MAP formulary

NON-COMMUNITYCARE PROVIDERS: Medications restricted to CUC Prescribers and/or CUC in-house pharmacies are considered non-formulary outside of CUC. These medications may be obtained via Prescription Assistance Programs (PAP). If the patient does not qualify for PAP, the provider may submit a NON-FORMULARY DRUG REQUEST (NFDR) FORM. Documentation of PAP ineligibility or rejection should be submitted with the NDFR form.

More information on pharmacy benefits can be found in the MAP and MAP Basic Provider Handbook.

NON-FORMULARY DRUG REQUEST (NFDR) FORM

Request an addition to the MAP/MAP Basic formulary

Request an addition to the Central Health floor stock formulary

MAP Formulary (October 2025 edition)

Generic Code	Generic Sequence Number	Therapeutic Class	BrandName	GenericName	Formulation	Strength	Coverage	Location	Comments
49.291	17.037	040800-SECOND GENERATION ANTIHISTAMINES	Zyrtec	CETIRIZINE HCL	TABLET	10 MG	COVERED	FORMULARY
60.563	18.698	040800-SECOND GENERATION ANTIHISTAMINES	Claritin	LORATADINE	TABLET	10 MG	COVERED	FORMULARY
17.853	50.714	120808-ANTIMUSCARINICS/ANTISPASMODICS	Spiriva Handihaler	TIOTROPIUM BROMIDE	CAP W/DEV	18 MCG	COVERED	FORMULARY	CUC/CH prescribers must send to in-house pharmacies only. Non-CUC/CH may fill at network pharmacies
3.421	16.425	129200-AUTONOMIC DRUGS, MISCELLANEOUS	NICOTINE	NICOTINE	PATCH TD24	7 MG/24HR	COVERED	FORMULARY
3.422	16.426	129200-AUTONOMIC DRUGS, MISCELLANEOUS	NICOTINE	NICOTINE	PATCH TD24	14 MG/24HR	COVERED	FORMULARY
3.423	16.427	129200-AUTONOMIC DRUGS, MISCELLANEOUS	NICOTINE	NICOTINE	PATCH TD24	21 MG/24HR	COVERED	FORMULARY
27.047	60.897	129200-AUTONOMIC DRUGS, MISCELLANEOUS	Varenicline (Chantix)	VARENICLINE TARTRATE	TABLET	1 MG	COVERED	FORMULARY
27.046	60.896	129200-AUTONOMIC DRUGS, MISCELLANEOUS	Varenicline (Chantix)	VARENICLINE TARTRATE	TABLET	0.5 MG	COVERED	FORMULARY
18.387	51.214	240605-CHOLESTEROL ABSORPTION INHIBITORS	Zetia	EZETIMIBE	TABLET	10 MG	COVERED	FORMULARY
42.001	41.285	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Celebrex	CELECOXIB	CAPSULE	100 MG	COVERED	FORMULARY
42.002	41.286	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Celebrex	CELECOXIB	CAPSULE	200 MG	COVERED	FORMULARY
97.785	62.001	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Celebrex	CELECOXIB	CAPSULE	50 MG	COVERED	FORMULARY
18.127	50.832	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Celebrex	CELECOXIB	CAPSULE	400 MG	COVERED	FORMULARY
23.046	57.800	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	50 MG	COVERED	FORMULARY
23.047	57.801	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	75 MG	COVERED	FORMULARY
23.048	57.802	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	100 MG	COVERED	FORMULARY
23.049	57.803	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	150 MG	COVERED	FORMULARY
23.051	57.804	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	200 MG	COVERED	FORMULARY
23.052	57.805	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	300 MG	COVERED	FORMULARY
23.039	57.799	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	25 MG	COVERED	FORMULARY
25.019	59.401	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	225 MG	COVERED	FORMULARY
32.359	69.339	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	Solution	20 mg/ml	COVERED	FORMULARY
18.537	51.333	281608-ANTIPSYCHOTIC AGENTS	Abilify	ARIPIPRAZOLE	TABLET	10 MG	COVERED	FORMULARY
18.538	51.334	281608-ANTIPSYCHOTIC AGENTS	Abilify	ARIPIPRAZOLE	TABLET	15 MG	COVERED	FORMULARY
18.539	51.335	281608-ANTIPSYCHOTIC AGENTS	Abilify	ARIPIPRAZOLE	TABLET	20 MG	COVERED	FORMULARY
18.541	51.336	281608-ANTIPSYCHOTIC AGENTS	Abilify	ARIPIPRAZOLE	TABLET	30 MG	COVERED	FORMULARY
20.173	52.898	281608-ANTIPSYCHOTIC AGENTS	Abilify	ARIPIPRAZOLE	TABLET	5 MG	COVERED	FORMULARY
26.305	60.225	281608-ANTIPSYCHOTIC AGENTS	Abilify	ARIPIPRAZOLE	TABLET	2 MG	COVERED	FORMULARY
30.139	67.555	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Dulera MDI	MOMETASONE/FORMOTEROL	HFA AER AD	50-5 MCG	COVERED	FORMULARY
28.766	66.480	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Dulera MDI	MOMETASONE/FORMOTEROL	HFA AER AD	100-5 MCG	COVERED	FORMULARY
28.767	66.481	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Dulera MDI	MOMETASONE/FORMOTEROL	HFA AER AD	200-5 MCG	COVERED	FORMULARY
17.528	50.464	681200-CONTRACEPTIVES	Nuvaring	ETONOGESTREL/ETHINYL ESTRADIOL	VAG RING	0.12-.015 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC/CH Prescribers. Send to a CUC in-house pharmacy
24.471	58.938	681200-CONTRACEPTIVES	Depo-SubQ Provera 104	MEDROXYPROGESTERONE ACETATE	SYRINGE	104 MG	COVERED	FORMULARY
98.306	62.531	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Janumet	SITAGLIPTIN PHOS/METFORMIN HCL	TABLET	50-500 MG	NOT COVERED	NON-FORMULARY
98.307	62.532	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Janumet	SITAGLIPTIN PHOS/METFORMIN HCL	TABLET	50-1000 MG	NOT COVERED	NON-FORMULARY
31.339	68.538	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Janumet XR	SITAGLIPTIN PHOS/METFORMIN HCL	TBMP 24HR	50-500 MG	NOT COVERED	NON-FORMULARY
31.340	68.539	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Janumet XR	SITAGLIPTIN PHOS/METFORMIN HCL	TBMP 24HR	50-1000 MG	NOT COVERED	NON-FORMULARY
31.348	68.540	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Janumet XR	SITAGLIPTIN PHOS/METFORMIN HCL	TBMP 24HR	100-1000 MG	NOT COVERED	NON-FORMULARY
97.398	61.612	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Januvia	SITAGLIPTIN PHOSPHATE	TABLET	25 MG	NOT COVERED	NON-FORMULARY
97.399	61.613	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Januvia	SITAGLIPTIN PHOSPHATE	TABLET	50 MG	NOT COVERED	NON-FORMULARY
97.400	61.614	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Januvia	SITAGLIPTIN PHOSPHATE	TABLET	100 MG	NOT COVERED	NON-FORMULARY
24.614	59.073	682006-INCRETIN MIMETICS	Byetta	EXENATIDE	PEN INJCTR	10 MCG/0.04	NOT COVERED	NON-FORMULARY
24.613	59.072	682006-INCRETIN MIMETICS	Byetta	EXENATIDE	PEN INJCTR	5 MCG/0.04	NOT COVERED	NON-FORMULARY
12.263	47.327	861204-ANTIMUSCARINICS	Detrol LA	TOLTERODINE TARTRATE	CAP ER 24H	4 MG	COVERED	FORMULARY
12.264	47.328	861204-ANTIMUSCARINICS	Detrol LA	TOLTERODINE TARTRATE	CAP ER 24H	2 MG	COVERED	FORMULARY
13.977	48.495	040412-PHENOTHIAZINE DERIVATIVES	Promethazine VC	PHENYLEPHRINE HCL-PROMETHAZINE HCL	SYRUP	5-6.25 MG/5ML	COVERED	FORMULARY
15.001	3.873	040412-PHENOTHIAZINE DERIVATIVES	Phenergan Suppository	PROMETHAZINE HCL	SUPP.RECT	25 MG	COVERED	FORMULARY
15.002	3.874	040412-PHENOTHIAZINE DERIVATIVES	Phenergan Suppository	PROMETHAZINE HCL	SUPP.RECT	50 MG	COVERED	FORMULARY
15.003	3.872	040412-PHENOTHIAZINE DERIVATIVES	Phenergan Suppository	PROMETHAZINE HCL	SUPP.RECT	12.5 MG	COVERED	FORMULARY
15.035	3.876	040412-PHENOTHIAZINE DERIVATIVES	Promethazine	PROMETHAZINE HCL	SYRUP	6.25 MG/5ML	COVERED	FORMULARY
15.042	3.877	040412-PHENOTHIAZINE DERIVATIVES	Promethazine	PROMETHAZINE HCL	TABLET	12.5 MG	COVERED	FORMULARY
15.043	3.878	040412-PHENOTHIAZINE DERIVATIVES	Promethazine	PROMETHAZINE HCL	TABLET	25 MG	COVERED	FORMULARY
15.044	3.879	040412-PHENOTHIAZINE DERIVATIVES	Promethazine	PROMETHAZINE HCL	TABLET	50 MG	COVERED	FORMULARY
96.609	991	040420-PROPYLAMINE DERIVATIVES	Brohist D	BROMPHENIRAMIN-PHENYLEPHRINE	TABLET	4-10 MG	COVERED	FORMULARY
44.023	26.792	040420-PROPYLAMINE DERIVATIVES	Sudogest	PSEUDOEPHEDRINE-CHLORPHENIRAMINE	TABLET	60 MG-4 MG	COVERED	FORMULARY
15.803	4.010	040492-FIRST GEN. ANTIHIST. DERIVATIVES, MISC.	Cypropheptadine	CYPROHEPTADINE HCL	SYRUP	2 MG/5ML	COVERED	FORMULARY
15.811	4.011	040492-FIRST GEN. ANTIHIST. DERIVATIVES, MISC.	Cypropheptadine	CYPROHEPTADINE HCL	TABLET	4 MG	COVERED	FORMULARY
97.950	62.168	040800-SECOND GENERATION ANTIHISTAMINES	Xyzal	LEVOCETIRIZINE DIHYDROCHLORIDE	SOLUTION	2.5 MG/5ML	COVERED	FORMULARY
14.901	48.920	040800-SECOND GENERATION ANTIHISTAMINES	Xyzal	LEVOCETIRIZINE DIHYDROCHLORIDE	TABLET	5 MG	COVERED	FORMULARY
53.290	19.283	080800-ANTHELMINTICS	Albenza	ALBENDAZOLE	TABLET	200 MG	COVERED	FORMULARY
93.064	43.094	080800-ANTHELMINTICS	Stromectol	IVERMECTIN	TABLET	3 MG	COVERED	FORMULARY
41.072	9.284	081202-AMINOGLYCOSIDES	Neomycin	NEOMYCIN SULFATE	TABLET	500 MG	COVERED	FORMULARY
32.231	40.257	081206-CEPHALOSPORINS	Cefdinir	CEFDINIR	CAPSULE	300 MG	COVERED	FORMULARY
23.308	58.005	081206-CEPHALOSPORINS	Cefdinir	CEFDINIR	SUSP RECON	250 MG/5ML	COVERED	FORMULARY
32.232	40.258	081206-CEPHALOSPORINS	Cefdinir	CEFDINIR	SUSP RECON	125 MG/5ML	COVERED	FORMULARY
29.291	16.582	081206-CEPHALOSPORINS	Cefprozil	CEFPROZIL	SUSP RECON	125 MG/5ML	COVERED	FORMULARY
29.292	16.583	081206-CEPHALOSPORINS	Cefprozil	CEFPROZIL	SUSP RECON	250 MG/5ML	COVERED	FORMULARY
29.271	16.584	081206-CEPHALOSPORINS	Cefprozil	CEFPROZIL	TABLET	250 MG	COVERED	FORMULARY
29.272	16.585	081206-CEPHALOSPORINS	Cefprozil	CEFPROZIL	TABLET	500 MG	COVERED	FORMULARY
47.281	9.136	081206-CEPHALOSPORINS	Ceftin	CEFUROXIME AXETIL	TABLET	250 MG	COVERED	FORMULARY
47.282	9.137	081206-CEPHALOSPORINS	Ceftin	CEFUROXIME AXETIL	TABLET	500 MG	COVERED	FORMULARY
39.801	9.042	081206-CEPHALOSPORINS	Keflex	CEPHALEXIN	CAPSULE	250 MG	COVERED	FORMULARY
39.802	9.043	081206-CEPHALOSPORINS	Keflex	CEPHALEXIN	CAPSULE	500 MG	COVERED	FORMULARY
39.812	9.046	081206-CEPHALOSPORINS	Keflex	CEPHALEXIN	SUSP RECON	250 MG/5ML	COVERED	FORMULARY
39.831	9.049	081206-CEPHALOSPORINS	Keflex	CEPHALEXIN	TABLET	500 MG	COVERED	FORMULARY
39.832	9.048	081206-CEPHALOSPORINS	Keflex	CEPHALEXIN	TABLET	250 MG	COVERED	FORMULARY
48.792	24.194	081212-MACROLIDES	Zithromax	AZITHROMYCIN	SUSP RECON	100 MG/5ML	COVERED	FORMULARY
61.199	18.544	081212-MACROLIDES	Zithromax	AZITHROMYCIN	SUSP RECON	200 MG/5ML	COVERED	FORMULARY
48.793	26.721	081212-MACROLIDES	Zithromax	AZITHROMYCIN	TABLET	250 MG	COVERED	FORMULARY
48.794	27.252	081212-MACROLIDES	Zithromax	AZITHROMYCIN	TABLET	600 MG	COVERED	FORMULARY
61.198	22.624	081212-MACROLIDES	Zithromax	AZITHROMYCIN	TABLET	500 MG	COVERED	FORMULARY
11.670	19.146	081212-MACROLIDES	Clarithromycin	CLARITHROMYCIN	SUSP RECON	125 MG/5ML	COVERED	FORMULARY
48.851	16.368	081212-MACROLIDES	Biaxin	CLARITHROMYCIN	TABLET	500 MG	COVERED	FORMULARY
48.852	16.373	081212-MACROLIDES	Biaxin	CLARITHROMYCIN	TABLET	250 MG	COVERED	FORMULARY
40.660	9.258	081212-MACROLIDES	Erythromycin	ERYTHROMYCIN BASE	CAPSULE DR	250 MG	COVERED	FORMULARY
40.720	9.260	081212-MACROLIDES	Erythrocin	ERYTHROMYCIN BASE	TABLET	250 MG	COVERED	FORMULARY
40.721	9.262	081212-MACROLIDES	Erythromycin	ERYTHROMYCIN BASE	TABLET	500 MG	COVERED	FORMULARY
40.730	9.263	081212-MACROLIDES	Ery-Tab	ERYTHROMYCIN BASE	TABLET DR	250 MG	COVERED	FORMULARY
40.731	9.264	081212-MACROLIDES	Ery-Tab	ERYTHROMYCIN BASE	TABLET DR	333 MG	COVERED	FORMULARY
40.732	9.265	081212-MACROLIDES	Ery-Tab	ERYTHROMYCIN BASE	TABLET DR	500 MG	COVERED	FORMULARY
40.523	21.205	081212-MACROLIDES	EryPed 200	ERYTHROMYCIN ETHYLSUCCINATE	SUSP RECON	200 MG/5ML	COVERED	FORMULARY
40.524	21.206	081212-MACROLIDES	EryPed 400	ERYTHROMYCIN ETHYLSUCCINATE	SUSP RECON	400 MG/5ML	COVERED	FORMULARY
40.560	9.245	081212-MACROLIDES	E.E.S 400	ERYTHROMYCIN ETHYLSUCCINATE	TABLET	400 MG	COVERED	FORMULARY
40.642	9.255	081212-MACROLIDES	Erythromycin	ERYTHROMYCIN STEARATE	TABLET	250 MG	COVERED	FORMULARY
39.660	8.995	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	CAPSULE	250 MG	COVERED	FORMULARY
39.661	8.996	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	CAPSULE	500 MG	COVERED	FORMULARY
39.681	8.997	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	SUSP RECON	125 MG/5ML	COVERED	FORMULARY
39.683	8.998	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	SUSP RECON	250 MG/5ML	COVERED	FORMULARY
93.375	42.683	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	SUSP RECON	400 MG/5ML	COVERED	FORMULARY
93.385	42.684	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	SUSP RECON	200 MG/5ML	COVERED	FORMULARY
39.651	9.001	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	TAB CHEW	250 MG	COVERED	FORMULARY
39.632	40.292	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	TABLET	875 MG	COVERED	FORMULARY
61.252	20.493	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	TABLET	500 MG	COVERED	FORMULARY
67.150	8.989	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	SUSP RECON	125-31.25 MG/5ML	COVERED	FORMULARY
67.151	8.990	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	SUSP RECON	250-62.5 MG/5ML	COVERED	FORMULARY
67.153	25.898	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	SUSP RECON	400-57 MG/5ML	COVERED	FORMULARY
67.154	26.720	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	SUSP RECON	200-28.5 MG/5ML	COVERED	FORMULARY
28.020	48.449	081216-PENICILLINS	Augmentin ES	AMOXICILLIN-POTASSIUM CLAVULANATE	SUSP RECON	600-42.9 MG/5ML	COVERED	FORMULARY
67.078	26.719	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	TAB CHEW	200-28.5 MG	COVERED	FORMULARY
91.941	50.991	081216-PENICILLINS	Augmentin XR	AMOXICILLIN-POTASSIUM CLAVULANATE	TAB ER 12H	1000-62.5 MG	COVERED	FORMULARY
67.070	8.991	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	TABLET	250-125 MG	COVERED	FORMULARY
67.071	8.992	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	TABLET	500-125 MG	COVERED	FORMULARY
67.076	24.668	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	TABLET	875-125 MG	COVERED	FORMULARY
39.271	8.941	081216-PENICILLINS	Ampicillin	AMPICILLIN TRIHYDRATE	CAPSULE	250 MG	COVERED	FORMULARY
39.272	8.942	081216-PENICILLINS	Ampicillin	AMPICILLIN TRIHYDRATE	CAPSULE	500 MG	COVERED	FORMULARY
39.313	8.943	081216-PENICILLINS	Ampicillin	AMPICILLIN TRIHYDRATE	SUSP RECON	125 MG/5ML	COVERED	FORMULARY
39.316	8.944	081216-PENICILLINS	Ampicillin	AMPICILLIN TRIHYDRATE	SUSP RECON	250 MG/5ML	COVERED	FORMULARY
39.541	8.983	081216-PENICILLINS	Dicloxacillin	DICLOXACILLIN SODIUM	CAPSULE	250 MG	COVERED	FORMULARY
39.542	8.984	081216-PENICILLINS	Dicloxacillin	DICLOXACILLIN SODIUM	CAPSULE	500 MG	COVERED	FORMULARY
39.022	8.876	081216-PENICILLINS	Penicillin V Potassium	PENICILLIN V POTASSIUM	SOLN RECON	125 MG/5ML	COVERED	FORMULARY
39.024	8.877	081216-PENICILLINS	Penicillin V Potassium	PENICILLIN V POTASSIUM	SOLN RECON	250 MG/5ML	COVERED	FORMULARY
39.053	8.879	081216-PENICILLINS	Penicillin V Potassium	PENICILLIN V POTASSIUM	TABLET	250 MG	COVERED	FORMULARY
39.055	8.880	081216-PENICILLINS	Penicillin V Potassium	PENICILLIN V POTASSIUM	TABLET	500 MG	COVERED	FORMULARY
47.050	9.509	081218-QUINOLONES	Cipro	CIPROFLOXACIN HCL	TABLET	250 MG	COVERED	FORMULARY
47.051	9.510	081218-QUINOLONES	Cipro	CIPROFLOXACIN HCL	TABLET	500 MG	COVERED	FORMULARY
47.052	9.511	081218-QUINOLONES	Cipro	CIPROFLOXACIN HCL	TABLET	750 MG	COVERED	FORMULARY
23.725	58.310	081218-QUINOLONES	Levofloxacin	LEVOFLOXACIN	SOLUTION	250 MG/10ML	COVERED	FORMULARY
47.073	29.927	081218-QUINOLONES	Levaquin	LEVOFLOXACIN	TABLET	250 MG	COVERED	FORMULARY
47.074	29.928	081218-QUINOLONES	Levaquin	LEVOFLOXACIN	TABLET	500 MG	COVERED	FORMULARY
89.597	46.771	081218-QUINOLONES	Levaquin	LEVOFLOXACIN	TABLET	750 MG	COVERED	FORMULARY
34.942	71.217	081220-SULFONAMIDES (SYSTEMIC)	Sulfamethoxazole-Trimethoprim	SULFAMETHOXAZOLE-TRIMETHOPRIM	ORAL SUSP	800-160 MG/20ML	COVERED	FORMULARY
90.150	9.394	081220-SULFONAMIDES (SYSTEMIC)	Sulfamethoxazole-Trimethoprim	SULFAMETHOXAZOLE-TRIMETHOPRIM	ORAL SUSP	200-40 MG/5ML	COVERED	FORMULARY
90.161	9.395	081220-SULFONAMIDES (SYSTEMIC)	Bactrim	SULFAMETHOXAZOLE-TRIMETHOPRIM	TABLET	400-80 MG	COVERED	FORMULARY
90.163	9.396	081220-SULFONAMIDES (SYSTEMIC)	Bactrim	SULFAMETHOXAZOLE-TRIMETHOPRIM	TABLET	800-160 MG	COVERED	FORMULARY
41.611	9.402	081220-SULFONAMIDES (SYSTEMIC)	Azulfidine	SULFASALAZINE	TABLET	500 MG	COVERED	FORMULARY
41.620	9.403	081220-SULFONAMIDES (SYSTEMIC)	Azulfidine EN	SULFASALAZINE	TABLET DR	500 MG	COVERED	FORMULARY
40.073	9.190	08122400-TETRACYCLINE	Tetracycline	Tetracycline	CAPSULE	500 MG	COVERED	FORMULARY
40.370	9.225	081224-TETRACYCLINES	Doxycycline Suspension	DOXYCYCLINE	ORAL SUSP	25 MG/ML	COVERED	FORMULARY
40.331	9.218	081224-TETRACYCLINES	Doxycyline	DOXYCYCLINE HYCLATE	CAPSULE	100 MG	COVERED	FORMULARY
40.333	9.219	081224-TETRACYCLINES	Doxycyline	DOXYCYCLINE HYCLATE	CAPSULE	50 MG	COVERED	FORMULARY
40.360	9.223	081224-TETRACYCLINES	Doxycyline	DOXYCYCLINE HYCLATE	TABLET	100 MG	COVERED	FORMULARY
40.651	15.943	081224-TETRACYCLINES	Doxycyline	DOXYCYCLINE MONOHYDRATE	CAPSULE	100 MG	COVERED	FORMULARY
40.652	16.815	081224-TETRACYCLINES	Doxycyline	DOXYCYCLINE MONOHYDRATE	CAPSULE	50 MG	COVERED	FORMULARY
98.271	62.496	081224-TETRACYCLINES	Doxycyline	DOXYCYCLINE MONOHYDRATE	CAPSULE	75 MG	COVERED	FORMULARY
40.363	27.050	081224-TETRACYCLINES	Doxycyline	DOXYCYCLINE MONOHYDRATE	TABLET	100 MG	COVERED	FORMULARY
40.410	9.226	081224-TETRACYCLINES	Minocycline	MINOCYCLINE HCL	CAPSULE	100 MG	COVERED	FORMULARY
40.411	9.227	081224-TETRACYCLINES	Minocycline	MINOCYCLINE HCL	CAPSULE	50 MG	COVERED	FORMULARY
93.387	42.778	081224-TETRACYCLINES	Minocycline	MINOCYCLINE HCL	CAPSULE	75 MG	COVERED	FORMULARY
19.549	52.057	081224-TETRACYCLINES	Minocycline	MINOCYCLINE HCL	TABLET	75 MG	COVERED	FORMULARY
40.450	9.230	081224-TETRACYCLINES	Minocycline	MINOCYCLINE HCL	TABLET	100 MG	COVERED	FORMULARY
40.451	9.231	081224-TETRACYCLINES	Minocycline	MINOCYCLINE HCL	TABLET	50 MG	COVERED	FORMULARY
40.830	9.339	081228-ANTIBACTERIALS, MISCELLANEOUS	Cleocin	CLINDAMYCIN HCL	CAPSULE	150 MG	COVERED	FORMULARY
40.831	9.341	081228-ANTIBACTERIALS, MISCELLANEOUS	Cleocin	CLINDAMYCIN HCL	CAPSULE	75 MG	COVERED	FORMULARY
40.832	9.340	081228-ANTIBACTERIALS, MISCELLANEOUS	Cleocin	CLINDAMYCIN HCL	CAPSULE	300 MG	COVERED	FORMULARY
40.860	9.346	081228-ANTIBACTERIALS, MISCELLANEOUS	Cleocin Pediatric Granules	CLINDAMYCIN PALMITATE HCL	SOLN RECON	75 MG/5ML	COVERED	FORMULARY	Restricted to age < 19
60.823	18.638	081404-ALLYLAMINES	Lamisil	TERBINAFINE HCL	TABLET	250 MG	COVERED	FORMULARY
60.821	18.636	081408-AZOLES	Diflucan	FLUCONAZOLE	SUSP RECON	40 MG/ML	COVERED	FORMULARY
42.190	13.723	081408-AZOLES	Diflucan	FLUCONAZOLE	TABLET	100 MG	COVERED	FORMULARY
42.191	13.724	081408-AZOLES	Diflucan	FLUCONAZOLE	TABLET	200 MG	COVERED	FORMULARY
42.192	13.725	081408-AZOLES	Diflucan	FLUCONAZOLE	TABLET	50 MG	COVERED	FORMULARY
42.193	22.141	081408-AZOLES	Diflucan	FLUCONAZOLE	TABLET	150 MG	COVERED	FORMULARY
42.440	9.537	081428-POLYENES	Nystatin	NYSTATIN	ORAL SUSP	100000 UNIT/ML	COVERED	FORMULARY
42.452	9.538	081428-POLYENES	Nystatin	NYSTATIN	TABLET	500000 UNIT	COVERED	FORMULARY
42.390	9.517	081492-ANTIFUNGALS, MISCELLANEOUS	Griseofulvin	GRISEOFULVIN MICROSIZE	ORAL SUSP	125 MG/5ML	COVERED	FORMULARY
42.402	9.519	081492-ANTIFUNGALS, MISCELLANEOUS	Griseofulvin	GRISEOFULVIN MICROSIZE	TABLET	500 MG	COVERED	FORMULARY
42.410	9.520	081492-ANTIFUNGALS, MISCELLANEOUS	Gris-Peg	GRISEOFULVIN ULTRAMICROSIZE	TABLET	125 MG	COVERED	FORMULARY
42.412	9.522	081492-ANTIFUNGALS, MISCELLANEOUS	Gris-Peg	GRISEOFULVIN ULTRAMICROSIZE	TABLET	250 MG	COVERED	FORMULARY
73.441	43.706	081828-NEURAMINIDASE INHIBITORS	Tamiflu	OSELTAMIVIR PHOSPHATE	CAPSULE	75 MG	COVERED	FORMULARY
98.980	63.223	081828-NEURAMINIDASE INHIBITORS	Tamiflu	OSELTAMIVIR PHOSPHATE	CAPSULE	30 MG	COVERED	FORMULARY
98.981	63.224	081828-NEURAMINIDASE INHIBITORS	Tamiflu	OSELTAMIVIR PHOSPHATE	CAPSULE	45 MG	COVERED	FORMULARY
29.729	67.561	081828-NEURAMINIDASE INHIBITORS	Tamiflu	OSELTAMIVIR PHOSPHATE	SUSP RECON	6 MG/ML	COVERED	FORMULARY
92.221	43.119	081828-NEURAMINIDASE INHIBITORS	Relenza	ZANAMIVIR	BLST W/DEV	5 MG	COVERED	FORMULARY
43.790	9.630	081832-NUCLEOSIDES AND NUCLEOTIDES	Zovirax	ACYCLOVIR	CAPSULE	200 MG	COVERED	FORMULARY
13.721	15.979	081832-NUCLEOSIDES AND NUCLEOTIDES	Zovirax	ACYCLOVIR	TABLET	800 MG	COVERED	FORMULARY
13.724	16.408	081832-NUCLEOSIDES AND NUCLEOTIDES	Zovirax	ACYCLOVIR	TABLET	400 MG	COVERED	FORMULARY
14.179	48.664	081832-NUCLEOSIDES AND NUCLEOTIDES	Ribavirin	RIBAVIRIN	CAPSULE	200 MG	COVERED	FORMULARY
13.740	23.989	081832-NUCLEOSIDES AND NUCLEOTIDES	Valtrex	VALACYCLOVIR HCL	TABLET	500 MG	COVERED	FORMULARY
13.742	30.607	081832-NUCLEOSIDES AND NUCLEOTIDES	Valtrex	VALACYCLOVIR HCL	TABLET	1000 MG	COVERED	FORMULARY
42.940	9.580	083008-ANTIMALARIALS	Plaquenil	HYDROXYCHLOROQUINE SULFATE	TABLET	200 MG	COVERED	FORMULARY
43.031	9.591	083092-ANTIPROTOZOALS, MISCELLANEOUS	Flagyl	METRONIDAZOLE	TABLET	250 MG	COVERED	FORMULARY
43.032	9.592	083092-ANTIPROTOZOALS, MISCELLANEOUS	Flagyl	METRONIDAZOLE	TABLET	500 MG	COVERED	FORMULARY
41.870	9.434	083600-URINARY ANTI-INFECTIVES	Furadantin	NITROFURANTOIN	ORAL SUSP	25 MG/5ML	COVERED	FORMULARY
41.820	9.428	083600-URINARY ANTI-INFECTIVES	Macrodantin	NITROFURANTOIN MACROCRYSTAL	CAPSULE	100 MG	COVERED	FORMULARY
41.822	9.430	083600-URINARY ANTI-INFECTIVES	Macrodantin	NITROFURANTOIN MACROCRYSTAL	CAPSULE	50 MG	COVERED	FORMULARY
49.001	16.598	083600-URINARY ANTI-INFECTIVES	Macrobid	NITROFURANTOIN MONOHYDRATE-MACROCRYSTAL	CAPSULE	100 MG	COVERED	FORMULARY
5.987	35.495	084080-ANTIPRURITICS AND LOCAL ANESTHETICS	Emla Cream	LIDOCAINE/PRILOCAINE	CREAM (G)	2.5 %-2.5%	COVERED	FORMULARY
38.370	8.772	100000-ANTINEOPLASTIC AGENTS	Leukeran	CHLORAMBUCIL	TABLET	2 MG	COVERED	FORMULARY
38.400	8.775	100000-ANTINEOPLASTIC AGENTS	Hydrea	HYDROXYUREA	CAPSULE	500 MG	COVERED	FORMULARY
49.541	29.821	100000-ANTINEOPLASTIC AGENTS	Femara	LETROZOLE	TABLET	2.5 MG	COVERED	FORMULARY
33.559	70.193	100000-ANTINEOPLASTIC AGENTS	Megace	MEGESTROL ACETATE	ORAL SUSP	400 MG/10ML	COVERED	FORMULARY
40.381	21.004	100000-ANTINEOPLASTIC AGENTS	Megace	MEGESTROL ACETATE	ORAL SUSP	400 MG/10ML	COVERED	FORMULARY
38.681	8.829	100000-ANTINEOPLASTIC AGENTS	Megace	MEGESTROL ACETATE	TABLET	40 MG	COVERED	FORMULARY
38.380	8.773	100000-ANTINEOPLASTIC AGENTS	Alkeran	MELPHALAN	TABLET	2 MG	COVERED	FORMULARY
38.520	8.802	100000-ANTINEOPLASTIC AGENTS	Mercaptopurine	MERCAPTOPURINE	TABLET	50 MG	COVERED	FORMULARY
38.489	36.872	100000-ANTINEOPLASTIC AGENTS	Methotrexate	METHOTREXATE SODIUM	TABLET	2.5 MG	COVERED	FORMULARY
38.720	8.832	100000-ANTINEOPLASTIC AGENTS	Tamoxifen	TAMOXIFEN CITRATE	TABLET	10 MG	COVERED	FORMULARY
38.721	13.574	100000-ANTINEOPLASTIC AGENTS	Tamoxifen	TAMOXIFEN CITRATE	TABLET	20 MG	COVERED	FORMULARY
18.351	4.740	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Urecholine	BETHANECHOL CHLORIDE	TABLET	10 MG	COVERED	FORMULARY
18.352	4.741	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Urecholine	BETHANECHOL CHLORIDE	TABLET	25 MG	COVERED	FORMULARY
4.300	29.334	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Aricept	DONEPEZIL HCL	TABLET	10 MG	COVERED	FORMULARY
4.302	29.335	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Aricept	DONEPEZIL HCL	TABLET	5 MG	COVERED	FORMULARY
84.853	46.925	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Razadyne	GALANTAMINE HBR	TABLET	12 MG	COVERED	FORMULARY
84.854	46.926	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Razadyne	GALANTAMINE HBR	TABLET	4 MG	COVERED	FORMULARY
84.855	46.927	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Razadyne	GALANTAMINE HBR	TABLET	8 MG	COVERED	FORMULARY
21.353	53.658	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Salagen	PILOCARPINE HCL	TABLET	7.5 MG	COVERED	FORMULARY
24.671	21.731	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Salagen	PILOCARPINE HCL	TABLET	5 MG	COVERED	FORMULARY
90.396	40.155	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Exelon	RIVASTIGMINE TARTRATE	CAPSULE	1.5 MG	COVERED	FORMULARY
90.397	40.156	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Exelon	RIVASTIGMINE TARTRATE	CAPSULE	3 MG	COVERED	FORMULARY
90.398	40.157	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Exelon	RIVASTIGMINE TARTRATE	CAPSULE	4.5 MG	COVERED	FORMULARY
90.399	40.158	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Exelon	RIVASTIGMINE TARTRATE	CAPSULE	6 MG	COVERED	FORMULARY
74.801	4.902	120808-ANTIMUSCARINICS/ANTISPASMODICS	Librax	CHLORDIAZEPOXIDE-CLIDINIUM BR	CAPSULE	5-2.5 MG	COVERED	FORMULARY
19.261	4.918	120808-ANTIMUSCARINICS/ANTISPASMODICS	Bentyl	DICYCLOMINE HCL	CAPSULE	10 MG	COVERED	FORMULARY
34.719	71.032	120808-ANTIMUSCARINICS/ANTISPASMODICS	Bentyl	DICYCLOMINE HCL	SOLUTION	10 MG/5ML	COVERED	FORMULARY
19.331	4.924	120808-ANTIMUSCARINICS/ANTISPASMODICS	Bentyl	DICYCLOMINE HCL	TABLET	20 MG	COVERED	FORMULARY
18.960	23.715	120808-ANTIMUSCARINICS/ANTISPASMODICS	Symax SR	HYOSCYAMINE SULFATE	TAB ER 12H	0.375 MG	COVERED	FORMULARY
13.299	47.546	120808-ANTIMUSCARINICS/ANTISPASMODICS	Anaspaz, Symax FT	HYOSCYAMINE SULFATE	TAB RAPDIS	0.125 MG	COVERED	FORMULARY
18.970	4.868	120808-ANTIMUSCARINICS/ANTISPASMODICS	Symax SL	HYOSCYAMINE SULFATE	TAB SUBL	0.125 MG	COVERED	FORMULARY
18.961	4.865	120808-ANTIMUSCARINICS/ANTISPASMODICS	Levsin, Oscimin	HYOSCYAMINE SULFATE	TABLET	0.125 MG	COVERED	FORMULARY
42.235	21.700	120808-ANTIMUSCARINICS/ANTISPASMODICS	Ipratropium Bromide	IPRATROPIUM BROMIDE	SOLUTION	0.2 MG/ML	COVERED	FORMULARY
13.456	48.018	120808-ANTIMUSCARINICS/ANTISPASMODICS	Ipatropium-Albuterol Inhalation	IPRATROPIUM-ALBUTEROL SULFATE	AMPUL-NEB	0.5-3 MG/3ML	COVERED	FORMULARY
22.913	28.090	121208-BETA-ADRENERGIC AGONISTS	Proventil HFA, Ventolin HFA, ProAir HFA	ALBUTEROL SULFATE	HFA AER AD	90 MCG	COVERED	FORMULARY
22.780	5.032	121208-BETA-ADRENERGIC AGONISTS	Albuterol Sulfate	ALBUTEROL SULFATE	SYRUP	2 MG/5ML	COVERED	FORMULARY
20.100	5.033	121208-BETA-ADRENERGIC AGONISTS	Albuterol Sulfate	ALBUTEROL SULFATE	TABLET	2 MG	COVERED	FORMULARY
20.101	5.034	121208-BETA-ADRENERGIC AGONISTS	Albuterol Sulfate	ALBUTEROL SULFATE	TABLET	4 MG	COVERED	FORMULARY
14.634	48.699	121208-BETA-ADRENERGIC AGONISTS	Albuterol Sulfate Inhalation	ALBUTEROL SULFATE	VIAL-NEB	1.25 MG/3ML	COVERED	FORMULARY
41.681	5.039	121208-BETA-ADRENERGIC AGONISTS	Albuterol Sulfate Inhalation	ALBUTEROL SULFATE	VIAL-NEB	2.5 MG/3ML	COVERED	FORMULARY
20.071	5.026	121208-BETA-ADRENERGIC AGONISTS	Terbutaline	TERBUTALINE SULFATE	TABLET	5 MG	COVERED	FORMULARY
20.072	5.025	121208-BETA-ADRENERGIC AGONISTS	Terbutaline	TERBUTALINE SULFATE	TABLET	2.5 MG	COVERED	FORMULARY
19.861	16.878	121212-ALPHA- AND BETA-ADRENERGIC AGONISTS	EPINEPHRINE AUTO-INJECT	EPINEPHRINE	AUTO INJCT	0.15 MG/0.3ML	COVERED	FORMULARY
19.862	16.879	121212-ALPHA- AND BETA-ADRENERGIC AGONISTS	EPINEPHRINE AUTO-INJECT	EPINEPHRINE	AUTO INJCT	0.3 MG/0.3ML	COVERED	FORMULARY
48.191	27.546	121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)	Flomax	TAMSULOSIN HCL	CAP ER 24H	0.4 MG	COVERED	FORMULARY
17.901	4.660	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Parafon Forte	CHLORZOXAZONE	TABLET	500 MG	COVERED	FORMULARY
12.805	47.478	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Flexeril	CYCLOBENZAPRINE HCL	TABLET	5 MG	COVERED	FORMULARY
18.020	4.681	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Flexeril	CYCLOBENZAPRINE HCL	TABLET	10 MG	COVERED	FORMULARY
17.892	4.654	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Robaxin	METHOCARBAMOL	TABLET	500 MG	COVERED	FORMULARY
17.893	4.655	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Robaxin	METHOCARBAMOL	TABLET	750 MG	COVERED	FORMULARY
24.433	58.904	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Zanaflex	TIZANIDINE HCL	CAPSULE	2 MG	COVERED	FORMULARY
24.434	58.905	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Zanaflex	TIZANIDINE HCL	CAPSULE	4 MG	COVERED	FORMULARY
14.690	27.447	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Zanaflex	TIZANIDINE HCL	TABLET	2 MG	COVERED	FORMULARY
14.693	30.274	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Zanaflex	TIZANIDINE HCL	TABLET	4 MG	COVERED	FORMULARY
18.012	27.229	122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT	Baclofen	BACLOFEN	TABLET	5 MG	COVERED	FORMULARY
18.010	4.679	122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT	Baclofen	BACLOFEN	TABLET	10 MG	COVERED	FORMULARY
18.011	4.680	122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT	Baclofen	BACLOFEN	TABLET	20 MG	COVERED	FORMULARY
420	19.331	201204-ANTICOAGULANTS	Lovenox	ENOXAPARIN SODIUM	SYRINGE	30 MG/0.3ML	COVERED	FORMULARY	Limited to 14 day supplies, Prior Auth for >14 days
42.071	44.668	201204-ANTICOAGULANTS	Lovenox	ENOXAPARIN SODIUM	SYRINGE	150 MG/ML	COVERED	FORMULARY	Limited to 14 day supplies, Prior Auth for >14 days
42.091	44.669	201204-ANTICOAGULANTS	Lovenox	ENOXAPARIN SODIUM	SYRINGE	120 MG/0.8ML	COVERED	FORMULARY	Limited to 14 day supplies, Prior Auth for >14 days
62.771	27.993	201204-ANTICOAGULANTS	Lovenox	ENOXAPARIN SODIUM	SYRINGE	60 MG/0.6ML	COVERED	FORMULARY	Limited to 14 day supplies, Prior Auth for >14 days
62.772	27.994	201204-ANTICOAGULANTS	Lovenox	ENOXAPARIN SODIUM	SYRINGE	80 MG/0.8ML	COVERED	FORMULARY	Limited to 14 day supplies, Prior Auth for >14 days
62.773	27.995	201204-ANTICOAGULANTS	Lovenox	ENOXAPARIN SODIUM	SYRINGE	100 MG/ML	COVERED	FORMULARY	Limited to 14 day supplies, Prior Auth for >14 days
70.022	39.482	201204-ANTICOAGULANTS	Lovenox	ENOXAPARIN SODIUM	SYRINGE	40 MG/0.4ML	COVERED	FORMULARY	Limited to 14 day supplies, Prior Auth for >14 days
25.691	6.549	201204-ANTICOAGULANTS	Heparin	HEPARIN SODIUM PORCINE	VIAL	5000 UNIT/ML	COVERED	FORMULARY
25.697	6.544	201204-ANTICOAGULANTS	Heparin	HEPARIN SODIUM PORCINE	VIAL	10000 UNIT/ML	COVERED	FORMULARY
25.790	6.559	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	10 MG	COVERED	FORMULARY
25.791	6.561	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	2 MG	COVERED	FORMULARY
25.792	14.198	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	1 MG	COVERED	FORMULARY
