MDwise Formulary Introduction – Healthy Indiana Plan Plus ...
FORMULARY - Amida Care
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Transcript of FORMULARY - Amida Care
1 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Table of Contents
Anti - Infectives .................................................................................................................................................... 3
Antineoplastic / Immunosuppressant Drugs ...................................................................................................... 13
Autonomic / Cns Drugs, Neurology / Psych ...................................................................................................... 18
Cardiovascular, Hypertension / Lipids ............................................................................................................... 38
Dermatologicals/Topical Therapy ...................................................................................................................... 48
Diagnostics / Miscellaneous Agents .................................................................................................................. 77
Ear, Nose / Throat Medications.......................................................................................................................... 87
Endocrine/Diabetes ............................................................................................................................................ 91
Gastroenterology .............................................................................................................................................. 140
Immunology, Vaccines / Biotechnology .......................................................................................................... 159
Musculoskeletal / Rheumatology ..................................................................................................................... 164
Obstetrics / Gynecology ................................................................................................................................... 164
Ophthalmology ................................................................................................................................................. 173
Respiratory And Allergy .................................................................................................................................. 181
Urologicals ....................................................................................................................................................... 204
Vitamins, Hematinics / Electrolytes ................................................................................................................. 206
Index ................................................................................................................................................................. 255
2 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
List of Abbreviations
Brand: Brand
Generic: Generic
NC: NC
NF: NF
OTC: Over the Counter. An OTC drug is a non-prescription drug.
PA: Prior Authorization. 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 don’t get approval, we
may not cover the drug.
QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat
your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for
you, we will then cover Drug B.
3 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
Anti - Infectives
Antifungal Agents
ABELCET Brand
AMBISOME Brand
amphotericin b Generic
CANCIDAS Brand
clotrimazole mucous membrane Generic
ERAXIS(WATER DILUENT) Brand
fluconazole Generic
FLUCONAZOLE (BULK) Brand
fluconazole in dextrose(iso-o) Generic
fluconazole in nacl (iso-osm) Generic
flucytosine Generic
griseofulvin microsize Generic
griseofulvin ultramicrosize Generic
itraconazole Generic
ketoconazole oral Generic
LAMISIL ORAL GRANULES IN PACKET Brand
MYCAMINE Brand
NOXAFIL ORAL SUSPENSION Brand
nystatin oral Generic
ORAVIG Brand
terbinafine hcl oral Generic
voriconazole Generic
Antivirals
abacavir Generic QL
abacavir-lamivudine Generic QL
abacavir-lamivudine-zidovudine Generic QL
acyclovir oral capsule Generic
acyclovir oral suspension 200 mg/5 ml Generic
4 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
acyclovir oral tablet Generic
acyclovir sodium Generic
adefovir Generic
amantadine hcl Generic
APTIVUS Brand QL
ATRIPLA Brand QL
BARACLUDE ORAL SOLUTION Brand
cidofovir Generic
COMBIVIR Brand QL
COMPLERA Brand QL
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG Brand QL
DESCOVY Brand QL
didanosine Generic QL
EDURANT Brand QL
EMTRIVA Brand QL
entecavir Generic
EPIVIR Brand QL
EPIVIR HBV ORAL SOLUTION Brand QL
EPZICOM Brand QL
EVOTAZ Brand QL
famciclovir Generic
fosamprenavir Generic QL
foscarnet Generic
FUZEON SUBCUTANEOUS RECON SOLN Brand QL
ganciclovir sodium Generic
GENVOYA Brand QL
INTELENCE ORAL TABLET 100 MG, 200 MG Brand QL
INTELENCE ORAL TABLET 25 MG Brand
INVIRASE Brand QL
ISENTRESS HD Brand QL
5 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ISENTRESS ORAL POWDER IN PACKET Brand QL
ISENTRESS ORAL TABLET Brand QL
ISENTRESS ORAL TABLET,CHEWABLE 100
MG
Brand QL
ISENTRESS ORAL TABLET,CHEWABLE 25
MG
Brand
KALETRA Brand QL
lamivudine Generic QL
lamivudine-zidovudine Generic QL
LEXIVA Brand QL
lopinavir-ritonavir Generic QL
MAVYRET Brand PA
nevirapine Generic QL
NORVIR Brand QL
ODEFSEY Brand QL
oseltamivir oral capsule Generic
oseltamivir oral suspension for reconstitution Generic QL
PREZCOBIX Brand QL
PREZISTA Brand QL
RELENZA DISKHALER Brand
RESCRIPTOR Brand QL
RETROVIR INTRAVENOUS Brand QL
RETROVIR ORAL CAPSULE Brand QL
RETROVIR ORAL SYRUP Brand QL
REYATAZ ORAL CAPSULE 150 MG, 200 MG,
300 MG
Brand QL
REYATAZ ORAL POWDER IN PACKET Brand QL
ribavirin inhalation Generic PA
rimantadine Generic
SELZENTRY ORAL TABLET 150 MG, 300 MG Brand QL
stavudine Generic QL
6 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
STRIBILD Brand QL
SUSTIVA Brand QL
SYNAGIS Brand PA
TIVICAY Brand QL
TRIUMEQ Brand QL
TRIZIVIR Brand QL
TRUVADA ORAL TABLET 200-300 MG Brand QL
TYBOST Brand
TYZEKA Brand
valacyclovir Generic
valganciclovir Generic
VEMLIDY Brand
VIDEX 2 GRAM PEDIATRIC Brand QL
VIRACEPT ORAL TABLET Brand QL
VIREAD Brand QL
VITEKTA Brand QL
ZIAGEN Brand QL
zidovudine Generic QL
Cephalosporins
cefaclor oral capsule Generic
cefaclor oral tablet extended release 12 hr Generic
cefadroxil oral capsule Generic
cefadroxil oral suspension for reconstitution 250
mg/5 ml, 500 mg/5 ml
Generic
cefadroxil oral tablet Generic
cefazolin in dextrose (iso-os) intravenous
piggyback 1 gram/50 ml, 2 gram/50 ml
Generic
cefazolin injection recon soln 1 gram, 10 gram, 20
gram, 500 mg
Generic
cefazolin intravenous Generic
cefdinir Generic
7 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
cefditoren pivoxil Generic
cefepime Generic
cefepime in dextrose,iso-osm Generic
cefixime Generic
cefotaxime Generic
cefotetan injection Generic
cefoxitin Generic
cefoxitin in dextrose, iso-osm Generic
cefpodoxime Generic
cefprozil Generic
ceftazidime Generic
CEFTAZIDIME IN D5W Brand
ceftibuten Generic
CEFTIN ORAL SUSPENSION FOR
RECONSTITUTION
Brand
ceftriaxone in dextrose,iso-os Generic
ceftriaxone injection recon soln 1 gram, 10 gram,
2 gram, 250 mg, 500 mg
Generic
ceftriaxone intravenous Generic
cefuroxime axetil oral tablet Generic
cefuroxime sodium injection recon soln 750 mg Generic
cefuroxime sodium intravenous Generic
cephalexin Generic
CLAFORAN INTRAVENOUS RECON SOLN Brand
FORTAZ IN DEXTROSE 5 % Brand
FORTAZ INJECTION RECON SOLN 1 GRAM,
6 GRAM
Brand
FORTAZ INTRAVENOUS Brand
TAZICEF Brand
TEFLARO Brand
ZINACEF IN STERILE WATER Brand
8 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ZINACEF INTRAVENOUS RECON SOLN 1.5
GRAM, 750 MG
Brand
Erythromycins / Other Macrolides
azithromycin Generic
AZITHROMYCIN (BULK) Brand
clarithromycin Generic
e.e.s. 400 oral tablet Generic
ERYPED 200 Brand
ERYPED 400 Brand
ery-tab oral tablet,delayed release (dr/ec) 250 mg,
333 mg
Generic
ERY-TAB ORAL TABLET,DELAYED
RELEASE (DR/EC) 500 MG
Brand
ERYTHROCIN Brand
erythrocin (as stearate) oral tablet 250 mg Generic
erythromycin ethylsuccinate oral suspension for
reconstitution
Generic
erythromycin ethylsuccinate oral tablet Generic
erythromycin oral capsule,delayed release(dr/ec) Generic
erythromycin oral tablet Generic
PCE Brand
ZMAX Brand
Miscellaneous Antiinfectives
ALBENZA Brand
ALINIA Brand
amikacin injection solution 1,000 mg/4 ml, 500
mg/2 ml
Generic
atovaquone Generic ST
atovaquone-proguanil Generic
AZACTAM IN DEXTROSE (ISO-OSM) Brand
aztreonam Generic
baciim Generic
9 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
bacitracin (bulk) powder 5 million unit Generic
bacitracin intramuscular Generic
BILTRICIDE Brand
CAPASTAT Brand
CAYSTON Brand
chloramphenicol sod succinate Generic
chloroquine phosphate Generic
clindamycin hcl Generic
clindamycin in 5 % dextrose Generic
clindamycin palmitate hcl Generic
clindamycin phosphate injection Generic
clindamycin phosphate intravenous solution 600
mg/4 ml, 900 mg/6 ml
Generic
COARTEM Brand
colistin (colistimethate na) Generic
CYCLOSERINE Brand
dapsone oral Generic
DARAPRIM Brand PA
ethambutol Generic
gentamicin in nacl (iso-osm) intravenous
piggyback 60 mg/50 ml, 80 mg/100 ml
Generic
gentamicin injection Generic
gentamicin sulfate (ped) (pf) Generic
gentamicin sulfate (pf) intravenous solution 100
mg/10 ml
Generic
hydroxychloroquine Generic
imipenem-cilastatin Generic
INVANZ Brand
isoniazid Generic
ivermectin Generic
KETEK ORAL TABLET 400 MG Brand
10 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
linezolid intravenous Generic
linezolid oral Generic PA
linezolid-0.9% sodium chloride Generic
mefloquine Generic
meropenem Generic
METRONIDAZOLE (BULK) Brand
metronidazole in nacl (iso-os) Generic
metronidazole oral Generic
NEBUPENT Brand
neomycin Generic
paromomycin Generic
PASER Brand
PENTAM Brand
pin-x oral suspension Generic OTC
polymyxin b sulfate Generic
PRIFTIN Brand
PRIMAQUINE Brand
PRIMAXIN IV Brand
pyrazinamide Generic
PYRIMETHAMINE (BULK) Brand
quinine sulfate Generic QL
reese's pinworm medicine Generic OTC
rifabutin Generic
rifampin Generic
RIFATER Brand
STREPTOMYCIN Brand
SYNERCID Brand
tinidazole Generic
tobramycin in 0.225 % nacl Generic
tobramycin in 0.9 % nacl intravenous piggyback
60 mg/50 ml
Generic
11 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
tobramycin sulfate Generic
TRECATOR Brand
TYGACIL Brand
XIFAXAN Brand
ZYVOX INTRAVENOUS PARENTERAL
SOLUTION 200 MG/100 ML
Brand
Penicillins
amoxicillin oral capsule Generic
amoxicillin oral suspension for reconstitution Generic
amoxicillin oral tablet Generic
amoxicillin oral tablet,chewable 125 mg, 250 mg Generic
amoxicillin-pot clavulanate Generic
ampicillin Generic
ampicillin sodium Generic
ampicillin-sulbactam Generic
AUGMENTIN ORAL SUSPENSION FOR
RECONSTITUTION 125-31.25 MG/5 ML
Brand
BICILLIN C-R Brand
BICILLIN L-A Brand
dicloxacillin Generic
MOXATAG Brand
nafcillin Generic
nafcillin in dextrose iso-osm Generic
oxacillin Generic
oxacillin in dextrose(iso-osm) intravenous
piggyback 2 gram/50 ml
Generic
PENICILLIN G POT IN DEXTROSE Brand
penicillin g potassium Generic
penicillin g sodium Generic
penicillin v potassium Generic
pfizerpen-g Generic
12 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
piperacillin-tazobactam intravenous recon soln
2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram
Generic
TIMENTIN Brand
ZOSYN IN DEXTROSE (ISO-OSM) Brand
Quinolones
AVELOX IN NACL (ISO-OSMOTIC) Brand
ciprofloxacin Generic
ciprofloxacin (mixture) Generic
ciprofloxacin hcl oral Generic
ciprofloxacin in 5 % dextrose Generic
ciprofloxacin lactate Generic
LEVOFLOXACIN (BULK) Brand
levofloxacin in d5w Generic
levofloxacin intravenous Generic
levofloxacin oral Generic
moxifloxacin oral Generic
ofloxacin oral tablet 300 mg, 400 mg Generic
Sulfa's / Related Agents
sulfadiazine Generic
sulfamethoxazole-trimethoprim Generic
sulfatrim Generic
Tetracyclines
avidoxy Generic
demeclocycline Generic
doxycycline hyclate intravenous Generic
doxycycline hyclate oral capsule Generic
doxycycline hyclate oral tablet Generic
doxycycline hyclate oral tablet,delayed release
(dr/ec)
Generic
doxycycline monohydrate oral capsule Generic
13 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
doxycycline monohydrate oral suspension for
reconstitution
Generic
doxycycline monohydrate oral tablet Generic
minocycline Generic
mondoxyne nl Generic
morgidox oral capsule 100 mg Generic
okebo Generic
SOLODYN ORAL TABLET EXTENDED
RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65
MG, 80 MG
Brand ST
tetracycline Generic
VIBRAMYCIN ORAL SYRUP Brand
Urinary Tract Agents
methenamine hippurate Generic
methenamine mandelate Generic
MONUROL Brand
nitrofurantoin Generic
nitrofurantoin macrocrystal Generic
nitrofurantoin monohyd/m-cryst Generic
PRIMSOL Brand
trimethoprim Generic
Vancomycin
VANCOMYCIN IN DEXTROSE 5 %
INTRAVENOUS PIGGYBACK
Brand
vancomycin intravenous recon soln 1,000 mg, 10
gram, 5 gram, 500 mg
Generic
vancomycin oral capsule Generic
Antineoplastic / Immunosuppressant Drugs
Adjunctive Agents
calcium folinate (leucovorin) Generic
leucovorin calcium Generic
LEUCOVORIN CALCIUM (BULK) Brand
14 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
MESNEX ORAL Brand
VISTOGARD Brand
Antineoplastic / Immunosuppressant Drugs
adriamycin Generic
adrucil Generic
AFINITOR Brand PA
AFINITOR DISPERZ Brand PA
anastrozole Generic
AZASAN Brand
azathioprine Generic
bexarotene Generic PA
bicalutamide Generic
BICNU Brand
bleomycin Generic
CABOMETYX ORAL TABLET 20 MG Brand PA; QL
CABOMETYX ORAL TABLET 40 MG, 60 MG Brand PA
capecitabine Generic
CAPRELSA Brand PA; QL
carboplatin Generic
cerubidine Generic
cisplatin Generic
cladribine Generic
cyclophosphamide intravenous Generic
cyclophosphamide oral tablet Generic
cyclosporine intravenous Generic
cyclosporine modified Generic
cyclosporine oral capsule Generic
cytarabine Generic
cytarabine (pf) Generic
dacarbazine Generic
15 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
daunorubicin Generic
docetaxel intravenous solution 160 mg/8 ml (20
mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml)
Generic
doxorubicin Generic
doxorubicin, peg-liposomal Generic
DROXIA Brand
EMCYT Brand
ETOPOPHOS Brand
etoposide Generic
exemestane Generic
FARESTON Brand
floxuridine Generic
fludarabine Generic
fluorouracil intravenous Generic
flutamide Generic
gemcitabine Generic
gengraf Generic
hecoria Generic
HEXALEN Brand
HYCAMTIN ORAL Brand
hydroxyurea Generic
IBRANCE Brand PA; QL
ifosfamide intravenous recon soln Generic
imatinib Generic PA; QL
IMBRUVICA Brand PA; QL
INLYTA Brand PA; QL
IRESSA Brand PA; QL
irinotecan intravenous solution 100 mg/5 ml, 40
mg/2 ml
Generic
JAKAFI Brand PA; QL
KISQALI Brand PA; QL
16 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
KISQALI FEMARA CO-PACK Brand PA; QL
LENVIMA Brand PA
letrozole Generic
LEUKERAN Brand
leuprolide subcutaneous kit Generic
lipodox Generic
LUPRON DEPOT Brand PA
LUPRON DEPOT (3 MONTH) Brand PA; QL
LUPRON DEPOT (4 MONTH) Brand PA
LUPRON DEPOT (6 MONTH) Brand PA
LUPRON DEPOT-PED Brand PA
LUPRON DEPOT-PED (3 MONTH) Brand PA; QL
LYNPARZA Brand PA
LYSODREN Brand
MATULANE Brand
megestrol oral suspension 400 mg/10 ml (40
mg/ml), 625 mg/5 ml
Generic
megestrol oral tablet Generic
melphalan Generic
melphalan hcl Generic
mercaptopurine Generic
methotrexate sodium Generic
methotrexate sodium (pf) Generic
mitomycin Generic
mitoxantrone Generic
MUSTARGEN Brand
mycophenolate mofetil Generic
mycophenolate sodium Generic
MYLERAN Brand
NEXAVAR Brand PA; QL
nilutamide Generic
17 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
NULOJIX Brand
octreotide acetate Generic
ONCASPAR Brand
paclitaxel Generic
PROGRAF INTRAVENOUS Brand
RAPAMUNE ORAL SOLUTION Brand
REVLIMID ORAL CAPSULE 10 MG, 15 MG,
2.5 MG, 25 MG, 5 MG
Brand PA
RITUXAN Brand
RUBRACA Brand PA; QL
RYDAPT Brand PA
SANDIMMUNE ORAL SOLUTION Brand
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR KIT
Brand
sirolimus Generic
SOMATULINE DEPOT Brand
SPRYCEL Brand PA; QL
SUTENT Brand PA; QL
TABLOID Brand
tacrolimus oral Generic
tamoxifen Generic
TARCEVA Brand PA; QL
TARGRETIN TOPICAL Brand PA
TASIGNA Brand PA; QL
temozolomide Generic PA
THALOMID Brand PA
thiotepa Generic
toposar Generic
tretinoin (chemotherapy) Generic
TREXALL Brand
TYKERB Brand PA; QL
18 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
VENCLEXTA Brand PA
VENCLEXTA STARTING PACK Brand PA; QL
vinblastine Generic
vincasar pfs Generic
vincristine Generic
vinorelbine Generic
VOTRIENT Brand PA; QL
XALKORI Brand PA; QL
XERMELO Brand PA; QL
ZEJULA Brand PA; QL
ZELBORAF Brand PA; QL
ZOLINZA Brand
ZORTRESS Brand
ZYDELIG Brand PA; QL
Autonomic / Cns Drugs, Neurology / Psych
Anticonvulsants
BANZEL Brand
carbamazepine oral capsule, er multiphase 12 hr Generic
carbamazepine oral suspension 100 mg/5 ml Generic
carbamazepine oral tablet Generic
carbamazepine oral tablet extended release 12 hr Generic
carbamazepine oral tablet,chewable Generic
CELONTIN ORAL CAPSULE 300 MG Brand
clonazepam Generic
DIASTAT Brand
diazepam rectal Generic
DILANTIN Brand
divalproex Generic
epitol Generic
EQUETRO Brand
19 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ethosuximide Generic
felbamate Generic
GABAPENTIN (BULK) Brand
gabapentin oral capsule Generic
gabapentin oral solution 250 mg/5 ml Generic
gabapentin oral tablet 600 mg, 800 mg Generic
GABITRIL ORAL TABLET 12 MG, 16 MG Brand
LAMICTAL STARTER (BLUE) KIT Brand
LAMICTAL STARTER (GREEN) KIT Brand
LAMICTAL STARTER (ORANGE) KIT Brand
lamotrigine Generic
levetiracetam Generic
LYRICA Brand
ONFI ORAL TABLET 10 MG, 20 MG Brand PA
oxcarbazepine Generic
PEGANONE Brand
phenobarbital Generic
phenobarbital sodium injection solution Generic
phenytoin oral suspension 125 mg/5 ml Generic
phenytoin oral tablet,chewable Generic
phenytoin sodium Generic
phenytoin sodium extended Generic
primidone Generic
roweepra Generic
SABRIL Brand
STAVZOR Brand
tiagabine Generic
topiragen Generic
topiramate oral capsule, sprinkle Generic
topiramate oral tablet Generic
20 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
valproate sodium Generic
valproic acid Generic
valproic acid (as sodium salt) oral solution 250
mg/5 ml
Generic
vigabatrin Generic
VIMPAT INTRAVENOUS Brand
VIMPAT ORAL SOLUTION Brand
VIMPAT ORAL TABLET Brand
zonisamide Generic
Antiparkinsonism Agents
APOKYN Brand
benztropine Generic
bromocriptine Generic
carbidopa Generic
carbidopa-levodopa Generic
carbidopa-levodopa-entacapone Generic
entacapone Generic
pramipexole Generic
rasagiline Generic
ropinirole Generic
selegiline hcl Generic
tolcapone Generic
trihexyphenidyl Generic
ZELAPAR Brand
Migraine / Cluster Headache Therapy
almotriptan malate Generic QL
dihydroergotamine Generic
eletriptan hbr Generic QL
ergotamine-caffeine Generic
frovatriptan Generic QL
isometh-dichloral-acetaminophn Generic
21 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
isomethepten-caf-acetaminophen oral tablet 65-
20-325 mg
Generic
migergot Generic
migragesic ida Generic
naratriptan Generic QL
nodolor Generic
rizatriptan Generic QL
sumatriptan Generic QL
sumatriptan succinate oral Generic QL
sumatriptan succinate subcutaneous cartridge Generic QL
sumatriptan succinate subcutaneous pen injector Generic QL
sumatriptan succinate subcutaneous solution Generic QL
sumatriptan succinate subcutaneous syringe 6
mg/0.5 ml
Generic QL
zolmitriptan Generic QL
Miscellaneous Neurological Therapy
AMPYRA Brand
COPAXONE SUBCUTANEOUS SYRINGE 20
MG/ML
Brand
donepezil Generic
galantamine Generic
memantine oral solution Generic
memantine oral tablet Generic
NAMENDA TITRATION PAK Brand
NUEDEXTA Brand PA
rivastigmine Generic
rivastigmine tartrate Generic
tetrabenazine Generic PA; QL
Muscle Relaxants / Antispasmodic Therapy
baclofen Generic
BACLOFEN (BULK) Brand
22 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
carisoprodol Generic
carisoprodol-asa-codeine Generic QL
carisoprodol-aspirin Generic
chlorzoxazone oral tablet 500 mg Generic
cyclobenzaprine oral tablet Generic
DANTRIUM INTRAVENOUS Brand
dantrolene Generic
LIORESAL INTRATHECAL SOLUTION 2,000
MCG/ML, 500 MCG/ML
Brand
meprobamate Generic
MESTINON ORAL SYRUP Brand
metaxall Generic
metaxalone Generic
methocarbamol oral Generic
orphenadrine citrate oral Generic
orphenadrine compound-ds Generic
pyridostigmine bromide Generic
revonto Generic
tizanidine Generic
Narcotic Analgesics
ABSTRAL Brand PA; QL
acetaminophen-codeine oral solution 120-12 mg/5
ml
Generic
acetaminophen-codeine oral tablet Generic QL
alagesic lq Generic
aspirin-caffeine-dihydrocodein Generic QL
buprenorphine hcl injection Generic
buprenorphine hcl sublingual Generic QL
butalbital-acetaminophen Generic
butalbital-acetaminophen-caff oral capsule Generic
23 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
butalbital-acetaminophen-caff oral tablet 50-325-
40 mg
Generic
butalbital-aspirin-caffeine Generic
capacet Generic
codeine sulfate oral tablet Generic QL
codeine-butalbital-asa-caff Generic QL
endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325
mg, 7.5-325 mg
Generic QL
endodan Generic QL
fentanyl citrate Generic PA; QL
fentanyl transdermal patch 72 hour 100 mcg/hr,
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
Generic PA; QL
hydrocodone-acetaminophen oral solution 7.5-325
mg/15 ml
Generic QL
hydrocodone-acetaminophen oral tablet 10-300
mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg,
7.5-300 mg, 7.5-325 mg
Generic QL
hydrocodone-ibuprofen Generic QL
hydromorphone oral liquid Generic QL
hydromorphone oral tablet Generic QL
hydromorphone oral tablet extended release 24 hr Generic PA; QL
hydromorphone rectal Generic
ibuprofen-oxycodone Generic QL
levorphanol tartrate Generic QL
lorcet (hydrocodone) Generic QL
lorcet hd Generic QL
lorcet plus oral tablet 7.5-325 mg Generic QL
lortab 10-325 Generic QL
lortab 5-325 Generic QL
lortab 7.5-325 Generic QL
margesic Generic
marten-tab Generic
24 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
methadone oral tablet Generic PA; QL
morphine concentrate oral solution Generic QL
morphine oral capsule, er multiphase 24 hr Generic PA; QL
morphine oral capsule,extend.release pellets Generic PA; QL
morphine oral solution Generic QL
morphine oral tablet Generic QL
morphine oral tablet extended release Generic PA; QL
morphine rectal Generic
oxycodone oral capsule Generic QL
oxycodone oral concentrate Generic QL
oxycodone oral solution Generic QL
oxycodone oral tablet Generic QL
oxycodone-acetaminophen oral solution Generic QL
oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 5-325 mg, 7.5-325 mg
Generic QL
oxycodone-aspirin Generic QL
oxymorphone oral tablet Generic QL
oxymorphone oral tablet extended release 12 hr Generic PA; QL
reprexain Generic QL
ROXICET ORAL SOLUTION Brand QL
SYNALGOS-DC Brand QL
tencon oral tablet 50-325 mg Generic
verdrocet Generic QL
vicodin Generic QL
vicodin es Generic QL
vicodin hp Generic QL
xylon 10 Generic QL
zamicet Generic QL
zebutal oral capsule 50-325-40 mg Generic
Non-Narcotic Analgesics
8 hour pain reliever Generic OTC
25 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
8hr muscle ache-pain Generic OTC
acephen Generic OTC
acetadryl Generic OTC
aceta-gesic Generic OTC
acetaminophen extra strength Generic OTC
acetaminophen oral capsule 500 mg Generic OTC
acetaminophen oral drops,suspension Generic OTC
acetaminophen oral elixir Generic OTC
acetaminophen oral solution 325 mg/10.15 ml Generic OTC
acetaminophen oral suspension 160 mg/5 ml Generic OTC
acetaminophen oral tablet Generic OTC
acetaminophen oral tablet extended release Generic OTC
acetaminophen oral tablet,chewable Generic OTC
acetaminophen oral tablet,disintegrating 80 mg Generic OTC
acetaminophen pm extra str Generic OTC
acetaminophen rectal Generic OTC
added strength headache relief Generic OTC
added strength pain reliever Generic OTC
adult aspirin regimen Generic OTC
adult low dose aspirin Generic OTC
advil oral tablet 100 mg Generic OTC
advil oral tablet,chewable Generic OTC
alka-seltzer original Generic OTC
all day pain relief Generic OTC
all day relief Generic OTC
antacid and pain relief Generic OTC
arthritis pain relief (acetam) Generic OTC
aspir-81 Generic OTC
aspirin low dose Generic OTC
aspirin oral tablet Generic OTC
26 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
aspirin oral tablet,chewable Generic OTC
aspirin oral tablet,delayed release (dr/ec) 325 mg,
500 mg, 650 mg, 81 mg
Generic OTC
aspirin rectal Generic OTC
aspirin, buffered Generic OTC
aspir-low Generic OTC
aspir-trin Generic OTC
athenol Generic OTC
back and body pain reliever Generic OTC
backache relief extra strength Generic OTC
bayer advanced Generic OTC
bayer plus extra strength Generic OTC
betatemp Generic OTC
bufferin Generic OTC
buprenorphine-naloxone Generic QL
butorphanol tartrate nasal Generic
celecoxib Generic ST
child non-aspirin quick melts Generic OTC
child pain rel-fever reducer Generic OTC
children's advil Generic OTC
children's aspirin Generic OTC
children's easy-melts Generic OTC
children's ibuprofen Generic OTC
children's mapap Generic OTC
children's medi-profen Generic OTC
children's medi-tabs Generic OTC
children's non-aspirin oral elixir Generic OTC
children's non-aspirin oral suspension Generic OTC
children's non-aspirin oral tablet,chewable Generic OTC
children's pain relief Generic OTC
children's pain reliever oral tablet,disintegrating Generic OTC
27 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
children's pain-fever relief oral liquid Generic OTC
children's pain-fever relief oral suspension Generic OTC
children's pain-fever relief oral tablet,chewable Generic OTC
children's profen ib Generic OTC
children's q-pap Generic OTC
children's silapap Generic OTC
children's tactinal Generic OTC
choline,magnesium salicylate Generic
cidatrine Generic OTC
clonidine (pf) epidural solution 5,000 mcg/10 ml Generic
condrolite Generic OTC
diclofenac potassium Generic
DICLOFENAC SODIUM (BULK) Brand
diclofenac sodium oral Generic
diclofenac sodium topical drops Generic
diclofenac sodium topical gel 1 % Generic
diclofenac-misoprostol Generic
diflunisal Generic
diphenhydramine-acetaminophen Generic OTC
DOLOGESIC (W-PHENYLTOLOXAMINE) Brand OTC
dona oral tablet Generic OTC
e.c. prin Generic OTC
eazzze the pain Generic OTC
ecotrin Generic OTC
ecotrin low strength Generic OTC
ed-apap Generic OTC
effervescent antacid Generic OTC
effervescent pain reliever Generic OTC
enteric coated aspirin Generic OTC
etodolac Generic
28 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ex-strength medi-tabs pm Generic OTC
extra strength bayer Generic OTC
extraprin Generic OTC
fenoprofen oral tablet Generic
fever reducer Generic OTC
fever reducer an pain reliever Generic OTC
feverall rectal suppository 120 mg, 325 mg, 650
mg
Generic OTC
flanax (naproxen) Generic OTC
flurbiprofen Generic
genicin Generic OTC
gluc-chon-msm3-mang-frankn-bor Generic OTC
glucos chond cplx advanced Generic OTC
glucosam su dip-chondroit-c-mn Generic OTC
glucosam-chondr-vit c-mn-boron Generic OTC
glucosam-chon-msm1-c-mang-bosw Generic OTC
glucosamine relief oral capsule Generic OTC
glucosamine su 2kcl-chondroit oral tablet Generic OTC
glucosamine sulfate 2kcl oral capsule 500 mg Generic OTC
glucosamine sulfate oral capsule 500 mg Generic OTC
glucosamine sulfate oral tablet Generic OTC
glucosamine-chondr (boswellia) Generic OTC
glucosamine-chondroitin 3x oral tablet 750-625-
30 mg
Generic OTC
glucosamine-chondroitin complx oral tablet 250-
200-30-2.5 mg, 500-416.6-20 mg, 750-625-30 mg
Generic OTC
glucosamine-chondroitin ds oral capsule Generic OTC
glucosamine-chondroitin ds oral tablet 500-416.6-
20 mg
Generic OTC
glucosamine-chondroitin oral tablet 750 mg-100
mg- 125 mg-1.65 mg
Generic OTC
glucosamine-d3-boswellia serr Generic OTC
29 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
GLUCOTEN Brand OTC
headache formula added str Generic OTC
headache pm Generic OTC
headache relief (asa-acet-caf) Generic OTC
headache relief pm Generic OTC
ibu-drops Generic OTC
IBUPROFEN (BULK) Brand
ibuprofen ib Generic OTC
ibuprofen jr strength Generic OTC
ibuprofen oral capsule Generic OTC
ibuprofen oral suspension Generic OTC
ibuprofen oral tablet 100 mg, 200 mg Generic OTC
ibuprofen oral tablet 400 mg, 600 mg, 800 mg Generic
ibuprofen pm oral tablet Generic OTC
ibuprofen-diphenhydramine hcl Generic OTC
indomethacin oral Generic
infant fever reducer-pain relf Generic OTC
infant's acetaminophen Generic OTC
infant's advil Generic OTC
infant's ibuprofen Generic OTC
infant's medi-profen Generic OTC
infant's motrin Generic OTC
infants' pain and fever Generic OTC
infants' pain relief Generic OTC
infant's pain relief Generic OTC
infant's pain reliever Generic OTC
infants profenib Generic OTC
jr str non-aspirin quick melts Generic OTC
jr. acetaminophen Generic OTC
jr. str non-aspirin pain Generic OTC
30 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
jr. strength pain reliever Generic OTC
junior mapap Generic OTC
KETOPROFEN (BULK) Brand
ketoprofen oral capsule Generic
ketoprofen oral capsule,ext rel. pellets 24 hr 200
mg
Generic
KETOPROFEN, MICRONIZED (BULK) Brand
ketorolac injection cartridge Generic
ketorolac injection solution Generic
ketorolac intramuscular cartridge Generic
ketorolac intramuscular solution Generic
ketorolac oral Generic
klofensaid ii Generic
lite coat aspirin Generic OTC
little remedies fever and pain Generic OTC
mapap (acetaminophen) oral capsule Generic OTC
mapap (acetaminophen) oral liquid Generic OTC
mapap (acetaminophen) oral suspension Generic OTC
mapap (acetaminophen) oral tablet Generic OTC
mapap (acetaminophen) oral tablet,chewable Generic OTC
mapap arthritis pain Generic OTC
mapap extra strength Generic OTC
mapap pm Generic OTC
masophen Generic OTC
meclofenamate Generic
medi-profen Generic OTC
medi-seltzer Generic OTC
medi-tabs Generic OTC
medi-tabs pm Generic OTC
mefenamic acid Generic
meloxicam Generic
31 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
menstrual relief Generic OTC
menstrual relief(pamabr-pyril) Generic OTC
midol pm Generic OTC
migraine formula Generic OTC
migraine pain reliever Generic OTC
migraine relief Generic OTC
motrin pm Generic OTC
nabumetone Generic
nalbuphine Generic
naloxone Generic QL
naltrexone Generic
naproxen Generic
naproxen sodium oral capsule Generic OTC
naproxen sodium oral tablet 220 mg Generic OTC
naproxen sodium oral tablet 275 mg, 550 mg Generic
NARCAN NASAL SPRAY,NON-AEROSOL 4
MG/ACTUATION
Brand QL
night time pain medicine Generic OTC
non-aspirin 8 hour Generic OTC
non-aspirin childrens Generic OTC
non-aspirin extra strength Generic OTC
non-aspirin jr strength Generic OTC
non-aspirin oral tablet Generic OTC
non-aspirin oral tablet,chewable 80 mg Generic OTC
non-aspirin pain relief oral tablet 500 mg Generic OTC
non-aspirin pain relief pm Generic OTC
non-aspirin pm Generic OTC
nortemp Generic OTC
NUCYNTA Brand QL
osteo bi-flex triple strength Generic OTC
oxaprozin Generic
32 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
pain and fever Generic OTC
pain relief (acetamin-asp-caf) Generic OTC
pain relief adult Generic OTC
pain relief oral capsule 500 mg Generic OTC
pain relief oral liquid Generic OTC
pain relief oral tablet Generic OTC
pain relief oral tablet extended release Generic OTC
pain relief pm Generic OTC
pain relief pm rapid release Generic OTC
pain relief regular strength Generic OTC
pain reliever (acetam-aspirin) Generic OTC
pain reliever extra strength Generic OTC
pain reliever jr strength Generic OTC
pain reliever oral capsule Generic OTC
pain reliever oral tablet 325 mg Generic OTC
pain reliever plus Generic OTC
pain-off Generic OTC
pamprin max Generic OTC
pediacare fever reducer Generic OTC
pentazocine-naloxone Generic
percogesic Generic OTC
percogesic extra strength Generic OTC
pharbetol Generic OTC
piroxicam Generic
pm pain reliever Generic OTC
pms maximum strength Generic OTC
pre-menstrual relief Generic OTC
premsyn pms Generic OTC
profeno Generic
provil Generic OTC
33 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
q-pap extra strength Generic OTC
q-pap oral drops Generic OTC
q-pap oral liquid Generic OTC
q-pap oral tablet 325 mg Generic OTC
relamine Generic OTC
salsalate Generic
severe allergy Generic OTC
shake that ache Generic OTC
silapap Generic OTC
SUBOXONE Brand QL
sulindac Generic
super pain relief Generic OTC
synovacin Generic OTC
tactinal Generic OTC
tactinal extra strength Generic OTC
TALWIN Brand
tolmetin Generic
tramadol oral tablet Generic
tramadol oral tablet extended release 24 hr Generic QL
tramadol oral tablet, er multiphase 24 hr Generic
tramadol-acetaminophen Generic
tri-buffered aspirin Generic OTC
tylophen Generic OTC
VIVITROL Brand
wal-profen Generic OTC
wal-proxen Generic OTC
women's menstrual relief Generic OTC
Psychotherapeutic Drugs
ABILIFY MAINTENA Brand PA
alprazolam Generic
34 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
alprazolam intensol Generic
amitriptyline Generic
AMITRIPTYLINE (BULK) Brand
amitriptyline-chlordiazepoxide Generic
amoxapine Generic
AMYTAL Brand
APLENZIN Brand ST
aripiprazole oral solution Generic
aripiprazole oral tablet Generic QL
aripiprazole oral tablet,disintegrating Generic QL
armodafinil Generic PA
atomoxetine Generic
bupropion hcl Generic
buspirone Generic
BUTISOL Brand
chlordiazepoxide hcl Generic
chlorpromazine Generic
citalopram Generic
clomipramine Generic
clonidine hcl oral tablet extended release 12 hr Generic
clorazepate dipotassium Generic
clozapine oral tablet Generic
clozapine oral tablet,disintegrating 100 mg, 12.5
mg, 25 mg
Generic
desipramine Generic
desvenlafaxine succinate Generic
dexedrine Generic QL
dexmethylphenidate Generic QL
dextroamphetamine Generic QL
dextroamphetamine-amphetamine Generic QL
diazepam injection Generic
35 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
diazepam intensol Generic
diazepam oral solution 5 mg/5 ml (1 mg/ml) Generic
diazepam oral tablet Generic
diphenhydramine hcl oral tablet 50 mg Generic OTC
doxepin oral Generic
duloxetine Generic
EMSAM Brand
ergoloid Generic
escitalopram oxalate Generic
estazolam Generic
eszopiclone Generic
FANAPT Brand ST; QL
FAZACLO ORAL TABLET,DISINTEGRATING
150 MG, 200 MG
Brand
fluoxetine Generic
fluphenazine decanoate Generic
fluphenazine hcl Generic
flurazepam Generic
fluvoxamine Generic
GEODON INTRAMUSCULAR Brand
guanfacine oral tablet extended release 24 hr Generic
guanidine Generic
haloperidol Generic
haloperidol decanoate Generic
haloperidol lactate Generic
imipramine hcl Generic
imipramine pamoate Generic
INVEGA SUSTENNA Brand PA
INVEGA TRINZA Brand PA
LATUDA Brand ST; QL
lithium carbonate Generic
36 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
lithium citrate oral solution 8 meq/5 ml Generic
lorazepam Generic
lorazepam intensol Generic
loxapine succinate Generic
maprotiline Generic
MARPLAN Brand
medi-sleep Generic OTC
metadate er Generic QL
methamphetamine Generic QL
methylphenidate hcl oral capsule, er biphasic 30-
70
Generic QL
methylphenidate hcl oral capsule,er biphasic 50-
50
Generic QL
methylphenidate hcl oral solution Generic
methylphenidate hcl oral tablet Generic QL
methylphenidate hcl oral tablet extended release Generic QL
methylphenidate hcl oral tablet extended release
24hr
Generic QL
methylphenidate hcl oral tablet,chewable Generic QL
midazolam oral syrup 2 mg/ml Generic
mirtazapine Generic
modafinil Generic PA
molindone Generic
nefazodone Generic
nighttime sleep-aid (doxylamn) Generic OTC
nortriptyline Generic
olanzapine oral Generic QL
olanzapine-fluoxetine Generic
OLEPTRO ER Brand
oxazepam Generic
paliperidone Generic QL
37 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
paroxetine hcl oral tablet Generic
paroxetine hcl oral tablet extended release 24 hr Generic
paroxetine mesylate Generic
perphenazine Generic
perphenazine-amitriptyline Generic
PEXEVA Brand
phenelzine Generic
pimozide Generic
procentra Generic QL
protriptyline Generic
quazepam Generic
quetiapine Generic QL
REXULTI Brand ST; QL
RISPERDAL CONSTA Brand PA
risperidone oral solution Generic
risperidone oral tablet Generic QL
risperidone oral tablet,disintegrating Generic QL
SAPHRIS Brand ST; QL
SAPHRIS (BLACK CHERRY) SUBLINGUAL
TABLET 2.5 MG
Brand ST; QL
seconal sodium Generic
sertraline Generic
sleep aid (doxylamine) Generic OTC
temazepam Generic
thioridazine Generic
thiothixene Generic
tranylcypromine Generic
trazodone Generic
triazolam Generic
trifluoperazine Generic
trimipramine Generic
38 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ultra sleep (doxylamine succ) Generic OTC
venlafaxine Generic
VYVANSE ORAL CAPSULE 20 MG, 30 MG, 40
MG, 50 MG, 60 MG, 70 MG
Brand QL
wal-som (doxylamine) Generic OTC
XYREM Brand
zaleplon Generic QL
zenzedi oral tablet 10 mg, 5 mg Generic QL
ziprasidone hcl Generic QL
zolpidem Generic QL
ZYPREXA RELPREVV Brand PA
Cardiovascular, Hypertension / Lipids
Antiarrhythmic Agents
amiodarone oral Generic
disopyramide phosphate oral capsule Generic
dofetilide Generic
flecainide Generic
lidocaine (pf) intravenous syringe 50 mg/5 ml (1
%)
Generic
mexiletine Generic
MULTAQ Brand
NORPACE CR ORAL CAPSULE, EXTENDED
RELEASE 100 MG
Brand
pacerone oral tablet 100 mg, 200 mg, 400 mg Generic
propafenone Generic
quinidine gluconate Generic
quinidine sulfate Generic
sotalol af Generic
sotalol oral Generic
Antihypertensive Therapy
acebutolol Generic
39 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
afeditab cr Generic
ALDACTAZIDE ORAL TABLET 50-50 MG Brand
amiloride Generic
amiloride-hydrochlorothiazide Generic
amlodipine Generic
amlodipine-benazepril Generic
amlodipine-olmesartan Generic ST
amlodipine-valsartan Generic ST
amlodipine-valsartan-hcthiazid Generic ST
atenolol Generic
atenolol-chlorthalidone Generic
benazepril Generic
benazepril-hydrochlorothiazide Generic
betaxolol oral Generic
BIDIL Brand
bisoprolol fumarate Generic
bisoprolol-hydrochlorothiazide Generic
bumetanide Generic
candesartan Generic ST
candesartan-hydrochlorothiazid Generic ST
captopril Generic
captopril-hydrochlorothiazide Generic
cartia xt Generic
carvedilol Generic
carvedilol phosphate Generic
chlorothiazide Generic
chlorthalidone oral tablet 25 mg, 50 mg Generic
clonidine Generic
clonidine (pf) epidural solution 1,000 mcg/10 ml
(100 mcg/ml)
Generic
CLONIDINE HCL (BULK) Brand
40 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
clonidine hcl oral tablet Generic
clorpres oral tablet 0.1-15 mg, 0.2-15 mg Generic
CLORPRES ORAL TABLET 0.3-15 MG Brand
DEMSER Brand
DILTIAZEM HCL (BULK) Brand
diltiazem hcl intravenous solution Generic
diltiazem hcl oral Generic
dilt-xr Generic
DIURIL Brand
doxazosin Generic
DUTOPROL Brand
enalapril maleate Generic
enalapril-hydrochlorothiazide Generic
eplerenone Generic
epoprostenol (glycine) Generic
eprosartan Generic ST
ethacrynic acid Generic
felodipine Generic
FLOLAN Brand
fosinopril Generic
fosinopril-hydrochlorothiazide Generic
furosemide injection Generic
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8
mg/ml)
Generic
furosemide oral tablet Generic
guanfacine oral tablet Generic
hydralazine Generic
hydrochlorothiazide Generic
indapamide Generic
irbesartan Generic ST
irbesartan-hydrochlorothiazide Generic ST
41 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
isradipine Generic
labetalol oral Generic
lisinopril Generic
lisinopril-hydrochlorothiazide Generic
losartan Generic ST
losartan-hydrochlorothiazide Generic ST
mannitol 20 % Generic
matzim la Generic
methyclothiazide Generic
methyldopa Generic
methyldopa-hydrochlorothiazide Generic
methyldopate Generic
metolazone Generic
metoprolol succinate Generic
metoprolol ta-hydrochlorothiaz Generic
metoprolol tartrate Generic
minoxidil oral Generic
moexipril Generic
moexipril-hydrochlorothiazide Generic
nadolol Generic
nadolol-bendroflumethiazide Generic
nicardipine oral Generic
nifedical xl Generic
nifedipine Generic
NIFEDIPINE (BULK) Brand
nimodipine Generic
nisoldipine Generic
olmesartan Generic ST
olmesartan-amlodipin-hcthiazid Generic ST
olmesartan-hydrochlorothiazide Generic ST
42 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
perindopril erbumine Generic
phenoxybenzamine Generic
pindolol Generic
prazosin Generic
propranolol Generic
propranolol-hydrochlorothiazid Generic
quinapril Generic
quinapril-hydrochlorothiazide Generic
ramipril Generic
REMODULIN Brand
RESECTISOL Brand
reserpine Generic
SODIUM EDECRIN Brand
spironolactone Generic
spironolacton-hydrochlorothiaz Generic
taztia xt Generic
TEKTURNA Brand
TEKTURNA HCT Brand
telmisartan Generic ST
telmisartan-amlodipine Generic ST
telmisartan-hydrochlorothiazid Generic ST
terazosin Generic
timolol maleate oral Generic
torsemide intravenous solution 20 mg/2 ml (10
mg/ml)
Generic
torsemide oral Generic
trandolapril Generic
trandolapril-verapamil Generic
triamterene-hydrochlorothiazid Generic
UPTRAVI Brand
valsartan Generic ST
43 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
valsartan-hydrochlorothiazide Generic ST
veletri Generic
verapamil oral Generic
Cardiac Glycosides
digitek Generic
digox Generic
digoxin injection Generic
digoxin oral solution 50 mcg/ml Generic
digoxin oral tablet Generic
LANOXIN PEDIATRIC Brand
Coagulation Therapy
ADVATE Brand PA
ADYNOVATE Brand PA
AFSTYLA Brand PA
ALPHANATE Brand PA
ALPHANINE SD Brand PA
ALPROLIX Brand PA
AMICAR ORAL TABLET 1,000 MG Brand
aminocaproic acid intravenous Generic
aminocaproic acid oral solution Generic
AMINOCAPROIC ACID ORAL TABLET 1,000
MG
Brand
aminocaproic acid oral tablet 500 mg Generic
aspirin-dipyridamole Generic
BEBULIN Brand PA
BENEFIX Brand PA
cilostazol Generic
clopidogrel Generic
CORIFACT Brand
dipyridamole oral Generic
EFFIENT Brand
44 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ELIQUIS Brand
ELOCTATE Brand PA
enoxaparin Generic
FEIBA NF Brand PA
fondaparinux Generic
FRAGMIN SUBCUTANEOUS SOLUTION Brand
FRAGMIN SUBCUTANEOUS SYRINGE Brand
HELIXATE FS Brand PA
HEMOFIL M HIGH Brand PA
HEMOFIL M LOW Brand PA
HEMOFIL M MID Brand PA
HEMOFIL M SUPER HIGH Brand PA
hep flush-10 (pf) Generic
heparin (porcine) in 5 % dex intravenous
parenteral solution 20,000 unit/500 ml (40
unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000
unit/500 ml (50 unit/ml)
Generic
heparin (porcine) in nacl (pf) Generic
heparin (porcine) injection cartridge Generic
heparin (porcine) injection solution Generic
heparin lock flush Generic
heparin lock flush (porcine) intravenous solution
100 unit/ml
Generic
heparin lockflush(porcine)(pf) Generic
heparin(porcine) in 0.45% nacl intravenous
parenteral solution 25,000 unit/250 ml
Generic
heparin, porcine (pf) injection Generic
heparin, porcine (pf) intravenous syringe 100
unit/ml
Generic
HUMATE-P Brand PA
IDELVION Brand PA
IXINITY Brand PA
45 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
jantoven Generic
KOATE Brand PA
KOATE-DVI INTRAVENOUS RECON SOLN Brand PA
KOGENATE FS Brand PA
KOVALTRY Brand PA
MEPHYTON Brand
MONOCLATE-P Brand PA
monoject prefill (pf) Generic
monoject prefill advanced (pf) Generic
MONONINE Brand PA
NOVOEIGHT Brand PA
NOVOSEVEN RT Brand PA
NUWIQ Brand PA
OBIZUR Brand PA
pentoxifylline Generic
PRADAXA ORAL CAPSULE 150 MG, 75 MG Brand
prasugrel Generic
PROFILNINE Brand PA
PROMACTA Brand PA
protamine Generic
RECOMBINATE Brand PA
RIXUBIS Brand PA
ticlopidine Generic
tranexamic acid intravenous Generic
vitamin k1 injection Generic
warfarin Generic
WILATE Brand PA
XARELTO ORAL TABLET Brand
XYNTHA Brand PA
XYNTHA SOLOFUSE Brand PA
46 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
Lipid/Cholesterol Lowering Agents
amlodipine-atorvastatin Generic
atorvastatin Generic
cholestyramine (with sugar) Generic
cholestyramine light Generic
colestipol Generic
endur-acin oral tablet extended release 250 mg,
500 mg
Generic OTC
ezetimibe Generic
ezetimibe-simvastatin Generic
fenofibrate micronized Generic
fenofibrate nanocrystallized Generic
fenofibrate oral tablet Generic
fenofibric acid Generic
fenofibric acid (choline) Generic
fish oil concentrate Generic OTC; QL
fish oil oral capsule 300 mg Generic OTC
fish oil oral capsule 500 mg Generic OTC; QL
fluvastatin Generic
gemfibrozil Generic
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5
MG
Brand PA
KYNAMRO Brand PA
lovastatin Generic
maxepa Generic OTC; QL
niacin (inositol niacinate) oral capsule 500 mg Generic OTC
niacin (inositol niacinate) oral tablet Generic OTC
niacin (niacinamide) Generic OTC
niacin oral capsule, extended release Generic OTC
niacin oral tablet Generic OTC
niacin oral tablet extended release 24 hr Generic
47 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
niacin oral tablet extended release 250 mg, 500
mg, 750 mg
Generic OTC
niacinamide oral tablet Generic OTC
omega-3 acid ethyl esters Generic ST
omega-3 fatty acids oral capsule Generic OTC; QL
PRALUENT PEN Brand PA; QL
PRALUENT SYRINGE Brand PA; QL
pravastatin Generic
prevalite Generic
REPATHA SURECLICK Brand PA; QL
REPATHA SYRINGE Brand PA; QL
rosuvastatin Generic
SIMCOR Brand
simvastatin Generic
slo-niacin oral tablet extended release 500 mg Generic OTC
super omega-3 oral capsule 1,000 mg Generic OTC; QL
triklo Generic PA
WELCHOL Brand
Miscellaneous Cardiovascular Agents
CATHFLO ACTIVASE Brand
CORLANOR Brand PA
dobutamine Generic
dobutamine in d5w intravenous parenteral
solution 1,000 mg/250 ml (4,000 mcg/ml), 250
mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000
mcg/ml)
Generic
dopamine in 5 % dextrose Generic
dopamine intravenous solution 200 mg/5 ml (40
mg/ml), 400 mg/10 ml (40 mg/ml)
Generic
ENTRESTO Brand ST
milrinone Generic
milrinone in 5 % dextrose Generic
48 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
phenylephrine hcl injection Generic
RANEXA Brand
Nitrates
DILATRATE-SR Brand
ISORDIL Brand
isosorbide dinitrate oral Generic
isosorbide mononitrate Generic
MINITRAN Brand
nitro-bid Generic
NITRO-DUR Brand
nitroglycerin in 5 % dextrose intravenous solution
100 mg/250 ml (400 mcg/ml), 200 mg/500 ml (400
mcg/ml), 50 mg/250 ml (200 mcg/ml)
Generic
nitroglycerin oral Generic
nitroglycerin sublingual Generic
nitroglycerin transdermal patch 24 hour Generic
nitroglycerin translingual Generic
nitro-time Generic
Dermatologicals/Topical Therapy
Antipsoriatic / Antiseborrheic
acitretin Generic
anti-dandruff Generic OTC
anti-dandruff (coal tar) Generic OTC
calcipotriene Generic
calcipotriene-betamethasone Generic
calcitrene Generic
calcitriol topical Generic
drithocreme hp Generic
hydrocortisone-pramoxine topical Generic
ionil t Generic OTC
pc-tar Generic OTC
49 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
seb-prev Generic
selenium sulfide topical lotion Generic
selenium sulfide topical shampoo 2.25 % Generic
selsun blue Generic OTC
sulfacetamide sodium topical Generic
tera-gel tar shampoo Generic OTC
thera-gel Generic OTC
therapeutic shampoo topical shampoo 0.5 %, 1 %,
2 %
Generic OTC
t-plus Generic OTC
x-seb t plus Generic OTC
Burn Therapy
silver sulfadiazine Generic
ssd Generic
thermazene Generic
Keratolytics
acne cleanser Generic OTC
acne cleansing pads Generic OTC
acne pads Generic OTC
callus removers Generic OTC
compound w topical liquid Generic OTC
corn remover Generic OTC
corn-callus remover topical liquid Generic OTC
daily face wash Generic OTC
dermarest psoriasis medicated topical lotion Generic OTC
dermarest psoriasis medicated topical shampoo Generic OTC
dr scholl's clear away Generic OTC
duofilm Generic OTC
foot moisturizer Generic OTC
hydrisalic Generic OTC
latrix xm Generic
50 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
liquid corn and callus remover topical liquid 17 % Generic OTC
medicated corn removers Generic OTC
mediplast corn-callus-wart Generic OTC
mosco callus-corn remover Generic OTC
mosco corn remover Generic OTC
one-step plantar wart remover Generic OTC
one-step wart remover Generic OTC
plantar wart remover Generic OTC
PSORIASIN MEDICATED Brand OTC
psoriasis medicated Generic OTC
rapid clear treatment pads Generic OTC
salactic film Generic OTC
salacyn Generic
salicylic acid er-ceramides Generic
salicylic acid topical cream Generic
salicylic acid topical cream,extended release Generic
salicylic acid topical film forming liquid w/appl Generic
salicylic acid topical film-forming soln er w/ appl Generic
salicylic acid topical foam Generic
salicylic acid topical gel Generic
salicylic acid topical liquid 26 % Generic
salicylic acid topical lotion Generic
salicylic acid topical lotion,extended release Generic
salicylic acid topical shampoo Generic
sal-plant Generic OTC
salvax Generic
scalp itch-dandruff relief Generic OTC
SCALP RELIEF TOPICAL LIQUID Brand OTC
sebex Generic OTC
selsun blue (salicylic acid) Generic OTC
51 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
sulfo-lo Generic OTC
therapeutic shampoo topical shampoo 3 % Generic OTC
therapeutic t plus Generic OTC
wart remover Generic OTC
x-seb t pearl Generic OTC
Miscellaneous Dermatologicals
4-n-1 no rinse wash topical cream Generic OTC
8-MOP Brand
a and d (lan, pet) Generic OTC
a.e.r. witch hazel Generic OTC
absorbine pain relieving Generic OTC
advanced healing (petrolatum) Generic OTC
al 12 Generic OTC
alcohol-benzocaine Generic OTC
allergy cream (diphenhyd, zn) Generic OTC
allergy cream (diphenhydramin) Generic OTC
allergy relief spray Generic OTC
alphabath Generic OTC
ALUMINUM ACETATE Brand OTC
amerigel Generic OTC
amerigel preventive barrier Generic OTC
ameriphor Generic OTC
amlactin topical lotion Generic OTC
ammonium lactate Generic
analgesic (trolamine salicyl) Generic OTC
analgesic creme Generic OTC
analgesic grx balm topical ointment Generic OTC
anti-dandruff with menthol Generic OTC
anti-itch (diphenhydramine) Generic OTC
anti-itch (menthol/camphor) Generic OTC
52 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
anti-itch(diphenhyd) with zinc Generic OTC
antiseptic oral cleanser Generic OTC
antiseptic skin clnsr(chlorhe) Generic OTC
aqua care Generic OTC
aqua glycolic face Generic OTC
aqua glycolic topical shampoo Generic OTC
aquaphilic Generic OTC
arthricream rub Generic OTC
arthritis Generic OTC
arthritis pain relief(capsaic) topical cream 0.1 % Generic OTC
asper-flex Generic OTC
astringent Generic OTC
aveeno intense relief Generic OTC
avo cream Generic
baby darlings Generic OTC
baby wash Generic OTC
banophen anti-itch Generic OTC
bath oil Generic OTC
benadryl itch stopping topical gel Generic OTC
bengay ultra strength(menthol) Generic OTC
benzoin Generic OTC
benzoin (bulk) Generic OTC
benzoin compound Generic OTC
beta care Generic OTC
betasept surgical scrub Generic OTC
blue gel Generic OTC
boro-packs Generic OTC
bp-50% urea Generic
calahist Generic OTC
calamine Generic OTC
53 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
calamine phenolated Generic OTC
calamine-zinc oxide topical lotion 8-8 % Generic OTC
calamine-zinc oxide-phenol Generic OTC
caldyphen clear topical lotion 1-0.1 % Generic OTC
calmoseptine topical ointment Generic OTC
calohist Generic OTC
cam Generic OTC
cameo oil Generic OTC
camphor Generic OTC
capsaicin topical adhesive patch,medicated Generic OTC
capsaicin topical cream 0.025 %, 0.1 % Generic OTC
capsicum Generic OTC
captracin Generic
capzasin-hp Generic OTC
CARAC Brand
carb-o-philic topical cream 10 %, 20 % Generic OTC
carb-o-philic topical cream 40 % Generic
CASTELLANI PAINT MODIFIED Brand OTC
celacyn Generic
cem-urea Generic
ceta-klenz mild Generic OTC
cetaphil gentle cleanser Generic OTC
cetaphil moisturizing topical cream Generic OTC
cetyl alcohol (bulk) flakes Generic OTC
chest rub topical stick Generic OTC
CHLORHEXIDINE GLUCONATE (BULK) Brand OTC
chlorhexidine gluconate topical liquid Generic OTC
cleansing skin cream Generic OTC
clear anti-itch Generic OTC
cloverine Generic OTC
54 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
cold and hot extra strength Generic OTC
cold and hot pain relief Generic OTC
cold and hot therapy balm Generic OTC
cold sore treatment topical solution Generic OTC
colloidal oatmeal Generic OTC
CONDYLOX TOPICAL GEL Brand
conti castile soap Generic OTC
cool and heat Generic OTC
cool bottoms Generic OTC
cool heat (m-salicylate-menth) Generic OTC
cure chrome Generic OTC
CUTTER BACKWOODS Brand PA; OTC; QL
daily moisturizing lotion Generic OTC
dandruff shampoo (selen-aloe) Generic OTC
dermabase Generic OTC
dermacerin Generic OTC
dermadrox topical ointment Generic OTC
dermamed (aluminum hydroxide) Generic OTC
dermaphor topical ointment Generic OTC
dermasarra Generic OTC
dermavantage Generic OTC
diabetiderm foot rejuvenating Generic OTC
diaper rash relief Generic OTC
diaper rash topical ointment Generic OTC
diclofenac sodium topical gel 3 % Generic PA; QL
diphenhydramine hcl topical Generic OTC
doxepin topical Generic
dry skin bath oil Generic OTC
dry skin care Generic OTC
dry skin therapy Generic OTC
55 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
dry skin therapy moisturizing Generic OTC
DUPIXENT Brand PA; QL
eletone Generic
ELIDEL Brand ST
emollient Generic OTC
emulsion sb Generic
eucalyptus oil oil Generic OTC
eucalyptus oil topical Generic OTC
eucerin original Generic OTC
excel-gel Generic OTC
fem moist andlub(glycerin-hec) Generic OTC
finger cream Generic OTC
fingers skin Generic OTC
FLUOROPLEX Brand
fluorouracil topical cream 5 % Generic
fluorouracil topical solution Generic
gentle moisturizing lotion Generic OTC
gentle skin cleanser Generic OTC
geri-hydrolac Generic OTC
geri-shampoo Generic OTC
geri-soft Generic OTC
glycerin (bulk) liquid 100 % Generic OTC
glycerin topical liquid Generic OTC
glycerin topical solution Generic OTC
gordon's vite a Generic OTC
gordo-vite e Generic OTC
gormel Generic OTC
gormel ten Generic OTC
green soap Generic OTC
grx rinse-free Generic OTC
56 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
hair regrowth for women Generic OTC
hair regrowth treatment topical solution 5 % Generic OTC
hand wash Generic OTC
hemorrhoidal hygiene Generic OTC
hemorrhoidal medicated Generic OTC
hibiclens Generic OTC
high potency capsaicin Generic OTC
hpr Generic
hpr plus Generic
hpr plus hydrogel Generic
hydrating healing Generic OTC
hydrocerin Generic OTC
hydrocerin (with petrolatum) Generic OTC
hydrogen peroxide topical towelette Generic OTC
hydrolatum Generic OTC
hygienic (witch hazel) cleans Generic OTC
hygienic cleansing Generic OTC
hypercare topical solution Generic
HYPER-HEAL Brand OTC
ice blue gel Generic OTC
ice gel Generic OTC
icy hot (menthol) topical adhesive patch,medicated Generic OTC
imiquimod Generic QL
INSECT REPELLENT (PICARIDIN) Brand PA; OTC; QL
iodine topical Generic OTC
iodine-sodium iodide Generic OTC
isopropyl alcohol-benzocaine Generic OTC
isopropyl alcohol-wintergreen Generic OTC
itch relief (diphenhydramine) Generic OTC
itch relief (pramoxine-zinc) Generic OTC
57 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
itch relief topical cream Generic OTC
johnson's baby oil Generic OTC
kerodex-71 wet Generic OTC
k-y lubricating Generic OTC
lactic acid Generic
lactic acid (bulk) Generic OTC
lactic acid e Generic
lanolin anhydrous Generic OTC
lanolin topical cream Generic OTC
lan-o-soothe Generic OTC
latrix Generic
lubricants Generic OTC
lubricating Generic OTC
lubricating jelly (chlorhexid) Generic OTC
lubricating lotion Generic OTC
lubriderm daily moisture (pet) Generic OTC
lubriderm skin nourishing Generic OTC
lubrisilk Generic OTC
lubriskin (with lanolin) Generic OTC
lubrisoft Generic OTC
luxamend Generic
mac Generic
mapo bath Generic OTC
maxilube Generic OTC
mb hydrogel Generic
mb hydrogel (cyclomethicone) Generic
medi pads Generic OTC
medicated body Generic OTC
medicated body powder topical powder 0.15-1 % Generic OTC
medicated chest rub Generic OTC
58 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
medicated pads topical pads, medicated 50 % Generic OTC
medicated wipes topical pads, medicated Generic OTC
medicated wipes with aloe Generic OTC
men-phor Generic OTC
menthol Generic OTC
methoxsalen Generic
methyl alcohol Generic OTC
methyl salicylate Generic OTC
mineral freez Generic OTC
mineral oil light topical Generic OTC
minerin Generic OTC
minoxidil topical Generic OTC
mobisyl Generic OTC
moisture barrier ointment Generic OTC
moisturizing Generic OTC
moisturizing cream Generic OTC
moisturizing lotion (with pet) Generic OTC
moiturizing lotion Generic OTC
muscle relief Generic OTC
muscle rub (with camphor) Generic OTC
muscle rub topical cream 15-10 % Generic OTC
muscle rub ultra-strength Generic OTC
NATRAPEL Brand PA; OTC; QL
natural cold sore Generic OTC
natural oatmeal bath treatment Generic OTC
neutraphor Generic OTC
nivatopic plus Generic
no sting barrier film Generic OTC
nutraderm Generic OTC
nutraplus Generic OTC
59 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
oatmeal bath regular Generic OTC
ocusoft hand soap Generic OTC
OFF ACTIVE Brand PA; OTC; QL
OFF DEEP WOODS DRY Brand PA; OTC; QL
OFF FAMILYCARE (WITH DEET) Brand PA; OTC; QL
olive oil Generic OTC
pain relief (capsaicin) Generic
pain relief (menthol) Generic OTC
pain relief (trolamine salicy) Generic OTC
pain relief cream Generic OTC
pain relieving (menthol) topical adhesive
patch,medicated
Generic OTC
pain relieving (menthol) topical gel Generic OTC
pain relieving (m-sal-men-cam) Generic OTC
pain relieving cream Generic OTC
pain relieving rub (camphor) Generic OTC
PANRETIN Brand
pediatric oint (cod liver oil) Generic OTC
pentravan Generic OTC
peroxide sore mouth cleanser Generic OTC
peroxyl Generic OTC
personal lubricant Generic OTC
personal lubricating jelly Generic OTC
petrolatum Generic OTC
petrolatum, yellow (bulk) Generic OTC
petroleum jelly, white Generic OTC
PICATO Brand
pine tar (bulk) Generic OTC
podofilox Generic
pr cream Generic
pre-moistened hemorrhoidal Generic OTC
60 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
pre-moistened medicated wipes Generic OTC
preparation h (witch hazel) Generic OTC
protective ointment Generic OTC
pruclair Generic
prudoxin Generic
prumyx Generic
prutect Generic
rea lo 39 Generic
rea lo 40 Generic
recedo Generic
REGRANEX Brand QL
REJUVENESS Brand OTC
remedy 4-in-1 cleanser Generic OTC
remedy cleansing body Generic OTC
remeven Generic
renewal Generic OTC
renewal daily moisture lotion Generic OTC
renewal healing Generic OTC
REPEL SPORTSMEN DRY Brand PA; OTC; QL
REPEL SPORTSMEN MAX TOPICAL
AEROSOL,SPRAY
Brand PA; OTC; QL
risamine Generic OTC
rose water Generic OTC
salonpas topical adhesive patch,medicated Generic OTC
scar gel Generic OTC
secura protective Generic OTC
SILICONE SCAR Brand OTC
silk skin bath Generic OTC
silver nitrate Generic
silver nitrate applicators Generic
61 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
sinelee topical adhesive patch,medicated 0.0375-5
%
Generic
skin cleanser Generic OTC
skin protectant a and d Generic OTC
skin treatment Generic OTC
sonafine Generic
sorbidon hydrate Generic OTC
sp antipruritic Generic
sp scar management Generic
special care lotion Generic OTC
sports pain relief rub Generic OTC
sports rub pain relieving Generic OTC
sportscreme Generic OTC
sprayzoin Generic OTC
surgilube Generic OTC
sween cream Generic OTC
sweet oil Generic OTC
tacrolimus topical Generic ST
talc (bulk) Generic OTC
thera bath Generic OTC
thera-derm Generic OTC
thera-derm bath Generic OTC
therapeutic blue Generic OTC
therapeutic moisturizing Generic OTC
theraseal Generic OTC
thritex Generic OTC
tiger balm topical adhesive patch,medicated Generic OTC
tiger balm topical ointment Generic OTC
TRIAD WOUND DRESSING Brand OTC
tri-chlor Generic
trixaicin Generic OTC
62 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
trolamine salicylate Generic OTC
tru-micin topical lotion Generic OTC
turpentine oil Generic OTC
ultra mide 25 Generic OTC
ultracin t Generic OTC
umecta topical foam Generic
unscented cold cream Generic OTC
URAMAXIN GT Brand
urea (with lactic,salicy acid) Generic
urea 50% Generic
urea nail stick Generic
urea topical cream 10 %, 20 % Generic OTC
urea topical cream 39 %, 40 %, 45 %, 47 %, 50 % Generic
urea topical foam Generic
urea topical gel Generic
urea topical lotion 10 % Generic OTC
urea topical lotion 40 %, 45 % Generic
urea topical nail film suspension Generic
ureacin-20 Generic OTC
urea-hyaluronate sodium Generic
ure-k Generic
vanicream Generic OTC
VEREGEN Brand
vitamin a and d Generic OTC
vitamin a and d diaper rash Generic OTC
vitamin e plus Generic OTC
vitamin e topical cream Generic OTC
vitamin e topical oil Generic OTC
vitamin e-vitamins a and d Generic OTC
vits a and d-white pet-lanolin Generic OTC
63 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
wal-dryl (diphenhydramine) Generic OTC
wal-dryl (diphenhydramine-zn) topical cream Generic OTC
walgreens dry skin treatment Generic OTC
white petrolatum Generic OTC
white petroleum jelly Generic OTC
wintergreen oil Generic OTC
witch hazel topical liquid Generic OTC
x-viate Generic
z-clinz Generic OTC
zinc oxide topical ointment Generic OTC
zostrix Generic OTC
zostrix-hp Generic OTC
ZYCLARA Brand
Therapy For Acne
acne cleansing bar Generic OTC
acne control cleanser Generic OTC
acne foaming wash Generic OTC
acne medication topical gel 10 % Generic OTC
acne treatment (benzoyl perox) Generic OTC
acne vanishing Generic OTC
acne-clear Generic OTC
adapalene topical cream Generic
adapalene topical gel Generic
adapalene topical gel with pump Generic
adapalene-benzoyl peroxide Generic
advanced exfoliating cleanser Generic OTC
AKNE-MYCIN Brand
amnesteem Generic
avar topical cleanser Generic
avita topical cream Generic PA
64 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
BENZAMYCINPAK Brand
benzepro topical foam Generic OTC
benzepro topical towelette Generic
benzoyl peroxide topical cleanser 10 %, 3 %, 5 %,
6 %, 9 %
Generic OTC
benzoyl peroxide topical cleanser 7 % Generic
benzoyl peroxide topical foam Generic
benzoyl peroxide topical gel 10 %, 2.5 %, 5 % Generic OTC
benzoyl peroxide topical lotion Generic OTC
bp Generic OTC
bp 10-1 Generic
bp foam Generic OTC
bp wash acne treatment Generic OTC
bp wash topical cleanser 10 %, 5 % Generic OTC
bpo Generic
bpo creamy wash pack Generic OTC
bpo-10 Generic OTC
bpo-5 Generic OTC
claravis Generic
claris clarifying wash Generic
cleansing wash topical cleanser Generic
clearasil daily clear(benzoyl) Generic OTC
clindacin p Generic
CLINDAGEL Brand
clindamycin phosphate topical Generic
clindamycin-benzoyl peroxide Generic
clindamycin-tretinoin Generic PA
creamy acne face Generic OTC
ery pads Generic
erygel Generic
erythromycin with ethanol Generic
65 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
erythromycin-benzoyl peroxide Generic
FINACEA TOPICAL GEL Brand
foaming acne face wash Generic OTC
invisible acne Generic OTC
metronidazole topical Generic
myorisan Generic
neuac Generic
panoxyl topical bar Generic OTC
panoxyl topical cleanser Generic OTC
panoxyl-4 Generic OTC
persa-gel Generic OTC
rosadan topical cream Generic
rosadan topical gel Generic
rosula cleansing cloths Generic
se 10-5 ss Generic
se bpo Generic
sss 10-5 Generic
sulfacetamide sodium-sulfur Generic
sulfacetamide sod-sulfur-urea topical cleanser Generic
sulfacetamide-sulfur-cleansr23 Generic
sulfacleanse 8-4 Generic
sulfact na-sul-avobnz-otn-ocsa Generic
targeted acne spot treatment Generic OTC
tazarotene Generic
TAZORAC Brand
tretinoin Generic PA
tretinoin microspheres Generic PA
virti-sulf Generic
zenatane Generic
zencia Generic
66 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
Topical Anesthetics
actisep mucous membrane spray,non-aerosol Generic OTC
aloe burn relief Generic OTC
anbesol (benzocaine) max str Generic OTC
anbesol (benzocaine) mucous membrane gel Generic OTC
anbesol (benzocaine) mucous membrane liquid 20
%
Generic OTC
anecream Generic OTC
anecream5 Generic OTC
anesthetic oral gel Generic OTC
anti-itch (benz-resor) Generic OTC
baby teething gel Generic OTC
baby teething pain medicine Generic OTC
benz-o-sthetic mucous membrane gel Generic OTC
benz-o-sthetic mucous membrane solution Generic OTC
boil relief Generic OTC
boil-ease (benzocaine) Generic OTC
BUPIVACAINE (BULK) Brand
bupivacaine (pf) injection solution 0.5 % (5
mg/ml), 0.75 % (7.5 mg/ml)
Generic
bupivacaine injection solution 0.5 % (5 mg/ml) Generic
burn relief Generic OTC
burn relief with aloe topical gel Generic OTC
calaclear Generic OTC
calagesic Generic OTC
calahist clear Generic OTC
calahist with pramoxine Generic OTC
calamine medicated Generic OTC
calamine plus (pramox-calamin) Generic OTC
caldyphen clear topical lotion Generic OTC
caldyphen topical lotion 1-8 % Generic OTC
67 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
callergy clear Generic OTC
chloraseptic sore throat Generic OTC
cidaleaze Generic
cocaine Generic
dent-o-kain Generic OTC
dermacinrx prizopak Generic
dibucaine Generic OTC
dynamic Generic
dynamic plus pak Generic
ethyl chloride Generic
first aid antiseptic topical liquid Generic OTC
first aid antiseptic topical spray,non-aerosol 1-
0.13 %
Generic OTC
glydo Generic
intense toothache pain relief Generic OTC
lc-4 Generic OTC
lc-5 Generic OTC
LIDOCAINE (BULK) Brand
lidocaine (pf) injection solution 10 mg/ml (1 %),
40 mg/ml (4 %)
Generic
LIDOCAINE HCL (BULK) Brand
lidocaine hcl injection solution 10 mg/ml (1 %) Generic
lidocaine hcl laryngotracheal Generic
lidocaine hcl mucous membrane jelly Generic
lidocaine hcl mucous membrane jelly in applicator Generic
lidocaine hcl mucous membrane solution 4 % (40
mg/ml)
Generic
lidocaine hcl topical cream 3 % Generic
lidocaine hcl topical lotion Generic
lidocaine hcl-hydrocortison ac topical Generic
lidocaine topical adhesive patch,medicated Generic
68 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
lidocaine topical ointment Generic
lidocaine viscous Generic
lidocaine-aloe vera Generic OTC
lidocaine-prilocaine Generic
lido-k Generic
lidopin topical cream 3 % Generic
lidopril Generic
lorenza patch Generic
lta pre-attached Generic
mouth pain Generic OTC
oral analgesic Generic OTC
oral anesthetic mucous membrane gel Generic OTC
oral pain relief mucous membrane liquid Generic OTC
oral pain relief mucous membrane solution Generic OTC
orasep Generic OTC
pain relieving (benzocaine) Generic OTC
pro dna collection Generic
provenza patch Generic
relador pak Generic
relador pak plus Generic
sore throat Generic OTC
sore throat (benzocaine-menth) mucous membrane
lozenge 6-10 mg
Generic OTC
synvexia patch Generic
vagicaine (with vit a,d) Generic OTC
vagicaine topical cream 5-2 % Generic OTC
vagicream Generic OTC
vaginal itch Generic OTC
vagisil topical cream 5-2 % Generic OTC
zeruvia Generic
zilactin-b Generic OTC
69 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
Topical Antibacterials
ALTABAX Brand
antibiotic (bacitracin zinc) Generic OTC
antibiotic (neomy-bacit-polym) Generic OTC
antibiotic plus (pramoxine) Generic OTC
antibiotic plus pain rel(pram) Generic OTC
antibiotic-pain relief (bacit) Generic OTC
antiseptic topical solution Generic OTC
bacitracin topical Generic OTC
bacitracin zinc topical ointment Generic OTC
bacitracin-polymyxin b topical ointment Generic OTC
bacitraycin plus topical ointment 500 unit/gram Generic OTC
ca-rezz topical soap Generic OTC
CORTISPORIN TOPICAL Brand
dermazene Generic
double antibiotic Generic OTC
double antibiotic (b.tracn zn) Generic OTC
first aid abx pain relief Generic OTC
first aid antibiotic-pain rlf Generic OTC
first aid antiseptic topical solution Generic OTC
gentamicin topical Generic
grx dyne Generic OTC
hydrocortisone-iodoquinl-aloe2 Generic
hydrocortisone-iodoquinol-aloe Generic
iodine strong Generic OTC
iodoquinol-hc Generic
lugols topical Generic OTC
mafenide acetate Generic
multi antibiotic plus Generic OTC
mupirocin Generic
70 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
mupirocin calcium Generic
neosporin (neo-bac-polym) topical ointment in
packet
Generic OTC
peri-wash Generic OTC
physicians antibacterial Generic OTC
poly bacitracin Generic OTC
povidone-iodine topical gel Generic OTC
povidone-iodine topical liquid in packet Generic OTC
povidone-iodine topical ointment Generic OTC
povidone-iodine topical pads, medicated Generic OTC
povidone-iodine topical solution Generic OTC
povidone-iodine topical spray,non-aerosol Generic OTC
povidone-iodine topical swab 10 % Generic OTC
strong iodine topical Generic OTC
sulfacetamide sodium (acne) Generic
SULFAMYLON TOPICAL CREAM Brand
tri-biozene Generic OTC
triple antibiotic (pram) extra Generic OTC
triple antibiotic plus Generic OTC
triple antibiotic topical ointment Generic OTC
triple antibiotic topical ointment in packet Generic OTC
triple antibiotic-pain relief Generic OTC
