MAP & MAP BASIC 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.

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MAP / MAP Basic Formulary (April 2022)

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	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to a CUC in-house pharmacy
60.563	18.698	040800-SECOND GENERATION ANTIHISTAMINES	Claritin	LORATADINE	TABLET	10 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to a CUC in-house pharmacy
17.853	50.714	120808-ANTIMUSCARINICS/ANTISPASMODICS	Spiriva Handihaler	TIOTROPIUM BROMIDE	CAP W/DEV	18 MCG	COVERED	FORMULARY
3.421	16.425	129200-AUTONOMIC DRUGS, MISCELLANEOUS	Nicoderm CQ Patch	NICOTINE	PATCH TD24	7 MG/24HR	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to a CUC in-house pharmacy
3.422	16.426	129200-AUTONOMIC DRUGS, MISCELLANEOUS	Nicoderm CQ Patch	NICOTINE	PATCH TD24	14 MG/24HR	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to a CUC in-house pharmacy
3.423	16.427	129200-AUTONOMIC DRUGS, MISCELLANEOUS	Nicoderm CQ Patch	NICOTINE	PATCH TD24	21 MG/24HR	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to a CUC in-house pharmacy
27.047	60.897	129200-AUTONOMIC DRUGS, MISCELLANEOUS	Chantix	VARENICLINE TARTRATE	TABLET	1 MG	COVERED	FORMULARY	only 12 week course, all strengths, in 12 month period & must be receiving tobacco cessation counseling during treatment
27.046	60.896	129200-AUTONOMIC DRUGS, MISCELLANEOUS	Chantix	VARENICLINE TARTRATE	TABLET	0.5 MG	COVERED	FORMULARY	only 12 week course, all strengths, in 12 month period & must be receiving tobacco cessation counseling during treatment
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
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
64.269	37.219	562836-PROTON-PUMP INHIBITORS	Prevpac	LANSOPRAZOLE/AMOXICILN/CLARITH	COMBO. PKG	30-500-500 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to a CUC in-house pharmacy
17.528	50.464	681200-CONTRACEPTIVES	Nuvaring	ETONOGESTREL/ETHINYL ESTRADIOL	VAG RING	0.12-.015 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC 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	COVERED	FORMULARY
98.307	62.532	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Janumet	SITAGLIPTIN PHOS/METFORMIN HCL	TABLET	50-1000 MG	COVERED	FORMULARY
31.339	68.538	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Janumet XR	SITAGLIPTIN PHOS/METFORMIN HCL	TBMP 24HR	50-500 MG	COVERED	FORMULARY
31.340	68.539	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Janumet XR	SITAGLIPTIN PHOS/METFORMIN HCL	TBMP 24HR	50-1000 MG	COVERED	FORMULARY
31.348	68.540	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Janumet XR	SITAGLIPTIN PHOS/METFORMIN HCL	TBMP 24HR	100-1000 MG	COVERED	FORMULARY
97.398	61.612	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Januvia	SITAGLIPTIN PHOSPHATE	TABLET	25 MG	COVERED	FORMULARY
97.399	61.613	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Januvia	SITAGLIPTIN PHOSPHATE	TABLET	50 MG	COVERED	FORMULARY
97.400	61.614	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Januvia	SITAGLIPTIN PHOSPHATE	TABLET	100 MG	COVERED	FORMULARY
24.614	59.073	682006-INCRETIN MIMETICS	Byetta	EXENATIDE	PEN INJCTR	10 MCG/0.04	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to a CUC in-house pharmacy
24.613	59.072	682006-INCRETIN MIMETICS	Byetta	EXENATIDE	PEN INJCTR	5 MCG/0.04	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to a CUC in-house pharmacy
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
0	0	081224-TETRACYCLINES	Doxycycline Suspension	DOXYCYCLINE	X	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
41.680	5.040	121208-BETA-ADRENERGIC AGONISTS	Albuterol Sulfate	ALBUTEROL SULFATE	SOLUTION	5 MG/ML	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
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
18.010	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	25 MG	COVERED	FORMULARY
35.851	8.373	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Diclofenac Sodium	DICLOFENAC SODIUM	TABLET DR	50 MG	COVERED	FORMULARY
35.852	8.374	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Diclofenac Sodium	DICLOFENAC SODIUM	TABLET DR	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
70.334	26.439	280808-OPIATE AGONISTS	Hydrocodone-Acetaminophen	HYDROCODONE-ACETAMINOPHEN	TABLET	10-500 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
92.219	45.100	281292-ANTICONVULSANTS, MISCELLANEOUS	Thioguanine	THIOGUANINE	TABLET	40 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	Max 40mg/day
16.343	46.204	281604-ANTIDEPRESSANTS	Celexa	CITALOPRAM HYDROBROMIDE	TABLET	40 MG	COVERED	FORMULARY	Max 40mg/day
16.345	46.206	281604-ANTIDEPRESSANTS	Celexa	CITALOPRAM HYDROBROMIDE	TABLET	10 MG	COVERED	FORMULARY	Max 40mg/day
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	Max 20mg/day
17.851	50.712	281604-ANTIDEPRESSANTS	Lexapro	ESCITALOPRAM OXALATE	TABLET	10 MG	COVERED	FORMULARY	Max 20mg/day
17.987	50.760	281604-ANTIDEPRESSANTS	Lexapro	ESCITALOPRAM OXALATE	TABLET	20 MG	COVERED	FORMULARY	Max 20mg/day
18.975	51.642	281604-ANTIDEPRESSANTS	Lexapro	ESCITALOPRAM OXALATE	TABLET	5 MG	COVERED	FORMULARY	Max 20mg/day
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
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	300 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 Glucose Test Strip	BLOOD SUGAR DIAGNOSTIC	STRIP		COVERED	FORMULARY
25.200	6.373	362600-DIABETES MELLITUS	True Metrix Glucose Test Strip	BLOOD SUGAR DIAGNOSTIC	STRIP		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