25.793	6.562	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	5 MG	COVERED	FORMULARY
25.794	6.560	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	2.5 MG	COVERED	FORMULARY
25.795	6.563	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	7.5 MG	COVERED	FORMULARY
25.796	18.080	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	3 MG	COVERED	FORMULARY
25.797	19.486	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	4 MG	COVERED	FORMULARY
25.798	30.475	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	6 MG	COVERED	FORMULARY
8.602	37.978	201218-PLATELET-AGGREGATION INHIBITORS	Pletal	CILOSTAZOL	TABLET	100 MG	COVERED	FORMULARY
8.603	37.979	201218-PLATELET-AGGREGATION INHIBITORS	Pletal	CILOSTAZOL	TABLET	50 MG	COVERED	FORMULARY
96.010	38.164	201218-PLATELET-AGGREGATION INHIBITORS	Plavix	CLOPIDOGREL BISULFATE	TABLET	75 MG	COVERED	FORMULARY
11.800	6.573	202400-HEMORRHEOLOGIC AGENTS	Pentoxifylline	PENTOXIFYLLINE	TABLET ER	400 MG	COVERED	FORMULARY
25.580	6.503	202816-HEMOSTATICS	Amicar	AMINOCAPROIC ACID	SOLUTION	250 MG/ML	COVERED	FORMULARY
10.920	266	240404-ANTIARRHYTHMIC AGENTS	Pacerone	AMIODARONE HCL	TABLET	200 MG	COVERED	FORMULARY
1.130	239	240404-ANTIARRHYTHMIC AGENTS	Norpace	DISOPYRAMIDE PHOSPHATE	CAPSULE	100 MG	COVERED	FORMULARY
1.580	263	240404-ANTIARRHYTHMIC AGENTS	Flecainide	FLECAINIDE ACETATE	TABLET	100 MG	COVERED	FORMULARY
1.581	265	240404-ANTIARRHYTHMIC AGENTS	Flecainide	FLECAINIDE ACETATE	TABLET	50 MG	COVERED	FORMULARY
1.011	215	240404-ANTIARRHYTHMIC AGENTS	Quinidine	QUINIDINE GLUCONATE	TABLET ER	324 MG	COVERED	FORMULARY
132	18	240408-CARDIOTONIC AGENTS	Lanoxin	DIGOXIN	TABLET	125 MCG	COVERED	FORMULARY
133	19	240408-CARDIOTONIC AGENTS	Lanoxin	DIGOXIN	TABLET	250 MCG	COVERED	FORMULARY
9.850	3.100	240604-BILE ACID SEQUESTRANTS	Prevalite	CHOLESTYRAMINE (WITH ASPARTAME)	POWD PACK	4 G	COVERED	FORMULARY
98.654	62.885	240604-BILE ACID SEQUESTRANTS	Questran Light	CHOLESTYRAMINE (WITH ASPARTAME)	POWDER	4 G	COVERED	FORMULARY
9.920	13.675	240604-BILE ACID SEQUESTRANTS	Questran	CHOLESTYRAMINE (WITH SUGAR)	POWD PACK	4 G	COVERED	FORMULARY
14.295	48.571	240604-BILE ACID SEQUESTRANTS	Questran	CHOLESTYRAMINE (WITH SUGAR)	POWDER	4 G	COVERED	FORMULARY
12.595	44.915	240606-FIBRIC ACID DERIVATIVES	Lofibra	FENOFIBRATE	TABLET	160 MG	COVERED	FORMULARY
13.266	64.310	240606-FIBRIC ACID DERIVATIVES	Lofibra	FENOFIBRATE	TABLET	54 MG	COVERED	FORMULARY
92.504	44.305	240606-FIBRIC ACID DERIVATIVES	Lofibra	FENOFIBRATE MICRONIZED	CAPSULE	134 MG	COVERED	FORMULARY
93.437	43.060	240606-FIBRIC ACID DERIVATIVES	Lofibra	FENOFIBRATE MICRONIZED	CAPSULE	200 MG	COVERED	FORMULARY
93.446	43.061	240606-FIBRIC ACID DERIVATIVES	Lofibra	FENOFIBRATE MICRONIZED	CAPSULE	67 MG	COVERED	FORMULARY
25.540	6.416	240606-FIBRIC ACID DERIVATIVES	Lopid	GEMFIBROZIL	TABLET	600 MG	COVERED	FORMULARY
43.720	29.967	240608-HMG-COA REDUCTASE INHIBITORS	Lipitor	ATORVASTATIN CALCIUM	TABLET	10 MG	COVERED	FORMULARY
43.721	29.968	240608-HMG-COA REDUCTASE INHIBITORS	Lipitor	ATORVASTATIN CALCIUM	TABLET	20 MG	COVERED	FORMULARY
43.722	29.969	240608-HMG-COA REDUCTASE INHIBITORS	Lipitor	ATORVASTATIN CALCIUM	TABLET	40 MG	COVERED	FORMULARY
43.723	45.772	240608-HMG-COA REDUCTASE INHIBITORS	Lipitor	ATORVASTATIN CALCIUM	TABLET	80 MG	COVERED	FORMULARY
47.040	6.460	240608-HMG-COA REDUCTASE INHIBITORS	Lovastatin	LOVASTATIN	TABLET	20 MG	COVERED	FORMULARY
47.041	6.461	240608-HMG-COA REDUCTASE INHIBITORS	Lovastatin	LOVASTATIN	TABLET	40 MG	COVERED	FORMULARY
47.042	16.310	240608-HMG-COA REDUCTASE INHIBITORS	Lovastatin	LOVASTATIN	TABLET	10 MG	COVERED	FORMULARY
15.412	49.758	240608-HMG-COA REDUCTASE INHIBITORS	Pravachol	PRAVASTATIN SODIUM	TABLET	80 MG	COVERED	FORMULARY
48.671	16.366	240608-HMG-COA REDUCTASE INHIBITORS	Pravachol	PRAVASTATIN SODIUM	TABLET	10 MG	COVERED	FORMULARY
48.672	16.367	240608-HMG-COA REDUCTASE INHIBITORS	Pravachol	PRAVASTATIN SODIUM	TABLET	20 MG	COVERED	FORMULARY
48.673	20.741	240608-HMG-COA REDUCTASE INHIBITORS	Pravachol	PRAVASTATIN SODIUM	TABLET	40 MG	COVERED	FORMULARY
26.531	16.576	240608-HMG-COA REDUCTASE INHIBITORS	Zocor	SIMVASTATIN	TABLET	5 MG	COVERED	FORMULARY
26.532	16.577	240608-HMG-COA REDUCTASE INHIBITORS	Zocor	SIMVASTATIN	TABLET	10 MG	COVERED	FORMULARY
26.533	16.578	240608-HMG-COA REDUCTASE INHIBITORS	Zocor	SIMVASTATIN	TABLET	20 MG	COVERED	FORMULARY
26.534	16.579	240608-HMG-COA REDUCTASE INHIBITORS	Zocor	SIMVASTATIN	TABLET	40 MG	COVERED	FORMULARY
42.331	33.364	240692-ANTILIPEMIC AGENTS, MISCELLANEOUS	Niaspan ER	NIACIN	TAB ER 24H	500 MG	COVERED	FORMULARY
42.332	33.365	240692-ANTILIPEMIC AGENTS, MISCELLANEOUS	Niaspan ER	NIACIN	TAB ER 24H	750 MG	COVERED	FORMULARY
42.333	33.366	240692-ANTILIPEMIC AGENTS, MISCELLANEOUS	Niaspan ER	NIACIN	TAB ER 24H	1000 MG	COVERED	FORMULARY
23.870	343	240816-CENTRAL ALPHA-AGONISTS	Catapres TTS	CLONIDINE	PATCH TDWK	0.1 MG/24HR	COVERED	FORMULARY
23.871	344	240816-CENTRAL ALPHA-AGONISTS	Catapres TTS	CLONIDINE	PATCH TDWK	0.2 MG/24HR	COVERED	FORMULARY
23.872	345	240816-CENTRAL ALPHA-AGONISTS	Catapres TTS	CLONIDINE	PATCH TDWK	0.3 MG/24HR	COVERED	FORMULARY
1.390	346	240816-CENTRAL ALPHA-AGONISTS	Catapres	CLONIDINE HCL	TABLET	0.1 MG	COVERED	FORMULARY
1.391	347	240816-CENTRAL ALPHA-AGONISTS	Catapres	CLONIDINE HCL	TABLET	0.2 MG	COVERED	FORMULARY
1.392	348	240816-CENTRAL ALPHA-AGONISTS	Catapres	CLONIDINE HCL	TABLET	0.3 MG	COVERED	FORMULARY
32.480	364	240816-CENTRAL ALPHA-AGONISTS	Tenex	GUANFACINE HCL	TABLET	1 MG	COVERED	FORMULARY
32.481	11.984	240816-CENTRAL ALPHA-AGONISTS	Tenex	GUANFACINE HCL	TABLET	2 MG	COVERED	FORMULARY
1.431	361	240816-CENTRAL ALPHA-AGONISTS	Methyldopa	METHYLDOPA	TABLET	250 MG	COVERED	FORMULARY
1.432	362	240816-CENTRAL ALPHA-AGONISTS	Methyldopa	METHYLDOPA	TABLET	500 MG	COVERED	FORMULARY
1.241	284	240820-DIRECT VASODILATORS	Hydralazine	HYDRALAZINE HCL	TABLET	10 MG	COVERED	FORMULARY
1.242	285	240820-DIRECT VASODILATORS	Hydralazine	HYDRALAZINE HCL	TABLET	100 MG	COVERED	FORMULARY
1.243	286	240820-DIRECT VASODILATORS	Hydralazine	HYDRALAZINE HCL	TABLET	25 MG	COVERED	FORMULARY
1.244	287	240820-DIRECT VASODILATORS	Hydralazine	HYDRALAZINE HCL	TABLET	50 MG	COVERED	FORMULARY
1.290	299	240820-DIRECT VASODILATORS	Minoxidil	MINOXIDIL	TABLET	10 MG	COVERED	FORMULARY
1.291	300	240820-DIRECT VASODILATORS	Minoxidil	MINOXIDIL	TABLET	2.5 MG	COVERED	FORMULARY
1.942	507	241208-NITRATES AND NITRITES	Isordil	ISOSORBIDE DINITRATE	TABLET	10 MG	COVERED	FORMULARY
1.944	508	241208-NITRATES AND NITRITES	Isordil	ISOSORBIDE DINITRATE	TABLET	20 MG	COVERED	FORMULARY
1.945	509	241208-NITRATES AND NITRITES	Isordil	ISOSORBIDE DINITRATE	TABLET	30 MG	COVERED	FORMULARY
1.947	511	241208-NITRATES AND NITRITES	Isordil	ISOSORBIDE DINITRATE	TABLET	5 MG	COVERED	FORMULARY
48.102	17.297	241208-NITRATES AND NITRITES	Isosorbide Mononitrate ER	ISOSORBIDE MONONITRATE	TAB ER 24H	60 MG	COVERED	FORMULARY
48.103	23.474	241208-NITRATES AND NITRITES	Isosorbide Mononitrate ER	ISOSORBIDE MONONITRATE	TAB ER 24H	120 MG	COVERED	FORMULARY
48.104	24.488	241208-NITRATES AND NITRITES	Isosorbide Mononitrate ER	ISOSORBIDE MONONITRATE	TAB ER 24H	30 MG	COVERED	FORMULARY
1.931	16.639	241208-NITRATES AND NITRITES	Isosorbide Mononitrate	ISOSORBIDE MONONITRATE	TABLET	20 MG	COVERED	FORMULARY
1.932	17.294	241208-NITRATES AND NITRITES	Isosorbide Mononitrate	ISOSORBIDE MONONITRATE	TABLET	10 MG	COVERED	FORMULARY
1.681	455	241208-NITRATES AND NITRITES	Nitro-Time	NITROGLYCERIN	CAPSULE ER	2.5 MG	COVERED	FORMULARY
1.682	456	241208-NITRATES AND NITRITES	Nitro-Time	NITROGLYCERIN	CAPSULE ER	6.5 MG	COVERED	FORMULARY
1.684	457	241208-NITRATES AND NITRITES	Nitro-Time	NITROGLYCERIN	CAPSULE ER	9 MG	COVERED	FORMULARY
1.740	465	241208-NITRATES AND NITRITES	Minitran	NITROGLYCERIN	PATCH TD24	0.4 MG/HR	COVERED	FORMULARY
1.741	467	241208-NITRATES AND NITRITES	Minitran	NITROGLYCERIN	PATCH TD24	0.1 MG/HR	COVERED	FORMULARY
1.742	468	241208-NITRATES AND NITRITES	Minitran	NITROGLYCERIN	PATCH TD24	0.2 MG/HR	COVERED	FORMULARY
92.257	44.359	241208-NITRATES AND NITRITES	Nitrolingual	NITROGLYCERIN	SPRAY	400 MCG/SPRAY	COVERED	FORMULARY
1.771	474	241208-NITRATES AND NITRITES	Nitrostat	NITROGLYCERIN	TAB SUBL	0.3 MG	COVERED	FORMULARY
1.772	475	241208-NITRATES AND NITRITES	Nitrostat	NITROGLYCERIN	TAB SUBL	0.4 MG	COVERED	FORMULARY
1.773	476	241208-NITRATES AND NITRITES	Nitrostat	NITROGLYCERIN	TAB SUBL	0.6 MG	COVERED	FORMULARY
53.141	41.698	241292-VASODILATING AGENTS, MISCELLANEOUS	Persantine	DIPYRIDAMOLE	TABLET	25 MG	COVERED	FORMULARY
53.142	41.699	241292-VASODILATING AGENTS, MISCELLANEOUS	Persantine	DIPYRIDAMOLE	TABLET	50 MG	COVERED	FORMULARY
53.143	41.700	241292-VASODILATING AGENTS, MISCELLANEOUS	Persantine	DIPYRIDAMOLE	TABLET	75 MG	COVERED	FORMULARY
84.848	46.923	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Cardura XL	DOXAZOSIN MESYLATE	TAB ER 24	8 MG	COVERED	FORMULARY
91.985	44.421	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Cardura XL	DOXAZOSIN MESYLATE	TAB ER 24	4 MG	COVERED	FORMULARY
33.431	15.584	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Cardura	DOXAZOSIN MESYLATE	TABLET	1 MG	COVERED	FORMULARY
33.432	15.585	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Cardura	DOXAZOSIN MESYLATE	TABLET	2 MG	COVERED	FORMULARY
33.433	15.586	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Cardura	DOXAZOSIN MESYLATE	TABLET	4 MG	COVERED	FORMULARY
33.434	15.587	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Cardura	DOXAZOSIN MESYLATE	TABLET	8 MG	COVERED	FORMULARY
1.250	291	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Minipress	PRAZOSIN HCL	CAPSULE	1 MG	COVERED	FORMULARY
1.251	292	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Minipress	PRAZOSIN HCL	CAPSULE	2 MG	COVERED	FORMULARY
1.252	293	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Minipress	PRAZOSIN HCL	CAPSULE	5 MG	COVERED	FORMULARY
47.124	22.649	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Terazosin	TERAZOSIN HCL	CAPSULE	1 MG	COVERED	FORMULARY
47.125	22.650	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Terazosin	TERAZOSIN HCL	CAPSULE	2 MG	COVERED	FORMULARY
47.126	22.651	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Terazosin	TERAZOSIN HCL	CAPSULE	5 MG	COVERED	FORMULARY
47.127	22.652	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Terazosin	TERAZOSIN HCL	CAPSULE	10 MG	COVERED	FORMULARY
12.947	47.586	242400-BETA-ADRENERGIC BLOCKING AGENTS	Toprol XL	METOPROLOL SUCCINATE	TAB ER 24H	25 MG	COVERED	FORMULARY
20.741	16.599	242400-BETA-ADRENERGIC BLOCKING AGENTS	Toprol XL	METOPROLOL SUCCINATE	TAB ER 24H	50 MG	COVERED	FORMULARY
20.742	16.600	242400-BETA-ADRENERGIC BLOCKING AGENTS	Toprol XL	METOPROLOL SUCCINATE	TAB ER 24H	100 MG	COVERED	FORMULARY
20.743	16.601	242400-BETA-ADRENERGIC BLOCKING AGENTS	Toprol XL	METOPROLOL SUCCINATE	TAB ER 24H	200 MG	COVERED	FORMULARY
20.660	5.138	242400-BETA-ADRENERGIC BLOCKING AGENTS	Tenormin	ATENOLOL	TABLET	100 MG	COVERED	FORMULARY
20.661	5.139	242400-BETA-ADRENERGIC BLOCKING AGENTS	Tenormin	ATENOLOL	TABLET	50 MG	COVERED	FORMULARY
20.662	15.864	242400-BETA-ADRENERGIC BLOCKING AGENTS	Tenormin	ATENOLOL	TABLET	25 MG	COVERED	FORMULARY
66.990	420	242400-BETA-ADRENERGIC BLOCKING AGENTS	Tenoretic	ATENOLOL-CHLORTHALIDONE	TABLET	50-25 MG	COVERED	FORMULARY
66.991	419	242400-BETA-ADRENERGIC BLOCKING AGENTS	Tenoretic	ATENOLOL-CHLORTHALIDONE	TABLET	100-25 MG	COVERED	FORMULARY
63.820	17.955	242400-BETA-ADRENERGIC BLOCKING AGENTS	Zebeta	BISOPROLOL FUMARATE	TABLET	10 MG	COVERED	FORMULARY
63.821	17.956	242400-BETA-ADRENERGIC BLOCKING AGENTS	Zebeta	BISOPROLOL FUMARATE	TABLET	5 MG	COVERED	FORMULARY
45.061	21.139	242400-BETA-ADRENERGIC BLOCKING AGENTS	Ziac	BISOPROLOL FUMARATE-HCTZ	TABLET	2.5-6.25 MG	COVERED	FORMULARY
45.062	21.140	242400-BETA-ADRENERGIC BLOCKING AGENTS	Ziac	BISOPROLOL FUMARATE-HCTZ	TABLET	5-6.25 MG	COVERED	FORMULARY
45.063	21.141	242400-BETA-ADRENERGIC BLOCKING AGENTS	Ziac	BISOPROLOL FUMARATE-HCTZ	TABLET	10-6.2 5MG	COVERED	FORMULARY
1.551	19.293	242400-BETA-ADRENERGIC BLOCKING AGENTS	Coreg	CARVEDILOL	TABLET	25 MG	COVERED	FORMULARY
1.552	22.233	242400-BETA-ADRENERGIC BLOCKING AGENTS	Coreg	CARVEDILOL	TABLET	12.5 MG	COVERED	FORMULARY
1.553	28.108	242400-BETA-ADRENERGIC BLOCKING AGENTS	Coreg	CARVEDILOL	TABLET	3.125 MG	COVERED	FORMULARY
1.554	28.109	242400-BETA-ADRENERGIC BLOCKING AGENTS	Coreg	CARVEDILOL	TABLET	6.25 MG	COVERED	FORMULARY
10.340	5.100	242400-BETA-ADRENERGIC BLOCKING AGENTS	Labetalol	LABETALOL HCL	TABLET	300 MG	COVERED	FORMULARY
10.341	5.099	242400-BETA-ADRENERGIC BLOCKING AGENTS	Labetalol	LABETALOL HCL	TABLET	200 MG	COVERED	FORMULARY
10.342	5.098	242400-BETA-ADRENERGIC BLOCKING AGENTS	Labetalol	LABETALOL HCL	TABLET	100 MG	COVERED	FORMULARY
17.734	50.631	242400-BETA-ADRENERGIC BLOCKING AGENTS	Lopressor	METOPROLOL TARTRATE	TABLET	25 MG	COVERED	FORMULARY
20.641	5.131	242400-BETA-ADRENERGIC BLOCKING AGENTS	Lopressor	METOPROLOL TARTRATE	TABLET	100 MG	COVERED	FORMULARY
20.642	5.132	242400-BETA-ADRENERGIC BLOCKING AGENTS	Lopressor	METOPROLOL TARTRATE	TABLET	50 MG	COVERED	FORMULARY
20.652	5.136	242400-BETA-ADRENERGIC BLOCKING AGENTS	Corgard	NADOLOL	TABLET	40 MG	COVERED	FORMULARY
20.653	5.137	242400-BETA-ADRENERGIC BLOCKING AGENTS	Corgard	NADOLOL	TABLET	80 MG	COVERED	FORMULARY
20.654	5.135	242400-BETA-ADRENERGIC BLOCKING AGENTS	Corgard	NADOLOL	TABLET	20 MG	COVERED	FORMULARY
3.230	5.116	242400-BETA-ADRENERGIC BLOCKING AGENTS	Inderal LA	PROPRANOLOL HCL	CAP SA 24H	80 MG	COVERED	FORMULARY
3.231	5.113	242400-BETA-ADRENERGIC BLOCKING AGENTS	Inderal LA	PROPRANOLOL HCL	CAP SA 24H	120 MG	COVERED	FORMULARY
3.232	5.114	242400-BETA-ADRENERGIC BLOCKING AGENTS	Inderal LA	PROPRANOLOL HCL	CAP SA 24H	160 MG	COVERED	FORMULARY
3.233	5.115	242400-BETA-ADRENERGIC BLOCKING AGENTS	Inderal LA	PROPRANOLOL HCL	CAP SA 24H	60 MG	COVERED	FORMULARY
20.630	5.123	242400-BETA-ADRENERGIC BLOCKING AGENTS	Propranolol	PROPRANOLOL HCL	TABLET	10 MG	COVERED	FORMULARY
20.631	5.124	242400-BETA-ADRENERGIC BLOCKING AGENTS	Propranolol	PROPRANOLOL HCL	TABLET	20 MG	COVERED	FORMULARY
20.632	5.125	242400-BETA-ADRENERGIC BLOCKING AGENTS	Propranolol	PROPRANOLOL HCL	TABLET	40 MG	COVERED	FORMULARY
20.633	5.126	242400-BETA-ADRENERGIC BLOCKING AGENTS	Propranolol	PROPRANOLOL HCL	TABLET	60 MG	COVERED	FORMULARY
20.634	5.127	242400-BETA-ADRENERGIC BLOCKING AGENTS	Propranolol	PROPRANOLOL HCL	TABLET	80 MG	COVERED	FORMULARY
39.511	13.497	242400-BETA-ADRENERGIC BLOCKING AGENTS	Betapace	SOTALOL HCL	TABLET	160 MG	COVERED	FORMULARY
39.512	17.196	242400-BETA-ADRENERGIC BLOCKING AGENTS	Betapace	SOTALOL HCL	TABLET	80 MG	COVERED	FORMULARY
39.516	24.097	242400-BETA-ADRENERGIC BLOCKING AGENTS	Betapace	SOTALOL HCL	TABLET	120 MG	COVERED	FORMULARY
2.681	16.925	242808-DIHYDROPYRIDINES	Norvasc	AMLODIPINE BESYLATE	TABLET	2.5 MG	COVERED	FORMULARY
2.682	16.927	242808-DIHYDROPYRIDINES	Norvasc	AMLODIPINE BESYLATE	TABLET	10 MG	COVERED	FORMULARY
2.683	16.926	242808-DIHYDROPYRIDINES	Norvasc	AMLODIPINE BESYLATE	TABLET	5 MG	COVERED	FORMULARY
17.604	50.519	242808-DIHYDROPYRIDINES	Lotrel	AMLODIPINE BESYLATE-BENAZEPRIL	CAPSULE	10-20 MG	COVERED	FORMULARY
26.949	60.722	242808-DIHYDROPYRIDINES	Lotrel	AMLODIPINE BESYLATE-BENAZEPRIL	CAPSULE	5-40 MG	COVERED	FORMULARY
26.950	60.723	242808-DIHYDROPYRIDINES	Lotrel	AMLODIPINE BESYLATE-BENAZEPRIL	CAPSULE	10-40 MG	COVERED	FORMULARY
33.090	23.768	242808-DIHYDROPYRIDINES	Lotrel	AMLODIPINE BESYLATE-BENAZEPRIL	CAPSULE	5-20 MG	COVERED	FORMULARY
33.092	23.769	242808-DIHYDROPYRIDINES	Lotrel	AMLODIPINE BESYLATE-BENAZEPRIL	CAPSULE	5-10 MG	COVERED	FORMULARY
33.093	23.770	242808-DIHYDROPYRIDINES	Lotrel	AMLODIPINE BESYLATE-BENAZEPRIL	CAPSULE	2.5-10 MG	COVERED	FORMULARY
2.350	568	242808-DIHYDROPYRIDINES	Procardia	NIFEDIPINE	CAPSULE	10 MG	COVERED	FORMULARY
2.351	569	242808-DIHYDROPYRIDINES	Procardia	NIFEDIPINE	CAPSULE	20 MG	COVERED	FORMULARY
2.221	20.616	242808-DIHYDROPYRIDINES	Procardia XL	NIFEDIPINE	TAB ER 24	30 MG	COVERED	FORMULARY
2.221	20.616	242808-DIHYDROPYRIDINES	Procardia XL	NIFEDIPINE	TAB ER 24	30 MG	COVERED	FORMULARY
2.222	20.617	242808-DIHYDROPYRIDINES	Procardia XL	NIFEDIPINE	TAB ER 24	60 MG	COVERED	FORMULARY
2.222	20.617	242808-DIHYDROPYRIDINES	Procardia XL	NIFEDIPINE	TAB ER 24	60 MG	COVERED	FORMULARY
2.223	20.618	242808-DIHYDROPYRIDINES	Procardia XL	NIFEDIPINE	TAB ER 24	90 MG	COVERED	FORMULARY
2.223	20.618	242808-DIHYDROPYRIDINES	Procardia XL	NIFEDIPINE	TAB ER 24	90 MG	COVERED	FORMULARY
2.228	12.061	242808-DIHYDROPYRIDINES	Adalat CC	NIFEDIPINE	TABLET ER	90 MG	COVERED	FORMULARY
2.226	12.059	242808-DIHYDROPYRIDINES	Adalat CC, Afeditab CR	NIFEDIPINE	TABLET ER	30 MG	COVERED	FORMULARY
2.227	12.060	242808-DIHYDROPYRIDINES	Adalat CC, Afeditab CR	NIFEDIPINE	TABLET ER	60 MG	COVERED	FORMULARY
2.320	572	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Diltiazem ER	DILTIAZEM HCL	CAP ER 12H	90 MG	COVERED	FORMULARY
2.321	570	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Diltiazem ER	DILTIAZEM HCL	CAP ER 12H	120 MG	COVERED	FORMULARY
2.322	571	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Diltiazem ER	DILTIAZEM HCL	CAP ER 12H	60 MG	COVERED	FORMULARY
7.460	32.600	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem CD	DILTIAZEM HCL	CAP ER 24H	360 MG	COVERED	FORMULARY
2.323	16.570	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem CD, Cartia XT	DILTIAZEM HCL	CAP ER 24H	180 MG	COVERED	FORMULARY
2.324	16.571	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem CD, Cartia XT	DILTIAZEM HCL	CAP ER 24H	240 MG	COVERED	FORMULARY
2.325	16.572	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem CD, Cartia XT	DILTIAZEM HCL	CAP ER 24H	300 MG	COVERED	FORMULARY
2.326	21.282	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem CD, Cartia XT	DILTIAZEM HCL	CAP ER 24H	120 MG	COVERED	FORMULARY
7.461	16.849	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Dilacor XR	DILTIAZEM HCL	CAP ER DEG	180 MG	COVERED	FORMULARY
7.462	16.850	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Dilacor XR	DILTIAZEM HCL	CAP ER DEG	240 MG	COVERED	FORMULARY
7.463	17.205	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Dilacor XR	DILTIAZEM HCL	CAP ER DEG	120 MG	COVERED	FORMULARY
94.691	40.966	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Tiazac	DILTIAZEM HCL	CAPSULE ER	420 MG	COVERED	FORMULARY
2.328	24.478	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Tiazac, Taztia XT	DILTIAZEM HCL	CAPSULE ER	360 MG	COVERED	FORMULARY
2.329	24.537	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Tiazac, Taztia XT	DILTIAZEM HCL	CAPSULE ER	180 MG	COVERED	FORMULARY
2.330	24.536	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Tiazac, Taztia XT	DILTIAZEM HCL	CAPSULE ER	120 MG	COVERED	FORMULARY
2.332	24.538	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Tiazac, Taztia XT	DILTIAZEM HCL	CAPSULE ER	240 MG	COVERED	FORMULARY
2.333	24.539	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Tiazac, Taztia XT	DILTIAZEM HCL	CAPSULE ER	300 MG	COVERED	FORMULARY
2.360	574	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem	DILTIAZEM HCL	TABLET	30 MG	COVERED	FORMULARY
2.361	575	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem	DILTIAZEM HCL	TABLET	60 MG	COVERED	FORMULARY
2.362	576	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem	DILTIAZEM HCL	TABLET	90 MG	COVERED	FORMULARY
2.363	573	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem	DILTIAZEM HCL	TABLET	120 MG	COVERED	FORMULARY
3.001	16.605	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Verelan SR	VERAPAMIL HCL	CAP24H PEL	180 MG	COVERED	FORMULARY
3.002	15.067	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Verelan SR	VERAPAMIL HCL	CAP24H PEL	240 MG	COVERED	FORMULARY
3.003	15.066	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Verelan SR	VERAPAMIL HCL	CAP24H PEL	120 MG	COVERED	FORMULARY
3.004	26.486	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Verelan SR	VERAPAMIL HCL	CAP24H PEL	360 MG	COVERED	FORMULARY
2.341	564	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Calan	VERAPAMIL HCL	TABLET	120 MG	COVERED	FORMULARY
2.342	566	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Calan	VERAPAMIL HCL	TABLET	80 MG	COVERED	FORMULARY
47.110	565	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Verapamil	VERAPAMIL HCL	TABLET	40 MG	COVERED	FORMULARY
32.470	567	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Calan SR	VERAPAMIL HCL	TABLET ER	240 MG	COVERED	FORMULARY
32.471	13.670	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Calan SR	VERAPAMIL HCL	TABLET ER	180 MG	COVERED	FORMULARY
32.472	15.959	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Calan SR	VERAPAMIL HCL	TABLET ER	120 MG	COVERED	FORMULARY
48.611	16.039	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Lotensin	BENAZEPRIL HCL	TABLET	5 MG	COVERED	FORMULARY
48.612	16.040	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Lotensin	BENAZEPRIL HCL	TABLET	10 MG	COVERED	FORMULARY
48.613	16.041	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Lotensin	BENAZEPRIL HCL	TABLET	20 MG	COVERED	FORMULARY
48.614	16.042	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Lotensin	BENAZEPRIL HCL	TABLET	40 MG	COVERED	FORMULARY
33.192	21.724	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Lotensin HCT	BENAZEPRIL-HYDROCHLOROTHIAZIDE	TABLET	10-12.5 MG	COVERED	FORMULARY
33.193	21.725	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Lotensin HCT	BENAZEPRIL-HYDROCHLOROTHIAZIDE	TABLET	20-12.5 MG	COVERED	FORMULARY
33.194	21.726	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Lotensin HCT	BENAZEPRIL-HYDROCHLOROTHIAZIDE	TABLET	20-25 MG	COVERED	FORMULARY
1.480	378	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Captopril	CAPTOPRIL	TABLET	100 MG	COVERED	FORMULARY
1.481	380	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Captopril	CAPTOPRIL	TABLET	25 MG	COVERED	FORMULARY
1.482	381	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Captopril	CAPTOPRIL	TABLET	50 MG	COVERED	FORMULARY
1.483	379	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Captopril	CAPTOPRIL	TABLET	12.5 MG	COVERED	FORMULARY
54.940	374	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Captopril-Hydrochlorothiazide	CAPTOPRIL-HYDROCHLOROTHIAZIDE	TABLET	25-15 MG	COVERED	FORMULARY
54.941	375	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Captopril-Hydrochlorothiazide	CAPTOPRIL-HYDROCHLOROTHIAZIDE	TABLET	25-25 MG	COVERED	FORMULARY
960	387	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Vasotec	ENALAPRIL MALEATE	TABLET	5 MG	COVERED	FORMULARY
961	384	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Vasotec	ENALAPRIL MALEATE	TABLET	10 MG	COVERED	FORMULARY
962	386	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Vasotec	ENALAPRIL MALEATE	TABLET	20 MG	COVERED	FORMULARY
963	385	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Vasotec	ENALAPRIL MALEATE	TABLET	2.5 MG	COVERED	FORMULARY
54.860	382	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Enalapril-Hydrochlorothiazide	ENALAPRIL-HYDROCHLOROTHIAZIDE	TABLET	10-25 MG	COVERED	FORMULARY
54.862	24.190	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Enalapril-Hydrochlorothiazide	ENALAPRIL-HYDROCHLOROTHIAZIDE	TABLET	5-12.5 MG	COVERED	FORMULARY
48.580	24.469	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Fosinopril	FOSINOPRIL SODIUM	TABLET	40 MG	COVERED	FORMULARY
48.581	16.017	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Fosinopril	FOSINOPRIL SODIUM	TABLET	10 MG	COVERED	FORMULARY
48.582	16.018	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Fosinopril	FOSINOPRIL SODIUM	TABLET	20 MG	COVERED	FORMULARY
10.455	40.395	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Fosinopril-Hydrochlorothiazide	FOSINOPRIL-HYDROCHLOROTHIAZIDE	TABLET	20-12.5 MG	COVERED	FORMULARY
15.621	44.935	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Fosinopril-Hydrochlorothiazide	FOSINOPRIL-HYDROCHLOROTHIAZIDE	TABLET	10-12.5 MG	COVERED	FORMULARY
47.260	393	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Prinvil, Zestril	LISINOPRIL	TABLET	5 MG	COVERED	FORMULARY
47.261	390	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Prinvil, Zestril	LISINOPRIL	TABLET	10 MG	COVERED	FORMULARY
47.262	391	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Prinvil, Zestril	LISINOPRIL	TABLET	20 MG	COVERED	FORMULARY
47.263	392	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Prinvil, Zestril	LISINOPRIL	TABLET	40 MG	COVERED	FORMULARY
47.264	17.266	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Prinvil, Zestril	LISINOPRIL	TABLET	2.5 MG	COVERED	FORMULARY
47.265	41.567	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Prinvil, Zestril	LISINOPRIL	TABLET	30 MG	COVERED	FORMULARY
88.000	388	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Zestoretic	LISINOPRIL-HYDROCHLOROTHIAZIDE	TABLET	20-12.5 MG	COVERED	FORMULARY
88.001	389	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Zestoretic	LISINOPRIL-HYDROCHLOROTHIAZIDE	TABLET	20-25 MG	COVERED	FORMULARY
88.002	21.277	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Zestoretic	LISINOPRIL-HYDROCHLOROTHIAZIDE	TABLET	10-12.5 MG	COVERED	FORMULARY
27.570	18.772	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Accupril	QUINAPRIL HCL	TABLET	10 MG	COVERED	FORMULARY
27.571	18.773	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Accupril	QUINAPRIL HCL	TABLET	20 MG	COVERED	FORMULARY
27.572	18.774	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Accupril	QUINAPRIL HCL	TABLET	5 MG	COVERED	FORMULARY
27.573	21.909	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Accupril	QUINAPRIL HCL	TABLET	40 MG	COVERED	FORMULARY
54.160	19.140	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Accuretic	QUINAPRIL-HYDROCHLOROTHIAZIDE	TABLET	10-12.5MG	COVERED	FORMULARY
54.161	24.002	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Accuretic	QUINAPRIL-HYDROCHLOROTHIAZIDE	TABLET	20-12.5 MG	COVERED	FORMULARY
94.490	41.016	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Accuretic	QUINAPRIL-HYDROCHLOROTHIAZIDE	TABLET	20-25MG	COVERED	FORMULARY
48.542	15.940	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Altace	RAMIPRIL	CAPSULE	2.5 MG	COVERED	FORMULARY
48.543	15.941	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Altace	RAMIPRIL	CAPSULE	5 MG	COVERED	FORMULARY
48.544	16.031	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Altace	RAMIPRIL	CAPSULE	10 MG	COVERED	FORMULARY
4.749	34.468	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Avapro	IRBESARTAN	TABLET	150 MG	COVERED	FORMULARY
4.750	34.469	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Avapro	IRBESARTAN	TABLET	300 MG	COVERED	FORMULARY
4.752	34.470	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Avapro	IRBESARTAN	TABLET	75 MG	COVERED	FORMULARY
11.042	41.234	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Avalide	IRBESARTAN-HYDROCHLOROTHIAZIDE	TABLET	150-12.5 MG	COVERED	FORMULARY
11.295	41.897	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Avalide	IRBESARTAN-HYDROCHLOROTHIAZIDE	TABLET	300-12.5 MG	COVERED	FORMULARY
14.850	23.381	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Cozaar	LOSARTAN POTASSIUM	TABLET	25 MG	COVERED	FORMULARY
14.851	23.382	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Cozaar	LOSARTAN POTASSIUM	TABLET	50 MG	COVERED	FORMULARY
14.853	38.686	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Cozaar	LOSARTAN POTASSIUM	TABLET	100 MG	COVERED	FORMULARY
14.852	23.465	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Hyzaar	LOSARTAN-HYDROCHLOROTHIAZIDE	TABLET	50-12.5 MG	COVERED	FORMULARY
14.854	40.923	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Hyzaar	LOSARTAN-HYDROCHLOROTHIAZIDE	TABLET	100-25 MG	COVERED	FORMULARY
25.851	59.919	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Hyzaar	LOSARTAN-HYDROCHLOROTHIAZIDE	TABLET	100-12.5 MG	COVERED	FORMULARY
91.883	51.036	243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS	Inspra	EPLERENONE	TABLET	25 MG	COVERED	FORMULARY
91.883	51.036	243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS	Inspra	EPLERENONE	TABLET	25 MG	COVERED	FORMULARY
91.884	51.037	243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS	Inspra	EPLERENONE	TABLET	50 MG	COVERED	FORMULARY
91.884	51.037	243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS	Inspra	EPLERENONE	TABLET	50 MG	COVERED	FORMULARY
27.690	6.816	243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS	Aldactone	SPIRONOLACTONE	TABLET	100 MG	COVERED	FORMULARY
27.691	6.817	243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS	Aldactone	SPIRONOLACTONE	TABLET	25 MG	COVERED	FORMULARY
27.692	6.818	243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS	Aldactone	SPIRONOLACTONE	TABLET	50 MG	COVERED	FORMULARY
71.150	4.308	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Fiorinal	BUTALBITAL-ASPIRIN-CAFFEINE	CAPSULE	50-325-40 MG	COVERED	FORMULARY
71.150	4.308	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Fiorinal	BUTALBITAL-ASPIRIN-CAFFEINE	CAPSULE	50-325-40 MG	COVERED	FORMULARY
45.680	18.293	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Voltaren	DICLOFENAC SODIUM	GEL (GRAM)	1 %	COVERED	FORMULARY
13.310	11.933	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Diclofenac Sodium	DICLOFENAC SODIUM	TAB ER 24H	100 MG	COVERED	FORMULARY
35.850	8.372	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Diclofenac Sodium	DICLOFENAC SODIUM	TABLET DR/EC	25 MG	COVERED	FORMULARY
