MAP & MAP BASIC Formulary

Created OnAugust 29, 2018

Last Updated OnNovember 21, 2019

byMike McKinnon, Communications Solutions & Innovation Manager

Download an Excel spreadsheet of the complete formulary.

Effective Date 11/9/2019

MAP Formulary

Generic Code	Generic Sequence Number	Therapeutic Class	BrandName	GenericName	Formulation	Strength	Coverage	Location	Comments
49291	17037	040800-SECOND GENERATION ANTIHISTAMINES	Zyrtec	CETIRIZINE HCL	TABLET	10 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
60563	18698	040800-SECOND GENERATION ANTIHISTAMINES	Claritin	LORATADINE	TABLET	10 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
26820	25484	081808-ANTIRETROVIRALS	Crixivan	INDINAVIR SULFATE	CAPSULE	200 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
26822	25485	081808-ANTIRETROVIRALS	Crixivan	INDINAVIR SULFATE	CAPSULE	400 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
98986	63231	081808-ANTIRETROVIRALS	Isentress	RALTEGRAVIR POTASSIUM	TABLET	400 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
17853	50714	120808-ANTIMUSCARINICS/ANTISPASMODICS	Spiriva Handihaler	TIOTROPIUM BROMIDE	CAP W/DEV	18 MCG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy,
7610	36857	129200-AUTONOMIC DRUGS, MISCELLANEOUS	Nicotrol Inhaler	NICOTINE	CARTRIDGE	10 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
3421	16425	129200-AUTONOMIC DRUGS, MISCELLANEOUS	Nicoderm CQ Patch	NICOTINE	PATCH TD24	7 MG/24HR	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
3422	16426	129200-AUTONOMIC DRUGS, MISCELLANEOUS	Nicoderm CQ Patch	NICOTINE	PATCH TD24	14 MG/24HR	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
3423	16427	129200-AUTONOMIC DRUGS, MISCELLANEOUS	Nicoderm CQ Patch	NICOTINE	PATCH TD24	21 MG/24HR	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
27048	60898	129200-AUTONOMIC DRUGS, MISCELLANEOUS	Chantix Starting Pack	VARENICLINE TARTRATE	TAB DS PK	0.5(11)-1(42) MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
27047	60897	129200-AUTONOMIC DRUGS, MISCELLANEOUS	Chantix Continuing Pack	VARENICLINE TARTRATE	TABLET	1 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
18387	51214	240605-CHOLESTEROL ABSORPTION INHIBITORS	Zetia	EZETIMIBE	TABLET	10 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
23125	57863	240605-CHOLESTEROL ABSORPTION INHIBITORS	Vytorin	EZETIMIBE/SIMVASTATIN	TABLET	10-20 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
23127	57865	240605-CHOLESTEROL ABSORPTION INHIBITORS	Vytorin	EZETIMIBE/SIMVASTATIN	TABLET	10-40 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
23121	57859	240605-CHOLESTEROL ABSORPTION INHIBITORS	Vytorin	EZETIMIBE/SIMVASTATIN	TABLET	10-10 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
23126	57864	240605-CHOLESTEROL ABSORPTION INHIBITORS	Vytorin	EZETIMIBE/SIMVASTATIN	TABLET	10-80 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
21392	53690	240608-HMG-COA REDUCTASE INHIBITORS	Caduet	AMLODIPINE/ATORVASTATIN	TABLET	5-20 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
21393	53691	240608-HMG-COA REDUCTASE INHIBITORS	Caduet	AMLODIPINE/ATORVASTATIN	TABLET	5-40 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
21396	53694	240608-HMG-COA REDUCTASE INHIBITORS	Caduet	AMLODIPINE/ATORVASTATIN	TABLET	10-20 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
21397	53695	240608-HMG-COA REDUCTASE INHIBITORS	Caduet	AMLODIPINE/ATORVASTATIN	TABLET	10-40 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
21391	53689	240608-HMG-COA REDUCTASE INHIBITORS	Caduet	AMLODIPINE/ATORVASTATIN	TABLET	5-10 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
21394	53692	240608-HMG-COA REDUCTASE INHIBITORS	Caduet	AMLODIPINE/ATORVASTATIN	TABLET	5-80 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
21395	53693	240608-HMG-COA REDUCTASE INHIBITORS	Caduet	AMLODIPINE/ATORVASTATIN	TABLET	10-10 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
21398	53696	240608-HMG-COA REDUCTASE INHIBITORS	Caduet	AMLODIPINE/ATORVASTATIN	TABLET	10-80 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
42001	41285	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Celebrex	CELECOXIB	CAPSULE	100 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
42002	41286	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Celebrex	CELECOXIB	CAPSULE	200 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
97785	62001	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Celebrex	CELECOXIB	CAPSULE	50 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
18127	50832	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Celebrex	CELECOXIB	CAPSULE	400 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
6263	35737	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Arthrotec	DICLOFENAC SODIUM/MISOPROSTOL	TAB IR DR	75 MG-200	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
62729	20279	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Arthrotex	DICLOFENAC SODIUM/MISOPROSTOL	TAB IR DR	50 MG-200	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
35820	8370	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Feldene	PIROXICAM	CAPSULE	10 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
35821	8371	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Feldene	PIROXICAM	CAPSULE	20 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
23046	57800	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	50 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
23047	57801	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	75 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
23048	57802	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	100 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
23049	57803	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	150 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
23051	57804	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	200 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
23052	57805	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	300 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
23039	57799	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	25 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
25019	59401	281292-ANTICONVULSANTS, MISCELLANEOUS	Lyrica	PREGABALIN	CAPSULE	225 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
99451	63736	281604-ANTIDEPRESSANTS	Pristiq	DESVENLAFAXINE SUCCINATE	TAB ER 24H	50 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
99452	63737	281604-ANTIDEPRESSANTS	Pristiq	DESVENLAFAXINE SUCCINATE	TAB ER 24H	100 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
38222	73778	281604-ANTIDEPRESSANTS	Pristiq	DESVENLAFAXINE SUCCINATE	TAB ER 24H	25 MG	NOT COVERED	PAP	Contact manufacturer for PAP
18537	51333	281608-ANTIPSYCHOTIC AGENTS	Abilify	ARIPIPRAZOLE	TABLET	10 MG	COVERED	FORMULARY
18538	51334	281608-ANTIPSYCHOTIC AGENTS	Abilify	ARIPIPRAZOLE	TABLET	15 MG	COVERED	FORMULARY
18539	51335	281608-ANTIPSYCHOTIC AGENTS	Abilify	ARIPIPRAZOLE	TABLET	20 MG	COVERED	FORMULARY
18541	51336	281608-ANTIPSYCHOTIC AGENTS	Abilify	ARIPIPRAZOLE	TABLET	30 MG	COVERED	FORMULARY
20173	52898	281608-ANTIPSYCHOTIC AGENTS	Abilify	ARIPIPRAZOLE	TABLET	5 MG	COVERED	FORMULARY
26305	60225	281608-ANTIPSYCHOTIC AGENTS	Abilify	ARIPIPRAZOLE	TABLET	2 MG	COVERED	FORMULARY
15173	49605	283228-SELECTIVE SEROTONIN AGONISTS	Relpax	ELETRIPTAN HBR	TABLET	20 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
15174	49606	283228-SELECTIVE SEROTONIN AGONISTS	Relpax	ELETRIPTAN HBR	TABLET	40 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
19594	40224	283228-SELECTIVE SEROTONIN AGONISTS	Maxalt MLT	RIZATRIPTAN BENZOATE	TAB RAPDIS	10 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
19592	40222	283228-SELECTIVE SEROTONIN AGONISTS	Maxalt	RIZATRIPTAN BENZOATE	TABLET	10 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
18987	51649	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Asmanex TWISTHALER	MOMETASONE FUROATE	AER POW BA	220 MCG 120	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
24929	59328	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Asmanex TWISTHALER	MOMETASONE FUROATE	AER POW BA	220 MCG(60)	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
99721	64010	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Asmanex TWISTHALER	MOMETASONE FUROATE	AER POW BA	110 MCG(30)	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
28766	66480	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Dulera MDI	MOMETASONE/FORMOTEROL	HFA AER AD	100-5 MCG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
28767	66481	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Dulera MDI	MOMETASONE/FORMOTEROL	HFA AER AD	200-5 MCG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
71431	31186	520808-CORTICOSTEROIDS (EENT)	Nasonex	MOMETASONE FUROATE	SPRAY/PUMP	50 MCG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
64269	37219	562836-PROTON-PUMP INHIBITORS	Prevpac	LANSOPRAZOLE/AMOXICILN/CLARITH	COMBO. PKG	30-500-500 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
17528	50464	681200-CONTRACEPTIVES	Nuvaring	ETONOGESTREL/ETHINYL ESTRADIOL	VAG RING	0.12-.015 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
98306	62531	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Janumet	SITAGLIPTIN PHOS/METFORMIN HCL	TABLET	50-500 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
98307	62532	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Janumet	SITAGLIPTIN PHOS/METFORMIN HCL	TABLET	50-1000 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
31339	68538	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Janumet XR	SITAGLIPTIN PHOS/METFORMIN HCL	TBMP 24HR	50-500 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
31340	68539	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Janumet XR	SITAGLIPTIN PHOS/METFORMIN HCL	TBMP 24HR	50-1000 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
31348	68540	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Janumet XR	SITAGLIPTIN PHOS/METFORMIN HCL	TBMP 24HR	100-1000 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
97398	61612	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Januvia	SITAGLIPTIN PHOSPHATE	TABLET	25 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
97399	61613	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Januvia	SITAGLIPTIN PHOSPHATE	TABLET	50 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
97400	61614	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Januvia	SITAGLIPTIN PHOSPHATE	TABLET	100 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
24614	59073	682006-INCRETIN MIMETICS	Byetta	EXENATIDE	PEN INJCTR	10 MCG/0.04	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
24613	59072	682006-INCRETIN MIMETICS	Byetta	EXENATIDE	PEN INJCTR	5 MCG/0.04	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
99711	64000	861204-ANTIMUSCARINICS	Toviaz	FESOTERODINE FUMARATE	TAB ER 24H	4 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
99712	64001	861204-ANTIMUSCARINICS	Toviaz	FESOTERODINE FUMARATE	TAB ER 24H	8 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
12263	47327	861204-ANTIMUSCARINICS	Detrol LA	TOLTERODINE TARTRATE	CAP ER 24H	4 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
12264	47328	861204-ANTIMUSCARINICS	Detrol LA	TOLTERODINE TARTRATE	CAP ER 24H	2 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
37062	39139	861204-ANTIMUSCARINICS	Detrol	TOLTERODINE TARTRATE	TABLET	2 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
37061	39138	861204-ANTIMUSCARINICS	Detrol	TOLTERODINE TARTRATE	TABLET	1 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy
13977	48495	040412-PHENOTHIAZINE DERIVATIVES	Promethazine VC	PHENYLEPHRINE HCL-PROMETHAZINE HCL	SYRUP	5-6.25 MG/5ML	COVERED	FORMULARY
15001	3873	040412-PHENOTHIAZINE DERIVATIVES	Phenergan Suppository	PROMETHAZINE HCL	SUPP.RECT	25 MG	COVERED	FORMULARY
15002	3874	040412-PHENOTHIAZINE DERIVATIVES	Phenergan Suppository	PROMETHAZINE HCL	SUPP.RECT	50 MG	COVERED	FORMULARY
15003	3872	040412-PHENOTHIAZINE DERIVATIVES	Phenergan Suppository	PROMETHAZINE HCL	SUPP.RECT	12.5 MG	COVERED	FORMULARY
15035	3876	040412-PHENOTHIAZINE DERIVATIVES	Promethazine	PROMETHAZINE HCL	SYRUP	6.25 MG/5ML	COVERED	FORMULARY
15042	3877	040412-PHENOTHIAZINE DERIVATIVES	Promethazine	PROMETHAZINE HCL	TABLET	12.5 MG	COVERED	FORMULARY
15043	3878	040412-PHENOTHIAZINE DERIVATIVES	Promethazine	PROMETHAZINE HCL	TABLET	25 MG	COVERED	FORMULARY
15044	3879	040412-PHENOTHIAZINE DERIVATIVES	Promethazine	PROMETHAZINE HCL	TABLET	50 MG	COVERED	FORMULARY
96609	991	040420-PROPYLAMINE DERIVATIVES	Brohist D	BROMPHENIRAMIN-PHENYLEPHRINE	TABLET	4-10 MG	COVERED	FORMULARY
44023	26792	040420-PROPYLAMINE DERIVATIVES	Sudogest	PSEUDOEPHEDRINE-CHLORPHENIRAMINE	TABLET	60 MG-4 MG	COVERED	FORMULARY
15803	4010	040492-FIRST GEN. ANTIHIST. DERIVATIVES, MISC.	Cypropheptadine	CYPROHEPTADINE HCL	SYRUP	2 MG/5ML	COVERED	FORMULARY
15811	4011	040492-FIRST GEN. ANTIHIST. DERIVATIVES, MISC.	Cypropheptadine	CYPROHEPTADINE HCL	TABLET	4 MG	COVERED	FORMULARY
97950	62168	040800-SECOND GENERATION ANTIHISTAMINES	Xyzal	LEVOCETIRIZINE DIHYDROCHLORIDE	SOLUTION	2.5 MG/5ML	COVERED	FORMULARY
14901	48920	040800-SECOND GENERATION ANTIHISTAMINES	Xyzal	LEVOCETIRIZINE DIHYDROCHLORIDE	TABLET	5 MG	COVERED	FORMULARY
53290	19283	080800-ANTHELMINTICS	Albenza	ALBENDAZOLE	TABLET	200 MG	COVERED	FORMULARY
93064	43094	080800-ANTHELMINTICS	Stromectol	IVERMECTIN	TABLET	3 MG	COVERED	FORMULARY
41072	9284	081202-AMINOGLYCOSIDES	Neomycin	NEOMYCIN SULFATE	TABLET	500 MG	COVERED	FORMULARY
32231	40257	081206-CEPHALOSPORINS	Cefdinir	CEFDINIR	CAPSULE	300 MG	COVERED	FORMULARY
23308	58005	081206-CEPHALOSPORINS	Cefdinir	CEFDINIR	SUSP RECON	250 MG/5ML	COVERED	FORMULARY
32232	40258	081206-CEPHALOSPORINS	Cefdinir	CEFDINIR	SUSP RECON	125 MG/5ML	COVERED	FORMULARY
29291	16582	081206-CEPHALOSPORINS	Cefprozil	CEFPROZIL	SUSP RECON	125 MG/5ML	COVERED	FORMULARY
29292	16583	081206-CEPHALOSPORINS	Cefprozil	CEFPROZIL	SUSP RECON	250 MG/5ML	COVERED	FORMULARY
29271	16584	081206-CEPHALOSPORINS	Cefprozil	CEFPROZIL	TABLET	250 MG	COVERED	FORMULARY
29272	16585	081206-CEPHALOSPORINS	Cefprozil	CEFPROZIL	TABLET	500 MG	COVERED	FORMULARY
47281	9136	081206-CEPHALOSPORINS	Ceftin	CEFUROXIME AXETIL	TABLET	250 MG	COVERED	FORMULARY
47282	9137	081206-CEPHALOSPORINS	Ceftin	CEFUROXIME AXETIL	TABLET	500 MG	COVERED	FORMULARY
39801	9042	081206-CEPHALOSPORINS	Keflex	CEPHALEXIN	CAPSULE	250 MG	COVERED	FORMULARY
39802	9043	081206-CEPHALOSPORINS	Keflex	CEPHALEXIN	CAPSULE	500 MG	COVERED	FORMULARY
39812	9046	081206-CEPHALOSPORINS	Keflex	CEPHALEXIN	SUSP RECON	250 MG/5ML	COVERED	FORMULARY
39831	9049	081206-CEPHALOSPORINS	Keflex	CEPHALEXIN	TABLET	500 MG	COVERED	FORMULARY
39832	9048	081206-CEPHALOSPORINS	Keflex	CEPHALEXIN	TABLET	250 MG	COVERED	FORMULARY
48792	24194	081212-MACROLIDES	Zithromax	AZITHROMYCIN	SUSP RECON	100 MG/5ML	COVERED	FORMULARY
61199	18544	081212-MACROLIDES	Zithromax	AZITHROMYCIN	SUSP RECON	200 MG/5ML	COVERED	FORMULARY
48793	26721	081212-MACROLIDES	Zithromax	AZITHROMYCIN	TABLET	250 MG	COVERED	FORMULARY
48794	27252	081212-MACROLIDES	Zithromax	AZITHROMYCIN	TABLET	600 MG	COVERED	FORMULARY
61198	22624	081212-MACROLIDES	Zithromax	AZITHROMYCIN	TABLET	500 MG	COVERED	FORMULARY
11670	19146	081212-MACROLIDES	Clarithromycin	CLARITHROMYCIN	SUSP RECON	125 MG/5ML	COVERED	FORMULARY
48851	16368	081212-MACROLIDES	Biaxin	CLARITHROMYCIN	TABLET	500 MG	COVERED	FORMULARY
48852	16373	081212-MACROLIDES	Biaxin	CLARITHROMYCIN	TABLET	250 MG	COVERED	FORMULARY
40660	9258	081212-MACROLIDES	Erythromycin	ERYTHROMYCIN BASE	CAPSULE DR	250 MG	COVERED	FORMULARY
40720	9260	081212-MACROLIDES	Erythrocin	ERYTHROMYCIN BASE	TABLET	250 MG	COVERED	FORMULARY
40721	9262	081212-MACROLIDES	Erythromycin	ERYTHROMYCIN BASE	TABLET	500 MG	COVERED	FORMULARY
40730	9263	081212-MACROLIDES	Ery-Tab	ERYTHROMYCIN BASE	TABLET DR	250 MG	COVERED	FORMULARY
40731	9264	081212-MACROLIDES	Ery-Tab	ERYTHROMYCIN BASE	TABLET DR	333 MG	COVERED	FORMULARY
40732	9265	081212-MACROLIDES	Ery-Tab	ERYTHROMYCIN BASE	TABLET DR	500 MG	COVERED	FORMULARY
40523	21205	081212-MACROLIDES	EryPed 200	ERYTHROMYCIN ETHYLSUCCINATE	SUSP RECON	200 MG/5ML	COVERED	FORMULARY
40524	21206	081212-MACROLIDES	EryPed 400	ERYTHROMYCIN ETHYLSUCCINATE	SUSP RECON	400 MG/5ML	COVERED	FORMULARY
40560	9245	081212-MACROLIDES	E.E.S 400	ERYTHROMYCIN ETHYLSUCCINATE	TABLET	400 MG	COVERED	FORMULARY
40642	9255	081212-MACROLIDES	Erythromycin	ERYTHROMYCIN STEARATE	TABLET	250 MG	COVERED	FORMULARY
39660	8995	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	CAPSULE	250 MG	COVERED	FORMULARY
39661	8996	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	CAPSULE	500 MG	COVERED	FORMULARY
39681	8997	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	SUSP RECON	125 MG/5ML	COVERED	FORMULARY
39683	8998	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	SUSP RECON	250 MG/5ML	COVERED	FORMULARY
93375	42683	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	SUSP RECON	400 MG/5ML	COVERED	FORMULARY
93385	42684	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	SUSP RECON	200 MG/5ML	COVERED	FORMULARY
39651	9001	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	TAB CHEW	250 MG	COVERED	FORMULARY
39632	40292	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	TABLET	875 MG	COVERED	FORMULARY
61252	20493	081216-PENICILLINS	Amoxicillin	AMOXICILLIN	TABLET	500 MG	COVERED	FORMULARY
67150	8989	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	SUSP RECON	125-31.25 MG/5ML	COVERED	FORMULARY
67151	8990	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	SUSP RECON	250-62.5 MG/5ML	COVERED	FORMULARY
67153	25898	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	SUSP RECON	400-57 MG/5ML	COVERED	FORMULARY
67154	26720	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	SUSP RECON	200-28.5 MG/5ML	COVERED	FORMULARY
28020	48449	081216-PENICILLINS	Augmentin ES	AMOXICILLIN-POTASSIUM CLAVULANATE	SUSP RECON	600-42.9 MG/5ML	COVERED	FORMULARY
67078	26719	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	TAB CHEW	200-28.5 MG	COVERED	FORMULARY
91941	50991	081216-PENICILLINS	Augmentin XR	AMOXICILLIN-POTASSIUM CLAVULANATE	TAB ER 12H	1000-62.5 MG	COVERED	FORMULARY
67070	8991	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	TABLET	250-125 MG	COVERED	FORMULARY
67071	8992	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	TABLET	500-125 MG	COVERED	FORMULARY
67076	24668	081216-PENICILLINS	Augmentin	AMOXICILLIN-POTASSIUM CLAVULANATE	TABLET	875-125 MG	COVERED	FORMULARY
39271	8941	081216-PENICILLINS	Ampicillin	AMPICILLIN TRIHYDRATE	CAPSULE	250 MG	COVERED	FORMULARY
39272	8942	081216-PENICILLINS	Ampicillin	AMPICILLIN TRIHYDRATE	CAPSULE	500 MG	COVERED	FORMULARY
39313	8943	081216-PENICILLINS	Ampicillin	AMPICILLIN TRIHYDRATE	SUSP RECON	125 MG/5ML	COVERED	FORMULARY
39316	8944	081216-PENICILLINS	Ampicillin	AMPICILLIN TRIHYDRATE	SUSP RECON	250 MG/5ML	COVERED	FORMULARY
39541	8983	081216-PENICILLINS	Dicloxacillin	DICLOXACILLIN SODIUM	CAPSULE	250 MG	COVERED	FORMULARY
39542	8984	081216-PENICILLINS	Dicloxacillin	DICLOXACILLIN SODIUM	CAPSULE	500 MG	COVERED	FORMULARY
39022	8876	081216-PENICILLINS	Penicillin V Potassium	PENICILLIN V POTASSIUM	SOLN RECON	125 MG/5ML	COVERED	FORMULARY
39024	8877	081216-PENICILLINS	Penicillin V Potassium	PENICILLIN V POTASSIUM	SOLN RECON	250 MG/5ML	COVERED	FORMULARY
39053	8879	081216-PENICILLINS	Penicillin V Potassium	PENICILLIN V POTASSIUM	TABLET	250 MG	COVERED	FORMULARY
39055	8880	081216-PENICILLINS	Penicillin V Potassium	PENICILLIN V POTASSIUM	TABLET	500 MG	COVERED	FORMULARY
47050	9509	081218-QUINOLONES	Cipro	CIPROFLOXACIN HCL	TABLET	250 MG	COVERED	FORMULARY
47051	9510	081218-QUINOLONES	Cipro	CIPROFLOXACIN HCL	TABLET	500 MG	COVERED	FORMULARY
47052	9511	081218-QUINOLONES	Cipro	CIPROFLOXACIN HCL	TABLET	750 MG	COVERED	FORMULARY
23725	58310	081218-QUINOLONES	Levofloxacin	LEVOFLOXACIN	SOLUTION	250 MG/10ML	COVERED	FORMULARY
47073	29927	081218-QUINOLONES	Levaquin	LEVOFLOXACIN	TABLET	250 MG	COVERED	FORMULARY
47074	29928	081218-QUINOLONES	Levaquin	LEVOFLOXACIN	TABLET	500 MG	COVERED	FORMULARY
89597	46771	081218-QUINOLONES	Levaquin	LEVOFLOXACIN	TABLET	750 MG	COVERED	FORMULARY
34942	71217	081220-SULFONAMIDES (SYSTEMIC)	Sulfamethoxazole-Trimethoprim	SULFAMETHOXAZOLE-TRIMETHOPRIM	ORAL SUSP	800-160 MG/20ML	COVERED	FORMULARY
90150	9394	081220-SULFONAMIDES (SYSTEMIC)	Sulfamethoxazole-Trimethoprim	SULFAMETHOXAZOLE-TRIMETHOPRIM	ORAL SUSP	200-40 MG/5ML	COVERED	FORMULARY
90161	9395	081220-SULFONAMIDES (SYSTEMIC)	Bactrim	SULFAMETHOXAZOLE-TRIMETHOPRIM	TABLET	400-80 MG	COVERED	FORMULARY
90163	9396	081220-SULFONAMIDES (SYSTEMIC)	Bactrim	SULFAMETHOXAZOLE-TRIMETHOPRIM	TABLET	800-160 MG	COVERED	FORMULARY
41611	9402	081220-SULFONAMIDES (SYSTEMIC)	Azulfidine	SULFASALAZINE	TABLET	500 MG	COVERED	FORMULARY
41620	9403	081220-SULFONAMIDES (SYSTEMIC)	Azulfidine EN	SULFASALAZINE	TABLET DR	500 MG	COVERED	FORMULARY
X	X	081224-TETRACYCLINES	Doxycycline Suspension	DOXYCYCLINE	X	25 MG/ML	COVERED	FORMULARY
40331	9218	081224-TETRACYCLINES	Doxycyline	DOXYCYCLINE HYCLATE	CAPSULE	100 MG	COVERED	FORMULARY
40333	9219	081224-TETRACYCLINES	Doxycyline	DOXYCYCLINE HYCLATE	CAPSULE	50 MG	COVERED	FORMULARY
40360	9223	081224-TETRACYCLINES	Doxycyline	DOXYCYCLINE HYCLATE	TABLET	100 MG	COVERED	FORMULARY
40651	15943	081224-TETRACYCLINES	Doxycyline	DOXYCYCLINE MONOHYDRATE	CAPSULE	100 MG	COVERED	FORMULARY
40652	16815	081224-TETRACYCLINES	Doxycyline	DOXYCYCLINE MONOHYDRATE	CAPSULE	50 MG	COVERED	FORMULARY
98271	62496	081224-TETRACYCLINES	Doxycyline	DOXYCYCLINE MONOHYDRATE	CAPSULE	75 MG	COVERED	FORMULARY
40363	27050	081224-TETRACYCLINES	Doxycyline	DOXYCYCLINE MONOHYDRATE	TABLET	100 MG	COVERED	FORMULARY
40410	9226	081224-TETRACYCLINES	Minocycline	MINOCYCLINE HCL	CAPSULE	100 MG	COVERED	FORMULARY
40411	9227	081224-TETRACYCLINES	Minocycline	MINOCYCLINE HCL	CAPSULE	50 MG	COVERED	FORMULARY
93387	42778	081224-TETRACYCLINES	Minocycline	MINOCYCLINE HCL	CAPSULE	75 MG	COVERED	FORMULARY
19549	52057	081224-TETRACYCLINES	Minocycline	MINOCYCLINE HCL	TABLET	75 MG	COVERED	FORMULARY
40450	9230	081224-TETRACYCLINES	Minocycline	MINOCYCLINE HCL	TABLET	100 MG	COVERED	FORMULARY
40451	9231	081224-TETRACYCLINES	Minocycline	MINOCYCLINE HCL	TABLET	50 MG	COVERED	FORMULARY
40830	9339	081228-ANTIBACTERIALS, MISCELLANEOUS	Cleocin	CLINDAMYCIN HCL	CAPSULE	150 MG	COVERED	FORMULARY
40831	9341	081228-ANTIBACTERIALS, MISCELLANEOUS	Cleocin	CLINDAMYCIN HCL	CAPSULE	75 MG	COVERED	FORMULARY
40832	9340	081228-ANTIBACTERIALS, MISCELLANEOUS	Cleocin	CLINDAMYCIN HCL	CAPSULE	300 MG	COVERED	FORMULARY
40860	9346	081228-ANTIBACTERIALS, MISCELLANEOUS	Cleocin Pediatric Granules	CLINDAMYCIN PALMITATE HCL	SOLN RECON	75 MG/5ML	COVERED	FORMULARY	Restricted to age < 19
60823	18638	081404-ALLYLAMINES	Lamisil	TERBINAFINE HCL	TABLET	250 MG	COVERED	FORMULARY
60821	18636	081408-AZOLES	Diflucan	FLUCONAZOLE	SUSP RECON	40 MG/ML	COVERED	FORMULARY
42190	13723	081408-AZOLES	Diflucan	FLUCONAZOLE	TABLET	100 MG	COVERED	FORMULARY
42191	13724	081408-AZOLES	Diflucan	FLUCONAZOLE	TABLET	200 MG	COVERED	FORMULARY
42192	13725	081408-AZOLES	Diflucan	FLUCONAZOLE	TABLET	50 MG	COVERED	FORMULARY
42193	22141	081408-AZOLES	Diflucan	FLUCONAZOLE	TABLET	150 MG	COVERED	FORMULARY
42440	9537	081428-POLYENES	Nystatin	NYSTATIN	ORAL SUSP	100000 UNIT/ML	COVERED	FORMULARY
42452	9538	081428-POLYENES	Nystatin	NYSTATIN	TABLET	500000 UNIT	COVERED	FORMULARY
42390	9517	081492-ANTIFUNGALS, MISCELLANEOUS	Griseofulvin	GRISEOFULVIN MICROSIZE	ORAL SUSP	125 MG/5ML	COVERED	FORMULARY
42402	9519	081492-ANTIFUNGALS, MISCELLANEOUS	Griseofulvin	GRISEOFULVIN MICROSIZE	TABLET	500 MG	COVERED	FORMULARY
42410	9520	081492-ANTIFUNGALS, MISCELLANEOUS	Gris-Peg	GRISEOFULVIN ULTRAMICROSIZE	TABLET	125 MG	COVERED	FORMULARY
42412	9522	081492-ANTIFUNGALS, MISCELLANEOUS	Gris-Peg	GRISEOFULVIN ULTRAMICROSIZE	TABLET	250 MG	COVERED	FORMULARY
73441	43706	081828-NEURAMINIDASE INHIBITORS	Tamiflu	OSELTAMIVIR PHOSPHATE	CAPSULE	75 MG	COVERED	FORMULARY
98980	63223	081828-NEURAMINIDASE INHIBITORS	Tamiflu	OSELTAMIVIR PHOSPHATE	CAPSULE	30 MG	COVERED	FORMULARY
98981	63224	081828-NEURAMINIDASE INHIBITORS	Tamiflu	OSELTAMIVIR PHOSPHATE	CAPSULE	45 MG	COVERED	FORMULARY
29729	67561	081828-NEURAMINIDASE INHIBITORS	Tamiflu	OSELTAMIVIR PHOSPHATE	SUSP RECON	6 MG/ML	COVERED	FORMULARY
92221	43119	081828-NEURAMINIDASE INHIBITORS	Relenza	ZANAMIVIR	BLST W/DEV	5 MG	COVERED	FORMULARY
43790	9630	081832-NUCLEOSIDES AND NUCLEOTIDES	Zovirax	ACYCLOVIR	CAPSULE	200 MG	COVERED	FORMULARY
13721	15979	081832-NUCLEOSIDES AND NUCLEOTIDES	Zovirax	ACYCLOVIR	TABLET	800 MG	COVERED	FORMULARY
13724	16408	081832-NUCLEOSIDES AND NUCLEOTIDES	Zovirax	ACYCLOVIR	TABLET	400 MG	COVERED	FORMULARY
14179	48664	081832-NUCLEOSIDES AND NUCLEOTIDES	Ribavirin	RIBAVIRIN	CAPSULE	200 MG	COVERED	FORMULARY
13740	23989	081832-NUCLEOSIDES AND NUCLEOTIDES	Valtrex	VALACYCLOVIR HCL	TABLET	500 MG	COVERED	FORMULARY
13742	30607	081832-NUCLEOSIDES AND NUCLEOTIDES	Valtrex	VALACYCLOVIR HCL	TABLET	1000 MG	COVERED	FORMULARY
42940	9580	083008-ANTIMALARIALS	Plaquenil	HYDROXYCHLOROQUINE SULFATE	TABLET	200 MG	COVERED	FORMULARY
43031	9591	083092-ANTIPROTOZOALS, MISCELLANEOUS	Flagyl	METRONIDAZOLE	TABLET	250 MG	COVERED	FORMULARY
43032	9592	083092-ANTIPROTOZOALS, MISCELLANEOUS	Flagyl	METRONIDAZOLE	TABLET	500 MG	COVERED	FORMULARY
41870	9434	083600-URINARY ANTI-INFECTIVES	Furadantin	NITROFURANTOIN	ORAL SUSP	25 MG/5ML	COVERED	FORMULARY
41820	9428	083600-URINARY ANTI-INFECTIVES	Macrodantin	NITROFURANTOIN MACROCRYSTAL	CAPSULE	100 MG	COVERED	FORMULARY
41822	9430	083600-URINARY ANTI-INFECTIVES	Macrodantin	NITROFURANTOIN MACROCRYSTAL	CAPSULE	50 MG	COVERED	FORMULARY
49001	16598	083600-URINARY ANTI-INFECTIVES	Macrobid	NITROFURANTOIN MONOHYDRATE-MACROCRYSTAL	CAPSULE	100 MG	COVERED	FORMULARY
5987	35495	084080-ANTIPRURITICS AND LOCAL ANESTHETICS	Emla Cream	LIDOCAINE/PRILOCAINE	CREAM (G)	2.5 %-2.5%	COVERED	FORMULARY
38370	8772	100000-ANTINEOPLASTIC AGENTS	Leukeran	CHLORAMBUCIL	TABLET	2 MG	COVERED	FORMULARY
38400	8775	100000-ANTINEOPLASTIC AGENTS	Hydrea	HYDROXYUREA	CAPSULE	500 MG	COVERED	FORMULARY
49541	29821	100000-ANTINEOPLASTIC AGENTS	Femara	LETROZOLE	TABLET	2.5 MG	COVERED	FORMULARY
33559	70193	100000-ANTINEOPLASTIC AGENTS	Megace	MEGESTROL ACETATE	ORAL SUSP	400 MG/10ML	COVERED	FORMULARY
40381	21004	100000-ANTINEOPLASTIC AGENTS	Megace	MEGESTROL ACETATE	ORAL SUSP	400 MG/10ML	COVERED	FORMULARY
38681	8829	100000-ANTINEOPLASTIC AGENTS	Megace	MEGESTROL ACETATE	TABLET	40 MG	COVERED	FORMULARY
38380	8773	100000-ANTINEOPLASTIC AGENTS	Alkeran	MELPHALAN	TABLET	2 MG	COVERED	FORMULARY
38520	8802	100000-ANTINEOPLASTIC AGENTS	Mercaptopurine	MERCAPTOPURINE	TABLET	50 MG	COVERED	FORMULARY
38489	36872	100000-ANTINEOPLASTIC AGENTS	Methotrexate	METHOTREXATE SODIUM	TABLET	2.5 MG	COVERED	FORMULARY
38720	8832	100000-ANTINEOPLASTIC AGENTS	Tamoxifen	TAMOXIFEN CITRATE	TABLET	10 MG	COVERED	FORMULARY
38721	13574	100000-ANTINEOPLASTIC AGENTS	Tamoxifen	TAMOXIFEN CITRATE	TABLET	20 MG	COVERED	FORMULARY
18351	4740	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Urecholine	BETHANECHOL CHLORIDE	TABLET	10 MG	COVERED	FORMULARY
18352	4741	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Urecholine	BETHANECHOL CHLORIDE	TABLET	25 MG	COVERED	FORMULARY
4300	29334	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Aricept	DONEPEZIL HCL	TABLET	10 MG	COVERED	FORMULARY
4302	29335	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Aricept	DONEPEZIL HCL	TABLET	5 MG	COVERED	FORMULARY
84853	46925	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Razadyne	GALANTAMINE HBR	TABLET	12 MG	COVERED	FORMULARY
84854	46926	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Razadyne	GALANTAMINE HBR	TABLET	4 MG	COVERED	FORMULARY
84855	46927	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Razadyne	GALANTAMINE HBR	TABLET	8 MG	COVERED	FORMULARY
21353	53658	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Salagen	PILOCARPINE HCL	TABLET	7.5 MG	COVERED	FORMULARY
24671	21731	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Salagen	PILOCARPINE HCL	TABLET	5 MG	COVERED	FORMULARY
90396	40155	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Exelon	RIVASTIGMINE TARTRATE	CAPSULE	1.5 MG	COVERED	FORMULARY
90397	40156	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Exelon	RIVASTIGMINE TARTRATE	CAPSULE	3 MG	COVERED	FORMULARY
90398	40157	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Exelon	RIVASTIGMINE TARTRATE	CAPSULE	4.5 MG	COVERED	FORMULARY
90399	40158	120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)	Exelon	RIVASTIGMINE TARTRATE	CAPSULE	6 MG	COVERED	FORMULARY
74801	4902	120808-ANTIMUSCARINICS/ANTISPASMODICS	Librax	CHLORDIAZEPOXIDE-CLIDINIUM BR	CAPSULE	5-2.5 MG	COVERED	FORMULARY
19261	4918	120808-ANTIMUSCARINICS/ANTISPASMODICS	Bentyl	DICYCLOMINE HCL	CAPSULE	10 MG	COVERED	FORMULARY
34719	71032	120808-ANTIMUSCARINICS/ANTISPASMODICS	Bentyl	DICYCLOMINE HCL	SOLUTION	10 MG/5ML	COVERED	FORMULARY
19331	4924	120808-ANTIMUSCARINICS/ANTISPASMODICS	Bentyl	DICYCLOMINE HCL	TABLET	20 MG	COVERED	FORMULARY
18960	23715	120808-ANTIMUSCARINICS/ANTISPASMODICS	Symax SR	HYOSCYAMINE SULFATE	TAB ER 12H	0.375 MG	COVERED	FORMULARY
13299	47546	120808-ANTIMUSCARINICS/ANTISPASMODICS	Anaspaz, Symax FT	HYOSCYAMINE SULFATE	TAB RAPDIS	0.125 MG	COVERED	FORMULARY
18970	4868	120808-ANTIMUSCARINICS/ANTISPASMODICS	Symax SL	HYOSCYAMINE SULFATE	TAB SUBL	0.125 MG	COVERED	FORMULARY
18961	4865	120808-ANTIMUSCARINICS/ANTISPASMODICS	Levsin, Oscimin	HYOSCYAMINE SULFATE	TABLET	0.125 MG	COVERED	FORMULARY
42235	21700	120808-ANTIMUSCARINICS/ANTISPASMODICS	Ipratropium Bromide	IPRATROPIUM BROMIDE	SOLUTION	0.2 MG/ML	COVERED	FORMULARY
13456	48018	120808-ANTIMUSCARINICS/ANTISPASMODICS	Ipatropium-Albuterol Inhalation	IPRATROPIUM-ALBUTEROL SULFATE	AMPUL-NEB	0.5-3 MG/3ML	COVERED	FORMULARY
22913	28090	121208-BETA-ADRENERGIC AGONISTS	Proventil HFA	ALBUTEROL SULFATE	HFA AER AD	90 MCG	COVERED	FORMULARY
41680	5040	121208-BETA-ADRENERGIC AGONISTS	Albuterol Sulfate	ALBUTEROL SULFATE	SOLUTION	5 MG/ML	COVERED	FORMULARY
22780	5032	121208-BETA-ADRENERGIC AGONISTS	Albuterol Sulfate	ALBUTEROL SULFATE	SYRUP	2 MG/5ML	COVERED	FORMULARY
20100	5033	121208-BETA-ADRENERGIC AGONISTS	Albuterol Sulfate	ALBUTEROL SULFATE	TABLET	2 MG	COVERED	FORMULARY
