NON-COMMUNITYCARE PROVIDERS: Medications restricted to CUC Prescribers and/or CUC in-house pharmacies are considered non-formulary outside of CUC. These medications may be obtained via Prescription Assistance Programs (PAP). If the patient does not qualify for PAP, the provider may submit a NON-FORMULARY DRUG REQUEST (NFDR) FORM. Documentation of PAP ineligibility or rejection should be submitted with the NDFR form.
More information on pharmacy benefits can be found in the MAP and MAP Basic Provider Handbook.
Generic Code | 通用序号 | 治疗类 | BrandName | GenericName | Formulation | Strength | Coverage | Location | Comments |
---|---|---|---|---|---|---|---|---|---|
49.291 | 17.037 | 040800-SECOND GENERATION ANTIHISTAMINES | Zyrtec | CETIRIZINE HCL | TABLET | 10 MG | COVERED | CommUnityCare药房 | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
60.563 | 18.698 | 040800-SECOND GENERATION ANTIHISTAMINES | Claritin | LORATADINE | TABLET | 10 MG | COVERED | CommUnityCare药房 | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
17.853 | 50.714 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Spiriva Handihaler | TIOTROPIUM溴化 | CAP W/DEV | 18 MCG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
3.421 | 16.425 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | Nicoderm CQ Patch | NICOTINE | PATCH TD24 | 7 MG/24HR | COVERED | FORMULARY | |
3.422 | 16.426 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | Nicoderm CQ Patch | NICOTINE | PATCH TD24 | 14 MG/24HR | COVERED | FORMULARY | |
3.423 | 16.427 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | Nicoderm CQ Patch | NICOTINE | PATCH TD24 | 21 MG/24HR | COVERED | FORMULARY | |
27.047 | 60.897 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | Chantix | 酒石酸伐伦克林 | TABLET | 1 MG | COVERED | FORMULARY | only 12 week course, all strengths, in 12 month period & must be receiving tobacco cessation counseling during treatment |
27.046 | 60.896 | 129200-AUTONOMIC DRUGS, MISCELLANEOUS | Chantix | 酒石酸伐伦克林 | TABLET | 0.5 MG | COVERED | FORMULARY | only 12 week course, all strengths, in 12 month period & must be receiving tobacco cessation counseling during treatment |
18.387 | 51.214 | 240605-CHOLESTEROL ABSORPTION INHIBITORS | Zetia | EZETIMIBE | TABLET | 10 MG | COVERED | FORMULARY | |
42.001 | 41.285 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Celebrex | CELECOXIB | CAPSULE | 100 MG | COVERED | FORMULARY | |
42.002 | 41.286 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Celebrex | CELECOXIB | CAPSULE | 200 MG | COVERED | FORMULARY | |
97.785 | 62.001 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Celebrex | CELECOXIB | CAPSULE | 50 MG | COVERED | FORMULARY | |
18.127 | 50.832 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Celebrex | CELECOXIB | CAPSULE | 400 MG | COVERED | FORMULARY | |
23.046 | 57.800 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 50 MG | COVERED | FORMULARY | |
23.047 | 57.801 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 75 MG | COVERED | FORMULARY | |
23.048 | 57.802 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 100 MG | COVERED | FORMULARY | |
23.049 | 57.803 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 150 MG | COVERED | FORMULARY | |
23.051 | 57.804 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 200 MG | COVERED | FORMULARY | |
23.052 | 57.805 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 300 MG | COVERED | FORMULARY | |
23.039 | 57.799 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 25 MG | COVERED | FORMULARY | |
25.019 | 59.401 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | CAPSULE | 225 MG | COVERED | FORMULARY | |
32.359 | 69.339 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lyrica | PREGABALIN | Solution | 20 mg/ml | COVERED | FORMULARY | |
18.537 | 51.333 | 281608 -抗精神病药物 | Abilify | ARIPIPRAZOLE | TABLET | 10 MG | COVERED | FORMULARY | |
18.538 | 51.334 | 281608 -抗精神病药物 | Abilify | ARIPIPRAZOLE | TABLET | 15 MG | COVERED | FORMULARY | |
18.539 | 51.335 | 281608 -抗精神病药物 | Abilify | ARIPIPRAZOLE | TABLET | 20 MG | COVERED | FORMULARY | |
18.541 | 51.336 | 281608 -抗精神病药物 | Abilify | ARIPIPRAZOLE | TABLET | 30 MG | COVERED | FORMULARY | |
20.173 | 52.898 | 281608 -抗精神病药物 | Abilify | ARIPIPRAZOLE | TABLET | 5 MG | COVERED | FORMULARY | |
26.305 | 60.225 | 281608 -抗精神病药物 | Abilify | ARIPIPRAZOLE | TABLET | 2 MG | COVERED | FORMULARY | |
28.766 | 66.480 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Dulera MDI | MOMETASONE / FORMOTEROL | HFA AER AD | 100-5 MCG | COVERED | FORMULARY | |
28.767 | 66.481 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Dulera MDI | MOMETASONE / FORMOTEROL | HFA AER AD | 200-5 MCG | COVERED | FORMULARY | |
64.269 | 37.219 | 562836-PROTON-PUMP INHIBITORS | Prevpac | LANSOPRAZOLE/AMOXICILN/CLARITH | COMBO. PKG | 30-500-500 MG | COVERED | CommUnityCare药房 | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy. |
17.528 | 50.464 | 681200 -避孕 | Nuvaring | ETONOGESTREL/ETHINYL ESTRADIOL | VAG RING | 0.12-.015 MG | COVERED | CommUnityCare药房 | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
24.471 | 58.938 | 681200 -避孕 | Depo-SubQ Provera 104 | MEDROXYPROGESTERONE ACETATE | SYRINGE | 104 MG | COVERED | FORMULARY | |
98.306 | 62.531 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Janumet | SITAGLIPTIN PHOS/METFORMIN HCL | TABLET | 50-500 MG | NOT COVERED | NON-FORMULARY | |
98.307 | 62.532 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Janumet | SITAGLIPTIN PHOS/METFORMIN HCL | TABLET | 50-1000 MG | NOT COVERED | NON-FORMULARY | |
31.339 | 68.538 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Janumet XR | SITAGLIPTIN PHOS/METFORMIN HCL | TBMP 24HR | 50-500 MG | NOT COVERED | NON-FORMULARY | |
31.340 | 68.539 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Janumet XR | SITAGLIPTIN PHOS/METFORMIN HCL | TBMP 24HR | 50-1000 MG | NOT COVERED | NON-FORMULARY | |
31.348 | 68.540 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Janumet XR | SITAGLIPTIN PHOS/METFORMIN HCL | TBMP 24HR | 100-1000 MG | NOT COVERED | NON-FORMULARY | |
97.398 | 61.612 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Januvia | SITAGLIPTIN磷酸 | TABLET | 25 MG | NOT COVERED | NON-FORMULARY | |
97.399 | 61.613 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Januvia | SITAGLIPTIN磷酸 | TABLET | 50 MG | NOT COVERED | NON-FORMULARY | |
97.400 | 61.614 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Januvia | SITAGLIPTIN磷酸 | TABLET | 100 MG | NOT COVERED | NON-FORMULARY | |
24.614 | 59.073 | 682006年的今天,肠促胰岛素模拟 | Byetta | EXENATIDE | PEN INJCTR | 10 MCG/0.04 | COVERED | CommUnityCare药房 | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
24.613 | 59.072 | 682006年的今天,肠促胰岛素模拟 | Byetta | EXENATIDE | PEN INJCTR | 5 MCG/0.04 | COVERED | CommUnityCare药房 | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
12.263 | 47.327 | 861204 - antimuscarinics | Detrol LA | TOLTERODINE酒石酸 | CAP ER 24H | 4 MG | COVERED | FORMULARY | |
12.264 | 47.328 | 861204 - antimuscarinics | Detrol LA | TOLTERODINE酒石酸 | CAP ER 24H | 2 MG | COVERED | FORMULARY | |
13.977 | 48.495 | 040412-PHENOTHIAZINE DERIVATIVES | Promethazine VC | PHENYLEPHRINE HCL-PROMETHAZINE HCL | SYRUP | 5-6.25 MG/5ML | COVERED | FORMULARY | |
15.001 | 3.873 | 040412-PHENOTHIAZINE DERIVATIVES | 异丙嗪栓剂 | PROMETHAZINE HCL | SUPP.RECT | 25 MG | COVERED | FORMULARY | |
15.002 | 3.874 | 040412-PHENOTHIAZINE DERIVATIVES | 异丙嗪栓剂 | PROMETHAZINE HCL | SUPP.RECT | 50 MG | COVERED | FORMULARY | |
15.003 | 3.872 | 040412-PHENOTHIAZINE DERIVATIVES | 异丙嗪栓剂 | PROMETHAZINE HCL | SUPP.RECT | 12.5 MG | COVERED | FORMULARY | |
15.035 | 3.876 | 040412-PHENOTHIAZINE DERIVATIVES | Promethazine | PROMETHAZINE HCL | SYRUP | 6.25 MG/5ML | COVERED | FORMULARY | |
15.042 | 3.877 | 040412-PHENOTHIAZINE DERIVATIVES | Promethazine | PROMETHAZINE HCL | TABLET | 12.5 MG | COVERED | FORMULARY | |
15.043 | 3.878 | 040412-PHENOTHIAZINE DERIVATIVES | Promethazine | PROMETHAZINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
15.044 | 3.879 | 040412-PHENOTHIAZINE DERIVATIVES | Promethazine | PROMETHAZINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
96.609 | 991 | 040420-PROPYLAMINE DERIVATIVES | Brohist D | BROMPHENIRAMIN-PHENYLEPHRINE | TABLET | 4-10 MG | COVERED | FORMULARY | |
44.023 | 26.792 | 040420-PROPYLAMINE DERIVATIVES | Sudogest | PSEUDOEPHEDRINE-CHLORPHENIRAMINE | TABLET | 60 MG-4 MG | COVERED | FORMULARY | |
15.803 | 4.010 | 040492-FIRST GEN. ANTIHIST. 衍生品、MISC. | Cypropheptadine | 盐酸赛庚啶 | SYRUP | 2 MG/5ML | COVERED | FORMULARY | |
15.811 | 4.011 | 040492-FIRST GEN. ANTIHIST. 衍生品、MISC. | Cypropheptadine | 盐酸赛庚啶 | TABLET | 4 MG | COVERED | FORMULARY | |
97.950 | 62.168 | 040800-SECOND GENERATION ANTIHISTAMINES | Xyzal | LEVOCETIRIZINE DIHYDROCHLORIDE | SOLUTION | 2.5 MG/5ML | COVERED | FORMULARY | |
14.901 | 48.920 | 040800-SECOND GENERATION ANTIHISTAMINES | Xyzal | LEVOCETIRIZINE DIHYDROCHLORIDE | TABLET | 5 MG | COVERED | FORMULARY | |
53.290 | 19.283 | 080800 -驱肠虫剂 | Albenza | ALBENDAZOLE | TABLET | 200 MG | COVERED | FORMULARY | |
93.064 | 43.094 | 080800 -驱肠虫剂 | Stromectol | IVERMECTIN | TABLET | 3 MG | COVERED | FORMULARY | |
41.072 | 9.284 | 081202 -氨基糖甙类 | Neomycin | NEOMYCIN SULFATE | TABLET | 500 MG | COVERED | FORMULARY | |
32.231 | 40.257 | 081206 -头孢菌素 | Cefdinir | CEFDINIR | CAPSULE | 300 MG | COVERED | FORMULARY | |
23.308 | 58.005 | 081206 -头孢菌素 | Cefdinir | CEFDINIR | SUSP RECON | 250 MG/5ML | COVERED | FORMULARY | |
32.232 | 40.258 | 081206 -头孢菌素 | Cefdinir | CEFDINIR | SUSP RECON | 125 MG/5ML | COVERED | FORMULARY | |
29.291 | 16.582 | 081206 -头孢菌素 | Cefprozil | CEFPROZIL | SUSP RECON | 125 MG/5ML | COVERED | FORMULARY | |
29.292 | 16.583 | 081206 -头孢菌素 | Cefprozil | CEFPROZIL | SUSP RECON | 250 MG/5ML | COVERED | FORMULARY | |
29.271 | 16.584 | 081206 -头孢菌素 | Cefprozil | CEFPROZIL | TABLET | 250 MG | COVERED | FORMULARY | |
29.272 | 16.585 | 081206 -头孢菌素 | Cefprozil | CEFPROZIL | TABLET | 500 MG | COVERED | FORMULARY | |
47.281 | 9.136 | 081206 -头孢菌素 | Ceftin | CEFUROXIME AXETIL | TABLET | 250 MG | COVERED | FORMULARY | |
47.282 | 9.137 | 081206 -头孢菌素 | Ceftin | CEFUROXIME AXETIL | TABLET | 500 MG | COVERED | FORMULARY | |
39.801 | 9.042 | 081206 -头孢菌素 | Keflex | CEPHALEXIN | CAPSULE | 250 MG | COVERED | FORMULARY | |
39.802 | 9.043 | 081206 -头孢菌素 | Keflex | CEPHALEXIN | CAPSULE | 500 MG | COVERED | FORMULARY | |
39.812 | 9.046 | 081206 -头孢菌素 | Keflex | CEPHALEXIN | SUSP RECON | 250 MG/5ML | COVERED | FORMULARY | |
39.831 | 9.049 | 081206 -头孢菌素 | Keflex | CEPHALEXIN | TABLET | 500 MG | COVERED | FORMULARY | |
39.832 | 9.048 | 081206 -头孢菌素 | Keflex | CEPHALEXIN | TABLET | 250 MG | COVERED | FORMULARY | |
48.792 | 24.194 | 081212-MACROLIDES | Zithromax | AZITHROMYCIN | SUSP RECON | 100 MG/5ML | COVERED | FORMULARY | |
61.199 | 18.544 | 081212-MACROLIDES | Zithromax | AZITHROMYCIN | SUSP RECON | 200 MG/5ML | COVERED | FORMULARY | |
48.793 | 26.721 | 081212-MACROLIDES | Zithromax | AZITHROMYCIN | TABLET | 250 MG | COVERED | FORMULARY | |
48.794 | 27.252 | 081212-MACROLIDES | Zithromax | AZITHROMYCIN | TABLET | 600 MG | COVERED | FORMULARY | |
61.198 | 22.624 | 081212-MACROLIDES | Zithromax | AZITHROMYCIN | TABLET | 500 MG | COVERED | FORMULARY | |
11.670 | 19.146 | 081212-MACROLIDES | Clarithromycin | CLARITHROMYCIN | SUSP RECON | 125 MG/5ML | COVERED | FORMULARY | |
48.851 | 16.368 | 081212-MACROLIDES | Biaxin | CLARITHROMYCIN | TABLET | 500 MG | COVERED | FORMULARY | |
48.852 | 16.373 | 081212-MACROLIDES | Biaxin | CLARITHROMYCIN | TABLET | 250 MG | COVERED | FORMULARY | |
40.660 | 9.258 | 081212-MACROLIDES | Erythromycin | 红霉素碱 | CAPSULE DR | 250 MG | COVERED | FORMULARY | |
40.720 | 9.260 | 081212-MACROLIDES | Erythrocin | 红霉素碱 | TABLET | 250 MG | COVERED | FORMULARY | |
40.721 | 9.262 | 081212-MACROLIDES | Erythromycin | 红霉素碱 | TABLET | 500 MG | COVERED | FORMULARY | |
40.730 | 9.263 | 081212-MACROLIDES | Ery-Tab | 红霉素碱 | TABLET DR | 250 MG | COVERED | FORMULARY | |
40.731 | 9.264 | 081212-MACROLIDES | Ery-Tab | 红霉素碱 | TABLET DR | 333 MG | COVERED | FORMULARY | |
40.732 | 9.265 | 081212-MACROLIDES | Ery-Tab | 红霉素碱 | TABLET DR | 500 MG | COVERED | FORMULARY | |
40.523 | 21.205 | 081212-MACROLIDES | EryPed 200 | 红霉素ETHYLSUCCINATE | SUSP RECON | 200 MG/5ML | COVERED | FORMULARY | |
40.524 | 21.206 | 081212-MACROLIDES | EryPed 400 | 红霉素ETHYLSUCCINATE | SUSP RECON | 400 MG/5ML | COVERED | FORMULARY | |
40.560 | 9.245 | 081212-MACROLIDES | E.E.S 400 | 红霉素ETHYLSUCCINATE | TABLET | 400 MG | COVERED | FORMULARY | |
40.642 | 9.255 | 081212-MACROLIDES | Erythromycin | 硬脂酸红霉素 | TABLET | 250 MG | COVERED | FORMULARY | |
39.660 | 8.995 | 081216 -青霉素 | Amoxicillin | AMOXICILLIN | CAPSULE | 250 MG | COVERED | FORMULARY | |
39.661 | 8.996 | 081216 -青霉素 | Amoxicillin | AMOXICILLIN | CAPSULE | 500 MG | COVERED | FORMULARY | |
39.681 | 8.997 | 081216 -青霉素 | Amoxicillin | AMOXICILLIN | SUSP RECON | 125 MG/5ML | COVERED | FORMULARY | |
39.683 | 8.998 | 081216 -青霉素 | Amoxicillin | AMOXICILLIN | SUSP RECON | 250 MG/5ML | COVERED | FORMULARY | |
93.375 | 42.683 | 081216 -青霉素 | Amoxicillin | AMOXICILLIN | SUSP RECON | 400 MG/5ML | COVERED | FORMULARY | |
93.385 | 42.684 | 081216 -青霉素 | Amoxicillin | AMOXICILLIN | SUSP RECON | 200 MG/5ML | COVERED | FORMULARY | |
39.651 | 9.001 | 081216 -青霉素 | Amoxicillin | AMOXICILLIN | TAB CHEW | 250 MG | COVERED | FORMULARY | |
39.632 | 40.292 | 081216 -青霉素 | Amoxicillin | AMOXICILLIN | TABLET | 875 MG | COVERED | FORMULARY | |
61.252 | 20.493 | 081216 -青霉素 | Amoxicillin | AMOXICILLIN | TABLET | 500 MG | COVERED | FORMULARY | |
67.150 | 8.989 | 081216 -青霉素 | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | SUSP RECON | 125-31.25 MG/5ML | COVERED | FORMULARY | |
67.151 | 8.990 | 081216 -青霉素 | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | SUSP RECON | 250-62.5 MG/5ML | COVERED | FORMULARY | |
67.153 | 25.898 | 081216 -青霉素 | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | SUSP RECON | 400-57 MG/5ML | COVERED | FORMULARY | |
67.154 | 26.720 | 081216 -青霉素 | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | SUSP RECON | 200-28.5 MG/5ML | COVERED | FORMULARY | |
28.020 | 48.449 | 081216 -青霉素 | Augmentin ES | AMOXICILLIN-POTASSIUM CLAVULANATE | SUSP RECON | 600-42.9 MG/5ML | COVERED | FORMULARY | |
67.078 | 26.719 | 081216 -青霉素 | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | TAB CHEW | 200-28.5 MG | COVERED | FORMULARY | |
91.941 | 50.991 | 081216 -青霉素 | Augmentin XR | AMOXICILLIN-POTASSIUM CLAVULANATE | TAB ER 12H | 1000-62.5 MG | COVERED | FORMULARY | |
67.070 | 8.991 | 081216 -青霉素 | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | TABLET | 250-125 MG | COVERED | FORMULARY | |
67.071 | 8.992 | 081216 -青霉素 | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | TABLET | 500-125 MG | COVERED | FORMULARY | |
67.076 | 24.668 | 081216 -青霉素 | Augmentin | AMOXICILLIN-POTASSIUM CLAVULANATE | TABLET | 875-125 MG | COVERED | FORMULARY | |
39.271 | 8.941 | 081216 -青霉素 | Ampicillin | 三水合氨苄青霉素 | CAPSULE | 250 MG | COVERED | FORMULARY | |
39.272 | 8.942 | 081216 -青霉素 | Ampicillin | 三水合氨苄青霉素 | CAPSULE | 500 MG | COVERED | FORMULARY | |
39.313 | 8.943 | 081216 -青霉素 | Ampicillin | 三水合氨苄青霉素 | SUSP RECON | 125 MG/5ML | COVERED | FORMULARY | |
39.316 | 8.944 | 081216 -青霉素 | Ampicillin | 三水合氨苄青霉素 | SUSP RECON | 250 MG/5ML | COVERED | FORMULARY | |
39.541 | 8.983 | 081216 -青霉素 | Dicloxacillin | 双氯青霉素钠 | CAPSULE | 250 MG | COVERED | FORMULARY | |
39.542 | 8.984 | 081216 -青霉素 | Dicloxacillin | 双氯青霉素钠 | CAPSULE | 500 MG | COVERED | FORMULARY | |
39.022 | 8.876 | 081216 -青霉素 | 青霉素V钾 | 青霉素v钾 | SOLN RECON | 125 MG/5ML | COVERED | FORMULARY | |
39.024 | 8.877 | 081216 -青霉素 | 青霉素V钾 | 青霉素v钾 | SOLN RECON | 250 MG/5ML | COVERED | FORMULARY | |
39.053 | 8.879 | 081216 -青霉素 | 青霉素V钾 | 青霉素v钾 | TABLET | 250 MG | COVERED | FORMULARY | |
39.055 | 8.880 | 081216 -青霉素 | 青霉素V钾 | 青霉素v钾 | TABLET | 500 MG | COVERED | FORMULARY | |
47.050 | 9.509 | 081218 -喹诺酮类 | Cipro | CIPROFLOXACIN HCL | TABLET | 250 MG | COVERED | FORMULARY | |
47.051 | 9.510 | 081218 -喹诺酮类 | Cipro | CIPROFLOXACIN HCL | TABLET | 500 MG | COVERED | FORMULARY | |
47.052 | 9.511 | 081218 -喹诺酮类 | Cipro | CIPROFLOXACIN HCL | TABLET | 750 MG | COVERED | FORMULARY | |
23.725 | 58.310 | 081218 -喹诺酮类 | Levofloxacin | LEVOFLOXACIN | SOLUTION | 250 MG/10ML | COVERED | FORMULARY | |
47.073 | 29.927 | 081218 -喹诺酮类 | Levaquin | LEVOFLOXACIN | TABLET | 250 MG | COVERED | FORMULARY | |
47.074 | 29.928 | 081218 -喹诺酮类 | Levaquin | LEVOFLOXACIN | TABLET | 500 MG | COVERED | FORMULARY | |
89.597 | 46.771 | 081218 -喹诺酮类 | Levaquin | LEVOFLOXACIN | TABLET | 750 MG | COVERED | FORMULARY | |
34.942 | 71.217 | 081220-SULFONAMIDES (SYSTEMIC) | Sulfamethoxazole-Trimethoprim | SULFAMETHOXAZOLE-TRIMETHOPRIM | ORAL SUSP | 800-160 MG/20ML | COVERED | FORMULARY | |
90.150 | 9.394 | 081220-SULFONAMIDES (SYSTEMIC) | Sulfamethoxazole-Trimethoprim | SULFAMETHOXAZOLE-TRIMETHOPRIM | ORAL SUSP | 200-40 MG/5ML | COVERED | FORMULARY | |
90.161 | 9.395 | 081220-SULFONAMIDES (SYSTEMIC) | Bactrim | SULFAMETHOXAZOLE-TRIMETHOPRIM | TABLET | 400-80 MG | COVERED | FORMULARY | |
90.163 | 9.396 | 081220-SULFONAMIDES (SYSTEMIC) | Bactrim | SULFAMETHOXAZOLE-TRIMETHOPRIM | TABLET | 800-160 MG | COVERED | FORMULARY | |
41.611 | 9.402 | 081220-SULFONAMIDES (SYSTEMIC) | Azulfidine | SULFASALAZINE | TABLET | 500 MG | COVERED | FORMULARY | |
41.620 | 9.403 | 081220-SULFONAMIDES (SYSTEMIC) | Azulfidine EN | SULFASALAZINE | TABLET DR | 500 MG | COVERED | FORMULARY | |
0 | 0 | 081224 -四环素 | 强力霉素悬挂 | DOXYCYCLINE | X | 25 MG/ML | COVERED | FORMULARY | |
40.331 | 9.218 | 081224 -四环素 | Doxycyline | 强力霉素HYCLATE | CAPSULE | 100 MG | COVERED | FORMULARY | |
40.333 | 9.219 | 081224 -四环素 | Doxycyline | 强力霉素HYCLATE | CAPSULE | 50 MG | COVERED | FORMULARY | |
40.360 | 9.223 | 081224 -四环素 | Doxycyline | 强力霉素HYCLATE | TABLET | 100 MG | COVERED | FORMULARY | |
40.651 | 15.943 | 081224 -四环素 | Doxycyline | 强力霉素一水 | CAPSULE | 100 MG | COVERED | FORMULARY | |
40.652 | 16.815 | 081224 -四环素 | Doxycyline | 强力霉素一水 | CAPSULE | 50 MG | COVERED | FORMULARY | |
98.271 | 62.496 | 081224 -四环素 | Doxycyline | 强力霉素一水 | CAPSULE | 75 MG | COVERED | FORMULARY | |
40.363 | 27.050 | 081224 -四环素 | Doxycyline | 强力霉素一水 | TABLET | 100 MG | COVERED | FORMULARY | |
40.410 | 9.226 | 081224 -四环素 | Minocycline | MINOCYCLINE HCL | CAPSULE | 100 MG | COVERED | FORMULARY | |
40.411 | 9.227 | 081224 -四环素 | Minocycline | MINOCYCLINE HCL | CAPSULE | 50 MG | COVERED | FORMULARY | |
93.387 | 42.778 | 081224 -四环素 | Minocycline | MINOCYCLINE HCL | CAPSULE | 75 MG | COVERED | FORMULARY | |
19.549 | 52.057 | 081224 -四环素 | Minocycline | MINOCYCLINE HCL | TABLET | 75 MG | COVERED | FORMULARY | |
40.450 | 9.230 | 081224 -四环素 | Minocycline | MINOCYCLINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
40.451 | 9.231 | 081224 -四环素 | Minocycline | MINOCYCLINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
40.830 | 9.339 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Cleocin | CLINDAMYCIN HCL | CAPSULE | 150 MG | COVERED | FORMULARY | |
40.831 | 9.341 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Cleocin | CLINDAMYCIN HCL | CAPSULE | 75 MG | COVERED | FORMULARY | |
40.832 | 9.340 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Cleocin | CLINDAMYCIN HCL | CAPSULE | 300 MG | COVERED | FORMULARY | |
40.860 | 9.346 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Cleocin小儿颗粒 | 棕榈酸克林霉素HCL | SOLN RECON | 75 MG/5ML | COVERED | FORMULARY | Restricted to age < 19 |
60.823 | 18.638 | 081404 -烯丙胺 | Lamisil | TERBINAFINE HCL | TABLET | 250 MG | COVERED | FORMULARY | |
60.821 | 18.636 | 081408-AZOLES | Diflucan | FLUCONAZOLE | SUSP RECON | 40 MG/ML | COVERED | FORMULARY | |
42.190 | 13.723 | 081408-AZOLES | Diflucan | FLUCONAZOLE | TABLET | 100 MG | COVERED | FORMULARY | |
42.191 | 13.724 | 081408-AZOLES | Diflucan | FLUCONAZOLE | TABLET | 200 MG | COVERED | FORMULARY | |
42.192 | 13.725 | 081408-AZOLES | Diflucan | FLUCONAZOLE | TABLET | 50 MG | COVERED | FORMULARY | |
42.193 | 22.141 | 081408-AZOLES | Diflucan | FLUCONAZOLE | TABLET | 150 MG | COVERED | FORMULARY | |
42.440 | 9.537 | 081428-POLYENES | Nystatin | NYSTATIN | ORAL SUSP | 100000 UNIT/ML | COVERED | FORMULARY | |
42.452 | 9.538 | 081428-POLYENES | Nystatin | NYSTATIN | TABLET | 500000 UNIT | COVERED | FORMULARY | |
42.390 | 9.517 | 081492-ANTIFUNGALS, MISCELLANEOUS | Griseofulvin | 灰黄霉素MICROSIZE | ORAL SUSP | 125 MG/5ML | COVERED | FORMULARY | |
42.402 | 9.519 | 081492-ANTIFUNGALS, MISCELLANEOUS | Griseofulvin | 灰黄霉素MICROSIZE | TABLET | 500 MG | COVERED | FORMULARY | |
42.410 | 9.520 | 081492-ANTIFUNGALS, MISCELLANEOUS | Gris-Peg | GRISEOFULVIN ULTRAMICROSIZE | TABLET | 125 MG | COVERED | FORMULARY | |
42.412 | 9.522 | 081492-ANTIFUNGALS, MISCELLANEOUS | Gris-Peg | GRISEOFULVIN ULTRAMICROSIZE | TABLET | 250 MG | COVERED | FORMULARY | |
73.441 | 43.706 | 081828-NEURAMINIDASE INHIBITORS | Tamiflu | 磷酸奥司他韦 | CAPSULE | 75 MG | COVERED | FORMULARY | |
98.980 | 63.223 | 081828-NEURAMINIDASE INHIBITORS | Tamiflu | 磷酸奥司他韦 | CAPSULE | 30 MG | COVERED | FORMULARY | |
98.981 | 63.224 | 081828-NEURAMINIDASE INHIBITORS | Tamiflu | 磷酸奥司他韦 | CAPSULE | 45 MG | COVERED | FORMULARY | |
29.729 | 67.561 | 081828-NEURAMINIDASE INHIBITORS | Tamiflu | 磷酸奥司他韦 | SUSP RECON | 6 MG/ML | COVERED | FORMULARY | |
92.221 | 43.119 | 081828-NEURAMINIDASE INHIBITORS | Relenza | ZANAMIVIR | BLST W/DEV | 5 MG | COVERED | FORMULARY | |
43.790 | 9.630 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Zovirax | ACYCLOVIR | CAPSULE | 200 MG | COVERED | FORMULARY | |
13.721 | 15.979 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Zovirax | ACYCLOVIR | TABLET | 800 MG | COVERED | FORMULARY | |
13.724 | 16.408 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Zovirax | ACYCLOVIR | TABLET | 400 MG | COVERED | FORMULARY | |
14.179 | 48.664 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Ribavirin | RIBAVIRIN | CAPSULE | 200 MG | COVERED | FORMULARY | |
13.740 | 23.989 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Valtrex | VALACYCLOVIR HCL | TABLET | 500 MG | COVERED | FORMULARY | |
13.742 | 30.607 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Valtrex | VALACYCLOVIR HCL | TABLET | 1000 MG | COVERED | FORMULARY | |
42.940 | 9.580 | 083008 -抗疟药 | Plaquenil | 硫酸羟氯喹 | TABLET | 200 MG | COVERED | FORMULARY | |
43.031 | 9.591 | 083092-ANTIPROTOZOALS, MISCELLANEOUS | Flagyl | METRONIDAZOLE | TABLET | 250 MG | COVERED | FORMULARY | |
43.032 | 9.592 | 083092-ANTIPROTOZOALS, MISCELLANEOUS | Flagyl | METRONIDAZOLE | TABLET | 500 MG | COVERED | FORMULARY | |
41.870 | 9.434 | 083600-URINARY ANTI-INFECTIVES | Furadantin | NITROFURANTOIN | ORAL SUSP | 25 MG/5ML | COVERED | FORMULARY | |
41.820 | 9.428 | 083600-URINARY ANTI-INFECTIVES | Macrodantin | 呋喃妥英大晶体 | CAPSULE | 100 MG | COVERED | FORMULARY | |
41.822 | 9.430 | 083600-URINARY ANTI-INFECTIVES | Macrodantin | 呋喃妥英大晶体 | CAPSULE | 50 MG | COVERED | FORMULARY | |
49.001 | 16.598 | 083600-URINARY ANTI-INFECTIVES | Macrobid | NITROFURANTOIN MONOHYDRATE-MACROCRYSTAL | CAPSULE | 100 MG | COVERED | FORMULARY | |
5.987 | 35.495 | 084080-ANTIPRURITICS AND LOCAL ANESTHETICS | Emla Cream | 利多卡因和丙胺卡因 | CREAM (G) | 2.5 %-2.5% | COVERED | FORMULARY | |
38.370 | 8.772 | 100000-ANTINEOPLASTIC AGENTS | Leukeran | CHLORAMBUCIL | TABLET | 2 MG | COVERED | FORMULARY | |
38.400 | 8.775 | 100000-ANTINEOPLASTIC AGENTS | Hydrea | HYDROXYUREA | CAPSULE | 500 MG | COVERED | FORMULARY | |
49.541 | 29.821 | 100000-ANTINEOPLASTIC AGENTS | Femara | LETROZOLE | TABLET | 2.5 MG | COVERED | FORMULARY | |
33.559 | 70.193 | 100000-ANTINEOPLASTIC AGENTS | Megace | MEGESTROL ACETATE | ORAL SUSP | 400 MG/10ML | COVERED | FORMULARY | |
40.381 | 21.004 | 100000-ANTINEOPLASTIC AGENTS | Megace | MEGESTROL ACETATE | ORAL SUSP | 400 MG/10ML | COVERED | FORMULARY | |
38.681 | 8.829 | 100000-ANTINEOPLASTIC AGENTS | Megace | MEGESTROL ACETATE | TABLET | 40 MG | COVERED | FORMULARY | |
38.380 | 8.773 | 100000-ANTINEOPLASTIC AGENTS | Alkeran | MELPHALAN | TABLET | 2 MG | COVERED | FORMULARY | |
38.520 | 8.802 | 100000-ANTINEOPLASTIC AGENTS | Mercaptopurine | MERCAPTOPURINE | TABLET | 50 MG | COVERED | FORMULARY | |
38.489 | 36.872 | 100000-ANTINEOPLASTIC AGENTS | Methotrexate | 甲氨蝶呤钠 | TABLET | 2.5 MG | COVERED | FORMULARY | |
38.720 | 8.832 | 100000-ANTINEOPLASTIC AGENTS | Tamoxifen | TAMOXIFEN CITRATE | TABLET | 10 MG | COVERED | FORMULARY | |
38.721 | 13.574 | 100000-ANTINEOPLASTIC AGENTS | Tamoxifen | TAMOXIFEN CITRATE | TABLET | 20 MG | COVERED | FORMULARY | |
18.351 | 4.740 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Urecholine | 氯化氨甲酰甲胆碱 | TABLET | 10 MG | COVERED | FORMULARY | |
18.352 | 4.741 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Urecholine | 氯化氨甲酰甲胆碱 | TABLET | 25 MG | COVERED | FORMULARY | |
4.300 | 29.334 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Aricept | DONEPEZIL HCL | TABLET | 10 MG | COVERED | FORMULARY | |
4.302 | 29.335 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Aricept | DONEPEZIL HCL | TABLET | 5 MG | COVERED | FORMULARY | |
84.853 | 46.925 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Razadyne | GALANTAMINE HBR | TABLET | 12 MG | COVERED | FORMULARY | |
84.854 | 46.926 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Razadyne | GALANTAMINE HBR | TABLET | 4 MG | COVERED | FORMULARY | |
84.855 | 46.927 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Razadyne | GALANTAMINE HBR | TABLET | 8 MG | COVERED | FORMULARY | |
21.353 | 53.658 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Salagen | PILOCARPINE HCL | TABLET | 7.5 MG | COVERED | FORMULARY | |
24.671 | 21.731 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Salagen | PILOCARPINE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
90.396 | 40.155 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Exelon | 酒石酸卡巴拉汀 | CAPSULE | 1.5 MG | COVERED | FORMULARY | |
90.397 | 40.156 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Exelon | 酒石酸卡巴拉汀 | CAPSULE | 3 MG | COVERED | FORMULARY | |
90.398 | 40.157 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Exelon | 酒石酸卡巴拉汀 | CAPSULE | 4.5 MG | COVERED | FORMULARY | |
90.399 | 40.158 | 120400-PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) | Exelon | 酒石酸卡巴拉汀 | CAPSULE | 6 MG | COVERED | FORMULARY | |
