MAP & MAP BASIC Formulary

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Download an Excel spreadsheet of the complete formulary.

Effective Date 11/9/2019

Generic CodeGeneric Sequence NumberTherapeutic ClassBrandNameGenericNameFormulationStrengthCoverageLocationComments
4929117037040800-SECOND GENERATION ANTIHISTAMINES ZyrtecCETIRIZINE HCLTABLET10 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
6056318698040800-SECOND GENERATION ANTIHISTAMINES ClaritinLORATADINETABLET10 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2682025484081808-ANTIRETROVIRALS CrixivanINDINAVIR SULFATECAPSULE200 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2682225485081808-ANTIRETROVIRALS CrixivanINDINAVIR SULFATECAPSULE400 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
9898663231081808-ANTIRETROVIRALS IsentressRALTEGRAVIR POTASSIUMTABLET400 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
1785350714120808-ANTIMUSCARINICS/ANTISPASMODICS Spiriva HandihalerTIOTROPIUM BROMIDECAP W/DEV18 MCGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy,
761036857129200-AUTONOMIC DRUGS, MISCELLANEOUS Nicotrol InhalerNICOTINECARTRIDGE10 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
342116425129200-AUTONOMIC DRUGS, MISCELLANEOUS Nicoderm CQ PatchNICOTINEPATCH TD247 MG/24HRCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
342216426129200-AUTONOMIC DRUGS, MISCELLANEOUS Nicoderm CQ PatchNICOTINEPATCH TD2414 MG/24HRCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
342316427129200-AUTONOMIC DRUGS, MISCELLANEOUS Nicoderm CQ PatchNICOTINEPATCH TD2421 MG/24HRCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2704860898129200-AUTONOMIC DRUGS, MISCELLANEOUS Chantix Starting PackVARENICLINE TARTRATETAB DS PK0.5(11)-1(42) MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2704760897129200-AUTONOMIC DRUGS, MISCELLANEOUS Chantix Continuing PackVARENICLINE TARTRATETABLET1 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
1838751214240605-CHOLESTEROL ABSORPTION INHIBITORS ZetiaEZETIMIBETABLET10 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2312557863240605-CHOLESTEROL ABSORPTION INHIBITORS VytorinEZETIMIBE/SIMVASTATINTABLET10-20 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2312757865240605-CHOLESTEROL ABSORPTION INHIBITORS VytorinEZETIMIBE/SIMVASTATINTABLET10-40 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2312157859240605-CHOLESTEROL ABSORPTION INHIBITORS VytorinEZETIMIBE/SIMVASTATINTABLET10-10 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2312657864240605-CHOLESTEROL ABSORPTION INHIBITORS VytorinEZETIMIBE/SIMVASTATINTABLET10-80 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2139253690240608-HMG-COA REDUCTASE INHIBITORS CaduetAMLODIPINE/ATORVASTATINTABLET5-20 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2139353691240608-HMG-COA REDUCTASE INHIBITORS CaduetAMLODIPINE/ATORVASTATINTABLET5-40 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2139653694240608-HMG-COA REDUCTASE INHIBITORS CaduetAMLODIPINE/ATORVASTATINTABLET10-20 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2139753695240608-HMG-COA REDUCTASE INHIBITORS CaduetAMLODIPINE/ATORVASTATINTABLET10-40 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2139153689240608-HMG-COA REDUCTASE INHIBITORS CaduetAMLODIPINE/ATORVASTATINTABLET5-10 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2139453692240608-HMG-COA REDUCTASE INHIBITORS CaduetAMLODIPINE/ATORVASTATINTABLET5-80 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2139553693240608-HMG-COA REDUCTASE INHIBITORS CaduetAMLODIPINE/ATORVASTATINTABLET10-10 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2139853696240608-HMG-COA REDUCTASE INHIBITORS CaduetAMLODIPINE/ATORVASTATINTABLET10-80 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
4200141285280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS CelebrexCELECOXIBCAPSULE100 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
4200241286280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS CelebrexCELECOXIBCAPSULE200 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
9778562001280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS CelebrexCELECOXIBCAPSULE50 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
1812750832280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS CelebrexCELECOXIBCAPSULE400 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
626335737280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS ArthrotecDICLOFENAC SODIUM/MISOPROSTOLTAB IR DR75 MG-200COVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
6272920279280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS ArthrotexDICLOFENAC SODIUM/MISOPROSTOLTAB IR DR50 MG-200COVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
358208370280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS FeldenePIROXICAMCAPSULE10 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
358218371280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS FeldenePIROXICAMCAPSULE20 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2304657800281292-ANTICONVULSANTS, MISCELLANEOUS LyricaPREGABALINCAPSULE50 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2304757801281292-ANTICONVULSANTS, MISCELLANEOUS LyricaPREGABALINCAPSULE75 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2304857802281292-ANTICONVULSANTS, MISCELLANEOUS LyricaPREGABALINCAPSULE100 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2304957803281292-ANTICONVULSANTS, MISCELLANEOUS LyricaPREGABALINCAPSULE150 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2305157804281292-ANTICONVULSANTS, MISCELLANEOUS LyricaPREGABALINCAPSULE200 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2305257805281292-ANTICONVULSANTS, MISCELLANEOUS LyricaPREGABALINCAPSULE300 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2303957799281292-ANTICONVULSANTS, MISCELLANEOUS LyricaPREGABALINCAPSULE25 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2501959401281292-ANTICONVULSANTS, MISCELLANEOUS LyricaPREGABALINCAPSULE225 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
9945163736281604-ANTIDEPRESSANTS PristiqDESVENLAFAXINE SUCCINATETAB ER 24H50 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
9945263737281604-ANTIDEPRESSANTS PristiqDESVENLAFAXINE SUCCINATETAB ER 24H100 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
3822273778281604-ANTIDEPRESSANTS PristiqDESVENLAFAXINE SUCCINATETAB ER 24H25 MGNOT COVEREDPAPContact manufacturer for PAP
1853751333281608-ANTIPSYCHOTIC AGENTS AbilifyARIPIPRAZOLETABLET10 MGCOVEREDFORMULARY
1853851334281608-ANTIPSYCHOTIC AGENTS AbilifyARIPIPRAZOLETABLET15 MGCOVEREDFORMULARY
1853951335281608-ANTIPSYCHOTIC AGENTS AbilifyARIPIPRAZOLETABLET20 MGCOVEREDFORMULARY
1854151336281608-ANTIPSYCHOTIC AGENTS AbilifyARIPIPRAZOLETABLET30 MGCOVEREDFORMULARY
2017352898281608-ANTIPSYCHOTIC AGENTS AbilifyARIPIPRAZOLETABLET5 MGCOVEREDFORMULARY
2630560225281608-ANTIPSYCHOTIC AGENTS AbilifyARIPIPRAZOLETABLET2 MGCOVEREDFORMULARY
1517349605283228-SELECTIVE SEROTONIN AGONISTS RelpaxELETRIPTAN HBRTABLET20 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
1517449606283228-SELECTIVE SEROTONIN AGONISTS RelpaxELETRIPTAN HBRTABLET40 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
1959440224283228-SELECTIVE SEROTONIN AGONISTS Maxalt MLTRIZATRIPTAN BENZOATETAB RAPDIS10 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
1959240222283228-SELECTIVE SEROTONIN AGONISTS MaxaltRIZATRIPTAN BENZOATETABLET10 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
1898751649481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Asmanex TWISTHALERMOMETASONE FUROATEAER POW BA220 MCG 120COVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2492959328481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Asmanex TWISTHALERMOMETASONE FUROATEAER POW BA220 MCG(60)COVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
9972164010481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Asmanex TWISTHALERMOMETASONE FUROATEAER POW BA110 MCG(30)COVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2876666480481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Dulera MDIMOMETASONE/FORMOTEROLHFA AER AD100-5 MCGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2876766481481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Dulera MDIMOMETASONE/FORMOTEROLHFA AER AD200-5 MCGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
7143131186520808-CORTICOSTEROIDS (EENT) NasonexMOMETASONE FUROATESPRAY/PUMP50 MCGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
6426937219562836-PROTON-PUMP INHIBITORS PrevpacLANSOPRAZOLE/AMOXICILN/CLARITHCOMBO. PKG30-500-500 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
1752850464681200-CONTRACEPTIVES NuvaringETONOGESTREL/ETHINYL ESTRADIOLVAG RING0.12-.015 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
9830662531682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSJanumetSITAGLIPTIN PHOS/METFORMIN HCLTABLET50-500 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
9830762532682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSJanumetSITAGLIPTIN PHOS/METFORMIN HCLTABLET50-1000 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
3133968538682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSJanumet XRSITAGLIPTIN PHOS/METFORMIN HCLTBMP 24HR50-500 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
3134068539682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSJanumet XRSITAGLIPTIN PHOS/METFORMIN HCLTBMP 24HR50-1000 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
3134868540682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSJanumet XRSITAGLIPTIN PHOS/METFORMIN HCLTBMP 24HR100-1000 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
9739861612682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSJanuviaSITAGLIPTIN PHOSPHATETABLET25 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
9739961613682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSJanuviaSITAGLIPTIN PHOSPHATETABLET50 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
9740061614682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSJanuviaSITAGLIPTIN PHOSPHATETABLET100 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2461459073682006-INCRETIN MIMETICS ByettaEXENATIDEPEN INJCTR10 MCG/0.04COVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
2461359072682006-INCRETIN MIMETICS ByettaEXENATIDEPEN INJCTR5 MCG/0.04COVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
9971164000861204-ANTIMUSCARINICSToviazFESOTERODINE FUMARATETAB ER 24H4 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
9971264001861204-ANTIMUSCARINICSToviazFESOTERODINE FUMARATETAB ER 24H8 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
1226347327861204-ANTIMUSCARINICSDetrol LATOLTERODINE TARTRATECAP ER 24H4 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
1226447328861204-ANTIMUSCARINICSDetrol LATOLTERODINE TARTRATECAP ER 24H2 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
3706239139861204-ANTIMUSCARINICSDetrolTOLTERODINE TARTRATETABLET2 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
3706139138861204-ANTIMUSCARINICSDetrolTOLTERODINE TARTRATETABLET1 MGCOVEREDCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy
1397748495040412-PHENOTHIAZINE DERIVATIVES Promethazine VCPHENYLEPHRINE HCL-PROMETHAZINE HCLSYRUP5-6.25 MG/5MLCOVEREDFORMULARY
150013873040412-PHENOTHIAZINE DERIVATIVES Phenergan SuppositoryPROMETHAZINE HCLSUPP.RECT25 MGCOVEREDFORMULARY
150023874040412-PHENOTHIAZINE DERIVATIVES Phenergan SuppositoryPROMETHAZINE HCLSUPP.RECT50 MGCOVEREDFORMULARY
150033872040412-PHENOTHIAZINE DERIVATIVES Phenergan SuppositoryPROMETHAZINE HCLSUPP.RECT12.5 MGCOVEREDFORMULARY
150353876040412-PHENOTHIAZINE DERIVATIVES PromethazinePROMETHAZINE HCLSYRUP6.25 MG/5MLCOVEREDFORMULARY
150423877040412-PHENOTHIAZINE DERIVATIVES PromethazinePROMETHAZINE HCLTABLET12.5 MGCOVEREDFORMULARY
150433878040412-PHENOTHIAZINE DERIVATIVES PromethazinePROMETHAZINE HCLTABLET25 MGCOVEREDFORMULARY
150443879040412-PHENOTHIAZINE DERIVATIVES PromethazinePROMETHAZINE HCLTABLET50 MGCOVEREDFORMULARY
96609991040420-PROPYLAMINE DERIVATIVES Brohist DBROMPHENIRAMIN-PHENYLEPHRINETABLET4-10 MGCOVEREDFORMULARY
4402326792040420-PROPYLAMINE DERIVATIVES SudogestPSEUDOEPHEDRINE-CHLORPHENIRAMINETABLET60 MG-4 MGCOVEREDFORMULARY
158034010040492-FIRST GEN. ANTIHIST. DERIVATIVES, MISC. CypropheptadineCYPROHEPTADINE HCLSYRUP2 MG/5MLCOVEREDFORMULARY
158114011040492-FIRST GEN. ANTIHIST. DERIVATIVES, MISC. CypropheptadineCYPROHEPTADINE HCLTABLET4 MGCOVEREDFORMULARY
9795062168040800-SECOND GENERATION ANTIHISTAMINES XyzalLEVOCETIRIZINE DIHYDROCHLORIDESOLUTION2.5 MG/5MLCOVEREDFORMULARY
1490148920040800-SECOND GENERATION ANTIHISTAMINES XyzalLEVOCETIRIZINE DIHYDROCHLORIDETABLET5 MGCOVEREDFORMULARY
5329019283080800-ANTHELMINTICS AlbenzaALBENDAZOLETABLET200 MGCOVEREDFORMULARY
9306443094080800-ANTHELMINTICS StromectolIVERMECTINTABLET3 MGCOVEREDFORMULARY
410729284081202-AMINOGLYCOSIDES NeomycinNEOMYCIN SULFATETABLET500 MGCOVEREDFORMULARY
3223140257081206-CEPHALOSPORINS CefdinirCEFDINIRCAPSULE300 MGCOVEREDFORMULARY
2330858005081206-CEPHALOSPORINS CefdinirCEFDINIRSUSP RECON250 MG/5MLCOVEREDFORMULARY
3223240258081206-CEPHALOSPORINS CefdinirCEFDINIRSUSP RECON125 MG/5MLCOVEREDFORMULARY
2929116582081206-CEPHALOSPORINS CefprozilCEFPROZILSUSP RECON125 MG/5MLCOVEREDFORMULARY
2929216583081206-CEPHALOSPORINS CefprozilCEFPROZILSUSP RECON250 MG/5MLCOVEREDFORMULARY
2927116584081206-CEPHALOSPORINS CefprozilCEFPROZILTABLET250 MGCOVEREDFORMULARY
2927216585081206-CEPHALOSPORINS CefprozilCEFPROZILTABLET500 MGCOVEREDFORMULARY
472819136081206-CEPHALOSPORINS CeftinCEFUROXIME AXETILTABLET250 MGCOVEREDFORMULARY
472829137081206-CEPHALOSPORINS CeftinCEFUROXIME AXETILTABLET500 MGCOVEREDFORMULARY
398019042081206-CEPHALOSPORINS KeflexCEPHALEXINCAPSULE250 MGCOVEREDFORMULARY
398029043081206-CEPHALOSPORINS KeflexCEPHALEXINCAPSULE500 MGCOVEREDFORMULARY
398129046081206-CEPHALOSPORINS KeflexCEPHALEXINSUSP RECON250 MG/5MLCOVEREDFORMULARY
398319049081206-CEPHALOSPORINS KeflexCEPHALEXINTABLET500 MGCOVEREDFORMULARY
398329048081206-CEPHALOSPORINS KeflexCEPHALEXINTABLET250 MGCOVEREDFORMULARY
4879224194081212-MACROLIDES ZithromaxAZITHROMYCINSUSP RECON100 MG/5MLCOVEREDFORMULARY
6119918544081212-MACROLIDES ZithromaxAZITHROMYCINSUSP RECON200 MG/5MLCOVEREDFORMULARY
4879326721081212-MACROLIDES ZithromaxAZITHROMYCINTABLET250 MGCOVEREDFORMULARY
4879427252081212-MACROLIDES ZithromaxAZITHROMYCINTABLET600 MGCOVEREDFORMULARY
6119822624081212-MACROLIDES ZithromaxAZITHROMYCINTABLET500 MGCOVEREDFORMULARY
1167019146081212-MACROLIDES ClarithromycinCLARITHROMYCINSUSP RECON125 MG/5MLCOVEREDFORMULARY
4885116368081212-MACROLIDES BiaxinCLARITHROMYCINTABLET500 MGCOVEREDFORMULARY
4885216373081212-MACROLIDES BiaxinCLARITHROMYCINTABLET250 MGCOVEREDFORMULARY
406609258081212-MACROLIDES ErythromycinERYTHROMYCIN BASECAPSULE DR250 MGCOVEREDFORMULARY
407209260081212-MACROLIDES ErythrocinERYTHROMYCIN BASETABLET250 MGCOVEREDFORMULARY
407219262081212-MACROLIDES ErythromycinERYTHROMYCIN BASETABLET500 MGCOVEREDFORMULARY
407309263081212-MACROLIDES Ery-TabERYTHROMYCIN BASETABLET DR250 MGCOVEREDFORMULARY
407319264081212-MACROLIDES Ery-TabERYTHROMYCIN BASETABLET DR333 MGCOVEREDFORMULARY
407329265081212-MACROLIDES Ery-TabERYTHROMYCIN BASETABLET DR500 MGCOVEREDFORMULARY
4052321205081212-MACROLIDES EryPed 200ERYTHROMYCIN ETHYLSUCCINATESUSP RECON200 MG/5MLCOVEREDFORMULARY
4052421206081212-MACROLIDES EryPed 400ERYTHROMYCIN ETHYLSUCCINATESUSP RECON400 MG/5MLCOVEREDFORMULARY
405609245081212-MACROLIDES E.E.S 400ERYTHROMYCIN ETHYLSUCCINATETABLET400 MGCOVEREDFORMULARY
406429255081212-MACROLIDES ErythromycinERYTHROMYCIN STEARATETABLET250 MGCOVEREDFORMULARY
396608995081216-PENICILLINS AmoxicillinAMOXICILLINCAPSULE250 MGCOVEREDFORMULARY
396618996081216-PENICILLINS AmoxicillinAMOXICILLINCAPSULE500 MGCOVEREDFORMULARY
396818997081216-PENICILLINS AmoxicillinAMOXICILLINSUSP RECON125 MG/5MLCOVEREDFORMULARY
396838998081216-PENICILLINS AmoxicillinAMOXICILLINSUSP RECON250 MG/5MLCOVEREDFORMULARY
9337542683081216-PENICILLINS AmoxicillinAMOXICILLINSUSP RECON400 MG/5MLCOVEREDFORMULARY
9338542684081216-PENICILLINS AmoxicillinAMOXICILLINSUSP RECON200 MG/5MLCOVEREDFORMULARY
396519001081216-PENICILLINS AmoxicillinAMOXICILLINTAB CHEW250 MGCOVEREDFORMULARY
3963240292081216-PENICILLINS AmoxicillinAMOXICILLINTABLET875 MGCOVEREDFORMULARY
6125220493081216-PENICILLINS AmoxicillinAMOXICILLINTABLET500 MGCOVEREDFORMULARY
671508989081216-PENICILLINS AugmentinAMOXICILLIN-POTASSIUM CLAVULANATESUSP RECON125-31.25 MG/5MLCOVEREDFORMULARY
671518990081216-PENICILLINS AugmentinAMOXICILLIN-POTASSIUM CLAVULANATESUSP RECON250-62.5 MG/5MLCOVEREDFORMULARY
6715325898081216-PENICILLINS AugmentinAMOXICILLIN-POTASSIUM CLAVULANATESUSP RECON400-57 MG/5MLCOVEREDFORMULARY
6715426720081216-PENICILLINS AugmentinAMOXICILLIN-POTASSIUM CLAVULANATESUSP RECON200-28.5 MG/5MLCOVEREDFORMULARY
2802048449081216-PENICILLINS Augmentin ESAMOXICILLIN-POTASSIUM CLAVULANATESUSP RECON600-42.9 MG/5MLCOVEREDFORMULARY
6707826719081216-PENICILLINS AugmentinAMOXICILLIN-POTASSIUM CLAVULANATETAB CHEW200-28.5 MGCOVEREDFORMULARY
9194150991081216-PENICILLINS Augmentin XRAMOXICILLIN-POTASSIUM CLAVULANATETAB ER 12H1000-62.5 MGCOVEREDFORMULARY
670708991081216-PENICILLINS AugmentinAMOXICILLIN-POTASSIUM CLAVULANATETABLET250-125 MGCOVEREDFORMULARY
670718992081216-PENICILLINS AugmentinAMOXICILLIN-POTASSIUM CLAVULANATETABLET500-125 MGCOVEREDFORMULARY
6707624668081216-PENICILLINS AugmentinAMOXICILLIN-POTASSIUM CLAVULANATETABLET875-125 MGCOVEREDFORMULARY
392718941081216-PENICILLINS AmpicillinAMPICILLIN TRIHYDRATECAPSULE250 MGCOVEREDFORMULARY
392728942081216-PENICILLINS AmpicillinAMPICILLIN TRIHYDRATECAPSULE500 MGCOVEREDFORMULARY
393138943081216-PENICILLINS AmpicillinAMPICILLIN TRIHYDRATESUSP RECON125 MG/5MLCOVEREDFORMULARY
393168944081216-PENICILLINS AmpicillinAMPICILLIN TRIHYDRATESUSP RECON250 MG/5MLCOVEREDFORMULARY
395418983081216-PENICILLINS DicloxacillinDICLOXACILLIN SODIUMCAPSULE250 MGCOVEREDFORMULARY
395428984081216-PENICILLINS DicloxacillinDICLOXACILLIN SODIUMCAPSULE500 MGCOVEREDFORMULARY
390228876081216-PENICILLINS Penicillin V PotassiumPENICILLIN V POTASSIUMSOLN RECON125 MG/5MLCOVEREDFORMULARY
390248877081216-PENICILLINS Penicillin V PotassiumPENICILLIN V POTASSIUMSOLN RECON250 MG/5MLCOVEREDFORMULARY
390538879081216-PENICILLINS Penicillin V PotassiumPENICILLIN V POTASSIUMTABLET250 MGCOVEREDFORMULARY
390558880081216-PENICILLINS Penicillin V PotassiumPENICILLIN V POTASSIUMTABLET500 MGCOVEREDFORMULARY
470509509081218-QUINOLONES CiproCIPROFLOXACIN HCLTABLET250 MGCOVEREDFORMULARY
470519510081218-QUINOLONES CiproCIPROFLOXACIN HCLTABLET500 MGCOVEREDFORMULARY
470529511081218-QUINOLONES CiproCIPROFLOXACIN HCLTABLET750 MGCOVEREDFORMULARY
2372558310081218-QUINOLONES LevofloxacinLEVOFLOXACINSOLUTION250 MG/10MLCOVEREDFORMULARY
4707329927081218-QUINOLONES LevaquinLEVOFLOXACINTABLET250 MGCOVEREDFORMULARY
4707429928081218-QUINOLONES LevaquinLEVOFLOXACINTABLET500 MGCOVEREDFORMULARY
8959746771081218-QUINOLONES LevaquinLEVOFLOXACINTABLET750 MGCOVEREDFORMULARY
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901509394081220-SULFONAMIDES (SYSTEMIC) Sulfamethoxazole-TrimethoprimSULFAMETHOXAZOLE-TRIMETHOPRIMORAL SUSP200-40 MG/5MLCOVEREDFORMULARY
901619395081220-SULFONAMIDES (SYSTEMIC) BactrimSULFAMETHOXAZOLE-TRIMETHOPRIMTABLET400-80 MGCOVEREDFORMULARY
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416119402081220-SULFONAMIDES (SYSTEMIC) AzulfidineSULFASALAZINETABLET500 MGCOVEREDFORMULARY
416209403081220-SULFONAMIDES (SYSTEMIC) Azulfidine ENSULFASALAZINETABLET DR500 MGCOVEREDFORMULARY
XX081224-TETRACYCLINES Doxycycline SuspensionDOXYCYCLINEX25 MG/MLCOVEREDFORMULARY
403319218081224-TETRACYCLINES DoxycylineDOXYCYCLINE HYCLATECAPSULE100 MGCOVEREDFORMULARY
403339219081224-TETRACYCLINES DoxycylineDOXYCYCLINE HYCLATECAPSULE50 MGCOVEREDFORMULARY
403609223081224-TETRACYCLINES DoxycylineDOXYCYCLINE HYCLATETABLET100 MGCOVEREDFORMULARY
4065115943081224-TETRACYCLINES DoxycylineDOXYCYCLINE MONOHYDRATECAPSULE100 MGCOVEREDFORMULARY
4065216815081224-TETRACYCLINES DoxycylineDOXYCYCLINE MONOHYDRATECAPSULE50 MGCOVEREDFORMULARY
9827162496081224-TETRACYCLINES DoxycylineDOXYCYCLINE MONOHYDRATECAPSULE75 MGCOVEREDFORMULARY
4036327050081224-TETRACYCLINES DoxycylineDOXYCYCLINE MONOHYDRATETABLET100 MGCOVEREDFORMULARY
404109226081224-TETRACYCLINES MinocyclineMINOCYCLINE HCLCAPSULE100 MGCOVEREDFORMULARY
404119227081224-TETRACYCLINES MinocyclineMINOCYCLINE HCLCAPSULE50 MGCOVEREDFORMULARY
9338742778081224-TETRACYCLINES MinocyclineMINOCYCLINE HCLCAPSULE75 MGCOVEREDFORMULARY
1954952057081224-TETRACYCLINES MinocyclineMINOCYCLINE HCLTABLET75 MGCOVEREDFORMULARY
404509230081224-TETRACYCLINES MinocyclineMINOCYCLINE HCLTABLET100 MGCOVEREDFORMULARY
404519231081224-TETRACYCLINES MinocyclineMINOCYCLINE HCLTABLET50 MGCOVEREDFORMULARY
408309339081228-ANTIBACTERIALS, MISCELLANEOUS CleocinCLINDAMYCIN HCLCAPSULE150 MGCOVEREDFORMULARY
408319341081228-ANTIBACTERIALS, MISCELLANEOUS CleocinCLINDAMYCIN HCLCAPSULE75 MGCOVEREDFORMULARY
408329340081228-ANTIBACTERIALS, MISCELLANEOUS CleocinCLINDAMYCIN HCLCAPSULE300 MGCOVEREDFORMULARY
408609346081228-ANTIBACTERIALS, MISCELLANEOUS Cleocin Pediatric GranulesCLINDAMYCIN PALMITATE HCLSOLN RECON75 MG/5MLCOVEREDFORMULARYRestricted to age < 19
6082318638081404-ALLYLAMINES LamisilTERBINAFINE HCLTABLET250 MGCOVEREDFORMULARY
6082118636081408-AZOLES DiflucanFLUCONAZOLESUSP RECON40 MG/MLCOVEREDFORMULARY
4219013723081408-AZOLES DiflucanFLUCONAZOLETABLET100 MGCOVEREDFORMULARY
4219113724081408-AZOLES DiflucanFLUCONAZOLETABLET200 MGCOVEREDFORMULARY
4219213725081408-AZOLES DiflucanFLUCONAZOLETABLET50 MGCOVEREDFORMULARY
4219322141081408-AZOLES DiflucanFLUCONAZOLETABLET150 MGCOVEREDFORMULARY
424409537081428-POLYENES NystatinNYSTATINORAL SUSP100000 UNIT/MLCOVEREDFORMULARY
424529538081428-POLYENES NystatinNYSTATINTABLET500000 UNITCOVEREDFORMULARY
423909517081492-ANTIFUNGALS, MISCELLANEOUS GriseofulvinGRISEOFULVIN MICROSIZEORAL SUSP125 MG/5MLCOVEREDFORMULARY
424029519081492-ANTIFUNGALS, MISCELLANEOUS GriseofulvinGRISEOFULVIN MICROSIZETABLET500 MGCOVEREDFORMULARY
424109520081492-ANTIFUNGALS, MISCELLANEOUS Gris-PegGRISEOFULVIN ULTRAMICROSIZETABLET125 MGCOVEREDFORMULARY
424129522081492-ANTIFUNGALS, MISCELLANEOUS Gris-PegGRISEOFULVIN ULTRAMICROSIZETABLET250 MGCOVEREDFORMULARY
7344143706081828-NEURAMINIDASE INHIBITORS TamifluOSELTAMIVIR PHOSPHATECAPSULE75 MGCOVEREDFORMULARY
9898063223081828-NEURAMINIDASE INHIBITORS TamifluOSELTAMIVIR PHOSPHATECAPSULE30 MGCOVEREDFORMULARY
9898163224081828-NEURAMINIDASE INHIBITORS TamifluOSELTAMIVIR PHOSPHATECAPSULE45 MGCOVEREDFORMULARY
2972967561081828-NEURAMINIDASE INHIBITORS TamifluOSELTAMIVIR PHOSPHATESUSP RECON6 MG/MLCOVEREDFORMULARY
9222143119081828-NEURAMINIDASE INHIBITORS RelenzaZANAMIVIRBLST W/DEV5 MGCOVEREDFORMULARY
437909630081832-NUCLEOSIDES AND NUCLEOTIDES ZoviraxACYCLOVIRCAPSULE200 MGCOVEREDFORMULARY
1372115979081832-NUCLEOSIDES AND NUCLEOTIDES ZoviraxACYCLOVIRTABLET800 MGCOVEREDFORMULARY
1372416408081832-NUCLEOSIDES AND NUCLEOTIDES ZoviraxACYCLOVIRTABLET400 MGCOVEREDFORMULARY
1417948664081832-NUCLEOSIDES AND NUCLEOTIDES RibavirinRIBAVIRINCAPSULE200 MGCOVEREDFORMULARY
1374023989081832-NUCLEOSIDES AND NUCLEOTIDES ValtrexVALACYCLOVIR HCLTABLET500 MGCOVEREDFORMULARY
1374230607081832-NUCLEOSIDES AND NUCLEOTIDES ValtrexVALACYCLOVIR HCLTABLET1000 MGCOVEREDFORMULARY
429409580083008-ANTIMALARIALS PlaquenilHYDROXYCHLOROQUINE SULFATETABLET200 MGCOVEREDFORMULARY
430319591083092-ANTIPROTOZOALS, MISCELLANEOUS FlagylMETRONIDAZOLETABLET250 MGCOVEREDFORMULARY
430329592083092-ANTIPROTOZOALS, MISCELLANEOUS FlagylMETRONIDAZOLETABLET500 MGCOVEREDFORMULARY
418709434083600-URINARY ANTI-INFECTIVES FuradantinNITROFURANTOINORAL SUSP25 MG/5MLCOVEREDFORMULARY
418209428083600-URINARY ANTI-INFECTIVES MacrodantinNITROFURANTOIN MACROCRYSTALCAPSULE100 MGCOVEREDFORMULARY