20101	5034	121208-BETA-ADRENERGIC AGONISTS	Albuterol Sulfate	ALBUTEROL SULFATE	TABLET	4 MG	COVERED	FORMULARY
41681	5039	121208-BETA-ADRENERGIC AGONISTS	Albuterol Sulfate Inhalation	ALBUTEROL SULFATE	VIAL-NEB	2.5 MG/3ML	COVERED	FORMULARY
20071	5026	121208-BETA-ADRENERGIC AGONISTS	Terbutaline	TERBUTALINE SULFATE	TABLET	5 MG	COVERED	FORMULARY
20072	5025	121208-BETA-ADRENERGIC AGONISTS	Terbutaline	TERBUTALINE SULFATE	TABLET	2.5 MG	COVERED	FORMULARY
19861	16878	121212-ALPHA- AND BETA-ADRENERGIC AGONISTS	EPINEPHRINE AUTO-INJECT	EPINEPHRINE	AUTO INJCT	0.15 MG/0.3ML	COVERED	FORMULARY
19862	16879	121212-ALPHA- AND BETA-ADRENERGIC AGONISTS	EPINEPHRINE AUTO-INJECT	EPINEPHRINE	AUTO INJCT	0.3 MG/0.3ML	COVERED	FORMULARY
48191	27546	121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)	Flomax	TAMSULOSIN HCL	CAP ER 24H	0.4 MG	COVERED	FORMULARY
17901	4660	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Parafon Forte	CHLORZOXAZONE	TABLET	500 MG	COVERED	FORMULARY
12805	47478	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Flexeril	CYCLOBENZAPRINE HCL	TABLET	5 MG	COVERED	FORMULARY
18020	4681	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Flexeril	CYCLOBENZAPRINE HCL	TABLET	10 MG	COVERED	FORMULARY
17892	4654	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Robaxin	METHOCARBAMOL	TABLET	500 MG	COVERED	FORMULARY
17893	4655	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Robaxin	METHOCARBAMOL	TABLET	750 MG	COVERED	FORMULARY
24433	58904	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Zanaflex	TIZANIDINE HCL	CAPSULE	2 MG	COVERED	FORMULARY
24434	58905	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Zanaflex	TIZANIDINE HCL	CAPSULE	4 MG	COVERED	FORMULARY
14690	27447	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Zanaflex	TIZANIDINE HCL	TABLET	2 MG	COVERED	FORMULARY
14693	30274	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Zanaflex	TIZANIDINE HCL	TABLET	4 MG	COVERED	FORMULARY
18010	4679	122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT	Baclofen	BACLOFEN	TABLET	10 MG	COVERED	FORMULARY
18011	4680	122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT	Baclofen	BACLOFEN	TABLET	20 MG	COVERED	FORMULARY
420	19331	201204-ANTICOAGULANTS	Lovenox	ENOXAPARIN SODIUM	SYRINGE	30 MG/0.3ML	COVERED	FORMULARY	Limited to 14 day supplies, Prior Auth for >14 days
42071	44668	201204-ANTICOAGULANTS	Lovenox	ENOXAPARIN SODIUM	SYRINGE	150 MG/ML	COVERED	FORMULARY	Limited to 14 day supplies, Prior Auth for >14 days
42091	44669	201204-ANTICOAGULANTS	Lovenox	ENOXAPARIN SODIUM	SYRINGE	120 MG/0.8ML	COVERED	FORMULARY	Limited to 14 day supplies, Prior Auth for >14 days
62771	27993	201204-ANTICOAGULANTS	Lovenox	ENOXAPARIN SODIUM	SYRINGE	60 MG/0.6ML	COVERED	FORMULARY	Limited to 14 day supplies, Prior Auth for >14 days
62772	27994	201204-ANTICOAGULANTS	Lovenox	ENOXAPARIN SODIUM	SYRINGE	80 MG/0.8ML	COVERED	FORMULARY	Limited to 14 day supplies, Prior Auth for >14 days
62773	27995	201204-ANTICOAGULANTS	Lovenox	ENOXAPARIN SODIUM	SYRINGE	100 MG/ML	COVERED	FORMULARY	Limited to 14 day supplies, Prior Auth for >14 days
70022	39482	201204-ANTICOAGULANTS	Lovenox	ENOXAPARIN SODIUM	SYRINGE	40 MG/0.4ML	COVERED	FORMULARY	Limited to 14 day supplies, Prior Auth for >14 days
25691	6549	201204-ANTICOAGULANTS	Heparin	HEPARIN SODIUM PORCINE	VIAL	5000 UNIT/ML	COVERED	FORMULARY
25697	6544	201204-ANTICOAGULANTS	Heparin	HEPARIN SODIUM PORCINE	VIAL	10000 UNIT/ML	COVERED	FORMULARY
25790	6559	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	10 MG	COVERED	FORMULARY
25791	6561	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	2 MG	COVERED	FORMULARY
25792	14198	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	1 MG	COVERED	FORMULARY
25793	6562	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	5 MG	COVERED	FORMULARY
25794	6560	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	2.5 MG	COVERED	FORMULARY
25795	6563	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	7.5 MG	COVERED	FORMULARY
25796	18080	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	3 MG	COVERED	FORMULARY
25797	19486	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	4 MG	COVERED	FORMULARY
25798	30475	201204-ANTICOAGULANTS	Coumadin, Jantoven	WARFARIN SODIUM	TABLET	6 MG	COVERED	FORMULARY
8602	37978	201218-PLATELET-AGGREGATION INHIBITORS	Pletal	CILOSTAZOL	TABLET	100 MG	COVERED	FORMULARY
8603	37979	201218-PLATELET-AGGREGATION INHIBITORS	Pletal	CILOSTAZOL	TABLET	50 MG	COVERED	FORMULARY
96010	38164	201218-PLATELET-AGGREGATION INHIBITORS	Plavix	CLOPIDOGREL BISULFATE	TABLET	75 MG	COVERED	FORMULARY
11800	6573	202400-HEMORRHEOLOGIC AGENTS	Pentoxifylline	PENTOXIFYLLINE	TABLET ER	400 MG	COVERED	FORMULARY
25580	6503	202816-HEMOSTATICS	Amicar	AMINOCAPROIC ACID	SOLUTION	250 MG/ML	COVERED	FORMULARY
10920	266	240404-ANTIARRHYTHMIC AGENTS	Pacerone	AMIODARONE HCL	TABLET	200 MG	COVERED	FORMULARY
1130	239	240404-ANTIARRHYTHMIC AGENTS	Norpace	DISOPYRAMIDE PHOSPHATE	CAPSULE	100 MG	COVERED	FORMULARY
1580	263	240404-ANTIARRHYTHMIC AGENTS	Flecainide	FLECAINIDE ACETATE	TABLET	100 MG	COVERED	FORMULARY
1581	265	240404-ANTIARRHYTHMIC AGENTS	Flecainide	FLECAINIDE ACETATE	TABLET	50 MG	COVERED	FORMULARY
1011	215	240404-ANTIARRHYTHMIC AGENTS	Quinidine	QUINIDINE GLUCONATE	TABLET ER	324 MG	COVERED	FORMULARY
132	18	240408-CARDIOTONIC AGENTS	Lanoxin	DIGOXIN	TABLET	125 MCG	COVERED	FORMULARY
133	19	240408-CARDIOTONIC AGENTS	Lanoxin	DIGOXIN	TABLET	250 MCG	COVERED	FORMULARY
9850	3100	240604-BILE ACID SEQUESTRANTS	Prevalite	CHOLESTYRAMINE (WITH ASPARTAME)	POWD PACK	4 G	COVERED	FORMULARY
98654	62885	240604-BILE ACID SEQUESTRANTS	Questran Light	CHOLESTYRAMINE (WITH ASPARTAME)	POWDER	4 G	COVERED	FORMULARY
9920	13675	240604-BILE ACID SEQUESTRANTS	Questran	CHOLESTYRAMINE (WITH SUGAR)	POWD PACK	4 G	COVERED	FORMULARY
14295	48571	240604-BILE ACID SEQUESTRANTS	Questran	CHOLESTYRAMINE (WITH SUGAR)	POWDER	4 G	COVERED	FORMULARY
12595	44915	240606-FIBRIC ACID DERIVATIVES	Lofibra	FENOFIBRATE	TABLET	160 MG	COVERED	FORMULARY
13266	64310	240606-FIBRIC ACID DERIVATIVES	Lofibra	FENOFIBRATE	TABLET	54 MG	COVERED	FORMULARY
92504	44305	240606-FIBRIC ACID DERIVATIVES	Lofibra	FENOFIBRATE MICRONIZED	CAPSULE	134 MG	COVERED	FORMULARY
93437	43060	240606-FIBRIC ACID DERIVATIVES	Lofibra	FENOFIBRATE MICRONIZED	CAPSULE	200 MG	COVERED	FORMULARY
93446	43061	240606-FIBRIC ACID DERIVATIVES	Lofibra	FENOFIBRATE MICRONIZED	CAPSULE	67 MG	COVERED	FORMULARY
25540	6416	240606-FIBRIC ACID DERIVATIVES	Lopid	GEMFIBROZIL	TABLET	600 MG	COVERED	FORMULARY
43720	29967	240608-HMG-COA REDUCTASE INHIBITORS	Lipitor	ATORVASTATIN CALCIUM	TABLET	10 MG	COVERED	FORMULARY
43721	29968	240608-HMG-COA REDUCTASE INHIBITORS	Lipitor	ATORVASTATIN CALCIUM	TABLET	20 MG	COVERED	FORMULARY
43722	29969	240608-HMG-COA REDUCTASE INHIBITORS	Lipitor	ATORVASTATIN CALCIUM	TABLET	40 MG	COVERED	FORMULARY
43723	45772	240608-HMG-COA REDUCTASE INHIBITORS	Lipitor	ATORVASTATIN CALCIUM	TABLET	80 MG	COVERED	FORMULARY
47040	6460	240608-HMG-COA REDUCTASE INHIBITORS	Lovastatin	LOVASTATIN	TABLET	20 MG	COVERED	FORMULARY
47041	6461	240608-HMG-COA REDUCTASE INHIBITORS	Lovastatin	LOVASTATIN	TABLET	40 MG	COVERED	FORMULARY
47042	16310	240608-HMG-COA REDUCTASE INHIBITORS	Lovastatin	LOVASTATIN	TABLET	10 MG	COVERED	FORMULARY
15412	49758	240608-HMG-COA REDUCTASE INHIBITORS	Pravachol	PRAVASTATIN SODIUM	TABLET	80 MG	COVERED	FORMULARY
48671	16366	240608-HMG-COA REDUCTASE INHIBITORS	Pravachol	PRAVASTATIN SODIUM	TABLET	10 MG	COVERED	FORMULARY
48672	16367	240608-HMG-COA REDUCTASE INHIBITORS	Pravachol	PRAVASTATIN SODIUM	TABLET	20 MG	COVERED	FORMULARY
48673	20741	240608-HMG-COA REDUCTASE INHIBITORS	Pravachol	PRAVASTATIN SODIUM	TABLET	40 MG	COVERED	FORMULARY
26531	16576	240608-HMG-COA REDUCTASE INHIBITORS	Zocor	SIMVASTATIN	TABLET	5 MG	COVERED	FORMULARY
26532	16577	240608-HMG-COA REDUCTASE INHIBITORS	Zocor	SIMVASTATIN	TABLET	10 MG	COVERED	FORMULARY
26533	16578	240608-HMG-COA REDUCTASE INHIBITORS	Zocor	SIMVASTATIN	TABLET	20 MG	COVERED	FORMULARY
26534	16579	240608-HMG-COA REDUCTASE INHIBITORS	Zocor	SIMVASTATIN	TABLET	40 MG	COVERED	FORMULARY
42331	33364	240692-ANTILIPEMIC AGENTS, MISCELLANEOUS	Niaspan ER	NIACIN	TAB ER 24H	500 MG	COVERED	FORMULARY
42332	33365	240692-ANTILIPEMIC AGENTS, MISCELLANEOUS	Niaspan ER	NIACIN	TAB ER 24H	750 MG	COVERED	FORMULARY
42333	33366	240692-ANTILIPEMIC AGENTS, MISCELLANEOUS	Niaspan ER	NIACIN	TAB ER 24H	1000 MG	COVERED	FORMULARY
23870	343	240816-CENTRAL ALPHA-AGONISTS	Catapres TTS	CLONIDINE	PATCH TDWK	0.1 MG/24HR	COVERED	FORMULARY
23871	344	240816-CENTRAL ALPHA-AGONISTS	Catapres TTS	CLONIDINE	PATCH TDWK	0.2 MG/24HR	COVERED	FORMULARY
23872	345	240816-CENTRAL ALPHA-AGONISTS	Catapres TTS	CLONIDINE	PATCH TDWK	0.3 MG/24HR	COVERED	FORMULARY
1390	346	240816-CENTRAL ALPHA-AGONISTS	Catapres	CLONIDINE HCL	TABLET	0.1 MG	COVERED	FORMULARY
1391	347	240816-CENTRAL ALPHA-AGONISTS	Catapres	CLONIDINE HCL	TABLET	0.2 MG	COVERED	FORMULARY
1392	348	240816-CENTRAL ALPHA-AGONISTS	Catapres	CLONIDINE HCL	TABLET	0.3 MG	COVERED	FORMULARY
32480	364	240816-CENTRAL ALPHA-AGONISTS	Tenex	GUANFACINE HCL	TABLET	1 MG	COVERED	FORMULARY
32481	11984	240816-CENTRAL ALPHA-AGONISTS	Tenex	GUANFACINE HCL	TABLET	2 MG	COVERED	FORMULARY
1431	361	240816-CENTRAL ALPHA-AGONISTS	Methyldopa	METHYLDOPA	TABLET	250 MG	COVERED	FORMULARY
1432	362	240816-CENTRAL ALPHA-AGONISTS	Methyldopa	METHYLDOPA	TABLET	500 MG	COVERED	FORMULARY
1241	284	240820-DIRECT VASODILATORS	Hydralazine	HYDRALAZINE HCL	TABLET	10 MG	COVERED	FORMULARY
1242	285	240820-DIRECT VASODILATORS	Hydralazine	HYDRALAZINE HCL	TABLET	100 MG	COVERED	FORMULARY
1243	286	240820-DIRECT VASODILATORS	Hydralazine	HYDRALAZINE HCL	TABLET	25 MG	COVERED	FORMULARY
1244	287	240820-DIRECT VASODILATORS	Hydralazine	HYDRALAZINE HCL	TABLET	50 MG	COVERED	FORMULARY
1290	299	240820-DIRECT VASODILATORS	Minoxidil	MINOXIDIL	TABLET	10 MG	COVERED	FORMULARY
1291	300	240820-DIRECT VASODILATORS	Minoxidil	MINOXIDIL	TABLET	2.5 MG	COVERED	FORMULARY
1942	507	241208-NITRATES AND NITRITES	Isordil	ISOSORBIDE DINITRATE	TABLET	10 MG	COVERED	FORMULARY
1944	508	241208-NITRATES AND NITRITES	Isordil	ISOSORBIDE DINITRATE	TABLET	20 MG	COVERED	FORMULARY
1945	509	241208-NITRATES AND NITRITES	Isordil	ISOSORBIDE DINITRATE	TABLET	30 MG	COVERED	FORMULARY
1947	511	241208-NITRATES AND NITRITES	Isordil	ISOSORBIDE DINITRATE	TABLET	5 MG	COVERED	FORMULARY
48102	17297	241208-NITRATES AND NITRITES	Isosorbide Mononitrate ER	ISOSORBIDE MONONITRATE	TAB ER 24H	60 MG	COVERED	FORMULARY
48103	23474	241208-NITRATES AND NITRITES	Isosorbide Mononitrate ER	ISOSORBIDE MONONITRATE	TAB ER 24H	120 MG	COVERED	FORMULARY
48104	24488	241208-NITRATES AND NITRITES	Isosorbide Mononitrate ER	ISOSORBIDE MONONITRATE	TAB ER 24H	30 MG	COVERED	FORMULARY
1931	16639	241208-NITRATES AND NITRITES	Isosorbide Mononitrate	ISOSORBIDE MONONITRATE	TABLET	20 MG	COVERED	FORMULARY
1932	17294	241208-NITRATES AND NITRITES	Isosorbide Mononitrate	ISOSORBIDE MONONITRATE	TABLET	10 MG	COVERED	FORMULARY
1681	455	241208-NITRATES AND NITRITES	Nitro-Time	NITROGLYCERIN	CAPSULE ER	2.5 MG	COVERED	FORMULARY
1682	456	241208-NITRATES AND NITRITES	Nitro-Time	NITROGLYCERIN	CAPSULE ER	6.5 MG	COVERED	FORMULARY
1684	457	241208-NITRATES AND NITRITES	Nitro-Time	NITROGLYCERIN	CAPSULE ER	9 MG	COVERED	FORMULARY
1740	465	241208-NITRATES AND NITRITES	Minitran	NITROGLYCERIN	PATCH TD24	0.4 MG/HR	COVERED	FORMULARY
1741	467	241208-NITRATES AND NITRITES	Minitran	NITROGLYCERIN	PATCH TD24	0.1 MG/HR	COVERED	FORMULARY
1742	468	241208-NITRATES AND NITRITES	Minitran	NITROGLYCERIN	PATCH TD24	0.2 MG/HR	COVERED	FORMULARY
92257	44359	241208-NITRATES AND NITRITES	Nitrolingual	NITROGLYCERIN	SPRAY	400 MCG/SPRAY	COVERED	FORMULARY
1771	474	241208-NITRATES AND NITRITES	Nitrostat	NITROGLYCERIN	TAB SUBL	0.3 MG	COVERED	FORMULARY
1772	475	241208-NITRATES AND NITRITES	Nitrostat	NITROGLYCERIN	TAB SUBL	0.4 MG	COVERED	FORMULARY
1773	476	241208-NITRATES AND NITRITES	Nitrostat	NITROGLYCERIN	TAB SUBL	0.6 MG	COVERED	FORMULARY
53141	41698	241292-VASODILATING AGENTS, MISCELLANEOUS	Persantine	DIPYRIDAMOLE	TABLET	25 MG	COVERED	FORMULARY
53142	41699	241292-VASODILATING AGENTS, MISCELLANEOUS	Persantine	DIPYRIDAMOLE	TABLET	50 MG	COVERED	FORMULARY
53143	41700	241292-VASODILATING AGENTS, MISCELLANEOUS	Persantine	DIPYRIDAMOLE	TABLET	75 MG	COVERED	FORMULARY
84848	46923	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Cardura XL	DOXAZOSIN MESYLATE	TAB ER 24	8 MG	COVERED	FORMULARY
91985	44421	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Cardura XL	DOXAZOSIN MESYLATE	TAB ER 24	4 MG	COVERED	FORMULARY
33431	15584	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Cardura	DOXAZOSIN MESYLATE	TABLET	1 MG	COVERED	FORMULARY
33432	15585	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Cardura	DOXAZOSIN MESYLATE	TABLET	2 MG	COVERED	FORMULARY
33433	15586	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Cardura	DOXAZOSIN MESYLATE	TABLET	4 MG	COVERED	FORMULARY
33434	15587	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Cardura	DOXAZOSIN MESYLATE	TABLET	8 MG	COVERED	FORMULARY
1250	291	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Minipress	PRAZOSIN HCL	CAPSULE	1 MG	COVERED	FORMULARY
1251	292	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Minipress	PRAZOSIN HCL	CAPSULE	2 MG	COVERED	FORMULARY
1252	293	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Minipress	PRAZOSIN HCL	CAPSULE	5 MG	COVERED	FORMULARY
47124	22649	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Terazosin	TERAZOSIN HCL	CAPSULE	1 MG	COVERED	FORMULARY
47125	22650	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Terazosin	TERAZOSIN HCL	CAPSULE	2 MG	COVERED	FORMULARY
47126	22651	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Terazosin	TERAZOSIN HCL	CAPSULE	5 MG	COVERED	FORMULARY
47127	22652	242000-ALPHA-ADRENERGIC BLOCKING AGENTS	Terazosin	TERAZOSIN HCL	CAPSULE	10 MG	COVERED	FORMULARY
12947	47586	242400-BETA-ADRENERGIC BLOCKING AGENTS	Toprol XL	METOPROLOL SUCCINATE	TAB ER 24H	25 MG	COVERED	FORMULARY
20741	16599	242400-BETA-ADRENERGIC BLOCKING AGENTS	Toprol XL	METOPROLOL SUCCINATE	TAB ER 24H	50 MG	COVERED	FORMULARY
20742	16600	242400-BETA-ADRENERGIC BLOCKING AGENTS	Toprol XL	METOPROLOL SUCCINATE	TAB ER 24H	100 MG	COVERED	FORMULARY
20743	16601	242400-BETA-ADRENERGIC BLOCKING AGENTS	Toprol XL	METOPROLOL SUCCINATE	TAB ER 24H	200 MG	COVERED	FORMULARY
20660	5138	242400-BETA-ADRENERGIC BLOCKING AGENTS	Tenormin	ATENOLOL	TABLET	100 MG	COVERED	FORMULARY
20661	5139	242400-BETA-ADRENERGIC BLOCKING AGENTS	Tenormin	ATENOLOL	TABLET	50 MG	COVERED	FORMULARY
20662	15864	242400-BETA-ADRENERGIC BLOCKING AGENTS	Tenormin	ATENOLOL	TABLET	25 MG	COVERED	FORMULARY
66990	420	242400-BETA-ADRENERGIC BLOCKING AGENTS	Tenoretic	ATENOLOL-CHLORTHALIDONE	TABLET	50-25 MG	COVERED	FORMULARY
66991	419	242400-BETA-ADRENERGIC BLOCKING AGENTS	Tenoretic	ATENOLOL-CHLORTHALIDONE	TABLET	100-25 MG	COVERED	FORMULARY
63820	17955	242400-BETA-ADRENERGIC BLOCKING AGENTS	Zebeta	BISOPROLOL FUMARATE	TABLET	10 MG	COVERED	FORMULARY
63821	17956	242400-BETA-ADRENERGIC BLOCKING AGENTS	Zebeta	BISOPROLOL FUMARATE	TABLET	5 MG	COVERED	FORMULARY
45061	21139	242400-BETA-ADRENERGIC BLOCKING AGENTS	Ziac	BISOPROLOL FUMARATE-HCTZ	TABLET	2.5-6.25 MG	COVERED	FORMULARY
45062	21140	242400-BETA-ADRENERGIC BLOCKING AGENTS	Ziac	BISOPROLOL FUMARATE-HCTZ	TABLET	5-6.25 MG	COVERED	FORMULARY
45063	21141	242400-BETA-ADRENERGIC BLOCKING AGENTS	Ziac	BISOPROLOL FUMARATE-HCTZ	TABLET	10-6.2 5MG	COVERED	FORMULARY
1551	19293	242400-BETA-ADRENERGIC BLOCKING AGENTS	Coreg	CARVEDILOL	TABLET	25 MG	COVERED	FORMULARY
1552	22233	242400-BETA-ADRENERGIC BLOCKING AGENTS	Coreg	CARVEDILOL	TABLET	12.5 MG	COVERED	FORMULARY
1553	28108	242400-BETA-ADRENERGIC BLOCKING AGENTS	Coreg	CARVEDILOL	TABLET	3.125 MG	COVERED	FORMULARY
1554	28109	242400-BETA-ADRENERGIC BLOCKING AGENTS	Coreg	CARVEDILOL	TABLET	6.25 MG	COVERED	FORMULARY
10340	5100	242400-BETA-ADRENERGIC BLOCKING AGENTS	Labetalol	LABETALOL HCL	TABLET	300 MG	COVERED	FORMULARY
10341	5099	242400-BETA-ADRENERGIC BLOCKING AGENTS	Labetalol	LABETALOL HCL	TABLET	200 MG	COVERED	FORMULARY
10342	5098	242400-BETA-ADRENERGIC BLOCKING AGENTS	Labetalol	LABETALOL HCL	TABLET	100 MG	COVERED	FORMULARY
17734	50631	242400-BETA-ADRENERGIC BLOCKING AGENTS	Lopressor	METOPROLOL TARTRATE	TABLET	25 MG	COVERED	FORMULARY
20641	5131	242400-BETA-ADRENERGIC BLOCKING AGENTS	Lopressor	METOPROLOL TARTRATE	TABLET	100 MG	COVERED	FORMULARY
20642	5132	242400-BETA-ADRENERGIC BLOCKING AGENTS	Lopressor	METOPROLOL TARTRATE	TABLET	50 MG	COVERED	FORMULARY
20652	5136	242400-BETA-ADRENERGIC BLOCKING AGENTS	Corgard	NADOLOL	TABLET	40 MG	COVERED	FORMULARY
20653	5137	242400-BETA-ADRENERGIC BLOCKING AGENTS	Corgard	NADOLOL	TABLET	80 MG	COVERED	FORMULARY
20654	5135	242400-BETA-ADRENERGIC BLOCKING AGENTS	Corgard	NADOLOL	TABLET	20 MG	COVERED	FORMULARY
3230	5116	242400-BETA-ADRENERGIC BLOCKING AGENTS	Inderal LA	PROPRANOLOL HCL	CAP SA 24H	80 MG	COVERED	FORMULARY
3231	5113	242400-BETA-ADRENERGIC BLOCKING AGENTS	Inderal LA	PROPRANOLOL HCL	CAP SA 24H	120 MG	COVERED	FORMULARY
3232	5114	242400-BETA-ADRENERGIC BLOCKING AGENTS	Inderal LA	PROPRANOLOL HCL	CAP SA 24H	160 MG	COVERED	FORMULARY
3233	5115	242400-BETA-ADRENERGIC BLOCKING AGENTS	Inderal LA	PROPRANOLOL HCL	CAP SA 24H	60 MG	COVERED	FORMULARY
20630	5123	242400-BETA-ADRENERGIC BLOCKING AGENTS	Propranolol	PROPRANOLOL HCL	TABLET	10 MG	COVERED	FORMULARY
20631	5124	242400-BETA-ADRENERGIC BLOCKING AGENTS	Propranolol	PROPRANOLOL HCL	TABLET	20 MG	COVERED	FORMULARY
20632	5125	242400-BETA-ADRENERGIC BLOCKING AGENTS	Propranolol	PROPRANOLOL HCL	TABLET	40 MG	COVERED	FORMULARY
20633	5126	242400-BETA-ADRENERGIC BLOCKING AGENTS	Propranolol	PROPRANOLOL HCL	TABLET	60 MG	COVERED	FORMULARY
20634	5127	242400-BETA-ADRENERGIC BLOCKING AGENTS	Propranolol	PROPRANOLOL HCL	TABLET	80 MG	COVERED	FORMULARY
39511	13497	242400-BETA-ADRENERGIC BLOCKING AGENTS	Betapace	SOTALOL HCL	TABLET	160 MG	COVERED	FORMULARY
39512	17196	242400-BETA-ADRENERGIC BLOCKING AGENTS	Betapace	SOTALOL HCL	TABLET	80 MG	COVERED	FORMULARY
39516	24097	242400-BETA-ADRENERGIC BLOCKING AGENTS	Betapace	SOTALOL HCL	TABLET	120 MG	COVERED	FORMULARY
2681	16925	242808-DIHYDROPYRIDINES	Norvasc	AMLODIPINE BESYLATE	TABLET	2.5 MG	COVERED	FORMULARY
2682	16927	242808-DIHYDROPYRIDINES	Norvasc	AMLODIPINE BESYLATE	TABLET	10 MG	COVERED	FORMULARY
2683	16926	242808-DIHYDROPYRIDINES	Norvasc	AMLODIPINE BESYLATE	TABLET	5 MG	COVERED	FORMULARY
17604	50519	242808-DIHYDROPYRIDINES	Lotrel	AMLODIPINE BESYLATE-BENAZEPRIL	CAPSULE	10-20 MG	COVERED	FORMULARY
26949	60722	242808-DIHYDROPYRIDINES	Lotrel	AMLODIPINE BESYLATE-BENAZEPRIL	CAPSULE	5-40 MG	COVERED	FORMULARY
26950	60723	242808-DIHYDROPYRIDINES	Lotrel	AMLODIPINE BESYLATE-BENAZEPRIL	CAPSULE	10-40 MG	COVERED	FORMULARY
33090	23768	242808-DIHYDROPYRIDINES	Lotrel	AMLODIPINE BESYLATE-BENAZEPRIL	CAPSULE	5-20 MG	COVERED	FORMULARY
33092	23769	242808-DIHYDROPYRIDINES	Lotrel	AMLODIPINE BESYLATE-BENAZEPRIL	CAPSULE	5-10 MG	COVERED	FORMULARY
33093	23770	242808-DIHYDROPYRIDINES	Lotrel	AMLODIPINE BESYLATE-BENAZEPRIL	CAPSULE	2.5-10 MG	COVERED	FORMULARY
2350	568	242808-DIHYDROPYRIDINES	Procardia	NIFEDIPINE	CAPSULE	10 MG	COVERED	FORMULARY
2351	569	242808-DIHYDROPYRIDINES	Procardia	NIFEDIPINE	CAPSULE	20 MG	COVERED	FORMULARY
2221	20616	242808-DIHYDROPYRIDINES	Procardia XL	NIFEDIPINE	TAB ER 24	30 MG	COVERED	FORMULARY
2221	20616	242808-DIHYDROPYRIDINES	Procardia XL	NIFEDIPINE	TAB ER 24	30 MG	COVERED	FORMULARY
2222	20617	242808-DIHYDROPYRIDINES	Procardia XL	NIFEDIPINE	TAB ER 24	60 MG	COVERED	FORMULARY
2222	20617	242808-DIHYDROPYRIDINES	Procardia XL	NIFEDIPINE	TAB ER 24	60 MG	COVERED	FORMULARY
2223	20618	242808-DIHYDROPYRIDINES	Procardia XL	NIFEDIPINE	TAB ER 24	90 MG	COVERED	FORMULARY
2223	20618	242808-DIHYDROPYRIDINES	Procardia XL	NIFEDIPINE	TAB ER 24	90 MG	COVERED	FORMULARY
2228	12061	242808-DIHYDROPYRIDINES	Adalat CC	NIFEDIPINE	TABLET ER	90 MG	COVERED	FORMULARY
2226	12059	242808-DIHYDROPYRIDINES	Adalat CC, Afeditab CR	NIFEDIPINE	TABLET ER	30 MG	COVERED	FORMULARY
2227	12060	242808-DIHYDROPYRIDINES	Adalat CC, Afeditab CR	NIFEDIPINE	TABLET ER	60 MG	COVERED	FORMULARY
2320	572	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Diltiazem ER	DILTIAZEM HCL	CAP ER 12H	90 MG	COVERED	FORMULARY
2321	570	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Diltiazem ER	DILTIAZEM HCL	CAP ER 12H	120 MG	COVERED	FORMULARY
2322	571	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Diltiazem ER	DILTIAZEM HCL	CAP ER 12H	60 MG	COVERED	FORMULARY
7460	32600	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem CD	DILTIAZEM HCL	CAP ER 24H	360 MG	COVERED	FORMULARY
2323	16570	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem CD, Cartia XT	DILTIAZEM HCL	CAP ER 24H	180 MG	COVERED	FORMULARY
2324	16571	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem CD, Cartia XT	DILTIAZEM HCL	CAP ER 24H	240 MG	COVERED	FORMULARY
2325	16572	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem CD, Cartia XT	DILTIAZEM HCL	CAP ER 24H	300 MG	COVERED	FORMULARY
2326	21282	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem CD, Cartia XT	DILTIAZEM HCL	CAP ER 24H	120 MG	COVERED	FORMULARY
7461	16849	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Dilacor XR	DILTIAZEM HCL	CAP ER DEG	180 MG	COVERED	FORMULARY
7462	16850	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Dilacor XR	DILTIAZEM HCL	CAP ER DEG	240 MG	COVERED	FORMULARY
7463	17205	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Dilacor XR	DILTIAZEM HCL	CAP ER DEG	120 MG	COVERED	FORMULARY
94691	40966	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Tiazac	DILTIAZEM HCL	CAPSULE ER	420 MG	COVERED	FORMULARY
2328	24478	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Tiazac, Taztia XT	DILTIAZEM HCL	CAPSULE ER	360 MG	COVERED	FORMULARY
2329	24537	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Tiazac, Taztia XT	DILTIAZEM HCL	CAPSULE ER	180 MG	COVERED	FORMULARY
2330	24536	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Tiazac, Taztia XT	DILTIAZEM HCL	CAPSULE ER	120 MG	COVERED	FORMULARY
2332	24538	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Tiazac, Taztia XT	DILTIAZEM HCL	CAPSULE ER	240 MG	COVERED	FORMULARY
2333	24539	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Tiazac, Taztia XT	DILTIAZEM HCL	CAPSULE ER	300 MG	COVERED	FORMULARY
2360	574	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem	DILTIAZEM HCL	TABLET	30 MG	COVERED	FORMULARY
2361	575	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem	DILTIAZEM HCL	TABLET	60 MG	COVERED	FORMULARY
2362	576	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem	DILTIAZEM HCL	TABLET	90 MG	COVERED	FORMULARY
2363	573	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Cardizem	DILTIAZEM HCL	TABLET	120 MG	COVERED	FORMULARY
3001	16605	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Verelan SR	VERAPAMIL HCL	CAP24H PEL	180 MG	COVERED	FORMULARY
3002	15067	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Verelan SR	VERAPAMIL HCL	CAP24H PEL	240 MG	COVERED	FORMULARY
3003	15066	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Verelan SR	VERAPAMIL HCL	CAP24H PEL	120 MG	COVERED	FORMULARY
3004	26486	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Verelan SR	VERAPAMIL HCL	CAP24H PEL	360 MG	COVERED	FORMULARY
2341	564	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Calan	VERAPAMIL HCL	TABLET	120 MG	COVERED	FORMULARY
2342	566	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Calan	VERAPAMIL HCL	TABLET	80 MG	COVERED	FORMULARY
47110	565	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Verapamil	VERAPAMIL HCL	TABLET	40 MG	COVERED	FORMULARY
32470	567	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Calan SR	VERAPAMIL HCL	TABLET ER	240 MG	COVERED	FORMULARY
32471	13670	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Calan SR	VERAPAMIL HCL	TABLET ER	180 MG	COVERED	FORMULARY
32472	15959	242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.	Calan SR	VERAPAMIL HCL	TABLET ER	120 MG	COVERED	FORMULARY
48611	16039	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Lotensin	BENAZEPRIL HCL	TABLET	5 MG	COVERED	FORMULARY
48612	16040	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Lotensin	BENAZEPRIL HCL	TABLET	10 MG	COVERED	FORMULARY
48613	16041	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Lotensin	BENAZEPRIL HCL	TABLET	20 MG	COVERED	FORMULARY
48614	16042	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Lotensin	BENAZEPRIL HCL	TABLET	40 MG	COVERED	FORMULARY
33192	21724	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Lotensin HCT	BENAZEPRIL-HYDROCHLOROTHIAZIDE	TABLET	10-12.5 MG	COVERED	FORMULARY
33193	21725	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Lotensin HCT	BENAZEPRIL-HYDROCHLOROTHIAZIDE	TABLET	20-12.5 MG	COVERED	FORMULARY
33194	21726	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Lotensin HCT	BENAZEPRIL-HYDROCHLOROTHIAZIDE	TABLET	20-25 MG	COVERED	FORMULARY
1480	378	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Captopril	CAPTOPRIL	TABLET	100 MG	COVERED	FORMULARY
1481	380	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Captopril	CAPTOPRIL	TABLET	25 MG	COVERED	FORMULARY
1482	381	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Captopril	CAPTOPRIL	TABLET	50 MG	COVERED	FORMULARY
1483	379	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Captopril	CAPTOPRIL	TABLET	12.5 MG	COVERED	FORMULARY
54940	374	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Captopril-Hydrochlorothiazide	CAPTOPRIL-HYDROCHLOROTHIAZIDE	TABLET	25-15 MG	COVERED	FORMULARY
54941	375	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Captopril-Hydrochlorothiazide	CAPTOPRIL-HYDROCHLOROTHIAZIDE	TABLET	25-25 MG	COVERED	FORMULARY
960	387	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Vasotec	ENALAPRIL MALEATE	TABLET	5 MG	COVERED	FORMULARY
961	384	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Vasotec	ENALAPRIL MALEATE	TABLET	10 MG	COVERED	FORMULARY
962	386	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Vasotec	ENALAPRIL MALEATE	TABLET	20 MG	COVERED	FORMULARY
963	385	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Vasotec	ENALAPRIL MALEATE	TABLET	2.5 MG	COVERED	FORMULARY
54860	382	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Enalapril-Hydrochlorothiazide	ENALAPRIL-HYDROCHLOROTHIAZIDE	TABLET	10-25 MG	COVERED	FORMULARY
54862	24190	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Enalapril-Hydrochlorothiazide	ENALAPRIL-HYDROCHLOROTHIAZIDE	TABLET	5-12.5 MG	COVERED	FORMULARY
48580	24469	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Fosinopril	FOSINOPRIL SODIUM	TABLET	40 MG	COVERED	FORMULARY
48581	16017	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Fosinopril	FOSINOPRIL SODIUM	TABLET	10 MG	COVERED	FORMULARY
48582	16018	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Fosinopril	FOSINOPRIL SODIUM	TABLET	20 MG	COVERED	FORMULARY
10455	40395	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Fosinopril-Hydrochlorothiazide	FOSINOPRIL-HYDROCHLOROTHIAZIDE	TABLET	20-12.5 MG	COVERED	FORMULARY
15621	44935	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Fosinopril-Hydrochlorothiazide	FOSINOPRIL-HYDROCHLOROTHIAZIDE	TABLET	10-12.5 MG	COVERED	FORMULARY
47260	393	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Prinvil, Zestril	LISINOPRIL	TABLET	5 MG	COVERED	FORMULARY
47261	390	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Prinvil, Zestril	LISINOPRIL	TABLET	10 MG	COVERED	FORMULARY
47262	391	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Prinvil, Zestril	LISINOPRIL	TABLET	20 MG	COVERED	FORMULARY
47263	392	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Prinvil, Zestril	LISINOPRIL	TABLET	40 MG	COVERED	FORMULARY
47264	17266	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Prinvil, Zestril	LISINOPRIL	TABLET	2.5 MG	COVERED	FORMULARY
47265	41567	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Prinvil, Zestril	LISINOPRIL	TABLET	30 MG	COVERED	FORMULARY
88000	388	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Zestoretic	LISINOPRIL-HYDROCHLOROTHIAZIDE	TABLET	20-12.5 MG	COVERED	FORMULARY
88001	389	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Zestoretic	LISINOPRIL-HYDROCHLOROTHIAZIDE	TABLET	20-25 MG	COVERED	FORMULARY
88002	21277	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Zestoretic	LISINOPRIL-HYDROCHLOROTHIAZIDE	TABLET	10-12.5 MG	COVERED	FORMULARY
27570	18772	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Accupril	QUINAPRIL HCL	TABLET	10 MG	COVERED	FORMULARY
27571	18773	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Accupril	QUINAPRIL HCL	TABLET	20 MG	COVERED	FORMULARY
27572	18774	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Accupril	QUINAPRIL HCL	TABLET	5 MG	COVERED	FORMULARY
27573	21909	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Accupril	QUINAPRIL HCL	TABLET	40 MG	COVERED	FORMULARY
54160	19140	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Accuretic	QUINAPRIL-HYDROCHLOROTHIAZIDE	TABLET	10-12.5MG	COVERED	FORMULARY
54161	24002	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Accuretic	QUINAPRIL-HYDROCHLOROTHIAZIDE	TABLET	20-12.5 MG	COVERED	FORMULARY
94490	41016	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Accuretic	QUINAPRIL-HYDROCHLOROTHIAZIDE	TABLET	20-25MG	COVERED	FORMULARY
48542	15940	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Altace	RAMIPRIL	CAPSULE	2.5 MG	COVERED	FORMULARY
48543	15941	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Altace	RAMIPRIL	CAPSULE	5 MG	COVERED	FORMULARY
48544	16031	243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS	Altace	RAMIPRIL	CAPSULE	10 MG	COVERED	FORMULARY
4749	34468	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Avapro	IRBESARTAN	TABLET	150 MG	COVERED	FORMULARY
4750	34469	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Avapro	IRBESARTAN	TABLET	300 MG	COVERED	FORMULARY
4752	34470	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Avapro	IRBESARTAN	TABLET	75 MG	COVERED	FORMULARY
11042	41234	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Avalide	IRBESARTAN-HYDROCHLOROTHIAZIDE	TABLET	150-12.5 MG	COVERED	FORMULARY
11295	41897	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Avalide	IRBESARTAN-HYDROCHLOROTHIAZIDE	TABLET	300-12.5 MG	COVERED	FORMULARY
