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Amerigroup Washington, Inc.

The medications included in the Amerigroup formulary are reviewed and approved by the Amerigroup Pharmacy and Therapeutics Committee, which includes Practitioners and Pharmacists from the Amerigroup Provider community.

Please select a drug from the list below to see all coverage details regarding the medication. Some medications listed may have additional requirements or limitations of coverage. These requirements and limits may include prior authorization, quantity limits, age limits or step therapy.

Medications not listed on the formulary are considered to be non-formulary and are subject to prior authorization.

Additionally, if a medication is available as a generic formulation, this will be Amerigroup's preferred agent, unless otherwise noted. If you have any questions about coverage of a certain product, please contact us at 800-454-3730.

Amerigroup will follow the Washington Health Care Authority (HCA) PDL for coverage of Atypical Antipsychotics.  All members UNDER 18 must utilize state UM's. Children less than 18 years of age that exceed clinically established age/dosing limitations for these medications will require a referral to Second Opinion Network (SON).

Machine Readable Data for Prescription Drug Formulary: Washington Medicaid Machine Readable File

The WA HCA PDL can be located at http://www.hca.wa.gov


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Please select a drug from the list below to continue.


Varying Coverage: This drug has varying coverage. Click to see the detail.
Benefit Exclusion C 1000-Bioflavonoids-Rose Hips capsuleBenefit Exclusion C Complex 1,000 mg tablet,extended releaseBenefit Exclusion C Complex 500 mg tablet,extended releaseBenefit Exclusion C-1000 1,000 mg tabletBenefit Exclusion C-1000 ER 1,000 mg tablet,extended releaseBenefit Exclusion C-1000 with Rose Hips 1,000 mg tabletBenefit Exclusion C-500 500 mg chewable tabletBenefit Exclusion C-500 500 mg tabletBenefit Exclusion C-500 500 mg tablet,extended releaseNon-Preferred C-Nate DHA 28 mg iron-1 mg-200 mg capsuleBenefit Exclusion C-Tub miscBenefit Exclusion Ca 600 mg-D3 400 unit-mag ox 40 mg-Zn-copper-Mn-boron chewable tabletBenefit Exclusion Ca 600 mg-D3 800 unit-mag ox 40 mg-Zn-copper-Mn-boron chewable tabletBenefit Exclusion Ca 600 mg-D3 800 unit-mag oxide 50 mg-Zn-copper-manganese-boron tabletBenefit Exclusion Ca-Rezz 0.3 % topical creamNon-Preferred Ca-Rezz Norisc 0.12 % topical sprayNon-Preferred Ca-Rezz Norisc 0.2 % topical creamFormulary cabergoline 0.5 mg tabletState Carve-Out Cablivi 11 mg injection kitFormulary Cabometyx 20 mg tabletFormulary Cabometyx 40 mg tabletFormulary Cabometyx 60 mg tabletNon-Preferred Cadeau DHA 29 mg iron-1 mg-150 mg capsuleBenefit Exclusion Cadira Compliant Blood Stat 21 gauge x 3/4"-2.5 %-2.5 % kitNon-Preferred Caduet 10 mg-10 mg tabletNon-Preferred Caduet 10 mg-20 mg tabletNon-Preferred Caduet 10 mg-40 mg tabletNon-Preferred Caduet 10 mg-80 mg tabletNon-Preferred Caduet 5 mg-10 mg tabletNon-Preferred Caduet 5 mg-20 mg tabletNon-Preferred Caduet 5 mg-40 mg tabletNon-Preferred Caduet 5 mg-80 mg tabletNon-Preferred Cafcit 60 mg/3 mL (20 mg/mL) intravenous solutionFormulary Cafergot 1 mg-100 mg tabletNon-Preferred caffeine (bulk) 100 % powderBenefit Exclusion caffeine 200 mg tabletNon-Preferred caffeine citrate (bulk) powderFormulary caffeine citrate 60 mg/3 mL (20 mg/mL) intravenous solutionFormulary caffeine citrate 60 mg/3 mL (20 mg/mL) oral solutionBenefit Exclusion caffeine-sodium benzoate 250 mg/mL(125 mg/mL caffeine) injection solnBenefit Exclusion Cal Mag Zinc Plus D3 333 mg-133 unit-133 mg-5 mg tabletBenefit Exclusion Cal-Citrate 250 mg-100 unit tabletFormulary Cal-Gest Antacid 200 mg calcium (500 mg) chewable tabletBenefit Exclusion Cal-Mag 200 mg calcium-100 mg chewable tabletNon-Preferred Cal-Mag Complex 300 mg-150 mg-400 unit tabletBenefit Exclusion Cal-Mint 260 mg calcium (650 mg) chewable tabletBenefit Exclusion Cal-Quick 500 mg calcium-400 unit/5 mL oral liquidBenefit Exclusion Calaclear lotionBenefit Exclusion Caladrox 0.44 %-20 % topical ointmentBenefit Exclusion Caladryl 1 %-8 % lotionBenefit Exclusion Calagesic 1 %-8 % lotionBenefit Exclusion Calahist 1 %-0.1 % lotionBenefit Exclusion Calahist Clear lotionBenefit Exclusion Calahist with Pramoxine 1 %-8 % lotionNon-Preferred calamine (bulk) powderBenefit Exclusion calamine 8 %-zinc oxide 8 % lotionBenefit Exclusion Calamine Medicated 1 %-8 % lotionBenefit Exclusion calamine phenolated lotionBenefit Exclusion Calamine Plus (pramoxine-calamine) 1 %-8 % lotionBenefit Exclusion calamine-zinc oxide lotionBenefit Exclusion calamine-zinc oxide-phenol liquid 8 %-8 %-1 % topical suspensionNon-Preferred Calan 120 mg tabletNon-Preferred Calan 80 mg tabletNon-Preferred Calan SR 120 mg tablet,extended releaseNon-Preferred Calan SR 180 mg tablet,extended releaseNon-Preferred Calan SR 240 mg tablet,extended releaseBenefit Exclusion Calcet Petites 200 mg calcium-250 unit tabletFormulary Calci-Chew 500 mg calcium (1,250 mg) tabletBenefit Exclusion Calci-Max 600 mg-1 mg-500 unit-30 unit capsuleBenefit Exclusion Calci-Mix 500 mg calcium (1,250 mg) capsuleBenefit Exclusion Calcidol 8,000 unit/mL oral dropsNon-Preferred Calcilo Xd oral powderFormulary calcipotriene 0.005 % scalp solutionFormulary calcipotriene 0.005 % topical creamFormulary calcipotriene 0.005 % topical ointmentFormulary calcipotriene-betamethasone 0.005 %-0.064 % topical ointmentNon-Preferred Calcipotriol (bulk) 100 % powderFormulary calcitonin (salmon) 200 unit/actuation nasal sprayBenefit Exclusion Calcitrate 200 mg (950 mg) tabletFormulary Calcitrene 0.005 % topical ointmentNon-Preferred calcitriol (bulk) 100 % crystalsNon-Preferred calcitriol (bulk) 100 % powderFormulary calcitriol 0.25 mcg capsuleFormulary calcitriol 0.5 mcg capsuleNon-Preferred calcitriol 1 mcg/mL intravenous solutionFormulary calcitriol 1 mcg/mL oral solutionNon-Preferred calcitriol 3 mcg/gram topical ointmentNon-Preferred calcitriol-almond oil (bulk) 1 mcg/mL liquidNon-Preferred calcium 250 mg-D3 400 unit-magnesium 40 mg-B6-Zn-copper-mangan tabletFormulary Calcium 500 500 mg calcium (1,250 mg) chewable tabletFormulary Calcium 500 + D 500 mg (1,250 mg)-200 unit tabletFormulary Calcium 500 + D 500 mg (1,250 mg)-400 unit tabletBenefit Exclusion Calcium 500 + D 500 mg(1,250 mg)-400 unit chewable tabletBenefit Exclusion Calcium 500 mg (1,250 mg) + D3 125 unit tabletFormulary Calcium 500 With D 500 mg (1,250 mg)-400 unit tabletBenefit Exclusion Calcium 600 600 mg calcium (1,500 mg) tabletFormulary Calcium 600 + D(3) 600 mg (1,500 mg)-200 unit tabletFormulary Calcium 600 + D(3) 600 mg (1,500 mg)-400 unit tabletBenefit Exclusion Calcium 600 + D(3) 600 mg calcium-200 unit capsuleNon-Preferred Calcium 600 + D(3) 600 mg-125 unit tabletBenefit Exclusion Calcium 600 + Minerals 600 mg calcium-200 unit tabletBenefit Exclusion Calcium 600 + Minerals 600 mg calcium-400 unit tabletBenefit Exclusion Calcium 600 with Vitamin D3 600 mg (1,500 mg)-500 unit capsuleBenefit Exclusion Calcium 600 with Vitamin D3 600 mg(1,500 mg)-400 unit chewable tabletBenefit Exclusion Calcium 600-D3 Plus (mag-zinc) 600 mg calcium-800 unit-50 mg tabletBenefit Exclusion calcium acetate (bulk) powderFormulary calcium acetate 667 mg capsuleFormulary calcium acetate 667 mg tabletBenefit Exclusion calcium acetate 668 mg (169 mg calcium) tabletNon-Preferred Calcium Adult (calcium phos) 250 mg calcium-350 unit chewable tabletBenefit Exclusion calcium alginate (bulk) 100 % powderNon-Preferred calcium amino acid chelate (bulk) 30 % granulesBenefit Exclusion calcium amino acid chelate 200 mg calcium tabletFormulary Calcium Antacid 200 mg calcium (500 mg) chewable tabletFormulary Calcium Antacid 300 mg (750 mg) chewable tabletFormulary Calcium Antacid 320 mg calcium (750 mg) chewable tabletFormulary Calcium Antacid 400 mg calcium (1,000 mg) chewable tabletFormulary Calcium Antacid 430 mg calcium (1,000 mg) chewable tabletFormulary Calcium Antacid Tropical 300 mg (750 mg) chewable tabletFormulary Calcium Antacid Ultra Max St 400 mg calcium (1,000 mg) chewable tabletBenefit Exclusion calcium carb,cit ER 600 mg calcium-vit D3 500 unit tablet,ext.releaseBenefit Exclusion calcium carb-vit D3-magnesium-zinc 333 mg-200 unit-133 mg-5 mg tabletBenefit Exclusion calcium carb-vit D3-minerals 600 mg calcium-400 unit tabletBenefit Exclusion calcium carbonate (bulk) 100 % powderBenefit Exclusion calcium carbonate (bulk) powderFormulary calcium carbonate 200 mg calcium (500 mg) chewable tabletFormulary calcium carbonate 260 mg calcium (648 mg) tabletBenefit Exclusion calcium carbonate 260 mg calcium (650 mg) chewable tabletFormulary calcium carbonate 300 mg (750 mg) chewable tabletFormulary calcium carbonate 320 mg calcium (750 mg) chewable tabletBenefit Exclusion calcium carbonate 333 mg-magnesium oxide 133 mg-zinc gluc 5 mg tabletBenefit Exclusion calcium carbonate 333 mg-magnesium oxide 133 mg-zinc sulf 5 mg tabletBenefit Exclusion calcium carbonate 334 mg-magnesium oxide 134 mg-zinc oxide 5 mg tabletFormulary calcium carbonate 400 mg calcium (1,000 mg) chewable tabletBenefit Exclusion calcium carbonate 500 mg (1,250 mg)-vitamin D3 125 unit tabletFormulary calcium carbonate 500 mg (1,250 mg)-vitamin D3 200 unit tabletFormulary calcium carbonate 500 mg (1,250 mg)-vitamin D3 400 unit tabletFormulary calcium carbonate 500 mg calcium (1,250 mg) chewable tabletFormulary calcium carbonate 500 mg calcium (1,250 mg) tabletBenefit Exclusion calcium carbonate 500 mg(1,250 mg)-vitamin D3 400 unit chewable tabletFormulary calcium carbonate 500 mg/5 mL calcium (1,250 mg/5 mL) oral suspensionNon-Preferred calcium carbonate 600 mg (1,500 mg)-vitamin D3 2,500 unit capsuleFormulary calcium carbonate 600 mg (1,500 mg)-vitamin D3 200 unit tabletFormulary calcium carbonate 600 mg (1,500 mg)-vitamin D3 400 unit tabletBenefit Exclusion calcium carbonate 600 mg (1,500 mg)-vitamin D3 500 unit capsuleBenefit Exclusion calcium carbonate 600 mg calcium (1,500 mg) tabletBenefit Exclusion calcium carbonate 600 mg calcium (1,500 mg)-vit D3 1,000 unit capsuleBenefit Exclusion calcium carbonate 650 mg calcium (1,625 mg) tabletBenefit Exclusion calcium carbonate 800 mg calcium/2 gram oral powderBenefit Exclusion calcium carbonate-vitamin D3 1,000 mg (2,500 mg)-800 unit tabletBenefit Exclusion calcium carbonate-vitamin D3 250 mg-125 unit tabletBenefit Exclusion calcium carbonate-vitamin D3 500 mg (1,250 mg)-600 unit tabletBenefit Exclusion calcium carbonate-vitamin D3 500 mg-100 unit chewable tabletBenefit Exclusion calcium carbonate-vitamin D3 600 mg (1,500 mg)-400 unit capsuleFormulary calcium carbonate-vitamin D3 600 mg (1,500 mg)-800 unit tabletNon-Preferred calcium chloride (bulk) 95 % powderBenefit Exclusion calcium chloride (bulk) granulesBenefit Exclusion calcium chloride (bulk) powderNon-Preferred calcium chloride 100 mg/mL (10 %) intravenous solutionNon-Preferred calcium chloride 100 mg/mL (10 %) intravenous syringeNon-Preferred calcium cit 250 mg-magnesium ox,aspartat 125 mg-D3 200 unit oral waferNon-Preferred calcium citrate (bulk) 100 % powderBenefit Exclusion Calcium Citrate + D 315 mg-200 unit tabletNon-Preferred calcium citrate 1,000 mg-vitamin D3 400 unit/30 mL oral liquidBenefit Exclusion calcium citrate 200 mg (950 mg) tabletBenefit Exclusion calcium citrate 250 mg calcium-vitamin D3 200 unit tabletBenefit Exclusion calcium citrate 250 mg tabletBenefit Exclusion calcium citrate 315 mg-vitamin D3 250 unit tabletBenefit Exclusion calcium citrate 760 mg calcium/3.5 gram oral granulesBenefit Exclusion calcium citrate malate-vitamin D3 250 mg-100 unit tabletBenefit Exclusion Calcium Citrate Plus (pyridoxine) 250 mg-40 mg-5 mg-125 unit tabletNon-Preferred Calcium Citrate Plus 250 mg-40 mg-125 unit-3.75 mg tabletBenefit Exclusion calcium citrate-ergocalciferol (vitamin D2) 1,500 mg-200 unit tabletBenefit Exclusion calcium citrate-vitamin D3 200 mg calcium-250 unit tabletBenefit Exclusion calcium citrate-vitamin D3 200 mg-125 unit tabletBenefit Exclusion calcium citrate-vitamin D3 315 mg-200 unit tabletNon-Preferred Calcium Disodium Versenate 200 mg/mL injection solutionBenefit Exclusion Calcium for Women 500 mg-100 unit-40 mcg chewable tabletNon-Preferred calcium glubionate (bulk) 100 % oral powderBenefit Exclusion calcium gluconate (bulk) powderNon-Preferred calcium gluconate 1 gram/10 mL (100 mg/mL) in sterile water IV syringeNon-Preferred calcium gluconate 1 gram/100 mL in 0.9 % sodium chloride intravenousNon-Preferred calcium gluconate 1 gram/50 mL in sodium chloride, iso-osm IV solutionNon-Preferred calcium gluconate 100 mg/mL (10 %) intravenous solutionBenefit Exclusion calcium gluconate 45 mg (500 mg) tabletBenefit Exclusion calcium gluconate 50 mg calcium tabletBenefit Exclusion calcium gluconate 60 mg calcium (650 mg) tabletNon-Preferred calcium gluconate monohydrate (bulk) 100 % powderBenefit Exclusion calcium hydroxide (bulk) powderBenefit Exclusion calcium lactate (bulk) 100 % powderBenefit Exclusion calcium lactate 100 mg calcium tabletBenefit Exclusion calcium lactate 84 mg (648 mg) tabletNon-Preferred calcium levulinate dihydrate (bulk) 100 % powderBenefit Exclusion Calcium Magnesium + D 400 mg-167 mg-133 unit tabletBenefit Exclusion Calcium Magnesium 500 mg calcium-250 mg tabletNon-Preferred calcium pantothenate (bulk) powderBenefit Exclusion calcium pantothenate 100 mg tabletBenefit Exclusion calcium pantothenate 200 mg tabletBenefit Exclusion calcium pantothenate 500 mg tabletNon-Preferred calcium phosphate (bulk) powderBenefit Exclusion calcium phosphate 250 mg-vitamin D3 200 unit chewable tabletBenefit Exclusion calcium phosphate 250 mg-vitamin D3 400 unit chewable tabletBenefit Exclusion calcium phosphate, tribasic (bulk) 100 % powderBenefit Exclusion calcium phosphate-vitamin D3 200 mg calcium-200 unit chewable tabletBenefit Exclusion calcium phosphate-vitamin D3 250 mg calcium-500 unit chewable tabletNon-Preferred Calcium Plus MenaQ7 Adult 500 mg calcium-200 unit-90mcg tabletNon-Preferred Calcium Plus MenaQ7 Senior 600 mg-1,000 unit-90 mcg tabletNon-Preferred Calcium PNV 28 mg-1 mg-250 mg capsuleBenefit Exclusion calcium polycarbophil 625 mg tabletBenefit Exclusion calcium pyruvate (bulk) 100 % powderBenefit Exclusion Calcium Saccharate 100 % powderBenefit Exclusion Calcium Soft Chew 500 mg-1,000 unit-40 mcg tabletBenefit Exclusion Calcium Soft Chew 500 mg-100 unit-40 mcg tabletBenefit Exclusion Calcium Soft Chew 500 mg-200 unit-40 mcg tabletNon-Preferred calcium sulfate (bulk) powderBenefit Exclusion calcium thioglycolate trihydrate (bulk) 100 % powderBenefit Exclusion Calcium with Boron 500 mg-1.5 mg tabletFormulary Calcium with Vitamin D 600 mg (1,500 mg)-400 unit tabletBenefit Exclusion calcium-D3-mag-Zn-coppr-mang-boron 600 mg-200 unit-40 mg-7.5 mg tabletFormulary Calcium-Folic Acid-Vitamin D 500 mg-50 mg-300 unit-1 mg oral waferBenefit Exclusion calcium-magnesium 300 mg-300 mg tabletBenefit Exclusion calcium-magnesium-copper-zinc tabletBenefit Exclusion calcium-magnesium-zinc 333 mg-133 mg-5 mg tabletBenefit Exclusion calcium-magnesium-zinc 333 mg-133 mg-8.3 mg tabletBenefit Exclusion calcium-magnesium-zinc tabletBenefit Exclusion calcium-vitamin D3-vitamin K 500 mg-1,000 unit-40 mcg chewable tabletBenefit Exclusion calcium-vitamin D3-vitamin K 500 mg-200 unit-40 mcg chewable tabletBenefit Exclusion calcium-vitamin D3-vitamin K 500 mg-500 unit-40 mcg chewable tabletBenefit Exclusion Caldesene 15 %-81 % topical powderNon-Preferred Caldolor 800 mg/8 mL (100 mg/mL) intravenous solutionBenefit Exclusion Caldyphen 1 %-8 % lotionBenefit Exclusion Caldyphen Clear 1 %-0.1 % lotionBenefit Exclusion Caldyphen Clear lotionBenefit Exclusion Calicylic 10 % topical creamBenefit Exclusion Callergy Clear lotionBenefit Exclusion Callus Cushion topicalBenefit Exclusion Callus Remover 40 % topical patchBenefit Exclusion Callus Removers 40 % topical patchBenefit Exclusion CalMag Thins 200 mg calcium-50 mg tabletBenefit Exclusion Calmme tabletBenefit Exclusion Calmol-4 76 %-10 % rectal suppositoryBenefit Exclusion Calmoseptine 0.44 %-20.6 % topical ointmentBenefit Exclusion Calmoseptine 0.44 %-20.6 % topical ointment in packetFormulary Calphron 667 mg tabletFormulary Calquence 100 mg capsuleBenefit Exclusion Caltrate + D3 Plus Minerals 300 mg-800 unit-25 mg-0.5 mg tabletBenefit Exclusion Caltrate 600 plus D 600 mg (1,500 mg)-800 unit chewable tabletBenefit Exclusion Caltrate 600-D Plus Minerals 600 mg calcium-800 unit-40 mg chew tabletBenefit Exclusion Caltrate 600-D Plus Minerals 600 mg calcium-800 unit-50 mg tabletBenefit Exclusion Caltrate Gummy Bites 250 mg-400 unit chewable tabletNon-Preferred Caltrate with Vitamin D3 600 mg (1,500 mg)-800 unit tabletBenefit Exclusion Calypxo 10 %-3 % topical creamBenefit Exclusion Cam lotionFormulary Cambia 50 mg oral powder packetFormulary Camila 0.35 mg tabletBenefit Exclusion Camino Pro 15 PE MSUD 15 gram-140 kcal/140 mL oral liquid in packetBenefit Exclusion Camino Pro 15 PE PKU 15 gram-140 kcal/140 mL oral liquid in packetBenefit Exclusion Campho-Phenique 10.8 %-4.7 % topical solutionNon-Preferred camphor (bulk) crystalsBenefit Exclusion Camphor Blocks gum (non-oral)Benefit Exclusion camphor topical spiritsNon-Preferred Camphotrex 4 %-10 % topical gelNon-Preferred Camptosar 100 mg/5 mL intravenous solutionNon-Preferred Camptosar 300 mg/15 mL intravenous solutionNon-Preferred Camptosar 40 mg/2 mL intravenous solutionFormulary Camrese 0.15 mg-30 mcg (84)/10 mcg(7) tablets,3 month dose packFormulary Camrese Lo 0.10 mg-20 mcg (84)/10 mcg(7) tablets,3 month dose packBenefit Exclusion Canada Balsam liquidFormulary Canasa 1,000 mg rectal suppositoryNon-Preferred Cancidas 50 mg intravenous solutionNon-Preferred Cancidas 70 mg intravenous solutionNon-Preferred candesartan 16 mg tabletNon-Preferred candesartan 16 mg-hydrochlorothiazide 12.5 mg tabletNon-Preferred candesartan 32 mg tabletNon-Preferred candesartan 32 mg-hydrochlorothiazide 12.5 mg tabletNon-Preferred candesartan 32 mg-hydrochlorothiazide 25 mg tabletNon-Preferred candesartan 4 mg tabletNon-Preferred candesartan 8 mg tabletNon-Preferred Candin FDA STANDARD allergen prep intradermalBenefit Exclusion caneBenefit Exclusion cane tipsBenefit Exclusion Cank-Oxide 10 % mucosal solutionNon-Preferred cantharidin (bulk) powderNon-Preferred Capastat 1 gram solution for injectionNon-Preferred CapCof 2 mg-5 mg-10 mg/5 mL oral liquidFormulary capecitabine 150 mg tabletFormulary capecitabine 500 mg tabletNon-Preferred Capex 0.01 % shampooNon-Preferred Caphosol mucosal solutionBenefit Exclusion Capmist DM 60 mg-15 mg-400 mg tabletFormulary Caprelsa 100 mg tabletFormulary Caprelsa 300 mg tabletBenefit Exclusion Capron DM 7.5 mg-7.5 mg/5 mL oral liquidNon-Preferred Capron DMT 30 mg-30 mg tabletBenefit Exclusion caprylic-capric triglyceride (bulk) liquidNon-Preferred capsaicin (bulk) powderBenefit Exclusion capsaicin 0.025 % topical creamBenefit Exclusion capsaicin 0.025 % topical patchBenefit Exclusion capsaicin 0.1 % topical creamBenefit Exclusion capsaicin 0.15 % topical liquidNon-Preferred capsaicin palmitate (bulk) powderNon-Preferred CapsFenac Pak 1.5 %-0.025 % kit, cream and solutionNon-Preferred capsicum (cayenne) 450 mg capsuleBenefit Exclusion Capsicum 0.025 % topical patchNon-Preferred capsicum oleoresin (bulk) 15 % liquidBenefit Exclusion CapsuBlend-H powderBenefit Exclusion CapsuBlend-P powderBenefit Exclusion CapsuBlend-S powderBenefit Exclusion Capsule #0 (cellulose) capsuleNon-Preferred Capsule #0 (hypromellose) capsuleNon-Preferred Capsule #0 capsuleNon-Preferred Capsule #0 DRcaps capsule,delayed releaseBenefit Exclusion Capsule #00 (cellulose) capsuleNon-Preferred Capsule #00 (hypromellose) capsuleNon-Preferred Capsule #00 capsuleNon-Preferred Capsule #000 capsuleBenefit Exclusion Capsule #1 (cellulose) capsuleNon-Preferred Capsule #1 (hypromellose) capsuleNon-Preferred Capsule #1 capsuleNon-Preferred Capsule #1 DRcaps capsule,delayed releaseNon-Preferred Capsule #10 capsuleNon-Preferred Capsule #11 capsuleNon-Preferred Capsule #13 capsuleNon-Preferred Capsule #2 capsuleBenefit Exclusion Capsule #3 (cellulose) capsuleNon-Preferred Capsule #3 (hypromellose) capsuleNon-Preferred Capsule #3 capsuleNon-Preferred Capsule #4 capsuleNon-Preferred Capsule #5 capsuleNon-Preferred Capsule #7 capsuleNon-Preferred Capsule Coni-Snap #0 (gelatin) capsuleNon-Preferred Capsule Coni-Snap #0 (hypromellose) capsuleNon-Preferred Capsule Coni-Snap #00 (gelatin) capsuleNon-Preferred Capsule Coni-Snap #000 (gelatin) capsuleNon-Preferred Capsule Coni-Snap #1 (gelatin) capsuleNon-Preferred Capsule Coni-Snap #1 (hypromellose) capsuleNon-Preferred Capsule Coni-Snap #2 (gelatin) capsuleNon-Preferred Capsule Coni-Snap #3 (gelatin) capsuleNon-Preferred Capsule Coni-Snap #3 (hypromellose) capsuleNon-Preferred Capsule Coni-Snap #4 (gelatin) capsuleNon-Preferred captopril (bulk) 100 % powderFormulary captopril 100 mg tabletFormulary captopril 12.5 mg tabletFormulary captopril 25 mg tabletNon-Preferred captopril 25 mg-hydrochlorothiazide 15 mg tabletNon-Preferred captopril 25 mg-hydrochlorothiazide 25 mg tabletFormulary captopril 50 mg tabletNon-Preferred captopril 50 mg-hydrochlorothiazide 15 mg tabletNon-Preferred captopril 50 mg-hydrochlorothiazide 25 mg tabletBenefit Exclusion CapXib 200 mg-0.0375 %-5 % capsule and patchBenefit Exclusion Capzasin 0.025 %-10 % topical gelBenefit Exclusion Capzasin 0.15 % topical liquidBenefit Exclusion Capzasin-HP 0.1 % topical creamNon-Preferred Carac 0.5 % topical creamNon-Preferred Carafate 1 gram tabletFormulary Carafate 100 mg/mL oral suspensionBenefit Exclusion caramel flavor (bulk) liquidBenefit Exclusion Carb Intercept 20 mcg-500 mg capsuleNon-Preferred carbachol (bulk) 99 % powderFormulary Carbaglu 200 mg dispersible tabletNon-Preferred carbamazepine (bulk) powderFormulary carbamazepine 100 mg chewable tabletFormulary carbamazepine 100 mg/5 mL (5 mL) oral suspensionFormulary carbamazepine 100 mg/5 mL oral suspensionFormulary carbamazepine 200 mg tabletFormulary carbamazepine 200 mg/10 mL oral suspensionFormulary carbamazepine ER 100 mg capsule,extended release mphase12hrFormulary carbamazepine ER 100 mg tablet,extended release,12 hrFormulary carbamazepine