418229430083600-URINARY ANTI-INFECTIVES MacrodantinNITROFURANTOIN MACROCRYSTALCAPSULE50 MGCOVEREDFORMULARY
4900116598083600-URINARY ANTI-INFECTIVES MacrobidNITROFURANTOIN MONOHYDRATE-MACROCRYSTALCAPSULE100 MGCOVEREDFORMULARY
598735495084080-ANTIPRURITICS AND LOCAL ANESTHETICSEmla CreamLIDOCAINE/PRILOCAINECREAM (G)2.5 %-2.5%COVEREDFORMULARY
383708772100000-ANTINEOPLASTIC AGENTS LeukeranCHLORAMBUCILTABLET2 MGCOVEREDFORMULARY
384008775100000-ANTINEOPLASTIC AGENTS HydreaHYDROXYUREACAPSULE500 MGCOVEREDFORMULARY
4954129821100000-ANTINEOPLASTIC AGENTS FemaraLETROZOLETABLET2.5 MGCOVEREDFORMULARY
3355970193100000-ANTINEOPLASTIC AGENTS MegaceMEGESTROL ACETATEORAL SUSP400 MG/10MLCOVEREDFORMULARY
4038121004100000-ANTINEOPLASTIC AGENTS MegaceMEGESTROL ACETATEORAL SUSP400 MG/10MLCOVEREDFORMULARY
386818829100000-ANTINEOPLASTIC AGENTS MegaceMEGESTROL ACETATETABLET40 MGCOVEREDFORMULARY
383808773100000-ANTINEOPLASTIC AGENTS AlkeranMELPHALANTABLET2 MGCOVEREDFORMULARY
385208802100000-ANTINEOPLASTIC AGENTS MercaptopurineMERCAPTOPURINETABLET50 MGCOVEREDFORMULARY
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387208832100000-ANTINEOPLASTIC AGENTS TamoxifenTAMOXIFEN CITRATETABLET10 MGCOVEREDFORMULARY
3872113574100000-ANTINEOPLASTIC AGENTS TamoxifenTAMOXIFEN CITRATETABLET20 MGCOVEREDFORMULARY
183514740120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)UrecholineBETHANECHOL CHLORIDETABLET10 MGCOVEREDFORMULARY
183524741120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)UrecholineBETHANECHOL CHLORIDETABLET25 MGCOVEREDFORMULARY
430029334120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)AriceptDONEPEZIL HCLTABLET10 MGCOVEREDFORMULARY
430229335120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)AriceptDONEPEZIL HCLTABLET5 MGCOVEREDFORMULARY
8485346925120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)RazadyneGALANTAMINE HBRTABLET12 MGCOVEREDFORMULARY
8485446926120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)RazadyneGALANTAMINE HBRTABLET4 MGCOVEREDFORMULARY
8485546927120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)RazadyneGALANTAMINE HBRTABLET8 MGCOVEREDFORMULARY
2135353658120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)SalagenPILOCARPINE HCLTABLET7.5 MGCOVEREDFORMULARY
2467121731120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)SalagenPILOCARPINE HCLTABLET5 MGCOVEREDFORMULARY
9039640155120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)ExelonRIVASTIGMINE TARTRATECAPSULE1.5 MGCOVEREDFORMULARY
9039740156120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)ExelonRIVASTIGMINE TARTRATECAPSULE3 MGCOVEREDFORMULARY
9039840157120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)ExelonRIVASTIGMINE TARTRATECAPSULE4.5 MGCOVEREDFORMULARY
9039940158120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)ExelonRIVASTIGMINE TARTRATECAPSULE6 MGCOVEREDFORMULARY
748014902120808-ANTIMUSCARINICS/ANTISPASMODICS LibraxCHLORDIAZEPOXIDE-CLIDINIUM BRCAPSULE5-2.5 MGCOVEREDFORMULARY
192614918120808-ANTIMUSCARINICS/ANTISPASMODICS BentylDICYCLOMINE HCLCAPSULE10 MGCOVEREDFORMULARY
3471971032120808-ANTIMUSCARINICS/ANTISPASMODICS BentylDICYCLOMINE HCLSOLUTION10 MG/5MLCOVEREDFORMULARY
193314924120808-ANTIMUSCARINICS/ANTISPASMODICS BentylDICYCLOMINE HCLTABLET20 MGCOVEREDFORMULARY
1896023715120808-ANTIMUSCARINICS/ANTISPASMODICS Symax SRHYOSCYAMINE SULFATETAB ER 12H0.375 MGCOVEREDFORMULARY
1329947546120808-ANTIMUSCARINICS/ANTISPASMODICS Anaspaz, Symax FTHYOSCYAMINE SULFATETAB RAPDIS0.125 MGCOVEREDFORMULARY
189704868120808-ANTIMUSCARINICS/ANTISPASMODICS Symax SLHYOSCYAMINE SULFATETAB SUBL0.125 MGCOVEREDFORMULARY
189614865120808-ANTIMUSCARINICS/ANTISPASMODICS Levsin, OsciminHYOSCYAMINE SULFATETABLET0.125 MGCOVEREDFORMULARY
4223521700120808-ANTIMUSCARINICS/ANTISPASMODICS Ipratropium BromideIPRATROPIUM BROMIDESOLUTION0.2 MG/MLCOVEREDFORMULARY
1345648018120808-ANTIMUSCARINICS/ANTISPASMODICS Ipatropium-Albuterol InhalationIPRATROPIUM-ALBUTEROL SULFATEAMPUL-NEB0.5-3 MG/3MLCOVEREDFORMULARY
2291328090121208-BETA-ADRENERGIC AGONISTS Proventil HFAALBUTEROL SULFATEHFA AER AD90 MCGCOVEREDFORMULARY
416805040121208-BETA-ADRENERGIC AGONISTS Albuterol SulfateALBUTEROL SULFATESOLUTION5 MG/MLCOVEREDFORMULARY
227805032121208-BETA-ADRENERGIC AGONISTS Albuterol SulfateALBUTEROL SULFATESYRUP2 MG/5MLCOVEREDFORMULARY
201005033121208-BETA-ADRENERGIC AGONISTS Albuterol SulfateALBUTEROL SULFATETABLET2 MGCOVEREDFORMULARY
201015034121208-BETA-ADRENERGIC AGONISTS Albuterol SulfateALBUTEROL SULFATETABLET4 MGCOVEREDFORMULARY
416815039121208-BETA-ADRENERGIC AGONISTS Albuterol Sulfate InhalationALBUTEROL SULFATEVIAL-NEB2.5 MG/3MLCOVEREDFORMULARY
200715026121208-BETA-ADRENERGIC AGONISTS TerbutalineTERBUTALINE SULFATETABLET5 MGCOVEREDFORMULARY
200725025121208-BETA-ADRENERGIC AGONISTS TerbutalineTERBUTALINE SULFATETABLET2.5 MGCOVEREDFORMULARY
1986116878121212-ALPHA- AND BETA-ADRENERGIC AGONISTS EPINEPHRINE AUTO-INJECTEPINEPHRINEAUTO INJCT0.15 MG/0.3MLCOVEREDFORMULARY
1986216879121212-ALPHA- AND BETA-ADRENERGIC AGONISTS EPINEPHRINE AUTO-INJECTEPINEPHRINEAUTO INJCT0.3 MG/0.3MLCOVEREDFORMULARY
4819127546121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)FlomaxTAMSULOSIN HCLCAP ER 24H0.4 MGCOVEREDFORMULARY
179014660122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNTParafon ForteCHLORZOXAZONETABLET500 MGCOVEREDFORMULARY
1280547478122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNTFlexerilCYCLOBENZAPRINE HCLTABLET5 MGCOVEREDFORMULARY
180204681122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNTFlexerilCYCLOBENZAPRINE HCLTABLET10 MGCOVEREDFORMULARY
178924654122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNTRobaxinMETHOCARBAMOLTABLET500 MGCOVEREDFORMULARY
178934655122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNTRobaxinMETHOCARBAMOLTABLET750 MGCOVEREDFORMULARY
2443358904122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNTZanaflexTIZANIDINE HCLCAPSULE2 MGCOVEREDFORMULARY
2443458905122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNTZanaflexTIZANIDINE HCLCAPSULE4 MGCOVEREDFORMULARY
1469027447122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNTZanaflexTIZANIDINE HCLTABLET2 MGCOVEREDFORMULARY
1469330274122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNTZanaflexTIZANIDINE HCLTABLET4 MGCOVEREDFORMULARY
180104679122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTBaclofenBACLOFENTABLET10 MGCOVEREDFORMULARY
180114680122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTBaclofenBACLOFENTABLET20 MGCOVEREDFORMULARY
42019331201204-ANTICOAGULANTS LovenoxENOXAPARIN SODIUMSYRINGE30 MG/0.3MLCOVEREDFORMULARYLimited to 14 day supplies, Prior Auth for >14 days
4207144668201204-ANTICOAGULANTS LovenoxENOXAPARIN SODIUMSYRINGE150 MG/MLCOVEREDFORMULARYLimited to 14 day supplies, Prior Auth for >14 days
4209144669201204-ANTICOAGULANTS LovenoxENOXAPARIN SODIUMSYRINGE120 MG/0.8MLCOVEREDFORMULARYLimited to 14 day supplies, Prior Auth for >14 days
6277127993201204-ANTICOAGULANTS LovenoxENOXAPARIN SODIUMSYRINGE60 MG/0.6MLCOVEREDFORMULARYLimited to 14 day supplies, Prior Auth for >14 days
6277227994201204-ANTICOAGULANTS LovenoxENOXAPARIN SODIUMSYRINGE80 MG/0.8MLCOVEREDFORMULARYLimited to 14 day supplies, Prior Auth for >14 days
6277327995201204-ANTICOAGULANTS LovenoxENOXAPARIN SODIUMSYRINGE100 MG/MLCOVEREDFORMULARYLimited to 14 day supplies, Prior Auth for >14 days
7002239482201204-ANTICOAGULANTS LovenoxENOXAPARIN SODIUMSYRINGE40 MG/0.4MLCOVEREDFORMULARYLimited to 14 day supplies, Prior Auth for >14 days
256916549201204-ANTICOAGULANTS HeparinHEPARIN SODIUM PORCINEVIAL5000 UNIT/MLCOVEREDFORMULARY
256976544201204-ANTICOAGULANTS HeparinHEPARIN SODIUM PORCINEVIAL10000 UNIT/MLCOVEREDFORMULARY
257906559201204-ANTICOAGULANTS Coumadin, JantovenWARFARIN SODIUMTABLET10 MGCOVEREDFORMULARY
257916561201204-ANTICOAGULANTS Coumadin, JantovenWARFARIN SODIUMTABLET2 MGCOVEREDFORMULARY
2579214198201204-ANTICOAGULANTS Coumadin, JantovenWARFARIN SODIUMTABLET1 MGCOVEREDFORMULARY
257936562201204-ANTICOAGULANTS Coumadin, JantovenWARFARIN SODIUMTABLET5 MGCOVEREDFORMULARY
257946560201204-ANTICOAGULANTS Coumadin, JantovenWARFARIN SODIUMTABLET2.5 MGCOVEREDFORMULARY
257956563201204-ANTICOAGULANTS Coumadin, JantovenWARFARIN SODIUMTABLET7.5 MGCOVEREDFORMULARY
2579618080201204-ANTICOAGULANTS Coumadin, JantovenWARFARIN SODIUMTABLET3 MGCOVEREDFORMULARY
2579719486201204-ANTICOAGULANTS Coumadin, JantovenWARFARIN SODIUMTABLET4 MGCOVEREDFORMULARY
2579830475201204-ANTICOAGULANTS Coumadin, JantovenWARFARIN SODIUMTABLET6 MGCOVEREDFORMULARY
860237978201218-PLATELET-AGGREGATION INHIBITORS PletalCILOSTAZOLTABLET100 MGCOVEREDFORMULARY
860337979201218-PLATELET-AGGREGATION INHIBITORS PletalCILOSTAZOLTABLET50 MGCOVEREDFORMULARY
9601038164201218-PLATELET-AGGREGATION INHIBITORS PlavixCLOPIDOGREL BISULFATETABLET75 MGCOVEREDFORMULARY
118006573202400-HEMORRHEOLOGIC AGENTS PentoxifyllinePENTOXIFYLLINETABLET ER400 MGCOVEREDFORMULARY
255806503202816-HEMOSTATICS AmicarAMINOCAPROIC ACIDSOLUTION250 MG/MLCOVEREDFORMULARY
10920266240404-ANTIARRHYTHMIC AGENTS PaceroneAMIODARONE HCLTABLET200 MGCOVEREDFORMULARY
1130239240404-ANTIARRHYTHMIC AGENTS NorpaceDISOPYRAMIDE PHOSPHATECAPSULE100 MGCOVEREDFORMULARY
1580263240404-ANTIARRHYTHMIC AGENTS FlecainideFLECAINIDE ACETATETABLET100 MGCOVEREDFORMULARY
1581265240404-ANTIARRHYTHMIC AGENTS FlecainideFLECAINIDE ACETATETABLET50 MGCOVEREDFORMULARY
1011215240404-ANTIARRHYTHMIC AGENTS QuinidineQUINIDINE GLUCONATETABLET ER324 MGCOVEREDFORMULARY
13218240408-CARDIOTONIC AGENTS LanoxinDIGOXINTABLET125 MCGCOVEREDFORMULARY
13319240408-CARDIOTONIC AGENTS LanoxinDIGOXINTABLET250 MCGCOVEREDFORMULARY
98503100240604-BILE ACID SEQUESTRANTS PrevaliteCHOLESTYRAMINE (WITH ASPARTAME)POWD PACK4 GCOVEREDFORMULARY
9865462885240604-BILE ACID SEQUESTRANTS Questran LightCHOLESTYRAMINE (WITH ASPARTAME)POWDER4 GCOVEREDFORMULARY
992013675240604-BILE ACID SEQUESTRANTS QuestranCHOLESTYRAMINE (WITH SUGAR)POWD PACK4 GCOVEREDFORMULARY
1429548571240604-BILE ACID SEQUESTRANTS QuestranCHOLESTYRAMINE (WITH SUGAR)POWDER4 GCOVEREDFORMULARY
1259544915240606-FIBRIC ACID DERIVATIVES LofibraFENOFIBRATETABLET160 MGCOVEREDFORMULARY
1326664310240606-FIBRIC ACID DERIVATIVES LofibraFENOFIBRATETABLET54 MGCOVEREDFORMULARY
9250444305240606-FIBRIC ACID DERIVATIVES LofibraFENOFIBRATE MICRONIZEDCAPSULE134 MGCOVEREDFORMULARY
9343743060240606-FIBRIC ACID DERIVATIVES LofibraFENOFIBRATE MICRONIZEDCAPSULE200 MGCOVEREDFORMULARY
9344643061240606-FIBRIC ACID DERIVATIVES LofibraFENOFIBRATE MICRONIZEDCAPSULE67 MGCOVEREDFORMULARY
255406416240606-FIBRIC ACID DERIVATIVES LopidGEMFIBROZILTABLET600 MGCOVEREDFORMULARY
4372029967240608-HMG-COA REDUCTASE INHIBITORS LipitorATORVASTATIN CALCIUMTABLET10 MGCOVEREDFORMULARY
4372129968240608-HMG-COA REDUCTASE INHIBITORS LipitorATORVASTATIN CALCIUMTABLET20 MGCOVEREDFORMULARY
4372229969240608-HMG-COA REDUCTASE INHIBITORS LipitorATORVASTATIN CALCIUMTABLET40 MGCOVEREDFORMULARY
4372345772240608-HMG-COA REDUCTASE INHIBITORS LipitorATORVASTATIN CALCIUMTABLET80 MGCOVEREDFORMULARY
470406460240608-HMG-COA REDUCTASE INHIBITORS LovastatinLOVASTATINTABLET20 MGCOVEREDFORMULARY
470416461240608-HMG-COA REDUCTASE INHIBITORS LovastatinLOVASTATINTABLET40 MGCOVEREDFORMULARY
4704216310240608-HMG-COA REDUCTASE INHIBITORS LovastatinLOVASTATINTABLET10 MGCOVEREDFORMULARY
1541249758240608-HMG-COA REDUCTASE INHIBITORS PravacholPRAVASTATIN SODIUMTABLET80 MGCOVEREDFORMULARY
4867116366240608-HMG-COA REDUCTASE INHIBITORS PravacholPRAVASTATIN SODIUMTABLET10 MGCOVEREDFORMULARY
4867216367240608-HMG-COA REDUCTASE INHIBITORS PravacholPRAVASTATIN SODIUMTABLET20 MGCOVEREDFORMULARY
4867320741240608-HMG-COA REDUCTASE INHIBITORS PravacholPRAVASTATIN SODIUMTABLET40 MGCOVEREDFORMULARY
2653116576240608-HMG-COA REDUCTASE INHIBITORS ZocorSIMVASTATINTABLET5 MGCOVEREDFORMULARY
2653216577240608-HMG-COA REDUCTASE INHIBITORS ZocorSIMVASTATINTABLET10 MGCOVEREDFORMULARY
2653316578240608-HMG-COA REDUCTASE INHIBITORS ZocorSIMVASTATINTABLET20 MGCOVEREDFORMULARY
2653416579240608-HMG-COA REDUCTASE INHIBITORS ZocorSIMVASTATINTABLET40 MGCOVEREDFORMULARY
4233133364240692-ANTILIPEMIC AGENTS, MISCELLANEOUS Niaspan ERNIACINTAB ER 24H500 MGCOVEREDFORMULARY
4233233365240692-ANTILIPEMIC AGENTS, MISCELLANEOUS Niaspan ERNIACINTAB ER 24H750 MGCOVEREDFORMULARY
4233333366240692-ANTILIPEMIC AGENTS, MISCELLANEOUS Niaspan ERNIACINTAB ER 24H1000 MGCOVEREDFORMULARY
23870343240816-CENTRAL ALPHA-AGONISTS Catapres TTSCLONIDINEPATCH TDWK0.1 MG/24HRCOVEREDFORMULARY
23871344240816-CENTRAL ALPHA-AGONISTS Catapres TTSCLONIDINEPATCH TDWK0.2 MG/24HRCOVEREDFORMULARY
23872345240816-CENTRAL ALPHA-AGONISTS Catapres TTSCLONIDINEPATCH TDWK0.3 MG/24HRCOVEREDFORMULARY
1390346240816-CENTRAL ALPHA-AGONISTS CatapresCLONIDINE HCLTABLET0.1 MGCOVEREDFORMULARY
1391347240816-CENTRAL ALPHA-AGONISTS CatapresCLONIDINE HCLTABLET0.2 MGCOVEREDFORMULARY
1392348240816-CENTRAL ALPHA-AGONISTS CatapresCLONIDINE HCLTABLET0.3 MGCOVEREDFORMULARY
32480364240816-CENTRAL ALPHA-AGONISTS TenexGUANFACINE HCLTABLET1 MGCOVEREDFORMULARY
3248111984240816-CENTRAL ALPHA-AGONISTS TenexGUANFACINE HCLTABLET2 MGCOVEREDFORMULARY
1431361240816-CENTRAL ALPHA-AGONISTS MethyldopaMETHYLDOPATABLET250 MGCOVEREDFORMULARY
1432362240816-CENTRAL ALPHA-AGONISTS MethyldopaMETHYLDOPATABLET500 MGCOVEREDFORMULARY
1241284240820-DIRECT VASODILATORS HydralazineHYDRALAZINE HCLTABLET10 MGCOVEREDFORMULARY
1242285240820-DIRECT VASODILATORS HydralazineHYDRALAZINE HCLTABLET100 MGCOVEREDFORMULARY
1243286240820-DIRECT VASODILATORS HydralazineHYDRALAZINE HCLTABLET25 MGCOVEREDFORMULARY
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1944508241208-NITRATES AND NITRITES IsordilISOSORBIDE DINITRATETABLET20 MGCOVEREDFORMULARY
1945509241208-NITRATES AND NITRITES IsordilISOSORBIDE DINITRATETABLET30 MGCOVEREDFORMULARY
1947511241208-NITRATES AND NITRITES IsordilISOSORBIDE DINITRATETABLET5 MGCOVEREDFORMULARY
4810217297241208-NITRATES AND NITRITES Isosorbide Mononitrate ERISOSORBIDE MONONITRATETAB ER 24H60 MGCOVEREDFORMULARY
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4810424488241208-NITRATES AND NITRITES Isosorbide Mononitrate ERISOSORBIDE MONONITRATETAB ER 24H30 MGCOVEREDFORMULARY
193116639241208-NITRATES AND NITRITES Isosorbide MononitrateISOSORBIDE MONONITRATETABLET20 MGCOVEREDFORMULARY
193217294241208-NITRATES AND NITRITES Isosorbide MononitrateISOSORBIDE MONONITRATETABLET10 MGCOVEREDFORMULARY
1681455241208-NITRATES AND NITRITES Nitro-TimeNITROGLYCERINCAPSULE ER2.5 MGCOVEREDFORMULARY
1682456241208-NITRATES AND NITRITES Nitro-TimeNITROGLYCERINCAPSULE ER6.5 MGCOVEREDFORMULARY
1684457241208-NITRATES AND NITRITES Nitro-TimeNITROGLYCERINCAPSULE ER9 MGCOVEREDFORMULARY
1740465241208-NITRATES AND NITRITES MinitranNITROGLYCERINPATCH TD240.4 MG/HRCOVEREDFORMULARY
1741467241208-NITRATES AND NITRITES MinitranNITROGLYCERINPATCH TD240.1 MG/HRCOVEREDFORMULARY
1742468241208-NITRATES AND NITRITES MinitranNITROGLYCERINPATCH TD240.2 MG/HRCOVEREDFORMULARY
9225744359241208-NITRATES AND NITRITES NitrolingualNITROGLYCERINSPRAY400 MCG/SPRAYCOVEREDFORMULARY
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3343215585242000-ALPHA-ADRENERGIC BLOCKING AGENTS CarduraDOXAZOSIN MESYLATETABLET2 MGCOVEREDFORMULARY
3343315586242000-ALPHA-ADRENERGIC BLOCKING AGENTS CarduraDOXAZOSIN MESYLATETABLET4 MGCOVEREDFORMULARY
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1251292242000-ALPHA-ADRENERGIC BLOCKING AGENTS MinipressPRAZOSIN HCLCAPSULE2 MGCOVEREDFORMULARY
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32315113242400-BETA-ADRENERGIC BLOCKING AGENTS Inderal LAPROPRANOLOL HCLCAP SA 24H120 MGCOVEREDFORMULARY
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3951624097242400-BETA-ADRENERGIC BLOCKING AGENTS BetapaceSOTALOL HCLTABLET120 MGCOVEREDFORMULARY
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268316926242808-DIHYDROPYRIDINES NorvascAMLODIPINE BESYLATETABLET5 MGCOVEREDFORMULARY
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3309023768242808-DIHYDROPYRIDINES LotrelAMLODIPINE BESYLATE-BENAZEPRILCAPSULE5-20 MGCOVEREDFORMULARY
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2350568242808-DIHYDROPYRIDINES ProcardiaNIFEDIPINECAPSULE10 MGCOVEREDFORMULARY
2351569242808-DIHYDROPYRIDINES ProcardiaNIFEDIPINECAPSULE20 MGCOVEREDFORMULARY
222120616242808-DIHYDROPYRIDINES Procardia XLNIFEDIPINETAB ER 2430 MGCOVEREDFORMULARY
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222220617242808-DIHYDROPYRIDINES Procardia XLNIFEDIPINETAB ER 2460 MGCOVEREDFORMULARY
222220617242808-DIHYDROPYRIDINES Procardia XLNIFEDIPINETAB ER 2460 MGCOVEREDFORMULARY
222320618242808-DIHYDROPYRIDINES Procardia XLNIFEDIPINETAB ER 2490 MGCOVEREDFORMULARY
222320618242808-DIHYDROPYRIDINES Procardia XLNIFEDIPINETAB ER 2490 MGCOVEREDFORMULARY
222812061242808-DIHYDROPYRIDINES Adalat CCNIFEDIPINETABLET ER90 MGCOVEREDFORMULARY
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746317205242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. Dilacor XRDILTIAZEM HCLCAP ER DEG120 MGCOVEREDFORMULARY
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233324539242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. Tiazac, Taztia XTDILTIAZEM HCLCAPSULE ER300 MGCOVEREDFORMULARY
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2341564242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. CalanVERAPAMIL HCLTABLET120 MGCOVEREDFORMULARY
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4861116039243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSLotensinBENAZEPRIL HCLTABLET5 MGCOVEREDFORMULARY
4861216040243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSLotensinBENAZEPRIL HCLTABLET10 MGCOVEREDFORMULARY
4861316041243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSLotensinBENAZEPRIL HCLTABLET20 MGCOVEREDFORMULARY
4861416042243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSLotensinBENAZEPRIL HCLTABLET40 MGCOVEREDFORMULARY
3319221724243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSLotensin HCTBENAZEPRIL-HYDROCHLOROTHIAZIDETABLET10-12.5 MGCOVEREDFORMULARY
3319321725243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSLotensin HCTBENAZEPRIL-HYDROCHLOROTHIAZIDETABLET20-12.5 MGCOVEREDFORMULARY
3319421726243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSLotensin HCTBENAZEPRIL-HYDROCHLOROTHIAZIDETABLET20-25 MGCOVEREDFORMULARY
1480378243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSCaptoprilCAPTOPRILTABLET100 MGCOVEREDFORMULARY
1481380243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSCaptoprilCAPTOPRILTABLET25 MGCOVEREDFORMULARY
1482381243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSCaptoprilCAPTOPRILTABLET50 MGCOVEREDFORMULARY
1483379243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSCaptoprilCAPTOPRILTABLET12.5 MGCOVEREDFORMULARY
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960387243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSVasotecENALAPRIL MALEATETABLET5 MGCOVEREDFORMULARY
961384243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSVasotecENALAPRIL MALEATETABLET10 MGCOVEREDFORMULARY
962386243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSVasotecENALAPRIL MALEATETABLET20 MGCOVEREDFORMULARY
963385243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSVasotecENALAPRIL MALEATETABLET2.5 MGCOVEREDFORMULARY
54860382243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSEnalapril-HydrochlorothiazideENALAPRIL-HYDROCHLOROTHIAZIDETABLET10-25 MGCOVEREDFORMULARY
5486224190243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSEnalapril-HydrochlorothiazideENALAPRIL-HYDROCHLOROTHIAZIDETABLET5-12.5 MGCOVEREDFORMULARY
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88000388243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSZestoreticLISINOPRIL-HYDROCHLOROTHIAZIDETABLET20-12.5 MGCOVEREDFORMULARY
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8800221277243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSZestoreticLISINOPRIL-HYDROCHLOROTHIAZIDETABLET10-12.5 MGCOVEREDFORMULARY
2757018772243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSAccuprilQUINAPRIL HCLTABLET10 MGCOVEREDFORMULARY
2757118773243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSAccuprilQUINAPRIL HCLTABLET20 MGCOVEREDFORMULARY
2757218774243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSAccuprilQUINAPRIL HCLTABLET5 MGCOVEREDFORMULARY
2757321909243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSAccuprilQUINAPRIL HCLTABLET40 MGCOVEREDFORMULARY
5416019140243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSAccureticQUINAPRIL-HYDROCHLOROTHIAZIDETABLET10-12.5MGCOVEREDFORMULARY
5416124002243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSAccureticQUINAPRIL-HYDROCHLOROTHIAZIDETABLET20-12.5 MGCOVEREDFORMULARY
9449041016243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSAccureticQUINAPRIL-HYDROCHLOROTHIAZIDETABLET20-25MGCOVEREDFORMULARY
4854215940243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSAltaceRAMIPRILCAPSULE2.5 MGCOVEREDFORMULARY
4854315941243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSAltaceRAMIPRILCAPSULE5 MGCOVEREDFORMULARY
4854416031243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORSAltaceRAMIPRILCAPSULE10 MGCOVEREDFORMULARY
474934468243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS AvaproIRBESARTANTABLET150 MGCOVEREDFORMULARY
475034469243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS AvaproIRBESARTANTABLET300 MGCOVEREDFORMULARY
475234470243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS AvaproIRBESARTANTABLET75 MGCOVEREDFORMULARY
1104241234243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS AvalideIRBESARTAN-HYDROCHLOROTHIAZIDETABLET150-12.5 MGCOVEREDFORMULARY
1129541897243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS AvalideIRBESARTAN-HYDROCHLOROTHIAZIDETABLET300-12.5 MGCOVEREDFORMULARY
1485023381243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS CozaarLOSARTAN POTASSIUMTABLET25 MGCOVEREDFORMULARY
1485123382243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS CozaarLOSARTAN POTASSIUMTABLET50 MGCOVEREDFORMULARY
1485338686243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS CozaarLOSARTAN POTASSIUMTABLET100 MGCOVEREDFORMULARY
1485223465243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS HyzaarLOSARTAN-HYDROCHLOROTHIAZIDETABLET50-12.5 MGCOVEREDFORMULARY
1485440923243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS HyzaarLOSARTAN-HYDROCHLOROTHIAZIDETABLET100-25 MGCOVEREDFORMULARY
2585159919243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS HyzaarLOSARTAN-HYDROCHLOROTHIAZIDETABLET100-12.5 MGCOVEREDFORMULARY
9188351036243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTSInspraEPLERENONETABLET25 MGCOVEREDFORMULARY
9188351036243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTSInspraEPLERENONETABLET25 MGCOVEREDFORMULARY
9188451037243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTSInspraEPLERENONETABLET50 MGCOVEREDFORMULARY
9188451037243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTSInspraEPLERENONETABLET50 MGCOVEREDFORMULARY
276906816243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTSAldactoneSPIRONOLACTONETABLET100 MGCOVEREDFORMULARY
276916817243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTSAldactoneSPIRONOLACTONETABLET25 MGCOVEREDFORMULARY
276926818243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTSAldactoneSPIRONOLACTONETABLET50 MGCOVEREDFORMULARY
711504308280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS FiorinalBUTALBITAL-ASPIRIN-CAFFEINECAPSULE50-325-40 MGCOVEREDFORMULARY
711504308280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS FiorinalBUTALBITAL-ASPIRIN-CAFFEINECAPSULE50-325-40 MGCOVEREDFORMULARY
4568018293280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS VoltarenDICLOFENAC SODIUMGEL (GRAM)1 %COVEREDFORMULARY
1331011933280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS Diclofenac SodiumDICLOFENAC SODIUMTAB ER 24H100 MGCOVEREDFORMULARY
358508372280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS Diclofenac SodiumDICLOFENAC SODIUMTABLET DR25 MGCOVEREDFORMULARY
