2014 Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia Inter-pregnancy Care 00 9 lease read: This document contains information about the drugs we cover in this plan. ara solicitar este documento en español o para escuchar la traducción, llame al Servicio al Cliente al 1-866-231-1821 (TTY/TDD: 1-877-247-6272). lease note that the Georgia Inter-pregnancy Care referred Drug List is updated quarterly. roviders, please visit our website at http://georgia.wellcare.com/provider/p4hb to view updates to the preferred drug list. Members, please visit our website at https://georgia.wellcare.com/member/p4hb to view updates to the preferred drug list. Last updated (01/01/2014)
Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the A process. UERCASE = Brand name drugs italics = Generic drugs reference Details = referred Dagger ( ) = N/A Asterisk (*) = N/A Asterisk (**) = N/A Asterisk (***) = N/A XX = N/A Coverage Details A = rior Authorization ST = Step Therapy QL = Quantity Limit AL = Age Limit OTC = OTC- Covered w/rx Drug Name reference Details Coverage Details *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexia nts* *Amphetamines** *Amphetamine Mixtures*** ADDERALL XR ORAL CASULE EXTENDED RELEASE 24 HOUR 10, 15, 20, 25, 30, 5 Amphetamine-Dextroamphetamine ORAL TABLET 10, 12.5, 15, 5, 7.5 Amphetamine-Dextroamphetamine ORAL TABLET 20 Amphetamine-Dextroamphetamine ORAL TABLET 30 *Amphetamines*** Dextroamphetamine Sulfate ORAL TABLET 10, 5 Dextroamphetamine Sulfate ER ORAL CASULE EXTENDED RELEASE 24 HOUR 10, 15, 5 VYVANSE ORAL CASULE 20, 30, 40, 50, 60, 70 *Stimulants - Misc.** QL (62 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 day(s)) QL (62 EA per 31 day(s)) ST; QL (31 EA per 31 day(s)); AL (Min 5 Years and Max 20 Years) QL (31 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) 1
Drug Name reference Details Coverage Details *Stimulants - Misc.*** Dexmethylphenidate HCl ORAL TABLET 10, 2.5, 5 METHYLIN ORAL TABLET CHEWABLE 10, 2.5, 5 Methylphenidate HCl ORAL TABLET 10, 5 Methylphenidate HCl ORAL TABLET 20 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 10 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 18, 27, 36 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 20 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 54 *Alternative Medicines* *Alternative Medicine - M's** *Alternative Medicine - Me's*** Melatonin ORAL TABLET 5 OTC Melatonin Maximum Strength ORAL TABLET 5 *Aminoglycosides* *Aminoglycosides** *Aminoglycosides*** TOBI INHALATION NEBULIZATION SOLUTION 300 /5ML *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies** *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA SUBCUTANEOUS* KIT 20 /0.4ML, 40 /0.8ML HUMIRA EN SUBCUTANEOUS* KIT 40 /0.8ML HUMIRA EN-CROHNS STARTER SUBCUTANEOUS* KIT 40 /0.8ML QL (62 EA per 31 day(s)); AL (Min 6 Years) AL (Min 6 Years) AL (Min 6 Years) QL (93 EA per 31 day(s)); AL (Min 6 Years) AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) OTC A A A A 2
Drug Name reference Details Coverage Details SIMONI SUBCUTANEOUS* SOLUTION 100 /ML, 50 /0.5ML *Gold Compounds** *Gold Compounds*** RIDAURA ORAL CASULE 3 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)** *Cyclooxygenase 2 (Cox-2) Inhibitors*** CELEBREX ORAL CASULE 100, 200, 400, 50 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** Diclofenac otassium ORAL TABLET 50 Diclofenac Sodium ORAL TABLET DELAYED RELEASE 25, 50, 75 Etodolac ORAL CASULE 200, 300 Etodolac ORAL TABLET 400, 500 Flurbiprofen ORAL TABLET 100, 50 Ibuprofen ORAL SUSENSION 100 /5ML Ibuprofen ORAL TABLET 400, 600, 800 Indomethacin ORAL CASULE 25, 50 Ketorolac Tromethamine ORAL TABLET 10 Meloxicam ORAL TABLET 15, 7.5 Nabumetone ORAL TABLET 500, 750 Naproxen ORAL SUSENSION 125 /5ML Naproxen ORAL TABLET 250, 375, 500 Naproxen Sodium ORAL TABLET 275, 550 iroxicam ORAL CASULE 10, 20 Sulindac ORAL TABLET 150, 200 *Analgesics - Nonnarcotic* *Salicylates** A ST; QL (31 EA per 31 day(s)) OTC QL (20 EA per 31 day(s)) QL (2000 ML per 31 day(s)) 3
Drug Name reference Details Coverage Details *Salicylates*** Diflunisal ORAL TABLET 500 *Androgens-Anabolic* *Anabolic Steroids** *Anabolic Steroids*** Oxandrolone ORAL TABLET 10, 2.5 A *Androgens** *Androgens*** Danazol ORAL CASULE 100, 200, 50 *Anthelmintics* *Anthelmintics** *Anthelmintics*** ALBENZA ORAL TABLET 200 A BILTRICIDE ORAL TABLET 600 A Reeses inworm Medicine ORAL SUSENSION 144 /ML OTC STROMECTOL ORAL TABLET 3 QL (10 EA per 31 day(s)) *Antianginal Agents* *Nitrates** *Nitrates*** Isosorbide Dinitrate ORAL TABLET 10, 20, 30, 5 Isosorbide Dinitrate ER ORAL TABLET EXTENDEDRELEASE* 40 Isosorbide Mononitrate ORAL TABLET 10, 20 Isosorbide Mononitrate ER ORAL TABLET EXTENDED RELEASE 24 HR* 120, 30, 60 NITRO-BID TRANSDERMAL OINTMENT 2 % Nitroglycerin TRANSDERMAL ATCH 24 HR 0.1 /HR, 0.2 /HR, 0.4 /HR, 0.6 /HR NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3, 0.4, 0.6 *Antianxiety Agents* 4
Drug Name reference Details Coverage Details *Antianxiety Agents - Misc.** *Antianxiety Agents - Misc.*** BusIRone HCl ORAL TABLET 10, 15, 30, 5, 7.5 Meprobamate ORAL TABLET 200, 400 *Benzodiazepines** *Benzodiazepines*** Diazepam ORAL SOLUTION 1 /ML QL (1240 ML per 31 day(s)) *Antiarrhythmics* *Antiarrhythmics Type I-A** *Antiarrhythmics Type I-A*** Disopyramide hosphate ORAL CASULE 100, 150 rocainamide HCl INJECTION SOLUTION 100 /ML, 500 /ML QuiNIDine Gluconate INJECTION SOLUTION 80 /ML QuiNIDine Gluconate ER ORAL TABLET EXTENDEDRELEASE* 324 QuiNIDine Sulfate ORAL TABLET 300 *Antiarrhythmics Type I-B** *Antiarrhythmics Type I-B*** Mexiletine HCl ORAL CASULE 150, 200, 250 *Antiarrhythmics Type I-C** *Antiarrhythmics Type I-C*** Flecainide Acetate ORAL TABLET 100, 150, 50 ropafenone HCl ORAL TABLET 150, 225, 300 *Antiarrhythmics Type Iii** *Antiarrhythmics Type Iii*** Amiodarone HCl INTRAVENOUS* SOLUTION 150 /3ML Amiodarone HCl ORAL TABLET 200, 400 5
