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 | 通用序号 | 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 | Nicoderm CQ Patch | NICOTINE | PATCH TD24 | 7 MG/24HR | COVERED | FORMULARY | |
3.422 | 16.426 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | Nicoderm CQ Patch | NICOTINE | PATCH TD24 | 14 MG/24HR | COVERED | FORMULARY | |
3.423 | 16.427 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | Nicoderm CQ Patch | 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 | |
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 | 醋酸甲羟孕酮 | 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年的今天,肠促胰岛素模拟 | 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年的今天,肠促胰岛素模拟 | 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 -氨基糖甙类 | 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 | 红霉素ETHYLSUCCINATE | SUSP RECON | 200 MG/5ML | COVERED | FORMULARY | |
40.524 | 21.206 | 081212-MACROLIDES | EryPed 400 | 红霉素ETHYLSUCCINATE | SUSP RECON | 400 MG/5ML | COVERED | FORMULARY | |
40.560 | 9.245 | 081212-MACROLIDES | E.E.S 400 | 红霉素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 | 强力霉素悬挂 | 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 | 强力霉素一水 | CAPSULE | 100 MG | COVERED | FORMULARY | |
40.652 | 16.815 | 081224-TETRACYCLINES | Doxycyline | 强力霉素一水 | CAPSULE | 50 MG | COVERED | FORMULARY | |
98.271 | 62.496 | 081224-TETRACYCLINES | Doxycyline | 强力霉素一水 | CAPSULE | 75 MG | COVERED | FORMULARY | |
40.363 | 27.050 | 081224-TETRACYCLINES | Doxycyline | 强力霉素一水 | 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小儿颗粒 | 棕榈酸克林霉素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 | 灰黄霉素MICROSIZE | ORAL SUSP | 125 MG/5ML | COVERED | FORMULARY | |
42.402 | 9.519 | 081492-ANTIFUNGALS, MISCELLANEOUS | Griseofulvin | 灰黄霉素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 | 硫酸羟氯喹 | 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 | 呋喃妥英大晶体 | CAPSULE | 100 MG | COVERED | FORMULARY | |
41.822 | 9.430 | 083600-URINARY ANTI-INFECTIVES | Macrodantin | 呋喃妥英大晶体 | 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 | |
41.680 | 5.040 | 121208-BETA-ADRENERGIC AGONISTS | Albuterol Sulfate | ALBUTEROL SULFATE | SOLUTION | 5 MG/ML | 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 | 肾上腺素AUTO-INJECT | EPINEPHRINE | AUTO INJCT | 0.15 MG/0.3ML | COVERED | FORMULARY | |
19.862 | 16.879 | 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS | 肾上腺素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 | 丙吡胺磷酸盐 | 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 -强心的代理 | Lanoxin | DIGOXIN | TABLET | 125 MCG | COVERED | FORMULARY | |
133 | 19 | 240408 -强心的代理 | 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 -直接血管舒张药 | Hydralazine | HYDRALAZINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
1.242 | 285 | 240820 -直接血管舒张药 | Hydralazine | HYDRALAZINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
1.243 | 286 | 240820 -直接血管舒张药 | Hydralazine | HYDRALAZINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
1.244 | 287 | 240820 -直接血管舒张药 | Hydralazine | HYDRALAZINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
1.290 | 299 | 240820 -直接血管舒张药 | Minoxidil | MINOXIDIL | TABLET | 10 MG | COVERED | FORMULARY | |
1.291 | 300 | 240820 -直接血管舒张药 | 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 | 单硝酸异山梨酯ER | ISOSORBIDE MONONITRATE | TAB ER 24H | 60 MG | COVERED | FORMULARY | |
48.103 | 23.474 | 241208-NITRATES AND NITRITES | 单硝酸异山梨酯ER | ISOSORBIDE MONONITRATE | TAB ER 24H | 120 MG | COVERED | FORMULARY | |
48.104 | 24.488 | 241208-NITRATES AND NITRITES | 单硝酸异山梨酯ER | ISOSORBIDE MONONITRATE | TAB ER 24H | 30 MG | COVERED | FORMULARY | |
1.931 | 16.639 | 241208-NITRATES AND NITRITES | 单硝酸异山梨酯 | ISOSORBIDE MONONITRATE | TABLET | 20 MG | COVERED | FORMULARY | |
1.932 | 17.294 | 241208-NITRATES AND NITRITES | 单硝酸异山梨酯 | 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 | 比索洛尔FUMARATE-HCTZ | TABLET | 2.5-6.25 MG | COVERED | FORMULARY | |
45.062 | 21.140 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Ziac | 比索洛尔FUMARATE-HCTZ | TABLET | 5-6.25 MG | COVERED | FORMULARY | |
45.063 | 21.141 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Ziac | 比索洛尔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. | 卡迪泽姆CD,卡蒂亚XT | DILTIAZEM HCL | CAP ER 24H | 180 MG | COVERED | FORMULARY | |
2.324 | 16.571 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | 卡迪泽姆CD,卡蒂亚XT | DILTIAZEM HCL | CAP ER 24H | 240 MG | COVERED | FORMULARY | |
2.325 | 16.572 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | 卡迪泽姆CD,卡蒂亚XT | DILTIAZEM HCL | CAP ER 24H | 300 MG | COVERED | FORMULARY | |
2.326 | 21.282 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | 卡迪泽姆CD,卡蒂亚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 -阿片受体激动剂 | Acetaminophen-Codeine Solution | ACETAMINOPHEN-CODEINE | SOLUTION | 120-12 MG/5ML | COVERED | FORMULARY | |
70.131 | 4.163 | 280808 -阿片受体激动剂 | Acetaminophen-Codeine Tablet | ACETAMINOPHEN-CODEINE | TABLET | 300-15 MG | COVERED | FORMULARY | |
70.134 | 4.165 | 280808 -阿片受体激动剂 | Tylenol-Codeine #3 | ACETAMINOPHEN-CODEINE | TABLET | 300-30 MG | COVERED | FORMULARY | |
70.136 | 4.169 | 280808 -阿片受体激动剂 | Tylenol-Codeine #4 | ACETAMINOPHEN-CODEINE | TABLET | 300-60 MG | COVERED | FORMULARY | |
70.140 | 4.149 | 280808 -阿片受体激动剂 | Butalbital-Acetaminophen-Caffeine-Codeine | BUTALBITAL-ACETAMINOPHEN-CAFFEINE-CODEINE | CAPSULE | 50-325-30 MG | COVERED | FORMULARY | |
21.146 | 53.582 | 280808 -阿片受体激动剂 | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | SOLUTION | 7.5-325/15 | COVERED | FORMULARY | |
12.486 | 47.430 | 280808 -阿片受体激动剂 | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | TABLET | 5-325 MG | COVERED | FORMULARY | |
12.488 | 47.431 | 280808 -阿片受体激动剂 | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | TABLET | 7.5-325 MG | COVERED | FORMULARY | |
70.330 | 30.623 | 280808 -阿片受体激动剂 | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | TABLET | 10-325 MG | COVERED | FORMULARY | |
70.334 | 26.439 | 280808 -阿片受体激动剂 | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | TABLET | 10-500 MG | COVERED | FORMULARY | |
12.488 | 47.431 | 280808 -阿片受体激动剂 | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | TABLET | 7.5-325 MG | COVERED | FORMULARY | |
63.101 | 34.068 | 280808 -阿片受体激动剂 | Vicoprofen | HYDROCODONE-IBUPROFEN | TABLET | 7.5-200 MG | COVERED | FORMULARY | |
16.141 | 4.110 | 280808 -阿片受体激动剂 | Dilaudid | HYDROMORPHONE HCL | TABLET | 2 MG | COVERED | FORMULARY | |
16.143 | 4.112 | 280808 -阿片受体激动剂 | Dilaudid | HYDROMORPHONE HCL | TABLET | 4 MG | COVERED | FORMULARY | |
16.144 | 15.190 | 280808 -阿片受体激动剂 | Dilaudid | HYDROMORPHONE HCL | TABLET | 8 MG | COVERED | FORMULARY | |
16.420 | 4.240 | 280808 -阿片受体激动剂 | Dolophine | METHADONE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
16.422 | 4.242 | 280808 -阿片受体激动剂 | Dolophine | METHADONE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
16.060 | 4.087 | 280808 -阿片受体激动剂 | Morphine | MORPHINE SULFATE | SOLUTION | 10 MG/5ML | COVERED | FORMULARY | |
16.062 | 4.089 | 280808 -阿片受体激动剂 | Morphine | MORPHINE SULFATE | SOLUTION | 20 MG/5ML | COVERED | FORMULARY | |
16.063 | 4.090 | 280808 -阿片受体激动剂 | Morphine | MORPHINE SULFATE | SOLUTION | 100 MG/5ML | COVERED | FORMULARY | |
16.070 | 4.091 | 280808 -阿片受体激动剂 | Morphine | MORPHINE SULFATE | TABLET | 15 MG | COVERED | FORMULARY | |
16.071 | 4.092 | 280808 -阿片受体激动剂 | Morphine | MORPHINE SULFATE | TABLET | 30 MG | COVERED | FORMULARY | |
16.640 | 4.096 | 280808 -阿片受体激动剂 | MS Contin CR | MORPHINE SULFATE | TABLET ER | 30 MG | COVERED | FORMULARY | |
16.641 | 4.097 | 280808 -阿片受体激动剂 | MS Contin CR | MORPHINE SULFATE | TABLET ER | 60 MG | COVERED | FORMULARY | |
16.643 | 11.887 | 280808 -阿片受体激动剂 | MS Contin CR | MORPHINE SULFATE | TABLET ER | 15 MG | COVERED | FORMULARY | |
16.285 | 24.507 | 280808 -阿片受体激动剂 | Oxycodone | OXYCODONE HCL | CAPSULE | 5 MG | COVERED | FORMULARY | |
16.290 | 4.225 | 280808 -阿片受体激动剂 | Oxycodone | OXYCODONE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
