HOOSIER HEALTHWISE2016 CareSource. All Rights Reserved.IN-MMED-1472; Issue Date 12/28/2016OMPP Approved 12/28/2016Tiene preguntas sobre Hoosier Healthwise?Si desea ms informacin sobre Hoosier Healthwise, visite www.indianamedicaid.com o llame al 1-800-403-0864. Esperamos que se encuentre a gusto con CareSource y nos haga saber si tiene algn problema o inquietud para que podamos resolverlo.Como afiliado a Hoosier Healthwise, usted tendr derecho a elegir dar de baja su afiliacin en ciertos momentos del ao. Puede elegir darla de baja durante los primeros tres meses de su afiliacin o durante el mes de inscripcin anual para su rea.CareSource complies with applicable state and federal civil rights laws and does not discriminate on the basis of age, gender, gender identity, color, race, disability, national origin, marital status, sexual preference, religious affiliation, health status, or public assistance status.Si usted o alguien a quien ayuda tienen preguntas sobre CareSource, tiene derecho a recibir esta informacin y ayuda en su propio idioma sin costo. Para hablar con un intrprete, llame al 1-844-607-2829. CareSource 1-844-607-2829. ATTN: CARESOURCE ADVANTAGECARESOURCEPO BOX 8738DA YTON OH 45482-0459CS-BRE-905BUSINESS REPLY MAILFIRST-CLASS MAIL PERMIT NO. 817DAYTON OHPOSTAGE WILL BE PAID BY ADDRESSEENO POSTAGE NECESSARY IF MAILED IN THEUNITED STATESCDTAFTTDDTFDFDTTTFTAAFTATFATTFDATTFDDTFTDAFATDTAFFDFATAFFTAAADFFDDHuman Readable Barcode Information:00,708,900999,112000000,45482045910/05/15765,000BlackJL3-7/8 x 8-7/8OSSS 24# White Wove782144One Touch Point1-1/4CARESOURCE MEDICAIDATTN: CARESOURCE ADVANTAGECARESOURCEPO BOX 8738DA YTON OH 45482-0459CS-BRE-905BUSINESS REPLY MAILFIRST-CLASS MAIL PERMIT NO. 817DAYTON OHPOSTAGE WILL BE PAID BY ADDRESSEE NO POSTAGENECESSARY IF MAILED IN THEUNITED STATESCDTAFTTDDTFDFDTTTFTAAFTATFATTFDATTFDDTFTDAFATDTAFFDFATAFFTAAADFFDDHuman Readable Barcode Information:00,708,900999,112000000,45482045910/05/15765,000BlackJL3-7/8 x 8-7/8OSSS 24# White Wove782144One Touch Point1-1/4 Correo electrnicoTelfonoCul es el horario ms conveniente para que un representante de CareSource se comunique con usted para explicarle los beneficios del plan y responder sus preguntas?A.M.P.M.Le gustara comunicarse con nosotros por correo electrnico?S NOPor qu elegir CareSource? CareSource ofrece servicios de salud para madres y nios de Indiana que califican para Hoosier Healthwise. Adems de los beneficios estipulados por el Estado de Indiana, ofrecemos:Si desea ms informacin acerca de CareSource, enve esta tarjeta por correo postal.No se le cobrar a usted cargo alguno por realizar este envo.mucho ms que un SEGURO DE SALUDAtencin oftalmolgica y odontolgica, que incluye controles, limpieza dental y anteojosMedicamentos con receta a bajo costo, incluidos todos los medicamentos cubiertos por Medicaid que se consideren mdicamente necesariosCareSource24: Nuestra lnea de asesora en enfermera las 24 horas del da, los 7 das de la semana, los 365 das del aoJobConnect: Apoyo laboral que incluye orientacin y capacitacin (as como viajes de ida y vuelta a las sesiones de orientacin y capacitacin)Help4U: Administradores de caso que pueden apoyar con el alojamiento, el equipo mdico, los servicios bsicos y otras necesidades bsicas urgentesPrograma gratuito de telfonos celulares SafeLink (para afiliados elegibles) a fin de que puedan comunicarse con CareSource24 y el equipo de atencin y defensa del clienteBabies First: Un programa de incentivos que recompensa a mujeres embarazadas y madres primerizas por sus hbitos saludablesText4baby: Un mensaje de texto gratuito tres veces a la semana, programados para la fecha estimada del parto o de nacimiento del beb; desde el embarazo hasta el primer cumpleaos del bebGestin de terapia de medicamentos: Una evaluacin personalizada de los medicamentos por parte del farmacutico para asegurarse de que sus medicamentos sean los adecuados y los ms seguros para sus necesidades de atencin mdica Afiliacin al club para nios y nias (para nios entre 6 y 18 aos)Afiliacin a las nias exploradoras (para nias desde el Kindergarten hasta el octavo grado)Express Banking: Se trata de una cuenta bancaria a travs del Fifth Third Bank sin cargo mensual por servicios, no requiere un saldo mnimo, no cobra cargos por sobregiro y ofrece una tarjeta de dbito para hacer comprasAplicacin para celular de CareSource: Podr acceder a la tarjeta de identificacin del afiliado (ID), a videos explicativos y adems podr realizar una bsqueda rpida de mdicosTarjetas de ayuda adicional: Tarjetas de regalo de hasta por $50 para realizar actividades saludables. Las puede usar en artculos de venta libre como Tylenol, medicamento para la tos y vitaminas; en productos para el hogar incluidos papel higinico, detergente y artculos de uso personal como jabn, champ, paales; y alimentos saludables MyHealth: Programas en lnea para el control de la obesidad infantil, para dejar de fumar y otros cambios para lograr un estilo de vida saludableProgramas para el manejo de enfermedades como el asma, trastorno por dficit de atencin e hiperactividad (ADHD), autismo, salud conductual, enfermedad renal crnica y muchas msElija CareSource Nos preocupamos por usted y su salud. Nos gustara que se afiliara al Hoosier Healthwise Plan. Si ya est afiliado a un plan de salud, puede cambiar de plan durante el perodo de inscripcin abierta. Visite www.indianamedicaid.com.Para obtener ms informacin acerca de CareSource: VISITE www.caresource.com/HHW LLAME AL 1-844-607-2829 (TTY: 800-743-3333 or 711)NombreApellidoDireccinCiudadEstado Cdigo postalEmail
Programa Planning for Healthy Babies (P4HB) Cuidado entre embarazos (IPC) de CareSource Programa Plannin g for Healthy Babies Cuidado entre embarazos (IPC) de P4HB de CareSource 10/1/2026INTRODUCCIN Este es el Formulario de CareSource Medicaid o Lista de medicamentos preferidos (PDL) 2026. Esta lista puede ayudar a los proveedores en la seleccin de productos clnicamente adecu ados yde menor precio. Todos los medicamentos de Medicaid de Georgia estn cu biertos por CareSource. Esta es una lista de los m edicamentos preferidos. Estos medicamentos ha n sido revisados por el Comit de Far macia y Teraputica (P&T) de CareSource. La l ista est actualizada al momento de l a revisin. No garantizamos l a exactitud de losdatos. Tampoco pret ende ser una lista de naturaleza exhaustiva. No sustituye el conocimiento, la habilidad y el c riterio del proveedor. Todos l os datos de la lista so n una gua. Los pr oveedores son totalmente responsables de t odas las opciones de m edicamentos. La lista est sujeta a l as leyes y normas especficas en cada es tado. Estas pueden incluir, ent re otras:Las relacionadas con opciones de medicamentos genricos. Las categoras de sustancias controladas.Las preferencias de marca.Los medicamentos genricos obligatorios (cuando corresponda).No asumimos ninguna responsabilidad por las acciones o las deficiencias de ningn proveedor. Deben revisar los datos de los productos del fabricante de medicamentos o las referencias estndar. PREFACIO La lista est ordenada por secciones. Cada seccin se divide por categora de medicamento teraputico, segn su mtodo de accin. Los productos estn enumerados por nombre genrico. Tambin figura el nombre de marca. Esto es solo a modo de informacin. A menos que el medicamento sea una inyeccin o un caso especial, se enumera la dosis, las presentaciones y las concentraciones. Entrada en vigor 10/1/2026 COMIT DE P&T Un comit nacional de P&T aprueba las terapias con medicamentos seguros y tiles. Est formado por: Los directores mdicos del plan.El personal de farmacia.Miembros de la comunidad mdica.DETALLES DE LA COBERTURA DE MEDICAMENTOS S olo se puede cubrir una concentracin, dosificacin u otra formulacin si se incluyen en la lista. No se cubren otras concentraciones/dosificaciones/formulaciones, por ejemplo: formas de dosis inyectables del producto. Los productos de liberacin prolongada y retardada tienen su propia lista. M etformina Glucophage La lista de productos de liberacin inmediata no incluira el producto de liberacin prolongada. M etformina de liberacin prolongada Glucophage XR Un segundo listado muestra el producto de liberacin prolongada. Las formas de dosificacin sern parte de la seccin donde figuren.Neomicina/polimixina B/hidrocortisona Cortisporin C ortisporin solo est en la lista de TICOS. Est limitado a solucin y suspensin. No se puede asumir que la crema est en la lista. Debera ser parte de la seccin de DERMATOLOGA. Autorizaciones previas (PA) CareSource puede solicitar que los proveedores nos informen la razn por la cual se necesita un medicamento o una cantidad. Esto se llama una autorizacin previa (PA). CareSource debe autorizar esta solicitud antes de que un afiliado reciba el medicamento. "PA" significa que se necesita una