14850	23381	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Cozaar	LOSARTAN POTASSIUM	TABLET	25 MG	COVERED	FORMULARY
14851	23382	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Cozaar	LOSARTAN POTASSIUM	TABLET	50 MG	COVERED	FORMULARY
14853	38686	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Cozaar	LOSARTAN POTASSIUM	TABLET	100 MG	COVERED	FORMULARY
14852	23465	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Hyzaar	LOSARTAN-HYDROCHLOROTHIAZIDE	TABLET	50-12.5 MG	COVERED	FORMULARY
14854	40923	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Hyzaar	LOSARTAN-HYDROCHLOROTHIAZIDE	TABLET	100-25 MG	COVERED	FORMULARY
25851	59919	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Hyzaar	LOSARTAN-HYDROCHLOROTHIAZIDE	TABLET	100-12.5 MG	COVERED	FORMULARY
91883	51036	243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS	Inspra	EPLERENONE	TABLET	25 MG	COVERED	FORMULARY
91883	51036	243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS	Inspra	EPLERENONE	TABLET	25 MG	COVERED	FORMULARY
91884	51037	243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS	Inspra	EPLERENONE	TABLET	50 MG	COVERED	FORMULARY
91884	51037	243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS	Inspra	EPLERENONE	TABLET	50 MG	COVERED	FORMULARY
27690	6816	243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS	Aldactone	SPIRONOLACTONE	TABLET	100 MG	COVERED	FORMULARY
27691	6817	243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS	Aldactone	SPIRONOLACTONE	TABLET	25 MG	COVERED	FORMULARY
27692	6818	243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS	Aldactone	SPIRONOLACTONE	TABLET	50 MG	COVERED	FORMULARY
71150	4308	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Fiorinal	BUTALBITAL-ASPIRIN-CAFFEINE	CAPSULE	50-325-40 MG	COVERED	FORMULARY
71150	4308	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Fiorinal	BUTALBITAL-ASPIRIN-CAFFEINE	CAPSULE	50-325-40 MG	COVERED	FORMULARY
45680	18293	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Voltaren	DICLOFENAC SODIUM	GEL (GRAM)	1 %	COVERED	FORMULARY
13310	11933	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Diclofenac Sodium	DICLOFENAC SODIUM	TAB ER 24H	100 MG	COVERED	FORMULARY
35850	8372	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Diclofenac Sodium	DICLOFENAC SODIUM	TABLET DR	25 MG	COVERED	FORMULARY
35851	8373	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Diclofenac Sodium	DICLOFENAC SODIUM	TABLET DR	50 MG	COVERED	FORMULARY
35852	8374	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Diclofenac Sodium	DICLOFENAC SODIUM	TABLET DR	75 MG	COVERED	FORMULARY
33870	15960	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Etodolac	ETODOLAC	CAPSULE	200 MG	COVERED	FORMULARY
33871	15961	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Etodolac	ETODOLAC	CAPSULE	300 MG	COVERED	FORMULARY
61767	38259	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Etodolac	ETODOLAC	TAB ER 24H	500 MG	COVERED	FORMULARY
61761	20175	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Etodolac	ETODOLAC	TABLET	400 MG	COVERED	FORMULARY
61766	27368	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Etodolac	ETODOLAC	TABLET	500 MG	COVERED	FORMULARY
35741	8348	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Ibuprofen	IBUPROFEN	TABLET	400 MG	COVERED	FORMULARY
35742	8349	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Ibuprofen	IBUPROFEN	TABLET	600 MG	COVERED	FORMULARY
35744	8350	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Ibuprofen	IBUPROFEN	TABLET	800 MG	COVERED	FORMULARY
35680	8336	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Indomethacin	INDOMETHACIN	CAPSULE	25 MG	COVERED	FORMULARY
35681	8337	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Indomethacin	INDOMETHACIN	CAPSULE	50 MG	COVERED	FORMULARY
35690	8338	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Indomethacin	INDOMETHACIN	CAPSULE ER	75 MG	COVERED	FORMULARY
33792	16406	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Ketoprofen ER	KETOPROFEN	CAP24H PEL	200 MG	COVERED	FORMULARY
34420	8379	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Ketoprofen	KETOPROFEN	CAPSULE	50 MG	COVERED	FORMULARY
34421	8380	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Ketoprofen	KETOPROFEN	CAPSULE	75 MG	COVERED	FORMULARY
31661	29156	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Mobic	MELOXICAM	TABLET	7.5 MG	COVERED	FORMULARY
31662	29157	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Mobic	MELOXICAM	TABLET	15 MG	COVERED	FORMULARY
32961	16574	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Nabumetone	NABUMETONE	TABLET	500 MG	COVERED	FORMULARY
32962	16575	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Nabumetone	NABUMETONE	TABLET	750 MG	COVERED	FORMULARY
35790	8360	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Naprosyn	NAPROXEN	TABLET	250 MG	COVERED	FORMULARY
35792	8361	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Naprosyn	NAPROXEN	TABLET	375 MG	COVERED	FORMULARY
35793	8362	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Naprosyn	NAPROXEN	TABLET	500 MG	COVERED	FORMULARY
47130	8357	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Anaprox	NAPROXEN SODIUM	TABLET	275 MG	COVERED	FORMULARY
47131	8358	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Anaprox	NAPROXEN SODIUM	TABLET	550 MG	COVERED	FORMULARY
16801	4438	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Salsalate	SALSALATE	TABLET	500 MG	COVERED	FORMULARY
16802	4439	280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS	Salsalate	SALSALATE	TABLET	750 MG	COVERED	FORMULARY
55402	45155	280808-OPIATE AGONISTS	Acetaminophen-Codeine Solution	ACETAMINOPHEN-CODEINE	SOLUTION	120-12 MG/5ML	COVERED	FORMULARY
70131	4163	280808-OPIATE AGONISTS	Acetaminophen-Codeine Tablet	ACETAMINOPHEN-CODEINE	TABLET	300-15 MG	COVERED	FORMULARY
70134	4165	280808-OPIATE AGONISTS	Tylenol-Codeine #3	ACETAMINOPHEN-CODEINE	TABLET	300-30 MG	COVERED	FORMULARY
70136	4169	280808-OPIATE AGONISTS	Tylenol-Codeine #4	ACETAMINOPHEN-CODEINE	TABLET	300-60 MG	COVERED	FORMULARY
70140	4149	280808-OPIATE AGONISTS	Butalbital-Acetaminophen-Caffeine-Codeine	BUTALBITAL-ACETAMINOPHEN-CAFFEINE-CODEINE	CAPSULE	50-325-30 MG	COVERED	FORMULARY
21146	53582	280808-OPIATE AGONISTS	Hydrocodone-Acetaminophen	HYDROCODONE-ACETAMINOPHEN	SOLUTION	7.5-325/15	COVERED	FORMULARY
12486	47430	280808-OPIATE AGONISTS	Hydrocodone-Acetaminophen	HYDROCODONE-ACETAMINOPHEN	TABLET	5-325 MG	COVERED	FORMULARY
12488	47431	280808-OPIATE AGONISTS	Hydrocodone-Acetaminophen	HYDROCODONE-ACETAMINOPHEN	TABLET	7.5-325 MG	COVERED	FORMULARY
70330	30623	280808-OPIATE AGONISTS	Hydrocodone-Acetaminophen	HYDROCODONE-ACETAMINOPHEN	TABLET	10-325 MG	COVERED	FORMULARY
70334	26439	280808-OPIATE AGONISTS	Hydrocodone-Acetaminophen	HYDROCODONE-ACETAMINOPHEN	TABLET	10-500 MG	COVERED	FORMULARY
12488	47431	280808-OPIATE AGONISTS	Hydrocodone-Acetaminophen	HYDROCODONE-ACETAMINOPHEN	TABLET	7.5-325 MG	COVERED	FORMULARY
63101	34068	280808-OPIATE AGONISTS	Vicoprofen	HYDROCODONE-IBUPROFEN	TABLET	7.5-200 MG	COVERED	FORMULARY
16141	4110	280808-OPIATE AGONISTS	Dilaudid	HYDROMORPHONE HCL	TABLET	2 MG	COVERED	FORMULARY
16143	4112	280808-OPIATE AGONISTS	Dilaudid	HYDROMORPHONE HCL	TABLET	4 MG	COVERED	FORMULARY
16144	15190	280808-OPIATE AGONISTS	Dilaudid	HYDROMORPHONE HCL	TABLET	8 MG	COVERED	FORMULARY
16420	4240	280808-OPIATE AGONISTS	Dolophine	METHADONE HCL	TABLET	10 MG	COVERED	FORMULARY
16422	4242	280808-OPIATE AGONISTS	Dolophine	METHADONE HCL	TABLET	5 MG	COVERED	FORMULARY
16060	4087	280808-OPIATE AGONISTS	Morphine	MORPHINE SULFATE	SOLUTION	10 MG/5ML	COVERED	FORMULARY
16062	4089	280808-OPIATE AGONISTS	Morphine	MORPHINE SULFATE	SOLUTION	20 MG/5ML	COVERED	FORMULARY
16063	4090	280808-OPIATE AGONISTS	Morphine	MORPHINE SULFATE	SOLUTION	100 MG/5ML	COVERED	FORMULARY
16070	4091	280808-OPIATE AGONISTS	Morphine	MORPHINE SULFATE	TABLET	15 MG	COVERED	FORMULARY
16071	4092	280808-OPIATE AGONISTS	Morphine	MORPHINE SULFATE	TABLET	30 MG	COVERED	FORMULARY
16640	4096	280808-OPIATE AGONISTS	MS Contin CR	MORPHINE SULFATE	TABLET ER	30 MG	COVERED	FORMULARY
16641	4097	280808-OPIATE AGONISTS	MS Contin CR	MORPHINE SULFATE	TABLET ER	60 MG	COVERED	FORMULARY
16643	11887	280808-OPIATE AGONISTS	MS Contin CR	MORPHINE SULFATE	TABLET ER	15 MG	COVERED	FORMULARY
16285	24507	280808-OPIATE AGONISTS	Oxycodone	OXYCODONE HCL	CAPSULE	5 MG	COVERED	FORMULARY
16290	4225	280808-OPIATE AGONISTS	Oxycodone	OXYCODONE HCL	TABLET	5 MG	COVERED	FORMULARY
14965	48976	280808-OPIATE AGONISTS	Percocet	OXYCODONE HCL-ACETAMINOPHEN	TABLET	7.5-325MG	COVERED	FORMULARY
14966	48977	280808-OPIATE AGONISTS	Percocet	OXYCODONE HCL-ACETAMINOPHEN	TABLET	10MG-325MG	COVERED	FORMULARY
70491	4222	280808-OPIATE AGONISTS	Percocet	OXYCODONE HCL-ACETAMINOPHEN	TABLET	5 MG-325MG	COVERED	FORMULARY
7221	23139	280808-OPIATE AGONISTS	Ultram	TRAMADOL HCL	TABLET	50 MG	COVERED	FORMULARY
13909	48456	280808-OPIATE AGONISTS	Ultracet	TRAMADOL HCL-ACETAMINOPHEN	TABLET	37.5-325MG	COVERED	FORMULARY
72510	4450	280892-ANALGESICS AND ANTIPYRETICS, MISC.	Capacet	BUTALBITAL-ACETAMINOPHEN-CAFFEINE	CAPSULE	50-325-40 MG	COVERED	FORMULARY
72530	4451	280892-ANALGESICS AND ANTIPYRETICS, MISC.	Esgic	BUTALBITAL-ACETAMINOPHEN-CAFFEINE	TABLET	50-325-40 MG	COVERED	FORMULARY
13996	48520	280892-ANALGESICS AND ANTIPYRETICS, MISC.	Nodolor	ISOMETHEPT-DICHLPHN/ACETAMINOPHEN	CAPSULE	65-100-325 MG	COVERED	FORMULARY
40233	75222	281000-OPIATE ANTAGONISTS	Narcan Nasal	NALOXONE HCL	SPRAY	4 MG	COVERED	FORMULARY
17070	4518	281000-OPIATE ANTAGONISTS	Naltrexone	NALTREXONE HCL	TABLET	50 MG	COVERED	FORMULARY
17321	4543	281204-BARBITURATES (ANTICONVULSANTS)	Mysoline	PRIMIDONE	TABLET	250 MG	COVERED	FORMULARY
17322	4544	281204-BARBITURATES (ANTICONVULSANTS)	Mysoline	PRIMIDONE	TABLET	50 MG	COVERED	FORMULARY
17470	4560	281208-BENZODIAZEPINES (ANTICONVULSANTS)	Klonopin	CLONAZEPAM	TABLET	0.5 MG	COVERED	FORMULARY
17471	4561	281208-BENZODIAZEPINES (ANTICONVULSANTS)	Klonopin	CLONAZEPAM	TABLET	1 MG	COVERED	FORMULARY
17472	4562	281208-BENZODIAZEPINES (ANTICONVULSANTS)	Klonopin	CLONAZEPAM	TABLET	2 MG	COVERED	FORMULARY
17260	4532	281212-HYDANTOINS	Peganone	ETHOTOIN	TABLET	250 MG	COVERED	FORMULARY
17241	4529	281212-HYDANTOINS	Dilantin	PHENYTOIN	ORAL SUSP	125 MG/5ML	COVERED	FORMULARY
99557	63845	281212-HYDANTOINS	Phenytoin	PHENYTOIN	ORAL SUSP	100 MG/4ML	COVERED	FORMULARY
17250	4531	281212-HYDANTOINS	Dilantin	PHENYTOIN	TAB CHEW	50 MG	COVERED	FORMULARY
15037	49444	281212-HYDANTOINS	Dilantin, Phenytek	PHENYTOIN SODIUM EXTENDED	CAPSULE	300 MG	COVERED	FORMULARY
15038	49445	281212-HYDANTOINS	Dilantin, Phenytek	PHENYTOIN SODIUM EXTENDED	CAPSULE	200 MG	COVERED	FORMULARY
17700	4521	281212-HYDANTOINS	Dilantin, Phenytek	PHENYTOIN SODIUM EXTENDED	CAPSULE	100 MG	COVERED	FORMULARY
17701	4522	281212-HYDANTOINS	Dilantin, Phenytek	PHENYTOIN SODIUM EXTENDED	CAPSULE	30 MG	COVERED	FORMULARY
23932	58487	281292-ANTICONVULSANTS, MISCELLANEOUS	Carbatrol	CARBAMAZEPINE	CPMP 12HR	200 MG	COVERED	FORMULARY
23933	58488	281292-ANTICONVULSANTS, MISCELLANEOUS	Carbatrol	CARBAMAZEPINE	CPMP 12HR	300 MG	COVERED	FORMULARY
23934	58489	281292-ANTICONVULSANTS, MISCELLANEOUS	Carbatrol	CARBAMAZEPINE	CPMP 12HR	100 MG	COVERED	FORMULARY
47500	4557	281292-ANTICONVULSANTS, MISCELLANEOUS	Carbamazepine	CARBAMAZEPINE	ORAL SUSP	100 MG/5ML	COVERED	FORMULARY
17460	4559	281292-ANTICONVULSANTS, MISCELLANEOUS	Carbamazepine	CARBAMAZEPINE	TAB CHEW	100 MG	COVERED	FORMULARY
27820	26868	281292-ANTICONVULSANTS, MISCELLANEOUS	Tegreol XR	CARBAMAZEPINE	TAB ER 12H	100 MG	COVERED	FORMULARY
27821	16773	281292-ANTICONVULSANTS, MISCELLANEOUS	Tegreol XR	CARBAMAZEPINE	TAB ER 12H	200 MG	COVERED	FORMULARY
27822	17876	281292-ANTICONVULSANTS, MISCELLANEOUS	Tegreol XR	CARBAMAZEPINE	TAB ER 12H	400 MG	COVERED	FORMULARY
17450	4558	281292-ANTICONVULSANTS, MISCELLANEOUS	Tegretol	CARBAMAZEPINE	TABLET	200 MG	COVERED	FORMULARY
18040	46315	281292-ANTICONVULSANTS, MISCELLANEOUS	Depakote ER	DIVALPROEX SODIUM	TAB ER 24H	500 MG	COVERED	FORMULARY
18754	51469	281292-ANTICONVULSANTS, MISCELLANEOUS	Depakote ER	DIVALPROEX SODIUM	TAB ER 24H	250 MG	COVERED	FORMULARY
17290	4539	281292-ANTICONVULSANTS, MISCELLANEOUS	Depakote	DIVALPROEX SODIUM	TABLET DR	250 MG	COVERED	FORMULARY
17291	4540	281292-ANTICONVULSANTS, MISCELLANEOUS	Depakote	DIVALPROEX SODIUM	TABLET DR	500 MG	COVERED	FORMULARY
17292	4538	281292-ANTICONVULSANTS, MISCELLANEOUS	Depakote	DIVALPROEX SODIUM	TABLET DR	125 MG	COVERED	FORMULARY
780	21413	281292-ANTICONVULSANTS, MISCELLANEOUS	Neurontin	GABAPENTIN	CAPSULE	100 MG	COVERED	FORMULARY
781	21414	281292-ANTICONVULSANTS, MISCELLANEOUS	Neurontin	GABAPENTIN	CAPSULE	300 MG	COVERED	FORMULARY
782	21415	281292-ANTICONVULSANTS, MISCELLANEOUS	Neurontin	GABAPENTIN	CAPSULE	400 MG	COVERED	FORMULARY
13235	47927	281292-ANTICONVULSANTS, MISCELLANEOUS	Neurontin	GABAPENTIN	SOLUTION	250 MG/5ML	COVERED	FORMULARY
94447	41806	281292-ANTICONVULSANTS, MISCELLANEOUS	Neurontin	GABAPENTIN	TABLET	800 MG	COVERED	FORMULARY
94624	41805	281292-ANTICONVULSANTS, MISCELLANEOUS	Neurontin	GABAPENTIN	TABLET	600 MG	COVERED	FORMULARY
64316	17871	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal	LAMOTRIGINE	TABLET	100 MG	COVERED	FORMULARY
64317	17872	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal	LAMOTRIGINE	TABLET	25 MG	COVERED	FORMULARY
64324	22550	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal	LAMOTRIGINE	TABLET	150 MG	COVERED	FORMULARY
64325	22551	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal	LAMOTRIGINE	TABLET	200 MG	COVERED	FORMULARY
16779	64819	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra	LEVETIRACETAM	SOLUTION	500 MG/5ML	COVERED	FORMULARY
20353	53031	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra	LEVETIRACETAM	SOLUTION	100 MG/ML	COVERED	FORMULARY
41586	45652	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra	LEVETIRACETAM	TABLET	750 MG	COVERED	FORMULARY
41587	44632	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra	LEVETIRACETAM	TABLET	250 MG	COVERED	FORMULARY
41597	44633	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra	LEVETIRACETAM	TABLET	500 MG	COVERED	FORMULARY
86223	47077	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra	LEVETIRACETAM	TABLET	1000 MG	COVERED	FORMULARY
21723	33724	281292-ANTICONVULSANTS, MISCELLANEOUS	Trileptal	OXCARBAZEPINE	ORAL SUSP	300 MG/5ML	COVERED	FORMULARY
21721	27779	281292-ANTICONVULSANTS, MISCELLANEOUS	Trileptal	OXCARBAZEPINE	TABLET	300 MG	COVERED	FORMULARY
21722	27780	281292-ANTICONVULSANTS, MISCELLANEOUS	Trileptal	OXCARBAZEPINE	TABLET	600 MG	COVERED	FORMULARY
21724	44336	281292-ANTICONVULSANTS, MISCELLANEOUS	Trileptal	OXCARBAZEPINE	TABLET	150 MG	COVERED	FORMULARY
92219	45100	281292-ANTICONVULSANTS, MISCELLANEOUS	Thioguanine	THIOGUANINE	TABLET	40 MG	COVERED	FORMULARY
36550	26169	281292-ANTICONVULSANTS, MISCELLANEOUS	Topamax	TOPIRAMATE	TABLET	50 MG	COVERED	FORMULARY
36551	26170	281292-ANTICONVULSANTS, MISCELLANEOUS	Topamax	TOPIRAMATE	TABLET	100 MG	COVERED	FORMULARY
36552	26171	281292-ANTICONVULSANTS, MISCELLANEOUS	Topamax	TOPIRAMATE	TABLET	200 MG	COVERED	FORMULARY
36553	29837	281292-ANTICONVULSANTS, MISCELLANEOUS	Topamax	TOPIRAMATE	TABLET	25 MG	COVERED	FORMULARY
17270	4536	281292-ANTICONVULSANTS, MISCELLANEOUS	Depakene	VALPROIC ACID	CAPSULE	250 MG	COVERED	FORMULARY
17280	4535	281292-ANTICONVULSANTS, MISCELLANEOUS	Depakene Syrup	VALPROIC ACID (AS SODIUM SALT)	SOLUTION	250 MG/5ML	COVERED	FORMULARY
30965	68220	281292-ANTICONVULSANTS, MISCELLANEOUS	Valproic Solution	VALPROIC ACID (AS SODIUM SALT)	SOLUTION	250 MG/5ML	COVERED	FORMULARY
30986	68236	281292-ANTICONVULSANTS, MISCELLANEOUS	Valproic Syrup	VALPROIC ACID (AS SODIUM SALT)	SOLUTION	500 MG/10ML	COVERED	FORMULARY
30987	68237	281292-ANTICONVULSANTS, MISCELLANEOUS	Valproic Syrup	VALPROIC ACID (AS SODIUM SALT)	SYRINGE	250 MG/5ML	COVERED	FORMULARY
20831	53367	281292-ANTICONVULSANTS, MISCELLANEOUS	Zonegran	ZONISAMIDE	CAPSULE	25 MG	COVERED	FORMULARY
20833	53368	281292-ANTICONVULSANTS, MISCELLANEOUS	Zonegran	ZONISAMIDE	CAPSULE	50 MG	COVERED	FORMULARY
92219	45100	281292-ANTICONVULSANTS, MISCELLANEOUS	Zonegran	ZONISAMIDE	CAPSULE	100 MG	COVERED	FORMULARY
16512	46043	281604-ANTIDEPRESSANTS	Elavil	AMITRIPTYLINE HCL	TABLET	10 MG	COVERED	FORMULARY
16513	46044	281604-ANTIDEPRESSANTS	Elavil	AMITRIPTYLINE HCL	TABLET	100 MG	COVERED	FORMULARY
16514	46045	281604-ANTIDEPRESSANTS	Elavil	AMITRIPTYLINE HCL	TABLET	150 MG	COVERED	FORMULARY
16515	46046	281604-ANTIDEPRESSANTS	Elavil	AMITRIPTYLINE HCL	TABLET	25 MG	COVERED	FORMULARY
16516	46047	281604-ANTIDEPRESSANTS	Elavil	AMITRIPTYLINE HCL	TABLET	50 MG	COVERED	FORMULARY
16517	46048	281604-ANTIDEPRESSANTS	Elavil	AMITRIPTYLINE HCL	TABLET	75 MG	COVERED	FORMULARY
20317	53006	281604-ANTIDEPRESSANTS	Wellbutrin XL	BUPROPION HCL	TAB ER 24H	150 MG	COVERED	FORMULARY
20318	53007	281604-ANTIDEPRESSANTS	Wellbutrin XL	BUPROPION HCL	TAB ER 24H	300 MG	COVERED	FORMULARY
16384	46236	281604-ANTIDEPRESSANTS	Wellbutrin	BUPROPION HCL	TABLET	75 MG	COVERED	FORMULARY
16385	46237	281604-ANTIDEPRESSANTS	Wellbutrin	BUPROPION HCL	TABLET	100 MG	COVERED	FORMULARY
16386	46238	281604-ANTIDEPRESSANTS	Wellbutrin SR	BUPROPION HCL	TABLET ER	150 MG	COVERED	FORMULARY
16387	46239	281604-ANTIDEPRESSANTS	Wellbutrin SR	BUPROPION HCL	TABLET ER	100 MG	COVERED	FORMULARY
17573	50496	281604-ANTIDEPRESSANTS	Wellbutrin SR	BUPROPION HCL	TABLET ER	200 MG	COVERED	FORMULARY
27901	31439	281604-ANTIDEPRESSANTS	Zyban SR	BUPROPION HCL	TABLET ER	150 MG	COVERED	FORMULARY
16342	46203	281604-ANTIDEPRESSANTS	Celexa	CITALOPRAM HYDROBROMIDE	TABLET	20 MG	COVERED	FORMULARY	Max 40mg/day
16343	46204	281604-ANTIDEPRESSANTS	Celexa	CITALOPRAM HYDROBROMIDE	TABLET	40 MG	COVERED	FORMULARY	Max 40mg/day
16345	46206	281604-ANTIDEPRESSANTS	Celexa	CITALOPRAM HYDROBROMIDE	TABLET	10 MG	COVERED	FORMULARY	Max 40mg/day
16563	46086	281604-ANTIDEPRESSANTS	Doxepin	DOXEPIN HCL	CAPSULE	10 MG	COVERED	FORMULARY
16564	46087	281604-ANTIDEPRESSANTS	Doxepin	DOXEPIN HCL	CAPSULE	100 MG	COVERED	FORMULARY
16565	46088	281604-ANTIDEPRESSANTS	Doxepin	DOXEPIN HCL	CAPSULE	150 MG	COVERED	FORMULARY
16566	46089	281604-ANTIDEPRESSANTS	Doxepin	DOXEPIN HCL	CAPSULE	25 MG	COVERED	FORMULARY
16567	46090	281604-ANTIDEPRESSANTS	Doxepin	DOXEPIN HCL	CAPSULE	50 MG	COVERED	FORMULARY
16568	46091	281604-ANTIDEPRESSANTS	Doxepin	DOXEPIN HCL	CAPSULE	75 MG	COVERED	FORMULARY
23161	57891	281604-ANTIDEPRESSANTS	Cymbalta	DULOXETINE HCL	CAPSULE DR	20 MG	COVERED	FORMULARY
23162	57892	281604-ANTIDEPRESSANTS	Cymbalta	DULOXETINE HCL	CAPSULE DR	30 MG	COVERED	FORMULARY
23164	57893	281604-ANTIDEPRESSANTS	Cymbalta	DULOXETINE HCL	CAPSULE DR	60 MG	COVERED	FORMULARY
38728	74166	281604-ANTIDEPRESSANTS	Cymbalta	DULOXETINE HCL	CAPSULE DR	40 MG	COVERED	FORMULARY
19035	51698	281604-ANTIDEPRESSANTS	Lexapro Solution	ESCITALOPRAM OXALATE	SOLUTION	5 MG/5ML	COVERED	FORMULARY	Max 20mg/day
17851	50712	281604-ANTIDEPRESSANTS	Lexapro	ESCITALOPRAM OXALATE	TABLET	10 MG	COVERED	FORMULARY	Max 20mg/day
17987	50760	281604-ANTIDEPRESSANTS	Lexapro	ESCITALOPRAM OXALATE	TABLET	20 MG	COVERED	FORMULARY	Max 20mg/day
18975	51642	281604-ANTIDEPRESSANTS	Lexapro	ESCITALOPRAM OXALATE	TABLET	5 MG	COVERED	FORMULARY	Max 20mg/day
16353	46213	281604-ANTIDEPRESSANTS	Prozac	FLUOXETINE HCL	CAPSULE	10 MG	COVERED	FORMULARY
16354	46214	281604-ANTIDEPRESSANTS	Prozac	FLUOXETINE HCL	CAPSULE	20 MG	COVERED	FORMULARY
16355	46215	281604-ANTIDEPRESSANTS	Prozac	FLUOXETINE HCL	CAPSULE	40 MG	COVERED	FORMULARY
16348	46209	281604-ANTIDEPRESSANTS	Fluvoxamine	FLUVOXAMINE MALEATE	TABLET	50 MG	COVERED	FORMULARY
16349	46210	281604-ANTIDEPRESSANTS	Fluvoxamine	FLUVOXAMINE MALEATE	TABLET	100 MG	COVERED	FORMULARY
16541	46068	281604-ANTIDEPRESSANTS	Tofranil	IMIPRAMINE HCL	TABLET	10 MG	COVERED	FORMULARY
16542	46069	281604-ANTIDEPRESSANTS	Tofranil	IMIPRAMINE HCL	TABLET	25 MG	COVERED	FORMULARY
16543	46070	281604-ANTIDEPRESSANTS	Tofranil	IMIPRAMINE HCL	TABLET	50 MG	COVERED	FORMULARY
16732	46450	281604-ANTIDEPRESSANTS	Remeron	MIRTAZAPINE	TABLET	15 MG	COVERED	FORMULARY
16733	46451	281604-ANTIDEPRESSANTS	Remeron	MIRTAZAPINE	TABLET	30 MG	COVERED	FORMULARY
16734	46452	281604-ANTIDEPRESSANTS	Remeron	MIRTAZAPINE	TABLET	45 MG	COVERED	FORMULARY
16529	46059	281604-ANTIDEPRESSANTS	Pamelor	NORTRIPTYLINE HCL	CAPSULE	10 MG	COVERED	FORMULARY
16532	46060	281604-ANTIDEPRESSANTS	Pamelor	NORTRIPTYLINE HCL	CAPSULE	25 MG	COVERED	FORMULARY
16533	46061	281604-ANTIDEPRESSANTS	Pamelor	NORTRIPTYLINE HCL	CAPSULE	50 MG	COVERED	FORMULARY
16534	46062	281604-ANTIDEPRESSANTS	Pamelor	NORTRIPTYLINE HCL	CAPSULE	75 MG	COVERED	FORMULARY
17077	50136	281604-ANTIDEPRESSANTS	Paxil CR	PAROXETINE HCL	TAB ER 24H	25 MG	COVERED	FORMULARY
17078	50137	281604-ANTIDEPRESSANTS	Paxil CR	PAROXETINE HCL	TAB ER 24H	12.5 MG	COVERED	FORMULARY
17079	50138	281604-ANTIDEPRESSANTS	Paxil CR	PAROXETINE HCL	TAB ER 24H	37.5 MG	COVERED	FORMULARY
16364	46222	281604-ANTIDEPRESSANTS	Paxil	PAROXETINE HCL	TABLET	10 MG	COVERED	FORMULARY
16366	46223	281604-ANTIDEPRESSANTS	Paxil	PAROXETINE HCL	TABLET	20 MG	COVERED	FORMULARY
16367	46224	281604-ANTIDEPRESSANTS	Paxil	PAROXETINE HCL	TABLET	30 MG	COVERED	FORMULARY
16368	46225	281604-ANTIDEPRESSANTS	Paxil	PAROXETINE HCL	TABLET	40 MG	COVERED	FORMULARY
16373	46227	281604-ANTIDEPRESSANTS	Zoloft	SERTRALINE HCL	TABLET	25 MG	COVERED	FORMULARY
16374	46228	281604-ANTIDEPRESSANTS	Zoloft	SERTRALINE HCL	TABLET	50 MG	COVERED	FORMULARY
16375	46229	281604-ANTIDEPRESSANTS	Zoloft	SERTRALINE HCL	TABLET	100 MG	COVERED	FORMULARY
16391	46241	281604-ANTIDEPRESSANTS	Trazodone	TRAZODONE HCL	TABLET	50 MG	COVERED	FORMULARY
16392	46242	281604-ANTIDEPRESSANTS	Trazodone	TRAZODONE HCL	TABLET	100 MG	COVERED	FORMULARY
16393	46243	281604-ANTIDEPRESSANTS	Trazodone	TRAZODONE HCL	TABLET	150 MG	COVERED	FORMULARY
16394	46244	281604-ANTIDEPRESSANTS	Trazodone	TRAZODONE HCL	TABLET	300 MG	COVERED	FORMULARY
16816	46403	281604-ANTIDEPRESSANTS	Effexor XR	VENLAFAXINE HCL	CAP ER 24H	37.5 MG	COVERED	FORMULARY
16817	46404	281604-ANTIDEPRESSANTS	Effexor XR	VENLAFAXINE HCL	CAP ER 24H	75 MG	COVERED	FORMULARY
16818	46405	281604-ANTIDEPRESSANTS	Effexor XR	VENLAFAXINE HCL	CAP ER 24H	150 MG	COVERED	FORMULARY
16811	46398	281604-ANTIDEPRESSANTS	Venlafaxine	VENLAFAXINE HCL	TABLET	25 MG	COVERED	FORMULARY
16812	46399	281604-ANTIDEPRESSANTS	Venlafaxine	VENLAFAXINE HCL	TABLET	37.5 MG	COVERED	FORMULARY
16813	46400	281604-ANTIDEPRESSANTS	Venlafaxine	VENLAFAXINE HCL	TABLET	50 MG	COVERED	FORMULARY
16814	46401	281604-ANTIDEPRESSANTS	Venlafaxine	VENLAFAXINE HCL	TABLET	75 MG	COVERED	FORMULARY
16815	46402	281604-ANTIDEPRESSANTS	Venlafaxine	VENLAFAXINE HCL	TABLET	100 MG	COVERED	FORMULARY
14431	3796	281608-ANTIPSYCHOTIC AGENTS	Chlorpromazine	CHLORPROMAZINE HCL	TABLET	10 MG	COVERED	FORMULARY
14432	3799	281608-ANTIPSYCHOTIC AGENTS	Chlorpromazine	CHLORPROMAZINE HCL	TABLET	25 MG	COVERED	FORMULARY
14433	3800	281608-ANTIPSYCHOTIC AGENTS	Chlorpromazine	CHLORPROMAZINE HCL	TABLET	50 MG	COVERED	FORMULARY
14434	3797	281608-ANTIPSYCHOTIC AGENTS	Chlorpromazine	CHLORPROMAZINE HCL	TABLET	100 MG	COVERED	FORMULARY
14435	3798	281608-ANTIPSYCHOTIC AGENTS	Chlorpromazine	CHLORPROMAZINE HCL	TABLET	200 MG	COVERED	FORMULARY
14602	3823	281608-ANTIPSYCHOTIC AGENTS	Fluphenazine	FLUPHENAZINE HCL	TABLET	1 MG	COVERED	FORMULARY
14603	3824	281608-ANTIPSYCHOTIC AGENTS	Fluphenazine	FLUPHENAZINE HCL	TABLET	10 MG	COVERED	FORMULARY
14604	3825	281608-ANTIPSYCHOTIC AGENTS	Fluphenazine	FLUPHENAZINE HCL	TABLET	2.5 MG	COVERED	FORMULARY
14605	3826	281608-ANTIPSYCHOTIC AGENTS	Fluphenazine	FLUPHENAZINE HCL	TABLET	5 MG	COVERED	FORMULARY
15530	3972	281608-ANTIPSYCHOTIC AGENTS	Haloperidol	HALOPERIDOL	TABLET	0.5 MG	COVERED	FORMULARY
15531	3973	281608-ANTIPSYCHOTIC AGENTS	Haloperidol	HALOPERIDOL	TABLET	1 MG	COVERED	FORMULARY
15532	3974	281608-ANTIPSYCHOTIC AGENTS	Haloperidol	HALOPERIDOL	TABLET	10 MG	COVERED	FORMULARY
15533	3975	281608-ANTIPSYCHOTIC AGENTS	Haloperidol	HALOPERIDOL	TABLET	2 MG	COVERED	FORMULARY
15534	3976	281608-ANTIPSYCHOTIC AGENTS	Haloperidol	HALOPERIDOL	TABLET	20 MG	COVERED	FORMULARY
15535	3977	281608-ANTIPSYCHOTIC AGENTS	Haloperidol	HALOPERIDOL	TABLET	5 MG	COVERED	FORMULARY
15520	3971	281608-ANTIPSYCHOTIC AGENTS	Haloperidol	HALOPERIDOL LACTATE	ORAL CONC	2 MG/ML	COVERED	FORMULARY
15560	3981	281608-ANTIPSYCHOTIC AGENTS	Loxapine	LOXAPINE SUCCINATE	CAPSULE	10 MG	COVERED	FORMULARY
15561	3982	281608-ANTIPSYCHOTIC AGENTS	Loxapine	LOXAPINE SUCCINATE	CAPSULE	25 MG	COVERED	FORMULARY
15563	3984	281608-ANTIPSYCHOTIC AGENTS	Loxapine	LOXAPINE SUCCINATE	CAPSULE	50 MG	COVERED	FORMULARY
15081	27959	281608-ANTIPSYCHOTIC AGENTS	Zyprexa	OLANZAPINE	TABLET	7.5 MG	COVERED	FORMULARY
15082	27960	281608-ANTIPSYCHOTIC AGENTS	Zyprexa	OLANZAPINE	TABLET	10 MG	COVERED	FORMULARY
15083	27961	281608-ANTIPSYCHOTIC AGENTS	Zyprexa	OLANZAPINE	TABLET	5 MG	COVERED	FORMULARY
15084	29077	281608-ANTIPSYCHOTIC AGENTS	Zyprexa	OLANZAPINE	TABLET	2.5 MG	COVERED	FORMULARY
15085	41026	281608-ANTIPSYCHOTIC AGENTS	Zyprexa	OLANZAPINE	TABLET	15 MG	COVERED	FORMULARY
15086	41027	281608-ANTIPSYCHOTIC AGENTS	Zyprexa	OLANZAPINE	TABLET	20 MG	COVERED	FORMULARY
14650	3830	281608-ANTIPSYCHOTIC AGENTS	Perphenazine	PERPHENAZINE	TABLET	16 MG	COVERED	FORMULARY
14651	3831	281608-ANTIPSYCHOTIC AGENTS	Perphenazine	PERPHENAZINE	TABLET	2 MG	COVERED	FORMULARY
14652	3832	281608-ANTIPSYCHOTIC AGENTS	Perphenazine	PERPHENAZINE	TABLET	4 MG	COVERED	FORMULARY
14653	3833	281608-ANTIPSYCHOTIC AGENTS	Perphenazine	PERPHENAZINE	TABLET	8 MG	COVERED	FORMULARY
26409	60292	281608-ANTIPSYCHOTIC AGENTS	Seroquel	QUETIAPINE FUMARATE	TABLET	50 MG	COVERED	FORMULARY	Max 800mg/day
26411	60293	281608-ANTIPSYCHOTIC AGENTS	Seroquel	QUETIAPINE FUMARATE	TABLET	400 MG	COVERED	FORMULARY	Max 800mg/day
67661	34187	281608-ANTIPSYCHOTIC AGENTS	Seroquel	QUETIAPINE FUMARATE	TABLET	25 MG	COVERED	FORMULARY	Max 800mg/day
67662	34188	281608-ANTIPSYCHOTIC AGENTS	Seroquel	QUETIAPINE FUMARATE	TABLET	100 MG	COVERED	FORMULARY	Max 800mg/day
67663	34189	281608-ANTIPSYCHOTIC AGENTS	Seroquel	QUETIAPINE FUMARATE	TABLET	200 MG	COVERED	FORMULARY	Max 800mg/day
67665	47198	281608-ANTIPSYCHOTIC AGENTS	Seroquel	QUETIAPINE FUMARATE	TABLET	300 MG	COVERED	FORMULARY	Max 800mg/day
16135	26177	281608-ANTIPSYCHOTIC AGENTS	Risperdal	RISPERIDONE	SOLUTION	1 MG/ML	COVERED	FORMULARY	Max 16mg/day
16136	21154	281608-ANTIPSYCHOTIC AGENTS	Risperdal	RISPERIDONE	TABLET	1 MG	COVERED	FORMULARY	Max 16mg/day
16137	21155	281608-ANTIPSYCHOTIC AGENTS	Risperdal	RISPERIDONE	TABLET	2 MG	COVERED	FORMULARY	Max 16mg/day
16138	21156	281608-ANTIPSYCHOTIC AGENTS	Risperdal	RISPERIDONE	TABLET	3 MG	COVERED	FORMULARY	Max 16mg/day
16139	21157	281608-ANTIPSYCHOTIC AGENTS	Risperdal	RISPERIDONE	TABLET	4 MG	COVERED	FORMULARY	Max 16mg/day
92872	42922	281608-ANTIPSYCHOTIC AGENTS	Risperdal	RISPERIDONE	TABLET	0.25 MG	COVERED	FORMULARY	Max 16mg/day
92892	42923	281608-ANTIPSYCHOTIC AGENTS	Risperdal	RISPERIDONE	TABLET	0.5 MG	COVERED	FORMULARY	Max 16mg/day
15691	3996	281608-ANTIPSYCHOTIC AGENTS	Thiothixene	THIOTHIXENE	CAPSULE	10 MG	COVERED	FORMULARY
15692	3997	281608-ANTIPSYCHOTIC AGENTS	Thiothixene	THIOTHIXENE	CAPSULE	2 MG	COVERED	FORMULARY
15694	3999	281608-ANTIPSYCHOTIC AGENTS	Thiothixene	THIOTHIXENE	CAPSULE	5 MG	COVERED	FORMULARY
19880	5009	282004-AMPHETAMINES	Zenzedi	DEXTROAMPHETAMINE SULFATE	TABLET	10 MG	COVERED	FORMULARY	Max 60mg/day
19881	5011	282004-AMPHETAMINES	Zenzedi	DEXTROAMPHETAMINE SULFATE	TABLET	5 MG	COVERED	FORMULARY	Max 60mg/day
14635	48701	282004-AMPHETAMINES	Adderall XR	DEXTROAMPHETAMINE-AMPHETAMINE	CAP ER 24H	10 MG	COVERED	FORMULARY	Max 60mg/day
14636	48702	282004-AMPHETAMINES	Adderall XR	DEXTROAMPHETAMINE-AMPHETAMINE	CAP ER 24H	20 MG	COVERED	FORMULARY	Max 60mg/day
14637	48703	282004-AMPHETAMINES	Adderall XR	DEXTROAMPHETAMINE-AMPHETAMINE	CAP ER 24H	30 MG	COVERED	FORMULARY	Max 60mg/day
17459	50428	282004-AMPHETAMINES	Adderall XR	DEXTROAMPHETAMINE-AMPHETAMINE	CAP ER 24H	5 MG	COVERED	FORMULARY	Max 60mg/day
17468	50429	282004-AMPHETAMINES	Adderall XR	DEXTROAMPHETAMINE-AMPHETAMINE	CAP ER 24H	15 MG	COVERED	FORMULARY	Max 60mg/day
17469	50430	282004-AMPHETAMINES	Adderall XR	DEXTROAMPHETAMINE-AMPHETAMINE	CAP ER 24H	25 MG	COVERED	FORMULARY	Max 60mg/day
29007	47131	282004-AMPHETAMINES	Adderall	DEXTROAMPHETAMINE-AMPHETAMINE	TABLET	7.5 MG	COVERED	FORMULARY	Max 60mg/day
29008	47132	282004-AMPHETAMINES	Adderall	DEXTROAMPHETAMINE-AMPHETAMINE	TABLET	12.5 MG	COVERED	FORMULARY	Max 60mg/day
29009	47133	282004-AMPHETAMINES	Adderall	DEXTROAMPHETAMINE-AMPHETAMINE	TABLET	15 MG	COVERED	FORMULARY	Max 60mg/day
56970	4999	282004-AMPHETAMINES	Adderall	DEXTROAMPHETAMINE-AMPHETAMINE	TABLET	5 MG	COVERED	FORMULARY	Max 60mg/day
56971	5000	282004-AMPHETAMINES	Adderall	DEXTROAMPHETAMINE-AMPHETAMINE	TABLET	10 MG	COVERED	FORMULARY	Max 60mg/day
56972	34359	282004-AMPHETAMINES	Adderall	DEXTROAMPHETAMINE-AMPHETAMINE	TABLET	30 MG	COVERED	FORMULARY	Max 60mg/day
56973	5001	282004-AMPHETAMINES	Adderall	DEXTROAMPHETAMINE-AMPHETAMINE	TABLET	20 MG	COVERED	FORMULARY	Max 60mg/day
20384	53056	282032-RESPIRATORY AND CNS STIMULANTS	Metadate CD	METHYLPHENIDATE HCL	CPBP 30-70	10 MG	COVERED	FORMULARY	Max 100mg/day
20385	53057	282032-RESPIRATORY AND CNS STIMULANTS	Metadate CD	METHYLPHENIDATE HCL	CPBP 30-70	20 MG	COVERED	FORMULARY	Max 100mg/day
20386	53058	282032-RESPIRATORY AND CNS STIMULANTS	Metadate CD	METHYLPHENIDATE HCL	CPBP 30-70	30 MG	COVERED	FORMULARY	Max 100mg/day
26734	60545	282032-RESPIRATORY AND CNS STIMULANTS	Metadate CD	METHYLPHENIDATE HCL	CPBP 30-70	40 MG	COVERED	FORMULARY	Max 100mg/day
26735	60546	282032-RESPIRATORY AND CNS STIMULANTS	Metadate CD	METHYLPHENIDATE HCL	CPBP 30-70	50 MG	COVERED	FORMULARY	Max 100mg/day
26736	60547	282032-RESPIRATORY AND CNS STIMULANTS	Metadate CD	METHYLPHENIDATE HCL	CPBP 30-70	60 MG	COVERED	FORMULARY	Max 100mg/day
20387	53059	282032-RESPIRATORY AND CNS STIMULANTS	Ritalin LA	METHYLPHENIDATE HCL	CPBP 50-50	20 MG	COVERED	FORMULARY	Max 100mg/day
20388	53060	282032-RESPIRATORY AND CNS STIMULANTS	Ritalin LA	METHYLPHENIDATE HCL	CPBP 50-50	30 MG	COVERED	FORMULARY	Max 100mg/day
20391	53061	282032-RESPIRATORY AND CNS STIMULANTS	Ritalin LA	METHYLPHENIDATE HCL	CPBP 50-50	40 MG	COVERED	FORMULARY	Max 100mg/day