wal-sporin Generic OTC
Topical Antifungals
af Generic OTC
aloe vesta antifungal (micon) Generic OTC
antifungal (clotrimazole) Generic OTC
antifungal (tolnaftate) Generic OTC
antifungal cream Generic OTC
antifungal spray Generic OTC
anti-fungal topical powder Generic OTC
71 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
athlete's foot (clotrimazole) Generic OTC
athlete's foot (terbinafine) Generic OTC
athlete's foot (tolnaftate) Generic OTC
athletic foot cream Generic OTC
azolen tincture Generic OTC
baza antifungal Generic OTC
blis-to-sol (tolnaftate) Generic OTC
ciclodan Generic
ciclopirox Generic
ciclopirox-ure-camph-menth-euc Generic
clotrimazole topical Generic
clotrimazole-betamethasone Generic
critic-aid clear af Generic OTC
derma cidol 2000 Generic OTC
desenex spray Generic OTC
desenex topical powder Generic OTC
econazole Generic
ERTACZO Brand
EXELDERM Brand
foot and sneaker Generic OTC
foot odor control Generic OTC
formula 3 Generic OTC
fungoid-d Generic OTC
gentian violet Generic OTC
inzo antifungal Generic OTC
itch relief (clotrimazole) Generic OTC
jock itch Generic OTC
jock itch (clotrimazole) Generic OTC
jock itch (terbinafine) Generic OTC
ketoconazole topical Generic
72 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ketodan Generic
ketodan kit Generic
lamisil af Generic OTC
lamisil at topical cream Generic OTC
lotrimin af powder Generic OTC
lotrimin ultra Generic OTC
MENTAX Brand
micatin Generic OTC
miconazole nitrate topical Generic OTC
miconazorb af Generic OTC
micro-guard Generic OTC
naftifine Generic
nuzole Generic OTC
nyamyc Generic
nyata Generic
nystatin topical Generic
nystatin-triamcinolone Generic
nystop Generic
odor control foot-sneaker Generic OTC
oxiconazole Generic
OXISTAT TOPICAL LOTION Brand
pedi-dri Generic
podactin Generic OTC
remedy antifungal Generic OTC
remedy phytoplex antifungal topical powder Generic OTC
ringworm Generic OTC
secura antifungal Generic OTC
sween prep Generic OTC
terbinafine hcl topical Generic OTC
tinactin topical aerosol powder Generic OTC
73 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
tinactin topical powder Generic OTC
tolnaftate topical aerosol powder Generic OTC
tolnaftate topical cream Generic OTC
tolnaftate topical solution Generic OTC
triple paste af Generic OTC
VUSION Brand QL
XOLEGEL Brand
zeasorb (miconazole) Generic OTC
Topical Antivirals
ABREVA Brand OTC
acyclovir topical Generic QL
Topical Corticosteroids
ala-cort topical cream Generic
alclometasone Generic
amcinonide Generic
anti-itch (hc) topical cream Generic OTC
anti-itch (hc) topical ointment Generic OTC
anti-itch (hc) with aloe-vit e Generic OTC
ANTI-ITCH PLUS Brand OTC
apexicon e Generic
beta-hc Generic OTC
betamethasone dipropionate Generic
betamethasone valerate Generic
betamethasone, augmented Generic
clobetasol Generic
clobetasol-emollient Generic
clodan Generic
CLODERM Brand ST
CORDRAN TAPE LARGE ROLL Brand ST
cormax scalp Generic
74 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
cortisone (hydrocortisone) Generic OTC
cortisone + cooling relief Generic OTC
cortizone-10 topical cream Generic OTC
cortizone-10 topical gel Generic OTC
cortizone-10 topical ointment Generic OTC
dermarest eczema (hydrocort) Generic OTC
dermasilkrx sds Generic
DESONATE Brand ST
desonide Generic
desoximetasone Generic
diflorasone Generic
eczema anti-itch Generic OTC
fluocinolone Generic
fluocinolone and shower cap Generic
fluocinonide Generic
fluocinonide-e Generic
flurandrenolide Generic
fluticasone topical Generic
halobetasol propionate Generic
HALOG Brand ST
hydrocortisone acet-aloe vera topical gel Generic
HYDROCORTISONE ACETATE (BULK) Brand
hydrocortisone acetate topical cream Generic OTC
hydrocortisone acetate topical ointment Generic OTC
hydrocortisone butyrate Generic
hydrocortisone butyr-emollient Generic
hydrocortisone plus Generic OTC
hydrocortisone topical cream 0.5 % Generic OTC
hydrocortisone topical cream 1 %, 2.5 % Generic
hydrocortisone topical lotion 1 % Generic OTC
75 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
hydrocortisone topical lotion 2.5 % Generic
hydrocortisone topical ointment 0.5 % Generic OTC
hydrocortisone topical ointment 1 %, 2.5 % Generic
hydrocortisone valerate Generic
hydrocortisone-aloe vera Generic OTC
hydrocortisone-min oil-wht pet Generic
hydrocream Generic OTC
hydroskin Generic OTC
hydroskin with aloe Generic OTC
medi-cortisone Generic OTC
mometasone topical Generic
neosporin anti-itch Generic OTC
noble formula hc topical cream Generic OTC
nolix Generic
NUCORT Brand ST
PANDEL Brand ST
prednicarbate Generic
recort plus Generic OTC
scalacort Generic
scalp relief topical solution Generic OTC
scalpicin anti-itch Generic OTC
soothing care (hydrocortisone) Generic OTC
TEXACORT Brand ST
triamcinolone acetonide topical aerosol Generic
triamcinolone acetonide topical cream Generic
triamcinolone acetonide topical lotion Generic
triamcinolone acetonide topical ointment 0.025 %,
0.1 %, 0.5 %
Generic
trianex Generic
triderm topical cream Generic
VERDESO Brand ST
76 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
Topical Enzymes
SANTYL Brand
vasolex Generic
Topical Pharmaceutical Adjuvants & Non-Medicinals
certain dri Generic OTC
foot powder Generic OTC
M9 ODOR ELIMINATOR Brand OTC
Topical Scabicides / Pediculicides
beta med Generic OTC
complete lice treatment Generic OTC
dandruff shampoo (pyrithione) Generic OTC
dermazinc shampoo Generic OTC
dermazinc spray Generic OTC
dhs zinc Generic OTC
lice bedding spray Generic OTC
lice complete kit 1-2-3 Generic OTC
lice cream rinse Generic OTC
lice killing Generic OTC
lice killing (permethrin) Generic OTC
lice pyrinyl shampoo Generic OTC
lice solution Generic OTC
lice treatment (resmethrin) Generic OTC
lice treatment topical liquid 1 % Generic OTC
lice treatment topical shampoo Generic OTC
lindane Generic
malathion Generic
noble formula scalp Generic OTC
noble formula topical bar Generic OTC
pediculicide 11 Generic OTC
permethrin topical cream Generic
77 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
permethrin topical liquid Generic OTC
pyrethrin lice treatment m Generic OTC
rid complete lice elim kit topical Generic OTC
rid lice killing Generic OTC
selsun blue (pyrithione zinc) Generic OTC
SKLICE Brand ST
spinosad Generic
stop lice Generic OTC
ULESFIA Brand
Diagnostics / Miscellaneous Agents
Enzymes
co q-10 oral capsule 10 mg, 100 mg, 150 mg, 200
mg, 30 mg, 50 mg, 75 mg
Generic OTC
coenzyme q10 oral capsule 100 mg, 200 mg, 30
mg, 400 mg, 50 mg, 60 mg
Generic OTC
coenzyme q10 oral tablet extended release 24 hr Generic OTC
h2q Generic OTC
q-sorb co q-10 oral capsule 100 mg, 200 mg Generic OTC
Irrigating Solutions
lactated ringers irrigation Generic
neomycin-polymyxin b gu Generic
ringer's irrigation Generic
tis-u-sol pentalyte Generic
Miscellaneous Agents
acamprosate Generic
acetic acid irrigation Generic
ADAGEN Brand
albustix reagent Generic OTC
alcohol, denatured Generic OTC
alendronate oral tablet 40 mg Generic QL
alertness aid Generic OTC; QL
78 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
alpha lipoic acid oral capsule 100 mg, 600 mg Generic OTC
alpha lipoic acid oral tablet 50 mg Generic OTC
alum, ammonium (bulk) Generic OTC
ammonia aromatic inhalation solution Generic OTC
anagrelide Generic
ARALAST NP Brand
awake Generic OTC
AZO TEST STRIPS Brand OTC
bacteriostatic water(parabens) Generic
bd pre-filled normal saline Generic
bentonite Generic OTC
caffeine Generic OTC; QL
caffeine citrate Generic
calcium-melatonin Generic OTC
CARBAGLU Brand
CARNITOR (SUGAR-FREE) Brand
cevimeline Generic
CHEMET Brand
CHEMSTRIP 2 Brand OTC
CHEMSTRIP MICRAL Brand OTC
CHERRY FLAVOR (BULK) Brand OTC
chromium picolinate oral capsule Generic OTC
chromium picolinate oral tablet 200 mcg, 400 mcg Generic OTC
citric acid anhydrous (bulk) Generic OTC
citric acid monohydrate (bulk) Generic OTC
compound 347 Generic
corn starch Generic OTC
cranberry extract oral capsule 425 mg, 500 mg Generic OTC
cranberry oral capsule 405 mg Generic OTC
cran-max Generic OTC
79 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
cryoserv Generic
curity sterile water Generic OTC
d2.5 %-0.45 % sodium chloride Generic
d5 % and 0.9 % sodium chloride Generic
d5 %-0.45 % sodium chloride Generic
dakin's solution solution 0.5 % Generic OTC
deferoxamine Generic
dex4 glucose bits Generic OTC
dex4 glucose oral gel Generic OTC
dex4 glucose oral tablet,chewable Generic OTC
dextrose 10 % in water (d10w) Generic
dextrose 5 % in ringer's Generic
dextrose 5 % in water (d5w) Generic QL
dextrose 5 %-lactated ringers Generic
dextrose 5%-0.2 % sod chloride Generic
dextrose 5%-0.3 % sod.chloride Generic
dextrose 50 % in water (d50w) Generic
diafoods thick-it oral powder Generic OTC
diluent for epoprostenol/flola Generic
disulfiram Generic
ENFAMIL GLUCOSE Brand OTC
enfamil water Generic PA; OTC
ethanol (ethyl alcohol) Generic
etidronate disodium Generic
evening primrose oil Generic OTC
EXJADE Brand
FERRIPROX ORAL TABLET Brand PA
forane Generic
formadon Generic
formaldehyde Generic
80 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
forma-ray Generic
FOSRENOL ORAL TABLET,CHEWABLE Brand
garlic-parsley Generic OTC
gelatin Generic OTC
gerber good start glucose Generic OTC
gerber good start water Generic OTC
gluco burst Generic OTC
glucosamine hcl oral tablet 1,500 mg Generic OTC
glucosamine sulf-chondroitinsa oral capsule 250-
200 mg
Generic OTC
glucosamine-chondroitin complx oral capsule 500-
400 mg
Generic OTC
glucosamine-chondroitin oral capsule 500-400 mg Generic OTC
glucosamine-chondroitin oral tablet 250-200 mg,
500-400 mg, 750-600 mg
Generic OTC
glucose bits Generic OTC
glucose gel Generic OTC
glucose oral tablet,chewable 4 gram Generic OTC
GLYCEROL FORMAL (BULK) Brand OTC
guar gum Generic OTC
h-chlor 12 Generic OTC
hemorrhoidal rectal suppository 0.25-3 % Generic OTC
hydrogen peroxide Generic OTC
hysept Generic OTC
ichthammol Generic OTC
INCRELEX Brand
indigo carmine Generic
insta-glucose Generic OTC
isoflurane Generic
isopropyl alcohol solution 91 %, 99 % Generic OTC
isopropyl palmitate Generic OTC
81 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
isopropyl palmitate (bulk) Generic OTC
kionex Generic
kionex (with sorbitol) Generic
lanthanum Generic
l-carnitine oral tablet Generic OTC
levocarnitine (with sugar) Generic
levocarnitine intravenous Generic
levocarnitine oral tablet Generic
l-glutamine oral tablet Generic OTC
LIPOCHOL Brand OTC
LITHOSTAT Brand
md-76 r Generic
meladox Generic OTC
melatin Generic OTC
melatonin oral liquid 5 mg/15 ml Generic OTC
melatonin oral tablet 1 mg, 10 mg, 3 mg, 5 mg Generic OTC
melatonin oral tablet extended release 1 mg, 3 mg Generic OTC
melatonin oral tablet,disintegrating 3 mg Generic OTC
methylcellulose 1500cps (bulk) Generic OTC
methylsulfonylmethane oral capsule Generic OTC
midodrine Generic
mineral oil heavy Generic OTC
mineral oil light Generic OTC
msm Generic OTC
no doz Generic OTC; QL
normal saline flush Generic
oleic acid Generic OTC
ora-sweet Generic OTC
ORA-SWEET SF Brand OTC
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5
MG
Brand
82 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
peanut oil Generic OTC
pedi-whirl Generic OTC
peppermint oil Generic OTC
peppermint spirit Generic OTC
pilocarpine hcl oral Generic
polyethylene glycol 1000(bulk) Generic OTC
polyoxyl 40 stearate Generic OTC
polysorbate 80 Generic OTC
PROLASTIN-C Brand
RENAGEL Brand
resource thickenup oral powder Generic OTC; QL
riluzole Generic
risedronate oral tablet 30 mg Generic QL
rosin (bulk) lump Generic OTC
safe wash Generic OTC
saline wound wash Generic OTC
sesame oil Generic OTC
sevelamer carbonate Generic
sevoflurane Generic
shark fin cartilage Generic OTC
similac sterilized water Generic OTC
simple syrup Generic OTC
sodium bisulfite Generic OTC
sodium chlor 0.9% bacteriostat Generic
sodium chloride 0.9 % injection solution Generic
sodium chloride 0.9 % injection syringe Generic
sodium chloride 0.9 % intravenous Generic
sodium chloride irrigation Generic
sodium ferric gluconat-sucrose Generic
sodium phenylbutyrate Generic
83 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
sodium polystyrene sulfonate oral Generic
sodium polystyrene sulfonate rectal enema 30
gram/120 ml
Generic
sodium saccharin (bulk) oral powder Generic OTC
sodium succinate Generic
sojourn Generic
soothe and cool body powder Generic OTC
sorbitol solution 70 % Generic OTC
soy isoflavones oral tablet Generic OTC
sps (with sorbitol) Generic
stay awake Generic OTC; QL
stearyl alcohol Generic OTC
sterile saline irrigation Generic OTC
sucrose (bulk) crystals Generic OTC
SYPRINE Brand
syrex sodium chloride 0.9% Generic
syrpalta Generic OTC
syrpalta vehicle Generic OTC
tea tree oil topical oil Generic OTC
terrell Generic
THIOLA Brand
tragacanth Generic OTC
URINARY TRACT INF.TEST (WBCS) Brand OTC
water for inject, bacteriostat Generic
water for injection, sterile Generic
water for irrigation, sterile Generic
white wax (beeswax) Generic OTC
ZEMAIRA Brand
Miscellaneous Devices
alcohol, rubbing Generic OTC
aquabase Generic OTC
84 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
delbase compounding Generic OTC
dermafix topical ointment Generic OTC
dy-o-derm Generic OTC
hydrophilic Generic OTC
isopropyl alcohol solution 70 % Generic OTC
peg Generic OTC
polyethylene glycol 1450(bulk) Generic OTC
Neutraceuticals
alfalfa oral tablet 250 mg Generic OTC
aloe vera oral capsule 5,000 mg Generic OTC
arnica Generic OTC
asafetida Generic OTC
black cohosh oral capsule 200 mg Generic OTC
calmme Generic OTC
capsicum (cayenne) Generic OTC
carica papaya Generic OTC
cat's claw (uncaria tomentosa) Generic OTC
central vite Generic OTC
cinnamon oil Generic OTC
colon herbal cleanser Generic OTC
complete premium vitamin Generic OTC
cranberry urinary comfort Generic OTC
daily garlic once-a-day Generic OTC
detox dietary Generic OTC
dong quai (angelica sinensis) Generic OTC
echinacea oral capsule 400 mg Generic OTC
echinacea oral tablet 125 mg Generic OTC
flaxseed oil oral capsule 1,000 mg Generic OTC
garlic oil oral capsule 3 mg Generic OTC
garlic oral capsule , 1,000 mg, 1,500 mg, 3 mg,
500 mg
Generic OTC
85 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
garlic oral tablet , 100 mg, 300 mg, 400 mg Generic OTC
garlic-x Generic OTC
ginger (zingiber officinalis) oral capsule 500 mg Generic OTC
ginkgo biloba oral capsule 40 mg Generic OTC
ginkgo biloba oral tablet 40 mg Generic OTC
ginseng Generic OTC
goldenseal root oral capsule 500 mg Generic OTC
grape seed Generic OTC
grape seed extract oral capsule 60 mg Generic OTC
hawthorn berry oral capsule 500 mg Generic OTC
innermost nature for men Generic OTC
kava kava oral capsule 500 mg Generic OTC
kelp Generic OTC
lavender oil Generic OTC
maximum energy Generic OTC
melatonin-chamomile flower Generic OTC
melatonin-pyridoxine hcl (b6) oral tablet 3-1 mg,
3-10 mg
Generic OTC
melatonin-pyridoxine hcl (b6) oral tablet extended
release
Generic OTC
melatonin-pyridoxine hcl (b6) oral tablet,ext
release multiphase 5-10 mg
Generic OTC
milk thistle extract Generic OTC
milk thistle oral capsule 150 mg Generic OTC
multivital performance Generic OTC
odor free garlic-x Generic OTC
odorless garlic oral tablet Generic OTC
omega-3 flaxseed oil Generic OTC
panax ginseng oral capsule Generic OTC
papaya enzyme Generic OTC
red yeast rice oral capsule Generic OTC
86 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
resver-red-bfl-grpsd-pol-c-pom Generic OTC
rutin Generic OTC
saw palmetto fruit Generic OTC
saw palmetto oral capsule 160 mg, 500 mg Generic OTC
saw palmto frt xtr-zinc picoli Generic OTC
st. john's wort Generic OTC
super energy herbal complex Generic OTC
valerian root oral capsule 500 mg Generic OTC
Pharmaceutical Adjuvants
almond oil, sweet (bulk) Generic OTC
anise Generic OTC
citronella oil Generic OTC
coconut oil (bulk) Generic OTC
ethyl acetate Generic
FLAVOR PACKETS Brand PA; OTC
magnesium stearate Generic OTC
methylene blue (bulk-solid) Generic OTC
orange oil Generic OTC
polybase Generic OTC
spearmint oil Generic OTC
Smoking Deterrents
buproban Generic
bupropion hcl (smoking deter) Generic
CHANTIX CONTINUING MONTH BOX Brand
CHANTIX ORAL TABLET 0.5 MG Brand
CHANTIX STARTING MONTH BOX Brand
nicorelief Generic OTC
nicorette buccal gum 4 mg Generic OTC
nicotine (polacrilex) Generic OTC
nicotine transdermal patch 24 hour 14 mg/24 hr,
21 mg/24 hr, 7 mg/24 hr
Generic OTC
87 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
nicotine transdermal patch, td daily, sequential Generic OTC
NICOTROL Brand
NICOTROL NS Brand
nts step 1 Generic OTC
quit 2 buccal gum Generic OTC
quit 4 buccal gum Generic OTC
stop smoking aid Generic OTC
Ear, Nose / Throat Medications
Miscellaneous Agents
12 hour nasal spray Generic OTC
4 way Generic OTC
afrin no drip(oxymetazolin) Generic OTC
altamist Generic OTC
anefrin Generic OTC
anti-itch medicated Generic OTC
ayr saline nasal aerosol,spray Generic OTC
ayr saline nasal drops Generic OTC
ayr saline nasal neti rinse Generic OTC
azelastine nasal Generic
baby ayr saline Generic OTC
cank-oxide Generic OTC
cheracol throat spray Generic OTC
children's saline nasal spray Generic OTC
chloraseptic Generic OTC
chloraseptic throat spray Generic OTC
chlorhexidine gluconate mucous membrane Generic
CLINPRO 5000 Brand
cough drops mucous membrane lozenge 10 mg Generic OTC
decongestant inhaler Generic OTC
deep sea nasal Generic OTC
88 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
denta 5000 plus Generic
dentagel Generic
dristan long lasting Generic OTC
ephrine Generic OTC
FAST ACTING NASAL Brand OTC
fluoride (sodium) dental Generic
fluoridex daily defense dental gel Generic
FLUORIDEX SENSITIVITY RELIEF Brand
ipratropium bromide nasal Generic QL
little remedies Generic OTC
mouth cleanser Generic OTC
mucinex sinus-max Generic OTC
nasadock plus kit Generic OTC
nasaflo porcelain kit Generic OTC
nasal decongestant (oxymetazl) Generic OTC
nasal four Generic OTC
nasal mist Generic OTC
nasal moisturizing Generic OTC
nasal relief Generic OTC
nasal relief sinus wash w/neti Generic OTC
nasal relief sinus wash-bottle Generic OTC
nasal spray (oxymetazoline) Generic OTC
nasal spray (sodium chloride) Generic OTC
nasal spray 12 hour nasal mist Generic OTC
nasal spray 12 hour sinus Generic OTC
nasal spray long acting Generic OTC
nasal spray x-moist Generic OTC
natural herb Generic OTC
neilmed nasaflo Generic OTC
neilmed pediat sinus rinse ref Generic OTC
89 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
neilmed sinus rinse complete Generic OTC
neilmed sinus rinse refill Generic OTC
no drip Generic OTC
no drip nasal relief Generic OTC
nose drops Generic OTC
nrs nasal relief Generic OTC
nu way Generic OTC
ocean nasal Generic OTC
olopatadine nasal Generic
ora relief Generic OTC
oral cleansing Generic OTC
oral relief sore throat spray Generic OTC
oralone Generic
original nasal spray Generic OTC
oxymetazoline Generic OTC
perio med Generic OTC
periogard Generic
phenaseptic Generic OTC
PREVIDENT 5000 BOOSTER PLUS Brand
PREVIDENT 5000 DRY MOUTH Brand
PREVIDENT 5000 ENAMEL PROTECT Brand
PREVIDENT 5000 SENSITIVE Brand
RHINARIS NASAL SPRAY,NON-AEROSOL Brand OTC
saline mist Generic OTC
saline nasal Generic OTC
saline nose Generic OTC
sea soft nasal mist Generic OTC
severe congestion Generic OTC
sf Generic
sf 5000 plus Generic
90 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
sinugator nasal wash kit Generic OTC
sinus nasal spray Generic OTC
sinus relief (oxymetazoline) Generic OTC
sinus rinse pediatric Generic OTC
sinus rinse pediatric starter Generic OTC
sinus wash nasal packet Generic OTC
SINUS WASH NASAL PACKET 700-2,300 MG Brand OTC
sinus wash netipot Generic OTC
SODIUM BENZOATE (BULK) Brand
sore throat (hexylresorcinol) mucous membrane
lozenge 2.4 mg
Generic OTC
sore throat (phenol) Generic OTC
sore throat relief (pectin) Generic OTC
stannous fluoride Generic
sterile saline nasal Generic OTC
throat drops mucous membrane lozenge 2 mg, 2.8
mg
Generic OTC
triamcinolone acetonide dental Generic
vicks qlearquil(oxymetazoline) Generic OTC
vicks sinex 12-hour Generic OTC
vicks sinex ultra fine mist 12 Generic OTC
wal-four Generic OTC
Miscellaneous Otic Preparations
acetasol hc Generic
acetic acid otic (ear) Generic
acetic acid-aluminum acetate Generic
aero otic hc Generic
antipyrine-benzocaine Generic
auraphene-b Generic OTC
aurodex Generic
auroguard Generic
91 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
carbamoxide ear drops Generic OTC
ciprofloxacin hcl otic (ear) Generic
cortane-b aqueous Generic
cortane-b otic (ear) Generic
ear drops (carbamide peroxide) Generic OTC
ear drops otc Generic OTC
ear dry Generic OTC
ear wax removal drops Generic OTC
ear wax treatment Generic OTC
exotic-hc Generic
floxin otic (ear) drops Generic
fluocinolone acetonide oil Generic
hydrocortisone-acetic acid Generic
murine ear wax removal system Generic OTC
ofloxacin otic (ear) Generic
oticin Generic
oticin hc (bak free) Generic
oto-end 10 Generic
otomax-hc Generic
otozin Generic
treagan otic Generic
TRIOXIN Brand
Otic Steroid / Antibiotic
CIPRODEX Brand
COLY-MYCIN S Brand
CORTISPORIN-TC Brand
neomycin-polymyxin-hc otic (ear) Generic
Endocrine/Diabetes
Adrenal Hormones
ACTHAR H.P. Brand
92 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
a-hydrocort Generic
ARISTOSPAN INTRA-ARTICULAR Brand
ARISTOSPAN INTRALESIONAL Brand
cortisone Generic
deltasone oral tablet 20 mg Generic
DEPO-MEDROL Brand
dexamethasone Generic
dexamethasone intensol Generic
dexamethasone sodium phos (pf) Generic
dexamethasone sodium phosphate injection
solution
Generic
DEXPAK 10 DAY Brand
DEXPAK 13 DAY Brand
DEXPAK 6 DAY Brand
fludrocortisone Generic
hydrocortisone oral Generic
KENALOG INJECTION Brand
MEDROL ORAL TABLET 2 MG Brand
methylprednisolone Generic
methylprednisolone acetate Generic
methylprednisolone sodium succ injection recon
soln 125 mg, 40 mg
Generic
methylprednisolone sodium succ intravenous Generic
millipred dp Generic
MILLIPRED ORAL SOLUTION Brand
millipred oral tablet Generic
prednisolone oral solution 15 mg/5 ml Generic
prednisolone sodium phosphate oral solution 10
mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4
mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7
mg/5 ml)
Generic
93 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
prednisolone sodium phosphate oral
tablet,disintegrating
Generic
prednisone Generic
prednisone intensol Generic
RAYOS Brand PA
SOLU-CORTEF (PF) INJECTION RECON
SOLN 1,000 MG/8 ML, 100 MG/2 ML, 250
MG/2 ML
Brand
SOLU-MEDROL Brand
SOLU-MEDROL (PF) INTRAVENOUS Brand
triamcinolone acetonide injection Generic
veripred 20 Generic
Antithyroid Agents
methimazole oral tablet 10 mg, 5 mg Generic
propylthiouracil Generic
SSKI Brand
thyroshield Generic OTC
Diabetes Therapy
1ST TIER UNIFINE PENTIPS NEEDLE 29
GAUGE X 1/2"
Brand OTC
1ST TIER UNILET COMFORTOUCH 28
GAUGE
Brand OTC
2TEK CONTROL (HIGH-NORMAL) Brand OTC
3M NEXCARE DURAPORE Brand OTC
ACAPELLA Brand
acarbose Generic
ACCU-CHEK RAPID D INFUSION
SUBCUTANEOUS INFUSION SET 6 X 50 MM-
CM
Brand
ACCU-CHEK SAFE-T-PRO Brand OTC
ACCU-CHEK SOFTCLIX LANCETS Brand OTC
ACCU-CHEK SPIRIT BATTERY COVER Brand OTC
94 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ACCU-CHEK TENDER SUBCUTANEOUS
INFUSION SET 13 X 110 MM-CM
Brand
ACCU-CHEK ULTRAFLEX SUBCUTANEOUS
INFUSION SET 8 X 60 MM-CM
Brand
ACCUTREND CHOLESTEROL TEST Brand OTC
ACCUTREND GLUCOSE Brand OTC
ACCUTREND GLUCOSE CONTROL Brand OTC
ACE AEROSOL CLOUD ENHANCER Brand
ACETEST Brand OTC
ACTICOAT 7 DRESSING TOPICAL
BANDAGE 4 X 5 "
Brand
ACTI-LANCE LANCETS 23 GAUGE Brand OTC
acti-lance lancets 28 gauge Generic OTC
ACTIVE CATH Brand OTC
ACTIVE LIFE 1-PC STOMA CAP Brand OTC
ACTIVE LIFE CONVEX UROSTOMY Brand OTC
ACTIVE LIFE CUT-TO-FIT CLOSED Brand OTC
ACTIVE LIFE DRAINABLE POUCH Brand OTC
ACTIVE LIFE UROSTOMY POUCH 1 3/4 " (9") Brand OTC
ACURA CONTROL HIGH Brand OTC
ACURA CONTROL LOW Brand OTC
ACURA CONTROL NORMAL Brand OTC
ACURA PLUS Brand OTC; QL
ADAPT BARRIER RING 2 " Brand OTC
ADAPT BARRIER STRIPS Brand OTC
ADAPT CONVEX BARRIER RINGS Brand OTC
ADAPT LUBRICATING DEODORANT Brand OTC
ADAPT OSTOMY PASTE Brand OTC
ADAPT STOMA POWDER Brand OTC
ADAPTER CAP FOR BOTTLE Brand OTC
ADD-A-FOLEY CATH-MONO-FLO DRNG Brand OTC
95 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ADD-A-FOLEY CATH-PRE-FILL SYRN Brand OTC
ADD-A-FOLEY TRAY Brand OTC
ADHESIVE BANDAGE TOPICAL BANDAGE ,
1 ", 3 X 4 ", 3/4 "
Brand OTC
ADHESIVE BARRIERS Brand OTC
ADHESIVE GAUZE PAD TOPICAL BANDAGE
2.375 X 4 "
Brand OTC
ADHESIVE REMOVER AEROSOL,SPRAY Brand OTC
ADHESIVE TAPE TOPICAL TAPE 1/2 X 5 "-
YARD
Brand OTC
ADJUSTABLE LANCING DEVICE Brand OTC
ADULT BRIEF - EXTRA LARGE Brand OTC
ADULT DISPOSABLE MOUTHPIECE Brand OTC
ADVANCED LANCING DEVICE Brand OTC
ADVANCED TRAVEL LANCETS 30 GAUGE Brand OTC
ADVOCATE BLOOD GLUCOSE MONITOR Brand OTC; QL
ADVOCATE DUO Brand OTC; QL
ADVOCATE LANCET 30 GAUGE Brand OTC
ADVOCATE LANCING DEVICE Brand OTC
ADVOCATE LOW CONTROL Brand OTC
ADVOCATE PEN NEEDLE NEEDLE 33
GAUGE X 5/32"
Brand OTC
ADVOCATE REDI-CODE Brand OTC
ADVOCATE REDI-CODE DUO METER Brand OTC; QL
ADVOCATE REDI-CODE GLU MONITOR Brand OTC; QL
ADVOCATE REDI-CODE+ CTRL LOW Brand OTC
ADVOCATE SYRINGES SYRINGE 1 ML 30
GAUGE X 5/16
Brand
ADVOCATE TEST STRIPS Brand OTC
AEROCHAMBER PLUS FLOW-VU,S MSK Brand
AEROCHAMBER PLUS Z STAT MD MSK Brand
AEROCHAMBER WITH FLOWSIGNAL Brand
96 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
AEROTRACH PLUS Brand
AGAMATRIX CONTROL HIGH Brand OTC
AIMSCO LATEX CONDOM Brand OTC
AIR TUBE WITH AIR PLUGS Brand OTC
AIRS ADULT AEROSOL MASK Brand OTC
AIRS DISPOSABLE NEBULIZER Brand OTC
AIRS PEDIATRIC DISPOSABLE MASK Brand OTC
AIRZONE PEAK FLOW METER Brand OTC
alcohol prep pads Generic OTC
ALCOHOL WIPES Brand OTC
ALLKARE ADHESIVE REMOVER WIPES Brand OTC
ALLKARE PROTECT BARRIER WIPES Brand OTC
ALTERNATE SITE LANCET Brand OTC
ALTERNATE SITE LANCING DEVICE Brand OTC
AMERIGEL DRESSING Brand OTC
ANTIBACTERIAL BANDAGES TOPICAL
BANDAGE
Brand OTC
APIDRA Brand
APIDRA SOLOSTAR Brand
AQUA LANCE LANCING DEVICE Brand OTC
AQUACEL EXTRA TOPICAL BANDAGE 2 X 2
"
Brand OTC
AQUACEL FOAM TOPICAL BANDAGE 7 X 7
"
Brand OTC
AQUACEL-AG TOPICAL BANDAGE 1.2-3.5 X
4 %-"
Brand OTC
ARGYLE TROCAR 8 FR Brand OTC
ASEPTO BULB Brand OTC
ASSESS FULL RANGE PEAK METER Brand OTC
ASSURA 2PC DRAINABLE Brand OTC
ASSURA 2PC IRRIGATION SLEEVE Brand OTC
ASSURA AC BASEPLATE Brand OTC
97 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ASSURA CONVEX SKIN BARRIER Brand OTC
ASSURA CONVEX SKIN BARRIER FLA 1/2 " Brand OTC
ASSURA CONVEX UROPOUCH Brand OTC
ASSURA EASICLOSE MINI POUCH Brand OTC
ASSURA EASICLOSE WIDE MAXI Brand OTC
ASSURA EXTRA CONVEX POUCH Brand OTC
ASSURA IRRIG FCE PLT 1/2-2 1/4 Brand OTC
ASSURA LIGHT EASICLOSE DRAINAB Brand OTC
ASSURA NON-CONVEX DRAINABLE Brand OTC
ASSURA OSTOMY BELT Brand OTC
ASSURA PEDIATRIC POUCH Brand OTC
ASSURA PEDIATRIC SKIN BARRIER Brand OTC
ASSURA POUCH Brand OTC
ASSURA WOUND MANAGER 1/2-2 3/4 Brand OTC
ASSURE 4 CONTROL SOLUTION Brand OTC
ASSURE 4 STRIPS Brand OTC
ASSURE DOSE NORMAL CONTROL Brand OTC
ASSURE HAEMOLANCE PLUS 1.2 MM Brand OTC
ASSURE ID INSULIN SAFETY SYRINGE 1
ML 29 GAUGE X 1/2"
Brand
ASSURE LANCE 25 GAUGE Brand OTC
ASSURE LANCE PLUS 21 GAUGE Brand OTC
ASSURE PLATINUM Brand OTC; QL
ASSURE PLATINUM STRIP Brand OTC
ASSURE PRO TEST STRIPS Brand OTC
ASTHMA CHECK METER Brand OTC
ASTHMAMENTOR PEAK FLOW METER Brand OTC
ASTHMAPACK CHILDREN'S Brand
ATN BRIEF Brand OTC
AUTOJECT 2 INJECTION DEVICE Brand OTC
AUTO-LANCET MINI Brand OTC
98 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
AUTOLET IMPRESSION LANC DEV Brand OTC
AUTOPEN 2 TO 32 UNITS Brand OTC
AVOGEL DRESSING TOPICAL BANDAGE 4
X 4 "
Brand OTC
BABY BASICS XX LARGE DIAPER Brand OTC
BABY THERMOMETER Brand OTC
BACT-POLLEN-DUST FILTER MASK Brand OTC
BANDAGES TOPICAL BANDAGE 3/4 " Brand OTC
BAND-AID FLEXIBLE FABRIC TOPICAL
BANDAGE 3/4 X 3 "
Brand OTC
BARD ADHESIVE REMOVER WIPES Brand OTC
BARD CENTER ENTRY CLOSE SYSTEM Brand OTC
BARD COUDE TIP CATHETER 12 FR Brand OTC
BARD DELUXE FABRIC LEG STRAPS Brand OTC
BARD EXTENSION TUBING/CONNECT Brand OTC
BARD FEMALE INTERMITTENT CATH Brand OTC
BARD INFECT CONT TRAY-NO CATH Brand OTC
BARD INFECTION CONTROL BAG Brand OTC
BARD LATEX LEG STRAPS Brand OTC
BARD LEG BAG HOLDER Brand OTC
BARD LEG BAG STRAPS/FABRIC Brand OTC
BARD LUBRICATH FOLEY TRAY Brand OTC
BARD PLASTIC TUBING/ADAPTER Brand OTC
BARD RUBBER UTILITY CATHETER 8 FR Brand OTC
BARD UNIVERSAL FOLEY CATH TRAY Brand OTC
BARD URETHRAL CATHETER TRAY TRAY
16 FR
Brand OTC
BARDEX ALL-SILICONE FOLEY CATH 14 FR Brand OTC
BARDEX CLOSED SYSTEM CATH TRAY Brand OTC
BARDEX URETHRAL CATHETERTRAY Brand OTC
BARDIA URINARY DRAINAGE BAG Brand OTC
99 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
BASAL THERMOMETER, ELECTRONIC Brand OTC
BASICS FOR KIDS Brand OTC
BD ALCOHOL SWABS Brand OTC
BD AUTOSHIELD PEN NEEDLE NEEDLE 29
GAUGE X 3/16"
Brand OTC
BD ECLIPSE LUER-LOK SYRINGE 1 ML 30
GAUGE X 1/2"
Brand
BD INSULIN PEN NEEDLE UF SHORT Brand
BD INSULIN SYRINGE MICRO-FINE
SYRINGE 1 ML 28 GAUGE X 1/2"
Brand
BD LANCET DEVICE Brand OTC
BD LO-DOSE MICRO-FINE IV SYRINGE 0.3
ML 28 GAUGE X 1/2"
Brand
BD LUER-LOK SYRINGE SYRINGE 1 ML, 1
ML 20 GAUGE X 1"
Brand OTC
BD MAGNI-GUIDE SYRINGE MAGNIFI Brand OTC
BD MICROTAINER LANCET 30 GAUGE Brand OTC
BD REGULAR BEVEL NEEDLES NEEDLE 27
GAUGE X 1/2"
Brand
BD SAFETYGLIDE SYRINGE SYRINGE 1 ML
27 GAUGE X 5/8"
Brand
BD SYRINGE SYRINGE 60 ML Brand OTC
BD ULTRA FINE LANCETS Brand OTC
BD ULTRA-FINE NANO PEN NEEDLES Brand OTC
BEDSIDE DRAINAGE COLLECT SYSTM Brand OTC
BELTED UNDERGARMENTS Brand OTC
BELTLESS UNDERGARMENTS Brand OTC
BEN-E-FIT BRIEFS Brand OTC
BIATAIN ADHESIVE FOAM DRESSING
TOPICAL BANDAGE 7 X 7 "
Brand OTC
BIOBRANE GLOVES MEDIUM Brand OTC
BIONIME RIGHTEST TEST STRIPS Brand OTC
BLADDER CONTROL PAD EXTRA PLUS Brand OTC
100 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
BLADDER CONTROL PADS FOR WOMEN Brand OTC
BLENDERM SURGICAL TOPICAL TAPE 1/2 X
5 "-YARD
Brand OTC
BLISTER CARE Brand OTC
BLISTER RELIEF BANDAGES Brand OTC
BLOOD GLUCOSE CONTROL, NORMAL Brand OTC
BLOOD GLUCOSE TEST Brand OTC
BLOOD PRESSURE KIT Brand OTC
BLOOD PRESSURE KIT MED AND LRG Brand OTC
BLOOD PRESSURE TEST KIT-LARGE Brand OTC
BLOOD PRESSURE TEST KIT-MEDIUM Brand OTC
BLOOD-GLUCOSE METER Brand OTC; QL
BORDERED GAUZE TOPICAL BANDAGE 4 X
4 "
Brand OTC
BOTTLE Brand OTC
BOTTLETOP DISPENSER ADAPTER Brand OTC
BOXERS FOR MEN Brand OTC
BREATHE RIGHT Brand OTC
BREATHERITE VALVED MDI CHAMBER Brand
BREEZE 2 Brand OTC; QL
BREEZE 2 TEST STRIPS Brand OTC
BREEZERS ADULT BRIEF Brand OTC
BSS/BSS PLUS ADMIN SET Brand OTC
BUBBLES THE FISH PEDI MASK Brand OTC
BULLSEYE MINI SAFETY LANCETS 21
GAUGE
Brand OTC
BURNS-SCALDS-ABRASIONS Brand OTC
BUTTERFLY CLOSURES Brand OTC
BYETTA Brand PA
CAMO BANDAGES Brand OTC
CANE Brand OTC
101 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
CAREFINE PEN NEEDLE NEEDLE 31 GAUGE
X 1/4"
Brand OTC
CAREONE THIN LANCET Brand OTC
CARESENS CONTROL A NORMAL Brand OTC
CARETOUCH PEN NEEDLE NEEDLE 31
GAUGE X 3/16"
Brand OTC
CARETOUCH TWIST LANCET 28 GAUGE Brand OTC
CARRASYN HYDROGEL WOUND DRESS Brand
CARTRIDGE PUMP STAMP IR1000 Brand OTC
CARTRIDGE STAMPED IR 1200 Brand OTC
CENTERPOINTLOCK CLOSED POUCH 1 3/4 " Brand OTC
CENTERPOINTLOCK DRAIN FILTER 1 3/4 ",
2 3/4 "
Brand OTC
CENTERPOINTLOCK DRAINABLE MINI 1 3/4
"
Brand OTC
CENTERPOINTLOCK DRAINABLE POUC 1
3/4 "
Brand OTC
CENTERPOINTLOCK FLEXTEND SKIN 1 1/4 " Brand OTC
CENTERPOINTLOCK FLEXWEAR CONVE 1/2
"
Brand OTC
CENTERPOINTLOCK SOFTFLEX SKIN 1 3/4 " Brand OTC
CENTERPOINTLOCK STOMA CAP 1 3/4 " Brand OTC
CENTERPOINTLOCK STOMA IRRIGAT 1 3/4
"
Brand OTC
CENTERPOINTLOCK UROSTOMY POUCH 1
1/2 ", 1 3/4 "
Brand OTC
CERTAINTY REGULAR Brand OTC
CHEK-STIX CONTROL Brand OTC
CHEMO TRANSFER PIN Brand OTC
CHEMSTRIP 10 MD Brand OTC
CHEMSTRIP 10/SG Brand OTC
CHEMSTRIP 2 GP Brand OTC
CHEMSTRIP 50B Brand OTC
102 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
CHEMSTRIP 7 Brand OTC
CHEMSTRIP 9 Brand OTC
CHEMSTRIP BG LOG BOOK Brand OTC
CHEMSTRIP K Brand OTC
CHEMSTRIP UGK Brand OTC
chlorpropamide Generic
CLEAR BANDAGES Brand OTC
CLEAR STRIPS TOPICAL BANDAGE Brand OTC
CLEAR WATERPROOF STRIPS TOPICAL
BANDAGE 1 "
Brand OTC
CLEVER CHEK BLOOD GLUCOSE Brand OTC
CLEVER CHEK LANCETS Brand OTC
CLEVER CHOICE GLUCOSE MONITOR Brand OTC; QL
CLEVER CHOICE LEVEL 2 CONTROL Brand OTC
CLEVER CHOICE MICRO Brand OTC; QL
CLEVER CHOICE PRO Brand OTC; QL
CLEVER CHOICE PRO STRIP Brand OTC
CLEVER CHOICE TEST STRIPS Brand OTC
CLEVER CHOICE VOICE+ TEST Brand OTC
CLICKFINE NEEDLE 31 GAUGE X 1/4" Brand OTC
CLINITEST REAGENT Brand OTC
CLOSED-END POUCH Brand OTC
CLOTH FIRST AID TAPE Brand OTC
CLOTH TAPE Brand OTC
COAGUCHEK LANCETS Brand OTC
COLOPLAST BARRIER RING 3/8 " Brand OTC
COLOPLAST IRRIGATION SET KIT Brand OTC
COLOPLAST PASTE PASTE Brand OTC
COLOPLAST SKIN BARRIER WAFER 4 X 4 " Brand OTC
COLOR LANCETS Brand OTC
103 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
COMBIDERM ACD DRESSING TOPICAL
BANDAGE 5 1/4 X 5 1/4 "
Brand OTC
COMBINATION CONE/TUBE DRAIN Brand OTC
COMBINE ABD Brand OTC
COMBISTIX REAGENT Brand OTC
COMFEEL PLUS ULCER DRESSING
TOPICAL BANDAGE 4 X 4 "
Brand OTC
COMFEEL PURILON Brand OTC
COMFEEL ULCER CARE DRESSING
TOPICAL BANDAGE 4 X 4 "
Brand OTC
COMFORT EZ PEN NEEDLES NEEDLE 31
GAUGE X 5/16"
Brand OTC
COMFORT LANCETS Brand OTC
COMFORT-STRETCH TRAINING PANTS Brand OTC
COMPACT COMPRESSOR NEBULIZER Brand OTC
COMPACT ULTRASONIC NEBULIZER Brand OTC
COMP-AIR ELITE COMP NEB SYSTEM Brand OTC
COMP-AIR XLT COMPRESSOR NEB Brand OTC
CONDOMS-PREM LUBRICATED Brand OTC
CONE-TUBE IRRIGATION SET Brand OTC
CONFORM TOPICAL BANDAGE 1 X 5 "-
YARD
Brand OTC
CONTOUR CONTROL SOLUTION, NML Brand OTC
CONTOUR I STOMA CAP Brand OTC
CONTOUR LINK Brand OTC; QL
CONTOUR NEXT EZ METER Brand OTC; QL
CONTOUR NEXT LEV 2 CONTROL SOL Brand OTC
CONTOUR NEXT LINK Brand OTC; QL
CONTOUR NEXT METER Brand OTC
CONTOUR NEXT STRIPS Brand OTC
CONTOUR NEXT USB METER Brand OTC
CONTOUR TEST STRIPS Brand OTC
104 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
CONTROL AST MONITORING SYSTEM Brand OTC
CONTROL AST TEST Brand OTC
CONVATEC NIGHT DRAINAGE TUBING Brand OTC
CONVEEN DRIP COLLECTOR Brand OTC
COOL MIST HUMIDIFIER 1 GALLON Brand OTC
COOLMAGIC TOPICAL BANDAGE 6 X 8 " Brand OTC
COPA HYDROPHILIC FOAM Brand OTC
CORNWALL METAL PIPETTING Brand OTC
COSMETIC BALLS Brand OTC
COTTON BALLS Brand OTC
COTTON SNAP PANTS Brand OTC
COTTON SWABS Brand OTC
COTTON, STERILE Brand OTC
CPL DRAINABLE POUCH 1 3/4 ", 2 3/4 " Brand OTC
CRUTCH Brand OTC
CRUTCH TIPS Brand OTC
CURASOL WOUND DRESSING Brand OTC
CURI-STRIP WOUND CLOSURES TOPICAL
STRIP 1/8 X 3 "
Brand OTC
CURITY 8000 URINE MTR FLY TRAY TRAY
16 FR
Brand OTC
CURITY ABDOMINAL PAD TOPICAL
BANDAGE 5 X 9 "
Brand OTC
CURITY ALCOHOL SWABS Brand OTC
CURITY BEDSIDE DRAINAGE BAG Brand OTC
CURITY BEDSIDE DRAINAGE SET Brand OTC
CURITY BEDSIDE-MONO-FLO DRANGE Brand OTC
CURITY FOLEY CATHETER KIT Brand OTC
CURITY GAUZE TOPICAL SPONGE 2 X 2 " Brand OTC
CURITY IODOFORM PACKING STRIP
TOPICAL BANDAGE 1/4 X 5 "-YARD
Brand
105 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
CURITY PREMIUM CATHETER TRAY TRAY
16 FR
Brand OTC
CURITY ULTRAMER 2-WAY CATHETER 16
FR
Brand OTC
CURITY UNIVERSAL - NO DRAINAGE TRAY
16 FR
Brand OTC
CURITY URETERAL DRAIN SET Brand OTC
CURITY URETH CATH CLOSED SYSTM Brand OTC
CURITY URETH CATH OPEN SYSTEM Brand OTC
CURITY URETHRAL CATHETER Brand OTC
CURITY URINE METER Brand OTC
cushion insole Generic OTC
CUTIEPANTS TRAINING PANTS Brand OTC
CUTIES BABY DIAPERS Brand OTC
DAVOL COMPLETE FOLEY Brand OTC
DAVOL FOLEY CATH INSERT TRAY Brand OTC
DAVOL SILICONE FOLEY CATHETER 16 FR Brand OTC
DAVOL URINARY DRAINAGE BAG Brand OTC
DAY AND NIGHT BRIEF,MEDIUM Brand OTC
DAY, PLUS PAD Brand OTC
DELTEC COZMO CLEO INFUSION SET Brand
DELUXE ARM BLOOD PRESSURE MON Brand OTC
DELUXE INSTANT EAR THERMOMETER Brand OTC
DEPEND PROTECTION SZ S-M Brand OTC
DEPEND REAL FIT BRIEF MEN S-M Brand OTC
DEPEND SILHOUETTE WOMEN S/M Brand OTC
DEPEND UNDERWEAR FOR WOMEN S-M Brand OTC
DERMACEA NON-WOVEN TOPICAL
SPONGE 4 X 4 "
Brand OTC
DERMACEA STRETCH TOPICAL BANDAGE
2 X 4 "-YARD
Brand OTC
106 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
DERMACEA TOPICAL BANDAGE 3.4 X 3.6 "-
YARD
Brand OTC
DERMADRESS TOPICAL BANDAGE 4 X 4 " Brand OTC
DERMAGAUZE Brand OTC
DERMAGINATE TOPICAL BANDAGE 12 " Brand OTC
DERMALEVIN TOPICAL BANDAGE 4 X 4 " Brand OTC
DERMASYN TOPICAL GEL Brand OTC
DERMAVIEW Brand OTC
DERMAVIEW II TOPICAL BANDAGE 2 3/8 X
2 3/4 "
Brand OTC
DETACHOL ADHESIVE REMOVER Brand OTC
DEVILBISS COMPACT COMPRESSOR Brand OTC
DEVILBISS DISPOSABLE NEBULIZER Brand OTC
DEVILBISS PULMO-AIDE COMPRESSR Brand
DEVILBISS PULMOMATE COMPRESSOR Brand OTC
DEVILBISS TRAVELER COMPRESSOR Brand
DIAPERS, UNISEX SIZE 3 Brand OTC
DIAPERS-DISP-POLYETHYLENE BACK Brand OTC
DIASTIX Brand OTC
DIGITAL PREGNANCY TEST Brand OTC
DIGITAL THERMOMETER Brand OTC
DISPOSABLE BRIEF Brand OTC
DISPOSABLE GLOVES PACKAGE Brand OTC
DISPOSABLE LATEX-FREE GLOVES Brand OTC
DISPOSABLE POWER Brand OTC
DISPOZ-A-BAG LEG BAG SMALL Brand OTC
DOVER CATHETER Brand OTC
DOVER PEDIATRIC URINE METER Brand OTC
DOVER TEXAS MALE EXTERNAL CATH Brand OTC
DOVER URI-DRAIN DELUXE LEG BAG Brand OTC
DOVER URI-DRAIN MALE EXT CATH Brand OTC
107 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
DOVER URINARY LEG BAG Brand OTC
DRAINABLE FECAL COLLECTOR Brand OTC
DRAINABLE POUCH CLAMP Brand OTC
DRAINABLE POUCH CLOSURE Brand OTC
DROPLET LANCETS Brand OTC
DROPLET LANCING DEVICE Brand OTC
DROPLET PEN NEEDLE NEEDLE 29 GAUGE
X 3/8"
Brand OTC
DRY COMFORT Brand OTC
DRY COMFORT EXTRA BRIEFS Brand OTC
DUODERM CGF DRESSING TOPICAL
BANDAGE 6 X 8 "
Brand OTC
DUODERM CGF EXTRA THIN TOPICAL
BANDAGE 6 X 6 "
Brand OTC
DUODERM HYDROACTIVE TOPICAL PASTE Brand OTC
DUOLOCK CURVED TAIL CLOSURE Brand OTC
DURAHESIVE MOLDABLE CONVEX Brand OTC
DURAPORE SURGICAL TOPICAL TAPE 1/2 X
10 "-YARD
Brand OTC
DURASORB UNDERPAD PAD 23 X 24 " Brand OTC
E.P.T. Brand OTC
E.P.T. DIGITAL Brand OTC
EAKIN COHESIVE SEALS Brand OTC
EAKIN COHESIVE SLIMS Brand OTC
EAR POPPER INFLATION DEVICE Brand
EARLY PREGNANCY TEST Brand OTC
EARLY RESULT PREGNANCY TEST Brand OTC
EASIVENT HOLDING CHAMBER Brand
EASY CLICK LANCING DEVICE Brand OTC
EASY COMFORT INSULIN SYRINGE
SYRINGE 1 ML 30 GAUGE X 5/16
Brand
EASY COMFORT LANCETS Brand OTC
108 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
EASY COMFORT PEN NEEDLES NEEDLE 31
GAUGE X 3/16"
Brand OTC
EASY PLUS II LOW CONTROL Brand OTC
EASY STEP BLOOD GLUCOSE METER Brand OTC; QL
EASY TALK LOW CONTROL Brand OTC
EASY TOUCH ALCOHOL PREP PADS Brand OTC
EASY TOUCH INSULIN SYRINGE SYRINGE 1
ML 31 GAUGE X 5/16
Brand
EASY TOUCH LANCING DEVICE Brand OTC
EASY TRAK BLOOD GLUCOSE METER Brand OTC; QL
EASY TRAK GLUCOSE TEST Brand OTC
EASYGLUCO MONITORING SYSTEM Brand OTC; QL
EASYGLUCO TEST Brand OTC
EASYMAX Brand OTC
EASYMAX LOW CONTROL Brand OTC
EASYMAX NORMAL CONTROL Brand OTC
EASYMAX V SPEAKING GLUCOSE SYS Brand OTC; QL
EASYMAX V2 BLOOD GLUCOSE METER Brand OTC; QL
ELASTO-GEL CAST-SPLINT PADDING
TOPICAL BANDAGE 12 X 12 "
Brand OTC
ELASTO-GEL CIRCLE DRESSING Brand OTC
ELASTO-GEL FACE DRESSING Brand OTC
ELEMENT NORMAL CONTROL Brand OTC
ELEMENT TEST STRIPS Brand OTC
ELIMINATOR ODOR SPRAY Brand OTC
EMBRACE BLOOD GLUCOSE SYSTEM Brand OTC; QL
EMBRACE BLOOD GLUCOSE SYSTEM
STRIP
Brand OTC
EMBRACE GLUCOSE CONTROL LOW Brand OTC
ENTRUST PLUS BRIEFS Brand OTC
ENTRUST PLUS SUPER UNDERPADS Brand OTC
ENTRUST PLUS UNDERGARMENTS Brand OTC
109 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ENTRUST PLUS UNDERWEAR Brand OTC
ESTEEM DRAINABLE POUCH 13/16-2 3/4 "
(12")
Brand OTC
ESTEEM SYNERGY Brand OTC
ESTEEM SYNERGY CLOSED POUCH 1 3/8 " Brand OTC
EVOLUTION BLOOD GLUCOSE METER Brand OTC; QL
EVOLUTION NORMAL CONTROL Brand OTC
EVOLUTION TEST STRIPS Brand OTC
EXCILON TOPICAL SPONGE 4 X 4 " Brand OTC
EXEL HYPODERMIC NEEDLES NEEDLE 27
GAUGE X 1/2"
Brand
EXPIRATORY MOUTHPIECE Brand OTC
EXTENSION TUBING W-CONNECTOR Brand OTC
EXTERNAL CATHETER, MALE 31 MM TO 35
MM
Brand OTC
EXUDERM ULTRA Brand OTC
EXU-DRY SCALP DRESSING Brand OTC
EXU-DRY WOUND DRESSING TOPICAL
BANDAGE 2 X 3 "
Brand OTC
EYE PAD Brand OTC
EYE PATCH Brand OTC
e-z ject lancets 26 gauge Generic OTC
EZ SMART LANCETS Brand OTC
EZ SMART PLUS TEST Brand OTC
EZ SMART SYSTEM Brand OTC; QL
EZ SMART TEST Brand OTC
E-Z SPACER Brand
FABRIC STRIP EXTRA LARGE Brand OTC
FACE MASK,EARLOOP-STYLE Brand OTC
FANTASY CONDOM Brand OTC
FAST READ THERMOMETER Brand OTC
FECAL COLLECTOR Brand OTC
110 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
FEMALE URINARY POUCH Brand OTC
FEVER FLASH THERMOMETER Brand OTC
FIFTY50 SAFETY SEAL LANCETS 30 GAUGE Brand OTC
FIFTY50 TEST STRIP Brand OTC
FILTER CLOSED MINI-POUCH 1 " Brand OTC
FILTERS REPLACEMENT Brand OTC
FILTRODOR POUCH FILTER Brand OTC
FINE 30 UNIVERSAL LANCETS Brand OTC
FINGERSTIX LANCETS Brand OTC
FIRST AID CLOTH TAPE Brand OTC
FIRST AID KITS Brand OTC
FIRST AID PAPER TAPE Brand OTC
FIRST CHOICE LANCETS THIN Brand OTC
FITTED BRIEFS MEDIUM Brand OTC
FLEXIBLE FABRIC BANDAGES TOPICAL
BANDAGE 2 X 3 ", 3/4 X 3 "
Brand OTC
FLEXIBLE FOAM Brand OTC
FLEXI-SEAL FMS Brand OTC
FLEXI-TRAK ANCHORING DEVICE Brand OTC
FLEXTEND SKIN BARRIER WAFER 4 X 4 " Brand OTC
FLEXZAN WOUND DRESSING TOPICAL
BANDAGE 2 X 3 "
Brand OTC
FLUTTER Brand
FOLEY CATHETER 14 FR Brand OTC
FOLEY CATHETER TRAY TRAY 16 FR Brand OTC
FORA D10 Brand OTC; QL
FORA D15G Brand OTC
FORA D20 KIT Brand OTC; QL
FORA G20 STRIP Brand OTC
FORA G30A Brand OTC; QL
FORA G30A STRIP Brand OTC
111 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
FORA LANCING DEVICE Brand OTC
FORA TEST STRIP Brand OTC
FORA V10 KIT Brand OTC; QL
FORA V10 STRIP Brand OTC
FORA V12 BLOOD GLUCOSE SYSTEM Brand OTC
FORA V12 GLUCOSE Brand OTC
FORA V20 KIT Brand OTC; QL
FORA V30A Brand OTC; QL
FOREHEAD THERMOMETER Brand OTC
FREESTYLE PRECISION SYRINGE 1 ML 30
GAUGE X 5/16
Brand
FRESHNET Brand OTC
GAUZE BANDAGE TOPICAL BANDAGE , 2
X 2.5 "-YARD, 3 X 147 ", 4 1/2 X 4 "-YARD, 4 X
4 "
Brand OTC
gauze roll Generic OTC
GE100 CONTROL SOLUTION NORMAL Brand OTC
GELPAD TOPICAL BANDAGE 4 X 4 " Brand OTC
GENTLECATH 12-16 FR-" Brand OTC
glimepiride Generic
glipizide Generic
glipizide-metformin Generic
GLUCAGEN DIAGNOSTIC KIT Brand
GLUCAGEN HYPOKIT Brand
GLUCAGON EMERGENCY KIT (HUMAN) Brand
GLUCOCARD 01 METER Brand OTC; QL
GLUCOCARD 01 NORMAL CONTROL Brand OTC
GLUCOCARD 01 SENSOR PLUS Brand OTC
GLUCOCARD 01-MINI Brand OTC; QL
GLUCOCARD EXPRESSION SOLUTION Brand OTC
GLUCOCARD VITAL Brand OTC; QL
112 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
GLUCOCARD VITAL SENSOR Brand OTC
GLUCOCARD VITAL TEST STRIPS Brand OTC
GLUCOCOM BLOOD GLUCOSE Brand OTC; QL
GLUCOCOM CONTROL NORMAL Brand OTC
GLUCOCOM GLUCOSE Brand OTC
GLUCOCOM LANCETS 28 GAUGE, 33
GAUGE
Brand OTC
GLUCOLET 2 AUTOMATIC LANCING Brand OTC
GLUCOSE CONTROL Brand OTC
GLUCOSOURCE Brand OTC
glyburide Generic
glyburide micronized Generic
glyburide-metformin Generic
GM100 KIT Brand OTC; QL
GM100 STRIP Brand OTC
GMATE LANCETS Brand OTC
GOODNITES UNDERPANTS L-XL Brand OTC
GRX WOUND GEL Brand OTC
GUARD MALE Brand OTC
GUARDIAN RT TEST PLUG DEVICE Brand
GUARDS FOR MEN Brand OTC
HANDICARE GARMENT LINER Brand OTC
HARMONIE UNDERPAD Brand OTC
HEALTHMIST Brand OTC
HEALTHY ACCENTS AUTOLET Brand OTC
HEALTHY ACCENTS UNIFINE PENTIP
NEEDLE 29 GAUGE X 1/2"
Brand OTC
HEALTHY ACCENTS UNILET LANCET Brand OTC
HEARING AID BATTERIES Brand OTC
HEATING PADS Brand OTC
heatwraps back and hip pads Generic OTC
113 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
HEAVY DUTY FABRIC STRIPS Brand OTC
HEMA-COMBISTIX Brand OTC
HEX-ON LIGHT ODOR Brand OTC
HOLLIHESIVE SKIN BARRIER Brand OTC
HOLLISTER REPLACEMENT FILTERS Brand OTC
hot and cold pack Generic OTC
huber safety needles (disp.) Generic
HUGGIES PULL-UPS 2T-3T Brand OTC
HUGO ROLLING WALKER Brand OTC
HUMALOG Brand
HUMALOG JUNIOR KWIKPEN Brand
HUMALOG KWIKPEN SUBCUTANEOUS
INSULIN PEN 100 UNIT/ML
Brand
HUMALOG MIX 50-50 Brand
HUMALOG MIX 50-50 KWIKPEN Brand
HUMALOG MIX 75-25 Brand
HUMALOG MIX 75-25 KWIKPEN Brand
HUMAPEN LUXURA HD Brand
HUMIDIFIERS Brand OTC
HUMULIN 70/30 Brand
HUMULIN N Brand
HUMULIN R U-100 Brand
HUMULIN R U-500 (CONCENTRATED) Brand
HURRICAINE LUER-LOCK DIS CAP Brand OTC
HYDROCOL II Brand OTC
HYDROCOLLOID DRESSING TOPICAL
BANDAGE 4 X 4 "
Brand OTC
HYPO-ALLERGENIC BANDAGES Brand OTC
HYPOLANCE AST LANCING Brand OTC
ILE-SORB ORIGINAL Brand OTC
INCARE INVIEW CATHETER 36 MM Brand OTC
114 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
IN-CHECK NASAL WITH MASK Brand OTC
IN-CHECK ORAL FLOW METER Brand OTC
INCONTROL BP MONITOR Brand OTC
INCONTROL LANCING DEVICE Brand OTC
INCONTROL PEN NEEDLE NEEDLE 29
GAUGE X 1/2"
Brand OTC
INCONTROL SUPER THIN LANCETS Brand OTC
INCONTROL ULTRA THIN LANCETS Brand OTC
INFINITY CONTROL SOLUTION NORM Brand OTC
INFINITY STARTER KIT Brand OTC; QL
INFINITY TEST STRIPS Brand OTC
INJECT EASE LANCETS 28 GAUGE Brand OTC
INJECT-EASE Brand OTC
INJECT-EASE AUTOMATIC INJECTOR Brand OTC
INNOSPIRE ELEGANCE Brand
INS SYRINGE/NEEDLE 0.5 ML 27 G Brand
INSPIRATION ELITE Brand
INSPIRATION NEBULIZER SYSTEM Brand
INSTANT EAR THERMOMETER Brand OTC
INSUFLON Brand
INSULIN PUMP IR1250 Brand
INSULIN SYRINGE-NEEDLE U-100 SYRINGE
0.5 ML 29 GAUGE X 1/2"
Brand
insulin syringe-needle u-100 syringe 1 ml 30
gauge x 3/8"
Generic
INSULIN SYRINGES (DISPOSABLE) Brand
INSUPEN NEEDLE 29 GAUGE X 1/2" Brand OTC
INTEGRA SYRINGE SYRINGE 1 ML 25
GAUGE X 1"
Brand OTC
INVACARE LANCETS Brand OTC
IRRIGATION SLEEVE Brand OTC
J AND J NON-STICK PADS MEDIUM Brand OTC
115 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
JANUMET Brand ST
JANUMET XR Brand ST; QL
JANUVIA Brand ST
JAZZ WIRELESS 2 METER KIT Brand OTC; QL
KALTOSTAT ROPE Brand OTC
KANGAROO ENTERAL-FEED-IRRIG KT Brand OTC
KANGAROO RIGID CONTAINER PUMP Brand OTC
KARAYA 5 CLOSED POUCH - TAPE 1 1/2 " Brand OTC
KARAYA 5 DRAINABLE POUCH 1 " Brand OTC
KARAYA PASTE Brand OTC
KARAYA POWDER Brand OTC
KENDALL PAPER TAPE Brand OTC
KENDALL TOPICAL BANDAGE 2 X 2 3/4 " Brand OTC
KENGUARD URINARY DRAIN BAG Brand OTC
KENLINE ADD-A-FOLEY TRAY 30CC Brand OTC
KERLIX TOPICAL SPONGE Brand OTC
KETO-DIASTIX Brand OTC
KETONE URINE TEST Brand OTC
KETOSTIX Brand OTC
KID PANTS FOR GIRLS Brand OTC
KIMONO CONDOMS(NON-LUBRICATED) Brand OTC
KIMONO MAXX CONDOMS Brand OTC
KIMONO MICROTHIN AQUA LUBE CON Brand OTC
KIMONO MICROTHIN CONDOMS Brand OTC
KIMONO TEXTURED CONDOMS Brand OTC
KINNEY BRAND LANCETS Brand OTC
LABSTIX REAGENT Brand OTC
LANCETS , 30 GAUGE Brand OTC
LANCETS,THIN , 28 GAUGE Brand OTC
LANCING DEVICE Brand OTC
116 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
LANCING SYSTEM Brand OTC
LANTUS Brand
LANTUS SOLOSTAR Brand
latex gloves Generic OTC
LC D NEBULIZER SET Brand
LC PLUS Brand
LEVEMIR Brand
LEVEMIR FLEXPEN Brand
LEVEMIR FLEXTOUCH Brand
LIBERTY BLOOD GLUCOSE MONITOR Brand OTC; QL
LIBERTY LEV 1 GLUCOSE CONTROL Brand OTC
LIBERTY LEV 2 GLUCOSE CONTROL Brand OTC
LIBERTY TEST Brand OTC
LISCO TOPICAL SPONGE 2 X 2 " Brand OTC
LITE TOUCH LANCING DEVICE Brand OTC
LITEAIRE MDI CHAMBER Brand
LITETOUCH-SMALL MASK Brand
LITTLE ONES CLOSED-END POUCH 1 1/4 " Brand OTC
LITTLE ONES DRAINABLE POUCH , 1 3/4 " Brand OTC
LITTLE ONES FLEXIBLE SKIN 1 1/4 " Brand OTC
LITTLE ONES SKIN BARRIER Brand OTC
LITTLE ONES UROSTOMY POUCH Brand OTC
LOOP OSTOMY BRIDGE STERILE Brand OTC
LO-PROFILE UROSTOMY POUCH 1 " Brand OTC
LUVS SIZE 6 Brand OTC
M9 CLEANER-DECRYSTALLIZER Brand OTC
MAGELLAN INSULIN SAFETY SYRNG
SYRINGE 1 ML 29 GAUGE X 1/2"
Brand
MAGELLAN SYRINGE SYRINGE 0.5 ML 30
GAUGE X 5/16"
Brand
MASK VORTEX BABY WHIRL DUCK Brand OTC
117 Updated 1/2018
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– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
MASTISOL ADHESIVE Brand OTC
MAXICARE BELTED UNDERGARMENT Brand OTC
MAXICARE UNDERPADS PAD 30 X 30 " Brand OTC
MAXI-COMFORT INSULIN SYRINGE
SYRINGE 1/2 ML 28 GAUGE X 1/2"
Brand
MAXIMA CONTROL SOLUTION, NORMA Brand OTC
MEDICAL ADHESIVE Brand OTC
MEDICINE DROPPER Brand OTC
MEDICINE DROPPER AND SPOON Brand OTC
MEDICINE SPOON Brand OTC
medigrip elasticated support Generic OTC
MEDI-LANCE LANCETS Brand OTC
MEDIPORE Brand OTC
MEDIPORE H TOPICAL TAPE 3 X 10 "-YARD Brand OTC
MEDISENSE Brand OTC
MEDISENSE GLUCOSE KETONE Brand OTC
MEDISENSE THIN LANCETS Brand OTC
MEDLANCE PLUS LANCETS 25 GAUGE Brand OTC
MEDLANCE PLUS SPECIAL BLADE Brand OTC
MEDTRONIC REMOTE CONTROL Brand OTC
MESH PANTS Brand OTC
metformin Generic
MICRO AIR Brand OTC
MICRO BLOOD GLUCOSE Brand OTC
MICRO ELITE COMP-NEBUL Brand
MICRO ELITE REPLACEMENT FILTER Brand OTC
MICRO THIN LANCETS Brand OTC
MICROCHAMBER Brand
MICRODERM 1 " Brand OTC
MICRODERM PLUS 1 " Brand OTC
118 Updated 1/2018
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– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
MICRODOT BLOOD GLUCOSE SYSTEM
STRIP
Brand OTC
MICRODOT NORMAL CONTROL Brand OTC
MICROFOAM SURGICAL TOPICAL TAPE 1 X
5 1/2 "-YARD
Brand OTC
MICROHESIVE STOMA PASTE Brand OTC
MICROLET LANCET Brand OTC
MICROLIFE PEAK FLOW METER Brand OTC
MICROPORE SURGICAL TOPICAL TAPE 1/2
X 10 "-YARD
Brand OTC
MICROSPACER Brand
MICROSPONGE Brand OTC
miglitol Generic
MINI ELITE COMPRESSOR-NEBULIZE Brand
MINI ELITE FILTER REPLACEMENT Brand OTC
MINI LANCING DEVICE Brand OTC
MINI TRANSFER PIN Brand OTC
MINI ULTRA-THIN II Brand OTC
MIRASORB Brand OTC
MONOJECT HYPODERMIC NEEDLES
NEEDLE 18 GAUGE X 1"
Brand
MONOJECT INSULIN SYRINGE SYRINGE 1
ML
Brand
MONOJECT SAFETY SYRINGES SYRINGE Brand
MONOJECT SAFETY SYRINGES SYRINGE 3
ML 21 GAUGE X 1"
Brand OTC
MONOJECT SYRINGE SYRINGE 1/2 ML 28
GAUGE
Brand
MONOLET LANCETS Brand OTC
MONOLET THIN LANCETS Brand OTC
MPM FOAM DRESSING TOPICAL BANDAGE
4 X 4 "
Brand OTC
MULTI-LANCET DEVICE Brand OTC
119 Updated 1/2018
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– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
multi-purpose soft contact len Generic OTC
MULTISTIX Brand OTC
MULTISTIX 10 SG Brand OTC
MULTISTIX 5 Brand OTC
MULTISTIX 7 Brand OTC
MULTISTIX 8 SG Brand OTC
MULTISTIX 9 Brand OTC
MULTISTIX 9 SG Brand OTC
MYGLUCOHEALTH LANCETS Brand OTC
NASAL STRIPS LARGE Brand OTC
nateglinide Generic
NATURA CLOSED POUCH 1 1/4 " Brand OTC
NATURA DURAHESIVE SKIN BARRIER 1 3/4
"
Brand OTC
NATURA STOMAHESIVE SKN BARRIER 1
3/4 "
Brand OTC
NATURAL CARE BANDAGES Brand OTC
NEW GENERATION Brand OTC
NEW IMAGE CLOSED MINI-POUCH 1 3/4 " Brand OTC
NEW IMAGE CLOSED POUCH 2 1/4 ", 2 3/4 " Brand OTC
NEW IMAGE DRAIN MINI-POUCH 1 3/4 " Brand OTC
NEW IMAGE DRAINABLE POUCH 1 3/4 " Brand OTC
NEW IMAGE FLEXTEND BARRIER FLA 1 3/4
"
Brand OTC
NEW IMAGE FLEXWEAR FLAT 1 3/4 " Brand OTC
NEW IMAGE IRRIGATOR SLEEVE 1 3/4 " Brand OTC
NEW IMAGE OSTOMY KIT 2 1/4 " (12 ") Brand OTC
NEW IMAGE SKIN BARRIER-FLANGE 1 3/4 ",
2 1/4 "
Brand OTC
NEW IMAGE UROSTOMY POUCH 1 3/4 " (9") Brand OTC
NEXCARE GENTLE PAPER TAPE Brand OTC
NEXCARE TEGADERM Brand OTC
120 Updated 1/2018
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– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
NIGHT DRAIN ADAPTER Brand OTC
NITRILE EXAM GLOVES Brand OTC
NON-ADHERENT BANDAGE TOPICAL
BANDAGE 2 X 3 "
Brand OTC
NON-STICK PAD TOPICAL BANDAGE 3 X 4 " Brand OTC
NO-STING SKIN-PREP Brand OTC
NOVA MAX BLOOD GLUCOSE METER Brand OTC; QL
NOVA MAX GLUCOSE CONTROL Brand OTC
NOVA MAX GLUCOSE TEST Brand OTC
NOVA SAFETY LANCETS 28 GAUGE Brand OTC
NOVA SUREFLEX LANCETS Brand OTC
NOVAMAX PLUS KETONE Brand OTC
NOVOFINE 32 Brand OTC
NOVOFINE AUTOCOVER Brand OTC
NOVOFINE PLUS Brand OTC
NOVOLIN 70/30 Brand
NOVOLIN N Brand
NOVOLIN R Brand
NOVOLOG Brand
NOVOLOG FLEXPEN Brand
NOVOLOG MIX 70-30 Brand
NOVOLOG MIX 70-30 FLEXPEN Brand
NOVOLOG PENFILL Brand
NOVOPEN 3 Brand OTC
NOVOTWIST NEEDLE 30 GAUGE X 1/3" Brand OTC
NU-FIT BRIEF MEDIUM Brand OTC
O.A.D. Brand OTC
ODOR ELIMINATOR DROPS Brand OTC
OMNIPOD INSULIN REFILL Brand
ON CALL LANCET Brand OTC
ON CALL LANCING DEVICE Brand OTC
121 Updated 1/2018
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– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ON CALL PLUS CONTROL Brand OTC
ON CALL PLUS LANCET Brand OTC
ON CALL PLUS LANCING DEVICE Brand OTC
ONE STEP PREGNANCY TEST Brand OTC
ONE WAY VALVED MOUTHPIECE Brand OTC
ONETOUCH DELICA LANCETS 30 GAUGE Brand OTC
ONETOUCH FINEPOINT LANCETS Brand OTC
ONETOUCH SURESOFT LANCING DEV Brand OTC
ONETOUCH ULTRA CONTROL Brand OTC
ONETOUCH ULTRA TEST Brand OTC
ONETOUCH ULTRA2 Brand OTC; QL
ONETOUCH ULTRALINK Brand OTC; QL
ONETOUCH ULTRAMINI Brand OTC; QL
ONETOUCH ULTRASOFT LANCETS Brand OTC
ONETOUCH VERIO Brand OTC
ONETOUCH VERIO IQ METER Brand OTC; QL
ONETOUCH VERIO MID CONTROL Brand OTC
ON-THE-GO LANCETS Brand OTC
OPSITE IV 3000 TOPICAL BANDAGE 2 3/8 X
2 3/4 "
Brand OTC
OPTICHAMBER ADULT MASK-LARGE Brand
OPTICHAMBER DIAMOND VHC Brand
OPTICLUDE EYE PATCH JUNIOR Brand OTC
OPTIFOAM TOPICAL BANDAGE 4 X 4 " Brand OTC
OPTIUM EZ Brand OTC
OPTIUM TEST Brand OTC
ORAL THERMOMETER Brand OTC
OSTOMY BELT LARGE Brand OTC
OSTOMY PASTE Brand OTC
OSTOMY SUPPLIES Brand OTC
OVER NITES Brand OTC
122 Updated 1/2018
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– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
OVERNIGHT UNDERWEAR SMALL-MED Brand OTC
PAIN FREE TAPE Brand OTC
PAMPERS UNISEX BABY-DRY Brand OTC
PANDA MASK Brand OTC
PANT LINERS, LARGE Brand OTC
PANT LINERS, LARGE PLUS Brand OTC
PAPER TAPE Brand OTC
PARI BABY CONV KIT - SIZE 1 Brand
PARI BABY NEBULIZER Brand
PARI LC MASK SET Brand
PARI LC SPRINT NEBULIZER SET Brand
PARI TREK S COMBO PACK Brand
PARI TREK S COMPACT COMPRESSOR Brand
PEAK AIR PEAK FLOW METER Brand OTC
PEDIATRIC PANDA MASK Brand OTC
PEN NEEDLE NEEDLE 29 GAUGE X 1/2" Brand OTC
PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE
X 1/2"
Brand OTC
PENLET PLUS BLOOD SAMPLER Brand OTC
PENTIPS NEEDLE 29 GAUGE X 1/2" Brand OTC
PER-FIT BRIEFS Brand OTC
PER-FIT UNDERWEAR Brand OTC
PERSONAL BEST FULL RANGE Brand OTC
PERSONAL CONFIDENCE BRIEFS Brand OTC
personal confidence liners Generic OTC
PERSONAL CONFIDENCE PADS Brand OTC
PERSONAL CONFIDENCE UNDERWEAR Brand OTC
PETROLATUM GAUZE TOPICAL BANDAGE
3 X 18 "
Brand OTC
PHARMACIST CHOICE Brand OTC
PHARMACIST CHOICE GLUCOSE SYS Brand OTC; QL
123 Updated 1/2018
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– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
PIKO 1 Brand OTC
PILLOW MASK PEDIATRIC Brand OTC
pioglitazone Generic
pioglitazone-glimepiride Generic
pioglitazone-metformin Generic
PIPETTE 30ML CATHETER TIP Brand OTC
PLASTIC STRIPS TOPICAL BANDAGE 3/4 X 3
"
Brand OTC
PLASTIC SWABS Brand OTC
POCKET CHAMBER Brand
POCKET PEAK FLOW METER Brand OTC
POISE PADS Brand OTC
POLY HUB NEEDLE NEEDLE 27 GAUGE X
1/2"
Brand
POLYSKIN II TOPICAL BANDAGE 4 X 4 3/4 " Brand OTC
POUCH CLAMP Brand OTC
POUCHKINS DRAINABLE POUCH 2 " Brand OTC
POUCHKINS OSTOMY SYSTEM Brand OTC
POUCHKINS PED OSTOMY BELT Brand OTC
POUCHKINS SKIN BARRIER Brand OTC
POUCHKINS UROSTOMY POUCH Brand OTC
PRECISE PREGNANCY Brand OTC
PRECISEDOSE DISPENSER TIP CAP Brand OTC
PRECISION 200 CATHETER TRAY Brand OTC
PRECISION PCX PLUS TEST Brand OTC
PRECISION PCX TEST Brand OTC
PRECISION POINT OF CARE TEST Brand OTC
PRECISION Q-I-D TEST Brand OTC
PRECISION XTRA B-KETONE Brand OTC
PRECISION XTRA TEST Brand OTC
PREGNANCY TEST Brand OTC
124 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
PREMIER CLOSED MINI-POUCH 5/8-2 1/8 "
(7")
Brand OTC
PREMIER DRAINABLE MINI-POUCH 2 1/2 "
(9")
Brand OTC
PREMIER DRAINABLE POUCH 2 1/2 " Brand OTC
PREMIER LOCK N ROLL 1 " Brand OTC
PREMIER UROSTOMY POUCH 1 " Brand OTC
PREMIUM BABY DIAPERS Brand OTC
PREMIUM BLOOD GLUCOSE MONITOR Brand OTC; QL
PREMIUM COMFORT-STRETCH Brand OTC
PREMIUM DRAINABLE POUCH/KARAYA 1 " Brand OTC
PREMIUM NITRILE GLOVES Brand OTC
PREMIUM SKIN BARRIER Brand OTC
PREMIUM TRAINING PANTS Brand OTC
PRESSURE ACTIVATED LANCETS 21
GAUGE
Brand OTC
PREVAIL ADJUST UNDERWEAR SM-MD Brand OTC
PREVAIL BLADDER CONTROL PAD Brand OTC
PREVAIL BLADDER PAD EXTRA Brand OTC
PREVAIL BOXERS Brand OTC
PREVAIL BRIEF BARIATRIC Brand OTC
PREVAIL BRIEF EXTRA LARGE Brand OTC
PREVAIL CLASSIC FIT UNDERWEAR Brand OTC
PREVAIL EXTRA UNDERWEAR Brand OTC
PREVAIL FULL COVERAGE UNDRWEAR Brand OTC
PREVAIL GUARDS FOR MEN Brand OTC
PREVAIL MALE GUARD Brand OTC
PREVAIL PADS Brand OTC
PREVAIL PANTY LINER Brand OTC
PREVAIL PM BRIEF MEDIUM Brand OTC
PREVAIL PROTECTIVE UNDERWEAR Brand OTC
125 Updated 1/2018
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– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
PREVAIL SIMPLY STRETCH FIT Brand OTC
PREVAIL STRETCH FIT Brand OTC
PREVAIL SUPER PLUS Brand OTC
PREVAIL UNDERWEAR Brand OTC
PRIMEAIRE Brand
PRO COMFORT LANCET 30 GAUGE Brand OTC
PRO COMFORT PEN NEEDLE NEEDLE 32
GAUGE X 1/4"
Brand OTC
PRO SPORTS TAPE Brand OTC
PROCARE PROTECTIVE UNDERWEAR Brand OTC
PROCHAMBER Brand
PRODIGY AUTOCODE METER Brand OTC; QL
PRODIGY CONTROL SOLUTION, LOW Brand OTC
PRODIGY INSULIN SYRINGE SYRINGE 1 ML
28 GAUGE X 1/2"
Brand
PRODIGY LANCETS 26 GAUGE Brand OTC
PRODIGY LANCING DEVICE Brand OTC
PRODIGY MINI-MIST NEBULIZER Brand
PRODIGY NO CODING Brand OTC
PRODIGY POCKET METER Brand OTC; QL
PRODIGY TWIST TOP LANCET Brand OTC
PRODIGY VOICE GLUCOSE METER Brand OTC; QL
PROGLYCEM Brand
PRONEB ULTRA II Brand
PROTECTIVE BARRIER FILM WIPES Brand OTC
PROTECTIVE PADS Brand OTC
PROTECTIVE UNDERWEAR SMALL-MED Brand OTC
PROVENT Brand
PULMO-AIDE COMPRESSOR Brand
PULMONEB LT COMPRESSOR NEBUL Brand OTC
PURE COTTON Brand OTC
126 Updated 1/2018
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– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
Q-TIPS/SINGLE-TIP APPLICATOR Brand OTC
QUICK READ DIGITAL THERMOMETER Brand OTC
QUICK RESPONSE BP MONITOR-LARG Brand OTC
RCRA HAZARDOUS WASTE Brand OTC
READYLANCE SAFETY LANCETS 30
GAUGE
Brand OTC
RECTAL THERMOMETER Brand OTC
REFUAH PLUS GLUCOSE CONTROL Brand OTC
RELIAMED LANCET 28 GAUGE Brand OTC
RELIAMED MINI LANCING DEVICE Brand OTC
RELIAMED SAFETY SEAL LANCETS 28
GAUGE
Brand OTC
RELION CONFIRM Brand OTC; QL
RELION CONFIRM-MICRO Brand OTC
relion glucose Generic OTC
RELION MICRO GLUCOSE MONITOR KIT Brand OTC; QL
RELION NEEDLES Brand OTC
RELION PEN NEEDLES Brand OTC
RELION THIN LANCETS Brand OTC
RELION ULTRA THIN PLUS LANCETS Brand OTC
repaglinide Generic
repaglinide-metformin Generic
RESTORE CALCIUM ALGINATE TOPICAL
BANDAGE 2 X 2 "
Brand OTC
RESTORE EXTRA THIN DRESSING TOPICAL
BANDAGE 4 X 4 "
Brand OTC
RESTORE FOAM DRESSING SILVER
TOPICAL BANDAGE 4 X 4 "
Brand
RESTORE HYDROGEL GAUZE Brand OTC
RESTORE HYDROGEL GAUZE SPONGE Brand OTC
RESTORE TRIO TOPICAL BANDAGE 4 X 5 " Brand OTC
RETRACTED PENIS POUCH Brand OTC
127 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
REUSABLE HOT-COLD COMPRESS Brand OTC
REUSABLE NEBULIZER KIT Brand
REVEAL PREGNANCY TEST Brand OTC
rewetting drops Generic OTC
RIGHTEST CONTROL SOLUTION HIGH Brand OTC
RIGHTEST GD500 LANCING DEVICE Brand OTC
RIGHTEST GL300 LANCETS Brand OTC
RIGHTEST GM550 SYSTEM Brand OTC; QL
RIGHTEST GS550 TEST STRIPS Brand OTC
RITEFLO AEROCHAMBER Brand
ROB-NEL URETHRAL CATHETER 10-16 FR-" Brand OTC
ROLLED ABSORBENT COTTON Brand OTC
RONDIC Brand OTC
SAFE-CLIP NEEDLE STORAGE DEV Brand OTC
SAFESNAP INSULIN SYRINGE SYRINGE 0.3
ML 30 GAUGE X 5/16"
Brand
SAFETY LANCETS 21 GAUGE Brand OTC
SAFETY SEAL LANCETS 28 GAUGE Brand OTC
SAFETY-LET LANCETS Brand OTC
SAF-GEL Brand OTC
SAMI THE SEAL Brand
SAMI THE SEAL MASK Brand
scar treatment topical sheet 1.5 x 2.75 " Generic OTC
SELECT BRIEFS Brand OTC
SELECT DISPOSABLE BRIEFS Brand OTC
SELECT KIDS BRIEFS Brand OTC
SELECT UNDERPADS Brand OTC
SELECT UNDERWEAR Brand OTC
SELF-ADHERING BANDAGE TOPICAL
BANDAGE 3 "
Brand OTC
SELF-CATHETER, FEMALE 14 FR Brand
128 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
SELF-CATHETER, FEMALE 8 FR Brand OTC
SELF-GRIP TOPICAL TAPE Brand OTC
SEN-SERTER Brand
SENSURA EASICLOSE WIDE OUTLET Brand OTC
SEVEN SYSTEM SENSOR Brand
SHEER BANDAGE TOPICAL BANDAGE Brand OTC
SHEER STRIPS ASSORTED Brand OTC
SHIELDS Brand OTC
SIDEKICK BLOOD GLUCOSE SYSTEM Brand OTC; QL
SIDESTREAM Brand
SIDESTREAM ADULT FACE MASK Brand OTC
SIDESTREAM PEDIATRIC FACE MASK Brand OTC
SILICONE MASK - INFANT Brand
SIMPLICITY ADULT FLAT FOLD XL Brand OTC
SIMPLICITY ADULT POLY MEDIUM Brand OTC
SIMPLICITY CONTOURED LINER Brand OTC
SIMPLICITY PAD Brand OTC
SINGLE-LET Brand OTC
SINUSTAR AEROSOL Brand
SKIN CLOSURE STRIPS TOPICAL STRIP Brand OTC
SKIN GEL PROTECT DRESSING WIPE Brand OTC
SKIN PREP WIPES Brand OTC
SKINTEGRITY HYDROGEL Brand OTC
SLEEP COMFORTS Brand OTC
SLEEP OVERS PANTS Brand OTC
SLEEP PANTS Brand OTC
SLIP-ON UNDERGARMENT Brand OTC
SMART SENSE LANCETS 26 GAUGE, 33
GAUGE
Brand OTC
SMARTDIABETES VANTAGE Brand OTC
SMARTDIABETES XPRES KIT Brand OTC; QL
129 Updated 1/2018
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– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
SMARTDIABETES XPRES STRIP Brand OTC
SMARTEST CONTROL Brand OTC
SMARTEST LANCET Brand OTC
SMARTEST PERSONA STARTER Brand OTC; QL
SMARTEST PRONTO STARTER Brand OTC; QL
SMS GLUCOSE CONTROL Brand OTC
SOF-SENSOR Brand
SOF-SET ADHESIVE PATCH Brand OTC
SOFT CLOTH TOPICAL BANDAGE 2.375 X 4
"
Brand OTC
SOFT TOUCH LANCETS Brand OTC
SOFTFLEX SKIN BARRIER RING Brand OTC
SOFT-TIP THERMOMETER Brand OTC
SOLOSITE WOUND GEL Brand OTC
SOLUS V2 AUDIBLE METER KIT Brand OTC; QL
SOLUS V2 CONTROL SOLUTION,HIGH Brand OTC
SOLUS V2 LANCETS Brand OTC
SOLUS V2 LANCING DEVICE Brand OTC
SOLUS V2 TEST STRIPS Brand OTC
SORBSAN WOUND DRESSING Brand OTC
SORESPOT Brand OTC
SPECTRAGEL Brand
SPORTS TAPE Brand OTC
STA-PUT UNDERPAD Brand OTC
STERILANCE TL 30 GAUGE Brand OTC
STERILE PADS TOPICAL BANDAGE 2 X 2 " Brand OTC
STERI-STRIP DRESSING Brand OTC
STERI-STRIP SKIN CLOSURES TOPICAL
STRIP 1/8 X 3 "
Brand OTC
STOMA CAP-ADHESIVE-FILTER Brand OTC
STOMA CONE-CONNECTOR REPL UNIT Brand OTC
130 Updated 1/2018
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– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
STOMA LUBRICANT Brand OTC
STOMAHESIVE PROTECTIVE Brand OTC
STOMAHESIVE SKIN BARRIER , 1 3/4 " Brand OTC
STRATASORB ISLAND DRESSING TOPICAL
BANDAGE 4 X 4 "
Brand OTC
STRETCH GAUZE BANDAGE TOPICAL
BANDAGE 2 X 4.1 "-YARD
Brand OTC
STRONG STRIPS TOPICAL BANDAGE 1 X 3 " Brand OTC
sunrise compressor-nebulizer Generic
SUPER STRIP BANDAGES Brand OTC
SUPER THIN LANCETS 30 GAUGE Brand OTC
SUPPOSISTRIP Brand OTC
SUPPOSITORY MOLDS Brand OTC
SUPPOSITORY SHELL, MEDIUM Brand OTC
SUPPOSITORY SHELL, SMALL Brand OTC
SUPREME DIAPERS SIZE 6 Brand OTC
SURE CARE PROTECTIVE UNDERWEAR Brand OTC
SURE COMFORT ALCOHOL PREP PADS Brand OTC
SURE COMFORT LANCETS 18 GAUGE Brand OTC
SURE COMFORT LANCING PEN Brand OTC
SURE COMFORT PEN NEEDLE NEEDLE 29
GAUGE X 1/2"
Brand OTC
SURE EDGE Brand OTC
SURE EDGE BLOOD GLUCOSE METER Brand OTC; QL
SURE EDGE CONTROL LOW Brand OTC
SURECARE PAD 17 X 24 " Brand OTC
SURECHEK GLUCOSE CONTROL Brand OTC
SURECHEK TEST STRIPS Brand OTC
SURECHOICE BLADDER CONTROL Brand OTC
SURE-FINE PEN NEEDLES NEEDLE 29
GAUGE X 1/2"
Brand OTC
SUREFLEX LANCING DEVICE Brand OTC
131 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
SURE-JECT INSULIN SYRINGE SYRINGE 1
ML 28 GAUGE X 1/2"
Brand
SURE-LANCE 28 GAUGE Brand OTC
SURE-PEN LANCING DEVICE Brand OTC
SURE-PREP ALCOHOL PREP PADS Brand OTC
SUREPRESS HIGH COMPRESSION Brand OTC
SURE-TEST EASYPLUS MINI SOLUTION Brand OTC
SURE-TOUCH LANCET Brand OTC
SUR-FIT NATURA ADAPTOR Brand OTC
SUR-FIT NATURA CLOSED POUCH 1 1/2 " Brand OTC
SUR-FIT NATURA CONVEX INSERTS 3/4 " Brand OTC
SUR-FIT NATURA DRAINABLE POUCH 1 1/4
"
Brand OTC
SUR-FIT NATURA DURAHESIVE 4 " Brand OTC
SUR-FIT NATURA FLANGE CAP Brand OTC
SUR-FIT NATURA HIGH OUTPUT 1 3/4 ", 2
3/4 "
Brand OTC
SUR-FIT NATURA IRRIG FACEPLATE 1 3/4 " Brand OTC
SUR-FIT NATURA LOW-PRESSURE Brand OTC
SUR-FIT NATURA MINI-POUCH 1 1/4 ", 2 1/4
"
Brand OTC
SUR-FIT NATURA STOMAHESIVE 1 1/4 " Brand OTC
SUR-FIT NATURA UROSTOMY POUCH 1 1/4
"
Brand OTC
SUR-FIT-ACTIVE LIFE TAIL CLOS Brand OTC
SURGICAL DRESSING EXTR PROTCT Brand OTC
SYMLINPEN 120 Brand
SYMLINPEN 60 Brand
TECHLITE LANCETS 25 GAUGE Brand OTC
TECHLITE PEN NEEDLE NEEDLE 29 GAUGE
X 3/8"
Brand OTC
TEGADERM FIRST AID STYLE TOPICAL
BANDAGE 2 3/8 X 2 3/4 "
Brand OTC
132 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
TEGADERM HP FRAME STYLE TOPICAL
BANDAGE 2 3/8 X 2 3/4 "
Brand OTC
TEGADERM HYDROCOLLOID THIN
TOPICAL BANDAGE 4 X 4 3/4 "
Brand OTC
TEGADERM HYDROCOLLOID TOPICAL
BANDAGE 4 X 4 3/4 "
Brand OTC
TEGAGEN HG TOPICAL BANDAGE 12 " Brand OTC
TEGAGEN HI TOPICAL BANDAGE 12 " Brand OTC
TELCARE CONTROL Brand OTC
TELCARE LANCETS Brand OTC
TELFA AMD Brand OTC
TELFA CLEAR WOUND DRESSING TOPICAL
BANDAGE 3 X 3 "
Brand OTC
TELFA OUCHLESS NON-ADHERENT
TOPICAL BANDAGE 4 X 3 "
Brand OTC
TENA PANTS SUPER LARGE Brand OTC
TENA PROTECTIVE UNDERWEAR Brand OTC
TENA SERENITY Brand OTC
TENA STRETCH ULTRA Brand OTC
TENDERSORB UNDERPAD PAD Brand OTC
TENS UNIT ELECTRODES PAD 2X2 " Brand OTC
TERUMO INSULIN SYRINGE SYRINGE 0.3
ML 30 X 3/8"
Brand
thermometer covers Generic OTC
THERMOPHORE MAXHEAT Brand OTC
THERMOPHORE PACK STANDARD Brand OTC
THERMOSCAN THERMOMETER Brand OTC
thinpro insulin syringe syringe 0.3 ml 29 gauge x
1/2"
Generic
THINPRO INSULIN SYRINGE SYRINGE 0.3
ML 31 X 3/8"
Brand
tolazamide Generic
tolbutamide Generic
133 Updated 1/2018
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– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
TOOTHETTE Brand OTC
TOPCARE ULTRA COMFORT SYRINGE 0.3
ML 29 GAUGE X 1/2"
Brand
TOPCARE UNIVERSAL1 LANCET Brand OTC
TOUCH-TROL Brand
TRAINING PANTS 2T-3T Brand OTC
TRANQUILITY PREMIUM UNDERWEAR Brand OTC
TRANQUILITY TOPLINER PADS Brand OTC
TRANSFER PIN Brand OTC
TRANSPARENT DRESSINGS TOPICAL
BANDAGE 2 X 2 3/4 ", 4 X 4 3/4 "
Brand OTC
TRANSPORE SURGICAL TOPICAL TAPE 1/2
X 10 "-YARD
Brand OTC
TRANSPORT CHAIR Brand OTC
TRUE2GO BLOOD GLUCOSE SYSTEM Brand OTC; QL
TRUECONTROL LEVEL 0 Brand OTC
TRUEDRAW LANCING DEVICE Brand OTC
TRUEPLUS INSULIN SYRINGE 1/2 ML 28
GAUGE X 1/2"
Brand
TRUEPLUS KETONE Brand OTC
TRUEPLUS LANCETS 28 GAUGE Brand OTC
TRUEPLUS PEN NEEDLE NEEDLE 29 GAUGE
X 1/2"
Brand OTC
TRUERESULT BLOOD GLUCOSE SYSTM KIT Brand OTC; QL
TRUETRACK BLOOD GLUCOSE SYSTEM Brand OTC; QL
TRUETRACK SMART SYSTEM KIT Brand OTC; QL
TRUETRACK SMART SYSTEM STRIP Brand OTC
TRUETRACK TEST Brand OTC
TRUSTEX LUBRICATED CONDOMS Brand OTC
TRUSTEX-RIA LUB/SPERMICIDE Brand OTC
TRUZONE PEAK FLOW METER Brand
TUGABOOS DIAPERS Brand OTC
134 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
TUGABOOS OVERNIGHTS Brand OTC
TUGABOOS TRAINING PANTS Brand OTC
ULTICARE SYRINGE 1 ML 29 X 1/2" Brand
ulticare syringe 1 ml 30 gauge x 1/2" Generic
ULTI-LANCE KIT Brand OTC
ULTILET ALCOHOL SWAB Brand OTC
ULTILET BASIC LANCETS Brand OTC
ULTILET CLASSIC LANCETS Brand OTC
ULTILET INSULIN SYRINGE SYRINGE 1 ML
29 GAUGE
Brand
ULTILET LANCETS 28 GAUGE Brand OTC
ULTILET PEN NEEDLE NEEDLE 29 GAUGE Brand OTC
ULTILET SAFETY LANCETS Brand OTC
ULTIMA MONITOR Brand OTC; QL
ULTIMA TEST STRIPS Brand OTC
ultra comfort insulin syringe syringe 1 ml 28
gauge
Generic
ULTRA COMFORT INSULIN SYRINGE
SYRINGE 1/2 ML 28 GAUGE X 1/2"
Brand
ULTRA FINE CUT N CRUSH Brand OTC
ULTRA THIN LANCETS 28 GAUGE Brand OTC
ULTRA THIN PLUS LANCETS Brand OTC
ULTRA TLC LANCETS Brand OTC
ULTRA-FLEX Brand OTC
ULTRALANCE LANCETS 26 GAUGE Brand OTC
ULTRA-LIGHT ROLLATOR Brand OTC
ULTRA-SOFT GLOVES Brand OTC
ULTRA-THIN II INSULIN SYRINGE SYRINGE
0.5 ML 29 GAUGE X 1/2"
Brand
ULTRATRAK Brand OTC
ULTRATRAK GLUCOSE METER Brand OTC; QL
ULTRATRAK ULTIMATE SOLUTION Brand OTC
135 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
UNDERGARMENT EXTRA ABSORBENT Brand OTC
UNDERJAMS SMALL-MEDIUM Brand OTC
UNDERPADS PAD 30 X 36 " Brand OTC
UNDERPADS REGULAR PAD Brand OTC
UNDERWEAR Brand OTC
UNDERWEAR FOR MEN Brand OTC
UNGUATOR LID Brand OTC
UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2" Brand OTC
UNIFINE PENTIPS PLUS NEEDLE 31 GAUGE
X 5/16"
Brand OTC
UNIGARD INCONTINENT PAD Brand OTC
UNILET COMFORTOUCH LANCET 26
GAUGE
Brand OTC
UNILET EXCELITE II LANCET Brand OTC
UNILET EXCELITE LANCET Brand OTC
UNILET GP LANCET Brand OTC
UNILET LANCET 28 GAUGE Brand OTC
UNISOLVE ADHESIVE REMOVER WIPE Brand OTC
UNISTIK 2 DEVICE Brand OTC
UNISTIK 2 NORMAL LANCET,DEVICE Brand OTC
UNISTIK 3 Brand OTC
UNISTIK 3 EXTRA LANCET Brand OTC
UNISTIK CZT LANCET 23 GAUGE Brand OTC
UNISTIK SAFETY 30 GAUGE Brand OTC
UNISTIK TOUCH LANCETS 23 GAUGE Brand OTC
UNIVERSAL 1 LANCETS 26 GAUGE Brand OTC
UNIVERSAL REMOVER WIPES Brand OTC
UP AND UP BABY DIAPER Brand OTC
URETHRAL CATHETER Brand OTC
URINARY LEG MEDIUM BAG Brand OTC
URISTIX 4 Brand OTC
136 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
URISTIX REAGENT Brand OTC
URO MINICAP Brand OTC
UROSTOMY DRAIN TUBE ADAPTER Brand OTC
UROSTOMY MICRO-POUCH Brand OTC
UROSTOMY MULTI-CHAMBER POUCH Brand OTC
UROSTOMY NIGHT BAG Brand OTC
UROSTOMY POUCH 1 3/4 " (9") Brand OTC