autorizacin previa. Estas son algunas de las razones para una solicitar una PA: Existe un medicamento genrico o alternativo disponible.Podra haber abuso o uso indebido del medicamento.El medicamento necesita un manejo especial, supervisin o tiene limitaciones en el envo.Existen otros medicamentos que se deben probar primero.Solicitudes de PA Los asociados del sector salud pueden solicitar una autorizacin previa en lnea o por fax. Obtenga ms informacin en la pgina de Proveedores en CareSource.com . Es posible que no aprobemos una solicitud de PA para un medicamento. Si no lo hacemos, le diremos al afiliado cmo presentar una apelacin. Programa Planning for Healthy Babies (P4HB) Cuidado entre embarazos (IPC) de CareSource Entrada en vigor 10/1/2026 L mites de cantidad Algunos medicamentos pueden tener lmites sobre cunto se puede administrar por vez. "QL" se usa para indicar que hay un lmite de cantidad. Los lmites de cantidad se basan en las dosis sugeridas por los fabricantes de medicamentos. Tambin se tiene en cuenta la seguridad del paciente. La terapia con analgsicos opioides puede tener lmites de cantidad basados en las dosis recomendadas por los fabricantes de medicamentos y/o las regulaciones estatales. Los lmites de cantidad figuran en la lista a continuacin. Terapia escalonada Es posible que los afiliados deban probar un medicamento antes de tomar otro. Esto se denomina terapia escalonada. Se debe probar un medicamento antes de que se apruebe el uso de otro. CareSource cubrir algunos medicamentos solo si se sigue el protocolo de terapia escalonada. "ST" se usa en la lista cuando es necesario. Sustitucin por medicamento genrico e intercambio teraputico La sustitucin por un medicamento genrico es una accin farmacutica. Se administra una versin genrica en lugar de un producto de marca. La letra cursiva indica que hay un medicamento genrico disponible. Es posible que no todos los medicamentos genricos estn disponibles en todas las concentraciones o formas de dosificacin. Un medicamento de marca que tenga un producto genrico no pertenecer al formular io. El producto genrico se cubrir en lugar del producto de marca. La lista est sujeta a regulaciones estatales especficas y se aplican reglas sobre la sustitucin por medicamentos genricos. Los medicamentos genricos suelen tener precios ms bajos que los de marca. Deben ser recetados primero si se siguen las normas. Los medicamentos genricos de venta con receta estn: Aprobados por la Administracin de Alimentos y Medicamentos de EE. UU.(U.S. Food and Drug Administration, FDA), con el objetivo de garantizar la seguridad y la eficacia. Se fabrican bajo los mismos estndares estrictos que los productos de marca.Se prueban en humanos. El medicamento genrico debe ser absorbido a la misma velocidad que el producto de marca. Pueden diferir del product o de m arca en tamao, color y componentes inactivos. Esto no altera su uso.Se fabrican con la misma concentracin y forma de dosificacin que los medicamentos de marca.Un medicamento genrico tendr el mismo efecto y seguridad que el de marca. Programa Planning for Healthy Babies (P4HB) Cuidado entre embarazos (IPC) de CareSource Entrada en vigor 10/1/2026 DISEO DEL PLAN AV ISO La list a muestra un di seo cerrado de pl an del formulario. Los medicamentos incluidos en la lista estn cu biertos por el pl an se gn se muestra. Ciertos medicamentos es tn cubiertos si se cumplen l as normas de gestin de uso . Esto puede incluir ST, PA y/o QL. Las solicitudes de m edicamentos que no cu mplan con los estndares enum erados ser n revisadas. Si un m edicamento no est en l a lista, puede solicitar un a excepcin al f ormulario para l a cobertura. Las so licitudes de necesidad mdica o exc epcin al formul ario ser n revisadas se gn medidas de PA o criterios est nda r de indicacin de medicamentos que no pertenecen al f ormulario. Un afiliado o proveedor puede solicitar una excepcin al formulario. Complete el f ormulario que se encuentra en la pgina de la Lista de Medicamentos Preferidos (PDL) en CareSource.com . Los dat os que f iguran en est a lista son pr ivados. La informacin no se puede copiar sin una autorizacin por esc rito. 2024. Todos l os derechos reservados. Esta lista i ncluye medicamentos co n nombre de marca que son marcas c omerciales o m arcas r egistradas. CareSource no oper a las or ganizaciones que se incluyen en este documento. CareSource no es responsable de l a confiabilidad del contenido. Estas listas no son una recomendacin por parte de CareSource. Nota: Esta lista se actualiza regularmente. Los cambios pueden mostrarse antes de su fecha de entrada en vigor. Programa Planning for Healthy Babies (P4HB) Cuidado entre embarazos (IPC) de CareSource Entrada en vigor 10/1/2026 GA-MED-M-29 64348-SP A-V.9 Aprobado por DCH: 7/19/2024List of Abbreviations1: Preferred generic product 2: Preferred brand product ACA: Affordable Care Act AR: Age Restriction. For certain drugs, the drug may be covered for members in a certain age range without a prior a uthorization. OTC: Over-t he-Counter. An OTC drug is a non-p rescription drug. PA: Prior A uthorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you dont get approval, we may not cover the drug. QL: QuantityLimit. For c ertain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some c ases, the Plan requires you to firs t try c ertain drugs to treat your medical condition before we will c over another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, we may not cov er Drug Bunless you try Drug A first. If Drug A does not work for y ou, we will then cover Drug B. Georgia P4HB Inter-Pregnancy CareTable of ContentsANALGESICS………………………………………………………………………………………………………………………… 3ANESTHETICS ………………………………………………………………………………………………………………………. 3ANTIARTHRITICS …………………………………………………………………………………………………………………… 3ANTIASTHMATICS …………………………………………………………………………………………………………………. 3ANTIBIOTICS …………………………………………………………………………………………………………………………. 4ANTICOAGULANTS ……………………………………………………………………………………………………………….. 6ANTIFUNGALS ………………………………………………………………………………………………………………………. 6ANTIHYPERGLYCEMICS ………………………………………………………………………………………………………… 6ANTIINFECTIVES/MISCELLANEOUS ……………………………………………………………………………………….. 7ANTINEOPLASTICS ……………………………………………………………………………………………………………….. 8ANTIPLATELET DRUGS …………………………………………………………………………………………………………. 8ANTIVIRALS ………………………………………………………………………………………………………………………….. 8AUTONOMIC DRUGS …………………………………………………………………………………………………………….. 8BIOLOGICALS ……………………………………………………………………………………………………………………….. 9BLOOD ………………………………………………………………………………………………………………………………….. 9CARDIAC DRUGS ………………………………………………………………………………………………………………….. 9CARDIOVASCULAR ……………………………………………………………………………………………………………… 10CNS DRUGS ………………………………………………………………………………………………………………………… 11CONTRACEPTIVES ……………………………………………………………………………………………………………… 12DIURETICS ………………………………………………………………………………………………………………………….. 15ELECT/CALORIC/H2O ………………………………………………………………………………………………………….. 15GASTROINTESTINAL …………………………………………………………………………………………………………… 16HORMONES ………………………………………………………………………………………………………………………… 16MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ………………………………………………17PRE-NATAL VITAMINS …………………………………………………………………………………………………………. 18PSYCHOTHERAPEUTIC DRUGS …………………………………………………………………………………………… 19SEDATIVE/HYPNOTICS ………………………………………………………………………………………………………… 20THYROID PREPS …………………………………………………………………………………………………………………. 21UNCLASSIFIED DRUG PRODUCTS ……………………………………………………………………………………….. 21VITAMINS ……………………………………………………………………………………………………………………………. 212 CURRENT AS OF 10/1/2026Drug NameTierRestrictions / LimitsANALGESICS diclofenac potassium oral tablet 50 mg1diflunisal1ketorolac oral1QL (20 EA per30 days)ANESTHETICS phenazopyridine oral tablet 100 mg, 200mg1ANTIARTHRITICScelecoxib1STcolchicine oral tablet 1QL (1 EA per1 day)diclofenac sodium oral 1diclofenac-misoprostol1etodolac1flurbiprofen1IBU1ibuprofen oral tablet400 mg, 600 mg, 800mg1ketoprofen oral capsule 50 mg, 75 mg1meloxicam oral tablet1nabumetone1naproxen oral tablet,delayed release(dr/ec)1naproxen sodium oral tablet 275 mg, 550mg1oxaprozin oral tablet1probenecid1sulindac1 Drug NameTier Restrictions /LimitsANTIASTHMATICS albuterol sulfate inhalation hfa aerosol inhaler1QL (4 GM per90 days)albuterol sulfate inhalation solution for nebulization 0.63mg/3 ml, 1.25 mg/3ml, 2.5 mg /3 ml(0.083 %) 1QL (375 MLper 30 days)albuterol sulfate inhalation solution for nebulization 2.5mg/0.5 ml 1QL (2 EA per1 day)albuterol sulfate inhalation solution for nebulization 5 mg/ml 1QL (2 ML per1 day)albuterol sulfate oral 1 ARNUITY ELLIPTA2QL (1 EA per1 day)ATROVENT HFA 2QL (65 GMper 30 days)budesonide inhalation 1QL (4 ML per1 day)COMBIVENTRESPIMAT 2QL (4 GM per30 days)cromolyn inhalation 1QL (8 ML per1 day)DULERAINHALATION HFAAEROSOL INHALER100-5MCG/ACTUATION,200-5MCG/ACTUATION 2QL (13 GMper 30 days)DULERAINHALATION HFAAEROSOL INHALER50-5MCG/ACTUATION 2GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/20263 Drug NameTier Restrictions /Limits fluticasone propionate inhalation hfa aerosol inhaler 110mcg/actuation, 220mcg/actuation 2QL (24 GMper 30 days)fluticasone propionate inhalation hfa aerosol inhaler 44mcg/actuation 2QL (22 GMper 30 days)fluticasone propion-salmeterol inhalation aerosol powdr breath activated 2QL (1 EA per30 days)fluticasone propion-salmeterol inhalation blister with device 1QL (2 EA per1 day)ipratropium bromide inhalation solution 1QL (10 MLper 1 day)ipratropium-albuterol 1QL (18 MLper 1 day)levalbuterol tartrate 2QL (1 GM per1 day)montelukast 1SEREVENT DISKUS2QL (2 EA per1 day)SPIRIVA RESPIMAT 2QL (4 GM per30 days)STIOLTO RESPIMAT 2QL (4 GM per30 days)STRIVERDIRESPIMAT 2QL (4 GM per30 days)terbutaline oral 1THEO-242theophylline oral elixir1theophylline oral solution1theophylline oral tablet extended release 12 hr 300 mg,450 mg1 Drug NameTier Restrictions /Limits theophylline oral tablet extended release 24 hr 1 TRELEGY ELLIPTA2PA; QL (1 EAper 28 days)ANTIBIOTICS amoxicillin1 amoxicillin-pot clavulanate oral suspension for reconstitution1 amoxicillin-pot clavulanate oral tablet1 amoxicillin-pot clavulanate oral tablet,chewable1 ampicillin1 AVIDOXY1 azithromycin oral1 cefadroxil1 cefdinir1 cefprozil1 cefuroxime axetil1 cephalexin1 ciprofloxacin hcl oral1 ciprofloxacin oral suspension,microcaps ule recon 250 mg/5 ml1 clarithromycin1 CLEOCIN VAGINALSUPPOSITORY2 clindamycin hcl1 CLINDAMYCINPEDIATRIC1 clindamycin phosphate vaginal1 dapsone oral1 dicloxacillin1GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/20264 Drug NameTier Restrictions /Limits doxycycline hyclate oral capsule 100 mg,50 mg 1doxycycline hyclate oral tablet 100 mg,150 mg, 50 mg, 75mg1doxycycline monohydrate oral capsule1doxycycline monohydrate oral suspension for reconstitution1doxycycline monohydrate oral tablet1E.E.S. 4001ERY-TAB ORALTABLET,DELAYEDRELEASE (DR/EC)250 MG, 333 MG1ERY-TAB ORALTABLET,DELAYEDRELEASE (DR/EC)500 MG2ERYTHROCIN (ASSTEARATE)1erythromycin ethylsuccinate1erythromycin oral capsule,delayed release(dr/ec)1erythromycin oral tablet1levofloxacin oral1methen-sod phos-meth blue-hyos1metronidazole oral capsule1 Drug NameTier Restrictions /Limits metronidazole oral tablet 250 mg, 500mg 1 metronidazole vaginal gel 0.75 % (37.5mg/5gram)1QL (70 GMper 30 days)minocycline oral capsule 1 minocycline oral tablet1 MONDOXYNE NL1 MORGIDOX1 moxifloxacin ophthalmic (eye)drops, viscous1 neomycin1 nitrofurantoin macrocrystal1 nitrofurantoin monohyd/m-cryst1 ofloxacin oral1QL (2 EA per1 day)penicillin v potassium 1 sulfacetamide sodium-sulfur topical pads, medicated1 sulfamethoxazole-trimethoprim oral1 SULFATRIM1 tetracycline oral capsule1 trimethoprim1 URETRON D-S1 URYL1 vancomycin oral capsule1PAVANDAZOLE 1QL (70 GMper 30 days)GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/2026 5 Drug NameTier Restrictions /LimitsANTICOAGULANTS ELIQUIS DVT-PETREAT 30D START2ELIQUIS ORALTABLET2enoxaparin1rivaroxaban1warfarin1XARELTO DVT-PETREAT 30D START2QL (51 EA per30 days)XARELTO ORALTABLET 10 MG, 15MG, 20 MG 2ANTIFUNGALSclotrimazole mucous membrane1fluconazole1griseofulvin ultramicrosize oral tablet 125 mg, 250mg1ketoconazole oral1NATACYN2QL (15 MLper 30 days)nystatin oral suspension 1terbinafine hcl oral1QL (1 EA per1 day)terconazole 1voriconazole oral1PAANTIHYPERGLYCEMICS acarbose1alogliptin2STalogliptin-metformin 2STalogliptin-pioglitazone 2STdapagliflozin oral tablet 10 mg 1ST; QL (1 EAper 1 day) Drug NameTier Restrictions /Limits dapagliflozin oral tablet 5 mg 1ST; QL (2 EAper 1 day)dapagliflozin-metformin oral tablet,ir-er, biphasic 24hr10-1,000 mg 1ST; QL (1 EAper 1 day)dapagliflozin-metformin oral tablet,ir-er, biphasic 24hr5-1,000 mg 1ST; QL (2 EAper 1 day)glimepiride oral tablet1 mg, 2 mg, 4 mg 1 glipizide oral tablet 10mg, 5 mg1 glipizide-metformin1 glyburide oral tablet1.25 mg1QL (16 EA per1 day)glyburide oral tablet2.5 mg 1QL (8 EA per1 day)glyburide oral tablet 5mg 1QL (4 EA per1 day)glyburide-metformin oral tablet 1.25-250mg 1QL (260 EAper 30 days)glyburide-metformin oral tablet 2.5-500mg, 5-500 mg 1QL (5 EA per1 day)HUMULIN RU-500(CONC) KWIKPEN 2 insulin glargine-yfgn2 insulin lispro subcutaneous insulin pen2QL (45 MLper 30 days)insulin lispro subcutaneous insulin pen, half-unit 2QL (1 ML per1 day)insulin lispro subcutaneous solution 2QL (45 MLper 30 days)INVOKAMET 1STINVOKAMET XR 1GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/20266 Drug NameTier Restrictions /Limits metformin oral solution 1metformin oral tablet1,000 mg, 500 mg,850 mg1metformin oral tablet extended release 24hr1miglitol1STnateglinide 1pioglitazone1pioglitazone-glimepiride1STpioglitazone-metformin 1repaglinide1RYBELSUS2QL (1 EA per1 day)ANTIINFECTIVES/MISCELLANEOUS CUTTERBACKWOODSOTCQL (1prescription claim per 30days)CUTTERBACKWOODS DRY OTCQL (1prescription claim per 30days)CUTTER LEMONEUCALYPTUS OTCQL (1prescription claim per 30days)CUTTER NATURALINSECT REPELLNT OTCQL (1prescription claim per 30days)CUTTER NATURALREPELLENT2 OTCQL (1prescription claim per 30days) Drug NameTier Restrictions /LimitsCUTTERSKINSATIONSTOPICALSPRAY,NON-AEROSOL OTCQL (1prescription claim per 30days)INSECT REPELLENT(DEET) OTCQL (1prescription claim per 30days)INSECT REPELLENT(PICARIDIN) OTCQL (1prescription claim per 30days)NATRAPEL TOPICALAEROSOL,SPRAY OTCQL (1prescription claim per 30days)OFF ACTIVE OTCQL (1prescription claim per 30days)OFF DEEP WOODSDRY OTCQL (1prescription claim per 30days)OFF DEEP WOODSSPORTSMEN OTCQL (1prescription claim per 30days)OFF DEEP WOODSTOPICALAEROSOL,SPRAY OTCQL (1prescription claim per 30days)OFF DEEP WOODSTOPICALSPRAY,NON-AEROSOL OTCQL (1prescription claim per 30days)OFF FAMILYCARE(WITH DEET) OTCQL (1prescription claim per 30days)GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/2026 7 Drug NameTier Restrictions /LimitsOFFFAMILYCARE(WITHPICARIDIN) OTCQL (1prescription claim per 30days)RANGER READYREPELLENT OTCQL (1prescription claim per 30days)REPEL 100 OTCQL (1prescription claim per 30days)REPEL FAMILY OTCQL (1prescription claim per 30days)REPEL HUNTER'S OTCQL (1prescription claim per 30days)REPEL LEMONEUCALYPTUS OTCQL (1prescription claim per 30days)REPEL SPORTSMEN OTCQL (1prescription claim per 30days)REPEL SPORTSMENDRY OTCQL (1prescription claim per 30days)REPEL SPORTSMENMAX OTCQL (1prescription claim per 30days)REPEL TICKDEFENSE OTCQL (1prescription claim per 30days) Drug NameTier Restrictions /LimitsTOTAL HOMEINSECT REPELLENT OTCQL (1prescription claim per 30days)ULTRATHON OTCQL (1prescription claim per 30days)ANTINEOPLASTICS VOTRIENT2 ANTIPLATELETDRUGSBRILINTA2PA; STcilostazol 1 clopidogrel1 dipyridamole oral1 prasugrel hcl1 ANTIVIRALSacyclovir oral capsule1 acyclovir oral suspension 200 mg/5ml1 acyclovir oral tablet1 LAGEVRIO (EUA)2 valacyclovir1 AUTONOMICDRUGSdextroamphetamine sulfate oral capsule,extended release1QL (2 EA per1 day)dextroamphetamine sulfate oral tablet 10mg 1QL (4 EA per1 day)dextroamphetamine sulfate oral tablet 15mg, 20 mg, 30 mg 1 dextroamphetamine sulfate oral tablet 5mg1QL (1 EA per1 day)GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/20268 Drug NameTier Restrictions /Limits dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg,15 mg, 5 mg 1QL (1 EA per1 day)dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg,25 mg, 30 mg 1QL (2 EA per1 day)dextroamphetamine-amphetamine oral tablet 1QL (3 EA per1 day)midodrine 1pyridostigmine bromide oral syrup1pyridostigmine bromide oral tablet 60mg1pyridostigmine bromide oral tablet extended release 180mg1BIOLOGICALSADACEL(TDAPADOLESN/ADULT)(PF)2BOOSTRIX TDAP2ENGERIX-B (PF)2ENGERIX-BPEDIATRIC (PF)2HEPLISAV-B (PF)2RECOMBIVAX HB(PF)INTRAMUSCULARSUSPENSION 40MCG/ML, 5 MCG/0.5ML2RECOMBIVAX HB(PF)INTRAMUSCULARSYRINGE2 Drug NameTier Restrictions /LimitsRHOGAM ULTRA-FILTERED PLUS 2 TENIVAC (PF)2 BLOODpentoxifylline1 CARDIAC DRUGSamiodarone oral tablet 200 mg1 amlodipine1 CARTIA XT1 digoxin oral solution1 digoxin oral tablet 125mcg (0.125 mg), 250mcg (0.25 mg)1 diltiazem hcl oral capsule,ext.rel 24h degradable1 diltiazem hcl oral capsule,extended release 12 hr1 diltiazem hcl oral capsule,extended release 24 hr1 diltiazem hcl oral capsule,extended release 24hr1 diltiazem hcl oral tablet1 diltiazem hcl oral tablet extended release 24 hr 180 mg,240 mg, 300 mg, 360mg, 420 mg1 DILT-XR1 disopyramide phosphate1 dofetilide1 felodipine1 flecainide1GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/20269 Drug NameTier Restrictions /Limits isosorbide mononitrate 1MATZIM LA1nifedipine oral tablet extended release1nitroglycerin transdermal patch 24hour1propafenone1ranolazine1verapamil oral capsule,ext rel. pellets24 hr1verapamil oral tablet120 mg, 80 mg1verapamil oral tablet40 mg1QL (12 EA per1 day)verapamil oral tablet extended release 