Drug Name reference Details Coverage Details ACERONE ORAL TABLET 200, 400 *Antiasthmatic And Bronchodilator Agents* *Antiasthmatic - Monoclonal Antibodies** *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 *Anti-Inflammatory Agents** *Anti-Inflammatory Agents*** Cromolyn Sodium INHALATION NEBULIZATION SOLUTION 20 /2ML *Bronchodilators - Anticholinergics** *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT Ipratropium Bromide INHALATION SOLUTION 0.02 % TUDORZA RESSAIR INHALATION AEROSOL OWDER, BREATH ACTIVATED 400 MCG/ACT *Leukotriene Modulators** *Leukotriene Receptor Antagonists*** Montelukast Sodium ORAL ACKET 4 Montelukast Sodium ORAL TABLET 10 Montelukast Sodium ORAL TABLET CHEWABLE 4, 5 Zafirlukast ORAL TABLET 10, 20 *Steroid Inhalants** *Steroid Inhalants*** ASMANEX 120 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH A QL (25.8 GM per 31 day(s)) QL (480 ML per 31 day(s)) QL (1 EA per 30 day(s)) QL (1 EA per 30 day(s)) QL (1 EA per 30 day(s)) QL (1 EA per 30 day(s)) 6
Drug Name reference Details Coverage Details Budesonide INHALATION SUSENSION 0.25 /2ML, 0.5 /2ML FLOVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT ULMICORT INHALATION SUSENSION 1 /2ML QVAR INHALATION AEROSOL, SOLUTION 40 MCG/ACT QVAR INHALATION AEROSOL, SOLUTION 80 MCG/ACT *Sympathomimetics** *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT COMBIVENT INHALATION AEROSOL 18-103 MCG/ACT COMBIVENT RESIMAT INHALATION AEROSOL, SOLUTION 20-100 MCG/ACT DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT Ipratropium-Albuterol INHALATION SOLUTION 0.5-2.5 (3) /3ML SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT *Beta Adrenergics*** Albuterol Sulfate INHALATION NEBULIZATION SOLUTION (2.5 /3ML) 0.083% QL (120 ML per 31 day(s)); AL (Max 8 Years) QL (60 EA per 30 day(s)) QL (12 GM per 30 day(s)) QL (10.6 GM per 30 day(s)) QL (120 ML per 31 day(s)); AL (Max 8 Years) QL (8.7 GM per 30 day(s)) QL (17.4 GM per 30 day(s)) QL (60 EA per 30 day(s)) QL (12 GM per 30 day(s)) QL (29.4 GM per 31 day(s)) QL (4 GM per 20 day(s)) QL (13 GM per 31 day(s)) QL (720 ML per 31 day(s)) QL (10.2 GM per 30 day(s)) QL (720 ML per 31 day(s)) 7
Drug Name reference Details Coverage Details Albuterol Sulfate INHALATION NEBULIZATION SOLUTION (5 /ML) 0.5% Albuterol Sulfate INHALATION NEBULIZATION SOLUTION 0.63 /3ML, 1.25 /3ML QL (60 ML per 30 day(s)) QL (300 ML per 31 day(s)) Albuterol Sulfate ORAL SYRU 2 /5ML QL (2480 ML per 31 day(s)) Albuterol Sulfate ORAL TABLET 2, 4 FORADIL AEROLIZER INHALATION CASULE 12 MCG Metaproterenol Sulfate ORAL SYRU 10 /5ML SEREVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 50 MCG/DOSE Terbutaline Sulfate INJECTION SOLUTION 1 /ML Terbutaline Sulfate ORAL TABLET 2.5, 5 VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT *Xanthines** *Xanthines*** ELIXOHYLLIN ORAL ELIXIR 80 /15ML Theophylline ORAL SOLUTION 80 /15ML Theophylline ER ORAL TABLET EXTENDED RELEASE 12 HR* 100, 200, 300, 450 Theophylline ER ORAL TABLET EXTENDED RELEASE 24 HR* 400, 600 *Anticoagulants* *Coumarin Anticoagulants** *Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 QL (60 EA per 30 day(s)) QL (60 EA per 30 day(s)) QL (36 GM per 31 day(s)) 8
Drug Name reference Details Coverage Details Warfarin Sodium ORAL TABLET 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *Anticonvulsants* *Anticonvulsants - Benzodiazepines** *Anticonvulsants - Benzodiazepines*** ClonazeAM ORAL TABLET 0.5, 1, 2 *Anticonvulsants - Misc.** *Anticonvulsants - Misc.*** CarBAMazepine ORAL SUSENSION 100 /5ML QL (2480 ML per 31 day(s)) CarBAMazepine ORAL TABLET 200 QL (248 EA per 31 day(s)) CarBAMazepine ORAL TABLET CHEWABLE 100 QL (310 EA per 31 day(s)) EITOL ORAL TABLET 200 QL (248 EA per 31 day(s)) Gabapentin ORAL CASULE 100 QL (310 EA per 31 day(s)) Gabapentin ORAL CASULE 300 QL (372 EA per 31 day(s)) Gabapentin ORAL CASULE 400 QL (279 EA per 31 day(s)) Gabapentin ORAL SOLUTION 250 /5ML QL (2230 ML per 31 day(s)) Gabapentin ORAL TABLET 600, 800 LamoTRIgine ORAL TABLET 100, 150, 200 LamoTRIgine ORAL TABLET 25 QL (310 EA per 31 day(s)) LamoTRIgine ORAL TABLET CHEWABLE 25, 5 LevETIRAcetam INTRAVENOUS* SOLUTION 500 /5ML LevETIRAcetam ORAL SOLUTION 100 /ML LevETIRAcetam ORAL TABLET 1000, 500, 750 QL (310 EA per 31 day(s)) QL (1000 ML per 31 day(s)) LevETIRAcetam ORAL TABLET 250 QL (372 EA per 31 day(s)) OXcarbazepine ORAL SUSENSION 300 /5ML QL (1240 ML per 31 day(s)) OXcarbazepine ORAL TABLET 150 QL (310 EA per 31 day(s)) OXcarbazepine ORAL TABLET 300 QL (248 EA per 31 day(s)) OXcarbazepine ORAL TABLET 600 9
Drug Name reference Details Coverage Details rimidone ORAL TABLET 250 QL (248 EA per 31 day(s)) rimidone ORAL TABLET 50 QL (310 EA per 31 day(s)) Topiramate ORAL CASULE SRINKLE 15, 25 Topiramate ORAL TABLET 100, 25, 50 QL (310 EA per 31 day(s)) QL (310 EA per 31 day(s)) Topiramate ORAL TABLET 200 QL (248 EA per 31 day(s)) Zonisamide ORAL CASULE 100 QL (186 EA per 31 day(s)) Zonisamide ORAL CASULE 25 QL (310 EA per 31 day(s)) Zonisamide ORAL CASULE 50 QL (372 EA per 31 day(s)) *Gaba Modulators** *Gaba Modulators*** GABITRIL ORAL TABLET 12, 16 TiaGABine HCl ORAL TABLET 2, 4 *Hydantoins** *Hydantoins*** DILANTIN ORAL CASULE 30 QL (310 EA per 31 day(s)) Fosphenytoin Sodium INJECTION SOLUTION 100 E/2ML EGANONE ORAL TABLET 250 QL (372 EA per 31 day(s)) henytoin ORAL SUSENSION 125 /5ML henytoin ORAL TABLET CHEWABLE 50 henytoin Sodium INJECTION SOLUTION 50 /ML henytoin Sodium Extended ORAL CASULE 100, 200, 300 *Succinimides** *Succinimides*** Ethosuximide ORAL CASULE 250 Ethosuximide ORAL SOLUTION 250 /5ML *Valproic Acid** *Valproic Acid*** Divalproex Sodium ORAL CASULE SRINKLE 125 QL (930 ML per 31 day(s)) QL (372 EA per 31 day(s)) QL (930 ML per 31 day(s)) QL (310 EA per 31 day(s)) 10
Drug Name reference Details Coverage Details Divalproex Sodium ORAL TABLET DELAYED RELEASE 125, 250 Divalproex Sodium ORAL TABLET DELAYED RELEASE 500 Divalproex Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 250 Divalproex Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 500 QL (310 EA per 31 day(s)) QL (279 EA per 31 day(s)) QL (310 EA per 31 day(s)) QL (279 EA per 31 day(s)) Valproic Acid ORAL CASULE 250 QL (310 EA per 31 day(s)) Valproic Acid ORAL SOLUTION 250 /5ML QL (2790 ML per 31 day(s)) Valproic Acid ORAL SYRU 250 /5ML QL (2790 ML per 31 day(s)) *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)** *Alpha-2 Receptor Antagonists (Tetracyclics)*** Mirtazapine ORAL TABLET 15, 30, 45, 7.5 Mirtazapine ORAL TABLET DISERSIBLE 15, 30, 45 *Antidepressants - Misc.** *Antidepressants - Misc.*** BUDERION SR ORAL TABLET EXTENDED RELEASE 12 HR* 150 BuROion HCl ORAL TABLET 100, 75 BuROion HCl ER (SR) ORAL TABLET EXTENDED RELEASE 12 HR* 100, 150, 200 BuROion HCl ER (XL) ORAL TABLET EXTENDED RELEASE 24 HR* 150, 300 Maprotiline HCl ORAL TABLET 25, 50, 75 *Modified Cyclics** *Modified Cyclics*** Nefazodone HCl ORAL TABLET 100, 150, 200, 250, 50 TraZODone HCl ORAL TABLET 100, 150, 50 11
