MAP & MAP BASIC Formulary
Download an Excel spreadsheet of the complete formulary.
Effective Date 9.23.20
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 a CUC in-house pharmacy |
60563 | 18698 | 040800-SECOND GENERATION ANTIHISTAMINES | Claritin | LORATADINE | TABLET | 10 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
26820 | 25484 | 081808-ANTIRETROVIRALS | Crixivan | INDINAVIR SULFATE | CAPSULE | 200 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
26822 | 25485 | 081808-ANTIRETROVIRALS | Crixivan | INDINAVIR SULFATE | CAPSULE | 400 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
98986 | 63231 | 081808-ANTIRETROVIRALS | Isentress | RALTEGRAVIR POTASSIUM | TABLET | 400 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
17853 | 50714 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Spiriva Handihaler | TIOTROPIUM BROMIDE | CAP W/DEV | 18 MCG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy, |
7610 | 36857 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | Nicotrol Inhaler | NICOTINE | CARTRIDGE | 10 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
3421 | 16425 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | Nicoderm CQ Patch | FESOTERODINE FUMARATE | PATCH TD24 | 7 MG/24HR | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house 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 a CUC in-house 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 a CUC in-house 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 a CUC in-house pharmacy |
27047 | 60897 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | Chantix Continuing Pack | VARENICLINE TARTRATE | TABLET | 1 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
18387 | 51214 | 240605-CHOLESTEROL ABSORPTION INHIBITORS | Zetia | EZETIMIBE | TABLET | 10 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
23125 | 57863 | 240605-CHOLESTEROL ABSORPTION INHIBITORS | Vytorin | EZETIMIBE/SIMVASTATIN | TABLET | 10-20 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
23127 | 57865 | 240605-CHOLESTEROL ABSORPTION INHIBITORS | Vytorin | EZETIMIBE/SIMVASTATIN | TABLET | 10-40 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
23121 | 57859 | 240605-CHOLESTEROL ABSORPTION INHIBITORS | Vytorin | EZETIMIBE/SIMVASTATIN | TABLET | 10-10 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
23126 | 57864 | 240605-CHOLESTEROL ABSORPTION INHIBITORS | Vytorin | EZETIMIBE/SIMVASTATIN | TABLET | 10-80 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
21392 | 53690 | 240608-HMG-COA REDUCTASE INHIBITORS | Caduet | AMLODIPINE/ATORVASTATIN | TABLET | 5-20 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
21393 | 53691 | 240608-HMG-COA REDUCTASE INHIBITORS | Caduet | AMLODIPINE/ATORVASTATIN | TABLET | 5-40 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
21396 | 53694 | 240608-HMG-COA REDUCTASE INHIBITORS | Caduet | AMLODIPINE/ATORVASTATIN | TABLET | 10-20 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
21397 | 53695 | 240608-HMG-COA REDUCTASE INHIBITORS | Caduet | AMLODIPINE/ATORVASTATIN | TABLET | 10-40 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
21391 | 53689 | 240608-HMG-COA REDUCTASE INHIBITORS | Caduet | AMLODIPINE/ATORVASTATIN | TABLET | 5-10 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
21394 | 53692 | 240608-HMG-COA REDUCTASE INHIBITORS | Caduet | AMLODIPINE/ATORVASTATIN | TABLET | 5-80 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
21395 | 53693 | 240608-HMG-COA REDUCTASE INHIBITORS | Caduet | AMLODIPINE/ATORVASTATIN | TABLET | 10-10 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
21398 | 53696 | 240608-HMG-COA REDUCTASE INHIBITORS | Caduet | AMLODIPINE/ATORVASTATIN | TABLET | 10-80 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
42001 | 41285 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Celebrex | CELECOXIB | CAPSULE | 100 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
42002 | 41286 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Celebrex | CELECOXIB | CAPSULE | 200 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
97785 | 62001 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Celebrex | CELECOXIB | CAPSULE | 50 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
18127 | 50832 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Celebrex | CELECOXIB | CAPSULE | 400 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house 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 a CUC in-house 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 a CUC in-house pharmacy |
35820 | 8370 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Feldene | PIROXICAM | CAPSULE | 10 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
35821 | 8371 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Feldene | PIROXICAM | CAPSULE | 20 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
23046 | 57800 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 50 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
23047 | 57801 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 75 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
23048 | 57802 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 100 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
23049 | 57803 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 150 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
23051 | 57804 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 200 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
23052 | 57805 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 300 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
23039 | 57799 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 25 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
25019 | 59401 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 225 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