35.851	8.373	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Diclofenac Sodium	DICLOFENAC SODIUM	TABLET DR/EC	50 MG	COVERED	FORMULARY
35.852	8.374	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Diclofenac Sodium	DICLOFENAC SODIUM	TABLET DR/EC	75 MG	COVERED	FORMULARY
33.870	15.960	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Etodolac	ETODOLAC	CAPSULE	200 MG	COVERED	FORMULARY
33.871	15.961	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Etodolac	ETODOLAC	CAPSULE	300 MG	COVERED	FORMULARY
61.767	38.259	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Etodolac	ETODOLAC	TAB ER 24H	500 MG	COVERED	FORMULARY
61.761	20.175	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Etodolac	ETODOLAC	TABLET	400 MG	COVERED	FORMULARY
61.766	27.368	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Etodolac	ETODOLAC	TABLET	500 MG	COVERED	FORMULARY
35.741	8.348	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Ibuprofen	IBUPROFEN	TABLET	400 MG	COVERED	FORMULARY
35.742	8.349	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Ibuprofen	IBUPROFEN	TABLET	600 MG	COVERED	FORMULARY
35.744	8.350	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Ibuprofen	IBUPROFEN	TABLET	800 MG	COVERED	FORMULARY
35.680	8.336	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Indomethacin	INDOMETHACIN	CAPSULE	25 MG	COVERED	FORMULARY
35.681	8.337	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Indomethacin	INDOMETHACIN	CAPSULE	50 MG	COVERED	FORMULARY
35.690	8.338	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Indomethacin	INDOMETHACIN	CAPSULE ER	75 MG	COVERED	FORMULARY
33.792	16.406	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Ketoprofen ER	KETOPROFEN	CAP24H PEL	200 MG	COVERED	FORMULARY
34.420	8.379	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Ketoprofen	KETOPROFEN	CAPSULE	50 MG	COVERED	FORMULARY
34.421	8.380	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Ketoprofen	KETOPROFEN	CAPSULE	75 MG	COVERED	FORMULARY
31.661	29.156	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Mobic	MELOXICAM	TABLET	7.5 MG	COVERED	FORMULARY
31.662	29.157	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Mobic	MELOXICAM	TABLET	15 MG	COVERED	FORMULARY
32.961	16.574	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Nabumetone	NABUMETONE	TABLET	500 MG	COVERED	FORMULARY
32.962	16.575	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Nabumetone	NABUMETONE	TABLET	750 MG	COVERED	FORMULARY
35.790	8.360	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Naprosyn	NAPROXEN	TABLET	250 MG	COVERED	FORMULARY
35.792	8.361	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Naprosyn	NAPROXEN	TABLET	375 MG	COVERED	FORMULARY
35.793	8.362	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Naprosyn	NAPROXEN	TABLET	500 MG	COVERED	FORMULARY
47.130	8.357	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Anaprox	NAPROXEN SODIUM	TABLET	275 MG	COVERED	FORMULARY
47.131	8.358	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Anaprox	NAPROXEN SODIUM	TABLET	550 MG	COVERED	FORMULARY
16.801	4.438	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Salsalate	SALSALATE	TABLET	500 MG	COVERED	FORMULARY
16.802	4.439	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Salsalate	SALSALATE	TABLET	750 MG	COVERED	FORMULARY
55.402	45.155	280808-OPIATE AGONISTS	Acetaminophen-Codeine Solution	ACETAMINOPHEN-CODEINE	SOLUTION	120-12 MG/5ML	COVERED	FORMULARY
70.131	4.163	280808-OPIATE AGONISTS	Acetaminophen-Codeine Tablet	ACETAMINOPHEN-CODEINE	TABLET	300-15 MG	COVERED	FORMULARY
70.134	4.165	280808-OPIATE AGONISTS	Tylenol-Codeine #3	ACETAMINOPHEN-CODEINE	TABLET	300-30 MG	COVERED	FORMULARY
70.136	4.169	280808-OPIATE AGONISTS	Tylenol-Codeine #4	ACETAMINOPHEN-CODEINE	TABLET	300-60 MG	COVERED	FORMULARY
70.140	4.149	280808-OPIATE AGONISTS	Butalbital-Acetaminophen-Caffeine-Codeine	BUTALBITAL-ACETAMINOPHEN-CAFFEINE-CODEINE	CAPSULE	50-325-30 MG	COVERED	FORMULARY
21.146	53.582	280808-OPIATE AGONISTS	Hydrocodone-Acetaminophen	HYDROCODONE-ACETAMINOPHEN	SOLUTION	7.5-325/15	COVERED	FORMULARY
12.486	47.430	280808-OPIATE AGONISTS	Hydrocodone-Acetaminophen	HYDROCODONE-ACETAMINOPHEN	TABLET	5-325 MG	COVERED	FORMULARY
12.488	47.431	280808-OPIATE AGONISTS	Hydrocodone-Acetaminophen	HYDROCODONE-ACETAMINOPHEN	TABLET	7.5-325 MG	COVERED	FORMULARY
70.330	30.623	280808-OPIATE AGONISTS	Hydrocodone-Acetaminophen	HYDROCODONE-ACETAMINOPHEN	TABLET	10-325 MG	COVERED	FORMULARY
12.488	47.431	280808-OPIATE AGONISTS	Hydrocodone-Acetaminophen	HYDROCODONE-ACETAMINOPHEN	TABLET	7.5-325 MG	COVERED	FORMULARY
63.101	34.068	280808-OPIATE AGONISTS	Vicoprofen	HYDROCODONE-IBUPROFEN	TABLET	7.5-200 MG	COVERED	FORMULARY
16.141	4.110	280808-OPIATE AGONISTS	Dilaudid	HYDROMORPHONE HCL	TABLET	2 MG	COVERED	FORMULARY
16.143	4.112	280808-OPIATE AGONISTS	Dilaudid	HYDROMORPHONE HCL	TABLET	4 MG	COVERED	FORMULARY
16.144	15.190	280808-OPIATE AGONISTS	Dilaudid	HYDROMORPHONE HCL	TABLET	8 MG	COVERED	FORMULARY
16.420	4.240	280808-OPIATE AGONISTS	Dolophine	METHADONE HCL	TABLET	10 MG	COVERED	FORMULARY
16.422	4.242	280808-OPIATE AGONISTS	Dolophine	METHADONE HCL	TABLET	5 MG	COVERED	FORMULARY
16.060	4.087	280808-OPIATE AGONISTS	Morphine	MORPHINE SULFATE	SOLUTION	10 MG/5ML	COVERED	FORMULARY
16.062	4.089	280808-OPIATE AGONISTS	Morphine	MORPHINE SULFATE	SOLUTION	20 MG/5ML	COVERED	FORMULARY
16.063	4.090	280808-OPIATE AGONISTS	Morphine	MORPHINE SULFATE	SOLUTION	100 MG/5ML	COVERED	FORMULARY
16.070	4.091	280808-OPIATE AGONISTS	Morphine	MORPHINE SULFATE	TABLET	15 MG	COVERED	FORMULARY
16.071	4.092	280808-OPIATE AGONISTS	Morphine	MORPHINE SULFATE	TABLET	30 MG	COVERED	FORMULARY
16.640	4.096	280808-OPIATE AGONISTS	MS Contin CR	MORPHINE SULFATE	TABLET ER	30 MG	COVERED	FORMULARY
16.641	4.097	280808-OPIATE AGONISTS	MS Contin CR	MORPHINE SULFATE	TABLET ER	60 MG	COVERED	FORMULARY
16.643	11.887	280808-OPIATE AGONISTS	MS Contin CR	MORPHINE SULFATE	TABLET ER	15 MG	COVERED	FORMULARY
16.285	24.507	280808-OPIATE AGONISTS	Oxycodone	OXYCODONE HCL	CAPSULE	5 MG	COVERED	FORMULARY
16.290	4.225	280808-OPIATE AGONISTS	Oxycodone	OXYCODONE HCL	TABLET	5 MG	COVERED	FORMULARY
14.965	48.976	280808-OPIATE AGONISTS	Percocet	OXYCODONE HCL-ACETAMINOPHEN	TABLET	7.5-325MG	COVERED	FORMULARY
14.966	48.977	280808-OPIATE AGONISTS	Percocet	OXYCODONE HCL-ACETAMINOPHEN	TABLET	10MG-325MG	COVERED	FORMULARY
70.491	4.222	280808-OPIATE AGONISTS	Percocet	OXYCODONE HCL-ACETAMINOPHEN	TABLET	5 MG-325MG	COVERED	FORMULARY
7.221	23.139	280808-OPIATE AGONISTS	Ultram	TRAMADOL HCL	TABLET	50 MG	COVERED	FORMULARY
13.909	48.456	280808-OPIATE AGONISTS	Ultracet	TRAMADOL HCL-ACETAMINOPHEN	TABLET	37.5-325MG	COVERED	FORMULARY
72.510	4.450	280892-ANALGESICS AND ANTIPYRETICS, MISC.	Capacet	BUTALBITAL-ACETAMINOPHEN-CAFFEINE	CAPSULE	50-325-40 MG	COVERED	FORMULARY
72.530	4.451	280892-ANALGESICS AND ANTIPYRETICS, MISC.	Esgic	BUTALBITAL-ACETAMINOPHEN-CAFFEINE	TABLET	50-325-40 MG	COVERED	FORMULARY
13.996	48.520	280892-ANALGESICS AND ANTIPYRETICS, MISC.	Nodolor	ISOMETHEPT-DICHLPHN/ACETAMINOPHEN	CAPSULE	65-100-325 MG	COVERED	FORMULARY
40.233	75.222	281000-OPIATE ANTAGONISTS	Narcan Nasal	NALOXONE HCL	SPRAY	4 MG	COVERED	FORMULARY
17.070	4.518	281000-OPIATE ANTAGONISTS	Naltrexone	NALTREXONE HCL	TABLET	50 MG	COVERED	FORMULARY
17.321	4.543	281204-BARBITURATES (ANTICONVULSANTS)	Mysoline	PRIMIDONE	TABLET	250 MG	COVERED	FORMULARY
17.322	4.544	281204-BARBITURATES (ANTICONVULSANTS)	Mysoline	PRIMIDONE	TABLET	50 MG	COVERED	FORMULARY
17.470	4.560	281208-BENZODIAZEPINES (ANTICONVULSANTS)	Klonopin	CLONAZEPAM	TABLET	0.5 MG	COVERED	FORMULARY
17.471	4.561	281208-BENZODIAZEPINES (ANTICONVULSANTS)	Klonopin	CLONAZEPAM	TABLET	1 MG	COVERED	FORMULARY
17.472	4.562	281208-BENZODIAZEPINES (ANTICONVULSANTS)	Klonopin	CLONAZEPAM	TABLET	2 MG	COVERED	FORMULARY
17.260	4.532	281212-HYDANTOINS	Peganone	ETHOTOIN	TABLET	250 MG	COVERED	FORMULARY
17.241	4.529	281212-HYDANTOINS	Dilantin	PHENYTOIN	ORAL SUSP	125 MG/5ML	COVERED	FORMULARY
99.557	63.845	281212-HYDANTOINS	Phenytoin	PHENYTOIN	ORAL SUSP	100 MG/4ML	COVERED	FORMULARY
17.250	4.531	281212-HYDANTOINS	Dilantin	PHENYTOIN	TAB CHEW	50 MG	COVERED	FORMULARY
15.037	49.444	281212-HYDANTOINS	Dilantin, Phenytek	PHENYTOIN SODIUM EXTENDED	CAPSULE	300 MG	COVERED	FORMULARY
15.038	49.445	281212-HYDANTOINS	Dilantin, Phenytek	PHENYTOIN SODIUM EXTENDED	CAPSULE	200 MG	COVERED	FORMULARY
17.700	4.521	281212-HYDANTOINS	Dilantin, Phenytek	PHENYTOIN SODIUM EXTENDED	CAPSULE	100 MG	COVERED	FORMULARY
17.701	4.522	281212-HYDANTOINS	Dilantin, Phenytek	PHENYTOIN SODIUM EXTENDED	CAPSULE	30 MG	COVERED	FORMULARY
23.932	58.487	281292-ANTICONVULSANTS, MISCELLANEOUS	Carbatrol	CARBAMAZEPINE	CPMP 12HR	200 MG	COVERED	FORMULARY
23.933	58.488	281292-ANTICONVULSANTS, MISCELLANEOUS	Carbatrol	CARBAMAZEPINE	CPMP 12HR	300 MG	COVERED	FORMULARY
23.934	58.489	281292-ANTICONVULSANTS, MISCELLANEOUS	Carbatrol	CARBAMAZEPINE	CPMP 12HR	100 MG	COVERED	FORMULARY
47.500	4.557	281292-ANTICONVULSANTS, MISCELLANEOUS	Carbamazepine	CARBAMAZEPINE	ORAL SUSP	100 MG/5ML	COVERED	FORMULARY
17.460	4.559	281292-ANTICONVULSANTS, MISCELLANEOUS	Carbamazepine	CARBAMAZEPINE	TAB CHEW	100 MG	COVERED	FORMULARY
27.820	26.868	281292-ANTICONVULSANTS, MISCELLANEOUS	Tegreol XR	CARBAMAZEPINE	TAB ER 12H	100 MG	COVERED	FORMULARY
27.821	16.773	281292-ANTICONVULSANTS, MISCELLANEOUS	Tegreol XR	CARBAMAZEPINE	TAB ER 12H	200 MG	COVERED	FORMULARY
27.822	17.876	281292-ANTICONVULSANTS, MISCELLANEOUS	Tegreol XR	CARBAMAZEPINE	TAB ER 12H	400 MG	COVERED	FORMULARY
17.450	4.558	281292-ANTICONVULSANTS, MISCELLANEOUS	Tegretol	CARBAMAZEPINE	TABLET	200 MG	COVERED	FORMULARY
18.040	46.315	281292-ANTICONVULSANTS, MISCELLANEOUS	Depakote ER	DIVALPROEX SODIUM	TAB ER 24H	500 MG	COVERED	FORMULARY
18.754	51.469	281292-ANTICONVULSANTS, MISCELLANEOUS	Depakote ER	DIVALPROEX SODIUM	TAB ER 24H	250 MG	COVERED	FORMULARY
17.290	4.539	281292-ANTICONVULSANTS, MISCELLANEOUS	Depakote	DIVALPROEX SODIUM	TABLET DR	250 MG	COVERED	FORMULARY
17.291	4.540	281292-ANTICONVULSANTS, MISCELLANEOUS	Depakote	DIVALPROEX SODIUM	TABLET DR	500 MG	COVERED	FORMULARY
17.292	4.538	281292-ANTICONVULSANTS, MISCELLANEOUS	Depakote	DIVALPROEX SODIUM	TABLET DR	125 MG	COVERED	FORMULARY
780	21.413	281292-ANTICONVULSANTS, MISCELLANEOUS	Neurontin	GABAPENTIN	CAPSULE	100 MG	COVERED	FORMULARY
781	21.414	281292-ANTICONVULSANTS, MISCELLANEOUS	Neurontin	GABAPENTIN	CAPSULE	300 MG	COVERED	FORMULARY
782	21.415	281292-ANTICONVULSANTS, MISCELLANEOUS	Neurontin	GABAPENTIN	CAPSULE	400 MG	COVERED	FORMULARY
13.235	47.927	281292-ANTICONVULSANTS, MISCELLANEOUS	Neurontin	GABAPENTIN	SOLUTION	250 MG/5ML	COVERED	FORMULARY
94.447	41.806	281292-ANTICONVULSANTS, MISCELLANEOUS	Neurontin	GABAPENTIN	TABLET	800 MG	COVERED	FORMULARY
94.624	41.805	281292-ANTICONVULSANTS, MISCELLANEOUS	Neurontin	GABAPENTIN	TABLET	600 MG	COVERED	FORMULARY
64.316	17.871	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal	LAMOTRIGINE	TABLET	100 MG	COVERED	FORMULARY
64.317	17.872	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal	LAMOTRIGINE	TABLET	25 MG	COVERED	FORMULARY
64.324	22.550	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal	LAMOTRIGINE	TABLET	150 MG	COVERED	FORMULARY
64.325	22.551	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal	LAMOTRIGINE	TABLET	200 MG	COVERED	FORMULARY
16.779	64.819	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra	LEVETIRACETAM	SOLUTION	500 MG/5ML	COVERED	FORMULARY
20.353	53.031	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra	LEVETIRACETAM	SOLUTION	100 MG/ML	COVERED	FORMULARY
41.586	45.652	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra	LEVETIRACETAM	TABLET	750 MG	COVERED	FORMULARY
41.587	44.632	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra	LEVETIRACETAM	TABLET	250 MG	COVERED	FORMULARY
41.597	44.633	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra	LEVETIRACETAM	TABLET	500 MG	COVERED	FORMULARY
86.223	47.077	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra	LEVETIRACETAM	TABLET	1000 MG	COVERED	FORMULARY
21.723	33.724	281292-ANTICONVULSANTS, MISCELLANEOUS	Trileptal	OXCARBAZEPINE	ORAL SUSP	300 MG/5ML	COVERED	FORMULARY
21.721	27.779	281292-ANTICONVULSANTS, MISCELLANEOUS	Trileptal	OXCARBAZEPINE	TABLET	300 MG	COVERED	FORMULARY
21.722	27.780	281292-ANTICONVULSANTS, MISCELLANEOUS	Trileptal	OXCARBAZEPINE	TABLET	600 MG	COVERED	FORMULARY
21.724	44.336	281292-ANTICONVULSANTS, MISCELLANEOUS	Trileptal	OXCARBAZEPINE	TABLET	150 MG	COVERED	FORMULARY
36.550	26.169	281292-ANTICONVULSANTS, MISCELLANEOUS	Topamax	TOPIRAMATE	TABLET	50 MG	COVERED	FORMULARY
36.551	26.170	281292-ANTICONVULSANTS, MISCELLANEOUS	Topamax	TOPIRAMATE	TABLET	100 MG	COVERED	FORMULARY
36.552	26.171	281292-ANTICONVULSANTS, MISCELLANEOUS	Topamax	TOPIRAMATE	TABLET	200 MG	COVERED	FORMULARY
36.553	29.837	281292-ANTICONVULSANTS, MISCELLANEOUS	Topamax	TOPIRAMATE	TABLET	25 MG	COVERED	FORMULARY
17.270	4.536	281292-ANTICONVULSANTS, MISCELLANEOUS	Depakene	VALPROIC ACID	CAPSULE	250 MG	COVERED	FORMULARY
17.280	4.535	281292-ANTICONVULSANTS, MISCELLANEOUS	Depakene Syrup	VALPROIC ACID (AS SODIUM SALT)	SOLUTION	250 MG/5ML	COVERED	FORMULARY
30.965	68.220	281292-ANTICONVULSANTS, MISCELLANEOUS	Valproic Solution	VALPROIC ACID (AS SODIUM SALT)	SOLUTION	250 MG/5ML	COVERED	FORMULARY
30.986	68.236	281292-ANTICONVULSANTS, MISCELLANEOUS	Valproic Syrup	VALPROIC ACID (AS SODIUM SALT)	SOLUTION	500 MG/10ML	COVERED	FORMULARY
30.987	68.237	281292-ANTICONVULSANTS, MISCELLANEOUS	Valproic Syrup	VALPROIC ACID (AS SODIUM SALT)	SYRINGE	250 MG/5ML	COVERED	FORMULARY
20.831	53.367	281292-ANTICONVULSANTS, MISCELLANEOUS	Zonegran	ZONISAMIDE	CAPSULE	25 MG	COVERED	FORMULARY
20.833	53.368	281292-ANTICONVULSANTS, MISCELLANEOUS	Zonegran	ZONISAMIDE	CAPSULE	50 MG	COVERED	FORMULARY
92.219	45.100	281292-ANTICONVULSANTS, MISCELLANEOUS	Zonegran	ZONISAMIDE	CAPSULE	100 MG	COVERED	FORMULARY
16.512	46.043	281604-ANTIDEPRESSANTS	Elavil	AMITRIPTYLINE HCL	TABLET	10 MG	COVERED	FORMULARY
16.513	46.044	281604-ANTIDEPRESSANTS	Elavil	AMITRIPTYLINE HCL	TABLET	100 MG	COVERED	FORMULARY
16.514	46.045	281604-ANTIDEPRESSANTS	Elavil	AMITRIPTYLINE HCL	TABLET	150 MG	COVERED	FORMULARY
16.515	46.046	281604-ANTIDEPRESSANTS	Elavil	AMITRIPTYLINE HCL	TABLET	25 MG	COVERED	FORMULARY
16.516	46.047	281604-ANTIDEPRESSANTS	Elavil	AMITRIPTYLINE HCL	TABLET	50 MG	COVERED	FORMULARY
16.517	46.048	281604-ANTIDEPRESSANTS	Elavil	AMITRIPTYLINE HCL	TABLET	75 MG	COVERED	FORMULARY
20.317	53.006	281604-ANTIDEPRESSANTS	Wellbutrin XL	BUPROPION HCL	TAB ER 24H	150 MG	COVERED	FORMULARY
20.318	53.007	281604-ANTIDEPRESSANTS	Wellbutrin XL	BUPROPION HCL	TAB ER 24H	300 MG	COVERED	FORMULARY
16.384	46.236	281604-ANTIDEPRESSANTS	Wellbutrin	BUPROPION HCL	TABLET	75 MG	COVERED	FORMULARY
16.385	46.237	281604-ANTIDEPRESSANTS	Wellbutrin	BUPROPION HCL	TABLET	100 MG	COVERED	FORMULARY
16.386	46.238	281604-ANTIDEPRESSANTS	Wellbutrin SR	BUPROPION HCL	TABLET ER	150 MG	COVERED	FORMULARY
16.387	46.239	281604-ANTIDEPRESSANTS	Wellbutrin SR	BUPROPION HCL	TABLET ER	100 MG	COVERED	FORMULARY
17.573	50.496	281604-ANTIDEPRESSANTS	Wellbutrin SR	BUPROPION HCL	TABLET ER	200 MG	COVERED	FORMULARY
27.901	31.439	281604-ANTIDEPRESSANTS	Zyban SR	BUPROPION HCL	TABLET ER	150 MG	COVERED	FORMULARY
16.342	46.203	281604-ANTIDEPRESSANTS	Celexa	CITALOPRAM HYDROBROMIDE	TABLET	20 MG	COVERED	FORMULARY
16.343	46.204	281604-ANTIDEPRESSANTS	Celexa	CITALOPRAM HYDROBROMIDE	TABLET	40 MG	COVERED	FORMULARY
16.345	46.206	281604-ANTIDEPRESSANTS	Celexa	CITALOPRAM HYDROBROMIDE	TABLET	10 MG	COVERED	FORMULARY
16.563	46.086	281604-ANTIDEPRESSANTS	Doxepin	DOXEPIN HCL	CAPSULE	10 MG	COVERED	FORMULARY
16.564	46.087	281604-ANTIDEPRESSANTS	Doxepin	DOXEPIN HCL	CAPSULE	100 MG	COVERED	FORMULARY
16.565	46.088	281604-ANTIDEPRESSANTS	Doxepin	DOXEPIN HCL	CAPSULE	150 MG	COVERED	FORMULARY
16.566	46.089	281604-ANTIDEPRESSANTS	Doxepin	DOXEPIN HCL	CAPSULE	25 MG	COVERED	FORMULARY
16.567	46.090	281604-ANTIDEPRESSANTS	Doxepin	DOXEPIN HCL	CAPSULE	50 MG	COVERED	FORMULARY
16.568	46.091	281604-ANTIDEPRESSANTS	Doxepin	DOXEPIN HCL	CAPSULE	75 MG	COVERED	FORMULARY
23.161	57.891	281604-ANTIDEPRESSANTS	Cymbalta	DULOXETINE HCL	CAPSULE DR	20 MG	COVERED	FORMULARY
23.162	57.892	281604-ANTIDEPRESSANTS	Cymbalta	DULOXETINE HCL	CAPSULE DR	30 MG	COVERED	FORMULARY
23.164	57.893	281604-ANTIDEPRESSANTS	Cymbalta	DULOXETINE HCL	CAPSULE DR	60 MG	COVERED	FORMULARY
38.728	74.166	281604-ANTIDEPRESSANTS	Cymbalta	DULOXETINE HCL	CAPSULE DR	40 MG	COVERED	FORMULARY
19.035	51.698	281604-ANTIDEPRESSANTS	Lexapro Solution	ESCITALOPRAM OXALATE	SOLUTION	5 MG/5ML	COVERED	FORMULARY
17.851	50.712	281604-ANTIDEPRESSANTS	Lexapro	ESCITALOPRAM OXALATE	TABLET	10 MG	COVERED	FORMULARY
17.987	50.760	281604-ANTIDEPRESSANTS	Lexapro	ESCITALOPRAM OXALATE	TABLET	20 MG	COVERED	FORMULARY
18.975	51.642	281604-ANTIDEPRESSANTS	Lexapro	ESCITALOPRAM OXALATE	TABLET	5 MG	COVERED	FORMULARY
16.353	46.213	281604-ANTIDEPRESSANTS	Prozac	FLUOXETINE HCL	CAPSULE	10 MG	COVERED	FORMULARY
16.354	46.214	281604-ANTIDEPRESSANTS	Prozac	FLUOXETINE HCL	CAPSULE	20 MG	COVERED	FORMULARY
16.355	46.215	281604-ANTIDEPRESSANTS	Prozac	FLUOXETINE HCL	CAPSULE	40 MG	COVERED	FORMULARY
16.348	46.209	281604-ANTIDEPRESSANTS	Fluvoxamine	FLUVOXAMINE MALEATE	TABLET	50 MG	COVERED	FORMULARY
16.349	46.210	281604-ANTIDEPRESSANTS	Fluvoxamine	FLUVOXAMINE MALEATE	TABLET	100 MG	COVERED	FORMULARY
16.541	46.068	281604-ANTIDEPRESSANTS	Tofranil	IMIPRAMINE HCL	TABLET	10 MG	COVERED	FORMULARY
16.542	46.069	281604-ANTIDEPRESSANTS	Tofranil	IMIPRAMINE HCL	TABLET	25 MG	COVERED	FORMULARY
16.543	46.070	281604-ANTIDEPRESSANTS	Tofranil	IMIPRAMINE HCL	TABLET	50 MG	COVERED	FORMULARY
21.817	54.009	281604-ANTIDEPRESSANTS	Remeron	MIRTAZAPINE	TABLET	7.5 MG	COVERED	FORMULARY
16.732	46.450	281604-ANTIDEPRESSANTS	Remeron	MIRTAZAPINE	TABLET	15 MG	COVERED	FORMULARY
16.733	46.451	281604-ANTIDEPRESSANTS	Remeron	MIRTAZAPINE	TABLET	30 MG	COVERED	FORMULARY
16.734	46.452	281604-ANTIDEPRESSANTS	Remeron	MIRTAZAPINE	TABLET	45 MG	COVERED	FORMULARY
16.529	46.059	281604-ANTIDEPRESSANTS	Pamelor	NORTRIPTYLINE HCL	CAPSULE	10 MG	COVERED	FORMULARY
16.532	46.060	281604-ANTIDEPRESSANTS	Pamelor	NORTRIPTYLINE HCL	CAPSULE	25 MG	COVERED	FORMULARY
16.533	46.061	281604-ANTIDEPRESSANTS	Pamelor	NORTRIPTYLINE HCL	CAPSULE	50 MG	COVERED	FORMULARY
16.534	46.062	281604-ANTIDEPRESSANTS	Pamelor	NORTRIPTYLINE HCL	CAPSULE	75 MG	COVERED	FORMULARY
17.077	50.136	281604-ANTIDEPRESSANTS	Paxil CR	PAROXETINE HCL	TAB ER 24H	25 MG	COVERED	FORMULARY
17.078	50.137	281604-ANTIDEPRESSANTS	Paxil CR	PAROXETINE HCL	TAB ER 24H	12.5 MG	COVERED	FORMULARY
17.079	50.138	281604-ANTIDEPRESSANTS	Paxil CR	PAROXETINE HCL	TAB ER 24H	37.5 MG	COVERED	FORMULARY
16.364	46.222	281604-ANTIDEPRESSANTS	Paxil	PAROXETINE HCL	TABLET	10 MG	COVERED	FORMULARY
16.366	46.223	281604-ANTIDEPRESSANTS	Paxil	PAROXETINE HCL	TABLET	20 MG	COVERED	FORMULARY
16.367	46.224	281604-ANTIDEPRESSANTS	Paxil	PAROXETINE HCL	TABLET	30 MG	COVERED	FORMULARY
16.368	46.225	281604-ANTIDEPRESSANTS	Paxil	PAROXETINE HCL	TABLET	40 MG	COVERED	FORMULARY
16.373	46.227	281604-ANTIDEPRESSANTS	Zoloft	SERTRALINE HCL	TABLET	25 MG	COVERED	FORMULARY
16.374	46.228	281604-ANTIDEPRESSANTS	Zoloft	SERTRALINE HCL	TABLET	50 MG	COVERED	FORMULARY
16.375	46.229	281604-ANTIDEPRESSANTS	Zoloft	SERTRALINE HCL	TABLET	100 MG	COVERED	FORMULARY
16.391	46.241	281604-ANTIDEPRESSANTS	Trazodone	TRAZODONE HCL	TABLET	50 MG	COVERED	FORMULARY
16.392	46.242	281604-ANTIDEPRESSANTS	Trazodone	TRAZODONE HCL	TABLET	100 MG	COVERED	FORMULARY
16.393	46.243	281604-ANTIDEPRESSANTS	Trazodone	TRAZODONE HCL	TABLET	150 MG	COVERED	FORMULARY
16.394	46.244	281604-ANTIDEPRESSANTS	Trazodone	TRAZODONE HCL	TABLET	300 MG	COVERED	FORMULARY
16.816	46.403	281604-ANTIDEPRESSANTS	Effexor XR	VENLAFAXINE HCL	CAP ER 24H	37.5 MG	COVERED	FORMULARY
16.817	46.404	281604-ANTIDEPRESSANTS	Effexor XR	VENLAFAXINE HCL	CAP ER 24H	75 MG	COVERED	FORMULARY
16.818	46.405	281604-ANTIDEPRESSANTS	Effexor XR	VENLAFAXINE HCL	CAP ER 24H	150 MG	COVERED	FORMULARY
16.811	46.398	281604-ANTIDEPRESSANTS	Venlafaxine	VENLAFAXINE HCL	TABLET	25 MG	COVERED	FORMULARY
16.812	46.399	281604-ANTIDEPRESSANTS	Venlafaxine	VENLAFAXINE HCL	TABLET	37.5 MG	COVERED	FORMULARY
16.813	46.400	281604-ANTIDEPRESSANTS	Venlafaxine	VENLAFAXINE HCL	TABLET	50 MG	COVERED	FORMULARY
16.814	46.401	281604-ANTIDEPRESSANTS	Venlafaxine	VENLAFAXINE HCL	TABLET	75 MG	COVERED	FORMULARY
16.815	46.402	281604-ANTIDEPRESSANTS	Venlafaxine	VENLAFAXINE HCL	TABLET	100 MG	COVERED	FORMULARY
14.431	3.796	281608-ANTIPSYCHOTIC AGENTS	Chlorpromazine	CHLORPROMAZINE HCL	TABLET	10 MG	COVERED	FORMULARY
14.432	3.799	281608-ANTIPSYCHOTIC AGENTS	Chlorpromazine	CHLORPROMAZINE HCL	TABLET	25 MG	COVERED	FORMULARY
14.433	3.800	281608-ANTIPSYCHOTIC AGENTS	Chlorpromazine	CHLORPROMAZINE HCL	TABLET	50 MG	COVERED	FORMULARY
14.434	3.797	281608-ANTIPSYCHOTIC AGENTS	Chlorpromazine	CHLORPROMAZINE HCL	TABLET	100 MG	COVERED	FORMULARY
14.435	3.798	281608-ANTIPSYCHOTIC AGENTS	Chlorpromazine	CHLORPROMAZINE HCL	TABLET	200 MG	COVERED	FORMULARY
14.602	3.823	281608-ANTIPSYCHOTIC AGENTS	Fluphenazine	FLUPHENAZINE HCL	TABLET	1 MG	COVERED	FORMULARY
14.603	3.824	281608-ANTIPSYCHOTIC AGENTS	Fluphenazine	FLUPHENAZINE HCL	TABLET	10 MG	COVERED	FORMULARY
14.604	3.825	281608-ANTIPSYCHOTIC AGENTS	Fluphenazine	FLUPHENAZINE HCL	TABLET	2.5 MG	COVERED	FORMULARY
14.605	3.826	281608-ANTIPSYCHOTIC AGENTS	Fluphenazine	FLUPHENAZINE HCL	TABLET	5 MG	COVERED	FORMULARY
15.530	3.972	281608-ANTIPSYCHOTIC AGENTS	Haloperidol	HALOPERIDOL	TABLET	0.5 MG	COVERED	FORMULARY
15.531	3.973	281608-ANTIPSYCHOTIC AGENTS	Haloperidol	HALOPERIDOL	TABLET	1 MG	COVERED	FORMULARY
15.532	3.974	281608-ANTIPSYCHOTIC AGENTS	Haloperidol	HALOPERIDOL	TABLET	10 MG	COVERED	FORMULARY
15.533	3.975	281608-ANTIPSYCHOTIC AGENTS	Haloperidol	HALOPERIDOL	TABLET	2 MG	COVERED	FORMULARY
15.534	3.976	281608-ANTIPSYCHOTIC AGENTS	Haloperidol	HALOPERIDOL	TABLET	20 MG	COVERED	FORMULARY
15.535	3.977	281608-ANTIPSYCHOTIC AGENTS	Haloperidol	HALOPERIDOL	TABLET	5 MG	COVERED	FORMULARY
15.520	3.971	281608-ANTIPSYCHOTIC AGENTS	Haloperidol	HALOPERIDOL LACTATE	ORAL CONC	2 MG/ML	COVERED	FORMULARY
15.560	3.981	281608-ANTIPSYCHOTIC AGENTS	Loxapine	LOXAPINE SUCCINATE	CAPSULE	10 MG	COVERED	FORMULARY
15.561	3.982	281608-ANTIPSYCHOTIC AGENTS	Loxapine	LOXAPINE SUCCINATE	CAPSULE	25 MG	COVERED	FORMULARY
15.563	3.984	281608-ANTIPSYCHOTIC AGENTS	Loxapine	LOXAPINE SUCCINATE	CAPSULE	50 MG	COVERED	FORMULARY
15.081	27.959	281608-ANTIPSYCHOTIC AGENTS	Zyprexa	OLANZAPINE	TABLET	7.5 MG	COVERED	FORMULARY
15.082	27.960	281608-ANTIPSYCHOTIC AGENTS	Zyprexa	OLANZAPINE	TABLET	10 MG	COVERED	FORMULARY
15.083	27.961	281608-ANTIPSYCHOTIC AGENTS	Zyprexa	OLANZAPINE	TABLET	5 MG	COVERED	FORMULARY
15.084	29.077	281608-ANTIPSYCHOTIC AGENTS	Zyprexa	OLANZAPINE	TABLET	2.5 MG	COVERED	FORMULARY
15.085	41.026	281608-ANTIPSYCHOTIC AGENTS	Zyprexa	OLANZAPINE	TABLET	15 MG	COVERED	FORMULARY
15.086	41.027	281608-ANTIPSYCHOTIC AGENTS	Zyprexa	OLANZAPINE	TABLET	20 MG	COVERED	FORMULARY
14.650	3.830	281608-ANTIPSYCHOTIC AGENTS	Perphenazine	PERPHENAZINE	TABLET	16 MG	COVERED	FORMULARY
14.651	3.831	281608-ANTIPSYCHOTIC AGENTS	Perphenazine	PERPHENAZINE	TABLET	2 MG	COVERED	FORMULARY
14.652	3.832	281608-ANTIPSYCHOTIC AGENTS	Perphenazine	PERPHENAZINE	TABLET	4 MG	COVERED	FORMULARY
14.653	3.833	281608-ANTIPSYCHOTIC AGENTS	Perphenazine	PERPHENAZINE	TABLET	8 MG	COVERED	FORMULARY
26.409	60.292	281608-ANTIPSYCHOTIC AGENTS	Seroquel	QUETIAPINE FUMARATE	TABLET	50 MG	COVERED	FORMULARY	Max 800mg/day
26.411	60.293	281608-ANTIPSYCHOTIC AGENTS	Seroquel	QUETIAPINE FUMARATE	TABLET	400 MG	COVERED	FORMULARY	Max 800mg/day
67.661	34.187	281608-ANTIPSYCHOTIC AGENTS	Seroquel	QUETIAPINE FUMARATE	TABLET	25 MG	COVERED	FORMULARY	Max 800mg/day
67.662	34.188	281608-ANTIPSYCHOTIC AGENTS	Seroquel	QUETIAPINE FUMARATE	TABLET	100 MG	COVERED	FORMULARY	Max 800mg/day
67.663	34.189	281608-ANTIPSYCHOTIC AGENTS	Seroquel	QUETIAPINE FUMARATE	TABLET	200 MG	COVERED	FORMULARY	Max 800mg/day
67.665	47.198	281608-ANTIPSYCHOTIC AGENTS	Seroquel	QUETIAPINE FUMARATE	TABLET	300 MG	COVERED	FORMULARY	Max 800mg/day
16.135	26.177	281608-ANTIPSYCHOTIC AGENTS	Risperdal	RISPERIDONE	SOLUTION	1 MG/ML	COVERED	FORMULARY	Max 16mg/day
16.136	21.154	281608-ANTIPSYCHOTIC AGENTS	Risperdal	RISPERIDONE	TABLET	1 MG	COVERED	FORMULARY	Max 16mg/day
16.137	21.155	281608-ANTIPSYCHOTIC AGENTS	Risperdal	RISPERIDONE	TABLET	2 MG	COVERED	FORMULARY	Max 16mg/day
16.138	21.156	281608-ANTIPSYCHOTIC AGENTS	Risperdal	RISPERIDONE	TABLET	3 MG	COVERED	FORMULARY	Max 16mg/day
16.139	21.157	281608-ANTIPSYCHOTIC AGENTS	Risperdal	RISPERIDONE	TABLET	4 MG	COVERED	FORMULARY	Max 16mg/day
92.872	42.922	281608-ANTIPSYCHOTIC AGENTS	Risperdal	RISPERIDONE	TABLET	0.25 MG	COVERED	FORMULARY	Max 16mg/day
92.892	42.923	281608-ANTIPSYCHOTIC AGENTS	Risperdal	RISPERIDONE	TABLET	0.5 MG	COVERED	FORMULARY	Max 16mg/day
15.691	3.996	281608-ANTIPSYCHOTIC AGENTS	Thiothixene	THIOTHIXENE	CAPSULE	10 MG	COVERED	FORMULARY
15.692	3.997	281608-ANTIPSYCHOTIC AGENTS	Thiothixene	THIOTHIXENE	CAPSULE	2 MG	COVERED	FORMULARY
15.694	3.999	281608-ANTIPSYCHOTIC AGENTS	Thiothixene	THIOTHIXENE	CAPSULE	5 MG	COVERED	FORMULARY
19.880	5.009	282004-AMPHETAMINES	Zenzedi	DEXTROAMPHETAMINE SULFATE	TABLET	10 MG	COVERED	FORMULARY	Max 60mg/day
19.881	5.011	282004-AMPHETAMINES	Zenzedi	DEXTROAMPHETAMINE SULFATE	TABLET	5 MG	COVERED	FORMULARY	Max 60mg/day
14.635	48.701	282004-AMPHETAMINES	Adderall XR	DEXTROAMPHETAMINE-AMPHETAMINE	CAP ER 24H	10 MG	COVERED	FORMULARY	Max 60mg/day
14.636	48.702	282004-AMPHETAMINES	Adderall XR	DEXTROAMPHETAMINE-AMPHETAMINE	CAP ER 24H	20 MG	COVERED	FORMULARY	Max 60mg/day
14.637	48.703	282004-AMPHETAMINES	Adderall XR	DEXTROAMPHETAMINE-AMPHETAMINE	CAP ER 24H	30 MG	COVERED	FORMULARY	Max 60mg/day
17.459	50.428	282004-AMPHETAMINES	Adderall XR	DEXTROAMPHETAMINE-AMPHETAMINE	CAP ER 24H	5 MG	COVERED	FORMULARY	Max 60mg/day
17.468	50.429	282004-AMPHETAMINES	Adderall XR	DEXTROAMPHETAMINE-AMPHETAMINE	CAP ER 24H	15 MG	COVERED	FORMULARY	Max 60mg/day
17.469	50.430	282004-AMPHETAMINES	Adderall XR	DEXTROAMPHETAMINE-AMPHETAMINE	CAP ER 24H	25 MG	COVERED	FORMULARY	Max 60mg/day
29.007	47.131	282004-AMPHETAMINES	Adderall	DEXTROAMPHETAMINE-AMPHETAMINE	TABLET	7.5 MG	COVERED	FORMULARY	Max 60mg/day
29.008	47.132	282004-AMPHETAMINES	Adderall	DEXTROAMPHETAMINE-AMPHETAMINE	TABLET	12.5 MG	COVERED	FORMULARY	Max 60mg/day
29.009	47.133	282004-AMPHETAMINES	Adderall	DEXTROAMPHETAMINE-AMPHETAMINE	TABLET	15 MG	COVERED	FORMULARY	Max 60mg/day
56.970	4.999	282004-AMPHETAMINES	Adderall	DEXTROAMPHETAMINE-AMPHETAMINE	TABLET	5 MG	COVERED	FORMULARY	Max 60mg/day
56.971	5.000	282004-AMPHETAMINES	Adderall	DEXTROAMPHETAMINE-AMPHETAMINE	TABLET	10 MG	COVERED	FORMULARY	Max 60mg/day
56.972	34.359	282004-AMPHETAMINES	Adderall	DEXTROAMPHETAMINE-AMPHETAMINE	TABLET	30 MG	COVERED	FORMULARY	Max 60mg/day
56.973	5.001	282004-AMPHETAMINES	Adderall	DEXTROAMPHETAMINE-AMPHETAMINE	TABLET	20 MG	COVERED	FORMULARY	Max 60mg/day
20.384	53.056	282032-RESPIRATORY AND CNS STIMULANTS	Metadate CD	METHYLPHENIDATE HCL	CPBP 30-70	10 MG	COVERED	FORMULARY	Max 100mg/day
20.385	53.057	282032-RESPIRATORY AND CNS STIMULANTS	Metadate CD	METHYLPHENIDATE HCL	CPBP 30-70	20 MG	COVERED	FORMULARY	Max 100mg/day
20.386	53.058	282032-RESPIRATORY AND CNS STIMULANTS	Metadate CD	METHYLPHENIDATE HCL	CPBP 30-70	30 MG	COVERED	FORMULARY	Max 100mg/day
26.734	60.545	282032-RESPIRATORY AND CNS STIMULANTS	Metadate CD	METHYLPHENIDATE HCL	CPBP 30-70	40 MG	COVERED	FORMULARY	Max 100mg/day
26.735	60.546	282032-RESPIRATORY AND CNS STIMULANTS	Metadate CD	METHYLPHENIDATE HCL	CPBP 30-70	50 MG	COVERED	FORMULARY	Max 100mg/day
26.736	60.547	282032-RESPIRATORY AND CNS STIMULANTS	Metadate CD	METHYLPHENIDATE HCL	CPBP 30-70	60 MG	COVERED	FORMULARY	Max 100mg/day
20.387	53.059	282032-RESPIRATORY AND CNS STIMULANTS	Ritalin LA	METHYLPHENIDATE HCL	CPBP 50-50	20 MG	COVERED	FORMULARY	Max 100mg/day
20.388	53.060	282032-RESPIRATORY AND CNS STIMULANTS	Ritalin LA	METHYLPHENIDATE HCL	CPBP 50-50	30 MG	COVERED	FORMULARY	Max 100mg/day
20.391	53.061	282032-RESPIRATORY AND CNS STIMULANTS	Ritalin LA	METHYLPHENIDATE HCL	CPBP 50-50	40 MG	COVERED	FORMULARY	Max 100mg/day
15.911	4.026	282032-RESPIRATORY AND CNS STIMULANTS	Ritalin	METHYLPHENIDATE HCL	TABLET	10 MG	COVERED	FORMULARY	Max 100mg/day
15.913	4.028	282032-RESPIRATORY AND CNS STIMULANTS	Ritalin	METHYLPHENIDATE HCL	TABLET	5 MG	COVERED	FORMULARY	Max 100mg/day
15.920	4.027	282032-RESPIRATORY AND CNS STIMULANTS	Ritalin	METHYLPHENIDATE HCL	TABLET	20 MG	COVERED	FORMULARY	Max 100mg/day
16.180	4.029	282032-RESPIRATORY AND CNS STIMULANTS	Methylphenidate ER	METHYLPHENIDATE HCL	TABLET ER	20 MG	COVERED	FORMULARY	Max 100mg/day
93.075	44.072	282032-RESPIRATORY AND CNS STIMULANTS	Methylphenidate ER	METHYLPHENIDATE HCL	TABLET ER	10 MG	COVERED	FORMULARY	Max 100mg/day
12.956	3.586	282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)	Phenobarbital	PHENOBARBITAL	ELIXIR	20 MG/5 ML	COVERED	FORMULARY
12.971	3.589	282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)	Phenobarbital	PHENOBARBITAL	TABLET	15 MG	COVERED	FORMULARY
12.972	3.591	282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)	Phenobarbital	PHENOBARBITAL	TABLET	60 MG	COVERED	FORMULARY
12.973	3.590	282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)	Phenobarbital	PHENOBARBITAL	TABLET	30 MG	COVERED	FORMULARY
