{"id":180040,"date":"2023-08-03T16:07:01","date_gmt":"2023-08-03T21:07:01","guid":{"rendered":"https:\/\/staging.centralhealth.net\/?page_id=180040"},"modified":"2026-01-21T08:16:28","modified_gmt":"2026-01-21T14:16:28","slug":"formulary","status":"publish","type":"page","link":"https:\/\/www.centralhealth.net\/zh\/clinical-services\/for-providers\/formulary\/","title":{"rendered":"MAP \/ MAP \u57fa\u672c\u5904\u65b9\u96c6"},"content":{"rendered":"
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NON-COMMUNITYCARE PROVIDERS: Medications restricted to CUC Prescribers and\/or CUC in-house pharmacies are considered non-formulary outside of CUC. These medications may be obtained via Prescription Assistance Programs (PAP). <\/em><\/strong>If the patient does not qualify for PAP, the provider may submit a\u00a0NON-FORMULARY DRUG REQUEST (NFDR) FORM<\/a>. Documentation of PAP ineligibility or rejection should be submitted with the NDFR form.<\/em><\/strong><\/div>\n
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More information on pharmacy benefits can be found in the MAP and MAP Basic Provider Handbook<\/a>.<\/p>\n

NON-FORMULARY DRUG REQUEST (NFDR) FORM<\/a><\/p>\n

Request an addition to the MAP\/MAP Basic formulary<\/a><\/p>\n

Request an addition to the Central Health floor stock formulary<\/a>\n<\/div>\n<\/div>\n

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MAP Formulary (March 2026 edition)<\/h3>\n
\n \n \n\n \n \n \n \n\n\n Generic Code<\/th> Generic Sequence Number<\/th> Therapeutic Class<\/th> Brand Name<\/th> Generic Name<\/th> Formulation<\/th> Strength<\/th> Coverage<\/th> Location<\/th> Comments<\/th> <\/tr>\n<\/thead>\n \n\n \n \n\n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n Generic Code<\/td> Generic Sequence Number<\/td> Therapeutic Class<\/td> Brand Name<\/td> Generic Name<\/td> Formulation<\/td> Strength<\/td> Coverage<\/td> Location<\/td> Comments<\/td> <\/tr>\n <\/tfoot>\n \n <\/table>\n\n<\/div>
49.291<\/td>\n 17.037<\/td>\n 040800-SECOND GENERATION ANTIHISTAMINES<\/td>\n Zyrtec<\/td>\n CETIRIZINE HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
60.563<\/td>\n 18.698<\/td>\n 040800-SECOND GENERATION ANTIHISTAMINES<\/td>\n Claritin<\/td>\n LORATADINE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.853<\/td>\n 50.714<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Spiriva Handihaler<\/td>\n TIOTROPIUM BROMIDE<\/td>\n CAP W\/DEV<\/td>\n 18 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n CUC\/CH prescribers must send to in-house pharmacies only. Non-CUC\/CH may fill at network pharmacies<\/td>\n <\/tr>\n
3.421<\/td>\n 16.425<\/td>\n 129200-AUTONOMIC DRUGS, MISCELLANEOUS<\/td>\n NICOTINE<\/td>\n NICOTINE<\/td>\n PATCH TD24<\/td>\n 7 MG\/24HR<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.422<\/td>\n 16.426<\/td>\n 129200-AUTONOMIC DRUGS, MISCELLANEOUS<\/td>\n NICOTINE<\/td>\n NICOTINE<\/td>\n PATCH TD24<\/td>\n 14 MG\/24HR<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.423<\/td>\n 16.427<\/td>\n 129200-AUTONOMIC DRUGS, MISCELLANEOUS<\/td>\n NICOTINE<\/td>\n NICOTINE<\/td>\n PATCH TD24<\/td>\n 21 MG\/24HR<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.047<\/td>\n 60.897<\/td>\n 129200-AUTONOMIC DRUGS, MISCELLANEOUS<\/td>\n Varenicline (Chantix)<\/td>\n VARENICLINE TARTRATE<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.046<\/td>\n 60.896<\/td>\n 129200-AUTONOMIC DRUGS, MISCELLANEOUS<\/td>\n Varenicline (Chantix)<\/td>\n VARENICLINE TARTRATE<\/td>\n TABLET<\/td>\n 0.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.387<\/td>\n 51.214<\/td>\n 240605-CHOLESTEROL ABSORPTION INHIBITORS<\/td>\n Zetia<\/td>\n EZETIMIBE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.001<\/td>\n 41.285<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Celebrex<\/td>\n CELECOXIB<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.002<\/td>\n 41.286<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Celebrex<\/td>\n CELECOXIB<\/td>\n CAPSULE<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
97.785<\/td>\n 62.001<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Celebrex<\/td>\n CELECOXIB<\/td>\n CAPSULE<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.127<\/td>\n 50.832<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Celebrex<\/td>\n CELECOXIB<\/td>\n CAPSULE<\/td>\n 400 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.046<\/td>\n 57.800<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lyrica<\/td>\n PREGABALIN<\/td>\n CAPSULE<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.047<\/td>\n 57.801<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lyrica<\/td>\n PREGABALIN<\/td>\n CAPSULE<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.048<\/td>\n 57.802<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lyrica<\/td>\n PREGABALIN<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.049<\/td>\n 57.803<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lyrica<\/td>\n PREGABALIN<\/td>\n CAPSULE<\/td>\n 150 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.051<\/td>\n 57.804<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lyrica<\/td>\n PREGABALIN<\/td>\n CAPSULE<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.052<\/td>\n 57.805<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lyrica<\/td>\n PREGABALIN<\/td>\n CAPSULE<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.039<\/td>\n 57.799<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lyrica<\/td>\n PREGABALIN<\/td>\n CAPSULE<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.019<\/td>\n 59.401<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lyrica<\/td>\n PREGABALIN<\/td>\n CAPSULE<\/td>\n 225 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.359<\/td>\n 69.339<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lyrica<\/td>\n PREGABALIN<\/td>\n Solution<\/td>\n 20 mg\/ml<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.537<\/td>\n 51.333<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Abilify<\/td>\n ARIPIPRAZOLE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.538<\/td>\n 51.334<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Abilify<\/td>\n ARIPIPRAZOLE<\/td>\n TABLET<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.539<\/td>\n 51.335<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Abilify<\/td>\n ARIPIPRAZOLE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.541<\/td>\n 51.336<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Abilify<\/td>\n ARIPIPRAZOLE<\/td>\n TABLET<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.173<\/td>\n 52.898<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Abilify<\/td>\n ARIPIPRAZOLE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.305<\/td>\n 60.225<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Abilify<\/td>\n ARIPIPRAZOLE<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.139<\/td>\n 67.555<\/td>\n 481008-CORTICOSTEROIDS (RESPIRATORY TRACT)<\/td>\n Dulera MDI<\/td>\n MOMETASONE\/FORMOTEROL<\/td>\n HFA AER AD<\/td>\n 50-5 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.766<\/td>\n 66.480<\/td>\n 481008-CORTICOSTEROIDS (RESPIRATORY TRACT)<\/td>\n Dulera MDI<\/td>\n MOMETASONE\/FORMOTEROL<\/td>\n HFA AER AD<\/td>\n 100-5 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.767<\/td>\n 66.481<\/td>\n 481008-CORTICOSTEROIDS (RESPIRATORY TRACT)<\/td>\n Dulera MDI<\/td>\n MOMETASONE\/FORMOTEROL<\/td>\n HFA AER AD<\/td>\n 200-5 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.528<\/td>\n 50.464<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Nuvaring<\/td>\n ETONOGESTREL\/ETHINYL ESTRADIOL<\/td>\n VAG RING<\/td>\n 0.12-.015 MG<\/td>\n COVERED<\/td>\n CommUnityCare Pharmacy<\/td>\n Restricted to CUC\/CH Prescribers. Send to a CUC in-house pharmacy<\/td>\n <\/tr>\n
24.471<\/td>\n 58.938<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Depo-SubQ Provera 104<\/td>\n MEDROXYPROGESTERONE ACETATE<\/td>\n SYRINGE<\/td>\n 104 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.306<\/td>\n 62.531<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Janumet<\/td>\n SITAGLIPTIN PHOS\/METFORMIN HCL<\/td>\n TABLET<\/td>\n 50-500 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.307<\/td>\n 62.532<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Janumet<\/td>\n SITAGLIPTIN PHOS\/METFORMIN HCL<\/td>\n TABLET<\/td>\n 50-1000 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.339<\/td>\n 68.538<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Janumet XR<\/td>\n SITAGLIPTIN PHOS\/METFORMIN HCL<\/td>\n TBMP 24HR<\/td>\n 50-500 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.340<\/td>\n 68.539<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Janumet XR<\/td>\n SITAGLIPTIN PHOS\/METFORMIN HCL<\/td>\n TBMP 24HR<\/td>\n 50-1000 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.348<\/td>\n 68.540<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Janumet XR<\/td>\n SITAGLIPTIN PHOS\/METFORMIN HCL<\/td>\n TBMP 24HR<\/td>\n 100-1000 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
97.398<\/td>\n 61.612<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Januvia<\/td>\n SITAGLIPTIN PHOSPHATE<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
97.399<\/td>\n 61.613<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Januvia<\/td>\n SITAGLIPTIN PHOSPHATE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
97.400<\/td>\n 61.614<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Januvia<\/td>\n SITAGLIPTIN PHOSPHATE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
24.614<\/td>\n 59.073<\/td>\n 682006-INCRETIN MIMETICS<\/td>\n Byetta<\/td>\n EXENATIDE<\/td>\n PEN INJCTR<\/td>\n 10 MCG\/0.04<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
24.613<\/td>\n 59.072<\/td>\n 682006-INCRETIN MIMETICS<\/td>\n Byetta<\/td>\n EXENATIDE<\/td>\n PEN INJCTR<\/td>\n 5 MCG\/0.04<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.263<\/td>\n 47.327<\/td>\n 861204-ANTIMUSCARINICS<\/td>\n Detrol LA<\/td>\n TOLTERODINE TARTRATE<\/td>\n CAP ER 24H<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.264<\/td>\n 47.328<\/td>\n 861204-ANTIMUSCARINICS<\/td>\n Detrol LA<\/td>\n TOLTERODINE TARTRATE<\/td>\n CAP ER 24H<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.977<\/td>\n 48.495<\/td>\n 040412-PHENOTHIAZINE DERIVATIVES<\/td>\n Promethazine VC<\/td>\n PHENYLEPHRINE HCL-PROMETHAZINE HCL<\/td>\n SYRUP<\/td>\n 5-6.25 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.001<\/td>\n 3.873<\/td>\n 040412-PHENOTHIAZINE DERIVATIVES<\/td>\n Phenergan Suppository<\/td>\n PROMETHAZINE HCL<\/td>\n SUPP.RECT<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.002<\/td>\n 3.874<\/td>\n 040412-PHENOTHIAZINE DERIVATIVES<\/td>\n Phenergan Suppository<\/td>\n PROMETHAZINE HCL<\/td>\n SUPP.RECT<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.003<\/td>\n 3.872<\/td>\n 040412-PHENOTHIAZINE DERIVATIVES<\/td>\n Phenergan Suppository<\/td>\n PROMETHAZINE HCL<\/td>\n SUPP.RECT<\/td>\n 12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.035<\/td>\n 3.876<\/td>\n 040412-PHENOTHIAZINE DERIVATIVES<\/td>\n Promethazine<\/td>\n PROMETHAZINE HCL<\/td>\n SYRUP<\/td>\n 6.25 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.042<\/td>\n 3.877<\/td>\n 040412-PHENOTHIAZINE DERIVATIVES<\/td>\n Promethazine<\/td>\n PROMETHAZINE HCL<\/td>\n TABLET<\/td>\n 12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.043<\/td>\n 3.878<\/td>\n 040412-PHENOTHIAZINE DERIVATIVES<\/td>\n Promethazine<\/td>\n PROMETHAZINE HCL<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.044<\/td>\n 3.879<\/td>\n 040412-PHENOTHIAZINE DERIVATIVES<\/td>\n Promethazine<\/td>\n PROMETHAZINE HCL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
96.609<\/td>\n 991<\/td>\n 040420-PROPYLAMINE DERIVATIVES<\/td>\n Brohist D<\/td>\n BROMPHENIRAMIN-PHENYLEPHRINE<\/td>\n TABLET<\/td>\n 4-10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
44.023<\/td>\n 26.792<\/td>\n 040420-PROPYLAMINE DERIVATIVES<\/td>\n Sudogest<\/td>\n PSEUDOEPHEDRINE-CHLORPHENIRAMINE<\/td>\n TABLET<\/td>\n 60 MG-4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.803<\/td>\n 4.010<\/td>\n 040492-FIRST GEN. ANTIHIST. DERIVATIVES, MISC.<\/td>\n Cypropheptadine<\/td>\n CYPROHEPTADINE HCL<\/td>\n SYRUP<\/td>\n 2 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.811<\/td>\n 4.011<\/td>\n 040492-FIRST GEN. ANTIHIST. DERIVATIVES, MISC.<\/td>\n Cypropheptadine<\/td>\n CYPROHEPTADINE HCL<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
97.950<\/td>\n 62.168<\/td>\n 040800-SECOND GENERATION ANTIHISTAMINES<\/td>\n Xyzal<\/td>\n LEVOCETIRIZINE DIHYDROCHLORIDE<\/td>\n SOLUTION<\/td>\n 2.5 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.901<\/td>\n 48.920<\/td>\n 040800-SECOND GENERATION ANTIHISTAMINES<\/td>\n Xyzal<\/td>\n LEVOCETIRIZINE DIHYDROCHLORIDE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
53.290<\/td>\n 19.283<\/td>\n 080800-ANTHELMINTICS<\/td>\n Albenza<\/td>\n ALBENDAZOLE<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
93.064<\/td>\n 43.094<\/td>\n 080800-ANTHELMINTICS<\/td>\n Stromectol<\/td>\n IVERMECTIN<\/td>\n TABLET<\/td>\n 3 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.072<\/td>\n 9.284<\/td>\n 081202-AMINOGLYCOSIDES<\/td>\n Neomycin<\/td>\n NEOMYCIN SULFATE<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.231<\/td>\n 40.257<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Cefdinir<\/td>\n CEFDINIR<\/td>\n CAPSULE<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.308<\/td>\n 58.005<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Cefdinir<\/td>\n CEFDINIR<\/td>\n SUSP RECON<\/td>\n 250 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.232<\/td>\n 40.258<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Cefdinir<\/td>\n CEFDINIR<\/td>\n SUSP RECON<\/td>\n 125 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
29.291<\/td>\n 16.582<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Cefprozil<\/td>\n CEFPROZIL<\/td>\n SUSP RECON<\/td>\n 125 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
29.292<\/td>\n 16.583<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Cefprozil<\/td>\n CEFPROZIL<\/td>\n SUSP RECON<\/td>\n 250 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
29.271<\/td>\n 16.584<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Cefprozil<\/td>\n CEFPROZIL<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
29.272<\/td>\n 16.585<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Cefprozil<\/td>\n CEFPROZIL<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.281<\/td>\n 9.136<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Ceftin<\/td>\n CEFUROXIME AXETIL<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.282<\/td>\n 9.137<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Ceftin<\/td>\n CEFUROXIME AXETIL<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.801<\/td>\n 9.042<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Keflex<\/td>\n CEPHALEXIN<\/td>\n CAPSULE<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.802<\/td>\n 9.043<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Keflex<\/td>\n CEPHALEXIN<\/td>\n CAPSULE<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.812<\/td>\n 9.046<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Keflex<\/td>\n CEPHALEXIN<\/td>\n SUSP RECON<\/td>\n 250 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.831<\/td>\n 9.049<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Keflex<\/td>\n CEPHALEXIN<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.832<\/td>\n 9.048<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Keflex<\/td>\n CEPHALEXIN<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.792<\/td>\n 24.194<\/td>\n 081212-MACROLIDES<\/td>\n Zithromax<\/td>\n AZITHROMYCIN<\/td>\n SUSP RECON<\/td>\n 100 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
61.199<\/td>\n 18.544<\/td>\n 081212-MACROLIDES<\/td>\n Zithromax<\/td>\n AZITHROMYCIN<\/td>\n SUSP RECON<\/td>\n 200 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.793<\/td>\n 26.721<\/td>\n 081212-MACROLIDES<\/td>\n Zithromax<\/td>\n AZITHROMYCIN<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.794<\/td>\n 27.252<\/td>\n 081212-MACROLIDES<\/td>\n Zithromax<\/td>\n AZITHROMYCIN<\/td>\n TABLET<\/td>\n 600 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
61.198<\/td>\n 22.624<\/td>\n 081212-MACROLIDES<\/td>\n Zithromax<\/td>\n AZITHROMYCIN<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.670<\/td>\n 19.146<\/td>\n 081212-MACROLIDES<\/td>\n Clarithromycin<\/td>\n CLARITHROMYCIN<\/td>\n SUSP RECON<\/td>\n 125 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.851<\/td>\n 16.368<\/td>\n 081212-MACROLIDES<\/td>\n Biaxin<\/td>\n CLARITHROMYCIN<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.852<\/td>\n 16.373<\/td>\n 081212-MACROLIDES<\/td>\n Biaxin<\/td>\n CLARITHROMYCIN<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.660<\/td>\n 9.258<\/td>\n 081212-MACROLIDES<\/td>\n Erythromycin<\/td>\n ERYTHROMYCIN BASE<\/td>\n CAPSULE DR<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.720<\/td>\n 9.260<\/td>\n 081212-MACROLIDES<\/td>\n Erythrocin<\/td>\n ERYTHROMYCIN BASE<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.721<\/td>\n 9.262<\/td>\n 081212-MACROLIDES<\/td>\n Erythromycin<\/td>\n ERYTHROMYCIN BASE<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.730<\/td>\n 9.263<\/td>\n 081212-MACROLIDES<\/td>\n Ery-Tab<\/td>\n ERYTHROMYCIN BASE<\/td>\n TABLET DR<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.731<\/td>\n 9.264<\/td>\n 081212-MACROLIDES<\/td>\n Ery-Tab<\/td>\n ERYTHROMYCIN BASE<\/td>\n TABLET DR<\/td>\n 333 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.732<\/td>\n 9.265<\/td>\n 081212-MACROLIDES<\/td>\n Ery-Tab<\/td>\n ERYTHROMYCIN BASE<\/td>\n TABLET DR<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.523<\/td>\n 21.205<\/td>\n 081212-MACROLIDES<\/td>\n EryPed 200<\/td>\n ERYTHROMYCIN ETHYLSUCCINATE<\/td>\n SUSP RECON<\/td>\n 200 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.524<\/td>\n 21.206<\/td>\n 081212-MACROLIDES<\/td>\n EryPed 400<\/td>\n ERYTHROMYCIN ETHYLSUCCINATE<\/td>\n SUSP RECON<\/td>\n 400 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.560<\/td>\n 9.245<\/td>\n 081212-MACROLIDES<\/td>\n E.E.S 400<\/td>\n ERYTHROMYCIN ETHYLSUCCINATE<\/td>\n TABLET<\/td>\n 400 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.642<\/td>\n 9.255<\/td>\n 081212-MACROLIDES<\/td>\n Erythromycin<\/td>\n ERYTHROMYCIN STEARATE<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.660<\/td>\n 8.995<\/td>\n 081216-PENICILLINS<\/td>\n Amoxicillin<\/td>\n AMOXICILLIN<\/td>\n CAPSULE<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.661<\/td>\n 8.996<\/td>\n 081216-PENICILLINS<\/td>\n Amoxicillin<\/td>\n AMOXICILLIN<\/td>\n CAPSULE<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.681<\/td>\n 8.997<\/td>\n 081216-PENICILLINS<\/td>\n Amoxicillin<\/td>\n AMOXICILLIN<\/td>\n SUSP RECON<\/td>\n 125 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.683<\/td>\n 8.998<\/td>\n 081216-PENICILLINS<\/td>\n Amoxicillin<\/td>\n AMOXICILLIN<\/td>\n SUSP RECON<\/td>\n 250 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
93.375<\/td>\n 42.683<\/td>\n 081216-PENICILLINS<\/td>\n Amoxicillin<\/td>\n AMOXICILLIN<\/td>\n SUSP RECON<\/td>\n 400 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
93.385<\/td>\n 42.684<\/td>\n 081216-PENICILLINS<\/td>\n Amoxicillin<\/td>\n AMOXICILLIN<\/td>\n SUSP RECON<\/td>\n 200 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.651<\/td>\n 9.001<\/td>\n 081216-PENICILLINS<\/td>\n Amoxicillin<\/td>\n AMOXICILLIN<\/td>\n TAB CHEW<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.632<\/td>\n 40.292<\/td>\n 081216-PENICILLINS<\/td>\n Amoxicillin<\/td>\n AMOXICILLIN<\/td>\n TABLET<\/td>\n 875 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
61.252<\/td>\n 20.493<\/td>\n 081216-PENICILLINS<\/td>\n Amoxicillin<\/td>\n AMOXICILLIN<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
67.150<\/td>\n 8.989<\/td>\n 081216-PENICILLINS<\/td>\n Augmentin<\/td>\n AMOXICILLIN-POTASSIUM CLAVULANATE<\/td>\n SUSP RECON<\/td>\n 125-31.25 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
67.151<\/td>\n 8.990<\/td>\n 081216-PENICILLINS<\/td>\n Augmentin<\/td>\n AMOXICILLIN-POTASSIUM CLAVULANATE<\/td>\n SUSP RECON<\/td>\n 250-62.5 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
67.153<\/td>\n 25.898<\/td>\n 081216-PENICILLINS<\/td>\n Augmentin<\/td>\n AMOXICILLIN-POTASSIUM CLAVULANATE<\/td>\n SUSP RECON<\/td>\n 400-57 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
67.154<\/td>\n 26.720<\/td>\n 081216-PENICILLINS<\/td>\n Augmentin<\/td>\n AMOXICILLIN-POTASSIUM CLAVULANATE<\/td>\n SUSP RECON<\/td>\n 200-28.5 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.020<\/td>\n 48.449<\/td>\n 081216-PENICILLINS<\/td>\n Augmentin ES<\/td>\n AMOXICILLIN-POTASSIUM CLAVULANATE<\/td>\n SUSP RECON<\/td>\n 600-42.9 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
67.078<\/td>\n 26.719<\/td>\n 081216-PENICILLINS<\/td>\n Augmentin<\/td>\n AMOXICILLIN-POTASSIUM CLAVULANATE<\/td>\n TAB CHEW<\/td>\n 200-28.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
91.941<\/td>\n 50.991<\/td>\n 081216-PENICILLINS<\/td>\n Augmentin XR<\/td>\n AMOXICILLIN-POTASSIUM CLAVULANATE<\/td>\n TAB ER 12H<\/td>\n 1000-62.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
67.070<\/td>\n 8.991<\/td>\n 081216-PENICILLINS<\/td>\n Augmentin<\/td>\n AMOXICILLIN-POTASSIUM CLAVULANATE<\/td>\n TABLET<\/td>\n 250-125 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
67.071<\/td>\n 8.992<\/td>\n 081216-PENICILLINS<\/td>\n Augmentin<\/td>\n AMOXICILLIN-POTASSIUM CLAVULANATE<\/td>\n TABLET<\/td>\n 500-125 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
67.076<\/td>\n 24.668<\/td>\n 081216-PENICILLINS<\/td>\n Augmentin<\/td>\n AMOXICILLIN-POTASSIUM CLAVULANATE<\/td>\n TABLET<\/td>\n 875-125 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.271<\/td>\n 8.941<\/td>\n 081216-PENICILLINS<\/td>\n Ampicillin<\/td>\n AMPICILLIN TRIHYDRATE<\/td>\n CAPSULE<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.272<\/td>\n 8.942<\/td>\n 081216-PENICILLINS<\/td>\n Ampicillin<\/td>\n AMPICILLIN TRIHYDRATE<\/td>\n CAPSULE<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.313<\/td>\n 8.943<\/td>\n 081216-PENICILLINS<\/td>\n Ampicillin<\/td>\n AMPICILLIN TRIHYDRATE<\/td>\n SUSP RECON<\/td>\n 125 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.316<\/td>\n 8.944<\/td>\n 081216-PENICILLINS<\/td>\n Ampicillin<\/td>\n AMPICILLIN TRIHYDRATE<\/td>\n SUSP RECON<\/td>\n 250 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.541<\/td>\n 8.983<\/td>\n 081216-PENICILLINS<\/td>\n Dicloxacillin<\/td>\n DICLOXACILLIN SODIUM<\/td>\n CAPSULE<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.542<\/td>\n 8.984<\/td>\n 081216-PENICILLINS<\/td>\n Dicloxacillin<\/td>\n DICLOXACILLIN SODIUM<\/td>\n CAPSULE<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.022<\/td>\n 8.876<\/td>\n 081216-PENICILLINS<\/td>\n Penicillin V Potassium<\/td>\n PENICILLIN V POTASSIUM<\/td>\n SOLN RECON<\/td>\n 125 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.024<\/td>\n 8.877<\/td>\n 081216-PENICILLINS<\/td>\n Penicillin V Potassium<\/td>\n PENICILLIN V POTASSIUM<\/td>\n SOLN RECON<\/td>\n 250 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.053<\/td>\n 8.879<\/td>\n 081216-PENICILLINS<\/td>\n Penicillin V Potassium<\/td>\n PENICILLIN V POTASSIUM<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.055<\/td>\n 8.880<\/td>\n 081216-PENICILLINS<\/td>\n Penicillin V Potassium<\/td>\n PENICILLIN V POTASSIUM<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.050<\/td>\n 9.509<\/td>\n 081218-QUINOLONES<\/td>\n Cipro<\/td>\n CIPROFLOXACIN HCL<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.051<\/td>\n 9.510<\/td>\n 081218-QUINOLONES<\/td>\n Cipro<\/td>\n CIPROFLOXACIN HCL<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.052<\/td>\n 9.511<\/td>\n 081218-QUINOLONES<\/td>\n Cipro<\/td>\n CIPROFLOXACIN HCL<\/td>\n TABLET<\/td>\n 750 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.725<\/td>\n 58.310<\/td>\n 081218-QUINOLONES<\/td>\n Levofloxacin<\/td>\n LEVOFLOXACIN<\/td>\n SOLUTION<\/td>\n 250 MG\/10ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.073<\/td>\n 29.927<\/td>\n 081218-QUINOLONES<\/td>\n Levaquin<\/td>\n LEVOFLOXACIN<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.074<\/td>\n 29.928<\/td>\n 081218-QUINOLONES<\/td>\n Levaquin<\/td>\n LEVOFLOXACIN<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
89.597<\/td>\n 46.771<\/td>\n 081218-QUINOLONES<\/td>\n Levaquin<\/td>\n LEVOFLOXACIN<\/td>\n TABLET<\/td>\n 750 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.942<\/td>\n 71.217<\/td>\n 081220-SULFONAMIDES (SYSTEMIC)<\/td>\n Sulfamethoxazole-Trimethoprim<\/td>\n SULFAMETHOXAZOLE-TRIMETHOPRIM<\/td>\n ORAL SUSP<\/td>\n 800-160 MG\/20ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
90.150<\/td>\n 9.394<\/td>\n 081220-SULFONAMIDES (SYSTEMIC)<\/td>\n Sulfamethoxazole-Trimethoprim<\/td>\n SULFAMETHOXAZOLE-TRIMETHOPRIM<\/td>\n ORAL SUSP<\/td>\n 200-40 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
90.161<\/td>\n 9.395<\/td>\n 081220-SULFONAMIDES (SYSTEMIC)<\/td>\n Bactrim<\/td>\n SULFAMETHOXAZOLE-TRIMETHOPRIM<\/td>\n TABLET<\/td>\n 400-80 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
90.163<\/td>\n 9.396<\/td>\n 081220-SULFONAMIDES (SYSTEMIC)<\/td>\n Bactrim<\/td>\n SULFAMETHOXAZOLE-TRIMETHOPRIM<\/td>\n TABLET<\/td>\n 800-160 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.611<\/td>\n 9.402<\/td>\n 081220-SULFONAMIDES (SYSTEMIC)<\/td>\n Azulfidine<\/td>\n SULFASALAZINE<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.620<\/td>\n 9.403<\/td>\n 081220-SULFONAMIDES (SYSTEMIC)<\/td>\n Azulfidine EN<\/td>\n SULFASALAZINE<\/td>\n TABLET DR<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.073<\/td>\n 9.190<\/td>\n 08122400-TETRACYCLINE<\/td>\n Tetracycline<\/td>\n Tetracycline<\/td>\n CAPSULE<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.370<\/td>\n 9.225<\/td>\n 081224-TETRACYCLINES<\/td>\n Doxycycline Suspension<\/td>\n DOXYCYCLINE<\/td>\n ORAL SUSP<\/td>\n 25 MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.331<\/td>\n 9.218<\/td>\n 081224-TETRACYCLINES<\/td>\n Doxycyline<\/td>\n DOXYCYCLINE HYCLATE<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.333<\/td>\n 9.219<\/td>\n 081224-TETRACYCLINES<\/td>\n Doxycyline<\/td>\n DOXYCYCLINE HYCLATE<\/td>\n CAPSULE<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.360<\/td>\n 9.223<\/td>\n 081224-TETRACYCLINES<\/td>\n Doxycyline<\/td>\n DOXYCYCLINE HYCLATE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.651<\/td>\n 15.943<\/td>\n 081224-TETRACYCLINES<\/td>\n Doxycyline<\/td>\n DOXYCYCLINE MONOHYDRATE<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.652<\/td>\n 16.815<\/td>\n 081224-TETRACYCLINES<\/td>\n Doxycyline<\/td>\n DOXYCYCLINE MONOHYDRATE<\/td>\n CAPSULE<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.271<\/td>\n 62.496<\/td>\n 081224-TETRACYCLINES<\/td>\n Doxycyline<\/td>\n DOXYCYCLINE MONOHYDRATE<\/td>\n CAPSULE<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.363<\/td>\n 27.050<\/td>\n 081224-TETRACYCLINES<\/td>\n Doxycyline<\/td>\n DOXYCYCLINE MONOHYDRATE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.410<\/td>\n 9.226<\/td>\n 081224-TETRACYCLINES<\/td>\n Minocycline<\/td>\n MINOCYCLINE HCL<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.411<\/td>\n 9.227<\/td>\n 081224-TETRACYCLINES<\/td>\n Minocycline<\/td>\n MINOCYCLINE HCL<\/td>\n CAPSULE<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
93.387<\/td>\n 42.778<\/td>\n 081224-TETRACYCLINES<\/td>\n Minocycline<\/td>\n MINOCYCLINE HCL<\/td>\n CAPSULE<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.549<\/td>\n 52.057<\/td>\n 081224-TETRACYCLINES<\/td>\n Minocycline<\/td>\n MINOCYCLINE HCL<\/td>\n TABLET<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.450<\/td>\n 9.230<\/td>\n 081224-TETRACYCLINES<\/td>\n Minocycline<\/td>\n MINOCYCLINE HCL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.451<\/td>\n 9.231<\/td>\n 081224-TETRACYCLINES<\/td>\n Minocycline<\/td>\n MINOCYCLINE HCL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.830<\/td>\n 9.339<\/td>\n 081228-ANTIBACTERIALS, MISCELLANEOUS<\/td>\n Cleocin<\/td>\n CLINDAMYCIN HCL<\/td>\n CAPSULE<\/td>\n 150 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.831<\/td>\n 9.341<\/td>\n 081228-ANTIBACTERIALS, MISCELLANEOUS<\/td>\n Cleocin<\/td>\n CLINDAMYCIN HCL<\/td>\n CAPSULE<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.832<\/td>\n 9.340<\/td>\n 081228-ANTIBACTERIALS, MISCELLANEOUS<\/td>\n Cleocin<\/td>\n CLINDAMYCIN HCL<\/td>\n CAPSULE<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.860<\/td>\n 9.346<\/td>\n 081228-ANTIBACTERIALS, MISCELLANEOUS<\/td>\n Cleocin Pediatric Granules<\/td>\n CLINDAMYCIN PALMITATE HCL<\/td>\n SOLN RECON<\/td>\n 75 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Restricted to age < 19<\/td>\n <\/tr>\n
60.823<\/td>\n 18.638<\/td>\n 081404-ALLYLAMINES<\/td>\n Lamisil<\/td>\n TERBINAFINE HCL<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
60.821<\/td>\n 18.636<\/td>\n 081408-AZOLES<\/td>\n Diflucan<\/td>\n FLUCONAZOLE<\/td>\n SUSP RECON<\/td>\n 40 MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.190<\/td>\n 13.723<\/td>\n 081408-AZOLES<\/td>\n Diflucan<\/td>\n FLUCONAZOLE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.191<\/td>\n 13.724<\/td>\n 081408-AZOLES<\/td>\n Diflucan<\/td>\n FLUCONAZOLE<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.192<\/td>\n 13.725<\/td>\n 081408-AZOLES<\/td>\n Diflucan<\/td>\n FLUCONAZOLE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.193<\/td>\n 22.141<\/td>\n 081408-AZOLES<\/td>\n Diflucan<\/td>\n FLUCONAZOLE<\/td>\n TABLET<\/td>\n 150 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.440<\/td>\n 9.537<\/td>\n 081428-POLYENES<\/td>\n Nystatin<\/td>\n NYSTATIN<\/td>\n ORAL SUSP<\/td>\n 100000 UNIT\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.452<\/td>\n 9.538<\/td>\n 081428-POLYENES<\/td>\n Nystatin<\/td>\n NYSTATIN<\/td>\n TABLET<\/td>\n 500000 UNIT<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.390<\/td>\n 9.517<\/td>\n 081492-ANTIFUNGALS, MISCELLANEOUS<\/td>\n Griseofulvin<\/td>\n GRISEOFULVIN MICROSIZE<\/td>\n ORAL SUSP<\/td>\n 125 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.402<\/td>\n 9.519<\/td>\n 081492-ANTIFUNGALS, MISCELLANEOUS<\/td>\n Griseofulvin<\/td>\n GRISEOFULVIN MICROSIZE<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.410<\/td>\n 9.520<\/td>\n 081492-ANTIFUNGALS, MISCELLANEOUS<\/td>\n Gris-Peg<\/td>\n GRISEOFULVIN ULTRAMICROSIZE<\/td>\n TABLET<\/td>\n 125 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.412<\/td>\n 9.522<\/td>\n 081492-ANTIFUNGALS, MISCELLANEOUS<\/td>\n Gris-Peg<\/td>\n GRISEOFULVIN ULTRAMICROSIZE<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
73.441<\/td>\n 43.706<\/td>\n 081828-NEURAMINIDASE INHIBITORS<\/td>\n Tamiflu<\/td>\n OSELTAMIVIR PHOSPHATE<\/td>\n CAPSULE<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.980<\/td>\n 63.223<\/td>\n 081828-NEURAMINIDASE INHIBITORS<\/td>\n Tamiflu<\/td>\n OSELTAMIVIR PHOSPHATE<\/td>\n CAPSULE<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.981<\/td>\n 63.224<\/td>\n 081828-NEURAMINIDASE INHIBITORS<\/td>\n Tamiflu<\/td>\n OSELTAMIVIR PHOSPHATE<\/td>\n CAPSULE<\/td>\n 45 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
29.729<\/td>\n 67.561<\/td>\n 081828-NEURAMINIDASE INHIBITORS<\/td>\n Tamiflu<\/td>\n OSELTAMIVIR PHOSPHATE<\/td>\n SUSP RECON<\/td>\n 6 MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
92.221<\/td>\n 43.119<\/td>\n 081828-NEURAMINIDASE INHIBITORS<\/td>\n Relenza<\/td>\n ZANAMIVIR<\/td>\n BLST W\/DEV<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
43.790<\/td>\n 9.630<\/td>\n 081832-NUCLEOSIDES AND NUCLEOTIDES<\/td>\n Zovirax<\/td>\n ACYCLOVIR<\/td>\n CAPSULE<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.721<\/td>\n 15.979<\/td>\n 081832-NUCLEOSIDES AND NUCLEOTIDES<\/td>\n Zovirax<\/td>\n ACYCLOVIR<\/td>\n TABLET<\/td>\n 800 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.724<\/td>\n 16.408<\/td>\n 081832-NUCLEOSIDES AND NUCLEOTIDES<\/td>\n Zovirax<\/td>\n ACYCLOVIR<\/td>\n TABLET<\/td>\n 400 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.179<\/td>\n 48.664<\/td>\n 081832-NUCLEOSIDES AND NUCLEOTIDES<\/td>\n Ribavirin<\/td>\n RIBAVIRIN<\/td>\n CAPSULE<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.740<\/td>\n 23.989<\/td>\n 081832-NUCLEOSIDES AND NUCLEOTIDES<\/td>\n Valtrex<\/td>\n VALACYCLOVIR HCL<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.742<\/td>\n 30.607<\/td>\n 081832-NUCLEOSIDES AND NUCLEOTIDES<\/td>\n Valtrex<\/td>\n VALACYCLOVIR HCL<\/td>\n TABLET<\/td>\n 1000 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.940<\/td>\n 9.580<\/td>\n 083008-ANTIMALARIALS<\/td>\n Plaquenil<\/td>\n HYDROXYCHLOROQUINE SULFATE<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
43.031<\/td>\n 9.591<\/td>\n 083092-ANTIPROTOZOALS, MISCELLANEOUS<\/td>\n Flagyl<\/td>\n METRONIDAZOLE<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
43.032<\/td>\n 9.592<\/td>\n 083092-ANTIPROTOZOALS, MISCELLANEOUS<\/td>\n Flagyl<\/td>\n METRONIDAZOLE<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.870<\/td>\n 9.434<\/td>\n 083600-URINARY ANTI-INFECTIVES<\/td>\n Furadantin<\/td>\n NITROFURANTOIN<\/td>\n ORAL SUSP<\/td>\n 25 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.820<\/td>\n 9.428<\/td>\n 083600-URINARY ANTI-INFECTIVES<\/td>\n Macrodantin<\/td>\n NITROFURANTOIN MACROCRYSTAL<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.822<\/td>\n 9.430<\/td>\n 083600-URINARY ANTI-INFECTIVES<\/td>\n Macrodantin<\/td>\n NITROFURANTOIN MACROCRYSTAL<\/td>\n CAPSULE<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
49.001<\/td>\n 16.598<\/td>\n 083600-URINARY ANTI-INFECTIVES<\/td>\n Macrobid<\/td>\n NITROFURANTOIN MONOHYDRATE-MACROCRYSTAL<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
5.987<\/td>\n 35.495<\/td>\n 084080-ANTIPRURITICS AND LOCAL ANESTHETICS<\/td>\n Emla Cream<\/td>\n LIDOCAINE\/PRILOCAINE<\/td>\n CREAM (G)<\/td>\n 2.5 %-2.5%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
38.370<\/td>\n 8.772<\/td>\n 100000-ANTINEOPLASTIC AGENTS<\/td>\n Leukeran<\/td>\n CHLORAMBUCIL<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
38.400<\/td>\n 8.775<\/td>\n 100000-ANTINEOPLASTIC AGENTS<\/td>\n Hydrea<\/td>\n HYDROXYUREA<\/td>\n CAPSULE<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
49.541<\/td>\n 29.821<\/td>\n 100000-ANTINEOPLASTIC AGENTS<\/td>\n Femara<\/td>\n LETROZOLE<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.559<\/td>\n 70.193<\/td>\n 100000-ANTINEOPLASTIC AGENTS<\/td>\n Megace<\/td>\n MEGESTROL ACETATE<\/td>\n ORAL SUSP<\/td>\n 400 MG\/10ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.381<\/td>\n 21.004<\/td>\n 100000-ANTINEOPLASTIC AGENTS<\/td>\n Megace<\/td>\n MEGESTROL ACETATE<\/td>\n ORAL SUSP<\/td>\n 400 MG\/10ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
38.681<\/td>\n 8.829<\/td>\n 100000-ANTINEOPLASTIC AGENTS<\/td>\n Megace<\/td>\n MEGESTROL ACETATE<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
38.380<\/td>\n 8.773<\/td>\n 100000-ANTINEOPLASTIC AGENTS<\/td>\n Alkeran<\/td>\n MELPHALAN<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
38.520<\/td>\n 8.802<\/td>\n 100000-ANTINEOPLASTIC AGENTS<\/td>\n Mercaptopurine<\/td>\n MERCAPTOPURINE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
38.489<\/td>\n 36.872<\/td>\n 100000-ANTINEOPLASTIC AGENTS<\/td>\n Methotrexate<\/td>\n METHOTREXATE SODIUM<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
38.720<\/td>\n 8.832<\/td>\n 100000-ANTINEOPLASTIC AGENTS<\/td>\n Tamoxifen<\/td>\n TAMOXIFEN CITRATE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
38.721<\/td>\n 13.574<\/td>\n 100000-ANTINEOPLASTIC AGENTS<\/td>\n Tamoxifen<\/td>\n TAMOXIFEN CITRATE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.351<\/td>\n 4.740<\/td>\n 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)<\/td>\n Urecholine<\/td>\n BETHANECHOL CHLORIDE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.352<\/td>\n 4.741<\/td>\n 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)<\/td>\n Urecholine<\/td>\n BETHANECHOL CHLORIDE<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
4.300<\/td>\n 29.334<\/td>\n 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)<\/td>\n Aricept<\/td>\n DONEPEZIL HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
4.302<\/td>\n 29.335<\/td>\n 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)<\/td>\n Aricept<\/td>\n DONEPEZIL HCL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
84.853<\/td>\n 46.925<\/td>\n 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)<\/td>\n Razadyne<\/td>\n GALANTAMINE HBR<\/td>\n TABLET<\/td>\n 12 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
84.854<\/td>\n 46.926<\/td>\n 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)<\/td>\n Razadyne<\/td>\n GALANTAMINE HBR<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
84.855<\/td>\n 46.927<\/td>\n 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)<\/td>\n Razadyne<\/td>\n GALANTAMINE HBR<\/td>\n TABLET<\/td>\n 8 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
21.353<\/td>\n 53.658<\/td>\n 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)<\/td>\n Salagen<\/td>\n PILOCARPINE HCL<\/td>\n TABLET<\/td>\n 7.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
24.671<\/td>\n 21.731<\/td>\n 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)<\/td>\n Salagen<\/td>\n PILOCARPINE HCL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
90.396<\/td>\n 40.155<\/td>\n 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)<\/td>\n Exelon<\/td>\n RIVASTIGMINE TARTRATE<\/td>\n CAPSULE<\/td>\n 1.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
90.397<\/td>\n 40.156<\/td>\n 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)<\/td>\n Exelon<\/td>\n RIVASTIGMINE TARTRATE<\/td>\n CAPSULE<\/td>\n 3 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
90.398<\/td>\n 40.157<\/td>\n 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)<\/td>\n Exelon<\/td>\n RIVASTIGMINE TARTRATE<\/td>\n CAPSULE<\/td>\n 4.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
90.399<\/td>\n 40.158<\/td>\n 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)<\/td>\n Exelon<\/td>\n RIVASTIGMINE TARTRATE<\/td>\n CAPSULE<\/td>\n 6 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
74.801<\/td>\n 4.902<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Librax<\/td>\n CHLORDIAZEPOXIDE-CLIDINIUM BR<\/td>\n CAPSULE<\/td>\n 5-2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.261<\/td>\n 4.918<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Bentyl<\/td>\n DICYCLOMINE HCL<\/td>\n CAPSULE<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.719<\/td>\n 71.032<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Bentyl<\/td>\n DICYCLOMINE HCL<\/td>\n SOLUTION<\/td>\n 10 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.331<\/td>\n 4.924<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Bentyl<\/td>\n DICYCLOMINE HCL<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.960<\/td>\n 23.715<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Symax SR<\/td>\n HYOSCYAMINE SULFATE<\/td>\n TAB ER 12H<\/td>\n 0.375 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.299<\/td>\n 47.546<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Anaspaz, Symax FT<\/td>\n HYOSCYAMINE SULFATE<\/td>\n TAB RAPDIS<\/td>\n 0.125 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.970<\/td>\n 4.868<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Symax SL<\/td>\n HYOSCYAMINE SULFATE<\/td>\n TAB SUBL<\/td>\n 0.125 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.961<\/td>\n 4.865<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Levsin, Oscimin<\/td>\n HYOSCYAMINE SULFATE<\/td>\n TABLET<\/td>\n 0.125 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.235<\/td>\n 21.700<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Ipratropium Bromide<\/td>\n IPRATROPIUM BROMIDE<\/td>\n SOLUTION<\/td>\n 0.2 MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.456<\/td>\n 48.018<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Ipatropium-Albuterol Inhalation<\/td>\n IPRATROPIUM-ALBUTEROL SULFATE<\/td>\n AMPUL-NEB<\/td>\n 0.5-3 MG\/3ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
22.913<\/td>\n 28.090<\/td>\n 121208-BETA-ADRENERGIC AGONISTS<\/td>\n Proventil HFA, Ventolin HFA, ProAir HFA<\/td>\n ALBUTEROL SULFATE<\/td>\n HFA AER AD<\/td>\n 90 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
22.780<\/td>\n 5.032<\/td>\n 121208-BETA-ADRENERGIC AGONISTS<\/td>\n Albuterol Sulfate<\/td>\n ALBUTEROL SULFATE<\/td>\n SYRUP<\/td>\n 2 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.100<\/td>\n 5.033<\/td>\n 121208-BETA-ADRENERGIC AGONISTS<\/td>\n Albuterol Sulfate<\/td>\n ALBUTEROL SULFATE<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.101<\/td>\n 5.034<\/td>\n 121208-BETA-ADRENERGIC AGONISTS<\/td>\n Albuterol Sulfate<\/td>\n ALBUTEROL SULFATE<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.634<\/td>\n 48.699<\/td>\n 121208-BETA-ADRENERGIC AGONISTS<\/td>\n Albuterol Sulfate Inhalation<\/td>\n ALBUTEROL SULFATE<\/td>\n VIAL-NEB<\/td>\n 1.25 MG\/3ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.681<\/td>\n 5.039<\/td>\n 121208-BETA-ADRENERGIC AGONISTS<\/td>\n Albuterol Sulfate Inhalation<\/td>\n ALBUTEROL SULFATE<\/td>\n VIAL-NEB<\/td>\n 2.5 MG\/3ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.071<\/td>\n 5.026<\/td>\n 121208-BETA-ADRENERGIC AGONISTS<\/td>\n Terbutaline<\/td>\n TERBUTALINE SULFATE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.072<\/td>\n 5.025<\/td>\n 121208-BETA-ADRENERGIC AGONISTS<\/td>\n Terbutaline<\/td>\n TERBUTALINE SULFATE<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.861<\/td>\n 16.878<\/td>\n 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS<\/td>\n EPINEPHRINE AUTO-INJECT<\/td>\n EPINEPHRINE<\/td>\n AUTO INJCT<\/td>\n 0.15 MG\/0.3ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.862<\/td>\n 16.879<\/td>\n 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS<\/td>\n EPINEPHRINE AUTO-INJECT<\/td>\n EPINEPHRINE<\/td>\n AUTO INJCT<\/td>\n 0.3 MG\/0.3ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.191<\/td>\n 27.546<\/td>\n 121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)<\/td>\n Flomax<\/td>\n TAMSULOSIN HCL<\/td>\n CAP ER 24H<\/td>\n 0.4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.901<\/td>\n 4.660<\/td>\n 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT<\/td>\n Parafon Forte<\/td>\n CHLORZOXAZONE<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.805<\/td>\n 47.478<\/td>\n 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT<\/td>\n Flexeril<\/td>\n CYCLOBENZAPRINE HCL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.020<\/td>\n 4.681<\/td>\n 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT<\/td>\n Flexeril<\/td>\n CYCLOBENZAPRINE HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.892<\/td>\n 4.654<\/td>\n 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT<\/td>\n Robaxin<\/td>\n METHOCARBAMOL<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.893<\/td>\n 4.655<\/td>\n 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT<\/td>\n Robaxin<\/td>\n METHOCARBAMOL<\/td>\n TABLET<\/td>\n 750 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
24.433<\/td>\n 58.904<\/td>\n 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT<\/td>\n Zanaflex<\/td>\n TIZANIDINE HCL<\/td>\n CAPSULE<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
24.434<\/td>\n 58.905<\/td>\n 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT<\/td>\n Zanaflex<\/td>\n TIZANIDINE HCL<\/td>\n CAPSULE<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.690<\/td>\n 27.447<\/td>\n 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT<\/td>\n Zanaflex<\/td>\n TIZANIDINE HCL<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.693<\/td>\n 30.274<\/td>\n 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT<\/td>\n Zanaflex<\/td>\n TIZANIDINE HCL<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.012<\/td>\n 27.229<\/td>\n 122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT<\/td>\n Baclofen<\/td>\n BACLOFEN<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.010<\/td>\n 4.679<\/td>\n 122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT<\/td>\n Baclofen<\/td>\n BACLOFEN<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.011<\/td>\n 4.680<\/td>\n 122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT<\/td>\n Baclofen<\/td>\n BACLOFEN<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
420<\/td>\n 19.331<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Lovenox<\/td>\n ENOXAPARIN SODIUM<\/td>\n SYRINGE<\/td>\n 30 MG\/0.3ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Limited to 14 day supplies, Prior Auth for >14 days<\/td>\n <\/tr>\n
42.071<\/td>\n 44.668<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Lovenox<\/td>\n ENOXAPARIN SODIUM<\/td>\n SYRINGE<\/td>\n 150 MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Limited to 14 day supplies, Prior Auth for >14 days<\/td>\n <\/tr>\n
42.091<\/td>\n 44.669<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Lovenox<\/td>\n ENOXAPARIN SODIUM<\/td>\n SYRINGE<\/td>\n 120 MG\/0.8ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Limited to 14 day supplies, Prior Auth for >14 days<\/td>\n <\/tr>\n
