2017 Formulary for North Dakota Medicaid Expansion Members

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "2017 Formulary for North Dakota Medicaid Expansion Members"

Transcription

1 07 Formulary for North Dakota Medicaid Expansion Members Please refer to the following list (formulary) of commonly prescribed medications that are covered by insurance. This is not a complete list; to view the full list, please log in in to your secure member portal at sanfordhealthplan. com/memberlogin and select the Find a pharmacy/link to Express Scripts tab located under My Information. When reviewing the list, please use the guide on page 3. For more information about your pharmacy benefits, covered drugs, copays and more, please check your Summary of Benefits and Coverage and Certificate of Coverage. This information can also be found online or by contacting our Pharmacy Management Team at (855) ; TTY (877) between 8 am and 5 pm CT Monday through Friday. HP-73_-0-7

2 Table of Contents ANTI - INFECTIVES... 5 ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS... 3 AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCHOLOGY... 4 CARDIOVASCULAR, HYPERTENSION & LIPIDS... 3 DERMATOLOGICALS/TOPICAL THERAPY DIAGNOSTICS & MISCELLANEOUS AGENTS EAR, NOSE & THROAT MEDICATIONS... 5 ENDOCRINE/DIABETES GASTROENTEROLOGY IMMUNOLOGY, VACCINES & BIOTECHNOLOGY MUSCULOSKELETAL & RHEUMATOLOGY OBSTETRICS & GYNECOLOGY OPHTHALMOLOGY RESPIRATORY, ALLERGY, COUGH & COLD UROLOGICALS VITAMINS, HEMATINICS & ELECTROLYTES INDEX... 9 HP-73_LZCA eff date -0-7

3

4 ABBREVIATIONS Tier: : These drugs take a copay : Generics (these drugs take a copay) : Brands (these drugs take a $3 copay) LA (Limited Availability): PA (Pre-Approval Needed): QL (Quantity Limit /Number Allowed) SP (Specialty Medications): ST (Step Therapy): May be available only at certain pharmacies. For more information, please call Customer Service. You or your provider must get pre-approval for the medicine with Sanford Health Plan before you can get the prescription filled. The Plan may limit the amount of medicine you can receive of certain coverage medications.. These drugs may require frequent dosing adjustments, close monitoring, special training, compliance assistance, or need special handling and/or administration. They may also be limited in supply. With certain medications, you must first try lower cost and/or generic versions before high cost options are covered. If the first step medication does not work or you have side effects, the next step may be covered. 3

5

6 ANTI - INFECTIVES Antifungal Agents clotrimazole mucous membrane troche 0 fluconazole oral suspension for recon 0 /ml, 40 /ml fluconazole oral tablet 50,00,50,00 flucytosine oral capsule 50, 500 griseofulvin microsize oral suspension 5 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 5, 50 GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET 5 MG, 50 MG itraconazole oral capsule 00 ketoconazole oral tablet 00 nystatin oral powder 50 million unit, 500 million unit nystatin oral suspension 00,000 unit/ml nystatin oral tablet 500,000 unit terbinafine hcl oral tablet 50 voriconazole oral suspension for recon 00 /5 ml (40 /ml) QL voriconazole oral tablet 00, 50 Antivirals abacavir oral soln 0 /ml abacavir oral tablet 300 abacavir-lamivudine oral tablet abacavir-lamivudinezidovudine oral tablet acyclovir oral capsule 00 acyclovir oral suspension 00 /5 ml acyclovir oral tablet 400, 800 adefovir oral tablet 0 amantadine hcl oral capsule 00 amantadine hcl oral soln 50 /5 ml amantadine hcl oral tablet 00 APTIVUS ORAL CAPSULE 50 MG APTIVUS ORAL SOLN 00 MG/ML ATRIPLA ORAL TABLET MG COMBIVIR ORAL TABLET MG COMPLERA ORAL TABLET MG 5

7 CRIXIVAN ORAL CAPSULE 00 MG, 400 MG GENVOYA ORAL TABLET MG DESCOVY ORAL TABLET 00-5 MG INTELENCE ORAL TABLET 00 MG, 00 MG, 5 MG didanosine oral capsule, del-release(dr/ec) 5, 00 50,400 EDURANT ORAL TABLET 5 MG EMTRIVA ORAL CAPSULE 00 MG EMTRIVA ORAL SOLN 0 MG/ML entecavir oral tablet 0.5, EPCLUSA ORAL TABLET MG EPIVIR HBV ORAL SOLN 5 MG/5 ML (5 MG/ML) EPIVIR HBV ORAL TABLET 00 MG EPIVIR ORAL SOLN 0 MG/ML EPIVIR ORAL TABLET 50 MG EPIVIR ORAL TABLET 300 MG EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG famciclovir oral tablet 5, 50, 500 fosamprenavir oral tablet 700 PA; SP QL QL INVIRASE ORAL CAPSULE 00 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL POWDER IN PACKET 00 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET, CHEW 5 MG, 00 MG KALETRA ORAL SOLN MG/5 ML KALETRA ORAL TABLET 00-5 MG, MG lamivudine oral soln 0 /ml lamivudine oral tablet 00, 300 lamivudine oral tablet 50 lamivudine-zidovudine oral tablet LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG lopinavir-ritonavir oral soln /5 ml QL 6

8 MAVYRET ORAL TABLET MG PA; SP; QL RETROVIR ORAL SYRUP 0 MG/ML nevirapine oral suspension 50 /5 ml REYATAZ ORAL CAPSULE 50 MG, 00 MG, 300 MG nevirapine oral tablet 00 REYATAZ ORAL POWDER IN PACKET 50 MG nevirapine oral tablet extended release 4 hr 00, 400 NORVIR ORAL CAPSULE 00 MG NORVIR ORAL SOLN 80 MG/ML NORVIR ORAL TABLET 00 MG ribavirin inhalation recon soln 6 gram rimantadine oral tablet 00 SELZENTRY ORAL SOLN 0 MG/ML SELZENTRY ORAL TABLET 50 MG, 5 MG, 300 MG, 75 MG ODEFSEY ORAL TABLET MG stavudine oral capsule 5, 0, 30, 40 oseltamivir oral capsule 30, 45 stavudine oral recon soln /ml PREZCOBIX ORAL TABLET MG-MG STRIBILD ORAL TABLET MG PREZISTA ORAL SUSPENSION 00 MG/ML SUSTIVA ORAL CAPSULE 00 MG, 50 MG PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG, 800 MG RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION RESCRIPTOR ORAL TABLET 00 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG RETROVIR ORAL CAPSULE 00 MG QL SUSTIVA ORAL TABLET 600 MG TAMIFLU ORAL SUSPENSION 6 MG/ML TECHNIVIE ORAL TABLET MG TIVICAY ORAL TABLET 0 MG, 5 MG, 50 MG TRIUMEQ ORAL TABLET MG TRIZIVIR ORAL TABLET MG QL PA; SP 7

9 TRUVADA ORAL TABLET MG, MG, MG, MG valacyclovir oral tablet gram, 500 VALCYTE ORAL RECONSTITUTE SOLUTION 50 MG/ML VALCYTE ORAL TABLET 450 MG valganciclovir oral recon soln 50 /ml valganciclovir oral tablet 450 VEMLIDY ORAL TABLET 5 MG VIDEX GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIDEX EC ORAL CAPSULE, DEL-REL(DR/EC) 5 MG, 00 MG, 50 MG, 400 MG VIRACEPT ORAL TABLET 50 MG, 65 MG VIRAMUNE ORAL SUSP 50 MG/5 ML VIRAMUNE ORAL TABLET 00 MG VIRAMUNE XR ORAL TABLET EXT-REL 4 HR 00 MG, 400 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) QL VIREAD ORAL TABLET 50 MG, 00 MG, 50 MG, 300 MG ZERIT ORAL CAPSULE 5 MG, 0MG, 30MG, 40MG ZERIT ORAL RECON SOLN MG/ML ZIAGEN ORAL SOLN 0 MG/ML ZIAGEN ORAL TABLET 300 MG zidovudine oral capsule 00 zidovudine oral syrup 0 /ml zidovudine oral tablet 300 Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for recon 5 /5 ml, 50 /5 ml, 375 /5 ml cefaclor oral tablet extrelease hr 500 cefadroxil oral capsule 500 cefadroxil oral susp for recon 50 /5 ml, 500 /5 ml cefadroxil oral tablet gm cefdinir oral capsule 300 8

10 cefdinir oral suspension for recon 5 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00, 400 cefixime oral suspension for recon 00 /5 ml, 00 /5 ml cefpodoxime oral suspension for recon 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 00 cefprozil oral suspension for recon 5 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 CEFTIN ORAL SUSPENSION FOR RECON 5 MG/5 ML, 50 MG/5 ML cefuroxime axetil oral tablet 50, 500 cephalexin oral capsule 50, 500, 750 cephalexin oral suspension for recon 5 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 Erythromycins & Other Macrolides azithromycin oral pkt gm azithromycin oral suspension for recon 00 /5 ml, 00 /5 ml azithromycin oral tablet 50, 500, 600 clarithromycin oral susp for recon 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet ext-release 4 hr 500 e.e.s. 400 oral tablet 400 ERYPED 00 ORAL SUSPENSION FOR RECON 00 MG/5 ML ERYPED 400 ORAL SUSP FOR RECON 400 MG/5 ML ery-tab oral tablet, delayed release (dr/ec) 50, 333 ERY-TAB ORAL TABLET, DEL- REL (DR/EC) 500 MG erythrocin (as stearate) oral tablet 50 erythromycin ethylsuccinate oral susp for recon 00 /5 ml erythromycin ethylsuccinate oral tablet 400 erythromycin oral capsule, del-release(dr/ec) 50 erythromycin oral tablet 50, 500 ZMAX ORAL SUSP, EXTENDED RELEASE RECON GRAM/60 ML 9

11 Miscellaneous Antiinfectives ALBENZA ORAL TABLET 00 MG ALINIA ORAL SUSPENSION FOR RECON 00 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 /5 ml atovaquone-proguanil oral tablet 50-00, BETHKIS INHALATION SOLN FOR NEBULIZATION 300 MG/4 ML BILTRICIDE ORAL TABLET 600 MG chloroquine phosphate oral tablet 50,500 clindamycin hcl oral capsule 50, 300, 75 clindamycin palmitate hcl oral recon soln 75 /5 ml clindamycin pediatric oral recon soln 75 /5 ml COARTEM ORAL TABLET 0-0 MG CYCLOSERINE ORAL CAPSULE 50 MG dapsone oral tablet 00, 5 ethambutol oral tablet 00, 400 SP hydroxychloroquine oral tablet 00 isoniazid oral soln 50 /5 ml isoniazid oral tablet 00, 300 ivermectin oral tablet 3 KITABIS PAK INHALATION SOLN FOR NEBULIZATION 300 MG/5 ML linezolid oral suspension for recon 00 /5 ml linezolid oral tablet 600 mefloquine oral tablet 50 MEPRON ORAL SUSPENSION 750 MG/5 ML metronidazole oral capsule 375 metronidazole oral tablet 50, 500 MYCOBUTIN ORAL CAPSULE 50 MG NEBUPENT INHALATION RECON SOLN 300 MG neomycin oral tablet 500 paromomycin oral capsule 50 PASER ORAL GRANULES DR FOR SUSP IN PKT 4 GM PRIFTIN ORAL TABLET 50 MG SP PA PA QL QL 0