358518373280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS Diclofenac SodiumDICLOFENAC SODIUMTABLET DR50 MGCOVEREDFORMULARY
358528374280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS Diclofenac SodiumDICLOFENAC SODIUMTABLET DR75 MGCOVEREDFORMULARY
3387015960280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS EtodolacETODOLACCAPSULE200 MGCOVEREDFORMULARY
3387115961280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS EtodolacETODOLACCAPSULE300 MGCOVEREDFORMULARY
6176738259280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS EtodolacETODOLACTAB ER 24H500 MGCOVEREDFORMULARY
6176120175280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS EtodolacETODOLACTABLET400 MGCOVEREDFORMULARY
6176627368280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS EtodolacETODOLACTABLET500 MGCOVEREDFORMULARY
357418348280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS IbuprofenIBUPROFENTABLET400 MGCOVEREDFORMULARY
357428349280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS IbuprofenIBUPROFENTABLET600 MGCOVEREDFORMULARY
357448350280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS IbuprofenIBUPROFENTABLET800 MGCOVEREDFORMULARY
356808336280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS IndomethacinINDOMETHACINCAPSULE25 MGCOVEREDFORMULARY
356818337280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS IndomethacinINDOMETHACINCAPSULE50 MGCOVEREDFORMULARY
356908338280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS IndomethacinINDOMETHACINCAPSULE ER75 MGCOVEREDFORMULARY
3379216406280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS Ketoprofen ERKETOPROFENCAP24H PEL200 MGCOVEREDFORMULARY
344208379280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS KetoprofenKETOPROFENCAPSULE50 MGCOVEREDFORMULARY
344218380280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS KetoprofenKETOPROFENCAPSULE75 MGCOVEREDFORMULARY
3166129156280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS MobicMELOXICAMTABLET7.5 MGCOVEREDFORMULARY
3166229157280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS MobicMELOXICAMTABLET15 MGCOVEREDFORMULARY
3296116574280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS NabumetoneNABUMETONETABLET500 MGCOVEREDFORMULARY
3296216575280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS NabumetoneNABUMETONETABLET750 MGCOVEREDFORMULARY
357908360280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS NaprosynNAPROXENTABLET250 MGCOVEREDFORMULARY
357928361280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS NaprosynNAPROXENTABLET375 MGCOVEREDFORMULARY
357938362280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS NaprosynNAPROXENTABLET500 MGCOVEREDFORMULARY
471308357280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS AnaproxNAPROXEN SODIUMTABLET275 MGCOVEREDFORMULARY
471318358280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS AnaproxNAPROXEN SODIUMTABLET550 MGCOVEREDFORMULARY
168014438280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS SalsalateSALSALATETABLET500 MGCOVEREDFORMULARY
168024439280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS SalsalateSALSALATETABLET750 MGCOVEREDFORMULARY
5540245155280808-OPIATE AGONISTS Acetaminophen-Codeine SolutionACETAMINOPHEN-CODEINESOLUTION120-12 MG/5MLCOVEREDFORMULARY
701314163280808-OPIATE AGONISTS Acetaminophen-Codeine TabletACETAMINOPHEN-CODEINETABLET300-15 MGCOVEREDFORMULARY
701344165280808-OPIATE AGONISTS Tylenol-Codeine #3ACETAMINOPHEN-CODEINETABLET300-30 MGCOVEREDFORMULARY
701364169280808-OPIATE AGONISTS Tylenol-Codeine #4ACETAMINOPHEN-CODEINETABLET300-60 MGCOVEREDFORMULARY
701404149280808-OPIATE AGONISTS Butalbital-Acetaminophen-Caffeine-CodeineBUTALBITAL-ACETAMINOPHEN-CAFFEINE-CODEINECAPSULE50-325-30 MGCOVEREDFORMULARY
2114653582280808-OPIATE AGONISTS Hydrocodone-AcetaminophenHYDROCODONE-ACETAMINOPHENSOLUTION7.5-325/15COVEREDFORMULARY
1248647430280808-OPIATE AGONISTS Hydrocodone-AcetaminophenHYDROCODONE-ACETAMINOPHENTABLET5-325 MGCOVEREDFORMULARY
1248847431280808-OPIATE AGONISTS Hydrocodone-AcetaminophenHYDROCODONE-ACETAMINOPHENTABLET7.5-325 MGCOVEREDFORMULARY
7033030623280808-OPIATE AGONISTS Hydrocodone-AcetaminophenHYDROCODONE-ACETAMINOPHENTABLET10-325 MGCOVEREDFORMULARY
7033426439280808-OPIATE AGONISTS Hydrocodone-AcetaminophenHYDROCODONE-ACETAMINOPHENTABLET10-500 MGCOVEREDFORMULARY
1248847431280808-OPIATE AGONISTS Hydrocodone-AcetaminophenHYDROCODONE-ACETAMINOPHENTABLET7.5-325 MGCOVEREDFORMULARY
6310134068280808-OPIATE AGONISTS VicoprofenHYDROCODONE-IBUPROFENTABLET7.5-200 MGCOVEREDFORMULARY
161414110280808-OPIATE AGONISTS DilaudidHYDROMORPHONE HCLTABLET2 MGCOVEREDFORMULARY
161434112280808-OPIATE AGONISTS DilaudidHYDROMORPHONE HCLTABLET4 MGCOVEREDFORMULARY
1614415190280808-OPIATE AGONISTS DilaudidHYDROMORPHONE HCLTABLET8 MGCOVEREDFORMULARY
164204240280808-OPIATE AGONISTS DolophineMETHADONE HCLTABLET10 MGCOVEREDFORMULARY
164224242280808-OPIATE AGONISTS DolophineMETHADONE HCLTABLET5 MGCOVEREDFORMULARY
160604087280808-OPIATE AGONISTS MorphineMORPHINE SULFATESOLUTION10 MG/5MLCOVEREDFORMULARY
160624089280808-OPIATE AGONISTS MorphineMORPHINE SULFATESOLUTION20 MG/5MLCOVEREDFORMULARY
160634090280808-OPIATE AGONISTS MorphineMORPHINE SULFATESOLUTION100 MG/5MLCOVEREDFORMULARY
160704091280808-OPIATE AGONISTS MorphineMORPHINE SULFATETABLET15 MGCOVEREDFORMULARY
160714092280808-OPIATE AGONISTS MorphineMORPHINE SULFATETABLET30 MGCOVEREDFORMULARY
166404096280808-OPIATE AGONISTS MS Contin CRMORPHINE SULFATETABLET ER30 MGCOVEREDFORMULARY
166414097280808-OPIATE AGONISTS MS Contin CRMORPHINE SULFATETABLET ER60 MGCOVEREDFORMULARY
1664311887280808-OPIATE AGONISTS MS Contin CRMORPHINE SULFATETABLET ER15 MGCOVEREDFORMULARY
1628524507280808-OPIATE AGONISTS OxycodoneOXYCODONE HCLCAPSULE5 MGCOVEREDFORMULARY
162904225280808-OPIATE AGONISTS OxycodoneOXYCODONE HCLTABLET5 MGCOVEREDFORMULARY
1496548976280808-OPIATE AGONISTS PercocetOXYCODONE HCL-ACETAMINOPHENTABLET7.5-325MGCOVEREDFORMULARY
1496648977280808-OPIATE AGONISTS PercocetOXYCODONE HCL-ACETAMINOPHENTABLET10MG-325MGCOVEREDFORMULARY
704914222280808-OPIATE AGONISTS PercocetOXYCODONE HCL-ACETAMINOPHENTABLET5 MG-325MGCOVEREDFORMULARY
722123139280808-OPIATE AGONISTS UltramTRAMADOL HCLTABLET50 MGCOVEREDFORMULARY
1390948456280808-OPIATE AGONISTS UltracetTRAMADOL HCL-ACETAMINOPHENTABLET37.5-325MGCOVEREDFORMULARY
725104450280892-ANALGESICS AND ANTIPYRETICS, MISC. CapacetBUTALBITAL-ACETAMINOPHEN-CAFFEINECAPSULE50-325-40 MGCOVEREDFORMULARY
725304451280892-ANALGESICS AND ANTIPYRETICS, MISC. EsgicBUTALBITAL-ACETAMINOPHEN-CAFFEINETABLET50-325-40 MGCOVEREDFORMULARY
1399648520280892-ANALGESICS AND ANTIPYRETICS, MISC. NodolorISOMETHEPT-DICHLPHN/ACETAMINOPHENCAPSULE65-100-325 MGCOVEREDFORMULARY
4023375222281000-OPIATE ANTAGONISTS Narcan NasalNALOXONE HCLSPRAY4 MGCOVEREDFORMULARY
170704518281000-OPIATE ANTAGONISTS NaltrexoneNALTREXONE HCLTABLET50 MGCOVEREDFORMULARY
173214543281204-BARBITURATES (ANTICONVULSANTS) MysolinePRIMIDONETABLET250 MGCOVEREDFORMULARY
173224544281204-BARBITURATES (ANTICONVULSANTS) MysolinePRIMIDONETABLET50 MGCOVEREDFORMULARY
174704560281208-BENZODIAZEPINES (ANTICONVULSANTS) KlonopinCLONAZEPAMTABLET0.5 MGCOVEREDFORMULARY
174714561281208-BENZODIAZEPINES (ANTICONVULSANTS) KlonopinCLONAZEPAMTABLET1 MGCOVEREDFORMULARY
174724562281208-BENZODIAZEPINES (ANTICONVULSANTS) KlonopinCLONAZEPAMTABLET2 MGCOVEREDFORMULARY
172604532281212-HYDANTOINS PeganoneETHOTOINTABLET250 MGCOVEREDFORMULARY
172414529281212-HYDANTOINS DilantinPHENYTOINORAL SUSP125 MG/5MLCOVEREDFORMULARY
9955763845281212-HYDANTOINS PhenytoinPHENYTOINORAL SUSP100 MG/4MLCOVEREDFORMULARY
172504531281212-HYDANTOINS DilantinPHENYTOINTAB CHEW50 MGCOVEREDFORMULARY
1503749444281212-HYDANTOINS Dilantin, PhenytekPHENYTOIN SODIUM EXTENDEDCAPSULE300 MGCOVEREDFORMULARY
1503849445281212-HYDANTOINS Dilantin, PhenytekPHENYTOIN SODIUM EXTENDEDCAPSULE200 MGCOVEREDFORMULARY
177004521281212-HYDANTOINS Dilantin, PhenytekPHENYTOIN SODIUM EXTENDEDCAPSULE100 MGCOVEREDFORMULARY
177014522281212-HYDANTOINS Dilantin, PhenytekPHENYTOIN SODIUM EXTENDEDCAPSULE30 MGCOVEREDFORMULARY
2393258487281292-ANTICONVULSANTS, MISCELLANEOUS CarbatrolCARBAMAZEPINECPMP 12HR200 MGCOVEREDFORMULARY
2393358488281292-ANTICONVULSANTS, MISCELLANEOUS CarbatrolCARBAMAZEPINECPMP 12HR300 MGCOVEREDFORMULARY
2393458489281292-ANTICONVULSANTS, MISCELLANEOUS CarbatrolCARBAMAZEPINECPMP 12HR100 MGCOVEREDFORMULARY
475004557281292-ANTICONVULSANTS, MISCELLANEOUS CarbamazepineCARBAMAZEPINEORAL SUSP100 MG/5MLCOVEREDFORMULARY
174604559281292-ANTICONVULSANTS, MISCELLANEOUS CarbamazepineCARBAMAZEPINETAB CHEW100 MGCOVEREDFORMULARY
2782026868281292-ANTICONVULSANTS, MISCELLANEOUS Tegreol XRCARBAMAZEPINETAB ER 12H100 MGCOVEREDFORMULARY
2782116773281292-ANTICONVULSANTS, MISCELLANEOUS Tegreol XRCARBAMAZEPINETAB ER 12H200 MGCOVEREDFORMULARY
2782217876281292-ANTICONVULSANTS, MISCELLANEOUS Tegreol XRCARBAMAZEPINETAB ER 12H400 MGCOVEREDFORMULARY
174504558281292-ANTICONVULSANTS, MISCELLANEOUS TegretolCARBAMAZEPINETABLET200 MGCOVEREDFORMULARY
1804046315281292-ANTICONVULSANTS, MISCELLANEOUS Depakote ERDIVALPROEX SODIUMTAB ER 24H500 MGCOVEREDFORMULARY
1875451469281292-ANTICONVULSANTS, MISCELLANEOUS Depakote ERDIVALPROEX SODIUMTAB ER 24H250 MGCOVEREDFORMULARY
172904539281292-ANTICONVULSANTS, MISCELLANEOUS DepakoteDIVALPROEX SODIUMTABLET DR250 MGCOVEREDFORMULARY
172914540281292-ANTICONVULSANTS, MISCELLANEOUS DepakoteDIVALPROEX SODIUMTABLET DR500 MGCOVEREDFORMULARY
172924538281292-ANTICONVULSANTS, MISCELLANEOUS DepakoteDIVALPROEX SODIUMTABLET DR125 MGCOVEREDFORMULARY
78021413281292-ANTICONVULSANTS, MISCELLANEOUS NeurontinGABAPENTINCAPSULE100 MGCOVEREDFORMULARY
78121414281292-ANTICONVULSANTS, MISCELLANEOUS NeurontinGABAPENTINCAPSULE300 MGCOVEREDFORMULARY
78221415281292-ANTICONVULSANTS, MISCELLANEOUS NeurontinGABAPENTINCAPSULE400 MGCOVEREDFORMULARY
1323547927281292-ANTICONVULSANTS, MISCELLANEOUS NeurontinGABAPENTINSOLUTION250 MG/5MLCOVEREDFORMULARY
9444741806281292-ANTICONVULSANTS, MISCELLANEOUS NeurontinGABAPENTINTABLET800 MGCOVEREDFORMULARY
9462441805281292-ANTICONVULSANTS, MISCELLANEOUS NeurontinGABAPENTINTABLET600 MGCOVEREDFORMULARY
6431617871281292-ANTICONVULSANTS, MISCELLANEOUS LamictalLAMOTRIGINETABLET100 MGCOVEREDFORMULARY
6431717872281292-ANTICONVULSANTS, MISCELLANEOUS LamictalLAMOTRIGINETABLET25 MGCOVEREDFORMULARY
6432422550281292-ANTICONVULSANTS, MISCELLANEOUS LamictalLAMOTRIGINETABLET150 MGCOVEREDFORMULARY
6432522551281292-ANTICONVULSANTS, MISCELLANEOUS LamictalLAMOTRIGINETABLET200 MGCOVEREDFORMULARY
1677964819281292-ANTICONVULSANTS, MISCELLANEOUS KeppraLEVETIRACETAMSOLUTION500 MG/5MLCOVEREDFORMULARY
2035353031281292-ANTICONVULSANTS, MISCELLANEOUS KeppraLEVETIRACETAMSOLUTION100 MG/MLCOVEREDFORMULARY
4158645652281292-ANTICONVULSANTS, MISCELLANEOUS KeppraLEVETIRACETAMTABLET750 MGCOVEREDFORMULARY
4158744632281292-ANTICONVULSANTS, MISCELLANEOUS KeppraLEVETIRACETAMTABLET250 MGCOVEREDFORMULARY
4159744633281292-ANTICONVULSANTS, MISCELLANEOUS KeppraLEVETIRACETAMTABLET500 MGCOVEREDFORMULARY
8622347077281292-ANTICONVULSANTS, MISCELLANEOUS KeppraLEVETIRACETAMTABLET1000 MGCOVEREDFORMULARY
2172333724281292-ANTICONVULSANTS, MISCELLANEOUS TrileptalOXCARBAZEPINEORAL SUSP300 MG/5MLCOVEREDFORMULARY
2172127779281292-ANTICONVULSANTS, MISCELLANEOUS TrileptalOXCARBAZEPINETABLET300 MGCOVEREDFORMULARY
2172227780281292-ANTICONVULSANTS, MISCELLANEOUS TrileptalOXCARBAZEPINETABLET600 MGCOVEREDFORMULARY
2172444336281292-ANTICONVULSANTS, MISCELLANEOUS TrileptalOXCARBAZEPINETABLET150 MGCOVEREDFORMULARY
9221945100281292-ANTICONVULSANTS, MISCELLANEOUS ThioguanineTHIOGUANINETABLET40 MGCOVEREDFORMULARY
3655026169281292-ANTICONVULSANTS, MISCELLANEOUS TopamaxTOPIRAMATETABLET50 MGCOVEREDFORMULARY
3655126170281292-ANTICONVULSANTS, MISCELLANEOUS TopamaxTOPIRAMATETABLET100 MGCOVEREDFORMULARY
3655226171281292-ANTICONVULSANTS, MISCELLANEOUS TopamaxTOPIRAMATETABLET200 MGCOVEREDFORMULARY
3655329837281292-ANTICONVULSANTS, MISCELLANEOUS TopamaxTOPIRAMATETABLET25 MGCOVEREDFORMULARY
172704536281292-ANTICONVULSANTS, MISCELLANEOUS DepakeneVALPROIC ACIDCAPSULE250 MGCOVEREDFORMULARY
172804535281292-ANTICONVULSANTS, MISCELLANEOUS Depakene SyrupVALPROIC ACID (AS SODIUM SALT)SOLUTION250 MG/5MLCOVEREDFORMULARY
3096568220281292-ANTICONVULSANTS, MISCELLANEOUS Valproic SolutionVALPROIC ACID (AS SODIUM SALT)SOLUTION250 MG/5MLCOVEREDFORMULARY
3098668236281292-ANTICONVULSANTS, MISCELLANEOUS Valproic SyrupVALPROIC ACID (AS SODIUM SALT)SOLUTION500 MG/10MLCOVEREDFORMULARY
3098768237281292-ANTICONVULSANTS, MISCELLANEOUS Valproic SyrupVALPROIC ACID (AS SODIUM SALT)SYRINGE250 MG/5MLCOVEREDFORMULARY
2083153367281292-ANTICONVULSANTS, MISCELLANEOUS ZonegranZONISAMIDECAPSULE25 MGCOVEREDFORMULARY
2083353368281292-ANTICONVULSANTS, MISCELLANEOUS ZonegranZONISAMIDECAPSULE50 MGCOVEREDFORMULARY
9221945100281292-ANTICONVULSANTS, MISCELLANEOUS ZonegranZONISAMIDECAPSULE100 MGCOVEREDFORMULARY
1651246043281604-ANTIDEPRESSANTS ElavilAMITRIPTYLINE HCLTABLET10 MGCOVEREDFORMULARY
1651346044281604-ANTIDEPRESSANTS ElavilAMITRIPTYLINE HCLTABLET100 MGCOVEREDFORMULARY
1651446045281604-ANTIDEPRESSANTS ElavilAMITRIPTYLINE HCLTABLET150 MGCOVEREDFORMULARY
1651546046281604-ANTIDEPRESSANTS ElavilAMITRIPTYLINE HCLTABLET25 MGCOVEREDFORMULARY
1651646047281604-ANTIDEPRESSANTS ElavilAMITRIPTYLINE HCLTABLET50 MGCOVEREDFORMULARY
1651746048281604-ANTIDEPRESSANTS ElavilAMITRIPTYLINE HCLTABLET75 MGCOVEREDFORMULARY
2031753006281604-ANTIDEPRESSANTS Wellbutrin XLBUPROPION HCLTAB ER 24H150 MGCOVEREDFORMULARY
2031853007281604-ANTIDEPRESSANTS Wellbutrin XLBUPROPION HCLTAB ER 24H300 MGCOVEREDFORMULARY
1638446236281604-ANTIDEPRESSANTS WellbutrinBUPROPION HCLTABLET75 MGCOVEREDFORMULARY
1638546237281604-ANTIDEPRESSANTS WellbutrinBUPROPION HCLTABLET100 MGCOVEREDFORMULARY
1638646238281604-ANTIDEPRESSANTS Wellbutrin SRBUPROPION HCLTABLET ER150 MGCOVEREDFORMULARY
1638746239281604-ANTIDEPRESSANTS Wellbutrin SRBUPROPION HCLTABLET ER100 MGCOVEREDFORMULARY
1757350496281604-ANTIDEPRESSANTS Wellbutrin SRBUPROPION HCLTABLET ER200 MGCOVEREDFORMULARY
2790131439281604-ANTIDEPRESSANTS Zyban SRBUPROPION HCLTABLET ER150 MGCOVEREDFORMULARY
1634246203281604-ANTIDEPRESSANTS CelexaCITALOPRAM HYDROBROMIDETABLET20 MGCOVEREDFORMULARYMax 40mg/day
1634346204281604-ANTIDEPRESSANTS CelexaCITALOPRAM HYDROBROMIDETABLET40 MGCOVEREDFORMULARYMax 40mg/day
1634546206281604-ANTIDEPRESSANTS CelexaCITALOPRAM HYDROBROMIDETABLET10 MGCOVEREDFORMULARYMax 40mg/day
1656346086281604-ANTIDEPRESSANTS DoxepinDOXEPIN HCLCAPSULE10 MGCOVEREDFORMULARY
1656446087281604-ANTIDEPRESSANTS DoxepinDOXEPIN HCLCAPSULE100 MGCOVEREDFORMULARY
1656546088281604-ANTIDEPRESSANTS DoxepinDOXEPIN HCLCAPSULE150 MGCOVEREDFORMULARY
1656646089281604-ANTIDEPRESSANTS DoxepinDOXEPIN HCLCAPSULE25 MGCOVEREDFORMULARY
1656746090281604-ANTIDEPRESSANTS DoxepinDOXEPIN HCLCAPSULE50 MGCOVEREDFORMULARY
1656846091281604-ANTIDEPRESSANTS DoxepinDOXEPIN HCLCAPSULE75 MGCOVEREDFORMULARY
2316157891281604-ANTIDEPRESSANTS CymbaltaDULOXETINE HCLCAPSULE DR20 MGCOVEREDFORMULARY
2316257892281604-ANTIDEPRESSANTS CymbaltaDULOXETINE HCLCAPSULE DR30 MGCOVEREDFORMULARY
2316457893281604-ANTIDEPRESSANTS CymbaltaDULOXETINE HCLCAPSULE DR60 MGCOVEREDFORMULARY
3872874166281604-ANTIDEPRESSANTS CymbaltaDULOXETINE HCLCAPSULE DR40 MGCOVEREDFORMULARY
1903551698281604-ANTIDEPRESSANTS Lexapro SolutionESCITALOPRAM OXALATESOLUTION5 MG/5MLCOVEREDFORMULARYMax 20mg/day
1785150712281604-ANTIDEPRESSANTS LexaproESCITALOPRAM OXALATETABLET10 MGCOVEREDFORMULARYMax 20mg/day
1798750760281604-ANTIDEPRESSANTS LexaproESCITALOPRAM OXALATETABLET20 MGCOVEREDFORMULARYMax 20mg/day
1897551642281604-ANTIDEPRESSANTS LexaproESCITALOPRAM OXALATETABLET5 MGCOVEREDFORMULARYMax 20mg/day
1635346213281604-ANTIDEPRESSANTS ProzacFLUOXETINE HCLCAPSULE10 MGCOVEREDFORMULARY
1635446214281604-ANTIDEPRESSANTS ProzacFLUOXETINE HCLCAPSULE20 MGCOVEREDFORMULARY
1635546215281604-ANTIDEPRESSANTS ProzacFLUOXETINE HCLCAPSULE40 MGCOVEREDFORMULARY
1634846209281604-ANTIDEPRESSANTS FluvoxamineFLUVOXAMINE MALEATETABLET50 MGCOVEREDFORMULARY
1634946210281604-ANTIDEPRESSANTS FluvoxamineFLUVOXAMINE MALEATETABLET100 MGCOVEREDFORMULARY
1654146068281604-ANTIDEPRESSANTS TofranilIMIPRAMINE HCLTABLET10 MGCOVEREDFORMULARY
1654246069281604-ANTIDEPRESSANTS TofranilIMIPRAMINE HCLTABLET25 MGCOVEREDFORMULARY
1654346070281604-ANTIDEPRESSANTS TofranilIMIPRAMINE HCLTABLET50 MGCOVEREDFORMULARY
1673246450281604-ANTIDEPRESSANTS RemeronMIRTAZAPINETABLET15 MGCOVEREDFORMULARY
1673346451281604-ANTIDEPRESSANTS RemeronMIRTAZAPINETABLET30 MGCOVEREDFORMULARY
1673446452281604-ANTIDEPRESSANTS RemeronMIRTAZAPINETABLET45 MGCOVEREDFORMULARY
1652946059281604-ANTIDEPRESSANTS PamelorNORTRIPTYLINE HCLCAPSULE10 MGCOVEREDFORMULARY
1653246060281604-ANTIDEPRESSANTS PamelorNORTRIPTYLINE HCLCAPSULE25 MGCOVEREDFORMULARY
1653346061281604-ANTIDEPRESSANTS PamelorNORTRIPTYLINE HCLCAPSULE50 MGCOVEREDFORMULARY
1653446062281604-ANTIDEPRESSANTS PamelorNORTRIPTYLINE HCLCAPSULE75 MGCOVEREDFORMULARY
1707750136281604-ANTIDEPRESSANTS Paxil CRPAROXETINE HCLTAB ER 24H25 MGCOVEREDFORMULARY
1707850137281604-ANTIDEPRESSANTS Paxil CRPAROXETINE HCLTAB ER 24H12.5 MGCOVEREDFORMULARY
1707950138281604-ANTIDEPRESSANTS Paxil CRPAROXETINE HCLTAB ER 24H37.5 MGCOVEREDFORMULARY
1636446222281604-ANTIDEPRESSANTS PaxilPAROXETINE HCLTABLET10 MGCOVEREDFORMULARY
1636646223281604-ANTIDEPRESSANTS PaxilPAROXETINE HCLTABLET20 MGCOVEREDFORMULARY
1636746224281604-ANTIDEPRESSANTS PaxilPAROXETINE HCLTABLET30 MGCOVEREDFORMULARY
1636846225281604-ANTIDEPRESSANTS PaxilPAROXETINE HCLTABLET40 MGCOVEREDFORMULARY
1637346227281604-ANTIDEPRESSANTS ZoloftSERTRALINE HCLTABLET25 MGCOVEREDFORMULARY
1637446228281604-ANTIDEPRESSANTS ZoloftSERTRALINE HCLTABLET50 MGCOVEREDFORMULARY
1637546229281604-ANTIDEPRESSANTS ZoloftSERTRALINE HCLTABLET100 MGCOVEREDFORMULARY
1639146241281604-ANTIDEPRESSANTS TrazodoneTRAZODONE HCLTABLET50 MGCOVEREDFORMULARY
1639246242281604-ANTIDEPRESSANTS TrazodoneTRAZODONE HCLTABLET100 MGCOVEREDFORMULARY
1639346243281604-ANTIDEPRESSANTS TrazodoneTRAZODONE HCLTABLET150 MGCOVEREDFORMULARY
1639446244281604-ANTIDEPRESSANTS TrazodoneTRAZODONE HCLTABLET300 MGCOVEREDFORMULARY
1681646403281604-ANTIDEPRESSANTS Effexor XRVENLAFAXINE HCLCAP ER 24H37.5 MGCOVEREDFORMULARY
1681746404281604-ANTIDEPRESSANTS Effexor XRVENLAFAXINE HCLCAP ER 24H75 MGCOVEREDFORMULARY
1681846405281604-ANTIDEPRESSANTS Effexor XRVENLAFAXINE HCLCAP ER 24H150 MGCOVEREDFORMULARY
1681146398281604-ANTIDEPRESSANTS VenlafaxineVENLAFAXINE HCLTABLET25 MGCOVEREDFORMULARY
1681246399281604-ANTIDEPRESSANTS VenlafaxineVENLAFAXINE HCLTABLET37.5 MGCOVEREDFORMULARY
1681346400281604-ANTIDEPRESSANTS VenlafaxineVENLAFAXINE HCLTABLET50 MGCOVEREDFORMULARY
1681446401281604-ANTIDEPRESSANTS VenlafaxineVENLAFAXINE HCLTABLET75 MGCOVEREDFORMULARY
1681546402281604-ANTIDEPRESSANTS VenlafaxineVENLAFAXINE HCLTABLET100 MGCOVEREDFORMULARY
144313796281608-ANTIPSYCHOTIC AGENTS ChlorpromazineCHLORPROMAZINE HCLTABLET10 MGCOVEREDFORMULARY
144323799281608-ANTIPSYCHOTIC AGENTS ChlorpromazineCHLORPROMAZINE HCLTABLET25 MGCOVEREDFORMULARY
144333800281608-ANTIPSYCHOTIC AGENTS ChlorpromazineCHLORPROMAZINE HCLTABLET50 MGCOVEREDFORMULARY
144343797281608-ANTIPSYCHOTIC AGENTS ChlorpromazineCHLORPROMAZINE HCLTABLET100 MGCOVEREDFORMULARY
144353798281608-ANTIPSYCHOTIC AGENTS ChlorpromazineCHLORPROMAZINE HCLTABLET200 MGCOVEREDFORMULARY
146023823281608-ANTIPSYCHOTIC AGENTS FluphenazineFLUPHENAZINE HCLTABLET1 MGCOVEREDFORMULARY
146033824281608-ANTIPSYCHOTIC AGENTS FluphenazineFLUPHENAZINE HCLTABLET10 MGCOVEREDFORMULARY
146043825281608-ANTIPSYCHOTIC AGENTS FluphenazineFLUPHENAZINE HCLTABLET2.5 MGCOVEREDFORMULARY
146053826281608-ANTIPSYCHOTIC AGENTS FluphenazineFLUPHENAZINE HCLTABLET5 MGCOVEREDFORMULARY
155303972281608-ANTIPSYCHOTIC AGENTS HaloperidolHALOPERIDOLTABLET0.5 MGCOVEREDFORMULARY
155313973281608-ANTIPSYCHOTIC AGENTS HaloperidolHALOPERIDOLTABLET1 MGCOVEREDFORMULARY
155323974281608-ANTIPSYCHOTIC AGENTS HaloperidolHALOPERIDOLTABLET10 MGCOVEREDFORMULARY
155333975281608-ANTIPSYCHOTIC AGENTS HaloperidolHALOPERIDOLTABLET2 MGCOVEREDFORMULARY
155343976281608-ANTIPSYCHOTIC AGENTS HaloperidolHALOPERIDOLTABLET20 MGCOVEREDFORMULARY
155353977281608-ANTIPSYCHOTIC AGENTS HaloperidolHALOPERIDOLTABLET5 MGCOVEREDFORMULARY
155203971281608-ANTIPSYCHOTIC AGENTS HaloperidolHALOPERIDOL LACTATEORAL CONC2 MG/MLCOVEREDFORMULARY
155603981281608-ANTIPSYCHOTIC AGENTS LoxapineLOXAPINE SUCCINATECAPSULE10 MGCOVEREDFORMULARY
155613982281608-ANTIPSYCHOTIC AGENTS LoxapineLOXAPINE SUCCINATECAPSULE25 MGCOVEREDFORMULARY
155633984281608-ANTIPSYCHOTIC AGENTS LoxapineLOXAPINE SUCCINATECAPSULE50 MGCOVEREDFORMULARY
1508127959281608-ANTIPSYCHOTIC AGENTS ZyprexaOLANZAPINETABLET7.5 MGCOVEREDFORMULARY
1508227960281608-ANTIPSYCHOTIC AGENTS ZyprexaOLANZAPINETABLET10 MGCOVEREDFORMULARY
1508327961281608-ANTIPSYCHOTIC AGENTS ZyprexaOLANZAPINETABLET5 MGCOVEREDFORMULARY
1508429077281608-ANTIPSYCHOTIC AGENTS ZyprexaOLANZAPINETABLET2.5 MGCOVEREDFORMULARY
1508541026281608-ANTIPSYCHOTIC AGENTS ZyprexaOLANZAPINETABLET15 MGCOVEREDFORMULARY
1508641027281608-ANTIPSYCHOTIC AGENTS ZyprexaOLANZAPINETABLET20 MGCOVEREDFORMULARY
146503830281608-ANTIPSYCHOTIC AGENTS PerphenazinePERPHENAZINETABLET16 MGCOVEREDFORMULARY
146513831281608-ANTIPSYCHOTIC AGENTS PerphenazinePERPHENAZINETABLET2 MGCOVEREDFORMULARY
146523832281608-ANTIPSYCHOTIC AGENTS PerphenazinePERPHENAZINETABLET4 MGCOVEREDFORMULARY
146533833281608-ANTIPSYCHOTIC AGENTS PerphenazinePERPHENAZINETABLET8 MGCOVEREDFORMULARY
2640960292281608-ANTIPSYCHOTIC AGENTS SeroquelQUETIAPINE FUMARATETABLET50 MGCOVEREDFORMULARYMax 800mg/day
2641160293281608-ANTIPSYCHOTIC AGENTS SeroquelQUETIAPINE FUMARATETABLET400 MGCOVEREDFORMULARYMax 800mg/day
6766134187281608-ANTIPSYCHOTIC AGENTS SeroquelQUETIAPINE FUMARATETABLET25 MGCOVEREDFORMULARYMax 800mg/day
6766234188281608-ANTIPSYCHOTIC AGENTS SeroquelQUETIAPINE FUMARATETABLET100 MGCOVEREDFORMULARYMax 800mg/day
6766334189281608-ANTIPSYCHOTIC AGENTS SeroquelQUETIAPINE FUMARATETABLET200 MGCOVEREDFORMULARYMax 800mg/day
6766547198281608-ANTIPSYCHOTIC AGENTS SeroquelQUETIAPINE FUMARATETABLET300 MGCOVEREDFORMULARYMax 800mg/day
1613526177281608-ANTIPSYCHOTIC AGENTS RisperdalRISPERIDONESOLUTION1 MG/MLCOVEREDFORMULARYMax 16mg/day
1613621154281608-ANTIPSYCHOTIC AGENTS RisperdalRISPERIDONETABLET1 MGCOVEREDFORMULARYMax 16mg/day
1613721155281608-ANTIPSYCHOTIC AGENTS RisperdalRISPERIDONETABLET2 MGCOVEREDFORMULARYMax 16mg/day
1613821156281608-ANTIPSYCHOTIC AGENTS RisperdalRISPERIDONETABLET3 MGCOVEREDFORMULARYMax 16mg/day
1613921157281608-ANTIPSYCHOTIC AGENTS RisperdalRISPERIDONETABLET4 MGCOVEREDFORMULARYMax 16mg/day
9287242922281608-ANTIPSYCHOTIC AGENTS RisperdalRISPERIDONETABLET0.25 MGCOVEREDFORMULARYMax 16mg/day
9289242923281608-ANTIPSYCHOTIC AGENTS RisperdalRISPERIDONETABLET0.5 MGCOVEREDFORMULARYMax 16mg/day
156913996281608-ANTIPSYCHOTIC AGENTS ThiothixeneTHIOTHIXENECAPSULE10 MGCOVEREDFORMULARY
156923997281608-ANTIPSYCHOTIC AGENTS ThiothixeneTHIOTHIXENECAPSULE2 MGCOVEREDFORMULARY
156943999281608-ANTIPSYCHOTIC AGENTS ThiothixeneTHIOTHIXENECAPSULE5 MGCOVEREDFORMULARY
198805009282004-AMPHETAMINES ZenzediDEXTROAMPHETAMINE SULFATETABLET10 MGCOVEREDFORMULARYMax 60mg/day
198815011282004-AMPHETAMINES ZenzediDEXTROAMPHETAMINE SULFATETABLET5 MGCOVEREDFORMULARYMax 60mg/day
1463548701282004-AMPHETAMINES Adderall XRDEXTROAMPHETAMINE-AMPHETAMINECAP ER 24H10 MGCOVEREDFORMULARYMax 60mg/day
1463648702282004-AMPHETAMINES Adderall XRDEXTROAMPHETAMINE-AMPHETAMINECAP ER 24H20 MGCOVEREDFORMULARYMax 60mg/day
1463748703282004-AMPHETAMINES Adderall XRDEXTROAMPHETAMINE-AMPHETAMINECAP ER 24H30 MGCOVEREDFORMULARYMax 60mg/day
1745950428282004-AMPHETAMINES Adderall XRDEXTROAMPHETAMINE-AMPHETAMINECAP ER 24H5 MGCOVEREDFORMULARYMax 60mg/day
1746850429282004-AMPHETAMINES Adderall XRDEXTROAMPHETAMINE-AMPHETAMINECAP ER 24H15 MGCOVEREDFORMULARYMax 60mg/day
1746950430282004-AMPHETAMINES Adderall XRDEXTROAMPHETAMINE-AMPHETAMINECAP ER 24H25 MGCOVEREDFORMULARYMax 60mg/day