62.771<\/td>\n 27.993<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Lovenox<\/td>\n ENOXAPARIN SODIUM<\/td>\n SYRINGE<\/td>\n 60 MG\/0.6ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Limited to 14 day supplies, Prior Auth for >14 days<\/td>\n <\/tr>\n
62.772<\/td>\n 27.994<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Lovenox<\/td>\n ENOXAPARIN SODIUM<\/td>\n SYRINGE<\/td>\n 80 MG\/0.8ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Limited to 14 day supplies, Prior Auth for >14 days<\/td>\n <\/tr>\n
62.773<\/td>\n 27.995<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Lovenox<\/td>\n ENOXAPARIN SODIUM<\/td>\n SYRINGE<\/td>\n 100 MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Limited to 14 day supplies, Prior Auth for >14 days<\/td>\n <\/tr>\n
70.022<\/td>\n 39.482<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Lovenox<\/td>\n ENOXAPARIN SODIUM<\/td>\n SYRINGE<\/td>\n 40 MG\/0.4ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Limited to 14 day supplies, Prior Auth for >14 days<\/td>\n <\/tr>\n
25.691<\/td>\n 6.549<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Heparin<\/td>\n HEPARIN SODIUM PORCINE<\/td>\n VIAL<\/td>\n 5000 UNIT\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.697<\/td>\n 6.544<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Heparin<\/td>\n HEPARIN SODIUM PORCINE<\/td>\n VIAL<\/td>\n 10000 UNIT\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.790<\/td>\n 6.559<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Coumadin, Jantoven<\/td>\n WARFARIN SODIUM<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.791<\/td>\n 6.561<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Coumadin, Jantoven<\/td>\n WARFARIN SODIUM<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.792<\/td>\n 14.198<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Coumadin, Jantoven<\/td>\n WARFARIN SODIUM<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.793<\/td>\n 6.562<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Coumadin, Jantoven<\/td>\n WARFARIN SODIUM<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.794<\/td>\n 6.560<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Coumadin, Jantoven<\/td>\n WARFARIN SODIUM<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.795<\/td>\n 6.563<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Coumadin, Jantoven<\/td>\n WARFARIN SODIUM<\/td>\n TABLET<\/td>\n 7.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.796<\/td>\n 18.080<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Coumadin, Jantoven<\/td>\n WARFARIN SODIUM<\/td>\n TABLET<\/td>\n 3 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.797<\/td>\n 19.486<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Coumadin, Jantoven<\/td>\n WARFARIN SODIUM<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.798<\/td>\n 30.475<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Coumadin, Jantoven<\/td>\n WARFARIN SODIUM<\/td>\n TABLET<\/td>\n 6 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
8.602<\/td>\n 37.978<\/td>\n 201218-PLATELET-AGGREGATION INHIBITORS<\/td>\n Pletal<\/td>\n CILOSTAZOL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
8.603<\/td>\n 37.979<\/td>\n 201218-PLATELET-AGGREGATION INHIBITORS<\/td>\n Pletal<\/td>\n CILOSTAZOL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
96.010<\/td>\n 38.164<\/td>\n 201218-PLATELET-AGGREGATION INHIBITORS<\/td>\n Plavix<\/td>\n CLOPIDOGREL BISULFATE<\/td>\n TABLET<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.800<\/td>\n 6.573<\/td>\n 202400-HEMORRHEOLOGIC AGENTS<\/td>\n Pentoxifylline<\/td>\n PENTOXIFYLLINE<\/td>\n TABLET ER<\/td>\n 400 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.580<\/td>\n 6.503<\/td>\n 202816-HEMOSTATICS<\/td>\n Amicar<\/td>\n AMINOCAPROIC ACID<\/td>\n SOLUTION<\/td>\n 250 MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.920<\/td>\n 266<\/td>\n 240404-ANTIARRHYTHMIC AGENTS<\/td>\n Pacerone<\/td>\n AMIODARONE HCL<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.130<\/td>\n 239<\/td>\n 240404-ANTIARRHYTHMIC AGENTS<\/td>\n Norpace<\/td>\n DISOPYRAMIDE PHOSPHATE<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.580<\/td>\n 263<\/td>\n 240404-ANTIARRHYTHMIC AGENTS<\/td>\n Flecainide<\/td>\n FLECAINIDE ACETATE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.581<\/td>\n 265<\/td>\n 240404-ANTIARRHYTHMIC AGENTS<\/td>\n Flecainide<\/td>\n FLECAINIDE ACETATE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.011<\/td>\n 215<\/td>\n 240404-ANTIARRHYTHMIC AGENTS<\/td>\n Quinidine<\/td>\n QUINIDINE GLUCONATE<\/td>\n TABLET ER<\/td>\n 324 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
132<\/td>\n 18<\/td>\n 240408-CARDIOTONIC AGENTS<\/td>\n Lanoxin<\/td>\n DIGOXIN<\/td>\n TABLET<\/td>\n 125 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
133<\/td>\n 19<\/td>\n 240408-CARDIOTONIC AGENTS<\/td>\n Lanoxin<\/td>\n DIGOXIN<\/td>\n TABLET<\/td>\n 250 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
9.850<\/td>\n 3.100<\/td>\n 240604-BILE ACID SEQUESTRANTS<\/td>\n Prevalite<\/td>\n CHOLESTYRAMINE (WITH ASPARTAME)<\/td>\n POWD PACK<\/td>\n 4 G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.654<\/td>\n 62.885<\/td>\n 240604-BILE ACID SEQUESTRANTS<\/td>\n Questran Light<\/td>\n CHOLESTYRAMINE (WITH ASPARTAME)<\/td>\n POWDER<\/td>\n 4 G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
9.920<\/td>\n 13.675<\/td>\n 240604-BILE ACID SEQUESTRANTS<\/td>\n Questran<\/td>\n CHOLESTYRAMINE (WITH SUGAR)<\/td>\n POWD PACK<\/td>\n 4 G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.295<\/td>\n 48.571<\/td>\n 240604-BILE ACID SEQUESTRANTS<\/td>\n Questran<\/td>\n CHOLESTYRAMINE (WITH SUGAR)<\/td>\n POWDER<\/td>\n 4 G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.595<\/td>\n 44.915<\/td>\n 240606-FIBRIC ACID DERIVATIVES<\/td>\n Lofibra<\/td>\n FENOFIBRATE<\/td>\n TABLET<\/td>\n 160 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.266<\/td>\n 64.310<\/td>\n 240606-FIBRIC ACID DERIVATIVES<\/td>\n Lofibra<\/td>\n FENOFIBRATE<\/td>\n TABLET<\/td>\n 54 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
92.504<\/td>\n 44.305<\/td>\n 240606-FIBRIC ACID DERIVATIVES<\/td>\n Lofibra<\/td>\n FENOFIBRATE MICRONIZED<\/td>\n CAPSULE<\/td>\n 134 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
93.437<\/td>\n 43.060<\/td>\n 240606-FIBRIC ACID DERIVATIVES<\/td>\n Lofibra<\/td>\n FENOFIBRATE MICRONIZED<\/td>\n CAPSULE<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
93.446<\/td>\n 43.061<\/td>\n 240606-FIBRIC ACID DERIVATIVES<\/td>\n Lofibra<\/td>\n FENOFIBRATE MICRONIZED<\/td>\n CAPSULE<\/td>\n 67 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.540<\/td>\n 6.416<\/td>\n 240606-FIBRIC ACID DERIVATIVES<\/td>\n Lopid<\/td>\n GEMFIBROZIL<\/td>\n TABLET<\/td>\n 600 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
43.720<\/td>\n 29.967<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Lipitor<\/td>\n ATORVASTATIN CALCIUM<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
43.721<\/td>\n 29.968<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Lipitor<\/td>\n ATORVASTATIN CALCIUM<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
43.722<\/td>\n 29.969<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Lipitor<\/td>\n ATORVASTATIN CALCIUM<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
43.723<\/td>\n 45.772<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Lipitor<\/td>\n ATORVASTATIN CALCIUM<\/td>\n TABLET<\/td>\n 80 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.040<\/td>\n 6.460<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Lovastatin<\/td>\n LOVASTATIN<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.041<\/td>\n 6.461<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Lovastatin<\/td>\n LOVASTATIN<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.042<\/td>\n 16.310<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Lovastatin<\/td>\n LOVASTATIN<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.412<\/td>\n 49.758<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Pravachol<\/td>\n PRAVASTATIN SODIUM<\/td>\n TABLET<\/td>\n 80 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.671<\/td>\n 16.366<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Pravachol<\/td>\n PRAVASTATIN SODIUM<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.672<\/td>\n 16.367<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Pravachol<\/td>\n PRAVASTATIN SODIUM<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.673<\/td>\n 20.741<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Pravachol<\/td>\n PRAVASTATIN SODIUM<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.531<\/td>\n 16.576<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Zocor<\/td>\n SIMVASTATIN<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.532<\/td>\n 16.577<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Zocor<\/td>\n SIMVASTATIN<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.533<\/td>\n 16.578<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Zocor<\/td>\n SIMVASTATIN<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.534<\/td>\n 16.579<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Zocor<\/td>\n SIMVASTATIN<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.331<\/td>\n 33.364<\/td>\n 240692-ANTILIPEMIC AGENTS, MISCELLANEOUS<\/td>\n Niaspan ER<\/td>\n NIACIN<\/td>\n TAB ER 24H<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.332<\/td>\n 33.365<\/td>\n 240692-ANTILIPEMIC AGENTS, MISCELLANEOUS<\/td>\n Niaspan ER<\/td>\n NIACIN<\/td>\n TAB ER 24H<\/td>\n 750 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.333<\/td>\n 33.366<\/td>\n 240692-ANTILIPEMIC AGENTS, MISCELLANEOUS<\/td>\n Niaspan ER<\/td>\n NIACIN<\/td>\n TAB ER 24H<\/td>\n 1000 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.870<\/td>\n 343<\/td>\n 240816-CENTRAL ALPHA-AGONISTS<\/td>\n Catapres TTS<\/td>\n CLONIDINE<\/td>\n PATCH TDWK<\/td>\n 0.1 MG\/24HR<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.871<\/td>\n 344<\/td>\n 240816-CENTRAL ALPHA-AGONISTS<\/td>\n Catapres TTS<\/td>\n CLONIDINE<\/td>\n PATCH TDWK<\/td>\n 0.2 MG\/24HR<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.872<\/td>\n 345<\/td>\n 240816-CENTRAL ALPHA-AGONISTS<\/td>\n Catapres TTS<\/td>\n CLONIDINE<\/td>\n PATCH TDWK<\/td>\n 0.3 MG\/24HR<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.390<\/td>\n 346<\/td>\n 240816-CENTRAL ALPHA-AGONISTS<\/td>\n Catapres<\/td>\n CLONIDINE HCL<\/td>\n TABLET<\/td>\n 0.1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.391<\/td>\n 347<\/td>\n 240816-CENTRAL ALPHA-AGONISTS<\/td>\n Catapres<\/td>\n CLONIDINE HCL<\/td>\n TABLET<\/td>\n 0.2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.392<\/td>\n 348<\/td>\n 240816-CENTRAL ALPHA-AGONISTS<\/td>\n Catapres<\/td>\n CLONIDINE HCL<\/td>\n TABLET<\/td>\n 0.3 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.480<\/td>\n 364<\/td>\n 240816-CENTRAL ALPHA-AGONISTS<\/td>\n Tenex<\/td>\n GUANFACINE HCL<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.481<\/td>\n 11.984<\/td>\n 240816-CENTRAL ALPHA-AGONISTS<\/td>\n Tenex<\/td>\n GUANFACINE HCL<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.431<\/td>\n 361<\/td>\n 240816-CENTRAL ALPHA-AGONISTS<\/td>\n Methyldopa<\/td>\n METHYLDOPA<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.432<\/td>\n 362<\/td>\n 240816-CENTRAL ALPHA-AGONISTS<\/td>\n Methyldopa<\/td>\n METHYLDOPA<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.241<\/td>\n 284<\/td>\n 240820-DIRECT VASODILATORS<\/td>\n Hydralazine<\/td>\n HYDRALAZINE HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.242<\/td>\n 285<\/td>\n 240820-DIRECT VASODILATORS<\/td>\n Hydralazine<\/td>\n HYDRALAZINE HCL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.243<\/td>\n 286<\/td>\n 240820-DIRECT VASODILATORS<\/td>\n Hydralazine<\/td>\n HYDRALAZINE HCL<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.244<\/td>\n 287<\/td>\n 240820-DIRECT VASODILATORS<\/td>\n Hydralazine<\/td>\n HYDRALAZINE HCL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.290<\/td>\n 299<\/td>\n 240820-DIRECT VASODILATORS<\/td>\n Minoxidil<\/td>\n MINOXIDIL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.291<\/td>\n 300<\/td>\n 240820-DIRECT VASODILATORS<\/td>\n Minoxidil<\/td>\n MINOXIDIL<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.942<\/td>\n 507<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Isordil<\/td>\n ISOSORBIDE DINITRATE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.944<\/td>\n 508<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Isordil<\/td>\n ISOSORBIDE DINITRATE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.945<\/td>\n 509<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Isordil<\/td>\n ISOSORBIDE DINITRATE<\/td>\n TABLET<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.947<\/td>\n 511<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Isordil<\/td>\n ISOSORBIDE DINITRATE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.102<\/td>\n 17.297<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Isosorbide Mononitrate ER<\/td>\n ISOSORBIDE MONONITRATE<\/td>\n TAB ER 24H<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.103<\/td>\n 23.474<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Isosorbide Mononitrate ER<\/td>\n ISOSORBIDE MONONITRATE<\/td>\n TAB ER 24H<\/td>\n 120 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.104<\/td>\n 24.488<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Isosorbide Mononitrate ER<\/td>\n ISOSORBIDE MONONITRATE<\/td>\n TAB ER 24H<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.931<\/td>\n 16.639<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Isosorbide Mononitrate<\/td>\n ISOSORBIDE MONONITRATE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.932<\/td>\n 17.294<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Isosorbide Mononitrate<\/td>\n ISOSORBIDE MONONITRATE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.681<\/td>\n 455<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Nitro-Time<\/td>\n NITROGLYCERIN<\/td>\n CAPSULE ER<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.682<\/td>\n 456<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Nitro-Time<\/td>\n NITROGLYCERIN<\/td>\n CAPSULE ER<\/td>\n 6.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.684<\/td>\n 457<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Nitro-Time<\/td>\n NITROGLYCERIN<\/td>\n CAPSULE ER<\/td>\n 9 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.740<\/td>\n 465<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Minitran<\/td>\n NITROGLYCERIN<\/td>\n PATCH TD24<\/td>\n 0.4 MG\/HR<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.741<\/td>\n 467<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Minitran<\/td>\n NITROGLYCERIN<\/td>\n PATCH TD24<\/td>\n 0.1 MG\/HR<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.742<\/td>\n 468<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Minitran<\/td>\n NITROGLYCERIN<\/td>\n PATCH TD24<\/td>\n 0.2 MG\/HR<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
92.257<\/td>\n 44.359<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Nitrolingual<\/td>\n NITROGLYCERIN<\/td>\n SPRAY<\/td>\n 400 MCG\/SPRAY<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.771<\/td>\n 474<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Nitrostat<\/td>\n NITROGLYCERIN<\/td>\n TAB SUBL<\/td>\n 0.3 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.772<\/td>\n 475<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Nitrostat<\/td>\n NITROGLYCERIN<\/td>\n TAB SUBL<\/td>\n 0.4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.773<\/td>\n 476<\/td>\n 241208-NITRATES AND NITRITES<\/td>\n Nitrostat<\/td>\n NITROGLYCERIN<\/td>\n TAB SUBL<\/td>\n 0.6 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
53.141<\/td>\n 41.698<\/td>\n 241292-VASODILATING AGENTS, MISCELLANEOUS<\/td>\n Persantine<\/td>\n DIPYRIDAMOLE<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
53.142<\/td>\n 41.699<\/td>\n 241292-VASODILATING AGENTS, MISCELLANEOUS<\/td>\n Persantine<\/td>\n DIPYRIDAMOLE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
53.143<\/td>\n 41.700<\/td>\n 241292-VASODILATING AGENTS, MISCELLANEOUS<\/td>\n Persantine<\/td>\n DIPYRIDAMOLE<\/td>\n TABLET<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
84.848<\/td>\n 46.923<\/td>\n 242000-ALPHA-ADRENERGIC BLOCKING AGENTS<\/td>\n Cardura XL<\/td>\n DOXAZOSIN MESYLATE<\/td>\n TAB ER 24<\/td>\n 8 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
91.985<\/td>\n 44.421<\/td>\n 242000-ALPHA-ADRENERGIC BLOCKING AGENTS<\/td>\n Cardura XL<\/td>\n DOXAZOSIN MESYLATE<\/td>\n TAB ER 24<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.431<\/td>\n 15.584<\/td>\n 242000-ALPHA-ADRENERGIC BLOCKING AGENTS<\/td>\n Cardura<\/td>\n DOXAZOSIN MESYLATE<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.432<\/td>\n 15.585<\/td>\n 242000-ALPHA-ADRENERGIC BLOCKING AGENTS<\/td>\n Cardura<\/td>\n DOXAZOSIN MESYLATE<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.433<\/td>\n 15.586<\/td>\n 242000-ALPHA-ADRENERGIC BLOCKING AGENTS<\/td>\n Cardura<\/td>\n DOXAZOSIN MESYLATE<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.434<\/td>\n 15.587<\/td>\n 242000-ALPHA-ADRENERGIC BLOCKING AGENTS<\/td>\n Cardura<\/td>\n DOXAZOSIN MESYLATE<\/td>\n TABLET<\/td>\n 8 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.250<\/td>\n 291<\/td>\n 242000-ALPHA-ADRENERGIC BLOCKING AGENTS<\/td>\n Minipress<\/td>\n PRAZOSIN HCL<\/td>\n CAPSULE<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.251<\/td>\n 292<\/td>\n 242000-ALPHA-ADRENERGIC BLOCKING AGENTS<\/td>\n Minipress<\/td>\n PRAZOSIN HCL<\/td>\n CAPSULE<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.252<\/td>\n 293<\/td>\n 242000-ALPHA-ADRENERGIC BLOCKING AGENTS<\/td>\n Minipress<\/td>\n PRAZOSIN HCL<\/td>\n CAPSULE<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.124<\/td>\n 22.649<\/td>\n 242000-ALPHA-ADRENERGIC BLOCKING AGENTS<\/td>\n Terazosin<\/td>\n TERAZOSIN HCL<\/td>\n CAPSULE<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.125<\/td>\n 22.650<\/td>\n 242000-ALPHA-ADRENERGIC BLOCKING AGENTS<\/td>\n Terazosin<\/td>\n TERAZOSIN HCL<\/td>\n CAPSULE<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.126<\/td>\n 22.651<\/td>\n 242000-ALPHA-ADRENERGIC BLOCKING AGENTS<\/td>\n Terazosin<\/td>\n TERAZOSIN HCL<\/td>\n CAPSULE<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.127<\/td>\n 22.652<\/td>\n 242000-ALPHA-ADRENERGIC BLOCKING AGENTS<\/td>\n Terazosin<\/td>\n TERAZOSIN HCL<\/td>\n CAPSULE<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.947<\/td>\n 47.586<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Toprol XL<\/td>\n METOPROLOL SUCCINATE<\/td>\n TAB ER 24H<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.741<\/td>\n 16.599<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Toprol XL<\/td>\n METOPROLOL SUCCINATE<\/td>\n TAB ER 24H<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.742<\/td>\n 16.600<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Toprol XL<\/td>\n METOPROLOL SUCCINATE<\/td>\n TAB ER 24H<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.743<\/td>\n 16.601<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Toprol XL<\/td>\n METOPROLOL SUCCINATE<\/td>\n TAB ER 24H<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.660<\/td>\n 5.138<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Tenormin<\/td>\n ATENOLOL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.661<\/td>\n 5.139<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Tenormin<\/td>\n ATENOLOL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.662<\/td>\n 15.864<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Tenormin<\/td>\n ATENOLOL<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
66.990<\/td>\n 420<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Tenoretic<\/td>\n ATENOLOL-CHLORTHALIDONE<\/td>\n TABLET<\/td>\n 50-25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
66.991<\/td>\n 419<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Tenoretic<\/td>\n ATENOLOL-CHLORTHALIDONE<\/td>\n TABLET<\/td>\n 100-25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
63.820<\/td>\n 17.955<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Zebeta<\/td>\n BISOPROLOL FUMARATE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
63.821<\/td>\n 17.956<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Zebeta<\/td>\n BISOPROLOL FUMARATE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
45.061<\/td>\n 21.139<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Ziac<\/td>\n BISOPROLOL FUMARATE-HCTZ<\/td>\n TABLET<\/td>\n 2.5-6.25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
45.062<\/td>\n 21.140<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Ziac<\/td>\n BISOPROLOL FUMARATE-HCTZ<\/td>\n TABLET<\/td>\n 5-6.25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
45.063<\/td>\n 21.141<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Ziac<\/td>\n BISOPROLOL FUMARATE-HCTZ<\/td>\n TABLET<\/td>\n 10-6.2 5MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.551<\/td>\n 19.293<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Coreg<\/td>\n CARVEDILOL<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.552<\/td>\n 22.233<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Coreg<\/td>\n CARVEDILOL<\/td>\n TABLET<\/td>\n 12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.553<\/td>\n 28.108<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Coreg<\/td>\n CARVEDILOL<\/td>\n TABLET<\/td>\n 3.125 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.554<\/td>\n 28.109<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Coreg<\/td>\n CARVEDILOL<\/td>\n TABLET<\/td>\n 6.25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.340<\/td>\n 5.100<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Labetalol<\/td>\n LABETALOL HCL<\/td>\n TABLET<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.341<\/td>\n 5.099<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Labetalol<\/td>\n LABETALOL HCL<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.342<\/td>\n 5.098<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Labetalol<\/td>\n LABETALOL HCL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.734<\/td>\n 50.631<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Lopressor<\/td>\n METOPROLOL TARTRATE<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.641<\/td>\n 5.131<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Lopressor<\/td>\n METOPROLOL TARTRATE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.642<\/td>\n 5.132<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Lopressor<\/td>\n METOPROLOL TARTRATE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.652<\/td>\n 5.136<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Corgard<\/td>\n NADOLOL<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.653<\/td>\n 5.137<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Corgard<\/td>\n NADOLOL<\/td>\n TABLET<\/td>\n 80 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.654<\/td>\n 5.135<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Corgard<\/td>\n NADOLOL<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.230<\/td>\n 5.116<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Inderal LA<\/td>\n PROPRANOLOL HCL<\/td>\n CAP SA 24H<\/td>\n 80 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.231<\/td>\n 5.113<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Inderal LA<\/td>\n PROPRANOLOL HCL<\/td>\n CAP SA 24H<\/td>\n 120 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.232<\/td>\n 5.114<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Inderal LA<\/td>\n PROPRANOLOL HCL<\/td>\n CAP SA 24H<\/td>\n 160 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.233<\/td>\n 5.115<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Inderal LA<\/td>\n PROPRANOLOL HCL<\/td>\n CAP SA 24H<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.630<\/td>\n 5.123<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Propranolol<\/td>\n PROPRANOLOL HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.631<\/td>\n 5.124<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Propranolol<\/td>\n PROPRANOLOL HCL<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.632<\/td>\n 5.125<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Propranolol<\/td>\n PROPRANOLOL HCL<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.633<\/td>\n 5.126<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Propranolol<\/td>\n PROPRANOLOL HCL<\/td>\n TABLET<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.634<\/td>\n 5.127<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Propranolol<\/td>\n PROPRANOLOL HCL<\/td>\n TABLET<\/td>\n 80 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.511<\/td>\n 13.497<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Betapace<\/td>\n SOTALOL HCL<\/td>\n TABLET<\/td>\n 160 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.512<\/td>\n 17.196<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Betapace<\/td>\n SOTALOL HCL<\/td>\n TABLET<\/td>\n 80 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.516<\/td>\n 24.097<\/td>\n 242400-BETA-ADRENERGIC BLOCKING AGENTS<\/td>\n Betapace<\/td>\n SOTALOL HCL<\/td>\n TABLET<\/td>\n 120 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.681<\/td>\n 16.925<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Norvasc<\/td>\n AMLODIPINE BESYLATE<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.682<\/td>\n 16.927<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Norvasc<\/td>\n AMLODIPINE BESYLATE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.683<\/td>\n 16.926<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Norvasc<\/td>\n AMLODIPINE BESYLATE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.604<\/td>\n 50.519<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Lotrel<\/td>\n AMLODIPINE BESYLATE-BENAZEPRIL<\/td>\n CAPSULE<\/td>\n 10-20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.949<\/td>\n 60.722<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Lotrel<\/td>\n AMLODIPINE BESYLATE-BENAZEPRIL<\/td>\n CAPSULE<\/td>\n 5-40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.950<\/td>\n 60.723<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Lotrel<\/td>\n AMLODIPINE BESYLATE-BENAZEPRIL<\/td>\n CAPSULE<\/td>\n 10-40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.090<\/td>\n 23.768<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Lotrel<\/td>\n AMLODIPINE BESYLATE-BENAZEPRIL<\/td>\n CAPSULE<\/td>\n 5-20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.092<\/td>\n 23.769<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Lotrel<\/td>\n AMLODIPINE BESYLATE-BENAZEPRIL<\/td>\n CAPSULE<\/td>\n 5-10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.093<\/td>\n 23.770<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Lotrel<\/td>\n AMLODIPINE BESYLATE-BENAZEPRIL<\/td>\n CAPSULE<\/td>\n 2.5-10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.350<\/td>\n 568<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Procardia<\/td>\n NIFEDIPINE<\/td>\n CAPSULE<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.351<\/td>\n 569<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Procardia<\/td>\n NIFEDIPINE<\/td>\n CAPSULE<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.221<\/td>\n 20.616<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Procardia XL<\/td>\n NIFEDIPINE<\/td>\n TAB ER 24<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.221<\/td>\n 20.616<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Procardia XL<\/td>\n NIFEDIPINE<\/td>\n TAB ER 24<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.222<\/td>\n 20.617<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Procardia XL<\/td>\n NIFEDIPINE<\/td>\n TAB ER 24<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.222<\/td>\n 20.617<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Procardia XL<\/td>\n NIFEDIPINE<\/td>\n TAB ER 24<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.223<\/td>\n 20.618<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Procardia XL<\/td>\n NIFEDIPINE<\/td>\n TAB ER 24<\/td>\n 90 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.223<\/td>\n 20.618<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Procardia XL<\/td>\n NIFEDIPINE<\/td>\n TAB ER 24<\/td>\n 90 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.228<\/td>\n 12.061<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Adalat CC<\/td>\n NIFEDIPINE<\/td>\n TABLET ER<\/td>\n 90 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.226<\/td>\n 12.059<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Adalat CC, Afeditab CR<\/td>\n NIFEDIPINE<\/td>\n TABLET ER<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.227<\/td>\n 12.060<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Adalat CC, Afeditab CR<\/td>\n NIFEDIPINE<\/td>\n TABLET ER<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.320<\/td>\n 572<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Diltiazem ER<\/td>\n DILTIAZEM HCL<\/td>\n CAP ER 12H<\/td>\n 90 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.321<\/td>\n 570<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Diltiazem ER<\/td>\n DILTIAZEM HCL<\/td>\n CAP ER 12H<\/td>\n 120 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.322<\/td>\n 571<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Diltiazem ER<\/td>\n DILTIAZEM HCL<\/td>\n CAP ER 12H<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
7.460<\/td>\n 32.600<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Cardizem CD<\/td>\n DILTIAZEM HCL<\/td>\n CAP ER 24H<\/td>\n 360 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.323<\/td>\n 16.570<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Cardizem CD, Cartia XT<\/td>\n DILTIAZEM HCL<\/td>\n CAP ER 24H<\/td>\n 180 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.324<\/td>\n 16.571<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Cardizem CD, Cartia XT<\/td>\n DILTIAZEM HCL<\/td>\n CAP ER 24H<\/td>\n 240 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.325<\/td>\n 16.572<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Cardizem CD, Cartia XT<\/td>\n DILTIAZEM HCL<\/td>\n CAP ER 24H<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.326<\/td>\n 21.282<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Cardizem CD, Cartia XT<\/td>\n DILTIAZEM HCL<\/td>\n CAP ER 24H<\/td>\n 120 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
7.461<\/td>\n 16.849<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Dilacor XR<\/td>\n DILTIAZEM HCL<\/td>\n CAP ER DEG<\/td>\n 180 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
7.462<\/td>\n 16.850<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Dilacor XR<\/td>\n DILTIAZEM HCL<\/td>\n CAP ER DEG<\/td>\n 240 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
7.463<\/td>\n 17.205<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Dilacor XR<\/td>\n DILTIAZEM HCL<\/td>\n CAP ER DEG<\/td>\n 120 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.691<\/td>\n 40.966<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Tiazac<\/td>\n DILTIAZEM HCL<\/td>\n CAPSULE ER<\/td>\n 420 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.328<\/td>\n 24.478<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Tiazac, Taztia XT<\/td>\n DILTIAZEM HCL<\/td>\n CAPSULE ER<\/td>\n 360 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.329<\/td>\n 24.537<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Tiazac, Taztia XT<\/td>\n DILTIAZEM HCL<\/td>\n CAPSULE ER<\/td>\n 180 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.330<\/td>\n 24.536<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Tiazac, Taztia XT<\/td>\n DILTIAZEM HCL<\/td>\n CAPSULE ER<\/td>\n 120 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.332<\/td>\n 24.538<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Tiazac, Taztia XT<\/td>\n DILTIAZEM HCL<\/td>\n CAPSULE ER<\/td>\n 240 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.333<\/td>\n 24.539<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Tiazac, Taztia XT<\/td>\n DILTIAZEM HCL<\/td>\n CAPSULE ER<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.360<\/td>\n 574<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Cardizem<\/td>\n DILTIAZEM HCL<\/td>\n TABLET<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.361<\/td>\n 575<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Cardizem<\/td>\n DILTIAZEM HCL<\/td>\n TABLET<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.362<\/td>\n 576<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Cardizem<\/td>\n DILTIAZEM HCL<\/td>\n TABLET<\/td>\n 90 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.363<\/td>\n 573<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Cardizem<\/td>\n DILTIAZEM HCL<\/td>\n TABLET<\/td>\n 120 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.001<\/td>\n 16.605<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Verelan SR<\/td>\n VERAPAMIL HCL<\/td>\n CAP24H PEL<\/td>\n 180 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.002<\/td>\n 15.067<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Verelan SR<\/td>\n VERAPAMIL HCL<\/td>\n CAP24H PEL<\/td>\n 240 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.003<\/td>\n 15.066<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Verelan SR<\/td>\n VERAPAMIL HCL<\/td>\n CAP24H PEL<\/td>\n 120 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.004<\/td>\n 26.486<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Verelan SR<\/td>\n VERAPAMIL HCL<\/td>\n CAP24H PEL<\/td>\n 360 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.341<\/td>\n 564<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Calan<\/td>\n VERAPAMIL HCL<\/td>\n TABLET<\/td>\n 120 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.342<\/td>\n 566<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Calan<\/td>\n VERAPAMIL HCL<\/td>\n TABLET<\/td>\n 80 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.110<\/td>\n 565<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Verapamil<\/td>\n VERAPAMIL HCL<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.470<\/td>\n 567<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Calan SR<\/td>\n VERAPAMIL HCL<\/td>\n TABLET ER<\/td>\n 240 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.471<\/td>\n 13.670<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Calan SR<\/td>\n VERAPAMIL HCL<\/td>\n TABLET ER<\/td>\n 180 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.472<\/td>\n 15.959<\/td>\n 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC.<\/td>\n Calan SR<\/td>\n VERAPAMIL HCL<\/td>\n TABLET ER<\/td>\n 120 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.611<\/td>\n 16.039<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Lotensin<\/td>\n BENAZEPRIL HCL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.612<\/td>\n 16.040<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Lotensin<\/td>\n BENAZEPRIL HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.613<\/td>\n 16.041<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Lotensin<\/td>\n BENAZEPRIL HCL<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.614<\/td>\n 16.042<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Lotensin<\/td>\n BENAZEPRIL HCL<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.192<\/td>\n 21.724<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Lotensin HCT<\/td>\n BENAZEPRIL-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 10-12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.193<\/td>\n 21.725<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Lotensin HCT<\/td>\n BENAZEPRIL-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 20-12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.194<\/td>\n 21.726<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Lotensin HCT<\/td>\n BENAZEPRIL-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 20-25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.480<\/td>\n 378<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Captopril<\/td>\n CAPTOPRIL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.481<\/td>\n 380<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Captopril<\/td>\n CAPTOPRIL<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.482<\/td>\n 381<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Captopril<\/td>\n CAPTOPRIL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.483<\/td>\n 379<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Captopril<\/td>\n CAPTOPRIL<\/td>\n TABLET<\/td>\n 12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
54.940<\/td>\n 374<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Captopril-Hydrochlorothiazide<\/td>\n CAPTOPRIL-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 25-15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
54.941<\/td>\n 375<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Captopril-Hydrochlorothiazide<\/td>\n CAPTOPRIL-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 25-25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
960<\/td>\n 387<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Vasotec<\/td>\n ENALAPRIL MALEATE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
961<\/td>\n 384<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Vasotec<\/td>\n ENALAPRIL MALEATE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
962<\/td>\n 386<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Vasotec<\/td>\n ENALAPRIL MALEATE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
963<\/td>\n 385<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Vasotec<\/td>\n ENALAPRIL MALEATE<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
54.860<\/td>\n 382<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Enalapril-Hydrochlorothiazide<\/td>\n ENALAPRIL-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 10-25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
54.862<\/td>\n 24.190<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Enalapril-Hydrochlorothiazide<\/td>\n ENALAPRIL-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 5-12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.580<\/td>\n 24.469<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Fosinopril<\/td>\n FOSINOPRIL SODIUM<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.581<\/td>\n 16.017<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Fosinopril<\/td>\n FOSINOPRIL SODIUM<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.582<\/td>\n 16.018<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Fosinopril<\/td>\n FOSINOPRIL SODIUM<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.455<\/td>\n 40.395<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Fosinopril-Hydrochlorothiazide<\/td>\n FOSINOPRIL-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 20-12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.621<\/td>\n 44.935<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Fosinopril-Hydrochlorothiazide<\/td>\n FOSINOPRIL-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 10-12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.260<\/td>\n 393<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Prinvil, Zestril<\/td>\n LISINOPRIL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.261<\/td>\n 390<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Prinvil, Zestril<\/td>\n LISINOPRIL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.262<\/td>\n 391<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Prinvil, Zestril<\/td>\n LISINOPRIL<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.263<\/td>\n 392<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Prinvil, Zestril<\/td>\n LISINOPRIL<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.264<\/td>\n 17.266<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Prinvil, Zestril<\/td>\n LISINOPRIL<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.265<\/td>\n 41.567<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Prinvil, Zestril<\/td>\n LISINOPRIL<\/td>\n TABLET<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
88.000<\/td>\n 388<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Zestoretic<\/td>\n LISINOPRIL-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 20-12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
88.001<\/td>\n 389<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Zestoretic<\/td>\n LISINOPRIL-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 20-25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
88.002<\/td>\n 21.277<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Zestoretic<\/td>\n LISINOPRIL-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 10-12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.570<\/td>\n 18.772<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Accupril<\/td>\n QUINAPRIL HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.571<\/td>\n 18.773<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Accupril<\/td>\n QUINAPRIL HCL<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.572<\/td>\n 18.774<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Accupril<\/td>\n QUINAPRIL HCL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.573<\/td>\n 21.909<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Accupril<\/td>\n QUINAPRIL HCL<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
54.160<\/td>\n 19.140<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Accuretic<\/td>\n QUINAPRIL-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 10-12.5MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
54.161<\/td>\n 24.002<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Accuretic<\/td>\n QUINAPRIL-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 20-12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.490<\/td>\n 41.016<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Accuretic<\/td>\n QUINAPRIL-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 20-25MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.542<\/td>\n 15.940<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Altace<\/td>\n RAMIPRIL<\/td>\n CAPSULE<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.543<\/td>\n 15.941<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Altace<\/td>\n RAMIPRIL<\/td>\n CAPSULE<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.544<\/td>\n 16.031<\/td>\n 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS<\/td>\n Altace<\/td>\n RAMIPRIL<\/td>\n CAPSULE<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
4.749<\/td>\n 34.468<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Avapro<\/td>\n IRBESARTAN<\/td>\n TABLET<\/td>\n 150 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
4.750<\/td>\n 34.469<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Avapro<\/td>\n IRBESARTAN<\/td>\n TABLET<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
4.752<\/td>\n 34.470<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Avapro<\/td>\n IRBESARTAN<\/td>\n TABLET<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.042<\/td>\n 41.234<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Avalide<\/td>\n IRBESARTAN-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 150-12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.295<\/td>\n 41.897<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Avalide<\/td>\n IRBESARTAN-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 300-12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.850<\/td>\n 23.381<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Cozaar<\/td>\n LOSARTAN POTASSIUM<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.851<\/td>\n 23.382<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Cozaar<\/td>\n LOSARTAN POTASSIUM<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.853<\/td>\n 38.686<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Cozaar<\/td>\n LOSARTAN POTASSIUM<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.852<\/td>\n 23.465<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Hyzaar<\/td>\n LOSARTAN-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 50-12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.854<\/td>\n 40.923<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Hyzaar<\/td>\n LOSARTAN-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 100-25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.851<\/td>\n 59.919<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Hyzaar<\/td>\n LOSARTAN-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 100-12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
91.883<\/td>\n 51.036<\/td>\n 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS<\/td>\n Inspra<\/td>\n EPLERENONE<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
91.883<\/td>\n 51.036<\/td>\n 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS<\/td>\n Inspra<\/td>\n EPLERENONE<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
91.884<\/td>\n 51.037<\/td>\n 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS<\/td>\n Inspra<\/td>\n EPLERENONE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
