County Health Plan Formulary Copay 100% copay Brand ......Jun 08, 2020 · Dilantin Generic *Valproic Acid*** divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg

1

County Health Plan Formulary

lowercase = Generic drugs

UPPERCASE = Brand name drugs

Copay

100% copay = 100%

Brand = $3.00

Generic = $3.00

Zero Copay = $0.00

Note

QL = Quantity Limit

Drug Name Reference Copay Note

*Adhd/Anti-Narcolepsy/Anti-

Obesity/Anorexiants*

*Stimulants - Misc.***

methylphenidate hcl er oral tablet

extended release 20 mg Metadate ER Generic Prior Auth Required

methylphenidate hcl oral tablet 10 mg, 20

mg, 5 mg Ritalin Generic Prior Auth Required

*Analgesics - Anti-Inflammatory*

*Nonsteroidal Anti-Inflammatory

Agents (Nsaids)***

diclofenac sodium oral tablet delayed

release 25 mg, 50 mg, 75 mg

Generic

etodolac oral capsule 300 mg Generic

etodolac oral tablet 400 mg Lodine Generic

etodolac oral tablet 500 mg Generic

fenoprofen calcium oral tablet 600 mg Nalfon Generic

flurbiprofen oral tablet 100 mg, 50 mg Generic

ibuprofen oral tablet 200 mg Advil Generic OTC

ibuprofen oral tablet 400 mg, 600 mg, 800

mg IBU Generic

indomethacin er oral capsule extended

release 75 mg

Generic

indomethacin oral capsule 25 mg, 50 mg Generic

meclofenamate sodium oral capsule 100

mg, 50 mg

Generic

meloxicam oral tablet 15 mg, 7.5 mg Mobic Generic

nabumetone oral tablet 500 mg, 750 mg Generic

naproxen oral tablet 250 mg, 500 mg Naprosyn Generic

naproxen oral tablet 375 mg Generic

naproxen sodium oral tablet 220 mg Aleve Generic OTC

piroxicam oral capsule 10 mg, 20 mg Feldene Generic

sulindac oral tablet 150 mg, 200 mg Generic

tolmetin sodium oral capsule 400 mg Generic

2


tolmetin sodium oral tablet 200 mg Generic

*Analgesics - Nonnarcotic*

*Analgesics Other***

acetaminophen extra strength oral tablet

500 mg

Healthy Mama Shake

That Ache Generic OTC

acetaminophen oral tablet 325 mg Pharbetol Generic OTC

*Analgesics-Sedatives***

butalbital-aspirin-caffeine oral capsule 50-

325-40 mg Fiorinal Generic

*Salicylates***

diflunisal oral tablet 500 mg Generic

salsalate oral tablet 500 mg, 750 mg Generic

*Analgesics - Opioid*

*Codeine Combinations***

acetaminophen-codeine #2 oral tablet 300-

15 mg

100% copay

Discount applies to

only 6 fills per year.;

QL (12 tabs per 1 day)


30 mg

Tylenol with Codeine #3

100% copay

Discount applies to




60 mg

Tylenol with Codeine #4

100% copay

Discount applies to



acetaminophen-codeine oral solution 120-

12 mg/5ml

100% copay

Discount applies to

only 6 fills per year.

butalbital-asa-caff-codeine oral capsule

50-325-40-30 mg Ascomp-Codeine 100% copay

Discount applies to


*Hydrocodone Combinations***

hydrocodone-acetaminophen oral solution

7.5-325 mg/15ml

100% copay

Discount applies to


hydrocodone-acetaminophen oral tablet

10-325 mg

Lorcet HD

100% copay

Discount applies to



hydrocodone-acetaminophen oral tablet 5-

325 mg

Lorcet

100% copay

Discount applies to



hydrocodone-acetaminophen oral tablet

7.5-325 mg

Lorcet Plus

100% copay

Discount applies to



*Opioid Agonists***

methadone hcl oral tablet 10 mg, 5 mg Dolophine 100% copay Discount applies to


3


morphine sulfate er oral tablet extended

release 100 mg, 15 mg, 30 mg, 60 mg MS Contin Generic Prior Auth Required

tramadol hcl oral tablet 50 mg Ultram 100% copay Discount applies to


*Opioid Combinations***

oxycodone-acetaminophen oral tablet 5-

325 mg

Endocet

100% copay

Discount applies to



oxycodone-aspirin oral tablet 4.8355-325

mg

100% copay

Discount applies to


QL (12 EA per 1 day)

*Anorectal Agents*

*Rectal Steroids***

hydrocortisone acetate rectal suppository

25 mg Anusol-HC Generic

*Antianginal Agents*

*Nitrates***

NITRO-BID TRANSDERMAL

OINTMENT 2 %

Brand

isosorbide dinitrate er oral tablet extended

release 40 mg

Generic

isosorbide dinitrate oral tablet 10 mg, 20

mg, 30 mg

Generic

isosorbide dinitrate oral tablet 5 mg Isordil Titradose Generic

isosorbide mononitrate er oral tablet

extended release 24 hour 120 mg, 30 mg,

60 mg

Generic

nitroglycerin er oral capsule extended

release 2.5 mg, 6.5 mg, 9 mg Nitro-Time Generic

nitroglycerin sublingual tablet sublingual

0.3 mg, 0.4 mg, 0.6 mg Nitrostat Generic

*Antianxiety Agents*

*Antianxiety Agents - Misc.***

buspirone hcl oral tablet 10 mg, 15 mg, 5

mg

Generic

hydroxyzine hcl oral tablet 10 mg, 25 mg,

50 mg

Generic

hydroxyzine pamoate oral capsule 25 mg,

50 mg Vistaril Generic

meprobamate oral tablet 200 mg, 400 mg Generic

4


*Benzodiazepines***

alprazolam oral tablet 0.25 mg, 0.5 mg, 1

mg, 2 mg

Xanax

100% copay

Limit of 1 fill of any

Benzodiazepine per 30

days

chlordiazepoxide hcl oral capsule 10 mg,

25 mg, 5 mg

100% copay



days

clorazepate dipotassium oral tablet 15 mg,

3.75 mg

100% copay



days

clorazepate dipotassium oral tablet 7.5 mg

Tranxene-T

100% copay



days

diazepam oral tablet 10 mg, 2 mg, 5 mg

Valium

100% copay



days

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg

Ativan

100% copay



days

oxazepam oral capsule 10 mg, 15 mg, 30

mg

100% copay



days

*Antiarrhythmics*

*Antiarrhythmics Type I-A***

disopyramide phosphate oral capsule 150

mg Norpace Generic

quinidine gluconate er oral tablet extended

release 324 mg

Generic

quinidine sulfate oral tablet 200 mg, 300

mg

Generic

*Antiarrhythmics Type I-B***

mexiletine hcl oral capsule 150 mg, 200

mg, 250 mg

Generic

*Antiarrhythmics Type Iii***

amiodarone hcl oral tablet 200 mg Pacerone Generic

*Antiasthmatic And

Bronchodilator Agents*

*Anti-Inflammatory Agents***

cromolyn sodium inhalation nebulization

solution 20 mg/2ml

Generic

5


*Beta Adrenergics***

PROAIR HFA AEROSOL SOLUTION

108 (90 BASE) MCG/ACT

INHALATION 108 (90 BASE)