2900747131282004-AMPHETAMINES AdderallDEXTROAMPHETAMINE-AMPHETAMINETABLET7.5 MGCOVEREDFORMULARYMax 60mg/day
2900847132282004-AMPHETAMINES AdderallDEXTROAMPHETAMINE-AMPHETAMINETABLET12.5 MGCOVEREDFORMULARYMax 60mg/day
2900947133282004-AMPHETAMINES AdderallDEXTROAMPHETAMINE-AMPHETAMINETABLET15 MGCOVEREDFORMULARYMax 60mg/day
569704999282004-AMPHETAMINES AdderallDEXTROAMPHETAMINE-AMPHETAMINETABLET5 MGCOVEREDFORMULARYMax 60mg/day
569715000282004-AMPHETAMINES AdderallDEXTROAMPHETAMINE-AMPHETAMINETABLET10 MGCOVEREDFORMULARYMax 60mg/day
5697234359282004-AMPHETAMINES AdderallDEXTROAMPHETAMINE-AMPHETAMINETABLET30 MGCOVEREDFORMULARYMax 60mg/day
569735001282004-AMPHETAMINES AdderallDEXTROAMPHETAMINE-AMPHETAMINETABLET20 MGCOVEREDFORMULARYMax 60mg/day
2038453056282032-RESPIRATORY AND CNS STIMULANTSMetadate CDMETHYLPHENIDATE HCLCPBP 30-7010 MGCOVEREDFORMULARYMax 100mg/day
2038553057282032-RESPIRATORY AND CNS STIMULANTSMetadate CDMETHYLPHENIDATE HCLCPBP 30-7020 MGCOVEREDFORMULARYMax 100mg/day
2038653058282032-RESPIRATORY AND CNS STIMULANTSMetadate CDMETHYLPHENIDATE HCLCPBP 30-7030 MGCOVEREDFORMULARYMax 100mg/day
2673460545282032-RESPIRATORY AND CNS STIMULANTSMetadate CDMETHYLPHENIDATE HCLCPBP 30-7040 MGCOVEREDFORMULARYMax 100mg/day
2673560546282032-RESPIRATORY AND CNS STIMULANTSMetadate CDMETHYLPHENIDATE HCLCPBP 30-7050 MGCOVEREDFORMULARYMax 100mg/day
2673660547282032-RESPIRATORY AND CNS STIMULANTSMetadate CDMETHYLPHENIDATE HCLCPBP 30-7060 MGCOVEREDFORMULARYMax 100mg/day
2038753059282032-RESPIRATORY AND CNS STIMULANTSRitalin LAMETHYLPHENIDATE HCLCPBP 50-5020 MGCOVEREDFORMULARYMax 100mg/day
2038853060282032-RESPIRATORY AND CNS STIMULANTSRitalin LAMETHYLPHENIDATE HCLCPBP 50-5030 MGCOVEREDFORMULARYMax 100mg/day
2039153061282032-RESPIRATORY AND CNS STIMULANTSRitalin LAMETHYLPHENIDATE HCLCPBP 50-5040 MGCOVEREDFORMULARYMax 100mg/day
159114026282032-RESPIRATORY AND CNS STIMULANTSRitalinMETHYLPHENIDATE HCLTABLET10 MGCOVEREDFORMULARYMax 100mg/day
159134028282032-RESPIRATORY AND CNS STIMULANTSRitalinMETHYLPHENIDATE HCLTABLET5 MGCOVEREDFORMULARYMax 100mg/day
159204027282032-RESPIRATORY AND CNS STIMULANTSRitalinMETHYLPHENIDATE HCLTABLET20 MGCOVEREDFORMULARYMax 100mg/day
161804029282032-RESPIRATORY AND CNS STIMULANTSMethylphenidate ERMETHYLPHENIDATE HCLTABLET ER20 MGCOVEREDFORMULARYMax 100mg/day
9307544072282032-RESPIRATORY AND CNS STIMULANTSMethylphenidate ERMETHYLPHENIDATE HCLTABLET ER10 MGCOVEREDFORMULARYMax 100mg/day
129563586282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) PhenobarbitalPHENOBARBITALELIXIR20 MG/5 MLCOVEREDFORMULARY
129713589282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) PhenobarbitalPHENOBARBITALTABLET15 MGCOVEREDFORMULARY
129723591282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) PhenobarbitalPHENOBARBITALTABLET60 MGCOVEREDFORMULARY
129733590282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) PhenobarbitalPHENOBARBITALTABLET30 MGCOVEREDFORMULARY
129753588282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) PhenobarbitalPHENOBARBITALTABLET100 MGCOVEREDFORMULARY
9796527611282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) PhenobarbitalPHENOBARBITALTABLET32.4 MGCOVEREDFORMULARY
9796627612282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) PhenobarbitalPHENOBARBITALTABLET64.8 MGCOVEREDFORMULARY
142603773282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)XanaxALPRAZOLAMTABLET0.25 MGCOVEREDFORMULARY
142613774282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)XanaxALPRAZOLAMTABLET0.5 MGCOVEREDFORMULARY
142623775282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)XanaxALPRAZOLAMTABLET1 MGCOVEREDFORMULARY
1426315566282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)XanaxALPRAZOLAMTABLET2 MGCOVEREDFORMULARY
140313734282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)ChlordiazepoxideCHLORDIAZEPOXIDE HCLCAPSULE10 MGCOVEREDFORMULARY
140323735282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)ChlordiazepoxideCHLORDIAZEPOXIDE HCLCAPSULE25 MGCOVEREDFORMULARY
140903744282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)TranxeneCLORAZEPATE DIPOTASSIUMTABLET15 MGCOVEREDFORMULARY
140923745282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)TranxeneCLORAZEPATE DIPOTASSIUMTABLET3.75 MGCOVEREDFORMULARY
140933746282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)TranxeneCLORAZEPATE DIPOTASSIUMTABLET7.5 MGCOVEREDFORMULARY
142203766282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)ValiumDIAZEPAMTABLET10 MGCOVEREDFORMULARY
142213767282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)ValiumDIAZEPAMTABLET2 MGCOVEREDFORMULARY
142223768282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)ValiumDIAZEPAMTABLET5 MGCOVEREDFORMULARY
142503691282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)FlurazepamFLURAZEPAM HCLCAPSULE15 MGCOVEREDFORMULARY
142513692282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)FlurazepamFLURAZEPAM HCLCAPSULE30 MGCOVEREDFORMULARY
141603757282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)AtivanLORAZEPAMTABLET0.5 MGCOVEREDFORMULARY
141613758282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)AtivanLORAZEPAMTABLET1 MGCOVEREDFORMULARY
141623759282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)AtivanLORAZEPAMTABLET2 MGCOVEREDFORMULARY
142303769282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)OxazepamOXAZEPAMCAPSULE10 MGCOVEREDFORMULARY
142313770282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)OxazepamOXAZEPAMCAPSULE15 MGCOVEREDFORMULARY
142323771282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)OxazepamOXAZEPAMCAPSULE30 MGCOVEREDFORMULARY
138403689282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)RestorilTEMAZEPAMCAPSULE15 MGCOVEREDFORMULARY
138413690282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)RestorilTEMAZEPAMCAPSULE30 MGCOVEREDFORMULARY
1384519182282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)RestorilTEMAZEPAMCAPSULE7.5 MGCOVEREDFORMULARY
1303747644282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.BusparBUSPIRONE HCLTABLET7.5 MGCOVEREDFORMULARY
288903782282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.BusparBUSPIRONE HCLTABLET5 MGCOVEREDFORMULARY
288913781282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.BusparBUSPIRONE HCLTABLET10 MGCOVEREDFORMULARY
2889227378282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.BusparBUSPIRONE HCLTABLET15 MGCOVEREDFORMULARY
9212144210282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.BusparBUSPIRONE HCLTABLET30 MGCOVEREDFORMULARY
139323725282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.HydroxyzineHYDROXYZINE HCLSOLUTION10 MG/5MLCOVEREDFORMULARY
139413726282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.HydroxyzineHYDROXYZINE HCLTABLET10 MGCOVEREDFORMULARY
139433728282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.HydroxyzineHYDROXYZINE HCLTABLET25 MGCOVEREDFORMULARY
139443729282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.HydroxyzineHYDROXYZINE HCLTABLET50 MGCOVEREDFORMULARY
139513730282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.VistarilHYDROXYZINE PAMOATECAPSULE100 MGCOVEREDFORMULARY
139523731282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.VistarilHYDROXYZINE PAMOATECAPSULE25 MGCOVEREDFORMULARY
139533732282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.VistarilHYDROXYZINE PAMOATECAPSULE50 MGCOVEREDFORMULARY
87019187282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.AmbienZOLPIDEM TARTRATETABLET5 MGCOVEREDFORMULARYMax 10mg/day
87119188282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.AmbienZOLPIDEM TARTRATETABLET10 MGCOVEREDFORMULARYMax 10mg/day
157104001282800-ANTIMANIC AGENTS LithiumLITHIUM CARBONATECAPSULE300 MGCOVEREDFORMULARY
157114000282800-ANTIMANIC AGENTS LithiumLITHIUM CARBONATECAPSULE150 MGCOVEREDFORMULARY
157214003282800-ANTIMANIC AGENTS LithiumLITHIUM CARBONATETABLET300 MGCOVEREDFORMULARY
157304005282800-ANTIMANIC AGENTS LithobidLITHIUM CARBONATETABLET ER450 MGCOVEREDFORMULARY
157314004282800-ANTIMANIC AGENTS LithobidLITHIUM CARBONATETABLET ER300 MGCOVEREDFORMULARY
5074030735283228-SELECTIVE SEROTONIN AGONISTS Imitrex NasalSUMATRIPTANSPRAY5 MGCOVEREDFORMULARYMax 2 boxes/month
5074430742283228-SELECTIVE SEROTONIN AGONISTS Imitrex NasalSUMATRIPTANSPRAY20 MGCOVEREDFORMULARYMax 2 boxes/month
2470819239283228-SELECTIVE SEROTONIN AGONISTS Imitrex StatdoseSUMATRIPTAN SUCCINATECARTRIDGE6 MG/0.5MLCOVEREDFORMULARYMax 2 boxes/month
5074119192283228-SELECTIVE SEROTONIN AGONISTS Imitrex StatdoseSUMATRIPTAN SUCCINATEPEN INJCTR6 MG/0.5MLCOVEREDFORMULARYMax 2 boxes/month
570022479283228-SELECTIVE SEROTONIN AGONISTS ImitrexSUMATRIPTAN SUCCINATETABLET50 MGCOVEREDFORMULARYMax 9 tablets/month
570117129283228-SELECTIVE SEROTONIN AGONISTS ImitrexSUMATRIPTAN SUCCINATETABLET100 MGCOVEREDFORMULARYMax 9 tablets/month
570223799283228-SELECTIVE SEROTONIN AGONISTS ImitrexSUMATRIPTAN SUCCINATETABLET25 MGCOVEREDFORMULARYMax 9 tablets/month
5074219193283228-SELECTIVE SEROTONIN AGONISTS ImitrexSUMATRIPTAN SUCCINATEVIAL6 MG/0.5MLCOVEREDFORMULARYMax 2 boxes/month
175204575283604-ADAMANTANES (CNS)AmantadineAMANTADINE HCLCAPSULE100 MGCOVEREDFORMULARY
175304576283604-ADAMANTANES (CNS)AmantadineAMANTADINE HCLSOLUTION50 MG/5MLCOVEREDFORMULARY
1752127637283604-ADAMANTANES (CNS)AmantadineAMANTADINE HCLTABLET100 MGCOVEREDFORMULARY
176204589283608-ANTICHOLINERGIC AGENTS (CNS)CogentinBENZTROPINE MESYLATETABLET0.5 MGCOVEREDFORMULARY
176214590283608-ANTICHOLINERGIC AGENTS (CNS)CogentinBENZTROPINE MESYLATETABLET1 MGCOVEREDFORMULARY
176224591283608-ANTICHOLINERGIC AGENTS (CNS)CogentinBENZTROPINE MESYLATETABLET2 MGCOVEREDFORMULARY
175614581283608-ANTICHOLINERGIC AGENTS (CNS)TrihexyphenidylTRIHEXYPHENIDYL HCLTABLET2 MGCOVEREDFORMULARY
175634582283608-ANTICHOLINERGIC AGENTS (CNS)TrihexyphenidylTRIHEXYPHENIDYL HCLTABLET5 MGCOVEREDFORMULARY
9507941199283612-CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.ComtanENTACAPONETABLET200 MGCOVEREDFORMULARY
2328557987283616-DOPAMINE PRECURSORSCarbidopa-LevodopaCARBIDOPA-LEVODOPATAB RAPDIS10-100 MGCOVEREDFORMULARY
2328657988283616-DOPAMINE PRECURSORSCarbidopa-LevodopaCARBIDOPA-LEVODOPATAB RAPDIS25-100 MGCOVEREDFORMULARY
2328757989283616-DOPAMINE PRECURSORSCarbidopa-LevodopaCARBIDOPA-LEVODOPATAB RAPDIS25-250 MGCOVEREDFORMULARY
627402537283616-DOPAMINE PRECURSORSSinemetCARBIDOPA-LEVODOPATABLET10-100 MGCOVEREDFORMULARY
627412538283616-DOPAMINE PRECURSORSSinemetCARBIDOPA-LEVODOPATABLET25-100 MGCOVEREDFORMULARY
627422539283616-DOPAMINE PRECURSORSSinemetCARBIDOPA-LEVODOPATABLET25-250 MGCOVEREDFORMULARY
6259116043283616-DOPAMINE PRECURSORSSinemet CRCARBIDOPA-LEVODOPATABLET ER50-200 MGCOVEREDFORMULARY
6259219563283616-DOPAMINE PRECURSORSSinemet CRCARBIDOPA-LEVODOPATABLET ER25-100 MGCOVEREDFORMULARY
260706603283620-DOPAMINE RECEPTOR AGONISTSParlodelBROMOCRIPTINE MESYLATECAPSULE5 MGCOVEREDFORMULARY
260816604283620-DOPAMINE RECEPTOR AGONISTSParlodelBROMOCRIPTINE MESYLATETABLET2.5 MGCOVEREDFORMULARY
2605125738283620-DOPAMINE RECEPTOR AGONISTSCabergolineCABERGOLINETABLET0.5 MGCOVEREDFORMULARY
1987131779283620-DOPAMINE RECEPTOR AGONISTSMirapexPRAMIPEXOLETABLET1 MGCOVEREDFORMULARY
1987231780283620-DOPAMINE RECEPTOR AGONISTSMirapexPRAMIPEXOLETABLET1.5 MGCOVEREDFORMULARY
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2772965703561600-DIGESTANTS ZenpepLIPASE/PROTEASE/AMYLASECAPSULE DR20-68-109KNOT COVEREDPAPContact manufacturer for PAP
3059767944561600-DIGESTANTS ZenpepLIPASE/PROTEASE/AMYLASECAPSULE DR3K-10K-16KNOT COVEREDPAPContact manufacturer for PAP
3059867945561600-DIGESTANTS ZenpepLIPASE/PROTEASE/AMYLASECAPSULE DR25-85-136KNOT COVEREDPAPContact manufacturer for PAP
3759273217561600-DIGESTANTS ZenpepLIPASE/PROTEASE/AMYLASECAPSULE DR40K-136KNOT COVEREDPAPContact manufacturer for PAP
147613844562208-ANTIHISTAMINES (GI DRUGS) ProchlorperazinePROCHLORPERAZINESUPP.RECT25 MGCOVEREDFORMULARY
147713846562208-ANTIHISTAMINES (GI DRUGS) ProchlorperazinePROCHLORPERAZINE MALEATETABLET10 MGCOVEREDFORMULARY
147733848562208-ANTIHISTAMINES (GI DRUGS) ProchlorperazinePROCHLORPERAZINE MALEATETABLET5 MGCOVEREDFORMULARY
2004541562562220-5-HT3 RECEPTOR ANTAGONISTS Zofran ODTONDANSETRONTAB RAPDIS4 MGCOVEREDFORMULARY
2004641563562220-5-HT3 RECEPTOR ANTAGONISTS Zofran ODTONDANSETRONTAB RAPDIS8 MGCOVEREDFORMULARY
2004028107562220-5-HT3 RECEPTOR ANTAGONISTS ZofranONDANSETRON HCLSOLUTION4 MG/5MLCOVEREDFORMULARYRestricted to age <19
2004116392562220-5-HT3 RECEPTOR ANTAGONISTS ZofranONDANSETRON HCLTABLET4 MGCOVEREDFORMULARY
2004216393562220-5-HT3 RECEPTOR ANTAGONISTS ZofranONDANSETRON HCLTABLET8 MGCOVEREDFORMULARY
4596011676562812-HISTAMINE H2-ANTAGONISTS PepcidFAMOTIDINEORAL SUSP40 MG/5MLCOVEREDFORMULARY
4643011677562812-HISTAMINE H2-ANTAGONISTS PepcidFAMOTIDINETABLET20 MGCOVEREDFORMULARY
4643111678562812-HISTAMINE H2-ANTAGONISTS PepcidFAMOTIDINETABLET40 MGCOVEREDFORMULARY
1955116223562812-HISTAMINE H2-ANTAGONISTS RanitidineRANITIDINE HCLCAPSULE150 MGCOVEREDFORMULARY
1955216224562812-HISTAMINE H2-ANTAGONISTS RanitidineRANITIDINE HCLCAPSULE300 MGCOVEREDFORMULARY
1209011672562812-HISTAMINE H2-ANTAGONISTS RanitidineRANITIDINE HCLSYRUP15 MG/MLCOVEREDFORMULARY
1020011673562812-HISTAMINE H2-ANTAGONISTS ZantacRANITIDINE HCLTABLET150 MGCOVEREDFORMULARY
1020111674562812-HISTAMINE H2-ANTAGONISTS ZantacRANITIDINE HCLTABLET300 MGCOVEREDFORMULARY
82502767562828-PROSTAGLANDINS CytotecMISOPROSTOLTABLET200 MCGCOVEREDFORMULARY
825115197562828-PROSTAGLANDINS CytotecMISOPROSTOLTABLET100 MCGCOVEREDFORMULARY
765116133562832-PROTECTANTS CarafateSUCRALFATEORAL SUSP1 G/10 MLCOVEREDFORMULARY
82002766562832-PROTECTANTS CarafateSUCRALFATETABLET1 GCOVEREDFORMULARY
4012027462562836-PROTON-PUMP INHIBITORS ProtonixPANTOPRAZOLE SODIUMTABLET DR40 MGCOVEREDFORMULARY
9597639545562836-PROTON-PUMP INHIBITORS ProtonixPANTOPRAZOLE SODIUMTABLET DR20 MGCOVEREDFORMULARY
36105230563200-PROKINETIC AGENTS MetoclopramideMETOCLOPRAMIDE HCLSOLUTION5 MG/5MLCOVEREDFORMULARY
3479871108563200-PROKINETIC AGENTS MetoclopramideMETOCLOPRAMIDE HCLSOLUTION10 MG/10MLCOVEREDFORMULARY
210205231563200-PROKINETIC AGENTS ReglanMETOCLOPRAMIDE HCLTABLET10 MGCOVEREDFORMULARY
210215232563200-PROKINETIC AGENTS ReglanMETOCLOPRAMIDE HCLTABLET5 MGCOVEREDFORMULARY
274126782680400-ADRENALS DexamethasoneDEXAMETHASONEDROPS1 MG/MLCOVEREDFORMULARY
274226784680400-ADRENALS DexamethasoneDEXAMETHASONETABLET0.5 MGCOVEREDFORMULARY
274246787680400-ADRENALS DexamethasoneDEXAMETHASONETABLET1 MGCOVEREDFORMULARY
274256785680400-ADRENALS DexamethasoneDEXAMETHASONETABLET0.75 MGCOVEREDFORMULARY
274266788680400-ADRENALS DexamethasoneDEXAMETHASONETABLET2 MGCOVEREDFORMULARY
274286789680400-ADRENALS DexamethasoneDEXAMETHASONETABLET4 MGCOVEREDFORMULARY
274296790680400-ADRENALS DexamethasoneDEXAMETHASONETABLET6 MGCOVEREDFORMULARY
276806812680400-ADRENALS FludrocortisoneFLUDROCORTISONE ACETATETABLET0.1 MGCOVEREDFORMULARY
267816703680400-ADRENALS CortefHYDROCORTISONETABLET10 MGCOVEREDFORMULARY
267826704680400-ADRENALS CortefHYDROCORTISONETABLET20 MGCOVEREDFORMULARY
267836705680400-ADRENALS CortefHYDROCORTISONETABLET5 MGCOVEREDFORMULARY
3749945311680400-ADRENALS Medrol DosepakMETHYLPREDNISOLONETAB DS PK4 MGCOVEREDFORMULARY
270566741680400-ADRENALS MedrolMETHYLPREDNISOLONETABLET4 MGCOVEREDFORMULARY
268006719680400-ADRENALS PrednisolonePREDNISOLONESOLUTION15 MG/5 MLCOVEREDFORMULARY
3380647282680400-ADRENALS Prednisolone Sodium PhosphatePREDNISOLONE SOD PHOSPHATESOLUTION15 MG/5 MLCOVEREDFORMULARY
3836345267680400-ADRENALS PrednisonePREDNISONETAB DS PK5 MGCOVEREDFORMULARY
3836445268680400-ADRENALS PrednisonePREDNISONETAB DS PK10 MGCOVEREDFORMULARY
271716748680400-ADRENALS PrednisonePREDNISONETABLET1 MGCOVEREDFORMULARY
271726749680400-ADRENALS PrednisonePREDNISONETABLET10 MGCOVEREDFORMULARY
271736750680400-ADRENALS PrednisonePREDNISONETABLET2.5 MGCOVEREDFORMULARY
271746751680400-ADRENALS PrednisonePREDNISONETABLET20 MGCOVEREDFORMULARY
271766753680400-ADRENALS PrednisonePREDNISONETABLET5 MGCOVEREDFORMULARY
271776754680400-ADRENALS PrednisonePREDNISONETABLET50 MGCOVEREDFORMULARY
4785145215680800-ANDROGENS Androgel 1%TESTOSTERONEGEL PACKET25 MG(1%)COVEREDFORMULARY
4785245216680800-ANDROGENS Androgel 1%TESTOSTERONEGEL PACKET50 MG (1%)COVEREDFORMULARY
1812650831681200-CONTRACEPTIVESOrtho Tri-Cyclen LoNORGESTIMATE-ETHINYL ESTRADIOLTABLET7DAYSX3 LOCOVEREDFORMULARY
1308347787681200-CONTRACEPTIVES YasminETHINYL ESTRADIOL-DROSPIRENONETABLET0.03-3 MGCOVEREDFORMULARY
115303314681200-CONTRACEPTIVES Altavera, Chateal, Kurvelo, Levora, Marlissa, PortiaLEVONORGESTREL-ETHINYL ESTRADIOLTABLET0.15-0.03 MGCOVEREDFORMULARY
1153430986681200-CONTRACEPTIVES Aviane, Aubra, Delyla, Falmina, Lessina, Lutera, Orsythia, SronyxLEVONORGESTREL-ETHINYL ESTRADIOLTABLET0.1-0.02 MGCOVEREDFORMULARY
115313315681200-CONTRACEPTIVES Enpresse, Trivora, MyzilraLEVONORGESTREL-ETHINYL ESTRADIOLTABLET50-30(6)/75-40(5)/125/30(10) MCGCOVEREDFORMULARY
115203313681200-CONTRACEPTIVES Ortho Micronor, Errin, Camila, Deblitane, Sharobel, Norlyro, Nor-Be, Jolivette, Jencycla, HeatherNORETHINDRONETABLET0.35 MGCOVEREDFORMULARY
114803304681200-CONTRACEPTIVES Gildess, Junel, Larin, Loestrin 21 1.5/30NORETHINDRONE ACETATE-ETHINYL ESTRADIOLTABLET1.5-30 MCGCOVEREDFORMULARY
114813305681200-CONTRACEPTIVES Gildess, Junel, Larin, Loestrin 21 1/20NORETHINDRONE ACETATE-ETHINYL ESTRADIOLTABLET1-20 MCGCOVEREDFORMULARY
114773298681200-CONTRACEPTIVES Alyacen 7/7/7, Cyclafem 7/7/7, Diasetta 7/7/7, Necon 7/7/7, Nortrel 7/7/7, Ortho-Novum 7/7/7NORETHINDRONE-ETHINYL ESTRADIOLTABLET0.5/0.75/1 MG-35MCGCOVEREDFORMULARY
114743295681200-CONTRACEPTIVES Alyacen, Cyclafem, Dasetta, Necon 1/35, Nortrel 1/35, Norinyl, Ortho Novum, PrimellaNORETHINDRONE-ETHINYL ESTRADIOLTABLET1-0.35 MGCOVEREDFORMULARY
114713294681200-CONTRACEPTIVES Brevicon, Modicone, Necon 0.5/35, Nortrel 0.5/35, WeraNORETHINDRONE-ETHINYL ESTRADIOLTABLET0.5-0.35 MGCOVEREDFORMULARY
681013300681200-CONTRACEPTIVES Blisovi FE, Gildess FE, Junel FE, Larin FE, Loestrin FE 1.5/30 NORETHINDRONE-ETHINYL ESTRADIOL-IRONTABLET1.5MG-30 MCG(21)/75MG(7)COVEREDFORMULARY
681023301681200-CONTRACEPTIVES Blisovi FE, Gildess FE, Junel FE, Larin FE, Loestrin FE 1/20 NORETHINDRONE-ETHINYL ESTRADIOL-IRONTABLET1 MG-20 MCG(21)/75MG(7)COVEREDFORMULARY
1130013662681200-CONTRACEPTIVES Estarylla, Mononessa, Ortho-Cyclen, Previfem, SprintecNORGESTIMATE-ETHINYL ESTRADIOLTABLET0.25-0.035 MGCOVEREDFORMULARY
1130116963681200-CONTRACEPTIVES Tri-Estarylla, Tri-Mononessa, Otrho Tri-Cyclen, Tri-Previfem, Tri-SprintecNORGESTIMATE-ETHINYL ESTRADIOLTABLET0.18/0.215/0.25 MG-35MCG(28)COVEREDFORMULARY
115003310681200-CONTRACEPTIVES Low-Ogestrel, Elinest, CryselleNORGESTREL-ETHINYL ESTRADIOLTABLET0.3 MG-30MCGCOVEREDFORMULARY
107703204681604-ESTROGENS EstraceESTRADIOLTABLET1 MGCOVEREDFORMULARY
107713205681604-ESTROGENS EstraceESTRADIOLTABLET2 MGCOVEREDFORMULARY
1077221411681604-ESTROGENS EstraceESTRADIOLTABLET0.5 MGCOVEREDFORMULARY
1973952179681604-ESTROGENS PremproESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATETABLET0.45-1.5 MGCOVEREDFORMULARY
2076953321681604-ESTROGENS PremproESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATETABLET0.3-1.5 MGCOVEREDFORMULARY
5573022647681604-ESTROGENS PremproESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATETABLET0.625-5 MGCOVEREDFORMULARY
5573122648681604-ESTROGENS PremproESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATETABLET0.625-2.5 MGCOVEREDFORMULARY
284107013681604-ESTROGENS Premarin VaginalESTROGENS CONJUGATEDCREAM/APPL0.625 MG/GCOVEREDFORMULARY
109423212681604-ESTROGENS PremarinESTROGENS CONJUGATEDTABLET0.625 MGCOVEREDFORMULARY
109433211681604-ESTROGENS PremarinESTROGENS CONJUGATEDTABLET0.3 MGCOVEREDFORMULARY
109443213681604-ESTROGENS PremarinESTROGENS CONJUGATEDTABLET0.9 MGCOVEREDFORMULARY
109453214681604-ESTROGENS PremarinESTROGENS CONJUGATEDTABLET1.25 MGCOVEREDFORMULARY
1997552766681604-ESTROGENS PremarinESTROGENS CONJUGATEDTABLET0.45MGCOVEREDFORMULARY
5901137022681612-ESTROGEN AGONIST-ANTAGONISTS EvistaRALOXIFENE HCLTABLET60 MGCOVEREDFORMULARY
1957852080682004-BIGUANIDES Glucophage XRMETFORMIN HCLTAB ER 24H750 MGCOVEREDFORMULARY
8986346754682004-BIGUANIDES Glucophage XRMETFORMIN HCLTAB ER 24H500 MGCOVEREDFORMULARY
1081013318682004-BIGUANIDES GlucophageMETFORMIN HCLTABLET500 MGCOVEREDFORMULARY
1081116441682004-BIGUANIDES GlucophageMETFORMIN HCLTABLET850 MGCOVEREDFORMULARY
1085740974682004-BIGUANIDES GlucophageMETFORMIN HCLTABLET1000 MGCOVEREDFORMULARY
9233644341682008-INSULINS Novolog FlexpenINSULIN ASPARTINSULN PEN100 UNIT/MLCOVEREDFORMULARY
9232644340682008-INSULINS NovologINSULIN ASPARTVIAL100 UNIT/MLCOVEREDFORMULARY
1707550134682008-INSULINS Novolog 70/30 FlexpenINSULIN ASPART PROTAMINE-INSULIN ASPARTINSULN PEN70-30 UNIT/MLCOVEREDFORMULARY
1905751718682008-INSULINS Novolog 70/30INSULIN ASPART PROTAMINE-INSULIN ASPARTVIAL70-30 UNIT/MLCOVEREDFORMULARY
2283657439682008-INSULINS Levemir FlexTouchINSULIN DETEMIRINSULN PEN100 UNIT/MLCOVEREDFORMULARY
2530559586682008-INSULINS LevemirINSULIN DETEMIRVIAL100 UNIT/MLCOVEREDFORMULARY
9671934731682008-INSULINS Humalog Kwik PenINSULIN LISPROINSULN PEN100 UNIT/MLCOVEREDFORMULARY
567927413682008-INSULINS HumalogINSULIN LISPROVIAL100 UNIT/MLCOVEREDFORMULARY
116601740682008-INSULINS Novolin NINSULIN NPH HUMAN ISOPHANEVIAL100 UNIT/MLCOVEREDFORMULARY
5000116311682008-INSULINS Novolin 70/30INSULIN NPH HUM-REG INSULIN HMVIAL70-30 UNIT/MLCOVEREDFORMULARY
9371742076682008-INSULINS Humalog 75/25 Kwik PenINSULIN NPL-INSULIN LISPROINSULN PEN75-25 UNIT/MLCOVEREDFORMULARY
2268147172682008-INSULINS Humalog 75/25INSULIN NPL-INSULIN LISPROVIAL75-25 UNIT/MLCOVEREDFORMULARY
116421723682008-INSULINS Novolin RINSULIN REGULAR HUMANVIAL100 UNIT/MLCOVEREDFORMULARY
1227747333682016-MEGLITINIDES StarlixNATEGLINIDETABLET60 MGCOVEREDFORMULARY
3402747292682016-MEGLITINIDES StarlixNATEGLINIDETABLET120 MGCOVEREDFORMULARY
583025179682020-SULFONYLUREAS AmarylGLIMEPIRIDETABLET1 MGCOVEREDFORMULARY
583225180682020-SULFONYLUREAS AmarylGLIMEPIRIDETABLET2 MGCOVEREDFORMULARY
583325181682020-SULFONYLUREAS AmarylGLIMEPIRIDETABLET4 MGCOVEREDFORMULARY
1084321839682020-SULFONYLUREAS Glucotrol XLGLIPIZIDETAB ER 2410 MGCOVEREDFORMULARY
1084421840682020-SULFONYLUREAS Glucotrol XLGLIPIZIDETAB ER 245 MGCOVEREDFORMULARY
5063843463682020-SULFONYLUREAS Glucotrol XLGLIPIZIDETAB ER 242.5 MGCOVEREDFORMULARY
108401777682020-SULFONYLUREAS GlucotrolGLIPIZIDETABLET5 MGCOVEREDFORMULARY
108411776682020-SULFONYLUREAS GlucotrolGLIPIZIDETABLET10 MGCOVEREDFORMULARY
1836651194682020-SULFONYLUREAS Glipizide-MetforminGLIPIZIDE-METFORMIN HCLTABLET2.5-250 MGCOVEREDFORMULARY
1836751195682020-SULFONYLUREAS Glipizide-MetforminGLIPIZIDE-METFORMIN HCLTABLET2.5-500 MGCOVEREDFORMULARY
1836851196682020-SULFONYLUREAS Glipizide-MetforminGLIPIZIDE-METFORMIN HCLTABLET5-500 MGCOVEREDFORMULARY
57101773682020-SULFONYLUREAS DiabetaGLYBURIDETABLET1.25 MGCOVEREDFORMULARY
57111774682020-SULFONYLUREAS DiabetaGLYBURIDETABLET2.5 MGCOVEREDFORMULARY
57121775682020-SULFONYLUREAS DiabetaGLYBURIDETABLET5 MGCOVEREDFORMULARY
8987845929682020-SULFONYLUREAS GlucovanceGLYBURIDE-METFORMIN HCLTABLET1.25-250 MGCOVEREDFORMULARY
8987945930682020-SULFONYLUREAS GlucovanceGLYBURIDE-METFORMIN HCLTABLET5-500 MGCOVEREDFORMULARY
9288922735682020-SULFONYLUREAS GlucovanceGLYBURIDE-METFORMIN HCLTABLET2.5-500 MGCOVEREDFORMULARY
9299142943682028-THIAZOLIDINEDIONES ActosPIOGLITAZONE HCLTABLET15 MGCOVEREDFORMULARY
9300142944682028-THIAZOLIDINEDIONES ActosPIOGLITAZONE HCLTABLET30 MGCOVEREDFORMULARY
9301142945682028-THIAZOLIDINEDIONES ActosPIOGLITAZONE HCLTABLET45 MGCOVEREDFORMULARY
2547441661682212-GLYCOGENOLYTIC AGENTS GlucagonGLUCAGON HUMAN RECOMBINANTKIT1 MGCOVEREDFORMULARY
2547341660682212-GLYCOGENOLYTIC AGENTS GlucagenGLUCAGON HUMAN RECOMBINANTVIAL1 MGCOVEREDFORMULARY
2328124138682400-PARATHYROID Miacalcin NasalCALCITONIN SALMON SYNTHETICSPRAY/PUMP200 UNIT/SPRAYCOVEREDFORMULARY