74.801 | 4.902 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Librax | CHLORDIAZEPOXIDE-CLIDINIUM BR | CAPSULE | 5-2.5 MG | COVERED | FORMULARY | |
19.261 | 4.918 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Bentyl | DICYCLOMINE HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
34.719 | 71.032 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Bentyl | DICYCLOMINE HCL | SOLUTION | 10 MG/5ML | COVERED | FORMULARY | |
19.331 | 4.924 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Bentyl | DICYCLOMINE HCL | TABLET | 20 MG | COVERED | FORMULARY | |
18.960 | 23.715 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Symax SR | 莨菪碱硫酸 | TAB ER 12H | 0.375 MG | COVERED | FORMULARY | |
13.299 | 47.546 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Anaspaz, Symax FT | 莨菪碱硫酸 | TAB RAPDIS | 0.125 MG | COVERED | FORMULARY | |
18.970 | 4.868 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Symax SL | 莨菪碱硫酸 | TAB SUBL | 0.125 MG | COVERED | FORMULARY | |
18.961 | 4.865 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Levsin, Oscimin | 莨菪碱硫酸 | TABLET | 0.125 MG | COVERED | FORMULARY | |
42.235 | 21.700 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Ipratropium溴化 | IPRATROPIUM溴化 | SOLUTION | 0.2 MG/ML | COVERED | FORMULARY | |
13.456 | 48.018 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Ipatropium-Albuterol Inhalation | IPRATROPIUM-硫酸沙丁胺醇 | AMPUL-NEB | 0.5-3 MG/3ML | COVERED | FORMULARY | |
22.913 | 28.090 | 121208-BETA-ADRENERGIC AGONISTS | Proventil HFA, Ventolin HFA, ProAir HFA | 硫酸沙丁胺醇 | HFA AER AD | 90 MCG | COVERED | FORMULARY | |
41.680 | 5.040 | 121208-BETA-ADRENERGIC AGONISTS | Albuterol Sulfate | 硫酸沙丁胺醇 | SOLUTION | 5 MG/ML | COVERED | FORMULARY | |
22.780 | 5.032 | 121208-BETA-ADRENERGIC AGONISTS | Albuterol Sulfate | 硫酸沙丁胺醇 | SYRUP | 2 MG/5ML | COVERED | FORMULARY | |
20.100 | 5.033 | 121208-BETA-ADRENERGIC AGONISTS | Albuterol Sulfate | 硫酸沙丁胺醇 | TABLET | 2 MG | COVERED | FORMULARY | |
20.101 | 5.034 | 121208-BETA-ADRENERGIC AGONISTS | Albuterol Sulfate | 硫酸沙丁胺醇 | TABLET | 4 MG | COVERED | FORMULARY | |
14.634 | 48.699 | 121208-BETA-ADRENERGIC AGONISTS | Albuterol Sulfate Inhalation | 硫酸沙丁胺醇 | VIAL-NEB | 1.25 MG/3ML | COVERED | FORMULARY | |
41.681 | 5.039 | 121208-BETA-ADRENERGIC AGONISTS | Albuterol Sulfate Inhalation | 硫酸沙丁胺醇 | VIAL-NEB | 2.5 MG/3ML | COVERED | FORMULARY | |
20.071 | 5.026 | 121208-BETA-ADRENERGIC AGONISTS | Terbutaline | 硫酸特布他林 | TABLET | 5 MG | COVERED | FORMULARY | |
20.072 | 5.025 | 121208-BETA-ADRENERGIC AGONISTS | Terbutaline | 硫酸特布他林 | TABLET | 2.5 MG | COVERED | FORMULARY | |
19.861 | 16.878 | 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS | 肾上腺素AUTO-INJECT | EPINEPHRINE | AUTO INJCT | 0.15 MG/0.3ML | COVERED | FORMULARY | |
19.862 | 16.879 | 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS | 肾上腺素AUTO-INJECT | EPINEPHRINE | AUTO INJCT | 0.3 MG/0.3ML | COVERED | FORMULARY | |
48.191 | 27.546 | 121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) | Flomax | TAMSULOSIN HCL | CAP ER 24H | 0.4 MG | COVERED | FORMULARY | |
17.901 | 4.660 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Parafon Forte | CHLORZOXAZONE | TABLET | 500 MG | COVERED | FORMULARY | |
12.805 | 47.478 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Flexeril | 盐酸环苯扎林 | TABLET | 5 MG | COVERED | FORMULARY | |
18.020 | 4.681 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Flexeril | 盐酸环苯扎林 | TABLET | 10 MG | COVERED | FORMULARY | |
17.892 | 4.654 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Robaxin | METHOCARBAMOL | TABLET | 500 MG | COVERED | FORMULARY | |
17.893 | 4.655 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Robaxin | METHOCARBAMOL | TABLET | 750 MG | COVERED | FORMULARY | |
24.433 | 58.904 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Zanaflex | TIZANIDINE HCL | CAPSULE | 2 MG | COVERED | FORMULARY | |
24.434 | 58.905 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Zanaflex | TIZANIDINE HCL | CAPSULE | 4 MG | COVERED | FORMULARY | |
14.690 | 27.447 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Zanaflex | TIZANIDINE HCL | TABLET | 2 MG | COVERED | FORMULARY | |
14.693 | 30.274 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Zanaflex | TIZANIDINE HCL | TABLET | 4 MG | COVERED | FORMULARY | |
18.012 | 27.229 | 122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT | Baclofen | BACLOFEN | TABLET | 5 MG | COVERED | FORMULARY | |
18.010 | 4.679 | 122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT | Baclofen | BACLOFEN | TABLET | 10 MG | COVERED | FORMULARY | |
18.011 | 4.680 | 122012-GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT | Baclofen | BACLOFEN | TABLET | 20 MG | COVERED | FORMULARY | |
420 | 19.331 | 201204 -抗凝血剂 | Lovenox | 伊诺肝素钠 | SYRINGE | 30 MG/0.3ML | COVERED | FORMULARY | Limited to 14 day supplies, Prior Auth for >14 days |
42.071 | 44.668 | 201204 -抗凝血剂 | Lovenox | 伊诺肝素钠 | SYRINGE | 150 MG/ML | COVERED | FORMULARY | Limited to 14 day supplies, Prior Auth for >14 days |
42.091 | 44.669 | 201204 -抗凝血剂 | Lovenox | 伊诺肝素钠 | SYRINGE | 120 MG/0.8ML | COVERED | FORMULARY | Limited to 14 day supplies, Prior Auth for >14 days |
62.771 | 27.993 | 201204 -抗凝血剂 | Lovenox | 伊诺肝素钠 | SYRINGE | 60 MG/0.6ML | COVERED | FORMULARY | Limited to 14 day supplies, Prior Auth for >14 days |
62.772 | 27.994 | 201204 -抗凝血剂 | Lovenox | 伊诺肝素钠 | SYRINGE | 80 MG/0.8ML | COVERED | FORMULARY | Limited to 14 day supplies, Prior Auth for >14 days |
62.773 | 27.995 | 201204 -抗凝血剂 | Lovenox | 伊诺肝素钠 | SYRINGE | 100 MG/ML | COVERED | FORMULARY | Limited to 14 day supplies, Prior Auth for >14 days |
70.022 | 39.482 | 201204 -抗凝血剂 | Lovenox | 伊诺肝素钠 | SYRINGE | 40 MG/0.4ML | COVERED | FORMULARY | Limited to 14 day supplies, Prior Auth for >14 days |
25.691 | 6.549 | 201204 -抗凝血剂 | Heparin | 猪肝素钠 | VIAL | 5000 UNIT/ML | COVERED | FORMULARY | |
25.697 | 6.544 | 201204 -抗凝血剂 | Heparin | 猪肝素钠 | VIAL | 10000 UNIT/ML | COVERED | FORMULARY | |
25.790 | 6.559 | 201204 -抗凝血剂 | 香豆素,Jantoven | WARFARIN SODIUM | TABLET | 10 MG | COVERED | FORMULARY | |
25.791 | 6.561 | 201204 -抗凝血剂 | 香豆素,Jantoven | WARFARIN SODIUM | TABLET | 2 MG | COVERED | FORMULARY | |
25.792 | 14.198 | 201204 -抗凝血剂 | 香豆素,Jantoven | WARFARIN SODIUM | TABLET | 1 MG | COVERED | FORMULARY | |
25.793 | 6.562 | 201204 -抗凝血剂 | 香豆素,Jantoven | WARFARIN SODIUM | TABLET | 5 MG | COVERED | FORMULARY | |
25.794 | 6.560 | 201204 -抗凝血剂 | 香豆素,Jantoven | WARFARIN SODIUM | TABLET | 2.5 MG | COVERED | FORMULARY | |
25.795 | 6.563 | 201204 -抗凝血剂 | 香豆素,Jantoven | WARFARIN SODIUM | TABLET | 7.5 MG | COVERED | FORMULARY | |
25.796 | 18.080 | 201204 -抗凝血剂 | 香豆素,Jantoven | WARFARIN SODIUM | TABLET | 3 MG | COVERED | FORMULARY | |
25.797 | 19.486 | 201204 -抗凝血剂 | 香豆素,Jantoven | WARFARIN SODIUM | TABLET | 4 MG | COVERED | FORMULARY | |
25.798 | 30.475 | 201204 -抗凝血剂 | 香豆素,Jantoven | WARFARIN SODIUM | TABLET | 6 MG | COVERED | FORMULARY | |
8.602 | 37.978 | 201218-PLATELET-AGGREGATION INHIBITORS | Pletal | CILOSTAZOL | TABLET | 100 MG | COVERED | FORMULARY | |
8.603 | 37.979 | 201218-PLATELET-AGGREGATION INHIBITORS | Pletal | CILOSTAZOL | TABLET | 50 MG | COVERED | FORMULARY | |
96.010 | 38.164 | 201218-PLATELET-AGGREGATION INHIBITORS | Plavix | 硫酸氢氯吡格雷 | TABLET | 75 MG | COVERED | FORMULARY | |
11.800 | 6.573 | 202400-HEMORRHEOLOGIC AGENTS | Pentoxifylline | PENTOXIFYLLINE | TABLET ER | 400 MG | COVERED | FORMULARY | |
25.580 | 6.503 | 202816年的今天,止血 | Amicar | AMINOCAPROIC ACID | SOLUTION | 250 MG/ML | COVERED | FORMULARY | |
10.920 | 266 | 240404-ANTIARRHYTHMIC AGENTS | Pacerone | AMIODARONE HCL | TABLET | 200 MG | COVERED | FORMULARY | |
1.130 | 239 | 240404-ANTIARRHYTHMIC AGENTS | Norpace | 丙吡胺磷酸盐 | CAPSULE | 100 MG | COVERED | FORMULARY | |
1.580 | 263 | 240404-ANTIARRHYTHMIC AGENTS | Flecainide | 醋酸氟卡尼 | TABLET | 100 MG | COVERED | FORMULARY | |
1.581 | 265 | 240404-ANTIARRHYTHMIC AGENTS | Flecainide | 醋酸氟卡尼 | TABLET | 50 MG | COVERED | FORMULARY | |
1.011 | 215 | 240404-ANTIARRHYTHMIC AGENTS | Quinidine | 奎尼丁葡萄糖酸 | TABLET ER | 324 MG | COVERED | FORMULARY | |
132 | 18 | 240408 -强心的代理 | Lanoxin | DIGOXIN | TABLET | 125 MCG | COVERED | FORMULARY | |
133 | 19 | 240408 -强心的代理 | Lanoxin | DIGOXIN | TABLET | 250 MCG | COVERED | FORMULARY | |
9.850 | 3.100 | 240604-BILE ACID SEQUESTRANTS | Prevalite | CHOLESTYRAMINE (WITH ASPARTAME) | POWD PACK | 4 G | COVERED | FORMULARY | |
98.654 | 62.885 | 240604-BILE ACID SEQUESTRANTS | Questran Light | CHOLESTYRAMINE (WITH ASPARTAME) | POWDER | 4 G | COVERED | FORMULARY | |
9.920 | 13.675 | 240604-BILE ACID SEQUESTRANTS | Questran | 消胆胺(含糖) | POWD PACK | 4 G | COVERED | FORMULARY | |
14.295 | 48.571 | 240604-BILE ACID SEQUESTRANTS | Questran | 消胆胺(含糖) | POWDER | 4 G | COVERED | FORMULARY | |
12.595 | 44.915 | 240606-FIBRIC ACID DERIVATIVES | Lofibra | FENOFIBRATE | TABLET | 160 MG | COVERED | FORMULARY | |
13.266 | 64.310 | 240606-FIBRIC ACID DERIVATIVES | Lofibra | FENOFIBRATE | TABLET | 54 MG | COVERED | FORMULARY | |
92.504 | 44.305 | 240606-FIBRIC ACID DERIVATIVES | Lofibra | 非诺贝特微粒化 | CAPSULE | 134 MG | COVERED | FORMULARY | |
93.437 | 43.060 | 240606-FIBRIC ACID DERIVATIVES | Lofibra | 非诺贝特微粒化 | CAPSULE | 200 MG | COVERED | FORMULARY | |
93.446 | 43.061 | 240606-FIBRIC ACID DERIVATIVES | Lofibra | 非诺贝特微粒化 | CAPSULE | 67 MG | COVERED | FORMULARY | |
25.540 | 6.416 | 240606-FIBRIC ACID DERIVATIVES | Lopid | GEMFIBROZIL | TABLET | 600 MG | COVERED | FORMULARY | |
43.720 | 29.967 | 240608-HMG-COA REDUCTASE INHIBITORS | Lipitor | 阿托伐他汀钙 | TABLET | 10 MG | COVERED | FORMULARY | |
43.721 | 29.968 | 240608-HMG-COA REDUCTASE INHIBITORS | Lipitor | 阿托伐他汀钙 | TABLET | 20 MG | COVERED | FORMULARY | |
43.722 | 29.969 | 240608-HMG-COA REDUCTASE INHIBITORS | Lipitor | 阿托伐他汀钙 | TABLET | 40 MG | COVERED | FORMULARY | |
43.723 | 45.772 | 240608-HMG-COA REDUCTASE INHIBITORS | Lipitor | 阿托伐他汀钙 | TABLET | 80 MG | COVERED | FORMULARY | |
47.040 | 6.460 | 240608-HMG-COA REDUCTASE INHIBITORS | Lovastatin | LOVASTATIN | TABLET | 20 MG | COVERED | FORMULARY | |
47.041 | 6.461 | 240608-HMG-COA REDUCTASE INHIBITORS | Lovastatin | LOVASTATIN | TABLET | 40 MG | COVERED | FORMULARY | |
47.042 | 16.310 | 240608-HMG-COA REDUCTASE INHIBITORS | Lovastatin | LOVASTATIN | TABLET | 10 MG | COVERED | FORMULARY | |
15.412 | 49.758 | 240608-HMG-COA REDUCTASE INHIBITORS | Pravachol | 普伐他汀钠 | TABLET | 80 MG | COVERED | FORMULARY | |
48.671 | 16.366 | 240608-HMG-COA REDUCTASE INHIBITORS | Pravachol | 普伐他汀钠 | TABLET | 10 MG | COVERED | FORMULARY | |
48.672 | 16.367 | 240608-HMG-COA REDUCTASE INHIBITORS | Pravachol | 普伐他汀钠 | TABLET | 20 MG | COVERED | FORMULARY | |
48.673 | 20.741 | 240608-HMG-COA REDUCTASE INHIBITORS | Pravachol | 普伐他汀钠 | TABLET | 40 MG | COVERED | FORMULARY | |
26.531 | 16.576 | 240608-HMG-COA REDUCTASE INHIBITORS | Zocor | SIMVASTATIN | TABLET | 5 MG | COVERED | FORMULARY | |
26.532 | 16.577 | 240608-HMG-COA REDUCTASE INHIBITORS | Zocor | SIMVASTATIN | TABLET | 10 MG | COVERED | FORMULARY | |
26.533 | 16.578 | 240608-HMG-COA REDUCTASE INHIBITORS | Zocor | SIMVASTATIN | TABLET | 20 MG | COVERED | FORMULARY | |
26.534 | 16.579 | 240608-HMG-COA REDUCTASE INHIBITORS | Zocor | SIMVASTATIN | TABLET | 40 MG | COVERED | FORMULARY | |
42.331 | 33.364 | 240692-ANTILIPEMIC AGENTS, MISCELLANEOUS | Niaspan ER | NIACIN | TAB ER 24H | 500 MG | COVERED | FORMULARY | |
42.332 | 33.365 | 240692-ANTILIPEMIC AGENTS, MISCELLANEOUS | Niaspan ER | NIACIN | TAB ER 24H | 750 MG | COVERED | FORMULARY | |
42.333 | 33.366 | 240692-ANTILIPEMIC AGENTS, MISCELLANEOUS | Niaspan ER | NIACIN | TAB ER 24H | 1000 MG | COVERED | FORMULARY | |
23.870 | 343 | 240816-CENTRAL ALPHA-AGONISTS | Catapres TTS | CLONIDINE | PATCH TDWK | 0.1 MG/24HR | COVERED | FORMULARY | |
23.871 | 344 | 240816-CENTRAL ALPHA-AGONISTS | Catapres TTS | CLONIDINE | PATCH TDWK | 0.2 MG/24HR | COVERED | FORMULARY | |
23.872 | 345 | 240816-CENTRAL ALPHA-AGONISTS | Catapres TTS | CLONIDINE | PATCH TDWK | 0.3 MG/24HR | COVERED | FORMULARY | |
1.390 | 346 | 240816-CENTRAL ALPHA-AGONISTS | Catapres | CLONIDINE HCL | TABLET | 0.1 MG | COVERED | FORMULARY | |
1.391 | 347 | 240816-CENTRAL ALPHA-AGONISTS | Catapres | CLONIDINE HCL | TABLET | 0.2 MG | COVERED | FORMULARY | |
1.392 | 348 | 240816-CENTRAL ALPHA-AGONISTS | Catapres | CLONIDINE HCL | TABLET | 0.3 MG | COVERED | FORMULARY | |
32.480 | 364 | 240816-CENTRAL ALPHA-AGONISTS | Tenex | GUANFACINE HCL | TABLET | 1 MG | COVERED | FORMULARY | |
32.481 | 11.984 | 240816-CENTRAL ALPHA-AGONISTS | Tenex | GUANFACINE HCL | TABLET | 2 MG | COVERED | FORMULARY | |
1.431 | 361 | 240816-CENTRAL ALPHA-AGONISTS | Methyldopa | METHYLDOPA | TABLET | 250 MG | COVERED | FORMULARY | |
1.432 | 362 | 240816-CENTRAL ALPHA-AGONISTS | Methyldopa | METHYLDOPA | TABLET | 500 MG | COVERED | FORMULARY | |
1.241 | 284 | 240820 -直接血管舒张药 | Hydralazine | HYDRALAZINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
1.242 | 285 | 240820 -直接血管舒张药 | Hydralazine | HYDRALAZINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
1.243 | 286 | 240820 -直接血管舒张药 | Hydralazine | HYDRALAZINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
1.244 | 287 | 240820 -直接血管舒张药 | Hydralazine | HYDRALAZINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
1.290 | 299 | 240820 -直接血管舒张药 | Minoxidil | MINOXIDIL | TABLET | 10 MG | COVERED | FORMULARY | |
1.291 | 300 | 240820 -直接血管舒张药 | Minoxidil | MINOXIDIL | TABLET | 2.5 MG | COVERED | FORMULARY | |
1.942 | 507 | 241208-NITRATES AND NITRITES | Isordil | 硝酸异山梨酯 | TABLET | 10 MG | COVERED | FORMULARY | |
1.944 | 508 | 241208-NITRATES AND NITRITES | Isordil | 硝酸异山梨酯 | TABLET | 20 MG | COVERED | FORMULARY | |
1.945 | 509 | 241208-NITRATES AND NITRITES | Isordil | 硝酸异山梨酯 | TABLET | 30 MG | COVERED | FORMULARY | |
1.947 | 511 | 241208-NITRATES AND NITRITES | Isordil | 硝酸异山梨酯 | TABLET | 5 MG | COVERED | FORMULARY | |
48.102 | 17.297 | 241208-NITRATES AND NITRITES | 单硝酸异山梨酯ER | 单硝酸异山梨酯 | TAB ER 24H | 60 MG | COVERED | FORMULARY | |
48.103 | 23.474 | 241208-NITRATES AND NITRITES | 单硝酸异山梨酯ER | 单硝酸异山梨酯 | TAB ER 24H | 120 MG | COVERED | FORMULARY | |
48.104 | 24.488 | 241208-NITRATES AND NITRITES | 单硝酸异山梨酯ER | 单硝酸异山梨酯 | TAB ER 24H | 30 MG | COVERED | FORMULARY | |
1.931 | 16.639 | 241208-NITRATES AND NITRITES | 单硝酸异山梨酯 | 单硝酸异山梨酯 | TABLET | 20 MG | COVERED | FORMULARY | |
1.932 | 17.294 | 241208-NITRATES AND NITRITES | 单硝酸异山梨酯 | 单硝酸异山梨酯 | TABLET | 10 MG | COVERED | FORMULARY | |
1.681 | 455 | 241208-NITRATES AND NITRITES | Nitro-Time | NITROGLYCERIN | CAPSULE ER | 2.5 MG | COVERED | FORMULARY | |
1.682 | 456 | 241208-NITRATES AND NITRITES | Nitro-Time | NITROGLYCERIN | CAPSULE ER | 6.5 MG | COVERED | FORMULARY | |
1.684 | 457 | 241208-NITRATES AND NITRITES | Nitro-Time | NITROGLYCERIN | CAPSULE ER | 9 MG | COVERED | FORMULARY | |
1.740 | 465 | 241208-NITRATES AND NITRITES | Minitran | NITROGLYCERIN | PATCH TD24 | 0.4 MG/HR | COVERED | FORMULARY | |
1.741 | 467 | 241208-NITRATES AND NITRITES | Minitran | NITROGLYCERIN | PATCH TD24 | 0.1 MG/HR | COVERED | FORMULARY | |
1.742 | 468 | 241208-NITRATES AND NITRITES | Minitran | NITROGLYCERIN | PATCH TD24 | 0.2 MG/HR | COVERED | FORMULARY | |
92.257 | 44.359 | 241208-NITRATES AND NITRITES | Nitrolingual | NITROGLYCERIN | SPRAY | 400 MCG/SPRAY | COVERED | FORMULARY | |
1.771 | 474 | 241208-NITRATES AND NITRITES | Nitrostat | NITROGLYCERIN | TAB SUBL | 0.3 MG | COVERED | FORMULARY | |
1.772 | 475 | 241208-NITRATES AND NITRITES | Nitrostat | NITROGLYCERIN | TAB SUBL | 0.4 MG | COVERED | FORMULARY | |
1.773 | 476 | 241208-NITRATES AND NITRITES | Nitrostat | NITROGLYCERIN | TAB SUBL | 0.6 MG | COVERED | FORMULARY | |
53.141 | 41.698 | 241292-VASODILATING AGENTS, MISCELLANEOUS | Persantine | DIPYRIDAMOLE | TABLET | 25 MG | COVERED | FORMULARY | |
53.142 | 41.699 | 241292-VASODILATING AGENTS, MISCELLANEOUS | Persantine | DIPYRIDAMOLE | TABLET | 50 MG | COVERED | FORMULARY | |
53.143 | 41.700 | 241292-VASODILATING AGENTS, MISCELLANEOUS | Persantine | DIPYRIDAMOLE | TABLET | 75 MG | COVERED | FORMULARY | |
84.848 | 46.923 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Cardura XL | DOXAZOSIN甲磺酸 | TAB ER 24 | 8 MG | COVERED | FORMULARY | |
91.985 | 44.421 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Cardura XL | DOXAZOSIN甲磺酸 | TAB ER 24 | 4 MG | COVERED | FORMULARY | |
33.431 | 15.584 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Cardura | DOXAZOSIN甲磺酸 | TABLET | 1 MG | COVERED | FORMULARY | |
33.432 | 15.585 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Cardura | DOXAZOSIN甲磺酸 | TABLET | 2 MG | COVERED | FORMULARY | |
33.433 | 15.586 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Cardura | DOXAZOSIN甲磺酸 | TABLET | 4 MG | COVERED | FORMULARY | |
33.434 | 15.587 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Cardura | DOXAZOSIN甲磺酸 | TABLET | 8 MG | COVERED | FORMULARY | |
1.250 | 291 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Minipress | PRAZOSIN HCL | CAPSULE | 1 MG | COVERED | FORMULARY | |
1.251 | 292 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Minipress | PRAZOSIN HCL | CAPSULE | 2 MG | COVERED | FORMULARY | |
1.252 | 293 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Minipress | PRAZOSIN HCL | CAPSULE | 5 MG | COVERED | FORMULARY | |
47.124 | 22.649 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Terazosin | TERAZOSIN HCL | CAPSULE | 1 MG | COVERED | FORMULARY | |
47.125 | 22.650 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Terazosin | TERAZOSIN HCL | CAPSULE | 2 MG | COVERED | FORMULARY | |
47.126 | 22.651 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Terazosin | TERAZOSIN HCL | CAPSULE | 5 MG | COVERED | FORMULARY | |
47.127 | 22.652 | 242000-ALPHA-ADRENERGIC BLOCKING AGENTS | Terazosin | TERAZOSIN HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
12.947 | 47.586 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Toprol XL | 琥珀酸美托洛尔 | TAB ER 24H | 25 MG | COVERED | FORMULARY | |
20.741 | 16.599 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Toprol XL | 琥珀酸美托洛尔 | TAB ER 24H | 50 MG | COVERED | FORMULARY | |
20.742 | 16.600 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Toprol XL | 琥珀酸美托洛尔 | TAB ER 24H | 100 MG | COVERED | FORMULARY | |
20.743 | 16.601 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Toprol XL | 琥珀酸美托洛尔 | TAB ER 24H | 200 MG | COVERED | FORMULARY | |
20.660 | 5.138 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Tenormin | ATENOLOL | TABLET | 100 MG | COVERED | FORMULARY | |
20.661 | 5.139 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Tenormin | ATENOLOL | TABLET | 50 MG | COVERED | FORMULARY | |
20.662 | 15.864 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Tenormin | ATENOLOL | TABLET | 25 MG | COVERED | FORMULARY | |
66.990 | 420 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Tenoretic | ATENOLOL-CHLORTHALIDONE | TABLET | 50-25 MG | COVERED | FORMULARY | |
66.991 | 419 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Tenoretic | ATENOLOL-CHLORTHALIDONE | TABLET | 100-25 MG | COVERED | FORMULARY | |
63.820 | 17.955 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Zebeta | 比索洛尔延胡索酸酯 | TABLET | 10 MG | COVERED | FORMULARY | |
63.821 | 17.956 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Zebeta | 比索洛尔延胡索酸酯 | TABLET | 5 MG | COVERED | FORMULARY | |
45.061 | 21.139 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Ziac | 比索洛尔FUMARATE-HCTZ | TABLET | 2.5-6.25 MG | COVERED | FORMULARY | |
45.062 | 21.140 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Ziac | 比索洛尔FUMARATE-HCTZ | TABLET | 5-6.25 MG | COVERED | FORMULARY | |
45.063 | 21.141 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Ziac | 比索洛尔FUMARATE-HCTZ | TABLET | 10-6.2 5MG | COVERED | FORMULARY | |
1.551 | 19.293 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg | CARVEDILOL | TABLET | 25 MG | COVERED | FORMULARY | |
1.552 | 22.233 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg | CARVEDILOL | TABLET | 12.5 MG | COVERED | FORMULARY | |
1.553 | 28.108 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg | CARVEDILOL | TABLET | 3.125 MG | COVERED | FORMULARY | |
1.554 | 28.109 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg | CARVEDILOL | TABLET | 6.25 MG | COVERED | FORMULARY | |
10.340 | 5.100 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Labetalol | LABETALOL HCL | TABLET | 300 MG | COVERED | FORMULARY | |
10.341 | 5.099 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Labetalol | LABETALOL HCL | TABLET | 200 MG | COVERED | FORMULARY | |
10.342 | 5.098 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Labetalol | LABETALOL HCL | TABLET | 100 MG | COVERED | FORMULARY | |
17.734 | 50.631 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Lopressor | 酒石酸美托洛尔 | TABLET | 25 MG | COVERED | FORMULARY | |
20.641 | 5.131 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Lopressor | 酒石酸美托洛尔 | TABLET | 100 MG | COVERED | FORMULARY | |
20.642 | 5.132 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Lopressor | 酒石酸美托洛尔 | TABLET | 50 MG | COVERED | FORMULARY | |
20.652 | 5.136 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Corgard | NADOLOL | TABLET | 40 MG | COVERED | FORMULARY | |
20.653 | 5.137 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Corgard | NADOLOL | TABLET | 80 MG | COVERED | FORMULARY | |
20.654 | 5.135 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Corgard | NADOLOL | TABLET | 20 MG | COVERED | FORMULARY | |
3.230 | 5.116 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Inderal LA | PROPRANOLOL HCL | CAP SA 24H | 80 MG | COVERED | FORMULARY | |
3.231 | 5.113 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Inderal LA | PROPRANOLOL HCL | CAP SA 24H | 120 MG | COVERED | FORMULARY | |
3.232 | 5.114 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Inderal LA | PROPRANOLOL HCL | CAP SA 24H | 160 MG | COVERED | FORMULARY | |
3.233 | 5.115 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Inderal LA | PROPRANOLOL HCL | CAP SA 24H | 60 MG | COVERED | FORMULARY | |
20.630 | 5.123 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Propranolol | PROPRANOLOL HCL | TABLET | 10 MG | COVERED | FORMULARY | |
20.631 | 5.124 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Propranolol | PROPRANOLOL HCL | TABLET | 20 MG | COVERED | FORMULARY | |
20.632 | 5.125 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Propranolol | PROPRANOLOL HCL | TABLET | 40 MG | COVERED | FORMULARY | |
20.633 | 5.126 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Propranolol | PROPRANOLOL HCL | TABLET | 60 MG | COVERED | FORMULARY | |
20.634 | 5.127 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Propranolol | PROPRANOLOL HCL | TABLET | 80 MG | COVERED | FORMULARY | |
39.511 | 13.497 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Betapace | SOTALOL HCL | TABLET | 160 MG | COVERED | FORMULARY | |
39.512 | 17.196 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Betapace | SOTALOL HCL | TABLET | 80 MG | COVERED | FORMULARY | |
39.516 | 24.097 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Betapace | SOTALOL HCL | TABLET | 120 MG | COVERED | FORMULARY | |
2.681 | 16.925 | 242808 - dihydropyridines | Norvasc | 氨氯地平BESYLATE | TABLET | 2.5 MG | COVERED | FORMULARY | |
2.682 | 16.927 | 242808 - dihydropyridines | Norvasc | 氨氯地平BESYLATE | TABLET | 10 MG | COVERED | FORMULARY | |
2.683 | 16.926 | 242808 - dihydropyridines | Norvasc | 氨氯地平BESYLATE | TABLET | 5 MG | COVERED | FORMULARY | |
17.604 | 50.519 | 242808 - dihydropyridines | Lotrel | 氨氯地平BESYLATE-BENAZEPRIL | CAPSULE | 10-20 MG | COVERED | FORMULARY | |
26.949 | 60.722 | 242808 - dihydropyridines | Lotrel | 氨氯地平BESYLATE-BENAZEPRIL | CAPSULE | 5-40 MG | COVERED | FORMULARY | |
26.950 | 60.723 | 242808 - dihydropyridines | Lotrel | 氨氯地平BESYLATE-BENAZEPRIL | CAPSULE | 10-40 MG | COVERED | FORMULARY | |
33.090 | 23.768 | 242808 - dihydropyridines | Lotrel | 氨氯地平BESYLATE-BENAZEPRIL | CAPSULE | 5-20 MG | COVERED | FORMULARY | |
33.092 | 23.769 | 242808 - dihydropyridines | Lotrel | 氨氯地平BESYLATE-BENAZEPRIL | CAPSULE | 5-10 MG | COVERED | FORMULARY | |
33.093 | 23.770 | 242808 - dihydropyridines | Lotrel | 氨氯地平BESYLATE-BENAZEPRIL | CAPSULE | 2.5-10 MG | COVERED | FORMULARY | |
2.350 | 568 | 242808 - dihydropyridines | Procardia | NIFEDIPINE | CAPSULE | 10 MG | COVERED | FORMULARY | |
2.351 | 569 | 242808 - dihydropyridines | Procardia | NIFEDIPINE | CAPSULE | 20 MG | COVERED | FORMULARY | |
2.221 | 20.616 | 242808 - dihydropyridines | Procardia XL | NIFEDIPINE | TAB ER 24 | 30 MG | COVERED | FORMULARY | |
2.221 | 20.616 | 242808 - dihydropyridines | Procardia XL | NIFEDIPINE | TAB ER 24 | 30 MG | COVERED | FORMULARY | |
2.222 | 20.617 | 242808 - dihydropyridines | Procardia XL | NIFEDIPINE | TAB ER 24 | 60 MG | COVERED | FORMULARY | |
2.222 | 20.617 | 242808 - dihydropyridines | Procardia XL | NIFEDIPINE | TAB ER 24 | 60 MG | COVERED | FORMULARY | |
2.223 | 20.618 | 242808 - dihydropyridines | Procardia XL | NIFEDIPINE | TAB ER 24 | 90 MG | COVERED | FORMULARY | |
2.223 | 20.618 | 242808 - dihydropyridines | Procardia XL | NIFEDIPINE | TAB ER 24 | 90 MG | COVERED | FORMULARY | |
2.228 | 12.061 | 242808 - dihydropyridines | Adalat CC | NIFEDIPINE | TABLET ER | 90 MG | COVERED | FORMULARY | |
2.226 | 12.059 | 242808 - dihydropyridines | Adalat CC, Afeditab CR | NIFEDIPINE | TABLET ER | 30 MG | COVERED | FORMULARY | |
2.227 | 12.060 | 242808 - dihydropyridines | Adalat CC, Afeditab CR | NIFEDIPINE | TABLET ER | 60 MG | COVERED | FORMULARY | |
2.320 | 572 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Diltiazem ER | DILTIAZEM HCL | CAP ER 12H | 90 MG | COVERED | FORMULARY | |
2.321 | 570 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Diltiazem ER | DILTIAZEM HCL | CAP ER 12H | 120 MG | COVERED | FORMULARY | |
2.322 | 571 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Diltiazem ER | DILTIAZEM HCL | CAP ER 12H | 60 MG | COVERED | FORMULARY | |
7.460 | 32.600 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Cardizem CD | DILTIAZEM HCL | CAP ER 24H | 360 MG | COVERED | FORMULARY | |
2.323 | 16.570 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | 卡迪泽姆CD,卡蒂亚XT | DILTIAZEM HCL | CAP ER 24H | 180 MG | COVERED | FORMULARY | |
2.324 | 16.571 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | 卡迪泽姆CD,卡蒂亚XT | DILTIAZEM HCL | CAP ER 24H | 240 MG | COVERED | FORMULARY | |