MCG/ACT

Brand

PROAIR RESPICLICK AEROSOL

POWDER BREATH ACTIVATED 108

(90 BASE) MCG/ACT INHALATION

108 (90 BASE) MCG/ACT

Brand

albuterol sulfate inhalation nebulization

solution (2.5 mg/3ml) 0.083%, (5 mg/ml)

0.5%

Generic

albuterol sulfate oral syrup 2 mg/5ml Generic

albuterol sulfate oral tablet 2 mg, 4 mg Generic

metaproterenol sulfate oral syrup 10

mg/5ml

Generic

metaproterenol sulfate oral tablet 10 mg Generic

*Bronchodilators -

Anticholinergics***

ipratropium bromide inhalation solution

0.02 %

Generic

*Leukotriene Receptor

Antagonists***

montelukast sodium oral tablet 10 mg Singulair Generic

*Xanthines***

ELIXOPHYLLIN ORAL ELIXIR 80

MG/15ML

Brand

theophylline er oral tablet extended

release 12 hour 100 mg, 200 mg, 300 mg Theochron Generic

*Anticoagulants*

*Coumarin Anticoagulants***

COUMADIN ORAL TABLET 1 MG, 10

MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG,

6 MG, 7.5 MG

Coumadin

Brand

warfarin sodium oral tablet 1 mg, 10 mg, 2

mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5

mg

Coumadin

Generic

6


*Anticonvulsants*

*Anticonvulsants -

Benzodiazepines***

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg

KlonoPIN

100% copay



days

*Anticonvulsants - Misc.***

TEGRETOL ORAL TABLET 200 MG Epitol Brand

carbamazepine oral tablet 200 mg Epitol Generic

carbamazepine oral tablet chewable 100

mg

Generic

gabapentin oral capsule 100 mg, 300 mg,

400 mg Neurontin Generic

gabapentin oral tablet 600 mg, 800 mg Neurontin Generic

lamotrigine oral tablet 100 mg, 150 mg,

200 mg, 25 mg LaMICtal Generic

primidone oral tablet 250 mg, 50 mg Mysoline Generic

*Hydantoins***

DILANTIN ORAL CAPSULE 100 MG Dilantin Brand

DILANTIN ORAL SUSPENSION 125

MG/5ML Dilantin Brand

phenytoin oral suspension 125 mg/5ml Dilantin Generic

phenytoin sodium extended oral capsule

100 mg Dilantin Generic

*Valproic Acid***

divalproex sodium oral tablet delayed

release 125 mg, 250 mg, 500 mg Depakote Generic

valproic acid oral capsule 250 mg Depakene Generic

*Antidepressants*

*Antidepressants - Misc.***

bupropion hcl er (sr) oral tablet extended

release 12 hour 100 mg, 150 mg Wellbutrin SR Generic

bupropion hcl oral tablet 100 mg, 75 mg Generic

maprotiline hcl oral tablet 25 mg, 50 mg,

75 mg

Generic

*Modified Cyclics***

trazodone hcl oral tablet 100 mg, 150 mg,

300 mg, 50 mg

Generic

7


*Selective Serotonin Reuptake

Inhibitors (Ssris)***

citalopram hydrobromide oral tablet 10

mg, 20 mg, 40 mg CeleXA Generic

escitalopram oxalate oral tablet 10 mg, 20

mg, 5 mg Lexapro Generic

fluoxetine hcl oral capsule 10 mg, 20 mg,

40 mg PROzac Generic

paroxetine hcl oral tablet 10 mg, 20 mg,

30 mg, 40 mg Paxil Generic

sertraline hcl oral tablet 100 mg, 25 mg,

50 mg Zoloft Generic

*Serotonin-Norepinephrine

Reuptake Inhibitors (Snris)***

duloxetine hcl oral capsule delayed release

particles 20 mg, 30 mg, 60 mg Cymbalta Generic

venlafaxine hcl er oral capsule extended

release 24 hour 150 mg, 37.5 mg, 75 mg Effexor XR Generic

venlafaxine hcl oral tablet 100 mg, 25 mg,

37.5 mg, 50 mg, 75 mg

Generic

*Tricyclic Agents***

amitriptyline hcl oral tablet 10 mg, 100

mg, 150 mg, 25 mg, 50 mg, 75 mg

Generic

amoxapine oral tablet 100 mg, 150 mg, 25

mg, 50 mg

Generic

clomipramine hcl oral capsule 25 mg, 50

mg, 75 mg Anafranil Generic

desipramine hcl oral tablet 10 mg, 25 mg Norpramin Generic

desipramine hcl oral tablet 100 mg, 150

mg, 50 mg, 75 mg

Generic

doxepin hcl oral capsule 10 mg, 100 mg,

150 mg, 25 mg, 50 mg, 75 mg

Generic

doxepin hcl oral concentrate 10 mg/ml Generic

imipramine hcl oral tablet 10 mg, 25 mg,

50 mg Tofranil Generic

nortriptyline hcl oral capsule 10 mg, 25

mg, 50 mg, 75 mg Pamelor Generic

protriptyline hcl oral tablet 10 mg, 5 mg Generic

*Antidiabetics*

*Biguanides***

metformin hcl oral tablet 1000 mg, 500

mg, 850 mg Glucophage Zero Copay

8


*Human Insulin***

BASAGLAR KWIKPEN

SUBCUTANEOUS SOLUTION PEN-

INJECTOR 100 UNIT/ML

Zero Copay

LISPRO INJ 100/ML

Zero Copay

LISPRO INJ PENFILL

Zero Copay

LISPRO INJ FLEXPEN Zero Copay

ASPART INJ 100/ML

Zero Copay

ASPART INJ PENFILL Zero Copay

ASPART INJ FLEXPEN Zero Copay

HUMULIN N SUSPENSION 100

UNIT/ML SUBCUTANEOUS 100

UNIT/ML

Zero Copay

OTC

HUMULIN R SOLUTION

100 UNIT/ML INJECTION

100 UNIT/ML

Zero Copay OTC

*Sulfonylureas***

chlorpropamide oral tablet 100 mg, 250

mg

Zero Copay

glimepiride oral tablet 1 mg, 2 mg, 4 mg Amaryl Zero Copay

glipizide oral tablet 10 mg, 5 mg Glucotrol Zero Copay

glipizide xl oral tablet extended release 24