VAGINAL CREAM APPLICATOR Brand OTC
VAGINAL SUPPOSITORY APPLICATOR Brand OTC
VANISHPOINT SYRINGE SYRINGE 1 ML 29
GAUGE X 1/2"
Brand
VAPORIZER INHALANT Brand OTC
VAPORIZERS Brand OTC
VASELINE PETROLATUM GAUZE TOPICAL
BANDAGE
Brand OTC
VENTED URINARY LEG BAG Brand OTC
VERSALON TOPICAL SPONGE 2 X 2 " Brand OTC
VERSIVA XC TOPICAL BANDAGE 3 X 3 " Brand OTC
VGO 20 Brand
VGO 30 Brand
VGO 40 Brand
VICKS DIGITAL THERMOMETER Brand OTC
VICKS WARM MIST HUMIDIFIER Brand OTC
VICTORY BLOOD GLUCOSE MONITOR Brand OTC; QL
VICTORY GLUCOSE TEST Brand OTC
VICTOZA 2-PAK Brand PA
VIGILON PRIMARY WOUND DRESSING
TOPICAL BANDAGE 4 X 4 "
Brand OTC
VINYL CATHETER 14-6 FR-" Brand OTC
vinyl gloves Generic OTC
VIOS AEROSOL DELIVERY SYSTEM Brand
137 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
VISI-FLOW IRRIGATION SLEEVE 1 1/2 " Brand OTC
VISI-FLOW IRRIGATION STARTER 45 MM Brand OTC
VISI-FLOW IRRIGATOR-STOMA CONE Brand OTC
VISI-FLOW SLEEVE TAIL CLOSURES Brand OTC
VISI-FLOW STOMA CONE Brand OTC
VISTEC X-RAY DETECT TOPICAL SPONGE 4
X 4 "
Brand OTC
VORTEX HOLDING CHAMBER Brand
VORTEX VHC FROG MASK-CHILD Brand
VORTEX VHC LADYBUG MASK-TODDLR Brand
WATCHHALER Brand
WATER SHIELD BANDAGES Brand OTC
WATERPROOF STRONG STRIPS Brand OTC
WAVESENSE CONTROL SOLUTION Brand OTC
WAVESENSE JAZZ Brand OTC
WAVESENSE PRESTO Brand OTC; QL
WAVESENSE PRESTO STRIP Brand OTC
WEBCOL Brand OTC
WELL BEGINNINGS SLEEP PANTS Brand OTC
WHEELCHAIR Brand OTC
WIDE-SEAL DIAPHRAGM 65 Brand
WING TIP TUBING Brand OTC
WINGS CHOICE ADULT BRIEF Brand OTC
WINGS CHOICE PLUS ADULT BRIEFS Brand OTC
WINGS CHOICE PLUS YOUTH BRIEFS Brand OTC
WINGS CLASSIC ADULT BRIEFS Brand OTC
WINGS CLASSIC ADULT BRIEFS X-L Brand OTC
WINGS FLUFF AND POLYMER Brand OTC
WINGS MAXIMA UNDERPADS Brand OTC
WINGS UNDERPAD Brand OTC
WINGS XXL ADULT BRIEF Brand OTC
138 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
WOMEN'S ADVANCED BP MONITOR Brand OTC
WOMEN'S UNDERWEAR Brand OTC
WONDERPANTS Brand OTC
WOUND DRAINAGE COLLECTOR Brand OTC
WOUN'DRES HYDROGEL WOUND DRESS Brand OTC
XEROFLO GAUZE DRESSING TOPICAL
BANDAGE 2 X 2 "
Brand OTC
XEROFORM PETROLATUM OVERWRAP
TOPICAL BANDAGE 1 X 8 "
Brand
XPRES NORMAL CONTROL Brand OTC
Miscellaneous Hormones
ANADROL-50 Brand PA
ANDRODERM Brand PA
ANDROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 20.25 MG/1.25 GRAM
(1.62 %)
Brand PA
ANDROGEL TRANSDERMAL GEL IN
PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62
% (40.5 MG/2.5 GRAM)
Brand PA
androxy Generic PA
cabergoline Generic
calcitonin (salmon) Generic
calcitriol intravenous solution 1 mcg/ml Generic
calcitriol oral Generic
CEREZYME INTRAVENOUS RECON SOLN
400 UNIT
Brand
danazol Generic PA
DDAVP NASAL SOLUTION Brand
DEPO-TESTOSTERONE INTRAMUSCULAR
OIL 100 MG/ML
Brand PA
desmopressin injection Generic
desmopressin nasal solution Generic
desmopressin nasal spray,non-aerosol Generic
139 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
desmopressin oral Generic
dhea oral capsule 25 mg Generic PA; OTC
dhea oral tablet 25 mg Generic PA; OTC
doxercalciferol Generic
fortical Generic
HECTOROL INTRAVENOUS SOLUTION 2
MCG/ML (1 ML)
Brand
KUVAN ORAL TABLET,SOLUBLE Brand PA
METHITEST Brand PA
methyltestosterone oral capsule Generic PA
MIACALCIN INJECTION Brand
NATPARA Brand PA
oxandrolone Generic PA
pamidronate Generic
paricalcitol intravenous Generic
paricalcitol oral Generic
SAMSCA Brand PA
SENSIPAR Brand
SOMAVERT SUBCUTANEOUS RECON SOLN
10 MG, 15 MG, 20 MG
Brand
STIMATE Brand
SYNAREL Brand
TESTIM Brand PA
TESTOSTERONE (BULK) Brand PA
testosterone cypionate Generic PA
testosterone enanthate Generic PA
testosterone transdermal gel Generic PA
testosterone transdermal gel in metered-dose
pump 12.5 mg/ 1.25 gram (1 %)
Generic PA
testosterone transdermal gel in packet Generic PA
testosterone transdermal solution in metered pump
w/app
Generic PA
140 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
VPRIV Brand
ZAVESCA Brand
zoledronic acid Generic
ZOMETA INTRAVENOUS PIGGYBACK Brand
Thyroid Hormones
ARMOUR THYROID Brand
LEVOTHYROXINE INTRAVENOUS RECON
SOLN 100 MCG
Brand
levothyroxine intravenous recon soln 200 mcg,
500 mcg
Generic
levothyroxine oral Generic
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,
137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50
mcg, 75 mcg, 88 mcg
Generic
liothyronine oral Generic
nature-throid Generic
np thyroid Generic
thyroid (pork) Generic
THYROLAR-1 Brand
THYROLAR-1/2 Brand
THYROLAR-1/4 Brand
THYROLAR-2 Brand
THYROLAR-3 Brand
TIROSINT Brand
unithroid Generic
westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65
mg, 97.5 mg
Generic
WP THYROID ORAL TABLET 81.25 MG Brand
Gastroenterology
Antidiarrheals / Antispasmodics
acidophilus-pectin oral capsule 75 million cell -
100 mg
Generic OTC
141 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
anaspaz Generic
anti-diarrhea Generic OTC
anti-diarrheal Generic OTC
anti-diarrheal (lope)-anti-gas Generic OTC
anti-diarrheal (loperamide) oral capsule Generic OTC
anti-diarrheal (loperamide) oral liquid 1 mg/5 ml Generic OTC
anti-diarrheal (loperamide) oral tablet Generic OTC
atropine injection solution Generic
atropine injection syringe 0.1 mg/ml Generic
b-donna Generic
belladonna alkaloids-opium Generic
belladonna-opium Generic
bismatrol Generic OTC
bismuth Generic OTC
bismuth maximum strength Generic OTC
CANTIL Brand
chlordiazepoxide-clidinium Generic
CUVPOSA Brand
diamode Generic OTC
diarrhea relief (bismuth subs) Generic OTC
dicyclomine intramuscular Generic
dicyclomine oral capsule Generic
dicyclomine oral solution Generic
dicyclomine oral tablet Generic
digestive relief oral tablet Generic OTC
diotame Generic OTC
diphenoxylate-atropine Generic
ed-spaz Generic
geri-pectate Generic OTC
glycopyrrolate injection Generic
142 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
glycopyrrolate oral tablet 1 mg, 2 mg Generic
hyoscyamine sulfate Generic
hyosyne Generic
kaolin-pectin Generic OTC
kaopectate (bismuth subsalicy) oral suspension Generic OTC
kaopectate ex str (bismuth ss) Generic OTC
kao-tin (bismuth subsalicylat) Generic OTC
kola-pectin ds Generic OTC
k-pec antidiarrheal (bism sub) Generic OTC
l.acidophilus-bifido.longum oral capsule,delayed
release(dr/ec) 16 mg
Generic OTC
lactobac acidoph-fructooligos Generic OTC
loperamide oral capsule Generic
loperamide oral liquid Generic OTC
loperamide oral tablet Generic OTC
medi-bismuth Generic OTC
me-pb-hyos Generic
methscopolamine Generic
MOTOFEN Brand
opium tincture Generic
oscimin Generic
oscimin sl Generic
oscimin sr Generic
paregoric Generic
peptic relief Generic OTC
pepto-bismol to-go Generic OTC
phenobarb-hyoscy-atropine-scop oral tablet Generic
phenohytro Generic
pink bismuth Generic OTC
probiotic 4x Generic OTC
probiotic colon care Generic OTC
143 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
probiotic digestive care oral tablet,delayed release
(dr/ec)
Generic OTC
probiotic oral capsule 20 billion cell, 3 billion cell Generic OTC
probiotic oral capsule, sprinkle 20 billion cell Generic OTC
propantheline Generic
risaquad Generic OTC
risaquad-2 Generic OTC
senior probiotic Generic OTC
soothe (bismuth subsalicylate) Generic OTC
soothe regular strength Generic OTC
stomach relief max strength Generic OTC
stomach relief oral suspension 262 mg/15 ml Generic OTC
stomach relief oral tablet Generic OTC
stomach relief oral tablet,chewable Generic OTC
super probiotic Generic OTC
symax fastabs Generic
symax-sl Generic
symax-sr Generic
Miscellaneous Gastrointestinal Agents
acid gone antacid Generic OTC
acid gone antacid e.strength Generic OTC
actidose/sorbitol Generic OTC
actidose-aqua oral suspension 25 gram/120 ml Generic OTC
activated charcoal oral capsule Generic OTC
advanced antacid-antigas Generic OTC
almacone oral suspension Generic OTC
almacone-2 Generic OTC
alophen Generic OTC
alosetron Generic
aluminum hydroxide gel Generic OTC
ambizine Generic OTC
144 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
AMITIZA Brand
antacid anti-gas Generic OTC
antacid anti-gas (ca carb-sim) Generic OTC
antacid anti-gas double str Generic OTC
antacid exst (mag carb-al hyd) Generic OTC
antacid extra-strength oral suspension 400-400-40
mg/5 ml
Generic OTC
antacid m Generic OTC
antacid maximum strength Generic OTC
antacid plus anti-gas Generic OTC
antacid regular strength Generic OTC
antacid supreme Generic OTC
antacid tablet Generic OTC
antacid ultra strength oral tablet,chewable 1,177
mg
Generic OTC
antacid-simethicone Generic OTC
antacid-simethicone ds Generic OTC
anti-gas ultra strength Generic OTC
anti-nausea Generic OTC
anucort-hc Generic
anu-med Generic OTC
ANZEMET INTRAVENOUS Brand
aprepitant Generic
APRISO Brand
balsalazide Generic
best fiber Generic OTC
bicarsim forte Generic OTC
bisac-evac Generic OTC
bisacodyl rectal Generic OTC
bisa-lax Generic OTC
biscolax Generic OTC
145 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
budesonide oral Generic
calcium polycarbophil Generic OTC
CANASA Brand
castor oil Generic OTC
castor oil oral oil , 100 % Generic OTC
CESAMET Brand
CHENODAL Brand PA
child suppository Generic OTC
children's pepto Generic OTC
children's soothe Generic OTC
chocolate laxative Generic OTC
citrate of magnesia Generic OTC
citroma Generic OTC
citrucel Generic OTC
CITRUCEL SUGAR FREE Brand OTC
clearlax Generic OTC
cola (syrup) Generic OTC
colocort Generic
col-rite Generic OTC
COLYTE WITH FLAVOR PACKS ORAL
RECON SOLN 227.1-21.5-6.36 GRAM
Brand
comfort gel Generic OTC
comfort gel extra strength Generic OTC
compro Generic
constulose Generic
CORTIFOAM Brand
CREON ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT,
24,000-76,000 -120,000 UNIT, 3,000-9,500-
15,000 UNIT, 6,000-19,000 -30,000 UNIT
Brand
cromolyn oral Generic
daily fiber Generic OTC
146 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
dairy aid Generic OTC
dairy digestive oral tablet Generic OTC
dairy relief Generic OTC
DELZICOL Brand
digestive enzymes Generic OTC
dimenhydrinate oral Generic OTC
diocto Generic OTC
dioctyl Generic OTC
DIPENTUM Brand
doc-q-lace Generic OTC
doc-q-lax Generic OTC
docu Generic OTC
docu soft Generic OTC
docuprene Generic OTC
docusate calcium Generic OTC
docusate sodium oral capsule Generic OTC
docusate sodium oral tablet Generic OTC
docusil Generic OTC
DOCUSOL Brand OTC
dok Generic OTC
dok plus Generic OTC
dramamine less drowsy Generic OTC
dramamine oral tablet Generic OTC
driminate Generic OTC
dronabinol Generic PA
dss Generic OTC
ducodyl Generic OTC
dulcolax stool softener (dss) Generic OTC
easy fiber oral powder Generic OTC
EMEND ORAL CAPSULE Brand
147 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
enema Generic OTC
enema disposable Generic OTC
ENEMEEZ Brand OTC
ENEMEEZ PLUS Brand OTC
enulose Generic
enzyme digest Generic OTC
epsom salt Generic OTC
evac-u-gen (sennosides) Generic OTC
fiber (calcium polycarbophil) Generic OTC
fiber (dextrin) Generic OTC
fiber (psyllium husk) oral capsule 0.52 gram Generic OTC
fiber (psyllium husk/sugar) Generic OTC
fiber (with aspartame) oral powder 3.4 gram/5.8
gram
Generic OTC
fiber laxative (ca polycarbo) Generic OTC
fiber laxative (husk/sugar) Generic OTC
fiber laxative (methylcellulo) Generic OTC
fiber laxative (psyllium husk) Generic OTC
fiber laxative (psyllium) s/f Generic OTC
fiber oral powder Generic OTC
fiber oral tablet,chewable Generic PA; OTC
fiber smooth Generic OTC
fiber smooth (sucrose) Generic OTC
fiber supplement (inulin) Generic OTC
fiber therapy (ca polycarboph) Generic OTC
fiber therapy (m-cell/sugar) Generic OTC
fiber therapy (m-cellulose) Generic OTC
fiber therapy (psyllium seed) Generic OTC
fiber therapy laxative (husk) Generic OTC
fiber therapy sugar free Generic OTC
fiber-tabs Generic OTC
148 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
flanax antacid Generic OTC
FLEET BISACODYL Brand OTC
fleet enema Generic OTC
fleet glycerin (adult) Generic OTC
fleet laxative Generic OTC
foaming antacid Generic OTC
foaming antacid extra strength Generic OTC
formula em Generic OTC
gas free extra strength Generic OTC
gas relief extra strength oral tablet,chewable Generic OTC
gas relief oral capsule 125 mg Generic OTC
gas relief oral drops,suspension Generic OTC
gas relief oral tablet,chewable 80 mg Generic OTC
gas relief ultra strength Generic OTC
gavilax oral powder Generic OTC
gavilyte-c Generic
gavilyte-g Generic
gavilyte-h and bisacodyl Generic
gavilyte-n Generic
GAVISCON Brand OTC
GAVISCON EXTRA STRENGTH Brand OTC
generlac Generic
gentle laxative Generic OTC
gentlelax Generic OTC
geri-kot Generic OTC
geri-lanta Generic OTC
geri-mox antacid-antigas Generic OTC
GERI-MUCIL Brand OTC
glycerin (adult) Generic OTC
glycerin (child) Generic OTC
149 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
glycolax oral powder Generic OTC
GOLYTELY ORAL POWDER IN PACKET Brand
granisetron (pf) Generic
granisetron hcl Generic
granisol Generic
grx hicort 25 Generic OTC
healthylax Generic OTC
heartburn antacid Generic OTC
heartburn relief oral tablet,chewable Generic OTC
hemmorex-hc Generic
hemorrhoid preparation Generic OTC
hemorrhoidal (phenyleph-cocoa) Generic OTC
hemorrhoidal cooling Generic OTC
hemorrhoidal cream Generic OTC
hemorrhoidal h Generic OTC
hemorrhoidal rectal cream Generic OTC
hemorrhoidal rectal ointment , 0.25-14-74.9 % Generic OTC
hemorrhoidal rectal suppository 51 % Generic OTC
hemorrhoidal suppository Generic OTC
hemril-30 Generic
hydrochloric acid (bulk) liquid 37 % Generic
hydrocortisone acetate rectal Generic
hydrocortisone rectal Generic
hydrocortisone topical cream with perineal
applicator
Generic
hydrocortisone-pramox-e-pram#1 Generic
hydrocortisone-pramoxine rectal Generic
hyfiber with fos oral liquid Generic OTC
infants gas relief Generic OTC
insta-char oral suspension 50 gram/240 ml Generic OTC
150 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
insta-char-sorbitol oral suspension 50 gram/240
ml
Generic OTC
ipecac Generic OTC
kao-tin (docusate calcium) Generic OTC
KARAYA GUM (BULK) Brand OTC
konsyl (sugar) Generic OTC
konsyl fiber Generic OTC
konsyl formula-d Generic OTC
konsyl sugar-free (aspartame) oral powder Generic OTC
konsyl sugar-free oral capsule Generic OTC
konsyl sugar-free oral powder Generic OTC
KRISTALOSE Brand
lac-dose Generic OTC
lactase Generic OTC
lactase fast acting Generic OTC
lactulose oral solution 10 gram/15 ml Generic
laxacin Generic OTC
laxaclear Generic OTC
laxative (bisacodyl) Generic OTC
laxative (glycerin-pediatric) Generic OTC
laxative (sennosides) oral tablet 15 mg, 17.2 mg Generic OTC
laxative (sennosides) oral tablet,chewable Generic OTC
laxative feminine Generic OTC
laxative maximum strength Generic OTC
laxative peg 3350 oral powder Generic OTC
laxative pills Generic OTC
laxative pills regular Generic OTC
laxative plus stool softener Generic OTC
laxative-senna Generic OTC
lidocaine hcl-hydrocortison ac rectal cream 3-0.5
%
Generic
151 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
lidocaine hcl-hydrocortison ac rectal kit Generic
lidocaine-hydrocortisone-aloe Generic
LINZESS ORAL CAPSULE 145 MCG, 290 MCG Brand PA
liquid antacid oral suspension 200-200-20 mg/5
ml
Generic OTC
MAALOX ADVANCED ORAL
TABLET,CHEWABLE
Brand OTC
maalox maximum strength Generic OTC
magnesium citrate oral solution Generic OTC
magnesium oral tablet 250 mg Generic OTC
major-prep (phenylephrine-fat) Generic OTC
masanti double strength Generic OTC
meclizine oral tablet 12.5 mg, 25 mg Generic
meclizine oral tablet,chewable Generic OTC
medi-lax Generic OTC
medi-laxx Generic OTC
medi-meclizine Generic OTC
medi-mucil Generic OTC
medi-natural Generic OTC
medi-natural senna-stool Generic OTC
mesalamine oral tablet,delayed release (dr/ec) 1.2
gram
Generic
mesalamine rectal Generic
mesalamine with cleansing wipe Generic
METAMUCIL (WITH SUGAR) ORAL
POWDER 3.4 GRAM/7 GRAM
Brand OTC
metamucil fiber singles Generic OTC
METAMUCIL MULTIHEALTH FIBER Brand OTC
METAMUCIL SUGAR-FREE (ASPART) ORAL
POWDER 3.4 GRAM/5.8 GRAM
Brand OTC
metoclopramide hcl Generic
mi-acid Generic OTC
152 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
mi-acid gas relief Generic OTC
milco-zyme Generic OTC
milk of magnesia Generic OTC
milk of magnesia concentrated Generic OTC
MINERAL OIL (BULK) Brand OTC
mineral oil extra heavy Generic OTC
MINERAL OIL HEAVY ORAL Brand OTC
mineral oil oral Generic OTC
mineral oil rectal Generic OTC
mintox Generic OTC
mintox maximum strength Generic OTC
mintox plus Generic OTC
miralax oral powder in packet Generic OTC
motion relief (meclizine) Generic OTC
motion sickness Generic OTC
motion sickness (meclizine) Generic OTC
motion sickness relief Generic OTC
motion sickness relief ii Generic OTC
motion sickness relief(mecliz) Generic OTC
motion-time Generic OTC
move it along Generic OTC
MOVIPREP Brand
mytab gas Generic OTC
mytab gas maximum strength Generic OTC
natural fiber laxative Generic OTC
NATURAL FIBER LAXATIVE (SUGAR) ORAL
POWDER 3.4 GRAM/11 GRAM, 3.4 GRAM/7
GRAM
Brand OTC
natural fiber laxative (sugar) oral powder 3.4
gram/12 gram
Generic OTC
natural fiber laxative smooth Generic OTC
153 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
natural fiber laxative therapy Generic OTC
natural fiber laxative(aspart) oral powder Generic OTC
NATURAL FIBER LAXATIVE(ASPART)
ORAL POWDER 3.4 GRAM/5.8 GRAM
Brand OTC
natural fiber supplement oral powder in packet Generic OTC
natural laxative Generic OTC
NATURAL PSYLLIUM FIBER Brand OTC
natural veg laxative(sennosid) Generic OTC
natural vegetable Generic OTC
natural vegetable (psyllium) Generic OTC
natural vegetable powder Generic OTC
natura-lax Generic OTC
nausea control Generic OTC
nausea relief Generic OTC
ondansetron Generic
ondansetron hcl Generic
ondansetron hcl (pf) Generic
oral saline laxative oral liquid Generic OTC
OSMOPREP Brand
pancrelipase 5000 Generic
p-col rite Generic OTC
PEDIA-LAX STOOL SOFTENER Brand OTC
pediatric enema Generic OTC
peg 3350-electrolytes Generic
peg3350 Generic OTC
peg-electrolyte soln Generic
peg-prep Generic
PENTASA Brand
perdiem overnight relief Generic OTC
peri-colace Generic OTC
phosphate laxative oral liquid Generic OTC
154 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
PHOSPHATE LAXATIVE ORAL SOLUTION Brand OTC
polyethylene glycol 3350 Generic
powderlax Generic OTC
pramcort Generic
pramoxine Generic OTC
prochlorperazine Generic
prochlorperazine edisylate Generic
prochlorperazine maleate Generic
procto-med hc Generic
procto-pak Generic
proctosol hc topical Generic
proctozone-hc Generic
promolaxin Generic OTC
psyllium husk oral capsule 0.52 gram Generic OTC
purelax Generic OTC
ready-to-use enema (min oil) Generic OTC
rectacort-hc Generic
RECTIV Brand
reguloid Generic OTC
reguloid (psyllium husk) oral capsule 0.52 gram Generic OTC
reguloid, sugar free Generic OTC
RELISTOR ORAL Brand PA
RELISTOR SUBCUTANEOUS KIT Brand ST
RELISTOR SUBCUTANEOUS SYRINGE Brand ST
ri-gel Generic OTC
ri-gel ii Generic OTC
riginic Generic OTC
ri-mag Generic OTC
ri-mag plus Generic OTC
ri-mox Generic OTC
155 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ri-mox plus Generic OTC
sani-supp (adult) Generic OTC
sani-supp (infant) Generic OTC
sarna sensitive Generic OTC
scopolamine base Generic
SCOPOLAMINE HBR Brand
senexon Generic OTC
senexon-s Generic OTC
senna lax Generic OTC
senna laxative Generic OTC
senna laxative-stool softener Generic OTC
senna oral capsule Generic OTC
senna oral syrup 8.8 mg/5 ml Generic OTC
senna oral tablet Generic OTC
senna plus Generic OTC
senna with docusate sodium Generic OTC
senna-extra Generic OTC
senna-s Generic OTC
senna-time s Generic OTC
senno Generic OTC
sennosides-docusate sodium Generic OTC
sen-o-tab Generic OTC
silace Generic OTC
simethicone Generic OTC
smoothlax Generic OTC
sodium bicarbonate oral Generic OTC
sof-lax Generic OTC
soluble fiber Generic OTC
stimulant laxative plus Generic OTC
stool softener (docusate cal) Generic OTC
156 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
stool softener oral capsule 100 mg, 250 mg Generic OTC
stool softener oral liquid Generic OTC
stool softener oral syrup Generic OTC
stool softener oral tablet Generic OTC
stool softener-laxative Generic OTC
stool softener-stimulant laxat Generic OTC
SUCRAID Brand
sulfasalazine Generic
suppository adult Generic OTC
supreme antacid Generic OTC
SUPREP BOWEL PREP KIT Brand
surfak Generic OTC
the magic bullet Generic OTC
TIGAN INTRAMUSCULAR Brand
TRANSDERM-SCOP Brand
travel sickness Generic OTC
travel sickness (meclizine) Generic OTC
trilyte with flavor packets Generic
trimethobenzamide oral Generic
tums ultra oral tablet,chewable 1,177 mg Generic OTC
ultra dairy digestive Generic OTC
ursodiol Generic
vegetable laxative Generic OTC
wal-dram Generic OTC
wal-mucil fiber Generic OTC
wal-mucil fiber (aspartame) Generic OTC
wal-mucil fiber (sugar) Generic OTC
wal-mucil natural fiber lax Generic OTC
wal-mucil with calcium Generic OTC
woman's laxative Generic OTC
157 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
women's gentle laxative(bisac) Generic OTC
women's laxative (bisacodyl) Generic OTC
women's stool softener Generic OTC
ZYPRAM Brand
Ulcer Therapy
acid control (ranitidine) oral tablet 150 mg Generic OTC
acid controller Generic OTC
acid controller complete Generic OTC
acid reducer (cimetidine) Generic OTC
acid reducer (famotidine) Generic OTC
acid reducer (omeprazole) Generic OTC
acid reducer (ranitidine) Generic OTC
acid reducer complete (famot) Generic OTC
acid relief (cimetidine) Generic OTC
amoxicil-clarithromy-lansopraz Generic
cimetidine hcl oral Generic
cimetidine oral tablet 200 mg Generic OTC
cimetidine oral tablet 300 mg, 400 mg, 800 mg Generic
complete oral tablet,chewable Generic OTC
dual action complete Generic OTC
duo fusion Generic OTC
esomeprazole magnesium oral capsule,delayed
release(dr/ec) 20 mg
Generic QL
esomeprazole magnesium oral capsule,delayed
release(dr/ec) 40 mg
Generic
famotidine (pf) Generic
famotidine (pf)-nacl (iso-os) Generic
famotidine intravenous solution Generic
famotidine oral suspension Generic
famotidine oral tablet 10 mg Generic OTC
famotidine oral tablet 20 mg, 40 mg Generic
158 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
FIRST-LANSOPRAZOLE Brand
FIRST-OMEPRAZOLE Brand
heartburn prevention Generic OTC
heartburn relief (cimetidine) Generic OTC
heartburn relief (famotidine) Generic OTC
heartburn relief (ranitidine) Generic OTC
heartburn relief 24 hour Generic OTC
heartburn treatment 24 hour Generic OTC
LANSOPRAZOLE (BULK) Brand
lansoprazole oral capsule,delayed release(dr/ec)
15 mg
Generic QL
lansoprazole oral capsule,delayed release(dr/ec)
30 mg
Generic
misoprostol Generic
nizatidine Generic
omeppi oral capsule 20-1.1 mg-gram Generic ST; QL
omeppi oral capsule 40-1.1 mg-gram Generic ST
OMEPRAZOLE (BULK) Brand
omeprazole magnesium Generic OTC
omeprazole oral capsule,delayed release(dr/ec) 10
mg
Generic QL
omeprazole oral capsule,delayed release(dr/ec) 20
mg, 40 mg
Generic
omeprazole oral tablet,delayed release (dr/ec) Generic OTC
omeprazole-sodium bicarbonate oral capsule 20-
1.1 mg-gram
Generic ST; QL
omeprazole-sodium bicarbonate oral capsule 40-
1.1 mg-gram
Generic ST
omeprazole-sodium bicarbonate oral packet 20-
1,680 mg
Generic ST; QL
omeprazole-sodium bicarbonate oral packet 40-
1,680 mg
Generic ST
pantoprazole intravenous Generic
159 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
pantoprazole oral tablet,delayed release (dr/ec) 20
mg
Generic QL
pantoprazole oral tablet,delayed release (dr/ec) 40
mg
Generic
pepcid ac oral tablet 20 mg Generic OTC
PRILOSEC OTC Brand ST; OTC
PYLERA Brand
rabeprazole Generic QL
ranitidine hcl injection Generic
ranitidine hcl oral capsule Generic
ranitidine hcl oral syrup Generic
ranitidine hcl oral tablet 150 mg, 300 mg Generic
ranitidine hcl oral tablet 75 mg Generic OTC
sucralfate oral tablet Generic
tagamet hb Generic OTC
tums dual action (famotidine) Generic OTC
wal-zan 150 Generic OTC
wal-zan 75 Generic OTC
zantac maximum strength Generic OTC
Immunology, Vaccines / Biotechnology
Biotechnology Drugs
ACTIMMUNE Brand
ALFERON N Brand
ARANESP (IN POLYSORBATE) INJECTION
SOLUTION
Brand
ARANESP (IN POLYSORBATE) INJECTION
SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML,
200 MCG/0.4 ML, 25 MCG/0.42 ML, 300
MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML,
60 MCG/0.3 ML
Brand
ARCALYST Brand PA
AVONEX (WITH ALBUMIN) Brand
160 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
AVONEX INTRAMUSCULAR PEN INJECTOR
KIT
Brand QL
AVONEX INTRAMUSCULAR SYRINGE Brand
AVONEX INTRAMUSCULAR SYRINGE KIT Brand
BETASERON SUBCUTANEOUS KIT Brand
EPOGEN INJECTION SOLUTION 10,000
UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML,
20,000 UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML
Brand
GENOTROPIN Brand PA
GENOTROPIN MINIQUICK Brand PA
INTRON A INJECTION Brand
LEUKINE INJECTION RECON SOLN Brand
NEUMEGA Brand
NEUPOGEN Brand
NUTROPIN AQ Brand PA
NUTROPIN AQ NUSPIN Brand PA
PEGASYS Brand PA; QL
PEGASYS CONVENIENCE PACK Brand PA; QL
PEGASYS PROCLICK Brand PA; QL
PROCRIT Brand
PROLEUKIN Brand
REBIF (WITH ALBUMIN) Brand
REBIF REBIDOSE Brand
REBIF TITRATION PACK Brand
SAIZEN Brand PA
SAIZEN CLICK.EASY Brand PA
SEROSTIM SUBCUTANEOUS RECON SOLN 4
MG, 5 MG, 6 MG
Brand PA
TEV-TROPIN Brand PA
ZARXIO Brand PA
Vaccines / Miscellaneous Immunologicals
161 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
AFLURIA 2014-2015 Brand
AFLURIA 2014-2015 (PF) Brand
AFLURIA 2015-2016 Brand QL
AFLURIA 2015-2016 (PF) Brand QL
AFLURIA 2016-2017 Brand
AFLURIA 2016-2017 (PF) Brand
AFLURIA 2017-2018 Brand
AFLURIA 2017-2018 (PF) Brand
AFLURIA QUAD 2016-2017 (PF) Brand
AFLURIA QUAD 2017-2018 Brand
AFLURIA QUAD 2017-2018 (PF) Brand
ATGAM Brand
EZ FLU 2015-16 (FLUVIRIN) (PF) Brand QL
EZ FLU 2015-16(FLUCELVAX)(PF) Brand QL
EZ FLU 2016-17 (AFLURIA) (PF) Brand
EZ FLU 2016-17 (FLUVIRIN) (PF) Brand
EZ FLU16-17(FLUZON QD PED)(PF) Brand
FLUAD 2016-2017 (65 YR UP)(PF) Brand
FLUAD 2017-2018 (65 YR UP)(PF) Brand
FLUARIX 2013-2014 (PF) Brand
FLUARIX 2014-2015 (PF) Brand
FLUARIX QUAD 2013-2014 (PF) Brand
FLUARIX QUAD 2014-2015 (PF) Brand
FLUARIX QUAD 2015-2016 (PF) Brand QL
FLUARIX QUAD 2016-2017 (PF) Brand
FLUARIX QUAD 2017-2018 (PF) Brand
FLUBLOK 2014-2015 (PF) Brand
FLUBLOK 2015-2016 (PF) Brand QL
FLUBLOK 2016-2017 (PF) Brand
FLUBLOK 2017-2018 (PF) Brand
162 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
FLUBLOK QUAD 2017-2018 (PF) Brand
FLUCELVAX 2013-2014 (PF) Brand
FLUCELVAX 2014-2015 (PF) Brand
FLUCELVAX 2015-2016 (PF) Brand QL
FLUCELVAX QUAD 2016-2017 (PF) Brand
FLUCELVAX QUAD 2017-2018 Brand
FLUCELVAX QUAD 2017-2018 (PF) Brand
FLULAVAL 2013-2014 Brand
FLULAVAL 2014-2015 Brand
FLULAVAL QUAD 2013-2014 Brand
FLULAVAL QUAD 2014-2015 Brand
FLULAVAL QUAD 2014-2015 (PF) Brand
FLULAVAL QUAD 2015-2016 Brand QL
FLULAVAL QUAD 2016-2017 Brand
FLULAVAL QUAD 2016-2017 (PF) Brand
FLULAVAL QUAD 2017-2018 Brand
FLULAVAL QUAD 2017-2018 (PF) Brand
FLUMIST QUAD 2014-2015 Brand
FLUMIST QUAD 2015-2016 Brand QL
FLUMIST QUAD 2016-2017 Brand
FLUMIST QUAD 2017-2018 Brand
FLUVIRIN 2013-2014 Brand
FLUVIRIN 2013-2014 (PF) Brand
FLUVIRIN 2014-2015 Brand
FLUVIRIN 2014-2015 (PF) Brand
FLUVIRIN 2015-2016 Brand QL
FLUVIRIN 2015-2016 (PF) Brand QL
FLUVIRIN 2016-2017 Brand
FLUVIRIN 2016-2017 (PF) Brand
FLUVIRIN 2017-2018 Brand
163 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
FLUVIRIN 2017-2018 (PF) Brand
FLUZONE 2014-2015 Brand
FLUZONE 2014-2015 (PF) Brand
FLUZONE 2015-2016 Brand QL
FLUZONE HIGH-DOSE 2014-15 (PF) Brand
FLUZONE HIGH-DOSE 2015-16 (PF) Brand QL
FLUZONE HIGH-DOSE 2016-17 (PF) Brand
FLUZONE HIGH-DOSE 2017-18 (PF) Brand
FLUZONE INTRADERM 2014-15 (PF) Brand
FLUZONE INTRADERM QUAD 2015-16 Brand QL
FLUZONE INTRADERM QUAD 2016-17 Brand
FLUZONE INTRADERM QUAD 2017-18 Brand
FLUZONE QUAD 2014-2015 Brand
FLUZONE QUAD 2014-2015 (PF) Brand
FLUZONE QUAD 2015-2016 Brand QL
FLUZONE QUAD 2015-2016 (PF) Brand QL
FLUZONE QUAD 2016-2017 Brand
FLUZONE QUAD 2016-2017 (PF) Brand
FLUZONE QUAD 2017-2018 Brand
FLUZONE QUAD 2017-2018 (PF) Brand
FLUZONE QUAD PEDI 2014-15 (PF) Brand
FLUZONE QUAD PEDI 2015-16 (PF) Brand QL
FLUZONE QUAD PEDI 2016-17 (PF) Brand
FLUZONE QUAD PEDI 2017-18 (PF) Brand
GRASTEK Brand ST
PNEUMOVAX 23 Brand QL
PREVNAR 13 (PF) Brand QL
RAGWITEK Brand ST
SINGLE USE EZ FLU 2013-14 (PF)
INTRAMUSCULAR KIT
Brand
SINGLE USE EZ FLU 2014-15(PF) Brand
164 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
TICE BCG Brand
Musculoskeletal / Rheumatology
Gout Therapy
allopurinol Generic
COLCRYS Brand
probenecid Generic
probenecid-colchicine Generic
Osteoporosis Therapy
alendronate oral solution Generic
alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg Generic QL
ibandronate oral Generic QL
raloxifene Generic
risedronate oral tablet 150 mg, 35 mg, 5 mg Generic QL
risedronate oral tablet,delayed release (dr/ec) Generic
TYMLOS Brand PA
Other Rheumatologicals
CUPRIMINE Brand
DEPEN TITRATABS Brand
ENBREL Brand PA; QL
ENBREL SURECLICK Brand PA; QL
HUMIRA Brand PA; QL
HUMIRA PEDIATRIC CROHN'S START Brand PA; QL
HUMIRA PEN Brand PA; QL
leflunomide Generic
OTEZLA Brand PA
OTEZLA STARTER Brand PA
RIDAURA Brand
SAVELLA Brand ST
Obstetrics / Gynecology
Estrogens / Progestins
165 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ALORA Brand
amabelz Generic
ANGELIQ Brand
camila Generic QL
CLIMARA PRO Brand
COMBIPATCH Brand
covaryx Generic
covaryx h.s. Generic
deblitane Generic QL
DEPO-ESTRADIOL Brand
DEPO-PROVERA INTRAMUSCULAR
SOLUTION
Brand
DEPO-SUBQ PROVERA 104 Brand QL
eemt Generic
eemt hs Generic
errin Generic QL
ESTRACE VAGINAL Brand
estradiol Generic
ESTRADIOL (BULK) Brand
ESTRADIOL HEMIHYD,MICRO (BULK) Brand
ESTRADIOL MICRONIZED (BULK) Brand
estradiol valerate Generic
estradiol-norethindrone acet Generic
ESTRING Brand QL
estrogens-methyltestosterone Generic
estropipate Generic
FEMRING Brand QL
fyavolv Generic
heather Generic QL
HYDROXYPROGESTERONE CAPR(BULK) Brand
jencycla Generic QL
166 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
jevantique lo Generic
jinteli Generic
jolivette Generic QL
lopreeza Generic
lyza Generic QL
medroxyprogesterone intramuscular Generic QL
medroxyprogesterone oral Generic
MENEST Brand
MENOSTAR Brand
mimvey Generic
mimvey lo Generic
nora-be Generic QL
norethindrone (contraceptive) Generic QL
norethindrone acetate Generic
norethindrone ac-eth estradiol oral tablet 0.5-2.5
mg-mcg, 1-5 mg-mcg
Generic
norlyda Generic QL
norlyroc Generic QL
PREFEST Brand
PREMARIN Brand
PREMPHASE Brand
PREMPRO Brand
PROGESTERONE (BULK) Brand
progesterone micronized Generic
PROGESTERONE MICRONIZED (BULK) Brand
sharobel Generic QL
yuvafem Generic
Miscellaneous Ob/Gyn
3 day vaginal Generic OTC
3-day vaginal Generic OTC
AVC VAGINAL Brand
167 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
CLEOCIN VAGINAL SUPPOSITORY Brand
clindamycin phosphate vaginal Generic
CLINDESSE Brand
clotrimazole vaginal Generic OTC
clotrimazole-3 Generic OTC
douche vinegar and water extra Generic OTC
extra cleansing douche Generic OTC
fem ph Generic
feminine care douche Generic OTC
feminine wash Generic OTC
fresh scent douche Generic OTC
gynol ii Generic OTC
isoxsuprine Generic
medicated douche Generic OTC
metronidazole vaginal Generic
miconazole 7 Generic OTC
miconazole nitrate vaginal comb pack,prefill appl,
cream
Generic OTC
miconazole nitrate vaginal cream Generic OTC
miconazole nitrate vaginal kit 1,200-2 mg-% Generic OTC
miconazole nitrate vaginal suppository Generic OTC
MICONAZOLE-3 PREFIL,CREAM,WIPE Brand OTC
miconazole-3 vaginal kit Generic OTC
miconazole-3 vaginal suppository Generic
miconazole-skin clnsr17 vaginal kit 4 % (200 mg)-
2 % (9 gram)
Generic OTC
NUVARING Brand QL
povidone-iodine vaginal solution 0.3 % Generic OTC
romantic mist douche Generic OTC
summer's eve douche Generic OTC
terconazole Generic
168 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
tioconazole-1 Generic OTC
tranexamic acid oral Generic
tropical breeze douche Generic OTC
VAGINAL CONTRACEPTIVE FILM Brand OTC
vaginal contraceptive foam Generic OTC
vagistat-3 Generic OTC
vandazole Generic
xulane Generic QL
Oral Contraceptives / Related Agents
altavera (28) Generic QL
alyacen 1/35 (28) Generic QL
alyacen 7/7/7 (28) Generic QL
amethia Generic QL
amethia lo Generic QL
amethyst Generic QL
apri Generic QL
aranelle (28) Generic QL
ashlyna Generic QL
aubra Generic QL
aviane Generic QL
azurette (28) Generic QL
balziva (28) Generic QL
bekyree (28) Generic QL
blisovi 24 fe Generic QL
blisovi fe 1.5/30 (28) Generic QL
blisovi fe 1/20 (28) Generic QL
briellyn Generic QL
camrese Generic QL
camrese lo Generic QL
caziant (28) Generic QL
169 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
chateal Generic QL
cryselle (28) Generic QL
cyclafem 1/35 (28) Generic QL
cyclafem 7/7/7 (28) Generic QL
cyred Generic QL
dasetta 1/35 (28) Generic QL
dasetta 7/7/7 (28) Generic QL
daysee Generic QL
delyla (28) Generic QL
desog-e.estradiol/e.estradiol Generic QL
desogestrel-ethinyl estradiol Generic QL
drospirenone-e.estradiol-lm.fa Generic QL
drospirenone-ethinyl estradiol Generic QL
econtra ez Generic OTC; QL
elinest Generic QL
ELLA Brand QL
emoquette Generic QL
enpresse Generic QL
enskyce Generic QL
estarylla Generic QL
ethynodiol diac-eth estradiol Generic QL
fallback solo Generic OTC; QL
falmina (28) Generic QL
fayosim Generic QL
femynor Generic QL
gianvi (28) Generic QL
gildagia Generic QL
gildess 1.5/30 (21) Generic QL
gildess 1/20 (21) Generic QL
gildess 24 fe Generic QL
170 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
gildess fe 1.5/30 (28) Generic QL
gildess fe 1/20 (28) Generic QL
introvale Generic QL
isibloom Generic QL
jolessa Generic QL
juleber Generic QL
junel 1.5/30 (21) Generic QL
junel 1/20 (21) Generic QL
junel fe 1.5/30 (28) Generic QL
junel fe 1/20 (28) Generic QL
junel fe 24 Generic QL
kaitlib fe Generic QL
kariva (28) Generic QL
kelnor 1/35 (28) Generic QL
kimidess (28) Generic QL
kurvelo Generic QL
l norgest/e.estradiol-e.estrad Generic QL
larin 1.5/30 (21) Generic QL
larin 1/20 (21) Generic QL
larin 24 fe Generic QL
larin fe 1.5/30 (28) Generic QL
larin fe 1/20 (28) Generic QL
larissia Generic QL
layolis fe Generic QL
leena 28 Generic QL
lessina Generic QL
levonest (28) Generic QL
levonorgestrel Generic QL
levonorgestrel-ethinyl estrad Generic QL
levonorg-eth estrad triphasic Generic QL
171 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
levora-28 Generic QL
lillow Generic QL
LO LOESTRIN FE Brand QL
lomedia 24 fe Generic QL
loryna (28) Generic QL
low-ogestrel (28) Generic QL
lutera (28) Generic QL
marlissa Generic QL
melodetta 24 fe Generic QL
mibelas 24 fe Generic QL
microgestin 1.5/30 (21) Generic QL
microgestin 1/20 (21) Generic QL
microgestin fe 1.5/30 (28) Generic QL
microgestin fe 1/20 (28) Generic QL
mono-linyah Generic QL
mononessa (28) Generic QL
my way Generic OTC; QL
myzilra Generic QL
NATAZIA Brand QL
necon 0.5/35 (28) Generic QL
necon 1/35 (28) Generic QL
necon 1/50 (28) Generic QL
necon 10/11 (28) Generic QL
necon 7/7/7 (28) Generic QL
next choice one dose Generic OTC; QL
nikki (28) Generic QL
noreth-ethinyl estradiol-iron Generic QL
norethindrone ac-eth estradiol oral tablet 1-20
mg-mcg
Generic QL
norethindrone-e.estradiol-iron Generic QL
norgestimate-ethinyl estradiol Generic QL
172 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
nortrel 0.5/35 (28) Generic QL
nortrel 1/35 (21) Generic QL
nortrel 7/7/7 (28) Generic QL
ocella Generic QL
ogestrel (28) Generic QL
opcicon one-step Generic OTC; QL
option-2 Generic OTC; QL
orsythia Generic QL
philith Generic QL
pimtrea (28) Generic QL
pirmella Generic QL
portia Generic QL
previfem Generic QL
quasense Generic QL
rajani Generic QL
react Generic OTC; QL
reclipsen (28) Generic QL
rivelsa Generic QL
SAFYRAL Brand QL
setlakin Generic QL
sprintec (28) Generic QL
sronyx Generic QL
syeda Generic QL
tarina fe 1/20 (28) Generic QL
tilia fe Generic QL
tri femynor Generic QL
tri-estarylla Generic QL
tri-legest fe Generic QL
tri-linyah Generic QL
tri-lo-estarylla Generic QL
173 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
tri-lo-marzia Generic QL
tri-lo-sprintec Generic QL
trinessa (28) Generic QL
trinessa lo Generic QL
tri-previfem (28) Generic QL
tri-sprintec (28) Generic QL
trivora (28) Generic QL
velivet triphasic regimen (28) Generic QL
vestura (28) Generic QL
vienva Generic QL
viorele (28) Generic QL
vyfemla (28) Generic QL
wera (28) Generic QL
wymzya fe Generic QL
zarah Generic QL
zenchent (28) Generic QL
zenchent fe Generic QL
zeosa Generic QL
zovia 1/35e (28) Generic QL
zovia 1/50e (28) Generic QL
Oxytocics
HEMABATE Brand
methylergonovine Generic
Ophthalmology
Antibiotics
ak-poly-bac Generic
AZASITE Brand
bacitracin ophthalmic (eye) Generic
bacitracin-polymyxin b ophthalmic (eye) Generic
ciprofloxacin hcl ophthalmic (eye) Generic
174 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
erythromycin ophthalmic (eye) Generic
garamycin ophthalmic (eye) drops Generic
gatifloxacin Generic
gentak ophthalmic (eye) ointment Generic
gentamicin ophthalmic (eye) Generic
levofloxacin ophthalmic (eye) Generic
moxifloxacin ophthalmic (eye) Generic
NATACYN Brand
neomycin-bacitracin-polymyxin Generic
neomycin-polymyxin-gramicidin Generic
neo-polycin Generic
ofloxacin ophthalmic (eye) Generic
polycin Generic
polymyxin b sulf-trimethoprim Generic
tobramycin Generic
TOBREX OPHTHALMIC (EYE) OINTMENT Brand
VIGAMOX Brand
Antivirals
trifluridine Generic
ZIRGAN Brand
Beta-Blockers
betaxolol ophthalmic (eye) Generic
BETIMOL Brand
BETOPTIC S Brand
carteolol Generic
ISTALOL Brand
levobunolol ophthalmic (eye) drops 0.5 % Generic
metipranolol Generic
timolol maleate ophthalmic (eye) Generic
Cholinesterase Inhibitor Miotics
175 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
PHOSPHOLINE IODIDE Brand
Cycloplegic Mydriatics
atropine ophthalmic (eye) Generic
atropine-care Generic
CYCLOGYL OPHTHALMIC (EYE) DROPS 1 % Brand
cyclopentolate Generic
homatropaire Generic
homatropine hbr Generic
ISOPTO HYOSCINE Brand
tropicamide Generic
Direct Acting Miotics
pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,
4 %
Generic
Miscellaneous Ophthalmologics
acuicyn Generic
advanced eye relief Generic OTC
AKTEN (PF) Brand
alaway Generic OTC
allergy eye (ketotifen) Generic OTC
ALOCRIL Brand
ALOMIDE Brand
altacaine Generic
altachlore Generic OTC
altafluor Generic
antihistamine eye drops Generic OTC
artificial tears (petro/min) Generic OTC
artificial tears (pf) ophthalmic (eye) dropperette Generic OTC
ARTIFICIAL TEARS (PF) OPHTHALMIC
(EYE) DROPPERETTE 0.1-0.3 %
Brand OTC
artificial tears (polyvin alc) Generic OTC
artificial tears(dext70-hypro) Generic OTC
176 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
artificial tears(glycerin-peg) Generic OTC
artificial tears(hypromellose) Generic OTC
artificial tears(pg-hypm-glyc) Generic OTC
artificial tears(pvalch-povid) Generic OTC
azelastine ophthalmic (eye) Generic
bion tears (pf) Generic OTC
bss Generic
children's alaway Generic OTC
cleansing eyelid Generic OTC
cromolyn ophthalmic (eye) Generic
dry eye relief Generic OTC
epinastine Generic
eye drop tears Generic OTC
eye itch relief Generic OTC
eye wash (boric acid) Generic OTC
EYELID WIPES Brand OTC
flucaine Generic
fluorescein-benoxinate Generic
fluorescein-proparacaine Generic
flurox Generic
for sty relief Generic OTC
GENTEAL MILD TO MODERATE Brand OTC
GENTEAL GEL Brand OTC
GENTEAL SEVERE Brand OTC
gonak Generic OTC
goniosoft Generic OTC
goniotaire Generic OTC
goniovisc Generic OTC
green glo Generic
ISOPTO TEARS Brand OTC
177 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
itchy eye drops Generic OTC
ketotifen fumarate Generic OTC
LACRISERT Brand
liquitears Generic OTC
lubricant eye (pg-peg 400) Generic OTC
lubricant eye (polyv alcohol) Generic OTC
lubricant eye drops (glyc-pg) Generic OTC
lubricant eye drops ophthalmic (eye) dropperette Generic OTC
LUBRICANT EYE DROPS OPHTHALMIC
(EYE) DROPS
Brand OTC
lubricant eye ophthalmic (eye) ointment 56.8-41.5
%, 57.3-42.5 %, 83-15 %
Generic OTC
lubricating plus Generic OTC
lubrifresh pm Generic OTC
methocel e 4 m granules Generic OTC
moisture drops Generic OTC
MURO 128 OPHTHALMIC (EYE) DROPS 2 % Brand OTC
natural balance Generic OTC
natural tears (pf) Generic OTC
nature's tears (hypromellose) Generic OTC
ocucoat Generic
olopatadine ophthalmic (eye) Generic
PATADAY Brand
polyvinyl alcohol Generic OTC
proparacaine Generic
puralube Generic OTC
pure and gentle eye Generic OTC
REFRESH CELLUVISC Brand OTC
REFRESH CLASSIC (PF) Brand OTC
REFRESH LACRI-LUBE Brand OTC
178 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
REFRESH OPTIVE OPHTHALMIC (EYE)
DROPS
Brand OTC
REFRESH OPTIVE SENSITIVE (PF) Brand OTC
REFRESH P.M. Brand OTC
REFRESH PLUS Brand OTC
REFRESH TEARS Brand OTC
RESTASIS Brand PA; QL
retaine cmc Generic OTC
revive plus Generic OTC
sochlor Generic OTC
sodium chloride ophthalmic (eye) Generic OTC
SOOTHE NIGHT TIME LUBRICANT Brand OTC
SYSTANE (PF) Brand OTC
SYSTANE (PROPYLENE GLYCOL) Brand OTC
SYSTANE GEL Brand OTC
SYSTANE ULTRA Brand OTC
SYSTANE ULTRA (PF) Brand OTC
tears again Generic OTC
tears again (pva) Generic OTC
TEARS NATURALE FORTE Brand OTC
TEARS NATURALE FREE (PF) Brand OTC
tears pure Generic OTC
tetcaine Generic
tetracaine hcl Generic
tetracaine hcl (pf) ophthalmic (eye) Generic
ultra fresh Generic OTC
ULTRA FRESH PM Brand OTC
ULTRA LUBRICANT EYE Brand OTC
wal-zyr (ketotifen) Generic OTC
Non-Steroidal Anti-Inflammatory Agents
bromfenac Generic
179 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
diclofenac sodium ophthalmic (eye) Generic
flurbiprofen sodium Generic
ketorolac ophthalmic (eye) Generic
Oral Drugs For Glaucoma
acetazolamide Generic
methazolamide Generic
Other Glaucoma Drugs
AZOPT Brand
bimatoprost ophthalmic (eye) Generic
COMBIGAN Brand
dorzolamide Generic
dorzolamide-timolol Generic
latanoprost Generic
miostat Generic
TRAVATAN Z Brand
travoprost (benzalkonium) Generic
Steroid-Antibiotic Combinations
neomycin-bacitracin-poly-hc Generic
neomycin-polymyxin b-dexameth Generic
neomycin-polymyxin-hc ophthalmic (eye) Generic
neo-polycin hc Generic
PRED-G Brand
PRED-G S.O.P. Brand
TOBRADEX OPHTHALMIC (EYE)
OINTMENT
Brand
TOBRADEX ST Brand
tobramycin-dexamethasone Generic
ZYLET Brand
Steroids
ALREX Brand
180 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
dexamethasone sodium phosphate ophthalmic
(eye)
Generic
FLAREX Brand
fluorometholone Generic
FML S.O.P. Brand
LOTEMAX OPHTHALMIC (EYE)
DROPS,SUSPENSION
Brand
MAXIDEX Brand
PRED MILD Brand
prednisolone acetate Generic
prednisolone sodium phosphate ophthalmic (eye) Generic
Steroid-Sulfonamide Combinations
BLEPHAMIDE Brand
BLEPHAMIDE S.O.P. Brand
sulfacetamide-prednisolone Generic
Sulfonamides
BLEPH-10 Brand
sulfacetamide sodium ophthalmic (eye) Generic
Sympathomimetics
ALPHAGAN P OPHTHALMIC (EYE) DROPS
0.1 %
Brand
apraclonidine Generic
brimonidine Generic
Vasoconstrictor Decongestants
advanced formula eye drops Generic OTC
altazine Generic OTC
CYCLOMYDRIL Brand
eye allergy relief Generic OTC
eye drops Generic OTC
eye drops (tetrahydrozoline) Generic OTC
eye drops (with povidone) Generic OTC
181 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
eye drops advanced relief Generic OTC
eye drops allergy relief Generic OTC
lubricant redness reliever Generic OTC
maximum redness relief Generic OTC
naphazoline Generic
opti-clear Generic OTC
phenylephrine hcl ophthalmic (eye) Generic
redness relief ophthalmic (eye) drops 0.012-0.2 % Generic OTC
redness reliever eye drops Generic OTC
redness reliever lubricant Generic OTC
sterile eye drops Generic OTC
visine-a Generic OTC
Respiratory And Allergy
Antihistamine / Antiallergenic Agents
12 hour cold relief Generic OTC
12 hour decongestant Generic OTC
24hour allergy Generic OTC
abanatuss ped Generic OTC
acta-tabs pe Generic OTC
acticon (dexbromph-pse) oral tablet Generic OTC
actidom dmx Generic OTC
adrenalin injection Generic
adt robitussin peak cld dm max Generic OTC
adult cough formula dm max Generic OTC
adult robitussin lingering cld Generic OTC
adult robitussin m-s cold Generic OTC
adult robitussin peak cold dm Generic OTC
adult robitussin peak cold m-s Generic OTC
adult tussin chest congestion Generic OTC
adult tussin cough congest dm Generic OTC
182 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
adult tussin dm Generic OTC
adult tussin multi-symp cold Generic OTC
adult wal-tussin Generic OTC
adult wal-tussin dm max Generic OTC
advil cold and sinus oral tablet Generic OTC
ala-hist ir Generic OTC
alavert Generic OTC
alavert d-12 allergy-sinus Generic OTC
aler-cap Generic OTC
aler-tab Generic OTC
alka-seltzer plus allergy Generic OTC
ALKA-SELTZER PLUS COLD/COUGHFM Brand OTC
ALKA-SELTZER PLUS DAY Brand OTC
alka-seltzer plus mucus-conges Generic OTC
ALKA-SELTZER PLUS SINUS-COUGH Brand OTC
all day allergy (cetirizine) Generic OTC
all day allergy-d Generic OTC
ALLEGRA ALLERGY Brand OTC
aller-chlor oral tablet Generic OTC
allerclear Generic OTC
allerclear d-12hr Generic OTC
allerclear d-24hr Generic OTC
aller-ease oral tablet Generic OTC
allerfed cold and allergy Generic OTC
aller-fex Generic OTC
aller-g-time Generic OTC
allergy (chlorpheniramine) Generic OTC
allergy (diphenhydramine) oral capsule Generic OTC
allergy (diphenhydramine) oral tablet Generic OTC
allergy 4-hour Generic OTC
183 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
allergy and congestion relief Generic OTC
allergy and sinus relief Generic OTC
allergy complete-d Generic OTC
allergy d-12 Generic OTC
allergy medication Generic OTC
allergy medicine oral liquid Generic OTC
allergy medicine oral tablet Generic OTC
allergy m-s nighttime Generic OTC
allergy multi-symptom Generic OTC
allergy plus severe sinus ha Generic OTC
allergy relief (cetirizine) Generic OTC
allergy relief (clemastine) Generic OTC
allergy relief (fexofenadine) Generic OTC
allergy relief (loratadine) Generic OTC
allergy relief d-24 Generic OTC
allergy relief multi-symptom Generic OTC
allergy relief(chlorpheniramn) Generic OTC
allergy relief(diphenhydramin) Generic OTC
allergy relief,nasal decongest Generic OTC
allergy relief-d (cetirizine) Generic OTC
allergy relief-d (loratadine) Generic OTC
allergy relief-d(fexofenadine) Generic OTC
allergy sinus pe Generic OTC
allergy sinus-d Generic OTC
allergy-congest relief-d (cet) Generic OTC
allergy-congestion relief-d oral tablet extended
release 24 hr
Generic OTC
allergy-d Generic OTC
allergy-time Generic OTC
allerhist-1 Generic OTC
aller-tec Generic OTC
184 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
aller-tec d Generic OTC
allfen Generic OTC
allfen dm Generic OTC
ambi 10peh-4cpm Generic OTC
AMBI 10PEH-4CPM-20DM Brand OTC
AMBI 20DM-4CPM Brand OTC
ambi 40pse-400gfn-20dm Generic OTC
ambi 60pse-400gfn Generic OTC
ambi 60pse-4cpm Generic OTC
ambitussin ac Generic
antitussive dm Generic OTC
ap-hist dm Generic OTC
aprodine Generic OTC
arbinoxa Generic
banophen allergy Generic OTC
banophen oral capsule Generic OTC
banophen oral tablet Generic OTC
benzonatate Generic
biobron sf Generic OTC
biocotron Generic OTC
biogil Generic OTC
bionel Generic OTC
brohist d Generic OTC
brompheniramine-pseudoeph-dm oral syrup Generic
brompheniramin-phenylephrin-dm Generic OTC
bronchial asthma relief Generic OTC
broncotron ped oral liquid Generic OTC
brotapp Generic OTC
brotapp dm Generic OTC
carbinoxamine maleate Generic
185 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
centergy Generic
centergy dm Generic
cetiri-d Generic OTC
cetirizine oral solution 1 mg/ml Generic
cetirizine oral tablet Generic OTC
cetirizine oral tablet,chewable 5 mg Generic OTC
cetirizine-pseudoephedrine Generic OTC
cheracol d Generic OTC
cheratussin ac Generic
cheratussin dac Generic
cherry menthol Generic OTC
chest congestion Generic OTC
chest congestion relief Generic OTC
chest congestion relief + dm Generic OTC
chest congestion relief d Generic OTC
chest congestion relief pe Generic OTC
chest congestion-cough relief Generic OTC
chest-sinus congestion relief Generic OTC
child allergy relf(cetirizine) oral solution Generic OTC
child allergy relief (diphen) Generic OTC
child chest congestion + cough Generic OTC
child delsym cough+chest dm Generic OTC
child mucinex chest congestion Generic OTC
child mucus relief cough Generic OTC
child mucus relief expectorant Generic OTC
CHILD MULTI-SYMPTOM COLD/COUGH Brand OTC
child triaminic cold-allergy Generic OTC
child wal-tap cold-allergy Generic OTC
child wal-tussin cough relief Generic OTC
children night time cold-cough Generic OTC
186 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
children's allegra allergy Generic OTC
children's allergy (diphenhyd) oral elixir Generic OTC
children's allergy (diphenhyd) oral liquid Generic OTC
children's allergy (diphenhyd) oral
tablet,disintegrating
Generic OTC
children's allergy complete Generic OTC
children's allergy medicine Generic OTC
children's allergy relief(lor) Generic OTC
children's aller-tec Generic OTC
children's benadryl allergy oral tablet,chewable Generic OTC
children's cetirizine Generic OTC
children's chest congestion Generic OTC
CHILDREN'S CLARITIN ORAL
TABLET,CHEWABLE
Brand OTC
children's cold and cough (pe) Generic OTC
children's cold-allergy (pe) Generic OTC
children's complete allergy Generic OTC
children's cough Generic OTC
children's dibromm cold-allerg Generic OTC
children's dibromm dm cold-cou Generic OTC
children's dimetapp cold-flu Generic OTC
children's flu relief Generic OTC
children's mucinex cough Generic OTC
CHILDREN'S MUCINEX MULTI-SYMP Brand OTC
childrens plus cold Generic OTC
children's plus flu Generic OTC
CHILDRENS PLUS MULTI-SYMP COLD Brand OTC
children's silfedrine Generic OTC
CHILDREN'S SUDAFED Brand OTC
children's sudafed pe cough Generic OTC
children's wal-dryl allergy Generic OTC
187 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
children's wal-zyr Generic OTC
child's all day allergy(cetir) Generic OTC
child's benadryl-d allergy-sin Generic OTC
childs triacting cold-cough Generic OTC
chlorhist Generic OTC
chlorpheniramine maleate oral tablet Generic OTC
chlorpheniramine maleate oral tablet extended
release
Generic OTC
chlortabs Generic OTC
clemastine oral syrup Generic
clemastine oral tablet 1.34 mg Generic OTC
clemastine oral tablet 2.68 mg Generic
codeine-guaifenesin Generic
codituss dm Generic OTC
cold and allergy Generic OTC
cold and allergy (bromphen-pe) Generic OTC
cold and allergy pe Generic OTC
cold and cough (diphenhydr-pe) Generic OTC
cold and cough (pe-dm) Generic OTC
cold and cough (pe-dm-gg-acet) Generic OTC
cold and cough dm Generic OTC
cold and cough elixir Generic OTC
cold and flu severe Generic OTC
cold and sinus pain relief Generic OTC
COLD HEAD CONGESTION DAY/NITE Brand OTC
COLD HEAD CONGESTION DAYTIME Brand OTC
cold head congestion nighttime Generic OTC
cold head congestion sever day Generic OTC
COLD MULTI-SYMPTOM Brand OTC
COLD MULTI-SYMPTOM DAY/NIGHT Brand OTC
cold multi-symptom nighttime Generic OTC
188 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
cold relief m/s day/night Generic OTC
COLD RELIEF ORAL TABLET,
EFFERVESCENT
Brand OTC
cold relief plus Generic OTC
cold-flu relief oral liquid 5-10-325 mg/15 ml Generic OTC
cold-flu relief, day/night Generic OTC
complete allergy medicine oral tablet Generic OTC
complete allergy oral capsule Generic OTC
complete allergy oral liquid Generic OTC
conex oral tablet Generic OTC
congestac Generic OTC
CORICIDIN HBP COUGH AND COLD Brand OTC
cough and cold (chlorphen-dm) Generic OTC
cough and cold mucus relief cf Generic OTC
cough and cold oral liquid Generic OTC
cough control (dextromethorph) Generic OTC
cough control (guaifenesin) Generic OTC
cough control cf (pe) Generic OTC
cough control dm Generic OTC
cough control dm max Generic OTC
cough dm er Generic OTC
cough drops (with eucalyptus) mucous membrane
lozenge , 6.5 mg, 7 mg, 7.6 mg, 8 mg
Generic OTC
cough formula dm Generic OTC
cough relief Generic OTC
cough suppressant-expectorant Generic OTC
cough syrup Generic OTC
cough syrup dm Generic OTC
cough-chest congestion dm Generic OTC
coughtab Generic OTC
cyproheptadine Generic
189 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
day multi-symp flu-severe cold Generic OTC
DAY TIME PE Brand OTC
dayhist allergy Generic OTC
DAYTIME Brand OTC
DAYTIME AND NIGHTTIME COLD Brand OTC
DAYTIME COLD-FLU Brand OTC
DAYTIME COLD-FLU RELIEF (PE) ORAL
CAPSULE
Brand OTC
daytime cold-flu relief (pe) oral liquid Generic OTC
day-time cough Generic OTC
daytime mucus relief dm Generic OTC
day-time oral capsule 30-15-325 mg Generic OTC
daytime-nighttime Generic OTC
delsym cough-chest congest dm Generic OTC
desgen dm oral liquid 5-10-100 mg/5 ml Generic OTC
desloratadine Generic
despec dm-g Generic OTC
despec eda cough-cold drops Generic OTC
despec-dm (phenyleph-dm-guaif) oral liquid 5-10-
100 mg/5 ml
Generic OTC
DEXTROMETHORPHAN HBR (BULK) Brand
dextromethorphan polistirex Generic OTC
dextromethorphan-guaifenesin Generic OTC
diabetic siltussin das-na Generic OTC
diabetic siltussin-dm Generic OTC
diabetic siltussin-dm max str Generic OTC
diabetic tussin dm Generic OTC
diabetic tussin ex Generic OTC
diabetic tussin max st Generic OTC
dimaphen (pe) Generic OTC
dimaphen dm Generic OTC
190 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
dimetapp cold-congestion Generic OTC
dimetapp dm cold-cough (pe) Generic OTC
DIMETAPP LONG-ACTING (CPM-DM) Brand OTC
diphedryl allergy Generic OTC
diphedryl oral capsule Generic OTC
diphedryl oral tablet Generic OTC
diphen Generic OTC
diphenhist Generic OTC
diphenhydramine hcl injection solution 50 mg/ml Generic
diphenhydramine hcl injection syringe Generic
diphenhydramine hcl oral capsule 25 mg Generic OTC
diphenhydramine hcl oral capsule 50 mg Generic
diphenhydramine hcl oral elixir Generic OTC
diphenhydramine hcl oral liquid Generic OTC
diphenhydramine hcl oral syrup Generic OTC
diphenhydramine hcl oral tablet 25 mg Generic OTC
dm max Generic OTC
dometuss-dmx Generic OTC
double-tussin dm Generic OTC
dristan cold Generic OTC
ed a-hist Generic OTC
ed a-hist dm oral liquid Generic OTC
ed a-hist pse Generic OTC
ed bron gp Generic OTC
ed chlorped jr Generic OTC
ed-chlortan Generic OTC
endacof - dm Generic OTC
endacof-c Generic
endacon Generic OTC
entre-cough Generic OTC
191 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
entre-hist pse Generic OTC
epinephrine hcl (pf) Generic
epinephrine injection solution Generic
EPIPEN Brand
EPIPEN JR Brand
expectorant oral liquid Generic OTC
fenesin dm ir oral tablet 20-400 mg Generic OTC
fenesin ir Generic OTC
fenesin pe ir Generic OTC
fexofenadine oral tablet 180 mg, 60 mg Generic OTC
fexofenadine-pseudoephedrine Generic OTC
flu and severe cold-nighttime Generic OTC
flu bp Generic OTC
flu hbp Generic OTC
flu relief therapy daytime Generic OTC
flu relief therapy nighttime Generic OTC
g tussin ac Generic
geri-dryl oral capsule Generic OTC
geri-dryl oral tablet Generic OTC
geri-tussin Generic OTC
geri-tussin dm Generic OTC
glenmax peb dm Generic OTC
g-p-tuss dxp Generic OTC
g-tron Generic OTC
g-tron ped oral drops Generic OTC
guaiasorb dm Generic OTC
guaiatussin ac Generic
guaifenesin ac Generic
guaifenesin dac Generic
guaifenesin oral liquid Generic OTC
192 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
guaifenesin oral tablet Generic OTC
guaifenesin oral tablet extended release 12hr 600
mg
Generic OTC
G-ZYNCOF Brand OTC
honey lemon Generic OTC
hot steam liquid Generic OTC
hydrocodone-chlorpheniramine Generic
hydrocodone-cpm-pseudoephed Generic
hydrocodone-homatropine oral syrup 5-1.5 mg/5
ml
Generic
hydrocodone-homatropine oral tablet Generic
hydromet Generic
hydroxyzine hcl intramuscular solution 50 mg/ml Generic
hydroxyzine hcl oral solution 10 mg/5 ml Generic
hydroxyzine hcl oral tablet Generic
hydroxyzine pamoate Generic
ibuprofen cold Generic OTC
ibuprofen cold-sinus(with pse) Generic OTC
intense cough reliever oral liquid 30-200 mg/5 ml Generic OTC
iophen c-nr Generic
iophen dm-nr Generic OTC
iophen-nr Generic OTC
kidkare cough/cold Generic OTC
levocetirizine Generic
liquibid d-r Generic OTC
lohist - d Generic OTC
lohist peb dm Generic OTC
lohist-dm Generic OTC
lohist-peb Generic OTC
lorata-d Generic OTC
loratadine Generic OTC
193 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
loratadine-d Generic OTC
lortuss ex oral syrup Generic
mapap cold formula Generic OTC
mapap sinus max strength (pe) Generic OTC
maximum strength flu Generic OTC
maxiphen Generic OTC
m-clear wc Generic
medifin expectorant mucus rlf Generic OTC
medikoff drops Generic OTC
medi-phedrine Generic OTC
medi-phedryl Generic OTC
medi-tussin Generic OTC
medi-tussin dm Generic OTC
medi-tussin dm diabetic Generic OTC
m-end dm Generic OTC
menthol cough drops Generic OTC
menthol cough mucous membrane lozenge 6.5 mg Generic OTC
menthol drops Generic OTC
m-hist dm Generic OTC
mucaphed Generic OTC
mucinex allergy Generic OTC
mucinex d Generic OTC
mucinex d maximum strength Generic OTC
mucinex dm oral tablet extended release 12 hr 30-
600 mg
Generic OTC
MUCINEX DM ORAL TABLET EXTENDED
RELEASE 12 HR 60-1,200 MG
Brand OTC
mucinex fast-max cold-flu-thrt oral tablet Generic OTC
MUCINEX FAST-MAX CONGEST-COUGH
ORAL LIQUID
Brand OTC
mucinex fast-max dm max Generic OTC
194 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
mucinex fast-max severe cold oral tablet Generic OTC
mucinex oral tablet extended release 12hr 600 mg Generic OTC
mucosa Generic OTC
mucosa dm Generic OTC
mucus and cough relief Generic OTC
mucus d Generic OTC
mucus dm Generic OTC
mucus dm max Generic OTC
mucus relief Generic OTC
MUCUS RELIEF CONGESTION-COUGH Brand OTC
mucus relief cough Generic OTC
mucus relief d (phenylephrine) Generic OTC
mucus relief d (pseudoephed) oral tablet Generic OTC
mucus relief d (pseudoephed) oral tablet extended
release 12 hr 60-600 mg
Generic OTC
mucus relief dm Generic OTC
mucus relief dm max Generic OTC
mucus relief er oral tablet extended release Generic OTC
mucus relief er oral tablet extended release 12hr
600 mg
Generic OTC
mucus relief pe Generic OTC
mucus relief plus Generic OTC
mucus relief sinus Generic OTC
multi-symptom cold (pe) Generic OTC
multi-symptom cold (pe-cpm) Generic OTC
multi-symptom cold daytime Generic OTC
multi-symptom cold night time Generic OTC
nasal decongestant (pe) oral tablet 10 mg Generic OTC
nasal decongestant (pseudoeph) oral liquid Generic OTC
nasal decongestant (pseudoeph) oral tablet Generic OTC
195 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
nasal decongestant (pseudoeph) oral tablet
extended release
Generic OTC
natural herb cough drops mucous membrane
lozenge 3 mg
Generic OTC
neo-tuss Generic OTC
night time cold oral tablet Generic OTC
night time cold-flu oral capsule Generic OTC
nightime sleep Generic OTC
nighttime allergy relief Generic OTC
nighttime cough Generic OTC
nighttime cough-cold Generic OTC
nighttime sinus Generic OTC
nighttime sleep aid (diphen) oral capsule 50 mg Generic OTC
nighttime sleep aid (diphen) oral tablet Generic OTC
nite time cough Generic OTC
nite time-d cold-flu relief Generic OTC
nohist-dm Generic OTC
nohist-lq Generic OTC
non-aspirin flu oral tablet 30-15-500 mg Generic OTC
non-aspirin severe congest m-s Generic OTC
non-drowsy allergy Generic OTC
non-drying sinus oral capsule Generic OTC
NOREL AD Brand OTC
nyquil d Generic OTC
organ-i nr Generic OTC
ormir Generic OTC
pain relief allergy sinus Generic OTC
pain reliever flu Generic OTC
pcm la Generic
pedia relief cough-cold Generic OTC
pedia relief infant nasal Generic OTC
196 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
pediacare multi-symptom cold Generic OTC
pediatric cough and cold oral liquid 1-15-5 mg/5
ml
Generic OTC
pe-guai Generic
pharbechlor Generic OTC
pharbedryl Generic OTC
phenadoz Generic
phenergan rectal Generic
phenylhistine dh Generic
poly-tussin Generic
poly-tussin d Generic
pres gen Generic OTC
PRESGEN B Brand OTC
promethazine injection solution Generic
promethazine oral Generic
promethazine rectal Generic
promethazine vc-codeine Generic
promethazine-codeine Generic
promethazine-dm Generic
promethazine-phenyleph-codeine Generic
promethegan Generic
pseudoephedrine hcl Generic OTC
pseudoephedrine-guaifenesin Generic OTC
pyrilamine-phenylephrine oral suspension Generic OTC
q-dryl Generic OTC
q-tapp Generic OTC
q-tapp dm Generic OTC
q-tussin Generic OTC
q-tussin dm Generic OTC
quenalin Generic OTC
refenesen Generic OTC
197 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
refenesen dm Generic OTC
refenesen pe Generic OTC
relcof c Generic
relcof dm Generic OTC
rescon-gg Generic OTC
rest simply nighttime sleep Generic OTC
restfully sleep Generic OTC
ritifed Generic OTC
ri-tussin Generic OTC
ri-tussin dm Generic OTC
robafen Generic OTC
robafen cf (phenylephrine) Generic OTC
robafen cough Generic OTC
robafen dm Generic OTC
robafen dm cough Generic OTC
robafen dm cough-chest congest Generic OTC
robitussin cold-flu day Generic OTC
robitussin cough and cold cf Generic OTC
robitussin cough-chest cong dm Generic OTC
ROBITUSSIN LONG-ACTING Brand OTC
robitussin pediatric Generic OTC
r-tanna Generic
rydex Generic
rynex dm Generic OTC
rynex pe Generic OTC
rynex pse Generic OTC
scot-tussin dm Generic OTC
scot-tussin expectorant Generic OTC
severe cold Generic OTC
severe cold multi-symptom Generic OTC
198 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
SEVERE CONGESTION AND COUGHMAX Brand OTC
siladryl sa Generic OTC
silphen cough Generic OTC
siltussin dm das Generic OTC
siltussin sa Generic OTC
siltussin-dm Generic OTC
simply sleep Generic OTC
sinus 12 hour Generic OTC
sinus and allergy non-drowsy Generic OTC
sinus and allergy pe Generic OTC
sinus congestion and pain Generic OTC
sinus congestion-pain(chlorph) Generic OTC
sinus congestion-pain(guaif) Generic OTC
sinus congest-pain day-night Generic OTC
sinus decongestant (pe) Generic OTC
sinus headache pe Generic OTC
sinus pain relief Generic OTC
sinus pe decongestant Generic OTC
sinus relief (non-drowsy) Generic OTC
sinus-allergy (phenylephrine) Generic OTC
sleep aid (diphenhydramine) oral capsule 50 mg Generic OTC
SLEEP AID (DIPHENHYDRAMINE) ORAL
LIQUID
Brand OTC
sleep aid (diphenhydramine) oral tablet Generic OTC
sleep ii Generic OTC
sleep-tabs Generic OTC
sorbugen nr Generic OTC
sudogest Generic OTC
sudogest 12-hour Generic OTC
sudogest cold and allergy Generic OTC
sudogest pe Generic OTC
199 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
sudogest sinus and allergy Generic OTC
suphedrin Generic OTC
suphedrine Generic OTC
suphedrine 12 hour Generic OTC
suphedrine pe Generic OTC
suphedrine pe cold and allergy Generic OTC
suphedrine pe sinus headache Generic OTC
supress dx Generic OTC
tab tussin Generic OTC
tab tussin dm Generic OTC
tg 10peh-380gfn-15dm Generic OTC
throat lozenges Generic OTC
total allergy medicine Generic OTC
TRIAMINIC COLD AND COUGH (PE) Brand OTC
trigofen dm Generic OTC
trymine cg Generic
tusnel c Generic
tusnel diabetic Generic OTC
tusnel pediatric oral drops Generic OTC
tussi pres-b oral liquid 4-10-20 mg/5 ml Generic OTC
tussigon Generic
tussin Generic OTC
tussin cf Generic OTC
tussin cf (pe-dm-guaif) Generic OTC
tussin cf max Generic OTC
tussin chest congestion Generic OTC
tussin cold-congestion Generic OTC
tussin cough (dm only) Generic OTC
tussin cough dm Generic OTC
tussin cough-chest congestion Generic OTC
200 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
tussin dm clear Generic OTC
tussin dm cough Generic OTC
tussin dm cough and chest Generic OTC
tussin dm max Generic OTC
tussin dm oral syrup 10-100 mg/5 ml Generic OTC
tussin dm oral tablet Generic OTC
tussin honey Generic OTC
tussin long-acting Generic OTC
tussin maximum strength Generic OTC
tussin maximum strength cough Generic OTC
tussin pe oral liquid Generic OTC
tussi-pres oral liquid Generic OTC
unisom sleepgels Generic OTC
valu-tapp Generic OTC
vaporizing steam Generic OTC
vazobid-pd Generic OTC
vicks dayquil cold-flu relief Generic OTC
vicks dayquil cough Generic OTC
VICKS NATURE FUSION Brand OTC
vicks nature fusion cough Generic OTC
vicks qlearquil allergy Generic OTC
vicks qlearquil nighttime rlf Generic OTC
vicks vaposteam Generic OTC
virdec Generic OTC
virdec dm Generic OTC
virtussin ac Generic
virtussin dac Generic
wal-act d cold and allergy Generic OTC
wal-dryl allergy Generic OTC
wal-dryl severe allergy-sinus Generic OTC
201 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
wal-dryl-d allergy and sinus Generic OTC
wal-fex allergy Generic OTC
wal-fex d 12 hour Generic OTC
wal-fex d 24 hour Generic OTC
wal-finate Generic OTC
wal-finate-d Generic OTC
wal-flu night severe cold Generic OTC
wal-itin Generic OTC
wal-itin d Generic OTC
wal-itin d 12 hour Generic OTC
wal-phed Generic OTC
wal-phed 12 hour Generic OTC
wal-phed d Generic OTC
wal-phed pe Generic OTC
wal-phed pe nighttime cold Generic OTC
wal-phed pe sinus and allergy Generic OTC
wal-profen cold-sinus Generic OTC
wal-profen d cold and sinus Generic OTC
wal-som (diphenhydramine) oral capsule Generic OTC
wal-tap dm Generic OTC
wal-tussin cough Generic OTC
wal-tussin cough and cold cf Generic OTC
wal-tussin dm Generic OTC
wal-tussin max strength cough Generic OTC
wal-zyr (cetirizine) Generic OTC
wal-zyr d Generic OTC
ZYNCOF ORAL LIQUID Brand OTC
zyncof oral tablet Generic OTC
ZZZQUIL ORAL LIQUID Brand OTC
Pulmonary Agents
202 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
acetylcysteine Generic
ADCIRCA Brand PA; ST
ADVAIR DISKUS Brand QL
ADVAIR HFA Brand QL
albuterol sulfate inhalation solution for
nebulization
Generic
albuterol sulfate oral Generic
aller-flo Generic OTC; QL
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 110
MCG (30 DOSES), 220 MCG (120 DOSES), 220
MCG (30 DOSES), 220 MCG (60 DOSES)
Brand QL
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 220
MCG (14 DOSES)
Brand
ATROVENT HFA Brand QL
bronchial mist refill Generic OTC
budesonide inhalation Generic
budesonide nasal Generic OTC; QL
caffeine-sodium benzoate Generic
COMBIVENT RESPIMAT Brand QL
cromolyn inhalation Generic
cromolyn nasal Generic OTC
DALIRESP Brand
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML Brand
ephedrine sulfate oral Generic OTC
FIRAZYR Brand PA
FLOVENT DISKUS Brand QL
FLOVENT HFA Brand QL
flunisolide nasal spray,non-aerosol 25 mcg (0.025
%)
Generic QL
fluticasone nasal Generic OTC; QL
FORADIL AEROLIZER Brand
203 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
INCRUSE ELLIPTA Brand
ipratropium bromide inhalation Generic
ipratropium-albuterol Generic
LETAIRIS Brand PA; ST
levalbuterol hcl Generic
LUFYLLIN Brand
metaproterenol Generic
mometasone nasal Generic QL
montelukast Generic
nasal allergy Generic OTC; QL
nasal allergy symptom control Generic OTC
nebusal inhalation solution for nebulization 3 % Generic
pulmosal Generic
PULMOZYME Brand
QVAR Brand QL
REVATIO ORAL SUSPENSION FOR
RECONSTITUTION
Brand PA; ST
SEREVENT DISKUS Brand
sildenafil (antihypertensive) oral Generic PA
sodium chloride inhalation Generic
SPIRIVA RESPIMAT Brand
SPIRIVA WITH HANDIHALER Brand
SYMBICORT Brand QL
terbutaline Generic
THEO-24 Brand
theochron Generic
theophylline oral elixir Generic
theophylline oral solution Generic
theophylline oral tablet extended release 12 hr Generic
theophylline oral tablet extended release 24 hr Generic
TRACLEER ORAL TABLET Brand PA
204 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
triamcinolone acetonide nasal Generic OTC; QL
TYVASO Brand PA
TYVASO REFILL KIT Brand PA
TYVASO STARTER KIT Brand PA
VENTAVIS Brand PA
VENTOLIN HFA Brand QL
XOLAIR Brand PA
zafirlukast Generic
zileuton Generic
ZYFLO Brand
ZYFLO CR Brand
Urologicals
Anticholinergics / Antispasmodics
darifenacin Generic
flavoxate Generic
oxybutynin chloride oral syrup Generic
oxybutynin chloride oral tablet Generic
OXYTROL Brand
tolterodine Generic
TOVIAZ Brand
trospium Generic
VESICARE Brand
Benign Prostatic Hyperplasia(Bph) Therapy
alfuzosin Generic
dutasteride Generic
dutasteride-tamsulosin Generic
finasteride oral tablet 5 mg Generic
tamsulosin Generic
Cholinergic Stimulants
bethanechol chloride Generic
205 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
Miscellaneous Urologicals
azuphen mb Generic
CYSTAGON Brand
cytra k crystals Generic
cytra-2 Generic
cytra-3 Generic
cytra-k Generic
ELMIRON Brand
glycine urologic Generic
glycine urologic solution Generic
hyolev mb Generic
hyophen Generic
K-PHOS NO 2 Brand
K-PHOS ORIGINAL Brand
methen-sod phos-meth blue-hyos Generic
phosphasal Generic
pot,sodium citrate-citric acid Generic
potassium citrate Generic
potassium citrate-citric acid Generic
RENACIDIN Brand
sodium citrate-citric acid Generic
tricitrates Generic
ur n-c Generic
uramit mb Generic
uretron d-s Generic
urimar-t Generic