2617331610682800-PITUITARY DDAVP NasalDESMOPRESSIN (NONREFRIGERATED)SPRAY/PUMP10 MCG/SPRAYCOVEREDFORMULARY
261706617682800-PITUITARY DDAVPDESMOPRESSIN ACETATESOLUTION0.1 MG/MLCOVEREDFORMULARY
2617119596682800-PITUITARY DDAVPDESMOPRESSIN ACETATETABLET0.1 MGCOVEREDFORMULARY
2617219597682800-PITUITARY DDAVPDESMOPRESSIN ACETATETABLET0.2 MGCOVEREDFORMULARY
112603271683200-PROGESTINS ProveraMEDROXYPROGESTERONE ACETATETABLET10 MGCOVEREDFORMULARY
112613272683200-PROGESTINS ProveraMEDROXYPROGESTERONE ACETATETABLET2.5 MGCOVEREDFORMULARY
112623273683200-PROGESTINS ProveraMEDROXYPROGESTERONE ACETATETABLET5 MGCOVEREDFORMULARY
112803274683200-PROGESTINS AygestinNORETHINDRONE ACETATETABLET5 MGCOVEREDFORMULARY
9858662815683200-PROGESTINS Endometrin VaginalPROGESTERONE MICRONIZEDINSERT100 MGCOVEREDFORMULARY
263206652683604-THYROID AGENTS LevothyroxineLEVOTHYROXINE SODIUMTABLET112 MCGCOVEREDFORMULARY
263216648683604-THYROID AGENTS LevothyroxineLEVOTHYROXINE SODIUMTABLET25 MCGCOVEREDFORMULARY
263226649683604-THYROID AGENTS LevothyroxineLEVOTHYROXINE SODIUMTABLET50 MCGCOVEREDFORMULARY
263236651683604-THYROID AGENTS LevothyroxineLEVOTHYROXINE SODIUMTABLET100 MCGCOVEREDFORMULARY
263246650683604-THYROID AGENTS LevothyroxineLEVOTHYROXINE SODIUMTABLET75 MCGCOVEREDFORMULARY
263256656683604-THYROID AGENTS LevothyroxineLEVOTHYROXINE SODIUMTABLET200 MCGCOVEREDFORMULARY
263266653683604-THYROID AGENTS LevothyroxineLEVOTHYROXINE SODIUMTABLET125 MCGCOVEREDFORMULARY
263276654683604-THYROID AGENTS LevothyroxineLEVOTHYROXINE SODIUMTABLET150 MCGCOVEREDFORMULARY
263286655683604-THYROID AGENTS LevothyroxineLEVOTHYROXINE SODIUMTABLET175MCGCOVEREDFORMULARY
263296657683604-THYROID AGENTS LevothyroxineLEVOTHYROXINE SODIUMTABLET300 MCGCOVEREDFORMULARY
4763115523683604-THYROID AGENTS LevothyroxineLEVOTHYROXINE SODIUMTABLET88 MCGCOVEREDFORMULARY
4763220176683604-THYROID AGENTS LevothyroxineLEVOTHYROXINE SODIUMTABLET137 MCGCOVEREDFORMULARY
263406658683604-THYROID AGENTS CytomelLIOTHYRONINE SODIUMTABLET25 MCGCOVEREDFORMULARY
263416659683604-THYROID AGENTS CytomelLIOTHYRONINE SODIUMTABLET5 MCGCOVEREDFORMULARY
263426660683604-THYROID AGENTS CytomelLIOTHYRONINE SODIUMTABLET50 MCGCOVEREDFORMULARY
264006674683608-ANTITHYROID AGENTS TapazoleMETHIMAZOLETABLET10 MGCOVEREDFORMULARY
264016675683608-ANTITHYROID AGENTS TapazoleMETHIMAZOLETABLET5 MGCOVEREDFORMULARY
2858116924840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) Cleocin VaginalCLINDAMYCIN PHOSPHATECREAM/APPL2 %COVEREDFORMULARY
454107726840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) Cleocin TCLINDAMYCIN PHOSPHATEGEL (GRAM)1 %COVEREDFORMULARY
3177011752840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) Cleocin TCLINDAMYCIN PHOSPHATELOTION1 %COVEREDFORMULARY
317207727840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) Cleocin TCLINDAMYCIN PHOSPHATESOLUTION1 %COVEREDFORMULARY
7756229325840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) Erythromycin with EthanolERYTHROMYCIN BASE (WITH ETHANOL)SOLUTION2 %COVEREDFORMULARY
4320341799840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) Metrocream, RosadanMETRONIDAZOLECREAM (G)0.75 %COVEREDFORMULARY
2492659325840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) MetrogelMETRONIDAZOLEGEL (GRAM)1 %COVEREDFORMULARY
4320241798840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) RosadanMETRONIDAZOLEGEL (GRAM)0.75 %COVEREDFORMULARY
4926116939840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) Metrogel VaginalMETRONIDAZOLEGEL W/APPL0.75 %COVEREDFORMULARY
3177468879840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) Metrogel PumpMETRONIDAZOLEGEL W/PUMP1 %COVEREDFORMULARY
4320141797840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) MetrolotionMETRONIDAZOLELOTION0.75 %COVEREDFORMULARY
474507732840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) BactrobanMUPIROCINOINT. (G)2 %COVEREDFORMULARY
854597694840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) Triple Antibiotic OintmentNEOMYCIN-BACITRACIN-POLYMYXIN BOINT. (G)3.5-400-5000 MG/G-UNIT/G-UNIT/GCOVEREDFORMULARY
1427448538840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) CortisporinNEOMYCIN-BACITRACIN-POLYMYXIN B-HYDROCORTISONEOINT. (G)3.5-400-10000-1 MG/G-UNIT/G-UNIT/G-%COVEREDFORMULARY
1427548539840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) CortisporinNEOMYCIN-POLYMYXIN B-HYDROCORTISONECREAM (G)3.5-10000-0.50 MG/G-UNIT/G-%COVEREDFORMULARY
6242018315840406-ANTIVIRALS (SKIN & MUCOUS MEMBRANE) ZoviraxACYCLOVIRCREAM (G)5 %COVEREDFORMULARY
316407670840406-ANTIVIRALS (SKIN & MUCOUS MEMBRANE) ZoviraxACYCLOVIROINT. (G)5 %COVEREDFORMULARY
1261844922840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) CiclopiroxCICLOPIROXGEL (GRAM)0.77 %COVEREDFORMULARY
1921851825840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) Loprox ShampooCICLOPIROXSHAMPOO1 %COVEREDFORMULARY
804037020840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) Ciclodan, PenlacCICLOPIROXSOLUTION8 %COVEREDFORMULARY
9467740971840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) Ciclopirox OlamineCICLOPIROX OLAMINECREAM (G)0.77 %COVEREDFORMULARY
303807362840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) ClotrimazoleCLOTRIMAZOLESOLUTION1 %COVEREDFORMULARY
75909553840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) MycelexCLOTRIMAZOLETROCHE10 MGCOVEREDFORMULARY
691936534840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) LotrisoneCLOTRIMAZOLE-BETAMETHASONE DIPROPIONATECREAM (G)1-0.05 %COVEREDFORMULARY
1412548627840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) Clotrimazole-BetamethasoneCLOTRIMAZOLE-BETAMETHASONE DIPROPIONATELOTION1-0.05 %COVEREDFORMULARY
318507334840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) KetoconazoleKETOCONAZOLECREAM (G)2 %COVEREDFORMULARY
3127115568840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) Nizoral ShampooKETOCONAZOLESHAMPOO2 %COVEREDFORMULARY
301407282840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) NystatinNYSTATINCREAM (G)100000 UNIT/GCOVEREDFORMULARY
301507283840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) NystatinNYSTATINOINT. (G)100000 UNIT/GCOVEREDFORMULARY
301607284840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) NystatinNYSTATINPOWDER100000 UNIT/GCOVEREDFORMULARY
1400748529840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) Nystatin/TriamcinoloneNYSTATIN-TRIAMCINCINOLONECREAM (G)100000-0.1 UNIT/G-%COVEREDFORMULARY
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483807008840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) Terazol 7TERCONAZOLECREAM/APPL0.4 %COVEREDFORMULARY
315507650840412-SCABICIDES AND PEDICULICIDES LindaneLINDANELOTION1 %COVEREDFORMULARY
315707651840412-SCABICIDES AND PEDICULICIDES LindaneLINDANESHAMPOO1 %COVEREDFORMULARY
4437013631840412-SCABICIDES AND PEDICULICIDES ElimitePERMETHRINCREAM (G)5 %COVEREDFORMULARY
445207663840412-SCABICIDES AND PEDICULICIDES NixPERMETHRINLIQUID1 %COVEREDFORMULARY
316307669840492-LOCAL ANTI-INFECTIVES, MISCELLANEOUS SilvadeneSILVER SULFADIAZINECREAM (G)1 %COVEREDFORMULARY
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319107562840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)DiproleneBETAMETHASONE-PROPYLENE GLYCOLOINT. (G)0.05 %COVEREDFORMULARY
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321307635840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)TemovateCLOBETASOL PROPIONATEOINT. (G)0.05 %COVEREDFORMULARY
1589115349840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)CormaxCLOBETASOL PROPIONATESOLUTION0.05 %COVEREDFORMULARY
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314257620840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)DesonideDESONIDECREAM (G)0.05 %COVEREDFORMULARY
314307622840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)DesonideDESONIDEOINT. (G)0.05 %COVEREDFORMULARY
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421219477840800-ANTIPRURITICS AND LOCAL ANESTHETICS PyridiumPHENAZOPYRIDINE HCLTABLET100 MGCOVEREDFORMULARY
421229478840800-ANTIPRURITICS AND LOCAL ANESTHETICS PyridiumPHENAZOPYRIDINE HCLTABLET200 MGCOVEREDFORMULARY
2229111998841200-ASTRINGENTS DrysolALUMINUM CHLORIDESOLUTION20 %COVEREDFORMULARY
228805800841600-CELL STIMULANTS AND PROLIFERANTS Retin-ATRETINOINCREAM (G)0.05 %COVEREDFORMULARY
228815801841600-CELL STIMULANTS AND PROLIFERANTS Retin-ATRETINOINCREAM (G)0.01 %COVEREDFORMULARY
228825799841600-CELL STIMULANTS AND PROLIFERANTS Retin-ATRETINOINCREAM (G)0.025 %COVEREDFORMULARY
228705797841600-CELL STIMULANTS AND PROLIFERANTS Retin-ATRETINOINGEL (GRAM)0.01 %COVEREDFORMULARY
228715798841600-CELL STIMULANTS AND PROLIFERANTS Retin-ATRETINOINGEL (GRAM)0.025 %COVEREDFORMULARY
1744350417841600-CELL STIMULANTS AND PROLIFERANTS Retin-A MicroTRETINOIN MICROSPHERESGEL (GRAM)0.04 %COVEREDFORMULARY
2287430614841600-CELL STIMULANTS AND PROLIFERANTS Retin-A MicroTRETINOIN MICROSPHERESGEL (GRAM)0.1 %COVEREDFORMULARY
3177668881841600-CELL STIMULANTS AND PROLIFERANTS Retin-A Micro PumpTRETINOIN MICROSPHERESGEL W/PUMP0.04 %COVEREDFORMULARY
3177768882841600-CELL STIMULANTS AND PROLIFERANTS Retin-A Micro PumpTRETINOIN MICROSPHERESGEL W/PUMP0.1 %COVEREDFORMULARY
6344745214841600-CELL STIMULANTS AND PROLIFERANTS RefissaTRETINOIN-EMOLLIENT BASECREAM (G)0.05 %COVEREDFORMULARY
229315813842800-KERATOLYTIC AGENTS Benzoyl PeroxideBENZOYL PEROXIDEGEL (GRAM)5 %COVEREDFORMULARY
2477416308842800-KERATOLYTIC AGENTS UreaUREACREAM (G)40 %COVEREDFORMULARY
6287418229849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. AzelexAZELAIC ACIDCREAM (G)20 %COVEREDFORMULARY
185121134849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. DovonexCALCIPOTRIENECREAM (G)0.01 %COVEREDFORMULARY
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5420131099849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. AldaraIMIQUIMODCREAM PACK5 %COVEREDFORMULARY
1534849724849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ElidelPIMECROLIMUSCREAM (G)1 %COVEREDFORMULARY
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2345115942849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. CondyloxPODOFILOXSOLUTION0.5 %COVEREDFORMULARY
193704928 861204-ANTIMUSCARINICSOxybutyninOXYBUTYNIN CHLORIDESYRUP5 MG/5 MLCOVEREDFORMULARY
1938841046861204-ANTIMUSCARINICSOxybutynin EROXYBUTYNIN CHLORIDETAB ER 245 MGCOVEREDFORMULARY
1938941047861204-ANTIMUSCARINICSOxybutynin EROXYBUTYNIN CHLORIDETAB ER 2410 MGCOVEREDFORMULARY
9355742606861204-ANTIMUSCARINICSOxybutynin EROXYBUTYNIN CHLORIDETAB ER 2415 MGCOVEREDFORMULARY
193804929 861204-ANTIMUSCARINICSDitropanOXYBUTYNIN CHLORIDETABLET5 MGCOVEREDFORMULARY
41090861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS Theophylline ERTHEOPHYLLINE ANHYDROUSTAB ER 12H100 MGCOVEREDFORMULARY
41191861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS Theophylline ERTHEOPHYLLINE ANHYDROUSTAB ER 12H200 MGCOVEREDFORMULARY
41393861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS Theophylline ERTHEOPHYLLINE ANHYDROUSTAB ER 12H300 MGCOVEREDFORMULARY
944812184881600-VITAMIN D RocaltrolCALCITRIOLCAPSULE0.25 MCGCOVEREDFORMULARY
944822185881600-VITAMIN D RocaltrolCALCITRIOLCAPSULE0.5 MCGCOVEREDFORMULARY
9842562651881600-VITAMIN D Cholecalciferol (Vitamin D3)CHOLECALCIFEROL (VITAMIN D3)CAPSULE50000 UNITCOVEREDFORMULARY
944222169881600-VITAMIN D DrisdolERGOCALCIFEROL (VITAMIN D2)CAPSULE50000 UNITCOVEREDFORMULARY
947112305882400-VITAMIN K ACTIVITY MephytonPHYTONADIONETABLET5 MGCOVEREDFORMULARY
28811192920400-ALCOHOL DETERRENTSAntabuseDISULFIRAMTABLET250 MGCOVEREDFORMULARY
3052141440920800-5-ALPHA-REDUCTASE INHIBITORSProscarFINASTERIDETABLET5 MGCOVEREDFORMULARY
70702535921600-ANTIGOUT AGENTSZyloprimALLOPURINOLTABLET100 MGCOVEREDFORMULARY
70712536921600-ANTIGOUT AGENTSZyloprimALLOPURINOLTABLET300 MGCOVEREDFORMULARY
356748334921600-ANTIGOUT AGENTSColcrysCOLCHICINETABLET0.6 MGCOVEREDFORMULARYMax 6 tablets/month, Enroll in PAP for more.
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2168024053922400-BONE RESORPTION INHIBITORSFosamaxALENDRONATE SODIUMTABLET10 MGCOVEREDFORMULARY
2168231006922400-BONE RESORPTION INHIBITORSFosamaxALENDRONATE SODIUMTABLET5 MGCOVEREDFORMULARY
8536146941922400-BONE RESORPTION INHIBITORSFosamaxALENDRONATE SODIUMTABLET70 MGCOVEREDFORMULARY
6703140549923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTSAravaLEFLUNOMIDETABLET10 MGCOVEREDFORMULARY
6703240550923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTSAravaLEFLUNOMIDETABLET20 MGCOVEREDFORMULARY
4677111682924400-IMMUNOSUPPRESSIVE AGENTSImuranAZATHIOPRINETABLET50 MGCOVEREDFORMULARY
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9420050622940000-DEVICES Pen Needle 31 G x 1/4"PEN NEEDLE DIABETICDIS NEEDLE31 G X 1/4"COVEREDFORMULARY
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9420050622940000-DEVICES Pen Needle 31 G x 1/4"PEN NEEDLE DIABETICDIS NEEDLE31 G X 1/4"COVEREDFORMULARY
9420050622940000-DEVICES Pen Needle 31 G x 1/4"PEN NEEDLE DIABETICDIS NEEDLE31 G X 1/4"COVEREDFORMULARY
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9420049394940000-DEVICES Insulin Syringe 0.3mL 30 G x 5/16"SYRING W-NDL DISP INSUL 0.3 MLDISP SYRIN30G X 5/16"COVEREDFORMULARY
9420049394940000-DEVICES Insulin Syringe 0.3mL 30 G x 5/16"SYRING W-NDL DISP INSUL 0.3 MLDISP SYRIN30G X 5/16"COVEREDFORMULARY
9420049394940000-DEVICES Insulin Syringe 0.3mL 30 G x 5/16"SYRING W-NDL DISP INSUL 0.3 MLDISP SYRIN30G X 5/16"COVEREDFORMULARY
9420049394940000-DEVICES Insulin Syringe 0.3mL 30 G x 5/16"SYRING W-NDL DISP INSUL 0.3 MLDISP SYRIN30G X 5/16"COVEREDFORMULARY
9420049394940000-DEVICES Insulin Syringe 0.3mL 30 G x 5/16"SYRING W-NDL DISP INSUL 0.3 MLDISP SYRIN30G X 5/16"COVEREDFORMULARY
9420049394940000-DEVICES Insulin Syringe 0.3mL 30 G x 5/16"SYRING W-NDL DISP INSUL 0.3 MLDISP SYRIN30G X 5/16"COVEREDFORMULARY
9420049394940000-DEVICES Insulin Syringe 0.3mL 30 G x 5/16"SYRING W-NDL DISP INSUL 0.3 MLDISP SYRIN30G X 5/16"COVEREDFORMULARY
9420049403940000-DEVICES Insulin Syringe 0.3mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.3 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049403940000-DEVICES Insulin Syringe 0.3mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.3 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049403940000-DEVICES Insulin Syringe 0.3mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.3 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049403940000-DEVICES Insulin Syringe 0.3mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.3 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049403940000-DEVICES Insulin Syringe 0.3mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.3 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049403940000-DEVICES Insulin Syringe 0.3mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.3 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049403940000-DEVICES Insulin Syringe 0.3mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.3 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049403940000-DEVICES Insulin Syringe 0.3mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.3 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049276940000-DEVICES Insulin Syringe 0.5mL 28GX1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN28 G X 1/2"COVEREDFORMULARY
9420049276940000-DEVICES Insulin Syringe 0.5mL 28GX1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN28 G X 1/2"COVEREDFORMULARY
9420049276940000-DEVICES Insulin Syringe 0.5mL 28GX1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN28 G X 1/2"COVEREDFORMULARY
9420049276940000-DEVICES Insulin Syringe 0.5mL 28GX1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN28 G X 1/2"COVEREDFORMULARY
9420049276940000-DEVICES Insulin Syringe 0.5mL 28GX1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN28 G X 1/2"COVEREDFORMULARY
9420049276940000-DEVICES Insulin Syringe 0.5mL 28GX1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN28 G X 1/2"COVEREDFORMULARY
9420049383940000-DEVICES Insulin Syringe 0.5mL 29 G X1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN29 G X 1/2"COVEREDFORMULARY
9420049383940000-DEVICES Insulin Syringe 0.5mL 29 G X1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN29 G X 1/2"COVEREDFORMULARY
9420049383940000-DEVICES Insulin Syringe 0.5mL 29 G X1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN29 G X 1/2"COVEREDFORMULARY
9420049383940000-DEVICES Insulin Syringe 0.5mL 29 G X1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN29 G X 1/2"COVEREDFORMULARY
9420049383940000-DEVICES Insulin Syringe 0.5mL 29 G X1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN29 G X 1/2"COVEREDFORMULARY
9420049383940000-DEVICES Insulin Syringe 0.5mL 29 G X1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN29 G X 1/2"COVEREDFORMULARY
9420049383940000-DEVICES Insulin Syringe 0.5mL 29 G X1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN29 G X 1/2"COVEREDFORMULARY
9420049395940000-DEVICES Insulin Syringe 0.5mL 30GX 5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN30G X 5/16"COVEREDFORMULARY
9420049395940000-DEVICES Insulin Syringe 0.5mL 30GX 5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN30G X 5/16"COVEREDFORMULARY
9420049395940000-DEVICES Insulin Syringe 0.5mL 30GX 5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN30G X 5/16"COVEREDFORMULARY
9420049395940000-DEVICES Insulin Syringe 0.5mL 30GX 5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN30G X 5/16"COVEREDFORMULARY
9420049395940000-DEVICES Insulin Syringe 0.5mL 30GX 5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN30G X 5/16"COVEREDFORMULARY
9420049395940000-DEVICES Insulin Syringe 0.5mL 30GX 5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN30G X 5/16"COVEREDFORMULARY
9420049395940000-DEVICES Insulin Syringe 0.5mL 30GX 5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN30G X 5/16"COVEREDFORMULARY
9420049400940000-DEVICES Insulin Syringe 0.5mL 30GX1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN30 G X 1/2"COVEREDFORMULARY
9420049400940000-DEVICES Insulin Syringe 0.5mL 30GX1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN30 G X 1/2"COVEREDFORMULARY
9420049400940000-DEVICES Insulin Syringe 0.5mL 30GX1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN30 G X 1/2"COVEREDFORMULARY
9420049400940000-DEVICES Insulin Syringe 0.5mL 30GX1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN30 G X 1/2"COVEREDFORMULARY
9420049404940000-DEVICES Insulin Syringe 0.5mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049404940000-DEVICES Insulin Syringe 0.5mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049404940000-DEVICES Insulin Syringe 0.5mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049404940000-DEVICES Insulin Syringe 0.5mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049404940000-DEVICES Insulin Syringe 0.5mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049404940000-DEVICES Insulin Syringe 0.5mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049404940000-DEVICES Insulin Syringe 0.5mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049404940000-DEVICES Insulin Syringe 0.5mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049404940000-DEVICES Insulin Syringe 0.5mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049275940000-DEVICES Insulin Syringe 1mL 28GX1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN28 G X 1/2"COVEREDFORMULARY
9420049275940000-DEVICES Insulin Syringe 1mL 28GX1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN28 G X 1/2"COVEREDFORMULARY
9420049275940000-DEVICES Insulin Syringe 1mL 28GX1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN28 G X 1/2"COVEREDFORMULARY
9420049275940000-DEVICES Insulin Syringe 1mL 28GX1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN28 G X 1/2"COVEREDFORMULARY
9420049275940000-DEVICES Insulin Syringe 1mL 28GX1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN28 G X 1/2"COVEREDFORMULARY
9420049275940000-DEVICES Insulin Syringe 1mL 28GX1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN28 G X 1/2"COVEREDFORMULARY
9420049275940000-DEVICES Insulin Syringe 1mL 28GX1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN28 G X 1/2"COVEREDFORMULARY
9420049384940000-DEVICES Insulin Syringe 1mL 29 G X1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN29 G X 1/2"COVEREDFORMULARY
9420049384940000-DEVICES Insulin Syringe 1mL 29 G X1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN29 G X 1/2"COVEREDFORMULARY
9420049384940000-DEVICES Insulin Syringe 1mL 29 G X1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN29 G X 1/2"COVEREDFORMULARY
9420049384940000-DEVICES Insulin Syringe 1mL 29 G X1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN29 G X 1/2"COVEREDFORMULARY
9420049384940000-DEVICES Insulin Syringe 1mL 29 G X1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN29 G X 1/2"COVEREDFORMULARY
9420049384940000-DEVICES Insulin Syringe 1mL 29 G X1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN29 G X 1/2"COVEREDFORMULARY
9420049384940000-DEVICES Insulin Syringe 1mL 29 G X1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN29 G X 1/2"COVEREDFORMULARY
9420049384940000-DEVICES Insulin Syringe 1mL 29 G X1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN29 G X 1/2"COVEREDFORMULARY
9420049358940000-DEVICES Insulin Syringe 1mL 30GX 5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN30 G X 5/16"COVEREDFORMULARY
9420049358940000-DEVICES Insulin Syringe 1mL 30GX 5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN30 G X 5/16"COVEREDFORMULARY
9420049358940000-DEVICES Insulin Syringe 1mL 30GX 5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN30 G X 5/16"COVEREDFORMULARY
9420049358940000-DEVICES Insulin Syringe 1mL 30GX 5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN30 G X 5/16"COVEREDFORMULARY
9420049358940000-DEVICES Insulin Syringe 1mL 30GX 5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN30 G X 5/16"COVEREDFORMULARY
9420049358940000-DEVICES Insulin Syringe 1mL 30GX 5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN30 G X 5/16"COVEREDFORMULARY
9420049358940000-DEVICES Insulin Syringe 1mL 30GX 5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN30 G X 5/16"COVEREDFORMULARY
9420049358940000-DEVICES Insulin Syringe 1mL 30GX 5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN30 G X 5/16"COVEREDFORMULARY
9420049401940000-DEVICES Insulin Syringe 1mL 30GX1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN30 G X 1/2"COVEREDFORMULARY
9420049401940000-DEVICES Insulin Syringe 1mL 30GX1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN30 G X 1/2"COVEREDFORMULARY
9420049401940000-DEVICES Insulin Syringe 1mL 30GX1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN30 G X 1/2"COVEREDFORMULARY
9420049405940000-DEVICES Insulin Syringe 1mL 31 GX5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049405940000-DEVICES Insulin Syringe 1mL 31 GX5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049405940000-DEVICES Insulin Syringe 1mL 31 GX5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049405940000-DEVICES Insulin Syringe 1mL 31 GX5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049405940000-DEVICES Insulin Syringe 1mL 31 GX5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049405940000-DEVICES Insulin Syringe 1mL 31 GX5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049405940000-DEVICES Insulin Syringe 1mL 31 GX5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049405940000-DEVICES Insulin Syringe 1mL 31 GX5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049405940000-DEVICES Insulin Syringe 1mL 31 GX5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
9420049405940000-DEVICES Insulin Syringe 1mL 31 GX5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN31 G X 5/16"COVEREDFORMULARY
3311828142081206-CEPHALOSPORINSSuprax CapsuleCEFIXIMECAPSULE400 MGCOVEREDFORMULARYRestricted to CUC Prescribers. Send to Central Pharmacy. Quantity limit #1 capsule/ prescription.