12 PRIMAQUINE ORAL TABLET 6.3 MG pyrazinamide oral tablet 500 quinine sulfate oral capsule 34 rifabutin oral capsule 50 RIFAMATE ORAL CAPSULE MG rifampin oral capsule 50, 300 RIFATER ORAL TABLET MG SIVEXTRO ORAL TABLET 00 MG STROMECTOL ORAL TABLET 3 MG tinidazole oral tablet 50, 500 TRECATOR ORAL TABLET 50 MG XIFAXAN ORAL TABLET 550 MG Penicillins amoxicillin oral capsule 50, 500 amoxicillin oral suspension for recon 5 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet, chewable 5, 50 QL PA amoxicillin-pot clavulanate oral susp for recon /5 ml, /5 ml, /5 ml, /5 ml amoxicillin-pot clavulanate oral tablet 50-5, 500-5, amoxicillin-pot clavulanate oral tablet extended release hr, amoxicillin-pot clavulanate oral tablet, chewable , ampicillin oral capsule 50, 500 AUGMENTIN ORAL SUSPENSION FOR RECON MG/5 ML dicloxacillin oral capsule 50, 500 penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 Quinolones ciprofloxacin (mixture) oral tablet, er multiphase 4 hr,000, 500 ciprofloxacin hcl oral tablet 00, 50, 500, 750

13 ciprofloxacin oral suspension, microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin oral soln 50 /0 ml levofloxacin oral tablet 50, 500, 750 moxifloxacin oral tablet 400 ofloxacin oral tablet 300, 400 Sulfa's & Related Agents sulfadiazine oral tablet 500 sulfamethoxazoletrimethoprim oral suspension /5 ml sulfamethoxazoletrimethoprim oral tablet , sulfatrim oral suspension /5 ml Tetracyclines avidoxy oral tablet 00 demeclocycline oral tablet 50, 300 doxycycline hyclate oral capsule 00, 50 doxycycline hyclate oral tablet 00, 50, 0, 75 doxycycline hyclate oral tablet, delayed release (dr/ec) 00, 50, 00, 50, 75 doxycycline monohydrate oral capsule 00, 50, 50, 75 doxycycline monohydrate oral suspension for recon 5 /5 ml doxycycline monohydrate oral tablet 00, 50, 50, 75 minocycline oral capsule 00, 50, 75 minocycline oral tablet 00, 50, 75 minocycline oral tablet extended release 4 hr 35, 45, 90 mondoxyne nl oral capsule 50, 75, 00 morgidox oral capsule 00 tetracycline oral capsule 50, 500 Urinary Tract Agents FURADANTIN ORAL SUSPENSION 5 MG/5 ML MACROBID ORAL CAPSULE 00 MG MACRODANTIN ORAL CAPSULE 5 MG, 50 MG, 00 MG methenamine hippurate oral tablet gram methenamine mandelate oral tablet 0.5 g, gram MONUROL ORAL PKT 3GM

14 nitrofurantoin macrocrystal oral capsule 00, 5, 50 nitrofurantoin monohyd/ m-cryst oral capsule 00 nitrofurantoin oral suspension 5 /5 ml PRIMSOL ORAL SOLN 50 MG/5 ML trimethoprim oral tablet 00 Vancomycin vancomycin oral capsule 5, 50 ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS Adjunctive Agents leucovorin calcium oral tablet 0, 5, 5, 5 MESNEX ORAL TABLET 400 MG Antineoplastic & Immunosuppressant Drugs anastrozole oral tablet azathioprine oral tablet 50 bicalutamide oral tablet 50 CELLCEPT ORAL SUSPENSION FOR RECON 00 MG/ML cyclosporine modified oral capsule 00, 5, 50 cyclosporine modified oral soln 00 /ml cyclosporine oral capsule 00, 5 DROXIA ORAL CAPSULE 00 MG, 300 MG, 400 MG EMCYT ORAL CAPSULE 40 MG exemestane oral tablet 5 FARESTON ORAL TABLET 60 MG flutamide oral capsule 5 gengraf oral capsule 00, 5, 50 gengraf oral soln 00 /ml HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 letrozole oral tablet.5 LEUKERAN ORAL TABLET MG LYSODREN ORAL TABLET 500 MG MEGACE ES ORAL SUSPENSION 65 MG/5 ML megestrol oral suspension 400 /0 ml (40 /ml), 65 /5 ml 3

15 megestrol oral tablet 0, 40 mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon soln gram methotrexate sodium (pf) injection soln 5 /ml methotrexate sodium injection soln 5 /ml methotrexate sodium oral tablet.5 mycophenolate mofetil oral capsule 50 mycophenolate mofetil oral suspension for recon 00 /ml mycophenolate mofetil oral tablet 500 mycophenolate sodium oral tablet, delayed release (dr/ec) 80, 360 NILANDRON ORAL TABLET 50 MG nilutamide oral tablet 50 octreotide acetate injection soln,000 mcg/ml, 00 mcg/ml, 00 mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection syringe 00 mcg/ml ( ml), 50 mcg/ml ( ml), 500 mcg/ml ( ml) SP SP PURIXAN ORAL SUSPENSION 0 MG/ML RAPAMUNE ORAL SOLN MG/ML RAPAMUNE ORAL TABLET 0.5 MG, MG, MG SANDIMMUNE ORAL CAPSULE 00 MG, 5 MG SANDIMMUNE ORAL SOLN 00 MG/ML sirolimus oral tablet 0.5,, TABLOID ORAL TABLET 40 MG tacrolimus oral capsule 0.5,, 5 tamoxifen oral tablet 0, 0 tretinoin (chemotherapy) oral capsule 0 TREXALL ORAL TABLET 0 MG, 5 MG, 5 MG, 7.5 MG XERMELO ORAL TABLET 50 MG ZORTRESS ORAL TABLET 0.5 MG, 0.5 MG, 0.75 MG AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCHOLOGY Anticonvulsants APTIOM ORAL TABLET 00 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML SP 4 PA; QL

16 BANZEL ORAL TABLET 00 MG, 400 MG BRIVIACT ORAL SOLN 0 MG/ML BRIVIACT ORAL TABLET 0 MG, 00 MG, 5 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase hr 00, 00, 300 carbamazepine oral suspension 00 /5 ml carbamazepine oral tablet 00 carbamazepine oral tablet ext-release hr 00, 00, 400 carbamazepine oral tablet, chewable 00 CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5,, clonazepam oral tablet, disintegrating 0.5, 0.5, 0.5,, DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG diazepam rectal kit ,.5, divalproex oral capsule, del-rel sprinkle 5 divalproex oral tablet extended release 4 hr 50, 500 divalproex oral tablet, delayed release (dr/ec) 5, 50, 500 ethosuximide oral capsule 50 ethosuximide oral soln 50 /5 ml felbamate oral suspension 600 /5 ml felbamate oral tablet 400, 600 FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 0 MG, MG, MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 00, 300, 400 gabapentin oral soln 50 /5 ml gabapentin oral tablet 600, 800 GABITRIL ORAL TABLET MG, 6 MG, MG, 4 MG GRALISE 30-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 4 HR 300 MG (9)- 600 MG (69) GRALISE ORAL TABLET EXTENDED RELEASE 4 HR 300 MG, 600 MG 5

17 LAMICTAL ODT ORAL TABLET, DISINTEGRATING 00 MG, 00 MG, 5 MG, 50 MG LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK 5 MG () -50 MG (7) LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK 50 MG (4) -00 MG (4) LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK 5 MG(4)-50 MG (4)-00 MG (7) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 4HR 00 MG, 00 MG, 5 MG, 50 MG, 300 MG, 50 MG LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK 5 MG () -50 MG (7) LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 50 MG(4)-00MG (4)- 00 MG (7) LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK 5MG (4)-50 MG (4)- 00MG (7) lamotrigine oral tablet 00, 50, 00, 5 lamotrigine oral tablet disintegrating, dose pk 5 () -50 (7), 5 (4)-50 (4)-00 (7), 50 (4) -00 (4) lamotrigine oral tablet extended release 4hr 00, 00, 5, 50, 300, 50 lamotrigine oral tablet, chewable dispersible 5, 5 lamotrigine oral tablet, disintegrating 00, 00, 5, 50 lamotrigine oral tablets, dose pack 5 (35), 5 (4) -00 (7), 5 (84) -00 (4) levetiracetam oral soln 00 /ml, 500 /5 ml (5 ml) levetiracetam oral tablet,000, 50, 500, 750 levetiracetam oral tablet extended release 4 hr 500, 750 LYRICA ORAL CAPSULE 00 MG, 50 MG, 00 MG, 5 MG, 5 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML ONFI ORAL SUSPENSION.5 MG/ML QL QL 6

18 ONFI ORAL TABLET 0 MG, 0 MG oxcarbazepine oral suspension 300 /5 ml (60 /ml) oxcarbazepine oral tablet 50, 300, 600 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 4 HR 50 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 /5 ml (4 /ml) phenobarbital oral tablet 00, 5, 6., 30, 3.4, 60, 64.8, 97. PHENYTEK ORAL CAPSULE 00 MG, 300 MG phenytoin oral suspension 5 /5 ml phenytoin oral tablet, chewable 50 phenytoin sodium extended oral capsule 00, 00, 300 primidone oral tablet 50, 50 roweepra oral tablet,000, 500, 750 SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SP; LA SP; LA TEGRETOL ORAL TABLET 00 MG tiagabine oral tablet, 4 topiramate oral capsule, sprinkle 5, 5 TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 4HR 00 MG, 50 MG, 00 MG, 5 MG, 50 MG topiramate oral tablet 00, 00, 5, 50 TROKENDI XR CAPSULE, EXT-REL 4HR 5 MG, 50 MG, 00 MG, 00 MG valproic acid (as sodium salt) oral soln 50 /5 ml valproic acid oral capsule 50 vigabatrin oral powder in packet 500 VIMPAT ORAL SOLN 0 MG/ML VIMPAT ORAL TABLET 50MG, 00MG, 50MG, 00MG zonisamide oral capsule 00, 5, 50 Antiparkinsonism Agents APOKYN SUBCUTANEOUS CARTRIDGE 0 MG/ML AZILECT ORAL TABLET 0.5 MG, MG benztropine oral tablet 0.5,, SP; LA 7

