
32
EDLUAR
90
EDURANT
39
EFFEXOR XR
21
EFFIENT
88
EFLOW SCF AEROSOL
HEAD
141
EFUDEX
54
ELASTO-GEL 12"X12"
71
ELASTO-GEL 2"X3"
71
ELASTO-GEL 3" ROUND 71
ELASTO-GEL 4"X4"
71
ELASTO-GEL 5"X5"
71
ELASTO-GEL 6"X8"
71
ELASTO-GEL 8"X16"
71
ELASTO-GEL CAST/SPLINT
12"X12"
71
ELASTO-GEL CAST/SPLINT
4"X4"
71
ELASTO-GEL CAST/SPLINT
6"X8"
71
ELASTO-GEL CAST/SPLINT
8"X16"
71
ELASTO-GEL FACE MASK 71
ELASTO-GEL PLUS 2"X3" 71
ELASTO-GEL PLUS 4"X4" 71
ELASTO-GEL PLUS 8"X8" 71
ELAVIL
21
ELDEPRYL
36
ELDERTONIC
153
ELEMENT COMPACT
CONTROL SOLUTION LEVEL
2
99
ELEMENT COMPACT
CONTROL SOLUTION LEVEL
3
99
ELEMENT COMPACT TEST
STRIPS
77
ELEMENT HIGH CONTROL 99
ELEMENT LOW CONTROL 99
ELEMENT NORMAL
CONTROL
99
ELEMENT TEST STRIPS 77
ELESTAT
174
ELEXA NATURAL FEEL
92
ELEXA STIMULATING
92
ELEXA ULTRA SENSITIVE 92
ELIDEL
65
ELIMITE
67
ELIPHOS
86
ELIQUIS
16
ELITE DC AUTO
ADAPTER
141
ELITE-OB
161
ELITE-THIN INSULIN
SYRINGE/0.3ML/31G X
5/16"
119
ELITE-THIN INSULIN
SYRINGE/0.5ML/29G X
1/2"
119
ELITE-THIN INSULIN
SYRINGE/0.5ML/30G X
5/16"
119
ELITE-THIN INSULIN
SYRINGE/1ML/30G X
5/16"
119
ELITE-THIN INSULIN
SYRINGE/U-100/0.5ML/28G X
1/2"
119
ELITE-THIN INSULIN
SYRINGE/U-100/0.5ML/31G X
5/16"
119
ELITE-THIN INSULIN
SYRINGE/U-100/1ML/28G X
1/2"
119
ELITE-THIN INSULIN
SYRINGE/U-100/1ML/29G X
1/2"
119
ELITE-THIN INSULIN
SYRINGE/U-100/1ML/31G X
5/16"
119
ELIXOPHYLLIN
16
ELLA
46
ELLIS TONIC
153
ELMIRON
87
ELOCON
57
ELON MATRIX 5000
166
ELON MATRIX PLUS
166
ELON MATRIX 5000
COMPLETE
166
ELON MATRIX
COMPLETE
166
ELON R3
166
ELON SKIN REPAIR
SYSTEM
61
ELTA
61
ELTA DERMAL WOUND
DRESSING
71
EMADINE
174
EMBEDA
8
EMBRACE BLOOD GLUCOSE
TEST STRIPS
77
EMBRACE CONTROL
SOLUTIONLOW
99
EMBRACE EVO BLOOD
GLUCOSETEST STRIPS 77
EMBRACE EVO GLUCOSE
CONTROL SOLUTION LEVEL
1
99
EMBRACE EVO GLUCOSE
CONTROL SOLUTION LEVEL
2
99
EMBRACE GLUCOSE
CONTROL SOLUTION
HIGH
99
EMBRACE LANCETS ULTRA
THIN 30G
99
EMBRACE PRO BLOOD
GLUCOSETEST STRIPS
77
EMBRACE PRO GLUCOSE
CONTROL SOLUTION
99
EMCYT
34
EMEND
26
EMERGEN-C BLUE
153
EMERGEN-C FIVE
153
EMERGEN-C HEART
HEALTH
153
EMERGEN-C IMMUNE
153
EMERGEN-C IMMUNE
PLUS
153
EMERGEN-C IMMUNE
PLUS/VITAMIN D
153
EMERGEN-C IMMUNE+
WARMERS
153
EMERGEN-C JOINT
HEALTH
153
EMERGEN-C KIDZ
153
EMERGEN-C MSM LITE 153
EMERGEN-C PINK
153
EMERGEN-C SUPER
FRUIT
153
EMERGEN-C VITAMIN C 153
EMERGEN-C VITAMIN C
LITE
153
EMERGEN-C VITAMIN D &
CALCIUM
153
EMETROL
26
EMLA
66
EMOLLIA-CREME
61
EMOLLIA-LOTION
61
emollient
61
EMSAM
20
EMTRIVA
39
ENABLEX
182
enalapril maleate
30
enalapril maleate &
hydrochlorothiazide
32
ENBRACE HR
161
ENBREL
6
ENBREL 25 MG/0.5ML
6
ENBREL 50 MG/ML
6
ENBREL SURECLICK
6
END FATIGUE DAILY
ENERGYENFUSION
153
ENERGY BOOSTER
153
ENFAMIL ENFALYTE
145
ENFAMIL EXPECTA
161
Index 20
enoxaparin sodium 100 mg/ml,
150 mg/ml
16
enoxaparin sodium 120
mg/0.8ml, 40 mg/0.4ml
16
enoxaparin sodium 30
mg/0.3ml
16
enoxaparin sodium 300
mg/3ml
16
enoxaparin sodium 60
mg/0.6ml
16
enoxaparin sodium 80
mg/0.8ml
16
ENSTILAR
57
entacapone
36
entecavir
41
ENTRESTO
44
EPANED
30
EPCLUSA
41
EPIDUO
51
EPIDUO FORTE
51
EPIFOAM
57
EPILYT
61
epinastine hcl (ophth)
174
EPINEPHRINE 0.15
MG/0.15ML
185
EPINEPHRINE 0.15
MG/0.3ML
185
EPINEPHRINE 0.3
MG/0.3ML
185
EPIPEN 2-PAK
185
EPIPEN-JR 2-PAK
185
EPIVIR
39
EPIVIR 150 MG
39
EPIVIR 300 MG
39
EPIVIR HBV
41
EPOGEN
88
EPROSARTAN MESYLATE 31
EPZICOM
39
EQ BLOOD GLUCOSE TEST
STRIPS
77
EQ COMPLETE
MULTIVITAMINADULTS UNDER
50
153
EQ ONE DAILY MENS
HEALTH
153
EQ ONE DAILY WOMENS
HEALTH
153
EQ THERAPEUTIC
MOISTURIZING CREAM
61
EQL ADVANCED RECOVERY
SKIN CARE
61
EQL ALCOHOL SWABS 111
Index 21
EQL CENTURY MATURE
ADULTS50+
153
EQL CENTURY MENS 153
EQL CENTURY
WOMENS
153
EQL COLOR LANCETS
21G
99
EQL COLOR LANCETS
MICRO THIN 33G
99
EQL DRY MOUTH ORAL
RINSE
149
EQL INSULIN
SYRINGE/0.3ML/29G X
1/2"
119
EQL INSULIN
SYRINGE/0.3ML/30G X
5/16"
119
EQL INSULIN
SYRINGE/0.3ML/31G X
5/16"
119
EQL INSULIN
SYRINGE/0.5ML/29G X
1/2"
119
EQL INSULIN
SYRINGE/0.5ML/30G X
5/16"
119
EQL INSULIN
SYRINGE/0.5ML/31G X
5/16"
119
EQL INSULIN
SYRINGE/1ML/29G X
1/2"
119
EQL INSULIN
SYRINGE/1ML/30G X
5/16"
119
EQL INSULIN
SYRINGE/1ML/31G X
5/16"
119
EQL INSULIN SYRINGE/U100/0.3ML/29G X 1/2"
120
EQL INSULIN SYRINGE/U100/0.5ML/29G X 1/2"
120
EQL INSULIN SYRINGE/U100/1ML/29G X 1/2"
120
EQL MEGA SELECT
MENS
154
EQL MEGA SELECT
WOMENS
154
EQL MOISTURIZING
CREAM
61
EQL ONE DAILY ADULT
GUMMIES
154
EQL ONE DAILY DIET
SUPPORT
154
EQL ONE DAILY MENS 154
EQL ONE DAILY MENS 50+
ADVANCED
154
EQL PRENATAL
FORMULA
161
EQL PROTECTAVISION 154
EQL SHORT PEN NEEDLES
31G X 8MM
120
EQL SUPER ENERGY
BOOSTER
154
EQL SUPER THIN LANCETS
30G
99
EQL THIN LANCETS 26G 99
EQL TRUETEST BLOOD
GLUCOSE TEST
77
EQL TRUETRACK TEST
77
EQL ULTRA COMFORT
INSULINSYRINGE/0.3ML/31G X
5/16"
120
EQL ULTRA COMFORT
INSULINSYRINGE/1ML/30G X
5/16"
120
EQL ULTRA MOISTURIZING
DAILY LOTION
61
EQL ULTRA SHORT PEN
NEEDLES 31G X 6MM
120
EQUALYTE
145
EQUETRO
37
ergocalciferol
185
ERGOLOID MESYLATES 178
ergoloid mesylates
178
ergotamine w/ caffeine
143
ERIVEDGE
34
ERTACZO
53
ERY-TAB
92
ERYGEL
51
ERYPED 200
92
ERYPED 400
92
ERYTHROCIN STEARATE 92
erythromycin (acne aid)
51
erythromycin (ophth)
172
erythromycin base
92
ERYTHROMYCIN BASE
92
erythromycin ethylsuccinate 92
ERYTHROMYCIN
ETHYLSUCCINATE
92
ESBRIET
178
ESCAVITE LQ
159
escitalopram oxalate
20
ESGIC
6
esomeprazole magnesium 20
mg
181
esomeprazole magnesium 40
mg
181
ESOMEPRAZOLE
STRONTIUM
181
estazolam
90
ESTER-C 200MG-60MG500MG
150
ESTRACE
84
estradiol
84
estradiol & norethindrone
acetate
84
estropipate 0.75 mg, 1.5 mg 84
ESTROPIPATE 0.75 MG, 3 MG,
1.5 MG
84
eszopiclone
90
ethambutol hcl
33
ethosuximide
19
ethynodiol diacet & eth
estrad
45
ETIDRONATE DISODIUM 200
MG
83
ETIDRONATE DISODIUM 400
MG
83
etodolac
5
EUCERIN
61
EUCERIN CALMING DAILY
MOISTURIZER
61
EUCERIN DAILY
PROTECTION/SPF 30
61
EUCERIN INTENSIVE
REPAIR
61
EUCERIN INTENSIVE
REPAIRHAND
61
EUCERIN ORIGINAL
HEALINGSOOTHING
REPAIR
61
EUCERIN PLUS
61
EUCERIN PLUS INTENSIVE
REPAIR
61
EUCERIN SKIN CALMING
DAILY MOISTURIZING
61
EUCERIN SMOOTHING
REPAIRADVANCED
FORMULA
61
EUCRISA
67
EURAX
68
EVAC
90
EVEKEO
2
EVENCARE + BLOOD
GLUCOSETEST STRIP
77
EVENCARE BLOOD GLUCOSE
TEST STRIP
77
EVENCARE CONTROL
SOLUTION
99
EVENCARE G2 GLUCOSE
CONTROL SOLUTION/LOWHIGH
99
EVENCARE G2 TEST
STRIPS
77
EVENCARE G3 GLUCOSE
CONTROL SOLUTION/LOWHIGH
99
EVENCARE G3 TEST
STRIPS
78
EVENCARE MINI BLOOD
GLUCOSE TEST STRIPS 78
EVENCARE MINI GLUCOSE
CONTROL SOLUTION
NORMAL
99
EVISTA
84
EVOCLIN
51
EVOLUTION AUTOCODE 78
EVOLUTION CONTROL
SOLUTION NORMAL
99
EVOTAZ
39
EVZIO
26
EX-LAX MAXIMUM
STRENGTH
91
EXACTECH R-S-G TEST
STRIPS
78
EXACTECH TEST
STRIPS
78
EXALGO 12 MG, 8 MG, 16
MG
8
EXALGO 32 MG
8
EXCEDRIN EXTRA
STRENGTH
6
EXCEDRIN MENSTRUAL
COMPLETE
6
EXCEDRIN MIGRAINE
6
EXEL COMFORT POINT
INSULIN PEN NEEDLES 29G
X 12MM
120
EXEL COMFORT POINT
INSULIN PEN NEEDLES 31G
X 6MM
120
EXEL COMFORT POINT
INSULIN PEN NEEDLES 31G
X 8MM
120
EXEL COMFORT POINT
INSULIN SYRINGE/0.3ML/29G
X 1/2"
120
EXEL COMFORT POINT
INSULIN SYRINGE/0.3ML/30G
X 5/16"
120
EXEL COMFORT POINT
INSULIN SYRINGE/0.5ML/28G
X 1/2"
120
EXEL COMFORT POINT
INSULIN SYRINGE/0.5ML/29G
X 1/2"
120
EXEL COMFORT POINT
INSULIN SYRINGE/0.5ML/30G
X 5/16"
120
EXEL COMFORT POINT
INSULIN SYRINGE/1ML/28G X
1/2"
120
EXEL COMFORT POINT
INSULIN SYRINGE/1ML/29G X
1/2"
120
EXEL COMFORT POINT
INSULIN SYRINGE/1ML/30G X
5/16"
120
EXELDERM
53
EXELON
176
EXELON 13.3 MG/24HR 176
EXELON 4.6 MG/24HR, 9.5
MG/24HR
176
exemestane
34
EXFORGE
32
EXFORGE HCT
32
EXTAVIA
177
EXTINA
53
EXTRA SENSITIVE
SPERMICIDAL
92
EXTRA-VIRT PLUS DHA 161
EXU-DRY 15"X18"
71
EXU-DRY 15"X24"
71
EXU-DRY 20"X28"
71
EXU-DRY 3"X4"
71
EXU-DRY 4"X6"
71
EXU-DRY 6"X9"
71
EXU-DRY 9"X15"
71
EXU-DRY ARM 27"X31"
71
EXU-DRY ARM/SHOULDER
TIES 27"X31"
71
EXU-DRY BURN JACKET
31"X32"
71
EXU-DRY BURN JACKET CHILD
17"X20"
71
EXU-DRY BUTTOCKS
23"X53"
71
EXU-DRY ELBOW/KNEE/HEEL
10"X17"
71
EXU-DRY FACE 9"X14"
71
EXU-DRY INCISION 3"X9" 71
EXU-DRY NON-PERMEABLE
PAD 24"X36"
71
EXU-DRY PADDED HAND
12"X13"
71
EXU-DRY PADDED HAND
CHILD 8"X8"
71
EXU-DRY PADDED NECK
6"X25"
71
EXU-DRY PERMEABLE PAD
24"X36"
71
EXU-DRY SCALP 3"X14"
71
Index 22
EXU-DRY SLIT TUBE 2"X3" 71
EYE HEALTH
154
EYEAID IRRIGATING
SOLUTION
174
EZ SMART BLOOD GLUCOSE
LANCETS
99
EZ SMART BLOOD GLUCOSE
TEST STRIPS
78
EZ SMART PLUS BLOOD
GLUCOSE TEST STRIPS 78
EZ-LETS LANCETS 21G
99
EZ-LETS LANCETS 23G
99
EZ-LETS LANCETS 26G
SUPER-SOFT
99
EZ-LETS LANCETS 28G
ULTRA-SOFT
99
EZ-LETS LANCETS 30G
99
ezetimibe
30
ezetimibe-simvastatin
29
EZFE FORTE
161
FABIOR
51
famciclovir
42
famotidine
180
famotidine 20 mg
180
famotidine 40 mg, 10 mg 180
FAMVIR
42
FANAPT
37
FANAPT TITRATION PACK 37
FANATREX FUSEPAQ
17
FANTASY LUBRICATED
92
FANTASY
LUBRICATED/SPERMICIDE
92
FARESTON
34
FARXIGA
25
FARYDAK
35
FAZACLO 100 MG, 25 MG 38
FAZACLO 12.5 MG, 200 MG,
150 MG
38
felbamate
19
FELBATOL
19
FELDENE
5
felodipine
43
FEM-CAL CITRATE
146
FEMARA
34
FENOFIBRATE
29
fenofibrate 145 mg, 48 mg 29
fenofibrate 160 mg, 120 mg, 54
mg, 40 mg
29
fenofibrate micronized
29
Index 23
FENOFIBRIC ACID
29
FENOGLIDE
29
FENOPROFEN CALCIUM 5
FENOPROFEN CALCIUM 200
MG, 400 MG
5
FENORTHO 200 MG, 400
MG
5
fentanyl 12 mcg/hr
8
fentanyl 25 mcg/hr, 100 mcg/hr,
75 mcg/hr, 50 mcg/hr
8
FENTANYL 87.5 MCG/HR,
62.5 MCG/HR, 37.5
MCG/HR
8
fentanyl citrate
8
FENTORA
8
FEOSOL 200 MG
88
FER-IN-SOL
88
FERGON
88
ferrous fumarate 324 mg 89
ferrous fumarate-fa-b complexc-zn-mg-mn-cu
88
FERROUS GLUCONATE 225
MG
89
ferrous gluconate 240 mg, 27
mg, 324 mg
89
ferrous sulfate
89
FERROUS SULFATE
89
FERROUS SULFATE 140
MG
89
ferrous sulfate 142 mg, 45
mg
89
FERROUS SULFATE 324
MG
89
ferrous sulfate 325 mg, 65
mg
89
ferrous sulfate dried
89
FETZIMA
21
FETZIMA TITRATION
PACK
21
FEVERALL INFANTS
7
FEXMID
167
fexofenadine hcl
28
fexofenadine hcl 180 mg 28
fexofenadine hcl 60 mg
28
FIBERCON
90
FIBRACOL COLLAGENALGINATE WOUND
DRESSING/2" X 2"
71
FIBRACOL COLLAGENALGINATE WOUND
DRESSING/4" X 8-3/4"
71
FIBRICOR
29
FIFTY50 ALCOHOL PREP
PADS
111
FIFTY50 CONTROL
SOLUTION2.0
99
FIFTY50 GLUCOSE TEST
STRIP 2.0
78
FIFTY50 LANCING DEVICE 99
FIFTY50 PEN NEEDLES 31G
X3/16" (5MM)
120
FIFTY50 PEN NEEDLES 31G
X5/16" (8MM)
120
FIFTY50 PEN NEEDLES
31GX5MM
120
FIFTY50 PEN
NEEDLES/31GX8MM
120
FIFTY50 PEN
NEEDLES/32GX4MM
120
FIFTY50 PEN
NEEDLES/32GX6MM
120
FIFTY50 SAFETY SEAL
LANCETS 30G
99
FIFTY50 SAFETY SEAL
LANCETS 32G
99
FIFTY50 SUPERIOR
COMFORTINSULIN
SYRINGE/0.3ML/31G X
5/16"
120
FIFTY50 SUPERIOR
COMFORTINSULIN
SYRINGE/0.5ML/31G X
5/16"
120
FIFTY50 SUPERIOR
COMFORTINSULIN
SYRINGE/1ML/31G X
5/16"
120
FIFTY50 UNILET LANCETS
33G
99
FILTER AIR PP
141
finasteride
87
FINE 30
99
FINGERSTIX LANCETS
99
FIORINAL
6
FIORINAL/CODEINE #3
9
FITNESS TABS FOR MEN
AM/PM/LYCOPENE
154
FITNESS TABS FOR WOMEN
AM/PM/LYCOPENE
154
FLAGYL
12
FLAREX
173
flavoxate hcl
182
flecainide acetate
14
FLECTOR
52
FLEET ENEMA
91
FLEET ENEMA SIX PACK 91
FLEET PEDIATRIC
91
FLEXICHAMBER
141
FLINTSTONES GUMMIES 159
FLINTSTONES GUMMIES
COMPLETE 1.25MG-15MCG2.5MG-1000UNIT-1.5MCG300UNIT-100MCG-9UNIT37.5MCG-0.5MG-15MG
159
FLINTSTONES GUMMIES
COMPLETE 1.25MG-15MCG2.5MG-1000UNIT-1.5MG300UNIT-100MCG-9UNIT37.5MCG-0.5MG-15MG
159
FLINTSTONES GUMMIES
PLUSIMMUNITY
SUPPORT/EXTRA C
160
FLINTSTONES SOUR
GUMMIES
160
FLINTSTONES
TODDLER/TASTISMOOTH
160
FLOMAX
87
FLONASE ALLERGY
RELIEF
168
FLONASE ALLERGY RELIEF
CHILDRENS
168
FLONASE SENSIMIST
168
FLORIVA PLUS
159
FLOVENT DISKUS
15
FLOVENT HFA
15
FLOXIN OTIC
175
FLUAD 2016-2017
183
FLUARIX 2014-2015
183
FLUARIX QUADRIVALENT
2014-2015
183
FLUARIX QUADRIVALENT
2015-2016
183
FLUARIX QUADRIVALENT
2016-2017
183
FLUBLOK 2014-2015
183
FLUBLOK 2015-2016
183
FLUBLOK 2016-2017
183
FLUCELVAX QUADRIVALENT
2016-2017
183
fluconazole
27
flucytosine
27
fludrocortisone acetate
47
FLULAVAL 2014-2015
183
FLULAVAL QUADRIVALENT
2014-2015
183
FLULAVAL QUADRIVALENT
2015-2016
183
FLULAVAL QUADRIVALENT
2016-2017
183
FLUMADINE
42
flunisolide (nasal)
168
fluocinolone acetonide
57
fluocinolone acetonide
(otic)
175
fluocinonide
57
fluocinonide emulsified
base
57
fluorometholone (ophth) 173
FLUOROURACIL
54
fluorouracil (topical)
54
FLUOXETINE
177
FLUOXETINE DR
20
fluoxetine hcl
20
fluoxetine hcl 10 mg, 20
mg
20
FLUOXETINE HCL 60 MG 20
fluphenazine decanoate 38
FLUPHENAZINE HCL
38
fluphenazine hcl
38
flurandrenolide
57
FLURAZEPAM HCL
90
flurbiprofen
5
flurbiprofen sodium
174
flutamide
34
fluticasone propionate
57
fluticasone propionate
(nasal)
168
fluvastatin sodium
30
FLUVIRIN 2014-2015
183
FLUVIRIN 2015-2016
183
FLUVIRIN 2016-2017
183
fluvoxamine maleate
20
FLUZONE HIGH-DOSE PF
2014-2015
183
FLUZONE HIGH-DOSE PF
2015-2016
183
FLUZONE HIGH-DOSE PF
2016-2017
183
FLUZONE INTRADERMAL
QUADRIVALENT 20152016
183
FLUZONE INTRADERMAL
QUADRIVALENT 20162017
184
FLUZONE PF 2014-2015 184
FLUZONE QUADRIVALENT
2014-2015
184
FLUZONE QUADRIVALENT
2015-2016
184
FLUZONE QUADRIVALENT
2016-2017
184
FLUZONE SPLIT 20142015
184
FLUZONE SPLIT 20152016
184
FML
173
FML FORTE
173
FML LIQUIFILM
173
FOAM DRESSING
BORDERED
72
FOAM DRESSING CIRCULAR
BORDERED
72
FOAM DRESSING NONBORDERED
72
FOCALGIN 90 DHA
161
FOCALGIN CA
161
FOCALIN 10 MG
3
FOCALIN 2.5 MG
3
FOCALIN 5 MG
3
FOCALIN XR
3
FOLBEE AR
81
FOLCAL DHA
161
FOLCAPS OMEGA 3
161
FOLIC ACID
88
folic acid 1 mg
88
folic acid 400 mcg, 800 mcg 88
folic acid-vitamin b6-vitamin b12
115mcg-800mcg-10mg
88
FOLIVANE-OB
161
fondaparinux sodium
16
FORA BLOOD GLUCOSE TEST
STRIPS
78
FORA CONTROL SOLUTION
HIGH
99
FORA CONTROL SOLUTION
LOW
99
FORA CONTROL SOLUTION
NORMAL
100
FORA D15G BLOOD GLUCOSE
TEST STRIPS
78
FORA D20 BLOOD GLUCOSE
TEST STRIPS
78
FORA D40/G31 BLOOD
GLUCOSE TEST STRIPS 78
FORA G20 BLOOD GLUCOSE
TEST STRIPS
78
FORA G30A BLOOD GLUCOSE
TEST STRIPS
78
FORA GD20 TEST STRIPS 78
FORA GD50 BLOOD GLUCOSE
TEST STRIPS
78
FORA LANCETS
100
FORA LANCING DEVICE 100
FORA LANCING
DEVICE/CLEARCAP
100
Index 24
FORA TN'G/TN'G VOICE
BLOOD GLUCOSE TEST
STRIPS
78
FORA V10 BLOOD GLUCOSE
TEST STRIPS
78
FORA V12 BLOOD GLUCOSE
TEST STRIPS
78
FORA V20 BLOOD GLUCOSE
TEST STRIPS
78
FORA V30A BLOOD GLUCOSE
TEST STRIPS
78
FORACARE GD40
78
FORACARE GDH CONTROL
SOLUTION HIGH
100
FORACARE GDH CONTROL
SOLUTION LOW
100
FORACARE GDH CONTROL
SOLUTION NORMAL
100
FORACARE PREMIUM V10
TESTSTRIPS
78
FORACARE TEST N GO TEST
STRIPS
78
FORADIL AEROLIZER
15
FORFIVO XL
20
formaldehyde 10%, 10 %
39
FORMULA 405 ENRICHED
EYE
61
FORMULA 405 FACE
CREAM
61
FORMULA 405 LIGHT
TEXTURED MOISTURIZER 61
FORMULA 405
MOISTURIZING
61
FORTAMET
22
FORTAVIT
154
FORTEO
83
FORTESTA
11
FORTICAL
83
FORTISCARE BLOOD
GLUCOSETEST STRIP
78
FORTISCARE CONTROL
SOLUTIONS HIGH
100
FORTISCARE CONTROL
SOLUTIONS LOW
100
FORTISCARE CONTROL
SOLUTIONS NORMAL
100
FOSAMAX
83
FOSAMAX PLUS D
83
FOSFREE
154
fosinopril sodium
30
fosinopril sodium &
hydrochlorothiazide
32
fosphenytoin sodium
19
FOSRENOL
86
FRAGMIN
16
Index 25
FREDS PHARMACY
AUTOLET LANCING
DEVICE
100
FREDS PHARMACY UNIFINE
PENTIPS PEN NEEDLES
32GX4MM
120
FREDS PHARMACY UNIFINE
PENTIPS PLUS
31GX5MM
121
FREDS PHARMACY UNIFINE
PENTIPS PLUS
31GX8MM
121
FREDS PHARMACY UNILET
LANCETS SUPER THIN
30G
100
FREDS PHARMACY UNILET
LANCETS ULTRA THIN
28G
100
FREEDAVITE
154
FREESTYLE CONTROL
SOLUTION
100
FREESTYLE CONTROL
SOLUTION HIGH/LOW 100
FREESTYLE INSULINX
BLOODGLUCOSE TEST 78
FREESTYLE INSULINX
BLOODGLUCOSE TEST
STRIPS
78
FREESTYLE LANCETS 100
FREESTYLE LITE TEST
STRIPS
78
FREESTYLE PRECISION
INSULIN SYRINGE/U100/0.5ML/30G X 5/16" 121
FREESTYLE PRECISION
INSULIN SYRINGE/U100/0.5ML/31G X 5/16" 121
FREESTYLE PRECISION
INSULIN SYRINGE/U100/1ML/31G X 5/16"
121
FREESTYLE PRECISION
INSULIN SYRINGES/U100/1ML/30G X 5/16"
121
FREESTYLE PRECISION NEO
BLOOD GLUCOSE TEST
STRIPS
78
FREESTYLE TEST
STRIPS
78
FREESTYLE UNISTICK II
LANCETS
100
FROVA
144
frovatriptan succinate
144
fructose-dextrose-phosphoric
acid
26
FRUIT C 200
150
FULL KIT NEBULIZER
SET
141
FUNGOID TINCTURE
53
FURADANTIN
182
furosemide
82
furosemide 10 mg/ml
82
FUROSEMIDE 8 MG/ML
82
FYCOMPA
16
gabapentin
17
GABITRIL 16 MG, 12 MG
19
GABITRIL 2 MG, 4 MG
19
galantamine hydrobromide 176
GALANTAMINE
HYDROBROMIDE
176
GAS-X
85
GAS-X EXTRA STRENGTH 85