2.325 | 16.572 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | 卡迪泽姆CD,卡蒂亚XT | DILTIAZEM HCL | CAP ER 24H | 300 MG | COVERED | FORMULARY | |
2.326 | 21.282 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | 卡迪泽姆CD,卡蒂亚XT | DILTIAZEM HCL | CAP ER 24H | 120 MG | COVERED | FORMULARY | |
7.461 | 16.849 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Dilacor XR | DILTIAZEM HCL | CAP ER DEG | 180 MG | COVERED | FORMULARY | |
7.462 | 16.850 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Dilacor XR | DILTIAZEM HCL | CAP ER DEG | 240 MG | COVERED | FORMULARY | |
7.463 | 17.205 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Dilacor XR | DILTIAZEM HCL | CAP ER DEG | 120 MG | COVERED | FORMULARY | |
94.691 | 40.966 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Tiazac | DILTIAZEM HCL | CAPSULE ER | 420 MG | COVERED | FORMULARY | |
2.328 | 24.478 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Tiazac, Taztia XT | DILTIAZEM HCL | CAPSULE ER | 360 MG | COVERED | FORMULARY | |
2.329 | 24.537 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Tiazac, Taztia XT | DILTIAZEM HCL | CAPSULE ER | 180 MG | COVERED | FORMULARY | |
2.330 | 24.536 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Tiazac, Taztia XT | DILTIAZEM HCL | CAPSULE ER | 120 MG | COVERED | FORMULARY | |
2.332 | 24.538 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Tiazac, Taztia XT | DILTIAZEM HCL | CAPSULE ER | 240 MG | COVERED | FORMULARY | |
2.333 | 24.539 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Tiazac, Taztia XT | DILTIAZEM HCL | CAPSULE ER | 300 MG | COVERED | FORMULARY | |
2.360 | 574 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Cardizem | DILTIAZEM HCL | TABLET | 30 MG | COVERED | FORMULARY | |
2.361 | 575 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Cardizem | DILTIAZEM HCL | TABLET | 60 MG | COVERED | FORMULARY | |
2.362 | 576 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Cardizem | DILTIAZEM HCL | TABLET | 90 MG | COVERED | FORMULARY | |
2.363 | 573 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Cardizem | DILTIAZEM HCL | TABLET | 120 MG | COVERED | FORMULARY | |
3.001 | 16.605 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Verelan SR | VERAPAMIL HCL | CAP24H PEL | 180 MG | COVERED | FORMULARY | |
3.002 | 15.067 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Verelan SR | VERAPAMIL HCL | CAP24H PEL | 240 MG | COVERED | FORMULARY | |
3.003 | 15.066 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Verelan SR | VERAPAMIL HCL | CAP24H PEL | 120 MG | COVERED | FORMULARY | |
3.004 | 26.486 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Verelan SR | VERAPAMIL HCL | CAP24H PEL | 360 MG | COVERED | FORMULARY | |
2.341 | 564 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Calan | VERAPAMIL HCL | TABLET | 120 MG | COVERED | FORMULARY | |
2.342 | 566 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Calan | VERAPAMIL HCL | TABLET | 80 MG | COVERED | FORMULARY | |
47.110 | 565 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Verapamil | VERAPAMIL HCL | TABLET | 40 MG | COVERED | FORMULARY | |
32.470 | 567 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Calan SR | VERAPAMIL HCL | TABLET ER | 240 MG | COVERED | FORMULARY | |
32.471 | 13.670 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Calan SR | VERAPAMIL HCL | TABLET ER | 180 MG | COVERED | FORMULARY | |
32.472 | 15.959 | 242892-CALCIUM-CHANNEL BLOCKING AGENTS, MISC. | Calan SR | VERAPAMIL HCL | TABLET ER | 120 MG | COVERED | FORMULARY | |
48.611 | 16.039 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Lotensin | BENAZEPRIL HCL | TABLET | 5 MG | COVERED | FORMULARY | |
48.612 | 16.040 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Lotensin | BENAZEPRIL HCL | TABLET | 10 MG | COVERED | FORMULARY | |
48.613 | 16.041 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Lotensin | BENAZEPRIL HCL | TABLET | 20 MG | COVERED | FORMULARY | |
48.614 | 16.042 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Lotensin | BENAZEPRIL HCL | TABLET | 40 MG | COVERED | FORMULARY | |
33.192 | 21.724 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Lotensin HCT | BENAZEPRIL-氢氯噻嗪 | TABLET | 10-12.5 MG | COVERED | FORMULARY | |
33.193 | 21.725 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Lotensin HCT | BENAZEPRIL-氢氯噻嗪 | TABLET | 20-12.5 MG | COVERED | FORMULARY | |
33.194 | 21.726 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Lotensin HCT | BENAZEPRIL-氢氯噻嗪 | TABLET | 20-25 MG | COVERED | FORMULARY | |
1.480 | 378 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Captopril | CAPTOPRIL | TABLET | 100 MG | COVERED | FORMULARY | |
1.481 | 380 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Captopril | CAPTOPRIL | TABLET | 25 MG | COVERED | FORMULARY | |
1.482 | 381 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Captopril | CAPTOPRIL | TABLET | 50 MG | COVERED | FORMULARY | |
1.483 | 379 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Captopril | CAPTOPRIL | TABLET | 12.5 MG | COVERED | FORMULARY | |
54.940 | 374 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Captopril-氢氯噻嗪 | CAPTOPRIL-氢氯噻嗪 | TABLET | 25-15 MG | COVERED | FORMULARY | |
54.941 | 375 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Captopril-氢氯噻嗪 | CAPTOPRIL-氢氯噻嗪 | TABLET | 25-25 MG | COVERED | FORMULARY | |
960 | 387 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Vasotec | 马来酸依那普利二 | TABLET | 5 MG | COVERED | FORMULARY | |
961 | 384 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Vasotec | 马来酸依那普利二 | TABLET | 10 MG | COVERED | FORMULARY | |
962 | 386 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Vasotec | 马来酸依那普利二 | TABLET | 20 MG | COVERED | FORMULARY | |
963 | 385 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Vasotec | 马来酸依那普利二 | TABLET | 2.5 MG | COVERED | FORMULARY | |
54.860 | 382 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Enalapril-氢氯噻嗪 | ENALAPRIL-氢氯噻嗪 | TABLET | 10-25 MG | COVERED | FORMULARY | |
54.862 | 24.190 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Enalapril-氢氯噻嗪 | ENALAPRIL-氢氯噻嗪 | TABLET | 5-12.5 MG | COVERED | FORMULARY | |
48.580 | 24.469 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Fosinopril | FOSINOPRIL SODIUM | TABLET | 40 MG | COVERED | FORMULARY | |
48.581 | 16.017 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Fosinopril | FOSINOPRIL SODIUM | TABLET | 10 MG | COVERED | FORMULARY | |
48.582 | 16.018 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Fosinopril | FOSINOPRIL SODIUM | TABLET | 20 MG | COVERED | FORMULARY | |
10.455 | 40.395 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Fosinopril-氢氯噻嗪 | FOSINOPRIL-氢氯噻嗪 | TABLET | 20-12.5 MG | COVERED | FORMULARY | |
15.621 | 44.935 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Fosinopril-氢氯噻嗪 | FOSINOPRIL-氢氯噻嗪 | TABLET | 10-12.5 MG | COVERED | FORMULARY | |
47.260 | 393 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Prinvil, Zestril | LISINOPRIL | TABLET | 5 MG | COVERED | FORMULARY | |
47.261 | 390 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Prinvil, Zestril | LISINOPRIL | TABLET | 10 MG | COVERED | FORMULARY | |
47.262 | 391 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Prinvil, Zestril | LISINOPRIL | TABLET | 20 MG | COVERED | FORMULARY | |
47.263 | 392 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Prinvil, Zestril | LISINOPRIL | TABLET | 40 MG | COVERED | FORMULARY | |
47.264 | 17.266 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Prinvil, Zestril | LISINOPRIL | TABLET | 2.5 MG | COVERED | FORMULARY | |
47.265 | 41.567 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Prinvil, Zestril | LISINOPRIL | TABLET | 30 MG | COVERED | FORMULARY | |
88.000 | 388 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Zestoretic | LISINOPRIL-氢氯噻嗪 | TABLET | 20-12.5 MG | COVERED | FORMULARY | |
88.001 | 389 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Zestoretic | LISINOPRIL-氢氯噻嗪 | TABLET | 20-25 MG | COVERED | FORMULARY | |
88.002 | 21.277 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Zestoretic | LISINOPRIL-氢氯噻嗪 | TABLET | 10-12.5 MG | COVERED | FORMULARY | |
27.570 | 18.772 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Accupril | QUINAPRIL HCL | TABLET | 10 MG | COVERED | FORMULARY | |
27.571 | 18.773 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Accupril | QUINAPRIL HCL | TABLET | 20 MG | COVERED | FORMULARY | |
27.572 | 18.774 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Accupril | QUINAPRIL HCL | TABLET | 5 MG | COVERED | FORMULARY | |
27.573 | 21.909 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Accupril | QUINAPRIL HCL | TABLET | 40 MG | COVERED | FORMULARY | |
54.160 | 19.140 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Accuretic | QUINAPRIL-氢氯噻嗪 | TABLET | 10-12.5MG | COVERED | FORMULARY | |
54.161 | 24.002 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Accuretic | QUINAPRIL-氢氯噻嗪 | TABLET | 20-12.5 MG | COVERED | FORMULARY | |
94.490 | 41.016 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Accuretic | QUINAPRIL-氢氯噻嗪 | TABLET | 20-25MG | COVERED | FORMULARY | |
48.542 | 15.940 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Altace | RAMIPRIL | CAPSULE | 2.5 MG | COVERED | FORMULARY | |
48.543 | 15.941 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Altace | RAMIPRIL | CAPSULE | 5 MG | COVERED | FORMULARY | |
48.544 | 16.031 | 243204-ANGIOTENSIN-CONVERTING ENZYME INHIBITORS | Altace | RAMIPRIL | CAPSULE | 10 MG | COVERED | FORMULARY | |
4.749 | 34.468 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Avapro | IRBESARTAN | TABLET | 150 MG | COVERED | FORMULARY | |
4.750 | 34.469 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Avapro | IRBESARTAN | TABLET | 300 MG | COVERED | FORMULARY | |
4.752 | 34.470 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Avapro | IRBESARTAN | TABLET | 75 MG | COVERED | FORMULARY | |
11.042 | 41.234 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Avalide | IRBESARTAN-氢氯噻嗪 | TABLET | 150-12.5 MG | COVERED | FORMULARY | |
11.295 | 41.897 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Avalide | IRBESARTAN-氢氯噻嗪 | TABLET | 300-12.5 MG | COVERED | FORMULARY | |
14.850 | 23.381 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Cozaar | 洛沙坦钾 | TABLET | 25 MG | COVERED | FORMULARY | |
14.851 | 23.382 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Cozaar | 洛沙坦钾 | TABLET | 50 MG | COVERED | FORMULARY | |
14.853 | 38.686 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Cozaar | 洛沙坦钾 | TABLET | 100 MG | COVERED | FORMULARY | |
14.852 | 23.465 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Hyzaar | LOSARTAN-氢氯噻嗪 | TABLET | 50-12.5 MG | COVERED | FORMULARY | |
14.854 | 40.923 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Hyzaar | LOSARTAN-氢氯噻嗪 | TABLET | 100-25 MG | COVERED | FORMULARY | |
25.851 | 59.919 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Hyzaar | LOSARTAN-氢氯噻嗪 | TABLET | 100-12.5 MG | COVERED | FORMULARY | |
91.883 | 51.036 | 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS | Inspra | EPLERENONE | TABLET | 25 MG | COVERED | FORMULARY | |
91.883 | 51.036 | 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS | Inspra | EPLERENONE | TABLET | 25 MG | COVERED | FORMULARY | |
91.884 | 51.037 | 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS | Inspra | EPLERENONE | TABLET | 50 MG | COVERED | FORMULARY | |
91.884 | 51.037 | 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS | Inspra | EPLERENONE | TABLET | 50 MG | COVERED | FORMULARY | |
27.690 | 6.816 | 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS | Aldactone | SPIRONOLACTONE | TABLET | 100 MG | COVERED | FORMULARY | |
27.691 | 6.817 | 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS | Aldactone | SPIRONOLACTONE | TABLET | 25 MG | COVERED | FORMULARY | |
27.692 | 6.818 | 243220-MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS | Aldactone | SPIRONOLACTONE | TABLET | 50 MG | COVERED | FORMULARY | |
71.150 | 4.308 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Fiorinal | BUTALBITAL-ASPIRIN-CAFFEINE | CAPSULE | 50-325-40 MG | COVERED | FORMULARY | |
71.150 | 4.308 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Fiorinal | BUTALBITAL-ASPIRIN-CAFFEINE | CAPSULE | 50-325-40 MG | COVERED | FORMULARY | |
45.680 | 18.293 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Voltaren | 双氯芬酸钠 | GEL (GRAM) | 1 % | COVERED | FORMULARY | |
13.310 | 11.933 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | 双氯芬酸钠 | 双氯芬酸钠 | TAB ER 24H | 100 MG | COVERED | FORMULARY | |
35.850 | 8.372 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | 双氯芬酸钠 | 双氯芬酸钠 | TABLET DR | 25 MG | COVERED | FORMULARY | |
35.851 | 8.373 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | 双氯芬酸钠 | 双氯芬酸钠 | TABLET DR | 50 MG | COVERED | FORMULARY | |
35.852 | 8.374 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | 双氯芬酸钠 | 双氯芬酸钠 | TABLET DR | 75 MG | COVERED | FORMULARY | |
33.870 | 15.960 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Etodolac | ETODOLAC | CAPSULE | 200 MG | COVERED | FORMULARY | |
33.871 | 15.961 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Etodolac | ETODOLAC | CAPSULE | 300 MG | COVERED | FORMULARY | |
61.767 | 38.259 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Etodolac | ETODOLAC | TAB ER 24H | 500 MG | COVERED | FORMULARY | |
61.761 | 20.175 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Etodolac | ETODOLAC | TABLET | 400 MG | COVERED | FORMULARY | |
61.766 | 27.368 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Etodolac | ETODOLAC | TABLET | 500 MG | COVERED | FORMULARY | |
35.741 | 8.348 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Ibuprofen | IBUPROFEN | TABLET | 400 MG | COVERED | FORMULARY | |
35.742 | 8.349 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Ibuprofen | IBUPROFEN | TABLET | 600 MG | COVERED | FORMULARY | |
35.744 | 8.350 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Ibuprofen | IBUPROFEN | TABLET | 800 MG | COVERED | FORMULARY | |
35.680 | 8.336 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Indomethacin | INDOMETHACIN | CAPSULE | 25 MG | COVERED | FORMULARY | |
35.681 | 8.337 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Indomethacin | INDOMETHACIN | CAPSULE | 50 MG | COVERED | FORMULARY | |
35.690 | 8.338 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Indomethacin | INDOMETHACIN | CAPSULE ER | 75 MG | COVERED | FORMULARY | |
33.792 | 16.406 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Ketoprofen ER | KETOPROFEN | CAP24H PEL | 200 MG | COVERED | FORMULARY | |
34.420 | 8.379 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Ketoprofen | KETOPROFEN | CAPSULE | 50 MG | COVERED | FORMULARY | |
34.421 | 8.380 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Ketoprofen | KETOPROFEN | CAPSULE | 75 MG | COVERED | FORMULARY | |
31.661 | 29.156 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Mobic | MELOXICAM | TABLET | 7.5 MG | COVERED | FORMULARY | |
31.662 | 29.157 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Mobic | MELOXICAM | TABLET | 15 MG | COVERED | FORMULARY | |
32.961 | 16.574 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Nabumetone | NABUMETONE | TABLET | 500 MG | COVERED | FORMULARY | |
32.962 | 16.575 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Nabumetone | NABUMETONE | TABLET | 750 MG | COVERED | FORMULARY | |
35.790 | 8.360 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Naprosyn | NAPROXEN | TABLET | 250 MG | COVERED | FORMULARY | |
35.792 | 8.361 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Naprosyn | NAPROXEN | TABLET | 375 MG | COVERED | FORMULARY | |
35.793 | 8.362 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Naprosyn | NAPROXEN | TABLET | 500 MG | COVERED | FORMULARY | |
47.130 | 8.357 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Anaprox | NAPROXEN SODIUM | TABLET | 275 MG | COVERED | FORMULARY | |
47.131 | 8.358 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Anaprox | NAPROXEN SODIUM | TABLET | 550 MG | COVERED | FORMULARY | |
16.801 | 4.438 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Salsalate | SALSALATE | TABLET | 500 MG | COVERED | FORMULARY | |
16.802 | 4.439 | 280804-NONSTEROIDAL ANTI-INFLAMMATORY AGENTS | Salsalate | SALSALATE | TABLET | 750 MG | COVERED | FORMULARY | |
55.402 | 45.155 | 280808 -阿片受体激动剂 | Acetaminophen-Codeine Solution | ACETAMINOPHEN-CODEINE | SOLUTION | 120-12 MG/5ML | COVERED | FORMULARY | |
70.131 | 4.163 | 280808 -阿片受体激动剂 | Acetaminophen-Codeine Tablet | ACETAMINOPHEN-CODEINE | TABLET | 300-15 MG | COVERED | FORMULARY | |
70.134 | 4.165 | 280808 -阿片受体激动剂 | Tylenol-Codeine # 3 | ACETAMINOPHEN-CODEINE | TABLET | 300-30 MG | COVERED | FORMULARY | |
70.136 | 4.169 | 280808 -阿片受体激动剂 | Tylenol-Codeine # 4 | ACETAMINOPHEN-CODEINE | TABLET | 300-60 MG | COVERED | FORMULARY | |
70.140 | 4.149 | 280808 -阿片受体激动剂 | Butalbital-Acetaminophen-Caffeine-Codeine | BUTALBITAL-ACETAMINOPHEN-CAFFEINE-CODEINE | CAPSULE | 50-325-30 MG | COVERED | FORMULARY | |
21.146 | 53.582 | 280808 -阿片受体激动剂 | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | SOLUTION | 7.5-325/15 | COVERED | FORMULARY | |
12.486 | 47.430 | 280808 -阿片受体激动剂 | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | TABLET | 5-325 MG | COVERED | FORMULARY | |
12.488 | 47.431 | 280808 -阿片受体激动剂 | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | TABLET | 7.5-325 MG | COVERED | FORMULARY | |
70.330 | 30.623 | 280808 -阿片受体激动剂 | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | TABLET | 10-325 MG | COVERED | FORMULARY | |
70.334 | 26.439 | 280808 -阿片受体激动剂 | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | TABLET | 10-500 MG | COVERED | FORMULARY | |
12.488 | 47.431 | 280808 -阿片受体激动剂 | Hydrocodone-Acetaminophen | HYDROCODONE-ACETAMINOPHEN | TABLET | 7.5-325 MG | COVERED | FORMULARY | |
63.101 | 34.068 | 280808 -阿片受体激动剂 | Vicoprofen | HYDROCODONE-IBUPROFEN | TABLET | 7.5-200 MG | COVERED | FORMULARY | |
16.141 | 4.110 | 280808 -阿片受体激动剂 | Dilaudid | HYDROMORPHONE HCL | TABLET | 2 MG | COVERED | FORMULARY | |
16.143 | 4.112 | 280808 -阿片受体激动剂 | Dilaudid | HYDROMORPHONE HCL | TABLET | 4 MG | COVERED | FORMULARY | |
16.144 | 15.190 | 280808 -阿片受体激动剂 | Dilaudid | HYDROMORPHONE HCL | TABLET | 8 MG | COVERED | FORMULARY | |
16.420 | 4.240 | 280808 -阿片受体激动剂 | Dolophine | METHADONE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
16.422 | 4.242 | 280808 -阿片受体激动剂 | Dolophine | METHADONE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
16.060 | 4.087 | 280808 -阿片受体激动剂 | Morphine | MORPHINE SULFATE | SOLUTION | 10 MG/5ML | COVERED | FORMULARY | |
16.062 | 4.089 | 280808 -阿片受体激动剂 | Morphine | MORPHINE SULFATE | SOLUTION | 20 MG/5ML | COVERED | FORMULARY | |
16.063 | 4.090 | 280808 -阿片受体激动剂 | Morphine | MORPHINE SULFATE | SOLUTION | 100 MG/5ML | COVERED | FORMULARY | |
16.070 | 4.091 | 280808 -阿片受体激动剂 | Morphine | MORPHINE SULFATE | TABLET | 15 MG | COVERED | FORMULARY | |
16.071 | 4.092 | 280808 -阿片受体激动剂 | Morphine | MORPHINE SULFATE | TABLET | 30 MG | COVERED | FORMULARY | |
16.640 | 4.096 | 280808 -阿片受体激动剂 | MS Contin CR | MORPHINE SULFATE | TABLET ER | 30 MG | COVERED | FORMULARY | |
16.641 | 4.097 | 280808 -阿片受体激动剂 | MS Contin CR | MORPHINE SULFATE | TABLET ER | 60 MG | COVERED | FORMULARY | |
16.643 | 11.887 | 280808 -阿片受体激动剂 | MS Contin CR | MORPHINE SULFATE | TABLET ER | 15 MG | COVERED | FORMULARY | |
16.285 | 24.507 | 280808 -阿片受体激动剂 | Oxycodone | OXYCODONE HCL | CAPSULE | 5 MG | COVERED | FORMULARY | |
16.290 | 4.225 | 280808 -阿片受体激动剂 | Oxycodone | OXYCODONE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
14.965 | 48.976 | 280808 -阿片受体激动剂 | Percocet | OXYCODONE HCL-ACETAMINOPHEN | TABLET | 7.5-325MG | COVERED | FORMULARY | |
14.966 | 48.977 | 280808 -阿片受体激动剂 | Percocet | OXYCODONE HCL-ACETAMINOPHEN | TABLET | 10MG-325MG | COVERED | FORMULARY | |
70.491 | 4.222 | 280808 -阿片受体激动剂 | Percocet | OXYCODONE HCL-ACETAMINOPHEN | TABLET | 5 MG-325MG | COVERED | FORMULARY | |
7.221 | 23.139 | 280808 -阿片受体激动剂 | Ultram | TRAMADOL HCL | TABLET | 50 MG | COVERED | FORMULARY | |
13.909 | 48.456 | 280808 -阿片受体激动剂 | Ultracet | 曲马多HCL-ACETAMINOPHEN | TABLET | 37.5-325MG | COVERED | FORMULARY | |
72.510 | 4.450 | 280892-ANALGESICS AND ANTIPYRETICS, MISC. | Capacet | BUTALBITAL-ACETAMINOPHEN-CAFFEINE | CAPSULE | 50-325-40 MG | COVERED | FORMULARY | |
72.530 | 4.451 | 280892-ANALGESICS AND ANTIPYRETICS, MISC. | Esgic | BUTALBITAL-ACETAMINOPHEN-CAFFEINE | TABLET | 50-325-40 MG | COVERED | FORMULARY | |
13.996 | 48.520 | 280892-ANALGESICS AND ANTIPYRETICS, MISC. | Nodolor | ISOMETHEPT-DICHLPHN/ACETAMINOPHEN | CAPSULE | 65-100-325 MG | COVERED | FORMULARY | |
40.233 | 75.222 | 281000年鸦片拮抗剂 | Narcan Nasal | NALOXONE HCL | SPRAY | 4 MG | COVERED | FORMULARY | |
17.070 | 4.518 | 281000年鸦片拮抗剂 | Naltrexone | NALTREXONE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
17.321 | 4.543 | 281204-BARBITURATES (ANTICONVULSANTS) | Mysoline | PRIMIDONE | TABLET | 250 MG | COVERED | FORMULARY | |
17.322 | 4.544 | 281204-BARBITURATES (ANTICONVULSANTS) | Mysoline | PRIMIDONE | TABLET | 50 MG | COVERED | FORMULARY | |
17.470 | 4.560 | 281208-BENZODIAZEPINES (ANTICONVULSANTS) | Klonopin | CLONAZEPAM | TABLET | 0.5 MG | COVERED | FORMULARY | |
17.471 | 4.561 | 281208-BENZODIAZEPINES (ANTICONVULSANTS) | Klonopin | CLONAZEPAM | TABLET | 1 MG | COVERED | FORMULARY | |
17.472 | 4.562 | 281208-BENZODIAZEPINES (ANTICONVULSANTS) | Klonopin | CLONAZEPAM | TABLET | 2 MG | COVERED | FORMULARY | |
17.260 | 4.532 | 281212-HYDANTOINS | Peganone | ETHOTOIN | TABLET | 250 MG | COVERED | FORMULARY | |
17.241 | 4.529 | 281212-HYDANTOINS | Dilantin | PHENYTOIN | ORAL SUSP | 125 MG/5ML | COVERED | FORMULARY | |
99.557 | 63.845 | 281212-HYDANTOINS | Phenytoin | PHENYTOIN | ORAL SUSP | 100 MG/4ML | COVERED | FORMULARY | |
17.250 | 4.531 | 281212-HYDANTOINS | Dilantin | PHENYTOIN | TAB CHEW | 50 MG | COVERED | FORMULARY | |
15.037 | 49.444 | 281212-HYDANTOINS | 狄兰汀,Phenytek | 苯妥英钠延伸 | CAPSULE | 300 MG | COVERED | FORMULARY | |
15.038 | 49.445 | 281212-HYDANTOINS | 狄兰汀,Phenytek | 苯妥英钠延伸 | CAPSULE | 200 MG | COVERED | FORMULARY | |
17.700 | 4.521 | 281212-HYDANTOINS | 狄兰汀,Phenytek | 苯妥英钠延伸 | CAPSULE | 100 MG | COVERED | FORMULARY | |
17.701 | 4.522 | 281212-HYDANTOINS | 狄兰汀,Phenytek | 苯妥英钠延伸 | CAPSULE | 30 MG | COVERED | FORMULARY | |
23.932 | 58.487 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Carbatrol | CARBAMAZEPINE | CPMP 12HR | 200 MG | COVERED | FORMULARY | |
23.933 | 58.488 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Carbatrol | CARBAMAZEPINE | CPMP 12HR | 300 MG | COVERED | FORMULARY | |
23.934 | 58.489 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Carbatrol | CARBAMAZEPINE | CPMP 12HR | 100 MG | COVERED | FORMULARY | |
47.500 | 4.557 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Carbamazepine | CARBAMAZEPINE | ORAL SUSP | 100 MG/5ML | COVERED | FORMULARY | |
17.460 | 4.559 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Carbamazepine | CARBAMAZEPINE | TAB CHEW | 100 MG | COVERED | FORMULARY | |
27.820 | 26.868 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Tegreol XR | CARBAMAZEPINE | TAB ER 12H | 100 MG | COVERED | FORMULARY | |
27.821 | 16.773 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Tegreol XR | CARBAMAZEPINE | TAB ER 12H | 200 MG | COVERED | FORMULARY | |
27.822 | 17.876 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Tegreol XR | CARBAMAZEPINE | TAB ER 12H | 400 MG | COVERED | FORMULARY | |
17.450 | 4.558 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Tegretol | CARBAMAZEPINE | TABLET | 200 MG | COVERED | FORMULARY | |
18.040 | 46.315 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Depakote ER | DIVALPROEX SODIUM | TAB ER 24H | 500 MG | COVERED | FORMULARY | |
18.754 | 51.469 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Depakote ER | DIVALPROEX SODIUM | TAB ER 24H | 250 MG | COVERED | FORMULARY | |
17.290 | 4.539 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Depakote | DIVALPROEX SODIUM | TABLET DR | 250 MG | COVERED | FORMULARY | |
17.291 | 4.540 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Depakote | DIVALPROEX SODIUM | TABLET DR | 500 MG | COVERED | FORMULARY | |
17.292 | 4.538 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Depakote | DIVALPROEX SODIUM | TABLET DR | 125 MG | COVERED | FORMULARY | |
780 | 21.413 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Neurontin | GABAPENTIN | CAPSULE | 100 MG | COVERED | FORMULARY | |
781 | 21.414 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Neurontin | GABAPENTIN | CAPSULE | 300 MG | COVERED | FORMULARY | |
782 | 21.415 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Neurontin | GABAPENTIN | CAPSULE | 400 MG | COVERED | FORMULARY | |
13.235 | 47.927 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Neurontin | GABAPENTIN | SOLUTION | 250 MG/5ML | COVERED | FORMULARY | |
94.447 | 41.806 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Neurontin | GABAPENTIN | TABLET | 800 MG | COVERED | FORMULARY | |
94.624 | 41.805 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Neurontin | GABAPENTIN | TABLET | 600 MG | COVERED | FORMULARY | |
64.316 | 17.871 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal | LAMOTRIGINE | TABLET | 100 MG | COVERED | FORMULARY | |
64.317 | 17.872 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal | LAMOTRIGINE | TABLET | 25 MG | COVERED | FORMULARY | |
64.324 | 22.550 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal | LAMOTRIGINE | TABLET | 150 MG | COVERED | FORMULARY | |
64.325 | 22.551 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal | LAMOTRIGINE | TABLET | 200 MG | COVERED | FORMULARY | |
16.779 | 64.819 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra | LEVETIRACETAM | SOLUTION | 500 MG/5ML | COVERED | FORMULARY | |
20.353 | 53.031 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra | LEVETIRACETAM | SOLUTION | 100 MG/ML | COVERED | FORMULARY | |
41.586 | 45.652 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra | LEVETIRACETAM | TABLET | 750 MG | COVERED | FORMULARY | |
41.587 | 44.632 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra | LEVETIRACETAM | TABLET | 250 MG | COVERED | FORMULARY | |
41.597 | 44.633 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra | LEVETIRACETAM | TABLET | 500 MG | COVERED | FORMULARY | |