ER 200 mg capsule,extended release mphase12hrFormulary carbamazepine ER 200 mg tablet,extended release,12 hrFormulary carbamazepine ER 300 mg capsule,extended release mphase12hrFormulary carbamazepine ER 400 mg tablet,extended release,12 hrBenefit Exclusion carbamide peroxide (bulk) 100 % powderFormulary carbamide peroxide 6.5 % ear dropsFormulary Carbamoxide Ear Drops 6.5 %Non-Preferred Carbatrol 100 mg capsule, extended releaseNon-Preferred Carbatrol 200 mg capsule, extended releaseNon-Preferred Carbatrol 300 mg capsule, extended releaseBenefit Exclusion carbazochrome (bulk) 100 % powderNon-Preferred carbidopa (bulk) powderNon-Preferred carbidopa 10 mg-levodopa 100 mg disintegrating tabletFormulary carbidopa 10 mg-levodopa 100 mg tabletNon-Preferred carbidopa 12.5 mg-levodopa 50 mg-entacapone 200 mg tabletNon-Preferred carbidopa 18.75 mg-levodopa 75 mg-entacapone 200 mg tabletFormulary carbidopa 25 mg tabletNon-Preferred carbidopa 25 mg-levodopa 100 mg disintegrating tabletFormulary carbidopa 25 mg-levodopa 100 mg tabletNon-Preferred carbidopa 25 mg-levodopa 100 mg-entacapone 200 mg tabletNon-Preferred carbidopa 25 mg-levodopa 250 mg disintegrating tabletFormulary carbidopa 25 mg-levodopa 250 mg tabletNon-Preferred carbidopa 31.25 mg-levodopa 125 mg-entacapone 200 mg tabletNon-Preferred carbidopa 37.5 mg-levodopa 150 mg-entacapone 200 mg tabletNon-Preferred carbidopa 50 mg-levodopa 200 mg-entacapone 200 mg tabletFormulary carbidopa ER 25 mg-levodopa 100 mg tablet,extended releaseFormulary carbidopa ER 50 mg-levodopa 200 mg tablet,extended releaseNon-Preferred carbimazole (bulk) 100 % powderFormulary carbinoxamine 4 mg tabletFormulary carbinoxamine 4 mg/5 mL oral liquidNon-Preferred carbinoxamine 6 mg tabletNon-Preferred Carbocaine (PF) 10 mg/mL (1 %) injection solutionNon-Preferred Carbocaine (PF) 15 mg/mL (1.5 %) injection solutionNon-Preferred Carbocaine (PF) 20 mg/mL (2 %) injection solutionNon-Preferred Carbocaine 1 % (10 mg/mL) injection solutionNon-Preferred Carbocaine 2 % injection solutionBenefit Exclusion CarboFlex Odor Control Dressing 3" X 6"Benefit Exclusion CarboFlex Odor Control Dressing 4" X 4"Benefit Exclusion CarboFlex Odor Control Dressing 6" X 8"Benefit Exclusion CarbogelBenefit Exclusion Carbohol gelBenefit Exclusion carbomer 934 (bulk) 56 % to 68 % powderBenefit Exclusion carbomer 940 (bulk) powderBenefit Exclusion Carbomer Gel-AqueousBenefit Exclusion Carbomer Gel-HydroalcoholicBenefit Exclusion carbomer homopolymer type C (bulk) 56 % to 68 % powderFormulary carboplatin 10 mg/mL intravenous solutionFormulary carboplatin 150 mg intravenous solutionBenefit Exclusion carboxymethylcellulose sod, low substituted (bulk) 100 % powderBenefit Exclusion carboxymethylcellulose sodium (bulk) granulesBenefit Exclusion Carbzero 20 gram-180 kcal/100 mL oral emulsionFormulary Cardene 20 mg/200 mL in dextrose (iso) intravenous piggybackFormulary Cardene 20 mg/200 mL in sodium chloride(iso-osm) intravenous piggybackNon-Preferred Cardene 25 mg/10 mL intravenous solutionFormulary Cardene 40 mg/200 mL in sodium chloride(iso-osm) intravenous piggybackBenefit Exclusion Cardio Tea capsuleNon-Preferred cardioplegic solution 16 mEq/L (potassium) for perfusionBenefit Exclusion Cardiopress 60 mg-5 mg-2.5 mg capsuleBenefit Exclusion CardioSterol 0.5 gram-3.84 mg-5.76 mg capsuleBenefit Exclusion Cardiotek-RX (bioperine) 2 mg-500 mg-500 mcg-50 mg tabletNon-Preferred CardioVid PLUS 600 mg-20 mg-500 mcg-800 mcg capsuleNon-Preferred Cardizem 120 mg tabletNon-Preferred Cardizem 30 mg tabletNon-Preferred Cardizem 60 mg tabletNon-Preferred Cardizem CD 120 mg capsule,extended releaseNon-Preferred Cardizem CD 180 mg capsule,extended releaseNon-Preferred Cardizem CD 240 mg capsule,extended releaseNon-Preferred Cardizem CD 300 mg capsule,extended releaseNon-Preferred Cardizem CD 360 mg capsule,extended releaseNon-Preferred Cardizem LA 120 mg tablet,extended releaseNon-Preferred Cardizem LA 180 mg tablet,extended releaseNon-Preferred Cardizem LA 240 mg tablet,extended releaseNon-Preferred Cardizem LA 300 mg tablet,extended releaseNon-Preferred Cardizem LA 360 mg tablet,extended releaseNon-Preferred Cardizem LA 420 mg tablet,extended releaseNon-Preferred Cardura 1 mg tabletNon-Preferred Cardura 2 mg tabletNon-Preferred Cardura 4 mg tabletNon-Preferred Cardura 8 mg tabletNon-Preferred Cardura XL 4 mg tablet,extended releaseNon-Preferred Cardura XL 8 mg tablet,extended releaseNon-Preferred CareFine Pen Needle 29 gauge x 1/2"Non-Preferred CareFine Pen Needle 30 gauge x 5/16"Non-Preferred CareFine Pen Needle 31 gauge x 1/4"Non-Preferred CareFine Pen Needle 31 gauge x 5/16"Non-Preferred CareFine Pen Needle 32 gauge x 1/4"Non-Preferred CareFine Pen Needle 32 gauge x 3/16"Non-Preferred CareFine Pen Needle 32 gauge x 5/32"Formulary Careone Lancing DeviceFormulary Careone Ultra Thin LancetNon-Preferred Carepoint Luer Slip Syringe 1 mLNon-Preferred CareSens Control A Normal solutionNon-Preferred CareSens NNon-Preferred CareSens N Test StripsNon-Preferred CareSens N VoiceNon-Preferred CareTouch Alcohol Prep Pad topical padsBenefit Exclusion CareTouch Blood Pressure Monitor kitNon-Preferred CareTouch Glucose Monitoring System kitNon-Preferred CareTouch Lancing DeviceNon-Preferred CareTouch Pen Needle 31 gauge x 1/4"Non-Preferred CareTouch Pen Needle 31 gauge x 3/16"Non-Preferred CareTouch Pen Needle 31 gauge x 5/16"Non-Preferred CareTouch Pen Needle 32 gauge x 3/16"Non-Preferred CareTouch Pen Needle 32 gauge x 5/32"Non-Preferred CareTouch Test StripFormulary CareTouch Twist Lancet 28 gaugeFormulary CareTouch Twist Lancet 30 gaugeFormulary CareTouch Twist Lancet 33 gaugeBenefit Exclusion CareTouch Wrist Blood Pressure Monitor kitBenefit Exclusion carica papaya chewable tabletBenefit Exclusion carica papaya tabletNon-Preferred carisoprodol (bulk) powderNon-Preferred carisoprodol 250 mg tabletNon-Preferred carisoprodol 350 mg tabletNon-Preferred carisoprodol-ASA-codeine 200 mg-325 mg-16 mg tabletNon-Preferred carisoprodol-aspirin 200 mg-325 mg tabletNon-Preferred carmustine 100 mg intravenous solutionBenefit Exclusion carnauba wax (bulk) flakesBenefit Exclusion Carni Q-Gel Forte 30 mg-250 mg-12 mg-75 unit capsuleNon-Preferred Carnitor (sugar-free) 100 mg/mL oral solutionNon-Preferred Carnitor 100 mg/mL oral solutionNon-Preferred Carnitor 200 mg/mL intravenous solutionNon-Preferred Carnitor 330 mg tabletBenefit Exclusion carnosine (bulk) 100 % powderNon-Preferred CaroSpir 25 mg/5 mL oral suspensionBenefit Exclusion carrageenan (bulk) powderNon-Preferred Carraklenz Dermal Wound Cleanser topical sprayBenefit Exclusion CARRASYN GEL MFG UNRESPONSIVE (OTC)Non-Preferred CARRASYN HYDROGEL WOUND DRESS 12'S, LATEX-FREE (Rx)Non-Preferred Carrington Moist Barrier-Zinc 10 %-78 % topical creamNon-Preferred Carrington Moisture Barrier Cr 61 % topical creamNon-Preferred carteolol 1 % eye dropsNon-Preferred Cartia XT 120 mg capsule,extended releaseNon-Preferred Cartia XT 180 mg capsule,extended releaseNon-Preferred Cartia XT 240 mg capsule,extended releaseNon-Preferred Cartia XT 300 mg capsule,extended releaseNon-Preferred Cartivisc 500 mg-200 mg-150 mg tabletNon-Preferred Cartridge Stamped IR 1200 subcutaneous cartridgeFormulary carvedilol 12.5 mg tabletFormulary carvedilol 25 mg tabletFormulary carvedilol 3.125 mg tabletFormulary carvedilol 6.25 mg tabletFormulary carvedilol phosphate ER 10 mg capsule,ext.release24hr multiphaseFormulary carvedilol phosphate ER 20 mg capsule,ext.release24hr multiphaseFormulary carvedilol phosphate ER 40 mg capsule,ext.release24hr multiphaseFormulary carvedilol phosphate ER 80 mg capsule,ext.release24hr multiphaseNon-Preferred Casodex 50 mg tabletFormulary caspofungin 50 mg intravenous solutionFormulary caspofungin 70 mg intravenous solutionBenefit Exclusion Castellani Paint 1.5 % topical liquidBenefit Exclusion Castellani Paint Modified 1.5 % topical liquidBenefit Exclusion Castiva Cooling 5 %-14 % topical liquidBenefit Exclusion Castiva Warming 0.035% topical liquidBenefit Exclusion castor oilBenefit Exclusion castor oil 100 % oralBenefit Exclusion castor oil oralNon-Preferred cat hair std allergenic extract 10,000 BAU/mL injection solutionBenefit Exclusion cat's claw (uncaria tomentosa) 500 mg capsuleNon-Preferred Catapres 0.1 mg tabletNon-Preferred Catapres 0.2 mg tabletNon-Preferred Catapres 0.3 mg tabletNon-Preferred Catapres-TTS-1 0.1 mg/24 hr transdermal patchNon-Preferred Catapres-TTS-2 0.2 mg/24 hr transdermal patchNon-Preferred Catapres-TTS-3 0.3 mg/24 hr transdermal patchBenefit Exclusion Cath-Secure Tube HolderFormulary Cathflo Activase 2 mg intra-catheter solutionNon-Preferred Caverject 20 mcg intracavernosal solutionNon-Preferred Caverject 40 mcg intracavernosal solutionNon-Preferred Caverject Impulse 10 mcg intracavernosal kitNon-Preferred Caverject Impulse 20 mcg intracavernosal kitBenefit Exclusion Cavilon Durable Barrier 1.3 % topical creamBenefit Exclusion Cavilon Moisturizing Body topical creamBenefit Exclusion Cavilon Skin Cleanser topical sprayNon-Preferred Caya Contoured 65 mm-80 mm vaginal diaphragmFormulary Cayston 75 mg/mL solution for nebulizationFormulary Caziant (28) 0.1 mg/0.125 mg/0.15 mg-25 mcg tabletBenefit Exclusion CCP Caffeine Free 10 mg-325 mg-200 mg tabletBenefit Exclusion cedar leaf oil (bulk)Formulary cefaclor 125 mg/5 mL oral suspensionFormulary cefaclor 250 mg capsuleFormulary cefaclor 250 mg/5 mL oral suspensionFormulary cefaclor 375 mg/5 mL oral suspensionFormulary cefaclor 500 mg capsuleNon-Preferred cefaclor ER 500 mg tablet,extended release,12 hrFormulary cefadroxil 1 gram tabletFormulary cefadroxil 250 mg/5 mL oral suspensionFormulary cefadroxil 500 mg capsuleFormulary cefadroxil 500 mg/5 mL oral suspensionNon-Preferred Cefaly combo packFormulary cefazolin 1 gram intravenous solutionFormulary cefazolin 1 gram solution for injectionNon-Preferred cefazolin 1 gram/10 mL in sterile water intravenous syringeFormulary cefazolin 1 gram/50 mL in dextrose (iso-osmotic) intravenous piggybackFormulary cefazolin 10 gram solution for injectionNon-Preferred cefazolin 100 gram solution for injectionNon-Preferred cefazolin 2 gram/100 mL in 0.9 % sodium chloride intravenous solutionNon-Preferred cefazolin 2 gram/100 mL in dextrose 5 % intravenous solutionFormulary cefazolin 2 gram/100 mL in dextrose(iso-osmotic) intravenous piggybackNon-Preferred cefazolin 2 gram/20 mL in sterile water intravenous syringeFormulary cefazolin 2 gram/50 mL in dextrose (iso-osmotic) intravenous piggybackFormulary cefazolin 20 gram solution for injectionNon-Preferred cefazolin 3 gram/100 mL in 0.9 % sodium chloride intravenous piggybackNon-Preferred cefazolin 300 g solution for injectionFormulary cefazolin 500 mg solution for injectionFormulary cefdinir 125 mg/5 mL oral suspensionFormulary cefdinir 250 mg/5 mL oral suspensionFormulary cefdinir 300 mg capsuleNon-Preferred cefditoren pivoxil 200 mg tabletNon-Preferred cefditoren pivoxil 400 mg tabletFormulary cefepime 1 gram solution for injectionFormulary cefepime 1 gram/50 mL in dextrose (iso-osmotic) intravenous piggybackFormulary cefepime 1 gram/50 mL in dextrose 5 % intravenous piggybackFormulary