Presbyterian SCI 2013 Presbyterian State Coverage Insurance (SCI)docs.phs.org/idc/groups/public/@phs/@php/documents... · 2020-03-13 · MORPHINE SULFATE. TABS (QL) morphine sulfate

Presbyterian SCI

Drug Name Dosage Form Note

acetaminophen/codeine #2 TABS (QL)



ADULT ASPIRIN LOW STRENGTH TBDP (AG)

aspirin CHEW (AG)

aspirin ec TBEC (AG)

aspirin low dose TABS (AG)

AVINZA (120MG) CP24 (QL) (ST)






butalbital/acetaminophen/caffeine * (QL)

butalbital/acetaminophen/caffeine CAPS (QL)

butalbital/acetaminophen/caffeine (325mg; 50mg; 40mg) TABS (QL)



butalbital/acetaminophen/caffeine/codeine CAPS (QL)

butalbital/aspirin/caffeie/codeine CAPS

carisoprodol/aspirin TABS

carisoprodol/aspirin/codeine TABS

CELEBREX CAPS (QL) (ST)

CODEINE SULFATE TABS (QL)

diclofenac sodium dr TBEC

diclofenac sodium er TB24

diflunisal TABS

DOLGIC PLUS TABS

endocet TABS (QL)

etodolac *

etodolac er TB24

fentanyl PT72 (ST) (QL)

2013 Presbyterian State Coverage Insurance (SCI) Formulary/Preferred Drug Listing - By Therapeutic Class

Some medications may be excluded as determined by benefit.

Analgesics

[MPC021249] Page 1 of 46 August 15, 2013


flurbiprofen TABS

hydrocodone bitartrate/acetaminophen TABS (QL)

hydrocodone/acetaminophen SOLN (QL)

hydrocodone/acetaminophen (325mg; 10mg) TABS (QL)


hydrocodone/acetaminophen (325mg; 7.5mg) TABS (QL)









hydrocodone/ibuprofen TABS

hydrogesic CAPS (QL)

hydromorphone hcl TABS (QL)

hydromorphone hcl LIQD (QL)

ibuprofen *

ibuprofen TABS

ibuprofen SUSP

INDOCIN *

indomethacin CAPS

indomethacin er CPCR

KADIAN CP24 (QL) (ST)

ketoprofen CAPS

KETOPROFEN ER CP24

MELOXICAM *

meloxicam *

MEPERIDINE HCL SOLN

meperidine hcl TABS (QL)

methadone hcl TABS (PA) (QL)

METHADONE HCL SOLN (PA)

MORPHINE SULFATE TABS (QL)

morphine sulfate (10mg/5ml) SOLN (QL)

morphine sulfate (20mg/5ml) SOLN (QL)

morphine sulfate (20mg/ml) SOLN (QL)

morphine sulfate er CP24 (QL) (ST)

morphine sulfate er TBCR (QL)

nabumetone TABS

naproxen *

naproxen dr TBEC

naproxen sodium TABS

oxaprozin TABS



OXYCODONE HCL SOLN (QL)

OXYCODONE HCL CONC (QL)

oxycodone hcl TABS (QL)

oxycodone/acetaminophen * (QL)

oxycodone/acetaminophen (325mg; 10mg) TABS (QL)


oxycodone/acetaminophen (325mg; 7.5mg) TABS (QL)

oxycodone/acetaminophen (500mg; 7.5mg) TABS (QL)


oxycodone/aspirin TABS

OXYMORPHONE HYDROCHLORIDE ER TB12 (ST) (QL)

OXYMORPHONE HYDROCHLORIDE ER TB12 (QL) (ST)

oxymorphone hydrochloride er TB12 (ST) (QL)

piroxicam CAPS

ROXICET SOLN (QL)

ROXICET TABS (QL)

salsalate TABS

ST JOSEPH ADULT CHEW (AG)

sulindac TABS

tramadol hcl TABS (QL)


antipyrine/benzocaine SOLN

lidocaine OINT

lidocaine CREA

LIDOCAINE HCL LOTN

lidocaine viscous SOLN

lidocaine/prilocaine CREA

LIDODERM PTCH (PA) (QL)


acamprosate calcium dr TBEC (PA) (QL)

buprenorphine hcl SUBL (PA) (QL)

buproban TB12 (QL)

bupropion hcl sr TB12 (QL)

CHANTIX TABS (QL)

CHANTIX STARTING MONTH PAK TABS (QL)

disulfiram TABS

Anesthetics

Anti-Addiction/Substance Abuse Treatment Agents



naltrexone hcl TABS

SUBOXONE * (PA) (QL)

SUBOXONE (12MG; 3MG) FILM (PA) (QL)

SUBOXONE (2MG; 0.5MG) FILM (PA) (QL)



VIVITROL SUSR (PA) (QL) (SP)


ADULT ASPIRIN LOW STRENGTH TBDP (AG)

aspirin CHEW (AG)

aspirin ec TBEC (AG)

aspirin low dose TABS (AG)

CELEBREX CAPS (QL) (ST)

COLY-MYCIN S SUSP

diclofenac sodium dr TBEC

diclofenac sodium er TB24

diflunisal TABS

etodolac *

etodolac er TB24

flurbiprofen TABS

hydrocortisone/acetic acid SOLN

ibuprofen *

ibuprofen TABS

ibuprofen SUSP

INDOCIN *

indomethacin CAPS

indomethacin er CPCR

ketoprofen CAPS

KETOPROFEN ER CP24

meloxicam *

MELOXICAM *

nabumetone TABS

naproxen *

naproxen dr TBEC

naproxen sodium TABS

NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP

neomycin/polymyxin/hydrocortisone SOLN

neomycin/polymyxin/hydrocortisone SUSP

nystatin/triamcinolone *

NYSTATIN/TRIAMCINOLONE *

Anti-inflammatory Agents



oxaprozin TABS

piroxicam CAPS

ST JOSEPH ADULT CHEW (AG)

sulindac TABS


ak-poly-bac OINT

AKNE-MYCIN OINT

AMOXICILLIN *

amoxicillin *

amoxicillin/clavulanate potassium *

amoxicillin/potassium clavulanate SUSR

AMPICILLIN *

ampicillin *

azithromycin *

BACITRACIN OINT

bacitracin/polymyxin b OINT

BACTROBAN NASAL OINT

BLEPHAMIDE SUSP

BLEPHAMIDE S.O.P. OINT

cefaclor CAPS

cefdinir *

cefpodoxime proxetil *

cefprozil *

cefuroxime axetil *

cephalexin *

CIPRO SUSR

CIPRODEX SUSP (AG) (PA) (QL)

ciprofloxacin hcl SOLN

ciprofloxacin hcl TABS

clarithromycin SUSR

clarithromycin TABS (QL)

CLEOCIN SUPP

clindamycin hcl CAPS

clindamycin palmitate hcl SOLR

clindamycin phosphate CREA

COLY-MYCIN S SUSP

CORTISPORIN CREA

CORTISPORIN OINT

dicloxacillin sodium CAPS

DIFICID TABS (PA) (QL)

Antibacterials



doxycycline hyclate *

doxycycline hyclate TABS (QL)