86.223 | 47.077 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra | LEVETIRACETAM | TABLET | 1000 MG | COVERED | FORMULARY | |
21.723 | 33.724 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Trileptal | OXCARBAZEPINE | ORAL SUSP | 300 MG/5ML | COVERED | FORMULARY | |
21.721 | 27.779 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Trileptal | OXCARBAZEPINE | TABLET | 300 MG | COVERED | FORMULARY | |
21.722 | 27.780 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Trileptal | OXCARBAZEPINE | TABLET | 600 MG | COVERED | FORMULARY | |
21.724 | 44.336 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Trileptal | OXCARBAZEPINE | TABLET | 150 MG | COVERED | FORMULARY | |
92.219 | 45.100 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Thioguanine | THIOGUANINE | TABLET | 40 MG | COVERED | FORMULARY | |
36.550 | 26.169 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Topamax | TOPIRAMATE | TABLET | 50 MG | COVERED | FORMULARY | |
36.551 | 26.170 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Topamax | TOPIRAMATE | TABLET | 100 MG | COVERED | FORMULARY | |
36.552 | 26.171 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Topamax | TOPIRAMATE | TABLET | 200 MG | COVERED | FORMULARY | |
36.553 | 29.837 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Topamax | TOPIRAMATE | TABLET | 25 MG | COVERED | FORMULARY | |
17.270 | 4.536 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Depakene | VALPROIC ACID | CAPSULE | 250 MG | COVERED | FORMULARY | |
17.280 | 4.535 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Depakene Syrup | VALPROIC ACID (AS SODIUM SALT) | SOLUTION | 250 MG/5ML | COVERED | FORMULARY | |
30.965 | 68.220 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Valproic Solution | VALPROIC ACID (AS SODIUM SALT) | SOLUTION | 250 MG/5ML | COVERED | FORMULARY | |
30.986 | 68.236 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Valproic Syrup | VALPROIC ACID (AS SODIUM SALT) | SOLUTION | 500 MG/10ML | COVERED | FORMULARY | |
30.987 | 68.237 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Valproic Syrup | VALPROIC ACID (AS SODIUM SALT) | SYRINGE | 250 MG/5ML | COVERED | FORMULARY | |
20.831 | 53.367 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Zonegran | ZONISAMIDE | CAPSULE | 25 MG | COVERED | FORMULARY | |
20.833 | 53.368 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Zonegran | ZONISAMIDE | CAPSULE | 50 MG | COVERED | FORMULARY | |
92.219 | 45.100 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Zonegran | ZONISAMIDE | CAPSULE | 100 MG | COVERED | FORMULARY | |
16.512 | 46.043 | 281604 -抗抑郁药 | Elavil | AMITRIPTYLINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
16.513 | 46.044 | 281604 -抗抑郁药 | Elavil | AMITRIPTYLINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
16.514 | 46.045 | 281604 -抗抑郁药 | Elavil | AMITRIPTYLINE HCL | TABLET | 150 MG | COVERED | FORMULARY | |
16.515 | 46.046 | 281604 -抗抑郁药 | Elavil | AMITRIPTYLINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
16.516 | 46.047 | 281604 -抗抑郁药 | Elavil | AMITRIPTYLINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
16.517 | 46.048 | 281604 -抗抑郁药 | Elavil | AMITRIPTYLINE HCL | TABLET | 75 MG | COVERED | FORMULARY | |
20.317 | 53.006 | 281604 -抗抑郁药 | Wellbutrin XL | BUPROPION HCL | TAB ER 24H | 150 MG | COVERED | FORMULARY | |
20.318 | 53.007 | 281604 -抗抑郁药 | Wellbutrin XL | BUPROPION HCL | TAB ER 24H | 300 MG | COVERED | FORMULARY | |
16.384 | 46.236 | 281604 -抗抑郁药 | Wellbutrin | BUPROPION HCL | TABLET | 75 MG | COVERED | FORMULARY | |
16.385 | 46.237 | 281604 -抗抑郁药 | Wellbutrin | BUPROPION HCL | TABLET | 100 MG | COVERED | FORMULARY | |
16.386 | 46.238 | 281604 -抗抑郁药 | Wellbutrin SR | BUPROPION HCL | TABLET ER | 150 MG | COVERED | FORMULARY | |
16.387 | 46.239 | 281604 -抗抑郁药 | Wellbutrin SR | BUPROPION HCL | TABLET ER | 100 MG | COVERED | FORMULARY | |
17.573 | 50.496 | 281604 -抗抑郁药 | Wellbutrin SR | BUPROPION HCL | TABLET ER | 200 MG | COVERED | FORMULARY | |
27.901 | 31.439 | 281604 -抗抑郁药 | Zyban SR | BUPROPION HCL | TABLET ER | 150 MG | COVERED | FORMULARY | |
16.342 | 46.203 | 281604 -抗抑郁药 | Celexa | 西酞普兰氢溴酸盐 | TABLET | 20 MG | COVERED | FORMULARY | Max 40mg/day |
16.343 | 46.204 | 281604 -抗抑郁药 | Celexa | 西酞普兰氢溴酸盐 | TABLET | 40 MG | COVERED | FORMULARY | Max 40mg/day |
16.345 | 46.206 | 281604 -抗抑郁药 | Celexa | 西酞普兰氢溴酸盐 | TABLET | 10 MG | COVERED | FORMULARY | Max 40mg/day |
16.563 | 46.086 | 281604 -抗抑郁药 | Doxepin | DOXEPIN HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
16.564 | 46.087 | 281604 -抗抑郁药 | Doxepin | DOXEPIN HCL | CAPSULE | 100 MG | COVERED | FORMULARY | |
16.565 | 46.088 | 281604 -抗抑郁药 | Doxepin | DOXEPIN HCL | CAPSULE | 150 MG | COVERED | FORMULARY | |
16.566 | 46.089 | 281604 -抗抑郁药 | Doxepin | DOXEPIN HCL | CAPSULE | 25 MG | COVERED | FORMULARY | |
16.567 | 46.090 | 281604 -抗抑郁药 | Doxepin | DOXEPIN HCL | CAPSULE | 50 MG | COVERED | FORMULARY | |
16.568 | 46.091 | 281604 -抗抑郁药 | Doxepin | DOXEPIN HCL | CAPSULE | 75 MG | COVERED | FORMULARY | |
23.161 | 57.891 | 281604 -抗抑郁药 | Cymbalta | DULOXETINE HCL | CAPSULE DR | 20 MG | COVERED | FORMULARY | |
23.162 | 57.892 | 281604 -抗抑郁药 | Cymbalta | DULOXETINE HCL | CAPSULE DR | 30 MG | COVERED | FORMULARY | |
23.164 | 57.893 | 281604 -抗抑郁药 | Cymbalta | DULOXETINE HCL | CAPSULE DR | 60 MG | COVERED | FORMULARY | |
38.728 | 74.166 | 281604 -抗抑郁药 | Cymbalta | DULOXETINE HCL | CAPSULE DR | 40 MG | COVERED | FORMULARY | |
19.035 | 51.698 | 281604 -抗抑郁药 | Lexapro Solution | 草酸酞 | SOLUTION | 5 MG/5ML | COVERED | FORMULARY | Max 20mg/day |
17.851 | 50.712 | 281604 -抗抑郁药 | Lexapro | 草酸酞 | TABLET | 10 MG | COVERED | FORMULARY | Max 20mg/day |
17.987 | 50.760 | 281604 -抗抑郁药 | Lexapro | 草酸酞 | TABLET | 20 MG | COVERED | FORMULARY | Max 20mg/day |
18.975 | 51.642 | 281604 -抗抑郁药 | Lexapro | 草酸酞 | TABLET | 5 MG | COVERED | FORMULARY | Max 20mg/day |
16.353 | 46.213 | 281604 -抗抑郁药 | Prozac | FLUOXETINE HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
16.354 | 46.214 | 281604 -抗抑郁药 | Prozac | FLUOXETINE HCL | CAPSULE | 20 MG | COVERED | FORMULARY | |
16.355 | 46.215 | 281604 -抗抑郁药 | Prozac | FLUOXETINE HCL | CAPSULE | 40 MG | COVERED | FORMULARY | |
16.348 | 46.209 | 281604 -抗抑郁药 | Fluvoxamine | 马来酸氟伏沙明 | TABLET | 50 MG | COVERED | FORMULARY | |
16.349 | 46.210 | 281604 -抗抑郁药 | Fluvoxamine | 马来酸氟伏沙明 | TABLET | 100 MG | COVERED | FORMULARY | |
16.541 | 46.068 | 281604 -抗抑郁药 | Tofranil | IMIPRAMINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
16.542 | 46.069 | 281604 -抗抑郁药 | Tofranil | IMIPRAMINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
16.543 | 46.070 | 281604 -抗抑郁药 | Tofranil | IMIPRAMINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
21.817 | 54.009 | 281604 -抗抑郁药 | Remeron | MIRTAZAPINE | TABLET | 7.5 MG | COVERED | FORMULARY | |
16.732 | 46.450 | 281604 -抗抑郁药 | Remeron | MIRTAZAPINE | TABLET | 15 MG | COVERED | FORMULARY | |
16.733 | 46.451 | 281604 -抗抑郁药 | Remeron | MIRTAZAPINE | TABLET | 30 MG | COVERED | FORMULARY | |
16.734 | 46.452 | 281604 -抗抑郁药 | Remeron | MIRTAZAPINE | TABLET | 45 MG | COVERED | FORMULARY | |
16.529 | 46.059 | 281604 -抗抑郁药 | Pamelor | NORTRIPTYLINE HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
16.532 | 46.060 | 281604 -抗抑郁药 | Pamelor | NORTRIPTYLINE HCL | CAPSULE | 25 MG | COVERED | FORMULARY | |
16.533 | 46.061 | 281604 -抗抑郁药 | Pamelor | NORTRIPTYLINE HCL | CAPSULE | 50 MG | COVERED | FORMULARY | |
16.534 | 46.062 | 281604 -抗抑郁药 | Pamelor | NORTRIPTYLINE HCL | CAPSULE | 75 MG | COVERED | FORMULARY | |
17.077 | 50.136 | 281604 -抗抑郁药 | Paxil CR | PAROXETINE HCL | TAB ER 24H | 25 MG | COVERED | FORMULARY | |
17.078 | 50.137 | 281604 -抗抑郁药 | Paxil CR | PAROXETINE HCL | TAB ER 24H | 12.5 MG | COVERED | FORMULARY | |
17.079 | 50.138 | 281604 -抗抑郁药 | Paxil CR | PAROXETINE HCL | TAB ER 24H | 37.5 MG | COVERED | FORMULARY | |
16.364 | 46.222 | 281604 -抗抑郁药 | Paxil | PAROXETINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
16.366 | 46.223 | 281604 -抗抑郁药 | Paxil | PAROXETINE HCL | TABLET | 20 MG | COVERED | FORMULARY | |
16.367 | 46.224 | 281604 -抗抑郁药 | Paxil | PAROXETINE HCL | TABLET | 30 MG | COVERED | FORMULARY | |
16.368 | 46.225 | 281604 -抗抑郁药 | Paxil | PAROXETINE HCL | TABLET | 40 MG | COVERED | FORMULARY | |
16.373 | 46.227 | 281604 -抗抑郁药 | Zoloft | SERTRALINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
16.374 | 46.228 | 281604 -抗抑郁药 | Zoloft | SERTRALINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
16.375 | 46.229 | 281604 -抗抑郁药 | Zoloft | SERTRALINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
16.391 | 46.241 | 281604 -抗抑郁药 | Trazodone | TRAZODONE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
16.392 | 46.242 | 281604 -抗抑郁药 | Trazodone | TRAZODONE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
16.393 | 46.243 | 281604 -抗抑郁药 | Trazodone | TRAZODONE HCL | TABLET | 150 MG | COVERED | FORMULARY | |
16.394 | 46.244 | 281604 -抗抑郁药 | Trazodone | TRAZODONE HCL | TABLET | 300 MG | COVERED | FORMULARY | |
16.816 | 46.403 | 281604 -抗抑郁药 | Effexor XR | VENLAFAXINE HCL | CAP ER 24H | 37.5 MG | COVERED | FORMULARY | |
16.817 | 46.404 | 281604 -抗抑郁药 | Effexor XR | VENLAFAXINE HCL | CAP ER 24H | 75 MG | COVERED | FORMULARY | |
16.818 | 46.405 | 281604 -抗抑郁药 | Effexor XR | VENLAFAXINE HCL | CAP ER 24H | 150 MG | COVERED | FORMULARY | |
16.811 | 46.398 | 281604 -抗抑郁药 | Venlafaxine | VENLAFAXINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
16.812 | 46.399 | 281604 -抗抑郁药 | Venlafaxine | VENLAFAXINE HCL | TABLET | 37.5 MG | COVERED | FORMULARY | |
16.813 | 46.400 | 281604 -抗抑郁药 | Venlafaxine | VENLAFAXINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
16.814 | 46.401 | 281604 -抗抑郁药 | Venlafaxine | VENLAFAXINE HCL | TABLET | 75 MG | COVERED | FORMULARY | |
16.815 | 46.402 | 281604 -抗抑郁药 | Venlafaxine | VENLAFAXINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
14.431 | 3.796 | 281608 -抗精神病药物 | Chlorpromazine | 盐酸氯丙嗪 | TABLET | 10 MG | COVERED | FORMULARY | |
14.432 | 3.799 | 281608 -抗精神病药物 | Chlorpromazine | 盐酸氯丙嗪 | TABLET | 25 MG | COVERED | FORMULARY | |
14.433 | 3.800 | 281608 -抗精神病药物 | Chlorpromazine | 盐酸氯丙嗪 | TABLET | 50 MG | COVERED | FORMULARY | |
14.434 | 3.797 | 281608 -抗精神病药物 | Chlorpromazine | 盐酸氯丙嗪 | TABLET | 100 MG | COVERED | FORMULARY | |
14.435 | 3.798 | 281608 -抗精神病药物 | Chlorpromazine | 盐酸氯丙嗪 | TABLET | 200 MG | COVERED | FORMULARY | |
14.602 | 3.823 | 281608 -抗精神病药物 | Fluphenazine | FLUPHENAZINE HCL | TABLET | 1 MG | COVERED | FORMULARY | |
14.603 | 3.824 | 281608 -抗精神病药物 | Fluphenazine | FLUPHENAZINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
14.604 | 3.825 | 281608 -抗精神病药物 | Fluphenazine | FLUPHENAZINE HCL | TABLET | 2.5 MG | COVERED | FORMULARY | |
14.605 | 3.826 | 281608 -抗精神病药物 | Fluphenazine | FLUPHENAZINE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
15.530 | 3.972 | 281608 -抗精神病药物 | Haloperidol | HALOPERIDOL | TABLET | 0.5 MG | COVERED | FORMULARY | |
15.531 | 3.973 | 281608 -抗精神病药物 | Haloperidol | HALOPERIDOL | TABLET | 1 MG | COVERED | FORMULARY | |
15.532 | 3.974 | 281608 -抗精神病药物 | Haloperidol | HALOPERIDOL | TABLET | 10 MG | COVERED | FORMULARY | |
15.533 | 3.975 | 281608 -抗精神病药物 | Haloperidol | HALOPERIDOL | TABLET | 2 MG | COVERED | FORMULARY | |
15.534 | 3.976 | 281608 -抗精神病药物 | Haloperidol | HALOPERIDOL | TABLET | 20 MG | COVERED | FORMULARY | |
15.535 | 3.977 | 281608 -抗精神病药物 | Haloperidol | HALOPERIDOL | TABLET | 5 MG | COVERED | FORMULARY | |
15.520 | 3.971 | 281608 -抗精神病药物 | Haloperidol | 乳酸氟哌啶醇 | ORAL CONC | 2 MG/ML | COVERED | FORMULARY | |
15.560 | 3.981 | 281608 -抗精神病药物 | Loxapine | 洛沙平琥珀酸 | CAPSULE | 10 MG | COVERED | FORMULARY | |
15.561 | 3.982 | 281608 -抗精神病药物 | Loxapine | 洛沙平琥珀酸 | CAPSULE | 25 MG | COVERED | FORMULARY | |
15.563 | 3.984 | 281608 -抗精神病药物 | Loxapine | 洛沙平琥珀酸 | CAPSULE | 50 MG | COVERED | FORMULARY | |
15.081 | 27.959 | 281608 -抗精神病药物 | Zyprexa | OLANZAPINE | TABLET | 7.5 MG | COVERED | FORMULARY | |
15.082 | 27.960 | 281608 -抗精神病药物 | Zyprexa | OLANZAPINE | TABLET | 10 MG | COVERED | FORMULARY | |
15.083 | 27.961 | 281608 -抗精神病药物 | Zyprexa | OLANZAPINE | TABLET | 5 MG | COVERED | FORMULARY | |
15.084 | 29.077 | 281608 -抗精神病药物 | Zyprexa | OLANZAPINE | TABLET | 2.5 MG | COVERED | FORMULARY | |
15.085 | 41.026 | 281608 -抗精神病药物 | Zyprexa | OLANZAPINE | TABLET | 15 MG | COVERED | FORMULARY | |
15.086 | 41.027 | 281608 -抗精神病药物 | Zyprexa | OLANZAPINE | TABLET | 20 MG | COVERED | FORMULARY | |
14.650 | 3.830 | 281608 -抗精神病药物 | Perphenazine | PERPHENAZINE | TABLET | 16 MG | COVERED | FORMULARY | |
14.651 | 3.831 | 281608 -抗精神病药物 | Perphenazine | PERPHENAZINE | TABLET | 2 MG | COVERED | FORMULARY | |
14.652 | 3.832 | 281608 -抗精神病药物 | Perphenazine | PERPHENAZINE | TABLET | 4 MG | COVERED | FORMULARY | |
14.653 | 3.833 | 281608 -抗精神病药物 | Perphenazine | PERPHENAZINE | TABLET | 8 MG | COVERED | FORMULARY | |
26.409 | 60.292 | 281608 -抗精神病药物 | Seroquel | 喹硫平延胡索酸酯 | TABLET | 50 MG | COVERED | FORMULARY | Max 800mg/day |
26.411 | 60.293 | 281608 -抗精神病药物 | Seroquel | 喹硫平延胡索酸酯 | TABLET | 400 MG | COVERED | FORMULARY | Max 800mg/day |
67.661 | 34.187 | 281608 -抗精神病药物 | Seroquel | 喹硫平延胡索酸酯 | TABLET | 25 MG | COVERED | FORMULARY | Max 800mg/day |
67.662 | 34.188 | 281608 -抗精神病药物 | Seroquel | 喹硫平延胡索酸酯 | TABLET | 100 MG | COVERED | FORMULARY | Max 800mg/day |
67.663 | 34.189 | 281608 -抗精神病药物 | Seroquel | 喹硫平延胡索酸酯 | TABLET | 200 MG | COVERED | FORMULARY | Max 800mg/day |
67.665 | 47.198 | 281608 -抗精神病药物 | Seroquel | 喹硫平延胡索酸酯 | TABLET | 300 MG | COVERED | FORMULARY | Max 800mg/day |
16.135 | 26.177 | 281608 -抗精神病药物 | Risperdal | RISPERIDONE | SOLUTION | 1 MG/ML | COVERED | FORMULARY | Max 16mg/day |
16.136 | 21.154 | 281608 -抗精神病药物 | Risperdal | RISPERIDONE | TABLET | 1 MG | COVERED | FORMULARY | Max 16mg/day |
16.137 | 21.155 | 281608 -抗精神病药物 | Risperdal | RISPERIDONE | TABLET | 2 MG | COVERED | FORMULARY | Max 16mg/day |
16.138 | 21.156 | 281608 -抗精神病药物 | Risperdal | RISPERIDONE | TABLET | 3 MG | COVERED | FORMULARY | Max 16mg/day |
16.139 | 21.157 | 281608 -抗精神病药物 | Risperdal | RISPERIDONE | TABLET | 4 MG | COVERED | FORMULARY | Max 16mg/day |
92.872 | 42.922 | 281608 -抗精神病药物 | Risperdal | RISPERIDONE | TABLET | 0.25 MG | COVERED | FORMULARY | Max 16mg/day |
92.892 | 42.923 | 281608 -抗精神病药物 | Risperdal | RISPERIDONE | TABLET | 0.5 MG | COVERED | FORMULARY | Max 16mg/day |
15.691 | 3.996 | 281608 -抗精神病药物 | Thiothixene | THIOTHIXENE | CAPSULE | 10 MG | COVERED | FORMULARY | |
15.692 | 3.997 | 281608 -抗精神病药物 | Thiothixene | THIOTHIXENE | CAPSULE | 2 MG | COVERED | FORMULARY | |
15.694 | 3.999 | 281608 -抗精神病药物 | Thiothixene | THIOTHIXENE | CAPSULE | 5 MG | COVERED | FORMULARY | |
19.880 | 5.009 | 282004 -安非他命 | Zenzedi | 硫酸右旋安非他命 | TABLET | 10 MG | COVERED | FORMULARY | Max 60mg/day |
19.881 | 5.011 | 282004 -安非他命 | Zenzedi | 硫酸右旋安非他命 | TABLET | 5 MG | COVERED | FORMULARY | Max 60mg/day |
14.635 | 48.701 | 282004 -安非他命 | Adderall XR | DEXTROAMPHETAMINE-AMPHETAMINE | CAP ER 24H | 10 MG | COVERED | FORMULARY | Max 60mg/day |
14.636 | 48.702 | 282004 -安非他命 | Adderall XR | DEXTROAMPHETAMINE-AMPHETAMINE | CAP ER 24H | 20 MG | COVERED | FORMULARY | Max 60mg/day |
14.637 | 48.703 | 282004 -安非他命 | Adderall XR | DEXTROAMPHETAMINE-AMPHETAMINE | CAP ER 24H | 30 MG | COVERED | FORMULARY | Max 60mg/day |
17.459 | 50.428 | 282004 -安非他命 | Adderall XR | DEXTROAMPHETAMINE-AMPHETAMINE | CAP ER 24H | 5 MG | COVERED | FORMULARY | Max 60mg/day |
17.468 | 50.429 | 282004 -安非他命 | Adderall XR | DEXTROAMPHETAMINE-AMPHETAMINE | CAP ER 24H | 15 MG | COVERED | FORMULARY | Max 60mg/day |
17.469 | 50.430 | 282004 -安非他命 | Adderall XR | DEXTROAMPHETAMINE-AMPHETAMINE | CAP ER 24H | 25 MG | COVERED | FORMULARY | Max 60mg/day |
29.007 | 47.131 | 282004 -安非他命 | Adderall | DEXTROAMPHETAMINE-AMPHETAMINE | TABLET | 7.5 MG | COVERED | FORMULARY | Max 60mg/day |
29.008 | 47.132 | 282004 -安非他命 | Adderall | DEXTROAMPHETAMINE-AMPHETAMINE | TABLET | 12.5 MG | COVERED | FORMULARY | Max 60mg/day |
29.009 | 47.133 | 282004 -安非他命 | Adderall | DEXTROAMPHETAMINE-AMPHETAMINE | TABLET | 15 MG | COVERED | FORMULARY | Max 60mg/day |
56.970 | 4.999 | 282004 -安非他命 | Adderall | DEXTROAMPHETAMINE-AMPHETAMINE | TABLET | 5 MG | COVERED | FORMULARY | Max 60mg/day |
56.971 | 5.000 | 282004 -安非他命 | Adderall | DEXTROAMPHETAMINE-AMPHETAMINE | TABLET | 10 MG | COVERED | FORMULARY | Max 60mg/day |
56.972 | 34.359 | 282004 -安非他命 | Adderall | DEXTROAMPHETAMINE-AMPHETAMINE | TABLET | 30 MG | COVERED | FORMULARY | Max 60mg/day |
56.973 | 5.001 | 282004 -安非他命 | Adderall | DEXTROAMPHETAMINE-AMPHETAMINE | TABLET | 20 MG | COVERED | FORMULARY | Max 60mg/day |
20.384 | 53.056 | 282032-RESPIRATORY AND CNS STIMULANTS | Metadate CD | 盐酸哌醋甲酯 | CPBP 30-70 | 10 MG | COVERED | FORMULARY | Max 100mg/day |
20.385 | 53.057 | 282032-RESPIRATORY AND CNS STIMULANTS | Metadate CD | 盐酸哌醋甲酯 | CPBP 30-70 | 20 MG | COVERED | FORMULARY | Max 100mg/day |
20.386 | 53.058 | 282032-RESPIRATORY AND CNS STIMULANTS | Metadate CD | 盐酸哌醋甲酯 | CPBP 30-70 | 30 MG | COVERED | FORMULARY | Max 100mg/day |
26.734 | 60.545 | 282032-RESPIRATORY AND CNS STIMULANTS | Metadate CD | 盐酸哌醋甲酯 | CPBP 30-70 | 40 MG | COVERED | FORMULARY | Max 100mg/day |
26.735 | 60.546 | 282032-RESPIRATORY AND CNS STIMULANTS | Metadate CD | 盐酸哌醋甲酯 | CPBP 30-70 | 50 MG | COVERED | FORMULARY | Max 100mg/day |
26.736 | 60.547 | 282032-RESPIRATORY AND CNS STIMULANTS | Metadate CD | 盐酸哌醋甲酯 | CPBP 30-70 | 60 MG | COVERED | FORMULARY | Max 100mg/day |
20.387 | 53.059 | 282032-RESPIRATORY AND CNS STIMULANTS | Ritalin LA | 盐酸哌醋甲酯 | CPBP 50-50 | 20 MG | COVERED | FORMULARY | Max 100mg/day |
20.388 | 53.060 | 282032-RESPIRATORY AND CNS STIMULANTS | Ritalin LA | 盐酸哌醋甲酯 | CPBP 50-50 | 30 MG | COVERED | FORMULARY | Max 100mg/day |
20.391 | 53.061 | 282032-RESPIRATORY AND CNS STIMULANTS | Ritalin LA | 盐酸哌醋甲酯 | CPBP 50-50 | 40 MG | COVERED | FORMULARY | Max 100mg/day |
15.911 | 4.026 | 282032-RESPIRATORY AND CNS STIMULANTS | Ritalin | 盐酸哌醋甲酯 | TABLET | 10 MG | COVERED | FORMULARY | Max 100mg/day |
15.913 | 4.028 | 282032-RESPIRATORY AND CNS STIMULANTS | Ritalin | 盐酸哌醋甲酯 | TABLET | 5 MG | COVERED | FORMULARY | Max 100mg/day |
15.920 | 4.027 | 282032-RESPIRATORY AND CNS STIMULANTS | Ritalin | 盐酸哌醋甲酯 | TABLET | 20 MG | COVERED | FORMULARY | Max 100mg/day |
16.180 | 4.029 | 282032-RESPIRATORY AND CNS STIMULANTS | 哌醋甲酯呃 | 盐酸哌醋甲酯 | TABLET ER | 20 MG | COVERED | FORMULARY | Max 100mg/day |
93.075 | 44.072 | 282032-RESPIRATORY AND CNS STIMULANTS | 哌醋甲酯呃 | 盐酸哌醋甲酯 | TABLET ER | 10 MG | COVERED | FORMULARY | Max 100mg/day |
12.956 | 3.586 | 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) | Phenobarbital | PHENOBARBITAL | ELIXIR | 20 MG/5 ML | COVERED | FORMULARY | |
12.971 | 3.589 | 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) | Phenobarbital | PHENOBARBITAL | TABLET | 15 MG | COVERED | FORMULARY | |
12.972 | 3.591 | 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) | Phenobarbital | PHENOBARBITAL | TABLET | 60 MG | COVERED | FORMULARY | |
12.973 | 3.590 | 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) | Phenobarbital | PHENOBARBITAL | TABLET | 30 MG | COVERED | FORMULARY | |
12.975 | 3.588 | 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) | Phenobarbital | PHENOBARBITAL | TABLET | 100 MG | COVERED | FORMULARY | |
97.965 | 27.611 | 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) | Phenobarbital | PHENOBARBITAL | TABLET | 32.4 MG | COVERED | FORMULARY | |
97.966 | 27.612 | 282404-BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) | Phenobarbital | PHENOBARBITAL | TABLET | 64.8 MG | COVERED | FORMULARY | |
14.260 | 3.773 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Xanax | ALPRAZOLAM | TABLET | 0.25 MG | COVERED | FORMULARY | |
14.261 | 3.774 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Xanax | ALPRAZOLAM | TABLET | 0.5 MG | COVERED | FORMULARY | |
14.262 | 3.775 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Xanax | ALPRAZOLAM | TABLET | 1 MG | COVERED | FORMULARY | |
14.263 | 15.566 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Xanax | ALPRAZOLAM | TABLET | 2 MG | COVERED | FORMULARY | |
14.031 | 3.734 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Chlordiazepoxide | 盐酸利眠宁 | CAPSULE | 10 MG | COVERED | FORMULARY | |
14.032 | 3.735 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Chlordiazepoxide | 盐酸利眠宁 | CAPSULE | 25 MG | COVERED | FORMULARY | |
14.090 | 3.744 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Tranxene | CLORAZEPATE钾 | TABLET | 15 MG | COVERED | FORMULARY | |
14.092 | 3.745 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Tranxene | CLORAZEPATE钾 | TABLET | 3.75 MG | COVERED | FORMULARY | |
14.093 | 3.746 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Tranxene | CLORAZEPATE钾 | TABLET | 7.5 MG | COVERED | FORMULARY | |
14.220 | 3.766 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Valium | DIAZEPAM | TABLET | 10 MG | COVERED | FORMULARY | |
14.221 | 3.767 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Valium | DIAZEPAM | TABLET | 2 MG | COVERED | FORMULARY | |
14.222 | 3.768 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Valium | DIAZEPAM | TABLET | 5 MG | COVERED | FORMULARY | |
14.250 | 3.691 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Flurazepam | FLURAZEPAM HCL | CAPSULE | 15 MG | COVERED | FORMULARY | |
14.251 | 3.692 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Flurazepam | FLURAZEPAM HCL | CAPSULE | 30 MG | COVERED | FORMULARY | |
14.160 | 3.757 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Ativan | LORAZEPAM | TABLET | 0.5 MG | COVERED | FORMULARY | |
14.161 | 3.758 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Ativan | LORAZEPAM | TABLET | 1 MG | COVERED | FORMULARY | |
14.162 | 3.759 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Ativan | LORAZEPAM | TABLET | 2 MG | COVERED | FORMULARY | |
14.230 | 3.769 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Oxazepam | OXAZEPAM | CAPSULE | 10 MG | COVERED | FORMULARY | |
14.231 | 3.770 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Oxazepam | OXAZEPAM | CAPSULE | 15 MG | COVERED | FORMULARY | |
14.232 | 3.771 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Oxazepam | OXAZEPAM | CAPSULE | 30 MG | COVERED | FORMULARY | |
13.840 | 3.689 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Restoril | TEMAZEPAM | CAPSULE | 15 MG | COVERED | FORMULARY | |
13.841 | 3.690 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Restoril | TEMAZEPAM | CAPSULE | 30 MG | COVERED | FORMULARY | |
13.845 | 19.182 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Restoril | TEMAZEPAM | CAPSULE | 7.5 MG | COVERED | FORMULARY | |
13.037 | 47.644 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Buspar | BUSPIRONE HCL | TABLET | 7.5 MG | COVERED | FORMULARY | |
28.890 | 3.782 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Buspar | BUSPIRONE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
28.891 | 3.781 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Buspar | BUSPIRONE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
28.892 | 27.378 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Buspar | BUSPIRONE HCL | TABLET | 15 MG | COVERED | FORMULARY | |
92.121 | 44.210 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Buspar | BUSPIRONE HCL | TABLET | 30 MG | COVERED | FORMULARY | |
13.932 | 3.725 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Hydroxyzine | HYDROXYZINE HCL | SOLUTION | 10 MG/5ML | COVERED | FORMULARY | |
13.941 | 3.726 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Hydroxyzine | HYDROXYZINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
13.943 | 3.728 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Hydroxyzine | HYDROXYZINE HCL | TABLET | 25 MG | COVERED | FORMULARY | |
13.944 | 3.729 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Hydroxyzine | HYDROXYZINE HCL | TABLET | 50 MG | COVERED | FORMULARY | |
13.951 | 3.730 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Vistaril | 羟嗪PAMOATE | CAPSULE | 100 MG | COVERED | FORMULARY | |
13.952 | 3.731 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Vistaril | 羟嗪PAMOATE | CAPSULE | 25 MG | COVERED | FORMULARY | |
13.953 | 3.732 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Vistaril | 羟嗪PAMOATE | CAPSULE | 50 MG | COVERED | FORMULARY | |
870 | 19.187 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Ambien | ZOLPIDEM TARTRATE | TABLET | 5 MG | COVERED | FORMULARY | Max 10mg/day |
871 | 19.188 | 282492-ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. | Ambien | ZOLPIDEM TARTRATE | TABLET | 10 MG | COVERED | FORMULARY | Max 10mg/day |
15.710 | 4.001 | 282800 -抗躁狂药物 | Lithium | LITHIUM CARBONATE | CAPSULE | 300 MG | COVERED | FORMULARY | |
15.711 | 4.000 | 282800 -抗躁狂药物 | Lithium | LITHIUM CARBONATE | CAPSULE | 150 MG | COVERED | FORMULARY | |
15.721 | 4.003 | 282800 -抗躁狂药物 | Lithium | LITHIUM CARBONATE | TABLET/CAPSULE | 300 MG | COVERED | FORMULARY | |
15.712 | 4.002 | 282800 -抗躁狂药物 | Lithium | LITHIUM CARBONATE | CAPSULE | 600 MG | COVERED | FORMULARY | |
15.730 | 4.005 | 282800 -抗躁狂药物 | Lithobid | LITHIUM CARBONATE | TABLET ER | 450 MG | COVERED | FORMULARY | |
15.731 | 4.004 | 282800 -抗躁狂药物 | Lithobid | LITHIUM CARBONATE | TABLET ER | 300 MG | COVERED | FORMULARY | |
50.740 | 30.735 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex Nasal | SUMATRIPTAN | SPRAY | 5 MG | COVERED | FORMULARY | Max 2 boxes/month |
50.744 | 30.742 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex Nasal | SUMATRIPTAN | SPRAY | 20 MG | COVERED | FORMULARY | Max 2 boxes/month |
24.708 | 19.239 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex Statdose | 琥珀酸舒马曲坦 | CARTRIDGE | 6 MG/0.5ML | COVERED | FORMULARY | Max 2 boxes/month |
50.741 | 19.192 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex Statdose | 琥珀酸舒马曲坦 | PEN INJCTR | 6 MG/0.5ML | COVERED | FORMULARY | Max 2 boxes/month |
5.700 | 22.479 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex | 琥珀酸舒马曲坦 | TABLET | 50 MG | COVERED | FORMULARY | 最多9片/月 |
5.701 | 17.129 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex | 琥珀酸舒马曲坦 | TABLET | 100 MG | COVERED | FORMULARY | 最多9片/月 |
5.702 | 23.799 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex | 琥珀酸舒马曲坦 | TABLET | 25 MG | COVERED | FORMULARY | 最多9片/月 |