urin ds Generic
uro-458 Generic
uro-blue Generic
urogesic-blue Generic
206 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
uro-l Generic
urolet mb Generic
uro-mp Generic
urophen mb Generic
UROQID-ACID NO.2 Brand
uryl Generic
ustell Generic
utira-c Generic
virtrate-2 Generic
virtrate-3 Generic
virtrate-k Generic
Urinary Anesthetics
azo-dine oral tablet 95 mg Generic OTC
azo-tabs Generic OTC
phenazopyridine oral tablet 100 mg, 200 mg Generic
urinary pain relief oral tablet 95 mg Generic OTC
uristat oral Generic OTC
Vitamins, Hematinics / Electrolytes
Blood Derivatives
albumin, human 25 % Generic
albuminar 25 % Generic
albuminar 5 % Generic
alburx (human) 25 % Generic
alburx (human) 5 % Generic
albutein 25 % Generic
albutein 5 % Generic
buminate 25 % Generic
buminate 5 % Generic
plasbumin 25 % Generic
Electrolytes
207 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
alcalak Generic OTC
antacid (calcium carbonate) Generic OTC
antacid ext str (calcium carb) Generic OTC
antacid extra-strength oral tablet,chewable 168
mg calcium (420 mg), 300 mg (750 mg)
Generic OTC
antacid ultra strength oral tablet,chewable 400 mg
calcium (1,000 mg)
Generic OTC
calci-chew Generic OTC
calcionate Generic OTC
calcitrate Generic OTC
CALCITRATE-VITAMIN D Brand OTC
calcium 500 + d oral tablet 500 mg(1,250mg) -200
unit
Generic OTC
calcium 500 with d Generic OTC
calcium 600 + d(3) oral capsule Generic OTC
calcium 600 + d(3) oral tablet 600 mg(1,500mg) -
400 unit
Generic OTC
calcium 600 with vitamin d3 oral capsule 600
mg(1,500mg) -400 unit
Generic OTC
CALCIUM 600 WITH VITAMIN D3 ORAL
CAPSULE 600 MG(1,500MG) -500 UNIT
Brand OTC
calcium 600 with vitamin d3 oral tablet,chewable Generic OTC
calcium acetate oral capsule Generic
calcium acetate oral tablet 667 mg Generic
calcium antacid oral tablet,chewable 200 mg
calcium (500 mg), 300 mg (750 mg), 320 mg
calcium (750 mg), 430 mg calcium (1,000 mg)
Generic OTC
calcium antacid ultra max st Generic OTC
calcium carb and citrate-vitd3 Generic OTC
calcium carbonate oral suspension Generic OTC
calcium carbonate oral tablet 260 mg calcium
(648 mg), 500 mg calcium (1,250 mg), 600 mg
calcium (1,500 mg)
Generic OTC
208 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
calcium carbonate oral tablet,chewable 200 mg
calcium (500 mg), 300 mg (750 mg), 400 mg
calcium (1,000 mg), 500 mg calcium (1,250 mg)
Generic OTC
calcium carbonate-vitamin d3 oral capsule 600
mg(1,500mg) -400 unit
Generic OTC
CALCIUM CARBONATE-VITAMIN D3 ORAL
TABLET 1,000 MG(2,500 MG)-800 UNIT, 600
MG(1,500MG) -800 UNIT
Brand OTC
calcium carbonate-vitamin d3 oral tablet 250-125
mg-unit, 500 mg(1,250mg) -125 unit, 500mg
(1,250mg) -600 unit, 600 mg(1,500mg) -200 unit,
600 mg(1,500mg) -400 unit
Generic OTC
calcium carbonate-vitamin d3 oral
tablet,chewable
Generic OTC
calcium citrate + Generic OTC
calcium citrate + d Generic OTC
calcium citrate + d with mag Generic OTC
calcium citrate oral tablet Generic OTC
calcium citrate plus (vit b6) Generic OTC
calcium citrate-vitamin d2 Generic OTC
calcium citrate-vitamin d3 oral tablet 200 mg
calcium -250 unit, 200-125 mg-unit, 250 mg
calcium- 200 unit, 315-250 mg-unit
Generic OTC
calcium gluconate intravenous Generic
calcium gluconate oral tablet 45 mg (500 mg), 60
mg (650 mg)
Generic OTC
calcium lactate oral tablet 650 mg, 84 mg (648
mg)
Generic OTC
calcium-magnesium-zinc Generic OTC
cal-gest antacid Generic OTC
CALTRATE WITH VITAMIN D3 Brand OTC
chelated zinc Generic OTC
CITRACAL + D MAXIMUM Brand OTC
CITRACAL PLUS MAGNESIUM Brand OTC
citrus calcium Generic OTC
209 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
copper chloride Generic
effer-k oral tablet, effervescent 25 meq Generic
eliphos Generic
flavor chews antacid Generic OTC
GALZIN Brand
hi-cal plus vit d Generic OTC
high potency calcium Generic OTC
k-effervescent Generic
klor-con Generic
klor-con 10 Generic
klor-con 8 Generic
klor-con m10 Generic
klor-con m15 Generic
klor-con m20 Generic
klor-con sprinkle Generic
klor-con/ef Generic
k-phos-neutral Generic
k-sol Generic
K-TAB ORAL TABLET EXTENDED RELEASE
10 MEQ
Brand
k-tab oral tablet extended release 8 meq Generic
lactated ringers intravenous Generic
laxative dietary supplement Generic OTC
lugols oral Generic
mag 64 Generic OTC
mag-delay Generic OTC
mag-g Generic OTC
MAGNEBIND 300 Brand OTC
MAGNESIUM AMINO ACID CHELATE Brand OTC
magnesium gluconate oral tablet 27 mg (500 mg),
27.5 mg (500 mg)
Generic OTC
210 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
magnesium oral tablet 200 mg Generic OTC
magnesium oxide oral capsule 500 mg Generic OTC
magnesium oxide oral tablet Generic OTC
magnesium sulfate injection Generic
mgo Generic OTC
oralyte Generic OTC
OS-CAL 500 + D3 ORAL TABLET 500MG
(1,250MG) -600 UNIT
Brand OTC
oysco 500/d oral tablet Generic OTC
oysco d Generic OTC
oysco-500 Generic OTC
oyster shell calcium Generic OTC
oyster shell calcium 500 Generic OTC
oyster shell calcium and mag Generic OTC
oyster shell calcium-vit d3 oral tablet 500
mg(1,250mg) -200 unit, 500 mg(1,250mg) -400
unit
Generic OTC
oystercal-d Generic OTC
pedialyte oral solution Generic OTC
pedialyte singles Generic OTC
pediatric electrolyte oral solution Generic OTC
pediatric freezer pops Generic OTC
phos-nak Generic OTC
phospha 250 neutral Generic
phospho-trin 250 neutral Generic OTC
potassium Generic OTC
potassium acetate Generic
potassium bicarb and chloride Generic
potassium bicarb-citric acid Generic
potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 20 meq/l
Generic
potassium chloride Generic
211 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
potassium chloride in 5 % dex intravenous
parenteral solution 40 meq/l
Generic
potassium chloride-0.45 % nacl Generic
potassium gluconate oral tablet 2.5 meq, 500 mg
(83 mg), 550 mg (90 mg), 595 mg (99 mg)
Generic OTC
potassium phosphate m-/d-basic Generic
ringer's intravenous Generic
selenium oral tablet Generic OTC
selenium oral tablet,delayed release (dr/ec) Generic OTC
selenomax Generic OTC
SLOW-MAG Brand OTC
smooth antacid Generic OTC
sodium acetate Generic
sodium bicarbonate intravenous solution Generic
sodium bicarbonate intravenous syringe 10
meq/10 ml (8.4 %), 4.2 % (0.5 meq/ml), 8.4 % (1
meq/ml)
Generic
sodium chloride Generic OTC
sodium chloride 0.45 % intravenous Generic
sodium chloride 3 % Generic
sodium chloride 5 % Generic
sodium chloride intravenous Generic
sodium chloride oral Generic OTC
sodium phosphate Generic
strong iodine oral Generic
super calcium Generic OTC
thermotabs Generic OTC
TRACE ELEMENTS 4/PEDIATRIC Brand
tums ultra oral tablet,chewable 400 mg calcium
(1,000 mg)
Generic OTC
virt-phos 250 neutral Generic
zinc Generic OTC
212 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
zinc amino acid chelate Generic OTC
zinc gluconate oral Generic OTC
zinc sulfate intravenous solution 5 mg/ml Generic
zinc sulfate oral Generic OTC
Miscellaneous Nutrition Products
5-htp Generic OTC
5-hydroxytryptophan (5-htp) Generic OTC
ACERFLEX Brand PA; OTC; QL
acidophilus oral capsule Generic OTC
ADVANTAGE WITH IRON Brand PA; OTC
amino acid Generic OTC
amino acid super formula Generic OTC
amino action Generic OTC
arginine (l-arginine) oral tablet Generic OTC
balanced nutritional Generic PA; OTC; QL
BCAD 1 Brand PA; OTC; QL
benecalorie Generic PA; OTC; QL
beneprotein oral powder Generic OTC; QL
beneprotein oral powder in packet Generic OTC
bioflex Generic OTC
biotect plus Generic OTC; QL
boost high protein oral liquid Generic PA; OTC; QL
boost kid essentials oral liquid 0.03-1 gram-
kcal/ml
Generic PA; OTC; QL
BOOST KID ESSENTIALS ORAL LIQUID 0.04-
1.5 GRAM-KCAL/ML
Brand PA; OTC; QL
BOOST KID ESSENTIALS W-FIBER Brand PA; OTC; QL
boost oral liquid 0.04 gram- 1 kcal/ml Generic PA; OTC; QL
boost plus oral liquid 0.06 gram- 1.5 kcal/ml Generic PA; OTC; QL
BOOST PUDDING Brand PA; OTC
BOOST VHC Brand PA; OTC; QL
213 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
bright beginnings soy Generic PA; OTC
CALCILO XD Brand PA; OTC; QL
CAMINO PRO 15 PKU Brand PA; OTC; QL
co q-10 (with vit e) Generic OTC
coenzyme q10-vitamin e oral capsule 100-5 mg-
unit
Generic OTC
compleat pediatric oral liquid Generic PA; OTC; QL
compleat pediatric reduced cal Generic PA; OTC; QL
compleat-modified Generic PA; OTC; QL
complete amino acid mix Generic OTC
complete nutrition Generic PA; OTC; QL
complete nutrition plus Generic PA; OTC; QL
CYCLINEX-1 Brand PA; OTC; QL
CYCLINEX-2 Brand PA; OTC; QL
cytolline Generic OTC
cyto-q max Generic OTC
DIABETISOURCE AC Brand PA; OTC; QL
DUOCAL Brand PA; OTC; QL
EAA SUPPLEMENT Brand PA; OTC; QL
ear care Generic OTC
ear health formula Generic OTC
ELECARE Brand PA; OTC; QL
ELECARE INFANT FORMULA Brand PA; OTC; QL
ELECARE JR Brand PA; OTC; QL
ENFAGROW NEXT STEP LIPIL Brand PA; OTC; QL
ENFAGROW PREMIUM TODDLER Brand PA; OTC; QL
ENFAGROW TODDLR TRANSITION SOY Brand PA; OTC
enfamil a.r. lipil Generic PA; OTC; QL
ENFAMIL A.R. ORAL LIQUID Brand OTC
enfamil a.r. oral powder Generic PA; OTC
ENFAMIL ENFACARE LIPIL Brand PA; OTC; QL
214 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
enfamil enfacare oral liquid Generic OTC
ENFAMIL ENFACARE ORAL POWDER Brand PA; OTC
ENFAMIL GENTLEASE LIPIL LIQUID Brand PA; OTC
ENFAMIL GENTLEASE LIPIL POWD Brand PA; OTC; QL
ENFAMIL GENTLEASE ORAL LIQUID Brand PA; OTC
ENFAMIL GENTLEASE ORAL POWDER Brand PA; OTC
ENFAMIL HUMAN MILK FORTIFIER ORAL
POWDER IN PACKET
Brand PA; OTC
ENFAMIL INFANT ORAL CONCENTRATE Brand PA; OTC
ENFAMIL INFANT ORAL LIQUID Brand PA; OTC
ENFAMIL INFANT ORAL POWDER Brand PA; OTC
ENFAMIL LIPIL NURSETTE Brand PA; OTC
ENFAMIL NEWBORN Brand PA; OTC
ENFAMIL PREMATURE LOW IRON 24 Brand OTC
enfamil premium lipil oral liquid Generic PA; OTC
enfamil premium lipil oral powder Generic PA; OTC; QL
ENFAMIL PROSOBEE LIPIL Brand PA; OTC
ENFAPORT LIPIL Brand PA; OTC
ensure active clear Generic PA; OTC; QL
ensure active heart health Generic PA; OTC; QL
ensure active light Generic PA; OTC; QL
ensure active protein-muscle Generic PA; OTC; QL
ENSURE CLEAR Brand PA; OTC; QL
ensure compact Generic PA; OTC; QL
ENSURE COMPLETE Brand PA; OTC; QL
ensure high protein oral powder Generic OTC; QL
ensure high protein-muscle Generic PA; OTC; QL
ENSURE MUSCLE HEALTH Brand PA; OTC; QL
ensure oral liquid Generic PA; OTC; QL
ENSURE ORAL POWDER Brand PA; OTC; QL
215 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ENSURE ORIGINAL ORAL LIQUID 0.04-1.05
GRAM-KCAL/ML
Brand PA; OTC; QL
ENSURE PLUS Brand PA; OTC; QL
ENSURE PUDDING Brand PA; OTC
EO28 SPLASH Brand PA; OTC; QL
essential amino acid mix Generic OTC
FIBERSOURCE HN FEEDING TUBE Brand PA; OTC
FIBERSOURCE HN ORAL Brand PA; OTC; QL
fish oil extra strength Generic OTC
fish oil oral capsule 100-160-1,000 mg, 120-180
mg, 300-1,000 mg, 300-500 mg, 340-1,000 mg
Generic OTC; QL
FISH OIL ORAL CAPSULE 360-1,200 MG Brand OTC; QL
FISH OIL ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG-180 MG- 60 MG-
1,200 MG
Brand OTC
fish oil oral capsule,delayed release(dr/ec) 300-
1,000 mg
Generic OTC
fish oil oral capsule,delayed release(dr/ec) 60-90-
500 mg
Generic OTC; QL
fish,bora,flax oils-om3,6,9no1 Generic OTC
floranex oral granules in packet Generic OTC
FORTAVIT Brand
GA GEL Brand PA; OTC; QL
GA POWDER Brand PA; OTC; QL
gastrace Generic OTC
GERBER GOOD START GENTLE Brand PA; OTC
GERBER GOOD START PREMATURE 24
ORAL LIQUID 3-5.2 GRAM/100 KCAL
Brand PA; OTC
GERBER GOOD START SOY Brand PA; OTC
GERBER GRADUATES GENTLE Brand PA; OTC
GERBER GRADUATES SOY Brand PA; OTC
GERBER GS GENTLE - SUPPLEMENT Brand PA; OTC
GLUCERNA 1 CAL Brand PA; OTC; QL
216 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
GLUCERNA HUNGER SMART Brand PA; OTC; QL
GLUCERNA ORAL BAR Brand PA; OTC
GLUTAREX-1 Brand PA; OTC; QL
GLUTAREX-2 Brand PA; OTC; QL
GLYCOSADE Brand PA; OTC; QL
glytrol Generic PA; OTC; QL
GOOD START 2 SUPREME Brand PA; OTC
GOOD START ORAL CONCENTRATE Brand PA; OTC
good start oral liquid Generic PA; OTC
GOOD START ORAL POWDER Brand PA; OTC; QL
GOOD START SUPREME Brand PA; OTC
GOOD START SUPREME DHA AND ARA
ORAL CONCENTRATE
Brand PA; OTC
good start supreme dha and ara oral powder Generic PA; OTC
GOOD START SUPREME DHA AND ARA
ORAL SUSPENSION
Brand PA; OTC
GOOD START SUPREME NAT CULTURE Brand PA; OTC
HCU COOLER Brand PA; OTC; QL
hcu express powder Generic PA; OTC; QL
HCU GEL POWDER Brand PA; OTC; QL
HCY 1 POWDER Brand PA; OTC; QL
HCY 2 Brand PA; OTC; QL
HI-CAL Brand PA; OTC; QL
high protein Generic OTC
high-protein nutritional shake Generic PA; OTC; QL
HOM 2 Brand PA; OTC; QL
HOMINEX-1 Brand PA; OTC; QL
HOMINEX-2 Brand PA; OTC; QL
immulife Generic PA; OTC; QL
IMPACT 1 CAL Brand PA; OTC; QL
217 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
impact advanced recovery oral liquid 0.08-1.4
gram-kcal/ml
Generic PA; OTC; QL
IMPACT GLUTAMINE Brand PA; OTC; QL
IMPACT PEPTIDE 1.5 CAL Brand PA; OTC; QL
IMPACT/FIBER Brand PA; OTC; QL
IMUPLUS Brand PA; OTC; QL
infant formula with iron oral powder Generic PA; OTC; QL
inositol Generic OTC
ISOMIL ADVANCE Brand PA; OTC
ISOMIL DF Brand PA; OTC
ISOMIL/IRON Brand PA; OTC
ISOSOURCE 1.5 CAL Brand PA; OTC; QL
isosource hn Generic PA; OTC; QL
I-VALEX-1 Brand PA; OTC; QL
I-VALEX-2 Brand PA; OTC; QL
JEVITY 1 CAL Brand PA; OTC; QL
JEVITY 1.2 CAL Brand PA; OTC; QL
JEVITY 1.5 CAL Brand PA; OTC; QL
JUVEN Brand PA; OTC; QL
KETOCAL 3:1 Brand PA; OTC; QL
KETOCAL 4:1 (MILK-SOY) ORAL LIQUID Brand PA; OTC; QL
KETONEX-1 Brand PA; OTC; QL
KETONEX-2 Brand PA; OTC; QL
KETOVOLVE ORAL POWDER 14.5 GRAM-
712 KCAL/100 GRAM
Brand PA; OTC; QL
lactobacillus acidophilus oral capsule , 100
million cell
Generic OTC
lactobacillus acidophilus oral tablet 0.5 mg (100
million cell), 1 billion cell
Generic OTC
LANAFLEX Brand PA; OTC; QL
l-carnitine (tartrate) oral capsule 250 mg Generic OTC
lecithin (bulk) Generic OTC
218 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
lecithin oral capsule 1,200 mg Generic OTC
lecithin, soy Generic OTC
LEU-FREE COOLER Brand PA; OTC; QL
lipistart Generic PA; OTC; QL
lipoflavovit Generic OTC
LIPOGEN Brand OTC
liquacel oral liquid Generic OTC; QL
liquid nutrition Generic PA; OTC; QL
liquid nutrition plus Generic PA; OTC; QL
l-lysine oral tablet Generic OTC
LMD POWDER Brand PA; OTC; QL
lmefol ca-acetyl-meb12-algal Generic OTC
l-methyl-mc nac Generic OTC
LOPHLEX Brand PA; OTC; QL
lysine Generic OTC
lysine hcl oral tablet 1,000 mg Generic OTC
mct procal Generic PA; OTC; QL
mct pro-cal Generic PA; OTC; QL
metafolbic plus Generic OTC
metafolbic plus rf Generic OTC
METHIONAID Brand PA; OTC; QL
MMA-PA COOLER15 Brand PA; OTC; QL
MMA-PA EXPRESS Brand PA; OTC; QL
MMA-PA GEL Brand PA; OTC; QL
MSUD 2 Brand PA; OTC; QL
MSUD AID Brand PA; OTC; QL
MSUD ANALOG Brand PA; OTC
MSUD COOLER Brand PA; OTC; QL
MSUD EXPRESS COOLER Brand PA; OTC; QL
msud express15 Generic PA; OTC; QL
219 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
MSUD GEL POWDER Brand PA; OTC; QL
MSUD MAXAMAID Brand PA; OTC; QL
MSUD MAXAMUM Brand PA; OTC; QL
NEOCATE JUNIOR Brand PA; OTC; QL
NEOCATE JUNIOR WITH PREBIOTICS ORAL
POWDER 16 GRAM-459 KCAL/100 GRAM, 16
GRAM-478 KCAL/100 GRAM
Brand PA; OTC; QL
NEOCATE NUTRA Brand PA; OTC; QL
NEPRO Brand PA; OTC; QL
NEPRO CARB STEADY Brand PA; OTC; QL
niacin (inositol niacinate) oral capsule 400 mg
niacin (500 mg)
Generic OTC
niacin flush free oral capsule 400 mg niacin (500
mg)
Generic OTC
niacin-aze ac-turmer-fa-b6-zn Generic
NICAZEL Brand
novasource renal Generic PA; OTC; QL
novasource renal 2 cal Generic PA; OTC; QL
NUTRA PRO HIGH PROTEIN Brand PA; OTC; QL
nutrafit Generic PA; OTC; QL
nutrafit plus Generic PA; OTC; QL
nutrament Generic PA; OTC; QL
NUTRAMIGEN AA LIPIL Brand PA; OTC
NUTRAMIGEN DHA-ARA Brand PA; OTC
NUTRAMIGEN LIPIL Brand PA; OTC
NUTRAMIGEN WITH ENFLORA LGG Brand PA; OTC
nutren 1.0 feeding tube Generic PA; OTC
nutren 1.0 oral Generic PA; OTC; QL
nutren 1.0 with fiber Generic OTC
nutren 1.5 feeding tube Generic PA; OTC
nutren 2.0 feeding tube Generic PA; OTC
nutren junior fiber Generic OTC
220 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
nutren junior oral liquid 0.03-1 gram-kcal/ml Generic PA; OTC; QL
NUTREN PULMONARY Brand PA; OTC; QL
NUTRIHEP ORAL LIQUID 0.16-1.5 GRAM-
KCAL/ML
Brand PA; OTC; QL
nutrition plus Generic PA; OTC; QL
nutritional drink mix Generic OTC; QL
nutritional drink plus Generic PA; OTC; QL
nutritional shake oral liquid Generic PA; OTC; QL
NUTRITIONAL SHAKE ORAL LIQUID 0.04-
1.05 GRAM-KCAL/ML
Brand PA; OTC; QL
nutritional shake plus oral liquid Generic PA; OTC; QL
NUTRITIONAL SHAKE PLUS ORAL LIQUID
0.05-1.5 GRAM-KCAL/ML
Brand PA; OTC; QL
nutritional supplement oral liquid Generic PA; OTC; QL
nutritional supplement plus oral liquid Generic PA; OTC; QL
OA 1 POWDER Brand PA; OTC; QL
OA2 POWDER Brand PA; OTC; QL
omega 3-6-9 complex Generic OTC
omega 3-6-9 fatty acids Generic OTC
omega 3-dha-epa-fish oil oral capsule 1,000 mg
(120 mg-180 mg), 300-1,000 mg, 500-1,000 mg
Generic OTC; QL
omega 3-dha-epa-fish oil oral capsule,delayed
release(dr/ec) 300-1,000 mg
Generic OTC
omega-3 fatty acids-fish oil oral capsule 300-
1,000 mg, 360-1,200 mg
Generic OTC; QL
omega-3s-dha-epa-fish oil-d3 oral capsule 360
mg-1,200 mg -1,000 unit
Generic OTC
OS 2 Brand PA; OTC; QL
OSMOLITE 1 CAL Brand PA; OTC
OSMOLITE 1.2 CAL Brand PA; OTC; QL
OSMOLITE 1.5 CAL Brand PA; OTC; QL
OXEPA Brand PA; OTC; QL
PEDIASURE ENTERAL Brand PA; OTC; QL
221 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
PEDIASURE ORAL LIQUID 0.06-1.5 GRAM-
KCAL/ML
Brand PA; OTC; QL
pediasure peptide 1.0 cal Generic PA; OTC; QL
PEDIASURE SIDEKICKS Brand PA; OTC; QL
PEDIASURE WITH FIBER Brand PA; OTC; QL
pediatric balanced nutrition Generic PA; OTC; QL
PEPDITE JUNIOR Brand PA; OTC; QL
peptamen 1.5 cal with prebio1 Generic OTC
PEPTAMEN 1.5 ORAL LIQUID 0.068 GRAM-
1.5 KCAL/ML
Brand PA; OTC
PEPTAMEN AF Brand PA; OTC; QL
PEPTAMEN JUNIOR 1.5 Brand OTC
peptamen junior fiber Generic PA; OTC; QL
PEPTAMEN JUNIOR ORAL LIQUID 0.03-1
GRAM-KCAL/ML
Brand PA; OTC; QL
PEPTAMEN JUNIOR WITH PREBIO1 Brand PA; OTC; QL
PEPTAMEN ORAL LIQUID Brand PA; OTC; QL
PEPTAMEN ORAL LIQUID 0.04 GRAM- 1
KCAL/ML
Brand PA; OTC
PEPTAMEN W-PREBIO1 ORAL LIQUID Brand PA; OTC; QL
PEPTAMEN W-PREBIO1 ORAL LIQUID 0.04
GRAM- 1 KCAL/ML
Brand OTC
PERATIVE Brand PA; OTC; QL
PERIFLEX ADVANCE Brand PA; OTC; QL
PERIFLEX INFANT Brand PA; OTC
PERIFLEX JUNIOR Brand PA; OTC; QL
PERIFLEX LQ PKU Brand OTC
PFD 2 Brand PA; OTC; QL
PFD TODDLER Brand PA; OTC; QL
PHENEX-1 Brand PA; OTC; QL
PHENEX-2 Brand PA; OTC; QL
PHENYLADE 40 Brand OTC
222 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
PHENYLADE 60 Brand PA; OTC; QL
PHENYLADE DRINK MIX Brand PA; OTC; QL
PHENYLADE ESSENTIAL Brand PA; OTC; QL
phenylade phebloc oral tablet Generic OTC
PHENYLADE RTD PKU 10 Brand PA; OTC; QL
PHENYL-FREE 1 Brand PA; OTC
PHENYL-FREE 2 PKU Brand PA; OTC; QL
PHLEXY-10 DRINK MIX POWDER Brand PA; OTC; QL
phlexy-vits Generic PA; OTC; QL
pivot 1.5 cal Generic PA; OTC; QL
PKU 2 Brand PA; OTC; QL
PKU 3 Brand PA; OTC; QL
PKU COOLER 10 Brand PA; OTC; QL
PKU COOLER 15 Brand PA; OTC; QL
PKU COOLER 20 Brand PA; OTC; QL
PKU EXPRESS20 Brand PA; OTC
PKU LOPHLEX Brand PA; OTC; QL
PORTAGEN ORAL POWDER Brand PA; OTC; QL
PREGESTIMIL ORAL LIQUID Brand PA; OTC
PREGESTIMIL ORAL POWDER Brand PA; OTC; QL
PREMIUM INFANT FORMULA Brand PA; OTC
PRE-PROTEIN (WHEY) Brand OTC
pre-protein oral liquid Generic OTC; QL
probalance Generic PA; OTC; QL
probiotic oral capsule 10 billion cell Generic OTC
procel Generic OTC; QL
procel singles Generic OTC; QL
PRODUCT 3232A Brand PA; OTC; QL
PROMOD PROTEIN Brand PA; OTC; QL
PROMOTE WITH FIBER Brand PA; OTC; QL
223 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
PRO-PHREE Brand PA; OTC; QL
PROPIMEX-1 Brand PA; OTC; QL
PROPIMEX-2 Brand PA; OTC; QL
PROSOBEE Brand PA; OTC
prosource no carb Generic PA; OTC; QL
PROSOURCE ORAL LIQUID Brand PA; OTC; QL
prosource oral powder Generic PA; OTC; QL
pro-stat awc Generic PA; OTC
PROSYNMINIC Brand OTC
protein oral powder Generic OTC; QL
protein oral tablet Generic OTC
proteinex oral tablet Generic OTC
PULMOCARE Brand PA; OTC; QL
PURAMINO DHA-ARA ORAL POWDER 2.8-
5.3-10.3 GRAM/100 KCAL
Brand PA; OTC
pure l-citrulline oral powder Generic OTC
RCF SOY PROTEIN FORMULA BASE Brand PA; OTC
RENA START Brand PA; OTC; QL
renalcal Generic PA; OTC; QL
replete Generic PA; OTC; QL
replete fiber Generic PA; OTC; QL
replete-fiber Generic PA; OTC; QL
resource 2.0 Generic PA; OTC; QL
RESOURCE ARGINAID Brand PA; OTC; QL
RESOURCE ARGINAID EXTRA Brand PA; OTC; QL
resource breeze Generic PA; OTC; QL
resource just for kids w/fiber Generic PA; OTC; QL
restone Generic OTC
risanoid plus Generic OTC
salmon oil-1000 Generic OTC
sam-e (enteric coated) Generic OTC
224 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
scandical Generic PA; OTC; QL
scandishake (lactose free) Generic PA; OTC; QL
SCANDISHAKE ORAL PACKET Brand PA; OTC; QL
scandishake oral powder Generic PA; OTC; QL
sea-omega Generic OTC
sea-omega 30 Generic OTC; QL
SIMILAC ADVANCE ORAL CONCENTRATE Brand PA; OTC
SIMILAC ADVANCE ORAL LIQUID Brand PA; OTC
SIMILAC ADVANCE ORAL POWDER IN
PACKET
Brand PA; OTC
SIMILAC ADVANCE ORAL SUSPENSION Brand PA; OTC
SIMILAC ADVANCE ORGANIC ORAL
LIQUID
Brand PA; OTC
similac advance organic oral powder Generic PA; OTC; QL
SIMILAC ADVANCE WITH IRON Brand PA; OTC; QL
similac alimentum Generic PA; OTC
similac expert care alimentum oral powder Generic PA; OTC
SIMILAC EXPERT CARE ALIMENTUM ORAL
SUSPENSION
Brand PA; OTC
similac expert care neosure oral liquid Generic PA; OTC
SIMILAC EXPERT CARE NEOSURE ORAL
POWDER
Brand PA; OTC
SIMILAC EXPERT CARE ORAL LIQUID Brand PA; OTC
SIMILAC FOR SPIT-UP ORAL LIQUID 2.14-
5.4-11 GRAM/100 KCAL
Brand PA; OTC
SIMILAC FOR SPIT-UP ORAL POWDER Brand PA; OTC
SIMILAC HUMAN MILK FORTIFIER ORAL
POWDER IN PACKET
Brand PA; OTC
SIMILAC LOW-IRON Brand PA; OTC
SIMILAC NEOSURE Brand PA; OTC
SIMILAC PM Brand PA; OTC
SIMILAC PRO-ADVANCE NON-GMO ORAL
LIQUID
Brand PA; OTC
225 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
SIMILAC SENSITIVE Brand PA; OTC
similac sensitive fuss and gas oral concentrate 2.1-
5.4-11.1 gram/100 kcal
Generic PA; OTC
SIMILAC SENSITIVE FUSS AND GAS ORAL
LIQUID 2.14-5.4-11.1 GRAM/100 KCAL
Brand PA; OTC
similac sensitive fuss and gas oral powder 2.1-5.4-
11.1 gram/100 kcal
Generic PA; OTC
SIMILAC SENSITIVE ISOMIL SOY Brand PA; OTC
SIMILAC SOY ISOMIL Brand PA; OTC
super omega-3 oral capsule 400-400-200 mg Generic OTC
SUPLENA CARB STEADY Brand PA; OTC; QL
triple omega 3-6-9 Generic OTC
TWOCAL HN Brand PA; OTC; QL
tyr cooler oral liquid Generic PA; OTC; QL
TYR EXPRESS20 Brand PA; OTC; QL
TYR GEL POWDER Brand PA; OTC; QL
TYREX-1 Brand PA; OTC; QL
TYREX-2 Brand PA; OTC; QL
TYROS 1 Brand PA; OTC; QL
TYROS 2 Brand PA; OTC; QL
UCD 2 Brand PA; OTC; QL
UCD ANAMIX JUNIOR Brand PA; OTC; QL
ultra omega-3 oral capsule 500-1,000 mg Generic OTC; QL
ULTRACAL Brand PA; OTC; QL
VITAL 1.0 CAL Brand PA; OTC; QL
VITAL 1.5 CAL Brand PA; OTC; QL
VITAL AF 1.2 CAL Brand PA; OTC; QL
VITAL HIGH NITROGEN Brand PA; OTC; QL
vivonex rtf Generic PA; OTC; QL
vp-gstn Generic OTC
vp-zel Generic
226 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
WND 2 Brand PA; OTC; QL
wrestone Generic OTC
XLEU ANALOG Brand PA; OTC
XLEU MAXAMAID Brand PA; OTC; QL
XLEU MAXAMUM Brand PA; OTC; QL
XLYS- XTRP ANALOG Brand PA; OTC
XLYS, XTRP MAXAMAID Brand PA; OTC; QL
XLYS, XTRP MAXAMUM Brand PA; OTC; QL
XMET ANALOG Brand PA; OTC
XMET MAXAMUM Brand PA; OTC; QL
XMTVI ANALOG Brand PA; OTC
xmtvi maxamaid Generic PA; OTC; QL
xmtvi maxamum Generic PA; OTC; QL
XPHE MAXAMAID Brand PA; OTC; QL
xphe maxamum oral powder Generic OTC
XPHE MAXAMUM ORAL POWDER IN
PACKET
Brand OTC
XPHE, XTRP MAXAMAID Brand PA; OTC; QL
XPHE, XTYR ANALOG Brand PA; OTC
XPTM ANALOG Brand PA; OTC
XTRACAL PLUS Brand PA; OTC; QL
Vitamins / Hematinics
a thru z Generic OTC
a thru z advanced formula Generic OTC
a thru z high potency Generic OTC
a thru z select 50+ formula Generic OTC
a thru z select oral tablet , 500-300-250 mcg Generic OTC
a thru z select women's Generic OTC
abc plus Generic OTC
acerola c-500 Generic OTC
actical Generic OTC
227 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
adults 50 plus Generic OTC
adults' daily formula Generic OTC
advanced am-pm Generic
AKEDAMINS Brand OTC
ALGAL OMEGA-3 DHA Brand OTC
animal chews Generic OTC
animal shape vitamins Generic OTC
antioxidant formula Generic OTC
antioxidant vitamins oral tablet Generic OTC
ANTIOXIDANT VITAMINS ORAL TABLET
1,000 UNIT-200 MG-60 UNIT-2 MG
Brand OTC
apatate forte Generic OTC
apetigen plus oral liquid Generic OTC
AQUADEKS Brand OTC
AQUADEKS PEDIATRIC Brand OTC
aquasol e (d-alpha tocopherol) Generic OTC
ascorbate calcium Generic OTC
ascorbic acid (vitamin c) oral tablet 250 mg, 500
mg
Generic OTC
ascorbic acid (vitamin c) oral tablet extended
release 1,500 mg
Generic OTC
ascorbic acid (vitamin c) oral tablet,chewable
1,000 mg
Generic OTC
ascorbic acid with rose hips Generic OTC
ATABEX EC Brand
b complete Generic OTC
b complex oral Generic OTC
b complex-vitamin b12 Generic OTC
b complex-vitamin c-folic acid Generic OTC
b-12 dots Generic OTC
b-50 complex oral tablet extended release Generic OTC
BACMIN Brand
228 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
BALANCED B COMPLEX-VIT C Brand OTC
balanced b-100 complex Generic OTC
balanced b-100 oral tablet 0.4 mg, 100 mg Generic OTC
balanced b-50 oral tablet Generic OTC
bal-care dha Generic
BAL-CARE DHA ESSENTIAL Brand
b-complex with vitamin c oral tablet Generic OTC
b-complex with vitamin c oral tablet extended
release
Generic OTC
bee-zee Generic OTC
beta carotene Generic OTC
biosupp Generic OTC
BIOTIN (BULK) Brand
biotin oral capsule 2,500 mcg, 5 mg Generic OTC
biotin oral tablet 1 mg, 300 mcg, 800 mcg Generic OTC
biovol Generic OTC
BLADDER 2.2 Brand PA; OTC
bone meal-vitamin d2 Generic OTC
bp vit 3 plus Generic
brewer's yeast oral tablet 500 mg (7.5 gr) Generic OTC
c 500 timed released Generic OTC
c complex Generic OTC
c-1000 Generic OTC
c-1000 with rose hips Generic OTC
c-500 Generic OTC
ca-d3-mag ox-zinc-cop-mang-bor Generic OTC
ca-d3-mag-zinc-cop-mang-bor Generic OTC
calcidol Generic OTC
calciferol Generic OTC
calcium 600 + minerals Generic OTC
calcium 600-d3 plus Generic OTC
229 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
calcium carbonate-vit d3-min Generic OTC
calcium for women Generic OTC
calcium pnv Generic
calcium soft chew oral tablet,chewable 500-100-
40 mg-unit-mcg, 500-200-40 mg-unit-mcg
Generic OTC
calcium-folic acid-vitamin d Generic
calcium-magnesium-copper-zinc Generic OTC
calcium-vitamin d3-vitamin k oral tablet,chewable
500-200-40 mg-unit-mcg, 500-500-40 mg-unit-
mcg
Generic OTC
CALTRATE 600+D PLUS MINERALS ORAL
TABLET,CHEWABLE
Brand OTC
calvite p and d Generic OTC
cavan-ec sod dha Generic
centamin Generic OTC
central-vite men's under 50 Generic OTC
central-vite oral tablet 18-400 mg-mcg Generic OTC
central-vite select Generic OTC
central-vite senior Generic OTC
central-vite with lycopene Generic OTC
central-vite women's under 50 Generic OTC
centratex Generic
centravites Generic OTC
centravites 50 plus oral tablet Generic OTC
CENTRUM COMPLETE Brand OTC
CENTRUM ORAL TABLET,CHEWABLE Brand OTC
CENTRUM SILVER ORAL
TABLET,CHEWABLE
Brand OTC
CENTRUM SILVER ULTRA MEN'S Brand OTC
centrum silver ultra women's Generic OTC
CENTRUM SPECIALIST HEART Brand OTC
CENTRUM SPECIALIST PRENATAL Brand OTC
230 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
CENTRUM ULTRA MEN'S Brand OTC
centrum women Generic OTC
century Generic OTC
century adults 50+ Generic OTC
century advanced formula Generic OTC
century cardio Generic OTC
century mature oral tablet , 0.4-300-250 mg-mcg-
mcg
Generic OTC
CENTURY MATURE ORAL TABLET 400-30
MCG
Brand OTC
CENTURY ULTIMATE MEN'S ORAL TABLET
8 MG IRON- 200 MCG-600 MCG
Brand OTC
century ultimate women's Generic OTC
cerovite Generic OTC
cerovite advanced formula Generic OTC
cerovite jr Generic OTC
cerovite senior Generic OTC
certa plus Generic OTC
certavite senior-antioxidant Generic OTC
certavite-antioxid (iron gluc) oral liquid 9 mg
iron/15 ml
Generic OTC
certavite-antioxidant Generic OTC
chewable iron Generic OTC
chewable multi vitamin Generic OTC
chewable multivit-a,b,d,e,k,zn Generic
chewable-vite Generic OTC
chewable-vite with iron Generic OTC
child vitamin with minerals Generic OTC
children's chewable multivitmn Generic OTC
children's chewable vitamin Generic OTC
children's chewable w/minerals Generic OTC
children's chewables Generic OTC
231 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
children's chewables extra c Generic OTC
children's chewables with iron Generic OTC
children's iron Generic OTC
children's multivit w/extra c Generic OTC
CHILDREN'S REPLESTA Brand OTC
childs chew vite Generic OTC
child's chewable vitamins/iron oral
tablet,chewable
Generic OTC
childs/iron Generic OTC
cholecalciferol (vitamin d3) oral capsule 1,000
unit, 10,000 unit, 2,000 unit, 5,000 unit, 50,000
unit
Generic OTC
cholecalciferol (vitamin d3) oral drops 400
unit/ml, 5,000 unit/ml
Generic OTC
cholecalciferol (vitamin d3) oral tablet 1,000 unit,
2,000 unit, 5,000 unit
Generic OTC
cholecalciferol (vitamin d3) oral tablet,chewable
1,000 unit
Generic OTC
CHOLECALCIFEROL (VITAMIN D3) ORAL
TABLET,CHEWABLE 400 UNIT
Brand OTC
ciferex Generic
CITRANATAL B-CALM (FE GLUC) Brand
classic prenatal Generic OTC
c-nate dha Generic
cod liver oil conc with vit c Generic OTC
cod liver oil oral capsule , 1,250-135 unit Generic OTC
cod liver oil oral oil Generic OTC
cod liver oil-ascorbic acid Generic OTC
compete Generic OTC
complete 50+ Generic OTC
complete multi Generic OTC
complete multi 50+ Generic OTC
complete multivitamin oral tablet Generic OTC
232 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
complete multivitamin-mineral oral tablet Generic OTC
complete natal dha Generic
complete oral tablet 18-500-300-250 mg-mcg-
mcg-mcg
Generic OTC
complete senior Generic OTC
complete women Generic OTC
completenate Generic
complex b-100 oral tablet extended release Generic OTC
corvita Generic
corvita 150 Generic
CORVITE FREE Brand
cyanocobalamin (vitamin b-12) injection Generic
cyanocobalamin (vitamin b-12) oral liquid Generic OTC
cyanocobalamin (vitamin b-12) oral tablet 1,000
mcg
Generic OTC
cyanocobalamin (vitamin b-12) oral tablet
extended release 1,000 mcg
Generic OTC
cyanocobalamin (vitamin b-12) sublingual lozenge
2,500 mcg
Generic OTC
cyanocobalamin (vitamin b-12) sublingual tablet
1,000 mcg
Generic OTC
d3-2000 Generic OTC
daily energy Generic OTC
daily multiple for men Generic OTC
daily multiple for men 50+ Generic OTC
DAILY MULTIPLE FOR WOMEN Brand OTC
daily multiple oral tablet , 18-400 mg-mcg Generic OTC
daily multivitamin with iron Generic OTC
daily multivitamin-minerals Generic OTC
daily multi-vitamins/iron Generic OTC
daily value Generic OTC
daily vitamin formula Generic OTC
233 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
daily vitamin formula-iron Generic OTC
daily vitamin with iron and ca Generic OTC
daily vites/iron Generic OTC
daily-vite Generic OTC
delta d3 Generic OTC
dexferrum Generic
dexpanthenol Generic
dialyvite Generic
dialyvite 800 Generic OTC
DIALYVITE 800-ULTRA D Brand OTC
dialyvite vitamin d Generic OTC
dino-life Generic OTC
dino-life with extra c Generic OTC
dino-life with iron-zinc Generic OTC
dothelle dha Generic
DUET DHA EC-OM 3 Brand
DUET DHA WITH OMEGA-3 Brand
duofer Generic OTC
d-vi-sol Generic OTC
d-vita Generic OTC
e-400 c-500 and beta carotene Generic OTC
ECEE PLUS Brand OTC
eldertonic Generic OTC
elfolate oral tablet 7.5 mg Generic OTC
elite ob with dha Generic
elite-ob 400 Generic
ellis tonic Generic OTC
ergocalciferol (vitamin d2) oral capsule Generic
ergocalciferol (vitamin d2) oral drops Generic OTC
ergocalciferol (vitamin d2) oral tablet 400 unit Generic OTC
234 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
essentia Generic OTC
ESSENTIAL BALANCE WITH LUTEIN Brand OTC
essential daily Generic OTC
ester-c with bioflavonoids oral tablet 500-200 mg Generic OTC
estro support es Generic OTC
estronatural Generic PA; OTC
ESTROVEN MOOD AND MEMORY Brand PA; OTC
eye health plus lutein Generic OTC
ezfe 200 Generic OTC
ezfe forte Generic OTC
fabb Generic OTC
farbee with c Generic OTC
fe 90 plus Generic
fe c Generic OTC
fe c plus Generic OTC
feosol oral tablet 325 mg (65 mg iron) Generic OTC
ferate oral tablet 240 mg (27 mg iron) Generic OTC
fer-iron Generic OTC
ferocon Generic
ferosul Generic OTC
ferraplus 90 Generic
ferretts Generic OTC
ferrex 150 Generic OTC
ferrex 150 plus Generic OTC
ferric x-150 Generic OTC
ferrocite Generic OTC
ferrocite plus Generic
ferrogels forte Generic
ferro-time Generic OTC
ferrous fumarate oral tablet 324 mg (106 mg iron) Generic OTC
235 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ferrous gluconate oral tablet 236 mg (27 mg iron),
240 mg (27 mg iron), 256 mg (28 mg iron), 324
mg (36 mg iron), 324 mg (37.5 mg iron), 324 mg
(38 mg iron)
Generic OTC
ferrous sulfate oral drops Generic OTC
ferrous sulfate oral elixir Generic OTC
ferrous sulfate oral liquid Generic OTC
ferrous sulfate oral solution Generic OTC
ferrous sulfate oral tablet Generic OTC
ferrous sulfate oral tablet,delayed release (dr/ec) Generic OTC
ferrousul Generic OTC
fish oil-dha-epa Generic OTC; QL
FLUOR-A-DAY Brand
fluor-a-day (with xylitol) Generic
fluoride (sodium) oral drops Generic
fluoride (sodium) oral tablet,chewable Generic
FLUORITAB ORAL DROPS Brand
fluoritab oral tablet,chewable Generic
FLURA-DROPS Brand
focalgin 90 dha Generic
focalgin ca Generic
focalgin dss Generic
folbecal Generic
folbee Generic
folbee plus oral tablet 5 mg Generic
folbic rf Generic OTC
FOLGARD Brand OTC
folic acid injection Generic
folic acid oral tablet 1 mg Generic
folic acid oral tablet 400 mcg, 800 mcg Generic OTC
folic acid-vit b6-vit b12 oral tablet 2.2-25-0.5 mg Generic
236 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
folinatal plus b Generic
folitab Generic OTC
folivane-f Generic
folivane-ob Generic
folivane-plus Generic
folivane-prx dha nf Generic
folplex 2.2 Generic
foltabs 800 Generic OTC
foltanx Generic OTC
foltanx rf Generic OTC
fosfree Generic OTC
fruit c Generic OTC
fruit c-500 Generic OTC
fruity chews Generic OTC
full spectrum b-vitamin c Generic OTC
geravim Generic OTC
geriaton Generic OTC
GERITOL COMPLETE Brand OTC
GESTICARE DHA Brand
glucosamine-chondroitin complx oral capsule Generic OTC
gummi bear multivitamin Generic OTC
gummy dinos oral tablet,chewable 200 mcg Generic OTC
hair vitamins Generic OTC
hair, skin and nails advanced Generic OTC
hair,skin and nails oral tablet Generic OTC
halls defense Generic OTC
healthy eyes Generic OTC
healthy eyes supervision Generic OTC
hematinic plus vit/minerals Generic
hematinic/folic acid Generic
237 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
hematogen Generic
hematogen fa Generic
hematogen forte Generic
hemenatal ob Generic
hemenatal ob + dha Generic
hemetab Generic
high potency iron Generic OTC
honey bears Generic OTC
honey bears with iron-zinc Generic OTC
hydroxocobalamin Generic
I-CAPS Brand OTC
icaps areds oral capsule Generic OTC
ICAPS MV Brand OTC
iferex 150 Generic OTC
inatal advance Generic
inatal ultra Generic
infanate plus Generic
infed Generic
iron (dried) Generic OTC
iron 100 plus Generic OTC
iron aspgly-c-b12-ca-suc-stoma Generic OTC
iron chews Generic OTC
iron fum,ag-c-b12-fa-ca-succ Generic
iron high potency Generic OTC
iron oral tablet 325 mg (65 mg iron) Generic OTC
iron oral tablet extended release 159 mg (45 mg
iron)
Generic OTC
iron, carbonyl Generic OTC
iron,carbonyl-vitamin c Generic OTC
i-vite Generic OTC
i-vite protect Generic OTC
238 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
kid's vitamins Generic OTC
kid's vitamins + extra c Generic OTC
kids vitamins + iron Generic OTC
kid's vitamins + iron Generic OTC
kids vitamins complete Generic OTC
kobee Generic OTC
kpn oral tablet Generic OTC
KPN ORAL TABLET 9 MG IRON- 267 MCG Brand OTC
lecithin-kelp-b6 Generic OTC
lecithin-kelp-b6 (100-8.3) Generic OTC
levomefolate dha Generic
levomefolate-algal oil Generic OTC
levomefol-b6-meb12-algal oil Generic OTC
LIQUID B 12 Brand OTC
little animals Generic OTC
little animals-iron oral tablet,chewable Generic OTC
l-methyl-b6-b12 Generic OTC
l-methylfolate Generic OTC
l-methylfolate ca p-5-p me-cbl Generic OTC
l-methylfolate forte Generic OTC
l-methyl-mc Generic OTC
lmthf-pyridoxine-cyanocobalamn Generic OTC
ludent fluoride Generic
lumitene Generic OTC
lutein oral capsule 20 mg, 6 mg Generic OTC
lysiplex plus oral liquid Generic OTC
LYSIPLEX PLUS ORAL TABLET Brand
macnatal cn dha Generic
macuvite Generic OTC
macuvite eye care Generic OTC
239 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
MARNATAL-F Brand
maximum daily multivitamin Generic OTC
MAXINATE Brand
mega multi for women Generic OTC
mega multiple/chelated mineral Generic OTC
mega multivitamin for men Generic OTC
mega multivitamin with mineral oral tablet 13.5-
200-250 mg-mcg-mcg
Generic OTC
mens 50+ daily formula(gingko) Generic OTC
men's daily formula oral tablet 0.4 mg Generic OTC
men's daily multivit-mineral Generic OTC
men's multi-vitamin Generic OTC
men's one daily oral tablet Generic OTC
metafolbic Generic OTC
milltrium senior Generic OTC
miseflex Generic OTC
multi complete with iron Generic OTC
multi for her oral tablet Generic OTC
MULTI-BETIC Brand OTC
multi-day with iron Generic OTC
multi-delyn Generic OTC
multi-delyn with iron Generic OTC
multigen Generic OTC
multigen folic Generic
multigen plus Generic
multilex Generic OTC
multilex-t and m Generic OTC
multiple vitamin, womens Generic OTC
multiple vitamin-minerals Generic OTC
multi-vit with fluoride-iron Generic
multivital Generic OTC
240 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
multivital platinum Generic OTC
multivitamin 50 plus Generic OTC
multi-vitamin hp/minerals Generic OTC
multivitamin oral tablet Generic OTC
multivitamin with fluoride Generic
multi-vitamin with fluoride oral drops Generic
multivitamin with iron Generic OTC
multivitamin with minerals oral liquid Generic OTC
multivitamins with fluoride Generic
multivit-fluor (vit e acetate) Generic
multivit-min-iron fum-folic ac Generic OTC
mvc-fluoride Generic
M-VIT Brand
myferon 150 Generic OTC
MYKIDZ IRON Brand OTC
MYKIDZ IRON FLUORIDE Brand
mynatal Generic
mynatal advance Generic
mynatal plus Generic
mynatal-z Generic
mynate 90 plus Generic
mynephrocaps Generic
mynephron Generic
myofibex Generic OTC
my-vitalife Generic OTC
NASCOBAL Brand
natalvirt 90 dha Generic
natalvirt ca Generic
natalvirt flt Generic
NATALVIT Brand
241 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
NATELLE ONE Brand
natural b-100 complex Generic OTC
nephplex rx Generic
NEPHRON FA Brand
nephronex Generic OTC
nephronex-sl Generic OTC
NEPHRO-VITE Brand OTC
nephro-vite rx Generic
NESTABS Brand
NESTABS DHA Brand
neuro vite Generic OTC
newgen Generic
NEXA PLUS Brand
norwegian cod liver oil Generic OTC
NUTRICAP Brand
OB COMPLETE 400 Brand
OB COMPLETE ONE Brand
OB COMPLETE ORAL TABLET,CHEWABLE Brand
OB COMPLETE PREMIER Brand
OB COMPLETE WITH DHA Brand
obstetrix dha Generic
OBSTETRIX EC Brand
OBTREX Brand
OBTREX DHA Brand
O-CAL FA Brand
O-CAL PRENATAL Brand
ocutabs Generic OTC
OCUVITE Brand OTC
OCUVITE LUTEIN AND ZEAXANTHIN Brand OTC
OCUVITE WITH LUTEIN Brand OTC
242 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
omnicap Generic OTC
once daily Generic OTC
one daily 50 plus Generic OTC
one daily calcium/iron Generic OTC
one daily complete Generic OTC
one daily energy oral tablet , 250-9-400 mg-mg-
mcg
Generic OTC
one daily essential oral tablet , 0.4 mg Generic OTC
one daily for men Generic OTC
one daily for men 50+ advanced Generic OTC
one daily for women Generic OTC
one daily maximum Generic OTC
one daily maximum (with ca) Generic OTC
one daily men's 50+ oral tablet 400-600-120 mcg-
mcg-mg
Generic OTC
one daily multi-vit w-mineral Generic OTC
one daily multivitamin oral tablet Generic OTC
one daily multivit-iron(folic) Generic OTC
one daily oral tablet , 0.4-600 mg-mcg Generic OTC
one daily plus iron Generic OTC
one daily plus minerals Generic OTC
one daily prenatal oral combo pack 28-800-440
mg-mcg-mg
Generic OTC
one daily women 50 plus Generic OTC
one daily women's Generic OTC
one daily womens 50 plus Generic OTC
one daily women's health Generic OTC
one-a-day essential Generic OTC
one-a-day maximum formula Generic OTC
one-a-day teen advantage Generic OTC
opti-vitamins Generic OTC
243 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ortho d Generic
oyster shell calcium-vit d2 Generic OTC
PAIRE OB PLUS DHA Brand
pantothenic acid (vit b5) Generic OTC
perry prenatal Generic OTC
pnv 29-1 Generic
pnv ob+dha oral combo pack 27-1-50-250 mg Generic
pnv-dha Generic
pnv-dha + docusate Generic
pnv-ferrous fumarate-docu-fa Generic
pnv-omega Generic
pnv-select Generic
pnv-total Generic
pnv-vp-u Generic
polysaccharide iron Generic OTC
POLY-VI-FLOR Brand
POLY-VI-FLOR WITH IRON Brand
poly-vita Generic OTC
poly-vita (iron) Generic OTC
poly-vitamin Generic OTC
polyvitamin with iron Generic OTC
poly-vitamin with iron Generic OTC
poly-vitamins Generic OTC
pr natal 400 Generic
pr natal 400 ec Generic
pr natal 430 Generic
pr natal 430 ec Generic
PREFERA-OB Brand
PREFERA-OB ONE Brand
PREFERA-OB PLUS DHA Brand
244 Updated 1/2018
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– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
prefol-dha Generic
prena1 Generic
prena1 chew Generic
prena1 pearl Generic
prena1 plus Generic
prena1 true Generic
prenaissance Generic
prenaissance 90 dha Generic
prenaissance balance Generic
prenaissance dha Generic
prenaissance next Generic
prenaissance plus Generic
prenaissance promise Generic
prenaplus Generic
PRENATA Brand
prenatabs fa Generic
prenatabs rx Generic
prenatal + dha oral combo pack 28 mg iron- 975
mcg-200 mg
Generic OTC
PRENATAL + DHA ORAL COMBO PACK 28
MG IRON-800 MCG-200 MG
Brand OTC
prenatal 19 Generic OTC
prenatal 19 (with docusate) Generic OTC
prenatal ad Generic
prenatal complete Generic OTC
prenatal dha oral capsule 200 mg Generic OTC
PRENATAL DHA+COMPLETE PRENATAL Brand OTC
prenatal formula oral tablet 28 mg iron- 800 mcg Generic OTC
PRENATAL FORMULA ORAL TABLET 9 MG
IRON- 267 MCG
Brand OTC
prenatal low iron Generic
245 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
PRENATAL MULTI-DHA (ALGAL OIL) Brand OTC
prenatal multivitamins Generic OTC
prenatal one daily Generic OTC
prenatal oral tablet 28 mg iron- 800 mcg Generic OTC
prenatal plus Generic
prenatal plus (calcium carb) Generic
prenatal tablet Generic OTC
prenatal vitamin oral tablet , 27 mg iron- 0.8 mg,
28 mg iron- 800 mcg
Generic OTC
prenatal vitamin plus low iron Generic
prenatal vits96-iron fum-folic Generic OTC
PRENATAL-1 Brand OTC
prenatal-u Generic
PRENATE DHA Brand
PRENATE ELITE Brand
PRENATE ESSENTIAL Brand
preplus Generic
PRESERVISION AREDS Brand OTC
PRESERVISION LUTEIN Brand OTC
pretab Generic
PREVENT Brand OTC
PROFE FORTE Brand OTC
PRORENAL Brand OTC
PRORENAL QD Brand OTC
prosight Generic OTC
PROSIGHT WITH LUTEIN Brand OTC
PUREFE OB PLUS Brand
PUREFE PLUS Brand
purevit dualfe plus Generic
pyridoxine (vitamin b6) injection Generic
246 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg,
250 mg, 50 mg
Generic OTC
quintabs-m iron free Generic OTC
relnate dha Generic
renal caps Generic
rena-vite Generic OTC
rena-vite rx Generic
reno caps Generic
replesta Generic OTC
REPLESTA NX Brand OTC
REQ49+ Brand
riboflavin (vitamin b2) oral tablet 100 mg, 50 mg Generic OTC
risacal-d Generic OTC
rulavite dha Generic
SAVISION Brand OTC
SELECT-OB + DHA Brand
se-natal 19 Generic
se-natal 19 (with docusate) Generic
senior tabs Generic OTC
sentry Generic OTC
sentry (with lutein) Generic OTC
sentry senior Generic OTC
se-tan dha Generic
se-tan plus Generic
SIDEROL ORAL TABLET Brand OTC
slow release iron oral tablet extended release 142
mg (45 mg iron), 143 mg (45 mg iron), 159 mg (45
mg iron), 160 mg (50 mg iron), 250 mg (50 mg
iron), 47.5 mg iron
Generic OTC
soothing pureway-c Generic OTC
spectravite adult 50+ oral tablet Generic OTC
247 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
spectravite advanced formula oral tablet 18-400
mg-mcg
Generic OTC
spectravite men's Generic OTC
spectravite senior Generic OTC
spectravite senior w-lycopene Generic OTC
spectravite ultra women Generic OTC
spectravite ultra women's sr Generic OTC
stress 500 plus zinc Generic OTC
stress b plus zinc Generic OTC
stress b with zinc Generic OTC
stress formula Generic OTC
stress formula advanced Generic OTC
stress formula plus iron Generic OTC
stress formula with iron Generic OTC
stress formula with iron(sulf) Generic OTC
stress formula with zinc Generic OTC
stresstabs with zinc Generic OTC
STROVITE ONE Brand
sunvite Generic OTC
super antioxidant Generic OTC
super b complex-vitamin c Generic OTC
super b maxi complex Generic OTC
super b/c Generic OTC
super b-50 complex Generic OTC
super b-50 complex plus Generic OTC
super multiple oral tablet Generic OTC
super multivitamin Generic OTC
super quints Generic OTC
super quints b-50 Generic OTC
super thera vite m Generic OTC
superplex-t Generic OTC
248 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
support Generic OTC
tab a vite oral tablet 18-0.4 mg Generic OTC
tab-a-vite Generic OTC
tab-a-vite/iron Generic OTC
tab-a-vite-minerals Generic OTC
taron forte Generic
taron-bc Generic
taron-c dha Generic
taron-prex prenatal-dha Generic
thera Generic OTC
thera-d Generic OTC
theralogix companion Generic OTC
thera-m Generic OTC
therapeutic formula/hematinics Generic
therapeutic liquid Generic OTC
therapeutic m + beta-carotene Generic OTC
therapeutic-m oral tablet 9 mg iron-400 mcg Generic OTC
therapeutic-m vitamin/minerals Generic OTC
thera-tabs Generic OTC
thera-tabs m Generic OTC
theratrum complete 50 plus Generic OTC
theratrum complete 50 plus/lut Generic OTC
theratrum complete with lutein Generic OTC
therems Generic OTC
THEREMS-H Brand OTC
therems-m Generic OTC
thiamine hcl (vitamin b1) injection Generic
thiamine hcl (vitamin b1) oral tablet 100 mg, 250
mg, 50 mg
Generic OTC
thrivite-19 Generic
tl gard rx Generic
249 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
tl g-fol os Generic
tl icon Generic
tl-care dha Generic
tl-fluorivite Generic
tl-hem 150 Generic
tl-select Generic
total b/c Generic OTC
totalday multiple Generic OTC
triadvance Generic
TRICARE Brand
TRICARE PRENATAL DHA ONE Brand
tricon Generic
trigels-f forte Generic
trinatal gt Generic
trinatal rx 1 Generic
trinate Generic
triphrocaps Generic
triple vitamin with fluoride Generic
tri-tabs dha Generic
triveen-duo dha Generic
triveen-one Generic
triveen-prx rnf Generic
TRI-VI-SOL WITH IRON Brand OTC
tri-vit with fluoride and iron Generic
tri-vita Generic OTC
tri-vitamin Generic OTC
tri-vitamin with fluoride Generic
trust natal dha Generic
ultimate women's complete 50+ Generic OTC
ultimatecare one Generic
250 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
ultimatecare one nf Generic
ultra antioxidant formula Generic OTC
ultra b-100 complex oral tablet Generic OTC
unicomplex-m Generic OTC
v-c forte Generic
vemavite-prx-2 Generic
vena-bal dha Generic
venatal-fa Generic
VENOFER Brand
vic-forte Generic
vinate care Generic
vinate dha Generic
vinate ii Generic
vinate m Generic
vinate one Generic
virt-advance Generic
virt-bal dha Generic
virt-bal dha plus Generic
virt-c dha Generic
virt-care one Generic
virt-gard Generic
virt-nate Generic
virt-nate dha Generic
virt-pn Generic
virt-pn dha Generic
virt-pn plus Generic
virt-select Generic
virt-vite Generic
virt-vite gt Generic
VISION FORMULA (WITH LUTEIN) Brand OTC
251 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
vision-vite + zinc Generic OTC
vit 3 Generic
vit b complex-folic acid oral tablet Generic OTC
vitabee/c Generic OTC
vita-c Generic OTC
vitacel (with lutein) Generic OTC
VITAFOL-OB+DHA Brand
VITAFOL-ONE Brand
vitajoy daily d Generic OTC
vitalee Generic OTC
vitalets Generic OTC
VITAMED MD ONE RX Brand
VITAMED MD PLUS RX Brand
vitamin a Generic OTC
vitamin a palmitate oral capsule Generic OTC
vitamin b complex Generic OTC
vitamin b complex with c Generic OTC
vitamin b-1 Generic OTC
vitamin b-1 (mononitrate) Generic OTC
vitamin b-12 oral lozenge 500 mcg Generic OTC
vitamin b-12 oral tablet 100 mcg, 250 mcg, 50
mcg, 500 mcg
Generic OTC
vitamin b-12 oral tablet extended release 2,000
mcg, 500 mcg
Generic OTC
vitamin b-12 sublingual tablet 2,500 mcg, 5,000
mcg
Generic OTC
vitamin b-2 Generic OTC
vitamin b-6 oral tablet 100 mg, 25 mg, 250 mg, 50
mg
Generic OTC
vitamin b-6 oral tablet extended release Generic OTC
vitamin c cough drops Generic OTC
vitamin c drops Generic OTC
252 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
vitamin c oral capsule, extended release Generic OTC
vitamin c oral powder Generic OTC
vitamin c oral syrup Generic OTC
vitamin c oral tablet Generic OTC
vitamin c oral tablet extended release Generic OTC
vitamin c oral tablet,chewable 250 mg, 500 mg Generic OTC
vitamin c with rose hips oral tablet 500 mg Generic OTC
vitamin c with rose hips oral tablet extended
release
Generic OTC
vitamin d3 oral capsule 400 unit Generic OTC
vitamin d3 oral tablet 400 unit Generic OTC
vitamin d3 oral tablet,chewable Generic OTC
vitamin e (dl, acetate) oral capsule 100 unit, 400
unit
Generic OTC
vitamin e acetate Generic OTC
vitamin e mixed oral capsule 400 unit Generic OTC
vitamin e natural blend Generic OTC
vitamin e oral capsule Generic OTC
vitamin e oral drops 50 unit/ml Generic OTC
vitamins a and d Generic OTC
vitamins a,c,d and fluoride Generic
vitamins and minerals Generic OTC
vitamins b complex oral capsule Generic OTC
VITAMINS B COMPLEX ORAL TABLET 500
MG-400 MCG- 18 MG IRON
Brand OTC
vitamins for hair oral tablet Generic OTC
vitatrum Generic OTC
vitrum senior oral tablet Generic OTC
VITRUM SENIOR ORAL TABLET 500-300-250
MCG
Brand OTC
vol-care rx Generic
vol-nate Generic
253 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
vol-plus Generic
vol-tab rx Generic
vp-ch plus Generic
vp-ch-pnv Generic
vp-era ob plus Generic
vp-ggr-b6 Generic
vp-heme ob Generic
vp-heme one Generic
VP-PNV-DHA Brand
vp-vite rx Generic
wee care Generic OTC
wheat germ oil oral capsule Generic OTC
women's 50+ daily form (gkb) Generic OTC
WOMEN'S COMPLEX Brand OTC
WOMEN'S DAILY CAPLET Brand OTC
women's daily formula oral tablet 18 mg iron-400
mcg-500 mg ca, 27-0.4 mg
Generic OTC
women's one daily Generic OTC
women's prenatal + dha Generic OTC
yeast Generic OTC
yelets Generic OTC
zatean-ch Generic
zatean-pn Generic
zatean-pn dha Generic
zatean-pn plus Generic
zavara Generic
zinc and c Generic OTC
zinc with vitamins a and c Generic OTC
zingiber Generic
zolate Generic
zoo chews Generic OTC
254 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Drug Name Tier PA/Step/QLLs/OTC
zoo friends oral tablet,chewable 15 mg Generic OTC
zoo friends original Generic OTC
255 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
Index
1 12 hour cold relief .............. 166
12 hour decongestant .......... 166
12 hour nasal spray ............... 80
1ST TIER UNIFINE PENTIPS
.......................................... 86
1ST TIER UNILET
COMFORTOUCH ........... 86
2 24hour allergy .................... 166
2TEK CONTROL (HIGH-
NORMAL) ....................... 86
3 3 day vaginal ...................... 153
3-day vaginal ...................... 153
3M NEXCARE DURAPORE
.......................................... 86
4 4 way .................................... 80
4-n-1 no rinse wash .............. 47
5 5-htp ................................... 194
5-hydroxytryptophan (5-htp)
........................................ 194
8 8 hour pain reliever .............. 23
8hr muscle ache-pain ............ 23
8-MOP .................................. 47
A a and d (lan, pet) ................... 47
a thru z ................................ 208
a thru z advanced formula .. 208
a thru z high potency .......... 208
a thru z select ...................... 208
a thru z select 50+ formula . 208
a thru z select women's ....... 208
a.e.r. witch hazel ................... 47
abacavir .................................. 3
abacavir-lamivudine ............... 3
abacavir-lamivudine-
zidovudine .......................... 3
abanatuss ped...................... 166
abc plus ............................... 208
ABELCET .............................. 3
ABILIFY MAINTENA ........ 31
ABREVA.............................. 67
absorbine pain relieving ....... 47
ABSTRAL ............................ 21
acamprosate .......................... 71
ACAPELLA ......................... 86
acarbose ................................ 86
ACCU-CHEK RAPID D
INFUSION ....................... 86
ACCU-CHEK SAFE-T-PRO
.......................................... 86
ACCU-CHEK SOFTCLIX
LANCETS ........................ 86
ACCU-CHEK SPIRIT
BATTERY COVER ......... 86
ACCU-CHEK TENDER ...... 86
ACCU-CHEK ULTRAFLEX
.......................................... 86
ACCUTREND
CHOLESTEROL TEST ... 86
ACCUTREND GLUCOSE .. 86
ACCUTREND GLUCOSE
CONTROL ....................... 86
ACE AEROSOL CLOUD
ENHANCER .................... 86
acebutolol ............................. 36
acephen ................................. 23
ACERFLEX ....................... 195
acerola c-500 ...................... 208
acetadryl ............................... 23
aceta-gesic ............................ 23
acetaminophen ...................... 23
acetaminophen extra strength
.......................................... 23
acetaminophen pm extra str .. 23
acetaminophen-codeine ........ 21
acetasol hc ............................ 83
acetazolamide ..................... 164
ACETEST ............................ 86
acetic acid ....................... 71, 83
acetic acid-aluminum acetate 83
acetylcysteine ..................... 185
acid control (ranitidine) ...... 144
acid controller ..................... 144
acid controller complete ..... 144
acid gone antacid ................ 132
acid gone antacid e.strength 132
acid reducer (cimetidine) .... 144
acid reducer (famotidine) ... 144
acid reducer (omeprazole) .. 144
acid reducer (ranitidine) ..... 144
acid reducer complete (famot)
........................................ 144
acid relief (cimetidine) ....... 144
acidophilus .......................... 195
acidophilus-pectin ............... 129
acitretin ................................. 44
acne cleanser ......................... 45
acne cleansing bar ................. 58
acne cleansing pads .............. 45
acne control cleanser ............ 58
acne foaming wash ............... 58
acne medication .................... 58
acne pads .............................. 45
acne treatment (benzoyl perox)
.......................................... 58
acne vanishing ...................... 58
acne-clear .............................. 58
acta-tabs pe ......................... 166
ACTHAR H.P. ...................... 84
actical .................................. 208
ACTICOAT 7 DRESSING .. 86
acticon (dexbromph-pse) .... 166
actidom dmx ....................... 167
actidose/sorbitol .................. 132
actidose-aqua ...................... 132
acti-lance lancets .................. 86
ACTI-LANCE LANCETS ... 86
ACTIMMUNE ................... 146
actisep ................................... 60
activated charcoal ............... 132
ACTIVE CATH .................... 86
ACTIVE LIFE 1-PC STOMA
CAP .................................. 86
ACTIVE LIFE CONVEX
UROSTOMY .................... 86
ACTIVE LIFE CUT-TO-FIT
CLOSED ........................... 86
256 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
ACTIVE LIFE DRAINABLE
POUCH ............................ 87
ACTIVE LIFE UROSTOMY
POUCH ............................ 87
acuicyn ............................... 161
ACURA CONTROL HIGH . 87
ACURA CONTROL LOW .. 87
ACURA CONTROL
NORMAL......................... 87
ACURA PLUS ..................... 87
acyclovir ........................... 3, 67
acyclovir sodium .................... 3
ADAGEN ............................. 71
adapalene .............................. 58
adapalene-benzoyl peroxide . 58
ADAPT BARRIER RING ... 87
ADAPT BARRIER STRIPS 87
ADAPT CONVEX BARRIER
RINGS .............................. 87
ADAPT LUBRICATING
DEODORANT ................. 87
ADAPT OSTOMY PASTE . 87
ADAPT STOMA POWDER 87
ADAPTER CAP FOR
BOTTLE........................... 87
ADCIRCA .......................... 185
ADD-A-FOLEY CATH-
MONO-FLO DRNG ........ 87
ADD-A-FOLEY CATH-PRE-
FILL SYRN ...................... 87
ADD-A-FOLEY TRAY ....... 87
added strength headache relief
.......................................... 23
added strength pain reliever . 23
adefovir................................... 3
ADHESIVE BANDAGE ..... 87
ADHESIVE BARRIERS ..... 87
ADHESIVE GAUZE PAD .. 87
ADHESIVE REMOVER ..... 87
ADHESIVE TAPE ............... 87
ADJUSTABLE LANCING
DEVICE ........................... 87
adrenalin ............................. 167
adriamycin ............................ 13
adrucil ................................... 13
adt robitussin peak cld dm max
........................................ 167
adult aspirin regimen ............ 23
ADULT BRIEF - EXTRA
LARGE ............................. 87
adult cough formula dm max
........................................ 167
ADULT DISPOSABLE
MOUTHPIECE ................ 87
adult low dose aspirin ........... 23
adult robitussin lingering cld
........................................ 167
adult robitussin m-s cold .... 167
adult robitussin peak cold dm
........................................ 167
adult robitussin peak cold m-s
........................................ 167
adult tussin chest congestion
........................................ 167
adult tussin cough congest dm
........................................ 167
adult tussin dm.................... 167
adult tussin multi-symp cold
........................................ 167
adult wal-tussin................... 167
adult wal-tussin dm max..... 167
adults 50 plus ...................... 208
adults' daily formula ........... 208
ADVAIR DISKUS ............. 185
ADVAIR HFA ................... 185
advanced am-pm................. 208
advanced antacid-antigas .... 132
advanced exfoliating cleanser
.......................................... 58
advanced eye relief ............. 161
advanced formula eye drops
........................................ 166
advanced healing (petrolatum)
.......................................... 47
ADVANCED LANCING
DEVICE ........................... 87
ADVANCED TRAVEL
LANCETS ........................ 87
ADVANTAGE WITH IRON
........................................ 195
ADVATE.............................. 40
advil ...................................... 23
advil cold and sinus ............ 167
ADVOCATE BLOOD
GLUCOSE MONITOR .... 87
ADVOCATE DUO .............. 87
ADVOCATE LANCET ....... 87
ADVOCATE LANCING
DEVICE ........................... 87
ADVOCATE LOW
CONTROL ....................... 87
ADVOCATE PEN NEEDLE
.......................................... 88
ADVOCATE REDI-CODE .. 88
ADVOCATE REDI-CODE
DUO METER ................... 88
ADVOCATE REDI-CODE
GLU MONITOR .............. 88
ADVOCATE REDI-CODE+
CTRL LOW ...................... 88
ADVOCATE SYRINGES .... 88
ADVOCATE TEST STRIPS 88
ADYNOVATE ..................... 40
aero otic hc ........................... 83
AEROCHAMBER PLUS
FLOW-VU,S MSK ........... 88
AEROCHAMBER PLUS Z
STAT MD MSK ............... 88
AEROCHAMBER WITH
FLOWSIGNAL ................ 88
AEROTRACH PLUS ........... 88
af 65
afeditab cr ............................. 36
AFINITOR ........................... 13
AFINITOR DISPERZ .......... 13
AFLURIA 2014-2015 ........ 148
AFLURIA 2014-2015 (PF) 148
AFLURIA 2015-2016 ........ 148
AFLURIA 2015-2016 (PF) 148
AFLURIA 2016-2017 ........ 148
AFLURIA 2016-2017 (PF) 148
AFLURIA 2017-2018 ........ 148
AFLURIA 2017-2018 (PF) 148
AFLURIA QUAD 2016-2017
(PF) ................................. 148
AFLURIA QUAD 2017-2018
........................................ 148
257 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
AFLURIA QUAD 2017-2018
(PF) ................................. 148
afrin no drip(oxymetazolin) . 80
AFSTYLA ............................ 40
AGAMATRIX CONTROL
HIGH ................................ 88
a-hydrocort ........................... 84
AIMSCO LATEX CONDOM
.......................................... 88
AIR TUBE WITH AIR
PLUGS ............................. 88
AIRS ADULT AEROSOL
MASK .............................. 88
AIRS DISPOSABLE
NEBULIZER .................... 88
AIRS PEDIATRIC
DISPOSABLE MASK ..... 88
AIRZONE PEAK FLOW
METER ............................ 88
AKEDAMINS .................... 208
AKNE-MYCIN .................... 58
ak-poly-bac ......................... 159
AKTEN (PF) ...................... 161
al 12 ...................................... 47
ala-cort .................................. 67
alagesic lq ............................. 21
ala-hist ir ............................. 167
alavert ................................. 167
alavert d-12 allergy-sinus ... 167
alaway................................. 161
ALBENZA ............................. 8
albumin, human 25 %......... 189
albuminar 25 % .................. 189
albuminar 5 % .................... 189
alburx (human) 25 % .......... 189
alburx (human) 5 % ............ 190
albustix reagent .................... 71
albutein 25 % ...................... 190
albutein 5 % ........................ 190
albuterol sulfate .................. 185
alcalak................................. 190
alclometasone ....................... 67
alcohol prep pads .................. 88
ALCOHOL WIPES .............. 88
alcohol, denatured ................ 71
alcohol, rubbing .................... 77
alcohol-benzocaine ............... 47
ALDACTAZIDE .................. 36
alendronate ................... 71, 151
aler-cap ............................... 167
aler-tab ................................ 167
alertness aid .......................... 71
alfalfa .................................... 77
ALFERON N ...................... 146
alfuzosin ............................. 188
ALGAL OMEGA-3 DHA .. 208
ALINIA .................................. 8
alka-seltzer original .............. 23
alka-seltzer plus allergy ...... 167
ALKA-SELTZER PLUS
COLD/COUGHFM ........ 167
ALKA-SELTZER PLUS DAY
........................................ 167
alka-seltzer plus mucus-conges
........................................ 167
ALKA-SELTZER PLUS
SINUS-COUGH ............. 167
all day allergy (cetirizine) ... 167
all day allergy-d .................. 167
all day pain relief .................. 23
all day relief .......................... 23
ALLEGRA ALLERGY ...... 167
aller-chlor ........................... 167
allerclear ............................. 167
allerclear d-12hr ................. 167
allerclear d-24hr ................. 167
aller-ease ............................. 167
allerfed cold and allergy ..... 168
aller-fex .............................. 168
aller-flo ............................... 185
aller-g-time ......................... 168
allergy (chlorpheniramine) . 168
allergy (diphenhydramine) . 168
allergy 4-hour ..................... 168
allergy and congestion relief
........................................ 168
allergy and sinus relief ....... 168
allergy complete-d .............. 168
allergy cream (diphenhyd, zn)
.......................................... 47
allergy cream
(diphenhydramin) ............. 47
allergy d-12 ......................... 168
allergy eye (ketotifen) ......... 161
allergy medication .............. 168
allergy medicine ................. 168
allergy m-s nighttime .......... 168
allergy multi-symptom ....... 168
allergy plus severe sinus ha 168
allergy relief (cetirizine) ..... 168
allergy relief (clemastine) ... 168
allergy relief (fexofenadine)
........................................ 168
allergy relief (loratadine) .... 168
allergy relief d-24 ............... 168
allergy relief multi-symptom
........................................ 168
allergy relief spray ................ 47
allergy relief(chlorpheniramn)
........................................ 168
allergy relief(diphenhydramin)
........................................ 168
allergy relief,nasal decongest
........................................ 168
allergy relief-d (cetirizine) .. 168
allergy relief-d (loratadine) . 168
allergy relief-d(fexofenadine)
........................................ 168
allergy sinus pe ................... 168
allergy sinus-d .................... 168
allergy-congest relief-d (cet)
........................................ 168
allergy-congestion relief-d .. 169
allergy-d .............................. 169
allergy-time ......................... 169
allerhist-1 ............................ 169
aller-tec ............................... 169
aller-tec d ............................ 169
allfen ................................... 169
allfen dm ............................. 169
ALLKARE ADHESIVE
REMOVER WIPES .......... 88
ALLKARE PROTECT
BARRIER WIPES ............ 88
allopurinol ........................... 150
almacone ............................. 132
almacone-2 ......................... 132
almond oil, sweet (bulk) ....... 79
258 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
almotriptan malate ................ 19
ALOCRIL........................... 161
aloe burn relief ..................... 60
aloe vera ............................... 77
aloe vesta antifungal (micon)65
ALOMIDE ......................... 161
alophen ............................... 132
ALORA .............................. 151
alosetron ............................. 132
alpha lipoic acid ................... 71
alphabath .............................. 47
ALPHAGAN P ................... 166
ALPHANATE ...................... 40
ALPHANINE SD ................. 40
alprazolam ............................ 31
alprazolam intensol .............. 31
ALPROLIX .......................... 40
ALREX............................... 165
ALTABAX ........................... 63
altacaine .............................. 161
altachlore ............................ 161
altafluor .............................. 161
altamist ................................. 80
altavera (28)........................ 154
altazine ............................... 166
ALTERNATE SITE LANCET
.......................................... 88
ALTERNATE SITE
LANCING DEVICE ........ 88
alum, ammonium (bulk) ....... 71
ALUMINUM ACETATE .... 47
aluminum hydroxide gel..... 132
alyacen 1/35 (28) ................ 154
alyacen 7/7/7 (28) ............... 154
amabelz............................... 151
amantadine hcl........................ 4
ambi 10peh-4cpm ............... 169
AMBI 10PEH-4CPM-20DM
........................................ 169
AMBI 20DM-4CPM .......... 169
ambi 40pse-400gfn-20dm .. 169
ambi 60pse-400gfn ............. 169
ambi 60pse-4cpm ............... 169
AMBISOME .......................... 3
ambitussin ac ...................... 169
ambizine ............................. 132
amcinonide ........................... 67
amerigel ................................ 47
AMERIGEL DRESSING ..... 88
amerigel preventive barrier .. 47
ameriphor.............................. 47
amethia ............................... 154
amethia lo ........................... 154
amethyst.............................. 154
AMICAR .............................. 40
amikacin ................................. 8
amiloride ............................... 36
amiloride-hydrochlorothiazide
.......................................... 36
amino acid .......................... 195
amino acid super formula ... 195
amino action ....................... 195
aminocaproic acid................. 40
AMINOCAPROIC ACID .... 40
amiodarone ........................... 35
AMITIZA ........................... 132
amitriptyline ......................... 31
AMITRIPTYLINE (BULK). 31
amitriptyline-chlordiazepoxide
.......................................... 31
amlactin ................................ 47
amlodipine ............................ 36
amlodipine-atorvastatin ........ 42
amlodipine-benazepril .......... 36
amlodipine-olmesartan ......... 36
amlodipine-valsartan ............ 36
amlodipine-valsartan-hcthiazid
.......................................... 36
ammonia aromatic ................ 71
ammonium lactate ................ 47
amnesteem ............................ 58
amoxapine ............................ 31
amoxicil-clarithromy-lansopraz
........................................ 144
amoxicillin ............................ 10
amoxicillin-pot clavulanate .. 10
amphotericin b ........................ 3
ampicillin .............................. 10
ampicillin sodium ................. 10
ampicillin-sulbactam ............ 10