E.E.S. 400 TABS

E.E.S. GRANULES SUSR

ERY-TAB TBEC

ERYPED 200 SUSR

ERYPED 400 SUSR

ERYTHROCIN STEARATE TABS

erythromycin OINT

ERYTHROMYCIN *

erythromycin *

ERYTHROMYCIN BASE TABS

ERYTHROMYCIN ETHYLSUCCINATE TABS

erythromycin/sulfisoxazole SUSR

garamycin OINT

gentak OINT

gentamicin sulfate SOLN

GENTAMICIN SULFATE *

levofloxacin *

MACRODANTIN CAPS

methenamine hippurate TABS

METHENAMINE MANDELATE TABS

methenamine mandelate TABS

metronidazole *

metronidazole TABS

metronidazole vaginal GEL

minocycline hcl CAPS

mupirocin OINT

neomycin sulfate TABS

neomycin/bacitracin/polymyxin OINT

neomycin/polymyxin b sulfates SOLN

neomycin/polymyxin/bacitracin/hydrocortisone OINT

neomycin/polymyxin/dexamethasone *

neomycin/polymyxin/gramicidin SOLN




nitrofurantoin SUSP

nitrofurantoin macrocrystalline CAPS

nitrofurantoin monohydrate CAPS

ofloxacin SOLN

penicillin v potassium *

polycin b OINT

polymyxin b sulfate/trimethoprim sulfate SOLN



silver sulfadiazine CREA

sulfacetamide sodium SOLN

sulfamethoxazole/trimethoprim *

sulfamethoxazole/trimethoprim ds TABS

TETRACYCLINE HCL CAPS

TOBI NEBU

TOBI PODHALER CAPS (QL)

tobramycin sulfate SOLN

trimethoprim TABS

vancomycin hcl SOLR

vancomycin hcl CAPS (PA)

VIBRAMYCIN SUSR

XIFAXAN TABS (PA) (QL)

ZYVOX * (PA)


carbamazepine *

carbamazepine er *

clonazepam TABS (QL)

clonazepam odt TBDP (QL)

diazepam TABS (QL)

DIAZEPAM GEL (ST)

DILANTIN CAPS

divalproex sodium CPSP

divalproex sodium dr TBEC

divalproex sodium er TB24

ethosuximide *

gabapentin *

LAMICTAL CHEW (QL)

lamotrigine CHEW (QL)

lamotrigine (100mg) TABS (QL)




levetiracetam *

LYRICA (100MG) CAPS (PA) (QL)






Anticonvulsants





oxcarbazepine TABS

PHENOBARBITAL *

phenobarbital *

phenytoin CHEW

phenytoin SUSP

phenytoin sodium extended CAPS

POTIGA TABS (PA) (QL)

primidone TABS

TEGRETOL-XR TB12

topiramate *

valproic acid CAPS

valproic acid SYRP

zonisamide CAPS


donepezil hcl * (QL)

ERGOLOID MESYLATES TABS

galantamine hydrobromide CP24

galantamine hydrobromide *


ABILIFY SOLN (PA) (QL)

ABILIFY TABS (PA) (QL)

ABILIFY DISCMELT TBDP (PA) (QL)

ABILIFY MAINTENA SUSR (MB) (PA) (SP)

amitriptyline hcl TABS

AMOXAPINE TABS

budeprion sr TB12 (QL)

bupropion hcl TABS (QL)

bupropion hcl sr TB12 (QL)

bupropion hcl xl TB24 (QL)

citalopram hydrobromide SOLN (QL)

citalopram hydrobromide (10mg) TABS (QL)



clomipramine hcl CAPS

Antidementia Agents

Antidepressants



CYMBALTA (20MG) CPEP (PA) (QL)



desipramine hcl TABS

doxepin hcl *

DOXEPIN HCL *

EMSAM PT24 (PA) (QL)

escitalopram oxalate SOLN (QL)

escitalopram oxalate (10mg) TABS (QL)



FLUOXETINE HCL * (QL)

fluoxetine hcl SOLN (QL)

fluoxetine hcl * (QL)

fluoxetine hcl (10mg) CAPS (QL)



fluvoxamine maleate (100mg) TABS (QL) (ST)



imipramine hcl TABS

MAPROTILINE HCL TABS

mirtazapine * (QL)

mirtazapine odt TBDP (QL)

NEFAZODONE HCL TABS (QL)

nefazodone hcl TABS (QL)

nortriptyline hcl CAPS

paroxetine hcl (10mg) TABS (QL)




paroxetine hcl er TB24 (ST)

PAXIL SUSP (QL)

PERPHENAZINE/AMITRIPTYLINE TABS

phenelzine sulfate TABS

quetiapine fumarate (100mg) TABS (AG) (QL)






selegiline hcl *

sertraline hcl CONC (QL)

sertraline hcl (100mg) TABS (QL)





tranylcypromine sulfate TABS

trazodone hcl TABS

venlafaxine hcl TABS (QL)

venlafaxine hcl er (150mg) TB24 (QL)

venlafaxine hcl er (150mg) CP24 (QL)

venlafaxine hcl er (37.5mg) CP24 (QL)

venlafaxine hcl er (37.5mg) TB24 (QL)



VIIBRYD TABS (PA) (QL)


ALOXI SOLN (PA) (QL)

ANZEMET TABS (PA) (QL)

chlorpromazine hcl TABS

compro SUPP

EMEND SOLR (PA) (QL) (SP)

EMEND (0) CAPS (PA) (QL)

EMEND (125MG) CAPS (PA) (QL)



granisetron hcl SOLN

granisetron hcl TABS (QL) (ST)

hydroxyzine hcl *

hydroxyzine pamoate CAPS

HYDROXYZINE PAMOATE CAPS

metoclopramide hcl *

ondansetron hcl TABS (QL)

ondansetron odt TBDP (QL)

perphenazine TABS

phenadoz SUPP

prochlorperazine SUPP

PROCHLORPERAZINE EDISYLATE SOLN

prochlorperazine maleate TABS

promethazine hcl *

promethazine hcl plain SYRP

PROMETHEGAN SUPP

trimethobenzamide hcl CAPS

Antiemetics




BIO-STATIN CAPS

ciclopirox SUSP

ciclopirox GEL

ciclopirox nail lacquer SOLN (QL)

ciclopirox olamine CREA

clotrimazole TROC

clotrimazole/betamethasone dipropionate *

econazole nitrate CREA

fluconazole *

GRIFULVIN V TABS

GRIS-PEG TABS

griseofulvin microsize SUSP

ketoconazole TABS

ketoconazole *

nyamyc POWD

nystatin SUSP

nystatin *

nystatin TABS

NYSTATIN VAGINAL TABS

nystatin/triamcinolone *

NYSTATIN/TRIAMCINOLONE *

nystop POWD

pedi-dri POWD

terbinafine hcl TABS (QL)

terconazole *

VFEND SUSR (PA) (QL)

voriconazole TABS (PA) (QL)


allopurinol TABS

COLCRYS TABS

probenecid TABS

probenecid/colchicine TABS

ULORIC TABS (PA) (QL)

Antigout Agents

Antimigraine Agents

Antifungals







CAFERGOT TABS




MIGERGOT SUPP

naratriptan hcl TABS (QL) (ST)

rizatriptan benzoate TABS (ST) (QL)