15911	4026	282032-RESPIRATORY AND CNS STIMULANTS	Ritalin	METHYLPHENIDATE HCL	TABLET	10 MG	COVERED	FORMULARY	Max 100mg/day
15913	4028	282032-RESPIRATORY AND CNS STIMULANTS	Ritalin	METHYLPHENIDATE HCL	TABLET	5 MG	COVERED	FORMULARY	Max 100mg/day
15920	4027	282032-RESPIRATORY AND CNS STIMULANTS	Ritalin	METHYLPHENIDATE HCL	TABLET	20 MG	COVERED	FORMULARY	Max 100mg/day
16180	4029	282032-RESPIRATORY AND CNS STIMULANTS	Methylphenidate ER	METHYLPHENIDATE HCL	TABLET ER	20 MG	COVERED	FORMULARY	Max 100mg/day
93075	44072	282032-RESPIRATORY AND CNS STIMULANTS	Methylphenidate ER	METHYLPHENIDATE HCL	TABLET ER	10 MG	COVERED	FORMULARY	Max 100mg/day
12956	3586	282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)	Phenobarbital	PHENOBARBITAL	ELIXIR	20 MG/5 ML	COVERED	FORMULARY
12971	3589	282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)	Phenobarbital	PHENOBARBITAL	TABLET	15 MG	COVERED	FORMULARY
12972	3591	282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)	Phenobarbital	PHENOBARBITAL	TABLET	60 MG	COVERED	FORMULARY
12973	3590	282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)	Phenobarbital	PHENOBARBITAL	TABLET	30 MG	COVERED	FORMULARY
12975	3588	282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)	Phenobarbital	PHENOBARBITAL	TABLET	100 MG	COVERED	FORMULARY
97965	27611	282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)	Phenobarbital	PHENOBARBITAL	TABLET	32.4 MG	COVERED	FORMULARY
97966	27612	282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)	Phenobarbital	PHENOBARBITAL	TABLET	64.8 MG	COVERED	FORMULARY
14260	3773	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Xanax	ALPRAZOLAM	TABLET	0.25 MG	COVERED	FORMULARY
14261	3774	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Xanax	ALPRAZOLAM	TABLET	0.5 MG	COVERED	FORMULARY
14262	3775	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Xanax	ALPRAZOLAM	TABLET	1 MG	COVERED	FORMULARY
14263	15566	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Xanax	ALPRAZOLAM	TABLET	2 MG	COVERED	FORMULARY
14031	3734	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Chlordiazepoxide	CHLORDIAZEPOXIDE HCL	CAPSULE	10 MG	COVERED	FORMULARY
14032	3735	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Chlordiazepoxide	CHLORDIAZEPOXIDE HCL	CAPSULE	25 MG	COVERED	FORMULARY
14090	3744	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Tranxene	CLORAZEPATE DIPOTASSIUM	TABLET	15 MG	COVERED	FORMULARY
14092	3745	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Tranxene	CLORAZEPATE DIPOTASSIUM	TABLET	3.75 MG	COVERED	FORMULARY
14093	3746	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Tranxene	CLORAZEPATE DIPOTASSIUM	TABLET	7.5 MG	COVERED	FORMULARY
14220	3766	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Valium	DIAZEPAM	TABLET	10 MG	COVERED	FORMULARY
14221	3767	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Valium	DIAZEPAM	TABLET	2 MG	COVERED	FORMULARY
14222	3768	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Valium	DIAZEPAM	TABLET	5 MG	COVERED	FORMULARY
14250	3691	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Flurazepam	FLURAZEPAM HCL	CAPSULE	15 MG	COVERED	FORMULARY
14251	3692	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Flurazepam	FLURAZEPAM HCL	CAPSULE	30 MG	COVERED	FORMULARY
14160	3757	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Ativan	LORAZEPAM	TABLET	0.5 MG	COVERED	FORMULARY
14161	3758	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Ativan	LORAZEPAM	TABLET	1 MG	COVERED	FORMULARY
14162	3759	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Ativan	LORAZEPAM	TABLET	2 MG	COVERED	FORMULARY
14230	3769	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Oxazepam	OXAZEPAM	CAPSULE	10 MG	COVERED	FORMULARY
14231	3770	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Oxazepam	OXAZEPAM	CAPSULE	15 MG	COVERED	FORMULARY
14232	3771	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Oxazepam	OXAZEPAM	CAPSULE	30 MG	COVERED	FORMULARY
13840	3689	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Restoril	TEMAZEPAM	CAPSULE	15 MG	COVERED	FORMULARY
13841	3690	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Restoril	TEMAZEPAM	CAPSULE	30 MG	COVERED	FORMULARY
13845	19182	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Restoril	TEMAZEPAM	CAPSULE	7.5 MG	COVERED	FORMULARY
13037	47644	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Buspar	BUSPIRONE HCL	TABLET	7.5 MG	COVERED	FORMULARY
28890	3782	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Buspar	BUSPIRONE HCL	TABLET	5 MG	COVERED	FORMULARY
28891	3781	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Buspar	BUSPIRONE HCL	TABLET	10 MG	COVERED	FORMULARY
28892	27378	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Buspar	BUSPIRONE HCL	TABLET	15 MG	COVERED	FORMULARY
92121	44210	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Buspar	BUSPIRONE HCL	TABLET	30 MG	COVERED	FORMULARY
13932	3725	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Hydroxyzine	HYDROXYZINE HCL	SOLUTION	10 MG/5ML	COVERED	FORMULARY
13941	3726	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Hydroxyzine	HYDROXYZINE HCL	TABLET	10 MG	COVERED	FORMULARY
13943	3728	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Hydroxyzine	HYDROXYZINE HCL	TABLET	25 MG	COVERED	FORMULARY
13944	3729	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Hydroxyzine	HYDROXYZINE HCL	TABLET	50 MG	COVERED	FORMULARY
13951	3730	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Vistaril	HYDROXYZINE PAMOATE	CAPSULE	100 MG	COVERED	FORMULARY
13952	3731	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Vistaril	HYDROXYZINE PAMOATE	CAPSULE	25 MG	COVERED	FORMULARY
13953	3732	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Vistaril	HYDROXYZINE PAMOATE	CAPSULE	50 MG	COVERED	FORMULARY
870	19187	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Ambien	ZOLPIDEM TARTRATE	TABLET	5 MG	COVERED	FORMULARY	Max 10mg/day
871	19188	282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.	Ambien	ZOLPIDEM TARTRATE	TABLET	10 MG	COVERED	FORMULARY	Max 10mg/day
15710	4001	282800-ANTIMANIC AGENTS	Lithium	LITHIUM CARBONATE	CAPSULE	300 MG	COVERED	FORMULARY
15711	4000	282800-ANTIMANIC AGENTS	Lithium	LITHIUM CARBONATE	CAPSULE	150 MG	COVERED	FORMULARY
15721	4003	282800-ANTIMANIC AGENTS	Lithium	LITHIUM CARBONATE	TABLET	300 MG	COVERED	FORMULARY
15730	4005	282800-ANTIMANIC AGENTS	Lithobid	LITHIUM CARBONATE	TABLET ER	450 MG	COVERED	FORMULARY
15731	4004	282800-ANTIMANIC AGENTS	Lithobid	LITHIUM CARBONATE	TABLET ER	300 MG	COVERED	FORMULARY
50740	30735	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex Nasal	SUMATRIPTAN	SPRAY	5 MG	COVERED	FORMULARY	Max 2 boxes/month
50744	30742	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex Nasal	SUMATRIPTAN	SPRAY	20 MG	COVERED	FORMULARY	Max 2 boxes/month
24708	19239	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex Statdose	SUMATRIPTAN SUCCINATE	CARTRIDGE	6 MG/0.5ML	COVERED	FORMULARY	Max 2 boxes/month
50741	19192	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex Statdose	SUMATRIPTAN SUCCINATE	PEN INJCTR	6 MG/0.5ML	COVERED	FORMULARY	Max 2 boxes/month
5700	22479	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex	SUMATRIPTAN SUCCINATE	TABLET	50 MG	COVERED	FORMULARY	Max 9 tablets/month
5701	17129	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex	SUMATRIPTAN SUCCINATE	TABLET	100 MG	COVERED	FORMULARY	Max 9 tablets/month
5702	23799	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex	SUMATRIPTAN SUCCINATE	TABLET	25 MG	COVERED	FORMULARY	Max 9 tablets/month
50742	19193	283228-SELECTIVE SEROTONIN AGONISTS	Imitrex	SUMATRIPTAN SUCCINATE	VIAL	6 MG/0.5ML	COVERED	FORMULARY	Max 2 boxes/month
17520	4575	283604-ADAMANTANES (CNS)	Amantadine	AMANTADINE HCL	CAPSULE	100 MG	COVERED	FORMULARY
17530	4576	283604-ADAMANTANES (CNS)	Amantadine	AMANTADINE HCL	SOLUTION	50 MG/5ML	COVERED	FORMULARY
17521	27637	283604-ADAMANTANES (CNS)	Amantadine	AMANTADINE HCL	TABLET	100 MG	COVERED	FORMULARY
17620	4589	283608-ANTICHOLINERGIC AGENTS (CNS)	Cogentin	BENZTROPINE MESYLATE	TABLET	0.5 MG	COVERED	FORMULARY
17621	4590	283608-ANTICHOLINERGIC AGENTS (CNS)	Cogentin	BENZTROPINE MESYLATE	TABLET	1 MG	COVERED	FORMULARY
17622	4591	283608-ANTICHOLINERGIC AGENTS (CNS)	Cogentin	BENZTROPINE MESYLATE	TABLET	2 MG	COVERED	FORMULARY
17561	4581	283608-ANTICHOLINERGIC AGENTS (CNS)	Trihexyphenidyl	TRIHEXYPHENIDYL HCL	TABLET	2 MG	COVERED	FORMULARY
17563	4582	283608-ANTICHOLINERGIC AGENTS (CNS)	Trihexyphenidyl	TRIHEXYPHENIDYL HCL	TABLET	5 MG	COVERED	FORMULARY
95079	41199	283612-CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.	Comtan	ENTACAPONE	TABLET	200 MG	COVERED	FORMULARY
23285	57987	283616-DOPAMINE PRECURSORS	Carbidopa-Levodopa	CARBIDOPA-LEVODOPA	TAB RAPDIS	10-100 MG	COVERED	FORMULARY
23286	57988	283616-DOPAMINE PRECURSORS	Carbidopa-Levodopa	CARBIDOPA-LEVODOPA	TAB RAPDIS	25-100 MG	COVERED	FORMULARY
23287	57989	283616-DOPAMINE PRECURSORS	Carbidopa-Levodopa	CARBIDOPA-LEVODOPA	TAB RAPDIS	25-250 MG	COVERED	FORMULARY
62740	2537	283616-DOPAMINE PRECURSORS	Sinemet	CARBIDOPA-LEVODOPA	TABLET	10-100 MG	COVERED	FORMULARY
62741	2538	283616-DOPAMINE PRECURSORS	Sinemet	CARBIDOPA-LEVODOPA	TABLET	25-100 MG	COVERED	FORMULARY
62742	2539	283616-DOPAMINE PRECURSORS	Sinemet	CARBIDOPA-LEVODOPA	TABLET	25-250 MG	COVERED	FORMULARY
62591	16043	283616-DOPAMINE PRECURSORS	Sinemet CR	CARBIDOPA-LEVODOPA	TABLET ER	50-200 MG	COVERED	FORMULARY
62592	19563	283616-DOPAMINE PRECURSORS	Sinemet CR	CARBIDOPA-LEVODOPA	TABLET ER	25-100 MG	COVERED	FORMULARY
26070	6603	283620-DOPAMINE RECEPTOR AGONISTS	Parlodel	BROMOCRIPTINE MESYLATE	CAPSULE	5 MG	COVERED	FORMULARY
26081	6604	283620-DOPAMINE RECEPTOR AGONISTS	Parlodel	BROMOCRIPTINE MESYLATE	TABLET	2.5 MG	COVERED	FORMULARY
26051	25738	283620-DOPAMINE RECEPTOR AGONISTS	Cabergoline	CABERGOLINE	TABLET	0.5 MG	COVERED	FORMULARY
19871	31779	283620-DOPAMINE RECEPTOR AGONISTS	Mirapex	PRAMIPEXOLE	TABLET	1 MG	COVERED	FORMULARY
19872	31780	283620-DOPAMINE RECEPTOR AGONISTS	Mirapex	PRAMIPEXOLE	TABLET	1.5 MG	COVERED	FORMULARY
19873	31781	283620-DOPAMINE RECEPTOR AGONISTS	Mirapex	PRAMIPEXOLE	TABLET	0.125 MG	COVERED	FORMULARY
19874	31782	283620-DOPAMINE RECEPTOR AGONISTS	Mirapex	PRAMIPEXOLE	TABLET	0.25 MG	COVERED	FORMULARY
19875	39100	283620-DOPAMINE RECEPTOR AGONISTS	Mirapex	PRAMIPEXOLE	TABLET	0.5 MG	COVERED	FORMULARY
34100	29159	283620-DOPAMINE RECEPTOR AGONISTS	Requip	ROPINIROLE HCL	TABLET	0.25 MG	COVERED	FORMULARY
34101	29160	283620-DOPAMINE RECEPTOR AGONISTS	Requip	ROPINIROLE HCL	TABLET	1 MG	COVERED	FORMULARY
34102	29161	283620-DOPAMINE RECEPTOR AGONISTS	Requip	ROPINIROLE HCL	TABLET	2 MG	COVERED	FORMULARY
34104	34166	283620-DOPAMINE RECEPTOR AGONISTS	Requip	ROPINIROLE HCL	TABLET	0.5 MG	COVERED	FORMULARY
93038	43203	283620-DOPAMINE RECEPTOR AGONISTS	Requip	ROPINIROLE HCL	TABLET	4 MG	COVERED	FORMULARY
93048	43202	283620-DOPAMINE RECEPTOR AGONISTS	Requip	ROPINIROLE HCL	TABLET	3 MG	COVERED	FORMULARY
3253	32492	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Memantine	MEMANTINE HCL	TABLET	10 MG	COVERED	FORMULARY
20773	53324	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Memantine	MEMANTINE HCL	TABLET	5 MG	COVERED	FORMULARY
25200	6373	362600-DIABETES MELLITUS	True Metrix Glucose Test Strip	BLOOD SUGAR DIAGNOSTIC	STRIP		COVERED	FORMULARY
25200	6373	362600-DIABETES MELLITUS	True Metrix Glucose Test Strip	BLOOD SUGAR DIAGNOSTIC	STRIP		COVERED	FORMULARY
25200	6373	362600-DIABETES MELLITUS	True Metrix Test Strips	BLOOD SUGAR DIAGNOSTIC	STRIP		COVERED	FORMULARY
35600	8321	368812-KETONES	Ketocare Test Strip	URINE ACETONE TEST STRIPS	STRIP		COVERED	FORMULARY
35600	8321	368812-KETONES	Ketocare Test Strips	URINE ACETONE TEST STRIPS	STRIP		COVERED	FORMULARY
14950	8250	400800-ALKALINIZING AGENTS	Urocit-K	POTASSIUM CITRATE	TABLET ER	5 MEQ	COVERED	FORMULARY
14951	17000	400800-ALKALINIZING AGENTS	Urocit-K	POTASSIUM CITRATE	TABLET ER	10 MEQ	COVERED	FORMULARY
28095	65955	400800-ALKALINIZING AGENTS	Urocit-K	POTASSIUM CITRATE	TABLET ER	15 MEQ	COVERED	FORMULARY
10160	3143	401000-AMMONIA DETOXICANTS	Lactulose	LACTULOSE	SOLUTION	10 G/15ML	COVERED	FORMULARY
10167	29054	401000-AMMONIA DETOXICANTS	Lactulose	LACTULOSE	SOLUTION	10 G/15ML	COVERED	FORMULARY
30962	68217	401000-AMMONIA DETOXICANTS	Lactulose	LACTULOSE	SOLUTION	20 G/30ML	COVERED	FORMULARY
30994	68243	401000-AMMONIA DETOXICANTS	Lactulose	LACTULOSE	SOLUTION	10 G/15ML	COVERED	FORMULARY
3321	1248	401200-REPLACEMENT PREPARATIONS	Potassium Chloride	POTASSIUM CHLORIDE	CAPSULE ER	10 MEQ	COVERED	FORMULARY
3404	1262	401200-REPLACEMENT PREPARATIONS	Potassium Chloride	POTASSIUM CHLORIDE	PACKET	20 MEQ	COVERED	FORMULARY
3512	22345	401200-REPLACEMENT PREPARATIONS	Potassium Chloride	POTASSIUM CHLORIDE	TAB ER PRT	10 MEQ	COVERED	FORMULARY
3513	22346	401200-REPLACEMENT PREPARATIONS	Potassium Chloride	POTASSIUM CHLORIDE	TAB ER PRT	20 MEQ	COVERED	FORMULARY
3510	1275	401200-REPLACEMENT PREPARATIONS	Potassium Chloride	POTASSIUM CHLORIDE	TABLET ER	10 MEQ	COVERED	FORMULARY
3515	1276	401200-REPLACEMENT PREPARATIONS	Potassium Chloride	POTASSIUM CHLORIDE	TABLET ER	20 MEQ	COVERED	FORMULARY
2373	588	401200-REPLACEMENT PREPARATIONS	Sodium Chloride For Inhalation	SODIUM CHLORIDE FOR INHALATION	VIAL-NEB	3 %	COVERED	FORMULARY
98520	62746	401200-REPLACEMENT PREPARATIONS	Sodium Chloride For Inhalation	SODIUM CHLORIDE FOR INHALATION	VIAL-NEB	7 %	COVERED	FORMULARY
930	1196	401818-POTASSIUM-REMOVING AGENTS	Sodium Polystyrene Sulfonate	SODIUM POLYSTYRENE SULFONATE	ENEMA	30 G/120ML	COVERED	FORMULARY
1710	1195	401818-POTASSIUM-REMOVING AGENTS	Kionex	SODIUM POLYSTYRENE SULFONATE	ORAL SUSP	15 G/60 ML	COVERED	FORMULARY
13675	48241	401819-PHOSPHATE-REMOVING AGENTS	Phoslo	CALCIUM ACETATE	CAPSULE	667 MG	COVERED	FORMULARY
99200	63473	401819-PHOSPHATE-REMOVING AGENTS	Renvela	SEVELAMER CARBONATE	TABLET	800 MG	COVERED	FORMULARY
16853	46485	401819-PHOSPHATE-REMOVING AGENTS	Renagel	SEVELAMER HCL	TABLET	800 MG	COVERED	FORMULARY
21130	21406	402808-LOOP DIURETICS	Demadex	TORSEMIDE	TABLET	5 MG	COVERED	FORMULARY
21131	21407	402808-LOOP DIURETICS	Demadex	TORSEMIDE	TABLET	10 MG	COVERED	FORMULARY
21132	21408	402808-LOOP DIURETICS	Demadex	TORSEMIDE	TABLET	20 MG	COVERED	FORMULARY
21133	21409	402808-LOOP DIURETICS	Demadex	TORSEMIDE	TABLET	100 MG	COVERED	FORMULARY
34950	8206	402808-LOOP DIURETICS	Furosemide	FUROSEMIDE	SOLUTION	10 MG/ML	COVERED	FORMULARY
34961	8208	402808-LOOP DIURETICS	Lasix	FUROSEMIDE	TABLET	20 MG	COVERED	FORMULARY
34962	8209	402808-LOOP DIURETICS	Lasix	FUROSEMIDE	TABLET	40 MG	COVERED	FORMULARY
34963	8210	402808-LOOP DIURETICS	Lasix	FUROSEMIDE	TABLET	80 MG	COVERED	FORMULARY
27700	8227	402816-POTASSIUM-SPARING DIURETICS	Amiloride	AMILORIDE HCL	TABLET	5 MG	COVERED	FORMULARY
82341	8178	402816-POTASSIUM-SPARING DIURETICS	Amiloride-Hydrochlorothiazide	AMILORIDE-HYDROCHLOROTHIAZIDE	TABLET	5-50 MG	COVERED	FORMULARY
88730	8175	402816-POTASSIUM-SPARING DIURETICS	Dyazide	TRIAMTERENE-HYDROCHLOROTHIAZIDE	CAPSULE	50-25 MG	COVERED	FORMULARY
88731	21718	402816-POTASSIUM-SPARING DIURETICS	Dyazide	TRIAMTERENE-HYDROCHLOROTHIAZIDE	CAPSULE	37.5-25 MG	COVERED	FORMULARY
88740	8177	402816-POTASSIUM-SPARING DIURETICS	Triamterene-Hydrochlorothiazide	TRIAMTERENE-HYDROCHLOROTHIAZIDE	TABLET	75-50 MG	COVERED	FORMULARY
88741	8176	402816-POTASSIUM-SPARING DIURETICS	Triamterene-Hydrochlorothiazide	TRIAMTERENE-HYDROCHLOROTHIAZIDE	TABLET	37.5-25 MG	COVERED	FORMULARY
34820	29832	402820-THIAZIDE DIURETICS	Microzide	HYDROCHLOROTHIAZIDE	CAPSULE	12.5 MG	COVERED	FORMULARY
842	28915	402820-THIAZIDE DIURETICS	Hydrochlorothiazide	HYDROCHLOROTHIAZIDE	TABLET	12.5 MG	COVERED	FORMULARY
34824	8182	402820-THIAZIDE DIURETICS	Hydrochlorothiazide	HYDROCHLOROTHIAZIDE	TABLET	25 MG	COVERED	FORMULARY
34825	8183	402820-THIAZIDE DIURETICS	Hydrochlorothiazide	HYDROCHLOROTHIAZIDE	TABLET	50 MG	COVERED	FORMULARY
34982	8213	402824-THIAZIDE-LIKE DIURETICS	Chlorthalidone	CHLORTHALIDONE	TABLET	25 MG	COVERED	FORMULARY
34984	8214	402824-THIAZIDE-LIKE DIURETICS	Chlorthalidone	CHLORTHALIDONE	TABLET	50 MG	COVERED	FORMULARY
7310	8224	402824-THIAZIDE-LIKE DIURETICS	Indapamide	INDAPAMIDE	TABLET	2.5 MG	COVERED	FORMULARY
7311	19412	402824-THIAZIDE-LIKE DIURETICS	Indapamide	INDAPAMIDE	TABLET	1.25 MG	COVERED	FORMULARY
34990	8216	402824-THIAZIDE-LIKE DIURETICS	Metolazone	METOLAZONE	TABLET	10 MG	COVERED	FORMULARY
34991	8217	402824-THIAZIDE-LIKE DIURETICS	Metolazone	METOLAZONE	TABLET	2.5 MG	COVERED	FORMULARY
34992	8218	402824-THIAZIDE-LIKE DIURETICS	Metolazone	METOLAZONE	TABLET	5 MG	COVERED	FORMULARY
35072	8236	404000-URICOSURIC AGENTS	Probenecid	PROBENECID	TABLET	500 MG	COVERED	FORMULARY
29840	4641	480800-ANTITUSSIVES	Tessalon Perles	BENZONATATE	CAPSULE	100 MG	COVERED	FORMULARY
93007	44168	480800-ANTITUSSIVES	Tessalon Perles	BENZONATATE	CAPSULE	200 MG	COVERED	FORMULARY
96136	909	480800-ANTITUSSIVES	Bromfed DM	BROMPHENIRAMINE-PSEUDOEPHEDRINE-DM	SYRUP	2-30-10 MG/5ML	COVERED	FORMULARY
19347	51896	480800-ANTITUSSIVES	Chlorpheniramine-Phenylephrine-Dextromethorphan	CHLORPHENIRAMINE-PHENYLEPHRINE-DM	LIQUID	4-10-15 MG/5ML	COVERED	FORMULARY
91713	45669	480800-ANTITUSSIVES	Cheratussin AC, Virtussin AC, Iophen-C NR	GUAIFENESIN-CODEINE PHOSPHATE	LIQUID	100-10 MG/5ML	COVERED	FORMULARY
34672	70992	480800-ANTITUSSIVES	Guaifenesin AC	GUAIFENESIN-CODEINE PHOSPHATE	LIQUID	100-10 MG/5ML	COVERED	FORMULARY
13974	48492	480800-ANTITUSSIVES	Tussionex ER	HYDROCODONE-CHLORPHENIRAMINE	SUS ER 12H	10-8 MG/5ML	COVERED	FORMULARY
13973	48491	480800-ANTITUSSIVES	Hydrocodone-Homatropine	HYDROCODONE-HOMATROPINE	SYRUP	5-1.5 MG/5ML	COVERED	FORMULARY
96041	846	480800-ANTITUSSIVES	Hydrocodone-Homatropine	HYDROCODONE-HOMATROPINE	TABLET	5-1.5 MG	COVERED	FORMULARY
13975	48493	480800-ANTITUSSIVES	Promethazine-DM	PROMETHAZINE-DEXTROMETHORPHAN	SYRUP	6.25-15 MG/5ML	COVERED	FORMULARY
13978	48496	480800-ANTITUSSIVES	Promethazine VC Codeine	PROMETHAZINE-PHENYLEPHRINE-CODEINE	SYRUP	6.25-5-10 MG/5ML	COVERED	FORMULARY
54670	728	480800-ANTITUSSIVES	Lortuss EX, Cheratussin DAC, Guaifenesin DAC	PSEUDOEPHEDRINE-CODEINE-GUAIFENESIN	SYRUP	30-10-100 MG/5ML	COVERED	FORMULARY
53636	21251	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Flovent HFA	FLUTICASONE PROPIONATE	AER W/ADAP	110 MCG	COVERED	FORMULARY
53638	21253	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Flovent HFA	FLUTICASONE PROPIONATE	AER W/ADAP	44 MCG	COVERED	FORMULARY
53639	21483	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Flovent HFA	FLUTICASONE PROPIONATE	AER W/ADAP	220 MCG	COVERED	FORMULARY
42373	44803	481024-LEUKOTRIENE MODIFIERS	Singulair	MONTELUKAST SODIUM	TAB CHEW	4 MG	COVERED	FORMULARY
94440	37003	481024-LEUKOTRIENE MODIFIERS	Singulair	MONTELUKAST SODIUM	TAB CHEW	5 MG	COVERED	FORMULARY
94444	38451	481024-LEUKOTRIENE MODIFIERS	Singulair	MONTELUKAST SODIUM	TABLET	10 MG	COVERED	FORMULARY
69069	44694	481032-MAST-CELL STABLILIZERS	Cromolyn Ophthalmic	CROMOLYN SODIUM	DROPS	0.04	COVERED	FORMULARY
60544	29893	520200-ANTIALLERGIC AGENTS	Azelastine	AZELASTINE HCL	SPRAY/PUMP	137 MCG	COVERED	FORMULARY
60544	29893	520200-ANTIALLERGIC AGENTS	Astelin Nasal Spray	AZELASTINE HCL	SPRAY/PUMP	137 MCG	COVERED	FORMULARY
68321	30796	520200-ANTIALLERGIC AGENTS	Patanol	OLOPATADINE HCL	DROPS	0.1 %	COVERED	FORMULARY
33641	7990	520404-ANTIBACTERIALS (EENT)	Bacitracin Ophthalmic	BACITRACIN	OINT. (G)	500 UNIT/G	COVERED	FORMULARY
33580	15861	520404-ANTIBACTERIALS (EENT)	Ciloxan	CIPROFLOXACIN HCL	DROPS	0.3 %	COVERED	FORMULARY
9076	38351	520404-ANTIBACTERIALS (EENT)	Ciloxan	CIPROFLOXACIN HCL	OINT. (G)	0.3 %	COVERED	FORMULARY
20188	52911	520404-ANTIBACTERIALS (EENT)	Ciprodex	CIPROFLOXACIN HCL-DEXAMETHASONE	DROPS SUSP	0.3-0.1 %	COVERED	FORMULARY
82031	39806	520404-ANTIBACTERIALS (EENT)	Cipro HC	CIPROFLOXACIN-HYDROCORTISONE	DROPS SUSP	0.2-1 %	COVERED	FORMULARY
13521	48077	520404-ANTIBACTERIALS (EENT)	Doxycyline	DOXYCYCLINE HYCLATE	TABLET	20 MG	COVERED	FORMULARY
33540	7948	520404-ANTIBACTERIALS (EENT)	Ilotycin	ERYTHROMYCIN BASE	OINT. (G)	5 MG/G	COVERED	FORMULARY
33600	7984	520404-ANTIBACTERIALS (EENT)	Gentamicin	GENTAMICIN SULFATE	DROPS	0.3 %	COVERED	FORMULARY
33590	7983	520404-ANTIBACTERIALS (EENT)	Gentamicin	GENTAMICIN SULFATE	OINT. (G)	0.3 %	COVERED	FORMULARY
19542	52050	520404-ANTIBACTERIALS (EENT)	Vigamox	MOXIFLOXACIN HCL	DROPS	0.5 %	COVERED	FORMULARY
62265	18370	520404-ANTIBACTERIALS (EENT)	Bactroban Nasal	MUPIROCIN CALCIUM	OINT. (G)	2 %	COVERED	FORMULARY
14283	48544	520404-ANTIBACTERIALS (EENT)	Neomycin-Bacitracin-Polymyxin Eye Ointment	NEOMYCIN-BACITRACIN-POLYMYXIN B	OINT. (G)	3.5-400-10000 MG/G-UNIT/G-UNIT/G	COVERED	FORMULARY
14279	48543	520404-ANTIBACTERIALS (EENT)	Neomycin-Bacitracin-Polymyxin-HC Eye Ointment	NEOMYCIN-BACITRACIN-POLYMYXIN B-HYDROCORTISONE	OINT. (G)	3.5-400-10000-1 MG/G-UNIT/G-UNIT/G-%	COVERED	FORMULARY
14106	48618	520404-ANTIBACTERIALS (EENT)	Coly-Mycin S, Cortisporin TC	NEOMYCIN-COLISTIN-HYDROCORTISONE-THONZONIUM	DROPS SUSP	3.3-3-10-0.5 MG/ML	COVERED	FORMULARY
14285	48546	520404-ANTIBACTERIALS (EENT)	Neomycin-Polymxyin-Dexamethasone Eye Ointment	NEOMYCIN-POLYMYX B-DEXAMETHASONE	OINT. (G)	3.5-10000-0.1 MG/G-UNIT/G-%	COVERED	FORMULARY
14286	48547	520404-ANTIBACTERIALS (EENT)	Neomycin-Polymxyin-Dexamethasone Eye Drops	NEOMYCIN-POLYMYXIN B-DEXAMETHASONE	DROPS SUSP	3.5-10000-0.1 MG/ML-UNIT/ML-%	COVERED	FORMULARY
87270	7964	520404-ANTIBACTERIALS (EENT)	Neomycin-Polymyxin-HC Eye Drops	NEOMYCIN-POLYMYXIN B-HYDROCORTISONE	DROPS SUSP	3.5-10000-10 MG/ML-UNIT/ML-%	COVERED	FORMULARY
14025	48559	520404-ANTIBACTERIALS (EENT)	Neomycin-Polymyxin-HC Otic Drops	NEOMYCIN-POLYMYXIN B-HYDROCORTISONE	DROPS SUSP	3.5-10000-1 MG/ML-UNIT/ML-%	COVERED	FORMULARY
14023	48557	520404-ANTIBACTERIALS (EENT)	Neomycin-Polymyxin-HC Otic	NEOMYCIN-POLYMYXIN B-HYDROCORTISONE	SOLUTION	3.5-10000-1 MG/ML-UNIT/ML-%	COVERED	FORMULARY
98446	62672	520404-ANTIBACTERIALS (EENT)	Neomycin-Polymyxin-Gramicidin Eye Drops	NEOMYCIN-POLYMYXN B-GRAMICIDIN	DROPS	1.75-10000-0.025 MG/ML-UNIT/ML-MG/ML	COVERED	FORMULARY
13880	48292	520404-ANTIBACTERIALS (EENT)	Ofloxacin	OFLOXACIN	DROPS	0.3 %	COVERED	FORMULARY
36600	19734	520404-ANTIBACTERIALS (EENT)	Ofloxacin	OFLOXACIN	DROPS	0.3 %	COVERED	FORMULARY
33340	7920	520404-ANTIBACTERIALS (EENT)	Bleph-10	SULFACETAMIDE SODIUM	DROPS	10 %	COVERED	FORMULARY
9384	38588	520404-ANTIBACTERIALS (EENT)	Tobrex	TOBRAMYCIN	DROPS	0.3 %	COVERED	FORMULARY
92280	7986	520404-ANTIBACTERIALS (EENT)	Tobradex	TOBRAMYCIN-DEXAMETHASONE	DROPS SUSP	0.3-0.1 %	COVERED	FORMULARY
33500	7942	520420-ANTIVIRALS (EENT)	Viroptic	TRIFLURIDINE	DROPS	1 %	COVERED	FORMULARY
34341	8101	520492-EENT ANTI-INFECTIVES, MISCELLANEOUS	Acetic Acid	ACETIC ACID	SOLUTION	2 %	COVERED	FORMULARY
14017	48554	520492-EENT ANTI-INFECTIVES, MISCELLANEOUS	Acetasol HC	ACETIC ACID-HYDROCORTISONE	DROPS	2-1 %	COVERED	FORMULARY
34280	8079	520808-CORTICOSTEROIDS (EENT)	Flunisolide	FLUNISOLIDE	SPRAY	25 MCG	COVERED	FORMULARY
62263	18368	520808-CORTICOSTEROIDS (EENT)	Flonase	FLUTICASONE PROPIONATE	SPRAY SUSP	50 MCG	COVERED	FORMULARY
95464	39106	520808-CORTICOSTEROIDS (EENT)	Lotemax	LOTEPREDNOL ETABONATE	DROPS SUSP	0.5 %	COVERED	FORMULARY
33153	7894	520808-CORTICOSTEROIDS (EENT)	Omnipred	PREDNISOLONE ACETATE	DROPS SUSP	1 %	COVERED	FORMULARY
33150	7892	520808-CORTICOSTEROIDS (EENT)	Prednisolone Acetate	PREDNISOLONE ACETATE	DROPS SUSP	0.12 %	COVERED	FORMULARY
33181	7897	520808-CORTICOSTEROIDS (EENT)	Prednisolone Sodium Phosphate	PREDNISOLONE SOD PHOSPHATE	DROPS	1 %	COVERED	FORMULARY
33831	16008	520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS	Diclofenac Sodium	DICLOFENAC SODIUM	DROPS	0.1 %	COVERED	FORMULARY
34360	7905	520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS	Ocufen	FLURBIPROFEN SODIUM	DROPS	0.03 %	COVERED	FORMULARY
20255	52960	520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS	Acular	KETOROLAC TROMETHAMINE	DROPS	0.4 %	COVERED	FORMULARY
52700	19067	520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS	Acular	KETOROLAC TROMETHAMINE	DROPS	0.5 %	COVERED	FORMULARY
32952	7866	522400-MYDRIATICS	ATROPINE SULFATE	ATROPINE SULFATE	DROPS	1%	COVERED	FORMULARY
32931	7864	522400-MYDRIATICS	ATROPINE SULFATE	ATROPINE SULFATE	OINT. (G)	1%	COVERED	FORMULARY
33031	7875	522400-MYDRIATICS	Cyclogyl 1%	CYCLOPENTOLATE HCL	DROPS	1 %	COVERED	FORMULARY
33032	7876	522400-MYDRIATICS	Cyclogyl 2%	CYCLOPENTOLATE HCL	DROPS	2 %	COVERED	FORMULARY
36281	27882	524004-ALPHA-ADRENERGIC AGONISTS (EENT)	Alphagan	BRIMONIDINE TARTRATE	DROPS	0.2 %	COVERED	FORMULARY
13752	48333	524004-ALPHA-ADRENERGIC AGONISTS (EENT)	Alphagan-P	BRIMONIDINE TARTRATE	DROPS	0.15 %	COVERED	FORMULARY
33310	7858	524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT)	Betagan	LEVOBUNOLOL HCL	DROPS	0.5 %	COVERED	FORMULARY
32820	7855	524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT)	Timoptic	TIMOLOL MALEATE	DROPS	0.25 %	COVERED	FORMULARY
32821	7856	524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT)	Timoptic	TIMOLOL MALEATE	DROPS	0.5 %	COVERED	FORMULARY
32823	21401	524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT)	Timoptic-XE	TIMOLOL MALEATE	SOL-GEL	0.5 %	COVERED	FORMULARY
34700	8164	524012-CARBONIC ANHYDRASE INHIBITORS (EENT)	Diamox Sequels	ACETAZOLAMIDE	CAPSULE ER	500 MG	COVERED	FORMULARY
34721	8165	524012-CARBONIC ANHYDRASE INHIBITORS (EENT)	Acetazolamide	ACETAZOLAMIDE	TABLET	125 MG	COVERED	FORMULARY
34722	8166	524012-CARBONIC ANHYDRASE INHIBITORS (EENT)	Acetazolamide	ACETAZOLAMIDE	TABLET	250 MG	COVERED	FORMULARY
95773	39498	524012-CARBONIC ANHYDRASE INHIBITORS (EENT)	Azopt	BRINZOLAMIDE	DROPS SUSP	1 %	COVERED	FORMULARY
33380	23513	524012-CARBONIC ANHYDRASE INHIBITORS (EENT)	Trusopt	DORZOLAMIDE HCL	DROPS	2 %	COVERED	FORMULARY
95919	39531	524012-CARBONIC ANHYDRASE INHIBITORS (EENT)	Cosopt	DORZOLAMIDE HCL-TIMOLOL MALEATE	DROPS	22.3-6.8 MG/1ML	COVERED	FORMULARY
32704	7822	524020-MIOTICS	Isopto Carpine	PILOCARPINE HCL	DROPS	1 %	COVERED	FORMULARY
32706	7824	524020-MIOTICS	Isopto Carpine	PILOCARPINE HCL	DROPS	2 %	COVERED	FORMULARY
32752	7826	524020-MIOTICS	Isopto Carpine	PILOCARPINE HCL	DROPS	4 %	COVERED	FORMULARY
32749	27370	524028-PROSTAGLANDIN ANALOGS	Xalatan	LATANOPROST	DROPS	0.005 %	COVERED	FORMULARY
32749	27370	524028-PROSTAGLANDIN ANALOGS	Xalatan	LATANOPROST	DROPS	0.005 %	COVERED	FORMULARY
98379	62605	524028-PROSTAGLANDIN ANALOGS	Travoprost	TRAVOPROST (BENZALKONIUM)	DROPS	0.004%	COVERED	FORMULARY
7855	2661	560400-ANTACIDS AND ADSORBENTS	Sodium Bicarbonate	SODIUM BICARBONATE	TABLET	650 MG	COVERED	FORMULARY
65020	2839	560800-ANTIDIARRHEA AGENTS	Lomotil	DIPHENOXYLATE HCL-ATROPINE	LIQUID	2.5-0.025 MG/5ML	COVERED	FORMULARY
65030	2841	560800-ANTIDIARRHEA AGENTS	Lomotil	DIPHENOXYLATE HCL-ATROPINE	TABLET	2.5-0.025 MG	COVERED	FORMULARY
98433	62659	561200-CATHARTICS AND LAXATIVES	Colyte, Gavilyte	PEG 3350-NA SULF BICARB CL-KCL	SOLN RECON	240-22.72 G	COVERED	FORMULARY
98308	62533	561200-CATHARTICS AND LAXATIVES	Golytely, Gavilyte	PEG 3350-NA SULF BICARB CL-KCL	SOLN RECON	236-22.74 G	COVERED	FORMULARY
86212	41843	561200-CATHARTICS AND LAXATIVES	Clearlax	POLYETHYLENE GLYCOL 3350	POWDER	17 G/DOSE	COVERED	FORMULARY	Restricted to age <19
25865	59931	561200-CATHARTICS AND LAXATIVES	Nulytely Flavor Pack, Gavilyte N, Trilyte	SODIUM CHLORIDE-NAHCO3-KCL-PEG	SOLN RECON	420 G	COVERED	FORMULARY
25865	59931	561200-CATHARTICS AND LAXATIVES	Nulytely, Gavilyte, Trilyte	SODIUM CHLORIDE-NAHCO3-KCL-PEG	SOLN RECON	420 G	COVERED	FORMULARY
1070	3095	561400-CHOLELITHOLYTIC AGENTS	Actigall	URSODIOL	CAPSULE	300 MG	COVERED	FORMULARY
1072	24333	561400-CHOLELITHOLYTIC AGENTS	Urso	URSODIOL	TABLET	250 MG	COVERED	FORMULARY
17730	50628	561400-CHOLELITHOLYTIC AGENTS	Urso Forte	URSODIOL	TABLET	500 MG	COVERED	FORMULARY
26176	65328	561600-DIGESTANTS	Creon	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	6K-19K-30K	NOT COVERED	PAP	Contact manufacturer for PAP
26177	65329	561600-DIGESTANTS	Creon	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	12K-38K-60	NOT COVERED	PAP	Contact manufacturer for PAP
26178	65330	561600-DIGESTANTS	Creon	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	24-76-120K	NOT COVERED	PAP	Contact manufacturer for PAP
30217	67625	561600-DIGESTANTS	Creon	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	3-9.5-15K	NOT COVERED	PAP	Contact manufacturer for PAP
34557	70893	561600-DIGESTANTS	Creon	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	36-114-180	NOT COVERED	PAP	Contact manufacturer for PAP
42317	76625	561600-DIGESTANTS	Pancreaze	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	16.8-56.8K	NOT COVERED	PAP	Contact manufacturer for PAP
42318	76626	561600-DIGESTANTS	Pancreaze	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	21 K-54.7K	NOT COVERED	PAP	Contact manufacturer for PAP
42319	76627	561600-DIGESTANTS	Pancreaze	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	10.5-35.5K	NOT COVERED	PAP	Contact manufacturer for PAP
42324	76628	561600-DIGESTANTS	Pancreaze	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	4.2K-14.2K	NOT COVERED	PAP	Contact manufacturer for PAP
42596	76797	561600-DIGESTANTS	Pancreaze	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	2.6 K-6.2K	NOT COVERED	PAP	Contact manufacturer for PAP
27726	65700	561600-DIGESTANTS	Zenpep	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	5K-17K-27K	NOT COVERED	PAP	Contact manufacturer for PAP
27727	65701	561600-DIGESTANTS	Zenpep	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	10-34-55K	NOT COVERED	PAP	Contact manufacturer for PAP
27728	65702	561600-DIGESTANTS	Zenpep	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	15-51-82K	NOT COVERED	PAP	Contact manufacturer for PAP
27729	65703	561600-DIGESTANTS	Zenpep	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	20-68-109K	NOT COVERED	PAP	Contact manufacturer for PAP
30597	67944	561600-DIGESTANTS	Zenpep	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	3K-10K-16K	NOT COVERED	PAP	Contact manufacturer for PAP
30598	67945	561600-DIGESTANTS	Zenpep	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	25-85-136K	NOT COVERED	PAP	Contact manufacturer for PAP
37592	73217	561600-DIGESTANTS	Zenpep	LIPASE/PROTEASE/AMYLASE	CAPSULE DR	40K-136K	NOT COVERED	PAP	Contact manufacturer for PAP
14761	3844	562208-ANTIHISTAMINES (GI DRUGS)	Prochlorperazine	PROCHLORPERAZINE	SUPP.RECT	25 MG	COVERED	FORMULARY