12.975	3.588	282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)	Phenobarbital	PHENOBARBITAL	TABLET	100 MG	COVERED	FORMULARY
97.965	27.611	282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)	Phenobarbital	PHENOBARBITAL	TABLET	32.4 MG	COVERED	FORMULARY
97.966	27.612	282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)	Phenobarbital	PHENOBARBITAL	TABLET	64.8 MG	COVERED	FORMULARY
14.260	3.773	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Xanax	ALPRAZOLAM	TABLET	0.25 MG	COVERED	FORMULARY
14.261	3.774	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Xanax	ALPRAZOLAM	TABLET	0.5 MG	COVERED	FORMULARY
14.262	3.775	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Xanax	ALPRAZOLAM	TABLET	1 MG	COVERED	FORMULARY
14.263	15.566	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Xanax	ALPRAZOLAM	TABLET	2 MG	COVERED	FORMULARY
14.031	3.734	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Chlordiazepoxide	CHLORDIAZEPOXIDE HCL	CAPSULE	10 MG	COVERED	FORMULARY
14.032	3.735	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Chlordiazepoxide	CHLORDIAZEPOXIDE HCL	CAPSULE	25 MG	COVERED	FORMULARY
14.090	3.744	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Tranxene	CLORAZEPATE DIPOTASSIUM	TABLET	15 MG	COVERED	FORMULARY
14.092	3.745	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Tranxene	CLORAZEPATE DIPOTASSIUM	TABLET	3.75 MG	COVERED	FORMULARY
14.093	3.746	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Tranxene	CLORAZEPATE DIPOTASSIUM	TABLET	7.5 MG	COVERED	FORMULARY
14.220	3.766	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Valium	DIAZEPAM	TABLET	10 MG	COVERED	FORMULARY
14.221	3.767	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Valium	DIAZEPAM	TABLET	2 MG	COVERED	FORMULARY
14.222	3.768	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Valium	DIAZEPAM	TABLET	5 MG	COVERED	FORMULARY
14.250	3.691	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Flurazepam	FLURAZEPAM HCL	CAPSULE	15 MG	COVERED	FORMULARY
14.251	3.692	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Flurazepam	FLURAZEPAM HCL	CAPSULE	30 MG	COVERED	FORMULARY
14.160	3.757	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Ativan	LORAZEPAM	TABLET	0.5 MG	COVERED	FORMULARY
14.161	3.758	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Ativan	LORAZEPAM	TABLET	1 MG	COVERED	FORMULARY
14.162	3.759	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Ativan	LORAZEPAM	TABLET	2 MG	COVERED	FORMULARY
14.230	3.769	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Oxazepam	OXAZEPAM	CAPSULE	10 MG	COVERED	FORMULARY
14.231	3.770	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Oxazepam	OXAZEPAM	CAPSULE	15 MG	COVERED	FORMULARY
14.232	3.771	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Oxazepam	OXAZEPAM	CAPSULE	30 MG	COVERED	FORMULARY
13.840	3.689	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Restoril	TEMAZEPAM	CAPSULE	15 MG	COVERED	FORMULARY
13.841	3.690	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Restoril	TEMAZEPAM	CAPSULE	30 MG	COVERED	FORMULARY
13.845	19.182	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Restoril	TEMAZEPAM	CAPSULE	7.5 MG	COVERED	FORMULARY
13.037	47.644	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Buspar	BUSPIRONE HCL	TABLET	7.5 MG	COVERED	FORMULARY
28.890	3.782	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Buspar	BUSPIRONE HCL	TABLET	5 MG	COVERED	FORMULARY
28.891	3.781	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Buspar	BUSPIRONE HCL	TABLET	10 MG	COVERED	FORMULARY
28.892	27.378	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Buspar	BUSPIRONE HCL	TABLET	15 MG	COVERED	FORMULARY
92.121	44.210	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Buspar	BUSPIRONE HCL	TABLET	30 MG	COVERED	FORMULARY
13.932	3.725	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Hydroxyzine	HYDROXYZINE HCL	SOLUTION	10 MG/5ML	COVERED	FORMULARY
13.941	3.726	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Hydroxyzine	HYDROXYZINE HCL	TABLET	10 MG	COVERED	FORMULARY
13.943	3.728	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Hydroxyzine	HYDROXYZINE HCL	TABLET	25 MG	COVERED	FORMULARY
13.944	3.729	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Hydroxyzine	HYDROXYZINE HCL	TABLET	50 MG	COVERED	FORMULARY
13.951	3.730	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Vistaril	HYDROXYZINE PAMOATE	CAPSULE	100 MG	COVERED	FORMULARY
13.952	3.731	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Vistaril	HYDROXYZINE PAMOATE	CAPSULE	25 MG	COVERED	FORMULARY
13.953	3.732	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Vistaril	HYDROXYZINE PAMOATE	CAPSULE	50 MG	COVERED	FORMULARY
870	19.187	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Ambien	ZOLPIDEM TARTRATE	TABLET	5 MG	COVERED	FORMULARY	Max 10mg/day
871	19.188	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Ambien	ZOLPIDEM TARTRATE	TABLET	10 MG	COVERED	FORMULARY	Max 10mg/day
15.710	4.001	282800-ANTIMANIC AGENTS	Lithium	LITHIUM CARBONATE	CAPSULE	300 MG	COVERED	FORMULARY
15.711	4.000	282800-ANTIMANIC AGENTS	Lithium	LITHIUM CARBONATE	CAPSULE	150 MG	COVERED	FORMULARY
15.721	4.003	282800-ANTIMANIC AGENTS	Lithium	LITHIUM CARBONATE	TABLET/CAPSULE	300 MG	COVERED	FORMULARY
15.712	4.002	282800-ANTIMANIC AGENTS	Lithium	LITHIUM CARBONATE	CAPSULE	600 MG	COVERED	FORMULARY
15.730	4.005	282800-ANTIMANIC AGENTS	Lithobid	LITHIUM CARBONATE	TABLET ER	450 MG	COVERED	FORMULARY
15.731	4.004	282800-ANTIMANIC AGENTS	Lithobid	LITHIUM CARBONATE	TABLET ER	300 MG	COVERED	FORMULARY
50.740	30.735	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex Nasal	SUMATRIPTAN	SPRAY	5 MG	COVERED	FORMULARY	Max 2 boxes/month
50.744	30.742	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex Nasal	SUMATRIPTAN	SPRAY	20 MG	COVERED	FORMULARY	Max 2 boxes/month
24.708	19.239	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex Statdose	SUMATRIPTAN SUCCINATE	CARTRIDGE	6 MG/0.5ML	COVERED	FORMULARY	Max 2 boxes/month
50.741	19.192	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex Statdose	SUMATRIPTAN SUCCINATE	PEN INJCTR	6 MG/0.5ML	COVERED	FORMULARY	Max 2 boxes/month
5.700	22.479	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex	SUMATRIPTAN SUCCINATE	TABLET	50 MG	COVERED	FORMULARY	Max 9 tablets/month
5.701	17.129	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex	SUMATRIPTAN SUCCINATE	TABLET	100 MG	COVERED	FORMULARY	Max 9 tablets/month
5.702	23.799	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex	SUMATRIPTAN SUCCINATE	TABLET	25 MG	COVERED	FORMULARY	Max 9 tablets/month
50.742	19.193	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex	SUMATRIPTAN SUCCINATE	VIAL	6 MG/0.5ML	COVERED	FORMULARY	Max 2 boxes/month
17.520	4.575	283604-ADAMANTANES (CNS)	Amantadine	AMANTADINE HCL	CAPSULE	100 MG	COVERED	FORMULARY
17.530	4.576	283604-ADAMANTANES (CNS)	Amantadine	AMANTADINE HCL	SOLUTION	50 MG/5ML	COVERED	FORMULARY
17.521	27.637	283604-ADAMANTANES (CNS)	Amantadine	AMANTADINE HCL	TABLET	100 MG	COVERED	FORMULARY
17.620	4.589	283608-ANTICHOLINERGIC AGENTS (CNS)	Cogentin	BENZTROPINE MESYLATE	TABLET	0.5 MG	COVERED	FORMULARY
17.621	4.590	283608-ANTICHOLINERGIC AGENTS (CNS)	Cogentin	BENZTROPINE MESYLATE	TABLET	1 MG	COVERED	FORMULARY
17.622	4.591	283608-ANTICHOLINERGIC AGENTS (CNS)	Cogentin	BENZTROPINE MESYLATE	TABLET	2 MG	COVERED	FORMULARY
17.561	4.581	283608-ANTICHOLINERGIC AGENTS (CNS)	Trihexyphenidyl	TRIHEXYPHENIDYL HCL	TABLET	2 MG	COVERED	FORMULARY
17.563	4.582	283608-ANTICHOLINERGIC AGENTS (CNS)	Trihexyphenidyl	TRIHEXYPHENIDYL HCL	TABLET	5 MG	COVERED	FORMULARY
95.079	41.199	283612-CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.	Comtan	ENTACAPONE	TABLET	200 MG	COVERED	FORMULARY
23.285	57.987	283616-DOPAMINE PRECURSORS	Carbidopa-Levodopa	CARBIDOPA-LEVODOPA	TAB RAPDIS	10-100 MG	COVERED	FORMULARY
23.286	57.988	283616-DOPAMINE PRECURSORS	Carbidopa-Levodopa	CARBIDOPA-LEVODOPA	TAB RAPDIS	25-100 MG	COVERED	FORMULARY
23.287	57.989	283616-DOPAMINE PRECURSORS	Carbidopa-Levodopa	CARBIDOPA-LEVODOPA	TAB RAPDIS	25-250 MG	COVERED	FORMULARY
62.740	2.537	283616-DOPAMINE PRECURSORS	Sinemet	CARBIDOPA-LEVODOPA	TABLET	10-100 MG	COVERED	FORMULARY
62.741	2.538	283616-DOPAMINE PRECURSORS	Sinemet	CARBIDOPA-LEVODOPA	TABLET	25-100 MG	COVERED	FORMULARY
62.742	2.539	283616-DOPAMINE PRECURSORS	Sinemet	CARBIDOPA-LEVODOPA	TABLET	25-250 MG	COVERED	FORMULARY
62.591	16.043	283616-DOPAMINE PRECURSORS	Sinemet CR	CARBIDOPA-LEVODOPA	TABLET ER	50-200 MG	COVERED	FORMULARY
62.592	19.563	283616-DOPAMINE PRECURSORS	Sinemet CR	CARBIDOPA-LEVODOPA	TABLET ER	25-100 MG	COVERED	FORMULARY
26.070	6.603	283620-DOPAMINE RECEPTOR AGONISTS	Parlodel	BROMOCRIPTINE MESYLATE	CAPSULE	5 MG	COVERED	FORMULARY
26.081	6.604	283620-DOPAMINE RECEPTOR AGONISTS	Parlodel	BROMOCRIPTINE MESYLATE	TABLET	2.5 MG	COVERED	FORMULARY
26.051	25.738	283620-DOPAMINE RECEPTOR AGONISTS	Cabergoline	CABERGOLINE	TABLET	0.5 MG	COVERED	FORMULARY
19.871	31.779	283620-DOPAMINE RECEPTOR AGONISTS	Mirapex	PRAMIPEXOLE	TABLET	1 MG	COVERED	FORMULARY
19.872	31.780	283620-DOPAMINE RECEPTOR AGONISTS	Mirapex	PRAMIPEXOLE	TABLET	1.5 MG	COVERED	FORMULARY
19.873	31.781	283620-DOPAMINE RECEPTOR AGONISTS	Mirapex	PRAMIPEXOLE	TABLET	0.125 MG	COVERED	FORMULARY
19.874	31.782	283620-DOPAMINE RECEPTOR AGONISTS	Mirapex	PRAMIPEXOLE	TABLET	0.25 MG	COVERED	FORMULARY
19.875	39.100	283620-DOPAMINE RECEPTOR AGONISTS	Mirapex	PRAMIPEXOLE	TABLET	0.5 MG	COVERED	FORMULARY
34.100	29.159	283620-DOPAMINE RECEPTOR AGONISTS	Requip	ROPINIROLE HCL	TABLET	0.25 MG	COVERED	FORMULARY
34.101	29.160	283620-DOPAMINE RECEPTOR AGONISTS	Requip	ROPINIROLE HCL	TABLET	1 MG	COVERED	FORMULARY
34.102	29.161	283620-DOPAMINE RECEPTOR AGONISTS	Requip	ROPINIROLE HCL	TABLET	2 MG	COVERED	FORMULARY
34.104	34.166	283620-DOPAMINE RECEPTOR AGONISTS	Requip	ROPINIROLE HCL	TABLET	0.5 MG	COVERED	FORMULARY
93.038	43.203	283620-DOPAMINE RECEPTOR AGONISTS	Requip	ROPINIROLE HCL	TABLET	4 MG	COVERED	FORMULARY
93.048	43.202	283620-DOPAMINE RECEPTOR AGONISTS	Requip	ROPINIROLE HCL	TABLET	3 MG	COVERED	FORMULARY
3.253	32.492	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Namenda	MEMANTINE HCL	TABLET	10 MG	COVERED	FORMULARY
20.773	53.324	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Namenda	MEMANTINE HCL	TABLET	5 MG	COVERED	FORMULARY
25.200	6.373	362600-DIABETES MELLITUS	True Metrix Test Strips	BLOOD SUGAR DIAGNOSTIC	STRIP		COVERED	FORMULARY
35.600	8.321	368812-KETONES	Ketocare Test Strip	URINE ACETONE TEST STRIPS	STRIP		COVERED	FORMULARY
35.600	8.321	368812-KETONES	Ketocare Test Strips	URINE ACETONE TEST STRIPS	STRIP		COVERED	FORMULARY
14.950	8.250	400800-ALKALINIZING AGENTS	Urocit-K	POTASSIUM CITRATE	TABLET ER	5 MEQ	COVERED	FORMULARY
14.951	17.000	400800-ALKALINIZING AGENTS	Urocit-K	POTASSIUM CITRATE	TABLET ER	10 MEQ	COVERED	FORMULARY
28.095	65.955	400800-ALKALINIZING AGENTS	Urocit-K	POTASSIUM CITRATE	TABLET ER	15 MEQ	COVERED	FORMULARY
10.160	3.143	401000-AMMONIA DETOXICANTS	Lactulose	LACTULOSE	SOLUTION	10 G/15ML	COVERED	FORMULARY
10.167	29.054	401000-AMMONIA DETOXICANTS	Lactulose	LACTULOSE	SOLUTION	10 G/15ML	COVERED	FORMULARY
30.962	68.217	401000-AMMONIA DETOXICANTS	Lactulose	LACTULOSE	SOLUTION	20 G/30ML	COVERED	FORMULARY
30.994	68.243	401000-AMMONIA DETOXICANTS	Lactulose	LACTULOSE	SOLUTION	10 G/15ML	COVERED	FORMULARY
3.321	1.248	401200-REPLACEMENT PREPARATIONS	Potassium Chloride	POTASSIUM CHLORIDE	CAPSULE ER	10 MEQ	COVERED	FORMULARY
3.404	1.262	401200-REPLACEMENT PREPARATIONS	Potassium Chloride	POTASSIUM CHLORIDE	PACKET	20 MEQ	COVERED	FORMULARY
3.512	22.345	401200-REPLACEMENT PREPARATIONS	Potassium Chloride	POTASSIUM CHLORIDE	TAB ER PRT	10 MEQ	COVERED	FORMULARY
3.513	22.346	401200-REPLACEMENT PREPARATIONS	Potassium Chloride	POTASSIUM CHLORIDE	TAB ER PRT	20 MEQ	COVERED	FORMULARY
3.510	1.275	401200-REPLACEMENT PREPARATIONS	Potassium Chloride	POTASSIUM CHLORIDE	TABLET ER	10 MEQ	COVERED	FORMULARY
3.515	1.276	401200-REPLACEMENT PREPARATIONS	Potassium Chloride	POTASSIUM CHLORIDE	TABLET ER	20 MEQ	COVERED	FORMULARY
2.373	588	401200-REPLACEMENT PREPARATIONS	Sodium Chloride For Inhalation	SODIUM CHLORIDE FOR INHALATION	VIAL-NEB	3 %	COVERED	FORMULARY
98.520	62.746	401200-REPLACEMENT PREPARATIONS	Sodium Chloride For Inhalation	SODIUM CHLORIDE FOR INHALATION	VIAL-NEB	7 %	COVERED	FORMULARY
930	1.196	401818-POTASSIUM-REMOVING AGENTS	Sodium Polystyrene Sulfonate	SODIUM POLYSTYRENE SULFONATE	ENEMA	30 G/120ML	COVERED	FORMULARY
1.710	1.195	401818-POTASSIUM-REMOVING AGENTS	Kionex	SODIUM POLYSTYRENE SULFONATE	ORAL SUSP	15 G/60 ML	COVERED	FORMULARY
13.675	48.241	401819-PHOSPHATE-REMOVING AGENTS	Phoslo	CALCIUM ACETATE	CAPSULE	667 MG	COVERED	FORMULARY
99.200	63.473	401819-PHOSPHATE-REMOVING AGENTS	Renvela	SEVELAMER CARBONATE	TABLET	800 MG	COVERED	FORMULARY
16.853	46.485	401819-PHOSPHATE-REMOVING AGENTS	Renagel	SEVELAMER HCL	TABLET	800 MG	COVERED	FORMULARY
21.130	21.406	402808-LOOP DIURETICS	Demadex	TORSEMIDE	TABLET	5 MG	COVERED	FORMULARY
21.131	21.407	402808-LOOP DIURETICS	Demadex	TORSEMIDE	TABLET	10 MG	COVERED	FORMULARY
21.132	21.408	402808-LOOP DIURETICS	Demadex	TORSEMIDE	TABLET	20 MG	COVERED	FORMULARY
21.133	21.409	402808-LOOP DIURETICS	Demadex	TORSEMIDE	TABLET	100 MG	COVERED	FORMULARY
34.950	8.206	402808-LOOP DIURETICS	Furosemide	FUROSEMIDE	SOLUTION	10 MG/ML	COVERED	FORMULARY
34.961	8.208	402808-LOOP DIURETICS	Lasix	FUROSEMIDE	TABLET	20 MG	COVERED	FORMULARY
34.962	8.209	402808-LOOP DIURETICS	Lasix	FUROSEMIDE	TABLET	40 MG	COVERED	FORMULARY
34.963	8.210	402808-LOOP DIURETICS	Lasix	FUROSEMIDE	TABLET	80 MG	COVERED	FORMULARY
35.020	8.221	402808-LOOP DIURETICS	Bumetanide	Bumetanide	TABLET	O.5 MG	COVERED	FORMULARY
35.021	8.222	402808-LOOP DIURETICS	Bumetanide	Bumetanide	TABLET	1 MG	COVERED	FORMULARY
35.022	8.223	402808-LOOP DIURETICS	Bumetanide	Bumetanide	TABLET	2 MG	COVERED	FORMULARY
27.700	8.227	402816-POTASSIUM-SPARING DIURETICS	Amiloride	AMILORIDE HCL	TABLET	5 MG	COVERED	FORMULARY
82.341	8.178	402816-POTASSIUM-SPARING DIURETICS	Amiloride-Hydrochlorothiazide	AMILORIDE-HYDROCHLOROTHIAZIDE	TABLET	5-50 MG	COVERED	FORMULARY
88.730	8.175	402816-POTASSIUM-SPARING DIURETICS	Dyazide	TRIAMTERENE-HYDROCHLOROTHIAZIDE	CAPSULE	50-25 MG	COVERED	FORMULARY
88.731	21.718	402816-POTASSIUM-SPARING DIURETICS	Dyazide	TRIAMTERENE-HYDROCHLOROTHIAZIDE	CAPSULE	37.5-25 MG	COVERED	FORMULARY
88.740	8.177	402816-POTASSIUM-SPARING DIURETICS	Triamterene-Hydrochlorothiazide	TRIAMTERENE-HYDROCHLOROTHIAZIDE	TABLET	75-50 MG	COVERED	FORMULARY
88.741	8.176	402816-POTASSIUM-SPARING DIURETICS	Triamterene-Hydrochlorothiazide	TRIAMTERENE-HYDROCHLOROTHIAZIDE	TABLET	37.5-25 MG	COVERED	FORMULARY
34.820	29.832	402820-THIAZIDE DIURETICS	Microzide	HYDROCHLOROTHIAZIDE	CAPSULE	12.5 MG	COVERED	FORMULARY
842	28.915	402820-THIAZIDE DIURETICS	Hydrochlorothiazide	HYDROCHLOROTHIAZIDE	TABLET	12.5 MG	COVERED	FORMULARY
34.824	8.182	402820-THIAZIDE DIURETICS	Hydrochlorothiazide	HYDROCHLOROTHIAZIDE	TABLET	25 MG	COVERED	FORMULARY
34.825	8.183	402820-THIAZIDE DIURETICS	Hydrochlorothiazide	HYDROCHLOROTHIAZIDE	TABLET	50 MG	COVERED	FORMULARY
34.982	8.213	402824-THIAZIDE-LIKE DIURETICS	Chlorthalidone	CHLORTHALIDONE	TABLET	25 MG	COVERED	FORMULARY
34.984	8.214	402824-THIAZIDE-LIKE DIURETICS	Chlorthalidone	CHLORTHALIDONE	TABLET	50 MG	COVERED	FORMULARY
7.310	8.224	402824-THIAZIDE-LIKE DIURETICS	Indapamide	INDAPAMIDE	TABLET	2.5 MG	COVERED	FORMULARY
7.311	19.412	402824-THIAZIDE-LIKE DIURETICS	Indapamide	INDAPAMIDE	TABLET	1.25 MG	COVERED	FORMULARY
34.990	8.216	402824-THIAZIDE-LIKE DIURETICS	Metolazone	METOLAZONE	TABLET	10 MG	COVERED	FORMULARY
34.991	8.217	402824-THIAZIDE-LIKE DIURETICS	Metolazone	METOLAZONE	TABLET	2.5 MG	COVERED	FORMULARY
34.992	8.218	402824-THIAZIDE-LIKE DIURETICS	Metolazone	METOLAZONE	TABLET	5 MG	COVERED	FORMULARY
35.072	8.236	404000-URICOSURIC AGENTS	Probenecid	PROBENECID	TABLET	500 MG	COVERED	FORMULARY
29.840	4.641	480800-ANTITUSSIVES	Tessalon Perles	BENZONATATE	CAPSULE	100 MG	COVERED	FORMULARY
93.007	44.168	480800-ANTITUSSIVES	Tessalon Perles	BENZONATATE	CAPSULE	200 MG	COVERED	FORMULARY
96.136	909	480800-ANTITUSSIVES	Bromfed DM	BROMPHENIRAMINE-PSEUDOEPHEDRINE-DM	SYRUP	2-30-10 MG/5ML	COVERED	FORMULARY
19.347	51.896	480800-ANTITUSSIVES	Chlorpheniramine-Phenylephrine-Dextromethorphan	CHLORPHENIRAMINE-PHENYLEPHRINE-DM	LIQUID	4-10-15 MG/5ML	COVERED	FORMULARY
91.713	45.669	480800-ANTITUSSIVES	Cheratussin AC, Virtussin AC, Iophen-C NR	GUAIFENESIN-CODEINE PHOSPHATE	LIQUID	100-10 MG/5ML	COVERED	FORMULARY
34.672	70.992	480800-ANTITUSSIVES	Guaifenesin AC	GUAIFENESIN-CODEINE PHOSPHATE	LIQUID	100-10 MG/5ML	COVERED	FORMULARY
13.974	48.492	480800-ANTITUSSIVES	Tussionex ER	HYDROCODONE-CHLORPHENIRAMINE	SUS ER 12H	10-8 MG/5ML	COVERED	FORMULARY
13.973	48.491	480800-ANTITUSSIVES	Hydrocodone-Homatropine	HYDROCODONE-HOMATROPINE	SYRUP	5-1.5 MG/5ML	COVERED	FORMULARY
96.041	846	480800-ANTITUSSIVES	Hydrocodone-Homatropine	HYDROCODONE-HOMATROPINE	TABLET	5-1.5 MG	COVERED	FORMULARY
13.975	48.493	480800-ANTITUSSIVES	Promethazine-DM	PROMETHAZINE-DEXTROMETHORPHAN	SYRUP	6.25-15 MG/5ML	COVERED	FORMULARY
13.978	48.496	480800-ANTITUSSIVES	Promethazine VC Codeine	PROMETHAZINE-PHENYLEPHRINE-CODEINE	SYRUP	6.25-5-10 MG/5ML	COVERED	FORMULARY
54.670	728	480800-ANTITUSSIVES	Lortuss EX, Cheratussin DAC, Guaifenesin DAC	PSEUDOEPHEDRINE-CODEINE-GUAIFENESIN	SYRUP	30-10-100 MG/5ML	COVERED	FORMULARY
53.636	21.251	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Fluticasone HFA	FLUTICASONE PROPIONATE	AER W/ADAP	110 MCG	COVERED	FORMULARY
53.638	21.253	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Fluticasone HFA	FLUTICASONE PROPIONATE	AER W/ADAP	44 MCG	COVERED	FORMULARY
53.639	21.483	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Fluticasone HFA	FLUTICASONE PROPIONATE	AER W/ADAP	220 MCG	COVERED	FORMULARY
42.373	44.803	481024-LEUKOTRIENE MODIFIERS	Singulair	MONTELUKAST SODIUM	TAB CHEW	4 MG	COVERED	FORMULARY
94.440	37.003	481024-LEUKOTRIENE MODIFIERS	Singulair	MONTELUKAST SODIUM	TAB CHEW	5 MG	COVERED	FORMULARY
94.444	38.451	481024-LEUKOTRIENE MODIFIERS	Singulair	MONTELUKAST SODIUM	TABLET	10 MG	COVERED	FORMULARY
69.069	44.694	481032-MAST-CELL STABLILIZERS	Cromolyn Ophthalmic	CROMOLYN SODIUM	DROPS	0.04	COVERED	FORMULARY
60.544	29.893	520200-ANTIALLERGIC AGENTS	Astelin Nasal Spray	AZELASTINE HCL	SPRAY/PUMP	137 MCG	COVERED	FORMULARY
68.321	30.796	520200-ANTIALLERGIC AGENTS	Patanol	OLOPATADINE HCL	DROPS	0.1 %	COVERED	FORMULARY
33.641	7.990	520404-ANTIBACTERIALS (EENT)	Bacitracin Ophthalmic	BACITRACIN	OINT. (G)	500 UNIT/G	COVERED	FORMULARY
33.580	15.861	520404-ANTIBACTERIALS (EENT)	Ciloxan	CIPROFLOXACIN HCL	DROPS	0.3 %	COVERED	FORMULARY
9.076	38.351	520404-ANTIBACTERIALS (EENT)	Ciloxan	CIPROFLOXACIN HCL	OINT. (G)	0.3 %	COVERED	FORMULARY
20.188	52.911	520404-ANTIBACTERIALS (EENT)	Ciprodex	CIPROFLOXACIN HCL-DEXAMETHASONE	DROPS SUSP	0.3-0.1 %	COVERED	FORMULARY
82.031	39.806	520404-ANTIBACTERIALS (EENT)	Cipro HC	CIPROFLOXACIN-HYDROCORTISONE	DROPS SUSP	0.2-1 %	COVERED	FORMULARY
13.521	48.077	520404-ANTIBACTERIALS (EENT)	Doxycyline	DOXYCYCLINE HYCLATE	TABLET	20 MG	COVERED	FORMULARY
33.540	7.948	520404-ANTIBACTERIALS (EENT)	Ilotycin	ERYTHROMYCIN BASE	OINT. (G)	5 MG/G	COVERED	FORMULARY
33.600	7.984	520404-ANTIBACTERIALS (EENT)	Gentamicin	GENTAMICIN SULFATE	DROPS	0.3 %	COVERED	FORMULARY
33.590	7.983	520404-ANTIBACTERIALS (EENT)	Gentamicin	GENTAMICIN SULFATE	OINT. (G)	0.3 %	COVERED	FORMULARY
19.542	52.050	520404-ANTIBACTERIALS (EENT)	Vigamox	MOXIFLOXACIN HCL	DROPS	0.5 %	COVERED	FORMULARY
62.265	18.370	520404-ANTIBACTERIALS (EENT)	Bactroban Nasal	MUPIROCIN CALCIUM	OINT. (G)	2 %	COVERED	FORMULARY
14.294	48.570	520404-ANTIBACTERIALS (EENT)	POLYMYXIN B- TRIMETHOPRIM DROPS	POLYMYXIN B- TRIMETHOPRIM DROPS	DROPS	10000-1/ML	COVERED	FORMULARY
14.283	48.544	520404-ANTIBACTERIALS (EENT)	Neomycin-Bacitracin-Polymyxin Eye Ointment	NEOMYCIN-BACITRACIN-POLYMYXIN B	OINT. (G)	3.5-400-10000 MG/G-UNIT/G-UNIT/G	COVERED	FORMULARY
14.279	48.543	520404-ANTIBACTERIALS (EENT)	Neomycin-Bacitracin-Polymyxin-HC Eye Ointment	NEOMYCIN-BACITRACIN-POLYMYXIN B-HYDROCORTISONE	OINT. (G)	3.5-400-10000-1 MG/G-UNIT/G-UNIT/G-%	COVERED	FORMULARY
14.106	48.618	520404-ANTIBACTERIALS (EENT)	Coly-Mycin S, Cortisporin TC	NEOMYCIN-COLISTIN-HYDROCORTISONE-THONZONIUM	DROPS SUSP	3.3-3-10-0.5 MG/ML	COVERED	FORMULARY
14.285	48.546	520404-ANTIBACTERIALS (EENT)	Neomycin-Polymyxin-Dexamethasone Eye Ointment	NEOMYCIN-POLYMYXIN B-DEXAMETHASONE	OINT. (G)	3.5-10000-0.1 MG/G-UNIT/G-%	COVERED	FORMULARY
14.286	48.547	520404-ANTIBACTERIALS (EENT)	Neomycin-Polymyxin-Dexamethasone Eye Drops	NEOMYCIN-POLYMYXIN B-DEXAMETHASONE	DROPS SUSP	3.5-10000-0.1 MG/ML-UNIT/ML-%	COVERED	FORMULARY
87.270	7.964	520404-ANTIBACTERIALS (EENT)	Neomycin-Polymyxin-HC Eye Drops	NEOMYCIN-POLYMYXIN B-HYDROCORTISONE	DROPS SUSP	3.5-10000-10 MG/ML-UNIT/ML-%	COVERED	FORMULARY
14.025	48.559	520404-ANTIBACTERIALS (EENT)	Neomycin-Polymyxin-HC Otic Drops	NEOMYCIN-POLYMYXIN B-HYDROCORTISONE	DROPS SUSP	3.5-10000-1 MG/ML-UNIT/ML-%	COVERED	FORMULARY
14.023	48.557	520404-ANTIBACTERIALS (EENT)	Neomycin-Polymyxin-HC Otic	NEOMYCIN-POLYMYXIN B-HYDROCORTISONE	SOLUTION	3.5-10000-1 MG/ML-UNIT/ML-%	COVERED	FORMULARY
98.446	62.672	520404-ANTIBACTERIALS (EENT)	Neomycin-Polymyxin-Gramicidin Eye Drops	NEOMYCIN-POLYMYXIN B-GRAMICIDIN	DROPS	1.75-10000-0.025 MG/ML-UNIT/ML-MG/ML	COVERED	FORMULARY
13.880	48.292	520404-ANTIBACTERIALS (EENT)	Ofloxacin	OFLOXACIN	DROPS	0.3 %	COVERED	FORMULARY
36.600	19.734	520404-ANTIBACTERIALS (EENT)	Ofloxacin	OFLOXACIN	DROPS	0.3 %	COVERED	FORMULARY
33.340	7.920	520404-ANTIBACTERIALS (EENT)	Bleph-10	SULFACETAMIDE SODIUM	DROPS	10 %	COVERED	FORMULARY
9.384	38.588	520404-ANTIBACTERIALS (EENT)	Tobrex	TOBRAMYCIN	DROPS	0.3 %	COVERED	FORMULARY
92.280	7.986	520404-ANTIBACTERIALS (EENT)	Tobradex	TOBRAMYCIN-DEXAMETHASONE	DROPS SUSP	0.3-0.1 %	COVERED	FORMULARY
33.500	7.942	520420-ANTIVIRALS (EENT)	Viroptic	TRIFLURIDINE	DROPS	1 %	COVERED	FORMULARY
34.341	8.101	520492-EENT ANTI-INFECTIVES, MISCELLANEOUS	Acetic Acid	ACETIC ACID	SOLUTION	2 %	COVERED	FORMULARY
14.017	48.554	520492-EENT ANTI-INFECTIVES, MISCELLANEOUS	Acetasol HC	ACETIC ACID-HYDROCORTISONE	DROPS	2-1 %	COVERED	FORMULARY
34.280	8.079	520808-CORTICOSTEROIDS (EENT)	Flunisolide	FLUNISOLIDE	SPRAY	25 MCG	COVERED	FORMULARY
62.263	18.368	520808-CORTICOSTEROIDS (EENT)	Flonase	FLUTICASONE PROPIONATE	SPRAY SUSP	50 MCG	COVERED	FORMULARY
95.464	39.106	520808-CORTICOSTEROIDS (EENT)	Lotemax	LOTEPREDNOL ETABONATE	DROPS SUSP	0.5 %	COVERED	FORMULARY
33.153	7.894	520808-CORTICOSTEROIDS (EENT)	Omnipred	PREDNISOLONE ACETATE	DROPS SUSP	1 %	COVERED	FORMULARY
33.150	7.892	520808-CORTICOSTEROIDS (EENT)	Prednisolone Acetate	PREDNISOLONE ACETATE	DROPS SUSP	0.12 %	COVERED	FORMULARY
33.181	7.897	520808-CORTICOSTEROIDS (EENT)	Prednisolone Sodium Phosphate	PREDNISOLONE SOD PHOSPHATE	DROPS	1 %	COVERED	FORMULARY
33.831	16.008	520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS	Diclofenac Sodium	DICLOFENAC SODIUM	DROPS	0.1 %	COVERED	FORMULARY
34.360	7.905	520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS	Ocufen	FLURBIPROFEN SODIUM	DROPS	0.03 %	COVERED	FORMULARY
20.255	52.960	520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS	Acular	KETOROLAC TROMETHAMINE	DROPS	0.4 %	COVERED	FORMULARY
52.700	19.067	520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS	Acular	KETOROLAC TROMETHAMINE	DROPS	0.5 %	COVERED	FORMULARY
32.952	7.866	522400-MYDRIATICS	ATROPINE SULFATE	ATROPINE SULFATE	DROPS	1%	COVERED	FORMULARY
32.931	7.864	522400-MYDRIATICS	ATROPINE SULFATE	ATROPINE SULFATE	OINT. (G)	1%	COVERED	FORMULARY
33.031	7.875	522400-MYDRIATICS	Cyclogyl 1%	CYCLOPENTOLATE HCL	DROPS	1 %	COVERED	FORMULARY
33.032	7.876	522400-MYDRIATICS	Cyclogyl 2%	CYCLOPENTOLATE HCL	DROPS	2 %	COVERED	FORMULARY
36.281	27.882	524004-ALPHA-ADRENERGIC AGONISTS (EENT)	Alphagan	BRIMONIDINE TARTRATE	DROPS	0.2 %	COVERED	FORMULARY
13.752	48.333	524004-ALPHA-ADRENERGIC AGONISTS (EENT)	Alphagan-P	BRIMONIDINE TARTRATE	DROPS	0.15 %	COVERED	FORMULARY
33.310	7.858	524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT)	Betagan	LEVOBUNOLOL HCL	DROPS	0.5 %	COVERED	FORMULARY
32.820	7.855	524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT)	Timoptic	TIMOLOL MALEATE	DROPS	0.25 %	COVERED	FORMULARY
32.821	7.856	524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT)	Timoptic	TIMOLOL MALEATE	DROPS	0.5 %	COVERED	FORMULARY
32.823	21.401	524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT)	Timoptic-XE	TIMOLOL MALEATE	SOL-GEL	0.5 %	COVERED	FORMULARY
34.700	8.164	524012-CARBONIC ANHYDRASE INHIBITORS (EENT)	Diamox Sequels	ACETAZOLAMIDE	CAPSULE ER	500 MG	COVERED	FORMULARY
34.721	8.165	524012-CARBONIC ANHYDRASE INHIBITORS (EENT)	Acetazolamide	ACETAZOLAMIDE	TABLET	125 MG	COVERED	FORMULARY
34.722	8.166	524012-CARBONIC ANHYDRASE INHIBITORS (EENT)	Acetazolamide	ACETAZOLAMIDE	TABLET	250 MG	COVERED	FORMULARY
95.773	39.498	524012-CARBONIC ANHYDRASE INHIBITORS (EENT)	Azopt	BRINZOLAMIDE	DROPS SUSP	1 %	COVERED	FORMULARY
33.380	23.513	524012-CARBONIC ANHYDRASE INHIBITORS (EENT)	Trusopt	DORZOLAMIDE HCL	DROPS	2 %	COVERED	FORMULARY
95.919	39.531	524012-CARBONIC ANHYDRASE INHIBITORS (EENT)	Cosopt	DORZOLAMIDE HCL-TIMOLOL MALEATE	DROPS	22.3-6.8 MG/1ML	COVERED	FORMULARY
32.704	7.822	524020-MIOTICS	Isopto Carpine	PILOCARPINE HCL	DROPS	1 %	COVERED	FORMULARY
32.706	7.824	524020-MIOTICS	Isopto Carpine	PILOCARPINE HCL	DROPS	2 %	COVERED	FORMULARY
32.752	7.826	524020-MIOTICS	Isopto Carpine	PILOCARPINE HCL	DROPS	4 %	COVERED	FORMULARY
32.749	27.370	524028-PROSTAGLANDIN ANALOGS	Xalatan	LATANOPROST	DROPS	0.005 %	COVERED	FORMULARY
32.749	27.370	524028-PROSTAGLANDIN ANALOGS	Xalatan	LATANOPROST	DROPS	0.005 %	COVERED	FORMULARY
98.379	62.605	524028-PROSTAGLANDIN ANALOGS	Travoprost	TRAVOPROST (BENZALKONIUM)	DROPS	0.004%	COVERED	FORMULARY
7.855	2.661	560400-ANTACIDS AND ADSORBENTS	Sodium Bicarbonate	SODIUM BICARBONATE	TABLET	650 MG	COVERED	FORMULARY
65.020	2.839	560800-ANTIDIARRHEA AGENTS	Lomotil	DIPHENOXYLATE HCL-ATROPINE	LIQUID	2.5-0.025 MG/5ML	COVERED	FORMULARY
65.030	2.841	560800-ANTIDIARRHEA AGENTS	Lomotil	DIPHENOXYLATE HCL-ATROPINE	TABLET	2.5-0.025 MG	COVERED	FORMULARY
98.433	62.659	561200-CATHARTICS AND LAXATIVES	Colyte, Gavilyte	PEG 3350-NA SULF BICARB CL-KCL	SOLN RECON	240-22.72 G	COVERED	FORMULARY
98.308	62.533	561200-CATHARTICS AND LAXATIVES	Golytely, Gavilyte	PEG 3350-NA SULF BICARB CL-KCL	SOLN RECON	236-22.74 G	COVERED	FORMULARY
86.212	41.843	561200-CATHARTICS AND LAXATIVES	Clearlax, Miralax	POLYETHYLENE GLYCOL 3350	POWDER	17 G/DOSE	COVERED	FORMULARY
25.865	59.931	561200-CATHARTICS AND LAXATIVES	Nulytely Flavor Pack, Gavilyte N, Trilyte	SODIUM CHLORIDE-NAHCO3-KCL-PEG	SOLN RECON	420 G	COVERED	FORMULARY
25.865	59.931	561200-CATHARTICS AND LAXATIVES	Nulytely, Gavilyte, Trilyte	SODIUM CHLORIDE-NAHCO3-KCL-PEG	SOLN RECON	420 G	COVERED	FORMULARY
28.997	66.670	561200-CATHARTICS AND LAXATIVES	Suprep	sodium, potassium,mag sulfates	SOLN RECON	17.5-3.13 G	COVERED	FORMULARY
97.248	61.457	561200-CATHARTICS AND LAXATIVES	Moviprep	PEG 3350-NA SULF BICARB CL-KCL-Ascorbic acid	POWDER PACKETS	7.5 -2.691 G	COVERED	FORMULARY
1.070	3.095	561400-CHOLELITHOLYTIC AGENTS	Actigall	URSODIOL	CAPSULE	300 MG	COVERED	FORMULARY
1.072	24.333	561400-CHOLELITHOLYTIC AGENTS	Urso	URSODIOL	TABLET	250 MG	COVERED	FORMULARY
17.730	50.628	561400-CHOLELITHOLYTIC AGENTS	Urso Forte	URSODIOL	TABLET	500 MG	COVERED	FORMULARY
26.176	65.328	561600-DIGESTANTS	Creon	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	6K-19K-30K	NOT COVERED	PAP	Contact manufacturer for PAP
26.177	65.329	561600-DIGESTANTS	Creon	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	12K-38K-60	NOT COVERED	PAP	Contact manufacturer for PAP
26.178	65.330	561600-DIGESTANTS	Creon	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	24-76-120K	NOT COVERED	PAP	Contact manufacturer for PAP
30.217	67.625	561600-DIGESTANTS	Creon	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	3-9.5-15K	NOT COVERED	PAP	Contact manufacturer for PAP
34.557	70.893	561600-DIGESTANTS	Creon	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	36-114-180	NOT COVERED	PAP	Contact manufacturer for PAP
42.317	76.625	561600-DIGESTANTS	Pancreaze	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	16.8-56.8K	NOT COVERED	NON-FORMULARY
42.318	76.626	561600-DIGESTANTS	Pancreaze	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	21 K-54.7K	NOT COVERED	NON-FORMULARY
42.319	76.627	561600-DIGESTANTS	Pancreaze	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	10.5-35.5K	NOT COVERED	NON-FORMULARY
42.324	76.628	561600-DIGESTANTS	Pancreaze	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	4.2K-14.2K	NOT COVERED	NON-FORMULARY
42.596	76.797	561600-DIGESTANTS	Pancreaze	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	2.6 K-6.2K	NOT COVERED	NON-FORMULARY
27.726	65.700	561600-DIGESTANTS	Zenpep	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	5K-17K-27K	NOT COVERED	PAP	Contact manufacturer for PAP
27.727	65.701	561600-DIGESTANTS	Zenpep	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	10-34-55K	NOT COVERED	PAP	Contact manufacturer for PAP
27.728	65.702	561600-DIGESTANTS	Zenpep	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	15-51-82K	NOT COVERED	PAP	Contact manufacturer for PAP