gatifloxacin (ophth)
172
GE100 BLOOD GLUCOSE
TESTSTRIPS
78
GE100 CONTROL SOLUTION
NORMAL
100
GELNIQUE
182
GELNIQUE PUMP
182
gemfibrozil
29
GENOTROPIN
83
GENOTROPIN MINIQUICK 83
GENSTRIP 50
78
GENTAMICIN SULFATE
52
gentamicin sulfate (ophth) 172
gentamicin sulfate (topical) 52
GENTEAL
170
GENTEAL MILD
170
GENTEAL MILD TO
MODERATE
170
GENTEAL SEVERE
170
GENTEAL TEARS
MODERATEPF
170
GENTLE
61
GENTLE-LET GP
LANCETS
100
GENTLE-LET LANCETS
GENERAL PURPOSE
STYLE/FINE POINT
100
GENTLE-LET LANCETS
GENERAL PURPOSE
STYLE/MEDIUM POINT
100
GENTLE-LET LANCETS
SAFETY STYLE/FINE
POINT
100
GENTLE-LET LANCETS
SAFETY STYLE/MEDIUM
POINT
100
GENVOYA
39
GEODON
37
GEODON 20 MG
37
GEODON 40 MG
37
GEODON 60 MG
37
GEODON 80 MG
37
GERI PROTECT
67
GERI-FREEDA SENIOR
FORMULA
154
GERI-SOFT
61
GHT TEST STRIPS
78
GIAZO
86
GILENYA
177
GILOTRIF
35
glatiramer acetate
177
GLEEVEC 100 MG, 400 MG 35
GLEEVEC 400 MG
35
GLEOSTINE
33
glimepiride
25
glipizide
25
glipizide-metformin hcl
22
GLOBAL ALCOHOL PREP
EASEPADS
111
GLOBAL EASE INJECT PEN
NEEDLES 29GX12MM
121
GLOBAL EASE INJECT PEN
NEEDLES 31GX8MM
121
GLOBAL EASE INJECT PEN
NEEDLES 32GX4MM
121
GLOBAL EASE INJECT PEN
NEEEDLES 31GX5MM
121
GLOBAL EASY GLIDE
INSULINSYRINGE/U100/0.3ML/31G X 5/16"
121
GLOBAL EASY GLIDE PEN
NEEDLES 32GX4MM
121
GLOBAL INJECT EASE INSULIN
SYRINGE/U-100/0.3ML/29G X
1/2"
121
GLOBAL INJECT EASE INSULIN
SYRINGE/U-100/0.3ML/30G X
1/2"
121
GLOBAL INJECT EASE INSULIN
SYRINGE/U-100/0.3ML/30G X
5/16"
121
GLOBAL INJECT EASE INSULIN
SYRINGE/U-100/0.3ML/31G X
5/16"
121
GLOBAL INJECT EASE INSULIN
SYRINGE/U-100/0.5ML/28G X
1/2"
121
GLOBAL INJECT EASE INSULIN
SYRINGE/U-100/0.5ML/29G X
1/2"
121
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/0.5ML/30G X 1/2"
121
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/0.5ML/30G X 5/16" 121
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/0.5ML/31G X 5/16" 121
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/1ML/28G X 1/2"
121
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/1ML/29G X 1/2"
121
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/1ML/30G X 1/2"
121
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/1ML/30G X 5/16"
121
GLOBAL INJECT EASE
INSULIN SYRINGE/U100/1ML/31G X 5/16"
122
GLOBAL INJECT EASE
LANCETS 28G
100
GLOBAL INJECT EASE
LANCETS 30G
100
GLOBAL INSULIN
SYRINGE/U-100/0.3ML/30G X
1/2"
122
GLOBAL INSULIN
SYRINGES/U100/0.3ML/30GX5/16"
122
GLOBAL LANCING
DEVICE
100
GLUCAGEN
DIAGNOSTIC
76
GLUCAGEN HYPOKIT
23
GLUCAGON EMERGENCY
KIT
23
GLUCO PERFECT 3 TEST
STRIPS
78
GLUCOCARD 01 CONTROL
SOLUTION
NORMAL/HIGH
100
GLUCOCARD 01 CONTROL
SOLUTION/NORMAL
100
GLUCOCARD 01 SENSOR
PLUS
78
GLUCOCARD 01 SENSOR
PLUSTEST STRIPS
78
GLUCOCARD EXPRESSION
BLOOD GLUCOSE TEST
STRIPS
78
GLUCOCARD EXPRESSION
CONTROL SOLUTION LEVEL
1
100
GLUCOCARD SHINE CONTROL
SOLUTION LEVEL 1
100
GLUCOCARD SHINE TEST
STRIPS
79
GLUCOCARD VITAL TEST
STRIPS
79
GLUCOCARD X-METER
CONTROLSOLUTION/NORMAL
100
GLUCOCARD X-SENSOR 79
GLUCOCOM HIGH
CONTROL
100
GLUCOCOM LANCETS
28G
100
GLUCOCOM LANCETS
30G
100
GLUCOCOM LANCETS
33G
101
GLUCOCOM NORMAL
CONTROL
101
GLUCOCOM TEST STRIPS 79
GLUCOLET 2 AUTOMATIC
LANCING DEVICE
101
GLUCONAVII BLOOD
GLUCOSETEST STRIPS
79
GLUCOPHAGE
22
GLUCOPHAGE XR
22
GLUCOPRO INSULIN
SYRINGE/U-100/0.3ML/30G X
1/2"
122
GLUCOPRO INSULIN
SYRINGE/U-100/0.3ML/30G X
5/16"
122
GLUCOPRO INSULIN
SYRINGE/U-100/0.3ML/31G X
5/16"
122
GLUCOPRO INSULIN
SYRINGE/U-100/0.5ML/30G X
1/2"
122
GLUCOPRO INSULIN
SYRINGE/U-100/0.5ML/30G X
5/16"
122
GLUCOPRO INSULIN
SYRINGE/U-100/0.5ML/31G X
5/16"
122
GLUCOPRO INSULIN
SYRINGE/U-100/1ML/30G X
1/2"
122
GLUCOPRO INSULIN
SYRINGE/U-100/1ML/30G X
5/16"
122
GLUCOPRO INSULIN
SYRINGE/U-100/1ML/31G X
5/16"
122
GLUCOSE 4 GM
23
GLUCOSE 4GM-4GM-6MG,
4GM-6MG
23
Index 26
GLUCOSE CONTROL
NORMAL
101
GLUCOSE CONTROL
SOLUTION
101
GLUCOSE INSTANT
ENERGY
23
GLUCOSE METER TEST
STRIPS ADVANCED
79
GLUCOSOURCE LANCET
DEVICE
101
GLUCOSOURCE
LANCETS
101
GLUCOTROL
25
GLUCOTROL XL
25
GLUCOVANCE
22
GLUMETZA
22
glyburide
25
glyburide micronized
25
glyburide-metformin
22
GLYCERIN
45
glycerin (laxative) 1 gm, 80.7 %,
2 gm, 1.2 gm
91
glycerin (topical)
61
GLYCERIN ADULT
91
GLYCERINE
45
GLYCEROL FORMAL
45
glycopyrrolate
180
GLYNASE
25
GLYSET
22
GLYXAMBI
22
GMATE BLOOD GLUCOSE
TESTSTRIPS
79
GMATE CONTROL SOLUTION
LEVEL 2
101
GMATE LANCETS 30G
101
GMATE LANCING DEVICE101
GNP ADVANCED
RECOVERY
61
GNP ALCOHOL SWABS 111
GNP CHILDRENS COMPLETE
CHEWABLES
160
GNP CLICKFINE PEN
NEEDLEUNIVERSAL/31GX5/16"
122
GNP CLICKFINE UNIVERSAL
PEN NEEDLES 31GX1/4" 122
GNP CLICKFINE UNIVERSAL
PEN NEEDLES 31GX5/16" 122
GNP DAILY PRENATAL 161
GNP EASY TOUCH CONTROL
SOLUTION HIGH/LOW
101
GNP EASY TOUCH GLUCOSE
TEST STRIPS
79
Index 27
GNP GLUCOSE 4 GM
23
GNP GLUCOSE 4GM6MG
23
GNP INSULIN
SYRINGE/0.3ML/29G X
1/2"
122
GNP INSULIN
SYRINGE/0.3ML/30G X
5/16"
122
GNP INSULIN
SYRINGE/0.3ML/31G X
5/16"
122
GNP INSULIN
SYRINGE/0.5ML/28G X
1/2"
122
GNP INSULIN
SYRINGE/0.5ML/29G X
1/2"
122
GNP INSULIN
SYRINGE/0.5ML/30G X
5/16"
122
GNP INSULIN
SYRINGE/0.5ML/31G X
5/16"
122
GNP INSULIN
SYRINGE/1ML/28G X
1/2"
122
GNP INSULIN
SYRINGE/1ML/29G X
1/2"
122
GNP INSULIN
SYRINGE/1ML/30G X
5/16"
122
GNP INSULIN
SYRINGE/1ML/31G X
5/16"
122
GNP LANCETS
101
GNP LANCETS 21G
101
GNP LANCETS MICRO THIN
33G
101
GNP LANCETS SUPER THIN
30G
101
GNP LANCETS THIN
101
GNP LANCETS THIN
26G
101
GNP MICRO THIN LANCETS
33G
101
GNP PRENATAL
161
GNP QUICK DISSOLVE
GLUCOSE
23
GNP SUPER THIN
LANCETS/30G
101
GNP ULTRA COMFORT
INSULIN SYRINGE/0.3ML/29G
X 1/2"
122
GNP ULTRA COMFORT
INSULIN SYRINGE/0.3ML/30G
X 5/16" SHORT
122
GNP ULTRA COMFORT
INSULIN SYRINGE/0.3ML/31G X
5/16" SHORT
123
GNP ULTRA COMFORT
INSULIN SYRINGE/0.5ML/28G X
1/2"
123
GNP ULTRA COMFORT
INSULIN SYRINGE/0.5ML/29G X
1/2"
123
GNP ULTRA COMFORT
INSULIN SYRINGE/0.5ML/30G X
5/16" SHORT
123
GNP ULTRA COMFORT
INSULIN SYRINGE/0.5ML/31G X
5/16" SHORT
123
GNP ULTRA COMFORT
INSULIN SYRINGE/1ML/28G X
1/2"
123
GNP ULTRA COMFORT
INSULIN SYRINGE/1ML/29G X
1/2"
123
GNP ULTRA COMFORT
INSULIN SYRINGE/1ML/30G X
5/16" SHORT
123
GNP ULTRA COMFORT
INSULIN SYRINGE/1ML/31G X
5/16" SHORT
123
GNP VITAMIN D-400
145
GOLD BOND
67
GOLD BOND EXTRA
STRENGTH
67
GOLD BOND MEDICATED
BODYLOTION
62
GOLD BOND MEDICATED
BODYLOTION EXTRA
STRENGTH
62
GOLD BOND ULTIMATE
62
GOLD BOND ULTIMATE
DIABETICS' DRY RELIEF 62
GOLD BOND ULTIMATE
HEALING
62
GOLD BOND ULTIMATE
PROTECTION
62
GOLD BOND ULTIMATE
RESTORING
62
GOLD BOND ULTIMATE
SHEERRIBBONS
PEARLRADIANCE
62
GOLD BOND ULTIMATE
SHEERRIBBONS
SILKSOFTNESS
62
GOLD BOND ULTIMATE
SOFTENING
62
GOLD BOND ULTIMATE
SOOTHING
62
GOLYTELY 236GM-22.74GM5.86GM-2.97GM-6.74GM
90
GONAK
170
GONIOSOL
170
GOODSENSE GLUCOSE 23
GOODSENSE LANCING
DEVICE
101
GOODSENSE PRENATAL
VITAMINS
161
granisetron hcl
26
GRANIX
88
GRASTEK
3
GREEN SOURCE
166
GRIFULVIN V
27
GRIS-PEG
27
griseofulvin microsize
27
griseofulvin ultramicrosize 27
GRX HYDROGEL GAUZE
2X2
72
GRX HYDROGEL GAUZE
4X4
72
GRX VITAMIN E
62
guaifenesin
49
guaifenesin 200 mg
49
guaifenesin 400 mg/20ml, 100
mg/5ml
49
guaifenesin 600 mg
49
guaifenesin-codeine
48
guaifenesin-codeine 100mg/5ml10mg/5ml
48
guanfacine hcl
31
guanfacine hcl (adhd)
2
GYNAZOLE-1
184
GYNE-LOTRIMIN
184
GYNE-LOTRIMIN 3
184
H-E-B IN CONTROL PEN
NEEDLES 31GX5MM
123
H-E-B IN CONTROL PEN
NEEDLES 31GX6MM
123
H-E-B IN CONTROL PEN
NEEDLES 31GX8MM
123
H-E-B IN CONTROL PEN
NEEDLES/NANO/32GX4MM
123
H-E-B IN CONTROL
UNIFINEPENTIPS PLUS
31GX5MM
123
H-E-B IN CONTROL
UNIFINEPENTIPS PLUS
32GX4MM
123
H-E-B INCONTROL
ADVANCEDLANCING
DEVICE
101
H-E-B INCONTROL ALCOHOL
PADS
111
H-E-B INCONTROL LANCETS
MICRO THIN 33G
101
H-E-B INCONTROL LANCETS
SUPER THIN 30G
101
H-E-B INCONTROL LANCETS
ULTRA THIN 28G
101
H-E-B INCONTROL PEN
NEEDLES 29GX12MM 123
HAEMOLANCE
101
HAEMOLANCE LOW FLOW
LANCETS
101
HAEMOLANCE PLUS
101
HAEMOLANCE PLUS HIGH
FLOW
101
HAEMOLANCE PLUS LOW
FLOW
101
HAEMOLANCE PLUS MAX
FLOW
101
HAEMOLANCE PLUS
PEDIATRIC FLOW
101
HAIR FARE
166
HAIR NOURISHING
SUPPLEMENT
166
HAIR-VITES
154
HAIR/SKIN/NAILS
154
HALCION
90
HALDOL
37
HALDOL DECANOATE
100
37
HALDOL DECANOATE 50 37
halobetasol propionate
57
HALOG
57
haloperidol
38
haloperidol decanoate
38
haloperidol lactate
38
HARVONI
41
HEALTH CARE LANCING
DEVICE
101
HEALTHWISE ALCOHOL
PREP PADS
111
HEALTHWISE LANCETS
30G
101
HEALTHWISE LANCING
PEN
101
HEALTHWISE MINI PEN
NEEDLES 31GX6MM
123
HEALTHWISE PEN NEEDLES
29GX12MM
123
HEALTHWISE SHORT PEN
NEEDLES 31GX8MM
123
HEALTHWISE UNIFINE
PENTIPS PEN NEEDLES
32GX4MM
123
HEALTHY ACCENTS
AUTOLET IMPRESSION
LANCING DEVICE
101
HEALTHY ACCENTS UNIFINE
PENTIPS PEN NEEDLES
29GX12MM
123
HEALTHY ACCENTS UNIFINE
PENTIPS PEN NEEDLES
31GX5MM
123
HEALTHY ACCENTS UNIFINE
PENTIPS PEN NEEDLES
31GX6MM
123
HEALTHY ACCENTS UNIFINE
PENTIPS PEN NEEDLES
31GX8MM
123
HEALTHY ACCENTS UNIFINE
PENTIPS PEN NEEDLES
32GX4MM
123
HEALTHY ACCENTS UNILET
LANCETS SUPER THIN
30G
101
HEALTHY HEART
COMPLEX
166
HEALTHY KIDS GUMMIES160
HEALTHY LIVING
REPLACEMENT FILTERS 141
HEALTHY LIVING
REPLACEMENT KIT FOR
NEBULIZER
141
HEALTHY LIVING
REPLACEMENT MASKS 141
HEART
166
HEMANGEOL
43
HEMENATAL OB
161
HEMENATAL OB + DHA 161
HEMOCYTE
89
heparin sodium (porcine)
16
HEPSERA
41
HETLIOZ
90
HEXALEN
33
HIBICLENS
39
HIGH SENSATION
SPERMICIDAL
92
HM COMPLETE
154
HM COMPLETE 50+ MENS
ULTIMATE
154
HM COMPLETE 50+ WOMENS
ULTIMATE
154
HM ESTROPLUS
166
HM GLUCOSE
23
HM HAIR/SKIN/NAILS
154
HM ONE DAILY
ESSENTIAL
150
HM ONE DAILY MENS
154
HM ONE DAILY PRENATAL
COMBO
161
HM ONE DAILY WOMENS 154
Index 28
HM PRENATAL
161
HONEY BEARS
160
HUDSON RCI SEE-THRU
AEROSOL MASK
ELONGATED/ADULT
141
HUMALOG
24
HUMALOG KWIKPEN 100
UNIT/ML
24
HUMALOG KWIKPEN 200
UNIT/ML
24
HUMALOG MIX 50/50
24
HUMALOG MIX 50/50
KWIKPEN
24
HUMALOG MIX 75/25
24
HUMALOG MIX 75/25
KWIKPEN
24
HUMATROPE
83
HUMATROPE COMBO
PACK
83
HUMIRA 20 MG/0.4ML, 10
MG/0.2ML
4
HUMIRA 40 MG/0.8ML
4
HUMIRA PEDIATRIC CROHNS
DISEASE STARTER PACK 4
HUMIRA PEN
4
HUMIRA PEN-CROHNS
DISEASESTARTER
4
HUMIRA PEN-PSORIASIS
STARTER
4
HUMULIN 70/30
24
HUMULIN 70/30 KWIKPEN 24
HUMULIN N
24
HUMULIN N KWIKPEN
24
HUMULIN R
24
HUMULIN R U-500
(CONCENTRATED)
24
HUMULIN R U-500
KWIKPEN
24
HY-VEE GLUCOSE
23
HY-VEE LANCETS
101
HY-VEE THIN LANCETS 101
HYALEX
154
HYCAMTIN
35
HYCET
9
HYCOLOID-GRX
72
hydralazine hcl
33
HYDRASYN25
62
HYDREA
35
HYDRO-LAN
62
HYDROCERIN
67
hydrochlorothiazide
82
Index 29
hydrochlorothiazide 25 mg, 50
mg
82
HYDROCIL INSTANT
90
hydrocodone w/
homatropine
47
hydrocodoneacetaminophen
9
hydrocodone-acetaminophen
10mg/15ml-325mg/15ml
9
hydrocodone-acetaminophen
7.5mg/15ml-325mg/15ml,
5mg/10ml-217mg/10ml,
2.5mg/5ml-108mg/5ml
9
hydrocodone-ibuprofen 200mg2.5mg, 200mg-5mg, 200mg10mg
9
hydrocodone-ibuprofen 200mg7.5mg, 200mg-10mg, 200mg5mg
9
HYDROCOL II
72
HYDROCOL II SACRAL 72
HYDROCOL II THIN
72
hydrocortisone
47
hydrocortisone (intrarectal) 11
hydrocortisone (rectal)
12
hydrocortisone (topical)
57
hydrocortisone (topical) 0.5 %,
2.5 %
57
hydrocortisone (topical) 1
%
57
hydrocortisone (topical) 1%, 1
%
57
hydrocortisone (topical) 2.5 %,
0.5 %
57
hydrocortisone (topical) 2.5 %,
1%
57
hydrocortisone acetate
(topical)
57
hydrocortisone butyrate
57
hydrocortisone butyrate
hydrophilic lipo base
57
hydrocortisone valerate
58
hydrocortisone w/acetic
acid
175
hydrocortisone-aloe vera 58
HYDROFERA BLUE 4"X4" 72
HYDROFERA BLUE FOAM
DRESSING
72
HYDROFERA BLUE FOAM
DRESSING 2"X2"
72
HYDROFERA BLUE FOAM
DRESSING 4"X4"
72
HYDROFERA BLUE FOAM
DRESSING 6"X6"
72
HYDROFERA BLUE FOAM
DRESSING/MOISTURE
RETENTIVE FILM
72
HYDROFERA BLUE FOAM
DRESSING/MOISTURE
RETENTIVE FILM/2-1/4X8 72
HYDROFERA BLUE FOAM
DRESSING/MOISTURE
RETENTIVE FILM/4"X4"
72
HYDROFERA BLUE FOAM
DRESSING/MOISTURE
RETENTIVE FILM/ISLAND 72
HYDROFERA BLUE FOAM
DRESSING/MOISTURE
RETENTIVE/OSTOMY/2.5" 72
HYDROFERA BLUE FOAM
DRESSING/TUNNELING/9MM
72
HYDROFERA BLUE HEAVY
DRAINAGE 4"X4"
72
HYDROFERA BLUE HEAVY
DRAINAGE 6"X6"
72
HYDROFERA BLUE READY
FOAMDRESSING 2.5"X2.5" 72
HYDROFERA BLUE READY
FOAMDRESSING 4"X5"
72
HYDROFERA BLUE READY
FOAMDRESSING 8"X8"
72
hydromorphone hcl
8
HYDROMORPHONE HCL
8
hydromorphone hcl 12 mg, 8mg,
8 mg, 16 mg
8
hydromorphone hcl 32 mg
8
hydroxychloroquine sulfate 33
hydroxyurea
35
HYDROXYZINE PAMOATE 100
MG
13
hydroxyzine pamoate 50 mg, 25
mg
13
hyoscyamine sulfate
180
HYPER-SAL
49
HYPERSAL 3.5 %
49
HYPERSAL 7 %
49
HYPOTEARS
170
hypromellose (gonioscopic) 170
hypromellose (ophth)
170
HYSINGLA ER
8
HYVEE ADVANCED ANTACID
MAXIMUM STRENGTH
12
HYZAAR
32
ibandronate sodium
83
IBRANCE
35
IBUDONE
10
ibuprofen
5
ibuprofen 100 mg/5ml
5
ibuprofen 40 mg/ml, 50
mg/1.25ml
5
ICAPS AREDS FORMULA 154
ICAPS PLUS
154
ICLUSIG 15 MG
35
ICLUSIG 45 MG
35
ILEVRO
174
imatinib mesylate
35
IMBRUVICA
35
imipramine hcl
21
imipramine pamoate
21
imiquimod
65
IMITREX
144
IMITREX 20 MG/ACT
144
IMITREX 5 MG/ACT
144
IMITREX 6 MG/0.5ML
144
IMITREX STATDOSE
REFILL
144
IMITREX STATDOSE SYSTEM 4
MG/0.5ML
144
IMITREX STATDOSE SYSTEM 6
MG/0.5ML
144
IMMUNE SUPPORT
154
IMMUNE SUPPORT VITAMIN
C
154
IMODIUM A-D
25
IMURAN
147
IN TOUCH BLOOD GLUCOSE
TEST STRIPS
79
IN TOUCH GLUCOSE
CONTROLSOLUTION
101
IN TOUCH LANCING
DEVICE
101
IN TOUCH STERILE
LANCETS30G
101
INATAL ADVANCE
161
INATAL GT
161
INATAL ULTRA
161
INCRUSE ELLIPTA
14
indapamide
82
INDERAL LA
43
INDERAL XL
43
INDOCIN
5
indomethacin
5
INFANATE BALANCE
161
INFANATE PLUS
161
INFANTS ADVIL
5
INFANTS SILAPAP
7
INFINITY BLOOD GLUCOSE
TEST STRIPS
79
INFINITY CONTROL
SOLUTION HIGH
102
INFINITY CONTROL
SOLUTION LOW
102
INFINITY CONTROL
SOLUTION NORMAL
102
INLYTA
35
INNOPRAN XL
43
INNOSPIRE REPLACEMENT
FILTER
141
inositol niacinate
44
INSPIRACHAMBER/ANTISTATIC
VALVED/MOUTHPIECE 141
INSPIRACHAMBER/LARGE
141
INSPIRACHAMBER/SOOTHE
RMASK/INSPIRAMASK/MEDIU
M
141
INSPIRACHAMBER/SOOTHE
RMASK/INSPIRAMASK/SMAL
L
141
INSPIREASE BAGS
141
INSPIREASE DRUG
DELIVERYSYSTEM
141
INSPIREASE RESERVOIR
BAGS
141
INSTA-GLUCOSE
23
INSULIN SYRINGE/0.3ML/29G
X 1"
123
INSULIN SYRINGE/0.3ML/29G
X 1/2"
123
INSULIN SYRINGE/0.3ML/30G
X 5/16"
124
INSULIN SYRINGE/0.3ML/31G
X 5/16"
124
INSULIN SYRINGE/0.5ML/27G
X 1/2"
124
INSULIN SYRINGE/0.5ML/28G
X 1/2"
124
INSULIN SYRINGE/0.5ML/29G
X 1/2"
124
INSULIN SYRINGE/0.5ML/30G
X 1/2"
124
INSULIN SYRINGE/0.5ML/30G
X 5/16"
124
INSULIN SYRINGE/0.5ML/31G
X 5/16"
124
INSULIN SYRINGE/1ML/28G X
1/2"
124
INSULIN SYRINGE/1ML/29G X
1/2"
124
INSULIN SYRINGE/1ML/30G X
5/16"
124
INSULIN SYRINGE/1ML/31G X
5/16"
124
INSULIN SYRINGE/U100/0.3ML/29G X 1/2"
124
INSULIN SYRINGE/U100/0.5ML/28G X 1/2"
124
INSULIN SYRINGE/U100/0.5ML/29G X 1/2"
124
INSULIN SYRINGE/U100/1ML/28G X 1/2"
124
INSULIN SYRINGE/U100/1ML/29G X 1/2"
124
INSULIN SYRINGE/U100/1ML/30G X 5/16"
124
INSULIN SYRINGE/U100/1ML/31G X 5/16"
124
INSULIN
SYRINGES/0.5ML/27GX1/2"
124
INSULIN
SYRINGES/0.5ML/28GX1/2"
124
INSULIN
SYRINGES/0.5ML/29GX1/2"
124
INSULIN
SYRINGES/0.5ML/30GX5/16"
124
INSULIN
SYRINGES/0.5ML/31GX
5/16"
124
INSULIN
SYRINGES/0.5ML/31GX5/16"
124
INSULIN
SYRINGES/1ML/27GX/1/2"
124
INSULIN
SYRINGES/1ML/27GX1/2" 124
INSULIN
SYRINGES/1ML/28GX1/2" 124
INSULIN
SYRINGES/1ML/29GX1/2" 124
INSULIN
SYRINGES/1ML/30GX1/2" 124
INSULIN
SYRINGES/1ML/31GX5/16"
124
INSUPEN PEN NEEDLES 32G
X4MM
124
INSUPEN SENSITIVE
32GX6MM
125
INSUPEN ULTRAFIN
29GX12MM
125
INSUPEN ULTRAFIN
30GX8MM
125
INSUPEN ULTRAFIN
31GX6MM
125
INSUPEN ULTRAFIN
31GX8MM
125
INTEGRA
88
Index 30
INTELENCE 100 MG, 25
MG
39
INTELENCE 200 MG
39
INTENSE SENSATION
92
INTERMEZZO
90
INTUNIV
2
INVEGA 3 MG, 1.5 MG, 9
MG
37
INVEGA 6 MG
37
INVEGA SUSTENNA
37
INVEGA TRINZA
37
INVIRASE
39
INVOKAMET
22
INVOKAMET XR
22
INVOKANA
25
IOPIDINE 0.5 %
172
IOPIDINE 1 %
172
ipratropium bromide
14
ipratropium bromide (nasal) 168
ipratropium-albuterol
15
irbesartan
31
irbesartan-hydrochlorothiazide
32
IRENKA
21
IRESSA
35
iron polysaccharide complex-vit
b12-folic acid
88
ISENTRESS
40
ISENTRESS 100 MG
40
ISENTRESS 25 MG
40
isometheptene-caffeineacetaminophen
143
isometheptenedichloralphenazoneacetaminophen
143
ISONIAZID
33
isoniazid
33
ISOPTO ATROPINE
171
ISOPTO CARPINE
171
ISOPTO TEARS
170
ISORDIL TITRADOSE 5 MG 13
isosorbide dinitrate
13
ISOSORBIDE DINITRATE