91.884<\/td>\n 51.037<\/td>\n 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS<\/td>\n Inspra<\/td>\n EPLERENONE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.690<\/td>\n 6.816<\/td>\n 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS<\/td>\n Aldactone<\/td>\n SPIRONOLACTONE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.691<\/td>\n 6.817<\/td>\n 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS<\/td>\n Aldactone<\/td>\n SPIRONOLACTONE<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.692<\/td>\n 6.818<\/td>\n 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS<\/td>\n Aldactone<\/td>\n SPIRONOLACTONE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
71.150<\/td>\n 4.308<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Fiorinal<\/td>\n BUTALBITAL-ASPIRIN-CAFFEINE<\/td>\n CAPSULE<\/td>\n 50-325-40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
71.150<\/td>\n 4.308<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Fiorinal<\/td>\n BUTALBITAL-ASPIRIN-CAFFEINE<\/td>\n CAPSULE<\/td>\n 50-325-40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
45.680<\/td>\n 18.293<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Voltaren<\/td>\n DICLOFENAC SODIUM<\/td>\n GEL (GRAM)<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.310<\/td>\n 11.933<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Diclofenac Sodium<\/td>\n DICLOFENAC SODIUM<\/td>\n TAB ER 24H<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.850<\/td>\n 8.372<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Diclofenac Sodium<\/td>\n DICLOFENAC SODIUM<\/td>\n TABLET DR\/EC<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.851<\/td>\n 8.373<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Diclofenac Sodium<\/td>\n DICLOFENAC SODIUM<\/td>\n TABLET DR\/EC<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.852<\/td>\n 8.374<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Diclofenac Sodium<\/td>\n DICLOFENAC SODIUM<\/td>\n TABLET DR\/EC<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.870<\/td>\n 15.960<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Etodolac<\/td>\n ETODOLAC<\/td>\n CAPSULE<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.871<\/td>\n 15.961<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Etodolac<\/td>\n ETODOLAC<\/td>\n CAPSULE<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
61.767<\/td>\n 38.259<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Etodolac<\/td>\n ETODOLAC<\/td>\n TAB ER 24H<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
61.761<\/td>\n 20.175<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Etodolac<\/td>\n ETODOLAC<\/td>\n TABLET<\/td>\n 400 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
61.766<\/td>\n 27.368<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Etodolac<\/td>\n ETODOLAC<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.741<\/td>\n 8.348<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Ibuprofen<\/td>\n IBUPROFEN<\/td>\n TABLET<\/td>\n 400 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.742<\/td>\n 8.349<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Ibuprofen<\/td>\n IBUPROFEN<\/td>\n TABLET<\/td>\n 600 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.744<\/td>\n 8.350<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Ibuprofen<\/td>\n IBUPROFEN<\/td>\n TABLET<\/td>\n 800 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.680<\/td>\n 8.336<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Indomethacin<\/td>\n INDOMETHACIN<\/td>\n CAPSULE<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.681<\/td>\n 8.337<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Indomethacin<\/td>\n INDOMETHACIN<\/td>\n CAPSULE<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.690<\/td>\n 8.338<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Indomethacin<\/td>\n INDOMETHACIN<\/td>\n CAPSULE ER<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.792<\/td>\n 16.406<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Ketoprofen ER<\/td>\n KETOPROFEN<\/td>\n CAP24H PEL<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.420<\/td>\n 8.379<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Ketoprofen<\/td>\n KETOPROFEN<\/td>\n CAPSULE<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.421<\/td>\n 8.380<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Ketoprofen<\/td>\n KETOPROFEN<\/td>\n CAPSULE<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.661<\/td>\n 29.156<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Mobic<\/td>\n MELOXICAM<\/td>\n TABLET<\/td>\n 7.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.662<\/td>\n 29.157<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Mobic<\/td>\n MELOXICAM<\/td>\n TABLET<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.961<\/td>\n 16.574<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Nabumetone<\/td>\n NABUMETONE<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.962<\/td>\n 16.575<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Nabumetone<\/td>\n NABUMETONE<\/td>\n TABLET<\/td>\n 750 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.790<\/td>\n 8.360<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Naprosyn<\/td>\n NAPROXEN<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.792<\/td>\n 8.361<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Naprosyn<\/td>\n NAPROXEN<\/td>\n TABLET<\/td>\n 375 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.793<\/td>\n 8.362<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Naprosyn<\/td>\n NAPROXEN<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.130<\/td>\n 8.357<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Anaprox<\/td>\n NAPROXEN SODIUM<\/td>\n TABLET<\/td>\n 275 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.131<\/td>\n 8.358<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Anaprox<\/td>\n NAPROXEN SODIUM<\/td>\n TABLET<\/td>\n 550 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.801<\/td>\n 4.438<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Salsalate<\/td>\n SALSALATE<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.802<\/td>\n 4.439<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Salsalate<\/td>\n SALSALATE<\/td>\n TABLET<\/td>\n 750 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
55.402<\/td>\n 45.155<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Acetaminophen-Codeine Solution<\/td>\n ACETAMINOPHEN-CODEINE<\/td>\n SOLUTION<\/td>\n 120-12 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
70.131<\/td>\n 4.163<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Acetaminophen-Codeine Tablet<\/td>\n ACETAMINOPHEN-CODEINE<\/td>\n TABLET<\/td>\n 300-15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
70.134<\/td>\n 4.165<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Tylenol-Codeine #3<\/td>\n ACETAMINOPHEN-CODEINE<\/td>\n TABLET<\/td>\n 300-30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
70.136<\/td>\n 4.169<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Tylenol-Codeine #4<\/td>\n ACETAMINOPHEN-CODEINE<\/td>\n TABLET<\/td>\n 300-60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
70.140<\/td>\n 4.149<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Butalbital-Acetaminophen-Caffeine-Codeine<\/td>\n BUTALBITAL-ACETAMINOPHEN-CAFFEINE-CODEINE<\/td>\n CAPSULE<\/td>\n 50-325-30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
21.146<\/td>\n 53.582<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Hydrocodone-Acetaminophen<\/td>\n HYDROCODONE-ACETAMINOPHEN<\/td>\n SOLUTION<\/td>\n 7.5-325\/15<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.486<\/td>\n 47.430<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Hydrocodone-Acetaminophen<\/td>\n HYDROCODONE-ACETAMINOPHEN<\/td>\n TABLET<\/td>\n 5-325 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.488<\/td>\n 47.431<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Hydrocodone-Acetaminophen<\/td>\n HYDROCODONE-ACETAMINOPHEN<\/td>\n TABLET<\/td>\n 7.5-325 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
70.330<\/td>\n 30.623<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Hydrocodone-Acetaminophen<\/td>\n HYDROCODONE-ACETAMINOPHEN<\/td>\n TABLET<\/td>\n 10-325 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.488<\/td>\n 47.431<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Hydrocodone-Acetaminophen<\/td>\n HYDROCODONE-ACETAMINOPHEN<\/td>\n TABLET<\/td>\n 7.5-325 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
63.101<\/td>\n 34.068<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Vicoprofen<\/td>\n HYDROCODONE-IBUPROFEN<\/td>\n TABLET<\/td>\n 7.5-200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.141<\/td>\n 4.110<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Dilaudid<\/td>\n HYDROMORPHONE HCL<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.143<\/td>\n 4.112<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Dilaudid<\/td>\n HYDROMORPHONE HCL<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.144<\/td>\n 15.190<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Dilaudid<\/td>\n HYDROMORPHONE HCL<\/td>\n TABLET<\/td>\n 8 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.420<\/td>\n 4.240<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Dolophine<\/td>\n METHADONE HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.422<\/td>\n 4.242<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Dolophine<\/td>\n METHADONE HCL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.060<\/td>\n 4.087<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Morphine<\/td>\n MORPHINE SULFATE<\/td>\n SOLUTION<\/td>\n 10 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.062<\/td>\n 4.089<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Morphine<\/td>\n MORPHINE SULFATE<\/td>\n SOLUTION<\/td>\n 20 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.063<\/td>\n 4.090<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Morphine<\/td>\n MORPHINE SULFATE<\/td>\n SOLUTION<\/td>\n 100 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.070<\/td>\n 4.091<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Morphine<\/td>\n MORPHINE SULFATE<\/td>\n TABLET<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.071<\/td>\n 4.092<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Morphine<\/td>\n MORPHINE SULFATE<\/td>\n TABLET<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.640<\/td>\n 4.096<\/td>\n 280808-OPIATE AGONISTS<\/td>\n MS Contin CR<\/td>\n MORPHINE SULFATE<\/td>\n TABLET ER<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.641<\/td>\n 4.097<\/td>\n 280808-OPIATE AGONISTS<\/td>\n MS Contin CR<\/td>\n MORPHINE SULFATE<\/td>\n TABLET ER<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.643<\/td>\n 11.887<\/td>\n 280808-OPIATE AGONISTS<\/td>\n MS Contin CR<\/td>\n MORPHINE SULFATE<\/td>\n TABLET ER<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.285<\/td>\n 24.507<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Oxycodone<\/td>\n OXYCODONE HCL<\/td>\n CAPSULE<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.290<\/td>\n 4.225<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Oxycodone<\/td>\n OXYCODONE HCL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.965<\/td>\n 48.976<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Percocet<\/td>\n OXYCODONE HCL-ACETAMINOPHEN<\/td>\n TABLET<\/td>\n 7.5-325MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.966<\/td>\n 48.977<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Percocet<\/td>\n OXYCODONE HCL-ACETAMINOPHEN<\/td>\n TABLET<\/td>\n 10MG-325MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
70.491<\/td>\n 4.222<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Percocet<\/td>\n OXYCODONE HCL-ACETAMINOPHEN<\/td>\n TABLET<\/td>\n 5 MG-325MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
7.221<\/td>\n 23.139<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Ultram<\/td>\n TRAMADOL HCL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.909<\/td>\n 48.456<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Ultracet<\/td>\n TRAMADOL HCL-ACETAMINOPHEN<\/td>\n TABLET<\/td>\n 37.5-325MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
72.510<\/td>\n 4.450<\/td>\n 280892-ANALGESICS AND ANTIPYRETICS, MISC.<\/td>\n Capacet<\/td>\n BUTALBITAL-ACETAMINOPHEN-CAFFEINE<\/td>\n CAPSULE<\/td>\n 50-325-40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
72.530<\/td>\n 4.451<\/td>\n 280892-ANALGESICS AND ANTIPYRETICS, MISC.<\/td>\n Esgic<\/td>\n BUTALBITAL-ACETAMINOPHEN-CAFFEINE<\/td>\n TABLET<\/td>\n 50-325-40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.996<\/td>\n 48.520<\/td>\n 280892-ANALGESICS AND ANTIPYRETICS, MISC.<\/td>\n Nodolor<\/td>\n ISOMETHEPT-DICHLPHN\/ACETAMINOPHEN<\/td>\n CAPSULE<\/td>\n 65-100-325 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.233<\/td>\n 75.222<\/td>\n 281000-OPIATE ANTAGONISTS<\/td>\n Narcan Nasal<\/td>\n NALOXONE HCL<\/td>\n SPRAY<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.070<\/td>\n 4.518<\/td>\n 281000-OPIATE ANTAGONISTS<\/td>\n Naltrexone<\/td>\n NALTREXONE HCL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.321<\/td>\n 4.543<\/td>\n 281204-BARBITURATES (ANTICONVULSANTS)<\/td>\n Mysoline<\/td>\n PRIMIDONE<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.322<\/td>\n 4.544<\/td>\n 281204-BARBITURATES (ANTICONVULSANTS)<\/td>\n Mysoline<\/td>\n PRIMIDONE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.470<\/td>\n 4.560<\/td>\n 281208-BENZODIAZEPINES (ANTICONVULSANTS)<\/td>\n Klonopin<\/td>\n CLONAZEPAM<\/td>\n TABLET<\/td>\n 0.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.471<\/td>\n 4.561<\/td>\n 281208-BENZODIAZEPINES (ANTICONVULSANTS)<\/td>\n Klonopin<\/td>\n CLONAZEPAM<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.472<\/td>\n 4.562<\/td>\n 281208-BENZODIAZEPINES (ANTICONVULSANTS)<\/td>\n Klonopin<\/td>\n CLONAZEPAM<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.260<\/td>\n 4.532<\/td>\n 281212-HYDANTOINS<\/td>\n Peganone<\/td>\n ETHOTOIN<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.241<\/td>\n 4.529<\/td>\n 281212-HYDANTOINS<\/td>\n Dilantin<\/td>\n PHENYTOIN<\/td>\n ORAL SUSP<\/td>\n 125 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
99.557<\/td>\n 63.845<\/td>\n 281212-HYDANTOINS<\/td>\n Phenytoin<\/td>\n PHENYTOIN<\/td>\n ORAL SUSP<\/td>\n 100 MG\/4ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.250<\/td>\n 4.531<\/td>\n 281212-HYDANTOINS<\/td>\n Dilantin<\/td>\n PHENYTOIN<\/td>\n TAB CHEW<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.037<\/td>\n 49.444<\/td>\n 281212-HYDANTOINS<\/td>\n Dilantin, Phenytek<\/td>\n PHENYTOIN SODIUM EXTENDED<\/td>\n CAPSULE<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.038<\/td>\n 49.445<\/td>\n 281212-HYDANTOINS<\/td>\n Dilantin, Phenytek<\/td>\n PHENYTOIN SODIUM EXTENDED<\/td>\n CAPSULE<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.700<\/td>\n 4.521<\/td>\n 281212-HYDANTOINS<\/td>\n Dilantin, Phenytek<\/td>\n PHENYTOIN SODIUM EXTENDED<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.701<\/td>\n 4.522<\/td>\n 281212-HYDANTOINS<\/td>\n Dilantin, Phenytek<\/td>\n PHENYTOIN SODIUM EXTENDED<\/td>\n CAPSULE<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.932<\/td>\n 58.487<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Carbatrol<\/td>\n CARBAMAZEPINE<\/td>\n CPMP 12HR<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.933<\/td>\n 58.488<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Carbatrol<\/td>\n CARBAMAZEPINE<\/td>\n CPMP 12HR<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.934<\/td>\n 58.489<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Carbatrol<\/td>\n CARBAMAZEPINE<\/td>\n CPMP 12HR<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.500<\/td>\n 4.557<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Carbamazepine<\/td>\n CARBAMAZEPINE<\/td>\n ORAL SUSP<\/td>\n 100 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.460<\/td>\n 4.559<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Carbamazepine<\/td>\n CARBAMAZEPINE<\/td>\n TAB CHEW<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.820<\/td>\n 26.868<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Tegreol XR<\/td>\n CARBAMAZEPINE<\/td>\n TAB ER 12H<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.821<\/td>\n 16.773<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Tegreol XR<\/td>\n CARBAMAZEPINE<\/td>\n TAB ER 12H<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.822<\/td>\n 17.876<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Tegreol XR<\/td>\n CARBAMAZEPINE<\/td>\n TAB ER 12H<\/td>\n 400 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.450<\/td>\n 4.558<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Tegretol<\/td>\n CARBAMAZEPINE<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.040<\/td>\n 46.315<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Depakote ER<\/td>\n DIVALPROEX SODIUM<\/td>\n TAB ER 24H<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.754<\/td>\n 51.469<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Depakote ER<\/td>\n DIVALPROEX SODIUM<\/td>\n TAB ER 24H<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.290<\/td>\n 4.539<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Depakote<\/td>\n DIVALPROEX SODIUM<\/td>\n TABLET DR<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.291<\/td>\n 4.540<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Depakote<\/td>\n DIVALPROEX SODIUM<\/td>\n TABLET DR<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.292<\/td>\n 4.538<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Depakote<\/td>\n DIVALPROEX SODIUM<\/td>\n TABLET DR<\/td>\n 125 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
780<\/td>\n 21.413<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Neurontin<\/td>\n GABAPENTIN<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
781<\/td>\n 21.414<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Neurontin<\/td>\n GABAPENTIN<\/td>\n CAPSULE<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
782<\/td>\n 21.415<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Neurontin<\/td>\n GABAPENTIN<\/td>\n CAPSULE<\/td>\n 400 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.235<\/td>\n 47.927<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Neurontin<\/td>\n GABAPENTIN<\/td>\n SOLUTION<\/td>\n 250 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.447<\/td>\n 41.806<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Neurontin<\/td>\n GABAPENTIN<\/td>\n TABLET<\/td>\n 800 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.624<\/td>\n 41.805<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Neurontin<\/td>\n GABAPENTIN<\/td>\n TABLET<\/td>\n 600 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
64.316<\/td>\n 17.871<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lamictal<\/td>\n LAMOTRIGINE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
64.317<\/td>\n 17.872<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lamictal<\/td>\n LAMOTRIGINE<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
64.324<\/td>\n 22.550<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lamictal<\/td>\n LAMOTRIGINE<\/td>\n TABLET<\/td>\n 150 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
64.325<\/td>\n 22.551<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lamictal<\/td>\n LAMOTRIGINE<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.779<\/td>\n 64.819<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Keppra<\/td>\n LEVETIRACETAM<\/td>\n SOLUTION<\/td>\n 500 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.353<\/td>\n 53.031<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Keppra<\/td>\n LEVETIRACETAM<\/td>\n SOLUTION<\/td>\n 100 MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.586<\/td>\n 45.652<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Keppra<\/td>\n LEVETIRACETAM<\/td>\n TABLET<\/td>\n 750 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.587<\/td>\n 44.632<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Keppra<\/td>\n LEVETIRACETAM<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.597<\/td>\n 44.633<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Keppra<\/td>\n LEVETIRACETAM<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
86.223<\/td>\n 47.077<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Keppra<\/td>\n LEVETIRACETAM<\/td>\n TABLET<\/td>\n 1000 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
21.723<\/td>\n 33.724<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Trileptal<\/td>\n OXCARBAZEPINE<\/td>\n ORAL SUSP<\/td>\n 300 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
21.721<\/td>\n 27.779<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Trileptal<\/td>\n OXCARBAZEPINE<\/td>\n TABLET<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
21.722<\/td>\n 27.780<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Trileptal<\/td>\n OXCARBAZEPINE<\/td>\n TABLET<\/td>\n 600 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
21.724<\/td>\n 44.336<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Trileptal<\/td>\n OXCARBAZEPINE<\/td>\n TABLET<\/td>\n 150 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
36.550<\/td>\n 26.169<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Topamax<\/td>\n TOPIRAMATE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
36.551<\/td>\n 26.170<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Topamax<\/td>\n TOPIRAMATE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
36.552<\/td>\n 26.171<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Topamax<\/td>\n TOPIRAMATE<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
36.553<\/td>\n 29.837<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Topamax<\/td>\n TOPIRAMATE<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.270<\/td>\n 4.536<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Depakene<\/td>\n VALPROIC ACID<\/td>\n CAPSULE<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.280<\/td>\n 4.535<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Depakene Syrup<\/td>\n VALPROIC ACID (AS SODIUM SALT)<\/td>\n SOLUTION<\/td>\n 250 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.965<\/td>\n 68.220<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Valproic Solution<\/td>\n VALPROIC ACID (AS SODIUM SALT)<\/td>\n SOLUTION<\/td>\n 250 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.986<\/td>\n 68.236<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Valproic Syrup<\/td>\n VALPROIC ACID (AS SODIUM SALT)<\/td>\n SOLUTION<\/td>\n 500 MG\/10ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.987<\/td>\n 68.237<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Valproic Syrup<\/td>\n VALPROIC ACID (AS SODIUM SALT)<\/td>\n SYRINGE<\/td>\n 250 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.831<\/td>\n 53.367<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Zonegran<\/td>\n ZONISAMIDE<\/td>\n CAPSULE<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.833<\/td>\n 53.368<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Zonegran<\/td>\n ZONISAMIDE<\/td>\n CAPSULE<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
92.219<\/td>\n 45.100<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Zonegran<\/td>\n ZONISAMIDE<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.512<\/td>\n 46.043<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Elavil<\/td>\n AMITRIPTYLINE HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.513<\/td>\n 46.044<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Elavil<\/td>\n AMITRIPTYLINE HCL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.514<\/td>\n 46.045<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Elavil<\/td>\n AMITRIPTYLINE HCL<\/td>\n TABLET<\/td>\n 150 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.515<\/td>\n 46.046<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Elavil<\/td>\n AMITRIPTYLINE HCL<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.516<\/td>\n 46.047<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Elavil<\/td>\n AMITRIPTYLINE HCL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.517<\/td>\n 46.048<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Elavil<\/td>\n AMITRIPTYLINE HCL<\/td>\n TABLET<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.317<\/td>\n 53.006<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Wellbutrin XL<\/td>\n BUPROPION HCL<\/td>\n TAB ER 24H<\/td>\n 150 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.318<\/td>\n 53.007<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Wellbutrin XL<\/td>\n BUPROPION HCL<\/td>\n TAB ER 24H<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.384<\/td>\n 46.236<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Wellbutrin<\/td>\n BUPROPION HCL<\/td>\n TABLET<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.385<\/td>\n 46.237<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Wellbutrin<\/td>\n BUPROPION HCL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.386<\/td>\n 46.238<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Wellbutrin SR<\/td>\n BUPROPION HCL<\/td>\n TABLET ER<\/td>\n 150 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.387<\/td>\n 46.239<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Wellbutrin SR<\/td>\n BUPROPION HCL<\/td>\n TABLET ER<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.573<\/td>\n 50.496<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Wellbutrin SR<\/td>\n BUPROPION HCL<\/td>\n TABLET ER<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.901<\/td>\n 31.439<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Zyban SR<\/td>\n BUPROPION HCL<\/td>\n TABLET ER<\/td>\n 150 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.342<\/td>\n 46.203<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Celexa<\/td>\n CITALOPRAM HYDROBROMIDE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.343<\/td>\n 46.204<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Celexa<\/td>\n CITALOPRAM HYDROBROMIDE<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.345<\/td>\n 46.206<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Celexa<\/td>\n CITALOPRAM HYDROBROMIDE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.563<\/td>\n 46.086<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Doxepin<\/td>\n DOXEPIN HCL<\/td>\n CAPSULE<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.564<\/td>\n 46.087<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Doxepin<\/td>\n DOXEPIN HCL<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.565<\/td>\n 46.088<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Doxepin<\/td>\n DOXEPIN HCL<\/td>\n CAPSULE<\/td>\n 150 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.566<\/td>\n 46.089<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Doxepin<\/td>\n DOXEPIN HCL<\/td>\n CAPSULE<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.567<\/td>\n 46.090<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Doxepin<\/td>\n DOXEPIN HCL<\/td>\n CAPSULE<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.568<\/td>\n 46.091<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Doxepin<\/td>\n DOXEPIN HCL<\/td>\n CAPSULE<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.161<\/td>\n 57.891<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Cymbalta<\/td>\n DULOXETINE HCL<\/td>\n CAPSULE DR<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.162<\/td>\n 57.892<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Cymbalta<\/td>\n DULOXETINE HCL<\/td>\n CAPSULE DR<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.164<\/td>\n 57.893<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Cymbalta<\/td>\n DULOXETINE HCL<\/td>\n CAPSULE DR<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
38.728<\/td>\n 74.166<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Cymbalta<\/td>\n DULOXETINE HCL<\/td>\n CAPSULE DR<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.035<\/td>\n 51.698<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Lexapro Solution<\/td>\n ESCITALOPRAM OXALATE<\/td>\n SOLUTION<\/td>\n 5 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.851<\/td>\n 50.712<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Lexapro<\/td>\n ESCITALOPRAM OXALATE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.987<\/td>\n 50.760<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Lexapro<\/td>\n ESCITALOPRAM OXALATE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.975<\/td>\n 51.642<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Lexapro<\/td>\n ESCITALOPRAM OXALATE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.353<\/td>\n 46.213<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Prozac<\/td>\n FLUOXETINE HCL<\/td>\n CAPSULE<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.354<\/td>\n 46.214<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Prozac<\/td>\n FLUOXETINE HCL<\/td>\n CAPSULE<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.355<\/td>\n 46.215<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Prozac<\/td>\n FLUOXETINE HCL<\/td>\n CAPSULE<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.348<\/td>\n 46.209<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Fluvoxamine<\/td>\n FLUVOXAMINE MALEATE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.349<\/td>\n 46.210<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Fluvoxamine<\/td>\n FLUVOXAMINE MALEATE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.541<\/td>\n 46.068<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Tofranil<\/td>\n IMIPRAMINE HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.542<\/td>\n 46.069<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Tofranil<\/td>\n IMIPRAMINE HCL<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.543<\/td>\n 46.070<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Tofranil<\/td>\n IMIPRAMINE HCL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
21.817<\/td>\n 54.009<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Remeron<\/td>\n MIRTAZAPINE<\/td>\n TABLET<\/td>\n 7.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.732<\/td>\n 46.450<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Remeron<\/td>\n MIRTAZAPINE<\/td>\n TABLET<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.733<\/td>\n 46.451<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Remeron<\/td>\n MIRTAZAPINE<\/td>\n TABLET<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.734<\/td>\n 46.452<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Remeron<\/td>\n MIRTAZAPINE<\/td>\n TABLET<\/td>\n 45 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.529<\/td>\n 46.059<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Pamelor<\/td>\n NORTRIPTYLINE HCL<\/td>\n CAPSULE<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.532<\/td>\n 46.060<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Pamelor<\/td>\n NORTRIPTYLINE HCL<\/td>\n CAPSULE<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.533<\/td>\n 46.061<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Pamelor<\/td>\n NORTRIPTYLINE HCL<\/td>\n CAPSULE<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.534<\/td>\n 46.062<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Pamelor<\/td>\n NORTRIPTYLINE HCL<\/td>\n CAPSULE<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.077<\/td>\n 50.136<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Paxil CR<\/td>\n PAROXETINE HCL<\/td>\n TAB ER 24H<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.078<\/td>\n 50.137<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Paxil CR<\/td>\n PAROXETINE HCL<\/td>\n TAB ER 24H<\/td>\n 12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.079<\/td>\n 50.138<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Paxil CR<\/td>\n PAROXETINE HCL<\/td>\n TAB ER 24H<\/td>\n 37.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.364<\/td>\n 46.222<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Paxil<\/td>\n PAROXETINE HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.366<\/td>\n 46.223<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Paxil<\/td>\n PAROXETINE HCL<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.367<\/td>\n 46.224<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Paxil<\/td>\n PAROXETINE HCL<\/td>\n TABLET<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.368<\/td>\n 46.225<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Paxil<\/td>\n PAROXETINE HCL<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.373<\/td>\n 46.227<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Zoloft<\/td>\n SERTRALINE HCL<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.374<\/td>\n 46.228<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Zoloft<\/td>\n SERTRALINE HCL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.375<\/td>\n 46.229<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Zoloft<\/td>\n SERTRALINE HCL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.391<\/td>\n 46.241<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Trazodone<\/td>\n TRAZODONE HCL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.392<\/td>\n 46.242<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Trazodone<\/td>\n TRAZODONE HCL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.393<\/td>\n 46.243<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Trazodone<\/td>\n TRAZODONE HCL<\/td>\n TABLET<\/td>\n 150 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.394<\/td>\n 46.244<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Trazodone<\/td>\n TRAZODONE HCL<\/td>\n TABLET<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.816<\/td>\n 46.403<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Effexor XR<\/td>\n VENLAFAXINE HCL<\/td>\n CAP ER 24H<\/td>\n 37.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.817<\/td>\n 46.404<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Effexor XR<\/td>\n VENLAFAXINE HCL<\/td>\n CAP ER 24H<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.818<\/td>\n 46.405<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Effexor XR<\/td>\n VENLAFAXINE HCL<\/td>\n CAP ER 24H<\/td>\n 150 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.811<\/td>\n 46.398<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Venlafaxine<\/td>\n VENLAFAXINE HCL<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.812<\/td>\n 46.399<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Venlafaxine<\/td>\n VENLAFAXINE HCL<\/td>\n TABLET<\/td>\n 37.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.813<\/td>\n 46.400<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Venlafaxine<\/td>\n VENLAFAXINE HCL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.814<\/td>\n 46.401<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Venlafaxine<\/td>\n VENLAFAXINE HCL<\/td>\n TABLET<\/td>\n 75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.815<\/td>\n 46.402<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Venlafaxine<\/td>\n VENLAFAXINE HCL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.431<\/td>\n 3.796<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Chlorpromazine<\/td>\n CHLORPROMAZINE HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.432<\/td>\n 3.799<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Chlorpromazine<\/td>\n CHLORPROMAZINE HCL<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.433<\/td>\n 3.800<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Chlorpromazine<\/td>\n CHLORPROMAZINE HCL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.434<\/td>\n 3.797<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Chlorpromazine<\/td>\n CHLORPROMAZINE HCL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.435<\/td>\n 3.798<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Chlorpromazine<\/td>\n CHLORPROMAZINE HCL<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.602<\/td>\n 3.823<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Fluphenazine<\/td>\n FLUPHENAZINE HCL<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.603<\/td>\n 3.824<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Fluphenazine<\/td>\n FLUPHENAZINE HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.604<\/td>\n 3.825<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Fluphenazine<\/td>\n FLUPHENAZINE HCL<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.605<\/td>\n 3.826<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Fluphenazine<\/td>\n FLUPHENAZINE HCL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.530<\/td>\n 3.972<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Haloperidol<\/td>\n HALOPERIDOL<\/td>\n TABLET<\/td>\n 0.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.531<\/td>\n 3.973<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Haloperidol<\/td>\n HALOPERIDOL<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.532<\/td>\n 3.974<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Haloperidol<\/td>\n HALOPERIDOL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.533<\/td>\n 3.975<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Haloperidol<\/td>\n HALOPERIDOL<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.534<\/td>\n 3.976<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Haloperidol<\/td>\n HALOPERIDOL<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.535<\/td>\n 3.977<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Haloperidol<\/td>\n HALOPERIDOL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.520<\/td>\n 3.971<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Haloperidol<\/td>\n HALOPERIDOL LACTATE<\/td>\n ORAL CONC<\/td>\n 2 MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.560<\/td>\n 3.981<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Loxapine<\/td>\n LOXAPINE SUCCINATE<\/td>\n CAPSULE<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.561<\/td>\n 3.982<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Loxapine<\/td>\n LOXAPINE SUCCINATE<\/td>\n CAPSULE<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.563<\/td>\n 3.984<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Loxapine<\/td>\n LOXAPINE SUCCINATE<\/td>\n CAPSULE<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.081<\/td>\n 27.959<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Zyprexa<\/td>\n OLANZAPINE<\/td>\n TABLET<\/td>\n 7.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.082<\/td>\n 27.960<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Zyprexa<\/td>\n OLANZAPINE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.083<\/td>\n 27.961<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Zyprexa<\/td>\n OLANZAPINE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.084<\/td>\n 29.077<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Zyprexa<\/td>\n OLANZAPINE<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.085<\/td>\n 41.026<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Zyprexa<\/td>\n OLANZAPINE<\/td>\n TABLET<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.086<\/td>\n 41.027<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Zyprexa<\/td>\n OLANZAPINE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.650<\/td>\n 3.830<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Perphenazine<\/td>\n PERPHENAZINE<\/td>\n TABLET<\/td>\n 16 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.651<\/td>\n 3.831<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Perphenazine<\/td>\n PERPHENAZINE<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.652<\/td>\n 3.832<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Perphenazine<\/td>\n PERPHENAZINE<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.653<\/td>\n 3.833<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Perphenazine<\/td>\n PERPHENAZINE<\/td>\n TABLET<\/td>\n 8 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.409<\/td>\n 60.292<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Seroquel<\/td>\n QUETIAPINE FUMARATE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 800mg\/day<\/td>\n <\/tr>\n
26.411<\/td>\n 60.293<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Seroquel<\/td>\n QUETIAPINE FUMARATE<\/td>\n TABLET<\/td>\n 400 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 800mg\/day<\/td>\n <\/tr>\n
67.661<\/td>\n 34.187<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Seroquel<\/td>\n QUETIAPINE FUMARATE<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 800mg\/day<\/td>\n <\/tr>\n
67.662<\/td>\n 34.188<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Seroquel<\/td>\n QUETIAPINE FUMARATE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 800mg\/day<\/td>\n <\/tr>\n
67.663<\/td>\n 34.189<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Seroquel<\/td>\n QUETIAPINE FUMARATE<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 800mg\/day<\/td>\n <\/tr>\n
67.665<\/td>\n 47.198<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Seroquel<\/td>\n QUETIAPINE FUMARATE<\/td>\n TABLET<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 800mg\/day<\/td>\n <\/tr>\n
16.135<\/td>\n 26.177<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Risperdal<\/td>\n RISPERIDONE<\/td>\n SOLUTION<\/td>\n 1 MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 16mg\/day<\/td>\n <\/tr>\n
16.136<\/td>\n 21.154<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Risperdal<\/td>\n RISPERIDONE<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 16mg\/day<\/td>\n <\/tr>\n
16.137<\/td>\n 21.155<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Risperdal<\/td>\n RISPERIDONE<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 16mg\/day<\/td>\n <\/tr>\n
16.138<\/td>\n 21.156<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Risperdal<\/td>\n RISPERIDONE<\/td>\n TABLET<\/td>\n 3 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 16mg\/day<\/td>\n <\/tr>\n
16.139<\/td>\n 21.157<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Risperdal<\/td>\n RISPERIDONE<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 16mg\/day<\/td>\n <\/tr>\n
92.872<\/td>\n 42.922<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Risperdal<\/td>\n RISPERIDONE<\/td>\n TABLET<\/td>\n 0.25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 16mg\/day<\/td>\n <\/tr>\n
92.892<\/td>\n 42.923<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Risperdal<\/td>\n RISPERIDONE<\/td>\n TABLET<\/td>\n 0.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 16mg\/day<\/td>\n <\/tr>\n
15.691<\/td>\n 3.996<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Thiothixene<\/td>\n THIOTHIXENE<\/td>\n CAPSULE<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.692<\/td>\n 3.997<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Thiothixene<\/td>\n THIOTHIXENE<\/td>\n CAPSULE<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.694<\/td>\n 3.999<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Thiothixene<\/td>\n THIOTHIXENE<\/td>\n CAPSULE<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.880<\/td>\n 5.009<\/td>\n 282004-AMPHETAMINES<\/td>\n Zenzedi<\/td>\n DEXTROAMPHETAMINE SULFATE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 60mg\/day<\/td>\n <\/tr>\n
19.881<\/td>\n 5.011<\/td>\n 282004-AMPHETAMINES<\/td>\n Zenzedi<\/td>\n DEXTROAMPHETAMINE SULFATE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 60mg\/day<\/td>\n <\/tr>\n
14.635<\/td>\n 48.701<\/td>\n 282004-AMPHETAMINES<\/td>\n Adderall XR<\/td>\n DEXTROAMPHETAMINE-AMPHETAMINE<\/td>\n CAP ER 24H<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 60mg\/day<\/td>\n <\/tr>\n
14.636<\/td>\n 48.702<\/td>\n 282004-AMPHETAMINES<\/td>\n Adderall XR<\/td>\n DEXTROAMPHETAMINE-AMPHETAMINE<\/td>\n CAP ER 24H<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 60mg\/day<\/td>\n <\/tr>\n
14.637<\/td>\n 48.703<\/td>\n 282004-AMPHETAMINES<\/td>\n Adderall XR<\/td>\n DEXTROAMPHETAMINE-AMPHETAMINE<\/td>\n CAP ER 24H<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 60mg\/day<\/td>\n <\/tr>\n
17.459<\/td>\n 50.428<\/td>\n 282004-AMPHETAMINES<\/td>\n Adderall XR<\/td>\n DEXTROAMPHETAMINE-AMPHETAMINE<\/td>\n CAP ER 24H<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 60mg\/day<\/td>\n <\/tr>\n
17.468<\/td>\n 50.429<\/td>\n 282004-AMPHETAMINES<\/td>\n Adderall XR<\/td>\n DEXTROAMPHETAMINE-AMPHETAMINE<\/td>\n CAP ER 24H<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 60mg\/day<\/td>\n <\/tr>\n
17.469<\/td>\n 50.430<\/td>\n 282004-AMPHETAMINES<\/td>\n Adderall XR<\/td>\n DEXTROAMPHETAMINE-AMPHETAMINE<\/td>\n CAP ER 24H<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 60mg\/day<\/td>\n <\/tr>\n
29.007<\/td>\n 47.131<\/td>\n 282004-AMPHETAMINES<\/td>\n Adderall<\/td>\n DEXTROAMPHETAMINE-AMPHETAMINE<\/td>\n TABLET<\/td>\n 7.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 60mg\/day<\/td>\n <\/tr>\n
29.008<\/td>\n 47.132<\/td>\n 282004-AMPHETAMINES<\/td>\n Adderall<\/td>\n DEXTROAMPHETAMINE-AMPHETAMINE<\/td>\n TABLET<\/td>\n 12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 60mg\/day<\/td>\n <\/tr>\n
29.009<\/td>\n 47.133<\/td>\n 282004-AMPHETAMINES<\/td>\n Adderall<\/td>\n DEXTROAMPHETAMINE-AMPHETAMINE<\/td>\n TABLET<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 60mg\/day<\/td>\n <\/tr>\n
56.970<\/td>\n 4.999<\/td>\n 282004-AMPHETAMINES<\/td>\n Adderall<\/td>\n DEXTROAMPHETAMINE-AMPHETAMINE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 60mg\/day<\/td>\n <\/tr>\n
56.971<\/td>\n 5.000<\/td>\n 282004-AMPHETAMINES<\/td>\n Adderall<\/td>\n DEXTROAMPHETAMINE-AMPHETAMINE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 60mg\/day<\/td>\n <\/tr>\n
56.972<\/td>\n 34.359<\/td>\n 282004-AMPHETAMINES<\/td>\n Adderall<\/td>\n DEXTROAMPHETAMINE-AMPHETAMINE<\/td>\n TABLET<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 60mg\/day<\/td>\n <\/tr>\n