27.729	65.703	561600-DIGESTANTS	Zenpep	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	20-68-109K	NOT COVERED	PAP	Contact manufacturer for PAP
30.597	67.944	561600-DIGESTANTS	Zenpep	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	3K-10K-16K	NOT COVERED	PAP	Contact manufacturer for PAP
30.598	67.945	561600-DIGESTANTS	Zenpep	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	25-85-136K	NOT COVERED	PAP	Contact manufacturer for PAP
37.592	73.217	561600-DIGESTANTS	Zenpep	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	40K-136K	NOT COVERED	PAP	Contact manufacturer for PAP
14.761	3.844	562208-ANTIHISTAMINES (GI DRUGS)	Prochlorperazine	PROCHLORPERAZINE	SUPP.RECT	25 MG	COVERED	FORMULARY
14.771	3.846	562208-ANTIHISTAMINES (GI DRUGS)	Prochlorperazine	PROCHLORPERAZINE MALEATE	TABLET	10 MG	COVERED	FORMULARY
14.773	3.848	562208-ANTIHISTAMINES (GI DRUGS)	Prochlorperazine	PROCHLORPERAZINE MALEATE	TABLET	5 MG	COVERED	FORMULARY
20.045	41.562	562220-5-HT3 RECEPTOR ANTAGONISTS	Zofran ODT	ONDANSETRON	TAB RAPDIS	4 MG	COVERED	FORMULARY
20.046	41.563	562220-5-HT3 RECEPTOR ANTAGONISTS	Zofran ODT	ONDANSETRON	TAB RAPDIS	8 MG	COVERED	FORMULARY
20.040	28.107	562220-5-HT3 RECEPTOR ANTAGONISTS	Zofran	ONDANSETRON HCL	SOLUTION	4 MG/5ML	COVERED	FORMULARY	Restricted to age <19
20.041	16.392	562220-5-HT3 RECEPTOR ANTAGONISTS	Zofran	ONDANSETRON HCL	TABLET	4 MG	COVERED	FORMULARY
20.042	16.393	562220-5-HT3 RECEPTOR ANTAGONISTS	Zofran	ONDANSETRON HCL	TABLET	8 MG	COVERED	FORMULARY
45.960	11.676	562812-HISTAMINE H2-ANTAGONISTS	Pepcid	FAMOTIDINE	ORAL SUSP	40 MG/5ML	COVERED	FORMULARY
46.430	11.677	562812-HISTAMINE H2-ANTAGONISTS	Pepcid	FAMOTIDINE	TABLET	20 MG	COVERED	FORMULARY
46.431	11.678	562812-HISTAMINE H2-ANTAGONISTS	Pepcid	FAMOTIDINE	TABLET	40 MG	COVERED	FORMULARY
8.250	2.767	562828-PROSTAGLANDINS	Cytotec	MISOPROSTOL	TABLET	200 MCG	COVERED	FORMULARY
8.251	15.197	562828-PROSTAGLANDINS	Cytotec	MISOPROSTOL	TABLET	100 MCG	COVERED	FORMULARY
7.651	16.133	562832-PROTECTANTS	Carafate	SUCRALFATE	ORAL SUSP	1 G/10 ML	COVERED	FORMULARY
8.200	2.766	562832-PROTECTANTS	Carafate	SUCRALFATE	TABLET	1 G	COVERED	FORMULARY
40.120	27.462	562836-PROTON-PUMP INHIBITORS	Protonix	PANTOPRAZOLE SODIUM	TABLET DR	40 MG	COVERED	FORMULARY
95.976	39.545	562836-PROTON-PUMP INHIBITORS	Protonix	PANTOPRAZOLE SODIUM	TABLET DR	20 MG	COVERED	FORMULARY
3.610	5.230	563200-PROKINETIC AGENTS	Metoclopramide	METOCLOPRAMIDE HCL	SOLUTION	5 MG/5ML	COVERED	FORMULARY
34.798	71.108	563200-PROKINETIC AGENTS	Metoclopramide	METOCLOPRAMIDE HCL	SOLUTION	10 MG/10ML	COVERED	FORMULARY
21.020	5.231	563200-PROKINETIC AGENTS	Reglan	METOCLOPRAMIDE HCL	TABLET	10 MG	COVERED	FORMULARY
21.021	5.232	563200-PROKINETIC AGENTS	Reglan	METOCLOPRAMIDE HCL	TABLET	5 MG	COVERED	FORMULARY
27.412	6.782	680400-ADRENALS	Dexamethasone	DEXAMETHASONE	DROPS	1 MG/ML	COVERED	FORMULARY
27.422	6.784	680400-ADRENALS	Dexamethasone	DEXAMETHASONE	TABLET	0.5 MG	COVERED	FORMULARY
27.424	6.787	680400-ADRENALS	Dexamethasone	DEXAMETHASONE	TABLET	1 MG	COVERED	FORMULARY
27.425	6.785	680400-ADRENALS	Dexamethasone	DEXAMETHASONE	TABLET	0.75 MG	COVERED	FORMULARY
27.426	6.788	680400-ADRENALS	Dexamethasone	DEXAMETHASONE	TABLET	2 MG	COVERED	FORMULARY
27.428	6.789	680400-ADRENALS	Dexamethasone	DEXAMETHASONE	TABLET	4 MG	COVERED	FORMULARY
27.429	6.790	680400-ADRENALS	Dexamethasone	DEXAMETHASONE	TABLET	6 MG	COVERED	FORMULARY
27.680	6.812	680400-ADRENALS	Fludrocortisone	FLUDROCORTISONE ACETATE	TABLET	0.1 MG	COVERED	FORMULARY
26.781	6.703	680400-ADRENALS	Cortef	HYDROCORTISONE	TABLET	10 MG	COVERED	FORMULARY
26.782	6.704	680400-ADRENALS	Cortef	HYDROCORTISONE	TABLET	20 MG	COVERED	FORMULARY
26.783	6.705	680400-ADRENALS	Cortef	HYDROCORTISONE	TABLET	5 MG	COVERED	FORMULARY
37.499	45.311	680400-ADRENALS	Medrol Dosepak	METHYLPREDNISOLONE	TAB DS PK	4 MG	COVERED	FORMULARY
27.056	6.741	680400-ADRENALS	Medrol	METHYLPREDNISOLONE	TABLET	4 MG	COVERED	FORMULARY
26.800	6.719	680400-ADRENALS	Prednisolone	PREDNISOLONE	SOLUTION	15 MG/5 ML	COVERED	FORMULARY
33.806	47.282	680400-ADRENALS	Prednisolone Sodium Phosphate	PREDNISOLONE SOD PHOSPHATE	SOLUTION	15 MG/5 ML	COVERED	FORMULARY
38.363	45.267	680400-ADRENALS	Prednisone	PREDNISONE	TAB DS PK	5 MG	COVERED	FORMULARY
38.364	45.268	680400-ADRENALS	Prednisone	PREDNISONE	TAB DS PK	10 MG	COVERED	FORMULARY
27.171	6.748	680400-ADRENALS	Prednisone	PREDNISONE	TABLET	1 MG	COVERED	FORMULARY
27.172	6.749	680400-ADRENALS	Prednisone	PREDNISONE	TABLET	10 MG	COVERED	FORMULARY
27.173	6.750	680400-ADRENALS	Prednisone	PREDNISONE	TABLET	2.5 MG	COVERED	FORMULARY
27.174	6.751	680400-ADRENALS	Prednisone	PREDNISONE	TABLET	20 MG	COVERED	FORMULARY
27.176	6.753	680400-ADRENALS	Prednisone	PREDNISONE	TABLET	5 MG	COVERED	FORMULARY
27.177	6.754	680400-ADRENALS	Prednisone	PREDNISONE	TABLET	50 MG	COVERED	FORMULARY
47.851	45.215	680800-ANDROGENS	Androgel 1%	TESTOSTERONE	GEL PACKET	25 MG(1%)	COVERED	FORMULARY
47.852	45.216	680800-ANDROGENS	Androgel 1%	TESTOSTERONE	GEL PACKET	50 MG (1%)	COVERED	FORMULARY
18.126	50.831	681200-CONTRACEPTIVES	Ortho Tri-Cyclen Lo, Tri-Lo-Marzia, Tri-Lo-Sprintec, Tri-Lo-Estarylla	NORGESTIMATE-ETHINYL ESTRADIOL	TABLET	0.18/0.215/0.25 mg - 25mcg	COVERED	FORMULARY
13.083	47.787	681200-CONTRACEPTIVES	Yasmin	ETHINYL ESTRADIOL-DROSPIRENONE	TABLET	0.03-3 MG	COVERED	FORMULARY
11.530	3.314	681200-CONTRACEPTIVES	Altavera, Chateal, Kurvelo, Levora, Marlissa, Portia	LEVONORGESTREL-ETHINYL ESTRADIOL	TABLET	0.15-0.03 MG	COVERED	FORMULARY
11.534	30.986	681200-CONTRACEPTIVES	Aviane, Aubra, Delyla, Falmina, Lessina, Lutera, Orsythia, Sronyx	LEVONORGESTREL-ETHINYL ESTRADIOL	TABLET	0.1-0.02 MG	COVERED	FORMULARY
11.531	3.315	681200-CONTRACEPTIVES	Enpresse, Trivora, Myzilra	LEVONORGESTREL-ETHINYL ESTRADIOL	TABLET	50-30(6)/75-40(5)/125/30(10) MCG	COVERED	FORMULARY
11.520	3.313	681200-CONTRACEPTIVES	Ortho Micronor, Errin, Camila, Deblitane, Sharobel, Norlyro, Nor-Be, Jolivette, Jencycla, Heather	NORETHINDRONE	TABLET	0.35 MG	COVERED	FORMULARY
11.480	3.304	681200-CONTRACEPTIVES	Gildess, Junel, Larin, Loestrin 21 1.5/30	NORETHINDRONE ACETATE-ETHINYL ESTRADIOL	TABLET	1.5-30 MCG	COVERED	FORMULARY
11.481	3.305	681200-CONTRACEPTIVES	Gildess, Junel, Larin, Loestrin 21 1/20	NORETHINDRONE ACETATE-ETHINYL ESTRADIOL	TABLET	1-20 MCG	COVERED	FORMULARY
11.477	3.298	681200-CONTRACEPTIVES	Alyacen 7/7/7, Cyclafem 7/7/7, Diasetta 7/7/7, Necon 7/7/7, Nortrel 7/7/7, Ortho-Novum 7/7/7	NORETHINDRONE-ETHINYL ESTRADIOL	TABLET	0.5/0.75/1 MG-35MCG	COVERED	FORMULARY
11.474	3.295	681200-CONTRACEPTIVES	Alyacen, Cyclafem, Dasetta, Necon 1/35, Nortrel 1/35, Norinyl, Ortho Novum, Primella	NORETHINDRONE-ETHINYL ESTRADIOL	TABLET	1-0.35 MG	COVERED	FORMULARY
11.471	3.294	681200-CONTRACEPTIVES	Brevicon, Modicone, Necon 0.5/35, Nortrel 0.5/35, Wera	NORETHINDRONE-ETHINYL ESTRADIOL	TABLET	0.5-0.35 MG	COVERED	FORMULARY
68.101	3.300	681200-CONTRACEPTIVES	Blisovi FE, Gildess FE, Junel FE, Larin FE, Loestrin FE 1.5/30	NORETHINDRONE-ETHINYL ESTRADIOL-IRON	TABLET	1.5MG-30 MCG(21)/75MG(7)	COVERED	FORMULARY
68.102	3.301	681200-CONTRACEPTIVES	Blisovi FE, Gildess FE, Junel FE, Larin FE, Loestrin FE 1/20	NORETHINDRONE-ETHINYL ESTRADIOL-IRON	TABLET	1 MG-20 MCG(21)/75MG(7)	COVERED	FORMULARY
11.300	13.662	681200-CONTRACEPTIVES	Estarylla, Mononessa, Ortho-Cyclen, Previfem, Sprintec	NORGESTIMATE-ETHINYL ESTRADIOL	TABLET	0.25-0.035 MG	COVERED	FORMULARY
11.301	16.963	681200-CONTRACEPTIVES	Tri-Estarylla, Tri-Mononessa, Otrho Tri-Cyclen, Tri-Previfem, Tri-Sprintec	NORGESTIMATE-ETHINYL ESTRADIOL	TABLET	0.18/0.215/0.25 MG-35MCG(28)	COVERED	FORMULARY
11.500	3.310	681200-CONTRACEPTIVES	Low-Ogestrel, Elinest, Cryselle	NORGESTREL-ETHINYL ESTRADIOL	TABLET	0.3 MG-30MCG	COVERED	FORMULARY
10.770	3.204	681604-ESTROGENS	Estrace	ESTRADIOL	TABLET	1 MG	COVERED	FORMULARY
10.771	3.205	681604-ESTROGENS	Estrace	ESTRADIOL	TABLET	2 MG	COVERED	FORMULARY
10.772	21.411	681604-ESTROGENS	Estrace	ESTRADIOL	TABLET	0.5 MG	COVERED	FORMULARY
19.739	52.179	681604-ESTROGENS	Prempro	ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE	TABLET	0.45-1.5 MG	COVERED	FORMULARY
20.769	53.321	681604-ESTROGENS	Prempro	ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE	TABLET	0.3-1.5 MG	COVERED	FORMULARY
55.730	22.647	681604-ESTROGENS	Prempro	ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE	TABLET	0.625-5 MG	COVERED	FORMULARY
55.731	22.648	681604-ESTROGENS	Prempro	ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE	TABLET	0.625-2.5 MG	COVERED	FORMULARY
28.410	7.013	681604-ESTROGENS	Premarin Vaginal	ESTROGENS CONJUGATED	CREAM/APPL	0.625 MG/G	COVERED	FORMULARY
10.942	3.212	681604-ESTROGENS	Premarin	ESTROGENS CONJUGATED	TABLET	0.625 MG	COVERED	FORMULARY
10.943	3.211	681604-ESTROGENS	Premarin	ESTROGENS CONJUGATED	TABLET	0.3 MG	COVERED	FORMULARY
10.944	3.213	681604-ESTROGENS	Premarin	ESTROGENS CONJUGATED	TABLET	0.9 MG	COVERED	FORMULARY
10.945	3.214	681604-ESTROGENS	Premarin	ESTROGENS CONJUGATED	TABLET	1.25 MG	COVERED	FORMULARY
19.975	52.766	681604-ESTROGENS	Premarin	ESTROGENS CONJUGATED	TABLET	0.45MG	COVERED	FORMULARY
59.011	37.022	681612-ESTROGEN AGONIST-ANTAGONISTS	Evista	RALOXIFENE HCL	TABLET	60 MG	COVERED	FORMULARY
19.578	52.080	682004-BIGUANIDES	Glucophage XR	METFORMIN HCL	TAB ER 24H	750 MG	COVERED	FORMULARY
89.863	46.754	682004-BIGUANIDES	Glucophage XR	METFORMIN HCL	TAB ER 24H	500 MG	COVERED	FORMULARY
10.810	13.318	682004-BIGUANIDES	Glucophage	METFORMIN HCL	TABLET	500 MG	COVERED	FORMULARY
10.811	16.441	682004-BIGUANIDES	Glucophage	METFORMIN HCL	TABLET	850 MG	COVERED	FORMULARY
10.857	40.974	682004-BIGUANIDES	Glucophage	METFORMIN HCL	TABLET	1000 MG	COVERED	FORMULARY
92.336	44.341	682008-INSULINS	Novolog Flexpen	INSULIN ASPART	INSULN PEN	100 UNIT/ML	COVERED	FORMULARY
92.326	44.340	682008-INSULINS	Novolog	INSULIN ASPART	VIAL	100 UNIT/ML	COVERED	FORMULARY
17.075	50.134	682008-INSULINS	Novolog 70/30	INSULIN ASPART PROTAMINE-INSULIN ASPART	INSULN PEN	70-30 UNIT/ML	COVERED	FORMULARY
19.057	51.718	682008-INSULINS	Novolog 70/30	INSULIN ASPART PROTAMINE-INSULIN ASPART	VIAL	70-30 UNIT/ML	COVERED	FORMULARY
96.719	34.731	682008-INSULINS	Humalog Kwik Pen	INSULIN LISPRO	INSULN PEN	100 UNIT/ML	NOT COVERED	NON-FORMULARY
5.679	27.413	682008-INSULINS	Humalog	INSULIN LISPRO	VIAL	100 UNIT/ML	NOT COVERED	NON-FORMULARY
11.660	1.740	682008-INSULINS	Novolin N	INSULIN NPH HUMAN ISOPHANE	VIAL	100 UNIT/ML	COVERED	FORMULARY
50.001	16.311	682008-INSULINS	Novolin 70/30	INSULIN NPH HUM-REG INSULIN HM	VIAL	70-30 UNIT/ML	COVERED	FORMULARY
93.717	42.076	682008-INSULINS	Humalog 75/25 Kwik Pen	INSULIN NPL-INSULIN LISPRO	INSULN PEN	75-25 UNIT/ML	NOT COVERED	NON-FORMULARY
22.681	47.172	682008-INSULINS	Humalog 75/25	INSULIN NPL-INSULIN LISPRO	VIAL	75-25 UNIT/ML	NOT COVERED	NON-FORMULARY
11.642	1.723	682008-INSULINS	Novolin R	INSULIN REGULAR HUMAN	VIAL	100 UNIT/ML	COVERED	FORMULARY
12.277	47.333	682016-MEGLITINIDES	Starlix	NATEGLINIDE	TABLET	60 MG	COVERED	FORMULARY
34.027	47.292	682016-MEGLITINIDES	Starlix	NATEGLINIDE	TABLET	120 MG	COVERED	FORMULARY
5.830	25.179	682020-SULFONYLUREAS	Amaryl	GLIMEPIRIDE	TABLET	1 MG	COVERED	FORMULARY
5.832	25.180	682020-SULFONYLUREAS	Amaryl	GLIMEPIRIDE	TABLET	2 MG	COVERED	FORMULARY
5.833	25.181	682020-SULFONYLUREAS	Amaryl	GLIMEPIRIDE	TABLET	4 MG	COVERED	FORMULARY
10.843	21.839	682020-SULFONYLUREAS	Glucotrol XL	GLIPIZIDE	TAB ER 24	10 MG	COVERED	FORMULARY
10.844	21.840	682020-SULFONYLUREAS	Glucotrol XL	GLIPIZIDE	TAB ER 24	5 MG	COVERED	FORMULARY
50.638	43.463	682020-SULFONYLUREAS	Glucotrol XL	GLIPIZIDE	TAB ER 24	2.5 MG	COVERED	FORMULARY
10.840	1.777	682020-SULFONYLUREAS	Glucotrol	GLIPIZIDE	TABLET	5 MG	COVERED	FORMULARY
10.841	1.776	682020-SULFONYLUREAS	Glucotrol	GLIPIZIDE	TABLET	10 MG	COVERED	FORMULARY
18.366	51.194	682020-SULFONYLUREAS	Glipizide-Metformin	GLIPIZIDE-METFORMIN HCL	TABLET	2.5-250 MG	COVERED	FORMULARY
18.367	51.195	682020-SULFONYLUREAS	Glipizide-Metformin	GLIPIZIDE-METFORMIN HCL	TABLET	2.5-500 MG	COVERED	FORMULARY
18.368	51.196	682020-SULFONYLUREAS	Glipizide-Metformin	GLIPIZIDE-METFORMIN HCL	TABLET	5-500 MG	COVERED	FORMULARY
5.710	1.773	682020-SULFONYLUREAS	Diabeta	GLYBURIDE	TABLET	1.25 MG	COVERED	FORMULARY
5.711	1.774	682020-SULFONYLUREAS	Diabeta	GLYBURIDE	TABLET	2.5 MG	COVERED	FORMULARY
5.712	1.775	682020-SULFONYLUREAS	Diabeta	GLYBURIDE	TABLET	5 MG	COVERED	FORMULARY
89.878	45.929	682020-SULFONYLUREAS	Glucovance	GLYBURIDE-METFORMIN HCL	TABLET	1.25-250 MG	COVERED	FORMULARY
89.879	45.930	682020-SULFONYLUREAS	Glucovance	GLYBURIDE-METFORMIN HCL	TABLET	5-500 MG	COVERED	FORMULARY
92.889	22.735	682020-SULFONYLUREAS	Glucovance	GLYBURIDE-METFORMIN HCL	TABLET	2.5-500 MG	COVERED	FORMULARY
92.991	42.943	682028-THIAZOLIDINEDIONES	Actos	PIOGLITAZONE HCL	TABLET	15 MG	COVERED	FORMULARY
93.001	42.944	682028-THIAZOLIDINEDIONES	Actos	PIOGLITAZONE HCL	TABLET	30 MG	COVERED	FORMULARY
93.011	42.945	682028-THIAZOLIDINEDIONES	Actos	PIOGLITAZONE HCL	TABLET	45 MG	COVERED	FORMULARY
25.474	41.661	682212-GLYCOGENOLYTIC AGENTS	Glucagon	GLUCAGON HUMAN RECOMBINANT	KIT	1 MG	NOT COVERED	NON-FORMULARY
25.473	41.660	682212-GLYCOGENOLYTIC AGENTS	Glucagen	GLUCAGON HUMAN RECOMBINANT	VIAL	1 MG	COVERED	FORMULARY
23.281	24.138	682400-PARATHYROID	Miacalcin Nasal	CALCITONIN SALMON SYNTHETIC	SPRAY/PUMP	200 UNIT/SPRAY	COVERED	FORMULARY
26.173	31.610	682800-PITUITARY	DDAVP Nasal	DESMOPRESSIN (NONREFRIGERATED)	SPRAY/PUMP	10 MCG/SPRAY	COVERED	FORMULARY
26.170	6.617	682800-PITUITARY	DDAVP	DESMOPRESSIN ACETATE	SOLUTION	0.1 MG/ML	COVERED	FORMULARY
26.171	19.596	682800-PITUITARY	DDAVP	DESMOPRESSIN ACETATE	TABLET	0.1 MG	COVERED	FORMULARY
26.172	19.597	682800-PITUITARY	DDAVP	DESMOPRESSIN ACETATE	TABLET	0.2 MG	COVERED	FORMULARY
11.260	3.271	683200-PROGESTINS	Provera	MEDROXYPROGESTERONE ACETATE	TABLET	10 MG	COVERED	FORMULARY
11.261	3.272	683200-PROGESTINS	Provera	MEDROXYPROGESTERONE ACETATE	TABLET	2.5 MG	COVERED	FORMULARY
11.262	3.273	683200-PROGESTINS	Provera	MEDROXYPROGESTERONE ACETATE	TABLET	5 MG	COVERED	FORMULARY
11.280	3.274	683200-PROGESTINS	Aygestin	NORETHINDRONE ACETATE	TABLET	5 MG	COVERED	FORMULARY
98.586	62.815	683200-PROGESTINS	Endometrin Vaginal	PROGESTERONE MICRONIZED	INSERT	100 MG	COVERED	FORMULARY
26.320	6.652	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	112 MCG	COVERED	FORMULARY
26.321	6.648	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	25 MCG	COVERED	FORMULARY
26.322	6.649	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	50 MCG	COVERED	FORMULARY
26.323	6.651	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	100 MCG	COVERED	FORMULARY
26.324	6.650	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	75 MCG	COVERED	FORMULARY
26.325	6.656	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	200 MCG	COVERED	FORMULARY
26.326	6.653	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	125 MCG	COVERED	FORMULARY
26.327	6.654	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	150 MCG	COVERED	FORMULARY
26.328	6.655	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	175MCG	COVERED	FORMULARY
26.329	6.657	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	300 MCG	COVERED	FORMULARY
47.631	15.523	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	88 MCG	COVERED	FORMULARY
47.632	20.176	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	137 MCG	COVERED	FORMULARY
26.340	6.658	683604-THYROID AGENTS	Cytomel	LIOTHYRONINE SODIUM	TABLET	25 MCG	COVERED	FORMULARY
26.341	6.659	683604-THYROID AGENTS	Cytomel	LIOTHYRONINE SODIUM	TABLET	5 MCG	COVERED	FORMULARY
26.342	6.660	683604-THYROID AGENTS	Cytomel	LIOTHYRONINE SODIUM	TABLET	50 MCG	COVERED	FORMULARY
26.400	6.674	683608-ANTITHYROID AGENTS	Tapazole	METHIMAZOLE	TABLET	10 MG	COVERED	FORMULARY
26.401	6.675	683608-ANTITHYROID AGENTS	Tapazole	METHIMAZOLE	TABLET	5 MG	COVERED	FORMULARY
28.581	16.924	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Cleocin Vaginal	CLINDAMYCIN PHOSPHATE	CREAM/APPL	2 %	COVERED	FORMULARY
45.410	7.726	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Cleocin T	CLINDAMYCIN PHOSPHATE	GEL (GRAM)	1 %	COVERED	FORMULARY
31.770	11.752	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Cleocin T	CLINDAMYCIN PHOSPHATE	LOTION	1 %	COVERED	FORMULARY
31.720	7.727	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Cleocin T	CLINDAMYCIN PHOSPHATE	SOLUTION	1 %	COVERED	FORMULARY
77.562	29.325	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Erythromycin with Ethanol	ERYTHROMYCIN BASE (WITH ETHANOL)	SOLUTION	2 %	COVERED	FORMULARY
43.203	41.799	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Metrocream, Rosadan	METRONIDAZOLE	CREAM (G)	0.75 %	COVERED	FORMULARY
24.926	59.325	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Metrogel	METRONIDAZOLE	GEL (GRAM)	1 %	COVERED	FORMULARY
43.202	41.798	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Rosadan	METRONIDAZOLE	GEL (GRAM)	0.75 %	COVERED	FORMULARY
49.261	16.939	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Metrogel Vaginal	METRONIDAZOLE	GEL W/APPL	0.75 %	COVERED	FORMULARY
31.774	68.879	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Metrogel Pump	METRONIDAZOLE	GEL W/PUMP	1 %	COVERED	FORMULARY
43.201	41.797	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Metrolotion	METRONIDAZOLE	LOTION	0.75 %	COVERED	FORMULARY
47.450	7.732	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Bactroban	MUPIROCIN	OINT. (G)	2 %	COVERED	FORMULARY
85.459	7.694	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Triple Antibiotic Ointment	NEOMYCIN-BACITRACIN-POLYMYXIN B	OINT. (G)	3.5-400-5000 MG/G-UNIT/G-UNIT/G	COVERED	FORMULARY
14.274	48.538	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Cortisporin	NEOMYCIN-BACITRACIN-POLYMYXIN B-HYDROCORTISONE	OINT. (G)	3.5-400-10000-1 MG/G-UNIT/G-UNIT/G-%	COVERED	FORMULARY
14.275	48.539	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Cortisporin	NEOMYCIN-POLYMYXIN B-HYDROCORTISONE	CREAM (G)	3.5-10000-0.50 MG/G-UNIT/G-%	COVERED	FORMULARY
62.420	18.315	840406-ANTIVIRALS (SKIN & MUCOUS MEMBRANE)	Zovirax	ACYCLOVIR	CREAM (G)	5 %	COVERED	FORMULARY
31.640	7.670	840406-ANTIVIRALS (SKIN & MUCOUS MEMBRANE)	Zovirax	ACYCLOVIR	OINT. (G)	5 %	COVERED	FORMULARY
12.618	44.922	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Ciclopirox	CICLOPIROX	GEL (GRAM)	0.77 %	COVERED	FORMULARY
19.218	51.825	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Loprox Shampoo	CICLOPIROX	SHAMPOO	1 %	COVERED	FORMULARY
8.040	37.020	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Ciclodan, Penlac	CICLOPIROX	SOLUTION	8 %	COVERED	FORMULARY
94.677	40.971	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Ciclopirox Olamine	CICLOPIROX OLAMINE	CREAM (G)	0.77 %	COVERED	FORMULARY
30.370	7.361	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Clotrimazole	CLOTRIMAZOLE	Cream	1 %	COVERED	FORMULARY
30.380	7.362	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Clotrimazole	CLOTRIMAZOLE	SOLUTION	1 %	COVERED	FORMULARY
7.590	9.553	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Mycelex	CLOTRIMAZOLE	TROCHE	10 MG	COVERED	FORMULARY
6.919	36.534	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Lotrisone	CLOTRIMAZOLE-BETAMETHASONE DIPROPIONATE	CREAM (G)	1-0.05 %	COVERED	FORMULARY
14.125	48.627	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Clotrimazole-Betamethasone	CLOTRIMAZOLE-BETAMETHASONE DIPROPIONATE	LOTION	1-0.05 %	COVERED	FORMULARY
31.850	7.334	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Ketoconazole	KETOCONAZOLE	CREAM (G)	2 %	COVERED	FORMULARY
31.271	15.568	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Nizoral Shampoo	KETOCONAZOLE	SHAMPOO	2 %	COVERED	FORMULARY
30.140	7.282	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Nystatin	NYSTATIN	CREAM (G)	100000 UNIT/G	COVERED	FORMULARY
30.150	7.283	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Nystatin	NYSTATIN	OINT. (G)	100000 UNIT/G	COVERED	FORMULARY
30.160	7.284	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Nystatin	NYSTATIN	POWDER	100000 UNIT/G	COVERED	FORMULARY
14.007	48.529	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Nystatin/Triamcinolone	NYSTATIN-TRIAMCINCINOLONE	CREAM (G)	100000-0.1 UNIT/G-%	COVERED	FORMULARY
14.008	48.530	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Nystatin/Triamcinolone	NYSTATIN-TRIAMCINCINOLONE	OINT. (G)	100000-0.1 UNIT/G-%	COVERED	FORMULARY
48.381	15.931	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Terazol 3	TERCONAZOLE	CREAM/APPL	0.8 %	COVERED	FORMULARY
48.380	7.008	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Terazol 7	TERCONAZOLE	CREAM/APPL	0.4 %	COVERED	FORMULARY
31.550	7.650	840412-SCABICIDES AND PEDICULICIDES	Lindane	LINDANE	LOTION	1 %	COVERED	FORMULARY
31.570	7.651	840412-SCABICIDES AND PEDICULICIDES	Lindane	LINDANE	SHAMPOO	1 %	COVERED	FORMULARY
44.370	13.631	840412-SCABICIDES AND PEDICULICIDES	Elimite	PERMETHRIN	CREAM (G)	5 %	COVERED	FORMULARY
44.520	7.663	840412-SCABICIDES AND PEDICULICIDES	Nix	PERMETHRIN	LIQUID	1 %	COVERED	FORMULARY
31.630	7.669	840492-LOCAL ANTI-INFECTIVES, MISCELLANEOUS	Silvadene	SILVER SULFADIAZINE	CREAM (G)	1 %	COVERED	FORMULARY
31.060	7.568	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Betamethasone Diproprionate	BETAMETHASONE DIPROPIONATE	CREAM (G)	0.05 %	COVERED	FORMULARY
31.080	7.570	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Betamethasone Diproprionate	BETAMETHASONE DIPROPIONATE	LOTION	0.05 %	COVERED	FORMULARY
31.070	7.569	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Betamethasone Diproprionate	BETAMETHASONE DIPROPIONATE	OINT. (G)	0.05 %	COVERED	FORMULARY
31.101	7.572	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Betamethasone Valerate	BETAMETHASONE VALERATE	CREAM (G)	0.1 %	COVERED	FORMULARY
31.120	7.574	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Betamethasone Valerate	BETAMETHASONE VALERATE	LOTION	0.1 %	COVERED	FORMULARY
31.110	7.573	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Betamethasone Valerate	BETAMETHASONE VALERATE	OINT. (G)	0.1 %	COVERED	FORMULARY
31.890	7.561	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Diprolene AF	BETAMETHASONE-PROPYLENE GLYCOL	CREAM (G)	0.05 %	COVERED	FORMULARY
31.910	7.562	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Diprolene	BETAMETHASONE-PROPYLENE GLYCOL	OINT. (G)	0.05 %	COVERED	FORMULARY
32.140	7.634	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Temovate	CLOBETASOL PROPIONATE	CREAM (G)	0.05 %	COVERED	FORMULARY
34.040	18.288	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Clobex	CLOBETASOL PROPIONATE	LOTION	0.05 %	COVERED	FORMULARY
32.130	7.635	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Temovate	CLOBETASOL PROPIONATE	OINT. (G)	0.05 %	COVERED	FORMULARY
15.891	15.349	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Cormax	CLOBETASOL PROPIONATE	SOLUTION	0.05 %	COVERED	FORMULARY
34.141	21.986	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Temovate E	CLOBETASOL PROPIONATE-EMOLLIENT BASE	CREAM (G)	0.05 %	COVERED	FORMULARY
31.425	7.620	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Desonide	DESONIDE	CREAM (G)	0.05 %	COVERED	FORMULARY
31.430	7.622	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Desonide	DESONIDE	OINT. (G)	0.05 %	COVERED	FORMULARY
24.484	58.950	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Derma-Smoothe-FS Scalp Oil	FLUOCINOLONE (WITH SHOWER CAP)	OIL	0.01 %	COVERED	FORMULARY
85.080	7.507	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Derma-Smoothe-FS Body Oil	FLUOCINOLONE ACETONIDE	OIL	0.01 %	COVERED	FORMULARY
31.390	7.616	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Fluocinonide	FLUOCINONIDE	CREAM (G)	0.05 %	COVERED	FORMULARY
31.380	7.615	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Fluocinonide	FLUOCINONIDE	GEL (GRAM)	0.05 %	COVERED	FORMULARY
31.400	7.617	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Fluocinonide	FLUOCINONIDE	OINT. (G)	0.05 %	COVERED	FORMULARY
31.401	7.618	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Fluocinonide	FLUOCINONIDE	SOLUTION	0.05 %	COVERED	FORMULARY
30.943	7.545	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Hydrocortisone	HYDROCORTISONE	CREAM (G)	2.5 %	COVERED	FORMULARY
28.850	23.906	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Proctosol-HC, Proctozone	HYDROCORTISONE	CREAM/APPL	2.5 %	COVERED	FORMULARY
66.392	37.045	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Cortenema, Colocort	HYDROCORTISONE	ENEMA	100 MG/60ML	COVERED	FORMULARY
30.975	7.554	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Hydrocortisone	HYDROCORTISONE	LOTION	2.5 %	COVERED	FORMULARY
30.952	7.548	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Hydrocortisone	HYDROCORTISONE	OINT. (G)	2.5 %	COVERED	FORMULARY
66.391	37.044	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Cortifoam	HYDROCORTISONE ACETATE	FOAM/APPL	10 %	COVERED	FORMULARY
27.941	6.858	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Anusol-HC	HYDROCORTISONE ACETATE	SUPP.RECT	25 MG	COVERED	FORMULARY
31.231	7.593	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	CREAM (G)	0.025 %	COVERED	FORMULARY
31.232	7.594	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	CREAM (G)	0.1 %	COVERED	FORMULARY
31.233	7.595	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	CREAM (G)	0.5 %	COVERED	FORMULARY
31.260	7.599	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	LOTION	0.025 %	COVERED	FORMULARY
31.261	7.600	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	LOTION	0.1 %	COVERED	FORMULARY
31.241	7.596	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	OINT. (G)	0.025 %	COVERED	FORMULARY
31.242	7.597	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	OINT. (G)	0.1 %	COVERED	FORMULARY
31.243	15.542	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	OINT. (G)	0.05 %	COVERED	FORMULARY
31.244	7.598	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	OINT. (G)	0.5 %	COVERED	FORMULARY
42.121	9.477	840800-ANTIPRURITICS AND LOCAL ANESTHETICS	Pyridium	PHENAZOPYRIDINE HCL	TABLET	100 MG	COVERED	FORMULARY
42.122	9.478	840800-ANTIPRURITICS AND LOCAL ANESTHETICS	Pyridium	PHENAZOPYRIDINE HCL	TABLET	200 MG	COVERED	FORMULARY
22.291	11.998	841200-ASTRINGENTS	Drysol	ALUMINUM CHLORIDE	SOLUTION	20 %	COVERED	FORMULARY
22.880	5.800	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A	TRETINOIN	CREAM (G)	0.05 %	COVERED	FORMULARY
22.881	5.801	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A	TRETINOIN	CREAM (G)	0.01 %	COVERED	FORMULARY
22.882	5.799	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A	TRETINOIN	CREAM (G)	0.025 %	COVERED	FORMULARY
22.870	5.797	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A	TRETINOIN	GEL (GRAM)	0.01 %	COVERED	FORMULARY
22.871	5.798	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A	TRETINOIN	GEL (GRAM)	0.025 %	COVERED	FORMULARY
17.443	50.417	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A Micro	TRETINOIN MICROSPHERES	GEL (GRAM)	0.04 %	COVERED	FORMULARY
22.874	30.614	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A Micro	TRETINOIN MICROSPHERES	GEL (GRAM)	0.1 %	COVERED	FORMULARY
31.776	68.881	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A Micro Pump	TRETINOIN MICROSPHERES	GEL W/PUMP	0.04 %	COVERED	FORMULARY
31.777	68.882	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A Micro Pump	TRETINOIN MICROSPHERES	GEL W/PUMP	0.1 %	COVERED	FORMULARY
63.447	45.214	841600-CELL STIMULANTS AND PROLIFERANTS	Refissa	TRETINOIN-EMOLLIENT BASE	CREAM (G)	0.05 %	COVERED	FORMULARY
22.931	5.813	842800-KERATOLYTIC AGENTS	Benzoyl Peroxide	BENZOYL PEROXIDE	GEL (GRAM)	5 %	COVERED	FORMULARY
24.774	16.308	842800-KERATOLYTIC AGENTS	Urea	UREA	CREAM (G)	40 %	COVERED	FORMULARY
19.198	51.812	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Azelaic Acid	AZELAIC ACID	Gel	15%	COVERED	FORMULARY
39.274	74.590	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Azelaic Acid	AZELAIC ACID	FOAM	15%	COVERED	FORMULARY
1.851	21.134	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Dovonex	CALCIPOTRIENE	CREAM (G)	0.005%	COVERED	FORMULARY
1.850	19.160	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Calcipotriene	CALCIPOTRIENE	OINT. (G)	0.005%	COVERED	FORMULARY
1.852	22.483	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Calcipotriene	CALCIPOTRIENE	SOLUTION	0.005%	COVERED	FORMULARY
30.781	7.502	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Efudex	FLUOROURACIL	CREAM (G)	5 %	COVERED	FORMULARY
30.791	7.504	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Fluorouracil	FLUOROURACIL	SOLUTION	2 %	COVERED	FORMULARY
30.792	7.505	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Fluorouracil	FLUOROURACIL	SOLUTION	5 %	COVERED	FORMULARY
54.201	31.099	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Aldara	IMIQUIMOD	CREAM PACK	5 %	COVERED	FORMULARY
15.348	49.724	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Elidel	PIMECROLIMUS	CREAM (G)	1 %	COVERED	FORMULARY
23.450	30.857	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Condylox	PODOFILOX	GEL (GRAM)	0.5 %	COVERED	FORMULARY
23.451	15.942	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Condylox	PODOFILOX	SOLUTION	0.5 %	COVERED	FORMULARY
19.370	4.928	861204-ANTIMUSCARINICS	Oxybutynin	OXYBUTYNIN CHLORIDE	SYRUP	5 MG/5 ML	COVERED	FORMULARY
