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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 (January 2023)

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 CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies
3.421 16.425 129200-AUTONOMIC DRUGS, MISCELLANEOUS Nicoderm CQ Patch NICOTINE PATCH TD24 7 MG/24HR COVERED FORMULARY
3.422 16.426 129200-AUTONOMIC DRUGS, MISCELLANEOUS Nicoderm CQ Patch NICOTINE PATCH TD24 14 MG/24HR COVERED FORMULARY
3.423 16.427 129200-AUTONOMIC DRUGS, MISCELLANEOUS Nicoderm CQ Patch NICOTINE PATCH TD24 21 MG/24HR COVERED FORMULARY
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 NOT COVERED NON-FORMULARY
98.307 62.532 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS Janumet SITAGLIPTIN PHOS/METFORMIN HCL TABLET 50-1000 MG NOT COVERED NON-FORMULARY
31.339 68.538 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS Janumet XR SITAGLIPTIN PHOS/METFORMIN HCL TBMP 24HR 50-500 MG NOT COVERED NON-FORMULARY
31.340 68.539 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS Janumet XR SITAGLIPTIN PHOS/METFORMIN HCL TBMP 24HR 50-1000 MG NOT COVERED NON-FORMULARY
31.348 68.540 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS Janumet XR SITAGLIPTIN PHOS/METFORMIN HCL TBMP 24HR 100-1000 MG NOT COVERED NON-FORMULARY
97.398 61.612 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS Januvia SITAGLIPTIN PHOSPHATE TABLET 25 MG NOT COVERED NON-FORMULARY
97.399 61.613 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS Januvia SITAGLIPTIN PHOSPHATE TABLET 50 MG NOT COVERED NON-FORMULARY
97.400 61.614 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS Januvia SITAGLIPTIN PHOSPHATE TABLET 100 MG NOT COVERED NON-FORMULARY
24.614 59.073 682006-INCRETIN MIMETICS Byetta EXENATIDE PEN INJCTR 10 MCG/0.04 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, Tri-Lo-Marzia, Tri-Lo-Sprintec, Tri-Lo-Estarylla NORGESTIMATE-ETHINYL ESTRADIOL TABLET 0.18/0.215/0.25 mg - 25mcg COVERED FORMULARY
13.083 47.787 681200-CONTRACEPTIVES Yasmin ETHINYL ESTRADIOL-DROSPIRENONE TABLET 0.03-3 MG COVERED FORMULARY
11.530 3.314 681200-CONTRACEPTIVES Altavera, Chateal, Kurvelo, Levora, Marlissa, Portia LEVONORGESTREL-ETHINYL ESTRADIOL TABLET 0.15-0.03 MG COVERED FORMULARY
11.534 30.986 681200-CONTRACEPTIVES Aviane, Aubra, Delyla, Falmina, Lessina, Lutera, Orsythia, Sronyx LEVONORGESTREL-ETHINYL ESTRADIOL TABLET 0.1-0.02 MG COVERED FORMULARY
11.531 3.315 681200-CONTRACEPTIVES Enpresse, Trivora, Myzilra LEVONORGESTREL-ETHINYL ESTRADIOL TABLET 50-30(6)/75-40(5)/125/30(10) MCG COVERED FORMULARY
11.520 3.313 681200-CONTRACEPTIVES Ortho Micronor, Errin, Camila, Deblitane, Sharobel, Norlyro, Nor-Be, Jolivette, Jencycla, Heather NORETHINDRONE TABLET 0.35 MG COVERED FORMULARY
11.480 3.304 681200-CONTRACEPTIVES Gildess, Junel, Larin, Loestrin 21 1.5/30 NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TABLET 1.5-30 MCG COVERED FORMULARY
11.481 3.305 681200-CONTRACEPTIVES Gildess, Junel, Larin, Loestrin 21 1/20 NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TABLET 1-20 MCG COVERED FORMULARY
11.477 3.298 681200-CONTRACEPTIVES Alyacen 7/7/7, Cyclafem 7/7/7, Diasetta 7/7/7, Necon 7/7/7, Nortrel 7/7/7, Ortho-Novum 7/7/7 NORETHINDRONE-ETHINYL ESTRADIOL TABLET 0.5/0.75/1 MG-35MCG COVERED FORMULARY
11.474 3.295 681200-CONTRACEPTIVES Alyacen, Cyclafem, Dasetta, Necon 1/35, Nortrel 1/35, Norinyl, Ortho Novum, Primella NORETHINDRONE-ETHINYL ESTRADIOL TABLET 1-0.35 MG COVERED FORMULARY