1CARDIOVASCULARamlodipine-benazepril1amlodipine-olmesartan1amlodipine-valsartan1amlodipine-valsartan-hcthiazid1atenolol1atenolol-chlorthalidone1atorvastatin1benazepril1benazepril-hydrochlorothiazide1bisoprolol fumarate oral tablet 10 mg, 5mg1bisoprolol-hydrochlorothiazide1candesartan1 Drug NameTier Restrictions /Limits candesartan-hydrochlorothiazid 1 captopril1 captopril-hydrochlorothiazide1 carvedilol1 CHOLESTYRAMINELIGHT1 clonidine1 colestipol oral tablet1 doxazosin1 enalapril maleate oral tablet1 enalapril-hydrochlorothiazide1 ENTRESTO2PAezetimibe 1 fenofibrate micronized1 fosinopril1 fosinopril-hydrochlorothiazide1 gemfibrozil1 guanfacine oral tablet1 hydralazine oral1 irbesartan1 irbesartan-hydrochlorothiazide1 labetalol oral tablet100 mg, 200 mg, 300mg1 lisinopril1 lisinopril-hydrochlorothiazide1 losartan1 losartan-hydrochlorothiazide1 lovastatin1 methyldopa1GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/202610 Drug NameTier Restrictions /Limits metoprolol succinate 1metoprolol ta-hydrochlorothiaz1metoprolol tartrate oral tablet 100 mg, 25mg, 37.5 mg, 50 mg,75 mg1metyrosine1minoxidil oral1nadolol1olmesartan1olmesartan-amlodipin-hcthiazid1olmesartan-hydrochlorothiazide1pravastatin1PREVALITE1propranolol oral1quinapril1quinapril-hydrochlorothiazide1ramipril1rosuvastatin1salmon oil-omega-3fatty acidsOTCsimvastatin1SOTALOL AF1sotalol oral1telmisartan1telmisartan-amlodipine1telmisartan-hydrochlorothiazid1terazosin1trandolapril1valsartan oral tablet1valsartan-hydrochlorothiazide1 Drug NameTier Restrictions /LimitsCNS DRUGS carbamazepine oral capsule, er multiphase 12 hr1 carbamazepine oral suspension 100 mg/5ml1 carbamazepine oral tablet1 carbamazepine oral tablet extended release 12 hr1 carbamazepine oral tablet,chewable 100mg1 CELONTIN2 clobazam oral suspension1STclobazam oral tablet 1STclonazepam oral tablet 1QL (4 EA per1 day)diazepam rectal 1 DILANTIN2 DILANTINEXTENDED2 divalproex1 ethosuximide1 felbamate1 FYCOMPA2STgabapentin oral capsule 100 mg, 400mg 1QL (6 EA per1 day)gabapentin oral capsule 300 mg 1QL (9 EA per1 day)gabapentin oral solution 1QL (72 MLper 1 day)gabapentin oral tablet600 mg 1QL (6 EA per1 day)gabapentin oral tablet800 mg 1QL (4 EA per1 day)GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/2026 11 Drug NameTier Restrictions /Limits lamotrigine oral tablet 1lamotrigine oral tablet,chewable dispersible1levetiracetam oral solution1levetiracetam oral tablet1levetiracetam oral tablet extended release 24 hr1oxcarbazepine oral suspension1oxcarbazepine oral tablet1OXTELLAR XR2PAphenytoin 1phenytoin sodium extended1pregabalin oral capsule 100 mg, 150mg, 200 mg, 25 mg,50 mg, 75 mg1PA; QL (3 EAper 1 day)pregabalin oral capsule 225 mg, 300mg 1PA; QL (2 EAper 1 day)pregabalin oral solution 1PA; QL (30ML per 1 day)primidone oral tablet250 mg, 50 mg 1ROWEEPRA1SUBVENITE ORALTABLET1tiagabine1topiramate oral capsule, sprinkle 15mg, 25 mg1topiramate oral tablet1zonisamide1CONTRACEPTIVESAFIRMELLE1 Drug NameTier Restrictions /LimitsALTAVERA (28) 1 ALYACEN 1/35 (28)1 ALYACEN 7/7/7 (28)1 AMETHIA1QL (1 EA per1 day)AMETHYST (28) 1QL (1 EA per1 day)APRI 1 ARANELLE (28)1 ASHLYNA1QL (1 EA per1 day)AUBRA 1 AUBRA EQ1 AUROVELA 1.5/30(21)1 AUROVELA 1/20 (21)1 AUROVELA 24 FE1 AUROVELA FE1.5/30 (28)1 AUROVELA FE 1-20(28)1 AVIANE1 AYUNA1 AZURETTE (28)1 BALZIVA (28)1 BLISOVI 24 FE1 BLISOVI FE 1.5/30(28)1 BLISOVI FE 1/20 (28)1 BRIELLYN1 CAMILA1 CAMRESE1QL (1 EA per1 day)CAMRESE LO 1QL (1 EA per1 day)CAYA CONTOURED 2QL (2 EA per365 Days)CAZIANT (28) 1GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/202612 Drug NameTier Restrictions /LimitsCHATEAL EQ (28) 1CRYSELLE (28)1CYRED1CYRED EQ1DASETTA 1/35 (28)1DASETTA 7/7/7 (28)1DAYSEE1QL (1 EA per1 day)DEBLITANE 1DEPO-SUBQPROVERA 1042desog-e.estradiol/e.estradiol1drospirenone-e.estradiol-lm.fa oral tablet 3-0.02-0.451mg (24) (4)1PAdrospirenone-ethinyl estradiol 1ELINEST1ELURYNG1ENPRESSE1ENSKYCE1ERRIN1ESTARYLLA1etonogestrel-ethinyl estradiol1FALMINA (28)1FEMCAP2QL (2 EA per365 Days)HAILEY 24 FE 1HAILEY FE 1.5/30(28)1HAILEY FE 1/20 (28)1HEATHER1INCASSIA1ISIBLOOM1JASMIEL (28)1 Drug NameTier Restrictions /LimitsJENCYCLA 1 JOLESSA1QL (1 EA per1 day)JULEBER 1 JUNEL 1.5/30 (21)1 JUNEL 1/20 (21)1 JUNEL FE 1.5/30 (28)1 JUNEL FE 1/20 (28)1 JUNEL FE 241 KAITLIB FE1 KARIVA (28)1 KELNOR 1/35 (28)1 KURVELO (28)1 LARIN 1.5/30 (21)1 LARIN 1/20 (21)1 LARIN 24 FE1 LARIN FE 1.5/30 (28)1 LARIN FE 1/20 (28)1 LESSINA1 LEVONEST (28)1 levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03mg1 levonorgestrel-ethinyl estrad oral tablet 90-20 mcg (28)1QL (1 EA per1 day)levonorgestrel-ethinyl estrad oral tablets,dose pack,3month 1QL (1 EA per1 day)levonorg-eth estrad triphasic 1 LORYNA (28)1 LOW-OGESTREL(28)1 LO-ZUMANDIMINE(28)1GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/202613 Drug NameTier Restrictions /LimitsLUTERA (28) 1LYZA1MARLISSA (28)1medroxyprogesterone intramuscular1MICROGESTIN1.5/30 (21)1MICROGESTIN 1/20(21)1MICROGESTIN FE1.5/30 (28)1MICROGESTIN FE1/20 (28)1MILI1MONO-LINYAH1NECON 0.5/35 (28)1NIKKI (28)1NORA-BE1norethindrone(contraceptive)1norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg1norgestimate-ethinyl estradiol1NORTREL 0.5/35 (28)1NORTREL 1/35 (21)1NORTREL 1/35 (28)1NORTREL 7/7/7 (28)1OCELLA1PHILITH1PIMTREA (28)1PORTIA 281RECLIPSEN (28)1SETLAKIN1QL (1 EA per1 day)SHAROBEL 1SIMLIYA (28)1 Drug NameTier Restrictions /LimitsSIMPESSE 1QL (1 EA per1 day)SPRINTEC (28) 1 SYEDA1 TARINA 24 FE1 TARINA FE 1/20 (28)1 TARINA FE 1-20 EQ(28)1 TILIA FE1 TRI-ESTARYLLA1 TRI-LEGEST FE1 TRI-LINYAH1 TRI-LO-ESTARYLLA1 TRI-LO-MARZIA1 TRI-LO-MILI1 TRI-LO-SPRINTEC1 TRI-MILI1 TRI-SPRINTEC (28)1 TRI-VYLIBRA1 TRI-VYLIBRA LO1 TULANA1 VELIVET TRIPHASICREGIMEN (28)1 VESTURA (28)1 VIENVA1 VIORELE (28)1 VYFEMLA (28)1 VYLIBRA1 WERA (28)1 WYMZYA FE1 XULANE1 ZAFEMY1 ZARAH1 ZOVIA 1-35 (28)1 ZUMANDIMINE (28)1GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/202614 Drug NameTier Restrictions /LimitsDIURETICS acetazolamide1amiloride1amiloride-hydrochlorothiazide1bumetanide oral1chlorthalidone1eplerenone1furosemide oral1hydrochlorothiazide1indapamide1methazolamide1metolazone1spironolactone oral tablet1spironolacton-hydrochlorothiaz1torsemide1triamterene-hydrochlorothiazid oral capsule1triamterene-hydrochlorothiazid oral tablet 37.5-25 mg1QL (1 EA per1 day)triamterene-hydrochlorothiazid oral tablet 75-50 mg 1ELECT/CALORIC/H2OCALCIUM 500 + DORAL TABLET 500MG-5 MCG (200UNIT)OTCCALCIUM 500 WITHDOTCCALCIUM 600 WITHVITAMIN D3 ORALCAPSULEOTC Drug NameTier Restrictions /Limits calcium acetate(phosphat bind) 1 calcium carbonate-vitamin d3 oral capsule 600 mg-25mcg (1,000 unit)OTC calcium carbonate-vitamin d3 oral tablet250 mg-3.125 mcg(125 unit), 500 mg-10mcg (400 unit), 500mg-15 mcg (600 unit),500 mg-3.125 mcg(125 unit), 500 mg-5mcg (200 unit), 600mg-10 mcg (400 unit),600 mg-20 mcg (800unit), 600 mg-5 mcg(200 unit)OTC CALCIUM WITHVITAMIN DOTC CENTRATEXOTC CHROMAGEN(SUMALATE-QUATREFOLI)OTC fluoride (sodium) oralOTC GLUCOSE GELOTC glucose oral tablet,chewable 4gramOTC GLUTOSE-15OTC GLUTOSE-45OTC GLUTOSE-5OTC HEMATINIC PLUSVIT/MINERALSOTC HEMATINIC/FOLICACIDOTC HEMATOGENFORTEOTC HEMOCYTE-PLUSOTC KLOR-CON 101GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/202615 Drug NameTier Restrictions /LimitsKLOR-CON 8 1KLOR-CON M101KLOR-CON M151KLOR-CON M201LIQUID CALCIUMWITH VITAMIN DOTCONEVITE CALCIUM-D3 ORAL TABLET500 MG-5 MCG (200UNIT)OTCOYSCO 500/DOTCOYSTER SHELL +D3OTCOYSTER SHELLCALCIUM-VIT D3OTCpotassium chloride oral capsule,extended release1potassium chloride oral liquid1potassium chloride oral tablet extended release 10 meq, 20meq, 8 meq1potassium chloride oral tablet,er particles/crystals1potassium citrate oral tablet extended release1potassium citrate-citric acidOTCTRICONOTCTRIGELS-F FORTEOTCGASTROINTESTINA Lamoxicil-clarithromy-lansopraz1omega-3 acid ethyl esters1 Drug NameTier Restrictions /LimitsSUPER OMEGA-3 OTC HORMONESCOMBIPATCH2 COVARYX1 COVARYX H.S.1 danazol1 desmopressin oral1 EEMT1 EEMT HS1 estradiol-norethindrone acet1 estrogens-methyltestosterone1 FYAVOLV1 hydrocortisone oral1 JINTELI1 medroxyprogesterone oral1 methylergonovine oral1 methylprednisolone1 MIMVEY1 norethindrone ac-eth estradiol oral tablet0.5-2.5 mg-mcg, 1-5mg-mcg1 prednisolone oral solution1 prednisolone sodium phosphate oral1 PREDNISONEINTENSOL1 prednisone oral solution1 prednisone oral tablet1 prednisone oral tablets,dose pack1 progesterone micronized oral1GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/202616 Drug NameTier Restrictions /LimitsMISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG AEROCHAMBERMINI2QL (2 EA per365 days)AEROCHAMBER MV 2QL (2 EA per365 days)AEROCHAMBERPLUS FLOW-VU 2QL (2 EA per365 days)AEROCHAMBERPLUS FLOW-VU,LMSK 2QL (2 EA per365 days)AEROCHAMBERPLUS FLOW-VU,MMSK 2QL (2 EA per365 days)AEROCHAMBERPLUS FLOW-VU,SMSK 2QL (2 EA per365 days)AEROCHAMBERPLUS ZSTAT 