19.388	41.046	861204-ANTIMUSCARINICS	Oxybutynin ER	OXYBUTYNIN CHLORIDE	TAB ER 24	5 MG	COVERED	FORMULARY
19.389	41.047	861204-ANTIMUSCARINICS	Oxybutynin ER	OXYBUTYNIN CHLORIDE	TAB ER 24	10 MG	COVERED	FORMULARY
93.557	42.606	861204-ANTIMUSCARINICS	Oxybutynin ER	OXYBUTYNIN CHLORIDE	TAB ER 24	15 MG	COVERED	FORMULARY
19.380	4.929	861204-ANTIMUSCARINICS	Ditropan	OXYBUTYNIN CHLORIDE	TABLET	5 MG	COVERED	FORMULARY
410	90	861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS	Theophylline ER	THEOPHYLLINE ANHYDROUS	TAB ER 12H	100 MG	COVERED	FORMULARY
411	91	861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS	Theophylline ER	THEOPHYLLINE ANHYDROUS	TAB ER 12H	200 MG	COVERED	FORMULARY
413	93	861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS	Theophylline ER	THEOPHYLLINE ANHYDROUS	TAB ER 12H	300 MG	COVERED	FORMULARY
94.481	2.184	881600-VITAMIN D	Rocaltrol	CALCITRIOL	CAPSULE	0.25 MCG	COVERED	FORMULARY
94.482	2.185	881600-VITAMIN D	Rocaltrol	CALCITRIOL	CAPSULE	0.5 MCG	COVERED	FORMULARY
98.425	62.651	881600-VITAMIN D	Cholecalciferol (Vitamin D3)	CHOLECALCIFEROL (VITAMIN D3)	CAPSULE	50000 UNIT	COVERED	FORMULARY
94.422	2.169	881600-VITAMIN D	Drisdol	ERGOCALCIFEROL (VITAMIN D2)	CAPSULE	50000 UNIT	COVERED	FORMULARY
94.711	2.305	882400-VITAMIN K ACTIVITY	Mephyton	PHYTONADIONE	TABLET	5 MG	COVERED	FORMULARY
2.881	1.192	920400-ALCOHOL DETERRENTS	Antabuse	DISULFIRAM	TABLET	250 MG	COVERED	FORMULARY
30.521	41.440	920800-5-ALPHA-REDUCTASE INHIBITORS	Proscar	FINASTERIDE	TABLET	5 MG	COVERED	FORMULARY
7.070	2.535	921600-ANTIGOUT AGENTS	Zyloprim	ALLOPURINOL	TABLET	100 MG	COVERED	FORMULARY
7.071	2.536	921600-ANTIGOUT AGENTS	Zyloprim	ALLOPURINOL	TABLET	300 MG	COVERED	FORMULARY
35.674	8.334	921600-ANTIGOUT AGENTS	Colcrys	COLCHICINE	TABLET	0.6 MG	COVERED	FORMULARY
12.389	47.381	922400-BONE RESORPTION INHIBITORS	Fosamax	ALENDRONATE SODIUM	TABLET	35 MG	COVERED	FORMULARY
21.680	24.053	922400-BONE RESORPTION INHIBITORS	Fosamax	ALENDRONATE SODIUM	TABLET	10 MG	COVERED	FORMULARY
21.682	31.006	922400-BONE RESORPTION INHIBITORS	Fosamax	ALENDRONATE SODIUM	TABLET	5 MG	COVERED	FORMULARY
85.361	46.941	922400-BONE RESORPTION INHIBITORS	Fosamax	ALENDRONATE SODIUM	TABLET	70 MG	COVERED	FORMULARY
67.031	40.549	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Arava	LEFLUNOMIDE	TABLET	10 MG	COVERED	FORMULARY
67.032	40.550	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Arava	LEFLUNOMIDE	TABLET	20 MG	COVERED	FORMULARY
46.771	11.682	924400-IMMUNOSUPPRESSIVE AGENTS	Imuran	AZATHIOPRINE	TABLET	50 MG	COVERED	FORMULARY
94.200	62.137	940000-DEVICES	True Metrix Level 3	BLOOD-GLUCOSE CONTROL HIGH	EACH		COVERED	FORMULARY
94.200	62.137	940000-DEVICES	True Metrix Level 1	BLOOD-GLUCOSE CONTROL LOW	EACH		COVERED	FORMULARY
94.200	62.137	940000-DEVICES	True Metrix Level 2	BLOOD-GLUCOSE CONTROL NORMAL	EACH		COVERED	FORMULARY
94.200	19.413	940000-DEVICES	True Metrix Air Meter	BLOOD-GLUCOSE METER	EACH		COVERED	FORMULARY
94.200	19.413	940000-DEVICES	True Metrix Meter	BLOOD-GLUCOSE METER	EACH		COVERED	FORMULARY
94.200	19.413	940000-DEVICES	True Metrix Pro	BLOOD-GLUCOSE METER	EACH		NOT COVERED	NON-FORMULARY
94.200	19.413	940000-DEVICES	True Metrix Go	BLOOD-GLUCOSE METER	EACH		NOT COVERED	NON-FORMULARY
94.200	21.900	940000-DEVICES	Aerochamber Plus Flow-Vu	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94.200	21.900	940000-DEVICES	Aerochamber Plus Flow-Vu Mask, Large	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94.200	21.900	940000-DEVICES	Aerochamber Plus Flow-Vu Mask, Medium	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94.200	21.900	940000-DEVICES	Aerochamber Plus Flow-Vu Mask, Small	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94.200	21.900	940000-DEVICES	Optichamber Diamond VHC	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94.200	21.900	940000-DEVICES	Optichamber Diamond VHC with Large Mask	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94.200	21.900	940000-DEVICES	Optichamber Diamond VHC with Medium Mask	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94.200	21.900	940000-DEVICES	Optichamber Diamond VHC with Small Mask	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94.200	64.800	940000-DEVICES	Optichamber Large Mask	INHALER ASSIST DEVICE ACCESORY	EACH		COVERED	FORMULARY
94.200	64.800	940000-DEVICES	Optichamber Medium Mask	INHALER ASSIST DEVICE ACCESORY	EACH		COVERED	FORMULARY
94.200	70.184	940000-DEVICES	True Plus Lancet 28G	LANCETS	EACH	28 GAUGE	COVERED	FORMULARY
94.200	70.013	940000-DEVICES	True Plus Lancet 30G	LANCETS	EACH	30 GAUGE	COVERED	FORMULARY
94.200	70.013	940000-DEVICES	True Plus Lancet 30G	LANCETS	EACH	30 GAUGE	COVERED	FORMULARY
94.200	70.012	940000-DEVICES	True Plus Lancet 33G	LANCETS	EACH	33 GAUGE	COVERED	FORMULARY
94.200	70.012	940000-DEVICES	True Plus Lancet 33G	LANCETS	EACH	33 GAUGE	COVERED	FORMULARY
94.200	70.184	940000-DEVICES	True PlusLancet 28G	LANCETS	EACH	28 GAUGE	COVERED	FORMULARY
94.200	70.184	940000-DEVICES	True PlusLancet 28G	LANCETS	EACH	28 GAUGE	COVERED	FORMULARY
94.200	65.779	940000-DEVICES	True Plus Lancing Device	LANCING DEVICE	EACH		COVERED	FORMULARY
94.200	65.779	940000-DEVICES	True Plus Lancing Device	LANCING DEVICE	EACH		COVERED	FORMULARY
94.200	16.606	940000-DEVICES	Peak Flow Meter	PEAK FLOW METER	EACH		COVERED	FORMULARY
94.200	16.606	940000-DEVICES	Peak Flow Meter	PEAK FLOW METER	EACH		COVERED	FORMULARY
94.200	16.606	940000-DEVICES	Peak Flow Meter	PEAK FLOW METER	EACH		COVERED	FORMULARY
94.200	49.235	940000-DEVICES	Pen Needle 29 G X 1/2"	PEN NEEDLE DIABETIC	DIS NEEDLE	29 G X 1/2"	COVERED	FORMULARY
94.200	49.235	940000-DEVICES	Pen Needle 29 G X 1/2"	PEN NEEDLE DIABETIC	DIS NEEDLE	29 G X 1/2"	COVERED	FORMULARY
94.200	49.235	940000-DEVICES	Pen Needle 29 G X 1/2"	PEN NEEDLE DIABETIC	DIS NEEDLE	29 G X 1/2"	COVERED	FORMULARY
94.200	49.235	940000-DEVICES	Pen Needle 29 G X 1/2"	PEN NEEDLE DIABETIC	DIS NEEDLE	29 G X 1/2"	COVERED	FORMULARY
94.200	49.235	940000-DEVICES	Pen Needle 29 G X 1/2"	PEN NEEDLE DIABETIC	DIS NEEDLE	29 G X 1/2"	COVERED	FORMULARY
94.200	61.638	940000-DEVICES	Pen Needle 30 G x 1/3"	PEN NEEDLE DIABETIC	DIS NEEDLE	30 G X 1/3"	COVERED	FORMULARY
94.200	61.638	940000-DEVICES	Pen Needle 30 G x 1/3"	PEN NEEDLE DIABETIC	DIS NEEDLE	30 G X 1/3"	COVERED	FORMULARY
94.200	50.622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94.200	50.622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94.200	50.622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94.200	50.622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94.200	50.622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94.200	50.622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94.200	50.622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94.200	50.622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94.200	50.622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94.200	50.622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94.200	60.904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94.200	60.904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94.200	60.904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94.200	60.904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94.200	60.904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94.200	60.904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94.200	60.904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94.200	60.904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94.200	49.240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94.200	49.240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94.200	49.240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94.200	49.240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94.200	49.240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94.200	49.240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94.200	49.240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94.200	49.240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94.200	49.240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94.200	49.240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94.200	49.240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94.200	49.240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94.200	49.240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94.200	62.868	940000-DEVICES	Pen Needle 32 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	32 G X 1/4"	COVERED	FORMULARY
94.200	66.936	940000-DEVICES	Pen Needle 32 G X 1/5"	PEN NEEDLE DIABETIC	DIS NEEDLE	32 G X 1/5"	COVERED	FORMULARY
94.200	72.859	940000-DEVICES	Pen Needle 32 G x 1/6"	PEN NEEDLE DIABETIC	DIS NEEDLE	32 G X 1/6"	COVERED	FORMULARY
94.200	66.308	940000-DEVICES	Pen Needle 32 G x 5/32"	PEN NEEDLE DIABETIC	DIS NEEDLE	32G X 5/32"	COVERED	FORMULARY
94.200	66.308	940000-DEVICES	Pen Needle 32 G x 5/32"	PEN NEEDLE DIABETIC	DIS NEEDLE	32G X 5/32"	COVERED	FORMULARY
94.200	66.308	940000-DEVICES	Pen Needle 32 G x 5/32"	PEN NEEDLE DIABETIC	DIS NEEDLE	32G X 5/32"	COVERED	FORMULARY
94.200	66.308	940000-DEVICES	Pen Needle 32 G x 5/32"	PEN NEEDLE DIABETIC	DIS NEEDLE	32G X 5/32"	COVERED	FORMULARY
94.200	66.308	940000-DEVICES	Pen Needle 32 G x 5/32"	PEN NEEDLE DIABETIC	DIS NEEDLE	32G X 5/32"	COVERED	FORMULARY
94.200	66.308	940000-DEVICES	Pen Needle 32 G x 5/32"	PEN NEEDLE DIABETIC	DIS NEEDLE	32G X 5/32"	COVERED	FORMULARY
94.200	66.308	940000-DEVICES	Pen Needle 32 G x 5/32"	PEN NEEDLE DIABETIC	DIS NEEDLE	32G X 5/32"	COVERED	FORMULARY
94.200	62.772	940000-DEVICES	Pen Needle 30 G x 1/3"	PEN NEEDLE DIABETIC SAFETY	DIS NEEDLE	30 G X 1/3"	COVERED	FORMULARY
94.200	49.277	940000-DEVICES	Insulin Syringe 0.3mL 29 G x 1/2"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.277	940000-DEVICES	Insulin Syringe 0.3mL 29 G x 1/2"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.277	940000-DEVICES	Insulin Syringe 0.3mL 29 G x 1/2"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.399	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 1/2"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 1/2"	COVERED	FORMULARY
94.200	49.399	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 1/2"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 1/2"	COVERED	FORMULARY
94.200	49.394	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94.200	49.394	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94.200	49.394	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94.200	49.394	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94.200	49.394	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94.200	49.394	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94.200	49.394	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94.200	49.403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94.200	49.276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94.200	49.276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94.200	49.276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94.200	49.276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94.200	49.276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94.200	49.383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94.200	49.395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94.200	49.395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94.200	49.395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94.200	49.395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94.200	49.395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94.200	49.395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94.200	49.400	940000-DEVICES	Insulin Syringe 0.5mL 30GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30 G X 1/2"	COVERED	FORMULARY
94.200	49.400	940000-DEVICES	Insulin Syringe 0.5mL 30GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30 G X 1/2"	COVERED	FORMULARY
94.200	49.400	940000-DEVICES	Insulin Syringe 0.5mL 30GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30 G X 1/2"	COVERED	FORMULARY
94.200	49.400	940000-DEVICES	Insulin Syringe 0.5mL 30GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30 G X 1/2"	COVERED	FORMULARY
94.200	49.404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94.200	49.275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94.200	49.275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94.200	49.275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94.200	49.275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94.200	49.275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94.200	49.275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94.200	49.384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94.200	49.358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94.200	49.358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94.200	49.358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94.200	49.358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94.200	49.358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94.200	49.358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94.200	49.358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94.200	49.358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94.200	49.401	940000-DEVICES	Insulin Syringe 1mL 30GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 1/2"	COVERED	FORMULARY
94.200	49.401	940000-DEVICES	Insulin Syringe 1mL 30GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 1/2"	COVERED	FORMULARY
94.200	49.401	940000-DEVICES	Insulin Syringe 1mL 30GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 1/2"	COVERED	FORMULARY
94.200	49.405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94.200	49.405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
33.118	28.142	081206-CEPHALOSPORINS	Suprax Capsule	CEFIXIME	CAPSULE	400 MG	COVERED	FORMULARY	Restricted to CUC/CH Prescribers. Send to a CUC in-house pharmacy. Quantity limit #1 capsule/ prescription.
33.120	9.182	081206-CEPHALOSPORINS	Suprax Suspension	CEFIXIME	SUSP RECON	100 MG/5ML	NOT COVERED	NON-FORMULARY	Formulary: Cefdinir
92.368	44.428	081206-CEPHALOSPORINS	Suprax Suspension	CEFIXIME	SUSP RECON	200 MG/5ML	NOT COVERED	NON-FORMULARY	Formulary: Cefdinir
34.277	70.665	081206-CEPHALOSPORINS	Suprax Suspension	CEFIXIME	SUSP RECON	500 MG/5ML	NOT COVERED	NON-FORMULARY	Formulary: Cefdinir
33.445	70.122	081206-CEPHALOSPORINS	Suprax Chewable	CEFIXIME	TAB CHEW	100 MG	NOT COVERED	NON-FORMULARY	Formulary: Cefdinir
33.446	70.123	081206-CEPHALOSPORINS	Suprax Chewable	CEFIXIME	TAB CHEW	200 MG	NOT COVERED	NON-FORMULARY	Formulary: Cefdinir
33.110		081206-CEPHALOSPORINS	Suprax Tablet	CEFIXIME	TABLET	400 MG	NOT COVERED	NON-FORMULARY	Formulary: Cefdinir
26.871	45.132	081228-ANTIBACTERIALS, MISCELLANEOUS	Zyvox Suspension	LINEZOLID	SUSP RECON	100 MG/5ML	NOT COVERED	NON-FORMULARY
26.870	45.131	081228-ANTIBACTERIALS, MISCELLANEOUS	Zyvox Tablet	LINEZOLID	TABLET	600 MG	NOT COVERED	NON-FORMULARY
33.787	70.295	081408-AZOLES	Onmel	ITRACONAZOLE	CAPSULE	200 MG	NOT COVERED	NON-FORMULARY
55.389	21.871	083600-URINARY ANTI-INFECTIVES	Monurol	FOSFOMYCIN TROMETHAMINE	PACKET	3 G	NOT COVERED	NON-FORMULARY
74.040	4.773	120808-ANTIMUSCARINICS/ANTISPASMODICS	Donnatal Elixir	PHENOBARBITAL-HYOSCYAMINE-ATROPINE-SCOPOLAMINE	ELIXIR	16.2-0.1037-0.0194 MG/5ML	NOT COVERED	NON-FORMULARY
74.070	4.777	120808-ANTIMUSCARINICS/ANTISPASMODICS	Donnatal	PHENOBARBITAL-HYOSCYAMINE-ATROPINE-SCOPOLAMINE	TABLET	16.2-0.1037-0.0194 MG	NOT COVERED	NON-FORMULARY
28.038	65.912	121212-ALPHA- AND BETA-ADRENERGIC AGONISTS	Adrenaclick	EPINEPHRINE	AUTO INJCT	0.15 MG/0.15ML	NOT COVERED	NON-FORMULARY	Formulary: Epinephrine generic
19.861	16.878	121212-ALPHA- AND BETA-ADRENERGIC AGONISTS	Epipen Jr.	EPINEPHRINE	AUTO INJCT	0.15 MG/0.3ML	NOT COVERED	NON-FORMULARY	Formulary: Epinephrine generic
19.862	16.879	121212-ALPHA- AND BETA-ADRENERGIC AGONISTS	Epipen, Adrenaclick	EPINEPHRINE	AUTO INJCT	0.3 MG/0.3ML	NOT COVERED	NON-FORMULARY	Formulary: Epinephrine generic
17.912	4.663	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Soma	CARISOPRODOL	TABLET	350 MG	NOT COVERED	NON-FORMULARY	Formulary: Cyclobenzaprine, methocarbamol, and tizanidine
91.765	51.112	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Skelaxin	METAXALONE	TABLET	800 MG	NOT COVERED	NON-FORMULARY	Formulary: Cyclobenzaprine, methocarbamol, and tizanidine
19.153	51.784	240608-HMG-COA REDUCTASE INHIBITORS	Crestor	ROSUVASTATIN CALCIUM	TABLET	10 MG	COVERED	FORMULARY
19.154	51.785	240608-HMG-COA REDUCTASE INHIBITORS	Crestor	ROSUVASTATIN CALCIUM	TABLET	20 MG	COVERED	FORMULARY
19.155	51.786	240608-HMG-COA REDUCTASE INHIBITORS	Crestor	ROSUVASTATIN CALCIUM	TABLET	40 MG	COVERED	FORMULARY
20.229	52.944	240608-HMG-COA REDUCTASE INHIBITORS	Crestor	ROSUVASTATIN CALCIUM	TABLET	5 MG	COVERED	FORMULARY
23.929	58.486	240692-ANTILIPEMIC AGENTS, MISCELLANEOUS	Lovaza	OMEGA-3 ACID ETHYL ESTERS	CAPSULE	1 G	NOT COVERED	NON-FORMULARY	Formulary: Fenofibrate
73.542	37.015	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand	CANDESARTAN CILEXETIL	TABLET	4 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
73.543	37.016	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand	CANDESARTAN CILEXETIL	TABLET	8 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
73.544	37.017	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand	CANDESARTAN CILEXETIL	TABLET	16 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
73.545	40.659	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand	CANDESARTAN CILEXETIL	TABLET	32 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
13.258	64.285	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand HCT	CANDESARTAN/HYDROCHLOROTHIAZID	TABLET	32MG-25MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
21.559	45.425	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand HCT	CANDESARTAN/HYDROCHLOROTHIAZID	TABLET	16-12.5MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
21.569	46.624	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand HCT	CANDESARTAN/HYDROCHLOROTHIAZID	TABLET	32-12.5MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
23.831	40.910	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Micardis	TELMISARTAN	TABLET	40 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
23.832	40.911	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Micardis	TELMISARTAN	TABLET	80 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
23.833	47.126	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Micardis	TELMISARTAN	TABLET	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
27.783	65.746	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Twynsta	TELMISARTAN/AMLODIPINE	TABLET	40 MG-5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
27.784	65.747	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Twynsta	TELMISARTAN/AMLODIPINE	TABLET	40 MG-10MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
27.785	65.748	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Twynsta	TELMISARTAN/AMLODIPINE	TABLET	80 MG-5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
27.786	65.749	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Twynsta	TELMISARTAN/AMLODIPINE	TABLET	80 MG-10MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
12.257	47.326	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Micardis HCT	TELMISARTAN/HYDROCHLOROTHIAZID	TABLET	40-12.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
12.259	47.324	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Micardis HCT	TELMISARTAN/HYDROCHLOROTHIAZID	TABLET	80-12.5MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
22.866	57.690	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Micardis HCT	TELMISARTAN/HYDROCHLOROTHIAZID	TABLET	80 MG-25MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan
24.635	59.102	280808-OPIATE AGONISTS	Duragesic	FENTANYL	PATCH TD72	12 MCG/HR	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
19.200	15.880	280808-OPIATE AGONISTS	Duragesic	FENTANYL	PATCH TD72	25 MCG/HR	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
19.201	15.881	280808-OPIATE AGONISTS	Duragesic	FENTANYL	PATCH TD72	50MCG/HR	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
19.202	15.882	280808-OPIATE AGONISTS	Duragesic	FENTANYL	PATCH TD72	75MCG/HR	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
19.203	15.883	280808-OPIATE AGONISTS	Duragesic	FENTANYL	PATCH TD72	100 MCG/HR	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
16.281	15.065	280808-OPIATE AGONISTS	Oxyocodone Solution	OXYCODONE HCL	Oral Solution	20 MG/ML	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
16.280	4.224	280808-OPIATE AGONISTS	Oxycodone Solution	OXYCODONE HCL	Oral Solution	5 MG/5 ML	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
16.291	13.467	280808-OPIATE AGONISTS	Oxyocodone	OXYCODONE HCL	TABLET	10 MG	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
20.091	46.474	280808-OPIATE AGONISTS	Oxyocodone	OXYCODONE HCL	TABLET	15 MG	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
21.194	45.298	280808-OPIATE AGONISTS	Oxyocodone	OXYCODONE HCL	TABLET	20 MG	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
20.092	46.475	280808-OPIATE AGONISTS	Oxyocodone	OXYCODONE HCL	TABLET	30 MG	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
64.672	29.312	280812-OPIATE PARTIAL AGONISTS	Buprenorphine	BUPRENORPHINE HCL	TAB SUBL	2 MG	COVERED	FORMULARY
64.673	29.313	280812-OPIATE PARTIAL AGONISTS	Buprenorphine	BUPRENORPHINE HCL	TAB SUBL	8 MG	COVERED	FORMULARY
33.744	70.262	280812-OPIATE PARTIAL AGONISTS	Suboxone Film	BUPRENORPHINE HCL/NALOXONE HCL	Subl Film	12 MG-3 MG	COVERED	FORMULARY
28.958	66.635	280812-OPIATE PARTIAL AGONISTS	Suboxone Film	BUPRENORPHINE HCL/NALOXONE HCL	Subl Film	2 MG-0.5MG	COVERED	FORMULARY
33.741	70.259	280812-OPIATE PARTIAL AGONISTS	Suboxone Film	BUPRENORPHINE HCL/NALOXONE HCL	Subl Film	4MG-1MG	COVERED	FORMULARY
28.959	66.636	280812-OPIATE PARTIAL AGONISTS	Suboxone Film	BUPRENORPHINE HCL/NALOXONE HCL	Subl Film	8 MG-2 MG	COVERED	FORMULARY
18.973	51.640	280812-OPIATE PARTIAL AGONISTS	Suboxone Tablet	BUPRENORPHINE HCL/NALOXONE HCL	TAB SUBL	2 MG-0.5MG	COVERED	FORMULARY
18.974	51.641	280812-OPIATE PARTIAL AGONISTS	Suboxone Tablet	BUPRENORPHINE HCL/NALOXONE HCL	TAB SUBL	8 MG-2 MG	COVERED	FORMULARY
28.626	66.372	280892-ANALGESICS AND ANTIPYRETICS, MISC.	Fioricet	BUTALBITAL-ACETAMINOPHEN-CAFFEINE	CAPSULE	50-300-40 MG	NOT COVERED	NON-FORMULARY	Formulary: Capacet, Esgic
27.095	60.935	281000-OPIATE ANTAGONISTS	Vivitrol	NALTREXONE MICROSPHERES	SUS ER REC	380MG	NOT COVERED	NON-FORMULARY	Formulary: Naltrexone tablet
16.356	46.216	281604-ANTIDEPRESSANTS	Sarafem	FLUOXETINE HCL	TABLET	10 MG	NOT COVERED	NON-FORMULARY	Formulary: capsules
16.359	46.219	281604-ANTIDEPRESSANTS	Sarafem	FLUOXETINE HCL	TABLET	20 MG	NOT COVERED	NON-FORMULARY	Formulary: capsules
14.349	64.444	281604-ANTIDEPRESSANTS	Venlafaxine ER	VENLAFAXINE HCL	TAB ER 24	37.5 MG	NOT COVERED	NON-FORMULARY	Formulary: capsules
14.352	64.445	281604-ANTIDEPRESSANTS	Venlafaxine ER	VENLAFAXINE HCL	TAB ER 24	75 MG	NOT COVERED	NON-FORMULARY	Formulary: capsules
14.353	64.446	281604-ANTIDEPRESSANTS	Venlafaxine ER	VENLAFAXINE HCL	TAB ER 24	150 MG	NOT COVERED	NON-FORMULARY	Formulary: capsules
14.354	64.447	281604-ANTIDEPRESSANTS	Venlafaxine ER	VENLAFAXINE HCL	TAB ER 24	225 MG	NOT COVERED	NON-FORMULARY	Formulary: capsules
25.598	59.781	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Diastat	DIAZEPAM	KIT	5-7.5-10MG	NOT COVERED	NON-FORMULARY
25.599	59.782	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Diastat	DIAZEPAM	KIT	12.5-15-20	NOT COVERED	NON-FORMULARY
48.131	34.015	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Diastat	DIAZEPAM	KIT	2.5 MG	NOT COVERED	NON-FORMULARY
19.593	40.223	283228-SELECTIVE SEROTONIN AGONISTS	Maxalt MLT	RIZATRIPTAN BENZOATE	TAB RAPDIS	5 MG	NOT COVERED	Non-Formulary	Formulary: Imitrex (Sumatriptan)
19.591	40.221	283228-SELECTIVE SEROTONIN AGONISTS	Maxalt	RIZATRIPTAN BENZOATE	TABLET	5 MG	NOT COVERED	Non-Formulary	Formulary: Imitrex (Sumatriptan)
13.971	48.489	480800-ANTITUSSIVES	Promethazine/Codeine	PROMETHAZINE HCL-CODEINE	SYRUP	6.25-10 MG/5ML	NOT COVERED	NON-FORMULARY
54.980	12.073	481600-EXPECTORANTS	Mucinex D	GUAIFENESIN-PSEUDOEPHEDRINE HCL	TAB ER 12H	600-60 MG	NOT COVERED	NON-FORMULARY	Available OTC
26.056	60.055	520808-CORTICOSTEROIDS (EENT)	Dermotic	FLUOCINOLONE ACETONIDE OIL	DROPS	0.01%	Covered	FORMULARY
1.697	30.106	562836-PROTON-PUMP INHIBITORS	Prevacid	LANSOPRAZOLE	CAPSULE DR	15 MG	NOT COVERED	NON-FORMULARY	Formulary: Pantoprazole
1.698	30.107	562836-PROTON-PUMP INHIBITORS	Prevacid	LANSOPRAZOLE	CAPSULE DR	30 MG	NOT COVERED	NON-FORMULARY	Formulary: Pantoprazole
4.348	33.530	562836-PROTON-PUMP INHIBITORS	Prilosec	OMEPRAZOLE	CAPSULE DR	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Pantoprazole
92.989	43.136	562836-PROTON-PUMP INHIBITORS	Prilosec	OMEPRAZOLE	CAPSULE DR	10 MG	NOT COVERED	NON-FORMULARY	Formulary: Pantoprazole
92.999	43.137	562836-PROTON-PUMP INHIBITORS	Prilosec	OMEPRAZOLE	CAPSULE DR	40 MG	NOT COVERED	NON-FORMULARY	Formulary: Pantoprazole
94.639	40.941	562836-PROTON-PUMP INHIBITORS	Aciphex	RABEPRAZOLE SODIUM	TABLET DR	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Pantoprazole
30.220	19.863	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Pentasa CR	MESALAMINE	CAPSULE ER	250 MG	NOT COVERED	PAP	Formulary: Sulfasalazine. Contact manufacturer for PAP
21.663	53.882	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Asacol HD	MESALAMINE	TABLET DR	800 MG	NOT COVERED	NON-FORMULARY	Formulary: Sulfasalazine. Contact manufacturer for PAP
37.726	73.336	569200-GI DRUGS, MISCELLANEOUS	Movantik	NALOXEGOL OXALATE	TABLET	25 MG	NOT COVERED	NON-FORMULARY	Contact manufacturer for PAP
37.725	73.335	569200-GI DRUGS, MISCELLANEOUS	Movantik	NALOXEGOL OXALATE	TABLET	12.5 MG	NOT COVERED	NON-FORMULARY	Contact manufacturer for PAP
28.841	3.203	681604-ESTROGENS	Vivelle-DOT, Minivelle	ESTRADIOL	TRANSDERMAL PATCH TWICE-WEEKLY	0.1MG/24HR	COVERED	FORMULARY
28.840	3.202	681604-ESTROGENS	Vivelle-DOT, Minivelle	ESTRADIOL	TRANSDERMAL PATCH TWICE-WEEKLY	0.05MG/24H	COVERED	FORMULARY
28.842	16.767	681604-ESTROGENS	Vivelle-DOT, Minivelle	ESTRADIOL	TRANSDERMAL PATCH TWICE-WEEKLY	0.025MG/24H	COVERED	FORMULARY
28.843	23.270	681604-ESTROGENS	Vivelle-DOT, Minivelle	ESTRADIOL	TRANSDERMAL PATCH TWICE-WEEKLY	0.075MG/24H	COVERED	FORMULARY
28.846	24.555	681604-ESTROGENS	Vivelle-DOT, Minivelle	ESTRADIOL	TRANSDERMAL PATCH TWICE-WEEKLY	0.0375MG/24	COVERED	FORMULARY
28.844	23.471	681604-ESTROGENS	Climara	ESTRADIOL	TRANSDERMAL PATCH ONCE-WEEKLY	0.1MG/24HR	COVERED	FORMULARY
28.845	23.472	681604-ESTROGENS	Climara	ESTRADIOL	TRANSDERMAL PATCH ONCE-WEEKLY	0.05MG/24H	COVERED	FORMULARY
28.848	32.174	681604-ESTROGENS	Climara	ESTRADIOL	TRANSDERMAL PATCH ONCE-WEEKLY	0.025MG/24H	COVERED	FORMULARY
28.853	40.366	681604-ESTROGENS	Climara	ESTRADIOL	TRANSDERMAL PATCH ONCE-WEEKLY	0.075MG/24H	COVERED	FORMULARY
20.068	52.830	681604-ESTROGENS	Climara	ESTRADIOL	TRANSDERMAL PATCH ONCE-WEEKLY	0.06MG/24H	COVERED	FORMULARY
20.069	52.831	681604-ESTROGENS	Climara	ESTRADIOL	TRANSDERMAL PATCH ONCE-WEEKLY	0.0375MG/24	COVERED	FORMULARY
28.107	65.966	681604-ESTROGENS	Vagifem	ESTRADIOL	TABLET	10 MCG	NOT COVERED	NON-FORMULARY
67.170	7.011	681604-ESTROGENS	Estrace Vaginal Cream	ESTRADIOL	CREAM/APPL	0.01%	NOT COVERED	NON-FORMULARY	Formulary: Premarin Vaginal Cream
34.336	70.705	681612-ESTROGEN AGONIST-ANTAGONISTS	Osphena	OSPEMIFENE	TABLET	60 MG	NOT COVERED	NON-FORMULARY
2.318	20.241	682002-ALPHA-GLUCOSIDASE INHIBITORS	Precose	ACARBOSE	TABLET	100 MG	NOT COVERED	NON-FORMULARY
2.319	20.242	682002-ALPHA-GLUCOSIDASE INHIBITORS	Precose	ACARBOSE	TABLET	50 MG	NOT COVERED	NON-FORMULARY
8.070	36.767	682002-ALPHA-GLUCOSIDASE INHIBITORS	Precose	ACARBOSE	TABLET	25 MG	NOT COVERED	NON-FORMULARY
95.252	40.357	682002-ALPHA-GLUCOSIDASE INHIBITORS	Glyset	MIGLITOL	TABLET	25 MG	NOT COVERED	NON-FORMULARY
95.253	40.358	682002-ALPHA-GLUCOSIDASE INHIBITORS	Glyset	MIGLITOL	TABLET	50 MG	NOT COVERED	NON-FORMULARY
95.254	40.359	682002-ALPHA-GLUCOSIDASE INHIBITORS	Glyset	MIGLITOL	TABLET	100 MG	NOT COVERED	NON-FORMULARY
35.836	71.842	682008-INSULINS	Tresiba FlexTouch	INSULIN DEGLUDEC	INSULN PEN	100/ML (3)	NOT COVERED	NON-FORMULARY	Formulary: insulin glargine-yfgn
35.837	71.843	682008-INSULINS	Tresiba FlexTouch	INSULIN DEGLUDEC	INSULN PEN	200/ML (3)	NOT COVERED	NON-FORMULARY	Formulary: insulin glargine-yfgn
11.660	1.740	682008-INSULINS	Humulin N	INSULIN NPH HUMAN ISOPHANE	VIAL	100 UNIT/ML	NOT COVERED	NON-FORMULARY	Formulary: Novolin N
50.001	16.311	682008-INSULINS	Humulin 70/30	INSULIN NPH HUM-REG INSULIN HM	VIAL	70-30 UNIT/ML	NOT COVERED	NON-FORMULARY	Formulary: Novolin 70/30
11.642	1.723	682008-INSULINS	Humulin R	INSULIN REGULAR HUMAN	VIAL	100 UNIT/ML	NOT COVERED	NON-FORMULARY	Formulary: Novolin R
50.776	43.801	683200-PROGESTINS	Prometrium	PROGESTERONE, MICRONIZED	CAPSULE	100 MG	COVERED	FORMULARY
50.786	43.802	683200-PROGESTINS	Prometrium	PROGESTERONE, MICRONIZED	CAPSULE	200 MG	COVERED	FORMULARY
98.238	62.462	81228-ANTIBACTERIALS, MISCELLANEOUS	Pylera	BISMUTH/METRONID/TETRACYCLINE	CAPSULE	140-125-125 MG	COVERED - SEE COMMENTS	FORMULARY	14 - day supply covered. Must be dispensed from CUC in-house pharmacies only.