56.973<\/td>\n 5.001<\/td>\n 282004-AMPHETAMINES<\/td>\n Adderall<\/td>\n DEXTROAMPHETAMINE-AMPHETAMINE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 60mg\/day<\/td>\n <\/tr>\n
20.384<\/td>\n 53.056<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Metadate CD<\/td>\n METHYLPHENIDATE HCL<\/td>\n CPBP 30-70<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 100mg\/day<\/td>\n <\/tr>\n
20.385<\/td>\n 53.057<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Metadate CD<\/td>\n METHYLPHENIDATE HCL<\/td>\n CPBP 30-70<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 100mg\/day<\/td>\n <\/tr>\n
20.386<\/td>\n 53.058<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Metadate CD<\/td>\n METHYLPHENIDATE HCL<\/td>\n CPBP 30-70<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 100mg\/day<\/td>\n <\/tr>\n
26.734<\/td>\n 60.545<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Metadate CD<\/td>\n METHYLPHENIDATE HCL<\/td>\n CPBP 30-70<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 100mg\/day<\/td>\n <\/tr>\n
26.735<\/td>\n 60.546<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Metadate CD<\/td>\n METHYLPHENIDATE HCL<\/td>\n CPBP 30-70<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 100mg\/day<\/td>\n <\/tr>\n
26.736<\/td>\n 60.547<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Metadate CD<\/td>\n METHYLPHENIDATE HCL<\/td>\n CPBP 30-70<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 100mg\/day<\/td>\n <\/tr>\n
20.387<\/td>\n 53.059<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Ritalin LA<\/td>\n METHYLPHENIDATE HCL<\/td>\n CPBP 50-50<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 100mg\/day<\/td>\n <\/tr>\n
20.388<\/td>\n 53.060<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Ritalin LA<\/td>\n METHYLPHENIDATE HCL<\/td>\n CPBP 50-50<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 100mg\/day<\/td>\n <\/tr>\n
20.391<\/td>\n 53.061<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Ritalin LA<\/td>\n METHYLPHENIDATE HCL<\/td>\n CPBP 50-50<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 100mg\/day<\/td>\n <\/tr>\n
15.911<\/td>\n 4.026<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Ritalin<\/td>\n METHYLPHENIDATE HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 100mg\/day<\/td>\n <\/tr>\n
15.913<\/td>\n 4.028<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Ritalin<\/td>\n METHYLPHENIDATE HCL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 100mg\/day<\/td>\n <\/tr>\n
15.920<\/td>\n 4.027<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Ritalin<\/td>\n METHYLPHENIDATE HCL<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 100mg\/day<\/td>\n <\/tr>\n
16.180<\/td>\n 4.029<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Methylphenidate ER<\/td>\n METHYLPHENIDATE HCL<\/td>\n TABLET ER<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 100mg\/day<\/td>\n <\/tr>\n
93.075<\/td>\n 44.072<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Methylphenidate ER<\/td>\n METHYLPHENIDATE HCL<\/td>\n TABLET ER<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 100mg\/day<\/td>\n <\/tr>\n
12.956<\/td>\n 3.586<\/td>\n 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE\/HYP)<\/td>\n Phenobarbital<\/td>\n PHENOBARBITAL<\/td>\n ELIXIR<\/td>\n 20 MG\/5 ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.971<\/td>\n 3.589<\/td>\n 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE\/HYP)<\/td>\n Phenobarbital<\/td>\n PHENOBARBITAL<\/td>\n TABLET<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.972<\/td>\n 3.591<\/td>\n 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE\/HYP)<\/td>\n Phenobarbital<\/td>\n PHENOBARBITAL<\/td>\n TABLET<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.973<\/td>\n 3.590<\/td>\n 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE\/HYP)<\/td>\n Phenobarbital<\/td>\n PHENOBARBITAL<\/td>\n TABLET<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.975<\/td>\n 3.588<\/td>\n 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE\/HYP)<\/td>\n Phenobarbital<\/td>\n PHENOBARBITAL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
97.965<\/td>\n 27.611<\/td>\n 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE\/HYP)<\/td>\n Phenobarbital<\/td>\n PHENOBARBITAL<\/td>\n TABLET<\/td>\n 32.4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
97.966<\/td>\n 27.612<\/td>\n 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE\/HYP)<\/td>\n Phenobarbital<\/td>\n PHENOBARBITAL<\/td>\n TABLET<\/td>\n 64.8 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.260<\/td>\n 3.773<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Xanax<\/td>\n ALPRAZOLAM<\/td>\n TABLET<\/td>\n 0.25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.261<\/td>\n 3.774<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Xanax<\/td>\n ALPRAZOLAM<\/td>\n TABLET<\/td>\n 0.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.262<\/td>\n 3.775<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Xanax<\/td>\n ALPRAZOLAM<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.263<\/td>\n 15.566<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Xanax<\/td>\n ALPRAZOLAM<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.031<\/td>\n 3.734<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Chlordiazepoxide<\/td>\n CHLORDIAZEPOXIDE HCL<\/td>\n CAPSULE<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.032<\/td>\n 3.735<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Chlordiazepoxide<\/td>\n CHLORDIAZEPOXIDE HCL<\/td>\n CAPSULE<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.090<\/td>\n 3.744<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Tranxene<\/td>\n CLORAZEPATE DIPOTASSIUM<\/td>\n TABLET<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.092<\/td>\n 3.745<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Tranxene<\/td>\n CLORAZEPATE DIPOTASSIUM<\/td>\n TABLET<\/td>\n 3.75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.093<\/td>\n 3.746<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Tranxene<\/td>\n CLORAZEPATE DIPOTASSIUM<\/td>\n TABLET<\/td>\n 7.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.220<\/td>\n 3.766<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Valium<\/td>\n DIAZEPAM<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.221<\/td>\n 3.767<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Valium<\/td>\n DIAZEPAM<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.222<\/td>\n 3.768<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Valium<\/td>\n DIAZEPAM<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.250<\/td>\n 3.691<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Flurazepam<\/td>\n FLURAZEPAM HCL<\/td>\n CAPSULE<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.251<\/td>\n 3.692<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Flurazepam<\/td>\n FLURAZEPAM HCL<\/td>\n CAPSULE<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.160<\/td>\n 3.757<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Ativan<\/td>\n LORAZEPAM<\/td>\n TABLET<\/td>\n 0.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.161<\/td>\n 3.758<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Ativan<\/td>\n LORAZEPAM<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.162<\/td>\n 3.759<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Ativan<\/td>\n LORAZEPAM<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.230<\/td>\n 3.769<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Oxazepam<\/td>\n OXAZEPAM<\/td>\n CAPSULE<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.231<\/td>\n 3.770<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Oxazepam<\/td>\n OXAZEPAM<\/td>\n CAPSULE<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.232<\/td>\n 3.771<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Oxazepam<\/td>\n OXAZEPAM<\/td>\n CAPSULE<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.840<\/td>\n 3.689<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Restoril<\/td>\n TEMAZEPAM<\/td>\n CAPSULE<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.841<\/td>\n 3.690<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Restoril<\/td>\n TEMAZEPAM<\/td>\n CAPSULE<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.845<\/td>\n 19.182<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Restoril<\/td>\n TEMAZEPAM<\/td>\n CAPSULE<\/td>\n 7.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.037<\/td>\n 47.644<\/td>\n 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.<\/td>\n Buspar<\/td>\n BUSPIRONE HCL<\/td>\n TABLET<\/td>\n 7.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.890<\/td>\n 3.782<\/td>\n 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.<\/td>\n Buspar<\/td>\n BUSPIRONE HCL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.891<\/td>\n 3.781<\/td>\n 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.<\/td>\n Buspar<\/td>\n BUSPIRONE HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.892<\/td>\n 27.378<\/td>\n 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.<\/td>\n Buspar<\/td>\n BUSPIRONE HCL<\/td>\n TABLET<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
92.121<\/td>\n 44.210<\/td>\n 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.<\/td>\n Buspar<\/td>\n BUSPIRONE HCL<\/td>\n TABLET<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.932<\/td>\n 3.725<\/td>\n 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.<\/td>\n Hydroxyzine<\/td>\n HYDROXYZINE HCL<\/td>\n SOLUTION<\/td>\n 10 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.941<\/td>\n 3.726<\/td>\n 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.<\/td>\n Hydroxyzine<\/td>\n HYDROXYZINE HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.943<\/td>\n 3.728<\/td>\n 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.<\/td>\n Hydroxyzine<\/td>\n HYDROXYZINE HCL<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.944<\/td>\n 3.729<\/td>\n 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.<\/td>\n Hydroxyzine<\/td>\n HYDROXYZINE HCL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.951<\/td>\n 3.730<\/td>\n 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.<\/td>\n Vistaril<\/td>\n HYDROXYZINE PAMOATE<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.952<\/td>\n 3.731<\/td>\n 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.<\/td>\n Vistaril<\/td>\n HYDROXYZINE PAMOATE<\/td>\n CAPSULE<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.953<\/td>\n 3.732<\/td>\n 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.<\/td>\n Vistaril<\/td>\n HYDROXYZINE PAMOATE<\/td>\n CAPSULE<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
870<\/td>\n 19.187<\/td>\n 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.<\/td>\n Ambien<\/td>\n ZOLPIDEM TARTRATE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 10mg\/day<\/td>\n <\/tr>\n
871<\/td>\n 19.188<\/td>\n 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.<\/td>\n Ambien<\/td>\n ZOLPIDEM TARTRATE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 10mg\/day<\/td>\n <\/tr>\n
15.710<\/td>\n 4.001<\/td>\n 282800-ANTIMANIC AGENTS<\/td>\n Lithium<\/td>\n LITHIUM CARBONATE<\/td>\n CAPSULE<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.711<\/td>\n 4.000<\/td>\n 282800-ANTIMANIC AGENTS<\/td>\n Lithium<\/td>\n LITHIUM CARBONATE<\/td>\n CAPSULE<\/td>\n 150 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.721<\/td>\n 4.003<\/td>\n 282800-ANTIMANIC AGENTS<\/td>\n Lithium<\/td>\n LITHIUM CARBONATE<\/td>\n TABLET\/CAPSULE<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.712<\/td>\n 4.002<\/td>\n 282800-ANTIMANIC AGENTS<\/td>\n Lithium<\/td>\n LITHIUM CARBONATE<\/td>\n CAPSULE<\/td>\n 600 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.730<\/td>\n 4.005<\/td>\n 282800-ANTIMANIC AGENTS<\/td>\n Lithobid<\/td>\n LITHIUM CARBONATE<\/td>\n TABLET ER<\/td>\n 450 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.731<\/td>\n 4.004<\/td>\n 282800-ANTIMANIC AGENTS<\/td>\n Lithobid<\/td>\n LITHIUM CARBONATE<\/td>\n TABLET ER<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
50.740<\/td>\n 30.735<\/td>\n 283228-SELECTIVE SEROTONIN AGONISTS<\/td>\n Imitrex Nasal<\/td>\n SUMATRIPTAN<\/td>\n SPRAY<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 2 boxes\/month<\/td>\n <\/tr>\n
50.744<\/td>\n 30.742<\/td>\n 283228-SELECTIVE SEROTONIN AGONISTS<\/td>\n Imitrex Nasal<\/td>\n SUMATRIPTAN<\/td>\n SPRAY<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 2 boxes\/month<\/td>\n <\/tr>\n
24.708<\/td>\n 19.239<\/td>\n 283228-SELECTIVE SEROTONIN AGONISTS<\/td>\n Imitrex Statdose<\/td>\n SUMATRIPTAN SUCCINATE<\/td>\n CARTRIDGE<\/td>\n 6 MG\/0.5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 2 boxes\/month<\/td>\n <\/tr>\n
50.741<\/td>\n 19.192<\/td>\n 283228-SELECTIVE SEROTONIN AGONISTS<\/td>\n Imitrex Statdose<\/td>\n SUMATRIPTAN SUCCINATE<\/td>\n PEN INJCTR<\/td>\n 6 MG\/0.5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 2 boxes\/month<\/td>\n <\/tr>\n
5.700<\/td>\n 22.479<\/td>\n 283228-SELECTIVE SEROTONIN AGONISTS<\/td>\n Imitrex<\/td>\n SUMATRIPTAN SUCCINATE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 9 tablets\/month<\/td>\n <\/tr>\n
5.701<\/td>\n 17.129<\/td>\n 283228-SELECTIVE SEROTONIN AGONISTS<\/td>\n Imitrex<\/td>\n SUMATRIPTAN SUCCINATE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 9 tablets\/month<\/td>\n <\/tr>\n
5.702<\/td>\n 23.799<\/td>\n 283228-SELECTIVE SEROTONIN AGONISTS<\/td>\n Imitrex<\/td>\n SUMATRIPTAN SUCCINATE<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 9 tablets\/month<\/td>\n <\/tr>\n
50.742<\/td>\n 19.193<\/td>\n 283228-SELECTIVE SEROTONIN AGONISTS<\/td>\n Imitrex<\/td>\n SUMATRIPTAN SUCCINATE<\/td>\n VIAL<\/td>\n 6 MG\/0.5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Max 2 boxes\/month<\/td>\n <\/tr>\n
17.520<\/td>\n 4.575<\/td>\n 283604-ADAMANTANES (CNS)<\/td>\n Amantadine<\/td>\n AMANTADINE HCL<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.530<\/td>\n 4.576<\/td>\n 283604-ADAMANTANES (CNS)<\/td>\n Amantadine<\/td>\n AMANTADINE HCL<\/td>\n SOLUTION<\/td>\n 50 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.521<\/td>\n 27.637<\/td>\n 283604-ADAMANTANES (CNS)<\/td>\n Amantadine<\/td>\n AMANTADINE HCL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.620<\/td>\n 4.589<\/td>\n 283608-ANTICHOLINERGIC AGENTS (CNS)<\/td>\n Cogentin<\/td>\n BENZTROPINE MESYLATE<\/td>\n TABLET<\/td>\n 0.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.621<\/td>\n 4.590<\/td>\n 283608-ANTICHOLINERGIC AGENTS (CNS)<\/td>\n Cogentin<\/td>\n BENZTROPINE MESYLATE<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.622<\/td>\n 4.591<\/td>\n 283608-ANTICHOLINERGIC AGENTS (CNS)<\/td>\n Cogentin<\/td>\n BENZTROPINE MESYLATE<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.561<\/td>\n 4.581<\/td>\n 283608-ANTICHOLINERGIC AGENTS (CNS)<\/td>\n Trihexyphenidyl<\/td>\n TRIHEXYPHENIDYL HCL<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.563<\/td>\n 4.582<\/td>\n 283608-ANTICHOLINERGIC AGENTS (CNS)<\/td>\n Trihexyphenidyl<\/td>\n TRIHEXYPHENIDYL HCL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
95.079<\/td>\n 41.199<\/td>\n 283612-CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.<\/td>\n Comtan<\/td>\n ENTACAPONE<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.285<\/td>\n 57.987<\/td>\n 283616-DOPAMINE PRECURSORS<\/td>\n Carbidopa-Levodopa<\/td>\n CARBIDOPA-LEVODOPA<\/td>\n TAB RAPDIS<\/td>\n 10-100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.286<\/td>\n 57.988<\/td>\n 283616-DOPAMINE PRECURSORS<\/td>\n Carbidopa-Levodopa<\/td>\n CARBIDOPA-LEVODOPA<\/td>\n TAB RAPDIS<\/td>\n 25-100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.287<\/td>\n 57.989<\/td>\n 283616-DOPAMINE PRECURSORS<\/td>\n Carbidopa-Levodopa<\/td>\n CARBIDOPA-LEVODOPA<\/td>\n TAB RAPDIS<\/td>\n 25-250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
62.740<\/td>\n 2.537<\/td>\n 283616-DOPAMINE PRECURSORS<\/td>\n Sinemet<\/td>\n CARBIDOPA-LEVODOPA<\/td>\n TABLET<\/td>\n 10-100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
62.741<\/td>\n 2.538<\/td>\n 283616-DOPAMINE PRECURSORS<\/td>\n Sinemet<\/td>\n CARBIDOPA-LEVODOPA<\/td>\n TABLET<\/td>\n 25-100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
62.742<\/td>\n 2.539<\/td>\n 283616-DOPAMINE PRECURSORS<\/td>\n Sinemet<\/td>\n CARBIDOPA-LEVODOPA<\/td>\n TABLET<\/td>\n 25-250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
62.591<\/td>\n 16.043<\/td>\n 283616-DOPAMINE PRECURSORS<\/td>\n Sinemet CR<\/td>\n CARBIDOPA-LEVODOPA<\/td>\n TABLET ER<\/td>\n 50-200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
62.592<\/td>\n 19.563<\/td>\n 283616-DOPAMINE PRECURSORS<\/td>\n Sinemet CR<\/td>\n CARBIDOPA-LEVODOPA<\/td>\n TABLET ER<\/td>\n 25-100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.070<\/td>\n 6.603<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Parlodel<\/td>\n BROMOCRIPTINE MESYLATE<\/td>\n CAPSULE<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.081<\/td>\n 6.604<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Parlodel<\/td>\n BROMOCRIPTINE MESYLATE<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.051<\/td>\n 25.738<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Cabergoline<\/td>\n CABERGOLINE<\/td>\n TABLET<\/td>\n 0.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.871<\/td>\n 31.779<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Mirapex<\/td>\n PRAMIPEXOLE<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.872<\/td>\n 31.780<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Mirapex<\/td>\n PRAMIPEXOLE<\/td>\n TABLET<\/td>\n 1.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.873<\/td>\n 31.781<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Mirapex<\/td>\n PRAMIPEXOLE<\/td>\n TABLET<\/td>\n 0.125 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.874<\/td>\n 31.782<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Mirapex<\/td>\n PRAMIPEXOLE<\/td>\n TABLET<\/td>\n 0.25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.875<\/td>\n 39.100<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Mirapex<\/td>\n PRAMIPEXOLE<\/td>\n TABLET<\/td>\n 0.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.100<\/td>\n 29.159<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Requip<\/td>\n ROPINIROLE HCL<\/td>\n TABLET<\/td>\n 0.25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.101<\/td>\n 29.160<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Requip<\/td>\n ROPINIROLE HCL<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.102<\/td>\n 29.161<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Requip<\/td>\n ROPINIROLE HCL<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.104<\/td>\n 34.166<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Requip<\/td>\n ROPINIROLE HCL<\/td>\n TABLET<\/td>\n 0.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
93.038<\/td>\n 43.203<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Requip<\/td>\n ROPINIROLE HCL<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
93.048<\/td>\n 43.202<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Requip<\/td>\n ROPINIROLE HCL<\/td>\n TABLET<\/td>\n 3 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.253<\/td>\n 32.492<\/td>\n 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.<\/td>\n Namenda<\/td>\n MEMANTINE HCL\u00a0<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.773<\/td>\n 53.324<\/td>\n 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.<\/td>\n Namenda<\/td>\n MEMANTINE HCL\u00a0<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.200<\/td>\n 6.373<\/td>\n 362600-DIABETES MELLITUS<\/td>\n True Metrix Test Strips<\/td>\n BLOOD SUGAR DIAGNOSTIC<\/td>\n STRIP<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.600<\/td>\n 8.321<\/td>\n 368812-KETONES<\/td>\n Ketocare Test Strip<\/td>\n URINE ACETONE TEST STRIPS<\/td>\n STRIP<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.600<\/td>\n 8.321<\/td>\n 368812-KETONES<\/td>\n Ketocare Test Strips<\/td>\n URINE ACETONE TEST STRIPS<\/td>\n STRIP<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.950<\/td>\n 8.250<\/td>\n 400800-ALKALINIZING AGENTS<\/td>\n Urocit-K<\/td>\n POTASSIUM CITRATE<\/td>\n TABLET ER<\/td>\n 5 MEQ<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.951<\/td>\n 17.000<\/td>\n 400800-ALKALINIZING AGENTS<\/td>\n Urocit-K<\/td>\n POTASSIUM CITRATE<\/td>\n TABLET ER<\/td>\n 10 MEQ<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.095<\/td>\n 65.955<\/td>\n 400800-ALKALINIZING AGENTS<\/td>\n Urocit-K<\/td>\n POTASSIUM CITRATE<\/td>\n TABLET ER<\/td>\n 15 MEQ<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.160<\/td>\n 3.143<\/td>\n 401000-AMMONIA DETOXICANTS<\/td>\n Lactulose<\/td>\n LACTULOSE<\/td>\n SOLUTION<\/td>\n 10 G\/15ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.167<\/td>\n 29.054<\/td>\n 401000-AMMONIA DETOXICANTS<\/td>\n Lactulose<\/td>\n LACTULOSE<\/td>\n SOLUTION<\/td>\n 10 G\/15ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.962<\/td>\n 68.217<\/td>\n 401000-AMMONIA DETOXICANTS<\/td>\n Lactulose<\/td>\n LACTULOSE<\/td>\n SOLUTION<\/td>\n 20 G\/30ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.994<\/td>\n 68.243<\/td>\n 401000-AMMONIA DETOXICANTS<\/td>\n Lactulose<\/td>\n LACTULOSE<\/td>\n SOLUTION<\/td>\n 10 G\/15ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.321<\/td>\n 1.248<\/td>\n 401200-REPLACEMENT PREPARATIONS<\/td>\n Potassium Chloride<\/td>\n POTASSIUM CHLORIDE<\/td>\n CAPSULE ER<\/td>\n 10 MEQ<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.404<\/td>\n 1.262<\/td>\n 401200-REPLACEMENT PREPARATIONS<\/td>\n Potassium Chloride<\/td>\n POTASSIUM CHLORIDE<\/td>\n PACKET<\/td>\n 20 MEQ<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.512<\/td>\n 22.345<\/td>\n 401200-REPLACEMENT PREPARATIONS<\/td>\n Potassium Chloride<\/td>\n POTASSIUM CHLORIDE<\/td>\n TAB ER PRT<\/td>\n 10 MEQ<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.513<\/td>\n 22.346<\/td>\n 401200-REPLACEMENT PREPARATIONS<\/td>\n Potassium Chloride<\/td>\n POTASSIUM CHLORIDE<\/td>\n TAB ER PRT<\/td>\n 20 MEQ<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.510<\/td>\n 1.275<\/td>\n 401200-REPLACEMENT PREPARATIONS<\/td>\n Potassium Chloride<\/td>\n POTASSIUM CHLORIDE<\/td>\n TABLET ER<\/td>\n 10 MEQ<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.515<\/td>\n 1.276<\/td>\n 401200-REPLACEMENT PREPARATIONS<\/td>\n Potassium Chloride<\/td>\n POTASSIUM CHLORIDE<\/td>\n TABLET ER<\/td>\n 20 MEQ<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.373<\/td>\n 588<\/td>\n 401200-REPLACEMENT PREPARATIONS<\/td>\n Sodium Chloride For Inhalation<\/td>\n SODIUM CHLORIDE FOR INHALATION<\/td>\n VIAL-NEB<\/td>\n 3 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.520<\/td>\n 62.746<\/td>\n 401200-REPLACEMENT PREPARATIONS<\/td>\n Sodium Chloride For Inhalation<\/td>\n SODIUM CHLORIDE FOR INHALATION<\/td>\n VIAL-NEB<\/td>\n 7 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
930<\/td>\n 1.196<\/td>\n 401818-POTASSIUM-REMOVING AGENTS<\/td>\n Sodium Polystyrene Sulfonate<\/td>\n SODIUM POLYSTYRENE SULFONATE<\/td>\n ENEMA<\/td>\n 30 G\/120ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.710<\/td>\n 1.195<\/td>\n 401818-POTASSIUM-REMOVING AGENTS<\/td>\n Kionex<\/td>\n SODIUM POLYSTYRENE SULFONATE<\/td>\n ORAL SUSP<\/td>\n 15 G\/60 ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.675<\/td>\n 48.241<\/td>\n 401819-PHOSPHATE-REMOVING AGENTS<\/td>\n Phoslo<\/td>\n CALCIUM ACETATE<\/td>\n CAPSULE<\/td>\n 667 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
99.200<\/td>\n 63.473<\/td>\n 401819-PHOSPHATE-REMOVING AGENTS<\/td>\n Renvela<\/td>\n SEVELAMER CARBONATE<\/td>\n TABLET<\/td>\n 800 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.853<\/td>\n 46.485<\/td>\n 401819-PHOSPHATE-REMOVING AGENTS<\/td>\n Renagel<\/td>\n SEVELAMER HCL<\/td>\n TABLET<\/td>\n 800 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
21.130<\/td>\n 21.406<\/td>\n 402808-LOOP DIURETICS<\/td>\n Demadex<\/td>\n TORSEMIDE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
21.131<\/td>\n 21.407<\/td>\n 402808-LOOP DIURETICS<\/td>\n Demadex<\/td>\n TORSEMIDE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
21.132<\/td>\n 21.408<\/td>\n 402808-LOOP DIURETICS<\/td>\n Demadex<\/td>\n TORSEMIDE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
21.133<\/td>\n 21.409<\/td>\n 402808-LOOP DIURETICS<\/td>\n Demadex<\/td>\n TORSEMIDE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.950<\/td>\n 8.206<\/td>\n 402808-LOOP DIURETICS<\/td>\n Furosemide<\/td>\n FUROSEMIDE<\/td>\n SOLUTION<\/td>\n 10 MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.961<\/td>\n 8.208<\/td>\n 402808-LOOP DIURETICS<\/td>\n Lasix<\/td>\n FUROSEMIDE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.962<\/td>\n 8.209<\/td>\n 402808-LOOP DIURETICS<\/td>\n Lasix<\/td>\n FUROSEMIDE<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.963<\/td>\n 8.210<\/td>\n 402808-LOOP DIURETICS<\/td>\n Lasix<\/td>\n FUROSEMIDE<\/td>\n TABLET<\/td>\n 80 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.020<\/td>\n 8.221<\/td>\n 402808-LOOP DIURETICS<\/td>\n Bumetanide<\/td>\n Bumetanide<\/td>\n TABLET<\/td>\n O.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.021<\/td>\n 8.222<\/td>\n 402808-LOOP DIURETICS<\/td>\n Bumetanide<\/td>\n Bumetanide<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.022<\/td>\n 8.223<\/td>\n 402808-LOOP DIURETICS<\/td>\n Bumetanide<\/td>\n Bumetanide<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.700<\/td>\n 8.227<\/td>\n 402816-POTASSIUM-SPARING DIURETICS<\/td>\n Amiloride<\/td>\n AMILORIDE HCL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
82.341<\/td>\n 8.178<\/td>\n 402816-POTASSIUM-SPARING DIURETICS<\/td>\n Amiloride-Hydrochlorothiazide<\/td>\n AMILORIDE-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 5-50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
88.730<\/td>\n 8.175<\/td>\n 402816-POTASSIUM-SPARING DIURETICS<\/td>\n Dyazide<\/td>\n TRIAMTERENE-HYDROCHLOROTHIAZIDE<\/td>\n CAPSULE<\/td>\n 50-25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
88.731<\/td>\n 21.718<\/td>\n 402816-POTASSIUM-SPARING DIURETICS<\/td>\n Dyazide<\/td>\n TRIAMTERENE-HYDROCHLOROTHIAZIDE<\/td>\n CAPSULE<\/td>\n 37.5-25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
88.740<\/td>\n 8.177<\/td>\n 402816-POTASSIUM-SPARING DIURETICS<\/td>\n Triamterene-Hydrochlorothiazide<\/td>\n TRIAMTERENE-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 75-50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
88.741<\/td>\n 8.176<\/td>\n 402816-POTASSIUM-SPARING DIURETICS<\/td>\n Triamterene-Hydrochlorothiazide<\/td>\n TRIAMTERENE-HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 37.5-25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.820<\/td>\n 29.832<\/td>\n 402820-THIAZIDE DIURETICS<\/td>\n Microzide<\/td>\n HYDROCHLOROTHIAZIDE<\/td>\n CAPSULE<\/td>\n 12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
842<\/td>\n 28.915<\/td>\n 402820-THIAZIDE DIURETICS<\/td>\n Hydrochlorothiazide<\/td>\n HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.824<\/td>\n 8.182<\/td>\n 402820-THIAZIDE DIURETICS<\/td>\n Hydrochlorothiazide<\/td>\n HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.825<\/td>\n 8.183<\/td>\n 402820-THIAZIDE DIURETICS<\/td>\n Hydrochlorothiazide<\/td>\n HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.982<\/td>\n 8.213<\/td>\n 402824-THIAZIDE-LIKE DIURETICS<\/td>\n Chlorthalidone<\/td>\n CHLORTHALIDONE<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.984<\/td>\n 8.214<\/td>\n 402824-THIAZIDE-LIKE DIURETICS<\/td>\n Chlorthalidone<\/td>\n CHLORTHALIDONE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
7.310<\/td>\n 8.224<\/td>\n 402824-THIAZIDE-LIKE DIURETICS<\/td>\n Indapamide<\/td>\n INDAPAMIDE<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
7.311<\/td>\n 19.412<\/td>\n 402824-THIAZIDE-LIKE DIURETICS<\/td>\n Indapamide<\/td>\n INDAPAMIDE<\/td>\n TABLET<\/td>\n 1.25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.990<\/td>\n 8.216<\/td>\n 402824-THIAZIDE-LIKE DIURETICS<\/td>\n Metolazone<\/td>\n METOLAZONE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.991<\/td>\n 8.217<\/td>\n 402824-THIAZIDE-LIKE DIURETICS<\/td>\n Metolazone<\/td>\n METOLAZONE<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.992<\/td>\n 8.218<\/td>\n 402824-THIAZIDE-LIKE DIURETICS<\/td>\n Metolazone<\/td>\n METOLAZONE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.072<\/td>\n 8.236<\/td>\n 404000-URICOSURIC AGENTS<\/td>\n Probenecid<\/td>\n PROBENECID<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
29.840<\/td>\n 4.641<\/td>\n 480800-ANTITUSSIVES<\/td>\n Tessalon Perles<\/td>\n BENZONATATE<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
93.007<\/td>\n 44.168<\/td>\n 480800-ANTITUSSIVES<\/td>\n Tessalon Perles<\/td>\n BENZONATATE<\/td>\n CAPSULE<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
96.136<\/td>\n 909<\/td>\n 480800-ANTITUSSIVES<\/td>\n Bromfed DM<\/td>\n BROMPHENIRAMINE-PSEUDOEPHEDRINE-DM<\/td>\n SYRUP<\/td>\n 2-30-10 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.347<\/td>\n 51.896<\/td>\n 480800-ANTITUSSIVES<\/td>\n Chlorpheniramine-Phenylephrine-Dextromethorphan<\/td>\n CHLORPHENIRAMINE-PHENYLEPHRINE-DM<\/td>\n LIQUID<\/td>\n 4-10-15 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
91.713<\/td>\n 45.669<\/td>\n 480800-ANTITUSSIVES<\/td>\n Cheratussin AC, Virtussin AC, Iophen-C NR<\/td>\n GUAIFENESIN-CODEINE PHOSPHATE<\/td>\n LIQUID<\/td>\n 100-10 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.672<\/td>\n 70.992<\/td>\n 480800-ANTITUSSIVES<\/td>\n Guaifenesin AC<\/td>\n GUAIFENESIN-CODEINE PHOSPHATE<\/td>\n LIQUID<\/td>\n 100-10 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.974<\/td>\n 48.492<\/td>\n 480800-ANTITUSSIVES<\/td>\n Tussionex ER<\/td>\n HYDROCODONE-CHLORPHENIRAMINE<\/td>\n SUS ER 12H<\/td>\n 10-8 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.973<\/td>\n 48.491<\/td>\n 480800-ANTITUSSIVES<\/td>\n Hydrocodone-Homatropine<\/td>\n HYDROCODONE-HOMATROPINE<\/td>\n SYRUP<\/td>\n 5-1.5 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
96.041<\/td>\n 846<\/td>\n 480800-ANTITUSSIVES<\/td>\n Hydrocodone-Homatropine<\/td>\n HYDROCODONE-HOMATROPINE<\/td>\n TABLET<\/td>\n 5-1.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.975<\/td>\n 48.493<\/td>\n 480800-ANTITUSSIVES<\/td>\n Promethazine-DM<\/td>\n PROMETHAZINE-DEXTROMETHORPHAN<\/td>\n SYRUP<\/td>\n 6.25-15 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.978<\/td>\n 48.496<\/td>\n 480800-ANTITUSSIVES<\/td>\n Promethazine VC Codeine<\/td>\n PROMETHAZINE-PHENYLEPHRINE-CODEINE<\/td>\n SYRUP<\/td>\n 6.25-5-10 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
54.670<\/td>\n 728<\/td>\n 480800-ANTITUSSIVES<\/td>\n Lortuss EX, Cheratussin DAC, Guaifenesin DAC<\/td>\n PSEUDOEPHEDRINE-CODEINE-GUAIFENESIN<\/td>\n SYRUP<\/td>\n 30-10-100 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
53.636<\/td>\n 21.251<\/td>\n 481008-CORTICOSTEROIDS (RESPIRATORY TRACT)<\/td>\n Fluticasone HFA<\/td>\n FLUTICASONE PROPIONATE<\/td>\n AER W\/ADAP<\/td>\n 110 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
53.638<\/td>\n 21.253<\/td>\n 481008-CORTICOSTEROIDS (RESPIRATORY TRACT)<\/td>\n Fluticasone HFA<\/td>\n FLUTICASONE PROPIONATE<\/td>\n AER W\/ADAP<\/td>\n 44 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
53.639<\/td>\n 21.483<\/td>\n 481008-CORTICOSTEROIDS (RESPIRATORY TRACT)<\/td>\n Fluticasone HFA<\/td>\n FLUTICASONE PROPIONATE<\/td>\n AER W\/ADAP<\/td>\n 220 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.373<\/td>\n 44.803<\/td>\n 481024-LEUKOTRIENE MODIFIERS<\/td>\n Singulair<\/td>\n MONTELUKAST SODIUM<\/td>\n TAB CHEW<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.440<\/td>\n 37.003<\/td>\n 481024-LEUKOTRIENE MODIFIERS<\/td>\n Singulair<\/td>\n MONTELUKAST SODIUM<\/td>\n TAB CHEW<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.444<\/td>\n 38.451<\/td>\n 481024-LEUKOTRIENE MODIFIERS<\/td>\n Singulair<\/td>\n MONTELUKAST SODIUM<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
69.069<\/td>\n 44.694<\/td>\n 481032-MAST-CELL STABLILIZERS<\/td>\n Cromolyn Ophthalmic<\/td>\n CROMOLYN SODIUM<\/td>\n DROPS<\/td>\n 0.04<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
60.544<\/td>\n 29.893<\/td>\n 520200-ANTIALLERGIC AGENTS<\/td>\n Astelin Nasal Spray<\/td>\n AZELASTINE HCL<\/td>\n SPRAY\/PUMP<\/td>\n 137 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
68.321<\/td>\n 30.796<\/td>\n 520200-ANTIALLERGIC AGENTS<\/td>\n Patanol<\/td>\n OLOPATADINE HCL<\/td>\n DROPS<\/td>\n 0.1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.641<\/td>\n 7.990<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Bacitracin Ophthalmic<\/td>\n BACITRACIN<\/td>\n OINT. (G)<\/td>\n 500 UNIT\/G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.580<\/td>\n 15.861<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Ciloxan<\/td>\n CIPROFLOXACIN HCL<\/td>\n DROPS<\/td>\n 0.3 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
9.076<\/td>\n 38.351<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Ciloxan<\/td>\n CIPROFLOXACIN HCL<\/td>\n OINT. (G)<\/td>\n 0.3 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.188<\/td>\n 52.911<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Ciprodex<\/td>\n CIPROFLOXACIN HCL-DEXAMETHASONE<\/td>\n DROPS SUSP<\/td>\n 0.3-0.1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
82.031<\/td>\n 39.806<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Cipro HC<\/td>\n CIPROFLOXACIN-HYDROCORTISONE<\/td>\n DROPS SUSP<\/td>\n 0.2-1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.521<\/td>\n 48.077<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Doxycyline<\/td>\n DOXYCYCLINE HYCLATE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.540<\/td>\n 7.948<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Ilotycin<\/td>\n ERYTHROMYCIN BASE<\/td>\n OINT. (G)<\/td>\n 5 MG\/G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.600<\/td>\n 7.984<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Gentamicin<\/td>\n GENTAMICIN SULFATE<\/td>\n DROPS<\/td>\n 0.3 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.590<\/td>\n 7.983<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Gentamicin<\/td>\n GENTAMICIN SULFATE<\/td>\n OINT. (G)<\/td>\n 0.3 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.542<\/td>\n 52.050<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Vigamox<\/td>\n MOXIFLOXACIN HCL<\/td>\n DROPS<\/td>\n 0.5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
62.265<\/td>\n 18.370<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Bactroban Nasal<\/td>\n MUPIROCIN CALCIUM<\/td>\n OINT. (G)<\/td>\n 2 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.294<\/td>\n 48.570<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n POLYMYXIN B- TRIMETHOPRIM DROPS<\/td>\n POLYMYXIN B- TRIMETHOPRIM DROPS<\/td>\n DROPS<\/td>\n 10000-1\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.283<\/td>\n 48.544<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Neomycin-Bacitracin-Polymyxin Eye Ointment<\/td>\n NEOMYCIN-BACITRACIN-POLYMYXIN B<\/td>\n OINT. (G)<\/td>\n 3.5-400-10000 MG\/G-UNIT\/G-UNIT\/G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.279<\/td>\n 48.543<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Neomycin-Bacitracin-Polymyxin-HC Eye Ointment<\/td>\n NEOMYCIN-BACITRACIN-POLYMYXIN B-HYDROCORTISONE<\/td>\n OINT. (G)<\/td>\n 3.5-400-10000-1 MG\/G-UNIT\/G-UNIT\/G-%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.106<\/td>\n 48.618<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Coly-Mycin S, Cortisporin TC<\/td>\n NEOMYCIN-COLISTIN-HYDROCORTISONE-THONZONIUM<\/td>\n DROPS SUSP<\/td>\n 3.3-3-10-0.5 MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.285<\/td>\n 48.546<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Neomycin-Polymyxin-Dexamethasone Eye Ointment<\/td>\n NEOMYCIN-POLYMYXIN B-DEXAMETHASONE<\/td>\n OINT. (G)<\/td>\n 3.5-10000-0.1 MG\/G-UNIT\/G-%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.286<\/td>\n 48.547<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Neomycin-Polymyxin-Dexamethasone Eye Drops<\/td>\n NEOMYCIN-POLYMYXIN B-DEXAMETHASONE<\/td>\n DROPS SUSP<\/td>\n 3.5-10000-0.1 MG\/ML-UNIT\/ML-%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
87.270<\/td>\n 7.964<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Neomycin-Polymyxin-HC Eye Drops<\/td>\n NEOMYCIN-POLYMYXIN B-HYDROCORTISONE<\/td>\n DROPS SUSP<\/td>\n 3.5-10000-10 MG\/ML-UNIT\/ML-%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.025<\/td>\n 48.559<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Neomycin-Polymyxin-HC Otic Drops<\/td>\n NEOMYCIN-POLYMYXIN B-HYDROCORTISONE<\/td>\n DROPS SUSP<\/td>\n 3.5-10000-1 MG\/ML-UNIT\/ML-%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.023<\/td>\n 48.557<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Neomycin-Polymyxin-HC Otic<\/td>\n NEOMYCIN-POLYMYXIN B-HYDROCORTISONE<\/td>\n SOLUTION<\/td>\n 3.5-10000-1 MG\/ML-UNIT\/ML-%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.446<\/td>\n 62.672<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Neomycin-Polymyxin-Gramicidin Eye Drops<\/td>\n NEOMYCIN-POLYMYXIN B-GRAMICIDIN<\/td>\n DROPS<\/td>\n 1.75-10000-0.025 MG\/ML-UNIT\/ML-MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.880<\/td>\n 48.292<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Ofloxacin<\/td>\n OFLOXACIN<\/td>\n DROPS<\/td>\n 0.3 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
36.600<\/td>\n 19.734<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Ofloxacin<\/td>\n OFLOXACIN<\/td>\n DROPS<\/td>\n 0.3 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.340<\/td>\n 7.920<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Bleph-10<\/td>\n SULFACETAMIDE SODIUM<\/td>\n DROPS<\/td>\n 10 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
9.384<\/td>\n 38.588<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Tobrex<\/td>\n TOBRAMYCIN<\/td>\n DROPS<\/td>\n 0.3 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
92.280<\/td>\n 7.986<\/td>\n 520404-ANTIBACTERIALS (EENT)<\/td>\n Tobradex<\/td>\n TOBRAMYCIN-DEXAMETHASONE<\/td>\n DROPS SUSP<\/td>\n 0.3-0.1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.500<\/td>\n 7.942<\/td>\n 520420-ANTIVIRALS (EENT)<\/td>\n Viroptic<\/td>\n TRIFLURIDINE<\/td>\n DROPS<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.341<\/td>\n 8.101<\/td>\n 520492-EENT ANTI-INFECTIVES, MISCELLANEOUS<\/td>\n Acetic Acid<\/td>\n ACETIC ACID<\/td>\n SOLUTION<\/td>\n 2 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.017<\/td>\n 48.554<\/td>\n 520492-EENT ANTI-INFECTIVES, MISCELLANEOUS<\/td>\n Acetasol HC<\/td>\n ACETIC ACID-HYDROCORTISONE<\/td>\n DROPS<\/td>\n 2-1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.280<\/td>\n 8.079<\/td>\n 520808-CORTICOSTEROIDS (EENT)<\/td>\n Flunisolide<\/td>\n FLUNISOLIDE<\/td>\n SPRAY<\/td>\n 25 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
62.263<\/td>\n 18.368<\/td>\n 520808-CORTICOSTEROIDS (EENT)<\/td>\n Flonase<\/td>\n FLUTICASONE PROPIONATE<\/td>\n SPRAY SUSP<\/td>\n 50 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
95.464<\/td>\n 39.106<\/td>\n 520808-CORTICOSTEROIDS (EENT)<\/td>\n Lotemax<\/td>\n LOTEPREDNOL ETABONATE<\/td>\n DROPS SUSP<\/td>\n 0.5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.153<\/td>\n 7.894<\/td>\n 520808-CORTICOSTEROIDS (EENT)<\/td>\n Omnipred<\/td>\n PREDNISOLONE ACETATE<\/td>\n DROPS SUSP<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.150<\/td>\n 7.892<\/td>\n 520808-CORTICOSTEROIDS (EENT)<\/td>\n Prednisolone Acetate<\/td>\n PREDNISOLONE ACETATE<\/td>\n DROPS SUSP<\/td>\n 0.12 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.181<\/td>\n 7.897<\/td>\n 520808-CORTICOSTEROIDS (EENT)<\/td>\n Prednisolone Sodium Phosphate<\/td>\n PREDNISOLONE SOD PHOSPHATE<\/td>\n DROPS<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.831<\/td>\n 16.008<\/td>\n 520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS<\/td>\n Diclofenac Sodium<\/td>\n DICLOFENAC SODIUM<\/td>\n DROPS<\/td>\n 0.1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.360<\/td>\n 7.905<\/td>\n 520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS<\/td>\n Ocufen<\/td>\n FLURBIPROFEN SODIUM<\/td>\n DROPS<\/td>\n 0.03 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.255<\/td>\n 52.960<\/td>\n 520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS<\/td>\n Acular<\/td>\n KETOROLAC TROMETHAMINE<\/td>\n DROPS<\/td>\n 0.4 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
52.700<\/td>\n 19.067<\/td>\n 520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS<\/td>\n Acular<\/td>\n KETOROLAC TROMETHAMINE<\/td>\n DROPS<\/td>\n 0.5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.952<\/td>\n 7.866<\/td>\n 522400-MYDRIATICS<\/td>\n ATROPINE SULFATE<\/td>\n ATROPINE SULFATE<\/td>\n DROPS<\/td>\n 1%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.931<\/td>\n 7.864<\/td>\n 522400-MYDRIATICS<\/td>\n ATROPINE SULFATE<\/td>\n ATROPINE SULFATE<\/td>\n OINT. (G)<\/td>\n 1%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.031<\/td>\n 7.875<\/td>\n 522400-MYDRIATICS<\/td>\n Cyclogyl 1%<\/td>\n CYCLOPENTOLATE HCL<\/td>\n DROPS<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.032<\/td>\n 7.876<\/td>\n 522400-MYDRIATICS<\/td>\n Cyclogyl 2%<\/td>\n CYCLOPENTOLATE HCL<\/td>\n DROPS<\/td>\n 2 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
36.281<\/td>\n 27.882<\/td>\n 524004-ALPHA-ADRENERGIC AGONISTS (EENT)<\/td>\n Alphagan<\/td>\n BRIMONIDINE TARTRATE<\/td>\n DROPS<\/td>\n 0.2 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.752<\/td>\n 48.333<\/td>\n 524004-ALPHA-ADRENERGIC AGONISTS (EENT)<\/td>\n Alphagan-P<\/td>\n BRIMONIDINE TARTRATE<\/td>\n DROPS<\/td>\n 0.15 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.310<\/td>\n 7.858<\/td>\n 524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT)<\/td>\n Betagan<\/td>\n LEVOBUNOLOL HCL<\/td>\n DROPS<\/td>\n 0.5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.820<\/td>\n 7.855<\/td>\n 524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT)<\/td>\n Timoptic<\/td>\n TIMOLOL MALEATE<\/td>\n DROPS<\/td>\n 0.25 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.821<\/td>\n 7.856<\/td>\n 524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT)<\/td>\n Timoptic<\/td>\n TIMOLOL MALEATE<\/td>\n DROPS<\/td>\n 0.5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.823<\/td>\n 21.401<\/td>\n 524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT)<\/td>\n Timoptic-XE<\/td>\n TIMOLOL MALEATE<\/td>\n SOL-GEL<\/td>\n 0.5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.700<\/td>\n 8.164<\/td>\n 524012-CARBONIC ANHYDRASE INHIBITORS (EENT)<\/td>\n Diamox Sequels<\/td>\n ACETAZOLAMIDE<\/td>\n CAPSULE ER<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.721<\/td>\n 8.165<\/td>\n 524012-CARBONIC ANHYDRASE INHIBITORS (EENT)<\/td>\n Acetazolamide<\/td>\n ACETAZOLAMIDE<\/td>\n TABLET<\/td>\n 125 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.722<\/td>\n 8.166<\/td>\n 524012-CARBONIC ANHYDRASE INHIBITORS (EENT)<\/td>\n Acetazolamide<\/td>\n ACETAZOLAMIDE<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
95.773<\/td>\n 39.498<\/td>\n 524012-CARBONIC ANHYDRASE INHIBITORS (EENT)<\/td>\n Azopt<\/td>\n BRINZOLAMIDE<\/td>\n DROPS SUSP<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.380<\/td>\n 23.513<\/td>\n 524012-CARBONIC ANHYDRASE INHIBITORS (EENT)<\/td>\n Trusopt<\/td>\n DORZOLAMIDE HCL<\/td>\n DROPS<\/td>\n 2 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
95.919<\/td>\n 39.531<\/td>\n 524012-CARBONIC ANHYDRASE INHIBITORS (EENT)<\/td>\n Cosopt<\/td>\n DORZOLAMIDE HCL-TIMOLOL MALEATE<\/td>\n DROPS<\/td>\n 22.3-6.8 MG\/1ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.704<\/td>\n 7.822<\/td>\n 524020-MIOTICS<\/td>\n Isopto Carpine<\/td>\n PILOCARPINE HCL<\/td>\n DROPS<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.706<\/td>\n 7.824<\/td>\n 524020-MIOTICS<\/td>\n Isopto Carpine<\/td>\n PILOCARPINE HCL<\/td>\n DROPS<\/td>\n 2 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.752<\/td>\n 7.826<\/td>\n 524020-MIOTICS<\/td>\n Isopto Carpine<\/td>\n PILOCARPINE HCL<\/td>\n DROPS<\/td>\n 4 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.749<\/td>\n 27.370<\/td>\n 524028-PROSTAGLANDIN ANALOGS<\/td>\n Xalatan<\/td>\n LATANOPROST<\/td>\n DROPS<\/td>\n 0.005 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.749<\/td>\n 27.370<\/td>\n 524028-PROSTAGLANDIN ANALOGS<\/td>\n Xalatan<\/td>\n LATANOPROST<\/td>\n DROPS<\/td>\n 0.005 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.379<\/td>\n 62.605<\/td>\n 524028-PROSTAGLANDIN ANALOGS<\/td>\n Travoprost<\/td>\n TRAVOPROST (BENZALKONIUM)<\/td>\n DROPS<\/td>\n 0.004%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
7.855<\/td>\n 2.661<\/td>\n 560400-ANTACIDS AND ADSORBENTS<\/td>\n Sodium Bicarbonate<\/td>\n SODIUM BICARBONATE<\/td>\n TABLET<\/td>\n 650 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
65.020<\/td>\n 2.839<\/td>\n 560800-ANTIDIARRHEA AGENTS<\/td>\n Lomotil<\/td>\n DIPHENOXYLATE HCL-ATROPINE<\/td>\n LIQUID<\/td>\n 2.5-0.025 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