19 bromocriptine oral capsule 5 bromocriptine oral tablet.5 carbidopa oral tablet 5 carbidopa-levodopa oral tablet 0-00, 5-00, 5-50 carbidopa-levodopa oral tablet extended release 5-00, carbidopa-levodopa oral tablet, disintegrating 0-00, 5-00, 5-50 carbidopa-levodopaentacapone oral tablet , , , , , COMTAN TABLET 00 MG ELDEPRYL CAPSULE 5 MG Entacapone tablet 00 LODOSYN TABLET 5 MG MIRAPEX ER ORAL TABLET EXTENDED RELEASE 4 HR MG, 0.75 MG,.5 MG,.5 MG, 3 MG, 3.75 MG, 4.5 MG NEUPRO TRANSDERMAL PATCH 4 HOUR MG/4 HR, MG/4 HR, 3 MG/4 HR, 4 MG/4 HR, 6 MG/4 HR, 8 MG/4 HR pramipexole oral tablet 0.5, 0.5, 0.5, 0.75,,.5 pramipexole oral tablet ext-rel 4 hr 0.375, 0.75,.5,.5, 3, 3.75, 4.5 rasagiline oral tablet 0.5, ropinirole oral tablet 0.5, 0.5,,, 3, 4, 5 ropinirole oral tablet extrel 4 hr,, 4, 6, 8 selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 TASMAR ORAL TABLET 00 MG tolcapone oral tablet 00 trihexyphenidyl oral elixir 0.4 /ml trihexyphenidyl oral tablet, 5 Migraine & Cluster Headache Therapy AXERT ORAL TABLET.5 MG, 6.5 MG D.H.E.45 INJECTION SOLN MG/ML dihydroergotamine injection soln /ml QL QL 8

20 dihydroergotamine nasal spray, non-aerosol 0.5 /pump act. (4 /ml) ERGOMAR SUBLINGUAL TABLET MG ergotamine-caffeine oral tablet -00 frovatriptan oral tablet.5 isomethepten-caffeineacetaminophen oral tablet migergot rectal suppository -00 MIGRANAL NASAL SPRAY, NON-AEROSOL 0.5 MG/PUMP ACT. (4 MG/ML) RELPAX ORAL TABLET 0 MG, 40 MG rizatriptan oral tablet 0, 5 rizatriptan oral tablet, disintegrating 0, 5 sumatriptan succinate oral tablet 5, 50, 00 QL QL QL QL QL QL QL Miscellaneous Neurological Therapy AMPYRA ORAL TABLET EXT- RELEASE HR 0 MG donepezil oral tablet 0, 3, 5 EXELON TRANSDERMAL PATCH 4 HOUR 3.3 MG/4 HOUR, 4.6 MG/4 HR, 9.5 MG/4 HR PA; SP; LA galantamine oral capsule, ext rel. pellets 4 hr 6, 4, 8 galantamine oral soln 4 /ml galantamine oral tablet, 4, 8 HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG, 600 MG memantine oral soln /ml memantine oral tablet 0, 5 MEMANTINE TABLETS, DOSE PACK 5-0 MG NAMENDA TITRATION PAK ORAL TABLETS, DOSE PACK 5-0 MG NAMENDA XR ORAL CAP,SPRINKLE,ER 4HR DOSE PACK MG NAMENDA XR CAPSULE, SPRINKLE,ER 4HR 7 MG, 4 MG, MG, 8 MG NUEDEXTA ORAL CAPSULE 0-0 MG rivastigmine tartrate oral capsule.5, 3, 4.5, 6 tetrabenazine oral tablet.5, 5 ST ST PA; SP Muscle Relaxants & Antispasmodic Therapy baclofen oral tablet 0, 0 9

21 carisoprodol oral tablet 50, 350 carisoprodol-asa-codeine oral tablet carisoprodol-aspirin oral tablet chlorzoxazone oral tablet 50, 500 cyclobenzaprine oral tablet 5 7.5,0 dantrolene oral capsule 00, 5, 50 meprobamate oral tablet 00, 400 MESTINON ORAL SYRUP 60 MG/5 ML MESTINON ORAL TABLET 60 MG MESTINON TIMESPAN ORAL TABLET EXT-REL 80 MG metaxall oral tablet 800 metaxalone oral tablet 400, 800 methocarbamol oral tablet 500, 750 orphenadrine citrate oral tablet ext- release 00 pyridostigmine bromide oral tablet 60 pyridostigmine bromide oral tablet extended release 80 ROBAXIN-750 ORAL TABLET 750 MG tizanidine oral capsule, 4, 6 tizanidine oral tablet, 4 Narcotic Analgesics acetaminophen-caffeinedihydrocodeine oral capsule acetaminophen-codeine oral soln 0- /5 ml acetaminophen-codeine oral tablet 300-5, , ascomp with codeine oral capsule ASTRAMORPH-PF INJECTION SOLN 0.5 MG/ML butalbital compound w/codeine oral capsule butalbital-acetamincaffeine-cod oral capsule , butalbital-acetaminophen oral tablet , butalbitalacetaminophen-caffeine oral capsule , butalbitalacetaminophen-caffeine oral tablet butalbital-aspirin-caffeine oral capsule

22 butalbital-aspirin-caffeine oral tablet BUTRANS TRANSDERMAL PATCH WEEKLY 5 MCG/HR, 7.5 MCG/HR, 0 MCG/HR, 5 MCG/HR, 0 MCG/HR capacet oral capsule CAPITAL WITH CODEINE ORAL SUSPENSION 0- MG/5 ML codeine sulfate oral tablet 5, 30, 60 diskets oral tablet, soluble 40 EMBEDA ORAL CAPSULE, ORAL ONLY, EXT.REL PELL 00-4 MG, MG, 30-. MG, 50- MG, MG, MG QL hydrocodoneacetaminophen oral tablet.5-35, 5-300, 5-35, , , 0-300, 0-35 hydrocodone-ibuprofen oral tablet 5-00, , 0-00 HYDROMORPHONE INJECTION SYRINGE 0.5 MG/0.5 ML hydromorphone oral tablet, 4, 8 hydromorphone rectal suppository 3 ibuprofen-oxycodone oral tablet INFUMORPH P/F INJECTION SOLN 0 MG/ML, 5 MG/ML endocet oral tablet 0-35,.5-35, 5-35, fentanyl citrate buccal lozenge on a handle 00 mcg, 400 mcg, 600 mcg, 800 mcg,,00 mcg,,600 mcg fentanyl transdermal patch 7 hour mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr, 00 mcg/hr hydrocodoneacetaminophen oral soln /5 ml levorphanol tartrate oral tablet lorcet (hydrocodone) oral tablet 5-35 lorcet hd oral tablet 0-35 lorcet plus oral tablet marten-tab oral tablet meperidine oral soln 50 /5 ml meperidine oral tablet 00, 50

23 methadose oral concentrate 0 /ml methadose oral tablet, soluble 40 morphine concentrate oral soln 00 /5 ml (0 /ml) morphine oral capsule, extend. release pellets 0, 0, 30, 50, 60, 80, 00 morphine oral soln 0 /5 ml, 0 /5 ml (4 /ml) morphine oral tablet 5, 30 morphine oral tablet extrel 5, 30, , 00 morphine rectal suppository 5, 0, 0, 30 oxycodone oral capsule 5 oxycodone oral concentrate 0 /ml oxycodone oral solution 5 /5 ml oxycodone oral tablet 5, 0, 5, 0, 30 oxycodoneacetaminophen oral soln 5-35 /5 ml oxycodoneacetaminophen oral tablet 0-35,.5-35, 5-35, oxycodone-aspirin oral tablet oxymorphone oral tablet 0, 5 SYNALGOS-DC ORAL CAPSULE MG tencon oral tablet verdrocet oral tablet.5-35 vicodin es oral tablet vicodin hp oral tablet vicodin oral tablet xylon 0 oral tablet 0-00 zamicet oral soln 0-35 /5 ml zebutal oral capsule Non-Narcotic Analgesics aspirin low dose oral tablet, delayed release (dr/ec) 8 aspirin oral tablet 35 aspirin oral tablet, chewable 8

24 aspirin oral tablet, delayed release (dr/ec) 35, 8 ecotrin low strength oral tablet, delayed release (dr/ec) 8 bayer aspirin oral tablet 35 butorphanol tartrate nasal spray, non-aerosol 0 /ml QL ecotrin oral tablet, delayed release (dr/ec) 35 etodolac oral capsule 00, 300 celecoxib oral capsule 50 00, 00, 400 children's aspirin oral tablet, chewable 8 etodolac oral tablet 400, 500 etodolac oral tablet extended release 4 hr 400, 500, 600 choline, magnesium salicylate oral liquid 500 /5 ml diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended release 4 hr 00 diclofenac sodium oral tablet, del-rel (dr/ec) 5, 50, 75 diclofenac sodium topical drops.5 % diclofenac sodium topical gel % diclofenac-misoprostol oral tablet, ir, delayed rel, biphasic mcg, mcg diflunisal oral tablet 500 e.c. prin oral tablet, del-rel (dr/ec) 35 QL QL fenoprofen oral tablet 600 FLECTOR TRANSDERMAL PATCH HOUR.3 % flurbiprofen oral tablet 00, 50 ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 5, 50 indomethacin oral capsule, extended release 75 ketoprofen oral capsule 50, 75 ketoprofen oral capsule, ext rel. pellets 4 hr 00 ketorolac injection syringe 5 /ml, 30 /ml ketorolac intramuscular syringe 60 / ml ketorolac oral tablet 0 QL 3

25 lite coat aspirin oral tablet 35 meclofenamate oral capsule 00, 50 mefenamic acid oral capsule 50 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 5, 7.5 nabumetone oral tablet 500, 750 naltrexone oral tablet 50 naproxen oral suspension 5 /5 ml naproxen oral tablet 50, 375, 500 naproxen oral tablet, delayed release (dr/ec) 375, 500 naproxen sodium oral tablet 550 naproxen sodium oral tablet, er multiphase 4 hr 375, 500 NARCAN NASAL SPRAY, NON-AEROSOL 4 MG/ACTUATION NUCYNTA ER ORAL TABLET EXTENDED RELEASE HR 50 MG, 00 MG, 50 MG, 00 MG, 50 MG oxaprozin oral tablet 600 QL pentazocine-naloxone oral tablet piroxicam oral capsule 0, 0 REVIA ORAL TABLET 50 MG salsalate oral tablet 500, 750 sulindac oral tablet 50, 00 tolmetin oral capsule 400 tolmetin oral tablet 00, 600 TRAMADOL ORAL CAPSULE,ER BIPHASE 4 HR MG TRAMADOL ORAL CAPSULE, ER BIPHASE 4 HR MG, 50 MG, 00 MG tramadol oral tablet 50 tramadol oral tablet extended release 4 hr 00, 00, 300 tramadol oral tablet, er multiphase 4 hr 00, 00, 300 tramadol-acetaminophen oral tablet VOLTAREN TOPICAL GEL % QL 4