26.339	60.244	83600-URINARY ANTI-INFECTIVES	Hyophen	METHENAM/M.BLUE/SALICYL/HYOSCY	TABLET	81.6-0.12	NOT COVERED	NON-FORMULARY
31.812	7.731	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Bacitracin	BACITRACIN	OINT. (G)	500 UNIT/G	NOT COVERED	NON-FORMULARY
60.050	23.447	840800-ANTIPRURITICS AND LOCAL ANESTHETICS	Lidocaine Patch	LIDOCAINE	ADH. PATCH	4%	COVERED	FORMULARY
50.272	43.256	840800-ANTIPRURITICS AND LOCAL ANESTHETICS	Lidoderm	LIDOCAINE	ADH. PATCH	5%	NOT COVERED	NON-FORMULARY
95.404	40.261	840800-ANTIPRURITICS AND LOCAL ANESTHETICS	Lindocaine Anorectal Cream	LIDOCAINE	CREAM (G)	5%	NOT COVERED	NON-FORMULARY
95.405	40.262	840800-ANTIPRURITICS AND LOCAL ANESTHETICS	Liocaine Cream	LIDOCAINE	CREAM (G)	4%	NOT COVERED	NON-FORMULARY	Available OTC
30.750	14.476	840800-ANTIPRURITICS AND LOCAL ANESTHETICS	Lidocaine Ointment	LIDOCAINE	OINT. (G)	5%	NOT COVERED	NON-FORMULARY	Lidocaine 4% Cream is OTC
24.882	6.312	845004-DEPIGMENTING AGENTS	ESOTERICA FADE CREAM	HYDROQUINONE	CREAM (G)	2%	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
24.883	6.313	845004-DEPIGMENTING AGENTS	MELQUIN HP 4% CREAM	HYDROQUINONE	CREAM (G)	4%	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
47.830	6.314	845004-DEPIGMENTING AGENTS	HYDROQUINONE 4% CREAM	HYDROQUINONE	POWDER		NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
24.890	6.315	845004-DEPIGMENTING AGENTS	HYDROQUINONE POWDER	HYDROQUINONE	SOLUTION	30 MG/ML	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
20.120	52.863	845004-DEPIGMENTING AGENTS	NUQUIN HP 4% CREAM	HYDROQUINONE MICROSPHERES	CRM ER (G)	4%	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
97.674	61.889	845004-DEPIGMENTING AGENTS	ESOTERICA FADE CREAM	HYDROQUINONE/AVOBENZ/OCTINOX	EMUL ADHES	4%	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
21.864	54.046	845004-DEPIGMENTING AGENTS	ALPHAQUIN HP 4% CREAM	HYDROQUINONE/AVOBENZ/OCTINOX	EMULSN(G)	4%	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
20.915	53.438	845004-DEPIGMENTING AGENTS	HYDROQUINONE TR 4% CREAM	HYDROQUINONE/OXYBEN/OCTINOXATE	CREAM (G)	4%(5-7.5%)	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
97.229	61.438	845004-DEPIGMENTING AGENTS	ACLARO 4% EMULSION	HYDROQUINONE/OXYBENZONE/PADIMA	CREAM (G)	2%-SPF10	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
66.899	31.427	845004-DEPIGMENTING AGENTS	MELQUIN-3 SOLUTION	HYDROQUINONE/SUNSCREEN(FER OX)	CREAM (G)	4%	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
96.071	39.542	848000-SUNSCREEN AGENTS	MELPAQUE HP 4% CREAM	DIOXYBENZONE/PDO/HYDROQUINONE	CREAM (G)	3%-5%-4%	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
20.383	53.055	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Claravis	ISOTRETINOIN	TABLET	30 MG	NOT COVERED	NON-FORMULARY	Prior auths restricted to Dermatology prescriber. Claravis prefererred
59.841	36.045	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Claravis	ISOTRETINOIN	TABLET	10 MG	NOT COVERED	NON-FORMULARY	Prior auths restricted to Dermatology prescriber. Claravis prefererred
59.842	36.046	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Claravis	ISOTRETINOIN	TABLET	20 MG	NOT COVERED	NON-FORMULARY	Prior auths restricted to Dermatology prescriber. Claravis prefererred
59.843	36.047	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Claravis	ISOTRETINOIN	TABLET	40 MG	NOT COVERED	NON-FORMULARY	Prior auths restricted to Dermatology prescriber. Claravis prefererred
24.043	58.576	861204-ANTIMUSCARINICS	Enablex	DARIFENACIN HYDROBROMIDE	TAB ER 24H	7.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Oxybutynin ER
24.044	58.577	861204-ANTIMUSCARINICS	Enablex	DARIFENACIN HYDROBROMIDE	TAB ER 24H	15 MG	NOT COVERED	NON-FORMULARY	Formulary: Oxybutynin ER
99.193	63.466	861204-ANTIMUSCARINICS	Sanctura XR	TROSPIUM CHLORIDE	CAP ER 24H	60 MG	NOT COVERED	NON-FORMULARY	Formulary: Oxybutynin ER
8.744	38.085	861204-ANTIMUSCARINICS	Sanctura	TROSPIUM CHLORIDE	TABLET	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Oxybutynin ER
18.428	51.246	920800-5-ALPHA-REDUCTASE INHIBITORS	Avodart	DUTASTERIDE	CAPSULE	0.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Finasteride
28.596	66.352	920800-5-ALPHA-REDUCTASE INHIBITORS	Jalyn	DUTASTERIDE/TAMSULOSIN HCL	CPMP 24HR	0.5-0.4 MG	NOT COVERED	NON-FORMULARY	Formulary: Finasteride
24.444	58.915	922400-BONE RESORPTION INHIBITORS	Boniva	IBANDRONATE SODIUM	TABLET	150 MG	NOT COVERED	NON-FORMULARY	Formulary: Alendronate
17.378	50.364	922400-BONE RESORPTION INHIBITORS	Actonel	RISEDRONATE SODIUM	TABLET	35 MG	NOT COVERED	NON-FORMULARY	Formulary: Alendronate
92.238	45.102	922400-BONE RESORPTION INHIBITORS	Actonel	RISEDRONATE SODIUM	TABLET	5 MG	NOT COVERED	NON-FORMULARY	Formulary: Alendronate
94.200	74.210	940000-DEVICES	Contour Next	BLOOD-GLUCOSE METER	EACH		NOT COVERED	NON-FORMULARY	Prior Auths restricted to insulin pumps
94.200	70.198	940000-DEVICES	TruePlus Lancet 26G	LANCETS	EACH	26 GAUGE	NOT COVERED	NON-FORMULARY
94.200	49.276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	NOT COVERED	NON-FORMULARY
94.200	49.276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	NOT COVERED	NON-FORMULARY
94.200	49.383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	NOT COVERED	NON-FORMULARY
94.200	49.395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	NOT COVERED	NON-FORMULARY
94.200	49.400	940000-DEVICES	Insulin Syringe 0.5mL 30GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30 G X 1/2"	NOT COVERED	NON-FORMULARY
94.200	49.404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	NOT COVERED	NON-FORMULARY
94.200	49.365	940000-DEVICES	Insulin Syringe 1mL 27GX5/8"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	27 G X 5/8"	NOT COVERED	NON-FORMULARY
94.200	49.275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	NOT COVERED	NON-FORMULARY
94.200	49.275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	NOT COVERED	NON-FORMULARY
94.200	49.275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	NOT COVERED	NON-FORMULARY
94.200	49.384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	NOT COVERED	NON-FORMULARY
94.200	49.384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	NOT COVERED	NON-FORMULARY
94.200	49.401	940000-DEVICES	Insulin Syringe 1mL 30GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 1/2"	NOT COVERED	NON-FORMULARY
94.200	49.405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	NOT COVERED	NON-FORMULARY
30.025	67.462	081202-AMINOGLYCOSIDES	Tobi Podhaler	TOBRAMYCIN	CAP W/DEV	28 MG	NOT COVERED	PAP
61.551	37.042	081202-AMINOGLYCOSIDES	Tobi	TOBRAMYCIN IN 0.225% NACL	AMPUL-NEB	300 MG/5ML	NOT COVERED	NON-FORMULARY
28.530	66.295	081228-ANTIBACTERIALS, MISCELLANEOUS	Xifaxan	RIFAXIMIN	TABLET	550 MG	NOT COVERED	PAP
93.749	41.880	081228-ANTIBACTERIALS, MISCELLANEOUS	Xifaxan	RIFAXIMIN	TABLET	200 MG	NOT COVERED	PAP
49.101	16.949	081408-AZOLES	Sporanox capsule	ITRACONAZOLE	CAPSULE	100 MG	NOT COVERED	NON-FORMULARY
49.100	27.465	081408-AZOLES	Sporanox solution	ITRACONAZOLE	SOLUTION	10 MG/ML	NOT COVERED	NON-FORMULARY
17.497	50.442	081408-AZOLES	Vfend	VORICONAZOLE	TABLET	50 MG	NOT COVERED	NON-FORMULARY
17.498	50.443	081408-AZOLES	Vfend	VORICONAZOLE	TABLET	200 MG	NOT COVERED	NON-FORMULARY
35.079	71.322	081808-ANTIRETROVIRALS	Tivicay	DOLUTEGRAVIR SODIUM	TABLET	50 MG	NOT COVERED	PAP	Contact manufacturer for PAP
41.564	76.226	081808-ANTIRETROVIRALS	Tivicay	DOLUTEGRAVIR SODIUM	TABLET	10 MG	NOT COVERED	PAP	Contact manufacturer for PAP
41.566	76.227	081808-ANTIRETROVIRALS	Tivicay	DOLUTEGRAVIR SODIUM	TABLET	25 MG	NOT COVERED	PAP	Contact manufacturer for PAP
41.369	76.097	081808-ANTIRETROVIRALS	Truvada	EMTRICITABINE/TENOFOVIR (TDF)	TABLET	100-150 MG	NOT COVERED	NON-FORMULARY
41.375	76.101	081808-ANTIRETROVIRALS	Truvada	EMTRICITABINE/TENOFOVIR (TDF)	TABLET	133-200 MG	NOT COVERED	NON-FORMULARY
41.376	76.102	081808-ANTIRETROVIRALS	Truvada	EMTRICITABINE/TENOFOVIR (TDF)	TABLET	167-250 MG	NOT COVERED	NON-FORMULARY
31.227	68.449	081808-ANTIRETROVIRALS	Viread	TENOFOVIR DISOPROXIL FUMARATE	POWDER	40 MG/SCOOP	NOT COVERED	NON-FORMULARY
14.822	48.843	081808-ANTIRETROVIRALS	Viread	TENOFOVIR DISOPROXIL FUMARATE	TABLET	300 MG	NOT COVERED	NON-FORMULARY
31.228	68.450	081808-ANTIRETROVIRALS	Viread	TENOFOVIR DISOPROXIL FUMARATE	TABLET	150 MG	NOT COVERED	NON-FORMULARY
31.229	68.451	081808-ANTIRETROVIRALS	Viread	TENOFOVIR DISOPROXIL FUMARATE	TABLET	200 MG	NOT COVERED	NON-FORMULARY
31.234	68.453	081808-ANTIRETROVIRALS	Viread	TENOFOVIR DISOPROXIL FUMARATE	TABLET	250 MG	NOT COVERED	NON-FORMULARY
24.465	58.933	081832-NUCLEOSIDES AND NUCLEOTIDES	Baraclude	ENTECAVIR	SOLUTION	0.05 MG/ML	NOT COVERED	NON-FORMULARY	Prior Auths's Restricted to Hep B diagnosis
24.466	58.934	081832-NUCLEOSIDES AND NUCLEOTIDES	Baraclude	ENTECAVIR	TABLET	0.5 MG	NOT COVERED	NON-FORMULARY	Prior Auths's Restricted to Hep B diagnosis
24.467	58.935	081832-NUCLEOSIDES AND NUCLEOTIDES	Baraclude	ENTECAVIR	TABLET	1 MG	NOT COVERED	NON-FORMULARY	Prior Auths's Restricted to Hep B diagnosis
28.648	66.391	083600-URINARY ANTI-INFECTIVES	Uribel	MTH/ME BLUE/SOD PHOS/PHEN/HYOS	CAPSULE	118-10-36 MG	NOT COVERED	PAP	Contact manufacturer for PAP
24.410	24.515	100000-ANTINEOPLASTIC AGENTS	Arimidex	ANASTROZOLE	TABLET	1 MG	NOT COVERED	NON-FORMULARY
33.084	69.855	120808-ANTIMUSCARINICS/ANTISPASMODICS	Tudorza Pressair DPI	ACLIDINIUM BROMIDE	AER POW BA	400 MCG	NOT COVERED	NON-FORMULARY	Formulary: Spiriva Handihaler
24.621	59.081	120808-ANTIMUSCARINICS/ANTISPASMODICS	Atrovent HFA	IPRATROPIUM BROMIDE	HFA AER AD	17 MCG	NOT COVERED	NON-FORMULARY	Formulary: Spiriva Handihaler
32.395	69.371	120808-ANTIMUSCARINICS/ANTISPASMODICS	Combivent MDI	IPRATROPIUM/ALBUTEROL SULFATE	MIST INHAL	20-100 MCG	NOT COVERED	NON-FORMULARY
98.921	63.164	120808-ANTIMUSCARINICS/ANTISPASMODICS	Spiriva Respimat	TIOTROPIUM BROMIDE	MIST INHAL	2.5 MCG	NOT COVERED	NON-FORMULARY	Formulary: Spiriva Handihaler
35.903	71.883	120808-ANTIMUSCARINICS/ANTISPASMODICS	Anoro Ellipta	UMECLIDINIUM BRM/VILANTEROL TR	BLST W/DEV	62.5-25 MCG	COVERED	FORMULARY	CUC/CH prescribers must send to in-house pharmacies only. Non-CUC/CH may fill at network pharmacies
36.574	72.375	120808-ANTIMUSCARINICS/ANTISPASMODICS	Incruse Ellipta	UMECLIDINIUM BROMIDE	BLST W/DEV	62.5 MCG	NOT COVERED	NON-FORMULARY	Formulary: Spiriva Handihaler
97.366	61.579	121208-BETA-ADRENERGIC AGONISTS	Brovana	ARFORMOTEROL TARTRATE	VIAL-NEB	15 MCG/2ML	NOT COVERED	NON-FORMULARY	Formulary: Albuterol nebulized solution is formulary.
92.024	45.052	121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)	Uroxatral	ALFUZOSIN HCL	TAB ER 24H	10 MG	NOT COVERED	NON-FORMULARY	Formulary: Tamsulosin, Terazosin, Prazosin.
33.935	70.414	201204-ANTICOAGULANTS	Eliquis	APIXABAN	TABLET	5 MG	NOT COVERED	PAP	Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
30.239	67.642	201204-ANTICOAGULANTS	Eliquis	APIXABAN	TABLET	2.5 MG	NOT COVERED	PAP	Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
29.166	66.781	201204-ANTICOAGULANTS	Pradaxa	DABIGATRAN ETEXILATE MESYLATE	CAPSULE	150 MG	NOT COVERED	NON-FORMULARY	Formulary: Enoxaparin, Warfarin.
99.708	63.997	201204-ANTICOAGULANTS	Pradaxa	DABIGATRAN ETEXILATE MESYLATE	CAPSULE	75 MG	NOT COVERED	NON-FORMULARY	Formulary: Enoxaparin, Warfarin.
37.675	73.293	201204-ANTICOAGULANTS	Savaysa	EDOXABAN	TABLET	15 MG	NOT COVERED	NON-FORMULARY	Formulary: Enoxaparin, Warfarin.
37.676	73.294	201204-ANTICOAGULANTS	Savaysa	EDOXABAN	TABLET	30 MG	NOT COVERED	NON-FORMULARY	Formulary: Enoxaparin, Warfarin.
37.677	73.295	201204-ANTICOAGULANTS	Savaysa	EDOXABAN	TABLET	60 MG	NOT COVERED	NON-FORMULARY	Formulary: Enoxaparin, Warfarin.
37.212	72.904	201204-ANTICOAGULANTS	Xarelto Starting Month Pack	RIVAROXABAN	TAB DS PK	15(42)-20(9) MG	NOT COVERED	PAP	Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
14.427	64.493	201204-ANTICOAGULANTS	Xarelto	RIVAROXABAN	TABLET	10 MG	NOT COVERED	PAP	Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
30.818	68.118	201204-ANTICOAGULANTS	Xarelto	RIVAROXABAN	TABLET	15 MG	NOT COVERED	PAP	Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
30.819	68.119	201204-ANTICOAGULANTS	Xarelto	RIVAROXABAN	TABLET	20 MG	NOT COVERED	PAP	Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
17.157	64.902	201218-PLATELET-AGGREGATION INHIBITORS	Effient	PRASUGREL HCL	TABLET	10 MG	Covered	FORMULARY
17.056	64.901	201218-PLATELET-AGGREGATION INHIBITORS	Effient	PRASUGREL HCL	TABLET	5 MG	Covered	FORMULARY
29.385	66.950	201218-PLATELET-AGGREGATION INHIBITORS	Brilinta	TICAGRELOR	TABLET	90 MG	NOT COVERED	PAP	Contact manufacturer for PAP
39.407	74.696	201218-PLATELET-AGGREGATION INHIBITORS	Brilinta	TICAGRELOR	TABLET	60 MG	NOT COVERED	PAP	Contact manufacturer for PAP
48.885	81.692	201600-HEMATOPOIETIC AGENTS	Retacrit	Epoetin alfa-epbx	VIAL	20,000/2ML	Covered	FORMULARY
44.764	78.432	201600-HEMATOPOIETIC AGENTS	Retacrit	Epoetin alfa-epbx	VIAL	2,000/ML	Covered	FORMULARY
44.766	78.434	201600-HEMATOPOIETIC AGENTS	Retacrit	Epoetin alfa-epbx	VIAL	4,000/ML	Covered	FORMULARY
44.767	78.435	201600-HEMATOPOIETIC AGENTS	Retacrit	Epoetin alfa-epbx	VIAL	10,000/ML	Covered	FORMULARY
44.765	78.433	201600-HEMATOPOIETIC AGENTS	Retacrit	Epoetin alfa-epbx	VIAL	3,000/ML	Covered	FORMULARY
48.911	81.714	201600-HEMATOPOIETIC AGENTS	Retacrit	Epoetin alfa-epbx	VIAL	20,000/ML	Covered	FORMULARY
44.768	78.436	201600-HEMATOPOIETIC AGENTS	Retacrit	Epoetin alfa-epbx	VIAL	40,000/ML	Covered	FORMULARY
26.586	65.367	240404-ANTIARRHYTHMIC AGENTS	Multaq	DRONEDARONE HCL	TABLET	400 MG	NOT COVERED	PAP	Formulary: Amiodarone. Contact manufacturer for PAP
95.347	40.303	241292-VASODILATING AGENTS, MISCELLANEOUS	Aggrenox	ASPIRIN/DIPYRIDAMOLE	CPMP 12HR	25-200 MG	NOT COVERED	NON-FORMULARY
97.962	62.180	242808-DIHYDROPYRIDINES	Exforge	AMLODIPINE/VALSARTAN	TABLET	5-160 MG	NOT COVERED	PAP	Prescribe amlodipine and valsartan or Lotrel
97.963	62.181	242808-DIHYDROPYRIDINES	Exforge	AMLODIPINE/VALSARTAN	TABLET	10-160 MG	NOT COVERED	PAP	Prescribe amlodipine and valsartan or Lotrel
98.579	62.808	242808-DIHYDROPYRIDINES	Exforge	AMLODIPINE/VALSARTAN	TABLET	5-320 MG	NOT COVERED	PAP	Prescribe amlodipine and valsartan or Lotrel
98.580	62.809	242808-DIHYDROPYRIDINES	Exforge	AMLODIPINE/VALSARTAN	TABLET	10-320 MG	NOT COVERED	PAP	Prescribe amlodipine and valsartan or Lotrel
39.046	74.408	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Entresto	SACUBITRIL/VALSARTAN	TABLET	24 MG-26MG	NOT COVERED	PAP	Formulary: Losartan, Irbesartan, Valsartan. Contact manufacturer for PAP
39.047	74.409	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Entresto	SACUBITRIL/VALSARTAN	TABLET	49 MG-51MG	NOT COVERED	PAP	Formulary: Losartan, Irbesartan, Valsartan. Contact manufacturer for PAP
39.048	74.410	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Entresto	SACUBITRIL/VALSARTAN	TABLET	97MG-103MG	NOT COVERED	PAP	Formulary: Losartan, Irbesartan, Valsartan. Contact manufacturer for PAP
17.285	50.289	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Benicar	OLMESARTAN MEDOXOMIL	TABLET	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan.
17.286	50.290	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Benicar	OLMESARTAN MEDOXOMIL	TABLET	40 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan.
17.284	50.288	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Benicar	OLMESARTAN MEDOXOMIL	TABLET	5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan.
28.837	66.538	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Tribenzor	OLMESARTAN/AMLODIPIN/HCTHIAZID	TABLET	20-5-12.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan.
28.838	66.539	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Tribenzor	OLMESARTAN/AMLODIPIN/HCTHIAZID	TABLET	40-5-12.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan.
28.839	66.540	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Tribenzor	OLMESARTAN/AMLODIPIN/HCTHIAZID	TABLET	40-5-25 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan.
28.854	66.541	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Tribenzor	OLMESARTAN/AMLODIPIN/HCTHIAZID	TABLET	40-10-12.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan.
28.855	66.542	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Tribenzor	OLMESARTAN/AMLODIPIN/HCTHIAZID	TABLET	40-10-25 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan.
20.074	52.833	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Benicar HCT	OLMESARTAN/HYDROCHLOROTHIAZIDE	TABLET	20-12.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan.
20.075	52.834	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Benicar HCT	OLMESARTAN/HYDROCHLOROTHIAZIDE	TABLET	40-12.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan.
20.076	52.835	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Benicar HCT	OLMESARTAN/HYDROCHLOROTHIAZIDE	TABLET	40-25 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan, Valsartan.
37.158	72.862	280808-OPIATE AGONISTS	Oxycodone ER	OXYCODONE HCL	TAB ER 12H	10 MG	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
37.159	72.863	280808-OPIATE AGONISTS	Oxycodone ER	OXYCODONE HCL	TAB ER 12H	15 MG	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
37.161	72.864	280808-OPIATE AGONISTS	Oxycodone ER	OXYCODONE HCL	TAB ER 12H	20 MG	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
37.162	72.865	280808-OPIATE AGONISTS	Oxycodone ER	OXYCODONE HCL	TAB ER 12H	30 MG	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
37.163	72.866	280808-OPIATE AGONISTS	Oxycodone ER	OXYCODONE HCL	TAB ER 12H	40 MG	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
37.164	72.867	280808-OPIATE AGONISTS	Oxycodone ER	OXYCODONE HCL	TAB ER 12H	60 MG	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
37.165	72.868	280808-OPIATE AGONISTS	Oxycodone ER	OXYCODONE HCL	TAB ER 12H	80 MG	COVERED - SEE COMMENTS	FORMULARY	For cancer-related pain only. Dx code G89.3 required on prescription
9.070	20.647	281208-BENZODIAZEPINES (ANTICONVULSANTS)	Onfi	CLOBAZAM	TABLET	20 MG	NOT COVERED	NON-FORMULARY
9.071	17.026	281208-BENZODIAZEPINES (ANTICONVULSANTS)	Onfi	CLOBAZAM	TABLET	10 MG	NOT COVERED	NON-FORMULARY
28.643	66.386	281292-ANTICONVULSANTS, MISCELLANEOUS	Vimpat	LACOSAMIDE	ORAL SOLUTION	10 MG/ML	COVERED	FORMULARY
14.338	64.432	281292-ANTICONVULSANTS, MISCELLANEOUS	Vimpat	LACOSAMIDE	TABLET	50 MG	COVERED	FORMULARY
14.339	64.433	281292-ANTICONVULSANTS, MISCELLANEOUS	Vimpat	LACOSAMIDE	TABLET	100 MG	COVERED	FORMULARY
14.341	64.434	281292-ANTICONVULSANTS, MISCELLANEOUS	Vimpat	LACOSAMIDE	TABLET	150 MG	COVERED	FORMULARY
14.342	64.435	281292-ANTICONVULSANTS, MISCELLANEOUS	Vimpat	LACOSAMIDE	TABLET	200 MG	COVERED	FORMULARY
24.693	65.250	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal XR	LAMOTRIGINE	TAB ER 24	25 MG	NOT COVERED	PAP	Formulary: Lamotrigine IR. Contact manufacturer for PAP
24.739	65.253	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal XR	LAMOTRIGINE	TAB ER 24	200 MG	NOT COVERED	PAP	Formulary: Lamotrigine IR. Contact manufacturer for PAP
24.697	65.251	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal XR	LAMOTRIGINE	TAB ER 24	50 MG	NOT COVERED	PAP	Formulary: Lamotrigine IR. Contact manufacturer for PAP
24.703	65.252	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal XR	LAMOTRIGINE	TAB ER 24	100 MG	NOT COVERED	PAP	Formulary: Lamotrigine IR. Contact manufacturer for PAP
29.725	67.221	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal XR	LAMOTRIGINE	TAB ER 24	300 MG	NOT COVERED	PAP	Formulary: Lamotrigine IR. Contact manufacturer for PAP
30.787	68.093	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal XR	LAMOTRIGINE	TAB ER 24	250 MG	NOT COVERED	PAP	Formulary: Lamotrigine IR. Contact manufacturer for PAP
14.305	64.416	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra XR	LEVETIRACETAM	TAB ER 24H	500 MG	NOT COVERED	NON-FORMULARY	Formulary: Levetiracetam IR.
20.765	64.990	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra XR	LEVETIRACETAM	TAB ER 24H	750 MG	NOT COVERED	NON-FORMULARY	Formulary: Levetiracetam IR.
36.556	40.901	281292-ANTICONVULSANTS, MISCELLANEOUS	Topamax Sprinkle Cap	TOPIRAMATE	CAP SPRINK	15 MG	NOT COVERED	NON-FORMULARY
36.557	40.902	281292-ANTICONVULSANTS, MISCELLANEOUS	Topamax Sprinkle Cap	TOPIRAMATE	CAP SPRINK	25 MG	NOT COVERED	NON-FORMULARY
35.328	71.496	281604-ANTIDEPRESSANTS	Fetzima	LEVOMILNACIPRAN HYDROCHLORIDE	CAP SA 24H	40 MG	NOT COVERED	NON-FORMULARY	Formulary: Venlafaxine ER capsules, Duloxetine DR.
35.327	71.495	281604-ANTIDEPRESSANTS	Fetzima	LEVOMILNACIPRAN HYDROCHLORIDE	CAP SA 24H	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Venlafaxine ER capsules, Duloxetine DR.
35.329	71.497	281604-ANTIDEPRESSANTS	Fetzima	LEVOMILNACIPRAN HYDROCHLORIDE	CAP SA 24H	80 MG	NOT COVERED	NON-FORMULARY	Formulary: Venlafaxine ER capsules, Duloxetine DR.
35.334	71.498	281604-ANTIDEPRESSANTS	Fetzima	LEVOMILNACIPRAN HYDROCHLORIDE	CAP SA 24H	120 MG	NOT COVERED	NON-FORMULARY	Formulary: Venlafaxine ER capsules, Duloxetine DR.
35.335	71.499	281604-ANTIDEPRESSANTS	Fetzima	LEVOMILNACIPRAN HYDROCHLORIDE	CAP24HDSPK	20-40 MG	NOT COVERED	NON-FORMULARY	Formulary: Venlafaxine ER capsules, Duloxetine DR.
38.253	73.810	281604-ANTIDEPRESSANTS	Viibryd Titration Pack	VILAZODONE HYDROCHLORIDE	TAB DS PK	10 MG-20 MG	NOT COVERED	PAP	Contact manufacturer for PAP
29.918	67.378	281604-ANTIDEPRESSANTS	Viibryd	VILAZODONE HYDROCHLORIDE	TABLET	40 MG	NOT COVERED	PAP	Contact manufacturer for PAP
29.916	67.376	281604-ANTIDEPRESSANTS	Viibryd	VILAZODONE HYDROCHLORIDE	TABLET	10 MG	NOT COVERED	PAP	Contact manufacturer for PAP
29.917	67.377	281604-ANTIDEPRESSANTS	Viibryd	VILAZODONE HYDROCHLORIDE	TABLET	20 MG	NOT COVERED	PAP	Contact manufacturer for PAP
28.034	65.908	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TAB DS PK	1-2-4-6 MG	NOT COVERED	NON-FORMULARY
28.025	65.901	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TABLET	1 MG	NOT COVERED	NON-FORMULARY
28.026	65.902	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TABLET	2 MG	NOT COVERED	NON-FORMULARY
28.027	65.903	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TABLET	4 MG	NOT COVERED	NON-FORMULARY
28.028	65.904	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TABLET	6 MG	NOT COVERED	NON-FORMULARY
28.029	65.905	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TABLET	8 MG	NOT COVERED	NON-FORMULARY
28.030	65.906	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TABLET	10 MG	NOT COVERED	NON-FORMULARY
28.033	65.907	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TABLET	12 MG	NOT COVERED	NON-FORMULARY
29.366	66.932	281608-ANTIPSYCHOTIC AGENTS	Latuda	LURASIDONE HCL	TABLET	40 MG	COVERED	FORMULARY
29.367	66.933	281608-ANTIPSYCHOTIC AGENTS	Latuda	LURASIDONE HCL	TABLET	80 MG	COVERED	FORMULARY
31.226	68.448	281608-ANTIPSYCHOTIC AGENTS	Latuda	LURASIDONE HCL	TABLET	20 MG	COVERED	FORMULARY
33.147	69.894	281608-ANTIPSYCHOTIC AGENTS	Latuda	LURASIDONE HCL	TABLET	120 MG	COVERED	FORMULARY
35.192	71.415	281608-ANTIPSYCHOTIC AGENTS	Latuda	LURASIDONE HCL	TABLET	60 MG	COVERED	FORMULARY
34.022	47.285	281608-ANTIPSYCHOTIC AGENTS	Zyprexa Zydis	OLANZAPINE	TAB RAPDIS	15 MG	NOT COVERED	NON-FORMULARY
34.023	47.286	281608-ANTIPSYCHOTIC AGENTS	Zyprexa Zydis	OLANZAPINE	TAB RAPDIS	20 MG	NOT COVERED	NON-FORMULARY
92.007	45.190	281608-ANTIPSYCHOTIC AGENTS	Zyprexa Zydis	OLANZAPINE	TAB RAPDIS	5 MG	NOT COVERED	NON-FORMULARY
92.008	45.191	281608-ANTIPSYCHOTIC AGENTS	Zyprexa Zydis	OLANZAPINE	TAB RAPDIS	10 MG	NOT COVERED	NON-FORMULARY
97.769	61.985	281608-ANTIPSYCHOTIC AGENTS	Invega	PALIPERIDONE	TAB ER 24	3 MG	NOT COVERED	NON-FORMULARY
97.770	61.986	281608-ANTIPSYCHOTIC AGENTS	Invega	PALIPERIDONE	TAB ER 24	6 MG	NOT COVERED	NON-FORMULARY
97.771	61.987	281608-ANTIPSYCHOTIC AGENTS	Invega	PALIPERIDONE	TAB ER 24	9 MG	NOT COVERED	NON-FORMULARY
27.685	65.667	281608-ANTIPSYCHOTIC AGENTS	Invega	PALIPERIDONE	TAB ER 24	1.5 MG	NOT COVERED	NON-FORMULARY
98.994	63.240	281608-ANTIPSYCHOTIC AGENTS	Seroquel XR	QUETIAPINE FUMARATE	TAB ER 24H	50 MG	Covered	CommUnityCare Pharmacy	Restricted to CUC/CH Prescribers. Send to a CUC in-house pharmacy
16.193	64.725	281608-ANTIPSYCHOTIC AGENTS	Seroquel XR	QUETIAPINE FUMARATE	TAB ER 24H	150 MG	Covered	CommUnityCare Pharmacy	Restricted to CUC/CH Prescribers. Send to a CUC in-house pharmacy
98.522	62.748	281608-ANTIPSYCHOTIC AGENTS	Seroquel XR	QUETIAPINE FUMARATE	TAB ER 24H	200 MG	Covered	CommUnityCare Pharmacy	Restricted to CUC/CH Prescribers. Send to a CUC in-house pharmacy
98.523	62.749	281608-ANTIPSYCHOTIC AGENTS	Seroquel XR	QUETIAPINE FUMARATE	TAB ER 24H	300 MG	Covered	CommUnityCare Pharmacy	Restricted to CUC/CH Prescribers. Send to a CUC in-house pharmacy
98.524	62.750	281608-ANTIPSYCHOTIC AGENTS	Seroquel XR	QUETIAPINE FUMARATE	TAB ER 24H	400 MG	Covered	CommUnityCare Pharmacy	Restricted to CUC/CH Prescribers. Send to a CUC in-house pharmacy
12.248	47.318	282032-RESPIRATORY AND CNS STIMULANTS	Concerta	METHYLPHENIDATE HCL	TAB ER 24	54 MG	NOT COVERED	NON-FORMULARY	Formulary: Ritalin LA, Metadate CD.