ER
13
isosorbide mononitrate
13
isotretinoin 20 mg, 10 mg, 40
mg
51
isradipine
43
ISTALOL
171
itraconazole
27
Index 31
J & J BURN CREAM
62
JADENU
26
JAKAFI
35
JALYN
87
JANUMET
22
JANUMET XR
22
JANUVIA
23
JARDIANCE
25
JENTADUETO
22
JENTADUETO XR
22
JUBLIA
53
JUXTAPID
30
K-PAX IMMUNE SUPPORT
FORMULA DOUBLE
STRENGTH
154
K-PAX IMMUNE SUPPORT
FORMULA PROFESSIONAL
STRENGTH
154
K-PAX IMMUNE SUPPORT
FORMULA SINGLE
STRENGTH
154
K-PHOS NEUTRAL
146
K-TAB 10 MEQ
146
K-TAB 8 MEQ
146
KADIAN 10 MG, 20 MG, 30
MG, 50 MG, 60 MG, 80 MG 8
KADIAN 100 MG
8
KADIAN 200 MG
8
KADIAN 40 MG
8
KALBITOR
88
KALETRA
40
KALETRA 100MG-25MG 40
KALETRA 200MG-50MG 40
KALTOSTAT
72
KALTOSTAT FORTEX
72
KALTOSTAT WOUND
DRESSING
72
KALYDECO
178
KAMELEON
LUBRICATED
92
KAPVAY
2
KAYEXALATE
148
KAZANO
22
KEFLEX
45
KENALOG
58
KENDALL ALGINATE
HYDROCOLLOID DRESSING
4"X4"
72
KENDALL ALGINATE
HYDROCOLLOID DRESSING
4"X5"
72
KENDALL ALGINATE
HYDROCOLLOID DRESSING
6"X6"
72
KENDALL ALGINATE
HYDROCOLLOID DRESSING
6"X7"
72
KENDALL ALGINATE
HYDROCOLLOID DRESSING
8"X8"
73
KENDALL ZINC CALCIUM
ALGINATE DRESSING
2"X2"
73
KENDALL ZINC CALCIUM
ALGINATE DRESSING
4"X4"
73
KENDALL ZINC CALCIUM
ALGINATE DRESSING
4"X8"
73
KEPPRA
17
KEPPRA 100 MG/ML
17
KEPPRA 500 MG/5ML
17
KEPPRA XR
17
KERADAN
62
KERAMATRIX REPLICINE
10CMX10CM
73
KERAMATRIX REPLICINE
5CMX5CM
73
KERI ADVANCED MOISTURE
THERAPY
62
KERI BASIC ESSENTIALS 62
KERI LONG LASTING
62
KERI NOURISHING SHEA
BUTTER
62
KERI ORIGINAL
62
KERI OVERNIGHT
62
KERI RENEWAL MILK
BODY
62
KERI RENEWAL SKIN
FIRMING
62
KERI RENEWAL STRETCH
MARK MINIMIZER
62
KERI SENSITIVE SKIN
62
KERLIX SUPER SPONGE
SALINE DRESSING
73
KETEK
12
KETOCARE
79
ketoconazole
27
ketoconazole (topical)
53
KETONE TEST STRIPS
79
ketoprofen
5
KETOPROFEN ER
5
ketorolac tromethamine
5
ketorolac tromethamine
(ophth)
174
KETOSTIX
79
ketotifen fumarate (ophth) 174
KHEDEZLA
21
KIDNEY
166
KIMONO COLORS
92
KIMONO LUBRICATED
92
KIMONO MICRO THIN PLUS
SPERMICIDE LUBRICATED92
KIMONO PLUS SPERMICIDE
LUBRICATED
92
KIMONO PLUS
SPERMICIDE/LUBRICATED
92
KIMONO PS LUBRICATED 92
KIMONO PS PLUS
SPERMICIDE/LUBRICATED
92
KIMONO SENSATION
LUBRICATED
92
KIMONO SENSATION PLUS
SPERMICIDE LUBRICATED92
KIMONO SPECIAL
92
KINERET
4
KINNEY LANCETS
102
KINNEY THIN LANCETS 102
KINRAY INSULIN SYRINGE
PREFERRED PLUS/0.3ML/31G
X 5/16"
125
KINRAY INSULIN SYRINGE
PREFERRED PLUS/0.5ML/31G
X 5/16"
125
KINRAY INSULIN SYRINGE
PREFERRED PLUS/1ML/31G X
5/16"
125
KINRAY INSULIN
SYRINGE/0.5ML/29G X
1/2"
125
KITABIS PAK
3
KLARON
51
KLONOPIN
17
KLOR-CON M15
146
KMART VALU PLUS INSULIN
SYRINGE/1ML/29G
125
KMART VALU PLUS INSULIN
SYRINGE/1ML/30G
125
KOMBIGLYZE XR
22
KONSYL 100 %
90
KP PRENATAL
MULTIVITAMINS
161
KP WOMENS DAILY
PACK
154
KPN PRENATAL
161
KROGER BLOOD GLUCOSE
TESTSTRIPS
79
KROGER GLUCOSE
23
KROGER INSULIN
SYRINGE/0.3ML/29G X
1/2"
125
KROGER INSULIN
SYRINGE/0.3ML/30G X
5/16"
125
KROGER INSULIN
SYRINGE/0.3ML/31G X
5/16"
125
KROGER INSULIN
SYRINGE/0.5ML/29G X
1/2"
125
KROGER INSULIN
SYRINGE/0.5ML/30G X
5/16"
125
KROGER INSULIN
SYRINGE/0.5ML/31G X
5/16"
125
KROGER INSULIN
SYRINGE/1ML/29G X
1/2"
125
KROGER INSULIN
SYRINGE/1ML/30G X
5/16"
125
KROGER INSULIN
SYRINGE/1ML/31G X
5/16"
125
KROGER LANCETS
102
KROGER LANCETS 21G 102
KROGER LANCETS MICRO
THIN33G
102
KROGER LANCETS SUPER
THIN
102
KROGER LANCETS
THIN
102
KROGER LANCETS THIN
26G
102
KROGER LANCETS
ULTRATHIN30G
102
KROGER LANCING
DEVICE
102
KROGER PEN NEEDLES 29G
X12MM
125
KROGER PEN NEEDLES 31G
X8MM
125
KROGER PEN NEEDLES
31GX1/4"
125
KROGER PREMIUM BLOOD
GLUCOSE TEST STRIPS 79
KROGER TEST STRIPS 79
KYNAMRO
29
labetalol hcl
42
LAC-HYDRIN
62
LAC-HYDRIN TWELVE
62
LACTAID
81
LACTAID FAST ACT
81
lactase
81
lactase 9000 unit, 3000 unit 81
lactic acid (ammonium
lactate)
62
lactic acid (ammonium lactate) 12
%
62
LACTINOL HX
62
lactobacillus acidophiluspectin
25
lactulose
91
lactulose (encephalopathy) 86
LADY ESTHER 4 PURPOSE
FACE CREAM
62
LAMICTAL
17
LAMICTAL CHEWABLE
DISPERSIBLE 25 MG
17
LAMICTAL CHEWABLE
DISPERSIBLE 5 MG
17
LAMICTAL ODT
17
LAMICTAL STARTER/NOT
TAKING CARBAMAZEPINE 17
LAMICTAL STARTER/TAKING
CARBAMAZEPINE/NOT TAKING
VALPROATE
17
LAMICTAL STARTER/TAKING
VALPROATE
17
LAMICTAL XR
17
LAMISIL
27
LAMISIL ADVANCED
53
LAMISIL AT
53
LAMISIL AT JOCK ITCH
53
LAMISIL AT SPRAY
53
lamivudine
40
lamivudine (hbv)
41
lamivudine 150 mg
40
lamivudine 300 mg
40
lamivudine-zidovudine
40
lamotrigine
17
lamotrigine 25 mg
17
lamotrigine 5 mg
17
LANAPHILIC
62
LANCET DEVICE
ADJUSTABLE
102
LANCET DEVICE WITH
EJECTOR
102
LANCETS
102
LANCETS 26G TWIST
TOP
102
LANCETS 28G
102
LANCETS 30G
102
Index 32
LANCETS 30G TWIST
TOP
102
LANCETS 30G/TWIST
TOP
102
LANCETS 31G TWIST
TOP
102
LANCETS 33G UNIVERSAL
DESIGN
102
LANCETS MICRO THIN
33G
102
LANCETS SAFETY SEAL
21G
102
LANCETS SAFETY SEAL
26G
102
LANCETS SAFETY SEAL
28G
102
LANCETS SAFETY SEAL
30G
102
LANCETS SUPER THIN
28G
102
LANCETS THIN
102
LANCETS TWIST TOP
102
LANCETS ULTRA FINE
102
LANCETS ULTRA THIN
102
LANCETS ULTRA THIN
30G
102
LANCETSBULLSEYE
SAFETY
102
LANCING DEVICE
102
LANCING DEVICE
ADJUSTABLE
102
LANOLOR
62
LANOXIN 250 MCG, 125
MCG
44
lansoprazole 15 mg
181
lansoprazole 30 mg
181
LANTISEPTIC SKIN
PROTECTANT
67
LANTISEPTIC
THERAPEUTIC
62
LANTUS
24
LANTUS SOLOSTAR
24
LANZO
102
LASIX
82
LASTACAFT
174
latanoprost
175
LATUDA
37
LAZANDA
8
LEADER ADVANCED LANCING
DEVICE
102
LEADER FINGER CREAM 62
LEADER GLUCOSE
23
Index 33
LEADER INSULIN
SYRINGE/0.3ML/29G X
1/2"
125
LEADER INSULIN
SYRINGE/0.3ML/30G X
5/16"
125
LEADER INSULIN
SYRINGE/0.3ML/31G X
5/16"
125
LEADER INSULIN
SYRINGE/0.5ML/28G X
1/2"
125
LEADER INSULIN
SYRINGE/0.5ML/29G X
1/2"
125
LEADER INSULIN
SYRINGE/0.5ML/30G X
5/16"
125
LEADER INSULIN
SYRINGE/0.5ML/31G X
5/16"
125
LEADER INSULIN
SYRINGE/1ML/28G X
1/2"
125
LEADER INSULIN
SYRINGE/1ML/29G X
1/2"
125
LEADER INSULIN
SYRINGE/1ML/30G X
5/16"
126
LEADER INSULIN
SYRINGE/1ML/31G X
5/16"
126
LEADER QUICK DISSOLVE
GLUCOSE
23
LEADER UNIFINE PENTIPS
PLUS/MINI/31GX3/16" 126
LEADER UNIFINE PENTIPS
PLUS/SHORT/31GX5/16"
126
LEADER UNIFINE
PENTIPS/MINI/31GX3/16"
126
LEADER UNIFINE
PENTIPS/NANO/32GX5/32"
126
LEADER UNIFINE
PENTIPS/PLUS/32GX5/32"
126
leflunomide
6
LENVIMA 10 MG DAILY
DOSE
35
LENVIMA 14 MG DAILY
DOSE
35
LENVIMA 18 MG DAILY
DOSE
35
LENVIMA 20 MG DAILY
DOSE
35
LENVIMA 24 MG DAILY
DOSE
35
LENVIMA 8 MG DAILY
DOSE
35
LESCOL
30
LESCOL XL
30
LETAIRIS
44
letrozole
34
LEUCOVORIN CALCIUM 10 MG,
15 MG
35
leucovorin calcium 25 mg, 5
mg
35
LEUKERAN
33
levalbuterol hcl
15
LEVALBUTEROL TARTRATE
HFA
15
LEVAQUIN
85
LEVAQUIN 25 MG/ML
85
LEVBID
180
LEVEMIR
24
LEVEMIR FLEXTOUCH
24
levetiracetam
18
levetiracetam 100 mg/ml, 500
mg/5ml
18
LEVETIRACETAM
1000MG/100ML-750MG/100ML
18
levetiracetam 500 mg/5ml 18
LEVETIRACETAM
500MG/100ML-820MG/100ML,
1500MG/100ML-540MG/100ML
18
levetiracetam in sodium chloride
1000mg/100ml750mg/100ml
18
levetiracetam in sodium chloride
1500mg/100ml-540mg/100ml,
500mg/100ml-820mg/100ml 18
levobunolol hcl
171
levocarnitine (metabolic
modifiers)
84
levocetirizine dihydrochloride28
levofloxacin
85
LEVOFLOXACIN
85
levofloxacin (ophth)
172
levonorgestrel & eth
estradiol
45
levonorgestrel (emergency
oc)
47
LEVONORGESTREL AND
ETHINYL ESTRADIOL
46
levonorgestrel-eth estradiol
(triphasic)
46
levonorgestrel-ethinyl estradiol
(91-day)
46
levonorgestrel-ethinyl estradiol
(continuous)
46
LEVORPHANOL TARTRATE 8
levothyroxine sodium
179
LEVSIN
180
LEVSIN/SL
180
LEXAPRO
20
LEXIVA
40
LEXIXRYL
52
LIALDA
86
LIBERTY CONTROL SOLUTION
HIGH
102
LIBERTY CONTROL
SOLUTIONNORMAL
102
LIBERTY GLUCOSE CONTROL
LEVEL 1
102
LIBERTY GLUCOSE CONTROL
LEVEL 2
103
LIBERTY GLUCOSE CONTROL
MID
103
LIBERTY GLUCOSE CONTROL
NORMAL
103
LIBERTY MEDICAL LANCETS
30G
103
LIBERTY MINI LANCING
DEVICE
103
LIBERTY NEXT GENERATION
BLOOD GLUCOSE TEST
STRIPS
79
LIBERTY TEST STRIPS
79
lidocaine
66
lidocaine 5 %
66
lidocaine hcl
66
lidocaine hcl (mouth-throat) 148
lidocaine hcl 2 %
66
lidocaine-prilocaine
66
LIDODERM
66
LIFE PACK MENS
154
LIFE PACK WOMENS
154
LIFESCAN UNISTIK 2 DEEP
PENETRATION
103
LIFESCAN UNISTIK II
LANCETS
103
LINDANE
68
lindane
68
liniments & rubs
65
LINZESS 290 MCG, 145
MCG
86
LINZESS 72 MCG
86
liothyronine sodium
179
LIPIDSHIELD PLUS
166
LIPITOR
30
LIPOFEN
29
LIPOTRIAD
167
lisinopril
30
lisinopril &
hydrochlorothiazide
32
LITE TOUCH LANCETS 103
LITE TOUCH LANCING
DEVICE
103
LITE TOUCH LANCING
PEN
103
LITE TOUCH PEN
NEEDLES/31G X 3/16" 126
LITEAIRE
141
LITETOUCH INSULIN
SYRINGE/0.3ML/29G X
1/2"
126
LITETOUCH INSULIN
SYRINGE/0.3ML/30G X
5/16"
126
LITETOUCH INSULIN
SYRINGE/0.3ML/31G X
5/16"
126
LITETOUCH INSULIN
SYRINGE/0.5ML/30G X
5/16"
126
LITETOUCH INSULIN
SYRINGE/0.5ML/31G X
5/16"
126
LITETOUCH INSULIN
SYRINGE/1ML/30G X
5/16"
126
LITETOUCH INSULIN
SYRINGE/U-100/0.5ML/28G X
1/2"
126
LITETOUCH INSULIN
SYRINGE/U-100/0.5ML/29G X
1/2"
126
LITETOUCH INSULIN
SYRINGE/U-100/1ML/28G X
1/2"
126
LITETOUCH INSULIN
SYRINGE/U-100/1ML/29G X
1/2"
126
LITETOUCH INSULIN
SYRINGE/U-100/1ML/31G X
5/16"
126
LITETOUCH LANCETS MICRO
THIN 33G
103
LITETOUCH MASK
LARGE
141
LITETOUCH MASK
MEDIUM
141
LITETOUCH MASK
SMALL
141
LITETOUCH PEN NEEDLES
29GX12.7MM
126
LITETOUCH PEN NEEDLES
31G X 6MM
126
LITETOUCH PEN NEEDLES
31GX8MM SHORT
126
LITHIUM
37
lithium carbonate
37
LITHIUM CARBONATE 150 MG,
600 MG
37
lithium carbonate 300 mg, 600
mg, 150 mg
37
LITHOBID
37
LIVALO
30
LIVE BETTER ADVANCED
LANCING DEVICE
103
LIVE BETTER LANCET
SUPERTHIN 30G
103
LIVE BETTER LANCET
ULTRATHIN 28G
103
LIVE BETTER PEN NEEDLES
29G X 12MM
126
LIVE BETTER PEN NEEDLES
31G X 12MM
126
LIVE BETTER PEN NEEDLES
31G X 6MM
126
LOCOID
58
LOCOID LIPOCREAM
58
LODINE
5
LODOSYN
36
LOESTRIN 1.5/30-21
46
LOESTRIN 1/20-21
46
LOESTRIN FE 1.5/30
46
LOESTRIN FE 1/20
46
LOFIBRA
29
LOMOTIL
25
LOMUSTINE
33
LONGS GLUCOSE
23
LONGS INSULIN
SYRINGE/0.5ML/31G X
5/16"
126
LONGS LANCETS
STANDARD
103
LONGS LANCETS THIN 103
LONGS LANCETS ULTRA
THIN
103
LONSURF
34
loperamide hcl
25
LOPID
29
lopinavir-ritonavir
40
LOPRESSOR
42
LOPRESSOR HCT
32
Index 34
LOPROX
53
LOPROX KIT
53
LOPROX SHAMPOO
53
loratadine
28
loratadine &
pseudoephedrine
48
lorazepam
13
lorazepam 2 mg/ml, 20
mg/10ml
13
LORTAB
10
LORZONE
167
losartan potassium
31
losartan potassium &
hydrochlorothiazide
32
LOTEMAX
173
LOTENSIN
30
LOTENSIN HCT
32
LOTREL
32
LOTRIMIN AF
53
LOTRIMIN AF FOR HER
53
LOTRIMIN AF JOCK ITCH 53
LOTRIMIN ULTRA
53
LOTRISONE
53
LOTRONEX
86
lovastatin
30
LOVAZA
29
LOVENOX 100 MG/ML, 150
MG/ML
16
LOVENOX 120 MG/0.8ML, 40
MG/0.4ML
16
LOVENOX 30 MG/0.3ML
16
LOVENOX 300 MG/3ML
16
LOVENOX 60 MG/0.6ML
16
LOVENOX 80 MG/0.8ML
16
loxapine succinate
38
lubricants
67
LUBRIDERM
63
LUBRIDERM ADVANCED
THERAPY
62
LUBRIDERM DAILY
MOISTURE/NORMAL TO DRY
SKIN
62
LUBRIDERM DAILY
MOISTURESHEA + CALMING
LAVENDER JASMINE
63
LUBRIDERM DAILY
MOISTUREWITH SPF 15 63
LUBRIDERM INTENSE SKIN
REPAIR
63
LUBRIDERM MENS 3-IN-1 63
Index 35
LUBRIDERM SERIOUSLY
SENSITIVE
63
LUBRIDERM SKIN
NOURISHINGWITH SHEA
AND COCOA BUTTERS 63
LUBRIDERM SOOTHING
RELIEF/COOLING
63
LUBRISOFT
63
LUMIGAN
175
LUNESTA
90
LUNG
166
LURIDE
146
LUXIQ
58
LUZU
53
LYMPH
166
LYNPARZA
35
LYRICA
18
LYRICA 225 MG, 300 MG 18
LYRICA 25 MG, 150 MG, 50
MG, 200 MG, 75 MG, 100
MG
18
LYSTEDA
89
M-VIT
161
M2 B-60
154
M2 CALCIUM
166
M2 CHROMIUM
166
MACNATAL CN DHA
161
MACROBID
182
MACRODANTIN 50 MG, 100
MG
182
MACULAR VITAMIN
BENEFIT
154
MAG64
146
MAGELLAN INSULIN SAFETY
SYRINGE/U-100/0.3ML/29G X
1/2"
126
MAGELLAN INSULIN SAFETY
SYRINGE/U-100/0.3ML/30G X
5/16"
126
MAGELLAN INSULIN SAFETY
SYRINGE/U-100/0.5ML/29G X
1/2"
126
MAGELLAN INSULIN SAFETY
SYRINGE/U-100/0.5ML/30G X
5/16"
127
MAGELLAN INSULIN SAFETY
SYRINGE/U-100/1ML/29G X
1/2"
127
MAGELLAN INSULIN SAFETY
SYRINGE/U-100/1ML/30G X
5/16"
127
magnesium citrate
91
MAGNESIUM GLUCONATE 500
MG
146
magnesium gluconate 500
mg
146
magnesium hydroxide
91
magnesium oxide (mg
supplement) 400 mg, 241.3
mg
146
magnesium oxide 400 mg 12
MAGONATE
146
MAGOX 400
146
MAKENA
176
malathion
68
MAMMARY
166
MANGANESE
GLUCONATE
146
MAPROTILINE HCL
20
MARINOL
26
MARNATAL-F
161
MARPLAN
20
MATULANE
35
MAVIK
30
MAXALT
144
MAXALT-MLT
144
MAXAM
63
MAXI-COMFORT INSULIN
SYRINGE/U100/0.5ML/28GX1/2"
127
MAXI-COMFORT INSULIN
SYRINGE/U-100/1ML/28GX1/2"
127
MAXIDEX
173
MAXIMA BLOOD GLUCOSE
TESTSTRIPS
79
MAXIMA CONTROL
SOLUTION
103
MAXIMA CONTROL
SOLUTION/NORMAL
103
MAXIMIN PACK
154
MAXITROL
173
MAXORB EXTRA AG+
73
MAXX LUBRICATED
93
MAXX PLUS SPERMICIDE
LUBRICATED
93
MAXZIDE
82
MAXZIDE-25
82
meclizine hcl
26
MECLOFENAMATE SODIUM 5
MEDELA TENDER CARE
LANOLIN
63
MEDERMA AG FACE
CREAM
63
MEDERMA AG HAND & BODY
LOTION
63
MEDERMA STRETCH MARKS
THERAPY
63
MEDI-PAK PERFORMANCE
PLUSCOMBINE ABD PAD/8" X
7.5"
73
MEDIC INSULIN
SYRINGE/0.3ML/30G X
5/16"
127
MEDIC INSULIN
SYRINGE/0.5ML/30G X
5/16"
127
MEDICATED CHEST RUB 49
MEDICHOICE PRE-SET
SAFETY LANCET DUAL
USE
103
MEDICHOICE PRE-SET
SAFETY LANCET LOW
FLOW
103
MEDICHOICE PRE-SET
SAFETY LANCET MEDIUM
FLOW
103
MEDICHOICE PRE-SET
SAFETY LANCET MODERATE
FLOW
103
MEDICHOICE SAFETY
LANCETEXTRA
103
MEDICHOICE SAFETY
LANCETNORMAL
103
MEDICINE SHOPPE PEN
NEEDLES 29G X 12MM
127
MEDICINE SHOPPE PEN
NEEDLES 31G X 6MM
127
MEDICINE SHOPPE PEN
NEEDLES 31G X 8MM
127
MEDIHONEY CALCIUM
ALGINATE DRESSING
4"X5"
73
MEDIHONEY CALCIUM
ALGINATE
DRESSING/2"X2"
73
MEDIHONEY WOUND & BURN
DRESSING 3/4"X12"
73
MEDIHONEY
WOUND/BURNDRESSING
4"X5"
73
MEDISENSE GLUCOSE
KETONECONTROL SOLUTION
1-LOW,1-MED,1 HIGH
103
MEDISENSE GLUCOSE
KETONECONTROL SOLUTION
1-NORMAL
103
MEDISENSE HIGH/LOW
CONTROL SOLUTION
103
MEDISENSE HIGH/MID/LOW
CONTROL SOLUTION
103
MEDISENSE MID CONTROL
SOLUTION
103
MEDISENSE THIN
LANCETS
103
MEDLANCE PLUS EXTRA
LANCETS 21G
103
MEDLANCE PLUS
LANCETS
103
MEDLANCE PLUS LANCETS
LITE 25G
103
MEDLANCE PLUS LITE
LANCETS 25G
103
MEDLANCE PLUS SPECIAL
LANCETS 0.8MM
103
MEDLANCE PLUS
SUPERLITE 30G
103
MEDLANCE PLUS
SUPERLITE 30G/COMFORT
MAX
103
MEDLANCE PLUS
UNIVERSAL LANCETS
21G
104
MEDLANCE PLUS/LITE
25G
104
MEDLANCE/EXTRA
104
MEDLANCE/LITE
104
MEDLANCE/UNIVERSAL104
MEDROL 4 MG, 8 MG
47
MEDROL DOSEPAK
47
medroxyprogesterone
acetate
176
medroxyprogesterone acetate
(contraceptive)
47
mefenamic acid
5
mefloquine hcl
33
MEGA MULTI MEN
154
MEGA MULTI WOMEN 154
MEGA MULTIVITAMIN 155
MEGA MULTIVITAMIN FOR
MEN
154
MEGA MULTIVITAMIN FOR
WOMEN
154
MEGACE ORAL
34
MEGAVITE FRUITS &
VEGGIES
155
MEGAVITE GOLDEN YEARS
55+
155
megestrol acetate
34
MEIJER ALCOHOL SWABS
EXTRA-THICK
111
MEIJER BLOOD GLUCOSE
TESTSTRIPS
79
MEIJER COLOR LANCETS
UNIVERSAL 33G
104
MEIJER ESSENTIAL BLOOD
GLUCOSE TEST STRIPS 79
MEIJER GLUCOSE
23
MEIJER LANCETS
104
MEIJER LANCETS THIN 104
MEIJER LANCETS
UNIVERSAL21G
104
MEIJER LANCETS
UNIVERSAL30G
104
MEIJER LANCETS
UNIVERSAL33G
104
MEIJER PEN NEEDLES 29G
X12MM
127
MEIJER PEN NEEDLES 31G
X6MM
127
MEIJER PEN NEEDLES 31G
X8MM
127
MEIJER PREMIUM BLOOD
GLUCOSE TEST STRIPS 79
MEIJER SUPER THIN
LANCETS
104
MEIJER TRUETEST BLOOD
GLUCOSE TEST STRIPS 79
MEIJER TRUETRACK BLOOD
GLUCOSE TEST STRIPS 79
MEKINIST
35
MELATONIN 3MG-10MG
3
melatonin 5 mg, 10 mg, 3 mg, 1
mg
3
MELOXICAM
5
meloxicam
5
memantine hcl
176
MENACTRA
182
MENOMUNE-A/C/Y/W-135
183
MENOPAUSE RELIEF
166
MENS 50+ ADVANCED
155
MENS 50+ MULTI VITAMIN
&MINERAL FORMULA
155
MENS MULTI VITAMIN &
MINERAL FORMULA
155
MENS PACK
155
MENTAX
53
menthol (topical analgesic) 2
%
52
menthol-methyl salicylate
(liniments)
65
menthol-zinc oxide
67
MENVEO
183
meperidine hcl
8
MEPERIDINE HCL 50
MG/5ML
8
MEPHYTON
185
meprobamate
13
mercaptopurine
34
mesalamine
86
MESALAMINE DR
86
Index 36
mesalamine w/ cleanser
86
MESTINON
33
MESTINON TIMESPAN
33
METADATE CD
3
METAMUCIL
90
METAPROTERENOL
SULFATE
15
METAXALONE 400 MG
167
metaxalone 800 mg
167
metformin hcl
22
metformin hcl 1000 mg, 500
mg
23
metformin hcl 750 mg, 500
mg
23
methadone hcl
8
METHADONE HCL 10 MG/5ML,
5 MG/5ML
8
methadone hcl 5 mg/5ml, 10
mg/5ml
8
METHADOSE
8
METHADOSE SUGAR-FREE 8
methamphetamine hcl
2
methazolamide
82
METHENAMINE MANDELATE
0.5 GM
182
methenamine mandelate 1
gm
182
methenamine-hyosc-methylene
blue-sod phos-phenyl sal
40.8mg-0.12mg-36.2mg-81.6mg10.8mg, 40.8mg-36.2mg-0.12mg81.6mg-10.8mg
182
METHERGINE
175
methimazole