26 ZUBSOLV SUBLINGUAL TABLET MG, MG,.4-.9 MG, MG, MG, MG Psychotherapeutic Drugs ABILIFY MAINTENA INTRAMUSCULAR SUS, EXT- REL RECON 300MG,400MG ABILIFY MAINTENA INTRAMUSCULAR SUSP, EXT-REL SYRINGE 300 MG, 400 MG ADZENYS XR-ODT ORAL TABLET, DISINTEG ER BIPHASE 4H.5 MG, 5.7 MG, 8.8 MG, 3. MG, 6.3 MG, 9.4 MG alprazolam intensol oral concentrate /ml alprazolam tablet 0.5, 0.5,, alprazolam oral tablet extended release 4 hr 0.5,,, 3 alprazolam oral tablet, disintegrating 0.5, 0.5,, amitriptyline oral tablet 0, 00, 50, 5, 50, 75 amitriptylinechlordiazepoxide oral tablet.5-5, 5-0 amoxapine oral tablet 00, 50, 5, 50 PA APTENSIO XR ORAL CAP, ER SPRINKLE, BIPHASIC MG, 5 MG, 0 MG, 30 MG, 40 MG, 50 MG, 60 MG aripiprazole oral solution /ml aripiprazole oral tablet 0, 5,, 0, 30, 5 aripiprazole oral tablet, disintegrating 0, 5 ARISTADA INTRAMUSCULAR SUSP, EXTENDED REL SYRING,064 MG/3.9 ML, 44 MG/.6 ML, 66 MG/.4 ML, 88 MG/3. ML armodafinil oral tablet 50, 50, 00, 50 bupropion hcl oral tablet 00, 75 bupropion hcl oral tablet extended release hr 00, 50, 00 bupropion hcl oral tablet extended release 4 hr 50, 300 buspirone oral tablet 0, 5, 30, 5, 7.5 chlordiazepoxide hcl oral capsule 5, 0, 5 QL QL QL 5

27 chlorpromazine oral tablet 0, 00, 00, 5, 50 citalopram oral soln 0 /5 ml citalopram oral tablet 0, 0 citalopram oral tablet 40 clomipramine capsule 5, 50, 75 clorazepate dipotassium oral tablet 5, 3.75, 7.5 clozapine oral tablet 00, 00, 5, 50 clozapine oral tablet, disintegrating 00,.5, 5 CLOZAPINE ORAL TABLET, DISINTEGRATING 50 MG, 00 MG COTEMPLA XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 4H 7.3 MG, 5.9 MG, 8.6 MG DAYTRANA TRANSDERMAL PATCH 4 HOUR 0 MG/9 HR, 5 MG/9 HR, 0 MG/9 HR, 30 MG/9 HR desipramine oral tablet 0, 00, 50, 5, 50, 75 DESOXYN TABLET 5 MG DESVENLAFAXINE FUMARATE TABLET EXT-REL 4HR 00 MG, 50 MG QL DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 4 HR 00 MG, 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 4HR 00 MG, 50 MG desvenlafaxine succinate oral tablet extended release 4 hr 00, 5, 50 dexmethylphenidate oral tablet.5, 5, 0 dextroamphetamine oral capsule, ext-rel 0, 5, 5 dextroamphetamine oral soln 5 /5 ml dextroamphetamine oral tablet 0, 5 dextroamphetamineamphetamine oral tablet 0,.5, 5, 0, 30, 5, 7.5 diazepam intensol oral concentrate 5 /ml diazepam oral soln 5 /5 ml ( /ml) diazepam oral tablet 0,, 5 doxepin oral capsule 0, 00, 50, 5, 50, 75 doxepin oral concentrate 0 /ml duloxetine oral capsule, delayed release(dr/ec) 0, 30, 40, 60 6

28 DYANAVEL XR ORAL SUSPEN, IR - ER, BIPHASIC 4HR.5 MG/ML ergoloid oral tablet escitalopram oxalate oral soln 5 /5 ml escitalopram oxalate oral tablet 0, 0, 5 estazolam oral tablet, eszopiclone oral tablet,, 3 EVEKEO ORAL TABLET 0 MG, 5 MG FANAPT ORAL TABLET MG, 0 MG, MG, MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS, DOSE PACK MG()- MG()- 4MG()-6MG() FAZACLO ORAL TABLET, DISINTEGRATING.5 MG, 5 MG, 00 MG, 50 MG, 00 MG FETZIMA ORAL CAPSULE, EXT REL 4HR DOSE PACK 0 MG ()- 40 MG (6) FETZIMA ORAL CAPSULE, EXT-REL 4 HR 0 MG, 0 MG, 40 MG, 80 MG fluoxetine oral capsule 0, 0, 40 fluoxetine oral soln 0 /5 ml (4 /ml) fluoxetine oral tablet 0, 0 FLUOXETINE ORAL TABLET 60 MG fluphenazine decanoate injection soln 5 /ml fluphenazine hcl injection soln.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir.5 /5 ml fluphenazine hcl oral tablet, 0,.5, 5 flurazepam oral capsule 5, 30 fluvoxamine oral capsule, extended release 4hr 00, 50 fluvoxamine oral tablet 00, 50 fluvoxamine oral tablet 5 FOCALIN XR ORAL CAPSULE,ER BIPHASIC MG, 5 MG, 0 MG, 5 MG, 30 MG, 35 MG, 40 MG, 5 MG guanfacine oral tablet extended release 4 hr,, 3, 4 guanidine oral tablet 5 HALDOL DECANOATE INTRAMUSCULAR SOLN 00 MG/ML, 50 MG/ML QL 7

29 HALDOL INJECTION SOLN 5 MG/ML haloperidol decanoate intramuscular soln 00 /ml, 50 /ml lithium carbonate oral capsule 50, 300, 600 lithium carbonate oral tablet 300 haloperidol lactate injection soln 5 /ml haloperidol lactate oral concentrate /ml haloperidol oral tablet 0.5,, 0,, 0, 5 lithium carbonate oral tablet extended release 300, 450 lithium citrate oral soln 8 meq/5 ml lorazepam intensol oral concentrate /ml imipramine hcl oral tablet 0, 5, 50 lorazepam oral concentrate /ml imipramine pamoate oral capsule 00, 5, 50, 75 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.5 ML, 78 MG/0.5 ML, 7 MG/0.75 ML, 56 MG/ML, 34 MG/.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 73 MG/0.875 ML, 40 MG/.35 ML, 546 MG/.75 ML, 89 MG/.65 ML lorazepam oral tablet 0.5,, loxapine succinate oral capsule 0, 5, 5, 50 maprotiline oral tablet 5, 50, 75 methamphetamine oral tablet 5 methylphenidate hcl oral capsule, er biphasic , 0, 30, 40, 50, 60 KAPVAY ORAL TABLET EXTENDED RELEASE HR 0. MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 4HR 00 MG, 50 MG LATUDA ORAL TABLET 0 MG, 0 MG, 40 MG, 60 MG, 80 MG ST methylphenidate hcl oral capsule, er biphasic , 30, 40, 60 methylphenidate hcl oral solution 0 /5 ml, 5 /5 ml methylphenidate hcl oral tablet 0, 0, 5 8

30 methylphenidate hcl oral tablet extended release 0, 0 methylphenidate hcl oral tablet ext-rel 4hr 8, 7, 36, 54 methylphenidate hcl oral tablet, chewable 0,.5, 5 midazolam oral syrup /ml mirtazapine oral tablet 5, 30, 45, 7.5 mirtazapine oral tablet, disintegrating 5, 30, 45 modafinil oral tablet 00, 00 MYDAYIS CAPSULE, ER TRIPHASIC 4 HR.5 MG, 5 MG, 37.5 MG, 50 MG nefazodone oral tablet 00, 50, 00, 50, 50 nortriptyline oral capsule 0,5,50,75 nortriptyline oral soln 0 /5 ml NUPLAZID TABLET 7 MG NUVIGIL TABLET 50 MG, 00 MG, 50 MG, 50 MG olanzapine intramuscular recon soln 0 olanzapine oral tablet 0, 5,.5, 0, 5, 7.5 QL ST; SP; QL QL olanzapine oral tablet, disintegrating 0, 5, 0, 5 olanzapine-fluoxetine oral capsule -5, -50, 3-5, 6-5, 6-50 ORAP TABLET MG, MG oxazepam oral capsule 0, 5, 30 paliperidone oral tablet extended release 4hr.5, 3, 6, 9 paroxetine hcl tablet 0, 0, 30, 40 paroxetine hcl oral tablet extended release 4 hr.5, 5, 37.5 paroxetine mesylate oral capsule 7.5 PAXIL ORAL SUSPENSION 0 MG/5 ML perphenazine oral tablet 6,, 4, 8 perphenazineamitriptyline oral tablet - 0, -5, 4-0, 4-5, 4-50 PEXEVA ORAL TABLET 0 MG,0 MG, 30 MG, 40 MG phenelzine tablet 5 pimozide tablet, PRISTIQ ORAL TABLET EXTENDED RELEASE 4 HR 00 MG, 5 MG, 50 MG QL 9

31 procentra oral solution 5 /5 ml protriptyline oral tablet 0, 5 quazepam tablet 5 quetiapine oral tablet 5, 50, 00, 00, 300, 400 quetiapine oral tablet extended release 4 hr 50, 00, 300, 400, 50 QUILLICHEW ER ORAL TABLET, CHEW,IR- ER.BIPHASIC 4HR 0 MG, 30 MG, 40 MG QUILLIVANT XR ORAL SUSPENSION,EXT REL 4HR,RECON 5 MG/ML (5 MG/5 ML) REXULTI ORAL TABLET 0.5 MG, 0.5 MG, MG, MG, 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE.5 MG/ ML, 5 MG/ ML, 37.5 MG/ ML, 50 MG/ ML risperidone oral solution /ml risperidone oral tablet 0.5, 0.5,,, 3, 4 risperidone oral tablet, disintegrating 0.5, 0.5,,, 3, 4 QL SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 MG,.5 MG, 5 MG seconal sodium oral capsule 00 sertraline oral concentrate 0 /ml sertraline oral tablet 00, 5, 50 SURMONTIL ORAL CAPSULE 00 MG, 5 MG, 50 MG SYMBYAX ORAL CAPSULE -5 MG, -50 MG, 3-5 MG, 6-5 MG, 6-50 MG temazepam capsule, 7.5, 5,.5, 30 thioridazine oral tablet 0, 00, 5, 50 thiothixene oral capsule, 0,, 5 tranylcypromine oral tablet 0 trazodone tablet, 50, 00, 50, 300 triazolam oral tablet 0.5, 0.5 trifluoperazine oral tablet, 0,, 5 trimipramine oral capsule 00, 5, 50 TRINTELLIX ORAL TABLET 0 MG, 0 MG, 5 MG venlafaxine oral capsule, extended release 4hr 50, 37.5, 75 30