12.568	45.982	282032-RESPIRATORY AND CNS STIMULANTS	Concerta	METHYLPHENIDATE HCL	TAB ER 24	36 MG	NOT COVERED	NON-FORMULARY	Formulary: Ritalin LA, Metadate CD.
17.123	50.172	282032-RESPIRATORY AND CNS STIMULANTS	Concerta	METHYLPHENIDATE HCL	TAB ER 24	27 MG	NOT COVERED	NON-FORMULARY	Formulary: Ritalin LA, Metadate CD.
12.567	45.981	282032-RESPIRATORY AND CNS STIMULANTS	Concerta	METHYLPHENIDATE HCL	TAB ER 24	18 MG	NOT COVERED	NON-FORMULARY	Formulary: Ritalin LA, Metadate CD.
26.515	65.356	283620-DOPAMINE RECEPTOR AGONISTS	Neupro	ROTIGOTINE	PATCH TD24	1 MG/24 HR	NOT COVERED	PAP	Formulary: Ropinirole. Contact manufacturer for PAP
26.516	65.357	283620-DOPAMINE RECEPTOR AGONISTS	Neupro	ROTIGOTINE	PATCH TD24	3 MG/24 HR	NOT COVERED	PAP	Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP
26.648	60.486	283620-DOPAMINE RECEPTOR AGONISTS	Neupro	ROTIGOTINE	PATCH TD24	2 MG/24 HR	NOT COVERED	PAP	Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP
26.649	60.487	283620-DOPAMINE RECEPTOR AGONISTS	Neupro	ROTIGOTINE	PATCH TD24	4 MG/24 HR	NOT COVERED	PAP	Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP
26.654	60.488	283620-DOPAMINE RECEPTOR AGONISTS	Neupro	ROTIGOTINE	PATCH TD24	6 MG/24 HR	NOT COVERED	PAP	Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP
26.655	60.489	283620-DOPAMINE RECEPTOR AGONISTS	Neupro	ROTIGOTINE	PATCH TD24	8 MG/24 HR	NOT COVERED	PAP	Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP
27.576	65.570	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Intuniv	GUANFACINE HCL	TAB ER 24H	1 MG	NOT COVERED	PAP	Formulary: Guanfacine IR. Contact manufacturer for PAP
27.578	65.572	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Intuniv	GUANFACINE HCL	TAB ER 24H	2 MG	NOT COVERED	PAP	Formulary: Guanfacine IR. Contact manufacturer for PAP
27.579	65.573	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Intuniv	GUANFACINE HCL	TAB ER 24H	3 MG	NOT COVERED	PAP	Formulary: Guanfacine IR. Contact manufacturer for PAP
27.582	65.574	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Intuniv	GUANFACINE HCL	TAB ER 24H	4 MG	NOT COVERED	PAP	Formulary: Guanfacine IR. Contact manufacturer for PAP
18.776	51.489	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Strattera	ATOMOXETINE HCL	CAPSULE	10 MG	COVERED	FORMULARY
18.777	51.490	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Strattera	ATOMOXETINE HCL	CAPSULE	18 MG	COVERED	FORMULARY
18.778	51.491	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Strattera	ATOMOXETINE HCL	CAPSULE	25 MG	COVERED	FORMULARY
18.779	51.492	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Strattera	ATOMOXETINE HCL	CAPSULE	40 MG	COVERED	FORMULARY
18.781	51.493	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Strattera	ATOMOXETINE HCL	CAPSULE	60 MG	COVERED	FORMULARY
26.538	60.390	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Strattera	ATOMOXETINE HCL	CAPSULE	80 MG	COVERED	FORMULARY
26.539	60.391	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Strattera	ATOMOXETINE HCL	CAPSULE	100 MG	COVERED	FORMULARY
95.200	40.962	366000-THYROID FUNCTION	Thyrogen	THYROTROPIN ALFA	VIAL	1.1 MG	NOT COVERED	PAP
34.647	70.972	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Breo Ellipta	FLUTICASONE/VILANTEROL	BLST W/DEV	100-25 MCG	NOT COVERED	PAP	Formulary: Flovent HFA, Dulera Contact manufacturer for PAP
35.808	71.815	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Breo Ellipta	FLUTICASONE/VILANTEROL	BLST W/DEV	200-25 MCG	NOT COVERED	PAP	Formulary: Flovent HFA, Dulera Contact manufacturer for PAP
40.321	29.803	481024-LEUKOTRIENE MODIFIERS	Zyflo Filmtab	ZILEUTON	TABLET	600 MG	NOT COVERED	NON-FORMULARY	Formulary: Montelukast.
98.822	63.062	481024-LEUKOTRIENE MODIFIERS	Zyflo Filmtab	ZILEUTON	TBMP 12HR	600 MG	NOT COVERED	NON-FORMULARY	Formulary: Montelukast.
44.498	78.213	483200-PHOSPHODIESTERASE TYPE 4 INHIBITORS	Daliresp	ROFLUMILAST	TABLET	250 MCG	NOT COVERED	NON-FORMULARY
28.934	66.612	483200-PHOSPHODIESTERASE TYPE 4 INHIBITORS	Daliresp	ROFLUMILAST	TABLET	500 MCG	NOT COVERED	NON-FORMULARY
19.216	51.820	520892-EENT ANTI-INFLAMMATORY AGENTS, MISC.	Restasis	CYCLOSPORINE	DROPS	0.05 %	NOT COVERED	PAP	Contact manufacturer for PAP
27.131	65.392	524028-PROSTAGLANDIN ANALOGS	Lumigan	BIMATOPROST	DROPS	0.01 %	NOT COVERED	PAP	Formulary: Latanoprost. Contact manufacturer for PAP
13.017	47.624	524028-PROSTAGLANDIN ANALOGS	Bimatoprost	BIMATOPROST	Drops	0.03%	NOT COVERED	NON-FORMULARY	Formulary: Latanoprost.
27.594	65.587	524028-PROSTAGLANDIN ANALOGS	Zioptan	TAFLUPROST/PF	DROPS	0.0015%	NOT COVERED	NON-FORMULARY	Formulary: Latanoprost.
13.002	47.612	524028-PROSTAGLANDIN ANALOGS	Travatan Z	TRAVOPROST	DROPS	0.004%	NOT COVERED	NON-FORMULARY	Formulary: Latanoprost.
26.473	60.341	561200-CATHARTICS AND LAXATIVES	Amitiza	LUBIPROSTONE	CAPSULE	24 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
99.658	63.946	561200-CATHARTICS AND LAXATIVES	Amitiza	LUBIPROSTONE	CAPSULE	8 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
16.305	64.793	562836-PROTON-PUMP INHIBITORS	Dexilant	DEXLANSOPRAZOLE	CAP DR BP	30 MG	NOT COVERED	PAP	Formulary: Pantoprazole. Contact manufacturer for PAP
16.306	64.794	562836-PROTON-PUMP INHIBITORS	Dexilant	DEXLANSOPRAZOLE	CAP DR BP	60 MG	NOT COVERED	PAP	Formulary: Pantoprazole. Contact manufacturer for PAP
16.305	64.793	562836-PROTON-PUMP INHIBITORS	Dexilant	DEXLANSOPRAZOLE	CAP DR BP	30 MG	NOT COVERED	PAP	Formulary: Pantoprazole. Contact manufacturer for PAP
16.306	64.794	562836-PROTON-PUMP INHIBITORS	Dexilant	DEXLANSOPRAZOLE	CAP DR BP	60 MG	NOT COVERED	PAP	Formulary: Pantoprazole. Contact manufacturer for PAP
95.348	40.304	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Colazal	BALSALAZIDE DISODIUM	CAPSULE	750 MG	NOT COVERED	NON-FORMULARY	Formulary: sulfasalazine.
99.847	64.139	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Rowasa	MESALAMINE W/CLEANSING WIPES	ENEMA KIT	4 G/60 ML	NOT COVERED	NON-FORMULARY
16.159	64.701	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Apriso ER	MESALAMINE	CAP ER 24H	0.375 G	NOT COVERED	PAP	Formulary: Sulfasalazine. Contact manufacturer for PAP
34.113	70.543	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Delzicol DR	MESALAMINE	CAPSULE DR	400 MG	NOT COVERED	PAP	Formulary: Sulfasalazine. Contact manufacturer for PAP
23.422	58.091	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Pentasa	MESALAMINE	CAPSULE ER	500 MG	NOT COVERED	PAP	Formulary: Sulfasalazine. Contact manufacturer for PAP
97.842	62.058	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Lialda	MESALAMINE	TABLET DR	1.2 G	NOT COVERED	PAP	Formulary: Sulfasalazine. Contact manufacturer for PAP
39.354	74.654	569200-GI DRUGS, MISCELLANEOUS	Viberzi	ELUXADOLINE	TABLET	75 MG	NOT COVERED	PAP	Contact manufacturer for PAP
39.355	74.655	569200-GI DRUGS, MISCELLANEOUS	Viberzi	ELUXADOLINE	TABLET	100 MG	NOT COVERED	PAP	Contact manufacturer for PAP
33.187	69.922	569200-GI DRUGS, MISCELLANEOUS	Linzess	LINACLOTIDE	CAPSULE	145 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
33.188	69.923	569200-GI DRUGS, MISCELLANEOUS	Linzess	LINACLOTIDE	CAPSULE	290 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
99.450	63.735	682003-AMYLINOMIMETICS	Symlin	PRAMLINTIDE ACETATE	PEN INJCTR	2700 MCG/2.7ML	NOT COVERED	NON-FORMULARY
99.514	63.804	682003-AMYLINOMIMETICS	Symlin	PRAMLINTIDE ACETATE	PEN INJCTR	1500 MCG/1.5ML	NOT COVERED	NON-FORMULARY
34.086	70.525	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Nesina	ALOGLIPTIN	TABLET	6.25 MG	NOT COVERED	PAP
34.085	70.524	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Nesina	ALOGLIPTIN	TABLET	12.5 GM	NOT COVERED	PAP
34.076	70.517	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Nesina	ALOGLIPTIN	TABLET	25 MG	NOT COVERED	PAP
26.189	65.344	682006-INCRETIN MIMETICS GLP-1	Victoza	LIRAGLUTIDE	PEN INJCTR	0.6 MG/0.1ML	Covered	FORMULARY
98.637	62.867	682008-INSULINS	Lantus Solostar	INSULIN GLARGINE HUM.REC.ANLOG	INSULN PEN	100 UNIT/ML	NOT COVERED	NON-FORMULARY	Formulary: insulin glargine-yfgn.
37.988	73.567	682008-INSULINS	Toujeo Solostar	INSULIN GLARGINE HUM.REC.ANLOG	INSULN PEN	300 UNIT/ML	NOT COVERED	NON-FORMULARY	Formulary: insulin glargine-yfgn.
13.072	47.780	682008-INSULINS	Lantus	INSULIN GLARGINE HUM.REC.ANLOG	VIAL	100 UNIT/ML	NOT COVERED	NON-FORMULARY	Formulary: insulin glargine-yfgn.
26.508	60.371	682008-INSULINS	Apidra Solostar	INSULIN GLULISINE	INSULN PEN	100 UNIT/ML	NOT COVERED	NON-FORMULARY	Formulary: Novolog
25.936	59.985	682008-INSULINS	Apidra	INSULIN GLULISINE	VIAL	100 UNIT/ML	NOT COVERED	NON-FORMULARY	Formulary: Novolog
9.633	29.916	682008-INSULINS	Humulin R U500	INSULIN REGULAR HUMAN	VIAL	500 UNIT/ML	NOT COVERED	PAP	Prescribe U500 Syringes, Contact manufacturer for PAP
34.439	70.791	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokana	CANAGLIFLOZIN	TABLET	100 MG	NOT COVERED	PAP	Contact manufacturer for PAP
34.441	70.792	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokana	CANAGLIFLOZIN	TABLET	300 MG	NOT COVERED	PAP	Contact manufacturer for PAP
42.315	76.623	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Inokamet XR	CANAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	150-1000MG	NOT COVERED	PAP	Contact manufacturer for PAP
42.312	76.620	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokamet XR	CANAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	50MG-500MG	NOT COVERED	PAP	Contact manufacturer for PAP
42.313	76.621	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokamet XR	CANAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	50-1000 MG	NOT COVERED	PAP	Contact manufacturer for PAP
42.314	76.622	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokamet XR	CANAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	150-500 MG	NOT COVERED	PAP	Contact manufacturer for PAP
36.857	72.587	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokamet	CANAGLIFLOZIN/METFORMIN HCL	TABLET	50-1000 MG	NOT COVERED	PAP	Contact manufacturer for PAP
36.859	72.589	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokamet	CANAGLIFLOZIN/METFORMIN HCL	TABLET	150-1000MG	NOT COVERED	PAP	Contact manufacturer for PAP
36.953	72.677	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokamet	CANAGLIFLOZIN/METFORMIN HCL	TABLET	150-500 MG	NOT COVERED	PAP	Contact manufacturer for PAP
36.954	72.678	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokamet	CANAGLIFLOZIN/METFORMIN HCL	TABLET	50MG-500MG	NOT COVERED	PAP	Contact manufacturer for PAP
34.394	70.755	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Farxiga	DAPAGLIFLOZIN PROPANEDIOL	TABLET	10 MG	NOT COVERED	PAP	Contact manufacturer for PAP
35.698	71.740	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Farxiga	DAPAGLIFLOZIN PROPANEDIOL	TABLET	5 MG	NOT COVERED	PAP	Contact manufacturer for PAP
37.343	73.031	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Xigduo XR	DAPAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	5-1000 MG	NOT COVERED	PAP	Contact manufacturer for PAP
37.339	73.029	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Xigduo XR	DAPAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	5-500 MG	NOT COVERED	PAP	Contact manufacturer for PAP
37.342	73.030	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Xigduo XR	DAPAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	10-500 MG	NOT COVERED	PAP	Contact manufacturer for PAP
37.344	73.032	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Xigduo XR	DAPAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	10-1000 MG	NOT COVERED	PAP	Contact manufacturer for PAP
36.716	72.488	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Jardiance	EMPAGLIFLOZIN	TABLET	10 MG	NOT COVERED	PAP	Contact manufacturer for PAP
36.723	72.489	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Jardiance	EMPAGLIFLOZIN	TABLET	25 MG	NOT COVERED	PAP	Contact manufacturer for PAP
37.832	73.432	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Glyxambi	EMPAGLIFLOZIN/LINAGLIPTIN	TABLET	10 MG-5 MG	NOT COVERED	PAP	Contact manufacturer for PAP
37.833	73.433	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Glyxambi	EMPAGLIFLOZIN/LINAGLIPTIN	TABLET	25 MG-5 MG	NOT COVERED	PAP	Contact manufacturer for PAP
38.929	74.316	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Synjardy	EMPAGLIFLOZIN/METFORMIN HCL	TABLET	5MG-1000MG	NOT COVERED	PAP	Contact manufacturer for PAP
38.932	74.318	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Synjardy	EMPAGLIFLOZIN/METFORMIN HCL	TABLET	12.5-1000	NOT COVERED	PAP	Contact manufacturer for PAP
39.377	74.675	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Synjardy	EMPAGLIFLOZIN/METFORMIN HCL	TABLET	5 MG-500MG	NOT COVERED	PAP	Contact manufacturer for PAP
39.378	74.676	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Synjardy	EMPAGLIFLOZIN/METFORMIN HCL	TABLET	12.5-500MG	NOT COVERED	PAP	Contact manufacturer for PAP
14.404	64.481	682400-PARATHYROID	Forteo	TERIPARATIDE	PEN INJCTR	20 MCG/DOSE	NOT COVERED	PAP	Contact manufacturer for PAP
13.480	19.141	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Soriatane	ACITRETIN	CAPSULE	10 MG	NOT COVERED	NON-FORMULARY
13.481	19.142	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Soriatane	ACITRETIN	CAPSULE	25 MG	NOT COVERED	NON-FORMULARY
18.782	51.494	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Avage	TAZAROTENE	CREAM (G)	0.1 %	NOT COVERED	NON-FORMULARY
85.362	46.983	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Tazorac Cream	TAZAROTENE	CREAM (G)	0.05 %	NOT COVERED	NON-FORMULARY
85.363	46.984	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Tazorac Cream	TAZAROTENE	CREAM (G)	0.1 %	NOT COVERED	NON-FORMULARY
32.178	69.204	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Fabior Foam	TAZAROTENE	FOAM	0.1 %	NOT COVERED	NON-FORMULARY
29.222	31.601	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Tazorac Cream	TAZAROTENE	GEL (GRAM)	0.1 %	NOT COVERED	NON-FORMULARY
29.221	31.600	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Tazorac Cream	TAZAROTENE	GEL (GRAM)	0.05 %	NOT COVERED	NON-FORMULARY
23.276	57.982	861204-ANTIMUSCARINICS	Vesicare	SOLIFENACIN SUCCINATE	TABLET	5 MG	NOT COVERED	NON-FORMULARY
23.277	57.983	861204-ANTIMUSCARINICS	Vesicare	SOLIFENACIN SUCCINATE	TABLET	10 MG	NOT COVERED	NON-FORMULARY
32.766	69.630	861208-BETA-3-ADRENERGIC AGONISTS	Myrbetriq ER	MIRABEGRON	TAB ER 24H	25 MG	NOT COVERED	NON-FORMULARY
32.767	69.631	861208-BETA-3-ADRENERGIC AGONISTS	Myrbetriq ER	MIRABEGRON	TAB ER 24H	50 MG	NOT COVERED	NON-FORMULARY
16.808	64.829	921600-ANTIGOUT AGENTS	Uloric	FEBUXOSTAT	TABLET	40 MG	NOT COVERED	NON-FORMULARY	Allopurinol is formulary,
16.809	64.830	921600-ANTIGOUT AGENTS	Uloric	FEBUXOSTAT	TABLET	80 MG	NOT COVERED	NON-FORMULARY	Allopurinol is formulary,
29.073	66.709	922000-IMMUNOMODULATORY AGENTS	Gilenya	FINGOLIMOD HCL	CAPSULE	0.5 MG	NOT COVERED	PAP	Contact manufacturer for PAP
28.656	66.396	922400-BONE RESORPTION INHIBITORS	Prolia	DENOSUMAB	SYRINGE	60 MG/ML	NOT COVERED	PAP	Contact manufacturer for PAP
97.005	61.205	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Humira	ADALIMUMAB	PEN IJ KIT	40 MG/0.8ML	NOT COVERED	PAP	Contact manufacturer for PAP
18.924	51.599	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Humira	ADALIMUMAB	SYRINGEKIT	40 MG/0.8ML	NOT COVERED	PAP	Contact manufacturer for PAP
37.262	72.952	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Humira	ADALIMUMAB	SYRINGEKIT	10 MG/0.2ML	NOT COVERED	PAP	Contact manufacturer for PAP
99.439	63.724	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Humira	ADALIMUMAB	SYRINGEKIT	20 MG/0.4ML	NOT COVERED	PAP	Contact manufacturer for PAP
97.724	61.938	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Enbrel	ETANERCEPT	PEN INJCTR	50 MG/ML	NOT COVERED	PAP	Contact manufacturer for PAP
98.398	62.624	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Enbrel	ETANERCEPT	SYRINGE	25 MG/0.5ML	NOT COVERED	PAP	Contact manufacturer for PAP
23.574	58.214	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Enbrel	ETANERCEPT	SYRINGE	50 MG/ML	NOT COVERED	PAP	Contact manufacturer for PAP
52.651	40.869	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Enbrel	ETANERCEPT	VIAL	25 MG	NOT COVERED	PAP	Contact manufacturer for PAP
47.560	23.724	924400-IMMUNOSUPPRESSIVE AGENTS	Cellcept	MYCOPHENOLATE MOFETIL	CAPSULE	250 MG	Covered	FORMULARY
47.561	32.599	924400-IMMUNOSUPPRESSIVE AGENTS	Cellcept	MYCOPHENOLATE MOFETIL	CAPSULE	500 MG	Covered	FORMULARY
19.646	52.119	902808 IMMUNOSUPRESIVE THERAPY	Myfortic	MYCOPHENOLIC ACID	TABLET DR	180 MG	Covered	FORMULARY
19.647	52.120	902808 IMMUNOSUPRESIVE THERAPY	Myfortic	MYCOPHENOLIC ACID	TABLET DR	360 MG	Covered	FORMULARY
41.229	21.175	925600-PROTECTIVE AGENTS	Elmiron	PENTOSAN POLYSULFATE SODIUM	CAPSULE	100 MG	NOT COVERED	PAP	Contact manufacturer for PAP
45.026	78.657	681804-ANTIGONADOTROPINS	Orilissa	ELAGOLIX	TABLET	150 MG	NOT COVERED	PAP	Contact manufacturer for PAP
45.026	78.657	681804-ANTIGONADOTROPINS	Orilissa	ELAGOLIX	TABLET	200 MG	NOT COVERED	PAP	Contact manufacturer for PAP
42.676	76.864	682008-INSULINS	Soliqua	INSULIN GLARGINE/LIXISENATIDE	INSULN PEN	100 UNIT-33 MCG/ML	NOT COVERED	PAP	Contact manufacturer for PAP
29.890	67.353	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Tradjenta	LINAGLIPTIN	TABLET	5 MG	COVERED	FORMULARY	CUC/CH prescribers must send to in-house pharmacies only. Non-CUC/CH may fill at network pharmacies
31.315	68.516	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Jentadueto	LINAGLIPTIN/METFORMIN	TABLET	2.5-500 MG	COVERED	FORMULARY	CUC/CH prescribers must send to in-house pharmacies only. Non-CUC/CH may fill at network pharmacies
31.316	68.517	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Jentadueto	LINAGLIPTIN/METFORMIN	TABLET	2.5-850 MG	COVERED	FORMULARY	CUC/CH prescribers must send to in-house pharmacies only. Non-CUC/CH may fill at network pharmacies
31.317	68.518	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Jentadueto	LINAGLIPTIN/METFORMIN	TABLET	2.5-1000 MG	COVERED	FORMULARY	CUC/CH prescribers must send to in-house pharmacies only. Non-CUC/CH may fill at network pharmacies
41.637	76.256	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Jentadueto XR	LINAGLIPTIN/METFORMIN ER	TABLET	2.5-1000 MG	COVERED	FORMULARY	CUC/CH prescribers must send to in-house pharmacies only. Non-CUC/CH may fill at network pharmacies
41.639	76.257	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Jentadueto XR	LINAGLIPTIN/METFORMIN ER	TABLET	5-1000 MG	COVERED	FORMULARY	CUC/CH prescribers must send to in-house pharmacies only. Non-CUC/CH may fill at network pharmacies
34.525	70.868	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Namenda XR	MEMANTINE ER	TABLET	14 mg	NOT COVERED	NON-FORMULARY	Formulary: Memantine IR, Donepezil, Rivastigmine.
34.527	70.870	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Namenda XR	MEMANTINE ER	TABLET	28 mg	NOT COVERED	NON-FORMULARY	Formulary: Memantine IR, Donepezil, Rivastigmine.
41.370	9.326	081228-ANTIBACTERIALS, MISCELLANEOUS	Vancocin	VANCOMYCIN	CAPSULE	125 MG	Covered	FORMULARY
41.371	9.327	081228-ANTIBACTERIALS, MISCELLANEOUS	Vancocin	VANCOMYCIN	CAPSULE	250 MG	Covered	FORMULARY
46.908	80.199	68221200-GLYCOGENOLYTIC AGENTS, 92120000-ANTIDOTES	Gvoke	GLUCAGON	2 PACK AUTOINJECTOR	1 MG/0.2 ML	Covered	FORMULARY
46.907	80.198	68221200-GLYCOGENOLYTIC AGENTS, 92120000-ANTIDOTES	Gvoke	GLUCAGON	2 PACK AUTOINJECTOR	0.5 MG/0.1 ML	Covered	FORMULARY
14.781	11.876	281608-ANTIPSYCHOTIC AGENTS	Haldol Decanoate	Haloperidol Decanoate	Vial	100 mg/ml	Covered	FORMULARY
31.612	39.781	100000-ANTINEOPLASTIC AGENTS	Xeloda	Capecitabine	Tablet	500 mg	Covered	FORMULARY	Restricted to Oncology & Hematology prescribers only
23.549	58.193	681200-CONTRACEPTIVES	PLAN B ONE-STEP, ECONTRA ONE-STEP, NEW DAY, My Choice	Levonorgestrel	Tablet	1.5 mg	Covered	FORMULARY
27.585	65.578	681200-CONTRACEPTIVES	Ella	Ulipristal	Tablet	30 mg	Covered	FORMULARY
18.092	50.805	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan	Valsartan	Tablet	40 mg	Covered	FORMULARY
13.846	48.401	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan	Valsartan	Tablet	80 mg	Covered	FORMULARY
13.844	48.400	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan	Valsartan	Tablet	160 mg	Covered	FORMULARY
13.838	48.399	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan	Valsartan	Tablet	320 mg	Covered	FORMULARY
7.833	37.354	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan-HCT	Valsartan-Hydrochlorothiazide	Tablet	80 - 12.5 mg	Covered	FORMULARY
9.760	38.925	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan-HCT	Valsartan-Hydrochlorothiazide	Tablet	160 - 12.5 mg	Covered	FORMULARY
17.245	50.256	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan-HCT	Valsartan-Hydrochlorothiazide	Tablet	160 - 25 mg	Covered	FORMULARY
27.015	60.781	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan-HCT	Valsartan-Hydrochlorothiazide	Tablet	320 - 12.5 mg	Covered	FORMULARY
27.014	60.780	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan-HCT	Valsartan-Hydrochlorothiazide	Tablet	320 - 25 mg	Covered	FORMULARY
161	16.995	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Aspirin	Asprin	Tablet EC	81 mg	Covered	FORMULARY
16.713	4.380	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Aspirin	Asprin	Tablet Chew	81 mg	Covered	FORMULARY
16.701	4.376	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Aspirin	Aspirin	Tablet	325 mg	Covered	FORMULARY
32.000	4.930	129200-AUTONOMIC DRUGS, MISCELLANEOUS	NICOTINE	NICOTINE	GUM	2 MG	Covered	FORMULARY
3.201	13.486	129200-AUTONOMIC DRUGS, MISCELLANEOUS	NICOTINE	NICOTINE	GUM	4 MG	Covered	FORMULARY
14.689	48.776	129200-AUTONOMIC DRUGS, MISCELLANEOUS	NICOTINE	NICOTINE	LOZENGE	2 MG	Covered	FORMULARY
14.688	48.775	129200-AUTONOMIC DRUGS, MISCELLANEOUS	NICOTINE	NICOTINE	LOZENGE	4 MG	Covered	FORMULARY
49.992	82.541	68200800-INSULINS	INSULIN GLARGINE-YFGN (SEMGLEE)	INSULIN GLARGINE-YFGN	VIAL	100 UNITS/ML	Covered	FORMULARY
49.993	82.542	68200800-INSULINS	INSULIN GLARGINE-YFGN (SEMGLEE)	INSULIN GLARGINE-YFGN	INSULN PEN	100 UNITS/ML	Covered	FORMULARY
41.260	9.322	081604-ANTITUBERCULOSIS AGENTS	RIFAMPIN	RIFAMPIN	CAPSULE	150 MG	Covered	FORMULARY
41.261	9.323	081604-ANTITUBERCULOSIS AGENTS	RIFAMPIN	RIFAMPIN	CAPSULE	300 MG	Covered	FORMULARY
41.801	9.426	081604-ANTITUBERCULOSIS AGENTS	ETHAMBUTOL	ETHAMBUTOL	TABLET	400 MG	Covered	FORMULARY
13.331	47.563	281608-ANTIPSYCHOTIC AGENTS	GEODON	ZIPRASIDONE	CAPSULE	20 MG	Covered	FORMULARY
13.332	47.564	281608-ANTIPSYCHOTIC AGENTS	GEODON	ZIPRASIDONE	CAPSULE	40MG	Covered	FORMULARY
13.333	47.567	281608-ANTIPSYCHOTIC AGENTS	GEODON	ZIPRASIDONE	CAPSULE	60MG	Covered	FORMULARY
13.334	47.568	281608-ANTIPSYCHOTIC AGENTS	GEODON	ZIPRASIDONE	CAPSULE	80 MG	Covered	FORMULARY
4.695	1.645	200404-IRON PREPARATIONS	FERROUS SULFATE	FERROUS SULFATE	TABLET	325 (65) MG	Covered	FORMULARY
97.721	61.935	200404-IRON PREPARATIONS	FERROUS SULFATE	FERROUS SULFATE	DROPS/SOLUTION	75 (15) MG/ML	Covered	FORMULARY
97.503	61.717	200404-IRON PREPARATIONS	FERROUS GLUCONATE	FERROUS GLUCONATE	TABLET	324 (38) MG	Covered	FORMULARY
4.515	1.617	200404-IRON PREPARATIONS	FERROUS FUMARATE	FERROUS FUMARATE	TABLET	324 (1060 MG	Covered	FORMULARY
94.200	77.832	940000-DEVICES	FREESTYLE LIBRE 14 DAY	CONTINOUS GLUCOSE MONITOR	READER		COVERED - SEE COMMENTS	FORMULARY	Restricted to CUC & CH Endocrinology and CUC in-house only
94.200	77.832	940000-DEVICES	FREESTYLE LIBRE 2	CONTINOUS GLUCOSE MONITOR	READER		COVERED - SEE COMMENTS	FORMULARY	Restricted to CUC & CH Endocrinology and CUC in-house only
94.200	65.863	940000-DEVICES	FREESTYLE LIBRE 3	CONTINOUS GLUCOSE MONITOR	READER		COVERED - SEE COMMENTS	FORMULARY	Restricted to CUC & CH Endocrinology and CUC in-house only
94.200	65.744	940000-DEVICES	FREESTYLE LIBRE 2 PLUS	CONTINOUS GLUCOSE MONITOR	SENSOR		COVERED - SEE COMMENTS	FORMULARY	Restricted to CUC & CH Endocrinology and CUC in-house only
94.200	65.744	940000-DEVICES	FREESTYLE LIBRE 3 PLUS	CONTINOUS GLUCOSE MONITOR	SENSOR		COVERED - SEE COMMENTS	FORMULARY	Restricted to CUC & CH Endocrinology and CUC in-house only
94.200	65.863	940000-DEVICES	DEXCOM G6	CONTINOUS GLUCOSE MONITOR	RECEIVER		COVERED - SEE COMMENTS	FORMULARY	Restricted to CUC & CH Endocrinology, using integrated insulin pump and CUC in-house only
94.200	65.873	940000-DEVICES	DEXCOM G6	CONTINOUS GLUCOSE MONITOR	TRANSMITTER		COVERED - SEE COMMENTS	FORMULARY	Restricted to CUC & CH Endocrinology, using integrated insulin pump and CUC in-house only
94.200	65.744	940000-DEVICES	DEXCOM G6	CONTINOUS GLUCOSE MONITOR	SENSOR		COVERED - SEE COMMENTS	FORMULARY	Restricted to CUC & CH Endocrinology, using integrated insulin pump and CUC in-house only
94.200	65.863	940000-DEVICES	DEXCOM G7	CONTINOUS GLUCOSE MONITOR	RECEIVER		COVERED - SEE COMMENTS	FORMULARY	Restricted to CUC & CH Endocrinology, using integrated insulin pump and CUC in-house only
94.200	65.744	940000-DEVICES	DEXCOM G7	CONTINOUS GLUCOSE MONITOR	SENSOR		COVERED - SEE COMMENTS	FORMULARY	Restricted to CUC & CH Endocrinology, using integrated insulin pump and CUC in-house only
28.578	66.336	202816-HEMOSTATICS	TRANEXAMIC ACID	TRANEXAMIC ACID	TABLET	650 MG	COVERED	FORMULARY
8.762	2.947	561200-CATHARTICS AND LAXATIVES	Bisacodyl	Bisacodyl	Tablet	5 mg	COVERED	FORMULARY
8.731	2.944	561200-CATHARTICS AND LAXATIVES	Bisacodyl	Bisacodyl	Suppository	10 mg	COVERED	FORMULARY
44.774	78.441	401818-POTASSIUM-REMOVING AGENTS	Lokelma	Sodium Zirconium Cyclosilicate	Powder	5 g	NOT COVERED	NON-FORMULARY	Three 30 day fills allowed in a year with no NFDR/PA required. Longer use acquire via PAP
44.775	78.445	401818-POTASSIUM-REMOVING AGENTS	Lokelma	Sodium Zirconium Cyclosilicate	Powder	10 g	NOT COVERED	NON-FORMULARY	Three 30 day fills allowed in a year with no NFDR/PA required. Longer use acquire via PAP
25.308	59.589	280812-OPIATE PARTIAL AGONISTS	Butrans	Buprenorphine	PATCH TDWK	5 MCG/HR	Covered	FORMULARY
36.946	72.673	280812-OPIATE PARTIAL AGONISTS	Butrans	Buprenorphine	PATCH TDWK	7.5 MCG/HR	Covered	FORMULARY
25.309	59.590	280812-OPIATE PARTIAL AGONISTS	Butrans	Buprenorphine	PATCH TDWK	10 MCG/HR	Covered	FORMULARY
35.214	71.432	280812-OPIATE PARTIAL AGONISTS	Butrans	Buprenorphine	PATCH TDWK	15 MCG/HR	Covered	FORMULARY
25.312	59.591	280812-OPIATE PARTIAL AGONISTS	Butrans	Buprenorphine	PATCH TDWK	20 MCG/HR	Covered	FORMULARY
28.495	41.832	90282892-CALCINEURIN INHIBITORS	Prograf	Tacrolimus	CAPSULE	0.5 MG	Covered	FORMULARY
28.491	21.796	90282892-CALCINEURIN INHIBITORS	Prograf	Tacrolimus	CAPSULE	1 MG	Covered	FORMULARY
28.492	21.797	90282892-CALCINEURIN INHIBITORS	Prograf	Tacrolimus	CAPSULE	5 MG	Covered	FORMULARY
13.918	23.882	90282892-CALCINEURIN INHIBITORS	Gengraf/Neoral	CYCLOSPORINE MODIFIED	CAPSULE	25 MG	Covered	FORMULARY
13.916	23.885	90282892-CALCINEURIN INHIBITORS	Gengraf/Neoral	CYCLOSPORINE MODIFIED	CAPSULE	50 MG	Covered	FORMULARY
13.919	23.881	90282892-CALCINEURIN INHIBITORS	Gengraf/Neoral	CYCLOSPORINE MODIFIED	CAPSULE	100 MG	Covered	FORMULARY
23.152	57.883	081808-ANTIRETROVIRALS	Truvada	emtricitabine/tenofovir (TDF)	TABLET	200/300 MG	COVERED - SEE COMMENTS	FORMULARY	For PrEP use only. Not for HIV treatment. No NFDR/PA required
41.741	9.415	081604-ANTITUBERCULOSIS AGENT	Isoniazid	Isoniazid	TABLET	100 MG	Covered	FORMULARY
41.742	9.416	081604-ANTITUBERCULOSIS AGENT	Isoniazid	Isoniazid	TABLET	300 MG	Covered	FORMULARY
45.911	40.870	081604-ANTITUBERCULOSIS AGENT	Priftin	Rifapentine	TABLET	150 MG	Covered	FORMULARY
94.976	2.427	880800-VITAMIN B COMPLEX	Pyridoxine (Vitamin B6)	Vitamin B6	TABLET	50 MG	Covered	FORMULARY
94.977	2.423	880800-VITAMIN B COMPLEX	Pyridoxine (Vitamin B6)	Vitamin B6	TABLET	25 MG	Covered	FORMULARY
94.783	2.364	880800-VITAMIN B COMPLEX	FOLIC ACID	FOLIC ACID	TABLET	400 MCG	Covered	FORMULARY
68.738	24.665	929200-null	MELATONIN	MELATONIN	TABLET	3 MG	Covered	FORMULARY
99.671	63.960	929200-null	MELATONIN	MELATONIN	TABLET	5 MG	Covered	FORMULARY
8.420	2.860	560800-ANTIDIARRHEA AGENTS	PEPTO-BISMOL	BISMUTH SUBSALICYLATE	CHEWABLE TABLET	262 MG	Covered	FORMULARY
223	28.465	881600-VITAMIN D	VITAMIN D3	VITAMIN D3	TABLET	25 MCG (1000 IU)	Covered	FORMULARY
12.309	64.302	881600-VITAMIN D	VITAMIN D3	VITAMIN D3	TABLET	50 MCG (2000 IU)	Covered	FORMULARY
93.242	12.016	881600-VITAMIN D	VITAMIN D3	VITAMIN D3	CAPSULE	125 MCG (5000 IU)	Covered	FORMULARY
12.867	47.525	562836-PROTON-PUMP INHIBITORS	NEXIUM	ESOMEPRAZOLE	CAPSULE	20 MG	Covered	FORMULARY
12.868	47.526	562836-PROTON-PUMP INHIBITORS	NEXIUM	ESOMEPRAZOLE	CAPSULE	40 MG	Covered	FORMULARY
29.810	18.766	081604-ANTITUBERCULOSIS AGENTS	MYCOBUTIN	RIFABUTIN	CAPSULE	150 MG	Covered	FORMULARY
47.303	80.455	562892	TALICIA	OMEPRAZOLE/AMOXICILLIN/RIFABUTIN	CAPSULE	10-250-12.5 MG	Covered	FORMULARY
701	19.964	561200-CATHARTICS AND LAXATIVES	SENNA	SENNA	TABLET	8.6 MG	Covered	FORMULARY
8.660	2.922	561200-CATHARTICS AND LAXATIVES	SENNA	SENNA	SYRUP	8.8 MG/5 ML	Covered	FORMULARY
16.964	4.489	280816	ACETAMINOPHEN	ACETAMINOPHEN	TABLET	325 mg	Covered	FORMULARY
31.880	7.737	529200-EENT DRUGS	MURO-128	SODIUM CHLORIDE	OINTMENT	5%	Covered	FORMULARY
31.922	7.738	529200-EENT DRUGS	MURO-128	SODIUM CHLORIDE	DROPS	2%	Covered	FORMULARY
31.923	7.739	529200-EENT DRUGS	MURO-129	SODIUM CHLORIDE	DROPS	5%	Covered	FORMULARY
Generic Code	Generic Sequence Number	Therapeutic Class	BrandName	GenericName	Formulation	Strength	Coverage	Location	Comments

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MAP / MAP Basic Formulary

MAP Formulary (October 2025 edition)