331209182081206-CEPHALOSPORINSSuprax SuspensionCEFIXIMESUSP RECON100 MG/5MLNOT COVEREDNON-FORMULARYFormulary: Cefdinir
9236844428081206-CEPHALOSPORINSSuprax SuspensionCEFIXIMESUSP RECON200 MG/5MLNOT COVEREDNON-FORMULARYFormulary: Cefdinir
3427770665081206-CEPHALOSPORINSSuprax SuspensionCEFIXIMESUSP RECON500 MG/5MLNOT COVEREDNON-FORMULARYFormulary: Cefdinir
3344570122081206-CEPHALOSPORINSSuprax ChewableCEFIXIMETAB CHEW100 MGNOT COVEREDNON-FORMULARYFormulary: Cefdinir
3344670123081206-CEPHALOSPORINSSuprax ChewableCEFIXIMETAB CHEW200 MGNOT COVEREDNON-FORMULARYFormulary: Cefdinir
33110081206-CEPHALOSPORINSSuprax TabletCEFIXIMETABLET400 MGNOT COVEREDNON-FORMULARYFormulary: Cefdinir
2687145132081228-ANTIBACTERIALS, MISCELLANEOUSZyvox SuspensionLINEZOLIDSUSP RECON100 MG/5MLNOT COVEREDNON-FORMULARY
2687045131081228-ANTIBACTERIALS, MISCELLANEOUSZyvox TabletLINEZOLIDTABLET600 MGNOT COVEREDNON-FORMULARY
3378770295081408-AZOLESOnmelITRACONAZOLETABLET200 MGNOT COVEREDNON-FORMULARYFormulary: Itraconazole 100mg capsule
5538921871083600-URINARY ANTI-INFECTIVESMonurolFOSFOMYCIN TROMETHAMINEPACKET3 GNOT COVEREDNON-FORMULARY
740404773120808-ANTIMUSCARINICS/ANTISPASMODICS Donnatal ElixirPHENOBARBITAL-HYOSCYAMINE-ATROPINE-SCOPOLAMINEELIXIR16.2-0.1037-0.0194 MG/5MLNOT COVEREDNON-FORMULARY
740704777120808-ANTIMUSCARINICS/ANTISPASMODICS DonnatalPHENOBARBITAL-HYOSCYAMINE-ATROPINE-SCOPOLAMINETABLET16.2-0.1037-0.0194 MGNOT COVEREDNON-FORMULARY
2291328090121208-BETA-ADRENERGIC AGONISTS ProAir HFAALBUTEROL SULFATEHFA AER AD90 MCGNOT COVEREDNON-FORMULARYFormulary: Proventil
2291328090121208-BETA-ADRENERGIC AGONISTS Ventolin HFAALBUTEROL SULFATEHFA AER AD90 MCGNOT COVEREDNON-FORMULARYFormulary: Proventil
2803865912121212-ALPHA- AND BETA-ADRENERGIC AGONISTS AdrenaclickEPINEPHRINEAUTO INJCT0.15 MG/0.15MLNOT COVEREDNON-FORMULARYFormulary: Epinephrine generic
1986116878121212-ALPHA- AND BETA-ADRENERGIC AGONISTS Epipen Jr.EPINEPHRINEAUTO INJCT0.15 MG/0.3MLNOT COVEREDNON-FORMULARYFormulary: Epinephrine generic
1986216879121212-ALPHA- AND BETA-ADRENERGIC AGONISTS Epipen, AdrenaclickEPINEPHRINEAUTO INJCT0.3 MG/0.3MLNOT COVEREDNON-FORMULARYFormulary: Epinephrine generic
179124663122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNTSomaCARISOPRODOLTABLET350 MGNOT COVEREDNON-FORMULARYFormulary: Cyclobenzaprine, methocarbamol, and tizanidine
9176551112122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNTSkelaxinMETAXALONETABLET800 MGNOT COVEREDNON-FORMULARYFormulary: Cyclobenzaprine, methocarbamol, and tizanidine
2386658432240608-HMG-COA REDUCTASE INHIBITORS CaduetAMLODIPINE/ATORVASTATINTABLET2.5-10 MGNOT COVEREDNON-FORMULARYPrescribe amlodipine and atorvastatin seperately
2386758433240608-HMG-COA REDUCTASE INHIBITORS CaduetAMLODIPINE/ATORVASTATINTABLET2.5-20 MGNOT COVEREDNON-FORMULARYPrescribe amlodipine and atorvastatin seperately
2386858434240608-HMG-COA REDUCTASE INHIBITORS CaduetAMLODIPINE/ATORVASTATINTABLET2.5-40 MGNOT COVEREDNON-FORMULARYPrescribe amlodipine and atorvastatin seperately
1915351784240608-HMG-COA REDUCTASE INHIBITORS CrestorROSUVASTATIN CALCIUMTABLET10 MGNOT COVEREDNON-FORMULARYFormulary: Atorvastatin
1915451785240608-HMG-COA REDUCTASE INHIBITORS CrestorROSUVASTATIN CALCIUMTABLET20 MGNOT COVEREDNON-FORMULARYFormulary: Atorvastatin
1915551786240608-HMG-COA REDUCTASE INHIBITORS CrestorROSUVASTATIN CALCIUMTABLET40 MGNOT COVEREDNON-FORMULARYFormulary: Atorvastatin
2022952944240608-HMG-COA REDUCTASE INHIBITORS CrestorROSUVASTATIN CALCIUMTABLET5 MGNOT COVEREDNON-FORMULARYFormulary: Atorvastatin
2392958486240692-ANTILIPEMIC AGENTS, MISCELLANEOUS LovazaOMEGA-3 ACID ETHYL ESTERSCAPSULE1 GNOT COVEREDNON-FORMULARYFormulary: Fenofibrate
7354237015243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSAtacandCANDESARTAN CILEXETILTABLET4 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
7354337016243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSAtacandCANDESARTAN CILEXETILTABLET8 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
7354437017243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSAtacandCANDESARTAN CILEXETILTABLET16 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
7354540659243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSAtacandCANDESARTAN CILEXETILTABLET32 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
1325864285243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSAtacand HCTCANDESARTAN/HYDROCHLOROTHIAZIDTABLET32MG-25MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
2155945425243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSAtacand HCTCANDESARTAN/HYDROCHLOROTHIAZIDTABLET16-12.5MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
2156946624243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSAtacand HCTCANDESARTAN/HYDROCHLOROTHIAZIDTABLET32-12.5MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
2383140910243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSMicardisTELMISARTANTABLET40 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
2383240911243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSMicardisTELMISARTANTABLET80 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
2383347126243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSMicardisTELMISARTANTABLET20 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
2778365746243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSTwynstaTELMISARTAN/AMLODIPINETABLET40 MG-5 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
2778465747243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSTwynstaTELMISARTAN/AMLODIPINETABLET40 MG-10MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
2778565748243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSTwynstaTELMISARTAN/AMLODIPINETABLET80 MG-5 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
2778665749243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSTwynstaTELMISARTAN/AMLODIPINETABLET80 MG-10MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
1225747326243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSMicardis HCTTELMISARTAN/HYDROCHLOROTHIAZIDTABLET40-12.5 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
1225947324243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSMicardis HCTTELMISARTAN/HYDROCHLOROTHIAZIDTABLET80-12.5MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
2286657690243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSMicardis HCTTELMISARTAN/HYDROCHLOROTHIAZIDTABLET80 MG-25MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
1383848399243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS DiovanVALSARTANTABLET320 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
1384448400243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS DiovanVALSARTANTABLET160 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
1384648401243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS DiovanVALSARTANTABLET80 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
1809250805243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS DiovanVALSARTANTABLET40 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
1724550256243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS Diovan HCTVALSARTAN/HYDROCHLOROTHIAZIDETABLET160-25MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
2701460780243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS Diovan HCTVALSARTAN/HYDROCHLOROTHIAZIDETABLET320MG-25MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
2701560781243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS Diovan HCTVALSARTAN/HYDROCHLOROTHIAZIDETABLET320-12.5MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan
1920015880280808-OPIATE AGONISTSDuragesicFENTANYLPATCH TD7225 MCG/HRNOT COVEREDNON-FORMULARYFormulary: Morphine
1920115881280808-OPIATE AGONISTSDuragesicFENTANYLPATCH TD7250MCG/HRNOT COVEREDNON-FORMULARYFormulary: Morphine
1920215882280808-OPIATE AGONISTSDuragesicFENTANYLPATCH TD7275MCG/HRNOT COVEREDNON-FORMULARYFormulary: Morphine
1920315883280808-OPIATE AGONISTSDuragesicFENTANYLPATCH TD72100 MCG/HRNOT COVEREDNON-FORMULARYFormulary: Morphine
1628115065280808-OPIATE AGONISTSOxyocodone ConcentrateOXYCODONE HCLORAL CONC20 MG/MLNOT COVEREDNON-FORMULARYFormulary: Morphine
162804224280808-OPIATE AGONISTSOxycodone SolutionOXYCODONE HCLSOLUTION5 MG/5 MLNOT COVEREDNON-FORMULARYFormulary: Morphine
4185376361280808-OPIATE AGONISTSOxycodone Oral SyringeOXYCODONE HCLSYRINGE10MG/0.5MLNOT COVEREDNON-FORMULARYFormulary: Morphine
1629113467280808-OPIATE AGONISTSOxyocodoneOXYCODONE HCLTABLET10 MGNOT COVEREDNON-FORMULARYFormulary: Oxycodone 5 mg, Morphine
2009146474280808-OPIATE AGONISTSOxyocodoneOXYCODONE HCLTABLET15 MGNOT COVEREDNON-FORMULARYFormulary: Oxycodone 5 mg, Morphine
2119445298280808-OPIATE AGONISTSOxyocodoneOXYCODONE HCLTABLET20 MGNOT COVEREDNON-FORMULARYFormulary: Oxycodone 5 mg, Morphine
2009246475280808-OPIATE AGONISTSOxyocodoneOXYCODONE HCLTABLET30 MGNOT COVEREDNON-FORMULARYFormulary: Oxycodone 5 mg, Morphine
3204769101280808-OPIATE AGONISTSOxaydoOXYCODONE HCLTABLET ORL5 MGNOT COVEREDNON-FORMULARYFormulary: Oxycodone 5 mg, Morphine
3125668467280808-OPIATE AGONISTSOxaydoOXYCODONE HCLTABLET ORL7.5 MGNOT COVEREDNON-FORMULARYFormulary: Oxycodone 5 mg, Morphine
3521471432280812-OPIATE PARTIAL AGONISTSButrans PatchBUPRENORPHINEPATCH TDWK15 MCG/HRNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3694672673280812-OPIATE PARTIAL AGONISTSButrans PatchBUPRENORPHINEPATCH TDWK7.5 MCG/HRNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3996575051280812-OPIATE PARTIAL AGONISTSBelbuca FilmBUPRENORPHINE HCLFILM150 MCGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3996675052280812-OPIATE PARTIAL AGONISTSBelbuca FilmBUPRENORPHINE HCLFILM300 MCGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3996775053280812-OPIATE PARTIAL AGONISTSBelbuca FilmBUPRENORPHINE HCLFILM450 MCGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3996875054280812-OPIATE PARTIAL AGONISTSBelbuca FilmBUPRENORPHINE HCLFILM600 MCGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3995975050280812-OPIATE PARTIAL AGONISTSBelbuca FilmBUPRENORPHINE HCLFILM75 MCGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3996975055280812-OPIATE PARTIAL AGONISTSBelbuca FilmBUPRENORPHINE HCLFILM750 MCGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3997575056280812-OPIATE PARTIAL AGONISTSBelbuca FilmBUPRENORPHINE HCLFILM900 MCGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
6467229312280812-OPIATE PARTIAL AGONISTSSubutexBUPRENORPHINE HCLTAB SUBL2 MGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
6467329313280812-OPIATE PARTIAL AGONISTSSubutexBUPRENORPHINE HCLTAB SUBL8 MGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3374470262280812-OPIATE PARTIAL AGONISTSSuboxone FilmBUPRENORPHINE HCL/NALOXONE HCLFILM12 MG-3 MGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
2895866635280812-OPIATE PARTIAL AGONISTSSuboxone FilmBUPRENORPHINE HCL/NALOXONE HCLFILM2 MG-0.5MGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3667772449280812-OPIATE PARTIAL AGONISTSBunavail FilmBUPRENORPHINE HCL/NALOXONE HCLFILM2.1-0.3 MGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3667872450280812-OPIATE PARTIAL AGONISTSBunavail FilmBUPRENORPHINE HCL/NALOXONE HCLFILM4.2-0.7 MGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3374170259280812-OPIATE PARTIAL AGONISTSSuboxone FilmBUPRENORPHINE HCL/NALOXONE HCLFILM4MG-1MGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3667972451280812-OPIATE PARTIAL AGONISTSBunavail FilmBUPRENORPHINE HCL/NALOXONE HCLFILM6.3MG-1MGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
2895966636280812-OPIATE PARTIAL AGONISTSSuboxone FilmBUPRENORPHINE HCL/NALOXONE HCLFILM8 MG-2 MGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
4284376981280812-OPIATE PARTIAL AGONISTSZubsolvBUPRENORPHINE HCL/NALOXONE HCLTAB SUBL0.7-0.18MGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3490471189280812-OPIATE PARTIAL AGONISTSZubsolvBUPRENORPHINE HCL/NALOXONE HCLTAB SUBL1.4-0.36MGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3782473425280812-OPIATE PARTIAL AGONISTSZubsolvBUPRENORPHINE HCL/NALOXONE HCLTAB SUBL11.4-2.9MGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3939474685280812-OPIATE PARTIAL AGONISTSZubsolvBUPRENORPHINE HCL/NALOXONE HCLTAB SUBL2.9-0.71MGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3490571190280812-OPIATE PARTIAL AGONISTSZubsolvBUPRENORPHINE HCL/NALOXONE HCLTAB SUBL5.7-1.4 MGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
3782373424280812-OPIATE PARTIAL AGONISTSZubsolvBUPRENORPHINE HCL/NALOXONE HCLTAB SUBL8.6-2.1 MGNOT COVEREDNON-FORMULARYBuprenorphine products restricted to CommUnityCare Dove Spring
1897351640280812-OPIATE PARTIAL AGONISTSSuboxone TabletBUPRENORPHINE HCL/NALOXONE HCLTAB SUBL2 MG-0.5MGNOT COVEREDNON-FORMULARYRestricted to Suboxone clinic at CommUnityCare Dove Springs
1897451641280812-OPIATE PARTIAL AGONISTSSuboxone TabletBUPRENORPHINE HCL/NALOXONE HCLTAB SUBL8 MG-2 MGNOT COVEREDNON-FORMULARYRestricted to Suboxone clinic at CommUnityCare Dove Springs
2862666372280892-ANALGESICS AND ANTIPYRETICS, MISC. FioricetBUTALBITAL-ACETAMINOPHEN-CAFFEINECAPSULE50-300-40 MGNOT COVEREDNON-FORMULARYFormulary: Capacet, Esgic
2709560935281000-OPIATE ANTAGONISTSVivitrolNALTREXONE MICROSPHERESSUS ER REC380MGNOT COVEREDNON-FORMULARYFormulary: Naltrexone tablet
1635646216281604-ANTIDEPRESSANTS SarafemFLUOXETINE HCLTABLET10 MGNOT COVEREDNON-FORMULARYFormulary: capsules
1635946219281604-ANTIDEPRESSANTS SarafemFLUOXETINE HCLTABLET20 MGNOT COVEREDNON-FORMULARYFormulary: capsules
1434964444281604-ANTIDEPRESSANTS Venlafaxine ERVENLAFAXINE HCLTAB ER 2437.5 MGNOT COVEREDNON-FORMULARYFormulary: capsules
1435264445281604-ANTIDEPRESSANTS Venlafaxine ERVENLAFAXINE HCLTAB ER 2475 MGNOT COVEREDNON-FORMULARYFormulary: capsules
1435364446281604-ANTIDEPRESSANTS Venlafaxine ERVENLAFAXINE HCLTAB ER 24150 MGNOT COVEREDNON-FORMULARYFormulary: capsules
1435464447281604-ANTIDEPRESSANTS Venlafaxine ERVENLAFAXINE HCLTAB ER 24225 MGNOT COVEREDNON-FORMULARYFormulary: capsules
2559859781282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)DiastatDIAZEPAMKIT5-7.5-10MGNOT COVEREDNON-FORMULARYRestricted to Neurology prescribers
2559959782282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)DiastatDIAZEPAMKIT12.5-15-20NOT COVEREDNON-FORMULARYRestricted to Neurology prescribers
4813134015282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)DiastatDIAZEPAMKIT2.5 MGNOT COVEREDNON-FORMULARYRestricted to Neurology prescribers
1959340223283228-SELECTIVE SEROTONIN AGONISTS Maxalt MLTRIZATRIPTAN BENZOATETAB RAPDIS5 MGNOT COVEREDNon-FormularyFormulary: Imitrex (Sumatriptan)
1959140221283228-SELECTIVE SEROTONIN AGONISTS MaxaltRIZATRIPTAN BENZOATETABLET5 MGNOT COVEREDNon-FormularyFormulary: Imitrex (Sumatriptan)
1397148489480800-ANTITUSSIVES Promethazine/CodeinePROMETHAZINE HCL-CODEINESYRUP6.25-10 MG/5MLNOT COVEREDNON-FORMULARY
5498012073481600-EXPECTORANTS Mucinex DGUAIFENESIN-PSEUDOEPHEDRINE HCLTAB ER 12H600-60 MGNOT COVEREDNON-FORMULARYAvailable OTC
2605660055520808-CORTICOSTEROIDS (EENT)DermoticFLUOCINOLONE ACETONIDE OILDROPS0.01%NOT COVEREDNON-FORMULARYPrior Auth restricted to EENT prescribers
3046267826521600-LOCAL ANESTHETICS (EENT) Antipyrine-BenzocaineANTIPYRINE-BENZOCAINEDROPS5.5-1.4 %NOT COVEREDNON-FORMULARYNo longer available commerically
169730106562836-PROTON-PUMP INHIBITORS PrevacidLANSOPRAZOLECAPSULE DR15 MGNOT COVEREDNON-FORMULARYFormulary: Pantoprazole
169830107562836-PROTON-PUMP INHIBITORS PrevacidLANSOPRAZOLECAPSULE DR30 MGNOT COVEREDNON-FORMULARYFormulary: Pantoprazole
434833530562836-PROTON-PUMP INHIBITORS PrilosecOMEPRAZOLECAPSULE DR20 MGNOT COVEREDNON-FORMULARYFormulary: Pantoprazole
9298943136562836-PROTON-PUMP INHIBITORS PrilosecOMEPRAZOLECAPSULE DR10 MGNOT COVEREDNON-FORMULARYFormulary: Pantoprazole
9299943137562836-PROTON-PUMP INHIBITORS PrilosecOMEPRAZOLECAPSULE DR40 MGNOT COVEREDNON-FORMULARYFormulary: Pantoprazole
9463940941562836-PROTON-PUMP INHIBITORS AciphexRABEPRAZOLE SODIUMTABLET DR20 MGNOT COVEREDNON-FORMULARYFormulary: Pantoprazole
3022019863563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) Pentasa CRMESALAMINECAPSULE ER250 MGNOT COVEREDPAPFormulary: Sulfasalazine. Contact manufacturer for PAP
2166353882563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) Asacol HDMESALAMINETABLET DR800 MGNOT COVEREDNON-FORMULARYFormulary: Sulfasalazine. Contact manufacturer for PAP
3772673336569200-GI DRUGS, MISCELLANEOUS MovantikNALOXEGOL OXALATETABLET25 MGNOT COVEREDNON-FORMULARYContact manufacturer for PAP
3772573335569200-GI DRUGS, MISCELLANEOUS MovantikNALOXEGOL OXALATETABLET12.5 MGNOT COVEREDNON-FORMULARYContact manufacturer for PAP
288473203681604-ESTROGENSVivelle-DOTESTRADIOLPATCH TDSW0.1MG/24HRNOT COVEREDNON-FORMULARYPrior auth requires failure to oral options
288403202681604-ESTROGENSVivelle-DOTESTRADIOLPATCH TDSW0.05MG/24HNOT COVEREDNON-FORMULARYPrior auth requires failure to oral options
2884216767681604-ESTROGENSVivelle-DOTESTRADIOLPATCH TDSW.025MG/24HNOT COVEREDNON-FORMULARYPrior auth requires failure to oral options
2884323270681604-ESTROGENSVivelle-DOTESTRADIOLPATCH TDSW.075MG/24HNOT COVEREDNON-FORMULARYPrior auth requires failure to oral options
2884624555681604-ESTROGENSVivelle-DOTESTRADIOLPATCH TDSW.0375MG/24NOT COVEREDNON-FORMULARYPrior auth requires failure to oral options
2884423471681604-ESTROGENSClimaraESTRADIOLPATCH TDWK0.1MG/24HRNOT COVEREDNON-FORMULARYPrior auth requires failure to oral options
2884523472681604-ESTROGENSClimaraESTRADIOLPATCH TDWK0.05MG/24HNOT COVEREDNON-FORMULARYPrior auth requires failure to oral options
2884832174681604-ESTROGENSClimaraESTRADIOLPATCH TDWK.025MG/24HNOT COVEREDNON-FORMULARYPrior auth requires failure to oral options
2885340366681604-ESTROGENSClimaraESTRADIOLPATCH TDWK.075MG/24HNOT COVEREDNON-FORMULARYPrior auth requires failure to oral options
2006852830681604-ESTROGENSClimaraESTRADIOLPATCH TDWK0.06MG/24HNOT COVEREDNON-FORMULARYPrior auth requires failure to oral options
2006952831681604-ESTROGENSClimaraESTRADIOLPATCH TDWK.0375MG/24NOT COVEREDNON-FORMULARYPrior auth requires failure to oral options
2810765966681604-ESTROGENSVagifemESTRADIOLTABLET10 MCGNOT COVEREDNON-FORMULARY
671707011681604-ESTROGENS Estrace Vaginal CreamESTRADIOLCREAM/APPL0.01%NOT COVEREDNON-FORMULARYFormulary: Premarin Vaginal Cream
3433670705681612-ESTROGEN AGONIST-ANTAGONISTSOsphenaOSPEMIFENETABLET60 MGNOT COVEREDNON-FORMULARY
231820241682002-ALPHA-GLUCOSIDASE INHIBITORS PrecoseACARBOSETABLET100 MGNOT COVEREDNON-FORMULARY
231920242682002-ALPHA-GLUCOSIDASE INHIBITORS PrecoseACARBOSETABLET50 MGNOT COVEREDNON-FORMULARY
807036767682002-ALPHA-GLUCOSIDASE INHIBITORS PrecoseACARBOSETABLET25 MGNOT COVEREDNON-FORMULARY
9525240357682002-ALPHA-GLUCOSIDASE INHIBITORS GlysetMIGLITOLTABLET25 MGNOT COVEREDNON-FORMULARY
9525340358682002-ALPHA-GLUCOSIDASE INHIBITORS GlysetMIGLITOLTABLET50 MGNOT COVEREDNON-FORMULARY
9525440359682002-ALPHA-GLUCOSIDASE INHIBITORS GlysetMIGLITOLTABLET100 MGNOT COVEREDNON-FORMULARY
3583671842682008-INSULINS Tresiba FlexTouchINSULIN DEGLUDECINSULN PEN100/ML (3)NOT COVEREDNON-FORMULARYFormulary: Levemir
3583771843682008-INSULINS Tresiba FlexTouchINSULIN DEGLUDECINSULN PEN200/ML (3)NOT COVEREDNON-FORMULARYFormulary: Levemir
116601740682008-INSULINS Humulin NINSULIN NPH HUMAN ISOPHANEVIAL100 UNIT/MLNOT COVEREDNON-FORMULARYFormulary: Novolin
5000116311682008-INSULINS Humulin 70/30INSULIN NPH HUM-REG INSULIN HMVIAL70-30 UNIT/MLNOT COVEREDNON-FORMULARYFormulary: Novolin
116421723682008-INSULINS Humulin RINSULIN REGULAR HUMANVIAL100 UNIT/MLNOT COVEREDNON-FORMULARYFormulary: Novolin
5077643801683200-PROGESTINSPrometriumPROGESTERONE, MICRONIZEDCAPSULE100 MGNOT COVEREDNON-FORMULARYFormulary: Provera
5078643802683200-PROGESTINSPrometriumPROGESTERONE, MICRONIZEDCAPSULE200 MGNOT COVEREDNON-FORMULARYFormulary: Provera
982386246281228-ANTIBACTERIALS, MISCELLANEOUSPyleraBISMUTH/METRONID/TETRACYCLINECAPSULE125-125 MGNOT COVEREDNON-FORMULARYPrior auth requires failure of Amox/Clari/Metronidazole OR history of systemic macrolide exposure
263396024483600-URINARY ANTI-INFECTIVESHyophenMETHENAM/M.BLUE/SALICYL/HYOSCYTABLET81.6-0.12NOT COVEREDNON-FORMULARY
318127731840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) BacitracinBACITRACINOINT. (G)500 UNIT/GNOT COVEREDNON-FORMULARY
5027243256840800-ANTIPRURITICS AND LOCAL ANESTHETICS LidodermLIDOCAINEADH. PATCH5%NOT COVEREDNON-FORMULARYLidocaine 4% patch, cream are OTC
9540440261840800-ANTIPRURITICS AND LOCAL ANESTHETICS Lindocaine Anorectal CreamLIDOCAINECREAM (G)0.05NOT COVEREDNON-FORMULARY
9540540262840800-ANTIPRURITICS AND LOCAL ANESTHETICS Liocaine CreamLIDOCAINECREAM (G)0.04NOT COVEREDNON-FORMULARYAvailable OTC
3075014476840800-ANTIPRURITICS AND LOCAL ANESTHETICS Lidocaine OintmentLIDOCAINEOINT. (G)0.05NOT COVEREDNON-FORMULARYLidocaine 4% Cream is OTC
248826312845004-DEPIGMENTING AGENTSESOTERICA FADE CREAMHYDROQUINONECREAM (G)2%NOT COVEREDNON-FORMULARYNo coverage for hydroquinone
248836313845004-DEPIGMENTING AGENTSMELQUIN HP 4% CREAMHYDROQUINONECREAM (G)4%NOT COVEREDNON-FORMULARYNo coverage for hydroquinone
478306314845004-DEPIGMENTING AGENTSHYDROQUINONE 4% CREAMHYDROQUINONEPOWDERNOT COVEREDNON-FORMULARYNo coverage for hydroquinone
248906315845004-DEPIGMENTING AGENTSHYDROQUINONE POWDERHYDROQUINONESOLUTION30 MG/MLNOT COVEREDNON-FORMULARYNo coverage for hydroquinone
2012052863845004-DEPIGMENTING AGENTSNUQUIN HP 4% CREAMHYDROQUINONE MICROSPHERESCRM ER (G)4%NOT COVEREDNON-FORMULARYNo coverage for hydroquinone
9767461889845004-DEPIGMENTING AGENTSESOTERICA FADE CREAMHYDROQUINONE/AVOBENZ/OCTINOXEMUL ADHES4%NOT COVEREDNON-FORMULARYNo coverage for hydroquinone
2186454046845004-DEPIGMENTING AGENTSALPHAQUIN HP 4% CREAMHYDROQUINONE/AVOBENZ/OCTINOXEMULSN(G)4%NOT COVEREDNON-FORMULARYNo coverage for hydroquinone
2091553438845004-DEPIGMENTING AGENTSHYDROQUINONE TR 4% CREAMHYDROQUINONE/OXYBEN/OCTINOXATECREAM (G)4%(5-7.5%)NOT COVEREDNON-FORMULARYNo coverage for hydroquinone
9722961438845004-DEPIGMENTING AGENTSACLARO 4% EMULSIONHYDROQUINONE/OXYBENZONE/PADIMACREAM (G)2%-SPF10NOT COVEREDNON-FORMULARYNo coverage for hydroquinone
6689931427845004-DEPIGMENTING AGENTSMELQUIN-3 SOLUTIONHYDROQUINONE/SUNSCREEN(FER OX)CREAM (G)4%NOT COVEREDNON-FORMULARYNo coverage for hydroquinone
9607139542848000-SUNSCREEN AGENTSMELPAQUE HP 4% CREAMDIOXYBENZONE/PDO/HYDROQUINONECREAM (G)3%-5%-4%NOT COVEREDNON-FORMULARYNo coverage for hydroquinone
2038353055849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ClaravisISOTRETINOINTABLET30 MGNOT COVEREDNON-FORMULARYPrior auths restricted to Dermatology prescriber. Claravis prefererred
5984136045849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ClaravisISOTRETINOINTABLET10 MGNOT COVEREDNON-FORMULARYPrior auths restricted to Dermatology prescriber. Claravis prefererred