hour 10 mg, 2.5 mg, 5 mg Glucotrol XL Zero Copay

glyburide micronized oral tablet 1.5 mg, 3

mg, 6 mg Glynase Zero Copay

glyburide oral tablet 1.25 mg, 2.5 mg, 5

mg

Zero Copay

tolazamide oral tablet 250 mg, 500 mg Zero Copay

tolbutamide oral tablet 500 mg Zero Copay

*Antidiarrheals*

*Antidiarrheal Agents - Misc.***

pink bismuth oral suspension 262

mg/15ml Kao-Tin Generic OTC

9

*Antiperistaltic Agents***

diphenoxylate-atropine oral liquid 2.5-

0.025 mg/5ml

Generic

10


diphenoxylate-atropine oral tablet 2.5-

0.025 mg Lomotil Generic

loperamide hcl oral capsule 2 mg Imodium A-D Generic

*Antiemetics*

*5-Ht3 Receptor Antagonists***

ondansetron hcl oral tablet 4 mg, 8 mg Zofran Generic

*Antiemetics - Anticholinergic***

meclizine hcl oral tablet 12.5 mg Generic

meclizine hcl oral tablet 25 mg Dramamine Less Drowsy Generic

*Antifungals*

*Antifungals***

nystatin oral tablet 500000 unit Generic

*Imidazoles***

ketoconazole oral tablet 200 mg Generic

*Triazoles***

fluconazole oral tablet 100 mg, 150 mg,

200 mg, 50 mg Diflucan Generic

*Antihistamines*

*Antihistamines - Alkylamines***

chlorpheniramine maleate oral tablet 4 mg Chlor-Trimeton Generic OTC

*Antihistamines -

Ethanolamines***

clemastine fumarate oral tablet 2.68 mg Generic

diphenhydramine hcl oral capsule 25 mg,

50 mg Banophen Generic

*Antihistamines -

Phenothiazines***

promethazine hcl oral tablet 12.5 mg, 25

mg, 50 mg

Generic

*Antihistamines - Piperidines***

cyproheptadine hcl oral syrup 2 mg/5ml Generic

cyproheptadine hcl oral tablet 4 mg Generic

*Antihyperlipidemics*

*Bile Acid Sequestrants***

cholestyramine light oral powder 4

gm/dose Prevalite Generic

cholestyramine oral packet 4 gm Questran Generic

11


*Fibric Acid Derivatives***

gemfibrozil oral tablet 600 mg Lopid Generic

*Hmg Coa Reductase

Inhibitors***

atorvastatin calcium oral tablet 10 mg, 20

mg, 40 mg, 80 mg Lipitor Generic

pravastatin sodium oral tablet 10 mg Generic

pravastatin sodium oral tablet 20 mg, 40

mg, 80 mg Pravachol Generic

simvastatin oral tablet 10 mg, 20 mg, 40

mg, 5 mg, 80 mg Zocor Generic

*Antihypertensives*

*Ace Inhibitors***

benazepril hcl oral tablet 10 mg, 20 mg,

40 mg Lotensin Generic

benazepril hcl oral tablet 5 mg Generic

captopril oral tablet 100 mg, 12.5 mg, 25

mg, 50 mg

Generic

enalapril maleate oral tablet 10 mg, 2.5

mg, 20 mg, 5 mg Vasotec Generic

lisinopril oral tablet 10 mg, 20 mg, 5 mg Prinivil Generic

lisinopril oral tablet 2.5 mg, 30 mg, 40 mg Zestril Generic

quinapril hcl oral tablet 10 mg, 20 mg, 40

mg, 5 mg Accupril Generic

*Adrenolytics-Central &

Thiazide/Thiazide-Like Comb***

methyldopa-hydrochlorothiazide oral

tablet 250-15 mg, 250-25 mg

Generic

*Angiotensin Ii Receptor

Antagonists***

losartan potassium oral tablet 100 mg, 25

mg, 50 mg Cozaar Generic

valsartan oral tablet 160 mg, 320 mg, 40

mg, 80 mg Diovan Generic

*Antiadrenergics - Centrally

Acting***

clonidine hcl oral tablet 0.1 mg, 0.2 mg,

0.3 mg Catapres Generic

guanfacine hcl oral tablet 1 mg, 2 mg Generic

methyldopa oral tablet 250 mg, 500 mg Generic

12


*Antiadrenergics - Peripherally

Acting***

doxazosin mesylate oral tablet 1 mg, 2

mg, 4 mg, 8 mg Cardura Generic

prazosin hcl oral capsule 1 mg, 2 mg, 5

mg Minipress Generic

terazosin hcl oral capsule 1 mg, 10 mg, 2

mg, 5 mg

Generic

*Beta Blocker & Diuretic

Combinations***

atenolol-chlorthalidone oral tablet 100-25

mg Tenoretic 100 Generic

atenolol-chlorthalidone oral tablet 50-25

mg Tenoretic 50 Generic

*Vasodilators***

hydralazine hcl oral tablet 10 mg, 100 mg,

25 mg, 50 mg

Generic

minoxidil oral tablet 10 mg, 2.5 mg Generic

*Anti-Infective Agents - Misc.*

*Anti-Infective Agents - Misc.***

metronidazole oral capsule 375 mg Flagyl Generic

metronidazole oral tablet 250 mg, 500 mg Flagyl Generic

trimethoprim oral tablet 100 mg Generic

*Anti-Infective Misc. -

Combinations***

sulfamethoxazole-trimethoprim oral

suspension 200-40 mg/5ml Sulfatrim Pediatric Generic

sulfamethoxazole-trimethoprim oral tablet

400-80 mg Bactrim Generic

sulfamethoxazole-trimethoprim oral tablet

800-160 mg Bactrim DS Generic

*Lincosamides***

clindamycin hcl oral capsule 150 mg Cleocin Generic

*Antimalarials*

*Antimalarials***

hydroxychloroquine sulfate oral tablet 200

mg Plaquenil Generic

quinine sulfate oral capsule 324 mg Qualaquin Generic

13


*Antimycobacterial Agents*

*Antimycobacterial Agents***

ethambutol hcl oral tablet 100 mg, 400 mg Myambutol Generic

isoniazid oral tablet 100 mg, 300 mg Generic

pyrazinamide oral tablet 500 mg Generic