11.471 3.294 681200-CONTRACEPTIVES Brevicon, Modicone, Necon 0.5/35, Nortrel 0.5/35, Wera NORETHINDRONE-ETHINYL ESTRADIOL TABLET 0.5-0.35 MG COVERED FORMULARY
68.101 3.300 681200-CONTRACEPTIVES Blisovi FE, Gildess FE, Junel FE, Larin FE, Loestrin FE 1.5/30 NORETHINDRONE-ETHINYL ESTRADIOL-IRON TABLET 1.5MG-30 MCG(21)/75MG(7) COVERED FORMULARY
68.102 3.301 681200-CONTRACEPTIVES Blisovi FE, Gildess FE, Junel FE, Larin FE, Loestrin FE 1/20 NORETHINDRONE-ETHINYL ESTRADIOL-IRON TABLET 1 MG-20 MCG(21)/75MG(7) COVERED FORMULARY
11.300 13.662 681200-CONTRACEPTIVES Estarylla, Mononessa, Ortho-Cyclen, Previfem, Sprintec NORGESTIMATE-ETHINYL ESTRADIOL TABLET 0.25-0.035 MG COVERED FORMULARY
11.301 16.963 681200-CONTRACEPTIVES Tri-Estarylla, Tri-Mononessa, Otrho Tri-Cyclen, Tri-Previfem, Tri-Sprintec NORGESTIMATE-ETHINYL ESTRADIOL TABLET 0.18/0.215/0.25 MG-35MCG(28) COVERED FORMULARY
11.500 3.310 681200-CONTRACEPTIVES Low-Ogestrel, Elinest, Cryselle NORGESTREL-ETHINYL ESTRADIOL TABLET 0.3 MG-30MCG COVERED FORMULARY
10.770 3.204 681604-ESTROGENS Estrace ESTRADIOL TABLET 1 MG COVERED FORMULARY
10.771 3.205 681604-ESTROGENS Estrace ESTRADIOL TABLET 2 MG COVERED FORMULARY
10.772 21.411 681604-ESTROGENS Estrace ESTRADIOL TABLET 0.5 MG COVERED FORMULARY
19.739 52.179 681604-ESTROGENS Prempro ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE TABLET 0.45-1.5 MG COVERED FORMULARY
20.769 53.321 681604-ESTROGENS Prempro ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE TABLET 0.3-1.5 MG COVERED FORMULARY
55.730 22.647 681604-ESTROGENS Prempro ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE TABLET 0.625-5 MG COVERED FORMULARY
55.731 22.648 681604-ESTROGENS Prempro ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE TABLET 0.625-2.5 MG COVERED FORMULARY
28.410 7.013 681604-ESTROGENS Premarin Vaginal ESTROGENS CONJUGATED CREAM/APPL 0.625 MG/G COVERED FORMULARY
10.942 3.212 681604-ESTROGENS Premarin ESTROGENS CONJUGATED TABLET 0.625 MG COVERED FORMULARY
10.943 3.211 681604-ESTROGENS Premarin ESTROGENS CONJUGATED TABLET 0.3 MG COVERED FORMULARY
10.944 3.213 681604-ESTROGENS Premarin ESTROGENS CONJUGATED TABLET 0.9 MG COVERED FORMULARY
10.945 3.214 681604-ESTROGENS Premarin ESTROGENS CONJUGATED TABLET 1.25 MG COVERED FORMULARY
19.975 52.766 681604-ESTROGENS Premarin ESTROGENS CONJUGATED TABLET 0.45MG COVERED FORMULARY
59.011 37.022 681612-ESTROGEN AGONIST-ANTAGONISTS Evista RALOXIFENE HCL TABLET 60 MG COVERED FORMULARY
19.578 52.080 682004-BIGUANIDES Glucophage XR METFORMIN HCL TAB ER 24H 750 MG COVERED FORMULARY
89.863 46.754 682004-BIGUANIDES Glucophage XR METFORMIN HCL TAB ER 24H 500 MG COVERED FORMULARY
10.810 13.318 682004-BIGUANIDES Glucophage METFORMIN HCL TABLET 500 MG COVERED FORMULARY
10.811 16.441 682004-BIGUANIDES Glucophage METFORMIN HCL TABLET 850 MG COVERED FORMULARY
10.857 40.974 682004-BIGUANIDES Glucophage METFORMIN HCL TABLET 1000 MG COVERED FORMULARY
92.336 44.341 682008-INSULINS Novolog Flexpen INSULIN ASPART INSULN PEN 100 UNIT/ML COVERED FORMULARY
92.326 44.340 682008-INSULINS Novolog INSULIN ASPART VIAL 100 UNIT/ML COVERED FORMULARY
17.075 50.134 682008-INSULINS Novolog 70/30 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
19.198 51.812 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. Azelaic Acid AZELAIC ACID Gel 15% COVERED FORMULARY
39.274 74.590 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. Azelaic Acid AZELAIC ACID FOAM 15% COVERED FORMULARY
1.851 21.134 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. Dovonex CALCIPOTRIENE CREAM (G) 0.01 % 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 R