179
methocarbamol
167
methotrexate sodium
34
METHOTREXATE SODIUM 250
MG/10ML
34
methotrexate sodium 50 mg/2ml,
1 gm/40ml, 100 mg/4ml, 200
mg/8ml, 250 mg/10ml
34
methoxsalen rapid
55
methylcellulose (laxative)
90
methyldopa
31
METHYLDOPA/HYDROCHLOR
OTHIAZIDE
32
methylergonovine maleate 175
METHYLIN
3
METHYLPHENIDATE HCL 3
methylphenidate hcl
3
methylphenidate hcl 10 mg 3
methylphenidate hcl 20 mg 3
Index 37
methylphenidate hcl 54 mg, 36
mg, 18 mg, 27 mg
3
METHYLPHENIDATE HCL
ER
3
METHYLPHENIDATE HCL ER
(LA)
3
methylprednisolone
47
methylprednisolone 4 mg, 8
mg
47
metoclopramide hcl
85
metoclopramide hcl 10
mg/10ml, 5 mg/5ml
85
METOCLOPRAMIDE ODT 86
metolazone
82
metoprolol &
hydrochlorothiazide
32
metoprolol succinate
42
METOPROLOL SUCCINATE
ER/HYDROCHLOROTHIAZIDE
32
metoprolol tartrate 25 mg, 100
mg, 50 mg
42
METOPROLOL TARTRATE 75
MG, 37.5 MG
43
METOZOLV ODT
86
METROCREAM
67
METROGEL-VAGINAL 184
METROLOTION
67
metronidazole
12
metronidazole (topical)
67
metronidazole (topical) 0.75
%
67
metronidazole vaginal
184
MEVACOR
30
mexiletine hcl
14
MG-PLUS PROTEIN
166
MH MACULAR HEALTH 155
MIACALCIN 200
UNIT/ACT
83
MIACALCIN 200 UNIT/ML 83
MICARDIS
31
MICARDIS HCT
32
MICATIN
54
miconazole nitrate (topical) 54
miconazole nitrate
vaginal
184
miconazole nitrate vaginal 2
%
184
MICORT-HC
58
MICRO-K
146
MICROCHAMBER
141
MICRODOT CONTROL
SOLUTIONHIGH/LOW
104
MICRODOT TEST STRIPS 79
MICROELITE FILTER
REPLACEMENTS
141
MICROELITE RECHARGEABLE
BATTERY
141
MICROLET LANCETS
104
MICROLET NEXT
104
MICROSPACER
141
MICROTAINER SAFETY FLOW
LANCET/STERILE/SINGLE-USE
104
MICROZIDE
82
midodrine hcl
185
MIGERGOT
143
miglitol
22
MIGRANAL
144
MIGRANOW
143
MIL ADREGEN
166
MILADRENE FORTE
166
MILCO-B-FORTE
150
MILLIPRED
47
MILPAN
166
MINI LANCING DEVICE
104
MINIELITE FILTER
REPLACEMENTS
141
MINIELITE RECHARGEABLE
BATTERY
141
MINIVELLE
84
MINOCIN
179
minocycline hcl
179
MINOCYCLINE HCL ER 179
minoxidil
33
MIRALAX
91
MIRAPEX
36
MIRAPEX ER
36
MIRCERA 50 MCG/0.3ML, 200
MCG/0.3ML, 100 MCG/0.3ML, 75
MCG/0.3ML
88
MIRCETTE
46
mirtazapine
19
misoprostol
181
MITIGARE
87
MOBIC
5
MOBISYL
66
modafinil
3
MODICON
46
moexipril hcl
30
moexipril-hydrochlorothiazide
32
MOI-STIR
149
MOISTURIZING CREAM
63
MOLINDONE
HYDROCHLORIDE
38
mometasone furoate
58
mometasone furoate
(nasal)
168
MONISTAT 3 COMBINATION
PACK
184
MONISTAT 7 SIMPLY
CURE
184
MONISTAT SOOTHING CARE
ITCH RELIEF
58
MONODOX
179
MONOJECT INSULIN
SYRINGE/1ML
127
MONOJECT INSULIN
SYRINGE/1ML/31G X
5/16"
127
MONOJECT INSULIN
SYRINGE/DETACH
NEEDLE/1ML/25G X 5/8" 127
MONOJECT INSULIN
SYRINGE/DETACH
NEEDLE/1ML/27G X 1/2" 127
MONOJECT INSULIN
SYRINGE/PERM
NEEDLE/1ML/28G X 1/2" 127
MONOJECT INSULIN
SYRINGE/PERM NEEDLE/U100/0.5ML/28G X 1/2"
127
MONOJECT INSULIN
SYRINGE/SAFETY/PERM
NEEDLE/0.3ML/29G X 1/2" 127
MONOJECT INSULIN
SYRINGE/SAFETY/PERM
NEEDLE/0.3ML/29GX1/2" 127
MONOJECT INSULIN
SYRINGE/SAFETY/PERM
NEEDLE/0.5ML/29G X 1/2" 127
MONOJECT INSULIN
SYRINGE/SAFETY/PERM
NEEDLE/1ML/29G X 1/2" 127
MONOJECT INSULIN
SYRINGE/SOFTPACK/1ML/27G
X 1/2"
127
MONOJECT INSULIN
SYRINGE/SOFTPACK/U100/0.5ML/28G X 1/2"
127
MONOJECT INSULIN
SYRINGE/U-100/0.3ML/30G X
5/16"
127
MONOJECT INSULIN
SYRINGE/U-100/0.5ML/28G X
1/2"
127
MONOJECT INSULIN
SYRINGE/U-100/0.5ML/30G X
5/16"
127
MONOJECT INSULIN
SYRINGE/U-100/1ML/28G X
1/2"
128
MONOJECT INSULIN
SYRINGE/U-100/1ML/30G X
5/16"
128
MONOJECT INSULIN
SYRINGEREGULAR LUER
TIP/SOFTPACK/1ML
128
MONOJECT ULTRA
COMFORT INSULIN
SYRINGE/0.3ML/29G X
1/2"
128
MONOJECT ULTRA
COMFORT INSULIN
SYRINGE/0.3ML/30G X
5/16"
128
MONOJECT ULTRA
COMFORT INSULIN
SYRINGE/0.3ML/31G X
5/16"
128
MONOJECT ULTRA
COMFORT INSULIN
SYRINGE/0.5ML/28G X
1/2"
128
MONOJECT ULTRA
COMFORT INSULIN
SYRINGE/0.5ML/29G X
1/2"
128
MONOJECT ULTRA
COMFORT INSULIN
SYRINGE/0.5ML/30G X
5/16"
128
MONOJECT ULTRA
COMFORT INSULIN
SYRINGE/0.5ML/31G X
5/16"
128
MONOJECT ULTRA
COMFORT INSULIN
SYRINGE/1ML/28G X
1/2"
128
MONOJECT ULTRA
COMFORT INSULIN
SYRINGE/1ML/29G X
1/2"
128
MONOJECT ULTRA
COMFORT INSULIN
SYRINGE/1ML/30G X
5/16"
128
MONOLET LANCETS
104
MONOLET OPD
LANCETS
104
MONOLETTOR SAFETY
LANCETS
104
montelukast sodium
14
MOORE MED MONOJECT
INSULIN SYRINGE/U100/0.5ML/28G X 1/2"
128
MOORE MED MONOJECT
INSULIN SYRINGE/U100/0.5ML/29G X 1/2"
128
MOORE MED MONOJECT
INSULIN SYRINGE/U100/1ML/28G X 1/2"
128
MOORE MED MONOJECT
INSULIN SYRINGE/U100/1ML/29G X 1/2"
128
MORGIDOX 1X100MG
179
MORGIDOX 1X50MG KIT 179
MORGIDOX 2X100MG
179
MORPHINE SULFATE
8
morphine sulfate
8
morphine sulfate 10 mg/5ml, 20
mg/5ml, 100 mg/5ml, 20
mg/ml
8
morphine sulfate 100 mg
8
morphine sulfate 30 mg, 80 mg,
20 mg, 50 mg, 60 mg, 10 mg 8
MORPHINE SULFATE ER
8
MOTHERS FRIEND
63
MOTRIN INFANTS DROPS 5
MOUTHKOTE
149
MOVANTIK
86
MOXATAG
175
MOXEZA
172
moxifloxacin hcl
85
MS CONTIN
8
MS INSULIN
SYRINGE/0.3ML/31G X
5/16"
128
MS INSULIN
SYRINGE/0.5ML/31G X
5/16"
128
MS INSULIN SYRINGE/1ML/31G
X 5/16"
128
MSM SKIN LOTION
63
MTERYTI
161
MTERYTI FOLIC 5
161
MUCINEX
49
MUCINEX D
48
MUCINEX DM
48
MULTI FOR HER
155
MULTI FOR HIM
155
MULTI MEGA MINERALS 146
MULTI PRENATAL
161
MULTI-BETIC DIABETES 155
Index 38
MULTI-GLAN
166
MULTI-LANCET DEVICE 104
MULTI-VITAMIN
MONOCAPS
155
multiple minerals w/
vitamins
146
multiple vitamin
158
multiple vitamins w/ calcium150
multiple vitamins w/ iron
151
multiple vitamins w/
minerals
155
multiple vitamins w/ minerals &
folic acid
155
MULTISOURCE CALCIUM
MAGNESIUM & D
FORMULA
146
MULTIVITAL PLATINUM 155
MULTIVITAMIN ADULT
155
MULTIVITAMIN ADULT
EXTRAVITAMIN C
155
MULTIVITAMIN ADULTS 155
MULTIVITAMIN MEN
155
MULTIVITAMIN/FLUORIDE
0.5MG-2500UNIT-13.5MG1.2MG-4.5MCG-400UNIT1.05MG-0.3MG-15UNIT-1.05MG60MG
159
mupirocin
52
mupirocin calcium (topical) 52
MURO 128
174
MURO 128 2 %
174
MURO 128 5 %
174
MVW COMPLETE
FORMULATIONCHEWABLES
MULTIVITAMIN
155
MYAMBUTOL
33
mycophenolate mofetil
147
mycophenolate sodium
147
MYDRIACYL
171
MYFORTIC
147
MYGLUCOHEALTH BLOOD
GLUCOSE TEST
79
MYGLUCOHEALTH CONTROL
LOW/NORMAL/HIGH
104
MYGLUCOHEALTH MGH
SOFTLANCE LANCETS
30G
104
MYLANTA GAS
85
MYLERAN
33
MYLICON
85
MYLICON INFANTS GAS
RELIEF
85
MYNATAL ADVANCE
161
Index 39
MYNATAL PLUS
161
MYNATAL
ULTRACAPLET
161
MYNATAL-Z
161
MYOFLEX
66
MYRBETRIQ
182
MYSOLINE
18
nabumetone
5
nadolol
43
nadolol &
bendroflumethiazide
32
naftifine hcl
54
NAFTIN
54
NALFON
5
NALOXONE HCL
26
naloxone hcl
26
naltrexone hcl
26
NAMENDA
176
NAMENDA TITRATION
PAK
176
NAMENDA XR
176
NAMENDA XR TITRATION
PACK
177
NAMZARIC
177
NAPHAZOLINE HCL
172
NAPRELAN 375 MG, 500
MG
5
NAPRELAN 750 MG
5
NAPROSYN
5
naproxen
5
NAPROXEN
5
naproxen 375 mg, 500 mg 6
naproxen 500 mg
6
naproxen sodium
5
naproxen sodium 220 mg 5
naproxen sodium 550 mg, 275
mg
5
naratriptan hcl
144
NARCAN
26
NARDIL
20
NASACORT ALLERGY
24HR
168
NASACORT ALLERGY 24HR
CHILDRENS
168
NASAL
DECONGESTANT
169
NASALCROM
168
NASONEX
168
NAT-RUL C-COMPLEX 150
NAT-RUL C-COMPLEX TR 150
NAT-RUL PRENATAL
VITAMINS
161
NATACYN
172
NATALVIT
161
NATAZIA
46
nateglinide
25
NATELLE ONE
161
NATESTO
11
NATROBA
68
NATRUL-100
155
NATRUL-CAL
146
NATRUL-CHEWS
155
NATRUL-MEGA-75
155
NATRUL-VITES
155
NEBULIZER AIR
TUBE/PLUGS
141
NEBULIZER PEDIATRIC
MASK
141
NEBUSAL
49
NECON 1/50-28
46
NECON 10/11-28
46
NEEVO DHA
161
NEFAZODONE HCL 150 MG,
100 MG, 200 MG
21
nefazodone hcl 250 mg, 50
mg
21
NEO-SYNEPHRINE 12 HOUR
EXTRA MOISTURIZING 169
neomycin sulfate
4
neomycin-bacitracin znpolymyxin
172
neomycin-bacitracin-polymyxin
52
neomycin-bacitracin-polymyxinpramoxine
52
neomycin-polymydexameth
173
neomycin-polymyxin w/
pramoxine
52
neomycin-polymyxin-gramicidin
172
neomycin-polymyxin-hc
(otic)
175
neomycin/polymyxin b gu
87
NEOMYCIN/POLYMYXIN/HYDR
OCORTISONE
173
NEORAL
147
NEOSALUS
63
NEOSPORIN
172
NEOSPORIN GU IRRIGANT87
NEOSPORIN LIP HEALTH
OVERNIGHT RENEWAL
THERAPY
67
NEOSPORIN ORIGINAL
52
NEOSPORIN PLUS PAIN
RELIEF MAXIMUM
STRENGTH
52
NEPHROCAPS
150
NEPTAZANE
82
NESINA
23
NESTABS
161
NESTABS ABC
161
NESTABS DHA
161
NETGROUP LANCETS
104
NEUPOGEN
88
NEUPRO
36
NEURONTIN
18
NEUTEK 2TEK CONTROL
SOLUTIONS
104
NEUTEK 2TEK TEST
STRIPS
79
NEUTROGENA BODY LIGHT
SESAME FORMULA
63
NEUTROGENA HAND
63
NEUTROGENA
HAND/NORWEGIANFORMULA/
FAST ABSORBING
63
NEUTROGENA HEALTHY
SKIN
63
NEUTROGENA HEALTHY SKIN
FACE SPF 15
63
NEUTROGENA MOISTURE
SENSITIVE SKIN
63
NEUTROGENA T/GEL
68
NEUTROGENA T/GEL
CONDITIONER
68
NEUTROGENA T/GEL
STUBBORN ITCH
CONTROL
68
NEUTROGENA T/SAL
65
NEVANAC
174
NEVIRAPINE
40
nevirapine
40
nevirapine 100 mg
40
nevirapine 400 mg
40
NEW LIFE HAIR
167
NEWGEN
162
NEXA PLUS
162
NEXAFED SINUS PRESSURE
+PAIN
48
NEXAVAR
35
NEXGEN NORMAL
CONTROL
104
NEXGEN TEST STRIPS 79
NEXIUM
181
NEXIUM 20 MG
181
NEXIUM 24HR
181
NEXIUM 24HR CLEAR
MINIS
181
NEXIUM 40 MG
181
NF FORMULAS CHILDRENS
CHEWABLE
160
niacin
185
niacin (antihyperlipidemic) 30
niacin 250 mg, 500 mg 185
niacin 50 mg, 500 mg
185
niacinamide 500 mg
186
NIACOR
30
NIASPAN
30
NICADAN
155
NICADAN ZX
155
nicardipine hcl
43
NICAZEL
155
NICAZEL FORTE
155
NICODERM CQ 21 MG/24HR,
14 MG/24HR
178
NICODERM CQ 7
MG/24HR
178
NICORETTE
178
NICORETTE MINI
178
NICORETTE STARTER
KIT
178
nicotine 14 mg/24hr, 21
mg/24hr
178
nicotine 7 mg/24hr
178
nicotine polacrilex
178
NICOTINE TRANSDERMAL
SYSTEM
178
NICOTROL INHALER
178
NICOTROL NS
178
nifedipine
43
NILANDRON
34
nilutamide
34
nimodipine
43
NINLARO
35
NISEKO HYDRATING FACIAL
MOISTURIZER
63
nisoldipine
43
NISOLDIPINE ER
43
NITRO-BID
13
NITRO-DUR 0.2 MG/HR, 0.4
MG/HR, 0.1 MG/HR, 0.6
MG/HR
13
nitrofurantoin
182
nitrofurantoin macrocrystal 50
mg, 100 mg
182
nitrofurantoin monohyd
macro
182
nitroglycerin
13
NITROSTAT
13
NIVA-PLUS
162
NIVEA
63
NIVEA EXTRA ENRICHED 63
NIVEA EXTRA ENRICHED
LOTION
63
NIVEA GENTLE BODY
EXFOLIATOR
63
NIVEA LIGHT
63
NIVEA ORIGINAL
63
NIVEA ORIGINAL
MOISTURE
63
NIVEA SOFT
63
NIVEA VISAGE
63
NIVEA VISAGE INNER BEAUTY
NIGHTTIME RENEWAL
63
NIX CREME RINSE
68
nizatidine
180
NIZATIDINE
180
NIZORAL
54
NO IRON MULTIPLE
VITAMIN/MINERALS
155
NOR-QD
47
NORCO
10
NORDITROPIN FLEXPRO 83
NORDITROPIN NORDIFLEX
PEN
83
norethin acet & estrad-fe
46
norethindrone & eth estradiol46
norethindrone
(contraceptive)
47
norethindrone acet & eth
estra
46
norethindrone acetate
176
norethindrone-eth estradiol
(triphasic)
46
norgestimate-ethinyl
estradiol
46
norgestimate-ethinyl estradiol
(triphasic)
46
norgestrel & ethinyl estradiol 46
NORINYL 1+35
46
NORINYL 1+50
46
NORPACE
14
NORPACE CR 150 MG
14
NORPRAMIN
21
Index 40
nortriptyline hcl
21
NORTRIPTYLINE HCL
21
NORTUSS-EX
48
NORVASC
44
NORVIR
40
NORWEGIAN COD LIVER
OIL
167
NOSE CLIP
142
NOVA MAX GLUCOSE TEST
STRIPS
79
NOVA MAX PLUS GLU/KET
CONTROL SOLUTIONMID
104
NOVA MAX PLUS KETONE
TESTSTRIPS
79
NOVA SAFETY LANCETS
23G
104
NOVA SAFETY LANCETS
28G
104
NOVA SUREFLEX
LANCETS
104
NOVA SUREFLEX LANCING
DEVICE
104
NOVOFINE 30GX8MM
128
NOVOFINE 32GX6MM
128
NOVOFINE AUTOCOVER
30GX8MM
128
NOVOFINE PLUS
32GX4MM
128
NOVOLIN 70/30
24
NOVOLIN 70/30 RELION
24
NOVOLIN N
24
NOVOLIN N RELION
24
NOVOLIN R
25
NOVOLIN R RELION
25
NOVOLOG
25
NOVOLOG FLEXPEN
25
NOVOLOG MIX 70/30
25
NOVOLOG MIX 70/30
PREFILLED FLEXPEN
25
NOVOLOG PENFILL
25
NOVOTWIST 30GX8MM 128
NOVOTWIST 32GX5MM 128
NOXAFIL
27
NU-GEL WOUND DRESSING/33/4" X 3-3/4"
73
NU-GEL WOUND
DRESSING/6"X 8"
73
NU-MAG
146
NUCYNTA
9
NUCYNTA ER
8
Index 41
NULYTELY/FLAVOR
PACKS
90
NUMOISYN
149
NUPERCAINAL
11
NUPLAZID
37
NUTRADERM
63
NUTRADERM ADVANCED
FORMULA
63
NUTRICAP
155
NUTROPIN AQ NUSPIN
10
83
NUTROPIN AQ NUSPIN
20
83
NUTROPIN AQ NUSPIN 5 83
NUTROPIN AQ PEN
83
NUVARING
46
NUVESSA
184
NUVIGIL
3
NYMALIZE
44
nystatin
27
nystatin (mouth-throat) 148
nystatin (topical)
54
nystatin-triamcinolone
54
NYTOL MAXIMUM
STRENGTH
89
O-CAL FA
162
O-CAL PRENATAL
162
OB COMPLETE
162
OB COMPLETE GOLD 162
OB COMPLETE ONE
162
OB COMPLETE PETITE 162
OB COMPLETE
PREMIER
162
OB COMPLETE/DHA
162
OCALIVA
85
OCEAN NASAL SPRAY 168
OCUFEN
174
OCUFLOX
172
OCUVITE ADULT 50+
155
OCUVITE ADULT
FORMULA
155
OCUVITE LUTEIN
155
ODEFSEY
40
ODOMZO
34
OFEV
178
ofloxacin (ophth)
172
ofloxacin (otic)
175
OFLOXACIN 300 MG
85
ofloxacin 400 mg
85
OGESTREL
46
OINTMENT BASE
64
olanzapine
38
olanzapine 20 mg, 10 mg, 15
mg
38
olanzapine 7.5 mg, 5 mg, 2.5
mg
38
olanzapine-fluoxetine hcl 177
OLEPTRO
21
olmesartan medoxomil
31
olmesartan medoxomilamlodipine-hydrochlorothiazide
32
olmesartan medoxomilhydrochlorothiazide
32
olopatadine hcl
174
olopatadine hcl (nasal)
168
OLUX
58
OLUX-E
58
OLYSIO
41
OMECLAMOX-PAK
181
omega-3 fatty acids 210mg1000mg-75mg-90mg, 300mg180mg-1000mg-120mg-1unit,
300mg-200mg-1unit, 300mg180mg-120mg, 300mg-1000mg1unit, 400mg-1000mg-300mg,
180mg-120mg-1.8unit, 300mg1000mg-200mg, 180mg-1unit1000mg-120mg, 180mg-1000mg120mg-1unit, 350mg-1000mg250mg, 300mg-1000mg,
1000mg, 1000mg-180mg-120mg,
300mg-180mg-1000mg-120mg,
1000mg-180mg-120mg-1unit,
300mg-1000mg-200mg-1unit,
600mg-1000mg, 100mg-1000mg500mg-10unit, 500mg-1000mg250mg, 300mg-1unit-1000mg,
1000mg-180mg-120mg-1mg,
160mg-1000mg-100mg, 40mg340mg-180mg-1000mg-120mg5unit, 100mg-300mg-1000mg200mg, 270mg-1000mg-180mg,
300mg-180mg-1gm-120mg,
700mg-350mg-1000mg-250mg,
180mg-1000mg-120mg, 1000
mg, 350mg-1000mg, 180mg120mg-5unit, 340mg-180mg1000mg-120mg-5unit, 180mg120mg, 340mg-180mg-1unit1000mg-120mg
170
omega-3-acid ethyl esters 29
omeprazole 10 mg
181
omeprazole 20 mg
181
omeprazole 40 mg
181
omeprazole-sodium
bicarbonate
181
omeprazole-sodium bicarbonate
20mg-1100mg
181
omeprazole-sodium bicarbonate
40mg-1100mg
181
OMNARIS
168
OMNICAP
159
OMNIPRED
173
OMNITROPE
84
OMNITROPE 10 MG/1.5ML 83
OMNITROPE 5 MG/1.5ML, 10
MG/1.5ML
84
ON CALL EXPRESS BLOOD
GLUCOSE TEST STRIPS 79
ON CALL EXPRESS GLUCOSE
CONTROL SOLUTION
104
ON CALL LANCETS
104
ON CALL LANCING
DEVICE
104
ON CALL PLUS BLOOD
GLUCOSE TEST
79
ON CALL PLUS GLUCOSE
CONTROL LEVEL 1/2
104
ON CALL PLUS LANCETS 104
ON CALL PLUS LANCING
DEVICE
104
ON CALL VIVID BLOOD
GLUCOSE TEST
79
ON CALL VIVID BLOOD
GLUCOSE TEST STRIPS 79
ON CALL VIVID GLUCOSE
CONTROL LEVEL 1/2
104
ONCOVITE
155
ondansetron
26
ondansetron hcl
26
ondansetron hcl 8 mg, 4 mg 26
ONE DAILY MENS FORMULA
W/O IRON
155
ONE DAILY PLUS IRON 155
ONE-A-DAY ENERGY
155
ONE-A-DAY ESSENTIAL 159
ONE-A-DAY FOR HER
VITACRAVES TEEN MULTI
GUMMIES
155
ONE-A-DAY FOR
HIM/VITACRAVES TEEN MULTI
GUMMIES
155
ONE-A-DAY MENOPAUSE
FORMULA
156
ONE-A-DAY MENS
159
ONE-A-DAY MENS 50+
ADVANTAGE
156
ONE-A-DAY MENS HEALTH
FORMULA
156
ONE-A-DAY MENS PRO
EDGE
156
ONE-A-DAY MENS
VITACRAVES GUMMIES 156
ONE-A-DAY SCOOBY-DOO
GUMMIES
160
ONE-A-DAY TEEN
ADVANTAGEFOR HIM 156
ONE-A-DAY
VITACRAVES
156
ONE-A-DAY VITACRAVES
GUMMIES+OMEGA-3
DHA
160
ONE-A-DAY VITACRAVES
GUMMIES/IMMUNITY
SUPPORT
156
ONE-A-DAY VITACRAVES
SOURGUMMIES
156
ONE-A-DAY VITACRAVES
WOMENS MULTI
156
ONE-A-DAY WEIGHT SMART
ADVANCED
156
ONE-A-DAY WOMENS 50+
ADVANTAGE
156
ONE-A-DAY WOMENS
ACTIVE MIND & BODY 156
ONE-A-DAY WOMENS
FORMULA
150
ONE-A-DAY WOMENS
PETITES
156
ONE-A-DAY WOMENS PLUS
HEALTHY SKIN
SUPPORT
156
ONE-A-DAY WOMENS
PRENATAL
162
ONE-A-DAY WOMENS
VITACRAVES GUMMIES 156
ONE-A-DAY/JOLLY
RANCHER
160
ONETOUCH CLUB LANCETS
FINE POINT
105
ONETOUCH COMBO
PACK
105
ONETOUCH DELICA
LANCETS EXTRA FINE
33G
105
ONETOUCH DELICA
LANCETS FINE 30G
105
ONETOUCH DELICA
LANCING DEVICE
105
ONETOUCH FINEPOINT
LANCETS
105
ONETOUCH LANCETS 105
ONETOUCH ULTRA
BLUE
79
ONETOUCH ULTRA
CONTROL
105
ONETOUCH ULTRASOFT
LANCETS
105
ONETOUCH VERIO CONTROL
SOLUTION HIGH
105
ONETOUCH VERIO MID
CONTROL SOLUTION
105
ONETOUCH VERIO TEST
STRIPS
80
ONFI
17
ONGLYZA
23
ONMEL
27
ONZETRA XSAIL
144
OPANA
9
OPANA ER (CRUSH
RESISTANT)
9
ophthalmic irrigation
solution
174
OPSUMIT
44
OPTI-WOMAN
156
OPTICHAMBER
ADVANTAGE
142
OPTICHAMBER
ADVANTAGE/LARGE
MASK
142
OPTICHAMBER
ADVANTAGE/MEDIUM FACE
MASK
142
OPTICHAMBER
ADVANTAGE/SMALL FACE
MASK
142
OPTICHAMBER DIAMOND142
OPTICHAMBER
DIAMOND/LARGEFACE
MASK
142
OPTICHAMBER
DIAMOND/MEDIUM FACE
MASK
142
OPTICHAMBER
DIAMOND/SMALLFACE
MASK
142
OPTICHAMBER FACE
MASK/LARGE
142
OPTICHAMBER FACE
MASK/MEDIUM
142
OPTICHAMBER FACE
MASK/SMALL
142
OPTIHALER
142
OPTIHALER MDI DRUG
DELIVERY SYSTEM
142
OPTIMUM AIRVITES
156
OPTISOURCE POST
BARIATRIC SURGERY
156
OPTIUM TEST STRIPS
80
OPTIUMEZ TEST STRIPS 80
Index 42
OPTIVITE P.M.T.