Drug Name reference Details Coverage Details *Monoamine Oxidase Inhibitors (Maois)** *Monoamine Oxidase Inhibitors (Maois)*** henelzine Sulfate ORAL TABLET 15 Tranylcypromine Sulfate ORAL TABLET 10 *Selective Serotonin Reuptake Inhibitors (Ssris)** *Selective Serotonin Reuptake Inhibitors (Ssris)*** Citalopram Hydrobromide ORAL TABLET 10, 20, 40 Escitalopram Oxalate ORAL TABLET 10, 20, 5 FLUoxetine HCl ORAL CASULE 10, 20, 40 FLUoxetine HCl ORAL SOLUTION 20 /5ML FLUoxetine HCl ORAL TABLET 10, 20 FluvoxaMINE Maleate ORAL TABLET 100, 25, 50 ARoxetine HCl ORAL TABLET 10, 20, 30, 40 Sertraline HCl ORAL TABLET 100, 25, 50 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)** *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** Venlafaxine HCl ORAL TABLET 100, 25, 37.5, 50, 75 Venlafaxine HCl ER ORAL CASULE EXTENDED RELEASE 24 HOUR 150, 37.5, 75 *Tricyclic Agents** *Tricyclic Agents*** Amitriptyline HCl ORAL TABLET 10, 100, 150, 25, 50, 75 Amoxapine ORAL TABLET 100, 150, 25, 50 QL (31 EA per 31 day(s)) 12
Drug Name reference Details Coverage Details ClomiRAMINE HCl ORAL CASULE 25, 50, 75 Desipramine HCl ORAL TABLET 10, 100, 150, 25, 50, 75 Doxepin HCl ORAL CASULE 10, 100, 25, 50, 75 Doxepin HCl ORAL CONCENTRATE 10 /ML Imipramine HCl ORAL TABLET 10, 25, 50 Nortriptyline HCl ORAL CASULE 10, 25, 50, 75 Nortriptyline HCl ORAL SOLUTION 10 /5ML rotriptyline HCl ORAL TABLET 10, 5 *Antidiabetics* *Alpha-Glucosidase Inhibitors** *Alpha-Glucosidase Inhibitors*** Acarbose ORAL TABLET 100, 25, 50 *Antidiabetic Combinations** *Dipeptidyl eptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET 50-1000, 50-500 JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100-1000, 50-1000, 50-500 JENTADUETO ORAL TABLET 2.5-1000, 2.5-500, 2.5-850 *Sulfonylurea-Biguanide Combinations*** GlipiZIDE-MetFORMIN HCl ORAL TABLET 2.5-250, 2.5-500, 5-500 GlyBURIDE-MetFORMIN ORAL TABLET 1.25-250, 2.5-500, 5-500 *Sulfonylurea-Thiazolidinedione Combinations*** AVANDARYL ORAL TABLET 4-1, 4-2, 4-4, 8-2, 8-4 QL (2325 ML per 31 day(s)) ST ST ST; QL (31 EA per 31 day(s)) ST 13
Drug Name reference Details Coverage Details *Thiazolidinedione-Biguanide Combinations*** AVANDAMET ORAL TABLET 2-1000, 2-500, 4-1000, 4-500 ioglitazone HCl-Metformin HCl ORAL TABLET 15-500, 15-850 *Biguanides** *Biguanides*** MetFORMIN HCl ORAL TABLET 1000, 500, 850 MetFORMIN HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 500, 750 MetFORMIN HCl ER (OSM) ORAL TABLET EXTENDED RELEASE 24 HR* 500 RIOMET ORAL SOLUTION 500 /5ML QL (900 ML per 31 day(s)) *Diabetic Other** *Diabetic Other*** GLUCAGEN INJECTION SOLUTION RECONSTITUTED 1 GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 GLUCAGON EMERGENCY INJECTION KIT 1 *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors** *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100, 25, 50 ST ST QL (2 EA per 31 day(s)) QL (2 EA per 31 day(s)) QL (2 EA per 31 day(s)) TRADJENTA ORAL TABLET 5 ST; QL (31 EA per 31 Day(s)) *Incretin Mimetic Agents (Glp-1 Receptor Agonists)** *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS* SUSENSION RECONSTITUTED 2 *Insulin Sensitizing Agents** *Thiazolidinediones*** AVANDIA ORAL TABLET 2, 4, 8 ST ST; QL (4 EA per 28 day(s)) ST 14
Drug Name reference Details Coverage Details ioglitazone HCl ORAL TABLET 15, 30, 45 *Insulin** *Human Insulin*** AIDRA INJECTION SOLUTION 100 UNIT/ML AIDRA SOLOSTAR SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS* SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 50/50 KWIKEN SUBCUTANEOUS* SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS* SUSENSION (75-25) 100 UNIT/ML HUMALOG MIX 75/25 KWIKEN SUBCUTANEOUS* SUSENSION (75-25) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS* SUSENSION (70-30) 100 UNIT/ML HUMULIN 70/30 EN SUBCUTANEOUS* SUSENSION (70-30) 100 UNIT/ML HUMULIN N SUBCUTANEOUS* SUSENSION 100 UNIT/ML HUMULIN N EN SUBCUTANEOUS* SUSENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS* SOLUTION 100 UNIT/ML *Sulfonylureas** ST QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) OTC; QL (60 ML per 31 day(s)) OTC; QL (60 ML per 31 day(s)) OTC; QL (60 ML per 31 day(s)) OTC; QL (60 ML per 31 day(s)) OTC; QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) 15
Drug Name reference Details Coverage Details *Sulfonylureas*** ChlorproAMIDE ORAL TABLET 100, 250 Glimepiride ORAL TABLET 1, 2, 4 GlipiZIDE ORAL TABLET 10, 5 GlipiZIDE ER ORAL TABLET EXTENDED RELEASE 24 HR* 10, 2.5, 5 GLIIZIDE XL ORAL TABLET EXTENDED RELEASE 24 HR* 10, 2.5, 5 GlyBURIDE ORAL TABLET 1.25, 2.5, 5 GlyBURIDE Micronized ORAL TABLET 1.5, 3, 6 *Antifungals* *Antifungals** *Antifungals*** Griseofulvin Microsize ORAL SUSENSION 125 /5ML Griseofulvin Microsize ORAL TABLET 500 Griseofulvin Ultramicrosize ORAL TABLET 125, 250 Nystatin ORAL TABLET 500000 UNIT Terbinafine HCl ORAL TABLET 250 *Imidazole-Related Antifungals** *Imidazoles*** Ketoconazole ORAL TABLET 200 *Triazoles*** Fluconazole ORAL SUSENSION RECONSTITUTED 10 /ML, 40 /ML Fluconazole ORAL TABLET 100, 150, 200, 50 *Antihyperlipidemics* *Antihyperlipidemics - Combinations** *Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb*** QL (450 ML per 31 day(s)) 16
