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). If the patient does not qualify for PAP, the provider may submit a NON-FORMULARY DRUG REQUEST (NFDR) FORM. Documentation of PAP ineligibility or rejection should be submitted with the NDFR form.
More information on pharmacy benefits can be found in the MAP and MAP Basic Provider Handbook.
Generic Code | Generic Sequence Number | Therapeutic Class | BrandName | GenericName | Formulation | Strength | Coverage | Location | Comments |
---|---|---|---|---|---|---|---|---|---|
49.291 | 17.037 | 040800-SECOND GENERATION ANTIHISTAMINES | Zyrtec | CETIRIZINE HCL | TABLET | 10 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
60.563 | 18.698 | 040800-SECOND GENERATION ANTIHISTAMINES | Claritin | LORATADINE | TABLET | 10 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
17.853 | 50.714 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Spiriva Handihaler | TIOTROPIUM BROMIDE | CAP W/DEV | 18 MCG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
3.421 | 16.425 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | NICOTINE | NICOTINE | PATCH TD24 | 7 MG/24HR | COVERED | FORMULARY | |
3.422 | 16.426 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | NICOTINE | NICOTINE | PATCH TD24 | 14 MG/24HR | COVERED | FORMULARY | |
3.423 | 16.427 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | NICOTINE | NICOTINE | PATCH TD24 | 21 MG/24HR | COVERED | FORMULARY | |
27.047 | 60.897 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | Chantix | VARENICLINE TARTRATE | TABLET | 1 MG | COVERED | FORMULARY | only 12 week course, all strengths, in 12 month period & must be receiving tobacco cessation counseling during treatment |
27.046 | 60.896 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | Chantix | VARENICLINE TARTRATE | TABLET | 0.5 MG | COVERED | FORMULARY | only 12 week course, all strengths, in 12 month period & must be receiving tobacco cessation counseling during treatment |
18.387 | 51.214 | 240605-CHOLESTEROL ABSORPTION INHIBITORS | Zetia | EZETIMIBE | TABLET | 10 MG | COVERED | FORMULARY | |
42.001 | 41.285 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Celebrex | CELECOXIB | CAPSULE | 100 MG | COVERED | FORMULARY | |
42.002 | 41.286 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Celebrex | CELECOXIB | CAPSULE | 200 MG | COVERED | FORMULARY | |
97.785 | 62.001 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Celebrex | CELECOXIB | CAPSULE | 50 MG | COVERED | FORMULARY | |
18.127 | 50.832 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Celebrex | CELECOXIB | CAPSULE | 400 MG | COVERED | FORMULARY | |
23.046 | 57.800 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 50 MG | COVERED | FORMULARY | |
23.047 | 57.801 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 75 MG | COVERED | FORMULARY | |
23.048 | 57.802 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 100 MG | COVERED | FORMULARY | |
23.049 | 57.803 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 150 MG | COVERED | FORMULARY | |
23.051 | 57.804 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 200 MG | COVERED | FORMULARY | |
23.052 | 57.805 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 300 MG | COVERED | FORMULARY | |
23.039 | 57.799 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 25 MG | COVERED | FORMULARY | |
25.019 | 59.401 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 225 MG | COVERED | FORMULARY | |
32.359 | 69.339 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | Solution | 20 mg/ml | COVERED | FORMULARY | |
18.537 | 51.333 | 281608-ANTIPSYCHOTIC AGENTS | Abilify | ARIPIPRAZOLE | TABLET | 10 MG | COVERED | FORMULARY | |
18.538 | 51.334 | 281608-ANTIPSYCHOTIC AGENTS | Abilify | ARIPIPRAZOLE | TABLET | 15 MG | COVERED | FORMULARY | |
18.539 | 51.335 | 281608-ANTIPSYCHOTIC AGENTS | Abilify | ARIPIPRAZOLE | TABLET | 20 MG | COVERED | FORMULARY | |
18.541 | 51.336 | 281608-ANTIPSYCHOTIC AGENTS | Abilify | ARIPIPRAZOLE | TABLET | 30 MG | COVERED | FORMULARY | |
20.173 | 52.898 | 281608-ANTIPSYCHOTIC AGENTS | Abilify | ARIPIPRAZOLE | TABLET | 5 MG | COVERED | FORMULARY | |
26.305 | 60.225 | 281608-ANTIPSYCHOTIC AGENTS | Abilify | ARIPIPRAZOLE | TABLET | 2 MG | COVERED | FORMULARY | |
30.139 | 67.555 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Dulera MDI | MOMETASONE/FORMOTEROL | HFA AER AD | 50-5 MCG | COVERED | FORMULARY | |
28.766 | 66.480 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Dulera MDI | MOMETASONE/FORMOTEROL | HFA AER AD | 100-5 MCG | COVERED | FORMULARY | |
28.767 | 66.481 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Dulera MDI | MOMETASONE/FORMOTEROL | HFA AER AD | 200-5 MCG | COVERED | FORMULARY | |
64.269 | 37.219 | 562836-PROTON-PUMP INHIBITORS | Prevpac | LANSOPRAZOLE/AMOXICILN/CLARITH | COMBO. PKG | 30-500-500 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy. |
17.528 | 50.464 | 681200-CONTRACEPTIVES | Nuvaring | ETONOGESTREL/ETHINYL ESTRADIOL | VAG RING | 0.12-.015 MG | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
24.471 | 58.938 | 681200-CONTRACEPTIVES | Depo-SubQ Provera 104 | MEDROXYPROGESTERONE ACETATE | SYRINGE | 104 MG | COVERED | FORMULARY | |
98.306 | 62.531 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Janumet | SITAGLIPTIN PHOS/METFORMIN HCL | TABLET | 50-500 MG | NOT COVERED | NON-FORMULARY | |
98.307 | 62.532 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Janumet | SITAGLIPTIN PHOS/METFORMIN HCL | TABLET | 50-1000 MG | NOT COVERED | NON-FORMULARY | |
31.339 | 68.538 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Janumet XR | SITAGLIPTIN PHOS/METFORMIN HCL | TBMP 24HR | 50-500 MG | NOT COVERED | NON-FORMULARY | |
31.340 | 68.539 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Janumet XR | SITAGLIPTIN PHOS/METFORMIN HCL | TBMP 24HR | 50-1000 MG | NOT COVERED | NON-FORMULARY | |
31.348 | 68.540 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Janumet XR | SITAGLIPTIN PHOS/METFORMIN HCL | TBMP 24HR | 100-1000 MG | NOT COVERED | NON-FORMULARY | |
97.398 | 61.612 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Januvia | SITAGLIPTIN PHOSPHATE | TABLET | 25 MG | NOT COVERED | NON-FORMULARY | |
97.399 | 61.613 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Januvia | SITAGLIPTIN PHOSPHATE | TABLET | 50 MG | NOT COVERED | NON-FORMULARY | |
97.400 | 61.614 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Januvia | SITAGLIPTIN PHOSPHATE | TABLET | 100 MG | NOT COVERED | NON-FORMULARY | |
24.614 | 59.073 | 682006-INCRETIN MIMETICS | Byetta | EXENATIDE | PEN INJCTR | 10 MCG/0.04 | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
24.613 | 59.072 | 682006-INCRETIN MIMETICS | Byetta | EXENATIDE | PEN INJCTR | 5 MCG/0.04 | COVERED | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
12.263 | 47.327 | 861204-ANTIMUSCARINICS | Detrol LA | TOLTERODINE TARTRATE | CAP ER 24H | 4 MG | COVERED | FORMULARY | |
12.264 | 47.328 | 861204-ANTIMUSCARINICS | Detrol LA | TOLTERODINE TARTRATE | CAP ER 24H | 2 MG | COVERED | FORMULARY | |
13.977 | 48.495 | 040412-PHENOTHIAZINE DERIVATIVES | Promethazine VC | PHENYLEPHRINE HCL-PROMETHAZINE HCL | SYRUP | 5-6.25 MG/5ML | COVERED | FORMULARY | |
15.001 | 3.873 | 040412-PHENOTHIAZINE DERIVATIVES | Phenergan Suppository | PROMETHAZINE HCL | SUPP.RECT | 25 MG | COVERED | FORMULARY | |
15.002 | 3.874 | 040412-PHENOTHIAZINE DERIVATIVES | Phenergan Suppository | PROMETHAZINE HCL | SUPP.RECT | 50 MG | COVERED | FORMULARY | |
15.003 | 3.872 | 040412-PHENOTHIAZINE DERIVATIVES | Phenergan Suppository | PROMETHAZINE HCL | SUPP.RECT | 12.5 MG | COVERED | FORMULARY | |
15.035 | 3.876 | 040412-PHENOTHIAZINE DERIVATIVES | Promethazine | PROMETHAZINE HCL | SYRUP | 6.25 MG/5ML | COVERED | FORMULARY | |
15.042 | 3.877 | 040412-PHENOTHIAZINE DERIVATIVES | Promethazine | PROMETHAZINE HCL | TABLET | 12.5 MG | COVERED | FORMULARY | |
15.043 | 3.878 | 040412-PHENOTHIAZINE DERIVATIVES | Promethazine | PROMETHAZINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
15.044 | 3.879 | 040412-PHENOTHIAZINE DERIVATIVES | Promethazine | PROMETHAZINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
96.609 | 991 | 040420-PROPYLAMINE DERIVATIVES | Brohist D | BROMPHENIRAMIN-PHENYLEPHRINE | TABLET | 4-10 MG | COVERED | FORMULARY | |
44.023 | 26.792 | 040420-PROPYLAMINE DERIVATIVES | Sudogest | PSEUDOEPHEDRINE-CHLORPHENIRAMINE | TABLET | 60 MG-4 MG | COVERED | FORMULARY | |
15.803 | 4.010 | 040492-FIRST GEN. ANTIHIST. DERIVATIVES, MISC. | Cypropheptadine | CYPROHEPTADINE HCL | SYRUP | 2 MG/5ML | COVERED | FORMULARY | |
15.811 | 4.011 | 040492-FIRST GEN. ANTIHIST. DERIVATIVES, MISC. | Cypropheptadine | CYPROHEPTADINE HCL | TABLET | 4 MG | COVERED | FORMULARY | |
97.950 | 62.168 | 040800-SECOND GENERATION ANTIHISTAMINES | Xyzal | LEVOCETIRIZINE DIHYDROCHLORIDE | SOLUTION | 2.5 MG/5ML | COVERED | FORMULARY | |
14.901 | 48.920 | 040800-SECOND GENERATION ANTIHISTAMINES | Xyzal | LEVOCETIRIZINE DIHYDROCHLORIDE | TABLET | 5 MG | COVERED | FORMULARY | |
53.290 | 19.283 | 080800-ANTHELMINTICS | Albenza | ALBENDAZOLE | TABLET | 200 MG | COVERED | FORMULARY | |
93.064 | 43.094 | 080800-ANTHELMINTICS | Stromectol | IVERMECTIN | TABLET | 3 MG | COVERED | FORMULARY | |
41.072 | 9.284 | 081202-AMINOGLYCOSIDES | Neomycin | NEOMYCIN SULFATE | TABLET | 500 MG | COVERED | FORMULARY | |
32.231 | 40.257 | 081206-CEPHALOSPORINS | Cefdinir | CEFDINIR | CAPSULE | 300 MG | COVERED | FORMULARY | |
23.308 | 58.005 | 081206-CEPHALOSPORINS | Cefdinir | CEFDINIR | SUSP RECON | 250 MG/5ML | COVERED | FORMULARY | |
32.232 | 40.258 | 081206-CEPHALOSPORINS | Cefdinir | CEFDINIR | SUSP RECON | 125 MG/5ML | COVERED | FORMULARY | |
29.291 | 16.582 | 081206-CEPHALOSPORINS | Cefprozil | CEFPROZIL | SUSP RECON | 125 MG/5ML | COVERED | FORMULARY | |
29.292 | 16.583 | 081206-CEPHALOSPORINS | Cefprozil | CEFPROZIL | SUSP RECON | 250 MG/5ML | COVERED | FORMULARY | |
29.271 | 16.584 | 081206-CEPHALOSPORINS | Cefprozil | CEFPROZIL | TABLET | 250 MG | COVERED | FORMULARY | |
29.272 | 16.585 | 081206-CEPHALOSPORINS | Cefprozil | CEFPROZIL | TABLET | 500 MG | COVERED | FORMULARY | |
47.281 | 9.136 | 081206-CEPHALOSPORINS | Ceftin | CEFUROXIME AXETIL | TABLET | 250 MG | COVERED | FORMULARY | |
47.282 | 9.137 | 081206-CEPHALOSPORINS | Ceftin | CEFUROXIME AXETIL | TABLET | 500 MG | COVERED | FORMULARY | |
39.801 | 9.042 | 081206-CEPHALOSPORINS | Keflex | CEPHALEXIN | CAPSULE | 250 MG | COVERED | FORMULARY | |
39.802 | 9.043 | 081206-CEPHALOSPORINS | Keflex | CEPHALEXIN | CAPSULE | 500 MG | COVERED | FORMULARY | |
39.812 | 9.046 | 081206-CEPHALOSPORINS | Keflex | CEPHALEXIN | SUSP RECON | 250 MG/5ML | COVERED | FORMULARY | |
39.831 | 9.049 | 081206-CEPHALOSPORINS | Keflex | CEPHALEXIN | TABLET | 500 MG | COVERED | FORMULARY | |
39.832 | 9.048 | 081206-CEPHALOSPORINS | Keflex | CEPHALEXIN | TABLET | 250 MG | COVERED | FORMULARY | |
48.792 | 24.194 | 081212-MACROLIDES | Zithromax | AZITHROMYCIN | SUSP RECON | 100 MG/5ML | COVERED | FORMULARY | |
61.199 | 18.544 | 081212-MACROLIDES | Zithromax | AZITHROMYCIN | SUSP RECON | 200 MG/5ML | COVERED | FORMULARY | |
48.793 | 26.721 | 081212-MACROLIDES | Zithromax | AZITHROMYCIN | TABLET | 250 MG | COVERED | FORMULARY | |
48.794 | 27.252 | 081212-MACROLIDES | Zithromax | AZITHROMYCIN | TABLET | 600 MG | COVERED | FORMULARY | |
61.198 | 22.624 | 081212-MACROLIDES | Zithromax | AZITHROMYCIN | TABLET | 500 MG | COVERED | FORMULARY | |
11.670 | 19.146 | 081212-MACROLIDES | Clarithromycin | CLARITHROMYCIN | SUSP RECON | 125 MG/5ML | COVERED | FORMULARY | |
48.851 | 16.368 | 081212-MACROLIDES | Biaxin | CLARITHROMYCIN | TABLET | 500 MG | COVERED | FORMULARY | |
48.852 | 16.373 | 081212-MACROLIDES | Biaxin | CLARITHROMYCIN | TABLET | 250 MG | COVERED | FORMULARY | |
40.660 | 9.258 | 081212-MACROLIDES | Erythromycin | ERYTHROMYCIN BASE | CAPSULE DR | 250 MG | COVERED | FORMULARY | |
40.720 | 9.260 | 081212-MACROLIDES | Erythrocin | ERYTHROMYCIN BASE | TABLET | 250 MG | COVERED | FORMULARY | |
40.721 | 9.262 | 081212-MACROLIDES | Erythromycin | ERYTHROMYCIN BASE | TABLET | 500 MG | COVERED | FORMULARY | |
40.730 | 9.263 | 081212-MACROLIDES | Ery-Tab | ERYTHROMYCIN BASE | TABLET DR | 250 MG | COVERED | FORMULARY | |
40.731 | 9.264 | 081212-MACROLIDES | Ery-Tab | ERYTHROMYCIN BASE | TABLET DR | 333 MG | COVERED | FORMULARY | |
40.732 | 9.265 | 081212-MACROLIDES | Ery-Tab | ERYTHROMYCIN BASE | TABLET DR | 500 MG | COVERED | FORMULARY | |
40.523 | 21.205 | 081212-MACROLIDES | EryPed 200 | ERYTHROMYCIN ETHYLSUCCINATE | SUSP RECON | 200 MG/5ML | COVERED | FORMULARY | |
40.524 | 21.206 | 081212-MACROLIDES | EryPed 400 | ERYTHROMYCIN ETHYLSUCCINATE | SUSP RECON | 400 MG/5ML | COVERED | FORMULARY | |
40.560 | 9.245 | 081212-MACROLIDES | E.E.S 400 | ERYTHROMYCIN ETHYLSUCCINATE | TABLET | 400 MG | COVERED | FORMULARY | |
40.642 | 9.255 | 081212-MACROLIDES | Erythromycin | ERYTHROMYCIN STEARATE | TABLET | 250 MG | COVERED | FORMULARY | |
39.660 | 8.995 | 081216-PENICILLINS | Amoxicillin | AMOXICILLIN | CAPSULE | 250 MG | COVERED | FORMULARY | |
39.661 | 8.996 | 081216-PENICILLINS | Amoxicillin | AMOXICILLIN | CAPSULE | 500 MG | COVERED | FORMULARY | |
39.681 | 8.997 | 081216-PENICILLINS | Amoxicillin | AMOXICILLIN | SUSP RECON | 125 MG/5ML | COVERED | FORMULARY | |
39.683 | 8.998 | 081216-PENICILLINS | Amoxicillin | AMOXICILLIN | SUSP RECON | 250 MG/5ML | COVERED | FORMULARY | |
93.375 | 42.683 | 081216-PENICILLINS | Amoxicillin | AMOXICILLIN | SUSP RECON | 400 MG/5ML | COVERED | FORMULARY | |
93.385 | 42.684 | 081216-PENICILLINS | Amoxicillin | AMOXICILLIN | SUSP RECON | 200 MG/5ML | COVERED | FORMULARY | |
39.651 | 9.001 | 081216-PENICILLINS | Amoxicillin | AMOXICILLIN | TAB CHEW | 250 MG | COVERED | FORMULARY | |
39.632 | 40.292 | 081216-PENICILLINS | Amoxicillin | AMOXICILLIN | TABLET | 875 MG | COVERED | FORMULARY | |
61.252 | 20.493 | 081216-PENICILLINS | Amoxicillin | AMOXICILLIN | TABLET | 500 MG | COVERED | FORMULARY | |
67.150 | 8.989 | 081216-PENICILLINS | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | SUSP RECON | 125-31.25 MG/5ML | COVERED | FORMULARY | |
67.151 | 8.990 | 081216-PENICILLINS | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | SUSP RECON | 250-62.5 MG/5ML | COVERED | FORMULARY | |
67.153 | 25.898 | 081216-PENICILLINS | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | SUSP RECON | 400-57 MG/5ML | COVERED | FORMULARY | |
67.154 | 26.720 | 081216-PENICILLINS | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | SUSP RECON | 200-28.5 MG/5ML | COVERED | FORMULARY | |
28.020 | 48.449 | 081216-PENICILLINS | Augmentin ES | AMOXICILLIN-POTASSIUM CLAVULANATE | SUSP RECON | 600-42.9 MG/5ML | COVERED | FORMULARY | |
67.078 | 26.719 | 081216-PENICILLINS | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | TAB CHEW | 200-28.5 MG | COVERED | FORMULARY | |
91.941 | 50.991 | 081216-PENICILLINS | Augmentin XR | AMOXICILLIN-POTASSIUM CLAVULANATE | TAB ER 12H | 1000-62.5 MG | COVERED | FORMULARY | |
67.070 | 8.991 | 081216-PENICILLINS | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | TABLET | 250-125 MG | COVERED | FORMULARY | |
67.071 | 8.992 | 081216-PENICILLINS | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | TABLET | 500-125 MG | COVERED | FORMULARY | |
67.076 | 24.668 | 081216-PENICILLINS | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | TABLET | 875-125 MG | COVERED | FORMULARY | |
39.271 | 8.941 | 081216-PENICILLINS | Ampicillin | AMPICILLIN TRIHYDRATE | CAPSULE | 250 MG | COVERED | FORMULARY | |
39.272 | 8.942 | 081216-PENICILLINS | Ampicillin | AMPICILLIN TRIHYDRATE | CAPSULE | 500 MG | COVERED | FORMULARY | |
39.313 | 8.943 | 081216-PENICILLINS | Ampicillin | AMPICILLIN TRIHYDRATE | SUSP RECON | 125 MG/5ML | COVERED | FORMULARY | |
39.316 | 8.944 | 081216-PENICILLINS | Ampicillin | AMPICILLIN TRIHYDRATE | SUSP RECON | 250 MG/5ML | COVERED | FORMULARY | |
39.541 | 8.983 | 081216-PENICILLINS | Dicloxacillin | DICLOXACILLIN SODIUM | CAPSULE | 250 MG | COVERED | FORMULARY | |
39.542 | 8.984 | 081216-PENICILLINS | Dicloxacillin | DICLOXACILLIN SODIUM | CAPSULE | 500 MG | COVERED | FORMULARY | |
39.022 | 8.876 | 081216-PENICILLINS | Penicillin V Potassium | PENICILLIN V POTASSIUM | SOLN RECON | 125 MG/5ML | COVERED | FORMULARY | |
39.024 | 8.877 | 081216-PENICILLINS | Penicillin V Potassium | PENICILLIN V POTASSIUM | SOLN RECON | 250 MG/5ML | COVERED | FORMULARY | |
39.053 | 8.879 | 081216-PENICILLINS | Penicillin V Potassium | PENICILLIN V POTASSIUM | TABLET | 250 MG | COVERED | FORMULARY | |
39.055 | 8.880 | 081216-PENICILLINS | Penicillin V Potassium | PENICILLIN V POTASSIUM | TABLET | 500 MG | COVERED | FORMULARY | |
47.050 | 9.509 | 081218-QUINOLONES | Cipro | CIPROFLOXACIN HCL | TABLET | 250 MG | COVERED | FORMULARY | |
47.051 | 9.510 | 081218-QUINOLONES | Cipro | CIPROFLOXACIN HCL | TABLET | 500 MG | COVERED | FORMULARY | |
47.052 | 9.511 | 081218-QUINOLONES | Cipro | CIPROFLOXACIN HCL | TABLET | 750 MG | COVERED | FORMULARY | |
23.725 | 58.310 | 081218-QUINOLONES | Levofloxacin | LEVOFLOXACIN | SOLUTION | 250 MG/10ML | COVERED | FORMULARY | |
47.073 | 29.927 | 081218-QUINOLONES | Levaquin | LEVOFLOXACIN | TABLET | 250 MG | COVERED | FORMULARY | |
47.074 | 29.928 | 081218-QUINOLONES | Levaquin | LEVOFLOXACIN | TABLET | 500 MG | COVERED | FORMULARY | |
89.597 | 46.771 | 081218-QUINOLONES | Levaquin | LEVOFLOXACIN | TABLET | 750 MG | COVERED | FORMULARY | |
34.942 | 71.217 | 081220-SULFONAMIDES (SYSTEMIC) | Sulfamethoxazole-Trimethoprim | SULFAMETHOXAZOLE-TRIMETHOPRIM | ORAL SUSP | 800-160 MG/20ML | COVERED | FORMULARY | |
90.150 | 9.394 | 081220-SULFONAMIDES (SYSTEMIC) | Sulfamethoxazole-Trimethoprim | SULFAMETHOXAZOLE-TRIMETHOPRIM | ORAL SUSP | 200-40 MG/5ML | COVERED | FORMULARY | |
90.161 | 9.395 | 081220-SULFONAMIDES (SYSTEMIC) | Bactrim | SULFAMETHOXAZOLE-TRIMETHOPRIM | TABLET | 400-80 MG | COVERED | FORMULARY | |
90.163 | 9.396 | 081220-SULFONAMIDES (SYSTEMIC) | Bactrim | SULFAMETHOXAZOLE-TRIMETHOPRIM | TABLET | 800-160 MG | COVERED | FORMULARY | |
41.611 | 9.402 | 081220-SULFONAMIDES (SYSTEMIC) | Azulfidine | SULFASALAZINE | TABLET | 500 MG | COVERED | FORMULARY | |
41.620 | 9.403 | 081220-SULFONAMIDES (SYSTEMIC) | Azulfidine EN | SULFASALAZINE | TABLET DR | 500 MG | COVERED | FORMULARY | |
0 | 0 | 081224-TETRACYCLINES | Doxycycline Suspension | DOXYCYCLINE | X | 25 MG/ML | COVERED | FORMULARY | |
40.331 | 9.218 | 081224-TETRACYCLINES | Doxycyline | DOXYCYCLINE HYCLATE | CAPSULE | 100 MG | COVERED | FORMULARY | |
40.333 | 9.219 | 081224-TETRACYCLINES | Doxycyline | DOXYCYCLINE HYCLATE | CAPSULE | 50 MG | COVERED | FORMULARY | |
40.360 | 9.223 | 081224-TETRACYCLINES | Doxycyline | DOXYCYCLINE HYCLATE | TABLET | 100 MG | COVERED | FORMULARY | |
40.651 | 15.943 | 081224-TETRACYCLINES | Doxycyline | DOXYCYCLINE MONOHYDRATE | CAPSULE | 100 MG | COVERED | FORMULARY | |
40.652 | 16.815 | 081224-TETRACYCLINES | Doxycyline | DOXYCYCLINE MONOHYDRATE | CAPSULE | 50 MG | COVERED | FORMULARY | |
98.271 | 62.496 | 081224-TETRACYCLINES | Doxycyline | DOXYCYCLINE MONOHYDRATE | CAPSULE | 75 MG | COVERED | FORMULARY | |
40.363 | 27.050 | 081224-TETRACYCLINES | Doxycyline | DOXYCYCLINE MONOHYDRATE | TABLET | 100 MG | COVERED | FORMULARY | |
40.410 | 9.226 | 081224-TETRACYCLINES | Minocycline | MINOCYCLINE HCL | CAPSULE | 100 MG | COVERED | FORMULARY | |
40.411 | 9.227 | 081224-TETRACYCLINES | Minocycline | MINOCYCLINE HCL | CAPSULE | 50 MG | COVERED | FORMULARY | |
93.387 | 42.778 | 081224-TETRACYCLINES | Minocycline | MINOCYCLINE HCL | CAPSULE | 75 MG | COVERED | FORMULARY | |
19.549 | 52.057 | 081224-TETRACYCLINES | Minocycline | MINOCYCLINE HCL | TABLET | 75 MG | COVERED | FORMULARY | |
40.450 | 9.230 | 081224-TETRACYCLINES | Minocycline | MINOCYCLINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
40.451 | 9.231 | 081224-TETRACYCLINES | Minocycline | MINOCYCLINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
40.830 | 9.339 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Cleocin | CLINDAMYCIN HCL | CAPSULE | 150 MG | COVERED | FORMULARY | |
40.831 | 9.341 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Cleocin | CLINDAMYCIN HCL | CAPSULE | 75 MG | COVERED | FORMULARY | |
40.832 | 9.340 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Cleocin | CLINDAMYCIN HCL | CAPSULE | 300 MG | COVERED | FORMULARY | |
40.860 | 9.346 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Cleocin Pediatric Granules | CLINDAMYCIN PALMITATE HCL | SOLN RECON | 75 MG/5ML | COVERED | FORMULARY | Restricted to age < 19 |
60.823 | 18.638 | 081404-ALLYLAMINES | Lamisil | TERBINAFINE HCL | TABLET | 250 MG | COVERED | FORMULARY | |
60.821 | 18.636 | 081408-AZOLES | Diflucan | FLUCONAZOLE | SUSP RECON | 40 MG/ML | COVERED | FORMULARY | |
42.190 | 13.723 | 081408-AZOLES | Diflucan | FLUCONAZOLE | TABLET | 100 MG | COVERED | FORMULARY | |
42.191 | 13.724 | 081408-AZOLES | Diflucan | FLUCONAZOLE | TABLET | 200 MG | COVERED | FORMULARY | |
42.192 | 13.725 | 081408-AZOLES | Diflucan | FLUCONAZOLE | TABLET | 50 MG | COVERED | FORMULARY | |
42.193 | 22.141 | 081408-AZOLES | Diflucan | FLUCONAZOLE | TABLET | 150 MG | COVERED | FORMULARY | |
42.440 | 9.537 | 081428-POLYENES | Nystatin | NYSTATIN | ORAL SUSP | 100000 UNIT/ML | COVERED | FORMULARY | |
42.452 | 9.538 | 081428-POLYENES | Nystatin | NYSTATIN | TABLET | 500000 UNIT | COVERED | FORMULARY | |
42.390 | 9.517 | 081492-ANTIFUNGALS, MISCELLANEOUS | Griseofulvin | GRISEOFULVIN MICROSIZE | ORAL SUSP | 125 MG/5ML | COVERED | FORMULARY | |
42.402 | 9.519 | 081492-ANTIFUNGALS, MISCELLANEOUS | Griseofulvin | GRISEOFULVIN MICROSIZE | TABLET | 500 MG | COVERED | FORMULARY | |
42.410 | 9.520 | 081492-ANTIFUNGALS, MISCELLANEOUS | Gris-Peg | GRISEOFULVIN ULTRAMICROSIZE | TABLET | 125 MG | COVERED | FORMULARY | |
42.412 | 9.522 | 081492-ANTIFUNGALS, MISCELLANEOUS | Gris-Peg | GRISEOFULVIN ULTRAMICROSIZE | TABLET | 250 MG | COVERED | FORMULARY | |
73.441 | 43.706 | 081828-NEURAMINIDASE INHIBITORS | Tamiflu | OSELTAMIVIR PHOSPHATE | CAPSULE | 75 MG | COVERED | FORMULARY | |
98.980 | 63.223 | 081828-NEURAMINIDASE INHIBITORS | Tamiflu | OSELTAMIVIR PHOSPHATE | CAPSULE | 30 MG | COVERED | FORMULARY | |
98.981 | 63.224 | 081828-NEURAMINIDASE INHIBITORS | Tamiflu | OSELTAMIVIR PHOSPHATE | CAPSULE | 45 MG | COVERED | FORMULARY | |
29.729 | 67.561 | 081828-NEURAMINIDASE INHIBITORS | Tamiflu | OSELTAMIVIR PHOSPHATE | SUSP RECON | 6 MG/ML | COVERED | FORMULARY | |
92.221 | 43.119 | 081828-NEURAMINIDASE INHIBITORS | Relenza | ZANAMIVIR | BLST W/DEV | 5 MG | COVERED | FORMULARY | |
43.790 | 9.630 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Zovirax | ACYCLOVIR | CAPSULE | 200 MG | COVERED | FORMULARY | |
13.721 | 15.979 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Zovirax | ACYCLOVIR | TABLET | 800 MG | COVERED | FORMULARY | |
13.724 | 16.408 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Zovirax | ACYCLOVIR | TABLET | 400 MG | COVERED | FORMULARY | |
14.179 | 48.664 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Ribavirin | RIBAVIRIN | CAPSULE | 200 MG | COVERED | FORMULARY | |
13.740 | 23.989 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Valtrex | VALACYCLOVIR HCL | TABLET | 500 MG | COVERED | FORMULARY | |
13.742 | 30.607 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Valtrex | VALACYCLOVIR HCL | TABLET | 1000 MG | COVERED | FORMULARY | |
42.940 | 9.580 | 083008-ANTIMALARIALS | Plaquenil | HYDROXYCHLOROQUINE SULFATE | TABLET | 200 MG | COVERED | FORMULARY | |
43.031 | 9.591 | 083092-ANTIPROTOZOALS, MISCELLANEOUS | Flagyl | METRONIDAZOLE | TABLET | 250 MG | COVERED | FORMULARY | |
43.032 | 9.592 | 083092-ANTIPROTOZOALS, MISCELLANEOUS | Flagyl | METRONIDAZOLE | TABLET | 500 MG | COVERED | FORMULARY | |
41.870 | 9.434 | 083600-URINARY ANTI-INFECTIVES | Furadantin | NITROFURANTOIN | ORAL SUSP | 25 MG/5ML | COVERED | FORMULARY | |
41.820 | 9.428 | 083600-URINARY ANTI-INFECTIVES | Macrodantin | NITROFURANTOIN MACROCRYSTAL | CAPSULE | 100 MG | COVERED | FORMULARY | |
41.822 | 9.430 | 083600-URINARY ANTI-INFECTIVES | Macrodantin | NITROFURANTOIN MACROCRYSTAL | CAPSULE | 50 MG | COVERED | FORMULARY | |
49.001 | 16.598 | 083600-URINARY ANTI-INFECTIVES | Macrobid | NITROFURANTOIN MONOHYDRATE-MACROCRYSTAL | CAPSULE | 100 MG | COVERED | FORMULARY | |
5.987 | 35.495 | 084080-ANTIPRURITICS AND LOCAL ANESTHETICS | Emla Cream | LIDOCAINE/PRILOCAINE | CREAM (G) | 2.5 %-2.5% | COVERED | FORMULARY | |
38.370 | 8.772 | 100000-ANTINEOPLASTIC AGENTS | Leukeran | CHLORAMBUCIL | TABLET | 2 MG | COVERED | FORMULARY | |
38.400 | 8.775 | 100000-ANTINEOPLASTIC AGENTS | Hydrea | HYDROXYUREA | CAPSULE | 500 MG | COVERED | FORMULARY | |
49.541 | 29.821 | 100000-ANTINEOPLASTIC AGENTS | Femara | LETROZOLE | TABLET | 2.5 MG | COVERED | FORMULARY | |
33.559 | 70.193 | 100000-ANTINEOPLASTIC AGENTS | Megace | MEGESTROL ACETATE | ORAL SUSP | 400 MG/10ML | COVERED | FORMULARY | |
40.381 | 21.004 | 100000-ANTINEOPLASTIC AGENTS | Megace | MEGESTROL ACETATE | ORAL SUSP | 400 MG/10ML | COVERED | FORMULARY | |
38.681 | 8.829 | 100000-ANTINEOPLASTIC AGENTS | Megace | MEGESTROL ACETATE | TABLET | 40 MG | COVERED | FORMULARY | |
38.380 | 8.773 | 100000-ANTINEOPLASTIC AGENTS | Alkeran | MELPHALAN | TABLET | 2 MG | COVERED | FORMULARY | |
38.520 | 8.802 | 100000-ANTINEOPLASTIC AGENTS | Mercaptopurine | MERCAPTOPURINE | TABLET | 50 MG | COVERED | FORMULARY | |
38.489 | 36.872 | 100000-ANTINEOPLASTIC AGENTS | Methotrexate | METHOTREXATE SODIUM | TABLET | 2.5 MG | COVERED | FORMULARY | |
38.720 | 8.832 | 100000-ANTINEOPLASTIC AGENTS | Tamoxifen | TAMOXIFEN CITRATE | TABLET | 10 MG | COVERED | FORMULARY | |
38.721 | 13.574 | 100000-ANTINEOPLASTIC AGENTS | Tamoxifen | TAMOXIFEN CITRATE | TABLET | 20 MG | COVERED | FORMULARY | |
18.351 | 4.740 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Urecholine | BETHANECHOL CHLORIDE | TABLET | 10 MG | COVERED | FORMULARY | |
18.352 | 4.741 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Urecholine | BETHANECHOL CHLORIDE | TABLET | 25 MG | COVERED | FORMULARY | |
4.300 | 29.334 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Aricept | DONEPEZIL HCL | TABLET | 10 MG | COVERED | FORMULARY | |
4.302 | 29.335 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Aricept | DONEPEZIL HCL | TABLET | 5 MG | COVERED | FORMULARY | |
84.853 | 46.925 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Razadyne | GALANTAMINE HBR | TABLET | 12 MG | COVERED | FORMULARY | |
84.854 | 46.926 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Razadyne | GALANTAMINE HBR | TABLET | 4 MG | COVERED | FORMULARY | |
84.855 | 46.927 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Razadyne | GALANTAMINE HBR | TABLET | 8 MG | COVERED | FORMULARY | |
21.353 | 53.658 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Salagen | PILOCARPINE HCL | TABLET | 7.5 MG | COVERED | FORMULARY | |
24.671 | 21.731 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Salagen | PILOCARPINE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
90.396 | 40.155 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Exelon | RIVASTIGMINE TARTRATE | CAPSULE | 1.5 MG | COVERED | FORMULARY | |
90.397 | 40.156 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Exelon | RIVASTIGMINE TARTRATE | CAPSULE | 3 MG | COVERED | FORMULARY | |
90.398 | 40.157 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Exelon | RIVASTIGMINE TARTRATE | CAPSULE | 4.5 MG | COVERED | FORMULARY | |
90.399 | 40.158 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Exelon | RIVASTIGMINE TARTRATE | CAPSULE | 6 MG | COVERED | FORMULARY | |
74.801 | 4.902 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Librax | CHLORDIAZEPOXIDE-CLIDINIUM BR | CAPSULE | 5-2.5 MG | COVERED | FORMULARY | |
19.261 | 4.918 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Bentyl | DICYCLOMINE HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
34.719 | 71.032 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Bentyl | DICYCLOMINE HCL | SOLUTION | 10 MG/5ML | COVERED | FORMULARY | |
19.331 | 4.924 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Bentyl | DICYCLOMINE HCL | TABLET | 20 MG | COVERED | FORMULARY | |
18.960 | 23.715 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Symax SR | HYOSCYAMINE SULFATE | TAB ER 12H | 0.375 MG | COVERED | FORMULARY | |
13.299 | 47.546 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Anaspaz, Symax FT | HYOSCYAMINE SULFATE | TAB RAPDIS | 0.125 MG | COVERED | FORMULARY | |
18.970 | 4.868 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Symax SL | HYOSCYAMINE SULFATE | TAB SUBL | 0.125 MG | COVERED | FORMULARY | |
18.961 | 4.865 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Levsin, Oscimin | HYOSCYAMINE SULFATE | TABLET | 0.125 MG | COVERED | FORMULARY | |
42.235 | 21.700 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Ipratropium Bromide | IPRATROPIUM BROMIDE | SOLUTION | 0.2 MG/ML | COVERED | FORMULARY | |
13.456 | 48.018 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Ipatropium-Albuterol Inhalation | IPRATROPIUM-ALBUTEROL SULFATE | AMPUL-NEB | 0.5-3 MG/3ML | COVERED | FORMULARY | |
22.913 | 28.090 | 121208-BETA-ADRENERGIC AGONISTS | Proventil HFA, Ventolin HFA, ProAir HFA | ALBUTEROL SULFATE | HFA AER AD | 90 MCG | COVERED | FORMULARY | |
22.780 | 5.032 | 121208-BETA-ADRENERGIC AGONISTS | Albuterol Sulfate | ALBUTEROL SULFATE | SYRUP | 2 MG/5ML | COVERED | FORMULARY | |
20.100 | 5.033 | 121208-BETA-ADRENERGIC AGONISTS | Albuterol Sulfate | ALBUTEROL SULFATE | TABLET | 2 MG | COVERED | FORMULARY | |
20.101 | 5.034 | 121208-BETA-ADRENERGIC AGONISTS | Albuterol Sulfate | ALBUTEROL SULFATE | TABLET | 4 MG | COVERED | FORMULARY | |
14.634 | 48.699 | 121208-BETA-ADRENERGIC AGONISTS | Albuterol Sulfate Inhalation | ALBUTEROL SULFATE | VIAL-NEB | 1.25 MG/3ML | COVERED | FORMULARY | |
41.681 | 5.039 | 121208-BETA-ADRENERGIC AGONISTS | Albuterol Sulfate Inhalation | ALBUTEROL SULFATE | VIAL-NEB | 2.5 MG/3ML | COVERED | FORMULARY | |
20.071 | 5.026 | 121208-BETA-ADRENERGIC AGONISTS | Terbutaline | TERBUTALINE SULFATE | TABLET | 5 MG | COVERED | FORMULARY | |
20.072 | 5.025 | 121208-BETA-ADRENERGIC AGONISTS | Terbutaline | TERBUTALINE SULFATE | TABLET | 2.5 MG | COVERED | FORMULARY | |
19.861 | 16.878 | 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS | EPINEPHRINE AUTO-INJECT | EPINEPHRINE | AUTO INJCT | 0.15 MG/0.3ML | COVERED | FORMULARY | |
19.862 | 16.879 | 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS | EPINEPHRINE AUTO-INJECT | EPINEPHRINE | AUTO INJCT | 0.3 MG/0.3ML | COVERED | FORMULARY | |
48.191 | 27.546 | 121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) | Flomax | TAMSULOSIN HCL | CAP ER 24H | 0.4 MG | COVERED | FORMULARY | |
17.901 | 4.660 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Parafon Forte | CHLORZOXAZONE | TABLET | 500 MG | COVERED | FORMULARY | |
12.805 | 47.478 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Flexeril | CYCLOBENZAPRINE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
18.020 | 4.681 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Flexeril | CYCLOBENZAPRINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
17.892 | 4.654 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Robaxin | METHOCARBAMOL | TABLET | 500 MG | COVERED | FORMULARY | |
17.893 | 4.655 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Robaxin | METHOCARBAMOL | TABLET | 750 MG | COVERED | FORMULARY | |
24.433 | 58.904 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Zanaflex | TIZANIDINE HCL | CAPSULE | 2 MG | COVERED | FORMULARY | |
24.434 | 58.905 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Zanaflex | TIZANIDINE HCL | CAPSULE | 4 MG | COVERED | FORMULARY | |
14.690 | 27.447 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Zanaflex | TIZANIDINE HCL | TABLET | 2 MG | COVERED | FORMULARY | |
14.693 | 30.274 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Zanaflex | TIZANIDINE HCL | TABLET | 4 MG | COVERED | FORMULARY | |
18.012 | 27.229 | 122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT | Baclofen | BACLOFEN | TABLET | 5 MG | COVERED | FORMULARY | |
18.010 | 4.679 | 122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT | Baclofen | BACLOFEN | TABLET | 10 MG | COVERED | FORMULARY | |
18.011 | 4.680 | 122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT | Baclofen | BACLOFEN | TABLET | 20 MG | COVERED | FORMULARY | |
420 | 19.331 | 201204-ANTICOAGULANTS | Lovenox | ENOXAPARIN SODIUM | SYRINGE | 30 MG/0.3ML | COVERED | FORMULARY | Limited to 14 day supplies, Prior Auth for >14 days |
42.071 | 44.668 | 201204-ANTICOAGULANTS | Lovenox | ENOXAPARIN SODIUM | SYRINGE | 150 MG/ML | COVERED | FORMULARY | Limited to 14 day supplies, Prior Auth for >14 days |
42.091 | 44.669 | 201204-ANTICOAGULANTS | Lovenox | ENOXAPARIN SODIUM | SYRINGE | 120 MG/0.8ML | COVERED | FORMULARY | Limited to 14 day supplies, Prior Auth for >14 days |
62.771 | 27.993 | 201204-ANTICOAGULANTS | Lovenox | ENOXAPARIN SODIUM | SYRINGE | 60 MG/0.6ML | COVERED | FORMULARY | Limited to 14 day supplies, Prior Auth for >14 days |
62.772 | 27.994 | 201204-ANTICOAGULANTS | Lovenox | ENOXAPARIN SODIUM | SYRINGE | 80 MG/0.8ML | COVERED | FORMULARY | Limited to 14 day supplies, Prior Auth for >14 days |
62.773 | 27.995 | 201204-ANTICOAGULANTS | Lovenox | ENOXAPARIN SODIUM | SYRINGE | 100 MG/ML | COVERED | FORMULARY | Limited to 14 day supplies, Prior Auth for >14 days |
70.022 | 39.482 | 201204-ANTICOAGULANTS | Lovenox | ENOXAPARIN SODIUM | SYRINGE | 40 MG/0.4ML | COVERED | FORMULARY | Limited to 14 day supplies, Prior Auth for >14 days |