32 venlafaxine oral tablet 00, 5, 37.5, 50, 75 venlafaxine oral tablet ext-rel 4hr 50, 5, 37.5, 75 VIIBRYD ORAL TABLET 0 MG, 0 MG, 40 MG VIIBRYD ORAL TABLETS, DOSE PACK 0 MG (7)- 0 MG (3) VRAYLAR ORAL CAPSULE.5MG,3MG,4.5MG,6 MG VRAYLAR ORAL CAPSULE,DOSE PACK.5 MG ()- 3 MG (6) VYVANSE ORAL CAPSULE 0 MG, 0 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70MG VYVANSE ORAL TABLET, CHEWABLE 0 MG, 0 MG, 30MG,40MG,50 MG,60MG zaleplon oral capsule 5, 0 zenzedi oral tablet 0, 5 ZENZEDI ORAL TABLET 5 MG,.5 MG, 0 MG, 30 MG, 7.5 MG ziprasidone hcl oral capsule 0, 40, 60, 80 zolpidem oral tablet 0, 5 zolpidem oral tablet, ext release multiphase.5, 6.5 QL QL zolpidem sublingual tablet.75, 3.5 ZYPREXA INTRAMUSCULAR RECON SOLN 0 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECON 0 MG, 300 MG, 405 MG CARDIOVASCULAR, HYPERTENSION & LIPIDS Antiarrhythmic Agents amiodarone oral tablet 00, 00, 400 disopyramide phosphate oral capsule 0, 50 dofetilide oral capsule 5 mcg, 50 mcg, 500 mcg flecainide oral tablet 00, 50, 50 mexiletine oral capsule 50, 00, 50 MULTAQ TABLET 400 MG NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 00 MG, 50 MG NORPACE ORAL CAPSULE 00 MG, 50 MG pacerone oral tablet 00, 00, 400 propafenone oral capsule, ext-rel hr 5, 35, 45 propafenone oral tablet 50, 5, 300 3

33 quinidine gluconate oral tablet ext-rel 34 quinidine sulfate oral tablet 00, 300 sotalol af oral tablet 0, 60, 80 sotalol oral tablet 0, 60, 40, 80 TIKOSYN ORAL CAPSULE 5 MCG, 50 MCG, 500 MCG Antihypertensive Therapy acebutolol oral capsule 00, 400 afeditab cr oral tablet extrel 30, 60 amiloride oral tablet 5 amiloridehydrochlorothiazide oral tablet 5-50 amlodipine oral tablet 0,.5, 5 amlodipine-benazepril oral capsule 0-0, 0-40,.5-0, 5-0, 5-0, 5-40 amlodipine-olmesartan oral tablet 0-0, 0-40, 5-0, 5-40 amlodipine-valsartan oral tablet 0-60, 0-30, 5-60, 5-30 amlodipine-valsartanhydrochlorothiazide oral tablet , , , , atenolol oral tablet 00, 5, 50 atenolol-chlorthalidone tablet 00-5,50-5 benazepril oral tablet 0, 0, 40, 5 benazeprilhydrochlorothiazide oral tablet 0-.5, 0-.5, 0-5, betaxolol oral tablet 0, 0 BIDIL TABLET MG bisoprolol fumarate oral tablet 0, 5 bisoprololhydrochlorothiazide oral tablet 0-6.5,.5-6.5, bumetanide oral tablet 0.5,, BYSTOLIC ORAL TABLET 0 MG,.5 MG, 0 MG, 5 MG CALAN SR ORAL TABLET EXTENDED RELEASE 0 MG, 80 MG, 40 MG candesartan oral tablet 6, 3, 4, 8 candesartanhydrochlorothiazide oral tablet 6-.5, 3-.5, 3-5 3

34 captopril oral tablet.5, 5,50,00 captoprilhydrochlorothiazide oral tablet 5-5, 5-5, 50-5, 50-5 cartia xt oral capsule, extrelease 4hr 0, 80, 40, 300 carvedilol oral tablet 3.5,6.5,.5,5 chlorothiazide oral tablet 50, 500 chlorthalidone oral tablet 5, 50 clonidine hcl oral tablet 0., 0., 0.3 clonidine transdermal patch weekly 0. /4hr, 0. /4hr, 0.3 /4hr clorpres oral tablet 0.-5, 0.-5 CLORPRES ORAL TABLET MG COREG CR ORAL CAPSULE, ER MULTIPHASE 4 HR 0 MG, 0 MG, 40 MG, 80 MG DIBENZYLINE ORAL CAPSULE 0 MG diltiazem hcl oral capsule, ex-.rel 4hr degradable 40 diltiazem hcl oral capsule, extended release hr 0, 60, 90 diltiazem hcl oral capsule, extended release 4 hr 40, 40 diltiazem hcl oral capsule, extended release 4hr 0, 80, 40, 300, 360 diltiazem hcl tablet 0, 30, 60, 90 diltiazem hcl tablet ext-rel 4 hr 80, 40, 300, 360 dilt-xr oral capsule, ext.rel 4h degradable 0, 80, 40 DIOVAN HCT ORAL TABLET MG, 60-5 MG, MG, 30-5 MG, MG DIURIL ORAL SUSPENSION 50 MG/5 ML doxazosin oral tablet,, 4, 8 enalapril maleate oral tablet 0,.5, 0, 5 enalaprilhydrochlorothiazide oral tablet 0-5, 5-.5 eplerenone oral tablet 5, 50 eprosartan tablet 600 ethacrynic acid oral tablet 5 felodipine oral tablet extended release 4 hr 0,.5, 5 33 QL

35 fosinopril oral tablet 0, 0, 40 fosinoprilhydrochlorothiazide tablet 0-.5, 0-.5 furosemide oral soln 0 /ml, 40 /5 ml (8 /ml) furosemide oral tablet 0, 40, 80 guanfacine oral tablet, hydralazine oral tablet 0, 00, 5, 50 hydrochlorothiazide oral capsule.5 hydrochlorothiazide oral tablet.5,5,50 indapamide oral tablet.5,.5 irbesartan oral tablet 50, 300, 75 irbesartanhydrochlorothiazide tablet 50-.5, isradipine oral capsule.5, 5 labetalol oral tablet 00, 00, 300 lisinopril oral tablet 0,.5, 0, 30, 40, 5 lisinoprilhydrochlorothiazide oral tablet 0-.5, 0-.5, 0-5 losartan oral tablet 00, 5, 50 losartanhydrochlorothiazide oral tablet 00-.5, 00-5, matzim la oral tablet extended release 4 hr 80, 40, 300, 360, 40 MAXZIDE-5MG ORAL TABLET MG methyclothiazide oral tablet 5 methyldopa oral tablet 50, 500 methyldopahydrochlorothiazide oral tablet 50-5,50-5 metolazone oral tablet 0,.5, 5 metoprolol succinate oral tablet extended release 4 hr 00, 00, 5, 50 metoprolol tartratehydrochlorothiazide oral tablet 00-5, 00-50, 50-5 metoprolol tartrate oral tablet 00, 5, 37.5, 50, 75 minoxidil oral tablet 0,.5 moexipril oral tablet 5,

36 moexiprilhydrochlorothiazide oral tablet 5-.5, 5-5, nadolol oral tablet 0, 40, 80 nadololbendroflumethiazide oral tablet 40-5, 80-5 nicardipine oral capsule 0, 30 nifedipine oral capsule 0, 0 nifedipine oral tablet extended release 4hr 30, 60, 90 nifedipine oral tablet extended release 30, 60, 90 nimodipine oral capsule 30 nisoldipine oral tablet extended release 4 hr 7, 0, 5.5, 30, 34, 40, 8.5 olmesartan oral tablet 0, 40, 5 olmesartan-amlodipinehydrochlorothiazide tablet , , , , olmesartanhydrochlorothiazide oral tablet 0-.5, 40-.5, 40-5 ORENITRAM ORAL TABLET EXTENDED RELEASE 0.5 MG, 0.5 MG, MG,.5 MG, 5 MG perindopril erbumine oral tablet, 4, 8 phenoxybenzamine oral capsule 0 pindolol oral tablet 0, 5 prazosin oral capsule,, 5 propranolol oral capsule, extended release 4 hr 0, 60, 60, 80 propranolol oral soln 0 /5 ml (4 /ml), 40 /5 ml (8 /ml) propranolol oral tablet 0, 0, 40, 60, 80 propranololhydrochlorothiazide oral tablet 40-5, 80-5 quinapril oral tablet 0, 0, 40, 5 quinaprilhydrochlorothiazide oral tablet 0-.5, 0-.5, 0-5 ramipril oral capsule.5, 0,.5, 5 spironolactone oral tablet 00, 5, 50 PA; SP 35

37 spironolactonehydrochlorothiazide oral tablet 5-5 TARKA ORAL TABLET, IR - ER, BIPHASIC 4HR -40 MG, -80 MG, -40 MG, 4-40 MG taztia xt oral capsule, extended release 4 hr 0, 80, 40, 300, 360 TEKTURNA HCT TABLET MG, 50-5 MG, MG, MG TEKTURNA ORAL TABLET 50 MG, 300 MG telmisartan oral tablet 0, 40, 80 telmisartan-amlodipine oral tablet 40-0, 40-5, 80-0, 80-5 telmisartanhydrochlorothiazide oral tablet 40-.5, 80-.5, 80-5 terazosin oral capsule, 0,, 5 timolol maleate oral tablet 0, 0, 5 torsemide oral tablet 0, 00, 0, 5 trandolapril oral tablet,, 4 trandolapril-verapamil oral tablet, ir - er, biphasic 4hr -40, -80, -40, 4-40 QL triamterenehydrochlorothiazide oral capsule , 50-5 triamterenehydrochlorothiazide oral tablet , valsartan oral tablet 60, 30, 40, 80 valsartanhydrochlorothiazide oral tablet 60-.5, 60-5, 30-.5, 30-5, verapamil oral capsule, 4 hr er pellet ct 00, 00, 300 verapamil capsule, ext rel. pellets 4 hr 0, 80, 40, 360 verapamil oral tablet 0, 40, 80 verapamil oral tablet extended release 0, 80, 40 Cardiac Glycosides digitek oral tablet 5 mcg, 50 mcg digox oral tablet 5 mcg, 50 mcg digoxin oral soln 50 mcg/ml digoxin oral tablet 5 mcg, 50 mcg LANOXIN ORAL TABLET 5 MCG, 50 MCG 36

38 Coagulation Therapy AMICAR ORAL SOLN 50 MG/ML (5 %) AMICAR ORAL TABLET,000 MG, 500 MG ARIXTRA SUBCUTANEOUS SYRINGE 0 MG/0.8 ML,.5 MG/0.5 ML, 5 MG/0.4 ML, 7.5 MG/0.6 ML aspirin-dipyridamole oral capsule, er multiphase hr 5-00 fondaparinux subcutaneous syringe 0 /0.8 ml,.5 /0.5 ml, 5 /0.4 ml, 7.5 /0.6 ml hep flush-0 (pf) intravenous soln 0 unit/ml heparin (porcine) in 5 % dex intravenous parenteral soln 0,000 unit/500 ml (40 unit/ml), 5,000 unit/50 ml(00 unit/ml), 5,000 unit/500 ml (50 unit/ml) BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 00, 50 clopidogrel oral tablet 75 COUMADIN ORAL TABLET MG, 0 MG, MG,.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG dipyridamole oral tablet 5, 50, 75 EFFIENT ORAL TABLET 0 MG, 5 MG ELIQUIS ORAL TABLET.5 MG, 5 MG enoxaparin subcutaneous soln 300 /3 ml enoxaparin subcutaneous syringe 00 /ml, 0 /0.8 ml, 50 /ml, 30 /0.3 ml, 40 /0.4 ml, 60 /0.6 ml, 80 /0.8 ml heparin (porcine) in nacl (pf) intravenous parenteral soln,000 unit/500 ml,,000 unit/,000 ml heparin (porcine) injection cartridge 5,000 unit/ml ( ml) heparin (porcine) injection soln,000 unit/ml, 0,000 unit/ml, 0,000 unit/ml, 5,000 unit/ml heparin flush(porcine)- 0.9nacl intravenous kit 00 unit/ml heparin lock flush (porcine) intravenous soln 00 unit/ml heparin lock flush intravenous soln 0 unit/ml heparin lock flush intravenous syringe 0 unit/ml 37