156
OPTUMRX BLOOD GLUCOSE
TEST
80
OPTUMRX GLUCOSE
CONTROL LEVEL 1/2
105
OPURITY
156
OPURITY/BYPASS
OPTIMIZED
156
ORACEA
67
oral electrolytes
145
ORAL RELIEF SPRAY FOR
DRYMOUTH &
DISCOMFORT
149
ORALAIR
3
ORALAIR ADULT SAMPLE
KIT
3
ORALAIR ADULT STARTER
PACK
3
ORALAIR
CHILDREN/ADOLESCENTS
STARTER PACK
3
ORAP 1 MG
178
ORAP 2 MG
178
ORAVIG
148
ORCHIC
167
ORENCIA
6
ORENCIA CLICKJECT
6
ORENITRAM
44
ORKAMBI
178
orphenadrine citrate
167
ORTHO MICRONOR
47
ORTHO TRI-CYCLEN
46
ORTHO TRI-CYCLEN LO 46
ORTHO-CEPT
46
ORTHO-CYCLEN
46
ORTHO-NOVUM 1/35
46
ORTHO-NOVUM 7/7/7
46
oseltamivir phosphate 30 mg, 45
mg
42
oseltamivir phosphate 75 mg 42
OSENI
22
OTEZLA
6
OTOVEL
175
OTREXUP 7.5 MG/0.4ML
4
OVACE PLUS WASH
55
OVACE WASH
55
OVARY
167
OVCON-35
46
OVIDE
68
oxaprozin
6
Index 43
OXAYDO
9
oxazepam
13
oxcarbazepine
18
oxcarbazepine 150 mg, 300
mg
18
oxcarbazepine 600 mg
18
oxiconazole nitrate
54
OXISTAT
54
OXSORALEN ULTRA
55
OXTELLAR XR
18
oxybutynin chloride
182
oxycodone hcl
9
OXYCODONE HCL ER 30 MG,
20 MG, 60 MG, 15 MG, 10 MG,
40 MG
9
OXYCODONE HCL ER 80
MG
9
oxycodone w/
acetaminophen
10
oxycodone-aspirin
10
OXYCODONE/IBUPROFEN
10
OXYCONTIN 15 MG, 10 MG,
60 MG, 20 MG, 40 MG, 30
MG
9
OXYCONTIN 80 MG
9
oxymetazoline hcl
169
oxymorphone hcl
9
OXYMORPHONE
HYDROCHLORIDE ER
9
OXYTROL
182
OXYTROL FOR WOMEN 182
oyster shell
145
P&S
65
PA MENS 50 PLUS
VITAPAK
156
PA MENS VITAPAK
156
PA WOMENS 50 PLUS
VITAPAK
156
PA WOMENS VITAPAK 156
PAIN-A-LAY
148
PAIRE OB
162
paliperidone 1.5 mg, 9 mg, 3
mg
37
paliperidone 6 mg
37
PALOMAR E
67
PAMELOR
21
PANCREAZE
82
PANCRELIPASE
82
PANDEL
58
PANOXYL-4 CREAMY
WASH
51
pantoprazole sodium
181
PARAFON FORTE DSC 167
PARATHYROID
167
PARI ALTERA NEBULIZER
HANDSET
142
PARI BABY CONVERSION
KITSIZE 1
142
PARI BABY CONVERSION
KITSIZE 2
142
PARI BABY CONVERSION
KITSIZE 3
142
PARI ERAPID NEBULIZER
HANDSET
142
PARI EXPIRATORY FILTER
VALVE SET
142
PARI MASK SET
142
PARI SOFT PLASTIC ADULT
MASK
142
PARI SOFT PLASTIC
PEDIATRIC MASK
142
PARLODEL
36
PARNATE
20
paroxetine hcl
20
paroxetine hcl 12.5 mg
20
paroxetine hcl 37.5 mg, 25
mg
20
PARVLEX
156
PATADAY
174
PATANASE
168
PATANOL
174
PAXIL
20
PAXIL CR 12.5 MG
20
PAXIL CR 25 MG, 37.5 MG 20
PAZEO
174
PC LANCETS SUPER THIN
30G
105
PC UNIFINE PENTIPS 29G
X1/2"
128
PC UNIFINE PENTIPS 31G
X5MM MINI
128
PC UNIFINE PENTIPS 31G
X6MM ULTRA SHORT
128
PC UNIFINE PENTIPS 31G
X8MM SHORT
129
PCE
92
ped multivitamins w/fl &
iron
159
PEDIA-LAX 1 GM
91
PEDIALYTE
146
PEDIALYTE ADVANCED
CARE
145
PEDIALYTE FREEZER
POPS
145
PEDIALYTE SINGLES
146
PEDIAPRED
47
PEDIATRIC AEROSOL
MASK
142
PEDIATRIC
MOUTHPIECE/DISPOSABLE
142
pediatric multiple vitamin w/
c
160
pediatric multiple vitamin w/ c &
fa
160
pediatric multiple vitamin w/ extra
c & fa
160
pediatric multiple vitamin w/
minerals & c
160
pediatric multiple vitamins 160
pediatric multiple vitamins w/
iron
159
pediatric multivitamins w/fl 159
pediatric multivitamins w/fl 15unit0.5mg-2500unit-13.5mg-1.2mg4.5mcg-400unit-1.05mg-0.3mg1.05mg-60mg, 0.5mg-15unit1.2mg-2500unit-4.5mcg-400unit1.05mg-13.5mg-1.05mg-0.3mg60mg, 0.5mg-15unit-400unit2500unit-1.2mg-4.5mcg-13.5mg1.05mg-0.3mg-1.05mg-60mg,
0.5mg-2500unit-13.5mg-1.2mg4.5mcg-400unit-1.05mg-0.3mg15unit-1.05mg-60mg, 15unit0.5mg-1.05mg-13.5mg-1.2mg2500unit-4.5mcg-400unit-0.3mg1.05mg-60mg
159
pediatric vitamins acd w/
fluoride
159
pediatric vitamins adc
160
peg 3350-kcl-sod bicarb-sod
chloride-sod sulfate
90
peg 3350-potassium chloride-sod
bicarbonate-sod chloride
90
PEG-INTRON
41
PEG-INTRON REDIPEN
41
PEG-INTRON REDIPEN PAK
4
41
PEGANONE
19
PEGASYS
41
PEGASYS PROCLICK
41
PEGINTRON
41
PELEVERUS
67
PELEVERUS CLEAR
67
PELEVERUS GOLD
67
PEN NEEDLES 29G X
12MM
129
PEN NEEDLES
29GX1/2"
129
PEN NEEDLES
30GX5/16"
129
PEN NEEDLES
30GX8MM
129
PEN NEEDLES 31G X 1/4"
SHORT
129
PEN NEEDLES 31G X
3/16"
129
PEN NEEDLES 31G X
5MM
129
PEN NEEDLES 31G X
6MM
129
PEN NEEDLES
31GX5/16"
129
PEN NEEDLES 31GX6MM
(1/4")
129
PEN NEEDLES
31GX8MM
129
PEN NEEDLES 31GX8MM
(5/16")
129
PEN NEEDLES
32GX4MM
129
PEN-KERA
64
penicillin v potassium
175
PENLAC NAIL LACQUER 54
PENNSAID 1.5 %
52
PENNSAID 2 %
52
PENTASA
86
pentazocine w/ naloxone 10
PENTIPS 29GX12MM
129
PENTIPS 31GX5MM
129
PENTIPS 31GX6MM
129
PENTIPS 31GX8MM
129
PENTIPS 32GX4MM
129
pentoxifylline
88
PENTRAVAN
64
PENTRAVAN PLUS
64
PEPCID
180
PEPCID 20 MG
180
PEPCID 40 MG
180
PEPCID AC
180
PEPCID AC MAXIMUM
STRENGTH
180
PERCOCET
10
PERFECT LANCETS
30G
105
PERFECT PRESSURE
ACTIVATED SAFETY
LANCETS 28G
105
PERFOROMIST
15
PERIDEX
148
PERIDIN-C
150
perindopril erbumine
30
permethrin
68
perphenazine
38
PERPHENAZINE/AMITRIPTYLIN
E
177
PERSANTINE
88
PERTZYE
82
PETROLATUM
64
PETROLEUM JELLY LIP
TREATMENT
67
PEXEVA
20
PFLEX
142
PHARMACIST CHOICE
ALCOHOLPREP PADS
111
PHARMACIST CHOICE
AUTOCODE BLOOD GLUCOSE
TEST STRIPS
80
PHARMACIST CHOICE NO
CODING BLOOD GLUCOSE
TEST STRIPS
80
PHARMACIST CHOICE ULTRA
THIN LANCETS
105
PHARMACIST CHOICE ULTRA
THIN LANCETS 28G
105
PHARMACIST CHOICE ULTRA
THIN LANCETS 30G
105
PHARMACIST CHOICE ULTRA
THIN LANCETS 31G
105
PHARMACIST CHOICE ULTRA
THIN LANCETS 33G
105
PHARMACY COUNTER
LANCETS
105
PHAZYME
85
PHAZYME ULTRA
STRENGTH
85
phenazopyridine hcl 200 mg, 95
mg, 100 mg
87
phenelzine sulfate
20
phenobarbital
89
PHENOBARBITAL 100 MG, 60
MG, 15 MG, 30 MG
89
phenobarbital 64.8 mg, 97.2 mg,
16.2 mg, 32.4 mg
89
phenol (antiseptic)
148
phenylephrine hcl (ophth) 2.5
%
172
phenylephrine hcl (oral)
169
phenylephrine in hard fat
11
phenylephrine-chlorphen-dm
15mg/5ml-4mg/5ml10mg/5ml
48
Index 44
phenylephrine-cocoa butter
88.44%-0.25%
11
phenylephrine-dm-gg w/ apap
10mg-325mg-200mg-5mg, 10mg10mg-325mg-325mg-200mg200mg-5mg-5mg
48
phenylephrine-mineral oilpetrolatum 14%-74.9%0.25%
11
phenylephrine-shark liver oilcocoa butter
11
phenylephrine-shark liver oilmineral oil-petrolatum
11
phenylephrine-witch hazel 11
PHENYTEK
19
phenytoin
19
phenytoin sodium
19
phenytoin sodium extended 19
PHLEXY-VITS
156
PHOSLO
86
PHOSLYRA
86
PHOSPHOLINE IODIDE 171
PHYTOMULTI
156
PILLOW MASK/ADULT
142
PILLOW MASK/CHILD
142
PILLOW
MASK/PEDIATRIC
142
pilocarpine hcl
171
pilocarpine hcl (oral) 5 mg 149
pimozide 1 mg
178
pimozide 2 mg
178
pindolol
43
pioglitazone hcl
24
pioglitazone hcl-glimepiride 22
pioglitazone hcl-metformin
hcl
22
piroxicam
6
PITUITARY
167
PLAN B ONE-STEP
47
PLAQUENIL
33
PLAVIX
88
PLEGRIDY
177
PLEGRIDY STARTER
PACK
177
PLETAL
88
PNEUMOVAX 23
183
PNEUMOVAX 23/1 DOSE 183
PNV FERROUS
FUMARATE/DOCUSATE/FOLIC
ACID
162
Index 45
PNV FOLIC ACID + IRON
MULTIVITAMIN
162
PNV OB+DHA
162
PNV PRENATAL PLUS
MULTIVITAMIN
162
PNV TABS 29-1
162
PNV-DHA
162
PNV-DHA+DOCUSATE 162
PNV-OMEGA
162
PNV-SELECT
162
PNV-TOTAL
162
PNV-VP-U
162
POCKET CHAMBER
142
POCKET SPACER
142
POCKETCHEM EZ BLOOD
GLUCOSE TEST STRIPS 80
POCKETCHEM EZ CONTROL
LEVEL 1
105
podofilox
65
POLY-VI-SOL
160
POLY-VI-SOL/IRON
159
polyethylene glycol 3350 91
polyethylene glycol-propylene
glycol (ophth)
170
POLYMEM ALGINATE
DRESSING/3" X 3"
73
POLYMEM ALGINATE
DRESSING/4" X 4"
73
POLYMEM ALGINATE
DRESSING/5" X 5"
73
POLYMEM ALGINATE
DRESSING/6.5" X 7.5"
73
POLYMEM SILVER
DRESSING/4.25" X 4.25" 73
polymyxin b-trimethoprim 172
polysaccharide iron complex
150 mg
89
POLYSPORIN
52
POLYTRIM
172
polyvinyl alcohol
170
polyvinyl alcohol-povidone
(ophth)
170
POMALYST
34
PONSTEL
6
pot phosphate monobasic w/
sod phosphate dibasic &
monobasic
146
potassium 99 mg
147
potassium bicarbonate 147
potassium chloride
147
potassium chloride 10 %, 20
%
147
POTASSIUM CHLORIDE 20
%
147
POTASSIUM CHLORIDE ER 8
MEQ
147
potassium chloride
microencapsulated crystals
cr
147
potassium citrate (alkalinizer)
1080 mg, 540 mg
87
POTASSIUM GLUCONATE 2.5
MEQ
147
POTIGA 200 MG, 400 MG, 300
MG
18
POTIGA 50 MG
18
PR NATAL 400
162
PR NATAL 400 EC
162
PR NATAL 430
162
PR NATAL 430 EC
162
PRADAXA
16
PRALUENT
30
pramipexole dihydrochloride 36
PRAMLYTE
20
PRAMOTIC
175
pramoxine hcl (rectal)
11
pramoxine-phenylephrineglycerin-petrolatum
11
pramoxine-zinc acetate
66
PRANDIMET
22
PRANDIN
25
PRAVACHOL
30
pravastatin sodium
30
PRECISION GLUCOSE
CONTROL
105
PRECISION GLUCOSE
CONTROLSOLUTION (TRILEVEL/HI/LO/NORMAL) 105
PRECISION GLUCOSE
KETONECONTROL SOLUTION
1-LOW, 1-HIGH
105
PRECISION
GLUCOSE/KETONECONTROL
SOLUTIONS 1-HI 1-LO
105
PRECISION PCX
80
PRECISION PCX PLUS TEST
STRIPS
80
PRECISION POINT OF CARE
TEST STRIPS
80
PRECISION QID TEST
STRIPS
80
PRECISION SOF-TACT TEST
STRIPS
80
PRECISION SURE-DOSE
INSULIN SYRINGE/0.3ML/30G X
5/16"
129
PRECISION SURE-DOSE
INSULIN SYRINGE/0.5ML/28G X
1/2"
129
PRECISION SURE-DOSE
INSULIN SYRINGE/0.5ML/29G X
1/2"
129
PRECISION SURE-DOSE
INSULIN SYRINGE/0.5ML/30G X
3/8"
129
PRECISION SURE-DOSE
INSULIN SYRINGE/1ML/28G X
1/2"
129
PRECISION SURE-DOSE
PLUSINSULIN
SYRINGE/0.3ML/29G X
1/2"
129
PRECISION SURE-DOSE
PLUSINSULIN
SYRINGE/1ML/29G X 1/2" 129
PRECISION THIN
LANCETS
105
PRECISION THINS GP
LANCET
105
PRECISION ULTRA
LANCET
105
PRECISION XTRA
80
PRECISION XTRA BLOOD
GLUCOSE TEST STRIPS 80
PRECOSE
22
PRED FORTE
173
PRED MILD
173
PRED-G
173
PRED-G S.O.P.
173
prednicarbate
58
prednisolone
47
prednisolone acetate
(ophth)
173
PREDNISOLONE SODIUM
PHOSPHATE 1 %
173
prednisolone sodium phosphate
20 mg/5ml, 6.7 mg/5ml, 15
mg/5ml, 5 mg/5ml
47
PREDNISONE
47
prednisone 1 mg, 5 mg, 2.5 mg,
20 mg, 10 mg
47
PREDNISONE 50 MG
47
PREDNISONE INTENSOL 47
PREFERA OB
162
PREFERAOB +DHA
162
PREFERAOB ONE
162
PREFERRED PLUS
GLUCOSE
23
PREFERRED PLUS INSULIN
SYRINGE/U-100/0.3ML/29G X
1/2"
129
PREFERRED PLUS INSULIN
SYRINGE/U-100/0.3ML/30G X
5/16"
129
PREFERRED PLUS INSULIN
SYRINGE/U-100/0.5ML/28G X
1/2"
129
PREFERRED PLUS INSULIN
SYRINGE/U-100/0.5ML/29G X
1/2"
129
PREFERRED PLUS INSULIN
SYRINGE/U-100/0.5ML/30G X
5/16"
129
PREFERRED PLUS INSULIN
SYRINGE/U-100/1ML/28G X
1/2"
129
PREFERRED PLUS INSULIN
SYRINGE/U-100/1ML/29G X
1/2"
129
PREFERRED PLUS INSULIN
SYRINGE/U-100/1ML/30G X
5/16"
130
PREFERRED PLUS LANCETS
COLORED 21G
105
PREFERRED PLUS LANCETS
SUPER THIN 30G
105
PREFERRED PLUS LANCETS
THIN 26G
105
PREFERRED PLUS UNIFINE
PENTIPS 29G X 12MM 130
PREFERRED PLUS UNIFINE
PENTIPS 31G X 6MM ULTRA
SHORT
130
PREFERRED PLUS UNIFINE
PENTIPS 31G X 8MM
SHORT
130
PREFERRED PLUS UNIFINE
PENTIPS 32GX4MM
130
PREFERRED PLUS UNIFINE
PENTIPS/MINI/31GX5MM
130
PREMARIN
84
PREMIUM BLOOD GLUCOSE
TEST STRIPS
80
PREMIUM CONDOMS
LUBRICATED
93
PREMIUM PACKETS
156
PREMPRO
84
PRENAISSANCE
162
PRENAISSANCE 90
DHA
162
PRENAISSANCE
BALANCE
162
PRENAISSANCE DHA 162
PRENAISSANCE HARMONY
DHA
162
PRENAISSANCE NEXT 162
PRENAISSANCE NEXT-B 162
PRENAISSANCE PLUS
162
PRENAISSANCE
PROMISE
162
PRENATA
162
PRENATABS FA
162
PRENATABS RX
162
PRENATAL 19
162
PRENATAL 22MG-2MG-25MG1.84MG-200MG-27MG4000UNIT-20MG-3MG-12MCG400UNIT-1MG-10MG-120MG
163
PRENATAL 3.75UNIT-0.5MG50MG-0.5MG-25MG-15MG3.75MG-6.75MG-2.5MG-5MG0.75MG-500UNIT-2.5MCG0.5MG-200MCG-25MCG0.75MG-100UNIT, 11UNIT263MG-25MG-1.5MG-27MG4000UNIT-18MG-1.7MG-4MCG400UNIT-0.8MG-2.6MG-100MG,
160MG-11UNIT-200MG-25MG1.84MG-27MG-4000UNIT-18MG1.7MG-4MCG-400UNIT800MCG-2.6MG-100MG 163
PRENATAL 30UNIT-4000UNIT25MG-1.8MG-200MG-28MG20MG-1.7MG-8MCG-400UNIT0.8MG-2.6MG-120MG, 30UNIT25MG-1.8MG-200MG-28MG20MG-1.7MG-4000UNIT-8MCG400UNIT-800MCG-2.6MG120MG, 4000UNIT-30UNIT25MG-1.8MG-200MG-28MG20MG-1.7MG-8MCG-400UNIT800MCG-2.6MG-120MG,
30UNIT-4000UNIT-25MG1.8MG-200MG-28MG-20MG1.7MG-8MCG-400UNIT800MCG-2.6MG-120MG,
4000UNIT-30UNIT-200MG25MG-1.8MG-28MG-20MG1.7MG-8MCG-400UNIT800MCG-2.6MG-120MG 163
PRENATAL FORMULA
162
PRENATAL FORMULA AFREE
162
PRENATAL LOW IRON
163
PRENATAL
MULTIVITAMIN
163
PRENATAL MULTIVITAMIN +
DHA
163
PRENATAL ONE DAILY 163
PRENATAL PLUS
163
Index 46
PRENATAL PLUS IRON 163
PRENATAL VITAMIN
163
PRENATAL
VITAMIN/IRON
163
PRENATAL VITAMINS 30UNIT4000UNIT-25MG-1.8MG-200MG28MG-20MG-1.7MG-8MCG400UNIT-800MCG-2.6MG120MG
163
PRENATAL VITAMINS PLUS
LOW IRON
163
PRENATAL-U
163
PRENATE
163
PRENATE AM
163
PRENATE DHA
163
PRENATE ELITE 600MCG10UNIT-150MCG-2600UNIT1.5MG-15MG-15MG-25MG-3MG100MG-26MG-6MG-21MG3.5MG-13MCG-450UNIT400MCG-330MCG-21MG-75MG,
600MCG-10UNIT-150MCG2600UNIT-1.5MG-15MG-25MG3MG-100MG-26MG-6MG-21MG3.5MG-13MCG-450UNIT400MCG-330MCG-21MG-75MG
164
PRENATE ENHANCE
164
PRENATE ESSENTIAL
164
PRENATE MINI
164
PRENATE PIXIE
164
PRENATE RESTORE
164
PREPARATION H
11
PREPARATION H TOTABLES
BURN RELIEF
11
PREPARATION H TOTABLES
PAIN RELIEF
11
PREPLUS
164
PREQUE 10
164
PRESCRIPTIVE FORMULAS
OPTIMAL VITAMIN PACKS
MENS
156
PRESCRIPTIVE FORMULAS
OPTIMAL VITAMIN PACKS
WOMENS
156
PRESERVISION AREDS 156
PRESERVISION AREDS 2 156
PRESERVISION AREDS 2 +
MULTI VITAMIN
156
PRESERVISION/LUTEIN 156
PRESSURE ACTIVATED
SAFETYLANCET 21G
105
PRESTALIA
32
Index 47
PRETAB
164
PRETTY FEET & HANDS 64
PREVACID 15 MG
181
PREVACID 24HR
181
PREVACID 30 MG
181
PREVACID SOLUTAB 181
PREVIDENT 5000 DRY
MOUTH
148
PREVIDENT 5000 PLUS 148
PREVIDENT FLUORIDE 148
PREVNAR 13
183
PREVPAC
181
PREZCOBIX
40
PREZISTA
40
PREZISTA 150 MG
40
PREZISTA 600 MG, 75
MG
40
PREZISTA 800 MG
40
PRILOSEC
181
PRILOSEC 10 MG
181
PRILOSEC 20 MG
181
PRILOSEC 40 MG
181
PRIMACOL BORDERED
DRESSING 2"X2"
73
PRIMACOL BORDERED
DRESSING 4"X4"
73
PRIMACOL BORDERED
DRESSING 6"X6"
73
PRIMACOL DRESSING
4"X4"
73
PRIMACOL DRESSING
6"X6"
73
PRIMACOL DRESSING
8"X8"
73
PRIMACOL SPECIALTY
DRESSING
73
PRIMAQUINE
PHOSPHATE
33
primidone
18
PRIMLEV
10
PRINIVIL
30
PRISTIQ
21
PRO COMFORT ALCOHOL
PADS
111
PRO COMFORT LANCETS
30G
105
PRO COMFORT LANCETS
31G
105
PRO COMFORT PEN
NEEDLES/31G X 8MM 130
PRO COMFORT PEN
NEEDLES/32G X 4MM 130
PRO COMFORT PEN
NEEDLES/32G X 5MM
130
PRO COMFORT PEN
NEEDLES/32G X 6MM
130
PRO-CAL
157
PROAIR HFA
15
PROAIR RESPICLICK
15
probenecid
87
PROCARDIA
44
PROCARDIA XL
44
PROCENTRA
2
PROCERV HP
157
prochlorperazine
38
prochlorperazine edisylate 38
prochlorperazine maleate
38
PROCRIT 10000 UNIT/ML,
40000 UNIT/ML, 4000 UNIT/ML,
3000 UNIT/ML, 2000 UNIT/ML,
20000 UNIT/ML
88
PROCTOCORT
12
PROCTOFOAM
11
PRODIGY CONTROL
SOLUTIONHIGH
106
PRODIGY CONTROL
SOLUTIONLOW
106
PRODIGY INSULIN SYRING/U100/0.3ML/31G X 5/16"
130
PRODIGY INSULIN
SYRINGE/1/2ML/31G X
5/16"
130
PRODIGY INSULIN
SYRINGE/1ML/28G X 1/2" 130
PRODIGY LANCING
DEVICE
106
PRODIGY NO CODING BLOOD
GLUCOSE TEST STRIPS 80
PRODIGY PRESSURE
ACTIVATED SAFETY
LANCETS
106
PRODIGY SAFETY
LANCETS
106
PRODIGY TWIST TOP
LANCETS
106
PRODRIN
143
PROFE FORTE
164
progesterone micronized 176
PROGRAF
148
PROLENSA
174
promethazine &
phenylephrine
48
promethazine hcl
28
promethazine hcl 25 mg, 12.5
mg, 50 mg
28
promethazine hcl 50 mg
28