25.691 | 6.549 | 201204-ANTICOAGULANTS | Heparin | HEPARIN SODIUM PORCINE | VIAL | 5000 UNIT/ML | COVERED | FORMULARY | |
25.697 | 6.544 | 201204-ANTICOAGULANTS | Heparin | HEPARIN SODIUM PORCINE | VIAL | 10000 UNIT/ML | COVERED | FORMULARY | |
25.790 | 6.559 | 201204-ANTICOAGULANTS | Coumadin, Jantoven | WARFARIN SODIUM | TABLET | 10 MG | COVERED | FORMULARY | |
25.791 | 6.561 | 201204-ANTICOAGULANTS | Coumadin, Jantoven | WARFARIN SODIUM | TABLET | 2 MG | COVERED | FORMULARY | |
25.792 | 14.198 | 201204-ANTICOAGULANTS | Coumadin, Jantoven | WARFARIN SODIUM | TABLET | 1 MG | COVERED | FORMULARY | |
25.793 | 6.562 | 201204-ANTICOAGULANTS | Coumadin, Jantoven | WARFARIN SODIUM | TABLET | 5 MG | COVERED | FORMULARY | |
25.794 | 6.560 | 201204-ANTICOAGULANTS | Coumadin, Jantoven | WARFARIN SODIUM | TABLET | 2.5 MG | COVERED | FORMULARY | |
25.795 | 6.563 | 201204-ANTICOAGULANTS | Coumadin, Jantoven | WARFARIN SODIUM | TABLET | 7.5 MG | COVERED | FORMULARY | |
25.796 | 18.080 | 201204-ANTICOAGULANTS | Coumadin, Jantoven | WARFARIN SODIUM | TABLET | 3 MG | COVERED | FORMULARY | |
25.797 | 19.486 | 201204-ANTICOAGULANTS | Coumadin, Jantoven | WARFARIN SODIUM | TABLET | 4 MG | COVERED | FORMULARY | |
25.798 | 30.475 | 201204-ANTICOAGULANTS | Coumadin, Jantoven | WARFARIN SODIUM | TABLET | 6 MG | COVERED | FORMULARY | |
8.602 | 37.978 | 201218-PLATELET-AGGREGATION INHIBITORS | Pletal | CILOSTAZOL | TABLET | 100 MG | COVERED | FORMULARY | |
8.603 | 37.979 | 201218-PLATELET-AGGREGATION INHIBITORS | Pletal | CILOSTAZOL | TABLET | 50 MG | COVERED | FORMULARY | |
96.010 | 38.164 | 201218-PLATELET-AGGREGATION INHIBITORS | Plavix | CLOPIDOGREL BISULFATE | TABLET | 75 MG | COVERED | FORMULARY | |
11.800 | 6.573 | 202400-HEMORRHEOLOGIC AGENTS | Pentoxifylline | PENTOXIFYLLINE | TABLET ER | 400 MG | COVERED | FORMULARY | |
25.580 | 6.503 | 202816-HEMOSTATICS | Amicar | AMINOCAPROIC ACID | SOLUTION | 250 MG/ML | COVERED | FORMULARY | |
10.920 | 266 | 240404-ANTIARRHYTHMIC AGENTS | Pacerone | AMIODARONE HCL | TABLET | 200 MG | COVERED | FORMULARY | |
1.130 | 239 | 240404-ANTIARRHYTHMIC AGENTS | Norpace | DISOPYRAMIDE PHOSPHATE | CAPSULE | 100 MG | COVERED | FORMULARY | |
1.580 | 263 | 240404-ANTIARRHYTHMIC AGENTS | Flecainide | FLECAINIDE ACETATE | TABLET | 100 MG | COVERED | FORMULARY | |
1.581 | 265 | 240404-ANTIARRHYTHMIC AGENTS | Flecainide | FLECAINIDE ACETATE | TABLET | 50 MG | COVERED | FORMULARY | |
1.011 | 215 | 240404-ANTIARRHYTHMIC AGENTS | Quinidine | QUINIDINE GLUCONATE | TABLET ER | 324 MG | COVERED | FORMULARY | |
132 | 18 | 240408-CARDIOTONIC AGENTS | Lanoxin | DIGOXIN | TABLET | 125 MCG | COVERED | FORMULARY | |
133 | 19 | 240408-CARDIOTONIC AGENTS | Lanoxin | DIGOXIN | TABLET | 250 MCG | COVERED | FORMULARY | |
9.850 | 3.100 | 240604-BILE ACID SEQUESTRANTS | Prevalite | CHOLESTYRAMINE (WITH ASPARTAME) | POWD PACK | 4 G | COVERED | FORMULARY | |
98.654 | 62.885 | 240604-BILE ACID SEQUESTRANTS | Questran Light | CHOLESTYRAMINE (WITH ASPARTAME) | POWDER | 4 G | COVERED | FORMULARY | |
9.920 | 13.675 | 240604-BILE ACID SEQUESTRANTS | Questran | CHOLESTYRAMINE (WITH SUGAR) | POWD PACK | 4 G | COVERED | FORMULARY | |
14.295 | 48.571 | 240604-BILE ACID SEQUESTRANTS | Questran | CHOLESTYRAMINE (WITH SUGAR) | POWDER | 4 G | COVERED | FORMULARY | |
12.595 | 44.915 | 240606-FIBRIC ACID DERIVATIVES | Lofibra | FENOFIBRATE | TABLET | 160 MG | COVERED | FORMULARY | |
13.266 | 64.310 | 240606-FIBRIC ACID DERIVATIVES | Lofibra | FENOFIBRATE | TABLET | 54 MG | COVERED | FORMULARY | |
92.504 | 44.305 | 240606-FIBRIC ACID DERIVATIVES | Lofibra | FENOFIBRATE MICRONIZED | CAPSULE | 134 MG | COVERED | FORMULARY | |
93.437 | 43.060 | 240606-FIBRIC ACID DERIVATIVES | Lofibra | FENOFIBRATE MICRONIZED | CAPSULE | 200 MG | COVERED | FORMULARY | |
93.446 | 43.061 | 240606-FIBRIC ACID DERIVATIVES | Lofibra | FENOFIBRATE MICRONIZED | CAPSULE | 67 MG | COVERED | FORMULARY | |
25.540 | 6.416 | 240606-FIBRIC ACID DERIVATIVES | Lopid | GEMFIBROZIL | TABLET | 600 MG | COVERED | FORMULARY | |
43.720 | 29.967 | 240608-HMG-COA REDUCTASE INHIBITORS | Lipitor | ATORVASTATIN CALCIUM | TABLET | 10 MG | COVERED | FORMULARY | |
43.721 | 29.968 | 240608-HMG-COA REDUCTASE INHIBITORS | Lipitor | ATORVASTATIN CALCIUM | TABLET | 20 MG | COVERED | FORMULARY | |
43.722 | 29.969 | 240608-HMG-COA REDUCTASE INHIBITORS | Lipitor | ATORVASTATIN CALCIUM | TABLET | 40 MG | COVERED | FORMULARY | |
43.723 | 45.772 | 240608-HMG-COA REDUCTASE INHIBITORS | Lipitor | ATORVASTATIN CALCIUM | TABLET | 80 MG | COVERED | FORMULARY | |
47.040 | 6.460 | 240608-HMG-COA REDUCTASE INHIBITORS | Lovastatin | LOVASTATIN | TABLET | 20 MG | COVERED | FORMULARY | |
47.041 | 6.461 | 240608-HMG-COA REDUCTASE INHIBITORS | Lovastatin | LOVASTATIN | TABLET | 40 MG | COVERED | FORMULARY | |
47.042 | 16.310 | 240608-HMG-COA REDUCTASE INHIBITORS | Lovastatin | LOVASTATIN | TABLET | 10 MG | COVERED | FORMULARY | |
15.412 | 49.758 | 240608-HMG-COA REDUCTASE INHIBITORS | Pravachol | PRAVASTATIN SODIUM | TABLET | 80 MG | COVERED | FORMULARY | |
48.671 | 16.366 | 240608-HMG-COA REDUCTASE INHIBITORS | Pravachol | PRAVASTATIN SODIUM | TABLET | 10 MG | COVERED | FORMULARY | |
48.672 | 16.367 | 240608-HMG-COA REDUCTASE INHIBITORS | Pravachol | PRAVASTATIN SODIUM | TABLET | 20 MG | COVERED | FORMULARY | |
48.673 | 20.741 | 240608-HMG-COA REDUCTASE INHIBITORS | Pravachol | PRAVASTATIN SODIUM | TABLET | 40 MG | COVERED | FORMULARY | |
26.531 | 16.576 | 240608-HMG-COA REDUCTASE INHIBITORS | Zocor | SIMVASTATIN | TABLET | 5 MG | COVERED | FORMULARY | |
26.532 | 16.577 | 240608-HMG-COA REDUCTASE INHIBITORS | Zocor | SIMVASTATIN | TABLET | 10 MG | COVERED | FORMULARY | |
26.533 | 16.578 | 240608-HMG-COA REDUCTASE INHIBITORS | Zocor | SIMVASTATIN | TABLET | 20 MG | COVERED | FORMULARY | |
26.534 | 16.579 | 240608-HMG-COA REDUCTASE INHIBITORS | Zocor | SIMVASTATIN | TABLET | 40 MG | COVERED | FORMULARY | |
42.331 | 33.364 | 240692-ANTILIPEMIC AGENTS, MISCELLANEOUS | Niaspan ER | NIACIN | TAB ER 24H | 500 MG | COVERED | FORMULARY | |
42.332 | 33.365 | 240692-ANTILIPEMIC AGENTS, MISCELLANEOUS | Niaspan ER | NIACIN | TAB ER 24H | 750 MG | COVERED | FORMULARY | |
42.333 | 33.366 | 240692-ANTILIPEMIC AGENTS, MISCELLANEOUS | Niaspan ER | NIACIN | TAB ER 24H | 1000 MG | COVERED | FORMULARY | |
23.870 | 343 | 240816-CENTRAL ALPHA-AGONISTS | Catapres TTS | CLONIDINE | PATCH TDWK | 0.1 MG/24HR | COVERED | FORMULARY | |
23.871 | 344 | 240816-CENTRAL ALPHA-AGONISTS | Catapres TTS | CLONIDINE | PATCH TDWK | 0.2 MG/24HR | COVERED | FORMULARY | |
23.872 | 345 | 240816-CENTRAL ALPHA-AGONISTS | Catapres TTS | CLONIDINE | PATCH TDWK | 0.3 MG/24HR | COVERED | FORMULARY | |
1.390 | 346 | 240816-CENTRAL ALPHA-AGONISTS | Catapres | CLONIDINE HCL | TABLET | 0.1 MG | COVERED | FORMULARY | |
1.391 | 347 | 240816-CENTRAL ALPHA-AGONISTS | Catapres | CLONIDINE HCL | TABLET | 0.2 MG | COVERED | FORMULARY | |
1.392 | 348 | 240816-CENTRAL ALPHA-AGONISTS | Catapres | CLONIDINE HCL | TABLET | 0.3 MG | COVERED | FORMULARY | |
32.480 | 364 | 240816-CENTRAL ALPHA-AGONISTS | Tenex | GUANFACINE HCL | TABLET | 1 MG | COVERED | FORMULARY | |
32.481 | 11.984 | 240816-CENTRAL ALPHA-AGONISTS | Tenex | GUANFACINE HCL | TABLET | 2 MG | COVERED | FORMULARY | |
1.431 | 361 | 240816-CENTRAL ALPHA-AGONISTS | Methyldopa | METHYLDOPA | TABLET | 250 MG | COVERED | FORMULARY | |
1.432 | 362 | 240816-CENTRAL ALPHA-AGONISTS | Methyldopa | METHYLDOPA | TABLET | 500 MG | COVERED | FORMULARY | |
1.241 | 284 | 240820-DIRECT VASODILATORS | Hydralazine | HYDRALAZINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
1.242 | 285 | 240820-DIRECT VASODILATORS | Hydralazine | HYDRALAZINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
1.243 | 286 | 240820-DIRECT VASODILATORS | Hydralazine | HYDRALAZINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
1.244 | 287 | 240820-DIRECT VASODILATORS | Hydralazine | HYDRALAZINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
1.290 | 299 | 240820-DIRECT VASODILATORS | Minoxidil | MINOXIDIL | TABLET | 10 MG | COVERED | FORMULARY | |
1.291 | 300 | 240820-DIRECT VASODILATORS | Minoxidil | MINOXIDIL | TABLET | 2.5 MG | COVERED | FORMULARY | |
1.942 | 507 | 241208-NITRATES AND NITRITES | Isordil | ISOSORBIDE DINITRATE | TABLET | 10 MG | COVERED | FORMULARY | |
1.944 | 508 | 241208-NITRATES AND NITRITES | Isordil | ISOSORBIDE DINITRATE | TABLET | 20 MG | COVERED | FORMULARY | |
1.945 | 509 | 241208-NITRATES AND NITRITES | Isordil | ISOSORBIDE DINITRATE | TABLET | 30 MG | COVERED | FORMULARY | |
1.947 | 511 | 241208-NITRATES AND NITRITES | Isordil | ISOSORBIDE DINITRATE | TABLET | 5 MG | COVERED | FORMULARY | |
48.102 | 17.297 | 241208-NITRATES AND NITRITES | Isosorbide Mononitrate ER | ISOSORBIDE MONONITRATE | TAB ER 24H | 60 MG | COVERED | FORMULARY | |
48.103 | 23.474 | 241208-NITRATES AND NITRITES | Isosorbide Mononitrate ER | ISOSORBIDE MONONITRATE | TAB ER 24H | 120 MG | COVERED | FORMULARY | |
48.104 | 24.488 | 241208-NITRATES AND NITRITES | Isosorbide Mononitrate ER | ISOSORBIDE MONONITRATE | TAB ER 24H | 30 MG | COVERED | FORMULARY | |
1.931 | 16.639 | 241208-NITRATES AND NITRITES | Isosorbide Mononitrate | ISOSORBIDE MONONITRATE | TABLET | 20 MG | COVERED | FORMULARY | |
1.932 | 17.294 | 241208-NITRATES AND NITRITES | Isosorbide Mononitrate | ISOSORBIDE MONONITRATE | TABLET | 10 MG | COVERED | FORMULARY | |
1.681 | 455 | 241208-NITRATES AND NITRITES | Nitro-Time | NITROGLYCERIN | CAPSULE ER | 2.5 MG | COVERED | FORMULARY | |
1.682 | 456 | 241208-NITRATES AND NITRITES | Nitro-Time | NITROGLYCERIN | CAPSULE ER | 6.5 MG | COVERED | FORMULARY | |
1.684 | 457 | 241208-NITRATES AND NITRITES | Nitro-Time | NITROGLYCERIN | CAPSULE ER | 9 MG | COVERED | FORMULARY | |
1.740 | 465 | 241208-NITRATES AND NITRITES | Minitran | NITROGLYCERIN | PATCH TD24 | 0.4 MG/HR | COVERED | FORMULARY | |
1.741 | 467 | 241208-NITRATES AND NITRITES | Minitran | NITROGLYCERIN | PATCH TD24 | 0.1 MG/HR | COVERED | FORMULARY | |
1.742 | 468 | 241208-NITRATES AND NITRITES | Minitran | NITROGLYCERIN | PATCH TD24 | 0.2 MG/HR | COVERED | FORMULARY | |
92.257 | 44.359 | 241208-NITRATES AND NITRITES | Nitrolingual | NITROGLYCERIN | SPRAY | 400 MCG/SPRAY | COVERED | FORMULARY | |
1.771 | 474 | 241208-NITRATES AND NITRITES | Nitrostat | NITROGLYCERIN | TAB SUBL | 0.3 MG | COVERED | FORMULARY | |
1.772 | 475 | 241208-NITRATES AND NITRITES | Nitrostat | NITROGLYCERIN | TAB SUBL | 0.4 MG | COVERED | FORMULARY | |
1.773 | 476 | 241208-NITRATES AND NITRITES | Nitrostat | NITROGLYCERIN | TAB SUBL | 0.6 MG | COVERED | FORMULARY | |
53.141 | 41.698 | 241292-VASODILATING AGENTS, MISCELLANEOUS | Persantine | DIPYRIDAMOLE | TABLET | 25 MG | COVERED | FORMULARY | |
53.142 | 41.699 | 241292-VASODILATING AGENTS, MISCELLANEOUS | Persantine | DIPYRIDAMOLE | TABLET | 50 MG | COVERED | FORMULARY | |
53.143 | 41.700 | 241292-VASODILATING AGENTS, MISCELLANEOUS | Persantine | DIPYRIDAMOLE | TABLET | 75 MG | COVERED | FORMULARY | |
84.848 | 46.923 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Cardura XL | DOXAZOSIN MESYLATE | TAB ER 24 | 8 MG | COVERED | FORMULARY | |
91.985 | 44.421 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Cardura XL | DOXAZOSIN MESYLATE | TAB ER 24 | 4 MG | COVERED | FORMULARY | |
33.431 | 15.584 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Cardura | DOXAZOSIN MESYLATE | TABLET | 1 MG | COVERED | FORMULARY | |
33.432 | 15.585 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Cardura | DOXAZOSIN MESYLATE | TABLET | 2 MG | COVERED | FORMULARY | |
33.433 | 15.586 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Cardura | DOXAZOSIN MESYLATE | TABLET | 4 MG | COVERED | FORMULARY | |
33.434 | 15.587 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Cardura | DOXAZOSIN MESYLATE | TABLET | 8 MG | COVERED | FORMULARY | |
1.250 | 291 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Minipress | PRAZOSIN HCL | CAPSULE | 1 MG | COVERED | FORMULARY | |
1.251 | 292 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Minipress | PRAZOSIN HCL | CAPSULE | 2 MG | COVERED | FORMULARY | |
1.252 | 293 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Minipress | PRAZOSIN HCL | CAPSULE | 5 MG | COVERED | FORMULARY | |
47.124 | 22.649 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Terazosin | TERAZOSIN HCL | CAPSULE | 1 MG | COVERED | FORMULARY | |
47.125 | 22.650 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Terazosin | TERAZOSIN HCL | CAPSULE | 2 MG | COVERED | FORMULARY | |
47.126 | 22.651 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Terazosin | TERAZOSIN HCL | CAPSULE | 5 MG | COVERED | FORMULARY | |
47.127 | 22.652 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Terazosin | TERAZOSIN HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
12.947 | 47.586 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Toprol XL | METOPROLOL SUCCINATE | TAB ER 24H | 25 MG | COVERED | FORMULARY | |
20.741 | 16.599 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Toprol XL | METOPROLOL SUCCINATE | TAB ER 24H | 50 MG | COVERED | FORMULARY | |
20.742 | 16.600 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Toprol XL | METOPROLOL SUCCINATE | TAB ER 24H | 100 MG | COVERED | FORMULARY | |
20.743 | 16.601 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Toprol XL | METOPROLOL SUCCINATE | TAB ER 24H | 200 MG | COVERED | FORMULARY | |
20.660 | 5.138 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Tenormin | ATENOLOL | TABLET | 100 MG | COVERED | FORMULARY | |
20.661 | 5.139 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Tenormin | ATENOLOL | TABLET | 50 MG | COVERED | FORMULARY | |
20.662 | 15.864 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Tenormin | ATENOLOL | TABLET | 25 MG | COVERED | FORMULARY | |
66.990 | 420 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Tenoretic | ATENOLOL-CHLORTHALIDONE | TABLET | 50-25 MG | COVERED | FORMULARY | |
66.991 | 419 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Tenoretic | ATENOLOL-CHLORTHALIDONE | TABLET | 100-25 MG | COVERED | FORMULARY | |
63.820 | 17.955 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Zebeta | BISOPROLOL FUMARATE | TABLET | 10 MG | COVERED | FORMULARY | |
63.821 | 17.956 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Zebeta | BISOPROLOL FUMARATE | TABLET | 5 MG | COVERED | FORMULARY | |
45.061 | 21.139 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Ziac | BISOPROLOL FUMARATE-HCTZ | TABLET | 2.5-6.25 MG | COVERED | FORMULARY | |
45.062 | 21.140 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Ziac | BISOPROLOL FUMARATE-HCTZ | TABLET | 5-6.25 MG | COVERED | FORMULARY | |
45.063 | 21.141 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Ziac | BISOPROLOL FUMARATE-HCTZ | TABLET | 10-6.2 5MG | COVERED | FORMULARY | |
1.551 | 19.293 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg | CARVEDILOL | TABLET | 25 MG | COVERED | FORMULARY | |
1.552 | 22.233 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg | CARVEDILOL | TABLET | 12.5 MG | COVERED | FORMULARY | |
1.553 | 28.108 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg | CARVEDILOL | TABLET | 3.125 MG | COVERED | FORMULARY | |
1.554 | 28.109 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg | CARVEDILOL | TABLET | 6.25 MG | COVERED | FORMULARY | |
10.340 | 5.100 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Labetalol | LABETALOL HCL | TABLET | 300 MG | COVERED | FORMULARY | |
10.341 | 5.099 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Labetalol | LABETALOL HCL | TABLET | 200 MG | COVERED | FORMULARY | |
10.342 | 5.098 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Labetalol | LABETALOL HCL | TABLET | 100 MG | COVERED | FORMULARY | |
17.734 | 50.631 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Lopressor | METOPROLOL TARTRATE | TABLET | 25 MG | COVERED | FORMULARY | |
20.641 | 5.131 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Lopressor | METOPROLOL TARTRATE | TABLET | 100 MG | COVERED | FORMULARY | |
20.642 | 5.132 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Lopressor | METOPROLOL TARTRATE | TABLET | 50 MG | COVERED | FORMULARY | |
20.652 | 5.136 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Corgard | NADOLOL | TABLET | 40 MG | COVERED | FORMULARY | |
20.653 | 5.137 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Corgard | NADOLOL | TABLET | 80 MG | COVERED | FORMULARY | |
20.654 | 5.135 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Corgard | NADOLOL | TABLET | 20 MG | COVERED | FORMULARY | |
3.230 | 5.116 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Inderal LA | PROPRANOLOL HCL | CAP SA 24H | 80 MG | COVERED | FORMULARY | |
3.231 | 5.113 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Inderal LA | PROPRANOLOL HCL | CAP SA 24H | 120 MG | COVERED | FORMULARY | |
3.232 | 5.114 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Inderal LA | PROPRANOLOL HCL | CAP SA 24H | 160 MG | COVERED | FORMULARY | |
3.233 | 5.115 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Inderal LA | PROPRANOLOL HCL | CAP SA 24H | 60 MG | COVERED | FORMULARY | |
20.630 | 5.123 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Propranolol | PROPRANOLOL HCL | TABLET | 10 MG | COVERED | FORMULARY | |
20.631 | 5.124 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Propranolol | PROPRANOLOL HCL | TABLET | 20 MG | COVERED | FORMULARY | |
20.632 | 5.125 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Propranolol | PROPRANOLOL HCL | TABLET | 40 MG | COVERED | FORMULARY | |
20.633 | 5.126 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Propranolol | PROPRANOLOL HCL | TABLET | 60 MG | COVERED | FORMULARY | |
20.634 | 5.127 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Propranolol | PROPRANOLOL HCL | TABLET | 80 MG | COVERED | FORMULARY | |
39.511 | 13.497 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Betapace | SOTALOL HCL | TABLET | 160 MG | COVERED | FORMULARY | |
39.512 | 17.196 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Betapace | SOTALOL HCL | TABLET | 80 MG | COVERED | FORMULARY | |
39.516 | 24.097 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Betapace | SOTALOL HCL | TABLET | 120 MG | COVERED | FORMULARY | |
2.681 | 16.925 | 242808-DIHYDROPYRIDINES | Norvasc | AMLODIPINE BESYLATE | TABLET | 2.5 MG | COVERED | FORMULARY | |
2.682 | 16.927 | 242808-DIHYDROPYRIDINES | Norvasc | AMLODIPINE BESYLATE | TABLET | 10 MG | COVERED | FORMULARY | |
2.683 | 16.926 | 242808-DIHYDROPYRIDINES | Norvasc | AMLODIPINE BESYLATE | TABLET | 5 MG | COVERED | FORMULARY | |
17.604 | 50.519 | 242808-DIHYDROPYRIDINES | Lotrel | AMLODIPINE BESYLATE-BENAZEPRIL | CAPSULE | 10-20 MG | COVERED | FORMULARY | |
26.949 | 60.722 | 242808-DIHYDROPYRIDINES | Lotrel | AMLODIPINE BESYLATE-BENAZEPRIL | CAPSULE | 5-40 MG | COVERED | FORMULARY | |
26.950 | 60.723 | 242808-DIHYDROPYRIDINES | Lotrel | AMLODIPINE BESYLATE-BENAZEPRIL | CAPSULE | 10-40 MG | COVERED | FORMULARY | |
33.090 | 23.768 | 242808-DIHYDROPYRIDINES | Lotrel | AMLODIPINE BESYLATE-BENAZEPRIL | CAPSULE | 5-20 MG | COVERED | FORMULARY | |
33.092 | 23.769 | 242808-DIHYDROPYRIDINES | Lotrel | AMLODIPINE BESYLATE-BENAZEPRIL | CAPSULE | 5-10 MG | COVERED | FORMULARY | |
33.093 | 23.770 | 242808-DIHYDROPYRIDINES | Lotrel | AMLODIPINE BESYLATE-BENAZEPRIL | CAPSULE | 2.5-10 MG | COVERED | FORMULARY | |
2.350 | 568 | 242808-DIHYDROPYRIDINES | Procardia | NIFEDIPINE | CAPSULE | 10 MG | COVERED | FORMULARY | |
2.351 | 569 | 242808-DIHYDROPYRIDINES | Procardia | NIFEDIPINE | CAPSULE | 20 MG | COVERED | FORMULARY | |
2.221 | 20.616 | 242808-DIHYDROPYRIDINES | Procardia XL | NIFEDIPINE | TAB ER 24 | 30 MG | COVERED | FORMULARY | |
2.221 | 20.616 | 242808-DIHYDROPYRIDINES | Procardia XL | NIFEDIPINE | TAB ER 24 | 30 MG | COVERED | FORMULARY | |
2.222 | 20.617 | 242808-DIHYDROPYRIDINES | Procardia XL | NIFEDIPINE | TAB ER 24 | 60 MG | COVERED | FORMULARY | |
2.222 | 20.617 | 242808-DIHYDROPYRIDINES | Procardia XL | NIFEDIPINE | TAB ER 24 | 60 MG | COVERED | FORMULARY | |
2.223 | 20.618 | 242808-DIHYDROPYRIDINES | Procardia XL | NIFEDIPINE | TAB ER 24 | 90 MG | COVERED | FORMULARY | |
2.223 | 20.618 | 242808-DIHYDROPYRIDINES | Procardia XL | NIFEDIPINE | TAB ER 24 | 90 MG | COVERED | FORMULARY | |
2.228 | 12.061 | 242808-DIHYDROPYRIDINES | Adalat CC | NIFEDIPINE | TABLET ER | 90 MG | COVERED | FORMULARY | |
2.226 | 12.059 | 242808-DIHYDROPYRIDINES | Adalat CC, Afeditab CR | NIFEDIPINE | TABLET ER | 30 MG | COVERED | FORMULARY | |
2.227 | 12.060 | 242808-DIHYDROPYRIDINES | Adalat CC, Afeditab CR | NIFEDIPINE | TABLET ER | 60 MG | COVERED | FORMULARY | |
2.320 | 572 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Diltiazem ER | DILTIAZEM HCL | CAP ER 12H | 90 MG | COVERED | FORMULARY | |
2.321 | 570 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Diltiazem ER | DILTIAZEM HCL | CAP ER 12H | 120 MG | COVERED | FORMULARY | |
2.322 | 571 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Diltiazem ER | DILTIAZEM HCL | CAP ER 12H | 60 MG | COVERED | FORMULARY | |
7.460 | 32.600 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Cardizem CD | DILTIAZEM HCL | CAP ER 24H | 360 MG | COVERED | FORMULARY | |
2.323 | 16.570 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Cardizem CD, Cartia XT | DILTIAZEM HCL | CAP ER 24H | 180 MG | COVERED | FORMULARY | |
2.324 | 16.571 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Cardizem CD, Cartia XT | DILTIAZEM HCL | CAP ER 24H | 240 MG | COVERED | FORMULARY | |
2.325 | 16.572 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Cardizem CD, Cartia XT | DILTIAZEM HCL | CAP ER 24H | 300 MG | COVERED | FORMULARY | |
2.326 | 21.282 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Cardizem CD, Cartia XT | DILTIAZEM HCL | CAP ER 24H | 120 MG | COVERED | FORMULARY | |
7.461 | 16.849 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Dilacor XR | DILTIAZEM HCL | CAP ER DEG | 180 MG | COVERED | FORMULARY | |
7.462 | 16.850 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Dilacor XR | DILTIAZEM HCL | CAP ER DEG | 240 MG | COVERED | FORMULARY | |
7.463 | 17.205 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Dilacor XR | DILTIAZEM HCL | CAP ER DEG | 120 MG | COVERED | FORMULARY | |
94.691 | 40.966 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Tiazac | DILTIAZEM HCL | CAPSULE ER | 420 MG | COVERED | FORMULARY | |
2.328 | 24.478 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Tiazac, Taztia XT | DILTIAZEM HCL | CAPSULE ER | 360 MG | COVERED | FORMULARY | |
2.329 | 24.537 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Tiazac, Taztia XT | DILTIAZEM HCL | CAPSULE ER | 180 MG | COVERED | FORMULARY | |
2.330 | 24.536 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Tiazac, Taztia XT | DILTIAZEM HCL | CAPSULE ER | 120 MG | COVERED | FORMULARY | |
2.332 | 24.538 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Tiazac, Taztia XT | DILTIAZEM HCL | CAPSULE ER | 240 MG | COVERED | FORMULARY | |
2.333 | 24.539 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Tiazac, Taztia XT | DILTIAZEM HCL | CAPSULE ER | 300 MG | COVERED | FORMULARY | |
2.360 | 574 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Cardizem | DILTIAZEM HCL | TABLET | 30 MG | COVERED | FORMULARY | |
2.361 | 575 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Cardizem | DILTIAZEM HCL | TABLET | 60 MG | COVERED | FORMULARY | |
2.362 | 576 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Cardizem | DILTIAZEM HCL | TABLET | 90 MG | COVERED | FORMULARY | |
2.363 | 573 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Cardizem | DILTIAZEM HCL | TABLET | 120 MG | COVERED | FORMULARY | |
3.001 | 16.605 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Verelan SR | VERAPAMIL HCL | CAP24H PEL | 180 MG | COVERED | FORMULARY | |
3.002 | 15.067 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Verelan SR | VERAPAMIL HCL | CAP24H PEL | 240 MG | COVERED | FORMULARY | |
3.003 | 15.066 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Verelan SR | VERAPAMIL HCL | CAP24H PEL | 120 MG | COVERED | FORMULARY | |
3.004 | 26.486 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Verelan SR | VERAPAMIL HCL | CAP24H PEL | 360 MG | COVERED | FORMULARY | |
2.341 | 564 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Calan | VERAPAMIL HCL | TABLET | 120 MG | COVERED | FORMULARY | |
2.342 | 566 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Calan | VERAPAMIL HCL | TABLET | 80 MG | COVERED | FORMULARY | |
47.110 | 565 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Verapamil | VERAPAMIL HCL | TABLET | 40 MG | COVERED | FORMULARY | |
32.470 | 567 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Calan SR | VERAPAMIL HCL | TABLET ER | 240 MG | COVERED | FORMULARY | |
32.471 | 13.670 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Calan SR | VERAPAMIL HCL | TABLET ER | 180 MG | COVERED | FORMULARY | |
32.472 | 15.959 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Calan SR | VERAPAMIL HCL | TABLET ER | 120 MG | COVERED | FORMULARY | |
48.611 | 16.039 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Lotensin | BENAZEPRIL HCL | TABLET | 5 MG | COVERED | FORMULARY | |
48.612 | 16.040 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Lotensin | BENAZEPRIL HCL | TABLET | 10 MG | COVERED | FORMULARY | |
48.613 | 16.041 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Lotensin | BENAZEPRIL HCL | TABLET | 20 MG | COVERED | FORMULARY | |
48.614 | 16.042 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Lotensin | BENAZEPRIL HCL | TABLET | 40 MG | COVERED | FORMULARY | |
33.192 | 21.724 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Lotensin HCT | BENAZEPRIL-HYDROCHLOROTHIAZIDE | TABLET | 10-12.5 MG | COVERED | FORMULARY | |
33.193 | 21.725 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Lotensin HCT | BENAZEPRIL-HYDROCHLOROTHIAZIDE | TABLET | 20-12.5 MG | COVERED | FORMULARY | |
33.194 | 21.726 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Lotensin HCT | BENAZEPRIL-HYDROCHLOROTHIAZIDE | TABLET | 20-25 MG | COVERED | FORMULARY | |
1.480 | 378 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Captopril | CAPTOPRIL | TABLET | 100 MG | COVERED | FORMULARY | |
1.481 | 380 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Captopril | CAPTOPRIL | TABLET | 25 MG | COVERED | FORMULARY | |
1.482 | 381 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Captopril | CAPTOPRIL | TABLET | 50 MG | COVERED | FORMULARY | |
1.483 | 379 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Captopril | CAPTOPRIL | TABLET | 12.5 MG | COVERED | FORMULARY | |
54.940 | 374 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Captopril-Hydrochlorothiazide | CAPTOPRIL-HYDROCHLOROTHIAZIDE | TABLET | 25-15 MG | COVERED | FORMULARY | |
54.941 | 375 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Captopril-Hydrochlorothiazide | CAPTOPRIL-HYDROCHLOROTHIAZIDE | TABLET | 25-25 MG | COVERED | FORMULARY | |
960 | 387 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Vasotec | ENALAPRIL MALEATE | TABLET | 5 MG | COVERED | FORMULARY | |
961 | 384 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Vasotec | ENALAPRIL MALEATE | TABLET | 10 MG | COVERED | FORMULARY | |
962 | 386 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Vasotec | ENALAPRIL MALEATE | TABLET | 20 MG | COVERED | FORMULARY | |
963 | 385 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Vasotec | ENALAPRIL MALEATE | TABLET | 2.5 MG | COVERED | FORMULARY | |
54.860 | 382 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Enalapril-Hydrochlorothiazide | ENALAPRIL-HYDROCHLOROTHIAZIDE | TABLET | 10-25 MG | COVERED | FORMULARY | |
54.862 | 24.190 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Enalapril-Hydrochlorothiazide | ENALAPRIL-HYDROCHLOROTHIAZIDE | TABLET | 5-12.5 MG | COVERED | FORMULARY | |
48.580 | 24.469 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Fosinopril | FOSINOPRIL SODIUM | TABLET | 40 MG | COVERED | FORMULARY | |
48.581 | 16.017 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Fosinopril | FOSINOPRIL SODIUM | TABLET | 10 MG | COVERED | FORMULARY | |
48.582 | 16.018 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Fosinopril | FOSINOPRIL SODIUM | TABLET | 20 MG | COVERED | FORMULARY | |
10.455 | 40.395 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Fosinopril-Hydrochlorothiazide | FOSINOPRIL-HYDROCHLOROTHIAZIDE | TABLET | 20-12.5 MG | COVERED | FORMULARY | |
15.621 | 44.935 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Fosinopril-Hydrochlorothiazide | FOSINOPRIL-HYDROCHLOROTHIAZIDE | TABLET | 10-12.5 MG | COVERED | FORMULARY | |
47.260 | 393 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Prinvil, Zestril | LISINOPRIL | TABLET | 5 MG | COVERED | FORMULARY | |
47.261 | 390 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Prinvil, Zestril | LISINOPRIL | TABLET | 10 MG | COVERED | FORMULARY | |
47.262 | 391 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Prinvil, Zestril | LISINOPRIL | TABLET | 20 MG | COVERED | FORMULARY | |
47.263 | 392 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Prinvil, Zestril | LISINOPRIL | TABLET | 40 MG | COVERED | FORMULARY | |
47.264 | 17.266 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Prinvil, Zestril | LISINOPRIL | TABLET | 2.5 MG | COVERED | FORMULARY | |
47.265 | 41.567 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Prinvil, Zestril | LISINOPRIL | TABLET | 30 MG | COVERED | FORMULARY | |
88.000 | 388 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Zestoretic | LISINOPRIL-HYDROCHLOROTHIAZIDE | TABLET | 20-12.5 MG | COVERED | FORMULARY | |
88.001 | 389 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Zestoretic | LISINOPRIL-HYDROCHLOROTHIAZIDE | TABLET | 20-25 MG | COVERED | FORMULARY | |
88.002 | 21.277 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Zestoretic | LISINOPRIL-HYDROCHLOROTHIAZIDE | TABLET | 10-12.5 MG | COVERED | FORMULARY | |
27.570 | 18.772 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Accupril | QUINAPRIL HCL | TABLET | 10 MG | COVERED | FORMULARY | |
27.571 | 18.773 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Accupril | QUINAPRIL HCL | TABLET | 20 MG | COVERED | FORMULARY | |
27.572 | 18.774 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Accupril | QUINAPRIL HCL | TABLET | 5 MG | COVERED | FORMULARY | |
27.573 | 21.909 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Accupril | QUINAPRIL HCL | TABLET | 40 MG | COVERED | FORMULARY | |
54.160 | 19.140 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Accuretic | QUINAPRIL-HYDROCHLOROTHIAZIDE | TABLET | 10-12.5MG | COVERED | FORMULARY | |
54.161 | 24.002 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Accuretic | QUINAPRIL-HYDROCHLOROTHIAZIDE | TABLET | 20-12.5 MG | COVERED | FORMULARY | |
94.490 | 41.016 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Accuretic | QUINAPRIL-HYDROCHLOROTHIAZIDE | TABLET | 20-25MG | COVERED | FORMULARY | |
48.542 | 15.940 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Altace | RAMIPRIL | CAPSULE | 2.5 MG | COVERED | FORMULARY | |
48.543 | 15.941 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Altace | RAMIPRIL | CAPSULE | 5 MG | COVERED | FORMULARY | |
48.544 | 16.031 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Altace | RAMIPRIL | CAPSULE | 10 MG | COVERED | FORMULARY | |
4.749 | 34.468 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Avapro | IRBESARTAN | TABLET | 150 MG | COVERED | FORMULARY | |
4.750 | 34.469 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Avapro | IRBESARTAN | TABLET | 300 MG | COVERED | FORMULARY | |
4.752 | 34.470 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Avapro | IRBESARTAN | TABLET | 75 MG | COVERED | FORMULARY | |
11.042 | 41.234 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Avalide | IRBESARTAN-HYDROCHLOROTHIAZIDE | TABLET | 150-12.5 MG | COVERED | FORMULARY | |
11.295 | 41.897 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Avalide | IRBESARTAN-HYDROCHLOROTHIAZIDE | TABLET | 300-12.5 MG | COVERED | FORMULARY | |
14.850 | 23.381 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Cozaar | LOSARTAN POTASSIUM | TABLET | 25 MG | COVERED | FORMULARY | |
14.851 | 23.382 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Cozaar | LOSARTAN POTASSIUM | TABLET | 50 MG | COVERED | FORMULARY | |
14.853 | 38.686 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Cozaar | LOSARTAN POTASSIUM | TABLET | 100 MG | COVERED | FORMULARY | |
14.852 | 23.465 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Hyzaar | LOSARTAN-HYDROCHLOROTHIAZIDE | TABLET | 50-12.5 MG | COVERED | FORMULARY | |
14.854 | 40.923 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Hyzaar | LOSARTAN-HYDROCHLOROTHIAZIDE | TABLET | 100-25 MG | COVERED | FORMULARY | |
25.851 | 59.919 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Hyzaar | LOSARTAN-HYDROCHLOROTHIAZIDE | TABLET | 100-12.5 MG | COVERED | FORMULARY | |
91.883 | 51.036 | 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS | Inspra | EPLERENONE | TABLET | 25 MG | COVERED | FORMULARY | |
91.883 | 51.036 | 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS | Inspra | EPLERENONE | TABLET | 25 MG | COVERED | FORMULARY | |
91.884 | 51.037 | 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS | Inspra | EPLERENONE | TABLET | 50 MG | COVERED | FORMULARY | |
91.884 | 51.037 | 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS | Inspra | EPLERENONE | TABLET | 50 MG | COVERED | FORMULARY | |