SUMATRIPTAN SOLN (QL)

sumatriptan succinate SOLN (QL)

sumatriptan succinate TABS (QL)

topiramate *

valproic acid CAPS


MESTINON SYRP

pyridostigmine bromide TABS


CYCLOSERINE CAPS

DAPSONE TABS

ethambutol hcl TABS

ISONIAZID SYRP

isoniazid TABS

MYCOBUTIN CAPS

PASER PACK

pyrazinamide TABS

rifampin CAPS

SEROMYCIN CAPS

Antimyasthenic Agents

Antimycobacterials

Antineoplastics




AFINITOR TABS (PA) (SP)

AFINITOR DISPERZ TBSO (PA) (SP)

ALIMTA SOLR (PA)

ALKERAN TABS

anastrozole TABS

AVASTIN SOLN (PA)

BOSULIF TABS (PA) (QL) (SP)

CAMPATH SOLN (PA)

CAPRELSA TABS (PA)

CEENU CAPS (PA) (SP)

COMETRIQ KIT (PA)

CYCLOPHOSPHAMIDE TABS

EMCYT CAPS (PA) (SP)

ERIVEDGE CAPS (PA) (QL) (SP)

ERWINAZE SOLR (PA) (SP)

ETHYOL SOLR (PA)

ETOPOSIDE CAPS (SP)

FARESTON TABS (PA) (SP)

GLEEVEC TABS (PA) (SP)

HEXALEN CAPS (PA) (SP)

HYCAMTIN CAPS (PA) (SP)

hydroxyurea CAPS

INLYTA TABS (PA) (SP)

IRESSA TABS (PA)

JAKAFI TABS (PA) (SP)

KADCYLA SOLR (MB) (PA) (SP)

KYPROLIS SOLR (PA) (SP)

leucovorin calcium TABS

LEUCOVORIN CALCIUM TABS

LEUKERAN TABS (PA) (SP)

MATULANE CAPS (PA) (SP)

MEKINIST TABS (PA) (QL) (SP)

mercaptopurine TABS

MYLERAN TABS (PA) (SP)

NEXAVAR TABS (PA) (SP)

PERJETA SOLN (PA) (SP)

POMALYST CAPS (PA) (SP) (QL)

REVLIMID CAPS (PA) (SP)

RITUXAN CONC (PA)

SPRYCEL TABS (PA) (SP)

STIVARGA TABS (PA) (QL) (SP)

SUTENT CAPS (PA) (SP)

SYLATRON KIT (PA) (SP)



TABLOID TABS (PA) (SP)

TAFINLAR CAPS (PA) (QL) (SP)

tamoxifen citrate TABS

TARCEVA TABS (PA) (SP)

TARGRETIN CAPS (PA) (SP)

TASIGNA CAPS (PA) (SP)

temozolomide CAPS (PA) (SP)

THALOMID CAPS (PA)

TYKERB TABS (PA) (SP)

VOTRIENT TABS (PA) (SP)

XALKORI (200MG) CAPS (PA) (SP)

XALKORI (250MG) CAPS (PA) (SP)

XELODA TABS (PA) (SP)

YERVOY SOLN (PA)

ZALTRAP SOLN (PA) (SP)

ZELBORAF TABS (PA) (SP)

ZOLINZA CAPS (PA) (SP)

ZYTIGA TABS (PA) (SP)


chloroquine phosphate TABS

hydroxychloroquine sulfate TABS

lindane *

MEPRON SUSP

NEBUPENT SOLR

NEUTREXIN SOLR

PENTAM 300 SOLR

permethrin CREA

PRIMAQUINE PHOSPHATE TABS


amantadine hcl *

AMANTADINE HCL *

APOKYN SOLN (PA) (SP)

benztropine mesylate TABS

bromocriptine mesylate *

carbidopa/levodopa TABS

carbidopa/levodopa er TBCR

Antiparasitics

Antiparkinson Agents



carbidopa/levodopa odt TBDP

COGENTIN SOLN

COMTAN TABS

EMSAM PT24 (PA) (QL)

pramipexole dihydrochloride (0.125mg) TABS





pramipexole dihydrochloride (1mg) TABS

ropinirole hcl TABS

selegiline hcl *

trihexyphenidyl hcl *






chlorpromazine hcl TABS

clozapine (100mg) TABS (QL)




CLOZAPINE ODT (100MG) TBDP (QL)

CLOZAPINE ODT (12.5MG) TBDP (QL)

CLOZAPINE ODT (25MG) TBDP (QL)

compro SUPP

fluphenazine hcl *

FLUPHENAZINE HCL *

haloperidol TABS

loxapine succinate CAPS

olanzapine (10mg) TABS (AG) (QL)


olanzapine (2.5mg) TABS (AG) (QL)




olanzapine odt TBDP (PA) (QL)

perphenazine TABS

PERPHENAZINE/AMITRIPTYLINE TABS

Antipsychotics



prochlorperazine SUPP

PROCHLORPERAZINE EDISYLATE SOLN

prochlorperazine maleate TABS







RISPERDAL CONSTA SUSR (PA) (QL) (SP)

risperidone odt (0.25mg) TBDP (PA) (QL)

thioridazine hcl TABS

thiothixene CAPS

trifluoperazine hcl TABS

ziprasidone hcl CAPS (AG) (QL)


baclofen TABS

tizanidine hcl TABS


abacavir TABS (QL)

acyclovir *

ALFERON N SOLN (SP)

amantadine hcl *

AMANTADINE HCL *

APTIVUS SOLN (QL)

APTIVUS CAPS (QL)

ATRIPLA TABS (QL)

COMPLERA TABS (SP)

CRIXIVAN CAPS (QL)

didanosine CPDR (QL)

EDURANT TABS (SP)

EMTRIVA SOLN

EMTRIVA CAPS (QL)

EPIVIR SOLN (QL)

EPIVIR HBV *

EPZICOM TABS (QL)

Antispasticity Agents

Antivirals



famciclovir TABS

FUZEON KIT (QL)

INCIVEK TABS (PA) (QL) (SP)

INFERGEN INJ (SP)

INTELENCE (100MG) TABS (QL) (SP)



INTRON-A SOLN (SP)

INTRON-A W/DILUENT SOLR (SP)

INVIRASE * (QL)

ISENTRESS TABS (QL)

KALETRA SOLN

KALETRA TABS (QL)

lamivudine TABS (QL)

lamivudine/zidovudine TABS (QL)

LEXIVA TABS (QL)

LEXIVA SUSP

NEVIRAPINE SUSP (QL)

nevirapine TABS (QL)

NORVIR * (QL)

NORVIR SOLN (QL)

PEG-INTRON KIT (PA) (SP)

PEG-INTRON REDIPEN PAK 4 KIT (PA) (SP)

PEGASYS * (PA) (SP)

PREZISTA SUSP (QL)

PREZISTA (150MG) TABS (QL)





RELENZA DISKHALER AEPB (QL)

RESCRIPTOR TABS (QL) (SP)

RESCRIPTOR TABS (QL)

REYATAZ CAPS (QL)

ribasphere CAPS (SP)

ribavirin TABS (SP)

SELZENTRY TABS (QL)

SELZENTRY TABS (QL) (SP)

stavudine CAPS (QL)

stavudine SOLR (QL)

STRIBILD TABS (QL) (SP)

SUSTIVA * (QL)

TAMIFLU CAPS (QL)

TAMIFLU SUSR (QL)



trifluridine SOLN

TRIZIVIR TABS (QL)

TRUVADA TABS

VALCYTE TABS (PA) (QL)