rifampin oral capsule 150 mg, 300 mg Rifadin Generic

*Antineoplastics And Adjunctive

Therapies*

*Antimetabolites***

methotrexate oral tablet 2.5 mg Generic

*Folic Acid Antagonists Rescue

Agents***

leucovorin calcium oral tablet 5 mg Generic

*Progestins-Antineoplastic***

megestrol acetate oral tablet 20 mg, 40 mg Generic

*Antiparkinson Agents*

*Antiparkinson

Anticholinergics***

benztropine mesylate oral tablet 0.5 mg, 1

mg, 2 mg

Generic

trihexyphenidyl hcl oral elixir 0.4 mg/ml Generic

trihexyphenidyl hcl oral tablet 2 mg, 5 mg Generic

*Antiparkinson

Dopaminergics***

amantadine hcl oral syrup 50 mg/5ml Generic

amantadine hcl oral tablet 100 mg Generic

*Levodopa Combinations***

carbidopa-levodopa oral tablet 10-100 mg,

25-100 mg, 25-250 mg Sinemet Generic

*Antipsychotics/Antimanic

Agents*

*Antimanic Agents***

lithium carbonate oral capsule 150 mg,

300 mg, 600 mg

Generic

*Benzisoxazoles***

risperidone oral tablet 0.25 mg, 0.5 mg, 1

mg, 2 mg, 3 mg RisperDAL Generic

14


*Butyrophenones***

haloperidol lactate oral concentrate 2

mg/ml

Generic

haloperidol oral tablet 0.5 mg, 1 mg, 10

mg, 2 mg, 20 mg, 5 mg

Generic

*Dibenzoxazepines***

loxapine succinate oral capsule 10 mg, 25

mg, 5 mg, 50 mg

Generic

*Phenothiazines***

chlorpromazine hcl oral tablet 10 mg, 100

mg, 200 mg, 25 mg, 50 mg

Generic

fluphenazine hcl oral tablet 1 mg, 10 mg,

2.5 mg, 5 mg

Generic

prochlorperazine maleate oral tablet 10

mg, 5 mg

Generic

thioridazine hcl oral tablet 10 mg, 100 mg,

25 mg, 50 mg

Generic

trifluoperazine hcl oral tablet 1 mg, 10

mg, 2 mg, 5 mg

Generic

*Quinolinone Derivatives***

aripiprazole oral tablet 10 mg, 15 mg, 2

mg, 20 mg, 30 mg, 5 mg Abilify Generic

*Thienbenzodiazepines***

olanzapine oral tablet 10 mg, 15 mg, 2.5

mg, 20 mg, 5 mg, 7.5 mg ZyPREXA Generic

*Thioxanthenes***

thiothixene oral capsule 1 mg, 10 mg, 2

mg, 5 mg

Generic

*Antivirals*

*Herpes Agents - Purine

Analogues***

acyclovir oral capsule 200 mg Zovirax Generic

acyclovir oral tablet 400 mg, 800 mg Zovirax Generic

*Neuraminidase Inhibitors***

RELENZA DISKHALER INHALATION

AEROSOL POWDER BREATH

ACTIVATED 5 MG/BLISTER Zanamivir

Brand

oseltamivir phosphate oral capsule 75 mg Tamiflu Generic

15


*Assorted Classes*

*Purine Analogs***

azathioprine oral tablet 50 mg Imuran Generic

*Beta Blockers*

*Alpha-Beta Blockers***

carvedilol oral tablet 12.5 mg, 25 mg,

3.125 mg, 6.25 mg Coreg Generic

*Beta Blockers Cardio-

Selective***

acebutolol hcl oral capsule 200 mg, 400

mg

Generic

atenolol oral tablet 100 mg, 25 mg, 50 mg Tenormin Generic

metoprolol succinate er oral tablet


25 mg, 50 mg

Toprol XL

Generic

metoprolol tartrate oral tablet 100 mg, 50

mg Lopressor Generic

metoprolol tartrate oral tablet 25 mg Generic

*Beta Blockers Non-Selective***

nadolol oral tablet 20 mg, 40 mg, 80 mg Corgard Generic

pindolol oral tablet 10 mg, 5 mg Generic

propranolol hcl er oral capsule extended

release 24 hour 120 mg, 160 mg, 60 mg,

80 mg

Inderal LA

Generic

propranolol hcl oral tablet 10 mg, 20 mg,

40 mg, 60 mg, 80 mg

Generic

timolol maleate oral tablet 10 mg, 20 mg,

5 mg

Generic

*Calcium Channel Blockers*

*Calcium Channel Blockers***

amlodipine besylate oral tablet 10 mg, 2.5

mg, 5 mg Norvasc Generic

diltiazem hcl er coated beads oral capsule


240 mg, 300 mg

Cardizem CD

Generic

diltiazem hcl er oral capsule extended

release 12 hour 120 mg, 60 mg, 90 mg

Generic

diltiazem hcl oral tablet 120 mg, 30 mg,

60 mg Cardizem Generic

diltiazem hcl oral tablet 90 mg Generic

nicardipine hcl oral capsule 20 mg, 30 mg Generic

16


nifedipine er oral tablet extended release

24 hour 30 mg, 60 mg, 90 mg Adalat CC Generic

nifedipine er osmotic release oral tablet

extended release 24 hour 30 mg, 90 mg Procardia XL Generic

nifedipine er osmotic release oral tablet

extended release 24 hour 60 mg Nifedical XL Generic

nifedipine oral capsule 10 mg Procardia Generic

nifedipine oral capsule 20 mg Generic

verapamil hcl er oral tablet extended

release 120 mg, 180 mg, 240 mg Calan SR Generic

verapamil hcl oral tablet 120 mg, 80 mg Calan Generic

verapamil hcl oral tablet 40 mg Generic

*Cardiotonics*

*Cardiac Glycosides***

LANOXIN ORAL TABLET 125 MCG,

250 MCG Digitek Brand

digoxin oral solution 0.05 mg/ml Generic

digoxin oral tablet 125 mcg, 250 mcg Digitek Generic

*Cardiovascular Agents - Misc.*

*Peripheral Vasodilators***

isoxsuprine hcl oral tablet 10 mg, 20 mg Generic

*Cephalosporins*

*Cephalosporins - 1St

Generation***

cefadroxil oral capsule 500 mg Generic

cephalexin oral suspension reconstituted