27.690 | 6.816 | 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS | Aldactone | SPIRONOLACTONE | TABLET | 100 MG | COVERED | FORMULARY | |
27.691 | 6.817 | 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS | Aldactone | SPIRONOLACTONE | TABLET | 25 MG | COVERED | FORMULARY | |
27.692 | 6.818 | 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS | Aldactone | SPIRONOLACTONE | TABLET | 50 MG | COVERED | FORMULARY | |
71.150 | 4.308 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Fiorinal | BUTALBITAL-ASPIRIN-CAFFEINE | CAPSULE | 50-325-40 MG | COVERED | FORMULARY | |
71.150 | 4.308 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Fiorinal | BUTALBITAL-ASPIRIN-CAFFEINE | CAPSULE | 50-325-40 MG | COVERED | FORMULARY | |
45.680 | 18.293 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Voltaren | DICLOFENAC SODIUM | GEL (GRAM) | 1 % | COVERED | FORMULARY | |
13.310 | 11.933 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Diclofenac Sodium | DICLOFENAC SODIUM | TAB ER 24H | 100 MG | COVERED | FORMULARY | |
35.850 | 8.372 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Diclofenac Sodium | DICLOFENAC SODIUM | TABLET DR | 25 MG | COVERED | FORMULARY | |
35.851 | 8.373 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Diclofenac Sodium | DICLOFENAC SODIUM | TABLET DR | 50 MG | COVERED | FORMULARY | |
35.852 | 8.374 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Diclofenac Sodium | DICLOFENAC SODIUM | TABLET DR | 75 MG | COVERED | FORMULARY | |
33.870 | 15.960 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Etodolac | ETODOLAC | CAPSULE | 200 MG | COVERED | FORMULARY | |
33.871 | 15.961 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Etodolac | ETODOLAC | CAPSULE | 300 MG | COVERED | FORMULARY | |
61.767 | 38.259 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Etodolac | ETODOLAC | TAB ER 24H | 500 MG | COVERED | FORMULARY | |
61.761 | 20.175 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Etodolac | ETODOLAC | TABLET | 400 MG | COVERED | FORMULARY | |
61.766 | 27.368 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Etodolac | ETODOLAC | TABLET | 500 MG | COVERED | FORMULARY | |
35.741 | 8.348 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Ibuprofen | IBUPROFEN | TABLET | 400 MG | COVERED | FORMULARY | |
35.742 | 8.349 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Ibuprofen | IBUPROFEN | TABLET | 600 MG | COVERED | FORMULARY | |
35.744 | 8.350 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Ibuprofen | IBUPROFEN | TABLET | 800 MG | COVERED | FORMULARY | |
35.680 | 8.336 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Indomethacin | INDOMETHACIN | CAPSULE | 25 MG | COVERED | FORMULARY | |
35.681 | 8.337 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Indomethacin | INDOMETHACIN | CAPSULE | 50 MG | COVERED | FORMULARY | |
35.690 | 8.338 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Indomethacin | INDOMETHACIN | CAPSULE ER | 75 MG | COVERED | FORMULARY | |
33.792 | 16.406 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Ketoprofen ER | KETOPROFEN | CAP24H PEL | 200 MG | COVERED | FORMULARY | |
34.420 | 8.379 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Ketoprofen | KETOPROFEN | CAPSULE | 50 MG | COVERED | FORMULARY | |
34.421 | 8.380 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Ketoprofen | KETOPROFEN | CAPSULE | 75 MG | COVERED | FORMULARY | |
31.661 | 29.156 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Mobic | MELOXICAM | TABLET | 7.5 MG | COVERED | FORMULARY | |
31.662 | 29.157 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Mobic | MELOXICAM | TABLET | 15 MG | COVERED | FORMULARY | |
32.961 | 16.574 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Nabumetone | NABUMETONE | TABLET | 500 MG | COVERED | FORMULARY | |
32.962 | 16.575 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Nabumetone | NABUMETONE | TABLET | 750 MG | COVERED | FORMULARY | |
35.790 | 8.360 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Naprosyn | NAPROXEN | TABLET | 250 MG | COVERED | FORMULARY | |
35.792 | 8.361 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Naprosyn | NAPROXEN | TABLET | 375 MG | COVERED | FORMULARY | |
35.793 | 8.362 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Naprosyn | NAPROXEN | TABLET | 500 MG | COVERED | FORMULARY | |
47.130 | 8.357 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Anaprox | NAPROXEN SODIUM | TABLET | 275 MG | COVERED | FORMULARY | |
47.131 | 8.358 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Anaprox | NAPROXEN SODIUM | TABLET | 550 MG | COVERED | FORMULARY | |
16.801 | 4.438 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Salsalate | SALSALATE | TABLET | 500 MG | COVERED | FORMULARY | |
16.802 | 4.439 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Salsalate | SALSALATE | TABLET | 750 MG | COVERED | FORMULARY | |
55.402 | 45.155 | 280808-OPIATE AGONISTS | Acetaminophen-Codeine Solution | ACETAMINOPHEN-CODEINE | SOLUTION | 120-12 MG/5ML | COVERED | FORMULARY | |
70.131 | 4.163 | 280808-OPIATE AGONISTS | Acetaminophen-Codeine Tablet | ACETAMINOPHEN-CODEINE | TABLET | 300-15 MG | COVERED | FORMULARY | |
70.134 | 4.165 | 280808-OPIATE AGONISTS | Tylenol-Codeine #3 | ACETAMINOPHEN-CODEINE | TABLET | 300-30 MG | COVERED | FORMULARY | |
70.136 | 4.169 | 280808-OPIATE AGONISTS | Tylenol-Codeine #4 | ACETAMINOPHEN-CODEINE | TABLET | 300-60 MG | COVERED | FORMULARY | |
70.140 | 4.149 | 280808-OPIATE AGONISTS | Butalbital-Acetaminophen-Caffeine-Codeine | BUTALBITAL-ACETAMINOPHEN-CAFFEINE-CODEINE | CAPSULE | 50-325-30 MG | COVERED | FORMULARY | |
21.146 | 53.582 | 280808-OPIATE AGONISTS | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | SOLUTION | 7.5-325/15 | COVERED | FORMULARY | |
12.486 | 47.430 | 280808-OPIATE AGONISTS | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | TABLET | 5-325 MG | COVERED | FORMULARY | |
12.488 | 47.431 | 280808-OPIATE AGONISTS | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | TABLET | 7.5-325 MG | COVERED | FORMULARY | |
70.330 | 30.623 | 280808-OPIATE AGONISTS | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | TABLET | 10-325 MG | COVERED | FORMULARY | |
12.488 | 47.431 | 280808-OPIATE AGONISTS | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | TABLET | 7.5-325 MG | COVERED | FORMULARY | |
63.101 | 34.068 | 280808-OPIATE AGONISTS | Vicoprofen | HYDROCODONE-IBUPROFEN | TABLET | 7.5-200 MG | COVERED | FORMULARY | |
16.141 | 4.110 | 280808-OPIATE AGONISTS | Dilaudid | HYDROMORPHONE HCL | TABLET | 2 MG | COVERED | FORMULARY | |
16.143 | 4.112 | 280808-OPIATE AGONISTS | Dilaudid | HYDROMORPHONE HCL | TABLET | 4 MG | COVERED | FORMULARY | |
16.144 | 15.190 | 280808-OPIATE AGONISTS | Dilaudid | HYDROMORPHONE HCL | TABLET | 8 MG | COVERED | FORMULARY | |
16.420 | 4.240 | 280808-OPIATE AGONISTS | Dolophine | METHADONE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
16.422 | 4.242 | 280808-OPIATE AGONISTS | Dolophine | METHADONE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
16.060 | 4.087 | 280808-OPIATE AGONISTS | Morphine | MORPHINE SULFATE | SOLUTION | 10 MG/5ML | COVERED | FORMULARY | |
16.062 | 4.089 | 280808-OPIATE AGONISTS | Morphine | MORPHINE SULFATE | SOLUTION | 20 MG/5ML | COVERED | FORMULARY | |
16.063 | 4.090 | 280808-OPIATE AGONISTS | Morphine | MORPHINE SULFATE | SOLUTION | 100 MG/5ML | COVERED | FORMULARY | |
16.070 | 4.091 | 280808-OPIATE AGONISTS | Morphine | MORPHINE SULFATE | TABLET | 15 MG | COVERED | FORMULARY | |
16.071 | 4.092 | 280808-OPIATE AGONISTS | Morphine | MORPHINE SULFATE | TABLET | 30 MG | COVERED | FORMULARY | |
16.640 | 4.096 | 280808-OPIATE AGONISTS | MS Contin CR | MORPHINE SULFATE | TABLET ER | 30 MG | COVERED | FORMULARY | |
16.641 | 4.097 | 280808-OPIATE AGONISTS | MS Contin CR | MORPHINE SULFATE | TABLET ER | 60 MG | COVERED | FORMULARY | |
16.643 | 11.887 | 280808-OPIATE AGONISTS | MS Contin CR | MORPHINE SULFATE | TABLET ER | 15 MG | COVERED | FORMULARY | |
16.285 | 24.507 | 280808-OPIATE AGONISTS | Oxycodone | OXYCODONE HCL | CAPSULE | 5 MG | COVERED | FORMULARY | |
16.290 | 4.225 | 280808-OPIATE AGONISTS | Oxycodone | OXYCODONE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
14.965 | 48.976 | 280808-OPIATE AGONISTS | Percocet | OXYCODONE HCL-ACETAMINOPHEN | TABLET | 7.5-325MG | COVERED | FORMULARY | |
14.966 | 48.977 | 280808-OPIATE AGONISTS | Percocet | OXYCODONE HCL-ACETAMINOPHEN | TABLET | 10MG-325MG | COVERED | FORMULARY | |
70.491 | 4.222 | 280808-OPIATE AGONISTS | Percocet | OXYCODONE HCL-ACETAMINOPHEN | TABLET | 5 MG-325MG | COVERED | FORMULARY | |
7.221 | 23.139 | 280808-OPIATE AGONISTS | Ultram | TRAMADOL HCL | TABLET | 50 MG | COVERED | FORMULARY | |
13.909 | 48.456 | 280808-OPIATE AGONISTS | Ultracet | TRAMADOL HCL-ACETAMINOPHEN | TABLET | 37.5-325MG | COVERED | FORMULARY | |
72.510 | 4.450 | 280892-ANALGESICS AND ANTIPYRETICS, MISC. | Capacet | BUTALBITAL-ACETAMINOPHEN-CAFFEINE | CAPSULE | 50-325-40 MG | COVERED | FORMULARY | |
72.530 | 4.451 | 280892-ANALGESICS AND ANTIPYRETICS, MISC. | Esgic | BUTALBITAL-ACETAMINOPHEN-CAFFEINE | TABLET | 50-325-40 MG | COVERED | FORMULARY | |
13.996 | 48.520 | 280892-ANALGESICS AND ANTIPYRETICS, MISC. | Nodolor | ISOMETHEPT-DICHLPHN/ACETAMINOPHEN | CAPSULE | 65-100-325 MG | COVERED | FORMULARY | |
40.233 | 75.222 | 281000-OPIATE ANTAGONISTS | Narcan Nasal | NALOXONE HCL | SPRAY | 4 MG | COVERED | FORMULARY | |
17.070 | 4.518 | 281000-OPIATE ANTAGONISTS | Naltrexone | NALTREXONE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
17.321 | 4.543 | 281204-BARBITURATES (ANTICONVULSANTS) | Mysoline | PRIMIDONE | TABLET | 250 MG | COVERED | FORMULARY | |
17.322 | 4.544 | 281204-BARBITURATES (ANTICONVULSANTS) | Mysoline | PRIMIDONE | TABLET | 50 MG | COVERED | FORMULARY | |
17.470 | 4.560 | 281208-BENZODIAZEPINES (ANTICONVULSANTS) | Klonopin | CLONAZEPAM | TABLET | 0.5 MG | COVERED | FORMULARY | |
17.471 | 4.561 | 281208-BENZODIAZEPINES (ANTICONVULSANTS) | Klonopin | CLONAZEPAM | TABLET | 1 MG | COVERED | FORMULARY | |
17.472 | 4.562 | 281208-BENZODIAZEPINES (ANTICONVULSANTS) | Klonopin | CLONAZEPAM | TABLET | 2 MG | COVERED | FORMULARY | |
17.260 | 4.532 | 281212-HYDANTOINS | Peganone | ETHOTOIN | TABLET | 250 MG | COVERED | FORMULARY | |
17.241 | 4.529 | 281212-HYDANTOINS | Dilantin | PHENYTOIN | ORAL SUSP | 125 MG/5ML | COVERED | FORMULARY | |
99.557 | 63.845 | 281212-HYDANTOINS | Phenytoin | PHENYTOIN | ORAL SUSP | 100 MG/4ML | COVERED | FORMULARY | |
17.250 | 4.531 | 281212-HYDANTOINS | Dilantin | PHENYTOIN | TAB CHEW | 50 MG | COVERED | FORMULARY | |
15.037 | 49.444 | 281212-HYDANTOINS | Dilantin, Phenytek | PHENYTOIN SODIUM EXTENDED | CAPSULE | 300 MG | COVERED | FORMULARY | |
15.038 | 49.445 | 281212-HYDANTOINS | Dilantin, Phenytek | PHENYTOIN SODIUM EXTENDED | CAPSULE | 200 MG | COVERED | FORMULARY | |
17.700 | 4.521 | 281212-HYDANTOINS | Dilantin, Phenytek | PHENYTOIN SODIUM EXTENDED | CAPSULE | 100 MG | COVERED | FORMULARY | |
17.701 | 4.522 | 281212-HYDANTOINS | Dilantin, Phenytek | PHENYTOIN SODIUM EXTENDED | CAPSULE | 30 MG | COVERED | FORMULARY | |
23.932 | 58.487 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Carbatrol | CARBAMAZEPINE | CPMP 12HR | 200 MG | COVERED | FORMULARY | |
23.933 | 58.488 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Carbatrol | CARBAMAZEPINE | CPMP 12HR | 300 MG | COVERED | FORMULARY | |
23.934 | 58.489 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Carbatrol | CARBAMAZEPINE | CPMP 12HR | 100 MG | COVERED | FORMULARY | |
47.500 | 4.557 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Carbamazepine | CARBAMAZEPINE | ORAL SUSP | 100 MG/5ML | COVERED | FORMULARY | |
17.460 | 4.559 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Carbamazepine | CARBAMAZEPINE | TAB CHEW | 100 MG | COVERED | FORMULARY | |
27.820 | 26.868 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Tegreol XR | CARBAMAZEPINE | TAB ER 12H | 100 MG | COVERED | FORMULARY | |
27.821 | 16.773 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Tegreol XR | CARBAMAZEPINE | TAB ER 12H | 200 MG | COVERED | FORMULARY | |
27.822 | 17.876 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Tegreol XR | CARBAMAZEPINE | TAB ER 12H | 400 MG | COVERED | FORMULARY | |
17.450 | 4.558 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Tegretol | CARBAMAZEPINE | TABLET | 200 MG | COVERED | FORMULARY | |
18.040 | 46.315 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Depakote ER | DIVALPROEX SODIUM | TAB ER 24H | 500 MG | COVERED | FORMULARY | |
18.754 | 51.469 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Depakote ER | DIVALPROEX SODIUM | TAB ER 24H | 250 MG | COVERED | FORMULARY | |
17.290 | 4.539 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Depakote | DIVALPROEX SODIUM | TABLET DR | 250 MG | COVERED | FORMULARY | |
17.291 | 4.540 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Depakote | DIVALPROEX SODIUM | TABLET DR | 500 MG | COVERED | FORMULARY | |
17.292 | 4.538 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Depakote | DIVALPROEX SODIUM | TABLET DR | 125 MG | COVERED | FORMULARY | |
780 | 21.413 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Neurontin | GABAPENTIN | CAPSULE | 100 MG | COVERED | FORMULARY | |
781 | 21.414 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Neurontin | GABAPENTIN | CAPSULE | 300 MG | COVERED | FORMULARY | |
782 | 21.415 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Neurontin | GABAPENTIN | CAPSULE | 400 MG | COVERED | FORMULARY | |
13.235 | 47.927 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Neurontin | GABAPENTIN | SOLUTION | 250 MG/5ML | COVERED | FORMULARY | |
94.447 | 41.806 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Neurontin | GABAPENTIN | TABLET | 800 MG | COVERED | FORMULARY | |
94.624 | 41.805 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Neurontin | GABAPENTIN | TABLET | 600 MG | COVERED | FORMULARY | |
64.316 | 17.871 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal | LAMOTRIGINE | TABLET | 100 MG | COVERED | FORMULARY | |
64.317 | 17.872 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal | LAMOTRIGINE | TABLET | 25 MG | COVERED | FORMULARY | |
64.324 | 22.550 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal | LAMOTRIGINE | TABLET | 150 MG | COVERED | FORMULARY | |
64.325 | 22.551 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal | LAMOTRIGINE | TABLET | 200 MG | COVERED | FORMULARY | |
16.779 | 64.819 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra | LEVETIRACETAM | SOLUTION | 500 MG/5ML | COVERED | FORMULARY | |
20.353 | 53.031 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra | LEVETIRACETAM | SOLUTION | 100 MG/ML | COVERED | FORMULARY | |
41.586 | 45.652 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra | LEVETIRACETAM | TABLET | 750 MG | COVERED | FORMULARY | |
41.587 | 44.632 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra | LEVETIRACETAM | TABLET | 250 MG | COVERED | FORMULARY | |
41.597 | 44.633 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra | LEVETIRACETAM | TABLET | 500 MG | COVERED | FORMULARY | |
86.223 | 47.077 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra | LEVETIRACETAM | TABLET | 1000 MG | COVERED | FORMULARY | |
21.723 | 33.724 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Trileptal | OXCARBAZEPINE | ORAL SUSP | 300 MG/5ML | COVERED | FORMULARY | |
21.721 | 27.779 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Trileptal | OXCARBAZEPINE | TABLET | 300 MG | COVERED | FORMULARY | |
21.722 | 27.780 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Trileptal | OXCARBAZEPINE | TABLET | 600 MG | COVERED | FORMULARY | |
21.724 | 44.336 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Trileptal | OXCARBAZEPINE | TABLET | 150 MG | COVERED | FORMULARY | |
36.550 | 26.169 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Topamax | TOPIRAMATE | TABLET | 50 MG | COVERED | FORMULARY | |
36.551 | 26.170 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Topamax | TOPIRAMATE | TABLET | 100 MG | COVERED | FORMULARY | |
36.552 | 26.171 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Topamax | TOPIRAMATE | TABLET | 200 MG | COVERED | FORMULARY | |
36.553 | 29.837 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Topamax | TOPIRAMATE | TABLET | 25 MG | COVERED | FORMULARY | |
17.270 | 4.536 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Depakene | VALPROIC ACID | CAPSULE | 250 MG | COVERED | FORMULARY | |
17.280 | 4.535 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Depakene Syrup | VALPROIC ACID (AS SODIUM SALT) | SOLUTION | 250 MG/5ML | COVERED | FORMULARY | |
30.965 | 68.220 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Valproic Solution | VALPROIC ACID (AS SODIUM SALT) | SOLUTION | 250 MG/5ML | COVERED | FORMULARY | |
30.986 | 68.236 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Valproic Syrup | VALPROIC ACID (AS SODIUM SALT) | SOLUTION | 500 MG/10ML | COVERED | FORMULARY | |
30.987 | 68.237 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Valproic Syrup | VALPROIC ACID (AS SODIUM SALT) | SYRINGE | 250 MG/5ML | COVERED | FORMULARY | |
20.831 | 53.367 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Zonegran | ZONISAMIDE | CAPSULE | 25 MG | COVERED | FORMULARY | |
20.833 | 53.368 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Zonegran | ZONISAMIDE | CAPSULE | 50 MG | COVERED | FORMULARY | |
92.219 | 45.100 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Zonegran | ZONISAMIDE | CAPSULE | 100 MG | COVERED | FORMULARY | |
16.512 | 46.043 | 281604-ANTIDEPRESSANTS | Elavil | AMITRIPTYLINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
16.513 | 46.044 | 281604-ANTIDEPRESSANTS | Elavil | AMITRIPTYLINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
16.514 | 46.045 | 281604-ANTIDEPRESSANTS | Elavil | AMITRIPTYLINE HCL | TABLET | 150 MG | COVERED | FORMULARY | |
16.515 | 46.046 | 281604-ANTIDEPRESSANTS | Elavil | AMITRIPTYLINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
16.516 | 46.047 | 281604-ANTIDEPRESSANTS | Elavil | AMITRIPTYLINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
16.517 | 46.048 | 281604-ANTIDEPRESSANTS | Elavil | AMITRIPTYLINE HCL | TABLET | 75 MG | COVERED | FORMULARY | |
20.317 | 53.006 | 281604-ANTIDEPRESSANTS | Wellbutrin XL | BUPROPION HCL | TAB ER 24H | 150 MG | COVERED | FORMULARY | |
20.318 | 53.007 | 281604-ANTIDEPRESSANTS | Wellbutrin XL | BUPROPION HCL | TAB ER 24H | 300 MG | COVERED | FORMULARY | |
16.384 | 46.236 | 281604-ANTIDEPRESSANTS | Wellbutrin | BUPROPION HCL | TABLET | 75 MG | COVERED | FORMULARY | |
16.385 | 46.237 | 281604-ANTIDEPRESSANTS | Wellbutrin | BUPROPION HCL | TABLET | 100 MG | COVERED | FORMULARY | |
16.386 | 46.238 | 281604-ANTIDEPRESSANTS | Wellbutrin SR | BUPROPION HCL | TABLET ER | 150 MG | COVERED | FORMULARY | |
16.387 | 46.239 | 281604-ANTIDEPRESSANTS | Wellbutrin SR | BUPROPION HCL | TABLET ER | 100 MG | COVERED | FORMULARY | |
17.573 | 50.496 | 281604-ANTIDEPRESSANTS | Wellbutrin SR | BUPROPION HCL | TABLET ER | 200 MG | COVERED | FORMULARY | |
27.901 | 31.439 | 281604-ANTIDEPRESSANTS | Zyban SR | BUPROPION HCL | TABLET ER | 150 MG | COVERED | FORMULARY | |
16.342 | 46.203 | 281604-ANTIDEPRESSANTS | Celexa | CITALOPRAM HYDROBROMIDE | TABLET | 20 MG | COVERED | FORMULARY | Max 40mg/day |
16.343 | 46.204 | 281604-ANTIDEPRESSANTS | Celexa | CITALOPRAM HYDROBROMIDE | TABLET | 40 MG | COVERED | FORMULARY | Max 40mg/day |
16.345 | 46.206 | 281604-ANTIDEPRESSANTS | Celexa | CITALOPRAM HYDROBROMIDE | TABLET | 10 MG | COVERED | FORMULARY | Max 40mg/day |
16.563 | 46.086 | 281604-ANTIDEPRESSANTS | Doxepin | DOXEPIN HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
16.564 | 46.087 | 281604-ANTIDEPRESSANTS | Doxepin | DOXEPIN HCL | CAPSULE | 100 MG | COVERED | FORMULARY | |
16.565 | 46.088 | 281604-ANTIDEPRESSANTS | Doxepin | DOXEPIN HCL | CAPSULE | 150 MG | COVERED | FORMULARY | |
16.566 | 46.089 | 281604-ANTIDEPRESSANTS | Doxepin | DOXEPIN HCL | CAPSULE | 25 MG | COVERED | FORMULARY | |
16.567 | 46.090 | 281604-ANTIDEPRESSANTS | Doxepin | DOXEPIN HCL | CAPSULE | 50 MG | COVERED | FORMULARY | |
16.568 | 46.091 | 281604-ANTIDEPRESSANTS | Doxepin | DOXEPIN HCL | CAPSULE | 75 MG | COVERED | FORMULARY | |
23.161 | 57.891 | 281604-ANTIDEPRESSANTS | Cymbalta | DULOXETINE HCL | CAPSULE DR | 20 MG | COVERED | FORMULARY | |
23.162 | 57.892 | 281604-ANTIDEPRESSANTS | Cymbalta | DULOXETINE HCL | CAPSULE DR | 30 MG | COVERED | FORMULARY | |
23.164 | 57.893 | 281604-ANTIDEPRESSANTS | Cymbalta | DULOXETINE HCL | CAPSULE DR | 60 MG | COVERED | FORMULARY | |
38.728 | 74.166 | 281604-ANTIDEPRESSANTS | Cymbalta | DULOXETINE HCL | CAPSULE DR | 40 MG | COVERED | FORMULARY | |
19.035 | 51.698 | 281604-ANTIDEPRESSANTS | Lexapro Solution | ESCITALOPRAM OXALATE | SOLUTION | 5 MG/5ML | COVERED | FORMULARY | Max 20mg/day |
17.851 | 50.712 | 281604-ANTIDEPRESSANTS | Lexapro | ESCITALOPRAM OXALATE | TABLET | 10 MG | COVERED | FORMULARY | Max 20mg/day |
17.987 | 50.760 | 281604-ANTIDEPRESSANTS | Lexapro | ESCITALOPRAM OXALATE | TABLET | 20 MG | COVERED | FORMULARY | Max 20mg/day |
18.975 | 51.642 | 281604-ANTIDEPRESSANTS | Lexapro | ESCITALOPRAM OXALATE | TABLET | 5 MG | COVERED | FORMULARY | Max 20mg/day |
16.353 | 46.213 | 281604-ANTIDEPRESSANTS | Prozac | FLUOXETINE HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
16.354 | 46.214 | 281604-ANTIDEPRESSANTS | Prozac | FLUOXETINE HCL | CAPSULE | 20 MG | COVERED | FORMULARY | |
16.355 | 46.215 | 281604-ANTIDEPRESSANTS | Prozac | FLUOXETINE HCL | CAPSULE | 40 MG | COVERED | FORMULARY | |
16.348 | 46.209 | 281604-ANTIDEPRESSANTS | Fluvoxamine | FLUVOXAMINE MALEATE | TABLET | 50 MG | COVERED | FORMULARY | |
16.349 | 46.210 | 281604-ANTIDEPRESSANTS | Fluvoxamine | FLUVOXAMINE MALEATE | TABLET | 100 MG | COVERED | FORMULARY | |
16.541 | 46.068 | 281604-ANTIDEPRESSANTS | Tofranil | IMIPRAMINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
16.542 | 46.069 | 281604-ANTIDEPRESSANTS | Tofranil | IMIPRAMINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
16.543 | 46.070 | 281604-ANTIDEPRESSANTS | Tofranil | IMIPRAMINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
21.817 | 54.009 | 281604-ANTIDEPRESSANTS | Remeron | MIRTAZAPINE | TABLET | 7.5 MG | COVERED | FORMULARY | |
16.732 | 46.450 | 281604-ANTIDEPRESSANTS | Remeron | MIRTAZAPINE | TABLET | 15 MG | COVERED | FORMULARY | |
16.733 | 46.451 | 281604-ANTIDEPRESSANTS | Remeron | MIRTAZAPINE | TABLET | 30 MG | COVERED | FORMULARY | |
16.734 | 46.452 | 281604-ANTIDEPRESSANTS | Remeron | MIRTAZAPINE | TABLET | 45 MG | COVERED | FORMULARY | |
16.529 | 46.059 | 281604-ANTIDEPRESSANTS | Pamelor | NORTRIPTYLINE HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
16.532 | 46.060 | 281604-ANTIDEPRESSANTS | Pamelor | NORTRIPTYLINE HCL | CAPSULE | 25 MG | COVERED | FORMULARY | |
16.533 | 46.061 | 281604-ANTIDEPRESSANTS | Pamelor | NORTRIPTYLINE HCL | CAPSULE | 50 MG | COVERED | FORMULARY | |
16.534 | 46.062 | 281604-ANTIDEPRESSANTS | Pamelor | NORTRIPTYLINE HCL | CAPSULE | 75 MG | COVERED | FORMULARY | |
17.077 | 50.136 | 281604-ANTIDEPRESSANTS | Paxil CR | PAROXETINE HCL | TAB ER 24H | 25 MG | COVERED | FORMULARY | |
17.078 | 50.137 | 281604-ANTIDEPRESSANTS | Paxil CR | PAROXETINE HCL | TAB ER 24H | 12.5 MG | COVERED | FORMULARY | |
17.079 | 50.138 | 281604-ANTIDEPRESSANTS | Paxil CR | PAROXETINE HCL | TAB ER 24H | 37.5 MG | COVERED | FORMULARY | |
16.364 | 46.222 | 281604-ANTIDEPRESSANTS | Paxil | PAROXETINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
16.366 | 46.223 | 281604-ANTIDEPRESSANTS | Paxil | PAROXETINE HCL | TABLET | 20 MG | COVERED | FORMULARY | |
16.367 | 46.224 | 281604-ANTIDEPRESSANTS | Paxil | PAROXETINE HCL | TABLET | 30 MG | COVERED | FORMULARY | |
16.368 | 46.225 | 281604-ANTIDEPRESSANTS | Paxil | PAROXETINE HCL | TABLET | 40 MG | COVERED | FORMULARY | |
16.373 | 46.227 | 281604-ANTIDEPRESSANTS | Zoloft | SERTRALINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
16.374 | 46.228 | 281604-ANTIDEPRESSANTS | Zoloft | SERTRALINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
16.375 | 46.229 | 281604-ANTIDEPRESSANTS | Zoloft | SERTRALINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
16.391 | 46.241 | 281604-ANTIDEPRESSANTS | Trazodone | TRAZODONE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
16.392 | 46.242 | 281604-ANTIDEPRESSANTS | Trazodone | TRAZODONE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
16.393 | 46.243 | 281604-ANTIDEPRESSANTS | Trazodone | TRAZODONE HCL | TABLET | 150 MG | COVERED | FORMULARY | |
16.394 | 46.244 | 281604-ANTIDEPRESSANTS | Trazodone | TRAZODONE HCL | TABLET | 300 MG | COVERED | FORMULARY | |
16.816 | 46.403 | 281604-ANTIDEPRESSANTS | Effexor XR | VENLAFAXINE HCL | CAP ER 24H | 37.5 MG | COVERED | FORMULARY | |
16.817 | 46.404 | 281604-ANTIDEPRESSANTS | Effexor XR | VENLAFAXINE HCL | CAP ER 24H | 75 MG | COVERED | FORMULARY | |
16.818 | 46.405 | 281604-ANTIDEPRESSANTS | Effexor XR | VENLAFAXINE HCL | CAP ER 24H | 150 MG | COVERED | FORMULARY | |
16.811 | 46.398 | 281604-ANTIDEPRESSANTS | Venlafaxine | VENLAFAXINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
16.812 | 46.399 | 281604-ANTIDEPRESSANTS | Venlafaxine | VENLAFAXINE HCL | TABLET | 37.5 MG | COVERED | FORMULARY | |
16.813 | 46.400 | 281604-ANTIDEPRESSANTS | Venlafaxine | VENLAFAXINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
16.814 | 46.401 | 281604-ANTIDEPRESSANTS | Venlafaxine | VENLAFAXINE HCL | TABLET | 75 MG | COVERED | FORMULARY | |
16.815 | 46.402 | 281604-ANTIDEPRESSANTS | Venlafaxine | VENLAFAXINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
14.431 | 3.796 | 281608-ANTIPSYCHOTIC AGENTS | Chlorpromazine | CHLORPROMAZINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
14.432 | 3.799 | 281608-ANTIPSYCHOTIC AGENTS | Chlorpromazine | CHLORPROMAZINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
14.433 | 3.800 | 281608-ANTIPSYCHOTIC AGENTS | Chlorpromazine | CHLORPROMAZINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
14.434 | 3.797 | 281608-ANTIPSYCHOTIC AGENTS | Chlorpromazine | CHLORPROMAZINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
14.435 | 3.798 | 281608-ANTIPSYCHOTIC AGENTS | Chlorpromazine | CHLORPROMAZINE HCL | TABLET | 200 MG | COVERED | FORMULARY | |
14.602 | 3.823 | 281608-ANTIPSYCHOTIC AGENTS | Fluphenazine | FLUPHENAZINE HCL | TABLET | 1 MG | COVERED | FORMULARY | |
14.603 | 3.824 | 281608-ANTIPSYCHOTIC AGENTS | Fluphenazine | FLUPHENAZINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
14.604 | 3.825 | 281608-ANTIPSYCHOTIC AGENTS | Fluphenazine | FLUPHENAZINE HCL | TABLET | 2.5 MG | COVERED | FORMULARY | |
14.605 | 3.826 | 281608-ANTIPSYCHOTIC AGENTS | Fluphenazine | FLUPHENAZINE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
15.530 | 3.972 | 281608-ANTIPSYCHOTIC AGENTS | Haloperidol | HALOPERIDOL | TABLET | 0.5 MG | COVERED | FORMULARY | |
15.531 | 3.973 | 281608-ANTIPSYCHOTIC AGENTS | Haloperidol | HALOPERIDOL | TABLET | 1 MG | COVERED | FORMULARY | |
15.532 | 3.974 | 281608-ANTIPSYCHOTIC AGENTS | Haloperidol | HALOPERIDOL | TABLET | 10 MG | COVERED | FORMULARY | |
15.533 | 3.975 | 281608-ANTIPSYCHOTIC AGENTS | Haloperidol | HALOPERIDOL | TABLET | 2 MG | COVERED | FORMULARY | |
15.534 | 3.976 | 281608-ANTIPSYCHOTIC AGENTS | Haloperidol | HALOPERIDOL | TABLET | 20 MG | COVERED | FORMULARY | |
15.535 | 3.977 | 281608-ANTIPSYCHOTIC AGENTS | Haloperidol | HALOPERIDOL | TABLET | 5 MG | COVERED | FORMULARY | |
15.520 | 3.971 | 281608-ANTIPSYCHOTIC AGENTS | Haloperidol | HALOPERIDOL LACTATE | ORAL CONC | 2 MG/ML | COVERED | FORMULARY | |
15.560 | 3.981 | 281608-ANTIPSYCHOTIC AGENTS | Loxapine | LOXAPINE SUCCINATE | CAPSULE | 10 MG | COVERED | FORMULARY | |
15.561 | 3.982 | 281608-ANTIPSYCHOTIC AGENTS | Loxapine | LOXAPINE SUCCINATE | CAPSULE | 25 MG | COVERED | FORMULARY | |
15.563 | 3.984 | 281608-ANTIPSYCHOTIC AGENTS | Loxapine | LOXAPINE SUCCINATE | CAPSULE | 50 MG | COVERED | FORMULARY | |
15.081 | 27.959 | 281608-ANTIPSYCHOTIC AGENTS | Zyprexa | OLANZAPINE | TABLET | 7.5 MG | COVERED | FORMULARY | |
15.082 | 27.960 | 281608-ANTIPSYCHOTIC AGENTS | Zyprexa | OLANZAPINE | TABLET | 10 MG | COVERED | FORMULARY | |
15.083 | 27.961 | 281608-ANTIPSYCHOTIC AGENTS | Zyprexa | OLANZAPINE | TABLET | 5 MG | COVERED | FORMULARY | |
15.084 | 29.077 | 281608-ANTIPSYCHOTIC AGENTS | Zyprexa | OLANZAPINE | TABLET | 2.5 MG | COVERED | FORMULARY | |
15.085 | 41.026 | 281608-ANTIPSYCHOTIC AGENTS | Zyprexa | OLANZAPINE | TABLET | 15 MG | COVERED | FORMULARY | |
15.086 | 41.027 | 281608-ANTIPSYCHOTIC AGENTS | Zyprexa | OLANZAPINE | TABLET | 20 MG | COVERED | FORMULARY | |
14.650 | 3.830 | 281608-ANTIPSYCHOTIC AGENTS | Perphenazine | PERPHENAZINE | TABLET | 16 MG | COVERED | FORMULARY | |
14.651 | 3.831 | 281608-ANTIPSYCHOTIC AGENTS | Perphenazine | PERPHENAZINE | TABLET | 2 MG | COVERED | FORMULARY | |
14.652 | 3.832 | 281608-ANTIPSYCHOTIC AGENTS | Perphenazine | PERPHENAZINE | TABLET | 4 MG | COVERED | FORMULARY | |
14.653 | 3.833 | 281608-ANTIPSYCHOTIC AGENTS | Perphenazine | PERPHENAZINE | TABLET | 8 MG | COVERED | FORMULARY | |
26.409 | 60.292 | 281608-ANTIPSYCHOTIC AGENTS | Seroquel | QUETIAPINE FUMARATE | TABLET | 50 MG | COVERED | FORMULARY | Max 800mg/day |
26.411 | 60.293 | 281608-ANTIPSYCHOTIC AGENTS | Seroquel | QUETIAPINE FUMARATE | TABLET | 400 MG | COVERED | FORMULARY | Max 800mg/day |
67.661 | 34.187 | 281608-ANTIPSYCHOTIC AGENTS | Seroquel | QUETIAPINE FUMARATE | TABLET | 25 MG | COVERED | FORMULARY | Max 800mg/day |
67.662 | 34.188 | 281608-ANTIPSYCHOTIC AGENTS | Seroquel | QUETIAPINE FUMARATE | TABLET | 100 MG | COVERED | FORMULARY | Max 800mg/day |
67.663 | 34.189 | 281608-ANTIPSYCHOTIC AGENTS | Seroquel | QUETIAPINE FUMARATE | TABLET | 200 MG | COVERED | FORMULARY | Max 800mg/day |
67.665 | 47.198 | 281608-ANTIPSYCHOTIC AGENTS | Seroquel | QUETIAPINE FUMARATE | TABLET | 300 MG | COVERED | FORMULARY | Max 800mg/day |
16.135 | 26.177 | 281608-ANTIPSYCHOTIC AGENTS | Risperdal | RISPERIDONE | SOLUTION | 1 MG/ML | COVERED | FORMULARY | Max 16mg/day |
16.136 | 21.154 | 281608-ANTIPSYCHOTIC AGENTS | Risperdal | RISPERIDONE | TABLET | 1 MG | COVERED | FORMULARY | Max 16mg/day |
16.137 | 21.155 | 281608-ANTIPSYCHOTIC AGENTS | Risperdal | RISPERIDONE | TABLET | 2 MG | COVERED | FORMULARY | Max 16mg/day |
16.138 | 21.156 | 281608-ANTIPSYCHOTIC AGENTS | Risperdal | RISPERIDONE | TABLET | 3 MG | COVERED | FORMULARY | Max 16mg/day |
16.139 | 21.157 | 281608-ANTIPSYCHOTIC AGENTS | Risperdal | RISPERIDONE | TABLET | 4 MG | COVERED | FORMULARY | Max 16mg/day |
92.872 | 42.922 | 281608-ANTIPSYCHOTIC AGENTS | Risperdal | RISPERIDONE | TABLET | 0.25 MG | COVERED | FORMULARY | Max 16mg/day |
92.892 | 42.923 | 281608-ANTIPSYCHOTIC AGENTS | Risperdal | RISPERIDONE | TABLET | 0.5 MG | COVERED | FORMULARY | Max 16mg/day |
15.691 | 3.996 | 281608-ANTIPSYCHOTIC AGENTS | Thiothixene | THIOTHIXENE | CAPSULE | 10 MG | COVERED | FORMULARY | |
15.692 | 3.997 | 281608-ANTIPSYCHOTIC AGENTS | Thiothixene | THIOTHIXENE | CAPSULE | 2 MG | COVERED | FORMULARY | |
15.694 | 3.999 | 281608-ANTIPSYCHOTIC AGENTS | Thiothixene | THIOTHIXENE | CAPSULE | 5 MG | COVERED | FORMULARY | |
19.880 | 5.009 | 282004-AMPHETAMINES | Zenzedi | DEXTROAMPHETAMINE SULFATE | TABLET | 10 MG | COVERED | FORMULARY | Max 60mg/day |
19.881 | 5.011 | 282004-AMPHETAMINES | Zenzedi | DEXTROAMPHETAMINE SULFATE | TABLET | 5 MG | COVERED | FORMULARY | Max 60mg/day |
14.635 | 48.701 | 282004-AMPHETAMINES | Adderall XR | DEXTROAMPHETAMINE-AMPHETAMINE | CAP ER 24H | 10 MG | COVERED | FORMULARY | Max 60mg/day |
14.636 | 48.702 | 282004-AMPHETAMINES | Adderall XR | DEXTROAMPHETAMINE-AMPHETAMINE | CAP ER 24H | 20 MG | COVERED | FORMULARY | Max 60mg/day |
14.637 | 48.703 | 282004-AMPHETAMINES | Adderall XR | DEXTROAMPHETAMINE-AMPHETAMINE | CAP ER 24H | 30 MG | COVERED | FORMULARY | Max 60mg/day |
17.459 | 50.428 | 282004-AMPHETAMINES | Adderall XR | DEXTROAMPHETAMINE-AMPHETAMINE | CAP ER 24H | 5 MG | COVERED | FORMULARY | Max 60mg/day |
17.468 | 50.429 | 282004-AMPHETAMINES | Adderall XR | DEXTROAMPHETAMINE-AMPHETAMINE | CAP ER 24H | 15 MG | COVERED | FORMULARY | Max 60mg/day |
17.469 | 50.430 | 282004-AMPHETAMINES | Adderall XR | DEXTROAMPHETAMINE-AMPHETAMINE | CAP ER 24H | 25 MG | COVERED | FORMULARY | Max 60mg/day |
29.007 | 47.131 | 282004-AMPHETAMINES | Adderall | DEXTROAMPHETAMINE-AMPHETAMINE | TABLET | 7.5 MG | COVERED | FORMULARY | Max 60mg/day |
29.008 | 47.132 | 282004-AMPHETAMINES | Adderall | DEXTROAMPHETAMINE-AMPHETAMINE | TABLET | 12.5 MG | COVERED | FORMULARY | Max 60mg/day |
29.009 | 47.133 | 282004-AMPHETAMINES | Adderall | DEXTROAMPHETAMINE-AMPHETAMINE | TABLET | 15 MG | COVERED | FORMULARY | Max 60mg/day |
56.970 | 4.999 | 282004-AMPHETAMINES | Adderall | DEXTROAMPHETAMINE-AMPHETAMINE | TABLET | 5 MG | COVERED | FORMULARY | Max 60mg/day |
56.971 | 5.000 | 282004-AMPHETAMINES | Adderall | DEXTROAMPHETAMINE-AMPHETAMINE | TABLET | 10 MG | COVERED | FORMULARY | Max 60mg/day |
56.972 | 34.359 | 282004-AMPHETAMINES | Adderall | DEXTROAMPHETAMINE-AMPHETAMINE | TABLET | 30 MG | COVERED | FORMULARY | Max 60mg/day |
56.973 | 5.001 | 282004-AMPHETAMINES | Adderall | DEXTROAMPHETAMINE-AMPHETAMINE | TABLET | 20 MG | COVERED | FORMULARY | Max 60mg/day |
20.384 | 53.056 | 282032-RESPIRATORY AND CNS STIMULANTS | Metadate CD | METHYLPHENIDATE HCL | CPBP 30-70 | 10 MG | COVERED | FORMULARY | Max 100mg/day |
20.385 | 53.057 | 282032-RESPIRATORY AND CNS STIMULANTS | Metadate CD | METHYLPHENIDATE HCL | CPBP 30-70 | 20 MG | COVERED | FORMULARY | Max 100mg/day |