cefepime 2 gram solution for injectionFormulary cefepime 2 gram/100 mL in dextrose (iso-osmotic) intravenous piggybackFormulary cefepime 2 gram/50 mL in dextrose 5 % intravenous piggybackFormulary cefixime 100 mg/5 mL oral suspensionFormulary cefixime 200 mg/5 mL oral suspensionFormulary cefixime 400 mg capsuleFormulary Cefotan 1 gram solution for injectionFormulary Cefotan 2 gram solution for injectionFormulary cefotaxime 1 gram solution for injectionFormulary cefotaxime 10 gram solution for injectionFormulary cefotaxime 2 gram solution for injectionFormulary cefotetan 1 gram solution for injectionFormulary cefotetan 1 gram/50 mL in dextrose, iso-osmotic intravenous piggybackFormulary cefotetan 10 gram intravenous solutionFormulary cefotetan 2 gram solution for injectionFormulary cefotetan 2 gram/50 mL in dextrose (iso-osmotic) intravenous piggybackFormulary cefoxitin 1 gram intravenous solutionFormulary cefoxitin 1 gram/50 mL in dextrose, iso-osmotic intravenous piggybackFormulary cefoxitin 10 gram intravenous solutionFormulary cefoxitin 2 gram intravenous solutionFormulary cefoxitin 2 gram/50 mL in dextrose(iso-osmotic) intravenous piggybackFormulary cefpodoxime 100 mg tabletFormulary cefpodoxime 100 mg/5 mL oral suspensionFormulary cefpodoxime 200 mg tabletFormulary cefpodoxime 50 mg/5 mL oral suspensionFormulary cefprozil 125 mg/5 mL oral suspensionFormulary cefprozil 250 mg tabletFormulary cefprozil 250 mg/5 mL oral suspensionFormulary cefprozil 500 mg tabletNon-Preferred ceftazidime (bulk) 100 % powderFormulary ceftazidime 1 gram solution for injectionFormulary ceftazidime 1 gram/50 mL in dextrose 5 % intravenous piggybackFormulary ceftazidime 2 gram solution for injectionFormulary ceftazidime 2 gram/50 mL in dextrose 5 % intravenous piggybackFormulary ceftazidime 6 gram solution for injectionFormulary ceftriaxone 1 gram intravenous solutionFormulary ceftriaxone 1 gram solution for injectionFormulary ceftriaxone 1 gram/50 mL in dextrose (iso-osmot) intravenous piggybackFormulary ceftriaxone 10 gram solution for injectionNon-Preferred ceftriaxone 100 gram solution for injectionFormulary ceftriaxone 2 gram intravenous solutionFormulary ceftriaxone 2 gram solution for injectionFormulary ceftriaxone 2 gram/50 mL in dextrose (iso-osm) intravenous piggybackFormulary ceftriaxone 250 mg solution for injectionFormulary ceftriaxone 500 mg solution for injectionNon-Preferred ceftriaxone sodium (bulk) powderNon-Preferred cefuroxime (PF) 10 mg/mL (1 mg/ 0.1 mL) in 0.9% NaCl intravitreal solnFormulary cefuroxime axetil 250 mg tabletFormulary cefuroxime axetil 500 mg tabletFormulary cefuroxime sodium 1.5 gram intravenous solutionFormulary cefuroxime sodium 7.5 gram intravenous solutionFormulary cefuroxime sodium 750 mg solution for injectionBenefit Exclusion Cela Cream BaseBenefit Exclusion Celacyn Post Procedure 0.009 % topical pack, gel and sprayBenefit Exclusion Celacyn topical gel with pumpNon-Preferred Celebrex 100 mg capsuleNon-Preferred Celebrex 200 mg capsuleNon-Preferred Celebrex 400 mg capsuleNon-Preferred Celebrex 50 mg capsuleNon-Preferred celecoxib (bulk) 100 % powderNon-Preferred celecoxib 100 mg capsuleNon-Preferred celecoxib 200 mg capsuleNon-Preferred celecoxib 400 mg capsuleNon-Preferred celecoxib 50 mg capsuleNon-Preferred Celestone Soluspan 6 mg/mL suspension for injectionNon-Preferred Celexa 10 mg tabletNon-Preferred Celexa 20 mg tabletNon-Preferred Celexa 40 mg tabletNon-Preferred CellCept 200 mg/mL oral suspensionNon-Preferred CellCept 250 mg capsuleNon-Preferred CellCept 500 mg tabletNon-Preferred CellCept Intravenous 500 mg intravenous solutionNon-Preferred Cellugel 2 % intraocular syringeBenefit Exclusion cellulase (bulk) 5,000 unit/gram powderBenefit Exclusion cellulose (bulk) 100 % powderBenefit Exclusion cellulose (bulk) powderNon-Preferred Celontin 300 mg capsuleBenefit Exclusion CEM-Urea 45 % topical gelBenefit Exclusion Centamin 9 mg iron/15 mL oral liquidNon-Preferred Centany 2 % topical ointmentNon-Preferred Centany AT 2 % ointment topical kitNon-Preferred Centergy 1 mg-2 mg/mL oral dropsNon-Preferred Centergy DM 1 mg-2 mg-3 mg/mL oral dropsBenefit Exclusion CenterPointLock Closed Pouch 1 1/2"Benefit Exclusion CenterPointLock Closed Pouch 1 3/4"Benefit Exclusion CenterPointLock Closed Pouch 2 1/4"Benefit Exclusion CenterPointLock Closed Pouch 2 3/4"Benefit Exclusion CenterPointLock Drainable Mini-Pouch 1 1/2"Benefit Exclusion CenterPointLock Drainable Mini-Pouch 1 3/4"Benefit Exclusion CenterPointLock Drainable Mini-Pouch 2 1/4"Benefit Exclusion CenterPointLock Drainable Mini-Pouch 2 3/4"Benefit Exclusion CenterPointLock Drainable Pouch 1 1/2"Benefit Exclusion CenterPointLock Drainable Pouch 1 3/4"Benefit Exclusion CenterPointLock Drainable Pouch 2 1/4"Benefit Exclusion CenterPointLock Drainable Pouch 2 3/4"Benefit Exclusion CenterPointLock Drainable Pouch 4"Benefit Exclusion CenterPointLock Drainable Pouch with Filter 1 1/2"Benefit Exclusion CenterPointLock Drainable Pouch with Filter 1 3/4"Benefit Exclusion CenterPointLock Drainable Pouch with Filter 2 1/4"Benefit Exclusion CenterPointLock Drainable Pouch with Filter 2 3/4"Benefit Exclusion CenterPointLock Flextend Convex Skin Barrier 1 1/2"Benefit Exclusion CenterPointLock Flextend Convex Skin Barrier 1 1/4"Benefit Exclusion CenterPointLock Flextend Convex Skin Barrier 1 1/8"Benefit Exclusion CenterPointLock Flextend Convex Skin Barrier 1 3/8"Benefit Exclusion CenterPointLock Flextend Convex Skin Barrier 1"Benefit Exclusion CenterPointLock Flextend Convex Skin Barrier 3/4"Benefit Exclusion CenterPointLock Flextend Convex Skin Barrier 5/8"Benefit Exclusion CenterPointLock Flextend Convex Skin Barrier 7/8"Benefit Exclusion CenterPointLock Flextend Skin Barrier 1 1/2"Benefit Exclusion CenterPointLock Flextend Skin Barrier 1 1/4"Benefit Exclusion CenterPointLock Flextend Skin Barrier 1 1/8"Benefit Exclusion CenterPointLock Flextend Skin Barrier 1 3/4"Benefit Exclusion CenterPointLock Flextend Skin Barrier 1 3/8"Benefit Exclusion CenterPointLock Flextend Skin Barrier 1"Benefit Exclusion CenterPointLock Flextend Skin Barrier 2 1/4"Benefit Exclusion CenterPointLock Flextend Skin Barrier 7/8"Benefit Exclusion CenterPointLock FlexWear Convex Skin Barrier 1 1/2"Benefit Exclusion CenterPointLock FlexWear Convex Skin Barrier 1 1/4"Benefit Exclusion CenterPointLock FlexWear Convex Skin Barrier 1 1/8"Benefit Exclusion CenterPointLock FlexWear Convex Skin Barrier 1 3/8"Benefit Exclusion CenterPointLock FlexWear Convex Skin Barrier 1 5/8"Benefit Exclusion CenterPointLock FlexWear Convex Skin Barrier 1"Benefit Exclusion CenterPointLock FlexWear Convex Skin Barrier 1/2"Benefit Exclusion CenterPointLock FlexWear Convex Skin Barrier 3/4"Benefit Exclusion CenterPointLock FlexWear Convex Skin Barrier 5/8"Benefit Exclusion CenterPointLock FlexWear Convex Skin Barrier 7/8"Benefit Exclusion CenterPointLock FlexWear Skin Barrier 1 1/2"Benefit Exclusion CenterPointLock FlexWear Skin Barrier 1 1/4"Benefit Exclusion CenterPointLock FlexWear Skin Barrier 1 3/4"Benefit Exclusion CenterPointLock FlexWear Skin Barrier 1"Benefit Exclusion CenterPointLock FlexWear Skin Barrier 2 1/4"Benefit Exclusion CenterPointLock FlexWear Skin Barrier 2 3/4"Benefit Exclusion CenterPointLock FlexWear Skin Barrier 3/4"Benefit Exclusion CenterPointLock FlexWear Skin Barrier 4"Benefit Exclusion CenterPointLock SoftFlex Skin Barrier 1 1/2"Benefit Exclusion CenterPointLock SoftFlex Skin Barrier 1 1/4"Benefit Exclusion CenterPointLock SoftFlex Skin Barrier 1 3/4"Benefit Exclusion CenterPointLock SoftFlex Skin Barrier 1"Benefit Exclusion CenterPointLock SoftFlex Skin Barrier 2 1/4"Benefit Exclusion CenterPointLock SoftFlex Skin Barrier 2 3/4"Benefit Exclusion CenterPointLock SoftFlex Skin Barrier 3 1/2" waferBenefit Exclusion CenterPointLock SoftFlex Skin Barrier 4"Benefit Exclusion CenterPointLock Stoma Cap 1 1/2"Benefit Exclusion CenterPointLock Stoma Cap 1 3/4"Benefit Exclusion CenterPointLock Stoma Cap 2 1/4"Benefit Exclusion CenterPointLock Stoma Cap 2 3/4"Benefit Exclusion CenterPointLock Stoma Irrigator Drain 1 1/2"Benefit Exclusion CenterPointLock Stoma Irrigator Drain 1 3/4"Benefit Exclusion CenterPointLock Stoma Irrigator Drain 2 1/4"Benefit Exclusion CenterPointLock Stoma Irrigator Drain 2 3/4"Benefit Exclusion CenterPointLock Stoma Irrigator Drain 4"Benefit Exclusion CenterPointLock Urostomy Pouch 1 1/2"Benefit Exclusion CenterPointLock Urostomy Pouch 1 3/4"Benefit Exclusion CenterPointLock Urostomy Pouch 2 1/4"Benefit Exclusion CenterPointLock Urostomy Pouch 2 3/4"Benefit Exclusion Central-Vite 18 mg iron-400 mcg-25 mcg tabletBenefit Exclusion Central-Vite Women's Mature 8 mg iron-400 mcg-300 mcg tabletBenefit Exclusion Centram-Care 9 mg iron/15 mL oral liquidFormulary Centratex 106 mg iron-1 mg capsuleBenefit Exclusion Centravites 0.4 mg-162 mg-18 mg tabletBenefit Exclusion Centravites 50 Plus 0.4 mg-300 mcg-250 mcg tabletBenefit Exclusion Centravites 50 Plus tabletBenefit Exclusion Centravites Adults 18 mg iron-400 mcg-25 mcg tabletBenefit Exclusion Centrum 9 mg iron/15 mL oral liquidBenefit Exclusion Centrum Complete 18 mg-400 mcg tabletNon-Preferred Centrum Flavor Burst Adult chewable tabletNon-Preferred Centrum Flavor Burst Kids chewable tabletBenefit Exclusion Centrum Kids 18 mg iron chewable tabletBenefit Exclusion Centrum Men 8 mg iron-200 mcg-600 mcg tabletNon-Preferred Centrum MultiGummies 80 mcg chewable tabletNon-Preferred Centrum ProNutrients Omega-3 332.5 mg-100 mg-200 mg capsuleBenefit Exclusion Centrum Silver 0.4 mg-300 mcg-250 mcg tabletNon-Preferred Centrum Silver 400 mcg-250 mcg chewable tabletBenefit Exclusion Centrum Silver Men 300 mcg-600 mcg-300 mcg tabletBenefit Exclusion Centrum Silver Ultra Men's 300 mcg-600 mcg-300 mcg tabletBenefit Exclusion Centrum Silver Women 8 mg iron-400 mcg-300 mcg tabletBenefit Exclusion Centrum Specialist Energy 18 mg iron-400 mcg-25mcg-75mg tabletBenefit Exclusion Centrum Specialist Heart 3 mg-200 mcg-400 mg tabletNon-Preferred Centrum Specialist Prenatal 27 mg iron-800 mcg-200 mg oral packBenefit Exclusion Centrum Ultra Men's 8 mg iron-200 mcg-600 mcg tabletBenefit Exclusion Centrum Women 18 mg-400 mcg tabletBenefit Exclusion Century 18 mg-400 mcg tabletBenefit Exclusion Century Adults 50 Plus 0.4 mg-300 mcg-250 mcg tabletBenefit Exclusion Century Cardio 3 mg-200 mcg-400 mg tabletBenefit Exclusion Century Mature 0.4 mg-300 mcg-250 mcg tabletFormulary Century Mature 400 mcg-30 mcg tabletNon-Preferred Century Men's 8 mg iron-200 mcg-60 mcg tabletBenefit Exclusion Century Ultimate Men's 300 mcg-600 mcg-300 mcg tabletBenefit Exclusion Century Ultimate Men's 8 mg iron-200 mcg-600 mcg tabletBenefit Exclusion Century Ultimate Women's 18 mg-400 mcg tabletBenefit Exclusion Century Ultimate Women's 8 mg iron-400 mcg-300 mcg tabletBenefit Exclusion Ceo-Two 0.9 gram-0.6 gram rectal suppositoryBenefit Exclusion Cepacol Sore Throat (benzocaine-menthol) 15 mg-3.6 mg lozengesBenefit Exclusion Cepacol Sorethroat-Cough 5 mg-7.5 mg lozengesFormulary cephalexin 125 mg/5 mL oral suspensionFormulary cephalexin 250 mg capsuleFormulary cephalexin 250 mg tabletFormulary cephalexin 250 