14771	3846	562208-ANTIHISTAMINES (GI DRUGS)	Prochlorperazine	PROCHLORPERAZINE MALEATE	TABLET	10 MG	COVERED	FORMULARY
14773	3848	562208-ANTIHISTAMINES (GI DRUGS)	Prochlorperazine	PROCHLORPERAZINE MALEATE	TABLET	5 MG	COVERED	FORMULARY
20045	41562	562220-5-HT3 RECEPTOR ANTAGONISTS	Zofran ODT	ONDANSETRON	TAB RAPDIS	4 MG	COVERED	FORMULARY
20046	41563	562220-5-HT3 RECEPTOR ANTAGONISTS	Zofran ODT	ONDANSETRON	TAB RAPDIS	8 MG	COVERED	FORMULARY
20040	28107	562220-5-HT3 RECEPTOR ANTAGONISTS	Zofran	ONDANSETRON HCL	SOLUTION	4 MG/5ML	COVERED	FORMULARY	Restricted to age <19
20041	16392	562220-5-HT3 RECEPTOR ANTAGONISTS	Zofran	ONDANSETRON HCL	TABLET	4 MG	COVERED	FORMULARY
20042	16393	562220-5-HT3 RECEPTOR ANTAGONISTS	Zofran	ONDANSETRON HCL	TABLET	8 MG	COVERED	FORMULARY
45960	11676	562812-HISTAMINE H2-ANTAGONISTS	Pepcid	FAMOTIDINE	ORAL SUSP	40 MG/5ML	COVERED	FORMULARY
46430	11677	562812-HISTAMINE H2-ANTAGONISTS	Pepcid	FAMOTIDINE	TABLET	20 MG	COVERED	FORMULARY
46431	11678	562812-HISTAMINE H2-ANTAGONISTS	Pepcid	FAMOTIDINE	TABLET	40 MG	COVERED	FORMULARY
19551	16223	562812-HISTAMINE H2-ANTAGONISTS	Ranitidine	RANITIDINE HCL	CAPSULE	150 MG	COVERED	FORMULARY
19552	16224	562812-HISTAMINE H2-ANTAGONISTS	Ranitidine	RANITIDINE HCL	CAPSULE	300 MG	COVERED	FORMULARY
12090	11672	562812-HISTAMINE H2-ANTAGONISTS	Ranitidine	RANITIDINE HCL	SYRUP	15 MG/ML	COVERED	FORMULARY
10200	11673	562812-HISTAMINE H2-ANTAGONISTS	Zantac	RANITIDINE HCL	TABLET	150 MG	COVERED	FORMULARY
10201	11674	562812-HISTAMINE H2-ANTAGONISTS	Zantac	RANITIDINE HCL	TABLET	300 MG	COVERED	FORMULARY
8250	2767	562828-PROSTAGLANDINS	Cytotec	MISOPROSTOL	TABLET	200 MCG	COVERED	FORMULARY
8251	15197	562828-PROSTAGLANDINS	Cytotec	MISOPROSTOL	TABLET	100 MCG	COVERED	FORMULARY
7651	16133	562832-PROTECTANTS	Carafate	SUCRALFATE	ORAL SUSP	1 G/10 ML	COVERED	FORMULARY
8200	2766	562832-PROTECTANTS	Carafate	SUCRALFATE	TABLET	1 G	COVERED	FORMULARY
40120	27462	562836-PROTON-PUMP INHIBITORS	Protonix	PANTOPRAZOLE SODIUM	TABLET DR	40 MG	COVERED	FORMULARY
95976	39545	562836-PROTON-PUMP INHIBITORS	Protonix	PANTOPRAZOLE SODIUM	TABLET DR	20 MG	COVERED	FORMULARY
3610	5230	563200-PROKINETIC AGENTS	Metoclopramide	METOCLOPRAMIDE HCL	SOLUTION	5 MG/5ML	COVERED	FORMULARY
34798	71108	563200-PROKINETIC AGENTS	Metoclopramide	METOCLOPRAMIDE HCL	SOLUTION	10 MG/10ML	COVERED	FORMULARY
21020	5231	563200-PROKINETIC AGENTS	Reglan	METOCLOPRAMIDE HCL	TABLET	10 MG	COVERED	FORMULARY
21021	5232	563200-PROKINETIC AGENTS	Reglan	METOCLOPRAMIDE HCL	TABLET	5 MG	COVERED	FORMULARY
27412	6782	680400-ADRENALS	Dexamethasone	DEXAMETHASONE	DROPS	1 MG/ML	COVERED	FORMULARY
27422	6784	680400-ADRENALS	Dexamethasone	DEXAMETHASONE	TABLET	0.5 MG	COVERED	FORMULARY
27424	6787	680400-ADRENALS	Dexamethasone	DEXAMETHASONE	TABLET	1 MG	COVERED	FORMULARY
27425	6785	680400-ADRENALS	Dexamethasone	DEXAMETHASONE	TABLET	0.75 MG	COVERED	FORMULARY
27426	6788	680400-ADRENALS	Dexamethasone	DEXAMETHASONE	TABLET	2 MG	COVERED	FORMULARY
27428	6789	680400-ADRENALS	Dexamethasone	DEXAMETHASONE	TABLET	4 MG	COVERED	FORMULARY
27429	6790	680400-ADRENALS	Dexamethasone	DEXAMETHASONE	TABLET	6 MG	COVERED	FORMULARY
27680	6812	680400-ADRENALS	Fludrocortisone	FLUDROCORTISONE ACETATE	TABLET	0.1 MG	COVERED	FORMULARY
26781	6703	680400-ADRENALS	Cortef	HYDROCORTISONE	TABLET	10 MG	COVERED	FORMULARY
26782	6704	680400-ADRENALS	Cortef	HYDROCORTISONE	TABLET	20 MG	COVERED	FORMULARY
26783	6705	680400-ADRENALS	Cortef	HYDROCORTISONE	TABLET	5 MG	COVERED	FORMULARY
37499	45311	680400-ADRENALS	Medrol Dosepak	METHYLPREDNISOLONE	TAB DS PK	4 MG	COVERED	FORMULARY
27056	6741	680400-ADRENALS	Medrol	METHYLPREDNISOLONE	TABLET	4 MG	COVERED	FORMULARY
26800	6719	680400-ADRENALS	Prednisolone	PREDNISOLONE	SOLUTION	15 MG/5 ML	COVERED	FORMULARY
33806	47282	680400-ADRENALS	Prednisolone Sodium Phosphate	PREDNISOLONE SOD PHOSPHATE	SOLUTION	15 MG/5 ML	COVERED	FORMULARY
38363	45267	680400-ADRENALS	Prednisone	PREDNISONE	TAB DS PK	5 MG	COVERED	FORMULARY
38364	45268	680400-ADRENALS	Prednisone	PREDNISONE	TAB DS PK	10 MG	COVERED	FORMULARY
27171	6748	680400-ADRENALS	Prednisone	PREDNISONE	TABLET	1 MG	COVERED	FORMULARY
27172	6749	680400-ADRENALS	Prednisone	PREDNISONE	TABLET	10 MG	COVERED	FORMULARY
27173	6750	680400-ADRENALS	Prednisone	PREDNISONE	TABLET	2.5 MG	COVERED	FORMULARY
27174	6751	680400-ADRENALS	Prednisone	PREDNISONE	TABLET	20 MG	COVERED	FORMULARY
27176	6753	680400-ADRENALS	Prednisone	PREDNISONE	TABLET	5 MG	COVERED	FORMULARY
27177	6754	680400-ADRENALS	Prednisone	PREDNISONE	TABLET	50 MG	COVERED	FORMULARY
47851	45215	680800-ANDROGENS	Androgel 1%	TESTOSTERONE	GEL PACKET	25 MG(1%)	COVERED	FORMULARY
47852	45216	680800-ANDROGENS	Androgel 1%	TESTOSTERONE	GEL PACKET	50 MG (1%)	COVERED	FORMULARY
18126	50831	681200-CONTRACEPTIVES	Ortho Tri-Cyclen Lo	NORGESTIMATE-ETHINYL ESTRADIOL	TABLET	7DAYSX3 LO	COVERED	FORMULARY
13083	47787	681200-CONTRACEPTIVES	Yasmin	ETHINYL ESTRADIOL-DROSPIRENONE	TABLET	0.03-3 MG	COVERED	FORMULARY
11530	3314	681200-CONTRACEPTIVES	Altavera, Chateal, Kurvelo, Levora, Marlissa, Portia	LEVONORGESTREL-ETHINYL ESTRADIOL	TABLET	0.15-0.03 MG	COVERED	FORMULARY
11534	30986	681200-CONTRACEPTIVES	Aviane, Aubra, Delyla, Falmina, Lessina, Lutera, Orsythia, Sronyx	LEVONORGESTREL-ETHINYL ESTRADIOL	TABLET	0.1-0.02 MG	COVERED	FORMULARY
11531	3315	681200-CONTRACEPTIVES	Enpresse, Trivora, Myzilra	LEVONORGESTREL-ETHINYL ESTRADIOL	TABLET	50-30(6)/75-40(5)/125/30(10) MCG	COVERED	FORMULARY
11520	3313	681200-CONTRACEPTIVES	Ortho Micronor, Errin, Camila, Deblitane, Sharobel, Norlyro, Nor-Be, Jolivette, Jencycla, Heather	NORETHINDRONE	TABLET	0.35 MG	COVERED	FORMULARY
11480	3304	681200-CONTRACEPTIVES	Gildess, Junel, Larin, Loestrin 21 1.5/30	NORETHINDRONE ACETATE-ETHINYL ESTRADIOL	TABLET	1.5-30 MCG	COVERED	FORMULARY
11481	3305	681200-CONTRACEPTIVES	Gildess, Junel, Larin, Loestrin 21 1/20	NORETHINDRONE ACETATE-ETHINYL ESTRADIOL	TABLET	1-20 MCG	COVERED	FORMULARY
11477	3298	681200-CONTRACEPTIVES	Alyacen 7/7/7, Cyclafem 7/7/7, Diasetta 7/7/7, Necon 7/7/7, Nortrel 7/7/7, Ortho-Novum 7/7/7	NORETHINDRONE-ETHINYL ESTRADIOL	TABLET	0.5/0.75/1 MG-35MCG	COVERED	FORMULARY
11474	3295	681200-CONTRACEPTIVES	Alyacen, Cyclafem, Dasetta, Necon 1/35, Nortrel 1/35, Norinyl, Ortho Novum, Primella	NORETHINDRONE-ETHINYL ESTRADIOL	TABLET	1-0.35 MG	COVERED	FORMULARY
11471	3294	681200-CONTRACEPTIVES	Brevicon, Modicone, Necon 0.5/35, Nortrel 0.5/35, Wera	NORETHINDRONE-ETHINYL ESTRADIOL	TABLET	0.5-0.35 MG	COVERED	FORMULARY
68101	3300	681200-CONTRACEPTIVES	Blisovi FE, Gildess FE, Junel FE, Larin FE, Loestrin FE 1.5/30	NORETHINDRONE-ETHINYL ESTRADIOL-IRON	TABLET	1.5MG-30 MCG(21)/75MG(7)	COVERED	FORMULARY
68102	3301	681200-CONTRACEPTIVES	Blisovi FE, Gildess FE, Junel FE, Larin FE, Loestrin FE 1/20	NORETHINDRONE-ETHINYL ESTRADIOL-IRON	TABLET	1 MG-20 MCG(21)/75MG(7)	COVERED	FORMULARY
11300	13662	681200-CONTRACEPTIVES	Estarylla, Mononessa, Ortho-Cyclen, Previfem, Sprintec	NORGESTIMATE-ETHINYL ESTRADIOL	TABLET	0.25-0.035 MG	COVERED	FORMULARY
11301	16963	681200-CONTRACEPTIVES	Tri-Estarylla, Tri-Mononessa, Otrho Tri-Cyclen, Tri-Previfem, Tri-Sprintec	NORGESTIMATE-ETHINYL ESTRADIOL	TABLET	0.18/0.215/0.25 MG-35MCG(28)	COVERED	FORMULARY
11500	3310	681200-CONTRACEPTIVES	Low-Ogestrel, Elinest, Cryselle	NORGESTREL-ETHINYL ESTRADIOL	TABLET	0.3 MG-30MCG	COVERED	FORMULARY
10770	3204	681604-ESTROGENS	Estrace	ESTRADIOL	TABLET	1 MG	COVERED	FORMULARY
10771	3205	681604-ESTROGENS	Estrace	ESTRADIOL	TABLET	2 MG	COVERED	FORMULARY
10772	21411	681604-ESTROGENS	Estrace	ESTRADIOL	TABLET	0.5 MG	COVERED	FORMULARY
19739	52179	681604-ESTROGENS	Prempro	ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE	TABLET	0.45-1.5 MG	COVERED	FORMULARY
20769	53321	681604-ESTROGENS	Prempro	ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE	TABLET	0.3-1.5 MG	COVERED	FORMULARY
55730	22647	681604-ESTROGENS	Prempro	ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE	TABLET	0.625-5 MG	COVERED	FORMULARY
55731	22648	681604-ESTROGENS	Prempro	ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE	TABLET	0.625-2.5 MG	COVERED	FORMULARY
28410	7013	681604-ESTROGENS	Premarin Vaginal	ESTROGENS CONJUGATED	CREAM/APPL	0.625 MG/G	COVERED	FORMULARY
10942	3212	681604-ESTROGENS	Premarin	ESTROGENS CONJUGATED	TABLET	0.625 MG	COVERED	FORMULARY
10943	3211	681604-ESTROGENS	Premarin	ESTROGENS CONJUGATED	TABLET	0.3 MG	COVERED	FORMULARY
10944	3213	681604-ESTROGENS	Premarin	ESTROGENS CONJUGATED	TABLET	0.9 MG	COVERED	FORMULARY
10945	3214	681604-ESTROGENS	Premarin	ESTROGENS CONJUGATED	TABLET	1.25 MG	COVERED	FORMULARY
19975	52766	681604-ESTROGENS	Premarin	ESTROGENS CONJUGATED	TABLET	0.45MG	COVERED	FORMULARY
59011	37022	681612-ESTROGEN AGONIST-ANTAGONISTS	Evista	RALOXIFENE HCL	TABLET	60 MG	COVERED	FORMULARY
19578	52080	682004-BIGUANIDES	Glucophage XR	METFORMIN HCL	TAB ER 24H	750 MG	COVERED	FORMULARY
89863	46754	682004-BIGUANIDES	Glucophage XR	METFORMIN HCL	TAB ER 24H	500 MG	COVERED	FORMULARY
10810	13318	682004-BIGUANIDES	Glucophage	METFORMIN HCL	TABLET	500 MG	COVERED	FORMULARY
10811	16441	682004-BIGUANIDES	Glucophage	METFORMIN HCL	TABLET	850 MG	COVERED	FORMULARY
10857	40974	682004-BIGUANIDES	Glucophage	METFORMIN HCL	TABLET	1000 MG	COVERED	FORMULARY
92336	44341	682008-INSULINS	Novolog Flexpen	INSULIN ASPART	INSULN PEN	100 UNIT/ML	COVERED	FORMULARY
92326	44340	682008-INSULINS	Novolog	INSULIN ASPART	VIAL	100 UNIT/ML	COVERED	FORMULARY
17075	50134	682008-INSULINS	Novolog 70/30 Flexpen	INSULIN ASPART PROTAMINE-INSULIN ASPART	INSULN PEN	70-30 UNIT/ML	COVERED	FORMULARY
19057	51718	682008-INSULINS	Novolog 70/30	INSULIN ASPART PROTAMINE-INSULIN ASPART	VIAL	70-30 UNIT/ML	COVERED	FORMULARY
22836	57439	682008-INSULINS	Levemir FlexTouch	INSULIN DETEMIR	INSULN PEN	100 UNIT/ML	COVERED	FORMULARY
25305	59586	682008-INSULINS	Levemir	INSULIN DETEMIR	VIAL	100 UNIT/ML	COVERED	FORMULARY
96719	34731	682008-INSULINS	Humalog Kwik Pen	INSULIN LISPRO	INSULN PEN	100 UNIT/ML	COVERED	FORMULARY
5679	27413	682008-INSULINS	Humalog	INSULIN LISPRO	VIAL	100 UNIT/ML	COVERED	FORMULARY
11660	1740	682008-INSULINS	Novolin N	INSULIN NPH HUMAN ISOPHANE	VIAL	100 UNIT/ML	COVERED	FORMULARY
50001	16311	682008-INSULINS	Novolin 70/30	INSULIN NPH HUM-REG INSULIN HM	VIAL	70-30 UNIT/ML	COVERED	FORMULARY
93717	42076	682008-INSULINS	Humalog 75/25 Kwik Pen	INSULIN NPL-INSULIN LISPRO	INSULN PEN	75-25 UNIT/ML	COVERED	FORMULARY
22681	47172	682008-INSULINS	Humalog 75/25	INSULIN NPL-INSULIN LISPRO	VIAL	75-25 UNIT/ML	COVERED	FORMULARY
11642	1723	682008-INSULINS	Novolin R	INSULIN REGULAR HUMAN	VIAL	100 UNIT/ML	COVERED	FORMULARY
12277	47333	682016-MEGLITINIDES	Starlix	NATEGLINIDE	TABLET	60 MG	COVERED	FORMULARY
34027	47292	682016-MEGLITINIDES	Starlix	NATEGLINIDE	TABLET	120 MG	COVERED	FORMULARY
5830	25179	682020-SULFONYLUREAS	Amaryl	GLIMEPIRIDE	TABLET	1 MG	COVERED	FORMULARY
5832	25180	682020-SULFONYLUREAS	Amaryl	GLIMEPIRIDE	TABLET	2 MG	COVERED	FORMULARY
5833	25181	682020-SULFONYLUREAS	Amaryl	GLIMEPIRIDE	TABLET	4 MG	COVERED	FORMULARY
10843	21839	682020-SULFONYLUREAS	Glucotrol XL	GLIPIZIDE	TAB ER 24	10 MG	COVERED	FORMULARY
10844	21840	682020-SULFONYLUREAS	Glucotrol XL	GLIPIZIDE	TAB ER 24	5 MG	COVERED	FORMULARY
50638	43463	682020-SULFONYLUREAS	Glucotrol XL	GLIPIZIDE	TAB ER 24	2.5 MG	COVERED	FORMULARY
10840	1777	682020-SULFONYLUREAS	Glucotrol	GLIPIZIDE	TABLET	5 MG	COVERED	FORMULARY
10841	1776	682020-SULFONYLUREAS	Glucotrol	GLIPIZIDE	TABLET	10 MG	COVERED	FORMULARY
18366	51194	682020-SULFONYLUREAS	Glipizide-Metformin	GLIPIZIDE-METFORMIN HCL	TABLET	2.5-250 MG	COVERED	FORMULARY
18367	51195	682020-SULFONYLUREAS	Glipizide-Metformin	GLIPIZIDE-METFORMIN HCL	TABLET	2.5-500 MG	COVERED	FORMULARY
18368	51196	682020-SULFONYLUREAS	Glipizide-Metformin	GLIPIZIDE-METFORMIN HCL	TABLET	5-500 MG	COVERED	FORMULARY
5710	1773	682020-SULFONYLUREAS	Diabeta	GLYBURIDE	TABLET	1.25 MG	COVERED	FORMULARY
5711	1774	682020-SULFONYLUREAS	Diabeta	GLYBURIDE	TABLET	2.5 MG	COVERED	FORMULARY
5712	1775	682020-SULFONYLUREAS	Diabeta	GLYBURIDE	TABLET	5 MG	COVERED	FORMULARY
89878	45929	682020-SULFONYLUREAS	Glucovance	GLYBURIDE-METFORMIN HCL	TABLET	1.25-250 MG	COVERED	FORMULARY
89879	45930	682020-SULFONYLUREAS	Glucovance	GLYBURIDE-METFORMIN HCL	TABLET	5-500 MG	COVERED	FORMULARY
92889	22735	682020-SULFONYLUREAS	Glucovance	GLYBURIDE-METFORMIN HCL	TABLET	2.5-500 MG	COVERED	FORMULARY
92991	42943	682028-THIAZOLIDINEDIONES	Actos	PIOGLITAZONE HCL	TABLET	15 MG	COVERED	FORMULARY
93001	42944	682028-THIAZOLIDINEDIONES	Actos	PIOGLITAZONE HCL	TABLET	30 MG	COVERED	FORMULARY
93011	42945	682028-THIAZOLIDINEDIONES	Actos	PIOGLITAZONE HCL	TABLET	45 MG	COVERED	FORMULARY
25474	41661	682212-GLYCOGENOLYTIC AGENTS	Glucagon	GLUCAGON HUMAN RECOMBINANT	KIT	1 MG	COVERED	FORMULARY
25473	41660	682212-GLYCOGENOLYTIC AGENTS	Glucagen	GLUCAGON HUMAN RECOMBINANT	VIAL	1 MG	COVERED	FORMULARY
23281	24138	682400-PARATHYROID	Miacalcin Nasal	CALCITONIN SALMON SYNTHETIC	SPRAY/PUMP	200 UNIT/SPRAY	COVERED	FORMULARY
26173	31610	682800-PITUITARY	DDAVP Nasal	DESMOPRESSIN (NONREFRIGERATED)	SPRAY/PUMP	10 MCG/SPRAY	COVERED	FORMULARY
26170	6617	682800-PITUITARY	DDAVP	DESMOPRESSIN ACETATE	SOLUTION	0.1 MG/ML	COVERED	FORMULARY
26171	19596	682800-PITUITARY	DDAVP	DESMOPRESSIN ACETATE	TABLET	0.1 MG	COVERED	FORMULARY
26172	19597	682800-PITUITARY	DDAVP	DESMOPRESSIN ACETATE	TABLET	0.2 MG	COVERED	FORMULARY
11260	3271	683200-PROGESTINS	Provera	MEDROXYPROGESTERONE ACETATE	TABLET	10 MG	COVERED	FORMULARY
11261	3272	683200-PROGESTINS	Provera	MEDROXYPROGESTERONE ACETATE	TABLET	2.5 MG	COVERED	FORMULARY
11262	3273	683200-PROGESTINS	Provera	MEDROXYPROGESTERONE ACETATE	TABLET	5 MG	COVERED	FORMULARY
11280	3274	683200-PROGESTINS	Aygestin	NORETHINDRONE ACETATE	TABLET	5 MG	COVERED	FORMULARY
98586	62815	683200-PROGESTINS	Endometrin Vaginal	PROGESTERONE MICRONIZED	INSERT	100 MG	COVERED	FORMULARY
26320	6652	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	112 MCG	COVERED	FORMULARY
26321	6648	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	25 MCG	COVERED	FORMULARY
26322	6649	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	50 MCG	COVERED	FORMULARY
26323	6651	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	100 MCG	COVERED	FORMULARY
26324	6650	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	75 MCG	COVERED	FORMULARY
26325	6656	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	200 MCG	COVERED	FORMULARY
26326	6653	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	125 MCG	COVERED	FORMULARY
26327	6654	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	150 MCG	COVERED	FORMULARY
26328	6655	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	175MCG	COVERED	FORMULARY
26329	6657	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	300 MCG	COVERED	FORMULARY
47631	15523	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	88 MCG	COVERED	FORMULARY
47632	20176	683604-THYROID AGENTS	Levothyroxine	LEVOTHYROXINE SODIUM	TABLET	137 MCG	COVERED	FORMULARY
26340	6658	683604-THYROID AGENTS	Cytomel	LIOTHYRONINE SODIUM	TABLET	25 MCG	COVERED	FORMULARY
26341	6659	683604-THYROID AGENTS	Cytomel	LIOTHYRONINE SODIUM	TABLET	5 MCG	COVERED	FORMULARY
26342	6660	683604-THYROID AGENTS	Cytomel	LIOTHYRONINE SODIUM	TABLET	50 MCG	COVERED	FORMULARY
26400	6674	683608-ANTITHYROID AGENTS	Tapazole	METHIMAZOLE	TABLET	10 MG	COVERED	FORMULARY
26401	6675	683608-ANTITHYROID AGENTS	Tapazole	METHIMAZOLE	TABLET	5 MG	COVERED	FORMULARY
28581	16924	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Cleocin Vaginal	CLINDAMYCIN PHOSPHATE	CREAM/APPL	2 %	COVERED	FORMULARY
45410	7726	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Cleocin T	CLINDAMYCIN PHOSPHATE	GEL (GRAM)	1 %	COVERED	FORMULARY
31770	11752	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Cleocin T	CLINDAMYCIN PHOSPHATE	LOTION	1 %	COVERED	FORMULARY
31720	7727	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Cleocin T	CLINDAMYCIN PHOSPHATE	SOLUTION	1 %	COVERED	FORMULARY
77562	29325	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Erythromycin with Ethanol	ERYTHROMYCIN BASE (WITH ETHANOL)	SOLUTION	2 %	COVERED	FORMULARY
43203	41799	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Metrocream, Rosadan	METRONIDAZOLE	CREAM (G)	0.75 %	COVERED	FORMULARY
24926	59325	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Metrogel	METRONIDAZOLE	GEL (GRAM)	1 %	COVERED	FORMULARY
43202	41798	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Rosadan	METRONIDAZOLE	GEL (GRAM)	0.75 %	COVERED	FORMULARY
49261	16939	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Metrogel Vaginal	METRONIDAZOLE	GEL W/APPL	0.75 %	COVERED	FORMULARY
31774	68879	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Metrogel Pump	METRONIDAZOLE	GEL W/PUMP	1 %	COVERED	FORMULARY
43201	41797	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Metrolotion	METRONIDAZOLE	LOTION	0.75 %	COVERED	FORMULARY
47450	7732	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Bactroban	MUPIROCIN	OINT. (G)	2 %	COVERED	FORMULARY
85459	7694	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Triple Antibiotic Ointment	NEOMYCIN-BACITRACIN-POLYMYXIN B	OINT. (G)	3.5-400-5000 MG/G-UNIT/G-UNIT/G	COVERED	FORMULARY
14274	48538	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Cortisporin	NEOMYCIN-BACITRACIN-POLYMYXIN B-HYDROCORTISONE	OINT. (G)	3.5-400-10000-1 MG/G-UNIT/G-UNIT/G-%	COVERED	FORMULARY
14275	48539	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Cortisporin	NEOMYCIN-POLYMYXIN B-HYDROCORTISONE	CREAM (G)	3.5-10000-0.50 MG/G-UNIT/G-%	COVERED	FORMULARY
62420	18315	840406-ANTIVIRALS (SKIN & MUCOUS MEMBRANE)	Zovirax	ACYCLOVIR	CREAM (G)	5 %	COVERED	FORMULARY
31640	7670	840406-ANTIVIRALS (SKIN & MUCOUS MEMBRANE)	Zovirax	ACYCLOVIR	OINT. (G)	5 %	COVERED	FORMULARY
12618	44922	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Ciclopirox	CICLOPIROX	GEL (GRAM)	0.77 %	COVERED	FORMULARY
19218	51825	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Loprox Shampoo	CICLOPIROX	SHAMPOO	1 %	COVERED	FORMULARY
8040	37020	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Ciclodan, Penlac	CICLOPIROX	SOLUTION	8 %	COVERED	FORMULARY
94677	40971	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Ciclopirox Olamine	CICLOPIROX OLAMINE	CREAM (G)	0.77 %	COVERED	FORMULARY
30380	7362	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Clotrimazole	CLOTRIMAZOLE	SOLUTION	1 %	COVERED	FORMULARY
7590	9553	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Mycelex	CLOTRIMAZOLE	TROCHE	10 MG	COVERED	FORMULARY
6919	36534	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Lotrisone	CLOTRIMAZOLE-BETAMETHASONE DIPROPIONATE	CREAM (G)	1-0.05 %	COVERED	FORMULARY
14125	48627	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Clotrimazole-Betamethasone	CLOTRIMAZOLE-BETAMETHASONE DIPROPIONATE	LOTION	1-0.05 %	COVERED	FORMULARY
31850	7334	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Ketoconazole	KETOCONAZOLE	CREAM (G)	2 %	COVERED	FORMULARY
31271	15568	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Nizoral Shampoo	KETOCONAZOLE	SHAMPOO	2 %	COVERED	FORMULARY
30140	7282	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Nystatin	NYSTATIN	CREAM (G)	100000 UNIT/G	COVERED	FORMULARY
30150	7283	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Nystatin	NYSTATIN	OINT. (G)	100000 UNIT/G	COVERED	FORMULARY
30160	7284	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Nystatin	NYSTATIN	POWDER	100000 UNIT/G	COVERED	FORMULARY
14007	48529	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Nystatin/Triamcinolone	NYSTATIN-TRIAMCINCINOLONE	CREAM (G)	100000-0.1 UNIT/G-%	COVERED	FORMULARY
14008	48530	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Nystatin/Triamcinolone	NYSTATIN-TRIAMCINCINOLONE	OINT. (G)	100000-0.1 UNIT/G-%	COVERED	FORMULARY
48381	15931	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Terazol 3	TERCONAZOLE	CREAM/APPL	0.8 %	COVERED	FORMULARY
48380	7008	840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)	Terazol 7	TERCONAZOLE	CREAM/APPL	0.4 %	COVERED	FORMULARY
31550	7650	840412-SCABICIDES AND PEDICULICIDES	Lindane	LINDANE	LOTION	1 %	COVERED	FORMULARY
31570	7651	840412-SCABICIDES AND PEDICULICIDES	Lindane	LINDANE	SHAMPOO	1 %	COVERED	FORMULARY
44370	13631	840412-SCABICIDES AND PEDICULICIDES	Elimite	PERMETHRIN	CREAM (G)	5 %	COVERED	FORMULARY
44520	7663	840412-SCABICIDES AND PEDICULICIDES	Nix	PERMETHRIN	LIQUID	1 %	COVERED	FORMULARY
31630	7669	840492-LOCAL ANTI-INFECTIVES, MISCELLANEOUS	Silvadene	SILVER SULFADIAZINE	CREAM (G)	1 %	COVERED	FORMULARY
31060	7568	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Betamethasone Diproprionate	BETAMETHASONE DIPROPIONATE	CREAM (G)	0.05 %	COVERED	FORMULARY
31080	7570	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Betamethasone Diproprionate	BETAMETHASONE DIPROPIONATE	LOTION	0.05 %	COVERED	FORMULARY
31070	7569	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Betamethasone Diproprionate	BETAMETHASONE DIPROPIONATE	OINT. (G)	0.05 %	COVERED	FORMULARY
31101	7572	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Betamethasone Valerate	BETAMETHASONE VALERATE	CREAM (G)	0.1 %	COVERED	FORMULARY
31120	7574	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Betamethasone Valerate	BETAMETHASONE VALERATE	LOTION	0.1 %	COVERED	FORMULARY
31110	7573	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Betamethasone Valerate	BETAMETHASONE VALERATE	OINT. (G)	0.1 %	COVERED	FORMULARY
31890	7561	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Diprolene AF	BETAMETHASONE-PROPYLENE GLYCOL	CREAM (G)	0.05 %	COVERED	FORMULARY
31910	7562	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Diprolene	BETAMETHASONE-PROPYLENE GLYCOL	OINT. (G)	0.05 %	COVERED	FORMULARY
32140	7634	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Temovate	CLOBETASOL PROPIONATE	CREAM (G)	0.05 %	COVERED	FORMULARY
34040	18288	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Clobex	CLOBETASOL PROPIONATE	LOTION	0.05 %	COVERED	FORMULARY
32130	7635	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Temovate	CLOBETASOL PROPIONATE	OINT. (G)	0.05 %	COVERED	FORMULARY
15891	15349	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Cormax	CLOBETASOL PROPIONATE	SOLUTION	0.05 %	COVERED	FORMULARY
34141	21986	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Temovate E	CLOBETASOL PROPIONATE-EMOLLIENT BASE	CREAM (G)	0.05 %	COVERED	FORMULARY
31425	7620	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Desonide	DESONIDE	CREAM (G)	0.05 %	COVERED	FORMULARY
31430	7622	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Desonide	DESONIDE	OINT. (G)	0.05 %	COVERED	FORMULARY
24484	58950	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Derma-Smoothe-FS Scalp Oil	FLUOCINOLONE (WITH SHOWER CAP)	OIL	0.01 %	COVERED	FORMULARY
85080	7507	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Derma-Smoothe-FS Body Oil	FLUOCINOLONE ACETONIDE	OIL	0.01 %	COVERED	FORMULARY
31390	7616	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Fluocinonide	FLUOCINONIDE	CREAM (G)	0.05 %	COVERED	FORMULARY
31380	7615	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Fluocinonide	FLUOCINONIDE	GEL (GRAM)	0.05 %	COVERED	FORMULARY
31400	7617	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Fluocinonide	FLUOCINONIDE	OINT. (G)	0.05 %	COVERED	FORMULARY
31401	7618	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Fluocinonide	FLUOCINONIDE	SOLUTION	0.05 %	COVERED	FORMULARY
30943	7545	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Hydrocortisone	HYDROCORTISONE	CREAM (G)	2.5 %	COVERED	FORMULARY
28850	23906	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Proctosol-HC, Proctozone	HYDROCORTISONE	CREAM/APPL	2.5 %	COVERED	FORMULARY
66392	37045	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Cortenema, Colocort	HYDROCORTISONE	ENEMA	100 MG/60ML	COVERED	FORMULARY
30975	7554	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Hydrocortisone	HYDROCORTISONE	LOTION	2.5 %	COVERED	FORMULARY
30952	7548	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Hydrocortisone	HYDROCORTISONE	OINT. (G)	2.5 %	COVERED	FORMULARY
66391	37044	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Cortifoam	HYDROCORTISONE ACETATE	FOAM/APPL	10 %	COVERED	FORMULARY
27941	6858	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Anusol-HC	HYDROCORTISONE ACETATE	SUPP.RECT	25 MG	COVERED	FORMULARY
31231	7593	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	CREAM (G)	0.025 %	COVERED	FORMULARY
31232	7594	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	CREAM (G)	0.1 %	COVERED	FORMULARY
31233	7595	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	CREAM (G)	0.5 %	COVERED	FORMULARY
31260	7599	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	LOTION	0.025 %	COVERED	FORMULARY
31261	7600	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	LOTION	0.1 %	COVERED	FORMULARY
31241	7596	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	OINT. (G)	0.025 %	COVERED	FORMULARY
31242	7597	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	OINT. (G)	0.1 %	COVERED	FORMULARY
31243	15542	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	OINT. (G)	0.05 %	COVERED	FORMULARY
31244	7598	840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)	Triamcinolone	TRIAMCINOLONE ACETONIDE	OINT. (G)	0.5 %	COVERED	FORMULARY
42121	9477	840800-ANTIPRURITICS AND LOCAL ANESTHETICS	Pyridium	PHENAZOPYRIDINE HCL	TABLET	100 MG	COVERED	FORMULARY
42122	9478	840800-ANTIPRURITICS AND LOCAL ANESTHETICS	Pyridium	PHENAZOPYRIDINE HCL	TABLET	200 MG	COVERED	FORMULARY
22291	11998	841200-ASTRINGENTS	Drysol	ALUMINUM CHLORIDE	SOLUTION	20 %	COVERED	FORMULARY
22880	5800	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A	TRETINOIN	CREAM (G)	0.05 %	COVERED	FORMULARY
22881	5801	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A	TRETINOIN	CREAM (G)	0.01 %	COVERED	FORMULARY
22882	5799	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A	TRETINOIN	CREAM (G)	0.025 %	COVERED	FORMULARY
22870	5797	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A	TRETINOIN	GEL (GRAM)	0.01 %	COVERED	FORMULARY
22871	5798	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A	TRETINOIN	GEL (GRAM)	0.025 %	COVERED	FORMULARY
17443	50417	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A Micro	TRETINOIN MICROSPHERES	GEL (GRAM)	0.04 %	COVERED	FORMULARY
22874	30614	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A Micro	TRETINOIN MICROSPHERES	GEL (GRAM)	0.1 %	COVERED	FORMULARY
31776	68881	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A Micro Pump	TRETINOIN MICROSPHERES	GEL W/PUMP	0.04 %	COVERED	FORMULARY
31777	68882	841600-CELL STIMULANTS AND PROLIFERANTS	Retin-A Micro Pump	TRETINOIN MICROSPHERES	GEL W/PUMP	0.1 %	COVERED	FORMULARY
63447	45214	841600-CELL STIMULANTS AND PROLIFERANTS	Refissa	TRETINOIN-EMOLLIENT BASE	CREAM (G)	0.05 %	COVERED	FORMULARY
22931	5813	842800-KERATOLYTIC AGENTS	Benzoyl Peroxide	BENZOYL PEROXIDE	GEL (GRAM)	5 %	COVERED	FORMULARY
24774	16308	842800-KERATOLYTIC AGENTS	Urea	UREA	CREAM (G)	40 %	COVERED	FORMULARY
62874	18229	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Azelex	AZELAIC ACID	CREAM (G)	20 %	COVERED	FORMULARY
1851	21134	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Dovonex	CALCIPOTRIENE	CREAM (G)	0.01 %	COVERED	FORMULARY
1850	19160	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Calcipotriene	CALCIPOTRIENE	OINT. (G)	0.01 %	COVERED	FORMULARY
1852	22483	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Calcipotriene	CALCIPOTRIENE	SOLUTION	0.01 %	COVERED	FORMULARY
30781	7502	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Efudex	FLUOROURACIL	CREAM (G)	5 %	COVERED	FORMULARY
30791	7504	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Fluorouracil	FLUOROURACIL	SOLUTION	2 %	COVERED	FORMULARY
30792	7505	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Fluorouracil	FLUOROURACIL	SOLUTION	5 %	COVERED	FORMULARY
54201	31099	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Aldara	IMIQUIMOD	CREAM PACK	5 %	COVERED	FORMULARY
15348	49724	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Elidel	PIMECROLIMUS	CREAM (G)	1 %	COVERED	FORMULARY
23450	30857	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Condylox	PODOFILOX	GEL (GRAM)	0.5 %	COVERED	FORMULARY
23451	15942	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Condylox	PODOFILOX	SOLUTION	0.5 %	COVERED	FORMULARY
19370	4928	861204-ANTIMUSCARINICS	Oxybutynin	OXYBUTYNIN CHLORIDE	SYRUP	5 MG/5 ML	COVERED	FORMULARY
19388	41046	861204-ANTIMUSCARINICS	Oxybutynin ER	OXYBUTYNIN CHLORIDE	TAB ER 24	5 MG	COVERED	FORMULARY
19389	41047	861204-ANTIMUSCARINICS	Oxybutynin ER	OXYBUTYNIN CHLORIDE	TAB ER 24	10 MG	COVERED	FORMULARY
93557	42606	861204-ANTIMUSCARINICS	Oxybutynin ER	OXYBUTYNIN CHLORIDE	TAB ER 24	15 MG	COVERED	FORMULARY
19380	4929	861204-ANTIMUSCARINICS	Ditropan	OXYBUTYNIN CHLORIDE	TABLET	5 MG	COVERED	FORMULARY
410	90	861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS	Theophylline ER	THEOPHYLLINE ANHYDROUS	TAB ER 12H	100 MG	COVERED	FORMULARY
411	91	861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS	Theophylline ER	THEOPHYLLINE ANHYDROUS	TAB ER 12H	200 MG	COVERED	FORMULARY
413	93	861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS	Theophylline ER	THEOPHYLLINE ANHYDROUS	TAB ER 12H	300 MG	COVERED	FORMULARY
94481	2184	881600-VITAMIN D	Rocaltrol	CALCITRIOL	CAPSULE	0.25 MCG	COVERED	FORMULARY
94482	2185	881600-VITAMIN D	Rocaltrol	CALCITRIOL	CAPSULE	0.5 MCG	COVERED	FORMULARY
98425	62651	881600-VITAMIN D	Cholecalciferol (Vitamin D3)	CHOLECALCIFEROL (VITAMIN D3)	CAPSULE	50000 UNIT	COVERED	FORMULARY
94422	2169	881600-VITAMIN D	Drisdol	ERGOCALCIFEROL (VITAMIN D2)	CAPSULE	50000 UNIT	COVERED	FORMULARY
94711	2305	882400-VITAMIN K ACTIVITY	Mephyton	PHYTONADIONE	TABLET	5 MG	COVERED	FORMULARY
2881	1192	920400-ALCOHOL DETERRENTS	Antabuse	DISULFIRAM	TABLET	250 MG	COVERED	FORMULARY
30521	41440	920800-5-ALPHA-REDUCTASE INHIBITORS	Proscar	FINASTERIDE	TABLET	5 MG	COVERED	FORMULARY
7070	2535	921600-ANTIGOUT AGENTS	Zyloprim	ALLOPURINOL	TABLET	100 MG	COVERED	FORMULARY
7071	2536	921600-ANTIGOUT AGENTS	Zyloprim	ALLOPURINOL	TABLET	300 MG	COVERED	FORMULARY
35674	8334	921600-ANTIGOUT AGENTS	Colcrys	COLCHICINE	TABLET	0.6 MG	COVERED	FORMULARY	Max 6 tablets/month, Enroll in PAP for more.