14.965 | 48.976 | 280808 -阿片受体激动剂 | Percocet | OXYCODONE HCL-ACETAMINOPHEN | TABLET | 7.5-325MG | COVERED | FORMULARY | |
14.966 | 48.977 | 280808 -阿片受体激动剂 | Percocet | OXYCODONE HCL-ACETAMINOPHEN | TABLET | 10MG-325MG | COVERED | FORMULARY | |
70.491 | 4.222 | 280808 -阿片受体激动剂 | Percocet | OXYCODONE HCL-ACETAMINOPHEN | TABLET | 5 MG-325MG | COVERED | FORMULARY | |
7.221 | 23.139 | 280808 -阿片受体激动剂 | Ultram | TRAMADOL HCL | TABLET | 50 MG | COVERED | FORMULARY | |
13.909 | 48.456 | 280808 -阿片受体激动剂 | Ultracet | 曲马多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年鸦片拮抗剂 | Narcan Nasal | NALOXONE HCL | SPRAY | 4 MG | COVERED | FORMULARY | |
17.070 | 4.518 | 281000年鸦片拮抗剂 | 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 | 苯妥英钠延伸 | CAPSULE | 300 MG | COVERED | FORMULARY | |
15.038 | 49.445 | 281212-HYDANTOINS | Dilantin, Phenytek | 苯妥英钠延伸 | CAPSULE | 200 MG | COVERED | FORMULARY | |
17.700 | 4.521 | 281212-HYDANTOINS | Dilantin, Phenytek | 苯妥英钠延伸 | CAPSULE | 100 MG | COVERED | FORMULARY | |
17.701 | 4.522 | 281212-HYDANTOINS | Dilantin, Phenytek | 苯妥英钠延伸 | 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 | |
92.219 | 45.100 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Thioguanine | THIOGUANINE | TABLET | 40 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 -抗抑郁药 | Elavil | AMITRIPTYLINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
16.513 | 46.044 | 281604 -抗抑郁药 | Elavil | AMITRIPTYLINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
16.514 | 46.045 | 281604 -抗抑郁药 | Elavil | AMITRIPTYLINE HCL | TABLET | 150 MG | COVERED | FORMULARY | |
16.515 | 46.046 | 281604 -抗抑郁药 | Elavil | AMITRIPTYLINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
16.516 | 46.047 | 281604 -抗抑郁药 | Elavil | AMITRIPTYLINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
16.517 | 46.048 | 281604 -抗抑郁药 | Elavil | AMITRIPTYLINE HCL | TABLET | 75 MG | COVERED | FORMULARY | |
20.317 | 53.006 | 281604 -抗抑郁药 | Wellbutrin XL | BUPROPION HCL | TAB ER 24H | 150 MG | COVERED | FORMULARY | |
20.318 | 53.007 | 281604 -抗抑郁药 | Wellbutrin XL | BUPROPION HCL | TAB ER 24H | 300 MG | COVERED | FORMULARY | |
16.384 | 46.236 | 281604 -抗抑郁药 | Wellbutrin | BUPROPION HCL | TABLET | 75 MG | COVERED | FORMULARY | |
16.385 | 46.237 | 281604 -抗抑郁药 | Wellbutrin | BUPROPION HCL | TABLET | 100 MG | COVERED | FORMULARY | |
16.386 | 46.238 | 281604 -抗抑郁药 | Wellbutrin SR | BUPROPION HCL | TABLET ER | 150 MG | COVERED | FORMULARY | |
16.387 | 46.239 | 281604 -抗抑郁药 | Wellbutrin SR | BUPROPION HCL | TABLET ER | 100 MG | COVERED | FORMULARY | |
17.573 | 50.496 | 281604 -抗抑郁药 | Wellbutrin SR | BUPROPION HCL | TABLET ER | 200 MG | COVERED | FORMULARY | |
27.901 | 31.439 | 281604 -抗抑郁药 | Zyban SR | BUPROPION HCL | TABLET ER | 150 MG | COVERED | FORMULARY | |
16.342 | 46.203 | 281604 -抗抑郁药 | Celexa | 西酞普兰氢溴酸盐 | TABLET | 20 MG | COVERED | FORMULARY | Max 40mg/day |
16.343 | 46.204 | 281604 -抗抑郁药 | Celexa | 西酞普兰氢溴酸盐 | TABLET | 40 MG | COVERED | FORMULARY | Max 40mg/day |
16.345 | 46.206 | 281604 -抗抑郁药 | Celexa | 西酞普兰氢溴酸盐 | TABLET | 10 MG | COVERED | FORMULARY | Max 40mg/day |
16.563 | 46.086 | 281604 -抗抑郁药 | Doxepin | DOXEPIN HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
16.564 | 46.087 | 281604 -抗抑郁药 | Doxepin | DOXEPIN HCL | CAPSULE | 100 MG | COVERED | FORMULARY | |
16.565 | 46.088 | 281604 -抗抑郁药 | Doxepin | DOXEPIN HCL | CAPSULE | 150 MG | COVERED | FORMULARY | |
16.566 | 46.089 | 281604 -抗抑郁药 | Doxepin | DOXEPIN HCL | CAPSULE | 25 MG | COVERED | FORMULARY | |
16.567 | 46.090 | 281604 -抗抑郁药 | Doxepin | DOXEPIN HCL | CAPSULE | 50 MG | COVERED | FORMULARY | |
16.568 | 46.091 | 281604 -抗抑郁药 | Doxepin | DOXEPIN HCL | CAPSULE | 75 MG | COVERED | FORMULARY | |
23.161 | 57.891 | 281604 -抗抑郁药 | Cymbalta | DULOXETINE HCL | CAPSULE DR | 20 MG | COVERED | FORMULARY | |
23.162 | 57.892 | 281604 -抗抑郁药 | Cymbalta | DULOXETINE HCL | CAPSULE DR | 30 MG | COVERED | FORMULARY | |
23.164 | 57.893 | 281604 -抗抑郁药 | Cymbalta | DULOXETINE HCL | CAPSULE DR | 60 MG | COVERED | FORMULARY | |
38.728 | 74.166 | 281604 -抗抑郁药 | Cymbalta | DULOXETINE HCL | CAPSULE DR | 40 MG | COVERED | FORMULARY | |
19.035 | 51.698 | 281604 -抗抑郁药 | Lexapro Solution | ESCITALOPRAM OXALATE | SOLUTION | 5 MG/5ML | COVERED | FORMULARY | Max 20mg/day |
17.851 | 50.712 | 281604 -抗抑郁药 | Lexapro | ESCITALOPRAM OXALATE | TABLET | 10 MG | COVERED | FORMULARY | Max 20mg/day |
17.987 | 50.760 | 281604 -抗抑郁药 | Lexapro | ESCITALOPRAM OXALATE | TABLET | 20 MG | COVERED | FORMULARY | Max 20mg/day |
18.975 | 51.642 | 281604 -抗抑郁药 | Lexapro | ESCITALOPRAM OXALATE | TABLET | 5 MG | COVERED | FORMULARY | Max 20mg/day |
16.353 | 46.213 | 281604 -抗抑郁药 | Prozac | FLUOXETINE HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
16.354 | 46.214 | 281604 -抗抑郁药 | Prozac | FLUOXETINE HCL | CAPSULE | 20 MG | COVERED | FORMULARY | |
16.355 | 46.215 | 281604 -抗抑郁药 | Prozac | FLUOXETINE HCL | CAPSULE | 40 MG | COVERED | FORMULARY | |
16.348 | 46.209 | 281604 -抗抑郁药 | Fluvoxamine | FLUVOXAMINE MALEATE | TABLET | 50 MG | COVERED | FORMULARY | |
16.349 | 46.210 | 281604 -抗抑郁药 | Fluvoxamine | FLUVOXAMINE MALEATE | TABLET | 100 MG | COVERED | FORMULARY | |
16.541 | 46.068 | 281604 -抗抑郁药 | Tofranil | IMIPRAMINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
16.542 | 46.069 | 281604 -抗抑郁药 | Tofranil | IMIPRAMINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
16.543 | 46.070 | 281604 -抗抑郁药 | Tofranil | IMIPRAMINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
21.817 | 54.009 | 281604 -抗抑郁药 | Remeron | MIRTAZAPINE | TABLET | 7.5 MG | COVERED | FORMULARY | |
16.732 | 46.450 | 281604 -抗抑郁药 | Remeron | MIRTAZAPINE | TABLET | 15 MG | COVERED | FORMULARY | |
16.733 | 46.451 | 281604 -抗抑郁药 | Remeron | MIRTAZAPINE | TABLET | 30 MG | COVERED | FORMULARY | |
16.734 | 46.452 | 281604 -抗抑郁药 | Remeron | MIRTAZAPINE | TABLET | 45 MG | COVERED | FORMULARY | |
16.529 | 46.059 | 281604 -抗抑郁药 | Pamelor | NORTRIPTYLINE HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
16.532 | 46.060 | 281604 -抗抑郁药 | Pamelor | NORTRIPTYLINE HCL | CAPSULE | 25 MG | COVERED | FORMULARY | |
16.533 | 46.061 | 281604 -抗抑郁药 | Pamelor | NORTRIPTYLINE HCL | CAPSULE | 50 MG | COVERED | FORMULARY | |
16.534 | 46.062 | 281604 -抗抑郁药 | Pamelor | NORTRIPTYLINE HCL | CAPSULE | 75 MG | COVERED | FORMULARY | |
17.077 | 50.136 | 281604 -抗抑郁药 | Paxil CR | PAROXETINE HCL | TAB ER 24H | 25 MG | COVERED | FORMULARY | |
17.078 | 50.137 | 281604 -抗抑郁药 | Paxil CR | PAROXETINE HCL | TAB ER 24H | 12.5 MG | COVERED | FORMULARY | |
17.079 | 50.138 | 281604 -抗抑郁药 | Paxil CR | PAROXETINE HCL | TAB ER 24H | 37.5 MG | COVERED | FORMULARY | |
16.364 | 46.222 | 281604 -抗抑郁药 | Paxil | PAROXETINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
16.366 | 46.223 | 281604 -抗抑郁药 | Paxil | PAROXETINE HCL | TABLET | 20 MG | COVERED | FORMULARY | |
16.367 | 46.224 | 281604 -抗抑郁药 | Paxil | PAROXETINE HCL | TABLET | 30 MG | COVERED | FORMULARY | |
16.368 | 46.225 | 281604 -抗抑郁药 | Paxil | PAROXETINE HCL | TABLET | 40 MG | COVERED | FORMULARY | |
16.373 | 46.227 | 281604 -抗抑郁药 | Zoloft | SERTRALINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
16.374 | 46.228 | 281604 -抗抑郁药 | Zoloft | SERTRALINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
16.375 | 46.229 | 281604 -抗抑郁药 | Zoloft | SERTRALINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
16.391 | 46.241 | 281604 -抗抑郁药 | Trazodone | TRAZODONE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
16.392 | 46.242 | 281604 -抗抑郁药 | Trazodone | TRAZODONE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
16.393 | 46.243 | 281604 -抗抑郁药 | Trazodone | TRAZODONE HCL | TABLET | 150 MG | COVERED | FORMULARY | |
16.394 | 46.244 | 281604 -抗抑郁药 | Trazodone | TRAZODONE HCL | TABLET | 300 MG | COVERED | FORMULARY | |
16.816 | 46.403 | 281604 -抗抑郁药 | Effexor XR | VENLAFAXINE HCL | CAP ER 24H | 37.5 MG | COVERED | FORMULARY | |
16.817 | 46.404 | 281604 -抗抑郁药 | Effexor XR | VENLAFAXINE HCL | CAP ER 24H | 75 MG | COVERED | FORMULARY | |