AMPYRA ............................. 19
AMYTAL ............................. 31
ANADROL-50 ................... 127
anagrelide ............................. 72
analgesic (trolamine salicyl) . 47
analgesic creme .................... 47
analgesic grx balm ................ 47
anaspaz ............................... 129
anastrozole ............................ 13
anbesol (benzocaine) ...... 60, 61
anbesol (benzocaine) max str60
ANDRODERM .................. 127
ANDROGEL ...................... 127
androxy ............................... 127
anecream ............................... 61
anecream5 ............................. 61
anefrin ................................... 80
anesthetic oral gel ................. 61
ANGELIQ .......................... 151
animal chews ...................... 208
animal shape vitamins ........ 208
anise ...................................... 79
antacid (calcium carbonate) 190
antacid and pain relief .......... 23
antacid anti-gas ................... 132
antacid anti-gas (ca carb-sim)
........................................ 132
antacid anti-gas double str .. 132
antacid exst (mag carb-al hyd)
........................................ 132
antacid ext str (calcium carb)
........................................ 190
antacid extra-strength . 132, 190
antacid m ............................ 132
antacid maximum strength . 132
antacid plus anti-gas ........... 132
antacid regular strength ...... 132
antacid supreme .................. 132
antacid tablet ....................... 132
antacid ultra strength .. 132, 190
antacid-simethicone ............ 132
antacid-simethicone ds ....... 132
ANTIBACTERIAL
BANDAGES .................... 88
antibiotic (bacitracin zinc) .... 63
antibiotic (neomy-bacit-polym)
.......................................... 63
antibiotic plus (pramoxine) ... 63
259 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
antibiotic plus pain rel(pram)63
antibiotic-pain relief (bacit) .. 63
anti-dandruff ......................... 44
anti-dandruff (coal tar) ......... 45
anti-dandruff with menthol... 47
anti-diarrhea ....................... 129
anti-diarrheal ...................... 129
anti-diarrheal (lope)-anti-gas
........................................ 129
anti-diarrheal (loperamide) . 129
anti-fungal ............................ 65
antifungal (clotrimazole) ...... 65
antifungal (tolnaftate) ........... 65
antifungal cream ................... 65
antifungal spray .................... 65
anti-gas ultra strength ......... 133
antihistamine eye drops ...... 161
anti-itch (benz-resor) ............ 61
anti-itch (diphenhydramine) . 47
anti-itch (hc) ......................... 67
anti-itch (hc) with aloe-vit e . 67
anti-itch (menthol/camphor) . 48
anti-itch medicated ............... 80
ANTI-ITCH PLUS ............... 67
anti-itch(diphenhyd) with zinc
.......................................... 48
anti-nausea .......................... 133
antioxidant formula ............ 208
antioxidant vitamins ........... 208
ANTIOXIDANT VITAMINS
........................................ 208
antipyrine-benzocaine .......... 83
antiseptic............................... 63
antiseptic oral cleanser ......... 48
antiseptic skin clnsr(chlorhe) 48
antitussive dm ..................... 169
anucort-hc ........................... 133
anu-med .............................. 133
ANZEMET ......................... 133
apatate forte ........................ 208
apetigen plus ....................... 208
apexicon e ............................. 67
ap-hist dm ........................... 169
APIDRA ............................... 88
APIDRA SOLOSTAR ......... 88
APLENZIN .......................... 31
APOKYN ............................. 18
apraclonidine ...................... 166
aprepitant ............................ 133
apri ...................................... 155
APRISO .............................. 133
aprodine .............................. 169
APTIVUS ............................... 4
aqua care ............................... 48
aqua glycolic......................... 48
aqua glycolic face ................. 48
AQUA LANCE LANCING
DEVICE ........................... 88
aquabase ............................... 77
AQUACEL EXTRA............. 88
AQUACEL FOAM .............. 89
AQUACEL-AG .................... 89
AQUADEKS ...................... 209
AQUADEKS PEDIATRIC 209
aquaphilic ............................. 48
aquasol e (d-alpha tocopherol)
........................................ 209
ARALAST NP ..................... 72
aranelle (28) ........................ 155
ARANESP (IN
POLYSORBATE) .. 146, 147
arbinoxa .............................. 169
ARCALYST ....................... 147
arginine (l-arginine) ............ 195
ARGYLE TROCAR............. 89
aripiprazole ........................... 31
ARISTOSPAN INTRA-
ARTICULAR ................... 84
ARISTOSPAN
INTRALESIONAL .......... 84
armodafinil ........................... 31
ARMOUR THYROID ....... 128
arnica .................................... 77
arthricream rub ..................... 48
arthritis.................................. 48
arthritis pain relief (acetam) . 23
arthritis pain relief(capsaic) .. 48
artificial tears (petro/min) ... 161
artificial tears (pf) ............... 161
ARTIFICIAL TEARS (PF) 161
artificial tears (polyvin alc) 161
artificial tears(dext70-hypro)
........................................ 161
artificial tears(glycerin-peg)
........................................ 161
artificial tears(hypromellose)
........................................ 161
artificial tears(pg-hypm-glyc)
........................................ 161
artificial tears(pvalch-povid)
........................................ 161
asafetida ................................ 77
ascorbate calcium ............... 209
ascorbic acid (vitamin c) .... 209
ascorbic acid with rose hips 209
ASEPTO BULB ................... 89
ashlyna ................................ 155
ASMANEX TWISTHALER
........................................ 185
asper-flex .............................. 48
aspir-81 ................................. 23
aspirin ................................... 24
aspirin low dose .................... 24
aspirin, buffered .................... 24
aspirin-caffeine-dihydrocodein
.......................................... 21
aspirin-dipyridamole ............. 40
aspir-low ............................... 24
aspir-trin ............................... 24
ASSESS FULL RANGE
PEAK METER ................. 89
ASSURA 2PC DRAINABLE
.......................................... 89
ASSURA 2PC IRRIGATION
SLEEVE ........................... 89
ASSURA AC BASEPLATE 89
ASSURA CONVEX SKIN
BARRIER ......................... 89
ASSURA CONVEX SKIN
BARRIER FLA ................ 89
ASSURA CONVEX
UROPOUCH .................... 89
ASSURA EASICLOSE MINI
POUCH ............................. 89
ASSURA EASICLOSE WIDE
MAXI ............................... 89
260 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
ASSURA EXTRA CONVEX
POUCH ............................ 89
ASSURA IRRIG FCE PLT
1/2-2 1/4 ........................... 89
ASSURA LIGHT
EASICLOSE DRAINAB . 89
ASSURA NON-CONVEX
DRAINABLE ................... 89
ASSURA OSTOMY BELT . 89
ASSURA PEDIATRIC
POUCH ............................ 89
ASSURA PEDIATRIC SKIN
BARRIER......................... 89
ASSURA POUCH ............... 89
ASSURA WOUND
MANAGER 1/2-2 3/4 ...... 89
ASSURE 4 CONTROL
SOLUTION ...................... 89
ASSURE 4 STRIPS ............. 89
ASSURE DOSE NORMAL
CONTROL ....................... 89
ASSURE HAEMOLANCE
PLUS ................................ 89
ASSURE ID INSULIN
SAFETY ........................... 89
ASSURE LANCE ................ 89
ASSURE LANCE PLUS ..... 89
ASSURE PLATINUM ......... 89
ASSURE PRO TEST STRIPS
.......................................... 90
ASTHMA CHECK METER 90
ASTHMAMENTOR PEAK
FLOW METER ................ 90
ASTHMAPACK
CHILDREN'S ................... 90
astringent .............................. 48
ATABEX EC...................... 209
atenolol ................................. 36
atenolol-chlorthalidone......... 36
ATGAM ............................. 148
athenol .................................. 24
athlete's foot (clotrimazole) .. 65
athlete's foot (terbinafine) .... 65
athlete's foot (tolnaftate) ....... 65
athletic foot cream ................ 65
ATN BRIEF ......................... 90
atomoxetine .......................... 31
atorvastatin ........................... 42
atovaquone.............................. 8
atovaquone-proguanil ............. 8
ATRIPLA ............................... 4
atropine ....................... 129, 161
atropine-care ....................... 161
ATROVENT HFA ............. 186
aubra ................................... 155
AUGMENTIN ...................... 10
auraphene-b .......................... 83
aurodex ................................. 83
auroguard .............................. 83
AUTOJECT 2 INJECTION
DEVICE ........................... 90
AUTO-LANCET MINI ........ 90
AUTOLET IMPRESSION
LANC DEV ...................... 90
AUTOPEN 2 TO 32 UNITS 90
avar ....................................... 58
AVC VAGINAL ................ 153
aveeno intense relief ............. 48
AVELOX IN NACL (ISO-
OSMOTIC) ....................... 11
aviane.................................. 155
avidoxy ................................. 11
avita ...................................... 58
avo cream ............................. 48
AVOGEL DRESSING ......... 90
AVONEX ........................... 147
AVONEX (WITH ALBUMIN)
........................................ 147
awake .................................... 72
ayr saline............................... 80
ayr saline nasal neti rinse...... 80
AZACTAM IN DEXTROSE
(ISO-OSM) ......................... 8
AZASAN .............................. 13
AZASITE ........................... 159
azathioprine .......................... 13
azelastine ...................... 80, 161
azithromycin ........................... 7
AZITHROMYCIN (BULK)... 7
AZO TEST STRIPS ............. 72
azo-dine .............................. 189
azolen tincture ...................... 65
AZOPT ............................... 164
azo-tabs ............................... 189
aztreonam ............................... 8
azuphen mb ......................... 188
azurette (28) ........................ 155
B b complete .......................... 209
b complex ........................... 209
b complex-vitamin b12 ....... 209
b complex-vitamin c-folic acid
........................................ 209
b-12 dots ............................. 209
b-50 complex ...................... 209
baby ayr saline ...................... 80
BABY BASICS XX LARGE
DIAPER ............................ 90
baby darlings ........................ 48
baby teething gel ................... 61
baby teething pain medicine . 61
BABY THERMOMETER .... 90
baby wash ............................. 48
baciim ..................................... 8
bacitracin .................. 8, 63, 159
bacitracin (bulk) ...................... 8
bacitracin zinc ....................... 63
bacitracin-polymyxin b . 63, 159
bacitraycin plus ..................... 63
back and body pain reliever .. 24
backache relief extra strength
.......................................... 24
baclofen ................................ 20
BACLOFEN (BULK) .......... 20
BACMIN ............................ 209
bacteriostatic water(parabens)
.......................................... 72
BACT-POLLEN-DUST
FILTER MASK ................ 90
BALANCED B COMPLEX-
VIT C .............................. 209
balanced b-100 .................... 209
balanced b-100 complex ..... 209
balanced b-50 ...................... 209
balanced nutritional ............ 195
bal-care dha ........................ 209
BAL-CARE DHA
ESSENTIAL ................... 209
261 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
balsalazide .......................... 133
balziva (28) ......................... 155
BANDAGES ........................ 90
BAND-AID FLEXIBLE
FABRIC ........................... 90
banophen ............................ 169
banophen allergy ................ 169
banophen anti-itch ................ 48
BANZEL .............................. 17
BARACLUDE ....................... 4
BARD ADHESIVE
REMOVER WIPES ......... 90
BARD CENTER ENTRY
CLOSE SYSTEM ............ 90
BARD COUDE TIP
CATHETER ..................... 90
BARD DELUXE FABRIC
LEG STRAPS .................. 90
BARD EXTENSION
TUBING/CONNECT ....... 90
BARD FEMALE
INTERMITTENT CATH . 90
BARD INFECT CONT
TRAY-NO CATH ............ 90
BARD INFECTION
CONTROL BAG.............. 90
BARD LATEX LEG STRAPS
.......................................... 90
BARD LEG BAG HOLDER 90
BARD LEG BAG
STRAPS/FABRIC ............ 90
BARD LUBRICATH FOLEY
TRAY ............................... 90
BARD PLASTIC
TUBING/ADAPTER ....... 90
BARD RUBBER UTILITY
CATHETER ..................... 90
BARD UNIVERSAL FOLEY
CATH TRAY ................... 90
BARD URETHRAL
CATHETER TRAY ......... 90
BARDEX ALL-SILICONE
FOLEY CATH ................. 91
BARDEX CLOSED SYSTEM
CATH TRAY ................... 91
BARDEX URETHRAL
CATHETERTRAY .......... 91
BARDIA URINARY
DRAINAGE BAG ............ 91
BASAL THERMOMETER,
ELECTRONIC ................. 91
BASICS FOR KIDS ............. 91
bath oil .................................. 48
bayer advanced ..................... 24
bayer plus extra strength....... 24
baza antifungal ..................... 65
BCAD 1 .............................. 195
b-complex with vitamin c ... 209
BD ALCOHOL SWABS...... 91
BD AUTOSHIELD PEN
NEEDLE .......................... 91
BD ECLIPSE LUER-LOK ... 91
BD INSULIN PEN NEEDLE
UF SHORT ....................... 91
BD INSULIN SYRINGE
MICRO-FINE ................... 91
BD LANCET DEVICE ........ 91
BD LO-DOSE MICRO-FINE
IV ...................................... 91
BD LUER-LOK SYRINGE . 91
BD MAGNI-GUIDE
SYRINGE MAGNIFI....... 91
BD MICROTAINER
LANCET .......................... 91
bd pre-filled normal saline ... 72
BD REGULAR BEVEL
NEEDLES ........................ 91
BD SAFETYGLIDE
SYRINGE ......................... 91
BD SYRINGE ...................... 91
BD ULTRA FINE LANCETS
.......................................... 91
BD ULTRA-FINE NANO
PEN NEEDLES ................ 91
b-donna ............................... 130
BEBULIN ............................. 40
BEDSIDE DRAINAGE
COLLECT SYSTM .......... 91
bee-zee ................................ 209
bekyree (28) ........................ 155
belladonna alkaloids-opium 130
belladonna-opium ............... 130
BELTED
UNDERGARMENTS ...... 91
BELTLESS
UNDERGARMENTS ...... 91
benadryl itch stopping .......... 48
benazepril ............................. 36
benazepril-hydrochlorothiazide
.......................................... 36
benecalorie .......................... 195
BEN-E-FIT BRIEFS ............ 91
BENEFIX ............................. 40
beneprotein ......................... 195
bengay ultra strength(menthol)
.......................................... 48
bentonite ............................... 72
BENZAMYCINPAK ........... 59
benzepro ............................... 59
benzoin ................................. 48
benzoin (bulk) ....................... 48
benzoin compound ................ 48
benzonatate ......................... 169
benz-o-sthetic ....................... 61
benzoyl peroxide .................. 59
benztropine ........................... 18
best fiber ............................. 133
beta care ................................ 48
beta carotene ....................... 209
beta med ................................ 70
beta-hc .................................. 67
betamethasone dipropionate . 67
betamethasone valerate ......... 67
betamethasone, augmented ... 67
betasept surgical scrub .......... 48
BETASERON ..................... 147
betatemp ............................... 24
betaxolol ....................... 36, 160
bethanechol chloride ........... 188
BETIMOL .......................... 160
BETOPTIC S ...................... 160
bexarotene ............................. 13
BIATAIN ADHESIVE FOAM
DRESSING ....................... 91
bicalutamide ......................... 13
bicarsim forte ...................... 133
BICILLIN C-R ..................... 10
262 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
BICILLIN L-A ..................... 10
BICNU ................................. 13
BIDIL ................................... 36
BILTRICIDE .......................... 8
bimatoprost ......................... 164
BIOBRANE GLOVES
MEDIUM ......................... 91
biobron sf............................ 169
biocotron............................. 169
bioflex................................. 195
biogil................................... 169
bion tears (pf) ..................... 162
bionel .................................. 169
BIONIME RIGHTEST TEST
STRIPS ............................. 91
biosupp ............................... 209
biotect plus ......................... 195
biotin................................... 209
BIOTIN (BULK) ................ 209
biovol .................................. 210
bisac-evac ........................... 133
bisacodyl............................. 133
bisa-lax ............................... 133
biscolax............................... 133
bismatrol ............................. 130
bismuth ............................... 130
bismuth maximum strength 130
bisoprolol fumarate .............. 36
bisoprolol-hydrochlorothiazide
.......................................... 36
black cohosh ......................... 77
BLADDER 2.2 ................... 210
BLADDER CONTROL PAD
EXTRA PLUS .................. 92
BLADDER CONTROL PADS
FOR WOMEN.................. 92
BLENDERM SURGICAL ... 92
bleomycin ............................. 13
BLEPH-10 .......................... 165
BLEPHAMIDE .................. 165
BLEPHAMIDE S.O.P. ....... 165
blisovi 24 fe ........................ 155
blisovi fe 1.5/30 (28) .......... 155
blisovi fe 1/20 (28) ............. 155
BLISTER CARE .................. 92
BLISTER RELIEF
BANDAGES .................... 92
blis-to-sol (tolnaftate) ........... 65
BLOOD GLUCOSE
CONTROL, NORMAL .... 92
BLOOD GLUCOSE TEST .. 92
BLOOD PRESSURE KIT .... 92
BLOOD PRESSURE KIT
MED AND LRG .............. 92
BLOOD PRESSURE TEST
KIT-LARGE ..................... 92
BLOOD PRESSURE TEST
KIT-MEDIUM ................. 92
BLOOD-GLUCOSE METER
.......................................... 92
blue gel ................................. 48
boil relief .............................. 61
boil-ease (benzocaine) .......... 61
bone meal-vitamin d2 ......... 210
boost ................................... 195
boost high protein ............... 195
boost kid essentials ............. 195
BOOST KID ESSENTIALS
........................................ 195
BOOST KID ESSENTIALS
W-FIBER........................ 195
boost plus ............................ 195
BOOST PUDDING ............ 195
BOOST VHC ..................... 195
BORDERED GAUZE .......... 92
boro-packs ............................ 48
BOTTLE ............................... 92
BOTTLETOP DISPENSER
ADAPTER........................ 92
BOXERS FOR MEN............ 92
bp .......................................... 59
bp 10-1 .................................. 59
bp foam ................................. 59
bp vit 3 plus ........................ 210
bp wash ................................. 59
bp wash acne treatment ........ 59
bp-50% urea ......................... 48
bpo ........................................ 59
bpo creamy wash pack ......... 59
bpo-10 ................................... 59
bpo-5 ..................................... 59
BREATHE RIGHT .............. 92
BREATHERITE VALVED
MDI CHAMBER .............. 92
BREEZE 2 ............................ 92
BREEZE 2 TEST STRIPS ... 92
BREEZERS ADULT BRIEF
.......................................... 92
brewer's yeast...................... 210
briellyn ................................ 155
bright beginnings soy ......... 195
brimonidine ......................... 166
brohist d .............................. 169
bromfenac ........................... 164
bromocriptine ....................... 18
brompheniramine-pseudoeph-
dm ................................... 169
brompheniramin-phenylephrin-
dm ................................... 169
bronchial asthma relief ....... 169
bronchial mist refill ............ 186
broncotron ped .................... 169
brotapp ................................ 170
brotapp dm .......................... 170
bss ....................................... 162
BSS/BSS PLUS ADMIN SET
.......................................... 92
BUBBLES THE FISH PEDI
MASK ............................... 92
budesonide .................. 133, 186
bufferin ................................. 24
BULLSEYE MINI SAFETY
LANCETS ........................ 92
bumetanide ........................... 36
buminate 25 % .................... 190
buminate 5 % ...................... 190
bupivacaine ........................... 61
BUPIVACAINE (BULK) .... 61
bupivacaine (pf) .................... 61
buprenorphine hcl ................. 21
buprenorphine-naloxone ....... 24
buproban ............................... 79
bupropion hcl ........................ 31
bupropion hcl (smoking deter)
.......................................... 79
burn relief ............................. 61
burn relief with aloe .............. 61
263 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
BURNS-SCALDS-
ABRASIONS ................... 92
buspirone .............................. 31
butalbital-acetaminophen ..... 21
butalbital-acetaminophen-caff
.......................................... 21
butalbital-aspirin-caffeine .... 21
BUTISOL ............................. 31
butorphanol tartrate .............. 24
BUTTERFLY CLOSURES . 92
BYETTA .............................. 92
C c 500 timed released ........... 210
c complex ........................... 210
c-1000 ................................. 210
c-1000 with rose hips ......... 210
c-500 ................................... 210
cabergoline ......................... 127
CABOMETYX..................... 13
ca-d3-mag ox-zinc-cop-mang-
bor................................... 210
ca-d3-mag-zinc-cop-mang-bor
........................................ 210
caffeine ................................. 72
caffeine citrate ...................... 72
caffeine-sodium benzoate ... 186
calaclear ................................ 61
calagesic ............................... 61
calahist .................................. 48
calahist clear ......................... 61
calahist with pramoxine ....... 61
calamine ............................... 48
calamine medicated .............. 61
calamine phenolated ............. 48
calamine plus (pramox-
calamin) ............................ 61
calamine-zinc oxide.............. 48
calamine-zinc oxide-phenol . 49
calci-chew........................... 190
calcidol ............................... 210
calciferol ............................. 210
CALCILO XD .................... 195
calcionate ............................ 190
calcipotriene ......................... 45
calcipotriene-betamethasone 45
calcitonin (salmon) ............. 127
calcitrate ............................. 190
CALCITRATE-VITAMIN D
........................................ 190
calcitrene .............................. 45
calcitriol ........................ 45, 127
calcium 500 + d .................. 190
calcium 500 with d ............. 190
calcium 600 + d(3) ............. 190
calcium 600 + minerals ...... 210
calcium 600 with vitamin d3
........................................ 190
CALCIUM 600 WITH
VITAMIN D3 ................. 190
calcium 600-d3 plus ........... 210
calcium acetate ................... 190
calcium antacid ................... 190
calcium antacid ultra max st
........................................ 190
calcium carb and citrate-vitd3
........................................ 190
calcium carbonate ............... 191
calcium carbonate-vit d3-min
........................................ 210
calcium carbonate-vitamin d3
........................................ 191
CALCIUM CARBONATE-
VITAMIN D3 ................. 191
calcium citrate .................... 191
calcium citrate + ................. 191
calcium citrate + d .............. 191
calcium citrate + d with mag
........................................ 191
calcium citrate plus (vit b6) 191
calcium citrate-vitamin d2 .. 191
calcium citrate-vitamin d3 .. 191
calcium folinate (leucovorin) 12
calcium for women ............. 210
calcium gluconate ............... 191
calcium lactate .................... 191
calcium pnv ........................ 210
calcium polycarbophil ........ 133
calcium soft chew ............... 210
calcium-folic acid-vitamin d
........................................ 210
calcium-magnesium-copper-
zinc ................................. 210
calcium-magnesium-zinc .... 191
calcium-melatonin ................ 72
calcium-vitamin d3-vitamin k
........................................ 210
caldyphen .............................. 61
caldyphen clear ............... 49, 61
cal-gest antacid ................... 191
callergy clear ........................ 61
callus removers ..................... 45
calmme ................................. 77
calmoseptine ......................... 49
calohist .................................. 49
CALTRATE 600+D PLUS
MINERALS .................... 210
CALTRATE WITH VITAMIN
D3 ................................... 191
calvite p and d ..................... 210
cam ....................................... 49
cameo oil .............................. 49
camila ................................. 151
CAMINO PRO 15 PKU ..... 195
CAMO BANDAGES ........... 92
camphor ................................ 49
camrese ............................... 155
camrese lo ........................... 155
CANASA ............................ 133
CANCIDAS ............................ 3
candesartan ........................... 36
candesartan-hydrochlorothiazid
.......................................... 36
CANE ................................... 92
cank-oxide ............................ 80
CANTIL ............................. 130
capacet .................................. 21
CAPASTAT ........................... 8
capecitabine .......................... 13
CAPRELSA .......................... 13
capsaicin ............................... 49
capsicum ............................... 49
capsicum (cayenne) .............. 77
captopril ................................ 36
captopril-hydrochlorothiazide
.......................................... 36
captracin ............................... 49
capzasin-hp ........................... 49
CARAC ................................ 49
264 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
CARBAGLU ........................ 72
carbamazepine ...................... 17
carbamoxide ear drops ......... 83
carbidopa .............................. 18
carbidopa-levodopa .............. 18
carbidopa-levodopa-
entacapone ........................ 19
carbinoxamine maleate ....... 170
carb-o-philic ......................... 49
carboplatin ............................ 13
CAREFINE PEN NEEDLE . 92
CAREONE THIN LANCET 93
CARESENS CONTROL A
NORMAL......................... 93
CARETOUCH PEN NEEDLE
.......................................... 93
CARETOUCH TWIST
LANCET .......................... 93
ca-rezz .................................. 63
carica papaya ........................ 77
carisoprodol .......................... 20
carisoprodol-asa-codeine ...... 20
carisoprodol-aspirin .............. 20
CARNITOR (SUGAR-FREE)
.......................................... 72
CARRASYN HYDROGEL
WOUND DRESS ............. 93
carteolol .............................. 160
cartia xt ................................. 36
CARTRIDGE PUMP STAMP
IR1000 .............................. 93
CARTRIDGE STAMPED IR
1200 .................................. 93
carvedilol .............................. 36
carvedilol phosphate ............. 36
CASTELLANI PAINT
MODIFIED ...................... 49
castor oil ............................. 133
CATHFLO ACTIVASE ....... 44
cat's claw (uncaria tomentosa)
.......................................... 77
cavan-ec sod dha ................ 210
CAYSTON ............................. 8
caziant (28) ......................... 155
cefaclor ................................... 6
cefadroxil ................................ 6
cefazolin ................................. 6
cefazolin in dextrose (iso-os) . 6
cefdinir.................................... 6
cefditoren pivoxil ................... 6
cefepime ................................. 6
cefepime in dextrose,iso-osm . 6
cefixime .................................. 6
cefotaxime .............................. 6
cefotetan ................................. 6
cefoxitin .................................. 6
cefoxitin in dextrose, iso-osm 6
cefpodoxime ........................... 6
cefprozil .................................. 6
ceftazidime ............................. 6
CEFTAZIDIME IN D5W ...... 6
ceftibuten ................................ 7
CEFTIN .................................. 7
ceftriaxone .............................. 7
ceftriaxone in dextrose,iso-os . 7
cefuroxime axetil .................... 7
cefuroxime sodium ................. 7
celacyn .................................. 49
celecoxib ............................... 24
CELONTIN .......................... 17
cem-urea ............................... 49
centamin ............................. 210
centergy .............................. 170
centergy dm ........................ 170
CENTERPOINTLOCK
CLOSED POUCH ............ 93
CENTERPOINTLOCK
DRAIN FILTER ............... 93
CENTERPOINTLOCK
DRAINABLE MINI ......... 93
CENTERPOINTLOCK
DRAINABLE POUC ....... 93
CENTERPOINTLOCK
FLEXTEND SKIN ........... 93
CENTERPOINTLOCK
FLEXWEAR CONVE ..... 93
CENTERPOINTLOCK
SOFTFLEX SKIN ............ 93
CENTERPOINTLOCK
STOMA CAP ................... 93
CENTERPOINTLOCK
STOMA IRRIGAT ........... 93
CENTERPOINTLOCK
UROSTOMY POUCH ..... 93
central vite ............................ 77
central-vite .......................... 210
central-vite men's under 50 . 210
central-vite select ................ 210
central-vite senior ............... 211
central-vite with lycopene .. 211
central-vite women's under 50
........................................ 211
centratex ............................. 211
centravites ........................... 211
centravites 50 plus .............. 211
CENTRUM ......................... 211
CENTRUM COMPLETE .. 211
CENTRUM SILVER .......... 211
CENTRUM SILVER ULTRA
MEN'S ............................ 211
centrum silver ultra women's
........................................ 211
CENTRUM SPECIALIST
HEART ........................... 211
CENTRUM SPECIALIST
PRENATAL ................... 211
CENTRUM ULTRA MEN'S
........................................ 211
centrum women .................. 211
century ................................ 211
century adults 50+ .............. 211
century advanced formula .. 211
century cardio ..................... 211
century mature .................... 211
CENTURY MATURE ....... 211
CENTURY ULTIMATE
MEN'S ............................ 211
century ultimate women's ... 211
cephalexin ............................... 7
CEREZYME ....................... 127
cerovite ............................... 211
cerovite advanced formula . 211
cerovite jr ............................ 211
cerovite senior .................... 211
certa plus ............................. 211
certain dri .............................. 70
CERTAINTY REGULAR .... 93
certavite senior-antioxidant 211
265 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
certavite-antioxid (iron gluc)
........................................ 211
certavite-antioxidant ........... 212
cerubidine ............................. 13
CESAMET ......................... 133
ceta-klenz mild ..................... 49
cetaphil gentle cleanser ........ 49
cetaphil moisturizing ............ 49
cetiri-d ................................ 170
cetirizine ............................. 170
cetirizine-pseudoephedrine. 170
cetyl alcohol (bulk)............... 49
cevimeline ............................ 72
CHANTIX ............................ 79
CHANTIX CONTINUING
MONTH BOX .................. 79
CHANTIX STARTING
MONTH BOX .................. 80
chateal................................. 155
CHEK-STIX CONTROL ..... 93
chelated zinc ....................... 191
CHEMET ............................. 72
CHEMO TRANSFER PIN... 93
CHEMSTRIP 10 MD ........... 93
CHEMSTRIP 10/SG ............ 93
CHEMSTRIP 2 .................... 72
CHEMSTRIP 2 GP .............. 93
CHEMSTRIP 50B ................ 93
CHEMSTRIP 7 .................... 93
CHEMSTRIP 9 .................... 93
CHEMSTRIP BG LOG BOOK
.......................................... 93
CHEMSTRIP K.................... 93
CHEMSTRIP MICRAL ....... 72
CHEMSTRIP UGK .............. 94
CHENODAL ...................... 133
cheracol d ........................... 170
cheracol throat spray ............ 80
cheratussin ac ..................... 170
cheratussin dac ................... 170
CHERRY FLAVOR (BULK)
.......................................... 72
cherry menthol.................... 170
chest congestion ................. 170
chest congestion relief ........ 170
chest congestion relief + dm
........................................ 170
chest congestion relief d ..... 170
chest congestion relief pe ... 170
chest congestion-cough relief
........................................ 170
chest rub ............................... 49
chest-sinus congestion relief
........................................ 170
chewable iron ..................... 212
chewable multi vitamin ...... 212
chewable multivit-a,b,d,e,k,zn
........................................ 212
chewable-vite...................... 212
chewable-vite with iron ...... 212
child allergy relf(cetirizine) 170
child allergy relief (diphen) 170
child chest congestion + cough
........................................ 170
child delsym cough+chest dm
........................................ 170
child mucinex chest congestion
........................................ 170
child mucus relief cough .... 170
child mucus relief expectorant
........................................ 170
CHILD MULTI-SYMPTOM
COLD/COUGH .............. 170
child non-aspirin quick melts24
child pain rel-fever reducer .. 24
child suppository ................ 133
child triaminic cold-allergy 170
child vitamin with minerals 212
child wal-tap cold-allergy ... 170
child wal-tussin cough relief
........................................ 170
children night time cold-cough
........................................ 170
children's advil ...................... 24
children's alaway ................ 162
children's allegra allergy ..... 171
children's allergy (diphenhyd)
........................................ 171
children's allergy complete . 171
children's allergy medicine . 171
children's allergy relief(lor) 171
children's aller-tec ............... 171
children's aspirin ................... 24
children's benadryl allergy .. 171
children's cetirizine ............. 171
children's chest congestion . 171
children's chewable multivitmn
........................................ 212
children's chewable vitamin212
children's chewable w/minerals
........................................ 212
children's chewables ........... 212
children's chewables extra c212
children's chewables with iron
........................................ 212
CHILDREN'S CLARITIN . 171
children's cold and cough (pe)
........................................ 171
children's cold-allergy (pe) . 171
children's complete allergy . 171
children's cough .................. 171
children's dibromm cold-allerg
........................................ 171
children's dibromm dm cold-
cou .................................. 171
children's dimetapp cold-flu
........................................ 171
children's easy-melts ............. 24
children's flu relief .............. 171
children's ibuprofen .............. 24
children's iron ..................... 212
children's mapap ................... 24
children's medi-profen .......... 24
children's medi-tabs .............. 24
children's mucinex cough ... 171
CHILDREN'S MUCINEX
MULTI-SYMP ............... 171
children's multivit w/extra c212
children's non-aspirin............ 24
children's pain relief ............. 24
children's pain reliever .......... 24
children's pain-fever relief .... 25
children's pepto ................... 133
childrens plus cold .............. 171
children's plus flu ................ 171
CHILDRENS PLUS MULTI-
SYMP COLD ................. 171
266 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
children's profen ib ............... 25
children's q-pap .................... 25
CHILDREN'S REPLESTA 212
children's saline nasal spray . 80
children's silapap .................. 25
children's silfedrine ............ 171
children's soothe ................. 133
CHILDREN'S SUDAFED . 171
children's sudafed pe cough 171
children's tactinal .................. 25
children's wal-dryl allergy .. 171
children's wal-zyr ............... 171
child's all day allergy(cetir) 171
child's benadryl-d allergy-sin
........................................ 171
childs chew vite .................. 212
child's chewable vitamins/iron
........................................ 212
childs triacting cold-cough . 172
childs/iron ........................... 212
chloramphenicol sod succinate
............................................ 8
chloraseptic........................... 80
chloraseptic sore throat......... 61
chloraseptic throat spray....... 80
chlordiazepoxide hcl ............ 31
chlordiazepoxide-clidinium 130
chlorhexidine gluconate . 49, 80
CHLORHEXIDINE
GLUCONATE (BULK) ... 49
chlorhist .............................. 172
chloroquine phosphate............ 8
chlorothiazide ....................... 36
chlorpheniramine maleate .. 172
chlorpromazine ..................... 31
chlorpropamide..................... 94
chlortabs ............................. 172
chlorthalidone ....................... 36
chlorzoxazone....................... 20
chocolate laxative ............... 133
cholecalciferol (vitamin d3) 212
CHOLECALCIFEROL
(VITAMIN D3) .............. 212
cholestyramine (with sugar) . 42
cholestyramine light ............. 42
choline,magnesium salicylate
.......................................... 25
chromium picolinate ............. 72
ciclodan ................................ 65
ciclopirox .............................. 65
ciclopirox-ure-camph-menth-
euc .................................... 65
cidaleaze ............................... 61
cidatrine ................................ 25
cidofovir ................................. 4
ciferex ................................. 212
cilostazol ............................... 40
cimetidine ........................... 144
cimetidine hcl ..................... 144
cinnamon oil ......................... 77
CIPRODEX .......................... 84
ciprofloxacin ......................... 11
ciprofloxacin (mixture)......... 11
ciprofloxacin hcl ..... 11, 83, 160
ciprofloxacin in 5 % dextrose
.......................................... 11
ciprofloxacin lactate ............. 11
cisplatin ................................ 13
citalopram ............................. 31
CITRACAL + D MAXIMUM
........................................ 191
CITRACAL PLUS
MAGNESIUM ............... 191
CITRANATAL B-CALM (FE
GLUC) ............................ 212
citrate of magnesia.............. 133
citric acid anhydrous (bulk) .. 72
citric acid monohydrate (bulk)
.......................................... 72
citroma ................................ 133
citronella oil .......................... 79
citrucel ................................ 133
CITRUCEL SUGAR FREE
........................................ 133
citrus calcium ..................... 192
cladribine .............................. 13
CLAFORAN .......................... 7
claravis.................................. 59
claris clarifying wash............ 59
clarithromycin ........................ 7
classic prenatal ................... 212
cleansing eyelid .................. 162
cleansing skin cream ............. 49
cleansing wash ...................... 59
clear anti-itch ........................ 49
CLEAR BANDAGES .......... 94
CLEAR STRIPS ................... 94
CLEAR WATERPROOF
STRIPS ............................. 94
clearasil daily clear(benzoyl) 59
clearlax ............................... 133
clemastine ........................... 172
CLEOCIN ........................... 153
CLEVER CHEK BLOOD
GLUCOSE ........................ 94
CLEVER CHEK LANCETS 94
CLEVER CHOICE
GLUCOSE MONITOR .... 94
CLEVER CHOICE LEVEL 2
CONTROL ....................... 94
CLEVER CHOICE MICRO . 94
CLEVER CHOICE PRO ...... 94
CLEVER CHOICE TEST
STRIPS ............................. 94
CLEVER CHOICE VOICE+
TEST ................................. 94
CLICKFINE ......................... 94
CLIMARA PRO ................. 151
clindacin p ............................ 59
CLINDAGEL ....................... 59
clindamycin hcl ...................... 8
clindamycin in 5 % dextrose .. 8
clindamycin palmitate hcl ....... 8
clindamycin phosphate .... 8, 59,
153
clindamycin-benzoyl peroxide
.......................................... 59
clindamycin-tretinoin ........... 59
CLINDESSE ....................... 153
CLINITEST REAGENT ...... 94
CLINPRO 5000 .................... 80
clobetasol .............................. 68
clobetasol-emollient ............. 68
clodan ................................... 68
CLODERM ........................... 68
clomipramine ........................ 31
clonazepam ........................... 17
267 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
clonidine ............................... 36
clonidine (pf) .................. 25, 36
clonidine hcl ................... 32, 36
CLONIDINE HCL (BULK) 36
clopidogrel ............................ 40
clorazepate dipotassium ....... 32
clorpres ................................. 37
CLORPRES .......................... 37
CLOSED-END POUCH ...... 94
CLOTH FIRST AID TAPE . 94
CLOTH TAPE...................... 94
clotrimazole .............. 3, 65, 153
clotrimazole-3..................... 153
clotrimazole-betamethasone . 65
cloverine ............................... 49
clozapine............................... 32
c-nate dha ........................... 212
co q-10 .................................. 71
co q-10 (with vit e) ............. 195
COAGUCHEK LANCETS .. 94
COARTEM ............................ 8
cocaine .................................. 61
coconut oil (bulk) ................. 79
cod liver oil......................... 213
cod liver oil conc with vit c 213
cod liver oil-ascorbic acid .. 213
codeine sulfate ...................... 21
codeine-butalbital-asa-caff ... 21
codeine-guaifenesin ............ 172
codituss dm ......................... 172
coenzyme q10 ....................... 71
coenzyme q10-vitamin e .... 195
cola (syrup) ......................... 133
COLCRYS ......................... 150
cold and allergy .................. 172
cold and allergy (bromphen-pe)
........................................ 172
cold and allergy pe ............. 172
cold and cough (diphenhydr-
pe) ................................... 172
cold and cough (pe-dm)...... 172
cold and cough (pe-dm-gg-
acet) ................................ 172
cold and cough dm ............. 172
cold and cough elixir .......... 172
cold and flu severe.............. 172
cold and hot extra strength ... 49
cold and hot pain relief ......... 49
cold and hot therapy balm .... 49
cold and sinus pain relief .... 172
COLD HEAD CONGESTION
DAY/NITE ..................... 172
COLD HEAD CONGESTION
DAYTIME...................... 172
cold head congestion nighttime
........................................ 172
cold head congestion sever day
........................................ 172
COLD MULTI-SYMPTOM
........................................ 172
COLD MULTI-SYMPTOM
DAY/NIGHT .................. 172
cold multi-symptom nighttime
........................................ 172
COLD RELIEF................... 172
cold relief m/s day/night ..... 172
cold relief plus .................... 172
cold sore treatment ............... 49
cold-flu relief ...................... 172
cold-flu relief, day/night ..... 172
colestipol .............................. 42
colistin (colistimethate na) ..... 8
colloidal oatmeal .................. 49
colocort ............................... 133
colon herbal cleanser ............ 77
COLOPLAST BARRIER
RING ................................ 94
COLOPLAST IRRIGATION
SET ................................... 94
COLOPLAST PASTE .......... 94
COLOPLAST SKIN
BARRIER ......................... 94
COLOR LANCETS ............. 94
col-rite ................................ 133
COLY-MYCIN S ................. 84
COLYTE WITH FLAVOR
PACKS ........................... 134
COMBIDERM ACD
DRESSING ...................... 94
COMBIGAN ...................... 164
COMBINATION
CONE/TUBE DRAIN ...... 94
COMBINE ABD .................. 94
COMBIPATCH .................. 151
COMBISTIX REAGENT .... 94
COMBIVENT RESPIMAT 186
COMBIVIR ............................ 4
COMFEEL PLUS ULCER
DRESSING ....................... 94
COMFEEL PURILON ......... 94
COMFEEL ULCER CARE
DRESSING ....................... 95
COMFORT EZ PEN
NEEDLES ........................ 95
comfort gel .......................... 134
comfort gel extra strength ... 134
COMFORT LANCETS ........ 95
COMFORT-STRETCH
TRAINING PANTS ......... 95
COMPACT COMPRESSOR
NEBULIZER .................... 95
COMPACT ULTRASONIC
NEBULIZER .................... 95
COMP-AIR ELITE COMP
NEB SYSTEM ................. 95
COMP-AIR XLT
COMPRESSOR NEB ....... 95
compete ............................... 213
compleat pediatric .............. 195
compleat pediatric reduced cal
........................................ 195
compleat-modified .............. 195
COMPLERA .......................... 4
complete ..................... 144, 213
complete 50+ ...................... 213
complete allergy ................. 173
complete allergy medicine .. 173
complete amino acid mix .... 195
complete lice treatment ......... 70
complete multi .................... 213
complete multi 50+ ............. 213
complete multivitamin ........ 213
complete multivitamin-mineral
........................................ 213
complete natal dha .............. 213
complete nutrition ............... 196
complete nutrition plus ....... 196
complete premium vitamin ... 78
268 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
complete senior .................. 213
complete women ................ 213
completenate....................... 213
complex b-100 .................... 213
compound 347 ...................... 72
compound w ......................... 45
compro ................................ 134
CONDOMS-PREM
LUBRICATED................. 95
condrolite .............................. 25
CONDYLOX ....................... 50
CONE-TUBE IRRIGATION
SET ................................... 95
conex .................................. 173
CONFORM .......................... 95
congestac ............................ 173
constulose ........................... 134
conti castile soap .................. 50
CONTOUR CONTROL
SOLUTION, NML ........... 95
CONTOUR I STOMA CAP 95
CONTOUR LINK ................ 95
CONTOUR NEXT EZ
METER ............................ 95
CONTOUR NEXT LEV 2
CONTROL SOL .............. 95
CONTOUR NEXT LINK .... 95
CONTOUR NEXT METER 95
CONTOUR NEXT STRIPS . 95
CONTOUR NEXT USB
METER ............................ 95
CONTOUR TEST STRIPS .. 95
CONTROL AST
MONITORING SYSTEM 95
CONTROL AST TEST ........ 95
CONVATEC NIGHT
DRAINAGE TUBING ..... 95
CONVEEN DRIP
COLLECTOR .................. 95
cool and heat......................... 50
cool bottoms ......................... 50
cool heat (m-salicylate-menth)
.......................................... 50
COOL MIST HUMIDIFIER 1
GALLON ......................... 95
COOLMAGIC ...................... 95
COPA HYDROPHILIC
FOAM .............................. 95
COPAXONE ........................ 20
copper chloride ................... 192
CORDRAN TAPE LARGE
ROLL................................ 68
CORICIDIN HBP COUGH
AND COLD ................... 173
CORIFACT .......................... 40
CORLANOR ........................ 44
cormax .................................. 68
corn remover......................... 45
corn starch ............................ 72
corn-callus remover .............. 45
CORNWALL METAL
PIPETTING ...................... 95
cortane-b ............................... 83
cortane-b aqueous ................. 83
CORTIFOAM .................... 134
cortisone ............................... 84
cortisone (hydrocortisone) .... 68
cortisone + cooling relief ...... 68
CORTISPORIN .................... 64
CORTISPORIN-TC ............. 84
cortizone-10 .......................... 68
corvita ................................. 213
corvita 150 .......................... 213
CORVITE FREE ................ 213
COSMETIC BALLS ............ 95
COTTON BALLS ................ 95
COTTON SNAP PANTS ..... 96
COTTON SWABS ............... 96
COTTON, STERILE ............ 96
cough and cold.................... 173
cough and cold (chlorphen-dm)
........................................ 173
cough and cold mucus relief cf
........................................ 173
cough control
(dextromethorph) ............ 173
cough control (guaifenesin) 173
cough control cf (pe) .......... 173
cough control dm ................ 173
cough control dm max ........ 173
cough dm er ........................ 173
cough drops .......................... 81
cough drops (with eucalyptus)
........................................ 173
cough formula dm ............... 173
cough relief ......................... 173
cough suppressant-expectorant
........................................ 173
cough syrup ........................ 173
cough syrup dm .................. 173
cough-chest congestion dm 173
coughtab ............................. 173
covaryx ............................... 151
covaryx h.s. ......................... 151
CPL DRAINABLE POUCH 96
cranberry ............................... 72
cranberry extract ................... 72
cranberry urinary comfort ..... 78
cran-max ............................... 72
creamy acne face .................. 59
CREON ............................... 134
critic-aid clear af ................... 65
CRIXIVAN ............................. 4
cromolyn ............. 134, 162, 186
CRUTCH .............................. 96
CRUTCH TIPS ..................... 96
cryoserv ................................ 72
cryselle (28) ........................ 155
CUPRIMINE ...................... 151
CURASOL WOUND
DRESSING ....................... 96
cure chrome .......................... 50
CURI-STRIP WOUND
CLOSURES ...................... 96
CURITY 8000 URINE MTR
FLY TRAY ....................... 96
CURITY ABDOMINAL PAD
.......................................... 96
CURITY ALCOHOL SWABS
.......................................... 96
CURITY BEDSIDE
DRAINAGE BAG ............ 96
CURITY BEDSIDE
DRAINAGE SET ............. 96
CURITY BEDSIDE-MONO-
FLO DRANGE ................. 96
CURITY FOLEY CATHETER
KIT ................................... 96
269 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
CURITY GAUZE ................ 96
CURITY IODOFORM
PACKING STRIP ............ 96
CURITY PREMIUM
CATHETER TRAY ......... 96
curity sterile water ................ 72
CURITY ULTRAMER 2-
WAY CATHETER .......... 96
CURITY UNIVERSAL - NO
DRAINAGE ..................... 96
CURITY URETERAL DRAIN
SET ................................... 96
CURITY URETH CATH
CLOSED SYSTM ............ 96
CURITY URETH CATH
OPEN SYSTEM ............... 96
CURITY URETHRAL
CATHETER ..................... 96
CURITY URINE METER ... 96
cushion insole ....................... 96
CUTIEPANTS TRAINING
PANTS ............................. 96
CUTIES BABY DIAPERS .. 96
CUTTER BACKWOODS ... 50
CUVPOSA ......................... 130
cyanocobalamin (vitamin b-12)
........................................ 213
cyclafem 1/35 (28) ............. 155
cyclafem 7/7/7 (28) ............ 155
CYCLINEX-1 .................... 196
CYCLINEX-2 .................... 196
cyclobenzaprine .................... 20
CYCLOGYL ...................... 161
CYCLOMYDRIL............... 166
cyclopentolate..................... 161
cyclophosphamide ................ 13
CYCLOSERINE .................... 8
cyclosporine ......................... 13
cyclosporine modified .......... 13
cyproheptadine ................... 173
cyred ................................... 155
CYSTAGON ...................... 188
cytarabine ............................. 13
cytarabine (pf) ...................... 13
cytolline .............................. 196
cyto-q max .......................... 196
cytra k crystals .................... 188
cytra-2 ................................. 188
cytra-3 ................................. 188
cytra-k ................................. 188
D d2.5 %-0.45 % sodium
chloride ............................. 72
d3-2000 ............................... 213
d5 % and 0.9 % sodium
chloride ............................. 72
d5 %-0.45 % sodium chloride
.......................................... 72
dacarbazine ........................... 13
daily energy ........................ 213
daily face wash ..................... 45
daily fiber ........................... 134
daily garlic once-a-day ......... 78
daily moisturizing lotion ...... 50
daily multiple ...................... 214
daily multiple for men ........ 213
daily multiple for men 50+ . 213
DAILY MULTIPLE FOR
WOMEN ........................ 213
daily multivitamin with iron
........................................ 214
daily multivitamin-minerals214
daily multi-vitamins/iron .... 214
daily value .......................... 214
daily vitamin formula ......... 214
daily vitamin formula-iron . 214
daily vitamin with iron and ca
........................................ 214
daily vites/iron .................... 214
daily-vite ............................. 214
dairy aid .............................. 134
dairy digestive .................... 134
dairy relief .......................... 134
dakin's solution ..................... 72
DALIRESP ......................... 186
danazol................................ 127
dandruff shampoo (pyrithione)
.......................................... 70
dandruff shampoo (selen-aloe)
.......................................... 50
DANTRIUM ........................ 20
dantrolene ............................. 20
dapsone ................................... 8
DARAPRIM ........................... 9
darifenacin .......................... 187
dasetta 1/35 (28) ................. 155
dasetta 7/7/7 (28) ................ 155
daunorubicin ......................... 13
DAVOL COMPLETE FOLEY
.......................................... 97
DAVOL FOLEY CATH
INSERT TRAY ................ 97
DAVOL SILICONE FOLEY
CATHETER ..................... 97
DAVOL URINARY
DRAINAGE BAG ............ 97
DAY AND NIGHT
BRIEF,MEDIUM ............. 97
day multi-symp flu-severe cold
........................................ 173
DAY TIME PE ................... 173
DAY, PLUS PAD ................. 97
dayhist allergy .................... 173
daysee ................................. 155
day-time .............................. 174
DAYTIME .......................... 173
DAYTIME AND
NIGHTTIME COLD ...... 173
DAYTIME COLD-FLU ..... 173
daytime cold-flu relief (pe) . 173
DAYTIME COLD-FLU
RELIEF (PE) .................. 173
day-time cough ................... 174
daytime mucus relief dm .... 174
daytime-nighttime ............... 174
DDAVP .............................. 127
deblitane ............................. 152
decongestant inhaler ............. 81
deep sea nasal ....................... 81
deferoxamine ........................ 72
delbase compounding ........... 77
delsym cough-chest congest
dm ................................... 174
delta d3 ............................... 214
deltasone ............................... 84
DELTEC COZMO CLEO
INFUSION SET ............... 97
270 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
DELUXE ARM BLOOD
PRESSURE MON ............ 97
DELUXE INSTANT EAR
THERMOMETER ........... 97
delyla (28) .......................... 155
DELZICOL ........................ 134
demeclocycline ..................... 11
DEMSER .............................. 37
denta 5000 plus..................... 81
dentagel ................................ 81
dent-o-kain ........................... 61
DEPEN TITRATABS ........ 151
DEPEND PROTECTION SZ
S-M ................................... 97
DEPEND REAL FIT BRIEF
MEN S-M ......................... 97
DEPEND SILHOUETTE
WOMEN S/M .................. 97
DEPEND UNDERWEAR
FOR WOMEN S-M ......... 97
DEPO-ESTRADIOL .......... 152
DEPO-MEDROL ................. 84
DEPO-PROVERA ............. 152
DEPO-SUBQ PROVERA 104
........................................ 152
DEPO-TESTOSTERONE .. 127
derma cidol 2000 .................. 65
dermabase ............................. 50
DERMACEA ....................... 97
DERMACEA NON-WOVEN
.......................................... 97
DERMACEA STRETCH ..... 97
dermacerin ............................ 50
dermacinrx prizopak ............. 61
DERMADRESS ................... 97
dermadrox............................. 50
dermafix ............................... 77
DERMAGAUZE .................. 97
DERMAGINATE................. 97
DERMALEVIN ................... 97
dermamed (aluminum
hydroxide) ........................ 50
dermaphor............................. 50
dermarest eczema (hydrocort)
.......................................... 68
dermarest psoriasis medicated
.......................................... 46
dermasarra ............................ 50
dermasilkrx sds ..................... 68
DERMASYN........................ 97
dermavantage........................ 50
DERMAVIEW ..................... 97
DERMAVIEW II ................. 97
dermazene ............................. 64
dermazinc shampoo .............. 70
dermazinc spray .................... 70
DESCOVY ............................. 4
desenex ................................. 65
desenex spray ....................... 65
desgen dm ........................... 174
desipramine .......................... 32
desloratadine ....................... 174
desmopressin ...................... 127
desog-e.estradiol/e.estradiol
........................................ 155
desogestrel-ethinyl estradiol
........................................ 155
DESONATE ......................... 68
desonide ................................ 68
desoximetasone .................... 68
despec dm-g ........................ 174
despec eda cough-cold drops
........................................ 174
despec-dm (phenyleph-dm-
guaif) .............................. 174
desvenlafaxine succinate ...... 32
DETACHOL ADHESIVE
REMOVER ...................... 97
detox dietary ......................... 78
DEVILBISS COMPACT
COMPRESSOR................ 97
DEVILBISS DISPOSABLE
NEBULIZER .................... 97
DEVILBISS PULMO-AIDE
COMPRESSR .................. 97
DEVILBISS PULMOMATE
COMPRESSOR................ 97
DEVILBISS TRAVELER
COMPRESSOR................ 97
dex4 glucose ......................... 73
dex4 glucose bits .................. 73
dexamethasone ..................... 84
dexamethasone intensol ........ 84
dexamethasone sodium phos
(pf) .................................... 84
dexamethasone sodium
phosphate .................. 85, 165
dexedrine .............................. 32
dexferrum ........................... 214
dexmethylphenidate .............. 32
DEXPAK 10 DAY ............... 85
DEXPAK 13 DAY ............... 85
DEXPAK 6 DAY ................. 85
dexpanthenol ....................... 214
dextroamphetamine .............. 32
dextroamphetamine-
amphetamine ..................... 32
DEXTROMETHORPHAN
HBR (BULK) ................. 174
dextromethorphan polistirex
........................................ 174
dextromethorphan-guaifenesin
........................................ 174
dextrose 10 % in water (d10w)
.......................................... 73
dextrose 5 % in ringer's ........ 73
dextrose 5 % in water (d5w) . 73
dextrose 5 %-lactated ringers73
dextrose 5%-0.2 % sod
chloride ............................. 73
dextrose 5%-0.3 %
sod.chloride ...................... 73
dextrose 50 % in water (d50w)
.......................................... 73
dhea ..................................... 127
dhs zinc ................................. 70
diabetic siltussin das-na ...... 174
diabetic siltussin-dm ........... 174
diabetic siltussin-dm max str
........................................ 174
diabetic tussin dm ............... 174
diabetic tussin ex ................ 174
diabetic tussin max st .......... 174
diabetiderm foot rejuvenating
.......................................... 50
DIABETISOURCE AC ...... 196
diafoods thick-it .................... 73
271 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
dialyvite .............................. 214
dialyvite 800 ....................... 214
DIALYVITE 800-ULTRA D
........................................ 214
dialyvite vitamin d .............. 214
diamode .............................. 130
diaper rash ............................ 50
diaper rash relief ................... 50
DIAPERS, UNISEX SIZE 3 97
DIAPERS-DISP-
POLYETHYLENE BACK
.......................................... 98
diarrhea relief (bismuth subs)
........................................ 130
DIASTAT ............................. 17
DIASTIX .............................. 98
diazepam......................... 17, 32
diazepam intensol ................. 32
dibucaine .............................. 61
diclofenac potassium ............ 25
diclofenac sodium .. 25, 50, 164
DICLOFENAC SODIUM
(BULK) ............................ 25
diclofenac-misoprostol ......... 25
dicloxacillin .......................... 10
dicyclomine ........................ 130
didanosine............................... 4
diflorasone ............................ 68
diflunisal ............................... 25
digestive enzymes .............. 134
digestive relief .................... 130
DIGITAL PREGNANCY
TEST ................................ 98
DIGITAL THERMOMETER
.......................................... 98
digitek ................................... 39
digox ..................................... 39
digoxin ............................ 39, 40
dihydroergotamine ............... 19
DILANTIN ........................... 17
DILATRATE-SR ................. 44
diltiazem hcl ......................... 37
DILTIAZEM HCL (BULK) 37
dilt-xr .................................... 37
diluent for epoprostenol/flola
.......................................... 73
dimaphen (pe) ..................... 174
dimaphen dm ...................... 174
dimenhydrinate ................... 134
dimetapp cold-congestion... 174
dimetapp dm cold-cough (pe)
........................................ 174
DIMETAPP LONG-ACTING
(CPM-DM) ..................... 174
dino-life .............................. 214
dino-life with extra c .......... 214
dino-life with iron-zinc ....... 214
diocto .................................. 134
dioctyl ................................. 134
diotame ............................... 130
DIPENTUM ....................... 134
diphedryl ............................. 174
diphedryl allergy................. 174
diphen ................................. 174
diphenhist ........................... 174
diphenhydramine hcl ..... 32, 50,
174, 175
diphenhydramine-
acetaminophen .................. 25
diphenoxylate-atropine ....... 130
dipyridamole ......................... 40
disopyramide phosphate ....... 35
DISPOSABLE BRIEF ......... 98
DISPOSABLE GLOVES ..... 98
DISPOSABLE LATEX-FREE
GLOVES .......................... 98
DISPOSABLE POWER ....... 98
DISPOZ-A-BAG LEG BAG
SMALL ............................ 98
disulfiram.............................. 73
DIURIL ................................ 37
divalproex ............................. 17
dm max ............................... 175
dobutamine ........................... 44
dobutamine in d5w ............... 44
docetaxel ............................... 14
doc-q-lace ........................... 134
doc-q-lax ............................. 134
docu .................................... 134
docu soft ............................. 134
docuprene ........................... 134
docusate calcium ................ 134
docusate sodium ................. 134
docusil ................................. 134
DOCUSOL ......................... 134
dofetilide ............................... 35
dok ...................................... 134
dok plus .............................. 134
DOLOGESIC (W-
PHENYLTOLOXAMINE)
.......................................... 25
dometuss-dmx ..................... 175
dona ...................................... 25
donepezil ............................... 20
dong quai (angelica sinensis) 78
dopamine .............................. 44
dopamine in 5 % dextrose .... 44
dorzolamide ........................ 164
dorzolamide-timolol ........... 164
dothelle dha ........................ 214
double antibiotic ................... 64
double antibiotic (b.tracn zn) 64
double-tussin dm ................ 175
douche vinegar and water extra
........................................ 153
DOVER CATHETER .......... 98
DOVER PEDIATRIC URINE
METER ............................. 98
DOVER TEXAS MALE
EXTERNAL CATH ......... 98
DOVER URI-DRAIN
DELUXE LEG BAG ........ 98
DOVER URI-DRAIN MALE
EXT CATH ...................... 98
DOVER URINARY LEG
BAG .................................. 98
doxazosin .............................. 37
doxepin ........................... 32, 50
doxercalciferol .................... 127
doxorubicin ........................... 14
doxorubicin, peg-liposomal .. 14
doxycycline hyclate ........ 11, 12
doxycycline monohydrate .... 12
dr scholl's clear away ............ 46
DRAINABLE FECAL
COLLECTOR ................... 98
DRAINABLE POUCH
CLAMP ............................ 98
272 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
DRAINABLE POUCH
CLOSURE ........................ 98
dramamine .......................... 135
dramamine less drowsy ...... 135
driminate............................. 135
dristan cold ......................... 175
dristan long lasting ............... 81
drithocreme hp...................... 45
dronabinol........................... 135
DROPLET LANCETS ......... 98
DROPLET LANCING
DEVICE ........................... 98
DROPLET PEN NEEDLE ... 98
drospirenone-e.estradiol-lm.fa
........................................ 155
drospirenone-ethinyl estradiol
........................................ 155
DROXIA .............................. 14
DRY COMFORT ................. 98
DRY COMFORT EXTRA
BRIEFS ............................ 98
dry eye relief....................... 162
dry skin bath oil .................... 50
dry skin care ......................... 50
dry skin therapy .................... 50
dry skin therapy moisturizing
.......................................... 50
dss ....................................... 135
dual action complete........... 145
ducodyl ............................... 135
DUET DHA EC-OM 3 ....... 214
DUET DHA WITH OMEGA-3
........................................ 214
dulcolax stool softener (dss)
........................................ 135
duloxetine ............................. 32
duo fusion ........................... 145
DUOCAL ........................... 196
DUODERM CGF DRESSING
.......................................... 98
DUODERM CGF EXTRA
THIN ................................ 98
DUODERM HYDROACTIVE
.......................................... 98
duofer ................................. 214
duofilm ................................. 46
DUOLOCK CURVED TAIL
CLOSURE ........................ 98
DUPIXENT .......................... 50
DURAHESIVE MOLDABLE
CONVEX ......................... 98
DURAPORE SURGICAL ... 98
DURASORB UNDERPAD . 98
dutasteride .......................... 188
dutasteride-tamsulosin ........ 188
DUTOPROL ......................... 37
d-vi-sol................................ 214
d-vita ................................... 214
dynamic ................................ 61
dynamic plus pak .................. 62
dy-o-derm ............................. 77
E e.c. prin ................................. 25
e.e.s. 400 ................................. 7
E.P.T. .................................... 99
E.P.T. DIGITAL ................... 99
e-400 c-500 and beta carotene
........................................ 214
EAA SUPPLEMENT ......... 196
EAKIN COHESIVE SEALS 99
EAKIN COHESIVE SLIMS 99