VALCYTE SOLR (PA) (QL)

VICTRELIS CAPS (PA) (QL) (SP)

VIDEX PEDIATRIC SOLR (QL) (SP)

VIRACEPT TABS (QL)

VIRAMUNE XR TB24 (QL)

VIREAD * (QL)

VIREAD (150MG) TABS (QL)




ZIAGEN SOLN (QL)

zidovudine * (QL)

zidovudine SYRP

ZOVIRAX CREA

ZOVIRAX OINT (QL)


alprazolam (0.25mg) TABS (QL)

alprazolam (0.5mg) TABS (QL)

alprazolam (1mg) TABS (QL)

alprazolam (2mg) TABS (QL)

ALPRAZOLAM INTENSOL CONC

buspirone hcl TABS (QL)

chlordiazepoxide hcl CAPS (QL)

clonazepam TABS (QL)

clonazepam odt TBDP (QL)




diazepam TABS (QL)

DOXEPIN HCL *

doxepin hcl *

escitalopram oxalate SOLN (QL)




hydroxyzine hcl *

Anxiolytics





lorazepam TABS (QL)

lorazepam CONC

meprobamate TABS





paroxetine hcl er TB24 (ST)

PAXIL SUSP (QL)

sertraline hcl CONC (QL)




venlafaxine hcl TABS (QL)



venlafaxine hcl er (37.5mg) CP24 (QL)

venlafaxine hcl er (37.5mg) TB24 (QL)








carbamazepine *

carbamazepine er *




LAMICTAL CHEW (QL)

lamotrigine CHEW (QL)





lithium carbonate *

lithium carbonate er TBCR

Bipolar Agents



LITHIUM CITRATE SOLN







olanzapine odt TBDP (PA) (QL)







RISPERDAL CONSTA SUSR (PA) (QL) (SP)

risperidone SOLN (AG) (QL)

risperidone (0.25mg) TABS (AG) (QL)

risperidone (0.5mg) TABS (AG) (QL)

risperidone (1mg) TABS (AG) (QL)






risperidone odt (1mg) TBDP (PA) (QL)




TEGRETOL-XR TB12

valproic acid CAPS

ziprasidone hcl CAPS (AG) (QL)


acarbose TABS

AVANDAMET TABS (ST)

AVANDIA TABS (ST)

BYETTA (10MCG/0.04ML) SOLN (PA) (QL)

BYETTA (5MCG/0.02ML) SOLN (PA) (QL)

CHLORPROPAMIDE TABS

glimepiride TABS

glipizide TABS

Blood Glucose Regulators



glipizide er TB24

glipizide/metformin hcl TABS

GLUCAGEN SOLR

GLUCAGON EMERGENCY KIT KIT

glyburide TABS

glyburide/metformin hcl TABS

JANUMET TABS (QL) (ST)

JANUMET XR (1000MG; 100MG) TB24 (QL) (ST)



JANUVIA TABS (QL) (ST)

KOMBIGLYZE XR TB24 (PA)

LANTUS SOLN (QL)

LANTUS SOLOSTAR SOLN (QL)

LEVEMIR SOLN (QL)

LEVEMIR FLEXPEN SOLN (QL)

metformin hcl TABS

metformin hcl er TB24

nateglinide TABS

NOVOLIN 70/30 SUSP (QL)

NOVOLIN N SUSP (QL)

NOVOLIN R SOLN (QL)

NOVOLOG SOLN (QL)

NOVOLOG FLEXPEN SOLN (QL)

NOVOLOG MIX 70/30 SUSP (QL)

NOVOLOG MIX 70/30 PREFILLED FLEXPEN SUSP (QL)

NOVOLOG PENFILL SOLN (QL)

ONGLYZA TABS (PA) (QL)

pioglitazone hcl TABS (ST)

pioglitazone hcl-glimepiride TABS (ST)

pioglitazone hcl/metformin hcl TABS (ST)

PRANDIMET TABS (ST)

SYMLINPEN 120 SOLN (PA)

tolazamide TABS

TOLAZAMIDE TABS

VICTOZA SOLN (PA) (QL)

WELCHOL *


anagrelide hydrochloride CAPS

ARANESP ALBUMIN FREE SOLN (PA) (SP)

Blood Products/Modifiers/Volume Expanders



BERINERT KIT (PA) (SP)

BRILINTA TABS (PA) (QL)

cilostazol TABS

CINRYZE SOLR (PA)

clopidogrel TABS

dipyridamole TABS

EFFIENT TABS (PA)

enoxaparin sodium (100mg/ml) SOLN (QL)

enoxaparin sodium (120mg/0.8ml) SOLN (QL)

enoxaparin sodium (150mg/ml) SOLN (QL)

enoxaparin sodium (300mg/3ml) SOLN (QL)





EPOGEN SOLN (PA) (SP)

fondaparinux sodium SOLN (PA)

HEPARIN LOCK FLUSH SOLN

heparin lock flush SOLN

HEPARIN SODIUM SOLN

heparin sodium SOLN

heparin sodium lock flush SOLN

heparin sodium lock flush KIT

HEPARIN SODIUM/D5W SOLN

heparin sodium/d5w SOLN

HEPARIN SODIUM/NACL 0.45% SOLN

heparin sodium/sodium chloride 0.9% premix SOLN

jantoven TABS

NEULASTA SOLN (PA) (SP)

NEUMEGA SOLR (PA) (SP)

NEUPOGEN SOLN (PA) (SP)

PROCRIT SOLN (PA) (SP)

SOLIRIS SOLN PA, SP

ticlopidine hcl TABS

warfarin sodium TABS

XARELTO TABS (QL)


acebutolol hcl CAPS

acetazolamide TABS

ACETAZOLAMIDE TABS

Cardiovascular Agents



ADVICOR TB24 (ST)

ALDACTAZIDE TABS

amiloride hcl TABS

amiloride/hydrochlorothiazide TABS

amiodarone hcl TABS

amlodipine besylate TABS

AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM TABS (QL) (ST)

amlodipine besylate/benazepril hcl CAPS

amlodipine besylate/benazepril hydrochloride CAPS

atenolol TABS

atorvastatin calcium TABS (QL) (ST)

benazepril hcl TABS

benazepril hcl/hydrochlorothiazide TABS

betaxolol hcl TABS

bisoprolol fumarate TABS

bisoprolol fumarate/hydrochlorothiazide TABS

bumetanide TABS

candesartan cilexetil TABS (ST)

candesartan cilexetil/hydrochlorothiazide TABS (ST)

captopril TABS

CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS

cartia xt CP24

carvedilol TABS

CHLORTHALIDONE TABS

cholestyramine *

cholestyramine light *

clonidine hcl TABS

digoxin *

DIGOXIN *

DILATRATE SR CPCR

dilt-cd CP24

diltiazem cd CP24

diltiazem hcl *

diltiazem hcl CP24

diltiazem hcl er *

diltiazem hcl er CP24

diltiazem hcl er CP24

diltzac CP24

DIOVAN TABS (ST)

disopyramide phosphate CAPS

doxazosin mesylate TABS

DUTOPROL TB24

DYRENIUM CAPS

EDECRIN TABS



enalapril maleate TABS

enalapril maleate/hydrochlorothiazide TABS

felodipine er TB24

fenofibrate TABS

fenofibrate micronized CAPS

FIRAZYR SOLN (PA) (SP)