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)	Flovent HFA	FLUTICASONE PROPIONATE	AER W/ADAP	110 MCG	COVERED	FORMULARY
53.638	21.253	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Flovent HFA	FLUTICASONE PROPIONATE	AER W/ADAP	44 MCG	COVERED	FORMULARY
53.639	21.483	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Flovent 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	Azelastine	AZELASTINE HCL	SPRAY/PUMP	137 MCG	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
14.283	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-Polymxyin-Dexamethasone Eye Ointment	NEOMYCIN-POLYMYX B-DEXAMETHASONE	OINT. (G)	3.5-10000-0.1 MG/G-UNIT/G-%	COVERED	FORMULARY
14.286	48.547	520404-ANTIBACTERIALS (EENT)	Neomycin-Polymxyin-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-POLYMYXN 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	POLYETHYLENE GLYCOL 3350	POWDER	17 G/DOSE	COVERED	FORMULARY	Restricted to age <19
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
97.248	61.457	561200-CATHARTICS AND LAXATIVES	Moviprep	PEG 3350-NA SULF BICARB CL-KCL-Ascorbic acid	SOLN RECON	100G	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	PAP	Contact manufacturer for PAP
42.318	76.626	561600-DIGESTANTS	Pancreaze	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	21 K-54.7K	NOT COVERED	PAP	Contact manufacturer for PAP
42.319	76.627	561600-DIGESTANTS	Pancreaze	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	10.5-35.5K	NOT COVERED	PAP	Contact manufacturer for PAP
42.324	76.628	561600-DIGESTANTS	Pancreaze	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	4.2K-14.2K	NOT COVERED	PAP	Contact manufacturer for PAP
42.596	76.797	561600-DIGESTANTS	Pancreaze	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	2.6 K-6.2K	NOT COVERED	PAP	Contact manufacturer for PAP
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	NORGESTIMATE-ETHINYL ESTRADIOL	TABLET	7DAYSX3 LO	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 Flexpen	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
22.836	57.439	682008-INSULINS	Levemir FlexTouch	INSULIN DETEMIR	INSULN PEN	100 UNIT/ML	COVERED	FORMULARY
25.305	59.586	682008-INSULINS	Levemir	INSULIN DETEMIR	VIAL	100 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
30.380	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
62.874	18.229	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Azelex	AZELAIC ACID	CREAM (G)	20 %	COVERED	FORMULARY
1.851	21.134	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Dovonex	CALCIPOTRIENE	CREAM (G)	0.01 %	COVERED	FORMULARY
1.850	19.160	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Calcipotriene	CALCIPOTRIENE	OINT. (G)	0.01 %	COVERED	FORMULARY
1.852	22.483	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Calcipotriene	CALCIPOTRIENE	SOLUTION	0.01 %	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	Max 6 tablets/month, Enroll in PAP for more.
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 Glucose Meter	BLOOD-GLUCOSE METER	EACH		COVERED	FORMULARY
94.200	19.413	940000-DEVICES	True Metrix Glucose Meter	BLOOD-GLUCOSE METER	EACH		COVERED	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 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	NOT COVERED	NON-FORMULARY	Formulary: Atorvastatin
19.154	51.785	240608-HMG-COA REDUCTASE INHIBITORS	Crestor	ROSUVASTATIN CALCIUM	TABLET	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Atorvastatin
19.155	51.786	240608-HMG-COA REDUCTASE INHIBITORS	Crestor	ROSUVASTATIN CALCIUM	TABLET	40 MG	NOT COVERED	NON-FORMULARY	Formulary: Atorvastatin
20.229	52.944	240608-HMG-COA REDUCTASE INHIBITORS	Crestor	ROSUVASTATIN CALCIUM	TABLET	5 MG	NOT COVERED	NON-FORMULARY	Formulary: Atorvastatin
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
73.543	37.016	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand	CANDESARTAN CILEXETIL	TABLET	8 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
73.544	37.017	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand	CANDESARTAN CILEXETIL	TABLET	16 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
73.545	40.659	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand	CANDESARTAN CILEXETIL	TABLET	32 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
13.258	64.285	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand HCT	CANDESARTAN/HYDROCHLOROTHIAZID	TABLET	32MG-25MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
21.559	45.425	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand HCT	CANDESARTAN/HYDROCHLOROTHIAZID	TABLET	16-12.5MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
21.569	46.624	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand HCT	CANDESARTAN/HYDROCHLOROTHIAZID	TABLET	32-12.5MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
23.831	40.910	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Micardis	TELMISARTAN	TABLET	40 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
23.832	40.911	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Micardis	TELMISARTAN	TABLET	80 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
23.833	47.126	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Micardis	TELMISARTAN	TABLET	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
27.783	65.746	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Twynsta	TELMISARTAN/AMLODIPINE	TABLET	40 MG-5 MG

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