promethazine hcl 6.25
mg/5ml
28
promethazine w/codeine
48
promethazine-dm
48
promethazine-phenylephrinecodeine
48
PROMETHAZINE/PHENYLEPHR
INE
48
PROMETRIUM
176
PRONUTRIENTS SUPER BCOMPLEX+ANTIOXIDANTS
149
propafenone hcl
14
propranolol hcl
43
PROPRANOLOL HCL 40
MG/5ML, 20 MG/5ML
43
PROPRANOLOL/HYDROCHLOR
OTHIAZIDE
32
propylthiouracil
179
PRORENAL+D
157
PRORENAL+D/OMEGA-3 157
PROSCAR
87
PROSHIELD PROTECTIVE
HANDCREAM
67
PROSTATE
167
PROSTEON
146
PROTECT CARDIO AF
157
PROTECT PLUS
157
PROTECT PLUS NF
157
PROTECT PLUS SO
157
PROTONIX
181
PROTOPIC
65
protriptyline hcl
21
PROVENTIL HFA
15
PROVERA
176
PROVIDA DHA
164
PROVIDA OB
164
PROVIGIL
3
PROZAC
20
PROZAC WEEKLY
20
pseudoephed-bromphen-dm 48
pseudoephedrine hcl
169
pseudoephedrine w/ codeinegg
48
pseudoephedrine-guaifenesin
60mg-600mg
48
PSORCON
58
PSS SELECT GP
LANCETS
106
PSS SELECT SAFETY
LANCETS
106
psyllium
90
psyllium 95 %, 28.3 %, 100
%
90
PTS PANELS GLUCOSE
TEST
80
PTS PANELS KETONE
TEST
80
PULMICORT
15
PULMICORT FLEXHALER15
PULMOZYME
178
PUREFE OB PLUS
164
PURIXAN
34
PUSH BUTTON SAFETY
LANCETS 21G
106
PUSH BUTTON SAFETY
LANCETS 28G
106
PX ADVANCED LANCING
DEVICE
106
PX EXTRA SHORT PEN
NEEDLES 31GX6MM
130
PX GLUCOSE
23
PX INSULIN SYRINGE/U100/0.3ML/30G X 1/2"
130
PX INSULIN SYRINGE/U100/0.3ML/31G X 5/16" 130
PX INSULIN SYRINGE/U100/0.5ML/30G X 1/2"
130
PX INSULIN SYRINGE/U100/0.5ML/31G X 5/16" 130
PX INSULIN SYRINGE/U100/1ML/30G X 1/2"
130
PX INSULIN SYRINGE/U100/1ML/31G X 5/16"
130
PX LANCET AUTO
INJECTOR
106
PX LANCETS ULTRA
THIN
106
PX MINI PEN NEEDLES
31GX5MM
130
PX PEN NEEDLE
29GX12MM
130
PX PEN NEEDLE
31GX8MM
130
PX PRENATAL
MULTIVITAMINS
164
PX SHORTLENGTH PEN
NEEDLES/31GX8MM
130
PYLERA
181
pyrazinamide
33
pyrethrins-piperonyl
butoxide
68
pyrethrins-piperonyl butoxide
0.33%-4%
68
PYRIDIUM
87
pyridostigmine bromide
33
pyridoxine hcl 100 mg, 25 mg, 50
mg
186
pyrithione zinc 2 %,
55
QBRELIS
30
QC ADVANCED LANCING
DEVICE
106
QC ALCOHOL SWABS
111
QC COD LIVER OIL
167
QC LANCETS SUPER
THIN
106
QC LANCETS ULTRA
THIN
106
QC PEN NEEDLES 29G X
12MM
130
QC PEN NEEDLES 31G X
6MM
130
QC PEN NEEDLES 31G X
8MM
130
QC PRENATAL
164
QC UNIFINE PENTIPS
32GX4MM
130
QC UNILET LANCETS
28G/ULTRA THIN
106
QC UNILET LANCETS
33G/MICRO THIN
106
QNASL
168
QNASL CHILDRENS
168
QUDEXY XR
18
QUENCH
157
QUESTRAN
29
QUESTRAN LIGHT
29
quetiapine fumarate
38
quetiapine fumarate 150 mg, 200
mg
38
quetiapine fumarate 50 mg, 300
mg, 400 mg
38
QUFLORA PEDIATRIC
159
QUFLORA PEDIATRIC
108MCG-1MG-15UNIT-0.5MG15MG-1200UNIT-5MG-1.3MG4MCG-400UNIT-1.2MG100MCG-1.5MG-60MG
159
QUICKTEK CONTROL
SOLUTION
106
QUICKTEK TEST STRIPS 80
QUILLICHEW ER
3
QUILLIVANT XR
3
QUIN B STRONG
157
quinapril hcl
30
quinapril-hydrochlorothiazide
32
quinidine gluconate
14
QUINIDINE SULFATE 200 MG,
300 MG
14
Index 48
quinidine sulfate 300 mg
14
QUINIDINE SULFATE ER 14
QUINTABS
159
QUINTABS-M
157
QUINTET AC BLOOD
GLUCOSETEST STRIPS
80
QUINTET BLOOD GLUCOSE
TEST STRIPS
80
QUINTET GLUCOSE
CONTROL/HIGH/NORMAL
106
QVAR
15
R-NATAL OB
164
RA ALCOHOL SWABS
111
RA ARTHRITIS PAIN
RELIEF
66
RA CENTRAL-VITE UNDER
50MENS
157
RA CENTRAL-VITE UNDER
50WOMENS
157
RA COD LIVER OIL
167
RA DRY MOUTH
149
RA E-ZJECT COLOR
LANCETSMICRO-THIN
33G
106
RA E-ZJECT LANCETS
28G
106
RA E-ZJECT LANCETS THIN
26G
106
RA E-ZJECT LANCETS THIN
28G
106
RA E-ZJECT LANCETS
ULTRATHIN 30G
106
RA EAR CARE
167
RA ESSENCE-C
157
RA GENTLE SKIN CREAM 64
RA GLUCOSE
23
RA INSULIN
SYRINGE/0.5ML/29G X
1/2"
130
RA INSULIN SYRINGE/1ML/29G
X 1/2"
130
RA INSULIN SYRINGE/U100/0.5ML/30G X 5/16"
130
RA INSULIN SYRINGE/U-100/1
ML/30G X 5/16"
130
RA LANCING DEVICE
106
RA ONE DAILY
164
RA OYSTER SHELL
CALCIUM/VITAMIN D
145
RA PEN NEEDLES 31G X
5MM3/16"
130
RA PEN NEEDLES 31G X
8MM5/16"
130
RA PRENATAL
164
Index 49
RA PRENATAL
FORMULA/FOLICACID 164
RA RENEWAL ADVANCED
HEALING
67
RA RENEWAL DRY SKIN
THERAPY
64
RA TRUETEST STRIPS 80
rabeprazole sodium
181
RADIAGUARD
ADVANCED
64
RAGUS
157
RAGWITEK
3
raloxifene hcl
84
ramipril
31
ranitidine hcl
180
ranitidine hcl 150 mg
180
ranitidine hcl 75 mg, 300
mg
180
RAPAFLO
87
RAPAMUNE
148
rasagiline mesylate
36
RAZADYNE
177
RAZADYNE ER
177
READYLANCE SAFETY
LANCETS/30G/1.6MM 106
REALITY INSULIN
SYRINGE/U-100/0.5ML/28G X
1/2"
131
REALITY INSULIN
SYRINGE/U-100/0.5ML/29G X
1/2"
131
REALITY INSULIN
SYRINGE/U-100/1ML/28G X
1/2"
131
REALITY INSULIN
SYRINGE/U-100/1ML/29G X
1/2"
131
REALITY LANCETS
106
REALITY LATEX
CONDOMS/LUBRICATED 93
REALITY LATEX/ULTRA
TEXTURED
93
REALITY LATEX/ULTRA
THIN
93
REALITY SWABS
111
REALITY TRIGGER
LANCETS
106
REBETOL
41
REBIF
177
REBIF REBIDOSE
177
REBIF REBIDOSE
TITRATIONPACK
177
REBIF TITRATION PACK177
REFISSA
52
REFRESH
171
REFRESH CELLUVISC
170
REFRESH LIQUIGEL
170
REFRESH OPTIVE
171
REFRESH OPTIVE
ADVANCED
171
REFRESH OPTIVE ADVANCED
SENSITIVE
170
REFRESH OPTIVE
SENSITIVE
171
REFRESH PLUS
171
REFRESH TEARS
171
REFUAH PLUS BLOOD
GLUCOSETEST STRIPS
80
REFUAH PLUS GLUCOSE
CONTROL SOLUTION
106
REGLAN
86
RELENZA DISKHALER
42
RELION 2-IN-1 LANCING
DEVICE 25G
106
RELION 2-IN-1 LANCING
DEVICE 30G
106
RELION ALCOHOL
SWABS
111
RELION BLOOD GLUCOSE
TESTSTRIPS
80
RELION CONFIRM/MICRO
TEST STRIPS
80
RELION GLUCOSE
23
RELION INSULIN SYRINGE
1ML/31GX15/64"
131
RELION INSULIN SYRINGE/U00/1ML/29G X 1/2"
131
RELION INSULIN SYRINGE/U100/0.3ML/29G X 1/2"
131
RELION INSULIN SYRINGE/U100/0.3ML/30G X 5/16"
131
RELION INSULIN SYRINGE/U100/0.3ML/31G X 5/16"
131
RELION INSULIN SYRINGE/U100/0.5ML/29G X 1/2"
131
RELION INSULIN SYRINGE/U100/0.5ML/30G X 5/16"
131
RELION INSULIN SYRINGE/U100/0.5ML/31G X 5/16"
131
RELION INSULIN SYRINGE/U100/1ML/30G X 5/16"
131
RELION INSULIN SYRINGE/U100/1ML/31G X 5/16"
131
RELION KETONE
80
RELION KETONE TEST
STRIPS
80
RELION LANCETS MICROTHIN33G
106
RELION LANCETS STANDARD
21G
106
RELION LANCETS THIN
26G
106
RELION LANCETS ULTRATHIN30G
106
RELION LANCING
DEVICE
106
RELION MINI PEN NEEDLES
31GX6MM
131
RELION PEN NEEDLES
29GX12MM
131
RELION PEN NEEDLES
31GX6MM
131
RELION PEN NEEDLES
31GX8MM
131
RELION PEN NEEDLES
32GX4MM
131
RELION PRIME BLOOD
GLUCOSE TEST STRIPS 80
RELION SHORT PEN
NEEDLES31GX8MM
131
RELION ULTIMA BLOOD
GLUCOSE TEST STRIPS 80
RELION ULTIMA TEST
STRIPS
80
RELION ULTRA THIN
LANCETS30G
106
RELION ULTRA THIN PLUS
LANCETS 32G
106
RELION ULTRA THIN PLUS
LANCETS 33G
106
RELISTOR
86
RELNATE DHA
164
RELPAX
144
REMEDY CLEAR-AID
67
REMERON
19
REMERON SOLTAB
19
RENAGEL
86
RENAPLEX-D
157
RENVELA
86
repaglinide
25
REPAGLINIDE/METFORMIN
HYDROCHLORIDE
22
REPATHA
30
REPATHA PUSHTRONEX
SYSTEM
30
REPATHA SURECLICK
30
REPLACE
157
REPLACEMENT AIR
FILTER
143
REPLACEMENT FILTERS 143
REPLICARE 1-1/2"X2-1/2" 73
REPLICARE 4"X4"
73
REPLICARE 6"X6"
73
REPLICARE 8"X8"
73
REPLICARE THIN
2"X2.75"
73
REPLICARE THIN
3.5"X5.5"
73
REPLICARE THIN 6"X8" 73
REPLICARE ULTRA 4"X4"73
REPLICARE ULTRA 6"X6"73
REPLICARE ULTRA SACRUM
7"X8"
73
REPREXAIN
10
REQ 49+
157
REQUIP
36
REQUIP XL
36
RESCRIPTOR 100 MG
40
RESCRIPTOR 200 MG
40
RESERPINE
31
RESTA
64
RESTA LITE
64
RESTASIS
173
RESTASIS MULTIDOSE 173
RESTORE CLEANSER &
MOISTURIZER
67
RESTORE CX WOUND CARE
DRESSING-STERILE
73
RESTORE DRESSING FOR
PSORIASIS-STERILE
73
RESTORE EXTRA THIN
DRESSING 4"X4"
74
RESTORE EXTRA THIN
DRESSING 6"X8"
74
RESTORE EXTRA THIN
DRESSING 8"X8"
74
RESTORE HYDROGEL
GAUZE PAD 4"X4"
74
RESTORE PLUS WOUND
CARE DRESSING 4"X4" 74
RESTORE PLUS WOUND
CARE DRESSING 4"X4"
TAPERED EDGE
74
RESTORE PLUS WOUND
CARE DRESSING 6"X6"
TAPERED EDGE
74
RESTORE PLUS WOUND
CARE DRESSING 6"X8" 74
RESTORE PLUS WOUND
CARE DRESSING 6"X8"
TAPERED EDGE
74
RESTORE PLUS WOUND
CARE DRESSING 8"X8" 74
RESTORE PLUS WOUND
CARE DRESSING 8"X8"
TAPERED EDGE
74
RESTORE PLUS WOUND
CARE DRESSING
TRIANGLE
74
RESTORE SILVER DRESSING
2"X2"
74
RESTORE SILVER DRESSING
4"X4" NON-ADHESIVE
74
RESTORE SILVER DRESSING
4"X4.75"
74
RESTORE SILVER DRESSING
4"X5" CONTACT LAYER
74
RESTORE SILVER DRESSING
6"X8" CONTACT LAYER
74
RESTORE SILVER DRESSING
6"X8" NON-ADHESIVE
74
RESTORE WOUND CARE
DRESSING 4"X4"
74
RESTORE WOUND CARE
DRESSING 4"X4"
ADHESIVE
74
RESTORE WOUND CARE
DRESSING 4"X4" NONADHESIVE
74
RESTORE WOUND CARE
DRESSING 4"X5" CONTACT
LAYER
74
RESTORE WOUND CARE
DRESSING 6"X6"
ADHESIVE
74
RESTORE WOUND CARE
DRESSING 6"X8"
74
RESTORE WOUND CARE
DRESSING 6"X8"
ADHESIVE
74
RESTORE WOUND CARE
DRESSING 6"X8" CONTACT
LAYER
74
RESTORE WOUND CARE
DRESSING 6"X8" NONADHESIVE
74
RESTORE WOUND CARE
DRESSING 8"X8"
74
RESTORIL
90
RETIN-A
51
RETIN-A MICRO
51
RETIN-A MICRO PUMP 0.04 %,
0.1 %
51
RETIN-A MICRO PUMP 0.08
%
51
RETROVIR
40
REVATIO
44
REVEAL BLOOD GLUCOSE
TEST
80
REVIA
26
REVLIMID
147
REXALL BLOOD GLUCOSE
TEST STRIPS
80
REXALL LANCETS ULTRA
THIN
107
REXULTI
39
Index 50
REYATAZ
40
REYATAZ 150 MG, 200 MG 40
REYATAZ 300 MG
40
RHEUMATREX
4
RHINOCORT AQUA
169
ribavirin (hepatitis c)
41
riboflavin 100 mg
186
RID
68
RID ESSENTIAL LICE
ELIMINATION KIT
68
RIFADIN
33
rifampin
33
RIGHT STEP PRENATAL 164
RIGHTEST GC300 HIGH
CONTROL
107
RIGHTEST GC300 NORMAL
CONTROL
107
RIGHTEST GD500 LANCING
DEVICE
107
RIGHTEST GL300
LANCETS
107
RIGHTEST GS100 BLOOD
GLUCOSE TEST STRIPS 80
RIGHTEST GS300 BLOOD
GLUCOSE TEST STRIPS 80
RIGHTEST GS550 BLOOD
GLUCOSE TEST STRIPS 80
rimantadine hydrochloride 42
RIOMET
23
RISABAL-PH
64
risedronate sodium
83
risedronate sodium 150 mg 83
risedronate sodium 30 mg 83
risedronate sodium 35 mg 83
risedronate sodium 5 mg
83
RISPERDAL
37
RISPERDAL CONSTA
37
RISPERDAL M-TAB
37
risperidone
37
RITALIN
3
RITALIN LA 10 MG
3
RITALIN LA 20 MG, 30 MG, 40
MG
3
RITALIN LA 60 MG
3
RITEFLO
143
rivastigmine 13.3 mg/24hr 177
rivastigmine 4.6 mg/24hr, 9.5
mg/24hr
177
rivastigmine tartrate
177
rizatriptan benzoate
144
Index 51
ROBAXIN
167
ROBAXIN-750
167
ROBINUL
180
ROBINUL FORTE
180
ROBITUSSIN DM
48
ROBITUSSIN PEAK COLD
COUGH+ CHEST
CONGESTION DM MAX
STRENGTH
49
ROBITUSSIN PEAK COLD
DM
49
ROC DEEP WRINKLE
SERUM
64
ROC MULTI CORREXION 5
IN1 RESTORING EYE
CREAM
64
ROC MULTI CORREXION 5
IN1 RESTORING NIGHT
CREAM
64
ROC MULTI CORREXION
LIFTANTI-GRAVITY
NIGHT
64
ROC RETINOL
CORREXION
64
ROC RETINOL CORREXION
NIGHT
64
ROC RETINOL CORREXION
SENSITIVE EYE
64
ROC RETINOL CORREXION
SENSITIVE NIGHT
64
ROCALTROL
84
ropinirole hydrochloride
36
ROSE MILK
64
ROSULA
51
rosuvastatin calcium
30
ROWASA
86
ROXICODONE
9
ROZEREM
90
RTD WOUND CARE
DRESSING2" X 2"
74
RTD WOUND CARE
DRESSING4" X 4"
74
RTD WOUND CARE
DRESSING4" X 5"
74
RUBRACA
35
RULAVITE DHA
164
RYTARY
36
RYTHMOL
14
SABRIL
19
SAFE-T-LANCE LOW FLOW
25G
107
SAFE-T-LANCE NORMAL
FLOW21G
107
SAFE-T-LANCE PLUS
SAFETYLANCET HIGH
FLOW
107
SAFE-T-LANCE PLUS
SAFETYLANCET LOW
FLOW
107
SAFE-T-LANCE PLUS
SAFETYLANCET NORMAL
FLOW
107
SAFESNAP INSULIN
SYRINGE/0.3ML/30G X
5/16"
131
SAFESNAP INSULIN
SYRINGE/0.5ML/29G X
1/2"
131
SAFESNAP INSULIN
SYRINGE/0.5ML/30G X
5/16"
131
SAFESNAP INSULIN
SYRINGE/1ML/28G X 1/2" 131
SAFESNAP INSULIN
SYRINGE/1ML/29G X 1/2" 131
SAFETY INSULIN SYRINGES
0.5ML/29GX1/2"
131
SAFETY INSULIN SYRINGES
0.5ML/30GX5/16"
131
SAFETY INSULIN SYRINGES
1ML/27GX1/2"
131
SAFETY INSULIN SYRINGES
1ML/29GX1/2"
131
SAFETY INSULIN SYRINGES
1ML/30GX1/2"
131
SAFETY LANCET
21G/PRESSURE
ACTIVATED
107
SAFETY LANCET
28G/PRESSURE
ACTIVATED
107
SAFETY LANCETS
107
SAFETY LANCETS 21G 107
SAFETY LANCETS 28G 107
SAFETY LET LANCETS 107
SAFETY SEAL LANCETS
28G
107
SAFETY SEAL LANCETS
30G
107
SAFETY-GLIDE INSULIN
SYRINGE/0.3ML/29G X
1/2"
132
SAIZEN
84
SAIZEN CLICK.EASY
84
SAIZENPREP
RECONSTITUTIONKIT
84
SALAGEN 5 MG
149
SALESE
149
salicylic acid & sulfur
55
salicylic acid 17 %
65
saline
168
saline 0.65%-0.002%, 0.65%,
0.65 %
168
SAMI THE SEAL
REPLACEMENTFILTERS 143
SANCUSO
26
SANDIMMUNE
148
SANTYL
65
SAPHRIS
38
SAPS CARE ALCOHOL PREP
PADS
111
SAPSCARE TWIST TOP
LANCETS 30G
107
SARNA
54
SAVAYSA
16
SAVELLA
177
SAVELLA TITRATION
PACK
177
SAVISION
157
SB ALCOHOL PREP
PADS
111
SB INSULIN SYRINGE/U100/0.5ML/29G X 1/2"
132
SB INSULIN SYRINGE/U100/0.5ML/30G X 5/16"
132
SB INSULIN SYRINGE/U100/1ML/29G X 1/2"
132
SB INSULIN SYRINGE/U100/1ML/30G X 5/16"
132
SB INSULIN SYRINGE/U100/1ML/31G X 5/16"
132
SB LANCETS THIN
107
SB LANCETS ULTRA
THIN
107
SCHNUCKS INSULIN
SYRINGEULTI-FINE/U100/0.5ML/29G X 1/2"
132
SCHNUCKS INSULIN
SYRINGEULTI-FINE/U100/0.5ML/30G X 5/16"
132
SE PLUS PROTEIN
147
SE-NATAL 19
164
SE-TAN DHA
164
SEASONIQUE
46
SEASORB-AG
74
SEBULEX
55
SECTRAL
43
SEEBRI NEOHALER
14
SELECT-LITE LANCING
DEVICE
107
SELECT-OB
164
SELECT-OB+DHA
164
selegiline hcl
37
SELENIUM
147
selenium 200 mcg
147
selenium sulfide 2.5 %
55
SELSUN BLUE DEEP
CLEANSING
65
SELSUN BLUE
NATURALS
65
SELSUN BLUE NATURALS
DRYSCALP
65
SELZENTRY 150 MG, 75
MG
40
SELZENTRY 25 MG
40
SELZENTRY 300 MG
40
SENIOR VITES
157
sennosides
91
sennosides 8.6 mg, 25 mg 91
sennosides-docusate
sodium
91
SENOKOT
91
SENOKOT S
91
SENSI-CARE
MOISTURIZING
67
SENSI-CARE PROTECTIVE
BARRIER
67
SENTRY
157
SENTRY
SENIOR/LUTEIN
157
SEREVENT DISKUS
15
SERNIVO
58
SEROQUEL
38
SEROQUEL XR 200 MG, 150
MG
38
SEROQUEL XR 400 MG, 50
MG, 300 MG
38
SEROSTIM
84
sertraline hcl
20
SFROWASA
86
SHOHLS SOLUTION
MODIFIED
87
SHOPKO ALCOHOL
SWABS
111
SHOPKO AUTOLET LANCING
DEVICE
107
SHOPKO ON-THE-GO
COMFORTLANCETS
30G
107
SHOPKO UNIFINE PENTIPS
PEN
NEEDLES/MICRO/32GX4MM
132
SHOPKO UNIFINE PENTIPS
PEN NEEDLES/MINI/31GX5MM
132
SHOPKO UNIFINE PENTIPS
PEN
NEEDLES/ORIGINAL/29GX12M
M
132
SHOPKO UNIFINE PENTIPS
PEN
NEEDLES/SHORT/31GX8MM
132
SHOPKO UNIFINE PENTIPS
PLUS PEN
NEEDLES/MICRO/REMOVR/32
GX4MM
132
SHOPKO UNIFINE PENTIPS
PLUS PEN
NEEDLES/MINI/REMOVER/31G
X5MM
132
SHOPKO UNIFINE PENTIPS
PLUS PEN
NEEDLES/REMOVER/29GX12M
M
132
SHOPKO UNIFINE PENTIPS
PLUS PEN
NEEDLES/SHORT/REMOVR/31
GX8MM
132
SHOPKO UNILET LANCETS
SUPER THIN 30G
107
SHOPKO UNILET LANCETS
ULTRA THIN 28G
107
SIDE BUTTON SAFETY
LANCET21G
107
SIDEROL
157
SIDESTREAM ADULT FACE
MASK
143
SIDESTREAM PEDIATRIC
FACEMASK
143
SIDESTREAM PEDIATRIC
FACEMASK/SAMI THE
SEAL
143
SIDESTREAM PEDIATRIC
FACEMASK/TUCKER THE
TURTLE
143
SIDESTREAM PLUS ADULT
FACE MASK
143
sildenafil citrate (pulmonary
hypertension)
44
SILENOR
89
SILICONE MASK FOR
BREATHERITE
CHAMBER/ADULT
143
SILICONE MASK FOR
BREATHERITE
CHAMBER/INFANT
143
SILICONE MASK FOR
BREATHERITE
CHAMBER/PEDIATRIC
143
Index 52
SILICONE MASK FOR
BREATHRITE
CHAMBER/ADULT
143
SILVADENE
55
silver sulfadiazine
55
SIMBRINZA
172
simethicone
85
SIMPLE DIAGNOSTICS
LANCING DEVICE
107
SIMPONI
4
simvastatin
30
SINEMET
36
SINEMET CR
36
SINGLE-LET
107
SINGULAIR
14
sirolimus
148
SITAVIG
42
SIVEXTRO
13
SKELAXIN
167
SKIN BEAUTY &
WELLNESS
157
skin protectants, misc.