50.742 | 19.193 | 283228-SELECTIVE SEROTONIN AGONISTS | Imitrex | 琥珀酸舒马曲坦 | VIAL | 6 MG/0.5ML | COVERED | FORMULARY | Max 2 boxes/month |
17.520 | 4.575 | 283604 -金刚烷(中枢神经系统) | Amantadine | AMANTADINE HCL | CAPSULE | 100 MG | COVERED | FORMULARY | |
17.530 | 4.576 | 283604 -金刚烷(中枢神经系统) | Amantadine | AMANTADINE HCL | SOLUTION | 50 MG/5ML | COVERED | FORMULARY | |
17.521 | 27.637 | 283604 -金刚烷(中枢神经系统) | Amantadine | AMANTADINE HCL | TABLET | 100 MG | COVERED | FORMULARY | |
17.620 | 4.589 | 283608-ANTICHOLINERGIC AGENTS (CNS) | Cogentin | 苯托品甲磺酸 | TABLET | 0.5 MG | COVERED | FORMULARY | |
17.621 | 4.590 | 283608-ANTICHOLINERGIC AGENTS (CNS) | Cogentin | 苯托品甲磺酸 | TABLET | 1 MG | COVERED | FORMULARY | |
17.622 | 4.591 | 283608-ANTICHOLINERGIC AGENTS (CNS) | Cogentin | 苯托品甲磺酸 | TABLET | 2 MG | COVERED | FORMULARY | |
17.561 | 4.581 | 283608-ANTICHOLINERGIC AGENTS (CNS) | Trihexyphenidyl | 盐酸苯海索 | TABLET | 2 MG | COVERED | FORMULARY | |
17.563 | 4.582 | 283608-ANTICHOLINERGIC AGENTS (CNS) | Trihexyphenidyl | 盐酸苯海索 | TABLET | 5 MG | COVERED | FORMULARY | |
95.079 | 41.199 | 283612-CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. | Comtan | ENTACAPONE | TABLET | 200 MG | COVERED | FORMULARY | |
23.285 | 57.987 | 283616 -多巴胺前体 | Carbidopa-Levodopa | CARBIDOPA-LEVODOPA | TAB RAPDIS | 10-100 MG | COVERED | FORMULARY | |
23.286 | 57.988 | 283616 -多巴胺前体 | Carbidopa-Levodopa | CARBIDOPA-LEVODOPA | TAB RAPDIS | 25-100 MG | COVERED | FORMULARY | |
23.287 | 57.989 | 283616 -多巴胺前体 | Carbidopa-Levodopa | CARBIDOPA-LEVODOPA | TAB RAPDIS | 25-250 MG | COVERED | FORMULARY | |
62.740 | 2.537 | 283616 -多巴胺前体 | Sinemet | CARBIDOPA-LEVODOPA | TABLET | 10-100 MG | COVERED | FORMULARY | |
62.741 | 2.538 | 283616 -多巴胺前体 | Sinemet | CARBIDOPA-LEVODOPA | TABLET | 25-100 MG | COVERED | FORMULARY | |
62.742 | 2.539 | 283616 -多巴胺前体 | Sinemet | CARBIDOPA-LEVODOPA | TABLET | 25-250 MG | COVERED | FORMULARY | |
62.591 | 16.043 | 283616 -多巴胺前体 | Sinemet CR | CARBIDOPA-LEVODOPA | TABLET ER | 50-200 MG | COVERED | FORMULARY | |
62.592 | 19.563 | 283616 -多巴胺前体 | Sinemet CR | CARBIDOPA-LEVODOPA | TABLET ER | 25-100 MG | COVERED | FORMULARY | |
26.070 | 6.603 | 283620-DOPAMINE RECEPTOR AGONISTS | Parlodel | 甲磺酸溴麦角环肽 | CAPSULE | 5 MG | COVERED | FORMULARY | |
26.081 | 6.604 | 283620-DOPAMINE RECEPTOR AGONISTS | Parlodel | 甲磺酸溴麦角环肽 | TABLET | 2.5 MG | COVERED | FORMULARY | |
26.051 | 25.738 | 283620-DOPAMINE RECEPTOR AGONISTS | Cabergoline | CABERGOLINE | TABLET | 0.5 MG | COVERED | FORMULARY | |
19.871 | 31.779 | 283620-DOPAMINE RECEPTOR AGONISTS | Mirapex | PRAMIPEXOLE | TABLET | 1 MG | COVERED | FORMULARY | |
19.872 | 31.780 | 283620-DOPAMINE RECEPTOR AGONISTS | Mirapex | PRAMIPEXOLE | TABLET | 1.5 MG | COVERED | FORMULARY | |
19.873 | 31.781 | 283620-DOPAMINE RECEPTOR AGONISTS | Mirapex | PRAMIPEXOLE | TABLET | 0.125 MG | COVERED | FORMULARY | |
19.874 | 31.782 | 283620-DOPAMINE RECEPTOR AGONISTS | Mirapex | PRAMIPEXOLE | TABLET | 0.25 MG | COVERED | FORMULARY | |
19.875 | 39.100 | 283620-DOPAMINE RECEPTOR AGONISTS | Mirapex | PRAMIPEXOLE | TABLET | 0.5 MG | COVERED | FORMULARY | |
34.100 | 29.159 | 283620-DOPAMINE RECEPTOR AGONISTS | Requip | ROPINIROLE HCL | TABLET | 0.25 MG | COVERED | FORMULARY | |
34.101 | 29.160 | 283620-DOPAMINE RECEPTOR AGONISTS | Requip | ROPINIROLE HCL | TABLET | 1 MG | COVERED | FORMULARY | |
34.102 | 29.161 | 283620-DOPAMINE RECEPTOR AGONISTS | Requip | ROPINIROLE HCL | TABLET | 2 MG | COVERED | FORMULARY | |
34.104 | 34.166 | 283620-DOPAMINE RECEPTOR AGONISTS | Requip | ROPINIROLE HCL | TABLET | 0.5 MG | COVERED | FORMULARY | |
93.038 | 43.203 | 283620-DOPAMINE RECEPTOR AGONISTS | Requip | ROPINIROLE HCL | TABLET | 4 MG | COVERED | FORMULARY | |
93.048 | 43.202 | 283620-DOPAMINE RECEPTOR AGONISTS | Requip | ROPINIROLE HCL | TABLET | 3 MG | COVERED | FORMULARY | |
3.253 | 32.492 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Namenda | MEMANTINE HCL | TABLET | 10 MG | COVERED | FORMULARY | |
20.773 | 53.324 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Namenda | MEMANTINE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
25.200 | 6.373 | 362600 -糖尿病 | True Metrix Glucose Test Strip | 血糖诊断 | STRIP | COVERED | FORMULARY | ||
25.200 | 6.373 | 362600 -糖尿病 | True Metrix Glucose Test Strip | 血糖诊断 | STRIP | COVERED | FORMULARY | ||
25.200 | 6.373 | 362600 -糖尿病 | 真矩阵测试条 | 血糖诊断 | STRIP | COVERED | FORMULARY | ||
35.600 | 8.321 | 368812-KETONES | 酮疗试纸 | 尿丙酮试纸 | STRIP | COVERED | FORMULARY | ||
35.600 | 8.321 | 368812-KETONES | 酮疗试纸 | 尿丙酮试纸 | STRIP | COVERED | FORMULARY | ||
14.950 | 8.250 | 400800 -碱化剂 | Urocit-K | 柠檬酸钾 | TABLET ER | 5 MEQ | COVERED | FORMULARY | |
14.951 | 17.000 | 400800 -碱化剂 | Urocit-K | 柠檬酸钾 | TABLET ER | 10 MEQ | COVERED | FORMULARY | |
28.095 | 65.955 | 400800 -碱化剂 | Urocit-K | 柠檬酸钾 | TABLET ER | 15 MEQ | COVERED | FORMULARY | |
10.160 | 3.143 | 401000 -氨麻药的 | Lactulose | LACTULOSE | SOLUTION | 10 G/15ML | COVERED | FORMULARY | |
10.167 | 29.054 | 401000 -氨麻药的 | Lactulose | LACTULOSE | SOLUTION | 10 G/15ML | COVERED | FORMULARY | |
30.962 | 68.217 | 401000 -氨麻药的 | Lactulose | LACTULOSE | SOLUTION | 20 G/30ML | COVERED | FORMULARY | |
30.994 | 68.243 | 401000 -氨麻药的 | Lactulose | LACTULOSE | SOLUTION | 10 G/15ML | COVERED | FORMULARY | |
3.321 | 1.248 | 401200-REPLACEMENT PREPARATIONS | 氯化钾 | 氯化钾 | CAPSULE ER | 10 MEQ | COVERED | FORMULARY | |
3.404 | 1.262 | 401200-REPLACEMENT PREPARATIONS | 氯化钾 | 氯化钾 | PACKET | 20 MEQ | COVERED | FORMULARY | |
3.512 | 22.345 | 401200-REPLACEMENT PREPARATIONS | 氯化钾 | 氯化钾 | TAB ER PRT | 10 MEQ | COVERED | FORMULARY | |
3.513 | 22.346 | 401200-REPLACEMENT PREPARATIONS | 氯化钾 | 氯化钾 | TAB ER PRT | 20 MEQ | COVERED | FORMULARY | |
3.510 | 1.275 | 401200-REPLACEMENT PREPARATIONS | 氯化钾 | 氯化钾 | TABLET ER | 10 MEQ | COVERED | FORMULARY | |
3.515 | 1.276 | 401200-REPLACEMENT PREPARATIONS | 氯化钾 | 氯化钾 | TABLET ER | 20 MEQ | COVERED | FORMULARY | |
2.373 | 588 | 401200-REPLACEMENT PREPARATIONS | Sodium Chloride For Inhalation | SODIUM CHLORIDE FOR INHALATION | VIAL-NEB | 3 % | COVERED | FORMULARY | |
98.520 | 62.746 | 401200-REPLACEMENT PREPARATIONS | Sodium Chloride For Inhalation | SODIUM CHLORIDE FOR INHALATION | VIAL-NEB | 7 % | COVERED | FORMULARY | |
930 | 1.196 | 401818-POTASSIUM-REMOVING AGENTS | Sodium Polystyrene Sulfonate | SODIUM POLYSTYRENE SULFONATE | ENEMA | 30 G/120ML | COVERED | FORMULARY | |
1.710 | 1.195 | 401818-POTASSIUM-REMOVING AGENTS | Kionex | SODIUM POLYSTYRENE SULFONATE | ORAL SUSP | 15 G/60 ML | COVERED | FORMULARY | |
13.675 | 48.241 | 401819-PHOSPHATE-REMOVING AGENTS | Phoslo | CALCIUM ACETATE | CAPSULE | 667 MG | COVERED | FORMULARY | |
99.200 | 63.473 | 401819-PHOSPHATE-REMOVING AGENTS | Renvela | SEVELAMER碳酸盐 | TABLET | 800 MG | COVERED | FORMULARY | |
16.853 | 46.485 | 401819-PHOSPHATE-REMOVING AGENTS | Renagel | SEVELAMER HCL | TABLET | 800 MG | COVERED | FORMULARY | |
21.130 | 21.406 | 402808 -循环利尿剂 | Demadex | TORSEMIDE | TABLET | 5 MG | COVERED | FORMULARY | |
21.131 | 21.407 | 402808 -循环利尿剂 | Demadex | TORSEMIDE | TABLET | 10 MG | COVERED | FORMULARY | |
21.132 | 21.408 | 402808 -循环利尿剂 | Demadex | TORSEMIDE | TABLET | 20 MG | COVERED | FORMULARY | |
21.133 | 21.409 | 402808 -循环利尿剂 | Demadex | TORSEMIDE | TABLET | 100 MG | COVERED | FORMULARY | |
34.950 | 8.206 | 402808 -循环利尿剂 | Furosemide | FUROSEMIDE | SOLUTION | 10 MG/ML | COVERED | FORMULARY | |
34.961 | 8.208 | 402808 -循环利尿剂 | Lasix | FUROSEMIDE | TABLET | 20 MG | COVERED | FORMULARY | |
34.962 | 8.209 | 402808 -循环利尿剂 | Lasix | FUROSEMIDE | TABLET | 40 MG | COVERED | FORMULARY | |
34.963 | 8.210 | 402808 -循环利尿剂 | Lasix | FUROSEMIDE | TABLET | 80 MG | COVERED | FORMULARY | |
27.700 | 8.227 | 402816-POTASSIUM-SPARING DIURETICS | Amiloride | AMILORIDE HCL | TABLET | 5 MG | COVERED | FORMULARY | |
82.341 | 8.178 | 402816-POTASSIUM-SPARING DIURETICS | Amiloride-氢氯噻嗪 | AMILORIDE-氢氯噻嗪 | TABLET | 5-50 MG | COVERED | FORMULARY | |
88.730 | 8.175 | 402816-POTASSIUM-SPARING DIURETICS | Dyazide | TRIAMTERENE-氢氯噻嗪 | CAPSULE | 50-25 MG | COVERED | FORMULARY | |
88.731 | 21.718 | 402816-POTASSIUM-SPARING DIURETICS | Dyazide | TRIAMTERENE-氢氯噻嗪 | CAPSULE | 37.5-25 MG | COVERED | FORMULARY | |
88.740 | 8.177 | 402816-POTASSIUM-SPARING DIURETICS | Triamterene-氢氯噻嗪 | TRIAMTERENE-氢氯噻嗪 | TABLET | 75-50 MG | COVERED | FORMULARY | |
88.741 | 8.176 | 402816-POTASSIUM-SPARING DIURETICS | Triamterene-氢氯噻嗪 | TRIAMTERENE-氢氯噻嗪 | TABLET | 37.5-25 MG | COVERED | FORMULARY | |
34.820 | 29.832 | 402820 -噻嗪类利尿剂 | Microzide | 氢氯噻嗪 | CAPSULE | 12.5 MG | COVERED | FORMULARY | |
842 | 28.915 | 402820 -噻嗪类利尿剂 | 氢氯噻嗪 | 氢氯噻嗪 | TABLET | 12.5 MG | COVERED | FORMULARY | |
34.824 | 8.182 | 402820 -噻嗪类利尿剂 | 氢氯噻嗪 | 氢氯噻嗪 | TABLET | 25 MG | COVERED | FORMULARY | |
34.825 | 8.183 | 402820 -噻嗪类利尿剂 | 氢氯噻嗪 | 氢氯噻嗪 | TABLET | 50 MG | COVERED | FORMULARY | |
34.982 | 8.213 | 402824-THIAZIDE-LIKE DIURETICS | Chlorthalidone | CHLORTHALIDONE | TABLET | 25 MG | COVERED | FORMULARY | |
34.984 | 8.214 | 402824-THIAZIDE-LIKE DIURETICS | Chlorthalidone | CHLORTHALIDONE | TABLET | 50 MG | COVERED | FORMULARY | |
7.310 | 8.224 | 402824-THIAZIDE-LIKE DIURETICS | Indapamide | INDAPAMIDE | TABLET | 2.5 MG | COVERED | FORMULARY | |
7.311 | 19.412 | 402824-THIAZIDE-LIKE DIURETICS | Indapamide | INDAPAMIDE | TABLET | 1.25 MG | COVERED | FORMULARY | |
34.990 | 8.216 | 402824-THIAZIDE-LIKE DIURETICS | Metolazone | METOLAZONE | TABLET | 10 MG | COVERED | FORMULARY | |
34.991 | 8.217 | 402824-THIAZIDE-LIKE DIURETICS | Metolazone | METOLAZONE | TABLET | 2.5 MG | COVERED | FORMULARY | |
34.992 | 8.218 | 402824-THIAZIDE-LIKE DIURETICS | Metolazone | METOLAZONE | TABLET | 5 MG | COVERED | FORMULARY | |
35.072 | 8.236 | 404000 -促进尿酸排泄的代理 | Probenecid | PROBENECID | TABLET | 500 MG | COVERED | FORMULARY | |
29.840 | 4.641 | 480800 - antitussives | Tessalon Perles | BENZONATATE | CAPSULE | 100 MG | COVERED | FORMULARY | |
93.007 | 44.168 | 480800 - antitussives | Tessalon Perles | BENZONATATE | CAPSULE | 200 MG | COVERED | FORMULARY | |
96.136 | 909 | 480800 - antitussives | Bromfed DM | BROMPHENIRAMINE-PSEUDOEPHEDRINE-DM | SYRUP | 2-30-10 MG/5ML | COVERED | FORMULARY | |
19.347 | 51.896 | 480800 - antitussives | Chlorpheniramine-Phenylephrine-Dextromethorphan | CHLORPHENIRAMINE-PHENYLEPHRINE-DM | LIQUID | 4-10-15 MG/5ML | COVERED | FORMULARY | |
91.713 | 45.669 | 480800 - antitussives | Cheratussin AC, Virtussin AC, Iophen-C NR | GUAIFENESIN-CODEINE PHOSPHATE | LIQUID | 100-10 MG/5ML | COVERED | FORMULARY | |
34.672 | 70.992 | 480800 - antitussives | Guaifenesin AC | GUAIFENESIN-CODEINE PHOSPHATE | LIQUID | 100-10 MG/5ML | COVERED | FORMULARY | |
13.974 | 48.492 | 480800 - antitussives | Tussionex ER | HYDROCODONE-CHLORPHENIRAMINE | SUS ER 12H | 10-8 MG/5ML | COVERED | FORMULARY | |
13.973 | 48.491 | 480800 - antitussives | Hydrocodone-Homatropine | HYDROCODONE-HOMATROPINE | SYRUP | 5-1.5 MG/5ML | COVERED | FORMULARY | |
96.041 | 846 | 480800 - antitussives | Hydrocodone-Homatropine | HYDROCODONE-HOMATROPINE | TABLET | 5-1.5 MG | COVERED | FORMULARY | |
13.975 | 48.493 | 480800 - antitussives | Promethazine-DM | PROMETHAZINE-DEXTROMETHORPHAN | SYRUP | 6.25-15 MG/5ML | COVERED | FORMULARY | |
13.978 | 48.496 | 480800 - antitussives | 异丙嗪VC可待因 | PROMETHAZINE-PHENYLEPHRINE-CODEINE | SYRUP | 6.25-5-10 MG/5ML | COVERED | FORMULARY | |
54.670 | 728 | 480800 - antitussives | Lortuss EX, Cheratussin DAC, Guaifenesin DAC | PSEUDOEPHEDRINE-CODEINE-GUAIFENESIN | SYRUP | 30-10-100 MG/5ML | COVERED | FORMULARY | |
53.636 | 21.251 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent HFA | 丙酸 | AER W/ADAP | 110 MCG | COVERED | FORMULARY | |
53.638 | 21.253 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent HFA | 丙酸 | AER W/ADAP | 44 MCG | COVERED | FORMULARY | |
53.639 | 21.483 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent HFA | 丙酸 | AER W/ADAP | 220 MCG | COVERED | FORMULARY | |
42.373 | 44.803 | 481024-LEUKOTRIENE MODIFIERS | Singulair | MONTELUKAST钠 | TAB CHEW | 4 MG | COVERED | FORMULARY | |
94.440 | 37.003 | 481024-LEUKOTRIENE MODIFIERS | Singulair | MONTELUKAST钠 | TAB CHEW | 5 MG | COVERED | FORMULARY | |
94.444 | 38.451 | 481024-LEUKOTRIENE MODIFIERS | Singulair | MONTELUKAST钠 | TABLET | 10 MG | COVERED | FORMULARY | |
69.069 | 44.694 | 481032-MAST-CELL STABLILIZERS | 色甘酸眼 | CROMOLYN SODIUM | DROPS | 0.04 | COVERED | FORMULARY | |
60.544 | 29.893 | 520200 -抗过敏药制剂 | Azelastine | AZELASTINE HCL | SPRAY/PUMP | 137 MCG | COVERED | FORMULARY | |
60.544 | 29.893 | 520200 -抗过敏药制剂 | 阿斯德林鼻喷雾剂 | AZELASTINE HCL | SPRAY/PUMP | 137 MCG | COVERED | FORMULARY | |
68.321 | 30.796 | 520200 -抗过敏药制剂 | Patanol | OLOPATADINE HCL | DROPS | 0.1 % | COVERED | FORMULARY | |
33.641 | 7.990 | 520404-ANTIBACTERIALS (EENT) | 杆菌肽眼科 | BACITRACIN | OINT. (G) | 500 UNIT/G | COVERED | FORMULARY | |
33.580 | 15.861 | 520404-ANTIBACTERIALS (EENT) | Ciloxan | CIPROFLOXACIN HCL | DROPS | 0.3 % | COVERED | FORMULARY | |
9.076 | 38.351 | 520404-ANTIBACTERIALS (EENT) | Ciloxan | CIPROFLOXACIN HCL | OINT. (G) | 0.3 % | COVERED | FORMULARY | |
20.188 | 52.911 | 520404-ANTIBACTERIALS (EENT) | Ciprodex | CIPROFLOXACIN HCL-DEXAMETHASONE | DROPS SUSP | 0.3-0.1 % | COVERED | FORMULARY | |
82.031 | 39.806 | 520404-ANTIBACTERIALS (EENT) | Cipro HC | CIPROFLOXACIN-HYDROCORTISONE | DROPS SUSP | 0.2-1 % | COVERED | FORMULARY | |
13.521 | 48.077 | 520404-ANTIBACTERIALS (EENT) | Doxycyline | 强力霉素HYCLATE | TABLET | 20 MG | COVERED | FORMULARY | |
33.540 | 7.948 | 520404-ANTIBACTERIALS (EENT) | Ilotycin | 红霉素碱 | OINT. (G) | 5 MG/G | COVERED | FORMULARY | |
33.600 | 7.984 | 520404-ANTIBACTERIALS (EENT) | Gentamicin | 硫酸庆大霉素 | DROPS | 0.3 % | COVERED | FORMULARY | |
33.590 | 7.983 | 520404-ANTIBACTERIALS (EENT) | Gentamicin | 硫酸庆大霉素 | OINT. (G) | 0.3 % | COVERED | FORMULARY | |
19.542 | 52.050 | 520404-ANTIBACTERIALS (EENT) | Vigamox | MOXIFLOXACIN HCL | DROPS | 0.5 % | COVERED | FORMULARY | |
62.265 | 18.370 | 520404-ANTIBACTERIALS (EENT) | Bactroban Nasal | MUPIROCIN CALCIUM | OINT. (G) | 2 % | COVERED | FORMULARY | |
14.283 | 48.544 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Bacitracin-Polymyxin Eye Ointment | NEOMYCIN-BACITRACIN-POLYMYXIN B | OINT. (G) | 3.5-400-10000 MG/G-UNIT/G-UNIT/G | COVERED | FORMULARY | |
14.279 | 48.543 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Bacitracin-Polymyxin-HC Eye Ointment | NEOMYCIN-BACITRACIN-POLYMYXIN B-HYDROCORTISONE | OINT. (G) | 3.5-400-10000-1 MG/G-UNIT/G-UNIT/G-% | COVERED | FORMULARY | |
14.106 | 48.618 | 520404-ANTIBACTERIALS (EENT) | Coly-Mycin S, Cortisporin TC | NEOMYCIN-COLISTIN-HYDROCORTISONE-THONZONIUM | DROPS SUSP | 3.3-3-10-0.5 MG/ML | COVERED | FORMULARY | |
14.285 | 48.546 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Polymxyin-Dexamethasone Eye Ointment | NEOMYCIN-POLYMYX B-DEXAMETHASONE | OINT. (G) | 3.5-10000-0.1 MG/G-UNIT/G-% | COVERED | FORMULARY | |
14.286 | 48.547 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Polymxyin-Dexamethasone Eye Drops | NEOMYCIN-POLYMYXIN B-DEXAMETHASONE | DROPS SUSP | 3.5-10000-0.1毫克/ ML-UNIT / ML - % | COVERED | FORMULARY | |
87.270 | 7.964 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Polymyxin-HC Eye Drops | NEOMYCIN-POLYMYXIN B-HYDROCORTISONE | DROPS SUSP | 3.5-10000-10毫克/ ML-UNIT / ML - % | COVERED | FORMULARY | |
14.025 | 48.559 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Polymyxin-HC耳 Drops | NEOMYCIN-POLYMYXIN B-HYDROCORTISONE | DROPS SUSP | 3.5-10000-1毫克/ ML-UNIT / ML - % | COVERED | FORMULARY | |
14.023 | 48.557 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Polymyxin-HC耳 | NEOMYCIN-POLYMYXIN B-HYDROCORTISONE | SOLUTION | 3.5-10000-1毫克/ ML-UNIT / ML - % | COVERED | FORMULARY | |
98.446 | 62.672 | 520404-ANTIBACTERIALS (EENT) | Neomycin-Polymyxin-Gramicidin Eye Drops | NEOMYCIN-POLYMYXN B-GRAMICIDIN | DROPS | 1.75-10000-0.025毫克/ ML-UNIT / ML-MG /毫升 | COVERED | FORMULARY | |
13.880 | 48.292 | 520404-ANTIBACTERIALS (EENT) | Ofloxacin | OFLOXACIN | DROPS | 0.3 % | COVERED | FORMULARY | |
36.600 | 19.734 | 520404-ANTIBACTERIALS (EENT) | Ofloxacin | OFLOXACIN | DROPS | 0.3 % | COVERED | FORMULARY | |
33.340 | 7.920 | 520404-ANTIBACTERIALS (EENT) | Bleph-10 | 磺胺醋酰钠 | DROPS | 10 % | COVERED | FORMULARY | |
9.384 | 38.588 | 520404-ANTIBACTERIALS (EENT) | Tobrex | TOBRAMYCIN | DROPS | 0.3 % | COVERED | FORMULARY | |
92.280 | 7.986 | 520404-ANTIBACTERIALS (EENT) | Tobradex | TOBRAMYCIN-DEXAMETHASONE | DROPS SUSP | 0.3-0.1 % | COVERED | FORMULARY | |
33.500 | 7.942 | 520420 -抗病毒药物(事件) | Viroptic | TRIFLURIDINE | DROPS | 1 % | COVERED | FORMULARY | |
34.341 | 8.101 | 520492-EENT ANTI-INFECTIVES, MISCELLANEOUS | Acetic Acid | ACETIC ACID | SOLUTION | 2 % | COVERED | FORMULARY | |
14.017 | 48.554 | 520492-EENT ANTI-INFECTIVES, MISCELLANEOUS | Acetasol HC | 醋酸ACID-HYDROCORTISONE | DROPS | 2-1 % | COVERED | FORMULARY | |
34.280 | 8.079 | 520808-CORTICOSTEROIDS (EENT) | Flunisolide | FLUNISOLIDE | SPRAY | 25 MCG | COVERED | FORMULARY | |
62.263 | 18.368 | 520808-CORTICOSTEROIDS (EENT) | Flonase | 丙酸 | SPRAY SUSP | 50 MCG | COVERED | FORMULARY | |
95.464 | 39.106 | 520808-CORTICOSTEROIDS (EENT) | Lotemax | LOTEPREDNOL ETABONATE | DROPS SUSP | 0.5 % | COVERED | FORMULARY | |
33.153 | 7.894 | 520808-CORTICOSTEROIDS (EENT) | Omnipred | 醋酸强的松 | DROPS SUSP | 1 % | COVERED | FORMULARY | |
33.150 | 7.892 | 520808-CORTICOSTEROIDS (EENT) | 醋酸强的松 | 醋酸强的松 | DROPS SUSP | 0.12 % | COVERED | FORMULARY | |
33.181 | 7.897 | 520808-CORTICOSTEROIDS (EENT) | Prednisolone Sodium Phosphate | 强的松龙sod磷酸 | DROPS | 1 % | COVERED | FORMULARY | |
33.831 | 16.008 | 520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS | 双氯芬酸钠 | 双氯芬酸钠 | DROPS | 0.1 % | COVERED | FORMULARY | |
34.360 | 7.905 | 520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS | Ocufen | FLURBIPROFEN钠 | DROPS | 0.03 % | COVERED | FORMULARY | |
20.255 | 52.960 | 520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS | Acular | KETOROLAC氨丁三醇 | DROPS | 0.4 % | COVERED | FORMULARY | |
52.700 | 19.067 | 520820-EENT NONSTEROIDAL ANTI-INFLAM. AGENTS | Acular | KETOROLAC氨丁三醇 | DROPS | 0.5 % | COVERED | FORMULARY | |
32.952 | 7.866 | 522400-MYDRIATICS | ATROPINE SULFATE | ATROPINE SULFATE | DROPS | 1% | COVERED | FORMULARY | |
32.931 | 7.864 | 522400-MYDRIATICS | ATROPINE SULFATE | ATROPINE SULFATE | OINT. (G) | 1% | COVERED | FORMULARY | |
33.031 | 7.875 | 522400-MYDRIATICS | Cyclogyl 1% | CYCLOPENTOLATE盐酸 | DROPS | 1 % | COVERED | FORMULARY | |
33.032 | 7.876 | 522400-MYDRIATICS | Cyclogyl 2% | CYCLOPENTOLATE盐酸 | DROPS | 2 % | COVERED | FORMULARY | |
36.281 | 27.882 | 524004-ALPHA-ADRENERGIC AGONISTS (EENT) | Alphagan | BRIMONIDINE酒石酸 | DROPS | 0.2 % | COVERED | FORMULARY | |
13.752 | 48.333 | 524004-ALPHA-ADRENERGIC AGONISTS (EENT) | Alphagan-P | BRIMONIDINE酒石酸 | DROPS | 0.15 % | COVERED | FORMULARY | |
33.310 | 7.858 | 524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT) | Betagan | LEVOBUNOLOL HCL | DROPS | 0.5 % | COVERED | FORMULARY | |
32.820 | 7.855 | 524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT) | Timoptic | TIMOLOL MALEATE | DROPS | 0.25 % | COVERED | FORMULARY | |
32.821 | 7.856 | 524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT) | Timoptic | TIMOLOL MALEATE | DROPS | 0.5 % | COVERED | FORMULARY | |
32.823 | 21.401 | 524008-BETA-ADRENERGIC BLOCKING AGENTS (EENT) | Timoptic-XE | TIMOLOL MALEATE | SOL-GEL | 0.5 % | COVERED | FORMULARY | |
34.700 | 8.164 | 524012-CARBONIC ANHYDRASE INHIBITORS (EENT) | Diamox Sequels | ACETAZOLAMIDE | CAPSULE ER | 500 MG | COVERED | FORMULARY | |
34.721 | 8.165 | 524012-CARBONIC ANHYDRASE INHIBITORS (EENT) | Acetazolamide | ACETAZOLAMIDE | TABLET | 125 MG | COVERED | FORMULARY | |
34.722 | 8.166 | 524012-CARBONIC ANHYDRASE INHIBITORS (EENT) | Acetazolamide | ACETAZOLAMIDE | TABLET | 250 MG | COVERED | FORMULARY | |
95.773 | 39.498 | 524012-CARBONIC ANHYDRASE INHIBITORS (EENT) | Azopt | BRINZOLAMIDE | DROPS SUSP | 1 % | COVERED | FORMULARY | |
33.380 | 23.513 | 524012-CARBONIC ANHYDRASE INHIBITORS (EENT) | Trusopt | DORZOLAMIDE HCL | DROPS | 2 % | COVERED | FORMULARY | |
95.919 | 39.531 | 524012-CARBONIC ANHYDRASE INHIBITORS (EENT) | Cosopt | DORZOLAMIDE HCL-TIMOLOL MALEATE | DROPS | 22.3-6.8 MG/1ML | COVERED | FORMULARY | |
32.704 | 7.822 | 524020-MIOTICS | Isopto Carpine | PILOCARPINE HCL | DROPS | 1 % | COVERED | FORMULARY | |
32.706 | 7.824 | 524020-MIOTICS | Isopto Carpine | PILOCARPINE HCL | DROPS | 2 % | COVERED | FORMULARY | |
32.752 | 7.826 | 524020-MIOTICS | Isopto Carpine | PILOCARPINE HCL | DROPS | 4 % | COVERED | FORMULARY | |
32.749 | 27.370 | 524028-PROSTAGLANDIN ANALOGS | Xalatan | LATANOPROST | DROPS | 0.005 % | COVERED | FORMULARY | |
32.749 | 27.370 | 524028-PROSTAGLANDIN ANALOGS | Xalatan | LATANOPROST | DROPS | 0.005 % | COVERED | FORMULARY | |
98.379 | 62.605 | 524028-PROSTAGLANDIN ANALOGS | Travoprost | TRAVOPROST(苯扎) | DROPS | 0.004% | COVERED | FORMULARY | |
7.855 | 2.661 | 560400-ANTACIDS AND ADSORBENTS | 碳酸氢钠 | 碳酸氢钠 | TABLET | 650 MG | COVERED | FORMULARY | |
65.020 | 2.839 | 560800 - antidiarrhea代理 | Lomotil | 苯乙哌啶HCL-ATROPINE | LIQUID | 2.5-0.025 MG/5ML | COVERED | FORMULARY | |
65.030 | 2.841 | 560800 - antidiarrhea代理 | Lomotil | 苯乙哌啶HCL-ATROPINE | TABLET | 2.5-0.025 MG | COVERED | FORMULARY | |
98.433 | 62.659 | 561200-CATHARTICS AND LAXATIVES | Colyte, Gavilyte | PEG 3350-NA SULF BICARB CL-KCL | SOLN RECON | 240-22.72 G | COVERED | FORMULARY | |
98.308 | 62.533 | 561200-CATHARTICS AND LAXATIVES | Golytely, Gavilyte | PEG 3350-NA SULF BICARB CL-KCL | SOLN RECON | 236-22.74 G | COVERED | FORMULARY | |
86.212 | 41.843 | 561200-CATHARTICS AND LAXATIVES | Clearlax | 聚乙二醇3350 | POWDER | 17 G/DOSE | COVERED | FORMULARY | Restricted to age <19 |
25.865 | 59.931 | 561200-CATHARTICS AND LAXATIVES | Nulytely Flavor Pack, Gavilyte N, Trilyte | SODIUM CHLORIDE-NAHCO3-KCL-PEG | SOLN RECON | 420 G | COVERED | FORMULARY | |
25.865 | 59.931 | 561200-CATHARTICS AND LAXATIVES | Nulytely, Gavilyte, Trilyte | SODIUM CHLORIDE-NAHCO3-KCL-PEG | SOLN RECON | 420 G | COVERED | FORMULARY | |
97.248 | 61.457 | 561200-CATHARTICS AND LAXATIVES | Moviprep | PEG 3350-NA SULF BICARB CL-KCL-Ascorbic acid | SOLN RECON | 100G | COVERED | FORMULARY | |
1.070 | 3.095 | 561400-CHOLELITHOLYTIC AGENTS | Actigall | URSODIOL | CAPSULE | 300 MG | COVERED | FORMULARY | |
1.072 | 24.333 | 561400-CHOLELITHOLYTIC AGENTS | Urso | URSODIOL | TABLET | 250 MG | COVERED | FORMULARY | |
17.730 | 50.628 | 561400-CHOLELITHOLYTIC AGENTS | Urso Forte | URSODIOL | TABLET | 500 MG | COVERED | FORMULARY | |
26.176 | 65.328 | 561600-DIGESTANTS | Creon | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 6K-19K-30K | NOT COVERED | PAP | Contact manufacturer for PAP |
26.177 | 65.329 | 561600-DIGESTANTS | Creon | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 12K-38K-60 | NOT COVERED | PAP | Contact manufacturer for PAP |
26.178 | 65.330 | 561600-DIGESTANTS | Creon | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 24-76-120K | NOT COVERED | PAP | Contact manufacturer for PAP |
30.217 | 67.625 | 561600-DIGESTANTS | Creon | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 3-9.5-15K | NOT COVERED | PAP | Contact manufacturer for PAP |
34.557 | 70.893 | 561600-DIGESTANTS | Creon | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 36-114-180 | NOT COVERED | PAP | Contact manufacturer for PAP |
42.317 | 76.625 | 561600-DIGESTANTS | Pancreaze | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 16.8-56.8K | NOT COVERED | PAP | Contact manufacturer for PAP |
42.318 | 76.626 | 561600-DIGESTANTS | Pancreaze | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 21 K-54.7K | NOT COVERED | PAP | Contact manufacturer for PAP |
42.319 | 76.627 | 561600-DIGESTANTS | Pancreaze | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 10.5-35.5K | NOT COVERED | PAP | Contact manufacturer for PAP |
42.324 | 76.628 | 561600-DIGESTANTS | Pancreaze | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 4.2K-14.2K | NOT COVERED | PAP | Contact manufacturer for PAP |
42.596 | 76.797 | 561600-DIGESTANTS | Pancreaze | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 2.6 K-6.2K | NOT COVERED | PAP | Contact manufacturer for PAP |
27.726 | 65.700 | 561600-DIGESTANTS | Zenpep | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 5K-17K-27K | NOT COVERED | PAP | Contact manufacturer for PAP |
27.727 | 65.701 | 561600-DIGESTANTS | Zenpep | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 10-34-55K | NOT COVERED | PAP | Contact manufacturer for PAP |
27.728 | 65.702 | 561600-DIGESTANTS | Zenpep | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 15-51-82K | NOT COVERED | PAP | Contact manufacturer for PAP |
27.729 | 65.703 | 561600-DIGESTANTS | Zenpep | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 20-68-109K | NOT COVERED | PAP | Contact manufacturer for PAP |
30.597 | 67.944 | 561600-DIGESTANTS | Zenpep | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 3K-10K-16K | NOT COVERED | PAP | Contact manufacturer for PAP |
30.598 | 67.945 | 561600-DIGESTANTS | Zenpep | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 25-85-136K | NOT COVERED | PAP | Contact manufacturer for PAP |
37.592 | 73.217 | 561600-DIGESTANTS | Zenpep | 脂肪酶、蛋白酶、淀粉酶 | CAPSULE DR | 40K-136K | NOT COVERED | PAP | Contact manufacturer for PAP |
14.761 | 3.844 | 562208-ANTIHISTAMINES (GI DRUGS) | Prochlorperazine | PROCHLORPERAZINE | SUPP.RECT | 25 MG | COVERED | FORMULARY | |
14.771 | 3.846 | 562208-ANTIHISTAMINES (GI DRUGS) | Prochlorperazine | 普鲁氯嗪顺丁烯二酸盐 | TABLET | 10 MG | COVERED | FORMULARY | |
14.773 | 3.848 | 562208-ANTIHISTAMINES (GI DRUGS) | Prochlorperazine | 普鲁氯嗪顺丁烯二酸盐 | TABLET | 5 MG | COVERED | FORMULARY | |
20.045 | 41.562 | 562220-5-HT3 RECEPTOR ANTAGONISTS | Zofran ODT | ONDANSETRON | TAB RAPDIS | 4 MG | COVERED | FORMULARY | |
20.046 | 41.563 | 562220-5-HT3 RECEPTOR ANTAGONISTS | Zofran ODT | ONDANSETRON | TAB RAPDIS | 8 MG | COVERED | FORMULARY | |
20.040 | 28.107 | 562220-5-HT3 RECEPTOR ANTAGONISTS | Zofran | ONDANSETRON HCL | SOLUTION | 4 MG/5ML | COVERED | FORMULARY | Restricted to age <19 |
20.041 | 16.392 | 562220-5-HT3 RECEPTOR ANTAGONISTS | Zofran | ONDANSETRON HCL | TABLET | 4 MG | COVERED | FORMULARY | |
20.042 | 16.393 | 562220-5-HT3 RECEPTOR ANTAGONISTS | Zofran | ONDANSETRON HCL | TABLET | 8 MG | COVERED | FORMULARY | |
45.960 | 11.676 | 562812-HISTAMINE H2-ANTAGONISTS | Pepcid | FAMOTIDINE | ORAL SUSP | 40 MG/5ML | COVERED | FORMULARY | |