Drug Name reference Details Coverage Details VYTORIN ORAL TABLET 10-10, 10-20, 10-40, 10-80 *Bile Acid Sequestrants** *Bile Acid Sequestrants*** Cholestyramine ORAL ACKET 4 GM Cholestyramine ORAL OWDER 4 GM/DOSE Cholestyramine Light ORAL ACKET 4 GM Cholestyramine Light ORAL OWDER 4 GM/DOSE *Fibric Acid Derivatives** *Fibric Acid Derivatives*** Fenofibrate ORAL TABLET 160, 54 Fenofibrate Micronized ORAL CASULE 134, 200, 67 Gemfibrozil ORAL TABLET 600 *Hmg Coa Reductase Inhibitors** *Hmg Coa Reductase Inhibitors*** Atorvastatin Calcium ORAL TABLET 10, 20, 40, 80 Lovastatin ORAL TABLET 10, 20, 40 ravastatin Sodium ORAL TABLET 10, 20, 40, 80 Simvastatin ORAL TABLET 10, 20, 40, 5, 80 *Intestinal Cholesterol Absorption Inhibitors** *Intestinal Cholesterol Absorption Inhibitors*** ZETIA ORAL TABLET 10 A *Nicotinic Acid Derivatives** *Nicotinic Acid Derivatives*** NIACOR ORAL TABLET 500 *Antihypertensives* *Ace Inhibitors** *Ace Inhibitors*** Benazepril HCl ORAL TABLET 10, 20, 40, 5 A ST 17
Drug Name reference Details Coverage Details Captopril ORAL TABLET 100, 12.5, 25, 50 Enalapril Maleate ORAL TABLET 10, 2.5, 20, 5 Fosinopril Sodium ORAL TABLET 10, 20, 40 Lisinopril ORAL TABLET 10, 2.5, 20, 30, 40, 5 Quinapril HCl ORAL TABLET 10, 20, 40, 5 Ramipril ORAL CASULE 1.25, 10, 2.5, 5 *Angiotensin Ii Receptor Antagonists** *Angiotensin Ii Receptor Antagonists*** Losartan otassium ORAL TABLET 100, 25, 50 *Antiadrenergic Antihypertensives** *Antiadrenergics - Centrally Acting*** CloNIDine HCl ORAL TABLET 0.1, 0.2, 0.3 GuanFACINE HCl ORAL TABLET 1, 2 Methyldopa ORAL TABLET 250, 500 *Antihypertensive Combinations** *Ace Inhibitors & Thiazide/Thiazide-Like*** Benazepril-Hydrochlorothiazide ORAL TABLET 10-12.5, 20-12.5, 20-25, 5-6.25 Captopril-Hydrochlorothiazide ORAL TABLET 25-15, 25-25, 50-15, 50-25 Enalapril-Hydrochlorothiazide ORAL TABLET 10-25, 5-12.5 Lisinopril-Hydrochlorothiazide ORAL TABLET 10-12.5, 20-12.5, 20-25 *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** Losartan otassium-hctz ORAL TABLET 100-12.5, 100-25, 50-12.5 *Beta Blocker & Diuretic Combinations*** QL (31 EA per 31 day(s)) QL (31 EA per 31 day(s)) 18
Drug Name reference Details Coverage Details Atenolol-Chlorthalidone ORAL TABLET 100-25, 50-25 Bisoprolol-Hydrochlorothiazide ORAL TABLET 10-6.25, 2.5-6.25, 5-6.25 ropranolol-hctz ORAL TABLET 40-25, 80-25 *Vasodilators** *Vasodilators*** HydrALAZINE HCl INJECTION SOLUTION 20 /ML HydrALAZINE HCl ORAL TABLET 10, 100, 25, 50 Minoxidil ORAL TABLET 10, 2.5 *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.** *Anti-Infective Agents - Misc.*** MetroNIDAZOLE ORAL TABLET 250, 500 Trimethoprim ORAL TABLET 100 Vancomycin HCl INTRAVENOUS* SOLUTION RECONSTITUTED 1000, 500, 750 Vancomycin HCl ORAL CASULE 125, 250 *Anti-Infective Misc. - Combinations** *Anti-Infective Misc. - Combinations*** Erythromycin-Sulfisoxazole ORAL SUSENSION RECONSTITUTED 200-600 /5ML Sulfamethoxazole-TM DS ORAL TABLET 800-160 Sulfamethoxazole-Trimethoprim ORAL SUSENSION 200-40 /5ML Sulfamethoxazole-Trimethoprim ORAL TABLET 400-80 *Antiprotozoal Agents** *Antiprotozoal Agents*** A QL (1200 ML per 31 day(s)) 19
Drug Name reference Details Coverage Details MERON ORAL SUSENSION 750 /5ML *Leprostatics** *Leprostatics*** Dapsone ORAL TABLET 100, 25 *Lincosamides** *Lincosamides*** Clindamycin HCl ORAL CASULE 150, 300, 75 Clindamycin almitate HCl ORAL SOLUTION RECONSTITUTED 75 /5ML Clindamycin hosphate INJECTION SOLUTION 300 /2ML, 600 /4ML, 9 GM/60ML, 900 /6ML Clindamycin hosphate INTRAVENOUS* SOLUTION 300 /2ML *Antimalarials* *Antimalarial Combinations** *Antimalarial Combinations*** Atovaquone-roguanil HCl ORAL TABLET 250-100, 62.5-25 *Antimalarials** *Antimalarials*** DARARIM ORAL TABLET 25 Hydroxychloroquine Sulfate ORAL TABLET 200 Mefloquine HCl ORAL TABLET 250 rimaquine hosphate ORAL TABLET 26.3 *Antimyasthenic/Cholinergic Agents* *Antimyasthenic/Cholinergic Agents** *Antimyasthenic/Cholinergic Agents*** MESTINON ORAL SYRU 60 /5ML MESTINON ORAL TABLET EXTENDEDRELEASE* 180 ROSTIGMIN ORAL TABLET 15 yridostigmine Bromide ORAL TABLET 60 QL (2400 ML per 31 day(s)) 20
Drug Name reference Details Coverage Details *Antimycobacterial Agents* *Antimycobacterial Agents** *Antimycobacterial Agents*** Ethambutol HCl ORAL TABLET 100, 400 Isoniazid INJECTION SOLUTION 100 /ML Isoniazid ORAL TABLET 100, 300 MYCOBUTIN ORAL CASULE 150 yrazinamide ORAL TABLET 500 Rifampin INTRAVENOUS* SOLUTION RECONSTITUTED 600 Rifampin ORAL CASULE 150, 300 *Antineoplastics And Adjunctive Therapies* *Antineoplastic - Hormonal And Related Agents** *rogestins-antineoplastic*** Megestrol Acetate ORAL SUSENSION 40 /ML Megestrol Acetate ORAL TABLET 20, 40 *Antiparkinson Agents* *Antiparkinson Anticholinergics** *Antiparkinson Anticholinergics*** Benztropine Mesylate ORAL TABLET 0.5, 1, 2 Trihexyphenidyl HCl ORAL ELIXIR 0.4 /ML Trihexyphenidyl HCl ORAL TABLET 2, 5 *Antiparkinson Dopaminergics** *Antiparkinson Dopaminergics*** Amantadine HCl ORAL CASULE 100 Amantadine HCl ORAL SYRU 50 /5ML Amantadine HCl ORAL TABLET 100 Bromocriptine Mesylate ORAL CASULE 5 21
Drug Name reference Details Coverage Details Bromocriptine Mesylate ORAL TABLET 2.5 *Levodopa Combinations*** Carbidopa-Levodopa ORAL TABLET 10-100, 25-100, 25-250 Carbidopa-Levodopa ER ORAL TABLET EXTENDEDRELEASE* 25-100, 50-200 *Nonergoline Dopamine Receptor Agonists*** ramipexole Dihydrochloride ORAL TABLET 0.125, 0.25, 0.5, 0.75, 1, 1.5 ROINIRole HCl ORAL TABLET 0.25, 0.5, 1, 2, 3, 4, 5 *Antiparkinson Monoamine Oxidase Inhibitors** *Antiparkinson Monoamine Oxidase Inhibitors*** Selegiline HCl ORAL CASULE 5 Selegiline HCl ORAL TABLET 5 *Antipsychotics/Antimanic Agents* *Antimanic Agents** *Antimanic Agents*** Lithium Carbonate ORAL CASULE 150, 300, 600 Lithium Carbonate ORAL TABLET 300 Lithium Carbonate ER ORAL TABLET EXTENDEDRELEASE* 300, 450 Lithium Citrate ORAL SOLUTION 8 MEQ/5ML *Benzisoxazoles** *Benzisoxazoles*** INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 117 /0.75ML, 156 /ML, 234 /1.5ML, 39 /0.25ML, 78 /0.5ML RisperiDONE ORAL SOLUTION 1 /ML RisperiDONE ORAL TABLET 0.25, 0.5, 1, 2, 3, 4 ST A; QL (1 ML per 28 day(s)); AL (Min 18 Years) QL (496 ML per 31 day(s)); AL (Min 5 Years) QL (62 EA per 31 day(s)); AL (Min 5 Years) 22