16.818 | 46.405 | 281604 -抗抑郁药 | Effexor XR | VENLAFAXINE HCL | CAP ER 24H | 150 MG | COVERED | FORMULARY | |
16.811 | 46.398 | 281604 -抗抑郁药 | Venlafaxine | VENLAFAXINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
16.812 | 46.399 | 281604 -抗抑郁药 | Venlafaxine | VENLAFAXINE HCL | TABLET | 37.5 MG | COVERED | FORMULARY | |
16.813 | 46.400 | 281604 -抗抑郁药 | Venlafaxine | VENLAFAXINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
16.814 | 46.401 | 281604 -抗抑郁药 | Venlafaxine | VENLAFAXINE HCL | TABLET | 75 MG | COVERED | FORMULARY | |
16.815 | 46.402 | 281604 -抗抑郁药 | 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 | 硫酸右旋安非他命 | TABLET | 10 MG | COVERED | FORMULARY | Max 60mg/day |
19.881 | 5.011 | 282004-AMPHETAMINES | Zenzedi | 硫酸右旋安非他命 | 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钾 | TABLET | 15 MG | COVERED | FORMULARY | |
14.092 | 3.745 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Tranxene | CLORAZEPATE钾 | TABLET | 3.75 MG | COVERED | FORMULARY | |
14.093 | 3.746 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Tranxene | CLORAZEPATE钾 | 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 -抗躁狂药物 | Lithium | LITHIUM CARBONATE | CAPSULE | 300 MG | COVERED | FORMULARY | |
15.711 | 4.000 | 282800 -抗躁狂药物 | Lithium | LITHIUM CARBONATE | CAPSULE | 150 MG | COVERED | FORMULARY | |
15.721 | 4.003 | 282800 -抗躁狂药物 | Lithium | LITHIUM CARBONATE | TABLET/CAPSULE | 300 MG | COVERED | FORMULARY | |
15.712 | 4.002 | 282800 -抗躁狂药物 | Lithium | LITHIUM CARBONATE | CAPSULE | 600 MG | COVERED | FORMULARY | |
15.730 | 4.005 | 282800 -抗躁狂药物 | Lithobid | LITHIUM CARBONATE | TABLET ER | 450 MG | COVERED | FORMULARY | |
15.731 | 4.004 | 282800 -抗躁狂药物 | 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 -金刚烷(中枢神经系统) | Amantadine | AMANTADINE HCL | CAPSULE | 100 MG | COVERED | FORMULARY | |
17.530 | 4.576 | 283604 -金刚烷(中枢神经系统) | Amantadine | AMANTADINE HCL | SOLUTION | 50 MG/5ML | COVERED | FORMULARY | |
17.521 | 27.637 | 283604 -金刚烷(中枢神经系统) | 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 -多巴胺前体 | Carbidopa-Levodopa | CARBIDOPA-LEVODOPA | TAB RAPDIS | 10-100 MG | COVERED | FORMULARY | |
23.286 | 57.988 | 283616 -多巴胺前体 | Carbidopa-Levodopa | CARBIDOPA-LEVODOPA | TAB RAPDIS | 25-100 MG | COVERED | FORMULARY | |
23.287 | 57.989 | 283616 -多巴胺前体 | Carbidopa-Levodopa | CARBIDOPA-LEVODOPA | TAB RAPDIS | 25-250 MG | COVERED | FORMULARY | |
62.740 | 2.537 | 283616 -多巴胺前体 | Sinemet | CARBIDOPA-LEVODOPA | TABLET | 10-100 MG | COVERED | FORMULARY | |
62.741 | 2.538 | 283616 -多巴胺前体 | Sinemet | CARBIDOPA-LEVODOPA | TABLET | 25-100 MG | COVERED | FORMULARY | |
62.742 | 2.539 | 283616 -多巴胺前体 | Sinemet | CARBIDOPA-LEVODOPA | TABLET | 25-250 MG | COVERED | FORMULARY | |
62.591 | 16.043 | 283616 -多巴胺前体 | Sinemet CR | CARBIDOPA-LEVODOPA | TABLET ER | 50-200 MG | COVERED | FORMULARY | |
62.592 | 19.563 | 283616 -多巴胺前体 | Sinemet CR | CARBIDOPA-LEVODOPA | TABLET ER | 25-100 MG | COVERED | FORMULARY | |
26.070 | 6.603 | 283620-DOPAMINE RECEPTOR AGONISTS | Parlodel | 甲磺酸溴麦角环肽 | CAPSULE | 5 MG | COVERED | FORMULARY | |
26.081 | 6.604 | 283620-DOPAMINE RECEPTOR AGONISTS | Parlodel | 甲磺酸溴麦角环肽 | 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 -糖尿病 | True Metrix Glucose Test Strip | 血糖诊断 | STRIP | COVERED | FORMULARY | ||
25.200 | 6.373 | 362600 -糖尿病 | True Metrix Glucose Test Strip | 血糖诊断 | STRIP | COVERED | FORMULARY | ||
25.200 | 6.373 | 362600 -糖尿病 | 真矩阵测试条 | 血糖诊断 | STRIP | COVERED | FORMULARY | ||
35.600 | 8.321 | 368812-KETONES | Ketocare Test Strip | 尿丙酮试纸 | STRIP | COVERED | FORMULARY | ||
35.600 | 8.321 | 368812-KETONES | Ketocare Test Strips | 尿丙酮试纸 | STRIP | COVERED | FORMULARY | ||
14.950 | 8.250 | 400800 -碱化剂 | Urocit-K | POTASSIUM CITRATE | TABLET ER | 5 MEQ | COVERED | FORMULARY | |
14.951 | 17.000 | 400800 -碱化剂 | Urocit-K | POTASSIUM CITRATE | TABLET ER | 10 MEQ | COVERED | FORMULARY | |
28.095 | 65.955 | 400800 -碱化剂 | Urocit-K | POTASSIUM CITRATE | TABLET ER | 15 MEQ | COVERED | FORMULARY | |
10.160 | 3.143 | 401000 -氨麻药的 | Lactulose | LACTULOSE | SOLUTION | 10 G/15ML | COVERED | FORMULARY | |
10.167 | 29.054 | 401000 -氨麻药的 | Lactulose | LACTULOSE | SOLUTION | 10 G/15ML | COVERED | FORMULARY | |
30.962 | 68.217 | 401000 -氨麻药的 | Lactulose | LACTULOSE | SOLUTION | 20 G/30ML | COVERED | FORMULARY | |
30.994 | 68.243 | 401000 -氨麻药的 | 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 -噻嗪类利尿剂 | Microzide | HYDROCHLOROTHIAZIDE | CAPSULE | 12.5 MG | COVERED | FORMULARY | |
842 | 28.915 | 402820 -噻嗪类利尿剂 | Hydrochlorothiazide | HYDROCHLOROTHIAZIDE | TABLET | 12.5 MG | COVERED | FORMULARY | |
34.824 | 8.182 | 402820 -噻嗪类利尿剂 | Hydrochlorothiazide | HYDROCHLOROTHIAZIDE | TABLET | 25 MG | COVERED | FORMULARY | |
34.825 | 8.183 | 402820 -噻嗪类利尿剂 | 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 -促进尿酸排泄的代理 | 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 | 异丙嗪VC可待因 | 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 | 丙酸 | AER W/ADAP | 110 MCG | COVERED | FORMULARY | |
53.638 | 21.253 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent HFA | 丙酸 | AER W/ADAP | 44 MCG | COVERED | FORMULARY | |
53.639 | 21.483 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent HFA | 丙酸 | 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 -抗过敏药制剂 | Azelastine | AZELASTINE HCL | SPRAY/PUMP | 137 MCG | COVERED | FORMULARY | |
60.544 | 29.893 | 520200 -抗过敏药制剂 | Astelin Nasal Spray | AZELASTINE HCL | SPRAY/PUMP | 137 MCG | COVERED | FORMULARY | |
68.321 | 30.796 | 520200 -抗过敏药制剂 | 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毫克/ ML-UNIT / ML - % | COVERED | FORMULARY | |
14.025 | 48.559 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Polymyxin-HC耳 Drops | NEOMYCIN-POLYMYXIN B-HYDROCORTISONE | DROPS SUSP | 3.5-10000-1毫克/ ML-UNIT / ML - % | COVERED | FORMULARY | |
14.023 | 48.557 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Polymyxin-HC耳 | NEOMYCIN-POLYMYXIN B-HYDROCORTISONE | SOLUTION | 3.5-10000-1毫克/ 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毫克/ ML-UNIT / ML-MG /毫升 | 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 -抗病毒药物(事件) | 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 | 醋酸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 | 丙酸 | 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 | 强的松龙sod磷酸 | 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氨丁三醇 | DROPS | 0.4 % | COVERED | FORMULARY | |
52.700 | 19.067 | 520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS | Acular | KETOROLAC氨丁三醇 | 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(苯扎) | 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代理 | Lomotil | 苯乙哌啶HCL-ATROPINE | LIQUID | 2.5-0.025 MG/5ML | COVERED | FORMULARY | |
65.030 | 2.841 | 560800 - antidiarrhea代理 | Lomotil | 苯乙哌啶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 | 聚乙二醇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 | 没错,加维里特,特里里特 | 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 | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 6K-19K-30K | NOT COVERED | PAP | Contact manufacturer for PAP |
26.177 | 65.329 | 561600-DIGESTANTS | Creon | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 12K-38K-60 | NOT COVERED | PAP | Contact manufacturer for PAP |
26.178 | 65.330 | 561600-DIGESTANTS | Creon | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 24-76-120K | NOT COVERED | PAP | Contact manufacturer for PAP |
30.217 | 67.625 | 561600-DIGESTANTS | Creon | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 3-9.5-15K | NOT COVERED | PAP | Contact manufacturer for PAP |
34.557 | 70.893 | 561600-DIGESTANTS | Creon | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 36-114-180 | NOT COVERED | PAP | Contact manufacturer for PAP |
42.317 | 76.625 | 561600-DIGESTANTS | Pancreaze | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 16.8-56.8K | NOT COVERED | PAP | Contact manufacturer for PAP |
42.318 | 76.626 | 561600-DIGESTANTS | Pancreaze | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 21 K-54.7K | NOT COVERED | PAP | Contact manufacturer for PAP |