65.030<\/td>\n 2.841<\/td>\n 560800-ANTIDIARRHEA AGENTS<\/td>\n Lomotil<\/td>\n DIPHENOXYLATE HCL-ATROPINE<\/td>\n TABLET<\/td>\n 2.5-0.025 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.433<\/td>\n 62.659<\/td>\n 561200-CATHARTICS AND LAXATIVES<\/td>\n Colyte, Gavilyte<\/td>\n PEG 3350-NA SULF BICARB CL-KCL<\/td>\n SOLN RECON<\/td>\n 240-22.72 G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.308<\/td>\n 62.533<\/td>\n 561200-CATHARTICS AND LAXATIVES<\/td>\n Golytely, Gavilyte<\/td>\n PEG 3350-NA SULF BICARB CL-KCL<\/td>\n SOLN RECON<\/td>\n 236-22.74 G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
86.212<\/td>\n 41.843<\/td>\n 561200-CATHARTICS AND LAXATIVES<\/td>\n Clearlax, Miralax<\/td>\n POLYETHYLENE GLYCOL 3350<\/td>\n POWDER<\/td>\n 17 G\/DOSE<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.865<\/td>\n 59.931<\/td>\n 561200-CATHARTICS AND LAXATIVES<\/td>\n Nulytely Flavor Pack, Gavilyte N, Trilyte<\/td>\n SODIUM CHLORIDE-NAHCO3-KCL-PEG<\/td>\n SOLN RECON<\/td>\n 420 G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.865<\/td>\n 59.931<\/td>\n 561200-CATHARTICS AND LAXATIVES<\/td>\n Nulytely, Gavilyte, Trilyte<\/td>\n SODIUM CHLORIDE-NAHCO3-KCL-PEG<\/td>\n SOLN RECON<\/td>\n 420 G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.997<\/td>\n 66.670<\/td>\n 561200-CATHARTICS AND LAXATIVES<\/td>\n Suprep<\/td>\n sodium, potassium,mag sulfates<\/td>\n SOLN RECON<\/td>\n 17.5-3.13 G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
97.248<\/td>\n 61.457<\/td>\n 561200-CATHARTICS AND LAXATIVES<\/td>\n Moviprep<\/td>\n PEG 3350-NA SULF BICARB CL-KCL-Ascorbic acid<\/td>\n POWDER PACKETS<\/td>\n 7.5 -2.691 G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.070<\/td>\n 3.095<\/td>\n 561400-CHOLELITHOLYTIC AGENTS<\/td>\n Actigall<\/td>\n URSODIOL<\/td>\n CAPSULE<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.072<\/td>\n 24.333<\/td>\n 561400-CHOLELITHOLYTIC AGENTS<\/td>\n Urso<\/td>\n URSODIOL<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.730<\/td>\n 50.628<\/td>\n 561400-CHOLELITHOLYTIC AGENTS<\/td>\n Urso Forte<\/td>\n URSODIOL<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.176<\/td>\n 65.328<\/td>\n 561600-DIGESTANTS<\/td>\n Creon<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 6K-19K-30K<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
26.177<\/td>\n 65.329<\/td>\n 561600-DIGESTANTS<\/td>\n Creon<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 12K-38K-60<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
26.178<\/td>\n 65.330<\/td>\n 561600-DIGESTANTS<\/td>\n Creon<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 24-76-120K<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
30.217<\/td>\n 67.625<\/td>\n 561600-DIGESTANTS<\/td>\n Creon<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 3-9.5-15K<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
34.557<\/td>\n 70.893<\/td>\n 561600-DIGESTANTS<\/td>\n Creon<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 36-114-180<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
42.317<\/td>\n 76.625<\/td>\n 561600-DIGESTANTS<\/td>\n Pancreaze<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 16.8-56.8K<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.318<\/td>\n 76.626<\/td>\n 561600-DIGESTANTS<\/td>\n Pancreaze<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 21 K-54.7K<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.319<\/td>\n 76.627<\/td>\n 561600-DIGESTANTS<\/td>\n Pancreaze<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 10.5-35.5K<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.324<\/td>\n 76.628<\/td>\n 561600-DIGESTANTS<\/td>\n Pancreaze<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 4.2K-14.2K<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.596<\/td>\n 76.797<\/td>\n 561600-DIGESTANTS<\/td>\n Pancreaze<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 2.6 K-6.2K<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.726<\/td>\n 65.700<\/td>\n 561600-DIGESTANTS<\/td>\n Zenpep<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 5K-17K-27K<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
27.727<\/td>\n 65.701<\/td>\n 561600-DIGESTANTS<\/td>\n Zenpep<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 10-34-55K<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
27.728<\/td>\n 65.702<\/td>\n 561600-DIGESTANTS<\/td>\n Zenpep<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 15-51-82K<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
27.729<\/td>\n 65.703<\/td>\n 561600-DIGESTANTS<\/td>\n Zenpep<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 20-68-109K<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
30.597<\/td>\n 67.944<\/td>\n 561600-DIGESTANTS<\/td>\n Zenpep<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 3K-10K-16K<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
30.598<\/td>\n 67.945<\/td>\n 561600-DIGESTANTS<\/td>\n Zenpep<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 25-85-136K<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
37.592<\/td>\n 73.217<\/td>\n 561600-DIGESTANTS<\/td>\n Zenpep<\/td>\n LIPASE\/PROTEASE\/AMYLASE<\/td>\n CAPSULE DR<\/td>\n 40K-136K<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
14.761<\/td>\n 3.844<\/td>\n 562208-ANTIHISTAMINES (GI DRUGS)<\/td>\n Prochlorperazine<\/td>\n PROCHLORPERAZINE<\/td>\n SUPP.RECT<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.771<\/td>\n 3.846<\/td>\n 562208-ANTIHISTAMINES (GI DRUGS)<\/td>\n Prochlorperazine<\/td>\n PROCHLORPERAZINE MALEATE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.773<\/td>\n 3.848<\/td>\n 562208-ANTIHISTAMINES (GI DRUGS)<\/td>\n Prochlorperazine<\/td>\n PROCHLORPERAZINE MALEATE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.045<\/td>\n 41.562<\/td>\n 562220-5-HT3 RECEPTOR ANTAGONISTS<\/td>\n Zofran ODT<\/td>\n ONDANSETRON<\/td>\n TAB RAPDIS<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.046<\/td>\n 41.563<\/td>\n 562220-5-HT3 RECEPTOR ANTAGONISTS<\/td>\n Zofran ODT<\/td>\n ONDANSETRON<\/td>\n TAB RAPDIS<\/td>\n 8 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.040<\/td>\n 28.107<\/td>\n 562220-5-HT3 RECEPTOR ANTAGONISTS<\/td>\n Zofran<\/td>\n ONDANSETRON HCL<\/td>\n SOLUTION<\/td>\n 4 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Restricted to age <19<\/td>\n <\/tr>\n
20.041<\/td>\n 16.392<\/td>\n 562220-5-HT3 RECEPTOR ANTAGONISTS<\/td>\n Zofran<\/td>\n ONDANSETRON HCL<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.042<\/td>\n 16.393<\/td>\n 562220-5-HT3 RECEPTOR ANTAGONISTS<\/td>\n Zofran<\/td>\n ONDANSETRON HCL<\/td>\n TABLET<\/td>\n 8 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
45.960<\/td>\n 11.676<\/td>\n 562812-HISTAMINE H2-ANTAGONISTS<\/td>\n Pepcid<\/td>\n FAMOTIDINE<\/td>\n ORAL SUSP<\/td>\n 40 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
46.430<\/td>\n 11.677<\/td>\n 562812-HISTAMINE H2-ANTAGONISTS<\/td>\n Pepcid<\/td>\n FAMOTIDINE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
46.431<\/td>\n 11.678<\/td>\n 562812-HISTAMINE H2-ANTAGONISTS<\/td>\n Pepcid<\/td>\n FAMOTIDINE<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
8.250<\/td>\n 2.767<\/td>\n 562828-PROSTAGLANDINS<\/td>\n Cytotec<\/td>\n MISOPROSTOL<\/td>\n TABLET<\/td>\n 200 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
8.251<\/td>\n 15.197<\/td>\n 562828-PROSTAGLANDINS<\/td>\n Cytotec<\/td>\n MISOPROSTOL<\/td>\n TABLET<\/td>\n 100 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
7.651<\/td>\n 16.133<\/td>\n 562832-PROTECTANTS<\/td>\n Carafate<\/td>\n SUCRALFATE<\/td>\n ORAL SUSP<\/td>\n 1 G\/10 ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
8.200<\/td>\n 2.766<\/td>\n 562832-PROTECTANTS<\/td>\n Carafate<\/td>\n SUCRALFATE<\/td>\n TABLET<\/td>\n 1 G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
40.120<\/td>\n 27.462<\/td>\n 562836-PROTON-PUMP INHIBITORS<\/td>\n Protonix<\/td>\n PANTOPRAZOLE SODIUM<\/td>\n TABLET DR<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
95.976<\/td>\n 39.545<\/td>\n 562836-PROTON-PUMP INHIBITORS<\/td>\n Protonix<\/td>\n PANTOPRAZOLE SODIUM<\/td>\n TABLET DR<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.610<\/td>\n 5.230<\/td>\n 563200-PROKINETIC AGENTS<\/td>\n Metoclopramide<\/td>\n METOCLOPRAMIDE HCL<\/td>\n SOLUTION<\/td>\n 5 MG\/5ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.798<\/td>\n 71.108<\/td>\n 563200-PROKINETIC AGENTS<\/td>\n Metoclopramide<\/td>\n METOCLOPRAMIDE HCL<\/td>\n SOLUTION<\/td>\n 10 MG\/10ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
21.020<\/td>\n 5.231<\/td>\n 563200-PROKINETIC AGENTS<\/td>\n Reglan<\/td>\n METOCLOPRAMIDE HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
21.021<\/td>\n 5.232<\/td>\n 563200-PROKINETIC AGENTS<\/td>\n Reglan<\/td>\n METOCLOPRAMIDE HCL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.412<\/td>\n 6.782<\/td>\n 680400-ADRENALS<\/td>\n Dexamethasone<\/td>\n DEXAMETHASONE<\/td>\n DROPS<\/td>\n 1 MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.422<\/td>\n 6.784<\/td>\n 680400-ADRENALS<\/td>\n Dexamethasone<\/td>\n DEXAMETHASONE<\/td>\n TABLET<\/td>\n 0.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.424<\/td>\n 6.787<\/td>\n 680400-ADRENALS<\/td>\n Dexamethasone<\/td>\n DEXAMETHASONE<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.425<\/td>\n 6.785<\/td>\n 680400-ADRENALS<\/td>\n Dexamethasone<\/td>\n DEXAMETHASONE<\/td>\n TABLET<\/td>\n 0.75 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.426<\/td>\n 6.788<\/td>\n 680400-ADRENALS<\/td>\n Dexamethasone<\/td>\n DEXAMETHASONE<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.428<\/td>\n 6.789<\/td>\n 680400-ADRENALS<\/td>\n Dexamethasone<\/td>\n DEXAMETHASONE<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.429<\/td>\n 6.790<\/td>\n 680400-ADRENALS<\/td>\n Dexamethasone<\/td>\n DEXAMETHASONE<\/td>\n TABLET<\/td>\n 6 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.680<\/td>\n 6.812<\/td>\n 680400-ADRENALS<\/td>\n Fludrocortisone<\/td>\n FLUDROCORTISONE ACETATE<\/td>\n TABLET<\/td>\n 0.1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.781<\/td>\n 6.703<\/td>\n 680400-ADRENALS<\/td>\n Cortef<\/td>\n HYDROCORTISONE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.782<\/td>\n 6.704<\/td>\n 680400-ADRENALS<\/td>\n Cortef<\/td>\n HYDROCORTISONE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.783<\/td>\n 6.705<\/td>\n 680400-ADRENALS<\/td>\n Cortef<\/td>\n HYDROCORTISONE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
37.499<\/td>\n 45.311<\/td>\n 680400-ADRENALS<\/td>\n Medrol Dosepak<\/td>\n METHYLPREDNISOLONE<\/td>\n TAB DS PK<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.056<\/td>\n 6.741<\/td>\n 680400-ADRENALS<\/td>\n Medrol<\/td>\n METHYLPREDNISOLONE<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.800<\/td>\n 6.719<\/td>\n 680400-ADRENALS<\/td>\n Prednisolone<\/td>\n PREDNISOLONE<\/td>\n SOLUTION<\/td>\n 15 MG\/5 ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.806<\/td>\n 47.282<\/td>\n 680400-ADRENALS<\/td>\n Prednisolone Sodium Phosphate<\/td>\n PREDNISOLONE SOD PHOSPHATE<\/td>\n SOLUTION<\/td>\n 15 MG\/5 ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
38.363<\/td>\n 45.267<\/td>\n 680400-ADRENALS<\/td>\n Prednisone<\/td>\n PREDNISONE<\/td>\n TAB DS PK<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
38.364<\/td>\n 45.268<\/td>\n 680400-ADRENALS<\/td>\n Prednisone<\/td>\n PREDNISONE<\/td>\n TAB DS PK<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.171<\/td>\n 6.748<\/td>\n 680400-ADRENALS<\/td>\n Prednisone<\/td>\n PREDNISONE<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.172<\/td>\n 6.749<\/td>\n 680400-ADRENALS<\/td>\n Prednisone<\/td>\n PREDNISONE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.173<\/td>\n 6.750<\/td>\n 680400-ADRENALS<\/td>\n Prednisone<\/td>\n PREDNISONE<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.174<\/td>\n 6.751<\/td>\n 680400-ADRENALS<\/td>\n Prednisone<\/td>\n PREDNISONE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.176<\/td>\n 6.753<\/td>\n 680400-ADRENALS<\/td>\n Prednisone<\/td>\n PREDNISONE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.177<\/td>\n 6.754<\/td>\n 680400-ADRENALS<\/td>\n Prednisone<\/td>\n PREDNISONE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.851<\/td>\n 45.215<\/td>\n 680800-ANDROGENS<\/td>\n Androgel 1%<\/td>\n TESTOSTERONE<\/td>\n GEL PACKET<\/td>\n 25 MG(1%)<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.852<\/td>\n 45.216<\/td>\n 680800-ANDROGENS<\/td>\n Androgel 1%<\/td>\n TESTOSTERONE<\/td>\n GEL PACKET<\/td>\n 50 MG (1%)<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.126<\/td>\n 50.831<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Ortho Tri-Cyclen Lo, Tri-Lo-Marzia, Tri-Lo-Sprintec, Tri-Lo-Estarylla<\/td>\n NORGESTIMATE-ETHINYL ESTRADIOL<\/td>\n TABLET<\/td>\n 0.18\/0.215\/0.25 mg - 25mcg<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.083<\/td>\n 47.787<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Yasmin<\/td>\n ETHINYL ESTRADIOL-DROSPIRENONE<\/td>\n TABLET<\/td>\n 0.03-3 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.530<\/td>\n 3.314<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Altavera, Chateal, Kurvelo, Levora, Marlissa, Portia<\/td>\n LEVONORGESTREL-ETHINYL ESTRADIOL<\/td>\n TABLET<\/td>\n 0.15-0.03 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.534<\/td>\n 30.986<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Aviane, Aubra, Delyla, Falmina, Lessina, Lutera, Orsythia, Sronyx<\/td>\n LEVONORGESTREL-ETHINYL ESTRADIOL<\/td>\n TABLET<\/td>\n 0.1-0.02 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.531<\/td>\n 3.315<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Enpresse, Trivora, Myzilra<\/td>\n LEVONORGESTREL-ETHINYL ESTRADIOL<\/td>\n TABLET<\/td>\n 50-30(6)\/75-40(5)\/125\/30(10) MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.520<\/td>\n 3.313<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Ortho Micronor, Errin, Camila, Deblitane, Sharobel, Norlyro, Nor-Be, Jolivette, Jencycla, Heather<\/td>\n NORETHINDRONE<\/td>\n TABLET<\/td>\n 0.35 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.480<\/td>\n 3.304<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Gildess, Junel, Larin, Loestrin 21 1.5\/30<\/td>\n NORETHINDRONE ACETATE-ETHINYL ESTRADIOL<\/td>\n TABLET<\/td>\n 1.5-30 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.481<\/td>\n 3.305<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Gildess, Junel, Larin, Loestrin 21 1\/20<\/td>\n NORETHINDRONE ACETATE-ETHINYL ESTRADIOL<\/td>\n TABLET<\/td>\n 1-20 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.477<\/td>\n 3.298<\/td>\n 681200-CONTRACEPTIVES<\/td>\n 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<\/td>\n NORETHINDRONE-ETHINYL ESTRADIOL<\/td>\n TABLET<\/td>\n 0.5\/0.75\/1 MG-35MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.474<\/td>\n 3.295<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Alyacen, Cyclafem, Dasetta, Necon 1\/35, Nortrel 1\/35, Norinyl, Ortho Novum, Primella<\/td>\n NORETHINDRONE-ETHINYL ESTRADIOL<\/td>\n TABLET<\/td>\n 1-0.35 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.471<\/td>\n 3.294<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Brevicon, Modicone, Necon 0.5\/35, Nortrel 0.5\/35, Wera<\/td>\n NORETHINDRONE-ETHINYL ESTRADIOL<\/td>\n TABLET<\/td>\n 0.5-0.35 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
68.101<\/td>\n 3.300<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Blisovi FE, Gildess FE, Junel FE, Larin FE, Loestrin FE 1.5\/30<\/td>\n NORETHINDRONE-ETHINYL ESTRADIOL-IRON<\/td>\n TABLET<\/td>\n 1.5MG-30 MCG(21)\/75MG(7)<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
68.102<\/td>\n 3.301<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Blisovi FE, Gildess FE, Junel FE, Larin FE, Loestrin FE 1\/20<\/td>\n NORETHINDRONE-ETHINYL ESTRADIOL-IRON<\/td>\n TABLET<\/td>\n 1 MG-20 MCG(21)\/75MG(7)<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.300<\/td>\n 13.662<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Estarylla, Mononessa, Ortho-Cyclen, Previfem, Sprintec<\/td>\n NORGESTIMATE-ETHINYL ESTRADIOL<\/td>\n TABLET<\/td>\n 0.25-0.035 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.301<\/td>\n 16.963<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Tri-Estarylla, Tri-Mononessa, Otrho Tri-Cyclen, Tri-Previfem, Tri-Sprintec<\/td>\n NORGESTIMATE-ETHINYL ESTRADIOL<\/td>\n TABLET<\/td>\n 0.18\/0.215\/0.25 MG-35MCG(28)<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.500<\/td>\n 3.310<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Low-Ogestrel, Elinest, Cryselle<\/td>\n NORGESTREL-ETHINYL ESTRADIOL<\/td>\n TABLET<\/td>\n 0.3 MG-30MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.770<\/td>\n 3.204<\/td>\n 681604-ESTROGENS<\/td>\n Estrace<\/td>\n ESTRADIOL<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.771<\/td>\n 3.205<\/td>\n 681604-ESTROGENS<\/td>\n Estrace<\/td>\n ESTRADIOL<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.772<\/td>\n 21.411<\/td>\n 681604-ESTROGENS<\/td>\n Estrace<\/td>\n ESTRADIOL<\/td>\n TABLET<\/td>\n 0.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.739<\/td>\n 52.179<\/td>\n 681604-ESTROGENS<\/td>\n Prempro<\/td>\n ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE<\/td>\n TABLET<\/td>\n 0.45-1.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.769<\/td>\n 53.321<\/td>\n 681604-ESTROGENS<\/td>\n Prempro<\/td>\n ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE<\/td>\n TABLET<\/td>\n 0.3-1.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
55.730<\/td>\n 22.647<\/td>\n 681604-ESTROGENS<\/td>\n Prempro<\/td>\n ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE<\/td>\n TABLET<\/td>\n 0.625-5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
55.731<\/td>\n 22.648<\/td>\n 681604-ESTROGENS<\/td>\n Prempro<\/td>\n ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE<\/td>\n TABLET<\/td>\n 0.625-2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.942<\/td>\n 3.212<\/td>\n 681604-ESTROGENS<\/td>\n Premarin<\/td>\n ESTROGENS CONJUGATED<\/td>\n TABLET<\/td>\n 0.625 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.943<\/td>\n 3.211<\/td>\n 681604-ESTROGENS<\/td>\n Premarin<\/td>\n ESTROGENS CONJUGATED<\/td>\n TABLET<\/td>\n 0.3 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.944<\/td>\n 3.213<\/td>\n 681604-ESTROGENS<\/td>\n Premarin<\/td>\n ESTROGENS CONJUGATED<\/td>\n TABLET<\/td>\n 0.9 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.945<\/td>\n 3.214<\/td>\n 681604-ESTROGENS<\/td>\n Premarin<\/td>\n ESTROGENS CONJUGATED<\/td>\n TABLET<\/td>\n 1.25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.975<\/td>\n 52.766<\/td>\n 681604-ESTROGENS<\/td>\n Premarin<\/td>\n ESTROGENS CONJUGATED<\/td>\n TABLET<\/td>\n 0.45MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
59.011<\/td>\n 37.022<\/td>\n 681612-ESTROGEN AGONIST-ANTAGONISTS<\/td>\n Evista<\/td>\n RALOXIFENE HCL<\/td>\n TABLET<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.578<\/td>\n 52.080<\/td>\n 682004-BIGUANIDES<\/td>\n Glucophage XR<\/td>\n METFORMIN HCL<\/td>\n TAB ER 24H<\/td>\n 750 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
89.863<\/td>\n 46.754<\/td>\n 682004-BIGUANIDES<\/td>\n Glucophage XR<\/td>\n METFORMIN HCL<\/td>\n TAB ER 24H<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.810<\/td>\n 13.318<\/td>\n 682004-BIGUANIDES<\/td>\n Glucophage<\/td>\n METFORMIN HCL<\/td>\n TABLET<\/td>\n 500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.811<\/td>\n 16.441<\/td>\n 682004-BIGUANIDES<\/td>\n Glucophage<\/td>\n METFORMIN HCL<\/td>\n TABLET<\/td>\n 850 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.857<\/td>\n 40.974<\/td>\n 682004-BIGUANIDES<\/td>\n Glucophage<\/td>\n METFORMIN HCL<\/td>\n TABLET<\/td>\n 1000 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
92.336<\/td>\n 44.341<\/td>\n 682008-INSULINS<\/td>\n Novolog Flexpen<\/td>\n INSULIN ASPART<\/td>\n INSULN PEN<\/td>\n 100 UNIT\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
92.326<\/td>\n 44.340<\/td>\n 682008-INSULINS<\/td>\n Novolog<\/td>\n INSULIN ASPART<\/td>\n VIAL<\/td>\n 100 UNIT\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.075<\/td>\n 50.134<\/td>\n 682008-INSULINS<\/td>\n Novolog 70\/30<\/td>\n INSULIN ASPART PROTAMINE-INSULIN ASPART<\/td>\n INSULN PEN<\/td>\n 70-30 UNIT\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.057<\/td>\n 51.718<\/td>\n 682008-INSULINS<\/td>\n Novolog 70\/30<\/td>\n INSULIN ASPART PROTAMINE-INSULIN ASPART<\/td>\n VIAL<\/td>\n 70-30 UNIT\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
96.719<\/td>\n 34.731<\/td>\n 682008-INSULINS<\/td>\n Humalog Kwik Pen<\/td>\n INSULIN LISPRO<\/td>\n INSULN PEN<\/td>\n 100 UNIT\/ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
5.679<\/td>\n 27.413<\/td>\n 682008-INSULINS<\/td>\n Humalog<\/td>\n INSULIN LISPRO<\/td>\n VIAL<\/td>\n 100 UNIT\/ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.660<\/td>\n 1.740<\/td>\n 682008-INSULINS<\/td>\n Novolin N<\/td>\n INSULIN NPH HUMAN ISOPHANE<\/td>\n VIAL<\/td>\n 100 UNIT\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
50.001<\/td>\n 16.311<\/td>\n 682008-INSULINS<\/td>\n Novolin 70\/30<\/td>\n INSULIN NPH HUM-REG INSULIN HM<\/td>\n VIAL<\/td>\n 70-30 UNIT\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
93.717<\/td>\n 42.076<\/td>\n 682008-INSULINS<\/td>\n Humalog 75\/25 Kwik Pen<\/td>\n INSULIN NPL-INSULIN LISPRO<\/td>\n INSULN PEN<\/td>\n 75-25 UNIT\/ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
22.681<\/td>\n 47.172<\/td>\n 682008-INSULINS<\/td>\n Humalog 75\/25<\/td>\n INSULIN NPL-INSULIN LISPRO<\/td>\n VIAL<\/td>\n 75-25 UNIT\/ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.642<\/td>\n 1.723<\/td>\n 682008-INSULINS<\/td>\n Novolin R<\/td>\n INSULIN REGULAR HUMAN<\/td>\n VIAL<\/td>\n 100 UNIT\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.277<\/td>\n 47.333<\/td>\n 682016-MEGLITINIDES<\/td>\n Starlix<\/td>\n NATEGLINIDE<\/td>\n TABLET<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.027<\/td>\n 47.292<\/td>\n 682016-MEGLITINIDES<\/td>\n Starlix<\/td>\n NATEGLINIDE<\/td>\n TABLET<\/td>\n 120 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
5.830<\/td>\n 25.179<\/td>\n 682020-SULFONYLUREAS<\/td>\n Amaryl<\/td>\n GLIMEPIRIDE<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
5.832<\/td>\n 25.180<\/td>\n 682020-SULFONYLUREAS<\/td>\n Amaryl<\/td>\n GLIMEPIRIDE<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
5.833<\/td>\n 25.181<\/td>\n 682020-SULFONYLUREAS<\/td>\n Amaryl<\/td>\n GLIMEPIRIDE<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.843<\/td>\n 21.839<\/td>\n 682020-SULFONYLUREAS<\/td>\n Glucotrol XL<\/td>\n GLIPIZIDE<\/td>\n TAB ER 24<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.844<\/td>\n 21.840<\/td>\n 682020-SULFONYLUREAS<\/td>\n Glucotrol XL<\/td>\n GLIPIZIDE<\/td>\n TAB ER 24<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
50.638<\/td>\n 43.463<\/td>\n 682020-SULFONYLUREAS<\/td>\n Glucotrol XL<\/td>\n GLIPIZIDE<\/td>\n TAB ER 24<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.840<\/td>\n 1.777<\/td>\n 682020-SULFONYLUREAS<\/td>\n Glucotrol<\/td>\n GLIPIZIDE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
10.841<\/td>\n 1.776<\/td>\n 682020-SULFONYLUREAS<\/td>\n Glucotrol<\/td>\n GLIPIZIDE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.366<\/td>\n 51.194<\/td>\n 682020-SULFONYLUREAS<\/td>\n Glipizide-Metformin<\/td>\n GLIPIZIDE-METFORMIN HCL<\/td>\n TABLET<\/td>\n 2.5-250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.367<\/td>\n 51.195<\/td>\n 682020-SULFONYLUREAS<\/td>\n Glipizide-Metformin<\/td>\n GLIPIZIDE-METFORMIN HCL<\/td>\n TABLET<\/td>\n 2.5-500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.368<\/td>\n 51.196<\/td>\n 682020-SULFONYLUREAS<\/td>\n Glipizide-Metformin<\/td>\n GLIPIZIDE-METFORMIN HCL<\/td>\n TABLET<\/td>\n 5-500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
5.710<\/td>\n 1.773<\/td>\n 682020-SULFONYLUREAS<\/td>\n Diabeta<\/td>\n GLYBURIDE<\/td>\n TABLET<\/td>\n 1.25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
5.711<\/td>\n 1.774<\/td>\n 682020-SULFONYLUREAS<\/td>\n Diabeta<\/td>\n GLYBURIDE<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
5.712<\/td>\n 1.775<\/td>\n 682020-SULFONYLUREAS<\/td>\n Diabeta<\/td>\n GLYBURIDE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
89.878<\/td>\n 45.929<\/td>\n 682020-SULFONYLUREAS<\/td>\n Glucovance<\/td>\n GLYBURIDE-METFORMIN HCL<\/td>\n TABLET<\/td>\n 1.25-250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
89.879<\/td>\n 45.930<\/td>\n 682020-SULFONYLUREAS<\/td>\n Glucovance<\/td>\n GLYBURIDE-METFORMIN HCL<\/td>\n TABLET<\/td>\n 5-500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
92.889<\/td>\n 22.735<\/td>\n 682020-SULFONYLUREAS<\/td>\n Glucovance<\/td>\n GLYBURIDE-METFORMIN HCL<\/td>\n TABLET<\/td>\n 2.5-500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
92.991<\/td>\n 42.943<\/td>\n 682028-THIAZOLIDINEDIONES<\/td>\n Actos<\/td>\n PIOGLITAZONE HCL<\/td>\n TABLET<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
93.001<\/td>\n 42.944<\/td>\n 682028-THIAZOLIDINEDIONES<\/td>\n Actos<\/td>\n PIOGLITAZONE HCL<\/td>\n TABLET<\/td>\n 30 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
93.011<\/td>\n 42.945<\/td>\n 682028-THIAZOLIDINEDIONES<\/td>\n Actos<\/td>\n PIOGLITAZONE HCL<\/td>\n TABLET<\/td>\n 45 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.474<\/td>\n 41.661<\/td>\n 682212-GLYCOGENOLYTIC AGENTS<\/td>\n Glucagon<\/td>\n GLUCAGON HUMAN RECOMBINANT<\/td>\n KIT<\/td>\n 1 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.473<\/td>\n 41.660<\/td>\n 682212-GLYCOGENOLYTIC AGENTS<\/td>\n Glucagen<\/td>\n GLUCAGON HUMAN RECOMBINANT<\/td>\n VIAL<\/td>\n 1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.281<\/td>\n 24.138<\/td>\n 682400-PARATHYROID<\/td>\n Miacalcin Nasal<\/td>\n CALCITONIN SALMON SYNTHETIC<\/td>\n SPRAY\/PUMP<\/td>\n 200 UNIT\/SPRAY<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.173<\/td>\n 31.610<\/td>\n 682800-PITUITARY<\/td>\n DDAVP Nasal<\/td>\n DESMOPRESSIN (NONREFRIGERATED)<\/td>\n SPRAY\/PUMP<\/td>\n 10 MCG\/SPRAY<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.170<\/td>\n 6.617<\/td>\n 682800-PITUITARY<\/td>\n DDAVP<\/td>\n DESMOPRESSIN ACETATE<\/td>\n SOLUTION<\/td>\n 0.1 MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.171<\/td>\n 19.596<\/td>\n 682800-PITUITARY<\/td>\n DDAVP<\/td>\n DESMOPRESSIN ACETATE<\/td>\n TABLET<\/td>\n 0.1 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.172<\/td>\n 19.597<\/td>\n 682800-PITUITARY<\/td>\n DDAVP<\/td>\n DESMOPRESSIN ACETATE<\/td>\n TABLET<\/td>\n 0.2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.260<\/td>\n 3.271<\/td>\n 683200-PROGESTINS<\/td>\n Provera<\/td>\n MEDROXYPROGESTERONE ACETATE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.261<\/td>\n 3.272<\/td>\n 683200-PROGESTINS<\/td>\n Provera<\/td>\n MEDROXYPROGESTERONE ACETATE<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.262<\/td>\n 3.273<\/td>\n 683200-PROGESTINS<\/td>\n Provera<\/td>\n MEDROXYPROGESTERONE ACETATE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
11.280<\/td>\n 3.274<\/td>\n 683200-PROGESTINS<\/td>\n Aygestin<\/td>\n NORETHINDRONE ACETATE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.586<\/td>\n 62.815<\/td>\n 683200-PROGESTINS<\/td>\n Endometrin Vaginal<\/td>\n PROGESTERONE MICRONIZED<\/td>\n INSERT<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.320<\/td>\n 6.652<\/td>\n 683604-THYROID AGENTS<\/td>\n Levothyroxine<\/td>\n LEVOTHYROXINE SODIUM<\/td>\n TABLET<\/td>\n 112 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.321<\/td>\n 6.648<\/td>\n 683604-THYROID AGENTS<\/td>\n Levothyroxine<\/td>\n LEVOTHYROXINE SODIUM<\/td>\n TABLET<\/td>\n 25 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.322<\/td>\n 6.649<\/td>\n 683604-THYROID AGENTS<\/td>\n Levothyroxine<\/td>\n LEVOTHYROXINE SODIUM<\/td>\n TABLET<\/td>\n 50 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.323<\/td>\n 6.651<\/td>\n 683604-THYROID AGENTS<\/td>\n Levothyroxine<\/td>\n LEVOTHYROXINE SODIUM<\/td>\n TABLET<\/td>\n 100 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.324<\/td>\n 6.650<\/td>\n 683604-THYROID AGENTS<\/td>\n Levothyroxine<\/td>\n LEVOTHYROXINE SODIUM<\/td>\n TABLET<\/td>\n 75 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.325<\/td>\n 6.656<\/td>\n 683604-THYROID AGENTS<\/td>\n Levothyroxine<\/td>\n LEVOTHYROXINE SODIUM<\/td>\n TABLET<\/td>\n 200 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.326<\/td>\n 6.653<\/td>\n 683604-THYROID AGENTS<\/td>\n Levothyroxine<\/td>\n LEVOTHYROXINE SODIUM<\/td>\n TABLET<\/td>\n 125 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.327<\/td>\n 6.654<\/td>\n 683604-THYROID AGENTS<\/td>\n Levothyroxine<\/td>\n LEVOTHYROXINE SODIUM<\/td>\n TABLET<\/td>\n 150 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.328<\/td>\n 6.655<\/td>\n 683604-THYROID AGENTS<\/td>\n Levothyroxine<\/td>\n LEVOTHYROXINE SODIUM<\/td>\n TABLET<\/td>\n 175MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.329<\/td>\n 6.657<\/td>\n 683604-THYROID AGENTS<\/td>\n Levothyroxine<\/td>\n LEVOTHYROXINE SODIUM<\/td>\n TABLET<\/td>\n 300 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.631<\/td>\n 15.523<\/td>\n 683604-THYROID AGENTS<\/td>\n Levothyroxine<\/td>\n LEVOTHYROXINE SODIUM<\/td>\n TABLET<\/td>\n 88 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.632<\/td>\n 20.176<\/td>\n 683604-THYROID AGENTS<\/td>\n Levothyroxine<\/td>\n LEVOTHYROXINE SODIUM<\/td>\n TABLET<\/td>\n 137 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.340<\/td>\n 6.658<\/td>\n 683604-THYROID AGENTS<\/td>\n Cytomel<\/td>\n LIOTHYRONINE SODIUM<\/td>\n TABLET<\/td>\n 25 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.341<\/td>\n 6.659<\/td>\n 683604-THYROID AGENTS<\/td>\n Cytomel<\/td>\n LIOTHYRONINE SODIUM<\/td>\n TABLET<\/td>\n 5 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.342<\/td>\n 6.660<\/td>\n 683604-THYROID AGENTS<\/td>\n Cytomel<\/td>\n LIOTHYRONINE SODIUM<\/td>\n TABLET<\/td>\n 50 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.400<\/td>\n 6.674<\/td>\n 683608-ANTITHYROID AGENTS<\/td>\n Tapazole<\/td>\n METHIMAZOLE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.401<\/td>\n 6.675<\/td>\n 683608-ANTITHYROID AGENTS<\/td>\n Tapazole<\/td>\n METHIMAZOLE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.581<\/td>\n 16.924<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Cleocin Vaginal<\/td>\n CLINDAMYCIN PHOSPHATE<\/td>\n CREAM\/APPL<\/td>\n 2 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
45.410<\/td>\n 7.726<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Cleocin T<\/td>\n CLINDAMYCIN PHOSPHATE<\/td>\n GEL (GRAM)<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.770<\/td>\n 11.752<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Cleocin T<\/td>\n CLINDAMYCIN PHOSPHATE<\/td>\n LOTION<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.720<\/td>\n 7.727<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Cleocin T<\/td>\n CLINDAMYCIN PHOSPHATE<\/td>\n SOLUTION<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
77.562<\/td>\n 29.325<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Erythromycin with Ethanol<\/td>\n ERYTHROMYCIN BASE (WITH ETHANOL)<\/td>\n SOLUTION<\/td>\n 2 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
43.203<\/td>\n 41.799<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Metrocream, Rosadan<\/td>\n METRONIDAZOLE<\/td>\n CREAM (G)<\/td>\n 0.75 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
24.926<\/td>\n 59.325<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Metrogel<\/td>\n METRONIDAZOLE<\/td>\n GEL (GRAM)<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
43.202<\/td>\n 41.798<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Rosadan<\/td>\n METRONIDAZOLE<\/td>\n GEL (GRAM)<\/td>\n 0.75 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
49.261<\/td>\n 16.939<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Metrogel Vaginal<\/td>\n METRONIDAZOLE<\/td>\n GEL W\/APPL<\/td>\n 0.75 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.774<\/td>\n 68.879<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Metrogel Pump<\/td>\n METRONIDAZOLE<\/td>\n GEL W\/PUMP<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
43.201<\/td>\n 41.797<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Metrolotion<\/td>\n METRONIDAZOLE<\/td>\n LOTION<\/td>\n 0.75 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.450<\/td>\n 7.732<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Bactroban<\/td>\n MUPIROCIN<\/td>\n OINT. (G)<\/td>\n 2 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
85.459<\/td>\n 7.694<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Triple Antibiotic Ointment<\/td>\n NEOMYCIN-BACITRACIN-POLYMYXIN B<\/td>\n OINT. (G)<\/td>\n 3.5-400-5000 MG\/G-UNIT\/G-UNIT\/G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.274<\/td>\n 48.538<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Cortisporin<\/td>\n NEOMYCIN-BACITRACIN-POLYMYXIN B-HYDROCORTISONE<\/td>\n OINT. (G)<\/td>\n 3.5-400-10000-1 MG\/G-UNIT\/G-UNIT\/G-%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.275<\/td>\n 48.539<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Cortisporin<\/td>\n NEOMYCIN-POLYMYXIN B-HYDROCORTISONE<\/td>\n CREAM (G)<\/td>\n 3.5-10000-0.50 MG\/G-UNIT\/G-%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
62.420<\/td>\n 18.315<\/td>\n 840406-ANTIVIRALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Zovirax<\/td>\n ACYCLOVIR<\/td>\n CREAM (G)<\/td>\n 5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.640<\/td>\n 7.670<\/td>\n 840406-ANTIVIRALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Zovirax<\/td>\n ACYCLOVIR<\/td>\n OINT. (G)<\/td>\n 5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.618<\/td>\n 44.922<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Ciclopirox<\/td>\n CICLOPIROX<\/td>\n GEL (GRAM)<\/td>\n 0.77 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.218<\/td>\n 51.825<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Loprox Shampoo<\/td>\n CICLOPIROX<\/td>\n SHAMPOO<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
8.040<\/td>\n 37.020<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Ciclodan, Penlac<\/td>\n CICLOPIROX<\/td>\n SOLUTION<\/td>\n 8 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.677<\/td>\n 40.971<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Ciclopirox Olamine<\/td>\n CICLOPIROX OLAMINE<\/td>\n CREAM (G)<\/td>\n 0.77 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.370<\/td>\n 7.361<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Clotrimazole<\/td>\n CLOTRIMAZOLE<\/td>\n Cream<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.380<\/td>\n 7.362<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Clotrimazole<\/td>\n CLOTRIMAZOLE<\/td>\n SOLUTION<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
7.590<\/td>\n 9.553<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Mycelex<\/td>\n CLOTRIMAZOLE<\/td>\n TROCHE<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
6.919<\/td>\n 36.534<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Lotrisone<\/td>\n CLOTRIMAZOLE-BETAMETHASONE DIPROPIONATE<\/td>\n CREAM (G)<\/td>\n 1-0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.125<\/td>\n 48.627<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Clotrimazole-Betamethasone<\/td>\n CLOTRIMAZOLE-BETAMETHASONE DIPROPIONATE<\/td>\n LOTION<\/td>\n 1-0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.850<\/td>\n 7.334<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Ketoconazole<\/td>\n KETOCONAZOLE<\/td>\n CREAM (G)<\/td>\n 2 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.271<\/td>\n 15.568<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Nizoral Shampoo<\/td>\n KETOCONAZOLE<\/td>\n SHAMPOO<\/td>\n 2 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.140<\/td>\n 7.282<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Nystatin<\/td>\n NYSTATIN<\/td>\n CREAM (G)<\/td>\n 100000 UNIT\/G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.150<\/td>\n 7.283<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Nystatin<\/td>\n NYSTATIN<\/td>\n OINT. (G)<\/td>\n 100000 UNIT\/G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.160<\/td>\n 7.284<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Nystatin<\/td>\n NYSTATIN<\/td>\n POWDER<\/td>\n 100000 UNIT\/G<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.007<\/td>\n 48.529<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Nystatin\/Triamcinolone<\/td>\n NYSTATIN-TRIAMCINCINOLONE<\/td>\n CREAM (G)<\/td>\n 100000-0.1 UNIT\/G-%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.008<\/td>\n 48.530<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Nystatin\/Triamcinolone<\/td>\n NYSTATIN-TRIAMCINCINOLONE<\/td>\n OINT. (G)<\/td>\n 100000-0.1 UNIT\/G-%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.381<\/td>\n 15.931<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Terazol 3<\/td>\n TERCONAZOLE<\/td>\n CREAM\/APPL<\/td>\n 0.8 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.380<\/td>\n 7.008<\/td>\n 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Terazol 7<\/td>\n TERCONAZOLE<\/td>\n CREAM\/APPL<\/td>\n 0.4 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.550<\/td>\n 7.650<\/td>\n 840412-SCABICIDES AND PEDICULICIDES<\/td>\n Lindane<\/td>\n LINDANE<\/td>\n LOTION<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.570<\/td>\n 7.651<\/td>\n 840412-SCABICIDES AND PEDICULICIDES<\/td>\n Lindane<\/td>\n LINDANE<\/td>\n SHAMPOO<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
44.370<\/td>\n 13.631<\/td>\n 840412-SCABICIDES AND PEDICULICIDES<\/td>\n Elimite<\/td>\n PERMETHRIN<\/td>\n CREAM (G)<\/td>\n 5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
44.520<\/td>\n 7.663<\/td>\n 840412-SCABICIDES AND PEDICULICIDES<\/td>\n Nix<\/td>\n PERMETHRIN<\/td>\n LIQUID<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.630<\/td>\n 7.669<\/td>\n 840492-LOCAL ANTI-INFECTIVES, MISCELLANEOUS<\/td>\n Silvadene<\/td>\n SILVER SULFADIAZINE<\/td>\n CREAM (G)<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.060<\/td>\n 7.568<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Betamethasone Diproprionate<\/td>\n BETAMETHASONE DIPROPIONATE<\/td>\n CREAM (G)<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.080<\/td>\n 7.570<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Betamethasone Diproprionate<\/td>\n BETAMETHASONE DIPROPIONATE<\/td>\n LOTION<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.070<\/td>\n 7.569<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Betamethasone Diproprionate<\/td>\n BETAMETHASONE DIPROPIONATE<\/td>\n OINT. (G)<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.101<\/td>\n 7.572<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Betamethasone Valerate<\/td>\n BETAMETHASONE VALERATE<\/td>\n CREAM (G)<\/td>\n 0.1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.120<\/td>\n 7.574<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Betamethasone Valerate<\/td>\n BETAMETHASONE VALERATE<\/td>\n LOTION<\/td>\n 0.1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.110<\/td>\n 7.573<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Betamethasone Valerate<\/td>\n BETAMETHASONE VALERATE<\/td>\n OINT. (G)<\/td>\n 0.1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.890<\/td>\n 7.561<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Diprolene AF<\/td>\n BETAMETHASONE-PROPYLENE GLYCOL<\/td>\n CREAM (G)<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.910<\/td>\n 7.562<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Diprolene<\/td>\n BETAMETHASONE-PROPYLENE GLYCOL<\/td>\n OINT. (G)<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.140<\/td>\n 7.634<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Temovate<\/td>\n CLOBETASOL PROPIONATE<\/td>\n CREAM (G)<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.040<\/td>\n 18.288<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Clobex<\/td>\n CLOBETASOL PROPIONATE<\/td>\n LOTION<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.130<\/td>\n 7.635<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Temovate<\/td>\n CLOBETASOL PROPIONATE<\/td>\n OINT. (G)<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.891<\/td>\n 15.349<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Cormax<\/td>\n CLOBETASOL PROPIONATE<\/td>\n SOLUTION<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.141<\/td>\n 21.986<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Temovate E<\/td>\n CLOBETASOL PROPIONATE-EMOLLIENT BASE<\/td>\n CREAM (G)<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.425<\/td>\n 7.620<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Desonide<\/td>\n DESONIDE<\/td>\n CREAM (G)<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.430<\/td>\n 7.622<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Desonide<\/td>\n DESONIDE<\/td>\n OINT. (G)<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
24.484<\/td>\n 58.950<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Derma-Smoothe-FS Scalp Oil<\/td>\n FLUOCINOLONE (WITH SHOWER CAP)<\/td>\n OIL<\/td>\n 0.01 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
85.080<\/td>\n 7.507<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Derma-Smoothe-FS Body Oil<\/td>\n FLUOCINOLONE ACETONIDE<\/td>\n OIL<\/td>\n 0.01 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.390<\/td>\n 7.616<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Fluocinonide<\/td>\n FLUOCINONIDE<\/td>\n CREAM (G)<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.380<\/td>\n 7.615<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Fluocinonide<\/td>\n FLUOCINONIDE<\/td>\n GEL (GRAM)<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.400<\/td>\n 7.617<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Fluocinonide<\/td>\n FLUOCINONIDE<\/td>\n OINT. (G)<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.401<\/td>\n 7.618<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Fluocinonide<\/td>\n FLUOCINONIDE<\/td>\n SOLUTION<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.943<\/td>\n 7.545<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Hydrocortisone<\/td>\n HYDROCORTISONE<\/td>\n CREAM (G)<\/td>\n 2.5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.850<\/td>\n 23.906<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Proctosol-HC, Proctozone<\/td>\n HYDROCORTISONE<\/td>\n CREAM\/APPL<\/td>\n 2.5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
66.392<\/td>\n 37.045<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Cortenema, Colocort<\/td>\n HYDROCORTISONE<\/td>\n ENEMA<\/td>\n 100 MG\/60ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.975<\/td>\n 7.554<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Hydrocortisone<\/td>\n HYDROCORTISONE<\/td>\n LOTION<\/td>\n 2.5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.952<\/td>\n 7.548<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Hydrocortisone<\/td>\n HYDROCORTISONE<\/td>\n OINT. (G)<\/td>\n 2.5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
66.391<\/td>\n 37.044<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Cortifoam<\/td>\n HYDROCORTISONE ACETATE<\/td>\n FOAM\/APPL<\/td>\n 10 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.941<\/td>\n 6.858<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Anusol-HC<\/td>\n HYDROCORTISONE ACETATE<\/td>\n SUPP.RECT<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.231<\/td>\n 7.593<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Triamcinolone<\/td>\n TRIAMCINOLONE ACETONIDE<\/td>\n CREAM (G)<\/td>\n 0.025 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.232<\/td>\n 7.594<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Triamcinolone<\/td>\n TRIAMCINOLONE ACETONIDE<\/td>\n CREAM (G)<\/td>\n 0.1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.233<\/td>\n 7.595<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Triamcinolone<\/td>\n TRIAMCINOLONE ACETONIDE<\/td>\n CREAM (G)<\/td>\n 0.5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.260<\/td>\n 7.599<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Triamcinolone<\/td>\n TRIAMCINOLONE ACETONIDE<\/td>\n LOTION<\/td>\n 0.025 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.261<\/td>\n 7.600<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Triamcinolone<\/td>\n TRIAMCINOLONE ACETONIDE<\/td>\n LOTION<\/td>\n 0.1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.241<\/td>\n 7.596<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Triamcinolone<\/td>\n TRIAMCINOLONE ACETONIDE<\/td>\n OINT. (G)<\/td>\n 0.025 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.242<\/td>\n 7.597<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Triamcinolone<\/td>\n TRIAMCINOLONE ACETONIDE<\/td>\n OINT. (G)<\/td>\n 0.1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.243<\/td>\n 15.542<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Triamcinolone<\/td>\n TRIAMCINOLONE ACETONIDE<\/td>\n OINT. (G)<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.244<\/td>\n 7.598<\/td>\n 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)<\/td>\n Triamcinolone<\/td>\n TRIAMCINOLONE ACETONIDE<\/td>\n OINT. (G)<\/td>\n 0.5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.121<\/td>\n 9.477<\/td>\n 840800-ANTIPRURITICS AND LOCAL ANESTHETICS<\/td>\n Pyridium<\/td>\n PHENAZOPYRIDINE HCL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.122<\/td>\n 9.478<\/td>\n 840800-ANTIPRURITICS AND LOCAL ANESTHETICS<\/td>\n Pyridium<\/td>\n PHENAZOPYRIDINE HCL<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