Drug Name reference Details Coverage Details RisperiDONE ORAL TABLET DISERSIBLE 0.25, 0.5, 1, 2, 3, 4 RISERIDONE M-TAB ORAL TABLET DISERSIBLE 0.5, 1, 2, 3, 4 *Butyrophenones** *Butyrophenones*** Haloperidol ORAL TABLET 0.5, 1, 10, 2, 5 Haloperidol Decanoate INTRAMUSCULAR* SOLUTION 100 /ML, 50 /ML Haloperidol Lactate INJECTION SOLUTION 5 /ML Haloperidol Lactate ORAL CONCENTRATE 2 /ML *Dibenzapines** *Dibenzodiazepines*** CloZAine ORAL TABLET 100, 200, 25, 50 CloZAine ORAL TABLET DISERSIBLE 12.5 *Dibenzo-Oxepino yrroles*** SAHRIS SUBLINGUAL TABLET SUBLINGUAL 10, 5 *Dibenzothiazepines*** QUEtiapine Fumarate ORAL TABLET 100, 200, 25, 300, 400, 50 *Dibenzoxazepines*** Loxapine Succinate ORAL CASULE 10, 25, 5, 50 *Thienbenzodiazepines*** OLANZapine ORAL TABLET 10, 15, 2.5, 20, 5, 7.5 *henothiazines** *henothiazines*** ChlorproMAZINE HCl ORAL TABLET 10, 100, 200, 25, 50 QL (62 EA per 31 day(s)); AL (Min 5 Years) QL (62 EA per 31 day(s)); AL (Min 5 Years) AL (Min 3 Years) AL (Min 18 Years) AL (Min 3 Years) AL (Min 3 Years) AL (Min 18 Years) QL (31 EA per 31 day(s)); AL (Min 18 Years) ST; AL (Min 18 Years) AL (Min 10 Years) AL (Min 18 Years) QL (31 EA per 31 day(s)); AL (Min 13 Years) AL (Min 6 Months) 23
Drug Name reference Details Coverage Details FluHENAZine Decanoate INJECTION SOLUTION 25 /ML FluHENAZine HCl ORAL CONCENTRATE 5 /ML FluHENAZine HCl ORAL ELIXIR 2.5 /5ML FluHENAZine HCl ORAL TABLET 1, 10, 2.5, 5 erphenazine ORAL TABLET 16, 2, 4, 8 AL (Min 12 Years) QL (248 ML per 31 day(s)) QL (2480 ML per 31 day(s)) AL (Min 12 Years) rochlorperazine RE SUOSITORY 25 AL (Min 2 Years) rochlorperazine Maleate ORAL TABLET 10, 5 Thioridazine HCl ORAL TABLET 10, 100, 25, 50 Trifluoperazine HCl ORAL TABLET 1, 10, 2, 5 *Thioxanthenes** *Thioxanthenes*** Thiothixene ORAL CASULE 1, 10, 2, 5 *Antivirals* *Antiretrovirals** *Antiretrovirals - Rti-Nucleotide Analogues*** VIREAD ORAL TABLET 150, 200, 250 *Hepatitis Agents** *Hepatitis B Agents*** BARACLUDE ORAL TABLET 0.5, 1 *Herpes Agents** *Herpes Agents - urine Analogues*** Acyclovir ORAL CASULE 200 AL (Min 2 Years) AL (Min 2 Years) AL (Min 6 Years) AL (Min 12 Years) Acyclovir ORAL SUSENSION 200 /5ML QL (3500 ML per 31 day(s)) Acyclovir ORAL TABLET 400, 800 ValACYclovir HCl ORAL TABLET 1 GM, 500 *Influenza Agents** A QL (62 EA per 31 day(s)) 24
Drug Name reference Details Coverage Details *Influenza Agents*** Rimantadine HCl ORAL TABLET 100 *Neuraminidase Inhibitors*** RELENZA DISKHALER INHALATION AEROSOL OWDER, BREATH ACTIVATED 5 /BLISTER QL (40 EA per 365 day(s)); AL (Min 7 Years) TAMIFLU ORAL CASULE 30 QL (40 EA per 365 day(s)) TAMIFLU ORAL CASULE 45, 75 QL (20 EA per 365 day(s)) TAMIFLU ORAL SUSENSION RECONSTITUTED 6 /ML *Assorted Classes* *Immunosuppressive Agents** *Cyclosporine Analogs*** CycloSORINE ORAL CASULE 100, 25 CycloSORINE Modified ORAL CASULE 100, 25, 50 CycloSORINE Modified ORAL SOLUTION 100 /ML GENGRAF ORAL CASULE 100, 25 GENGRAF ORAL SOLUTION 100 /ML SANDIMMUNE ORAL SOLUTION 100 /ML *Inosine Monophosphate Dehydrogenase Inhibitors*** CELLCET ORAL SUSENSION RECONSTITUTED 200 /ML Mycophenolate Mofetil ORAL CASULE 250 Mycophenolate Mofetil ORAL TABLET 500 *Macrolide Immunosuppressants*** HECORIA ORAL CASULE 0.5, 1, 5 Tacrolimus ORAL CASULE 0.5, 1, 5 *urine Analogs*** AzaTHIOprine ORAL TABLET 50 QL (360 ML per 365 day(s)); AL (Max 18 Years) 25
Drug Name reference Details Coverage Details *Beta Blockers* *Alpha-Beta Blockers** *Alpha-Beta Blockers*** Carvedilol ORAL TABLET 12.5, 25, 3.125, 6.25 Labetalol HCl INTRAVENOUS* SOLUTION 5 /ML Labetalol HCl ORAL TABLET 100, 200, 300 *Beta Blockers Cardio-Selective** *Beta Blockers Cardio-Selective*** Atenolol ORAL TABLET 100, 25, 50 Bisoprolol Fumarate ORAL TABLET 10, 5 Metoprolol Succinate ER ORAL TABLET EXTENDED RELEASE 24 HR* 100, 200, 25, 50 Metoprolol Tartrate INTRAVENOUS* SOLUTION 1 /ML Metoprolol Tartrate ORAL TABLET 100, 25, 50 *Beta Blockers Non-Selective** *Beta Blockers Non-Selective*** Nadolol ORAL TABLET 20, 40, 80 indolol ORAL TABLET 10, 5 ropranolol HCl INTRAVENOUS* SOLUTION 1 /ML ropranolol HCl ORAL TABLET 10, 20, 40, 60, 80 ropranolol HCl ER ORAL CASULE EXTENDED RELEASE 24 HOUR 120, 160, 60, 80 SORINE ORAL TABLET 120, 160, 240, 80 Sotalol HCl ORAL TABLET 120, 160, 240, 80 Sotalol HCl (AF) ORAL TABLET 120, 160, 80 26
Drug Name reference Details Coverage Details Timolol Maleate ORAL TABLET 10, 20, 5 *Calcium Channel Blockers* *Calcium Channel Blockers** *Calcium Channel Blockers*** AmLODIine Besylate ORAL TABLET 10, 2.5, 5 CARTIA XT ORAL CASULE EXTENDED RELEASE 24 HOUR 120, 180, 240, 300 Dilt-XR ORAL CASULE EXTENDED RELEASE 24 HOUR 120, 180, 240 Diltiazem HCl INTRAVENOUS* SOLUTION 125 /25ML, 25 /5ML, 50 /10ML Diltiazem HCl ORAL TABLET 120, 30, 60, 90 Diltiazem HCl ER ORAL CASULE EXTENDED RELEASE 12 HOUR 120, 60, 90 Diltiazem HCl ER Beads ORAL CASULE EXTENDED RELEASE 24 HOUR 120, 180, 240, 300, 360, 420 Diltiazem HCl ER Coated Beads ORAL CASULE EXTENDED RELEASE 24 HOUR 120, 180, 240, 300, 360 MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180, 240, 300, 360, 420 NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30, 60, 90 NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30, 60 NIFEdipine ORAL CASULE 10 NIFEdipine ER Osmotic ORAL TABLET EXTENDED RELEASE 24 HR* 30, 60, 90 27
Drug Name reference Details Coverage Details Verapamil HCl ORAL TABLET 120, 40, 80 Verapamil HCl ER ORAL CASULE EXTENDED RELEASE 24 HOUR 100, 120, 180, 200, 240, 300, 360 Verapamil HCl ER ORAL TABLET EXTENDEDRELEASE* 120, 180, 240 *Cardiotonics* *Cardiac Glycosides** *Cardiac Glycosides*** Digoxin INJECTION SOLUTION 0.25 /ML Digoxin ORAL SOLUTION 0.05 /ML Digoxin ORAL TABLET 0.125, 0.25 *Cardiovascular Agents - Misc.* *ulmonary Hypertension - Endothelin Receptor Antagonists** *ulmonary Hypertension - Endothelin Receptor Antagonists*** LETAIRIS ORAL TABLET 10, 5 A *ulmonary Hypertension - hosphodiesterase Inhibitors** *ulmonary Hypertension - hosphodiesterase Inhibitors*** Sildenafil Citrate ORAL TABLET 20 A *Cephalosporins* *Cephalosporins - 1St Generation** *Cephalosporins - 1St Generation*** Cefadroxil ORAL CASULE 500 Cefadroxil ORAL SUSENSION RECONSTITUTED 250 /5ML, 500 /5ML Cefadroxil ORAL TABLET 1 GM Cephalexin ORAL CASULE 250, 500, 750 Cephalexin ORAL SUSENSION RECONSTITUTED 125 /5ML 28