5984236046849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ClaravisISOTRETINOINTABLET20 MGNOT COVEREDNON-FORMULARYPrior auths restricted to Dermatology prescriber. Claravis prefererred
5984336047849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. ClaravisISOTRETINOINTABLET40 MGNOT COVEREDNON-FORMULARYPrior auths restricted to Dermatology prescriber. Claravis prefererred
2404358576861204-ANTIMUSCARINICSEnablexDARIFENACIN HYDROBROMIDETAB ER 24H7.5 MGNOT COVEREDNON-FORMULARYFormulary: Oxybutynin ER
2404458577861204-ANTIMUSCARINICSEnablexDARIFENACIN HYDROBROMIDETAB ER 24H15 MGNOT COVEREDNON-FORMULARYFormulary: Oxybutynin ER
9919363466861204-ANTIMUSCARINICSSanctura XRTROSPIUM CHLORIDECAP ER 24H60 MGNOT COVEREDNON-FORMULARYFormulary: Oxybutynin ER
874438085861204-ANTIMUSCARINICSSancturaTROSPIUM CHLORIDETABLET20 MGNOT COVEREDNON-FORMULARYFormulary: Oxybutynin ER
1842851246920800-5-ALPHA-REDUCTASE INHIBITORSAvodartDUTASTERIDECAPSULE0.5 MGNOT COVEREDNON-FORMULARYFormulary: Finasteride
2859666352920800-5-ALPHA-REDUCTASE INHIBITORSJalynDUTASTERIDE/TAMSULOSIN HCLCPMP 24HR0.5-0.4 MGNOT COVEREDNON-FORMULARYFormulary: Finasteride
2444458915922400-BONE RESORPTION INHIBITORSBonivaIBANDRONATE SODIUMTABLET150 MGNOT COVEREDNON-FORMULARYFormulary: Alendronate
1737850364922400-BONE RESORPTION INHIBITORSActonelRISEDRONATE SODIUMTABLET35 MGNOT COVEREDNON-FORMULARYFormulary: Alendronate
9223845102922400-BONE RESORPTION INHIBITORSActonelRISEDRONATE SODIUMTABLET5 MGNOT COVEREDNON-FORMULARYFormulary: Alendronate
9420074210940000-DEVICES Contour NextBLOOD-GLUCOSE METEREACHNOT COVEREDNON-FORMULARYPrior Auths restricted to insulin pumps
9420070198940000-DEVICES TruePlus Lancet 26GLANCETSEACH26 GAUGENOT COVEREDNON-FORMULARY
9420049276940000-DEVICES Insulin Syringe 0.5mL 28GX1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN28 G X 1/2"NOT COVEREDNON-FORMULARY
9420049276940000-DEVICES Insulin Syringe 0.5mL 28GX1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN28 G X 1/2"NOT COVEREDNON-FORMULARY
9420049383940000-DEVICES Insulin Syringe 0.5mL 29 G X1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN29 G X 1/2"NOT COVEREDNON-FORMULARY
9420049395940000-DEVICES Insulin Syringe 0.5mL 30GX 5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN30G X 5/16"NOT COVEREDNON-FORMULARY
9420049400940000-DEVICES Insulin Syringe 0.5mL 30GX1/2"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN30 G X 1/2"NOT COVEREDNON-FORMULARY
9420049404940000-DEVICES Insulin Syringe 0.5mL 31 GX5/16"SYRING W-NDL DISP INSUL 0.5 MLDISP SYRIN31 G X 5/16"NOT COVEREDNON-FORMULARY
9420049365940000-DEVICES Insulin Syringe 1mL 27GX5/8"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN27 G X 5/8"NOT COVEREDNON-FORMULARY
9420049275940000-DEVICES Insulin Syringe 1mL 28GX1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN28 G X 1/2"NOT COVEREDNON-FORMULARY
9420049275940000-DEVICES Insulin Syringe 1mL 28GX1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN28 G X 1/2"NOT COVEREDNON-FORMULARY
9420049275940000-DEVICES Insulin Syringe 1mL 28GX1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN28 G X 1/2"NOT COVEREDNON-FORMULARY
9420049384940000-DEVICES Insulin Syringe 1mL 29 G X1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN29 G X 1/2"NOT COVEREDNON-FORMULARY
9420049384940000-DEVICES Insulin Syringe 1mL 29 G X1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN29 G X 1/2"NOT COVEREDNON-FORMULARY
9420049401940000-DEVICES Insulin Syringe 1mL 30GX1/2"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN30 G X 1/2"NOT COVEREDNON-FORMULARY
9420049405940000-DEVICES Insulin Syringe 1mL 31 GX5/16"SYRINGE & NEEDLE INSULIN 1 MLDISP SYRIN31 G X 5/16"NOT COVEREDNON-FORMULARY
3002567462081202-AMINOGLYCOSIDES Tobi PodhalerTOBRAMYCINCAP W/DEV28 MGNOT COVEREDPAPContact manufacturer for PAP
6155137042081202-AMINOGLYCOSIDES TobiTOBRAMYCIN IN 0.225% NACLAMPUL-NEB300 MG/5MLNOT COVEREDNON-FORMULARY
2853066295081228-ANTIBACTERIALS, MISCELLANEOUSXifaxanRIFAXIMINTABLET550 MGNOT COVEREDPAPContact manufacturer for PAP
9374941880081228-ANTIBACTERIALS, MISCELLANEOUSXifaxanRIFAXIMINTABLET200 MGNOT COVEREDPAPContact manufacturer for PAP
4910116949081408-AZOLESSporanox capsuleITRACONAZOLECAPSULE100 MGNOT COVEREDPAP
4910027465081408-AZOLESSporanox solutionITRACONAZOLESOLUTION10 MG/MLNOT COVEREDPAP
1749750442081408-AZOLESVfendVORICONAZOLETABLET50 MGNOT COVEREDPAPContact manufacturer for PAP
1749850443081408-AZOLESVfendVORICONAZOLETABLET200 MGNOT COVEREDPAPContact manufacturer for PAP
3507971322081808-ANTIRETROVIRALSTivicayDOLUTEGRAVIR SODIUMTABLET50 MGNOT COVEREDPAPContact manufacturer for PAP
4156476226081808-ANTIRETROVIRALSTivicayDOLUTEGRAVIR SODIUMTABLET10 MGNOT COVEREDPAPContact manufacturer for PAP
4156676227081808-ANTIRETROVIRALSTivicayDOLUTEGRAVIR SODIUMTABLET25 MGNOT COVEREDPAPContact manufacturer for PAP
2315257883081808-ANTIRETROVIRALSTruvadaEMTRICITABINE/TENOFOVIR (TDF)TABLET200-300 MGNOT COVEREDPAPContact manufacturer for PAP
4136976097081808-ANTIRETROVIRALSTruvadaEMTRICITABINE/TENOFOVIR (TDF)TABLET100-150 MGNOT COVEREDPAPContact manufacturer for PAP
4137576101081808-ANTIRETROVIRALSTruvadaEMTRICITABINE/TENOFOVIR (TDF)TABLET133-200 MGNOT COVEREDPAPContact manufacturer for PAP
4137676102081808-ANTIRETROVIRALSTruvadaEMTRICITABINE/TENOFOVIR (TDF)TABLET167-250 MGNOT COVEREDPAPContact manufacturer for PAP
9743061644081808-ANTIRETROVIRALS ReyatazATAZANAVIR SULFATECAPSULE300 MGNOT COVEREDPAPContact manufacturer for PAP
1555549849081808-ANTIRETROVIRALS SustivaEFAVIRENZTABLET600 MGNOT COVEREDPAPContact manufacturer for PAP
3122768449081808-ANTIRETROVIRALS VireadTENOFOVIR DISOPROXIL FUMARATEPOWDER40 MG/SCOOPNOT COVEREDNON-FORMULARY
1482248843081808-ANTIRETROVIRALS VireadTENOFOVIR DISOPROXIL FUMARATETABLET300 MGNOT COVEREDNON-FORMULARY
3122868450081808-ANTIRETROVIRALS VireadTENOFOVIR DISOPROXIL FUMARATETABLET150 MGNOT COVEREDNON-FORMULARY
3122968451081808-ANTIRETROVIRALS VireadTENOFOVIR DISOPROXIL FUMARATETABLET200 MGNOT COVEREDNON-FORMULARY
3123468453081808-ANTIRETROVIRALS VireadTENOFOVIR DISOPROXIL FUMARATETABLET250 MGNOT COVEREDNON-FORMULARY
2446558933081832-NUCLEOSIDES AND NUCLEOTIDES BaracludeENTECAVIRSOLUTION0.05 MG/MLNOT COVEREDPAPPrior Auths's Restricted to GI Clinic, Contact manufacturer for PAP
2446658934081832-NUCLEOSIDES AND NUCLEOTIDES BaracludeENTECAVIRTABLET0.5 MGNOT COVEREDPAPPrior Auths's Restricted to GI Clinic, Contact manufacturer for PAP
2446758935081832-NUCLEOSIDES AND NUCLEOTIDES BaracludeENTECAVIRTABLET1 MGNOT COVEREDPAPPrior Auths's Restricted to GI Clinic, Contact manufacturer for PAP
2864866391083600-URINARY ANTI-INFECTIVES UribelMTH/ME BLUE/SOD PHOS/PHEN/HYOSCAPSULE118-10-36 MGNOT COVEREDPAPContact manufacturer for PAP
2441024515100000-ANTINEOPLASTIC AGENTS ArimidexANASTROZOLETABLET1 MGNOT COVEREDNON-FORMULARY
3308469855120808-ANTIMUSCARINICS/ANTISPASMODICS Tudorza Pressair DPIACLIDINIUM BROMIDEAER POW BA400 MCGNOT COVEREDPAPFormulary: Ipratropium nebulized solution. Contact manufacturer for PAP
2462159081120808-ANTIMUSCARINICS/ANTISPASMODICS Atrovent HFAIPRATROPIUM BROMIDEHFA AER AD17 MCGNOT COVEREDPAPFormulary: Ipratropium nebulized solution, Contact manufacturer for PAP
3239569371120808-ANTIMUSCARINICS/ANTISPASMODICS Combivent MDIIPRATROPIUM/ALBUTEROL SULFATEMIST INHAL20-100 MCGNOT COVEREDPAPFormulary: Ipratropium/Albuterol nebulized solution formulary. Contact manufacturer for PAP
9892163164120808-ANTIMUSCARINICS/ANTISPASMODICS Spiriva RespimatTIOTROPIUM BROMIDEMIST INHAL2.5 MCGNOT COVEREDPAPFormulary: Ipratropium nebulized solution. Contact manufacturer for PAP
3590371883120808-ANTIMUSCARINICS/ANTISPASMODICS Anoro ElliptaUMECLIDINIUM BRM/VILANTEROL TRBLST W/DEV62.5-25 MCGNOT COVEREDPAPFormulary: Ipratropium/Albuterol nebulized solution formulary. Contact manufacturer for PAP
3657472375120808-ANTIMUSCARINICS/ANTISPASMODICS Incruse ElliptaUMECLIDINIUM BROMIDEBLST W/DEV62.5 MCGNOT COVEREDPAPFormulary: Ipratropium nebulized solution. Contact manufacturer for PAP
9736661579121208-BETA-ADRENERGIC AGONISTS BrovanaARFORMOTEROL TARTRATEVIAL-NEB15 MCG/2MLNOT COVEREDNON-FORMULARYFormulary: Albuterol nebulized solution is formulary.
9202445052121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)UroxatralALFUZOSIN HCLTAB ER 24H10 MGNOT COVEREDNON-FORMULARYFormulary: Tamsulosin, Terazosin, Prazosin.
1685764846121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)RapafloSILODOSINCAPSULE4 MGNOT COVEREDPAPFormulary: Tamsulosin, Terazosin, Prazosin. Contact manufacturer for PAP
1685864847121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)RapafloSILODOSINCAPSULE8 MGNOT COVEREDPAPFormulary: Tamsulosin, Terazosin, Prazosin. Contact manufacturer for PAP
3393570414201204-ANTICOAGULANTS EliquisAPIXABANTABLET5 MGNOT COVEREDPAPFormulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
3023967642201204-ANTICOAGULANTS EliquisAPIXABANTABLET2.5 MGNOT COVEREDPAPFormulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
2916666781201204-ANTICOAGULANTS PradaxaDABIGATRAN ETEXILATE MESYLATECAPSULE150 MGNOT COVEREDPAPFormulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
9970863997201204-ANTICOAGULANTS PradaxaDABIGATRAN ETEXILATE MESYLATECAPSULE75 MGNOT COVEREDPAPFormulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
3767573293201204-ANTICOAGULANTS SavaysaEDOXABANTABLET15 MGNOT COVEREDNON-FORMULARYFormulary: Enoxaparin, Warfarin.
3767673294201204-ANTICOAGULANTS SavaysaEDOXABANTABLET30 MGNOT COVEREDNON-FORMULARYFormulary: Enoxaparin, Warfarin.
3767773295201204-ANTICOAGULANTS SavaysaEDOXABANTABLET60 MGNOT COVEREDNON-FORMULARYFormulary: Enoxaparin, Warfarin.
3721272904201204-ANTICOAGULANTS Xarelto Starting Month PackRIVAROXABANTAB DS PK15(42)-20(9) MGNOT COVEREDPAPFormulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
1442764493201204-ANTICOAGULANTS XareltoRIVAROXABANTABLET10 MGNOT COVEREDPAPFormulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
3081868118201204-ANTICOAGULANTS XareltoRIVAROXABANTABLET15 MGNOT COVEREDPAPFormulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
3081968119201204-ANTICOAGULANTS XareltoRIVAROXABANTABLET20 MGNOT COVEREDPAPFormulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
1715764902201218-PLATELET-AGGREGATION INHIBITORS EffientPRASUGREL HCLTABLET10 MGNOT COVEREDNON-FORMULARYFormulary: Clopidogrel.
1705664901201218-PLATELET-AGGREGATION INHIBITORS EffientPRASUGREL HCLTABLET5 MGNOT COVEREDNON-FORMULARYFormulary: Clopidogrel.
2938566950201218-PLATELET-AGGREGATION INHIBITORS BrilintaTICAGRELORTABLET90 MGNOT COVEREDPAPFormulary: Clopidogrel. Contact manufacturer for PAP
3940774696201218-PLATELET-AGGREGATION INHIBITORS BrilintaTICAGRELORTABLET60 MGNOT COVEREDPAPFormulary: Clopidogrel. Contact manufacturer for PAP
2405958592201600-HEMATOPOIETIC AGENTSEpogen, ProcritEPOETIN ALFAVIAL20000/2MLNOT COVEREDPAPContact manufacturer for PAP
2511011740201600-HEMATOPOIETIC AGENTSEpogen, ProcritEPOETIN ALFAVIAL2000/MLNOT COVEREDPAPContact manufacturer for PAP
2511111741201600-HEMATOPOIETIC AGENTSEpogen, ProcritEPOETIN ALFAVIAL4000/MLNOT COVEREDPAPContact manufacturer for PAP
2511211742201600-HEMATOPOIETIC AGENTSEpogen, ProcritEPOETIN ALFAVIAL10000/MLNOT COVEREDPAPContact manufacturer for PAP
2511315164201600-HEMATOPOIETIC AGENTSEpogen, ProcritEPOETIN ALFAVIAL3000/MLNOT COVEREDPAPContact manufacturer for PAP
2511425708201600-HEMATOPOIETIC AGENTSEpogen, ProcritEPOETIN ALFAVIAL20000/MLNOT COVEREDPAPContact manufacturer for PAP
2511541394201600-HEMATOPOIETIC AGENTSEpogen, ProcritEPOETIN ALFAVIAL40000/MLNOT COVEREDPAPContact manufacturer for PAP
2658665367240404-ANTIARRHYTHMIC AGENTS MultaqDRONEDARONE HCLTABLET400 MGNOT COVEREDPAPFormulary: Amiodarone. Contact manufacturer for PAP
9534740303241292-VASODILATING AGENTS, MISCELLANEOUS AggrenoxASPIRIN/DIPYRIDAMOLECPMP 12HR25-200 MGNOT COVEREDNON-FORMULARYFormulary: Clopidogrel.
9759661811242400-BETA-ADRENERGIC BLOCKING AGENTS Coreg CRCARVEDILOL PHOSPHATECPMP 24HR10 MGNOT COVEREDPAPFormulary: Carvedilol IR. Contact manufacturer for PAP
9759761812242400-BETA-ADRENERGIC BLOCKING AGENTS Coreg CRCARVEDILOL PHOSPHATECPMP 24HR20 MGNOT COVEREDPAPFormulary: Carvedilol IR. Contact manufacturer for PAP
9759861813242400-BETA-ADRENERGIC BLOCKING AGENTS Coreg CRCARVEDILOL PHOSPHATECPMP 24HR40 MGNOT COVEREDPAPFormulary: Carvedilol IR. Contact manufacturer for PAP
9759961814242400-BETA-ADRENERGIC BLOCKING AGENTS Coreg CRCARVEDILOL PHOSPHATECPMP 24HR80 MGNOT COVEREDPAPFormulary: Carvedilol IR. Contact manufacturer for PAP
705536654242400-BETA-ADRENERGIC BLOCKING AGENTS BystolicNEBIVOLOL HCLTABLET5 MGNOT COVEREDPAPFormulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP
1870364945242400-BETA-ADRENERGIC BLOCKING AGENTS BystolicNEBIVOLOL HCLTABLET20 MGNOT COVEREDPAPFormulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP
9923563510242400-BETA-ADRENERGIC BLOCKING AGENTS BystolicNEBIVOLOL HCLTABLET2.5 MGNOT COVEREDPAPFormulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP
9923663511242400-BETA-ADRENERGIC BLOCKING AGENTS BystolicNEBIVOLOL HCLTABLET10 MGNOT COVEREDPAPFormulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP
9796262180242808-DIHYDROPYRIDINES ExforgeAMLODIPINE/VALSARTANTABLET5-160 MGNOT COVEREDPAPPrescribe amlodipine and irbesartan or Lotrel, Contact manufacturer for PAP
9796362181242808-DIHYDROPYRIDINES ExforgeAMLODIPINE/VALSARTANTABLET10-160 MGNOT COVEREDPAPPrescribe amlodipine and irbesartan or Lotrel, Contact manufacturer for PAP
9857962808242808-DIHYDROPYRIDINES ExforgeAMLODIPINE/VALSARTANTABLET5-320 MGNOT COVEREDPAPPrescribe amlodipine and irbesartan or Lotrel, Contact manufacturer for PAP
9858062809242808-DIHYDROPYRIDINES ExforgeAMLODIPINE/VALSARTANTABLET10-320 MGNOT COVEREDPAPPrescribe amlodipine and irbesartan or Lotrel, Contact manufacturer for PAP
3904674408243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSEntrestoSACUBITRIL/VALSARTANTABLET24 MG-26MGNOT COVEREDPAPFormulary: Losartan, Irbesartan. Contact manufacturer for PAP
3904774409243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSEntrestoSACUBITRIL/VALSARTANTABLET49 MG-51MGNOT COVEREDPAPFormulary: Losartan, Irbesartan. Contact manufacturer for PAP
3904874410243208-ANGIOTENSIN II RECEPTOR ANTAGONISTSEntrestoSACUBITRIL/VALSARTANTABLET97MG-103MGNOT COVEREDPAPFormulary: Losartan, Irbesartan. Contact manufacturer for PAP
1728550289243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS BenicarOLMESARTAN MEDOXOMILTABLET20 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan.
1728650290243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS BenicarOLMESARTAN MEDOXOMILTABLET40 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan.
1728450288243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS BenicarOLMESARTAN MEDOXOMILTABLET5 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan.
2883766538243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS TribenzorOLMESARTAN/AMLODIPIN/HCTHIAZIDTABLET20-5-12.5 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan.
2883866539243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS TribenzorOLMESARTAN/AMLODIPIN/HCTHIAZIDTABLET40-5-12.5 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan.
2883966540243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS TribenzorOLMESARTAN/AMLODIPIN/HCTHIAZIDTABLET40-5-25 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan.
2885466541243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS TribenzorOLMESARTAN/AMLODIPIN/HCTHIAZIDTABLET40-10-12.5 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan.
2885566542243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS TribenzorOLMESARTAN/AMLODIPIN/HCTHIAZIDTABLET40-10-25 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan.
2007452833243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS Benicar HCTOLMESARTAN/HYDROCHLOROTHIAZIDETABLET20-12.5 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan.
2007552834243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS Benicar HCTOLMESARTAN/HYDROCHLOROTHIAZIDETABLET40-12.5 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan.
2007652835243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS Benicar HCTOLMESARTAN/HYDROCHLOROTHIAZIDETABLET40-25 MGNOT COVEREDNON-FORMULARYFormulary: Losartan, Irbesartan.
3715872862280808-OPIATE AGONISTSOxycodone EROXYCODONE HCLTAB ER 12H10 MGNOT COVEREDNON-FORMULARYFormulary: Morphine
3715972863280808-OPIATE AGONISTSOxycodone EROXYCODONE HCLTAB ER 12H15 MGNOT COVEREDNON-FORMULARYFormulary: Morphine
3716172864280808-OPIATE AGONISTSOxycodone EROXYCODONE HCLTAB ER 12H20 MGNOT COVEREDNON-FORMULARYFormulary: Morphine
3716272865280808-OPIATE AGONISTSOxycodone EROXYCODONE HCLTAB ER 12H30 MGNOT COVEREDNON-FORMULARYFormulary: Morphine
3716372866280808-OPIATE AGONISTSOxycodone EROXYCODONE HCLTAB ER 12H40 MGNOT COVEREDNON-FORMULARYFormulary: Morphine
3716472867280808-OPIATE AGONISTSOxycodone EROXYCODONE HCLTAB ER 12H60 MGNOT COVEREDNON-FORMULARYFormulary: Morphine
3716572868280808-OPIATE AGONISTSOxycodone EROXYCODONE HCLTAB ER 12H80 MGNOT COVEREDNON-FORMULARYFormulary: Morphine
907020647281208-BENZODIAZEPINES (ANTICONVULSANTS)OnfiCLOBAZAMTABLET20 MGNOT COVEREDPAPContact manufacturer for PAP
907117026281208-BENZODIAZEPINES (ANTICONVULSANTS)OnfiCLOBAZAMTABLET10 MGNOT COVEREDPAPContact manufacturer for PAP
2864366386281292-ANTICONVULSANTS, MISCELLANEOUS VimpatLACOSAMIDESOLUTION10 MG/MLNOT COVEREDPAPContact manufacturer for PAP
1433864432281292-ANTICONVULSANTS, MISCELLANEOUS VimpatLACOSAMIDETABLET50 MGNOT COVEREDPAPContact manufacturer for PAP
1433964433281292-ANTICONVULSANTS, MISCELLANEOUS VimpatLACOSAMIDETABLET100 MGNOT COVEREDPAPContact manufacturer for PAP
1434164434281292-ANTICONVULSANTS, MISCELLANEOUS VimpatLACOSAMIDETABLET150 MGNOT COVEREDPAPContact manufacturer for PAP
1434264435281292-ANTICONVULSANTS, MISCELLANEOUS VimpatLACOSAMIDETABLET200 MGNOT COVEREDPAPContact manufacturer for PAP
1434464437 281292-ANTICONVULSANTS, MISCELLANEOUS VimpatLACOSAMIDEVIAL200 MG/20MLNOT COVEREDPAPContact manufacturer for PAP
2469365250281292-ANTICONVULSANTS, MISCELLANEOUS Lamictal XRLAMOTRIGINETAB ER 2425 MGNOT COVEREDPAPFormulary: Lamotrigine IR. Contact manufacturer for PAP
2473965253281292-ANTICONVULSANTS, MISCELLANEOUS Lamictal XRLAMOTRIGINETAB ER 24200 MGNOT COVEREDPAPFormulary: Lamotrigine IR. Contact manufacturer for PAP
2469765251281292-ANTICONVULSANTS, MISCELLANEOUS Lamictal XRLAMOTRIGINETAB ER 2450 MGNOT COVEREDPAPFormulary: Lamotrigine IR. Contact manufacturer for PAP
2470365252281292-ANTICONVULSANTS, MISCELLANEOUS Lamictal XRLAMOTRIGINETAB ER 24100 MGNOT COVEREDPAPFormulary: Lamotrigine IR. Contact manufacturer for PAP
2972567221281292-ANTICONVULSANTS, MISCELLANEOUS Lamictal XRLAMOTRIGINETAB ER 24300 MGNOT COVEREDPAPFormulary: Lamotrigine IR. Contact manufacturer for PAP
3078768093281292-ANTICONVULSANTS, MISCELLANEOUS Lamictal XRLAMOTRIGINETAB ER 24250 MGNOT COVEREDPAPFormulary: Lamotrigine IR. Contact manufacturer for PAP
1430564416281292-ANTICONVULSANTS, MISCELLANEOUS Keppra XRLEVETIRACETAMTAB ER 24H500 MGNOT COVEREDNON-FORMULARYFormulary: Levetiracetam IR.
2076564990281292-ANTICONVULSANTS, MISCELLANEOUS Keppra XRLEVETIRACETAMTAB ER 24H750 MGNOT COVEREDNON-FORMULARYFormulary: Levetiracetam IR.
3655640901281292-ANTICONVULSANTS, MISCELLANEOUS Topamax Sprinkle CapTOPIRAMATECAP SPRINK15 MGNOT COVEREDPAPContact manufacturer for PAP
3655740902281292-ANTICONVULSANTS, MISCELLANEOUS Topamax Sprinkle CapTOPIRAMATECAP SPRINK25 MGNOT COVEREDPAPContact manufacturer for PAP
3532871496281604-ANTIDEPRESSANTS FetzimaLEVOMILNACIPRAN HYDROCHLORIDECAP SA 24H40 MGNOT COVEREDNON-FORMULARYFormulary: Venlafaxine ER capsules, Duloxetine DR.
3532771495281604-ANTIDEPRESSANTS FetzimaLEVOMILNACIPRAN HYDROCHLORIDECAP SA 24H20 MGNOT COVEREDNON-FORMULARYFormulary: Venlafaxine ER capsules, Duloxetine DR.
3532971497281604-ANTIDEPRESSANTS FetzimaLEVOMILNACIPRAN HYDROCHLORIDECAP SA 24H80 MGNOT COVEREDNON-FORMULARYFormulary: Venlafaxine ER capsules, Duloxetine DR.
3533471498281604-ANTIDEPRESSANTS FetzimaLEVOMILNACIPRAN HYDROCHLORIDECAP SA 24H120 MGNOT COVEREDNON-FORMULARYFormulary: Venlafaxine ER capsules, Duloxetine DR.
3533571499281604-ANTIDEPRESSANTS FetzimaLEVOMILNACIPRAN HYDROCHLORIDECAP24HDSPK20-40 MGNOT COVEREDNON-FORMULARYFormulary: Venlafaxine ER capsules, Duloxetine DR.
2086953401281604-ANTIDEPRESSANTS SymbyaxOLANZAPINE/FLUOXETINE HCLCAPSULE6-50 MGNOT COVEREDPAPPrescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP
2086853400281604-ANTIDEPRESSANTS SymbyaxOLANZAPINE/FLUOXETINE HCLCAPSULE6-25 MGNOT COVEREDPAPPrescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP
2087053402281604-ANTIDEPRESSANTS SymbyaxOLANZAPINE/FLUOXETINE HCLCAPSULE12-25 MGNOT COVEREDPAPPrescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP
2087253403281604-ANTIDEPRESSANTS SymbyaxOLANZAPINE/FLUOXETINE HCLCAPSULE12-50 MGNOT COVEREDPAPPrescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP
9864862878281604-ANTIDEPRESSANTS SymbyaxOLANZAPINE/FLUOXETINE HCLCAPSULE3-25 MGNOT COVEREDPAPPrescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP
3825373810281604-ANTIDEPRESSANTS Viibryd Titration PackVILAZODONE HYDROCHLORIDETAB DS PK10 MG-20 MGNOT COVEREDPAPContact manufacturer for PAP
2991867378281604-ANTIDEPRESSANTS ViibrydVILAZODONE HYDROCHLORIDETABLET40 MGNOT COVEREDPAPContact manufacturer for PAP
2991667376281604-ANTIDEPRESSANTS ViibrydVILAZODONE HYDROCHLORIDETABLET10 MGNOT COVEREDPAPContact manufacturer for PAP
2991767377281604-ANTIDEPRESSANTS ViibrydVILAZODONE HYDROCHLORIDETABLET20 MGNOT COVEREDPAPContact manufacturer for PAP
2803465908281608-ANTIPSYCHOTIC AGENTS FanaptILOPERIDONETAB DS PK1-2-4-6 MGNOT COVEREDNON-FORMULARYFormulary: Olanzapine, Quetiapine, and Risperidone.
2802565901281608-ANTIPSYCHOTIC AGENTS FanaptILOPERIDONETABLET1 MGNOT COVEREDNON-FORMULARYFormulary: Olanzapine, Quetiapine, and Risperidone.
2802665902281608-ANTIPSYCHOTIC AGENTS FanaptILOPERIDONETABLET2 MGNOT COVEREDNON-FORMULARYFormulary: Olanzapine, Quetiapine, and Risperidone.
2802765903281608-ANTIPSYCHOTIC AGENTS FanaptILOPERIDONETABLET4 MGNOT COVEREDNON-FORMULARYFormulary: Olanzapine, Quetiapine, and Risperidone.
2802865904281608-ANTIPSYCHOTIC AGENTS FanaptILOPERIDONETABLET6 MGNOT COVEREDNON-FORMULARYFormulary: Olanzapine, Quetiapine, and Risperidone.
2802965905281608-ANTIPSYCHOTIC AGENTS FanaptILOPERIDONETABLET8 MGNOT COVEREDNON-FORMULARYFormulary: Olanzapine, Quetiapine, and Risperidone.
2803065906281608-ANTIPSYCHOTIC AGENTS FanaptILOPERIDONETABLET10 MGNOT COVEREDNON-FORMULARYFormulary: Olanzapine, Quetiapine, and Risperidone.
2803365907281608-ANTIPSYCHOTIC AGENTS FanaptILOPERIDONETABLET12 MGNOT COVEREDNON-FORMULARYFormulary: Olanzapine, Quetiapine, and Risperidone.