2QL (2 EA per365 days)AEROCHAMBERPLUS ZSTAT LGMSK 2QL (2 EA per365 days)AEROCHAMBERPLUS ZSTAT MDMSK 2QL (2 EA per365 days)AEROCHAMBERPLUS ZSTAT SMMSK 2QL (2 EA per365 days)AEROCHAMBER Z-STAT PLUS-FLW SG 2QL (2 EA per365 days)AEROVENT PLUS 2QL (2 EA per365 days)BREATHERITE MDISPACER 2QL (2 EA per365 days)BREATHERITESPACER-MASK,NEO. 2QL (2 EA per365 days) Drug NameTier Restrictions /LimitsBREATHERITESPACER-MASK,ADULT 2QL (2 EA per365 days)BREATHERITESPACER-MASK,CHILD 2QL (2 EA per365 days)BREATHERITESPACER-MASK,INFANT 2QL (2 EA per365 days)BREATHERITESPACER-MASK,S.CHLD 2QL (2 EA per365 days)BREATHERITEVALVED MDICHAMBER 2QL (2 EA per365 days)BREATHERITEVALVED MDISPACER 2QL (2 EA per365 days)CLEVER CHOICECHAMBER-LRGMASK 2QL (2 EA per365 days)CLEVER CHOICECHAMBER-MEDMASK 2QL (2 EA per365 days)CLEVER CHOICECHAMBER-SMMASK 2QL (2 EA per365 days)COMPACT SPACECHAMBER 2QL (2 EA per365 days)COMPACT SPACECHAMBER-LRGMASK 2QL (2 EA per365 days)COMPACT SPACECHAMBER-MEDMASK 2QL (2 EA per365 days)COMPACT SPACECHAMBER-SMMASK 2QL (2 EA per365 days)EASIVENT HOLDINGCHAMBER 2QL (2 EA per365 days)EASIVENT MASKLARGE 2QL (2 EA per365 days)GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/2026 17 Drug NameTier Restrictions /LimitsEASIVENT MASKMEDIUM 2QL (2 EA per365 days)EASIVENT MASKSMALL 2QL (2 EA per365 days)ECLIPSE SYRINGESYRINGE 3 ML 21GAUGE X 1", 3 ML 25GAUGE X 1" 2QL (400 EAper 30 days)FLEXICHAMBER 2QL (2 EA per365 days)FREESTYLE LIBRE14 DAY READER 2PA; QL (1 EAper 1 lifetime)FREESTYLE LIBRE 2READER 2PA; QL (1 EAper 1 lifetime)insulin syringe-needle u-100 syringe 1 ml 27gauge x 1/2", 1/2 ml27 gauge x 1/2" 2QL (400 EAper 30 days)LITEAIRE MDICHAMBER 2QL (2 EA per365 days)MICROCHAMBER 2QL (2 EA per365 days)MICROSPACER 2QL (2 EA per365 days)MONOJECT INSULINSAFETY SYRINGSYRINGE 0.3 ML 30GAUGE X 5/16", 0.5ML 29 GAUGE X 1/2",0.5 ML 30 GAUGE X5/16" 2QL (400 EAper 30 days)OPTICHAMBERDIAMOND LG MASK 2QL (2 EA per365 days)OPTICHAMBERDIAMOND VHC 2QL (2 EA per365 days)OPTICHAMBERDIAMOND-MED MSK 2QL (2 EA per365 days)OPTICHAMBERDIAMOND-SMLMASK 2QL (2 EA per365 days) Drug NameTier Restrictions /LimitsPEN NEEDLENEEDLE 30 GAUGEX 5/16" 2QL (400 EAper 30 days)POCKET CHAMBER 2QL (2 EA per365 days)PROCHAMBER 2QL (2 EA per365 days)RITEFLOAEROCHAMBER 2QL (2 EA per365 days)V-GO 20 2 V-GO 302 V-GO 402 VORTEX HOLDINGCHAMBER2QL (2 EA per365 days)PRE-NATALVITAMINS COMPLETENATEOTC KOSHER PRENATALPLUS IRON2 M-NATAL PLUS1 PRENATABS FA1 PRENATABS RX1 PRENATAL 19 ORALTABLET,CHEWABLEOTC PRENATAL MULTIOTC PRENATAL PLUS1 PRENATAL PLUS(CALCIUM CARB)1 PRENATAL TABLETOTC PRENATAL VITAMINORAL TABLET 27MG IRON-0.8 MG,27 MG IRON-800MCGOTC PRENATAL VITAMINPLUS LOW IRONOTC PRENATAL VITAMINWITH MINERALSOTCGEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/202618 Drug NameTier Restrictions /Limits prenatal vit-iron fum-folic ac OTCTHERANATAL ORALTABLETOTCTHRIVITE RX2TRICARE2TRINATAL RX 11PSYCHOTHERAPEUTIC DRUGSamitriptyline1amitriptyline-chlordiazepoxide1amoxapine1aripiprazole oral tablet10 mg, 15 mg, 30 mg1QL (1 EA per1 day)aripiprazole oral tablet2 mg, 20 mg 1QL (2 EA per1 day)aripiprazole oral tablet5 mg 1QL (1.5 EAper 1 day)atomoxetine oral capsule 10 mg, 18mg, 25 mg, 40 mg 1QL (2 EA per1 day)atomoxetine oral capsule 100 mg, 60mg, 80 mg 1QL (1 EA per1 day)bupropion hcl oral tablet 1bupropion hcl oral tablet extended release 24 hr 150 mg,300 mg1QL (1 EA per1 day)bupropion hcl oral tablet sustained-release 12 hr 1chlorpromazine oral tablet1citalopram oral solution1citalopram oral tablet1clomipramine1 Drug NameTier Restrictions /Limits clonidine hcl oral tablet extended release 12 hr 1QL (4 EA per1 day)clozapine oral tablet 1 desipramine1 dexmethylphenidate oral capsule,er biphasic 50-501QL (1 EA per1 day)dexmethylphenidate oral tablet 10 mg 1QL (4 EA per1 day)dexmethylphenidate oral tablet 2.5 mg, 5mg 1QL (2 EA per1 day)doxepin oral capsule 1 doxepin oral concentrate1 duloxetine oral capsule,delayed release(dr/ec) 20 mg,30 mg, 40 mg, 60 mg1 escitalopram oxalate oral solution1 escitalopram oxalate oral tablet1 fluoxetine oral capsule1 fluoxetine oral solution1 fluoxetine oral tablet1 fluphenazine hcl oral1 fluvoxamine1 guanfacine oral tablet extended release 24hr1QL (1 EA per1 day)haloperidol 1 haloperidol lactate oral1 imipramine hcl1 lithium carbonate1 loxapine succinate1GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/202619 Drug NameTier Restrictions /Limits methylphenidate hcl oral capsule,er biphasic 50-50 20 mg,40 mg 1QL (1 EA per1 day)methylphenidate hcl oral capsule,er biphasic 50-50 30 mg 1QL (2 EA per1 day)methylphenidate hcl oral solution 10 mg/5ml 1QL (30 MLper 1 day)methylphenidate hcl oral solution 5 mg/5ml 1QL (60 MLper 1 day)methylphenidate hcl oral tablet 1QL (3 EA per1 day)methylphenidate hcl oral tablet extended release 1QL (3 EA per1 day)methylphenidate hcl oral tablet,chewable 1QL (3 EA per1 day)mirtazapine 1nefazodone1QL (2 EA per1 day)nortriptyline 1olanzapine oral tablet10 mg, 15 mg1QL (2 EA per1 day)olanzapine oral tablet2.5 mg, 5 mg, 7.5 mg 1QL (1 EA per1 day)olanzapine oral tablet20 mg 1QL (3 EA per1 day)paroxetine hcl oral tablet 1paroxetine hcl oral tablet extended release 24 hr1perphenazine1perphenazine-amitriptyline1pimozide1 Drug NameTier Restrictions /Limits quetiapine oral tablet100 mg, 200 mg, 25mg, 50 mg 1QL (3 EA per1 day)quetiapine oral tablet300 mg, 400 mg 1QL (4 EA per1 day)quetiapine oral tablet extended release 24hr 150 mg, 200 mg 1QL (1 EA per1 day)quetiapine oral tablet extended release 24hr 300 mg 1QL (3 EA per1 day)quetiapine oral tablet extended release 24hr 400 mg, 50 mg 1QL (2 EA per1 day)risperidone oral solution 1 risperidone oral tablet1 sertraline oral concentrate1 sertraline oral tablet1 thioridazine1 thiothixene1 tranylcypromine1 trazodone oral tablet100 mg, 150 mg, 300mg, 50 mg1 trifluoperazine1 trimipramine1 venlafaxine oral capsule,extended release 24hr1 venlafaxine oral tablet1 ziprasidone hcl oral capsule 20 mg, 40 mg1QL (2 EA per1 day)ziprasidone hcl oral capsule 60 mg, 80 mg 1QL (3 EA per1 day)SEDATIVE/HYPNOTI CS phenobarbital1GEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/202620 Drug NameTier Restrictions /LimitsTHYROID PREPS levothyroxine oral tablet1LEVOXYL1liothyronine oral1methimazole1propylthiouracil1SYNTHROID2UNITHROID1UNCLASSIFIEDDRUG PRODUCTSAIRBORNE(ASCORBATESODIUM)OTCAIRBORNE (WITHLYSINE ACETATE)OTCalendronate oral tablet1buprenorphine-naloxone sublingual tablet1PA; QL (3 EAper 1 day);ARDIABETIC SUPPORTFORMULA OTCdoxycycline hyclate oral tablet 20 mg1DRY EYE FORMULAOTCHAIR, SKIN ANDNAILS ADVANCEDOTCHAIR-SKIN-NAIL(VITA,C-BIOTIN)OTCibandronate oral1IMMUNE SUPPORTORALTABLET,CHEWABLEOTCOFEV2PAOMEGA-3 FISH OILORAL CAPSULE300-1,000 MG OTC Drug NameTier Restrictions /LimitsONE DAILYWOMEN'SMETABOLISM OTC PHYTOMULTIOTC VITAMINS50 PLUS ADULT EYEHEALTHOTC A THRU ZOTC A THRU ZADVANCEDFORMULAOTC A THRU ZHIGHPOTENCYOTC A THRU ZMEN'SULTIMATEOTC A THRU ZSELECTOTC A THRU ZSELECT50PLUS FORMULAOTC A THRU ZSELECTWOMEN'SOTC ADULTMULTIVITAMINGUMMIES ORALTABLET,CHEWABLE200 MCGOTC ADULT ONE DAILYGUMMIESOTC ADULTS 50 PLUSOTC ADULTS' DAILYFORMULAOTC ADULTSMULTIVITAMINOTC ADVANCED MULTIEAOTC ALIVE WOMEN 50PLS ULT POTENCYOTC ALIVE WOMEN'SGUMMY VITAMINOTCGEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/202621 Drug NameTier Restrictions /LimitsBARIATRICMULTIVITAMINSORAL CAPSULE 45MG IRON-800 MCG-120 MCG OTCBIO-35, GLUTENFREEOTCBODY, HAIR, SKINAND NAILSOTCcalcitriol oral1CENTRAVITES 50PLUSOTCCENTRAVITESADULTSOTCCENTRUM SILVEROTCCENTRUM SILVERMENOTCCENTRUM SILVERWOMENOTCCENTRUM WOMENOTCCENTURYOTCCENTURY MATUREOTCCEROVITE SENIOROTCCERTA PLUSOTCCERTAVITE SENIOROTCCERTAVITE-ANTIOXIDANTOTCcholecalciferol(vitamin d3) oral capsule 125 mcg(5,000 unit)OTCcholecalciferol(vitamin d3) oral tablet10 mcg (400 unit),125 mcg (5,000 unit),25 mcg (1,000 unit),250 mcg (10,000unit), 50 mcg (2,000unit), 75 mcg (3,000unit)OTC Drug NameTier Restrictions /LimitsCOMPLETEMULTIVITAMIN-MINERAL ORALTABLET OTC cyanocobalamin(vitamin b-12)injection1 DAILY GUMMIESOTC DAILY MULTIPLEFOR WOMENOTC DAILYMULTIVITAMINOTC DAILY MULTI-VITAMINOTC DAILYMULTIVITAMIN-MINERALSOTC DAILY VITAMINFORMULAOTC DAILY VITAMINFORMULA-IRONOTC DAILY VITAMINFORMULA-MINERALSOTC DAILY VITAMINWITH IRONOTC DAILY VITES/IRONOTC DAILY-VITEOTC DECUBI VITEOTC DEKAS PLUS (FOLICACID)OTC DELTA D3OTC DIABETES HEALTHFORMULAOTC DIALYVITE 800-ULTRA DOTC EMERGEN-C ORALTABLET,CHEWABLEOTC ENDUR-VM IRON-FREEOTCGEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/202622 Drug NameTier Restrictions /LimitsENDUR-VM WITHIRON OTCESSENTIAOTCESSENTIAL MANOTCESSENTIAL MAN 50PLUSOTCEYE HEALTH PLUSLUTEINOTCEYEPROTECTOTCFLORIVA PLUSOTCFOLBEEOTCFOLBICOTCFOLBIC RFOTCFOLINIC-PLUSOTCFOLTANXOTCFOLTANX RFOTCFOLTXOTCHAIR,SKIN ANDNAILSOTCHAIR,SKIN ANDNAILS(FA-BIOTIN)ORAL TABLET 66.7-1,666.7 MCGOTCHAIR-SKIN-NAILS(MV-FA-BIOTIN)OTCHEALTHY EYESOTCHEALTHY