mg/5 mL oral suspensionFormulary cephalexin 500 mg capsuleFormulary cephalexin 500 mg tabletFormulary cephalexin 750 mg capsuleFormulary Ceprotin (Blue Bar) 500 unit intravenous solutionFormulary Ceprotin (Green Bar) 1,000 unit intravenous solutionNon-Preferred Cequa 0.09 % eye drops in a dropperetteBenefit Exclusion Ceracade topical emulsionBenefit Exclusion CeraLyte 50 240 mg-300 mg-32 kcal/10 g oral powder packetNon-Preferred Ceralyte 50 Potassium Free 50 mEq-20 mEq-30 mEq oral powder packetBenefit Exclusion CeraLyte 90 90 mEq-80 mEq-20 mEq-30 mEq oral packetBenefit Exclusion CeraLyte-70 440 mg-300 mg-32 kcal/10 gram oral powder packetBenefit Exclusion CeraLyte-70 70 mEq-60 mEq-20 mEq-30 mEq oral packetNon-Preferred CeraLyte-70 70 mEq-60 mEq-20 mEq-30 mEq/L oral solutionBenefit Exclusion CeraLyte-70 2.3 g-1.5 g-2.9 g-160 kcal/50 oral powder packetNon-Preferred Ceramax lotionNon-Preferred Ceramax topical creamNon-Preferred CeraSport 115 mg-40 mg-40 kcal/10.5 gram oral powderNon-Preferred CeraSport 115 mg-40 mg-40 kcal/250 mL oral liquidBenefit Exclusion CeraSport 200 mg-75 mg-80 kcal/20 gram oral powder packetNon-Preferred CeraSport EX1 200 mg-100 mg-20 kcal/250mL oral liquidBenefit Exclusion CeraSport EX1 400 mg-200 mg-40 kcal/12.5 g oral powder packetBenefit Exclusion Cerave Baby Moisturizing 1 % lotionNon-Preferred CeraVe lotionBenefit Exclusion CeraVe PM lotion,extended releaseBenefit Exclusion Cerave Sunscreen SPF 30 lotionBenefit Exclusion CeraVe topical cleanserBenefit Exclusion CeraVe topical creamNon-Preferred Cerdelga 84 mg capsuleFormulary Cerebyx 100 mg PE/2 mL injection solutionFormulary Cerebyx 500 mg PE/10 mL injection solutionNon-Preferred Cerefolin 6 mg-5 mg-50 mg-1 mg tabletNon-Preferred Cerefolin NAC (algal oil) 6 mg-600 mg-2 mg-90.314 mg tabletBenefit Exclusion ceresin (bulk) 100 % waxNon-Preferred Ceretec 0.5 mg intravenous kitNon-Preferred Cerezyme 400 unit intravenous solutionBenefit Exclusion Cerovite Advanced Formula 18 mg-400 mcg tabletBenefit Exclusion Cerovite Jr 18 mg iron-10 mcg chewable tabletBenefit Exclusion Cerovite Senior tabletBenefit Exclusion Certa Plus 18 mg-0.4 mg-250 mcg tabletBenefit Exclusion CERTAIN DRI topical liquidBenefit Exclusion Certainty Belted ShieldsBenefit Exclusion Certainty Guards miscBenefit Exclusion Certainty Large miscBenefit Exclusion Certainty Large-Extra LargeBenefit Exclusion Certainty Liners padsBenefit Exclusion Certainty PadsBenefit Exclusion Certainty Regular miscBenefit Exclusion Certainty Small-Medium miscBenefit Exclusion Certainty Underpads 23" X 36"Benefit Exclusion Certainty Underpads 30" X 36"Benefit Exclusion Certainty X-Large miscBenefit Exclusion Certainty X-Small miscBenefit Exclusion CertaVite Senior-Antioxidant 0.4 mg-300 mcg-250 mcg tabletBenefit Exclusion Certavite-Antioxidant 18 mg-400 mcg tabletBenefit Exclusion CertaVite-Antioxidants (iron gluc) 9 mg iron/15 mL (15 mL) oral liquidBenefit Exclusion Certuss-D 60 mg-25 mg-400 mg tabletNon-Preferred Cervidil 10 mg vaginal insert,controlled releaseNon-Preferred Cesamet 1 mg capsuleNon-Preferred cesium chloride (bulk) 100 % crystalsBenefit Exclusion Ceta-Klenz Gentle topicalBenefit Exclusion Ceta-Klenz Mild topical cleanserNon-Preferred CETACAINE SPRAYBenefit Exclusion CETACAINE SPRAY ONE CANNULABenefit Exclusion Cetaphil BarBenefit Exclusion Cetaphil Daily Facial SPF 15 lotionBenefit Exclusion Cetaphil DailyAdvance lotionBenefit Exclusion Cetaphil DermaControl SPF 30 lotionBenefit Exclusion Cetaphil Gentle Cleanser topical cleanserBenefit Exclusion Cetaphil Hand topical creamBenefit Exclusion Cetaphil Moisturizing lotionBenefit Exclusion Cetaphil Moisturizing topical creamBenefit Exclusion Cetaphil Restoraderm lotionBenefit Exclusion Cetaphil Restoraderm topical cleanserBenefit Exclusion Cetaphil topical cleanserBenefit Exclusion Cetaphil topical creamNon-Preferred Cetiri-D 5 mg-120 mg tablet,extended releaseNon-Preferred cetirizine 1 mg/mL oral solutionNon-Preferred cetirizine 10 mg chewable tabletNon-Preferred cetirizine 10 mg tabletNon-Preferred cetirizine 5 mg chewable tabletNon-Preferred cetirizine 5 mg tabletNon-Preferred cetirizine 5 mg-pseudoephedrine ER 120 mg tablet,extended release,12hrNon-Preferred cetirizine 5 mg/5 mL oral solutionBenefit Exclusion cetostearyl alcohol-ceteareth20 (bulk) 77 %-43 % flakesNon-Preferred Cetraxal 0.2 % ear drops in a dropperetteNon-Preferred Cetrotide 0.25 mg subcutaneous kitBenefit Exclusion cetyl alcohol (bulk) 100 % flakesBenefit Exclusion cetyl alcohol (bulk) 100 % granulesBenefit Exclusion cetyl alcohol powderBenefit Exclusion cetyl esters (bulk) 100 % flakesNon-Preferred cetyl myristoleate (bulk) 20 % powderBenefit Exclusion cetyl myristoleate (bulk) 40 % oilBenefit Exclusion cetyl myristoleate (bulk) 40 % waxNon-Preferred cetylpyridinium chloride (bulk) crystalsNon-Preferred cevimeline 30 mg capsuleBenefit Exclusion chamomile flower (bulk) powderBenefit Exclusion Chamosyn 0.45 %-20 % topical ointmentFormulary Chantix 0.5 mg tabletFormulary Chantix 1 mg tabletFormulary Chantix Continuing Month Box 1 mg tabletFormulary Chantix Starting Month Box 0.5 mg (11)-1 mg (42) tablets in dose packBenefit Exclusion CharcoCaps 260 mg capsuleFormulary Chateal (28) 0.15 mg-0.03 mg tabletFormulary Chateal EQ (28) 0.15 mg-0.03 mg tabletBenefit Exclusion cheesecake flavor (bulk) liquidNon-Preferred Chek-Stix Control stripsBenefit Exclusion Chelated Zinc 50 mg tabletNon-Preferred Chemet 100 mg capsuleBenefit Exclusion Chemo Transfer Pin miscFormulary Chemstrip 10 MDNon-Preferred Chemstrip 10/SGBenefit Exclusion Chemstrip 2Non-Preferred Chemstrip 2 GPNon-Preferred Chemstrip 50BNon-Preferred Chemstrip 7Non-Preferred Chemstrip 9Non-Preferred Chemstrip bG Log BookBenefit Exclusion Chemstrip MicralNon-Preferred Chenodal 250 mg tabletBenefit Exclusion Cherry Cough DropsFormulary cherry flavor (bulk) oral syrupBenefit Exclusion Cherry Menthol 7 mg lozengesBenefit Exclusion cherry-ade flavor (bulk) powderBenefit Exclusion Chest Congestion Relief 400 mg tabletBenefit Exclusion Chest Congestion Relief DM 20 mg-400 mg tabletBenefit Exclusion Chest Congestion Relief PE 10 mg-400 mg tabletBenefit Exclusion Chest Congestion-Cough Relief 20 mg-400 mg tabletBenefit Exclusion Chest Rub 4.8 %-1.2 %-2.6 % topical ointmentBenefit Exclusion Chest Rub 4.8 %-1.2 %-2.6 % topical stickBenefit Exclusion Chest-Sinus Congestion Relief 10 mg-400 mg tabletBenefit Exclusion Chew Q 100 mg tabletBenefit Exclusion Chew Q 30 mg tabletBenefit Exclusion Chew Q 600 mg oral waferBenefit Exclusion Chew-Hesive gelBenefit Exclusion Chewable Iron 30 mg-10 mg-25 mg tabletBenefit Exclusion Chewable-Vite tabletBenefit Exclusion Chewable-Vite with Iron tabletBenefit Exclusion chia seed oil-omega 3-6-9 1,000 mg (580 mg) capsuleBenefit Exclusion chia seed oil-omega 3-6-9 1,000 mg (600 mg-150 mg-50mg) capsuleBenefit Exclusion chia seed oil-omega 3-6-9 1,000 mg (630 mg-210 mg-72mg) capsuleBenefit Exclusion Child Benadryl Plus Congestion 12.5 mg-5 mg/5 mL oral solutionBenefit Exclusion Child Chest Congestion-Cough 5 mg-100 mg/5 mL oral liquidBenefit Exclusion Child Chewable Vitamins with Iron 15 mg tabletBenefit Exclusion Child Chewable Vitamins with Iron tabletBenefit Exclusion Child Cold-Cough Day-Night 6.25 mg-2.5 mg-5 mg/5 mL oral solutionBenefit Exclusion Child Complete Multivitamin 18 mg iron chewable tabletBenefit Exclusion Child Cough and Sore Throat 160 mg-5 mg/5 mL oral suspensionBenefit Exclusion Child Dometuss-DA 1 mg-2.5 mg/5 mL oral liquidBenefit Exclusion Child Ear SyringeBenefit Exclusion Child Mucinex M-S Cold Day-Nite 325 mg-12.5 mg-5 mg/10 mL(nt) oral liqBenefit Exclusion Child Mucus Relief Cough 5 mg-100 mg/5 mL oral liquidFormulary Child Mucus Relief Expectorant 100 mg/5 mL oral liquidBenefit Exclusion Child Multi-Symptom Cold/Cough 2.5 mg-5 mg-100 mg/5 mL oral liquidNon-Preferred Child Multivitamin Plus Iron 18 mg chewable tabletBenefit Exclusion Child Multivitamins chewable tabletBenefit Exclusion Child Plus Cough and Runny Nose 1 mg-5 mg-160 mg/5 mL oral suspensionBenefit Exclusion Child Robitussin Cough-Chest DM 5 mg-100 mg/5 mL oral liquidBenefit Exclusion Child Wal-Tussin Cough Relief 7.5 mg disintegrating tabletBenefit Exclusion Child's Mucus Relief M-S Cold 2.5 mg-5 mg-100 mg/5 mL oral liquidNon-Preferred Child's Omega-3 DHA Multivitamin 250 unit-3 mg-50 unit chewable tabletBenefit Exclusion Child's Tylenol plus Cough,Runny Nose 1 mg-5 mg-160 mg/5 mL oral suspBenefit Exclusion Children Dimetapp M-S Cold-Flu 6.25 mg-2.5 mg-160 mg/5 mL oral liquidBenefit Exclusion Children Mult-Sympt Cold Day-Nite 325 mg-12.5 mg-5 mg/10 mL(nt) liquidNon-Preferred Children Multivitamin chewable tabletBenefit Exclusion Children Night Time Cold-Cough 6.25 mg-2.5 mg/5 mL oral liquidBenefit Exclusion Children's Acetaminophen 160 mg chewable tabletFormulary Children's Acetaminophen 160 mg/5 mL (5 mL) oral suspensionFormulary Children's Acetaminophen 160 mg/5 mL oral suspensionNon-Preferred Children's Acetaminophen 32 mg/mL oral syringe (FOR ORAL USE ONLY)Formulary Children's Acetaminophen 325 mg/10.15 mL oral suspensionBenefit Exclusion Children's Acetaminophen 80 mg chewable tabletFormulary Children's Acetaminophen 80 mg disintegrating tabletFormulary Children's Advil 100 mg/5 mL oral suspensionFormulary Children's Alaway 0.025 % (0.035 %) eye dropsNon-Preferred Children's All Day Allergy (cetirizine) 1 mg/mL oral solutionFormulary Children's Allegra Allergy 30 mg disintegrating tabletNon-Preferred Children's Allegra Allergy 30 mg/5 mL oral suspensionNon-Preferred Children's Aller-Tec 1 mg/mL oral solutionNon-Preferred Children's Allergy (cetirizine) 1 mg/mL oral solutionFormulary Children's Allergy (diphenhydramine) 12.5 mg/5 mL oral liquidNon-Preferred Children's Allergy Relief (cetirizine) 1 mg/mL oral solutionBenefit Exclusion Children's Allergy Relief (diphenhyd) 12.5 mg disintegrating tabletFormulary Children's Allergy Relief (fexofenadine) 30 mg/5 mL oral suspensionNon-Preferred Children's Allergy Relief (loratadine) 5 mg chewable tabletFormulary Children's Allergy Relief (loratadine) 5 mg/5 mL oral solutionNon-Preferred Children's Antacid 400 mg/5 mL oral suspensionFormulary Children's Aspirin 81 mg chewable tabletBenefit Exclusion Children's Benadryl Allergy 12.5 mg chewable tabletBenefit Exclusion Children's Benadryl Itch Cooling (camphor) 0.45 % topical gelNon-Preferred Children's Cetirizine 1 mg/mL oral solutionNon-Preferred Children's Cetirizine 10 mg chewable tabletNon-Preferred Children's Cetirizine 5 mg chewable tabletFormulary Children's Chest Congestion 100 mg/5 mL oral liquidBenefit Exclusion Children's Chewable Complete 9 mg iron-200 mcg tabletBenefit Exclusion Children's Chewable Multivitamin 300 mcg tabletBenefit Exclusion Children's Chewable Probiotic 1.5 billion cell tabletNon-Preferred Children's Chewable Vitamin Complete 18 mg iron tabletBenefit Exclusion Children's Chewable Vitamin tabletBenefit Exclusion Children's Chewables 300 mcg tabletBenefit Exclusion Children's Chewables Extra C 300 mcg tabletBenefit Exclusion Children's Chewables with Iron 15 mg tabletNon-Preferred Children's Claritin 5 mg chewable