250 mg/5ml

Generic

cephalexin oral tablet 250 mg, 500 mg Generic

*Cephalosporins - 2Nd

Generation***

cefaclor oral capsule 250 mg, 500 mg Generic

cefaclor oral suspension reconstituted 250

mg/5ml, 375 mg/5ml

Generic

*Contraceptives*

*Triphasic Contraceptives -

Oral***

norgestim-eth estrad triphasic oral tablet

0.18/0.215/0.25 mg-35 mcg Ortho Tri-Cyclen (28) Generic Prior Auth Required

17


*Corticosteroids*

*Glucocorticosteroids***

dexamethasone oral solution 0.5 mg/5ml Generic

dexamethasone oral tablet 0.5 mg, 0.75

mg, 4 mg, 6 mg Decadron Generic

dexamethasone oral tablet 1 mg, 1.5 mg, 2

mg

Generic

methylprednisolone oral tablet therapy

pack 4 mg Medrol Generic

prednisone oral tablet 1 mg, 10 mg, 2.5

mg, 5 mg

Generic

prednisone oral tablet 20 mg Deltasone Generic

*Mineralocorticoids***

fludrocortisone acetate oral tablet 0.1 mg Generic

*Cough/Cold/Allergy*

*Antitussive - Nonnarcotic***

benzonatate oral capsule 100 mg Tessalon Perles Generic

benzonatate oral capsule 200 mg Generic

*Expectorants***

guaifenesin oral syrup 100 mg/5ml Diabetic Tussin EX Generic OTC

guaifenesin oral tablet 200 mg Generic OTC

*Dermatologicals*

*Acne Antibiotics***

clindamycin phosphate external solution 1

% Cleocin-T Generic

erythromycin external gel 2 % Erygel Generic

erythromycin external solution 2 % Generic

*Acne Combinations***

sulfacetamide sodium-sulfur external

emulsion 10-5 % Avar Cleanser Generic

*Antibiotics - Topical***

gentamicin sulfate external cream 0.1 % Generic

gentamicin sulfate external ointment 0.1

%

Generic

*Antifungals - Topical

Combinations***

nystatin-triamcinolone external cream

100000-0.1 unit/gm-%

Generic

18


nystatin-triamcinolone external ointment

100000-0.1 unit/gm-%

Generic

*Antifungals - Topical***

nystatin external cream 100000 unit/gm Generic

nystatin external ointment 100000 unit/gm Generic

*Antiseborrheic Products***

selenium sulfide external shampoo 2.3 % SelRx Generic

*Burn Products***

silver sulfadiazine external cream 1 % Silvadene Generic

*Corticosteroids - Topical***

betamethasone dipropionate external

cream 0.05 %

Generic


lotion 0.05 %

Generic


ointment 0.05 %

Generic

betamethasone valerate external cream 0.1

%

Generic

betamethasone valerate external lotion 0.1

%

Generic

betamethasone valerate external ointment

0.1 %

Generic

desonide external cream 0.05 % DesOwen Generic

desoximetasone external cream 0.05 %,

0.25 % Topicort Generic

desoximetasone external ointment 0.25 % Topicort Generic

fluocinolone acetonide external cream

0.025 % Synalar Generic

fluocinolone acetonide external ointment


fluocinolone acetonide external solution


fluocinonide emulsified base external

cream 0.05 %

Generic

fluocinonide external cream 0.05 % Generic

fluocinonide external gel 0.05 % Generic

fluocinonide external ointment 0.05 % Generic

fluocinonide external solution 0.05 % Generic

hydrocortisone external cream 1 % Aveeno Anti-Itch Max St Generic

hydrocortisone external cream 2.5 % Generic

19


hydrocortisone external lotion 1 % Anti-Itch Intensive

Healing Generic OTC

hydrocortisone external lotion 2.5 % Generic

hydrocortisone external ointment 1 % Cortizone-10 Generic

hydrocortisone external ointment 2.5 % Generic

triamcinolone acetonide external cream

0.025 %

Generic

triamcinolone acetonide external cream

0.1 %, 0.5 % Triderm Generic

triamcinolone acetonide external lotion

0.025 %, 0.1 %

Generic

triamcinolone acetonide external ointment

0.1 %

Generic

*Imidazole-Related Antifungals -

Topical***

ketoconazole external cream 2 % Generic

*Scabicides & Pediculicides***

lice treatment external liquid 1 % Nix Creme Rinse Generic OTC

permethrin external cream 5 % Elimite Generic

*Diagnostic Products*

*Diagnostic Tests***

FREESTYLE INSULINX TEST STRIP

IN VITRO

Zero Copay

OTC; QL (100 strips

per 30 days for

insulin dependent &

50 per 30 days for

non-insulin

dependent)

FREESTYLE LITE TEST STRIP IN

VITRO

Zero Copay

OTC; QL (100 strips

per 30 days for

insulin dependent &

50 per 30 days for

non-insulin

dependent)

FREESTYLE PRECISION NEO TEST

STRIP IN VITRO

Zero Copay

OTC; QL (100 strips

per 30 days for

insulin dependent &

50 per 30 days for

non-insulin

dependent)

FREESTYLE TEST STRIP IN VITRO

Zero Copay OTC; QL (100 strips

per 30 days for

insulin dependent &

50 per 30 days for

non-insulin

dependent)

20

PRECISION XTRA BLOOD GLUCOSE

STRIP IN VITRO

Zero Copay

OTC; QL (100 strips

per 30 days for

insulin dependent &

50 per 30 days for

non-insulin

dependent)