EYESSUPERVISIONOTCK-PAX IMMUNESUPPORTOTClevomefol-b6-meb12-algal oilOTCMACULAR HEALTHFORMULAOTCMACUVITE EYECAREOTCMEGA MULTI FORWOMENOTC Drug NameTier Restrictions /LimitsMEGAMULTIVITAMIN FORMEN OTC MEN 50 PLUSADVANCED ONEDAILYOTC MEN 50 PLUSMULTIVITAMINOTC MEN'S 50 PLUSDAILY FORMULAOTC MEN'S DAILYFORMULAOTC MEN'S DAILYGUMMIESOTC MEN'SMULTIVITAMINGUMMIES ORALTABLET,CHEWABLE200 MCGOTC MEN'S ONE DAILYOTC METANX (ALGALOIL)OTC MILLTRIUM SENIOROTC MULTI COMPLETEWITH IRONOTC MULTI FOR HEROTC MULTI FOR HER 50PLUS ORALCAPSULEOTC MULTIPLE VITAMIN-MINERALSOTC MULTIPLE VITAMINSOTC multivit with min-folic acid oral tabletOTC multivitaminOTC MULTIVITAMIN 50PLUSOTC MULTI-VITAMINWITH FLUORIDEOTC multivitamin with ironOTCGEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/202623 Drug NameTier Restrictions /LimitsMULTIVITAMINWOMEN 50 PLUS OTCmultivit-min-folic acid-luteinOTCmultivit-min-iron fum-folic acOTCMVW COMPLETEFORMUL MULTIVITOTCMVW COMPLETEFORMULATIOND3000 ORALCAPSULEOTCMVW COMPLETEFORMULATIOND5000 ORALCAPSULEOTCMYNEPHROCAPSOTCMYNEPHRONOTCMY-VITALIFEOTCOCULAR VITAMINSOTCOCUTABSOTCOCUVITE ADULT 50PLUSOTCOCUVITE EYE PLUSMULTIOTCOCUVITE WITHLUTEINOTCONCOVITEOTCONE DAILYOTCONE DAILYESSENTIAL ORALTABLET , 400 MCGOTCONE DAILY FORMENOTCONE DAILY FORMEN 50 PLUS ADVOTCONE DAILY FORWOMENOTCONE DAILYHEALTHY WEIGHTOTC Drug NameTier Restrictions /LimitsONE DAILYMAXIMUM ORALTABLET 18-0.4 MG OTC ONE DAILY MEN'S50 PLUS MEMORYOTC ONE DAILY MEN'S50 PLUS W-D3OTC ONE DAILY MULTI-VIT W-MINERALOTC ONE DAILYMULTIVITAMINOTC ONE DAILYMULTIVITAMIN-IRONOTC ONE DAILY PLUSIRONOTC ONE DAILY WOMEN50 PLUSOTC ONE DAILY WOMEN50 PLUS(VIT K)OTC ONE DAILYWOMENS 50 PLUSOTC ONE-A-DAYENERGYOTC ONE-A-DAY MENVITACRAVESOTC ONE-A-DAYMENOPAUSEFORMULAOTC ONE-A-DAY MEN'S50PLUS(GINKGO)OTC ONE-A-DAY MEN'SMULTIVITAMINOTC ONE-A-DAYPROACTIVE 65PLUSOTC ONE-A-DAY TEENADVANTAGEOTC ONE-A-DAY TEENHER VITACRAVESOTC ONE-A-DAY TEENHIM VITACRAVESOTCGEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/202624 Drug NameTier Restrictions /LimitsONE-A-DAYVITACRAVES OTCONE-A-DAYVITACRAVESIMMUNITYOTCONE-A-DAY WOMENVITACRAVESOTCOPURITYMULTIVITAMINOTCPRESERVISIONAREDSOTCPRESERVISIONLUTEINOTCPREVENTOTCPROCERV HPOTCPRORENALOTCPRORENAL QDOTCPROTECT CARDIOAFOTCPROTECT PLUS SOOTCRENAL CAPSOTCRENAPLEXOTCRENAPLEX-DOTCRENO CAPSOTCSENIOR TABSOTCSENTRYOTCSENTRY SENIOROTCSOLOOTCSPECTRAVITEADULT 50 PLUSOTCSPECTRAVITEADULT 50PLUS(LUT)OTCSPECTRAVITEADVANCEDFORMULAOTCSPECTRAVITEMEN'SOTC Drug NameTier Restrictions /LimitsSTRESS BWITHZINC OTC STRESS FORMULAOTC STRESS FORMULAWITH IRON(SULF)OTC SUPER THERA VITEMOTC TAB-A-VITEOTC TAB-A-VITEMULTIVITAMIN W-IRON ORAL TABLET15 MG IRON-400MCGOTC THERAOTC THERAGRAN-MPREMIER 50 PLUSOTC THERALOGIXCOMPANIONOTC THERA-M ORALTABLET 27-0.4 MGOTC THERAPEUTIC-MOTC THERA-TABSOTC THERATRUMCOMPLETE 50PLUS/LUTOTC THERATRUMCOMPLETE 50PLUS-LYCOTC THERATRUMCOMPLETE WITHLUTEINOTC THEREMSMULTIVITAMINOTC TRIPHROCAPSOTC VISION FORMULA(WITH LUTEIN)OTC VISION FORMULA(A-C-E-ZN-SE-CU)OTC VISION PLUSLUTEINOTCGEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/202625 Drug NameTier Restrictions /LimitsVITABEX PLUS OTCVITALEEOTCVITAMIN D3 ORALTABLETOTCVITA-RESPAOTCWESTAB MAXOTCWESTAB ONEOTCWOMEN'S 50 PLUSDAILY FORMULAOTCWOMEN'S DAILYFORMULAOTCWOMENS DAILYGUMMIESOTCWOMEN'SMULTIVITAMINOTCWOMEN'SMULTIVITAMINGUMMIES ORALTABLET,CHEWABLE200 MCGOTCWOMEN'S ONEDAILY ORALTABLET 18 MGIRON-400 MCG-500MG CAOTCGEORGIA P4HB INTER-PREGNANCY CARE | Effective 10/01/202626 Index50 PLUS ADULT EYE HEALTH………………………….. 21A THRU Z ………………………… 21A THRU ZADVANCED FORMULA ……………………….. 21A THRU ZHIGH POTENCY ..21A THRU ZMEN'S ULTIMATE ……………………….. 21A THRU ZSELECT ……………21A THRU ZSELECT 50PLUS FORMULA ……………………….. 21A THRU ZSELECT WOMEN'S ……………………….. 21acarbose ……………………………. 6acetazolamide ………………….. 15acyclovir …………………………….. 8ADACEL(TDAP ADOLESN/ADULT)(PF) ……….9ADULT MULTIVITAMIN GUMMIES ……………………….. 21ADULT ONE DAILY GUMMIES ……………………….. 21ADULTS 50 PLUS ……………..21ADULTS' DAILY FORMULA ..21ADULTS MULTIVITAMIN ……21ADVANCED MULTI EA ………21AEROCHAMBER MINI ……….17AEROCHAMBER MV …………17AEROCHAMBER PLUS FLOW-VU ………………………… 17AEROCHAMBER PLUS FLOW-VU,L MSK ………………17AEROCHAMBER PLUS FLOW-VU,M MSK ……………..17AEROCHAMBER PLUS FLOW-VU,S MSK ………………17AEROCHAMBER PLUS ZSTAT ………………………………. 17AEROCHAMBER PLUS ZSTAT LG MSK …………………..17AEROCHAMBER PLUS ZSTAT MD MSK ………………….17AEROCHAMBER PLUS ZSTAT SM MSK ………………….17AEROCHAMBER Z-STAT PLUS-FLW SG ………………….17AEROVENT PLUS …………….17AFIRMELLE ……………………… 12AIRBORNE (ASCORBATE SODIUM)…………………………. 21AIRBORNE (WITH LYSINE ACETATE) ……………………….. 21albuterol sulfate …………………..3alendronate ………………………. 21ALIVE WOMEN 50 PLS ULT POTENCY ……………………….. 21ALIVE WOMEN'S GUMMY VITAMIN ………………………….. 21alogliptin ……………………………. 6alogliptin-metformin ……………..6alogliptin-pioglitazone …………..6ALTAVERA (28) ………………..12ALYACEN 1/35 (28) …………..12ALYACEN 7/7/7 (28) ………….12AMETHIA …………………………. 12AMETHYST (28) ………………..12amiloride ………………………….. 15amiloride-hydrochlorothiazide ……………15amiodarone ………………………… 9amitriptyline ……………………… 19amitriptyline-chlordiazepoxide ………………..19amlodipine …………………………. 9amlodipine-benazepril ………..10amlodipine-olmesartan ……….10amlodipine-valsartan ………….10amlodipine-valsartan-hcthiazid ………………………….. 10amoxapine ……………………….. 19amoxicil-clarithromy-lansopraz …………………………. 16amoxicillin ………………………….. 4amoxicillin-pot clavulanate …….4ampicillin ……………………………. 4APRI ……………………………….. 12ARANELLE (28) ………………..12aripiprazole ………………………. 19ARNUITY ELLIPTA ……………..3ASHLYNA ………………………… 12atenolol ……………………………. 10atenolol-chlorthalidone ……….10atomoxetine ……………………… 19atorvastatin ………………………. 10ATROVENT HFA …………………3AUBRA ……………………………. 12AUBRA EQ ………………………. 12AUROVELA 1.5/30 (21)………12AUROVELA 1/20 (21) …………12AUROVELA 24 FE …………….12AUROVELA FE 1.5/30 (28) …12AUROVELA FE 1-20 (28) ……12AVIANE …………………………… 12AVIDOXY …………………………… 4AYUNA ……………………………. 12azithromycin ………………………. 4AZURETTE (28) ………………..12BALZIVA (28) …………………… 12BARIATRIC MULTIVITAMINS ……………….22benazepril ………………………… 10benazepril-hydrochlorothiazide ……………10BIO-35, GLUTEN FREE ……..22bisoprolol fumarate …………….10bisoprolol-hydrochlorothiazide ……………10 BLISOVI 24 FE………………….12BLISOVI FE 1.5/30 (28) ………12BLISOVI FE 1/20 (28) …………12BODY, HAIR, SKIN AND NAILS ……………………………… 22BOOSTRIX TDAP ……………….9BREATHERITE MDI SPACER ………………………….. 17BREATHERITE SPACER-MASK, NEO. …………………….. 17BREATHERITE SPACER-MASK,ADULT …………………… 17BREATHERITE SPACER-MASK,CHILD ……………………. 17BREATHERITE SPACER-MASK,INFANT ………………….17BREATHERITE SPACER-MASK,S.CHLD ………………….17BREATHERITE VALVED MDI CHAMBER …………………17BREATHERITE VALVED MDI SPACER …………………… 17BRIELLYN ……………………….. 12BRILINTA ………………………….. 8budesonide ………………………… 3bumetanide ………………………. 15buprenorphine-naloxone ……..21bupropion hcl ……………………. 19calcitriol ……………………………. 2227 CALCIUM 500 + D……………..15CALCIUM 500 WITH D ……….15CALCIUM 600 WITH VITAMIN D3 …………………….. 15calcium acetate(phosphat bind) ………………………………… 15calcium carbonate-vitamin d3 ……………………………………. 15CALCIUM WITH VITAMIN D .15CAMILA …………………………… 12CAMRESE ……………………….. 12CAMRESE LO …………………..12candesartan ……………………… 10candesartan-hydrochlorothiazid ……………..10captopril …………………………… 10captopril-hydrochlorothiazide .10carbamazepine ………………….11CARTIA XT ………………………… 9carvedilol …………………………. 10CAYA CONTOURED ………….12CAZIANT (28) …………………… 12cefadroxil …………………………… 4cefdinir ………………………………. 4cefprozil …………………………….. 4cefuroxime axetil ………………….4celecoxib ……………………………. 3CELONTIN ………………………. 11CENTRATEX ……………………. 15CENTRAVITES 50 PLUS ……22CENTRAVITES ADULTS ……22CENTRUM SILVER ……………22CENTRUM SILVER MEN ……22CENTRUM SILVER WOMEN ………………………….. 22CENTRUM WOMEN ………….22CENTURY ……………………….. 22CENTURY MATURE ………….22cephalexin …………………………. 4CEROVITE SENIOR ………….22CERTA PLUS …………………… 22CERTAVITE SENIOR …………22CERTAVITE-ANTIOXIDANT .22CHATEAL EQ (28) …………….13chlorpromazine ………………….19chlorthalidone …………………… 15cholecalciferol (vitamin d3) ….22CHOLESTYRAMINE LIGHT ..10CHROMAGEN(SUMALATE-QUATREFOLI) ………………….15cilostazol……………………………. 8ciprofloxacin ……………………….. 4ciprofloxacin hcl …………………..4citalopram ………………………… 19clarithromycin …………………….. 4CLEOCIN …………………………… 4CLEVER CHOICE CHAMBER-LRG MASK ………17CLEVER CHOICE CHAMBER-MED MASK ……..17CLEVER CHOICE CHAMBER-SM MASK ………..17clindamycin hcl ……………………4CLINDAMYCIN PEDIATRIC ….4clindamycin phosphate …………4clobazam …………………………. 11clomipramine ……………………. 19clonazepam ……………………… 11clonidine ………………………….. 10clonidine hcl ……………………… 19clopidogrel …………………………. 8clotrimazole ……………………….. 6clozapine …………………………. 19colchicine …………………………… 3colestipol ………………………….. 10COMBIPATCH …………………..16COMBIVENT RESPIMAT ……..3COMPACT SPACE CHAMBER ……………………….. 17COMPACT SPACE CHAMBER-LRG MASK ………17COMPACT SPACE CHAMBER-MED MASK ……..17COMPACT SPACE CHAMBER-SM MASK ………..17COMPLETE MULTIVITAMIN-MINERAL ….22COMPLETENATE ……………..18COVARYX ……………………….. 16COVARYX H.S. …………………16cromolyn ……………………………. 3CRYSELLE (28) ………………..13CUTTER BACKWOODS ………7CUTTER BACKWOODS DRY ………………………………….. 