12389	47381	922400-BONE RESORPTION INHIBITORS	Fosamax	ALENDRONATE SODIUM	TABLET	35 MG	COVERED	FORMULARY
21680	24053	922400-BONE RESORPTION INHIBITORS	Fosamax	ALENDRONATE SODIUM	TABLET	10 MG	COVERED	FORMULARY
21682	31006	922400-BONE RESORPTION INHIBITORS	Fosamax	ALENDRONATE SODIUM	TABLET	5 MG	COVERED	FORMULARY
85361	46941	922400-BONE RESORPTION INHIBITORS	Fosamax	ALENDRONATE SODIUM	TABLET	70 MG	COVERED	FORMULARY
67031	40549	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Arava	LEFLUNOMIDE	TABLET	10 MG	COVERED	FORMULARY
67032	40550	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Arava	LEFLUNOMIDE	TABLET	20 MG	COVERED	FORMULARY
46771	11682	924400-IMMUNOSUPPRESSIVE AGENTS	Imuran	AZATHIOPRINE	TABLET	50 MG	COVERED	FORMULARY
94200	62137	940000-DEVICES	True Metrix Level 3	BLOOD-GLUCOSE CONTROL HIGH	EACH		COVERED	FORMULARY
94200	62137	940000-DEVICES	True Metrix Level 1	BLOOD-GLUCOSE CONTROL LOW	EACH		COVERED	FORMULARY
94200	62137	940000-DEVICES	True Metrix Level 2	BLOOD-GLUCOSE CONTROL NORMAL	EACH		COVERED	FORMULARY
94200	19413	940000-DEVICES	True Metrix Glucose Meter	BLOOD-GLUCOSE METER	EACH		COVERED	FORMULARY
94200	19413	940000-DEVICES	True Metrix Glucose Meter	BLOOD-GLUCOSE METER	EACH		COVERED	FORMULARY
94200	21900	940000-DEVICES	Aerochamber Plus Flow-Vu	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94200	21900	940000-DEVICES	Aerochamber Plus Flow-Vu Mask, Large	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94200	21900	940000-DEVICES	Aerochamber Plus Flow-Vu Mask, Medium	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94200	21900	940000-DEVICES	Aerochamber Plus Flow-Vu Mask, Small	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94200	21900	940000-DEVICES	Optichamber Diamond VHC	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94200	21900	940000-DEVICES	Optichamber Diamond VHC with Large Mask	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94200	21900	940000-DEVICES	Optichamber Diamond VHC with Medium Mask	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94200	21900	940000-DEVICES	Optichamber Diamond VHC with Small Mask	INHALER ASSIST DEVICES	SPACER		COVERED	FORMULARY
94200	64800	940000-DEVICES	Optichamber Large Mask	INHALER ASSIST DEVICE ACCESORY	EACH		COVERED	FORMULARY
94200	64800	940000-DEVICES	Optichamber Medium Mask	INHALER ASSIST DEVICE ACCESORY	EACH		COVERED	FORMULARY
94200	70184	940000-DEVICES	True Plus Lancet 28G	LANCETS	EACH	28 GAUGE	COVERED	FORMULARY
94200	70013	940000-DEVICES	True Plus Lancet 30G	LANCETS	EACH	30 GAUGE	COVERED	FORMULARY
94200	70013	940000-DEVICES	True Plus Lancet 30G	LANCETS	EACH	30 GAUGE	COVERED	FORMULARY
94200	70012	940000-DEVICES	True Plus Lancet 33G	LANCETS	EACH	33 GAUGE	COVERED	FORMULARY
94200	70012	940000-DEVICES	True Plus Lancet 33G	LANCETS	EACH	33 GAUGE	COVERED	FORMULARY
94200	70184	940000-DEVICES	True PlusLancet 28G	LANCETS	EACH	28 GAUGE	COVERED	FORMULARY
94200	70184	940000-DEVICES	True PlusLancet 28G	LANCETS	EACH	28 GAUGE	COVERED	FORMULARY
94200	65779	940000-DEVICES	True Plus Lancing Device	LANCING DEVICE	EACH		COVERED	FORMULARY
94200	65779	940000-DEVICES	True Plus Lancing Device	LANCING DEVICE	EACH		COVERED	FORMULARY
94200	16606	940000-DEVICES	Peak Flow Meter	PEAK FLOW METER	EACH		COVERED	FORMULARY
94200	16606	940000-DEVICES	Peak Flow Meter	PEAK FLOW METER	EACH		COVERED	FORMULARY
94200	16606	940000-DEVICES	Peak Flow Meter	PEAK FLOW METER	EACH		COVERED	FORMULARY
94200	49235	940000-DEVICES	Pen Needle 29 G X 1/2"	PEN NEEDLE DIABETIC	DIS NEEDLE	29 G X 1/2"	COVERED	FORMULARY
94200	49235	940000-DEVICES	Pen Needle 29 G X 1/2"	PEN NEEDLE DIABETIC	DIS NEEDLE	29 G X 1/2"	COVERED	FORMULARY
94200	49235	940000-DEVICES	Pen Needle 29 G X 1/2"	PEN NEEDLE DIABETIC	DIS NEEDLE	29 G X 1/2"	COVERED	FORMULARY
94200	49235	940000-DEVICES	Pen Needle 29 G X 1/2"	PEN NEEDLE DIABETIC	DIS NEEDLE	29 G X 1/2"	COVERED	FORMULARY
94200	49235	940000-DEVICES	Pen Needle 29 G X 1/2"	PEN NEEDLE DIABETIC	DIS NEEDLE	29 G X 1/2"	COVERED	FORMULARY
94200	61638	940000-DEVICES	Pen Needle 30 G x 1/3"	PEN NEEDLE DIABETIC	DIS NEEDLE	30 G X 1/3"	COVERED	FORMULARY
94200	61638	940000-DEVICES	Pen Needle 30 G x 1/3"	PEN NEEDLE DIABETIC	DIS NEEDLE	30 G X 1/3"	COVERED	FORMULARY
94200	50622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94200	50622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94200	50622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94200	50622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94200	50622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94200	50622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94200	50622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94200	50622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94200	50622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94200	50622	940000-DEVICES	Pen Needle 31 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 1/4"	COVERED	FORMULARY
94200	60904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94200	60904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94200	60904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94200	60904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94200	60904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94200	60904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94200	60904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94200	60904	940000-DEVICES	Pen Needle 31 G x 3/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 3/16"	COVERED	FORMULARY
94200	49240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94200	49240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94200	49240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94200	49240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94200	49240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94200	49240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94200	49240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94200	49240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94200	49240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94200	49240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94200	49240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94200	49240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94200	49240	940000-DEVICES	Pen Needle 31 G x 5/16"	PEN NEEDLE DIABETIC	DIS NEEDLE	31 G X 5/16"	COVERED	FORMULARY
94200	62868	940000-DEVICES	Pen Needle 32 G x 1/4"	PEN NEEDLE DIABETIC	DIS NEEDLE	32 G X 1/4"	COVERED	FORMULARY
94200	66936	940000-DEVICES	Pen Needle 32 G X 1/5"	PEN NEEDLE DIABETIC	DIS NEEDLE	32 G X 1/5"	COVERED	FORMULARY
94200	72859	940000-DEVICES	Pen Needle 32 G x 1/6"	PEN NEEDLE DIABETIC	DIS NEEDLE	32 G X 1/6"	COVERED	FORMULARY
94200	66308	940000-DEVICES	Pen Needle 32 G x 5/32"	PEN NEEDLE DIABETIC	DIS NEEDLE	32G X 5/32"	COVERED	FORMULARY
94200	66308	940000-DEVICES	Pen Needle 32 G x 5/32"	PEN NEEDLE DIABETIC	DIS NEEDLE	32G X 5/32"	COVERED	FORMULARY
94200	66308	940000-DEVICES	Pen Needle 32 G x 5/32"	PEN NEEDLE DIABETIC	DIS NEEDLE	32G X 5/32"	COVERED	FORMULARY
94200	66308	940000-DEVICES	Pen Needle 32 G x 5/32"	PEN NEEDLE DIABETIC	DIS NEEDLE	32G X 5/32"	COVERED	FORMULARY
94200	66308	940000-DEVICES	Pen Needle 32 G x 5/32"	PEN NEEDLE DIABETIC	DIS NEEDLE	32G X 5/32"	COVERED	FORMULARY
94200	66308	940000-DEVICES	Pen Needle 32 G x 5/32"	PEN NEEDLE DIABETIC	DIS NEEDLE	32G X 5/32"	COVERED	FORMULARY
94200	66308	940000-DEVICES	Pen Needle 32 G x 5/32"	PEN NEEDLE DIABETIC	DIS NEEDLE	32G X 5/32"	COVERED	FORMULARY
94200	62772	940000-DEVICES	Pen Needle 30 G x 1/3"	PEN NEEDLE DIABETIC SAFETY	DIS NEEDLE	30 G X 1/3"	COVERED	FORMULARY
94200	49277	940000-DEVICES	Insulin Syringe 0.3mL 29 G x 1/2"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49277	940000-DEVICES	Insulin Syringe 0.3mL 29 G x 1/2"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49277	940000-DEVICES	Insulin Syringe 0.3mL 29 G x 1/2"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49399	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 1/2"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 1/2"	COVERED	FORMULARY
94200	49399	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 1/2"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 1/2"	COVERED	FORMULARY
94200	49394	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94200	49394	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94200	49394	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94200	49394	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94200	49394	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94200	49394	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94200	49394	940000-DEVICES	Insulin Syringe 0.3mL 30 G x 5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94200	49403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49403	940000-DEVICES	Insulin Syringe 0.3mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.3 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94200	49276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94200	49276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94200	49276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94200	49276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94200	49276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94200	49383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94200	49395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94200	49395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94200	49395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94200	49395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94200	49395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94200	49395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	COVERED	FORMULARY
94200	49400	940000-DEVICES	Insulin Syringe 0.5mL 30GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30 G X 1/2"	COVERED	FORMULARY
94200	49400	940000-DEVICES	Insulin Syringe 0.5mL 30GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30 G X 1/2"	COVERED	FORMULARY
94200	49400	940000-DEVICES	Insulin Syringe 0.5mL 30GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30 G X 1/2"	COVERED	FORMULARY
94200	49400	940000-DEVICES	Insulin Syringe 0.5mL 30GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30 G X 1/2"	COVERED	FORMULARY
94200	49404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94200	49275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94200	49275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94200	49275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94200	49275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94200	49275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94200	49275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	COVERED	FORMULARY
94200	49384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	COVERED	FORMULARY
94200	49358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94200	49358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94200	49358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94200	49358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94200	49358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94200	49358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94200	49358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94200	49358	940000-DEVICES	Insulin Syringe 1mL 30GX 5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 5/16"	COVERED	FORMULARY
94200	49401	940000-DEVICES	Insulin Syringe 1mL 30GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 1/2"	COVERED	FORMULARY
94200	49401	940000-DEVICES	Insulin Syringe 1mL 30GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 1/2"	COVERED	FORMULARY
94200	49401	940000-DEVICES	Insulin Syringe 1mL 30GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 1/2"	COVERED	FORMULARY
94200	49405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
94200	49405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	COVERED	FORMULARY
33118	28142	081206-CEPHALOSPORINS	Suprax Capsule	CEFIXIME	CAPSULE	400 MG	COVERED	FORMULARY	Restricted to CUC Prescribers. Send to Central Pharmacy. Quantity limit #1 capsule/ prescription.
33120	9182	081206-CEPHALOSPORINS	Suprax Suspension	CEFIXIME	SUSP RECON	100 MG/5ML	NOT COVERED	NON-FORMULARY	Formulary: Cefdinir
92368	44428	081206-CEPHALOSPORINS	Suprax Suspension	CEFIXIME	SUSP RECON	200 MG/5ML	NOT COVERED	NON-FORMULARY	Formulary: Cefdinir
34277	70665	081206-CEPHALOSPORINS	Suprax Suspension	CEFIXIME	SUSP RECON	500 MG/5ML	NOT COVERED	NON-FORMULARY	Formulary: Cefdinir
33445	70122	081206-CEPHALOSPORINS	Suprax Chewable	CEFIXIME	TAB CHEW	100 MG	NOT COVERED	NON-FORMULARY	Formulary: Cefdinir
33446	70123	081206-CEPHALOSPORINS	Suprax Chewable	CEFIXIME	TAB CHEW	200 MG	NOT COVERED	NON-FORMULARY	Formulary: Cefdinir
33110		081206-CEPHALOSPORINS	Suprax Tablet	CEFIXIME	TABLET	400 MG	NOT COVERED	NON-FORMULARY	Formulary: Cefdinir
26871	45132	081228-ANTIBACTERIALS, MISCELLANEOUS	Zyvox Suspension	LINEZOLID	SUSP RECON	100 MG/5ML	NOT COVERED	NON-FORMULARY
26870	45131	081228-ANTIBACTERIALS, MISCELLANEOUS	Zyvox Tablet	LINEZOLID	TABLET	600 MG	NOT COVERED	NON-FORMULARY
33787	70295	081408-AZOLES	Onmel	ITRACONAZOLE	TABLET	200 MG	NOT COVERED	NON-FORMULARY	Formulary: Itraconazole 100mg capsule
55389	21871	083600-URINARY ANTI-INFECTIVES	Monurol	FOSFOMYCIN TROMETHAMINE	PACKET	3 G	NOT COVERED	NON-FORMULARY
74040	4773	120808-ANTIMUSCARINICS/ANTISPASMODICS	Donnatal Elixir	PHENOBARBITAL-HYOSCYAMINE-ATROPINE-SCOPOLAMINE	ELIXIR	16.2-0.1037-0.0194 MG/5ML	NOT COVERED	NON-FORMULARY
74070	4777	120808-ANTIMUSCARINICS/ANTISPASMODICS	Donnatal	PHENOBARBITAL-HYOSCYAMINE-ATROPINE-SCOPOLAMINE	TABLET	16.2-0.1037-0.0194 MG	NOT COVERED	NON-FORMULARY
22913	28090	121208-BETA-ADRENERGIC AGONISTS	ProAir HFA	ALBUTEROL SULFATE	HFA AER AD	90 MCG	NOT COVERED	NON-FORMULARY	Formulary: Proventil
22913	28090	121208-BETA-ADRENERGIC AGONISTS	Ventolin HFA	ALBUTEROL SULFATE	HFA AER AD	90 MCG	NOT COVERED	NON-FORMULARY	Formulary: Proventil
28038	65912	121212-ALPHA- AND BETA-ADRENERGIC AGONISTS	Adrenaclick	EPINEPHRINE	AUTO INJCT	0.15 MG/0.15ML	NOT COVERED	NON-FORMULARY	Formulary: Epinephrine generic
19861	16878	121212-ALPHA- AND BETA-ADRENERGIC AGONISTS	Epipen Jr.	EPINEPHRINE	AUTO INJCT	0.15 MG/0.3ML	NOT COVERED	NON-FORMULARY	Formulary: Epinephrine generic
19862	16879	121212-ALPHA- AND BETA-ADRENERGIC AGONISTS	Epipen, Adrenaclick	EPINEPHRINE	AUTO INJCT	0.3 MG/0.3ML	NOT COVERED	NON-FORMULARY	Formulary: Epinephrine generic
17912	4663	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Soma	CARISOPRODOL	TABLET	350 MG	NOT COVERED	NON-FORMULARY	Formulary: Cyclobenzaprine, methocarbamol, and tizanidine
91765	51112	122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT	Skelaxin	METAXALONE	TABLET	800 MG	NOT COVERED	NON-FORMULARY	Formulary: Cyclobenzaprine, methocarbamol, and tizanidine
23866	58432	240608-HMG-COA REDUCTASE INHIBITORS	Caduet	AMLODIPINE/ATORVASTATIN	TABLET	2.5-10 MG	NOT COVERED	NON-FORMULARY	Prescribe amlodipine and atorvastatin seperately
23867	58433	240608-HMG-COA REDUCTASE INHIBITORS	Caduet	AMLODIPINE/ATORVASTATIN	TABLET	2.5-20 MG	NOT COVERED	NON-FORMULARY	Prescribe amlodipine and atorvastatin seperately
23868	58434	240608-HMG-COA REDUCTASE INHIBITORS	Caduet	AMLODIPINE/ATORVASTATIN	TABLET	2.5-40 MG	NOT COVERED	NON-FORMULARY	Prescribe amlodipine and atorvastatin seperately
19153	51784	240608-HMG-COA REDUCTASE INHIBITORS	Crestor	ROSUVASTATIN CALCIUM	TABLET	10 MG	NOT COVERED	NON-FORMULARY	Formulary: Atorvastatin
19154	51785	240608-HMG-COA REDUCTASE INHIBITORS	Crestor	ROSUVASTATIN CALCIUM	TABLET	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Atorvastatin
19155	51786	240608-HMG-COA REDUCTASE INHIBITORS	Crestor	ROSUVASTATIN CALCIUM	TABLET	40 MG	NOT COVERED	NON-FORMULARY	Formulary: Atorvastatin
20229	52944	240608-HMG-COA REDUCTASE INHIBITORS	Crestor	ROSUVASTATIN CALCIUM	TABLET	5 MG	NOT COVERED	NON-FORMULARY	Formulary: Atorvastatin
23929	58486	240692-ANTILIPEMIC AGENTS, MISCELLANEOUS	Lovaza	OMEGA-3 ACID ETHYL ESTERS	CAPSULE	1 G	NOT COVERED	NON-FORMULARY	Formulary: Fenofibrate
73542	37015	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand	CANDESARTAN CILEXETIL	TABLET	4 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
73543	37016	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand	CANDESARTAN CILEXETIL	TABLET	8 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
73544	37017	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand	CANDESARTAN CILEXETIL	TABLET	16 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
73545	40659	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand	CANDESARTAN CILEXETIL	TABLET	32 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
13258	64285	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand HCT	CANDESARTAN/HYDROCHLOROTHIAZID	TABLET	32MG-25MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
21559	45425	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand HCT	CANDESARTAN/HYDROCHLOROTHIAZID	TABLET	16-12.5MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
21569	46624	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Atacand HCT	CANDESARTAN/HYDROCHLOROTHIAZID	TABLET	32-12.5MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
23831	40910	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Micardis	TELMISARTAN	TABLET	40 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
23832	40911	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Micardis	TELMISARTAN	TABLET	80 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
23833	47126	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Micardis	TELMISARTAN	TABLET	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
27783	65746	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Twynsta	TELMISARTAN/AMLODIPINE	TABLET	40 MG-5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
27784	65747	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Twynsta	TELMISARTAN/AMLODIPINE	TABLET	40 MG-10MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
27785	65748	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Twynsta	TELMISARTAN/AMLODIPINE	TABLET	80 MG-5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
27786	65749	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Twynsta	TELMISARTAN/AMLODIPINE	TABLET	80 MG-10MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
12257	47326	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Micardis HCT	TELMISARTAN/HYDROCHLOROTHIAZID	TABLET	40-12.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
12259	47324	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Micardis HCT	TELMISARTAN/HYDROCHLOROTHIAZID	TABLET	80-12.5MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
22866	57690	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Micardis HCT	TELMISARTAN/HYDROCHLOROTHIAZID	TABLET	80 MG-25MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
13838	48399	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan	VALSARTAN	TABLET	320 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
13844	48400	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan	VALSARTAN	TABLET	160 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
13846	48401	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan	VALSARTAN	TABLET	80 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
18092	50805	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan	VALSARTAN	TABLET	40 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
17245	50256	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan HCT	VALSARTAN/HYDROCHLOROTHIAZIDE	TABLET	160-25MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
27014	60780	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan HCT	VALSARTAN/HYDROCHLOROTHIAZIDE	TABLET	320MG-25MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
27015	60781	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Diovan HCT	VALSARTAN/HYDROCHLOROTHIAZIDE	TABLET	320-12.5MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan
19200	15880	280808-OPIATE AGONISTS	Duragesic	FENTANYL	PATCH TD72	25 MCG/HR	NOT COVERED	NON-FORMULARY	Formulary: Morphine
19201	15881	280808-OPIATE AGONISTS	Duragesic	FENTANYL	PATCH TD72	50MCG/HR	NOT COVERED	NON-FORMULARY	Formulary: Morphine
19202	15882	280808-OPIATE AGONISTS	Duragesic	FENTANYL	PATCH TD72	75MCG/HR	NOT COVERED	NON-FORMULARY	Formulary: Morphine
19203	15883	280808-OPIATE AGONISTS	Duragesic	FENTANYL	PATCH TD72	100 MCG/HR	NOT COVERED	NON-FORMULARY	Formulary: Morphine
16281	15065	280808-OPIATE AGONISTS	Oxyocodone Concentrate	OXYCODONE HCL	ORAL CONC	20 MG/ML	NOT COVERED	NON-FORMULARY	Formulary: Morphine
16280	4224	280808-OPIATE AGONISTS	Oxycodone Solution	OXYCODONE HCL	SOLUTION	5 MG/5 ML	NOT COVERED	NON-FORMULARY	Formulary: Morphine
41853	76361	280808-OPIATE AGONISTS	Oxycodone Oral Syringe	OXYCODONE HCL	SYRINGE	10MG/0.5ML	NOT COVERED	NON-FORMULARY	Formulary: Morphine
16291	13467	280808-OPIATE AGONISTS	Oxyocodone	OXYCODONE HCL	TABLET	10 MG	NOT COVERED	NON-FORMULARY	Formulary: Oxycodone 5 mg, Morphine
20091	46474	280808-OPIATE AGONISTS	Oxyocodone	OXYCODONE HCL	TABLET	15 MG	NOT COVERED	NON-FORMULARY	Formulary: Oxycodone 5 mg, Morphine
21194	45298	280808-OPIATE AGONISTS	Oxyocodone	OXYCODONE HCL	TABLET	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Oxycodone 5 mg, Morphine
20092	46475	280808-OPIATE AGONISTS	Oxyocodone	OXYCODONE HCL	TABLET	30 MG	NOT COVERED	NON-FORMULARY	Formulary: Oxycodone 5 mg, Morphine
32047	69101	280808-OPIATE AGONISTS	Oxaydo	OXYCODONE HCL	TABLET ORL	5 MG	NOT COVERED	NON-FORMULARY	Formulary: Oxycodone 5 mg, Morphine
31256	68467	280808-OPIATE AGONISTS	Oxaydo	OXYCODONE HCL	TABLET ORL	7.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Oxycodone 5 mg, Morphine
35214	71432	280812-OPIATE PARTIAL AGONISTS	Butrans Patch	BUPRENORPHINE	PATCH TDWK	15 MCG/HR	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
36946	72673	280812-OPIATE PARTIAL AGONISTS	Butrans Patch	BUPRENORPHINE	PATCH TDWK	7.5 MCG/HR	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
39965	75051	280812-OPIATE PARTIAL AGONISTS	Belbuca Film	BUPRENORPHINE HCL	FILM	150 MCG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
39966	75052	280812-OPIATE PARTIAL AGONISTS	Belbuca Film	BUPRENORPHINE HCL	FILM	300 MCG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
39967	75053	280812-OPIATE PARTIAL AGONISTS	Belbuca Film	BUPRENORPHINE HCL	FILM	450 MCG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
39968	75054	280812-OPIATE PARTIAL AGONISTS	Belbuca Film	BUPRENORPHINE HCL	FILM	600 MCG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
39959	75050	280812-OPIATE PARTIAL AGONISTS	Belbuca Film	BUPRENORPHINE HCL	FILM	75 MCG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
39969	75055	280812-OPIATE PARTIAL AGONISTS	Belbuca Film	BUPRENORPHINE HCL	FILM	750 MCG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
39975	75056	280812-OPIATE PARTIAL AGONISTS	Belbuca Film	BUPRENORPHINE HCL	FILM	900 MCG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
64672	29312	280812-OPIATE PARTIAL AGONISTS	Subutex	BUPRENORPHINE HCL	TAB SUBL	2 MG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
64673	29313	280812-OPIATE PARTIAL AGONISTS	Subutex	BUPRENORPHINE HCL	TAB SUBL	8 MG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
33744	70262	280812-OPIATE PARTIAL AGONISTS	Suboxone Film	BUPRENORPHINE HCL/NALOXONE HCL	FILM	12 MG-3 MG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
28958	66635	280812-OPIATE PARTIAL AGONISTS	Suboxone Film	BUPRENORPHINE HCL/NALOXONE HCL	FILM	2 MG-0.5MG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
36677	72449	280812-OPIATE PARTIAL AGONISTS	Bunavail Film	BUPRENORPHINE HCL/NALOXONE HCL	FILM	2.1-0.3 MG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
36678	72450	280812-OPIATE PARTIAL AGONISTS	Bunavail Film	BUPRENORPHINE HCL/NALOXONE HCL	FILM	4.2-0.7 MG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
33741	70259	280812-OPIATE PARTIAL AGONISTS	Suboxone Film	BUPRENORPHINE HCL/NALOXONE HCL	FILM	4MG-1MG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
36679	72451	280812-OPIATE PARTIAL AGONISTS	Bunavail Film	BUPRENORPHINE HCL/NALOXONE HCL	FILM	6.3MG-1MG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
28959	66636	280812-OPIATE PARTIAL AGONISTS	Suboxone Film	BUPRENORPHINE HCL/NALOXONE HCL	FILM	8 MG-2 MG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
42843	76981	280812-OPIATE PARTIAL AGONISTS	Zubsolv	BUPRENORPHINE HCL/NALOXONE HCL	TAB SUBL	0.7-0.18MG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
34904	71189	280812-OPIATE PARTIAL AGONISTS	Zubsolv	BUPRENORPHINE HCL/NALOXONE HCL	TAB SUBL	1.4-0.36MG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
37824	73425	280812-OPIATE PARTIAL AGONISTS	Zubsolv	BUPRENORPHINE HCL/NALOXONE HCL	TAB SUBL	11.4-2.9MG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
39394	74685	280812-OPIATE PARTIAL AGONISTS	Zubsolv	BUPRENORPHINE HCL/NALOXONE HCL	TAB SUBL	2.9-0.71MG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
34905	71190	280812-OPIATE PARTIAL AGONISTS	Zubsolv	BUPRENORPHINE HCL/NALOXONE HCL	TAB SUBL	5.7-1.4 MG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
37823	73424	280812-OPIATE PARTIAL AGONISTS	Zubsolv	BUPRENORPHINE HCL/NALOXONE HCL	TAB SUBL	8.6-2.1 MG	NOT COVERED	NON-FORMULARY	Buprenorphine products restricted to CommUnityCare Dove Spring
18973	51640	280812-OPIATE PARTIAL AGONISTS	Suboxone Tablet	BUPRENORPHINE HCL/NALOXONE HCL	TAB SUBL	2 MG-0.5MG	NOT COVERED	NON-FORMULARY	Restricted to Suboxone clinic at CommUnityCare Dove Springs
18974	51641	280812-OPIATE PARTIAL AGONISTS	Suboxone Tablet	BUPRENORPHINE HCL/NALOXONE HCL	TAB SUBL	8 MG-2 MG	NOT COVERED	NON-FORMULARY	Restricted to Suboxone clinic at CommUnityCare Dove Springs
28626	66372	280892-ANALGESICS AND ANTIPYRETICS, MISC.	Fioricet	BUTALBITAL-ACETAMINOPHEN-CAFFEINE	CAPSULE	50-300-40 MG	NOT COVERED	NON-FORMULARY	Formulary: Capacet, Esgic
27095	60935	281000-OPIATE ANTAGONISTS	Vivitrol	NALTREXONE MICROSPHERES	SUS ER REC	380MG	NOT COVERED	NON-FORMULARY	Formulary: Naltrexone tablet
16356	46216	281604-ANTIDEPRESSANTS	Sarafem	FLUOXETINE HCL	TABLET	10 MG	NOT COVERED	NON-FORMULARY	Formulary: capsules
16359	46219	281604-ANTIDEPRESSANTS	Sarafem	FLUOXETINE HCL	TABLET	20 MG	NOT COVERED	NON-FORMULARY	Formulary: capsules
14349	64444	281604-ANTIDEPRESSANTS	Venlafaxine ER	VENLAFAXINE HCL	TAB ER 24	37.5 MG	NOT COVERED	NON-FORMULARY	Formulary: capsules
14352	64445	281604-ANTIDEPRESSANTS	Venlafaxine ER	VENLAFAXINE HCL	TAB ER 24	75 MG	NOT COVERED	NON-FORMULARY	Formulary: capsules
14353	64446	281604-ANTIDEPRESSANTS	Venlafaxine ER	VENLAFAXINE HCL	TAB ER 24	150 MG	NOT COVERED	NON-FORMULARY	Formulary: capsules
14354	64447	281604-ANTIDEPRESSANTS	Venlafaxine ER	VENLAFAXINE HCL	TAB ER 24	225 MG	NOT COVERED	NON-FORMULARY	Formulary: capsules
25598	59781	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Diastat	DIAZEPAM	KIT	5-7.5-10MG	NOT COVERED	NON-FORMULARY	Restricted to Neurology prescribers
25599	59782	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Diastat	DIAZEPAM	KIT	12.5-15-20	NOT COVERED	NON-FORMULARY	Restricted to Neurology prescribers
48131	34015	282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)	Diastat	DIAZEPAM	KIT	2.5 MG	NOT COVERED	NON-FORMULARY	Restricted to Neurology prescribers
19593	40223	283228-SELECTIVE SEROTONIN AGONISTS	Maxalt MLT	RIZATRIPTAN BENZOATE	TAB RAPDIS	5 MG	NOT COVERED	Non-Formulary	Formulary: Imitrex (Sumatriptan)
19591	40221	283228-SELECTIVE SEROTONIN AGONISTS	Maxalt	RIZATRIPTAN BENZOATE	TABLET	5 MG	NOT COVERED	Non-Formulary	Formulary: Imitrex (Sumatriptan)
13971	48489	480800-ANTITUSSIVES	Promethazine/Codeine	PROMETHAZINE HCL-CODEINE	SYRUP	6.25-10 MG/5ML	NOT COVERED	NON-FORMULARY
54980	12073	481600-EXPECTORANTS	Mucinex D	GUAIFENESIN-PSEUDOEPHEDRINE HCL	TAB ER 12H	600-60 MG	NOT COVERED	NON-FORMULARY	Available OTC
26056	60055	520808-CORTICOSTEROIDS (EENT)	Dermotic	FLUOCINOLONE ACETONIDE OIL	DROPS	0.01%	NOT COVERED	NON-FORMULARY	Prior Auth restricted to EENT prescribers
30462	67826	521600-LOCAL ANESTHETICS (EENT)	Antipyrine-Benzocaine	ANTIPYRINE-BENZOCAINE	DROPS	5.5-1.4 %	NOT COVERED	NON-FORMULARY	No longer available commerically
1697	30106	562836-PROTON-PUMP INHIBITORS	Prevacid	LANSOPRAZOLE	CAPSULE DR	15 MG	NOT COVERED	NON-FORMULARY	Formulary: Pantoprazole
1698	30107	562836-PROTON-PUMP INHIBITORS	Prevacid	LANSOPRAZOLE	CAPSULE DR	30 MG	NOT COVERED	NON-FORMULARY	Formulary: Pantoprazole