tabletNon-Preferred Children's Claritin 5 mg/5 mL oral solutionBenefit Exclusion Children's Cold and Cough (PE) 1 mg-2.5 mg-5 mg/5 mL oral solutionBenefit Exclusion Children's Cold-Allergy (phenylephrine) 1 mg-2.5 mg/5 mL oral solutionBenefit Exclusion Children's Cold-Cough Daytime 2.5 mg-5 mg/5 mL oral liquidBenefit Exclusion Children's Cold-Cough-Sore Throat 5 mg-10 mg-325 mg/10 mL oral liquidBenefit Exclusion Children's Cough 5 mg-100 mg/5 mL oral liquidBenefit Exclusion Children's Cough and Runny Nose 1 mg-5 mg-160 mg/5 mL oral suspensionBenefit Exclusion Children's Cough DM ER 30 mg/5 mL oral suspension,extended releaseBenefit Exclusion Children's Cough-Chest Congestion DM 5 mg-100 mg/5 mL oral liquidBenefit Exclusion Children's Delsym Cough 30 mg/5 mL oral suspension,extended releaseNon-Preferred Children's DiaResQ 4 gram-35 kcal/7 gram oral powder packetBenefit Exclusion Children's Dibromm Cold and Allergy 1 mg-2.5 mg/5 mL oral solutionBenefit Exclusion Children's Dibromm DM Cold-Cough 1 mg-2.5 mg-5 mg/5 mL oral solutionNon-Preferred Children's Diphenhydramine 12.5 mg/5 mL oral liquidFormulary Children's Easy-Melts 80 mg disintegrating tabletFormulary Children's Fever Reducing 120 mg rectal suppositoryBenefit Exclusion Children's Fiber Select Gummies 1.5 gram chewable tabletFormulary Children's Flonase Allergy Relief 50 mcg/actuation nasal spray,suspNon-Preferred Children's Flonase Sensimist 27.5 mcg/actuation nasal spray,suspensionBenefit Exclusion Children's Flu Relief 1 mg-2.5 mg-5 mg-160 mg/5 mL oral suspensionFormulary Children's Ibuprofen 100 mg/5 mL oral suspensionFormulary Children's Iron 15 mg iron (75 mg)/mL oral dropsNon-Preferred Children's Loratadine 5 mg chewable tabletBenefit Exclusion Children's Mapap 160 mg chewable tabletBenefit Exclusion Children's Mapap 80 mg chewable tabletNon-Preferred Children's Migrelief 100 mg-90 mg-25 mg capsuleNon-Preferred Children's Motrin 100 mg/5 mL oral suspensionBenefit Exclusion Children's Mucinex Cold-Fever 5 mg-10 mg-325 mg/10 mL oral liquidBenefit Exclusion Children's Mucinex Cough 5 mg-100 mg/5 mL oral liquidBenefit Exclusion Children's Mucinex Multi-Symptom 2.5 mg-5 mg-100 mg/5 mL oral liquidBenefit Exclusion Children's Mucinex Night Time 12.5 mg-5 mg-325 mg/10 mL oral liquidBenefit Exclusion Children's Multi-Vitamin Gummies 200 mcg chewable tabletBenefit Exclusion Children's Multivitamin chewable tabletBenefit Exclusion Children's Nasacort 55 mcg nasal spray aerosolFormulary Children's Non-Aspirin 160 mg/5 mL oral suspensionBenefit Exclusion Children's Non-Aspirin 80 mg chewable tabletBenefit Exclusion Children's Pain and Fever Relief 160 mg chewable tabletFormulary Children's Pain and Fever Relief 160 mg disintegrating tabletFormulary Children's Pain and Fever Relief 160 mg/5 mL oral suspensionBenefit Exclusion Children's Pain Relief 160 mg chewable tabletFormulary Children's Pain Relief 160 mg/5 mL oral suspensionFormulary Children's Pain Reliever 160 mg/5 mL oral suspensionFormulary Children's Pain Reliever and Fever Reducer 120 mg rectal suppositoryBenefit Exclusion Children's Pepto 400 mg chewable tabletBenefit Exclusion Children's Plus Flu 1 mg-2.5 mg-5 mg-160 mg/5 mL oral suspensionBenefit Exclusion Children's Plus Multi-Symp Cold 1 mg-2.5 mg-5 mg-160 mg/5 mL oral suspFormulary Children's Profen IB 100 mg/5 mL oral suspensionBenefit Exclusion Children's Robitussin ER 30 mg/5 mL oral suspension,extended releaseFormulary Children's Saline Nasal Spray 0.65 % aerosolFormulary Children's Silapap 160 mg/5 mL oral liquidBenefit Exclusion Children's Silfedrine 15 mg/5 mL oral liquidBenefit Exclusion Children's Soothe 400 mg chewable tabletBenefit Exclusion Children's Stuffy Nose-Cold 2.5 mg-100 mg/5 mL oral liquidBenefit Exclusion Children's Sudafed 15 mg/5 mL oral liquidBenefit Exclusion Children's Sudafed PE Cough and Cold 2.5 mg-5 mg/5 mL oral liquidBenefit Exclusion Children's Sudafed PE Nasal Decongestant 2.5 mg/5 mL oral solutionBenefit Exclusion Children's Tactinal 80 mg chewable tabletBenefit Exclusion Children's Triaminic Cold and Allergy 1 mg-2.5 mg/5 mL oral solutionBenefit Exclusion Children's Triaminic MS FevCold 1 mg-2.5 mg-5 mg-160 mg/5 mL oral suspBenefit Exclusion Children's Tylenol 160 mg chewable tabletNon-Preferred Children's Tylenol 160 mg/5 mL oral suspensionBenefit Exclusion Children's Wal-Dryl Allergy 12.5 mg disintegrating tabletFormulary Children's Wal-Dryl Allergy 12.5 mg/5 mL oral liquidFormulary Children's Wal-Dryl Allergy 12.5 mg/5 mL prefilled spoonFormulary Children's Wal-Fex 30 mg/5 mL oral suspensionBenefit Exclusion Children's Wal-Tap Cold-Allergy 1 mg-2.5 mg/5 mL oral solutionNon-Preferred Children's Wal-Zyr 1 mg/mL oral solutionNon-Preferred Children's Wal-Zyr 10 mg chewable tabletNon-Preferred Children's Zyrtec Allergy 1 mg/mL oral solutionNon-Preferred Children's Zyrtec Allergy 10 mg disintegrating tabletBenefit Exclusion Childrens Plus Cold 1 mg-2.5 mg-160 mg/5 mL oral suspensionBenefit Exclusion Childs Chew Vite tabletBenefit Exclusion Childs Triacting Cold and Cough 6.25 mg-2.5 mg/5 mL oral liquidBenefit Exclusion Childs/Iron chewable tabletNon-Preferred ChiRhoStim 16 mcg intravenous solutionBenefit Exclusion Chlo Hist 1 mg-12.5 mg/5 mL oral solutionBenefit Exclusion Chlo Tuss 1 mg-30 mg-12.5 mg/5 mL oral liquidNon-Preferred Chlor-Trimeton 4 mg tabletNon-Preferred chloral hydrate (bulk) crystalsNon-Preferred chlorambucil (bulk) powderNon-Preferred chloramphenicol (bulk) 100 % powderNon-Preferred chloramphenicol palmitate (bulk) powderNon-Preferred chloramphenicol sodium succinate 1 gram intravenous solutionBenefit Exclusion Chloraseptic 0.5 % aerosolBenefit Exclusion Chloraseptic Max 15 mg-10 mg lozengesBenefit Exclusion Chloraseptic Max Sore Throat 1.5 %-33 % mucosal sprayBenefit Exclusion Chloraseptic Sore Throat 6 mg-10 mg lozengesBenefit Exclusion Chloraseptic Throat Spray 1.4 % aerosolBenefit Exclusion Chloraseptic Total 5 mg-6 mg-10 mg lozengesFormulary chlordiazepoxide 10 mg capsuleFormulary chlordiazepoxide 25 mg capsuleFormulary chlordiazepoxide 5 mg capsuleNon-Preferred chlordiazepoxide-clidinium 5 mg-2.5 mg capsuleBenefit Exclusion chlorhexidine (bulk) liquidBenefit Exclusion chlorhexidine acetate (bulk) 100 % powderNon-Preferred chlorhexidine gluconate (bulk) 20 % solutionFormulary chlorhexidine gluconate 0.12 % mouthwashBenefit Exclusion chlorhexidine gluconate 2 % topical liquidBenefit Exclusion chlorhexidine gluconate 2 % toweletteBenefit Exclusion chlorhexidine gluconate 4 % topical liquidFormulary ChlorHist 4 mg tabletNon-Preferred chloroallyl methenamine chloride (bulk) 100 % powderNon-Preferred chlorobutanol (bulk) crystalsNon-Preferred Chlorocaps 10 mg-30 mcg-30 mcg capsuleBenefit Exclusion Chlorophyll (with alfalfa) 20 mg-100 mg tabletBenefit Exclusion Chlorophyll 0.6 mg-3 mg tabletBenefit Exclusion chlorophyllin copper complex (bulk) 4.25 % total copper (USP) powderNon-Preferred chloroprocaine (PF) 20 mg/mL (2 %) injection solutionNon-Preferred chloroprocaine (PF) 30 mg/mL (3 %) injection solutionFormulary chloroquine 250 mg tabletFormulary chloroquine 500 mg tabletNon-Preferred chloroquine phosphate (bulk) powderFormulary chlorothiazide 250 mg tabletFormulary chlorothiazide 500 mg tabletFormulary chlorothiazide sodium 500 mg intravenous solutionNon-Preferred chloroxine (bulk) 100 % powderNon-Preferred chloroxylenol (bulk) powderBenefit Exclusion Chlorphen SR 12 mg tablet,extended releaseFormulary chlorpheniramine 4 mg tabletBenefit Exclusion chlorpheniramine ER 12 mg tablet,extended releaseNon-Preferred chlorpheniramine maleate (bulk) powderNon-Preferred chlorpromazine (bulk) 100 % powderFormulary chlorpromazine 10 mg tabletFormulary chlorpromazine 100 mg tabletFormulary chlorpromazine 200 mg tabletFormulary chlorpromazine 25 mg tabletFormulary chlorpromazine 25 mg/mL injection solutionFormulary chlorpromazine 50 mg tabletNon-Preferred chlorpropamide 100 mg tabletNon-Preferred chlorpropamide 250 mg tabletFormulary ChlorTabs 4 mg tabletFormulary chlorthalidone 25 mg tabletFormulary chlorthalidone 50 mg tabletFormulary chlorzoxazone 250 mg tabletNon-Preferred chlorzoxazone 375 mg tabletNon-Preferred chlorzoxazone 500 mg tabletNon-Preferred chlorzoxazone 750 mg tabletBenefit Exclusion chocolate flavor (bulk) liquidBenefit Exclusion chocolate flavor (bulk) powderBenefit Exclusion chocolate hazelnut flavor (bulk) liquidBenefit Exclusion Chocolate Laxative 15 mg chewable tabletBenefit Exclusion Cholase Control 25 mg-5 mg-50 mg-100 mg-25 mg capsuleNon-Preferred Cholbam 250 mg capsuleNon-Preferred Cholbam 50 mg capsuleBenefit Exclusion cholecalciferol (vit D3) 1,000 unit/spray sublingual spray,suspensionBenefit Exclusion cholecalciferol (vitamin D3) (bulk) 1 million unit/gram liquidNon-Preferred cholecalciferol (vitamin D3) (bulk) 100,000 unit/gram powderNon-Preferred cholecalciferol (vitamin D3) (bulk) 2,400 unit/mL liquidBenefit Exclusion cholecalciferol (vitamin D3) (bulk) crystalsFormulary cholecalciferol (vitamin D3) 1,000 unit (25 mcg) tabletFormulary cholecalciferol (vitamin D3) 1,000 unit capsuleBenefit Exclusion cholecalciferol (vitamin D3) 1,000 unit chewable tabletBenefit Exclusion cholecalciferol (vitamin D3) 10 mcg/mL (400 unit/mL) oral dropsBenefit Exclusion cholecalciferol (vitamin D3) 10,000 unit capsuleNon-Preferred cholecalciferol (vitamin D3) 10,000 unit tabletBenefit Exclusion cholecalciferol (vitamin D3) 2,000 unit capsuleNon-Preferred cholecalciferol (vitamin D3) 2,000 unit chewable tabletBenefit Exclusion cholecalciferol (vitamin D3) 2,000 unit tabletBenefit Exclusion cholecalciferol (vitamin D3) 3,000 unit tabletBenefit Exclusion cholecalciferol (vitamin D3) 400 unit capsuleBenefit Exclusion cholecalciferol (vitamin D3) 400 unit chewable tabletBenefit Exclusion cholecalciferol (vitamin D3) 400 unit tabletBenefit Exclusion cholecalciferol (vitamin D3) 400 unit/5 mL oral liquidBenefit Exclusion cholecalciferol (vitamin D3) 400 unit/drop oral dropsBenefit Exclusion cholecalciferol (vitamin D3) 5,000 unit capsuleNon-Preferred cholecalciferol (vitamin D3) 5,000 unit disintegrating tabletBenefit Exclusion cholecalciferol (vitamin D3) 5,000 unit tabletBenefit Exclusion cholecalciferol (vitamin D3) 5,000 unit/mL oral dropsBenefit Exclusion cholecalciferol (vitamin D3) 50,000 unit capsuleNon-Preferred cholecalciferol (vitamin D3) 500 unit/5 mL oral liquidBenefit Exclusion Cholest Care 500 mg capsuleBenefit Exclusion Cholest Off 450 mg tabletBenefit Exclusion Cholest Off Plus 450 mg capsuleBenefit Exclusion cholesterol (bulk) 100 % powderBenefit Exclusion cholesterol (bulk) powderBenefit Exclusion Cholesterol Relief 650 mg-400 unit capsuleNon-Preferred cholestyramine (bulk) powderFormulary cholestyramine (with sugar) 4 gram oral powderFormulary cholestyramine (with sugar) 4 gram powder for susp in a packetFormulary Cholestyramine Light 4 gram oral powderFormulary Cholestyramine Light 4 gram powder for susp in a packetNon-Preferred Choletec 45 mg intravenous solutionBenefit Exclusion Cholextra 60 gram-200 mg-80 mg/100 gram oral powderNon-Preferred Cholextra t/f 1 gram-28 kcal/10 gram oral powderNon-Preferred choline