46.430 | 11.677 | 562812-HISTAMINE H2-ANTAGONISTS | Pepcid | FAMOTIDINE | TABLET | 20 MG | COVERED | FORMULARY | |
46.431 | 11.678 | 562812-HISTAMINE H2-ANTAGONISTS | Pepcid | FAMOTIDINE | TABLET | 40 MG | COVERED | FORMULARY | |
8.250 | 2.767 | 562828 -前列腺素 | Cytotec | MISOPROSTOL | TABLET | 200 MCG | COVERED | FORMULARY | |
8.251 | 15.197 | 562828 -前列腺素 | Cytotec | MISOPROSTOL | TABLET | 100 MCG | COVERED | FORMULARY | |
7.651 | 16.133 | 562832 -保护剂 | Carafate | SUCRALFATE | ORAL SUSP | 1 G/10 ML | COVERED | FORMULARY | |
8.200 | 2.766 | 562832 -保护剂 | Carafate | SUCRALFATE | TABLET | 1 G | COVERED | FORMULARY | |
40.120 | 27.462 | 562836-PROTON-PUMP INHIBITORS | Protonix | PANTOPRAZOLE钠 | TABLET DR | 40 MG | COVERED | FORMULARY | |
95.976 | 39.545 | 562836-PROTON-PUMP INHIBITORS | Protonix | PANTOPRAZOLE钠 | TABLET DR | 20 MG | COVERED | FORMULARY | |
3.610 | 5.230 | 563200 - prokinetic代理 | Metoclopramide | 盐酸胃复安 | SOLUTION | 5 MG/5ML | COVERED | FORMULARY | |
34.798 | 71.108 | 563200 - prokinetic代理 | Metoclopramide | 盐酸胃复安 | SOLUTION | 10 MG/10ML | COVERED | FORMULARY | |
21.020 | 5.231 | 563200 - prokinetic代理 | Reglan | 盐酸胃复安 | TABLET | 10 MG | COVERED | FORMULARY | |
21.021 | 5.232 | 563200 - prokinetic代理 | Reglan | 盐酸胃复安 | TABLET | 5 MG | COVERED | FORMULARY | |
27.412 | 6.782 | 680400-ADRENALS | Dexamethasone | DEXAMETHASONE | DROPS | 1 MG/ML | COVERED | FORMULARY | |
27.422 | 6.784 | 680400-ADRENALS | Dexamethasone | DEXAMETHASONE | TABLET | 0.5 MG | COVERED | FORMULARY | |
27.424 | 6.787 | 680400-ADRENALS | Dexamethasone | DEXAMETHASONE | TABLET | 1 MG | COVERED | FORMULARY | |
27.425 | 6.785 | 680400-ADRENALS | Dexamethasone | DEXAMETHASONE | TABLET | 0.75 MG | COVERED | FORMULARY | |
27.426 | 6.788 | 680400-ADRENALS | Dexamethasone | DEXAMETHASONE | TABLET | 2 MG | COVERED | FORMULARY | |
27.428 | 6.789 | 680400-ADRENALS | Dexamethasone | DEXAMETHASONE | TABLET | 4 MG | COVERED | FORMULARY | |
27.429 | 6.790 | 680400-ADRENALS | Dexamethasone | DEXAMETHASONE | TABLET | 6 MG | COVERED | FORMULARY | |
27.680 | 6.812 | 680400-ADRENALS | Fludrocortisone | 醋酸氟氢可的松 | TABLET | 0.1 MG | COVERED | FORMULARY | |
26.781 | 6.703 | 680400-ADRENALS | Cortef | HYDROCORTISONE | TABLET | 10 MG | COVERED | FORMULARY | |
26.782 | 6.704 | 680400-ADRENALS | Cortef | HYDROCORTISONE | TABLET | 20 MG | COVERED | FORMULARY | |
26.783 | 6.705 | 680400-ADRENALS | Cortef | HYDROCORTISONE | TABLET | 5 MG | COVERED | FORMULARY | |
37.499 | 45.311 | 680400-ADRENALS | Medrol Dosepak | 甲基强的松龙 | TAB DS PK | 4 MG | COVERED | FORMULARY | |
27.056 | 6.741 | 680400-ADRENALS | Medrol | 甲基强的松龙 | TABLET | 4 MG | COVERED | FORMULARY | |
26.800 | 6.719 | 680400-ADRENALS | Prednisolone | PREDNISOLONE | SOLUTION | 15 MG/5 ML | COVERED | FORMULARY | |
33.806 | 47.282 | 680400-ADRENALS | Prednisolone Sodium Phosphate | 强的松龙sod磷酸 | SOLUTION | 15 MG/5 ML | COVERED | FORMULARY | |
38.363 | 45.267 | 680400-ADRENALS | Prednisone | PREDNISONE | TAB DS PK | 5 MG | COVERED | FORMULARY | |
38.364 | 45.268 | 680400-ADRENALS | Prednisone | PREDNISONE | TAB DS PK | 10 MG | COVERED | FORMULARY | |
27.171 | 6.748 | 680400-ADRENALS | Prednisone | PREDNISONE | TABLET | 1 MG | COVERED | FORMULARY | |
27.172 | 6.749 | 680400-ADRENALS | Prednisone | PREDNISONE | TABLET | 10 MG | COVERED | FORMULARY | |
27.173 | 6.750 | 680400-ADRENALS | Prednisone | PREDNISONE | TABLET | 2.5 MG | COVERED | FORMULARY | |
27.174 | 6.751 | 680400-ADRENALS | Prednisone | PREDNISONE | TABLET | 20 MG | COVERED | FORMULARY | |
27.176 | 6.753 | 680400-ADRENALS | Prednisone | PREDNISONE | TABLET | 5 MG | COVERED | FORMULARY | |
27.177 | 6.754 | 680400-ADRENALS | Prednisone | PREDNISONE | TABLET | 50 MG | COVERED | FORMULARY | |
47.851 | 45.215 | 680800-ANDROGENS | Androgel 1% | TESTOSTERONE | GEL PACKET | 25 MG(1%) | COVERED | FORMULARY | |
47.852 | 45.216 | 680800-ANDROGENS | Androgel 1% | TESTOSTERONE | GEL PACKET | 50 MG (1%) | COVERED | FORMULARY | |
18.126 | 50.831 | 681200 -避孕 | Ortho Tri-Cyclen Lo, Tri-Lo-Marzia, Tri-Lo-Sprintec, Tri-Lo-Estarylla | NORGESTIMATE-ETHINYL ESTRADIOL | TABLET | 0.18/0.215/0.25 mg - 25mcg | COVERED | FORMULARY | |
13.083 | 47.787 | 681200 -避孕 | Yasmin | ETHINYL ESTRADIOL-DROSPIRENONE | TABLET | 0.03-3 MG | COVERED | FORMULARY | |
11.530 | 3.314 | 681200 -避孕 | Altavera, Chateal, Kurvelo, Levora, Marlissa, Portia | LEVONORGESTREL-ETHINYL ESTRADIOL | TABLET | 0.15-0.03 MG | COVERED | FORMULARY | |
11.534 | 30.986 | 681200 -避孕 | Aviane, Aubra, Delyla, Falmina, Lessina, Lutera, Orsythia, Sronyx | LEVONORGESTREL-ETHINYL ESTRADIOL | TABLET | 0.1-0.02 MG | COVERED | FORMULARY | |
11.531 | 3.315 | 681200 -避孕 | 恩斯特,特里沃拉,麦兹拉 | LEVONORGESTREL-ETHINYL ESTRADIOL | TABLET | 50-30(6)/75-40(5)/125/30(10) MCG | COVERED | FORMULARY | |
11.520 | 3.313 | 681200 -避孕 | Ortho Micronor, Errin, Camila, Deblitane, Sharobel, Norlyro, Nor-Be, Jolivette, Jencycla, Heather | NORETHINDRONE | TABLET | 0.35 MG | COVERED | FORMULARY | |
11.480 | 3.304 | 681200 -避孕 | Gildess, Junel, Larin, Loestrin 21 1.5/30 | 醋酸炔诺酮-ETHINYL ESTRADIOL | TABLET | 1.5-30 MCG | COVERED | FORMULARY | |
11.481 | 3.305 | 681200 -避孕 | Gildess, Junel, Larin, Loestrin 21 1/20 | 醋酸炔诺酮-ETHINYL ESTRADIOL | TABLET | 1-20 MCG | COVERED | FORMULARY | |
11.477 | 3.298 | 681200 -避孕 | Alyacen 7/7/7, Cyclafem 7/7/7, Diasetta 7/7/7, Necon 7/7/7, Nortrel 7/7/7, Ortho-Novum 7/7/7 | NORETHINDRONE-ETHINYL ESTRADIOL | TABLET | 0.5/0.75/1 MG-35MCG | COVERED | FORMULARY | |
11.474 | 3.295 | 681200 -避孕 | Alyacen, Cyclafem, Dasetta, Necon 1/35, Nortrel 1/35, Norinyl, Ortho Novum, Primella | NORETHINDRONE-ETHINYL ESTRADIOL | TABLET | 1-0.35 MG | COVERED | FORMULARY | |
11.471 | 3.294 | 681200 -避孕 | 布雷维康,莫迪康,Necon 0.5/35, Nortrel 0.5/35, Wera | NORETHINDRONE-ETHINYL ESTRADIOL | TABLET | 0.5-0.35 MG | COVERED | FORMULARY | |
68.101 | 3.300 | 681200 -避孕 | Blisovi FE, Gildess FE, Junel FE, Larin FE, Loestrin FE 1.5/30 | NORETHINDRONE-ETHINYL ESTRADIOL-IRON | TABLET | 1.5 mg-30微克(21)/ 75毫克(7) | COVERED | FORMULARY | |
68.102 | 3.301 | 681200 -避孕 | Blisovi FE, Gildess FE, Junel FE, Larin FE, Loestrin FE 1/20 | NORETHINDRONE-ETHINYL ESTRADIOL-IRON | TABLET | 1 mg - g - McG (21)/ 75mg (7) | COVERED | FORMULARY | |
11.300 | 13.662 | 681200 -避孕 | Estarylla, Mononessa, Ortho-Cyclen, Previfem, Sprintec | NORGESTIMATE-ETHINYL ESTRADIOL | TABLET | 0.25-0.035 MG | COVERED | FORMULARY | |
11.301 | 16.963 | 681200 -避孕 | Tri-Estarylla, Tri-Mononessa, Otrho Tri-Cyclen, Tri-Previfem, Tri-Sprintec | NORGESTIMATE-ETHINYL ESTRADIOL | TABLET | 0.18/0.215/0.25 MG-35MCG(28) | COVERED | FORMULARY | |
11.500 | 3.310 | 681200 -避孕 | Low-Ogestrel, Elinest, Cryselle | NORGESTREL-ETHINYL ESTRADIOL | TABLET | 0.3 MG-30MCG | COVERED | FORMULARY | |
10.770 | 3.204 | 681604-ESTROGENS | Estrace | ESTRADIOL | TABLET | 1 MG | COVERED | FORMULARY | |
10.771 | 3.205 | 681604-ESTROGENS | Estrace | ESTRADIOL | TABLET | 2 MG | COVERED | FORMULARY | |
10.772 | 21.411 | 681604-ESTROGENS | Estrace | ESTRADIOL | TABLET | 0.5 MG | COVERED | FORMULARY | |
19.739 | 52.179 | 681604-ESTROGENS | Prempro | ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE | TABLET | 0.45-1.5 MG | COVERED | FORMULARY | |
20.769 | 53.321 | 681604-ESTROGENS | Prempro | ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE | TABLET | 0.3-1.5 MG | COVERED | FORMULARY | |
55.730 | 22.647 | 681604-ESTROGENS | Prempro | ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE | TABLET | 0.625-5 MG | COVERED | FORMULARY | |
55.731 | 22.648 | 681604-ESTROGENS | Prempro | ESTROGEN CONJUGATED-MEDROYPROGESTERONE ACETATE | TABLET | 0.625-2.5 MG | COVERED | FORMULARY | |
28.410 | 7.013 | 681604-ESTROGENS | Premarin Vaginal | 雌激素共轭 | CREAM/APPL | 0.625 MG/G | COVERED | FORMULARY | |
10.942 | 3.212 | 681604-ESTROGENS | Premarin | 雌激素共轭 | TABLET | 0.625 MG | COVERED | FORMULARY | |
10.943 | 3.211 | 681604-ESTROGENS | Premarin | 雌激素共轭 | TABLET | 0.3 MG | COVERED | FORMULARY | |
10.944 | 3.213 | 681604-ESTROGENS | Premarin | 雌激素共轭 | TABLET | 0.9 MG | COVERED | FORMULARY | |
10.945 | 3.214 | 681604-ESTROGENS | Premarin | 雌激素共轭 | TABLET | 1.25 MG | COVERED | FORMULARY | |
19.975 | 52.766 | 681604-ESTROGENS | Premarin | 雌激素共轭 | TABLET | 0.45MG | COVERED | FORMULARY | |
59.011 | 37.022 | 681612-ESTROGEN AGONIST-ANTAGONISTS | Evista | RALOXIFENE HCL | TABLET | 60 MG | COVERED | FORMULARY | |
19.578 | 52.080 | 682004 -双胍类药物 | Glucophage XR | METFORMIN HCL | TAB ER 24H | 750 MG | COVERED | FORMULARY | |
89.863 | 46.754 | 682004 -双胍类药物 | Glucophage XR | METFORMIN HCL | TAB ER 24H | 500 MG | COVERED | FORMULARY | |
10.810 | 13.318 | 682004 -双胍类药物 | Glucophage | METFORMIN HCL | TABLET | 500 MG | COVERED | FORMULARY | |
10.811 | 16.441 | 682004 -双胍类药物 | Glucophage | METFORMIN HCL | TABLET | 850 MG | COVERED | FORMULARY | |
10.857 | 40.974 | 682004 -双胍类药物 | Glucophage | METFORMIN HCL | TABLET | 1000 MG | COVERED | FORMULARY | |
92.336 | 44.341 | 682008-INSULINS | Novolog Flexpen | INSULIN ASPART | INSULN PEN | 100 UNIT/ML | COVERED | FORMULARY | |
92.326 | 44.340 | 682008-INSULINS | Novolog | INSULIN ASPART | VIAL | 100 UNIT/ML | COVERED | FORMULARY | |
17.075 | 50.134 | 682008-INSULINS | Novolog 70/30 | INSULIN ASPART PROTAMINE-INSULIN ASPART | INSULN PEN | 70-30 UNIT/ML | COVERED | FORMULARY | |
19.057 | 51.718 | 682008-INSULINS | Novolog 70/30 | INSULIN ASPART PROTAMINE-INSULIN ASPART | VIAL | 70-30 UNIT/ML | COVERED | FORMULARY | |
22.836 | 57.439 | 682008-INSULINS | Levemir Flexpen | INSULIN DETEMIR | INSULN PEN | 100 UNIT/ML | COVERED | FORMULARY | |
25.305 | 59.586 | 682008-INSULINS | Levemir | INSULIN DETEMIR | VIAL | 100 UNIT/ML | COVERED | FORMULARY | |
96.719 | 34.731 | 682008-INSULINS | Humalog Kwik Pen | INSULIN LISPRO | INSULN PEN | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | |
5.679 | 27.413 | 682008-INSULINS | Humalog | INSULIN LISPRO | VIAL | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | |
11.660 | 1.740 | 682008-INSULINS | Novolin N | 胰岛素NPH人异黄酮 | VIAL | 100 UNIT/ML | COVERED | FORMULARY | |
50.001 | 16.311 | 682008-INSULINS | Novolin 70/30 | INSULIN NPH HUM-REG INSULIN HM | VIAL | 70-30 UNIT/ML | COVERED | FORMULARY | |
93.717 | 42.076 | 682008-INSULINS | Humalog 75/25快速笔 | 胰岛素npl -胰岛素lispro | INSULN PEN | 75-25 UNIT/ML | NOT COVERED | NON-FORMULARY | |
22.681 | 47.172 | 682008-INSULINS | Humalog 75/25 | 胰岛素npl -胰岛素lispro | VIAL | 75-25 UNIT/ML | NOT COVERED | NON-FORMULARY | |
11.642 | 1.723 | 682008-INSULINS | Novolin R | 胰岛素正常人 | VIAL | 100 UNIT/ML | COVERED | FORMULARY | |
12.277 | 47.333 | 682016 - meglitinides | Starlix | NATEGLINIDE | TABLET | 60 MG | COVERED | FORMULARY | |
34.027 | 47.292 | 682016 - meglitinides | Starlix | NATEGLINIDE | TABLET | 120 MG | COVERED | FORMULARY | |
5.830 | 25.179 | 682020 -磺酰脲类药物 | Amaryl | GLIMEPIRIDE | TABLET | 1 MG | COVERED | FORMULARY | |
5.832 | 25.180 | 682020 -磺酰脲类药物 | Amaryl | GLIMEPIRIDE | TABLET | 2 MG | COVERED | FORMULARY | |
5.833 | 25.181 | 682020 -磺酰脲类药物 | Amaryl | GLIMEPIRIDE | TABLET | 4 MG | COVERED | FORMULARY | |
10.843 | 21.839 | 682020 -磺酰脲类药物 | Glucotrol XL | GLIPIZIDE | TAB ER 24 | 10 MG | COVERED | FORMULARY | |
10.844 | 21.840 | 682020 -磺酰脲类药物 | Glucotrol XL | GLIPIZIDE | TAB ER 24 | 5 MG | COVERED | FORMULARY | |
50.638 | 43.463 | 682020 -磺酰脲类药物 | Glucotrol XL | GLIPIZIDE | TAB ER 24 | 2.5 MG | COVERED | FORMULARY | |
10.840 | 1.777 | 682020 -磺酰脲类药物 | Glucotrol | GLIPIZIDE | TABLET | 5 MG | COVERED | FORMULARY | |
10.841 | 1.776 | 682020 -磺酰脲类药物 | Glucotrol | GLIPIZIDE | TABLET | 10 MG | COVERED | FORMULARY | |
18.366 | 51.194 | 682020 -磺酰脲类药物 | Glipizide-Metformin | GLIPIZIDE-METFORMIN盐酸 | TABLET | 2.5-250 MG | COVERED | FORMULARY | |
18.367 | 51.195 | 682020 -磺酰脲类药物 | Glipizide-Metformin | GLIPIZIDE-METFORMIN盐酸 | TABLET | 2.5-500 MG | COVERED | FORMULARY | |
18.368 | 51.196 | 682020 -磺酰脲类药物 | Glipizide-Metformin | GLIPIZIDE-METFORMIN盐酸 | TABLET | 5-500 MG | COVERED | FORMULARY | |
5.710 | 1.773 | 682020 -磺酰脲类药物 | Diabeta | GLYBURIDE | TABLET | 1.25 MG | COVERED | FORMULARY | |
5.711 | 1.774 | 682020 -磺酰脲类药物 | Diabeta | GLYBURIDE | TABLET | 2.5 MG | COVERED | FORMULARY | |
5.712 | 1.775 | 682020 -磺酰脲类药物 | Diabeta | GLYBURIDE | TABLET | 5 MG | COVERED | FORMULARY | |
89.878 | 45.929 | 682020 -磺酰脲类药物 | Glucovance | GLYBURIDE-METFORMIN盐酸 | TABLET | 1.25-250 MG | COVERED | FORMULARY | |
89.879 | 45.930 | 682020 -磺酰脲类药物 | Glucovance | GLYBURIDE-METFORMIN盐酸 | TABLET | 5-500 MG | COVERED | FORMULARY | |
92.889 | 22.735 | 682020 -磺酰脲类药物 | Glucovance | GLYBURIDE-METFORMIN盐酸 | TABLET | 2.5-500 MG | COVERED | FORMULARY | |
92.991 | 42.943 | 682028 - thiazolidinediones | Actos | PIOGLITAZONE HCL | TABLET | 15 MG | COVERED | FORMULARY | |
93.001 | 42.944 | 682028 - thiazolidinediones | Actos | PIOGLITAZONE HCL | TABLET | 30 MG | COVERED | FORMULARY | |
93.011 | 42.945 | 682028 - thiazolidinediones | Actos | PIOGLITAZONE HCL | TABLET | 45 MG | COVERED | FORMULARY | |
25.474 | 41.661 | 682212-GLYCOGENOLYTIC AGENTS | Glucagon | 胰高血糖素人重组蛋白 | KIT | 1 MG | NOT COVERED | NON-FORMULARY | |
25.473 | 41.660 | 682212-GLYCOGENOLYTIC AGENTS | Glucagen | 胰高血糖素人重组蛋白 | VIAL | 1 MG | COVERED | FORMULARY | |
23.281 | 24.138 | 682400 -甲状旁腺 | Miacalcin Nasal | 鲑鱼合成降钙素 | SPRAY/PUMP | 200 UNIT/SPRAY | COVERED | FORMULARY | |
26.173 | 31.610 | 682800-PITUITARY | DDAVP Nasal | DESMOPRESSIN (NONREFRIGERATED) | SPRAY/PUMP | 10 MCG/SPRAY | COVERED | FORMULARY | |
26.170 | 6.617 | 682800-PITUITARY | DDAVP | 醋酸去氨加压素 | SOLUTION | 0.1 MG/ML | COVERED | FORMULARY | |
26.171 | 19.596 | 682800-PITUITARY | DDAVP | 醋酸去氨加压素 | TABLET | 0.1 MG | COVERED | FORMULARY | |
26.172 | 19.597 | 682800-PITUITARY | DDAVP | 醋酸去氨加压素 | TABLET | 0.2 MG | COVERED | FORMULARY | |
11.260 | 3.271 | 683200 -黄体酮 | Provera | MEDROXYPROGESTERONE ACETATE | TABLET | 10 MG | COVERED | FORMULARY | |
11.261 | 3.272 | 683200 -黄体酮 | Provera | MEDROXYPROGESTERONE ACETATE | TABLET | 2.5 MG | COVERED | FORMULARY | |
11.262 | 3.273 | 683200 -黄体酮 | Provera | MEDROXYPROGESTERONE ACETATE | TABLET | 5 MG | COVERED | FORMULARY | |
11.280 | 3.274 | 683200 -黄体酮 | Aygestin | 醋酸炔诺酮 | TABLET | 5 MG | COVERED | FORMULARY | |
98.586 | 62.815 | 683200 -黄体酮 | Endometrin阴道 | 孕酮微缩 | INSERT | 100 MG | COVERED | FORMULARY | |
26.320 | 6.652 | 683604 -甲状腺制剂 | Levothyroxine | 左旋甲状腺素钠 | TABLET | 112 MCG | COVERED | FORMULARY | |
26.321 | 6.648 | 683604 -甲状腺制剂 | Levothyroxine | 左旋甲状腺素钠 | TABLET | 25 MCG | COVERED | FORMULARY | |
26.322 | 6.649 | 683604 -甲状腺制剂 | Levothyroxine | 左旋甲状腺素钠 | TABLET | 50 MCG | COVERED | FORMULARY | |
26.323 | 6.651 | 683604 -甲状腺制剂 | Levothyroxine | 左旋甲状腺素钠 | TABLET | 100 MCG | COVERED | FORMULARY | |
26.324 | 6.650 | 683604 -甲状腺制剂 | Levothyroxine | 左旋甲状腺素钠 | TABLET | 75 MCG | COVERED | FORMULARY | |
26.325 | 6.656 | 683604 -甲状腺制剂 | Levothyroxine | 左旋甲状腺素钠 | TABLET | 200 MCG | COVERED | FORMULARY | |
26.326 | 6.653 | 683604 -甲状腺制剂 | Levothyroxine | 左旋甲状腺素钠 | TABLET | 125 MCG | COVERED | FORMULARY | |
26.327 | 6.654 | 683604 -甲状腺制剂 | Levothyroxine | 左旋甲状腺素钠 | TABLET | 150 MCG | COVERED | FORMULARY | |
26.328 | 6.655 | 683604 -甲状腺制剂 | Levothyroxine | 左旋甲状腺素钠 | TABLET | 175MCG | COVERED | FORMULARY | |
26.329 | 6.657 | 683604 -甲状腺制剂 | Levothyroxine | 左旋甲状腺素钠 | TABLET | 300 MCG | COVERED | FORMULARY | |
47.631 | 15.523 | 683604 -甲状腺制剂 | Levothyroxine | 左旋甲状腺素钠 | TABLET | 88 MCG | COVERED | FORMULARY | |
47.632 | 20.176 | 683604 -甲状腺制剂 | Levothyroxine | 左旋甲状腺素钠 | TABLET | 137 MCG | COVERED | FORMULARY | |
26.340 | 6.658 | 683604 -甲状腺制剂 | Cytomel | 碘塞罗宁钠 | TABLET | 25 MCG | COVERED | FORMULARY | |
26.341 | 6.659 | 683604 -甲状腺制剂 | Cytomel | 碘塞罗宁钠 | TABLET | 5 MCG | COVERED | FORMULARY | |
26.342 | 6.660 | 683604 -甲状腺制剂 | Cytomel | 碘塞罗宁钠 | TABLET | 50 MCG | COVERED | FORMULARY | |
26.400 | 6.674 | 683608 -抗甲状腺药物 | Tapazole | METHIMAZOLE | TABLET | 10 MG | COVERED | FORMULARY | |
26.401 | 6.675 | 683608 -抗甲状腺药物 | Tapazole | METHIMAZOLE | TABLET | 5 MG | COVERED | FORMULARY | |
28.581 | 16.924 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | Cleocin Vaginal | 克林霉素磷酸酯 | CREAM/APPL | 2 % | COVERED | FORMULARY | |
45.410 | 7.726 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | Cleocin T | 克林霉素磷酸酯 | GEL (GRAM) | 1 % | COVERED | FORMULARY | |
31.770 | 11.752 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | Cleocin T | 克林霉素磷酸酯 | LOTION | 1 % | COVERED | FORMULARY | |
31.720 | 7.727 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | Cleocin T | 克林霉素磷酸酯 | SOLUTION | 1 % | COVERED | FORMULARY | |
77.562 | 29.325 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | 红霉素与乙醇 | 红霉素碱 (WITH ETHANOL) | SOLUTION | 2 % | COVERED | FORMULARY | |
43.203 | 41.799 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | Metrocream, Rosadan | METRONIDAZOLE | CREAM (G) | 0.75 % | COVERED | FORMULARY | |
24.926 | 59.325 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | Metrogel | METRONIDAZOLE | GEL (GRAM) | 1 % | COVERED | FORMULARY | |
43.202 | 41.798 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | Rosadan | METRONIDAZOLE | GEL (GRAM) | 0.75 % | COVERED | FORMULARY | |
49.261 | 16.939 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | Metrogel Vaginal | METRONIDAZOLE | GEL W/APPL | 0.75 % | COVERED | FORMULARY | |
31.774 | 68.879 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | Metrogel Pump | METRONIDAZOLE | GEL W/PUMP | 1 % | COVERED | FORMULARY | |
43.201 | 41.797 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | Metrolotion | METRONIDAZOLE | LOTION | 0.75 % | COVERED | FORMULARY | |
47.450 | 7.732 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | Bactroban | MUPIROCIN | OINT. (G) | 2 % | COVERED | FORMULARY | |
85.459 | 7.694 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | 三联抗生素软膏 | NEOMYCIN-BACITRACIN-POLYMYXIN B | OINT. (G) | 3.5-400-5000 MG/G-UNIT/G-UNIT/G | COVERED | FORMULARY | |
14.274 | 48.538 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | Cortisporin | NEOMYCIN-BACITRACIN-POLYMYXIN B-HYDROCORTISONE | OINT. (G) | 3.5-400-10000-1 MG/G-UNIT/G-UNIT/G-% | COVERED | FORMULARY | |
14.275 | 48.539 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | Cortisporin | NEOMYCIN-POLYMYXIN B-HYDROCORTISONE | CREAM (G) | 3.5-10000-0.50 MG/G-UNIT/G-% | COVERED | FORMULARY | |
62.420 | 18.315 | 840406 -抗病毒药物(皮肤 & MUCOUS MEMBRANE) | Zovirax | ACYCLOVIR | CREAM (G) | 5 % | COVERED | FORMULARY | |
31.640 | 7.670 | 840406 -抗病毒药物(皮肤 & MUCOUS MEMBRANE) | Zovirax | ACYCLOVIR | OINT. (G) | 5 % | COVERED | FORMULARY | |
12.618 | 44.922 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Ciclopirox | CICLOPIROX | GEL (GRAM) | 0.77 % | COVERED | FORMULARY | |
19.218 | 51.825 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Loprox Shampoo | CICLOPIROX | SHAMPOO | 1 % | COVERED | FORMULARY | |
8.040 | 37.020 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Ciclodan, Penlac | CICLOPIROX | SOLUTION | 8 % | COVERED | FORMULARY | |
94.677 | 40.971 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Ciclopirox Olamine | CICLOPIROX OLAMINE | CREAM (G) | 0.77 % | COVERED | FORMULARY | |
30.380 | 7.362 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Clotrimazole | CLOTRIMAZOLE | SOLUTION | 1 % | COVERED | FORMULARY | |
7.590 | 9.553 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Mycelex | CLOTRIMAZOLE | TROCHE | 10 MG | COVERED | FORMULARY | |
6.919 | 36.534 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Lotrisone | CLOTRIMAZOLE-倍他米松DIPROPIONATE | CREAM (G) | 1-0.05 % | COVERED | FORMULARY | |
14.125 | 48.627 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Clotrimazole-Betamethasone | CLOTRIMAZOLE-倍他米松DIPROPIONATE | LOTION | 1-0.05 % | COVERED | FORMULARY | |
31.850 | 7.334 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Ketoconazole | KETOCONAZOLE | CREAM (G) | 2 % | COVERED | FORMULARY | |
31.271 | 15.568 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Nizoral Shampoo | KETOCONAZOLE | SHAMPOO | 2 % | COVERED | FORMULARY | |
30.140 | 7.282 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Nystatin | NYSTATIN | CREAM (G) | 100000 UNIT/G | COVERED | FORMULARY | |
30.150 | 7.283 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Nystatin | NYSTATIN | OINT. (G) | 100000 UNIT/G | COVERED | FORMULARY | |
30.160 | 7.284 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Nystatin | NYSTATIN | POWDER | 100000 UNIT/G | COVERED | FORMULARY | |
14.007 | 48.529 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | 制霉菌素/去炎松 | NYSTATIN-TRIAMCINCINOLONE | CREAM (G) | 100000-0.1 UNIT/G-% | COVERED | FORMULARY | |
14.008 | 48.530 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | 制霉菌素/去炎松 | NYSTATIN-TRIAMCINCINOLONE | OINT. (G) | 100000-0.1 UNIT/G-% | COVERED | FORMULARY | |
48.381 | 15.931 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Terazol 3 | TERCONAZOLE | CREAM/APPL | 0.8 % | COVERED | FORMULARY | |
48.380 | 7.008 | (840408 -抗真菌治疗皮肤 & MUCOUS MEMBRANE) | Terazol 7 | TERCONAZOLE | CREAM/APPL | 0.4 % | COVERED | FORMULARY | |
31.550 | 7.650 | 840412-SCABICIDES AND PEDICULICIDES | Lindane | LINDANE | LOTION | 1 % | COVERED | FORMULARY | |
31.570 | 7.651 | 840412-SCABICIDES AND PEDICULICIDES | Lindane | LINDANE | SHAMPOO | 1 % | COVERED | FORMULARY | |
44.370 | 13.631 | 840412-SCABICIDES AND PEDICULICIDES | Elimite | PERMETHRIN | CREAM (G) | 5 % | COVERED | FORMULARY | |
44.520 | 7.663 | 840412-SCABICIDES AND PEDICULICIDES | Nix | PERMETHRIN | LIQUID | 1 % | COVERED | FORMULARY | |
31.630 | 7.669 | 840492-LOCAL ANTI-INFECTIVES, MISCELLANEOUS | Silvadene | 磺胺嘧啶银 | CREAM (G) | 1 % | COVERED | FORMULARY | |
31.060 | 7.568 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | 倍他米松Diproprionate | 倍他米松DIPROPIONATE | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
31.080 | 7.570 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | 倍他米松Diproprionate | 倍他米松DIPROPIONATE | LOTION | 0.05 % | COVERED | FORMULARY | |
31.070 | 7.569 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | 倍他米松Diproprionate | 倍他米松DIPROPIONATE | OINT. (G) | 0.05 % | COVERED | FORMULARY | |
31.101 | 7.572 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | 倍他米松戊酸酯 | 倍他米松戊酸酯 | CREAM (G) | 0.1 % | COVERED | FORMULARY | |
31.120 | 7.574 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | 倍他米松戊酸酯 | 倍他米松戊酸酯 | LOTION | 0.1 % | COVERED | FORMULARY | |
31.110 | 7.573 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | 倍他米松戊酸酯 | 倍他米松戊酸酯 | OINT. (G) | 0.1 % | COVERED | FORMULARY | |
31.890 | 7.561 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Diprolene AF | BETAMETHASONE-PROPYLENE GLYCOL | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
31.910 | 7.562 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Diprolene | BETAMETHASONE-PROPYLENE GLYCOL | OINT. (G) | 0.05 % | COVERED | FORMULARY | |
32.140 | 7.634 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Temovate | 丙酸氯倍他索 | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
34.040 | 18.288 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Clobex | 丙酸氯倍他索 | LOTION | 0.05 % | COVERED | FORMULARY | |
32.130 | 7.635 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Temovate | 丙酸氯倍他索 | OINT. (G) | 0.05 % | COVERED | FORMULARY | |
15.891 | 15.349 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Cormax | 丙酸氯倍他索 | SOLUTION | 0.05 % | COVERED | FORMULARY | |
34.141 | 21.986 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Temovate E | 丙酸氯倍他索-EMOLLIENT BASE | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
31.425 | 7.620 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Desonide | DESONIDE | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
31.430 | 7.622 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Desonide | DESONIDE | OINT. (G) | 0.05 % | COVERED | FORMULARY | |
24.484 | 58.950 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | 皮肤光滑- fs头皮油 | FLUOCINOLONE (WITH SHOWER CAP) | OIL | 0.01 % | COVERED | FORMULARY | |
85.080 | 7.507 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | 皮肤光滑的fs身体油 | 肤轻松醋酸酯 | OIL | 0.01 % | COVERED | FORMULARY | |
31.390 | 7.616 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Fluocinonide | FLUOCINONIDE | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
31.380 | 7.615 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Fluocinonide | FLUOCINONIDE | GEL (GRAM) | 0.05 % | COVERED | FORMULARY | |
31.400 | 7.617 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Fluocinonide | FLUOCINONIDE | OINT. (G) | 0.05 % | COVERED | FORMULARY | |
31.401 | 7.618 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Fluocinonide | FLUOCINONIDE | SOLUTION | 0.05 % | COVERED | FORMULARY | |
30.943 | 7.545 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Hydrocortisone | HYDROCORTISONE | CREAM (G) | 2.5 % | COVERED | FORMULARY | |
28.850 | 23.906 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Proctosol-HC, Proctozone | HYDROCORTISONE | CREAM/APPL | 2.5 % | COVERED | FORMULARY | |
66.392 | 37.045 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Cortenema, Colocort | HYDROCORTISONE | ENEMA | 100 MG/60ML | COVERED | FORMULARY | |
30.975 | 7.554 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Hydrocortisone | HYDROCORTISONE | LOTION | 2.5 % | COVERED | FORMULARY | |
30.952 | 7.548 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Hydrocortisone | HYDROCORTISONE | OINT. (G) | 2.5 % | COVERED | FORMULARY | |
66.391 | 37.044 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Cortifoam | 醋酸氢化可的松 | FOAM/APPL | 10 % | COVERED | FORMULARY | |
27.941 | 6.858 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Anusol-HC | 醋酸氢化可的松 | SUPP.RECT | 25 MG | COVERED | FORMULARY | |
31.231 | 7.593 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | CREAM (G) | 0.025 % | COVERED | FORMULARY | |
31.232 | 7.594 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | CREAM (G) | 0.1 % | COVERED | FORMULARY | |
31.233 | 7.595 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | CREAM (G) | 0.5 % | COVERED | FORMULARY | |
31.260 | 7.599 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | LOTION | 0.025 % | COVERED | FORMULARY | |
31.261 | 7.600 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | LOTION | 0.1 % | COVERED | FORMULARY | |
31.241 | 7.596 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | OINT. (G) | 0.025 % | COVERED | FORMULARY | |