flecainide acetate TABS

fosinopril sodium TABS

fosinopril sodium/hydrochlorothiazide TABS

FUROSEMIDE *

furosemide *

gemfibrozil TABS

guanfacine hcl TABS

hydralazine hcl TABS

hydrochlorothiazide *

indapamide TABS

ISOSORBIDE DINITRATE *

isosorbide dinitrate *

isosorbide dinitrate er TBCR

isosorbide mononitrate TABS

isosorbide mononitrate er TB24

labetalol hcl TABS

lisinopril TABS

lisinopril/hydrochlorothiazide TABS

losartan potassium TABS

losartan potassium/hydrochlorothiazide TABS

lovastatin TABS

methyldopa TABS

metolazone TABS

metoprolol succinate er TB24

metoprolol tartrate TABS

metoprolol/hydrochlorothiazide TABS

mexiletine hcl CAPS

midodrine hcl TABS

minoxidil TABS

moexipril hcl TABS

moexipril/hydrochlorothiazide TABS

MULTAQ TABS (PA) (QL)

nadolol TABS

NIASPAN TBCR

nifediac cc TB24

nifedical xl TB24

nifedipine CAPS

nifedipine er TB24



nimodipine CAPS

NISOLDIPINE TB24

NITRO-BID OINT

NITRO-DUR PT24

nitroglycerin er CPCR

nitroglycerin transdermal (0.1mg/hr) PT24




NITROSTAT SUBL

NORPACE CR CP12

pacerone TABS

pentoxifylline er TBCR

PINDOLOL TABS

pravastatin sodium TABS

prazosin hcl CAPS

prevalite POWD

propafenone hcl TABS

propranolol hcl *

PROPRANOLOL HCL *

propranolol hcl er CP24

quinapril hcl TABS

quinapril/hydrochlorothiazide TABS

quinidine gluconate er TBCR

quinidine sulfate TABS

ramipril CAPS

RANEXA TB12 (ST)

SIMCOR TB24 (ST)

simvastatin TABS

sotalol hcl TABS

sotalol hcl (af) TABS

spironolactone TABS

spironolactone/hydrochlorothiazide TABS

taztia xt CP24

terazosin hcl CAPS

TIMOLOL MALEATE TABS

triamterene/hydrochlorothiazide *

valsartan/hydrochlorothiazide TABS (ST)

verapamil hcl TABS

VERAPAMIL HCL TABS

verapamil hcl er *

verapamil hcl sr CP24

VYTORIN TABS (ST)

WELCHOL *



ZETIA TABS


amphetamine/dextroamphetamine CP24 (AG) (QL) (ST)

amphetamine/dextroamphetamine (1.25mg; 1.25mg;

1.25mg; 1.25mg)

TABS (AG) (QL)


1.875mg; 1.875mg)

TABS (AG) (QL)


2.5mg; 2.5mg)

TABS (AG) (QL)


3.125mg; 3.125mg)

TABS (AG) (QL)


3.75mg; 3.75mg)

TABS (AG) (QL)

amphetamine/dextroamphetamine (5mg; 5mg; 5mg; 5mg) TABS (AG) (QL)


7.5mg; 7.5mg)

TABS (AG) (QL)

AMPYRA TB12 (PA) (QL) (SP)

AVONEX KIT (SP)

butalbital/acetaminophen/caffeine/codeine CAPS (QL)

butalbital/asa/caffeine CAPS

butalbital/aspirin/caffeie/codeine CAPS

BUTALBITAL/ASPIRIN/CAFFEINE TABS

caffeine citrate SOLN

COPAXONE KIT (SP)




dextroamphetamine sulfate TABS (AG) (QL)

dextroamphetamine sulfate er CP24 (AG) (QL)

EXTAVIA SOLR (PA) (SP)









methylphenidate hcl TABS (AG) (QL)

methylphenidate hcl cd CPCR (AG) (QL)

METHYLPHENIDATE HCL ER (10MG) TBCR (AG) (QL)

methylphenidate hcl er (18mg) TBCR (AG) (QL) (ST)

methylphenidate hcl er (20mg) TBCR (AG) (QL)


Central Nervous System Agents





REBIF SOLN (PA) (SP)

REBIF TITRATION PACK SOLN (PA) (SP)

STRATTERA CAPS (QL) (ST)

TYSABRI CONC (PA) (SP)

VYVANSE (20MG) CAPS (AG) (QL) (ST)







chlorhexidine gluconate SOLN

clinpro 5000 PSTE

oralone PSTE (QL)

periogard SOLN

phos-flur GEL

pilocarpine hcl TABS (QL)

pilocarpine hydrochloride TABS (QL)

sf GEL

triamcinolone in orabase PSTE (QL)


ACZONE GEL (PA)

adapalene * (AG)

AKNE-MYCIN OINT

alclometasone dipropionate OINT

amnesteem CAPS (QL)

betamethasone dipropionate *

betamethasone valerate *

calcipotriene *

calcipotriene CREA

calcitrene OINT

claravis CAPS (QL)

CLARAVIS CAPS (QL)

clindamax *

Dental and Oral Agents

Dermatological Agents



clindamycin phosphate *

clobetasol propionate *

clobetasol propionate e CREA


cormax scalp application SOLN

CORTISPORIN CREA

desonide *

ELIDEL CREA (PA)

ERYTHROMYCIN *

erythromycin *

erythromycin/benzoyl peroxide GEL

FINACEA GEL

fluocinolone acetonide *

fluocinolone acetonide OIL

fluocinolone acetonide body OIL

fluocinolone acetonide scalp OIL

fluocinonide *

fluorouracil *

fluticasone propionate *

hydrocortisone *

hydrocortisone valerate *

imiquimod CREA (QL)

lidocaine hcl/hydrocortisone acetate CREA

lokara LOTN

mometasone furoate *

NOVACORT GEL

OXSORALEN ULTRA CAPS

podofilox SOLN

proctocream hc CREA

proctosol hc CREA

PROTOPIC OINT (PA) (QL)

rosanil cleanser EMUL

selenium sulfide LOTN

SODIUM SULFACETAMIDE/SULFUR *

sodium sulfacetamide/sulfur *

sodium sulfacetamide/sulfur CREA

sotret CAPS (QL)

sulfacetamide sodium/sulfur cleanser EMUL

tretinoin CREA (AG)

tretinoin GEL (AG)

TRIAMCINOLONE ACETONIDE *

triamcinolone acetonide *

TRIANEX OINT




CREON CPEP

PANCREAZE CPEP


ACIPHEX TBEC (QL) (ST)

CARAFATE SUSP

cimetidine TABS

cimetidine hcl SOLN

COLYTE-FLAVOR PACKS SOLR

constulose SOLN

DICYCLOMINE HCL *

dicyclomine hcl *

DIPHENOXYLATE/ATROPINE LIQD

famotidine *

glycopyrrolate *

GOLYTELY SOLR

hyoscyamine sulfate *

hyoscyamine sulfate er TB12

ISOPTO HYOSCINE SOLN

lactulose SOLN

lactulose SOLN

lansoprazole CPDR (QL) (ST)

LINZESS CAPS (PA) (QL)