ear care ............................... 196
ear drops (carbamide peroxide)
.......................................... 83
ear drops otc ......................... 83
ear dry ................................... 84
ear health formula ............... 196
EAR POPPER INFLATION
DEVICE ........................... 99
ear wax removal drops ......... 84
ear wax treatment ................. 84
EARLY PREGNANCY TEST
.......................................... 99
EARLY RESULT
PREGNANCY TEST ....... 99
EASIVENT HOLDING
CHAMBER ...................... 99
EASY CLICK LANCING
DEVICE ........................... 99
EASY COMFORT INSULIN
SYRINGE ......................... 99
EASY COMFORT LANCETS
.......................................... 99
EASY COMFORT PEN
NEEDLES ........................ 99
easy fiber ............................ 135
EASY PLUS II LOW
CONTROL ....................... 99
EASY STEP BLOOD
GLUCOSE METER ......... 99
EASY TALK LOW
CONTROL ....................... 99
EASY TOUCH ALCOHOL
PREP PADS ..................... 99
EASY TOUCH INSULIN
SYRINGE ......................... 99
EASY TOUCH LANCING
DEVICE ........................... 99
EASY TRAK BLOOD
GLUCOSE METER ......... 99
EASY TRAK GLUCOSE
TEST ................................. 99
EASYGLUCO
MONITORING SYSTEM 99
EASYGLUCO TEST ........... 99
EASYMAX .......................... 99
EASYMAX LOW CONTROL
.......................................... 99
EASYMAX NORMAL
CONTROL ....................... 99
EASYMAX V SPEAKING
GLUCOSE SYS ............... 99
EASYMAX V2 BLOOD
GLUCOSE METER ......... 99
eazzze the pain ...................... 25
ECEE PLUS ....................... 214
echinacea .............................. 78
econazole .............................. 65
econtra ez ............................ 155
ecotrin ................................... 25
ecotrin low strength .............. 25
eczema anti-itch .................... 68
ed a-hist .............................. 175
ed a-hist dm ........................ 175
ed a-hist pse ........................ 175
ed bron gp ........................... 175
ed chlorped jr ...................... 175
273 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
ed-apap ................................. 25
ed-chlortan .......................... 175
ed-spaz ................................ 130
EDURANT ............................. 4
eemt .................................... 152
eemt hs................................ 152
effer-k ................................. 192
effervescent antacid .............. 25
effervescent pain reliever ..... 25
EFFIENT .............................. 40
ELASTO-GEL CAST-SPLINT
PADDING ........................ 99
ELASTO-GEL CIRCLE
DRESSING ...................... 99
ELASTO-GEL FACE
DRESSING ...................... 99
eldertonic ............................ 214
ELECARE .......................... 196
ELECARE INFANT
FORMULA .................... 196
ELECARE JR ..................... 196
ELEMENT NORMAL
CONTROL ..................... 100
ELEMENT TEST STRIPS. 100
eletone .................................. 50
eletriptan hbr ........................ 19
elfolate ................................ 214
ELIDEL ................................ 50
ELIMINATOR ODOR
SPRAY ........................... 100
elinest ................................. 155
eliphos ................................ 192
ELIQUIS .............................. 40
elite ob with dha ................. 214
elite-ob 400 ......................... 214
ELIXOPHYLLIN ............... 186
ELLA .................................. 155
ellis tonic ............................ 214
ELMIRON .......................... 188
ELOCTATE ......................... 40
EMBRACE BLOOD
GLUCOSE SYSTEM ..... 100
EMBRACE GLUCOSE
CONTROL LOW ........... 100
EMCYT ................................ 14
EMEND .............................. 135
emollient ............................... 50
emoquette ........................... 155
EMSAM ............................... 32
EMTRIVA .............................. 4
emulsion sb ........................... 50
enalapril maleate................... 37
enalapril-hydrochlorothiazide
.......................................... 37
ENBREL ............................ 151
ENBREL SURECLICK ..... 151
endacof - dm ....................... 175
endacof-c ............................ 175
endacon ............................... 175
endocet.................................. 21
endodan ................................ 21
endur-acin ............................. 42
enema.................................. 135
enema disposable ................ 135
ENEMEEZ ......................... 135
ENEMEEZ PLUS............... 135
ENFAGROW NEXT STEP
LIPIL .............................. 196
ENFAGROW PREMIUM
TODDLER ..................... 196
ENFAGROW TODDLR
TRANSITION SOY ....... 196
enfamil a.r. .......................... 196
ENFAMIL A.R. .................. 196
enfamil a.r. lipil .................. 196
enfamil enfacare ................. 196
ENFAMIL ENFACARE .... 196
ENFAMIL ENFACARE LIPIL
........................................ 196
ENFAMIL GENTLEASE .. 196
ENFAMIL GENTLEASE
LIPIL LIQUID ............... 196
ENFAMIL GENTLEASE
LIPIL POWD ................. 196
ENFAMIL GLUCOSE ......... 73
ENFAMIL HUMAN MILK
FORTIFIER .................... 196
ENFAMIL INFANT........... 196
ENFAMIL LIPIL NURSETTE
........................................ 196
ENFAMIL NEWBORN ..... 197
ENFAMIL PREMATURE
LOW IRON 24 ............... 197
enfamil premium lipil ......... 197
ENFAMIL PROSOBEE LIPIL
........................................ 197
enfamil water ........................ 73
ENFAPORT LIPIL ............. 197
enoxaparin ............................ 40
enpresse .............................. 155
enskyce ............................... 156
ensure .................................. 197
ENSURE ............................. 197
ensure active clear .............. 197
ensure active heart health ... 197
ensure active light ............... 197
ensure active protein-muscle
........................................ 197
ENSURE CLEAR .............. 197
ensure compact ................... 197
ENSURE COMPLETE ...... 197
ensure high protein ............. 197
ensure high protein-muscle . 197
ENSURE MUSCLE HEALTH
........................................ 197
ENSURE ORIGINAL ........ 197
ENSURE PLUS .................. 197
ENSURE PUDDING .......... 197
entacapone ............................ 19
entecavir ................................. 4
enteric coated aspirin ............ 25
entre-cough ......................... 175
entre-hist pse ....................... 175
ENTRESTO .......................... 44
ENTRUST PLUS BRIEFS . 100
ENTRUST PLUS SUPER
UNDERPADS ................ 100
ENTRUST PLUS
UNDERGARMENTS .... 100
ENTRUST PLUS
UNDERWEAR ............... 100
enulose ................................ 135
enzyme digest ..................... 135
EO28 SPLASH ................... 197
ephedrine sulfate ................. 186
ephrine .................................. 81
epinastine ............................ 162
274 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
epinephrine ......................... 175
epinephrine hcl (pf) ............ 175
EPIPEN .............................. 175
EPIPEN JR ......................... 175
epitol ..................................... 17
EPIVIR ................................... 4
EPIVIR HBV.......................... 4
eplerenone ............................ 37
EPOGEN ............................ 147
epoprostenol (glycine) .......... 37
eprosartan ............................. 37
epsom salt ........................... 135
EPZICOM .............................. 4
EQUETRO ........................... 17
ERAXIS(WATER DILUENT)
............................................ 3
ergocalciferol (vitamin d2) . 215
ergoloid................................. 32
ergotamine-caffeine .............. 19
errin .................................... 152
ERTACZO ........................... 65
ery pads ................................ 59
erygel .................................... 59
ERYPED 200 ......................... 7
ERYPED 400 ......................... 7
ery-tab..................................... 7
ERY-TAB............................... 7
ERYTHROCIN ...................... 7
erythrocin (as stearate) ........... 7
erythromycin .................. 8, 160
erythromycin ethylsuccinate .. 8
erythromycin with ethanol ... 59
erythromycin-benzoyl peroxide
.......................................... 59
escitalopram oxalate ............. 32
esomeprazole magnesium .. 145
essentia ............................... 215
essential amino acid mix .... 197
ESSENTIAL BALANCE
WITH LUTEIN .............. 215
essential daily ..................... 215
estarylla .............................. 156
estazolam .............................. 32
ESTEEM DRAINABLE
POUCH .......................... 100
ESTEEM SYNERGY ........ 100
ESTEEM SYNERGY
CLOSED POUCH .......... 100
ester-c with bioflavonoids .. 215
ESTRACE .......................... 152
estradiol .............................. 152
ESTRADIOL (BULK) ....... 152
ESTRADIOL
HEMIHYD,MICRO
(BULK) .......................... 152
ESTRADIOL MICRONIZED
(BULK) .......................... 152
estradiol valerate................. 152
estradiol-norethindrone acet
........................................ 152
ESTRING ........................... 152
estro support es ................... 215
estrogens-methyltestosterone
........................................ 152
estronatural ......................... 215
estropipate .......................... 152
ESTROVEN MOOD AND
MEMORY ...................... 215
eszopiclone ........................... 32
ethacrynic acid ...................... 37
ethambutol .............................. 9
ethanol (ethyl alcohol) .......... 73
ethosuximide ........................ 17
ethyl acetate .......................... 79
ethyl chloride ........................ 62
ethynodiol diac-eth estradiol
........................................ 156
etidronate disodium .............. 73
etodolac ................................ 25
ETOPOPHOS ....................... 14
etoposide ............................... 14
eucalyptus oil ........................ 50
eucerin original ..................... 51
evac-u-gen (sennosides) ..... 135
evening primrose oil ............. 73
EVOLUTION BLOOD
GLUCOSE METER ....... 100
EVOLUTION NORMAL
CONTROL ..................... 100
EVOLUTION TEST STRIPS
........................................ 100
EVOTAZ ................................ 4
excel-gel ............................... 51
EXCILON ........................... 100
EXEL HYPODERMIC
NEEDLES ...................... 100
EXELDERM ........................ 66
exemestane ........................... 14
EXJADE ............................... 73
exotic-hc ............................... 84
expectorant ......................... 175
EXPIRATORY
MOUTHPIECE .............. 100
ex-strength medi-tabs pm ..... 25
EXTENSION TUBING W-
CONNECTOR ................ 100
EXTERNAL CATHETER,
MALE ............................. 100
extra cleansing douche ....... 153
extra strength bayer .............. 25
extraprin ................................ 25
EXUDERM ULTRA .......... 100
EXU-DRY SCALP
DRESSING ..................... 100
EXU-DRY WOUND
DRESSING ..................... 100
eye allergy relief ................. 166
eye drop tears ...................... 162
eye drops ............................. 166
eye drops (tetrahydrozoline)
........................................ 166
eye drops (with povidone) .. 166
eye drops advanced relief ... 166
eye drops allergy relief ....... 166
eye health plus lutein .......... 215
eye itch relief ...................... 162
EYE PAD ........................... 100
EYE PATCH ...................... 100
eye wash (boric acid) .......... 162
EYELID WIPES ................. 162
EZ FLU 2015-16 (FLUVIRIN)
(PF) ................................. 148
EZ FLU 2015-
16(FLUCELVAX)(PF) ... 148
EZ FLU 2016-17 (AFLURIA)
(PF) ................................. 148
EZ FLU 2016-17 (FLUVIRIN)
(PF) ................................. 148
275 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
EZ FLU16-17(FLUZON QD
PED)(PF) ........................ 148
e-z ject lancets .................... 100
EZ SMART LANCETS ..... 100
EZ SMART PLUS TEST ... 100
EZ SMART SYSTEM ....... 100
EZ SMART TEST .............. 101
E-Z SPACER...................... 101
ezetimibe .............................. 42
ezetimibe-simvastatin ........... 42
ezfe 200 .............................. 215
ezfe forte ............................. 215
F fabb ..................................... 215
FABRIC STRIP EXTRA
LARGE........................... 101
FACE MASK,EARLOOP-
STYLE ........................... 101
fallback solo ....................... 156
falmina (28) ........................ 156
famciclovir ............................. 4
famotidine........................... 145
famotidine (pf).................... 145
famotidine (pf)-nacl (iso-os)
........................................ 145
FANAPT .............................. 32
FANTASY CONDOM ....... 101
farbee with c ....................... 215
FARESTON ......................... 14
FAST ACTING NASAL ...... 81
FAST READ
THERMOMETER ......... 101
fayosim ............................... 156
FAZACLO ........................... 32
fe 90 plus ............................ 215
fe c ...................................... 215
fe c plus .............................. 215
FECAL COLLECTOR ....... 101
FEIBA NF ............................ 40
felbamate .............................. 17
felodipine .............................. 37
fem moist andlub(glycerin-hec)
.......................................... 51
fem ph ................................. 153
FEMALE URINARY POUCH
........................................ 101
feminine care douche.......... 153
feminine wash..................... 153
FEMRING .......................... 152
femynor .............................. 156
fenesin dm ir ....................... 175
fenesin ir ............................. 175
fenesin pe ir ........................ 175
fenofibrate ............................ 42
fenofibrate micronized ......... 42
fenofibrate nanocrystallized . 42
fenofibric acid....................... 42
fenofibric acid (choline) ....... 42
fenoprofen ............................ 26
fentanyl ................................. 21
fentanyl citrate ...................... 21
feosol .................................. 215
ferate ................................... 215
fer-iron ................................ 215
ferocon ................................ 215
ferosul ................................. 215
ferraplus 90 ......................... 215
ferretts ................................. 215
ferrex 150 ........................... 215
ferrex 150 plus .................... 215
ferric x-150 ......................... 215
FERRIPROX ........................ 73
ferrocite .............................. 215
ferrocite plus ....................... 215
ferrogels forte ..................... 215
ferro-time ............................ 215
ferrous fumarate ................. 215
ferrous gluconate ................ 216
ferrous sulfate ..................... 216
ferrousul.............................. 216
FEVER FLASH
THERMOMETER.......... 101
fever reducer ......................... 26
fever reducer an pain reliever
.......................................... 26
feverall .................................. 26
fexofenadine ....................... 175
fexofenadine-pseudoephedrine
........................................ 175
fiber .................................... 135
fiber (calcium polycarbophil)
........................................ 135
fiber (dextrin) ...................... 135
fiber (psyllium husk) .......... 135
fiber (psyllium husk/sugar) . 135
fiber (with aspartame) ......... 135
fiber laxative (ca polycarbo)
........................................ 135
fiber laxative (husk/sugar) .. 135
fiber laxative (methylcellulo)
........................................ 135
fiber laxative (psyllium husk)
........................................ 135
fiber laxative (psyllium) s/f 135
fiber smooth ........................ 135
fiber smooth (sucrose) ........ 135
fiber supplement (inulin) .... 135
fiber therapy (ca polycarboph)
........................................ 136
fiber therapy (m-cell/sugar) 136
fiber therapy (m-cellulose) . 136
fiber therapy (psyllium seed)
........................................ 136
fiber therapy laxative (husk)
........................................ 136
fiber therapy sugar free ....... 136
FIBERSOURCE HN .......... 197
fiber-tabs ............................. 136
FIFTY50 SAFETY SEAL
LANCETS ...................... 101
FIFTY50 TEST STRIP ....... 101
FILTER CLOSED MINI-
POUCH ........................... 101
FILTERS REPLACEMENT
........................................ 101
FILTRODOR POUCH
FILTER ........................... 101
FINACEA ............................. 59
finasteride ........................... 188
FINE 30 UNIVERSAL
LANCETS ...................... 101
finger cream .......................... 51
fingers skin ........................... 51
FINGERSTIX LANCETS .. 101
FIRAZYR ........................... 186
first aid abx pain relief .......... 64
first aid antibiotic-pain rlf ..... 64
first aid antiseptic ........... 62, 64
276 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
FIRST AID CLOTH TAPE 101
FIRST AID KITS ............... 101
FIRST AID PAPER TAPE 101
FIRST CHOICE LANCETS
THIN .............................. 101
FIRST-LANSOPRAZOLE 145
FIRST-OMEPRAZOLE ..... 145
fish oil ................... 43, 197, 198
FISH OIL............................ 197
fish oil concentrate ............... 42
fish oil extra strength .......... 197
fish oil-dha-epa ................... 216
fish,bora,flax oils-om3,6,9no1
........................................ 198
FITTED BRIEFS MEDIUM
........................................ 101
flanax (naproxen) ................. 26
flanax antacid ..................... 136
FLAREX ............................ 165
flavor chews antacid ........... 192
FLAVOR PACKETS ........... 79
flavoxate ............................. 187
flaxseed oil ........................... 78
flecainide .............................. 35
FLEET BISACODYL ........ 136
fleet enema ......................... 136
fleet glycerin (adult) ........... 136
fleet laxative ....................... 136
FLEXIBLE FABRIC
BANDAGES .................. 101
FLEXIBLE FOAM ............ 101
FLEXI-SEAL FMS ............ 101
FLEXI-TRAK ANCHORING
DEVICE ......................... 101
FLEXTEND SKIN BARRIER
........................................ 101
FLEXZAN WOUND
DRESSING .................... 101
FLOLAN .............................. 37
floranex............................... 198
FLOVENT DISKUS .......... 186
FLOVENT HFA ................. 186
floxin .................................... 84
floxuridine ............................ 14
flu and severe cold-nighttime
........................................ 175
flu bp................................... 175
flu hbp................................. 175
flu relief therapy daytime ... 176
flu relief therapy nighttime . 176
FLUAD 2016-2017 (65 YR
UP)(PF) .......................... 148
FLUAD 2017-2018 (65 YR
UP)(PF) .......................... 148
FLUARIX 2013-2014 (PF) 148
FLUARIX 2014-2015 (PF) 148
FLUARIX QUAD 2013-2014
(PF) ................................. 148
FLUARIX QUAD 2014-2015
(PF) ................................. 148
FLUARIX QUAD 2015-2016
(PF) ................................. 148
FLUARIX QUAD 2016-2017
(PF) ................................. 148
FLUARIX QUAD 2017-2018
(PF) ................................. 148
FLUBLOK 2014-2015 (PF)
........................................ 148
FLUBLOK 2015-2016 (PF)
........................................ 148
FLUBLOK 2016-2017 (PF)
........................................ 148
FLUBLOK 2017-2018 (PF)
........................................ 148
FLUBLOK QUAD 2017-2018
(PF) ................................. 149
flucaine ............................... 162
FLUCELVAX 2013-2014 (PF)
........................................ 149
FLUCELVAX 2014-2015 (PF)
........................................ 149
FLUCELVAX 2015-2016 (PF)
........................................ 149
FLUCELVAX QUAD 2016-
2017 (PF) ........................ 149
FLUCELVAX QUAD 2017-
2018 ................................ 149
FLUCELVAX QUAD 2017-
2018 (PF) ........................ 149
fluconazole ............................. 3
FLUCONAZOLE (BULK) .... 3
fluconazole in dextrose(iso-o) 3
fluconazole in nacl (iso-osm) . 3
flucytosine .............................. 3
fludarabine ............................ 14
fludrocortisone ...................... 85
FLULAVAL 2013-2014 ..... 149
FLULAVAL 2014-2015 ..... 149
FLULAVAL QUAD 2013-
2014 ................................ 149
FLULAVAL QUAD 2014-
2015 ................................ 149
FLULAVAL QUAD 2014-
2015 (PF) ........................ 149
FLULAVAL QUAD 2015-
2016 ................................ 149
FLULAVAL QUAD 2016-
2017 ................................ 149
FLULAVAL QUAD 2016-
2017 (PF) ........................ 149
FLULAVAL QUAD 2017-
2018 ................................ 149
FLULAVAL QUAD 2017-
2018 (PF) ........................ 149
FLUMIST QUAD 2014-2015
........................................ 149
FLUMIST QUAD 2015-2016
........................................ 149
FLUMIST QUAD 2016-2017
........................................ 149
FLUMIST QUAD 2017-2018
........................................ 149
flunisolide ........................... 186
fluocinolone .......................... 68
fluocinolone acetonide oil .... 84
fluocinolone and shower cap 68
fluocinonide .......................... 68
fluocinonide-e ....................... 68
FLUOR-A-DAY ................. 216
fluor-a-day (with xylitol) .... 216
fluorescein-benoxinate ....... 162
fluorescein-proparacaine .... 162
fluoride (sodium) .......... 81, 216
fluoridex daily defense ......... 81
FLUORIDEX SENSITIVITY
RELIEF ............................. 81
fluoritab .............................. 216
FLUORITAB ...................... 216
277 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
fluorometholone ................. 165
FLUOROPLEX .................... 51
fluorouracil ..................... 14, 51
fluoxetine .............................. 32
fluphenazine decanoate ........ 32
fluphenazine hcl ................... 32
FLURA-DROPS ................ 216
flurandrenolide ..................... 68
flurazepam ............................ 32
flurbiprofen........................... 26
flurbiprofen sodium ............ 164
flurox .................................. 162
flutamide............................... 14
fluticasone .................... 68, 186
FLUTTER .......................... 101
fluvastatin ............................. 43
FLUVIRIN 2013-2014 ....... 149
FLUVIRIN 2013-2014 (PF)
........................................ 149
FLUVIRIN 2014-2015 ....... 149
FLUVIRIN 2014-2015 (PF)
........................................ 149
FLUVIRIN 2015-2016 ....... 149
FLUVIRIN 2015-2016 (PF)
........................................ 149
FLUVIRIN 2016-2017 ....... 149
FLUVIRIN 2016-2017 (PF)
........................................ 149
FLUVIRIN 2017-2018 ....... 149
FLUVIRIN 2017-2018 (PF)
........................................ 149
fluvoxamine .......................... 32
FLUZONE 2014-2015 ....... 149
FLUZONE 2014-2015 (PF) 149
FLUZONE 2015-2016 ....... 150
FLUZONE HIGH-DOSE
2014-15 (PF) .................. 150
FLUZONE HIGH-DOSE
2015-16 (PF) .................. 150
FLUZONE HIGH-DOSE
2016-17 (PF) .................. 150
FLUZONE HIGH-DOSE
2017-18 (PF) .................. 150
FLUZONE INTRADERM
2014-15 (PF) .................. 150
FLUZONE INTRADERM
QUAD 2015-16 .............. 150
FLUZONE INTRADERM
QUAD 2016-17 .............. 150
FLUZONE INTRADERM
QUAD 2017-18 .............. 150
FLUZONE QUAD 2014-2015
........................................ 150
FLUZONE QUAD 2014-2015
(PF) ................................. 150
FLUZONE QUAD 2015-2016
........................................ 150
FLUZONE QUAD 2015-2016
(PF) ................................. 150
FLUZONE QUAD 2016-2017
........................................ 150
FLUZONE QUAD 2016-2017
(PF) ................................. 150
FLUZONE QUAD 2017-2018
........................................ 150
FLUZONE QUAD 2017-2018
(PF) ................................. 150
FLUZONE QUAD PEDI
2014-15 (PF)................... 150
FLUZONE QUAD PEDI
2015-16 (PF)................... 150
FLUZONE QUAD PEDI
2016-17 (PF)................... 150
FLUZONE QUAD PEDI
2017-18 (PF)................... 150
FML S.O.P. ........................ 165
foaming acne face wash ....... 60
foaming antacid .................. 136
foaming antacid extra strength
........................................ 136
focalgin 90 dha ................... 216
focalgin ca .......................... 216
focalgin dss ......................... 216
folbecal ............................... 216
folbee .................................. 216
folbee plus .......................... 216
folbic rf ............................... 216
FOLEY CATHETER ......... 101
FOLEY CATHETER TRAY
........................................ 101
FOLGARD ......................... 216
folic acid ............................. 216
folic acid-vit b6-vit b12 ...... 216
folinatal plus b .................... 216
folitab .................................. 216
folivane-f ............................ 216
folivane-ob .......................... 217
folivane-plus ....................... 217
folivane-prx dha nf ............. 217
folplex 2.2 ........................... 217
foltabs 800 .......................... 217
foltanx ................................. 217
foltanx rf ............................. 217
fondaparinux ......................... 40
foot and sneaker .................... 66
foot moisturizer .................... 46
foot odor control ................... 66
foot powder ........................... 70
for sty relief ........................ 162
FORA D10 .......................... 101
FORA D15G ....................... 101
FORA D20 .......................... 102
FORA G20 .......................... 102
FORA G30A ....................... 102
FORA LANCING DEVICE
........................................ 102
FORA TEST STRIP ........... 102
FORA V10 .......................... 102
FORA V12 BLOOD
GLUCOSE SYSTEM ..... 102
FORA V12 GLUCOSE ...... 102
FORA V20 .......................... 102
FORA V30A ....................... 102
FORADIL AEROLIZER .... 186
forane .................................... 73
FOREHEAD
THERMOMETER .......... 102
formadon ............................... 73
formaldehyde ........................ 73
forma-ray .............................. 73
formula 3 .............................. 66
formula em .......................... 136
FORTAVIT ........................ 198
FORTAZ ................................. 7
FORTAZ IN DEXTROSE 5 %
............................................ 7
fortical ................................. 128
278 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
fosamprenavir ......................... 4
foscarnet ................................. 4
fosfree ................................. 217
fosinopril .............................. 37
fosinopril-hydrochlorothiazide
.......................................... 37
FOSRENOL ......................... 73
FRAGMIN ........................... 40
FREESTYLE PRECISION 102
fresh scent douche .............. 153
FRESHNET ........................ 102
frovatriptan ........................... 19
fruit c .................................. 217
fruit c-500 ........................... 217
fruity chews ........................ 217
full spectrum b-vitamin c ... 217
fungoid-d .............................. 66
furosemide ............................ 37
FUZEON ................................ 4
fyavolv ................................ 152
G g tussin ac ........................... 176
GA GEL ............................. 198
GA POWDER .................... 198
gabapentin ............................ 17
GABAPENTIN (BULK) ...... 17
GABITRIL ........................... 17
galantamine .......................... 20
GALZIN ............................. 192
ganciclovir sodium ................. 4
garamycin ........................... 160
garlic ..................................... 78
garlic oil................................ 78
garlic-parsley ........................ 73
garlic-x ................................. 78
gas free extra strength ........ 136
gas relief ............................. 136
gas relief extra strength ...... 136
gas relief ultra strength ....... 136
gastrace ............................... 198
gatifloxacin ......................... 160
GAUZE BANDAGE .......... 102
gauze roll ............................ 102
gavilax ................................ 136
gavilyte-c ............................ 136
gavilyte-g ............................ 136
gavilyte-h and bisacodyl ..... 136
gavilyte-n ............................ 136
GAVISCON ....................... 136
GAVISCON EXTRA
STRENGTH ................... 136
GE100 CONTROL
SOLUTION NORMAL .. 102
gelatin ................................... 73
GELPAD ............................ 102
gemcitabine .......................... 14
gemfibrozil ........................... 43
generlac .............................. 136
gengraf .................................. 14
genicin .................................. 26
GENOTROPIN .................. 147
GENOTROPIN MINIQUICK
........................................ 147
gentak ................................. 160
gentamicin ................ 9, 64, 160
gentamicin in nacl (iso-osm) .. 9
gentamicin sulfate (ped) (pf) .. 9
gentamicin sulfate (pf)............ 9
GENTEAL MILD TO
MODERATE .................. 162
GENTEAL GEL ................. 162
GENTEAL SEVERE ......... 162
gentian violet ........................ 66
gentle laxative..................... 136
gentle moisturizing lotion ..... 51
gentle skin cleanser .............. 51
GENTLECATH.................. 102
gentlelax ............................. 136
GENVOYA ............................ 4
GEODON ............................. 32
geravim ............................... 217
GERBER GOOD START
GENTLE ........................ 198
gerber good start glucose ...... 73
GERBER GOOD START
PREMATURE 24 ........... 198
GERBER GOOD START
SOY ................................ 198
gerber good start water ......... 73
GERBER GRADUATES
GENTLE ........................ 198
GERBER GRADUATES SOY
........................................ 198
GERBER GS GENTLE -
SUPPLEMENT .............. 198
geriaton ............................... 217
geri-dryl .............................. 176
geri-hydrolac ......................... 51
geri-kot ............................... 136
geri-lanta ............................. 136
geri-mox antacid-antigas .... 137
GERI-MUCIL ..................... 137
geri-pectate ......................... 130
geri-shampoo ........................ 51
geri-soft ................................. 51
GERITOL COMPLETE ..... 217
geri-tussin ........................... 176
geri-tussin dm ..................... 176
GESTICARE DHA ............ 217
gianvi (28) .......................... 156
gildagia ............................... 156
gildess 1.5/30 (21) .............. 156
gildess 1/20 (21) ................. 156
gildess 24 fe ........................ 156
gildess fe 1.5/30 (28) .......... 156
gildess fe 1/20 (28) ............. 156
ginger (zingiber officinalis) .. 78
ginkgo biloba ........................ 78
ginseng .................................. 78
glenmax peb dm ................. 176
glimepiride .......................... 102
glipizide .............................. 102
glipizide-metformin ............ 102
GLUCAGEN DIAGNOSTIC
KIT ................................. 102
GLUCAGEN HYPOKIT .... 102
GLUCAGON EMERGENCY
KIT (HUMAN) ............... 102
gluc-chon-msm3-mang-frankn-
bor ..................................... 26
GLUCERNA ...................... 198
GLUCERNA 1 CAL .......... 198
GLUCERNA HUNGER
SMART .......................... 198
gluco burst ............................ 73
GLUCOCARD 01 METER 102
279 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
GLUCOCARD 01 NORMAL
CONTROL ..................... 102
GLUCOCARD 01 SENSOR
PLUS .............................. 102
GLUCOCARD 01-MINI.... 102
GLUCOCARD EXPRESSION
........................................ 102
GLUCOCARD VITAL ...... 103
GLUCOCARD VITAL
SENSOR......................... 103
GLUCOCARD VITAL TEST
STRIPS ........................... 103
GLUCOCOM BLOOD
GLUCOSE ..................... 103
GLUCOCOM CONTROL
NORMAL....................... 103
GLUCOCOM GLUCOSE.. 103
GLUCOCOM LANCETS .. 103
GLUCOLET 2 AUTOMATIC
LANCING ...................... 103
glucos chond cplx advanced . 26
glucosam su dip-chondroit-c-
mn ..................................... 26
glucosam-chondr-vit c-mn-
boron................................. 26
glucosam-chon-msm1-c-mang-
bosw ................................. 26
glucosamine hcl .................... 73
glucosamine relief ................ 26
glucosamine su 2kcl-chondroit
.......................................... 26
glucosamine sulfate .............. 26
glucosamine sulfate 2kcl ...... 26
glucosamine sulf-chondroitinsa
.......................................... 73
glucosamine-chondr
(boswellia) ........................ 26
glucosamine-chondroitin 26, 74
glucosamine-chondroitin 3x . 26
glucosamine-chondroitin
complx ................ 26, 74, 217
glucosamine-chondroitin ds . 26
glucosamine-d3-boswellia serr
.......................................... 26
glucose .................................. 74
glucose bits ........................... 74
GLUCOSE CONTROL ...... 103
glucose gel ............................ 74
GLUCOSOURCE .............. 103
GLUCOTEN ........................ 26
GLUTAREX-1 ................... 198
GLUTAREX-2 ................... 198
glyburide ............................. 103
glyburide micronized .......... 103
glyburide-metformin .......... 103
glycerin ................................. 51
glycerin (adult) ................... 137
glycerin (bulk) ...................... 51
glycerin (child) ................... 137
GLYCEROL FORMAL
(BULK) ............................ 74
glycine urologic .................. 188
glycine urologic solution .... 188
glycolax .............................. 137
glycopyrrolate ..................... 130
GLYCOSADE .................... 198
glydo ..................................... 62
glytrol ................................. 198
GM100................................ 103
GMATE LANCETS ........... 103
goldenseal root ..................... 78
GOLYTELY ....................... 137
gonak .................................. 162
goniosoft ............................. 162
goniotaire ............................ 162
goniovisc ............................ 162
good start ............................ 198
GOOD START ................... 198
GOOD START 2 SUPREME
........................................ 198
GOOD START SUPREME 198
good start supreme dha and ara
........................................ 198
GOOD START SUPREME
DHA AND ARA ............ 198
GOOD START SUPREME
NAT CULTURE ............ 198
GOODNITES UNDERPANTS
L-XL ............................... 103
gordon's vite a ....................... 51
gordo-vite e........................... 51
gormel ................................... 51
gormel ten ............................. 51
g-p-tuss dxp ........................ 176
granisetron (pf) ................... 137
granisetron hcl .................... 137
granisol ............................... 137
grape seed ............................. 78
grape seed extract ................. 78
GRASTEK .......................... 150
green glo ............................. 162
green soap ............................. 51
griseofulvin microsize ............ 3
griseofulvin ultramicrosize ..... 3
grx dyne ................................ 64
grx hicort 25 ....................... 137
grx rinse-free ........................ 51
GRX WOUND GEL ........... 103
g-tron .................................. 176
g-tron ped ............................ 176
guaiasorb dm ...................... 176
guaiatussin ac ...................... 176
guaifenesin .......................... 176
guaifenesin ac ..................... 176
guaifenesin dac ................... 176
guanfacine ....................... 32, 37
guanidine .............................. 32
guar gum ............................... 74
GUARD MALE .................. 103
GUARDIAN RT TEST PLUG
DEVICE ......................... 103
GUARDS FOR MEN ......... 103
gummi bear multivitamin ... 217
gummy dinos ...................... 217
gynol ii ................................ 153
G-ZYNCOF ........................ 176
H h2q ........................................ 71
hair regrowth for women ...... 51
hair regrowth treatment ........ 51
hair vitamins ....................... 217
hair, skin and nails advanced
........................................ 217
hair,skin and nails ............... 217
halls defense ....................... 217
halobetasol propionate .......... 68
HALOG ................................ 68
haloperidol ............................ 33
280 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
haloperidol decanoate ........... 33
haloperidol lactate ................ 33
hand wash ............................. 51
HANDICARE GARMENT
LINER ............................ 103
HARMONIE UNDERPAD 103
hawthorn berry ..................... 78
h-chlor 12 ............................. 74
HCU COOLER .................. 198
hcu express powder ............ 199
HCU GEL POWDER ......... 199
HCY 1 POWDER............... 199
HCY 2 ................................ 199
headache formula added str .. 26
headache pm ......................... 26
headache relief (asa-acet-caf)
.......................................... 26
headache relief pm ............... 26
HEALTHMIST .................. 103
HEALTHY ACCENTS
AUTOLET ..................... 103
HEALTHY ACCENTS
UNIFINE PENTIP ......... 103
HEALTHY ACCENTS
UNILET LANCET ......... 103
healthy eyes ........................ 217
healthy eyes supervision..... 217
healthylax ........................... 137
HEARING AID BATTERIES
........................................ 103
heartburn antacid ................ 137
heartburn prevention .......... 145
heartburn relief ................... 137
heartburn relief (cimetidine)
........................................ 145
heartburn relief (famotidine)
........................................ 145
heartburn relief (ranitidine) 145
heartburn relief 24 hour ...... 145
heartburn treatment 24 hour145
heather ................................ 152
HEATING PADS ............... 103
heatwraps back and hip pads
........................................ 103
HEAVY DUTY FABRIC
STRIPS ........................... 103
hecoria .................................. 14
HECTOROL ....................... 128
HELIXATE FS ..................... 40
HEMABATE ...................... 159
HEMA-COMBISTIX ......... 103
hematinic plus vit/minerals 217
hematinic/folic acid ............ 217
hematogen .......................... 217
hematogen fa ...................... 217
hematogen forte .................. 217
hemenatal ob....................... 217
hemenatal ob + dha ............ 217
hemetab .............................. 217
hemmorex-hc ...................... 137
HEMOFIL M HIGH ............. 40
HEMOFIL M LOW.............. 40
HEMOFIL M MID ............... 41
HEMOFIL M SUPER HIGH41
hemorrhoid preparation ...... 137
hemorrhoidal ................ 74, 137
hemorrhoidal (phenyleph-
cocoa) ............................. 137
hemorrhoidal cooling ......... 137
hemorrhoidal cream ............ 137
hemorrhoidal h ................... 137
hemorrhoidal hygiene ........... 51
hemorrhoidal medicated ....... 51
hemorrhoidal suppository ... 137
hemril-30 ............................ 137
hep flush-10 (pf) ................... 41
heparin (porcine) .................. 41
heparin (porcine) in 5 % dex 41
heparin (porcine) in nacl (pf) 41
heparin lock flush ................. 41
heparin lock flush (porcine) . 41
heparin lockflush(porcine)(pf)
.......................................... 41
heparin(porcine) in 0.45% nacl
.......................................... 41
heparin, porcine (pf) ............. 41
HEXALEN ........................... 14
HEX-ON LIGHT ODOR ... 104
hibiclens................................ 51
HI-CAL .............................. 199
hi-cal plus vit d ................... 192
high potency calcium.......... 192
high potency capsaicin ......... 51
high potency iron ................ 218
high protein ......................... 199
high-protein nutritional shake
........................................ 199
HOLLIHESIVE SKIN
BARRIER ....................... 104
HOLLISTER
REPLACEMENT FILTERS
........................................ 104
HOM 2 ................................ 199
homatropaire ....................... 161
homatropine hbr .................. 161
HOMINEX-1 ...................... 199
HOMINEX-2 ...................... 199
honey bears ......................... 218
honey bears with iron-zinc . 218
honey lemon ....................... 176
hot and cold pack ................ 104
hot steam liquid .................. 176
hpr ......................................... 51
hpr plus ................................. 51
hpr plus hydrogel .................. 51
huber safety needles (disp.) 104
HUGGIES PULL-UPS 2T-3T
........................................ 104
HUGO ROLLING WALKER
........................................ 104
HUMALOG ........................ 104
HUMALOG JUNIOR
KWIKPEN ...................... 104
HUMALOG KWIKPEN .... 104
HUMALOG MIX 50-50 ..... 104
HUMALOG MIX 50-50
KWIKPEN ...................... 104
HUMALOG MIX 75-25 ..... 104
HUMALOG MIX 75-25
KWIKPEN ...................... 104
HUMAPEN LUXURA HD 104
HUMATE-P ......................... 41
HUMIDIFIERS .................. 104
HUMIRA ............................ 151
HUMIRA PEDIATRIC
CROHN'S START.......... 151
HUMIRA PEN ................... 151
HUMULIN 70/30 ............... 104
281 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
HUMULIN N ..................... 104
HUMULIN R U-100 .......... 104
HUMULIN R U-500
(CONCENTRATED) ..... 104
HURRICAINE LUER-LOCK
DIS CAP ......................... 104
HYCAMTIN ........................ 14
hydralazine ........................... 37
hydrating healing .................. 51
hydrisalic .............................. 46
hydrocerin............................. 52
hydrocerin (with petrolatum) 52
hydrochloric acid (bulk) ..... 137
hydrochlorothiazide .............. 37
hydrocodone-acetaminophen 21
hydrocodone-chlorpheniramine
........................................ 176
hydrocodone-cpm-
pseudoephed ................... 176
hydrocodone-homatropine . 176
hydrocodone-ibuprofen ........ 21
HYDROCOL II .................. 104
HYDROCOLLOID
DRESSING .................... 104
hydrocortisone ........ 69, 85, 137
hydrocortisone acet-aloe vera
.......................................... 68
hydrocortisone acetate .. 68, 137
HYDROCORTISONE
ACETATE (BULK) ......... 68
hydrocortisone butyrate ........ 68
hydrocortisone butyr-emollient
.......................................... 68
hydrocortisone plus .............. 68
hydrocortisone valerate ........ 69
hydrocortisone-acetic acid.... 84
hydrocortisone-aloe vera ...... 69
hydrocortisone-iodoquinl-aloe2
.......................................... 64
hydrocortisone-iodoquinol-aloe
.......................................... 64
hydrocortisone-min oil-wht pet
.......................................... 69
hydrocortisone-pramox-e-
pram#1 ............................ 137
hydrocortisone-pramoxine ... 45,
137
hydrocream ........................... 69
hydrogen peroxide .......... 52, 74
hydrolatum............................ 52
hydromet ............................. 176
hydromorphone .................... 21
hydrophilic............................ 77
hydroskin .............................. 69
hydroskin with aloe .............. 69
hydroxocobalamin .............. 218
hydroxychloroquine................ 9
HYDROXYPROGESTERON
E CAPR(BULK)............. 152
hydroxyurea .......................... 14
hydroxyzine hcl .................. 176
hydroxyzine pamoate ......... 176
hyfiber with fos .................. 137
hygienic (witch hazel) cleans52
hygienic cleansing ................ 52
hyolev mb ........................... 188
hyophen .............................. 188
hyoscyamine sulfate ........... 130
hyosyne ............................... 130
hypercare .............................. 52
HYPER-HEAL ..................... 52
HYPO-ALLERGENIC
BANDAGES .................. 104
HYPOLANCE AST
LANCING ...................... 104
hysept.................................... 74
I ibandronate ......................... 151
IBRANCE ............................ 14
ibu-drops ............................... 26
ibuprofen .............................. 27
IBUPROFEN (BULK) ......... 27
ibuprofen cold..................... 176
ibuprofen cold-sinus(with pse)
........................................ 176
ibuprofen ib .......................... 27
ibuprofen jr strength ............. 27
ibuprofen pm ........................ 27
ibuprofen-diphenhydramine hcl
.......................................... 27
ibuprofen-oxycodone............ 21
I-CAPS ............................... 218
icaps areds .......................... 218
ICAPS MV ......................... 218
ice blue gel ............................ 52
ice gel .................................... 52
ichthammol ........................... 74
icy hot (menthol) .................. 52
IDELVION ........................... 41
iferex 150 ............................ 218
ifosfamide ............................. 14
ILE-SORB ORIGINAL ...... 104
imatinib ................................. 14
IMBRUVICA ....................... 14
imipenem-cilastatin ................ 9
imipramine hcl ...................... 33
imipramine pamoate ............. 33
imiquimod ............................. 52
immulife ............................. 199
IMPACT 1 CAL ................. 199
impact advanced recovery .. 199
IMPACT GLUTAMINE .... 199
IMPACT PEPTIDE 1.5 CAL
........................................ 199
IMPACT/FIBER ................. 199
IMUPLUS ........................... 199
inatal advance ..................... 218
inatal ultra ........................... 218
INCARE INVIEW
CATHETER ................... 104
IN-CHECK NASAL WITH
MASK ............................. 104
IN-CHECK ORAL FLOW
METER ........................... 104
INCONTROL BP MONITOR
........................................ 104
INCONTROL LANCING
DEVICE ......................... 104
INCONTROL PEN NEEDLE
........................................ 105
INCONTROL SUPER THIN
LANCETS ...................... 105
INCONTROL ULTRA THIN
LANCETS ...................... 105
INCRELEX .......................... 74
INCRUSE ELLIPTA .......... 186
indapamide ........................... 37
282 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
indigo carmine ...................... 74
indomethacin ........................ 27
infanate plus ....................... 218
infant fever reducer-pain relf 27
infant formula with iron ..... 199
infant's acetaminophen ......... 27
infant's advil ......................... 27
infants gas relief ................. 137
infant's ibuprofen .................. 27
infant's medi-profen ............. 27
infant's motrin ....................... 27
infants' pain and fever .......... 27
infants' pain relief ................. 27
infant's pain relief ................. 27
infant's pain reliever ............. 27
infants profenib .................... 27
infed .................................... 218
INFINITY CONTROL
SOLUTION NORM ....... 105
INFINITY STARTER KIT 105
INFINITY TEST STRIPS .. 105
INJECT EASE LANCETS 105
INJECT-EASE ................... 105
INJECT-EASE AUTOMATIC
INJECTOR ..................... 105
INLYTA ............................... 14
innermost nature for men ..... 78
INNOSPIRE ELEGANCE . 105
inositol ................................ 199
INS SYRINGE/NEEDLE 0.5
ML 27 G ......................... 105
INSECT REPELLENT
(PICARIDIN) ................... 52
INSPIRATION ELITE ....... 105
INSPIRATION NEBULIZER
SYSTEM ........................ 105
insta-char ............................ 138
insta-char-sorbitol............... 138
insta-glucose ......................... 74
INSTANT EAR
THERMOMETER ......... 105
INSUFLON ........................ 105
INSULIN PUMP IR1250 ... 105
insulin syringe-needle u-100
........................................ 105
INSULIN SYRINGE-
NEEDLE U-100 ............. 105
INSULIN SYRINGES
(DISPOSABLE) ............. 105
INSUPEN ........................... 105
INTEGRA SYRINGE ........ 105
INTELENCE .......................... 4
intense cough reliever ......... 177
intense toothache pain relief . 62
INTRON A ......................... 147
introvale .............................. 156
INVACARE LANCETS .... 105
INVANZ ................................. 9
INVEGA SUSTENNA ......... 33
INVEGA TRINZA ............... 33
INVIRASE ............................. 4
invisible acne ........................ 60
inzo antifungal ...................... 66
iodine .................................... 52
iodine strong ......................... 64
iodine-sodium iodide ............ 52
iodoquinol-hc........................ 64
ionil t..................................... 45
iophen c-nr .......................... 177
iophen dm-nr ...................... 177
iophen-nr ............................ 177
ipecac .................................. 138
ipratropium bromide ..... 81, 186
ipratropium-albuterol.......... 186
irbesartan .............................. 37
irbesartan-hydrochlorothiazide
.......................................... 37
IRESSA ................................ 14
irinotecan .............................. 14
iron...................................... 218
iron (dried) .......................... 218
iron 100 plus ....................... 218
iron aspgly-c-b12-ca-suc-stoma
........................................ 218
iron chews........................... 218
iron fum,ag-c-b12-fa-ca-succ
........................................ 218
iron high potency ................ 218
iron, carbonyl...................... 218
iron,carbonyl-vitamin c ...... 218
IRRIGATION SLEEVE ..... 105
ISENTRESS ........................... 4
ISENTRESS HD .................... 4
isibloom .............................. 156
isoflurane .............................. 74
isometh-dichloral-
acetaminophn .................... 19
isomethepten-caf-
acetaminophen .................. 19
ISOMIL ADVANCE .......... 199
ISOMIL DF ........................ 199
ISOMIL/IRON ................... 199
isoniazid .................................. 9
isopropyl alcohol ............ 74, 77
isopropyl alcohol-benzocaine
.......................................... 52
isopropyl alcohol-wintergreen
.......................................... 52
isopropyl palmitate ............... 74
isopropyl palmitate (bulk) .... 74
ISOPTO HYOSCINE ......... 161
ISOPTO TEARS ................ 162
ISORDIL .............................. 44
isosorbide dinitrate ............... 44
isosorbide mononitrate ......... 44
ISOSOURCE 1.5 CAL ....... 199
isosource hn ........................ 199
isoxsuprine .......................... 154
isradipine .............................. 37
ISTALOL ........................... 160
itch relief ............................... 52
itch relief (clotrimazole) ....... 66
itch relief (diphenhydramine)
.......................................... 52
itch relief (pramoxine-zinc) .. 52
itchy eye drops .................... 162
itraconazole ............................. 3
I-VALEX-1 ......................... 199
I-VALEX-2 ......................... 199
ivermectin ............................... 9
i-vite .................................... 218
i-vite protect ........................ 218
IXINITY ............................... 41
J J AND J NON-STICK PADS
MEDIUM ....................... 105
JAKAFI ................................ 14
283 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
jantoven ................................ 41
JANUMET ......................... 105
JANUMET XR ................... 105
JANUVIA........................... 105
JAZZ WIRELESS 2 METER
KIT ................................. 105
jencycla............................... 152
jevantique lo ....................... 152
JEVITY 1 CAL .................. 199
JEVITY 1.2 CAL ............... 199
JEVITY 1.5 CAL ............... 199
jinteli................................... 152
jock itch ................................ 66
jock itch (clotrimazole) ........ 66
jock itch (terbinafine) ........... 66
johnson's baby oil ................. 52
jolessa ................................. 156
jolivette ............................... 152
jr str non-aspirin quick melts 27
jr. acetaminophen ................. 27
jr. str non-aspirin pain .......... 27
jr. strength pain reliever ....... 27
juleber ................................. 156
junel 1.5/30 (21) ................. 156
junel 1/20 (21) .................... 156
junel fe 1.5/30 (28) ............. 156
junel fe 1/20 (28) ................ 156
junel fe 24 ........................... 156
junior mapap ......................... 27
JUVEN ............................... 199
JUXTAPID ........................... 43
K kaitlib fe.............................. 156
KALETRA ............................. 4
KALTOSTAT ROPE ......... 105
KANGAROO ENTERAL-
FEED-IRRIG KT ........... 105
KANGAROO RIGID
CONTAINER PUMP ..... 106
kaolin-pectin ....................... 130
kaopectate (bismuth subsalicy)
........................................ 130
kaopectate ex str (bismuth ss)
........................................ 130
kao-tin (bismuth subsalicylat)
........................................ 130
kao-tin (docusate calcium) . 138
KARAYA 5 CLOSED
POUCH - TAPE ............. 106
KARAYA 5 DRAINABLE
POUCH .......................... 106
KARAYA GUM (BULK) .. 138
KARAYA PASTE .............. 106
KARAYA POWDER ......... 106
kariva (28) .......................... 156
kava kava .............................. 78
k-effervescent ..................... 192
kelnor 1/35 (28) .................. 156
kelp ....................................... 78
KENALOG ........................... 85
KENDALL ......................... 106
KENDALL PAPER TAPE . 106
KENGUARD URINARY
DRAIN BAG .................. 106
KENLINE ADD-A-FOLEY
TRAY 30CC ................... 106
KERLIX ............................. 106
kerodex-71 wet ..................... 52
KETEK ................................... 9
KETOCAL 3
1 199
KETOCAL 4
1 (MILK-SOY) ............... 199
ketoconazole ..................... 3, 66
ketodan ................................. 66
ketodan kit ............................ 66
KETO-DIASTIX ................ 106
KETONE URINE TEST .... 106
KETONEX-1 ...................... 200
KETONEX-2 ...................... 200
ketoprofen ............................. 27
KETOPROFEN (BULK) ..... 27
KETOPROFEN,
MICRONIZED (BULK) .. 27
ketorolac ................. 27, 28, 164
KETOSTIX ........................ 106
ketotifen fumarate............... 162
KETOVOLVE .................... 200
KID PANTS FOR GIRLS .. 106
kidkare cough/cold ............. 177
kid's vitamins ...................... 218
kid's vitamins + extra c ....... 218
kids vitamins + iron ............ 218
kid's vitamins + iron ........... 218
kids vitamins complete ....... 218
kimidess (28) ...................... 156
KIMONO CONDOMS(NON-
LUBRICATED) ............. 106
KIMONO MAXX CONDOMS
........................................ 106
KIMONO MICROTHIN
AQUA LUBE CON ........ 106
KIMONO MICROTHIN
CONDOMS .................... 106
KIMONO TEXTURED
CONDOMS .................... 106
KINNEY BRAND LANCETS
........................................ 106
kionex ................................... 74
kionex (with sorbitol) ........... 74
KISQALI .............................. 14
KISQALI FEMARA CO-
PACK ............................... 14
klofensaid ii .......................... 28
klor-con ............................... 192
klor-con 10 .......................... 192
klor-con 8 ............................ 192
klor-con m10 ...................... 192
klor-con m15 ...................... 192
klor-con m20 ...................... 192
klor-con sprinkle ................. 192
klor-con/ef .......................... 192
KOATE ................................. 41
KOATE-DVI ........................ 41
kobee ................................... 218
KOGENATE FS ................... 41
kola-pectin ds ...................... 130
konsyl (sugar) ..................... 138
konsyl fiber ......................... 138
konsyl formula-d ................ 138
konsyl sugar-free ................ 138
konsyl sugar-free (aspartame)
........................................ 138
KOVALTRY ........................ 41
k-pec antidiarrheal (bism sub)
........................................ 130
K-PHOS NO 2 .................... 188
K-PHOS ORIGINAL ......... 188
284 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
k-phos-neutral..................... 192
kpn ...................................... 218
KPN .................................... 218
KRISTALOSE ................... 138
k-sol .................................... 192
k-tab .................................... 192
K-TAB ................................ 192
kurvelo ................................ 156
KUVAN ............................. 128
k-y lubricating ...................... 52
KYNAMRO ......................... 43
L l norgest/e.estradiol-e.estrad
........................................ 156
l.acidophilus-bifido.longum 130
labetalol ................................ 37
LABSTIX REAGENT ....... 106
lac-dose............................... 138
LACRISERT ...................... 162
lactase ................................. 138
lactase fast acting ............... 138
lactated ringers ............. 71, 192
lactic acid.............................. 52
lactic acid (bulk) ................... 52
lactic acid e ........................... 52
lactobac acidoph-fructooligos
........................................ 130
lactobacillus acidophilus .... 200
lactulose .............................. 138
LAMICTAL STARTER
(BLUE) KIT ..................... 17
LAMICTAL STARTER
(GREEN) KIT .................. 17
LAMICTAL STARTER
(ORANGE) KIT ............... 17
LAMISIL ................................ 3
lamisil af ............................... 66
lamisil at ............................... 66
lamivudine .............................. 5
lamivudine-zidovudine ........... 5
lamotrigine ........................... 17
LANAFLEX ....................... 200
LANCETS .......................... 106
LANCETS,THIN ............... 106
LANCING DEVICE .......... 106
LANCING SYSTEM ......... 106
lanolin ................................... 52
lanolin anhydrous ................. 52
lan-o-soothe .......................... 52
LANOXIN PEDIATRIC ...... 40
lansoprazole ........................ 145
LANSOPRAZOLE (BULK)
........................................ 145
lanthanum ............................. 74
LANTUS ............................ 106
LANTUS SOLOSTAR....... 106
larin 1.5/30 (21) .................. 156
larin 1/20 (21) ..................... 156
larin 24 fe............................ 156
larin fe 1.5/30 (28) .............. 156
larin fe 1/20 (28) ................. 157
larissia ................................. 157
latanoprost .......................... 164
latex gloves ......................... 106
latrix...................................... 52
latrix xm ............................... 46
LATUDA.............................. 33
lavender oil ........................... 78
laxacin ................................ 138
laxaclear.............................. 138
laxative (bisacodyl) ............ 138
laxative (glycerin-pediatric)138
laxative (sennosides) .......... 138
laxative dietary supplement 192
laxative feminine ................ 138
laxative maximum strength 138
laxative peg 3350................ 138
laxative pills ....................... 138
laxative pills regular ........... 138
laxative plus stool softener . 138
laxative-senna ..................... 138
layolis fe ............................. 157
LC D NEBULIZER SET .... 106
LC PLUS ............................ 106
lc-4 ........................................ 62
lc-5 ........................................ 62
l-carnitine.............................. 74
l-carnitine (tartrate)............. 200
lecithin ................................ 200
lecithin (bulk) ..................... 200
lecithin, soy ........................ 200
lecithin-kelp-b6 .................. 219
lecithin-kelp-b6 (100-8.3) ... 219
leena 28 ............................... 157
leflunomide ......................... 151
LENVIMA ............................ 14
lessina ................................. 157
LETAIRIS .......................... 186
letrozole ................................ 14
leucovorin calcium ............... 13
LEUCOVORIN CALCIUM
(BULK) ............................. 13
LEU-FREE COOLER ........ 200
LEUKERAN ......................... 14
LEUKINE ........................... 147
leuprolide .............................. 15
levalbuterol hcl ................... 186
LEVEMIR .......................... 106
LEVEMIR FLEXPEN ........ 106
LEVEMIR FLEXTOUCH .. 106
levetiracetam ......................... 17
levobunolol ......................... 160
levocarnitine ......................... 74
levocarnitine (with sugar) ..... 74
levocetirizine ...................... 177
levofloxacin .................. 11, 160
LEVOFLOXACIN (BULK) . 11
levofloxacin in d5w .............. 11
levomefolate dha ................ 219
levomefolate-algal oil ......... 219
levomefol-b6-meb12-algal oil
........................................ 219
levonest (28) ....................... 157
levonorgestrel ..................... 157
levonorgestrel-ethinyl estrad
........................................ 157
levonorg-eth estrad triphasic
........................................ 157
levora-28 ............................. 157
levorphanol tartrate ............... 21
levothyroxine ...................... 129
LEVOTHYROXINE .......... 129
levoxyl ................................ 129
LEXIVA ................................. 5
l-glutamine ............................ 74
LIBERTY BLOOD
GLUCOSE MONITOR .. 107
285 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
LIBERTY LEV 1 GLUCOSE
CONTROL ..................... 107
LIBERTY LEV 2 GLUCOSE
CONTROL ..................... 107
LIBERTY TEST ................ 107
lice bedding spray................. 70
lice complete kit 1-2-3.......... 70
lice cream rinse..................... 70
lice killing ............................. 70
lice killing (permethrin) ....... 70
lice pyrinyl shampoo ............ 70
lice solution .......................... 70
lice treatment ........................ 70
lice treatment (resmethrin) ... 70
lidocaine ............................... 62
LIDOCAINE (BULK).......... 62
lidocaine (pf) .................. 35, 62
lidocaine hcl ......................... 62
LIDOCAINE HCL (BULK) 62
lidocaine hcl-hydrocortison ac
.................................. 62, 138
lidocaine viscous .................. 62
lidocaine-aloe vera ............... 62
lidocaine-hydrocortisone-aloe
........................................ 138
lidocaine-prilocaine .............. 62
lido-k .................................... 62
lidopin................................... 62
lidopril .................................. 62
lillow................................... 157
lindane .................................. 70
linezolid .................................. 9
linezolid-0.9% sodium chloride
............................................ 9
LINZESS ............................ 139
LIORESAL........................... 20
liothyronine ........................ 129
lipistart ................................ 200
LIPOCHOL .......................... 74
lipodox .................................. 15
lipoflavovit ......................... 200
LIPOGEN ........................... 200
liquacel ............................... 200
liquibid d-r .......................... 177
liquid antacid ...................... 139
LIQUID B 12 ..................... 219
liquid corn and callus remover
.......................................... 46
liquid nutrition .................... 200
liquid nutrition plus ............ 200
liquitears ............................. 162
LISCO ................................ 107
lisinopril................................ 37
lisinopril-hydrochlorothiazide
.......................................... 38
lite coat aspirin ..................... 28
LITE TOUCH LANCING
DEVICE ......................... 107
LITEAIRE MDI CHAMBER
........................................ 107
LITETOUCH-SMALL MASK
........................................ 107
lithium carbonate .................. 33
lithium citrate ....................... 33
LITHOSTAT ........................ 74
little animals ....................... 219
little animals-iron ............... 219
LITTLE ONES CLOSED-
END POUCH ................. 107
LITTLE ONES DRAINABLE
POUCH .......................... 107
LITTLE ONES FLEXIBLE
SKIN ............................... 107
LITTLE ONES SKIN
BARRIER ....................... 107
LITTLE ONES UROSTOMY
POUCH .......................... 107
little remedies ....................... 81
little remedies fever and pain 28
l-lysine ................................ 200
LMD POWDER ................. 200
lmefol ca-acetyl-meb12-algal
........................................ 200
l-methyl-b6-b12 .................. 219
l-methylfolate ..................... 219
l-methylfolate ca p-5-p me-cbl
........................................ 219
l-methylfolate forte ............. 219
l-methyl-mc ........................ 219
l-methyl-mc nac .................. 200
lmthf-pyridoxine-
cyanocobalamn ............... 219
LO LOESTRIN FE ............. 157
lohist - d .............................. 177
lohist peb dm ...................... 177
lohist-dm ............................. 177
lohist-peb ............................ 177
lomedia 24 fe ...................... 157
LOOP OSTOMY BRIDGE
STERILE ........................ 107
loperamide .......................... 131
LOPHLEX .......................... 200
lopinavir-ritonavir ................... 5
lopreeza ............................... 152
LO-PROFILE UROSTOMY
POUCH ........................... 107
lorata-d ................................ 177
loratadine ............................ 177
loratadine-d ......................... 177
lorazepam ............................. 33
lorazepam intensol ................ 33
lorcet (hydrocodone) ............ 21
lorcet hd ................................ 22
lorcet plus ............................. 22
lorenza patch ......................... 62
lortab 10-325 ........................ 22
lortab 5-325 .......................... 22
lortab 7.5-325 ....................... 22
lortuss ex ............................. 177
loryna (28) .......................... 157
losartan ................................. 38
losartan-hydrochlorothiazide 38
LOTEMAX ......................... 165
lotrimin af powder ................ 66
lotrimin ultra ......................... 66
lovastatin ............................... 43
low-ogestrel (28) ................ 157
loxapine succinate ................ 33
lta pre-attached ..................... 62
lubricant eye ....................... 163
lubricant eye (pg-peg 400) .. 162
lubricant eye (polyv alcohol)
........................................ 162
lubricant eye drops ............. 162
LUBRICANT EYE DROPS
........................................ 163
lubricant eye drops (glyc-pg)
........................................ 162
286 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
lubricant redness reliever ... 166
lubricants .............................. 52
lubricating............................. 52
lubricating jelly (chlorhexid) 52
lubricating lotion .................. 53
lubricating plus ................... 163
lubriderm daily moisture (pet)
.......................................... 53
lubriderm skin nourishing .... 53
lubrifresh pm ...................... 163
lubrisilk................................. 53
lubriskin (with lanolin) ......... 53
lubrisoft ................................ 53
ludent fluoride .................... 219
LUFYLLIN ........................ 186
lugols ............................ 64, 192
lumitene .............................. 219
LUPRON DEPOT ................ 15
LUPRON DEPOT (3
MONTH) .......................... 15
LUPRON DEPOT (4
MONTH) .......................... 15
LUPRON DEPOT (6