31.242 | 7.597 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | OINT. (G) | 0.1 % | COVERED | FORMULARY | |
31.243 | 15.542 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | OINT. (G) | 0.05 % | COVERED | FORMULARY | |
31.244 | 7.598 | 840600-ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) | Triamcinolone | 去炎松醋酸酯 | OINT. (G) | 0.5 % | COVERED | FORMULARY | |
42.121 | 9.477 | 840800-ANTIPRURITICS AND LOCAL ANESTHETICS | Pyridium | 盐酸非那吡啶 | TABLET | 100 MG | COVERED | FORMULARY | |
42.122 | 9.478 | 840800-ANTIPRURITICS AND LOCAL ANESTHETICS | Pyridium | 盐酸非那吡啶 | TABLET | 200 MG | COVERED | FORMULARY | |
22.291 | 11.998 | 841200 -收敛剂 | Drysol | ALUMINUM CHLORIDE | SOLUTION | 20 % | COVERED | FORMULARY | |
22.880 | 5.800 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A | TRETINOIN | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
22.881 | 5.801 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A | TRETINOIN | CREAM (G) | 0.01 % | COVERED | FORMULARY | |
22.882 | 5.799 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A | TRETINOIN | CREAM (G) | 0.025 % | COVERED | FORMULARY | |
22.870 | 5.797 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A | TRETINOIN | GEL (GRAM) | 0.01 % | COVERED | FORMULARY | |
22.871 | 5.798 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A | TRETINOIN | GEL (GRAM) | 0.025 % | COVERED | FORMULARY | |
17.443 | 50.417 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A Micro | 维甲酸微球 | GEL (GRAM) | 0.04 % | COVERED | FORMULARY | |
22.874 | 30.614 | 841600-CELL STIMULANTS AND PROLIFERANTS | Retin-A Micro | 维甲酸微球 | GEL (GRAM) | 0.1 % | COVERED | FORMULARY | |
31.776 | 68.881 | 841600-CELL STIMULANTS AND PROLIFERANTS | 全反维生素a酸微泵 | 维甲酸微球 | GEL W/PUMP | 0.04 % | COVERED | FORMULARY | |
31.777 | 68.882 | 841600-CELL STIMULANTS AND PROLIFERANTS | 全反维生素a酸微泵 | 维甲酸微球 | GEL W/PUMP | 0.1 % | COVERED | FORMULARY | |
63.447 | 45.214 | 841600-CELL STIMULANTS AND PROLIFERANTS | Refissa | TRETINOIN-EMOLLIENT基地 | CREAM (G) | 0.05 % | COVERED | FORMULARY | |
22.931 | 5.813 | 842800 -角质层分离的代理 | Benzoyl Peroxide | BENZOYL PEROXIDE | GEL (GRAM) | 5 % | COVERED | FORMULARY | |
24.774 | 16.308 | 842800 -角质层分离的代理 | Urea | UREA | CREAM (G) | 40 % | COVERED | FORMULARY | |
19.198 | 51.812 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Azelaic Acid | AZELAIC ACID | Gel | 15% | COVERED | FORMULARY | |
39.274 | 74.590 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Azelaic Acid | AZELAIC ACID | FOAM | 15% | COVERED | FORMULARY | |
1.851 | 21.134 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Dovonex | CALCIPOTRIENE | CREAM (G) | 0.01 % | COVERED | FORMULARY | |
1.850 | 19.160 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Calcipotriene | CALCIPOTRIENE | OINT. (G) | 0.01 % | COVERED | FORMULARY | |
1.852 | 22.483 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Calcipotriene | CALCIPOTRIENE | SOLUTION | 0.01 % | COVERED | FORMULARY | |
30.781 | 7.502 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Efudex | FLUOROURACIL | CREAM (G) | 5 % | COVERED | FORMULARY | |
30.791 | 7.504 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Fluorouracil | FLUOROURACIL | SOLUTION | 2 % | COVERED | FORMULARY | |
30.792 | 7.505 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Fluorouracil | FLUOROURACIL | SOLUTION | 5 % | COVERED | FORMULARY | |
54.201 | 31.099 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Aldara | IMIQUIMOD | CREAM PACK | 5 % | COVERED | FORMULARY | |
15.348 | 49.724 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Elidel | PIMECROLIMUS | CREAM (G) | 1 % | COVERED | FORMULARY | |
23.450 | 30.857 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Condylox | PODOFILOX | GEL (GRAM) | 0.5 % | COVERED | FORMULARY | |
23.451 | 15.942 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Condylox | PODOFILOX | SOLUTION | 0.5 % | COVERED | FORMULARY | |
19.370 | 4.928 | 861204 - antimuscarinics | Oxybutynin | OXYBUTYNIN氯 | SYRUP | 5 MG/5 ML | COVERED | FORMULARY | |
19.388 | 41.046 | 861204 - antimuscarinics | Oxybutynin ER | OXYBUTYNIN氯 | TAB ER 24 | 5 MG | COVERED | FORMULARY | |
19.389 | 41.047 | 861204 - antimuscarinics | Oxybutynin ER | OXYBUTYNIN氯 | TAB ER 24 | 10 MG | COVERED | FORMULARY | |
93.557 | 42.606 | 861204 - antimuscarinics | Oxybutynin ER | OXYBUTYNIN氯 | TAB ER 24 | 15 MG | COVERED | FORMULARY | |
19.380 | 4.929 | 861204 - antimuscarinics | Ditropan | OXYBUTYNIN氯 | TABLET | 5 MG | COVERED | FORMULARY | |
410 | 90 | 861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS | Theophylline ER | 茶碱无水 | TAB ER 12H | 100 MG | COVERED | FORMULARY | |
411 | 91 | 861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS | Theophylline ER | 茶碱无水 | TAB ER 12H | 200 MG | COVERED | FORMULARY | |
413 | 93 | 861600-RESPIRATORY SMOOTH MUSCLE RELAXANTS | Theophylline ER | 茶碱无水 | TAB ER 12H | 300 MG | COVERED | FORMULARY | |
94.481 | 2.184 | 881600-VITAMIN D | Rocaltrol | CALCITRIOL | CAPSULE | 0.25 MCG | COVERED | FORMULARY | |
94.482 | 2.185 | 881600-VITAMIN D | Rocaltrol | CALCITRIOL | CAPSULE | 0.5 MCG | COVERED | FORMULARY | |
98.425 | 62.651 | 881600-VITAMIN D | Cholecalciferol (Vitamin D3) | CHOLECALCIFEROL (VITAMIN D3) | CAPSULE | 50000 UNIT | COVERED | FORMULARY | |
94.422 | 2.169 | 881600-VITAMIN D | Drisdol | ERGOCALCIFEROL (VITAMIN D2) | CAPSULE | 50000 UNIT | COVERED | FORMULARY | |
94.711 | 2.305 | 882400维生素k活性 | Mephyton | PHYTONADIONE | TABLET | 5 MG | COVERED | FORMULARY | |
2.881 | 1.192 | 920400 -酒精威慑 | Antabuse | DISULFIRAM | TABLET | 250 MG | COVERED | FORMULARY | |
30.521 | 41.440 | 920800-5-ALPHA-REDUCTASE INHIBITORS | Proscar | FINASTERIDE | TABLET | 5 MG | COVERED | FORMULARY | |
7.070 | 2.535 | 921600 - antigout代理 | Zyloprim | ALLOPURINOL | TABLET | 100 MG | COVERED | FORMULARY | |
7.071 | 2.536 | 921600 - antigout代理 | Zyloprim | ALLOPURINOL | TABLET | 300 MG | COVERED | FORMULARY | |
35.674 | 8.334 | 921600 - antigout代理 | Colcrys | COLCHICINE | TABLET | 0.6 MG | COVERED | FORMULARY | Max 6 tablets/month, Enroll in PAP for more. |
12.389 | 47.381 | 922400-BONE RESORPTION INHIBITORS | Fosamax | ALENDRONATE钠 | TABLET | 35 MG | COVERED | FORMULARY | |
21.680 | 24.053 | 922400-BONE RESORPTION INHIBITORS | Fosamax | ALENDRONATE钠 | TABLET | 10 MG | COVERED | FORMULARY | |
21.682 | 31.006 | 922400-BONE RESORPTION INHIBITORS | Fosamax | ALENDRONATE钠 | TABLET | 5 MG | COVERED | FORMULARY | |
85.361 | 46.941 | 922400-BONE RESORPTION INHIBITORS | Fosamax | ALENDRONATE钠 | TABLET | 70 MG | COVERED | FORMULARY | |
67.031 | 40.549 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Arava | LEFLUNOMIDE | TABLET | 10 MG | COVERED | FORMULARY | |
67.032 | 40.550 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Arava | LEFLUNOMIDE | TABLET | 20 MG | COVERED | FORMULARY | |
46.771 | 11.682 | 924400-IMMUNOSUPPRESSIVE AGENTS | Imuran | AZATHIOPRINE | TABLET | 50 MG | COVERED | FORMULARY | |
94.200 | 62.137 | 940000-DEVICES | 真正的矩阵3级 | BLOOD-GLUCOSE CONTROL HIGH | EACH | COVERED | FORMULARY | ||
94.200 | 62.137 | 940000-DEVICES | 真矩阵1级 | 血糖控制低 | EACH | COVERED | FORMULARY | ||
94.200 | 62.137 | 940000-DEVICES | 真正的矩阵2级 | BLOOD-GLUCOSE CONTROL NORMAL | EACH | COVERED | FORMULARY | ||
94.200 | 19.413 | 940000-DEVICES | True Metrix血糖仪 | 血糖仪 | EACH | COVERED | FORMULARY | ||
94.200 | 19.413 | 940000-DEVICES | True Metrix血糖仪 | 血糖仪 | EACH | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | 航空舱加上Flow-Vu | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | 航空舱加上Flow-Vu Mask, Large | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | 航空舱加上Flow-Vu Mask, Medium | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | 航空舱加上Flow-Vu Mask, Small | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Optichamber Diamond VHC | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Optichamber Diamond VHC with Large Mask | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Optichamber Diamond VHC with Medium Mask | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 21.900 | 940000-DEVICES | Optichamber Diamond VHC with Small Mask | 吸入辅助装置 | SPACER | COVERED | FORMULARY | ||
94.200 | 64.800 | 940000-DEVICES | Optichamber大面罩 | INHALER ASSIST DEVICE ACCESORY | EACH | COVERED | FORMULARY | ||
94.200 | 64.800 | 940000-DEVICES | Optichamber介质掩膜 | INHALER ASSIST DEVICE ACCESORY | EACH | COVERED | FORMULARY | ||
94.200 | 70.184 | 940000-DEVICES | True Plus Lancet 28G | LANCETS | EACH | 28 GAUGE | COVERED | FORMULARY | |
94.200 | 70.013 | 940000-DEVICES | True Plus Lancet 30G | LANCETS | EACH | 30 GAUGE | COVERED | FORMULARY | |
94.200 | 70.013 | 940000-DEVICES | True Plus Lancet 30G | LANCETS | EACH | 30 GAUGE | COVERED | FORMULARY | |
94.200 | 70.012 | 940000-DEVICES | True Plus Lancet 33G | LANCETS | EACH | 33 GAUGE | COVERED | FORMULARY | |
94.200 | 70.012 | 940000-DEVICES | True Plus Lancet 33G | LANCETS | EACH | 33 GAUGE | COVERED | FORMULARY | |
94.200 | 70.184 | 940000-DEVICES | 真正的PlusLancet 28G | LANCETS | EACH | 28 GAUGE | COVERED | FORMULARY | |
94.200 | 70.184 | 940000-DEVICES | 真正的PlusLancet 28G | LANCETS | EACH | 28 GAUGE | COVERED | FORMULARY | |
94.200 | 65.779 | 940000-DEVICES | True Plus Lancing Device | LANCING DEVICE | EACH | COVERED | FORMULARY | ||
94.200 | 65.779 | 940000-DEVICES | True Plus Lancing Device | LANCING DEVICE | EACH | COVERED | FORMULARY | ||
94.200 | 16.606 | 940000-DEVICES | Peak Flow Meter | PEAK FLOW METER | EACH | COVERED | FORMULARY | ||
94.200 | 16.606 | 940000-DEVICES | Peak Flow Meter | PEAK FLOW METER | EACH | COVERED | FORMULARY | ||
94.200 | 16.606 | 940000-DEVICES | Peak Flow Meter | PEAK FLOW METER | EACH | COVERED | FORMULARY | ||
94.200 | 49.235 | 940000-DEVICES | 钢笔针29g X 1/2” | 钢笔针糖尿病患者 | DIS NEEDLE | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.235 | 940000-DEVICES | 钢笔针29g X 1/2” | 钢笔针糖尿病患者 | DIS NEEDLE | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.235 | 940000-DEVICES | 钢笔针29g X 1/2” | 钢笔针糖尿病患者 | DIS NEEDLE | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.235 | 940000-DEVICES | 钢笔针29g X 1/2” | 钢笔针糖尿病患者 | DIS NEEDLE | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.235 | 940000-DEVICES | 钢笔针29g X 1/2” | 钢笔针糖尿病患者 | DIS NEEDLE | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 61.638 | 940000-DEVICES | 钢笔针30g x 1/3” | 钢笔针糖尿病患者 | DIS NEEDLE | 30 G X 1/3" | COVERED | FORMULARY | |
94.200 | 61.638 | 940000-DEVICES | 钢笔针30g x 1/3” | 钢笔针糖尿病患者 | DIS NEEDLE | 30 G X 1/3" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | 钢笔针31g x 1/4” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | 钢笔针31g x 1/4” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | 钢笔针31g x 1/4” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | 钢笔针31g x 1/4” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | 钢笔针31g x 1/4” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | 钢笔针31g x 1/4” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | 钢笔针31g x 1/4” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | 钢笔针31g x 1/4” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | 钢笔针31g x 1/4” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 50.622 | 940000-DEVICES | 钢笔针31g x 1/4” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 1/4" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | 钢笔针31g × 3/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | 钢笔针31g × 3/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | 钢笔针31g × 3/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | 钢笔针31g × 3/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | 钢笔针31g × 3/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | 钢笔针31g × 3/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | 钢笔针31g × 3/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 60.904 | 940000-DEVICES | 钢笔针31g × 3/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 3/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.240 | 940000-DEVICES | 钢笔针31g × 5/16” | 钢笔针糖尿病患者 | DIS NEEDLE | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 62.868 | 940000-DEVICES | 钢笔针32g × 1/4” | 钢笔针糖尿病患者 | DIS NEEDLE | 32 G X 1/4" | COVERED | FORMULARY | |
94.200 | 66.936 | 940000-DEVICES | 钢笔针32g X 1/5” | 钢笔针糖尿病患者 | DIS NEEDLE | 32 G X 1/5" | COVERED | FORMULARY | |
94.200 | 72.859 | 940000-DEVICES | 钢笔针32g × 1/6” | 钢笔针糖尿病患者 | DIS NEEDLE | 32 G X 1/6" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | 钢笔针32g × 5/32” | 钢笔针糖尿病患者 | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | 钢笔针32g × 5/32” | 钢笔针糖尿病患者 | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | 钢笔针32g × 5/32” | 钢笔针糖尿病患者 | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | 钢笔针32g × 5/32” | 钢笔针糖尿病患者 | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | 钢笔针32g × 5/32” | 钢笔针糖尿病患者 | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | 钢笔针32g × 5/32” | 钢笔针糖尿病患者 | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 66.308 | 940000-DEVICES | 钢笔针32g × 5/32” | 钢笔针糖尿病患者 | DIS NEEDLE | 32G X 5/32" | COVERED | FORMULARY | |
94.200 | 62.772 | 940000-DEVICES | 钢笔针30g x 1/3” | 钢笔针糖尿病患者 SAFETY | DIS NEEDLE | 30 G X 1/3" | COVERED | FORMULARY | |
94.200 | 49.277 | 940000-DEVICES | 胰岛素注射器0.3mL 29 G x 1/2" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.277 | 940000-DEVICES | 胰岛素注射器0.3mL 29 G x 1/2" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.277 | 940000-DEVICES | 胰岛素注射器0.3mL 29 G x 1/2" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.399 | 940000-DEVICES | 胰岛素注射器0.3mL 30 G x 1/2" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 30G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.399 | 940000-DEVICES | 胰岛素注射器0.3mL 30 G x 1/2" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 30G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.394 | 940000-DEVICES | 胰岛素注射器0.3mL 30 G x 5/16" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.394 | 940000-DEVICES | 胰岛素注射器0.3mL 30 G x 5/16" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.394 | 940000-DEVICES | 胰岛素注射器0.3mL 30 G x 5/16" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.394 | 940000-DEVICES | 胰岛素注射器0.3mL 30 G x 5/16" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.394 | 940000-DEVICES | 胰岛素注射器0.3mL 30 G x 5/16" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.394 | 940000-DEVICES | 胰岛素注射器0.3mL 30 G x 5/16" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.394 | 940000-DEVICES | 胰岛素注射器0.3mL 30 G x 5/16" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | 胰岛素注射器0.3mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | 胰岛素注射器0.3mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | 胰岛素注射器0.3mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | 胰岛素注射器0.3mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | 胰岛素注射器0.3mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | 胰岛素注射器0.3mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | 胰岛素注射器0.3mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.403 | 940000-DEVICES | 胰岛素注射器0.3mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.3 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | 胰岛素注射器0.5mL 28GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | 胰岛素注射器0.5mL 28GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | 胰岛素注射器0.5mL 28GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | 胰岛素注射器0.5mL 28GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | 胰岛素注射器0.5mL 28GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | 胰岛素注射器0.5mL 28GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | 胰岛素注射器0.5mL 29 G X1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | 胰岛素注射器0.5mL 29 G X1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | 胰岛素注射器0.5mL 29 G X1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | 胰岛素注射器0.5mL 29 G X1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | 胰岛素注射器0.5mL 29 G X1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | 胰岛素注射器0.5mL 29 G X1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | 胰岛素注射器0.5mL 29 G X1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | 胰岛素注射器0.5mL 30GX 5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | 胰岛素注射器0.5mL 30GX 5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | 胰岛素注射器0.5mL 30GX 5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | 胰岛素注射器0.5mL 30GX 5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | 胰岛素注射器0.5mL 30GX 5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | 胰岛素注射器0.5mL 30GX 5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | 胰岛素注射器0.5mL 30GX 5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.400 | 940000-DEVICES | 胰岛素注射器0.5mL 30GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.400 | 940000-DEVICES | 胰岛素注射器0.5mL 30GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.400 | 940000-DEVICES | 胰岛素注射器0.5mL 30GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.400 | 940000-DEVICES | 胰岛素注射器0.5mL 30GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | 胰岛素注射器0.5mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | 胰岛素注射器0.5mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | 胰岛素注射器0.5mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | 胰岛素注射器0.5mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | 胰岛素注射器0.5mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | 胰岛素注射器0.5mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | 胰岛素注射器0.5mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | 胰岛素注射器0.5mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | 胰岛素注射器0.5mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 28 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 29 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.358 | 940000-DEVICES | Insulin Syringe 1mL 30GX 5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 30 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.401 | 940000-DEVICES | Insulin Syringe 1mL 30GX1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.401 | 940000-DEVICES | Insulin Syringe 1mL 30GX1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.401 | 940000-DEVICES | Insulin Syringe 1mL 30GX1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 30 G X 1/2" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 31 G X 5/16" | COVERED | FORMULARY | |
33.118 | 28.142 | 081206 -头孢菌素 | Suprax Capsule | CEFIXIME | CAPSULE | 400 MG | COVERED | FORMULARY | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy. Quantity limit #1 capsule/ prescription. |
33.120 | 9.182 | 081206 -头孢菌素 | Suprax Suspension | CEFIXIME | SUSP RECON | 100 MG/5ML | NOT COVERED | NON-FORMULARY | 规定:Cefdinir |
92.368 | 44.428 | 081206 -头孢菌素 | Suprax Suspension | CEFIXIME | SUSP RECON | 200 MG/5ML | NOT COVERED | NON-FORMULARY | 规定:Cefdinir |
34.277 | 70.665 | 081206 -头孢菌素 | Suprax Suspension | CEFIXIME | SUSP RECON | 500 MG/5ML | NOT COVERED | NON-FORMULARY | 规定:Cefdinir |
33.445 | 70.122 | 081206 -头孢菌素 | Suprax Chewable | CEFIXIME | TAB CHEW | 100 MG | NOT COVERED | NON-FORMULARY | 规定:Cefdinir |
33.446 | 70.123 | 081206 -头孢菌素 | Suprax Chewable | CEFIXIME | TAB CHEW | 200 MG | NOT COVERED | NON-FORMULARY | 规定:Cefdinir |
33.110 | 081206 -头孢菌素 | Suprax Tablet | CEFIXIME | TABLET | 400 MG | NOT COVERED | NON-FORMULARY | 规定:Cefdinir | |
26.871 | 45.132 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Zyvox Suspension | LINEZOLID | SUSP RECON | 100 MG/5ML | NOT COVERED | NON-FORMULARY | |
26.870 | 45.131 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Zyvox Tablet | LINEZOLID | TABLET | 600 MG | NOT COVERED | NON-FORMULARY | |
33.787 | 70.295 | 081408-AZOLES | Onmel | ITRACONAZOLE | CAPSULE | 200 MG | NOT COVERED | NON-FORMULARY | |
55.389 | 21.871 | 083600-URINARY ANTI-INFECTIVES | Monurol | 磷霉素氨丁三醇 | PACKET | 3 G | NOT COVERED | NON-FORMULARY | |
74.040 | 4.773 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Donnatal Elixir | PHENOBARBITAL-HYOSCYAMINE-ATROPINE-SCOPOLAMINE | ELIXIR | 16.2-0.1037-0.0194 MG/5ML | NOT COVERED | NON-FORMULARY | |
74.070 | 4.777 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Donnatal | PHENOBARBITAL-HYOSCYAMINE-ATROPINE-SCOPOLAMINE | TABLET | 16.2-0.1037-0.0194 MG | NOT COVERED | NON-FORMULARY | |
28.038 | 65.912 | 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS | Adrenaclick | EPINEPHRINE | AUTO INJCT | 0.15 MG/0.15ML | NOT COVERED | NON-FORMULARY | Formulary: Epinephrine generic |
19.861 | 16.878 | 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS | Epipen Jr. | EPINEPHRINE | AUTO INJCT | 0.15 MG/0.3ML | NOT COVERED | NON-FORMULARY | Formulary: Epinephrine generic |
19.862 | 16.879 | 121212-ALPHA- AND BETA-ADRENERGIC AGONISTS | Epipen, Adrenaclick | EPINEPHRINE | AUTO INJCT | 0.3 MG/0.3ML | NOT COVERED | NON-FORMULARY | Formulary: Epinephrine generic |
17.912 | 4.663 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Soma | CARISOPRODOL | TABLET | 350 MG | NOT COVERED | NON-FORMULARY | Formulary: Cyclobenzaprine, methocarbamol, and tizanidine |
91.765 | 51.112 | 122004-CENTRALLY ACTING SKELETAL MUSCLE RELAXNT | Skelaxin | METAXALONE | TABLET | 800 MG | NOT COVERED | NON-FORMULARY | Formulary: Cyclobenzaprine, methocarbamol, and tizanidine |
19.153 | 51.784 | 240608-HMG-COA REDUCTASE INHIBITORS | Crestor | 伐钙 | TABLET | 10 MG | COVERED | FORMULARY | |
19.154 | 51.785 | 240608-HMG-COA REDUCTASE INHIBITORS | Crestor | 伐钙 | TABLET | 20 MG | COVERED | FORMULARY | |
19.155 | 51.786 | 240608-HMG-COA REDUCTASE INHIBITORS | Crestor | 伐钙 | TABLET | 40 MG | COVERED | FORMULARY | |
20.229 | 52.944 | 240608-HMG-COA REDUCTASE INHIBITORS | Crestor | 伐钙 | TABLET | 5 MG | COVERED | FORMULARY | |
23.929 | 58.486 | 240692-ANTILIPEMIC AGENTS, MISCELLANEOUS | Lovaza | Omega-3酸乙酯 | CAPSULE | 1 G | NOT COVERED | NON-FORMULARY | 规定:非诺贝特 |
73.542 | 37.015 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Atacand | 坎地沙坦CILEXETIL | TABLET | 4 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
73.543 | 37.016 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Atacand | 坎地沙坦CILEXETIL | TABLET | 8 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
73.544 | 37.017 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Atacand | 坎地沙坦CILEXETIL | TABLET | 16 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
73.545 | 40.659 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Atacand | 坎地沙坦CILEXETIL | TABLET | 32 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
13.258 | 64.285 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Atacand HCT | CANDESARTAN/HYDROCHLOROTHIAZID | TABLET | 32MG-25MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
21.559 | 45.425 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Atacand HCT | CANDESARTAN/HYDROCHLOROTHIAZID | TABLET | 16-12.5MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
21.569 | 46.624 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Atacand HCT | CANDESARTAN/HYDROCHLOROTHIAZID | TABLET | 32-12.5MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
23.831 | 40.910 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Micardis | TELMISARTAN | TABLET | 40 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
23.832 | 40.911 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Micardis | TELMISARTAN | TABLET | 80 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
23.833 | 47.126 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Micardis | TELMISARTAN | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
27.783 | 65.746 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Twynsta | 替米沙坦/氨氯地平 | TABLET | 40 MG-5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
27.784 | 65.747 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Twynsta | 替米沙坦/氨氯地平 | TABLET | 40 MG-10MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
27.785 | 65.748 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Twynsta | 替米沙坦/氨氯地平 | TABLET | 80 MG-5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
27.786 | 65.749 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Twynsta | 替米沙坦/氨氯地平 | TABLET | 80 MG-10MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
12.257 | 47.326 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Micardis HCT | TELMISARTAN/HYDROCHLOROTHIAZID | TABLET | 40-12.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
12.259 | 47.324 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Micardis HCT | TELMISARTAN/HYDROCHLOROTHIAZID | TABLET | 80-12.5MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
22.866 | 57.690 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Micardis HCT | TELMISARTAN/HYDROCHLOROTHIAZID | TABLET | 80 MG-25MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan |
19.200 | 15.880 | 280808 -阿片受体激动剂 | Duragesic | FENTANYL | PATCH TD72 | 25 MCG/HR | NOT COVERED | NON-FORMULARY | 规定:吗啡 |
19.201 | 15.881 | 280808 -阿片受体激动剂 | Duragesic | FENTANYL | PATCH TD72 | 50MCG/HR | NOT COVERED | NON-FORMULARY | 规定:吗啡 |
19.202 | 15.882 | 280808 -阿片受体激动剂 | Duragesic | FENTANYL | PATCH TD72 | 75MCG/HR | NOT COVERED | NON-FORMULARY | 规定:吗啡 |
19.203 | 15.883 | 280808 -阿片受体激动剂 | Duragesic | FENTANYL | PATCH TD72 | 100 MCG/HR | NOT COVERED | NON-FORMULARY | 规定:吗啡 |
16.281 | 15.065 | 280808 -阿片受体激动剂 | Oxyocodone集中 | OXYCODONE HCL | ORAL CONC | 20 MG/ML | NOT COVERED | NON-FORMULARY | 规定:吗啡 |
16.280 | 4.224 | 280808 -阿片受体激动剂 | 羟考酮溶液 | OXYCODONE HCL | SOLUTION | 5 MG/5 ML | NOT COVERED | NON-FORMULARY | 规定:吗啡 |
41.853 | 76.361 | 280808 -阿片受体激动剂 | 羟考酮口服注射器 | OXYCODONE HCL | SYRINGE | 10MG/0.5ML | NOT COVERED | NON-FORMULARY | 规定:吗啡 |
16.291 | 13.467 | 280808 -阿片受体激动剂 | Oxyocodone | OXYCODONE HCL | TABLET | 10 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
20.091 | 46.474 | 280808 -阿片受体激动剂 | Oxyocodone | OXYCODONE HCL | TABLET | 15 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
21.194 | 45.298 | 280808 -阿片受体激动剂 | Oxyocodone | OXYCODONE HCL | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
20.092 | 46.475 | 280808 -阿片受体激动剂 | Oxyocodone | OXYCODONE HCL | TABLET | 30 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
32.047 | 69.101 | 280808 -阿片受体激动剂 | Oxaydo | OXYCODONE HCL | TABLET ORL | 5 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
31.256 | 68.467 | 280808 -阿片受体激动剂 | Oxaydo | OXYCODONE HCL | TABLET ORL | 7.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Oxycodone 5 mg, Morphine |
64.672 | 29.312 | 280812-OPIATE PARTIAL AGONISTS | Buprenorphine | 盐酸丁丙诺啡 | TAB SUBL | 2 MG | COVERED | FORMULARY | |
64.673 | 29.313 | 280812-OPIATE PARTIAL AGONISTS | Buprenorphine | 盐酸丁丙诺啡 | TAB SUBL | 8 MG | COVERED | FORMULARY | |