20.386 | 53.058 | 282032-RESPIRATORY AND CNS STIMULANTS | Metadate CD | METHYLPHENIDATE HCL | CPBP 30-70 | 30 MG | COVERED | FORMULARY | Max 100mg/day |
26.734 | 60.545 | 282032-RESPIRATORY AND CNS STIMULANTS | Metadate CD | METHYLPHENIDATE HCL | CPBP 30-70 | 40 MG | COVERED | FORMULARY | Max 100mg/day |
26.735 | 60.546 | 282032-RESPIRATORY AND CNS STIMULANTS | Metadate CD | METHYLPHENIDATE HCL | CPBP 30-70 | 50 MG | COVERED | FORMULARY | Max 100mg/day |
26.736 | 60.547 | 282032-RESPIRATORY AND CNS STIMULANTS | Metadate CD | METHYLPHENIDATE HCL | CPBP 30-70 | 60 MG | COVERED | FORMULARY | Max 100mg/day |
20.387 | 53.059 | 282032-RESPIRATORY AND CNS STIMULANTS | Ritalin LA | METHYLPHENIDATE HCL | CPBP 50-50 | 20 MG | COVERED | FORMULARY | Max 100mg/day |
20.388 | 53.060 | 282032-RESPIRATORY AND CNS STIMULANTS | Ritalin LA | METHYLPHENIDATE HCL | CPBP 50-50 | 30 MG | COVERED | FORMULARY | Max 100mg/day |
20.391 | 53.061 | 282032-RESPIRATORY AND CNS STIMULANTS | Ritalin LA | METHYLPHENIDATE HCL | CPBP 50-50 | 40 MG | COVERED | FORMULARY | Max 100mg/day |
15.911 | 4.026 | 282032-RESPIRATORY AND CNS STIMULANTS | Ritalin | METHYLPHENIDATE HCL | TABLET | 10 MG | COVERED | FORMULARY | Max 100mg/day |
15.913 | 4.028 | 282032-RESPIRATORY AND CNS STIMULANTS | Ritalin | METHYLPHENIDATE HCL | TABLET | 5 MG | COVERED | FORMULARY | Max 100mg/day |
15.920 | 4.027 | 282032-RESPIRATORY AND CNS STIMULANTS | Ritalin | METHYLPHENIDATE HCL | TABLET | 20 MG | COVERED | FORMULARY | Max 100mg/day |
16.180 | 4.029 | 282032-RESPIRATORY AND CNS STIMULANTS | Methylphenidate ER | METHYLPHENIDATE HCL | TABLET ER | 20 MG | COVERED | FORMULARY | Max 100mg/day |
93.075 | 44.072 | 282032-RESPIRATORY AND CNS STIMULANTS | Methylphenidate ER | METHYLPHENIDATE HCL | TABLET ER | 10 MG | COVERED | FORMULARY | Max 100mg/day |
12.956 | 3.586 | 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) | Phenobarbital | PHENOBARBITAL | ELIXIR | 20 MG/5 ML | COVERED | FORMULARY | |
12.971 | 3.589 | 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) | Phenobarbital | PHENOBARBITAL | TABLET | 15 MG | COVERED | FORMULARY | |
12.972 | 3.591 | 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) | Phenobarbital | PHENOBARBITAL | TABLET | 60 MG | COVERED | FORMULARY | |
12.973 | 3.590 | 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) | Phenobarbital | PHENOBARBITAL | TABLET | 30 MG | COVERED | FORMULARY | |
12.975 | 3.588 | 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) | Phenobarbital | PHENOBARBITAL | TABLET | 100 MG | COVERED | FORMULARY | |
97.965 | 27.611 | 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) | Phenobarbital | PHENOBARBITAL | TABLET | 32.4 MG | COVERED | FORMULARY | |
97.966 | 27.612 | 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) | Phenobarbital | PHENOBARBITAL | TABLET | 64.8 MG | COVERED | FORMULARY | |
14.260 | 3.773 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Xanax | ALPRAZOLAM | TABLET | 0.25 MG | COVERED | FORMULARY | |
14.261 | 3.774 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Xanax | ALPRAZOLAM | TABLET | 0.5 MG | COVERED | FORMULARY | |
14.262 | 3.775 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Xanax | ALPRAZOLAM | TABLET | 1 MG | COVERED | FORMULARY | |
14.263 | 15.566 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Xanax | ALPRAZOLAM | TABLET | 2 MG | COVERED | FORMULARY | |
14.031 | 3.734 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Chlordiazepoxide | CHLORDIAZEPOXIDE HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
14.032 | 3.735 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Chlordiazepoxide | CHLORDIAZEPOXIDE HCL | CAPSULE | 25 MG | COVERED | FORMULARY | |
14.090 | 3.744 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Tranxene | CLORAZEPATE DIPOTASSIUM | TABLET | 15 MG | COVERED | FORMULARY | |
14.092 | 3.745 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Tranxene | CLORAZEPATE DIPOTASSIUM | TABLET | 3.75 MG | COVERED | FORMULARY | |
14.093 | 3.746 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Tranxene | CLORAZEPATE DIPOTASSIUM | TABLET | 7.5 MG | COVERED | FORMULARY | |
14.220 | 3.766 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Valium | DIAZEPAM | TABLET | 10 MG | COVERED | FORMULARY | |
14.221 | 3.767 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Valium | DIAZEPAM | TABLET | 2 MG | COVERED | FORMULARY | |
14.222 | 3.768 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Valium | DIAZEPAM | TABLET | 5 MG | COVERED | FORMULARY | |
14.250 | 3.691 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Flurazepam | FLURAZEPAM HCL | CAPSULE | 15 MG | COVERED | FORMULARY | |
14.251 | 3.692 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Flurazepam | FLURAZEPAM HCL | CAPSULE | 30 MG | COVERED | FORMULARY | |
14.160 | 3.757 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Ativan | LORAZEPAM | TABLET | 0.5 MG | COVERED | FORMULARY | |
14.161 | 3.758 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Ativan | LORAZEPAM | TABLET | 1 MG | COVERED | FORMULARY | |
14.162 | 3.759 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Ativan | LORAZEPAM | TABLET | 2 MG | COVERED | FORMULARY | |
14.230 | 3.769 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Oxazepam | OXAZEPAM | CAPSULE | 10 MG | COVERED | FORMULARY | |
14.231 | 3.770 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Oxazepam | OXAZEPAM | CAPSULE | 15 MG | COVERED | FORMULARY | |
14.232 | 3.771 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Oxazepam | OXAZEPAM | CAPSULE | 30 MG | COVERED | FORMULARY | |
13.840 | 3.689 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Restoril | TEMAZEPAM | CAPSULE | 15 MG | COVERED | FORMULARY | |
13.841 | 3.690 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Restoril | TEMAZEPAM | CAPSULE | 30 MG | COVERED | FORMULARY | |
13.845 | 19.182 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Restoril | TEMAZEPAM | CAPSULE | 7.5 MG | COVERED | FORMULARY | |
13.037 | 47.644 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Buspar | BUSPIRONE HCL | TABLET | 7.5 MG | COVERED | FORMULARY | |
28.890 | 3.782 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Buspar | BUSPIRONE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
28.891 | 3.781 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Buspar | BUSPIRONE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
28.892 | 27.378 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Buspar | BUSPIRONE HCL | TABLET | 15 MG | COVERED | FORMULARY | |
92.121 | 44.210 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Buspar | BUSPIRONE HCL | TABLET | 30 MG | COVERED | FORMULARY | |
13.932 | 3.725 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Hydroxyzine | HYDROXYZINE HCL | SOLUTION | 10 MG/5ML | COVERED | FORMULARY | |
13.941 | 3.726 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Hydroxyzine | HYDROXYZINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
13.943 | 3.728 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Hydroxyzine | HYDROXYZINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
13.944 | 3.729 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Hydroxyzine | HYDROXYZINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
13.951 | 3.730 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Vistaril | HYDROXYZINE PAMOATE | CAPSULE | 100 MG | COVERED | FORMULARY | |
13.952 | 3.731 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Vistaril | HYDROXYZINE PAMOATE | CAPSULE | 25 MG | COVERED | FORMULARY | |
13.953 | 3.732 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Vistaril | HYDROXYZINE PAMOATE | CAPSULE | 50 MG | COVERED | FORMULARY | |
870 | 19.187 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Ambien | ZOLPIDEM TARTRATE | TABLET | 5 MG | COVERED | FORMULARY | Max 10mg/day |
871 | 19.188 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Ambien | ZOLPIDEM TARTRATE | TABLET | 10 MG | COVERED | FORMULARY | Max 10mg/day |
15.710 | 4.001 | 282800-ANTIMANIC AGENTS | Lithium | LITHIUM CARBONATE | CAPSULE | 300 MG | COVERED | FORMULARY | |
15.711 | 4.000 | 282800-ANTIMANIC AGENTS | Lithium | LITHIUM CARBONATE | CAPSULE | 150 MG | COVERED | FORMULARY | |
15.721 | 4.003 | 282800-ANTIMANIC AGENTS | Lithium | LITHIUM CARBONATE | TABLET/CAPSULE | 300 MG | COVERED | FORMULARY | |
15.712 | 4.002 | 282800-ANTIMANIC AGENTS | Lithium | LITHIUM CARBONATE | CAPSULE | 600 MG | COVERED | FORMULARY | |
15.730 | 4.005 | 282800-ANTIMANIC AGENTS | Lithobid | LITHIUM CARBONATE | TABLET ER | 450 MG | COVERED | FORMULARY | |
15.731 | 4.004 | 282800-ANTIMANIC AGENTS | Lithobid | LITHIUM CARBONATE | TABLET ER | 300 MG | COVERED | FORMULARY | |
50.740 | 30.735 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex Nasal | SUMATRIPTAN | SPRAY | 5 MG | COVERED | FORMULARY | Max 2 boxes/month |
50.744 | 30.742 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex Nasal | SUMATRIPTAN | SPRAY | 20 MG | COVERED | FORMULARY | Max 2 boxes/month |
24.708 | 19.239 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex Statdose | SUMATRIPTAN SUCCINATE | CARTRIDGE | 6 MG/0.5ML | COVERED | FORMULARY | Max 2 boxes/month |
50.741 | 19.192 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex Statdose | SUMATRIPTAN SUCCINATE | PEN INJCTR | 6 MG/0.5ML | COVERED | FORMULARY | Max 2 boxes/month |
5.700 | 22.479 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex | SUMATRIPTAN SUCCINATE | TABLET | 50 MG | COVERED | FORMULARY | Max 9 tablets/month |
5.701 | 17.129 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex | SUMATRIPTAN SUCCINATE | TABLET | 100 MG | COVERED | FORMULARY | Max 9 tablets/month |
5.702 | 23.799 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex | SUMATRIPTAN SUCCINATE | TABLET | 25 MG | COVERED | FORMULARY | Max 9 tablets/month |
50.742 | 19.193 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex | SUMATRIPTAN SUCCINATE | VIAL | 6 MG/0.5ML | COVERED | FORMULARY | Max 2 boxes/month |
17.520 | 4.575 | 283604-ADAMANTANES (CNS) | Amantadine | AMANTADINE HCL | CAPSULE | 100 MG | COVERED | FORMULARY | |
17.530 | 4.576 | 283604-ADAMANTANES (CNS) | Amantadine | AMANTADINE HCL | SOLUTION | 50 MG/5ML | COVERED | FORMULARY | |
17.521 | 27.637 | 283604-ADAMANTANES (CNS) | Amantadine | AMANTADINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
17.620 | 4.589 | 283608-ANTICHOLINERGIC AGENTS (CNS) | Cogentin | BENZTROPINE MESYLATE | TABLET | 0.5 MG | COVERED | FORMULARY | |
17.621 | 4.590 | 283608-ANTICHOLINERGIC AGENTS (CNS) | Cogentin | BENZTROPINE MESYLATE | TABLET | 1 MG | COVERED | FORMULARY | |
17.622 | 4.591 | 283608-ANTICHOLINERGIC AGENTS (CNS) | Cogentin | BENZTROPINE MESYLATE | TABLET | 2 MG | COVERED | FORMULARY | |
17.561 | 4.581 | 283608-ANTICHOLINERGIC AGENTS (CNS) | Trihexyphenidyl | TRIHEXYPHENIDYL HCL | TABLET | 2 MG | COVERED | FORMULARY | |
17.563 | 4.582 | 283608-ANTICHOLINERGIC AGENTS (CNS) | Trihexyphenidyl | TRIHEXYPHENIDYL HCL | TABLET | 5 MG | COVERED | FORMULARY | |
95.079 | 41.199 | 283612-CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. | Comtan | ENTACAPONE | TABLET | 200 MG | COVERED | FORMULARY | |
23.285 | 57.987 | 283616-DOPAMINE PRECURSORS | Carbidopa-Levodopa | CARBIDOPA-LEVODOPA | TAB RAPDIS | 10-100 MG | COVERED | FORMULARY | |
23.286 | 57.988 | 283616-DOPAMINE PRECURSORS | Carbidopa-Levodopa | CARBIDOPA-LEVODOPA | TAB RAPDIS | 25-100 MG | COVERED | FORMULARY | |
23.287 | 57.989 | 283616-DOPAMINE PRECURSORS | Carbidopa-Levodopa | CARBIDOPA-LEVODOPA | TAB RAPDIS | 25-250 MG | COVERED | FORMULARY | |
62.740 | 2.537 | 283616-DOPAMINE PRECURSORS | Sinemet | CARBIDOPA-LEVODOPA | TABLET | 10-100 MG | COVERED | FORMULARY | |
62.741 | 2.538 | 283616-DOPAMINE PRECURSORS | Sinemet | CARBIDOPA-LEVODOPA | TABLET | 25-100 MG | COVERED | FORMULARY | |
62.742 | 2.539 | 283616-DOPAMINE PRECURSORS | Sinemet | CARBIDOPA-LEVODOPA | TABLET | 25-250 MG | COVERED | FORMULARY | |
62.591 | 16.043 | 283616-DOPAMINE PRECURSORS | Sinemet CR | CARBIDOPA-LEVODOPA | TABLET ER | 50-200 MG | COVERED | FORMULARY | |
62.592 | 19.563 | 283616-DOPAMINE PRECURSORS | Sinemet CR | CARBIDOPA-LEVODOPA | TABLET ER | 25-100 MG | COVERED | FORMULARY | |
26.070 | 6.603 | 283620-DOPAMINE RECEPTOR AGONISTS | Parlodel | BROMOCRIPTINE MESYLATE | CAPSULE | 5 MG | COVERED | FORMULARY | |
26.081 | 6.604 | 283620-DOPAMINE RECEPTOR AGONISTS | Parlodel | BROMOCRIPTINE MESYLATE | TABLET | 2.5 MG | COVERED | FORMULARY | |
26.051 | 25.738 | 283620-DOPAMINE RECEPTOR AGONISTS | Cabergoline | CABERGOLINE | TABLET | 0.5 MG | COVERED | FORMULARY | |
19.871 | 31.779 | 283620-DOPAMINE RECEPTOR AGONISTS | Mirapex | PRAMIPEXOLE | TABLET | 1 MG | COVERED | FORMULARY | |
19.872 | 31.780 | 283620-DOPAMINE RECEPTOR AGONISTS | Mirapex | PRAMIPEXOLE | TABLET | 1.5 MG | COVERED | FORMULARY | |
19.873 | 31.781 | 283620-DOPAMINE RECEPTOR AGONISTS | Mirapex | PRAMIPEXOLE | TABLET | 0.125 MG | COVERED | FORMULARY | |
19.874 | 31.782 | 283620-DOPAMINE RECEPTOR AGONISTS | Mirapex | PRAMIPEXOLE | TABLET | 0.25 MG | COVERED | FORMULARY | |
19.875 | 39.100 | 283620-DOPAMINE RECEPTOR AGONISTS | Mirapex | PRAMIPEXOLE | TABLET | 0.5 MG | COVERED | FORMULARY | |
34.100 | 29.159 | 283620-DOPAMINE RECEPTOR AGONISTS | Requip | ROPINIROLE HCL | TABLET | 0.25 MG | COVERED | FORMULARY | |
34.101 | 29.160 | 283620-DOPAMINE RECEPTOR AGONISTS | Requip | ROPINIROLE HCL | TABLET | 1 MG | COVERED | FORMULARY | |
34.102 | 29.161 | 283620-DOPAMINE RECEPTOR AGONISTS | Requip | ROPINIROLE HCL | TABLET | 2 MG | COVERED | FORMULARY | |
34.104 | 34.166 | 283620-DOPAMINE RECEPTOR AGONISTS | Requip | ROPINIROLE HCL | TABLET | 0.5 MG | COVERED | FORMULARY | |
93.038 | 43.203 | 283620-DOPAMINE RECEPTOR AGONISTS | Requip | ROPINIROLE HCL | TABLET | 4 MG | COVERED | FORMULARY | |
93.048 | 43.202 | 283620-DOPAMINE RECEPTOR AGONISTS | Requip | ROPINIROLE HCL | TABLET | 3 MG | COVERED | FORMULARY | |
3.253 | 32.492 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Namenda | MEMANTINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
20.773 | 53.324 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Namenda | MEMANTINE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
25.200 | 6.373 | 362600-DIABETES MELLITUS | True Metrix Glucose Test Strip | BLOOD SUGAR DIAGNOSTIC | STRIP | COVERED | FORMULARY | ||
25.200 | 6.373 | 362600-DIABETES MELLITUS | True Metrix Glucose Test Strip | BLOOD SUGAR DIAGNOSTIC | STRIP | COVERED | FORMULARY | ||
25.200 | 6.373 | 362600-DIABETES MELLITUS | True Metrix Test Strips | BLOOD SUGAR DIAGNOSTIC | STRIP | COVERED | FORMULARY | ||
35.600 | 8.321 | 368812-KETONES | Ketocare Test Strip | URINE ACETONE TEST STRIPS | STRIP | COVERED | FORMULARY | ||
35.600 | 8.321 | 368812-KETONES | Ketocare Test Strips | URINE ACETONE TEST STRIPS | STRIP | COVERED | FORMULARY | ||
14.950 | 8.250 | 400800-ALKALINIZING AGENTS | Urocit-K | POTASSIUM CITRATE | TABLET ER | 5 MEQ | COVERED | FORMULARY | |
14.951 | 17.000 | 400800-ALKALINIZING AGENTS | Urocit-K | POTASSIUM CITRATE | TABLET ER | 10 MEQ | COVERED | FORMULARY | |
28.095 | 65.955 | 400800-ALKALINIZING AGENTS | Urocit-K | POTASSIUM CITRATE | TABLET ER | 15 MEQ | COVERED | FORMULARY | |
10.160 | 3.143 | 401000-AMMONIA DETOXICANTS | Lactulose | LACTULOSE | SOLUTION | 10 G/15ML | COVERED | FORMULARY | |
10.167 | 29.054 | 401000-AMMONIA DETOXICANTS | Lactulose | LACTULOSE | SOLUTION | 10 G/15ML | COVERED | FORMULARY | |
30.962 | 68.217 | 401000-AMMONIA DETOXICANTS | Lactulose | LACTULOSE | SOLUTION | 20 G/30ML | COVERED | FORMULARY | |
30.994 | 68.243 | 401000-AMMONIA DETOXICANTS | Lactulose | LACTULOSE | SOLUTION | 10 G/15ML | COVERED | FORMULARY | |
3.321 | 1.248 | 401200-REPLACEMENT PREPARATIONS | Potassium Chloride | POTASSIUM CHLORIDE | CAPSULE ER | 10 MEQ | COVERED | FORMULARY | |
3.404 | 1.262 | 401200-REPLACEMENT PREPARATIONS | Potassium Chloride | POTASSIUM CHLORIDE | PACKET | 20 MEQ | COVERED | FORMULARY | |
3.512 | 22.345 | 401200-REPLACEMENT PREPARATIONS | Potassium Chloride | POTASSIUM CHLORIDE | TAB ER PRT | 10 MEQ | COVERED | FORMULARY | |
3.513 | 22.346 | 401200-REPLACEMENT PREPARATIONS | Potassium Chloride | POTASSIUM CHLORIDE | TAB ER PRT | 20 MEQ | COVERED | FORMULARY | |
3.510 | 1.275 | 401200-REPLACEMENT PREPARATIONS | Potassium Chloride | POTASSIUM CHLORIDE | TABLET ER | 10 MEQ | COVERED | FORMULARY | |
3.515 | 1.276 | 401200-REPLACEMENT PREPARATIONS | Potassium Chloride | POTASSIUM CHLORIDE | TABLET ER | 20 MEQ | COVERED | FORMULARY | |
2.373 | 588 | 401200-REPLACEMENT PREPARATIONS | Sodium Chloride For Inhalation | SODIUM CHLORIDE FOR INHALATION | VIAL-NEB | 3 % | COVERED | FORMULARY | |
98.520 | 62.746 | 401200-REPLACEMENT PREPARATIONS | Sodium Chloride For Inhalation | SODIUM CHLORIDE FOR INHALATION | VIAL-NEB | 7 % | COVERED | FORMULARY | |
930 | 1.196 | 401818-POTASSIUM-REMOVING AGENTS | Sodium Polystyrene Sulfonate | SODIUM POLYSTYRENE SULFONATE | ENEMA | 30 G/120ML | COVERED | FORMULARY | |
1.710 | 1.195 | 401818-POTASSIUM-REMOVING AGENTS | Kionex | SODIUM POLYSTYRENE SULFONATE | ORAL SUSP | 15 G/60 ML | COVERED | FORMULARY | |
13.675 | 48.241 | 401819-PHOSPHATE-REMOVING AGENTS | Phoslo | CALCIUM ACETATE | CAPSULE | 667 MG | COVERED | FORMULARY | |
99.200 | 63.473 | 401819-PHOSPHATE-REMOVING AGENTS | Renvela | SEVELAMER CARBONATE | TABLET | 800 MG | COVERED | FORMULARY | |
16.853 | 46.485 | 401819-PHOSPHATE-REMOVING AGENTS | Renagel | SEVELAMER HCL | TABLET | 800 MG | COVERED | FORMULARY | |
21.130 | 21.406 | 402808-LOOP DIURETICS | Demadex | TORSEMIDE | TABLET | 5 MG | COVERED | FORMULARY | |
21.131 | 21.407 | 402808-LOOP DIURETICS | Demadex | TORSEMIDE | TABLET | 10 MG | COVERED | FORMULARY | |
21.132 | 21.408 | 402808-LOOP DIURETICS | Demadex | TORSEMIDE | TABLET | 20 MG | COVERED | FORMULARY | |
21.133 | 21.409 | 402808-LOOP DIURETICS | Demadex | TORSEMIDE | TABLET | 100 MG | COVERED | FORMULARY | |
34.950 | 8.206 | 402808-LOOP DIURETICS | Furosemide | FUROSEMIDE | SOLUTION | 10 MG/ML | COVERED | FORMULARY | |
34.961 | 8.208 | 402808-LOOP DIURETICS | Lasix | FUROSEMIDE | TABLET | 20 MG | COVERED | FORMULARY | |
34.962 | 8.209 | 402808-LOOP DIURETICS | Lasix | FUROSEMIDE | TABLET | 40 MG | COVERED | FORMULARY | |
34.963 | 8.210 | 402808-LOOP DIURETICS | Lasix | FUROSEMIDE | TABLET | 80 MG | COVERED | FORMULARY | |
27.700 | 8.227 | 402816-POTASSIUM-SPARING DIURETICS | Amiloride | AMILORIDE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
82.341 | 8.178 | 402816-POTASSIUM-SPARING DIURETICS | Amiloride-Hydrochlorothiazide | AMILORIDE-HYDROCHLOROTHIAZIDE | TABLET | 5-50 MG | COVERED | FORMULARY | |
88.730 | 8.175 | 402816-POTASSIUM-SPARING DIURETICS | Dyazide | TRIAMTERENE-HYDROCHLOROTHIAZIDE | CAPSULE | 50-25 MG | COVERED | FORMULARY | |
88.731 | 21.718 | 402816-POTASSIUM-SPARING DIURETICS | Dyazide | TRIAMTERENE-HYDROCHLOROTHIAZIDE | CAPSULE | 37.5-25 MG | COVERED | FORMULARY | |
88.740 | 8.177 | 402816-POTASSIUM-SPARING DIURETICS | Triamterene-Hydrochlorothiazide | TRIAMTERENE-HYDROCHLOROTHIAZIDE | TABLET | 75-50 MG | COVERED | FORMULARY | |
88.741 | 8.176 | 402816-POTASSIUM-SPARING DIURETICS | Triamterene-Hydrochlorothiazide | TRIAMTERENE-HYDROCHLOROTHIAZIDE | TABLET | 37.5-25 MG | COVERED | FORMULARY | |
34.820 | 29.832 | 402820-THIAZIDE DIURETICS | Microzide | HYDROCHLOROTHIAZIDE | CAPSULE | 12.5 MG | COVERED | FORMULARY | |
842 | 28.915 | 402820-THIAZIDE DIURETICS | Hydrochlorothiazide | HYDROCHLOROTHIAZIDE | TABLET | 12.5 MG | COVERED | FORMULARY | |
34.824 | 8.182 | 402820-THIAZIDE DIURETICS | Hydrochlorothiazide | HYDROCHLOROTHIAZIDE | TABLET | 25 MG | COVERED | FORMULARY | |
34.825 | 8.183 | 402820-THIAZIDE DIURETICS | Hydrochlorothiazide | HYDROCHLOROTHIAZIDE | TABLET | 50 MG | COVERED | FORMULARY | |
34.982 | 8.213 | 402824-THIAZIDE-LIKE DIURETICS | Chlorthalidone | CHLORTHALIDONE | TABLET | 25 MG | COVERED | FORMULARY | |
34.984 | 8.214 | 402824-THIAZIDE-LIKE DIURETICS | Chlorthalidone | CHLORTHALIDONE | TABLET | 50 MG | COVERED | FORMULARY | |
7.310 | 8.224 | 402824-THIAZIDE-LIKE DIURETICS | Indapamide | INDAPAMIDE | TABLET | 2.5 MG | COVERED | FORMULARY | |
7.311 | 19.412 | 402824-THIAZIDE-LIKE DIURETICS | Indapamide | INDAPAMIDE | TABLET | 1.25 MG | COVERED | FORMULARY | |
34.990 | 8.216 | 402824-THIAZIDE-LIKE DIURETICS | Metolazone | METOLAZONE | TABLET | 10 MG | COVERED | FORMULARY | |
34.991 | 8.217 | 402824-THIAZIDE-LIKE DIURETICS | Metolazone | METOLAZONE | TABLET | 2.5 MG | COVERED | FORMULARY | |
34.992 | 8.218 | 402824-THIAZIDE-LIKE DIURETICS | Metolazone | METOLAZONE | TABLET | 5 MG | COVERED | FORMULARY | |
35.072 | 8.236 | 404000-URICOSURIC AGENTS | Probenecid | PROBENECID | TABLET | 500 MG | COVERED | FORMULARY | |
29.840 | 4.641 | 480800-ANTITUSSIVES | Tessalon Perles | BENZONATATE | CAPSULE | 100 MG | COVERED | FORMULARY | |
93.007 | 44.168 | 480800-ANTITUSSIVES | Tessalon Perles | BENZONATATE | CAPSULE | 200 MG | COVERED | FORMULARY | |
96.136 | 909 | 480800-ANTITUSSIVES | Bromfed DM | BROMPHENIRAMINE-PSEUDOEPHEDRINE-DM | SYRUP | 2-30-10 MG/5ML | COVERED | FORMULARY | |
19.347 | 51.896 | 480800-ANTITUSSIVES | Chlorpheniramine-Phenylephrine-Dextromethorphan | CHLORPHENIRAMINE-PHENYLEPHRINE-DM | LIQUID | 4-10-15 MG/5ML | COVERED | FORMULARY | |
91.713 | 45.669 | 480800-ANTITUSSIVES | Cheratussin AC, Virtussin AC, Iophen-C NR | GUAIFENESIN-CODEINE PHOSPHATE | LIQUID | 100-10 MG/5ML | COVERED | FORMULARY | |
34.672 | 70.992 | 480800-ANTITUSSIVES | Guaifenesin AC | GUAIFENESIN-CODEINE PHOSPHATE | LIQUID | 100-10 MG/5ML | COVERED | FORMULARY | |
13.974 | 48.492 | 480800-ANTITUSSIVES | Tussionex ER | HYDROCODONE-CHLORPHENIRAMINE | SUS ER 12H | 10-8 MG/5ML | COVERED | FORMULARY | |
13.973 | 48.491 | 480800-ANTITUSSIVES | Hydrocodone-Homatropine | HYDROCODONE-HOMATROPINE | SYRUP | 5-1.5 MG/5ML | COVERED | FORMULARY | |
96.041 | 846 | 480800-ANTITUSSIVES | Hydrocodone-Homatropine | HYDROCODONE-HOMATROPINE | TABLET | 5-1.5 MG | COVERED | FORMULARY | |
13.975 | 48.493 | 480800-ANTITUSSIVES | Promethazine-DM | PROMETHAZINE-DEXTROMETHORPHAN | SYRUP | 6.25-15 MG/5ML | COVERED | FORMULARY | |
13.978 | 48.496 | 480800-ANTITUSSIVES | Promethazine VC Codeine | PROMETHAZINE-PHENYLEPHRINE-CODEINE | SYRUP | 6.25-5-10 MG/5ML | COVERED | FORMULARY | |
54.670 | 728 | 480800-ANTITUSSIVES | Lortuss EX, Cheratussin DAC, Guaifenesin DAC | PSEUDOEPHEDRINE-CODEINE-GUAIFENESIN | SYRUP | 30-10-100 MG/5ML | COVERED | FORMULARY | |
53.636 | 21.251 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent HFA | FLUTICASONE PROPIONATE | AER W/ADAP | 110 MCG | COVERED | FORMULARY | |
53.638 | 21.253 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent HFA | FLUTICASONE PROPIONATE | AER W/ADAP | 44 MCG | COVERED | FORMULARY | |
53.639 | 21.483 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent HFA | FLUTICASONE PROPIONATE | AER W/ADAP | 220 MCG | COVERED | FORMULARY | |
42.373 | 44.803 | 481024-LEUKOTRIENE MODIFIERS | Singulair | MONTELUKAST SODIUM | TAB CHEW | 4 MG | COVERED | FORMULARY | |
94.440 | 37.003 | 481024-LEUKOTRIENE MODIFIERS | Singulair | MONTELUKAST SODIUM | TAB CHEW | 5 MG | COVERED | FORMULARY | |
94.444 | 38.451 | 481024-LEUKOTRIENE MODIFIERS | Singulair | MONTELUKAST SODIUM | TABLET | 10 MG | COVERED | FORMULARY | |
69.069 | 44.694 | 481032-MAST-CELL STABLILIZERS | Cromolyn Ophthalmic | CROMOLYN SODIUM | DROPS | 0.04 | COVERED | FORMULARY | |
60.544 | 29.893 | 520200-ANTIALLERGIC AGENTS | Azelastine | AZELASTINE HCL | SPRAY/PUMP | 137 MCG | COVERED | FORMULARY | |
60.544 | 29.893 | 520200-ANTIALLERGIC AGENTS | Astelin Nasal Spray | AZELASTINE HCL | SPRAY/PUMP | 137 MCG | COVERED | FORMULARY | |
68.321 | 30.796 | 520200-ANTIALLERGIC AGENTS | Patanol | OLOPATADINE HCL | DROPS | 0.1 % | COVERED | FORMULARY | |
33.641 | 7.990 | 520404-ANTIBACTERIALS (EENT) | Bacitracin Ophthalmic | BACITRACIN | OINT. (G) | 500 UNIT/G | COVERED | FORMULARY | |
33.580 | 15.861 | 520404-ANTIBACTERIALS (EENT) | Ciloxan | CIPROFLOXACIN HCL | DROPS | 0.3 % | COVERED | FORMULARY | |
9.076 | 38.351 | 520404-ANTIBACTERIALS (EENT) | Ciloxan | CIPROFLOXACIN HCL | OINT. (G) | 0.3 % | COVERED | FORMULARY | |
20.188 | 52.911 | 520404-ANTIBACTERIALS (EENT) | Ciprodex | CIPROFLOXACIN HCL-DEXAMETHASONE | DROPS SUSP | 0.3-0.1 % | COVERED | FORMULARY | |
82.031 | 39.806 | 520404-ANTIBACTERIALS (EENT) | Cipro HC | CIPROFLOXACIN-HYDROCORTISONE | DROPS SUSP | 0.2-1 % | COVERED | FORMULARY | |
13.521 | 48.077 | 520404-ANTIBACTERIALS (EENT) | Doxycyline | DOXYCYCLINE HYCLATE | TABLET | 20 MG | COVERED | FORMULARY | |
33.540 | 7.948 | 520404-ANTIBACTERIALS (EENT) | Ilotycin | ERYTHROMYCIN BASE | OINT. (G) | 5 MG/G | COVERED | FORMULARY | |
33.600 | 7.984 | 520404-ANTIBACTERIALS (EENT) | Gentamicin | GENTAMICIN SULFATE | DROPS | 0.3 % | COVERED | FORMULARY | |
33.590 | 7.983 | 520404-ANTIBACTERIALS (EENT) | Gentamicin | GENTAMICIN SULFATE | OINT. (G) | 0.3 % | COVERED | FORMULARY | |
19.542 | 52.050 | 520404-ANTIBACTERIALS (EENT) | Vigamox | MOXIFLOXACIN HCL | DROPS | 0.5 % | COVERED | FORMULARY | |
62.265 | 18.370 | 520404-ANTIBACTERIALS (EENT) | Bactroban Nasal | MUPIROCIN CALCIUM | OINT. (G) | 2 % | COVERED | FORMULARY | |
14.283 | 48.544 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Bacitracin-Polymyxin Eye Ointment | NEOMYCIN-BACITRACIN-POLYMYXIN B | OINT. (G) | 3.5-400-10000 MG/G-UNIT/G-UNIT/G | COVERED | FORMULARY | |
14.279 | 48.543 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Bacitracin-Polymyxin-HC Eye Ointment | NEOMYCIN-BACITRACIN-POLYMYXIN B-HYDROCORTISONE | OINT. (G) | 3.5-400-10000-1 MG/G-UNIT/G-UNIT/G-% | COVERED | FORMULARY | |
14.106 | 48.618 | 520404-ANTIBACTERIALS (EENT) | Coly-Mycin S, Cortisporin TC | NEOMYCIN-COLISTIN-HYDROCORTISONE-THONZONIUM | DROPS SUSP | 3.3-3-10-0.5 MG/ML | COVERED | FORMULARY | |
14.285 | 48.546 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Polymxyin-Dexamethasone Eye Ointment | NEOMYCIN-POLYMYX B-DEXAMETHASONE | OINT. (G) | 3.5-10000-0.1 MG/G-UNIT/G-% | COVERED | FORMULARY | |
14.286 | 48.547 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Polymxyin-Dexamethasone Eye Drops | NEOMYCIN-POLYMYXIN B-DEXAMETHASONE | DROPS SUSP | 3.5-10000-0.1 MG/ML-UNIT/ML-% | COVERED | FORMULARY | |
87.270 | 7.964 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Polymyxin-HC Eye Drops | NEOMYCIN-POLYMYXIN B-HYDROCORTISONE | DROPS SUSP | 3.5-10000-10 MG/ML-UNIT/ML-% | COVERED | FORMULARY | |
14.025 | 48.559 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Polymyxin-HC Otic Drops | NEOMYCIN-POLYMYXIN B-HYDROCORTISONE | DROPS SUSP | 3.5-10000-1 MG/ML-UNIT/ML-% | COVERED | FORMULARY | |
14.023 | 48.557 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Polymyxin-HC Otic | NEOMYCIN-POLYMYXIN B-HYDROCORTISONE | SOLUTION | 3.5-10000-1 MG/ML-UNIT/ML-% | COVERED | FORMULARY | |
98.446 | 62.672 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Polymyxin-Gramicidin Eye Drops | NEOMYCIN-POLYMYXN B-GRAMICIDIN | DROPS | 1.75-10000-0.025 MG/ML-UNIT/ML-MG/ML | COVERED | FORMULARY | |
13.880 | 48.292 | 520404-ANTIBACTERIALS (EENT) | Ofloxacin | OFLOXACIN | DROPS | 0.3 % | COVERED | FORMULARY | |
36.600 | 19.734 | 520404-ANTIBACTERIALS (EENT) | Ofloxacin | OFLOXACIN | DROPS | 0.3 % | COVERED | FORMULARY | |
33.340 | 7.920 | 520404-ANTIBACTERIALS (EENT) | Bleph-10 | SULFACETAMIDE SODIUM | DROPS | 10 % | COVERED | FORMULARY | |
9.384 | 38.588 | 520404-ANTIBACTERIALS (EENT) | Tobrex | TOBRAMYCIN | DROPS | 0.3 % | COVERED | FORMULARY | |
92.280 | 7.986 | 520404-ANTIBACTERIALS (EENT) | Tobradex | TOBRAMYCIN-DEXAMETHASONE | DROPS SUSP | 0.3-0.1 % | COVERED | FORMULARY | |
33.500 | 7.942 | 520420-ANTIVIRALS (EENT) | Viroptic | TRIFLURIDINE | DROPS | 1 % | COVERED | FORMULARY | |
34.341 | 8.101 | 520492-EENT ANTI-INFECTIVES, MISCELLANEOUS | Acetic Acid | ACETIC ACID | SOLUTION | 2 % | COVERED | FORMULARY | |
14.017 | 48.554 | 520492-EENT ANTI-INFECTIVES, MISCELLANEOUS | Acetasol HC | ACETIC ACID-HYDROCORTISONE | DROPS | 2-1 % | COVERED | FORMULARY | |
34.280 | 8.079 | 520808-CORTICOSTEROIDS (EENT) | Flunisolide | FLUNISOLIDE | SPRAY | 25 MCG | COVERED | FORMULARY | |
62.263 | 18.368 | 520808-CORTICOSTEROIDS (EENT) | Flonase | FLUTICASONE PROPIONATE | SPRAY SUSP | 50 MCG | COVERED | FORMULARY | |
95.464 | 39.106 | 520808-CORTICOSTEROIDS (EENT) | Lotemax | LOTEPREDNOL ETABONATE | DROPS SUSP | 0.5 % | COVERED | FORMULARY | |
33.153 | 7.894 | 520808-CORTICOSTEROIDS (EENT) | Omnipred | PREDNISOLONE ACETATE | DROPS SUSP | 1 % | COVERED | FORMULARY | |
33.150 | 7.892 | 520808-CORTICOSTEROIDS (EENT) | Prednisolone Acetate | PREDNISOLONE ACETATE | DROPS SUSP | 0.12 % | COVERED | FORMULARY | |
33.181 | 7.897 | 520808-CORTICOSTEROIDS (EENT) | Prednisolone Sodium Phosphate | PREDNISOLONE SOD PHOSPHATE | DROPS | 1 % | COVERED | FORMULARY | |
33.831 | 16.008 | 520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS | Diclofenac Sodium | DICLOFENAC SODIUM | DROPS | 0.1 % | COVERED | FORMULARY | |
34.360 | 7.905 | 520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS | Ocufen | FLURBIPROFEN SODIUM | DROPS | 0.03 % | COVERED | FORMULARY | |
20.255 | 52.960 | 520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS | Acular | KETOROLAC TROMETHAMINE | DROPS | 0.4 % | COVERED | FORMULARY | |
52.700 | 19.067 | 520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS | Acular | KETOROLAC TROMETHAMINE | DROPS | 0.5 % | COVERED | FORMULARY | |
32.952 | 7.866 | 522400-MYDRIATICS | ATROPINE SULFATE | ATROPINE SULFATE | DROPS | 1% | COVERED | FORMULARY | |
32.931 | 7.864 | 522400-MYDRIATICS | ATROPINE SULFATE | ATROPINE SULFATE | OINT. (G) | 1% | COVERED | FORMULARY | |
33.031 | 7.875 | 522400-MYDRIATICS | Cyclogyl 1% | CYCLOPENTOLATE HCL | DROPS | 1 % | COVERED | FORMULARY | |
33.032 | 7.876 | 522400-MYDRIATICS | Cyclogyl 2% | CYCLOPENTOLATE HCL | DROPS | 2 % | COVERED | FORMULARY | |
36.281 | 27.882 | 524004-ALPHA-ADRENERGIC AGONISTS (EENT) | Alphagan | BRIMONIDINE TARTRATE | DROPS | 0.2 % | COVERED | FORMULARY | |
13.752 | 48.333 | 524004-ALPHA-ADRENERGIC AGONISTS (EENT) | Alphagan-P | BRIMONIDINE TARTRATE | DROPS | 0.15 % | COVERED | FORMULARY | |
33.310 | 7.858 | 524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT) | Betagan | LEVOBUNOLOL HCL | DROPS | 0.5 % | COVERED | FORMULARY | |
32.820 | 7.855 | 524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT) | Timoptic | TIMOLOL MALEATE | DROPS | 0.25 % | COVERED | FORMULARY | |
32.821 | 7.856 | 524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT) | Timoptic | TIMOLOL MALEATE | DROPS | 0.5 % | COVERED | FORMULARY | |
32.823 | 21.401 | 524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT) | Timoptic-XE | TIMOLOL MALEATE | SOL-GEL | 0.5 % | COVERED | FORMULARY | |
34.700 | 8.164 | 524012-CARBONIC ANHYDRASE INHIBITORS (EENT) | Diamox Sequels | ACETAZOLAMIDE | CAPSULE ER | 500 MG | COVERED | FORMULARY | |
34.721 | 8.165 | 524012-CARBONIC ANHYDRASE INHIBITORS (EENT) | Acetazolamide | ACETAZOLAMIDE | TABLET | 125 MG | COVERED | FORMULARY | |
34.722 | 8.166 | 524012-CARBONIC ANHYDRASE INHIBITORS (EENT) | Acetazolamide | ACETAZOLAMIDE | TABLET | 250 MG | COVERED | FORMULARY | |
95.773 | 39.498 | 524012-CARBONIC ANHYDRASE INHIBITORS (EENT) | Azopt | BRINZOLAMIDE | DROPS SUSP | 1 % | COVERED | FORMULARY | |
33.380 | 23.513 | 524012-CARBONIC ANHYDRASE INHIBITORS (EENT) | Trusopt | DORZOLAMIDE HCL | DROPS | 2 % | COVERED | FORMULARY | |
95.919 | 39.531 | 524012-CARBONIC ANHYDRASE INHIBITORS (EENT) | Cosopt | DORZOLAMIDE HCL-TIMOLOL MALEATE | DROPS | 22.3-6.8 MG/1ML | COVERED | FORMULARY | |
32.704 | 7.822 | 524020-MIOTICS | Isopto Carpine | PILOCARPINE HCL | DROPS | 1 % | COVERED | FORMULARY | |
32.706 | 7.824 | 524020-MIOTICS | Isopto Carpine | PILOCARPINE HCL | DROPS | 2 % | COVERED | FORMULARY | |
32.752 | 7.826 | 524020-MIOTICS | Isopto Carpine | PILOCARPINE HCL | DROPS | 4 % | COVERED | FORMULARY | |
32.749 | 27.370 | 524028-PROSTAGLANDIN ANALOGS | Xalatan | LATANOPROST | DROPS | 0.005 % | COVERED | FORMULARY | |
32.749 | 27.370 | 524028-PROSTAGLANDIN ANALOGS | Xalatan | LATANOPROST | DROPS | 0.005 % | COVERED | FORMULARY | |
98.379 | 62.605 | 524028-PROSTAGLANDIN ANALOGS | Travoprost | TRAVOPROST (BENZALKONIUM) | DROPS | 0.004% | COVERED | FORMULARY | |
7.855 | 2.661 | 560400-ANTACIDS AND ADSORBENTS | Sodium Bicarbonate | SODIUM BICARBONATE | TABLET | 650 MG | COVERED | FORMULARY | |
65.020 | 2.839 | 560800-ANTIDIARRHEA AGENTS | Lomotil | DIPHENOXYLATE HCL-ATROPINE | LIQUID | 2.5-0.025 MG/5ML | COVERED | FORMULARY | |
65.030 | 2.841 | 560800-ANTIDIARRHEA AGENTS | Lomotil | DIPHENOXYLATE HCL-ATROPINE | TABLET | 2.5-0.025 MG | COVERED | FORMULARY | |
98.433 | 62.659 | 561200-CATHARTICS AND LAXATIVES | Colyte, Gavilyte | PEG 3350-NA SULF BICARB CL-KCL | SOLN RECON | 240-22.72 G | COVERED | FORMULARY | |
98.308 | 62.533 | 561200-CATHARTICS AND LAXATIVES | Golytely, Gavilyte | PEG 3350-NA SULF BICARB CL-KCL | SOLN RECON | 236-22.74 G | COVERED | FORMULARY | |
86.212 | 41.843 | 561200-CATHARTICS AND LAXATIVES | Clearlax | POLYETHYLENE GLYCOL 3350 | POWDER | 17 G/DOSE | COVERED | FORMULARY | Restricted to age <19 |
25.865 | 59.931 | 561200-CATHARTICS AND LAXATIVES | Nulytely Flavor Pack, Gavilyte N, Trilyte | SODIUM CHLORIDE-NAHCO3-KCL-PEG | SOLN RECON | 420 G | COVERED | FORMULARY | |
25.865 | 59.931 | 561200-CATHARTICS AND LAXATIVES | Nulytely, Gavilyte, Trilyte | SODIUM CHLORIDE-NAHCO3-KCL-PEG | SOLN RECON | 420 G | COVERED | FORMULARY | |
97.248 | 61.457 | 561200-CATHARTICS AND LAXATIVES | Moviprep | PEG 3350-NA SULF BICARB CL-KCL-Ascorbic acid | SOLN RECON | 100G | COVERED | FORMULARY | |
1.070 | 3.095 | 561400-CHOLELITHOLYTIC AGENTS | Actigall | URSODIOL | CAPSULE | 300 MG | COVERED | FORMULARY | |