99451 | 63736 | 281604-ANTIDEPRESSANTS | Pristiq | DESVENLAFAXINE SUCCINATE | TAB ER 24H | 50 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
99452 | 63737 | 281604-ANTIDEPRESSANTS | Pristiq | DESVENLAFAXINE SUCCINATE | TAB ER 24H | 100 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house 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 a CUC in-house pharmacy |
15174 | 49606 | 283228-SELECTIVE SEROTONIN AGONISTS | Relpax | ELETRIPTAN HBR | TABLET | 40 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
19594 | 40224 | 283228-SELECTIVE SEROTONIN AGONISTS | Maxalt MLT | RIZATRIPTAN BENZOATE | TAB RAPDIS | 10 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
19592 | 40222 | 283228-SELECTIVE SEROTONIN AGONISTS | Maxalt | RIZATRIPTAN BENZOATE | TABLET | 10 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house 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 a CUC in-house 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 a CUC in-house 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 a CUC in-house 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 a CUC in-house 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 a CUC in-house pharmacy |
71431 | 31186 | 520808-CORTICOSTEROIDS (EENT) | Nasonex | MOMETASONE FUROATE | SPRAY/PUMP | 50 MCG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house 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 a CUC in-house pharmacy |
17528 | 50464 | 681200-CONTRACEPTIVES | Nuvaring | ETONOGESTREL/ETHINYL ESTRADIOL | VAG RING | 0.12-.015 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
681200-CONTRACEPTIVES | Depo-SubQ Provera 104 | MEDROXYPROGESTERONE ACETATE | SYRINGE | 104 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house 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 a CUC in-house 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 a CUC in-house 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 a CUC in-house 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 a CUC in-house 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 a CUC in-house 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 a CUC in-house 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 a CUC in-house 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 a CUC in-house pharmacy |
24614 | 59073 | 682006-INCRETIN MIMETICS | Byetta | EXENATIDE | PEN INJCTR | 10 MCG/0.04 | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
24613 | 59072 | 682006-INCRETIN MIMETICS | Byetta | EXENATIDE | PEN INJCTR | 5 MCG/0.04 | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
99711 | 64000 | 861204-ANTIMUSCARINICS | Toviaz | FESOTERODINE FUMARATE | TAB ER 24H | 4 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
99712 | 64001 | 861204-ANTIMUSCARINICS | Toviaz | FESOTERODINE FUMARATE | TAB ER 24H | 8 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
12263 | 47327 | 861204-ANTIMUSCARINICS | Detrol LA | TOLTERODINE TARTRATE | CAP ER 24H | 4 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
12264 | 47328 | 861204-ANTIMUSCARINICS | Detrol LA | TOLTERODINE TARTRATE | CAP ER 24H | 2 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
37062 | 39139 | 861204-ANTIMUSCARINICS | Detrol | TOLTERODINE TARTRATE | TABLET | 2 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
37061 | 39138 | 861204-ANTIMUSCARINICS | Detrol | TOLTERODINE TARTRATE | TABLET | 1 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house 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. | Namenda | MEMANTINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
20773 | 53324 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Namenda | 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 | |
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 | CUC prescribers send to CUC in-house pharmacy only |
5679 | 27413 | 682008-INSULINS | Humalog | INSULIN LISPRO | VIAL | 100 UNIT/ML | COVERED | FORMULARY | CUC prescribers send to CUC in-house pharmacy only |
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 | CUC prescribers send to CUC in-house pharmacy only |
22681 | 47172 | 682008-INSULINS | Humalog 75/25 | INSULIN NPL-INSULIN LISPRO | VIAL | 75-25 UNIT/ML | COVERED | FORMULARY | CUC prescribers send to CUC in-house pharmacy only |
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 | CUC prescribers send to CUC in-house pharmacy only |
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 a CUC in-house 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 | Covered | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy, |
17056 | 64901 | 201218-PLATELET-AGGREGATION INHIBITORS | Effient | PRASUGREL HCL | TABLET | 5 MG | NOT COVERED | NON-FORMULARY | |
29385 | 66950 | 201218-PLATELET-AGGREGATION INHIBITORS | Brilinta | TICAGRELOR | TABLET | 90 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
39407 | 74696 | 201218-PLATELET-AGGREGATION INHIBITORS | Brilinta | TICAGRELOR | TABLET | 60 MG | NOT COVERED | PAP | 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 | |
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 a CUC in-house pharmacy |
16193 | 64725 | 281608-ANTIPSYCHOTIC AGENTS | Seroquel XR | QUETIAPINE FUMARATE | TAB ER 24H | 150 MG | Covered | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
98522 | 62748 | 281608-ANTIPSYCHOTIC AGENTS | Seroquel XR | QUETIAPINE FUMARATE | TAB ER 24H | 200 MG | Covered | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
98523 | 62749 | 281608-ANTIPSYCHOTIC AGENTS | Seroquel XR | QUETIAPINE FUMARATE | TAB ER 24H | 300 MG | Covered | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
98524 | 62750 | 281608-ANTIPSYCHOTIC AGENTS | Seroquel XR | QUETIAPINE FUMARATE | TAB ER 24H | 400 MG | Covered | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house 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 |
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 |