22.291<\/td>\n 11.998<\/td>\n 841200-ASTRINGENTS<\/td>\n Drysol<\/td>\n ALUMINUM CHLORIDE<\/td>\n SOLUTION<\/td>\n 20 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
22.880<\/td>\n 5.800<\/td>\n 841600-CELL STIMULANTS AND PROLIFERANTS<\/td>\n Retin-A<\/td>\n TRETINOIN<\/td>\n CREAM (G)<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
22.881<\/td>\n 5.801<\/td>\n 841600-CELL STIMULANTS AND PROLIFERANTS<\/td>\n Retin-A<\/td>\n TRETINOIN<\/td>\n CREAM (G)<\/td>\n 0.01 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
22.882<\/td>\n 5.799<\/td>\n 841600-CELL STIMULANTS AND PROLIFERANTS<\/td>\n Retin-A<\/td>\n TRETINOIN<\/td>\n CREAM (G)<\/td>\n 0.025 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
22.870<\/td>\n 5.797<\/td>\n 841600-CELL STIMULANTS AND PROLIFERANTS<\/td>\n Retin-A<\/td>\n TRETINOIN<\/td>\n GEL (GRAM)<\/td>\n 0.01 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
22.871<\/td>\n 5.798<\/td>\n 841600-CELL STIMULANTS AND PROLIFERANTS<\/td>\n Retin-A<\/td>\n TRETINOIN<\/td>\n GEL (GRAM)<\/td>\n 0.025 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.443<\/td>\n 50.417<\/td>\n 841600-CELL STIMULANTS AND PROLIFERANTS<\/td>\n Retin-A Micro<\/td>\n TRETINOIN MICROSPHERES<\/td>\n GEL (GRAM)<\/td>\n 0.04 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
22.874<\/td>\n 30.614<\/td>\n 841600-CELL STIMULANTS AND PROLIFERANTS<\/td>\n Retin-A Micro<\/td>\n TRETINOIN MICROSPHERES<\/td>\n GEL (GRAM)<\/td>\n 0.1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.776<\/td>\n 68.881<\/td>\n 841600-CELL STIMULANTS AND PROLIFERANTS<\/td>\n Retin-A Micro Pump<\/td>\n TRETINOIN MICROSPHERES<\/td>\n GEL W\/PUMP<\/td>\n 0.04 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.777<\/td>\n 68.882<\/td>\n 841600-CELL STIMULANTS AND PROLIFERANTS<\/td>\n Retin-A Micro Pump<\/td>\n TRETINOIN MICROSPHERES<\/td>\n GEL W\/PUMP<\/td>\n 0.1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
63.447<\/td>\n 45.214<\/td>\n 841600-CELL STIMULANTS AND PROLIFERANTS<\/td>\n Refissa<\/td>\n TRETINOIN-EMOLLIENT BASE<\/td>\n CREAM (G)<\/td>\n 0.05 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
22.931<\/td>\n 5.813<\/td>\n 842800-KERATOLYTIC AGENTS<\/td>\n Benzoyl Peroxide<\/td>\n BENZOYL PEROXIDE<\/td>\n GEL (GRAM)<\/td>\n 5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
24.774<\/td>\n 16.308<\/td>\n 842800-KERATOLYTIC AGENTS<\/td>\n Urea<\/td>\n UREA<\/td>\n CREAM (G)<\/td>\n 40 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.198<\/td>\n 51.812<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Azelaic Acid<\/td>\n AZELAIC ACID<\/td>\n Gel<\/td>\n 15%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.274<\/td>\n 74.590<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Azelaic Acid<\/td>\n AZELAIC ACID<\/td>\n FOAM<\/td>\n 15%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.851<\/td>\n 21.134<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Dovonex<\/td>\n CALCIPOTRIENE<\/td>\n CREAM (G)<\/td>\n 0.005%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.850<\/td>\n 19.160<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Calcipotriene<\/td>\n CALCIPOTRIENE<\/td>\n OINT. (G)<\/td>\n 0.005%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.852<\/td>\n 22.483<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Calcipotriene<\/td>\n CALCIPOTRIENE<\/td>\n SOLUTION<\/td>\n 0.005%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.781<\/td>\n 7.502<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Efudex<\/td>\n FLUOROURACIL<\/td>\n CREAM (G)<\/td>\n 5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.791<\/td>\n 7.504<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Fluorouracil<\/td>\n FLUOROURACIL<\/td>\n SOLUTION<\/td>\n 2 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.792<\/td>\n 7.505<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Fluorouracil<\/td>\n FLUOROURACIL<\/td>\n SOLUTION<\/td>\n 5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
54.201<\/td>\n 31.099<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Aldara<\/td>\n IMIQUIMOD<\/td>\n CREAM PACK<\/td>\n 5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
15.348<\/td>\n 49.724<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Elidel<\/td>\n PIMECROLIMUS<\/td>\n CREAM (G)<\/td>\n 1 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.450<\/td>\n 30.857<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Condylox<\/td>\n PODOFILOX<\/td>\n GEL (GRAM)<\/td>\n 0.5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.451<\/td>\n 15.942<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Condylox<\/td>\n PODOFILOX<\/td>\n SOLUTION<\/td>\n 0.5 %<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.370<\/td>\n 4.928<\/td>\n 861204-ANTIMUSCARINICS<\/td>\n Oxybutynin<\/td>\n OXYBUTYNIN CHLORIDE<\/td>\n SYRUP<\/td>\n 5 MG\/5 ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.388<\/td>\n 41.046<\/td>\n 861204-ANTIMUSCARINICS<\/td>\n Oxybutynin ER<\/td>\n OXYBUTYNIN CHLORIDE<\/td>\n TAB ER 24<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.389<\/td>\n 41.047<\/td>\n 861204-ANTIMUSCARINICS<\/td>\n Oxybutynin ER<\/td>\n OXYBUTYNIN CHLORIDE<\/td>\n TAB ER 24<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
93.557<\/td>\n 42.606<\/td>\n 861204-ANTIMUSCARINICS<\/td>\n Oxybutynin ER<\/td>\n OXYBUTYNIN CHLORIDE<\/td>\n TAB ER 24<\/td>\n 15 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.380<\/td>\n 4.929<\/td>\n 861204-ANTIMUSCARINICS<\/td>\n Ditropan<\/td>\n OXYBUTYNIN CHLORIDE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
410<\/td>\n 90<\/td>\n 861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS<\/td>\n Theophylline ER<\/td>\n THEOPHYLLINE ANHYDROUS<\/td>\n TAB ER 12H<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
411<\/td>\n 91<\/td>\n 861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS<\/td>\n Theophylline ER<\/td>\n THEOPHYLLINE ANHYDROUS<\/td>\n TAB ER 12H<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
413<\/td>\n 93<\/td>\n 861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS<\/td>\n Theophylline ER<\/td>\n THEOPHYLLINE ANHYDROUS<\/td>\n TAB ER 12H<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.481<\/td>\n 2.184<\/td>\n 881600-VITAMIN D<\/td>\n Rocaltrol<\/td>\n CALCITRIOL<\/td>\n CAPSULE<\/td>\n 0.25 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.482<\/td>\n 2.185<\/td>\n 881600-VITAMIN D<\/td>\n Rocaltrol<\/td>\n CALCITRIOL<\/td>\n CAPSULE<\/td>\n 0.5 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.425<\/td>\n 62.651<\/td>\n 881600-VITAMIN D<\/td>\n Cholecalciferol (Vitamin D3)<\/td>\n CHOLECALCIFEROL (VITAMIN D3)<\/td>\n CAPSULE<\/td>\n 50000 UNIT<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.422<\/td>\n 2.169<\/td>\n 881600-VITAMIN D<\/td>\n Drisdol<\/td>\n ERGOCALCIFEROL (VITAMIN D2)<\/td>\n CAPSULE<\/td>\n 50000 UNIT<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.711<\/td>\n 2.305<\/td>\n 882400-VITAMIN K ACTIVITY<\/td>\n Mephyton<\/td>\n PHYTONADIONE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.881<\/td>\n 1.192<\/td>\n 920400-ALCOHOL DETERRENTS<\/td>\n Antabuse<\/td>\n DISULFIRAM<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.521<\/td>\n 41.440<\/td>\n 920800-5-ALPHA-REDUCTASE INHIBITORS<\/td>\n Proscar<\/td>\n FINASTERIDE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
7.070<\/td>\n 2.535<\/td>\n 921600-ANTIGOUT AGENTS<\/td>\n Zyloprim<\/td>\n ALLOPURINOL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
7.071<\/td>\n 2.536<\/td>\n 921600-ANTIGOUT AGENTS<\/td>\n Zyloprim<\/td>\n ALLOPURINOL<\/td>\n TABLET<\/td>\n 300 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.674<\/td>\n 8.334<\/td>\n 921600-ANTIGOUT AGENTS<\/td>\n Colcrys<\/td>\n COLCHICINE<\/td>\n TABLET<\/td>\n 0.6 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.389<\/td>\n 47.381<\/td>\n 922400-BONE RESORPTION INHIBITORS<\/td>\n Fosamax<\/td>\n ALENDRONATE SODIUM<\/td>\n TABLET<\/td>\n 35 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
21.680<\/td>\n 24.053<\/td>\n 922400-BONE RESORPTION INHIBITORS<\/td>\n Fosamax<\/td>\n ALENDRONATE SODIUM<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
21.682<\/td>\n 31.006<\/td>\n 922400-BONE RESORPTION INHIBITORS<\/td>\n Fosamax<\/td>\n ALENDRONATE SODIUM<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
85.361<\/td>\n 46.941<\/td>\n 922400-BONE RESORPTION INHIBITORS<\/td>\n Fosamax<\/td>\n ALENDRONATE SODIUM<\/td>\n TABLET<\/td>\n 70 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
67.031<\/td>\n 40.549<\/td>\n 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS<\/td>\n Arava<\/td>\n LEFLUNOMIDE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
67.032<\/td>\n 40.550<\/td>\n 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS<\/td>\n Arava<\/td>\n LEFLUNOMIDE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
46.771<\/td>\n 11.682<\/td>\n 924400-IMMUNOSUPPRESSIVE AGENTS<\/td>\n Imuran<\/td>\n AZATHIOPRINE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 62.137<\/td>\n 940000-DEVICES<\/td>\n True Metrix Level 3<\/td>\n BLOOD-GLUCOSE CONTROL HIGH<\/td>\n EACH<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 62.137<\/td>\n 940000-DEVICES<\/td>\n True Metrix Level 1<\/td>\n BLOOD-GLUCOSE CONTROL LOW<\/td>\n EACH<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 62.137<\/td>\n 940000-DEVICES<\/td>\n True Metrix Level 2<\/td>\n BLOOD-GLUCOSE CONTROL NORMAL<\/td>\n EACH<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 19.413<\/td>\n 940000-DEVICES<\/td>\n True Metrix Air Meter<\/td>\n BLOOD-GLUCOSE METER<\/td>\n EACH<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 19.413<\/td>\n 940000-DEVICES<\/td>\n True Metrix Meter<\/td>\n BLOOD-GLUCOSE METER<\/td>\n EACH<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 19.413<\/td>\n 940000-DEVICES<\/td>\n True Metrix Pro<\/td>\n BLOOD-GLUCOSE METER<\/td>\n EACH<\/td>\n <\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 19.413<\/td>\n 940000-DEVICES<\/td>\n True Metrix Go<\/td>\n BLOOD-GLUCOSE METER<\/td>\n EACH<\/td>\n <\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 21.900<\/td>\n 940000-DEVICES<\/td>\n Aerochamber Plus Flow-Vu<\/td>\n INHALER ASSIST DEVICES<\/td>\n SPACER<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 21.900<\/td>\n 940000-DEVICES<\/td>\n Aerochamber Plus Flow-Vu Mask, Large<\/td>\n INHALER ASSIST DEVICES<\/td>\n SPACER<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 21.900<\/td>\n 940000-DEVICES<\/td>\n Aerochamber Plus Flow-Vu Mask, Medium<\/td>\n INHALER ASSIST DEVICES<\/td>\n SPACER<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 21.900<\/td>\n 940000-DEVICES<\/td>\n Aerochamber Plus Flow-Vu Mask, Small<\/td>\n INHALER ASSIST DEVICES<\/td>\n SPACER<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 21.900<\/td>\n 940000-DEVICES<\/td>\n Optichamber Diamond VHC<\/td>\n INHALER ASSIST DEVICES<\/td>\n SPACER<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 21.900<\/td>\n 940000-DEVICES<\/td>\n Optichamber Diamond VHC with Large Mask<\/td>\n INHALER ASSIST DEVICES<\/td>\n SPACER<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 21.900<\/td>\n 940000-DEVICES<\/td>\n Optichamber Diamond VHC with Medium Mask<\/td>\n INHALER ASSIST DEVICES<\/td>\n SPACER<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 21.900<\/td>\n 940000-DEVICES<\/td>\n Optichamber Diamond VHC with Small Mask<\/td>\n INHALER ASSIST DEVICES<\/td>\n SPACER<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 64.800<\/td>\n 940000-DEVICES<\/td>\n Optichamber Large Mask<\/td>\n INHALER ASSIST DEVICE ACCESORY<\/td>\n EACH<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 64.800<\/td>\n 940000-DEVICES<\/td>\n Optichamber Medium Mask<\/td>\n INHALER ASSIST DEVICE ACCESORY<\/td>\n EACH<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 70.184<\/td>\n 940000-DEVICES<\/td>\n True Plus Lancet 28G<\/td>\n LANCETS<\/td>\n EACH<\/td>\n 28 GAUGE<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 70.013<\/td>\n 940000-DEVICES<\/td>\n True Plus Lancet 30G<\/td>\n LANCETS<\/td>\n EACH<\/td>\n 30 GAUGE<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 70.013<\/td>\n 940000-DEVICES<\/td>\n True Plus Lancet 30G<\/td>\n LANCETS<\/td>\n EACH<\/td>\n 30 GAUGE<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 70.012<\/td>\n 940000-DEVICES<\/td>\n True Plus Lancet 33G<\/td>\n LANCETS<\/td>\n EACH<\/td>\n 33 GAUGE<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 70.012<\/td>\n 940000-DEVICES<\/td>\n True Plus Lancet 33G<\/td>\n LANCETS<\/td>\n EACH<\/td>\n 33 GAUGE<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 70.184<\/td>\n 940000-DEVICES<\/td>\n True PlusLancet 28G<\/td>\n LANCETS<\/td>\n EACH<\/td>\n 28 GAUGE<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 70.184<\/td>\n 940000-DEVICES<\/td>\n True PlusLancet 28G<\/td>\n LANCETS<\/td>\n EACH<\/td>\n 28 GAUGE<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 65.779<\/td>\n 940000-DEVICES<\/td>\n True Plus Lancing Device<\/td>\n LANCING DEVICE<\/td>\n EACH<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 65.779<\/td>\n 940000-DEVICES<\/td>\n True Plus Lancing Device<\/td>\n LANCING DEVICE<\/td>\n EACH<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 16.606<\/td>\n 940000-DEVICES<\/td>\n Peak Flow Meter<\/td>\n PEAK FLOW METER<\/td>\n EACH<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 16.606<\/td>\n 940000-DEVICES<\/td>\n Peak Flow Meter<\/td>\n PEAK FLOW METER<\/td>\n EACH<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 16.606<\/td>\n 940000-DEVICES<\/td>\n Peak Flow Meter<\/td>\n PEAK FLOW METER<\/td>\n EACH<\/td>\n <\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.235<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 29 G X 1\/2\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.235<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 29 G X 1\/2\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.235<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 29 G X 1\/2\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.235<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 29 G X 1\/2\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.235<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 29 G X 1\/2\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 61.638<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 30 G x 1\/3\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 30 G X 1\/3\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 61.638<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 30 G x 1\/3\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 30 G X 1\/3\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 50.622<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 1\/4\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 1\/4\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 50.622<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 1\/4\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 1\/4\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 50.622<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 1\/4\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 1\/4\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 50.622<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 1\/4\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 1\/4\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 50.622<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 1\/4\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 1\/4\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 50.622<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 1\/4\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 1\/4\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 50.622<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 1\/4\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 1\/4\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 50.622<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 1\/4\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 1\/4\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 50.622<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 1\/4\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 1\/4\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 50.622<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 1\/4\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 1\/4\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 60.904<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 3\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 3\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 60.904<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 3\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 3\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 60.904<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 3\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 3\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 60.904<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 3\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 3\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 60.904<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 3\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 3\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 60.904<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 3\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 3\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 60.904<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 3\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 3\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 60.904<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 3\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 3\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.240<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 5\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.240<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 5\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.240<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 5\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.240<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 5\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.240<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 5\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.240<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 5\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.240<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 5\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.240<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 5\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.240<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 5\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.240<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 5\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.240<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 5\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.240<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 5\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.240<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 31 G x 5\/16\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 62.868<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 32 G x 1\/4\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 32 G X 1\/4\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 66.936<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 32 G X 1\/5\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 32 G X 1\/5\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 72.859<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 32 G x 1\/6\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 32 G X 1\/6\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 66.308<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 32 G x 5\/32\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 32G X 5\/32\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 66.308<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 32 G x 5\/32\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 32G X 5\/32\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 66.308<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 32 G x 5\/32\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 32G X 5\/32\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 66.308<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 32 G x 5\/32\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 32G X 5\/32\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 66.308<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 32 G x 5\/32\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 32G X 5\/32\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 66.308<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 32 G x 5\/32\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 32G X 5\/32\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 66.308<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 32 G x 5\/32\"<\/td>\n PEN NEEDLE DIABETIC<\/td>\n DIS NEEDLE<\/td>\n 32G X 5\/32\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 62.772<\/td>\n 940000-DEVICES<\/td>\n Pen Needle 30 G x 1\/3\"<\/td>\n PEN NEEDLE DIABETIC SAFETY<\/td>\n DIS NEEDLE<\/td>\n 30 G X 1\/3\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.277<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 29 G x 1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.277<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 29 G x 1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.277<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 29 G x 1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.399<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 30 G x 1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.399<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 30 G x 1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.394<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 30 G x 5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.394<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 30 G x 5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.394<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 30 G x 5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.394<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 30 G x 5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.394<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 30 G x 5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.394<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 30 G x 5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.394<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 30 G x 5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.403<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.403<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.403<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.403<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.403<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.403<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.403<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.403<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.3mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.3 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.276<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 28GX1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.276<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 28GX1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.276<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 28GX1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.276<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 28GX1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.276<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 28GX1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.276<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 28GX1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.383<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 29 G X1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.383<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 29 G X1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.383<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 29 G X1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.383<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 29 G X1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.383<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 29 G X1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.383<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 29 G X1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.383<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 29 G X1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.395<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 30GX 5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.395<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 30GX 5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.395<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 30GX 5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.395<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 30GX 5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.395<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 30GX 5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.395<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 30GX 5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.395<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 30GX 5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.400<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 30GX1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.400<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 30GX1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.400<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 30GX1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.400<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 30GX1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.404<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.404<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.404<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.404<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.404<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.404<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.404<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.404<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.404<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.275<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 28GX1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.275<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 28GX1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.275<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 28GX1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.275<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 28GX1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.275<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 28GX1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.275<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 28GX1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.275<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 28GX1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.384<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 29 G X1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.384<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 29 G X1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.384<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 29 G X1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.384<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 29 G X1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.384<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 29 G X1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.384<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 29 G X1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.384<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 29 G X1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.384<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 29 G X1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.358<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 30GX 5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.358<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 30GX 5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.358<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 30GX 5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.358<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 30GX 5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.358<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 30GX 5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.358<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 30GX 5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.358<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 30GX 5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.358<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 30GX 5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.401<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 30GX1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.401<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 30GX1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.401<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 30GX1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 1\/2\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.405<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 31 GX5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.405<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 31 GX5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.405<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 31 GX5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.405<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 31 GX5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.405<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 31 GX5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.405<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 31 GX5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.405<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 31 GX5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.405<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 31 GX5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.405<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 31 GX5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.405<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 31 GX5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.118<\/td>\n 28.142<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Suprax Capsule<\/td>\n CEFIXIME<\/td>\n CAPSULE<\/td>\n 400 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n Restricted to CUC\/CH Prescribers. Send to a CUC in-house pharmacy. Quantity limit #1 capsule\/ prescription.<\/td>\n <\/tr>\n
33.120<\/td>\n 9.182<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Suprax Suspension<\/td>\n CEFIXIME<\/td>\n SUSP RECON<\/td>\n 100 MG\/5ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Cefdinir<\/td>\n <\/tr>\n
92.368<\/td>\n 44.428<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Suprax Suspension<\/td>\n CEFIXIME<\/td>\n SUSP RECON<\/td>\n 200 MG\/5ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Cefdinir<\/td>\n <\/tr>\n
34.277<\/td>\n 70.665<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Suprax Suspension<\/td>\n CEFIXIME<\/td>\n SUSP RECON<\/td>\n 500 MG\/5ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Cefdinir<\/td>\n <\/tr>\n
33.445<\/td>\n 70.122<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Suprax Chewable<\/td>\n CEFIXIME<\/td>\n TAB CHEW<\/td>\n 100 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Cefdinir<\/td>\n <\/tr>\n
33.446<\/td>\n 70.123<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Suprax Chewable<\/td>\n CEFIXIME<\/td>\n TAB CHEW<\/td>\n 200 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Cefdinir<\/td>\n <\/tr>\n
33.110<\/td>\n 44.428<\/td>\n 081206-CEPHALOSPORINS<\/td>\n Suprax Tablet<\/td>\n CEFIXIME<\/td>\n TABLET<\/td>\n 400 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Cefdinir<\/td>\n <\/tr>\n
26.871<\/td>\n 45.132<\/td>\n 081228-ANTIBACTERIALS, MISCELLANEOUS<\/td>\n Zyvox Suspension<\/td>\n LINEZOLID<\/td>\n SUSP RECON<\/td>\n 100 MG\/5ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.870<\/td>\n 45.131<\/td>\n 081228-ANTIBACTERIALS, MISCELLANEOUS<\/td>\n Zyvox Tablet<\/td>\n LINEZOLID<\/td>\n TABLET<\/td>\n 600 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.787<\/td>\n 70.295<\/td>\n 081408-AZOLES<\/td>\n Onmel<\/td>\n ITRACONAZOLE<\/td>\n CAPSULE<\/td>\n 200 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
55.389<\/td>\n 21.871<\/td>\n 083600-URINARY ANTI-INFECTIVES<\/td>\n Monurol<\/td>\n FOSFOMYCIN TROMETHAMINE<\/td>\n PACKET<\/td>\n 3 G<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
74.040<\/td>\n 4.773<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Donnatal Elixir<\/td>\n PHENOBARBITAL-HYOSCYAMINE-ATROPINE-SCOPOLAMINE<\/td>\n ELIXIR<\/td>\n 16.2-0.1037-0.0194 MG\/5ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
74.070<\/td>\n 4.777<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Donnatal<\/td>\n PHENOBARBITAL-HYOSCYAMINE-ATROPINE-SCOPOLAMINE<\/td>\n TABLET<\/td>\n 16.2-0.1037-0.0194 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.038<\/td>\n 65.912<\/td>\n 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS<\/td>\n Adrenaclick<\/td>\n EPINEPHRINE<\/td>\n AUTO INJCT<\/td>\n 0.15 MG\/0.15ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Epinephrine generic<\/td>\n <\/tr>\n
19.861<\/td>\n 16.878<\/td>\n 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS<\/td>\n Epipen Jr.<\/td>\n EPINEPHRINE<\/td>\n AUTO INJCT<\/td>\n 0.15 MG\/0.3ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Epinephrine generic<\/td>\n <\/tr>\n
19.862<\/td>\n 16.879<\/td>\n 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS<\/td>\n Epipen, Adrenaclick<\/td>\n EPINEPHRINE<\/td>\n AUTO INJCT<\/td>\n 0.3 MG\/0.3ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Epinephrine generic<\/td>\n <\/tr>\n
17.912<\/td>\n 4.663<\/td>\n 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT<\/td>\n Soma<\/td>\n CARISOPRODOL<\/td>\n TABLET<\/td>\n 350 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Cyclobenzaprine, methocarbamol, and tizanidine<\/td>\n <\/tr>\n
91.765<\/td>\n 51.112<\/td>\n 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT<\/td>\n Skelaxin<\/td>\n METAXALONE<\/td>\n TABLET<\/td>\n 800 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Cyclobenzaprine, methocarbamol, and tizanidine<\/td>\n <\/tr>\n
19.153<\/td>\n 51.784<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Crestor<\/td>\n ROSUVASTATIN CALCIUM<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.154<\/td>\n 51.785<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Crestor<\/td>\n ROSUVASTATIN CALCIUM<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.155<\/td>\n 51.786<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Crestor<\/td>\n ROSUVASTATIN CALCIUM<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.229<\/td>\n 52.944<\/td>\n 240608-HMG-COA REDUCTASE INHIBITORS<\/td>\n Crestor<\/td>\n ROSUVASTATIN CALCIUM<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.929<\/td>\n 58.486<\/td>\n 240692-ANTILIPEMIC AGENTS, MISCELLANEOUS<\/td>\n Lovaza<\/td>\n OMEGA-3 ACID ETHYL ESTERS<\/td>\n CAPSULE<\/td>\n 1 G<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Icosapent ethyl, Fenofibrate<\/td>\n <\/tr>\n
73.542<\/td>\n 37.015<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Atacand<\/td>\n CANDESARTAN CILEXETIL<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
73.543<\/td>\n 37.016<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Atacand<\/td>\n CANDESARTAN CILEXETIL<\/td>\n TABLET<\/td>\n 8 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
73.544<\/td>\n 37.017<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Atacand<\/td>\n CANDESARTAN CILEXETIL<\/td>\n TABLET<\/td>\n 16 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
73.545<\/td>\n 40.659<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Atacand<\/td>\n CANDESARTAN CILEXETIL<\/td>\n TABLET<\/td>\n 32 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
13.258<\/td>\n 64.285<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Atacand HCT<\/td>\n CANDESARTAN\/HYDROCHLOROTHIAZID<\/td>\n TABLET<\/td>\n 32MG-25MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
21.559<\/td>\n 45.425<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Atacand HCT<\/td>\n CANDESARTAN\/HYDROCHLOROTHIAZID<\/td>\n TABLET<\/td>\n 16-12.5MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
21.569<\/td>\n 46.624<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Atacand HCT<\/td>\n CANDESARTAN\/HYDROCHLOROTHIAZID<\/td>\n TABLET<\/td>\n 32-12.5MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
23.831<\/td>\n 40.910<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Micardis<\/td>\n TELMISARTAN<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
23.832<\/td>\n 40.911<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Micardis<\/td>\n TELMISARTAN<\/td>\n TABLET<\/td>\n 80 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
23.833<\/td>\n 47.126<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Micardis<\/td>\n TELMISARTAN<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
27.783<\/td>\n 65.746<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Twynsta<\/td>\n TELMISARTAN\/AMLODIPINE<\/td>\n TABLET<\/td>\n 40 MG-5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
27.784<\/td>\n 65.747<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Twynsta<\/td>\n TELMISARTAN\/AMLODIPINE<\/td>\n TABLET<\/td>\n 40 MG-10MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
27.785<\/td>\n 65.748<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Twynsta<\/td>\n TELMISARTAN\/AMLODIPINE<\/td>\n TABLET<\/td>\n 80 MG-5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
27.786<\/td>\n 65.749<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Twynsta<\/td>\n TELMISARTAN\/AMLODIPINE<\/td>\n TABLET<\/td>\n 80 MG-10MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
12.257<\/td>\n 47.326<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Micardis HCT<\/td>\n TELMISARTAN\/HYDROCHLOROTHIAZID<\/td>\n TABLET<\/td>\n 40-12.5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
12.259<\/td>\n 47.324<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Micardis HCT<\/td>\n TELMISARTAN\/HYDROCHLOROTHIAZID<\/td>\n TABLET<\/td>\n 80-12.5MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
22.866<\/td>\n 57.690<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Micardis HCT<\/td>\n TELMISARTAN\/HYDROCHLOROTHIAZID<\/td>\n TABLET<\/td>\n 80 MG-25MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan<\/td>\n <\/tr>\n
24.635<\/td>\n 59.102<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Duragesic<\/td>\n FENTANYL<\/td>\n PATCH TD72<\/td>\n 12 MCG\/HR<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
19.200<\/td>\n 15.880<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Duragesic<\/td>\n FENTANYL<\/td>\n PATCH TD72<\/td>\n 25 MCG\/HR<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
19.201<\/td>\n 15.881<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Duragesic<\/td>\n FENTANYL<\/td>\n PATCH TD72<\/td>\n 50MCG\/HR<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
19.202<\/td>\n 15.882<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Duragesic<\/td>\n FENTANYL<\/td>\n PATCH TD72<\/td>\n 75MCG\/HR<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
19.203<\/td>\n 15.883<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Duragesic<\/td>\n FENTANYL<\/td>\n PATCH TD72<\/td>\n 100 MCG\/HR<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
16.281<\/td>\n 15.065<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Oxyocodone Solution<\/td>\n OXYCODONE HCL<\/td>\n Oral Solution<\/td>\n 20 MG\/ML<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
16.280<\/td>\n 4.224<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Oxycodone Solution<\/td>\n OXYCODONE HCL<\/td>\n Oral Solution<\/td>\n 5 MG\/5 ML<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
16.291<\/td>\n 13.467<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Oxyocodone<\/td>\n OXYCODONE HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
20.091<\/td>\n 46.474<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Oxyocodone<\/td>\n OXYCODONE HCL<\/td>\n TABLET<\/td>\n 15 MG<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
21.194<\/td>\n 45.298<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Oxyocodone<\/td>\n OXYCODONE HCL<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
20.092<\/td>\n 46.475<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Oxyocodone<\/td>\n OXYCODONE HCL<\/td>\n TABLET<\/td>\n 30 MG<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
64.672<\/td>\n 29.312<\/td>\n 280812-OPIATE PARTIAL AGONISTS<\/td>\n Buprenorphine<\/td>\n BUPRENORPHINE HCL<\/td>\n TAB SUBL<\/td>\n 2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
64.673<\/td>\n 29.313<\/td>\n 280812-OPIATE PARTIAL AGONISTS<\/td>\n Buprenorphine<\/td>\n BUPRENORPHINE HCL<\/td>\n TAB SUBL<\/td>\n 8 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.744<\/td>\n 70.262<\/td>\n 280812-OPIATE PARTIAL AGONISTS<\/td>\n Suboxone Film<\/td>\n BUPRENORPHINE HCL\/NALOXONE HCL<\/td>\n Subl Film<\/td>\n 12 MG-3 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.958<\/td>\n 66.635<\/td>\n 280812-OPIATE PARTIAL AGONISTS<\/td>\n Suboxone Film<\/td>\n BUPRENORPHINE HCL\/NALOXONE HCL<\/td>\n Subl Film<\/td>\n 2 MG-0.5MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.741<\/td>\n 70.259<\/td>\n 280812-OPIATE PARTIAL AGONISTS<\/td>\n Suboxone Film<\/td>\n BUPRENORPHINE HCL\/NALOXONE HCL<\/td>\n Subl Film<\/td>\n 4MG-1MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.959<\/td>\n 66.636<\/td>\n 280812-OPIATE PARTIAL AGONISTS<\/td>\n Suboxone Film<\/td>\n BUPRENORPHINE HCL\/NALOXONE HCL<\/td>\n Subl Film<\/td>\n 8 MG-2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.973<\/td>\n 51.640<\/td>\n 280812-OPIATE PARTIAL AGONISTS<\/td>\n Suboxone Tablet<\/td>\n BUPRENORPHINE HCL\/NALOXONE HCL<\/td>\n TAB SUBL<\/td>\n 2 MG-0.5MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.974<\/td>\n 51.641<\/td>\n 280812-OPIATE PARTIAL AGONISTS<\/td>\n Suboxone Tablet<\/td>\n BUPRENORPHINE HCL\/NALOXONE HCL<\/td>\n TAB SUBL<\/td>\n 8 MG-2 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.626<\/td>\n 66.372<\/td>\n 280892-ANALGESICS AND ANTIPYRETICS, MISC.<\/td>\n Fioricet<\/td>\n BUTALBITAL-ACETAMINOPHEN-CAFFEINE<\/td>\n CAPSULE<\/td>\n 50-300-40 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Capacet, Esgic<\/td>\n <\/tr>\n
27.095<\/td>\n 60.935<\/td>\n 281000-OPIATE ANTAGONISTS<\/td>\n Vivitrol<\/td>\n NALTREXONE MICROSPHERES<\/td>\n SUS ER REC<\/td>\n 380MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Naltrexone tablet<\/td>\n <\/tr>\n
16.356<\/td>\n 46.216<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Sarafem<\/td>\n FLUOXETINE HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: capsules<\/td>\n <\/tr>\n
16.359<\/td>\n 46.219<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Sarafem<\/td>\n FLUOXETINE HCL<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: capsules<\/td>\n <\/tr>\n
14.349<\/td>\n 64.444<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Venlafaxine ER<\/td>\n VENLAFAXINE HCL<\/td>\n TAB ER 24<\/td>\n 37.5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: capsules<\/td>\n <\/tr>\n
14.352<\/td>\n 64.445<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Venlafaxine ER<\/td>\n VENLAFAXINE HCL<\/td>\n TAB ER 24<\/td>\n 75 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: capsules<\/td>\n <\/tr>\n
14.353<\/td>\n 64.446<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Venlafaxine ER<\/td>\n VENLAFAXINE HCL<\/td>\n TAB ER 24<\/td>\n 150 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: capsules<\/td>\n <\/tr>\n
14.354<\/td>\n 64.447<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Venlafaxine ER<\/td>\n VENLAFAXINE HCL<\/td>\n TAB ER 24<\/td>\n 225 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: capsules<\/td>\n <\/tr>\n
25.598<\/td>\n 59.781<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Diastat<\/td>\n DIAZEPAM<\/td>\n KIT<\/td>\n 5-7.5-10MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.599<\/td>\n 59.782<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Diastat<\/td>\n DIAZEPAM<\/td>\n KIT<\/td>\n 12.5-15-20<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.131<\/td>\n 34.015<\/td>\n 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV\/HYP)<\/td>\n Diastat<\/td>\n DIAZEPAM<\/td>\n KIT<\/td>\n 2.5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.593<\/td>\n 40.223<\/td>\n 283228-SELECTIVE SEROTONIN AGONISTS<\/td>\n Maxalt MLT<\/td>\n RIZATRIPTAN BENZOATE<\/td>\n TAB RAPDIS<\/td>\n 5 MG<\/td>\n NOT COVERED<\/td>\n Non-Formulary<\/td>\n Formulary: Imitrex (Sumatriptan)<\/td>\n <\/tr>\n