MONTH) .......................... 15
LUPRON DEPOT-PED ....... 15
LUPRON DEPOT-PED (3
MONTH) .......................... 15
lutein ................................... 219
lutera (28) ........................... 157
LUVS SIZE 6 ..................... 107
luxamend .............................. 53
LYNPARZA......................... 15
LYRICA ............................... 18
lysine .................................. 200
lysine hcl ............................ 200
lysiplex plus........................ 219
LYSIPLEX PLUS .............. 219
LYSODREN......................... 15
lyza ..................................... 152
M M9 CLEANER-
DECRYSTALLIZER ..... 107
M9 ODOR ELIMINATOR .. 70
MAALOX ADVANCED ... 139
maalox maximum strength . 139
mac ....................................... 53
macnatal cn dha .................. 219
macuvite ............................. 219
macuvite eye care ............... 219
mafenide acetate ................... 64
mag 64 ................................ 192
mag-delay ........................... 192
MAGELLAN INSULIN
SAFETY SYRNG .......... 107
MAGELLAN SYRINGE ... 107
mag-g .................................. 192
MAGNEBIND 300............. 192
magnesium.................. 139, 192
MAGNESIUM AMINO ACID
CHELATE ...................... 192
magnesium citrate............... 139
magnesium gluconate ......... 192
magnesium oxide ........ 192, 193
magnesium stearate .............. 79
magnesium sulfate .............. 193
major-prep (phenylephrine-fat)
........................................ 139
malathion .............................. 70
mannitol 20 % ...................... 38
mapap (acetaminophen) ....... 28
mapap arthritis pain .............. 28
mapap cold formula ............ 177
mapap extra strength ............ 28
mapap pm ............................. 28
mapap sinus max strength (pe)
........................................ 177
mapo bath ............................. 53
maprotiline............................ 33
margesic................................ 22
marlissa ............................... 157
MARNATAL-F .................. 219
MARPLAN .......................... 33
marten-tab ............................. 22
masanti double strength ...... 139
MASK VORTEX BABY
WHIRL DUCK............... 107
masophen .............................. 28
MASTISOL ADHESIVE ... 107
MATULANE........................ 15
matzim la .............................. 38
MAVYRET ............................ 5
maxepa.................................. 43
MAXICARE BELTED
UNDERGARMENT ....... 107
MAXICARE UNDERPADS
........................................ 107
MAXI-COMFORT INSULIN
SYRINGE ....................... 107
MAXIDEX ......................... 165
maxilube ............................... 53
MAXIMA CONTROL
SOLUTION, NORMA ... 107
maximum daily multivitamin
........................................ 219
maximum energy .................. 78
maximum redness relief ..... 166
maximum strength flu ......... 177
MAXINATE ....................... 219
maxiphen ............................ 177
mb hydrogel .......................... 53
mb hydrogel (cyclomethicone)
.......................................... 53
m-clear wc .......................... 177
mct procal ........................... 200
mct pro-cal .......................... 200
md-76 r ................................. 74
meclizine ............................. 139
meclofenamate ...................... 28
medi pads .............................. 53
medi-bismuth ...................... 131
MEDICAL ADHESIVE ..... 107
medicated body ..................... 53
medicated body powder ........ 53
medicated chest rub .............. 53
medicated corn removers ...... 46
medicated douche ............... 154
medicated pads ..................... 53
medicated wipes ................... 53
medicated wipes with aloe .... 53
MEDICINE DROPPER ...... 107
MEDICINE DROPPER AND
SPOON ........................... 107
MEDICINE SPOON .......... 107
medi-cortisone ...................... 69
medifin expectorant mucus rlf
........................................ 177
medigrip elasticated support
........................................ 107
287 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
medikoff drops ................... 177
MEDI-LANCE LANCETS 107
medi-lax .............................. 139
medi-laxx ............................ 139
medi-meclizine ................... 139
medi-mucil ......................... 139
medi-natural ....................... 139
medi-natural senna-stool .... 139
medi-phedrine..................... 177
medi-phedryl ...................... 177
mediplast corn-callus-wart ... 46
MEDIPORE ....................... 108
MEDIPORE H.................... 108
medi-profen .......................... 28
medi-seltzer .......................... 28
MEDISENSE ..................... 108
MEDISENSE GLUCOSE
KETONE ........................ 108
MEDISENSE THIN
LANCETS ...................... 108
medi-sleep ............................ 33
medi-tabs .............................. 28
medi-tabs pm ........................ 28
medi-tussin ......................... 177
medi-tussin dm ................... 177
medi-tussin dm diabetic ..... 177
MEDLANCE PLUS
LANCETS ...................... 108
MEDLANCE PLUS SPECIAL
BLADE........................... 108
MEDROL ............................. 85
medroxyprogesterone ......... 152
MEDTRONIC REMOTE
CONTROL ..................... 108
mefenamic acid .................... 28
mefloquine .............................. 9
mega multi for women ....... 219
mega multiple/chelated mineral
........................................ 219
mega multivitamin for men 219
mega multivitamin with
mineral ............................ 219
megestrol .............................. 15
meladox ................................ 74
melatin .................................. 75
melatonin .............................. 75
melatonin-chamomile flower 78
melatonin-pyridoxine hcl (b6)
.......................................... 78
melodetta 24 fe ................... 157
meloxicam ............................ 28
melphalan ............................. 15
melphalan hcl ....................... 15
memantine ............................ 20
m-end dm ............................ 177
MENEST ............................ 152
MENOSTAR ...................... 152
men-phor .............................. 53
mens 50+ daily
formula(gingko).............. 219
men's daily formula ............ 219
men's daily multivit-mineral
........................................ 219
men's multi-vitamin ............ 220
men's one daily ................... 220
menstrual relief ..................... 28
menstrual relief(pamabr-pyril)
.......................................... 28
MENTAX ............................. 66
menthol ................................. 53
menthol cough .................... 177
menthol cough drops .......... 177
menthol drops ..................... 177
me-pb-hyos ......................... 131
MEPHYTON ........................ 41
meprobamate ........................ 20
mercaptopurine ..................... 15
meropenem ............................. 9
mesalamine ......................... 139
mesalamine with cleansing
wipe ................................ 139
MESH PANTS ................... 108
MESNEX.............................. 13
MESTINON ......................... 20
metadate er ........................... 33
metafolbic ........................... 220
metafolbic plus ................... 200
metafolbic plus rf................ 200
METAMUCIL (WITH
SUGAR) ......................... 139
metamucil fiber singles ...... 139
METAMUCIL
MULTIHEALTH FIBER
........................................ 139
METAMUCIL SUGAR-FREE
(ASPART) ...................... 139
metaproterenol .................... 186
metaxall ................................ 20
metaxalone ............................ 20
metformin ........................... 108
methadone ............................. 22
methamphetamine ................. 33
methazolamide .................... 164
methenamine hippurate ........ 12
methenamine mandelate ....... 12
methen-sod phos-meth blue-
hyos ................................. 188
methimazole ......................... 85
METHIONAID ................... 200
METHITEST ...................... 128
methocarbamol ..................... 20
methocel e 4 m .................... 163
methotrexate sodium ............ 15
methotrexate sodium (pf) ..... 15
methoxsalen .......................... 53
methscopolamine ................ 131
methyclothiazide ................... 38
methyl alcohol ...................... 53
methyl salicylate ................... 53
methylcellulose 1500cps (bulk)
.......................................... 75
methyldopa ........................... 38
methyldopa-
hydrochlorothiazide .......... 38
methyldopate ........................ 38
methylene blue (bulk-solid) .. 79
methylergonovine ............... 159
methylphenidate hcl .............. 33
methylprednisolone .............. 85
methylprednisolone acetate .. 85
methylprednisolone sodium
succ ................................... 85
methylsulfonylmethane ........ 75
methyltestosterone .............. 128
metipranolol ........................ 160
metoclopramide hcl ............ 139
metolazone ............................ 38
288 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
metoprolol succinate ............ 38
metoprolol ta-hydrochlorothiaz
.......................................... 38
metoprolol tartrate ................ 38
metronidazole ........... 9, 60, 154
METRONIDAZOLE (BULK)9
metronidazole in nacl (iso-os) 9
mexiletine ............................. 35
mgo ..................................... 193
m-hist dm............................ 177
MIACALCIN ..................... 128
mi-acid ................................ 139
mi-acid gas relief ................ 139
mibelas 24 fe ...................... 157
micatin .................................. 66
miconazole 7 ...................... 154
miconazole nitrate ........ 66, 154
miconazole-3 ...................... 154
MICONAZOLE-3
PREFIL,CREAM,WIPE. 154
miconazole-skin clnsr17 ..... 154
miconazorb af ....................... 66
MICRO AIR ....................... 108
MICRO BLOOD GLUCOSE
........................................ 108
MICRO ELITE COMP-
NEBUL........................... 108
MICRO ELITE
REPLACEMENT FILTER
........................................ 108
MICRO THIN LANCETS . 108
MICROCHAMBER ........... 108
MICRODERM ................... 108
MICRODERM PLUS ........ 108
MICRODOT BLOOD
GLUCOSE SYSTEM ..... 108
MICRODOT NORMAL
CONTROL ..................... 108
MICROFOAM SURGICAL
........................................ 108
microgestin 1.5/30 (21) ...... 157
microgestin 1/20 (21) ......... 157
microgestin fe 1.5/30 (28) .. 157
microgestin fe 1/20 (28) ..... 157
micro-guard .......................... 66
MICROHESIVE STOMA
PASTE ............................ 108
MICROLET LANCET ....... 108
MICROLIFE PEAK FLOW
METER .......................... 108
MICROPORE SURGICAL 108
MICROSPACER ................ 108
MICROSPONGE ............... 108
midazolam ............................ 33
midodrine.............................. 75
midol pm............................... 28
migergot................................ 19
miglitol ............................... 108
migragesic ida....................... 19
migraine formula .................. 28
migraine pain reliever ........... 28
migraine relief ...................... 28
milco-zyme ......................... 139
milk of magnesia ................ 139
milk of magnesia concentrated
........................................ 139
milk thistle ............................ 79
milk thistle extract ................ 78
millipred ............................... 85
MILLIPRED ......................... 85
millipred dp .......................... 85
milltrium senior .................. 220
milrinone .............................. 44
milrinone in 5 % dextrose .... 44
mimvey ............................... 152
mimvey lo ........................... 153
mineral freez ......................... 53
mineral oil........................... 140
MINERAL OIL (BULK).... 139
mineral oil extra heavy ....... 140
mineral oil heavy .................. 75
MINERAL OIL HEAVY ... 140
mineral oil light .............. 53, 75
minerin.................................. 53
MINI ELITE COMPRESSOR-
NEBULIZE .................... 108
MINI ELITE FILTER
REPLACEMENT ........... 108
MINI LANCING DEVICE 108
MINI TRANSFER PIN ...... 109
MINI ULTRA-THIN II ...... 109
MINITRAN .......................... 44
minocycline .......................... 12
minoxidil ......................... 38, 53
mintox ................................. 140
mintox maximum strength .. 140
mintox plus ......................... 140
miostat ................................ 164
miralax ................................ 140
MIRASORB ....................... 109
mirtazapine ........................... 33
miseflex .............................. 220
misoprostol ......................... 145
mitomycin ............................. 15
mitoxantrone ......................... 15
MMA-PA COOLER15 ....... 200
MMA-PA EXPRESS .......... 200
MMA-PA GEL ................... 201
mobisyl ................................. 53
modafinil ............................... 33
moexipril ............................... 38
moexipril-hydrochlorothiazide
.......................................... 38
moisture barrier ointment ..... 53
moisture drops .................... 163
moisturizing .......................... 53
moisturizing cream ............... 53
moisturizing lotion (with pet)
.......................................... 53
moiturizing lotion ................. 54
molindone ............................. 33
mometasone .................. 69, 186
mondoxyne nl ....................... 12
MONOCLATE-P ................. 41
MONOJECT HYPODERMIC
NEEDLES ...................... 109
MONOJECT INSULIN
SYRINGE ....................... 109
monoject prefill (pf) ............. 41
monoject prefill advanced (pf)
.......................................... 41
MONOJECT SAFETY
SYRINGES ..................... 109
MONOJECT SYRINGE .... 109
MONOLET LANCETS ...... 109
MONOLET THIN LANCETS
........................................ 109
289 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
mono-linyah ....................... 157
mononessa (28) .................. 157
MONONINE ........................ 41
montelukast ........................ 186
MONUROL .......................... 12
morgidox .............................. 12
morphine............................... 22
morphine concentrate ........... 22
mosco callus-corn remover .. 46
mosco corn remover ............. 46
motion relief (meclizine) .... 140
motion sickness .................. 140
motion sickness (meclizine)
........................................ 140
motion sickness relief ......... 140
motion sickness relief ii...... 140
motion sickness relief(mecliz)
........................................ 140
motion-time ........................ 140
MOTOFEN......................... 131
motrin pm ............................. 28
mouth cleanser...................... 81
mouth pain ............................ 62
move it along ...................... 140
MOVIPREP ........................ 140
MOXATAG ......................... 10
moxifloxacin................. 11, 160
MPM FOAM DRESSING . 109
msm ...................................... 75
MSUD 2 ............................. 201
MSUD AID ........................ 201
MSUD ANALOG .............. 201
MSUD COOLER ............... 201
MSUD EXPRESS COOLER
........................................ 201
msud express15 .................. 201
MSUD GEL POWDER ...... 201
MSUD MAXAMAID ........ 201
MSUD MAXAMUM ......... 201
mucaphed ........................... 177
mucinex .............................. 178
mucinex allergy .................. 178
mucinex d ........................... 178
mucinex d maximum strength
........................................ 178
mucinex dm ........................ 178
MUCINEX DM .................. 178
mucinex fast-max cold-flu-thrt
........................................ 178
MUCINEX FAST-MAX
CONGEST-COUGH ...... 178
mucinex fast-max dm max . 178
mucinex fast-max severe cold
........................................ 178
mucinex sinus-max ............... 81
mucosa ................................ 178
mucosa dm .......................... 178
mucus and cough relief....... 178
mucus d............................... 178
mucus dm ........................... 178
mucus dm max.................... 178
mucus relief ........................ 178
MUCUS RELIEF
CONGESTION-COUGH
........................................ 178
mucus relief cough ............. 178
mucus relief d (phenylephrine)
........................................ 178
mucus relief d (pseudoephed)
........................................ 178
mucus relief dm .................. 178
mucus relief dm max .......... 178
mucus relief er .................... 178
mucus relief pe ................... 178
mucus relief plus ................ 178
mucus relief sinus ............... 178
MULTAQ ............................. 35
multi antibiotic plus .............. 64
multi complete with iron .... 220
multi for her ........................ 220
MULTI-BETIC .................. 220
multi-day with iron ............. 220
multi-delyn ......................... 220
multi-delyn with iron .......... 220
multigen .............................. 220
multigen folic ..................... 220
multigen plus ...................... 220
MULTI-LANCET DEVICE
........................................ 109
multilex ............................... 220
multilex-t and m ................. 220
multiple vitamin, womens .. 220
multiple vitamin-minerals .. 220
multi-purpose soft contact len
........................................ 109
MULTISTIX ....................... 109
MULTISTIX 10 SG ........... 109
MULTISTIX 5 .................... 109
MULTISTIX 7 .................... 109
MULTISTIX 8 SG ............. 109
MULTISTIX 9 .................... 109
MULTISTIX 9 SG ............. 109
multi-symptom cold (pe) .... 178
multi-symptom cold (pe-cpm)
........................................ 179
multi-symptom cold daytime
........................................ 179
multi-symptom cold night time
........................................ 179
multi-vit with fluoride-iron . 220
multivital ............................. 220
multivital performance ......... 79
multivital platinum ............. 220
multivitamin ....................... 220
multivitamin 50 plus ........... 220
multi-vitamin hp/minerals .. 220
multivitamin with fluoride .. 220
multi-vitamin with fluoride 220
multivitamin with iron ........ 220
multivitamin with minerals . 220
multivitamins with fluoride 220
multivit-fluor (vit e acetate) 220
multivit-min-iron fum-folic ac
........................................ 220
mupirocin .............................. 64
mupirocin calcium ................ 64
murine ear wax removal
system ............................... 84
MURO 128 ......................... 163
muscle relief ......................... 54
muscle rub ............................ 54
muscle rub (with camphor) ... 54
muscle rub ultra-strength ...... 54
MUSTARGEN ..................... 15
mvc-fluoride ....................... 220
M-VIT ................................. 220
my way ............................... 157
MYCAMINE .......................... 3
290 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
mycophenolate mofetil ......... 15
mycophenolate sodium ......... 15
myferon 150 ....................... 221
MYGLUCOHEALTH
LANCETS ...................... 109
MYKIDZ IRON ................. 221
MYKIDZ IRON FLUORIDE
........................................ 221
MYLERAN .......................... 15
mynatal ............................... 221
mynatal advance ................. 221
mynatal plus ....................... 221
mynatal-z ............................ 221
mynate 90 plus ................... 221
mynephrocaps..................... 221
mynephron .......................... 221
myofibex............................. 221
myorisan ............................... 60
mytab gas............................ 140
mytab gas maximum strength
........................................ 140
my-vitalife .......................... 221
myzilra ................................ 157
N nabumetone .......................... 28
nadolol .................................. 38
nadolol-bendroflumethiazide 38
nafcillin................................. 10
nafcillin in dextrose iso-osm 10
naftifine ................................ 66
nalbuphine ............................ 28
naloxone ............................... 28
naltrexone ............................. 28
NAMENDA TITRATION
PAK .................................. 20
naphazoline......................... 166
naproxen ............................... 29
naproxen sodium .................. 29
naratriptan............................. 19
NARCAN ............................. 29
nasadock plus kit .................. 81
nasaflo porcelain kit ............. 81
nasal allergy........................ 186
nasal allergy symptom control
........................................ 186
nasal decongestant (oxymetazl)
.......................................... 81
nasal decongestant (pe) ...... 179
nasal decongestant
(pseudoeph) .................... 179
nasal four .............................. 81
nasal mist .............................. 81
nasal moisturizing................. 81
nasal relief ............................ 81
nasal relief sinus wash w/neti
.......................................... 81
nasal relief sinus wash-bottle 81
nasal spray (oxymetazoline) . 81
nasal spray (sodium chloride)
.......................................... 81
nasal spray 12 hour ............... 81
nasal spray 12 hour sinus...... 81
nasal spray long acting ......... 81
nasal spray x-moist ............... 81
NASAL STRIPS LARGE .. 109
NASCOBAL ...................... 221
NATACYN ........................ 160
natalvirt 90 dha ................... 221
natalvirt ca .......................... 221
natalvirt flt .......................... 221
NATALVIT ........................ 221
NATAZIA .......................... 157
nateglinide .......................... 109
NATELLE ONE ................. 221
NATPARA ......................... 128
NATRAPEL ......................... 54
NATURA CLOSED POUCH
........................................ 109
NATURA DURAHESIVE
SKIN BARRIER ............ 109
NATURA STOMAHESIVE
SKN BARRIER .............. 109
natural b-100 complex ........ 221
natural balance .................... 163
NATURAL CARE
BANDAGES .................. 109
natural cold sore ................... 54
natural fiber laxative ........... 140
natural fiber laxative (sugar)
........................................ 140
NATURAL FIBER
LAXATIVE (SUGAR) ... 140
natural fiber laxative smooth
........................................ 140
natural fiber laxative therapy
........................................ 140
natural fiber laxative(aspart)
........................................ 140
NATURAL FIBER
LAXATIVE(ASPART) .. 140
natural fiber supplement ..... 140
natural herb ........................... 81
natural herb cough drops .... 179
natural laxative ................... 140
natural oatmeal bath treatment
.......................................... 54
NATURAL PSYLLIUM
FIBER ............................. 140
natural tears (pf) ................. 163
natural veg laxative(sennosid)
........................................ 140
natural vegetable ................. 141
natural vegetable (psyllium)
........................................ 141
natural vegetable powder .... 141
natura-lax ............................ 141
nature's tears (hypromellose)
........................................ 163
nature-throid ....................... 129
nausea control ..................... 141
nausea relief ........................ 141
NEBUPENT ........................... 9
nebusal ................................ 186
necon 0.5/35 (28) ................ 157
necon 1/35 (28) ................... 157
necon 1/50 (28) ................... 157
necon 10/11 (28) ................. 157
necon 7/7/7 (28) .................. 157
nefazodone ............................ 33
neilmed nasaflo ..................... 81
neilmed pediat sinus rinse ref
.......................................... 81
neilmed sinus rinse complete 82
neilmed sinus rinse refill ...... 82
NEOCATE JUNIOR .......... 201
291 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
NEOCATE JUNIOR WITH
PREBIOTICS ................. 201
NEOCATE NUTRA .......... 201
neomycin ................................ 9
neomycin-bacitracin-poly-hc
........................................ 165
neomycin-bacitracin-
polymyxin....................... 160
neomycin-polymyxin b gu ... 71
neomycin-polymyxin b-
dexameth ........................ 165
neomycin-polymyxin-
gramicidin....................... 160
neomycin-polymyxin-hc ..... 84,
165
neo-polycin ......................... 160
neo-polycin hc .................... 165
neosporin (neo-bac-polym) .. 64
neosporin anti-itch ................ 69
neo-tuss............................... 179
nephplex rx ......................... 221
NEPHRON FA ................... 221
nephronex ........................... 221
nephronex-sl ....................... 221
NEPHRO-VITE ................. 221
nephro-vite rx ..................... 221
NEPRO ............................... 201
NEPRO CARB STEADY .. 201
NESTABS .......................... 221
NESTABS DHA ................ 221
neuac..................................... 60
NEUMEGA ........................ 147
NEUPOGEN ...................... 147
neuro vite ............................ 221
neutraphor............................. 54
nevirapine ............................... 5
NEW GENERATION ........ 109
NEW IMAGE CLOSED
MINI-POUCH ................ 110
NEW IMAGE CLOSED
POUCH .......................... 110
NEW IMAGE DRAIN MINI-
POUCH .......................... 110
NEW IMAGE DRAINABLE
POUCH .......................... 110
NEW IMAGE FLEXTEND
BARRIER FLA .............. 110
NEW IMAGE FLEXWEAR
FLAT .............................. 110
NEW IMAGE IRRIGATOR
SLEEVE ......................... 110
NEW IMAGE OSTOMY KIT
........................................ 110
NEW IMAGE SKIN
BARRIER-FLANGE...... 110
NEW IMAGE UROSTOMY
POUCH .......................... 110
newgen................................ 221
NEXA PLUS ...................... 221
NEXAVAR .......................... 15
NEXCARE GENTLE PAPER
TAPE .............................. 110
NEXCARE TEGADERM .. 110
next choice one dose........... 158
niacin .................................... 43
niacin (inositol niacinate) .... 43,
201
niacin (niacinamide) ............. 43
niacin flush free .................. 201
niacinamide .......................... 43
niacin-aze ac-turmer-fa-b6-zn
........................................ 201
nicardipine ............................ 38
NICAZEL ........................... 201
nicorelief ............................... 80
nicorette ................................ 80
nicotine ................................. 80
nicotine (polacrilex) ............. 80
NICOTROL .......................... 80
NICOTROL NS .................... 80
nifedical xl ............................ 38
nifedipine .............................. 38
NIFEDIPINE (BULK) ......... 38
NIGHT DRAIN ADAPTER
........................................ 110
night time cold .................... 179
night time cold-flu .............. 179
night time pain medicine ...... 29
nightime sleep..................... 179
nighttime allergy relief ....... 179
nighttime cough .................. 179
nighttime cough-cold .......... 179
nighttime sinus .................... 179
nighttime sleep aid (diphen)
........................................ 179
nighttime sleep-aid (doxylamn)
.......................................... 33
nikki (28) ............................ 158
nilutamide ............................. 15
nimodipine ............................ 38
nisoldipine ............................ 38
nite time cough ................... 179
nite time-d cold-flu relief .... 179
NITRILE EXAM GLOVES
........................................ 110
nitro-bid ................................ 44
NITRO-DUR ........................ 44
nitrofurantoin ........................ 12
nitrofurantoin macrocrystal .. 12
nitrofurantoin monohyd/m-
cryst .................................. 12
nitroglycerin ......................... 44
nitroglycerin in 5 % dextrose 44
nitro-time .............................. 44
nivatopic plus ........................ 54
nizatidine ............................ 145
no doz ................................... 75
no drip ................................... 82
no drip nasal relief ................ 82
no sting barrier film .............. 54
noble formula ........................ 70
noble formula hc ................... 69
nodolor .................................. 19
nohist-dm ............................ 179
nohist-lq .............................. 179
nolix ...................................... 69
NON-ADHERENT
BANDAGE ..................... 110
non-aspirin ............................ 29
non-aspirin 8 hour ................. 29
non-aspirin childrens ............ 29
non-aspirin extra strength ..... 29
non-aspirin flu .................... 179
non-aspirin jr strength ........... 29
non-aspirin pain relief ........... 29
non-aspirin pain relief pm .... 29
non-aspirin pm ...................... 29
292 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
non-aspirin severe congest m-s
........................................ 179
non-drowsy allergy ............. 179
non-drying sinus ................. 179
NON-STICK PAD ............. 110
nora-be ................................ 153
NOREL AD ........................ 179
noreth-ethinyl estradiol-iron
........................................ 158
norethindrone (contraceptive)
........................................ 153
norethindrone acetate ......... 153
norethindrone ac-eth estradiol
................................ 153, 158
norethindrone-e.estradiol-iron
........................................ 158
norgestimate-ethinyl estradiol
........................................ 158
norlyda ................................ 153
norlyroc .............................. 153
normal saline flush ............... 75
NORPACE CR ..................... 35
nortemp................................. 29
nortrel 0.5/35 (28) .............. 158
nortrel 1/35 (21) ................. 158
nortrel 7/7/7 (28) ................ 158
nortriptyline .......................... 34
NORVIR................................. 5
norwegian cod liver oil ....... 221
nose drops ............................. 82
NO-STING SKIN-PREP .... 110
NOVA MAX BLOOD
GLUCOSE METER ....... 110
NOVA MAX GLUCOSE
CONTROL ..................... 110
NOVA MAX GLUCOSE
TEST .............................. 110
NOVA SAFETY LANCETS
........................................ 110
NOVA SUREFLEX
LANCETS ...................... 110
NOVAMAX PLUS KETONE
........................................ 110
novasource renal ................. 201
novasource renal 2 cal ........ 201
NOVOEIGHT ...................... 41
NOVOFINE 32................... 110
NOVOFINE AUTOCOVER
........................................ 110
NOVOFINE PLUS ............. 110
NOVOLIN 70/30 ................ 110
NOVOLIN N ...................... 110
NOVOLIN R ...................... 110
NOVOLOG ........................ 110
NOVOLOG FLEXPEN ...... 110
NOVOLOG MIX 70-30 ..... 111
NOVOLOG MIX 70-30
FLEXPEN ...................... 111
NOVOLOG PENFILL ....... 111
NOVOPEN 3 ...................... 111
NOVOSEVEN RT ............... 41
NOVOTWIST .................... 111
NOXAFIL .............................. 3
np thyroid ........................... 129
nrs nasal relief ...................... 82
nts step 1 ............................... 80
nu way .................................. 82
NUCORT.............................. 69
NUCYNTA .......................... 29
NUEDEXTA ........................ 20
NU-FIT BRIEF MEDIUM . 111
NULOJIX ............................. 15
NUTRA PRO HIGH
PROTEIN ....................... 201
nutraderm.............................. 54
nutrafit ................................ 201
nutrafit plus......................... 201
nutrament ............................ 201
NUTRAMIGEN AA LIPIL 201
NUTRAMIGEN DHA-ARA
........................................ 201
NUTRAMIGEN LIPIL ...... 201
NUTRAMIGEN WITH
ENFLORA LGG ............ 201
nutraplus ............................... 54
nutren 1.0 .................... 201, 202
nutren 1.0 with fiber ........... 202
nutren 1.5 ............................ 202
nutren 2.0 ............................ 202
nutren junior ....................... 202
nutren junior fiber ............... 202
NUTREN PULMONARY . 202
NUTRICAP ........................ 221
NUTRIHEP ........................ 202
nutrition plus ....................... 202
nutritional drink mix ........... 202
nutritional drink plus .......... 202
nutritional shake ................. 202
NUTRITIONAL SHAKE ... 202
nutritional shake plus .......... 202
NUTRITIONAL SHAKE
PLUS .............................. 202
nutritional supplement ........ 202
nutritional supplement plus 202
NUTROPIN AQ ................. 147
NUTROPIN AQ NUSPIN .. 147
NUVARING ....................... 154
NUWIQ ................................ 41
nuzole ................................... 66
nyamyc ................................. 66
nyata ..................................... 66
nyquil d ............................... 179
nystatin ............................. 3, 66
nystatin-triamcinolone .......... 66
nystop ................................... 66
O O.A.D. ................................ 111
OA 1 POWDER ................. 202
OA2 POWDER .................. 202
oatmeal bath regular ............. 54
OB COMPLETE ................ 222
OB COMPLETE 400 ......... 221
OB COMPLETE ONE ....... 222
OB COMPLETE PREMIER
........................................ 222
OB COMPLETE WITH DHA
........................................ 222
OBIZUR ............................... 42
obstetrix dha ....................... 222
OBSTETRIX EC ................ 222
OBTREX ............................ 222
OBTREX DHA .................. 222
O-CAL FA .......................... 222
O-CAL PRENATAL .......... 222
ocean nasal ............................ 82
ocella ................................... 158
octreotide acetate .................. 15
ocucoat ................................ 163
293 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
ocusoft hand soap ................. 54
ocutabs ................................ 222
OCUVITE .......................... 222
OCUVITE LUTEIN AND
ZEAXANTHIN .............. 222
OCUVITE WITH LUTEIN 222
ODEFSEY .............................. 5
odor control foot-sneaker ..... 66
ODOR ELIMINATOR
DROPS ........................... 111
odor free garlic-x .................. 79
odorless garlic ...................... 79
OFF ACTIVE ....................... 54
OFF DEEP WOODS DRY .. 54
OFF FAMILYCARE (WITH
DEET) .............................. 54
ofloxacin ................. 11, 84, 160
ogestrel (28)........................ 158
okebo .................................... 12
olanzapine............................. 34
olanzapine-fluoxetine ........... 34
oleic acid .............................. 75
OLEPTRO ER ...................... 34
olive oil ................................. 54
olmesartan ............................ 38
olmesartan-amlodipin-
hcthiazid ........................... 38
olmesartan-
hydrochlorothiazide .......... 38
olopatadine ................... 82, 163
omega 3-6-9 complex ......... 202
omega 3-6-9 fatty acids ...... 202
omega 3-dha-epa-fish oil .... 202
omega-3 acid ethyl esters ..... 43
omega-3 fatty acids .............. 43
omega-3 fatty acids-fish oil 202
omega-3 flaxseed oil ............ 79
omega-3s-dha-epa-fish oil-d3
........................................ 202
omeppi ................................ 145
omeprazole ................. 145, 146
OMEPRAZOLE (BULK) .. 145
omeprazole magnesium ...... 145
omeprazole-sodium
bicarbonate ..................... 146
omnicap .............................. 222
OMNIPOD INSULIN REFILL
........................................ 111
ON CALL LANCET .......... 111
ON CALL LANCING
DEVICE ......................... 111
ON CALL PLUS CONTROL
........................................ 111
ON CALL PLUS LANCET111
ON CALL PLUS LANCING
DEVICE ......................... 111
ONCASPAR ......................... 15
once daily ........................... 222
ondansetron ........................ 141
ondansetron hcl................... 141
ondansetron hcl (pf)............ 141
one daily ............................. 222
one daily 50 plus................. 222
one daily calcium/iron ........ 222
one daily complete.............. 222
one daily energy ................. 222
one daily essential .............. 222
one daily for men ................ 222
one daily for men 50+
advanced ......................... 222
one daily for women ........... 222
one daily maximum ............ 222
one daily maximum (with ca)
........................................ 222
one daily men's 50+ ............ 222
one daily multi-vit w-mineral
........................................ 222
one daily multivitamin........ 222
one daily multivit-iron(folic)
........................................ 222
one daily plus iron .............. 222
one daily plus minerals ....... 223
one daily prenatal ............... 223
one daily women 50 plus .... 223
one daily women's .............. 223
one daily womens 50 plus .. 223
one daily women's health ... 223
ONE STEP PREGNANCY
TEST .............................. 111
ONE WAY VALVED
MOUTHPIECE .............. 111
one-a-day essential ............. 223
one-a-day maximum formula
........................................ 223
one-a-day teen advantage ... 223
one-step plantar wart remover
.......................................... 46
one-step wart remover .......... 46
ONETOUCH DELICA
LANCETS ...................... 111
ONETOUCH FINEPOINT
LANCETS ...................... 111
ONETOUCH SURESOFT
LANCING DEV ............. 111
ONETOUCH ULTRA
CONTROL ..................... 111
ONETOUCH ULTRA TEST
........................................ 111
ONETOUCH ULTRA2 ...... 111
ONETOUCH ULTRALINK
........................................ 111
ONETOUCH ULTRAMINI
........................................ 111
ONETOUCH ULTRASOFT
LANCETS ...................... 111
ONETOUCH VERIO ......... 111
ONETOUCH VERIO IQ
METER ........................... 111
ONETOUCH VERIO MID
CONTROL ..................... 111
ONFI ..................................... 18
ON-THE-GO LANCETS ... 111
opcicon one-step ................. 158
opium tincture ..................... 131
OPSITE IV 3000 ................ 111
OPTICHAMBER ADULT
MASK-LARGE .............. 111
OPTICHAMBER DIAMOND
VHC ................................ 111
opti-clear ............................. 166
OPTICLUDE EYE PATCH
JUNIOR .......................... 112
OPTIFOAM ........................ 112
option-2 ............................... 158
OPTIUM EZ ....................... 112
OPTIUM TEST .................. 112
opti-vitamins ....................... 223
ora relief ................................ 82
294 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
oral analgesic ........................ 62
oral anesthetic ....................... 63
oral cleansing........................ 82
oral pain relief ...................... 63
oral relief sore throat spray... 82
oral saline laxative .............. 141
ORAL THERMOMETER . 112
oralone .................................. 82
oralyte ................................. 193
orange oil .............................. 79
orasep ................................... 63
ora-sweet .............................. 75
ORA-SWEET SF ................. 75
ORAVIG ................................ 3
ORFADIN ............................ 75
organ-i nr ............................ 179
original nasal spray............... 82
ormir ................................... 179
orphenadrine citrate .............. 20
orphenadrine compound-ds .. 20
orsythia ............................... 158
ortho d ................................ 223
OS 2 .................................... 202
OS-CAL 500 + D3 ............. 193
oscimin ............................... 131
oscimin sl............................ 131
oscimin sr ........................... 131
oseltamivir .............................. 5
OSMOLITE 1 CAL ............ 202
OSMOLITE 1.2 CAL ......... 202
OSMOLITE 1.5 CAL ......... 203
OSMOPREP ....................... 141
osteo bi-flex triple strength .. 29
OSTOMY BELT LARGE .. 112
OSTOMY PASTE .............. 112
OSTOMY SUPPLIES ........ 112
OTEZLA ............................ 151
OTEZLA STARTER.......... 151
oticin ..................................... 84
oticin hc (bak free) ............... 84
oto-end 10 ............................. 84
otomax-hc ............................. 84
otozin .................................... 84
OVER NITES ..................... 112
OVERNIGHT UNDERWEAR
SMALL-MED ................ 112
oxacillin ................................ 11
oxacillin in dextrose(iso-osm)
.......................................... 11
oxandrolone ........................ 128
oxaprozin .............................. 29
oxazepam .............................. 34
oxcarbazepine ....................... 18
OXEPA ............................... 203
oxiconazole ........................... 66
OXISTAT ............................. 66
oxybutynin chloride ............ 187
oxycodone ............................ 22
oxycodone-acetaminophen ... 22
oxycodone-aspirin ................ 22
oxymetazoline ...................... 82
oxymorphone ........................ 22
OXYTROL ......................... 188
oysco 500/d......................... 193
oysco d ................................ 193
oysco-500 ........................... 193
oyster shell calcium ............ 193
oyster shell calcium 500 ..... 193
oyster shell calcium and mag
........................................ 193
oyster shell calcium-vit d2 . 223
oyster shell calcium-vit d3 . 193
oystercal-d .......................... 193
P pacerone................................ 35
paclitaxel .............................. 15
pain and fever ....................... 29
PAIN FREE TAPE ............. 112
pain relief .............................. 29
pain relief (acetamin-asp-caf)
.......................................... 29
pain relief (capsaicin) ........... 54
pain relief (menthol) ............. 54
pain relief (trolamine salicy) 54
pain relief adult ..................... 29
pain relief allergy sinus ...... 179
pain relief cream ................... 54
pain relief pm........................ 29
pain relief pm rapid release .. 29
pain relief regular strength ... 29
pain reliever .......................... 30
pain reliever (acetam-aspirin)
.......................................... 29
pain reliever extra strength ... 29
pain reliever flu ................... 179
pain reliever jr strength ......... 29
pain reliever plus .................. 30
pain relieving (benzocaine) .. 63
pain relieving (menthol) ....... 54
pain relieving (m-sal-men-
cam) .................................. 54
pain relieving cream ............. 54
pain relieving rub (camphor) 54
pain-off ................................. 30
PAIRE OB PLUS DHA ...... 223
paliperidone .......................... 34
pamidronate ........................ 128
PAMPERS UNISEX BABY-
DRY ................................ 112
pamprin max ......................... 30
panax ginseng ....................... 79
pancrelipase 5000 ............... 141
PANDA MASK .................. 112
PANDEL .............................. 69
panoxyl ................................. 60
panoxyl-4 .............................. 60
PANRETIN .......................... 54
PANT LINERS, LARGE ... 112
PANT LINERS, LARGE
PLUS .............................. 112
pantoprazole ....................... 146
pantothenic acid (vit b5) ..... 223
papaya enzyme ..................... 79
PAPER TAPE ..................... 112
paregoric ............................. 131
PARI BABY CONV KIT -
SIZE 1 ............................. 112
PARI BABY NEBULIZER 112
PARI LC MASK SET ........ 112
PARI LC SPRINT
NEBULIZER SET .......... 112
PARI TREK S COMBO
PACK ............................. 112
PARI TREK S COMPACT
COMPRESSOR .............. 112
paricalcitol .......................... 128
paromomycin .......................... 9
295 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
paroxetine hcl ....................... 34
paroxetine mesylate .............. 34
PASER ................................... 9
PATADAY ......................... 163
PCE......................................... 8
pcm la ................................. 180
p-col rite ............................. 141
pc-tar..................................... 45
PEAK AIR PEAK FLOW
METER .......................... 112
peanut oil .............................. 75
pedia relief cough-cold ....... 180
pedia relief infant nasal ...... 180
pediacare fever reducer ........ 30
pediacare multi-symptom cold
........................................ 180
PEDIA-LAX STOOL
SOFTENER .................... 141
pedialyte ............................. 193
pedialyte singles ................. 193
PEDIASURE ...................... 203
PEDIASURE ENTERAL ... 203
pediasure peptide 1.0 cal .... 203
PEDIASURE SIDEKICKS 203
PEDIASURE WITH FIBER
........................................ 203
pediatric balanced nutrition 203
pediatric cough and cold .... 180
pediatric electrolyte ............ 193
pediatric enema .................. 141
pediatric freezer pops ......... 193
pediatric oint (cod liver oil) .. 54
PEDIATRIC PANDA MASK
........................................ 112
pediculicide 11 ..................... 70
pedi-dri ................................. 67
pedi-whirl ............................. 75
peg ........................................ 77
peg 3350-electrolytes ......... 141
peg3350 .............................. 141
PEGANONE ........................ 18
PEGASYS .......................... 147
PEGASYS CONVENIENCE
PACK ............................. 147
PEGASYS PROCLICK ..... 147
peg-electrolyte soln ............ 141
peg-prep .............................. 141
pe-guai ................................ 180
PEN NEEDLE .................... 112
PEN NEEDLE, DIABETIC112
PENICILLIN G POT IN
DEXTROSE ..................... 11
penicillin g potassium ........... 11
penicillin g sodium ............... 11
penicillin v potassium ........... 11
PENLET PLUS BLOOD
SAMPLER...................... 112
PENTAM................................ 9
PENTASA .......................... 141
pentazocine-naloxone ........... 30
PENTIPS ............................ 112
pentoxifylline........................ 42
pentravan .............................. 54
pepcid ac ............................. 146
PEPDITE JUNIOR ............. 203
peppermint oil....................... 75
peppermint spirit................... 75
PEPTAMEN ....................... 203
PEPTAMEN 1.5 ................. 203
peptamen 1.5 cal with prebio1
........................................ 203
PEPTAMEN AF ................. 203
PEPTAMEN JUNIOR ........ 203
PEPTAMEN JUNIOR 1.5 .. 203
peptamen junior fiber ......... 203
PEPTAMEN JUNIOR WITH
PREBIO1 ........................ 203
PEPTAMEN W-PREBIO1. 203
peptic relief ......................... 131
pepto-bismol to-go ............. 131
PERATIVE ......................... 203
percogesic ............................. 30
percogesic extra strength ...... 30
perdiem overnight relief ..... 141
PER-FIT BRIEFS ............... 112
PER-FIT UNDERWEAR ... 112
peri-colace .......................... 141
PERIFLEX ADVANCE ..... 203
PERIFLEX INFANT .......... 203
PERIFLEX JUNIOR .......... 203
PERIFLEX LQ PKU .......... 203
perindopril erbumine ............ 38
perio med .............................. 82
periogard ............................... 82
peri-wash .............................. 64
permethrin ............................. 70
peroxide sore mouth cleanser
.......................................... 54
peroxyl .................................. 55
perphenazine ......................... 34
perphenazine-amitriptyline ... 34
perry prenatal ...................... 223
persa-gel ............................... 60
PERSONAL BEST FULL
RANGE .......................... 112
PERSONAL CONFIDENCE
BRIEFS ........................... 112
personal confidence liners .. 113
PERSONAL CONFIDENCE
PADS .............................. 113
PERSONAL CONFIDENCE
UNDERWEAR ............... 113
personal lubricant ................. 55
personal lubricating jelly ...... 55
petrolatum ............................. 55
PETROLATUM GAUZE ... 113
petrolatum, yellow (bulk) ..... 55
petroleum jelly, white ........... 55
PEXEVA .............................. 34
PFD 2 .................................. 203
PFD TODDLER ................. 203
pfizerpen-g ............................ 11
pharbechlor ......................... 180
pharbedryl ........................... 180
pharbetol ............................... 30
PHARMACIST CHOICE .. 113
PHARMACIST CHOICE
GLUCOSE SYS ............. 113
phenadoz ............................. 180
phenaseptic ........................... 82
phenazopyridine ................. 189
phenelzine ............................. 34
phenergan ........................... 180
PHENEX-1 ......................... 203
PHENEX-2 ......................... 203
phenobarb-hyoscy-atropine-
scop ................................. 131
phenobarbital ........................ 18
296 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
phenobarbital sodium ........... 18
phenohytro .......................... 131
phenoxybenzamine ............... 38
PHENYLADE 40 ............... 203
PHENYLADE 60 ............... 204
PHENYLADE DRINK MIX
........................................ 204
PHENYLADE ESSENTIAL
........................................ 204
phenylade phebloc .............. 204
PHENYLADE RTD PKU 10
........................................ 204
phenylephrine hcl ......... 44, 166
PHENYL-FREE 1 .............. 204
PHENYL-FREE 2 PKU ..... 204
phenylhistine dh ................. 180
phenytoin .............................. 18
phenytoin sodium ................. 18
phenytoin sodium extended .. 18
philith ................................. 158
PHLEXY-10 DRINK MIX
POWDER ....................... 204
phlexy-vits .......................... 204
phos-nak ............................. 193
phospha 250 neutral ........... 193
phosphasal .......................... 188
phosphate laxative .............. 141
PHOSPHATE LAXATIVE 141
PHOSPHOLINE IODIDE .. 160
phospho-trin 250 neutral .... 193
physicians antibacterial ........ 64
PICATO ............................... 55
PIKO 1................................ 113
PILLOW MASK PEDIATRIC
........................................ 113
pilocarpine hcl .............. 75, 161
pimozide ............................... 34
pimtrea (28) ........................ 158
pindolol................................. 38
pine tar (bulk) ....................... 55
pink bismuth ....................... 131
pin-x ....................................... 9
pioglitazone ........................ 113
pioglitazone-glimepiride .... 113
pioglitazone-metformin ...... 113
piperacillin-tazobactam ........ 11
PIPETTE 30ML CATHETER
TIP .................................. 113
pirmella ............................... 158
piroxicam .............................. 30
pivot 1.5 cal ........................ 204
PKU 2 ................................. 204
PKU 3 ................................. 204
PKU COOLER 10 .............. 204
PKU COOLER 15 .............. 204
PKU COOLER 20 .............. 204
PKU EXPRESS20 .............. 204
PKU LOPHLEX ................. 204
plantar wart remover ............ 46
plasbumin 25 % .................. 190
PLASTIC STRIPS .............. 113
PLASTIC SWABS ............. 113
pm pain reliever .................... 30
pms maximum strength ........ 30
PNEUMOVAX 23 ............. 150
pnv 29-1 .............................. 223
pnv ob+dha ......................... 223
pnv-dha ............................... 223
pnv-dha + docusate ............. 223
pnv-ferrous fumarate-docu-fa
........................................ 223
pnv-omega .......................... 223
pnv-select............................ 223
pnv-total.............................. 223
pnv-vp-u ............................. 223
POCKET CHAMBER ........ 113
POCKET PEAK FLOW
METER .......................... 113
podactin ................................ 67
podofilox .............................. 55
POISE PADS ...................... 113
poly bacitracin ...................... 64
POLY HUB NEEDLE........ 113
polybase ................................ 79
polycin ................................ 160
polyethylene glycol 1000(bulk)
.......................................... 75
polyethylene glycol 1450(bulk)
.......................................... 77
polyethylene glycol 3350 ... 141
polymyxin b sulfate ................ 9
polymyxin b sulf-trimethoprim
........................................ 160
polyoxyl 40 stearate .............. 75
polysaccharide iron ............. 223
POLYSKIN II ..................... 113
polysorbate 80 ...................... 75
poly-tussin .......................... 180
poly-tussin d ....................... 180
POLY-VI-FLOR ................. 223
POLY-VI-FLOR WITH IRON
........................................ 223
polyvinyl alcohol ................ 163
poly-vita .............................. 223
poly-vita (iron) .................... 223
poly-vitamin ....................... 223
polyvitamin with iron ......... 223
poly-vitamin with iron ........ 223
poly-vitamins ...................... 224
PORTAGEN ....................... 204
portia ................................... 158
pot,sodium citrate-citric acid
........................................ 188
potassium ............................ 193
potassium acetate ................ 193
potassium bicarb and chloride
........................................ 193
potassium bicarb-citric acid 193
potassium chlorid-d5-
0.45%nacl ....................... 193
potassium chloride .............. 193
potassium chloride in 5 % dex
........................................ 193
potassium chloride-0.45 % nacl
........................................ 193
potassium citrate ................. 188
potassium citrate-citric acid 188
potassium gluconate ........... 193
potassium phosphate m-/d-
basic ................................ 194
POUCH CLAMP ................ 113
POUCHKINS DRAINABLE
POUCH ........................... 113
POUCHKINS OSTOMY
SYSTEM ........................ 113
POUCHKINS PED OSTOMY
BELT .............................. 113
297 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
POUCHKINS SKIN
BARRIER....................... 113
POUCHKINS UROSTOMY
POUCH .......................... 113
povidone-iodine ............ 64, 154
powderlax ........................... 141
pr cream ................................ 55
pr natal 400 ......................... 224
pr natal 400 ec .................... 224
pr natal 430 ......................... 224
pr natal 430 ec .................... 224
PRADAXA........................... 42
PRALUENT PEN ................ 43
PRALUENT SYRINGE ....... 43
pramcort ............................. 141
pramipexole .......................... 19
pramoxine ........................... 141
prasugrel ............................... 42
pravastatin ............................ 43
prazosin ................................ 38
PRECISE PREGNANCY .. 113
PRECISEDOSE DISPENSER
TIP CAP ......................... 113
PRECISION 200 CATHETER
TRAY ............................. 113
PRECISION PCX PLUS TEST
........................................ 113
PRECISION PCX TEST .... 113
PRECISION POINT OF
CARE TEST ................... 113
PRECISION Q-I-D TEST .. 114
PRECISION XTRA B-
KETONE ........................ 114
PRECISION XTRA TEST . 114
PRED MILD ...................... 165
PRED-G ............................. 165
PRED-G S.O.P. .................. 165
prednicarbate ........................ 69
prednisolone ......................... 85
prednisolone acetate ........... 165
prednisolone sodium phosphate
.................................. 85, 165
prednisone ............................ 85
prednisone intensol ............... 85
PREFERA-OB ................... 224
PREFERA-OB ONE .......... 224
PREFERA-OB PLUS DHA
........................................ 224
PREFEST ........................... 153
prefol-dha ........................... 224
PREGESTIMIL .................. 204
PREGNANCY TEST ......... 114
PREMARIN ....................... 153
pre-menstrual relief .............. 30
PREMIER CLOSED MINI-
POUCH .......................... 114
PREMIER DRAINABLE
MINI-POUCH ................ 114
PREMIER DRAINABLE
POUCH .......................... 114
PREMIER LOCK N ROLL 114
PREMIER UROSTOMY
POUCH .......................... 114
PREMIUM BABY DIAPERS
........................................ 114
PREMIUM BLOOD
GLUCOSE MONITOR .. 114
PREMIUM COMFORT-
STRETCH ...................... 114
PREMIUM DRAINABLE
POUCH/KARAYA ........ 114
PREMIUM INFANT
FORMULA .................... 204
PREMIUM NITRILE
GLOVES ........................ 114
PREMIUM SKIN BARRIER
........................................ 114
PREMIUM TRAINING
PANTS ........................... 114
pre-moistened hemorrhoidal. 55
pre-moistened medicated wipes
.......................................... 55
PREMPHASE .................... 153
PREMPRO ......................... 153
premsyn pms......................... 30
prena1 ................................. 224
prena1 chew ........................ 224
prena1 pearl ........................ 224
prena1 plus ......................... 224
prena1 true .......................... 224
prenaissance........................ 224
prenaissance 90 dha ............ 224
prenaissance balance .......... 224
prenaissance dha ................. 224
prenaissance next ................ 224
prenaissance plus ................ 224
prenaissance promise .......... 224
prenaplus ............................. 224
PRENATA .......................... 224
prenatabs fa ......................... 224
prenatabs rx ........................ 224
prenatal ............................... 225
prenatal + dha ..................... 224
PRENATAL + DHA .......... 224
prenatal 19 .......................... 224
prenatal 19 (with docusate) 224
prenatal ad .......................... 224
prenatal complete ................ 224
prenatal dha ........................ 224
PRENATAL
DHA+COMPLETE
PRENATAL ................... 225
prenatal formula .................. 225
PRENATAL FORMULA ... 225
prenatal low iron ................. 225
PRENATAL MULTI-DHA
(ALGAL OIL) ................ 225
prenatal multivitamins ........ 225
prenatal one daily ............... 225
prenatal plus ........................ 225
prenatal plus (calcium carb)225
prenatal tablet ..................... 225
prenatal vitamin .................. 225
prenatal vitamin plus low iron
........................................ 225
prenatal vits96-iron fum-folic
........................................ 225
PRENATAL-1 .................... 225
prenatal-u ............................ 225
PRENATE DHA ................ 225
PRENATE ELITE .............. 225
PRENATE ESSENTIAL .... 225
preparation h (witch hazel) ... 55
preplus ................................ 225
pre-protein .......................... 204
PRE-PROTEIN (WHEY) ... 204
pres gen ............................... 180
PRESERVISION AREDS .. 225
298 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
PRESERVISION LUTEIN 225
PRESGEN B ...................... 180
PRESSURE ACTIVATED
LANCETS ...................... 114
pretab .................................. 225
PREVAIL ADJUST
UNDERWEAR SM-MD 114
PREVAIL BLADDER
CONTROL PAD ............ 114
PREVAIL BLADDER PAD
EXTRA........................... 114
PREVAIL BOXERS .......... 114
PREVAIL BRIEF
BARIATRIC .................. 114
PREVAIL BRIEF EXTRA
LARGE........................... 114
PREVAIL CLASSIC FIT
UNDERWEAR .............. 114
PREVAIL EXTRA
UNDERWEAR .............. 114
PREVAIL FULL COVERAGE
UNDRWEAR ................. 114
PREVAIL GUARDS FOR
MEN ............................... 114
PREVAIL MALE GUARD 114
PREVAIL PADS ................ 114
PREVAIL PANTY LINER 114
PREVAIL PM BRIEF
MEDIUM ....................... 114
PREVAIL PROTECTIVE
UNDERWEAR .............. 115
PREVAIL SIMPLY
STRETCH FIT ............... 115
PREVAIL STRETCH FIT . 115
PREVAIL SUPER PLUS ... 115
PREVAIL UNDERWEAR 115
prevalite ................................ 43
PREVENT .......................... 225
PREVIDENT 5000 BOOSTER
PLUS ................................ 82
PREVIDENT 5000 DRY
MOUTH ........................... 82
PREVIDENT 5000 ENAMEL
PROTECT ........................ 82
PREVIDENT 5000
SENSITIVE ...................... 82
previfem.............................. 158
PREVNAR 13 (PF) ............ 150
PREZCOBIX .......................... 5
PREZISTA ............................. 5
PRIFTIN ................................. 9
PRILOSEC OTC ................ 146
PRIMAQUINE ....................... 9
PRIMAXIN IV ....................... 9
PRIMEAIRE ...................... 115
primidone.............................. 18
PRIMSOL ............................. 12
PRO COMFORT LANCET
........................................ 115
PRO COMFORT PEN
NEEDLE ........................ 115
pro dna collection ................. 63
PRO SPORTS TAPE.......... 115
probalance .......................... 204
probenecid .......................... 151
probenecid-colchicine ........ 151
probiotic...................... 131, 204
probiotic 4x......................... 131
probiotic colon care ............ 131
probiotic digestive care ...... 131
PROCARE PROTECTIVE
UNDERWEAR .............. 115
procel .................................. 204
procel singles ...................... 204
procentra ............................... 34
PROCHAMBER ................ 115
prochlorperazine ................. 141
prochlorperazine edisylate .. 141
prochlorperazine maleate ... 141
PROCRIT ........................... 147
procto-med hc ..................... 141
procto-pak ........................... 141
proctosol hc ........................ 142
proctozone-hc ..................... 142
PRODIGY AUTOCODE
METER .......................... 115
PRODIGY CONTROL
SOLUTION, LOW ......... 115
PRODIGY INSULIN
SYRINGE ....................... 115
PRODIGY LANCETS ....... 115
PRODIGY LANCING
DEVICE ......................... 115
PRODIGY MINI-MIST
NEBULIZER .................. 115
PRODIGY NO CODING ... 115
PRODIGY POCKET METER
........................................ 115
PRODIGY TWIST TOP
LANCET ........................ 115
PRODIGY VOICE GLUCOSE
METER ........................... 115
PRODUCT 3232A .............. 204
PROFE FORTE .................. 225
profeno .................................. 30
PROFILNINE ....................... 42
PROGESTERONE (BULK)
........................................ 153
progesterone micronized .... 153
PROGESTERONE
MICRONIZED (BULK) 153
PROGLYCEM ................... 115
PROGRAF ............................ 15
PROLASTIN-C .................... 75
PROLEUKIN ..................... 147
PROMACTA ........................ 42
promethazine ...................... 180
promethazine vc-codeine .... 180
promethazine-codeine ......... 180
promethazine-dm ................ 180
promethazine-phenyleph-
codeine ............................ 180
promethegan ....................... 180
PROMOD PROTEIN ......... 204
promolaxin .......................... 142
PROMOTE WITH FIBER . 204
PRONEB ULTRA II .......... 115
propafenone .......................... 35
propantheline ...................... 131
proparacaine ....................... 163
PRO-PHREE ...................... 204
PROPIMEX-1 ..................... 204
PROPIMEX-2 ..................... 204
propranolol ........................... 38
propranolol-hydrochlorothiazid
.......................................... 38
propylthiouracil .................... 86
299 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
PRORENAL ....................... 225
PRORENAL QD ................ 225
prosight ............................... 225
PROSIGHT WITH LUTEIN
........................................ 225
PROSOBEE ....................... 205
prosource ............................ 205
PROSOURCE .................... 205
prosource no carb ............... 205
pro-stat awc ........................ 205
PROSYNMINIC ................ 205
protamine .............................. 42
PROTECTIVE BARRIER
FILM WIPES ................. 115
protective ointment ............... 55
PROTECTIVE PADS ........ 115
PROTECTIVE
UNDERWEAR SMALL-
MED ............................... 115
protein................................. 205
proteinex ............................. 205
protriptyline .......................... 34
PROVENT ......................... 115
provenza patch...................... 63
provil .................................... 30
pruclair ................................. 55
prudoxin ............................... 55
prumyx ................................. 55
prutect ................................... 55
pseudoephedrine hcl ........... 180
pseudoephedrine-guaifenesin
........................................ 180
PSORIASIN MEDICATED . 46
psoriasis medicated .............. 46
psyllium husk ..................... 142
PULMO-AIDE
COMPRESSOR ............. 115
PULMOCARE ................... 205
PULMONEB LT
COMPRESSOR NEBUL115
pulmosal ............................. 186
PULMOZYME................... 186
puralube .............................. 163
PURAMINO DHA-ARA ... 205
pure and gentle eye ............. 163
PURE COTTON ................ 115
pure l-citrulline ................... 205
PUREFE OB PLUS ............ 225
PUREFE PLUS .................. 225
purelax ................................ 142
purevit dualfe plus .............. 225
PYLERA ............................ 146
pyrazinamide .......................... 9
pyrethrin lice treatment m .... 70
pyridostigmine bromide ....... 20
pyridoxine (vitamin b6) ...... 226
pyrilamine-phenylephrine .. 180
PYRIMETHAMINE (BULK) 9
Q q-dryl .................................. 180
q-pap ..................................... 30
q-pap extra strength .............. 30
q-sorb co q-10 ....................... 71
q-tapp .................................. 180
q-tapp dm ............................ 180
Q-TIPS/SINGLE-TIP
APPLICATOR ............... 115
q-tussin ............................... 180
q-tussin dm ......................... 180
quasense.............................. 158
quazepam .............................. 34
quenalin .............................. 180
quetiapine ............................. 34
QUICK READ DIGITAL
THERMOMETER.......... 115
QUICK RESPONSE BP
MONITOR-LARG ......... 116
quinapril................................ 39
quinapril-hydrochlorothiazide
.......................................... 39
quinidine gluconate .............. 35
quinidine sulfate ................... 35
quinine sulfate ...................... 10
quintabs-m iron free ........... 226
quit 2 ..................................... 80
quit 4 ..................................... 80
QVAR ................................. 186
R rabeprazole ......................... 146
RAGWITEK ....................... 150
rajani ................................... 158
raloxifene ............................ 151
ramipril ................................. 39
RANEXA ............................. 44
ranitidine hcl ....................... 146
RAPAMUNE ........................ 15
rapid clear treatment pads ..... 46
rasagiline ............................... 19
RAYOS ................................. 85
RCF SOY PROTEIN
FORMULA BASE ......... 205
RCRA HAZARDOUS
WASTE .......................... 116
rea lo 39 ................................ 55
rea lo 40 ................................ 55
react .................................... 158
READYLANCE SAFETY
LANCETS ...................... 116
ready-to-use enema (min oil)
........................................ 142
REBIF (WITH ALBUMIN)
........................................ 147
REBIF REBIDOSE ............ 147
REBIF TITRATION PACK
........................................ 147
recedo ................................... 55
reclipsen (28) ...................... 158
RECOMBINATE ................. 42
recort plus ............................. 69
rectacort-hc ......................... 142
RECTAL THERMOMETER
........................................ 116
RECTIV .............................. 142
red yeast rice ......................... 79
redness relief ....................... 166
redness reliever eye drops .. 166
redness reliever lubricant .... 166
reese's pinworm medicine..... 10
refenesen ............................. 181
refenesen dm ....................... 181
refenesen pe ........................ 181
REFRESH CELLUVISC .... 163
REFRESH CLASSIC (PF) . 163
REFRESH LACRI-LUBE .. 163
REFRESH OPTIVE ........... 163
REFRESH OPTIVE
SENSITIVE (PF) ............ 163
REFRESH P.M. .................. 163
300 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
REFRESH PLUS ............... 163
REFRESH TEARS ............. 163
REFUAH PLUS GLUCOSE
CONTROL ..................... 116
REGRANEX ........................ 55
reguloid............................... 142
reguloid (psyllium husk) .... 142
reguloid, sugar free ............. 142
REJUVENESS ..................... 55
relador pak ............................ 63
relador pak plus .................... 63
relamine ................................ 30
relcof c ................................ 181
relcof dm ............................ 181
RELENZA DISKHALER ...... 5
RELIAMED LANCET ...... 116
RELIAMED MINI LANCING
DEVICE ......................... 116
RELIAMED SAFETY SEAL
LANCETS ...................... 116
RELION CONFIRM .......... 116
RELION CONFIRM-MICRO
........................................ 116
relion glucose ..................... 116
RELION MICRO GLUCOSE
MONITOR ..................... 116
RELION NEEDLES .......... 116
RELION PEN NEEDLES .. 116
RELION THIN LANCETS 116
RELION ULTRA THIN PLUS
LANCETS ...................... 116
RELISTOR ......................... 142
relnate dha .......................... 226
remedy 4-in-1 cleanser ......... 55
remedy antifungal ................. 67
remedy cleansing body ......... 55
remedy phytoplex antifungal 67
remeven ................................ 55
REMODULIN ...................... 39
RENA START ................... 205
RENACIDIN ...................... 188
RENAGEL ........................... 75
renal caps ............................ 226
renalcal ............................... 205
rena-vite .............................. 226
rena-vite rx ......................... 226
renewal ................................. 55
renewal daily moisture lotion
.......................................... 55
renewal healing..................... 55
reno caps ............................. 226
repaglinide .......................... 116
repaglinide-metformin ........ 116
REPATHA SURECLICK .... 43
REPATHA SYRINGE ......... 43
REPEL SPORTSMEN DRY 55
REPEL SPORTSMEN MAX
.......................................... 55
replesta................................ 226
REPLESTA NX ................. 226
replete ................................. 205
replete fiber......................... 205
replete-fiber ........................ 205
reprexain ............................... 22
REQ49+ .............................. 226
rescon-gg ............................ 181
RESCRIPTOR ........................ 5
RESECTISOL ...................... 39
reserpine ............................... 39
resource 2.0 ........................ 205
RESOURCE ARGINAID .. 205
RESOURCE ARGINAID
EXTRA ........................... 205
resource breeze ................... 205
resource just for kids w/fiber
........................................ 205
resource thickenup ................ 75
rest simply nighttime sleep . 181
RESTASIS.......................... 163
restfully sleep ..................... 181
restone ................................ 205
RESTORE CALCIUM
ALGINATE .................... 116
RESTORE EXTRA THIN
DRESSING .................... 116
RESTORE FOAM
DRESSING SILVER ..... 116
RESTORE HYDROGEL
GAUZE .......................... 116
RESTORE HYDROGEL
GAUZE SPONGE .......... 116
RESTORE TRIO ................ 116
resver-red-bfl-grpsd-pol-c-pom
.......................................... 79
retaine cmc .......................... 163
RETRACTED PENIS POUCH
........................................ 116
RETROVIR ............................ 5
REUSABLE HOT-COLD
COMPRESS ................... 116
REUSABLE NEBULIZER
KIT ................................. 116
REVATIO ........................... 187
REVEAL PREGNANCY
TEST ............................... 116
revive plus .......................... 163
REVLIMID ........................... 16
revonto .................................. 20
rewetting drops ................... 116
REXULTI ............................. 34
REYATAZ ............................. 5
RHINARIS ........................... 82
ribavirin .................................. 5
riboflavin (vitamin b2) ....... 226
rid complete lice elim kit ...... 71
rid lice killing ....................... 71
RIDAURA .......................... 151
rifabutin ................................ 10
rifampin ................................ 10
RIFATER ............................. 10
ri-gel ................................... 142
ri-gel ii ................................ 142
RIGHTEST CONTROL
SOLUTION HIGH ......... 116
RIGHTEST GD500
LANCING DEVICE ...... 117
RIGHTEST GL300 LANCETS
........................................ 117
RIGHTEST GM550 SYSTEM
........................................ 117
RIGHTEST GS550 TEST
STRIPS ........................... 117
riginic .................................. 142
riluzole .................................. 75
ri-mag ................................. 142
ri-mag plus .......................... 142
rimantadine ............................. 5
ri-mox ................................. 142
301 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
ri-mox plus ......................... 142
ringer's .......................... 71, 194
ringworm .............................. 67
risacal-d .............................. 226
risamine ................................ 55
risanoid plus ....................... 205
risaquad .............................. 131
risaquad-2 ........................... 131
risedronate .................... 75, 151
RISPERDAL CONSTA ....... 34
risperidone ............................ 34
RITEFLO AEROCHAMBER
........................................ 117
ritifed .................................. 181
ri-tussin ............................... 181
ri-tussin dm ......................... 181
RITUXAN ............................ 16
rivastigmine .......................... 20
rivastigmine tartrate.............. 20
rivelsa ................................. 158
RIXUBIS .............................. 42
rizatriptan ............................. 19
robafen ................................ 181
robafen cf (phenylephrine) . 181
robafen cough ..................... 181
robafen dm.......................... 181
robafen dm cough ............... 181
robafen dm cough-chest
congest ............................ 181
robitussin cold-flu day ........ 181
robitussin cough and cold cf
........................................ 181
robitussin cough-chest cong
dm ................................... 181
ROBITUSSIN LONG-
ACTING ......................... 181
robitussin pediatric ............. 181
ROB-NEL URETHRAL
CATHETER ................... 117
ROLLED ABSORBENT
COTTON ........................ 117
romantic mist douche ......... 154
RONDIC............................. 117
ropinirole .............................. 19
rosadan ................................. 60
rose water ............................. 56
rosin (bulk) ........................... 75
rosula cleansing cloths.......... 60
rosuvastatin ........................... 43
roweepra ............................... 18
ROXICET ............................. 22
r-tanna ................................. 181
RUBRACA ........................... 16
rulavite dha ......................... 226
rutin ...................................... 79
RYDAPT .............................. 16
rydex ................................... 181
rynex dm ............................. 181
rynex pe .............................. 181
rynex pse............................. 181
S SABRIL ................................ 18
safe wash .............................. 75
SAFE-CLIP NEEDLE
STORAGE DEV ............ 117
SAFESNAP INSULIN
SYRINGE ....................... 117
SAFETY LANCETS .......... 117
SAFETY SEAL LANCETS
........................................ 117
SAFETY-LET LANCETS . 117
SAF-GEL............................ 117
SAFYRAL .......................... 158
SAIZEN .............................. 147
SAIZEN CLICK.EASY ..... 147
salactic film .......................... 46
salacyn .................................. 46
salicylic acid ......................... 46
salicylic acid er-ceramides ... 46
saline mist ............................. 82
saline nasal ........................... 82
saline nose ............................ 82
saline wound wash................ 76
salmon oil-1000 .................. 205
salonpas ................................ 56
sal-plant ................................ 46
salsalate ................................ 30
salvax .................................... 46
sam-e (enteric coated) ........ 205
SAMI THE SEAL .............. 117
SAMI THE SEAL MASK .. 117
SAMSCA............................ 128
SANDIMMUNE ................... 16
SANDOSTATIN LAR
DEPOT ............................. 16
sani-supp (adult) ................. 142
sani-supp (infant) ................ 142
SANTYL .............................. 70
SAPHRIS .............................. 34
SAPHRIS (BLACK
CHERRY) ......................... 34
sarna sensitive ..................... 142
SAVELLA .......................... 151
SAVISION ......................... 226
saw palmetto ......................... 79
saw palmetto fruit ................. 79
saw palmto frt xtr-zinc picoli 79
scalacort ................................ 69
scalp itch-dandruff relief ...... 47
scalp relief ............................ 69
SCALP RELIEF ................... 47
scalpicin anti-itch .................. 69
scandical ............................. 205
scandishake ......................... 205
SCANDISHAKE ................ 205
scandishake (lactose free) ... 205
scar gel .................................. 56
scar treatment ...................... 117
scopolamine base ................ 142
SCOPOLAMINE HBR ...... 142
scot-tussin dm ..................... 181
scot-tussin expectorant ....... 181
se 10-5 ss .............................. 60
se bpo .................................... 60
sea soft nasal mist ................. 82
sea-omega ........................... 205
sea-omega 30 ...................... 206
sebex ..................................... 47
seb-prev ................................ 45
seconal sodium ..................... 34
secura antifungal ................... 67
secura protective ................... 56
SELECT BRIEFS ............... 117
SELECT DISPOSABLE
BRIEFS ........................... 117
SELECT KIDS BRIEFS ..... 117
SELECT UNDERPADS .... 117
SELECT UNDERWEAR ... 117
302 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
SELECT-OB + DHA ......... 226
selegiline hcl ......................... 19
selenium ............................. 194
selenium sulfide.................... 45
selenomax ........................... 194
SELF-ADHERING
BANDAGE .................... 117
SELF-CATHETER, FEMALE
........................................ 117
SELF-GRIP ........................ 117
selsun blue ............................ 45
selsun blue (pyrithione zinc) 71
selsun blue (salicylic acid) ... 47
SELZENTRY ......................... 5
se-natal 19 .......................... 226
se-natal 19 (with docusate) . 226
senexon ............................... 142
senexon-s ............................ 142
senior probiotic ................... 131
senior tabs ........................... 226
senna ........................... 142, 143
senna lax ............................. 142
senna laxative ..................... 142
senna laxative-stool softener
........................................ 142
senna plus ........................... 143
senna with docusate sodium
........................................ 143
senna-extra ......................... 143
senna-s ................................ 143
senna-time s ........................ 143
senno................................... 143
sennosides-docusate sodium
........................................ 143
sen-o-tab ............................. 143
SEN-SERTER .................... 117
SENSIPAR ......................... 128
SENSURA EASICLOSE
WIDE OUTLET ............. 117
sentry .................................. 226
sentry (with lutein) ............. 226
sentry senior ....................... 226
SEREVENT DISKUS ........ 187
SEROSTIM ........................ 147
sertraline ............................... 34
sesame oil ............................. 76
se-tan dha ............................ 226
se-tan plus ........................... 226
setlakin................................ 158
sevelamer carbonate ............. 76
SEVEN SYSTEM SENSOR
........................................ 117
severe allergy ........................ 30
severe cold .......................... 181
severe cold multi-symptom 181
severe congestion ................. 82
SEVERE CONGESTION
AND COUGHMAX ....... 181
sevoflurane ........................... 76
sf 82
sf 5000 plus .......................... 82
shake that ache...................... 30
shark fin cartilage ................. 76
sharobel .............................. 153
SHEER BANDAGE ........... 117
SHEER STRIPS ASSORTED
........................................ 117
SHIELDS............................ 117
SIDEKICK BLOOD
GLUCOSE SYSTEM ..... 118
SIDEROL ........................... 226
SIDESTREAM ................... 118
SIDESTREAM ADULT
FACE MASK ................. 118
SIDESTREAM PEDIATRIC
FACE MASK ................. 118
silace ................................... 143
siladryl sa ............................ 181
silapap ................................... 30
sildenafil (antihypertensive)
........................................ 187
SILICONE MASK - INFANT
........................................ 118
SILICONE SCAR ................ 56
silk skin bath ......................... 56
silphen cough ...................... 182
siltussin dm das .................. 182
siltussin sa........................... 182
siltussin-dm ........................ 182
silver nitrate .......................... 56
silver nitrate applicators ....... 56
silver sulfadiazine ................. 45
SIMCOR ............................... 43
simethicone ......................... 143
SIMILAC ADVANCE ....... 206
similac advance organic ..... 206
SIMILAC ADVANCE
ORGANIC ...................... 206
SIMILAC ADVANCE WITH
IRON .............................. 206
similac alimentum .............. 206
SIMILAC EXPERT CARE 206
similac expert care alimentum
........................................ 206
SIMILAC EXPERT CARE
ALIMENTUM ................ 206
similac expert care neosure 206
SIMILAC EXPERT CARE
NEOSURE ...................... 206
SIMILAC FOR SPIT-UP ... 206
SIMILAC HUMAN MILK
FORTIFIER .................... 206
SIMILAC LOW-IRON ...... 206
SIMILAC NEOSURE ........ 206
SIMILAC PM ..................... 206
SIMILAC PRO-ADVANCE
NON-GMO ..................... 206
SIMILAC SENSITIVE ...... 206
similac sensitive fuss and gas
........................................ 206
SIMILAC SENSITIVE FUSS
AND GAS ...................... 206
SIMILAC SENSITIVE
ISOMIL SOY ................. 206
SIMILAC SOY ISOMIL .... 207
similac sterilized water ......... 76
simple syrup .......................... 76
SIMPLICITY ADULT FLAT
FOLD XL ....................... 118
SIMPLICITY ADULT POLY
MEDIUM ....................... 118
SIMPLICITY CONTOURED
LINER ............................ 118
SIMPLICITY PAD ............. 118
simply sleep ........................ 182
simvastatin ............................ 43
sinelee ................................... 56
303 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
SINGLE USE EZ FLU 2013-
14 (PF) ............................ 150
SINGLE USE EZ FLU 2014-
15(PF) ............................. 150
SINGLE-LET ..................... 118
sinugator nasal wash kit ....... 82
sinus 12 hour ...................... 182
sinus and allergy non-drowsy
........................................ 182
sinus and allergy pe ............ 182
sinus congestion and pain ... 182
sinus congestion-pain(chlorph)
........................................ 182
sinus congestion-pain(guaif)
........................................ 182
sinus congest-pain day-night
........................................ 182
sinus decongestant (pe) ...... 182
sinus headache pe ............... 182
sinus nasal spray ................... 82
sinus pain relief .................. 182
sinus pe decongestant ......... 182
sinus relief (non-drowsy) ... 182
sinus relief (oxymetazoline) . 82
sinus rinse pediatric .............. 83
sinus rinse pediatric starter ... 83
sinus wash ............................ 83
SINUS WASH...................... 83
sinus wash netipot ................ 83
sinus-allergy (phenylephrine)
........................................ 182
SINUSTAR AEROSOL ..... 118
sirolimus ............................... 16
skin cleanser ......................... 56
SKIN CLOSURE STRIPS . 118
SKIN GEL PROTECT
DRESSING WIPE.......... 118
SKIN PREP WIPES ........... 118
skin protectant a and d .......... 56
skin treatment ....................... 56
SKINTEGRITY HYDROGEL
........................................ 118
SKLICE ................................ 71
sleep aid (diphenhydramine)
........................................ 182
SLEEP AID
(DIPHENHYDRAMINE)
........................................ 182
sleep aid (doxylamine) ......... 34
SLEEP COMFORTS .......... 118
sleep ii................................. 182
SLEEP OVERS PANTS .... 118
SLEEP PANTS................... 118
sleep-tabs ............................ 182
SLIP-ON UNDERGARMENT
........................................ 118
slo-niacin .............................. 43
slow release iron ................. 226
SLOW-MAG ...................... 194
SMART SENSE LANCETS
........................................ 118
SMARTDIABETES
VANTAGE ..................... 118
SMARTDIABETES XPRES
........................................ 118
SMARTEST CONTROL ... 118
SMARTEST LANCET ...... 118
SMARTEST PERSONA
STARTER ...................... 118
SMARTEST PRONTO
STARTER ...................... 118
smooth antacid .................... 194
smoothlax ........................... 143
SMS GLUCOSE CONTROL
........................................ 118
sochlor ................................ 163
sodium acetate .................... 194
SODIUM BENZOATE
(BULK) ............................ 83
sodium bicarbonate..... 143, 194
sodium bisulfite .................... 76
sodium chlor 0.9% bacteriostat
.......................................... 76
sodium chloride ... 76, 163, 187,
194
sodium chloride 0.45 % ...... 194
sodium chloride 0.9 % .......... 76
sodium chloride 3 % ........... 194
sodium chloride 5 % ........... 194
sodium citrate-citric acid .... 189
SODIUM EDECRIN ............ 39
sodium ferric gluconat-sucrose
.......................................... 76
sodium phenylbutyrate ......... 76
sodium phosphate ............... 194
sodium polystyrene sulfonate
.......................................... 76
sodium saccharin (bulk) ....... 76
sodium succinate .................. 76
sof-lax ................................. 143
SOF-SENSOR .................... 118
SOF-SET ADHESIVE
PATCH ........................... 118
SOFT CLOTH .................... 118
SOFT TOUCH LANCETS . 118
SOFTFLEX SKIN BARRIER
RING .............................. 119
SOFT-TIP THERMOMETER
........................................ 119
sojourn .................................. 76
SOLODYN ........................... 12
SOLOSITE WOUND GEL 119
soluble fiber ........................ 143
SOLU-CORTEF (PF) ........... 85
SOLU-MEDROL ................. 85
SOLU-MEDROL (PF) ......... 85
SOLUS V2 AUDIBLE
METER ........................... 119
SOLUS V2 CONTROL
SOLUTION,HIGH ......... 119
SOLUS V2 LANCETS ....... 119
SOLUS V2 LANCING
DEVICE ......................... 119
SOLUS V2 TEST STRIPS . 119
SOMATULINE DEPOT ...... 16
SOMAVERT ...................... 128
sonafine ................................. 56
soothe (bismuth subsalicylate)
........................................ 131
soothe and cool body powder
.......................................... 76
SOOTHE NIGHT TIME
LUBRICANT ................. 163
soothe regular strength ....... 131
soothing care (hydrocortisone)
.......................................... 69
soothing pureway-c ............ 226
304 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
sorbidon hydrate ................... 56
sorbitol .................................. 76
SORBSAN WOUND
DRESSING .................... 119
sorbugen nr ......................... 182
sore throat ............................. 63
sore throat (benzocaine-menth)
.......................................... 63
sore throat (hexylresorcinol) 83
sore throat (phenol) .............. 83
sore throat relief (pectin) ...... 83
SORESPOT ........................ 119
sotalol ................................... 35
sotalol af ............................... 35
soy isoflavones ..................... 76
sp antipruritic........................ 56
sp scar management ............. 56
spearmint oil ......................... 79
special care lotion ................. 56
SPECTRAGEL................... 119
spectravite adult 50+ .......... 226
spectravite advanced formula
........................................ 226
spectravite men's ................ 226
spectravite senior ................ 227
spectravite senior w-lycopene
........................................ 227
spectravite ultra women ..... 227
spectravite ultra women's sr 227
spinosad ................................ 71
SPIRIVA RESPIMAT ....... 187
SPIRIVA WITH
HANDIHALER .............. 187
spironolactone ...................... 39
spironolacton-hydrochlorothiaz
.......................................... 39
sports pain relief rub ............. 56
sports rub pain relieving ....... 56
SPORTS TAPE .................. 119
sportscreme........................... 56
sprayzoin .............................. 56
sprintec (28)........................ 158
SPRYCEL ............................ 16
sps (with sorbitol) ................. 76
sronyx ................................. 158
ssd ......................................... 45
SSKI ..................................... 86
sss 10-5 ................................. 60
st. john's wort ........................ 79
stannous fluoride .................. 83
STA-PUT UNDERPAD ..... 119
stavudine ................................. 5
STAVZOR............................ 18
stay awake ............................ 76
stearyl alcohol....................... 76
STERILANCE TL .............. 119
sterile eye drops .................. 166
STERILE PADS ................. 119
sterile saline .................... 76, 83
STERI-STRIP DRESSING 119
STERI-STRIP SKIN
CLOSURES.................... 119
STIMATE ........................... 128
stimulant laxative plus ........ 143
STOMA CAP-ADHESIVE-
FILTER .......................... 119
STOMA CONE-
CONNECTOR REPL UNIT
........................................ 119
STOMA LUBRICANT ...... 119
stomach relief ..................... 131
stomach relief max strength 131
STOMAHESIVE
PROTECTIVE................ 119
STOMAHESIVE SKIN
BARRIER ....................... 119
stool softener ...................... 143
stool softener (docusate cal)
........................................ 143
stool softener-laxative ........ 143
stool softener-stimulant laxat
........................................ 143
stop lice................................. 71
stop smoking aid ................... 80
STRATASORB ISLAND
DRESSING .................... 119
STREPTOMYCIN ............... 10
stress 500 plus zinc ............. 227
stress b plus zinc ................. 227
stress b with zinc ................ 227
stress formula ..................... 227
stress formula advanced ..... 227
stress formula plus iron ...... 227
stress formula with iron ...... 227
stress formula with iron(sulf)
........................................ 227
stress formula with zinc ...... 227
stresstabs with zinc ............. 227
STRETCH GAUZE
BANDAGE ..................... 119
STRIBILD .............................. 5
strong iodine ................. 64, 194
STRONG STRIPS .............. 119
STROVITE ONE ................ 227
SUBOXONE ........................ 30
SUCRAID ........................... 143
sucralfate ............................. 146
sucrose (bulk) ....................... 76
sudogest .............................. 182
sudogest 12-hour ................ 182
sudogest cold and allergy ... 182
sudogest pe ......................... 182
sudogest sinus and allergy .. 182
sulfacetamide sodium ... 45, 165
sulfacetamide sodium (acne) 64
sulfacetamide sodium-sulfur 60
sulfacetamide sod-sulfur-urea
.......................................... 60
sulfacetamide-prednisolone 165
sulfacetamide-sulfur-cleansr23
.......................................... 60
sulfacleanse 8-4 .................... 60
sulfact na-sul-avobnz-otn-ocsa
.......................................... 60
sulfadiazine ........................... 11
sulfamethoxazole-trimethoprim
.......................................... 11
SULFAMYLON ................... 64
sulfasalazine ....................... 143
sulfatrim ................................ 11
sulfo-lo .................................. 47
sulindac ................................. 30
sumatriptan ........................... 19
sumatriptan succinate ........... 19
summer's eve douche .......... 154
sunrise compressor-nebulizer
........................................ 119
sunvite ................................. 227
305 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
super antioxidant ................ 227
super b complex-vitamin c . 227
super b maxi complex ........ 227
super b/c ............................. 227
super b-50 complex ............ 227
super b-50 complex plus .... 227
super calcium...................... 194
super energy herbal complex 79
super multiple ..................... 227
super multivitamin.............. 227
super omega-3 .............. 43, 207
super pain relief .................... 30
super probiotic .................... 132
super quints ........................ 227
super quints b-50 ................ 227
SUPER STRIP BANDAGES
........................................ 119
super thera vite m ............... 227
SUPER THIN LANCETS .. 119
superplex-t .......................... 227
suphedrin ............................ 182
suphedrine .......................... 182
suphedrine 12 hour ............. 182
suphedrine pe...................... 183
suphedrine pe cold and allergy
........................................ 183
suphedrine pe sinus headache
........................................ 183
SUPLENA CARB STEADY
........................................ 207
support ................................ 227
SUPPOSISTRIP ................. 119
suppository adult ................ 143
SUPPOSITORY MOLDS .. 119
SUPPOSITORY SHELL,
MEDIUM ....................... 119
SUPPOSITORY SHELL,
SMALL .......................... 120
supreme antacid .................. 143
SUPREME DIAPERS SIZE 6
........................................ 120
SUPREP BOWEL PREP KIT
........................................ 143
supress dx ........................... 183
SURE CARE PROTECTIVE
UNDERWEAR .............. 120
SURE COMFORT ALCOHOL
PREP PADS ................... 120
SURE COMFORT LANCETS
........................................ 120
SURE COMFORT LANCING
PEN ................................ 120
SURE COMFORT PEN
NEEDLE ........................ 120
SURE EDGE ...................... 120
SURE EDGE BLOOD
GLUCOSE METER ....... 120
SURE EDGE CONTROL
LOW ............................... 120
SURECARE ....................... 120
SURECHEK GLUCOSE
CONTROL ..................... 120
SURECHEK TEST STRIPS
........................................ 120
SURECHOICE BLADDER
CONTROL ..................... 120
SURE-FINE PEN NEEDLES
........................................ 120
SUREFLEX LANCING
DEVICE ......................... 120
SURE-JECT INSULIN
SYRINGE ....................... 120
SURE-LANCE ................... 120
SURE-PEN LANCING
DEVICE ......................... 120
SURE-PREP ALCOHOL
PREP PADS ................... 120
SUREPRESS HIGH
COMPRESSION ............ 120
SURE-TEST EASYPLUS
MINI ............................... 120
SURE-TOUCH LANCET .. 120
surfak .................................. 143
SUR-FIT NATURA
ADAPTOR ..................... 120
SUR-FIT NATURA CLOSED
POUCH .......................... 120
SUR-FIT NATURA CONVEX
INSERTS ........................ 120
SUR-FIT NATURA
DRAINABLE POUCH .. 120
SUR-FIT NATURA
DURAHESIVE ............... 120
SUR-FIT NATURA FLANGE
CAP ................................ 120
SUR-FIT NATURA HIGH
OUTPUT ........................ 120
SUR-FIT NATURA IRRIG
FACEPLATE ................. 121
SUR-FIT NATURA LOW-
PRESSURE .................... 121
SUR-FIT NATURA MINI-
POUCH ........................... 121
SUR-FIT NATURA
STOMAHESIVE ............ 121
SUR-FIT NATURA
UROSTOMY POUCH ... 121
SUR-FIT-ACTIVE LIFE TAIL
CLOS .............................. 121
SURGICAL DRESSING
EXTR PROTCT ............. 121
surgilube ............................... 56
SUSTIVA ............................... 5
SUTENT ............................... 16
sween cream ......................... 56
sween prep ............................ 67
sweet oil ................................ 56
syeda ................................... 158
symax fastabs ...................... 132
symax-sl .............................. 132
symax-sr ............................. 132
SYMBICORT ..................... 187
SYMLINPEN 120 .............. 121
SYMLINPEN 60 ................ 121
SYNAGIS ............................... 5
SYNALGOS-DC .................. 22
SYNAREL .......................... 128
SYNERCID .......................... 10
synovacin .............................. 30
synvexia patch ...................... 63
SYPRINE ............................. 76
syrex sodium chloride 0.9% . 76
syrpalta ................................. 76
syrpalta vehicle ..................... 76
SYSTANE (PF) .................. 164
SYSTANE (PROPYLENE
GLYCOL) ....................... 164
306 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
SYSTANE GEL ................. 164
SYSTANE ULTRA............ 164
SYSTANE ULTRA (PF) ... 164
T tab a vite ............................. 227
tab tussin ............................. 183
tab tussin dm....................... 183
tab-a-vite............................. 227
tab-a-vite/iron ..................... 227
tab-a-vite-minerals ............. 227
TABLOID ............................ 16
tacrolimus ....................... 16, 56
tactinal .................................. 30
tactinal extra strength ........... 30
tagamet hb .......................... 146
talc (bulk) ............................. 56
TALWIN .............................. 30
tamoxifen .............................. 16
tamsulosin........................... 188
TARCEVA ........................... 16
targeted acne spot treatment . 60
TARGRETIN ....................... 16
tarina fe 1/20 (28) ............... 158
taron forte ........................... 228
taron-bc............................... 228
taron-c dha .......................... 228
taron-prex prenatal-dha ...... 228
TASIGNA ............................ 16
tazarotene ............................. 60
TAZICEF ............................... 7
TAZORAC ........................... 60
taztia xt ................................. 39
tea tree oil ............................. 77
tears again ........................... 164
tears again (pva) ................. 164
TEARS NATURALE FORTE
........................................ 164
TEARS NATURALE FREE
(PF) ................................. 164
tears pure ............................ 164
TECHLITE LANCETS ...... 121
TECHLITE PEN NEEDLE 121
TEFLARO .............................. 7
TEGADERM FIRST AID
STYLE ........................... 121
TEGADERM HP FRAME
STYLE............................ 121
TEGADERM
HYDROCOLLOID ........ 121
TEGADERM
HYDROCOLLOID THIN
........................................ 121
TEGAGEN HG .................. 121
TEGAGEN HI .................... 121
TEKTURNA ........................ 39
TEKTURNA HCT ............... 39
TELCARE CONTROL ...... 121
TELCARE LANCETS ....... 121
TELFA AMD ..................... 121
TELFA CLEAR WOUND
DRESSING .................... 121
TELFA OUCHLESS NON-
ADHERENT .................. 121
telmisartan ............................ 39
telmisartan-amlodipine ......... 39
telmisartan-hydrochlorothiazid
.......................................... 39
temazepam ............................ 34
temozolomide ....................... 16
TENA PANTS SUPER
LARGE ........................... 121
TENA PROTECTIVE
UNDERWEAR .............. 121
TENA SERENITY ............. 121
TENA STRETCH ULTRA 121
tencon ................................... 22
TENDERSORB UNDERPAD
........................................ 121
TENS UNIT ELECTRODES
........................................ 122
tera-gel tar shampoo ............. 45
terazosin................................ 39
terbinafine hcl ................... 3, 67
terbutaline ........................... 187
terconazole.......................... 154
terrell .................................... 77
TERUMO INSULIN
SYRINGE ....................... 122
TESTIM.............................. 128
testosterone ......................... 128
TESTOSTERONE (BULK)
........................................ 128
testosterone cypionate ........ 128
testosterone enanthate ......... 128
tetcaine ................................ 164
tetrabenazine ......................... 20
tetracaine hcl ....................... 164
tetracaine hcl (pf) ................ 164
tetracycline ........................... 12
TEV-TROPIN ..................... 148
TEXACORT ......................... 69
tg 10peh-380gfn-15dm ....... 183
THALOMID ......................... 16
the magic bullet .................. 143
THEO-24 ............................ 187
theochron ............................ 187
theophylline ........................ 187
thera .................................... 228
thera bath .............................. 56
thera-d ................................. 228
thera-derm ............................. 56
thera-derm bath ..................... 56
thera-gel ................................ 45
theralogix companion ......... 228
thera-m ................................ 228
therapeutic blue .................... 56
therapeutic formula/hematinics
........................................ 228
therapeutic liquid ................ 228
therapeutic m + beta-carotene
........................................ 228
therapeutic moisturizing ....... 56
therapeutic shampoo ....... 45, 47
therapeutic t plus ................... 47
therapeutic-m ...................... 228
therapeutic-m vitamin/minerals
........................................ 228
theraseal ................................ 56
thera-tabs ............................ 228
thera-tabs m ........................ 228
theratrum complete 50 plus 228
theratrum complete 50 plus/lut
........................................ 228
theratrum complete with lutein
........................................ 228
therems ............................... 228
307 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
THEREMS-H ..................... 228
therems-m ........................... 228
thermazene ........................... 45
thermometer covers ............ 122
THERMOPHORE
MAXHEAT .................... 122
THERMOPHORE PACK
STANDARD .................. 122
THERMOSCAN
THERMOMETER ......... 122
thermotabs .......................... 194
thiamine hcl (vitamin b1) ... 228
thinpro insulin syringe ........ 122
THINPRO INSULIN
SYRINGE....................... 122
THIOLA ............................... 77
thioridazine ........................... 34
thiotepa ................................. 16
thiothixene ............................ 34
thritex ................................... 57
thrivite-19 ........................... 228
throat drops ........................... 83
throat lozenges.................... 183
thyroid (pork) ..................... 129
THYROLAR-1 ................... 129
THYROLAR-1/2 ................ 129
THYROLAR-1/4 ................ 129
THYROLAR-2 ................... 129
THYROLAR-3 ................... 129
thyroshield ............................ 86
tiagabine ............................... 18
TICE BCG .......................... 150
ticlopidine ............................. 42
TIGAN ............................... 143
tiger balm.............................. 57
tilia fe.................................. 158
TIMENTIN........................... 11
timolol maleate ............. 39, 160
tinactin .................................. 67
tinidazole .............................. 10
tioconazole-1 ...................... 154
TIROSINT .......................... 129
tis-u-sol pentalyte ................. 71
TIVICAY ............................... 5
tizanidine .............................. 20
tl gard rx ............................. 228
tl g-fol os ............................ 228
tl icon .................................. 228
tl-care dha ........................... 228
tl-fluorivite.......................... 228
tl-hem 150........................... 228
tl-select ............................... 228
TOBRADEX ...................... 165
TOBRADEX ST................. 165
tobramycin .......................... 160
tobramycin in 0.225 % nacl .. 10
tobramycin in 0.9 % nacl ...... 10
tobramycin sulfate ................ 10
tobramycin-dexamethasone 165
TOBREX ............................ 160
tolazamide .......................... 122
tolbutamide ......................... 122
tolcapone .............................. 19
tolmetin ................................. 31
tolnaftate ............................... 67
tolterodine ........................... 188
TOOTHETTE ..................... 122
TOPCARE ULTRA
COMFORT ..................... 122
TOPCARE UNIVERSAL1
LANCET ........................ 122
topiragen ............................... 18
topiramate ............................. 18
toposar .................................. 16
torsemide .............................. 39
total allergy medicine ......... 183
total b/c ............................... 228
totalday multiple ................. 229
TOUCH-TROL .................. 122
TOVIAZ ............................. 188
t-plus ..................................... 45
TRACE ELEMENTS
4/PEDIATRIC ................ 194
TRACLEER ....................... 187
tragacanth ............................. 77
TRAINING PANTS 2T-3T 122
tramadol ................................ 31
tramadol-acetaminophen ...... 31
trandolapril ........................... 39
trandolapril-verapamil .......... 39
tranexamic acid............. 42, 154
TRANQUILITY PREMIUM
UNDERWEAR ............... 122
TRANQUILITY TOPLINER
PADS .............................. 122
TRANSDERM-SCOP ........ 143
TRANSFER PIN ................ 122
TRANSPARENT
DRESSINGS .................. 122
TRANSPORE SURGICAL 122
TRANSPORT CHAIR ....... 122
tranylcypromine .................... 34
TRAVATAN Z ................... 165
travel sickness ..................... 143
travel sickness (meclizine) . 144
travoprost (benzalkonium) .. 165
trazodone .............................. 35
treagan otic ........................... 84
TRECATOR ......................... 10
tretinoin ................................. 60
tretinoin (chemotherapy) ...... 16
tretinoin microspheres .......... 60
TREXALL ............................ 16
tri femynor .......................... 158
TRIAD WOUND DRESSING
.......................................... 57
triadvance ........................... 229
triamcinolone acetonide . 69, 83,
85, 187
TRIAMINIC COLD AND
COUGH (PE) .................. 183
triamterene-hydrochlorothiazid
.......................................... 39
trianex ................................... 69
triazolam ............................... 35
tri-biozene ............................. 65
tri-buffered aspirin ................ 31
TRICARE ........................... 229
TRICARE PRENATAL DHA
ONE ................................ 229
tri-chlor ................................. 57
tricitrates ............................. 189
tricon ................................... 229
triderm .................................. 69
tri-estarylla .......................... 159
trifluoperazine ....................... 35
trifluridine ........................... 160
308 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
trigels-f forte ....................... 229
trigofen dm ......................... 183
trihexyphenidyl..................... 19
triklo ..................................... 43
tri-legest fe.......................... 159
tri-linyah ............................. 159
tri-lo-estarylla ..................... 159
tri-lo-marzia ........................ 159
tri-lo-sprintec ...................... 159
trilyte with flavor packets ... 144
trimethobenzamide ............. 144
trimethoprim ......................... 12
trimipramine ......................... 35
trinatal gt ............................ 229
trinatal rx 1 ......................... 229
trinate .................................. 229
trinessa (28) ........................ 159
trinessa lo............................ 159
TRIOXIN ............................. 84
triphrocaps .......................... 229
triple antibiotic ..................... 65
triple antibiotic (pram) extra 65
triple antibiotic plus .............. 65
triple antibiotic-pain relief .... 65
triple omega 3-6-9 .............. 207
triple paste af ........................ 67
triple vitamin with fluoride 229
tri-previfem (28) ................. 159
tri-sprintec (28) ................... 159
tri-tabs dha .......................... 229
TRIUMEQ .............................. 5
triveen-duo dha ................... 229
triveen-one .......................... 229
triveen-prx rnf .................... 229
TRI-VI-SOL WITH IRON . 229
tri-vit with fluoride and iron
........................................ 229
tri-vita ................................. 229
tri-vitamin ........................... 229
tri-vitamin with fluoride ..... 229
trivora (28).......................... 159
trixaicin................................. 57
TRIZIVIR ............................... 5
trolamine salicylate .............. 57
tropical breeze douche ........ 154
tropicamide ......................... 161
trospium .............................. 188
TRUE2GO BLOOD
GLUCOSE SYSTEM ..... 122
TRUECONTROL LEVEL 0
........................................ 122
TRUEDRAW LANCING
DEVICE ......................... 122
TRUEPLUS INSULIN ....... 122
TRUEPLUS KETONE ....... 122
TRUEPLUS LANCETS ..... 122
TRUEPLUS PEN NEEDLE
........................................ 122
TRUERESULT BLOOD
GLUCOSE SYSTM ....... 123
TRUETRACK BLOOD
GLUCOSE SYSTEM ..... 123
TRUETRACK SMART
SYSTEM ........................ 123
TRUETRACK TEST ......... 123
tru-micin ............................... 57
trust natal dha ..................... 229
TRUSTEX LUBRICATED
CONDOMS .................... 123
TRUSTEX-RIA
LUB/SPERMICIDE ....... 123
TRUVADA ............................ 5
TRUZONE PEAK FLOW
METER .......................... 123
trymine cg ........................... 183
TUGABOOS DIAPERS..... 123
TUGABOOS OVERNIGHTS
........................................ 123
TUGABOOS TRAINING
PANTS ........................... 123
tums dual action (famotidine)
........................................ 146
tums ultra .................... 144, 194
turpentine oil......................... 57
tusnel c ................................ 183
tusnel diabetic ..................... 183
tusnel pediatric ................... 183
tussi pres-b .......................... 183
tussigon ............................... 183
tussin ................................... 183
tussin cf............................... 183
tussin cf (pe-dm-guaif) ....... 183
tussin cf max ....................... 183
tussin chest congestion ....... 183
tussin cold-congestion ........ 183
tussin cough (dm only) ....... 183
tussin cough dm .................. 183
tussin cough-chest congestion
........................................ 183
tussin dm ............................. 183
tussin dm clear .................... 183
tussin dm cough .................. 183
tussin dm cough and chest .. 183
tussin dm max ..................... 183
tussin honey ........................ 183
tussin long-acting ................ 184
tussin maximum strength .... 184
tussin maximum strength
cough .............................. 184
tussin pe .............................. 184
tussi-pres ............................. 184
TWOCAL HN .................... 207
TYBOST ................................. 5
TYGACIL ............................. 10
TYKERB .............................. 16
tylophen ................................ 31
TYMLOS ............................ 151
tyr cooler ............................. 207
TYR EXPRESS20 .............. 207
TYR GEL POWDER ......... 207
TYREX-1 ........................... 207
TYREX-2 ........................... 207
TYROS 1 ............................ 207
TYROS 2 ............................ 207
TYVASO ............................ 187
TYVASO REFILL KIT ...... 187
TYVASO STARTER KIT . 187
TYZEKA ................................ 5
U UCD 2 ................................. 207
UCD ANAMIX JUNIOR ... 207
ULESFIA .............................. 71
ulticare ................................ 123
ULTICARE ........................ 123
ULTI-LANCE .................... 123
ULTILET ALCOHOL SWAB
........................................ 123
309 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
ULTILET BASIC LANCETS
........................................ 123
ULTILET CLASSIC
LANCETS ...................... 123
ULTILET INSULIN
SYRINGE....................... 123
ULTILET LANCETS ........ 123
ULTILET PEN NEEDLE .. 123
ULTILET SAFETY
LANCETS ...................... 123
ULTIMA MONITOR ......... 123
ULTIMA TEST STRIPS .... 123
ultimate women's complete
50+ .................................. 229
ultimatecare one ................. 229
ultimatecare one nf ............. 229
ultra antioxidant formula .... 229
ultra b-100 complex ........... 229
ultra comfort insulin syringe
........................................ 123
ULTRA COMFORT INSULIN
SYRINGE....................... 123
ultra dairy digestive ............ 144
ULTRA FINE CUT N CRUSH
........................................ 123
ultra fresh............................ 164
ULTRA FRESH PM .......... 164
ULTRA LUBRICANT EYE
........................................ 164
ultra mide 25......................... 57
ultra omega-3...................... 207
ultra sleep (doxylamine succ)
.......................................... 35
ULTRA THIN LANCETS . 123
ULTRA THIN PLUS
LANCETS ...................... 123
ULTRA TLC LANCETS ... 123
ULTRACAL....................... 207
ultracin t................................ 57
ULTRA-FLEX ................... 123
ULTRALANCE LANCETS
........................................ 123
ULTRA-LIGHT ROLLATOR
........................................ 124
ULTRA-SOFT GLOVES ... 124
ULTRA-THIN II INSULIN
SYRINGE ....................... 124
ULTRATRAK .................... 124
ULTRATRAK GLUCOSE
METER .......................... 124
ULTRATRAK ULTIMATE
........................................ 124
umecta .................................. 57
UNDERGARMENT EXTRA
ABSORBENT ................ 124
UNDERJAMS SMALL-
MEDIUM ....................... 124
UNDERPADS .................... 124
UNDERPADS REGULAR 124
UNDERWEAR .................. 124
UNDERWEAR FOR MEN 124
UNGUATOR LID .............. 124
unicomplex-m ..................... 229
UNIFINE PENTIPS ........... 124
UNIFINE PENTIPS PLUS 124
UNIGARD INCONTINENT
PAD ................................ 124
UNILET COMFORTOUCH
LANCET ........................ 124
UNILET EXCELITE II
LANCET ........................ 124
UNILET EXCELITE
LANCET ........................ 124
UNILET GP LANCET ....... 124
UNILET LANCET ............. 124
UNISOLVE ADHESIVE
REMOVER WIPE .......... 124
unisom sleepgels................. 184
UNISTIK 2 DEVICE ......... 124
UNISTIK 2 NORMAL
LANCET,DEVICE......... 124
UNISTIK 3 ......................... 124
UNISTIK 3 EXTRA LANCET
........................................ 124
UNISTIK CZT LANCET ... 124
UNISTIK SAFETY ............ 124
UNISTIK TOUCH LANCETS
........................................ 124
unithroid ............................. 129
UNIVERSAL 1 LANCETS 124
UNIVERSAL REMOVER
WIPES ............................ 124
unscented cold cream ........... 57
UP AND UP BABY DIAPER
........................................ 125
UPTRAVI ............................. 39
ur n-c ................................... 189
URAMAXIN GT .................. 57
uramit mb ............................ 189
urea ....................................... 57
urea (with lactic,salicy acid) . 57
urea 50% ............................... 57
urea nail stick ........................ 57
ureacin-20 ............................. 57
urea-hyaluronate sodium ...... 57
ure-k ...................................... 57
URETHRAL CATHETER . 125
uretron d-s ........................... 189
urimar-t ............................... 189
urin ds ................................. 189
URINARY LEG MEDIUM
BAG ................................ 125
urinary pain relief ............... 189
URINARY TRACT INF.TEST
(WBCS) ............................ 77
uristat .................................. 189
URISTIX 4 ......................... 125
URISTIX REAGENT ......... 125
URO MINICAP .................. 125
uro-458 ............................... 189
uro-blue ............................... 189
urogesic-blue ...................... 189
uro-l .................................... 189
urolet mb ............................. 189
uro-mp ................................ 189
urophen mb ......................... 189
UROQID-ACID NO.2 ........ 189
UROSTOMY DRAIN TUBE
ADAPTER ...................... 125
UROSTOMY MICRO-
POUCH ........................... 125
UROSTOMY MULTI-
CHAMBER POUCH ...... 125
UROSTOMY NIGHT BAG
........................................ 125
UROSTOMY POUCH ....... 125
310 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
ursodiol ............................... 144
uryl ..................................... 189
ustell ................................... 189
utira-c ................................. 189
V vagicaine............................... 63
vagicaine (with vit a,d) ......... 63
vagicream ............................. 63
VAGINAL
CONTRACEPTIVE FILM
........................................ 154
vaginal contraceptive foam 154
VAGINAL CREAM
APPLICATOR ............... 125
vaginal itch ........................... 63
VAGINAL SUPPOSITORY
APPLICATOR ............... 125
vagisil ................................... 63
vagistat-3 ............................ 154
valacyclovir ............................ 6
valerian root.......................... 79
valganciclovir ......................... 6
valproate sodium .................. 18
valproic acid ......................... 18
valproic acid (as sodium salt)
.......................................... 18
valsartan ............................... 39
valsartan-hydrochlorothiazide
.......................................... 39
valu-tapp ............................. 184
vancomycin .......................... 12
VANCOMYCIN IN
DEXTROSE 5 % .............. 12
vandazole ............................ 154
vanicream ............................. 57
VANISHPOINT SYRINGE
........................................ 125
VAPORIZER INHALANT 125
VAPORIZERS ................... 125
vaporizing steam ................ 184
VASELINE PETROLATUM
GAUZE .......................... 125
vasolex .................................. 70
vazobid-pd .......................... 184
v-c forte .............................. 229
vegetable laxative ............... 144
veletri .................................... 39
velivet triphasic regimen (28)
........................................ 159
vemavite-prx-2 ................... 229
VEMLIDY.............................. 6
vena-bal dha ....................... 229
venatal-fa ............................ 229
VENCLEXTA ...................... 16
VENCLEXTA STARTING
PACK ............................... 16
venlafaxine ........................... 35
VENOFER.......................... 229
VENTAVIS ........................ 187
VENTED URINARY LEG
BAG................................ 125
VENTOLIN HFA ............... 187
verapamil .............................. 39
VERDESO............................ 70
verdrocet ............................... 22
VEREGEN ........................... 57
veripred 20 ............................ 85
VERSALON ....................... 125
VERSIVA XC .................... 125
VESICARE ........................ 188
vestura (28) ......................... 159
VGO 20 .............................. 125
VGO 30 .............................. 125
VGO 40 .............................. 125
VIBRAMYCIN .................... 12
vic-forte .............................. 229
vicks dayquil cold-flu relief 184
vicks dayquil cough ............ 184
VICKS DIGITAL
THERMOMETER.......... 125
VICKS NATURE FUSION 184
vicks nature fusion cough ... 184
vicks qlearquil allergy ........ 184
vicks qlearquil nighttime rlf184
vicks qlearquil(oxymetazoline)
.......................................... 83
vicks sinex 12-hour .............. 83
vicks sinex ultra fine mist 12 83
vicks vaposteam ................. 184
VICKS WARM MIST
HUMIDIFIER ................ 125
vicodin .................................. 22
vicodin es .............................. 22
vicodin hp ............................. 22
VICTORY BLOOD
GLUCOSE MONITOR .. 125
VICTORY GLUCOSE TEST
........................................ 125
VICTOZA 2-PAK .............. 125
VIDEX 2 GRAM PEDIATRIC
............................................ 6
vienva ................................. 159
vigabatrin .............................. 18
VIGAMOX ......................... 160
VIGILON PRIMARY
WOUND DRESSING .... 125
VIMPAT ............................... 18
vinate care ........................... 230
vinate dha ............................ 230
vinate ii ............................... 230
vinate m .............................. 230
vinate one ............................ 230
vinblastine ............................. 16
vincasar pfs ........................... 16
vincristine ............................. 16
vinorelbine ............................ 16
VINYL CATHETER .......... 125
vinyl gloves ........................ 125
viorele (28) ......................... 159
VIOS AEROSOL DELIVERY
SYSTEM ........................ 126
VIRACEPT ............................. 6
virdec .................................. 184
virdec dm ............................ 184
VIREAD ................................. 6
virt-advance ........................ 230
virt-bal dha .......................... 230
virt-bal dha plus .................. 230
virt-c dha ............................. 230
virt-care one ........................ 230
virt-gard .............................. 230
virti-sulf ................................ 60
virt-nate ............................... 230
virt-nate dha ........................ 230
virt-phos 250 neutral ........... 194
virt-pn ................................. 230
virt-pn dha .......................... 230
virt-pn plus .......................... 230
311 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
virtrate-2 ............................. 189
virtrate-3 ............................. 189
virtrate-k ............................. 189
virt-select ............................ 230
virtussin ac.......................... 184
virtussin dac........................ 184
virt-vite ............................... 230
virt-vite gt ........................... 230
VISI-FLOW IRRIGATION
SLEEVE ......................... 126
VISI-FLOW IRRIGATION
STARTER ...................... 126
VISI-FLOW IRRIGATOR-
STOMA CONE .............. 126
VISI-FLOW SLEEVE TAIL
CLOSURES ................... 126
VISI-FLOW STOMA CONE
........................................ 126
visine-a ............................... 166
VISION FORMULA (WITH
LUTEIN) ........................ 230
vision-vite + zinc ................ 230
VISTEC X-RAY DETECT 126
VISTOGARD ....................... 13
vit 3 ..................................... 230
vit b complex-folic acid...... 230
vitabee/c ............................. 230
vita-c ................................... 230
vitacel (with lutein) ............ 230
VITAFOL-OB+DHA ......... 230
VITAFOL-ONE ................. 230
vitajoy daily d ..................... 230
VITAL 1.0 CAL ................. 207
VITAL 1.5 CAL ................. 207
VITAL AF 1.2 CAL ........... 207
VITAL HIGH NITROGEN 207
vitalee ................................. 230
vitalets ................................ 230
VITAMED MD ONE RX .. 230
VITAMED MD PLUS RX . 230
vitamin a ............................. 231
vitamin a and d ..................... 57
vitamin a and d diaper rash .. 57
vitamin a palmitate ............. 231
vitamin b complex .............. 231
vitamin b complex with c ... 231
vitamin b-1 ......................... 231
vitamin b-1 (mononitrate) .. 231
vitamin b-12 ....................... 231
vitamin b-2 ......................... 231
vitamin b-6 ......................... 231
vitamin c ............................. 231
vitamin c cough drops ........ 231
vitamin c drops ................... 231
vitamin c with rose hips...... 231
vitamin d3 ........................... 231
vitamin e ................. 57, 58, 232
vitamin e (dl, acetate) ......... 231
vitamin e acetate ................. 231
vitamin e mixed .................. 231
vitamin e natural blend ....... 232
vitamin e plus ....................... 57
vitamin e-vitamins a and d ... 58
vitamin k1 ............................. 42
vitamins a and d .................. 232
vitamins a,c,d and fluoride . 232
vitamins and minerals ......... 232
vitamins b complex ............ 232
VITAMINS B COMPLEX . 232
vitamins for hair ................. 232
vitatrum .............................. 232
VITEKTA ............................... 6
vitrum senior....................... 232
VITRUM SENIOR ............. 232
vits a and d-white pet-lanolin
.......................................... 58
VIVITROL ........................... 31
vivonex rtf .......................... 207
vol-care rx........................... 232
vol-nate ............................... 232
vol-plus ............................... 232
vol-tab rx ............................ 232
voriconazole ........................... 3
VORTEX HOLDING
CHAMBER .................... 126
VORTEX VHC FROG
MASK-CHILD ............... 126
VORTEX VHC LADYBUG
MASK-TODDLR ........... 126
VOTRIENT .......................... 16
vp-ch plus ........................... 232
vp-ch-pnv............................ 232
vp-era ob plus ..................... 232
vp-ggr-b6 ............................ 232
vp-gstn ................................ 207
vp-heme ob ......................... 232
vp-heme one ....................... 232
VP-PNV-DHA .................... 232
VPRIV ................................ 128
vp-vite rx ............................ 232
vp-zel .................................. 207
VUSION ............................... 67
vyfemla (28) ....................... 159
VYVANSE ........................... 35
W wal-act d cold and allergy ... 184
wal-dram ............................. 144
wal-dryl (diphenhydramine) . 58
wal-dryl (diphenhydramine-zn)
.......................................... 58
wal-dryl allergy .................. 184
wal-dryl severe allergy-sinus
........................................ 184
wal-dryl-d allergy and sinus
........................................ 184
wal-fex allergy .................... 184
wal-fex d 12 hour ................ 184
wal-fex d 24 hour ................ 184
wal-finate ............................ 184
wal-finate-d ......................... 184
wal-flu night severe cold .... 184
wal-four ................................ 83
walgreens dry skin treatment 58
wal-itin ................................ 184
wal-itin d ............................. 184
wal-itin d 12 hour ............... 184
wal-mucil fiber ................... 144
wal-mucil fiber (aspartame) 144
wal-mucil fiber (sugar) ....... 144
wal-mucil natural fiber lax . 144
wal-mucil with calcium ...... 144
wal-phed ............................. 185
wal-phed 12 hour ................ 185
wal-phed d .......................... 185
wal-phed pe ........................ 185
wal-phed pe nighttime cold 185
wal-phed pe sinus and allergy
........................................ 185
312 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
wal-profen ............................ 31
wal-profen cold-sinus ......... 185
wal-profen d cold and sinus 185
wal-proxen ............................ 31
wal-som (diphenhydramine)
........................................ 185
wal-som (doxylamine).......... 35
wal-sporin ............................. 65
wal-tap dm .......................... 185
wal-tussin cough ................. 185
wal-tussin cough and cold cf
........................................ 185
wal-tussin dm ..................... 185
wal-tussin max strength cough
........................................ 185
wal-zan 150 ........................ 146
wal-zan 75 .......................... 146
wal-zyr (cetirizine) ............. 185
wal-zyr (ketotifen) .............. 164
wal-zyr d ............................. 185
warfarin ................................ 42
wart remover ........................ 47
WATCHHALER ................ 126
water for inject, bacteriostat . 77
water for injection, sterile..... 77
water for irrigation, sterile .... 77
WATER SHIELD
BANDAGES .................. 126
WATERPROOF STRONG
STRIPS ........................... 126
WAVESENSE CONTROL
SOLUTION .................... 126
WAVESENSE JAZZ ......... 126
WAVESENSE PRESTO .... 126
WEBCOL ........................... 126
wee care .............................. 232
WELCHOL .......................... 43
WELL BEGINNINGS SLEEP
PANTS ........................... 126
wera (28) ............................ 159
westhroid ............................ 129
wheat germ oil .................... 232
WHEELCHAIR ................. 126
white petrolatum ................... 58
white petroleum jelly ............ 58
white wax (beeswax) ............ 77
WIDE-SEAL DIAPHRAGM
65 .................................... 126
WILATE ............................... 42
WING TIP TUBING .......... 126
WINGS CHOICE ADULT
BRIEF ............................. 126
WINGS CHOICE PLUS
ADULT BRIEFS ............ 126
WINGS CHOICE PLUS
YOUTH BRIEFS ........... 126
WINGS CLASSIC ADULT
BRIEFS .......................... 126
WINGS CLASSIC ADULT
BRIEFS X-L ................... 126
WINGS FLUFF AND
POLYMER ..................... 126
WINGS MAXIMA
UNDERPADS ................ 126
WINGS UNDERPAD ........ 126
WINGS XXL ADULT BRIEF
........................................ 126
wintergreen oil ...................... 58
witch hazel ............................ 58
WND 2 ............................... 207
woman's laxative ................ 144
women's 50+ daily form (gkb)
........................................ 232
WOMEN'S ADVANCED BP
MONITOR ..................... 126
WOMEN'S COMPLEX ..... 232
WOMEN'S DAILY CAPLET
........................................ 232
women's daily formula ....... 232
women's gentle laxative(bisac)
........................................ 144
women's laxative (bisacodyl)
........................................ 144
women's menstrual relief ...... 31
women's one daily .............. 232
women's prenatal + dha ...... 233
women's stool softener ....... 144
WOMEN'S UNDERWEAR
........................................ 127
WONDERPANTS .............. 127
WOUND DRAINAGE
COLLECTOR ................ 127
WOUN'DRES HYDROGEL
WOUND DRESS ........... 127
WP THYROID ................... 129
wrestone .............................. 207
wymzya fe .......................... 159
X XALKORI ............................ 16
XARELTO ........................... 42
XERMELO ........................... 16
XEROFLO GAUZE
DRESSING ..................... 127
XEROFORM PETROLATUM
OVERWRAP .................. 127
XIFAXAN ............................ 10
XLEU ANALOG ................ 207
XLEU MAXAMAID .......... 207
XLEU MAXAMUM .......... 207
XLYS- XTRP ANALOG ... 207
XLYS, XTRP MAXAMAID
........................................ 207
XLYS, XTRP MAXAMUM
........................................ 207
XMET ANALOG ............... 207
XMET MAXAMUM .......... 207
XMTVI ANALOG ............. 208
xmtvi maxamaid ................. 208
xmtvi maxamum ................. 208
XOLAIR ............................. 187
XOLEGEL ............................ 67
XPHE MAXAMAID .......... 208
xphe maxamum .................. 208
XPHE MAXAMUM .......... 208
XPHE, XTRP MAXAMAID
........................................ 208
XPHE, XTYR ANALOG ... 208
XPRES NORMAL CONTROL
........................................ 127
XPTM ANALOG ............... 208
x-seb t pearl .......................... 47
x-seb t plus ............................ 45
XTRACAL PLUS .............. 208
xulane ................................. 154
x-viate ................................... 58
xylon 10 ................................ 23
XYNTHA ............................. 42
XYNTHA SOLOFUSE ........ 42
313 Updated 1/2018
Please contact Amida Care Member Services at 1-800-556-0689 or, for TTY users, 711, 8 a.m. to 6 p.m. Monday
– Friday for the most recent list of drugs. http://www.amidacareny.org
XYREM ............................... 35
Y yeast .................................... 233
yelets................................... 233
yuvafem .............................. 153
Z zafirlukast ........................... 187
zaleplon ................................ 35
zamicet ................................. 23
zantac maximum strength... 146
zarah ................................... 159
ZARXIO ............................. 148
zatean-ch............................. 233
zatean-pn ............................ 233
zatean-pn dha...................... 233
zatean-pn plus ..................... 233
zavara ................................. 233
ZAVESCA ......................... 128
z-clinz ................................... 58
zeasorb (miconazole)............ 67
zebutal .................................. 23
ZEJULA ............................... 17
ZELAPAR ............................ 19
ZELBORAF ......................... 17
ZEMAIRA ............................ 77
zenatane ................................ 60
zenchent (28) ...................... 159
zenchent fe .......................... 159
zencia .................................... 60
zenzedi .................................. 35
zeosa ................................... 159
zeruvia .................................. 63
ZIAGEN ................................. 6
zidovudine .............................. 6
zilactin-b ............................... 63
zileuton ............................... 187
ZINACEF ............................... 7
ZINACEF IN STERILE
WATER .............................. 7
zinc ..................................... 194
zinc amino acid chelate ...... 194
zinc and c ............................ 233
zinc gluconate ..................... 194
zinc oxide ............................. 58
zinc sulfate .......................... 194
zinc with vitamins a and c .. 233
zingiber ............................... 233
ziprasidone hcl ...................... 35
ZIRGAN ............................. 160
ZMAX .................................... 8
zolate .................................. 233
zoledronic acid ................... 128
ZOLINZA ............................. 17
zolmitriptan ........................... 19
zolpidem ............................... 35
ZOMETA ........................... 128
zonisamide ............................ 18
zoo chews ........................... 233
zoo friends .......................... 233
zoo friends original ............. 233
ZORTRESS .......................... 17
zostrix ................................... 58
zostrix-hp .............................. 58
ZOSYN IN DEXTROSE (ISO-
OSM) ................................ 11
zovia 1/35e (28) .................. 159
zovia 1/50e (28) .................. 159
ZYCLARA ........................... 58
ZYDELIG ............................. 17
ZYFLO ............................... 187
ZYFLO CR ......................... 187
ZYLET ............................... 165
zyncof ................................. 185
ZYNCOF ............................ 185
ZYPRAM ........................... 144
ZYPREXA RELPREVV ...... 35
ZYVOX ................................ 10
ZZZQUIL ........................... 185