42.319 | 76.627 | 561600-DIGESTANTS | Pancreaze | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 10.5-35.5K | NOT COVERED | PAP | Contact manufacturer for PAP |
42.324 | 76.628 | 561600-DIGESTANTS | Pancreaze | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 4.2K-14.2K | NOT COVERED | PAP | Contact manufacturer for PAP |
42.596 | 76.797 | 561600-DIGESTANTS | Pancreaze | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 2.6 K-6.2K | NOT COVERED | PAP | Contact manufacturer for PAP |
27.726 | 65.700 | 561600-DIGESTANTS | Zenpep | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 5K-17K-27K | NOT COVERED | PAP | Contact manufacturer for PAP |
27.727 | 65.701 | 561600-DIGESTANTS | Zenpep | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 10-34-55K | NOT COVERED | PAP | Contact manufacturer for PAP |
27.728 | 65.702 | 561600-DIGESTANTS | Zenpep | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 15-51-82K | NOT COVERED | PAP | Contact manufacturer for PAP |
27.729 | 65.703 | 561600-DIGESTANTS | Zenpep | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 20-68-109K | NOT COVERED | PAP | Contact manufacturer for PAP |
30.597 | 67.944 | 561600-DIGESTANTS | Zenpep | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 3K-10K-16K | NOT COVERED | PAP | Contact manufacturer for PAP |
30.598 | 67.945 | 561600-DIGESTANTS | Zenpep | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 25-85-136K | NOT COVERED | PAP | Contact manufacturer for PAP |
37.592 | 73.217 | 561600-DIGESTANTS | Zenpep | 脂肪酶、蛋白酶、淀粉酶 | 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 | 普鲁氯嗪顺丁烯二酸盐 | TABLET | 10 MG | COVERED | FORMULARY | |
14.773 | 3.848 | 562208-ANTIHISTAMINES (GI DRUGS) | Prochlorperazine | 普鲁氯嗪顺丁烯二酸盐 | 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代理 | Metoclopramide | METOCLOPRAMIDE HCL | SOLUTION | 5 MG/5ML | COVERED | FORMULARY | |
34.798 | 71.108 | 563200 - prokinetic代理 | Metoclopramide | METOCLOPRAMIDE HCL | SOLUTION | 10 MG/10ML | COVERED | FORMULARY | |
21.020 | 5.231 | 563200 - prokinetic代理 | Reglan | METOCLOPRAMIDE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
21.021 | 5.232 | 563200 - prokinetic代理 | 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 | 醋酸氟氢可的松 | 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 | 强的松龙sod磷酸 | 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 | 恩斯特,特里沃拉,麦兹拉 | 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 | 布雷维康,莫迪康,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 | 1.5 mg-30微克(21)/ 75毫克(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 - g - 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 | |
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 | |
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 | 胰岛素NPH人异黄酮 | 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快速笔 | 胰岛素npl -胰岛素lispro | INSULN PEN | 75-25 UNIT/ML | NOT COVERED | NON-FORMULARY | |
22.681 | 47.172 | 682008-INSULINS | Humalog 75/25 | 胰岛素npl -胰岛素lispro | VIAL | 75-25 UNIT/ML | NOT COVERED | NON-FORMULARY | |
11.642 | 1.723 | 682008-INSULINS | Novolin R | 胰岛素正常人 | 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盐酸 | TABLET | 2.5-250 MG | COVERED | FORMULARY | |
18.367 | 51.195 | 682020-SULFONYLUREAS | Glipizide-Metformin | GLIPIZIDE-METFORMIN盐酸 | TABLET | 2.5-500 MG | COVERED | FORMULARY | |
18.368 | 51.196 | 682020-SULFONYLUREAS | Glipizide-Metformin | GLIPIZIDE-METFORMIN盐酸 | 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盐酸 | TABLET | 1.25-250 MG | COVERED | FORMULARY | |
89.879 | 45.930 | 682020-SULFONYLUREAS | Glucovance | GLYBURIDE-METFORMIN盐酸 | TABLET | 5-500 MG | COVERED | FORMULARY | |
92.889 | 22.735 | 682020-SULFONYLUREAS | Glucovance | GLYBURIDE-METFORMIN盐酸 | 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 | 胰高血糖素人重组蛋白 | KIT | 1 MG | NOT COVERED | NON-FORMULARY | |
25.473 | 41.660 | 682212-GLYCOGENOLYTIC AGENTS | Glucagen | 胰高血糖素人重组蛋白 | VIAL | 1 MG | COVERED | FORMULARY | |
23.281 | 24.138 | 682400-PARATHYROID | Miacalcin Nasal | 鲑鱼合成降钙素 | 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 | 醋酸甲羟孕酮 | TABLET | 10 MG | COVERED | FORMULARY | |
11.261 | 3.272 | 683200-PROGESTINS | Provera | 醋酸甲羟孕酮 | TABLET | 2.5 MG | COVERED | FORMULARY | |
11.262 | 3.273 | 683200-PROGESTINS | Provera | 醋酸甲羟孕酮 | 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 | 孕酮微缩 | 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 -抗甲状腺药物 | Tapazole | METHIMAZOLE | TABLET | 10 MG | COVERED | FORMULARY | |
26.401 | 6.675 | 683608 -抗甲状腺药物 | 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) | 红霉素与乙醇 | 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) | 三联抗生素软膏 | 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 -抗病毒药物(皮肤 & MUCOUS MEMBRANE) | Zovirax | ACYCLOVIR | CREAM (G) | 5 % | COVERED | FORMULARY | |
31.640 | 7.670 | 840406 -抗病毒药物(皮肤 & MUCOUS MEMBRANE) | Zovirax | ACYCLOVIR | OINT. (G) | 5 % | COVERED | FORMULARY | |
12.618 | 44.922 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Ciclopirox | CICLOPIROX | GEL (GRAM) | 0.77 % | COVERED | FORMULARY | |
19.218 | 51.825 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Loprox Shampoo | CICLOPIROX | SHAMPOO | 1 % | COVERED | FORMULARY | |
8.040 | 37.020 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Ciclodan, Penlac | CICLOPIROX | SOLUTION | 8 % | COVERED | FORMULARY | |
94.677 | 40.971 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Ciclopirox Olamine | CICLOPIROX OLAMINE | CREAM (G) | 0.77 % | COVERED | FORMULARY | |
30.380 | 7.362 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Clotrimazole | CLOTRIMAZOLE | SOLUTION | 1 % | COVERED | FORMULARY | |
7.590 | 9.553 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Mycelex | CLOTRIMAZOLE | TROCHE | 10 MG | COVERED | FORMULARY | |
6.919 | 36.534 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Lotrisone | CLOTRIMAZOLE-倍他米松DIPROPIONATE | CREAM (G) | 1-0.05 % | COVERED | FORMULARY | |
14.125 | 48.627 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Clotrimazole-Betamethasone | CLOTRIMAZOLE-倍他米松DIPROPIONATE | LOTION | 1-0.05 % | COVERED | FORMULARY | |
31.850 | 7.334 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Ketoconazole | KETOCONAZOLE | CREAM (G) | 2 % | COVERED | FORMULARY | |
31.271 | 15.568 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Nizoral Shampoo | KETOCONAZOLE | SHAMPOO | 2 % | COVERED | FORMULARY | |
30.140 | 7.282 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Nystatin | NYSTATIN | CREAM (G) | 100000 UNIT/G | COVERED | FORMULARY | |
30.150 | 7.283 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Nystatin | NYSTATIN | OINT. (G) | 100000 UNIT/G | COVERED | FORMULARY | |
30.160 | 7.284 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Nystatin | NYSTATIN | POWDER | 100000 UNIT/G | COVERED | FORMULARY | |
14.007 | 48.529 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | 制霉菌素/去炎松 | NYSTATIN-TRIAMCINCINOLONE | CREAM (G) | 100000-0.1 UNIT/G-% | COVERED | FORMULARY | |
14.008 | 48.530 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | 制霉菌素/去炎松 | NYSTATIN-TRIAMCINCINOLONE | OINT. (G) | 100000-0.1 UNIT/G-% | COVERED | FORMULARY | |
48.381 | 15.931 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Terazol 3 | TERCONAZOLE | CREAM/APPL | 0.8 % | COVERED | FORMULARY | |
48.380 | 7.008 | (840408 -抗真菌治疗皮肤 & 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 | 倍他米松DIPROPIONATE | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
31.080 | 7.570 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Betamethasone Diproprionate | 倍他米松DIPROPIONATE | LOTION | 0.05 % | COVERED | FORMULARY | |
31.070 | 7.569 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Betamethasone Diproprionate | 倍他米松DIPROPIONATE | OINT. (G) | 0.05 % | COVERED | FORMULARY | |
31.101 | 7.572 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | 倍他米松戊酸酯 | 倍他米松戊酸酯 | CREAM (G) | 0.1 % | COVERED | FORMULARY | |