Drug Name reference Details Coverage Details Cephalexin ORAL SUSENSION RECONSTITUTED 250 /5ML *Cephalosporins - 2Nd Generation** *Cephalosporins - 2Nd Generation*** Cefaclor ORAL CASULE 250, 500 Cefprozil ORAL SUSENSION RECONSTITUTED 125 /5ML, 250 /5ML Cefprozil ORAL TABLET 250, 500 Cefuroxime Axetil ORAL SUSENSION RECONSTITUTED 125 /5ML Cefuroxime Axetil ORAL TABLET 250, 500 *Cephalosporins - 3Rd Generation** *Cephalosporins - 3Rd Generation*** Cefdinir ORAL CASULE 300 Cefdinir ORAL SUSENSION RECONSTITUTED 125 /5ML, 250 /5ML Cefpodoxime roxetil ORAL SUSENSION RECONSTITUTED 100 /5ML, 50 /5ML Cefpodoxime roxetil ORAL TABLET 100, 200 *Contraceptives* *Combination Contraceptives - Oral** *Biphasic Contraceptives - Oral*** KARIVA ORAL TABLET 0.15-0.02/0.01 (21/5) *Combination Contraceptives - Oral*** ALTAVERA ORAL TABLET 0.15-30 -MCG ARI ORAL TABLET 0.15-30 -MCG AVIANE ORAL TABLET 0.1-20 -MCG BALZIVA ORAL TABLET 0.4-35 -MCG Briellyn ORAL TABLET 0.4-35 -MCG CRYSELLE-28 ORAL TABLET 0.3-30 -MCG QL (300 ML per 31 day(s)) 29
Drug Name reference Details Coverage Details EMOQUETTE ORAL TABLET 0.15-30 -MCG ESTARYLLA ORAL TABLET 0.25-35 -MCG GIANVI ORAL TABLET 3-0.02 JUNEL 1.5/30 ORAL TABLET 1.5-30 -MCG JUNEL 1/20 ORAL TABLET 1-20 -MCG JUNEL FE 1.5/30 ORAL TABLET 1.5-30 -MCG JUNEL FE 1/20 ORAL TABLET 1-20 -MCG KELNOR 1/35 ORAL TABLET 1-35 -MCG LESSINA ORAL TABLET 0.1-20 -MCG LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 -MCG LORYNA ORAL TABLET 3-0.02 LOW-OGESTREL ORAL TABLET 0.3-30 -MCG LUTERA ORAL TABLET 0.1-20 -MCG MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 -MCG MICROGESTIN 1/20 ORAL TABLET 1-20 -MCG MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 -MCG MICROGESTIN FE 1/20 ORAL TABLET 1-20 -MCG MONONESSA ORAL TABLET 0.25-35 -MCG NECON 0.5/35 (28) ORAL TABLET 0.5-35 -MCG NECON 1/35 (28) ORAL TABLET 1-35 -MCG NECON 1/50 (28) ORAL TABLET 1-50 -MCG NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 -MCG 30
Drug Name reference Details Coverage Details NORTREL 1/35 (21) ORAL TABLET 1-35 -MCG NORTREL 1/35 (28) ORAL TABLET 1-35 -MCG OCELLA ORAL TABLET 3-0.03 ORTIA-28 ORAL TABLET 0.15-30 -MCG REVIFEM ORAL TABLET 0.25-35 -MCG RECLISEN ORAL TABLET 0.15-30 -MCG SOLIA ORAL TABLET 0.15-30 -MCG SRINTEC 28 ORAL TABLET 0.25-35 -MCG SRONYX ORAL TABLET 0.1-20 -MCG SYEDA ORAL TABLET 3-0.03 ZENCHENT FE ORAL TABLET CHEWABLE 0.4-35 -MCG ZOVIA 1/35E (28) ORAL TABLET 1-35 -MCG ZOVIA 1/50E (28) ORAL TABLET 1-50 -MCG *Extended-Cycle Contraceptives - Oral*** QUASENSE ORAL TABLET 0.15-0.03 QL (91 EA per 91 day(s)) *Triphasic Contraceptives - Oral*** CAZIANT ORAL TABLET 0.1/0.125/0.15-0.025 ENRESSE-28 ORAL TABLET NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 -MCG NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 -MCG TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25-35 MCG TRI-REVIFEM ORAL TABLET 0.18/0.215/0.25-35 MCG TRI-SRINTEC ORAL TABLET 0.18/0.215/0.25-35 MCG 31
Drug Name reference Details Coverage Details TRINESSA (28) ORAL TABLET 0.18/0.215/0.25-35 MCG TRIVORA (28) ORAL TABLET VELIVET ORAL TABLET 0.1/0.125/0.15-0.025 *Combination Contraceptives - Vaginal** *Combination Contraceptives - Vaginal*** NUVARING VAGINAL RING 0.12-0.015 /24HR *Emergency Contraceptives** *Emergency Contraceptives*** Levonorgestrel ORAL TABLET 0.75 QL (4 EA per 31 day(s)) LAN B ONE-STE ORAL TABLET 1.5 *rogestin Contraceptives - Injectable** *rogestin Contraceptives - Injectable*** MedroxyROGESTERone Acetate INTRAMUSCULAR* SUSENSION 150 /ML *rogestin Contraceptives - Oral** *rogestin Contraceptives - Oral*** CAMILA ORAL TABLET 0.35 ERRIN ORAL TABLET 0.35 JOLIVETTE ORAL TABLET 0.35 NOR-QD ORAL TABLET 0.35 NORA-BE ORAL TABLET 0.35 *Corticosteroids* *Glucocorticosteroids** *Glucocorticosteroids*** Hydrocortisone ORAL TABLET 10, 20, 5 rednisone ORAL SOLUTION 5 /5ML rednisone ORAL TABLET 1, 10, 2.5, 20, 5 *Mineralocorticoids** *Mineralocorticoids*** Fludrocortisone Acetate ORAL TABLET 0.1 OTC QL (1 ML per 93 day(s)) 32
Drug Name reference Details Coverage Details *Dermatologicals* *Acne roducts** *Acne Combinations*** Benzoyl eroxide-erythromycin EXTERNAL GEL 5-3 % *Acne roducts*** LAVOCLEN-4 CREAMY WASH EXTERNAL LIQUID 4 % LAVOCLEN-8 CREAMY WASH EXTERNAL LIQUID 8 % *Antibiotics - Topical** *Antibiotics - Topical*** Bacitracin Zinc EXTERNAL OINTMENT 500 UNIT/GM *Antifungals - Topical** *Antifungals - Topical*** Ciclopirox EXTERNAL SOLUTION 8 % Ciclopirox Olamine EXTERNAL CREAM 0.77 % Nystatin EXTERNAL CREAM 100000 UNIT/GM Nystatin EXTERNAL OINTMENT 100000 UNIT/GM Nystatin EXTERNAL OWDER 100000 UNIT/GM OTC Terbinafine HCl EXTERNAL CREAM 1 % OTC *Imidazole-Related Antifungals - Topical*** Baza Antifungal EXTERNAL CREAM 2 % OTC Clotrimazole EXTERNAL CREAM 1 % OTC Clotrimazole EXTERNAL SOLUTION 1 % OTC Econazole Nitrate EXTERNAL CREAM 1 % Ketoconazole EXTERNAL CREAM 2 % Ketoconazole EXTERNAL SHAMOO 2 % *Anti-Inflammatory Agents - Topical** *Anti-Inflammatory Agents - Topical*** VOLTAREN TRANSDERMAL GEL 1 % QL (300 GM per 31 day(s)) *Antivirals - Topical** 33
Drug Name reference Details Coverage Details *Antivirals - Topical*** DENAVIR EXTERNAL CREAM 1 % ST ZOVIRAX EXTERNAL CREAM 5 % ST *Emollient/Keratolytic Agents** *Emollient/Keratolytic Agents*** REMEVEN EXTERNAL CREAM 50 % X-VIATE EXTERNAL CREAM 40 % *Rosacea Agents** *Rosacea Agents*** MetroNIDAZOLE EXTERNAL CREAM 0.75 % MetroNIDAZOLE EXTERNAL GEL 1 % *Diagnostic roducts* *Diagnostic Drugs** *Diagnostic Drugs*** Dipyridamole INTRAVENOUS* SOLUTION 5 /ML *Diagnostic Tests** *Diagnostic Tests*** ACCU-CHEK ACTIVE IN VITRO STRI OTC; QL (100 EA per 31 day(s)) ACCU-CHEK AVIVA LUS IN VITRO STRI ACCU-CHEK COMFORT CURVE IN VITRO STRI OTC; QL (100 EA per 31 day(s)) OTC; QL (100 EA per 31 day(s)) ACCU-CHEK COMACT IN VITRO STRI OTC; QL (102 EA per 31 day(s)) ACCU-CHEK COMACT TEST DRUM IN VITRO STRI ACCU-CHEK SMARTVIEW IN VITRO STRI OTC; QL (102 EA per 31 day(s)) OTC; QL (100 EA per 31 day(s)) CLINISTIX IN VITRO STRI OTC; QL (100 EA per 31 day(s)) DIASTIX IN VITRO STRI OTC; QL (100 EA per 31 day(s)) FREESTYLE INSULINX TEST IN VITRO STRI OTC; QL (100 EA per 31 day(s)) FREESTYLE LITE TEST IN VITRO STRI OTC; QL (100 EA per 31 day(s)) FREESTYLE TEST IN VITRO STRI OTC; QL (100 EA per 31 day(s)) KETOSTIX IN VITRO STRI OTC; QL (100 EA per 31 day(s)) 34