7CUTTER LEMON EUCALYPTUS ……………………. 7CUTTER NATURAL INSECT REPELLNT …………….7CUTTER NATURAL REPELLENT2…………………….. 7CUTTER SKINSATIONS ………7cyanocobalamin (vitamin b-12) ………………………………….. 22CYRED ……………………………. 13CYRED EQ ………………………. 13DAILY GUMMIES ………………22DAILY MULTIPLE FOR WOMEN ………………………….. 22DAILY MULTIVITAMIN ……….22DAILY MULTI-VITAMIN ………22DAILY MULTIVITAMIN-MINERALS ………………………. 22DAILY VITAMIN FORMULA ..22DAILY VITAMIN FORMULA-IRON ……………………………….. 22DAILY VITAMIN FORMULA-MINERALS ………………………. 22DAILY VITAMIN WITH IRON 22DAILY VITES/IRON ……………22DAILY-VITE ……………………… 22danazol ……………………………. 16dapagliflozin ……………………….. 6dapagliflozin-metformin ………..6dapsone …………………………….. 4DASETTA 1/35 (28) ……………13DASETTA 7/7/7 (28) …………..13DAYSEE ………………………….. 13DEBLITANE ……………………… 13DECUBI VITE …………………… 22DEKAS PLUS (FOLIC ACID) 22DELTA D3 ……………………….. 22DEPO-SUBQ PROVERA 104 ………………………………….. 13desipramine ……………………… 19desmopressin …………………… 16desog-e.estradiol/e.estradiol .13dexmethylphenidate …………..19dextroamphetamine sulfate …..8dextroamphetamine-amphetamine ……………………… 9DIABETES HEALTH FORMULA ……………………….. 22DIABETIC SUPPORT FORMULA ……………………….. 21DIALYVITE 800-ULTRA D …..22diazepam …………………………. 11diclofenac potassium ……………3diclofenac sodium ………………..328 diclofenac-misoprostol………….3dicloxacillin ………………………… 4diflunisal …………………………….. 3digoxin ………………………………. 9DILANTIN ………………………… 11DILANTIN EXTENDED ……….11diltiazem hcl ……………………….. 9DILT-XR …………………………….. 9dipyridamole ………………………. 8disopyramide phosphate ………9divalproex ………………………… 11dofetilide ……………………………. 9doxazosin ………………………… 10doxepin ……………………………. 19doxycycline hyclate …………5, 21doxycycline monohydrate ……..5drospirenone-e.estradiol-lm.fa ………………………………… 13drospirenone-ethinyl estradiol …………………………… 13DRY EYE FORMULA …………21DULERA ……………………………. 3duloxetine ………………………… 19E.E.S. 400 …………………………. 5EASIVENT HOLDING CHAMBER ……………………….. 17EASIVENT MASK LARGE ….17EASIVENT MASK MEDIUM ..18EASIVENT MASK SMALL …..18ECLIPSE SYRINGE …………..18EEMT ………………………………. 16EEMT HS …………………………. 16ELINEST ………………………….. 13ELIQUIS ……………………………. 6ELIQUIS DVT-PE TREAT 30D START ……………………….. 6ELURYNG ……………………….. 13EMERGEN-C ……………………. 22enalapril maleate ……………….10enalapril-hydrochlorothiazide .10ENDUR-VM IRON-FREE ……22ENDUR-VM WITH IRON …….23ENGERIX-B (PF) …………………9ENGERIX-B PEDIATRIC (PF) …………………………………… 9enoxaparin …………………………. 6ENPRESSE ……………………… 13ENSKYCE ……………………….. 13ENTRESTO ……………………… 10eplerenone ……………………….. 15ERRIN…………………………….. 13ERY-TAB …………………………… 5ERYTHROCIN (AS STEARATE) ………………………. 5erythromycin ………………………. 5erythromycin ethylsuccinate ….5escitalopram oxalate …………..19ESSENTIA ……………………….. 23ESSENTIAL MAN ………………23ESSENTIAL MAN 50 PLUS ..23ESTARYLLA …………………….. 13estradiol-norethindrone acet ..16estrogens-methyltestosterone …………….16ethosuximide ……………………. 11etodolac …………………………….. 3etonogestrel-ethinyl estradiol .13EYE HEALTH PLUS LUTEIN ……………………………. 23EYEPROTECT ………………….23ezetimibe …………………………. 10FALMINA (28) …………………… 13felbamate …………………………. 11felodipine …………………………… 9FEMCAP ………………………….. 13fenofibrate micronized ………..10flecainide …………………………… 9FLEXICHAMBER ……………….18FLORIVA PLUS …………………23fluconazole ………………………… 6fluoride (sodium) ………………..15fluoxetine …………………………. 19fluphenazine hcl …………………19flurbiprofen …………………………. 3fluticasone propionate ………….4fluticasone propion-salmeterol ………………………….. 4fluvoxamine ……………………… 19FOLBEE ………………………….. 23FOLBIC ……………………………. 23FOLBIC RF ………………………. 23FOLINIC-PLUS ………………….23FOLTANX ………………………… 23FOLTANX RF …………………… 23FOLTX …………………………….. 23fosinopril ………………………….. 10fosinopril-hydrochlorothiazide ……………10FREESTYLE LIBRE 14 DAY READER ………………………….. 18FREESTYLE LIBRE 2 READER …………………………..18furosemide ……………………….. 15FYAVOLV ………………………… 16FYCOMPA ……………………….. 11gabapentin ……………………….. 11gemfibrozil ……………………….. 10glimepiride …………………………. 6glipizide ……………………………… 6glipizide-metformin ………………6glucose ……………………………. 15GLUCOSE GEL …………………15GLUTOSE-15 …………………… 15GLUTOSE-45 …………………… 15GLUTOSE-5 …………………….. 15glyburide ……………………………. 6glyburide-metformin ……………..6griseofulvin ultramicrosize …….6guanfacine ………………….. 10, 19HAILEY 24 FE …………………..13HAILEY FE 1.5/30 (28) ……….13HAILEY FE 1/20 (28) ………….13HAIR, SKIN AND NAILS ADVANCED ……………………… 21HAIR,SKIN AND NAILS ………23HAIR,SKIN AND NAILS(FA-BIOTIN) …………………………… 23HAIR-SKIN-NAIL(VIT A,C-BIOTIN) …………………………… 21HAIR-SKIN-NAILS (MV-FA-BIOTIN) …………………………… 23haloperidol ……………………….. 19haloperidol lactate ……………..19HEALTHY EYES ……………….23HEALTHY EYES SUPERVISION ………………….23HEATHER ……………………….. 13HEMATINIC PLUS VIT/MINERALS ………………….15HEMATINIC/FOLIC ACID ……15HEMATOGEN FORTE ……….15HEMOCYTE-PLUS …………….15HEPLISAV-B (PF) ……………….9HUMULIN RU-500 (CONC) KWIKPEN ………………………….. 6hydralazine ………………………. 10hydrochlorothiazide ……………15hydrocortisone …………………..16ibandronate ………………………. 21IBU ……………………………………. 329 ibuprofen……………………………. 3imipramine hcl ………………….. 19IMMUNE SUPPORT …………..21INCASSIA ………………………… 13indapamide ………………………. 15INSECT REPELLENT (DEET) ………………………………. 7INSECT REPELLENT (PICARIDIN) ………………………. 7insulin glargine-yfgn ……………..6insulin lispro ……………………….. 6insulin syringe-needle u-100 ..18INVOKAMET ……………………… 6INVOKAMET XR …………………6ipratropium bromide ……………..4ipratropium-albuterol …………….4irbesartan …………………………. 10irbesartan-hydrochlorothiazide ……………10ISIBLOOM ……………………….. 13isosorbide mononitrate ……….10JASMIEL (28) …………………… 13JENCYCLA ………………………. 13JINTELI ……………………………. 16JOLESSA ………………………… 13JULEBER ………………………… 13JUNEL 1.5/30 (21) ……………..13JUNEL 1/20 (21) ………………..13JUNEL FE 1.5/30 (28) ………..13JUNEL FE 1/20 (28) …………..13JUNEL FE 24 ……………………. 13KAITLIB FE ………………………. 13KARIVA (28) …………………….. 13KELNOR 1/35 (28) …………….13ketoconazole ……………………… 6ketoprofen ………………………….. 3ketorolac ……………………………. 3KLOR-CON 10 …………………..15KLOR-CON 8 ……………………. 16KLOR-CON M10 ………………..16KLOR-CON M15 ………………..16KLOR-CON M20 ………………..16KOSHER PRENATAL PLUS IRON ……………………………….. 18K-PAX IMMUNE SUPPORT ..23KURVELO (28) ………………….13labetalol …………………………… 10LAGEVRIO (EUA) ……………….8lamotrigine ……………………….. 12LARIN 1.5/30 (21) ………………13LARIN 1/20 (21)…………………13LARIN 24 FE ……………………. 13LARIN FE 1.5/30 (28) …………13LARIN FE 1/20 (28) ……………13LESSINA …………………………. 13levalbuterol tartrate ………………4levetiracetam ……………………. 12levofloxacin ………………………… 5levomefol-b6-meb12-algal oil 23LEVONEST (28) ………………..13levonorgestrel-ethinyl estrad .13levonorg-eth estrad triphasic .13levothyroxine ……………………. 21LEVOXYL ………………………… 21liothyronine ………………………. 21LIQUID CALCIUM WITH VITAMIN D ………………………. 16lisinopril ……………………………. 10lisinopril-hydrochlorothiazide .10LITEAIRE MDI CHAMBER ….18lithium carbonate ……………….19LORYNA (28) …………………… 13losartan ……………………………. 10losartan-hydrochlorothiazide .10lovastatin …………………………. 10LOW-OGESTREL (28) ……….13loxapine succinate ……………..19LO-ZUMANDIMINE (28) ……..13LUTERA (28) ……………………. 14LYZA ……………………………….. 14MACULAR HEALTH FORMULA ……………………….. 23MACUVITE EYE CARE ………23MARLISSA (28) …………………14MATZIM LA ……………………… 10medroxyprogesterone ……14, 16MEGA MULTI FOR WOMEN 23MEGA MULTIVITAMIN FOR MEN ………………………………… 23meloxicam …………………………. 3MEN 50 PLUS ADVANCED ONE DAILY ……………………… 23MEN 50 PLUS MULTIVITAMIN …………………23MEN'S 50 PLUS DAILY FORMULA ……………………….. 23MEN'S DAILY FORMULA …..23MEN'S DAILY GUMMIES ……23MEN'S MULTIVITAMIN GUMMIES ……………………….. 23MEN'S ONE DAILY……………23METANX (ALGAL OIL) ……….23metformin …………………………… 7methazolamide ………………….15methen-sod phos-meth blue-hyos ………………………………….. 5methimazole …………………….. 21methyldopa ………………………. 10methylergonovine ………………16methylphenidate hcl ……………20methylprednisolone ……………16metolazone ………………………. 15metoprolol succinate …………..11metoprolol ta-hydrochlorothiaz ………………..11metoprolol tartrate ……………..11metronidazole …………………….. 5metyrosine ……………………….. 11MICROCHAMBER ……………..18MICROGESTIN 1.5/30 (21) …14MICROGESTIN 1/20 (21) ……14MICROGESTIN FE 1.5/30 (28) …………………………………. 14MICROGESTIN FE 1/20 (28) …………………………………. 14MICROSPACER ………………..18midodrine …………………………… 9miglitol ………………………………. 7MILI …………………………………. 14MILLTRIUM SENIOR …………23MIMVEY ………………………….. 16minocycline ………………………… 5minoxidil …………………………… 11mirtazapine ………………………. 20M-NATAL PLUS ………………..18MONDOXYNE NL ……………….5MONOJECT INSULIN SAFETY SYRING ………………18MONO-LINYAH …………………14montelukast ……………………….. 4MORGIDOX ……………………….. 5moxifloxacin ………………………..5MULTI COMPLETE WITH IRON ……………………………….. 23MULTI FOR HER ……………….23MULTI FOR HER 50 PLUS …23MULTIPLE VITAMIN-MINERALS ………………………. 23MULTIPLE VITAMINS ………..23multivit with min-folic acid ……2330 multivitamin………………………. 23MULTIVITAMIN 50 PLUS ……23MULTI-VITAMIN WITH FLUORIDE ………………………. 23multivitamin with iron ………….23MULTIVITAMIN WOMEN 50 PLUS ………………………………. 24multivit-min-folic acid-lutein …24multivit-min-iron fum-folic ac ..24MVW COMPLETE FORMUL MULTIVIT ………………………… 24MVW COMPLETE FORMULATION D3000 ………24MVW COMPLETE FORMULATION D5000 ………24MYNEPHROCAPS …………….24MYNEPHRON …………………..24MY-VITALIFE …………………… 24nabumetone ……………………….. 3nadolol …………………………….. 