67
SKIN REPAIR
64
SKINTEGRITY 2" X 2"
74
SKINTEGRITY 4" X 4"
74
SKLICE
68
SLO-NIACIN 500 MG
186
SLOW FE
89
SLOW-MAG
146
SM ALCOHOL PREP
PADS
111
SM B-COMPLEX/VITAMIN
C
150
SM GLUCOSE 4 GM
23
SM GLUCOSE 4GM-6MG 23
SM INSULIN SYRINGE/1ML/31G
X 5/16"
132
SM MICRO THIN LANCETS
33G
107
SM ONE DAILY
ESSENTIAL
150
SM ONE DAILY MENS
157
SM ONE DAILY
PRENATAL
164
SM ONE DAILY WOMENS 157
SM PRENATAL VITAMINS 164
SMART DIABETES VANTAGE
LANCING DEVICE
107
SMART SENSE COLOR
LANCETS UNIVERSAL
33G
107
Index 53
SMART SENSE
GLUCOSE
23
SMART SENSE GLUCOSE
TABLETS
23
SMART SENSE PREMIUM
BLOODGLUCOSE
STRIPS
80
SMART SENSE STANDARD
LANCETS UNIVERSAL
21G
107
SMART SENSE SUPER THIN
LANCETS UNIVERSAL
30G
107
SMART SENSE THIN
LANCETSUNIVERSAL
26G
107
SMART SENSE VALUE
BLOOD GLUCOSE
STRIPS
81
SMARTEST BLOOD
GLUCOSE TEST STRIPS 81
SMARTEST CONTROL
SOLUTIONMEDIUM
107
SMARTEST LANCETS
28G
107
sodium chloride
147
sodium chloride (gu
irrigant)
87
sodium chloride (inhalant) 49
sodium chloride 0.9 %
147
sodium chloride
hypertonic
174
sodium citrate & citric acid 87
sodium fluoride
146
sodium fluoride (dental) 148
sodium phosphates
91
sodium polystyrene
sulfonate
148
sodium polystyrene sulfonate
15 gm/60ml
148
SODIUM
SULFACETAMIDE/SULFUR
51
SODIUM
SULFACETAMIDE/SULFUR
CLEANSER IN UREA
51
SOLARTEK GLUCOSE
CONTROLSOLUTIONS 107
SOLIQUA 100/33
22
SOLO
157
SOLODYN
179
SOLOSITE CONFORMABLE
WOUND 2"X2"
74
SOLOSITE CONFORMABLE
WOUND 4"X4"
75
SOLUS V2 AUDIBLE TEST 81
SOLUS V2 CONTROL
HIGH
107
SOLUS V2 CONTROL
LOW
108
SOLUS V2 LANCING
DEVICE
108
SOLUS V2 PRESSURE
ACTIVATED SAFETY LANCETS
28G
108
SOLUS V2 TWIST LANCETS
30G
108
SOMA 250 MG
167
SOMA 350 MG
168
SONATA
90
SOOTHE & COOL FREE
MEDSEPTIC
67
SOOTHE & COOL FREE
MOISTURE BARRIER
67
SOOTHE & COOL FREE SKIN
PASTE
67
SOOTHE & COOL MOISTURE
BARRIER
67
SOOTHE & COOL
MOISTURIZING BODY LOTION
WITH ALOE
64
SOOTHE & COOL PROTECT
MOISTURE BARRIER
67
SOOTHE & COOL SKIN
CREAMWITH ALOE &
VITAMINS A, D & E
64
SOOTHENEB NBL 100 CHILD
MASK
143
SOOTHENEB NBL 100
MEDICATION CUP
143
SOOTHENEB NBL 100 MESH
CAP
143
SOOTHENEB NBL100 ADULT
MASK
143
SORBACELL FOAM DRESSING
4"X4"
75
SORBACELL FOAM
DRESSINGSTRIP 1"X8"
75
SORBIDON HYDRATE
67
SORBOLENE
64
SORBSAN TOPICAL WOUND
DRESSING 12"
75
SORBSAN TOPICAL WOUND
DRESSING 2" X 2"
75
SORBSAN TOPICAL WOUND
DRESSING 3 X 3
75
SORBSAN TOPICAL WOUND
DRESSING 4 X 4
75
SORBSAN TOPICAL WOUND
DRESSING 4" X 8"
75
SORIATANE
55
SORILUX
55
sotalol hcl
43
sotalol hcl (afib/afl)
43
SOTYLIZE
43
SOVALDI
42
SPECIAL CARE CREAM
64
specialty vitamins products 167
SPINOSAD
68
SPIRIVA HANDIHALER
14
SPIRIVA RESPIMAT
14
spironolactone
82
spironolactone &
hydrochlorothiazide
82
SPLEEN
167
SPORANOX
27
SPORANOX PULSEPAK
27
SPORTSCREME
66
SPRITAM
18
SPRIX
6
SPRYCEL
35
SSKI
146
SSS 10-5
51
ST IVES SWISS FORMULA
24HOUR MOISTURE
64
STALEVO 100
36
STALEVO 125
36
STALEVO 150
36
STALEVO 200
36
STALEVO 50
36
STALEVO 75
36
STARLIX
25
stavudine
40
STERILANCE TL
108
STIOLTO RESPIMAT
15
STIVARGA
35
STOMACH
167
STRATASORB COMPOSITE
ISLAND DRESSING 4" X 4" 75
STRATTERA 18 MG, 10 MG, 40
MG, 25 MG
2
STRATTERA 80 MG, 60 MG, 100
MG
2
STRIBILD
40
STRIVERDI RESPIMAT
15
STROVITE FORTE
157
STROVITE ONE
157
STUART ONE
164
STUDIO 35 MOISTURIZING
SKIN
64
SUBOXONE 12MG-3MG
10
SUBOXONE 4MG-1MG, 8MG2MG, 2MG-0.5MG
10
SUBSYS
9
sucralfate
180
SUDAFED
169
SUDAFED CHILDRENS 169
SUDAFED
CONGESTION
169
SUDAFED NASAL
DECONGESTANT MAXIMUM
STRENGTH
169
SUDAFED PE
CONGESTION
169
SULAR
44
sulfacetamide sodprednisolone
173
sulfacetamide sodium
55
SULFACETAMIDE
SODIUM
172
sulfacetamide sodium
(acne)
51
sulfacetamide sodium
(ophth)
172
sulfacetamide sodium w/
sulfur
51
sulfacetamide sodium w/ sulfur
2%-10%
51
sulfacetamide sodium w/ sulfur
4%-9%, 2%-2%-10%-10%, 2%10%, 4.5%-9%
51
sulfacetamide sodium w/ sulfur
5%-10%
51
sulfamethoxazole-trimethoprim
12
sulfasalazine
86
sulindac
6
SUMADAN WASH
51
sumatriptan 20 mg/act
144
sumatriptan 5 mg/act
144
sumatriptan succinate
144
SUMATRIPTAN
SUCCINATE
144
sumatriptan succinate 4
mg/0.5ml
144
sumatriptan succinate 6
mg/0.5ml
144
SUMAVEL DOSEPRO 144
SUMAXIN
51
SUMAXIN TS
51
SUMAXIN WASH
51
SUPER ANTIOXIDANT 157
SUPER C-500
COMPLEX
150
SUPER NU-THERA
157
SUPER THIN LANCETS 108
SUPERB NAILS
157
SUPERVITE EC
157
SUPPORT
157
SUPRAX
45
SUPRAX 200 MG/5ML, 100
MG/5ML
45
SUPRAX 500 MG/5ML
45
SUPREME II HIGH/LOW
CONTROL SOLUTION
108
SUPREME TEST STRIPS 81
SURE COMFORT ALCOHOL
PREP PADS
111
SURE COMFORT INSULIN
SYRINGE/U-100/0.3ML/29G X
1/2"
132
SURE COMFORT INSULIN
SYRINGE/U-100/0.3ML/30G X
1/2"
132
SURE COMFORT INSULIN
SYRINGE/U-100/0.3ML/30G X
5/16"
132
SURE COMFORT INSULIN
SYRINGE/U-100/0.3ML/31G X
5/16
132
SURE COMFORT INSULIN
SYRINGE/U-100/0.3ML/31G X
5/16"
132
SURE COMFORT INSULIN
SYRINGE/U-100/0.5ML/28G X
1/2"
132
SURE COMFORT INSULIN
SYRINGE/U-100/0.5ML/29G X
1/2"
132
SURE COMFORT INSULIN
SYRINGE/U-100/0.5ML/30G X
1/2"
132
SURE COMFORT INSULIN
SYRINGE/U-100/0.5ML/30G X
5/16"
133
SURE COMFORT INSULIN
SYRINGE/U-100/0.5ML/31G X
5/16
133
SURE COMFORT INSULIN
SYRINGE/U-100/1ML/28G X
1/2"
133
SURE COMFORT INSULIN
SYRINGE/U-100/1ML/29G X
1/2"
133
SURE COMFORT INSULIN
SYRINGE/U-100/1ML/30G X
1/2"
133
SURE COMFORT INSULIN
SYRINGE/U-100/1ML/30G X
5/16"
133
Index 54
SURE COMFORT INSULIN
SYRINGE/U-100/1ML/31G X
5/16"
133
SURE COMFORT LANCETS
28G
108
SURE COMFORT LANCETS
30G
108
SURE COMFORT LANCING
PEN
108
SURE COMFORT PEN
NEEDLES29GX1/2"
12.7MM
133
SURE COMFORT PEN
NEEDLES30GX5/16"
SHORT
133
SURE COMFORT PEN
NEEDLES31GX3/16"
(5MM)
133
SURE COMFORT PEN
NEEDLES31GX5/16"
(8MM)
133
SURE COMFORT PEN
NEEDLES32GX5/32"
133
SURE COMFORT PEN
NEEDLES32GX6MM
133
SURE EDGE BLOOD GLUCOSE
TEST STRIPS
81
SURE-FINE PEN NEEDLES
29GX1/2" 12.7MM
133
SURE-FINE PEN NEEDLES
31GX3/16" 5MM
133
SURE-FINE PEN NEEDLES
31GX5/16" 8MM
133
SURE-JECT INSULIN
SYRINGE/U-100/0.3ML/29G X
1/2"
133
SURE-JECT INSULIN
SYRINGE/U-100/0.3ML/30G X
5/16"
133
SURE-JECT INSULIN
SYRINGE/U-100/0.3ML/31G X
5/16"
133
SURE-JECT INSULIN
SYRINGE/U-100/0.5ML/28G X
1/2"
133
SURE-JECT INSULIN
SYRINGE/U-100/0.5ML/29G X
1/2"
133
SURE-JECT INSULIN
SYRINGE/U-100/0.5ML/30G X
5/16"
133
SURE-JECT INSULIN
SYRINGE/U-100/0.5ML/31G X
5/16"
133
SURE-JECT INSULIN
SYRINGE/U-100/1ML/28G X
1/2"
133
Index 55
SURE-JECT INSULIN
SYRINGE/U-100/1ML/29G X
1/2"
133
SURE-JECT INSULIN
SYRINGE/U-100/1ML/30G X
5/16"
133
SURE-JECT INSULIN
SYRINGE/U-100/1ML/31G X
5/16"
133
SURE-LANCE FLAT
LANCETS
108
SURE-LANCE LANCETS
26G
108
SURE-LANCE THIN LANCETS
28G
108
SURE-LANCE ULTRA THIN
LANCETS
108
SURE-PEN
108
SURE-PREP ALCOHOL PREP
PADS
111
SURE-TEST EASYPLUS MINI
BLOOD GLUCOSE TEST
STRIPS
81
SURE-TOUCH LANCETS
UNIVERSAL
108
SURECHEK BLOOD
GLUCOSE TEST STRIPS 81
SURELITE LANCETS
108
SURESTEP GLUCOSE
CONTROL
108
SURESTEP GLUCOSE
CONTROLSOLUTION
108
SURESTEP PRO HIGH
GLUCOSECONTROL
108
SURESTEP PRO LOW
GLUCOSECONTROL
108
SURESTEP PRO NORMAL
GLUCOSE CONTROL 108
SURMONTIL
21
SUSTIVA
40
SUSTIVA 200 MG
40
SUSTIVA 50 MG
40
SUTENT
35
SWEEN 24
64
SWEEN CREAM
64
SYMBICORT
15
SYMBYAX
177
SYMLINPEN 120
22
SYMLINPEN 60
22
SYNAGEX
157
SYNALAR
58
SYNALGOS-DC
10
SYNATEK
157
SYNJARDY
22
SYNTHROID
179
SYSTANE
171
SYSTANE OVERNIGHT
THERAPY LUBRICANT
EYE
171
SYSTANE ULTRA
171
SYSTANE ULTRA HOME &
AWAY PACK
171
T-VITES
157
TAB-A-VITE WOMENS
167
TABLOID
34
TACLONEX
58
tacrolimus
148
tacrolimus (topical)
65
TAFINLAR
35
TAGAMET HB
180
TAGRISSO
35
TAI DOC CONTROL
108
TALTZ
55
TAMIFLU
42
TAMIFLU 30 MG, 45 MG
42
TAMIFLU 75 MG
42
tamoxifen citrate
34
tamsulosin hcl
87
TANZEUM
24
TAPAZOLE
179
TARCEVA
35
TARKA
32
TARON-BC
164
TARON-C DHA
164
TARON-PREX
164
TASIGNA
35
TASMAR
36
TAVIST ALLERGY
28
tazarotene
55
TAZORAC
55
TAZORAC 0.05 %
55
TAZORAC 0.1 %
55
TEARS NATURALE PM
171
TECFIDERA
177
TECFIDERA STARTER
PACK
177
TECHLITE AST LANCETS 108
TECHLITE LANCETS
108
TECHLITE LANCETS 30G 108
TECHLITE PEN NEEDLES/31GX
5MM
133
TECHLITE PEN NEEDLES/31GX
6 MM
134
TECHLITE PEN NEEDLES/31GX
8MM
134
TECHLITE PEN NEEDLES/32GX
4MM
134
TECHLITE PEN NEEDLES/32GX
6MM
134
TECHNIVIE
42
TEGADERM AG MESH
DRESSING WITH SILVER
2"X2"
75
TEGADERM AG MESH
DRESSING WITH SILVER
4"X5"
75
TEGADERM AG MESH
DRESSING WITH SILVER
4"X8"
75
TEGADERM AG MESH
DRESSING WITH SILVER
8"X8"
75
TEGADERM ALGINATE AG
DRESSING
75
TEGADERM HIGH GELLING
ALGINATE DRESSING
4"X4"
75
TEGADERM HIGH INTEGRITY
ALGINATE DRESSING
4"X4"
75
TEGADERM MATRIX
DRESSING
75
TEGRETOL
18
TEGRETOL-XR
18
TEKTURNA
33
TEKTURNA HCT
32
TELCARE BLOOD GLUCOSE
TEST STRIPS
81
TELCARE GLUCOSE CONTROL
SOLUTION LEVEL 1/2
108
telmisartan
31
telmisartan-amlodipine
32
telmisartan-hydrochlorothiazide
32
temazepam 22.5 mg, 7.5 mg 90
temazepam 30 mg, 15 mg 90
TEMODAR
33
TEMOVATE
58
TEMOVATE E
58
temozolomide
33
TENCON
6
TENEX
31
TENORETIC 100
32
TENORETIC 50
32
TENORMIN
43
TERAZOL 3
184
TERAZOL 7
184
terazosin hcl
31
terbinafine hcl
27
terbinafine hcl (topical)
54
terbutaline sulfate
15
terconazole vaginal
184
TESSALON PERLES
48
TESTIM
11
TESTONE CIK
11
TESTOSTERONE
11
testosterone 25 mg/2.5gm, 50
mg/5gm, 1 %
11
TESTOSTERONE 50 MG/5GM,
10 MG/ACT, 1 %, 25
MG/2.5GM
11
testosterone 50 mg/5gm, 25
mg/2.5gm
11
testosterone cypionate
11
TESTOSTERONE PUMP 11
tetracycline hcl 250 mg, 500
mg
179
TETRACYCLINE HCL 500 MG,
250 MG
179
tetrahydrozoline hcl
(ophth)
172
tetrahydrozoline w/
polyethylene glycol
172
tetrahydrozoline-dextranpolyethylene glycolpovidone
173
TEXACORT
58
TGT ADVANCED LANCING
DEVICE
108
TGT ALCOHOL SWABS 111
TGT BLOOD GLUCOSE TEST
STRIPS
81
TGT BLOOD GLUCOSE TEST
STRIPS PREMIUM
81
TGT GLUCOSE
23
TGT LANCET ALTERNATE
SITE
108
TGT LANCET MICRO THIN
33G
108
TGT LANCET SUPER THIN
30G
108
TGT LANCET THIN 23G 108
TGT LANCET THIN 26G 108
TGT LANCET ULTRA THIN
28G
108
TGT LANCET ULTRA THIN
30G
108
TGT LANCING DEVICE 108
TH PRENATAL VITAMINS 164
THALOMID
147
THEO-24
16
theophylline
16
THERA M PLUS
157
THERA-FLUR-N
148
THERA-M
157
THERA-TABS M
157
THERA/BETA-CAROTENE
159
THERABETIC EYE
HEALTH
167
THERABETIC MULTIVITAMIN
157
THERABETIC SKIN CARE 64
THERACAL D2000
146
THERACAL D4000
146
THERACAL RAPID
REPLETION
146
THERAGRAN-M
158
THERAGRAN-M
ADVANCED
157
THERAGRAN-M ADVANCED 50
PLUS
157
THERAGRAN-M PREMIER157
THERAGRAN-M PREMIER 50
PLUS
157
THERAMILL FORTE
158
THERANATAL CORE
NUTRITION
164
THERANATAL LACTATION
COMPLETE
158
THERANATAL LACTATION
ONE
158
THERANATAL LACTATION
SUPPORT
158
THERAPEUTIC
MOISTURIZING
64
THERAPEUTIC T+PLUS
MAXIMUM STRENGTH
65
THERAPLEX
HYDROLOTION
64
THERAPLEX T
68
THEREMS-H
158
THEREMS-M
158
thiamine hcl 100 mg, 50 mg186
thiamine mononitrate
186
THINLETS GP LANCETS 108
THINLETS LANCET
108
thioridazine hcl
38
thiothixene
39
THRESHOLD IMT
143
Index 56
THRIVITE 19
164
THRIVITE RX
164
throat lozenges
149
THYMUS
167
thyroid
179
THYROLAR-1
179
THYROLAR-1/2
179
THYROLAR-1/4
179
THYROLAR-2
179
THYROLAR-3
179
tiagabine hcl
19
TIAZAC
44
ticlopidine hcl
88
TIGAN
26
TIKOSYN
14
TIMOLOL MALEATE
43
timolol maleate (ophth)
171
TIMOPTIC
171
TIMOPTIC OCUDOSE
171
TIMOPTIC-XE
171
TINACTIN
54
TINACTIN DEODORANT
54
TINACTIN JOCK ITCH
54
TINDAMAX
12
tinidazole
12
TIVICAY 25 MG, 10 MG
40
TIVICAY 50 MG
40
TIVORBEX
6
tizanidine hcl
168
TL FOLATE
164
TL-CARE DHA
164
TL-SELECT
164
TOBI
4
TOBI PODHALER
4
TOBRADEX
173
TOBRADEX ST
173
tobramycin
4
TOBRAMYCIN
4
tobramycin (ophth)
172
tobramycin sulfate
4
TOBRAMYCIN SULFATE 40
MG/ML, 10 MG/ML
4
tobramycin sulfate 40 mg/ml, 10
mg/ml, 80 mg/2ml, 1.2
gm/30ml
4
tobramycindexamethasone
174
TOBREX
172
Index 57
TODAYS HEALTH ADVANCED
LANCING DEVICE
108
TODAYS HEALTH MINI PEN
NEEDLES 31G X 1/4"
134
TODAYS HEALTH ORIGINAL
PEN NEEDLES 29G X
1/2"
134
TODAYS HEALTH SHORT
PEN NEEDLES 31G X
5/16"
134
TODAYS HEALTH SUPER
THINLANCETS 30G
108
TODAYS HEALTH ULTRA
THINLANCETS 28G
108
TOE-AID
75
TOFRANIL
22
TOFRANIL-PM
22
tolazamide 250 mg
25
TOLAZAMIDE 250 MG, 500
MG
25
TOLBUTAMIDE
25
tolcapone
36
tolmetin sodium
6
TOLMETIN SODIUM
6
tolnaftate
54
tolterodine tartrate
182
TOPAMAX
18
TOPAMAX SPRINKLE
18
TOPCARE CLICKFINE
UNIVERSAL PEN EEDLES
31GX1/4"
134
TOPCARE CLICKFINE
UNIVERSAL PEN EEDLES
31GX5/16"
134
TOPCARE ULTRA COMFORT
INSULIN SYRINGE/0.3ML/30G
X 5/16"
134
TOPCARE ULTRA COMFORT
INSULIN SYRINGE/0.3ML/31G
X 5/16"
134
TOPCARE ULTRA COMFORT
INSULIN SYRINGE/0.5ML/30G
X 5/16"
134
TOPCARE ULTRA COMFORT
INSULIN SYRINGE/0.5ML/31G
X 5/16"
134
TOPCARE ULTRA COMFORT
INSULIN SYRINGE/1ML/30G X
5/16"
134
TOPCARE ULTRA COMFORT
INSULIN SYRINGE/1ML/31G X
5/16"
134
TOPCARE ULTRA COMFORT
INSULIN SYRINGE/U100/0.3ML/29G X 1/2"
134
TOPCARE ULTRA COMFORT
INSULIN SYRINGE/U100/0.5ML/29G X 1/2"
134
TOPCARE ULTRA COMFORT
INSULIN SYRINGE/U100/1ML/29G X 1/2"
134
TOPCO INSULIN SYRINGE/U100/0.3ML/29G X 1/2"
134
TOPCO INSULIN SYRINGE/U100/0.5ML/28G X 1/2"
134
TOPCO INSULIN SYRINGE/U100/0.5ML/29G X 1/2"
134
TOPCO INSULIN SYRINGE/U100/1ML/28G X 1/2"
134
TOPCO INSULIN SYRINGE/U100/1ML/29G X 1/2"
134
TOPICORT
58
topiramate
18
TOPIRAMATE ER
18
TOPROL XL
43
torsemide
82
TOUJEO SOLOSTAR
25
TOVIAZ
182
TRACLEER
44
TRADJENTA
24
tramadol hcl
9
TRAMADOL HCL ER 300 MG,
100 MG, 200 MG
9
tramadol-acetaminophen
10
trandolapril
31
trandolapril-verapamil hcl
32
tranexamic acid
89
TRANSDERM-SCOP
26
TRANXENE T
13
tranylcypromine sulfate
20
TRAVATAN Z
175
TRAVEL LANCETS 30G 109
TRAVOPROST
175
trazodone hcl 150 mg
21
trazodone hcl 300 mg
21
trazodone hcl 50 mg, 100
mg
21
TRECATOR
33
TRESIBA FLEXTOUCH
25
tretinoin
51
tretinoin (chemotherapy)
35
tretinoin 0.01 %, 0.025 %
52
tretinoin 0.05 %
52
TRETINOIN EMOLLIENT
52
tretinoin microsphere
52
TREXALL
34
TREXIMET 10MG-60MG 143
TREXIMET 85MG-500MG 143
TREZIX
10
TRI-NORINYL 28
46
TRI-TABS DHA
164
TRI-VIT/FLUORIDE/IRON 159
TRIADVANCE
165
triamcinolone acetonide
(mouth)
149
triamcinolone acetonide
(nasal)
169
triamcinolone acetonide
(topical)
58
triamcinolone acetonidedimethicone-silicone
58
TRIAMINIC COLD &
ALLERGY
49
TRIAMINIC FEVER
REDUCERPAIN RELIEVER
CHILDRENS
7
TRIAMINIC FEVER
REDUCERPAIN RELIEVER
INFANTS
7
triamterene &
hydrochlorothiazide
82
TRIAMTERENE/HYDROCHLOR
OTHIAZIDE
82
TRIANEX
58
TRIAZOLAM 0.125 MG
90
triazolam 0.25 mg
90
TRIBENZOR
32
TRICARE
165
TRICARE PRENATAL
165
TRICARE PRENATAL 1
165
TRICARE PRENATAL
COMPLEAT
165
TRICARE PRENATAL DHA
ONE
165
TRICOR
29
TRIDESILON
59
trifluoperazine hcl
38
trifluridine
172
TRIGLIDE
29
trihexyphenidyl hcl
36
TRILEPTAL
18
TRILEPTAL 150 MG, 300
MG
18
TRILEPTAL 600 MG
18
TRILIPIX
29
trimethobenzamide hcl
26
trimipramine maleate
22
TRINATAL GT
165
TRINATAL RX 1
165
TRINATE
165
TRINTELLIX
21
TRIPLE CREAM
64
TRIPLE HELIX COLLAGEN
2"X2"
75
TRISTART DHA
165
TRIUMEQ
40
TRIVEEN-DUO DHA
165
TRIVEEN-PRX RNF
165
TRIXAICIN
66
TRIZIVIR
41
TROJAN EXTENDED
PLEASURE/LUBRICATED
93
TROJAN MAGNUM
93
TROJAN MAGNUM WARM
SENSATIONS
93
TROJAN MAGNUM XL
LUBRICATED
93
TROJAN PLEASURE
MESH/SPERMICIDAL
93
TROJAN RIBBED
W/SPERMICIDAL
93
TROJAN SHARED
SENSATION/LUBRICATED
93
TROJAN SUPRAS
SPERMICIDAL
93
TROJAN TWISTED
PLEASURE
93
TROJAN ULTRA
PLEASURE/LUBRICATED
93
TROJAN VERY SENSITIVE
LUBRICATED
93
TROJAN VERY SENSITIVE
SPERMICIDAL
LUBRICANT
93
TROJAN VERY THIN
LUBRICATED
93
TROJAN VERY THIN
SPERMICIDAL
LUBRICANT
93
TROJAN-ENZ
LUBRICANT
93
TROJAN-ENZ
LUBRICATED
93
TROJAN-ENZ
W/SPERMICIDAL
93
TROKENDI XR
18
trolamine salicylate
66
TROPAZONE
64
tropicamide
171
trospium chloride
182
TRUE METRIX BLOOD
GLUCOSETEST STRIPS
81
TRUE METRIX CONTROL
SOLUTION LEVEL 1
109
TRUE METRIX CONTROL
SOLUTION LEVEL 2
109
TRUE METRIX CONTROL
SOLUTION LEVEL 3
109
TRUE METRIX SELF
MONITORING BLOOD
GLUCOSE STRIPS
81
TRUECONTROL GLUCOSE
CONTROL LEVEL 0
109
TRUECONTROL GLUCOSE
CONTROL LEVEL 1
109
TRUEDRAW LANCING
DEVICE
109
TRUEPLUS INSULIN
SYRINGE/U-100/0.3ML/29G X
1/2"
134
TRUEPLUS INSULIN
SYRINGE/U-100/0.3ML/30G X
5/16"
134
TRUEPLUS INSULIN
SYRINGE/U-100/0.3ML/31G X
5/16"
134
TRUEPLUS INSULIN
SYRINGE/U-100/0.5ML/28G X
1/2"
135
TRUEPLUS INSULIN
SYRINGE/U-100/0.5ML/29G X
1/2"
135
TRUEPLUS INSULIN
SYRINGE/U-100/0.5ML/30G X
5/16"
135
TRUEPLUS INSULIN
SYRINGE/U-100/0.5ML/31G X
5/16"
135
TRUEPLUS INSULIN
SYRINGE/U-100/1ML/28G X
1/2"
135
TRUEPLUS INSULIN
SYRINGE/U-100/1ML/29G X
1/2"
135
TRUEPLUS INSULIN
SYRINGE/U-100/1ML/30G X
5/16"
135
TRUEPLUS INSULIN
SYRINGE/U-100/1ML/31G X
5/16"
135
TRUEPLUS LANCETS
26G
109
TRUEPLUS LANCETS
28G
109
TRUEPLUS LANCETS 28G
SUPER THIN
109
TRUEPLUS LANCETS
30G
109
Index 58
TRUEPLUS LANCETS 30G
ULTRA THIN
109
TRUEPLUS LANCETS
33G
109
TRUEPLUS LANCETS 33G
MICRO THIN
109
TRUEPLUS PEN NEEDLES
29GX12MM
135
TRUEPLUS PEN NEEDLES
31GX5MM
135
TRUEPLUS PEN NEEDLES
31GX6MM
135
TRUEPLUS PEN NEEDLES