*Diuretics*

*Carbonic Anhydrase

Inhibitors***

acetazolamide oral tablet 125 mg, 250 mg Generic

methazolamide oral tablet 25 mg, 50 mg Generic

*Diuretic Combinations***

amiloride-hydrochlorothiazide oral tablet

5-50 mg

Generic

spironolactone-hctz oral tablet 25-25 mg Aldactazide Generic

21


triamterene-hctz oral capsule 37.5-25 mg Dyazide Generic

triamterene-hctz oral tablet 37.5-25 mg Maxzide-25 Generic

triamterene-hctz oral tablet 75-50 mg Maxzide Generic

*Loop Diuretics***

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg Bumex Generic

furosemide oral tablet 20 mg, 40 mg, 80

mg Lasix Generic

torsemide oral tablet 10 mg, 20 mg Demadex Generic

torsemide oral tablet 100 mg, 5 mg Generic

*Potassium Sparing Diuretics***

spironolactone oral tablet 100 mg, 25 mg,

50 mg Aldactone Generic

*Thiazides And Thiazide-Like

Diuretics***

chlorothiazide oral tablet 250 mg, 500 mg Generic

chlorthalidone oral tablet 25 mg, 50 mg Generic

hydrochlorothiazide oral capsule 12.5 mg Microzide Generic

hydrochlorothiazide oral tablet 12.5 mg,

25 mg, 50 mg

Generic

indapamide oral tablet 1.25 mg, 2.5 mg Generic

methyclothiazide oral tablet 5 mg Generic

*Endocrine And Metabolic

Agents - Misc.*

*Bisphosphonates***

alendronate sodium oral tablet 10 mg, 5

mg

Generic

alendronate sodium oral tablet 70 mg Fosamax Generic

*Hyperparathyroid Treatment -

Vitamin D Analogs***

calcitriol oral capsule 0.25 mcg, 0.5 mcg Rocaltrol Generic

*Estrogens*

*Estrogens***

estradiol oral tablet 0.5 mg, 1 mg, 2 mg Estrace Generic

*Fluoroquinolones*

*Fluoroquinolones***

ciprofloxacin hcl oral tablet 250 mg, 500

mg Cipro Generic

ciprofloxacin hcl oral tablet 750 mg Generic

22


levofloxacin oral tablet 250 mg, 500 mg,

750 mg Levaquin Generic

*Gastrointestinal Agents - Misc.*

*Gallstone Solubilizing Agents***

ursodiol oral capsule 300 mg Actigall Generic

*Gastrointestinal Stimulants***

metoclopramide hcl oral solution 5

mg/5ml

Generic

metoclopramide hcl oral tablet 10 mg, 5

mg Reglan Generic

*Inflammatory Bowel Agents***

AZULFIDINE ORAL TABLET 500 MG Generic

*Genitourinary Agents -

Miscellaneous*

*Alpha 1-Adrenoceptor

Antagonists***

tamsulosin hcl oral capsule 0.4 mg Flomax Generic

*Urinary Analgesics***

phenazopyridine hcl oral tablet 100 mg Pyridium Generic

phenazopyridine hcl oral tablet 200 mg Phenazo Generic

*Gout Agents*

*Gout Agent Combinations***

colchicine-probenecid oral tablet 0.5-500

mg

Generic

*Gout Agents***

allopurinol oral tablet 100 mg, 300 mg Zyloprim Generic

*Uricosurics***

probenecid oral tablet 500 mg Generic

*Hematological Agents - Misc.*

*Hematorheologic Agents***

pentoxifylline er oral tablet extended

release 400 mg

Generic

*Phosphodiesterase Iii

Inhibitors***

cilostazol oral tablet 100 mg, 50 mg Generic

23


*Platelet Aggregation

Inhibitors***

dipyridamole oral tablet 25 mg, 50 mg, 75

mg

Generic

*Thienopyridine Derivatives***

clopidogrel bisulfate oral tablet 75 mg Plavix Generic

*Hematopoietic Agents*

*Folic Acid/Folates***

folic acid oral tablet 1 mg Generic

*Hypnotics*

*Barbiturate Hypnotics***

phenobarbital oral tablet 100 mg, 15 mg,

30 mg, 60 mg

Generic

*Benzodiazepine Hypnotics***

flurazepam hcl oral capsule 15 mg, 30 mg

100% copay



days

temazepam oral capsule 15 mg, 30 mg

Restoril

100% copay



days

*Laxatives*

*Bowel Evacuant

Combinations***

peg 3350/electrolytes oral solution

reconstituted 240 gm Colyte with Flavor Packs Generic

peg-3350/electrolytes oral solution

reconstituted 236 gm GaviLyte-G Generic

*Laxatives - Miscellaneous***

lactulose oral solution 10 gm/15ml Generic

*Laxatives & Dss***

stool softener plus laxative oral tablet 8.6-

50 mg Colace 2-IN-1 Generic OTC

*Surfactant Laxatives***

docusate sodium oral capsule 100 mg Colace Generic OTC

ra col-rite oral capsule 50 mg Colace Clear Generic OTC

*Macrolides*

*Azithromycin***

azithromycin oral tablet 250 mg, 500 mg Zithromax Generic

24


*Erythromycins***

erythromycin base oral capsule delayed

release particles 250 mg

Generic

erythromycin ethylsuccinate oral tablet

400 mg E.E.S. 400 Generic

erythromycin stearate oral tablet 250 mg Erythrocin Stearate Generic

*Medical Devices*

*Glucose Monitoring Test

Supplies***

lancets Accu-Chek FastClix

Lancets Zero Copay OTC

lancets 28g Accu-Chek FastClix


lancets 30g Accu-Chek FastClix


lancets thin Accu-Chek FastClix


*Needles & Syringes***

BD INSULIN SYR ULTRAFINE II 31G

X 5/16" 0.3 ML, 31G X 5/16" 1 ML Advocate Insulin Syringe Zero Copay OTC

BD INSULIN SYR ULTRAFINE II 31G

X 5/16" 0.5 ML Advocate Insulin Syringe Zero Copay OTC

BD INSULIN SYRINGE 25G X 1" 1 ML,

25G X 5/8" 1 ML, 26G X 1/2" 1 ML,

27.5G X 5/8" 2 ML

Zero Copay

OTC

BD INSULIN SYRINGE 27G X 1/2" 1

ML

Zero Copay OTC

BD INSULIN SYRINGE MICROFINE

27G X 5/8" 1 ML

Zero Copay OTC


28G X 1/2" 0.5 ML

BD Insulin Syringe

MicroFine Zero Copay OTC


28G X 1/2" 1 ML

BD Insulin Syringe


BD INSULIN SYRINGE U/F 30G X 1/2"