4348	33530	562836-PROTON-PUMP INHIBITORS	Prilosec	OMEPRAZOLE	CAPSULE DR	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Pantoprazole
92989	43136	562836-PROTON-PUMP INHIBITORS	Prilosec	OMEPRAZOLE	CAPSULE DR	10 MG	NOT COVERED	NON-FORMULARY	Formulary: Pantoprazole
92999	43137	562836-PROTON-PUMP INHIBITORS	Prilosec	OMEPRAZOLE	CAPSULE DR	40 MG	NOT COVERED	NON-FORMULARY	Formulary: Pantoprazole
94639	40941	562836-PROTON-PUMP INHIBITORS	Aciphex	RABEPRAZOLE SODIUM	TABLET DR	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Pantoprazole
30220	19863	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Pentasa CR	MESALAMINE	CAPSULE ER	250 MG	NOT COVERED	PAP	Formulary: Sulfasalazine. Contact manufacturer for PAP
21663	53882	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Asacol HD	MESALAMINE	TABLET DR	800 MG	NOT COVERED	NON-FORMULARY	Formulary: Sulfasalazine. Contact manufacturer for PAP
37726	73336	569200-GI DRUGS, MISCELLANEOUS	Movantik	NALOXEGOL OXALATE	TABLET	25 MG	NOT COVERED	NON-FORMULARY	Contact manufacturer for PAP
37725	73335	569200-GI DRUGS, MISCELLANEOUS	Movantik	NALOXEGOL OXALATE	TABLET	12.5 MG	NOT COVERED	NON-FORMULARY	Contact manufacturer for PAP
28847	3203	681604-ESTROGENS	Vivelle-DOT	ESTRADIOL	PATCH TDSW	0.1MG/24HR	NOT COVERED	NON-FORMULARY	Prior auth requires failure to oral options
28840	3202	681604-ESTROGENS	Vivelle-DOT	ESTRADIOL	PATCH TDSW	0.05MG/24H	NOT COVERED	NON-FORMULARY	Prior auth requires failure to oral options
28842	16767	681604-ESTROGENS	Vivelle-DOT	ESTRADIOL	PATCH TDSW	.025MG/24H	NOT COVERED	NON-FORMULARY	Prior auth requires failure to oral options
28843	23270	681604-ESTROGENS	Vivelle-DOT	ESTRADIOL	PATCH TDSW	.075MG/24H	NOT COVERED	NON-FORMULARY	Prior auth requires failure to oral options
28846	24555	681604-ESTROGENS	Vivelle-DOT	ESTRADIOL	PATCH TDSW	.0375MG/24	NOT COVERED	NON-FORMULARY	Prior auth requires failure to oral options
28844	23471	681604-ESTROGENS	Climara	ESTRADIOL	PATCH TDWK	0.1MG/24HR	NOT COVERED	NON-FORMULARY	Prior auth requires failure to oral options
28845	23472	681604-ESTROGENS	Climara	ESTRADIOL	PATCH TDWK	0.05MG/24H	NOT COVERED	NON-FORMULARY	Prior auth requires failure to oral options
28848	32174	681604-ESTROGENS	Climara	ESTRADIOL	PATCH TDWK	.025MG/24H	NOT COVERED	NON-FORMULARY	Prior auth requires failure to oral options
28853	40366	681604-ESTROGENS	Climara	ESTRADIOL	PATCH TDWK	.075MG/24H	NOT COVERED	NON-FORMULARY	Prior auth requires failure to oral options
20068	52830	681604-ESTROGENS	Climara	ESTRADIOL	PATCH TDWK	0.06MG/24H	NOT COVERED	NON-FORMULARY	Prior auth requires failure to oral options
20069	52831	681604-ESTROGENS	Climara	ESTRADIOL	PATCH TDWK	.0375MG/24	NOT COVERED	NON-FORMULARY	Prior auth requires failure to oral options
28107	65966	681604-ESTROGENS	Vagifem	ESTRADIOL	TABLET	10 MCG	NOT COVERED	NON-FORMULARY
67170	7011	681604-ESTROGENS	Estrace Vaginal Cream	ESTRADIOL	CREAM/APPL	0.01%	NOT COVERED	NON-FORMULARY	Formulary: Premarin Vaginal Cream
34336	70705	681612-ESTROGEN AGONIST-ANTAGONISTS	Osphena	OSPEMIFENE	TABLET	60 MG	NOT COVERED	NON-FORMULARY
2318	20241	682002-ALPHA-GLUCOSIDASE INHIBITORS	Precose	ACARBOSE	TABLET	100 MG	NOT COVERED	NON-FORMULARY
2319	20242	682002-ALPHA-GLUCOSIDASE INHIBITORS	Precose	ACARBOSE	TABLET	50 MG	NOT COVERED	NON-FORMULARY
8070	36767	682002-ALPHA-GLUCOSIDASE INHIBITORS	Precose	ACARBOSE	TABLET	25 MG	NOT COVERED	NON-FORMULARY
95252	40357	682002-ALPHA-GLUCOSIDASE INHIBITORS	Glyset	MIGLITOL	TABLET	25 MG	NOT COVERED	NON-FORMULARY
95253	40358	682002-ALPHA-GLUCOSIDASE INHIBITORS	Glyset	MIGLITOL	TABLET	50 MG	NOT COVERED	NON-FORMULARY
95254	40359	682002-ALPHA-GLUCOSIDASE INHIBITORS	Glyset	MIGLITOL	TABLET	100 MG	NOT COVERED	NON-FORMULARY
35836	71842	682008-INSULINS	Tresiba FlexTouch	INSULIN DEGLUDEC	INSULN PEN	100/ML (3)	NOT COVERED	NON-FORMULARY	Formulary: Levemir
35837	71843	682008-INSULINS	Tresiba FlexTouch	INSULIN DEGLUDEC	INSULN PEN	200/ML (3)	NOT COVERED	NON-FORMULARY	Formulary: Levemir
11660	1740	682008-INSULINS	Humulin N	INSULIN NPH HUMAN ISOPHANE	VIAL	100 UNIT/ML	NOT COVERED	NON-FORMULARY	Formulary: Novolin
50001	16311	682008-INSULINS	Humulin 70/30	INSULIN NPH HUM-REG INSULIN HM	VIAL	70-30 UNIT/ML	NOT COVERED	NON-FORMULARY	Formulary: Novolin
11642	1723	682008-INSULINS	Humulin R	INSULIN REGULAR HUMAN	VIAL	100 UNIT/ML	NOT COVERED	NON-FORMULARY	Formulary: Novolin
50776	43801	683200-PROGESTINS	Prometrium	PROGESTERONE, MICRONIZED	CAPSULE	100 MG	NOT COVERED	NON-FORMULARY	Formulary: Provera
50786	43802	683200-PROGESTINS	Prometrium	PROGESTERONE, MICRONIZED	CAPSULE	200 MG	NOT COVERED	NON-FORMULARY	Formulary: Provera
98238	62462	81228-ANTIBACTERIALS, MISCELLANEOUS	Pylera	BISMUTH/METRONID/TETRACYCLINE	CAPSULE	125-125 MG	NOT COVERED	NON-FORMULARY	Prior auth requires failure of Amox/Clari/Metronidazole OR history of systemic macrolide exposure
26339	60244	83600-URINARY ANTI-INFECTIVES	Hyophen	METHENAM/M.BLUE/SALICYL/HYOSCY	TABLET	81.6-0.12	NOT COVERED	NON-FORMULARY
31812	7731	840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)	Bacitracin	BACITRACIN	OINT. (G)	500 UNIT/G	NOT COVERED	NON-FORMULARY
50272	43256	840800-ANTIPRURITICS AND LOCAL ANESTHETICS	Lidoderm	LIDOCAINE	ADH. PATCH	5%	NOT COVERED	NON-FORMULARY	Lidocaine 4% patch, cream are OTC
95404	40261	840800-ANTIPRURITICS AND LOCAL ANESTHETICS	Lindocaine Anorectal Cream	LIDOCAINE	CREAM (G)	0.05	NOT COVERED	NON-FORMULARY
95405	40262	840800-ANTIPRURITICS AND LOCAL ANESTHETICS	Liocaine Cream	LIDOCAINE	CREAM (G)	0.04	NOT COVERED	NON-FORMULARY	Available OTC
30750	14476	840800-ANTIPRURITICS AND LOCAL ANESTHETICS	Lidocaine Ointment	LIDOCAINE	OINT. (G)	0.05	NOT COVERED	NON-FORMULARY	Lidocaine 4% Cream is OTC
24882	6312	845004-DEPIGMENTING AGENTS	ESOTERICA FADE CREAM	HYDROQUINONE	CREAM (G)	2%	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
24883	6313	845004-DEPIGMENTING AGENTS	MELQUIN HP 4% CREAM	HYDROQUINONE	CREAM (G)	4%	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
47830	6314	845004-DEPIGMENTING AGENTS	HYDROQUINONE 4% CREAM	HYDROQUINONE	POWDER		NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
24890	6315	845004-DEPIGMENTING AGENTS	HYDROQUINONE POWDER	HYDROQUINONE	SOLUTION	30 MG/ML	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
20120	52863	845004-DEPIGMENTING AGENTS	NUQUIN HP 4% CREAM	HYDROQUINONE MICROSPHERES	CRM ER (G)	4%	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
97674	61889	845004-DEPIGMENTING AGENTS	ESOTERICA FADE CREAM	HYDROQUINONE/AVOBENZ/OCTINOX	EMUL ADHES	4%	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
21864	54046	845004-DEPIGMENTING AGENTS	ALPHAQUIN HP 4% CREAM	HYDROQUINONE/AVOBENZ/OCTINOX	EMULSN(G)	4%	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
20915	53438	845004-DEPIGMENTING AGENTS	HYDROQUINONE TR 4% CREAM	HYDROQUINONE/OXYBEN/OCTINOXATE	CREAM (G)	4%(5-7.5%)	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
97229	61438	845004-DEPIGMENTING AGENTS	ACLARO 4% EMULSION	HYDROQUINONE/OXYBENZONE/PADIMA	CREAM (G)	2%-SPF10	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
66899	31427	845004-DEPIGMENTING AGENTS	MELQUIN-3 SOLUTION	HYDROQUINONE/SUNSCREEN(FER OX)	CREAM (G)	4%	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
96071	39542	848000-SUNSCREEN AGENTS	MELPAQUE HP 4% CREAM	DIOXYBENZONE/PDO/HYDROQUINONE	CREAM (G)	3%-5%-4%	NOT COVERED	NON-FORMULARY	No coverage for hydroquinone
20383	53055	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Claravis	ISOTRETINOIN	TABLET	30 MG	NOT COVERED	NON-FORMULARY	Prior auths restricted to Dermatology prescriber. Claravis prefererred
59841	36045	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Claravis	ISOTRETINOIN	TABLET	10 MG	NOT COVERED	NON-FORMULARY	Prior auths restricted to Dermatology prescriber. Claravis prefererred
59842	36046	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Claravis	ISOTRETINOIN	TABLET	20 MG	NOT COVERED	NON-FORMULARY	Prior auths restricted to Dermatology prescriber. Claravis prefererred
59843	36047	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Claravis	ISOTRETINOIN	TABLET	40 MG	NOT COVERED	NON-FORMULARY	Prior auths restricted to Dermatology prescriber. Claravis prefererred
24043	58576	861204-ANTIMUSCARINICS	Enablex	DARIFENACIN HYDROBROMIDE	TAB ER 24H	7.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Oxybutynin ER
24044	58577	861204-ANTIMUSCARINICS	Enablex	DARIFENACIN HYDROBROMIDE	TAB ER 24H	15 MG	NOT COVERED	NON-FORMULARY	Formulary: Oxybutynin ER
99193	63466	861204-ANTIMUSCARINICS	Sanctura XR	TROSPIUM CHLORIDE	CAP ER 24H	60 MG	NOT COVERED	NON-FORMULARY	Formulary: Oxybutynin ER
8744	38085	861204-ANTIMUSCARINICS	Sanctura	TROSPIUM CHLORIDE	TABLET	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Oxybutynin ER
18428	51246	920800-5-ALPHA-REDUCTASE INHIBITORS	Avodart	DUTASTERIDE	CAPSULE	0.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Finasteride
28596	66352	920800-5-ALPHA-REDUCTASE INHIBITORS	Jalyn	DUTASTERIDE/TAMSULOSIN HCL	CPMP 24HR	0.5-0.4 MG	NOT COVERED	NON-FORMULARY	Formulary: Finasteride
24444	58915	922400-BONE RESORPTION INHIBITORS	Boniva	IBANDRONATE SODIUM	TABLET	150 MG	NOT COVERED	NON-FORMULARY	Formulary: Alendronate
17378	50364	922400-BONE RESORPTION INHIBITORS	Actonel	RISEDRONATE SODIUM	TABLET	35 MG	NOT COVERED	NON-FORMULARY	Formulary: Alendronate
92238	45102	922400-BONE RESORPTION INHIBITORS	Actonel	RISEDRONATE SODIUM	TABLET	5 MG	NOT COVERED	NON-FORMULARY	Formulary: Alendronate
94200	74210	940000-DEVICES	Contour Next	BLOOD-GLUCOSE METER	EACH		NOT COVERED	NON-FORMULARY	Prior Auths restricted to insulin pumps
94200	70198	940000-DEVICES	TruePlus Lancet 26G	LANCETS	EACH	26 GAUGE	NOT COVERED	NON-FORMULARY
94200	49276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	NOT COVERED	NON-FORMULARY
94200	49276	940000-DEVICES	Insulin Syringe 0.5mL 28GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	28 G X 1/2"	NOT COVERED	NON-FORMULARY
94200	49383	940000-DEVICES	Insulin Syringe 0.5mL 29 G X1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	29 G X 1/2"	NOT COVERED	NON-FORMULARY
94200	49395	940000-DEVICES	Insulin Syringe 0.5mL 30GX 5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30G X 5/16"	NOT COVERED	NON-FORMULARY
94200	49400	940000-DEVICES	Insulin Syringe 0.5mL 30GX1/2"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	30 G X 1/2"	NOT COVERED	NON-FORMULARY
94200	49404	940000-DEVICES	Insulin Syringe 0.5mL 31 GX5/16"	SYRING W-NDL DISP INSUL 0.5 ML	DISP SYRIN	31 G X 5/16"	NOT COVERED	NON-FORMULARY
94200	49365	940000-DEVICES	Insulin Syringe 1mL 27GX5/8"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	27 G X 5/8"	NOT COVERED	NON-FORMULARY
94200	49275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	NOT COVERED	NON-FORMULARY
94200	49275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	NOT COVERED	NON-FORMULARY
94200	49275	940000-DEVICES	Insulin Syringe 1mL 28GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	28 G X 1/2"	NOT COVERED	NON-FORMULARY
94200	49384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	NOT COVERED	NON-FORMULARY
94200	49384	940000-DEVICES	Insulin Syringe 1mL 29 G X1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	29 G X 1/2"	NOT COVERED	NON-FORMULARY
94200	49401	940000-DEVICES	Insulin Syringe 1mL 30GX1/2"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	30 G X 1/2"	NOT COVERED	NON-FORMULARY
94200	49405	940000-DEVICES	Insulin Syringe 1mL 31 GX5/16"	SYRINGE & NEEDLE INSULIN 1 ML	DISP SYRIN	31 G X 5/16"	NOT COVERED	NON-FORMULARY
30025	67462	081202-AMINOGLYCOSIDES	Tobi Podhaler	TOBRAMYCIN	CAP W/DEV	28 MG	NOT COVERED	PAP	Contact manufacturer for PAP
61551	37042	081202-AMINOGLYCOSIDES	Tobi	TOBRAMYCIN IN 0.225% NACL	AMPUL-NEB	300 MG/5ML	NOT COVERED	NON-FORMULARY
28530	66295	081228-ANTIBACTERIALS, MISCELLANEOUS	Xifaxan	RIFAXIMIN	TABLET	550 MG	NOT COVERED	PAP	Contact manufacturer for PAP
93749	41880	081228-ANTIBACTERIALS, MISCELLANEOUS	Xifaxan	RIFAXIMIN	TABLET	200 MG	NOT COVERED	PAP	Contact manufacturer for PAP
49101	16949	081408-AZOLES	Sporanox capsule	ITRACONAZOLE	CAPSULE	100 MG	NOT COVERED	PAP
49100	27465	081408-AZOLES	Sporanox solution	ITRACONAZOLE	SOLUTION	10 MG/ML	NOT COVERED	PAP
17497	50442	081408-AZOLES	Vfend	VORICONAZOLE	TABLET	50 MG	NOT COVERED	PAP	Contact manufacturer for PAP
17498	50443	081408-AZOLES	Vfend	VORICONAZOLE	TABLET	200 MG	NOT COVERED	PAP	Contact manufacturer for PAP
35079	71322	081808-ANTIRETROVIRALS	Tivicay	DOLUTEGRAVIR SODIUM	TABLET	50 MG	NOT COVERED	PAP	Contact manufacturer for PAP
41564	76226	081808-ANTIRETROVIRALS	Tivicay	DOLUTEGRAVIR SODIUM	TABLET	10 MG	NOT COVERED	PAP	Contact manufacturer for PAP
41566	76227	081808-ANTIRETROVIRALS	Tivicay	DOLUTEGRAVIR SODIUM	TABLET	25 MG	NOT COVERED	PAP	Contact manufacturer for PAP
23152	57883	081808-ANTIRETROVIRALS	Truvada	EMTRICITABINE/TENOFOVIR (TDF)	TABLET	200-300 MG	NOT COVERED	PAP	Contact manufacturer for PAP
41369	76097	081808-ANTIRETROVIRALS	Truvada	EMTRICITABINE/TENOFOVIR (TDF)	TABLET	100-150 MG	NOT COVERED	PAP	Contact manufacturer for PAP
41375	76101	081808-ANTIRETROVIRALS	Truvada	EMTRICITABINE/TENOFOVIR (TDF)	TABLET	133-200 MG	NOT COVERED	PAP	Contact manufacturer for PAP
41376	76102	081808-ANTIRETROVIRALS	Truvada	EMTRICITABINE/TENOFOVIR (TDF)	TABLET	167-250 MG	NOT COVERED	PAP	Contact manufacturer for PAP
97430	61644	081808-ANTIRETROVIRALS	Reyataz	ATAZANAVIR SULFATE	CAPSULE	300 MG	NOT COVERED	PAP	Contact manufacturer for PAP
15555	49849	081808-ANTIRETROVIRALS	Sustiva	EFAVIRENZ	TABLET	600 MG	NOT COVERED	PAP	Contact manufacturer for PAP
31227	68449	081808-ANTIRETROVIRALS	Viread	TENOFOVIR DISOPROXIL FUMARATE	POWDER	40 MG/SCOOP	NOT COVERED	NON-FORMULARY
14822	48843	081808-ANTIRETROVIRALS	Viread	TENOFOVIR DISOPROXIL FUMARATE	TABLET	300 MG	NOT COVERED	NON-FORMULARY
31228	68450	081808-ANTIRETROVIRALS	Viread	TENOFOVIR DISOPROXIL FUMARATE	TABLET	150 MG	NOT COVERED	NON-FORMULARY
31229	68451	081808-ANTIRETROVIRALS	Viread	TENOFOVIR DISOPROXIL FUMARATE	TABLET	200 MG	NOT COVERED	NON-FORMULARY
31234	68453	081808-ANTIRETROVIRALS	Viread	TENOFOVIR DISOPROXIL FUMARATE	TABLET	250 MG	NOT COVERED	NON-FORMULARY
24465	58933	081832-NUCLEOSIDES AND NUCLEOTIDES	Baraclude	ENTECAVIR	SOLUTION	0.05 MG/ML	NOT COVERED	PAP	Prior Auths's Restricted to GI Clinic, Contact manufacturer for PAP
24466	58934	081832-NUCLEOSIDES AND NUCLEOTIDES	Baraclude	ENTECAVIR	TABLET	0.5 MG	NOT COVERED	PAP	Prior Auths's Restricted to GI Clinic, Contact manufacturer for PAP
24467	58935	081832-NUCLEOSIDES AND NUCLEOTIDES	Baraclude	ENTECAVIR	TABLET	1 MG	NOT COVERED	PAP	Prior Auths's Restricted to GI Clinic, Contact manufacturer for PAP
28648	66391	083600-URINARY ANTI-INFECTIVES	Uribel	MTH/ME BLUE/SOD PHOS/PHEN/HYOS	CAPSULE	118-10-36 MG	NOT COVERED	PAP	Contact manufacturer for PAP
24410	24515	100000-ANTINEOPLASTIC AGENTS	Arimidex	ANASTROZOLE	TABLET	1 MG	NOT COVERED	NON-FORMULARY
33084	69855	120808-ANTIMUSCARINICS/ANTISPASMODICS	Tudorza Pressair DPI	ACLIDINIUM BROMIDE	AER POW BA	400 MCG	NOT COVERED	PAP	Formulary: Ipratropium nebulized solution. Contact manufacturer for PAP
24621	59081	120808-ANTIMUSCARINICS/ANTISPASMODICS	Atrovent HFA	IPRATROPIUM BROMIDE	HFA AER AD	17 MCG	NOT COVERED	PAP	Formulary: Ipratropium nebulized solution, Contact manufacturer for PAP
32395	69371	120808-ANTIMUSCARINICS/ANTISPASMODICS	Combivent MDI	IPRATROPIUM/ALBUTEROL SULFATE	MIST INHAL	20-100 MCG	NOT COVERED	PAP	Formulary: Ipratropium/Albuterol nebulized solution formulary. Contact manufacturer for PAP
98921	63164	120808-ANTIMUSCARINICS/ANTISPASMODICS	Spiriva Respimat	TIOTROPIUM BROMIDE	MIST INHAL	2.5 MCG	NOT COVERED	PAP	Formulary: Ipratropium nebulized solution. Contact manufacturer for PAP
35903	71883	120808-ANTIMUSCARINICS/ANTISPASMODICS	Anoro Ellipta	UMECLIDINIUM BRM/VILANTEROL TR	BLST W/DEV	62.5-25 MCG	NOT COVERED	PAP	Formulary: Ipratropium/Albuterol nebulized solution formulary. Contact manufacturer for PAP
36574	72375	120808-ANTIMUSCARINICS/ANTISPASMODICS	Incruse Ellipta	UMECLIDINIUM BROMIDE	BLST W/DEV	62.5 MCG	NOT COVERED	PAP	Formulary: Ipratropium nebulized solution. Contact manufacturer for PAP
97366	61579	121208-BETA-ADRENERGIC AGONISTS	Brovana	ARFORMOTEROL TARTRATE	VIAL-NEB	15 MCG/2ML	NOT COVERED	NON-FORMULARY	Formulary: Albuterol nebulized solution is formulary.
92024	45052	121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)	Uroxatral	ALFUZOSIN HCL	TAB ER 24H	10 MG	NOT COVERED	NON-FORMULARY	Formulary: Tamsulosin, Terazosin, Prazosin.
16857	64846	121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)	Rapaflo	SILODOSIN	CAPSULE	4 MG	NOT COVERED	PAP	Formulary: Tamsulosin, Terazosin, Prazosin. Contact manufacturer for PAP
16858	64847	121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)	Rapaflo	SILODOSIN	CAPSULE	8 MG	NOT COVERED	PAP	Formulary: Tamsulosin, Terazosin, Prazosin. Contact manufacturer for PAP
33935	70414	201204-ANTICOAGULANTS	Eliquis	APIXABAN	TABLET	5 MG	NOT COVERED	PAP	Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
30239	67642	201204-ANTICOAGULANTS	Eliquis	APIXABAN	TABLET	2.5 MG	NOT COVERED	PAP	Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
29166	66781	201204-ANTICOAGULANTS	Pradaxa	DABIGATRAN ETEXILATE MESYLATE	CAPSULE	150 MG	NOT COVERED	PAP	Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
99708	63997	201204-ANTICOAGULANTS	Pradaxa	DABIGATRAN ETEXILATE MESYLATE	CAPSULE	75 MG	NOT COVERED	PAP	Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
37675	73293	201204-ANTICOAGULANTS	Savaysa	EDOXABAN	TABLET	15 MG	NOT COVERED	NON-FORMULARY	Formulary: Enoxaparin, Warfarin.
37676	73294	201204-ANTICOAGULANTS	Savaysa	EDOXABAN	TABLET	30 MG	NOT COVERED	NON-FORMULARY	Formulary: Enoxaparin, Warfarin.
37677	73295	201204-ANTICOAGULANTS	Savaysa	EDOXABAN	TABLET	60 MG	NOT COVERED	NON-FORMULARY	Formulary: Enoxaparin, Warfarin.
37212	72904	201204-ANTICOAGULANTS	Xarelto Starting Month Pack	RIVAROXABAN	TAB DS PK	15(42)-20(9) MG	NOT COVERED	PAP	Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
14427	64493	201204-ANTICOAGULANTS	Xarelto	RIVAROXABAN	TABLET	10 MG	NOT COVERED	PAP	Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
30818	68118	201204-ANTICOAGULANTS	Xarelto	RIVAROXABAN	TABLET	15 MG	NOT COVERED	PAP	Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
30819	68119	201204-ANTICOAGULANTS	Xarelto	RIVAROXABAN	TABLET	20 MG	NOT COVERED	PAP	Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP
17157	64902	201218-PLATELET-AGGREGATION INHIBITORS	Effient	PRASUGREL HCL	TABLET	10 MG	NOT COVERED	NON-FORMULARY	Formulary: Clopidogrel.
17056	64901	201218-PLATELET-AGGREGATION INHIBITORS	Effient	PRASUGREL HCL	TABLET	5 MG	NOT COVERED	NON-FORMULARY	Formulary: Clopidogrel.
29385	66950	201218-PLATELET-AGGREGATION INHIBITORS	Brilinta	TICAGRELOR	TABLET	90 MG	NOT COVERED	PAP	Formulary: Clopidogrel. Contact manufacturer for PAP
39407	74696	201218-PLATELET-AGGREGATION INHIBITORS	Brilinta	TICAGRELOR	TABLET	60 MG	NOT COVERED	PAP	Formulary: Clopidogrel. Contact manufacturer for PAP
24059	58592	201600-HEMATOPOIETIC AGENTS	Epogen, Procrit	EPOETIN ALFA	VIAL	20000/2ML	NOT COVERED	PAP	Contact manufacturer for PAP
25110	11740	201600-HEMATOPOIETIC AGENTS	Epogen, Procrit	EPOETIN ALFA	VIAL	2000/ML	NOT COVERED	PAP	Contact manufacturer for PAP
25111	11741	201600-HEMATOPOIETIC AGENTS	Epogen, Procrit	EPOETIN ALFA	VIAL	4000/ML	NOT COVERED	PAP	Contact manufacturer for PAP
25112	11742	201600-HEMATOPOIETIC AGENTS	Epogen, Procrit	EPOETIN ALFA	VIAL	10000/ML	NOT COVERED	PAP	Contact manufacturer for PAP
25113	15164	201600-HEMATOPOIETIC AGENTS	Epogen, Procrit	EPOETIN ALFA	VIAL	3000/ML	NOT COVERED	PAP	Contact manufacturer for PAP
25114	25708	201600-HEMATOPOIETIC AGENTS	Epogen, Procrit	EPOETIN ALFA	VIAL	20000/ML	NOT COVERED	PAP	Contact manufacturer for PAP
25115	41394	201600-HEMATOPOIETIC AGENTS	Epogen, Procrit	EPOETIN ALFA	VIAL	40000/ML	NOT COVERED	PAP	Contact manufacturer for PAP
26586	65367	240404-ANTIARRHYTHMIC AGENTS	Multaq	DRONEDARONE HCL	TABLET	400 MG	NOT COVERED	PAP	Formulary: Amiodarone. Contact manufacturer for PAP
95347	40303	241292-VASODILATING AGENTS, MISCELLANEOUS	Aggrenox	ASPIRIN/DIPYRIDAMOLE	CPMP 12HR	25-200 MG	NOT COVERED	NON-FORMULARY	Formulary: Clopidogrel.
97596	61811	242400-BETA-ADRENERGIC BLOCKING AGENTS	Coreg CR	CARVEDILOL PHOSPHATE	CPMP 24HR	10 MG	NOT COVERED	PAP	Formulary: Carvedilol IR. Contact manufacturer for PAP
97597	61812	242400-BETA-ADRENERGIC BLOCKING AGENTS	Coreg CR	CARVEDILOL PHOSPHATE	CPMP 24HR	20 MG	NOT COVERED	PAP	Formulary: Carvedilol IR. Contact manufacturer for PAP
97598	61813	242400-BETA-ADRENERGIC BLOCKING AGENTS	Coreg CR	CARVEDILOL PHOSPHATE	CPMP 24HR	40 MG	NOT COVERED	PAP	Formulary: Carvedilol IR. Contact manufacturer for PAP
97599	61814	242400-BETA-ADRENERGIC BLOCKING AGENTS	Coreg CR	CARVEDILOL PHOSPHATE	CPMP 24HR	80 MG	NOT COVERED	PAP	Formulary: Carvedilol IR. Contact manufacturer for PAP
7055	36654	242400-BETA-ADRENERGIC BLOCKING AGENTS	Bystolic	NEBIVOLOL HCL	TABLET	5 MG	NOT COVERED	PAP	Formulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP
18703	64945	242400-BETA-ADRENERGIC BLOCKING AGENTS	Bystolic	NEBIVOLOL HCL	TABLET	20 MG	NOT COVERED	PAP	Formulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP
99235	63510	242400-BETA-ADRENERGIC BLOCKING AGENTS	Bystolic	NEBIVOLOL HCL	TABLET	2.5 MG	NOT COVERED	PAP	Formulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP
99236	63511	242400-BETA-ADRENERGIC BLOCKING AGENTS	Bystolic	NEBIVOLOL HCL	TABLET	10 MG	NOT COVERED	PAP	Formulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP
97962	62180	242808-DIHYDROPYRIDINES	Exforge	AMLODIPINE/VALSARTAN	TABLET	5-160 MG	NOT COVERED	PAP	Prescribe amlodipine and irbesartan or Lotrel, Contact manufacturer for PAP
97963	62181	242808-DIHYDROPYRIDINES	Exforge	AMLODIPINE/VALSARTAN	TABLET	10-160 MG	NOT COVERED	PAP	Prescribe amlodipine and irbesartan or Lotrel, Contact manufacturer for PAP
98579	62808	242808-DIHYDROPYRIDINES	Exforge	AMLODIPINE/VALSARTAN	TABLET	5-320 MG	NOT COVERED	PAP	Prescribe amlodipine and irbesartan or Lotrel, Contact manufacturer for PAP
98580	62809	242808-DIHYDROPYRIDINES	Exforge	AMLODIPINE/VALSARTAN	TABLET	10-320 MG	NOT COVERED	PAP	Prescribe amlodipine and irbesartan or Lotrel, Contact manufacturer for PAP
39046	74408	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Entresto	SACUBITRIL/VALSARTAN	TABLET	24 MG-26MG	NOT COVERED	PAP	Formulary: Losartan, Irbesartan. Contact manufacturer for PAP
39047	74409	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Entresto	SACUBITRIL/VALSARTAN	TABLET	49 MG-51MG	NOT COVERED	PAP	Formulary: Losartan, Irbesartan. Contact manufacturer for PAP
39048	74410	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Entresto	SACUBITRIL/VALSARTAN	TABLET	97MG-103MG	NOT COVERED	PAP	Formulary: Losartan, Irbesartan. Contact manufacturer for PAP
17285	50289	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Benicar	OLMESARTAN MEDOXOMIL	TABLET	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan.
17286	50290	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Benicar	OLMESARTAN MEDOXOMIL	TABLET	40 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan.
17284	50288	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Benicar	OLMESARTAN MEDOXOMIL	TABLET	5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan.
28837	66538	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Tribenzor	OLMESARTAN/AMLODIPIN/HCTHIAZID	TABLET	20-5-12.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan.
28838	66539	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Tribenzor	OLMESARTAN/AMLODIPIN/HCTHIAZID	TABLET	40-5-12.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan.
28839	66540	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Tribenzor	OLMESARTAN/AMLODIPIN/HCTHIAZID	TABLET	40-5-25 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan.
28854	66541	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Tribenzor	OLMESARTAN/AMLODIPIN/HCTHIAZID	TABLET	40-10-12.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan.
28855	66542	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Tribenzor	OLMESARTAN/AMLODIPIN/HCTHIAZID	TABLET	40-10-25 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan.
20074	52833	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Benicar HCT	OLMESARTAN/HYDROCHLOROTHIAZIDE	TABLET	20-12.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan.
20075	52834	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Benicar HCT	OLMESARTAN/HYDROCHLOROTHIAZIDE	TABLET	40-12.5 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan.
20076	52835	243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS	Benicar HCT	OLMESARTAN/HYDROCHLOROTHIAZIDE	TABLET	40-25 MG	NOT COVERED	NON-FORMULARY	Formulary: Losartan, Irbesartan.
37158	72862	280808-OPIATE AGONISTS	Oxycodone ER	OXYCODONE HCL	TAB ER 12H	10 MG	NOT COVERED	NON-FORMULARY	Formulary: Morphine
37159	72863	280808-OPIATE AGONISTS	Oxycodone ER	OXYCODONE HCL	TAB ER 12H	15 MG	NOT COVERED	NON-FORMULARY	Formulary: Morphine
37161	72864	280808-OPIATE AGONISTS	Oxycodone ER	OXYCODONE HCL	TAB ER 12H	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Morphine
37162	72865	280808-OPIATE AGONISTS	Oxycodone ER	OXYCODONE HCL	TAB ER 12H	30 MG	NOT COVERED	NON-FORMULARY	Formulary: Morphine
37163	72866	280808-OPIATE AGONISTS	Oxycodone ER	OXYCODONE HCL	TAB ER 12H	40 MG	NOT COVERED	NON-FORMULARY	Formulary: Morphine
37164	72867	280808-OPIATE AGONISTS	Oxycodone ER	OXYCODONE HCL	TAB ER 12H	60 MG	NOT COVERED	NON-FORMULARY	Formulary: Morphine
37165	72868	280808-OPIATE AGONISTS	Oxycodone ER	OXYCODONE HCL	TAB ER 12H	80 MG	NOT COVERED	NON-FORMULARY	Formulary: Morphine
9070	20647	281208-BENZODIAZEPINES (ANTICONVULSANTS)	Onfi	CLOBAZAM	TABLET	20 MG	NOT COVERED	PAP	Contact manufacturer for PAP
9071	17026	281208-BENZODIAZEPINES (ANTICONVULSANTS)	Onfi	CLOBAZAM	TABLET	10 MG	NOT COVERED	PAP	Contact manufacturer for PAP
28643	66386	281292-ANTICONVULSANTS, MISCELLANEOUS	Vimpat	LACOSAMIDE	SOLUTION	10 MG/ML	NOT COVERED	PAP	Contact manufacturer for PAP
14338	64432	281292-ANTICONVULSANTS, MISCELLANEOUS	Vimpat	LACOSAMIDE	TABLET	50 MG	NOT COVERED	PAP	Contact manufacturer for PAP
14339	64433	281292-ANTICONVULSANTS, MISCELLANEOUS	Vimpat	LACOSAMIDE	TABLET	100 MG	NOT COVERED	PAP	Contact manufacturer for PAP
14341	64434	281292-ANTICONVULSANTS, MISCELLANEOUS	Vimpat	LACOSAMIDE	TABLET	150 MG	NOT COVERED	PAP	Contact manufacturer for PAP
14342	64435	281292-ANTICONVULSANTS, MISCELLANEOUS	Vimpat	LACOSAMIDE	TABLET	200 MG	NOT COVERED	PAP	Contact manufacturer for PAP
14344	64437	281292-ANTICONVULSANTS, MISCELLANEOUS	Vimpat	LACOSAMIDE	VIAL	200 MG/20ML	NOT COVERED	PAP	Contact manufacturer for PAP
24693	65250	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal XR	LAMOTRIGINE	TAB ER 24	25 MG	NOT COVERED	PAP	Formulary: Lamotrigine IR. Contact manufacturer for PAP
24739	65253	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal XR	LAMOTRIGINE	TAB ER 24	200 MG	NOT COVERED	PAP	Formulary: Lamotrigine IR. Contact manufacturer for PAP
24697	65251	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal XR	LAMOTRIGINE	TAB ER 24	50 MG	NOT COVERED	PAP	Formulary: Lamotrigine IR. Contact manufacturer for PAP
24703	65252	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal XR	LAMOTRIGINE	TAB ER 24	100 MG	NOT COVERED	PAP	Formulary: Lamotrigine IR. Contact manufacturer for PAP
29725	67221	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal XR	LAMOTRIGINE	TAB ER 24	300 MG	NOT COVERED	PAP	Formulary: Lamotrigine IR. Contact manufacturer for PAP
30787	68093	281292-ANTICONVULSANTS, MISCELLANEOUS	Lamictal XR	LAMOTRIGINE	TAB ER 24	250 MG	NOT COVERED	PAP	Formulary: Lamotrigine IR. Contact manufacturer for PAP
14305	64416	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra XR	LEVETIRACETAM	TAB ER 24H	500 MG	NOT COVERED	NON-FORMULARY	Formulary: Levetiracetam IR.
20765	64990	281292-ANTICONVULSANTS, MISCELLANEOUS	Keppra XR	LEVETIRACETAM	TAB ER 24H	750 MG	NOT COVERED	NON-FORMULARY	Formulary: Levetiracetam IR.
36556	40901	281292-ANTICONVULSANTS, MISCELLANEOUS	Topamax Sprinkle Cap	TOPIRAMATE	CAP SPRINK	15 MG	NOT COVERED	PAP	Contact manufacturer for PAP
36557	40902	281292-ANTICONVULSANTS, MISCELLANEOUS	Topamax Sprinkle Cap	TOPIRAMATE	CAP SPRINK	25 MG	NOT COVERED	PAP	Contact manufacturer for PAP
35328	71496	281604-ANTIDEPRESSANTS	Fetzima	LEVOMILNACIPRAN HYDROCHLORIDE	CAP SA 24H	40 MG	NOT COVERED	NON-FORMULARY	Formulary: Venlafaxine ER capsules, Duloxetine DR.