39 heparin lockflush (porcine)(pf) intravenous syringe 0 unit/ml, 00 unit/ml heparin(porcine) in 0.45% nacl intravenous parenteral soln 00 unit/00 ml ( unit/ml), 5,000 unit/50 ml, 5,000 unit/500 ml heparin, porcine (pf) injection soln,000 unit/ml, 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml heparin, porcine (pf) intravenous soln 00 unit/ml ( ml) heparin, porcine (pf) intravenous syringe unit/ml, 0 unit/ml, 00 unit/ml jantoven oral tablet, 0,,.5, 3, 4, 5, 6, 7.5 MEPHYTON TABLET 5 MG pentoxifylline oral tablet extended release 400 PRADAXA ORAL CAPSULE 0 MG, 50 MG, 75 MG prasugrel oral tablet 0, 5 PROMACTA ORAL TABLET.5 MG, 5 MG, 50 MG, 75 MG PA; SP; LA ticlopidine tablet 50 warfarin tablet, 0,,.5, 3, 4, 5, 6, 7.5 XARELTO ORAL TABLET 0 MG, 5 MG, 0 MG XARELTO ORAL TABLETS, DOSE PACK 5 MG (4)- 0 MG (9) Lipid/Cholesterol Lowering Agents amlodipine-atorvastatin oral tablet 0-0, 0-0, 0-40, 0-80,.5-0,.5-0,.5-40, 5-0, 5-0, 5-40, 5-80 atorvastatin oral tablet 0, 0, 40, 80 CADUET TABLET 0-0 MG, 0-0 MG, 0-40 MG, 0-80 MG, 5-0 MG, 5-0 MG, 5-40 MG, 5-80 MG cholestyramine (with sugar) oral powder 4 gram cholestyramine (with sugar) oral powder in packet 4 gram cholestyramine light oral powder 4 gram cholestyramine light oral powder in packet 4 gram colestipol oral granules 5 gram colestipol oral packet 5 gram 38

40 colestipol oral tablet gram ezetimibe tablet 0 ezetimibe-simvastatin oral tablet 0-0, 0-0, 0-40, 0-80 fenofibrate micronized oral capsule 30, 34, 00, 43, 67 fenofibrate nanocrystallized oral tablet 45, 48 fenofibrate oral tablet 0, 60, 40, 54 fenofibric acid (choline) oral capsule, del-rel (dr/ec) 35, 45 fenofibric acid oral tablet 05, 35 fluvastatin oral capsule 0, 40 fluvastatin oral tablet extrel 4 hr 80 gemfibrozil tablet 600 lovastatin oral tablet 0, 0, 40 LOVAZA CAPSULE GRAM niacin oral tablet extended release 4 hr,000, 500, 750 omega-3 acid ethyl esters oral capsule gram PRALUENT PEN INJECTOR 50 MG/ML, 75 MG/ML QL PA; SP pravastatin oral tablet 0, 0, 40, 80 prevalite oral powder 4 gram prevalite oral powder in packet 4 gram QUESTRAN LIGHT ORAL POWDER 4 GRAM QUESTRAN ORAL POWDER 4 GRAM QUESTRAN ORAL POWDER IN PACKET 4 GRAM REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 40 MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 40 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE 40 MG/ML rosuvastatin oral tablet 0, 0 rosuvastatin oral tablet 40, 5 simvastatin oral tablet 0, 0, 40, 5, 80 triklo oral capsule gram TRILIPIX ORAL CAPSULE, DELAYED RELEASE(DR/EC) 35 MG, 45 MG WELCHOL ORAL POWDER IN PACKET 3.75 GRAM QL PA; SP PA; SP PA; SP QL 39

41 WELCHOL ORAL TABLET 65 MG Miscellaneous Cardiovascular Agents CORLANOR ORAL TABLET 5 MG, 7.5 MG ENTRESTO ORAL TABLET 4-6 MG, 49-5 MG, MG RANEXA ORAL TABLET EXTENDED RELEASE HR,000 MG, 500 MG Nitrates DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE 40 MG ISORDIL TABLET 40 MG ISORDIL TITRADOSE ORAL TABLET 5 MG isosorbide dinitrate oral tablet 0, 0, 30, 5 isosorbide dinitrate tablet extended release 40 isosorbide mononitrate oral tablet 0, 0 isosorbide mononitrate oral tablet ext-rel 4 hr 0, 30, 60 nitro-bid transdermal ointment % nitroglycerin oral capsule, extended release.5, 6.5, 9 nitroglycerin sublingual tablet 0.3, 0.4, 0.6 PA nitroglycerin transdermal patch 4 hour 0. /hr, 0. /hr, 0.4 /hr, 0.6 /hr nitroglycerin translingual aerosol, spray 400 mcg/spray nitroglycerin translingual spray, non-aerosol 400 mcg/spray NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG DERMATOLOGICALS/TOPICAL THERAPY Antipsoriatic / Antiseborrheic acitretin oral capsule 0, 7.5, 5 calcipotriene scalp soln % calcipotriene topical cream % calcipotriene topical ointment % calcipotrienebetamethasone topical ointment % calcitrene topical ointment % calcitriol topical ointment 3 mcg/gram COAL TAR TOPICAL SOLN 0 % COSENTYX ( SYRINGES) SUBCUTANEOUS SYRINGE 50 MG/ML QL PA; SP 40

42 COSENTYX PEN ( PENS) SUBCUTANEOUS PEN INJECTOR 50 MG/ML DOVONEX TOPICAL CREAM % drithocreme hp topical cream % EPIFOAM TOPICAL FOAM - % PRAMOSONE E TOPICAL CREAM.5- % PRAMOSONE TOPICAL CREAM - %,.5- % PRAMOSONE TOPICAL LOTION - %,.5- % PRAMOSONE TOPICAL OINTMENT - %,.5- % seb-prev topical cleanser 0 % selenium sulfide topical lotion.5 % selenium sulfide topical shampoo.5 % SORILUX TOPICAL FOAM % sulfacetamide sodium topical cleanser 0 % sulfacetamide sodium topical cleanser, gel 0 % sulfacetamide sodium topical shampoo 0 % TACLONEX TOPICAL OINTMENT % TACLONEX TOPICAL SUSPENSION % PA; SP QL QL Burn Therapy silver sulfadiazine topical cream % ssd topical cream % Keratolytics salicylic acid er-ceramides topical kit, cleanser and cream er 6 % salicylic acid topical cream 6 % salicylic acid topical cream, ext-rel 6 % salicylic acid topical film forming liq w/appl 7.5 % salicylic acid topical filmforming soln w/appl 8.5 % salicylic acid topical foam 6 % salicylic acid topical gel 6 % salicylic acid topical liquid 6 % salicylic acid topical lotion 6 % salicylic acid topical lotion, ext-rel 6 % salicylic acid topical shampoo 6 % salvax topical foam 6 % Miscellaneous Dermatologicals avo cream topical emulsion bp-50% urea topical emulsion 50 % 4

43 CARAC TOPICAL CREAM 0.5 % celacyn topical gel with pump cem-urea topical gel 45 % CONDYLOX TOPICAL GEL 0.5 % diclofenac sodium topical gel 3 % doxepin topical cream 5% DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/ ML eletone topical cream ELIDEL TOPICAL CREAM % emulsion sb topical emulsion FLUOROPLEX TOPICAL CREAM % fluorouracil topical cream 5 % fluorouracil topical soln %, 5 % hpr plus hydrogel topical kit,cream and gel hpr plus topical cream hpr plus topical foam hpr topical foam IODOFLEX TOPICAL PADS, MEDICATED 0.9 % IODOSORB TOPICAL GEL 0.9 % mb hydrogel (cyclomethicone) topical kit, cream and gel QL PA; SP; QL mb hydrogel topical kit, cream and gel % nivatopic plus topical cream podofilox topical solution 0.5 % PROTOPIC TOPICAL OINTMENT 0.03 %, 0. % pruclair topical cream prudoxin topical cream 5% prumyx topical cream prutect topical emulsion rea lo 39 topical cream 39 % rea lo 40 topical lotion 40 % REGRANEX TOPICAL GEL 0.0 % silver nitrate applicators topical stick 75-5 % silver nitrate topical ointment 0 % silver nitrate topical soln 0.5 %, 0 %, 5 %, 50 % sonafine topical emulsion sp antipruritic topical gel sp scar management topical gel with pump tacrolimus topical ointment 0.03 %, 0. % umecta topical foam 40 % QL 4

44 urea nail stick topical soln 50 % urea topical cream 39 %, 40 %, 45 %, 47 %, 50 % urea topical foam 35 % urea topical gel 45 % urea topical lotion 40 %, 45 % ure-k topical cream 50 % ZONALON TOPICAL CREAM 5 % Therapy For Acne ACANYA TOPICAL GEL WITH PUMP.-.5 % ACZONE TOPICAL GEL 5 % ACZONE TOPICAL GEL WITH PUMP 7.5 % adapalene topical gel 0.3 % adapalene topical gel with pump 0.3 % adapalene-benzoyl peroxide topical gel with pump % avar topical cleanser 0-5 % (w/w) avita topical cream 0.05 % AZELEX TOPICAL CREAM 0 % BENZACLIN PUMP TOPICAL GEL WITH PUMP -5 % BENZACLIN TOPICAL GEL -5 % bp 0- topical cleanser 0- % claravis oral capsule 0, 0, 30, 40 cleansing wash topical cleanser % clindacin p topical swab % CLINDAGEL TOPICAL GEL % clindamycin phosphate topical foam % clindamycin phosphate topical gel % clindamycin phosphate topical lotion % clindamycin phosphate topical soln % clindamycin phosphate topical swab % clindamycin-benzoyl peroxide topical gel -5 %,. %( % base) -5 % clindamycin-benzoyl peroxide topical gel with pump -5 % clindamycin-tretinoin topical gel % dapsone topical gel 5 % DIFFERIN TOPICAL GEL 0.3 % DIFFERIN TOPICAL GEL WITH PUMP 0.3 % DIFFERIN TOPICAL LOTION 0. % 43

2018 Ohana Community Care Services (CCS) Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Ohana Community Care Services (CCS) Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Ohana Community Care Services (CCS) Comprehensive referred Drug List (List of Covered Drugs) Ohana Health lan 00 lease read: This document contains information about the drugs we cover in this plan.

More information

2019 Ohana Community Care Services (CCS) Comprehensive Preferred Drug List (List of Covered Drugs)

2019 Ohana Community Care Services (CCS) Comprehensive Preferred Drug List (List of Covered Drugs) 2019 Ohana Community Care Services (CCS) Comprehensive referred Drug List (List of Covered Drugs) Ohana Health lan 00 lease read: This document contains information about the drugs we cover in this plan.

More information

2018 List of Covered Drugs (Formulary)

2018 List of Covered Drugs (Formulary) 208 List of Covered Drugs (Formulary) UCare s MSHO and UCare Connect + Medicare This is a list of drugs that members can get in UCare s MSHO and UCare Connect + Medicare. UCare s MSHO and UCare Connect

More information

2018 List of Covered Drugs (Formulary)

2018 List of Covered Drugs (Formulary) 208 List of Covered Drugs (Formulary) UCare s MSHO and UCare Connect + Medicare This is a list of drugs that members can get in UCare s MSHO and UCare Connect + Medicare. UCare s MSHO and UCare Connect

More information

New Jersey Department of Human Services State Upper Limit (SUL) List - PROPOSED Effective

New Jersey Department of Human Services State Upper Limit (SUL) List - PROPOSED Effective Generic_Name Current NJ SUL New NJ SUL Proposed ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-30MG 0.12455 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-60MG 0.25688 ALBUTEROL SULFATE

More information

Partnership 2017 Formulary. List of Covered Drugs

Partnership 2017 Formulary. List of Covered Drugs Partnership 207 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN ID 7379, Version Number 26 This formulary was updated on 0/24/207.

More information

Health First Health Plans 2018 Formulary (List of Covered Drugs)

Health First Health Plans 2018 Formulary (List of Covered Drugs) Updated: July 1, 2018 Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Employer Group Plus A Plan (HMO) Employer Group Plus B Plan (HMO) Employer Group POS Plan (HMO-POS) Health First Health

More information

PRESCRIPTION DRUGS FORMULARY 1. I ~~ [ tl-i I Classicare (HMO)

PRESCRIPTION DRUGS FORMULARY 1. I ~~ [ tl-i I Classicare (HMO) PRESCRIPTION DRUGS FORMULARY 1 2018 I ~~ [ tl-i I Classicare (HMO) MCS Classicare 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS

More information

Formulary for North Dakota Medicaid Expansion Members

Formulary for North Dakota Medicaid Expansion Members Formulary for North Dakota Medicaid Expansion Members Please refer to the following list (formulary) of commonly prescribed medications that are covered by insurance. This is not a complete list; to view

More information

Health First Health Plans 2019 Formulary (List of Covered Drugs)

Health First Health Plans 2019 Formulary (List of Covered Drugs) Updated: 10/2018 Health First Health Plans 2019 Formulary (List of Covered Drugs) Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Employer Group Plus A Plan (HMO) Employer Group Plus B Plan

More information

2018 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS)

2018 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS) 208 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS) This formulary was updated on 05/0/208. For more recent information or other questions, please

More information

COMPREHENSIVE FORMULARY

COMPREHENSIVE FORMULARY 08 COMPREHENSIVE FORMULARY CARE N CARE CHOICE PREMIUM (PPO) CARE N CARE CHOICE PLUS (PPO) CARE N CARE CHOICE (PPO) CARE N CARE CLASSIC (HMO) (LIST OF COVERED DRUGS) PLEASE READ: THIS DOCUMENT CONTAINS

More information

Memorial Hermann Advantage HMO Formulary. (List of Covered Drugs)

Memorial Hermann Advantage HMO Formulary. (List of Covered Drugs) Memorial Hermann Advantage H 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 19563,

More information

Partnership 2017 Formulary. List of Covered Drugs

Partnership 2017 Formulary. List of Covered Drugs Partnership 207 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN ID 7379, Version Number 9 This formulary was updated on 5/23/207. For

More information

Health First Health Plans 2019 Formulary (List of Covered Drugs)

Health First Health Plans 2019 Formulary (List of Covered Drugs) Updated: March 1, 2019 Health First Health Plans 2019 Formulary (List of Covered Drugs) SunSaver (HMO) Employer Group Plus C Plan (HMO) Employer Group Plus D Plan (HMO) Employer Group POS B Plan (HMO-POS)

More information

OPTIMA HEALTH OPTIMA FAMILY CARE (JANUARY MARCH 2019) PRESCRIPTION DRUG FORMULARY WITH MEDICAID EXPANSION (XP) Effective: January 1, 2019

OPTIMA HEALTH OPTIMA FAMILY CARE (JANUARY MARCH 2019) PRESCRIPTION DRUG FORMULARY WITH MEDICAID EXPANSION (XP) Effective: January 1, 2019 OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY OPTIMA FAMILY CARE WITH MEDICAID EXPANSION (XP) (JANUARY MARCH 2019) Revised: 1/2/2019 Table of Contents Analgesics - Drugs for Pain... 3 Analgesics - Drugs for

More information

PRESCRIPTION DRUG FORMULARY

PRESCRIPTION DRUG FORMULARY OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY OPTIMA FAMILY CARE (FAMIS) (April June 2019) Revised: 3/27/2019 Table of Contents Analgesics - Drugs for Pain... 3 Analgesics - Drugs for Pain and Inflammation...

More information

2018 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS)

2018 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS) 208 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS) This formulary was updated on 09/08/207. For more recent information or other questions, please

More information

Antibiotic Treatments. Arthritis & Pain. Asthma. Cholesterol

Antibiotic Treatments. Arthritis & Pain. Asthma. Cholesterol MAX Saver Plan Drug List 08/06/14 GENERIC NAME Allergies and Cold & Flu BENZONATATE CAP 100 MG 14 42 cap CETIRIZINE HCL TAB 10MG 30 90 tab CETIRIZINE HCL TAB 5MG 30 90 tab DIPHENHYDRAMINE HCL CAP 50 MG

More information

COMPREHENSIVE FORMULARY

COMPREHENSIVE FORMULARY COMPREHENSIVE FORMULARY HEALTHTEAM ADVANTAGE PLAN I (PPO) HEALTHTEAM ADVANTAGE PLAN II (PPO) (LIST OF COVERED DRUGS) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

More information

2018 Formulary. (List of Covered Drugs) Group UCare for Seniors (HMO-POS)

2018 Formulary. (List of Covered Drugs) Group UCare for Seniors (HMO-POS) 08 Formulary (List of Covered Drugs) Group UCare for Seniors (HMO-POS) This formulary was updated on 0/0/08. For more recent information or other questions, please contact UCare for Seniors Customer Services

More information

2018 Formulary (List of Covered Drugs)

2018 Formulary (List of Covered Drugs) 018 Formulary (List of Covered Drugs) UCare for Seniors Essentials Rx (HMO-POS) UCare for Seniors Value Plus (HMO-POS) UCare for Seniors Classic (HMO-POS) This formulary was updated on 11/01/018. For more

More information

2018 Formulary (List of Covered Drugs)

2018 Formulary (List of Covered Drugs) 08 Formulary (List of Covered Drugs) UCare for Seniors Essentials Rx (HMO-POS) UCare for Seniors Value Plus (HMO-POS) UCare for Seniors Classic (HMO-POS) This formulary was updated on 04/0/08. For more

More information

GuildNet Gold. Formulary Medicare Advantage Prescription Drug Plan

GuildNet Gold. Formulary Medicare Advantage Prescription Drug Plan GuildNet Gold Medicare Advantage Prescription Drug Plan Formulary 2018 This formulary was updated on 07/31/2017. For more recent information or other questions, please contact the Plan at 1-800-815-0000

More information

Health First Health Plans 2016 Formulary (List of Covered Drugs)

Health First Health Plans 2016 Formulary (List of Covered Drugs) Updated: November 1, 2016 Florida Hospital SunSaver Plan (HMO-POS) Florida Hospital Explorer Plan (HMO-POS) Health First Health Plans 2016 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS

More information

2018 Formulary. (List of Covered Drugs) Group UCare for Seniors (HMO-POS)

2018 Formulary. (List of Covered Drugs) Group UCare for Seniors (HMO-POS) 08 Formulary (List of Covered Drugs) Group UCare for Seniors (HMO-POS) This formulary was updated on 0/0/08. For more recent information or other questions, please contact UCare for Seniors Customer Services

More information

Memorial Hermann Advantage HMO & PPO Formulary. (List of Covered Drugs)

Memorial Hermann Advantage HMO & PPO Formulary. (List of Covered Drugs) Memorial Hermann Advantage H & PPO 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File 00017383, Version

More information

(List of Covered Drugs)

(List of Covered Drugs) Superior Select Health Plans H-POS SNP 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19550, Version Number 5

More information

Provider Partners Health Plan of Ohio (HMO SNP) 2019 Formulary (List of Covered Drugs)

Provider Partners Health Plan of Ohio (HMO SNP) 2019 Formulary (List of Covered Drugs) Provider Partners Health Plan of Ohio (H SNP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19582, Version 5

More information

2016 COMPREHENSIVE FORMULARY

2016 COMPREHENSIVE FORMULARY 016 COMPREHENSIVE FORMULARY (LIST OF COVERED DRUGS) PRESCRIPTION DRUG PLANS Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on

More information

Florida Hospital Care Advantage 2017 Formulary (List of Covered Drugs)

Florida Hospital Care Advantage 2017 Formulary (List of Covered Drugs) Updated: November 1, 2017 Explorer Plan (HMO-POS) SunSaver Plan (HMO-POS) Florida Hospital Care Advantage 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE

More information

Updated: November 1, 2017 Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Health First Health Plans 2017 Formulary (List of Covered Drugs)

Updated: November 1, 2017 Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Health First Health Plans 2017 Formulary (List of Covered Drugs) Updated: November 1, 2017 Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Health First Health Plans 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT

More information

HAP Empowered MI Health Link Medicare-Medicaid Plan 2019 List of Covered Drugs (Formulary)

HAP Empowered MI Health Link Medicare-Medicaid Plan 2019 List of Covered Drugs (Formulary) H9712_2019 LOCD; Approved HAP Empowered MI Health Link Medicare-Medicaid Plan 2019 List of Covered Drugs (Formulary) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT S WE COVER IN THIS PLAN. CMS Approved

More information

Provider Partners Pennsylvania Advantage Plan (HMO SNP) 2019 Formulary (List of Covered Drugs)

Provider Partners Pennsylvania Advantage Plan (HMO SNP) 2019 Formulary (List of Covered Drugs) Provider Partners Pennsylvania Advantage Plan (H SNP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19548, Version

More information

Provider Partners Illinois Advantage Plan (HMO SNP) 2019 Formulary (List of Covered Drugs)

Provider Partners Illinois Advantage Plan (HMO SNP) 2019 Formulary (List of Covered Drugs) Provider Partners Illinois Advantage Plan (H SNP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19547, Version

More information

SIGNATURE ADVANTAGE Formulary. (List of Covered Drugs)

SIGNATURE ADVANTAGE Formulary. (List of Covered Drugs) SIGNATURE ADVANTAGE 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19552, Version Number 5 This formulary was

More information

2015 MEDICARE PART D DRUG FORMULARY

2015 MEDICARE PART D DRUG FORMULARY 2015 MEDICARE PART D DRUG FORMULARY 1199SEIU Medicare Advantage Formulary This formulary was updated on 08/08/2014. For more recent information or other questions, please contact EmblemHealth at 1-877-447-1199

More information

2017 COMPREHENSIVE FORMULARY

2017 COMPREHENSIVE FORMULARY 017 COMPREHENSIVE FORMULARY (LIST OF COVERED DRUGS) PRESCRIPTION DRUG PLANS Please Read: This document contains information about the drugs we cover in this plan. This formulary was updated on 09/01/016.

More information

2017 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans

2017 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans We re in this together: Quality Health Care 017 Comprehensive Formulary (List of Covered s) Prescription Plans WellCare Prescription Insurance, Inc. Plans in all states: WellCare Extra (PDP) Plans in the

More information

2018 MEDICARE PART D DRUG FORMULARY EmblemHealth HMO 5-Tier Comprehensive Medication List

2018 MEDICARE PART D DRUG FORMULARY EmblemHealth HMO 5-Tier Comprehensive Medication List 2018 MEDICARE PART D DRUG FORMULARY EmblemHealth HMO 5-Tier Comprehensive Medication List This comprehensive formulary was updated on 09/13/2017. For more recent information or other questions, please

More information

BCBSGa Blue MedicareRx Standard (PDP) 2018 Formulary (List of Covered Drugs) Please read: ,

BCBSGa Blue MedicareRx Standard (PDP) 2018 Formulary (List of Covered Drugs) Please read: , BCBSGa Blue MedicareRx Standard (PDP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October, 08.

More information

Memorial Hermann Advantage HMO & PPO Abridged Formulary. (Partial List of Covered Drugs)

Memorial Hermann Advantage HMO & PPO Abridged Formulary. (Partial List of Covered Drugs) Memorial Hermann Advantage H & PPO 2017 Abridged Formulary (Partial List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary

More information

2019 HAP Formulary. List of covered drugs, cost tiers and how it all works

2019 HAP Formulary. List of covered drugs, cost tiers and how it all works HAP Empowered Duals (HMO SNP) 209 HAP Formulary List of covered drugs, cost tiers and how it all works PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THESE PLANS. This formulary

More information

Blue MedicareRx Value (PDP) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem.

Blue MedicareRx Value (PDP) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem. Blue MedicareRx Value (PDP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on May, 08. For more recent

More information

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans We re in this together: Quality Health Care 017 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans Easy Choice Health Plan Plans in the following state: CA Easy Choice Best Plan(HMO)

More information

Superior Select Health Plans Formulary. (List of Covered Drugs)

Superior Select Health Plans Formulary. (List of Covered Drugs) Superior Select Health Plans 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 18379, Version Number 6 This formulary

More information

2017 Formulary (List of Covered Drugs)

2017 Formulary (List of Covered Drugs) Tribute Health Plan of Arkansas (H POS SNP) H1587 001 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 17384, Version

More information

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN.

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN. HealthPartners Freedom Vital with Rx (Cost) HealthPartners Freedom Balance with Rx (Cost) HealthPartners Freedom Ultimate with Rx (Cost) HealthPartners Freedom Ultimate with Enhanced Rx (Cost) HealthPartners

More information

Health First Health Plans 2015 Formulary (List of Covered Drugs)

Health First Health Plans 2015 Formulary (List of Covered Drugs) Updated: October 27, 2015 Florida Hospital SunSaver Plan (HMO-POS) Florida Hospital Explorer Plan (HMO-POS) Health First Health Plans 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS

More information

2018 Formulary. (List of Covered Drugs)

2018 Formulary. (List of Covered Drugs) 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 18390 Version #: 18 This formulary

More information

Allergies and Cold & Flu

Allergies and Cold & Flu MAX Saver Plan Drug List 01/23/17 GENERIC NAME Allergies and Cold & Flu BENZONATATE CAP 100 MG 14 42 cap CETIRIZINE HCL TAB 10MG 30 90 tab CETIRIZINE HCL TAB 5MG 30 90 tab DIPHENHYDRAMINE HCL CAP 50 MG

More information

WELLCARE HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 10/2014)

WELLCARE HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 10/2014) WELLCARE HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 10/2014) **To get updated information about the drugs covered by WellCare, please visit our website (https://www.wellcare.com) or

More information

Amerivantage Classic (HMO) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO)

Amerivantage Classic (HMO) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO) Amerivantage Classic (H) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on November, 07. For more recent

More information

Superior Select Health Plans Formulary. (List of Covered Drugs)

Superior Select Health Plans Formulary. (List of Covered Drugs) Superior Select Health Plans 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 18379, Version Number 14 This formulary

More information

2016 COMPREHENSIVE FORMULARY

2016 COMPREHENSIVE FORMULARY 016 COMPREHENSIVE FORMULARY (LIST OF COVERED DRUGS) MEDICARE ADVANTAGE PLANS Please Read: This document contains information about the drugs we cover in this plan. This formulary was updated on 11/01/016.

More information

Y0070_NA026578_WCM_FOR_ENG_FINAL_02 CMS Approved NA5V02FOR59890E 0915 WellCare 2015 NA_09_15

Y0070_NA026578_WCM_FOR_ENG_FINAL_02 CMS Approved NA5V02FOR59890E 0915 WellCare 2015 NA_09_15 2015 Comprehensive e Formulary (List of Covered ed Drugs) Medicare e Advantage Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated

More information

Anthem MediBlue Select (HMO) 2016 Formulary (List of Covered Drugs)

Anthem MediBlue Select (HMO) 2016 Formulary (List of Covered Drugs) Anthem MediBlue Select (H) 06 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October, 06. For more recent

More information

PLEASE READ: This document contains information about the drugs we cover in this plan.

PLEASE READ: This document contains information about the drugs we cover in this plan. 01 Formulary (List of Covered s) CareMore Value Plus (H), CareMore Breathe (H SNP), CareMore Diabetes (H SNP), CareMore ESRD (H SNP), CareMore Heart (H SNP) CareMore Reliance (H SNP) PLEASE READ: This

More information

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans We re in this together: Quality Health Care 017 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare/ Ohana Plans in the following states: AR, CT, FL, IL, KY, LA, NJ, NY, TX, TN

More information

S5596_001, 006, 014, 018, 057, 063

S5596_001, 006, 014, 018, 057, 063 Anthem Blue MedicareRx Plus (PDP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on May, 08. For more

More information

PREFERRED DRUG LIST 2018

PREFERRED DRUG LIST 2018 PREFERRED DRUG LIST 2018 PDL National Formulary Preferred Drug List - May 2018 - The Preferred Drug List is a guide identifying preferred brandname medicines within select therapeutic categories. The Preferred

More information

Express Scripts Medicare (PDP) 2018 Formulary (List of Covered Drugs)

Express Scripts Medicare (PDP) 2018 Formulary (List of Covered Drugs) Saver Plan Express Scripts Medicare (PDP) 2018 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID Number: 18152, Version 9

More information

Express Scripts Medicare (PDP) 2017 Formulary (List of Covered Drugs)

Express Scripts Medicare (PDP) 2017 Formulary (List of Covered Drugs) Choice Plan Express Scripts Medicare (PDP) 017 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary File Submission ID: 17070, V18

More information

2019 Formulary (List of Covered Drugs)

2019 Formulary (List of Covered Drugs) MEDICARE ADVANTAGE PLANS 2019 Formulary (List of Covered Drugs) Presbyterian Senior Care (HMO) Presbyterian Senior Care (HMO-POS) Presbyterian MediCare PPO Please Read: This document contains information

More information

2015 Comprehensive Formulary (List of Covered Drugs)

2015 Comprehensive Formulary (List of Covered Drugs) 2015 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on

More information

2018 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans

2018 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans 018 Comprehensive Formulary (List of Covered s) Prescription Plans WellCare Prescription Insurance, Inc. Plans in all states: WellCare Classic (PDP) Please Read: This document contains information about

More information

Express Scripts Medicare (PDP) 2018 Formulary (List of Covered Drugs)

Express Scripts Medicare (PDP) 2018 Formulary (List of Covered Drugs) Choice Plan Express Scripts Medicare (PDP) 2018 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID Number: 18155, Version 9

More information

2018 Formulary. (List of Covered Drugs)

2018 Formulary. (List of Covered Drugs) 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 18390 Version #: 11 This formulary

More information

OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY

OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY 09 OPTIMAFIT INDIVIDUAL AND FAMILY PLANS (April - June 09) Revised: /7/09 NOTE: Formulary Status means Affordable Care () drugs are covered at 00%. Table of Contents

More information

Comprehensive Formulary (List of Covered Drugs)

Comprehensive Formulary (List of Covered Drugs) 2015 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on

More information

EnvisionRxPlus Formulary. (List of Covered Drugs)

EnvisionRxPlus Formulary. (List of Covered Drugs) EnvisionRxPlus 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission 18365, Version Number

More information

What is the CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Abridged Formulary?

What is the CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Abridged Formulary? CHRISTUS Health Plan Generations (HMO) CHRISTUS Health Plan Generations Plus (HMO) 019 Abridged Formulary Partial List of Covered s PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS

More information

2015 Comprehensive Formulary (List of Covered Drugs)

2015 Comprehensive Formulary (List of Covered Drugs) 2015 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on

More information

Comprehensive Formulary

Comprehensive Formulary 2015 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on

More information

<Add Logo> BlueShield of Northeastern New York Formulary. (List of Covered Drugs)

<Add Logo> BlueShield of Northeastern New York Formulary. (List of Covered Drugs) BlueShield of Northeastern New York 017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission

More information

2016 MEDICARE PART D DRUG FORMULARY

2016 MEDICARE PART D DRUG FORMULARY 2016 MEDICARE PART D DRUG FORMULARY 1199SEIU EmblemHealth VIP Medicare Plan Abridged Medication List This abridged formulary was updated on 11/01/2016. This is not a complete list of drugs covered by our

More information

Anthem MediBlue Access (PPO) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem.

Anthem MediBlue Access (PPO) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem. Anthem MediBlue Access (PPO) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on November, 07. For more

More information

2017 COMPREHENSIVE FORMULARY

2017 COMPREHENSIVE FORMULARY 017 COMPREHENSIVE FORMULARY (LIST OF COVERED DRUGS) MEDICARE ADVANTAGE PLANS Please Read: This document contains information about the drugs we cover in this plan. This formulary was updated on 09/01/016.

More information

Empire MediBlue Plus (HMO) 2018 Formulary (List of Covered Drugs) Please read: ,

Empire MediBlue Plus (HMO) 2018 Formulary (List of Covered Drugs) Please read: , Empire MediBlue Plus (H) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October, 08. For more recent

More information

2017 Formulary (List of Covered Drugs)

2017 Formulary (List of Covered Drugs) 017 Formulary (List of Covered s) PLEASE READ: This document contains information about the drugs we cover in this plan. Y011_17_0810A_CHP_MT_FINAL_ Populated Template (08901) 0001709_, v0 This formulary

More information