1 ML BD Insulin Syringe U/F Zero Copay OTC

BD INSULIN SYRINGE ULTRAFINE

29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML Advocate Insulin Syringe Zero Copay OTC

BD INSULIN SYRINGE ULTRAFINE

29G X 1/2" 0.5 ML Advocate Insulin Syringe Zero Copay OTC

BD SAFETYGLIDE INSULIN

SYRINGE 30G X 5/16" 0.5 ML Advocate Insulin Syringe Zero Copay OTC

25



SYRINGE 31G X 15/64" 0.3 ML

Zero Copay


SYRINGE 31G X 15/64" 0.5 ML, 31G X

15/64" 1 ML

Zero Copay

OTC

insulin syringe 27g x 1/2" 0.5 ml Easy Touch Insulin

Syringe Zero Copay OTC

insulin syringe 28g x 1/2" 0.5 ml, 28g x

1/2" 1 ml

BD Insulin Syringe


insulin syringe 29g x 1" 0.3 ml Zero Copay OTC


1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16"

0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1

ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5

ml, 31g x 5/16" 1 ml

Advocate Insulin Syringe

Zero Copay

OTC


1/2" 1 ml BD Insulin Syringe U/F Zero Copay OTC

insulin syringe-needle u-100 31g x 1/4"

0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml UltiCare Insulin Syringe Zero Copay OTC

pen needles 29g x 12mm , 31g x 6 mm ,

32g x 5 mm CareFine Pen Needles Zero Copay OTC

pen needles 3/16" 31g x 5 mm Advocate Insulin Pen

Needles Zero Copay OTC

pen needles 30g x 5 mm Assure ID Safety Pen


pen needles 32g x 4 mm BD Pen Needle Nano U/F Zero Copay OTC

pen needles 32g x 6 mm BD Pen Needle Micro

U/F Zero Copay OTC

pen needles 5/16" 30g x 8 mm Assure ID Safety Pen


pen needles 5/16" 31g x 8 mm Advocate Insulin Pen


*Migraine Products*

*Selective Serotonin Agonists 5-

Ht(1)***

rizatriptan benzoate oral tablet 10 mg Maxalt Generic QL (9 tabs per 30

days)

rizatriptan benzoate oral tablet 5 mg

Generic QL (9 tabs per 30

days)

rizatriptan benzoate oral tablet dispersible

10 mg, 5 mg Maxalt-MLT Generic

QL (9 tabs per 30

days)

sumatriptan succinate oral tablet 100 mg Imitrex Generic QL (9 TABS per 30

days)

26


sumatriptan succinate oral tablet 25 mg,

50 mg Imitrex Generic

QL (9 tabs per 30

days)

*Minerals & Electrolytes*

*Potassium***

potassium bicarbonate oral tablet

effervescent 25 meq Effer-K Generic

potassium chloride er oral capsule

extended release 10 meq Klor-Con Sprinkle Generic

potassium chloride er oral tablet extended

release 10 meq, 20 meq, 8 meq K-Tab Generic

potassium chloride oral solution 40

meq/15ml (20%)