LOTRONEX TABS

metoclopramide hcl *

misoprostol TABS

omeprazole CPDR

omeprazole/sodium bicarbonate CAPS (QL) (ST)

pantoprazole sodium TBEC (QL)

peg 3350/electrolytes SOLR

peg-3350/electrolytes SOLR

polyethylene glycol 3350 POWD

PREVACID SOLUTAB TBDP (PA)

PROPANTHELINE BROMIDE TABS

ranitidine hcl *

sucralfate TABS

ursodiol *

Enzyme Replacement/Modifiers

Gastrointestinal Agents



XIFAXAN TABS (PA) (QL)

ZEGERID PACK (QL) (ST)


AVODART CAPS (ST)

bethanechol chloride TABS

CUPRIMINE CAPS

DEPEN TITRATABS TABS

DETROL LA CP24

doxazosin mesylate TABS

ENABLEX TB24 (ST)

finasteride TABS

oxybutynin chloride *

oxybutynin chloride er TB24

phenazopyridine hcl TABS

prazosin hcl CAPS

RENAGEL TABS

RENVELA TABS

tamsulosin hcl CAPS

terazosin hcl CAPS

tolterodine tartrate TABS

trospium chloride TABS (ST)

VESICARE TABS (ST)


a-hydrocort SOLR

alclometasone dipropionate OINT

augmented betamethasone dipropionate *

betamethasone dipropionate *

betamethasone valerate *

clobetasol propionate *

clobetasol propionate e CREA


cormax scalp application SOLN

desonide *

DEXAMETHASONE *

dexamethasone *

DEXAMETHASONE INTENSOL CONC

Genitourinary Agents

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)



fludrocortisone acetate TABS

fluocinolone acetonide *

fluocinolone acetonide OIL

fluocinolone acetonide body OIL

fluocinolone acetonide scalp OIL

fluocinonide *

fluticasone propionate *

hydrocortisone ENEM

hydrocortisone TABS

hydrocortisone *

hydrocortisone valerate *

lidocaine hcl/hydrocortisone acetate CREA

lokara LOTN

MEDROL TABS

methylprednisolone TABS

methylprednisolone dose pack TABS

MILLIPRED TABS

MILLIPRED DP TABS

mometasone furoate *

prednisolone SOLN

prednisolone sodium phosphate SOLN

PREDNISONE *

prednisone *

proctocream hc CREA

proctosol hc CREA

SOLU-CORTEF SOLR

TRIAMCINOLONE ACETONIDE *

triamcinolone acetonide *

TRIANEX OINT


desmopressin acetate SOLN

desmopressin acetate TABS

desmopressin acetate SOLN

INCRELEX SOLN (PA) (SP)

NORDITROPIN FLEXPRO SOLN (PA) (SP)

NORDITROPIN NORDIFLEX PEN SOLN (PA) (SP)

OMNITROPE SOLN (PA) (SP)

TEV-TROPIN SOLR (PA) (SP)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)




misoprostol TABS


ALORA PTTW (QL)

altavera TABS

alyacen 1/35 TABS

ANDRODERM (2MG/24HR) PT24 (PA) (QL)

ANDRODERM (4MG/24HR) PT24 (PA) (QL)

ANDROGEL (25MG/2.5GM) GEL (PA) (QL)

ANDROGEL (50MG/5GM) GEL (PA) (QL)

ANDROGEL PUMP (1%) GEL (PA) (QL)

ANDROGEL PUMP (1.62%) GEL (PA) (QL)

ANDROXY TABS (PA)

apri TABS

aranelle TABS

aviane TABS

azurette TABS

balziva TABS

camila TABS

caziant TABS

cesia TABS

COMBIPATCH PTTW (ST)

cryselle-28 TABS

cyclafem 1/35 TABS

cyclafem 7/7/7 TABS

danazol CAPS

drospirenone/ethinyl estradiol TABS

emoquette TABS

enpresse-28 TABS

enskyce TABS

errin TABS

ESTRACE CREA

estradiol *

estradiol/norethindrone acetate TABS

ESTROPIPATE TABS

estropipate TABS

EVISTA TABS

FORTESTA GEL (PA) (QL)

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)



gildess fe 1.5/30 TABS

gildess fe 1/20 TABS

heather TABS

JINTELI TABS

jolivette TABS

junel 1.5/30 TABS

junel 1/20 TABS

junel fe 1.5/30 TABS

junel fe 1/20 TABS

kariva TABS

kelnor 1/35 TABS

kurvelo TABS

leena TABS

lessina TABS

levonorgestrel TABS (QL)

levora 0.15/30-28 TABS

LOESTRIN 24 FE TABS

low-ogestrel TABS

lutera TABS

marlissa TABS

medroxyprogesterone acetate SUSP

medroxyprogesterone acetate TABS

MEGACE ES SUSP (PA)

megestrol acetate *

MENEST TABS

microgestin 1.5/30 TABS

microgestin 1/20 TABS

microgestin fe TABS

microgestin fe 1.5/30 TABS

mimvey TABS

mononessa TABS

necon 0.5/35-28 TABS

necon 1/35 TABS

NECON 1/50-28 TABS

necon 7/7/7 TABS

NEXPLANON IMPL

next choice TABS (QL)

nora-be TABS

norethindrone TABS

norethindrone acetate TABS

norgestimate/ethinyl estradiol TABS

norgestimate/ethinyl estradiol TABS

nortrel 0.5/35 (28) TABS

nortrel 1/35 TABS



nortrel 7/7/7 TABS

ocella TABS

orsythia TABS

ORTHO TRI-CYCLEN LO TABS

ortho-est TABS

philith TABS

pirmella 1/35 TABS

pirmella 7/7/7 TABS

portia-28 TABS

PREFEST TABS

PREMARIN TABS

PREMARIN CREA

PREMPHASE TABS

PREMPRO TABS

previfem TABS

progesterone CAPS

reclipsen TABS

solia TABS

sprintec 28 TABS

sronyx TABS

syeda TABS

TESTIM GEL (PA) (QL)

TESTOPEL PLLT (PA) (QL)

testosterone cypionate OIL (PA)

testosterone enanthate OIL (PA)

tilia fe TABS

tri-legest fe TABS

tri-linyah TABS

tri-previfem TABS

tri-sprintec TABS

trinessa TABS

trivora-28 TABS

velivet TABS

VIVELLE-DOT PTTW (QL)

zarah TABS

zenchent TABS

zovia 1/35e TABS

ZOVIA 1/50E TABS


levothroid TABS

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)



levothyroxine sodium TABS

levoxyl TABS

liothyronine sodium TABS

np thyroid 30 TABS

np thyroid 60 TABS

np thyroid 90 TABS

unithroid TABS

WESTHROID TABS


LYSODREN TABS


SENSIPAR TABS (PA)


bromocriptine mesylate *

ELIGARD KIT (SP)

ELIGARD KIT (SP)

ELIGARD KIT (SP)

ELIGARD KIT (SP)

leuprolide acetate KIT

LUPRON DEPOT-PED KIT

ZOLADEX IMPL


AVODART CAPS (ST)

bicalutamide TABS (ST)

finasteride TABS

flutamide CAPS

XTANDI CAPS (PA) (QL) (SP)

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Parathyroid)

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Sex Hormones/Modifiers)




methimazole TABS

propylthiouracil TABS


ACTIMMUNE SOLN (SP)

AVONEX KIT (SP)

azathioprine TABS

BENLYSTA SOLR (PA)

BIVIGAM SOLN (PA)

CARIMUNE NANOFILTERED SOLR

CELLCEPT SUSR

CUPRIMINE CAPS

cyclosporine CAPS

CYCLOSPORINE MODIFIED *

cyclosporine modified *

cyclosporine modified (100mg/ml) SOLN

cyclosporine modified (100mg/ml) SOLN

CYTOGAM INJ (PA)


ELIDEL CREA (PA)

ENBREL * (PA) (SP)

EXTAVIA SOLR (PA) (SP)

FLEBOGAMMA SOLN (PA)

FLEBOGAMMA DIF SOLN (PA)

GAMASTAN S/D INJ (PA)

GAMMAGARD LIQUID SOLN (PA)

GAMMAGARD S/D SOLR (PA)

GAMMAGARD S/D IGA LESS THAN 1MCG/ML SOLR (PA)

GAMMAPLEX SOLN

GAMUNEX SOLN (PA)

GAMUNEX-C SOLN (PA)

gengraf *

hecoria CAPS

HEPAGAM B SOLN (PA)

HIZENTRA SOLN (PA) (SP)

HUMIRA KIT (PA) (SP)

leflunomide TABS

Hormonal Agents, Suppressant (Thyroid)

Immunological Agents



mercaptopurine TABS

methotrexate TABS

methotrexate sodium *

mycophenolate mofetil *

ORENCIA * (PA) (SP)

PRIVIGEN SOLN (PA)

PROTOPIC OINT (PA) (QL)

PROVENGE SUSP

REBIF SOLN (PA) (SP)

REBIF TITRATION PACK SOLN (PA) (SP)

REMICADE SOLR (PA) (SP)

RIDAURA CAPS

SANDIMMUNE SOLN

SYNAGIS SOLN

tacrolimus CAPS

TREXALL TABS

TYSABRI CONC (PA) (SP)

ZOSTAVAX SOLR (AG)


a-hydrocort SOLR

APRISO CP24 (QL) (ST)

ASACOL TBEC (ST)

balsalazide disodium CAPS

CANASA SUPP

DEXAMETHASONE *

dexamethasone *

DEXAMETHASONE INTENSOL CONC

hydrocortisone ENEM

hydrocortisone TABS

MEDROL TABS

mesalamine ENEM

mesalamine KIT

methylprednisolone TABS

methylprednisolone dose pack TABS

MILLIPRED TABS

MILLIPRED DP TABS

PENTASA CPCR (ST)

prednisolone SOLN

prednisolone sodium phosphate SOLN

PREDNISONE *

Inflammatory Bowel Disease Agents



prednisone *

SOLU-CORTEF SOLR

sulfasalazine *


alendronate sodium TABS

ALENDRONATE SODIUM TABS

calcitonin-salmon SOLN

calcitriol *

FORTEO SOLN (PA) (SP)

HECTOROL CAPS

ibandronate sodium TABS (QL) (ST)

PROLIA SOLN (PA) (SP)

XGEVA SOLN (PA) (SP)

zoledronic acid * (MB) (PA)


ACCU-CHEK ACTIVE STRIPS STRP (QL)

ACCU-CHEK AVIVA STRP (QL)

ACCU-CHEK COMFORT CURVE TEST STRIPS STRP (QL)

ACCU-CHEK COMPACT STRIPS STRP (QL)

ASSESS PEAK FLOW METER LOW RANGE DEVI

BD INSULIN SYRINGES MISC

BD PEN NEEDLES MISC

BOTOX SOLR (PA)

EUFLEXXA SOLN (SP)

KALBITOR SOLN (PA)

methylergonovine maleate TABS

NOVOFINE PEN NEEDLES MISC

NOVOTWIST PEN NEEDLES MISC

SYNVISC INJ (SP)

SYNVISC ONE INJ (SP)


acetazolamide TABS

Metabolic Bone Disease Agents

Miscellaneous Therapeutic Agents

Ophthalmic Agents



ACETAZOLAMIDE TABS

acetazolamide er CP12

ALPHAGAN P SOLN

ALREX SUSP (ST)

ATROPINE SULFATE *

atropine sulfate *

AZOPT SUSP

betaxolol hcl SOLN

BETOPTIC-S SUSP

BLEPHAMIDE SUSP

BLEPHAMIDE S.O.P. OINT

brimonidine tartrate SOLN

carteolol hcl SOLN

CIPRODEX SUSP (AG) (PA) (QL)

cromolyn sodium SOLN

dexamethasone sodium phosphate SOLN

diclofenac sodium SOLN

dorzolamide hcl SOLN

fluorometholone SUSP

FML OINT

FML FORTE SUSP

homatropaire SOLN

ISOPTO CARBACHOL SOLN

ISOPTO HOMATROPINE SOLN

ketorolac tromethamine SOLN

ketotifen fumarate SOLN

latanoprost SOLN

LEVOBUNOLOL HCL SOLN

levobunolol hcl SOLN

LOTEMAX SUSP (ST)

LUMIGAN SOLN

methazolamide TABS

NAPHCON-A SOLN

neomycin/polymyxin/bacitracin/hydrocortisone OINT

neomycin/polymyxin/dexamethasone *

OPCON-A SOLN

phenylephrine hcl SOLN

PHOSPHOLINE IODIDE SOLR

pilocarpine hcl SOLN

PRED MILD SUSP

prednisolone acetate SUSP

PREDNISOLONE SODIUM PHOSPHATE SOLN

RESTASIS EMUL (PA)

timolol maleate SOLN



timolol maleate ophthalmic gel forming SOLG

tropicamide SOLN


acetic acid SOLN

ACETIC ACID/ALUMINUM ACETATE SOLN

antipyrine/benzocaine SOLN

COLY-MYCIN S SUSP

hydrocortisone/acetic acid SOLN





acetylcysteine SOLN

ADVAIR DISKUS AEPB (PA) (QL)

ADVAIR HFA AERO (PA) (QL)

albuterol sulfate *

albuterol sulfate er TB12

ASMANEX 30 METERED DOSES AEPB

ASMANEX 60 METERED DOSES AEPB

ATROVENT HFA AERS

AUVI-Q DEVI

azelastine hcl SOLN (PA)

budesonide SUSP (AG)

COMBIVENT AERO

COMBIVENT RESPIMAT AERS (QL)

cromolyn sodium NEBU

cyproheptadine hcl *

DALIRESP TABS (PA) (QL)

DULERA AERO (ST) (QL)

ELIXOPHYLLIN ELIX

FLOVENT DISKUS AEPB

FLOVENT HFA AERO

FLUNISOLIDE SOLN

fluticasone propionate SUSP

FORADIL AEROLIZER CAPS

hydroxyzine hcl *

Otic Agents

Respiratory Tract Agents





ipratropium bromide SOLN

ipratropium bromide SOLN

ipratropium bromide/albuterol sulfate SOLN

LETAIRIS TABS (PA) (QL) (SP)

METAPROTERENOL SULFATE *

montelukast sodium * (QL)

phenadoz SUPP

PROAIR HFA AERS

promethazine hcl *

promethazine hcl plain SYRP

PROMETHEGAN SUPP

PULMICORT FLEXHALER AEPB

PULMOZYME SOLN

QVAR AERS

SEREVENT DISKUS AEPB

sildenafil citrate TABS (PA) (QL)

sodium chloride (0.9%) NEBU

sodium chloride (7%) NEBU

SPIRIVA HANDIHALER CAPS

SYMBICORT (160MCG/ACT; 4.5MCG/ACT) AERO (QL) (ST)