Drug Name reference Details Coverage Details RECISION XTRA BLOOD GLUCOSE IN VITRO STRI RECISION XTRA KETONE IN VITRO STRI *Digestive Aids* *Digestive Enzymes** *Digestive Enzymes*** CREON ORAL CASULE DELAYED RELEASE ARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT ERTZYE ORAL CASULE DELAYED RELEASE ARTICLES 16000 UNIT, 8000 UNIT *Diuretics* *Carbonic Anhydrase Inhibitors** *Carbonic Anhydrase Inhibitors*** AcetaZOLAMIDE ORAL TABLET 125, 250 Methazolamide ORAL TABLET 25, 50 *Diuretic Combinations** *Diuretic Combinations*** Amiloride-Hydrochlorothiazide ORAL TABLET 5-50 Spironolactone-HCTZ ORAL TABLET 25-25 Triamterene-HCTZ ORAL CASULE 37.5-25 Triamterene-HCTZ ORAL TABLET 37.5-25, 75-50 *Loop Diuretics** *Loop Diuretics*** Bumetanide INJECTION SOLUTION 0.25 /ML Bumetanide ORAL TABLET 0.5, 1, 2 Furosemide ORAL SOLUTION 10 /ML, 8 /ML OTC; QL (100 EA per 31 day(s)) OTC 35
Drug Name reference Details Coverage Details Furosemide ORAL TABLET 20, 40, 80 Torsemide ORAL TABLET 10, 100, 20, 5 *otassium Sparing Diuretics** *otassium Sparing Diuretics*** Spironolactone ORAL TABLET 100, 25, 50 *Thiazides And Thiazide-Like Diuretics** *Thiazides And Thiazide-Like Diuretics*** Chlorothiazide ORAL TABLET 250, 500 Chlorthalidone ORAL TABLET 25, 50 Hydrochlorothiazide ORAL CASULE 12.5 Hydrochlorothiazide ORAL TABLET 12.5, 25, 50 Indapamide ORAL TABLET 1.25, 2.5 Metolazone ORAL TABLET 10, 2.5, 5 *Endocrine And Metabolic Agents - Misc.* *Bone Density Regulators** *Bisphosphonates*** Alendronate Sodium ORAL TABLET 10, 35, 40, 5, 70 *Calcitonins*** Calcitonin (Salmon) NASAL SOLUTION 200 UNIT/ACT FORTICAL NASAL SOLUTION 200 UNIT/ACT *Metabolic Modifiers** *Gaa Deficiency Treatment - Agents*** LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 *Hyperparathyroid Treatment - Vitamin D Analogs*** Calcitriol ORAL CASULE 0.25 MCG, 0.5 MCG A 36
Drug Name reference Details Coverage Details Calcitriol ORAL SOLUTION 1 MCG/ML *osterior ituitary Hormones** *Vasopressin*** Desmopressin Ace Spray Refrig NASAL SOLUTION 0.01 % Desmopressin Acetate ORAL TABLET 0.1, 0.2 Desmopressin Acetate Spray NASAL SOLUTION 0.01 % *Estrogens* *Estrogen Combinations** *Estrogen & rogestin*** Estradiol-Norethindrone Acet ORAL TABLET 0.5-0.1, 1-0.5 REMHASE ORAL TABLET 0.625-5 REMRO ORAL TABLET 0.3-1.5, 0.45-1.5, 0.625-2.5, 0.625-5 *Estrogens** *Estrogens*** Estradiol ORAL TABLET 0.5, 1, 2 Estradiol TRANSDERMAL ATCH WEEKLY 0.025 /24HR, 0.0375 /24HR, 0.05 /24HR, 0.06 /24HR, 0.075 /24HR, 0.1 /24HR Estropipate ORAL TABLET 0.75, 1.5, 3 REMARIN INJECTION SOLUTION RECONSTITUTED 25 REMARIN ORAL TABLET 0.3, 0.45, 0.625, 0.9, 1.25 *Fluoroquinolones* *Fluoroquinolones** *Fluoroquinolones*** Ciprofloxacin HCl ORAL TABLET 250, 500, 750 Levofloxacin ORAL TABLET 250, 500, 750 *Gastrointestinal Agents - Misc.* QL (14 EA per 31 day(s)) 37
Drug Name reference Details Coverage Details *Antiflatulents** *Antiflatulents*** Simethicone ORAL SUSENSION 40 /0.6ML Simethicone ORAL TABLET CHEWABLE 80 *Gallstone Solubilizing Agents** *Gallstone Solubilizing Agents*** Ursodiol ORAL CASULE 300 *Inflammatory Bowel Agents** *Inflammatory Bowel Agents*** ARISO ORAL CASULE EXTENDED RELEASE 24 HOUR 0.375 GM Balsalazide Disodium ORAL CASULE 750 OTC OTC Mesalamine RE ENEMA 4 GM QL (1800 ML per 31 day(s)) SulfaSALAzine ORAL TABLET 500 SulfaSALAzine ORAL TABLET DELAYED RELEASE 500 *Intestinal Acidifiers** *Intestinal Acidifiers*** Generlac ORAL SOLUTION 10 GM/15ML QL (4185 ML per 31 day(s)) *hosphate Binder Agents** *hosphate Binder Agents*** ELIHOS ORAL TABLET 667 QL (372 EA per 31 day(s)) RENVELA ORAL ACKET 0.8 GM, 2.4 GM RENVELA ORAL TABLET 800 *Gout Agents* *Gout Agent Combinations** *Gout Agent Combinations*** Colchicine-robenecid ORAL TABLET 0.5-500 *Gout Agents** *Gout Agents*** Allopurinol ORAL TABLET 100, 300 COLCRYS ORAL TABLET 0.6 38
Drug Name reference Details Coverage Details *Uricosurics** *Uricosurics*** robenecid ORAL TABLET 500 *Hematological Agents - Misc.* *Hematorheologic Agents** *Hematorheologic Agents*** entoxifylline ER ORAL TABLET EXTENDEDRELEASE* 400 *latelet Aggregation Inhibitors** *hosphodiesterase Iii Inhibitors*** Cilostazol ORAL TABLET 100, 50 *latelet Aggregation Inhibitors*** Dipyridamole ORAL TABLET 25, 50, 75 *Quinazoline Agents*** Anagrelide HCl ORAL CASULE 0.5, 1 *Thienopyridine Derivatives*** Clopidogrel Bisulfate ORAL TABLET 75 *Hematopoietic Agents* *Folic Acid/Folates** *Folic Acid/Folates*** Folic Acid ORAL TABLET 1, 400 MCG, 800 MCG *Hypnotics* *Barbiturate Hypnotics** *Barbiturate Hypnotics*** OTC HENobarbital ORAL ELIXIR 20 /5ML QL (2000 ML per 31 day(s)) HENobarbital ORAL TABLET 100, 30, 32.4, 60, 64.8, 97.2 HENobarbital ORAL TABLET 15 QL (310 EA per 31 day(s)) HENobarbital ORAL TABLET 16.2 QL (383 EA per 31 day(s)) HENobarbital Sodium INJECTION SOLUTION 130 /ML, 65 /ML *Laxatives* *Laxatives - Miscellaneous** *Laxatives - Miscellaneous*** 39
Drug Name reference Details Coverage Details Lactulose ORAL SOLUTION 10 GM/15ML QL (4185 ML per 31 day(s)) *Macrolides* *Azithromycin** *Azithromycin*** Azithromycin INTRAVENOUS* SOLUTION RECONSTITUTED 500 Azithromycin ORAL SUSENSION RECONSTITUTED 100 /5ML, 200 /5ML Azithromycin ORAL TABLET 250 QL (6 EA per 31 day(s)) Azithromycin ORAL TABLET 500, 600 Azithromycin Hydrogencitrate INTRAVENOUS* SOLUTION RECONSTITUTED 2.5 GM *Clarithromycin** *Clarithromycin*** Clarithromycin ORAL SUSENSION RECONSTITUTED 125 /5ML, 250 /5ML Clarithromycin ORAL TABLET 250, 500 *Erythromycins** *Erythromycins*** E.E.S. GRANULES ORAL SUSENSION RECONSTITUTED 200 /5ML ERY-TAB ORAL TABLET DELAYED RELEASE 250, 333, 500 ERYED 200 ORAL SUSENSION RECONSTITUTED 200 /5ML ERYED 400 ORAL SUSENSION RECONSTITUTED 400 /5ML ERYTHROCIN STEARATE ORAL TABLET 250 Erythromycin Base ORAL CASULE DELAYED RELEASE ARTICLES 250 Erythromycin Base ORAL TABLET 250, 500 Erythromycin Ethylsuccinate ORAL TABLET 400 40