35327	71495	281604-ANTIDEPRESSANTS	Fetzima	LEVOMILNACIPRAN HYDROCHLORIDE	CAP SA 24H	20 MG	NOT COVERED	NON-FORMULARY	Formulary: Venlafaxine ER capsules, Duloxetine DR.
35329	71497	281604-ANTIDEPRESSANTS	Fetzima	LEVOMILNACIPRAN HYDROCHLORIDE	CAP SA 24H	80 MG	NOT COVERED	NON-FORMULARY	Formulary: Venlafaxine ER capsules, Duloxetine DR.
35334	71498	281604-ANTIDEPRESSANTS	Fetzima	LEVOMILNACIPRAN HYDROCHLORIDE	CAP SA 24H	120 MG	NOT COVERED	NON-FORMULARY	Formulary: Venlafaxine ER capsules, Duloxetine DR.
35335	71499	281604-ANTIDEPRESSANTS	Fetzima	LEVOMILNACIPRAN HYDROCHLORIDE	CAP24HDSPK	20-40 MG	NOT COVERED	NON-FORMULARY	Formulary: Venlafaxine ER capsules, Duloxetine DR.
20869	53401	281604-ANTIDEPRESSANTS	Symbyax	OLANZAPINE/FLUOXETINE HCL	CAPSULE	6-50 MG	NOT COVERED	PAP	Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP
20868	53400	281604-ANTIDEPRESSANTS	Symbyax	OLANZAPINE/FLUOXETINE HCL	CAPSULE	6-25 MG	NOT COVERED	PAP	Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP
20870	53402	281604-ANTIDEPRESSANTS	Symbyax	OLANZAPINE/FLUOXETINE HCL	CAPSULE	12-25 MG	NOT COVERED	PAP	Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP
20872	53403	281604-ANTIDEPRESSANTS	Symbyax	OLANZAPINE/FLUOXETINE HCL	CAPSULE	12-50 MG	NOT COVERED	PAP	Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP
98648	62878	281604-ANTIDEPRESSANTS	Symbyax	OLANZAPINE/FLUOXETINE HCL	CAPSULE	3-25 MG	NOT COVERED	PAP	Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP
38253	73810	281604-ANTIDEPRESSANTS	Viibryd Titration Pack	VILAZODONE HYDROCHLORIDE	TAB DS PK	10 MG-20 MG	NOT COVERED	PAP	Contact manufacturer for PAP
29918	67378	281604-ANTIDEPRESSANTS	Viibryd	VILAZODONE HYDROCHLORIDE	TABLET	40 MG	NOT COVERED	PAP	Contact manufacturer for PAP
29916	67376	281604-ANTIDEPRESSANTS	Viibryd	VILAZODONE HYDROCHLORIDE	TABLET	10 MG	NOT COVERED	PAP	Contact manufacturer for PAP
29917	67377	281604-ANTIDEPRESSANTS	Viibryd	VILAZODONE HYDROCHLORIDE	TABLET	20 MG	NOT COVERED	PAP	Contact manufacturer for PAP
28034	65908	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TAB DS PK	1-2-4-6 MG	NOT COVERED	NON-FORMULARY	Formulary: Olanzapine, Quetiapine, and Risperidone.
28025	65901	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TABLET	1 MG	NOT COVERED	NON-FORMULARY	Formulary: Olanzapine, Quetiapine, and Risperidone.
28026	65902	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TABLET	2 MG	NOT COVERED	NON-FORMULARY	Formulary: Olanzapine, Quetiapine, and Risperidone.
28027	65903	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TABLET	4 MG	NOT COVERED	NON-FORMULARY	Formulary: Olanzapine, Quetiapine, and Risperidone.
28028	65904	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TABLET	6 MG	NOT COVERED	NON-FORMULARY	Formulary: Olanzapine, Quetiapine, and Risperidone.
28029	65905	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TABLET	8 MG	NOT COVERED	NON-FORMULARY	Formulary: Olanzapine, Quetiapine, and Risperidone.
28030	65906	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TABLET	10 MG	NOT COVERED	NON-FORMULARY	Formulary: Olanzapine, Quetiapine, and Risperidone.
28033	65907	281608-ANTIPSYCHOTIC AGENTS	Fanapt	ILOPERIDONE	TABLET	12 MG	NOT COVERED	NON-FORMULARY	Formulary: Olanzapine, Quetiapine, and Risperidone.
29366	66932	281608-ANTIPSYCHOTIC AGENTS	Latuda	LURASIDONE HCL	TABLET	40 MG	NOT COVERED	PAP	Formulary: Olanzapine, Quetiapine, and Risperidone. Contact manufacturer for PAP
29367	66933	281608-ANTIPSYCHOTIC AGENTS	Latuda	LURASIDONE HCL	TABLET	80 MG	NOT COVERED	PAP	Formulary: Olanzapine, Quetiapine, and Risperidone. Contact manufacturer for PAP
31226	68448	281608-ANTIPSYCHOTIC AGENTS	Latuda	LURASIDONE HCL	TABLET	20 MG	NOT COVERED	PAP	Formulary: Olanzapine, Quetiapine, and Risperidone. Contact manufacturer for PAP
33147	69894	281608-ANTIPSYCHOTIC AGENTS	Latuda	LURASIDONE HCL	TABLET	120 MG	NOT COVERED	PAP	Formulary: Olanzapine, Quetiapine, and Risperidone. Contact manufacturer for PAP
35192	71415	281608-ANTIPSYCHOTIC AGENTS	Latuda	LURASIDONE HCL	TABLET	60 MG	NOT COVERED	PAP	Formulary: Olanzapine, Quetiapine, and Risperidone. Contact manufacturer for PAP
34022	47285	281608-ANTIPSYCHOTIC AGENTS	Zyprexa Zydis	OLANZAPINE	TAB RAPDIS	15 MG	NOT COVERED	PAP	Formulary: Olanzapine tablet. Contact manufacturer for PAP
34023	47286	281608-ANTIPSYCHOTIC AGENTS	Zyprexa Zydis	OLANZAPINE	TAB RAPDIS	20 MG	NOT COVERED	PAP	Formulary: Olanzapine tablet. Contact manufacturer for PAP
92007	45190	281608-ANTIPSYCHOTIC AGENTS	Zyprexa Zydis	OLANZAPINE	TAB RAPDIS	5 MG	NOT COVERED	PAP	Formulary: Olanzapine tablet. Contact manufacturer for PAP
92008	45191	281608-ANTIPSYCHOTIC AGENTS	Zyprexa Zydis	OLANZAPINE	TAB RAPDIS	10 MG	NOT COVERED	PAP	Formulary: Olanzapine tablet. Contact manufacturer for PAP
97769	61985	281608-ANTIPSYCHOTIC AGENTS	Invega	PALIPERIDONE	TAB ER 24	3 MG	NOT COVERED	PAP	Formulary: Risperidone. Contact manufacturer for PAP
97770	61986	281608-ANTIPSYCHOTIC AGENTS	Invega	PALIPERIDONE	TAB ER 24	6 MG	NOT COVERED	PAP	Formulary: Risperidone. Contact manufacturer for PAP
97771	61987	281608-ANTIPSYCHOTIC AGENTS	Invega	PALIPERIDONE	TAB ER 24	9 MG	NOT COVERED	PAP	Formulary: Risperidone. Contact manufacturer for PAP
27685	65667	281608-ANTIPSYCHOTIC AGENTS	Invega	PALIPERIDONE	TAB ER 24	1.5 MG	NOT COVERED	PAP	Formulary: Risperidone. Contact manufacturer for PAP
98994	63240	281608-ANTIPSYCHOTIC AGENTS	Seroquel XR	QUETIAPINE FUMARATE	TAB ER 24H	50 MG	Covered	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy,
16193	64725	281608-ANTIPSYCHOTIC AGENTS	Seroquel XR	QUETIAPINE FUMARATE	TAB ER 24H	150 MG	Covered	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy,
98522	62748	281608-ANTIPSYCHOTIC AGENTS	Seroquel XR	QUETIAPINE FUMARATE	TAB ER 24H	200 MG	Covered	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy,
98523	62749	281608-ANTIPSYCHOTIC AGENTS	Seroquel XR	QUETIAPINE FUMARATE	TAB ER 24H	300 MG	Covered	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy,
98524	62750	281608-ANTIPSYCHOTIC AGENTS	Seroquel XR	QUETIAPINE FUMARATE	TAB ER 24H	400 MG	Covered	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to Central Pharmacy,
98071	62283	282004-AMPHETAMINES	Vyvanse	LISDEXAMFETAMINE DIMESYLATE	CAPSULE	30 MG	NOT COVERED	PAP	Formulary: Adderall XR. Contact manufacturer for PAP
98072	62284	282004-AMPHETAMINES	Vyvanse	LISDEXAMFETAMINE DIMESYLATE	CAPSULE	50 MG	NOT COVERED	PAP	Formulary: Adderall XR. Contact manufacturer for PAP
99366	63645	282004-AMPHETAMINES	Vyvanse	LISDEXAMFETAMINE DIMESYLATE	CAPSULE	20 MG	NOT COVERED	PAP	Formulary: Adderall XR. Contact manufacturer for PAP
99367	63646	282004-AMPHETAMINES	Vyvanse	LISDEXAMFETAMINE DIMESYLATE	CAPSULE	40 MG	NOT COVERED	PAP	Formulary: Adderall XR. Contact manufacturer for PAP
99368	63647	282004-AMPHETAMINES	Vyvanse	LISDEXAMFETAMINE DIMESYLATE	CAPSULE	60 MG	NOT COVERED	PAP	Formulary: Adderall XR. Contact manufacturer for PAP
37674	73292	282004-AMPHETAMINES	Vyvanse	LISDEXAMFETAMINE DIMESYLATE	CAPSULE	10 MG	NOT COVERED	PAP	Formulary: Adderall XR. Contact manufacturer for PAP
98073	62285	282004-AMPHETAMINES	Vyvanse	LISDEXAMFETAMINE DIMESYLATE	CAPSULE	70 MG	NOT COVERED	PAP	Formulary: Adderall XR. Contact manufacturer for PAP
12248	47318	282032-RESPIRATORY AND CNS STIMULANTS	Concerta	METHYLPHENIDATE HCL	TAB ER 24	54 MG	NOT COVERED	PAP	Formulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP
12568	45982	282032-RESPIRATORY AND CNS STIMULANTS	Concerta	METHYLPHENIDATE HCL	TAB ER 24	36 MG	NOT COVERED	PAP	Formulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP
17123	50172	282032-RESPIRATORY AND CNS STIMULANTS	Concerta	METHYLPHENIDATE HCL	TAB ER 24	27 MG	NOT COVERED	PAP	Formulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP
12567	45981	282032-RESPIRATORY AND CNS STIMULANTS	Concerta	METHYLPHENIDATE HCL	TAB ER 24	18 MG	NOT COVERED	PAP	Formulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP
26515	65356	283620-DOPAMINE RECEPTOR AGONISTS	Neupro	ROTIGOTINE	PATCH TD24	1 MG/24 HR	NOT COVERED	PAP	Formulary: Ropinirole. Contact manufacturer for PAP
26516	65357	283620-DOPAMINE RECEPTOR AGONISTS	Neupro	ROTIGOTINE	PATCH TD24	3 MG/24 HR	NOT COVERED	PAP	Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP
26648	60486	283620-DOPAMINE RECEPTOR AGONISTS	Neupro	ROTIGOTINE	PATCH TD24	2 MG/24 HR	NOT COVERED	PAP	Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP
26649	60487	283620-DOPAMINE RECEPTOR AGONISTS	Neupro	ROTIGOTINE	PATCH TD24	4 MG/24 HR	NOT COVERED	PAP	Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP
26654	60488	283620-DOPAMINE RECEPTOR AGONISTS	Neupro	ROTIGOTINE	PATCH TD24	6 MG/24 HR	NOT COVERED	PAP	Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP
26655	60489	283620-DOPAMINE RECEPTOR AGONISTS	Neupro	ROTIGOTINE	PATCH TD24	8 MG/24 HR	NOT COVERED	PAP	Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP
27576	65570	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Intuniv	GUANFACINE HCL	TAB ER 24H	1 MG	NOT COVERED	PAP	Formulary: Guanfacine IR. Contact manufacturer for PAP
27578	65572	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Intuniv	GUANFACINE HCL	TAB ER 24H	2 MG	NOT COVERED	PAP	Formulary: Guanfacine IR. Contact manufacturer for PAP
27579	65573	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Intuniv	GUANFACINE HCL	TAB ER 24H	3 MG	NOT COVERED	PAP	Formulary: Guanfacine IR. Contact manufacturer for PAP
27582	65574	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Intuniv	GUANFACINE HCL	TAB ER 24H	4 MG	NOT COVERED	PAP	Formulary: Guanfacine IR. Contact manufacturer for PAP
18776	51489	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Strattera	ATOMOXETINE HCL	CAPSULE	10 MG	NOT COVERED	PAP	Contact manufacturer for PAP
18777	51490	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Strattera	ATOMOXETINE HCL	CAPSULE	18 MG	NOT COVERED	PAP	Contact manufacturer for PAP
18778	51491	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Strattera	ATOMOXETINE HCL	CAPSULE	25 MG	NOT COVERED	PAP	Contact manufacturer for PAP
18779	51492	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Strattera	ATOMOXETINE HCL	CAPSULE	40 MG	NOT COVERED	PAP	Contact manufacturer for PAP
18781	51493	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Strattera	ATOMOXETINE HCL	CAPSULE	60 MG	NOT COVERED	PAP	Contact manufacturer for PAP
26538	60390	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Strattera	ATOMOXETINE HCL	CAPSULE	80 MG	NOT COVERED	PAP	Contact manufacturer for PAP
26539	60391	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Strattera	ATOMOXETINE HCL	CAPSULE	100 MG	NOT COVERED	PAP	Contact manufacturer for PAP
95200	40962	366000-THYROID FUNCTION	Thyrogen	THYROTROPIN ALFA	VIAL	1.1 MG	NOT COVERED	PAP
43725	77644	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	QVAR Redihaler	BECLOMETHASONE DIPROPIONATE	HFA AEROBA	80 MCG	NOT COVERED	PAP	Formulary: Flovent HFA. Contact manufacturer for PAP
43724	77643	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	QVAR Redihaler	BECLOMETHASONE DIPROPIONATE	HFA AEROBA	40 MCG	NOT COVERED	PAP	Formulary: Flovent HFA. Contact manufacturer for PAP
98024	62240	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Pulmicort Flexhaler	BUDESONIDE	AER POW BA	90 MCG	NOT COVERED	PAP	Formulary: Flovent HFA. Contact manufacturer for PAP
98025	62241	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Pulmicort Flexhaler	BUDESONIDE	AER POW BA	180 MCG	NOT COVERED	PAP	Formulary: Flovent HFA. Contact manufacturer for PAP
98499	62725	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Symbicort MDI	BUDESONIDE/FORMOTEROL FUMARATE	HFA AER AD	80-4.5 MCG	NOT COVERED	PAP	Formulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
98500	62726	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Symbicort MDI	BUDESONIDE/FORMOTEROL FUMARATE	HFA AER AD	160-4.5 MCG	NOT COVERED	PAP	Formulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
53633	19317	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Flovent DIKUS	FLUTICASONE PROPIONATE	BLST W/DEV	100 MCG	NOT COVERED	PAP	Formulary: Flovent HFA. Contact manufacturer for PAP
53634	19318	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Flovent DIKUS	FLUTICASONE PROPIONATE	BLST W/DEV	250 MCG	NOT COVERED	PAP	Formulary: Flovent HFA. Contact manufacturer for PAP
53635	19319	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Flovent DIKUS	FLUTICASONE PROPIONATE	BLST W/DEV	50 MCG	NOT COVERED	PAP	Formulary: Flovent HFA. Contact manufacturer for PAP
50594	43367	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Advair DISKUS	FLUTICASONE/SALMETEROL	BLST W/DEV	250-50 MCG	NOT COVERED	PAP	Formulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
50604	43368	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Advair DISKUS	FLUTICASONE/SALMETEROL	BLST W/DEV	500-50 MCG	NOT COVERED	PAP	Formulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
50584	43366	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Advair DISKUS	FLUTICASONE/SALMETEROL	BLST W/DEV	100-50 MCG	NOT COVERED	PAP	Formulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
97135	61343	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Advair HFA	FLUTICASONE/SALMETEROL	HFA AER AD	45-21 MCG	NOT COVERED	PAP	Formulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
97136	61344	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Advair HFA	FLUTICASONE/SALMETEROL	HFA AER AD	115-21 MCG	NOT COVERED	PAP	Formulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
97137	61345	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Advair HFA	FLUTICASONE/SALMETEROL	HFA AER AD	230-21 MCG	NOT COVERED	PAP	Formulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
34647	70972	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Breo Ellipta	FLUTICASONE/VILANTEROL	BLST W/DEV	100-25 MCG	NOT COVERED	PAP	Formulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
35808	71815	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Breo Ellipta	FLUTICASONE/VILANTEROL	BLST W/DEV	200-25 MCG	NOT COVERED	PAP	Formulary: Flovent HFA, Dulera (restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
37565	73197	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Asmanex HFA	MOMETASONE FUROATE	HFA AER AD	200 MCG	NOT COVERED	PAP	Formulary: Flovent HFA. Contact manufacturer for PAP
37566	73198	481008-CORTICOSTEROIDS (RESPIRATORY TRACT)	Asmanex HFA	MOMETASONE FUROATE	HFA AER AD	100 MCG	NOT COVERED	PAP	Formulary: Flovent HFA. Contact manufacturer for PAP
40321	29803	481024-LEUKOTRIENE MODIFIERS	Zyflo Filmtab	ZILEUTON	TABLET	600 MG	NOT COVERED	NON-FORMULARY	Formulary: Montelukast.
98822	63062	481024-LEUKOTRIENE MODIFIERS	Zyflo Filmtab	ZILEUTON	TBMP 12HR	600 MG	NOT COVERED	NON-FORMULARY	Formulary: Montelukast.
28934	66612	483200-PHOSPHODIESTERASE TYPE 4 INHIBITORS	Daliresp	ROFLUMILAST	TABLET	500 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
19216	51820	520892-EENT ANTI-INFLAMMATORY AGENTS, MISC.	Restasis	CYCLOSPORINE	DROPERETTE	0.05 %	NOT COVERED	PAP	Prior auths restricted to opthamology prescriber, Contact manufacturer for PAP
27131	65392	524028-PROSTAGLANDIN ANALOGS	Lumigan	BIMATOPROST	DROPS	0.01 %	NOT COVERED	PAP	Formulary: Latanoprost. Prior Auths restricted to opthamology, Contact manufacturer for PAP
27594	65587	524028-PROSTAGLANDIN ANALOGS	Zioptan	TAFLUPROST/PF	DROPS	0.0015%	NOT COVERED	PAP	Formulary: Latanoprost. Prior Auths restricted to opthamology, Contact manufacturer for PAP
13002	47612	524028-PROSTAGLANDIN ANALOGS	Travatan Z	TRAVOPROST	DROPS	0.004%	NOT COVERED	PAP	Formulary: Latanoprost. Prior Auths restricted to opthamology, Contact manufacturer for PAP
26473	60341	561200-CATHARTICS AND LAXATIVES	Amitiza	LUBIPROSTONE	CAPSULE	24 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
99658	63946	561200-CATHARTICS AND LAXATIVES	Amitiza	LUBIPROSTONE	CAPSULE	8 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
16305	64793	562836-PROTON-PUMP INHIBITORS	Dexilant	DEXLANSOPRAZOLE	CAP DR BP	30 MG	NOT COVERED	PAP	Formulary: Pantoprazole. Contact manufacturer for PAP
16306	64794	562836-PROTON-PUMP INHIBITORS	Dexilant	DEXLANSOPRAZOLE	CAP DR BP	60 MG	NOT COVERED	PAP	Formulary: Pantoprazole. Contact manufacturer for PAP
16305	64793	562836-PROTON-PUMP INHIBITORS	Dexilant	DEXLANSOPRAZOLE	CAP DR BP	30 MG	NOT COVERED	PAP	Formulary: Pantoprazole. Contact manufacturer for PAP
16306	64794	562836-PROTON-PUMP INHIBITORS	Dexilant	DEXLANSOPRAZOLE	CAP DR BP	60 MG	NOT COVERED	PAP	Formulary: Pantoprazole. Contact manufacturer for PAP
95348	40304	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Colazal	BALSALAZIDE DISODIUM	CAPSULE	750 MG	NOT COVERED	NON-FORMULARY	Formulary: sulfasalazine.
99847	64139	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Rowasa	MESALAMINE W/CLEANSING WIPES	ENEMA KIT	4 G/60 ML	NOT COVERED	NON-FORMULARY
16159	64701	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Apriso ER	MESALAMINE	CAP ER 24H	0.375 G	NOT COVERED	PAP	Formulary: Sulfasalazine. Contact manufacturer for PAP
34113	70543	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Delzicol DR	MESALAMINE	CAPSULE DR	400 MG	NOT COVERED	PAP	Formulary: Sulfasalazine. Contact manufacturer for PAP
23422	58091	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Pentasa	MESALAMINE	CAPSULE ER	500 MG	NOT COVERED	PAP	Formulary: Sulfasalazine. Contact manufacturer for PAP
48490	21776	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Canasa Suppository	MESALAMINE	SUPP.RECT	1000 MG	NOT COVERED	PAP	Formulary: Sulfasalazine. Contact manufacturer for PAP
97842	62058	563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)	Lialda	MESALAMINE	TABLET DR	1.2 G	NOT COVERED	PAP	Formulary: Sulfasalazine. Contact manufacturer for PAP
39354	74654	569200-GI DRUGS, MISCELLANEOUS	Viberzi	ELUXADOLINE	TABLET	75 MG	NOT COVERED	PAP	Contact manufacturer for PAP
39355	74655	569200-GI DRUGS, MISCELLANEOUS	Viberzi	ELUXADOLINE	TABLET	100 MG	NOT COVERED	PAP	Contact manufacturer for PAP
33187	69922	569200-GI DRUGS, MISCELLANEOUS	Linzess	LINACLOTIDE	CAPSULE	145 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
33188	69923	569200-GI DRUGS, MISCELLANEOUS	Linzess	LINACLOTIDE	CAPSULE	290 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
99450	63735	682003-AMYLINOMIMETICS	Symlin	PRAMLINTIDE ACETATE	PEN INJCTR	2700 MCG/2.7ML	NOT COVERED	PAP	Contact manufacturer for PAP
99514	63804	682003-AMYLINOMIMETICS	Symlin	PRAMLINTIDE ACETATE	PEN INJCTR	1500 MCG/1.5ML	NOT COVERED	PAP	Contact manufacturer for PAP
34086	70525	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Nesina	ALOGLIPTIN	TABLET	6.25 MG	NOT COVERED	PAP	Formulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
34085	70524	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Nesina	ALOGLIPTIN	TABLET	12.5 GM	NOT COVERED	PAP	Formulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
34076	70517	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Nesina	ALOGLIPTIN	TABLET	25 MG	NOT COVERED	PAP	Formulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
27393	65430	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Onglyza	SAXAGLIPTIN HCL	TABLET	2.5 MG	NOT COVERED	PAP	Formulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
27394	65431	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Onglyza	SAXAGLIPTIN HCL	TABLET	5 MG	NOT COVERED	PAP	Formulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
29224	66817	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Kombiglyze XR	SAXAGLIPTIN HCL/METFORMIN HCL	TBMP 24HR	5-1000 MG	NOT COVERED	PAP	Formulary: Janumet (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
29225	66818	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Kombiglyze XR	SAXAGLIPTIN HCL/METFORMIN HCL	TBMP 24HR	2.5-1000 MG	NOT COVERED	PAP	Formulary: Janumet (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
29118	66816	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Kombiglyze XR	SAXAGLIPTIN HCL/METFORMIN HCL	TBMP 24HR	5-500 MG	NOT COVERED	PAP	Formulary: Janumet (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
37169	72872	682006-INCRETIN MIMETICS	Trulicity	DULAGLUTIDE	PEN INJCTR	0.75MG/0.5	NOT COVERED	PAP	Formulary: Byetta, Victoza. Contact manufacturer for PAP
37171	72873	682006-INCRETIN MIMETICS	Trulicity	DULAGLUTIDE	PEN INJCTR	1.5 MG/0.5	NOT COVERED	PAP	Formulary: Byetta, Victoza. Contact manufacturer for PAP
44039	77890	682006-INCRETIN MIMETICS	Bydureon Bcise	EXENATIDE MICROSPHERES	AUTO INJCT	2MG/0.85ML	NOT COVERED	PAP	Formulary: Byetta, Victoza. Contact manufacturer for PAP
36352	72230	682006-INCRETIN MIMETICS	Bydureon Pen	EXENATIDE MICROSPHERES	PEN INJCTR	2MG/0.65ML	NOT COVERED	PAP	Formulary: Byetta, Victoza. Contact manufacturer for PAP
26189	65344	682006-INCRETIN MIMETICS	Victoza	LIRAGLUTIDE	PEN INJCTR	0.6 MG/0.1ML	Covered	FORMULARY	Step therapy: Must demonstrate failure with Byetta
98637	62867	682008-INSULINS	Lantus Solostar	INSULIN GLARGINE HUM.REC.ANLOG	INSULN PEN	100 UNIT/ML	NOT COVERED	PAP	Formulary: Levemir. Contact manufacturer for PAP
37988	73567	682008-INSULINS	Toujeo Solostar	INSULIN GLARGINE HUM.REC.ANLOG	INSULN PEN	300 UNIT/ML	NOT COVERED	PAP	PA's Restricted to Dr. Dubois. Levemir is formulary, Contact manufacturer for PAP
13072	47780	682008-INSULINS	Lantus	INSULIN GLARGINE HUM.REC.ANLOG	VIAL	100 UNIT/ML	NOT COVERED	PAP	Formulary: Levemir. Contact manufacturer for PAP
26508	60371	682008-INSULINS	Apidra Solostar	INSULIN GLULISINE	INSULN PEN	100 UNIT/ML	NOT COVERED	PAP	Formulary: Novolog, Humalog. Contact manufacturer for PAP
25936	59985	682008-INSULINS	Apidra	INSULIN GLULISINE	VIAL	100 UNIT/ML	NOT COVERED	PAP	Formulary: Novolog, Humalog. Contact manufacturer for PAP
9633	29916	682008-INSULINS	Humulin R U500	INSULIN REGULAR HUMAN	VIAL	500 UNIT/ML	NOT COVERED	PAP	Prescribe U500 Syringes, Contact manufacturer for PAP
34439	70791	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokana	CANAGLIFLOZIN	TABLET	100 MG	NOT COVERED	PAP	Contact manufacturer for PAP
34441	70792	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokana	CANAGLIFLOZIN	TABLET	300 MG	NOT COVERED	PAP	Contact manufacturer for PAP
42315	76623	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Inokamet XR	CANAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	150-1000MG	NOT COVERED	PAP	Contact manufacturer for PAP
42312	76620	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokamet XR	CANAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	50MG-500MG	NOT COVERED	PAP	Contact manufacturer for PAP
42313	76621	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokamet XR	CANAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	50-1000 MG	NOT COVERED	PAP	Contact manufacturer for PAP
42314	76622	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokamet XR	CANAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	150-500 MG	NOT COVERED	PAP	Contact manufacturer for PAP
36857	72587	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokamet	CANAGLIFLOZIN/METFORMIN HCL	TABLET	50-1000 MG	NOT COVERED	PAP	Contact manufacturer for PAP
36859	72589	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokamet	CANAGLIFLOZIN/METFORMIN HCL	TABLET	150-1000MG	NOT COVERED	PAP	Contact manufacturer for PAP
36953	72677	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokamet	CANAGLIFLOZIN/METFORMIN HCL	TABLET	150-500 MG	NOT COVERED	PAP	Contact manufacturer for PAP
36954	72678	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Invokamet	CANAGLIFLOZIN/METFORMIN HCL	TABLET	50MG-500MG	NOT COVERED	PAP	Contact manufacturer for PAP
34394	70755	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Farxiga	DAPAGLIFLOZIN PROPANEDIOL	TABLET	10 MG	NOT COVERED	PAP	Contact manufacturer for PAP
35698	71740	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Farxiga	DAPAGLIFLOZIN PROPANEDIOL	TABLET	5 MG	NOT COVERED	PAP	Contact manufacturer for PAP
37343	73031	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Xigduo XR	DAPAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	5-1000 MG	NOT COVERED	PAP	Contact manufacturer for PAP
37339	73029	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Xigduo XR	DAPAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	5-500 MG	NOT COVERED	PAP	Contact manufacturer for PAP
37342	73030	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Xigduo XR	DAPAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	10-500 MG	NOT COVERED	PAP	Contact manufacturer for PAP
37344	73032	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Xigduo XR	DAPAGLIFLOZIN/METFORMIN HCL	TAB BP 24H	10-1000 MG	NOT COVERED	PAP	Contact manufacturer for PAP
36716	72488	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Jardiance	EMPAGLIFLOZIN	TABLET	10 MG	NOT COVERED	PAP	Contact manufacturer for PAP
36723	72489	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Jardiance	EMPAGLIFLOZIN	TABLET	25 MG	NOT COVERED	PAP	Contact manufacturer for PAP
37832	73432	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Glyxambi	EMPAGLIFLOZIN/LINAGLIPTIN	TABLET	10 MG-5 MG	NOT COVERED	PAP	Contact manufacturer for PAP
37833	73433	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Glyxambi	EMPAGLIFLOZIN/LINAGLIPTIN	TABLET	25 MG-5 MG	NOT COVERED	PAP	Contact manufacturer for PAP
38929	74316	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Synjardy	EMPAGLIFLOZIN/METFORMIN HCL	TABLET	5MG-1000MG	NOT COVERED	PAP	Contact manufacturer for PAP
38932	74318	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Synjardy	EMPAGLIFLOZIN/METFORMIN HCL	TABLET	12.5-1000	NOT COVERED	PAP	Contact manufacturer for PAP
39377	74675	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Synjardy	EMPAGLIFLOZIN/METFORMIN HCL	TABLET	5 MG-500MG	NOT COVERED	PAP	Contact manufacturer for PAP
39378	74676	682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB	Synjardy	EMPAGLIFLOZIN/METFORMIN HCL	TABLET	12.5-500MG	NOT COVERED	PAP	Contact manufacturer for PAP
14404	64481	682400-PARATHYROID	Forteo	TERIPARATIDE	PEN INJCTR	20 MCG/DOSE	NOT COVERED	PAP	Contact manufacturer for PAP
96805	34383	683200-PROGESTINS	Crinone Gel	PROGESTERONE, MICRONIZED	GEL/PF APP	4%	NOT COVERED	PAP	Endometrin preferred
63011	31769	683200-PROGESTINS	Crinone Gel	PROGESTERONE, MICRONIZED	GEL/PF APP	8%	NOT COVERED	PAP	Endometrin preferred
47632	20176	683604-THYROID AGENTS	Synthroid	LEVOTHYROXINE SODIUM	TABLET	137 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
26321	6648	683604-THYROID AGENTS	Synthroid	LEVOTHYROXINE SODIUM	TABLET	25 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
26322	6649	683604-THYROID AGENTS	Synthroid	LEVOTHYROXINE SODIUM	TABLET	50 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
26324	6650	683604-THYROID AGENTS	Synthroid	LEVOTHYROXINE SODIUM	TABLET	75 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
47631	15523	683604-THYROID AGENTS	Synthroid	LEVOTHYROXINE SODIUM	TABLET	88 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
26323	6651	683604-THYROID AGENTS	Synthroid	LEVOTHYROXINE SODIUM	TABLET	100 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
26326	6653	683604-THYROID AGENTS	Synthroid	LEVOTHYROXINE SODIUM	TABLET	125 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
26327	6654	683604-THYROID AGENTS	Synthroid	LEVOTHYROXINE SODIUM	TABLET	150 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
26328	6655	683604-THYROID AGENTS	Synthroid	LEVOTHYROXINE SODIUM	TABLET	175MCG	NOT COVERED	PAP	Contact manufacturer for PAP
26325	6656	683604-THYROID AGENTS	Synthroid	LEVOTHYROXINE SODIUM	TABLET	200 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
26329	6657	683604-THYROID AGENTS	Synthroid	LEVOTHYROXINE SODIUM	TABLET	300 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
26320	6652	683604-THYROID AGENTS	Synthroid	LEVOTHYROXINE SODIUM	TABLET	112 MCG	NOT COVERED	PAP	Contact manufacturer for PAP
13480	19141	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Soriatane	ACITRETIN	CAPSULE	10 MG	NOT COVERED	PAP	Contact manufacturer for PAP
13481	19142	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Soriatane	ACITRETIN	CAPSULE	25 MG	NOT COVERED	PAP	Contact manufacturer for PAP
18782	51494	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Avage	TAZAROTENE	CREAM (G)	0.1 %	NOT COVERED	NON-FORMULARY
85362	46983	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Tazorac Cream	TAZAROTENE	CREAM (G)	0.05 %	NOT COVERED	NON-FORMULARY
85363	46984	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Tazorac Cream	TAZAROTENE	CREAM (G)	0.1 %	NOT COVERED	NON-FORMULARY
32178	69204	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Fabior Foam	TAZAROTENE	FOAM	0.1 %	NOT COVERED	NON-FORMULARY
29222	31601	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Tazorac Cream	TAZAROTENE	GEL (GRAM)	0.1 %	NOT COVERED	NON-FORMULARY
29221	31600	849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.	Tazorac Cream	TAZAROTENE	GEL (GRAM)	0.05 %	NOT COVERED	NON-FORMULARY
23276	57982	861204-ANTIMUSCARINICS	Vesicare	SOLIFENACIN SUCCINATE	TABLET	5 MG	NOT COVERED	PAP	Oxybutynin ER preferred
23277	57983	861204-ANTIMUSCARINICS	Vesicare	SOLIFENACIN SUCCINATE	TABLET	10 MG	NOT COVERED	PAP	Oxybutynin ER preferred
32766	69630	861208-BETA-3-ADRENERGIC AGONISTS	Myrbetriq ER	MIRABEGRON	TAB ER 24H	25 MG	NOT COVERED	PAP	Contact manufacturer for PAP
32767	69631	861208-BETA-3-ADRENERGIC AGONISTS	Myrbetriq ER	MIRABEGRON	TAB ER 24H	50 MG	NOT COVERED	PAP	Contact manufacturer for PAP
16808	64829	921600-ANTIGOUT AGENTS	Uloric	FEBUXOSTAT	TABLET	40 MG	NOT COVERED	PAP	Allopurinol is formulary, Contact manufacturer for PAP
16809	64830	921600-ANTIGOUT AGENTS	Uloric	FEBUXOSTAT	TABLET	80 MG	NOT COVERED	PAP	Allopurinol is formulary, Contact manufacturer for PAP
29073	66709	922000-IMMUNOMODULATORY AGENTS	Gilenya	FINGOLIMOD HCL	CAPSULE	0.5 MG	NOT COVERED	PAP	Contact manufacturer for PAP
28656	66396	922400-BONE RESORPTION INHIBITORS	Prolia	DENOSUMAB	SYRINGE	60 MG/ML	NOT COVERED	PAP	Contact manufacturer for PAP
97005	61205	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Humira	ADALIMUMAB	PEN IJ KIT	40 MG/0.8ML	NOT COVERED	PAP	Contact manufacturer for PAP
18924	51599	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Humira	ADALIMUMAB	SYRINGEKIT	40 MG/0.8ML	NOT COVERED	PAP	Contact manufacturer for PAP
37262	72952	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Humira	ADALIMUMAB	SYRINGEKIT	10 MG/0.2ML	NOT COVERED	PAP	Contact manufacturer for PAP
99439	63724	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Humira	ADALIMUMAB	SYRINGEKIT	20 MG/0.4ML	NOT COVERED	PAP	Contact manufacturer for PAP
97724	61938	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Enbrel	ETANERCEPT	PEN INJCTR	50 MG/ML	NOT COVERED	PAP	Contact manufacturer for PAP
98398	62624	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Enbrel	ETANERCEPT	SYRINGE	25 MG/0.5ML	NOT COVERED	PAP	Contact manufacturer for PAP
23574	58214	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Enbrel	ETANERCEPT	SYRINGE	50 MG/ML	NOT COVERED	PAP	Contact manufacturer for PAP
52651	40869	923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS	Enbrel	ETANERCEPT	VIAL	25 MG	NOT COVERED	PAP	Contact manufacturer for PAP
47560	23724	924400-IMMUNOSUPPRESSIVE AGENTS	Cellcept	MYCOPHENOLATE MOFETIL	CAPSULE	250 MG	NOT COVERED	PAP	Contact manufacturer for PAP
47561	32599	924400-IMMUNOSUPPRESSIVE AGENTS	Cellcept	MYCOPHENOLATE MOFETIL	CAPSULE	500 MG	NOT COVERED	PAP	Contact manufacturer for PAP
41229	21175	925600-PROTECTIVE AGENTS	Elmiron	PENTOSAN POLYSULFATE SODIUM	CAPSULE	100 MG	NOT COVERED	PAP	Contact manufacturer for PAP
45026	78657	681804-ANTIGONADOTROPINS	Orilissa	ELAGOLIX	TABLET	150 MG	NOT COVERED	PAP	Contact manufacturer for PAP
45026	78657	681804-ANTIGONADOTROPINS	Orilissa	ELAGOLIX	TABLET	200 MG	NOT COVERED	PAP	Contact manufacturer for PAP
42676	76864	682008-INSULINS	Soliqua	INSULIN GLARGINE/LIXISENATIDE	INSULN PEN	100 UNIT-33 MCG/ML	NOT COVERED	PAP	Contact manufacturer for PAP
29890	67353	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Tradjenta	LINAGLIPTIN	TABLET	5 MG	NOT COVERED	PAP	Formulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
31315	68516	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Jentadueto	LINAGLIPTIN/METFORMIN	TABLET	2.5-500 MG	NOT COVERED	PAP	Formulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
31316	68517	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Jentadueto	LINAGLIPTIN/METFORMIN	TABLET	2.5-850 MG	NOT COVERED	PAP	Formulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
31317	68518	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Jentadueto	LINAGLIPTIN/METFORMIN	TABLET	2.5-1000 MG	NOT COVERED	PAP	Formulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
41637	76256	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Jentadueto XR	LINAGLIPTIN/METFORMIN ER	TABLET	2.5-1000 MG	NOT COVERED	PAP	Formulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
41639	76257	682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS	Jentadueto XR	LINAGLIPTIN/METFORMIN ER	TABLET	5-1000 MG	NOT COVERED	PAP	Formulary: Januvia (Restricted to CUC Prescribers and Central Pharmacy). Contact manufacturer for PAP
20773	53324	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Namenda	MEMANTINE	TABLET	5 MG	NOT COVERED	PAP	Formulary: Donepezil, Rivastigmine. Contact manufacturer for PAP
3253	32492	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Namenda	MEMANTINE	TABLET	10 mg	NOT COVERED	PAP	Formulary: Donepezil, Rivastigmine. Contact manufacturer for PAP
34525	70868	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Namenda XR	MEMANTINE ER	TABLET	14 mg	NOT COVERED	PAP	Formulary: Donepezil, Rivastigmine. Contact manufacturer for PAP
34527	70870	289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.	Namenda XR	MEMANTINE ER	TABLET	28 mg	NOT COVERED	PAP	Formulary: Donepezil, Rivastigmine. Contact manufacturer for PAP
41370	9326	081228-ANTIBACTERIALS, MISCELLANEOUS	Vancocin	VANCOMYCIN	CAPSULE	125 MG	Covered	FORMULARY	Restricted to CUC Prescribers and Seton Outpatient Central Pharmacy
41371	9327	081228-ANTIBACTERIALS, MISCELLANEOUS	Vancocin	VANCOMYCIN	CAPSULE	250 MG	Covered	FORMULARY	Restricted to CUC Prescribers and Seton Outpatient Central Pharmacy

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MAP & MAP BASIC Formulary

Download an Excel spreadsheet of the complete formulary.