MAP & MAP BASIC Formulary

Created OnAugust 29, 2018

Last Updated OnNovember 24, 2020

byMike McKinnon, Communications Solutions & Innovation Manager

Download an Excel spreadsheet of the complete formulary.

Effective Date 9.23.20

MAP Formulary

Generic Code	Generic Sequence Number	Therapeutic Class	BrandName	GenericName	Formulation	Strength	Coverage	Location	Comments
49291	17037	040800-SECOND GENERATION ANTIHISTAMINES	Zyrtec	CETIRIZINE HCL	TABLET	10 MG	COVERED	CommUnityCare Pharmacy	Restricted to CUC Prescribers. Send to 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

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MAP & MAP BASIC Formulary

Download an Excel spreadsheet of the complete formulary.