Generic

*Mouth/Throat/Dental Agents*

*Anesthetics Topical Oral***

lidocaine viscous mouth/throat solution 2

%

Generic

*Anti-Infectives - Throat***

nystatin mouth/throat suspension 100000

unit/ml

Generic

*Antiseptics - Mouth/Throat***

chlorhexidine gluconate mouth/throat

solution 0.12 % Paroex Generic

*Steroids - Mouth/Throat***

triamcinolone acetonide mouth/throat

paste 0.1 % Oralone Generic

*Multivitamins*

*B-Complex W/ C***

b complex-vitamin c oral capsule Generic OTC

*B-Complex W/ Folic Acid***

b complex plus oral tablet Generic OTC

*Musculoskeletal Therapy

Agents*

*Central Muscle Relaxants***

baclofen oral tablet 10 mg, 20 mg Generic

chlorzoxazone oral tablet 500 mg Generic

cyclobenzaprine hcl oral tablet 10 mg Generic

methocarbamol oral tablet 500 mg Robaxin Generic

methocarbamol oral tablet 750 mg Robaxin-750 Generic

tizanidine hcl oral tablet 2 mg Generic

27


tizanidine hcl oral tablet 4 mg Zanaflex Generic

*Ophthalmic Agents*

*Beta-Blockers - Ophthalmic***

levobunolol hcl ophthalmic solution 0.5 % Betagan Generic

timolol maleate ophthalmic solution 0.25

%, 0.5 % Timoptic Generic

*Cycloplegic Mydriatics***

tropicamide ophthalmic solution 1 % Mydriacyl Generic

*Miotics - Direct Acting***

pilocarpine hcl ophthalmic solution 1 %, 2

%, 4 % Isopto Carpine Generic

*Ophthalmic Antibiotics***

GENTAK OPHTHALMIC OINTMENT

0.3 %

Generic

bacitracin ophthalmic ointment 500

unit/gm

Generic

erythromycin ophthalmic ointment 5

mg/gm

Generic

gentamicin sulfate ophthalmic solution 0.3

%

Generic

tobramycin ophthalmic solution 0.3 % Tobrex Generic

*Ophthalmic Anti-Infective

Combinations***

neomycin-bacitracin zn-polymyx

ophthalmic ointment 3.5-400-10000 Neo-Polycin Generic

neomycin-polymyxin-gramicidin

ophthalmic solution 1.75-10000-.025 Neosporin Generic

*Ophthalmic Decongestant

Combinations***

eye allergy relief ophthalmic solution

0.025-0.3 % Naphcon-A Generic OTC

*Ophthalmic Steroid

Combinations***

bacitra-neomycin-polymyxin-hc

ophthalmic ointment 1 % Neo-Polycin HC Generic

neomycin-polymyxin-dexameth

ophthalmic ointment 3.5-10000-0.1 Maxitrol Generic

neomycin-polymyxin-dexameth

ophthalmic suspension 0.1 % Maxitrol Generic

neomycin-polymyxin-hc ophthalmic

suspension 3.5-10000-1

Generic

28


*Ophthalmic Steroids***

dexamethasone sodium phosphate

ophthalmic solution 0.1 %

Generic

fluorometholone ophthalmic suspension

0.1 % FML Liquifilm Generic

prednisolone acetate ophthalmic

suspension 1 % Omnipred Generic

*Ophthalmic Sulfonamides***

sulfacetamide sodium ophthalmic

ointment 10 %

Generic

sulfacetamide sodium ophthalmic solution

10 % Bleph-10 Generic

*Otic Agents*

*Otic Agents - Miscellaneous***

acetic acid otic solution 2 % Generic

*Otic Steroid-Anti-Infective

Combinations***

neomycin-polymyxin-hc otic solution 1 % Generic

neomycin-polymyxin-hc otic suspension

3.5-10000-1

Generic

*Otic Steroids***

hydrocortisone-acetic acid otic solution 1-

2 % Acetasol HC Generic

*Penicillins*

*Aminopenicillins***

amoxicillin oral capsule 250 mg, 500 mg Generic

amoxicillin oral suspension reconstituted

250 mg/5ml

Generic

amoxicillin oral tablet chewable 250 mg Generic

ampicillin oral capsule 500 mg Generic

*Natural Penicillins***

penicillin v potassium oral solution

reconstituted 250 mg/5ml

Generic

penicillin v potassium oral tablet 250 mg,

500 mg

Generic

*Penicillin Combinations***

amoxicillin-pot clavulanate oral tablet

500-125 mg, 875-125 mg Augmentin Generic

29


*Penicillinase-Resistant

Penicillins***

dicloxacillin sodium oral capsule 250 mg,

500 mg

Generic

*Progestins*

*Progestins***

medroxyprogesterone acetate oral tablet

10 mg, 2.5 mg, 5 mg Provera Generic

*Psychotherapeutic And

Neurological Agents - Misc.*

*Benzodiazepines & Tricyclic

Agents***

chlordiazepoxide-amitriptyline oral tablet

10-25 mg, 5-12.5 mg

Generic

*Phenothiazines & Tricyclic

Agents***

perphenazine-amitriptyline oral tablet 2-

10 mg, 2-25 mg, 4-10 mg, 4-25 mg

Generic

*Tetracyclines*

*Tetracyclines***

doxycycline hyclate oral capsule 100 mg,

50 mg Morgidox Generic

minocycline hcl oral capsule 100 mg, 50

mg Minocin Generic

tetracycline hcl oral capsule 250 mg, 500

mg

Generic

*Thyroid Agents*

*Antithyroid Agents***

methimazole oral tablet 10 mg, 5 mg Tapazole Generic

propylthiouracil oral tablet 50 mg Generic

*Thyroid Hormones***

SYNTHROID ORAL TABLET 100

MCG, 112 MCG, 125 MCG, 137 MCG,

150 MCG, 175 MCG, 200 MCG, 25

MCG, 300 MCG, 50 MCG, 75 MCG, 88

MCG

Levo-T

Brand

levothyroxine sodium oral tablet 100 mcg,

112 mcg, 125 mcg, 137 mcg, 150 mcg,

175 mcg, 200 mcg, 25 mcg, 300 mcg, 50

mcg, 75 mcg, 88 mcg

Levo-T

Generic

30


levothyroxine-liothyronine oral tablet 120

mg, 15 mg, 30 mg, 60 mg, 90 mg Armour Thyroid Generic

*Ulcer Drugs*

*Anticholinergic

Combinations***

chlordiazepoxide-clidinium oral capsule

5-2.5 mg Librax Generic

*Antispasmodics***

dicyclomine hcl oral capsule 10 mg Generic

dicyclomine hcl oral tablet 20 mg Generic

*Belladonna Alkaloids***

hyoscyamine sulfate er oral tablet

extended release 12 hour 0.375 mg Levbid Generic

hyoscyamine sulfate sl sublingual tablet

sublingual 0.125 mg Levsin/SL Generic

*H-2 Antagonists***

cimetidine oral tablet 300 mg, 400 mg,

800 mg

Generic

*Misc. Anti-Ulcer***

sucralfate oral tablet 1 gm Carafate Generic

*Proton Pump Inhibitors***

omeprazole oral capsule delayed release

10 mg, 20 mg, 40 mg

Generic

pantoprazole sodium oral tablet delayed

release 20 mg, 40 mg Protonix Generic

*Urinary Anti-Infectives*

*Urinary Anti-Infectives***

nitrofurantoin macrocrystal oral capsule

100 mg, 25 mg, 50 mg Macrodantin Generic

nitrofurantoin monohyd macro oral

capsule 100 mg Macrobid Generic

*Urinary Antispasmodics*

*Urinary Antispasmodic -

Antimuscarinics

(Antichol)***(New)

oxybutynin chloride oral tablet 5 mg Generic

31


*Urinary Antispasmodics -

Cholinergic Agonists*** (New)

bethanechol chloride oral tablet 10 mg, 25

mg, 5 mg, 50 mg Urecholine Generic

*Vaccines*

*Bacterial Vaccines***

PNEUMOVAX 23 INJECTION

INJECTABLE 25 MCG/0.5ML

Brand

PREVNAR 13 INTRAMUSCULAR

SUSPENSION

Brand

*Viral Vaccines***

AFLURIA INTRAMUSCULAR

SUSPENSION

Brand

AFLURIA PRESERVATIVE FREE

INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 0.5 ML

Brand

FLUZONE HIGH-DOSE



Brand

FLUZONE QUADRIVALENT

INTRAMUSCULAR SUSPENSION ,

0.5 ML

Brand

FLUZONE QUADRIVALENT



Brand

SHINGRIX INTRAMUSCULAR

SUSPENSION RECONSTITUTED 50

MCG/0.5ML

Brand

*Vaginal Products*

*Imidazole-Related

Antifungals***

clotrimazole-7 vaginal cream 1 % Gyne-Lotrimin Generic OTC

miconazole 3 vaginal suppository 200 mg Generic

miconazole 7 vaginal cream 2 % Monistat 7 Simply Cure Generic OTC

*Vasopressors*

*Anaphylaxis Therapy Agents***

EPIPEN 2-PAK INJECTION SOLUTION

AUTO-INJECTOR 0.3 MG/0.3ML Adrenaclick Brand

epinephrine injection solution auto-

injector 0.3 mg/0.3ml Generic

32


*Vitamins*

*Vitamin D***

vitamin d (ergocalciferol) oral capsule

50000 unit Drisdol Generic

Documents

County Health Plan Formulary Copay 100% copay Brand ......Jun 08, 2020 · Dilantin Generic *Valproic Acid*** divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg