Blue Shield Promise Medi-Cal Formulary

Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association Medi_20_167

Blue Shield of California

Promise Health Plan

Medi-Cal Drug Formulary

(Preferred Drug List)

December 2020

This formulary is for the following plans Blue Shield of California Promise Health Plan Medi-Cal

Los Angeles and Blue Shield of California Promise Health Plan Medi-Cal San Diego

We last updated it on 1212020 This formulary may change and all earlier versions of the formulary no longer apply For the most current information about the Medi-Cal Drug

Formulary visit wwwblueshieldcacompromisemedi-cal

You can find information about drug benefits in the Member HandbookEvidence of

Coverage For plan and coverage documents visit wwwblueshieldcacompromisemedi-

cal For additional information about your plan please call Customer Care at (800) 605-2556

(Los Angeles County) or (855) 699-5557 (San Diego County)

Blue Shield of California Promise Health Plan is contracted with LA Care Health Plan to

provide Medi-Cal managed care services in Los Angeles County

You can get this document for free in other formats such as large print braille andor audio

Call (800) 605-2556 (Los Angeles County) or (855) 699-5557 (San Diego County) (TTY 711) 800

am ndash 6 00 pm Monday through Friday The call is free

ii

Medi-Cal Formulary

The Blue Shield of California Promise Health Plan Medi-Cal Formulary is a list of covered drugs

(Formulary) This list includes drugs used to treat common health problems A team of doctors

and pharmacists meets four times a year to decide which drugs should be on the drug list

They review new and old drugs and choose the ones that are safe and work best

Definitions The following words and definitions will be used throughout the formulary drug list

Word

ldquoBrand name drugrdquo is a drug that is sold under a trademark name We will list the

brand name drug will in all CAPITAL letters

ldquoDrug Tierrdquo shows a group of drugs and how we cover them (see below)

ldquoEnrolleerdquo or ldquomemberrdquo is a person enrolled in a health plan and receives services

from the plan

ldquoException requestrdquo is when the member requests for the plan to cover a drug The

health plan must cover the drug if medically required to treat the members condition

ldquoExigent circumstancesrdquo are when a member suffers from a health condition that may

seriously risk their life health or daily life This is also when a member currently uses a

drug that is not covered

ldquoFormularyrdquo or ldquopreferred drug listrdquo is the list of drugs covered under the drug benefit

ldquoGeneric drugrdquo is the same drug as its brand name version in strength how it is taken

quality and safety A generic drug is listed in bold and italicized lowercase letters

ldquoNon-formulary drugrdquo is a drug not listed on the plans drug list

ldquoPrescribing providerrdquo may prescribe a drug to treat a medical condition for a

member

ldquoPrescriptionrdquo is an oral written or electronic order by a prescribing provider that

contains the name of the drug amount date providerrsquos name and contact

signature of the provider (if in writing) and the medical condition or purpose for

which the drug is being prescribed (if requested by the member)

ldquoPrescription drugrdquo is a drug that requires a prescription and prescribed by the

memberrsquos provider

ldquoPrior authorizationrdquo is a plans requirement that the member or provider get the

health plans approval for a drug before the plan will cover it The plan will approve

the drug when it is medically required

ldquoStep therapyrdquo is when the plan requires the member to try one or more drugs to treat

the medical condition before it will cover a certain drug If the memberrsquos provider

submits a request for approval the plan will approve the drug is medically required

iii

How do I use the Blue Shield of California Promise Health Plan Medi-Cal

Formulary

To look for a drug check the index at the end It lists all of the drugs on the Formulary Next to

your drug you will see the page number where you can find it The drugs are listed in

alphabetical order under the column ldquoPrescription Drug Namerdquo under its category and class

To look for a drug class check the Table of Contents

Even if the drug is on the list this does not guarantee that your doctor will prescribe it

The Formulary covers generics and certain brands when available If there is an approved

generic drug then we will cover the generic only

bull A generic name for a brand name drug is listed after the brand name of the drug in all

lowercase italics

o If both a generic and brand are covered we will list the generic separately from

the brand name in all lowercase italics

o When a drug is sold as a brand name we will list the brand name after the

generic name in parentheses in all CAPITALS

bull We will list a brand name drug in all CAPITALS followed by the name in parentheses in

lowercase italics

Example

Drug Type How the drug name will appear

in the formulary drug list

generic drug atorvastatin calcium

generic drug marketed with a

brand name

oxycodoneacetaminophen

(ENDOCET)

brand drug LIPITOR (atorvastatin calcium)

Some drugs are injections that are not listed but they may be covered for up to a 10-day

supply after you leave the hospital These include drugs for parenteral nutrition (TPN) lipids

and other unlisted drugs and antibiotics

iv

What are drug tiers

Drugs are placed into drug tiers

Drug Tier What Does it mean

Covered (Tier 1) These drugs are covered on the Drug

List (Formulary) at $0 co-payment

Medi-Cal Carve Out (Tier 2) These drugs are carved out by the

Department of Health Care Services

This means these drugs are covered by

the Medi-Cal Fee-for Service program

and can be billed to the State

Medical Benefit (Tier 3) These drugs may be available at the

doctorrsquos office or medical setting

How to read the formulary

The column titled ldquoCoverage Requirements and Limitationsrdquo shows how the drug is covered

and if there are limits

Coverage Requirements

and Limitations

What does it stand for What does it mean

AL1 Age Restrictions We cover some drugs only

for some ages

PA Prior Authorization

Required

Your doctor must ask for

approval from us before

we cover some drugs

QL Quantity Limit We only cover some drugs

for a certain amount

ST Step Therapy Required In some cases you must

first try certain drugs

before we cover another

drug for your condition

STAR Extended Day Supply You may fill this drug for a

90 day supply

MDD Max Daily Dose We limit the amount of this

drug covered per day

C Custom This drug has special limits

QLC Quantity Limit (Custom) We limit the amount of this

drug covered each fill or

within a time frame

SP Specialty Pharmacy A network specialty

pharmacy will fill this drug

v

How often will the formulary change

The formulary may change monthly Some changes that can happen without notice include

bull When we remove a brand name drug if a generic is available

bull When we remove a drug taken off the market because the Food and Drug

Administration (FDA) has found it unsafe or if the manufacturer has removed it

bull When we add a drug to the formulary or if we remove a limit (like prior authorization or

step therapy)

Changes to formulary that we will notify you of at least 30 days before include

bull When we remove a drug or dosage form

bull When we add or change limits on the drug

What is a medical benefit drug

A medical benefit drug is a drug that usually is given as an injection or infusion in a medical

setting

What if my drug requires a prior authorization or step therapy

A prior authorization means that your doctor asks for approval for the drug because it is

medically necessary A step therapy means that you need to try certain drugs before we

cover your drug

You may ask for an exception by calling Customer Care at (800) 605-2556 (Los Angeles

County) or (855) 699-5557 (San Diego County) Or your doctor can call us at (877) 792-2731 or

fax at (866) 712-2731 to request that drug be covered

What if my drug is not on the Blue Shield of California Promise Health Plan Medi-

Cal Formulary

If your doctor gives you a drug that is not on the drug list you can ask your doctor for another

drug that is on formulary or you may request for us to cover the drug (exception) by calling

Customer Care at (800) 605-2556 (Los Angeles County) or (855) 699-5557 (San Diego County)

Your doctor can call us at (877) 792-2731 or fax at (866) 712-2731 to request that drug be

covered

You might now take a drug and your doctor still prescribes it If the drug is safe and effective

for your condition we will continue to cover it if we covered it before

vi

Participating retail pharmacies

You can fill prescriptions at any participating pharmacy (network pharmacy) unless it is for a

specialty drug You may find a network pharmacy by visiting

httpspromiseblueshieldcacomcapharmacysearchversion=2020amplob=mcal

What are specialty drugs

Specialty drugs require extra training before you take them extra visits with your doctor need

special handling and transport and are usually high-cost These drugs may require prior

authorization or non-formulary exception If approved a network specialty pharmacy will

deliver them by mail Please visit wwwblueshieldcacompromisemedi-cal for more

information

What if I have additional questions

If you want a copy of the Blue Shield of California Promise Health Plan Medi-Cal Formulary or

have questions please call Customer Care at (800) 605-2556 (Los Angeles County) or (855)

699-5557 (San Diego County)

Blue Shield of California Promise Health Plan

601 Potrero Grande Drive Monterey Park CA 91755

vii

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8)

Discrimination is Against the Law

Blue Shield of California Promise Health Plan complies with applicable state laws and federal civil rights laws and does not discriminate on the basis of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability Blue Shield of California Promise Health Plan does not exclude people or treat them differently because of race color national origin ancestry religion sex marital status gender gender identity sexual orientation age or disability

Blue Shield of California Promise Health Plan provides bull Aids and services at no cost to people with disabilities to communicate effectively with us

such aso Qualified sign language interpreterso Written information in other formats (large print audio accessible electronic

formats other formats)bull Language services at no cost to people whose primary language is not English such as

o Qualified interpreterso Information written in other languages

If you need these services contact the Blue Shield of California Promise Health Plan Civil Rights Coordinator

If you believe that Blue Shield of California Promise Health Plan has failed to provide these

services or discriminated in another way on the basis of race color national origin

ancestry religion sex marital status gender gender identity sexual orientation age or

disability you can file a grievance with


Civil Rights Coordinator

601 Potrero Grande Dr

Monterey Park CA 91755

Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228

Email BSCPHPCivilRightsblueshieldcacom

You can file a grievance in person or by mail fax or email If you need help filing a

grievance the Civil Rights Coordinator is available to help you

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at

US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD)

Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language Assistance Notice for LA County

viii

English

ATTENTION Language assistance services free of charge are available to you Call 1-800-605-

2556 (TTY 711)

繁體中文 (Chinese)

注意如果您使用繁體中文您可以免費獲得語言援助服務請致電1-800-605-2556（TTY

711)

한국어 (Korean)

주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-800-

605-2556 (TTY 711)번으로 전화해 주십시오

Русский (Russian)

ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги

перевода Звоните 1-800-605-2556 (телетайп 711)

Kreyogravel Ayisyen (Haitian-Creole)

ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 1-

800-605-2556 (TTY 711)

Franccedilais (French)

ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes

gratuitement Appelez le 1-800-605-2556 (TTY 711)

Portuguecircs (Portuguese)

ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para 1-

800-605-2556 (TTY 711)

Italiano (Italian)

ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza

linguistica gratuiti Chiamare il numero 1-800-605-2556 (TTY 711)

(Farsi) فارسی

2556-605-800-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه

(TTY 771) بگیرید تماس

ह िदी (Hindi)

धयान द यदद आप द िदी बोलत तो आपक ललए मफत म भाषा स ायता सवाएि उपलबध 1-800-605-

2556 (TTY 711) पर कॉल करHmong (Hmong)

LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb rau koj Hu rau

1-800-605-2556 (TTY 711)

Espantildeol (Spanish)

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica

Llame al 1-800-605-2556 (TTY 711)

Language Assistance Notice for LA County (Continued)

ix

Tiếng Việt (Vietnamese)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-

800-605-2556 (TTY 711)

Tagalog (Tagalog - Filipino)

PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa

wika nang walang bayad Tumawag sa 1-800-605-2556 (TTY 711)

(Arabic) العربية

2556-605-800-1مجان اتصل برقم ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بال

(711YTT)

Polski (Polish)

UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń

pod numer 1-800-605-2556 (TTY 711)

ພາສາລາວ (Lao)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ ໂທຣ 1-800-605-2556 (TTY 711)

日本語 (Japanese)

注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-605-

2556（TTY711）までお電話にてご連絡ください

ภาษาไทย (Thai)

เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-800-605-2556 (TTY 711)

λληνικά (Greek)

ΠΡΟΣΟΧΗ Αν μιλάτε ελληνικά στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης

οι οποίες παρέχονται δωρεάν Καλέστε 1-800-605-2556 (TTY 711)

ਪਜਾਬੀ ਦ (Punjabi)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-800-605-

2556 (TTY 711) ਤ ਕਾਲ ਕਰ

ខមែរ (Cambodian)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល

គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-800-605-2556 (TTY 711)

Հայերեն (Armenian)

ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն ապա ձեզ անվճար կարող են

տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-800-605-2556

(TTY (հեռատիպ)711)

Language Assistance Notice for San Diego County

x

English

ATTENTION Language assistance services free of charge are available to you

Call 1-855-699-5557 (TTY 711)



711)

한국어 (Korean)




ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные

услуги перевода Звоните 1-855-699-5557 (телетайп 711)

Italiano (Italian)

ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di

assistenza linguistica gratuiti Chiamare il numero 1-855-699-5557 (TTY 711)

(Farsi) فارسی

-699-855-1 با باشد می فراهم شما برای رایگان بصورت زبانی تسهیلات کنید می گفتگو فارسی زبان به اگر توجه

5557 (TTY 771) بگیرید تماس



5557 (TTY 711) पर कॉल कर

Hmong (Hmong)

LUS CEEV Yog tias koj hais lus Hmoob cov kev pab txog lus muaj kev pab dawb

rau koj Hu rau 1-855-699-5557 (TTY 711)


ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia

linguumliacutestica Llame al 1-855-699-5557 (TTY 711)


CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho

bạn Gọi số 1-855-699-5557 (TTY 711)


PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga

serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-855-699-5557 (TTY

711)

Language Assistance Notice for San Diego County (Continued)

xi


5557-699-855-1 برقم اتصل بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا ملحوظة

(711YTT)









ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-855-

699-5557 (TTY 711) ਤ ਕਾਲ ਕਰ






տրամադրվել լեզվական աջակցության ծառայություններ Զանգահարեք 1-855-699-

5557 (TTY (հեռատիպ)711)

Categorical List of Prescription DrugsANALGESICS (Drugs for Pain) 1

ANESTHETICS (Drugs for Numbing) 6

ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs for AddictionSubstance Abuse) 6

ANTIBACTERIALS (Drugs for Bacterial Infections) 8

ANTICONVULSANTS (Drugs for Seizures) 14

ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease and Dementia) 17

ANTIDEPRESSANTS (Drugs for Depression) 17

ANTIEMETICS (Drugs for Nausea and Vomiting) 20

ANTIFUNGALS (Drugs for Fungal Infections) 21

ANTIGOUT AGENTS (Drugs for Gout) 24

ANTIMIGRAINE AGENTS (Drugs for Migraine) 25

ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis) 25

ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections) 26

ANTINEOPLASTICS (Drugs for Cancer) 26

ANTIPARASITICS (Drugs for Parasitic Infections) 28

ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease) 29

ANTIPSYCHOTICS (Drugs for Mental Health) 30

ANTISPASTICITY AGENTS (Drugs for Muscle Spasm) 35

ANTIVIRALS (Drugs for Viral Infections) 35

ANXIOLYTICS (Drugs for Anxiety) 41

BIPOLAR AGENTS (Drugs for Bipolar Disorder) 42

BLOOD GLUCOSE REGULATORS (Drugs for Diabetes) 42

BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs for Blood Disorders) 46

CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation) 51

CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions) 61

DENTAL AND ORAL AGENTS (Drugs for the Mouth) 66

DERMATOLOGICAL AGENTS (Drugs for the Skin) 66

ELECTROLYTESMINERALSMETALSVITAMINS 69

GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach) 77

GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERS TREATMENT (Drugs for Genetic or

Enzyme Disorders) 85

GENITOURINARY AGENTS (Drugs for the Genital Bladder and Kidney) 86

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (ADRENAL) (Drugs for

ReplacingStimulating Adrenal Gland Hormones) 87

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (PITUITARY) (Drugs for

ReplacingStimulating Pituitary Gland Hormones) 90

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEX HORMONESMODIFIERS) (Drugs

for ReplacingStimulating Sex Hormones) 91

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (THYROID) (Drugs for the Thyroid) 102

HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs for Suppressing Hormones from the Pituitary

Gland) 104

HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for the Thyroid) 104

LAST UPDATED 12012020

IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing the Immune System) 104

INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for Inflammatory Bowel Disease) 109

METABOLIC BONE DISEASE AGENTS (Drugs for the Bone) 109

MISCELLANEOUS THERAPEUTIC AGENTS 110

OPHTHALMIC AGENTS (Drugs for the Eyes) 112

OTIC AGENTS (Drugs for the Ears) 116

RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs) 116

SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles) 130

SLEEP DISORDER AGENTS (Drugs for Insomnia) 130


PRESCRIPTION DRUGNAME

DRUG TIER COVERAGEREQUIREMENTS ANDLIMITS

ANALGESICS (Drugs for Pain)

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (Pain and ArthritisDrugs)

aspirin (ADULT ASPIRIN REGIMEN)81 mg tablet dr

1-Covered

aspirin (ADULT LOW DOSE ASPIRINEC) 81 mg tablet dr

1-Covered

aspirin (ASPIR 81) mg tablet dr ) 1-Covered

aspirin (ASPIR-TRIN) 325 mg tabletdr -

1-Covered

aspirin (ASPIRIN) 325 mg tablet 1-Covered

aspirin (ECOTRIN) 81 mg tablet dr 1-Covered

aspirin (ECPIRIN) 325 mg tablet dr 1-Covered

aspirin (ST JOSEPH ASPIRIN EC) 81mg tablet dr

1-Covered

aspirin (ST JOSEPH ASPIRIN) 81 mgtab chew

1-Covered

aspirin 325mg tablet 1-Covered

aspirin 81 mg tab chew 81 mgtablet dr 325 mg tablet

1-Covered

ASPIRIN 81MG TABLET ASPIRIN81MG TABLET ASPIRIN 81MGTABLET

1-Covered

aspirinacetaminophencaffeine(ADDED STRENGTH HEADACHE)250-250-65 tablet

1-Covered

aspirinacetaminophencaffeine(BAYER MIGRAINE) 250-250-65tablet

1-Covered

aspirinacetaminophencaffeine(EXTRA PAIN RELIEF) 250-250-65tablet

1-Covered

aspirinacetaminophencaffeine(EXTRAPRIN) 250-250-65 tablet

1-Covered

aspirinacetaminophencaffeine(HEADACHE RELIEF) 250-250-65tablet

1-Covered


AL1 ndash Age Restrictions PA ndash Prior Authorization Required QL ndash Quantity LimitST ndash Step Therapy Required STAR ndash Extended Day Supply MDD ndash Max Daily Dose

C ndash Custom QLC ndash Quantity Limit (Custom) SP ndash Specialty Pharmacy

1



aspirinacetaminophencaffeine(MIGRAINE FORMULA) 250-250-65tablet

1-Covered

aspirinacetaminophencaffeine(MIGRAINE RELIEF) 250-250-65tablet

1-Covered

aspirinacetaminophencaffeine(PAIN RELIEVER PLUS) 250-250-65tablet

1-Covered

aspirinacetaminophencaffeine(PAIN RELIEVER) 250-250-65 tablet

1-Covered

aspirinacetaminophencaffeine(PAIN-OFF) 250-250-65 tablet -

1-Covered

butalbitalaspirincaffeine 50-325-40 capsule

1-Covered QL (48 PER 30 DAY(S)) MDD (6 PerDay)

butalbitalaspirincaffeine 50-325-40 tablet

1-Covered

celecoxib 50 mg capsule 100 mgcapsule 200 mg capsule 400 mgcapsule

1-Covered ST

CELECOXIB 50 MG CAPSULE 100MG CAPSULE 200 MG CAPSULE400 MG CAPSULE

1-Covered ST

CHILDRENS IBUPROFEN CHILD 200MG10 ML CHILDREN 100 MG5 ML

1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)

diclofenac sodium 25 mg tablet dr50 mg tablet dr 75 mg tablet dr100 mg tab er 24h

1-Covered

diflunisal 500 mg tablet 1-Covered

etodolac 600 mg tab er 24h 1-Covered PA

EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine)CAPLET

1-Covered

EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine)CAPLET GELTAB

1-Covered

flurbiprofen 50 mg tablet 100 mgtablet

1-Covered

HEADACHE RELIEF HM 250-250-65MG CPLT

1-Covered

ibuprofen (ADDAPRIN) 200 mgtablet

1-Covered




2



ibuprofen (I-PRIN) 200 mg tablet - 1-Covered

ibuprofen (IBU) 400 mg tablet 600mg tablet 800 mg tablet

1-Covered

ibuprofen (IBU-200) mg tablet -) 1-Covered

ibuprofen (PROVIL) 200 mg tablet 1-Covered

ibuprofen (WAL-PROFEN) 200 mgtablet -

1-Covered

ibuprofen 100 mg5ml oral susp 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)

IBUPROFEN 400 MG TABLET 600 MGTABLET 800 MG TABLET

1-Covered

ibuprofen 50 mg125 drops susp100 mg tab chew 200 mg tablet400 mg tablet 600 mg tablet 800mg tablet

1-Covered

indomethacin 25 mg capsule 50mg capsule 75 mg capsule er

1-Covered

ketoprofen 50 mg capsule 75 mgcapsule

1-Covered

meloxicam 75 mg tablet 15 mgtablet

1-Covered

naproxen 250 mg tablet 375 mgtablet 500 mg tablet

1-Covered

naproxen sodium 275 mg tablet550 mg tablet

1-Covered

piroxicam 10 mg capsule 20 mgcapsule

1-Covered

salsalate 500 mg tablet 750 mgtablet

1-Covered

sulindac 150 mg tablet 200 mgtablet

1-Covered

tolmetin sodium 200 mg tablet 400mg capsule 600 mg tablet

1-Covered

OPIOID ANALGESICS LONG-ACTING (Long-acting Narcotic PainRelievers)

BELBUCA (buprenorphine hcl) 75MCG FILM 150 MCG FILM 300MCG FILM 450 MCG FILM 600MCG FILM 750 MCG FILM 900MCG FILM

2-MedicalCarve out




3



buprenorphine 5 mcghr patch75 mcghr patch 10 mcghrpatch 15 mcghr patch 20mcghr patch

2-MedicalCarve out

BUTRANS (buprenorphine) 5MCGHR PATCH 75 MCGHRPATCH 10 MCGHR PATCH 15MCGHR PATCH 20 MCGHRPATCH

2-MedicalCarve out

fentanyl 25 mcghr patch50mcghr patch 75mcghr patch100 mcghr patch

1-Covered PA QL (10 PER 30 DAY(S))

methadone hcl (METHADONEINTENSOL) 10 mgml oral conc

1-Covered PA

methadone hcl (METHADOSE) 40mg tablet sol

1-Covered PA

METHADONE HCL 10 MG TABLET 1-Covered QL (60 PER 30 DAYS)

METHADONE HCL 10 MGML ORALCONC

1-Covered PA

methadone hcl 5 mg tablet 10 mgtablet

1-Covered QL (60 PER 30 DAYS)

methadone hcl 5 mg5 ml solution10 mg5 ml solution 10 mgml oralconc

1-Covered PA

morphine sulfate 15 mg tablet er 1-Covered QL (90 PER 30 DAYS)


morphine sulfate 60 mg tablet er100 mg tablet er 200 mg tablet er

1-Covered PA

oxycodone hcl 10 mg tab er 20mg tab er 40 mg tab er 80 mgtab er

1-Covered PA QL (60 PER 30 DAYS)

SUBLOCADE (buprenorphine) 100MG05 ML SYRING 300 MG15 MLSYRING

2-MedicalCarve out

OPIOID ANALGESICS SHORT-ACTING (Short-acting Narcotic PainRelievers)

acetaminophen with codeinephosphate -15mg tablet -30mgtablet -60mg tablet

1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 100TABS TOTAL APAPCODEINETABLETS PER MONTH)




4



acetaminophen with codeinephosphate 120-12mg5 solution

1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old)

butorphanol tartrate 10 mgmlspray

1-Covered PA

codeinephosphatebutalbitalaspirincaffeine codeinebutalbitalasacaffein30-50-325 capsule

1-Covered QL (60 PER 30 DAYS) AL1 (At least12 yrs old)

codeine sulfate 15 mg tablet 30mg tablet 60 mg tablet

1-Covered PA AL1 (At least 12 yrs old)

hydrocodonebitartrateacetaminophen(LORCET HD)hydrocodoneacetaminophen10mg-325mg tablet

1-Covered QL (100 PER 30 DAY(S))

hydrocodonebitartrateacetaminophen(LORTAB)hydrocodoneacetaminophen10mg-325mg tablet


hydrocodonebitartrateacetaminophenhydrocodoneacetaminophen 5mg-325mg tablethydrocodoneacetaminophen75-325 mg tablethydrocodoneacetaminophen10mg-325mg tablet

1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS OF HYDROCODONEPRODUCTS PER 30 DAYS)

hydromorphone hcl 1 mgml liquid3 mg supprect

1-Covered

hydromorphone hcl 2 mg tablet 4mg tablet 8 mg tablet


meperidine hcl 50 mg tablet 100mg tablet


morphine sulfate 10 mg5 ml 20mg5 ml 100 mg5ml

1-Covered PA

morphine sulfate 15 mg tablet 30mg tablet


morphine sulfate 30 mg supprect 1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)

morphine sulfate 5 mg 10 mg 20mg

1-Covered QL (24 PER 30 DAY(S)) QLC (LIMIT24 SUPPOSITORIES IN 30 DAYS)




5



oxycodone hcl 5 mg capsule 5mg tablet 5 mg5 ml solution 15mg tablet 20 mgml oral conc 30mg tablet

1-Covered PA

oxycodone hclacetaminophen(ENDOCET) 5 mg-325mg tablet

1-Covered QL (100 PER 30 DAYS) QLC (LIMIT100 TABS PER 30 DAYS OF TOTALOXYCODONE APAP ANDOXYCODONE ASA PER MONTH)

oxycodone hclacetaminophen 5mg-325mg tablet


oxycodone hclacetaminophen 5-3255 ml solution

1-Covered PA

oxycodone hclaspirin 48355-325tablet


tramadol hcl 50 mg tablet 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)

TRAMADOL HCL 50 MG TABLET 1-Covered QL (100 PER 30 DAYS) AL1 (Atleast 12 yrs old)

ANESTHETICS (Drugs for Numbing)

LOCAL ANESTHETICS (Skin Numbing Drugs)lidocaine hcl 10 mgml vial 1-Covered PA

lidocaine hcl 2 solution 1-Covered

LIDOCAINE HCL VISCOUS 2 SOLN 1-Covered

lidocaine hclpf 10 mgml vial 10mgml ampul

1-Covered PA

ANTI-ADDICTIONSUBSTANCE ABUSE TREATMENT AGENTS (Drugs forAddictionSubstance Abuse)

ALCOHOL DETERRENTSANTI-CRAVING (Drugs for AlcoholDependence)

acamprosate calcium 333 mgtablet dr

2-MedicalCarve out

disulfiram 250 mg tablet 500 mgtablet

2-MedicalCarve out




6



naltrexone hcl 50 mg tablet 2-MedicalCarve out

NALTREXONE HCL 50 MG TABLET 2-MedicalCarve out

VIVITROL (naltrexonemicrospheres) 380 MG VIAL +DILUENT

2-MedicalCarve out

OPIOID DEPENDENCE TREATMENTS (Drugs for Opioid Dependence)BUNAVAIL (buprenorphinehclnaloxone hcl) 21-03 MG FILM42-07 MG FILM 63-1 MG FILM

2-MedicalCarve out

BUPRENEX (buprenorphine hcl) 03MGML AMPUL

2-MedicalCarve out

buprenorphine hcl 03 mgml vial03 mgml cartridge 2 mg tab subl8 mg tab subl

2-MedicalCarve out

buprenorphine hclnaloxone hclnaloxone 2 mg-05mg filmnaloxone 2 mg-05mg tab sublnaloxone 4mg-1mg filmnaloxone 8 mg-2 mg filmnaloxone 8 mg-2 mg tab subl

2-MedicalCarve out

LUCEMYRA (lofexidine hcl) 018 MGTABLET

2-MedicalCarve out

PROBUPHINE (buprenorphine hcl)742 MG IMPLANT

2-MedicalCarve out

SUBOXONE (buprenorphinehclnaloxone hcl) 2 MG-05 MGFILM 4 MG-1 MG FILM 8 MG-2 MGFILM 12 MG-3 MG FILM

2-MedicalCarve out

ZUBSOLV (buprenorphinehclnaloxone hcl) 07-018 MGTABLET 14-036 MG TABLET 29-071 MG TABLET 57-14 MG TABLET86-21 MG TABLET 114-29 MGTABLET

2-MedicalCarve out

OPIOID REVERSAL AGENTS (Drugs for Opioid Overdose)EVZIO (naloxone hcl) 04 MGAUTO- 2 MG AUTO-

2-MedicalCarve out

naloxone hcl 04 mgml cartridge04 mgml vial 1 mgml syringe 2mg04ml auto injct

2-MedicalCarve out




7



NARCAN (naloxone hcl) 4 MGNASAL SPRAY

2-MedicalCarve out

SMOKING CESSATION AGENTS (Drugs to Help Quit Smoking)bupropion hcl (BUPROBAN) 150 mgtab er 12h


bupropion hcl 150 mg tab er 12h 1-Covered QL (2 PER 1 DAY(S))

CHANTIX (varenicline tartrate) 05MG TABLET 1 MG TABLET 1 MGCONT MONTH BOX STARTINGMONTH BOX

1-Covered PA

nicotine 14mg patch 1-Covered QL (1 PER 1 DAY(S))


nicotine 2mg gum 1-Covered QL (24 PER 1 DAY(S))



NICOTINE LOZENGE 2 MGLOZENGE HM 2 MG LOZENGE 4MG LOZENGE HM 4 MG LOZENGE


nicotine polacrilex (QUIT 2) mglozenge )




nicotine polacrilex (STOP SMOKINGAID) 2 mg 4 mg


nicotine polacrilex 2 mg 4 mg 1-Covered QL (24 PER 1 DAY(S))

NICOTROL (nicotine) CARTRIDGEINHALER

1-Covered PA

NICOTROL NS (nicotine) 10 MGMLSPRAY

1-Covered PA

ANTIBACTERIALS (Drugs for Bacterial Infections)

AMINOGLYCOSIDESgentamicin sulfate (GENTAK) 03 oint (g)

1-Covered

gentamicin sulfate 01 oint (g)01 cream (g) 03 oint (g) 03 drops

1-Covered




8



GENTAMICIN SULFATE 01 CREAM 1-Covered

neomycin sulfate 500 mg tablet 1-Covered

paromomycin sulfate 250 mgcapsule

1-Covered

tobramycin 03 drops 1-Covered

TOBREX (tobramycin) 03 EYEOINTMENT

1-Covered

ANTIBACTERIALS OTHERbacitracin (BACITRAYCIN PLUS) 500unitg oint (g)

1-Covered

bacitracin 500 unitg packet 500unitg oint (g)

1-Covered

BACITRACIN 500 UNITGM OINTMNT 1-Covered

bacitracin zinc (ANTIBIOTIC) 500unitg oint (g)

1-Covered

bacitracin zinc 500 unitg ointpack 500 unitg oint (g)

1-Covered

BACITRACIN ZINC ZN 500 UNITGMOINT

1-Covered

CLEOCIN (clindamycin phosphate)100 MG VAGINAL OVULE

1-Covered

clindamycin hcl 75 mg capsule150 mg capsule 300 mg capsule

1-Covered

clindamycin palmitate hcl 75 mg5ml soln recon

1-Covered

clindamycin phosphate 1 gel(gram) 1 lotion 1 med swab1 solution 1 gel daily 2 creamappl

1-Covered

CLINDAMYCIN PHOSPHATE 1SOLUTION 1 GEL

1-Covered

erythromycin basebenzoylperoxide erythromycinbenzoyl 3-5 gel (gram)

1-Covered ST

methenaminemethylenebluesodphospsalicylatehyoscyamine(PHOSPHASAL) methmebluesodphospsalhyos 816-108 tablet

1-Covered PA




9



methenaminemethylenebluesodphospsalicylatehyoscyamine(URIN DS) methmebluesodphospsalhyos 816-108 tablet

1-Covered PA

METRO IV (metronidazole in sodiumchloride) 500 MG100 ML

1-Covered

metronidazole 075 gel wappl250 mg tablet 375 mg capsule500 mg tablet

1-Covered

METRONIDAZOLE 250 MG TABLET500 MG TABLET

1-Covered

metronidazole in sodium chloridemetronidazolesodium 500mg01lpiggyback

1-Covered PA

mupirocin 2 oint (g) 1-Covered QL (22 PER 30 DAY(S))

mupirocin calcium 2 cream (g) 1-Covered PA

neomycin sulfatebacitracinzincpolymyxin b (ANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)

1-Covered

neomycin sulfatebacitracinzincpolymyxin b (FIRST AIDANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)

1-Covered

neomycin sulfatebacitracinzincpolymyxin b (TRIPLEANTIBIOTIC)neomycinbacitracinpolymyxinb35-400-5k oint (g)

1-Covered

nitrofurantoin 25 mg5 ml oral susp 1-Covered

NITROFURANTOIN 50 MG CAP 100MG CAP

1-Covered

nitrofurantoin macrocrystal 50 mgcapsule 100 mg capsule

1-Covered

nitrofurantoinmonohydratemacrocrystalsmonohydm-100 mg capsule

1-Covered

trimethoprim 100 mg tablet 1-Covered




10



TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxinb) CURAD OINT MEDI-FIRSTMEDICHOICE OINTMENTOINTMENT PKT

1-Covered

TRIPLE ANTIBIOTIC HM PKT 1-Covered

URETRON D-S(methenaminemethylenebluesodphospsalicylatehyoscyamine) -TABLET

1-Covered PA

VANDAZOLE (metronidazole)VAGINAL 075 GEL

1-Covered

BETA-LACTAM CEPHALOSPORINScefaclor 125 mg5ml susp recon250 mg5ml susp recon 250 mgcapsule 375 mg5ml susp recon500 mg capsule

1-Covered

CEFDINIR 125 MG5 ML SUSP 250MG5 ML SUSP


cefdinir 125 mg5ml 250 mg5ml 1-Covered QL (200 PER 10 DAY(S))

cefdinir 300 mg capsule 1-Covered QL (20 PER 10 DAY(S))

cephalexin 125 mg5ml susprecon 250 mg capsule 250mg5ml susp recon 500 mgcapsule

1-Covered

BETA-LACTAM PENICILLINSamoxicillin 125 mg5ml susp recon125 mg tab chew 200 mg5mlsusp recon 250 mg tab chew 250mg5ml susp recon 250 mgcapsule 400 mg5ml susp recon500 mg tablet 500 mg capsule875 mg tablet

1-Covered

AMOXICILLIN-CLAVULANATEPOTASS -600-429 MG5 ML SUS

1-Covered QL (300 PER FILL) QLC (1 FILL IN 30DAYS)

AMOXICILLIN-CLAVULANATEPOTASS -875-125 MG TABLET

1-Covered

amoxicillinpotassium clavulanate1000-625 tab er 12h

1-Covered QL (40 PER FILL(S)) MFL (1 30day(s))




11



amoxicillinpotassium clavulanate200-2855 susp recon 200-285mgtab chew 250-125 mg tablet 400-57mg5 susp recon 400-57mg tabchew 500-125 mg tablet 875-125mg tablet

1-Covered

amoxicillinpotassium clavulanate600-4295 susp recon


ampicillin trihydrate 125 mg5mlsusp recon 250 mg capsule 250mg5ml susp recon 500 mgcapsule

1-Covered

dicloxacillin sodium 250 mgcapsule 500 mg capsule

1-Covered

penicillin v potassium 125 mg5mlsoln recon 250 mg5ml soln recon250 mg tablet 500 mg tablet

1-Covered

MACROLIDESazithromycin 1 g packet 1-Covered QL (1 PER 30 DAYS)

azithromycin 100 mg5ml 200mg5ml

1-Covered

AZITHROMYCIN 200 MG5 ML SUSP 1-Covered

azithromycin 250 mg tablet 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))

AZITHROMYCIN 250 MG TABLET 1-Covered QL (6 PER FILL(S)) MFL (2 30day(s))



azithromycin 600 mg tablet 1-Covered QL (2 PER 7 DAY(S)) MFL (8 28day(s))

clarithromycin 500 mg tablet 1-Covered ST

EES 200 (erythromycinethylsuccinate) MG5 MLSUSPENSION

1-Covered

EES 400 (erythromycinethylsuccinate) FILMTAB

1-Covered

ERYTHROCIN STEARATE(erythromycin stearate) 250 MGFILMTAB

1-Covered




12



ERYTHROMYCIN 250 MG 500 MG 1-Covered

erythromycin base 5 mggramoint (g) 250 mg capsule dr 250mg tablet dr 250 mg tablet 333mg tablet dr 500 mg tablet 500mg tablet dr

1-Covered

erythromycin base in ethanol (ERY)2 med swab

1-Covered

erythromycin base in ethanol 2 solution 2 med swab

1-Covered

ERYTHROMYCIN ETHYLSUCCINATE200 MG5 ML SUSP

1-Covered

erythromycin ethylsuccinate 200mg5ml susp recon 400 mg tablet

1-Covered

QUINOLONESCILOXAN (ciprofloxacin hcl) 03OINTMENT

1-Covered

ciprofloxacin hcl 03 drops 1-Covered

ciprofloxacin hcl 100 mg tablet 1-Covered PA AL1 (At least 18 yrs old)

ciprofloxacin hcl 250 mg tablet500 mg tablet 750 mg tablet

1-Covered AL1 (At least 18 yrs old)

CIPROFLOXACIN HCL 500 MG TAB 1-Covered AL1 (At least 18 yrs old)

levofloxacin 250 mg tablet 500 mgtablet 750 mg tablet


moxifloxacin hcl 400 mg tablet 1-Covered PA AL1 (At least 18 yrs old)

ofloxacin 03 drops 1-Covered QL (5 PER 30 DAY(S))

SULFONAMIDESBLEPH-10 (sulfacetamide sodium) - EYE DROPS

1-Covered

silver sulfadiazine 1 cream (g) 1-Covered

SSD (silver sulfadiazine) 1 CREAM 1-Covered

sulfacetamide sodium 10 oint(g) 10 drops

1-Covered

sulfamethoxazoletrimethoprim200-40mg5 oral susp 400mg-80mgtablet 800-16020 oral susp 800-160 mg tablet

1-Covered




13



SULFATRIM(sulfamethoxazoletrimethoprim)PEDIATRIC SUSPENSION

1-Covered

TETRACYCLINESDOXYCYCLINE HYCLATE 100 MGCAP


doxycycline hyclate 100 mgcapsule


DOXYCYCLINE HYCLATE 20 MG TAB 1-Covered QL (60 PER 30 DAYS)

doxycycline hyclate 20 mg tablet 1-Covered QL (60 PER 30 DAYS)

doxycycline monohydrate 50 mgcapsule 100 mg capsule


minocycline hcl 50 mg capsule100 mg capsule

1-Covered

ANTICONVULSANTS (Drugs for Seizures)

ANTICONVULSANTS OTHER (Other Seizure Control Drugs)LEVETIRACETAM 100 MGML SOLN250 MG TABLET 500 MG5 ML SOLN

1-Covered

levetiracetam 100 mgml solution250 mg tablet 500 mg tablet 500mg5ml solution 750 mg tablet1000 mg tablet

1-Covered

levetiracetam 500 mg tab er 24h 1-Covered MDD (6 Per Day)

levetiracetam 750 mg tab er 24h 1-Covered QL (120 PER 30 DAY(S))

LEVETIRACETAM ER 500 MG TABLET 1-Covered MDD (6 Per Day)

LEVETIRACETAM ER 750 MG TABLET 1-Covered QL (120 PER 30 DAY(S))

CALCIUM CHANNEL MODIFYING AGENTSCELONTIN (methsuximide) 300 MGKAPSEAL

1-Covered

ETHOSUXIMIDE 250 MG CAPSULE 1-Covered

ethosuximide 250 mg5ml solution250 mg capsule

1-Covered

zonisamide 25 mg capsule 50 mgcapsule 100 mg capsule

1-Covered




14



GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSDEPAKENE (valproic acid (assodium salt) (valproate sodium))250 MG5 ML SOLUTION

1-Covered

DEPAKENE (valproic acid) 250 MGCAPSULE

1-Covered

diazepam 5-75-10mg kit 1-Covered

divalproex sodium 125 mg tabletdr 125 mg cap dr spr 250 mgtablet dr 500 mg tablet dr

1-Covered

DIVALPROEX SODIUM DR 125 MGCAP SPRNK

1-Covered

gabapentin 100 mg capsule 250mg5ml solution 300 mg capsule400 mg capsule 600 mg tablet800 mg tablet

1-Covered

GABAPENTIN 100 MG CAPSULE 300MG CAPSULE 400 MG CAPSULE

1-Covered

phenobarbital 15 mg tablet 20mg5 ml elixir 30 mg tablet 324mg tablet 60 mg tablet 648 mgtablet 972mg tablet 100 mgtablet

1-Covered

PHENOBARBITAL 20 MG5 ML SOLN324 MG TABLET 648 MG TABLET972 MG TABLET

1-Covered

primidone 50 mg tablet 250 mgtablet

1-Covered

valproic acid (as sodium salt)(valproate sodium) 250 mg5ml500mg10ml

1-Covered

valproic acid 250 mg capsule 1-Covered

VALPROIC ACID 250 MG CAPSULE 1-Covered

GLUTAMATE REDUCING AGENTSlamotrigine 25 mg tablet 100 mgtablet 150 mg tablet 200 mgtablet

1-Covered

lamotrigine 5 mg 25 mg 1-Covered PA




15



topiramate 15 mg cap sprink 25mg tablet 25 mg cap sprink 50mg tablet 100 mg tablet 200 mgtablet

1-Covered

TOPIRAMATE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET

1-Covered

SODIUM CHANNEL AGENTScarbamazepine (EPITOL) 200 mgtablet

1-Covered

carbamazepine 100 mg cpmp12hr 100 mg5ml oral susp 100 mgtab chew 100 mg tab er 12h 200mg cpmp 12hr 200 mg tab er 12h200 mg tablet 300 mg cpmp 12hr400 mg tab er 12h

1-Covered

CARBATROL (carbamazepine) ER100 MG CAPSULE ER 200 MGCAPSULE ER 300 MG CAPSULE

1-Covered

DILANTIN (phenytoin sodiumextended) 30 MG CAPSULE 100MG CAPSULE

1-Covered

DILANTIN (phenytoin) 50 MGINFATAB

1-Covered

DILANTIN-125 (phenytoin) MG5 MLSUSP

1-Covered

DILANTIN-125 MG5 ML SUSP 1-Covered

oxcarbazepine 150 mg tablet 300mg tablet 600 mg tablet

1-Covered

phenytoin 50 mg tab chew 100mg4ml oral susp 125 mg5ml oralsusp

1-Covered

phenytoin sodium extended 100mg capsule

1-Covered

TEGRETOL (carbamazepine) 100MG5 ML SUSP 200 MG TABLET

1-Covered

TEGRETOL XR (carbamazepine) 100MG TABLET 200 MG TABLET 400MG TABLET

1-Covered




16



ANTIDEMENTIA AGENTS (Drugs for Alzheimers Disease andDementia)

CHOLINESTERASE INHIBITORSdonepezil hcl 5 mg tab rapdis 5mg tablet 10 mg tab rapdis 10mg tablet

1-Covered

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl 5 mg tablet 10 mgtablet

1-Covered

MEMANTINE HCL 5 MG TABLET 10MG TABLET

1-Covered

ANTIDEPRESSANTS (Drugs for Depression)

ANTIDEPRESSANTS OTHERbupropion hcl 100 mg tab 150 mgtab 200 mg tab


bupropion hcl 150 mg tab er 300mg tab er

1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day)

bupropion hcl 75 mg tablet 100mg tablet

1-Covered

BUPROPION HCL SR SR 100 MGTABLET SR 150 MG TABLET SR 200MG TABLET


BUPROPION XL 150 MG TABLET 300MG TABLET


mirtazapine 15 mg tab rapdis 1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old)

mirtazapine 15 mg tablet 30 mgtab rapdis 30 mg tablet 45 mgtab rapdis 45 mg tablet


olanzapinefluoxetine hcl 3 mg-25mg capsule 6mg-25mg capsule6mg-50mg capsule 12mg-50mgcapsule 12mg-25mg capsule

2-MedicalCarve out




17



SYMBYAX (olanzapinefluoxetinehcl) 3-25 MG CAPSULE 6-50 MGCAPSULE 6-25 MG CAPSULE 12-50MG CAPSULE 12-25 MG CAPSULE

2-MedicalCarve out

MONOAMINE OXIDASE INHIBITORSEMSAM (selegiline) 6 MG24PATCH 9 MG24 PATCH 12 MG24PATCH

2-MedicalCarve out

MARPLAN (isocarboxazid) 10 MGTABLET

2-MedicalCarve out

NARDIL (phenelzine sulfate) 15 MGTABLET

2-MedicalCarve out

PARNATE (tranylcypromine sulfate)10 MG TABLET

2-MedicalCarve out

phenelzine sulfate 15 mg tablet 2-MedicalCarve out

tranylcypromine sulfate 10 mgtablet

2-MedicalCarve out

SSRISSNRIS (SELECTIVE SEROTONIN REUPTAKEINHIBITORSEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)

citalopram hydrobromide 10 mgtablet 20 mg tablet 40 mg tablet

1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)

escitalopram oxalate 5 mg tablet10 mg tablet 20 mg tablet

1-Covered

ESCITALOPRAM OXALATE 5 MGTABLET 10 MG TABLET 20 MGTABLET

1-Covered

fluoxetine hcl 10 mg capsule 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)

fluoxetine hcl 20 mg capsule 1-Covered QL (120 PER 30 DAY(S))

fluoxetine hcl 20 mg5 ml solution 1-Covered

FLUOXETINE HCL 20 MG5 MLSOLUTION

1-Covered

fluvoxamine maleate 25 mg tablet50 mg tablet 100 mg tablet


paroxetine hcl 10 mg tablet 20 mgtablet 30 mg tablet 40 mg tablet


sertraline hcl 25 mg tablet 50 mgtablet 100 mg tablet





18



TRAZODONE HCL 50 MG TABLET100 MG TABLET

1-Covered

trazodone hcl 50 mg tablet 100mg tablet 150 mg tablet

1-Covered

venlafaxine hcl 25 mg tablet 375mg tablet 50 mg tablet 75 mgtablet 100 mg tablet


venlafaxine hcl 375 mg cap er 75mg cap er 150 mg cap er


VENLAFAXINE HCL ER ER 375 MGCAP ER 75 MG CAP ER 150 MGCAP


TRICYCLICSamitriptyline hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet

1-Covered

amoxapine 25 mg tablet 50 mgtablet 100 mg tablet 150 mgtablet

1-Covered

clomipramine hcl 25 mg capsule50 mg capsule 75 mg capsule

1-Covered PA

CLOMIPRAMINE HCL 25 MGCAPSULE 50 MG CAPSULE 75 MGCAPSULE

1-Covered PA

desipramine hcl 10 mg tablet 25mg tablet 50 mg tablet 75 mgtablet 100 mg tablet 150 mgtablet

1-Covered

DOXEPIN HCL 10 MG CAPSULE 25MG CAPSULE 50 MG CAPSULE 75MG CAPSULE 100 MG CAPSULE

1-Covered

doxepin hcl 10 mgml oral conc10 mg capsule 25 mg capsule 50mg capsule 75 mg capsule 100mg capsule 150 mg capsule

1-Covered

imipramine hcl 10 mg tablet 25mg tablet 50 mg tablet

1-Covered

IMIPRAMINE HCL 10 MG TABLET 25MG TABLET 50 MG TABLET

1-Covered

nortriptyline hcl 10 mg capsule 25mg capsule 50 mg capsule 75 mgcapsule

1-Covered




19



ANTIEMETICS (Drugs for Nausea and Vomiting)

ANTIEMETICS OTHER (Other Drugs for Nausea and Vomiting)meclizine hcl (DRAMAMINE LESSDROWSY) 25 mg tablet

1-Covered

meclizine hcl (MEDI-MECLIZINE) 25mg tablet -

1-Covered

meclizine hcl (MOTION RELIEF) 25mg tablet

1-Covered

meclizine hcl (MOTION SICKNESS II)25 mg tablet

1-Covered

meclizine hcl (MOTION SICKNESSRELIEF) 25 mg tablet 25 mg tabchew

1-Covered

meclizine hcl (MOTION SICKNESS)25 mg tablet

1-Covered

meclizine hcl (MOTION-TIME) 25 mgtab chew -

1-Covered

meclizine hcl (TRAVEL-EASE) 25 mgtablet -

1-Covered

meclizine hcl (VERTICALM) 25 mgtablet

1-Covered

meclizine hcl (WAL-DRAM 2) 25 mgtablet -

1-Covered

MECLIZINE HCL 125 MG CAPLET 25MG TABLET CHEW

1-Covered

meclizine hcl 125 mg tablet 25mg tab chew 25 mg tablet

1-Covered

metoclopramide hcl 5 mg tablet 5mg5 ml solution 10 mg tablet 10mg10ml solution

1-Covered

perphenazine 2 mg tablet 4 mgtablet 8 mg tablet 16 mg tablet

2-MedicalCarve out

prochlorperazine (COMPRO) 25mg supprect

1-Covered

prochlorperazine 25 mg supprect 1-Covered

prochlorperazine maleate 5 mgtablet 10 mg tablet

1-Covered




20



promethazine hcl (PHENADOZ)125 mg 25 mg

1-Covered

promethazine hcl (PROMETHEGAN)125 mg 25 mg 50 mg

1-Covered

promethazine hcl 125 mgsupprect 25 mg supprect 50 mgtablet 50 mg supprect

1-Covered

TRAVEL SICKNESS (meclizine hcl) 25MG TAB CHEW

1-Covered

trimethobenzamide hcl 300 mgcapsule

1-Covered

EMETOGENIC THERAPY ADJUNCTS (Drugs for Nausea and Vomiting)aprepitant 40 mg capsule 80 mgcapsule 125mg-80mg cap ds pk125 mg capsule

1-Covered PA

dronabinol 25 mg capsule 5 mgcapsule 10 mg capsule

1-Covered PA

granisetron hcl 1 mg tablet 1-Covered PA

ondansetron 4 mg tab rapdis 8mg tab rapdis

1-Covered QL (12 PER FILL(S)) MDD (3 PerDay) QLC (LIMIT TO 2 FILLS OF 12TABLETS IN 30 DAYS)

ondansetron hcl 4 mg tablet 8 mgtablet


ondansetron hcl 4 mg5 mlsolution 24 mg tablet

1-Covered PA

ANTIFUNGALS (Drugs for Fungal Infections)

ANTIFUNGALSANTIFUNGAL 1 TOPICAL CREAM 1-Covered

ATHLETES FOOT (terbinafine hcl) 1CREAM

1-Covered

ciclopirox 077 gel (gram) 1-Covered QLC (100 GRAMSMONTH)

ciclopirox 1 shampoo 1-Covered QLC (120 ozMONTH)

ciclopirox 8 solution 1-Covered

ciclopirox olamine 077 cream(g)

1-Covered QLC (90 GRAMSMONTH)




21



ciclopirox olamine 077 suspension

1-Covered QLC (60 MLMONTH)

clotrimazole (ANTIFUNGALRINGWORM) 1 cream (g)

1-Covered

clotrimazole (ANTIFUNGAL) 1 cream (g)

1-Covered

clotrimazole (ATHLETES FOOT) 1 cream (g)

1-Covered

clotrimazole (ATHLETIC FOOTCREAM) 1 cream (g)

1-Covered

clotrimazole (CLOTRIMAZOLE AF) 1 cream (g)

1-Covered

clotrimazole (ITCH RELIEF) 1 cream (g)

1-Covered

clotrimazole (JOCK ITCH RELIEF) 1 cream (g)

1-Covered

clotrimazole (JOCK ITCH) 1 cream (g)

1-Covered

clotrimazole (RINGWORM) 1 cream (g)

1-Covered

clotrimazole 1 cream (g) 1 solution 1 creamappl 10 mgtroche

1-Covered

CLOTRIMAZOLE 1 SOLUTION 1TOPICAL CREAM

1-Covered

fluconazole 10 mgml 40 mgml 1-Covered QL (70 PER 30 DAY(S))

fluconazole 150 mg tablet 1-Covered QL (2 PER 30 DAY(S))

FLUCONAZOLE 200 MG TABLET 1-Covered

fluconazole 50 mg tablet 100 mgtablet 200 mg tablet

1-Covered

fluconazole in dextrose iso-osmotic in dextreiso-200mg01l indextreiso-400mg02l

1-Covered PA

flucytosine 250 mg capsule 500mg capsule

1-Covered

FLUCYTOSINE 250 MG CAPSULE500 MG CAPSULE

1-Covered

griseofulvin ultramicrosize 125 mgtablet 250 mg tablet

1-Covered QL (60 PER 30 DAYS) AL1 (Up to18 yrs old)




22



griseofulvin microsize 125 mg5mloral susp

1-Covered AL1 (Up to 12 yrs old) MDD (20Per Day)

griseofulvin microsize 500 mgtablet


itraconazole 100 mg capsule 1-Covered PA

ketoconazole 2 cream (g) 2 shampoo

1-Covered

ketoconazole 200 mg tablet 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)

LAMISIL (terbinafine hcl)ANTIFUNGAL 1 SPRAY

1-Covered

LOTRIMIN AF (clotrimazole) 1CREAM

1-Covered

miconazole nitrate (ANTI-FUNGALCREAM) 2 cream (g) -

1-Covered

miconazole nitrate (ANTIFUNGALCREAM) 2 cream (g)

1-Covered

miconazole nitrate (BAZAANTIFUNGAL) 2 cream (g)

1-Covered

miconazole nitrate (INZOANTIFUNGAL) 2 cream (g)

1-Covered

miconazole nitrate (LOTRIMIN AF) 2 spray

1-Covered

miconazole nitrate (MICATIN) 2 cream (g)

1-Covered

miconazole nitrate (SECURAANTIFUNGAL) 2 cream (g)

1-Covered

miconazole nitrate 2 aero powd2 creamappl 2 cream (g)100 mg suppvag

1-Covered

MONISTAT 3 (miconazole nitrate)4 CREAM

1-Covered

MONISTAT 7 (miconazole nitrate)CREAM

1-Covered

NYSTATIN 100000 UNITGM CREAM100000 UNITGM OINT 100000UNITML SUSP 500000 UNIT5 MLSUS

1-Covered

nystatin 500k unit tablet 100000mloral susp 100000g cream (g)100000g oint (g)

1-Covered




23



terbinafine hcl (ANTIFUNGAL) 1 cream (g)

1-Covered

terbinafine hcl (ATHLETES FOOT AF)1 cream (g)

1-Covered

terbinafine hcl (ATHLETES FOOT) 1 cream (g)

1-Covered

terbinafine hcl (JOCK ITCH) 1 cream (g)

1-Covered

terbinafine hcl (LAMISIL AT) 1 cream (g)

1-Covered

terbinafine hcl 1 cream (g) 250mg tablet

1-Covered

tioconazole 65 oinpf app 1-Covered

tolnaftate (ANTIFUNGAL CREAM) 1 cream (g)

1-Covered

tolnaftate (ATHLETES FOOT) 1 cream (g)

1-Covered

tolnaftate (FUNGOID-D) 1 cream(g) -

1-Covered

tolnaftate 1 cream (g) 1-Covered

ANTIGOUT AGENTS (Drugs for Gout)

ANTIGOUT AGENTSallopurinol 100 mg tablet 300 mgtablet

1-Covered

ALLOPURINOL 100 MG TABLET 300MG TABLET

1-Covered

colchicine 06 mg tablet 1-Covered

COLCHICINE 06 MG TABLET 1-Covered

probenecid 500 mg tablet 1-Covered

probenecidcolchicine 500-05 mgtablet

1-Covered




24



ANTIMIGRAINE AGENTS (Drugs for Migraine)

ERGOT ALKALOIDSergotamine tartratecaffeine 1mg-100mg tablet

1-Covered

SEROTONIN (5-HT) 1B1D RECEPTOR AGONISTSrizatriptan benzoate 5 mg tablet10 mg tablet

1-Covered QL (12 PER 30 DAY(S)) AL1 (Atleast 6 yrs old)

SUMATRIPTAN 5 MG SPRAY 20 MGSPRAY


sumatriptan 5 mg 20 mg 1-Covered QL (6 PER 30 DAY(S))

sumatriptan succinate 25 mgtablet 50 mg tablet 100 mg tablet


SUMATRIPTAN SUCCINATE 25 MGTABLET 50 MG TABLET 100 MGTABLET


SUMATRIPTAN SUCCINATE 6 MG05ML CART


SUMATRIPTAN SUCCINATE 6 MG05ML INJECT

1-Covered QL (2 PER 30 DAY(S)) MFL (1 30day(s))

sumatriptan succinate 6 mg05mlcartridge 6 mg05ml vial


sumatriptan succinate 6 mg05mlpen injctr 6 mg05ml syringe


ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis)

PARASYMPATHOMIMETICSMESTINON (pyridostigminebromide) 60 MG5 ML SOLUTION

1-Covered

pyridostigmine bromide 60 mg5ml solution 60 mg tablet 180 mgtablet er

1-Covered




25



ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections)

ANTIMYCOBACTERIALS OTHER (Other Drugs for MycobacterialInfection)

dapsone 25 mg tablet 100 mgtablet

1-Covered

rifabutin 150 mg capsule 1-Covered

ANTITUBERCULARS (Drugs for Tuberculosis)ethambutol hcl 100 mg tablet 400mg tablet

1-Covered

ETHAMBUTOL HCL 100 MG TABLET400 MG TABLET

1-Covered

isoniazid 50 mg5 ml solution 100mg tablet 300 mg tablet

1-Covered

PRIFTIN (rifapentine) 150 MG TABLET 1-Covered AL1 (At least 12 yrs old)

pyrazinamide 500 mg tablet 1-Covered

rifampin 150 mg capsule 300 mgcapsule

1-Covered

ANTINEOPLASTICS (Drugs for Cancer)

ALKYLATING AGENTScyclophosphamide 25 mgcapsule 50 mg capsule

1-Covered PA

CYCLOPHOSPHAMIDE 25 MGCAPSULE 50 MG CAPSULE

1-Covered PA

GLEOSTINE (lomustine) 10 MGCAPSULE 40 MG CAPSULE 100 MGCAPSULE

1-Covered PA

HEXALEN (altretamine) 50 MGCAPSULE

1-Covered

LEUKERAN (chlorambucil) 2 MGTABLET

1-Covered PA

MATULANE (procarbazine hcl) 50MG CAPSULE

1-Covered PA SP

melphalan 2 mg tablet 1-Covered PA




26



MYLERAN (busulfan) 2 MG TABLET 1-Covered

temozolomide 20 mg capsule 1-Covered PA SP

ANTIANDROGENSbicalutamide 50 mg tablet 1-Covered PA

flutamide 125 mg capsule 1-Covered PA

ANTIANGIOGENIC AGENTSTHALOMID (thalidomide) 50 MGCAPSULE

1-Covered PA SP

ANTIESTROGENSMODIFIERSEMCYT (estramustine phosphatesodium) 140 MG CAPSULE

1-Covered PA

TAMOXIFEN CITRATE 10 MG TABLET 1-Covered

tamoxifen citrate 10 mg tablet 20mg tablet

1-Covered

TOREMIFENE CITRATE 60 MG TAB 1-Covered PA

toremifene citrate 60 mg tablet 1-Covered PA

ANTIMETABOLITEScapecitabine 500 mg tablet 1-Covered PA SP

CAPECITABINE 500 MG TABLET 1-Covered PA SP

DROXIA (hydroxyurea) 200 MGCAPSULE 300 MG CAPSULE 400MG CAPSULE

1-Covered

fluorouracil (ADRUCIL) 25 g50mlvial 5 g100 ml vial

1-Covered PA

hydroxyurea 500 mg capsule 1-Covered PA

mercaptopurine 50 mg tablet 1-Covered PA

TABLOID (thioguanine) 40 MGTABLET

1-Covered PA

ANTINEOPLASTICS OTHERLEUCOVORIN CALCIUM 5 MG TAB25 MG TAB

1-Covered

leucovorin calcium 5 mg tablet 10mg tablet 15 mg tablet 25 mgtablet

1-Covered




27



LYSODREN (mitotane) 500 MGTABLET

1-Covered PA

AROMATASE INHIBITORS 3RD GENERATIONanastrozole 1 mg tablet 1-Covered

ANASTROZOLE 1 MG TABLET 1-Covered

letrozole 25 mg tablet 1-Covered

ENZYME INHIBITORSetoposide 50 mg capsule 1-Covered PA

MOLECULAR TARGET INHIBITORSJAKAFI (ruxolitinib phosphate) 5MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 25 MGTABLET

1-Covered PA SP QL (2 PER 1 DAY(S))

RETINOIDStretinoin 10 mg capsule 1-Covered PA

ANTIPARASITICS (Drugs for Parasitic Infections)

ANTIHELMINTHICS (Drugs for Worm Infection)mebendazole (EMVERM) 100 mgtab chew

1-Covered

praziquantel 600 mg tablet 1-Covered

ANTIPROTOZOALS (Drugs for Protozoal Infection)chloroquine phosphate 250 mgtablet


chloroquine phosphate 500 mgtablet


HYDROXYCHLOROQUINE SULFATE200 MG TAB


hydroxychloroquine sulfate 200 mgtablet


mefloquine hcl 250 mg tablet 1-Covered

primaquine phosphate 263 mgtablet

1-Covered




28



PEDICULICIDESSCABICIDES (Drugs for Scabies and Lice)permethrin (LICE TREATMENT) 1 liquid

1-Covered

permethrin 5 cream (g) 1-Covered

ANTIPARKINSON AGENTS (Drugs for Parkinsons Disease)

ANTICHOLINERGICSbenztropine mesylate 05 mgtablet 1 mg tablet 2 mg tablet 2mg2 ml ampul 2 mg2 ml vial

2-MedicalCarve out

COGENTIN (benztropine mesylate)2 MG2 ML AMPULE

2-MedicalCarve out

trihexyphenidyl hcl 2 mg5 ml elixir2 mg tablet 5 mg tablet

2-MedicalCarve out

ANTIPARKINSON AGENTS OTHERAMANTADINE 100 MG CAPSULE 2-Medical

Carve out

amantadine hcl 50 mg5 mlsolution 100 mg capsule 100 mgtablet

2-MedicalCarve out

entacapone 200 mg tablet 1-Covered ST

GOCOVRI (amantadine hcl) ER685 MG CAPSULE ER 137 MGCAPSULE

2-MedicalCarve out

OSMOLEX ER (amantadine hcl) ER129 MG TABLET ER 193 MG TABLETER 258 MG TABLET ER 322 MGDAILY DOSE

2-MedicalCarve out

DOPAMINE AGONISTSbromocriptine mesylate 25 mgtablet

1-Covered

pramipexole di-hcl -0125 mgtablet -025 mg tablet -05 mgtablet -075 mg tablet -1 mgtablet -15 mg tablet

1-Covered

ropinirole hcl 025 mg tablet 05mg tablet 1 mg tablet 2 mgtablet 3 mg tablet 4 mg tablet 5mg tablet

1-Covered




29



DOPAMINE PRECURSORSL-AMINO ACID DECARBOXYLASEINHIBITORS

carbidopalevodopa 10mg-100mgtablet 25mg-100mg tablet 25mg-100mg tablet er 25mg-250mgtablet 50mg-200mg tablet er

1-Covered

MONOAMINE OXIDASE B (MAO-B) INHIBITORSselegiline hcl 5 mg tablet 5 mgcapsule

1-Covered

ANTIPSYCHOTICS (Drugs for Mental Health)

1ST GENERATIONTYPICALADASUVE (loxapine) 10 MG POWD10 MG POWDR

2-MedicalCarve out

chlorpromazine hcl 10 mg tablet25 mg tablet 25 mgml ampul 50mg tablet 100 mg tablet 200 mgtablet

2-MedicalCarve out

CHLORPROMAZINE HCL 10 MGTABLET 25 MGML AMPULE 25 MGTABLET 50 MG TABLET 50 MG2 MLAMP 100 MG TABLET 200 MGTABLET

2-MedicalCarve out

fluphenazine decanoate 25 mgmlvial

2-MedicalCarve out

fluphenazine hcl 1 mg tablet 25mg tablet 25 mg5ml elixir 25mgml vial 5 mgml oral conc 5mg tablet 10 mg tablet

2-MedicalCarve out

FLUPHENAZINE HCL 1 MG TABLET25 MG TABLET 5 MG TABLET 10MG TABLET

2-MedicalCarve out

HALDOL (haloperidol lactate) 5MGML AMPUL

2-MedicalCarve out

HALDOL DECANOATE 100(haloperidol decanoate) AMPUL

2-MedicalCarve out


2-MedicalCarve out




30



haloperidol 05 mg tablet 1 mgtablet 2 mg tablet 5 mg tablet 10mg tablet 20 mg tablet

2-MedicalCarve out

HALOPERIDOL 5 MG TABLET 2-MedicalCarve out

haloperidol decanoate 50 mgmlvial 50 mgml ampul 100 mgmlampul 100 mgml vial

2-MedicalCarve out

haloperidol lactate 2 mgml oralconc 5 mgml vial 5 mgmlampul 5 mgml syringe

2-MedicalCarve out

HALOPERIDOL LACTATE 5 MGMLSYRING

2-MedicalCarve out

loxapine succinate 5 mg capsule10 mg capsule 25 mg capsule 50mg capsule

2-MedicalCarve out

molindone hcl 5 mg tablet 10 mgtablet 25 mg tablet

2-MedicalCarve out

ORAP (pimozide) 1 MG TABLET 2MG TABLET

2-MedicalCarve out

pimozide 1 mg tablet 2 mg tablet 2-MedicalCarve out

thioridazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet

2-MedicalCarve out

thiothixene 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule

2-MedicalCarve out

trifluoperazine hcl 1 mg tablet 2mg tablet 5 mg tablet 10 mgtablet

2-MedicalCarve out

2ND GENERATIONATYPICALABILIFY (aripiprazole) 2 MG TABLET5 MG TABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET 30 MGTABLET

2-MedicalCarve out

ABILIFY MAINTENA (aripiprazole) ER300 MG VL ER 300 MG SYR ER 400MG SYR ER 400 MG VL

2-MedicalCarve out

ABILIFY MYCITE (aripiprazole) 2 MGKIT 5 MG KIT 10 MG KIT 15 MG KIT20 MG KIT 30 MG KIT

2-MedicalCarve out




31



aripiprazole 1 mgml solution 2 mgtablet 5 mg tablet 10 mg tabrapdis 10 mg tablet 15 mg tablet15 mg tab rapdis 20 mg tablet 30mg tablet

2-MedicalCarve out

ARIPIPRAZOLE 1 MGML SOLUTION2 MG TABLET 5 MG TABLET 10 MGTABLET 15 MG TABLET 20 MGTABLET 30 MG TABLET

2-MedicalCarve out

ARISTADA (aripiprazole lauroxil) ER441 MG16 ML SYRN ER 662MG24 ML SYRN ER 882 MG32ML SYRN ER 1064 MG39 ML SYR

2-MedicalCarve out

ARISTADA INITIO (aripiprazolelauroxil submicronized) ER 675MG24

2-MedicalCarve out

CAPLYTA (lumateperone tosylate)42 MG CAPSULE

2-MedicalCarve out

FANAPT (iloperidone) 1 MG TABLET2 MG TABLET 4 MG TABLET 6 MGTABLET 8 MG TABLET 10 MGTABLET 12 MG TABLET TITRATIONPACK

2-MedicalCarve out

GEODON (ziprasidone hcl) 20 MGCAPSULE 40 MG CAPSULE 60 MGCAPSULE 80 MG CAPSULE

2-MedicalCarve out

GEODON (ziprasidone mesylate)20 MGML VIAL

2-MedicalCarve out

INVEGA (paliperidone) ER 15 MGTABLET ER 3 MG TABLET ER 6 MGTABLET ER 9 MG TABLET

2-MedicalCarve out

INVEGA SUSTENNA (paliperidonepalmitate) 39 MG025 ML 78MG05 ML 117 MG075 ML 156MGML SYRG 234 MG15 ML

2-MedicalCarve out

INVEGA TRINZA (paliperidonepalmitate) 273 MG0875 ML 410MG1315 ML 546 MG175 ML 819MG2625 ML

2-MedicalCarve out

LATUDA (lurasidone hcl) 20 MGTABLET 40 MG TABLET 60 MGTABLET 80 MG TABLET 120 MGTABLET

2-MedicalCarve out

NUPLAZID (pimavanserin tartrate)10 MG TABLET 17 MG TABLET 34MG CAPSULE

2-MedicalCarve out

SP




32



olanzapine 25 mg tablet 5 mgtab rapdis 5 mg tablet 75 mgtablet 10 mg tab rapdis 10 mgtablet 10 mg vial 15 mg tabrapdis 15 mg tablet 20 mg tablet20 mg tab rapdis

2-MedicalCarve out

paliperidone 15 mg tab er 24 3mg tab er 24 6 mg tab er 24 9 mgtab er 24

2-MedicalCarve out

PERSERIS (risperidone) ER 90 MGSYRINGE KIT ER 120 MG SYRINGEKIT

2-MedicalCarve out

quetiapine fumarate 25 mg tablet50 mg tab er 24h 50 mg tablet100 mg tablet 150 mg tab er 24h200 mg tab er 24h 200 mg tablet300 mg tablet 300 mg tab er 24h400 mg tab er 24h 400 mg tablet

2-MedicalCarve out

REXULTI (brexpiprazole) 025 MGTABLET 05 MG TABLET 1 MGTABLET 2 MG TABLET 3 MG TABLET4 MG TABLET

2-MedicalCarve out

RISPERDAL (risperidone) 025 MGTABLET 05 MG TABLET 1 MGMLSOLUTION 1 MG TABLET 2 MGTABLET 3 MG TABLET 4 MG TABLET

2-MedicalCarve out

RISPERDAL CONSTA (risperidonemicrospheres) 125 MG VIAL 25MG VIAL 375 MG VIAL 50 MGVIAL

2-MedicalCarve out

RISPERDAL M-TAB (risperidone) -TAB05 G ODT -TAB 1 G ODT -TAB 2 GODT -TAB 3 G ODT -TAB 4 G ODT

2-MedicalCarve out

risperidone 025 mg tab rapdis025 mg tablet 05 mg tab rapdis05 mg tablet 1 mg tablet 1mgml solution 1 mg tab rapdis 2mg tab rapdis 2 mg tablet 3 mgtablet 3 mg tab rapdis 4 mg tabrapdis 4 mg tablet

2-MedicalCarve out

SAPHRIS (asenapine maleate) 25MG TAB 5 MG TAB 10 MG TAB

2-MedicalCarve out

SECUADO (asenapine) 38 MG24HR PATCH 57 MG24 HR PATCH76 MG24 HR PATCH

2-MedicalCarve out




33



SEROQUEL (quetiapine fumarate)25 MG TABLET 50 MG TABLET 100MG TABLET 200 MG TABLET 300MG TABLET 400 MG TABLET

2-MedicalCarve out

SEROQUEL XR (quetiapinefumarate) 50 MG TABLET 150 MGTABLET 200 MG TABLET 300 MGTABLET 400 MG TABLET

2-MedicalCarve out

VRAYLAR (cariprazine hcl) 15 MG-3 MG PACK 15 MG CAPSULE 3MG CAPSULE 45 MG CAPSULE 6MG CAPSULE

2-MedicalCarve out

ziprasidone hcl 20 mg capsule 40mg capsule 60 mg capsule 80 mgcapsule

2-MedicalCarve out

ZIPRASIDONE HCL 20 MG CAPSULE40 MG CAPSULE 60 MG CAPSULE80 MG CAPSULE

2-MedicalCarve out

ZIPRASIDONE MESYLATE 20 MGMLVIAL

2-MedicalCarve out

ziprasidone mesylate fnl 20mg1vial

2-MedicalCarve out

ZYPREXA (olanzapine) 25 MGTABLET 5 MG TABLET 75 MGTABLET 10 MG VIAL 10 MG TABLET15 MG TABLET 20 MG TABLET

2-MedicalCarve out

ZYPREXA RELPREVV (olanzapinepamoate) 210 MG VL KIT 300 MGVL KIT 405 MG VL KIT

2-MedicalCarve out

ZYPREXA ZYDIS (olanzapine) 5 MGTABLET 10 MG TABLET 15 MGTABLET 20 MG TABLET

2-MedicalCarve out

TREATMENT-RESISTANTclozapine 125 mg tab rapdis 25mg tab rapdis 25 mg tablet 50mg tablet 100 mg tablet 100 mgtab rapdis 150 mg tab rapdis 200mg tablet 200 mg tab rapdis

2-MedicalCarve out

CLOZAPINE 25 MG TABLET 50 MGTABLET 100 MG TABLET 200 MGTABLET

2-MedicalCarve out

CLOZAPINE ODT ODT 150 MGTABLET ODT 200 MG TABLET

2-MedicalCarve out




34



CLOZARIL (clozapine) 25 MGTABLET 50 MG TABLET 100 MGTABLET 200 MG TABLET

2-MedicalCarve out

FAZACLO (clozapine) 125 MGODT 25 MG ODT 100 MG ODT 150MG ODT 200 MG ODT

2-MedicalCarve out

VERSACLOZ (clozapine) 50 MGMLSUSPENSION

2-MedicalCarve out

ANTISPASTICITY AGENTS (Drugs for Muscle Spasm)baclofen 10 mg tablet 20 mgtablet


BACLOFEN 10 MG TABLET 20 MGTABLET


tizanidine hcl 2 mg tablet 4 mgtablet


ANTIVIRALS (Drugs for Viral Infections)

ANTI-HEPATITIS B (HBV) AGENTSEPIVIR HBV (lamivudine) 100 MGTABLET

2-MedicalCarve out

EPIVIR HBV (lamivudine) 25 MG5ML SOLN

1-Covered PA

lamivudine 100 mg tablet 1-Covered PA

VEMLIDY (tenofovir alafenamide)25 MG TABLET

2-MedicalCarve out

ANTI-HEPATITIS C (HCV) AGENTS DIRECT ACTING AGENTSsofosbuvirvelpatasvir 400-100 mgtablet

1-Covered PA SP

ANTI-HEPATITIS C (HCV) AGENTS OTHERINTRON A (interferon alfa-2brecomb) 10 MILLION UNITS VIL -18 MILLION UNITS VIL - 18 MILLIONUNIT3 ML - 25 MILLION UNIT25ML- 50 MILLION UNITS VIL -

1-Covered PA SP

PEGINTRON REDIPEN(peginterferon alfa-2b) 50 MCG -

1-Covered PA SP




35



ribavirin (RIBASPHERE) 200 mgtablet

1-Covered PA

ribavirin 200 mg tablet 1-Covered PA

ANTI-HIV AGENTSCIMDUO (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET

2-MedicalCarve out

EFAVIRENZ-LAMIVU-TENOFOVDISOP --600-300-300

2-MedicalCarve out

SYMFI(efavirenzlamivudinetenofovirdisoproxil fumarate) 600-300-300MG TABLET

2-MedicalCarve out

TEMIXYS (lamivudinetenofovirdisoproxil fumarate) 300-300 MGTABLET

2-MedicalCarve out

ANTI-HIV AGENTS INTEGRASE INHIBITORS (INSTI)BIKTARVY (bictegravirsodiumemtricitabinetenofoviralafenamide fumar) 50-200-25 MGTABLET

2-MedicalCarve out

GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) TABLET

2-MedicalCarve out

ISENTRESS (raltegravir potassium) 25MG TABLET CHEW 100 MG TABLETCHEW 100 MG POWDER PACKET400 MG TABLET

2-MedicalCarve out

ISENTRESS HD (raltegravirpotassium) 600 MG TABLET

2-MedicalCarve out

STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) TABLET

2-MedicalCarve out

TIVICAY (dolutegravir sodium) 10MG TABLET 25 MG TABLET 50 MGTABLET

2-MedicalCarve out

TIVICAY PD 5 MG TAB FOR SUSP 2-MedicalCarve out

VITEKTA (elvitegravir) 85 MGTABLET 150 MG TABLET

2-MedicalCarve out




36



ANTI-HIV AGENTS NON-NUCLEOSIDE REVERSE TRANSCRIPTASEINHIBITORS (NNRTI)

ATRIPLA(efavirenzemtricitabinetenofovirdisoproxil fumarate) TABLET

2-MedicalCarve out

COMPLERA(emtricitabinerilpivirinehcltenofovir disoproxil fumarate)TABLET

2-MedicalCarve out

DELSTRIGO(doravirinelamivudinetenofovirdisoproxil fumarate) 100-300-300MG TAB

2-MedicalCarve out

EDURANT (rilpivirine hcl) 25 MGTABLET

2-MedicalCarve out

efavirenz 50 mg capsule 200 mgcapsule 600 mg tablet

2-MedicalCarve out

EFAVIRENZ-EMTRIC-TENOFOVDISOP --600-200-300

2-MedicalCarve out


2-MedicalCarve out

INTELENCE (etravirine) 25 MGTABLET 100 MG TABLET 200 MGTABLET

2-MedicalCarve out

nevirapine 50 mg5 ml oral susp100 mg tab er 24h 200 mg tablet400 mg tab er 24h

2-MedicalCarve out

ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamidefumarate) TABLET

2-MedicalCarve out

PIFELTRO (doravirine) 100 MGTABLET

2-MedicalCarve out

RESCRIPTOR (delavirdine mesylate)100 MG TABLET 200 MG TABLET

2-MedicalCarve out

SUSTIVA (efavirenz) 50 MGCAPSULE 200 MG CAPSULE 600MG TABLET

2-MedicalCarve out

SYMFI LO(efavirenzlamivudinetenofovirdisoproxil fumarate) 400-300-300MG TABLET

2-MedicalCarve out




37



VIRAMUNE (nevirapine) 50 MG5ML SUSP 200 MG TABLET

2-MedicalCarve out

VIRAMUNE XR (nevirapine) 100 MGTABLET 400 MG TABLET

2-MedicalCarve out

ANTI-HIV AGENTS NUCLEOSIDE AND NUCLEOTIDE REVERSETRANSCRIPTASE INHIBITORS (NRTI)

abacavir sulfate 20 mgml solution300 mg tablet

2-MedicalCarve out

abacavir sulfatelamivudine 600-300mg tablet

2-MedicalCarve out

abacavirsulfatelamivudinezidovudineabacavirlamivudinezidovudine150-300 mg tablet

2-MedicalCarve out

ABACAVIR-LAMIVUDINE -600-300MG

2-MedicalCarve out

COMBIVIR (lamivudinezidovudine)TABLET

2-MedicalCarve out

EMTRICITABINE 200 MG CAPSULE 2-MedicalCarve out

EMTRICITABINE-TENOFOVIR DISOP -TENOFV 200-300MG

2-MedicalCarve out

EMTRIVA (emtricitabine) 10 MGMLSOLUTION 200 MG CAPSULE

2-MedicalCarve out

EPIVIR (lamivudine) 10 MGMLORAL SOLN 150 MG TABLET 300MG TABLET

2-MedicalCarve out

EPZICOM (abacavirsulfatelamivudine) TABLET

2-MedicalCarve out

lamivudine 10 mgml solution 150mg tablet 300 mg tablet

2-MedicalCarve out

lamivudinezidovudine 150-300mgtablet 150-300 mg tablet

2-MedicalCarve out

stavudine 1 mgml soln recon 15mg capsule 20 mg capsule 30 mgcapsule 40 mg capsule

2-MedicalCarve out

tenofovir disoproxil fumarate 300mg tablet

2-MedicalCarve out

TRIZIVIR (abacavirsulfatelamivudinezidovudine)TABLET

2-MedicalCarve out




38



TRUVADA (emtricitabinetenofovirdisoproxil fumarate) 100 MG-150MG TABLET 133 MG-200 MGTABLET 167 MG-250 MG TABLET200 MG-300 MG TABLET

2-MedicalCarve out

VIREAD (tenofovir disoproxilfumarate) 150 MG TABLET 200 MGTABLET 250 MG TABLET 300 MGTABLET POWDER

2-MedicalCarve out

ZERIT (stavudine) 1 MGMLSOLUTION 15 MG CAPSULE 20 MGCAPSULE 30 MG CAPSULE 40 MGCAPSULE

2-MedicalCarve out

ZIAGEN (abacavir sulfate) 20MGML SOLUTION 300 MG TABLET

2-MedicalCarve out

ANTI-HIV AGENTS OTHERDESCOVY (emtricitabinetenofoviralafenamide fumarate) 200-25 MGTABLET

2-MedicalCarve out

DOVATO (dolutegravirsodiumlamivudine) 50-300 MGTABLET

2-MedicalCarve out

FUZEON (enfuvirtide) 90 MG VIAL 2-MedicalCarve out

SP

JULUCA (dolutegravirsodiumrilpivirine hcl) 50-25 MGTABLET

2-MedicalCarve out

RUKOBIA ER 600 MG TABLET 2-MedicalCarve out

SELZENTRY (maraviroc) 20 MGMLORAL SOLN 25 MG TABLET 75 MGTABLET 150 MG TABLET 300 MGTABLET

2-MedicalCarve out

TRIUMEQ (abacavirsulfatedolutegravirsodiumlamivudine) 600-50-300 MGTABLET

2-MedicalCarve out

TROGARZO (ibalizumab-uiyk) 200MG133 ML VIAL -

2-MedicalCarve out

TYBOST (cobicistat) 150 MG TABLET 2-MedicalCarve out




39



ANTI-HIV AGENTS PROTEASE INHIBITORSAPTIVUS (tipranavir) 250 MGCAPSULE

2-MedicalCarve out

APTIVUS (tipranavirvitamin e tpgs)100 MGML SOLUTION

2-MedicalCarve out

ATAZANAVIR SULFATE 150 MG CAP200 MG CAP 300 MG CAP

2-MedicalCarve out

atazanavir sulfate 150 mg capsule200 mg capsule 300 mg capsule

2-MedicalCarve out

CRIXIVAN (indinavir sulfate) 200MG CAPSULE 400 MG CAPSULE

2-MedicalCarve out

EVOTAZ (atazanavirsulfatecobicistat) 300 MG-150 MGTABLET

2-MedicalCarve out

fosamprenavir calcium 700 mgtablet

2-MedicalCarve out

FOSAMPRENAVIR CALCIUM 700MG TABLET

2-MedicalCarve out

INVIRASE (saquinavir mesylate) 200MG CAPSULE 500 MG TABLET

2-MedicalCarve out

KALETRA (lopinavirritonavir) 80MG-20 MGML SOLN 100-25 MGTABLET 200-50 MG TABLET

2-MedicalCarve out

LEXIVA (fosamprenavir calcium) 50MGML SUSPENSION 700 MGTABLET

2-MedicalCarve out

lopinavirritonavir 400-1005solution

2-MedicalCarve out

NORVIR (ritonavir) 80 MGMLSOLUTION 100 MG TABLET 100 MGSOFTGEL CAP 100 MG POWDERPACKET

2-MedicalCarve out

PREZCOBIX (darunavirethanolatecobicistat) 800 MG-150MG TABLET

2-MedicalCarve out

PREZISTA (darunavir ethanolate) 75MG TABLET 100 MGMLSUSPENSION 150 MG TABLET 400MG TABLET 600 MG TABLET 800MG TABLET

2-MedicalCarve out




40



REYATAZ (atazanavir sulfate) 50MG POWDER PACKET 150 MGCAPSULE 200 MG CAPSULE 300MG CAPSULE

2-MedicalCarve out

ritonavir 100 mg tablet 2-MedicalCarve out

SYMTUZA (darunavirethcobicistatemtricitabinetenofovir alafenamide) 800-150-200-10MG TAB

2-MedicalCarve out

VIRACEPT (nelfinavir mesylate) 250MG TABLET 625 MG TABLET

2-MedicalCarve out

ANTI-INFLUENZA AGENTSoseltamivir phosphate 30 mgcapsule 45 mg capsule 75 mgcapsule

1-Covered QL (10 PER 30 DAY(S)) MFL (1 180 day(s))

OSELTAMIVIR PHOSPHATE 30 MGCAPSULE 45 MG CAPSULE 75 MGCAPSULE


oseltamivir phosphate 6 mgmlsusp recon


OSELTAMIVIR PHOSPHATE 6 MGMLSUSPENSION


RELENZA (zanamivir) 5 MGDISKHALER


ANTIHERPETIC AGENTSacyclovir 200 mg capsule 200mg5ml oral susp 400 mg tablet800 mg tablet

1-Covered

ACYCLOVIR 200 MG5 ML SUSP400 MG TABLET 800 MG TABLET

1-Covered

trifluridine 1 drops 1-Covered

valacyclovir hcl 500 mg tablet1000 mg tablet


ANXIOLYTICS (Drugs for Anxiety)

ANXIOLYTICS OTHER (Other Drugs for Anxiety)BUSPIRONE HCL 5 MG TABLET 10MG TABLET 15 MG TABLET 30 MGTABLET

1-Covered




41



buspirone hcl 5 mg tablet 75 mgtablet 10 mg tablet 15 mg tablet30 mg tablet

1-Covered

BENZODIAZEPINESalprazolam (ALPRAZOLAMINTENSOL) 1 mgml oral conc

1-Covered

alprazolam 025 mg tablet 05 mgtablet 1 mg tablet 2 mg tablet


clonazepam 05 mg tablet 1 mgtablet 2 mg tablet


diazepam 2 mg tablet 5 mgtablet 10 mg tablet


diazepam 5 mg5 ml solution 5mgml oral conc

1-Covered

lorazepam (LORAZEPAM INTENSOL)2 mgml oral conc

1-Covered

lorazepam 05 mg tablet 1 mgtablet 2 mg tablet


lorazepam 2 mgml oral conc 1-Covered

oxazepam 10 mg capsule 15 mgcapsule 30 mg capsule

1-Covered

BIPOLAR AGENTS (Drugs for Bipolar Disorder)

MOOD STABILIZERSlithium carbonate 150 mg capsule300 mg tablet er 300 mg capsule300 mg tablet 450 mg tablet er600 mg capsule

2-MedicalCarve out

lithium citrate 8 meq5 ml solution 2-MedicalCarve out

LITHOBID (lithium carbonate) ER300 MG TABLET

2-MedicalCarve out

BLOOD GLUCOSE REGULATORS (Drugs for Diabetes)

ANTIDIABETIC AGENTS (Drugs for High Blood Sugar)acarbose 100 mg tablet 1-Covered QL (3 PER 1 DAYS)




42



acarbose 25 mg tablet 1-Covered QL (12 PER 1 DAYS)


ADLYXIN (lixisenatide) 10-20 MCGSTARTER PACK 20 MCGMAINTENANCE PK

1-Covered PA

alogliptin benzoate 625 mg tablet125 mg tablet 25 mg tablet

1-Covered ST

alogliptin benzoatemetformin hclbenzmetformin 125-1000 tabletbenzmetformin 125-500mg tablet

1-Covered ST

alogliptin benzoatepioglitazonehcl benzpioglitazone 125-15 mgtablet benzpioglitazone 125-45mg tablet benzpioglitazone 125-30 mg tablet benzpioglitazone 25mg-30mg tabletbenzpioglitazone 25 mg-45mgtablet benzpioglitazone 25 mg-15mg tablet

1-Covered ST

AVANDIA (rosiglitazone maleate) 2MG TABLET 4 MG TABLET


glimepiride 1 mg tablet 2 mgtablet 4 mg tablet

1-Covered STAR (Preferred Drug)

glipizide 25 mg tab er 24 5 mgtablet 5 mg tab er 24 10 mg taber 24 10 mg tablet


glyburide 125 mg tablet 25 mgtablet 5 mg tablet


glyburidemetformin hcl 125-250mg tablet 25-500 mg tablet 5mg-500mg tablet


JARDIANCE (empagliflozin) 10 MGTABLET 25 MG TABLET


metformin hcl 500 mg tablet 500mg tab er 24h 750 mg tab er 24h850 mg tablet 1000 mg tablet


METFORMIN HCL ER ER 500 MGTABLET ER 750 MG TABLET


nateglinide 60 mg tablet 120 mgtablet

1-Covered ST

pioglitazone hcl 15 mg tablet 30mg tablet 45 mg tablet

1-Covered




43



PIOGLITAZONE HCL 15 MG TABLET30 MG TABLET 45 MG TABLET

1-Covered

SYNJARDY(empagliflozinmetformin hcl) 5-1000 MG TABLET


SYNJARDY(empagliflozinmetformin hcl) 5-500 MG TABLET 125-500 MGTABLET 125-1000 MG TABLET


SYNJARDY XR(empagliflozinmetformin hcl) 10-MG TABLET 125-MG TAB


SYNJARDY XR(empagliflozinmetformin hcl) 25-1000 MG TABLET



1-Covered PA QL (2 PER 1)

tolbutamide 500 mg tablet 1-Covered

TRULICITY (dulaglutide) 075MG05 ML PEN 15 MG05 ML PEN

1-Covered PA QLC (1 penweek)

TRULICITY 3 MG05 ML PEN 45MG05 ML PEN

1-Covered PA QL (05 PER 1 WEEK(S))

VICTOZA 2-PAK (liraglutide) -18MG3 ML PEN

1-Covered PA QLC (6 ml (2 pens)30 days)

VICTOZA 3-PAK (liraglutide) -18MGML PEN


GLYCEMIC AGENTS (Drugs for Low Blood Sugar)BAQSIMI (glucagon) 3 MG SPRAYTWO PACK 3 MG SPRAY ONEPACK


GLUCAGON EMERGENCY KIT(glucagon hcl) 1 MG

1-Covered

GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 1MG

1-Covered


1-Covered




44



INSULINSADMELOG (insulin lispro) 100UNITML VIAL

1-Covered

ADMELOG SOLOSTAR (insulin lispro)100 UNITML

1-Covered PA

BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinantanalog) UNITML

1-Covered

HUMALOG (insulin lispro) 100UNITML CARTRIDGE

1-Covered PA

HUMALOG MIX 75-25 (insulin lisproprotamine and insulin lispro) -VIAL (

1-Covered

HUMALOG MIX 75-25 KWIKPEN(insulin lispro protamine and insulinlispro) -(

1-Covered PA

HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) -VIAL

1-Covered

HUMULIN 7030 KWIKPEN (insulinnph human isophaneinsulinregular human)

1-Covered PA

HUMULIN N (insulin nph humanisophane) 100 UITML VIAL

1-Covered

HUMULIN R (insulin regular human)100 UNITML VIAL

1-Covered

HUMULIN R U-500 (insulin regularhuman) UNITML VIAL

1-Covered

insulin lispro 100ml insuln pen 1-Covered PA

insulin lispro 100ml vial 1-Covered

INSULIN LISPRO PROTAMINE MIX(insulin lispro protamine and insulinlispro) 75-25 KWKPN (

1-Covered PA

NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human)70-30 100 UNITML VIAL RELION 70-30 VIAL

1-Covered

NOVOLIN N (insulin nph humanisophane) N 100 UNITML VIALRELION N 100 UNITML

1-Covered

NOVOLIN R (insulin regular human)R 100 UNITML VIAL RELION R 100UNITML

1-Covered




45



BLOOD PRODUCTSMODIFIERSVOLUME EXPANDERS (Drugs forBlood Disorders)

ANTICOAGULANTS (Blood Thinners)COUMADIN (warfarin sodium) 1MG TABLET 2 MG TABLET 25 MGTABLET 3 MG TABLET 4 MG TABLET5 MG TABLET 6 MG TABLET 75 MGTABLET 10 MG TABLET

1-Covered

ELIQUIS (apixaban) 25 MG TABLET5 MG TABLET


ELIQUIS (apixaban) DVT-PE TREATSTART 5MG

1-Covered QLC (1 PACK6 MONTHS)

ENOXAPARIN SODIUM 120 MG08ML SYR

1-Covered

ENOXAPARIN SODIUM 30 MG03ML SYR 40 MG04 ML SYR 60MG06 ML SYR 80 MG08 ML SYR100 MGML SYRINGE 150 MGMLSYRINGE

1-Covered PA

enoxaparin sodium 30mg03ml40mg04ml 60mg06ml80mg08ml 100 mgml120mg8ml 150 mgml

1-Covered PA

HEPARIN SODIUM SOD 5000UNITML VIAL SOD 10000 UNITMLVL SOD 20000 UNITML VL 50000UNIT5 ML VIAL

1-Covered

heparin sodiumporcine 5000mlvial 10000ml vial 20000ml vial

1-Covered

heparin sodiumporcinepf 1000mlvial

1-Covered

warfarin sodium (JANTOVEN) 1 mgtablet 2 mg tablet 25 mg tablet3 mg tablet 4 mg tablet 5 mgtablet 6 mg tablet 75 mg tablet10 mg tablet

1-Covered

warfarin sodium 1 mg tablet 2 mgtablet 25 mg tablet 3 mg tablet4 mg tablet 5 mg tablet 6 mgtablet 75 mg tablet 10 mg tablet

1-Covered

XARELTO (rivaroxaban) 10 MGTABLET 15 MG TABLET 20 MGTABLET





46



XARELTO (rivaroxaban) DVT-PETREAT START 30D


BLOOD FORMATION MODIFIERS (Blood Formation Drugs)anagrelide hcl 05 mg capsule 1mg capsule

1-Covered

EPOGEN (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL

1-Covered PA SP

PROCRIT (epoetin alfa) 2000UNITSML VIAL 3000 UNITSMLVIAL 4000 UNITSML VIAL 10000UNITSML VIAL 20000 UNITSMLVIAL 40000 UNITSML VIAL

1-Covered PA SP

HEMOSTASIS AGENTS (Drugs to Stop Bleeding)ADVATE (antihemophilic factor(fviii) recombinantfull length) 200-400 VIAL 401-800 VIAL 801-1200VIAL 1201-1800 VIAL 1801-2400VIAL 2401-3600 VIAL 3601-4800VIAL

2-MedicalCarve out

ADYNOVATE (antihemophilicfactor (fviii) recombinant fulllength peg) 200-400 VIAL 401-800VIAL 750 VIAL 801-1250 VIAL1251-2500 VL 1500 VIAL 3000VIAL

2-MedicalCarve out

AFSTYLA (antihemophilic factor viiirecombsingle-chnb-domtruncated) 250 VIAL -- 500 VIAL --1000 VIAL -- 1500 RANGE VIAL --2000 VIAL -- 2500 RANGE VIAL --3000 VIAL --

2-MedicalCarve out

ALPHANATE (antihemophilic factorhumanvon willebrandfactorhuman) 250-100 VIALhuman) 500-200 VIAL human)1000-400 VIAL human) 1500-600VIAL human) 2000-800 VIALhuman)

2-MedicalCarve out

ALPHANINE SD (factor ix) SD 500VIAL SD 1000 VIAL SD 1500 VIAL

2-MedicalCarve out




47



ALPROLIX (factor ix recombinantfc fusion protein) 250 500 10002000 3000 4000

2-MedicalCarve out

BENEFIX (factor ix humanrecombinant) 250 500 10002000 3000

2-MedicalCarve out

COAGADEX (coagulation factor x)250 VIAL 500 VIAL

2-MedicalCarve out

CORIFACT (factor xiii) KIT 2-MedicalCarve out

ELOCTATE (antihemophilic factor(fviii) recombinant fc fusionprotein) 250 500 750 1000 15002000 3000 4000 5000 6000

2-MedicalCarve out

ESPEROCT (antihemophilic factor(fviii) rec b-dom truncated peg-exei) 500 VIAL -- 1000 VIAL --1500 VIAL -- 2000 VIAL -- 3000VIAL --

2-MedicalCarve out

FEIBA NF (anti-inhibitor coagulantcomplex) 500 (NOMINAL) - 1000(NOMINAL) - 2500 (NOMINAL) -

2-MedicalCarve out

FIBRYGA (fibrinogen) 1 GRAMRANGE VIAL

2-MedicalCarve out

HELIXATE FS (antihemophilic factor(fviii) recombinantfull length) 250UNIT VIAL 500 UNIT VIAL 1000 UNITVIAL 2000 UNIT VIAL 3000 UNITSVIAL

2-MedicalCarve out

HEMLIBRA (emicizumab-kxwh) 30MGML VIAL - 60 MG04 ML VIAL - 105 MG07 ML VIAL - 150 MGMLVIAL -

2-MedicalCarve out

HEMOFIL M (antihemophilic factorhuman) 250 500 1000 1700

2-MedicalCarve out

HUMATE-P (antihemophilic factorhumanvon willebrandfactorhuman) -600 human) -1200human) -2400 human)

2-MedicalCarve out

IDELVION (factor ixrecombinantalbumin fusionprotein) 250 VIAL 500 VIAL 1000VIAL 2000 VIAL 3500 VIAL

2-MedicalCarve out




48



IXINITY (factor ix humanrecombinant threonine 148) 500RANGE 500 VIAL 1000 VIAL 1000RANGE 1000 VIAL -2 VLS 1000RANGE-2 VLS 1500 RANGE-2 VLS1500 VIAL -2 VLS 1500 VIAL 1500RANGE

2-MedicalCarve out

JIVI (antihemophilic factor (fviii)rec b-domain deleted peg-aucl)500 VIAL -- 1000 VIAL -- 2000 VIAL-- 3000 VIAL --

2-MedicalCarve out

KCENTRA (human prothrombincomplex concentrate (pcc) 4-factor) 500 VIAL 4- 1000 VIAL 4-

2-MedicalCarve out

KOGENATE FS (antihemophilicfactor (fviii) recombinantfulllength) 250 UNIT VIAL 500 UNITVIAL 1000 UNITS VIAL 2000 UNITVIAL 3000 UNITS VIAL

2-MedicalCarve out

KOVALTRY (antihemophilic factor(fviii) recombinantfull length) 250KIT 500 KIT 1000 KIT 2000 KIT3000 KIT

2-MedicalCarve out

MONONINE (factor ix) 1000 UNITVIAL

2-MedicalCarve out

NOVOEIGHT (antihemophilic factorviii recombinant b-domaintruncated) 250 VIAL RECOMINANT- 500 VIAL RECOMINANT - 1000VIAL RECOMINANT - 1500 VIALRECOMINANT - 2000 VIALRECOMINANT - 3000 VIALRECOMINANT -

2-MedicalCarve out

NOVOSEVEN RT (coagulationfactor viia (recombinant)) 1 MGVIAL 2 MG VIAL 5 MG VIAL 8 MGVIAL

2-MedicalCarve out




49



NUWIQ (antihemophilic factor viiirec hek cell b-domain deleted)250 VIAL - 250 VIAL PACK - 500VIAL - 500 VIAL PACK - 1000 VIAL - 1000 VIAL PACK - 2000 VIALPACK - 2000 VIAL - 2500 VIALPACK - 2500 VIAL - 3000 VIAL -3000 VIAL PACK - 4000 VIAL PACK- 4000 VIAL -

2-MedicalCarve out

OBIZUR (antihemophilic factor viiirecombinant porcine sequence)500 VIAL 500 VIAL - 5 VIALS 500VIAL -10 VIALS

2-MedicalCarve out

phytonadione (vit k1) 5 mg tablet 1-Covered

PROFILNINE (factor ix complexprothrombin cplx conc(pcc) no43-factor) 500 VIAL 3- 1000 VIAL 3-1500 VIAL 3-

2-MedicalCarve out

REBINYN (factor ix (human)recombinant pegylated) 500 VIAL1000 VIAL 2000 VIAL

2-MedicalCarve out

RECOMBINATE (antihemophilicfactor viii human recombinant)220-400 VIAL 401-800 VIAL 801-1240 VL 1241-1800 V 1801-2400V

2-MedicalCarve out

RIASTAP (fibrinogen) VIAL 2-MedicalCarve out

RIXUBIS (factor ix humanrecombinant) 250 500 10002000 3000

2-MedicalCarve out

SEVENFACT 1 MG VIAL 5 MG VIAL 2-MedicalCarve out

TRETTEN (factor xiii a-subunitrecombinant) 2500 UNIT VIAL(fctor -recombinnt)

2-MedicalCarve out

VONVENDI (von willebrand factor(recombinant)) 650 VIAL 1300VIAL

2-MedicalCarve out

WILATE (antihemophilic factorhumanvon willebrandfactorhuman) 450-450 VIALhuman) 500-500 VIAL human)900-900 VIAL human) 1000-1000VIAL human)

2-MedicalCarve out




50



XYNTHA (antihemophilic factor(factor viii) recombb-domaindeleted) 250 KIT - 500 KIT - 1000KIT - 2000 KIT -

2-MedicalCarve out

XYNTHA SOLOFUSE (antihemophilicfactor (factor viii) recombb-domain deleted) 250 KIT - 500 KIT -1000 KIT - 2000 KIT - 3000 KIT -

2-MedicalCarve out

PLATELET MODIFYING AGENTScilostazol 50 mg tablet 100 mgtablet

1-Covered

clopidogrel bisulfate 75 mg tablet 1-Covered AL1 (At least 18 yrs old)

dipyridamole 25 mg tablet 50 mgtablet 75 mg tablet

1-Covered

CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation)

ALPHA-ADRENERGIC AGONISTSclonidine hcl 01 mg tablet 02 mgtablet 03 mg tablet

1-Covered

CLONIDINE HCL 01 MG TABLET 02MG TABLET 03 MG TABLET

1-Covered

guanfacine hcl 1 mg tablet 2 mgtablet

1-Covered

methyldopa 250 mg tablet 500mg tablet

1-Covered

ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate 1 mg tablet 2mg tablet 4 mg tablet 8 mgtablet

1-Covered

PHENOXYBENZAMINE HCL 10 MGCAP

1-Covered

phenoxybenzamine hcl 10 mgcapsule

1-Covered

prazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule

1-Covered

PRAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE

1-Covered




51



terazosin hcl 1 mg capsule 2 mgcapsule 5 mg capsule 10 mgcapsule

1-Covered

TERAZOSIN HCL 1 MG CAPSULE 2MG CAPSULE 5 MG CAPSULE 10MG CAPSULE

1-Covered

ANGIOTENSIN II RECEPTOR ANTAGONISTSirbesartan 75 mg tablet 150 mgtablet 300 mg tablet

1-Covered ST

LOSARTAN POTASSIUM 25 MG TAB50 MG TAB 100 MG TAB


losartan potassium 25 mg tablet50 mg tablet 100 mg tablet


valsartan 40 mg tablet 80 mgtablet 160 mg tablet 320 mgtablet

1-Covered ST

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet


captopril 125 mg tablet 25 mgtablet 50 mg tablet 100 mg tablet


CAPTOPRIL 125 MG TABLET 25 MGTABLET 50 MG TABLET 100 MGTABLET


ENALAPRIL MALEATE 25 MG TAB 5MG TABLET 10 MG TAB 20 MG TAB


enalapril maleate 25 mg tablet 5mg tablet 10 mg tablet 20 mgtablet


fosinopril sodium 10 mg tablet 20mg tablet 40 mg tablet

1-Covered

lisinopril 25 mg tablet 5 mg tablet10 mg tablet 20 mg tablet 30 mgtablet 40 mg tablet


moexipril hcl 75 mg tablet 15 mgtablet

1-Covered

quinapril hcl 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet

1-Covered

ramipril 125 mg capsule 25 mgcapsule 5 mg capsule 10 mgcapsule

1-Covered




52



RAMIPRIL 125 MG CAPSULE 25MG CAPSULE 5 MG CAPSULE 10MG CAPSULE

1-Covered

trandolapril 1 mg tablet 2 mgtablet 4 mg tablet

1-Covered

ANTIARRHYTHMICS (Drugs for Irregular Heart Rhythm)amiodarone hcl (PACERONE) 200mg tablet

1-Covered

amiodarone hcl 200 mg tablet 1-Covered

disopyramide phosphate 100 mgcapsule

1-Covered

flecainide acetate 50 mg tablet100 mg tablet 150 mg tablet

1-Covered

mexiletine hcl 150 mg capsule 200mg capsule 250 mg capsule

1-Covered

MEXILETINE HCL 150 MG CAPSULE200 MG CAPSULE 250 MGCAPSULE

1-Covered

propafenone hcl 150 mg tablet225 mg tablet 300 mg tablet

1-Covered

quinidine gluconate 324 mg tableter

1-Covered

quinidine sulfate 200 mg tablet300 mg tablet

1-Covered

SOTALOL 80 MG TABLET 120 MGTABLET 160 MG TABLET 240 MGTABLET

1-Covered

SOTALOL AF 80 MG TABLET 120 MGTABLET

1-Covered

sotalol hcl (SORINE) 80 mg tablet120 mg tablet 160 mg tablet 240mg tablet

1-Covered

sotalol hcl 80 mg tablet 120 mgtablet 160 mg tablet 240 mgtablet

1-Covered

BETA-ADRENERGIC BLOCKING AGENTSatenolol 25 mg tablet 50 mgtablet 100 mg tablet


ATENOLOL 25 MG TABLET 50 MGTABLET 100 MG TABLET





53



bisoprolol fumarate 5 mg tablet 10mg tablet

1-Covered

carvedilol 3125 mg tablet 625 mgtablet 125 mg tablet 25 mgtablet


labetalol hcl 100 mg tablet 200mg tablet 300 mg tablet

1-Covered

LABETALOL HCL 100 MG TABLET200 MG TABLET 300 MG TABLET

1-Covered

metoprolol succinate 200 mg taber 24h

1-Covered QL (60 PER 30 DAYS) MDD (2 PerDay) STAR (Preferred Drug)

metoprolol succinate 25 mg taber 50 mg tab er 100 mg tab er


METOPROLOL SUCCINATE ER 200MG TAB


METOPROLOL SUCCINATE ER 25MG TAB ER 50 MG TAB ER 100 MGTAB


metoprolol tartrate 25 mg tablet50 mg tablet 100 mg tablet


nadolol 20 mg tablet 40 mgtablet 80 mg tablet


NADOLOL 20 MG TABLET 40 MGTABLET 80 MG TABLET


pindolol 5 mg tablet 10 mg tablet 1-Covered STAR (Preferred Drug)

propranolol hcl 10 mg tablet 20mg5 ml solution 20 mg tablet 40mg tablet 40mg5ml solution 60mg tablet 60 mg cap sa 24h 80mg tablet 80 mg cap sa 24h 120mg cap sa 24h 160 mg cap sa 24h

1-Covered

CALCIUM CHANNEL BLOCKING AGENTSAMLODIPINE BESYLATE 25 MG TAB5 MG TAB 10 MG TAB


amlodipine besylate 25 mg tablet5 mg tablet 10 mg tablet


DILTIAZEM 24HR ER (CD) 24HER(CD) 120 MG CP 24H ER(CD)240 MG CP 24H ER(CD) 180 MGCP 24H ER(CD) 360 MG CP 24HER(CD) 300 MG CP

1-Covered




54



DILTIAZEM 24HR ER (XR) 24H ER(XR)240 MG CP 24H ER(XR) 180 MG CP

1-Covered

diltiazem hcl (CARTIA XT) 120 mgcap er 180 mg cap er 240 mgcap er 300 mg cap er

1-Covered

diltiazem hcl (DILT-XR) 120 mg caper - 180 mg cap er - 240 mg caper -

1-Covered

diltiazem hcl (TAZTIA XT) 120 mgcap 180 mg cap 240 mg cap 300mg cap 360 mg cap

1-Covered

diltiazem hcl 30 mg tablet 60 mgcap er 12h 60 mg tablet 90 mgtablet 90 mg cap er 12h 120 mgcap sa 24h 120 mg tablet 120 mgcap er 24h 120 mg cap er deg120 mg cap er 12h 180 mg cap sa24h 180 mg cap er deg 180 mgcap er 24h 240 mg cap er 24h 240mg cap er deg 240 mg cap sa24h 300 mg cap er 24h 300 mgcap sa 24h 360 mg cap sa 24h360 mg cap er 24h

1-Covered

felodipine 25 mg tab er 5 mg taber 10 mg tab er

1-Covered

FELODIPINE ER ER 25 MG TABLETER 5 MG TABLET ER 10 MG TABLET

1-Covered

nicardipine hcl 20 mg capsule 30mg capsule

1-Covered

nifedipine (AFEDITAB CR) 30 mgtablet er 60 mg tablet er

1-Covered

nifedipine (NIFEDICAL XL) 30 mgtab er 24 60 mg tab er 24

1-Covered

NIFEDIPINE 10 MG CAPSULE 1-Covered

nifedipine 10 mg capsule 20 mgcapsule 30 mg tablet er 30 mgtab er 24 60 mg tablet er 60 mgtab er 24 90 mg tablet er 90 mgtab er 24

1-Covered

nisoldipine 20 mg tab er 30 mgtab er 40 mg tab er

1-Covered

verapamil hcl 40 mg tablet 80 mgtablet 120 mg tablet 120 mgtablet er 180 mg tablet er 240 mgtablet er

1-Covered




55



CARDIOVASCULAR AGENTS OTHERamiloride hclhydrochlorothiazideamiloridehydrochlorothiazide 5mg-50 mg tablet

1-Covered

amlodipine besylatebenazeprilhcl 25mg-10mg capsule 5 mg-20mg capsule 5 mg-10 mg capsule5 mg-40 mg capsule 10 mg-20mgcapsule 10 mg-40mg capsule

1-Covered QL (30 PER 30 DAYS) AL1 (At least18 yrs old) MDD (1 Per Day) STAR(Preferred Drug)

atenololchlorthalidone 50 mg-tablet 100mg-tablet


benazepril hclhydrochlorothiazidebenazeprilhydrochlorothiazide 5-625mg tabletbenazeprilhydrochlorothiazide 10-125mg tabletbenazeprilhydrochlorothiazide 20mg-25mg tabletbenazeprilhydrochlorothiazide 20-125 mg tablet


bisoprololfumaratehydrochlorothiazidebisoprololhydrochlorothiazide 25-tabletbisoprololhydrochlorothiazide 5-tabletbisoprololhydrochlorothiazide 10-tablet

1-Covered

BISOPROLOL-HYDROCHLOROTHIAZIDE -10-625MG TAB -25-625 MG TB -5-625MG TAB

1-Covered

captoprilhydrochlorothiazide 25mg-25mg tablet 25 mg-15mgtablet 50 mg-25mg tablet 50 mg-15mg tablet


digoxin (DIGITEK) 125 mcg tablet250 mcg tablet


digoxin (DIGOX) 125 mcg tablet250 mcg tablet


digoxin 125 mcg tablet 250 mcgtablet


digoxin 50 mcgml solution 1-Covered




56



fosinoprilsodiumhydrochlorothiazidefosinoprilhydrochlorothiazide 10-125mg tabletfosinoprilhydrochlorothiazide 20-125 mg tablet

1-Covered

FOSINOPRIL-HYDROCHLOROTHIAZIDE -10-125MG TAB -20-125 MG TAB

1-Covered

irbesartanhydrochlorothiazide150-tablet 300-tablet

1-Covered ST

LANOXIN (digoxin) 125 MCGTABLET 250 MCG TABLET


lisinoprilhydrochlorothiazide 10-125mg tablet 20-125 mg tablet20 mg-25mg tablet


losartanpotassiumhydrochlorothiazidelosartanhydrochlorothiazide 50-125 mg tabletlosartanhydrochlorothiazide100mg-25mg tabletlosartanhydrochlorothiazide 100-125mg tablet


LOSARTAN-HYDROCHLOROTHIAZIDE -50-125MG TAB -100-125 MG TAB -100-25MG TAB


pentoxifylline 400 mg tablet er 1-Covered

spironolactonehydrochlorothiazide spironolacthydrochlorothiazid25 mg-25mg tablet

1-Covered

triamterenehydrochlorothiazide375-25 mg capsule 375-25 mgtablet 50 mg-25mg capsule 75mg-50mg tablet

1-Covered

valsartanhydrochlorothiazide 80-125mg tablet 160-125mg tablet160mg-25mg tablet 320-125mgtablet 320mg-25mg tablet

1-Covered ST

DIURETICS CARBONIC ANHYDRASE INHIBITORSacetazolamide 125 mg tablet 250mg tablet

1-Covered




57



ACETAZOLAMIDE 125 MG TABLET250 MG TABLET

1-Covered

DIURETICS LOOPbumetanide 05 mg tablet 1 mgtablet 2 mg tablet

1-Covered

furosemide 10 mgml solution 20mg tablet 40mg5ml solution 40mg tablet 80 mg tablet


DIURETICS POTASSIUM-SPARINGamiloride hcl 5 mg tablet 1-Covered

spironolactone 25 mg tablet 50mg tablet 100 mg tablet

1-Covered

SPIRONOLACTONE 25 MG TABLET50 MG TABLET 100 MG TABLET

1-Covered

DIURETICS THIAZIDEchlorothiazide 250 mg tablet 500mg tablet

1-Covered

chlorthalidone 25 mg tablet 50 mgtablet

1-Covered

CHLORTHALIDONE 25 MG TABLET50 MG TABLET

1-Covered

DIURIL (chlorothiazide) 250 MG5ML ORAL SUSP

1-Covered

hydrochlorothiazide 125 mgcapsule 25 mg tablet 50 mgtablet


indapamide 125 mg tablet 25mg tablet

1-Covered

methyclothiazide 5 mg tablet 1-Covered

metolazone 25 mg tablet 5 mgtablet 10 mg tablet

1-Covered

DYSLIPIDEMICS FIBRIC ACID DERIVATIVES (Drugs for HighCholesterol)

fenofibrate 54 mg tablet 160 mgtablet

1-Covered ST

FENOFIBRATE 54 MG TABLET 160MG TABLET

1-Covered ST




58



fenofibratemicronized 67 mgcapsule 134 mg capsule 200 mgcapsule

1-Covered ST

gemfibrozil 600 mg tablet 1-Covered

GEMFIBROZIL 600 MG TABLET 1-Covered

TRIGLIDE (fenofibratenanocrystallized) 160 MG TABLET

1-Covered ST

DYSLIPIDEMICS HMG COA REDUCTASE INHIBITORS (Drugs for HighCholesterol)

atorvastatin calcium 10 mg tablet20 mg tablet 40 mg tablet 80 mgtablet


ATORVASTATIN CALCIUM 10 MGTABLET 20 MG TABLET 40 MGTABLET 80 MG TABLET


lovastatin 10 mg tablet 20 mgtablet 40 mg tablet


rosuvastatin calcium 5 mg tablet10 mg tablet 20 mg tablet 40 mgtablet

1-Covered ST QL (30 PER 30 DAY(S))

simvastatin 5 mg tablet 10 mgtablet 20 mg tablet 40 mg tablet


DYSLIPIDEMICS OTHER (Other Drugs for High Cholesterol)cholestyramine (with sugar) suar) 4powder

1-Covered

cholestyramineaspartame(PREVALITE) 4 g powder

1-Covered

cholestyramineaspartame 4 gpowder

1-Covered

COLESTID (colestipol hcl)FLAVORED GRANULES

1-Covered

colestipol hcl 1 tablet 5 ranules 5packet

1-Covered

ezetimibe 10 mg tablet 1-Covered

niacin (ENDUR-ACIN) 250 mgtablet er - 500 mg tablet er - 750mg tablet er -

1-Covered

niacin (SLO-NIACIN) 500 mg tableter -

1-Covered




59



NIACIN 100 MG TABLET TR 500 MGTABLET

1-Covered

niacin 50 mg tablet 100 mg tablet250 mg capsule er 250 mg tablet250 mg tablet er 500 mg tablet500 mg tablet er 500 mg tab er24h 500 mg capsule er 750 mgtablet er 1000 mg tablet er

1-Covered

OMEGA-3 ACID ETHYL ESTERS -1GM CAP


omega-3 acid ethyl esters omea-1capsule


VASODILATORS DIRECT-ACTING ARTERIAL (Drugs for RelaxingArteries)

hydralazine hcl 10 mg tablet 25mg tablet 50 mg tablet 100 mgtablet

1-Covered

minoxidil 25 mg tablet 10 mgtablet

1-Covered

VASODILATORS DIRECT-ACTING ARTERIALVENOUS (Drugs forRelaxing Arteries and Veins)

ISOSORBIDE DINITRATE 5 MG TAB10 MG TAB 20 MG TAB 30 MG TAB


isosorbide dinitrate 5 mg tablet 10mg tablet 20 mg tablet 30 mgtablet 40 mg tablet er


isosorbide mononitrate 10 mgtablet 20 mg tablet 30 mg tab er24h 60 mg tab er 24h 120 mg taber 24h


NITRO-BID (nitroglycerin) -2OINTMENT

1-Covered

nitroglycerin (MINITRAN) 01mghrpatch 02mghr patch 04mghrpatch 06mghr patch

1-Covered

nitroglycerin (NITRO-TIME) 25 mgcapsule er - 65 mg capsule er - 9mg capsule er -

1-Covered




60



nitroglycerin 01mghr patch td2402mghr patch td24 03 mg tabsubl 04mghr patch td24 04 mgtab subl 06 mg tab subl 06mghrpatch td24 25 mg capsule er 65mg capsule er 9 mg capsule er400mcgspr spray

1-Covered

NITROGLYCERIN 400 MCG SPRAY 1-Covered

CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions)

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTSAMPHETAMINES

dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 15 mg cap er 24h

1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old) MDD (1 Per Day)

dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg cap erdextroamphetamineamphetamine 10 mg cap erdextroamphetamineamphetamine 20 mg cap erdextroamphetamineamphetamine 25 mg cap erdextroamphetamineamphetamine 30 mg cap er

1-Covered QL (30 PER 30 DAYS) AL1 (6 to 18yrs old)

dextroamphetamine sulf-saccharateamphetamine sulf-aspartatedextroamphetamineamphetamine 5 mg tabletdextroamphetamineamphetamine 75 mg tabletdextroamphetamineamphetamine 10 mg tabletdextroamphetamineamphetamine 125 mg tabletdextroamphetamineamphetamine 15 mg tabletdextroamphetamineamphetamine 20 mg tabletdextroamphetamineamphetamine 30 mg tablet

1-Covered AL1 (3 to 18 yrs old)




61



dextroamphetamine sulfate(ZENZEDI) 5 mg tablet 10 mgtablet


dextroamphetamine sulfate 5 mgcapsule er 5 mg tablet 10 mgcapsule er 10 mg tablet 15 mgcapsule er


DEXTROAMPHETAMINE SULFATE 5MG TAB 10 MG TAB


DEXTROAMPHETAMINE-AMPHET ER-15 MG CAP


DEXTROAMPHETAMINE-AMPHET ER-ER 5 MG CAP -ER 10 MG CAP -ER20 MG CAP -ER 25 MG CAP -ER 30MG CAP


ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS NON-AMPHETAMINES

atomoxetine hcl 10 mg capsule 18mg capsule 25 mg capsule 40 mgcapsule 60 mg capsule 80 mgcapsule 100 mg capsule

1-Covered PA

guanfacine hcl 1 mg tab er 2 mgtab er 3 mg tab er 4 mg tab er


METHYLPHENIDATE ER ER 18 MGTAB ER 27 MG TAB ER 36 MG TABER 54 MG TAB

1-Covered ST QL (30 PER 30 DAYS) AL1 (6 to18 yrs old) MDD (1 Per Day)

methylphenidate hcl (METADATEER) 20 mg tablet er


methylphenidate hcl 10 mg tableter 18 mg tab er 24 20 mg tableter 27 mg tab er 24 36 mg tab er24 54 mg tab er 24


methylphenidate hcl 5 mg tablet10 mg cpbp 30-70 10 mg tablet20 mg tablet 20 mg cpbp 30-7030 mg cpbp 30-70 40 mg cpbp 30-70 50 mg cpbp 30-70 60 mg cpbp30-70


METHYLPHENIDATE HCL 5 MGTABLET 10 MG TABLET 20 MGTABLET





62



CENTRAL NERVOUS SYSTEM OTHERacetaminophen (ATHENOL) 325mg tablet


acetaminophen (CHILD FEVERREDUCER) 120 mg supprect

1-Covered

acetaminophen (CHILD PAIN REL-FEVER REDUCER) 120 mg supprect-

1-Covered

acetaminophen (CHILDRENSFEVER REDUCER) 120 mg supprect

1-Covered

acetaminophen (CHILDRENSFEVER REDUCING) 120 mgsupprect

1-Covered

acetaminophen (CHILDRENS PAINAND FEVER) 160 mg5ml liquid


acetaminophen (CHILDRENSSILAPAP) 160 mg5ml liquid


acetaminophen (ED-APAP) 160mg5ml liquid -


acetaminophen (LITTLE REMEDIESFEVER-PAIN) 160 mg5ml liquid -


acetaminophen (M-PAP) 160mg5ml liquid -


acetaminophen (MAPAP) 160mg5ml liquid


acetaminophen (MAPAP) 325 mgtablet 500 mg tablet


acetaminophen (MASOPHEN) 325mg tablet 500 mg tablet


acetaminophen (NON-ASPIRINEXTRA STRENGTH) 500 mg tablet -


acetaminophen (NON-ASPIRINPAIN RELIEF) 500 mg tablet -


acetaminophen (NON-ASPIRIN)160 mg5ml elixir -

1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)

acetaminophen (NON-ASPIRIN)325 mg tablet -


acetaminophen (PAIN amp FEVER)500 mg tablet





63



acetaminophen (PAIN RELIEFEXTRA STRENGTH) 500 mg tablet


acetaminophen (PAIN RELIEF) 160mg5ml liquid


acetaminophen (PAIN RELIEF) 325mg tablet 500 mg tablet


acetaminophen (PAIN RELIEVER)325 mg tablet 500 mg tablet


acetaminophen (PHARBETOL) 325mg tablet 500 mg tablet


acetaminophen (SHAKE THATACHE) 500 mg tablet


acetaminophen (TACTINAL) 325mg tablet 500 mg tablet


acetaminophen 120 mg 650 mg 1-Covered

acetaminophen 160 mg5ml elixir 1-Covered QLC (LIMIT TO 2 FILLS OF 120ML IN30 DAYS)

acetaminophen 160 mg5ml liquid 1-Covered QL (120 PER FILL(S)) QLC (LIMIT TO2 FILLS OF 120ML IN 30 DAYS)

acetaminophen 160 mg5ml oralsusp


acetaminophen 160 mg5mlsolution


acetaminophen 325 mg tablet500 mg tablet


ACETAMINOPHEN CVS 325 MGGELCP 325 MG TABLET 500 MGTABLET 500 MG GELCAP


butalbitalacetaminophen(TENCON) 50mg-325mg tablet


butalbitalacetaminophen 50mg-325mg tablet


butalbitalacetaminophencaffeine butalbacetaminophencaffeine50-325-40 tablet


PAIN amp FEVER (acetaminophen)500 MG TABLET


PAIN RELIEF 325 MG TABLET 500MG GELCAP 500 MG TABLET





64



riluzole 50 mg tablet 1-Covered PA

RILUZOLE 50 MG TABLET 1-Covered PA

FIBROMYALGIA AGENTSduloxetine hcl 20 mg capsule dr30 mg capsule dr 60 mg capsuledr

1-Covered

pregabalin 20 mgml solution 1-Covered PA QLC (30 MLDAY)

pregabalin 225 mg capsule 300mg capsule


PREGABALIN 225 MG CAPSULE 300MG CAPSULE


pregabalin 25 mg capsule 50 mgcapsule 75 mg capsule 100 mgcapsule 150 mg capsule 200 mgcapsule


PREGABALIN 25 MG CAPSULE 50MG CAPSULE 75 MG CAPSULE 100MG CAPSULE 150 MG CAPSULE200 MG CAPSULE


SAVELLA (milnacipran hcl) 125 MGTABLET 25 MG TABLET 50 MGTABLET 100 MG TABLET TITRATIONPACK

1-Covered PA

MULTIPLE SCLEROSIS AGENTSAVONEX (interferon beta-1a)PREFILLED SYR 30 MCG KT -

1-Covered PA SP

AVONEX (interferon beta-1aalbumin human) 30 MCG VIALKIT -

1-Covered PA SP

AVONEX PEN (interferon beta-1a)30 MCG05 ML KIT -

1-Covered PA SP

DIMETHYL FUMARATE 30D START PK 1-Covered PA SP

DIMETHYL FUMARATE DR 120 MGCP DR 240 MG CP


glatiramer acetate (GLATOPA) 20mgml syringe

1-Covered PA SP QLC (1 SYRINGEDAY)


1-Covered PA SP QLC (12SYRINGESMONTH)

glatiramer acetate 20 mgmlsyringe





65





PLEGRIDY (peginterferon beta-1a)125 MCG05 ML SYRING - SYRINGESTARTER PACK -

1-Covered PA SP

PLEGRIDY PEN (peginterferon beta-1a) 125 MCG05 ML PEN - PEN INJSTARTER PACK -

1-Covered PA SP

TECFIDERA (dimethyl fumarate) DR120 MG CAPSULE DR 240 MGCAPSULE STARTER PACK

1-Covered PA SP

DENTAL AND ORAL AGENTS (Drugs for the Mouth)

DENTAL AND ORAL AGENTSchlorhexidine gluconate (PAROEX)012 mouthwash

1-Covered

chlorhexidine gluconate 012 mouthwash

1-Covered

PHOS-FLUR (fluoride (sodium)) -ORAL RINSE

1-Covered

triamcinolone acetonide(ORALONE) 01 paste (g)

1-Covered

triamcinolone acetonide 01 paste (g)

1-Covered

TRIAMCINOLONE ACETONIDE 01PASTE

1-Covered

DERMATOLOGICAL AGENTS (Drugs for the Skin)ACNE MEDICATION (benzoylperoxide) 5 GEL

1-Covered

ACNE MEDICATION 25 GEL 1-Covered

ammonium lactate (SKINTREATMENT) 12 lotion

1-Covered

ammonium lactate 12 cream(g) 12 lotion

1-Covered

benzoyl peroxide (ACNE CONTROLCLEANSER) 10 cleanser

1-Covered

benzoyl peroxide (ACNE FOAMINGWASH) 10 cleanser

1-Covered




66



benzoyl peroxide (ACNETREATMENT) 10 gel (gram)

1-Covered

benzoyl peroxide (ACNECLEAR) 10 gel (gram)

1-Covered

benzoyl peroxide (ADVANCEDEXFOLIATING CLEANSER) 5 cleanser

1-Covered

benzoyl peroxide (BP WASH) 5 10

1-Covered

benzoyl peroxide (BP) 5 gel(gram) 10 gel (gram)

1-Covered

benzoyl peroxide (BPO-10) cleanser -

1-Covered

benzoyl peroxide (BPO-5) cleanser -)

1-Covered

benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 10 cleanser -

1-Covered

benzoyl peroxide (DAYLOGICACNE FOAMING WASH) 10 cleanser

1-Covered

benzoyl peroxide (DAYLOGICACNE TREATMENT) 10 gel (gram)

1-Covered

benzoyl peroxide (FOAMING ACNEFACE WASH) 10 cleanser

1-Covered

benzoyl peroxide (PANOXYL) 10 cleanser

1-Covered

benzoyl peroxide 25 gel (gram)5 cleanser 5 gel (gram) 10 gel (gram) 10 cleanser

1-Covered

CALADRYL (pramoxinehclcalamine) 1-8 LOTION

1-Covered

calcipotriene 0005 cream (g)0005 oint (g) 0005 solution

1-Covered PA

chlorhexidine gluconate 4 liquid 1-Covered

CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) OINTMENT

1-Covered

DIFFERIN (adapalene) 01 GEL 1-Covered AL1 (Up to 25 yrs old)

DRITHOCREME HP (anthralin) 1CREAM

1-Covered




67



DRYSOL (aluminum chloride) DAB--MATIC SLUTIN

1-Covered

EPIFOAM (hydrocortisoneacetatepramoxine hcl)

1-Covered

hydrocortisoneacetatepramoxine hclhydrocortisonepramoxine 1 -1 creamapplhydrocortisonepramoxine 25 -1 cream (g)hydrocortisonepramoxine 25 -1 creamapplhydrocortisonepramoxine 25-1(4g) creamappl

1-Covered

isotretinoin (AMNESTEEM) 10 mgcapsule 20 mg capsule 40 mgcapsule

1-Covered PA

isotretinoin (CLARAVIS) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule

1-Covered PA

isotretinoin (MYORISAN) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule

1-Covered PA

isotretinoin (ZENATANE) 10 mgcapsule 20 mg capsule 30 mgcapsule 40 mg capsule

1-Covered PA

isotretinoin 10 mg capsule 20 mgcapsule 30 mg capsule 40 mgcapsule

1-Covered PA

LICE KILLING SHAMPOO 1-Covered

metronidazole 075 cream (g)075 gel (gram) 1 gel (gram)

1-Covered

pimecrolimus 1 cream (g) 1-Covered PA

piperonyl butoxidepyrethrins (LICEKILLING) 4-033 shampoo

1-Covered

piperonyl butoxidepyrethrins (LICEPYRINYL SHAMPOO) 4-033shampoo

1-Covered

piperonyl butoxidepyrethrins (LICETREATMENT) 4-033 shampoo

1-Covered

piperonyl butoxidepyrethrins (RID)4-033 shampoo

1-Covered




68



piperonylbutoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT)butoxpyrethrpermet 4-33-5 kit

1-Covered

piperonylbutoxidepyrethrinspermethrin(LICE SOLUTION)butoxpyrethrpermet 4-33-5 kit

1-Covered

podofilox 05 solution 1-Covered

pramoxine hclcalamine(CALAHIST) 1 -8 lotion

1-Covered

pramoxine hclcalamine(CALAMINE MEDICATED) 1 -8 lotion

1-Covered

PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) PROCTO-1-1

1-Covered

RID (piperonylbutoxidepyrethrinspermethrin) 1-2-3 KIT KIT

1-Covered

SANTYL (collagenase clostridiumhistolyticum) OINTMENT


selenium sulfide (ANTI-DANDRUFF)1 shampoo -

1-Covered

selenium sulfide (MEDICATEDDANDRUFF SHAMPOO) 1 shampoo

1-Covered

selenium sulfide (SELSUN BLUE) 1 shampoo

1-Covered

selenium sulfide 25 lotion 1-Covered

selenium sulfidealoe vera (SELSUNBLUE MOISTURIZING) 1 shampoo

1-Covered

tacrolimus 003 (g) 01 (g) 1-Covered PA

ELECTROLYTESMINERALSMETALSVITAMINS

ELECTROLYTEMINERAL REPLACEMENT09 sodium chloride iv soln 1-Covered PA

calcium carbonate 600 mg tablet 1-Covered

dextrose 5 in water in iv soln 1-Covered PA




69



levocarnitine 330 mg tablet 1-Covered

potassium chloride in 09 sodiumchloride 09nacl 10 meql iv soln

1-Covered PA

ringers solution iv soln 1-Covered

sodium chloride irrigating solution09 soln

1-Covered

ELECTROLYTEMINERALMETAL MODIFIERSCHEMET (succimer) 100 MGCAPSULE

1-Covered PA

09 sodium chloride iv soln 1-Covered PA

CLINIMIX (amino acids 425 indextrose 5 in water) -SOLUTION

1-Covered PA

dextrose 10 and 045 sodiumchloride nacl -iv soln

1-Covered PA

dextrose 10 in water 10 10 dehp fr bg 10 10 iv soln

1-Covered PA

dextrose 5 and 045 sodiumchloride -04chlord -04iv soln

1-Covered PA

dextrose 5 in water 5 5 ivsoln 5 5 vial

1-Covered PA

levocarnitine (with sugar) 100mgml solution

1-Covered

levocarnitine 100 mgml solution330 mg tablet

1-Covered

MYNATAL (prenatal vitamins withcalciumferrous fumaratefolicacid) CAPSULE

1-Covered

O-CAL PRENATAL (prenatal vit withcalcium no127ferrousfumaratefolic acid) -TABLET

1-Covered

potassium chloride (KLOR-CONM10) meq tab er prt -

1-Covered


1-Covered

potassium chloride 8 meq tableter 10 meq tablet er 10 meqcapsule er 10 meq tab er prt 20meq tablet er 20 meq tab er prt20meq15ml liquid

1-Covered




70



POTASSIUM CHLORIDE ER 8 MEQTABLET 10 (20 MEQ15ML) 10(40 MEQ30ML) ER 10 MEQ TABLETER 20 MEQ TABLET

1-Covered

potassium chloride in 09 sodiumchloride 20 meql soln 40 meqlsoln

1-Covered PA

PRENATABS FA (prenatal vits withcalcium no78ferrousfumaratefolic acid) TABLET

1-Covered

PRENATABS RX (prenatal vitaminwith calciumno76ironcarbonylfolic acid)TABLET

1-Covered

prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL PLUS) vitironfumfolic 65 mg-1 mg tablet

1-Covered

prenatal vitamins withcalciumferrous fumaratefolicacid (MYNATAL-Z) vitiron fumfolic65 mg-1 mg tablet -

1-Covered

prenatal vits with calcium118ferrous fumaratefolic acid (SE-NATAL 19) pnv no8ironfumaratefa 29 mg-mg tab chew -9)

1-Covered

prenatal vits with calcium136ferrous fumaratefolic acid(VINATE-M) vit36ironfolic acd 27mg-mg tablet -

1-Covered

prenatal vits with calciumno115iron fumaratefolic acidno5ironfolic 29 mg-mg tab chew

1-Covered

prenatal vits with calciumno72ferrous fumaratefolic acid(M-NATAL PLUS) pnvcalcium72ironfolic 27 mg-1 mg tablet -

1-Covered

prenatal vits with calciumno72ferrous fumaratefolic acid(PREPLUS) pnvcalcium 72ironfolic27 mg-1 mg tablet

1-Covered

prenatal vits with calciumno72ferrous fumaratefolic acidpnvcalcium 72ironfolic 27 mg-1mg tablet

1-Covered




71



prenatal vits with calciumno72ironcarbonylfolic acidpnvcalcium 72ironcarbfolic 29mg-1 mg tablet

1-Covered

prenatal vits with calciumno74ferrous fumaratefolic acidvitcal 74ironfolic 27 mg-1 mgtablet

1-Covered

SE-NATAL-19 (prenatal vitaminsno119iron fumaratefolic acid) --TABLET

1-Covered


1-Covered

sodium polystyrene sulfonate 15g60 ml oral susp

1-Covered

sodium polystyrenesulfonatesorbitol solution (KIONEX)sulfonsorb 15 g60 ml oral susp

1-Covered

SPS (sodium polystyrenesulfonatesorbitol solution) 15GM60 ML SUSPENSION

1-Covered

TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid)TABLET

1-Covered

VITAMINS09 sodium chloride iv soln 1-Covered PA

ascorbate calcium 500 mg tablet 1-Covered

ascorbic acid (SOOTHINGPUREWAY-C) 500 mg tablet -

1-Covered

ascorbic acid 250 mg tablet 500mg5ml syrup 500 mg tablet 1000mg tablet

1-Covered

CALCIUM 500-VIT D3 MG-MCG TB 1-Covered

CALCIUM 600 MG TABLET 1-Covered

CALCIUM 600-VIT D3 MG-10MCGTB

1-Covered

calcium carbonate (OYSCO-500)500(1250) tablet -

1-Covered

calcium carbonate (SUPERCALCIUM) 600 mg tablet

1-Covered




72



calcium carbonate 500(1250)tablet 600 mg tablet

1-Covered

calciumcarbonatecholecalciferol(vitamin d3) (HI-CAL)carbonatevitamin 500 mg-200tablet -

1-Covered

calciumcarbonatecholecalciferol(vitamin d3) (OS-CAL 500-VIT D3)carbonatevitamin mg-200 tablet --

1-Covered

calciumcarbonatecholecalciferol(vitamin d3) (OYSCO 500-VIT D3)carbonatevitamin mg-200 tablet -

1-Covered

calciumcarbonatecholecalciferol(vitamin d3) (OYSTERCAL-D)carbonatevitamin 500 mg-400tablet -

1-Covered

calciumcarbonatecholecalciferol(vitamin d3) carbonatevitamin250 mg-125 tabletcarbonatevitamin 500 mg-600tablet carbonatevitamin 500 mg-400 tablet carbonatevitamin 500mg-200 tablet carbonatevitamin600 mg-400 tablet

1-Covered

calcium gluconate 60(650) mgtablet

1-Covered

calcium lactate 84 mg(648) tablet 1-Covered

cyanocobalamin (vitamin b-12) (B-12 DOTS) cyanocoalamin -) 500mcg talet -

1-Covered

cyanocobalamin (vitamin b-12)cyanocoalamin -500 mcg talet

1-Covered

dextrose 10 in water iv soln 1-Covered PA


1-Covered PA

dextrose 5 in lactated ringers -ivsoln

1-Covered PA





73



DEXTROSE IN WATER 5-IV SOLN10-IV SOLUTION

1-Covered PA

electrolytesdextrose(ELECTROLYTE) solution

1-Covered QL (2 PER FILL(S)) AL1 (Up to 3 yrsold) MFL (4 30 day(s))

electrolytesdextrose (ORALYTE)solution


electrolytesdextrose (PEDIATRICELECTROLYTE) solution


electrolytesdextrose (PEDIATRICFREEZER POPS) solution


ferrous sulfate (CHILDRENS IRON)15 mgml drops

1-Covered

ferrous sulfate (FEOSOL) 325(65)mg tablet

1-Covered

ferrous sulfate (FEROSUL) 325(65)mg tablet

1-Covered

ferrous sulfate (FERRO-TIME) 325(65)mg tablet -

1-Covered

ferrous sulfate (FERROUSUL) 325(65)mg tablet

1-Covered

ferrous sulfate (PEDIA IRON) 15mgml drops

1-Covered

ferrous sulfate 15 mgml drops 220(44)5 solution 220 (44)5 elixir324(65)mg tablet dr 325(65) mgtablet dr 325(65) mg tablet

1-Covered

FERROUS SULFATE SULF 220 MG5ML LIQ SULF EC 325 MG TABLETSULFATE 325 MG TABLET

1-Covered

fluoride (sodium) 025(055) tabchew 05(11)mg tab chew 05mgml drops 1mg(22mg) tabchew


folic acid 04 mg tablet 08 mgtablet 1 mg tablet 20 mg capsule

1-Covered

FOLIC ACID 400 MCG TABLET 800MCG TABLET

1-Covered

IRON 65 MG TABLET 1-Covered

OYSTER SHELL CALCIUM 500 MG TB 1-Covered

OYSTER SHELL CALCIUM-VIT D3 250MG-312MCG

1-Covered




74



PEDIATRIC IRON PHARM CHC15MGML DRP

1-Covered

pediatric multivit with acd3no21sodium fluorideno21fluoride 025 mgml dropsno21fluoride 05 mgml drops


pediatric multivitaminno16sodium fluoride -025 mg tabche -05 mg tab che -1 mg tabche

1-Covered

pediatric multivitamin no2sodiumfluoride w-025 mgml drops

1-Covered



pediatric multivitaminno45sodium fluorideferroussulfate 45fluorideiron 025-10mldrops


pediatric multivitamins no17 withsodium fluoride -025 mg tab che -05 mg tab che -1 mg tab che


POLY-VITAMIN (multivitamin) -TABCHEW


POTASSIUM 99 MG TABLET 1-Covered

potassium bicarbonatecitric acid(EFFER-K) 25 meq tablet eff -

1-Covered

potassium bicarbonatecitric acid(K EFFERVESCENT) 25 meq tableteff

1-Covered

potassium bicarbonatecitric acid(KLOR-CON-EF) 25 meq tablet eff --

1-Covered

potassium bicarbonatecitric acid25 meq tablet eff

1-Covered

POTASSIUM CHL-NORMAL SALINE20 -ML IV SOLN 40 -ML IV SOLN

1-Covered

potassium chloride (KLOR-CONSPRINKLE) 10 meq capsule er -

1-Covered

potassium chloride 20meq15mlliquid

1-Covered

potassium chloridepotassiumbicarbonatecitric acidchloridebicarbcit 25 meq tableteff

1-Covered




75



potassium gluconate 595(99)mgtablet

1-Covered

PRENATAL MULTIVITAMIN TABLET 1-Covered

prenatal vit with calciumno129ferrous fumaratefolic acidno129ironfolic 27mg-08mgtablet

1-Covered



prenatal vitamins no121ferrousfumaratefolic acid pnvno121ironfolic 28mg-08mgtablet

1-Covered

prenatal vitamins withcalciumferrous fumaratefolicacid vitiron fumfolic 27mg-08mgtablet



1-Covered

prenatal vits with calcium118ferrous fumaratefolic acidpnv no8iron fumaratefa 29 mg-mg tab chew

1-Covered

prenatal vits with calcium137ferrous fumaratefolic acidno137ironfolic acd 27mg-08mgtablet


prenatal vits with calcium95ferrous fumaratefolic acid pnvno95ferrous fumfolic 28mg-08mg tablet

1-Covered

prenatal vits with calciumno96ferrous fumaratefolic acidvits96iron fumfolic 27mg-08mgtablet

1-Covered

pyridoxine hcl (vitamin b6) 25 mgtablet 50 mg tablet 100 mgtablet 250 mg tablet

1-Covered

ringers solution iv soln 1-Covered PA

SODIUM CHLORIDE 09 IRRIG 1-Covered




76



SODIUM CHLORIDE 09 SOLUTION 1-Covered PA

sodium chloride irrigating solution(AQUA CARE SODIUM CHLORIDE)09 soln

1-Covered

sodium chloride irrigating solution(CURITY) 09 soln

1-Covered


1-Covered

TRI-VI-SOL (vitamin apalmitateascorbicacidcholecalciferol (vit d3)) --DROPS (vitmin plmittescorbiccidcholeclciferol


VITAMIN B-12 -500 MCG TALET 1-Covered

VITAMIN C 1000 MG TABLET 1-Covered

GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach)

ANTISPASMODICS GASTROINTESTINAL (Drugs to Prevent Bowel andStomach Spasam)

CHLORDIAZEPOXIDE-CLIDINIUM -CAP

1-Covered MDD (8 Per Day)

chlordiazepoxideclidiniumbromide 5 mg-25mg capsule


DICYCLOMINE HCL 10 MG5 MLSOLN

1-Covered

dicyclomine hcl 10 mg5 mlsolution 10 mg capsule 20 mgtablet

1-Covered

hyoscyamine sulfate (HYOSYNE)0125mgml drops 125mcg5mlelixir

1-Covered

hyoscyamine sulfate 0125 mg tabsubl 0125 mg tablet 0125mgmldrops 0375 mg tab er 12h125mcg5ml elixir

1-Covered

propantheline bromide 15 mgtablet

1-Covered




77



GASTROINTESTINAL AGENTS OTHER (Other Drugs for the Bowel andStomach)

ALLI (orlistat) 60 MG CAPSULE 1-Covered PA

ANTACID 500 MG CHEW TABLET 1-Covered

ANTACID EXTRA STRENGTH -750 MGTAB CHEW CVS -750 MG CHEW

1-Covered

ANTI-DIARRHEAL HM -2 MGSOFTGEL

1-Covered

bismuth subsalicylate (BISMATROL)262 mg tab chew

1-Covered

bismuth subsalicylate (DIOTAME)262 mg tab chew

1-Covered

bismuth subsalicylate (PEP-T-MED)262 mg tab chew --

1-Covered

bismuth subsalicylate (PEPTICRELIEF) 262 mg tab chew

1-Covered

bismuth subsalicylate (PINKBISMUTH) 262 mg tab chew

1-Covered

bismuth subsalicylate (SOOTHE)262 mg tab chew

1-Covered

bismuth subsalicylate (STOMACHRELIEF) 262 mg tab chew

1-Covered

bismuth subsalicylate 262 mg tabchew

1-Covered

calcium carbonate (ANTACIDCALCIUM) 215(500)mg tab chew

1-Covered

calcium carbonate (ANTACIDEXTRA STRENGTH) 300mg(750) tabchew

1-Covered

calcium carbonate (ANTACID)200(500)mg tab chew 215(500)mgtab chew 300mg(750) tab chew

1-Covered

calcium carbonate (BAN-ACID)300mg(750) tab chew -

1-Covered

calcium carbonate (CAL-GEST)200(500)mg tab chew -

1-Covered

calcium carbonate (CALCIUMANTACID) 200(500)mg tab chew215(500)mg tab chew 300mg(750)tab chew

1-Covered




78



calcium carbonate (CHILDRENSPEPTO) 400 mg tab chew

1-Covered

calcium carbonate (CHILDRENSSOOTHE) 400 mg tab chew

1-Covered

calcium carbonate (FLAVORCHEWS ANTACID) 300mg(750) tabchew

1-Covered

calcium carbonate (SMOOTHANTACID) 300mg(750) tab chew

1-Covered

calcium carbonate (SMOOTHDISSOLVING ANTACID) 300mg(750)tab chew

1-Covered

calcium carbonate 200(500)mgtab chew 300mg(750) tab chew

1-Covered

diphenoxylate hclatropine sulfate25-0255 liquid 25-025mg tablet

1-Covered

DIPHENOXYLATE-ATROPINE -25-0025

1-Covered

GAS RELIEF (simethicone) (SIMETH)80 MG CHEW

1-Covered

GAS RELIEF GAS 125 MG CHEWTABLET GAS (SIMETH) 80 MGCHEW HM GAS 125 MG SOFTGELHM GAS 125 MG CHEW TAB

1-Covered

GAS-X (simethicone) -E-STR 125 MGTAB CHEW

1-Covered

INFANTS GAS RELIEF RLF 20 MG03ML

1-Covered

loperamide hcl (ANTI-DIARRHEAL) 2mg capsule - 2 mg tablet -

1-Covered

loperamide hcl (DIAMODE) 2 mgtablet

1-Covered

loperamide hcl (ULTRA A-D) 2 mgtablet -

1-Covered

loperamide hcl 1 mg5 ml liquid 2mg capsule 2 mg tablet

1-Covered

PEPTO-BISMOL (bismuthsubsalicylate) -TABLET CHEW

1-Covered

PEPTO-BISMOL TO-GO (bismuthsubsalicylate) --262 MG CHEW

1-Covered




79



simethicone (GAS RELIEF)40mg06ml drops susp 80 mg tabchew 125 mg tab chew 125 mgcapsule

1-Covered

simethicone (GAS-X) 125 mgcapsule -

1-Covered

simethicone (INFANT GAS RELIEF)40mg06ml drops susp

1-Covered

simethicone (INFANTS GAS RELIEF)40mg06ml drops susp

1-Covered

simethicone (MI-ACID) 80 mg tabchew -

1-Covered

simethicone 40mg06ml dropssusp 80 mg tab chew 125 mgcapsule 125 mg tab chew

1-Covered

STOMACH RELIEF 262 MG CHEWTAB

1-Covered

ursodiol 300 mg capsule 1-Covered

HISTAMINE2 (H2) RECEPTOR ANTAGONISTSACID CONTROLLER 20 MG TABLET 1-Covered

ACID REDUCER 10 MG TABLET 1-Covered PA

ACID REDUCER 20 MG TABLET 1-Covered

cimetidine (ACID REDUCER) 200mg tablet

1-Covered

cimetidine (HEARTBURN RELIEF) 200mg tablet

1-Covered

cimetidine 200 mg tablet 300 mgtablet 400 mg tablet 800 mgtablet

1-Covered

CIMETIDINE 300 MG5 ML SOLN 1-Covered

cimetidine hcl 300 mg5ml solution 1-Covered

famotidine (ACID CONTROLLER) 10mg tablet

1-Covered PA


1-Covered

famotidine (ACID REDUCER) 10 mgtablet

1-Covered PA


1-Covered




80



famotidine (HEARTBURNPREVENTION) 10 mg tablet

1-Covered PA


1-Covered

famotidine (HEARTBURN RELIEF) 10mg tablet

1-Covered PA


1-Covered

famotidine (PEPCID) 20 mg tablet 1-Covered

famotidine 10 mg tablet 1-Covered PA

FAMOTIDINE 10 MG TABLET 1-Covered PA

famotidine 20 mg tablet 40 mgtablet

1-Covered

FAMOTIDINE 20 MG TABLET EQ 20MG TABLET 40 MG TABLET

1-Covered

IRRITABLE BOWEL SYNDROME AGENTSAMITIZA (lubiprostone) 8 MCGCAPSULE 24 MCG CAPSULES

1-Covered PA

LAXATIVES (Drugs for Bowel Cleansing and Constipation)bisacodyl (ALOPHEN PILLS) 5 mgtablet dr

1-Covered

bisacodyl (BISA-LAX) 5 mg tablet dr-

1-Covered

bisacodyl (BISACODYL) 5 mgtablet dr

1-Covered

bisacodyl (BISCOLAX) 10 mgsupprect

1-Covered

bisacodyl (C-LAX LAXATIVE) 5 mgtablet dr -ATIVE)

1-Covered

bisacodyl (DUCODYL) 5 mg tabletdr

1-Covered

bisacodyl (FAST RELIEF LAXATIVE)10 mg supprect

1-Covered

bisacodyl (GENTLE LAXATIVE) 5 mgtablet dr 10 mg supprect

1-Covered

bisacodyl (LAXATIVE SUPPOSITORY)10 mg supprect

1-Covered




81



bisacodyl (LAXATIVE) 5 mg tabletdr

1-Covered

bisacodyl (MAGIC BULLET) 10 mgsupprect

1-Covered

bisacodyl (WOMENS GENTLELAXATIVE) 5 mg tablet dr

1-Covered

bisacodyl (WOMENS LAXATIVE) 5mg tablet dr

1-Covered

bisacodyl 5 mg tablet dr 10 mgsupprect

1-Covered

BISACODYL EC 5 MG TABLET 10MG SUPPOSITORY

1-Covered

docusate sodium (COL-RITE) 100mg capsule - 250 mg capsule -

1-Covered

docusate sodium (DIOCTYL) 60mg15ml syrup

1-Covered

docusate sodium (DOCU LIQUID)50 mg5 ml liquid

1-Covered

docusate sodium (DOCUSIL) 100mg capsule

1-Covered

docusate sodium (DSS) 250 mgcapsule

1-Covered

docusate sodium (DULCOEASE)100 mg capsule

1-Covered

docusate sodium (DULCOLAXSTOOL SOFTENER) 100 mg capsule

1-Covered

docusate sodium (LAXA BASIC 100)mg capsule )

1-Covered

docusate sodium (PHILLIPSLAXATIVE) 100 mg capsule

1-Covered

docusate sodium (SOF-LAX) 100mg capsule -

1-Covered

docusate sodium (STOOLSOFTENER) 50 mg capsule 50 mg5ml liquid 60 mg15ml syrup 100mg capsule 250 mg capsule

1-Covered

DOCUSATE SODIUM 50 MG5 MLLIQ 100 MG SOFTGEL

1-Covered

docusate sodium 50 mg5 mlliquid 60 mg15ml syrup 100 mgcapsule 250 mg capsule

1-Covered




82



DOK (docusate sodium) 100 MG250 MG

1-Covered

GENTLE LAXATIVE 10 MG SUPPOSIT 1-Covered

glycerin (ADULT GLYCERIN) adultsupprect

1-Covered

glycerin (LAXATIVE SUPPOSITORY)pediatric supprect

1-Covered

glycerin (PEDIA-LAX) pediatricsupprect -

1-Covered

glycerin (SUPPOSITORY) adultsupprect

1-Covered

glycerin adult pediatric 1-Covered

lactulose (CONSTULOSE) 10 g15 mlsolution

1-Covered

lactulose (ENULOSE) 10 g15 mlsolution

1-Covered

lactulose (GENERLAC) 10 g15 mlsolution

1-Covered

lactulose 10 g15 ml 20 g30 ml 1-Covered

MAGNESIUM CITRATE HM SOLUTION 1-Covered

magnesium citrate solution 1-Covered

peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-C) peg3350sodsulfbicarbclkcl 240-2272g solnrecon -

1-Covered

peg 3350sod sulfsod bicarbsodchloridepotassium chloride(GAVILYTE-G) peg3350sodsulfbicarbclkcl 236-2274g solnrecon -

1-Covered

peg 3350sod sulfsod bicarbsodchloridepotassium chloridepeg3350sod sulfbicarbclkcl 236-2274g soln peg3350sodsulfbicarbclkcl 240-2272g soln

1-Covered

PEG-3350 AND ELECTROLYTES -SOLN

1-Covered

polyethylene glycol 3350(CLEARLAX) 17gdose powder





83



polyethylene glycol 3350(GAVILAX) 17gdose powder


polyethylene glycol 3350(GENTLELAX) 17gdose powder


polyethylene glycol 3350(GLYCOLAX) 17gdose powder


polyethylene glycol 3350(LAXACLEAR) 17gdose powder


polyethylene glycol 3350 (NATURA-LAX) 17gdose powder -


polyethylene glycol 3350(POWDERLAX) 17gdose powder


polyethylene glycol 3350(PURELAX) 17gdose powder


polyethylene glycol 3350(SMOOTHLAX) 17gdose powder


polyethylene glycol 3350 17gdosepowder


SILACE (docusate sodium) 50MG5 ML LIQUID

1-Covered

sodium chloridesodiumbicarbonatepotassiumchloridepeg (GAVILYTE-N)chloridenahco3kclpeg 420gsoln recon -

1-Covered

sodium chloridesodiumbicarbonatepotassiumchloridepeg (TRILYTE WITH FLAVORPACKETS)chloridenahco3kclpeg 420gsoln recon

1-Covered

sodium chloridesodiumbicarbonatepotassiumchloridepegchloridenahco3kclpeg 420gsoln recon

1-Covered

STOOL SOFTENER (docusatesodium) 100 MG SOFTGEL 100 MGCAPSULE 250 MG SOFTGEL

1-Covered

STOOL SOFTENER HM 100 MGSFTGL 100 MG SOFTGEL HM 250MG SFTGL

1-Covered




84



PROTECTANTSmisoprostol 100 mcg tablet 200mcg tablet

1-Covered PA

sucralfate 1 g tablet 1-Covered

PROTON PUMP INHIBITORSlansoprazole 15 mg capsule dr 1-Covered ST

lansoprazole 30 mg capsule dr 1-Covered

LANSOPRAZOLE DR 15 MGCAPSULE

1-Covered ST


1-Covered

omeprazole 10 mg capsule dr 20mg tablet dr

1-Covered

omeprazole 20 mg capsule dr 1-Covered QL (60 PER 30 DAYS)

omeprazole 40 mg capsule dr 1-Covered QL (30 PER 30 DAYS) MDD (1 PerDay)

OMEPRAZOLE DR 20 MG CAPSULE 1-Covered QL (60 PER 30 DAYS)

OMEPRAZOLE DR 20 MG TABLET 1-Covered

pantoprazole sodium 20 mg tabletdr 40 mg tablet dr

1-Covered

PANTOPRAZOLE SODIUM DR 20 MGTAB DR 40 MG TAB

1-Covered

PREVACID (lansoprazole) DR 15MG CAPSULE

1-Covered

GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT (Drugs for Genetic or Enzyme Disorders)

GENETIC OR ENZYME DISORDER REPLACEMENT MODIFIERSTREATMENT

CREON (lipaseproteaseamylase)DR 6000 UNITS CAPSULE

1-Covered PA




85



GENITOURINARY AGENTS (Drugs for the Genital Bladder andKidney)

ANTISPASMODICS URINARY (Drugs for Bladder Spasms)oxybutynin chloride 5 mg5 mlsyrup 5 mg tab er 24 5 mg tablet10 mg tab er 24 15 mg tab er 24

1-Covered

OXYBUTYNIN CHLORIDE ER ER 5 MGTABLET ER 10 MG TABLET ER 15 MGTABLET

1-Covered

OXYTROL FOR WOMEN(oxybutynin) 39 MG24HR

1-Covered ST

trospium chloride 20 mg tablet 1-Covered ST

TROSPIUM CHLORIDE 20 MG TABLET 1-Covered ST

BENIGN PROSTATIC HYPERTROPHY AGENTSalfuzosin hcl 10 mg tab er 24h 1-Covered PA

finasteride 5 mg tablet 1-Covered

tamsulosin hcl 04 mg capsule 1-Covered

GENITOURINARY AGENTS OTHER (Other Drugs for the GenitalBladder and Kidney)

bethanechol chloride 5 mg tablet10 mg tablet 25 mg tablet 50 mgtablet

1-Covered

citric acidsodium citrate (CYTRA-2) 334-500mg solution -

1-Covered

citric acidsodium citrate(VIRTRATE-2) 334-500mg solution -

1-Covered

citric acidsodium citrate 334-500mg solution

1-Covered

nonoxynol 9 (VCF) 125 foamappl

1-Covered

penicillamine 250 mg capsule 1-Covered PA QL (16 PER 1 DAY(S))

PENICILLAMINE 250 MG CAPSULE 1-Covered PA QL (16 PER 1 DAY(S))

phenazopyridine hcl (URINARYPAIN RELIEF) 95 mg tablet

1-Covered




86



PHENAZOPYRIDINE HCL 100 MGTAB 200 MG TAB

1-Covered

phenazopyridine hcl 100 mgtablet 200 mg tablet

1-Covered

sodiumpotassiumpotassiumcitratesodium citratecit ac(CYTRA-3) sodpotk citsod citcitacid 500-5505 solution -

1-Covered

sodiumpotassiumpotassiumcitratesodium citratecit ac(TRICITRATES) sodpotk citsodcitcit acid 500-5505 solution

1-Covered

sodiumpotassiumpotassiumcitratesodium citratecit acsodpotk citsod citcit acid 500-5505 solution

1-Covered

URINARY PAIN RELIEF HM RLF 95 MGTAB

1-Covered

PHOSPHATE BINDERScalcium acetate (ELIPHOS) 667 mgtablet


calcium acetate 667 mg capsule667 mg tablet


lanthanum carbonate 500 mg tabchew 750 mg tab chew 1000 mgtab chew

1-Covered PA

sevelamer carbonate 800 mgtablet

1-Covered PA

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Drugs for ReplacingStimulating Adrenal GlandHormones)

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(ADRENAL) (Glucocorticoids)

betamethasone dipropionate 005 lotion

1-Covered

betamethasone dipropionate 005 oint (g) 005 cream (g)

1-Covered ST

BETAMETHASONE DIPROPIONATEDP 005 OINT

1-Covered ST




87



betamethasonedipropionatepropylene glycolbetamethasonepropylene 005 cream (g)

1-Covered ST

betamethasone valerate 01 lotion 01 cream (g) 01 oint(g)

1-Covered

clobetasol propionate 005 gel(gram) 005 solution 005 cream (g) 005 oint (g)

1-Covered ST

CLOBETASOL PROPIONATE 005CREAM

1-Covered ST

DELTASONE (prednisone) 20 MGTABLET

1-Covered

desonide 005 lotion 005 oint(g) 005 cream (g)

1-Covered ST

DESONIDE 005 LOTION 005CREAM

1-Covered ST

dexamethasone(DEXAMETHASONE INTENSOL) 1mgml drops

1-Covered

dexamethasone 05 mg5mlsolution 05 mg tablet 05 mg5mlelixir 075 mg tablet 1 mg tablet15 mg tablet 2 mg tablet 4 mgtablet 6 mg tablet

1-Covered

DEXAMETHASONE 4 MG TABLET 1-Covered

fludrocortisone acetate 01 mgtablet

1-Covered

fluocinolone acetonide 001 cream (g) 001 solution 0025 cream (g) 0025 oint (g)

1-Covered ST

fluocinonide 005 cream (g) 005 gel (gram) 005 oint (g) 005 solution

1-Covered

FLUOCINONIDE 005 OINTMENT 1-Covered

hydrocortisone (ANTI-ITCH) 1 cream (g) -

1-Covered

hydrocortisone (ANUSOL-HC) 25 crmpe app -

1-Covered

hydrocortisone (CORTISONE) 1 cream (g)

1-Covered




88



hydrocortisone (CORTIZONE-10PLUS) cream (g) -0

1-Covered

hydrocortisone (CORTIZONE-10) cream (g) -

1-Covered

hydrocortisone (HYDROCREAM) 1 cream (g)

1-Covered

hydrocortisone (NOBLE FORMULAHC) 1 cream (g)

1-Covered

hydrocortisone (PREPARATION H) 1 cream (g)

1-Covered

hydrocortisone (PROCTO-MED HC)25 crmpe app -

1-Covered

hydrocortisone (PROCTO-PAK) 1 crmpe app -

1-Covered

hydrocortisone (PROCTOSOL-HC)25 crmpe app -

1-Covered

hydrocortisone (PROCTOZONE-HC)25 crmpe app -

1-Covered

hydrocortisone (SOOTHING CARE)1 cream (g)

1-Covered

hydrocortisone 05 oint (g) 1 cream (g) 1 oint (g) 1 crmpe app 25 cream (g) 25 crmpe app 25 oint (g) 25 lotion 5 mg tablet 10 mg tablet20 mg tablet

1-Covered

HYDROCORTISONE 5 MG TABLET10 MG TABLET

1-Covered

hydrocortisone acetate(ANUCORT-HC) 25 mg supprect -

1-Covered

hydrocortisone acetate (ANUSOL-HC) 25 mg supprect -

1-Covered

hydrocortisone acetate(HEMMOREX-HC) 25 mg supprect -

1-Covered

HYDROCORTISONE ACETATE 25 MGSUPP

1-Covered

hydrocortisone acetate 25 mgsupprect

1-Covered

methylprednisolone 4 mg tablet 4mg tab ds pk 8 mg tablet 16 mgtablet 32 mg tablet

1-Covered




89



mometasone furoate 01 cream(g) 01 oint (g)

1-Covered

prednisolone (MILLIPRED DP) 5 mg(48) tab 5 mg (21) tab

1-Covered

prednisolone (MILLIPRED) 5 mgtablet

1-Covered

prednisolone 15 mg5 ml solution 1-Covered

prednisolone sodium phosphate 5mg5 ml 15 mg5 ml

1-Covered

prednisone (PREDNISONEINTENSOL) 5 mgml oral conc

1-Covered

prednisone 1 mg tablet 25 mgtablet 5 mg tab ds pk 5 mgtablet 5 mg5 ml solution 10 mgtablet 10 mg tab ds pk 20 mgtablet 50 mg tablet

1-Covered

triamcinolone acetonide 0025 oint (g) 0025 cream (g) 0025 lotion 01 cream (g) 01 lotion 01 oint (g) 0147mggaerosol 05 cream (g) 05 oint(g)

1-Covered

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs for ReplacingStimulating Pituitary GlandHormones)

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(PITUITARY) (Drugs to ReplaceStimulate Pituitary Gland Hormones)

desmopressin acetate (non-refrigerated) (nonrefrigerated)10spray spraypump

1-Covered PA AL1 (8 to 14 yrs old)

desmopressin acetate 01 mgmlsolution 01 mg tablet 02 mgtablet


desmopressin acetate 4 mcgmlvial 4 mcgml ampul 10sprayspraypump


DESMOPRESSIN ACETATE 40MCG10 ML VIAL





90



HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING (SEXHORMONESMODIFIERS) (Drugs for ReplacingStimulating SexHormones)

ANDROGENSdanazol 50 mg capsule 100 mgcapsule 200 mg capsule

1-Covered

fluoxymesterone (ANDROXY) 10mg tablet

1-Covered

testosterone 125125g gel mdpmp 50 mg (1) gel packet

1-Covered PA

testosterone cypionate 100 mgmlvial 200 mgml vial

1-Covered PA

ESTROGENS (Contraceptives and Drugs for Menopause)desogestrel-ethinyl estradiol (APRI)-015-003 tablet

1-Covered

desogestrel-ethinyl estradiol(CYRED EQ) -015-003 tablet

1-Covered

desogestrel-ethinyl estradiol(CYRED) -015-003 tablet

1-Covered

desogestrel-ethinyl estradiol(EMOQUETTE) -015-003 tablet

1-Covered

desogestrel-ethinyl estradiol(ENSKYCE) -015-003 tablet

1-Covered

desogestrel-ethinyl estradiol(ISIBLOOM) -015-003 tablet

1-Covered

desogestrel-ethinyl estradiol(JULEBER) -015-003 tablet

1-Covered

desogestrel-ethinyl estradiol(KALLIGA) -015-003 tablet

1-Covered

desogestrel-ethinyl estradiol(RECLIPSEN) -015-003 tablet

1-Covered

desogestrel-ethinyl estradiol -015-003 tablet

1-Covered

desogestrel-ethinyl estradiolethinylestradiol (AZURETTE) -eestradioleestradiol 21-5 (28)tablet

1-Covered




91



desogestrel-ethinyl estradiolethinylestradiol (BEKYREE) -eestradioleestradiol 21-5 (28)tablet

1-Covered

desogestrel-ethinyl estradiolethinylestradiol (KARIVA) -eestradioleestradiol 21-5 (28)tablet

1-Covered

desogestrel-ethinyl estradiolethinylestradiol (KIMIDESS) -eestradioleestradiol 21-5 (28)tablet

1-Covered

desogestrel-ethinyl estradiolethinylestradiol (PIMTREA) -eestradioleestradiol 21-5 (28)tablet

1-Covered

desogestrel-ethinyl estradiolethinylestradiol (SIMLIYA) -eestradioleestradiol 21-5 (28)tablet

1-Covered

desogestrel-ethinyl estradiolethinylestradiol (VIORELE) -eestradioleestradiol 21-5 (28)tablet

1-Covered

desogestrel-ethinyl estradiolethinylestradiol (VOLNEA) -eestradioleestradiol 21-5 (28)tablet

1-Covered

desogestrel-ethinyl estradiolethinylestradiol -eestradioleestradiol 21-5 (28) tablet

1-Covered

DROSPIRENONE-ETHINYL ESTRADIOL-EE 3-002 MG TAB

1-Covered

estradiol (DOTTI) 025mg24hpatch 0375mg24 patch005mg24h patch 075mg24hpatch 01mg24hr patch


estradiol 025mg24h patch0375mg24 patch 005mg24hpatch 075mg24h patch01mg24hr patch


estradiol 001 creamappl025mg24h patch tdwk005mg24h patch tdwk075mg24h patch tdwk01mg24hr patch tdwk 05 mgtablet 1 mg tablet 2 mg tablet

1-Covered




92



ESTRADIOL 1 MG TABLET 2 MGTABLET

1-Covered

estrogensesterifiedmethyltestosterone (COVARYX HS)estrogenesterme-0625-125tablet

1-Covered PA

estrogensesterifiedmethyltestosterone (EEMT HS) estrogenesterme-0625-125 tablet

1-Covered PA

estrogensesterifiedmethyltestosterone estrogenesterme-0625-125tablet

1-Covered PA

ethinyl estradioldrospirenone(GIANVI) 002-3(28) tablet

1-Covered

ethinyl estradioldrospirenone(JASMIEL) 002-3(28) tablet

1-Covered

ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 002-3(28) tablet -

1-Covered

ethinyl estradioldrospirenone(LORYNA) 002-3(28) tablet

1-Covered

ethinyl estradioldrospirenone(NIKKI) 002-3(28) tablet

1-Covered

ethinyl estradioldrospirenone(VESTURA) 002-3(28) tablet

1-Covered

ethinyl estradioldrospirenone 002-3(28) tablet

1-Covered

ethynodiol diacetate-ethinylestradiol (KELNOR 1-35) ethynoiol -estraiol mg-35mcg tablet -

1-Covered


1-Covered

ethynodiol diacetate-ethinylestradiol (ZOVIA 1-35E) ethynoiol -estraiol mg-35mcg tablet -

1-Covered

ethynodiol diacetate-ethinylestradiol ethynoiol -estraiol 1 mg-50mcg tablet ethynoiol -estraiol 1mg-35mcg tablet

1-Covered

etonogestrelethinyl estradiol(ELURYNG) 12-015mg vag ring





93



etonogestrelethinyl estradiol 12-015mg vag ring


HAILEY FE 1-20 TABLET 15-30 TABLET 1-Covered

LEVONORGESTREL-ETH ESTRADIOL -TRIPHASIC

1-Covered

levonorgestrelethinyl estradiol(AFIRMELLE)levonorgestrelethinestradiol 01-002mg tablet

1-Covered

levonorgestrelethinyl estradiol(ALTAVERA)levonorgestrelethinestradiol 015-003 tablet

1-Covered

levonorgestrelethinyl estradiol(AUBRA EQ)levonorgestrelethinestradiol 01-002mg tablet

1-Covered

levonorgestrelethinyl estradiol(AUBRA)levonorgestrelethinestradiol 01-002mg tablet

1-Covered

levonorgestrelethinyl estradiol(AVIANE)levonorgestrelethinestradiol 01-002mg tablet

1-Covered

levonorgestrelethinyl estradiol(AYUNA)levonorgestrelethinestradiol 015-003 tablet

1-Covered

levonorgestrelethinyl estradiol(CHATEAL EQ)levonorgestrelethinestradiol 015-003 tablet

1-Covered

levonorgestrelethinyl estradiol(CHATEAL)levonorgestrelethinestradiol 015-003 tablet

1-Covered

levonorgestrelethinyl estradiol(DELYLA)levonorgestrelethinestradiol 01-002mg tablet

1-Covered

levonorgestrelethinyl estradiol(ENPRESSE)levonorgestrelethinestradiol 6-5-10 tablet

1-Covered




94



levonorgestrelethinyl estradiol(FALMINA)levonorgestrelethinestradiol 01-002mg tablet

1-Covered

levonorgestrelethinyl estradiol(KURVELO)levonorgestrelethinestradiol 015-003 tablet

1-Covered

levonorgestrelethinyl estradiol(LARISSIA)levonorgestrelethinestradiol 01-002mg tablet

1-Covered

levonorgestrelethinyl estradiol(LESSINA)levonorgestrelethinestradiol 01-002mg tablet

1-Covered

levonorgestrelethinyl estradiol(LEVONEST)levonorgestrelethinestradiol 6-5-10 tablet

1-Covered

levonorgestrelethinyl estradiol(LEVORA-28)levonorgestrelethinestradiol 015-003 tablet -

1-Covered

levonorgestrelethinyl estradiol(LILLOW)levonorgestrelethinestradiol 015-003 tablet

1-Covered

levonorgestrelethinyl estradiol(LUTERA)levonorgestrelethinestradiol 01-002mg tablet

1-Covered

levonorgestrelethinyl estradiol(MARLISSA)levonorgestrelethinestradiol 015-003 tablet

1-Covered

levonorgestrelethinyl estradiol(MYZILRA)levonorgestrelethinestradiol 6-5-10 tablet

1-Covered

levonorgestrelethinyl estradiol(ORSYTHIA)levonorgestrelethinestradiol 01-002mg tablet

1-Covered




95



levonorgestrelethinyl estradiol(PORTIA)levonorgestrelethinestradiol 015-003 tablet

1-Covered

levonorgestrelethinyl estradiol(SRONYX)levonorgestrelethinestradiol 01-002mg tablet

1-Covered

levonorgestrelethinyl estradiol(TRIVORA-28)levonorgestrelethinestradiol 6-5-10 tablet -

1-Covered

levonorgestrelethinyl estradiol(VIENVA)levonorgestrelethinestradiol 01-002mg tablet

1-Covered

levonorgestrelethinyl estradiollevonorgestrelethinestradiol 01-002mg tabletlevonorgestrelethinestradiol 015-003 tabletlevonorgestrelethinestradiol 6-5-10 tablet

1-Covered

LYLLANA 0025 MG PATCH 00375MG PATCH 005 MG PATCH 0075MG PATCH 01 MG PATCH


MENEST (estrogensesterified) 03MG TABLET 0625 MG TABLET 125MG TABLET 25 MG TABLET

1-Covered

MICROGESTIN 21 1-20 TABLET 1-Covered

MICROGESTIN FE 1-20 TABLET 1-Covered

norelgestrominethinyl estradiol(XULANE)norelgestrominethinestradiol 150-3524h patch tdwk


norethindrone acetate-ethinylestradiol (AUROVELA) -1mg-20mcgtablet -15-003mg tablet

1-Covered

norethindrone acetate-ethinylestradiol (GILDESS) -15-003mgtablet

1-Covered

norethindrone acetate-ethinylestradiol (HAILEY) -15-003mgtablet

1-Covered




96



norethindrone acetate-ethinylestradiol (JUNEL) -1mg-20mcgtablet -15-003mg tablet

1-Covered

norethindrone acetate-ethinylestradiol (LARIN) -1mg-20mcgtablet -15-003mg tablet

1-Covered

norethindrone acetate-ethinylestradiol (MICROGESTIN) -1mg-20mcg tablet -15-003mg tablet

1-Covered

norethindrone acetate-ethinylestradiol -1mg-20mcg tablet -15-003mg tablet

1-Covered

norethindrone acetate-ethinylestradiolferrous fumarate(AUROVELA FE) -eestradiol-iron15-30(21) tablet

1-Covered

norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVIFE) --1mg-20(21) tablet --15-30(21)tablet

1-Covered

norethindrone acetate-ethinylestradiolferrous fumarate (JUNELFE) --1mg-20(21) tablet --15-30(21)tablet

1-Covered

norethindrone acetate-ethinylestradiolferrous fumarate (LARINFE) --1mg-20(21) tablet --15-30(21)tablet

1-Covered

norethindrone acetate-ethinylestradiolferrous fumarate(MICROGESTIN FE) --1mg-20(21)tablet --15-30(21) tablet

1-Covered

norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE 1-20 EQ) -eestradiol-iron mg-(2)tablet -

1-Covered

norethindrone acetate-ethinylestradiolferrous fumarate (TARINAFE) -eestradiol-iron 1mg-20(21)tablet

1-Covered

norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE)-eestradiol-iron 5-7-9-7 tablet

1-Covered




97



norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) -eestradiol-iron 5-7-9-7tablet -

1-Covered

norethindrone acetate-ethinylestradiolferrous fumarate --1mg-20(21) tablet --15-30(21) tablet

1-Covered

norethindrone-ethinyl estradiol(ALYACEN) -1 mg-35mcg tablet -7days x 3 tablet

1-Covered

norethindrone-ethinyl estradiol(ARANELLE) -ethin 7-9-5 tablet

1-Covered

norethindrone-ethinyl estradiol(BALZIVA) -ethin 04-0035 tablet

1-Covered

norethindrone-ethinyl estradiol(BRIELLYN) -ethin 04-0035 tablet

1-Covered

norethindrone-ethinyl estradiol(CYCLAFEM) -1 mg-35mcg tablet -7 days x 3 tablet

1-Covered

norethindrone-ethinyl estradiol(DASETTA) -1 mg-35mcg tablet -7days x 3 tablet

1-Covered

norethindrone-ethinyl estradiol(LEENA) -ethin 7-9-5 tablet

1-Covered

norethindrone-ethinyl estradiol(NECON) -ethin 05-0035 tablet

1-Covered

norethindrone-ethinyl estradiol(NORTREL) -05-0035 tablet -1 mg-35mcg tablet -7 days x 3 tablet

1-Covered

norethindrone-ethinyl estradiol(PHILITH) -ethin 04-0035 tablet

1-Covered

norethindrone-ethinyl estradiol(PIRMELLA) -1 mg-35mcg tablet -7days x 3 tablet

1-Covered

norethindrone-ethinyl estradiol(VYFEMLA) -ethin 04-0035 tablet

1-Covered

norethindrone-ethinyl estradiol(WERA) -ethin 05-0035 tablet

1-Covered

norethindrone-ethinyl estradiol(ZENCHENT) -ethin 04-0035 tablet

1-Covered

norgestimate-ethinyl estradiol(ESTARYLLA) -025-0035 tablet

1-Covered




98



norgestimate-ethinyl estradiol(FEMYNOR) -025-0035 tablet

1-Covered

norgestimate-ethinyl estradiol(MILI) -025-0035 tablet

1-Covered

norgestimate-ethinyl estradiol(MONO-LINYAH) -025-0035 tablet -

1-Covered

norgestimate-ethinyl estradiol(MONONESSA) -025-0035 tablet

1-Covered

norgestimate-ethinyl estradiol(PREVIFEM) -025-0035 tablet

1-Covered

norgestimate-ethinyl estradiol(SPRINTEC) -025-0035 tablet

1-Covered

norgestimate-ethinyl estradiol (TRIFEMYNOR) -7daysx3 28 tablet

1-Covered

norgestimate-ethinyl estradiol (TRI-ESTARYLLA) -7daysx3 28 tablet -

1-Covered

norgestimate-ethinyl estradiol (TRI-LINYAH) -7daysx3 28 tablet -

1-Covered

norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) -7daysx3 lo tablet --

1-Covered

norgestimate-ethinyl estradiol (TRI-LO-MARZIA) -7daysx3 lo tablet --

1-Covered

norgestimate-ethinyl estradiol (TRI-LO-MILI) -7daysx3 lo tablet --

1-Covered

norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) -7daysx3 lo tablet --

1-Covered

norgestimate-ethinyl estradiol (TRI-PREVIFEM) -7daysx3 28 tablet -

1-Covered

norgestimate-ethinyl estradiol (TRI-SPRINTEC) -7daysx3 28 tablet -

1-Covered

norgestimate-ethinyl estradiol (TRI-VYLIBRA LO) -7daysx3 lo tablet -

1-Covered

norgestimate-ethinyl estradiol (TRI-VYLIBRA) -7daysx3 28 tablet -

1-Covered

norgestimate-ethinyl estradiol(TRINESSA LO) -7daysx3 lo tablet

1-Covered

norgestimate-ethinyl estradiol(TRINESSA) -7daysx3 28 tablet

1-Covered

norgestimate-ethinyl estradiol(VYLIBRA) -025-0035 tablet

1-Covered




99



NORGESTIMATE-ETHINYL ESTRADIOL-025-0035 MG

1-Covered

norgestimate-ethinyl estradiol -025-0035 tablet -7daysx3 28tablet -7daysx3 lo tablet

1-Covered

norgestrel-ethinyl estradiol(CRYSELLE) -03-003mg tablet

1-Covered

norgestrel-ethinyl estradiol (ELINEST)-03-003mg tablet

1-Covered

norgestrel-ethinyl estradiol (LOW-OGESTREL) -03-003mg tablet -

1-Covered

norgestrel-ethinyl estradiol(OGESTREL) -05 mg-50 tablet

1-Covered

PREMARIN (estrogens conjugated)03 MG TABLET 045 MG TABLET0625 MG TABLET 09 MG TABLET125 MG TABLET

1-Covered

PREMARIN (estrogens conjugated)VAGINAL CREAM-APPL


PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 0625-5 MG TABLET

1-Covered

PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 03 MG-15 MG TABLET045-15 MG TABLET 0625-5 MGTABLET 0625-25 MG TABLET

1-Covered

ZOVIA 1-35 -TABLET 1-Covered

PROGESTINSDEPO-PROVERA(medroxyprogesterone acetate) -400 MGML VIAL

1-Covered

DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) -SYRINGE

1-Covered

hydroxyprogesterone caproate250 mgml vial

1-Covered PA SP

hydroxyprogesterone caproatepfcaproatpf 250 mgml vial

1-Covered PA SP

JENCYCLA 035 MG TABLET 1-Covered




100



levonorgestrel (AFTERA) 15 mgtablet

1-Covered

levonorgestrel (ECONTRA EZ) 15mg tablet

1-Covered

levonorgestrel (ECONTRA ONE-STEP) 15 mg tablet -

1-Covered

levonorgestrel (FALLBACK SOLO)15 mg tablet

1-Covered

levonorgestrel (MY CHOICE) 15mg tablet

1-Covered

levonorgestrel (MY WAY) 15 mgtablet

1-Covered

levonorgestrel (NEW DAY) 15 mgtablet

1-Covered

levonorgestrel (OPCICON ONE-STEP) 15 mg tablet -

1-Covered

levonorgestrel (OPTION 2) 15 mgtablet

1-Covered

levonorgestrel (TAKE ACTION) 15mg tablet

1-Covered

levonorgestrel 15 mg tablet 1-Covered QL (1 PER 1 DAYS)

MEDROXYPROGESTERONE ACETATE150 MGML


medroxyprogesterone acetate 150mgml vial 150 mgml syringe


MEDROXYPROGESTERONE ACETATE25 MG TAB

1-Covered

medroxyprogesterone acetate 25mg tablet 5 mg tablet 10 mgtablet

1-Covered

megestrol acetate 20 mg tablet40 mg tablet

1-Covered

megestrol acetate 400mg10mloral susp

1-Covered PA

norethindrone (CAMILA) 035 mgtablet

1-Covered

norethindrone (DEBLITANE) 035 mgtablet

1-Covered

norethindrone (ERRIN) 035 mgtablet

1-Covered




101



norethindrone (HEATHER) 035 mgtablet

1-Covered

norethindrone (INCASSIA) 035 mgtablet

1-Covered

norethindrone (JENCYCLA) 035mg tablet

1-Covered

norethindrone (JOLIVETTE) 035 mgtablet

1-Covered

norethindrone (LYZA) 035 mgtablet

1-Covered

norethindrone (NORA-BE) 035 mgtablet -

1-Covered

norethindrone (NORLYDA) 035 mgtablet

1-Covered

norethindrone (NORLYROC) 035mg tablet

1-Covered

norethindrone (SHAROBEL) 035 mgtablet

1-Covered

norethindrone (TULANA) 035 mgtablet

1-Covered

norethindrone 035 mg tablet 1-Covered

norethindrone acetate 5 mg tablet 1-Covered

PLAN B ONE-STEP (levonorgestrel) -15 MG TALET

1-Covered

TAKE ACTION (levonorgestrel) 15MG TABLET

1-Covered

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs for the Thyroid)

HORMONAL AGENTS STIMULANTREPLACEMENTMODIFYING(THYROID) (Drugs to Replace Thyroid Hormone)

ARMOUR THYROID (thyroidpork) 15MG TABLET 30 MG TABLET 60 MGTABLET 90 MG TABLET 120 MGTABLET 180 MG TABLET 240 MGTABLET 300 MG TABLET

1-Covered




102



LEVO-T (levothyroxine sodium) -25MCG ABLE -50 MCG ABLE -75MCG ABLE -88 MCG ABLE -100MCG ABLE -112 MCG ABLE -125MCG ABLE -137 MCG ABLE -150MCG ABLE -175 MCG ABLE -200MCG ABLE -300 MCG ABLE

1-Covered

levothyroxine sodium 25 mcgtablet 50 mcg tablet 75 mcgtablet 88 mcg tablet 100 mcgtablet 112 mcg tablet 125 mcgtablet 137 mcg tablet 150 mcgtablet 175 mcg tablet 200 mcgtablet 300 mcg tablet


LEVOTHYROXINE SODIUM 25 MCGTABLET 50 MCG TABLET 75 MCGTABLET 88 MCG TABLET 100 MCGTABLET 112 MCG TABLET 125 MCGTABLET 137 MCG TABLET 150 MCGTABLET 175 MCG TABLET 200 MCGTABLET 300 MCG TABLET


LEVOXYL (levothyroxine sodium) 25MCG TABLET 50 MCG TABLET 75MCG TABLET 88 MCG TABLET 100MCG TABLET 112 MCG TABLET 125MCG TABLET 137 MCG TABLET 150MCG TABLET 175 MCG TABLET 200MCG TABLET

1-Covered

SYNTHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET

1-Covered

thyroidpork (NP THYROID) 15 mgtablet 30 mg tablet 60 mg tablet90 mg tablet 120 mg tablet


UNITHROID (levothyroxine sodium)25 MCG TABLET 50 MCG TABLET75 MCG TABLET 88 MCG TABLET100 MCG TABLET 112 MCG TABLET125 MCG TABLET 137 MCG TABLET150 MCG TABLET 175 MCG TABLET200 MCG TABLET 300 MCG TABLET

1-Covered




103



HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs forSuppressing Hormones from the Pituitary Gland)

HORMONAL AGENTS SUPPRESSANT (PITUITARY) (Drugs to SuppressPituitary Hormones)

leuprolide acetate 1 mg02ml kit 1-Covered PA SP

LUPRON DEPOT-PED (leuprolideacetate) -15 MG KIT

1-Covered PA

SYNAREL (nafarelin acetate) 2MGML NASAL SPRAY

1-Covered PA

HORMONAL AGENTS SUPPRESSANT (THYROID) (Drugs for theThyroid)

ANTITHYROID AGENTS (Drugs to Suppress Thyroid Hormone)methimazole 5 mg tablet 10 mgtablet

1-Covered

propylthiouracil 50 mg tablet 1-Covered

IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing theImmune System)

IMMUNE SUPPRESSANTS (Drugs to Suppress the Immune System)azathioprine 50 mg tablet 1-Covered

AZATHIOPRINE 50 MG TABLET 1-Covered

cyclosporine 25 mg capsule 100mg capsule

1-Covered

cyclosporine modified (GENGRAF)25 mg capsule 100 mgml solution100 mg capsule

1-Covered

cyclosporine modified 25 mgcapsule 100 mgml solution 100mg capsule

1-Covered

ENBREL (etanercept) 25 MG KIT 1-Covered PA SP QLC (8 vials28 days)

ENBREL (etanercept) 25 MG05 MLSYRINGE 50 MGML SYRINGE

1-Covered PA SP QLC (4 syringes [1 kit]28days)




104



ENBREL 25 MG05 ML VIAL 1-Covered PA QL (4 PER 28 DAY(S))

ENBREL SURECLICK (etanercept) 50MGML

1-Covered PA SP QLC (4 pens [1 kit]28days)

HUMIRA (adalimumab) 10 MG02ML SYRINGE 20 MG04 MLSYRINGE 40 MG08 ML SYRINGE


HUMIRA PEDIATRIC CROHNS(adalimumab) 40 MG08 ML

1-Covered PA SP QLC (3 or 6 syringesyeardepending upon package size)

HUMIRA PEN (adalimumab) 40MG08 ML


HUMIRA PEN CROHNS-UC-HS(adalimumab) --40 MG

1-Covered PA SP QLC (6 pens [1 kit]year)

HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) --40 MG


HUMIRA(CF) (adalimumab) 10MG01 ML SYRING 20 MG02 MLSYRING 40 MG04 ML SYRING


HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80-40 MG

1-Covered PA SP QLC (2 syringes [1kit]year)

HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 80MG08


HUMIRA(CF) PEN (adalimumab) 40MG04 ML


HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) CRHN--80MG


HUMIRA(CF) PEN PSOR-UV-ADOLHS (adalimumab) --AHS 80-40


METHOTREXATE 25 MG TABLET 1-Covered

methotrexate sodium 25 mgtablet

1-Covered

mycophenolate mofetil 200 mgmlsusp recon

1-Covered PA

mycophenolate mofetil 250 mgcapsule 500 mg tablet


RHEUMATREX (methotrexatesodium) 25 MG TABLET

1-Covered

SANDIMMUNE (cyclosporine) 25MG CAPSULE 100 MGML SOLN

1-Covered

sirolimus 1 mgml solution 1-Covered PA




105



tacrolimus 05 mg capsule 1 mgcapsule 5 mg capsule


TACROLIMUS 05 MG CAPSULE 1MG CAPSULE 5 MG CAPSULE


IMMUNIZING AGENTS PASSIVE (Vaccines)HYPERTET S-D (tetanus immuneglobulinpf) -250 UNIT YRINGE

3-MedicalBenefit

NABI-HB (hepatitis b immuneglobulin) -VIAL gloulin)

3-MedicalBenefit

IMMUNOMODULATORSleflunomide 10 mg tablet 20 mgtablet

1-Covered

LEFLUNOMIDE 10 MG TABLET 20MG TABLET

1-Covered

RIDAURA (auranofin) 3 MGCAPSULE

1-Covered PA

VACCINESADACEL TDAP(diphtheriapertussis(acellular)tetanus vaccinepf) VIAL


AFLURIA QUAD 2020-2021 -VIAL 1-Covered AL1 (At least 19 yrs old)

AFLURIA QUAD 2020-21 (3YR UP) - 1-Covered AL1 (At least 19 yrs old)

BEXSERO (meningococcal group bvaccine 4-component) PREFILLEDSYRINGE -

1-Covered QL (2 PER LIFETIME) AL1 (19 to 25yrs old)

BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanus vaccine) SYRINGE VIAL


ENGERIX-B ADULT (hepatitis b virusvaccine recombinantpf) -20MCGML VIAL recominantpf) -20MCGML SYRN recominantpf)

1-Covered QL (3 PER LIFETIME) AL1 (At least19 yrs old)

FLUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 65 yrs old)

FLUAD QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)

FLUARIX QUAD 2020-2021 -SYRINGE 1-Covered AL1 (At least 19 yrs old)

FLUBLOK QUAD 2018-2019(influenza virus vaccine qv 2018-19(18 yrs and older)rcmbpf) -SYRINGE -





106



FLUBLOK QUAD 2020-2021 -SYRINGE


FLUCELVAX QUAD 2020-2021 2020-2021 SYR 2020-2021 VIAL


FLULAVAL QUAD 2019-2020(influenza virus vaccinequadrivalent 2019-20 (6 mos andup)) -VIAL -


FLULAVAL QUAD 2020-2021 -SYR 1-Covered AL1 (At least 19 yrs old)

FLUZONE HIGH-DOSE QUAD 2020-21 --


FLUZONE QUAD 2019-2020(influenza virus vaccine quadrival2019-2020(6 mos and up)pf) -VIAL-


FLUZONE QUAD 2020-2021 2020-2021 VIAL 2020-2021 SYRINGE


GARDASIL 9 (human papillomavirusvaccine 9-valentpf) 9 SYRINGE 9-9 VIAL 9-


HAVRIX (hepatitis a virusvaccinepf) 720 UNIT05 MLSYRINGE (heptitis vccinepf) 720UNITS05 ML VIAL (heptitisvccinepf) 1440 UNITSMLSYRINGE (heptitis vccinepf) 1440UNITSML VIAL (heptitis vccinepf)


HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvantcpg 1018pf) -20 MCG05 MLSYRNG RECOMINANT -20MCG05 ML VIAL RECOMINANT

1-Covered AL1 (At least 19 yrs old) QLC (2perlifetime)

IMOVAX RABIES VACCINE (rabiesvaccine human diploid cellpf)VIAL

3-MedicalBenefit

M-M-R II VACCINE (measlesmumps and rubella vaccinelivepf) --VIAL


MENACTRA(meningococcalvaccine acyw-135diphtheria toxoid conjpf) VIAL-


MENQUADFI VIAL 1-Covered QL (2 PER LIFETIME) AL1 (At least19 yrs old)




107



MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) -----VIL KT -DIPHTHERIA


PNEUMOVAX 23 (pneumococcal23-valent polysaccharide vaccine)23 VIAL 23- 23 SYRINGE 23-


PREVNAR 13 (pneumococcal 13-valent conjugate vaccine(diphtheria crm)pf) SYRINGE -


RABAVERT (rabies vaccine purifiedchicken embryo cell (pcec)pf)RABIES VACC W-DILUENT


RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML SYR recominantpf)10 MCGML SYR recominantpf)40 MCGML VIAL recominantpf)


RECOMBIVAX HB (hepatitis b virusvaccine recombinantpf) 5MCG05 ML VL recominantpf) 10MCGML VIAL recominantpf)


SHINGRIX (varicella-zoster virusglycoprotein erecas01badjuvantpf) VIAL KIT -


TDVAX (tetanus and diphtheriatoxoids adult) VIAL


TENIVAC (tetanus and diphtheriatoxoids adsorbed adultpf) VIAL


tetanus and diphtheria toxoidsadult tetanus toxadult 2-2 lf05vial


TRUMENBA (neisseria meningitidisgroup b lipidated fhbprecombinant) 120 MCG05 MLVACCIN


TWINRIX (hepatitis a virus andhepatitis b virus vaccinepf)VACCINE SYRINGE (heptitis ndheptitis vccinepf)





108



VAQTA (hepatitis a virusvaccinepf) 25 UNITS05 ML VIAL(heptitis vccinepf) 25 UNITS05ML SYRINGE (heptitis vccinepf) 50UNITSML VIAL (heptitis vccinepf)50 UNITSML SYRINGE (heptitisvccinepf)


VARIVAX VACCINE (varicella virusvaccine livepf) WITH DILUENT


ZOSTAVAX (zoster vaccine livepf)VIAL


INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for InflammatoryBowel Disease)

AMINOSALICYLATESbalsalazide disodium 750 mgcapsule

1-Covered

mesalamine 4 g60 ml enema 1-Covered

mesalamine 400 mg cap(drtab) 1-Covered QL (6 PER 1 DAY(S))

GLUCOCORTICOIDShydrocortisone (COLOCORT)100mg60ml enema

1-Covered

hydrocortisone 100mg60mlenema

1-Covered

SULFONAMIDESsulfasalazine 500 mg tablet dr 500mg tablet

1-Covered

METABOLIC BONE DISEASE AGENTS (Drugs for the Bone)

METABOLIC BONE DISEASE AGENTSalendronate sodium 10 mg tablet40 mg tablet

1-Covered PA STAR (Preferred Drug)

alendronate sodium 35 mg tablet70 mg tablet


alendronate sodium 5 mg tablet 1-Covered AL1 (At least 65 yrs old) STAR(Preferred Drug)




109



calcitoninsalmonsynthetic200spray spraypump

1-Covered PA

CALCITRIOL 025 MCG CAPSULE05 MCG CAPSULE

1-Covered

calcitriol 025 mcg capsule 05mcg capsule 1 mcgml solution

1-Covered

cholecalciferol (vitamin d3) 10mcg capsule 10 mcg tablet

1-Covered

cinacalcet hcl 30 mg tablet 60 mgtablet 90 mg tablet

1-Covered PA

CINACALCET HCL 30 MG TABLET60 MG TABLET 90 MG TABLET

1-Covered PA

ergocalciferol (vitamin d2)(CALCIDOL) 200 mcgml drops

1-Covered

ergocalciferol (vitamin d2) 10 mcgtablet 200 mcgml drops 1250mcg capsule

1-Covered

ERGOCALCIFEROL 200 MCGMLDROP

1-Covered

FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamind3)) 70 MG-2800 IU

1-Covered PA

MISCELLANEOUS THERAPEUTIC AGENTSalcohol antiseptic pads s med 1-Covered

ALCOHOL WIPES 70 1-Covered

ASSURE ID DUO-SHIELD -30GX316-30GX516

1-Covered

ASSURE ID INSULIN SAFETY SYR05ML 31GX1564 SYR 1 ML31GX1564

1-Covered

condoms female each 1-Covered

condoms latex lubricated each 1-Covered

cromolyn sodium 52 mgspraypump

1-Covered

DROPLET MICRON PEN NEEDLE 34GX 964

1-Covered

freestyle insulix test strips 1-Covered QL (100 PER 30 DAYS)




110



freestyle lite test strips 1-Covered QL (100 PER 30 DAYS)

freestyle test strips 1-Covered QL (100 PER 30 DAYS)

inhalerassist device with largemask devicelg spacer

1-Covered

inhalerassist device with mediummask devicemed spacer

1-Covered

inhalerassist device with smallmask devsmall spacer

1-Covered

INSULIN PEN NEEDLES INSULIN PENNEEDLES INSULIN PEN NEEDLES

1-Covered

insulin syringe 03 ml 1-Covered



lancets 28 gauge 30 gauge 33gauge

1-Covered

methylergonovine maleate 02 mgtablet

1-Covered

PEN NEEDLE 29G 12MM 1-Covered

pen needle diabetic 29 g x12 30gx516 31 g x14 31 gx316 31gx516 32gx 532 32 gx 14 32gx316 32 gx516 33 gx532

1-Covered

pen needle diabetic disposablesafety 30 gx516 30 gx316

1-Covered

pen needle diabetic removerand disposal unit 31 gx316 32gx532

1-Covered

pen needle diabetic safety 30gx316 dis

1-Covered

RID (permethrin) PEDICULICIDESSPRAY

1-Covered

syringe with needle insulin safety1 ml geneedleinsulnsafe1ml 30gx316 disp

1-Covered

syringe withneedledisposableinsulin 1 ml30gx12 disp 31 gx516 disp31gx1564 disp

1-Covered

syringe with needleinsulin03 ml -needldispinsul03 29 x12 disp

1-Covered




111



syringe with needleinsulin05 ml -ml 30gx12 disp -ml 31 gx516disp -ml 31gx1564 disp

1-Covered

UNIFINE PENTIPS MAXFLOW30GX316

1-Covered

OPHTHALMIC AGENTS (Drugs for the Eyes)

OPHTHALMIC AGENTS OTHER (Other Drugs for the Eyes)atropine sulfate 1 drops 1-Covered

bacitracinpolymyxin b sulfate (AK-POLY-BAC) 500-10kg oint (g) --

1-Covered

bacitracinpolymyxin b sulfate(POLYCIN) 500-10kg oint (g)

1-Covered

bacitracinpolymyxin b sulfate 500-10kg oint (g)

1-Covered

BEOVU (brolucizumab-dbll) 6MG005 ML VIAL -

3-MedicalBenefit

BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) EYEDROPS

1-Covered

CORTISPORIN (neomycinsulfatepolymyxin bsulfatehydrocortisone) CREAM

1-Covered

cyclopentolate hcl 05 drops 1 drops 2 drops

1-Covered

homatropine hbr (HOMATROPAIRE)5 drops

1-Covered

homatropine hbr 5 drops 1-Covered

MURO-128 (sodium chloride) -5EYE DROPS

1-Covered

neomycin sulfatebacitracinzincpolymyxin bhydrocortisone(NEO-POLYCIN HC)neomycinbacitp-myxhydrocort35-10k-1 oint (g) -

1-Covered

neomycin sulfatebacitracinzincpolymyxin bhydrocortisoneneomycinbacitp-myxhydrocort35-10k-1 oint (g)

1-Covered




112



neomycinsulfatebacitracinpolymyxin b(NEO-POLYCIN)sulfbacitracinpoly 35mg-400oint (g) -

1-Covered

neomycinsulfatebacitracinpolymyxin bsulfbacitracinpoly 35mg-400oint (g)

1-Covered

neomycin sulfatepolymyxin bsulfategramicidin dneomycinpolymyxn bgramicidin175mg-10k drops

1-Covered

neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35-10k-10 drops susp

1-Covered

neomycinpolymyxin bsulfatedexamethasonebdexametha 01 drops suspbdexametha 35-10k-1 oint (g)

1-Covered

phenylephrine hcl 25 drops 10 drops

1-Covered

polymyxin b sulfatetrimethoprimsulftrimethoprim 10000-1ml drops

1-Covered

proparacaine hcl 05 drops 1-Covered PA

sodium chloride (MURO-128) drops -18)

1-Covered

sodium chloride 5 drops 1-Covered

sulfacetamidesodiumprednisolone sodiumphosphatesulfacetamideprednisolone 10 -023 drops

1-Covered

TOBRADEX(tobramycindexamethasone) EYEOINTMENT

1-Covered

tobramycindexamethasone 03-01 drops susp

1-Covered

OPHTHALMIC ANTI-ALLERGY AGENTS (Drugs for Eye Allergies)ALAWAY (ketotifen fumarate)0025 EYE DROPS

1-Covered




113



ALOMIDE (lodoxamidetromethamine) 01 EYE DROPS

1-Covered

cromolyn sodium 4 drops 1-Covered

EYE ITCH RELIEF 0025 DROPS HM0025 DROP

1-Covered

ketotifen fumarate (ALLERGY EYEDROPS) 0025 drops

1-Covered

ketotifen fumarate (EYE ITCHRELIEF) 0025 drops

1-Covered

ketotifen fumarate (ITCHY EYE)0025 drops

1-Covered

ketotifen fumarate (WAL-ZYR) 0025 drops -

1-Covered

ketotifen fumarate (ZADITOR) 0025 drops

1-Covered

ketotifen fumarate 0025 drops 1-Covered

OPHTHALMIC ANTI-INFLAMMATORIES (Drugs to Reduce EyeSwelling)

dexamethasone sodiumphosphate 01 drops

1-Covered

diclofenac sodium 01 drops 1-Covered

fluorometholone 01 drops susp 1-Covered

flurbiprofen sodium 003 drops 1-Covered

FML FORTE (fluorometholone)025 EYE DROPS

1-Covered

FML SOP (fluorometholone) 01OINTMENT

1-Covered

ketorolac tromethamine 05 drops

1-Covered

PRED MILD (prednisolone acetate)012 EYE DROPS

1-Covered

prednisolone acetate 1 dropssusp

1-Covered

prednisolone sodium phosphate 1 drops

1-Covered




114



OPHTHALMIC ANTIGLAUCOMA AGENTS (Drugs for Glaucoma)ALPHAGAN P (brimonidinetartrate) ALHAGAN 01 DROS


apraclonidine hcl 05 drops 1-Covered

betaxolol hcl 05 drops 1-Covered

BETIMOL (timolol) 025 DROPS05 DROPS

1-Covered

BETOPTIC S (betaxolol hcl) 025EYE DROP

1-Covered

brimonidine tartrate 02 drops 1-Covered

dorzolamide hcl 2 drops 1-Covered

dorzolamide hcltimolol maleate223-681 drops


DORZOLAMIDE-TIMOLOL -EYEDROPS


IOPIDINE (apraclonidine hcl) 1EYE DROPS

1-Covered

levobunolol hcl 05 drops 1-Covered

methazolamide 25 mg tablet 50mg tablet

1-Covered

METHAZOLAMIDE 25 MG TABLET 50MG TABLET

1-Covered

PHOSPHOLINE IODIDE(echothiophate iodide) 0125

1-Covered

pilocarpine hcl 1 drops 2 drops 4 drops

1-Covered

PILOCARPINE HCL 1 DROPS 2DROPS

1-Covered

timolol maleate 025 sol-gel 025 drops 05 drops 05 sol-gel

1-Covered

TIMOLOL MALEATE 05 EYE DROPS 1-Covered

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS (Drugsfor Glaucoma)

latanoprost 0005 drops 1-Covered




115



OTIC AGENTS (Drugs for the Ears)

OTIC AGENTS (Drugs for Ear Infection)acetic acid 2 solution 1-Covered

ACETIC ACID 2 EAR SOLUTION 1-Covered

carbamide peroxide(CARBAMOXIDE) 65 drops

1-Covered

carbamide peroxide (EAR DROPS)65 drops

1-Covered

carbamide peroxide (EAR SYSTEM)65 drops

1-Covered

carbamide peroxide (EAR WAXREMOVAL) 65 drops

1-Covered

carbamide peroxide (MURINE EARWAX REMOVAL SYSTEM) 65 drops

1-Covered

DEBROX (carbamide peroxide)65 EAR DROPS

1-Covered

EAR DROPS (carbamide peroxide)65

1-Covered

hydrocortisoneacetic acid(ACETASOL HC) 1 -2 drops

1-Covered

hydrocortisoneacetic acid 1 -2 drops

1-Covered

MURINE EAR DROPS (carbamideperoxide) 65

1-Covered

neomycin sulfatepolymyxin bsulfatehydrocortisoneneomycinpolymyxin bhydrocort35--1 solutionneomycinpolymyxin bhydrocort35--1 drops susp

1-Covered

NEOMYCIN-POLYMYXIN-HC --EARSUSP

1-Covered

RESPIRATORY TRACTPULMONARY AGENTS (Drugs for the Lungs)

ANTI-INFLAMMATORIES INHALED CORTICOSTEROIDS (Inhaled Drugsto Prevent Swelling of the Airways)

BUDESONIDE 025 MG2 ML SUSP 1-Covered AL1 (Up to 6 yrs old)




116



budesonide 025mg2ml - 05mg2ml -

1-Covered AL1 (Up to 6 yrs old)

CHILDRENS NASACORT(triamcinolone acetonide)ALLERGY 24 HR


FLOVENT DISKUS (fluticasonepropionate) 50 MCG 100 MCG250 MCG

1-Covered

FLOVENT HFA (fluticasonepropionate) HFA 44 MCG INHALERHFA 110 MCG INHALER HFA 220MCG INHALER

1-Covered

fluticasone propionate (ALLERGYRELIEF) 50 mcg spray susp


fluticasone propionate 50 mcgspray susp


NASACORT (triamcinoloneacetonide) ALLERGY 24HR SPRAY

1-Covered

PULMICORT FLEXHALER(budesonide) 180 MCG

1-Covered

QVAR REDIHALER(beclomethasone dipropionate)40 MCG 80 MCG

1-Covered

triamcinolone acetonide 55 mcgspray


ANTIHISTAMINESALAVERT (loratadine) 10 MG ODT 1-Covered AL1 (Up to 12 yrs old)

ALL DAY ALLERGY ERGY 10 MGTABLET SM ERGY 10 MG TAB

1-Covered

ALLERGY RELIEF (LORATADINE) 10MG TAB RELIEF 10 MG TABLET


ALLERGY RELIEF 4 MG TABLET HM 4MG TABLET HM 25 MG CAP 25 MGSOFTGEL GS 25 MG TABLET

1-Covered

ALLERGY RELIEF HM 180 MG TAB180 MG TABLET

1-Covered ST

AZELASTINE HCL 01 (137 MCG)SPRY


azelastine hcl 137 mcgspraypump





117



cetirizine hcl (24HOUR ALLERGY) 10mg tablet

1-Covered

cetirizine hcl (ALL DAY ALLERGYRELIEF) 10 mg tablet

1-Covered

cetirizine hcl (ALL DAY ALLERGY) 10mg tablet

1-Covered

cetirizine hcl (ALLER-TEC) 10 mgtablet -

1-Covered

cetirizine hcl (ALLERGY RELIEF) 10mg tablet

1-Covered

cetirizine hcl (WAL-ZYR) 10 mgtablet -

1-Covered

cetirizine hcl 1 mgml 5 mg5 ml 1-Covered ST AL1 (Up to 5 yrs old)

CETIRIZINE HCL 10 MG TABLET 1-Covered

cetirizine hcl 5 mg tablet 10 mgtablet

1-Covered

CHILDRENS ALLERGY RELIEF 5MG5 ML

1-Covered QL (150 PER 30 DAY(S)) AL1 (Up to6 yrs old)

CHILDRENS ALLERGY RELIEF RLF125 MG5 ML

1-Covered

chlorpheniramine maleate(ALLERGY 4-HOUR) mg tablet -

1-Covered

chlorpheniramine maleate(ALLERGY RELIEF) 4 mg tablet

1-Covered

chlorpheniramine maleate(ALLERGY) 4 mg tablet

1-Covered

chlorpheniramine maleate(ALLERGY-TIME) 4 mg tablet -

1-Covered

chlorpheniramine maleate(CHLORHIST) 4 mg tablet

1-Covered

chlorpheniramine maleate(CHLORTABS) 4 mg tablet

1-Covered

chlorpheniramine maleate (EDCHLORPED JR) 2 mg5 ml syrup

1-Covered

chlorpheniramine maleate(PHARBECHLOR) 4 mg tablet

1-Covered

chlorpheniramine maleate (WAL-FINATE) 4 mg tablet -

1-Covered

chlorpheniramine maleate 4 mgtablet

1-Covered




118



clemastine fumarate 268 mgtablet

1-Covered

cyproheptadine hcl 2 mg5 mlsyrup 4 mg tablet 4 mg10 mlsyrup

1-Covered

diphenhydramine hcl (ALER-CAPS)25 mg capsule -

1-Covered

diphenhydramine hcl (ALLER-G-TIME) 25 mg tablet --

1-Covered

diphenhydramine hcl (ALLERGYMEDICATION) 25 mg capsule 25mg tablet

1-Covered

diphenhydramine hcl (ALLERGYMEDICINE) 25 mg tablet

1-Covered

diphenhydramine hcl (ALLERGYRELIEF) 125mg5ml liquid 25 mgcapsule 25 mg tablet

1-Covered

diphenhydramine hcl (ALLERGY)125mg5ml liquid 25 mg capsule25 mg tablet

1-Covered

diphenhydramine hcl (BANOPHEN)125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule

1-Covered

diphenhydramine hcl (BENADRYLALLERGY) 25 mg tablet

1-Covered

diphenhydramine hcl (CHILDRENSALLERGY RELIEF) 125mg5ml liquid

1-Covered

diphenhydramine hcl (CHILDRENSALLERGY) 125mg5ml elixir125mg5ml liquid

1-Covered

diphenhydramine hcl (CHILDRENSBENADRYL ALLERGY) 125mg5mlliquid

1-Covered

diphenhydramine hcl (CHILDRENSWAL-DRYL ALLERGY) 125mg5mlliquid -

1-Covered

diphenhydramine hcl (COMPLETEALLERGY) 25 mg capsule 25 mgtablet

1-Covered

diphenhydramine hcl (DIPHEDRYLALLERGY) 125mg5ml liquid

1-Covered




119



diphenhydramine hcl (DIPHEDRYL)125mg5ml liquid 25 mg capsule

1-Covered

diphenhydramine hcl (DIPHEN)125mg5ml elixir 25 mg tablet

1-Covered

diphenhydramine hcl (DIPHENHIST)125mg5ml liquid 25 mg tablet

1-Covered

diphenhydramine hcl (GERI-DRYL)125mg5ml liquid - 25 mg tablet -

1-Covered

diphenhydramine hcl (M-DRYL)125mg5ml liquid -

1-Covered

diphenhydramine hcl (NIGHTTIMEALLERGY RELIEF) 25 mg tablet

1-Covered

diphenhydramine hcl (NIGHTTIMESLEEP AID) 25 mg tablet

1-Covered

diphenhydramine hcl(PHARBEDRYL) 25 mg capsule 50mg capsule

1-Covered

diphenhydramine hcl (SILADRYL)125mg5ml liquid

1-Covered

diphenhydramine hcl (SIMPLYSLEEP) 25 mg tablet

1-Covered

diphenhydramine hcl (SLEEP AID)25 mg tablet

1-Covered

diphenhydramine hcl (TOTALALLERGY) 25 mg tablet

1-Covered

diphenhydramine hcl (WAL-DRYLALLERGY) 125mg5ml liquid - 25mg tablet -

1-Covered

diphenhydramine hcl (WAL-DRYL)25 mg capsule -

1-Covered

DIPHENHYDRAMINE HCL 125 MG5ML 25 MG10 ML

1-Covered

diphenhydramine hcl 125mg5mlelixir 125mg5ml syrup125mg5ml liquid 25 mg tablet 25mg capsule 50 mg capsule

1-Covered

fexofenadine hcl (ALLER-EASE) 60mg tablet - 180 mg tablet -

1-Covered ST

fexofenadine hcl (ALLER-FEX) 180mg tablet -

1-Covered ST




120



fexofenadine hcl (ALLERGY RELIEF)60 mg tablet 180 mg tablet

1-Covered ST

fexofenadine hcl (WAL-FEXALLERGY) 60 mg tablet - 180 mgtablet -

1-Covered ST

fexofenadine hcl 60 mg tablet 180mg tablet

1-Covered ST

FEXOFENADINE HCL HM 60 MGTAB 60 MG TABLET 180 MG TABLET

1-Covered ST

GERI-DRYL -125 MG5 ML LIQUID 1-Covered

hydroxyzine hcl 10 mg tablet 10mg5 ml solution 25 mg tablet 50mg tablet 50 mg25ml solution

1-Covered

HYDROXYZINE PAMOATE 25 MGCAP 50 MG CAP

1-Covered

hydroxyzine pamoate 25 mgcapsule 50 mg capsule 100 mgcapsule

1-Covered

loratadine (ALLERCLEAR) 10 mgtablet


loratadine (ALLERGY RELIEF) 10 mgtablet


loratadine (ALLERGY RELIEF) 5mg5 ml solution


loratadine (ALLERGY) 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)

loratadine (CHILDRENS ALLERGYRELIEF) 5 mg5 ml solution


loratadine (CHILDRENS ALLERGY) 5mg5 ml solution


loratadine (LORADAMED) 10 mgtablet


loratadine (NON-DROWSYALLERGY) 10 mg tablet -


loratadine (WAL-ITIN) 10 mg tablet-


loratadine (WAL-ITIN) 5 mg5 mlsolution -


loratadine 10 mg tablet 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)




121



LORATADINE 10 MG TABLET 1-Covered QL (30 PER 30 DAY(S)) MDD (1 PerDay)

loratadine 5 mg5 ml solution 1-Covered QL (150 PER 30 DAYS) AL1 (Up to6 yrs old)

NIGHTTIME SLEEP AID HM 25 MGCPLT

1-Covered

promethazine hcl 125 mg tablet25 mg tablet

1-Covered

PROMETHAZINE HCL 625 MG5 MLSOLN


promethazine hcl 625mg5mlsyrup


ANTILEUKOTRIENESmontelukast sodium 4 mg granpack

1-Covered ST

MONTELUKAST SODIUM 4 MGGRANULES

1-Covered ST

montelukast sodium 4 mg tabchew 5 mg tab chew 10 mgtablet


BRONCHODILATORS ANTICHOLINERGIC (Anticholinergic Drugs toOpen the Airway)

ATROVENT HFA (ipratropiumbromide) 17 MCG INHALER

1-Covered

INCRUSE ELLIPTA (umeclidiniumbromide) 625 MCG INH

1-Covered C (RESTRICTED TO THE DIAGNOSISOF CHRONIC OBSTRUCTIVEPULMONARY DISEASE (COPD))

ipratropium bromide 02 mgmlsolution 21 mcg spray 42 mcgspray

1-Covered

BRONCHODILATORS SYMPATHOMIMETIC (Sympathomimetic Drugsto Open the Airway)

albuterol 90mcg hfa inhaler(generic proair)

1-Covered QL (2 PER 30 [DAYS])

albuterol 90mcg hfa inhaler(generic proventil)


albuterol 90mcg hfa inhaler(generic ventolin)





122



ALBUTEROL SULFATE 100 MG20 MLSOLN

1-Covered

albuterol sulfate 2 mg tablet 2mg5 ml syrup 25 mg3ml vial-neb 25 mg05 vial-neb 4 mg taber 12h 4 mg tablet 5 mgmlsolution 8 mg tab er 12h

1-Covered

albuterol sulfate 90 mcg hfa aerad


ALBUTEROL SULFATE HFA 90 MCGINHALER


epinephrine 015mg03 03mg03 1-Covered QL (2 PER FILL(S))

FORADIL (formoterol fumarate)AEROLIZER 12 MCG CAP

1-Covered ST

levalbuterol tartrate 45 mcg hfaaer ad


metaproterenol sulfate 10 mg5 mlsyrup 10 mg tablet 20 mg tablet

1-Covered

NASAL DECONGESTANT(pseudoephedrine hcl) 30 MG TAB

1-Covered

pseudoephedrine hcl (NASALDECONGESTANT) 30 mg tablet

1-Covered

pseudoephedrine hcl (SUDOGEST)30 mg tablet 60 mg tablet

1-Covered

pseudoephedrine hcl (SUPHEDRIN)30 mg tablet

1-Covered

pseudoephedrine hcl (SUPHEDRINESINUS CONGESTION) 30 mg tablet

1-Covered

pseudoephedrine hcl(SUPHEDRINE) 30 mg tablet

1-Covered

pseudoephedrine hcl (WAL-PHED)30 mg tablet -

1-Covered

pseudoephedrine hcl 30 mgtablet 60 mg tablet

1-Covered

SEREVENT DISKUS (salmeterolxinafoate) 50 MCG


SUDAFED (pseudoephedrine hcl)30 MG TABLET

1-Covered

TERBUTALINE SULFATE 25 MG TAB 5MG TAB

1-Covered




123



terbutaline sulfate 25 mg tablet 5mg tablet

1-Covered

PHOSPHODIESTERASE INHIBITORS AIRWAYS DISEASE (Drugs thatBlock Phosphodiesterase)

ELIXOPHYLLIN (theophyllineanhydrous) OPHYLLIN 80 MG15 ML

1-Covered

THEO-24 (theophylline anhydrous) -24 ER 200 MG CAPSULE -24 ER 300MG CAPSULE -24 ER 100 MGCAPSULE -24 ER 400 MG CAPSULE

1-Covered

theophylline anhydrous(THEOCHRON) 100 mg tab er 200mg tab er 300 mg tab er

1-Covered

theophylline anhydrous 80mg15ml solution 80 mg15ml elixir100 mg tab er 12h 200 mg tab er12h 300 mg tab er 12h 400 mgtab er 24h 450 mg tab er 12h 600mg tab er 24h

1-Covered

PULMONARY ANTIHYPERTENSIVES (Drugs for PulmonaryHypertension)

ambrisentan 5 mg tablet 10 mgtablet

1-Covered PA QL (1 PER 1 DAY(S)) SP

bosentan 625 mg tablet 125 mgtablet


sildenafil citrate 20 mg tablet 1-Covered PA QL (3 PER 1 DAY(S)) SP

SILDENAFIL CITRATE 20 MG TABLET 1-Covered PA QL (3 PER 1 DAY(S)) SP

tadalafil (ALYQ) 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP

tadalafil 20 mg tablet 1-Covered PA QL (2 PER 1 DAY(S)) SP

RESPIRATORY TRACT AGENTS OTHER (Other Drugs for BreathingConditions)

acetylcysteine 100 mgml vial 200mgml vial

1-Covered

benzonatate 100 mg capsule 1-Covered

BEVESPI AEROSPHERE(glycopyrrolateformoterolfumarate) INHALER

1-Covered ST




124



brompheniraminemaleatepseudoephedrine hcl(RYNEX PSE)brompheniraminpseudoephedrine 1-15mg5ml liquid

1-Covered

BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 1-15-5MG5 ML LIQ

1-Covered

chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE)chlorpheniraminpseudoepheddm 1-15-5mg5 liquid

1-Covered

codeine phosphateguaifenesin(CHERATUSSIN AC) 10-100mg5liquid


codeine phosphateguaifenesin(G TUSSIN AC) 10-100mg5 liquid


codeine phosphateguaifenesin(GUAIATUSSIN AC) 10-100mg5 20-20010


codeine phosphateguaifenesin(GUAIFENESIN AC) 10-100mg5liquid


codeine phosphateguaifenesin(ROBAFEN AC) 10-100mg5 liquid


codeine phosphateguaifenesin(VIRTUSSIN AC) 10-100mg5 liquid


codeine phosphateguaifenesin10-100mg5 20-20010


CODEINE-GUAIFENESIN -10-100MG5 ML


COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 20-100MCG

1-Covered

COUGH FORMULA DM(guaifenesindextromethorphanhbr) SYRUP

1-Covered




125



fluticasone propionatesalmeterolxinafoate (WIXELA INHUB)propionsalmeterol 100-50 mcgwdev propionsalmeterol 250-50mcg wdev propionsalmeterol500-50 mcg wdev


fluticasone propionatesalmeterolxinafoate propionsalmeterol 100-50 mcg wdev propionsalmeterol250-50 mcg wdevpropionsalmeterol 500-50 mcgwdev


fluticasone propionatesalmeterolxinafoate propionsalmeterol 55-14mcg propionsalmeterol 113-14mcg propionsalmeterol 232-14mcg


GUAIASORB DM LIQUID 1-Covered

guaifenesin (MUCUS ER) 600 mgtab er 12h

1-Covered

guaifenesin (MUCUS RELIEF ER) 600mg tab er 12h

1-Covered

GUAIFENESIN-DEXTROMETHORPHAN DM SYRUP

1-Covered

guaifenesindextromethorphanhbr (ADULT ROBITUSSIN PEAK COLDDM) 100-10mg5 liquid

1-Covered

guaifenesindextromethorphanhbr (ADULT TUSSIN COUGHCONGEST DM) 100-10mg5 liquid

1-Covered

guaifenesindextromethorphanhbr (ADULT TUSSIN DM) 100-10mg5syrup

1-Covered

guaifenesindextromethorphanhbr (ADULT WAL-TUSSIN DM) 100-10mg5 syrup -

1-Covered

guaifenesindextromethorphanhbr (ANTITUSSIVE DM) 100-10mg5syrup

1-Covered

guaifenesindextromethorphanhbr (BIOCOTRON) 100-10mg5liquid

1-Covered

guaifenesindextromethorphanhbr (COUGH DM) 100-10mg5syrup

1-Covered




126



guaifenesindextromethorphanhbr (DIABETIC SILTUSSIN-DM) 100-10mg5 liquid -

1-Covered

guaifenesindextromethorphanhbr (DIABETIC TUSSIN DM) 100-10mg5 liquid

1-Covered

guaifenesindextromethorphanhbr (EXPECTORANT DM) 100-10mg5 syrup

1-Covered

guaifenesindextromethorphanhbr (EXTRA ACTION COUGH) 100-10mg5 syrup

1-Covered

guaifenesindextromethorphanhbr (GERI-TUSSIN DM) 100-10mg5liquid - 100-10mg5 syrup -

1-Covered

guaifenesindextromethorphanhbr (GILTUSS DIABETIC) 100-10mg5liquid

1-Covered

guaifenesindextromethorphanhbr (GILTUSS HBP) 100-10mg5liquid

1-Covered

guaifenesindextromethorphanhbr (GUAIASORB DM) 100-10mg5liquid

1-Covered

guaifenesindextromethorphanhbr (RI-TUSSIN DM) 100-10mg5syrup -

1-Covered

guaifenesindextromethorphanhbr (ROBAFEN DM COUGH) 100-10mg5 liquid

1-Covered

guaifenesindextromethorphanhbr (ROBAFEN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -

1-Covered

guaifenesindextromethorphanhbr (ROBAFEN DM PEAK COLD)100-10mg5 liquid

1-Covered

guaifenesindextromethorphanhbr (ROBAFEN-DM) 100-10mg5syrup -

1-Covered

guaifenesindextromethorphanhbr (SAFETUSSIN DM) 100-10mg5liquid

1-Covered

guaifenesindextromethorphanhbr (SILTUSSIN DM DAS) 100-10mg5liquid

1-Covered




127



guaifenesindextromethorphanhbr (SILTUSSIN DM) 100-10mg5syrup

1-Covered

guaifenesindextromethorphanhbr (SORBUGEN NR) 100-10mg5liquid

1-Covered

guaifenesindextromethorphanhbr (TUSNEL DIABETIC) 100-10mg5liquid

1-Covered

guaifenesindextromethorphanhbr (TUSSIN COUGH) 100-10mg5liquid

1-Covered

guaifenesindextromethorphanhbr (TUSSIN DM CLEAR) 100-10mg5syrup

1-Covered

guaifenesindextromethorphanhbr (TUSSIN DM COUGH) 100-10mg5 syrup

1-Covered

guaifenesindextromethorphanhbr (TUSSIN DM COUGH-CHESTCONGEST) 100-10mg5 syrup -

1-Covered

guaifenesindextromethorphanhbr (TUSSIN DM) 100-10mg5 liquid100-10mg5 syrup

1-Covered

guaifenesindextromethorphanhbr (ULTRA DM FREE amp CLEAR) 100-10mg5 liquid

1-Covered

guaifenesindextromethorphanhbr (ULTRA TUSS) 100-10mg5 syrup

1-Covered

guaifenesindextromethorphanhbr (WAL-TUSSIN DM) 100-10mg5syrup -

1-Covered

guaifenesindextromethorphanhbr 100-10mg5 syrup 100-10mg5liquid

1-Covered

guaifenesinpseudoephedrine hcl(MUCUS D)guaifenesinpseudoephedrne600mg-60mg tab er 12h

1-Covered

guaifenesinpseudoephedrine hcl(MUCUS RELIEF D)guaifenesinpseudoephedrne600mg-60mg tab er 12h

1-Covered




128



guaifenesinpseudoephedrine hclguaifenesinpseudoephedrne600mg-60mg tab er 12h

1-Covered

ipratropium bromidealbuterolsulfate ipratropiumalbuterol 05-3mg3 ampul-neb


IPRATROPIUM-ALBUTEROL -05-3(25) MG3 ML


MAXI-TUSS G -LIQUID 1-Covered

MUCUS ER CVS 600 MG TABLET 1-Covered

MUCUS RELIEF ER HM 600 MG TAB 1-Covered

phenylephrine hclpromethazinehcl prometh 5-625mg5 syrup


promethazine hclcodeine 625-105 syrup

1-Covered QL (240 PER 30 DAYS) AL1 (Atleast 12 yrs old) QLC (LIMIT 240ML(8OZ) PER 30 DAYS)

promethazinehcldextromethorphan hbrpromethazinedextromethorphan625-155 syrup


PROMETHAZINE-DM -625-15MG5ML


promethazinephenylephrinehclcodeinepromethazinephenylephcodeine625-5-10 syrup


sodium chloride for inhalation 09 vial- 3 vial- 10 vial-

1-Covered

triprolidine hclpseudoephedrinehcl (APRODINE)triprolidinepseudoephedrine25mg-60mg tablet

1-Covered

triprolidine hclpseudoephedrinehcl (ED A-HIST PSE)triprolidinepseudoephedrine25mg-60mg tablet -

1-Covered

triprolidine hclpseudoephedrinehcl (RITIFED)triprolidinepseudoephedrine 125-305 syrup

1-Covered

triprolidine hclpseudoephedrinehcl (WAL-ACT D COLD amp ALLERGY)triprolidinepseudoephedrine25mg-60mg tablet -col

1-Covered




129



SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles)

SKELETAL MUSCLE RELAXANTS (Drugs to Relax the Muscles)carisoprodol 350 mg tablet 1-Covered QL (90 PER 30 DAYS)

CARISOPRODOL 350 MG TABLET 1-Covered QL (90 PER 30 DAYS)

cyclobenzaprine hcl 10 mg tablet 1-Covered QL (90 PER 30 DAYS)

cyclobenzaprine hcl 5 mg tablet 1-Covered QL (90 PER 30 DAY(S))

methocarbamol 500 mg tablet750 mg tablet


METHOCARBAMOL 500 MG TABLET750 MG TABLET


VANADOM 350 MG TABLET 1-Covered QL (90 PER 30 DAY(S))

SLEEP DISORDER AGENTS (Drugs for Insomnia)

GABA RECEPTOR MODULATORSflurazepam hcl 15 mg capsule 30mg capsule


temazepam 75 mg capsule 15mg capsule 30 mg capsule

1-Covered

triazolam 0125 mg tablet 025 mgtablet


zaleplon 5 mg capsule 10 mgcapsule

1-Covered ST

zolpidem tartrate 5 mg tablet 10mg tablet

1-Covered

SLEEP DISORDERS OTHERdiphenhydramine hcl (ALKA-SELTZER PLUS ALLERGY) 25 mgtablet -

1-Covered

diphenhydramine hcl (COMPOZ)25 mg tablet

1-Covered


1-Covered

diphenhydramine hcl (NYTOLQUICKCAPS) 25 mg tablet

1-Covered




130




1-Covered


1-Covered

diphenhydramine hcl (SLEEP II) 25mg tablet

1-Covered

diphenhydramine hcl (SLEEPTABLET) 25 mg tablet

1-Covered

modafinil 100 mg tablet 200 mgtablet





131

Alphabetical Index of Prescription Drugs

009 sodium chloride 697072

Aabacavir sulfate 38abacavir sulfatelamivudine 38abacavir sulfatelamivudinezidovudine 38ABACAVIR-LAMIVUDINE 38ABILIFY (aripiprazole) 31ABILIFY MAINTENA (aripiprazole) 31ABILIFY MYCITE (aripiprazole) 31acamprosate calcium 6acarbose 4243acetaminophen 64ACETAMINOPHEN 64acetaminophen (ATHENOL) 63acetaminophen (CHILD FEVER REDUCER) 63acetaminophen (CHILD PAIN REL-FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCER) 63acetaminophen (CHILDRENS FEVERREDUCING) 63acetaminophen (CHILDRENS PAIN ANDFEVER) 63acetaminophen (CHILDRENS SILAPAP) 63acetaminophen (ED-APAP) 63acetaminophen (LITTLE REMEDIES FEVER-PAIN) 63acetaminophen (M-PAP) 63acetaminophen (MAPAP) 63acetaminophen (MASOPHEN) 63acetaminophen (NON-ASPIRIN EXTRASTRENGTH) 63acetaminophen (NON-ASPIRIN PAIN RELIEF) 63acetaminophen (NON-ASPIRIN) 63acetaminophen (PAIN amp FEVER) 63acetaminophen (PAIN RELIEF EXTRASTRENGTH) 64acetaminophen (PAIN RELIEF) 64

acetaminophen (PAIN RELIEVER) 64acetaminophen (PHARBETOL) 64acetaminophen (SHAKE THAT ACHE) 64acetaminophen (TACTINAL) 64ACETAMINOPHEN 160 MG5ML ORAL SUSP 64ACETAMINOPHEN 160 MG5ML SOLUTION 64acetaminophen with codeine phosphate 45acetazolamide 57ACETAZOLAMIDE 58acetic acid 116ACETIC ACID 116acetylcysteine 124ACID CONTROLLER 80ACID REDUCER 80ACNE MEDICATION 66ACNE MEDICATION (benzoyl peroxide) 66acyclovir 41ACYCLOVIR 41ADACEL TDAP(diphtheriapertussis(acellular)tetanusvaccinepf) 106ADASUVE (loxapine) 30ADLYXIN (lixisenatide) 43ADMELOG (insulin lispro) 45ADMELOG SOLOSTAR (insulin lispro) 45ADVATE (antihemophilic factor (fviii)recombinantfull length) 47ADYNOVATE (antihemophilic factor (fviii)recombinant full length peg) 47AFLURIA QUAD 2020-2021 106AFLURIA QUAD 2020-21 (3YR UP) 106AFSTYLA (antihemophilic factor viiirecombsingle-chnb-dom truncated) 47ALAVERT (loratadine) 117ALAWAY (ketotifen fumarate) 113Albuterol 90mcg HFA inhaler (GenericProair) 122Albuterol 90mcg HFA inhaler (GenericProventil) 122Albuterol 90mcg HFA inhaler (GenericVentolin) 122


ALBUTEROL SULFATE 123albuterol sulfate 123ALBUTEROL SULFATE HFA 123alcohol antiseptic pads 110ALCOHOL WIPES 110alendronate sodium 109alfuzosin hcl 86ALL DAY ALLERGY 117ALLERGY RELIEF 117ALLI (orlistat) 78allopurinol 24ALLOPURINOL 24alogliptin benzoate 43alogliptin benzoatemetformin hcl 43alogliptin benzoatepioglitazone hcl 43ALOMIDE (lodoxamide tromethamine) 114ALPHAGAN P (brimonidine tartrate) 115ALPHANATE (antihemophilic factorhumanvon willebrand factorhuman) 47ALPHANINE SD (factor ix) 47alprazolam 42alprazolam (ALPRAZOLAM INTENSOL) 42ALPROLIX (factor ix recombinant fc fusionprotein) 48AMANTADINE 29amantadine hcl 29ambrisentan 124amiloride hcl 58amiloride hclhydrochlorothiazide 56amiodarone hcl 53amiodarone hcl (PACERONE) 53AMITIZA (lubiprostone) 81amitriptyline hcl 19AMLODIPINE BESYLATE 54amlodipine besylate 54amlodipine besylatebenazepril hcl 56ammonium lactate 66ammonium lactate (SKIN TREATMENT) 66amoxapine 19amoxicillin 11AMOXICILLIN-CLAVULANATE POTASS 11

amoxicillinpotassium clavulanate 1112ampicillin trihydrate 12anagrelide hcl 47anastrozole 28ANASTROZOLE 28ANTACID 78ANTACID EXTRA STRENGTH 78ANTI-DIARRHEAL 78ANTIFUNGAL 21apraclonidine hcl 115aprepitant 21APTIVUS (tipranavir) 40APTIVUS (tipranavirvitamin e tpgs) 40aripiprazole 32ARIPIPRAZOLE 32ARISTADA (aripiprazole lauroxil) 32ARISTADA INITIO (aripiprazole lauroxilsubmicronized) 32ARMOUR THYROID (thyroidpork) 102ascorbate calcium 72ascorbic acid 72ascorbic acid (SOOTHING PUREWAY-C) 72aspirin 1aspirin (ADULT ASPIRIN REGIMEN) 1aspirin (ADULT LOW DOSE ASPIRIN EC) 1aspirin (ASPIR 81) 1aspirin (ASPIR-TRIN) 1aspirin (ASPIRIN) 1aspirin (ECOTRIN) 1aspirin (ECPIRIN) 1aspirin (ST JOSEPH ASPIRIN EC) 1aspirin (ST JOSEPH ASPIRIN) 1ASPIRIN 325MG TABLET 1ASPIRIN 81MG TABLET 1aspirinacetaminophencaffeine (ADDEDSTRENGTH HEADACHE) 1aspirinacetaminophencaffeine (BAYERMIGRAINE) 1aspirinacetaminophencaffeine (EXTRA PAINRELIEF) 1


aspirinacetaminophencaffeine(EXTRAPRIN) 1aspirinacetaminophencaffeine (HEADACHERELIEF) 1aspirinacetaminophencaffeine (MIGRAINEFORMULA) 2aspirinacetaminophencaffeine (MIGRAINERELIEF) 2aspirinacetaminophencaffeine (PAINRELIEVER PLUS) 2aspirinacetaminophencaffeine (PAINRELIEVER) 2aspirinacetaminophencaffeine (PAIN-OFF) 2ASSURE ID DUO-SHIELD 110ASSURE ID INSULIN SAFETY 110ATAZANAVIR SULFATE 40atazanavir sulfate 40atenolol 53ATENOLOL 53atenololchlorthalidone 56ATHLETES FOOT (terbinafine hcl) 21atomoxetine hcl 62atorvastatin calcium 59ATORVASTATIN CALCIUM 59ATRIPLA (efavirenzemtricitabinetenofovirdisoproxil fumarate) 37atropine sulfate 112ATROVENT HFA (ipratropium bromide) 122AVANDIA (rosiglitazone maleate) 43AVONEX (interferon beta-1a) 65AVONEX (interferon beta-1aalbuminhuman) 65AVONEX PEN (interferon beta-1a) 65azathioprine 104AZATHIOPRINE 104AZELASTINE HCL 117azelastine hcl 117azithromycin 12AZITHROMYCIN 12

Bbacitracin 9BACITRACIN 9bacitracin (BACITRAYCIN PLUS) 9bacitracin zinc 9BACITRACIN ZINC 9bacitracin zinc (ANTIBIOTIC) 9bacitracinpolymyxin b sulfate 112bacitracinpolymyxin b sulfate (AK-POLY-BAC) 112bacitracinpolymyxin b sulfate (POLYCIN) 112baclofen 35BACLOFEN 35balsalazide disodium 109BAQSIMI (glucagon) 44BASAGLAR KWIKPEN U-100 (insulinglarginehuman recombinant analog) 45BELBUCA (buprenorphine hcl) 3benazepril hcl 52benazepril hclhydrochlorothiazide 56BENEFIX (factor ix human recombinant) 48benzonatate 124benzoyl peroxide 67benzoyl peroxide (ACNE CONTROLCLEANSER) 66benzoyl peroxide (ACNE FOAMING WASH) 66benzoyl peroxide (ACNE TREATMENT) 67benzoyl peroxide (ACNECLEAR) 67benzoyl peroxide (ADVANCED EXFOLIATINGCLEANSER) 67benzoyl peroxide (BP WASH) 67benzoyl peroxide (BP) 67benzoyl peroxide (BPO-10) 67benzoyl peroxide (BPO-5) 67benzoyl peroxide (CLEAN-CLEARCONTINUOUS CONTROL) 67benzoyl peroxide (DAYLOGIC ACNEFOAMING WASH) 67benzoyl peroxide (DAYLOGIC ACNETREATMENT) 67


benzoyl peroxide (FOAMING ACNE FACEWASH) 67benzoyl peroxide (PANOXYL) 67benztropine mesylate 29BEOVU (brolucizumab-dbll) 112betamethasone dipropionate 87BETAMETHASONE DIPROPIONATE 87betamethasone dipropionatepropyleneglycol 88betamethasone valerate 88betaxolol hcl 115bethanechol chloride 86BETIMOL (timolol) 115BETOPTIC S (betaxolol hcl) 115BEVESPI AEROSPHERE(glycopyrrolateformoterol fumarate) 124BEXSERO (meningococcal group b vaccine4-component) 106bicalutamide 27BIKTARVY (bictegravirsodiumemtricitabinetenofovir alafenamidefumar) 36bisacodyl 82BISACODYL 82bisacodyl (ALOPHEN PILLS) 81bisacodyl (BISA-LAX) 81bisacodyl (BISACODYL) 81bisacodyl (BISCOLAX) 81bisacodyl (C-LAX LAXATIVE) 81bisacodyl (DUCODYL) 81bisacodyl (FAST RELIEF LAXATIVE) 81bisacodyl (GENTLE LAXATIVE) 81bisacodyl (LAXATIVE SUPPOSITORY) 81bisacodyl (LAXATIVE) 82bisacodyl (MAGIC BULLET) 82bisacodyl (WOMENS GENTLE LAXATIVE) 82bisacodyl (WOMENS LAXATIVE) 82bismuth subsalicylate 78bismuth subsalicylate (BISMATROL) 78bismuth subsalicylate (DIOTAME) 78bismuth subsalicylate (PEP-T-MED) 78

bismuth subsalicylate (PEPTIC RELIEF) 78bismuth subsalicylate (PINK BISMUTH) 78bismuth subsalicylate (SOOTHE) 78bismuth subsalicylate (STOMACH RELIEF) 78bisoprolol fumarate 54bisoprolol fumaratehydrochlorothiazide 56BISOPROLOL-HYDROCHLOROTHIAZIDE 56BLEPH-10 (sulfacetamide sodium) 13BLEPHAMIDE (sulfacetamidesodiumprednisolone acetate) 112BOOSTRIX TDAP(diphtheriapertussis(acellular)tetanusvaccine) 106bosentan 124brimonidine tartrate 115bromocriptine mesylate 29brompheniramine maleatepseudoephedrinehcl (RYNEX PSE) 125BROTAPP DM (brompheniraminemaleatepseudoephedrinehcldextromethorphan) 125BUDESONIDE 116budesonide 117bumetanide 58BUNAVAIL (buprenorphine hclnaloxone hcl) 7BUPRENEX (buprenorphine hcl) 7buprenorphine 4buprenorphine hcl 7buprenorphine hclnaloxone hcl 7bupropion hcl 817bupropion hcl (BUPROBAN) 8BUPROPION HCL SR 17BUPROPION XL 17BUSPIRONE HCL 41buspirone hcl 42butalbitalacetaminophen 64butalbitalacetaminophen (TENCON) 64butalbitalacetaminophencaffeine 64butalbitalaspirincaffeine 2butorphanol tartrate 5BUTRANS (buprenorphine) 4


CCALADRYL (pramoxine hclcalamine) 67calcipotriene 67calcitoninsalmonsynthetic 110CALCITRIOL 110calcitriol 110CALCIUM 72CALCIUM 500-VIT D3 72CALCIUM 600-VIT D3 72calcium acetate 87calcium acetate (ELIPHOS) 87calcium carbonate 697379calcium carbonate (ANTACID CALCIUM) 78calcium carbonate (ANTACID EXTRASTRENGTH) 78calcium carbonate (ANTACID) 78calcium carbonate (BAN-ACID) 78calcium carbonate (CAL-GEST) 78calcium carbonate (CALCIUM ANTACID) 78calcium carbonate (CHILDRENS PEPTO) 79calcium carbonate (CHILDRENS SOOTHE) 79calcium carbonate (FLAVOR CHEWSANTACID) 79calcium carbonate (OYSCO-500) 72calcium carbonate (SMOOTH ANTACID) 79calcium carbonate (SMOOTH DISSOLVINGANTACID) 79calcium carbonate (SUPER CALCIUM) 72calcium carbonatecholecalciferol (vitamind3) 73calcium carbonatecholecalciferol (vitamind3) (HI-CAL) 73calcium carbonatecholecalciferol (vitamind3) (OS-CAL 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSCO 500-VIT D3) 73calcium carbonatecholecalciferol (vitamind3) (OYSTERCAL-D) 73calcium gluconate 73calcium lactate 73

capecitabine 27CAPECITABINE 27CAPLYTA (lumateperone tosylate) 32captopril 52CAPTOPRIL 52captoprilhydrochlorothiazide 56carbamazepine 16carbamazepine (EPITOL) 16carbamide peroxide (CARBAMOXIDE) 116carbamide peroxide (EAR DROPS) 116carbamide peroxide (EAR SYSTEM) 116carbamide peroxide (EAR WAXREMOVAL) 116carbamide peroxide (MURINE EAR WAXREMOVAL SYSTEM) 116CARBATROL (carbamazepine) 16carbidopalevodopa 30carisoprodol 130CARISOPRODOL 130carvedilol 54cefaclor 11CEFDINIR 11cefdinir 11celecoxib 2CELECOXIB 2CELONTIN (methsuximide) 14cephalexin 11cetirizine hcl 118CETIRIZINE HCL 118cetirizine hcl (24HOUR ALLERGY) 118cetirizine hcl (ALL DAY ALLERGY RELIEF) 118cetirizine hcl (ALL DAY ALLERGY) 118cetirizine hcl (ALLER-TEC) 118cetirizine hcl (ALLERGY RELIEF) 118cetirizine hcl (WAL-ZYR) 118CHANTIX (varenicline tartrate) 8CHEMET (succimer) 70CHILDRENS ALLERGY RELIEF 118CHILDRENS IBUPROFEN 2CHILDRENS NASACORT (triamcinoloneacetonide) 117


CHLORDIAZEPOXIDE-CLIDINIUM 77chlordiazepoxideclidinium bromide 77chlorhexidine gluconate 6667chlorhexidine gluconate (PAROEX) 66chloroquine phosphate 28chlorothiazide 58chlorpheniramine maleate 118chlorpheniramine maleate (ALLERGY 4-HOUR) 118chlorpheniramine maleate (ALLERGYRELIEF) 118chlorpheniramine maleate (ALLERGY) 118chlorpheniramine maleate (ALLERGY-TIME) 118chlorpheniramine maleate (CHLORHIST) 118chlorpheniramine maleate (CHLORTABS) 118chlorpheniramine maleate (ED CHLORPEDJR) 118chlorpheniramine maleate(PHARBECHLOR) 118chlorpheniramine maleate (WAL-FINATE) 118chlorpheniraminemaleatepseudoephedrinedextromethorphan (KIDKARE) 125chlorpromazine hcl 30CHLORPROMAZINE HCL 30chlorthalidone 58CHLORTHALIDONE 58cholecalciferol (vitamin d3) 110cholestyramine (with sugar) 59cholestyramineaspartame 59cholestyramineaspartame (PREVALITE) 59ciclopirox 21ciclopirox olamine 2122cilostazol 51CILOXAN (ciprofloxacin hcl) 13CIMDUO (lamivudinetenofovir disoproxilfumarate) 36cimetidine 80CIMETIDINE 80cimetidine (ACID REDUCER) 80

cimetidine (HEARTBURN RELIEF) 80cimetidine hcl 80cinacalcet hcl 110CINACALCET HCL 110ciprofloxacin hcl 13CIPROFLOXACIN HCL 13citalopram hydrobromide 18citric acidsodium citrate 86citric acidsodium citrate (CYTRA-2) 86citric acidsodium citrate (VIRTRATE-2) 86clarithromycin 12clemastine fumarate 119CLEOCIN (clindamycin phosphate) 9clindamycin hcl 9clindamycin palmitate hcl 9clindamycin phosphate 9CLINDAMYCIN PHOSPHATE 9CLINIMIX (amino acids 425 in dextrose 5 in water) 70clobetasol propionate 88CLOBETASOL PROPIONATE 88clomipramine hcl 19CLOMIPRAMINE HCL 19clonazepam 42clonidine hcl 51CLONIDINE HCL 51clopidogrel bisulfate 51clotrimazole 22CLOTRIMAZOLE 22clotrimazole (ANTIFUNGAL RINGWORM) 22clotrimazole (ANTIFUNGAL) 22clotrimazole (ATHLETES FOOT) 22clotrimazole (ATHLETIC FOOT CREAM) 22clotrimazole (CLOTRIMAZOLE AF) 22clotrimazole (ITCH RELIEF) 22clotrimazole (JOCK ITCH RELIEF) 22clotrimazole (JOCK ITCH) 22clotrimazole (RINGWORM) 22clozapine 34CLOZAPINE 34CLOZAPINE ODT 34


CLOZARIL (clozapine) 35COAGADEX (coagulation factor x) 48codeinephosphatebutalbitalaspirincaffeine 5codeine phosphateguaifenesin 125codeine phosphateguaifenesin(CHERATUSSIN AC) 125codeine phosphateguaifenesin (G TUSSINAC) 125codeine phosphateguaifenesin(GUAIATUSSIN AC) 125codeine phosphateguaifenesin(GUAIFENESIN AC) 125codeine phosphateguaifenesin (ROBAFENAC) 125codeine phosphateguaifenesin (VIRTUSSINAC) 125codeine sulfate 5CODEINE-GUAIFENESIN 125COGENTIN (benztropine mesylate) 29colchicine 24COLCHICINE 24COLESTID (colestipol hcl) 59colestipol hcl 59COMBIVENT RESPIMAT (ipratropiumbromidealbuterol sulfate) 125COMBIVIR (lamivudinezidovudine) 38COMPLERA (emtricitabinerilpivirinehcltenofovir disoproxil fumarate) 37condoms female 110condoms latex lubricated 110CORIFACT (factor xiii) 48CORTISPORIN (neomycin sulfatepolymyxin bsulfatehydrocortisone) 112CORTISPORIN(neomycinbacitracinpolymyxinbhydrocortisone) 67COUGH FORMULA DM(guaifenesindextromethorphan hbr) 125COUMADIN (warfarin sodium) 46CREON (lipaseproteaseamylase) 85

CRIXIVAN (indinavir sulfate) 40cromolyn sodium 110114cyanocobalamin (vitamin b-12) 73cyanocobalamin (vitamin b-12) (B-12DOTS) 73cyclobenzaprine hcl 130cyclopentolate hcl 112cyclophosphamide 26CYCLOPHOSPHAMIDE 26cyclosporine 104cyclosporine modified 104cyclosporine modified (GENGRAF) 104cyproheptadine hcl 119

Ddanazol 91dapsone 26DEBROX (carbamide peroxide) 116DELSTRIGO (doravirinelamivudinetenofovirdisoproxil fumarate) 37DELTASONE (prednisone) 88DEPAKENE (valproic acid (as sodium salt)(valproate sodium)) 15DEPAKENE (valproic acid) 15DEPO-PROVERA (medroxyprogesteroneacetate) 100DEPO-SUBQ PROVERA 104(medroxyprogesterone acetate) 100DESCOVY (emtricitabinetenofoviralafenamide fumarate) 39desipramine hcl 19desmopressin acetate 90DESMOPRESSIN ACETATE 90desmopressin acetate (non-refrigerated) 90desogestrel-ethinyl estradiol 91desogestrel-ethinyl estradiol (APRI) 91desogestrel-ethinyl estradiol (CYRED EQ) 91desogestrel-ethinyl estradiol (CYRED) 91desogestrel-ethinyl estradiol (EMOQUETTE) 91desogestrel-ethinyl estradiol (ENSKYCE) 91desogestrel-ethinyl estradiol (ISIBLOOM) 91


desogestrel-ethinyl estradiol (JULEBER) 91desogestrel-ethinyl estradiol (KALLIGA) 91desogestrel-ethinyl estradiol (RECLIPSEN) 91desogestrel-ethinyl estradiolethinylestradiol 92desogestrel-ethinyl estradiolethinyl estradiol(AZURETTE) 91desogestrel-ethinyl estradiolethinyl estradiol(BEKYREE) 92desogestrel-ethinyl estradiolethinyl estradiol(KARIVA) 92desogestrel-ethinyl estradiolethinyl estradiol(KIMIDESS) 92desogestrel-ethinyl estradiolethinyl estradiol(PIMTREA) 92desogestrel-ethinyl estradiolethinyl estradiol(SIMLIYA) 92desogestrel-ethinyl estradiolethinyl estradiol(VIORELE) 92desogestrel-ethinyl estradiolethinyl estradiol(VOLNEA) 92desonide 88DESONIDE 88dexamethasone 88DEXAMETHASONE 88dexamethasone (DEXAMETHASONEINTENSOL) 88dexamethasone sodium phosphate 114dextroamphetamine sulf-saccharateamphetamine sulf-aspartate 61dextroamphetamine sulfate 62DEXTROAMPHETAMINE SULFATE 62dextroamphetamine sulfate (ZENZEDI) 62DEXTROAMPHETAMINE-AMPHET ER 62dextrose 10 and 045 sodium chloride 70dextrose 10 in water 7073dextrose 5 and 045 sodium chloride 7073dextrose 5 in lactated ringers 73dextrose 5 in water 697073DEXTROSE IN WATER 74diazepam 1542

diclofenac sodium 2114dicloxacillin sodium 12DICYCLOMINE HCL 77dicyclomine hcl 77DIFFERIN (adapalene) 67diflunisal 2digoxin 56digoxin (DIGITEK) 56digoxin (DIGOX) 56DILANTIN (phenytoin sodium extended) 16DILANTIN (phenytoin) 16DILANTIN-125 16DILANTIN-125 (phenytoin) 16DILTIAZEM 24HR ER (CD) 54DILTIAZEM 24HR ER (XR) 55diltiazem hcl 55diltiazem hcl (CARTIA XT) 55diltiazem hcl (DILT-XR) 55diltiazem hcl (TAZTIA XT) 55DIMETHYL FUMARATE 65DIPHENHYDRAMINE HCL 120diphenhydramine hcl 120diphenhydramine hcl (ALER-CAPS) 119diphenhydramine hcl (ALKA-SELTZER PLUSALLERGY) 130diphenhydramine hcl (ALLER-G-TIME) 119diphenhydramine hcl (ALLERGYMEDICATION) 119diphenhydramine hcl (ALLERGYMEDICINE) 119diphenhydramine hcl (ALLERGY RELIEF) 119diphenhydramine hcl (ALLERGY) 119diphenhydramine hcl (BANOPHEN) 119diphenhydramine hcl (BENADRYLALLERGY) 119diphenhydramine hcl (CHILDRENS ALLERGYRELIEF) 119diphenhydramine hcl (CHILDRENSALLERGY) 119diphenhydramine hcl (CHILDRENS BENADRYLALLERGY) 119


diphenhydramine hcl (CHILDRENS WAL-DRYLALLERGY) 119diphenhydramine hcl (COMPLETEALLERGY) 119diphenhydramine hcl (COMPOZ) 130diphenhydramine hcl (DIPHEDRYLALLERGY) 119diphenhydramine hcl (DIPHEDRYL) 120diphenhydramine hcl (DIPHEN) 120diphenhydramine hcl (DIPHENHIST) 120diphenhydramine hcl (GERI-DRYL) 120diphenhydramine hcl (M-DRYL) 120diphenhydramine hcl (NIGHTTIME ALLERGYRELIEF) 120diphenhydramine hcl (NIGHTTIME SLEEPAID) 120130diphenhydramine hcl (NYTOL QUICKCAPS)130diphenhydramine hcl (PHARBEDRYL) 120diphenhydramine hcl (SILADRYL) 120diphenhydramine hcl (SIMPLY SLEEP) 120131diphenhydramine hcl (SLEEP AID) 120131diphenhydramine hcl (SLEEP II) 131diphenhydramine hcl (SLEEP TABLET) 131diphenhydramine hcl (TOTAL ALLERGY) 120diphenhydramine hcl (WAL-DRYLALLERGY) 120diphenhydramine hcl (WAL-DRYL) 120diphenoxylate hclatropine sulfate 79DIPHENOXYLATE-ATROPINE 79dipyridamole 51disopyramide phosphate 53disulfiram 6DIURIL (chlorothiazide) 58divalproex sodium 15DIVALPROEX SODIUM 15DOCUSATE SODIUM 82docusate sodium 82docusate sodium (COL-RITE) 82docusate sodium (DIOCTYL) 82docusate sodium (DOCU LIQUID) 82docusate sodium (DOCUSIL) 82

docusate sodium (DSS) 82docusate sodium (DULCOEASE) 82docusate sodium (DULCOLAX STOOLSOFTENER) 82docusate sodium (LAXA BASIC 100) 82docusate sodium (PHILLIPS LAXATIVE) 82docusate sodium (SOF-LAX) 82docusate sodium (STOOL SOFTENER) 82DOK (docusate sodium) 83donepezil hcl 17dorzolamide hcl 115dorzolamide hcltimolol maleate 115DORZOLAMIDE-TIMOLOL 115DOVATO (dolutegravir sodiumlamivudine) 39doxazosin mesylate 51DOXEPIN HCL 19doxepin hcl 19DOXYCYCLINE HYCLATE 14doxycycline hyclate 14doxycycline monohydrate 14DRITHOCREME HP (anthralin) 67dronabinol 21DROPLET MICRON PEN NEEDLE 110DROSPIRENONE-ETHINYL ESTRADIOL 92DROXIA (hydroxyurea) 27DRYSOL (aluminum chloride) 68duloxetine hcl 65

EEES 200 (erythromycin ethylsuccinate) 12EES 400 (erythromycin ethylsuccinate) 12EAR DROPS (carbamide peroxide) 116EDURANT (rilpivirine hcl) 37efavirenz 37EFAVIRENZ-EMTRIC-TENOFOV DISOP 37EFAVIRENZ-LAMIVU-TENOFOV DISOP 3637electrolytesdextrose (ELECTROLYTE) 74electrolytesdextrose (ORALYTE) 74electrolytesdextrose (PEDIATRICELECTROLYTE) 74


electrolytesdextrose (PEDIATRIC FREEZERPOPS) 74ELIQUIS (apixaban) 46ELIXOPHYLLIN (theophylline anhydrous) 124ELOCTATE (antihemophilic factor (fviii)recombinant fc fusion protein) 48EMCYT (estramustine phosphate sodium) 27EMSAM (selegiline) 18EMTRICITABINE 38EMTRICITABINE-TENOFOVIR DISOP 38EMTRIVA (emtricitabine) 38ENALAPRIL MALEATE 52enalapril maleate 52ENBREL 105ENBREL (etanercept) 104ENBREL SURECLICK (etanercept) 105ENGERIX-B ADULT (hepatitis b virus vaccinerecombinantpf) 106ENOXAPARIN SODIUM 46enoxaparin sodium 46entacapone 29EPIFOAM (hydrocortisone acetatepramoxinehcl) 68epinephrine 123EPIVIR (lamivudine) 38EPIVIR HBV (lamivudine) 35EPOGEN (epoetin alfa) 47EPZICOM (abacavir sulfatelamivudine) 38ERGOCALCIFEROL 110ergocalciferol (vitamin d2) 110ergocalciferol (vitamin d2) (CALCIDOL) 110ergotamine tartratecaffeine 25ERYTHROCIN STEARATE (erythromycinstearate) 12ERYTHROMYCIN 13erythromycin base 13erythromycin base in ethanol 13erythromycin base in ethanol (ERY) 13erythromycin basebenzoyl peroxide 9ERYTHROMYCIN ETHYLSUCCINATE 13erythromycin ethylsuccinate 13

escitalopram oxalate 18ESCITALOPRAM OXALATE 18ESPEROCT (antihemophilic factor (fviii) rec b-dom truncated peg-exei) 48estradiol 92ESTRADIOL 93estradiol (DOTTI) 92estrogensesterifiedmethyltestosterone 93estrogensesterifiedmethyltestosterone(COVARYX HS) 93estrogensesterifiedmethyltestosterone (EEMTHS) 93ethambutol hcl 26ETHAMBUTOL HCL 26ethinyl estradioldrospirenone 93ethinyl estradioldrospirenone (GIANVI) 93ethinyl estradioldrospirenone (JASMIEL) 93ethinyl estradioldrospirenone (LO-ZUMANDIMINE) 93ethinyl estradioldrospirenone (LORYNA) 93ethinyl estradioldrospirenone (NIKKI) 93ethinyl estradioldrospirenone (VESTURA) 93ETHOSUXIMIDE 14ethosuximide 14ethynodiol diacetate-ethinyl estradiol 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-35) 93ethynodiol diacetate-ethinyl estradiol(KELNOR 1-50) 93ethynodiol diacetate-ethinyl estradiol (ZOVIA1-35E) 93etodolac 2etonogestrelethinyl estradiol 94etonogestrelethinyl estradiol (ELURYNG) 93etoposide 28EVOTAZ (atazanavir sulfatecobicistat) 40EVZIO (naloxone hcl) 7EXCEDRIN EXTRA STRENGTH(aspirinacetaminophencaffeine) 2EXCEDRIN MIGRAINE(aspirinacetaminophencaffeine) 2


EYE ITCH RELIEF 114ezetimibe 59

Ffamotidine 81FAMOTIDINE 81famotidine (ACID CONTROLLER) 80famotidine (ACID REDUCER) 80famotidine (HEARTBURN PREVENTION) 81famotidine (HEARTBURN RELIEF) 81famotidine (PEPCID) 81FANAPT (iloperidone) 32FAZACLO (clozapine) 35FEIBA NF (anti-inhibitor coagulant complex) 48felodipine 55FELODIPINE ER 55fenofibrate 58FENOFIBRATE 58fenofibratemicronized 59fentanyl 4ferrous sulfate 74FERROUS SULFATE 74ferrous sulfate (CHILDRENS IRON) 74ferrous sulfate (FEOSOL) 74ferrous sulfate (FEROSUL) 74ferrous sulfate (FERRO-TIME) 74ferrous sulfate (FERROUSUL) 74ferrous sulfate (PEDIA IRON) 74fexofenadine hcl 121FEXOFENADINE HCL 121fexofenadine hcl (ALLER-EASE) 120fexofenadine hcl (ALLER-FEX) 120fexofenadine hcl (ALLERGY RELIEF) 121fexofenadine hcl (WAL-FEX ALLERGY) 121FIBRYGA (fibrinogen) 48finasteride 86flecainide acetate 53FLOVENT DISKUS (fluticasone propionate) 117FLOVENT HFA (fluticasone propionate) 117FLUAD 2020-2021 106FLUAD QUAD 2020-2021 106

FLUARIX QUAD 2020-2021 106FLUBLOK QUAD 2018-2019 (influenza virusvaccine qv 2018-19(18 yrs andolder)rcmbpf) 106FLUBLOK QUAD 2020-2021 107FLUCELVAX QUAD 2020-2021 107fluconazole 22FLUCONAZOLE 22fluconazole in dextrose iso-osmotic 22flucytosine 22FLUCYTOSINE 22fludrocortisone acetate 88FLULAVAL QUAD 2019-2020 (influenza virusvaccine quadrivalent 2019-20 (6 mos andup)) 107FLULAVAL QUAD 2020-2021 107fluocinolone acetonide 88fluocinonide 88FLUOCINONIDE 88fluoride (sodium) 74fluorometholone 114fluorouracil (ADRUCIL) 27fluoxetine hcl 18FLUOXETINE HCL 18fluoxymesterone (ANDROXY) 91fluphenazine decanoate 30fluphenazine hcl 30FLUPHENAZINE HCL 30flurazepam hcl 130flurbiprofen 2flurbiprofen sodium 114flutamide 27fluticasone propionate 117fluticasone propionate (ALLERGY RELIEF) 117fluticasone propionatesalmeterolxinafoate 126fluticasone propionatesalmeterol xinafoate(WIXELA INHUB) 126fluvoxamine maleate 18FLUZONE HIGH-DOSE QUAD 2020-21 107


FLUZONE QUAD 2019-2020 (influenza virusvaccine quadrival 2019-2020(6 mos andup)pf) 107FLUZONE QUAD 2020-2021 107FML FORTE (fluorometholone) 114FML SOP (fluorometholone) 114folic acid 74FOLIC ACID 74FORADIL (formoterol fumarate) 123FOSAMAX PLUS D (alendronatesodiumcholecalciferol (vitamin d3)) 110fosamprenavir calcium 40FOSAMPRENAVIR CALCIUM 40fosinopril sodium 52fosinopril sodiumhydrochlorothiazide 57FOSINOPRIL-HYDROCHLOROTHIAZIDE 57Freestyle Insulix Test Strips 110Freestyle Lite Test Strips 111Freestyle Test Strips 111furosemide 58FUZEON (enfuvirtide) 39

Ggabapentin 15GABAPENTIN 15GARDASIL 9 (human papillomavirus vaccine9-valentpf) 107GAS RELIEF 79GAS RELIEF (simethicone) 79GAS-X (simethicone) 79gemfibrozil 59GEMFIBROZIL 59gentamicin sulfate 8GENTAMICIN SULFATE 9gentamicin sulfate (GENTAK) 8GENTLE LAXATIVE 83GENVOYA(elvitegravircobicistatemtricitabinetenofovir alafenamide) 36GEODON (ziprasidone hcl) 32GEODON (ziprasidone mesylate) 32

GERI-DRYL 121glatiramer acetate 6566glatiramer acetate (GLATOPA) 65GLEOSTINE (lomustine) 26glimepiride 43glipizide 43GLUCAGON EMERGENCY KIT (glucagonhcl) 44GLUCAGON EMERGENCY KIT(glucagonhuman recombinant) 44glyburide 43glyburidemetformin hcl 43glycerin 83glycerin (ADULT GLYCERIN) 83glycerin (LAXATIVE SUPPOSITORY) 83glycerin (PEDIA-LAX) 83glycerin (SUPPOSITORY) 83GOCOVRI (amantadine hcl) 29granisetron hcl 21griseofulvin ultramicrosize 22griseofulvin microsize 23GUAIASORB DM 126guaifenesin (MUCUS ER) 126guaifenesin (MUCUS RELIEF ER) 126GUAIFENESIN-DEXTROMETHORPHAN 126guaifenesindextromethorphan hbr 128guaifenesindextromethorphan hbr (ADULTROBITUSSIN PEAK COLD DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN COUGH CONGEST DM) 126guaifenesindextromethorphan hbr (ADULTTUSSIN DM) 126guaifenesindextromethorphan hbr (ADULTWAL-TUSSIN DM) 126guaifenesindextromethorphan hbr(ANTITUSSIVE DM) 126guaifenesindextromethorphan hbr(BIOCOTRON) 126guaifenesindextromethorphan hbr (COUGHDM) 126


guaifenesindextromethorphan hbr (DIABETICSILTUSSIN-DM) 127guaifenesindextromethorphan hbr (DIABETICTUSSIN DM) 127guaifenesindextromethorphan hbr(EXPECTORANT DM) 127guaifenesindextromethorphan hbr (EXTRAACTION COUGH) 127guaifenesindextromethorphan hbr (GERI-TUSSIN DM) 127guaifenesindextromethorphan hbr (GILTUSSDIABETIC) 127guaifenesindextromethorphan hbr (GILTUSSHBP) 127guaifenesindextromethorphan hbr(GUAIASORB DM) 127guaifenesindextromethorphan hbr (RI-TUSSINDM) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH) 127guaifenesindextromethorphan hbr (ROBAFENDM COUGH-CHEST CONGEST) 127guaifenesindextromethorphan hbr (ROBAFENDM PEAK COLD) 127guaifenesindextromethorphan hbr(ROBAFEN-DM) 127guaifenesindextromethorphan hbr(SAFETUSSIN DM) 127guaifenesindextromethorphan hbr (SILTUSSINDM DAS) 127guaifenesindextromethorphan hbr (SILTUSSINDM) 128guaifenesindextromethorphan hbr(SORBUGEN NR) 128guaifenesindextromethorphan hbr (TUSNELDIABETIC) 128guaifenesindextromethorphan hbr (TUSSINCOUGH) 128guaifenesindextromethorphan hbr (TUSSINDM CLEAR) 128

guaifenesindextromethorphan hbr (TUSSINDM COUGH) 128guaifenesindextromethorphan hbr (TUSSINDM COUGH-CHEST CONGEST) 128guaifenesindextromethorphan hbr (TUSSINDM) 128guaifenesindextromethorphan hbr (ULTRADM FREE amp CLEAR) 128guaifenesindextromethorphan hbr (ULTRATUSS) 128guaifenesindextromethorphan hbr (WAL-TUSSIN DM) 128guaifenesinpseudoephedrine hcl 129guaifenesinpseudoephedrine hcl (MUCUSD) 128guaifenesinpseudoephedrine hcl (MUCUSRELIEF D) 128guanfacine hcl 5162

HHAILEY FE 94HALDOL (haloperidol lactate) 30HALDOL DECANOATE 100 (haloperidoldecanoate) 30HALDOL DECANOATE 50 (haloperidoldecanoate) 30haloperidol 31HALOPERIDOL 31haloperidol decanoate 31haloperidol lactate 31HALOPERIDOL LACTATE 31HAVRIX (hepatitis a virus vaccinepf) 107HEADACHE RELIEF 2HELIXATE FS (antihemophilic factor (fviii)recombinantfull length) 48HEMLIBRA (emicizumab-kxwh) 48HEMOFIL M (antihemophilic factor human) 48HEPARIN SODIUM 46heparin sodiumporcine 46heparin sodiumporcinepf 46


HEPLISAV-B (hepatitis b vaccinerecombinantvaccine adjuvant cpg1018pf) 107HEXALEN (altretamine) 26homatropine hbr 112homatropine hbr (HOMATROPAIRE) 112HUMALOG (insulin lispro) 45HUMALOG MIX 75-25 (insulin lispro protamineand insulin lispro) 45HUMALOG MIX 75-25 KWIKPEN (insulin lisproprotamine and insulin lispro) 45HUMATE-P (antihemophilic factor humanvonwillebrand factorhuman) 48HUMIRA (adalimumab) 105HUMIRA PEDIATRIC CROHNS(adalimumab) 105HUMIRA PEN (adalimumab) 105HUMIRA PEN CROHNS-UC-HS(adalimumab) 105HUMIRA PEN PSOR-UVEITS-ADOL HS(adalimumab) 105HUMIRA(CF) (adalimumab) 105HUMIRA(CF) PEDIATRIC CROHNS(adalimumab) 105HUMIRA(CF) PEN (adalimumab) 105HUMIRA(CF) PEN CROHNS-UC-HS(adalimumab) 105HUMIRA(CF) PEN PSOR-UV-ADOL HS(adalimumab) 105HUMULIN 70-30 (insulin nph humanisophaneinsulin regular human) 45HUMULIN 7030 KWIKPEN (insulin nph humanisophaneinsulin regular human) 45HUMULIN N (insulin nph human isophane) 45HUMULIN R (insulin regular human) 45HUMULIN R U-500 (insulin regular human) 45hydralazine hcl 60hydrochlorothiazide 58hydrocodone bitartrateacetaminophen 5hydrocodone bitartrateacetaminophen(LORCET HD) 5

hydrocodone bitartrateacetaminophen(LORTAB) 5hydrocortisone 89109HYDROCORTISONE 89hydrocortisone (ANTI-ITCH) 88hydrocortisone (ANUSOL-HC) 88hydrocortisone (COLOCORT) 109hydrocortisone (CORTISONE) 88hydrocortisone (CORTIZONE-10 PLUS) 89hydrocortisone (CORTIZONE-10) 89hydrocortisone (HYDROCREAM) 89hydrocortisone (NOBLE FORMULA HC) 89hydrocortisone (PREPARATION H) 89hydrocortisone (PROCTO-MED HC) 89hydrocortisone (PROCTO-PAK) 89hydrocortisone (PROCTOSOL-HC) 89hydrocortisone (PROCTOZONE-HC) 89hydrocortisone (SOOTHING CARE) 89HYDROCORTISONE ACETATE 89hydrocortisone acetate 89hydrocortisone acetate (ANUCORT-HC) 89hydrocortisone acetate (ANUSOL-HC) 89hydrocortisone acetate (HEMMOREX-HC) 89hydrocortisone acetatepramoxine hcl 68hydrocortisoneacetic acid 116hydrocortisoneacetic acid (ACETASOLHC) 116hydromorphone hcl 5HYDROXYCHLOROQUINE SULFATE 28hydroxychloroquine sulfate 28hydroxyprogesterone caproate 100hydroxyprogesterone caproatepf 100hydroxyurea 27hydroxyzine hcl 121HYDROXYZINE PAMOATE 121hydroxyzine pamoate 121hyoscyamine sulfate 77hyoscyamine sulfate (HYOSYNE) 77HYPERTET S-D (tetanus immuneglobulinpf) 106


Iibuprofen 3IBUPROFEN 3ibuprofen (ADDAPRIN) 2ibuprofen (I-PRIN) 3ibuprofen (IBU) 3ibuprofen (IBU-200) 3ibuprofen (PROVIL) 3ibuprofen (WAL-PROFEN) 3IDELVION (factor ix recombinantalbuminfusion protein) 48imipramine hcl 19IMIPRAMINE HCL 19IMOVAX RABIES VACCINE (rabies vaccinehuman diploid cellpf) 107INCRUSE ELLIPTA (umeclidinium bromide) 122indapamide 58indomethacin 3INFANTS GAS RELIEF 79inhalerassist device with large mask 111inhalerassist device with medium mask 111inhalerassist device with small mask 111insulin lispro 45INSULIN LISPRO PROTAMINE MIX (insulin lisproprotamine and insulin lispro) 45Insulin pen needles 111INSULIN SYRINGE 03 ML 111INSULIN SYRINGE 05 ML 111INSULIN SYRINGE 1 ML 111INTELENCE (etravirine) 37INTRON A (interferon alfa-2brecomb) 35INVEGA (paliperidone) 32INVEGA SUSTENNA (paliperidone palmitate)32INVEGA TRINZA (paliperidone palmitate) 32INVIRASE (saquinavir mesylate) 40IOPIDINE (apraclonidine hcl) 115ipratropium bromide 122ipratropium bromidealbuterol sulfate 129IPRATROPIUM-ALBUTEROL 129irbesartan 52

irbesartanhydrochlorothiazide 57IRON 74ISENTRESS (raltegravir potassium) 36ISENTRESS HD (raltegravir potassium) 36isoniazid 26ISOSORBIDE DINITRATE 60isosorbide dinitrate 60isosorbide mononitrate 60isotretinoin 68isotretinoin (AMNESTEEM) 68isotretinoin (CLARAVIS) 68isotretinoin (MYORISAN) 68isotretinoin (ZENATANE) 68itraconazole 23IXINITY (factor ix human recombinantthreonine 148) 49

JJAKAFI (ruxolitinib phosphate) 28JARDIANCE (empagliflozin) 43JENCYCLA 100JIVI (antihemophilic factor (fviii) rec b-domain deleted peg-aucl) 49JULUCA (dolutegravir sodiumrilpivirine hcl) 39

KKALETRA (lopinavirritonavir) 40KCENTRA (human prothrombin complexconcentrate (pcc) 4-factor) 49ketoconazole 23ketoprofen 3ketorolac tromethamine 114ketotifen fumarate 114ketotifen fumarate (ALLERGY EYE DROPS) 114ketotifen fumarate (EYE ITCH RELIEF) 114ketotifen fumarate (ITCHY EYE) 114ketotifen fumarate (WAL-ZYR) 114ketotifen fumarate (ZADITOR) 114KOGENATE FS (antihemophilic factor (fviii)recombinantfull length) 49


KOVALTRY (antihemophilic factor (fviii)recombinantfull length) 49

Llabetalol hcl 54LABETALOL HCL 54lactulose 83lactulose (CONSTULOSE) 83lactulose (ENULOSE) 83lactulose (GENERLAC) 83LAMISIL (terbinafine hcl) 23lamivudine 3538lamivudinezidovudine 38lamotrigine 15lancets 111LANOXIN (digoxin) 57lansoprazole 85LANSOPRAZOLE 85lanthanum carbonate 87latanoprost 115LATUDA (lurasidone hcl) 32leflunomide 106LEFLUNOMIDE 106letrozole 28LEUCOVORIN CALCIUM 27leucovorin calcium 27LEUKERAN (chlorambucil) 26leuprolide acetate 104levalbuterol tartrate 123LEVETIRACETAM 14levetiracetam 14LEVETIRACETAM ER 14LEVO-T (levothyroxine sodium) 103levobunolol hcl 115levocarnitine 70levocarnitine (with sugar) 70levofloxacin 13levonorgestrel 101levonorgestrel (AFTERA) 101levonorgestrel (ECONTRA EZ) 101levonorgestrel (ECONTRA ONE-STEP) 101

levonorgestrel (FALLBACK SOLO) 101levonorgestrel (MY CHOICE) 101levonorgestrel (MY WAY) 101levonorgestrel (NEW DAY) 101levonorgestrel (OPCICON ONE-STEP) 101levonorgestrel (OPTION 2) 101levonorgestrel (TAKE ACTION) 101LEVONORGESTREL-ETH ESTRADIOL 94levonorgestrelethinyl estradiol 96levonorgestrelethinyl estradiol (AFIRMELLE) 94levonorgestrelethinyl estradiol (ALTAVERA) 94levonorgestrelethinyl estradiol (AUBRA EQ) 94levonorgestrelethinyl estradiol (AUBRA) 94levonorgestrelethinyl estradiol (AVIANE) 94levonorgestrelethinyl estradiol (AYUNA) 94levonorgestrelethinyl estradiol (CHATEALEQ) 94levonorgestrelethinyl estradiol (CHATEAL) 94levonorgestrelethinyl estradiol (DELYLA) 94levonorgestrelethinyl estradiol (ENPRESSE) 94levonorgestrelethinyl estradiol (FALMINA) 95levonorgestrelethinyl estradiol (KURVELO) 95levonorgestrelethinyl estradiol (LARISSIA) 95levonorgestrelethinyl estradiol (LESSINA) 95levonorgestrelethinyl estradiol (LEVONEST) 95levonorgestrelethinyl estradiol (LEVORA-28)95levonorgestrelethinyl estradiol (LILLOW) 95levonorgestrelethinyl estradiol (LUTERA) 95levonorgestrelethinyl estradiol (MARLISSA) 95levonorgestrelethinyl estradiol (MYZILRA) 95levonorgestrelethinyl estradiol (ORSYTHIA) 95levonorgestrelethinyl estradiol (PORTIA) 96levonorgestrelethinyl estradiol (SRONYX) 96levonorgestrelethinyl estradiol (TRIVORA-28) 96levonorgestrelethinyl estradiol (VIENVA) 96levothyroxine sodium 103LEVOTHYROXINE SODIUM 103LEVOXYL (levothyroxine sodium) 103LEXIVA (fosamprenavir calcium) 40LICE KILLING 68


lidocaine hcl 6LIDOCAINE HCL VISCOUS 6lidocaine hclpf 6lisinopril 52lisinoprilhydrochlorothiazide 57lithium carbonate 42lithium citrate 42LITHOBID (lithium carbonate) 42loperamide hcl 79loperamide hcl (ANTI-DIARRHEAL) 79loperamide hcl (DIAMODE) 79loperamide hcl (ULTRA A-D) 79lopinavirritonavir 40loratadine 121122LORATADINE 122loratadine (ALLERCLEAR) 121loratadine (ALLERGY RELIEF) 121loratadine (ALLERGY) 121loratadine (CHILDRENS ALLERGY RELIEF) 121loratadine (CHILDRENS ALLERGY) 121loratadine (LORADAMED) 121loratadine (NON-DROWSY ALLERGY) 121loratadine (WAL-ITIN) 121lorazepam 42lorazepam (LORAZEPAM INTENSOL) 42LOSARTAN POTASSIUM 52losartan potassium 52losartan potassiumhydrochlorothiazide 57LOSARTAN-HYDROCHLOROTHIAZIDE 57LOTRIMIN AF (clotrimazole) 23lovastatin 59loxapine succinate 31LUCEMYRA (lofexidine hcl) 7LUPRON DEPOT-PED (leuprolide acetate) 104LYLLANA 96LYSODREN (mitotane) 28

MM-M-R II VACCINE (measles mumps andrubella vaccine livepf) 107MAGNESIUM CITRATE 83

magnesium citrate 83MARPLAN (isocarboxazid) 18MATULANE (procarbazine hcl) 26MAXI-TUSS G 129mebendazole (EMVERM) 28MECLIZINE HCL 20meclizine hcl 20meclizine hcl (DRAMAMINE LESS DROWSY) 20meclizine hcl (MEDI-MECLIZINE) 20meclizine hcl (MOTION RELIEF) 20meclizine hcl (MOTION SICKNESS II) 20meclizine hcl (MOTION SICKNESS RELIEF) 20meclizine hcl (MOTION SICKNESS) 20meclizine hcl (MOTION-TIME) 20meclizine hcl (TRAVEL-EASE) 20meclizine hcl (VERTICALM) 20meclizine hcl (WAL-DRAM 2) 20MEDROXYPROGESTERONE ACETATE 101medroxyprogesterone acetate 101mefloquine hcl 28megestrol acetate 101meloxicam 3melphalan 26memantine hcl 17MEMANTINE HCL 17MENACTRA (meningococcalvaccine acyw-135diphtheria toxoid conjpf) 107MENEST (estrogensesterified) 96MENQUADFI 107MENVEO A-C-Y-W-135-DIP(meningococcalvaccine acyw-135diphtheria toxoid conjpf) 108meperidine hcl 5mercaptopurine 27mesalamine 109MESTINON (pyridostigmine bromide) 25metaproterenol sulfate 123metformin hcl 43METFORMIN HCL ER 43METHADONE HCL 4methadone hcl 4


methadone hcl (METHADONE INTENSOL) 4methadone hcl (METHADOSE) 4methazolamide 115METHAZOLAMIDE 115methenaminemethylene bluesodphospsalicylatehyoscyamine(PHOSPHASAL) 9methenaminemethylene bluesodphospsalicylatehyoscyamine (URIN DS) 10methimazole 104methocarbamol 130METHOCARBAMOL 130METHOTREXATE 105methotrexate sodium 105methyclothiazide 58methyldopa 51methylergonovine maleate 111METHYLPHENIDATE ER 62methylphenidate hcl 62METHYLPHENIDATE HCL 62methylphenidate hcl (METADATE ER) 62methylprednisolone 89metoclopramide hcl 20metolazone 58metoprolol succinate 54METOPROLOL SUCCINATE 54metoprolol tartrate 54METRO IV (metronidazole in sodiumchloride) 10metronidazole 1068METRONIDAZOLE 10metronidazole in sodium chloride 10mexiletine hcl 53MEXILETINE HCL 53miconazole nitrate 23miconazole nitrate (ANTI-FUNGAL CREAM) 23miconazole nitrate (ANTIFUNGAL CREAM) 23miconazole nitrate (BAZA ANTIFUNGAL) 23miconazole nitrate (INZO ANTIFUNGAL) 23miconazole nitrate (LOTRIMIN AF) 23miconazole nitrate (MICATIN) 23

miconazole nitrate (SECURA ANTIFUNGAL) 23MICROGESTIN 96MICROGESTIN FE 96minocycline hcl 14minoxidil 60mirtazapine 17misoprostol 85modafinil 131moexipril hcl 52molindone hcl 31mometasone furoate 90MONISTAT 3 (miconazole nitrate) 23MONISTAT 7 (miconazole nitrate) 23MONONINE (factor ix) 49montelukast sodium 122MONTELUKAST SODIUM 122morphine sulfate 45moxifloxacin hcl 13MUCUS ER 129MUCUS RELIEF ER 129mupirocin 10mupirocin calcium 10MURINE EAR DROPS (carbamide peroxide) 116MURO-128 (sodium chloride) 112mycophenolate mofetil 105MYLERAN (busulfan) 27MYNATAL (prenatal vitamins withcalciumferrous fumaratefolic acid) 70

NNABI-HB (hepatitis b immune globulin) 106nadolol 54NADOLOL 54naloxone hcl 7naltrexone hcl 7NALTREXONE HCL 7naproxen 3naproxen sodium 3NARCAN (naloxone hcl) 8NARDIL (phenelzine sulfate) 18NASACORT (triamcinolone acetonide) 117


NASAL DECONGESTANT (pseudoephedrinehcl) 123nateglinide 43neomycin sulfate 9neomycin sulfatebacitracin zincpolymyxin b(ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(FIRST AID ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxin b(TRIPLE ANTIBIOTIC) 10neomycin sulfatebacitracin zincpolymyxinbhydrocortisone 112neomycin sulfatebacitracin zincpolymyxinbhydrocortisone (NEO-POLYCIN HC) 112neomycin sulfatebacitracinpolymyxin b 113neomycin sulfatebacitracinpolymyxin b(NEO-POLYCIN) 113neomycin sulfatepolymyxin bsulfategramicidin d 113neomycin sulfatepolymyxin bsulfatehydrocortisone 113116NEOMYCIN-POLYMYXIN-HC 116neomycinpolymyxin bsulfatedexamethasone 113nevirapine 37NIACIN 60niacin 60niacin (ENDUR-ACIN) 59niacin (SLO-NIACIN) 59nicardipine hcl 55NICOTINE 14MG PATCH 8NICOTINE 21MG PATCH 8NICOTINE 2MG GUM 8NICOTINE 4MG GUM 8NICOTINE 7MG PATCH 8NICOTINE LOZENGE 8nicotine polacrilex 8nicotine polacrilex (QUIT 2) 8nicotine polacrilex (QUIT 4) 8nicotine polacrilex (STOP SMOKING AID) 8NICOTROL (nicotine) 8

NICOTROL NS (nicotine) 8NIFEDIPINE 55nifedipine 55nifedipine (AFEDITAB CR) 55nifedipine (NIFEDICAL XL) 55NIGHTTIME SLEEP AID 122nisoldipine 55NITRO-BID (nitroglycerin) 60nitrofurantoin 10NITROFURANTOIN 10nitrofurantoin macrocrystal 10nitrofurantoin monohydratemacrocrystals 10nitroglycerin 61NITROGLYCERIN 61nitroglycerin (MINITRAN) 60nitroglycerin (NITRO-TIME) 60nonoxynol 9 (VCF) 86norelgestrominethinyl estradiol (XULANE) 96norethindrone 102norethindrone (CAMILA) 101norethindrone (DEBLITANE) 101norethindrone (ERRIN) 101norethindrone (HEATHER) 102norethindrone (INCASSIA) 102norethindrone (JENCYCLA) 102norethindrone (JOLIVETTE) 102norethindrone (LYZA) 102norethindrone (NORA-BE) 102norethindrone (NORLYDA) 102norethindrone (NORLYROC) 102norethindrone (SHAROBEL) 102norethindrone (TULANA) 102norethindrone acetate 102norethindrone acetate-ethinyl estradiol 97norethindrone acetate-ethinyl estradiol(AUROVELA) 96norethindrone acetate-ethinyl estradiol(GILDESS) 96norethindrone acetate-ethinyl estradiol(HAILEY) 96


norethindrone acetate-ethinyl estradiol(JUNEL) 97norethindrone acetate-ethinyl estradiol(LARIN) 97norethindrone acetate-ethinyl estradiol(MICROGESTIN) 97norethindrone acetate-ethinylestradiolferrous fumarate 98norethindrone acetate-ethinylestradiolferrous fumarate (AUROVELA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (BLISOVI FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (JUNEL FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (LARIN FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (MICROGESTINFE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE 1-20EQ) 97norethindrone acetate-ethinylestradiolferrous fumarate (TARINA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TILIA FE) 97norethindrone acetate-ethinylestradiolferrous fumarate (TRI-LEGEST FE) 98norethindrone-ethinyl estradiol (ALYACEN) 98norethindrone-ethinyl estradiol (ARANELLE) 98norethindrone-ethinyl estradiol (BALZIVA) 98norethindrone-ethinyl estradiol (BRIELLYN) 98norethindrone-ethinyl estradiol (CYCLAFEM)98norethindrone-ethinyl estradiol (DASETTA) 98norethindrone-ethinyl estradiol (LEENA) 98norethindrone-ethinyl estradiol (NECON) 98norethindrone-ethinyl estradiol (NORTREL) 98norethindrone-ethinyl estradiol (PHILITH) 98norethindrone-ethinyl estradiol (PIRMELLA) 98norethindrone-ethinyl estradiol (VYFEMLA) 98norethindrone-ethinyl estradiol (WERA) 98

norethindrone-ethinyl estradiol (ZENCHENT) 98NORGESTIMATE-ETHINYL ESTRADIOL 100norgestimate-ethinyl estradiol 100norgestimate-ethinyl estradiol (ESTARYLLA) 98norgestimate-ethinyl estradiol (FEMYNOR) 99norgestimate-ethinyl estradiol (MILI) 99norgestimate-ethinyl estradiol (MONO-LINYAH) 99norgestimate-ethinyl estradiol(MONONESSA) 99norgestimate-ethinyl estradiol (PREVIFEM) 99norgestimate-ethinyl estradiol (SPRINTEC) 99norgestimate-ethinyl estradiol (TRIFEMYNOR) 99norgestimate-ethinyl estradiol (TRI-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LINYAH) 99norgestimate-ethinyl estradiol (TRI-LO-ESTARYLLA) 99norgestimate-ethinyl estradiol (TRI-LO-MARZIA) 99norgestimate-ethinyl estradiol (TRI-LO-MILI) 99norgestimate-ethinyl estradiol (TRI-LO-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-PREVIFEM) 99norgestimate-ethinyl estradiol (TRI-SPRINTEC) 99norgestimate-ethinyl estradiol (TRI-VYLIBRALO) 99norgestimate-ethinyl estradiol (TRI-VYLIBRA) 99norgestimate-ethinyl estradiol (TRINESSA LO)99norgestimate-ethinyl estradiol (TRINESSA) 99norgestimate-ethinyl estradiol (VYLIBRA) 99norgestrel-ethinyl estradiol (CRYSELLE) 100norgestrel-ethinyl estradiol (ELINEST) 100norgestrel-ethinyl estradiol (LOW-OGESTREL) 100norgestrel-ethinyl estradiol (OGESTREL) 100nortriptyline hcl 19NORVIR (ritonavir) 40


NOVOEIGHT (antihemophilic factor viiirecombinant b-domain truncated) 49NOVOLIN 70-30 (insulin nph humanisophaneinsulin regular human) 45NOVOLIN N (insulin nph human isophane) 45NOVOLIN R (insulin regular human) 45NOVOSEVEN RT (coagulation factor viia(recombinant)) 49NUPLAZID (pimavanserin tartrate) 32NUWIQ (antihemophilic factor viii rec hek cellb-domain deleted) 50NYSTATIN 23nystatin 23

OO-CAL PRENATAL (prenatal vit with calciumno127ferrous fumaratefolic acid) 70OBIZUR (antihemophilic factor viiirecombinant porcine sequence) 50ODEFSEY (emtricitabinerilpivirinehcltenofovir alafenamide fumarate) 37ofloxacin 13olanzapine 33olanzapinefluoxetine hcl 17OMEGA-3 ACID ETHYL ESTERS 60omega-3 acid ethyl esters 60omeprazole 85OMEPRAZOLE 85ondansetron 21ondansetron hcl 21ORAP (pimozide) 31oseltamivir phosphate 41OSELTAMIVIR PHOSPHATE 41OSMOLEX ER (amantadine hcl) 29oxazepam 42oxcarbazepine 16oxybutynin chloride 86OXYBUTYNIN CHLORIDE ER 86oxycodone hcl 46oxycodone hclacetaminophen 6oxycodone hclacetaminophen (ENDOCET) 6

oxycodone hclaspirin 6OXYTROL FOR WOMEN (oxybutynin) 86OYSTER SHELL CALCIUM 74OYSTER SHELL CALCIUM-VIT D3 74

PPAIN amp FEVER (acetaminophen) 64PAIN RELIEF 64paliperidone 33pantoprazole sodium 85PANTOPRAZOLE SODIUM 85PARNATE (tranylcypromine sulfate) 18paromomycin sulfate 9paroxetine hcl 18PEDIATRIC IRON 75pediatric multivit with acd3 no21sodiumfluoride 75pediatric multivitamin no16sodiumfluoride 75pediatric multivitamin no2sodium fluoride 75pediatric multivitamin no45sodiumfluorideferrous sulfate 75pediatric multivitamins no17 with sodiumfluoride 75peg 3350sod sulfsod bicarbsodchloridepotassium chloride 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-C) 83peg 3350sod sulfsod bicarbsodchloridepotassium chloride (GAVILYTE-G) 83PEG-3350 AND ELECTROLYTES 83PEGINTRON REDIPEN (peginterferon alfa-2b) 35PEN NEEDLE 111pen needle diabetic 111pen needle diabetic disposable safety 111pen needle diabetic remover and disposalunit 111pen needle diabetic safety 111penicillamine 86PENICILLAMINE 86


penicillin v potassium 12pentoxifylline 57PEPTO-BISMOL (bismuth subsalicylate) 79PEPTO-BISMOL TO-GO (bismuthsubsalicylate) 79permethrin 29permethrin (LICE TREATMENT) 29perphenazine 20PERSERIS (risperidone) 33PHENAZOPYRIDINE HCL 87phenazopyridine hcl 87phenazopyridine hcl (URINARY PAIN RELIEF) 86phenelzine sulfate 18phenobarbital 15PHENOBARBITAL 15PHENOXYBENZAMINE HCL 51phenoxybenzamine hcl 51phenylephrine hcl 113phenylephrine hclpromethazine hcl 129phenytoin 16phenytoin sodium extended 16PHOS-FLUR (fluoride (sodium)) 66PHOSPHOLINE IODIDE (echothiophateiodide) 115phytonadione (vit k1) 50PIFELTRO (doravirine) 37pilocarpine hcl 115PILOCARPINE HCL 115pimecrolimus 68pimozide 31pindolol 54pioglitazone hcl 43PIOGLITAZONE HCL 44piperonyl butoxidepyrethrins (LICE KILLING)68piperonyl butoxidepyrethrins (LICE PYRINYLSHAMPOO) 68piperonyl butoxidepyrethrins (LICETREATMENT) 68piperonyl butoxidepyrethrins (RID) 68piperonyl butoxidepyrethrinspermethrin(COMPLETE LICE TREATMENT) 69

piperonyl butoxidepyrethrinspermethrin(LICE SOLUTION) 69piroxicam 3PLAN B ONE-STEP (levonorgestrel) 102PLEGRIDY (peginterferon beta-1a) 66PLEGRIDY PEN (peginterferon beta-1a) 66PNEUMOVAX 23 (pneumococcal 23-valentpolysaccharide vaccine) 108podofilox 69POLY-VITAMIN (multivitamin) 75polyethylene glycol 3350 84polyethylene glycol 3350 (CLEARLAX) 83polyethylene glycol 3350 (GAVILAX) 84polyethylene glycol 3350 (GENTLELAX) 84polyethylene glycol 3350 (GLYCOLAX) 84polyethylene glycol 3350 (LAXACLEAR) 84polyethylene glycol 3350 (NATURA-LAX) 84polyethylene glycol 3350 (POWDERLAX) 84polyethylene glycol 3350 (PURELAX) 84polyethylene glycol 3350 (SMOOTHLAX) 84polymyxin b sulfatetrimethoprim 113POTASSIUM 75potassium bicarbonatecitric acid 75potassium bicarbonatecitric acid (EFFER-K)75potassium bicarbonatecitric acid (KEFFERVESCENT) 75potassium bicarbonatecitric acid (KLOR-CON-EF) 75POTASSIUM CHL-NORMAL SALINE 75potassium chloride 7075POTASSIUM CHLORIDE 71potassium chloride (KLOR-CON M10) 70potassium chloride (KLOR-CON M20) 70potassium chloride (KLOR-CON SPRINKLE) 75potassium chloride in 09 sodiumchloride 7071potassium chloridepotassiumbicarbonatecitric acid 75potassium gluconate 76pramipexole di-hcl 29pramoxine hclcalamine (CALAHIST) 69


pramoxine hclcalamine (CALAMINEMEDICATED) 69praziquantel 28prazosin hcl 51PRAZOSIN HCL 51PRED MILD (prednisolone acetate) 114prednisolone 90prednisolone (MILLIPRED DP) 90prednisolone (MILLIPRED) 90prednisolone acetate 114prednisolone sodium phosphate 90114prednisone 90prednisone (PREDNISONE INTENSOL) 90pregabalin 65PREGABALIN 65PREMARIN (estrogens conjugated) 100PREMPHASE (estrogensconjugatedmedroxyprogesteroneacetate) 100PREMPRO (estrogensconjugatedmedroxyprogesteroneacetate) 100PRENATABS FA (prenatal vits with calciumno78ferrous fumaratefolic acid) 71PRENATABS RX (prenatal vitamin with calciumno76ironcarbonylfolic acid) 71PRENATAL MULTIVITAMIN 76prenatal vit with calcium no129ferrousfumaratefolic acid 76prenatal vit with calcium no130ferrousfumaratefolic acid 76prenatal vitamins no121ferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid 76prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL PLUS) 71prenatal vitamins with calciumferrousfumaratefolic acid (MYNATAL-Z) 71prenatal vits with calcium 118ferrousfumaratefolic acid 76

prenatal vits with calcium 118ferrousfumaratefolic acid (SE-NATAL 19) 71prenatal vits with calcium 136ferrousfumaratefolic acid (VINATE-M) 71prenatal vits with calcium 137ferrousfumaratefolic acid 76prenatal vits with calcium 95ferrousfumaratefolic acid 76prenatal vits with calcium no115ironfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid 71prenatal vits with calcium no72ferrousfumaratefolic acid (M-NATAL PLUS) 71prenatal vits with calcium no72ferrousfumaratefolic acid (PREPLUS) 71prenatal vits with calciumno72ironcarbonylfolic acid 72prenatal vits with calcium no74ferrousfumaratefolic acid 72prenatal vits with calcium no96ferrousfumaratefolic acid 76PREVACID (lansoprazole) 85PREVNAR 13 (pneumococcal 13-valentconjugate vaccine (diphtheria crm)pf) 108PREZCOBIX (darunavirethanolatecobicistat) 40PREZISTA (darunavir ethanolate) 40PRIFTIN (rifapentine) 26primaquine phosphate 28primidone 15probenecid 24probenecidcolchicine 24PROBUPHINE (buprenorphine hcl) 7prochlorperazine 20prochlorperazine (COMPRO) 20prochlorperazine maleate 20PROCRIT (epoetin alfa) 47PROCTOFOAM-HC (hydrocortisoneacetatepramoxine hcl) 69


PROFILNINE (factor ix complex prothrombincplx conc(pcc) no4 3-factor) 50promethazine hcl 21122PROMETHAZINE HCL 122promethazine hcl (PHENADOZ) 21promethazine hcl (PROMETHEGAN) 21promethazine hclcodeine 129promethazine hcldextromethorphan hbr 129PROMETHAZINE-DM 129promethazinephenylephrine hclcodeine 129propafenone hcl 53propantheline bromide 77proparacaine hcl 113propranolol hcl 54propylthiouracil 104pseudoephedrine hcl 123pseudoephedrine hcl (NASALDECONGESTANT) 123pseudoephedrine hcl (SUDOGEST) 123pseudoephedrine hcl (SUPHEDRIN) 123pseudoephedrine hcl (SUPHEDRINE SINUSCONGESTION) 123pseudoephedrine hcl (SUPHEDRINE) 123pseudoephedrine hcl (WAL-PHED) 123PULMICORT FLEXHALER (budesonide) 117pyrazinamide 26pyridostigmine bromide 25pyridoxine hcl (vitamin b6) 76

Qquetiapine fumarate 33quinapril hcl 52quinidine gluconate 53quinidine sulfate 53QVAR REDIHALER (beclomethasonedipropionate) 117

RRABAVERT (rabies vaccine purified chickenembryo cell (pcec)pf) 108ramipril 52

RAMIPRIL 53REBINYN (factor ix (human) recombinantpegylated) 50RECOMBINATE (antihemophilic factor viiihuman recombinant) 50RECOMBIVAX HB (hepatitis b virus vaccinerecombinantpf) 108RELENZA (zanamivir) 41RESCRIPTOR (delavirdine mesylate) 37REXULTI (brexpiprazole) 33REYATAZ (atazanavir sulfate) 41RHEUMATREX (methotrexate sodium) 105RIASTAP (fibrinogen) 50ribavirin 36ribavirin (RIBASPHERE) 36RID (permethrin) 111RID (piperonylbutoxidepyrethrinspermethrin) 69RIDAURA (auranofin) 106rifabutin 26rifampin 26riluzole 65RILUZOLE 65ringers solution 7076RISPERDAL (risperidone) 33RISPERDAL CONSTA (risperidonemicrospheres) 33RISPERDAL M-TAB (risperidone) 33risperidone 33ritonavir 41RIXUBIS (factor ix human recombinant) 50rizatriptan benzoate 25ropinirole hcl 29rosuvastatin calcium 59RUKOBIA 39

Ssalsalate 3SANDIMMUNE (cyclosporine) 105SANTYL (collagenase clostridiumhistolyticum) 69


SAPHRIS (asenapine maleate) 33SAVELLA (milnacipran hcl) 65SE-NATAL-19 (prenatal vitamins no119ironfumaratefolic acid) 72SECUADO (asenapine) 33selegiline hcl 30selenium sulfide 69selenium sulfide (ANTI-DANDRUFF) 69selenium sulfide (MEDICATED DANDRUFFSHAMPOO) 69selenium sulfide (SELSUN BLUE) 69selenium sulfidealoe vera (SELSUN BLUEMOISTURIZING) 69SELZENTRY (maraviroc) 39SEREVENT DISKUS (salmeterol xinafoate) 123SEROQUEL (quetiapine fumarate) 34SEROQUEL XR (quetiapine fumarate) 34sertraline hcl 18sevelamer carbonate 87SEVENFACT 50SHINGRIX (varicella-zoster virus glycoproteinerecas01b adjuvantpf) 108SILACE (docusate sodium) 84sildenafil citrate 124SILDENAFIL CITRATE 124silver sulfadiazine 13simethicone 80simethicone (GAS RELIEF) 80simethicone (GAS-X) 80simethicone (INFANT GAS RELIEF) 80simethicone (INFANTS GAS RELIEF) 80simethicone (MI-ACID) 80simvastatin 59sirolimus 105SODIUM CHLORIDE 7677sodium chloride 113sodium chloride (MURO-128) 113sodium chloride for inhalation 129sodium chloride irrigating solution 707277sodium chloride irrigating solution (AQUACARE SODIUM CHLORIDE) 77

sodium chloride irrigating solution (CURITY) 77sodium chloridesodiumbicarbonatepotassium chloridepeg 84sodium chloridesodiumbicarbonatepotassium chloridepeg(GAVILYTE-N) 84sodium chloridesodiumbicarbonatepotassium chloridepeg (TRILYTEWITH FLAVOR PACKETS) 84sodium polystyrene sulfonate 72sodium polystyrene sulfonatesorbitol solution(KIONEX) 72sodiumpotassiumpotassium citratesodiumcitratecit ac 87sodiumpotassiumpotassium citratesodiumcitratecit ac (CYTRA-3) 87sodiumpotassiumpotassium citratesodiumcitratecit ac (TRICITRATES) 87sofosbuvirvelpatasvir 35SOTALOL 53SOTALOL AF 53sotalol hcl 53sotalol hcl (SORINE) 53spironolactone 58SPIRONOLACTONE 58spironolactonehydrochlorothiazide 57SPS (sodium polystyrene sulfonatesorbitolsolution) 72SSD (silver sulfadiazine) 13stavudine 38STOMACH RELIEF 80STOOL SOFTENER 84STOOL SOFTENER (docusate sodium) 84STRIBILD(elvitegravircobicistatemtricitabinetenofovir disoproxil) 36SUBLOCADE (buprenorphine) 4SUBOXONE (buprenorphine hclnaloxonehcl) 7sucralfate 85SUDAFED (pseudoephedrine hcl) 123


sulfacetamide sodium 13sulfacetamide sodiumprednisolone sodiumphosphate 113sulfamethoxazoletrimethoprim 13sulfasalazine 109SULFATRIM (sulfamethoxazoletrimethoprim)14sulindac 3SUMATRIPTAN 25sumatriptan 25sumatriptan succinate 25SUMATRIPTAN SUCCINATE 25SUSTIVA (efavirenz) 37SYMBYAX (olanzapinefluoxetine hcl) 18SYMFI (efavirenzlamivudinetenofovirdisoproxil fumarate) 36SYMFI LO (efavirenzlamivudinetenofovirdisoproxil fumarate) 37SYMTUZA (darunavirethcobicistatemtricitabinetenofoviralafenamide) 41SYNAREL (nafarelin acetate) 104SYNJARDY (empagliflozinmetformin hcl) 44SYNJARDY XR (empagliflozinmetformin hcl) 44SYNTHROID (levothyroxine sodium) 103syringe with needle insulin safety 1 ml 111syringe with needledisposableinsulin 1 ml 111syringe with needleinsulin03 ml 111syringe with needleinsulin05 ml 112

TTABLOID (thioguanine) 27tacrolimus 69106TACROLIMUS 106tadalafil 124tadalafil (ALYQ) 124TAKE ACTION (levonorgestrel) 102TAMOXIFEN CITRATE 27tamoxifen citrate 27tamsulosin hcl 86TDVAX (tetanus and diphtheria toxoidsadult) 108

TECFIDERA (dimethyl fumarate) 66TEGRETOL (carbamazepine) 16TEGRETOL XR (carbamazepine) 16temazepam 130TEMIXYS (lamivudinetenofovir disoproxilfumarate) 36temozolomide 27TENIVAC (tetanus and diphtheria toxoidsadsorbed adultpf) 108tenofovir disoproxil fumarate 38terazosin hcl 52TERAZOSIN HCL 52terbinafine hcl 24terbinafine hcl (ANTIFUNGAL) 24terbinafine hcl (ATHLETES FOOT AF) 24terbinafine hcl (ATHLETES FOOT) 24terbinafine hcl (JOCK ITCH) 2444terbinafine hcl (LAMISIL AT) 24TERBUTALINE SULFATE 123terbutaline sulfate 124testosterone 91testosterone cypionate 91tetanus and diphtheria toxoids adult 108THALOMID (thalidomide) 27THEO-24 (theophylline anhydrous) 124theophylline anhydrous 124theophylline anhydrous (THEOCHRON) 124thioridazine hcl 31thiothixene 31thyroidpork (NP THYROID) 103timolol maleate 115TIMOLOL MALEATE 115tioconazole 24TIVICAY (dolutegravir sodium) 36TIVICAY PD 36tizanidine hcl 35TOBRADEX (tobramycindexamethasone) 113tobramycin 9tobramycindexamethasone 113TOBREX (tobramycin) 9tolbutamide 44


tolmetin sodium 3tolnaftate 24tolnaftate (ANTIFUNGAL CREAM) 24tolnaftate (ATHLETES FOOT) 24tolnaftate (FUNGOID-D) 24topiramate 16TOPIRAMATE 16TOREMIFENE CITRATE 27toremifene citrate 27tramadol hcl 6TRAMADOL HCL 6trandolapril 53tranylcypromine sulfate 18TRAVEL SICKNESS (meclizine hcl) 21TRAZODONE HCL 19trazodone hcl 19tretinoin 28TRETTEN (factor xiii a-subunit recombinant) 50TRI-VI-SOL (vitamin a palmitateascorbicacidcholecalciferol (vit d3)) 77triamcinolone acetonide 6690117TRIAMCINOLONE ACETONIDE 66triamcinolone acetonide (ORALONE) 66triamterenehydrochlorothiazide 57triazolam 130trifluoperazine hcl 31trifluridine 41TRIGLIDE (fenofibrate nanocrystallized) 59trihexyphenidyl hcl 29trimethobenzamide hcl 21trimethoprim 10TRINATE (prenatal vits with calciumno73ferrous fumaratefolic acid) 72TRIPLE ANTIBIOTIC 11TRIPLE ANTIBIOTIC (neomycinsulfatebacitracin zincpolymyxin b) 11triprolidine hclpseudoephedrine hcl(APRODINE) 129triprolidine hclpseudoephedrine hcl (ED A-HIST PSE) 129

triprolidine hclpseudoephedrine hcl(RITIFED) 129triprolidine hclpseudoephedrine hcl (WAL-ACT D COLD amp ALLERGY) 129TRIUMEQ (abacavir sulfatedolutegravirsodiumlamivudine) 39TRIZIVIR (abacavirsulfatelamivudinezidovudine) 38TROGARZO (ibalizumab-uiyk) 39trospium chloride 86TROSPIUM CHLORIDE 86TRULICITY 44TRULICITY (dulaglutide) 44TRUMENBA (neisseria meningitidis group blipidated fhbp recombinant) 108TRUVADA (emtricitabinetenofovir disoproxilfumarate) 39TWINRIX (hepatitis a virus and hepatitis b virusvaccinepf) 108TYBOST (cobicistat) 39

UUNIFINE PENTIPS MAXFLOW 112UNITHROID (levothyroxine sodium) 103URETRON D-S (methenaminemethylenebluesod phospsalicylatehyoscyamine) 11URINARY PAIN RELIEF 87ursodiol 80

Vvalacyclovir hcl 41valproic acid 15VALPROIC ACID 15valproic acid (as sodium salt) (valproatesodium) 15valsartan 52valsartanhydrochlorothiazide 57VANADOM 130VANDAZOLE (metronidazole) 11VAQTA (hepatitis a virus vaccinepf) 109


VARIVAX VACCINE (varicella virus vaccinelivepf) 109VEMLIDY (tenofovir alafenamide) 35venlafaxine hcl 19VENLAFAXINE HCL ER 19verapamil hcl 55VERSACLOZ (clozapine) 35VICTOZA 2-PAK (liraglutide) 44VICTOZA 3-PAK (liraglutide) 44VIRACEPT (nelfinavir mesylate) 41VIRAMUNE (nevirapine) 38VIRAMUNE XR (nevirapine) 38VIREAD (tenofovir disoproxil fumarate) 39VITAMIN B-12 77VITAMIN C 77VITEKTA (elvitegravir) 36VIVITROL (naltrexone microspheres) 7VONVENDI (von willebrand factor(recombinant)) 50VRAYLAR (cariprazine hcl) 34

Wwarfarin sodium 46warfarin sodium (JANTOVEN) 46WILATE (antihemophilic factor humanvonwillebrand factorhuman) 50

XXARELTO (rivaroxaban) 4647XYNTHA (antihemophilic factor (factor viii)recombb-domain deleted) 51XYNTHA SOLOFUSE (antihemophilic factor(factor viii) recombb-domain deleted) 51

Zzaleplon 130ZERIT (stavudine) 39ZIAGEN (abacavir sulfate) 39ziprasidone hcl 34ZIPRASIDONE HCL 34ZIPRASIDONE MESYLATE 34

ziprasidone mesylate 34zolpidem tartrate 130zonisamide 14ZOSTAVAX (zoster vaccine livepf) 109ZOVIA 1-35 100ZUBSOLV (buprenorphine hclnaloxone hcl) 7ZYPREXA (olanzapine) 34ZYPREXA RELPREVV (olanzapine pamoate) 34ZYPREXA ZYDIS (olanzapine) 34


List of Covered Drugs

Alphabetical Listing

Table of Contents

ii

Medi-Cal Formulary

The Blue Shield of California Promise Health Plan Medi-Cal Formulary is a list of covered drugs

(Formulary) This list includes drugs used to treat common health problems A team of doctors

and pharmacists meets four times a year to decide which drugs should be on the drug list

They review new and old drugs and choose the ones that are safe and work best

Definitions The following words and definitions will be used throughout the formulary drug list

Word

ldquoBrand name drugrdquo is a drug that is sold under a trademark name We will list the

brand name drug will in all CAPITAL letters

ldquoDrug Tierrdquo shows a group of drugs and how we cover them (see below)

ldquoEnrolleerdquo or ldquomemberrdquo is a person enrolled in a health plan and receives services

from the plan

ldquoException requestrdquo is when the member requests for the plan to cover a drug The

health plan must cover the drug if medically required to treat the members condition

ldquoExigent circumstancesrdquo are when a member suffers from a health condition that may

seriously risk their life health or daily life This is also when a member currently uses a

drug that is not covered

ldquoFormularyrdquo or ldquopreferred drug listrdquo is the list of drugs covered under the drug benefit

ldquoGeneric drugrdquo is the same drug as its brand name version in strength how it is taken

quality and safety A generic drug is listed in bold and italicized lowercase letters

ldquoNon-formulary drugrdquo is a drug not listed on the plans drug list

ldquoPrescribing providerrdquo may prescribe a drug to treat a medical condition for a

member

ldquoPrescriptionrdquo is an oral written or electronic order by a prescribing provider that

contains the name of the drug amount date providerrsquos name and contact

signature of the provider (if in writing) and the medical condition or purpose for

which the drug is being prescribed (if requested by the member)

ldquoPrescription drugrdquo is a drug that requires a prescription and prescribed by the

memberrsquos provider

ldquoPrior authorizationrdquo is a plans requirement that the member or provider get the

health plans approval for a drug before the plan will cover it The plan will approve

the drug when it is medically required

ldquoStep therapyrdquo is when the plan requires the member to try one or more drugs to treat

the medical condition before it will cover a certain drug If the memberrsquos provider

submits a request for approval the plan will approve the drug is medically required

iii


Formulary









lowercase italics






lowercase italics

Example





brand name


(ENDOCET)





iv

What are drug tiers
















and Limitations



for some ages


Required



we cover some drugs








90 day supply






within a time frame



v







step therapy)






setting




cover your drug





Cal Formulary





covered



vi










information







vii

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lice

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f th

e B

lue

Sh

ield

Ass

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A512

47-C

MS (

91

8)
















Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228








viii

English


2556 (TTY 711)



711)

한국어 (Korean)








800-605-2556 (TTY 711)






800-605-2556 (TTY 711)

Italiano (Italian)



(Farsi) فارسی







1-800-605-2556 (TTY 711)



Llame al 1-800-605-2556 (TTY 711)


ix



800-605-2556 (TTY 711)






(711YTT)

Polski (Polish)


pod numer 1-800-605-2556 (TTY 711)













2556 (TTY 711) ਤ ਕਾਲ ਕਰ









x

English


Call 1-855-699-5557 (TTY 711)



711)

한국어 (Korean)






Italiano (Italian)



(Farsi) فارسی






Hmong (Hmong)


rau koj Hu rau 1-855-699-5557 (TTY 711)






bạn Gọi số 1-855-699-5557 (TTY 711)




711)


xi



(711YTT)










699-5557 (TTY 711) ਤ ਕਾਲ ਕਰ
















































Gland) 104


















1-Covered


1-Covered



1-Covered





1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered ST


1-Covered ST




1-Covered




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




2





1-Covered




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



2-MedicalCarve out




3




2-MedicalCarve out


2-MedicalCarve out




1-Covered PA


1-Covered PA



1-Covered PA




1-Covered PA




1-Covered PA




2-MedicalCarve out







4






1-Covered PA












1-Covered






1-Covered PA









5




1-Covered PA






1-Covered PA










1-Covered PA




2-MedicalCarve out


2-MedicalCarve out




6






2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




7




2-MedicalCarve out





1-Covered PA
















1-Covered PA


1-Covered PA



1-Covered


1-Covered




8






1-Covered



1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered ST


1-Covered PA




9




1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered PA




1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered





10




1-Covered



1-Covered PA


1-Covered


1-Covered






1-Covered


1-Covered




1-Covered






11




1-Covered




1-Covered


1-Covered


1-Covered



1-Covered









1-Covered


1-Covered


1-Covered




12





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered











1-Covered




1-Covered


1-Covered




13




1-Covered










1-Covered



1-Covered


1-Covered






1-Covered



1-Covered


1-Covered




14




1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered





15




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




16





1-Covered


1-Covered


1-Covered







1-Covered









2-MedicalCarve out




17




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out





1-Covered


1-Covered





1-Covered










18




1-Covered


1-Covered








1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




19





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


2-MedicalCarve out


1-Covered



1-Covered




20




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered PA







1-Covered PA




1-Covered









21






1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered





1-Covered


1-Covered PA


1-Covered


1-Covered






22









1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




23




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered




1-Covered


1-Covered





1-Covered




24





1-Covered




















1-Covered


1-Covered




25






1-Covered



1-Covered


1-Covered


1-Covered




1-Covered



1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


1-Covered PA


1-Covered PA SP





26








1-Covered PA SP


1-Covered PA



1-Covered






1-Covered


1-Covered PA




1-Covered PA


1-Covered


1-Covered




27




1-Covered PA










1-Covered












1-Covered




28




1-Covered




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


Carve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


1-Covered


1-Covered


1-Covered




29





1-Covered


1-Covered



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




30




2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




31




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out

SP




32




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




33




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




34




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out









2-MedicalCarve out


1-Covered PA



2-MedicalCarve out


1-Covered PA SP


1-Covered PA SP


1-Covered PA SP




35




1-Covered PA



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out




36





2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




37




2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




38




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


SP


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out





39




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




40




2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out












1-Covered


1-Covered






1-Covered




41




1-Covered


1-Covered








1-Covered


1-Covered





1-Covered



2-MedicalCarve out



2-MedicalCarve out






42






1-Covered PA


1-Covered ST


1-Covered ST


1-Covered ST


















1-Covered ST


1-Covered




43




1-Covered























1-Covered


1-Covered


1-Covered




44




1-Covered


1-Covered PA


1-Covered


1-Covered PA


1-Covered


1-Covered PA


1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered




1-Covered PA


1-Covered


1-Covered


1-Covered




45





1-Covered






1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






46






1-Covered


1-Covered PA SP


1-Covered PA SP


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




47




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




48




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




49




2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




50




2-MedicalCarve out


2-MedicalCarve out


1-Covered



1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




51




1-Covered


1-Covered


1-Covered ST






1-Covered ST












1-Covered




1-Covered


1-Covered


1-Covered




52




1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered








53




1-Covered




1-Covered


1-Covered

















1-Covered






1-Covered




54




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered




55




1-Covered








1-Covered


1-Covered













56




1-Covered


1-Covered


1-Covered ST











1-Covered


1-Covered


1-Covered ST


1-Covered




57




1-Covered


1-Covered





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered



1-Covered



1-Covered ST


1-Covered ST




58




1-Covered ST




1-Covered ST













1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered




59




1-Covered


1-Covered







1-Covered


1-Covered









1-Covered


1-Covered


1-Covered




60




1-Covered













61















1-Covered PA
















62






1-Covered


1-Covered


1-Covered


1-Covered






























63









































64






1-Covered











1-Covered PA


1-Covered PA SP


1-Covered PA SP


1-Covered PA SP













65






1-Covered PA SP


1-Covered PA SP


1-Covered PA SP



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




66




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered PA



1-Covered



1-Covered




67




1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA



1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




68




1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered


1-Covered



1-Covered









69





1-Covered PA



1-Covered


1-Covered PA



1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




70




1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




71




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




1-Covered


1-Covered


1-Covered




72




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered



1-Covered PA


1-Covered PA





73




1-Covered PA










1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




1-Covered




74




1-Covered




1-Covered


1-Covered











1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




75




1-Covered



1-Covered




1-Covered




1-Covered


1-Covered




1-Covered


1-Covered


1-Covered






76





1-Covered


1-Covered


1-Covered












1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




77







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




78




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




79




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






1-Covered


1-Covered


1-Covered




1-Covered PA


1-Covered


1-Covered PA


1-Covered




80




1-Covered PA


1-Covered


1-Covered PA


1-Covered





1-Covered


1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




81




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




82




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered





1-Covered


1-Covered


1-Covered


1-Covered






83






















1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




84




1-Covered PA





1-Covered ST


1-Covered


1-Covered






1-Covered


1-Covered


1-Covered




1-Covered PA




85





1-Covered


1-Covered


1-Covered ST








1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered




86




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






1-Covered PA


1-Covered PA




1-Covered


1-Covered ST


1-Covered ST




87




1-Covered ST


1-Covered


1-Covered ST


1-Covered ST


1-Covered


1-Covered ST


1-Covered ST


1-Covered


1-Covered



1-Covered


1-Covered ST


1-Covered



1-Covered


1-Covered


1-Covered




88




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




89




1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered














90





1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




91




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






1-Covered




92




1-Covered


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






93







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




94




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




95




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered






1-Covered


1-Covered


1-Covered




96




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




97




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




98




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




99




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered



1-Covered


1-Covered


1-Covered PA SP


1-Covered PA SP





100




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered




101




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




1-Covered




102




1-Covered






1-Covered


1-Covered




1-Covered




103







1-Covered PA


1-Covered PA



1-Covered






1-Covered


1-Covered


1-Covered







104






























1-Covered


1-Covered PA




1-Covered


1-Covered





105








3-MedicalBenefit


3-MedicalBenefit


1-Covered


1-Covered


1-Covered PA



















106























3-MedicalBenefit









107






























108











1-Covered




1-Covered


1-Covered


1-Covered










109




1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered PA




1-Covered


1-Covered




1-Covered


1-Covered





110






1-Covered


1-Covered


1-Covered


1-Covered





1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




111




1-Covered


1-Covered




1-Covered


1-Covered


1-Covered


3-MedicalBenefit


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered




112




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




113




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




114








1-Covered


1-Covered








1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







115







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







116








1-Covered


1-Covered






1-Covered


1-Covered


1-Covered





1-Covered




1-Covered


1-Covered ST








117




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




118




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




119




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered ST


1-Covered ST




120




1-Covered ST


1-Covered ST


1-Covered ST


1-Covered ST



1-Covered


1-Covered


1-Covered
























121






1-Covered


1-Covered






1-Covered ST


1-Covered ST





1-Covered




1-Covered











122




1-Covered


1-Covered







1-Covered ST




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




123




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered












1-Covered



1-Covered ST




124




1-Covered


1-Covered


1-Covered


















1-Covered


1-Covered




125











1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




126




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




127




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




128




1-Covered



















1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




129

















1-Covered




1-Covered ST


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




130




1-Covered


1-Covered


1-Covered


1-Covered






131














































































































Table of Contents

iii


Formulary









lowercase italics






lowercase italics

Example





brand name


(ENDOCET)





iv

What are drug tiers
















and Limitations



for some ages


Required



we cover some drugs








90 day supply






within a time frame



v







step therapy)






setting




cover your drug





Cal Formulary





covered



vi










information







vii

H5928_19_269A2_C 08302019

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hie

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alif

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ia P

rom

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He

alth

Pla

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an

ind

ep

en

de

nt

lice

nse

e o

f th

e B

lue

Sh

ield

Ass

oc

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n

A512

47-C

MS (

91

8)
















Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228








viii

English


2556 (TTY 711)



711)

한국어 (Korean)








800-605-2556 (TTY 711)






800-605-2556 (TTY 711)

Italiano (Italian)



(Farsi) فارسی







1-800-605-2556 (TTY 711)



Llame al 1-800-605-2556 (TTY 711)


ix



800-605-2556 (TTY 711)






(711YTT)

Polski (Polish)


pod numer 1-800-605-2556 (TTY 711)













2556 (TTY 711) ਤ ਕਾਲ ਕਰ









x

English


Call 1-855-699-5557 (TTY 711)



711)

한국어 (Korean)






Italiano (Italian)



(Farsi) فارسی






Hmong (Hmong)


rau koj Hu rau 1-855-699-5557 (TTY 711)






bạn Gọi số 1-855-699-5557 (TTY 711)




711)


xi



(711YTT)










699-5557 (TTY 711) ਤ ਕਾਲ ਕਰ
















































Gland) 104


















1-Covered


1-Covered



1-Covered





1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered ST


1-Covered ST




1-Covered




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




2





1-Covered




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



2-MedicalCarve out




3




2-MedicalCarve out


2-MedicalCarve out




1-Covered PA


1-Covered PA



1-Covered PA




1-Covered PA




1-Covered PA




2-MedicalCarve out







4






1-Covered PA












1-Covered






1-Covered PA









5




1-Covered PA






1-Covered PA










1-Covered PA




2-MedicalCarve out


2-MedicalCarve out




6






2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




7




2-MedicalCarve out





1-Covered PA
















1-Covered PA


1-Covered PA



1-Covered


1-Covered




8






1-Covered



1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered ST


1-Covered PA




9




1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered PA




1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered





10




1-Covered



1-Covered PA


1-Covered


1-Covered






1-Covered


1-Covered




1-Covered






11




1-Covered




1-Covered


1-Covered


1-Covered



1-Covered









1-Covered


1-Covered


1-Covered




12





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered











1-Covered




1-Covered


1-Covered




13




1-Covered










1-Covered



1-Covered


1-Covered






1-Covered



1-Covered


1-Covered




14




1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered





15




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




16





1-Covered


1-Covered


1-Covered







1-Covered









2-MedicalCarve out




17




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out





1-Covered


1-Covered





1-Covered










18




1-Covered


1-Covered








1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




19





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


2-MedicalCarve out


1-Covered



1-Covered




20




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered PA







1-Covered PA




1-Covered









21






1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered





1-Covered


1-Covered PA


1-Covered


1-Covered






22









1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




23




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered




1-Covered


1-Covered





1-Covered




24





1-Covered




















1-Covered


1-Covered




25






1-Covered



1-Covered


1-Covered


1-Covered




1-Covered



1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


1-Covered PA


1-Covered PA SP





26








1-Covered PA SP


1-Covered PA



1-Covered






1-Covered


1-Covered PA




1-Covered PA


1-Covered


1-Covered




27




1-Covered PA










1-Covered












1-Covered




28




1-Covered




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


Carve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


1-Covered


1-Covered


1-Covered




29





1-Covered


1-Covered



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




30




2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




31




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out

SP




32




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




33




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




34




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out









2-MedicalCarve out


1-Covered PA



2-MedicalCarve out


1-Covered PA SP


1-Covered PA SP


1-Covered PA SP




35




1-Covered PA



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out




36





2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




37




2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




38




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


SP


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out





39




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




40




2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out












1-Covered


1-Covered






1-Covered




41




1-Covered


1-Covered








1-Covered


1-Covered





1-Covered



2-MedicalCarve out



2-MedicalCarve out






42






1-Covered PA


1-Covered ST


1-Covered ST


1-Covered ST


















1-Covered ST


1-Covered




43




1-Covered























1-Covered


1-Covered


1-Covered




44




1-Covered


1-Covered PA


1-Covered


1-Covered PA


1-Covered


1-Covered PA


1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered




1-Covered PA


1-Covered


1-Covered


1-Covered




45





1-Covered






1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






46






1-Covered


1-Covered PA SP


1-Covered PA SP


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




47




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




48




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




49




2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




50




2-MedicalCarve out


2-MedicalCarve out


1-Covered



1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




51




1-Covered


1-Covered


1-Covered ST






1-Covered ST












1-Covered




1-Covered


1-Covered


1-Covered




52




1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered








53




1-Covered




1-Covered


1-Covered

















1-Covered






1-Covered




54




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered




55




1-Covered








1-Covered


1-Covered













56




1-Covered


1-Covered


1-Covered ST











1-Covered


1-Covered


1-Covered ST


1-Covered




57




1-Covered


1-Covered





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered



1-Covered



1-Covered ST


1-Covered ST




58




1-Covered ST




1-Covered ST













1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered




59




1-Covered


1-Covered







1-Covered


1-Covered









1-Covered


1-Covered


1-Covered




60




1-Covered













61















1-Covered PA
















62






1-Covered


1-Covered


1-Covered


1-Covered






























63









































64






1-Covered











1-Covered PA


1-Covered PA SP


1-Covered PA SP


1-Covered PA SP













65






1-Covered PA SP


1-Covered PA SP


1-Covered PA SP



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




66




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered PA



1-Covered



1-Covered




67




1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA



1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




68




1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered


1-Covered



1-Covered









69





1-Covered PA



1-Covered


1-Covered PA



1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




70




1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




71




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




1-Covered


1-Covered


1-Covered




72




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered



1-Covered PA


1-Covered PA





73




1-Covered PA










1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




1-Covered




74




1-Covered




1-Covered


1-Covered











1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




75




1-Covered



1-Covered




1-Covered




1-Covered


1-Covered




1-Covered


1-Covered


1-Covered






76





1-Covered


1-Covered


1-Covered












1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




77







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




78




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




79




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






1-Covered


1-Covered


1-Covered




1-Covered PA


1-Covered


1-Covered PA


1-Covered




80




1-Covered PA


1-Covered


1-Covered PA


1-Covered





1-Covered


1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




81




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




82




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered





1-Covered


1-Covered


1-Covered


1-Covered






83






















1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




84




1-Covered PA





1-Covered ST


1-Covered


1-Covered






1-Covered


1-Covered


1-Covered




1-Covered PA




85





1-Covered


1-Covered


1-Covered ST








1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered




86




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






1-Covered PA


1-Covered PA




1-Covered


1-Covered ST


1-Covered ST




87




1-Covered ST


1-Covered


1-Covered ST


1-Covered ST


1-Covered


1-Covered ST


1-Covered ST


1-Covered


1-Covered



1-Covered


1-Covered ST


1-Covered



1-Covered


1-Covered


1-Covered




88




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




89




1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered














90





1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




91




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






1-Covered




92




1-Covered


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






93







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




94




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




95




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered






1-Covered


1-Covered


1-Covered




96




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




97




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




98




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




99




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered



1-Covered


1-Covered


1-Covered PA SP


1-Covered PA SP





100




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered




101




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




1-Covered




102




1-Covered






1-Covered


1-Covered




1-Covered




103







1-Covered PA


1-Covered PA



1-Covered






1-Covered


1-Covered


1-Covered







104






























1-Covered


1-Covered PA




1-Covered


1-Covered





105








3-MedicalBenefit


3-MedicalBenefit


1-Covered


1-Covered


1-Covered PA



















106























3-MedicalBenefit









107






























108











1-Covered




1-Covered


1-Covered


1-Covered










109




1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered PA




1-Covered


1-Covered




1-Covered


1-Covered





110






1-Covered


1-Covered


1-Covered


1-Covered





1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




111




1-Covered


1-Covered




1-Covered


1-Covered


1-Covered


3-MedicalBenefit


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered




112




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




113




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




114








1-Covered


1-Covered








1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







115







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







116








1-Covered


1-Covered






1-Covered


1-Covered


1-Covered





1-Covered




1-Covered


1-Covered ST








117




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




118




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




119




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered ST


1-Covered ST




120




1-Covered ST


1-Covered ST


1-Covered ST


1-Covered ST



1-Covered


1-Covered


1-Covered
























121






1-Covered


1-Covered






1-Covered ST


1-Covered ST





1-Covered




1-Covered











122




1-Covered


1-Covered







1-Covered ST




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




123




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered












1-Covered



1-Covered ST




124




1-Covered


1-Covered


1-Covered


















1-Covered


1-Covered




125











1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




126




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




127




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




128




1-Covered



















1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




129

















1-Covered




1-Covered ST


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




130




1-Covered


1-Covered


1-Covered


1-Covered






131














































































































Table of Contents

iv

What are drug tiers
















and Limitations



for some ages


Required



we cover some drugs








90 day supply






within a time frame



v







step therapy)






setting




cover your drug





Cal Formulary





covered



vi










information







vii

H5928_19_269A2_C 08302019

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alif

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ia P

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de

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nse

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f th

e B

lue

Sh

ield

Ass

oc

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n

A512

47-C

MS (

91

8)
















Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228








viii

English


2556 (TTY 711)



711)

한국어 (Korean)








800-605-2556 (TTY 711)






800-605-2556 (TTY 711)

Italiano (Italian)



(Farsi) فارسی







1-800-605-2556 (TTY 711)



Llame al 1-800-605-2556 (TTY 711)


ix



800-605-2556 (TTY 711)






(711YTT)

Polski (Polish)


pod numer 1-800-605-2556 (TTY 711)













2556 (TTY 711) ਤ ਕਾਲ ਕਰ









x

English


Call 1-855-699-5557 (TTY 711)



711)

한국어 (Korean)






Italiano (Italian)



(Farsi) فارسی






Hmong (Hmong)


rau koj Hu rau 1-855-699-5557 (TTY 711)






bạn Gọi số 1-855-699-5557 (TTY 711)




711)


xi



(711YTT)










699-5557 (TTY 711) ਤ ਕਾਲ ਕਰ
















































Gland) 104


















1-Covered


1-Covered



1-Covered





1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered ST


1-Covered ST




1-Covered




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




2





1-Covered




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



2-MedicalCarve out




3




2-MedicalCarve out


2-MedicalCarve out




1-Covered PA


1-Covered PA



1-Covered PA




1-Covered PA




1-Covered PA




2-MedicalCarve out







4






1-Covered PA












1-Covered






1-Covered PA









5




1-Covered PA






1-Covered PA










1-Covered PA




2-MedicalCarve out


2-MedicalCarve out




6






2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




7




2-MedicalCarve out





1-Covered PA
















1-Covered PA


1-Covered PA



1-Covered


1-Covered




8






1-Covered



1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered ST


1-Covered PA




9




1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered PA




1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered





10




1-Covered



1-Covered PA


1-Covered


1-Covered






1-Covered


1-Covered




1-Covered






11




1-Covered




1-Covered


1-Covered


1-Covered



1-Covered









1-Covered


1-Covered


1-Covered




12





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered











1-Covered




1-Covered


1-Covered




13




1-Covered










1-Covered



1-Covered


1-Covered






1-Covered



1-Covered


1-Covered




14




1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered





15




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




16





1-Covered


1-Covered


1-Covered







1-Covered









2-MedicalCarve out




17




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out





1-Covered


1-Covered





1-Covered










18




1-Covered


1-Covered








1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




19





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


2-MedicalCarve out


1-Covered



1-Covered




20




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered PA







1-Covered PA




1-Covered









21






1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered





1-Covered


1-Covered PA


1-Covered


1-Covered






22









1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




23




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered




1-Covered


1-Covered





1-Covered




24





1-Covered




















1-Covered


1-Covered




25






1-Covered



1-Covered


1-Covered


1-Covered




1-Covered



1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


1-Covered PA


1-Covered PA SP





26








1-Covered PA SP


1-Covered PA



1-Covered






1-Covered


1-Covered PA




1-Covered PA


1-Covered


1-Covered




27




1-Covered PA










1-Covered












1-Covered




28




1-Covered




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


Carve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


1-Covered


1-Covered


1-Covered




29





1-Covered


1-Covered



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




30




2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




31




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out

SP




32




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




33




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




34




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out









2-MedicalCarve out


1-Covered PA



2-MedicalCarve out


1-Covered PA SP


1-Covered PA SP


1-Covered PA SP




35




1-Covered PA



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out




36





2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




37




2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




38




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


SP


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out





39




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




40




2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out












1-Covered


1-Covered






1-Covered




41




1-Covered


1-Covered








1-Covered


1-Covered





1-Covered



2-MedicalCarve out



2-MedicalCarve out






42






1-Covered PA


1-Covered ST


1-Covered ST


1-Covered ST


















1-Covered ST


1-Covered




43




1-Covered























1-Covered


1-Covered


1-Covered




44




1-Covered


1-Covered PA


1-Covered


1-Covered PA


1-Covered


1-Covered PA


1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered




1-Covered PA


1-Covered


1-Covered


1-Covered




45





1-Covered






1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






46






1-Covered


1-Covered PA SP


1-Covered PA SP


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




47




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




48




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




49




2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




50




2-MedicalCarve out


2-MedicalCarve out


1-Covered



1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




51




1-Covered


1-Covered


1-Covered ST






1-Covered ST












1-Covered




1-Covered


1-Covered


1-Covered




52




1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered








53




1-Covered




1-Covered


1-Covered

















1-Covered






1-Covered




54




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered




55




1-Covered








1-Covered


1-Covered













56




1-Covered


1-Covered


1-Covered ST











1-Covered


1-Covered


1-Covered ST


1-Covered




57




1-Covered


1-Covered





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered



1-Covered



1-Covered ST


1-Covered ST




58




1-Covered ST




1-Covered ST













1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered




59




1-Covered


1-Covered







1-Covered


1-Covered









1-Covered


1-Covered


1-Covered




60




1-Covered













61















1-Covered PA
















62






1-Covered


1-Covered


1-Covered


1-Covered






























63









































64






1-Covered











1-Covered PA


1-Covered PA SP


1-Covered PA SP


1-Covered PA SP













65






1-Covered PA SP


1-Covered PA SP


1-Covered PA SP



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




66




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered PA



1-Covered



1-Covered




67




1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA



1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




68




1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered


1-Covered



1-Covered









69





1-Covered PA



1-Covered


1-Covered PA



1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




70




1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




71




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




1-Covered


1-Covered


1-Covered




72




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered



1-Covered PA


1-Covered PA





73




1-Covered PA










1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




1-Covered




74




1-Covered




1-Covered


1-Covered











1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




75




1-Covered



1-Covered




1-Covered




1-Covered


1-Covered




1-Covered


1-Covered


1-Covered






76





1-Covered


1-Covered


1-Covered












1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




77







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




78




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




79




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






1-Covered


1-Covered


1-Covered




1-Covered PA


1-Covered


1-Covered PA


1-Covered




80




1-Covered PA


1-Covered


1-Covered PA


1-Covered





1-Covered


1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




81




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




82




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered





1-Covered


1-Covered


1-Covered


1-Covered






83






















1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




84




1-Covered PA





1-Covered ST


1-Covered


1-Covered






1-Covered


1-Covered


1-Covered




1-Covered PA




85





1-Covered


1-Covered


1-Covered ST








1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered




86




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






1-Covered PA


1-Covered PA




1-Covered


1-Covered ST


1-Covered ST




87




1-Covered ST


1-Covered


1-Covered ST


1-Covered ST


1-Covered


1-Covered ST


1-Covered ST


1-Covered


1-Covered



1-Covered


1-Covered ST


1-Covered



1-Covered


1-Covered


1-Covered




88




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




89




1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered














90





1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




91




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






1-Covered




92




1-Covered


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






93







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




94




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




95




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered






1-Covered


1-Covered


1-Covered




96




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




97




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




98




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




99




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered



1-Covered


1-Covered


1-Covered PA SP


1-Covered PA SP





100




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered




101




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




1-Covered




102




1-Covered






1-Covered


1-Covered




1-Covered




103







1-Covered PA


1-Covered PA



1-Covered






1-Covered


1-Covered


1-Covered







104






























1-Covered


1-Covered PA




1-Covered


1-Covered





105








3-MedicalBenefit


3-MedicalBenefit


1-Covered


1-Covered


1-Covered PA



















106























3-MedicalBenefit









107






























108











1-Covered




1-Covered


1-Covered


1-Covered










109




1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered PA




1-Covered


1-Covered




1-Covered


1-Covered





110






1-Covered


1-Covered


1-Covered


1-Covered





1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




111




1-Covered


1-Covered




1-Covered


1-Covered


1-Covered


3-MedicalBenefit


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered




112




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




113




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




114








1-Covered


1-Covered








1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







115







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







116








1-Covered


1-Covered






1-Covered


1-Covered


1-Covered





1-Covered




1-Covered


1-Covered ST








117




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




118




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




119




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered ST


1-Covered ST




120




1-Covered ST


1-Covered ST


1-Covered ST


1-Covered ST



1-Covered


1-Covered


1-Covered
























121






1-Covered


1-Covered






1-Covered ST


1-Covered ST





1-Covered




1-Covered











122




1-Covered


1-Covered







1-Covered ST




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




123




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered












1-Covered



1-Covered ST




124




1-Covered


1-Covered


1-Covered


















1-Covered


1-Covered




125











1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




126




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




127




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




128




1-Covered



















1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




129

















1-Covered




1-Covered ST


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




130




1-Covered


1-Covered


1-Covered


1-Covered






131














































































































Table of Contents

v







step therapy)






setting




cover your drug





Cal Formulary





covered



vi










information







vii

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Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228








viii

English


2556 (TTY 711)



711)

한국어 (Korean)








800-605-2556 (TTY 711)






800-605-2556 (TTY 711)

Italiano (Italian)



(Farsi) فارسی







1-800-605-2556 (TTY 711)



Llame al 1-800-605-2556 (TTY 711)


ix



800-605-2556 (TTY 711)






(711YTT)

Polski (Polish)


pod numer 1-800-605-2556 (TTY 711)













2556 (TTY 711) ਤ ਕਾਲ ਕਰ









x

English


Call 1-855-699-5557 (TTY 711)



711)

한국어 (Korean)






Italiano (Italian)



(Farsi) فارسی






Hmong (Hmong)


rau koj Hu rau 1-855-699-5557 (TTY 711)






bạn Gọi số 1-855-699-5557 (TTY 711)




711)


xi



(711YTT)










699-5557 (TTY 711) ਤ ਕਾਲ ਕਰ
















































Gland) 104


















1-Covered


1-Covered



1-Covered





1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered ST


1-Covered ST




1-Covered




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




2





1-Covered




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



2-MedicalCarve out




3




2-MedicalCarve out


2-MedicalCarve out




1-Covered PA


1-Covered PA



1-Covered PA




1-Covered PA




1-Covered PA




2-MedicalCarve out







4






1-Covered PA












1-Covered






1-Covered PA









5




1-Covered PA






1-Covered PA










1-Covered PA




2-MedicalCarve out


2-MedicalCarve out




6






2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




7




2-MedicalCarve out





1-Covered PA
















1-Covered PA


1-Covered PA



1-Covered


1-Covered




8






1-Covered



1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered ST


1-Covered PA




9




1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered PA




1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered





10




1-Covered



1-Covered PA


1-Covered


1-Covered






1-Covered


1-Covered




1-Covered






11




1-Covered




1-Covered


1-Covered


1-Covered



1-Covered









1-Covered


1-Covered


1-Covered




12





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered











1-Covered




1-Covered


1-Covered




13




1-Covered










1-Covered



1-Covered


1-Covered






1-Covered



1-Covered


1-Covered




14




1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered





15




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




16





1-Covered


1-Covered


1-Covered







1-Covered









2-MedicalCarve out




17




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out





1-Covered


1-Covered





1-Covered










18




1-Covered


1-Covered








1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




19





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


2-MedicalCarve out


1-Covered



1-Covered




20




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered PA







1-Covered PA




1-Covered









21






1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered





1-Covered


1-Covered PA


1-Covered


1-Covered






22









1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




23




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered




1-Covered


1-Covered





1-Covered




24





1-Covered




















1-Covered


1-Covered




25






1-Covered



1-Covered


1-Covered


1-Covered




1-Covered



1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


1-Covered PA


1-Covered PA SP





26








1-Covered PA SP


1-Covered PA



1-Covered






1-Covered


1-Covered PA




1-Covered PA


1-Covered


1-Covered




27




1-Covered PA










1-Covered












1-Covered




28




1-Covered




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


Carve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


1-Covered


1-Covered


1-Covered




29





1-Covered


1-Covered



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




30




2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




31




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out

SP




32




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




33




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




34




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out









2-MedicalCarve out


1-Covered PA



2-MedicalCarve out


1-Covered PA SP


1-Covered PA SP


1-Covered PA SP




35




1-Covered PA



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out




36





2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




37




2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




38




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


SP


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out





39




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




40




2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out












1-Covered


1-Covered






1-Covered




41




1-Covered


1-Covered








1-Covered


1-Covered





1-Covered



2-MedicalCarve out



2-MedicalCarve out






42






1-Covered PA


1-Covered ST


1-Covered ST


1-Covered ST


















1-Covered ST


1-Covered




43




1-Covered























1-Covered


1-Covered


1-Covered




44




1-Covered


1-Covered PA


1-Covered


1-Covered PA


1-Covered


1-Covered PA


1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered




1-Covered PA


1-Covered


1-Covered


1-Covered




45





1-Covered






1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






46






1-Covered


1-Covered PA SP


1-Covered PA SP


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




47




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




48




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




49




2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




50




2-MedicalCarve out


2-MedicalCarve out


1-Covered



1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




51




1-Covered


1-Covered


1-Covered ST






1-Covered ST












1-Covered




1-Covered


1-Covered


1-Covered




52




1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered








53




1-Covered




1-Covered


1-Covered

















1-Covered






1-Covered




54




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered




55




1-Covered








1-Covered


1-Covered













56




1-Covered


1-Covered


1-Covered ST











1-Covered


1-Covered


1-Covered ST


1-Covered




57




1-Covered


1-Covered





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered



1-Covered



1-Covered ST


1-Covered ST




58




1-Covered ST




1-Covered ST













1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered




59




1-Covered


1-Covered







1-Covered


1-Covered









1-Covered


1-Covered


1-Covered




60




1-Covered













61















1-Covered PA
















62






1-Covered


1-Covered


1-Covered


1-Covered






























63









































64






1-Covered











1-Covered PA


1-Covered PA SP


1-Covered PA SP


1-Covered PA SP













65






1-Covered PA SP


1-Covered PA SP


1-Covered PA SP



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




66




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered PA



1-Covered



1-Covered




67




1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA



1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




68




1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered


1-Covered



1-Covered









69





1-Covered PA



1-Covered


1-Covered PA



1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




70




1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




71




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




1-Covered


1-Covered


1-Covered




72




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered



1-Covered PA


1-Covered PA





73




1-Covered PA










1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




1-Covered




74




1-Covered




1-Covered


1-Covered











1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




75




1-Covered



1-Covered




1-Covered




1-Covered


1-Covered




1-Covered


1-Covered


1-Covered






76





1-Covered


1-Covered


1-Covered












1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




77







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




78




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




79




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






1-Covered


1-Covered


1-Covered




1-Covered PA


1-Covered


1-Covered PA


1-Covered




80




1-Covered PA


1-Covered


1-Covered PA


1-Covered





1-Covered


1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




81




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




82




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered





1-Covered


1-Covered


1-Covered


1-Covered






83






















1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




84




1-Covered PA





1-Covered ST


1-Covered


1-Covered






1-Covered


1-Covered


1-Covered




1-Covered PA




85





1-Covered


1-Covered


1-Covered ST








1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered




86




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






1-Covered PA


1-Covered PA




1-Covered


1-Covered ST


1-Covered ST




87




1-Covered ST


1-Covered


1-Covered ST


1-Covered ST


1-Covered


1-Covered ST


1-Covered ST


1-Covered


1-Covered



1-Covered


1-Covered ST


1-Covered



1-Covered


1-Covered


1-Covered




88




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




89




1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered














90





1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




91




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






1-Covered




92




1-Covered


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






93







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




94




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




95




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered






1-Covered


1-Covered


1-Covered




96




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




97




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




98




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




99




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered



1-Covered


1-Covered


1-Covered PA SP


1-Covered PA SP





100




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered




101




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




1-Covered




102




1-Covered






1-Covered


1-Covered




1-Covered




103







1-Covered PA


1-Covered PA



1-Covered






1-Covered


1-Covered


1-Covered







104






























1-Covered


1-Covered PA




1-Covered


1-Covered





105








3-MedicalBenefit


3-MedicalBenefit


1-Covered


1-Covered


1-Covered PA



















106























3-MedicalBenefit









107






























108











1-Covered




1-Covered


1-Covered


1-Covered










109




1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered PA




1-Covered


1-Covered




1-Covered


1-Covered





110






1-Covered


1-Covered


1-Covered


1-Covered





1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




111




1-Covered


1-Covered




1-Covered


1-Covered


1-Covered


3-MedicalBenefit


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered




112




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




113




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




114








1-Covered


1-Covered








1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







115







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







116








1-Covered


1-Covered






1-Covered


1-Covered


1-Covered





1-Covered




1-Covered


1-Covered ST








117




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




118




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




119




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered ST


1-Covered ST




120




1-Covered ST


1-Covered ST


1-Covered ST


1-Covered ST



1-Covered


1-Covered


1-Covered
























121






1-Covered


1-Covered






1-Covered ST


1-Covered ST





1-Covered




1-Covered











122




1-Covered


1-Covered







1-Covered ST




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




123




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered












1-Covered



1-Covered ST




124




1-Covered


1-Covered


1-Covered


















1-Covered


1-Covered




125











1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




126




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




127




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




128




1-Covered



















1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




129

















1-Covered




1-Covered ST


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




130




1-Covered


1-Covered


1-Covered


1-Covered






131














































































































Table of Contents

vi










information







vii

H5928_19_269A2_C 08302019

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A512

47-C

MS (

91

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Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228








viii

English


2556 (TTY 711)



711)

한국어 (Korean)








800-605-2556 (TTY 711)






800-605-2556 (TTY 711)

Italiano (Italian)



(Farsi) فارسی







1-800-605-2556 (TTY 711)



Llame al 1-800-605-2556 (TTY 711)


ix



800-605-2556 (TTY 711)






(711YTT)

Polski (Polish)


pod numer 1-800-605-2556 (TTY 711)













2556 (TTY 711) ਤ ਕਾਲ ਕਰ









x

English


Call 1-855-699-5557 (TTY 711)



711)

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Italiano (Italian)



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Gland) 104


















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1




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2





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2-MedicalCarve out




3




2-MedicalCarve out


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1-Covered PA


1-Covered PA



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2-MedicalCarve out







4






1-Covered PA












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5




1-Covered PA






1-Covered PA










1-Covered PA




2-MedicalCarve out


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6






2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


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2-MedicalCarve out





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1-Covered



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9




1-Covered PA


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10




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15




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2-MedicalCarve out




17




2-MedicalCarve out


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18




1-Covered


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22









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23




1-Covered


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24





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26








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27




1-Covered PA










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28




1-Covered




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


Carve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


1-Covered


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29





1-Covered


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2-MedicalCarve out


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2-MedicalCarve out


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30




2-MedicalCarve out



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31




2-MedicalCarve out


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2-MedicalCarve out


2-MedicalCarve out

SP




32




2-MedicalCarve out


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33




2-MedicalCarve out


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34




2-MedicalCarve out


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1-Covered PA



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1-Covered PA SP


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35




1-Covered PA



2-MedicalCarve out


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36





2-MedicalCarve out


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37




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38




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SP


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39




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40




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2-MedicalCarve out



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42






1-Covered PA


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43




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44




1-Covered


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45





1-Covered






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1-Covered PA


1-Covered PA


1-Covered


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46






1-Covered


1-Covered PA SP


1-Covered PA SP


2-MedicalCarve out


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47




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


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48




2-MedicalCarve out


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49




2-MedicalCarve out


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50




2-MedicalCarve out


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51




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58




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64






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65






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66




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67




1-Covered


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1-Covered PA


1-Covered PA


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68




1-Covered


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69





1-Covered PA



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1-Covered PA


1-Covered


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70




1-Covered


1-Covered PA


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71




1-Covered


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72




1-Covered


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1-Covered PA


1-Covered PA





73




1-Covered PA










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74




1-Covered




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75




1-Covered



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78




1-Covered


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79




1-Covered


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1-Covered PA


1-Covered


1-Covered PA


1-Covered




80




1-Covered PA


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1-Covered PA


1-Covered





1-Covered


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1-Covered PA


1-Covered


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81




1-Covered


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82




1-Covered



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83






















1-Covered


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84




1-Covered PA





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1-Covered PA




85





1-Covered


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1-Covered


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86




1-Covered


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1-Covered PA


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1-Covered ST




87




1-Covered ST


1-Covered


1-Covered ST


1-Covered ST


1-Covered


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88




1-Covered


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89




1-Covered


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90





1-Covered


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1-Covered


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91




1-Covered


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92




1-Covered


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


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93







1-Covered


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94




1-Covered


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95




1-Covered


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96




1-Covered


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97




1-Covered


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98




1-Covered


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99




1-Covered


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1-Covered PA SP


1-Covered PA SP





100




1-Covered


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101




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1-Covered PA


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104






























1-Covered


1-Covered PA




1-Covered


1-Covered





105








3-MedicalBenefit


3-MedicalBenefit


1-Covered


1-Covered


1-Covered PA



















106























3-MedicalBenefit









107






























108











1-Covered




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109




1-Covered PA


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110






1-Covered


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111




1-Covered


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112




1-Covered


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113




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114








1-Covered


1-Covered








1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







115







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







116








1-Covered


1-Covered






1-Covered


1-Covered


1-Covered





1-Covered




1-Covered


1-Covered ST








117




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




118




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




119




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered ST


1-Covered ST




120




1-Covered ST


1-Covered ST


1-Covered ST


1-Covered ST



1-Covered


1-Covered


1-Covered
























121






1-Covered


1-Covered






1-Covered ST


1-Covered ST





1-Covered




1-Covered











122




1-Covered


1-Covered







1-Covered ST




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




123




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered












1-Covered



1-Covered ST




124




1-Covered


1-Covered


1-Covered


















1-Covered


1-Covered




125











1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




126




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




127




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




128




1-Covered



















1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




129

















1-Covered




1-Covered ST


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




130




1-Covered


1-Covered


1-Covered


1-Covered






131














































































































Table of Contents



vii

H5928_19_269A2_C 08302019

Blu

e S

hie

ld o

f C

alif

orn

ia P

rom

ise

He

alth

Pla

n is

an

ind

ep

en

de

nt

lice

nse

e o

f th

e B

lue

Sh

ield

Ass

oc

iatio

n

A512

47-C

MS (

91

8)
















Phone (844) 883-2233 (TTY 711)

Fax (323) 889-2228








viii

English


2556 (TTY 711)



711)

한국어 (Korean)








800-605-2556 (TTY 711)






800-605-2556 (TTY 711)

Italiano (Italian)



(Farsi) فارسی







1-800-605-2556 (TTY 711)



Llame al 1-800-605-2556 (TTY 711)


ix



800-605-2556 (TTY 711)






(711YTT)

Polski (Polish)


pod numer 1-800-605-2556 (TTY 711)













2556 (TTY 711) ਤ ਕਾਲ ਕਰ









x

English


Call 1-855-699-5557 (TTY 711)



711)

한국어 (Korean)






Italiano (Italian)



(Farsi) فارسی






Hmong (Hmong)


rau koj Hu rau 1-855-699-5557 (TTY 711)






bạn Gọi số 1-855-699-5557 (TTY 711)




711)


xi



(711YTT)










699-5557 (TTY 711) ਤ ਕਾਲ ਕਰ
















































Gland) 104


















1-Covered


1-Covered



1-Covered





1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered ST


1-Covered ST




1-Covered




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




2





1-Covered




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



2-MedicalCarve out




3




2-MedicalCarve out


2-MedicalCarve out




1-Covered PA


1-Covered PA



1-Covered PA




1-Covered PA




1-Covered PA




2-MedicalCarve out







4






1-Covered PA












1-Covered






1-Covered PA









5




1-Covered PA






1-Covered PA










1-Covered PA




2-MedicalCarve out


2-MedicalCarve out




6






2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




7




2-MedicalCarve out





1-Covered PA
















1-Covered PA


1-Covered PA



1-Covered


1-Covered




8






1-Covered



1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered ST


1-Covered PA




9




1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered PA




1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered





10




1-Covered



1-Covered PA


1-Covered


1-Covered






1-Covered


1-Covered




1-Covered






11




1-Covered




1-Covered


1-Covered


1-Covered



1-Covered









1-Covered


1-Covered


1-Covered




12





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered











1-Covered




1-Covered


1-Covered




13




1-Covered










1-Covered



1-Covered


1-Covered






1-Covered



1-Covered


1-Covered




14




1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered





15




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




16





1-Covered


1-Covered


1-Covered







1-Covered









2-MedicalCarve out




17




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out





1-Covered


1-Covered





1-Covered










18




1-Covered


1-Covered








1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




19





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


2-MedicalCarve out


1-Covered



1-Covered




20




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered PA







1-Covered PA




1-Covered









21






1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered





1-Covered


1-Covered PA


1-Covered


1-Covered






22









1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




23




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered




1-Covered


1-Covered





1-Covered




24





1-Covered




















1-Covered


1-Covered




25






1-Covered



1-Covered


1-Covered


1-Covered




1-Covered



1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


1-Covered PA


1-Covered PA SP





26








1-Covered PA SP


1-Covered PA



1-Covered






1-Covered


1-Covered PA




1-Covered PA


1-Covered


1-Covered




27




1-Covered PA










1-Covered












1-Covered




28




1-Covered




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


Carve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


1-Covered


1-Covered


1-Covered




29





1-Covered


1-Covered



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




30




2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




31




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out

SP




32




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




33




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




34




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out









2-MedicalCarve out


1-Covered PA



2-MedicalCarve out


1-Covered PA SP


1-Covered PA SP


1-Covered PA SP




35




1-Covered PA



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out




36





2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




37




2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




38




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


SP


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out





39




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




40




2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out












1-Covered


1-Covered






1-Covered




41




1-Covered


1-Covered








1-Covered


1-Covered





1-Covered



2-MedicalCarve out



2-MedicalCarve out






42






1-Covered PA


1-Covered ST


1-Covered ST


1-Covered ST


















1-Covered ST


1-Covered




43




1-Covered























1-Covered


1-Covered


1-Covered




44




1-Covered


1-Covered PA


1-Covered


1-Covered PA


1-Covered


1-Covered PA


1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered




1-Covered PA


1-Covered


1-Covered


1-Covered




45





1-Covered






1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






46






1-Covered


1-Covered PA SP


1-Covered PA SP


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




47




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




48




2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




49




2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out



2-MedicalCarve out



2-MedicalCarve out


2-MedicalCarve out


2-MedicalCarve out




50




2-MedicalCarve out


2-MedicalCarve out


1-Covered



1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




51




1-Covered


1-Covered


1-Covered ST






1-Covered ST












1-Covered




1-Covered


1-Covered


1-Covered




52




1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered








53




1-Covered




1-Covered


1-Covered

















1-Covered






1-Covered




54




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered




55




1-Covered








1-Covered


1-Covered













56




1-Covered


1-Covered


1-Covered ST











1-Covered


1-Covered


1-Covered ST


1-Covered




57




1-Covered


1-Covered





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered



1-Covered



1-Covered ST


1-Covered ST




58




1-Covered ST




1-Covered ST













1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered




59




1-Covered


1-Covered







1-Covered


1-Covered









1-Covered


1-Covered


1-Covered




60




1-Covered













61















1-Covered PA
















62






1-Covered


1-Covered


1-Covered


1-Covered






























63









































64






1-Covered











1-Covered PA


1-Covered PA SP


1-Covered PA SP


1-Covered PA SP













65






1-Covered PA SP


1-Covered PA SP


1-Covered PA SP



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




66




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered PA



1-Covered



1-Covered




67




1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA



1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




68




1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered


1-Covered



1-Covered









69





1-Covered PA



1-Covered


1-Covered PA



1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




70




1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




71




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




1-Covered


1-Covered


1-Covered




72




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered



1-Covered PA


1-Covered PA





73




1-Covered PA










1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




1-Covered




74




1-Covered




1-Covered


1-Covered











1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




75




1-Covered



1-Covered




1-Covered




1-Covered


1-Covered




1-Covered


1-Covered


1-Covered






76





1-Covered


1-Covered


1-Covered












1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




77







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




78




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




79




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






1-Covered


1-Covered


1-Covered




1-Covered PA


1-Covered


1-Covered PA


1-Covered




80




1-Covered PA


1-Covered


1-Covered PA


1-Covered





1-Covered


1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




81




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




82




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered





1-Covered


1-Covered


1-Covered


1-Covered






83






















1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




84




1-Covered PA





1-Covered ST


1-Covered


1-Covered






1-Covered


1-Covered


1-Covered




1-Covered PA




85





1-Covered


1-Covered


1-Covered ST








1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered




86




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






1-Covered PA


1-Covered PA




1-Covered


1-Covered ST


1-Covered ST




87




1-Covered ST


1-Covered


1-Covered ST


1-Covered ST


1-Covered


1-Covered ST


1-Covered ST


1-Covered


1-Covered



1-Covered


1-Covered ST


1-Covered



1-Covered


1-Covered


1-Covered




88




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




89




1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered














90





1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




91




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






1-Covered




92




1-Covered


1-Covered PA


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered






93







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




94




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




95




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered






1-Covered


1-Covered


1-Covered




96




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




97




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




98




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




99




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered



1-Covered


1-Covered


1-Covered PA SP


1-Covered PA SP





100




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered


1-Covered


1-Covered




101




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




1-Covered




102




1-Covered






1-Covered


1-Covered




1-Covered




103







1-Covered PA


1-Covered PA



1-Covered






1-Covered


1-Covered


1-Covered







104






























1-Covered


1-Covered PA




1-Covered


1-Covered





105








3-MedicalBenefit


3-MedicalBenefit


1-Covered


1-Covered


1-Covered PA



















106























3-MedicalBenefit









107






























108











1-Covered




1-Covered


1-Covered


1-Covered










109




1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered PA


1-Covered PA


1-Covered


1-Covered


1-Covered


1-Covered PA




1-Covered


1-Covered




1-Covered


1-Covered





110






1-Covered


1-Covered


1-Covered


1-Covered





1-Covered


1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




111




1-Covered


1-Covered




1-Covered


1-Covered


1-Covered


3-MedicalBenefit


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered


1-Covered


1-Covered




112




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered



1-Covered



1-Covered


1-Covered


1-Covered


1-Covered




113




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered





1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




114








1-Covered


1-Covered








1-Covered



1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







115







1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered







116








1-Covered


1-Covered






1-Covered


1-Covered


1-Covered





1-Covered




1-Covered


1-Covered ST








117




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




118




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




119




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered ST


1-Covered ST




120




1-Covered ST


1-Covered ST


1-Covered ST


1-Covered ST



1-Covered


1-Covered


1-Covered
























121






1-Covered


1-Covered






1-Covered ST


1-Covered ST





1-Covered




1-Covered











122




1-Covered


1-Covered







1-Covered ST




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




1-Covered


1-Covered




123




1-Covered



1-Covered


1-Covered


1-Covered


1-Covered












1-Covered



1-Covered ST




124




1-Covered


1-Covered


1-Covered


















1-Covered


1-Covered




125











1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




126




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




127




1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




128




1-Covered



















1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




129

















1-Covered




1-Covered ST


1-Covered


1-Covered


1-Covered


1-Covered


1-Covered




130




1-Covered


1-Covered


1-Covered


1-Covered






131














































































































Table of Contents

Blue Shield Promise Medi-Cal Formulary

Documents

Transcript of Blue Shield Promise Medi-Cal Formulary