SYMBICORT (80MCG/ACT; 4.5MCG/ACT) AERO (QL) (ST)

terbutaline sulfate TABS

theophylline cr TB12

theophylline er *

triamcinolone acetonide INHA

TUDORZA PRESSAIR AEPB

VENTOLIN HFA AERS

XOLAIR SOLR (PA) (SP)

zafirlukast TABS


carisoprodol TABS

carisoprodol/aspirin TABS

carisoprodol/aspirin/codeine TABS

chlorzoxazone TABS

cyclobenzaprine hcl TABS

methocarbamol TABS

Skeletal Muscle Relaxants




LUNESTA TABS (PA) (QL)

modafinil TABS (PA) (QL)

PHENOBARBITAL *

phenobarbital *

ROZEREM TABS (PA) (QL)

temazepam CAPS (QL)

triazolam TABS (QL)

XYREM SOLN

zaleplon CAPS (QL)

zolpidem tartrate TABS (QL)

zolpidem tartrate er TBCR (PA) (QL)


calcium acetate CAPS

clinpro 5000 PSTE

CUPRIMINE CAPS

cytra-2 SOLN


dexferrum SOLN (PA)

dialyvite TABS

effervescent potassium TBEF

ferosul ELIX (AG)

FERRLECIT SOLN (PA)

FERROUS SULFATE SYRP (AG)

FLUORABON SOLN (AG)

FLURA-DROPS SOLN (AG)

flura-drops SOLN (AG)

folic acid TABS

gildess fe 1.5/30 TABS

gildess fe 1/20 TABS

infed SOLN (PA)

junel fe 1.5/30 TABS

junel fe 1/20 TABS

kalexate POWD

kionex *

klor-con PACK

klor-con 10 TBCR

KLOR-CON 25 PACK

Therapeutic Nutrients/Minerals/Electrolytes

Sleep Disorder Agents



klor-con 8 TBCR

klor-con m10 TBCR

KLOR-CON M15 TBCR

klor-con m20 TBCR

klor-con/ef TBEF

LOESTRIN 24 FE TABS

LOZI-FLUR LOZG (AG)

MEPHYTON TABS

microgestin fe TABS

microgestin fe 1.5/30 TABS

multi-vit/fluoride SOLN

multi-vit/iron/fluoride SOLN

multivitamins/fluoride CHEW

MYNATAL CAPS

nephronex TABS

NIACOR TABS

ORACIT SOLN

phos-flur GEL

PHOSLYRA SOLN

phospha 250 neutral TABS

potassium chloride LIQD

POTASSIUM CHLORIDE LIQD

potassium chloride er *

potassium chloride er TBCR

POTASSIUM CITRATE TBCR

rena-vite rx TABS

renal CAPS

renalpren CAPS

reno caps CAPS

sf GEL

sodium ferric gluconate complex/sucrose SOLN (PA)

sodium fluoride * (AG)

strovite plus TABS

tilia fe TABS

tri-legest fe TABS

triphrocaps CAPS

UROCIT-K 15 TBCR

VENOFER SOLN (PA)

vitamin d CAPS

vol-care rx TABS

UnClassified




ADCETRIS SOLR (PA)

CHEMSTRIP UGK STRP

FERAHEME SOLN (PA)

PRECISION XTRA STRP

Please see following page for disclaimer and explanation of terms.


DISCLAIMER Please be sure a prescription drug benefit is part of your specific coverage before consulting this list. If you do not know which list is correct, please contact the Presbyterian Customer Service Center at (505) 923-5225 or toll-free at 1-866-593-7434, Monday through Friday from 7:00 a.m. to 6:00 p.m. TTY users may call 1-888-872-7568. Coverage for some drugs may be limited to specific dosage forms and/or strengths. Your benefit design determines what is covered for you and what your copayment will be. Please refer to your benefit materials for your specific coverage information. The medications listed on this Formulary/Preferred Drug Listing (PDL) are subject to change pursuant to the Formulary/PDL management activities of Presbyterian Health Plan. This list is not all-inclusive nor does it imply a guarantee of coverage. In addition, coverage for some drugs listed may be limited to specific dosage forms and/or strengths. Substitution of a generic product for a brand-name drug is mandatory when a generic equivalent is available. If a member requests the brand-name drug in this situation, a Prior Authorization may be required and the member must pay the difference in cost between the generic and branded versions. Non-formulary medications are not considered for coverage unless trial and failure of formulary alternatives are documented. Explanation of Terms in your Formulary You may see these indicators next to some drug names: 1 Explanation of Terms in your Formulary 1. Age Limitation (AG) -- a coverage limit based on minimum or maximum age of the member imposed as a result of safety, efficacy or dosage form considerations. 2. Generics preferred/Generic equivalent available (GP -- if there is a generic available and the patient receives the brand name product, the patient pays the copay for the generic drug plus the difference in cost between the brand and the generic. 3. Medical Drugs (MED) -- Medications obtained through the medical benefit. Medical drugs are defined as medications administered in the office or facility that require a health care professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution and may be provided by a specialty pharmacy vendor. Some Medical Drugs may require Benefit Certification before they can be obtained. Office administered applies to all outpatient settings including, but are not limited to, physician's offices, emergency rooms, urgent care facilities and outpatient surgery facilities. For a complete list of Medical Drugs and to determine which require Benefit Certification please see the Presbyterian Pharmacy web site at: http://www.phs.org/PHS/programs/pharmacy/formulary/index.htm 4. Prior Authorization (PA) -- a drug that requires prior approval before the Plan will cover it, and when the patient meets the established criteria. The doctor must submit a


http://www.phs.org/PHS/programs/pharmacy/formulary/index.htm

Pharmacy Prior Authorization Form. The doctor can submit the request by fax, phone, or regular mail. 5. Quantity Limit (QL) -- a coverage limit on the medication quantity covered for a defined days' supply (usually 30 or 90 days) based on safety, efficacy and/or dose optimization issues. 6. Specialty (SP) -- Tier 4 medications obtained through the pharmacy benefit. Tier 4 medications are defined as high cost (greater than $600 per 30 day supply) injectable, infused, oral or inhaled drugs that generally require complex care and supervision. These medications involve unique distribution and are usually provided by a specialty pharmacy vendor. Specialty pharmaceuticals are self-administered, meaning they are administered by the patient or to the patient by a family member or caregiver. Non-formulary medications, when approved by prior authorization, may be subject to specialty pharmacy requirements. 7. Step Edit (ST) -- a drug that requires a prescription history of specific drugs in the pharmacy claims or data system, and these specific drugs must be taken during a given time frame. After the specific drugs have been taken within the given time frame, online coverage of the newly-prescribed drug occurs at the pharmacy. Step Edits make it easier to access drugs that would normally require a Prior Authorization. 8. Medical Exception -- a drug that is not on the Plan’s formulary. Non-formulary drugs require an Exception to the formulary due to allergy, adverse reactions, or no response to all formulary drugs.


Documents

Presbyterian SCI 2013 Presbyterian State Coverage Insurance (SCI)docs.phs.org/idc/groups/public/@phs/@php/documents... · 2020-03-13 · MORPHINE SULFATE. TABS (QL) morphine sulfate