Drug Name reference Details Coverage Details *Medical Devices* *Contraceptives** *Diaphragms*** ORTHO DIAHRAGM ALL-FLEX VAGINAL DIAHRAGM 65 MM, 70 MM, 75 MM, 80 MM *Diabetic Supplies** *Glucose Monitoring Test Supplies*** ACCU-CHEK AVIVA LUS XX KIT W/DEVICE ACCU-CHEK COMACT LUS CARE XX KIT ACCU-CHEK NANO SMARTVIEW XX KIT W/DEVICE FREESTYLE FREEDOM LITE XX KIT W/DEVICE FREESTYLE INSULINX SYSTEM XX KIT W/DEVICE OTC; QL (1 EA per 365 day(s)) OTC; QL (1 EA per 365 day(s)) OTC; QL (1 EA per 365 day(s)) OTC; QL (1 EA per 365 day(s)) OTC; QL (1 EA per 365 day(s)) FREESTYLE LITE XX DEVICE OTC; QL (1 EA per 365 day(s)) Glucose Control IN VITRO SOLUTION OTC Lancet Device XX MISC OTC Lancets XX MISC OTC RECISION XTRA XX DEVICE OTC; QL (1 EA per 365 day(s)) *Misc. Devices** *Applicators,Cotton Balls,Etc*** Alcohol ads XX AD 70 % OTC *arenteral Therapy Supplies** *Needles & Syringes*** BD INSULIN SYRINGE ULTRAFINE XX MISC 31G X 5/16" 1 ML EXEL EN NEEDLES 1/3" XX MISC 31G X 8 MM Insulin Syringe XX MISC 29G X 1/2" 0.3 ML, 30G X 5/16" 0.3 ML NOVOEN 3 XX MISC OTC *Respiratory Therapy Supplies** *eak Flow Meters*** OTC; QL (100 EA per 31 day(s)) OTC; QL (100 EA per 31 day(s)) OTC; QL (100 EA per 31 day(s)) eak Flow Meter XX DEVICE OTC; QL (2 EA per 365 day(s)) 41
Drug Name reference Details Coverage Details *Respiratory Therapy Supplies*** IN-CHECK DIAL FLOW TRAINER XX DEVICE *Spacer/Aerosol-Holding Chambers & Supplies*** AEROCHAMBER LUS FLO-VU XX MISC AEROCHAMBER LUS FLO-VU LARGE XX MISC AEROCHAMBER LUS FLO-VU SMALL XX MISC AEROCHAMBER LUS FLO-VU W/MASK XX MISC QL (2 EA per 365 day(s)) QL (2 EA per 365 day(s)) QL (2 EA per 365 day(s)) QL (2 EA per 365 day(s)) QL (2 EA per 365 day(s)) E-Z SACER XX DEVICE QL (2 EA per 365 day(s)) MICROCHAMBER XX MISC QL (2 EA per 365 day(s)) MICROSACER XX MISC QL (2 EA per 365 day(s)) OTICHAMBER ADVANTAGE XX MISC QL (2 EA per 365 day(s)) OTICHAMBER ADVANTAGE-LG MASK XX MISC OTICHAMBER ADVANTAGE-MED MASK XX MISC OTICHAMBER ADVANTAGE-SM MASK XX MISC OTICHAMBER FACE MASK-LARGE XX MISC OTICHAMBER FACE MASK-MEDIUM XX MISC OTICHAMBER FACE MASK-SMALL XX MISC QL (2 EA per 365 day(s)) QL (2 EA per 365 day(s)) QL (2 EA per 365 day(s)) OTC; QL (2 EA per 365 day(s)) OTC; QL (2 EA per 365 day(s)) OTC; QL (2 EA per 365 day(s)) OTIHALER XX MISC QL (2 EA per 365 day(s)) *Minerals & Electrolytes* *Calcium** *Calcium*** Calcium Acetate (hos Binder) ORAL TABLET 667 *Fluoride** *Fluoride Combinations*** QL (372 EA per 31 day(s)) 42
Drug Name reference Details Coverage Details FLUOR-A-DAY ORAL TABLET CHEWABLE 0.25 (F)-236.79, 0.5 (F)-236.79, 1 (F)-236.79 *Iodine roducts** *Iodine roducts*** SSKI ORAL SOLUTION 1 GM/ML *hosphate** *hosphate*** K-HOS-NEUTRAL ORAL TABLET 155-852-130 *otassium** *otassium*** KLOR-CON ORAL TABLET EXTENDEDRELEASE* 8 MEQ KLOR-CON 10 ORAL TABLET EXTENDEDRELEASE* 10 MEQ KLOR-CON M10 ORAL TABLET EXTENDEDRELEASE* 10 MEQ KLOR-CON M20 ORAL TABLET EXTENDEDRELEASE* 20 MEQ otassium Chloride ORAL LIQUID 20 MEQ/15ML (10%), 40 MEQ/15ML (20%) otassium Chloride ORAL SOLUTION 20 MEQ/15ML (10%) otassium Chloride Crys ER ORAL TABLET EXTENDEDRELEASE* 10 MEQ, 20 MEQ otassium Chloride ER ORAL TABLET EXTENDEDRELEASE* 10 MEQ, 8 MEQ *Mouth/Throat/Dental Agents* *Anesthetics Topical Oral** *Anesthetics Topical Oral*** Lidocaine Viscous MOUTH/THROAT SOLUTION 2 % *Anti-Infectives - Throat** *Anti-Infectives - Throat*** Clotrimazole MOUTH/THROAT LOZENGE 10 Clotrimazole MOUTH/THROAT TROCHE 10 43
Drug Name reference Details Coverage Details Nystatin MOUTH/THROAT SUSENSION 100000 UNIT/ML *Dental roducts** *Fluoride Dental roducts*** CAVAREST DENTAL GEL 1.1 % *Throat roducts - Misc.** *Saliva Stimulants*** ilocarpine HCl ORAL TABLET 5, 7.5 *Multivitamins* *B-Complex Vitamins** *B-Complex Vitamins*** B Complex ORAL TABLET OTC *B-Complex W/ C** *B-Complex W/ C*** B Complex-C ORAL TABLET OTC Vitamin B Complex-C ORAL CASULE OTC *B-Complex W/ Folic Acid** *B-Complex W/ C & Folic Acid*** Rena-Vite ORAL TABLET OTC *B-Complex W/ Folic Acid*** B Complex lus ORAL TABLET OTC *B-Complex W/Biotin & Folic Acid*** B-50 Complex ORAL TABLET EXTENDEDRELEASE* OTC B-Complex ORAL TABLET OTC *B-Complex W/ Iron** *B-Complex W/ Iron*** B Complex-Iron ORAL TABLET OTC *Multiple Vitamins W/ Minerals** *Multiple Vitamins W/ Minerals*** AQUADEKS ORAL CASULE OTC *Multivitamins** *Multivitamins*** Multi-Vitamins ORAL TABLET OTC *ed Multi Vitamins W/Fl & Fe** 44
Drug Name reference Details Coverage Details *ed Multi Vitamins W/Fl & Fe*** Multi-Vit/Fluoride/Iron ORAL SOLUTION 0.25-10 /ML *ed Vitamins Acd Fluoride & Iron*** Tri-Vit/Fluoride/Iron ORAL SOLUTION 0.25-10 /ML *ed Mv W/ Fluoride** *ed Mv W/ Fluoride*** Multi-Vit/Fluoride ORAL SOLUTION 0.25 /ML, 0.5 /ML Multi-Vitamin/Fluoride ORAL TABLET CHEWABLE 0.25, 0.5, 1 Multivitamin/Fluoride ORAL TABLET CHEWABLE 0.25, 0.5, 1 *ed Vitamins Acd W/ Fluoride*** Tri-Vit/Fluoride ORAL SOLUTION 0.25 /ML Vitamins ACD-Fluoride ORAL SOLUTION 0.25 /ML *ediatric Multiple Vitamins** *ediatric Multiple Vitamins W/ C*** oly-vitamin ORAL SOLUTION 35 /ML OTC *ediatric Vitamins** *ediatric Vitamins A & D W/ C*** Tri-Vitamin ORAL SOLUTION 1500-400-35 OTC *renatal Vitamins** *renatal Mv & Min W/Fe-Fa*** ELITE-OB ORAL TABLET 50-1.25 MYNATAL ADVANCE ORAL TABLET Mynatal-Z ORAL TABLET Mynate 90 lus ORAL TABLET EXTENDEDRELEASE* renatabs OBN ORAL TABLET 29-1 RENATABS RX ORAL TABLET 29-1 renatal ORAL TABLET 28-0.8 OTC renatal 19 ORAL TABLET CHEWABLE renatal Low Iron ORAL TABLET 27-0.8 OTC AL (Max 20 Years) AL (Max 20 Years) AL (Max 20 Years) AL (Max 20 Years) AL (Max 20 Years) AL (Max 20 Years) AL (Max 20 Years) 45
Drug Name reference Details Coverage Details renatal lus ORAL TABLET 27-1 renatal lus Iron ORAL TABLET 29-1 Trinatal Rx 1 ORAL TABLET 60-1 TRINATE ORAL TABLET TRIVEEN-U ORAL CASULE 106.5-1 UltimateCare Combo ORAL MISC 30-1 VINATE AZ ORAL TABLET 27-1 VINATE AZ EXTRA ORAL TABLET 29-1 VINATE GT ORAL TABLET 90-1 VINATE II ORAL TABLET 29-1 VINATE M ORAL TABLET 27-1 *renatal Mv & Min W/Fe-Fa-Ca-Omega 3 Fish Oil*** R NATAL 400 EC ORAL MISC 29-1-200 & 400 (DR) *Vitamins W/ Lipotropics** *Vitamins W/ Lipotropics*** B-100 Complex ORAL TABLET OTC B-100 CR ORAL TABLET EXTENDEDRELEASE* OTC B-Stress ORAL CASULE OTC Balanced B-100 Complex CR ORAL TABLET EXTENDEDRELEASE* *Musculoskeletal Therapy Agents* *Central Muscle Relaxants** *Central Muscle Relaxants*** Baclofen ORAL TABLET 10, 20 OTC Carisoprodol ORAL TABLET 350 QL (124 EA per 31 day(s)) Chlorzoxazone ORAL TABLET 500 Cyclobenzaprine HCl ORAL TABLET 10, 5 Methocarbamol ORAL TABLET 500, 750 *Direct Muscle Relaxants** *Direct Muscle Relaxants*** QL (93 EA per 31 day(s)) 46