and magnesium salicylate (bulk) powderFormulary choline and magnesium salicylate 500 mg/5 mL oral liquidBenefit Exclusion choline bitartrate (bulk) 100 % powderNon-Preferred choline bitartrate ER 300 mg tablet,extended releaseBenefit Exclusion choline chloride (bulk) 100 % crystalsBenefit Exclusion choline chloride (bulk) 100 % powderBenefit Exclusion choline dihydrogen citrate 650 mg tabletBenefit Exclusion Chondroitin Sulfate 100 % powderNon-Preferred chondroitin sulfate A sodium (bulk) 100 % powderBenefit Exclusion chondroitin sulfate A sodium (bulk) 88 % powderNon-Preferred chorionic gonadotropin, human (bulk) 1 million unit powderNon-Preferred chorionic gonadotropin, human (bulk) 10 million unit powderNon-Preferred chorionic gonadotropin, human (bulk) 2 million unit powderNon-Preferred chorionic gonadotropin, human (bulk) 5 million unit powderNon-Preferred chorionic gonadotropin, human 10,000 unit intramuscular solutionNon-Preferred Chromagen(Sumalate-Quatrefolic) 75 mg iron-60 mg-1 mg-10 mcg capsuleBenefit Exclusion Chromelin 5 % topical solutionBenefit Exclusion chromium amino acid chelate 400 mcg tabletNon-Preferred chromium chloride 4 mcg/mL intravenous solutionBenefit Exclusion chromium picolinate (bulk) 12 % powderBenefit Exclusion chromium picolinate 1,000 mcg tabletBenefit Exclusion chromium picolinate 200 mcg tabletBenefit Exclusion chromium picolinate 400 mcg tabletBenefit Exclusion Chromium Picolinate KLB6 10 mg-0.4 mg tabletNon-Preferred chromium polynicotinate (bulk) 100 % powderBenefit Exclusion chromium potassium sulfate dodecahydrate (bulk) 100 % powderBenefit Exclusion Chrysaderm Day Cream topicalBenefit Exclusion Chrysaderm Night Cream topicalNon-Preferred chrysin (bulk) powderNon-Preferred chymotrypsin (bulk) powderNon-Preferred Cialis 10 mg tabletNon-Preferred Cialis 2.5 mg tabletNon-Preferred Cialis 20 mg tabletNon-Preferred Cialis 5 mg tabletBenefit Exclusion Cica-Care Adhesive Silicone 5" X 6" topical sheetsNon-Preferred Cicatrace Pad 4.7" X 5.7" topical padsBenefit Exclusion Ciclodan 0.77 % topical creamBenefit Exclusion Ciclodan 8 % topical solutionBenefit Exclusion Ciclodan Kit 0.77 % topical combo packBenefit Exclusion Ciclodan Kit 8 % topical solutionFormulary ciclopirox 0.77 % topical creamNon-Preferred ciclopirox 0.77 % topical gelFormulary ciclopirox 0.77 % topical suspensionFormulary ciclopirox 1 % shampooNon-Preferred ciclopirox 8 % topical solutionNon-Preferred ciclopirox olamine (bulk) powderBenefit Exclusion ciclopirox-urea-camphor-menthol-eucalyptol 8 % topical solutionBenefit Exclusion Cidaflex 500 mg-400 mg tabletBenefit Exclusion Cidatrine 500 mg tabletNon-Preferred cidofovir (bulk) 100 % powderFormulary cidofovir 75 mg/mL intravenous solutionBenefit Exclusion Ciferex 3,775 unit-1 mg capsuleNon-Preferred Cifrazol 3,775 unit-1 mg capsuleFormulary cilostazol 100 mg tabletFormulary cilostazol 50 mg tabletNon-Preferred Ciloxan 0.3 % eye dropsNon-Preferred Ciloxan 0.3 % eye ointmentNon-Preferred Cimduo 300 mg-300 mg tabletNon-Preferred cimetidine (bulk) powderNon-Preferred cimetidine 200 mg tabletNon-Preferred cimetidine 300 mg tabletNon-Preferred cimetidine 300 mg/5 mL oral solutionNon-Preferred cimetidine 400 mg tabletNon-Preferred cimetidine 800 mg tabletNon-Preferred Cimzia 400 mg/2 mL (200 mg/mL x 2) subcutaneous syringe kitNon-Preferred Cimzia Powder for Recon 400 mg (200 mg x 2 vials) subcutaneous kitNon-Preferred Cimzia Starter Kit 400 mg/2 mL (200 mg/mL x2) subcutaneous syringe kitFormulary cinacalcet 30 mg tabletFormulary cinacalcet 60 mg tabletFormulary cinacalcet 90 mg tabletBenefit Exclusion Cinnamon 500 mg capsuleBenefit Exclusion cinnamon bark (bulk) powderBenefit Exclusion cinnamon bark 500 mg capsuleBenefit Exclusion cinnamon bark-chromium picolinate 500 mg-100 mcg capsuleBenefit Exclusion cinnamon bark-chromium picolinate-ALA 500 mg-100 mcg-150 mg capsuleBenefit Exclusion Cinnamon Flavoring oilBenefit Exclusion Cinnamon OilFormulary Cinqair 10 mg/mL intravenous solutionFormulary Cinryze 500 unit (5 mL) intravenous solutionNon-Preferred Cinvanti 7.2 mg/mL intravenous emulsionNon-Preferred Cipro 250 mg tabletNon-Preferred Cipro 250 mg/5 mL oral suspensionNon-Preferred Cipro 400 mg/200 mL in dextrose 5 % intravenous piggybackNon-Preferred Cipro 500 mg tabletNon-Preferred Cipro 500 mg/5 mL oral suspensionFormulary Cipro HC 0.2 %-1 % ear drops,suspensionNon-Preferred Cipro XR 1,000 mg tablet,extended releaseNon-Preferred Cipro XR 500 mg tablet,extended releaseFormulary Ciprodex 0.3 %-0.1 % ear drops,suspensionNon-Preferred ciprofloxacin (bulk) 100 % crystalsNon-Preferred ciprofloxacin (bulk) 100 % powderNon-Preferred ciprofloxacin 0.2 % ear drops in a dropperetteFormulary ciprofloxacin 0.3 % eye dropsFormulary ciprofloxacin 100 mg tabletNon-Preferred ciprofloxacin 200 mg/100 mL in 5 % dextrose intravenous piggybackFormulary ciprofloxacin 250 mg tabletNon-Preferred ciprofloxacin 250 mg/5 mL oral suspensionNon-Preferred ciprofloxacin 400 mg/200 mL in 5 % dextrose intravenous piggybackFormulary ciprofloxacin 500 mg tabletFormulary ciprofloxacin 500 mg/5 mL oral suspensionFormulary ciprofloxacin 750 mg tabletNon-Preferred ciprofloxacin ER 1,000 mg tablet,extended release 24hr mphaseNon-Preferred ciprofloxacin ER 500 mg tablet,extended release 24hr mphaseNon-Preferred cisatracurium 2 mg/mL intravenous solutionNon-Preferred cisatracurium concentrate 10 mg/mL (ICU USE ONLY) intravenous solutionFormulary cisplatin 1 mg/mL intravenous solutionFormulary citalopram 10 mg tabletNon-Preferred citalopram 10 mg/5 mL oral solutionFormulary citalopram 20 mg tabletFormulary citalopram 40 mg tabletNon-Preferred Citanest Forte Dental 40 mg/mL (4 %)-1:200,000 injection cartridgeNon-Preferred Citanest Plain Dental 4 % (40 mg/mL) injection cartridgeBenefit Exclusion Citracal + Bone Density 300 mg-200 unit-13.5 mg tabletBenefit Exclusion Citracal + D Slow Release 600 mg calcium-500 unit tablet,ext.releaseBenefit Exclusion Citracal + D3 (calcium phosphate) 250 mg calcium-500 unit chew tabletBenefit Exclusion Citracal D + Heart Health 315 mg-250 unit-200 mg tabletBenefit Exclusion Citracal Plus Magnesium 250 mg-40 mg-125 unit tabletBenefit Exclusion Citracal Regular 250 mg calcium-200 unit tabletBenefit Exclusion Citracal with Vitamin D Maximum 315 mg-250 unit tabletBenefit Exclusion Citracal with Vitamin D Petites 200 mg calcium-250 unit tabletNon-Preferred CitraNatal (dual-iron) 27 mg iron-1 mg-50 mg tabletBenefit Exclusion CitraNatal 90 DHA (algal oil) 90 mg iron-1 mg-50 mg-300 mg oral packBenefit Exclusion CitraNatal Assure 35 mg iron-1 mg-50 mg-300 mg oral packNon-Preferred Citranatal B-Calm (Fe Gluc) 20 mg iron-1 mg-25 mg/25 mg tabletsBenefit Exclusion CitraNatal Bloom 90 mg-1 mg-12 mcg-50 mg tabletBenefit Exclusion CitraNatal DHA (algal oil) 27 mg iron-1 mg-50 mg-250 mg oral packNon-Preferred CitraNatal Harmony(iron carb-fum) 27 mg iron-1 mg-50 mg-260 mg capsuleFormulary Citrate of Magnesia oralNon-Preferred citric acid (bulk) powderBenefit Exclusion citric acid anhydrous (bulk) 100 % granulesBenefit Exclusion citric acid monohydrate (bulk) 100 % granulesFormulary Citroma oral solutionBenefit Exclusion citronella oilBenefit Exclusion Citrucel (sucrose) oral powderBenefit Exclusion Citrucel 500 mg tabletBenefit Exclusion Citrucel Sugar Free oral powderBenefit Exclusion citrulline (bulk) powderBenefit Exclusion Citrulline 1000 1 gram/4 gram oral powder packetBenefit Exclusion Citrulline 200 200 mg/4 gram oral powder packetBenefit Exclusion Citrus Calcium 200 mg calcium-250 unit tabletBenefit Exclusion CLA 1,000 mg capsuleNon-Preferred cladribine 10 mg/10 mL intravenous solutionNon-Preferred Claforan 1 gram intravenous solutionNon-Preferred Claforan 10 gram solution for injectionNon-Preferred Claforan 2 gram intravenous solutionNon-Preferred Claforan 2 gram solution for injectionFormulary Claravis 10 mg capsuleFormulary Claravis 20 mg capsuleFormulary Claravis 30 mg capsuleFormulary Claravis 40 mg capsuleNon-Preferred Clarinex 5 mg tabletNon-Preferred Clarinex-D 12 HOUR 2.5 mg-120 mg tablet,extended releaseFormulary ClariSpray 50 mcg/actuation nasal spray,suspensionNon-Preferred clarithromycin (bulk) 100 % powderFormulary clarithromycin 125 mg/5 mL oral suspensionFormulary clarithromycin 250 mg tabletFormulary clarithromycin 250 mg/5 mL oral suspensionFormulary clarithromycin 500 mg tabletNon-Preferred clarithromycin ER 500 mg tablet,extended release 24 hrNon-Preferred Claritin 10 mg tabletNon-Preferred Claritin 5 mg/5 mL oral solutionNon-Preferred Claritin Liqui-Gel 10 mg capsuleNon-Preferred Claritin RediTabs 10 mg disintegrating tabletNon-Preferred Claritin RediTabs 5 mg disintegrating tabletNon-Preferred Claritin-D 12 Hour 5 mg-120 mg tablet,extended releaseNon-Preferred Claritin-D 24 Hour 10 mg-240 mg tablet,extended releaseFormulary Classic Prenatal 28 mg iron-800 mcg tabletBenefit Exclusion Clean and Clear Advantage 2 % lotionBenefit Exclusion Cleansing Eyelid Moist Pads topical padsBenefit Exclusion Cleansing Eyelid topical padsBenefit Exclusion Cleansing Skin CreamBenefit Exclusion Cleansing WashBenefit Exclusion Cleansing Wash 10 %-4 %-10 % topical cleanserBenefit Exclusion Clear Anti-Itch 1 %-0.1 % lotionBenefit Exclusion Clear Away 40 % topical patchBenefit Exclusion Clear BandagesBenefit Exclusion Clear Eyes Complete 0.025 %-0.2 %-0.5 %-0.25 % dropsBenefit Exclusion Clear Eyes Cooling Comfort 0.03 %-0.5 % dropsBenefit Exclusion Clear Eyes Itchy Eye Relief 0.012 %-0.25 %-0.25 % dropsBenefit Exclusion Clear Eyes Maximum Redness Relief 0.03 %-0.5 % dropsBenefit Exclusion Clear Eyes Natural Tears 0.5 %-0.6 % dropsNon-Preferred Clear Eyes Pure Relief Multi-Symptom (PF) 0.1 %-0.3 %-0.25 % dropsBenefit Exclusion Clear Eyes Redness Relief 0.012 %-0.2 % dropsBenefit Exclusion Clear Eyes Redness Relief 0.012 %-0.25 % dropsBenefit Exclusion Clear Glass Serum BottleBenefit Exclusion Clear Pore Cleanser-Mask 3.5 % topical cleanserBenefit Exclusion Clear Tape 1" X 10 yardBenefit Exclusion Clear Waterproof Strips 1" bandageBenefit Exclusion Clear Waterproof Strips bandageBenefit Exclusion Clearasil Daily Clear (benzoyl peroxide) 10 % topical creamBenefit Exclusion Clearasil Daily Clear 2 % topical cleanserBenefit Exclusion Clearblue Digital Ovulation kitBenefit Exclusion Clearblue Easy Ovulation Test kitBenefit Exclusion Clearblue Fertility Monitor kitBenefit Exclusion Clearblue Fertility Sticks kitBenefit Exclusion Clearcanal Ear Wax 6.5 %-0.9 % ear packFormulary ClearLax 17 gram oral powder packetFormulary ClearLax 17 gram/dose oral powderFormulary clemastine 1.34 mg tabletFormulary clemastine 2.68 mg tabletNon-Preferred clemastine fumarate (bulk) powderNon-Preferred clemizole HCl (bulk) powderNon-Preferred Clenpiq 10 mg-3.5 gram-12 gram/160 mL oral solutionNon-Preferred Cleo 90 Infusion Set 24"Non-Preferred Cleo 90 Infusion Set 31"Formulary Cleocin 100 mg vaginal suppositoryNon-Preferred Cleocin 150 mg/mL injection solutionNon-Preferred Cleocin 2 % vaginal creamNon-Preferred Cleocin 300 mg/2 mL intravenous solutionNon-Preferred Cleocin 600 mg/4 mL intravenous solutionNon-Preferred Cleocin 900 mg/6 mL intravenous solutionNon-Preferred Cleocin HCl 150 mg capsuleNon-Preferred Cleocin HCl 300 mg capsuleNon-Preferred Cleocin HCl 75 mg capsuleNon-Preferred Cleocin Pediatric 75 mg/5 mL oral solutionNon-Preferred Cleocin T 1 % lotionNon-Preferred Cleocin T 1 % solutionNon-Preferred Cleocin T 1 % topical gelNon-Preferred Clever Chek Blood GlucoseNon-Preferred Clever Chek Blood Glucose Syst kitBenefit Exclusion Clever Chek Blood Pressure kitNon-Preferred Clever Chek Lancets 30 gaugeNon-Preferred Clever Choice Blood Glucose SystemBenefit Exclusion Clever Choice Blood Pressure kitBenefit Exclusion Clever Choice Blood Pressure Monitor kitNon-Preferred Clever Choice Breast PumpBenefit Exclusion Clever Choice Digital60 ThermometerNon-Preferred Clever Choice Duo ThermometerNon-Preferred Clever Choice Holding Chamber-Large MaskNon-Preferred Clever Choice Holding Chamber-Medium MaskNon-Preferred Clever Choice Holding Chamber-Small MaskNon-Preferred Clever Choice Infrared ThermometerNon-Preferred Clever Choice Level 1 Control solutionNon-Preferred Clever Choice Level 2 Control solutionNon-Preferred Clever Choice Level 3 Control solutionNon-Preferred Clever Choice MicroNon-Preferred Clever Choice Micro Test StripNon-Preferred Clever Choice Mini Blood Glucose MonitorNon-Preferred Clever Choice NebulizerNon-Preferred Clever Choice Pro Blood Glucose MonitorNon-Preferred Clever Choice Pro Blood Glucose Monitor stripsNon-Preferred Clever Choice Talk Blood Glucose SystemNon-Preferred Clever Choice Talk Test stripsNon-Preferred Clever Choice Test StripsNon-Preferred Clever Choice Voice+ Test stripsNon-Preferred Clever Choice Whisper Aire Pediatric deviceFormulary Cleviprex 25 mg/50 mL intravenous emulsionFormulary Cleviprex 50 mg/100 mL intravenous emulsionNon-Preferred Clickfine Pen Needle 31 gauge x 1/4"Non-Preferred Clickfine Pen Needle 31 gauge x 5/16"Non-Preferred Clickfine Pen Needle 32 gauge x 5/32"Non-Preferred clidinium bromide (bulk) 100 % powderNon-Preferred Climara 0.025 mg/24 hr transdermal patchNon-Preferred Climara 0.0375 mg/24 hr transdermal patchNon-Preferred Climara 0.05 mg/24 hr transdermal patchNon-Preferred Climara 0.06 mg/24 hr transdermal patchNon-Preferred Climara 0.075 mg/24 hr transdermal patchNon-Preferred Climara 0.1 mg/24 hr transdermal patchFormulary Climara Pro 0.045 mg-0.015 mg/24 hr transdermal patchBenefit Exclusion Clindacin ETZ 1 % topical kitBenefit Exclusion Clindacin ETZ 1 % topical swabBenefit Exclusion Clindacin P 1 % topical swabBenefit Exclusion Clindacin Pac 1 % topical kitNon-Preferred Clindagel 1 % topical gel, once dailyNon-Preferred clindamycin 1 % lotionNon-Preferred clindamycin 1 % topical foamFormulary clindamycin 1 % topical gelNon-Preferred clindamycin 1 % topical gel, once dailyNon-Preferred clindamycin 1 %-benzoyl peroxide 5 % topical gelNon-Preferred clindamycin 1 %-benzoyl peroxide 5 % topical gel with pumpFormulary clindamycin 1.2 % (1 % base)-benzoyl peroxide 5 % topical gelNon-Preferred clindamycin 1.2 %-benzoyl peroxide 2.5 % topical gel with pumpNon-Preferred clindamycin 150 mg/mL injection solutionFormulary clindamycin 2 % vaginal creamNon-Preferred clindamycin 300 mg/2 mL intravenous solutionNon-Preferred clindamycin 300 mg/50 mL in 0.9% sodium chloride intravenous piggybackNon-Preferred clindamycin 300 mg/50 mL in 5 % dextrose intravenous piggybackNon-Preferred clindamycin 600 mg/4 mL intravenous solutionNon-Preferred clindamycin 600 mg/50 mL in 0.9% sodium chloride intravenous piggybackNon-Preferred clindamycin 600 mg/50 mL in 5 % dextrose intravenous piggybackFormulary clindamycin 75 mg/5 mL oral solutionNon-Preferred clindamycin 900 mg/50 mL in 0.9% sodium chloride intravenous piggybackNon-Preferred clindamycin 900 mg/50 mL in 5 % dextrose intravenous piggybackNon-Preferred clindamycin 900 mg/6 mL intravenous solutionNon-Preferred clindamycin HCl (bulk) powderFormulary clindamycin HCl 150 mg capsuleFormulary clindamycin HCl 300 mg capsuleFormulary clindamycin HCl 75 mg capsuleFormulary Clindamycin Pediatric 75 mg/5 mL oral solutionNon-Preferred clindamycin phosphate (bulk) crystalsNon-Preferred clindamycin phosphate (bulk) powderFormulary clindamycin phosphate 1 % topical solutionFormulary clindamycin phosphate 1 % topical swabNon-Preferred clindamycin-tretinoin 1.2 %-0.025 % topical gelNon-Preferred Clindesse 2 % vaginal cream,extended releaseNon-Preferred Clinimix 4.25 % in 10 % dextrose Sulfite Free intravenous solutionNon-Preferred Clinimix 4.25 % in 25 % dextrose (sulfite-free) intravenous solutionNon-Preferred Clinimix 4.25 % in 5 % dextrose Sulfite Free intravenous solutionNon-Preferred Clinimix 5 % in 15 % dextrose Sulfite Free intravenous solutionNon-Preferred Clinimix 5 % in 20 % dextrose (sulfite-free) intravenous solutionNon-Preferred Clinimix 5 % in 25 % dextrose sulfite-free intravenous solutionNon-Preferred Clinimix E 2.75 % in 10 % dextrose Sulfite Free intravenous solutionNon-Preferred Clinimix E 2.75 % in 5 % dextrose Sulfite Free intravenous solutionNon-Preferred Clinimix E 4.25 % in 10 % dextrose Sulfite Free intravenous solutionNon-Preferred Clinimix E 4.25 % in 25 % dextrose Sulfite Free intravenous solutionNon-Preferred Clinimix E 4.25 % in 5 % dextrose Sulfite Free intravenous solutionNon-Preferred Clinimix E 5 % in 15 % dextrose Sulfite Free intravenous solutionNon-Preferred Clinimix E 5 % in 20 % dextrose Sulfite Free intravenous solutionNon-Preferred Clinimix E 5 % in 25 % dextrose Sulfite Free intravenous solutionNon-Preferred Clinimix N14G30E 4.25 % in 15 % dextrose (sulfite-free) IV solutionNon-Preferred Clinimix N9G15E 2.75 % in 7.5 % dextrose (sulfite-free) IV solutionNon-Preferred Clinimix N9G20E 2.75 % in 10 % dextrose (sulfite-free) IV solutionNon-Preferred Clinisol SF 15 % intravenous solutionBenefit Exclusion Clinpro 5000 1.1 % dental pasteNon-Preferred clioquinol (bulk) powderNon-Preferred clobazam 10 mg tabletNon-Preferred clobazam 2.5 mg/mL oral suspensionNon-Preferred clobazam 20 mg tabletNon-Preferred clobetasol 0.05 % lotionFormulary clobetasol 0.05 % scalp solutionNon-Preferred clobetasol 0.05 % shampooFormulary clobetasol 0.05 % topical creamNon-Preferred clobetasol 0.05 % topical foamFormulary clobetasol 0.05 % topical gelFormulary clobetasol 0.05 % topical ointmentNon-Preferred clobetasol 0.05 % topical sprayNon-Preferred clobetasol propionate (bulk) powderNon-Preferred clobetasol-emollient 0.05 % topical creamNon-Preferred clobetasol-emollient 0.05 % topical foamNon-Preferred Clobex 0.05 % lotionNon-Preferred Clobex 0.05 % shampooNon-Preferred Clobex 0.05 % topical sprayNon-Preferred clocortolone pivalate 0.1 % topical creamNon-Preferred Clodan 0.05 % shampooNon-Preferred Clodan Kit 0.05 % topical kit, shampoo and cleanserNon-Preferred Cloderm 0.1 % topical creamNon-Preferred clofarabine 20 mg/20 mL intravenous solutionNon-Preferred clofazimine (bulk) powderNon-Preferred Clolar 20 mg/20 mL intravenous solutionBenefit Exclusion clomiphene citrate (bulk) 100 % powderBenefit Exclusion clomiphene citrate 50 mg tabletNon-Preferred clomipramine (bulk) 100 % powderNon-Preferred clomipramine 25 mg capsuleNon-Preferred clomipramine 50 mg capsuleNon-Preferred clomipramine 75 mg capsuleNon-Preferred clonazepam (bulk) 100 % powderNon-Preferred clonazepam 0.125 mg disintegrating tabletNon-Preferred clonazepam 0.25 mg disintegrating tabletNon-Preferred clonazepam 0.5 mg disintegrating tabletFormulary clonazepam 0.5 mg tabletNon-Preferred clonazepam 1 mg disintegrating tabletFormulary clonazepam 1 mg tabletNon-Preferred clonazepam 2 mg disintegrating tabletFormulary clonazepam 2 mg tabletNon-Preferred clonidine (PF) 1,000 mcg/10 mL (100 mcg/mL) epidural solutionNon-Preferred clonidine (PF) 5,000 mcg/10 mL epidural solutionFormulary clonidine 0.1 mg/24 hr weekly transdermal patchFormulary clonidine 0.2 mg/24 hr weekly transdermal patchFormulary clonidine 0.3 mg/24 hr weekly transdermal patchNon-Preferred clonidine HCl (bulk) powderFormulary clonidine HCl 0.1 mg tabletFormulary clonidine HCl 0.2 mg tabletFormulary clonidine HCl 0.3 mg tabletFormulary clonidine HCl ER 0.1 mg tablet,extended release,12 hrFormulary clopidogrel 300 mg tabletFormulary clopidogrel 75 mg tabletNon-Preferred clopidogrel bisulfate (bulk) 100 % powderFormulary clorazepate dipotassium 15 mg tabletFormulary clorazepate dipotassium 3.75 mg tabletFormulary clorazepate dipotassium 7.5 mg tabletNon-Preferred Clorotekal 10 mg/mL (1 %) intrathecal solutionBenefit Exclusion Clorpactin WCS-90 topical powder for solutionBenefit Exclusion Closed-End PouchBenefit Exclusion Cloth First Aid Tape 1" X 10 yardBenefit Exclusion Cloth Tape 1" X 10 yardNon-Preferred clotrimazole (bulk) powderFormulary clotrimazole 1 % topical creamFormulary clotrimazole 1 % vaginal creamBenefit Exclusion CLOTRIMAZOLE 1% SOLUTION (OTC)Formulary CLOTRIMAZOLE 1% SOLUTION (Rx)Formulary clotrimazole 10 mg trocheFormulary Clotrimazole 3 Day 2 % vaginal creamFormulary Clotrimazole AF 1 % topical creamFormulary Clotrimazole-3 2 % vaginal creamFormulary Clotrimazole-7 1 % vaginal creamFormulary clotrimazole-betamethasone 1 %-0.05 % lotionFormulary clotrimazole-betamethasone 1 %-0.05 % topical creamBenefit Exclusion Clove Flavoring oilBenefit Exclusion clove oil (bulk)Formulary Cloverine topical ointmentNon-Preferred clozapine 100 mg disintegrating tabletFormulary clozapine 100 mg tabletNon-Preferred clozapine 12.5 mg disintegrating tabletNon-Preferred clozapine 150 mg disintegrating tabletNon-Preferred clozapine 200 mg disintegrating tabletFormulary clozapine 200 mg tabletNon-Preferred clozapine 25 mg disintegrating tabletFormulary clozapine 25 mg tabletFormulary clozapine 50 mg tabletNon-Preferred Clozaril 100 mg tabletNon-Preferred Clozaril 25 mg tabletBenefit Exclusion CMX 0.0375 %-5 % topical patchBenefit Exclusion Co Q-10 400 mg capsuleBenefit Exclusion Co Q-10 50 mg capsuleBenefit Exclusion Co Q-10 75 mg capsuleBenefit Exclusion Co Q-10 (with Vit E) 100 mg-5 unit capsuleBenefit Exclusion Co Q-10 (with Vit E) 50 mg-5 unit capsuleBenefit Exclusion Co Q-10 10 mg capsuleBenefit Exclusion Co Q-10 100 mg capsuleBenefit Exclusion Co Q-10 150 mg capsuleBenefit Exclusion Co Q-10 200 mg capsuleBenefit Exclusion Co Q-10 30 mg capsuleBenefit Exclusion Co Q-10 300 mg capsuleBenefit Exclusion Co Q-10-Vitamin E-Fish Oil 25 mg-150 (90-60) mg-200 unit capsuleNon-Preferred Co-Veratrol 200 mg-5 mg-0.8 mg-400 mg capsuleState Carve-Out Coagadex 250 (+/-) unit range intravenous solutionState Carve-Out Coagadex 500 (+/-) unit range intravenous solutionNon-Preferred Coaguchek LancetsNon-Preferred Coaguchek PT stripsNon-Preferred Coaguchek XS miscBenefit Exclusion Coaguchek XS ProBenefit Exclusion Coaguchek XS stripsNon-Preferred coal tar (bulk) 20 % topical solutionNon-Preferred coal tar (crude) (bulk)Benefit Exclusion coal tar (crude) (bulk) solutionNon-Preferred coal tar 20 % topical solutionFormulary Coartem 20 mg-120 mg tabletBenefit Exclusion Coats Aloe 0.5 % topical creamBenefit Exclusion Coats Aloe 0.5 % topical gelBenefit Exclusion Coats Aloe Analgesic 10 % topical linimentBenefit Exclusion Coats Aloe Moisturizing 0.5 % 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