31.120 | 7.574 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | 倍他米松戊酸酯 | 倍他米松戊酸酯 | LOTION | 0.1 % | COVERED | FORMULARY | |
31.110 | 7.573 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | 倍他米松戊酸酯 | 倍他米松戊酸酯 | 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) | 皮肤光滑- fs头皮油 | FLUOCINOLONE (WITH SHOWER CAP) | OIL | 0.01 % | COVERED | FORMULARY | |
85.080 | 7.507 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | 皮肤光滑的fs身体油 | 肤轻松醋酸酯 | 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 | 醋酸氢化可的松 | FOAM/APPL | 10 % | COVERED | FORMULARY | |
27.941 | 6.858 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Anusol-HC | 醋酸氢化可的松 | SUPP.RECT | 25 MG | COVERED | FORMULARY | |
31.231 | 7.593 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | CREAM (G) | 0.025 % | COVERED | FORMULARY | |
31.232 | 7.594 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | CREAM (G) | 0.1 % | COVERED | FORMULARY | |
31.233 | 7.595 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | CREAM (G) | 0.5 % | COVERED | FORMULARY | |
31.260 | 7.599 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | LOTION | 0.025 % | COVERED | FORMULARY | |
31.261 | 7.600 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | LOTION | 0.1 % | COVERED | FORMULARY | |
31.241 | 7.596 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | OINT. (G) | 0.025 % | COVERED | FORMULARY | |
31.242 | 7.597 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | OINT. (G) | 0.1 % | COVERED | FORMULARY | |
31.243 | 15.542 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | OINT. (G) | 0.05 % | COVERED | FORMULARY | |
31.244 | 7.598 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | 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 | 维甲酸微球 | GEL (GRAM) | 0.04 % | COVERED | FORMULARY | |
22.874 | 30.614 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A Micro | 维甲酸微球 | GEL (GRAM) | 0.1 % | COVERED | FORMULARY | |
31.776 | 68.881 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A Micro Pump | 维甲酸微球 | GEL W/PUMP | 0.04 % | COVERED | FORMULARY | |
31.777 | 68.882 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A Micro Pump | 维甲酸微球 | GEL W/PUMP | 0.1 % | COVERED | FORMULARY | |
63.447 | 45.214 | 841600-CELL STIMULANTS AND PROLIFERANTS | Refissa | TRETINOIN-EMOLLIENT基地 | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
22.931 | 5.813 | 842800 -角质层分离的代理 | Benzoyl Peroxide | BENZOYL PEROXIDE | GEL (GRAM) | 5 % | COVERED | FORMULARY | |
24.774 | 16.308 | 842800 -角质层分离的代理 | 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 | 茶碱无水 | TAB ER 12H | 100 MG | COVERED | FORMULARY | |
411 | 91 | 861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS | Theophylline ER | 茶碱无水 | TAB ER 12H | 200 MG | COVERED | FORMULARY | |
413 | 93 | 861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS | Theophylline ER | 茶碱无水 | 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 | 麦角钙化醇(维生素d2) | CAPSULE | 50000 UNIT | COVERED | FORMULARY | |
94.711 | 2.305 | 882400维生素k活性 | Mephyton | PHYTONADIONE | TABLET | 5 MG | COVERED | FORMULARY | |
2.881 | 1.192 | 920400 -酒精威慑 | 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代理 | Zyloprim | ALLOPURINOL | TABLET | 100 MG | COVERED | FORMULARY | |
7.071 | 2.536 | 921600 - antigout代理 | Zyloprim | ALLOPURINOL | TABLET | 300 MG | COVERED | FORMULARY | |
35.674 | 8.334 | 921600 - antigout代理 | 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 | 血糖控制低 | 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血糖仪 | BLOOD-GLUCOSE METER | EACH | COVERED | FORMULARY | ||
94.200 | 19.413 | 940000-DEVICES | True Metrix血糖仪 | BLOOD-GLUCOSE METER | EACH | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | 航空舱加上Flow-Vu | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | 航空舱加上Flow-Vu Mask, Large | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | 航空舱加上Flow-Vu Mask, Medium | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | 航空舱加上Flow-Vu Mask, Small | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Optichamber Diamond VHC | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Optichamber Diamond VHC with Large Mask | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Optichamber Diamond VHC with Medium Mask | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Optichamber Diamond VHC with Small Mask | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 64.800 | 940000-DEVICES | Optichamber大面罩 | INHALER ASSIST DEVICE ACCESORY | EACH | COVERED | FORMULARY | ||
94.200 | 64.800 | 940000-DEVICES | Optichamber介质掩膜 | 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 | 钢笔针29g X 1/2” | PEN NEEDLE DIABETIC | DIS NEEDLE | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.235 | 940000-DEVICES | 钢笔针29g X 1/2” | PEN NEEDLE DIABETIC | DIS NEEDLE | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.235 | 940000-DEVICES | 钢笔针29g X 1/2” | PEN NEEDLE DIABETIC | DIS NEEDLE | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.235 | 940000-DEVICES | 钢笔针29g X 1/2” | PEN NEEDLE DIABETIC | DIS NEEDLE | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.235 | 940000-DEVICES | 钢笔针29g X 1/2” | PEN NEEDLE DIABETIC | DIS NEEDLE | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 61.638 | 940000-DEVICES | 钢笔针30g x 1/3” | PEN NEEDLE DIABETIC | DIS NEEDLE | 30 G X 1/3" | COVERED | FORMULARY | |
94.200 | 61.638 | 940000-DEVICES | 钢笔针30g 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 | 钢笔针31g × 3/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | 钢笔针31g × 3/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | 钢笔针31g × 3/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | 钢笔针31g × 3/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | 钢笔针31g × 3/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | 钢笔针31g × 3/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | 钢笔针31g × 3/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | 钢笔针31g × 3/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | PEN NEEDLE DIABETIC | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 62.868 | 940000-DEVICES | 钢笔针32g × 1/4” | PEN NEEDLE DIABETIC | DIS NEEDLE | 32 G X 1/4" | COVERED | FORMULARY | |
94.200 | 66.936 | 940000-DEVICES | 钢笔针32g X 1/5” | PEN NEEDLE DIABETIC | DIS NEEDLE | 32 G X 1/5" | COVERED | FORMULARY | |
94.200 | 72.859 | 940000-DEVICES | 钢笔针32g × 1/6” | PEN NEEDLE DIABETIC | DIS NEEDLE | 32 G X 1/6" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | 钢笔针32g × 5/32” | PEN NEEDLE DIABETIC | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | 钢笔针32g × 5/32” | PEN NEEDLE DIABETIC | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | 钢笔针32g × 5/32” | PEN NEEDLE DIABETIC | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | 钢笔针32g × 5/32” | PEN NEEDLE DIABETIC | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | 钢笔针32g × 5/32” | PEN NEEDLE DIABETIC | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | 钢笔针32g × 5/32” | PEN NEEDLE DIABETIC | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | 钢笔针32g × 5/32” | PEN NEEDLE DIABETIC | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 62.772 | 940000-DEVICES | 钢笔针30g 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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | Insulin Syringe 0.3mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | Insulin Syringe 0.5mL 28GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | Insulin Syringe 0.5mL 28GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | Insulin Syringe 0.5mL 28GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | Insulin Syringe 0.5mL 28GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | Insulin Syringe 0.5mL 28GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | Insulin Syringe 0.5mL 28GX1/2" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX 5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX 5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX 5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX 5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX 5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX 5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.400 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.400 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.400 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.400 | 940000-DEVICES | Insulin Syringe 0.5mL 30GX1/2" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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 | 磷霉素氨丁三醇 | 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酸乙酯 | CAPSULE | 1 G | NOT COVERED | NON-FORMULARY | 规定:非诺贝特 |