11naproxen ……………………………. 3naproxen sodium …………………3NATACYN …………………………. 6nateglinide …………………………. 7NATRAPEL ………………………… 7NECON 0.5/35 (28) ……………14nefazodone ………………………. 20neomycin …………………………… 5nifedipine …………………………. 10NIKKI (28) ………………………… 14nitrofurantoin macrocrystal ……5nitrofurantoin monohyd/m-cryst ………………………………….. 5nitroglycerin ……………………… 10NORA-BE ………………………… 14norethindrone (contraceptive) …………………..14norethindrone ac-eth estradiol ……………………… 14, 16norgestimate-ethinyl estradiol …………………………… 14NORTREL 0.5/35 (28) ………..14NORTREL 1/35 (21) …………..14NORTREL 1/35 (28) …………..14NORTREL 7/7/7 (28) ………….14nortriptyline ………………………. 20nystatin ……………………………… 6OCELLA ………………………….. 14OCULAR VITAMINS …………..24OCUTABS ……………………….. 24OCUVITE ADULT 50 PLUS..24OCUVITE EYE PLUS MULTI ……………………………… 24OCUVITE WITH LUTEIN …….24OFEV ………………………………. 21OFF ACTIVE ……………………… 7OFF DEEP WOODS …………….7OFF DEEP WOODS DRY …….7OFF DEEP WOODS SPORTSMEN …………………….. 7OFF FAMILYCARE (WITH DEET) ……………………………….. 7OFF FAMILYCARE(WITH PICARIDIN) ……………………….. 8ofloxacin ……………………………. 5olanzapine ……………………….. 20olmesartan ……………………….. 11olmesartan-amlodipin-hcthiazid ………………………….. 11olmesartan-hydrochlorothiazide ……………11omega-3 acid ethyl esters …..16OMEGA-3 FISH OIL …………..21ONCOVITE ………………………. 24ONE DAILY ……………………… 24ONE DAILY ESSENTIAL …….24ONE DAILY FOR MEN ……….24ONE DAILY FOR MEN 50 PLUS ADV ……………………….. 24ONE DAILY FOR WOMEN ….24ONE DAILY HEALTHY WEIGHT ………………………….. 24ONE DAILY MAXIMUM ………24ONE DAILY MEN'S 50 PLUS MEMORY ………………..24ONE DAILY MEN'S 50 PLUS W-D3 ……………………… 24ONE DAILY MULTI-VIT W-MINERAL …………………………. 24ONE DAILY MULTIVITAMIN .24ONE DAILY MULTIVITAMIN-IRON ………..24ONE DAILY PLUS IRON …….24ONE DAILY WOMEN 50 PLUS ………………………………. 24ONE DAILY WOMEN 50 PLUS(VIT K) …………………….. 24ONE DAILY WOMENS 50 PLUS ………………………………. 24ONE DAILY WOMEN'S METABOLISM…………………..21ONE-A-DAY ENERGY ……….24ONE-A-DAY MEN VITACRAVES …………………… 24ONE-A-DAY MENOPAUSE FORMULA ……………………….. 24ONE-A-DAY MEN'S 50PLUS(GINKGO) …………….24ONE-A-DAY MEN'S MULTIVITAMIN …………………24ONE-A-DAY PROACTIVE 65 PLUS ………………………….. 24ONE-A-DAY TEEN ADVANTAGE …………………… 24ONE-A-DAY TEEN HER VITACRAVES …………………… 24ONE-A-DAY TEEN HIM VITACRAVES …………………… 24ONE-A-DAY VITACRAVES …25ONE-A-DAY VITACRAVES IMMUNITY ……………………….. 25ONE-A-DAY WOMEN VITACRAVES …………………… 25ONEVITE CALCIUM-D3 ……..16OPTICHAMBER DIAMOND LG MASK ………………………….18OPTICHAMBER DIAMOND VHC ………………………………… 18OPTICHAMBER DIAMOND-MED MSK ………………………… 18OPTICHAMBER DIAMOND-SML MASK ………………………. 18OPURITY MULTIVITAMIN ….25oxaprozin …………………………… 3oxcarbazepine …………………..12OXTELLAR XR ………………….12OYSCO 500/D …………………..16OYSTER SHELL + D3 ………..16OYSTER SHELL CALCIUM-VIT D3 …………………………….. 16paroxetine hcl …………………… 20PEN NEEDLE …………………… 18penicillin v potassium ……………5pentoxifylline ………………………. 9perphenazine ……………………. 20perphenazine-amitriptyline ….20phenazopyridine ………………….3phenobarbital ……………………. 20phenytoin …………………………. 1231 phenytoin sodium extended…12PHILITH …………………………… 14PHYTOMULTI ………………….. 21pimozide ………………………….. 20PIMTREA (28) …………………..14pioglitazone ……………………….. 7pioglitazone-glimepiride ………..7pioglitazone-metformin …………7POCKET CHAMBER ………….18PORTIA 28 ………………………. 14potassium chloride ……………..16potassium citrate ……………….16potassium citrate-citric acid …16prasugrel hcl ………………………. 8pravastatin ……………………….. 11prednisolone …………………….. 16prednisolone sodium phosphate ………………………… 16prednisone ……………………….. 16PREDNISONE INTENSOL ….16pregabalin ………………………… 12PRENATABS FA ……………….18PRENATABS RX ……………….18PRENATAL 19 …………………..18PRENATAL MULTI …………….18PRENATAL PLUS ……………..18PRENATAL PLUS (CALCIUM CARB) ……………..18PRENATAL TABLET ………….18PRENATAL VITAMIN …………18PRENATAL VITAMIN PLUS LOW IRON ………………………. 18PRENATAL VITAMIN WITH MINERALS ………………………. 18prenatal vit-iron fum-folic ac ..19PRESERVISION AREDS ……25PRESERVISION LUTEIN ……25PREVALITE ……………………… 11PREVENT ………………………… 25primidone …………………………. 12probenecid …………………………. 3PROCERV HP …………………..25PROCHAMBER …………………18progesterone micronized …….16propafenone …………………….. 10propranolol ……………………….. 11propylthiouracil ………………….21PRORENAL ……………………… 25PRORENAL QD ……………….. 25PROTECT CARDIO AF ………25PROTECT PLUS SO………….25pyridostigmine bromide ………..9quetiapine ………………………… 20quinapril …………………………… 11quinapril-hydrochlorothiazide .11ramipril …………………………….. 11RANGER READY REPELLENT ………………………. 8ranolazine ………………………… 10RECLIPSEN (28) ……………….14RECOMBIVAX HB (PF) ………..9RENAL CAPS …………………… 25RENAPLEX ……………………… 25RENAPLEX-D …………………… 25RENO CAPS ……………………. 25repaglinide …………………………. 7REPEL 100 ………………………… 8REPEL FAMILY …………………..8REPEL HUNTER'S ………………8REPEL LEMON EUCALYPTUS ……………………. 8REPEL SPORTSMEN ………….8REPEL SPORTSMEN DRY ….8REPEL SPORTSMEN MAX ….8REPEL TICK DEFENSE ……….8RHOGAM ULTRA-FILTERED PLUS …………………9risperidone ……………………….. 20RITEFLO AEROCHAMBER ..18rivaroxaban ………………………… 6rosuvastatin ……………………… 11ROWEEPRA …………………….. 12RYBELSUS ……………………….. 7salmon oil-omega-3 fatty acids ……………………………….. 11SENIOR TABS ………………….25SENTRY ………………………….. 25SENTRY SENIOR ……………..25SEREVENT DISKUS ……………4sertraline ………………………….. 20SETLAKIN ……………………….. 14SHAROBEL ……………………… 14SIMLIYA (28) ……………………. 14SIMPESSE ………………………. 14simvastatin ……………………….. 11SOLO ………………………………. 25sotalol ……………………………… 11SOTALOL AF ……………………11SPECTRAVITE ADULT 50 PLUS ………………………………. 25SPECTRAVITE ADULT 50 PLUS(LUT)………………………. 25SPECTRAVITE ADVANCED FORMULA ……………………….. 25SPECTRAVITE MEN'S ………25SPIRIVA RESPIMAT ……………4spironolactone …………………..15spironolacton-hydrochlorothiaz ………………..15SPRINTEC (28) …………………14STIOLTO RESPIMAT …………..4STRESS BWITH ZINC ………25STRESS FORMULA …………..25STRESS FORMULA WITH IRON(SULF) …………………….. 25STRIVERDI RESPIMAT ……….4SUBVENITE …………………….. 12sulfacetamide sodium-sulfur ….5sulfamethoxazole-trimethoprim ……………………….. 5SULFATRIM ………………………. 5sulindac …………………………….. 3SUPER OMEGA-3 ……………..16SUPER THERA VITE M ……..25SYEDA ……………………………. 14SYNTHROID ……………………. 21TAB-A-VITE ……………………… 25TAB-A-VITE MULTIVITAMIN W-IRON …………………………… 25TARINA 24 FE …………………..14TARINA FE 1/20 (28) …………14TARINA FE 1-20 EQ (28) ……14telmisartan ……………………….. 11telmisartan-amlodipine ……….11telmisartan-hydrochlorothiazid ……………..11TENIVAC (PF) ……………………. 9terazosin ………………………….. 11terbinafine hcl …………………….. 6terbutaline ………………………….. 4terconazole ………………………… 6tetracycline ………………………… 5THEO-24 …………………………… 4theophylline ……………………….. 4THERA ……………………………. 25THERAGRAN-M PREMIER 50 PLUS ………………………….. 25THERALOGIX COMPANION …………………… 25THERA-M ………………………… 2532 THERANATAL…………………..19THERAPEUTIC-M ……………..25THERA-TABS …………………… 25THERATRUM COMPLETE 50 PLUS/LUT …………………… 25THERATRUM COMPLETE 50 PLUS-LYC …………………… 25THERATRUM COMPLETE WITH LUTEIN …………………… 25THEREMS MULTIVITAMIN …25thioridazine ………………………. 20thiothixene ……………………….. 20THRIVITE RX …………………… 19tiagabine ………………………….. 12TILIA FE ………………………….. 14topiramate ………………………… 12torsemide …………………………. 15TOTAL HOME INSECT REPELLENT ………………………. 8trandolapril ……………………….. 11tranylcypromine …………………20trazodone …………………………. 20TRELEGY ELLIPTA …………….4triamterene-hydrochlorothiazid ……………..15TRICARE …………………………. 19TRICON …………………………… 16TRI-ESTARYLLA ……………….14trifluoperazine …………………… 20TRIGELS-F FORTE ……………16TRI-LEGEST FE ………………..14TRI-LINYAH ……………………… 14TRI-LO-ESTARYLLA ………….14TRI-LO-MARZIA ………………..14TRI-LO-MILI ……………………… 14TRI-LO-SPRINTEC ……………14trimethoprim ……………………….. 5TRI-MILI …………………………… 14trimipramine ……………………… 20TRINATAL RX 1 ………………..19TRIPHROCAPS …………………25TRI-SPRINTEC (28) …………..14TRI-VYLIBRA …………………… 14TRI-VYLIBRA LO ……………….14TULANA ………………………….. 14ULTRATHON ……………………… 8UNITHROID ……………………… 21URETRON D-S ……………………5URYL ………………………………… 5valacyclovir ………………………… 8valsartan………………………….. 11valsartan-hydrochlorothiazide ……………11vancomycin ………………………… 5VANDAZOLE ……………………… 5VELIVET TRIPHASIC REGIMEN (28) ………………….14venlafaxine ………………………. 20verapamil …………………………. 10VESTURA (28) ………………….14V-GO 20 ………………………….. 18V-GO 30 ………………………….. 18V-GO 40 ………………………….. 18VIENVA …………………………… 14VIORELE (28) …………………… 14VISION FORMULA (WITH LUTEIN) …………………………… 25VISION FORMULA(A-C-E-ZN-SE-CU) ………………………. 25VISION PLUS LUTEIN ……….25VITABEX PLUS …………………26VITALEE ………………………….. 26VITAMIN D3 …………………….. 26VITA-RESPA ……………………. 26voriconazole ………………………. 6VORTEX HOLDING CHAMBER ……………………….. 18VOTRIENT ………………………… 8VYFEMLA (28) ………………….14VYLIBRA …………………………. 14warfarin ……………………………… 6WERA (28) ………………………. 14WESTAB MAX …………………..26WESTAB ONE …………………..26WOMEN'S 50 PLUS DAILY FORMULA ……………………….. 26WOMEN'S DAILY FORMULA ……………………….. 26WOMENS DAILY GUMMIES 26WOMEN'S MULTIVITAMIN …26WOMEN'S MULTIVITAMIN GUMMIES ……………………….. 26WOMEN'S ONE DAILY ………26WYMZYA FE ……………………. 14XARELTO ………………………….. 6XARELTO DVT-PE TREAT 30D START ……………………….. 6XULANE ………………………….. 14ZAFEMY ………………………….. 14ZARAH ……………………………. 14ziprasidone hcl…………………..20zonisamide ………………………. 12ZOVIA 1-35 (28) ………………..14ZUMANDIMINE (28) …………..1433 GA-MED-M-2 964348-SPA-V.9 Aprobado por DCH: 7/19/2024
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