FORMULARY - Amida Care

314
January 2018 FORMULARY

Transcript of FORMULARY - Amida Care

January 2018

FORMULARY

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

Please contact Amida Care Member Services at 1-800-556-0689 or, 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

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

Please contact Amida Care Member Services at 1-800-556-0689 or, 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

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

Please contact Amida Care Member Services at 1-800-556-0689 or, 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

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

Please contact Amida Care Member Services at 1-800-556-0689 or, 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

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

Please contact Amida Care Member Services at 1-800-556-0689 or, 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

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

Please contact Amida Care Member Services at 1-800-556-0689 or, 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

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

Please contact Amida Care Member Services at 1-800-556-0689 or, 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

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

Please contact Amida Care Member Services at 1-800-556-0689 or, 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

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

Please contact Amida Care Member Services at 1-800-556-0689 or, 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-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

Please contact Amida Care Member Services at 1-800-556-0689 or, 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

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

Please contact Amida Care Member Services at 1-800-556-0689 or, 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

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

Please contact Amida Care Member Services at 1-800-556-0689 or, 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

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

Please contact Amida Care Member Services at 1-800-556-0689 or, 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

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