31GX8MM
135
TRUEPLUS PEN NEEDLES
32GX4MM
135
TRUEPLUS SAFETY LANCETS
28G
109
TRUETEST BLOOD GLUCOSE
TEST
81
TRUETEST BLOOD GLUCOSE
TEST STRIPS
81
TRUETEST GLUCOSE
CONTROLLEVEL 1
109
TRUETEST GLUCOSE
CONTROLLEVEL 2
109
TRUETEST GLUCOSE
CONTROLLEVEL 3
109
TRUETEST STRIPS
81
TRUETRACK BLOOD
GLUCOSE TEST
81
TRUETRACK TEST
81
TRULICITY
24
TRUMENBA
183
TRUSOPT
174
TRUSTEX COLOR CONDOMS +
LUBE
93
TRUSTEX LUBRICATED
93
TRUSTEX LUBRICATED
EXTRALARGE
93
TRUSTEX LUBRICATED
EXTRASTRENGTH
93
TRUSTEX
LUBRICATED/RIBBED/STUDDE
D
93
TRUSTEX
LUBRICATED/SPERMICIDE
93
TRUSTEX
LUBRICATED/SPERMICIDE
EXTRA LARGE
93
TRUSTEX
LUBRICATED/SPERMICIDE
EXTRA STRENGTH
93
TRUSTEX NATURAL
CONDOMS
+LUBE/LUBRICATED
93
Index 59
TRUSTEX WITH
NONOXYNOL9/RIBBED/STUDDED
93
TRUSTEX/RIA
LUBRICATED
93
TRUSTEX/RIA LUBRICATED
SPERMICIDE
93
TRUSTEX/RIA
LUBRICATED/SPERMICIDE
93
TRUVADA
41
TUBING/WING TIP
143
TUDORZA PRESSAIR
14
TUMS
12
TUMS LASTING
EFFECTS
12
TUSNEL C
49
TWYNSTA
32
TYBOST
41
TYKERB
35
TYLENOL
7
TYLENOL 8 HOUR
7
TYLENOL 8 HOUR
ARTHRITISPAIN
7
TYLENOL CHILDRENS
7
TYLENOL COLD & FLU
SEVERE
49
TYLENOL EXTRA
STRENGTH
7
TYLENOL INFANTS
7
TYLENOL INFANTS
PAIN+FEVER
7
TYLENOL PM EXTRA
STRENGTH
89
TYLENOL SORE THROAT
DAYTIME
7
TYLENOL/CODEINE #3 10
TYLENOL/CODEINE #4 10
TYVASO
44
TYVASO REFILL
44
TYVASO STARTER
44
TYZEKA
42
UCERIS
11
UDDERLY SMOOTH
64
UDDERLY SMOOTH EXTRA
CARE
64
UDDERLY SMOOTH EXTRA
CARE20
64
ULORIC
87
ULTEC HYDROCOLLOID
DRESSING
75
ULTI-LANCE AUTOMATIC/
CLEAR TIP
109
ULTICARE ALCOHOL
SWABS
111
ULTICARE INSULIN SAFETY
SYRINGE/0.5ML/29G X
1/2"
135
ULTICARE INSULIN SAFETY
SYRINGE/1ML/29G X 1/2" 135
ULTICARE INSULIN
SYRINGE/0.3ML/29G X
1/2"
135
ULTICARE INSULIN
SYRINGE/0.3ML/30G X
1/2"
135
ULTICARE INSULIN
SYRINGE/0.3ML/30G X
5/16"
135
ULTICARE INSULIN
SYRINGE/0.5ML/28G X
1/2"
135
ULTICARE INSULIN
SYRINGE/0.5ML/29G X
1/2"
135
ULTICARE INSULIN
SYRINGE/0.5ML/30G X
1/2"
135
ULTICARE INSULIN
SYRINGE/0.5ML/30G X
5/16"
135
ULTICARE INSULIN
SYRINGE/1ML/28G X 1/2" 135
ULTICARE INSULIN
SYRINGE/1ML/29G X 1/2" 135
ULTICARE INSULIN
SYRINGE/1ML/30G X 1/2" 135
ULTICARE INSULIN
SYRINGE/1ML/30G X
5/16"
135
ULTICARE INSULIN
SYRINGE/SHORT/0.3ML/30G X
5/16"
135
ULTICARE INSULIN
SYRINGE/SHORT/0.3ML/31G X
5/16"
135
ULTICARE INSULIN
SYRINGE/SHORT/0.5ML/30G X
5/16"
135
ULTICARE INSULIN
SYRINGE/SHORT/0.5ML/31G X
5/16"
136
ULTICARE INSULIN
SYRINGE/SHORT/1ML/30G X
5/16"
136
ULTICARE INSULIN
SYRINGE/SHORT/1ML/31G X
5/16"
136
ULTICARE INSULIN
SYRINGE/U-100/0.3ML/29G X
1/2"
136
ULTICARE INSULIN
SYRINGE/U-100/0.3ML/30G X
1/2"
136
ULTICARE INSULIN
SYRINGE/U-100/0.3ML/30G X
5/16"
136
ULTICARE INSULIN
SYRINGE/U-100/0.3ML/31G X
5/16"
136
ULTICARE INSULIN
SYRINGE/U-100/0.5ML/29G X
1/2"
136
ULTICARE INSULIN
SYRINGE/U-100/0.5ML/30G X
1/2"
136
ULTICARE INSULIN
SYRINGE/U-100/0.5ML/30G X
5/16"
136
ULTICARE INSULIN
SYRINGE/U-100/0.5ML/31G X
5/16"
136
ULTICARE INSULIN
SYRINGE/U-100/1ML/29G X
1/2"
136
ULTICARE INSULIN
SYRINGE/U-100/1ML/30G X
1/2"
136
ULTICARE INSULIN
SYRINGE/U-100/1ML/30G X
5/16"
136
ULTICARE INSULIN
SYRINGE/U-100/1ML/31G X
5/16"
136
ULTICARE INSULIN
SYRINGEULTRAFINE U100/0.3ML/31G X 5/16"
136
ULTICARE INSULIN
SYRINGEULTRAFINE U100/0.5ML/31G X 5/16"
136
ULTICARE INSULIN
SYRINGEULTRAFINE U100/1ML/31G X 5/16"
136
ULTICARE MICRO PEN
NEEDLES 31G X 8MM
136
ULTICARE MICRO PEN
NEEDLES 32G X 4MM
136
ULTICARE MICRO PEN
NEEDLES/32G X 4MM
136
ULTICARE MINI PEN NEEDLES
31GX6MM
136
ULTICARE MINI PEN NEEDLES
ULTI-FINE IV
136
ULTICARE MINI PEN
NEEDLES/31G X 6MM
136
ULTICARE MINI PEN
NEEDLES31GX6MM
136
ULTICARE ORIGINAL PEN
NEEDLES ULTI-FINE
136
ULTICARE PEN
NEEDLES/29GX 12.7MM 136
ULTICARE SHORT PEN
NEEDLES 31GX8MM
136
ULTICARE SHORT PEN
NEEDLES ULTI-FINE IV 137
ULTICARE SHORT PEN
NEEDLES/31G X 8MM 137
ULTICARE THIN LANCETS
30G
109
ULTILET CLASSIC
LANCETS
109
ULTILET INSULIN
SYRINGE/SHORT/0.3ML/30G
X 5/16"
137
ULTILET INSULIN
SYRINGE/SHORT/0.3ML/31G
X 5/16"
137
ULTILET INSULIN
SYRINGE/SHORT/0.5ML/30G
X 5/16"
137
ULTILET INSULIN
SYRINGE/SHORT/0.5ML/31G
X 5/16"
137
ULTILET INSULIN
SYRINGE/SHORT/1ML/30G X
5/16"
137
ULTILET INSULIN
SYRINGE/SHORT/1ML/31G X
5/16"
137
ULTILET LANCETS
109
ULTILET LANCETS 33G 109
ULTILET PEN NEEDLE
32GX4MM/SHORT
137
ULTILET SAFETY LANCETS
23G
109
ULTILET SHORT PEN
NEEDLES 31GX5/16"
137
ULTILET SHORT PEN
NEEDLES31GX3/16"
137
ULTIMA TEST STRIPS
81
ULTIMATE FEELING
94
ULTIMATECARE ONE 165
ULTIMATECARE ONE
NF
165
ULTRA COMFORT INSULIN
SYRINGE/U-100/0.3ML/30G X
5/16"
137
ULTRA COMFORT INSULIN
SYRINGE/U-100/0.5ML/28G X
1/2"
137
ULTRA MEGA
158
ULTRA MEGA GOLD
158
ULTRA MEGA TWO
158
ULTRA MENS PACK
158
ULTRA THIN LANCETS
28G
109
ULTRA THIN LANCETS
30G
109
ULTRA WOMENS PACK 158
ULTRA-COMFORT INSULIN
SYRINGE/U-100/0.3ML/29G X
1/2"
137
ULTRA-COMFORT INSULIN
SYRINGE/U-100/0.3ML/30G X
5/16"
137
ULTRA-COMFORT INSULIN
SYRINGE/U-100/0.3ML/31G X
5/16"
137
ULTRA-COMFORT INSULIN
SYRINGE/U-100/0.5ML/28G X
1/2"
137
ULTRA-COMFORT INSULIN
SYRINGE/U-100/0.5ML/29G X
1/2"
137
ULTRA-COMFORT INSULIN
SYRINGE/U-100/0.5ML/30G X
5/16"
137
ULTRA-COMFORT INSULIN
SYRINGE/U-100/0.5ML/31G X
5/16"
137
ULTRA-COMFORT INSULIN
SYRINGE/U-100/1ML/28G X
1/2"
137
ULTRA-COMFORT INSULIN
SYRINGE/U-100/1ML/29G X
1/2"
137
ULTRA-COMFORT INSULIN
SYRINGE/U-100/1ML/30G X
5/16"
137
ULTRA-COMFORT INSULIN
SYRINGE/U-100/1ML/31G X
5/16"
137
ULTRA-THIN II AUTO
LANCET
109
ULTRA-THIN II INSULIN
SYRINGE SHORT/U100/0.3ML/30GX5/16"
137
ULTRA-THIN II INSULIN
SYRINGE SHORT/U100/0.3ML/31GX5/16"
137
ULTRA-THIN II INSULIN
SYRINGE SHORT/U100/0.5ML/30GX5/16"
137
ULTRA-THIN II INSULIN
SYRINGE SHORT/U100/0.5ML/31GX5/16"
138
ULTRA-THIN II INSULIN
SYRINGE SHORT/U100/1ML/30GX5/16"
138
ULTRA-THIN II INSULIN
SYRINGE SHORT/U100/1ML/31GX5/16"
138
ULTRA-THIN II INSULIN
SYRINGE/U100/0.3ML/29GX1/2"
138
Index 60
ULTRA-THIN II INSULIN
SYRINGE/U100/0.5ML/29GX1/2"
138
ULTRA-THIN II INSULIN
SYRINGE/U-100/1ML/29GX1/2"
138
ULTRA-THIN II LANCETS
28G
109
ULTRA-THIN II LANCETS
30G
109
ULTRA-THIN II MINI PEN
NEEEDLES/31GX3/16"
138
ULTRA-THIN II PEN NEEDLES
29GX1/2"
138
ULTRA-THIN II PEN
NEEDLES/SHORT/31GX5/16"
138
ULTRA-THIN II SAFETY
AUTOLANCETS 26G
109
ULTRACET
10
ULTRAM
9
ULTRAM ER
9
ULTRATRAK PRO CONTROL
SOLUTION 2 LEVELS
109
ULTRATRAK PRO NORMAL
CONTROL
109
ULTRATRAK PRO TEST
STRIPS
81
ULTRATRAK ULTIMATE
CONTROL SOLUTION 2
LEVELS
109
ULTRATRAK ULTIMATE TEST
STRIPS
81
ULTRAVATE
59
ULTRESA
82
UNICOMPLEX-M
158
UNIFINE PENTIPS
29GX12MM
138
UNIFINE PENTIPS 31G X
3/16"
138
UNIFINE PENTIPS
31GX5MM
138
UNIFINE PENTIPS
31GX6MM
138
UNIFINE PENTIPS
31GX8MM
138
UNIFINE PENTIPS
32GX4MM
138
UNIFINE PENTIPS PLUS
29GX12MM
138
UNIFINE PENTIPS PLUS
31GX5MM
138
UNIFINE PENTIPS PLUS
31GX6MM
138
UNIFINE PENTIPS PLUS
31GX8MM
138
UNIFINE PENTIPS PLUS
32GX4MM
138
Index 61
UNILET COMFORTOUCH
LANCET
109
UNILET EXCELITE
109
UNILET EXCELITE II
109
UNILET G.P. LANCET 109
UNILET G.P. SUPERLITE
LANCET
109
UNILET GP 28 ULTRA
THIN
109
UNILET LANCET
110
UNILET LANCETS MICROTHIN33G
110
UNILET LANCETS SUPERTHIN30G
110
UNILET LANCETS ULTRATHIN 28G
110
UNILET SUPERLITE
LANCET
110
UNISOM
89
UNISOM SLEEPGELS
89
UNISTIK 3 GENTLE
110
UNISTIK SAFETY LANCETS
28G
110
UNISTIK SAFETY LANCETS
30G
110
UNISTIK TOUCH SAFETY
LANCETS 21G
110
UNISTIK TOUCH SAFETY
LANCETS 23G
110
UNISTIK TOUCH SAFETY
LANCETS 28G
110
UNISTIK TOUCH SAFETY
LANCETS 30G
110
UNISTRIP CONTROL
SOLUTIONHIGH
110
UNISTRIP CONTROL
SOLUTIONLOW
110
UNISTRIP1 GENERIC
81
UNIVERSAL 1 LANCETS
THIN26G
110
UNIVERSAL 1 LANCETS
ULTRA THIN 30G
110
UNIVERSAL 1
LANCETS/33G/MICRO-THIN
110
UP & UP GLUCOSE
23
UPTRAVI
44
urea 20 %, 40 %
59
urea 40 %
59
URECHOLINE
182
UROCIT-K 10
87
UROCIT-K 5
87
UROXATRAL
87
URSO 250
85
URSO FORTE
85
ursodiol
85
UTERUS
167
UTIBRON NEOHALER
15
V-R MONOJECT INSULIN
SYRINGE/U-100/0.3ML/29G X
1/2"
138
V-R MONOJECT INSULIN
SYRINGE/U-100/0.5ML/28G X
1/2"
138
V-R MONOJECT INSULIN
SYRINGE/U-100/0.5ML/29G X
1/2"
138
V-R MONOJECT INSULIN
SYRINGE/U-100/1ML/28G X
1/2"
138
V-R MONOJECT INSULIN
SYRINGE/U-100/1ML/29G X
1/2"
138
valacyclovir hcl 1 gm, 1000
mg
42
valacyclovir hcl 500 mg
42
VALCYTE
41
valganciclovir hcl
41
VALIUM
13
valproate sodium
19
valproic acid
19
valsartan
31
valsartan-hydrochlorothiazide
33
VALTREX 1 GM
42
VALTREX 500 MG
42
VALUE HEALTH INSULIN
SYRINGE/U-100/0.5ML/29G X
1/2"
138
VALUE HEALTH INSULIN
SYRINGE/U-100/1ML/29G X
1/2"
138
VALUE PLUS GLUCOSE
23
VALUE PLUS LANCETS
STANDARD 21G
110
VALUE PLUS LANCETS
SUPERTHIN 30G
110
VALUE PLUS LANCETS THIN
26G
110
VALUE PLUS LANCING
DEVICE
110
VALUMARK LANCET SUPER
THIN 30G
110
VALUMARK LANCET ULTRA
THIN 28G
110
VALUMARK PEN NEEDLES
29GX12MM
138
VALUMARK PEN NEEDLES
31GX 6MM
138
VALUMARK PEN NEEDLES
31GX 8MM
138
VALVED HOLDING
CHAMBER
143
VANCOCIN HCL
12
vancomycin hcl
12
vancomycin hcl 1000 mg
12
vancomycin hcl 500 mg
12
VANICREAM
64
VANICREAM LITE
64
VANISHPOINT INSULIN
SYRINGE/0.5ML/30G X
1/2"
138
VANISHPOINT INSULIN
SYRINGE/0.5ML/30G X
5/16"
138
VANISHPOINT INSULIN
SYRINGE/1ML/29G X 1/2" 138
VANISHPOINT INSULIN
SYRINGE/1ML/30G X
5/16"
138
VANOS
59
VAPORX BALM
49
VARUBI
26
VASCEPA
29
VASELINE PETROLATUM
GAUZE
75
VASELINE PETROLATUM
GAUZECISION DRESSING 75
VASELINE PETROLATUM
GAUZECISION DRESSING
OVERWRAP
75
VASELINE PETROLATUM
GAUZEOVERWRAP
75
VASELINE PETROLATUM
GAUZESTRIP
75
VASELINE PETROLATUM
GAUZESTRIP OVERWRAP 75
VASELINE PETROLATUM
GAUZETUBE FOIL
OVERWRAP
75
VASERETIC
33
VASOTEC
31
VECTICAL
55
VELPHORO
87
VELTIN
52
VELVACHOL
64
VEMAVITE-PRX 2
165
VENA-BAL DHA
165
VENCLEXTA
34
VENCLEXTA STARTING
PACK
34
venlafaxine hcl
21
VENLAFAXINE HCL ER 150
MG, 75 MG, 37.5 MG
21
VENLAFAXINE HCL ER 225
MG
21
VENTAVIS 10 MCG/ML 44
VENTAVIS 20 MCG/ML 44
VENTOLIN HFA
15
VERAMYST
169
verapamil hcl
44
verapamil hcl 180 mg, 240 mg,
360 mg, 120 mg
44
verapamil hcl 300 mg, 200 mg,
100 mg
44
VERELAN
44
VERELAN PM
44
VERIPRED 20
47
VERSACLOZ
38
VESICARE
182
VEXOL
174
VFEND
27
VIBERZI
86
VIBRAMYCIN
179
VICKS BABYRUB
66
VICKS SINEX
169
VICKS SINEX 12 HOUR
DECONGESTANT
169
VICKS SINEX 12 HOUR
DECONGESTANT ULTRA
FINE MIST
169
VICKS SINEX 12 HOUR
DECONGESTANT ULTRA
FINE
MIST/MOISTURIZNG
169
VICKS SINEX
MOISTURIZING
169
VICKS SINEX SEVERE
NASALDECONGESTANT 16
9
VICKS VAPORUB
49
VICOPROFEN
10
VICTORY AGM-4000 TEST
STRIPS
81
VICTORY CONTROL LEVEL
1/2
110
VICTOZA
24
VIDA MIA AUTOLET
LANCINGDEVICE
110
VIDA MIA UNIFINE
PENTIPS32GX4MM
139
VIDA MIA UNIFINE
PENTIPSMINI 31GX6MM139
VIDA MIA UNIFINE
PENTIPSORIGINAL
29GX12MM
139
VIDA MIA UNILET LANCETS
SUPER THIN 30G
110
VIDA MIA UNILET LANCETS
ULTRA THIN 28G
110
VIDA MIA UNIPFINE
PENTIPSSHORT
31GX8MM
139
VIDEX EC
41
VIDEXPEDIATRIC
41
VIEKIRA PAK
42
VIEKIRA XR
42
VIGAMOX
172
VIGILON PRIMARY WOUND
DRESSING/13" X 24"
75
VIGILON PRIMARY WOUND
DRESSING/3" X 8"
75
VIGILON PRIMARY WOUND
DRESSING/4" X 4"
75
VIGILON PRIMARY WOUND
DRESSING/6" X 8"
75
VIIBRYD
21
VIIBRYD STARTER PACK 21
VIMOVO
6
VIMPAT
18
VINACAL B
165
VINATE AZ EXTRA
165
VINATE C
165
VINATE CALCIUM
165
VINATE CARE
165
VINATE DHA RF
165
VINATE IC
165
VINATE II
165
VINATE M
165
VINATE ONE
165
VIOKACE
82
VIRACEPT 250 MG
41
VIRACEPT 625 MG
41
VIRAMUNE
41
VIRAMUNE XR 100 MG
41
VIRAMUNE XR 400 MG
41
VIREAD
41
VIROPTIC
172
VIRT NATE
165
VIRT-ADVANCE
165
VIRT-C DHA
165
VIRT-CARE ONE
165
VIRT-NATE DHA
165
VIRT-PN
165
VIRT-PN DHA
165
Index 62
VIRT-PN PLUS
165
VIRT-SELECT
165
VIRT-VITE GT
165
VIRTPREX
165
VISINE
173
VISINE ADVANCED
RELIEF
173
VISINE EXTRA
173
VISTARIL
13
VITA-BOB
158
VITABEX
158
VITAFOL FE+
165
VITAFOL GUMMIES
165
VITAFOL ULTRA
165
VITAFOL-NANO
165
VITAFOL-OB
165
VITAFOL-OB+DHA
165
VITAFOL-ONE
165
VITALET PRO LANCETS 110
VITALET PRO PLUS
LANCETS
110
VITALETS
160
VITALETS CHILDRENS
160
VITALINE TOTAL FORMULA
2
158
VITALINE TOTAL FORMULA
3
158
VITAMAX
160
VITAMENT
158
vitamin a 10000 unit
185
vitamin a 8000 unit, 10000
unit
185
VITAMIN C
150
VITAMIN C EFFERVESCENT
BLEND
158
VITAMIN
C/ELECTROLYTES
158
VITAMIN D3 COMPLETE 158
vitamin e
185
vitamin e 100 unit, 1000 unit, 400
unit, 200 unit
185
VITAMIN E WITH
PANTHENOL
64
vitamins a & d
167
vitamins a & d (topical)
65
VITAMINS FOR THE HAIR 167
VITAMINS TO GO
MAXIMUM
158
VITAMINS TO GO MEN
158
VITAMINS TO GO
WOMEN
158
Index 63
vitamins w/ lipotropics
167
VITAROCA PLUS
158
VITASANA
158
VITATRUM
158
VITEKTA
41
VITRUM 50+ SENIOR
MULTI
158
VIVA DHA
165
VIVARIN
2
VIVELLE-DOT
84
VIVLODEX
6
VOCAL POINT BLOOD
GLUCOSE TEST STRIPS 81
VOGELXO
11
VOGELXO PUMP
11
VOL-NATE
165
VOL-PLUS
165
VOL-TAB RX
165
VOLTAREN
52
VOLTAREN-XR
6
VOPAC MDS
52
voriconazole
27
VORTEX VALVED HOLDING
CHAMBER
143
VOSPIRE ER
15
VOTRIENT
35
VP INSULIN SYRINGE/U100/0.3ML/29G X 1/2"
139
VP-CH PLUS
166
VP-CH-PNV
166
VP-GGR-B6 PRENATAL 166
VP-HEME OB
166
VP-HEME OB + DHA
166
VP-HEME ONE
166
VP-PNV-DHA
166
VP-ZEL
158
VRAYLAR
37
VUSION
54
VYTORIN
29
VYVANSE
2
W&F LANCETS 26G
110
W&F LANCETS COLORED
21G
110
WALGREENS ADVANCED
TRAVELLANCETS 28G 110
WALGREENS COMFORT
ASSUREDLANCETS MICRO
THIN/33G
110
WALGREENS COMFORT
ASSUREDLANCETS SUPER
THIN/28G
110
WALGREENS GLUCOSE 4
GM
23
WALGREENS GLUCOSE 4GM6MG
23
WALGREENS LANCETS 110
WALGREENS THIN
LANCETS
110
WALGREENS ULTRA THIN
LANCETS
110
warfarin sodium
16
WATCHHALER
143
WAVESENSE PRESTO TEST
STRIPS
81
WEBCOL ALCOHOL PREP
LARGE 1 PLY
111
WEBCOL ALCOHOL PREP
LARGE 2 PLY
111
WEBCOL ALCOHOL PREP
MEDIUM 2 PLY
111
WEGMANS UNIFINE PENTIPS
PLUS 32GX4MM
139
WEGMANS UNIFINE PENTIPS
PLUS/MINI/31GX5MM
139
WEGMANS UNIFINE PENTIPS
PLUS/SHORT/31GX8MM 139
WEGMANS UNIFINE PENTIPS
PLUS/ULTRA
SHORT/31GX6MM
139
WELCHOL
29
WELLBUTRIN
20
WELLBUTRIN SR
20
WELLBUTRIN XL
20
WESTCORT
59
white petrolatum-mineral oil 171
WHOLE FOOD
MULTIVITAMIN
158
WIBI
65
WINDMILL TRAINER
143
witch hazel (hamamelis
virginiana)
67
witch hazel-glycerin
67
WOMENS 50+ MULTI VITAMIN&
MINERAL FORMULA
158
WOMENS BIOMULTIPLE 158
WOMENS MULTI VITAMIN &
MINERAL FORMULA
158
WOMENS PACK
158
wound dressings
75
WOUNDGARD 2-1/2"X21/2"
75
WOUNDGARD 4"X4-1/4"
75
WOUNDGARD 4"X6"
75
XALATAN
175
XALKORI
35
XANAX
14
XANAX XR
14
XARELTO 10 MG
16
XARELTO 15 MG
16
XARELTO 20 MG
16
XARELTO STARTER PACK 16
XARTEMIS XR
10
XELJANZ
4
XELJANZ XR
4
XELODA
34
XERESE
55
XEROFLO DRESSING
1"X8"
76
XEROFLO DRESSING
2"X2"
76
XEROFLO DRESSING
5"X9"
76
XIFAXAN
12
XIGDUO XR 10MG-500MG,
5MG-500MG, 10MG1000MG
22
XIGDUO XR 5MG-1000MG 22
XIIDRA
173
XODOL
10
XOPENEX
16
XOPENEX CONCENTRATE 16
XOPENEX HFA
16
XRYLIX
52
XTAMPZA ER 36 MG
9
XTAMPZA ER 9 MG, 13.5 MG,
18 MG, 27 MG
9
XTANDI
34
XULTOPHY 100/3.6
22
XYREM
176
XYZAL
28
XYZAL ALLERGY 24HR
28
XYZAL ALLERGY 24HR
CHILDRENS
28
YASMIN 28
46
YAZ
46
YELETS TEENAGE
FORMULA
158
YOSPRALA
88
YOUR LIFE MULTI ADULT
GUMMIES
158
YOUR LIFE TEEN
MULTIVITAMIN GUMMIES 158
ZADITOR
zafirlukast
zaleplon
ZAMICET
ZANAFLEX
ZANTAC 150 MAXIMUM
STRENGTH
ZANTAC 150 MG
ZANTAC 300 MG
ZANTAC 75
ZARONTIN
ZARXIO
ZATEAN-CH
ZATEAN-PN
ZATEAN-PN DHA
ZATEAN-PN PLUS
ZE-PLUS
ZEBETA
ZECUITY
ZEGERID
ZEGERID 20MG1100MG
ZEGERID 40MG1100MG
ZEGERID OTC
ZELAPAR
ZELBORAF
ZEMBRACE
SYMTOUCH
ZENPEP
ZENZEDI 15 MG
ZENZEDI 2.5 MG
ZENZEDI 20 MG
ZENZEDI 30 MG
ZENZEDI 7.5 MG
ZEPATIER
ZERIT
ZESTORETIC
ZESTRIL
ZETIA
ZETONNA
ZIAC
ZIAGEN
ZIANA
zidovudine
zileuton
ZIMS CRACK CREME
DAYTIME
174
14
90
10
168
180
180
180
180
19
88
166
166
166
166
159
43
144
181
181
181
181
37
35
144
82
2
2
2
2
2
42
41
33
31
30
169
33
41
52
41
14
65
ZINBRYTA
177
zinc 50 mg
147
ZINC 50MG-15MG-10MG500UNIT-100MG, 50MG-15MG500UNIT-100MG, 10MG-5MG10MG-10MG-15MG-500UNIT60MG
158
zinc gluconate 50 mg
147
zinc oxide (topical) 10 %, 20 %,
40 %
67
zinc sulfate
147
ZINC W/A&C
149
ZIOPTAN
175
ziprasidone hcl 20 mg
37
ziprasidone hcl 40 mg
37
ziprasidone hcl 60 mg
37
ziprasidone hcl 80 mg
37
ZIPSOR
6
ZITHROMAX
91
ZITHROMAX TRI-PAK
91
ZITHROMAX Z-PAK
91
ZMAX
91
ZN-PLUS
167
ZOCOR
30
ZOFRAN
26
ZOFRAN ODT
26
ZOHYDRO ER
9
ZOHYDRO ER 40 MG, 30 MG,
20 MG
9
ZOLINZA
35
zolmitriptan
144
ZOLOFT
20
zolpidem tartrate
90
ZOLPIMIST
90
ZOMACTON
84
ZOMIG
145
ZOMIG ZMT
145
ZONEGRAN
18
zonisamide
19
ZONTIVITY
88
ZOO FRIENDS
COMPLETE
160
ZORBTIVE
84
ZORVOLEX
6
ZOSTAVAX
184
ZOSTRIX ARTHRITIS PAIN
RELIEF
66
ZOSTRIX DIABETIC FOOT
PAIN
66
Index 64
ZOVIRAX
42
ZUBSOLV 0.7MG-0.18MG 10
ZUBSOLV 11.4MG-2.9MG 10
ZUBSOLV 2.9MG-0.71MG,
8.6MG-2.1MG
10
ZUBSOLV 5.7MG-1.4MG,
1.4MG-0.36MG
10
ZUPLENZ
26
ZURAMPIC
87
ZYBAN
178
ZYCLARA
65
ZYCLARA PUMP
65
ZYDELIG
35
ZYFLO
14
ZYFLO CR
14
ZYKADIA
35
ZYLET
174
ZYLOPRIM
87
ZYMAXID
172
ZYPREXA
38
ZYPREXA 10 MG, 15 MG, 20
MG
38
ZYPREXA 2.5 MG, 7.5 MG, 5
MG
38
ZYPREXA RELPREVV
38
ZYPREXA ZYDIS
38
ZYRTEC ALLERGY
28
ZYRTEC CHILDRENS
ALLERGY
28
ZYTIGA
34
Index 65