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 | 替米沙坦/氨氯地平 | TABLET | 40 MG-5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
27.784 | 65.747 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Twynsta | 替米沙坦/氨氯地平 | TABLET | 40 MG-10MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
27.785 | 65.748 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Twynsta | 替米沙坦/氨氯地平 | TABLET | 80 MG-5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
27.786 | 65.749 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Twynsta | 替米沙坦/氨氯地平 | 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 -阿片受体激动剂 | Duragesic | FENTANYL | PATCH TD72 | 25 MCG/HR | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
19.201 | 15.881 | 280808 -阿片受体激动剂 | Duragesic | FENTANYL | PATCH TD72 | 50MCG/HR | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
19.202 | 15.882 | 280808 -阿片受体激动剂 | Duragesic | FENTANYL | PATCH TD72 | 75MCG/HR | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
19.203 | 15.883 | 280808 -阿片受体激动剂 | Duragesic | FENTANYL | PATCH TD72 | 100 MCG/HR | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
16.281 | 15.065 | 280808 -阿片受体激动剂 | Oxyocodone集中 | OXYCODONE HCL | ORAL CONC | 20 MG/ML | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
16.280 | 4.224 | 280808 -阿片受体激动剂 | Oxycodone Solution | OXYCODONE HCL | SOLUTION | 5 MG/5 ML | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
41.853 | 76.361 | 280808 -阿片受体激动剂 | 羟考酮口服注射器 | OXYCODONE HCL | SYRINGE | 10MG/0.5ML | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
16.291 | 13.467 | 280808 -阿片受体激动剂 | Oxyocodone | OXYCODONE HCL | TABLET | 10 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
20.091 | 46.474 | 280808 -阿片受体激动剂 | Oxyocodone | OXYCODONE HCL | TABLET | 15 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
21.194 | 45.298 | 280808 -阿片受体激动剂 | Oxyocodone | OXYCODONE HCL | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
20.092 | 46.475 | 280808 -阿片受体激动剂 | Oxyocodone | OXYCODONE HCL | TABLET | 30 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
32.047 | 69.101 | 280808 -阿片受体激动剂 | Oxaydo | OXYCODONE HCL | TABLET ORL | 5 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
31.256 | 68.467 | 280808 -阿片受体激动剂 | 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 | 配方:电容,电容 |
27.095 | 60.935 | 281000年鸦片拮抗剂 | Vivitrol | 环丙甲羟二羟吗啡酮微球 | SUS ER REC | 380MG | NOT COVERED | NON-FORMULARY | Formulary: Naltrexone tablet |
16.356 | 46.216 | 281604 -抗抑郁药 | Sarafem | FLUOXETINE HCL | TABLET | 10 MG | NOT COVERED | NON-FORMULARY | Formulary: capsules |
16.359 | 46.219 | 281604 -抗抑郁药 | Sarafem | FLUOXETINE HCL | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: capsules |
14.349 | 64.444 | 281604 -抗抑郁药 | Venlafaxine ER | VENLAFAXINE HCL | TAB ER 24 | 37.5 MG | NOT COVERED | NON-FORMULARY | Formulary: capsules |
14.352 | 64.445 | 281604 -抗抑郁药 | Venlafaxine ER | VENLAFAXINE HCL | TAB ER 24 | 75 MG | NOT COVERED | NON-FORMULARY | Formulary: capsules |
14.353 | 64.446 | 281604 -抗抑郁药 | Venlafaxine ER | VENLAFAXINE HCL | TAB ER 24 | 150 MG | NOT COVERED | NON-FORMULARY | Formulary: capsules |
14.354 | 64.447 | 281604 -抗抑郁药 | 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 | 异丙嗪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 | 醋酸氟西诺酮油 | 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 | 规定:Pantoprazole |
1.698 | 30.107 | 562836-PROTON-PUMP INHIBITORS | Prevacid | LANSOPRAZOLE | CAPSULE DR | 30 MG | NOT COVERED | NON-FORMULARY | 规定:Pantoprazole |
4.348 | 33.530 | 562836-PROTON-PUMP INHIBITORS | Prilosec | OMEPRAZOLE | CAPSULE DR | 20 MG | NOT COVERED | NON-FORMULARY | 规定:Pantoprazole |
92.989 | 43.136 | 562836-PROTON-PUMP INHIBITORS | Prilosec | OMEPRAZOLE | CAPSULE DR | 10 MG | NOT COVERED | NON-FORMULARY | 规定:Pantoprazole |
92.999 | 43.137 | 562836-PROTON-PUMP INHIBITORS | Prilosec | OMEPRAZOLE | CAPSULE DR | 40 MG | NOT COVERED | NON-FORMULARY | 规定:Pantoprazole |
94.639 | 40.941 | 562836-PROTON-PUMP INHIBITORS | Aciphex | RABEPRAZOLE SODIUM | TABLET DR | 20 MG | NOT COVERED | NON-FORMULARY | 规定:Pantoprazole |
30.220 | 19.863 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Pentasa CR | MESALAMINE | CAPSULE ER | 250 MG | NOT COVERED | PAP | 规定:柳氮磺胺吡啶. 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 | 规定:柳氮磺胺吡啶. 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: Levemir |
35.837 | 71.843 | 682008-INSULINS | Tresiba FlexTouch | INSULIN DEGLUDEC | INSULN PEN | 200/ML (3) | NOT COVERED | NON-FORMULARY | Formulary: Levemir |
11.660 | 1.740 | 682008-INSULINS | Humulin N | 胰岛素NPH人异黄酮 | 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 | 配方:诺沃林70/30 |
11.642 | 1.723 | 682008-INSULINS | Humulin R | 胰岛素正常人 | VIAL | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | Formulary: Novolin R |
50.776 | 43.801 | 683200-PROGESTINS | Prometrium | 孕激素,让 | CAPSULE | 100 MG | NOT COVERED | NON-FORMULARY | Formulary: Provera |
50.786 | 43.802 | 683200-PROGESTINS | Prometrium | 孕激素,让 | 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 | 林多卡因肛肠乳膏 | 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 | 4%利多卡因乳膏是非处方药 |
24.882 | 6.312 | 845004 -脱色剂 | ESOTERICA FADE CREAM | HYDROQUINONE | CREAM (G) | 2% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
24.883 | 6.313 | 845004 -脱色剂 | MELQUIN HP 4% CREAM | HYDROQUINONE | CREAM (G) | 4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
47.830 | 6.314 | 845004 -脱色剂 | HYDROQUINONE 4% CREAM | HYDROQUINONE | POWDER | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone | |
24.890 | 6.315 | 845004 -脱色剂 | HYDROQUINONE POWDER | HYDROQUINONE | SOLUTION | 30 MG/ML | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
20.120 | 52.863 | 845004 -脱色剂 | NUQUIN HP 4% CREAM | 苯二酚微球 | CRM ER (G) | 4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
97.674 | 61.889 | 845004 -脱色剂 | ESOTERICA FADE CREAM | HYDROQUINONE/AVOBENZ/OCTINOX | EMUL ADHES | 4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
21.864 | 54.046 | 845004 -脱色剂 | ALPHAQUIN HP 4% CREAM | HYDROQUINONE/AVOBENZ/OCTINOX | EMULSN(G) | 4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
20.915 | 53.438 | 845004 -脱色剂 | 对苯二酚tr 4%乳霜 | HYDROQUINONE/OXYBEN/OCTINOXATE | CREAM (G) | 4%(5-7.5%) | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
97.229 | 61.438 | 845004 -脱色剂 | ACLARO 4% EMULSION | HYDROQUINONE/OXYBENZONE/PADIMA | CREAM (G) | 2%-SPF10 | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
66.899 | 31.427 | 845004 -脱色剂 | MELQUIN-3 SOLUTION | HYDROQUINONE/SUNSCREEN(FER OX) | CREAM (G) | 4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
96.071 | 39.542 | 848000 -防晒剂 | 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氢溴酸盐 | TAB ER 24H | 7.5 MG | NOT COVERED | NON-FORMULARY | 处方:奥施布宁ER |
24.044 | 58.577 | 861204-ANTIMUSCARINICS | Enablex | DARIFENACIN氢溴酸盐 | TAB ER 24H | 15 MG | NOT COVERED | NON-FORMULARY | 处方:奥施布宁ER |
99.193 | 63.466 | 861204-ANTIMUSCARINICS | Sanctura XR | TROSPIUM CHLORIDE | CAP ER 24H | 60 MG | NOT COVERED | NON-FORMULARY | 处方:奥施布宁ER |
8.744 | 38.085 | 861204-ANTIMUSCARINICS | Sanctura | TROSPIUM CHLORIDE | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | 处方:奥施布宁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盐酸 | 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 | 规定:Alendronate |
17.378 | 50.364 | 922400-BONE RESORPTION INHIBITORS | Actonel | RISEDRONATE SODIUM | TABLET | 35 MG | NOT COVERED | NON-FORMULARY | 规定:Alendronate |
92.238 | 45.102 | 922400-BONE RESORPTION INHIBITORS | Actonel | RISEDRONATE SODIUM | TABLET | 5 MG | NOT COVERED | NON-FORMULARY | 规定: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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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" | 注射器w-ndl滴剂胰岛素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 -氨基糖甙类 | Tobi Podhaler | TOBRAMYCIN | CAP W/DEV | 28 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
61.551 | 37.042 | 081202 -氨基糖甙类 | 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年的今天,抗逆转录病毒药物 | Tivicay | DOLUTEGRAVIR SODIUM | TABLET | 50 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
41.564 | 76.226 | 081808年的今天,抗逆转录病毒药物 | Tivicay | DOLUTEGRAVIR SODIUM | TABLET | 10 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
41.566 | 76.227 | 081808年的今天,抗逆转录病毒药物 | Tivicay | DOLUTEGRAVIR SODIUM | TABLET | 25 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
23.152 | 57.883 | 081808年的今天,抗逆转录病毒药物 | Truvada | EMTRICITABINE/TENOFOVIR (TDF) | TABLET | 200-300 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
41.369 | 76.097 | 081808年的今天,抗逆转录病毒药物 | Truvada | EMTRICITABINE/TENOFOVIR (TDF) | TABLET | 100-150 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
41.375 | 76.101 | 081808年的今天,抗逆转录病毒药物 | Truvada | EMTRICITABINE/TENOFOVIR (TDF) | TABLET | 133-200 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
41.376 | 76.102 | 081808年的今天,抗逆转录病毒药物 | Truvada | EMTRICITABINE/TENOFOVIR (TDF) | TABLET | 167-250 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
97.430 | 61.644 | 081808年的今天,抗逆转录病毒药物 | Reyataz | ATAZANAVIR SULFATE | CAPSULE | 300 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
15.555 | 49.849 | 081808年的今天,抗逆转录病毒药物 | Sustiva | EFAVIRENZ | TABLET | 600 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
31.227 | 68.449 | 081808年的今天,抗逆转录病毒药物 | Viread | TENOFOVIR DISOPROXIL FUMARATE | POWDER | 40 MG/SCOOP | NOT COVERED | NON-FORMULARY | |
14.822 | 48.843 | 081808年的今天,抗逆转录病毒药物 | Viread | TENOFOVIR DISOPROXIL FUMARATE | TABLET | 300 MG | NOT COVERED | NON-FORMULARY | |
31.228 | 68.450 | 081808年的今天,抗逆转录病毒药物 | Viread | TENOFOVIR DISOPROXIL FUMARATE | TABLET | 150 MG | NOT COVERED | NON-FORMULARY | |
31.229 | 68.451 | 081808年的今天,抗逆转录病毒药物 | Viread | TENOFOVIR DISOPROXIL FUMARATE | TABLET | 200 MG | NOT COVERED | NON-FORMULARY | |
31.234 | 68.453 | 081808年的今天,抗逆转录病毒药物 | 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起始月包 | 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 -造血代理 | Epogen, Procrit | EPOETIN ALFA | VIAL | 20000/2ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.110 | 11.740 | 201600 -造血代理 | Epogen, Procrit | EPOETIN ALFA | VIAL | 2000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.111 | 11.741 | 201600 -造血代理 | Epogen, Procrit | EPOETIN ALFA | VIAL | 4000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.112 | 11.742 | 201600 -造血代理 | Epogen, Procrit | EPOETIN ALFA | VIAL | 10000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.113 | 15.164 | 201600 -造血代理 | Epogen, Procrit | EPOETIN ALFA | VIAL | 3000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.114 | 25.708 | 201600 -造血代理 | Epogen, Procrit | EPOETIN ALFA | VIAL | 20000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.115 | 41.394 | 201600 -造血代理 | 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 | 处方:卡维地洛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 | 处方:卡维地洛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 | 处方:卡维地洛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 | 处方:卡维地洛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 irbesartan or Lotrel, Contact manufacturer for PAP |
97.963 | 62.181 | 242808 - dihydropyridines | Exforge | AMLODIPINE/VALSARTAN | TABLET | 10-160 MG | NOT COVERED | PAP | Prescribe amlodipine and irbesartan or Lotrel, Contact manufacturer for PAP |
98.579 | 62.808 | 242808 - dihydropyridines | Exforge | AMLODIPINE/VALSARTAN | TABLET | 5-320 MG | NOT COVERED | PAP | Prescribe amlodipine and irbesartan or Lotrel, Contact manufacturer for PAP |
98.580 | 62.809 | 242808 - dihydropyridines | Exforge | AMLODIPINE/VALSARTAN | TABLET | 10-320 MG | NOT COVERED | PAP | Prescribe amlodipine and irbesartan or Lotrel, Contact manufacturer for PAP |
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 -阿片受体激动剂 | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 10 MG | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
37.159 | 72.863 | 280808 -阿片受体激动剂 | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 15 MG | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
37.161 | 72.864 | 280808 -阿片受体激动剂 | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
37.162 | 72.865 | 280808 -阿片受体激动剂 | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 30 MG | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
37.163 | 72.866 | 280808 -阿片受体激动剂 | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 40 MG | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
37.164 | 72.867 | 280808 -阿片受体激动剂 | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 60 MG | NOT COVERED | NON-FORMULARY | Formulary: Morphine |
37.165 | 72.868 | 280808 -阿片受体激动剂 | 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 | 处方:拉莫三嗪. Contact manufacturer for PAP |
24.739 | 65.253 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 200 MG | NOT COVERED | PAP | 处方:拉莫三嗪. Contact manufacturer for PAP |
24.697 | 65.251 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 50 MG | NOT COVERED | PAP | 处方:拉莫三嗪. Contact manufacturer for PAP |
24.703 | 65.252 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 100 MG | NOT COVERED | PAP | 处方:拉莫三嗪. Contact manufacturer for PAP |
29.725 | 67.221 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 300 MG | NOT COVERED | PAP | 处方:拉莫三嗪. Contact manufacturer for PAP |
30.787 | 68.093 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 250 MG | NOT COVERED | PAP | 处方:拉莫三嗪. Contact manufacturer for PAP |
14.305 | 64.416 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra XR | LEVETIRACETAM | TAB ER 24H | 500 MG | NOT COVERED | NON-FORMULARY | 处方:左乙拉西坦IR. |
20.765 | 64.990 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra XR | LEVETIRACETAM | TAB ER 24H | 750 MG | NOT COVERED | NON-FORMULARY | 处方:左乙拉西坦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 -抗抑郁药 | Fetzima | LEVOMILNACIPRAN HYDROCHLORIDE | CAP SA 24H | 40 MG | NOT COVERED | NON-FORMULARY | Formulary: Venlafaxine ER capsules, Duloxetine DR. |
35.327 | 71.495 | 281604 -抗抑郁药 | Fetzima | LEVOMILNACIPRAN HYDROCHLORIDE | CAP SA 24H | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Venlafaxine ER capsules, Duloxetine DR. |
35.329 | 71.497 | 281604 -抗抑郁药 | Fetzima | LEVOMILNACIPRAN HYDROCHLORIDE | CAP SA 24H | 80 MG | NOT COVERED | NON-FORMULARY | Formulary: Venlafaxine ER capsules, Duloxetine DR. |
35.334 | 71.498 | 281604 -抗抑郁药 | Fetzima | LEVOMILNACIPRAN HYDROCHLORIDE | CAP SA 24H | 120 MG | NOT COVERED | NON-FORMULARY | Formulary: Venlafaxine ER capsules, Duloxetine DR. |
35.335 | 71.499 | 281604 -抗抑郁药 | Fetzima | LEVOMILNACIPRAN HYDROCHLORIDE | CAP24HDSPK | 20-40 MG | NOT COVERED | NON-FORMULARY | Formulary: Venlafaxine ER capsules, Duloxetine DR. |
20.869 | 53.401 | 281604 -抗抑郁药 | Symbyax | 奥氮平/盐酸氟西汀 | CAPSULE | 6-50 MG | NOT COVERED | PAP | Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP |
20.868 | 53.400 | 281604 -抗抑郁药 | Symbyax | 奥氮平/盐酸氟西汀 | CAPSULE | 6-25 MG | NOT COVERED | PAP | Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP |
20.870 | 53.402 | 281604 -抗抑郁药 | Symbyax | 奥氮平/盐酸氟西汀 | CAPSULE | 12-25 MG | NOT COVERED | PAP | Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP |
20.872 | 53.403 | 281604 -抗抑郁药 | Symbyax | 奥氮平/盐酸氟西汀 | CAPSULE | 12-50 MG | NOT COVERED | PAP | Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP |
98.648 | 62.878 | 281604 -抗抑郁药 | Symbyax | 奥氮平/盐酸氟西汀 | CAPSULE | 3-25 MG | NOT COVERED | PAP | Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP |
38.253 | 73.810 | 281604 -抗抑郁药 | 弧菌滴定包 | 维拉佐酮盐酸盐 | TAB DS PK | 10 MG-20 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
29.918 | 67.378 | 281604 -抗抑郁药 | Viibryd | 维拉佐酮盐酸盐 | TABLET | 40 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
29.916 | 67.376 | 281604 -抗抑郁药 | Viibryd | 维拉佐酮盐酸盐 | TABLET | 10 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
29.917 | 67.377 | 281604 -抗抑郁药 | Viibryd | 维拉佐酮盐酸盐 | 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 | 规定:利培酮. Contact manufacturer for PAP |
97.770 | 61.986 | 281608-ANTIPSYCHOTIC AGENTS | Invega | PALIPERIDONE | TAB ER 24 | 6 MG | NOT COVERED | PAP | 规定:利培酮. Contact manufacturer for PAP |
97.771 | 61.987 | 281608-ANTIPSYCHOTIC AGENTS | Invega | PALIPERIDONE | TAB ER 24 | 9 MG | NOT COVERED | PAP | 规定:利培酮. Contact manufacturer for PAP |
27.685 | 65.667 | 281608-ANTIPSYCHOTIC AGENTS | Invega | PALIPERIDONE | TAB ER 24 | 1.5 MG | NOT COVERED | PAP | 规定:利培酮. 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 | 处方:胍法辛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 | 处方:胍法辛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 | 处方:胍法辛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 | 处方:胍法辛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 -甲状腺功能 | Thyrogen | THYROTROPIN ALFA | VIAL | 1.1 MG | NOT COVERED | PAP | |
43.725 | 77.644 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | QVAR Redihaler | 二丙酸倍氯米松 | HFA AEROBA | 80 MCG | NOT COVERED | PAP | 配方:芳香HFA. Contact manufacturer for PAP |
43.724 | 77.643 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | QVAR Redihaler | 二丙酸倍氯米松 | HFA AEROBA | 40 MCG | NOT COVERED | PAP | 配方:芳香HFA. Contact manufacturer for PAP |
98.024 | 62.240 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Pulmicort Flexhaler | BUDESONIDE | AER POW BA | 90 MCG | NOT COVERED | PAP | 配方:芳香HFA. Contact manufacturer for PAP |
98.025 | 62.241 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Pulmicort Flexhaler | BUDESONIDE | AER POW BA | 180 MCG | NOT COVERED | PAP | 配方:芳香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 | 配方:芳香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 | 配方:芳香HFA, DuleraContact manufacturer for PAP |
53.633 | 19.317 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent DIKUS | 丙酸 | BLST W/DEV | 100 MCG | NOT COVERED | PAP | 配方:芳香HFA. Contact manufacturer for PAP |
53.634 | 19.318 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent DIKUS | 丙酸 | BLST W/DEV | 250 MCG | NOT COVERED | PAP | 配方:芳香HFA. Contact manufacturer for PAP |
53.635 | 19.319 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent DIKUS | 丙酸 | BLST W/DEV | 50 MCG | NOT COVERED | PAP | 配方:芳香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 | 配方:芳香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 | 配方:芳香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 | 配方:芳香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 | 配方:芳香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 | 配方:芳香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 | 配方:芳香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 | 配方:芳香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 | 配方:芳香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 | 配方:芳香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 | 配方:芳香HFA. Contact manufacturer for PAP |
40.321 | 29.803 | 481024-LEUKOTRIENE MODIFIERS | Zyflo Filmtab | ZILEUTON | TABLET | 600 MG | NOT COVERED | NON-FORMULARY | 规定:Montelukast. |
98.822 | 63.062 | 481024-LEUKOTRIENE MODIFIERS | Zyflo Filmtab | ZILEUTON | TBMP 12HR | 600 MG | NOT COVERED | NON-FORMULARY | 规定: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 | 规定: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 | 规定: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 | 规定: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 | 规定:Pantoprazole. Contact manufacturer for PAP |
16.306 | 64.794 | 562836-PROTON-PUMP INHIBITORS | Dexilant | DEXLANSOPRAZOLE | CAP DR BP | 60 MG | NOT COVERED | PAP | 规定:Pantoprazole. Contact manufacturer for PAP |
16.305 | 64.793 | 562836-PROTON-PUMP INHIBITORS | Dexilant | DEXLANSOPRAZOLE | CAP DR BP | 30 MG | NOT COVERED | PAP | 规定:Pantoprazole. Contact manufacturer for PAP |
16.306 | 64.794 | 562836-PROTON-PUMP INHIBITORS | Dexilant | DEXLANSOPRAZOLE | CAP DR BP | 60 MG | NOT COVERED | PAP | 规定: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 | 规定:柳氮磺胺吡啶. |
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 | 规定:柳氮磺胺吡啶. Contact manufacturer for PAP |
34.113 | 70.543 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Delzicol DR | MESALAMINE | CAPSULE DR | 400 MG | NOT COVERED | PAP | 规定:柳氮磺胺吡啶. Contact manufacturer for PAP |
23.422 | 58.091 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Pentasa | MESALAMINE | CAPSULE ER | 500 MG | NOT COVERED | PAP | 规定:柳氮磺胺吡啶. Contact manufacturer for PAP |
48.490 | 21.776 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Canasa Suppository | MESALAMINE | SUPP.RECT | 1000 MG | NOT COVERED | PAP | 规定:柳氮磺胺吡啶. Contact manufacturer for PAP |
97.842 | 62.058 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Lialda | MESALAMINE | TABLET DR | 1.2 G | NOT COVERED | PAP | 规定:柳氮磺胺吡啶. 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年的今天,肠促胰岛素模拟 | Trulicity | DULAGLUTIDE | PEN INJCTR | 0.75MG/0.5 | NOT COVERED | PAP | 配方:再见,Victoza. Contact manufacturer for PAP |
37.171 | 72.873 | 682006年的今天,肠促胰岛素模拟 | Trulicity | DULAGLUTIDE | PEN INJCTR | 1.5 MG/0.5 | NOT COVERED | PAP | 配方:再见,Victoza. Contact manufacturer for PAP |
44.039 | 77.890 | 682006年的今天,肠促胰岛素模拟 | Bydureon Bcise | EXENATIDE微球 | AUTO INJCT | 2MG/0.85ML | NOT COVERED | PAP | 配方:再见,Victoza. Contact manufacturer for PAP |
36.352 | 72.230 | 682006年的今天,肠促胰岛素模拟 | Bydureon Pen | EXENATIDE微球 | PEN INJCTR | 2MG/0.65ML | NOT COVERED | PAP | 配方:再见,Victoza. Contact manufacturer for PAP |
26.189 | 65.344 | 682006年的今天,肠促胰岛素模拟 | 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: Levemir. 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 | PA's Restricted to Dr. Dubois. Levemir is formulary, 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: Levemir. 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 | 胰岛素正常人 | 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丙二醇 | TABLET | 10 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
35.698 | 71.740 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Farxiga | DAPAGLIFLOZIN丙二醇 | 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 /盐酸二甲双胍 | TABLET | 5MG-1000MG | NOT COVERED | PAP | Contact manufacturer for PAP |
38.932 | 74.318 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Synjardy | EMPAGLIFLOZIN /盐酸二甲双胍 | TABLET | 12.5-1000 | NOT COVERED | PAP | Contact manufacturer for PAP |
39.377 | 74.675 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Synjardy | EMPAGLIFLOZIN /盐酸二甲双胍 | TABLET | 5 MG-500MG | NOT COVERED | PAP | Contact manufacturer for PAP |
39.378 | 74.676 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Synjardy | EMPAGLIFLOZIN /盐酸二甲双胍 | 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 | 孕激素,让 | GEL/PF APP | 4% | NOT COVERED | PAP | Endometrin preferred |
63.011 | 31.769 | 683200-PROGESTINS | Crinone Gel | 孕激素,让 | 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 | 奥施布宁ER优先 |
23.277 | 57.983 | 861204-ANTIMUSCARINICS | Vesicare | SOLIFENACIN SUCCINATE | TABLET | 10 MG | NOT COVERED | PAP | 奥施布宁ER优先 |
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代理 | Uloric | FEBUXOSTAT | TABLET | 40 MG | NOT COVERED | PAP | Allopurinol is formulary, Contact manufacturer for PAP |
16.809 | 64.830 | 921600 - antigout代理 | 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 -保护剂 | 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 /二甲双胍呃 | 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 /二甲双胍呃 | 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 | 仅限于肿瘤学 & 仅限血液学处方医师 |
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 | |
Generic Code | 通用序号 | Therapeutic Class | BrandName | GenericName | Formulation | Strength | Coverage | Location | Comments |