2936666932281608-ANTIPSYCHOTIC AGENTS LatudaLURASIDONE HCLTABLET40 MGNOT COVEREDPAPFormulary: Olanzapine, Quetiapine, and Risperidone. Contact manufacturer for PAP
2936766933281608-ANTIPSYCHOTIC AGENTS LatudaLURASIDONE HCLTABLET80 MGNOT COVEREDPAPFormulary: Olanzapine, Quetiapine, and Risperidone. Contact manufacturer for PAP
3122668448281608-ANTIPSYCHOTIC AGENTS LatudaLURASIDONE HCLTABLET20 MGNOT COVEREDPAPFormulary: Olanzapine, Quetiapine, and Risperidone. Contact manufacturer for PAP
3314769894281608-ANTIPSYCHOTIC AGENTS LatudaLURASIDONE HCLTABLET120 MGNOT COVEREDPAPFormulary: Olanzapine, Quetiapine, and Risperidone. Contact manufacturer for PAP
3519271415281608-ANTIPSYCHOTIC AGENTS LatudaLURASIDONE HCLTABLET60 MGNOT COVEREDPAPFormulary: Olanzapine, Quetiapine, and Risperidone. Contact manufacturer for PAP
3402247285281608-ANTIPSYCHOTIC AGENTS Zyprexa ZydisOLANZAPINETAB RAPDIS15 MGNOT COVEREDPAPFormulary: Olanzapine tablet. Contact manufacturer for PAP
3402347286281608-ANTIPSYCHOTIC AGENTS Zyprexa ZydisOLANZAPINETAB RAPDIS20 MGNOT COVEREDPAPFormulary: Olanzapine tablet. Contact manufacturer for PAP
9200745190281608-ANTIPSYCHOTIC AGENTS Zyprexa ZydisOLANZAPINETAB RAPDIS5 MGNOT COVEREDPAPFormulary: Olanzapine tablet. Contact manufacturer for PAP
9200845191281608-ANTIPSYCHOTIC AGENTS Zyprexa ZydisOLANZAPINETAB RAPDIS10 MGNOT COVEREDPAPFormulary: Olanzapine tablet. Contact manufacturer for PAP
9776961985281608-ANTIPSYCHOTIC AGENTS InvegaPALIPERIDONETAB ER 243 MGNOT COVEREDPAPFormulary: Risperidone. Contact manufacturer for PAP
9777061986281608-ANTIPSYCHOTIC AGENTS InvegaPALIPERIDONETAB ER 246 MGNOT COVEREDPAPFormulary: Risperidone. Contact manufacturer for PAP
9777161987281608-ANTIPSYCHOTIC AGENTS InvegaPALIPERIDONETAB ER 249 MGNOT COVEREDPAPFormulary: Risperidone. Contact manufacturer for PAP
2768565667281608-ANTIPSYCHOTIC AGENTS InvegaPALIPERIDONETAB ER 241.5 MGNOT COVEREDPAPFormulary: Risperidone. Contact manufacturer for PAP
9899463240281608-ANTIPSYCHOTIC AGENTS Seroquel XRQUETIAPINE FUMARATETAB ER 24H50 MGCoveredCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy,
1619364725281608-ANTIPSYCHOTIC AGENTS Seroquel XRQUETIAPINE FUMARATETAB ER 24H150 MGCoveredCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy,
9852262748281608-ANTIPSYCHOTIC AGENTS Seroquel XRQUETIAPINE FUMARATETAB ER 24H200 MGCoveredCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy,
9852362749281608-ANTIPSYCHOTIC AGENTS Seroquel XRQUETIAPINE FUMARATETAB ER 24H300 MGCoveredCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy,
9852462750281608-ANTIPSYCHOTIC AGENTS Seroquel XRQUETIAPINE FUMARATETAB ER 24H400 MGCoveredCommUnityCare PharmacyRestricted to CUC Prescribers. Send to Central Pharmacy,
9807162283282004-AMPHETAMINES VyvanseLISDEXAMFETAMINE DIMESYLATECAPSULE30 MGNOT COVEREDPAPFormulary: Adderall XR. Contact manufacturer for PAP
9807262284282004-AMPHETAMINES VyvanseLISDEXAMFETAMINE DIMESYLATECAPSULE50 MGNOT COVEREDPAPFormulary: Adderall XR. Contact manufacturer for PAP
9936663645282004-AMPHETAMINES VyvanseLISDEXAMFETAMINE DIMESYLATECAPSULE20 MGNOT COVEREDPAPFormulary: Adderall XR. Contact manufacturer for PAP
9936763646282004-AMPHETAMINES VyvanseLISDEXAMFETAMINE DIMESYLATECAPSULE40 MGNOT COVEREDPAPFormulary: Adderall XR. Contact manufacturer for PAP
9936863647282004-AMPHETAMINES VyvanseLISDEXAMFETAMINE DIMESYLATECAPSULE60 MGNOT COVEREDPAPFormulary: Adderall XR. Contact manufacturer for PAP
3767473292282004-AMPHETAMINES VyvanseLISDEXAMFETAMINE DIMESYLATECAPSULE10 MGNOT COVEREDPAPFormulary: Adderall XR. Contact manufacturer for PAP
9807362285282004-AMPHETAMINES VyvanseLISDEXAMFETAMINE DIMESYLATECAPSULE70 MGNOT COVEREDPAPFormulary: Adderall XR. Contact manufacturer for PAP
1224847318282032-RESPIRATORY AND CNS STIMULANTSConcertaMETHYLPHENIDATE HCLTAB ER 2454 MGNOT COVEREDPAPFormulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP
1256845982282032-RESPIRATORY AND CNS STIMULANTSConcertaMETHYLPHENIDATE HCLTAB ER 2436 MGNOT COVEREDPAPFormulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP
1712350172282032-RESPIRATORY AND CNS STIMULANTSConcertaMETHYLPHENIDATE HCLTAB ER 2427 MGNOT COVEREDPAPFormulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP
1256745981282032-RESPIRATORY AND CNS STIMULANTSConcertaMETHYLPHENIDATE HCLTAB ER 2418 MGNOT COVEREDPAPFormulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP
2651565356283620-DOPAMINE RECEPTOR AGONISTSNeuproROTIGOTINEPATCH TD241 MG/24 HRNOT COVEREDPAPFormulary: Ropinirole. Contact manufacturer for PAP
2651665357283620-DOPAMINE RECEPTOR AGONISTSNeuproROTIGOTINEPATCH TD243 MG/24 HRNOT COVEREDPAPFormulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP
2664860486283620-DOPAMINE RECEPTOR AGONISTSNeuproROTIGOTINEPATCH TD242 MG/24 HRNOT COVEREDPAPFormulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP
2664960487283620-DOPAMINE RECEPTOR AGONISTSNeuproROTIGOTINEPATCH TD244 MG/24 HRNOT COVEREDPAPFormulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP
2665460488283620-DOPAMINE RECEPTOR AGONISTSNeuproROTIGOTINEPATCH TD246 MG/24 HRNOT COVEREDPAPFormulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP
2665560489283620-DOPAMINE RECEPTOR AGONISTSNeuproROTIGOTINEPATCH TD248 MG/24 HRNOT COVEREDPAPFormulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP
2757665570289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.IntunivGUANFACINE HCLTAB ER 24H1 MGNOT COVEREDPAPFormulary: Guanfacine IR. Contact manufacturer for PAP
2757865572289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.IntunivGUANFACINE HCLTAB ER 24H2 MGNOT COVEREDPAPFormulary: Guanfacine IR. Contact manufacturer for PAP
2757965573289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.IntunivGUANFACINE HCLTAB ER 24H3 MGNOT COVEREDPAPFormulary: Guanfacine IR. Contact manufacturer for PAP
2758265574289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.IntunivGUANFACINE HCLTAB ER 24H4 MGNOT COVEREDPAPFormulary: Guanfacine IR. Contact manufacturer for PAP
1877651489289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. StratteraATOMOXETINE HCLCAPSULE10 MGNOT COVEREDPAPContact manufacturer for PAP
1877751490289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. StratteraATOMOXETINE HCLCAPSULE18 MGNOT COVEREDPAPContact manufacturer for PAP
1877851491289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. StratteraATOMOXETINE HCLCAPSULE25 MGNOT COVEREDPAPContact manufacturer for PAP
1877951492289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. StratteraATOMOXETINE HCLCAPSULE40 MGNOT COVEREDPAPContact manufacturer for PAP
1878151493289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. StratteraATOMOXETINE HCLCAPSULE60 MGNOT COVEREDPAPContact manufacturer for PAP
2653860390289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. StratteraATOMOXETINE HCLCAPSULE80 MGNOT COVEREDPAPContact manufacturer for PAP
2653960391289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. StratteraATOMOXETINE HCLCAPSULE100 MGNOT COVEREDPAPContact manufacturer for PAP
9520040962366000-THYROID FUNCTIONThyrogenTHYROTROPIN ALFAVIAL1.1 MGNOT COVEREDPAP
4372577644481008-CORTICOSTEROIDS (RESPIRATORY TRACT)QVAR RedihalerBECLOMETHASONE DIPROPIONATEHFA AEROBA80 MCGNOT COVEREDPAPFormulary: Flovent HFA. Contact manufacturer for PAP
4372477643481008-CORTICOSTEROIDS (RESPIRATORY TRACT)QVAR RedihalerBECLOMETHASONE DIPROPIONATEHFA AEROBA40 MCGNOT COVEREDPAPFormulary: Flovent HFA. Contact manufacturer for PAP
9802462240481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Pulmicort FlexhalerBUDESONIDEAER POW BA90 MCGNOT COVEREDPAPFormulary: Flovent HFA. Contact manufacturer for PAP
9802562241481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Pulmicort FlexhalerBUDESONIDEAER POW BA180 MCGNOT COVEREDPAPFormulary: Flovent HFA. Contact manufacturer for PAP
9849962725481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Symbicort MDIBUDESONIDE/FORMOTEROL FUMARATEHFA AER AD80-4.5 MCGNOT COVEREDPAPFormulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
9850062726481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Symbicort MDIBUDESONIDE/FORMOTEROL FUMARATEHFA AER AD160-4.5 MCGNOT COVEREDPAPFormulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
5363319317481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Flovent DIKUSFLUTICASONE PROPIONATEBLST W/DEV100 MCGNOT COVEREDPAPFormulary: Flovent HFA. Contact manufacturer for PAP
5363419318481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Flovent DIKUSFLUTICASONE PROPIONATEBLST W/DEV250 MCGNOT COVEREDPAPFormulary: Flovent HFA. Contact manufacturer for PAP
5363519319481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Flovent DIKUSFLUTICASONE PROPIONATEBLST W/DEV50 MCGNOT COVEREDPAPFormulary: Flovent HFA. Contact manufacturer for PAP
5059443367481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Advair DISKUSFLUTICASONE/SALMETEROLBLST W/DEV250-50 MCGNOT COVEREDPAPFormulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
5060443368481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Advair DISKUSFLUTICASONE/SALMETEROLBLST W/DEV500-50 MCGNOT COVEREDPAPFormulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
5058443366481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Advair DISKUSFLUTICASONE/SALMETEROLBLST W/DEV100-50 MCGNOT COVEREDPAPFormulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
9713561343481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Advair HFAFLUTICASONE/SALMETEROLHFA AER AD45-21 MCGNOT COVEREDPAPFormulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
9713661344481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Advair HFAFLUTICASONE/SALMETEROLHFA AER AD115-21 MCGNOT COVEREDPAPFormulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
9713761345481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Advair HFAFLUTICASONE/SALMETEROLHFA AER AD230-21 MCGNOT COVEREDPAPFormulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
3464770972481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Breo ElliptaFLUTICASONE/VILANTEROLBLST W/DEV100-25 MCGNOT COVEREDPAPFormulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
3580871815481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Breo ElliptaFLUTICASONE/VILANTEROLBLST W/DEV200-25 MCGNOT COVEREDPAPFormulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
3756573197481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Asmanex HFAMOMETASONE FUROATEHFA AER AD200 MCGNOT COVEREDPAPFormulary: Flovent HFA. Contact manufacturer for PAP
3756673198481008-CORTICOSTEROIDS (RESPIRATORY TRACT) Asmanex HFAMOMETASONE FUROATEHFA AER AD100 MCGNOT COVEREDPAPFormulary: Flovent HFA. Contact manufacturer for PAP
4032129803481024-LEUKOTRIENE MODIFIERS Zyflo FilmtabZILEUTONTABLET600 MGNOT COVEREDNON-FORMULARYFormulary: Montelukast.
9882263062481024-LEUKOTRIENE MODIFIERS Zyflo FilmtabZILEUTONTBMP 12HR600 MGNOT COVEREDNON-FORMULARYFormulary: Montelukast.
2893466612483200-PHOSPHODIESTERASE TYPE 4 INHIBITORSDalirespROFLUMILASTTABLET500 MCGNOT COVEREDPAPContact manufacturer for PAP
1921651820520892-EENT ANTI-INFLAMMATORY AGENTS, MISC. RestasisCYCLOSPORINEDROPERETTE0.05 %NOT COVEREDPAPPrior auths restricted to opthamology prescriber, Contact manufacturer for PAP
2713165392524028-PROSTAGLANDIN ANALOGS LumiganBIMATOPROSTDROPS0.01 %NOT COVEREDPAPFormulary: Latanoprost. Prior Auths restricted to opthamology, Contact manufacturer for PAP
2759465587524028-PROSTAGLANDIN ANALOGS ZioptanTAFLUPROST/PFDROPS0.0015%NOT COVEREDPAPFormulary: Latanoprost. Prior Auths restricted to opthamology, Contact manufacturer for PAP
1300247612524028-PROSTAGLANDIN ANALOGS Travatan ZTRAVOPROSTDROPS0.004%NOT COVEREDPAPFormulary: Latanoprost. Prior Auths restricted to opthamology, Contact manufacturer for PAP
2647360341561200-CATHARTICS AND LAXATIVES AmitizaLUBIPROSTONECAPSULE24 MCGNOT COVEREDPAPContact manufacturer for PAP
9965863946561200-CATHARTICS AND LAXATIVES AmitizaLUBIPROSTONECAPSULE8 MCGNOT COVEREDPAPContact manufacturer for PAP
1630564793562836-PROTON-PUMP INHIBITORS DexilantDEXLANSOPRAZOLECAP DR BP30 MGNOT COVEREDPAPFormulary: Pantoprazole. Contact manufacturer for PAP
1630664794562836-PROTON-PUMP INHIBITORS DexilantDEXLANSOPRAZOLECAP DR BP60 MGNOT COVEREDPAPFormulary: Pantoprazole. Contact manufacturer for PAP
1630564793562836-PROTON-PUMP INHIBITORS DexilantDEXLANSOPRAZOLECAP DR BP30 MGNOT COVEREDPAPFormulary: Pantoprazole. Contact manufacturer for PAP
1630664794562836-PROTON-PUMP INHIBITORS DexilantDEXLANSOPRAZOLECAP DR BP60 MGNOT COVEREDPAPFormulary: Pantoprazole. Contact manufacturer for PAP
9534840304563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)ColazalBALSALAZIDE DISODIUMCAPSULE750 MGNOT COVEREDNON-FORMULARYFormulary: sulfasalazine.
9984764139563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)RowasaMESALAMINE W/CLEANSING WIPESENEMA KIT4 G/60 MLNOT COVEREDNON-FORMULARY
1615964701563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) Apriso ERMESALAMINECAP ER 24H0.375 GNOT COVEREDPAPFormulary: Sulfasalazine. Contact manufacturer for PAP
3411370543563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) Delzicol DRMESALAMINECAPSULE DR400 MGNOT COVEREDPAPFormulary: Sulfasalazine. Contact manufacturer for PAP
2342258091563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) PentasaMESALAMINECAPSULE ER500 MGNOT COVEREDPAPFormulary: Sulfasalazine. Contact manufacturer for PAP
4849021776563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) Canasa SuppositoryMESALAMINESUPP.RECT1000 MGNOT COVEREDPAPFormulary: Sulfasalazine. Contact manufacturer for PAP
9784262058563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) LialdaMESALAMINETABLET DR1.2 GNOT COVEREDPAPFormulary: Sulfasalazine. Contact manufacturer for PAP
3935474654569200-GI DRUGS, MISCELLANEOUSViberziELUXADOLINETABLET75 MGNOT COVEREDPAPContact manufacturer for PAP
3935574655569200-GI DRUGS, MISCELLANEOUSViberziELUXADOLINETABLET100 MGNOT COVEREDPAPContact manufacturer for PAP
3318769922569200-GI DRUGS, MISCELLANEOUS LinzessLINACLOTIDECAPSULE145 MCGNOT COVEREDPAPContact manufacturer for PAP
3318869923569200-GI DRUGS, MISCELLANEOUS LinzessLINACLOTIDECAPSULE290 MCGNOT COVEREDPAPContact manufacturer for PAP
9945063735682003-AMYLINOMIMETICS SymlinPRAMLINTIDE ACETATEPEN INJCTR2700 MCG/2.7MLNOT COVEREDPAPContact manufacturer for PAP
9951463804682003-AMYLINOMIMETICS SymlinPRAMLINTIDE ACETATEPEN INJCTR1500 MCG/1.5MLNOT COVEREDPAPContact manufacturer for PAP
3408670525682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSNesinaALOGLIPTINTABLET6.25 MGNOT COVEREDPAPFormulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
3408570524682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSNesinaALOGLIPTINTABLET12.5 GMNOT COVEREDPAPFormulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
3407670517682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSNesinaALOGLIPTINTABLET25 MGNOT COVEREDPAPFormulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
2739365430682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSOnglyzaSAXAGLIPTIN HCLTABLET2.5 MGNOT COVEREDPAPFormulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
2739465431682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSOnglyzaSAXAGLIPTIN HCLTABLET5 MGNOT COVEREDPAPFormulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
2922466817682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSKombiglyze XRSAXAGLIPTIN HCL/METFORMIN HCLTBMP 24HR5-1000 MGNOT COVEREDPAPFormulary: Janumet (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
2922566818682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSKombiglyze XRSAXAGLIPTIN HCL/METFORMIN HCLTBMP 24HR2.5-1000 MGNOT COVEREDPAPFormulary: Janumet (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
2911866816682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSKombiglyze XRSAXAGLIPTIN HCL/METFORMIN HCLTBMP 24HR5-500 MGNOT COVEREDPAPFormulary: Janumet (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
3716972872682006-INCRETIN MIMETICS TrulicityDULAGLUTIDEPEN INJCTR0.75MG/0.5NOT COVEREDPAPFormulary: Byetta, Victoza. Contact manufacturer for PAP
3717172873682006-INCRETIN MIMETICS TrulicityDULAGLUTIDEPEN INJCTR1.5 MG/0.5NOT COVEREDPAPFormulary: Byetta, Victoza. Contact manufacturer for PAP
4403977890682006-INCRETIN MIMETICS Bydureon BciseEXENATIDE MICROSPHERESAUTO INJCT2MG/0.85MLNOT COVEREDPAPFormulary: Byetta, Victoza. Contact manufacturer for PAP
3635272230682006-INCRETIN MIMETICS Bydureon PenEXENATIDE MICROSPHERESPEN INJCTR2MG/0.65MLNOT COVEREDPAPFormulary: Byetta, Victoza. Contact manufacturer for PAP
2618965344682006-INCRETIN MIMETICS VictozaLIRAGLUTIDEPEN INJCTR0.6 MG/0.1MLCoveredFORMULARYStep therapy: Must demonstrate failure with Byetta
9863762867682008-INSULINS Lantus SolostarINSULIN GLARGINE HUM.REC.ANLOGINSULN PEN100 UNIT/MLNOT COVEREDPAPFormulary: Levemir. Contact manufacturer for PAP
3798873567682008-INSULINS Toujeo SolostarINSULIN GLARGINE HUM.REC.ANLOGINSULN PEN300 UNIT/MLNOT COVEREDPAPPA's Restricted to Dr. Dubois. Levemir is formulary, Contact manufacturer for PAP
1307247780682008-INSULINS LantusINSULIN GLARGINE HUM.REC.ANLOGVIAL100 UNIT/MLNOT COVEREDPAPFormulary: Levemir. Contact manufacturer for PAP
2650860371682008-INSULINS Apidra SolostarINSULIN GLULISINEINSULN PEN100 UNIT/MLNOT COVEREDPAPFormulary: Novolog, Humalog. Contact manufacturer for PAP
2593659985682008-INSULINS ApidraINSULIN GLULISINEVIAL100 UNIT/MLNOT COVEREDPAPFormulary: Novolog, Humalog. Contact manufacturer for PAP
963329916682008-INSULINS Humulin R U500INSULIN REGULAR HUMANVIAL500 UNIT/MLNOT COVEREDPAPPrescribe U500 Syringes, Contact manufacturer for PAP
3443970791682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBInvokanaCANAGLIFLOZINTABLET100 MGNOT COVEREDPAPContact manufacturer for PAP
3444170792682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBInvokanaCANAGLIFLOZINTABLET300 MGNOT COVEREDPAPContact manufacturer for PAP
4231576623682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBInokamet XRCANAGLIFLOZIN/METFORMIN HCLTAB BP 24H150-1000MGNOT COVEREDPAPContact manufacturer for PAP
4231276620682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBInvokamet XRCANAGLIFLOZIN/METFORMIN HCLTAB BP 24H50MG-500MGNOT COVEREDPAPContact manufacturer for PAP
4231376621682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBInvokamet XRCANAGLIFLOZIN/METFORMIN HCLTAB BP 24H50-1000 MGNOT COVEREDPAPContact manufacturer for PAP
4231476622682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBInvokamet XRCANAGLIFLOZIN/METFORMIN HCLTAB BP 24H150-500 MGNOT COVEREDPAPContact manufacturer for PAP
3685772587682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBInvokametCANAGLIFLOZIN/METFORMIN HCLTABLET50-1000 MGNOT COVEREDPAPContact manufacturer for PAP
3685972589682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBInvokametCANAGLIFLOZIN/METFORMIN HCLTABLET150-1000MGNOT COVEREDPAPContact manufacturer for PAP
3695372677682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBInvokametCANAGLIFLOZIN/METFORMIN HCLTABLET150-500 MGNOT COVEREDPAPContact manufacturer for PAP
3695472678682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBInvokametCANAGLIFLOZIN/METFORMIN HCLTABLET50MG-500MGNOT COVEREDPAPContact manufacturer for PAP
3439470755682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBFarxigaDAPAGLIFLOZIN PROPANEDIOLTABLET10 MGNOT COVEREDPAPContact manufacturer for PAP
3569871740682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBFarxigaDAPAGLIFLOZIN PROPANEDIOLTABLET5 MGNOT COVEREDPAPContact manufacturer for PAP
3734373031682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBXigduo XRDAPAGLIFLOZIN/METFORMIN HCLTAB BP 24H5-1000 MGNOT COVEREDPAPContact manufacturer for PAP
3733973029682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBXigduo XRDAPAGLIFLOZIN/METFORMIN HCLTAB BP 24H5-500 MGNOT COVEREDPAPContact manufacturer for PAP
3734273030682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBXigduo XRDAPAGLIFLOZIN/METFORMIN HCLTAB BP 24H10-500 MGNOT COVEREDPAPContact manufacturer for PAP
3734473032682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBXigduo XRDAPAGLIFLOZIN/METFORMIN HCLTAB BP 24H10-1000 MGNOT COVEREDPAPContact manufacturer for PAP
3671672488682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBJardianceEMPAGLIFLOZINTABLET10 MGNOT COVEREDPAPContact manufacturer for PAP
3672372489682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBJardianceEMPAGLIFLOZINTABLET25 MGNOT COVEREDPAPContact manufacturer for PAP
3783273432682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBGlyxambiEMPAGLIFLOZIN/LINAGLIPTINTABLET10 MG-5 MGNOT COVEREDPAPContact manufacturer for PAP
3783373433682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBGlyxambiEMPAGLIFLOZIN/LINAGLIPTINTABLET25 MG-5 MGNOT COVEREDPAPContact manufacturer for PAP
3892974316682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBSynjardyEMPAGLIFLOZIN/METFORMIN HCLTABLET5MG-1000MGNOT COVEREDPAPContact manufacturer for PAP
3893274318682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBSynjardyEMPAGLIFLOZIN/METFORMIN HCLTABLET12.5-1000NOT COVEREDPAPContact manufacturer for PAP
3937774675682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBSynjardyEMPAGLIFLOZIN/METFORMIN HCLTABLET5 MG-500MGNOT COVEREDPAPContact manufacturer for PAP
3937874676682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBSynjardyEMPAGLIFLOZIN/METFORMIN HCLTABLET12.5-500MGNOT COVEREDPAPContact manufacturer for PAP
1440464481682400-PARATHYROID ForteoTERIPARATIDEPEN INJCTR20 MCG/DOSENOT COVEREDPAPContact manufacturer for PAP
9680534383683200-PROGESTINSCrinone GelPROGESTERONE, MICRONIZEDGEL/PF APP4%NOT COVEREDPAPEndometrin preferred
6301131769683200-PROGESTINSCrinone GelPROGESTERONE, MICRONIZEDGEL/PF APP8%NOT COVEREDPAPEndometrin preferred
4763220176683604-THYROID AGENTS SynthroidLEVOTHYROXINE SODIUMTABLET137 MCGNOT COVEREDPAPContact manufacturer for PAP
263216648683604-THYROID AGENTS SynthroidLEVOTHYROXINE SODIUMTABLET25 MCGNOT COVEREDPAPContact manufacturer for PAP
263226649683604-THYROID AGENTS SynthroidLEVOTHYROXINE SODIUMTABLET50 MCGNOT COVEREDPAPContact manufacturer for PAP
263246650683604-THYROID AGENTS SynthroidLEVOTHYROXINE SODIUMTABLET75 MCGNOT COVEREDPAPContact manufacturer for PAP
4763115523683604-THYROID AGENTS SynthroidLEVOTHYROXINE SODIUMTABLET88 MCGNOT COVEREDPAPContact manufacturer for PAP
263236651683604-THYROID AGENTS SynthroidLEVOTHYROXINE SODIUMTABLET100 MCGNOT COVEREDPAPContact manufacturer for PAP
263266653683604-THYROID AGENTS SynthroidLEVOTHYROXINE SODIUMTABLET125 MCGNOT COVEREDPAPContact manufacturer for PAP
263276654683604-THYROID AGENTS SynthroidLEVOTHYROXINE SODIUMTABLET150 MCGNOT COVEREDPAPContact manufacturer for PAP
263286655683604-THYROID AGENTS SynthroidLEVOTHYROXINE SODIUMTABLET175MCGNOT COVEREDPAPContact manufacturer for PAP
263256656683604-THYROID AGENTS SynthroidLEVOTHYROXINE SODIUMTABLET200 MCGNOT COVEREDPAPContact manufacturer for PAP
263296657683604-THYROID AGENTS SynthroidLEVOTHYROXINE SODIUMTABLET300 MCGNOT COVEREDPAPContact manufacturer for PAP
263206652683604-THYROID AGENTS SynthroidLEVOTHYROXINE SODIUMTABLET112 MCGNOT COVEREDPAPContact manufacturer for PAP
1348019141849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.SoriataneACITRETINCAPSULE10 MGNOT COVEREDPAPContact manufacturer for PAP
1348119142849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.SoriataneACITRETINCAPSULE25 MGNOT COVEREDPAPContact manufacturer for PAP
1878251494849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. AvageTAZAROTENECREAM (G)0.1 %NOT COVEREDNON-FORMULARY
8536246983849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. Tazorac CreamTAZAROTENECREAM (G)0.05 %NOT COVEREDNON-FORMULARY
8536346984849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. Tazorac CreamTAZAROTENECREAM (G)0.1 %NOT COVEREDNON-FORMULARY
3217869204849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. Fabior FoamTAZAROTENEFOAM0.1 %NOT COVEREDNON-FORMULARY
2922231601849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. Tazorac CreamTAZAROTENEGEL (GRAM)0.1 %NOT COVEREDNON-FORMULARY
2922131600849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. Tazorac CreamTAZAROTENEGEL (GRAM)0.05 %NOT COVEREDNON-FORMULARY
2327657982861204-ANTIMUSCARINICSVesicareSOLIFENACIN SUCCINATETABLET5 MGNOT COVEREDPAPOxybutynin ER preferred
2327757983861204-ANTIMUSCARINICSVesicareSOLIFENACIN SUCCINATETABLET10 MGNOT COVEREDPAPOxybutynin ER preferred
3276669630861208-BETA-3-ADRENERGIC AGONISTSMyrbetriq ERMIRABEGRONTAB ER 24H25 MGNOT COVEREDPAPContact manufacturer for PAP
3276769631861208-BETA-3-ADRENERGIC AGONISTSMyrbetriq ERMIRABEGRONTAB ER 24H50 MGNOT COVEREDPAPContact manufacturer for PAP
1680864829921600-ANTIGOUT AGENTSUloricFEBUXOSTATTABLET40 MGNOT COVEREDPAPAllopurinol is formulary, Contact manufacturer for PAP
1680964830921600-ANTIGOUT AGENTSUloricFEBUXOSTATTABLET80 MGNOT COVEREDPAPAllopurinol is formulary, Contact manufacturer for PAP
2907366709922000-IMMUNOMODULATORY AGENTSGilenyaFINGOLIMOD HCLCAPSULE0.5 MGNOT COVEREDPAPContact manufacturer for PAP
2865666396922400-BONE RESORPTION INHIBITORSProliaDENOSUMABSYRINGE60 MG/MLNOT COVEREDPAPContact manufacturer for PAP
9700561205923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHumiraADALIMUMABPEN IJ KIT40 MG/0.8MLNOT COVEREDPAPContact manufacturer for PAP
1892451599923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHumiraADALIMUMABSYRINGEKIT40 MG/0.8MLNOT COVEREDPAPContact manufacturer for PAP
3726272952923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHumiraADALIMUMABSYRINGEKIT10 MG/0.2MLNOT COVEREDPAPContact manufacturer for PAP
9943963724923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTSHumiraADALIMUMABSYRINGEKIT20 MG/0.4MLNOT COVEREDPAPContact manufacturer for PAP
9772461938923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTSEnbrelETANERCEPTPEN INJCTR50 MG/MLNOT COVEREDPAPContact manufacturer for PAP
9839862624923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTSEnbrelETANERCEPTSYRINGE25 MG/0.5MLNOT COVEREDPAPContact manufacturer for PAP
2357458214923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTSEnbrelETANERCEPTSYRINGE50 MG/MLNOT COVEREDPAPContact manufacturer for PAP
5265140869923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTSEnbrelETANERCEPTVIAL25 MGNOT COVEREDPAPContact manufacturer for PAP
4756023724924400-IMMUNOSUPPRESSIVE AGENTSCellceptMYCOPHENOLATE MOFETILCAPSULE250 MGNOT COVEREDPAPContact manufacturer for PAP
4756132599924400-IMMUNOSUPPRESSIVE AGENTSCellceptMYCOPHENOLATE MOFETILCAPSULE500 MGNOT COVEREDPAPContact manufacturer for PAP
4122921175925600-PROTECTIVE AGENTSElmironPENTOSAN POLYSULFATE SODIUMCAPSULE100 MGNOT COVEREDPAPContact manufacturer for PAP
4502678657681804-ANTIGONADOTROPINSOrilissaELAGOLIXTABLET150 MGNOT COVEREDPAPContact manufacturer for PAP
4502678657681804-ANTIGONADOTROPINSOrilissaELAGOLIXTABLET200 MGNOT COVEREDPAPContact manufacturer for PAP
4267676864682008-INSULINS SoliquaINSULIN GLARGINE/LIXISENATIDEINSULN PEN100 UNIT-33 MCG/MLNOT COVEREDPAPContact manufacturer for PAP
2989067353682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSTradjentaLINAGLIPTINTABLET5 MGNOT COVEREDPAPFormulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
3131568516682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSJentaduetoLINAGLIPTIN/METFORMINTABLET2.5-500 MGNOT COVEREDPAPFormulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
3131668517682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSJentaduetoLINAGLIPTIN/METFORMINTABLET2.5-850 MGNOT COVEREDPAPFormulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
3131768518682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSJentaduetoLINAGLIPTIN/METFORMINTABLET2.5-1000 MGNOT COVEREDPAPFormulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
4163776256682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSJentadueto XRLINAGLIPTIN/METFORMIN ERTABLET2.5-1000 MGNOT COVEREDPAPFormulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
4163976257682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORSJentadueto XRLINAGLIPTIN/METFORMIN ERTABLET5-1000 MGNOT COVEREDPAPFormulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
2077353324289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.NamendaMEMANTINETABLET5 MGNOT COVEREDPAPFormulary: Donepezil, Rivastigmine. Contact manufacturer for PAP
325332492289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.NamendaMEMANTINETABLET10 mgNOT COVEREDPAPFormulary: Donepezil, Rivastigmine. Contact manufacturer for PAP
3452570868289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.Namenda XRMEMANTINE ERTABLET14 mgNOT COVEREDPAPFormulary: Donepezil, Rivastigmine. Contact manufacturer for PAP
3452770870289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.Namenda XRMEMANTINE ERTABLET28 mgNOT COVEREDPAPFormulary: Donepezil, Rivastigmine. Contact manufacturer for PAP
413709326081228-ANTIBACTERIALS, MISCELLANEOUSVancocinVANCOMYCINCAPSULE125 MGCoveredFORMULARYRestricted to CUC Prescribers and Seton Outpatient Central Pharmacy
413719327081228-ANTIBACTERIALS, MISCELLANEOUSVancocinVANCOMYCINCAPSULE250 MGCoveredFORMULARYRestricted to CUC Prescribers and Seton Outpatient Central Pharmacy