19.591<\/td>\n 40.221<\/td>\n 283228-SELECTIVE SEROTONIN AGONISTS<\/td>\n Maxalt<\/td>\n RIZATRIPTAN BENZOATE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n NOT COVERED<\/td>\n Non-Formulary<\/td>\n Formulary: Imitrex (Sumatriptan)<\/td>\n <\/tr>\n
13.971<\/td>\n 48.489<\/td>\n 480800-ANTITUSSIVES<\/td>\n Promethazine\/Codeine<\/td>\n PROMETHAZINE HCL-CODEINE<\/td>\n SYRUP<\/td>\n 6.25-10 MG\/5ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
54.980<\/td>\n 12.073<\/td>\n 481600-EXPECTORANTS<\/td>\n Mucinex D<\/td>\n GUAIFENESIN-PSEUDOEPHEDRINE HCL<\/td>\n TAB ER 12H<\/td>\n 600-60 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Available OTC<\/td>\n <\/tr>\n
26.056<\/td>\n 60.055<\/td>\n 520808-CORTICOSTEROIDS (EENT)<\/td>\n Dermotic<\/td>\n FLUOCINOLONE ACETONIDE OIL<\/td>\n DROPS<\/td>\n 0.01%<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
1.697<\/td>\n 30.106<\/td>\n 562836-PROTON-PUMP INHIBITORS<\/td>\n Prevacid<\/td>\n LANSOPRAZOLE<\/td>\n CAPSULE DR<\/td>\n 15 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Pantoprazole<\/td>\n <\/tr>\n
1.698<\/td>\n 30.107<\/td>\n 562836-PROTON-PUMP INHIBITORS<\/td>\n Prevacid<\/td>\n LANSOPRAZOLE<\/td>\n CAPSULE DR<\/td>\n 30 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Pantoprazole<\/td>\n <\/tr>\n
4.348<\/td>\n 33.530<\/td>\n 562836-PROTON-PUMP INHIBITORS<\/td>\n Prilosec<\/td>\n OMEPRAZOLE<\/td>\n CAPSULE DR<\/td>\n 20 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Pantoprazole<\/td>\n <\/tr>\n
92.989<\/td>\n 43.136<\/td>\n 562836-PROTON-PUMP INHIBITORS<\/td>\n Prilosec<\/td>\n OMEPRAZOLE<\/td>\n CAPSULE DR<\/td>\n 10 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Pantoprazole<\/td>\n <\/tr>\n
92.999<\/td>\n 43.137<\/td>\n 562836-PROTON-PUMP INHIBITORS<\/td>\n Prilosec<\/td>\n OMEPRAZOLE<\/td>\n CAPSULE DR<\/td>\n 40 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Pantoprazole<\/td>\n <\/tr>\n
94.639<\/td>\n 40.941<\/td>\n 562836-PROTON-PUMP INHIBITORS<\/td>\n Aciphex<\/td>\n RABEPRAZOLE SODIUM<\/td>\n TABLET DR<\/td>\n 20 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Pantoprazole<\/td>\n <\/tr>\n
30.220<\/td>\n 19.863<\/td>\n 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)<\/td>\n Pentasa CR<\/td>\n MESALAMINE<\/td>\n CAPSULE ER<\/td>\n 250 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Sulfasalazine. Contact manufacturer for PAP<\/td>\n <\/tr>\n
21.663<\/td>\n 53.882<\/td>\n 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)<\/td>\n Asacol HD<\/td>\n MESALAMINE<\/td>\n TABLET DR<\/td>\n 800 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Sulfasalazine. Contact manufacturer for PAP<\/td>\n <\/tr>\n
37.726<\/td>\n 73.336<\/td>\n 569200-GI DRUGS, MISCELLANEOUS<\/td>\n Movantik<\/td>\n NALOXEGOL OXALATE<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
37.725<\/td>\n 73.335<\/td>\n 569200-GI DRUGS, MISCELLANEOUS<\/td>\n Movantik<\/td>\n NALOXEGOL OXALATE<\/td>\n TABLET<\/td>\n 12.5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
28.841<\/td>\n 3.203<\/td>\n 681604-ESTROGENS<\/td>\n Vivelle-DOT, Minivelle<\/td>\n ESTRADIOL<\/td>\n TRANSDERMAL PATCH TWICE-WEEKLY<\/td>\n 0.1MG\/24HR<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.840<\/td>\n 3.202<\/td>\n 681604-ESTROGENS<\/td>\n Vivelle-DOT, Minivelle<\/td>\n ESTRADIOL<\/td>\n TRANSDERMAL PATCH TWICE-WEEKLY<\/td>\n 0.05MG\/24H<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.842<\/td>\n 16.767<\/td>\n 681604-ESTROGENS<\/td>\n Vivelle-DOT, Minivelle<\/td>\n ESTRADIOL<\/td>\n TRANSDERMAL PATCH TWICE-WEEKLY<\/td>\n 0.025MG\/24H<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.843<\/td>\n 23.270<\/td>\n 681604-ESTROGENS<\/td>\n Vivelle-DOT, Minivelle<\/td>\n ESTRADIOL<\/td>\n TRANSDERMAL PATCH TWICE-WEEKLY<\/td>\n 0.075MG\/24H<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.846<\/td>\n 24.555<\/td>\n 681604-ESTROGENS<\/td>\n Vivelle-DOT, Minivelle<\/td>\n ESTRADIOL<\/td>\n TRANSDERMAL PATCH TWICE-WEEKLY<\/td>\n 0.0375MG\/24<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.844<\/td>\n 23.471<\/td>\n 681604-ESTROGENS<\/td>\n Climara<\/td>\n ESTRADIOL<\/td>\n TRANSDERMAL PATCH ONCE-WEEKLY<\/td>\n 0.1MG\/24HR<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.845<\/td>\n 23.472<\/td>\n 681604-ESTROGENS<\/td>\n Climara<\/td>\n ESTRADIOL<\/td>\n TRANSDERMAL PATCH ONCE-WEEKLY<\/td>\n 0.05MG\/24H<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.848<\/td>\n 32.174<\/td>\n 681604-ESTROGENS<\/td>\n Climara<\/td>\n ESTRADIOL<\/td>\n TRANSDERMAL PATCH ONCE-WEEKLY<\/td>\n 0.025MG\/24H<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.853<\/td>\n 40.366<\/td>\n 681604-ESTROGENS<\/td>\n Climara<\/td>\n ESTRADIOL<\/td>\n TRANSDERMAL PATCH ONCE-WEEKLY<\/td>\n 0.075MG\/24H<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.068<\/td>\n 52.830<\/td>\n 681604-ESTROGENS<\/td>\n Climara<\/td>\n ESTRADIOL<\/td>\n TRANSDERMAL PATCH ONCE-WEEKLY<\/td>\n 0.06MG\/24H<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.069<\/td>\n 52.831<\/td>\n 681604-ESTROGENS<\/td>\n Climara<\/td>\n ESTRADIOL<\/td>\n TRANSDERMAL PATCH ONCE-WEEKLY<\/td>\n 0.0375MG\/24<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.107<\/td>\n 65.966<\/td>\n 681604-ESTROGENS<\/td>\n Vagifem<\/td>\n ESTRADIOL<\/td>\n TABLET<\/td>\n 10 MCG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
67.170<\/td>\n 7.011<\/td>\n 681604-ESTROGENS<\/td>\n Estrace Vaginal Cream<\/td>\n ESTRADIOL<\/td>\n CREAM\/APPL<\/td>\n 0.01%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.336<\/td>\n 70.705<\/td>\n 681612-ESTROGEN AGONIST-ANTAGONISTS<\/td>\n Osphena<\/td>\n OSPEMIFENE<\/td>\n TABLET<\/td>\n 60 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.318<\/td>\n 20.241<\/td>\n 682002-ALPHA-GLUCOSIDASE INHIBITORS<\/td>\n Precose<\/td>\n ACARBOSE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
2.319<\/td>\n 20.242<\/td>\n 682002-ALPHA-GLUCOSIDASE INHIBITORS<\/td>\n Precose<\/td>\n ACARBOSE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
8.070<\/td>\n 36.767<\/td>\n 682002-ALPHA-GLUCOSIDASE INHIBITORS<\/td>\n Precose<\/td>\n ACARBOSE<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
95.252<\/td>\n 40.357<\/td>\n 682002-ALPHA-GLUCOSIDASE INHIBITORS<\/td>\n Glyset<\/td>\n MIGLITOL<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
95.253<\/td>\n 40.358<\/td>\n 682002-ALPHA-GLUCOSIDASE INHIBITORS<\/td>\n Glyset<\/td>\n MIGLITOL<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
95.254<\/td>\n 40.359<\/td>\n 682002-ALPHA-GLUCOSIDASE INHIBITORS<\/td>\n Glyset<\/td>\n MIGLITOL<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.836<\/td>\n 71.842<\/td>\n 682008-INSULINS<\/td>\n Tresiba FlexTouch<\/td>\n INSULIN DEGLUDEC<\/td>\n INSULN PEN<\/td>\n 100\/ML (3)<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: insulin glargine-yfgn<\/td>\n <\/tr>\n
35.837<\/td>\n 71.843<\/td>\n 682008-INSULINS<\/td>\n Tresiba FlexTouch<\/td>\n INSULIN DEGLUDEC<\/td>\n INSULN PEN<\/td>\n 200\/ML (3)<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: insulin glargine-yfgn<\/td>\n <\/tr>\n
11.660<\/td>\n 1.740<\/td>\n 682008-INSULINS<\/td>\n Humulin N<\/td>\n INSULIN NPH HUMAN ISOPHANE<\/td>\n VIAL<\/td>\n 100 UNIT\/ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Novolin N<\/td>\n <\/tr>\n
50.001<\/td>\n 16.311<\/td>\n 682008-INSULINS<\/td>\n Humulin 70\/30<\/td>\n INSULIN NPH HUM-REG INSULIN HM<\/td>\n VIAL<\/td>\n 70-30 UNIT\/ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Novolin 70\/30<\/td>\n <\/tr>\n
11.642<\/td>\n 1.723<\/td>\n 682008-INSULINS<\/td>\n Humulin R<\/td>\n INSULIN REGULAR HUMAN<\/td>\n VIAL<\/td>\n 100 UNIT\/ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Novolin R<\/td>\n <\/tr>\n
50.776<\/td>\n 43.801<\/td>\n 683200-PROGESTINS<\/td>\n Prometrium<\/td>\n PROGESTERONE, MICRONIZED<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
50.786<\/td>\n 43.802<\/td>\n 683200-PROGESTINS<\/td>\n Prometrium<\/td>\n PROGESTERONE, MICRONIZED<\/td>\n CAPSULE<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.238<\/td>\n 62.462<\/td>\n 81228-ANTIBACTERIALS, MISCELLANEOUS<\/td>\n Pylera<\/td>\n BISMUTH\/METRONID\/TETRACYCLINE<\/td>\n CAPSULE<\/td>\n 140-125-125 MG<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n 14 - day supply covered. Must be dispensed from CUC in-house pharmacies only.<\/td>\n <\/tr>\n
26.339<\/td>\n 60.244<\/td>\n 83600-URINARY ANTI-INFECTIVES<\/td>\n Hyophen<\/td>\n METHENAM\/M.BLUE\/SALICYL\/HYOSCY<\/td>\n TABLET<\/td>\n 81.6-0.12<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.812<\/td>\n 7.731<\/td>\n 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)<\/td>\n Bacitracin<\/td>\n BACITRACIN<\/td>\n OINT. (G)<\/td>\n 500 UNIT\/G<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
60.050<\/td>\n 23.447<\/td>\n 840800-ANTIPRURITICS AND LOCAL ANESTHETICS<\/td>\n Lidocaine Patch<\/td>\n LIDOCAINE<\/td>\n ADH. PATCH<\/td>\n 4%<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
50.272<\/td>\n 43.256<\/td>\n 840800-ANTIPRURITICS AND LOCAL ANESTHETICS<\/td>\n Lidoderm<\/td>\n LIDOCAINE<\/td>\n ADH. PATCH<\/td>\n 5%<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
95.404<\/td>\n 40.261<\/td>\n 840800-ANTIPRURITICS AND LOCAL ANESTHETICS<\/td>\n Lindocaine Anorectal Cream<\/td>\n LIDOCAINE<\/td>\n CREAM (G)<\/td>\n 5%<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
95.405<\/td>\n 40.262<\/td>\n 840800-ANTIPRURITICS AND LOCAL ANESTHETICS<\/td>\n Liocaine Cream<\/td>\n LIDOCAINE<\/td>\n CREAM (G)<\/td>\n 4%<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Available OTC<\/td>\n <\/tr>\n
30.750<\/td>\n 14.476<\/td>\n 840800-ANTIPRURITICS AND LOCAL ANESTHETICS<\/td>\n Lidocaine Ointment<\/td>\n LIDOCAINE<\/td>\n OINT. (G)<\/td>\n 5%<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Lidocaine 4% Cream is OTC<\/td>\n <\/tr>\n
24.882<\/td>\n 6.312<\/td>\n 845004-DEPIGMENTING AGENTS<\/td>\n ESOTERICA FADE CREAM<\/td>\n HYDROQUINONE<\/td>\n CREAM (G)<\/td>\n 2%<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n No coverage for hydroquinone<\/td>\n <\/tr>\n
24.883<\/td>\n 6.313<\/td>\n 845004-DEPIGMENTING AGENTS<\/td>\n MELQUIN HP 4% CREAM<\/td>\n HYDROQUINONE<\/td>\n CREAM (G)<\/td>\n 4%<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n No coverage for hydroquinone<\/td>\n <\/tr>\n
47.830<\/td>\n 6.314<\/td>\n 845004-DEPIGMENTING AGENTS<\/td>\n HYDROQUINONE 4% CREAM<\/td>\n HYDROQUINONE<\/td>\n POWDER<\/td>\n <\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n No coverage for hydroquinone<\/td>\n <\/tr>\n
24.890<\/td>\n 6.315<\/td>\n 845004-DEPIGMENTING AGENTS<\/td>\n HYDROQUINONE POWDER<\/td>\n HYDROQUINONE<\/td>\n SOLUTION<\/td>\n 30 MG\/ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n No coverage for hydroquinone<\/td>\n <\/tr>\n
20.120<\/td>\n 52.863<\/td>\n 845004-DEPIGMENTING AGENTS<\/td>\n NUQUIN HP 4% CREAM<\/td>\n HYDROQUINONE MICROSPHERES<\/td>\n CRM ER (G)<\/td>\n 4%<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n No coverage for hydroquinone<\/td>\n <\/tr>\n
97.674<\/td>\n 61.889<\/td>\n 845004-DEPIGMENTING AGENTS<\/td>\n ESOTERICA FADE CREAM<\/td>\n HYDROQUINONE\/AVOBENZ\/OCTINOX<\/td>\n EMUL ADHES<\/td>\n 4%<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n No coverage for hydroquinone<\/td>\n <\/tr>\n
21.864<\/td>\n 54.046<\/td>\n 845004-DEPIGMENTING AGENTS<\/td>\n ALPHAQUIN HP 4% CREAM<\/td>\n HYDROQUINONE\/AVOBENZ\/OCTINOX<\/td>\n EMULSN(G)<\/td>\n 4%<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n No coverage for hydroquinone<\/td>\n <\/tr>\n
20.915<\/td>\n 53.438<\/td>\n 845004-DEPIGMENTING AGENTS<\/td>\n HYDROQUINONE TR 4% CREAM<\/td>\n HYDROQUINONE\/OXYBEN\/OCTINOXATE<\/td>\n CREAM (G)<\/td>\n 4%(5-7.5%)<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n No coverage for hydroquinone<\/td>\n <\/tr>\n
97.229<\/td>\n 61.438<\/td>\n 845004-DEPIGMENTING AGENTS<\/td>\n ACLARO 4% EMULSION<\/td>\n HYDROQUINONE\/OXYBENZONE\/PADIMA<\/td>\n CREAM (G)<\/td>\n 2%-SPF10<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n No coverage for hydroquinone<\/td>\n <\/tr>\n
66.899<\/td>\n 31.427<\/td>\n 845004-DEPIGMENTING AGENTS<\/td>\n MELQUIN-3 SOLUTION<\/td>\n HYDROQUINONE\/SUNSCREEN(FER OX)<\/td>\n CREAM (G)<\/td>\n 4%<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n No coverage for hydroquinone<\/td>\n <\/tr>\n
96.071<\/td>\n 39.542<\/td>\n 848000-SUNSCREEN AGENTS<\/td>\n MELPAQUE HP 4% CREAM<\/td>\n DIOXYBENZONE\/PDO\/HYDROQUINONE<\/td>\n CREAM (G)<\/td>\n 3%-5%-4%<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n No coverage for hydroquinone<\/td>\n <\/tr>\n
20.383<\/td>\n 53.055<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Claravis<\/td>\n ISOTRETINOIN<\/td>\n TABLET<\/td>\n 30 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Prior auths restricted to Dermatology prescriber. Claravis prefererred<\/td>\n <\/tr>\n
59.841<\/td>\n 36.045<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Claravis<\/td>\n ISOTRETINOIN<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Prior auths restricted to Dermatology prescriber. Claravis prefererred<\/td>\n <\/tr>\n
59.842<\/td>\n 36.046<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Claravis<\/td>\n ISOTRETINOIN<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Prior auths restricted to Dermatology prescriber. Claravis prefererred<\/td>\n <\/tr>\n
59.843<\/td>\n 36.047<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Claravis<\/td>\n ISOTRETINOIN<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Prior auths restricted to Dermatology prescriber. Claravis prefererred<\/td>\n <\/tr>\n
24.043<\/td>\n 58.576<\/td>\n 861204-ANTIMUSCARINICS<\/td>\n Enablex<\/td>\n DARIFENACIN HYDROBROMIDE<\/td>\n TAB ER 24H<\/td>\n 7.5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Oxybutynin ER<\/td>\n <\/tr>\n
24.044<\/td>\n 58.577<\/td>\n 861204-ANTIMUSCARINICS<\/td>\n Enablex<\/td>\n DARIFENACIN HYDROBROMIDE<\/td>\n TAB ER 24H<\/td>\n 15 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Oxybutynin ER<\/td>\n <\/tr>\n
99.193<\/td>\n 63.466<\/td>\n 861204-ANTIMUSCARINICS<\/td>\n Sanctura XR<\/td>\n TROSPIUM CHLORIDE<\/td>\n CAP ER 24H<\/td>\n 60 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Oxybutynin ER<\/td>\n <\/tr>\n
8.744<\/td>\n 38.085<\/td>\n 861204-ANTIMUSCARINICS<\/td>\n Sanctura<\/td>\n TROSPIUM CHLORIDE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Oxybutynin ER<\/td>\n <\/tr>\n
18.428<\/td>\n 51.246<\/td>\n 920800-5-ALPHA-REDUCTASE INHIBITORS<\/td>\n Avodart<\/td>\n DUTASTERIDE<\/td>\n CAPSULE<\/td>\n 0.5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Finasteride<\/td>\n <\/tr>\n
28.596<\/td>\n 66.352<\/td>\n 920800-5-ALPHA-REDUCTASE INHIBITORS<\/td>\n Jalyn<\/td>\n DUTASTERIDE\/TAMSULOSIN HCL<\/td>\n CPMP 24HR<\/td>\n 0.5-0.4 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Finasteride<\/td>\n <\/tr>\n
24.444<\/td>\n 58.915<\/td>\n 922400-BONE RESORPTION INHIBITORS<\/td>\n Boniva<\/td>\n IBANDRONATE SODIUM<\/td>\n TABLET<\/td>\n 150 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Alendronate<\/td>\n <\/tr>\n
17.378<\/td>\n 50.364<\/td>\n 922400-BONE RESORPTION INHIBITORS<\/td>\n Actonel<\/td>\n RISEDRONATE SODIUM<\/td>\n TABLET<\/td>\n 35 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Alendronate<\/td>\n <\/tr>\n
92.238<\/td>\n 45.102<\/td>\n 922400-BONE RESORPTION INHIBITORS<\/td>\n Actonel<\/td>\n RISEDRONATE SODIUM<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Alendronate<\/td>\n <\/tr>\n
94.200<\/td>\n 74.210<\/td>\n 940000-DEVICES<\/td>\n Contour Next<\/td>\n BLOOD-GLUCOSE METER<\/td>\n EACH<\/td>\n <\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Prior Auths restricted to insulin pumps<\/td>\n <\/tr>\n
94.200<\/td>\n 70.198<\/td>\n 940000-DEVICES<\/td>\n TruePlus Lancet 26G<\/td>\n LANCETS<\/td>\n EACH<\/td>\n 26 GAUGE<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.276<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 28GX1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.276<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 28GX1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.383<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 29 G X1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.395<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 30GX 5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 30G X 5\/16\"<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.400<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 30GX1\/2\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 1\/2\"<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.404<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 0.5mL 31 GX5\/16\"<\/td>\n SYRING W-NDL DISP INSUL 0.5 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.365<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 27GX5\/8\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 27 G X 5\/8\"<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.275<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 28GX1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.275<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 28GX1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.275<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 28GX1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 28 G X 1\/2\"<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.384<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 29 G X1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.384<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 29 G X1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 29 G X 1\/2\"<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.401<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 30GX1\/2\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 30 G X 1\/2\"<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 49.405<\/td>\n 940000-DEVICES<\/td>\n Insulin Syringe 1mL 31 GX5\/16\"<\/td>\n SYRINGE & NEEDLE INSULIN 1 ML<\/td>\n DISP SYRIN<\/td>\n 31 G X 5\/16\"<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
30.025<\/td>\n 67.462<\/td>\n 081202-AMINOGLYCOSIDES<\/td>\n Tobi Podhaler<\/td>\n TOBRAMYCIN<\/td>\n CAP W\/DEV<\/td>\n 28 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n <\/td>\n <\/tr>\n
61.551<\/td>\n 37.042<\/td>\n 081202-AMINOGLYCOSIDES<\/td>\n Tobi<\/td>\n TOBRAMYCIN IN 0.225% NACL<\/td>\n AMPUL-NEB<\/td>\n 300 MG\/5ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.530<\/td>\n 66.295<\/td>\n 081228-ANTIBACTERIALS, MISCELLANEOUS<\/td>\n Xifaxan<\/td>\n RIFAXIMIN<\/td>\n TABLET<\/td>\n 550 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n <\/td>\n <\/tr>\n
93.749<\/td>\n 41.880<\/td>\n 081228-ANTIBACTERIALS, MISCELLANEOUS<\/td>\n Xifaxan<\/td>\n RIFAXIMIN<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n <\/td>\n <\/tr>\n
49.101<\/td>\n 16.949<\/td>\n 081408-AZOLES<\/td>\n Sporanox capsule<\/td>\n ITRACONAZOLE<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
49.100<\/td>\n 27.465<\/td>\n 081408-AZOLES<\/td>\n Sporanox solution<\/td>\n ITRACONAZOLE<\/td>\n SOLUTION<\/td>\n 10 MG\/ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.497<\/td>\n 50.442<\/td>\n 081408-AZOLES<\/td>\n Vfend<\/td>\n VORICONAZOLE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.498<\/td>\n 50.443<\/td>\n 081408-AZOLES<\/td>\n Vfend<\/td>\n VORICONAZOLE<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.079<\/td>\n 71.322<\/td>\n 081808-ANTIRETROVIRALS<\/td>\n Tivicay<\/td>\n DOLUTEGRAVIR SODIUM<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
41.564<\/td>\n 76.226<\/td>\n 081808-ANTIRETROVIRALS<\/td>\n Tivicay<\/td>\n DOLUTEGRAVIR SODIUM<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
41.566<\/td>\n 76.227<\/td>\n 081808-ANTIRETROVIRALS<\/td>\n Tivicay<\/td>\n DOLUTEGRAVIR SODIUM<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
41.369<\/td>\n 76.097<\/td>\n 081808-ANTIRETROVIRALS<\/td>\n Truvada<\/td>\n EMTRICITABINE\/TENOFOVIR (TDF)<\/td>\n TABLET<\/td>\n 100-150 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.375<\/td>\n 76.101<\/td>\n 081808-ANTIRETROVIRALS<\/td>\n Truvada<\/td>\n EMTRICITABINE\/TENOFOVIR (TDF)<\/td>\n TABLET<\/td>\n 133-200 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.376<\/td>\n 76.102<\/td>\n 081808-ANTIRETROVIRALS<\/td>\n Truvada<\/td>\n EMTRICITABINE\/TENOFOVIR (TDF)<\/td>\n TABLET<\/td>\n 167-250 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.227<\/td>\n 68.449<\/td>\n 081808-ANTIRETROVIRALS<\/td>\n Viread<\/td>\n TENOFOVIR DISOPROXIL FUMARATE<\/td>\n POWDER<\/td>\n 40 MG\/SCOOP<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.822<\/td>\n 48.843<\/td>\n 081808-ANTIRETROVIRALS<\/td>\n Viread<\/td>\n TENOFOVIR DISOPROXIL FUMARATE<\/td>\n TABLET<\/td>\n 300 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.228<\/td>\n 68.450<\/td>\n 081808-ANTIRETROVIRALS<\/td>\n Viread<\/td>\n TENOFOVIR DISOPROXIL FUMARATE<\/td>\n TABLET<\/td>\n 150 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.229<\/td>\n 68.451<\/td>\n 081808-ANTIRETROVIRALS<\/td>\n Viread<\/td>\n TENOFOVIR DISOPROXIL FUMARATE<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.234<\/td>\n 68.453<\/td>\n 081808-ANTIRETROVIRALS<\/td>\n Viread<\/td>\n TENOFOVIR DISOPROXIL FUMARATE<\/td>\n TABLET<\/td>\n 250 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
24.465<\/td>\n 58.933<\/td>\n 081832-NUCLEOSIDES AND NUCLEOTIDES<\/td>\n Baraclude<\/td>\n ENTECAVIR<\/td>\n SOLUTION<\/td>\n 0.05 MG\/ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Prior Auths's Restricted to Hep B diagnosis<\/td>\n <\/tr>\n
24.466<\/td>\n 58.934<\/td>\n 081832-NUCLEOSIDES AND NUCLEOTIDES<\/td>\n Baraclude<\/td>\n ENTECAVIR<\/td>\n TABLET<\/td>\n 0.5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Prior Auths's Restricted to Hep B diagnosis<\/td>\n <\/tr>\n
24.467<\/td>\n 58.935<\/td>\n 081832-NUCLEOSIDES AND NUCLEOTIDES<\/td>\n Baraclude<\/td>\n ENTECAVIR<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Prior Auths's Restricted to Hep B diagnosis<\/td>\n <\/tr>\n
28.648<\/td>\n 66.391<\/td>\n 083600-URINARY ANTI-INFECTIVES<\/td>\n Uribel<\/td>\n MTH\/ME BLUE\/SOD PHOS\/PHEN\/HYOS<\/td>\n CAPSULE<\/td>\n 118-10-36 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
24.410<\/td>\n 24.515<\/td>\n 100000-ANTINEOPLASTIC AGENTS<\/td>\n Arimidex<\/td>\n ANASTROZOLE<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.084<\/td>\n 69.855<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Tudorza Pressair DPI<\/td>\n ACLIDINIUM BROMIDE<\/td>\n AER POW BA<\/td>\n 400 MCG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Spiriva Handihaler<\/td>\n <\/tr>\n
24.621<\/td>\n 59.081<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Atrovent HFA<\/td>\n IPRATROPIUM BROMIDE<\/td>\n HFA AER AD<\/td>\n 17 MCG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Spiriva Handihaler<\/td>\n <\/tr>\n
32.395<\/td>\n 69.371<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Combivent MDI<\/td>\n IPRATROPIUM\/ALBUTEROL SULFATE<\/td>\n MIST INHAL<\/td>\n 20-100 MCG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.921<\/td>\n 63.164<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Spiriva Respimat<\/td>\n TIOTROPIUM BROMIDE<\/td>\n MIST INHAL<\/td>\n 2.5 MCG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Spiriva Handihaler<\/td>\n <\/tr>\n
35.903<\/td>\n 71.883<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Anoro Ellipta<\/td>\n UMECLIDINIUM BRM\/VILANTEROL TR<\/td>\n BLST W\/DEV<\/td>\n 62.5-25 MCG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n CUC\/CH prescribers must send to in-house pharmacies only. Non-CUC\/CH may fill at network pharmacies<\/td>\n <\/tr>\n
36.574<\/td>\n 72.375<\/td>\n 120808-ANTIMUSCARINICS\/ANTISPASMODICS<\/td>\n Incruse Ellipta<\/td>\n UMECLIDINIUM BROMIDE<\/td>\n BLST W\/DEV<\/td>\n 62.5 MCG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Spiriva Handihaler<\/td>\n <\/tr>\n
97.366<\/td>\n 61.579<\/td>\n 121208-BETA-ADRENERGIC AGONISTS<\/td>\n Brovana<\/td>\n ARFORMOTEROL TARTRATE<\/td>\n VIAL-NEB<\/td>\n 15 MCG\/2ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Albuterol nebulized solution is formulary.<\/td>\n <\/tr>\n
92.024<\/td>\n 45.052<\/td>\n 121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)<\/td>\n Uroxatral<\/td>\n ALFUZOSIN HCL<\/td>\n TAB ER 24H<\/td>\n 10 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Tamsulosin, Terazosin, Prazosin.<\/td>\n <\/tr>\n
33.935<\/td>\n 70.414<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Eliquis<\/td>\n APIXABAN<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n CUC\/CH prescribers must send to in-house pharmacies only. Non-CUC\/CH may fill at network pharmacies<\/td>\n <\/tr>\n
30.239<\/td>\n 67.642<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Eliquis<\/td>\n APIXABAN<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n CUC\/CH prescribers must send to in-house pharmacies only. Non-CUC\/CH may fill at network pharmacies<\/td>\n <\/tr>\n
29.166<\/td>\n 66.781<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Pradaxa<\/td>\n DABIGATRAN ETEXILATE MESYLATE<\/td>\n CAPSULE<\/td>\n 150 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
99.708<\/td>\n 63.997<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Pradaxa<\/td>\n DABIGATRAN ETEXILATE MESYLATE<\/td>\n CAPSULE<\/td>\n 75 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
37.675<\/td>\n 73.293<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Savaysa<\/td>\n EDOXABAN<\/td>\n TABLET<\/td>\n 15 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
37.676<\/td>\n 73.294<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Savaysa<\/td>\n EDOXABAN<\/td>\n TABLET<\/td>\n 30 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
37.677<\/td>\n 73.295<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Savaysa<\/td>\n EDOXABAN<\/td>\n TABLET<\/td>\n 60 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.427<\/td>\n 64.493<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Xarelto<\/td>\n RIVAROXABAN<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n <\/td>\n <\/tr>\n
30.818<\/td>\n 68.118<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Xarelto<\/td>\n RIVAROXABAN<\/td>\n TABLET<\/td>\n 15 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n <\/td>\n <\/tr>\n
30.819<\/td>\n 68.119<\/td>\n 201204-ANTICOAGULANTS<\/td>\n Xarelto<\/td>\n RIVAROXABAN<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n <\/td>\n <\/tr>\n
17.157<\/td>\n 64.902<\/td>\n 201218-PLATELET-AGGREGATION INHIBITORS<\/td>\n Effient<\/td>\n PRASUGREL HCL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.056<\/td>\n 64.901<\/td>\n 201218-PLATELET-AGGREGATION INHIBITORS<\/td>\n Effient<\/td>\n PRASUGREL HCL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
29.385<\/td>\n 66.950<\/td>\n 201218-PLATELET-AGGREGATION INHIBITORS<\/td>\n Brilinta<\/td>\n TICAGRELOR<\/td>\n TABLET<\/td>\n 90 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.407<\/td>\n 74.696<\/td>\n 201218-PLATELET-AGGREGATION INHIBITORS<\/td>\n Brilinta<\/td>\n TICAGRELOR<\/td>\n TABLET<\/td>\n 60 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.885<\/td>\n 81.692<\/td>\n 201600-HEMATOPOIETIC AGENTS<\/td>\n Retacrit<\/td>\n Epoetin alfa-epbx<\/td>\n VIAL<\/td>\n 20,000\/2ML<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
44.764<\/td>\n 78.432<\/td>\n 201600-HEMATOPOIETIC AGENTS<\/td>\n Retacrit<\/td>\n Epoetin alfa-epbx<\/td>\n VIAL<\/td>\n 2,000\/ML<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
44.766<\/td>\n 78.434<\/td>\n 201600-HEMATOPOIETIC AGENTS<\/td>\n Retacrit<\/td>\n Epoetin alfa-epbx<\/td>\n VIAL<\/td>\n 4,000\/ML<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
44.767<\/td>\n 78.435<\/td>\n 201600-HEMATOPOIETIC AGENTS<\/td>\n Retacrit<\/td>\n Epoetin alfa-epbx<\/td>\n VIAL<\/td>\n 10,000\/ML<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
44.765<\/td>\n 78.433<\/td>\n 201600-HEMATOPOIETIC AGENTS<\/td>\n Retacrit<\/td>\n Epoetin alfa-epbx<\/td>\n VIAL<\/td>\n 3,000\/ML<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
48.911<\/td>\n 81.714<\/td>\n 201600-HEMATOPOIETIC AGENTS<\/td>\n Retacrit<\/td>\n Epoetin alfa-epbx<\/td>\n VIAL<\/td>\n 20,000\/ML<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
44.768<\/td>\n 78.436<\/td>\n 201600-HEMATOPOIETIC AGENTS<\/td>\n Retacrit<\/td>\n Epoetin alfa-epbx<\/td>\n VIAL<\/td>\n 40,000\/ML<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.586<\/td>\n 65.367<\/td>\n 240404-ANTIARRHYTHMIC AGENTS<\/td>\n Multaq<\/td>\n DRONEDARONE HCL<\/td>\n TABLET<\/td>\n 400 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Amiodarone. Contact manufacturer for PAP<\/td>\n <\/tr>\n
95.347<\/td>\n 40.303<\/td>\n 241292-VASODILATING AGENTS, MISCELLANEOUS<\/td>\n Aggrenox<\/td>\n ASPIRIN\/DIPYRIDAMOLE<\/td>\n CPMP 12HR<\/td>\n 25-200 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
97.962<\/td>\n 62.180<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Exforge<\/td>\n AMLODIPINE\/VALSARTAN<\/td>\n TABLET<\/td>\n 5-160 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Prescribe amlodipine and valsartan or Lotrel<\/td>\n <\/tr>\n
97.963<\/td>\n 62.181<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Exforge<\/td>\n AMLODIPINE\/VALSARTAN<\/td>\n TABLET<\/td>\n 10-160 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Prescribe amlodipine and valsartan or Lotrel<\/td>\n <\/tr>\n
98.579<\/td>\n 62.808<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Exforge<\/td>\n AMLODIPINE\/VALSARTAN<\/td>\n TABLET<\/td>\n 5-320 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Prescribe amlodipine and valsartan or Lotrel<\/td>\n <\/tr>\n
98.580<\/td>\n 62.809<\/td>\n 242808-DIHYDROPYRIDINES<\/td>\n Exforge<\/td>\n AMLODIPINE\/VALSARTAN<\/td>\n TABLET<\/td>\n 10-320 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Prescribe amlodipine and valsartan or Lotrel<\/td>\n <\/tr>\n
39.046<\/td>\n 74.408<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Entresto<\/td>\n SACUBITRIL\/VALSARTAN<\/td>\n TABLET<\/td>\n 24 MG-26MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.047<\/td>\n 74.409<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Entresto<\/td>\n SACUBITRIL\/VALSARTAN<\/td>\n TABLET<\/td>\n 49 MG-51MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
39.048<\/td>\n 74.410<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Entresto<\/td>\n SACUBITRIL\/VALSARTAN<\/td>\n TABLET<\/td>\n 97MG-103MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.285<\/td>\n 50.289<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Benicar<\/td>\n OLMESARTAN MEDOXOMIL<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.286<\/td>\n 50.290<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Benicar<\/td>\n OLMESARTAN MEDOXOMIL<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.284<\/td>\n 50.288<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Benicar<\/td>\n OLMESARTAN MEDOXOMIL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.837<\/td>\n 66.538<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Tribenzor<\/td>\n OLMESARTAN\/AMLODIPIN\/HCTHIAZID<\/td>\n TABLET<\/td>\n 20-5-12.5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan.<\/td>\n <\/tr>\n
28.838<\/td>\n 66.539<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Tribenzor<\/td>\n OLMESARTAN\/AMLODIPIN\/HCTHIAZID<\/td>\n TABLET<\/td>\n 40-5-12.5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan.<\/td>\n <\/tr>\n
28.839<\/td>\n 66.540<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Tribenzor<\/td>\n OLMESARTAN\/AMLODIPIN\/HCTHIAZID<\/td>\n TABLET<\/td>\n 40-5-25 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan.<\/td>\n <\/tr>\n
28.854<\/td>\n 66.541<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Tribenzor<\/td>\n OLMESARTAN\/AMLODIPIN\/HCTHIAZID<\/td>\n TABLET<\/td>\n 40-10-12.5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan.<\/td>\n <\/tr>\n
28.855<\/td>\n 66.542<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Tribenzor<\/td>\n OLMESARTAN\/AMLODIPIN\/HCTHIAZID<\/td>\n TABLET<\/td>\n 40-10-25 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Losartan, Irbesartan, Valsartan.<\/td>\n <\/tr>\n
20.074<\/td>\n 52.833<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Benicar HCT<\/td>\n OLMESARTAN\/HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 20-12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.075<\/td>\n 52.834<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Benicar HCT<\/td>\n OLMESARTAN\/HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 40-12.5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
20.076<\/td>\n 52.835<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Benicar HCT<\/td>\n OLMESARTAN\/HYDROCHLOROTHIAZIDE<\/td>\n TABLET<\/td>\n 40-25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
37.158<\/td>\n 72.862<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Oxycodone ER<\/td>\n OXYCODONE HCL<\/td>\n TAB ER 12H<\/td>\n 10 MG<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
37.159<\/td>\n 72.863<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Oxycodone ER<\/td>\n OXYCODONE HCL<\/td>\n TAB ER 12H<\/td>\n 15 MG<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
37.161<\/td>\n 72.864<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Oxycodone ER<\/td>\n OXYCODONE HCL<\/td>\n TAB ER 12H<\/td>\n 20 MG<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
37.162<\/td>\n 72.865<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Oxycodone ER<\/td>\n OXYCODONE HCL<\/td>\n TAB ER 12H<\/td>\n 30 MG<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
37.163<\/td>\n 72.866<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Oxycodone ER<\/td>\n OXYCODONE HCL<\/td>\n TAB ER 12H<\/td>\n 40 MG<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
37.164<\/td>\n 72.867<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Oxycodone ER<\/td>\n OXYCODONE HCL<\/td>\n TAB ER 12H<\/td>\n 60 MG<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
37.165<\/td>\n 72.868<\/td>\n 280808-OPIATE AGONISTS<\/td>\n Oxycodone ER<\/td>\n OXYCODONE HCL<\/td>\n TAB ER 12H<\/td>\n 80 MG<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For cancer-related pain only. Dx code G89.3 required on prescription<\/td>\n <\/tr>\n
9.070<\/td>\n 20.647<\/td>\n 281208-BENZODIAZEPINES (ANTICONVULSANTS)<\/td>\n Onfi<\/td>\n CLOBAZAM<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
9.071<\/td>\n 17.026<\/td>\n 281208-BENZODIAZEPINES (ANTICONVULSANTS)<\/td>\n Onfi<\/td>\n CLOBAZAM<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.643<\/td>\n 66.386<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Vimpat<\/td>\n LACOSAMIDE<\/td>\n ORAL SOLUTION<\/td>\n 10 MG\/ML<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.338<\/td>\n 64.432<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Vimpat<\/td>\n LACOSAMIDE<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.339<\/td>\n 64.433<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Vimpat<\/td>\n LACOSAMIDE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.341<\/td>\n 64.434<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Vimpat<\/td>\n LACOSAMIDE<\/td>\n TABLET<\/td>\n 150 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.342<\/td>\n 64.435<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Vimpat<\/td>\n LACOSAMIDE<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
24.693<\/td>\n 65.250<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lamictal XR<\/td>\n LAMOTRIGINE<\/td>\n TAB ER 24<\/td>\n 25 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Lamotrigine IR. Contact manufacturer for PAP<\/td>\n <\/tr>\n
24.739<\/td>\n 65.253<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lamictal XR<\/td>\n LAMOTRIGINE<\/td>\n TAB ER 24<\/td>\n 200 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Lamotrigine IR. Contact manufacturer for PAP<\/td>\n <\/tr>\n
24.697<\/td>\n 65.251<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lamictal XR<\/td>\n LAMOTRIGINE<\/td>\n TAB ER 24<\/td>\n 50 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Lamotrigine IR. Contact manufacturer for PAP<\/td>\n <\/tr>\n
24.703<\/td>\n 65.252<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lamictal XR<\/td>\n LAMOTRIGINE<\/td>\n TAB ER 24<\/td>\n 100 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Lamotrigine IR. Contact manufacturer for PAP<\/td>\n <\/tr>\n
29.725<\/td>\n 67.221<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lamictal XR<\/td>\n LAMOTRIGINE<\/td>\n TAB ER 24<\/td>\n 300 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Lamotrigine IR. Contact manufacturer for PAP<\/td>\n <\/tr>\n
30.787<\/td>\n 68.093<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Lamictal XR<\/td>\n LAMOTRIGINE<\/td>\n TAB ER 24<\/td>\n 250 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Lamotrigine IR. Contact manufacturer for PAP<\/td>\n <\/tr>\n
14.305<\/td>\n 64.416<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Keppra XR<\/td>\n LEVETIRACETAM<\/td>\n TAB ER 24H<\/td>\n 500 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Levetiracetam IR.<\/td>\n <\/tr>\n
20.765<\/td>\n 64.990<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Keppra XR<\/td>\n LEVETIRACETAM<\/td>\n TAB ER 24H<\/td>\n 750 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Levetiracetam IR.<\/td>\n <\/tr>\n
36.556<\/td>\n 40.901<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Topamax Sprinkle Cap<\/td>\n TOPIRAMATE<\/td>\n CAP SPRINK<\/td>\n 15 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
36.557<\/td>\n 40.902<\/td>\n 281292-ANTICONVULSANTS, MISCELLANEOUS<\/td>\n Topamax Sprinkle Cap<\/td>\n TOPIRAMATE<\/td>\n CAP SPRINK<\/td>\n 25 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.328<\/td>\n 71.496<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Fetzima<\/td>\n LEVOMILNACIPRAN HYDROCHLORIDE<\/td>\n CAP SA 24H<\/td>\n 40 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Venlafaxine ER capsules, Duloxetine DR.<\/td>\n <\/tr>\n
35.327<\/td>\n 71.495<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Fetzima<\/td>\n LEVOMILNACIPRAN HYDROCHLORIDE<\/td>\n CAP SA 24H<\/td>\n 20 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Venlafaxine ER capsules, Duloxetine DR.<\/td>\n <\/tr>\n
35.329<\/td>\n 71.497<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Fetzima<\/td>\n LEVOMILNACIPRAN HYDROCHLORIDE<\/td>\n CAP SA 24H<\/td>\n 80 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Venlafaxine ER capsules, Duloxetine DR.<\/td>\n <\/tr>\n
35.334<\/td>\n 71.498<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Fetzima<\/td>\n LEVOMILNACIPRAN HYDROCHLORIDE<\/td>\n CAP SA 24H<\/td>\n 120 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Venlafaxine ER capsules, Duloxetine DR.<\/td>\n <\/tr>\n
35.335<\/td>\n 71.499<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Fetzima<\/td>\n LEVOMILNACIPRAN HYDROCHLORIDE<\/td>\n CAP24HDSPK<\/td>\n 20-40 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Venlafaxine ER capsules, Duloxetine DR.<\/td>\n <\/tr>\n
38.253<\/td>\n 73.810<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Viibryd Titration Pack<\/td>\n VILAZODONE HYDROCHLORIDE<\/td>\n TAB DS PK<\/td>\n 10 MG-20 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
29.918<\/td>\n 67.378<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Viibryd<\/td>\n VILAZODONE HYDROCHLORIDE<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
29.916<\/td>\n 67.376<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Viibryd<\/td>\n VILAZODONE HYDROCHLORIDE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
29.917<\/td>\n 67.377<\/td>\n 281604-ANTIDEPRESSANTS<\/td>\n Viibryd<\/td>\n VILAZODONE HYDROCHLORIDE<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
28.034<\/td>\n 65.908<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Fanapt<\/td>\n ILOPERIDONE<\/td>\n TAB DS PK<\/td>\n 1-2-4-6 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.025<\/td>\n 65.901<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Fanapt<\/td>\n ILOPERIDONE<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.026<\/td>\n 65.902<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Fanapt<\/td>\n ILOPERIDONE<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.027<\/td>\n 65.903<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Fanapt<\/td>\n ILOPERIDONE<\/td>\n TABLET<\/td>\n 4 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.028<\/td>\n 65.904<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Fanapt<\/td>\n ILOPERIDONE<\/td>\n TABLET<\/td>\n 6 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.029<\/td>\n 65.905<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Fanapt<\/td>\n ILOPERIDONE<\/td>\n TABLET<\/td>\n 8 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.030<\/td>\n 65.906<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Fanapt<\/td>\n ILOPERIDONE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.033<\/td>\n 65.907<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Fanapt<\/td>\n ILOPERIDONE<\/td>\n TABLET<\/td>\n 12 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
29.366<\/td>\n 66.932<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Latuda<\/td>\n LURASIDONE HCL<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
29.367<\/td>\n 66.933<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Latuda<\/td>\n LURASIDONE HCL<\/td>\n TABLET<\/td>\n 80 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.226<\/td>\n 68.448<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Latuda<\/td>\n LURASIDONE HCL<\/td>\n TABLET<\/td>\n 20 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
33.147<\/td>\n 69.894<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Latuda<\/td>\n LURASIDONE HCL<\/td>\n TABLET<\/td>\n 120 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.192<\/td>\n 71.415<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Latuda<\/td>\n LURASIDONE HCL<\/td>\n TABLET<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.022<\/td>\n 47.285<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Zyprexa Zydis<\/td>\n OLANZAPINE<\/td>\n TAB RAPDIS<\/td>\n 15 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.023<\/td>\n 47.286<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Zyprexa Zydis<\/td>\n OLANZAPINE<\/td>\n TAB RAPDIS<\/td>\n 20 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
92.007<\/td>\n 45.190<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Zyprexa Zydis<\/td>\n OLANZAPINE<\/td>\n TAB RAPDIS<\/td>\n 5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
92.008<\/td>\n 45.191<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Zyprexa Zydis<\/td>\n OLANZAPINE<\/td>\n TAB RAPDIS<\/td>\n 10 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
97.769<\/td>\n 61.985<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Invega<\/td>\n PALIPERIDONE<\/td>\n TAB ER 24<\/td>\n 3 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
97.770<\/td>\n 61.986<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Invega<\/td>\n PALIPERIDONE<\/td>\n TAB ER 24<\/td>\n 6 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
97.771<\/td>\n 61.987<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Invega<\/td>\n PALIPERIDONE<\/td>\n TAB ER 24<\/td>\n 9 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.685<\/td>\n 65.667<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Invega<\/td>\n PALIPERIDONE<\/td>\n TAB ER 24<\/td>\n 1.5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.994<\/td>\n 63.240<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Seroquel XR<\/td>\n QUETIAPINE FUMARATE<\/td>\n TAB ER 24H<\/td>\n 50 MG<\/td>\n Covered<\/td>\n CommUnityCare Pharmacy<\/td>\n Restricted to CUC\/CH Prescribers. Send to a CUC in-house pharmacy<\/td>\n <\/tr>\n
16.193<\/td>\n 64.725<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Seroquel XR<\/td>\n QUETIAPINE FUMARATE<\/td>\n TAB ER 24H<\/td>\n 150 MG<\/td>\n Covered<\/td>\n CommUnityCare Pharmacy<\/td>\n Restricted to CUC\/CH Prescribers. Send to a CUC in-house pharmacy<\/td>\n <\/tr>\n
98.522<\/td>\n 62.748<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Seroquel XR<\/td>\n QUETIAPINE FUMARATE<\/td>\n TAB ER 24H<\/td>\n 200 MG<\/td>\n Covered<\/td>\n CommUnityCare Pharmacy<\/td>\n Restricted to CUC\/CH Prescribers. Send to a CUC in-house pharmacy<\/td>\n <\/tr>\n
98.523<\/td>\n 62.749<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Seroquel XR<\/td>\n QUETIAPINE FUMARATE<\/td>\n TAB ER 24H<\/td>\n 300 MG<\/td>\n Covered<\/td>\n CommUnityCare Pharmacy<\/td>\n Restricted to CUC\/CH Prescribers. Send to a CUC in-house pharmacy<\/td>\n <\/tr>\n
98.524<\/td>\n 62.750<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Seroquel XR<\/td>\n QUETIAPINE FUMARATE<\/td>\n TAB ER 24H<\/td>\n 400 MG<\/td>\n Covered<\/td>\n CommUnityCare Pharmacy<\/td>\n Restricted to CUC\/CH Prescribers. Send to a CUC in-house pharmacy<\/td>\n <\/tr>\n
12.248<\/td>\n 47.318<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Concerta<\/td>\n METHYLPHENIDATE HCL<\/td>\n TAB ER 24<\/td>\n 54 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Ritalin LA, Metadate CD.<\/td>\n <\/tr>\n
12.568<\/td>\n 45.982<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Concerta<\/td>\n METHYLPHENIDATE HCL<\/td>\n TAB ER 24<\/td>\n 36 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Ritalin LA, Metadate CD.<\/td>\n <\/tr>\n