1.072 | 24.333 | 561400-CHOLELITHOLYTIC AGENTS | Urso | URSODIOL | TABLET | 250 MG | COVERED | FORMULARY | |
17.730 | 50.628 | 561400-CHOLELITHOLYTIC AGENTS | Urso Forte | URSODIOL | TABLET | 500 MG | COVERED | FORMULARY | |
26.176 | 65.328 | 561600-DIGESTANTS | Creon | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 6K-19K-30K | NOT COVERED | PAP | Contact manufacturer for PAP |
26.177 | 65.329 | 561600-DIGESTANTS | Creon | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 12K-38K-60 | NOT COVERED | PAP | Contact manufacturer for PAP |
26.178 | 65.330 | 561600-DIGESTANTS | Creon | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 24-76-120K | NOT COVERED | PAP | Contact manufacturer for PAP |
30.217 | 67.625 | 561600-DIGESTANTS | Creon | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 3-9.5-15K | NOT COVERED | PAP | Contact manufacturer for PAP |
34.557 | 70.893 | 561600-DIGESTANTS | Creon | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 36-114-180 | NOT COVERED | PAP | Contact manufacturer for PAP |
42.317 | 76.625 | 561600-DIGESTANTS | Pancreaze | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 16.8-56.8K | NOT COVERED | PAP | Contact manufacturer for PAP |
42.318 | 76.626 | 561600-DIGESTANTS | Pancreaze | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 21 K-54.7K | NOT COVERED | PAP | Contact manufacturer for PAP |
42.319 | 76.627 | 561600-DIGESTANTS | Pancreaze | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 10.5-35.5K | NOT COVERED | PAP | Contact manufacturer for PAP |
42.324 | 76.628 | 561600-DIGESTANTS | Pancreaze | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 4.2K-14.2K | NOT COVERED | PAP | Contact manufacturer for PAP |
42.596 | 76.797 | 561600-DIGESTANTS | Pancreaze | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 2.6 K-6.2K | NOT COVERED | PAP | Contact manufacturer for PAP |
27.726 | 65.700 | 561600-DIGESTANTS | Zenpep | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 5K-17K-27K | NOT COVERED | PAP | Contact manufacturer for PAP |
27.727 | 65.701 | 561600-DIGESTANTS | Zenpep | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 10-34-55K | NOT COVERED | PAP | Contact manufacturer for PAP |
27.728 | 65.702 | 561600-DIGESTANTS | Zenpep | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 15-51-82K | NOT COVERED | PAP | Contact manufacturer for PAP |
27.729 | 65.703 | 561600-DIGESTANTS | Zenpep | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 20-68-109K | NOT COVERED | PAP | Contact manufacturer for PAP |
30.597 | 67.944 | 561600-DIGESTANTS | Zenpep | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 3K-10K-16K | NOT COVERED | PAP | Contact manufacturer for PAP |
30.598 | 67.945 | 561600-DIGESTANTS | Zenpep | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 25-85-136K | NOT COVERED | PAP | Contact manufacturer for PAP |
37.592 | 73.217 | 561600-DIGESTANTS | Zenpep | LIPASE/PROTEASE/AMYLASE | CAPSULE DR | 40K-136K | NOT COVERED | PAP | Contact manufacturer for PAP |
14.761 | 3.844 | 562208-ANTIHISTAMINES (GI DRUGS) | Prochlorperazine | PROCHLORPERAZINE | SUPP.RECT | 25 MG | COVERED | FORMULARY | |
14.771 | 3.846 | 562208-ANTIHISTAMINES (GI DRUGS) | Prochlorperazine | PROCHLORPERAZINE MALEATE | TABLET | 10 MG | COVERED | FORMULARY | |
14.773 | 3.848 | 562208-ANTIHISTAMINES (GI DRUGS) | Prochlorperazine | PROCHLORPERAZINE MALEATE | TABLET | 5 MG | COVERED | FORMULARY | |
20.045 | 41.562 | 562220-5-HT3 RECEPTOR ANTAGONISTS | Zofran ODT | ONDANSETRON | TAB RAPDIS | 4 MG | COVERED | FORMULARY | |
20.046 | 41.563 | 562220-5-HT3 RECEPTOR ANTAGONISTS | Zofran ODT | ONDANSETRON | TAB RAPDIS | 8 MG | COVERED | FORMULARY | |
20.040 | 28.107 | 562220-5-HT3 RECEPTOR ANTAGONISTS | Zofran | ONDANSETRON HCL | SOLUTION | 4 MG/5ML | COVERED | FORMULARY | Restricted to age <19 |
20.041 | 16.392 | 562220-5-HT3 RECEPTOR ANTAGONISTS | Zofran | ONDANSETRON HCL | TABLET | 4 MG | COVERED | FORMULARY | |
20.042 | 16.393 | 562220-5-HT3 RECEPTOR ANTAGONISTS | Zofran | ONDANSETRON HCL | TABLET | 8 MG | COVERED | FORMULARY | |
45.960 | 11.676 | 562812-HISTAMINE H2-ANTAGONISTS | Pepcid | FAMOTIDINE | ORAL SUSP | 40 MG/5ML | COVERED | FORMULARY | |
46.430 | 11.677 | 562812-HISTAMINE H2-ANTAGONISTS | Pepcid | FAMOTIDINE | TABLET | 20 MG | COVERED | FORMULARY | |
46.431 | 11.678 | 562812-HISTAMINE H2-ANTAGONISTS | Pepcid | FAMOTIDINE | TABLET | 40 MG | COVERED | FORMULARY | |
8.250 | 2.767 | 562828-PROSTAGLANDINS | Cytotec | MISOPROSTOL | TABLET | 200 MCG | COVERED | FORMULARY | |
8.251 | 15.197 | 562828-PROSTAGLANDINS | Cytotec | MISOPROSTOL | TABLET | 100 MCG | COVERED | FORMULARY | |
7.651 | 16.133 | 562832-PROTECTANTS | Carafate | SUCRALFATE | ORAL SUSP | 1 G/10 ML | COVERED | FORMULARY | |
8.200 | 2.766 | 562832-PROTECTANTS | Carafate | SUCRALFATE | TABLET | 1 G | COVERED | FORMULARY | |
40.120 | 27.462 | 562836-PROTON-PUMP INHIBITORS | Protonix | PANTOPRAZOLE SODIUM | TABLET DR | 40 MG | COVERED | FORMULARY | |
95.976 | 39.545 | 562836-PROTON-PUMP INHIBITORS | Protonix | PANTOPRAZOLE SODIUM | TABLET DR | 20 MG | COVERED | FORMULARY | |
3.610 | 5.230 | 563200-PROKINETIC AGENTS | Metoclopramide | METOCLOPRAMIDE HCL | SOLUTION | 5 MG/5ML | COVERED | FORMULARY | |
34.798 | 71.108 | 563200-PROKINETIC AGENTS | Metoclopramide | METOCLOPRAMIDE HCL | SOLUTION | 10 MG/10ML | COVERED | FORMULARY | |
21.020 | 5.231 | 563200-PROKINETIC AGENTS | Reglan | METOCLOPRAMIDE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
21.021 | 5.232 | 563200-PROKINETIC AGENTS | Reglan | METOCLOPRAMIDE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
27.412 | 6.782 | 680400-ADRENALS | Dexamethasone | DEXAMETHASONE | DROPS | 1 MG/ML | COVERED | FORMULARY | |
27.422 | 6.784 | 680400-ADRENALS | Dexamethasone | DEXAMETHASONE | TABLET | 0.5 MG | COVERED | FORMULARY | |
27.424 | 6.787 | 680400-ADRENALS | Dexamethasone | DEXAMETHASONE | TABLET | 1 MG | COVERED | FORMULARY | |
27.425 | 6.785 | 680400-ADRENALS | Dexamethasone | DEXAMETHASONE | TABLET | 0.75 MG | COVERED | FORMULARY | |
27.426 | 6.788 | 680400-ADRENALS | Dexamethasone | DEXAMETHASONE | TABLET | 2 MG | COVERED | FORMULARY | |
27.428 | 6.789 | 680400-ADRENALS | Dexamethasone | DEXAMETHASONE | TABLET | 4 MG | COVERED | FORMULARY | |
27.429 | 6.790 | 680400-ADRENALS | Dexamethasone | DEXAMETHASONE | TABLET | 6 MG | COVERED | FORMULARY | |
27.680 | 6.812 | 680400-ADRENALS | Fludrocortisone | FLUDROCORTISONE ACETATE | TABLET | 0.1 MG | COVERED | FORMULARY | |
26.781 | 6.703 | 680400-ADRENALS | Cortef | HYDROCORTISONE | TABLET | 10 MG | COVERED | FORMULARY | |
26.782 | 6.704 | 680400-ADRENALS | Cortef | HYDROCORTISONE | TABLET | 20 MG | COVERED | FORMULARY | |
26.783 | 6.705 | 680400-ADRENALS | Cortef | HYDROCORTISONE | TABLET | 5 MG | COVERED | FORMULARY | |
37.499 | 45.311 | 680400-ADRENALS | Medrol Dosepak | METHYLPREDNISOLONE | TAB DS PK | 4 MG | COVERED | FORMULARY | |
27.056 | 6.741 | 680400-ADRENALS | Medrol | METHYLPREDNISOLONE | TABLET | 4 MG | COVERED | FORMULARY | |
26.800 | 6.719 | 680400-ADRENALS | Prednisolone | PREDNISOLONE | SOLUTION | 15 MG/5 ML | COVERED | FORMULARY | |
33.806 | 47.282 | 680400-ADRENALS | Prednisolone Sodium Phosphate | PREDNISOLONE SOD PHOSPHATE | SOLUTION | 15 MG/5 ML | COVERED | FORMULARY | |
38.363 | 45.267 | 680400-ADRENALS | Prednisone | PREDNISONE | TAB DS PK | 5 MG | COVERED | FORMULARY | |
38.364 | 45.268 | 680400-ADRENALS | Prednisone | PREDNISONE | TAB DS PK | 10 MG | COVERED | FORMULARY | |
27.171 | 6.748 | 680400-ADRENALS | Prednisone | PREDNISONE | TABLET | 1 MG | COVERED | FORMULARY | |
27.172 | 6.749 | 680400-ADRENALS | Prednisone | PREDNISONE | TABLET | 10 MG | COVERED | FORMULARY | |
27.173 | 6.750 | 680400-ADRENALS | Prednisone | PREDNISONE | TABLET | 2.5 MG | COVERED | FORMULARY | |
27.174 | 6.751 | 680400-ADRENALS | Prednisone | PREDNISONE | TABLET | 20 MG | COVERED | FORMULARY | |
27.176 | 6.753 | 680400-ADRENALS | Prednisone | PREDNISONE | TABLET | 5 MG | COVERED | FORMULARY | |
27.177 | 6.754 | 680400-ADRENALS | Prednisone | PREDNISONE | TABLET | 50 MG | COVERED | FORMULARY | |
47.851 | 45.215 | 680800-ANDROGENS | Androgel 1% | TESTOSTERONE | GEL PACKET | 25 MG(1%) | COVERED | FORMULARY | |
47.852 | 45.216 | 680800-ANDROGENS | Androgel 1% | TESTOSTERONE | GEL PACKET | 50 MG (1%) | COVERED | FORMULARY | |
18.126 | 50.831 | 681200-CONTRACEPTIVES | Ortho Tri-Cyclen Lo, Tri-Lo-Marzia, Tri-Lo-Sprintec, Tri-Lo-Estarylla | NORGESTIMATE-ETHINYL ESTRADIOL | TABLET | 0.18/0.215/0.25 mg - 25mcg | COVERED | FORMULARY | |
13.083 | 47.787 | 681200-CONTRACEPTIVES | Yasmin | ETHINYL ESTRADIOL-DROSPIRENONE | TABLET | 0.03-3 MG | COVERED | FORMULARY | |
11.530 | 3.314 | 681200-CONTRACEPTIVES | Altavera, Chateal, Kurvelo, Levora, Marlissa, Portia | LEVONORGESTREL-ETHINYL ESTRADIOL | TABLET | 0.15-0.03 MG | COVERED | FORMULARY | |
11.534 | 30.986 | 681200-CONTRACEPTIVES | Aviane, Aubra, Delyla, Falmina, Lessina, Lutera, Orsythia, Sronyx | LEVONORGESTREL-ETHINYL ESTRADIOL | TABLET | 0.1-0.02 MG | COVERED | FORMULARY | |
11.531 | 3.315 | 681200-CONTRACEPTIVES | Enpresse, Trivora, Myzilra | LEVONORGESTREL-ETHINYL ESTRADIOL | TABLET | 50-30(6)/75-40(5)/125/30(10) MCG | COVERED | FORMULARY | |
11.520 | 3.313 | 681200-CONTRACEPTIVES | Ortho Micronor, Errin, Camila, Deblitane, Sharobel, Norlyro, Nor-Be, Jolivette, Jencycla, Heather | NORETHINDRONE | TABLET | 0.35 MG | COVERED | FORMULARY | |
11.480 | 3.304 | 681200-CONTRACEPTIVES | Gildess, Junel, Larin, Loestrin 21 1.5/30 | NORETHINDRONE ACETATE-ETHINYL ESTRADIOL | TABLET | 1.5-30 MCG | COVERED | FORMULARY | |
11.481 | 3.305 | 681200-CONTRACEPTIVES | Gildess, Junel, Larin, Loestrin 21 1/20 | NORETHINDRONE ACETATE-ETHINYL ESTRADIOL | TABLET | 1-20 MCG | COVERED | FORMULARY | |
11.477 | 3.298 | 681200-CONTRACEPTIVES | Alyacen 7/7/7, Cyclafem 7/7/7, Diasetta 7/7/7, Necon 7/7/7, Nortrel 7/7/7, Ortho-Novum 7/7/7 | NORETHINDRONE-ETHINYL ESTRADIOL | TABLET | 0.5/0.75/1 MG-35MCG | COVERED | FORMULARY | |
11.474 | 3.295 | 681200-CONTRACEPTIVES | Alyacen, Cyclafem, Dasetta, Necon 1/35, Nortrel 1/35, Norinyl, Ortho Novum, Primella | NORETHINDRONE-ETHINYL ESTRADIOL | TABLET | 1-0.35 MG | COVERED | FORMULARY | |
11.471 | 3.294 | 681200-CONTRACEPTIVES | Brevicon, Modicone, Necon 0.5/35, Nortrel 0.5/35, Wera | NORETHINDRONE-ETHINYL ESTRADIOL | TABLET | 0.5-0.35 MG | COVERED | FORMULARY | |
68.101 | 3.300 | 681200-CONTRACEPTIVES | Blisovi FE, Gildess FE, Junel FE, Larin FE, Loestrin FE 1.5/30 | NORETHINDRONE-ETHINYL ESTRADIOL-IRON | TABLET | 1.5MG-30 MCG(21)/75MG(7) | COVERED | FORMULARY | |
68.102 | 3.301 | 681200-CONTRACEPTIVES | Blisovi FE, Gildess FE, Junel FE, Larin FE, Loestrin FE 1/20 | NORETHINDRONE-ETHINYL ESTRADIOL-IRON | TABLET | 1 MG-20 MCG(21)/75MG(7) | COVERED | FORMULARY | |
11.300 | 13.662 | 681200-CONTRACEPTIVES | Estarylla, Mononessa, Ortho-Cyclen, Previfem, Sprintec | NORGESTIMATE-ETHINYL ESTRADIOL | TABLET | 0.25-0.035 MG | COVERED | FORMULARY | |
11.301 | 16.963 | 681200-CONTRACEPTIVES | Tri-Estarylla, Tri-Mononessa, Otrho Tri-Cyclen, Tri-Previfem, Tri-Sprintec | NORGESTIMATE-ETHINYL ESTRADIOL | TABLET | 0.18/0.215/0.25 MG-35MCG(28) | COVERED | FORMULARY | |
11.500 | 3.310 | 681200-CONTRACEPTIVES | Low-Ogestrel, Elinest, Cryselle | NORGESTREL-ETHINYL ESTRADIOL | TABLET | 0.3 MG-30MCG | COVERED | FORMULARY | |
10.770 | 3.204 | 681604-ESTROGENS | Estrace | ESTRADIOL | TABLET | 1 MG | COVERED | FORMULARY | |
10.771 | 3.205 | 681604-ESTROGENS | Estrace | ESTRADIOL | TABLET | 2 MG | COVERED | FORMULARY | |
10.772 | 21.411 | 681604-ESTROGENS | Estrace | ESTRADIOL | TABLET | 0.5 MG | COVERED | FORMULARY | |
19.739 | 52.179 | 681604-ESTROGENS | Prempro | ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE | TABLET | 0.45-1.5 MG | COVERED | FORMULARY | |
20.769 | 53.321 | 681604-ESTROGENS | Prempro | ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE | TABLET | 0.3-1.5 MG | COVERED | FORMULARY | |
55.730 | 22.647 | 681604-ESTROGENS | Prempro | ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE | TABLET | 0.625-5 MG | COVERED | FORMULARY | |
55.731 | 22.648 | 681604-ESTROGENS | Prempro | ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE | TABLET | 0.625-2.5 MG | COVERED | FORMULARY | |
28.410 | 7.013 | 681604-ESTROGENS | Premarin Vaginal | ESTROGENS CONJUGATED | CREAM/APPL | 0.625 MG/G | COVERED | FORMULARY | |
10.942 | 3.212 | 681604-ESTROGENS | Premarin | ESTROGENS CONJUGATED | TABLET | 0.625 MG | COVERED | FORMULARY | |
10.943 | 3.211 | 681604-ESTROGENS | Premarin | ESTROGENS CONJUGATED | TABLET | 0.3 MG | COVERED | FORMULARY | |
10.944 | 3.213 | 681604-ESTROGENS | Premarin | ESTROGENS CONJUGATED | TABLET | 0.9 MG | COVERED | FORMULARY | |
10.945 | 3.214 | 681604-ESTROGENS | Premarin | ESTROGENS CONJUGATED | TABLET | 1.25 MG | COVERED | FORMULARY | |
19.975 | 52.766 | 681604-ESTROGENS | Premarin | ESTROGENS CONJUGATED | TABLET | 0.45MG | COVERED | FORMULARY | |
59.011 | 37.022 | 681612-ESTROGEN AGONIST-ANTAGONISTS | Evista | RALOXIFENE HCL | TABLET | 60 MG | COVERED | FORMULARY | |
19.578 | 52.080 | 682004-BIGUANIDES | Glucophage XR | METFORMIN HCL | TAB ER 24H | 750 MG | COVERED | FORMULARY | |
89.863 | 46.754 | 682004-BIGUANIDES | Glucophage XR | METFORMIN HCL | TAB ER 24H | 500 MG | COVERED | FORMULARY | |
10.810 | 13.318 | 682004-BIGUANIDES | Glucophage | METFORMIN HCL | TABLET | 500 MG | COVERED | FORMULARY | |
10.811 | 16.441 | 682004-BIGUANIDES | Glucophage | METFORMIN HCL | TABLET | 850 MG | COVERED | FORMULARY | |
10.857 | 40.974 | 682004-BIGUANIDES | Glucophage | METFORMIN HCL | TABLET | 1000 MG | COVERED | FORMULARY | |
92.336 | 44.341 | 682008-INSULINS | Novolog Flexpen | INSULIN ASPART | INSULN PEN | 100 UNIT/ML | COVERED | FORMULARY | |
92.326 | 44.340 | 682008-INSULINS | Novolog | INSULIN ASPART | VIAL | 100 UNIT/ML | COVERED | FORMULARY | |
17.075 | 50.134 | 682008-INSULINS | Novolog 70/30 | INSULIN ASPART PROTAMINE-INSULIN ASPART | INSULN PEN | 70-30 UNIT/ML | COVERED | FORMULARY | |
19.057 | 51.718 | 682008-INSULINS | Novolog 70/30 | INSULIN ASPART PROTAMINE-INSULIN ASPART | VIAL | 70-30 UNIT/ML | COVERED | FORMULARY | |
96.719 | 34.731 | 682008-INSULINS | Humalog Kwik Pen | INSULIN LISPRO | INSULN PEN | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | |
5.679 | 27.413 | 682008-INSULINS | Humalog | INSULIN LISPRO | VIAL | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | |
11.660 | 1.740 | 682008-INSULINS | Novolin N | INSULIN NPH HUMAN ISOPHANE | VIAL | 100 UNIT/ML | COVERED | FORMULARY | |
50.001 | 16.311 | 682008-INSULINS | Novolin 70/30 | INSULIN NPH HUM-REG INSULIN HM | VIAL | 70-30 UNIT/ML | COVERED | FORMULARY | |
93.717 | 42.076 | 682008-INSULINS | Humalog 75/25 Kwik Pen | INSULIN NPL-INSULIN LISPRO | INSULN PEN | 75-25 UNIT/ML | NOT COVERED | NON-FORMULARY | |
22.681 | 47.172 | 682008-INSULINS | Humalog 75/25 | INSULIN NPL-INSULIN LISPRO | VIAL | 75-25 UNIT/ML | NOT COVERED | NON-FORMULARY | |
11.642 | 1.723 | 682008-INSULINS | Novolin R | INSULIN REGULAR HUMAN | VIAL | 100 UNIT/ML | COVERED | FORMULARY | |
12.277 | 47.333 | 682016-MEGLITINIDES | Starlix | NATEGLINIDE | TABLET | 60 MG | COVERED | FORMULARY | |
34.027 | 47.292 | 682016-MEGLITINIDES | Starlix | NATEGLINIDE | TABLET | 120 MG | COVERED | FORMULARY | |
5.830 | 25.179 | 682020-SULFONYLUREAS | Amaryl | GLIMEPIRIDE | TABLET | 1 MG | COVERED | FORMULARY | |
5.832 | 25.180 | 682020-SULFONYLUREAS | Amaryl | GLIMEPIRIDE | TABLET | 2 MG | COVERED | FORMULARY | |
5.833 | 25.181 | 682020-SULFONYLUREAS | Amaryl | GLIMEPIRIDE | TABLET | 4 MG | COVERED | FORMULARY | |
10.843 | 21.839 | 682020-SULFONYLUREAS | Glucotrol XL | GLIPIZIDE | TAB ER 24 | 10 MG | COVERED | FORMULARY | |
10.844 | 21.840 | 682020-SULFONYLUREAS | Glucotrol XL | GLIPIZIDE | TAB ER 24 | 5 MG | COVERED | FORMULARY | |
50.638 | 43.463 | 682020-SULFONYLUREAS | Glucotrol XL | GLIPIZIDE | TAB ER 24 | 2.5 MG | COVERED | FORMULARY | |
10.840 | 1.777 | 682020-SULFONYLUREAS | Glucotrol | GLIPIZIDE | TABLET | 5 MG | COVERED | FORMULARY | |
10.841 | 1.776 | 682020-SULFONYLUREAS | Glucotrol | GLIPIZIDE | TABLET | 10 MG | COVERED | FORMULARY | |
18.366 | 51.194 | 682020-SULFONYLUREAS | Glipizide-Metformin | GLIPIZIDE-METFORMIN HCL | TABLET | 2.5-250 MG | COVERED | FORMULARY | |
18.367 | 51.195 | 682020-SULFONYLUREAS | Glipizide-Metformin | GLIPIZIDE-METFORMIN HCL | TABLET | 2.5-500 MG | COVERED | FORMULARY | |
18.368 | 51.196 | 682020-SULFONYLUREAS | Glipizide-Metformin | GLIPIZIDE-METFORMIN HCL | TABLET | 5-500 MG | COVERED | FORMULARY | |
5.710 | 1.773 | 682020-SULFONYLUREAS | Diabeta | GLYBURIDE | TABLET | 1.25 MG | COVERED | FORMULARY | |
5.711 | 1.774 | 682020-SULFONYLUREAS | Diabeta | GLYBURIDE | TABLET | 2.5 MG | COVERED | FORMULARY | |
5.712 | 1.775 | 682020-SULFONYLUREAS | Diabeta | GLYBURIDE | TABLET | 5 MG | COVERED | FORMULARY | |
89.878 | 45.929 | 682020-SULFONYLUREAS | Glucovance | GLYBURIDE-METFORMIN HCL | TABLET | 1.25-250 MG | COVERED | FORMULARY | |
89.879 | 45.930 | 682020-SULFONYLUREAS | Glucovance | GLYBURIDE-METFORMIN HCL | TABLET | 5-500 MG | COVERED | FORMULARY | |
92.889 | 22.735 | 682020-SULFONYLUREAS | Glucovance | GLYBURIDE-METFORMIN HCL | TABLET | 2.5-500 MG | COVERED | FORMULARY | |
92.991 | 42.943 | 682028-THIAZOLIDINEDIONES | Actos | PIOGLITAZONE HCL | TABLET | 15 MG | COVERED | FORMULARY | |
93.001 | 42.944 | 682028-THIAZOLIDINEDIONES | Actos | PIOGLITAZONE HCL | TABLET | 30 MG | COVERED | FORMULARY | |
93.011 | 42.945 | 682028-THIAZOLIDINEDIONES | Actos | PIOGLITAZONE HCL | TABLET | 45 MG | COVERED | FORMULARY | |
25.474 | 41.661 | 682212-GLYCOGENOLYTIC AGENTS | Glucagon | GLUCAGON HUMAN RECOMBINANT | KIT | 1 MG | NOT COVERED | NON-FORMULARY | |
25.473 | 41.660 | 682212-GLYCOGENOLYTIC AGENTS | Glucagen | GLUCAGON HUMAN RECOMBINANT | VIAL | 1 MG | COVERED | FORMULARY | |
23.281 | 24.138 | 682400-PARATHYROID | Miacalcin Nasal | CALCITONIN SALMON SYNTHETIC | SPRAY/PUMP | 200 UNIT/SPRAY | COVERED | FORMULARY | |
26.173 | 31.610 | 682800-PITUITARY | DDAVP Nasal | DESMOPRESSIN (NONREFRIGERATED) | SPRAY/PUMP | 10 MCG/SPRAY | COVERED | FORMULARY | |
26.170 | 6.617 | 682800-PITUITARY | DDAVP | DESMOPRESSIN ACETATE | SOLUTION | 0.1 MG/ML | COVERED | FORMULARY | |
26.171 | 19.596 | 682800-PITUITARY | DDAVP | DESMOPRESSIN ACETATE | TABLET | 0.1 MG | COVERED | FORMULARY | |
26.172 | 19.597 | 682800-PITUITARY | DDAVP | DESMOPRESSIN ACETATE | TABLET | 0.2 MG | COVERED | FORMULARY | |
11.260 | 3.271 | 683200-PROGESTINS | Provera | MEDROXYPROGESTERONE ACETATE | TABLET | 10 MG | COVERED | FORMULARY | |
11.261 | 3.272 | 683200-PROGESTINS | Provera | MEDROXYPROGESTERONE ACETATE | TABLET | 2.5 MG | COVERED | FORMULARY | |
11.262 | 3.273 | 683200-PROGESTINS | Provera | MEDROXYPROGESTERONE ACETATE | TABLET | 5 MG | COVERED | FORMULARY | |
11.280 | 3.274 | 683200-PROGESTINS | Aygestin | NORETHINDRONE ACETATE | TABLET | 5 MG | COVERED | FORMULARY | |
98.586 | 62.815 | 683200-PROGESTINS | Endometrin Vaginal | PROGESTERONE MICRONIZED | INSERT | 100 MG | COVERED | FORMULARY | |
26.320 | 6.652 | 683604-THYROID AGENTS | Levothyroxine | LEVOTHYROXINE SODIUM | TABLET | 112 MCG | COVERED | FORMULARY | |
26.321 | 6.648 | 683604-THYROID AGENTS | Levothyroxine | LEVOTHYROXINE SODIUM | TABLET | 25 MCG | COVERED | FORMULARY | |
26.322 | 6.649 | 683604-THYROID AGENTS | Levothyroxine | LEVOTHYROXINE SODIUM | TABLET | 50 MCG | COVERED | FORMULARY | |
26.323 | 6.651 | 683604-THYROID AGENTS | Levothyroxine | LEVOTHYROXINE SODIUM | TABLET | 100 MCG | COVERED | FORMULARY | |
26.324 | 6.650 | 683604-THYROID AGENTS | Levothyroxine | LEVOTHYROXINE SODIUM | TABLET | 75 MCG | COVERED | FORMULARY | |
26.325 | 6.656 | 683604-THYROID AGENTS | Levothyroxine | LEVOTHYROXINE SODIUM | TABLET | 200 MCG | COVERED | FORMULARY | |
26.326 | 6.653 | 683604-THYROID AGENTS | Levothyroxine | LEVOTHYROXINE SODIUM | TABLET | 125 MCG | COVERED | FORMULARY | |
26.327 | 6.654 | 683604-THYROID AGENTS | Levothyroxine | LEVOTHYROXINE SODIUM | TABLET | 150 MCG | COVERED | FORMULARY | |
26.328 | 6.655 | 683604-THYROID AGENTS | Levothyroxine | LEVOTHYROXINE SODIUM | TABLET | 175MCG | COVERED | FORMULARY | |
26.329 | 6.657 | 683604-THYROID AGENTS | Levothyroxine | LEVOTHYROXINE SODIUM | TABLET | 300 MCG | COVERED | FORMULARY | |
47.631 | 15.523 | 683604-THYROID AGENTS | Levothyroxine | LEVOTHYROXINE SODIUM | TABLET | 88 MCG | COVERED | FORMULARY | |
47.632 | 20.176 | 683604-THYROID AGENTS | Levothyroxine | LEVOTHYROXINE SODIUM | TABLET | 137 MCG | COVERED | FORMULARY | |
26.340 | 6.658 | 683604-THYROID AGENTS | Cytomel | LIOTHYRONINE SODIUM | TABLET | 25 MCG | COVERED | FORMULARY | |
26.341 | 6.659 | 683604-THYROID AGENTS | Cytomel | LIOTHYRONINE SODIUM | TABLET | 5 MCG | COVERED | FORMULARY | |
26.342 | 6.660 | 683604-THYROID AGENTS | Cytomel | LIOTHYRONINE SODIUM | TABLET | 50 MCG | COVERED | FORMULARY | |
26.400 | 6.674 | 683608-ANTITHYROID AGENTS | Tapazole | METHIMAZOLE | TABLET | 10 MG | COVERED | FORMULARY | |
26.401 | 6.675 | 683608-ANTITHYROID AGENTS | Tapazole | METHIMAZOLE | TABLET | 5 MG | COVERED | FORMULARY | |
28.581 | 16.924 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Cleocin Vaginal | CLINDAMYCIN PHOSPHATE | CREAM/APPL | 2 % | COVERED | FORMULARY | |
45.410 | 7.726 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Cleocin T | CLINDAMYCIN PHOSPHATE | GEL (GRAM) | 1 % | COVERED | FORMULARY | |
31.770 | 11.752 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Cleocin T | CLINDAMYCIN PHOSPHATE | LOTION | 1 % | COVERED | FORMULARY | |
31.720 | 7.727 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Cleocin T | CLINDAMYCIN PHOSPHATE | SOLUTION | 1 % | COVERED | FORMULARY | |
77.562 | 29.325 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Erythromycin with Ethanol | ERYTHROMYCIN BASE (WITH ETHANOL) | SOLUTION | 2 % | COVERED | FORMULARY | |
43.203 | 41.799 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Metrocream, Rosadan | METRONIDAZOLE | CREAM (G) | 0.75 % | COVERED | FORMULARY | |
24.926 | 59.325 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Metrogel | METRONIDAZOLE | GEL (GRAM) | 1 % | COVERED | FORMULARY | |
43.202 | 41.798 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Rosadan | METRONIDAZOLE | GEL (GRAM) | 0.75 % | COVERED | FORMULARY | |
49.261 | 16.939 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Metrogel Vaginal | METRONIDAZOLE | GEL W/APPL | 0.75 % | COVERED | FORMULARY | |
31.774 | 68.879 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Metrogel Pump | METRONIDAZOLE | GEL W/PUMP | 1 % | COVERED | FORMULARY | |
43.201 | 41.797 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Metrolotion | METRONIDAZOLE | LOTION | 0.75 % | COVERED | FORMULARY | |
47.450 | 7.732 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Bactroban | MUPIROCIN | OINT. (G) | 2 % | COVERED | FORMULARY | |
85.459 | 7.694 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Triple Antibiotic Ointment | NEOMYCIN-BACITRACIN-POLYMYXIN B | OINT. (G) | 3.5-400-5000 MG/G-UNIT/G-UNIT/G | COVERED | FORMULARY | |
14.274 | 48.538 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Cortisporin | NEOMYCIN-BACITRACIN-POLYMYXIN B-HYDROCORTISONE | OINT. (G) | 3.5-400-10000-1 MG/G-UNIT/G-UNIT/G-% | COVERED | FORMULARY | |
14.275 | 48.539 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Cortisporin | NEOMYCIN-POLYMYXIN B-HYDROCORTISONE | CREAM (G) | 3.5-10000-0.50 MG/G-UNIT/G-% | COVERED | FORMULARY | |
62.420 | 18.315 | 840406-ANTIVIRALS (SKIN & MUCOUS MEMBRANE) | Zovirax | ACYCLOVIR | CREAM (G) | 5 % | COVERED | FORMULARY | |
31.640 | 7.670 | 840406-ANTIVIRALS (SKIN & MUCOUS MEMBRANE) | Zovirax | ACYCLOVIR | OINT. (G) | 5 % | COVERED | FORMULARY | |
12.618 | 44.922 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Ciclopirox | CICLOPIROX | GEL (GRAM) | 0.77 % | COVERED | FORMULARY | |
19.218 | 51.825 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Loprox Shampoo | CICLOPIROX | SHAMPOO | 1 % | COVERED | FORMULARY | |
8.040 | 37.020 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Ciclodan, Penlac | CICLOPIROX | SOLUTION | 8 % | COVERED | FORMULARY | |
94.677 | 40.971 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Ciclopirox Olamine | CICLOPIROX OLAMINE | CREAM (G) | 0.77 % | COVERED | FORMULARY | |
30.380 | 7.362 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Clotrimazole | CLOTRIMAZOLE | SOLUTION | 1 % | COVERED | FORMULARY | |
7.590 | 9.553 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Mycelex | CLOTRIMAZOLE | TROCHE | 10 MG | COVERED | FORMULARY | |
6.919 | 36.534 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Lotrisone | CLOTRIMAZOLE-BETAMETHASONE DIPROPIONATE | CREAM (G) | 1-0.05 % | COVERED | FORMULARY | |
14.125 | 48.627 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Clotrimazole-Betamethasone | CLOTRIMAZOLE-BETAMETHASONE DIPROPIONATE | LOTION | 1-0.05 % | COVERED | FORMULARY | |
31.850 | 7.334 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Ketoconazole | KETOCONAZOLE | CREAM (G) | 2 % | COVERED | FORMULARY | |
31.271 | 15.568 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Nizoral Shampoo | KETOCONAZOLE | SHAMPOO | 2 % | COVERED | FORMULARY | |
30.140 | 7.282 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Nystatin | NYSTATIN | CREAM (G) | 100000 UNIT/G | COVERED | FORMULARY | |
30.150 | 7.283 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Nystatin | NYSTATIN | OINT. (G) | 100000 UNIT/G | COVERED | FORMULARY | |
30.160 | 7.284 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Nystatin | NYSTATIN | POWDER | 100000 UNIT/G | COVERED | FORMULARY | |
14.007 | 48.529 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Nystatin/Triamcinolone | NYSTATIN-TRIAMCINCINOLONE | CREAM (G) | 100000-0.1 UNIT/G-% | COVERED | FORMULARY | |
14.008 | 48.530 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Nystatin/Triamcinolone | NYSTATIN-TRIAMCINCINOLONE | OINT. (G) | 100000-0.1 UNIT/G-% | COVERED | FORMULARY | |
48.381 | 15.931 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Terazol 3 | TERCONAZOLE | CREAM/APPL | 0.8 % | COVERED | FORMULARY | |
48.380 | 7.008 | 840408-ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) | Terazol 7 | TERCONAZOLE | CREAM/APPL | 0.4 % | COVERED | FORMULARY | |
31.550 | 7.650 | 840412-SCABICIDES AND PEDICULICIDES | Lindane | LINDANE | LOTION | 1 % | COVERED | FORMULARY | |
31.570 | 7.651 | 840412-SCABICIDES AND PEDICULICIDES | Lindane | LINDANE | SHAMPOO | 1 % | COVERED | FORMULARY | |
44.370 | 13.631 | 840412-SCABICIDES AND PEDICULICIDES | Elimite | PERMETHRIN | CREAM (G) | 5 % | COVERED | FORMULARY | |
44.520 | 7.663 | 840412-SCABICIDES AND PEDICULICIDES | Nix | PERMETHRIN | LIQUID | 1 % | COVERED | FORMULARY | |
31.630 | 7.669 | 840492-LOCAL ANTI-INFECTIVES, MISCELLANEOUS | Silvadene | SILVER SULFADIAZINE | CREAM (G) | 1 % | COVERED | FORMULARY | |
31.060 | 7.568 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Betamethasone Diproprionate | BETAMETHASONE DIPROPIONATE | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
31.080 | 7.570 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Betamethasone Diproprionate | BETAMETHASONE DIPROPIONATE | LOTION | 0.05 % | COVERED | FORMULARY | |
31.070 | 7.569 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Betamethasone Diproprionate | BETAMETHASONE DIPROPIONATE | OINT. (G) | 0.05 % | COVERED | FORMULARY | |
31.101 | 7.572 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Betamethasone Valerate | BETAMETHASONE VALERATE | CREAM (G) | 0.1 % | COVERED | FORMULARY | |
31.120 | 7.574 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Betamethasone Valerate | BETAMETHASONE VALERATE | LOTION | 0.1 % | COVERED | FORMULARY | |
31.110 | 7.573 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Betamethasone Valerate | BETAMETHASONE VALERATE | OINT. (G) | 0.1 % | COVERED | FORMULARY | |
31.890 | 7.561 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Diprolene AF | BETAMETHASONE-PROPYLENE GLYCOL | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
31.910 | 7.562 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Diprolene | BETAMETHASONE-PROPYLENE GLYCOL | OINT. (G) | 0.05 % | COVERED | FORMULARY | |
32.140 | 7.634 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Temovate | CLOBETASOL PROPIONATE | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
34.040 | 18.288 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Clobex | CLOBETASOL PROPIONATE | LOTION | 0.05 % | COVERED | FORMULARY | |
32.130 | 7.635 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Temovate | CLOBETASOL PROPIONATE | OINT. (G) | 0.05 % | COVERED | FORMULARY | |
15.891 | 15.349 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Cormax | CLOBETASOL PROPIONATE | SOLUTION | 0.05 % | COVERED | FORMULARY | |
34.141 | 21.986 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Temovate E | CLOBETASOL PROPIONATE-EMOLLIENT BASE | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
31.425 | 7.620 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Desonide | DESONIDE | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
31.430 | 7.622 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Desonide | DESONIDE | OINT. (G) | 0.05 % | COVERED | FORMULARY | |
24.484 | 58.950 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Derma-Smoothe-FS Scalp Oil | FLUOCINOLONE (WITH SHOWER CAP) | OIL | 0.01 % | COVERED | FORMULARY | |
85.080 | 7.507 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Derma-Smoothe-FS Body Oil | FLUOCINOLONE ACETONIDE | OIL | 0.01 % | COVERED | FORMULARY | |
31.390 | 7.616 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Fluocinonide | FLUOCINONIDE | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
31.380 | 7.615 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Fluocinonide | FLUOCINONIDE | GEL (GRAM) | 0.05 % | COVERED | FORMULARY | |
31.400 | 7.617 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Fluocinonide | FLUOCINONIDE | OINT. (G) | 0.05 % | COVERED | FORMULARY | |
31.401 | 7.618 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Fluocinonide | FLUOCINONIDE | SOLUTION | 0.05 % | COVERED | FORMULARY | |
30.943 | 7.545 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Hydrocortisone | HYDROCORTISONE | CREAM (G) | 2.5 % | COVERED | FORMULARY | |
28.850 | 23.906 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Proctosol-HC, Proctozone | HYDROCORTISONE | CREAM/APPL | 2.5 % | COVERED | FORMULARY | |
66.392 | 37.045 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Cortenema, Colocort | HYDROCORTISONE | ENEMA | 100 MG/60ML | COVERED | FORMULARY | |
30.975 | 7.554 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Hydrocortisone | HYDROCORTISONE | LOTION | 2.5 % | COVERED | FORMULARY | |
30.952 | 7.548 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Hydrocortisone | HYDROCORTISONE | OINT. (G) | 2.5 % | COVERED | FORMULARY | |
66.391 | 37.044 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Cortifoam | HYDROCORTISONE ACETATE | FOAM/APPL | 10 % | COVERED | FORMULARY | |
27.941 | 6.858 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Anusol-HC | HYDROCORTISONE ACETATE | SUPP.RECT | 25 MG | COVERED | FORMULARY | |
31.231 | 7.593 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | TRIAMCINOLONE ACETONIDE | CREAM (G) | 0.025 % | COVERED | FORMULARY | |
31.232 | 7.594 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | TRIAMCINOLONE ACETONIDE | CREAM (G) | 0.1 % | COVERED | FORMULARY | |
31.233 | 7.595 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | TRIAMCINOLONE ACETONIDE | CREAM (G) | 0.5 % | COVERED | FORMULARY | |
31.260 | 7.599 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | TRIAMCINOLONE ACETONIDE | LOTION | 0.025 % | COVERED | FORMULARY | |
31.261 | 7.600 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | TRIAMCINOLONE ACETONIDE | LOTION | 0.1 % | COVERED | FORMULARY | |
31.241 | 7.596 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | TRIAMCINOLONE ACETONIDE | OINT. (G) | 0.025 % | COVERED | FORMULARY | |
31.242 | 7.597 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | TRIAMCINOLONE ACETONIDE | OINT. (G) | 0.1 % | COVERED | FORMULARY | |
31.243 | 15.542 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | TRIAMCINOLONE ACETONIDE | OINT. (G) | 0.05 % | COVERED | FORMULARY | |
31.244 | 7.598 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | TRIAMCINOLONE ACETONIDE | OINT. (G) | 0.5 % | COVERED | FORMULARY | |
42.121 | 9.477 | 840800-ANTIPRURITICS AND LOCAL ANESTHETICS | Pyridium | PHENAZOPYRIDINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
42.122 | 9.478 | 840800-ANTIPRURITICS AND LOCAL ANESTHETICS | Pyridium | PHENAZOPYRIDINE HCL | TABLET | 200 MG | COVERED | FORMULARY | |
22.291 | 11.998 | 841200-ASTRINGENTS | Drysol | ALUMINUM CHLORIDE | SOLUTION | 20 % | COVERED | FORMULARY | |
22.880 | 5.800 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A | TRETINOIN | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
22.881 | 5.801 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A | TRETINOIN | CREAM (G) | 0.01 % | COVERED | FORMULARY | |
22.882 | 5.799 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A | TRETINOIN | CREAM (G) | 0.025 % | COVERED | FORMULARY | |
22.870 | 5.797 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A | TRETINOIN | GEL (GRAM) | 0.01 % | COVERED | FORMULARY | |
22.871 | 5.798 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A | TRETINOIN | GEL (GRAM) | 0.025 % | COVERED | FORMULARY | |
17.443 | 50.417 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A Micro | TRETINOIN MICROSPHERES | GEL (GRAM) | 0.04 % | COVERED | FORMULARY | |
22.874 | 30.614 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A Micro | TRETINOIN MICROSPHERES | GEL (GRAM) | 0.1 % | COVERED | FORMULARY | |
31.776 | 68.881 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A Micro Pump | TRETINOIN MICROSPHERES | GEL W/PUMP | 0.04 % | COVERED | FORMULARY | |
31.777 | 68.882 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A Micro Pump | TRETINOIN MICROSPHERES | GEL W/PUMP | 0.1 % | COVERED | FORMULARY | |
63.447 | 45.214 | 841600-CELL STIMULANTS AND PROLIFERANTS | Refissa | TRETINOIN-EMOLLIENT BASE | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
22.931 | 5.813 | 842800-KERATOLYTIC AGENTS | Benzoyl Peroxide | BENZOYL PEROXIDE | GEL (GRAM) | 5 % | COVERED | FORMULARY | |
24.774 | 16.308 | 842800-KERATOLYTIC AGENTS | Urea | UREA | CREAM (G) | 40 % | COVERED | FORMULARY | |
19.198 | 51.812 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Azelaic Acid | AZELAIC ACID | Gel | 15% | COVERED | FORMULARY | |
39.274 | 74.590 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Azelaic Acid | AZELAIC ACID | FOAM | 15% | COVERED | FORMULARY | |
1.851 | 21.134 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Dovonex | CALCIPOTRIENE | CREAM (G) | 0.01 % | COVERED | FORMULARY | |
1.850 | 19.160 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Calcipotriene | CALCIPOTRIENE | OINT. (G) | 0.01 % | COVERED | FORMULARY | |
1.852 | 22.483 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Calcipotriene | CALCIPOTRIENE | SOLUTION | 0.01 % | COVERED | FORMULARY | |
30.781 | 7.502 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Efudex | FLUOROURACIL | CREAM (G) | 5 % | COVERED | FORMULARY | |
30.791 | 7.504 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Fluorouracil | FLUOROURACIL | SOLUTION | 2 % | COVERED | FORMULARY | |
30.792 | 7.505 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Fluorouracil | FLUOROURACIL | SOLUTION | 5 % | COVERED | FORMULARY | |
54.201 | 31.099 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Aldara | IMIQUIMOD | CREAM PACK | 5 % | COVERED | FORMULARY | |
15.348 | 49.724 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Elidel | PIMECROLIMUS | CREAM (G) | 1 % | COVERED | FORMULARY | |
23.450 | 30.857 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Condylox | PODOFILOX | GEL (GRAM) | 0.5 % | COVERED | FORMULARY | |
23.451 | 15.942 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Condylox | PODOFILOX | SOLUTION | 0.5 % | COVERED | FORMULARY | |
19.370 | 4.928 | 861204-ANTIMUSCARINICS | Oxybutynin | OXYBUTYNIN CHLORIDE | SYRUP | 5 MG/5 ML | COVERED | FORMULARY | |
19.388 | 41.046 | 861204-ANTIMUSCARINICS | Oxybutynin ER | OXYBUTYNIN CHLORIDE | TAB ER 24 | 5 MG | COVERED | FORMULARY | |
19.389 | 41.047 | 861204-ANTIMUSCARINICS | Oxybutynin ER | OXYBUTYNIN CHLORIDE | TAB ER 24 | 10 MG | COVERED | FORMULARY | |
93.557 | 42.606 | 861204-ANTIMUSCARINICS | Oxybutynin ER | OXYBUTYNIN CHLORIDE | TAB ER 24 | 15 MG | COVERED | FORMULARY | |
19.380 | 4.929 | 861204-ANTIMUSCARINICS | Ditropan | OXYBUTYNIN CHLORIDE | TABLET | 5 MG | COVERED | FORMULARY | |
410 | 90 | 861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS | Theophylline ER | THEOPHYLLINE ANHYDROUS | TAB ER 12H | 100 MG | COVERED | FORMULARY | |
411 | 91 | 861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS | Theophylline ER | THEOPHYLLINE ANHYDROUS | TAB ER 12H | 200 MG | COVERED | FORMULARY | |
413 | 93 | 861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS | Theophylline ER | THEOPHYLLINE ANHYDROUS | TAB ER 12H | 300 MG | COVERED | FORMULARY | |
94.481 | 2.184 | 881600-VITAMIN D | Rocaltrol | CALCITRIOL | CAPSULE | 0.25 MCG | COVERED | FORMULARY | |
94.482 | 2.185 | 881600-VITAMIN D | Rocaltrol | CALCITRIOL | CAPSULE | 0.5 MCG | COVERED | FORMULARY | |
98.425 | 62.651 | 881600-VITAMIN D | Cholecalciferol (Vitamin D3) | CHOLECALCIFEROL (VITAMIN D3) | CAPSULE | 50000 UNIT | COVERED | FORMULARY | |
94.422 | 2.169 | 881600-VITAMIN D | Drisdol | ERGOCALCIFEROL (VITAMIN D2) | CAPSULE | 50000 UNIT | COVERED | FORMULARY | |
94.711 | 2.305 | 882400-VITAMIN K ACTIVITY | Mephyton | PHYTONADIONE | TABLET | 5 MG | COVERED | FORMULARY | |
2.881 | 1.192 | 920400-ALCOHOL DETERRENTS | Antabuse | DISULFIRAM | TABLET | 250 MG | COVERED | FORMULARY | |
30.521 | 41.440 | 920800-5-ALPHA-REDUCTASE INHIBITORS | Proscar | FINASTERIDE | TABLET | 5 MG | COVERED | FORMULARY | |
7.070 | 2.535 | 921600-ANTIGOUT AGENTS | Zyloprim | ALLOPURINOL | TABLET | 100 MG | COVERED | FORMULARY | |
7.071 | 2.536 | 921600-ANTIGOUT AGENTS | Zyloprim | ALLOPURINOL | TABLET | 300 MG | COVERED | FORMULARY | |
35.674 | 8.334 | 921600-ANTIGOUT AGENTS | Colcrys | COLCHICINE | TABLET | 0.6 MG | COVERED | FORMULARY | Max 6 tablets/month, Enroll in PAP for more. |
12.389 | 47.381 | 922400-BONE RESORPTION INHIBITORS | Fosamax | ALENDRONATE SODIUM | TABLET | 35 MG | COVERED | FORMULARY | |
21.680 | 24.053 | 922400-BONE RESORPTION INHIBITORS | Fosamax | ALENDRONATE SODIUM | TABLET | 10 MG | COVERED | FORMULARY | |
21.682 | 31.006 | 922400-BONE RESORPTION INHIBITORS | Fosamax | ALENDRONATE SODIUM | TABLET | 5 MG | COVERED | FORMULARY | |
85.361 | 46.941 | 922400-BONE RESORPTION INHIBITORS | Fosamax | ALENDRONATE SODIUM | TABLET | 70 MG | COVERED | FORMULARY | |
67.031 | 40.549 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Arava | LEFLUNOMIDE | TABLET | 10 MG | COVERED | FORMULARY | |
67.032 | 40.550 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Arava | LEFLUNOMIDE | TABLET | 20 MG | COVERED | FORMULARY | |
46.771 | 11.682 | 924400-IMMUNOSUPPRESSIVE AGENTS | Imuran | AZATHIOPRINE | TABLET | 50 MG | COVERED | FORMULARY | |
94.200 | 62.137 | 940000-DEVICES | True Metrix Level 3 | BLOOD-GLUCOSE CONTROL HIGH | EACH | COVERED | FORMULARY | ||
94.200 | 62.137 | 940000-DEVICES | True Metrix Level 1 | BLOOD-GLUCOSE CONTROL LOW | EACH | COVERED | FORMULARY | ||
94.200 | 62.137 | 940000-DEVICES | True Metrix Level 2 | BLOOD-GLUCOSE CONTROL NORMAL | EACH | COVERED | FORMULARY | ||
94.200 | 19.413 | 940000-DEVICES | True Metrix Glucose Meter | BLOOD-GLUCOSE METER | EACH | COVERED | FORMULARY | ||
94.200 | 19.413 | 940000-DEVICES | True Metrix Glucose Meter | BLOOD-GLUCOSE METER | EACH | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Aerochamber Plus Flow-Vu | INHALER ASSIST DEVICES | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Aerochamber Plus Flow-Vu Mask, Large | INHALER ASSIST DEVICES | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Aerochamber Plus Flow-Vu Mask, Medium | INHALER ASSIST DEVICES | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Aerochamber Plus Flow-Vu Mask, Small | INHALER ASSIST DEVICES | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Optichamber Diamond VHC | INHALER ASSIST DEVICES | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Optichamber Diamond VHC with Large Mask | INHALER ASSIST DEVICES | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Optichamber Diamond VHC with Medium Mask | INHALER ASSIST DEVICES | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Optichamber Diamond VHC with Small Mask | INHALER ASSIST DEVICES | SPACER | COVERED | FORMULARY | ||
94.200 | 64.800 | 940000-DEVICES | Optichamber Large Mask | INHALER ASSIST DEVICE ACCESORY | EACH | COVERED | FORMULARY | ||
94.200 | 64.800 | 940000-DEVICES | Optichamber Medium Mask | INHALER ASSIST DEVICE ACCESORY | EACH | COVERED | FORMULARY | ||
94.200 | 70.184 | 940000-DEVICES | True Plus Lancet 28G | LANCETS | EACH | 28 GAUGE | COVERED | FORMULARY | |
94.200 | 70.013 | 940000-DEVICES | True Plus Lancet 30G | LANCETS | EACH | 30 GAUGE | COVERED | FORMULARY | |
94.200 | 70.013 | 940000-DEVICES | True Plus Lancet 30G | LANCETS | EACH | 30 GAUGE | COVERED | FORMULARY | |
94.200 | 70.012 | 940000-DEVICES | True Plus Lancet 33G | LANCETS | EACH | 33 GAUGE | COVERED | FORMULARY | |
94.200 | 70.012 | 940000-DEVICES | True Plus Lancet 33G | LANCETS | EACH | 33 GAUGE | COVERED | FORMULARY | |
94.200 | 70.184 | 940000-DEVICES | True PlusLancet 28G | LANCETS | EACH | 28 GAUGE | COVERED | FORMULARY | |
94.200 | 70.184 | 940000-DEVICES | True PlusLancet 28G | LANCETS | EACH | 28 GAUGE | COVERED | FORMULARY | |
94.200 | 65.779 | 940000-DEVICES | True Plus Lancing Device | LANCING DEVICE | EACH | COVERED | FORMULARY | ||
94.200 | 65.779 | 940000-DEVICES | True Plus Lancing Device | LANCING DEVICE | EACH | COVERED | FORMULARY | ||
94.200 | 16.606 | 940000-DEVICES | Peak Flow Meter | PEAK FLOW METER | EACH | COVERED | FORMULARY | ||
94.200 | 16.606 | 940000-DEVICES | Peak Flow Meter | PEAK FLOW METER | EACH | COVERED | FORMULARY | ||
94.200 | 16.606 | 940000-DEVICES | Peak Flow Meter | PEAK FLOW METER | EACH | COVERED | FORMULARY | ||
94.200 | 49.235 | 940000-DEVICES | Pen Needle 29 G X 1/2" | PEN NEEDLE DIABETIC | DIS NEEDLE | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.235 | 940000-DEVICES | Pen Needle 29 G X 1/2" | PEN NEEDLE DIABETIC | DIS NEEDLE | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.235 | 940000-DEVICES | Pen Needle 29 G X 1/2" | PEN NEEDLE DIABETIC | DIS NEEDLE | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.235 | 940000-DEVICES | Pen Needle 29 G X 1/2" | PEN NEEDLE DIABETIC | DIS NEEDLE | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.235 | 940000-DEVICES | Pen Needle 29 G X 1/2" | PEN NEEDLE DIABETIC | DIS NEEDLE | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 61.638 | 940000-DEVICES | Pen Needle 30 G x 1/3" | PEN NEEDLE DIABETIC | DIS NEEDLE | 30 G X 1/3" | COVERED | FORMULARY | |
94.200 | 61.638 | 940000-DEVICES | Pen Needle 30 G x 1/3" | PEN NEEDLE DIABETIC | DIS NEEDLE | 30 G X 1/3" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | Pen Needle 31 G x 1/4" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | Pen Needle 31 G x 1/4" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | Pen Needle 31 G x 1/4" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | Pen Needle 31 G x 1/4" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | Pen Needle 31 G x 1/4" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | Pen Needle 31 G x 1/4" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | Pen Needle 31 G x 1/4" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | Pen Needle 31 G x 1/4" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | Pen Needle 31 G x 1/4" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | Pen Needle 31 G x 1/4" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | Pen Needle 31 G x 3/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | Pen Needle 31 G x 3/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | Pen Needle 31 G x 3/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | Pen Needle 31 G x 3/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | Pen Needle 31 G x 3/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | Pen Needle 31 G x 3/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | Pen Needle 31 G x 3/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | Pen Needle 31 G x 3/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | Pen Needle 31 G x 5/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | Pen Needle 31 G x 5/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | Pen Needle 31 G x 5/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | Pen Needle 31 G x 5/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | Pen Needle 31 G x 5/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | Pen Needle 31 G x 5/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | Pen Needle 31 G x 5/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | Pen Needle 31 G x 5/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | Pen Needle 31 G x 5/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | Pen Needle 31 G x 5/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | Pen Needle 31 G x 5/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | Pen Needle 31 G x 5/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | Pen Needle 31 G x 5/16" | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 62.868 | 940000-DEVICES | Pen Needle 32 G x 1/4" | PEN NEEDLE DIABETIC | DIS NEEDLE | 32 G X 1/4" | COVERED | FORMULARY | |
94.200 | 66.936 | 940000-DEVICES | Pen Needle 32 G X 1/5" | PEN NEEDLE DIABETIC | DIS NEEDLE | 32 G X 1/5" | COVERED | FORMULARY | |
94.200 | 72.859 | 940000-DEVICES | Pen Needle 32 G x 1/6" | PEN NEEDLE DIABETIC | DIS NEEDLE | 32 G X 1/6" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | Pen Needle 32 G x 5/32" | PEN NEEDLE DIABETIC | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | Pen Needle 32 G x 5/32" | PEN NEEDLE DIABETIC | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | Pen Needle 32 G x 5/32" | PEN NEEDLE DIABETIC | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | Pen Needle 32 G x 5/32" | PEN NEEDLE DIABETIC | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | Pen Needle 32 G x 5/32" | PEN NEEDLE DIABETIC | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | Pen Needle 32 G x 5/32" | PEN NEEDLE DIABETIC | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | Pen Needle 32 G x 5/32" | PEN NEEDLE DIABETIC | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 62.772 | 940000-DEVICES | Pen Needle 30 G x 1/3" | PEN NEEDLE DIABETIC SAFETY | DIS NEEDLE | 30 G X 1/3" | COVERED | FORMULARY | |
94.200 | 49.277 | 940000-DEVICES | Insulin Syringe 0.3mL 29 G x 1/2" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.277 | 940000-DEVICES | Insulin Syringe 0.3mL 29 G x 1/2" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.277 | 940000-DEVICES | Insulin Syringe 0.3mL 29 G x 1/2" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.399 | 940000-DEVICES | Insulin Syringe 0.3mL 30 G x 1/2" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 30G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.399 | 940000-DEVICES | Insulin Syringe 0.3mL 30 G x 1/2" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 30G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.394 | 940000-DEVICES | Insulin Syringe 0.3mL 30 G x 5/16" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.394 | 940000-DEVICES | Insulin Syringe 0.3mL 30 G x 5/16" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.394 | 940000-DEVICES | Insulin Syringe 0.3mL 30 G x 5/16" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.394 | 940000-DEVICES | Insulin Syringe 0.3mL 30 G x 5/16" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.394 | 940000-DEVICES | Insulin Syringe 0.3mL 30 G x 5/16" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.394 | 940000-DEVICES | Insulin Syringe 0.3mL 30 G x 5/16" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.394 | 940000-DEVICES | Insulin Syringe 0.3mL 30 G x 5/16" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | Insulin Syringe 0.3mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | Insulin Syringe 0.3mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | Insulin Syringe 0.3mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | Insulin Syringe 0.3mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | Insulin Syringe 0.3mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | Insulin Syringe 0.3mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | Insulin Syringe 0.3mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | Insulin Syringe 0.3mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | Insulin Syringe 0.5mL 28GX1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | Insulin Syringe 0.5mL 28GX1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | Insulin Syringe 0.5mL 28GX1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | Insulin Syringe 0.5mL 28GX1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | Insulin Syringe 0.5mL 28GX1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | Insulin Syringe 0.5mL 28GX1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | Insulin Syringe 0.5mL 29 G X1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | Insulin Syringe 0.5mL 29 G X1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | Insulin Syringe 0.5mL 29 G X1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | Insulin Syringe 0.5mL 29 G X1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | Insulin Syringe 0.5mL 29 G X1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | Insulin Syringe 0.5mL 29 G X1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | Insulin Syringe 0.5mL 29 G X1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX 5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX 5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX 5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX 5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX 5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX 5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX 5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.400 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.400 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.400 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.400 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | Insulin Syringe 0.5mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | Insulin Syringe 0.5mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | Insulin Syringe 0.5mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | Insulin Syringe 0.5mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | Insulin Syringe 0.5mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | Insulin Syringe 0.5mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | Insulin Syringe 0.5mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | Insulin Syringe 0.5mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | Insulin Syringe 0.5mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.401 | 940000-DEVICES | Insulin Syringe 1mL 30GX1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.401 | 940000-DEVICES | Insulin Syringe 1mL 30GX1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.401 | 940000-DEVICES | Insulin Syringe 1mL 30GX1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
33.118 | 28.142 | 081206-CEPHALOSPORINS | Suprax Capsule | CEFIXIME | CAPSULE | 400 MG | COVERED | FORMULARY | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy. Quantity limit #1 capsule/ prescription. |
33.120 | 9.182 | 081206-CEPHALOSPORINS | Suprax Suspension | CEFIXIME | SUSP RECON | 100 MG/5ML | NOT COVERED | NON-FORMULARY | Formulary: Cefdinir |
92.368 | 44.428 | 081206-CEPHALOSPORINS | Suprax Suspension | CEFIXIME | SUSP RECON | 200 MG/5ML | NOT COVERED | NON-FORMULARY | Formulary: Cefdinir |
34.277 | 70.665 | 081206-CEPHALOSPORINS | Suprax Suspension | CEFIXIME | SUSP RECON | 500 MG/5ML | NOT COVERED | NON-FORMULARY | Formulary: Cefdinir |
33.445 | 70.122 | 081206-CEPHALOSPORINS | Suprax Chewable | CEFIXIME | TAB CHEW | 100 MG | NOT COVERED | NON-FORMULARY | Formulary: Cefdinir |
33.446 | 70.123 | 081206-CEPHALOSPORINS | Suprax Chewable | CEFIXIME | TAB CHEW | 200 MG | NOT COVERED | NON-FORMULARY | Formulary: Cefdinir |
33.110 | 081206-CEPHALOSPORINS | Suprax Tablet | CEFIXIME | TABLET | 400 MG | NOT COVERED | NON-FORMULARY | Formulary: Cefdinir | |
26.871 | 45.132 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Zyvox Suspension | LINEZOLID | SUSP RECON | 100 MG/5ML | NOT COVERED | NON-FORMULARY | |
26.870 | 45.131 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Zyvox Tablet | LINEZOLID | TABLET | 600 MG | NOT COVERED | NON-FORMULARY | |
33.787 | 70.295 | 081408-AZOLES | Onmel | ITRACONAZOLE | CAPSULE | 200 MG | NOT COVERED | NON-FORMULARY | |
55.389 | 21.871 | 083600-URINARY ANTI-INFECTIVES | Monurol | FOSFOMYCIN TROMETHAMINE | PACKET | 3 G | NOT COVERED | NON-FORMULARY | |
74.040 | 4.773 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Donnatal Elixir | PHENOBARBITAL-HYOSCYAMINE-ATROPINE-SCOPOLAMINE | ELIXIR | 16.2-0.1037-0.0194 MG/5ML | NOT COVERED | NON-FORMULARY | |
74.070 | 4.777 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Donnatal | PHENOBARBITAL-HYOSCYAMINE-ATROPINE-SCOPOLAMINE | TABLET | 16.2-0.1037-0.0194 MG | NOT COVERED | NON-FORMULARY | |
28.038 | 65.912 | 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS | Adrenaclick | EPINEPHRINE | AUTO INJCT | 0.15 MG/0.15ML | NOT COVERED | NON-FORMULARY | Formulary: Epinephrine generic |
19.861 | 16.878 | 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS | Epipen Jr. | EPINEPHRINE | AUTO INJCT | 0.15 MG/0.3ML | NOT COVERED | NON-FORMULARY | Formulary: Epinephrine generic |
19.862 | 16.879 | 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS | Epipen, Adrenaclick | EPINEPHRINE | AUTO INJCT | 0.3 MG/0.3ML | NOT COVERED | NON-FORMULARY | Formulary: Epinephrine generic |
17.912 | 4.663 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Soma | CARISOPRODOL | TABLET | 350 MG | NOT COVERED | NON-FORMULARY | Formulary: Cyclobenzaprine, methocarbamol, and tizanidine |
91.765 | 51.112 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Skelaxin | METAXALONE | TABLET | 800 MG | NOT COVERED | NON-FORMULARY | Formulary: Cyclobenzaprine, methocarbamol, and tizanidine |
19.153 | 51.784 | 240608-HMG-COA REDUCTASE INHIBITORS | Crestor | ROSUVASTATIN CALCIUM | TABLET | 10 MG | COVERED | FORMULARY | |
19.154 | 51.785 | 240608-HMG-COA REDUCTASE INHIBITORS | Crestor | ROSUVASTATIN CALCIUM | TABLET | 20 MG | COVERED | FORMULARY | |
19.155 | 51.786 | 240608-HMG-COA REDUCTASE INHIBITORS | Crestor | ROSUVASTATIN CALCIUM | TABLET | 40 MG | COVERED | FORMULARY | |
20.229 | 52.944 | 240608-HMG-COA REDUCTASE INHIBITORS | Crestor | ROSUVASTATIN CALCIUM | TABLET | 5 MG | COVERED | FORMULARY | |
23.929 | 58.486 | 240692-ANTILIPEMIC AGENTS, MISCELLANEOUS | Lovaza | OMEGA-3 ACID ETHYL ESTERS | CAPSULE | 1 G | NOT COVERED | NON-FORMULARY | Formulary: Fenofibrate |
73.542 | 37.015 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Atacand | CANDESARTAN CILEXETIL | TABLET | 4 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
73.543 | 37.016 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Atacand | CANDESARTAN CILEXETIL | TABLET | 8 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
73.544 | 37.017 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Atacand | CANDESARTAN CILEXETIL | TABLET | 16 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
73.545 | 40.659 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Atacand | CANDESARTAN CILEXETIL | TABLET | 32 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
13.258 | 64.285 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Atacand HCT | CANDESARTAN/HYDROCHLOROTHIAZID | TABLET | 32MG-25MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
21.559 | 45.425 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Atacand HCT | CANDESARTAN/HYDROCHLOROTHIAZID | TABLET | 16-12.5MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
21.569 | 46.624 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Atacand HCT | CANDESARTAN/HYDROCHLOROTHIAZID | TABLET | 32-12.5MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
23.831 | 40.910 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Micardis | TELMISARTAN | TABLET | 40 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
23.832 | 40.911 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Micardis | TELMISARTAN | TABLET | 80 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
23.833 | 47.126 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Micardis | TELMISARTAN | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
27.783 | 65.746 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Twynsta | TELMISARTAN/AMLODIPINE | TABLET | 40 MG-5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
27.784 | 65.747 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Twynsta | TELMISARTAN/AMLODIPINE | TABLET | 40 MG-10MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
27.785 | 65.748 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Twynsta | TELMISARTAN/AMLODIPINE | TABLET | 80 MG-5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
27.786 | 65.749 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Twynsta | TELMISARTAN/AMLODIPINE | TABLET | 80 MG-10MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
12.257 | 47.326 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Micardis HCT | TELMISARTAN/HYDROCHLOROTHIAZID | TABLET | 40-12.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
12.259 | 47.324 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Micardis HCT | TELMISARTAN/HYDROCHLOROTHIAZID | TABLET | 80-12.5MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
22.866 | 57.690 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Micardis HCT | TELMISARTAN/HYDROCHLOROTHIAZID | TABLET | 80 MG-25MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
19.200 | 15.880 | 280808-OPIATE AGONISTS | Duragesic | FENTANYL | PATCH TD72 | 25 MCG/HR | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
19.201 | 15.881 | 280808-OPIATE AGONISTS | Duragesic | FENTANYL | PATCH TD72 | 50MCG/HR | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
19.202 | 15.882 | 280808-OPIATE AGONISTS | Duragesic | FENTANYL | PATCH TD72 | 75MCG/HR | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
19.203 | 15.883 | 280808-OPIATE AGONISTS | Duragesic | FENTANYL | PATCH TD72 | 100 MCG/HR | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
16.281 | 15.065 | 280808-OPIATE AGONISTS | Oxyocodone Concentrate | OXYCODONE HCL | ORAL CONC | 20 MG/ML | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
16.280 | 4.224 | 280808-OPIATE AGONISTS | Oxycodone Solution | OXYCODONE HCL | SOLUTION | 5 MG/5 ML | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
41.853 | 76.361 | 280808-OPIATE AGONISTS | Oxycodone Oral Syringe | OXYCODONE HCL | SYRINGE | 10MG/0.5ML | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
16.291 | 13.467 | 280808-OPIATE AGONISTS | Oxyocodone | OXYCODONE HCL | TABLET | 10 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
20.091 | 46.474 | 280808-OPIATE AGONISTS | Oxyocodone | OXYCODONE HCL | TABLET | 15 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
21.194 | 45.298 | 280808-OPIATE AGONISTS | Oxyocodone | OXYCODONE HCL | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
20.092 | 46.475 | 280808-OPIATE AGONISTS | Oxyocodone | OXYCODONE HCL | TABLET | 30 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
32.047 | 69.101 | 280808-OPIATE AGONISTS | Oxaydo | OXYCODONE HCL | TABLET ORL | 5 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
31.256 | 68.467 | 280808-OPIATE AGONISTS | Oxaydo | OXYCODONE HCL | TABLET ORL | 7.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
64.672 | 29.312 | 280812-OPIATE PARTIAL AGONISTS | Buprenorphine | BUPRENORPHINE HCL | TAB SUBL | 2 MG | COVERED | FORMULARY | |
64.673 | 29.313 | 280812-OPIATE PARTIAL AGONISTS | Buprenorphine | BUPRENORPHINE HCL | TAB SUBL | 8 MG | COVERED | FORMULARY | |
33.744 | 70.262 | 280812-OPIATE PARTIAL AGONISTS | Suboxone Film | BUPRENORPHINE HCL/NALOXONE HCL | Subl Film | 12 MG-3 MG | COVERED | FORMULARY | |
28.958 | 66.635 | 280812-OPIATE PARTIAL AGONISTS | Suboxone Film | BUPRENORPHINE HCL/NALOXONE HCL | Subl Film | 2 MG-0.5MG | COVERED | FORMULARY | |
33.741 | 70.259 | 280812-OPIATE PARTIAL AGONISTS | Suboxone Film | BUPRENORPHINE HCL/NALOXONE HCL | Subl Film | 4MG-1MG | COVERED | FORMULARY | |
28.959 | 66.636 | 280812-OPIATE PARTIAL AGONISTS | Suboxone Film | BUPRENORPHINE HCL/NALOXONE HCL | Subl Film | 8 MG-2 MG | COVERED | FORMULARY | |
18.973 | 51.640 | 280812-OPIATE PARTIAL AGONISTS | Suboxone Tablet | BUPRENORPHINE HCL/NALOXONE HCL | TAB SUBL | 2 MG-0.5MG | COVERED | FORMULARY | |
18.974 | 51.641 | 280812-OPIATE PARTIAL AGONISTS | Suboxone Tablet | BUPRENORPHINE HCL/NALOXONE HCL | TAB SUBL | 8 MG-2 MG | COVERED | FORMULARY | |
28.626 | 66.372 | 280892-ANALGESICS AND ANTIPYRETICS, MISC. | Fioricet | BUTALBITAL-ACETAMINOPHEN-CAFFEINE | CAPSULE | 50-300-40 MG | NOT COVERED | NON-FORMULARY | Formulary: Capacet, Esgic |
27.095 | 60.935 | 281000-OPIATE ANTAGONISTS | Vivitrol | NALTREXONE MICROSPHERES | SUS ER REC | 380MG | NOT COVERED | NON-FORMULARY | Formulary: Naltrexone tablet |
16.356 | 46.216 | 281604-ANTIDEPRESSANTS | Sarafem | FLUOXETINE HCL | TABLET | 10 MG | NOT COVERED | NON-FORMULARY | Formulary: capsules |
16.359 | 46.219 | 281604-ANTIDEPRESSANTS | Sarafem | FLUOXETINE HCL | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: capsules |
14.349 | 64.444 | 281604-ANTIDEPRESSANTS | Venlafaxine ER | VENLAFAXINE HCL | TAB ER 24 | 37.5 MG | NOT COVERED | NON-FORMULARY | Formulary: capsules |
14.352 | 64.445 | 281604-ANTIDEPRESSANTS | Venlafaxine ER | VENLAFAXINE HCL | TAB ER 24 | 75 MG | NOT COVERED | NON-FORMULARY | Formulary: capsules |
14.353 | 64.446 | 281604-ANTIDEPRESSANTS | Venlafaxine ER | VENLAFAXINE HCL | TAB ER 24 | 150 MG | NOT COVERED | NON-FORMULARY | Formulary: capsules |
14.354 | 64.447 | 281604-ANTIDEPRESSANTS | Venlafaxine ER | VENLAFAXINE HCL | TAB ER 24 | 225 MG | NOT COVERED | NON-FORMULARY | Formulary: capsules |
25.598 | 59.781 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Diastat | DIAZEPAM | KIT | 5-7.5-10MG | NOT COVERED | NON-FORMULARY | Restricted to Neurology prescribers |
25.599 | 59.782 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Diastat | DIAZEPAM | KIT | 12.5-15-20 | NOT COVERED | NON-FORMULARY | Restricted to Neurology prescribers |
48.131 | 34.015 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Diastat | DIAZEPAM | KIT | 2.5 MG | NOT COVERED | NON-FORMULARY | Restricted to Neurology prescribers |
19.593 | 40.223 | 283228-SELECTIVE SEROTONIN AGONISTS | Maxalt MLT | RIZATRIPTAN BENZOATE | TAB RAPDIS | 5 MG | NOT COVERED | Non-Formulary | Formulary: Imitrex (Sumatriptan) |
19.591 | 40.221 | 283228-SELECTIVE SEROTONIN AGONISTS | Maxalt | RIZATRIPTAN BENZOATE | TABLET | 5 MG | NOT COVERED | Non-Formulary | Formulary: Imitrex (Sumatriptan) |
13.971 | 48.489 | 480800-ANTITUSSIVES | Promethazine/Codeine | PROMETHAZINE HCL-CODEINE | SYRUP | 6.25-10 MG/5ML | NOT COVERED | NON-FORMULARY | |
54.980 | 12.073 | 481600-EXPECTORANTS | Mucinex D | GUAIFENESIN-PSEUDOEPHEDRINE HCL | TAB ER 12H | 600-60 MG | NOT COVERED | NON-FORMULARY | Available OTC |
26.056 | 60.055 | 520808-CORTICOSTEROIDS (EENT) | Dermotic | FLUOCINOLONE ACETONIDE OIL | DROPS | 0.01% | NOT COVERED | NON-FORMULARY | Prior Auth restricted to EENT prescribers |
30.462 | 67.826 | 521600-LOCAL ANESTHETICS (EENT) | Antipyrine-Benzocaine | ANTIPYRINE-BENZOCAINE | DROPS | 5.5-1.4 % | NOT COVERED | NON-FORMULARY | No longer available commerically |
1.697 | 30.106 | 562836-PROTON-PUMP INHIBITORS | Prevacid | LANSOPRAZOLE | CAPSULE DR | 15 MG | NOT COVERED | NON-FORMULARY | Formulary: Pantoprazole |
1.698 | 30.107 | 562836-PROTON-PUMP INHIBITORS | Prevacid | LANSOPRAZOLE | CAPSULE DR | 30 MG | NOT COVERED | NON-FORMULARY | Formulary: Pantoprazole |
4.348 | 33.530 | 562836-PROTON-PUMP INHIBITORS | Prilosec | OMEPRAZOLE | CAPSULE DR | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Pantoprazole |
92.989 | 43.136 | 562836-PROTON-PUMP INHIBITORS | Prilosec | OMEPRAZOLE | CAPSULE DR | 10 MG | NOT COVERED | NON-FORMULARY | Formulary: Pantoprazole |
92.999 | 43.137 | 562836-PROTON-PUMP INHIBITORS | Prilosec | OMEPRAZOLE | CAPSULE DR | 40 MG | NOT COVERED | NON-FORMULARY | Formulary: Pantoprazole |
94.639 | 40.941 | 562836-PROTON-PUMP INHIBITORS | Aciphex | RABEPRAZOLE SODIUM | TABLET DR | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Pantoprazole |
30.220 | 19.863 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Pentasa CR | MESALAMINE | CAPSULE ER | 250 MG | NOT COVERED | PAP | Formulary: Sulfasalazine. Contact manufacturer for PAP |
21.663 | 53.882 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Asacol HD | MESALAMINE | TABLET DR | 800 MG | NOT COVERED | NON-FORMULARY | Formulary: Sulfasalazine. Contact manufacturer for PAP |
37.726 | 73.336 | 569200-GI DRUGS, MISCELLANEOUS | Movantik | NALOXEGOL OXALATE | TABLET | 25 MG | NOT COVERED | NON-FORMULARY | Contact manufacturer for PAP |
37.725 | 73.335 | 569200-GI DRUGS, MISCELLANEOUS | Movantik | NALOXEGOL OXALATE | TABLET | 12.5 MG | NOT COVERED | NON-FORMULARY | Contact manufacturer for PAP |
28.847 | 3.203 | 681604-ESTROGENS | Vivelle-DOT | ESTRADIOL | PATCH TDSW | 0.1MG/24HR | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.840 | 3.202 | 681604-ESTROGENS | Vivelle-DOT | ESTRADIOL | PATCH TDSW | 0.05MG/24H | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.842 | 16.767 | 681604-ESTROGENS | Vivelle-DOT | ESTRADIOL | PATCH TDSW | .025MG/24H | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.843 | 23.270 | 681604-ESTROGENS | Vivelle-DOT | ESTRADIOL | PATCH TDSW | .075MG/24H | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.846 | 24.555 | 681604-ESTROGENS | Vivelle-DOT | ESTRADIOL | PATCH TDSW | .0375MG/24 | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.844 | 23.471 | 681604-ESTROGENS | Climara | ESTRADIOL | PATCH TDWK | 0.1MG/24HR | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.845 | 23.472 | 681604-ESTROGENS | Climara | ESTRADIOL | PATCH TDWK | 0.05MG/24H | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.848 | 32.174 | 681604-ESTROGENS | Climara | ESTRADIOL | PATCH TDWK | .025MG/24H | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.853 | 40.366 | 681604-ESTROGENS | Climara | ESTRADIOL | PATCH TDWK | .075MG/24H | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
20.068 | 52.830 | 681604-ESTROGENS | Climara | ESTRADIOL | PATCH TDWK | 0.06MG/24H | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
20.069 | 52.831 | 681604-ESTROGENS | Climara | ESTRADIOL | PATCH TDWK | .0375MG/24 | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.107 | 65.966 | 681604-ESTROGENS | Vagifem | ESTRADIOL | TABLET | 10 MCG | NOT COVERED | NON-FORMULARY | |
67.170 | 7.011 | 681604-ESTROGENS | Estrace Vaginal Cream | ESTRADIOL | CREAM/APPL | 0.01% | NOT COVERED | NON-FORMULARY | Formulary: Premarin Vaginal Cream |
34.336 | 70.705 | 681612-ESTROGEN AGONIST-ANTAGONISTS | Osphena | OSPEMIFENE | TABLET | 60 MG | NOT COVERED | NON-FORMULARY | |
2.318 | 20.241 | 682002-ALPHA-GLUCOSIDASE INHIBITORS | Precose | ACARBOSE | TABLET | 100 MG | NOT COVERED | NON-FORMULARY | |
2.319 | 20.242 | 682002-ALPHA-GLUCOSIDASE INHIBITORS | Precose | ACARBOSE | TABLET | 50 MG | NOT COVERED | NON-FORMULARY | |
8.070 | 36.767 | 682002-ALPHA-GLUCOSIDASE INHIBITORS | Precose | ACARBOSE | TABLET | 25 MG | NOT COVERED | NON-FORMULARY | |
95.252 | 40.357 | 682002-ALPHA-GLUCOSIDASE INHIBITORS | Glyset | MIGLITOL | TABLET | 25 MG | NOT COVERED | NON-FORMULARY | |
95.253 | 40.358 | 682002-ALPHA-GLUCOSIDASE INHIBITORS | Glyset | MIGLITOL | TABLET | 50 MG | NOT COVERED | NON-FORMULARY | |
95.254 | 40.359 | 682002-ALPHA-GLUCOSIDASE INHIBITORS | Glyset | MIGLITOL | TABLET | 100 MG | NOT COVERED | NON-FORMULARY | |
35.836 | 71.842 | 682008-INSULINS | Tresiba FlexTouch | INSULIN DEGLUDEC | INSULN PEN | 100/ML (3) | NOT COVERED | NON-FORMULARY | Formulary: insulin glargine-yfgn |
35.837 | 71.843 | 682008-INSULINS | Tresiba FlexTouch | INSULIN DEGLUDEC | INSULN PEN | 200/ML (3) | NOT COVERED | NON-FORMULARY | Formulary: insulin glargine-yfgn |
11.660 | 1.740 | 682008-INSULINS | Humulin N | INSULIN NPH HUMAN ISOPHANE | VIAL | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | Formulary: Novolin N |
50.001 | 16.311 | 682008-INSULINS | Humulin 70/30 | INSULIN NPH HUM-REG INSULIN HM | VIAL | 70-30 UNIT/ML | NOT COVERED | NON-FORMULARY | Formulary: Novolin 70/30 |
11.642 | 1.723 | 682008-INSULINS | Humulin R | INSULIN REGULAR HUMAN | VIAL | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | Formulary: Novolin R |
50.776 | 43.801 | 683200-PROGESTINS | Prometrium | PROGESTERONE, MICRONIZED | CAPSULE | 100 MG | NOT COVERED | NON-FORMULARY | Formulary: Provera |
50.786 | 43.802 | 683200-PROGESTINS | Prometrium | PROGESTERONE, MICRONIZED | CAPSULE | 200 MG | NOT COVERED | NON-FORMULARY | Formulary: Provera |
98.238 | 62.462 | 81228-ANTIBACTERIALS, MISCELLANEOUS | Pylera | BISMUTH/METRONID/TETRACYCLINE | CAPSULE | 125-125 MG | NOT COVERED | NON-FORMULARY | Prior auth requires failure of Amox/Clari/Metronidazole OR history of systemic macrolide exposure |
26.339 | 60.244 | 83600-URINARY ANTI-INFECTIVES | Hyophen | METHENAM/M.BLUE/SALICYL/HYOSCY | TABLET | 81.6-0.12 | NOT COVERED | NON-FORMULARY | |
31.812 | 7.731 | 840404-ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) | Bacitracin | BACITRACIN | OINT. (G) | 500 UNIT/G | NOT COVERED | NON-FORMULARY | |
50.272 | 43.256 | 840800-ANTIPRURITICS AND LOCAL ANESTHETICS | Lidoderm | LIDOCAINE | ADH. PATCH | 5% | NOT COVERED | NON-FORMULARY | Lidocaine 4% patch, cream are OTC |
95.404 | 40.261 | 840800-ANTIPRURITICS AND LOCAL ANESTHETICS | Lindocaine Anorectal Cream | LIDOCAINE | CREAM (G) | 5% | NOT COVERED | NON-FORMULARY | |
95.405 | 40.262 | 840800-ANTIPRURITICS AND LOCAL ANESTHETICS | Liocaine Cream | LIDOCAINE | CREAM (G) | 4% | NOT COVERED | NON-FORMULARY | Available OTC |
30.750 | 14.476 | 840800-ANTIPRURITICS AND LOCAL ANESTHETICS | Lidocaine Ointment | LIDOCAINE | OINT. (G) | 5% | NOT COVERED | NON-FORMULARY | Lidocaine 4% Cream is OTC |
24.882 | 6.312 | 845004-DEPIGMENTING AGENTS | ESOTERICA FADE CREAM | HYDROQUINONE | CREAM (G) | 2% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
24.883 | 6.313 | 845004-DEPIGMENTING AGENTS | MELQUIN HP 4% CREAM | HYDROQUINONE | CREAM (G) | 4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
47.830 | 6.314 | 845004-DEPIGMENTING AGENTS | HYDROQUINONE 4% CREAM | HYDROQUINONE | POWDER | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone | |
24.890 | 6.315 | 845004-DEPIGMENTING AGENTS | HYDROQUINONE POWDER | HYDROQUINONE | SOLUTION | 30 MG/ML | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
20.120 | 52.863 | 845004-DEPIGMENTING AGENTS | NUQUIN HP 4% CREAM | HYDROQUINONE MICROSPHERES | CRM ER (G) | 4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
97.674 | 61.889 | 845004-DEPIGMENTING AGENTS | ESOTERICA FADE CREAM | HYDROQUINONE/AVOBENZ/OCTINOX | EMUL ADHES | 4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
21.864 | 54.046 | 845004-DEPIGMENTING AGENTS | ALPHAQUIN HP 4% CREAM | HYDROQUINONE/AVOBENZ/OCTINOX | EMULSN(G) | 4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
20.915 | 53.438 | 845004-DEPIGMENTING AGENTS | HYDROQUINONE TR 4% CREAM | HYDROQUINONE/OXYBEN/OCTINOXATE | CREAM (G) | 4%(5-7.5%) | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
97.229 | 61.438 | 845004-DEPIGMENTING AGENTS | ACLARO 4% EMULSION | HYDROQUINONE/OXYBENZONE/PADIMA | CREAM (G) | 2%-SPF10 | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
66.899 | 31.427 | 845004-DEPIGMENTING AGENTS | MELQUIN-3 SOLUTION | HYDROQUINONE/SUNSCREEN(FER OX) | CREAM (G) | 4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
96.071 | 39.542 | 848000-SUNSCREEN AGENTS | MELPAQUE HP 4% CREAM | DIOXYBENZONE/PDO/HYDROQUINONE | CREAM (G) | 3%-5%-4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
20.383 | 53.055 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Claravis | ISOTRETINOIN | TABLET | 30 MG | NOT COVERED | NON-FORMULARY | Prior auths restricted to Dermatology prescriber. Claravis prefererred |
59.841 | 36.045 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Claravis | ISOTRETINOIN | TABLET | 10 MG | NOT COVERED | NON-FORMULARY | Prior auths restricted to Dermatology prescriber. Claravis prefererred |
59.842 | 36.046 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Claravis | ISOTRETINOIN | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | Prior auths restricted to Dermatology prescriber. Claravis prefererred |
59.843 | 36.047 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Claravis | ISOTRETINOIN | TABLET | 40 MG | NOT COVERED | NON-FORMULARY | Prior auths restricted to Dermatology prescriber. Claravis prefererred |
24.043 | 58.576 | 861204-ANTIMUSCARINICS | Enablex | DARIFENACIN HYDROBROMIDE | TAB ER 24H | 7.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxybutynin ER |
24.044 | 58.577 | 861204-ANTIMUSCARINICS | Enablex | DARIFENACIN HYDROBROMIDE | TAB ER 24H | 15 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxybutynin ER |
99.193 | 63.466 | 861204-ANTIMUSCARINICS | Sanctura XR | TROSPIUM CHLORIDE | CAP ER 24H | 60 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxybutynin ER |
8.744 | 38.085 | 861204-ANTIMUSCARINICS | Sanctura | TROSPIUM CHLORIDE | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxybutynin ER |
18.428 | 51.246 | 920800-5-ALPHA-REDUCTASE INHIBITORS | Avodart | DUTASTERIDE | CAPSULE | 0.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Finasteride |
28.596 | 66.352 | 920800-5-ALPHA-REDUCTASE INHIBITORS | Jalyn | DUTASTERIDE/TAMSULOSIN HCL | CPMP 24HR | 0.5-0.4 MG | NOT COVERED | NON-FORMULARY | Formulary: Finasteride |
24.444 | 58.915 | 922400-BONE RESORPTION INHIBITORS | Boniva | IBANDRONATE SODIUM | TABLET | 150 MG | NOT COVERED | NON-FORMULARY | Formulary: Alendronate |
17.378 | 50.364 | 922400-BONE RESORPTION INHIBITORS | Actonel | RISEDRONATE SODIUM | TABLET | 35 MG | NOT COVERED | NON-FORMULARY | Formulary: Alendronate |
92.238 | 45.102 | 922400-BONE RESORPTION INHIBITORS | Actonel | RISEDRONATE SODIUM | TABLET | 5 MG | NOT COVERED | NON-FORMULARY | Formulary: Alendronate |
94.200 | 74.210 | 940000-DEVICES | Contour Next | BLOOD-GLUCOSE METER | EACH | NOT COVERED | NON-FORMULARY | Prior Auths restricted to insulin pumps | |
94.200 | 70.198 | 940000-DEVICES | TruePlus Lancet 26G | LANCETS | EACH | 26 GAUGE | NOT COVERED | NON-FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | Insulin Syringe 0.5mL 28GX1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 28 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | Insulin Syringe 0.5mL 28GX1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 28 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | Insulin Syringe 0.5mL 29 G X1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 29 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX 5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 30G X 5/16" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.400 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX1/2" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 30 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | Insulin Syringe 0.5mL 31 GX5/16" | SYRING W-NDL DISP INSUL 0.5 ML | DISP SYRIN | 31 G X 5/16" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.365 | 940000-DEVICES | Insulin Syringe 1mL 27GX5/8" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 27 G X 5/8" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 28 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 28 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 28 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 29 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 29 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.401 | 940000-DEVICES | Insulin Syringe 1mL 30GX1/2" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 30 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & NEEDLE INSULIN 1 ML | DISP SYRIN | 31 G X 5/16" | NOT COVERED | NON-FORMULARY | |
30.025 | 67.462 | 081202-AMINOGLYCOSIDES | Tobi Podhaler | TOBRAMYCIN | CAP W/DEV | 28 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
61.551 | 37.042 | 081202-AMINOGLYCOSIDES | Tobi | TOBRAMYCIN IN 0.225% NACL | AMPUL-NEB | 300 MG/5ML | NOT COVERED | NON-FORMULARY | |
28.530 | 66.295 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Xifaxan | RIFAXIMIN | TABLET | 550 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
93.749 | 41.880 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Xifaxan | RIFAXIMIN | TABLET | 200 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
49.101 | 16.949 | 081408-AZOLES | Sporanox capsule | ITRACONAZOLE | CAPSULE | 100 MG | NOT COVERED | NON-FORMULARY | |
49.100 | 27.465 | 081408-AZOLES | Sporanox solution | ITRACONAZOLE | SOLUTION | 10 MG/ML | NOT COVERED | NON-FORMULARY | |
17.497 | 50.442 | 081408-AZOLES | Vfend | VORICONAZOLE | TABLET | 50 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
17.498 | 50.443 | 081408-AZOLES | Vfend | VORICONAZOLE | TABLET | 200 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
35.079 | 71.322 | 081808-ANTIRETROVIRALS | Tivicay | DOLUTEGRAVIR SODIUM | TABLET | 50 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
41.564 | 76.226 | 081808-ANTIRETROVIRALS | Tivicay | DOLUTEGRAVIR SODIUM | TABLET | 10 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
41.566 | 76.227 | 081808-ANTIRETROVIRALS | Tivicay | DOLUTEGRAVIR SODIUM | TABLET | 25 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
23.152 | 57.883 | 081808-ANTIRETROVIRALS | Truvada | EMTRICITABINE/TENOFOVIR (TDF) | TABLET | 200-300 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
41.369 | 76.097 | 081808-ANTIRETROVIRALS | Truvada | EMTRICITABINE/TENOFOVIR (TDF) | TABLET | 100-150 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
41.375 | 76.101 | 081808-ANTIRETROVIRALS | Truvada | EMTRICITABINE/TENOFOVIR (TDF) | TABLET | 133-200 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
41.376 | 76.102 | 081808-ANTIRETROVIRALS | Truvada | EMTRICITABINE/TENOFOVIR (TDF) | TABLET | 167-250 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
97.430 | 61.644 | 081808-ANTIRETROVIRALS | Reyataz | ATAZANAVIR SULFATE | CAPSULE | 300 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
15.555 | 49.849 | 081808-ANTIRETROVIRALS | Sustiva | EFAVIRENZ | TABLET | 600 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
31.227 | 68.449 | 081808-ANTIRETROVIRALS | Viread | TENOFOVIR DISOPROXIL FUMARATE | POWDER | 40 MG/SCOOP | NOT COVERED | NON-FORMULARY | |
14.822 | 48.843 | 081808-ANTIRETROVIRALS | Viread | TENOFOVIR DISOPROXIL FUMARATE | TABLET | 300 MG | NOT COVERED | NON-FORMULARY | |
31.228 | 68.450 | 081808-ANTIRETROVIRALS | Viread | TENOFOVIR DISOPROXIL FUMARATE | TABLET | 150 MG | NOT COVERED | NON-FORMULARY | |
31.229 | 68.451 | 081808-ANTIRETROVIRALS | Viread | TENOFOVIR DISOPROXIL FUMARATE | TABLET | 200 MG | NOT COVERED | NON-FORMULARY | |
31.234 | 68.453 | 081808-ANTIRETROVIRALS | Viread | TENOFOVIR DISOPROXIL FUMARATE | TABLET | 250 MG | NOT COVERED | NON-FORMULARY | |
24.465 | 58.933 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Baraclude | ENTECAVIR | SOLUTION | 0.05 MG/ML | NOT COVERED | PAP | Prior Auths's Restricted to GI Clinic, Contact manufacturer for PAP |
24.466 | 58.934 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Baraclude | ENTECAVIR | TABLET | 0.5 MG | NOT COVERED | PAP | Prior Auths's Restricted to GI Clinic, Contact manufacturer for PAP |
24.467 | 58.935 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Baraclude | ENTECAVIR | TABLET | 1 MG | NOT COVERED | PAP | Prior Auths's Restricted to GI Clinic, Contact manufacturer for PAP |
28.648 | 66.391 | 083600-URINARY ANTI-INFECTIVES | Uribel | MTH/ME BLUE/SOD PHOS/PHEN/HYOS | CAPSULE | 118-10-36 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
24.410 | 24.515 | 100000-ANTINEOPLASTIC AGENTS | Arimidex | ANASTROZOLE | TABLET | 1 MG | NOT COVERED | NON-FORMULARY | |
33.084 | 69.855 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Tudorza Pressair DPI | ACLIDINIUM BROMIDE | AER POW BA | 400 MCG | NOT COVERED | NON-FORMULARY | Formulary: Spiriva Handihaler |
24.621 | 59.081 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Atrovent HFA | IPRATROPIUM BROMIDE | HFA AER AD | 17 MCG | NOT COVERED | NON-FORMULARY | Formulary: Spiriva Handihaler |
32.395 | 69.371 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Combivent MDI | IPRATROPIUM/ALBUTEROL SULFATE | MIST INHAL | 20-100 MCG | NOT COVERED | NON-FORMULARY | |
98.921 | 63.164 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Spiriva Respimat | TIOTROPIUM BROMIDE | MIST INHAL | 2.5 MCG | NOT COVERED | NON-FORMULARY | Formulary: Spiriva Handihaler |
35.903 | 71.883 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Anoro Ellipta | UMECLIDINIUM BRM/VILANTEROL TR | BLST W/DEV | 62.5-25 MCG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
36.574 | 72.375 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Incruse Ellipta | UMECLIDINIUM BROMIDE | BLST W/DEV | 62.5 MCG | NOT COVERED | NON-FORMULARY | Formulary: Spiriva Handihaler |
97.366 | 61.579 | 121208-BETA-ADRENERGIC AGONISTS | Brovana | ARFORMOTEROL TARTRATE | VIAL-NEB | 15 MCG/2ML | NOT COVERED | NON-FORMULARY | Formulary: Albuterol nebulized solution is formulary. |
92.024 | 45.052 | 121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) | Uroxatral | ALFUZOSIN HCL | TAB ER 24H | 10 MG | NOT COVERED | NON-FORMULARY | Formulary: Tamsulosin, Terazosin, Prazosin. |
16.857 | 64.846 | 121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) | Rapaflo | SILODOSIN | CAPSULE | 4 MG | NOT COVERED | PAP | Formulary: Tamsulosin, Terazosin, Prazosin. Contact manufacturer for PAP |
16.858 | 64.847 | 121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) | Rapaflo | SILODOSIN | CAPSULE | 8 MG | NOT COVERED | PAP | Formulary: Tamsulosin, Terazosin, Prazosin. Contact manufacturer for PAP |
33.935 | 70.414 | 201204-ANTICOAGULANTS | Eliquis | APIXABAN | TABLET | 5 MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
30.239 | 67.642 | 201204-ANTICOAGULANTS | Eliquis | APIXABAN | TABLET | 2.5 MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
29.166 | 66.781 | 201204-ANTICOAGULANTS | Pradaxa | DABIGATRAN ETEXILATE MESYLATE | CAPSULE | 150 MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
99.708 | 63.997 | 201204-ANTICOAGULANTS | Pradaxa | DABIGATRAN ETEXILATE MESYLATE | CAPSULE | 75 MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
37.675 | 73.293 | 201204-ANTICOAGULANTS | Savaysa | EDOXABAN | TABLET | 15 MG | NOT COVERED | NON-FORMULARY | Formulary: Enoxaparin, Warfarin. |
37.676 | 73.294 | 201204-ANTICOAGULANTS | Savaysa | EDOXABAN | TABLET | 30 MG | NOT COVERED | NON-FORMULARY | Formulary: Enoxaparin, Warfarin. |
37.677 | 73.295 | 201204-ANTICOAGULANTS | Savaysa | EDOXABAN | TABLET | 60 MG | NOT COVERED | NON-FORMULARY | Formulary: Enoxaparin, Warfarin. |
37.212 | 72.904 | 201204-ANTICOAGULANTS | Xarelto Starting Month Pack | RIVAROXABAN | TAB DS PK | 15(42)-20(9) MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
14.427 | 64.493 | 201204-ANTICOAGULANTS | Xarelto | RIVAROXABAN | TABLET | 10 MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
30.818 | 68.118 | 201204-ANTICOAGULANTS | Xarelto | RIVAROXABAN | TABLET | 15 MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
30.819 | 68.119 | 201204-ANTICOAGULANTS | Xarelto | RIVAROXABAN | TABLET | 20 MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
17.157 | 64.902 | 201218-PLATELET-AGGREGATION INHIBITORS | Effient | PRASUGREL HCL | TABLET | 10 MG | Covered | FORMULARY | |
17.056 | 64.901 | 201218-PLATELET-AGGREGATION INHIBITORS | Effient | PRASUGREL HCL | TABLET | 5 MG | Covered | FORMULARY | |
29.385 | 66.950 | 201218-PLATELET-AGGREGATION INHIBITORS | Brilinta | TICAGRELOR | TABLET | 90 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
39.407 | 74.696 | 201218-PLATELET-AGGREGATION INHIBITORS | Brilinta | TICAGRELOR | TABLET | 60 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
24.059 | 58.592 | 201600-HEMATOPOIETIC AGENTS | Epogen, Procrit | EPOETIN ALFA | VIAL | 20000/2ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.110 | 11.740 | 201600-HEMATOPOIETIC AGENTS | Epogen, Procrit | EPOETIN ALFA | VIAL | 2000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.111 | 11.741 | 201600-HEMATOPOIETIC AGENTS | Epogen, Procrit | EPOETIN ALFA | VIAL | 4000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.112 | 11.742 | 201600-HEMATOPOIETIC AGENTS | Epogen, Procrit | EPOETIN ALFA | VIAL | 10000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.113 | 15.164 | 201600-HEMATOPOIETIC AGENTS | Epogen, Procrit | EPOETIN ALFA | VIAL | 3000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.114 | 25.708 | 201600-HEMATOPOIETIC AGENTS | Epogen, Procrit | EPOETIN ALFA | VIAL | 20000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.115 | 41.394 | 201600-HEMATOPOIETIC AGENTS | Epogen, Procrit | EPOETIN ALFA | VIAL | 40000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
26.586 | 65.367 | 240404-ANTIARRHYTHMIC AGENTS | Multaq | DRONEDARONE HCL | TABLET | 400 MG | NOT COVERED | PAP | Formulary: Amiodarone. Contact manufacturer for PAP |
95.347 | 40.303 | 241292-VASODILATING AGENTS, MISCELLANEOUS | Aggrenox | ASPIRIN/DIPYRIDAMOLE | CPMP 12HR | 25-200 MG | NOT COVERED | NON-FORMULARY | |
97.596 | 61.811 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg CR | CARVEDILOL PHOSPHATE | CPMP 24HR | 10 MG | NOT COVERED | PAP | Formulary: Carvedilol IR. Contact manufacturer for PAP |
97.597 | 61.812 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg CR | CARVEDILOL PHOSPHATE | CPMP 24HR | 20 MG | NOT COVERED | PAP | Formulary: Carvedilol IR. Contact manufacturer for PAP |
97.598 | 61.813 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg CR | CARVEDILOL PHOSPHATE | CPMP 24HR | 40 MG | NOT COVERED | PAP | Formulary: Carvedilol IR. Contact manufacturer for PAP |
97.599 | 61.814 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg CR | CARVEDILOL PHOSPHATE | CPMP 24HR | 80 MG | NOT COVERED | PAP | Formulary: Carvedilol IR. Contact manufacturer for PAP |
7.055 | 36.654 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Bystolic | NEBIVOLOL HCL | TABLET | 5 MG | NOT COVERED | PAP | Formulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP |
18.703 | 64.945 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Bystolic | NEBIVOLOL HCL | TABLET | 20 MG | NOT COVERED | PAP | Formulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP |
99.235 | 63.510 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Bystolic | NEBIVOLOL HCL | TABLET | 2.5 MG | NOT COVERED | PAP | Formulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP |
99.236 | 63.511 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Bystolic | NEBIVOLOL HCL | TABLET | 10 MG | NOT COVERED | PAP | Formulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP |
97.962 | 62.180 | 242808-DIHYDROPYRIDINES | Exforge | AMLODIPINE/VALSARTAN | TABLET | 5-160 MG | NOT COVERED | PAP | Prescribe amlodipine and valsartan or Lotrel |
97.963 | 62.181 | 242808-DIHYDROPYRIDINES | Exforge | AMLODIPINE/VALSARTAN | TABLET | 10-160 MG | NOT COVERED | PAP | Prescribe amlodipine and valsartan or Lotrel |
98.579 | 62.808 | 242808-DIHYDROPYRIDINES | Exforge | AMLODIPINE/VALSARTAN | TABLET | 5-320 MG | NOT COVERED | PAP | Prescribe amlodipine and valsartan or Lotrel |
98.580 | 62.809 | 242808-DIHYDROPYRIDINES | Exforge | AMLODIPINE/VALSARTAN | TABLET | 10-320 MG | NOT COVERED | PAP | Prescribe amlodipine and valsartan or Lotrel |
39.046 | 74.408 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Entresto | SACUBITRIL/VALSARTAN | TABLET | 24 MG-26MG | NOT COVERED | PAP | Formulary: Losartan, Irbesartan, Valsartan. Contact manufacturer for PAP |
39.047 | 74.409 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Entresto | SACUBITRIL/VALSARTAN | TABLET | 49 MG-51MG | NOT COVERED | PAP | Formulary: Losartan, Irbesartan, Valsartan. Contact manufacturer for PAP |
39.048 | 74.410 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Entresto | SACUBITRIL/VALSARTAN | TABLET | 97MG-103MG | NOT COVERED | PAP | Formulary: Losartan, Irbesartan, Valsartan. Contact manufacturer for PAP |
17.285 | 50.289 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Benicar | OLMESARTAN MEDOXOMIL | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
17.286 | 50.290 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Benicar | OLMESARTAN MEDOXOMIL | TABLET | 40 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
17.284 | 50.288 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Benicar | OLMESARTAN MEDOXOMIL | TABLET | 5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
28.837 | 66.538 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Tribenzor | OLMESARTAN/AMLODIPIN/HCTHIAZID | TABLET | 20-5-12.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
28.838 | 66.539 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Tribenzor | OLMESARTAN/AMLODIPIN/HCTHIAZID | TABLET | 40-5-12.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
28.839 | 66.540 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Tribenzor | OLMESARTAN/AMLODIPIN/HCTHIAZID | TABLET | 40-5-25 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
28.854 | 66.541 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Tribenzor | OLMESARTAN/AMLODIPIN/HCTHIAZID | TABLET | 40-10-12.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
28.855 | 66.542 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Tribenzor | OLMESARTAN/AMLODIPIN/HCTHIAZID | TABLET | 40-10-25 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
20.074 | 52.833 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Benicar HCT | OLMESARTAN/HYDROCHLOROTHIAZIDE | TABLET | 20-12.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
20.075 | 52.834 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Benicar HCT | OLMESARTAN/HYDROCHLOROTHIAZIDE | TABLET | 40-12.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
20.076 | 52.835 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Benicar HCT | OLMESARTAN/HYDROCHLOROTHIAZIDE | TABLET | 40-25 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
37.158 | 72.862 | 280808-OPIATE AGONISTS | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 10 MG | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
37.159 | 72.863 | 280808-OPIATE AGONISTS | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 15 MG | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
37.161 | 72.864 | 280808-OPIATE AGONISTS | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
37.162 | 72.865 | 280808-OPIATE AGONISTS | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 30 MG | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
37.163 | 72.866 | 280808-OPIATE AGONISTS | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 40 MG | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
37.164 | 72.867 | 280808-OPIATE AGONISTS | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 60 MG | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
37.165 | 72.868 | 280808-OPIATE AGONISTS | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 80 MG | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
9.070 | 20.647 | 281208-BENZODIAZEPINES (ANTICONVULSANTS) | Onfi | CLOBAZAM | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | |
9.071 | 17.026 | 281208-BENZODIAZEPINES (ANTICONVULSANTS) | Onfi | CLOBAZAM | TABLET | 10 MG | NOT COVERED | NON-FORMULARY | |
28.643 | 66.386 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Vimpat | LACOSAMIDE | ORAL SOLUTION | 10 MG/ML | COVERED | FORMULARY | |
14.338 | 64.432 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Vimpat | LACOSAMIDE | TABLET | 50 MG | COVERED | FORMULARY | |
14.339 | 64.433 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Vimpat | LACOSAMIDE | TABLET | 100 MG | COVERED | FORMULARY | |
14.341 | 64.434 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Vimpat | LACOSAMIDE | TABLET | 150 MG | COVERED | FORMULARY | |
14.342 | 64.435 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Vimpat | LACOSAMIDE | TABLET | 200 MG | COVERED | FORMULARY | |
24.693 | 65.250 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 25 MG | NOT COVERED | PAP | Formulary: Lamotrigine IR. Contact manufacturer for PAP |
24.739 | 65.253 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 200 MG | NOT COVERED | PAP | Formulary: Lamotrigine IR. Contact manufacturer for PAP |
24.697 | 65.251 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 50 MG | NOT COVERED | PAP | Formulary: Lamotrigine IR. Contact manufacturer for PAP |
24.703 | 65.252 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 100 MG | NOT COVERED | PAP | Formulary: Lamotrigine IR. Contact manufacturer for PAP |
29.725 | 67.221 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 300 MG | NOT COVERED | PAP | Formulary: Lamotrigine IR. Contact manufacturer for PAP |
30.787 | 68.093 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 250 MG | NOT COVERED | PAP | Formulary: Lamotrigine IR. Contact manufacturer for PAP |
14.305 | 64.416 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra XR | LEVETIRACETAM | TAB ER 24H | 500 MG | NOT COVERED | NON-FORMULARY | Formulary: Levetiracetam IR. |
20.765 | 64.990 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra XR | LEVETIRACETAM | TAB ER 24H | 750 MG | NOT COVERED | NON-FORMULARY | Formulary: Levetiracetam IR. |
36.556 | 40.901 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Topamax Sprinkle Cap | TOPIRAMATE | CAP SPRINK | 15 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
36.557 | 40.902 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Topamax Sprinkle Cap | TOPIRAMATE | CAP SPRINK | 25 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
35.328 | 71.496 | 281604-ANTIDEPRESSANTS | Fetzima | LEVOMILNACIPRAN HYDROCHLORIDE | CAP SA 24H | 40 MG | NOT COVERED | NON-FORMULARY | Formulary: Venlafaxine ER capsules, Duloxetine DR. |
35.327 | 71.495 | 281604-ANTIDEPRESSANTS | Fetzima | LEVOMILNACIPRAN HYDROCHLORIDE | CAP SA 24H | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Venlafaxine ER capsules, Duloxetine DR. |
35.329 | 71.497 | 281604-ANTIDEPRESSANTS | Fetzima | LEVOMILNACIPRAN HYDROCHLORIDE | CAP SA 24H | 80 MG | NOT COVERED | NON-FORMULARY | Formulary: Venlafaxine ER capsules, Duloxetine DR. |
35.334 | 71.498 | 281604-ANTIDEPRESSANTS | Fetzima | LEVOMILNACIPRAN HYDROCHLORIDE | CAP SA 24H | 120 MG | NOT COVERED | NON-FORMULARY | Formulary: Venlafaxine ER capsules, Duloxetine DR. |
35.335 | 71.499 | 281604-ANTIDEPRESSANTS | Fetzima | LEVOMILNACIPRAN HYDROCHLORIDE | CAP24HDSPK | 20-40 MG | NOT COVERED | NON-FORMULARY | Formulary: Venlafaxine ER capsules, Duloxetine DR. |
20.869 | 53.401 | 281604-ANTIDEPRESSANTS | Symbyax | OLANZAPINE/FLUOXETINE HCL | CAPSULE | 6-50 MG | NOT COVERED | PAP | Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP |
20.868 | 53.400 | 281604-ANTIDEPRESSANTS | Symbyax | OLANZAPINE/FLUOXETINE HCL | CAPSULE | 6-25 MG | NOT COVERED | PAP | Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP |
20.870 | 53.402 | 281604-ANTIDEPRESSANTS | Symbyax | OLANZAPINE/FLUOXETINE HCL | CAPSULE | 12-25 MG | NOT COVERED | PAP | Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP |
20.872 | 53.403 | 281604-ANTIDEPRESSANTS | Symbyax | OLANZAPINE/FLUOXETINE HCL | CAPSULE | 12-50 MG | NOT COVERED | PAP | Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP |
98.648 | 62.878 | 281604-ANTIDEPRESSANTS | Symbyax | OLANZAPINE/FLUOXETINE HCL | CAPSULE | 3-25 MG | NOT COVERED | PAP | Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP |
38.253 | 73.810 | 281604-ANTIDEPRESSANTS | Viibryd Titration Pack | VILAZODONE HYDROCHLORIDE | TAB DS PK | 10 MG-20 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
29.918 | 67.378 | 281604-ANTIDEPRESSANTS | Viibryd | VILAZODONE HYDROCHLORIDE | TABLET | 40 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
29.916 | 67.376 | 281604-ANTIDEPRESSANTS | Viibryd | VILAZODONE HYDROCHLORIDE | TABLET | 10 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
29.917 | 67.377 | 281604-ANTIDEPRESSANTS | Viibryd | VILAZODONE HYDROCHLORIDE | TABLET | 20 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
28.034 | 65.908 | 281608-ANTIPSYCHOTIC AGENTS | Fanapt | ILOPERIDONE | TAB DS PK | 1-2-4-6 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
28.025 | 65.901 | 281608-ANTIPSYCHOTIC AGENTS | Fanapt | ILOPERIDONE | TABLET | 1 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
28.026 | 65.902 | 281608-ANTIPSYCHOTIC AGENTS | Fanapt | ILOPERIDONE | TABLET | 2 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
28.027 | 65.903 | 281608-ANTIPSYCHOTIC AGENTS | Fanapt | ILOPERIDONE | TABLET | 4 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
28.028 | 65.904 | 281608-ANTIPSYCHOTIC AGENTS | Fanapt | ILOPERIDONE | TABLET | 6 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
28.029 | 65.905 | 281608-ANTIPSYCHOTIC AGENTS | Fanapt | ILOPERIDONE | TABLET | 8 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
28.030 | 65.906 | 281608-ANTIPSYCHOTIC AGENTS | Fanapt | ILOPERIDONE | TABLET | 10 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
28.033 | 65.907 | 281608-ANTIPSYCHOTIC AGENTS | Fanapt | ILOPERIDONE | TABLET | 12 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
29.366 | 66.932 | 281608-ANTIPSYCHOTIC AGENTS | Latuda | LURASIDONE HCL | TABLET | 40 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
29.367 | 66.933 | 281608-ANTIPSYCHOTIC AGENTS | Latuda | LURASIDONE HCL | TABLET | 80 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
31.226 | 68.448 | 281608-ANTIPSYCHOTIC AGENTS | Latuda | LURASIDONE HCL | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
33.147 | 69.894 | 281608-ANTIPSYCHOTIC AGENTS | Latuda | LURASIDONE HCL | TABLET | 120 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
35.192 | 71.415 | 281608-ANTIPSYCHOTIC AGENTS | Latuda | LURASIDONE HCL | TABLET | 60 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
34.022 | 47.285 | 281608-ANTIPSYCHOTIC AGENTS | Zyprexa Zydis | OLANZAPINE | TAB RAPDIS | 15 MG | NOT COVERED | PAP | Formulary: Olanzapine tablet. Contact manufacturer for PAP |
34.023 | 47.286 | 281608-ANTIPSYCHOTIC AGENTS | Zyprexa Zydis | OLANZAPINE | TAB RAPDIS | 20 MG | NOT COVERED | PAP | Formulary: Olanzapine tablet. Contact manufacturer for PAP |
92.007 | 45.190 | 281608-ANTIPSYCHOTIC AGENTS | Zyprexa Zydis | OLANZAPINE | TAB RAPDIS | 5 MG | NOT COVERED | PAP | Formulary: Olanzapine tablet. Contact manufacturer for PAP |
92.008 | 45.191 | 281608-ANTIPSYCHOTIC AGENTS | Zyprexa Zydis | OLANZAPINE | TAB RAPDIS | 10 MG | NOT COVERED | PAP | Formulary: Olanzapine tablet. Contact manufacturer for PAP |
97.769 | 61.985 | 281608-ANTIPSYCHOTIC AGENTS | Invega | PALIPERIDONE | TAB ER 24 | 3 MG | NOT COVERED | PAP | Formulary: Risperidone. Contact manufacturer for PAP |
97.770 | 61.986 | 281608-ANTIPSYCHOTIC AGENTS | Invega | PALIPERIDONE | TAB ER 24 | 6 MG | NOT COVERED | PAP | Formulary: Risperidone. Contact manufacturer for PAP |
97.771 | 61.987 | 281608-ANTIPSYCHOTIC AGENTS | Invega | PALIPERIDONE | TAB ER 24 | 9 MG | NOT COVERED | PAP | Formulary: Risperidone. Contact manufacturer for PAP |
27.685 | 65.667 | 281608-ANTIPSYCHOTIC AGENTS | Invega | PALIPERIDONE | TAB ER 24 | 1.5 MG | NOT COVERED | PAP | Formulary: Risperidone. Contact manufacturer for PAP |
98.994 | 63.240 | 281608-ANTIPSYCHOTIC AGENTS | Seroquel XR | QUETIAPINE FUMARATE | TAB ER 24H | 50 MG | Covered | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
16.193 | 64.725 | 281608-ANTIPSYCHOTIC AGENTS | Seroquel XR | QUETIAPINE FUMARATE | TAB ER 24H | 150 MG | Covered | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
98.522 | 62.748 | 281608-ANTIPSYCHOTIC AGENTS | Seroquel XR | QUETIAPINE FUMARATE | TAB ER 24H | 200 MG | Covered | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
98.523 | 62.749 | 281608-ANTIPSYCHOTIC AGENTS | Seroquel XR | QUETIAPINE FUMARATE | TAB ER 24H | 300 MG | Covered | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
98.524 | 62.750 | 281608-ANTIPSYCHOTIC AGENTS | Seroquel XR | QUETIAPINE FUMARATE | TAB ER 24H | 400 MG | Covered | CommUnityCare Pharmacy | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy, |
98.071 | 62.283 | 282004-AMPHETAMINES | Vyvanse | LISDEXAMFETAMINE DIMESYLATE | CAPSULE | 30 MG | NOT COVERED | PAP | Formulary: Adderall XR. Contact manufacturer for PAP |
98.072 | 62.284 | 282004-AMPHETAMINES | Vyvanse | LISDEXAMFETAMINE DIMESYLATE | CAPSULE | 50 MG | NOT COVERED | PAP | Formulary: Adderall XR. Contact manufacturer for PAP |
99.366 | 63.645 | 282004-AMPHETAMINES | Vyvanse | LISDEXAMFETAMINE DIMESYLATE | CAPSULE | 20 MG | NOT COVERED | PAP | Formulary: Adderall XR. Contact manufacturer for PAP |
99.367 | 63.646 | 282004-AMPHETAMINES | Vyvanse | LISDEXAMFETAMINE DIMESYLATE | CAPSULE | 40 MG | NOT COVERED | PAP | Formulary: Adderall XR. Contact manufacturer for PAP |
99.368 | 63.647 | 282004-AMPHETAMINES | Vyvanse | LISDEXAMFETAMINE DIMESYLATE | CAPSULE | 60 MG | NOT COVERED | PAP | Formulary: Adderall XR. Contact manufacturer for PAP |
37.674 | 73.292 | 282004-AMPHETAMINES | Vyvanse | LISDEXAMFETAMINE DIMESYLATE | CAPSULE | 10 MG | NOT COVERED | PAP | Formulary: Adderall XR. Contact manufacturer for PAP |
98.073 | 62.285 | 282004-AMPHETAMINES | Vyvanse | LISDEXAMFETAMINE DIMESYLATE | CAPSULE | 70 MG | NOT COVERED | PAP | Formulary: Adderall XR. Contact manufacturer for PAP |
12.248 | 47.318 | 282032-RESPIRATORY AND CNS STIMULANTS | Concerta | METHYLPHENIDATE HCL | TAB ER 24 | 54 MG | NOT COVERED | PAP | Formulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP |
12.568 | 45.982 | 282032-RESPIRATORY AND CNS STIMULANTS | Concerta | METHYLPHENIDATE HCL | TAB ER 24 | 36 MG | NOT COVERED | PAP | Formulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP |
17.123 | 50.172 | 282032-RESPIRATORY AND CNS STIMULANTS | Concerta | METHYLPHENIDATE HCL | TAB ER 24 | 27 MG | NOT COVERED | PAP | Formulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP |
12.567 | 45.981 | 282032-RESPIRATORY AND CNS STIMULANTS | Concerta | METHYLPHENIDATE HCL | TAB ER 24 | 18 MG | NOT COVERED | PAP | Formulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP |
26.515 | 65.356 | 283620-DOPAMINE RECEPTOR AGONISTS | Neupro | ROTIGOTINE | PATCH TD24 | 1 MG/24 HR | NOT COVERED | PAP | Formulary: Ropinirole. Contact manufacturer for PAP |
26.516 | 65.357 | 283620-DOPAMINE RECEPTOR AGONISTS | Neupro | ROTIGOTINE | PATCH TD24 | 3 MG/24 HR | NOT COVERED | PAP | Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP |
26.648 | 60.486 | 283620-DOPAMINE RECEPTOR AGONISTS | Neupro | ROTIGOTINE | PATCH TD24 | 2 MG/24 HR | NOT COVERED | PAP | Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP |
26.649 | 60.487 | 283620-DOPAMINE RECEPTOR AGONISTS | Neupro | ROTIGOTINE | PATCH TD24 | 4 MG/24 HR | NOT COVERED | PAP | Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP |
26.654 | 60.488 | 283620-DOPAMINE RECEPTOR AGONISTS | Neupro | ROTIGOTINE | PATCH TD24 | 6 MG/24 HR | NOT COVERED | PAP | Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP |
26.655 | 60.489 | 283620-DOPAMINE RECEPTOR AGONISTS | Neupro | ROTIGOTINE | PATCH TD24 | 8 MG/24 HR | NOT COVERED | PAP | Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP |
27.576 | 65.570 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Intuniv | GUANFACINE HCL | TAB ER 24H | 1 MG | NOT COVERED | PAP | Formulary: Guanfacine IR. Contact manufacturer for PAP |
27.578 | 65.572 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Intuniv | GUANFACINE HCL | TAB ER 24H | 2 MG | NOT COVERED | PAP | Formulary: Guanfacine IR. Contact manufacturer for PAP |
27.579 | 65.573 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Intuniv | GUANFACINE HCL | TAB ER 24H | 3 MG | NOT COVERED | PAP | Formulary: Guanfacine IR. Contact manufacturer for PAP |
27.582 | 65.574 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Intuniv | GUANFACINE HCL | TAB ER 24H | 4 MG | NOT COVERED | PAP | Formulary: Guanfacine IR. Contact manufacturer for PAP |
18.776 | 51.489 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Strattera | ATOMOXETINE HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
18.777 | 51.490 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Strattera | ATOMOXETINE HCL | CAPSULE | 18 MG | COVERED | FORMULARY | |
18.778 | 51.491 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Strattera | ATOMOXETINE HCL | CAPSULE | 25 MG | COVERED | FORMULARY | |
18.779 | 51.492 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Strattera | ATOMOXETINE HCL | CAPSULE | 40 MG | COVERED | FORMULARY | |
18.781 | 51.493 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Strattera | ATOMOXETINE HCL | CAPSULE | 60 MG | COVERED | FORMULARY | |
26.538 | 60.390 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Strattera | ATOMOXETINE HCL | CAPSULE | 80 MG | COVERED | FORMULARY | |
26.539 | 60.391 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Strattera | ATOMOXETINE HCL | CAPSULE | 100 MG | COVERED | FORMULARY | |
95.200 | 40.962 | 366000-THYROID FUNCTION | Thyrogen | THYROTROPIN ALFA | VIAL | 1.1 MG | NOT COVERED | PAP | |
43.725 | 77.644 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | QVAR Redihaler | BECLOMETHASONE DIPROPIONATE | HFA AEROBA | 80 MCG | NOT COVERED | PAP | Formulary: Flovent HFA. Contact manufacturer for PAP |
43.724 | 77.643 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | QVAR Redihaler | BECLOMETHASONE DIPROPIONATE | HFA AEROBA | 40 MCG | NOT COVERED | PAP | Formulary: Flovent HFA. Contact manufacturer for PAP |
98.024 | 62.240 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Pulmicort Flexhaler | BUDESONIDE | AER POW BA | 90 MCG | NOT COVERED | PAP | Formulary: Flovent HFA. Contact manufacturer for PAP |
98.025 | 62.241 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Pulmicort Flexhaler | BUDESONIDE | AER POW BA | 180 MCG | NOT COVERED | PAP | Formulary: Flovent HFA. Contact manufacturer for PAP |
98.499 | 62.725 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Symbicort MDI | BUDESONIDE/FORMOTEROL FUMARATE | HFA AER AD | 80-4.5 MCG | NOT COVERED | PAP | Formulary: Flovent HFA, Dulera Contact manufacturer for PAP |
98.500 | 62.726 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Symbicort MDI | BUDESONIDE/FORMOTEROL FUMARATE | HFA AER AD | 160-4.5 MCG | NOT COVERED | PAP | Formulary: Flovent HFA, DuleraContact manufacturer for PAP |
53.633 | 19.317 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent DIKUS | FLUTICASONE PROPIONATE | BLST W/DEV | 100 MCG | NOT COVERED | PAP | Formulary: Flovent HFA. Contact manufacturer for PAP |
53.634 | 19.318 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent DIKUS | FLUTICASONE PROPIONATE | BLST W/DEV | 250 MCG | NOT COVERED | PAP | Formulary: Flovent HFA. Contact manufacturer for PAP |
53.635 | 19.319 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent DIKUS | FLUTICASONE PROPIONATE | BLST W/DEV | 50 MCG | NOT COVERED | PAP | Formulary: Flovent HFA. Contact manufacturer for PAP |
50.594 | 43.367 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Advair DISKUS | FLUTICASONE/SALMETEROL | BLST W/DEV | 250-50 MCG | NOT COVERED | PAP | Formulary: Flovent HFA, DuleraContact manufacturer for PAP |
50.604 | 43.368 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Advair DISKUS | FLUTICASONE/SALMETEROL | BLST W/DEV | 500-50 MCG | NOT COVERED | PAP | Formulary: Flovent HFA, Dulera Contact manufacturer for PAP |
50.584 | 43.366 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Advair DISKUS | FLUTICASONE/SALMETEROL | BLST W/DEV | 100-50 MCG | NOT COVERED | PAP | Formulary: Flovent HFA, DuleraContact manufacturer for PAP |
97.135 | 61.343 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Advair HFA | FLUTICASONE/SALMETEROL | HFA AER AD | 45-21 MCG | NOT COVERED | PAP | Formulary: Flovent HFA, Dulera Contact manufacturer for PAP |
97.136 | 61.344 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Advair HFA | FLUTICASONE/SALMETEROL | HFA AER AD | 115-21 MCG | NOT COVERED | PAP | Formulary: Flovent HFA, Dulera Contact manufacturer for PAP |
97.137 | 61.345 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Advair HFA | FLUTICASONE/SALMETEROL | HFA AER AD | 230-21 MCG | NOT COVERED | PAP | Formulary: Flovent HFA, Dulera Contact manufacturer for PAP |
34.647 | 70.972 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Breo Ellipta | FLUTICASONE/VILANTEROL | BLST W/DEV | 100-25 MCG | NOT COVERED | PAP | Formulary: Flovent HFA, Dulera Contact manufacturer for PAP |
35.808 | 71.815 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Breo Ellipta | FLUTICASONE/VILANTEROL | BLST W/DEV | 200-25 MCG | NOT COVERED | PAP | Formulary: Flovent HFA, Dulera Contact manufacturer for PAP |
37.565 | 73.197 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Asmanex HFA | MOMETASONE FUROATE | HFA AER AD | 200 MCG | NOT COVERED | PAP | Formulary: Flovent HFA. Contact manufacturer for PAP |
37.566 | 73.198 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Asmanex HFA | MOMETASONE FUROATE | HFA AER AD | 100 MCG | NOT COVERED | PAP | Formulary: Flovent HFA. Contact manufacturer for PAP |
40.321 | 29.803 | 481024-LEUKOTRIENE MODIFIERS | Zyflo Filmtab | ZILEUTON | TABLET | 600 MG | NOT COVERED | NON-FORMULARY | Formulary: Montelukast. |
98.822 | 63.062 | 481024-LEUKOTRIENE MODIFIERS | Zyflo Filmtab | ZILEUTON | TBMP 12HR | 600 MG | NOT COVERED | NON-FORMULARY | Formulary: Montelukast. |
28.934 | 66.612 | 483200-PHOSPHODIESTERASE TYPE 4 INHIBITORS | Daliresp | ROFLUMILAST | TABLET | 500 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
19.216 | 51.820 | 520892-EENT ANTI-INFLAMMATORY AGENTS, MISC. | Restasis | CYCLOSPORINE | DROPERETTE | 0.05 % | NOT COVERED | PAP | Prior auths restricted to opthamology prescriber, Contact manufacturer for PAP |
27.131 | 65.392 | 524028-PROSTAGLANDIN ANALOGS | Lumigan | BIMATOPROST | DROPS | 0.01 % | NOT COVERED | PAP | Formulary: Latanoprost. Prior Auths restricted to opthamology, Contact manufacturer for PAP |
27.594 | 65.587 | 524028-PROSTAGLANDIN ANALOGS | Zioptan | TAFLUPROST/PF | DROPS | 0.0015% | NOT COVERED | PAP | Formulary: Latanoprost. Prior Auths restricted to opthamology, Contact manufacturer for PAP |
13.002 | 47.612 | 524028-PROSTAGLANDIN ANALOGS | Travatan Z | TRAVOPROST | DROPS | 0.004% | NOT COVERED | PAP | Formulary: Latanoprost. Prior Auths restricted to opthamology, Contact manufacturer for PAP |
26.473 | 60.341 | 561200-CATHARTICS AND LAXATIVES | Amitiza | LUBIPROSTONE | CAPSULE | 24 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
99.658 | 63.946 | 561200-CATHARTICS AND LAXATIVES | Amitiza | LUBIPROSTONE | CAPSULE | 8 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
16.305 | 64.793 | 562836-PROTON-PUMP INHIBITORS | Dexilant | DEXLANSOPRAZOLE | CAP DR BP | 30 MG | NOT COVERED | PAP | Formulary: Pantoprazole. Contact manufacturer for PAP |
16.306 | 64.794 | 562836-PROTON-PUMP INHIBITORS | Dexilant | DEXLANSOPRAZOLE | CAP DR BP | 60 MG | NOT COVERED | PAP | Formulary: Pantoprazole. Contact manufacturer for PAP |
16.305 | 64.793 | 562836-PROTON-PUMP INHIBITORS | Dexilant | DEXLANSOPRAZOLE | CAP DR BP | 30 MG | NOT COVERED | PAP | Formulary: Pantoprazole. Contact manufacturer for PAP |
16.306 | 64.794 | 562836-PROTON-PUMP INHIBITORS | Dexilant | DEXLANSOPRAZOLE | CAP DR BP | 60 MG | NOT COVERED | PAP | Formulary: Pantoprazole. Contact manufacturer for PAP |
95.348 | 40.304 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Colazal | BALSALAZIDE DISODIUM | CAPSULE | 750 MG | NOT COVERED | NON-FORMULARY | Formulary: sulfasalazine. |
99.847 | 64.139 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Rowasa | MESALAMINE W/CLEANSING WIPES | ENEMA KIT | 4 G/60 ML | NOT COVERED | NON-FORMULARY | |
16.159 | 64.701 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Apriso ER | MESALAMINE | CAP ER 24H | 0.375 G | NOT COVERED | PAP | Formulary: Sulfasalazine. Contact manufacturer for PAP |
34.113 | 70.543 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Delzicol DR | MESALAMINE | CAPSULE DR | 400 MG | NOT COVERED | PAP | Formulary: Sulfasalazine. Contact manufacturer for PAP |
23.422 | 58.091 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Pentasa | MESALAMINE | CAPSULE ER | 500 MG | NOT COVERED | PAP | Formulary: Sulfasalazine. Contact manufacturer for PAP |
48.490 | 21.776 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Canasa Suppository | MESALAMINE | SUPP.RECT | 1000 MG | NOT COVERED | PAP | Formulary: Sulfasalazine. Contact manufacturer for PAP |
97.842 | 62.058 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Lialda | MESALAMINE | TABLET DR | 1.2 G | NOT COVERED | PAP | Formulary: Sulfasalazine. Contact manufacturer for PAP |
39.354 | 74.654 | 569200-GI DRUGS, MISCELLANEOUS | Viberzi | ELUXADOLINE | TABLET | 75 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
39.355 | 74.655 | 569200-GI DRUGS, MISCELLANEOUS | Viberzi | ELUXADOLINE | TABLET | 100 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
33.187 | 69.922 | 569200-GI DRUGS, MISCELLANEOUS | Linzess | LINACLOTIDE | CAPSULE | 145 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
33.188 | 69.923 | 569200-GI DRUGS, MISCELLANEOUS | Linzess | LINACLOTIDE | CAPSULE | 290 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
99.450 | 63.735 | 682003-AMYLINOMIMETICS | Symlin | PRAMLINTIDE ACETATE | PEN INJCTR | 2700 MCG/2.7ML | NOT COVERED | PAP | Contact manufacturer for PAP |
99.514 | 63.804 | 682003-AMYLINOMIMETICS | Symlin | PRAMLINTIDE ACETATE | PEN INJCTR | 1500 MCG/1.5ML | NOT COVERED | PAP | Contact manufacturer for PAP |
34.086 | 70.525 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Nesina | ALOGLIPTIN | TABLET | 6.25 MG | NOT COVERED | PAP | |
34.085 | 70.524 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Nesina | ALOGLIPTIN | TABLET | 12.5 GM | NOT COVERED | PAP | |
34.076 | 70.517 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Nesina | ALOGLIPTIN | TABLET | 25 MG | NOT COVERED | PAP | |
27.393 | 65.430 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Onglyza | SAXAGLIPTIN HCL | TABLET | 2.5 MG | NOT COVERED | PAP | |
27.394 | 65.431 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Onglyza | SAXAGLIPTIN HCL | TABLET | 5 MG | NOT COVERED | PAP | |
29.224 | 66.817 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Kombiglyze XR | SAXAGLIPTIN HCL/METFORMIN HCL | TBMP 24HR | 5-1000 MG | NOT COVERED | PAP | |
29.225 | 66.818 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Kombiglyze XR | SAXAGLIPTIN HCL/METFORMIN HCL | TBMP 24HR | 2.5-1000 MG | NOT COVERED | PAP | |
29.118 | 66.816 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Kombiglyze XR | SAXAGLIPTIN HCL/METFORMIN HCL | TBMP 24HR | 5-500 MG | NOT COVERED | PAP | |
37.169 | 72.872 | 682006-INCRETIN MIMETICS | Trulicity | DULAGLUTIDE | PEN INJCTR | 0.75MG/0.5 | NOT COVERED | PAP | Formulary: Byetta, Victoza. Contact manufacturer for PAP |
37.171 | 72.873 | 682006-INCRETIN MIMETICS | Trulicity | DULAGLUTIDE | PEN INJCTR | 1.5 MG/0.5 | NOT COVERED | PAP | Formulary: Byetta, Victoza. Contact manufacturer for PAP |
44.039 | 77.890 | 682006-INCRETIN MIMETICS | Bydureon Bcise | EXENATIDE MICROSPHERES | AUTO INJCT | 2MG/0.85ML | NOT COVERED | PAP | Formulary: Byetta, Victoza. Contact manufacturer for PAP |
36.352 | 72.230 | 682006-INCRETIN MIMETICS | Bydureon Pen | EXENATIDE MICROSPHERES | PEN INJCTR | 2MG/0.65ML | NOT COVERED | PAP | Formulary: Byetta, Victoza. Contact manufacturer for PAP |
26.189 | 65.344 | 682006-INCRETIN MIMETICS | Victoza | LIRAGLUTIDE | PEN INJCTR | 0.6 MG/0.1ML | Covered | FORMULARY | |
98.637 | 62.867 | 682008-INSULINS | Lantus Solostar | INSULIN GLARGINE HUM.REC.ANLOG | INSULN PEN | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | Formulary: insulin glargine-yfgn. Contact manufacturer for PAP |
37.988 | 73.567 | 682008-INSULINS | Toujeo Solostar | INSULIN GLARGINE HUM.REC.ANLOG | INSULN PEN | 300 UNIT/ML | NOT COVERED | NON-FORMULARY | Formulary: insulin glargine-yfgn. Contact manufacturer for PAP |
13.072 | 47.780 | 682008-INSULINS | Lantus | INSULIN GLARGINE HUM.REC.ANLOG | VIAL | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | Formulary: insulin glargine-yfgn. Contact manufacturer for PAP |
26.508 | 60.371 | 682008-INSULINS | Apidra Solostar | INSULIN GLULISINE | INSULN PEN | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | Formulary: Novolog Contact manufacturer for PAP |
25.936 | 59.985 | 682008-INSULINS | Apidra | INSULIN GLULISINE | VIAL | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | Formulary: Novolog. Contact manufacturer for PAP |
9.633 | 29.916 | 682008-INSULINS | Humulin R U500 | INSULIN REGULAR HUMAN | VIAL | 500 UNIT/ML | NOT COVERED | PAP | Prescribe U500 Syringes, Contact manufacturer for PAP |
34.439 | 70.791 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokana | CANAGLIFLOZIN | TABLET | 100 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
34.441 | 70.792 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokana | CANAGLIFLOZIN | TABLET | 300 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
42.315 | 76.623 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Inokamet XR | CANAGLIFLOZIN/METFORMIN HCL | TAB BP 24H | 150-1000MG | NOT COVERED | PAP | Contact manufacturer for PAP |
42.312 | 76.620 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokamet XR | CANAGLIFLOZIN/METFORMIN HCL | TAB BP 24H | 50MG-500MG | NOT COVERED | PAP | Contact manufacturer for PAP |
42.313 | 76.621 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokamet XR | CANAGLIFLOZIN/METFORMIN HCL | TAB BP 24H | 50-1000 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
42.314 | 76.622 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokamet XR | CANAGLIFLOZIN/METFORMIN HCL | TAB BP 24H | 150-500 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
36.857 | 72.587 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokamet | CANAGLIFLOZIN/METFORMIN HCL | TABLET | 50-1000 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
36.859 | 72.589 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokamet | CANAGLIFLOZIN/METFORMIN HCL | TABLET | 150-1000MG | NOT COVERED | PAP | Contact manufacturer for PAP |
36.953 | 72.677 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokamet | CANAGLIFLOZIN/METFORMIN HCL | TABLET | 150-500 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
36.954 | 72.678 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokamet | CANAGLIFLOZIN/METFORMIN HCL | TABLET | 50MG-500MG | NOT COVERED | PAP | Contact manufacturer for PAP |
34.394 | 70.755 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Farxiga | DAPAGLIFLOZIN PROPANEDIOL | TABLET | 10 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
35.698 | 71.740 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Farxiga | DAPAGLIFLOZIN PROPANEDIOL | TABLET | 5 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
37.343 | 73.031 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Xigduo XR | DAPAGLIFLOZIN/METFORMIN HCL | TAB BP 24H | 5-1000 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
37.339 | 73.029 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Xigduo XR | DAPAGLIFLOZIN/METFORMIN HCL | TAB BP 24H | 5-500 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
37.342 | 73.030 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Xigduo XR | DAPAGLIFLOZIN/METFORMIN HCL | TAB BP 24H | 10-500 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
37.344 | 73.032 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Xigduo XR | DAPAGLIFLOZIN/METFORMIN HCL | TAB BP 24H | 10-1000 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
36.716 | 72.488 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Jardiance | EMPAGLIFLOZIN | TABLET | 10 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
36.723 | 72.489 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Jardiance | EMPAGLIFLOZIN | TABLET | 25 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
37.832 | 73.432 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Glyxambi | EMPAGLIFLOZIN/LINAGLIPTIN | TABLET | 10 MG-5 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
37.833 | 73.433 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Glyxambi | EMPAGLIFLOZIN/LINAGLIPTIN | TABLET | 25 MG-5 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
38.929 | 74.316 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Synjardy | EMPAGLIFLOZIN/METFORMIN HCL | TABLET | 5MG-1000MG | NOT COVERED | PAP | Contact manufacturer for PAP |
38.932 | 74.318 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Synjardy | EMPAGLIFLOZIN/METFORMIN HCL | TABLET | 12.5-1000 | NOT COVERED | PAP | Contact manufacturer for PAP |
39.377 | 74.675 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Synjardy | EMPAGLIFLOZIN/METFORMIN HCL | TABLET | 5 MG-500MG | NOT COVERED | PAP | Contact manufacturer for PAP |
39.378 | 74.676 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Synjardy | EMPAGLIFLOZIN/METFORMIN HCL | TABLET | 12.5-500MG | NOT COVERED | PAP | Contact manufacturer for PAP |
14.404 | 64.481 | 682400-PARATHYROID | Forteo | TERIPARATIDE | PEN INJCTR | 20 MCG/DOSE | NOT COVERED | PAP | Contact manufacturer for PAP |
96.805 | 34.383 | 683200-PROGESTINS | Crinone Gel | PROGESTERONE, MICRONIZED | GEL/PF APP | 4% | NOT COVERED | PAP | Endometrin preferred |
63.011 | 31.769 | 683200-PROGESTINS | Crinone Gel | PROGESTERONE, MICRONIZED | GEL/PF APP | 8% | NOT COVERED | PAP | Endometrin preferred |
47.632 | 20.176 | 683604-THYROID AGENTS | Synthroid | LEVOTHYROXINE SODIUM | TABLET | 137 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.321 | 6.648 | 683604-THYROID AGENTS | Synthroid | LEVOTHYROXINE SODIUM | TABLET | 25 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.322 | 6.649 | 683604-THYROID AGENTS | Synthroid | LEVOTHYROXINE SODIUM | TABLET | 50 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.324 | 6.650 | 683604-THYROID AGENTS | Synthroid | LEVOTHYROXINE SODIUM | TABLET | 75 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
47.631 | 15.523 | 683604-THYROID AGENTS | Synthroid | LEVOTHYROXINE SODIUM | TABLET | 88 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.323 | 6.651 | 683604-THYROID AGENTS | Synthroid | LEVOTHYROXINE SODIUM | TABLET | 100 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.326 | 6.653 | 683604-THYROID AGENTS | Synthroid | LEVOTHYROXINE SODIUM | TABLET | 125 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.327 | 6.654 | 683604-THYROID AGENTS | Synthroid | LEVOTHYROXINE SODIUM | TABLET | 150 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.328 | 6.655 | 683604-THYROID AGENTS | Synthroid | LEVOTHYROXINE SODIUM | TABLET | 175MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.325 | 6.656 | 683604-THYROID AGENTS | Synthroid | LEVOTHYROXINE SODIUM | TABLET | 200 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.329 | 6.657 | 683604-THYROID AGENTS | Synthroid | LEVOTHYROXINE SODIUM | TABLET | 300 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.320 | 6.652 | 683604-THYROID AGENTS | Synthroid | LEVOTHYROXINE SODIUM | TABLET | 112 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
13.480 | 19.141 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Soriatane | ACITRETIN | CAPSULE | 10 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
13.481 | 19.142 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Soriatane | ACITRETIN | CAPSULE | 25 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
18.782 | 51.494 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Avage | TAZAROTENE | CREAM (G) | 0.1 % | NOT COVERED | NON-FORMULARY | |
85.362 | 46.983 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Tazorac Cream | TAZAROTENE | CREAM (G) | 0.05 % | NOT COVERED | NON-FORMULARY | |
85.363 | 46.984 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Tazorac Cream | TAZAROTENE | CREAM (G) | 0.1 % | NOT COVERED | NON-FORMULARY | |
32.178 | 69.204 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Fabior Foam | TAZAROTENE | FOAM | 0.1 % | NOT COVERED | NON-FORMULARY | |
29.222 | 31.601 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Tazorac Cream | TAZAROTENE | GEL (GRAM) | 0.1 % | NOT COVERED | NON-FORMULARY | |
29.221 | 31.600 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Tazorac Cream | TAZAROTENE | GEL (GRAM) | 0.05 % | NOT COVERED | NON-FORMULARY | |
23.276 | 57.982 | 861204-ANTIMUSCARINICS | Vesicare | SOLIFENACIN SUCCINATE | TABLET | 5 MG | NOT COVERED | PAP | Oxybutynin ER preferred |
23.277 | 57.983 | 861204-ANTIMUSCARINICS | Vesicare | SOLIFENACIN SUCCINATE | TABLET | 10 MG | NOT COVERED | PAP | Oxybutynin ER preferred |
32.766 | 69.630 | 861208-BETA-3-ADRENERGIC AGONISTS | Myrbetriq ER | MIRABEGRON | TAB ER 24H | 25 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
32.767 | 69.631 | 861208-BETA-3-ADRENERGIC AGONISTS | Myrbetriq ER | MIRABEGRON | TAB ER 24H | 50 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
16.808 | 64.829 | 921600-ANTIGOUT AGENTS | Uloric | FEBUXOSTAT | TABLET | 40 MG | NOT COVERED | PAP | Allopurinol is formulary, Contact manufacturer for PAP |
16.809 | 64.830 | 921600-ANTIGOUT AGENTS | Uloric | FEBUXOSTAT | TABLET | 80 MG | NOT COVERED | PAP | Allopurinol is formulary, Contact manufacturer for PAP |
29.073 | 66.709 | 922000-IMMUNOMODULATORY AGENTS | Gilenya | FINGOLIMOD HCL | CAPSULE | 0.5 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
28.656 | 66.396 | 922400-BONE RESORPTION INHIBITORS | Prolia | DENOSUMAB | SYRINGE | 60 MG/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
97.005 | 61.205 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Humira | ADALIMUMAB | PEN IJ KIT | 40 MG/0.8ML | NOT COVERED | PAP | Contact manufacturer for PAP |
18.924 | 51.599 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Humira | ADALIMUMAB | SYRINGEKIT | 40 MG/0.8ML | NOT COVERED | PAP | Contact manufacturer for PAP |
37.262 | 72.952 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Humira | ADALIMUMAB | SYRINGEKIT | 10 MG/0.2ML | NOT COVERED | PAP | Contact manufacturer for PAP |
99.439 | 63.724 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Humira | ADALIMUMAB | SYRINGEKIT | 20 MG/0.4ML | NOT COVERED | PAP | Contact manufacturer for PAP |
97.724 | 61.938 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Enbrel | ETANERCEPT | PEN INJCTR | 50 MG/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
98.398 | 62.624 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Enbrel | ETANERCEPT | SYRINGE | 25 MG/0.5ML | NOT COVERED | PAP | Contact manufacturer for PAP |
23.574 | 58.214 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Enbrel | ETANERCEPT | SYRINGE | 50 MG/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
52.651 | 40.869 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Enbrel | ETANERCEPT | VIAL | 25 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
47.560 | 23.724 | 924400-IMMUNOSUPPRESSIVE AGENTS | Cellcept | MYCOPHENOLATE MOFETIL | CAPSULE | 250 MG | Covered | FORMULARY | |
47.561 | 32.599 | 924400-IMMUNOSUPPRESSIVE AGENTS | Cellcept | MYCOPHENOLATE MOFETIL | CAPSULE | 500 MG | Covered | FORMULARY | |
41.229 | 21.175 | 925600-PROTECTIVE AGENTS | Elmiron | PENTOSAN POLYSULFATE SODIUM | CAPSULE | 100 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
45.026 | 78.657 | 681804-ANTIGONADOTROPINS | Orilissa | ELAGOLIX | TABLET | 150 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
45.026 | 78.657 | 681804-ANTIGONADOTROPINS | Orilissa | ELAGOLIX | TABLET | 200 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
42.676 | 76.864 | 682008-INSULINS | Soliqua | INSULIN GLARGINE/LIXISENATIDE | INSULN PEN | 100 UNIT-33 MCG/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
29.890 | 67.353 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Tradjenta | LINAGLIPTIN | TABLET | 5 MG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
31.315 | 68.516 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Jentadueto | LINAGLIPTIN/METFORMIN | TABLET | 2.5-500 MG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
31.316 | 68.517 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Jentadueto | LINAGLIPTIN/METFORMIN | TABLET | 2.5-850 MG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
31.317 | 68.518 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Jentadueto | LINAGLIPTIN/METFORMIN | TABLET | 2.5-1000 MG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
41.637 | 76.256 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Jentadueto XR | LINAGLIPTIN/METFORMIN ER | TABLET | 2.5-1000 MG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
41.639 | 76.257 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Jentadueto XR | LINAGLIPTIN/METFORMIN ER | TABLET | 5-1000 MG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
34.525 | 70.868 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Namenda XR | MEMANTINE ER | TABLET | 14 mg | NOT COVERED | PAP | Formulary: Memantine IR, Donepezil, Rivastigmine. Contact manufacturer for PAP |
34.527 | 70.870 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Namenda XR | MEMANTINE ER | TABLET | 28 mg | NOT COVERED | PAP | Formulary: Memantine IR, Donepezil, Rivastigmine. Contact manufacturer for PAP |
41.370 | 9.326 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Vancocin | VANCOMYCIN | CAPSULE | 125 MG | Covered | FORMULARY | |
41.371 | 9.327 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Vancocin | VANCOMYCIN | CAPSULE | 250 MG | Covered | FORMULARY | |
46.908 | 80.199 | 68221200-GLYCOGENOLYTIC AGENTS, 92120000-ANTIDOTES | Gvoke | GLUCAGON | 2 PACK AUTOINJECTOR | 1 MG/0.2 ML | Covered | FORMULARY | |
46.907 | 80.198 | 68221200-GLYCOGENOLYTIC AGENTS, 92120000-ANTIDOTES | Gvoke | GLUCAGON | 2 PACK AUTOINJECTOR | 0.5 MG/0.1 ML | Covered | FORMULARY | |
14.781 | 11.876 | 281608-ANTIPSYCHOTIC AGENTS | Haldol Decanoate | Haloperidol Decanoate | Vial | 100 mg/ml | Covered | FORMULARY | |
31.612 | 39.781 | 100000-ANTINEOPLASTIC AGENTS | Xeloda | Capecitabine | Tablet | 500 mg | Covered | FORMULARY | Restricted to Oncology & Hematology prescribers only |
23.549 | 58.193 | 681200-CONTRACEPTIVES | PLAN B ONE-STEP, ECONTRA ONE-STEP, NEW DAY, My Choice | Levonorgestrel | Tablet | 1.5 mg | Covered | FORMULARY | |
27.585 | 65.578 | 681200-CONTRACEPTIVES | Ella | Ulipristal | Tablet | 30 mg | Covered | FORMULARY | |
18.092 | 50.805 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan | Valsartan | Tablet | 40 mg | Covered | FORMULARY | |
13.846 | 48.401 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan | Valsartan | Tablet | 80 mg | Covered | FORMULARY | |
13.844 | 48.400 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan | Valsartan | Tablet | 160 mg | Covered | FORMULARY | |
13.838 | 48.399 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan | Valsartan | Tablet | 320 mg | Covered | FORMULARY | |
7.833 | 37.354 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan-HCT | Valsartan-Hydrochlorothiazide | Tablet | 80 - 12.5 mg | Covered | FORMULARY | |
9.760 | 38.925 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan-HCT | Valsartan-Hydrochlorothiazide | Tablet | 160 - 12.5 mg | Covered | FORMULARY | |
17.245 | 50.256 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan-HCT | Valsartan-Hydrochlorothiazide | Tablet | 160 - 25 mg | Covered | FORMULARY | |
27.015 | 60.781 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan-HCT | Valsartan-Hydrochlorothiazide | Tablet | 320 - 12.5 mg | Covered | FORMULARY | |
27.014 | 60.780 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan-HCT | Valsartan-Hydrochlorothiazide | Tablet | 320 - 25 mg | Covered | FORMULARY | |
161 | 16.995 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Aspirin | Asprin | Tablet EC | 81 mg | Covered | FORMULARY | |
16.713 | 4.380 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Aspirin | Asprin | Tablet Chew | 81 mg | Covered | FORMULARY | |
16.701 | 4.376 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Aspirin | Aspirin | Tablet | 325 mg | Covered | FORMULARY | |
16.720 | 4.381 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Aspirin | Aspirin | Tablet | 326 mg | Covered | FORMULARY | |
32.000 | 4.930 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | NICOTINE | NICOTINE | GUM | 2 MG | Covered | FORMULARY | |
3.201 | 13.486 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | NICOTINE | NICOTINE | GUM | 4 MG | Covered | FORMULARY | |
14.689 | 48.776 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | NICOTINE | NICOTINE | LOZENGE | 2 MG | Covered | FORMULARY | |
14.688 | 48.775 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | NICOTINE | NICOTINE | LOZENGE | 4 MG | Covered | FORMULARY | |
49.992 | 82.541 | 68200800-INSULINS | INSULIN GLARGINE-YFGN (SEMGLEE) | INSULIN GLARGINE-YFGN | VIAL | 100 UNITS/ML | Covered | FORMULARY | |
49.993 | 82.542 | 68200800-INSULINS | INSULIN GLARGINE-YFGN (SEMGLEE) | INSULIN GLARGINE-YFGN | INSULN PEN | 101 UNITS/ML | Covered | FORMULARY | |
22.836 | 57.439 | 682008-INSULINS | Levemir Flexpen | INSULIN DETEMIR | INSULN PEN | 100 UNIT/ML | COVERED | FORMULARY | |
25.305 | 59.586 | 682008-INSULINS | Levemir | INSULIN DETEMIR | VIAL | 100 UNIT/ML | COVERED | FORMULARY | |
Generic Code | Generic Sequence Number | Therapeutic Class | BrandName | GenericName | Formulation | Strength | Coverage | Location | Comments |