17.123<\/td>\n 50.172<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Concerta<\/td>\n METHYLPHENIDATE HCL<\/td>\n TAB ER 24<\/td>\n 27 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Ritalin LA, Metadate CD.<\/td>\n <\/tr>\n
12.567<\/td>\n 45.981<\/td>\n 282032-RESPIRATORY AND CNS STIMULANTS<\/td>\n Concerta<\/td>\n METHYLPHENIDATE HCL<\/td>\n TAB ER 24<\/td>\n 18 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Ritalin LA, Metadate CD.<\/td>\n <\/tr>\n
26.515<\/td>\n 65.356<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Neupro<\/td>\n ROTIGOTINE<\/td>\n PATCH TD24<\/td>\n 1 MG\/24 HR<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Ropinirole. Contact manufacturer for PAP<\/td>\n <\/tr>\n
26.516<\/td>\n 65.357<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Neupro<\/td>\n ROTIGOTINE<\/td>\n PATCH TD24<\/td>\n 3 MG\/24 HR<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP<\/td>\n <\/tr>\n
26.648<\/td>\n 60.486<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Neupro<\/td>\n ROTIGOTINE<\/td>\n PATCH TD24<\/td>\n 2 MG\/24 HR<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP<\/td>\n <\/tr>\n
26.649<\/td>\n 60.487<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Neupro<\/td>\n ROTIGOTINE<\/td>\n PATCH TD24<\/td>\n 4 MG\/24 HR<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP<\/td>\n <\/tr>\n
26.654<\/td>\n 60.488<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Neupro<\/td>\n ROTIGOTINE<\/td>\n PATCH TD24<\/td>\n 6 MG\/24 HR<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP<\/td>\n <\/tr>\n
26.655<\/td>\n 60.489<\/td>\n 283620-DOPAMINE RECEPTOR AGONISTS<\/td>\n Neupro<\/td>\n ROTIGOTINE<\/td>\n PATCH TD24<\/td>\n 8 MG\/24 HR<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP<\/td>\n <\/tr>\n
27.576<\/td>\n 65.570<\/td>\n 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.<\/td>\n Intuniv<\/td>\n GUANFACINE HCL<\/td>\n TAB ER 24H<\/td>\n 1 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Guanfacine IR. Contact manufacturer for PAP<\/td>\n <\/tr>\n
27.578<\/td>\n 65.572<\/td>\n 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.<\/td>\n Intuniv<\/td>\n GUANFACINE HCL<\/td>\n TAB ER 24H<\/td>\n 2 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Guanfacine IR. Contact manufacturer for PAP<\/td>\n <\/tr>\n
27.579<\/td>\n 65.573<\/td>\n 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.<\/td>\n Intuniv<\/td>\n GUANFACINE HCL<\/td>\n TAB ER 24H<\/td>\n 3 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Guanfacine IR. Contact manufacturer for PAP<\/td>\n <\/tr>\n
27.582<\/td>\n 65.574<\/td>\n 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.<\/td>\n Intuniv<\/td>\n GUANFACINE HCL<\/td>\n TAB ER 24H<\/td>\n 4 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Guanfacine IR. Contact manufacturer for PAP<\/td>\n <\/tr>\n
18.776<\/td>\n 51.489<\/td>\n 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.<\/td>\n Strattera<\/td>\n ATOMOXETINE HCL<\/td>\n CAPSULE<\/td>\n 10 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.777<\/td>\n 51.490<\/td>\n 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.<\/td>\n Strattera<\/td>\n ATOMOXETINE HCL<\/td>\n CAPSULE<\/td>\n 18 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.778<\/td>\n 51.491<\/td>\n 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.<\/td>\n Strattera<\/td>\n ATOMOXETINE HCL<\/td>\n CAPSULE<\/td>\n 25 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.779<\/td>\n 51.492<\/td>\n 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.<\/td>\n Strattera<\/td>\n ATOMOXETINE HCL<\/td>\n CAPSULE<\/td>\n 40 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.781<\/td>\n 51.493<\/td>\n 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.<\/td>\n Strattera<\/td>\n ATOMOXETINE HCL<\/td>\n CAPSULE<\/td>\n 60 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.538<\/td>\n 60.390<\/td>\n 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.<\/td>\n Strattera<\/td>\n ATOMOXETINE HCL<\/td>\n CAPSULE<\/td>\n 80 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
26.539<\/td>\n 60.391<\/td>\n 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.<\/td>\n Strattera<\/td>\n ATOMOXETINE HCL<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
95.200<\/td>\n 40.962<\/td>\n 366000-THYROID FUNCTION<\/td>\n Thyrogen<\/td>\n THYROTROPIN ALFA<\/td>\n VIAL<\/td>\n 1.1 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n <\/td>\n <\/tr>\n
34.647<\/td>\n 70.972<\/td>\n 481008-CORTICOSTEROIDS (RESPIRATORY TRACT)<\/td>\n Breo Ellipta<\/td>\n FLUTICASONE\/VILANTEROL<\/td>\n BLST W\/DEV<\/td>\n 100-25 MCG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Flovent HFA, Dulera Contact manufacturer for PAP<\/td>\n <\/tr>\n
35.808<\/td>\n 71.815<\/td>\n 481008-CORTICOSTEROIDS (RESPIRATORY TRACT)<\/td>\n Breo Ellipta<\/td>\n FLUTICASONE\/VILANTEROL<\/td>\n BLST W\/DEV<\/td>\n 200-25 MCG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Flovent HFA, Dulera Contact manufacturer for PAP<\/td>\n <\/tr>\n
40.321<\/td>\n 29.803<\/td>\n 481024-LEUKOTRIENE MODIFIERS<\/td>\n Zyflo Filmtab<\/td>\n ZILEUTON<\/td>\n TABLET<\/td>\n 600 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Montelukast.<\/td>\n <\/tr>\n
98.822<\/td>\n 63.062<\/td>\n 481024-LEUKOTRIENE MODIFIERS<\/td>\n Zyflo Filmtab<\/td>\n ZILEUTON<\/td>\n TBMP 12HR<\/td>\n 600 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Montelukast.<\/td>\n <\/tr>\n
44.498<\/td>\n 78.213<\/td>\n 483200-PHOSPHODIESTERASE TYPE 4 INHIBITORS<\/td>\n Daliresp<\/td>\n ROFLUMILAST<\/td>\n TABLET<\/td>\n 250 MCG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.934<\/td>\n 66.612<\/td>\n 483200-PHOSPHODIESTERASE TYPE 4 INHIBITORS<\/td>\n Daliresp<\/td>\n ROFLUMILAST<\/td>\n TABLET<\/td>\n 500 MCG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.216<\/td>\n 51.820<\/td>\n 520892-EENT ANTI-INFLAMMATORY AGENTS, MISC.<\/td>\n Restasis<\/td>\n CYCLOSPORINE<\/td>\n DROPS<\/td>\n 0.05 %<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
27.131<\/td>\n 65.392<\/td>\n 524028-PROSTAGLANDIN ANALOGS<\/td>\n Lumigan<\/td>\n BIMATOPROST<\/td>\n DROPS<\/td>\n 0.01 %<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Latanoprost. Contact manufacturer for PAP<\/td>\n <\/tr>\n
13.017<\/td>\n 47.624<\/td>\n 524028-PROSTAGLANDIN ANALOGS<\/td>\n Bimatoprost<\/td>\n BIMATOPROST<\/td>\n Drops<\/td>\n 0.03%<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Latanoprost.<\/td>\n <\/tr>\n
27.594<\/td>\n 65.587<\/td>\n 524028-PROSTAGLANDIN ANALOGS<\/td>\n Zioptan<\/td>\n TAFLUPROST\/PF<\/td>\n DROPS<\/td>\n 0.0015%<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Latanoprost.<\/td>\n <\/tr>\n
13.002<\/td>\n 47.612<\/td>\n 524028-PROSTAGLANDIN ANALOGS<\/td>\n Travatan Z<\/td>\n TRAVOPROST<\/td>\n DROPS<\/td>\n 0.004%<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Latanoprost.<\/td>\n <\/tr>\n
26.473<\/td>\n 60.341<\/td>\n 561200-CATHARTICS AND LAXATIVES<\/td>\n Amitiza<\/td>\n LUBIPROSTONE<\/td>\n CAPSULE<\/td>\n 24 MCG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
99.658<\/td>\n 63.946<\/td>\n 561200-CATHARTICS AND LAXATIVES<\/td>\n Amitiza<\/td>\n LUBIPROSTONE<\/td>\n CAPSULE<\/td>\n 8 MCG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
16.305<\/td>\n 64.793<\/td>\n 562836-PROTON-PUMP INHIBITORS<\/td>\n Dexilant<\/td>\n DEXLANSOPRAZOLE<\/td>\n CAP DR BP<\/td>\n 30 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Pantoprazole. Contact manufacturer for PAP<\/td>\n <\/tr>\n
16.306<\/td>\n 64.794<\/td>\n 562836-PROTON-PUMP INHIBITORS<\/td>\n Dexilant<\/td>\n DEXLANSOPRAZOLE<\/td>\n CAP DR BP<\/td>\n 60 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Pantoprazole. Contact manufacturer for PAP<\/td>\n <\/tr>\n
16.305<\/td>\n 64.793<\/td>\n 562836-PROTON-PUMP INHIBITORS<\/td>\n Dexilant<\/td>\n DEXLANSOPRAZOLE<\/td>\n CAP DR BP<\/td>\n 30 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Pantoprazole. Contact manufacturer for PAP<\/td>\n <\/tr>\n
16.306<\/td>\n 64.794<\/td>\n 562836-PROTON-PUMP INHIBITORS<\/td>\n Dexilant<\/td>\n DEXLANSOPRAZOLE<\/td>\n CAP DR BP<\/td>\n 60 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Pantoprazole. Contact manufacturer for PAP<\/td>\n <\/tr>\n
95.348<\/td>\n 40.304<\/td>\n 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)<\/td>\n Colazal<\/td>\n BALSALAZIDE DISODIUM<\/td>\n CAPSULE<\/td>\n 750 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: sulfasalazine.<\/td>\n <\/tr>\n
99.847<\/td>\n 64.139<\/td>\n 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)<\/td>\n Rowasa<\/td>\n MESALAMINE W\/CLEANSING WIPES<\/td>\n ENEMA KIT<\/td>\n 4 G\/60 ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.159<\/td>\n 64.701<\/td>\n 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)<\/td>\n Apriso ER<\/td>\n MESALAMINE<\/td>\n CAP ER 24H<\/td>\n 0.375 G<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Sulfasalazine. Contact manufacturer for PAP<\/td>\n <\/tr>\n
34.113<\/td>\n 70.543<\/td>\n 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)<\/td>\n Delzicol DR<\/td>\n MESALAMINE<\/td>\n CAPSULE DR<\/td>\n 400 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Sulfasalazine. Contact manufacturer for PAP<\/td>\n <\/tr>\n
23.422<\/td>\n 58.091<\/td>\n 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)<\/td>\n Pentasa<\/td>\n MESALAMINE<\/td>\n CAPSULE ER<\/td>\n 500 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Sulfasalazine. Contact manufacturer for PAP<\/td>\n <\/tr>\n
97.842<\/td>\n 62.058<\/td>\n 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS)<\/td>\n Lialda<\/td>\n MESALAMINE<\/td>\n TABLET DR<\/td>\n 1.2 G<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Formulary: Sulfasalazine. Contact manufacturer for PAP<\/td>\n <\/tr>\n
39.354<\/td>\n 74.654<\/td>\n 569200-GI DRUGS, MISCELLANEOUS<\/td>\n Viberzi<\/td>\n ELUXADOLINE<\/td>\n TABLET<\/td>\n 75 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
39.355<\/td>\n 74.655<\/td>\n 569200-GI DRUGS, MISCELLANEOUS<\/td>\n Viberzi<\/td>\n ELUXADOLINE<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
33.187<\/td>\n 69.922<\/td>\n 569200-GI DRUGS, MISCELLANEOUS<\/td>\n Linzess<\/td>\n LINACLOTIDE<\/td>\n CAPSULE<\/td>\n 145 MCG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
33.188<\/td>\n 69.923<\/td>\n 569200-GI DRUGS, MISCELLANEOUS<\/td>\n Linzess<\/td>\n LINACLOTIDE<\/td>\n CAPSULE<\/td>\n 290 MCG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
99.450<\/td>\n 63.735<\/td>\n 682003-AMYLINOMIMETICS<\/td>\n Symlin<\/td>\n PRAMLINTIDE ACETATE<\/td>\n PEN INJCTR<\/td>\n 2700 MCG\/2.7ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
99.514<\/td>\n 63.804<\/td>\n 682003-AMYLINOMIMETICS<\/td>\n Symlin<\/td>\n PRAMLINTIDE ACETATE<\/td>\n PEN INJCTR<\/td>\n 1500 MCG\/1.5ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
34.086<\/td>\n 70.525<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Nesina<\/td>\n ALOGLIPTIN<\/td>\n TABLET<\/td>\n 6.25 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n <\/td>\n <\/tr>\n
34.085<\/td>\n 70.524<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Nesina<\/td>\n ALOGLIPTIN<\/td>\n TABLET<\/td>\n 12.5 GM<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n <\/td>\n <\/tr>\n
34.076<\/td>\n 70.517<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Nesina<\/td>\n ALOGLIPTIN<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n <\/td>\n <\/tr>\n
26.189<\/td>\n 65.344<\/td>\n 682006-INCRETIN MIMETICS GLP-1<\/td>\n Victoza<\/td>\n LIRAGLUTIDE<\/td>\n PEN INJCTR<\/td>\n 0.6 MG\/0.1ML<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
98.637<\/td>\n 62.867<\/td>\n 682008-INSULINS<\/td>\n Lantus Solostar<\/td>\n INSULIN GLARGINE HUM.REC.ANLOG<\/td>\n INSULN PEN<\/td>\n 100 UNIT\/ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: insulin glargine-yfgn.<\/td>\n <\/tr>\n
37.988<\/td>\n 73.567<\/td>\n 682008-INSULINS<\/td>\n Toujeo Solostar<\/td>\n INSULIN GLARGINE HUM.REC.ANLOG<\/td>\n INSULN PEN<\/td>\n 300 UNIT\/ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: insulin glargine-yfgn.<\/td>\n <\/tr>\n
13.072<\/td>\n 47.780<\/td>\n 682008-INSULINS<\/td>\n Lantus<\/td>\n INSULIN GLARGINE HUM.REC.ANLOG<\/td>\n VIAL<\/td>\n 100 UNIT\/ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: insulin glargine-yfgn.<\/td>\n <\/tr>\n
26.508<\/td>\n 60.371<\/td>\n 682008-INSULINS<\/td>\n Apidra Solostar<\/td>\n INSULIN GLULISINE<\/td>\n INSULN PEN<\/td>\n 100 UNIT\/ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Novolog<\/td>\n <\/tr>\n
25.936<\/td>\n 59.985<\/td>\n 682008-INSULINS<\/td>\n Apidra<\/td>\n INSULIN GLULISINE<\/td>\n VIAL<\/td>\n 100 UNIT\/ML<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Novolog<\/td>\n <\/tr>\n
9.633<\/td>\n 29.916<\/td>\n 682008-INSULINS<\/td>\n Humulin R U500<\/td>\n INSULIN REGULAR HUMAN<\/td>\n VIAL<\/td>\n 500 UNIT\/ML<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Prescribe U500 Syringes, Contact manufacturer for PAP<\/td>\n <\/tr>\n
34.439<\/td>\n 70.791<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Invokana<\/td>\n CANAGLIFLOZIN<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
34.441<\/td>\n 70.792<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Invokana<\/td>\n CANAGLIFLOZIN<\/td>\n TABLET<\/td>\n 300 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
42.315<\/td>\n 76.623<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Inokamet XR<\/td>\n CANAGLIFLOZIN\/METFORMIN HCL<\/td>\n TAB BP 24H<\/td>\n 150-1000MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
42.312<\/td>\n 76.620<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Invokamet XR<\/td>\n CANAGLIFLOZIN\/METFORMIN HCL<\/td>\n TAB BP 24H<\/td>\n 50MG-500MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
42.313<\/td>\n 76.621<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Invokamet XR<\/td>\n CANAGLIFLOZIN\/METFORMIN HCL<\/td>\n TAB BP 24H<\/td>\n 50-1000 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
42.314<\/td>\n 76.622<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Invokamet XR<\/td>\n CANAGLIFLOZIN\/METFORMIN HCL<\/td>\n TAB BP 24H<\/td>\n 150-500 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
36.857<\/td>\n 72.587<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Invokamet<\/td>\n CANAGLIFLOZIN\/METFORMIN HCL<\/td>\n TABLET<\/td>\n 50-1000 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
36.859<\/td>\n 72.589<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Invokamet<\/td>\n CANAGLIFLOZIN\/METFORMIN HCL<\/td>\n TABLET<\/td>\n 150-1000MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
36.953<\/td>\n 72.677<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Invokamet<\/td>\n CANAGLIFLOZIN\/METFORMIN HCL<\/td>\n TABLET<\/td>\n 150-500 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
36.954<\/td>\n 72.678<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Invokamet<\/td>\n CANAGLIFLOZIN\/METFORMIN HCL<\/td>\n TABLET<\/td>\n 50MG-500MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
34.394<\/td>\n 70.755<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Farxiga<\/td>\n DAPAGLIFLOZIN PROPANEDIOL<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
35.698<\/td>\n 71.740<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Farxiga<\/td>\n DAPAGLIFLOZIN PROPANEDIOL<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
37.343<\/td>\n 73.031<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Xigduo XR<\/td>\n DAPAGLIFLOZIN\/METFORMIN HCL<\/td>\n TAB BP 24H<\/td>\n 5-1000 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
37.339<\/td>\n 73.029<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Xigduo XR<\/td>\n DAPAGLIFLOZIN\/METFORMIN HCL<\/td>\n TAB BP 24H<\/td>\n 5-500 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
37.342<\/td>\n 73.030<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Xigduo XR<\/td>\n DAPAGLIFLOZIN\/METFORMIN HCL<\/td>\n TAB BP 24H<\/td>\n 10-500 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
37.344<\/td>\n 73.032<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Xigduo XR<\/td>\n DAPAGLIFLOZIN\/METFORMIN HCL<\/td>\n TAB BP 24H<\/td>\n 10-1000 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
36.716<\/td>\n 72.488<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Jardiance<\/td>\n EMPAGLIFLOZIN<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
36.723<\/td>\n 72.489<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Jardiance<\/td>\n EMPAGLIFLOZIN<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
37.832<\/td>\n 73.432<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Glyxambi<\/td>\n EMPAGLIFLOZIN\/LINAGLIPTIN<\/td>\n TABLET<\/td>\n 10 MG-5 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
37.833<\/td>\n 73.433<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Glyxambi<\/td>\n EMPAGLIFLOZIN\/LINAGLIPTIN<\/td>\n TABLET<\/td>\n 25 MG-5 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
38.929<\/td>\n 74.316<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Synjardy<\/td>\n EMPAGLIFLOZIN\/METFORMIN HCL<\/td>\n TABLET<\/td>\n 5MG-1000MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
38.932<\/td>\n 74.318<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Synjardy<\/td>\n EMPAGLIFLOZIN\/METFORMIN HCL<\/td>\n TABLET<\/td>\n 12.5-1000<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
39.377<\/td>\n 74.675<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Synjardy<\/td>\n EMPAGLIFLOZIN\/METFORMIN HCL<\/td>\n TABLET<\/td>\n 5 MG-500MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
39.378<\/td>\n 74.676<\/td>\n 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB<\/td>\n Synjardy<\/td>\n EMPAGLIFLOZIN\/METFORMIN HCL<\/td>\n TABLET<\/td>\n 12.5-500MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
14.404<\/td>\n 64.481<\/td>\n 682400-PARATHYROID<\/td>\n Forteo<\/td>\n TERIPARATIDE<\/td>\n PEN INJCTR<\/td>\n 20 MCG\/DOSE<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
13.480<\/td>\n 19.141<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Soriatane<\/td>\n ACITRETIN<\/td>\n CAPSULE<\/td>\n 10 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.481<\/td>\n 19.142<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Soriatane<\/td>\n ACITRETIN<\/td>\n CAPSULE<\/td>\n 25 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.782<\/td>\n 51.494<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Avage<\/td>\n TAZAROTENE<\/td>\n CREAM (G)<\/td>\n 0.1 %<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
85.362<\/td>\n 46.983<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Tazorac Cream<\/td>\n TAZAROTENE<\/td>\n CREAM (G)<\/td>\n 0.05 %<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
85.363<\/td>\n 46.984<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Tazorac Cream<\/td>\n TAZAROTENE<\/td>\n CREAM (G)<\/td>\n 0.1 %<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.178<\/td>\n 69.204<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Fabior Foam<\/td>\n TAZAROTENE<\/td>\n FOAM<\/td>\n 0.1 %<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
29.222<\/td>\n 31.601<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Tazorac Cream<\/td>\n TAZAROTENE<\/td>\n GEL (GRAM)<\/td>\n 0.1 %<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
29.221<\/td>\n 31.600<\/td>\n 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC.<\/td>\n Tazorac Cream<\/td>\n TAZAROTENE<\/td>\n GEL (GRAM)<\/td>\n 0.05 %<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.276<\/td>\n 57.982<\/td>\n 861204-ANTIMUSCARINICS<\/td>\n Vesicare<\/td>\n SOLIFENACIN SUCCINATE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.277<\/td>\n 57.983<\/td>\n 861204-ANTIMUSCARINICS<\/td>\n Vesicare<\/td>\n SOLIFENACIN SUCCINATE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.766<\/td>\n 69.630<\/td>\n 861208-BETA-3-ADRENERGIC AGONISTS<\/td>\n Myrbetriq ER<\/td>\n MIRABEGRON<\/td>\n TAB ER 24H<\/td>\n 25 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.767<\/td>\n 69.631<\/td>\n 861208-BETA-3-ADRENERGIC AGONISTS<\/td>\n Myrbetriq ER<\/td>\n MIRABEGRON<\/td>\n TAB ER 24H<\/td>\n 50 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.808<\/td>\n 64.829<\/td>\n 921600-ANTIGOUT AGENTS<\/td>\n Uloric<\/td>\n FEBUXOSTAT<\/td>\n TABLET<\/td>\n 40 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Allopurinol is formulary,<\/td>\n <\/tr>\n
16.809<\/td>\n 64.830<\/td>\n 921600-ANTIGOUT AGENTS<\/td>\n Uloric<\/td>\n FEBUXOSTAT<\/td>\n TABLET<\/td>\n 80 MG<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Allopurinol is formulary,<\/td>\n <\/tr>\n
29.073<\/td>\n 66.709<\/td>\n 922000-IMMUNOMODULATORY AGENTS<\/td>\n Gilenya<\/td>\n FINGOLIMOD HCL<\/td>\n CAPSULE<\/td>\n 0.5 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
97.005<\/td>\n 61.205<\/td>\n 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS<\/td>\n Humira<\/td>\n ADALIMUMAB<\/td>\n PEN IJ KIT<\/td>\n 40 MG\/0.8ML<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
18.924<\/td>\n 51.599<\/td>\n 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS<\/td>\n Humira<\/td>\n ADALIMUMAB<\/td>\n SYRINGEKIT<\/td>\n 40 MG\/0.8ML<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
37.262<\/td>\n 72.952<\/td>\n 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS<\/td>\n Humira<\/td>\n ADALIMUMAB<\/td>\n SYRINGEKIT<\/td>\n 10 MG\/0.2ML<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
99.439<\/td>\n 63.724<\/td>\n 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS<\/td>\n Humira<\/td>\n ADALIMUMAB<\/td>\n SYRINGEKIT<\/td>\n 20 MG\/0.4ML<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
97.724<\/td>\n 61.938<\/td>\n 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS<\/td>\n Enbrel<\/td>\n ETANERCEPT<\/td>\n PEN INJCTR<\/td>\n 50 MG\/ML<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
98.398<\/td>\n 62.624<\/td>\n 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS<\/td>\n Enbrel<\/td>\n ETANERCEPT<\/td>\n SYRINGE<\/td>\n 25 MG\/0.5ML<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
23.574<\/td>\n 58.214<\/td>\n 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS<\/td>\n Enbrel<\/td>\n ETANERCEPT<\/td>\n SYRINGE<\/td>\n 50 MG\/ML<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
52.651<\/td>\n 40.869<\/td>\n 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS<\/td>\n Enbrel<\/td>\n ETANERCEPT<\/td>\n VIAL<\/td>\n 25 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
47.560<\/td>\n 23.724<\/td>\n 924400-IMMUNOSUPPRESSIVE AGENTS<\/td>\n Cellcept<\/td>\n MYCOPHENOLATE MOFETIL<\/td>\n CAPSULE<\/td>\n 250 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.561<\/td>\n 32.599<\/td>\n 924400-IMMUNOSUPPRESSIVE AGENTS<\/td>\n Cellcept<\/td>\n MYCOPHENOLATE MOFETIL<\/td>\n CAPSULE<\/td>\n 500 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.646<\/td>\n 52.119<\/td>\n 902808 IMMUNOSUPRESIVE THERAPY<\/td>\n Myfortic<\/td>\n MYCOPHENOLIC ACID<\/td>\n TABLET DR<\/td>\n 180 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
19.647<\/td>\n 52.120<\/td>\n 902808 IMMUNOSUPRESIVE THERAPY<\/td>\n Myfortic<\/td>\n MYCOPHENOLIC ACID<\/td>\n TABLET DR<\/td>\n 360 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.229<\/td>\n 21.175<\/td>\n 925600-PROTECTIVE AGENTS<\/td>\n Elmiron<\/td>\n PENTOSAN POLYSULFATE SODIUM<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
45.026<\/td>\n 78.657<\/td>\n 681804-ANTIGONADOTROPINS<\/td>\n Orilissa<\/td>\n ELAGOLIX<\/td>\n TABLET<\/td>\n 150 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
45.026<\/td>\n 78.657<\/td>\n 681804-ANTIGONADOTROPINS<\/td>\n Orilissa<\/td>\n ELAGOLIX<\/td>\n TABLET<\/td>\n 200 MG<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
42.676<\/td>\n 76.864<\/td>\n 682008-INSULINS<\/td>\n Soliqua<\/td>\n INSULIN GLARGINE\/LIXISENATIDE<\/td>\n INSULN PEN<\/td>\n 100 UNIT-33 MCG\/ML<\/td>\n NOT COVERED<\/td>\n PAP<\/td>\n Contact manufacturer for PAP<\/td>\n <\/tr>\n
29.890<\/td>\n 67.353<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Tradjenta<\/td>\n LINAGLIPTIN<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n CUC\/CH prescribers must send to in-house pharmacies only. Non-CUC\/CH may fill at network pharmacies<\/td>\n <\/tr>\n
31.315<\/td>\n 68.516<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Jentadueto<\/td>\n LINAGLIPTIN\/METFORMIN<\/td>\n TABLET<\/td>\n 2.5-500 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n CUC\/CH prescribers must send to in-house pharmacies only. Non-CUC\/CH may fill at network pharmacies<\/td>\n <\/tr>\n
31.316<\/td>\n 68.517<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Jentadueto<\/td>\n LINAGLIPTIN\/METFORMIN<\/td>\n TABLET<\/td>\n 2.5-850 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n CUC\/CH prescribers must send to in-house pharmacies only. Non-CUC\/CH may fill at network pharmacies<\/td>\n <\/tr>\n
31.317<\/td>\n 68.518<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Jentadueto<\/td>\n LINAGLIPTIN\/METFORMIN<\/td>\n TABLET<\/td>\n 2.5-1000 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n CUC\/CH prescribers must send to in-house pharmacies only. Non-CUC\/CH may fill at network pharmacies<\/td>\n <\/tr>\n
41.637<\/td>\n 76.256<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Jentadueto XR<\/td>\n LINAGLIPTIN\/METFORMIN ER<\/td>\n TABLET<\/td>\n 2.5-1000 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n CUC\/CH prescribers must send to in-house pharmacies only. Non-CUC\/CH may fill at network pharmacies<\/td>\n <\/tr>\n
41.639<\/td>\n 76.257<\/td>\n 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS<\/td>\n Jentadueto XR<\/td>\n LINAGLIPTIN\/METFORMIN ER<\/td>\n TABLET<\/td>\n 5-1000 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n CUC\/CH prescribers must send to in-house pharmacies only. Non-CUC\/CH may fill at network pharmacies<\/td>\n <\/tr>\n
34.525<\/td>\n 70.868<\/td>\n 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.<\/td>\n Namenda XR<\/td>\n MEMANTINE ER<\/td>\n TABLET<\/td>\n 14 mg<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Memantine IR, Donepezil, Rivastigmine.<\/td>\n <\/tr>\n
34.527<\/td>\n 70.870<\/td>\n 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC.<\/td>\n Namenda XR<\/td>\n MEMANTINE ER<\/td>\n TABLET<\/td>\n 28 mg<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Formulary: Memantine IR, Donepezil, Rivastigmine.<\/td>\n <\/tr>\n
41.370<\/td>\n 9.326<\/td>\n 081228-ANTIBACTERIALS, MISCELLANEOUS<\/td>\n Vancocin<\/td>\n VANCOMYCIN<\/td>\n CAPSULE<\/td>\n 125 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.371<\/td>\n 9.327<\/td>\n 081228-ANTIBACTERIALS, MISCELLANEOUS<\/td>\n Vancocin<\/td>\n VANCOMYCIN<\/td>\n CAPSULE<\/td>\n 250 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
46.908<\/td>\n 80.199<\/td>\n 68221200-GLYCOGENOLYTIC AGENTS, 92120000-ANTIDOTES<\/td>\n Gvoke<\/td>\n GLUCAGON<\/td>\n 2 PACK AUTOINJECTOR<\/td>\n 1 MG\/0.2 ML<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
46.907<\/td>\n 80.198<\/td>\n 68221200-GLYCOGENOLYTIC AGENTS, 92120000-ANTIDOTES<\/td>\n Gvoke<\/td>\n GLUCAGON<\/td>\n 2 PACK AUTOINJECTOR<\/td>\n 0.5 MG\/0.1 ML<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.781<\/td>\n 11.876<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n Haldol Decanoate<\/td>\n Haloperidol Decanoate<\/td>\n Vial<\/td>\n 100 mg\/ml<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.612<\/td>\n 39.781<\/td>\n 100000-ANTINEOPLASTIC AGENTS<\/td>\n Xeloda<\/td>\n Capecitabine<\/td>\n Tablet<\/td>\n 500 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n Restricted to Oncology & Hematology prescribers only<\/td>\n <\/tr>\n
23.549<\/td>\n 58.193<\/td>\n 681200-CONTRACEPTIVES<\/td>\n PLAN B ONE-STEP, ECONTRA ONE-STEP, NEW DAY, My Choice<\/td>\n Levonorgestrel<\/td>\n Tablet<\/td>\n 1.5 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.585<\/td>\n 65.578<\/td>\n 681200-CONTRACEPTIVES<\/td>\n Ella<\/td>\n Ulipristal<\/td>\n Tablet<\/td>\n 30 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
18.092<\/td>\n 50.805<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Diovan<\/td>\n Valsartan<\/td>\n Tablet<\/td>\n 40 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.846<\/td>\n 48.401<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Diovan<\/td>\n Valsartan<\/td>\n Tablet<\/td>\n 80 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.844<\/td>\n 48.400<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Diovan<\/td>\n Valsartan<\/td>\n Tablet<\/td>\n 160 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.838<\/td>\n 48.399<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Diovan<\/td>\n Valsartan<\/td>\n Tablet<\/td>\n 320 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
7.833<\/td>\n 37.354<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Diovan-HCT<\/td>\n Valsartan-Hydrochlorothiazide<\/td>\n Tablet<\/td>\n 80 - 12.5 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
9.760<\/td>\n 38.925<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Diovan-HCT<\/td>\n Valsartan-Hydrochlorothiazide<\/td>\n Tablet<\/td>\n 160 - 12.5 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.245<\/td>\n 50.256<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Diovan-HCT<\/td>\n Valsartan-Hydrochlorothiazide<\/td>\n Tablet<\/td>\n 160 - 25 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.015<\/td>\n 60.781<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Diovan-HCT<\/td>\n Valsartan-Hydrochlorothiazide<\/td>\n Tablet<\/td>\n 320 - 12.5 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
27.014<\/td>\n 60.780<\/td>\n 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS<\/td>\n Diovan-HCT<\/td>\n Valsartan-Hydrochlorothiazide<\/td>\n Tablet<\/td>\n 320 - 25 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
161<\/td>\n 16.995<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Aspirin<\/td>\n Asprin<\/td>\n Tablet EC<\/td>\n 81 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.713<\/td>\n 4.380<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Aspirin<\/td>\n Asprin<\/td>\n Tablet Chew<\/td>\n 81 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.701<\/td>\n 4.376<\/td>\n 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS<\/td>\n Aspirin<\/td>\n Aspirin<\/td>\n Tablet<\/td>\n 325 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
32.000<\/td>\n 4.930<\/td>\n 129200-AUTONOMIC DRUGS, MISCELLANEOUS<\/td>\n NICOTINE<\/td>\n NICOTINE<\/td>\n GUM<\/td>\n 2 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
3.201<\/td>\n 13.486<\/td>\n 129200-AUTONOMIC DRUGS, MISCELLANEOUS<\/td>\n NICOTINE<\/td>\n NICOTINE<\/td>\n GUM<\/td>\n 4 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.689<\/td>\n 48.776<\/td>\n 129200-AUTONOMIC DRUGS, MISCELLANEOUS<\/td>\n NICOTINE<\/td>\n NICOTINE<\/td>\n LOZENGE<\/td>\n 2 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
14.688<\/td>\n 48.775<\/td>\n 129200-AUTONOMIC DRUGS, MISCELLANEOUS<\/td>\n NICOTINE<\/td>\n NICOTINE<\/td>\n LOZENGE<\/td>\n 4 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
49.992<\/td>\n 82.541<\/td>\n 68200800-INSULINS<\/td>\n INSULIN GLARGINE-YFGN (SEMGLEE)<\/td>\n INSULIN GLARGINE-YFGN<\/td>\n VIAL<\/td>\n 100 UNITS\/ML<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
49.993<\/td>\n 82.542<\/td>\n 68200800-INSULINS<\/td>\n INSULIN GLARGINE-YFGN (SEMGLEE)<\/td>\n INSULIN GLARGINE-YFGN<\/td>\n INSULN PEN<\/td>\n 100 UNITS\/ML<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.260<\/td>\n 9.322<\/td>\n 081604-ANTITUBERCULOSIS AGENTS<\/td>\n RIFAMPIN<\/td>\n RIFAMPIN<\/td>\n CAPSULE<\/td>\n 150 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.261<\/td>\n 9.323<\/td>\n 081604-ANTITUBERCULOSIS AGENTS<\/td>\n RIFAMPIN<\/td>\n RIFAMPIN<\/td>\n CAPSULE<\/td>\n 300 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.801<\/td>\n 9.426<\/td>\n 081604-ANTITUBERCULOSIS AGENTS<\/td>\n ETHAMBUTOL<\/td>\n ETHAMBUTOL<\/td>\n TABLET<\/td>\n 400 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.331<\/td>\n 47.563<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n GEODON<\/td>\n ZIPRASIDONE<\/td>\n CAPSULE<\/td>\n 20 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.332<\/td>\n 47.564<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n GEODON<\/td>\n ZIPRASIDONE<\/td>\n CAPSULE<\/td>\n 40MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.333<\/td>\n 47.567<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n GEODON<\/td>\n ZIPRASIDONE<\/td>\n CAPSULE<\/td>\n 60MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.334<\/td>\n 47.568<\/td>\n 281608-ANTIPSYCHOTIC AGENTS<\/td>\n GEODON<\/td>\n ZIPRASIDONE<\/td>\n CAPSULE<\/td>\n 80 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
4.695<\/td>\n 1.645<\/td>\n 200404-IRON PREPARATIONS<\/td>\n FERROUS SULFATE<\/td>\n FERROUS SULFATE<\/td>\n TABLET<\/td>\n 325 (65) MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
97.721<\/td>\n 61.935<\/td>\n 200404-IRON PREPARATIONS<\/td>\n FERROUS SULFATE<\/td>\n FERROUS SULFATE<\/td>\n DROPS\/SOLUTION<\/td>\n 75 (15) MG\/ML<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
97.503<\/td>\n 61.717<\/td>\n 200404-IRON PREPARATIONS<\/td>\n FERROUS GLUCONATE<\/td>\n FERROUS GLUCONATE<\/td>\n TABLET<\/td>\n 324 (38) MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
4.515<\/td>\n 1.617<\/td>\n 200404-IRON PREPARATIONS<\/td>\n FERROUS FUMARATE<\/td>\n FERROUS FUMARATE<\/td>\n TABLET<\/td>\n 324 (1060 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.200<\/td>\n 77.832<\/td>\n 940000-DEVICES<\/td>\n FREESTYLE LIBRE 14 DAY<\/td>\n CONTINOUS GLUCOSE MONITOR<\/td>\n READER<\/td>\n <\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n Restricted to CUC & CH Endocrinology and CUC in-house only<\/td>\n <\/tr>\n
94.200<\/td>\n 77.832<\/td>\n 940000-DEVICES<\/td>\n FREESTYLE LIBRE 2<\/td>\n CONTINOUS GLUCOSE MONITOR<\/td>\n READER<\/td>\n <\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n Restricted to CUC & CH Endocrinology and CUC in-house only<\/td>\n <\/tr>\n
94.200<\/td>\n 65.863<\/td>\n 940000-DEVICES<\/td>\n FREESTYLE LIBRE 3<\/td>\n CONTINOUS GLUCOSE MONITOR<\/td>\n READER<\/td>\n <\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n Restricted to CUC & CH Endocrinology and CUC in-house only<\/td>\n <\/tr>\n
94.200<\/td>\n 65.744<\/td>\n 940000-DEVICES<\/td>\n FREESTYLE LIBRE 2 PLUS<\/td>\n CONTINOUS GLUCOSE MONITOR<\/td>\n SENSOR<\/td>\n <\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n Restricted to CUC & CH Endocrinology and CUC in-house only<\/td>\n <\/tr>\n
94.200<\/td>\n 65.744<\/td>\n 940000-DEVICES<\/td>\n FREESTYLE LIBRE 3 PLUS<\/td>\n CONTINOUS GLUCOSE MONITOR<\/td>\n SENSOR<\/td>\n <\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n Restricted to CUC & CH Endocrinology and CUC in-house only<\/td>\n <\/tr>\n
94.200<\/td>\n 65.863<\/td>\n 940000-DEVICES<\/td>\n DEXCOM G6<\/td>\n CONTINOUS GLUCOSE MONITOR<\/td>\n RECEIVER<\/td>\n <\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n Restricted to CUC & CH Endocrinology, using integrated insulin pump and CUC in-house only<\/td>\n <\/tr>\n
94.200<\/td>\n 65.873<\/td>\n 940000-DEVICES<\/td>\n DEXCOM G6<\/td>\n CONTINOUS GLUCOSE MONITOR<\/td>\n TRANSMITTER<\/td>\n <\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n Restricted to CUC & CH Endocrinology, using integrated insulin pump and CUC in-house only<\/td>\n <\/tr>\n
94.200<\/td>\n 65.744<\/td>\n 940000-DEVICES<\/td>\n DEXCOM G6<\/td>\n CONTINOUS GLUCOSE MONITOR<\/td>\n SENSOR<\/td>\n <\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n Restricted to CUC & CH Endocrinology, using integrated insulin pump and CUC in-house only<\/td>\n <\/tr>\n
94.200<\/td>\n 65.863<\/td>\n 940000-DEVICES<\/td>\n DEXCOM G7<\/td>\n CONTINOUS GLUCOSE MONITOR<\/td>\n RECEIVER<\/td>\n <\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n Restricted to CUC & CH Endocrinology, using integrated insulin pump and CUC in-house only<\/td>\n <\/tr>\n
94.200<\/td>\n 65.744<\/td>\n 940000-DEVICES<\/td>\n DEXCOM G7<\/td>\n CONTINOUS GLUCOSE MONITOR<\/td>\n SENSOR<\/td>\n <\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n Restricted to CUC & CH Endocrinology, using integrated insulin pump and CUC in-house only<\/td>\n <\/tr>\n
28.578<\/td>\n 66.336<\/td>\n 202816-HEMOSTATICS<\/td>\n TRANEXAMIC ACID<\/td>\n TRANEXAMIC ACID<\/td>\n TABLET<\/td>\n 650 MG<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
8.762<\/td>\n 2.947<\/td>\n 561200-CATHARTICS AND LAXATIVES<\/td>\n Bisacodyl<\/td>\n Bisacodyl<\/td>\n Tablet<\/td>\n 5 mg<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
8.731<\/td>\n 2.944<\/td>\n 561200-CATHARTICS AND LAXATIVES<\/td>\n Bisacodyl<\/td>\n Bisacodyl<\/td>\n Suppository<\/td>\n 10 mg<\/td>\n COVERED<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
44.774<\/td>\n 78.441<\/td>\n 401818-POTASSIUM-REMOVING AGENTS<\/td>\n Lokelma<\/td>\n Sodium Zirconium Cyclosilicate<\/td>\n Powder<\/td>\n 5 g<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Three 30 day fills allowed in a year with no NFDR\/PA required. Longer use acquire via PAP<\/td>\n <\/tr>\n
44.775<\/td>\n 78.445<\/td>\n 401818-POTASSIUM-REMOVING AGENTS<\/td>\n Lokelma<\/td>\n Sodium Zirconium Cyclosilicate<\/td>\n Powder<\/td>\n 10 g<\/td>\n NOT COVERED<\/td>\n NON-FORMULARY<\/td>\n Three 30 day fills allowed in a year with no NFDR\/PA required. Longer use acquire via PAP<\/td>\n <\/tr>\n
25.308<\/td>\n 59.589<\/td>\n 280812-OPIATE PARTIAL AGONISTS<\/td>\n Butrans<\/td>\n Buprenorphine<\/td>\n PATCH TDWK<\/td>\n 5 MCG\/HR<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
36.946<\/td>\n 72.673<\/td>\n 280812-OPIATE PARTIAL AGONISTS<\/td>\n Butrans<\/td>\n Buprenorphine<\/td>\n PATCH TDWK<\/td>\n 7.5 MCG\/HR<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.309<\/td>\n 59.590<\/td>\n 280812-OPIATE PARTIAL AGONISTS<\/td>\n Butrans<\/td>\n Buprenorphine<\/td>\n PATCH TDWK<\/td>\n 10 MCG\/HR<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
35.214<\/td>\n 71.432<\/td>\n 280812-OPIATE PARTIAL AGONISTS<\/td>\n Butrans<\/td>\n Buprenorphine<\/td>\n PATCH TDWK<\/td>\n 15 MCG\/HR<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.312<\/td>\n 59.591<\/td>\n 280812-OPIATE PARTIAL AGONISTS<\/td>\n Butrans<\/td>\n Buprenorphine<\/td>\n PATCH TDWK<\/td>\n 20 MCG\/HR<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.495<\/td>\n 41.832<\/td>\n 90282892-CALCINEURIN INHIBITORS<\/td>\n Prograf<\/td>\n Tacrolimus<\/td>\n CAPSULE<\/td>\n 0.5 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.491<\/td>\n 21.796<\/td>\n 90282892-CALCINEURIN INHIBITORS<\/td>\n Prograf<\/td>\n Tacrolimus<\/td>\n CAPSULE<\/td>\n 1 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.492<\/td>\n 21.797<\/td>\n 90282892-CALCINEURIN INHIBITORS<\/td>\n Prograf<\/td>\n Tacrolimus<\/td>\n CAPSULE<\/td>\n 5 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.918<\/td>\n 23.882<\/td>\n 90282892-CALCINEURIN INHIBITORS<\/td>\n Gengraf\/Neoral<\/td>\n CYCLOSPORINE MODIFIED<\/td>\n CAPSULE<\/td>\n 25 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.916<\/td>\n 23.885<\/td>\n 90282892-CALCINEURIN INHIBITORS<\/td>\n Gengraf\/Neoral<\/td>\n CYCLOSPORINE MODIFIED<\/td>\n CAPSULE<\/td>\n 50 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
13.919<\/td>\n 23.881<\/td>\n 90282892-CALCINEURIN INHIBITORS<\/td>\n Gengraf\/Neoral<\/td>\n CYCLOSPORINE MODIFIED<\/td>\n CAPSULE<\/td>\n 100 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
23.152<\/td>\n 57.883<\/td>\n 081808-ANTIRETROVIRALS<\/td>\n Truvada<\/td>\n emtricitabine\/tenofovir (TDF)<\/td>\n TABLET<\/td>\n 200\/300 MG<\/td>\n COVERED - SEE COMMENTS<\/td>\n FORMULARY<\/td>\n For PrEP use only. Not for HIV treatment. No NFDR\/PA required<\/td>\n <\/tr>\n
41.741<\/td>\n 9.415<\/td>\n 081604-ANTITUBERCULOSIS AGENT<\/td>\n Isoniazid<\/td>\n Isoniazid<\/td>\n TABLET<\/td>\n 100 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
41.742<\/td>\n 9.416<\/td>\n 081604-ANTITUBERCULOSIS AGENT<\/td>\n Isoniazid<\/td>\n Isoniazid<\/td>\n TABLET<\/td>\n 300 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
45.911<\/td>\n 40.870<\/td>\n 081604-ANTITUBERCULOSIS AGENT<\/td>\n Priftin<\/td>\n Rifapentine<\/td>\n TABLET<\/td>\n 150 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.976<\/td>\n 2.427<\/td>\n 880800-VITAMIN B COMPLEX<\/td>\n Pyridoxine (Vitamin B6)<\/td>\n Vitamin B6<\/td>\n TABLET<\/td>\n 50 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.977<\/td>\n 2.423<\/td>\n 880800-VITAMIN B COMPLEX<\/td>\n Pyridoxine (Vitamin B6)<\/td>\n Vitamin B6<\/td>\n TABLET<\/td>\n 25 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.783<\/td>\n 2.364<\/td>\n 880800-VITAMIN B COMPLEX<\/td>\n FOLIC ACID<\/td>\n FOLIC ACID<\/td>\n TABLET<\/td>\n 400 MCG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
68.738<\/td>\n 24.665<\/td>\n 929200-null<\/td>\n MELATONIN<\/td>\n MELATONIN<\/td>\n TABLET<\/td>\n 3 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
99.671<\/td>\n 63.960<\/td>\n 929200-null<\/td>\n MELATONIN<\/td>\n MELATONIN<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
8.420<\/td>\n 2.860<\/td>\n 560800-ANTIDIARRHEA AGENTS<\/td>\n PEPTO-BISMOL<\/td>\n BISMUTH SUBSALICYLATE<\/td>\n CHEWABLE TABLET<\/td>\n 262 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
223<\/td>\n 28.465<\/td>\n 881600-VITAMIN D<\/td>\n VITAMIN D3<\/td>\n VITAMIN D3<\/td>\n TABLET<\/td>\n 25 MCG (1000 IU)<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.309<\/td>\n 64.302<\/td>\n 881600-VITAMIN D<\/td>\n VITAMIN D3<\/td>\n VITAMIN D3<\/td>\n TABLET<\/td>\n 50 MCG (2000 IU)<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
93.242<\/td>\n 12.016<\/td>\n 881600-VITAMIN D<\/td>\n VITAMIN D3<\/td>\n VITAMIN D3<\/td>\n CAPSULE<\/td>\n 125 MCG (5000 IU)<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.867<\/td>\n 47.525<\/td>\n 562836-PROTON-PUMP INHIBITORS<\/td>\n NEXIUM<\/td>\n ESOMEPRAZOLE<\/td>\n CAPSULE<\/td>\n 20 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
12.868<\/td>\n 47.526<\/td>\n 562836-PROTON-PUMP INHIBITORS<\/td>\n NEXIUM<\/td>\n ESOMEPRAZOLE<\/td>\n CAPSULE<\/td>\n 40 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
29.810<\/td>\n 18.766<\/td>\n 081604-ANTITUBERCULOSIS AGENTS<\/td>\n MYCOBUTIN<\/td>\n RIFABUTIN<\/td>\n CAPSULE<\/td>\n 150 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
47.303<\/td>\n 80.455<\/td>\n 562892<\/td>\n TALICIA<\/td>\n OMEPRAZOLE\/AMOXICILLIN\/RIFABUTIN<\/td>\n CAPSULE<\/td>\n 10-250-12.5 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
701<\/td>\n 19.964<\/td>\n 561200-CATHARTICS AND LAXATIVES<\/td>\n SENNA<\/td>\n SENNA<\/td>\n TABLET<\/td>\n 8.6 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
8.660<\/td>\n 2.922<\/td>\n 561200-CATHARTICS AND LAXATIVES<\/td>\n SENNA<\/td>\n SENNA<\/td>\n SYRUP<\/td>\n 8.8 MG\/5 ML<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
16.964<\/td>\n 4.489<\/td>\n 280816<\/td>\n ACETAMINOPHEN<\/td>\n ACETAMINOPHEN<\/td>\n TABLET<\/td>\n 325 mg<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.880<\/td>\n 7.737<\/td>\n 529200-EENT DRUGS<\/td>\n MURO-128<\/td>\n SODIUM CHLORIDE<\/td>\n OINTMENT<\/td>\n 5%<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.922<\/td>\n 7.738<\/td>\n 529200-EENT DRUGS<\/td>\n MURO-128<\/td>\n SODIUM CHLORIDE<\/td>\n DROPS<\/td>\n 2%<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
31.923<\/td>\n 7.739<\/td>\n 529200-EENT DRUGS<\/td>\n MURO-129<\/td>\n SODIUM CHLORIDE<\/td>\n DROPS<\/td>\n 5%<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.239<\/td>\n 24.457<\/td>\n 529200-EENT DRUGS<\/td>\n IPRATROPIUM BROMIDE<\/td>\n IPRATROPIUM BROMIDE<\/td>\n SPRAY<\/td>\n 0.03% (21MCG)<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.238<\/td>\n 24.456<\/td>\n 529200-EENT DRUGS<\/td>\n IPRATROPIUM BROMIDE<\/td>\n IPRATROPIUM BROMIDE<\/td>\n SPRAY<\/td>\n 0.06% (42MCG)<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.322<\/td>\n 17.118<\/td>\n 121204-ALPHA-ADRENERGIC AGONISTS<\/td>\n MIDODRINE<\/td>\n MIDODRINE<\/td>\n TABLET<\/td>\n 2.5 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
28.321<\/td>\n 17.117<\/td>\n 121204-ALPHA-ADRENERGIC AGONISTS<\/td>\n MIDODRINE<\/td>\n MIDODRINE<\/td>\n TABLET<\/td>\n 5 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
17.566<\/td>\n 50.491<\/td>\n 121204-ALPHA-ADRENERGIC AGONISTS<\/td>\n MIDODRINE<\/td>\n MIDODRINE<\/td>\n TABLET<\/td>\n 10 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
94.781<\/td>\n 2.366<\/td>\n 880800-VITAMIN B COMPLEX<\/td>\n FOLIC ACID<\/td>\n FOLIC ACID<\/td>\n TABLET<\/td>\n 1 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
8.370<\/td>\n 2.842<\/td>\n 560800-ANTIDIARRHEA AGENTS<\/td>\n LOPERAMIDE<\/td>\n LOPERAMIDE<\/td>\n CAPSULE<\/td>\n 2 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
8.550<\/td>\n 13.672<\/td>\n 560800-ANTIDIARRHEA AGENTS<\/td>\n LOPERAMIDE<\/td>\n LOPERAMIDE<\/td>\n TABLET<\/td>\n 2 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
25.065<\/td>\n 59.430<\/td>\n 560800-ANTIDIARRHEA AGENTS<\/td>\n LOPERAMIDE<\/td>\n LOPERAMIDE<\/td>\n SOLUTION<\/td>\n 1 MG\/7.5 ML<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
36.441<\/td>\n 25.600<\/td>\n 91020000-ALCOHOL DETERRENTS<\/td>\n Acamprosate calcium<\/td>\n Acamprosate calcium<\/td>\n Tablet<\/td>\n 333 MG<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.365<\/td>\n 76.660<\/td>\n 24061200-OMEGA-3-MEDIATED ANTILIPEMICS<\/td>\n Vascepa<\/td>\n Icosapent Ethyl<\/td>\n CAPSULE<\/td>\n 0.5 G<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n
42.365<\/td>\n 76.660<\/td>\n 24061200-OMEGA-3-MEDIATED ANTILIPEMICS<\/td>\n Vascepa<\/td>\n Icosapent Ethyl<\/td>\n CAPSULE<\/td>\n 1 G<\/td>\n Covered<\/td>\n FORMULARY<\/td>\n <\/td>\n <\/tr>\n <\/tbody> \n\n \n \n