33.744 | 70.262 | 280812-OPIATE PARTIAL AGONISTS | Suboxone Film | 盐酸丁丙诺啡/NALOXONE HCL | Subl Film | 12 MG-3 MG | COVERED | FORMULARY | |
28.958 | 66.635 | 280812-OPIATE PARTIAL AGONISTS | Suboxone Film | 盐酸丁丙诺啡/NALOXONE HCL | Subl Film | 2 MG-0.5MG | COVERED | FORMULARY | |
33.741 | 70.259 | 280812-OPIATE PARTIAL AGONISTS | Suboxone Film | 盐酸丁丙诺啡/NALOXONE HCL | Subl Film | 4MG-1MG | COVERED | FORMULARY | |
28.959 | 66.636 | 280812-OPIATE PARTIAL AGONISTS | Suboxone Film | 盐酸丁丙诺啡/NALOXONE HCL | Subl Film | 8 MG-2 MG | COVERED | FORMULARY | |
18.973 | 51.640 | 280812-OPIATE PARTIAL AGONISTS | Suboxone Tablet | 盐酸丁丙诺啡/NALOXONE HCL | TAB SUBL | 2 MG-0.5MG | COVERED | FORMULARY | |
18.974 | 51.641 | 280812-OPIATE PARTIAL AGONISTS | Suboxone Tablet | 盐酸丁丙诺啡/NALOXONE HCL | TAB SUBL | 8 MG-2 MG | COVERED | FORMULARY | |
28.626 | 66.372 | 280892-ANALGESICS AND ANTIPYRETICS, MISC. | Fioricet | BUTALBITAL-ACETAMINOPHEN-CAFFEINE | CAPSULE | 50-300-40 MG | NOT COVERED | NON-FORMULARY | 配方:电容,电容 |
27.095 | 60.935 | 281000年鸦片拮抗剂 | Vivitrol | 环丙甲羟二羟吗啡酮微球 | SUS ER REC | 380MG | NOT COVERED | NON-FORMULARY | Formulary: Naltrexone tablet |
16.356 | 46.216 | 281604 -抗抑郁药 | Sarafem | FLUOXETINE HCL | TABLET | 10 MG | NOT COVERED | NON-FORMULARY | 规定:胶囊 |
16.359 | 46.219 | 281604 -抗抑郁药 | Sarafem | FLUOXETINE HCL | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | 规定:胶囊 |
14.349 | 64.444 | 281604 -抗抑郁药 | Venlafaxine ER | VENLAFAXINE HCL | TAB ER 24 | 37.5 MG | NOT COVERED | NON-FORMULARY | 规定:胶囊 |
14.352 | 64.445 | 281604 -抗抑郁药 | Venlafaxine ER | VENLAFAXINE HCL | TAB ER 24 | 75 MG | NOT COVERED | NON-FORMULARY | 规定:胶囊 |
14.353 | 64.446 | 281604 -抗抑郁药 | Venlafaxine ER | VENLAFAXINE HCL | TAB ER 24 | 150 MG | NOT COVERED | NON-FORMULARY | 规定:胶囊 |
14.354 | 64.447 | 281604 -抗抑郁药 | Venlafaxine ER | VENLAFAXINE HCL | TAB ER 24 | 225 MG | NOT COVERED | NON-FORMULARY | 规定:胶囊 |
25.598 | 59.781 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Diastat | DIAZEPAM | KIT | 5-7.5-10MG | NOT COVERED | NON-FORMULARY | Restricted to Neurology prescribers |
25.599 | 59.782 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Diastat | DIAZEPAM | KIT | 12.5-15-20 | NOT COVERED | NON-FORMULARY | Restricted to Neurology prescribers |
48.131 | 34.015 | 282408-BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) | Diastat | DIAZEPAM | KIT | 2.5 MG | NOT COVERED | NON-FORMULARY | Restricted to Neurology prescribers |
19.593 | 40.223 | 283228-SELECTIVE SEROTONIN AGONISTS | Maxalt MLT | RIZATRIPTAN苯甲酸 | TAB RAPDIS | 5 MG | NOT COVERED | Non-Formulary | Formulary: Imitrex (Sumatriptan) |
19.591 | 40.221 | 283228-SELECTIVE SEROTONIN AGONISTS | Maxalt | RIZATRIPTAN苯甲酸 | TABLET | 5 MG | NOT COVERED | Non-Formulary | Formulary: Imitrex (Sumatriptan) |
13.971 | 48.489 | 480800 - antitussives | 异丙嗪/可待因 | 异丙嗪HCL-CODEINE | SYRUP | 6.25-10 MG/5ML | NOT COVERED | NON-FORMULARY | |
54.980 | 12.073 | 481600 -化痰的 | Mucinex D | GUAIFENESIN-PSEUDOEPHEDRINE HCL | TAB ER 12H | 600-60 MG | NOT COVERED | NON-FORMULARY | Available OTC |
26.056 | 60.055 | 520808-CORTICOSTEROIDS (EENT) | Dermotic | 醋酸氟西诺酮油 | DROPS | 0.01% | NOT COVERED | NON-FORMULARY | Prior Auth restricted to EENT prescribers |
30.462 | 67.826 | 521600-LOCAL ANESTHETICS (EENT) | Antipyrine-Benzocaine | ANTIPYRINE-BENZOCAINE | DROPS | 5.5-1.4 % | NOT COVERED | NON-FORMULARY | No longer available commerically |
1.697 | 30.106 | 562836-PROTON-PUMP INHIBITORS | Prevacid | LANSOPRAZOLE | CAPSULE DR | 15 MG | NOT COVERED | NON-FORMULARY | 规定:Pantoprazole |
1.698 | 30.107 | 562836-PROTON-PUMP INHIBITORS | Prevacid | LANSOPRAZOLE | CAPSULE DR | 30 MG | NOT COVERED | NON-FORMULARY | 规定:Pantoprazole |
4.348 | 33.530 | 562836-PROTON-PUMP INHIBITORS | Prilosec | OMEPRAZOLE | CAPSULE DR | 20 MG | NOT COVERED | NON-FORMULARY | 规定:Pantoprazole |
92.989 | 43.136 | 562836-PROTON-PUMP INHIBITORS | Prilosec | OMEPRAZOLE | CAPSULE DR | 10 MG | NOT COVERED | NON-FORMULARY | 规定:Pantoprazole |
92.999 | 43.137 | 562836-PROTON-PUMP INHIBITORS | Prilosec | OMEPRAZOLE | CAPSULE DR | 40 MG | NOT COVERED | NON-FORMULARY | 规定:Pantoprazole |
94.639 | 40.941 | 562836-PROTON-PUMP INHIBITORS | Aciphex | 雷钠 | TABLET DR | 20 MG | NOT COVERED | NON-FORMULARY | 规定:Pantoprazole |
30.220 | 19.863 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Pentasa CR | MESALAMINE | CAPSULE ER | 250 MG | NOT COVERED | PAP | 规定:柳氮磺胺吡啶. Contact manufacturer for PAP |
21.663 | 53.882 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Asacol HD | MESALAMINE | TABLET DR | 800 MG | NOT COVERED | NON-FORMULARY | 规定:柳氮磺胺吡啶. Contact manufacturer for PAP |
37.726 | 73.336 | 569200-GI DRUGS, MISCELLANEOUS | Movantik | NALOXEGOL草酸 | TABLET | 25 MG | NOT COVERED | NON-FORMULARY | Contact manufacturer for PAP |
37.725 | 73.335 | 569200-GI DRUGS, MISCELLANEOUS | Movantik | NALOXEGOL草酸 | TABLET | 12.5 MG | NOT COVERED | NON-FORMULARY | Contact manufacturer for PAP |
28.847 | 3.203 | 681604-ESTROGENS | Vivelle-DOT | ESTRADIOL | PATCH TDSW | 0.1MG/24HR | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.840 | 3.202 | 681604-ESTROGENS | Vivelle-DOT | ESTRADIOL | PATCH TDSW | 0.05MG/24H | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.842 | 16.767 | 681604-ESTROGENS | Vivelle-DOT | ESTRADIOL | PATCH TDSW | .025MG/24H | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.843 | 23.270 | 681604-ESTROGENS | Vivelle-DOT | ESTRADIOL | PATCH TDSW | .075MG/24H | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.846 | 24.555 | 681604-ESTROGENS | Vivelle-DOT | ESTRADIOL | PATCH TDSW | .0375MG/24 | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.844 | 23.471 | 681604-ESTROGENS | Climara | ESTRADIOL | PATCH TDWK | 0.1MG/24HR | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.845 | 23.472 | 681604-ESTROGENS | Climara | ESTRADIOL | PATCH TDWK | 0.05MG/24H | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.848 | 32.174 | 681604-ESTROGENS | Climara | ESTRADIOL | PATCH TDWK | .025MG/24H | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.853 | 40.366 | 681604-ESTROGENS | Climara | ESTRADIOL | PATCH TDWK | .075MG/24H | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
20.068 | 52.830 | 681604-ESTROGENS | Climara | ESTRADIOL | PATCH TDWK | 0.06MG/24H | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
20.069 | 52.831 | 681604-ESTROGENS | Climara | ESTRADIOL | PATCH TDWK | .0375MG/24 | NOT COVERED | NON-FORMULARY | Prior auth requires failure to oral options |
28.107 | 65.966 | 681604-ESTROGENS | Vagifem | ESTRADIOL | TABLET | 10 MCG | NOT COVERED | NON-FORMULARY | |
67.170 | 7.011 | 681604-ESTROGENS | Estrace阴道乳霜 | ESTRADIOL | CREAM/APPL | 0.01% | NOT COVERED | NON-FORMULARY | Formulary: Premarin Vaginal Cream |
34.336 | 70.705 | 681612-ESTROGEN AGONIST-ANTAGONISTS | Osphena | OSPEMIFENE | TABLET | 60 MG | NOT COVERED | NON-FORMULARY | |
2.318 | 20.241 | 682002-ALPHA-GLUCOSIDASE INHIBITORS | Precose | ACARBOSE | TABLET | 100 MG | NOT COVERED | NON-FORMULARY | |
2.319 | 20.242 | 682002-ALPHA-GLUCOSIDASE INHIBITORS | Precose | ACARBOSE | TABLET | 50 MG | NOT COVERED | NON-FORMULARY | |
8.070 | 36.767 | 682002-ALPHA-GLUCOSIDASE INHIBITORS | Precose | ACARBOSE | TABLET | 25 MG | NOT COVERED | NON-FORMULARY | |
95.252 | 40.357 | 682002-ALPHA-GLUCOSIDASE INHIBITORS | Glyset | MIGLITOL | TABLET | 25 MG | NOT COVERED | NON-FORMULARY | |
95.253 | 40.358 | 682002-ALPHA-GLUCOSIDASE INHIBITORS | Glyset | MIGLITOL | TABLET | 50 MG | NOT COVERED | NON-FORMULARY | |
95.254 | 40.359 | 682002-ALPHA-GLUCOSIDASE INHIBITORS | Glyset | MIGLITOL | TABLET | 100 MG | NOT COVERED | NON-FORMULARY | |
35.836 | 71.842 | 682008-INSULINS | Tresiba FlexTouch | INSULIN DEGLUDEC | INSULN PEN | 100/ML (3) | NOT COVERED | NON-FORMULARY | 规定:Levemir |
35.837 | 71.843 | 682008-INSULINS | Tresiba FlexTouch | INSULIN DEGLUDEC | INSULN PEN | 200/ML (3) | NOT COVERED | NON-FORMULARY | 规定:Levemir |
11.660 | 1.740 | 682008-INSULINS | Humulin N | 胰岛素NPH人异黄酮 | VIAL | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | 配方:诺沃林N |
50.001 | 16.311 | 682008-INSULINS | Humulin 70/30 | INSULIN NPH HUM-REG INSULIN HM | VIAL | 70-30 UNIT/ML | NOT COVERED | NON-FORMULARY | 配方:诺沃林70/30 |
11.642 | 1.723 | 682008-INSULINS | Humulin R | 胰岛素正常人 | VIAL | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | 配方:诺沃林R |
50.776 | 43.801 | 683200 -黄体酮 | Prometrium | 孕激素,让 | CAPSULE | 100 MG | NOT COVERED | NON-FORMULARY | 规定:醋酸甲羟孕酮 |
50.786 | 43.802 | 683200 -黄体酮 | Prometrium | 孕激素,让 | CAPSULE | 200 MG | NOT COVERED | NON-FORMULARY | 规定:醋酸甲羟孕酮 |
98.238 | 62.462 | 81228-ANTIBACTERIALS, MISCELLANEOUS | Pylera | BISMUTH/METRONID/TETRACYCLINE | CAPSULE | 125-125 MG | NOT COVERED | NON-FORMULARY | Prior auth requires failure of Amox/Clari/Metronidazole OR history of systemic macrolide exposure |
26.339 | 60.244 | 83600-URINARY ANTI-INFECTIVES | Hyophen | METHENAM/M.蓝色/水杨基/ HYOSCY | TABLET | 81.6-0.12 | NOT COVERED | NON-FORMULARY | |
31.812 | 7.731 | 840404 -抗菌药物(皮肤 & MUCOUS MEMBRANE) | Bacitracin | BACITRACIN | OINT. (G) | 500 UNIT/G | NOT COVERED | NON-FORMULARY | |
50.272 | 43.256 | 840800-ANTIPRURITICS AND LOCAL ANESTHETICS | Lidoderm | LIDOCAINE | ADH. PATCH | 5% | NOT COVERED | NON-FORMULARY | Lidocaine 4% patch, cream are OTC |
95.404 | 40.261 | 840800-ANTIPRURITICS AND LOCAL ANESTHETICS | 林多卡因肛肠乳膏 | LIDOCAINE | CREAM (G) | 5% | NOT COVERED | NON-FORMULARY | |
95.405 | 40.262 | 840800-ANTIPRURITICS AND LOCAL ANESTHETICS | Liocaine Cream | LIDOCAINE | CREAM (G) | 4% | NOT COVERED | NON-FORMULARY | Available OTC |
30.750 | 14.476 | 840800-ANTIPRURITICS AND LOCAL ANESTHETICS | 利多卡因软膏 | LIDOCAINE | OINT. (G) | 5% | NOT COVERED | NON-FORMULARY | 4%利多卡因乳膏是非处方药 |
24.882 | 6.312 | 845004 -脱色剂 | 隐褪霜 | HYDROQUINONE | CREAM (G) | 2% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
24.883 | 6.313 | 845004 -脱色剂 | Melquin HP 4%乳膏 | HYDROQUINONE | CREAM (G) | 4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
47.830 | 6.314 | 845004 -脱色剂 | 对苯二酚4%乳霜 | HYDROQUINONE | POWDER | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone | |
24.890 | 6.315 | 845004 -脱色剂 | 对苯二酚粉 | HYDROQUINONE | SOLUTION | 30 MG/ML | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
20.120 | 52.863 | 845004 -脱色剂 | Nuquin HP 4%奶油 | 苯二酚微球 | CRM ER (G) | 4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
97.674 | 61.889 | 845004 -脱色剂 | 隐褪霜 | HYDROQUINONE/AVOBENZ/OCTINOX | EMUL ADHES | 4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
21.864 | 54.046 | 845004 -脱色剂 | Alphaquin HP 4%乳霜 | HYDROQUINONE/AVOBENZ/OCTINOX | EMULSN(G) | 4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
20.915 | 53.438 | 845004 -脱色剂 | 对苯二酚tr 4%乳霜 | HYDROQUINONE/OXYBEN/OCTINOXATE | CREAM (G) | 4%(5-7.5%) | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
97.229 | 61.438 | 845004 -脱色剂 | Aclaro 4%乳液 | HYDROQUINONE/OXYBENZONE/PADIMA | CREAM (G) | 2%-SPF10 | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
66.899 | 31.427 | 845004 -脱色剂 | MELQUIN-3解决方案 | HYDROQUINONE/SUNSCREEN(FER OX) | CREAM (G) | 4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
96.071 | 39.542 | 848000 -防晒剂 | Melpaque HP 4%乳霜 | DIOXYBENZONE/PDO/HYDROQUINONE | CREAM (G) | 3%-5%-4% | NOT COVERED | NON-FORMULARY | No coverage for hydroquinone |
20.383 | 53.055 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Claravis | ISOTRETINOIN | TABLET | 30 MG | NOT COVERED | NON-FORMULARY | Prior auths restricted to Dermatology prescriber. Claravis馋 |
59.841 | 36.045 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Claravis | ISOTRETINOIN | TABLET | 10 MG | NOT COVERED | NON-FORMULARY | Prior auths restricted to Dermatology prescriber. Claravis馋 |
59.842 | 36.046 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Claravis | ISOTRETINOIN | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | Prior auths restricted to Dermatology prescriber. Claravis馋 |
59.843 | 36.047 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Claravis | ISOTRETINOIN | TABLET | 40 MG | NOT COVERED | NON-FORMULARY | Prior auths restricted to Dermatology prescriber. Claravis馋 |
24.043 | 58.576 | 861204 - antimuscarinics | Enablex | DARIFENACIN氢溴酸盐 | TAB ER 24H | 7.5 MG | NOT COVERED | NON-FORMULARY | 处方:奥施布宁ER |
24.044 | 58.577 | 861204 - antimuscarinics | Enablex | DARIFENACIN氢溴酸盐 | TAB ER 24H | 15 MG | NOT COVERED | NON-FORMULARY | 处方:奥施布宁ER |
99.193 | 63.466 | 861204 - antimuscarinics | Sanctura XR | TROSPIUM CHLORIDE | CAP ER 24H | 60 MG | NOT COVERED | NON-FORMULARY | 处方:奥施布宁ER |
8.744 | 38.085 | 861204 - antimuscarinics | Sanctura | TROSPIUM CHLORIDE | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | 处方:奥施布宁ER |
18.428 | 51.246 | 920800-5-ALPHA-REDUCTASE INHIBITORS | Avodart | DUTASTERIDE | CAPSULE | 0.5 MG | NOT COVERED | NON-FORMULARY | 规定:非那雄胺 |
28.596 | 66.352 | 920800-5-ALPHA-REDUCTASE INHIBITORS | Jalyn | DUTASTERIDE / TAMSULOSIN盐酸 | CPMP 24HR | 0.5-0.4 MG | NOT COVERED | NON-FORMULARY | 规定:非那雄胺 |
24.444 | 58.915 | 922400-BONE RESORPTION INHIBITORS | Boniva | IBANDRONATE钠 | TABLET | 150 MG | NOT COVERED | NON-FORMULARY | 规定:Alendronate |
17.378 | 50.364 | 922400-BONE RESORPTION INHIBITORS | Actonel | RISEDRONATE钠 | TABLET | 35 MG | NOT COVERED | NON-FORMULARY | 规定:Alendronate |
92.238 | 45.102 | 922400-BONE RESORPTION INHIBITORS | Actonel | RISEDRONATE钠 | TABLET | 5 MG | NOT COVERED | NON-FORMULARY | 规定:Alendronate |
94.200 | 74.210 | 940000-DEVICES | Contour Next | 血糖仪 | EACH | NOT COVERED | NON-FORMULARY | Prior Auths restricted to insulin pumps | |
94.200 | 70.198 | 940000-DEVICES | TruePlus柳叶刀26G | LANCETS | EACH | 26 GAUGE | NOT COVERED | NON-FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | 胰岛素注射器0.5mL 28GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 28 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.276 | 940000-DEVICES | 胰岛素注射器0.5mL 28GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 28 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.383 | 940000-DEVICES | 胰岛素注射器0.5mL 29 G X1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 29 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.395 | 940000-DEVICES | 胰岛素注射器0.5mL 30GX 5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30G X 5/16" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.400 | 940000-DEVICES | 胰岛素注射器0.5mL 30GX1/2" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 30 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.404 | 940000-DEVICES | 胰岛素注射器0.5mL 31 GX5/16" | 注射器w-ndl滴剂胰岛素0.5 ML | DISP SYRIN | 31 G X 5/16" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.365 | 940000-DEVICES | Insulin Syringe 1mL 27GX5/8" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 27 G X 5/8" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 28 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 28 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.275 | 940000-DEVICES | Insulin Syringe 1mL 28GX1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 28 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 29 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.384 | 940000-DEVICES | Insulin Syringe 1mL 29 G X1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 29 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.401 | 940000-DEVICES | Insulin Syringe 1mL 30GX1/2" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 30 G X 1/2" | NOT COVERED | NON-FORMULARY | |
94.200 | 49.405 | 940000-DEVICES | Insulin Syringe 1mL 31 GX5/16" | SYRINGE & 针胰岛素1 ml | DISP SYRIN | 31 G X 5/16" | NOT COVERED | NON-FORMULARY | |
30.025 | 67.462 | 081202 -氨基糖甙类 | Tobi Podhaler | TOBRAMYCIN | CAP W/DEV | 28 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
61.551 | 37.042 | 081202 -氨基糖甙类 | Tobi | TOBRAMYCIN IN 0.225% NACL | AMPUL-NEB | 300 MG/5ML | NOT COVERED | NON-FORMULARY | |
28.530 | 66.295 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Xifaxan | RIFAXIMIN | TABLET | 550 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
93.749 | 41.880 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Xifaxan | RIFAXIMIN | TABLET | 200 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
49.101 | 16.949 | 081408-AZOLES | Sporanox capsule | ITRACONAZOLE | CAPSULE | 100 MG | NOT COVERED | NON-FORMULARY | |
49.100 | 27.465 | 081408-AZOLES | Sporanox solution | ITRACONAZOLE | SOLUTION | 10 MG/ML | NOT COVERED | NON-FORMULARY | |
17.497 | 50.442 | 081408-AZOLES | Vfend | VORICONAZOLE | TABLET | 50 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
17.498 | 50.443 | 081408-AZOLES | Vfend | VORICONAZOLE | TABLET | 200 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
35.079 | 71.322 | 081808年的今天,抗逆转录病毒药物 | Tivicay | DOLUTEGRAVIR钠 | TABLET | 50 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
41.564 | 76.226 | 081808年的今天,抗逆转录病毒药物 | Tivicay | DOLUTEGRAVIR钠 | TABLET | 10 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
41.566 | 76.227 | 081808年的今天,抗逆转录病毒药物 | Tivicay | DOLUTEGRAVIR钠 | TABLET | 25 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
23.152 | 57.883 | 081808年的今天,抗逆转录病毒药物 | Truvada | EMTRICITABINE/TENOFOVIR (TDF) | TABLET | 200-300 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
41.369 | 76.097 | 081808年的今天,抗逆转录病毒药物 | Truvada | EMTRICITABINE/TENOFOVIR (TDF) | TABLET | 100-150 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
41.375 | 76.101 | 081808年的今天,抗逆转录病毒药物 | Truvada | EMTRICITABINE/TENOFOVIR (TDF) | TABLET | 133-200 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
41.376 | 76.102 | 081808年的今天,抗逆转录病毒药物 | Truvada | EMTRICITABINE/TENOFOVIR (TDF) | TABLET | 167-250 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
97.430 | 61.644 | 081808年的今天,抗逆转录病毒药物 | Reyataz | ATAZANAVIR硫酸 | CAPSULE | 300 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
15.555 | 49.849 | 081808年的今天,抗逆转录病毒药物 | Sustiva | EFAVIRENZ | TABLET | 600 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
31.227 | 68.449 | 081808年的今天,抗逆转录病毒药物 | Viread | TENOFOVIR DISOPROXIL FUMARATE | POWDER | 40 MG/SCOOP | NOT COVERED | NON-FORMULARY | |
14.822 | 48.843 | 081808年的今天,抗逆转录病毒药物 | Viread | TENOFOVIR DISOPROXIL FUMARATE | TABLET | 300 MG | NOT COVERED | NON-FORMULARY | |
31.228 | 68.450 | 081808年的今天,抗逆转录病毒药物 | Viread | TENOFOVIR DISOPROXIL FUMARATE | TABLET | 150 MG | NOT COVERED | NON-FORMULARY | |
31.229 | 68.451 | 081808年的今天,抗逆转录病毒药物 | Viread | TENOFOVIR DISOPROXIL FUMARATE | TABLET | 200 MG | NOT COVERED | NON-FORMULARY | |
31.234 | 68.453 | 081808年的今天,抗逆转录病毒药物 | Viread | TENOFOVIR DISOPROXIL FUMARATE | TABLET | 250 MG | NOT COVERED | NON-FORMULARY | |
24.465 | 58.933 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Baraclude | ENTECAVIR | SOLUTION | 0.05 MG/ML | NOT COVERED | PAP | Prior Auths's Restricted to GI Clinic, Contact manufacturer for PAP |
24.466 | 58.934 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Baraclude | ENTECAVIR | TABLET | 0.5 MG | NOT COVERED | PAP | Prior Auths's Restricted to GI Clinic, Contact manufacturer for PAP |
24.467 | 58.935 | 081832-NUCLEOSIDES AND NUCLEOTIDES | Baraclude | ENTECAVIR | TABLET | 1 MG | NOT COVERED | PAP | Prior Auths's Restricted to GI Clinic, Contact manufacturer for PAP |
28.648 | 66.391 | 083600-URINARY ANTI-INFECTIVES | Uribel | MTH/ME BLUE/SOD PHOS/PHEN/HYOS | CAPSULE | 118-10-36 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
24.410 | 24.515 | 100000-ANTINEOPLASTIC AGENTS | Arimidex | ANASTROZOLE | TABLET | 1 MG | NOT COVERED | NON-FORMULARY | |
33.084 | 69.855 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Tudorza Pressair DPI | ACLIDINIUM溴化 | AER POW BA | 400 MCG | NOT COVERED | NON-FORMULARY | Formulary: Spiriva Handihaler |
24.621 | 59.081 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Atrovent HFA | IPRATROPIUM溴化 | HFA AER AD | 17 MCG | NOT COVERED | NON-FORMULARY | Formulary: Spiriva Handihaler |
32.395 | 69.371 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Combivent MDI | IPRATROPIUM/硫酸沙丁胺醇 | MIST INHAL | 20-100 MCG | NOT COVERED | NON-FORMULARY | |
98.921 | 63.164 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Spiriva Respimat | TIOTROPIUM溴化 | MIST INHAL | 2.5 MCG | NOT COVERED | NON-FORMULARY | Formulary: Spiriva Handihaler |
35.903 | 71.883 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Anoro Ellipta | UMECLIDINIUM BRM/VILANTEROL TR | BLST W/DEV | 62.5-25 MCG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
36.574 | 72.375 | 120808-ANTIMUSCARINICS/ANTISPASMODICS | Incruse Ellipta | UMECLIDINIUM溴化 | BLST W/DEV | 62.5 MCG | NOT COVERED | NON-FORMULARY | Formulary: Spiriva Handihaler |
97.366 | 61.579 | 121208-BETA-ADRENERGIC AGONISTS | Brovana | ARFORMOTEROL酒石酸 | VIAL-NEB | 15 MCG/2ML | NOT COVERED | NON-FORMULARY | Formulary: Albuterol nebulized solution is formulary. |
92.024 | 45.052 | 121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) | Uroxatral | ALFUZOSIN HCL | TAB ER 24H | 10 MG | NOT COVERED | NON-FORMULARY | Formulary: Tamsulosin, Terazosin, Prazosin. |
16.857 | 64.846 | 121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) | Rapaflo | SILODOSIN | CAPSULE | 4 MG | NOT COVERED | PAP | Formulary: Tamsulosin, Terazosin, Prazosin. Contact manufacturer for PAP |
16.858 | 64.847 | 121604-ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) | Rapaflo | SILODOSIN | CAPSULE | 8 MG | NOT COVERED | PAP | Formulary: Tamsulosin, Terazosin, Prazosin. Contact manufacturer for PAP |
33.935 | 70.414 | 201204 -抗凝血剂 | Eliquis | APIXABAN | TABLET | 5 MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
30.239 | 67.642 | 201204 -抗凝血剂 | Eliquis | APIXABAN | TABLET | 2.5 MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
29.166 | 66.781 | 201204 -抗凝血剂 | Pradaxa | DABIGATRAN ETEXILATE MESYLATE | CAPSULE | 150 MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
99.708 | 63.997 | 201204 -抗凝血剂 | Pradaxa | DABIGATRAN ETEXILATE MESYLATE | CAPSULE | 75 MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
37.675 | 73.293 | 201204 -抗凝血剂 | Savaysa | EDOXABAN | TABLET | 15 MG | NOT COVERED | NON-FORMULARY | Formulary: Enoxaparin, Warfarin. |
37.676 | 73.294 | 201204 -抗凝血剂 | Savaysa | EDOXABAN | TABLET | 30 MG | NOT COVERED | NON-FORMULARY | Formulary: Enoxaparin, Warfarin. |
37.677 | 73.295 | 201204 -抗凝血剂 | Savaysa | EDOXABAN | TABLET | 60 MG | NOT COVERED | NON-FORMULARY | Formulary: Enoxaparin, Warfarin. |
37.212 | 72.904 | 201204 -抗凝血剂 | Xarelto起始月包 | RIVAROXABAN | TAB DS PK | 15(42)-20(9) MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
14.427 | 64.493 | 201204 -抗凝血剂 | Xarelto | RIVAROXABAN | TABLET | 10 MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
30.818 | 68.118 | 201204 -抗凝血剂 | Xarelto | RIVAROXABAN | TABLET | 15 MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
30.819 | 68.119 | 201204 -抗凝血剂 | Xarelto | RIVAROXABAN | TABLET | 20 MG | NOT COVERED | PAP | Formulary: Enoxaparin, Warfarin. Contact manufacturer for PAP |
17.157 | 64.902 | 201218-PLATELET-AGGREGATION INHIBITORS | Effient | PRASUGREL HCL | TABLET | 10 MG | Covered | FORMULARY | |
17.056 | 64.901 | 201218-PLATELET-AGGREGATION INHIBITORS | Effient | PRASUGREL HCL | TABLET | 5 MG | Covered | FORMULARY | |
29.385 | 66.950 | 201218-PLATELET-AGGREGATION INHIBITORS | Brilinta | TICAGRELOR | TABLET | 90 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
39.407 | 74.696 | 201218-PLATELET-AGGREGATION INHIBITORS | Brilinta | TICAGRELOR | TABLET | 60 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
24.059 | 58.592 | 201600 -造血代理 | Epogen, Procrit | EPOETIN ALFA | VIAL | 20000/2ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.110 | 11.740 | 201600 -造血代理 | Epogen, Procrit | EPOETIN ALFA | VIAL | 2000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.111 | 11.741 | 201600 -造血代理 | Epogen, Procrit | EPOETIN ALFA | VIAL | 4000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.112 | 11.742 | 201600 -造血代理 | Epogen, Procrit | EPOETIN ALFA | VIAL | 10000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.113 | 15.164 | 201600 -造血代理 | Epogen, Procrit | EPOETIN ALFA | VIAL | 3000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.114 | 25.708 | 201600 -造血代理 | Epogen, Procrit | EPOETIN ALFA | VIAL | 20000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
25.115 | 41.394 | 201600 -造血代理 | Epogen, Procrit | EPOETIN ALFA | VIAL | 40000/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
26.586 | 65.367 | 240404-ANTIARRHYTHMIC AGENTS | Multaq | DRONEDARONE HCL | TABLET | 400 MG | NOT COVERED | PAP | 规定:胺碘酮. Contact manufacturer for PAP |
95.347 | 40.303 | 241292-VASODILATING AGENTS, MISCELLANEOUS | Aggrenox | 阿司匹林、双嘧达莫 | CPMP 12HR | 25-200 MG | NOT COVERED | NON-FORMULARY | |
97.596 | 61.811 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg CR | 卡维地洛磷酸 | CPMP 24HR | 10 MG | NOT COVERED | PAP | 处方:卡维地洛IR. Contact manufacturer for PAP |
97.597 | 61.812 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg CR | 卡维地洛磷酸 | CPMP 24HR | 20 MG | NOT COVERED | PAP | 处方:卡维地洛IR. Contact manufacturer for PAP |
97.598 | 61.813 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg CR | 卡维地洛磷酸 | CPMP 24HR | 40 MG | NOT COVERED | PAP | 处方:卡维地洛IR. Contact manufacturer for PAP |
97.599 | 61.814 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Coreg CR | 卡维地洛磷酸 | CPMP 24HR | 80 MG | NOT COVERED | PAP | 处方:卡维地洛IR. Contact manufacturer for PAP |
7.055 | 36.654 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Bystolic | NEBIVOLOL HCL | TABLET | 5 MG | NOT COVERED | PAP | Formulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP |
18.703 | 64.945 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Bystolic | NEBIVOLOL HCL | TABLET | 20 MG | NOT COVERED | PAP | Formulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP |
99.235 | 63.510 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Bystolic | NEBIVOLOL HCL | TABLET | 2.5 MG | NOT COVERED | PAP | Formulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP |
99.236 | 63.511 | 242400-BETA-ADRENERGIC BLOCKING AGENTS | Bystolic | NEBIVOLOL HCL | TABLET | 10 MG | NOT COVERED | PAP | Formulary: Atenolol, Bisoprolol, Metoprolol. Contact manufacturer for PAP |
97.962 | 62.180 | 242808 - dihydropyridines | Exforge | 缬沙坦/氨氯地平 | TABLET | 5-160 MG | NOT COVERED | PAP | Prescribe amlodipine and irbesartan or Lotrel, Contact manufacturer for PAP |
97.963 | 62.181 | 242808 - dihydropyridines | Exforge | 缬沙坦/氨氯地平 | TABLET | 10-160 MG | NOT COVERED | PAP | Prescribe amlodipine and irbesartan or Lotrel, Contact manufacturer for PAP |
98.579 | 62.808 | 242808 - dihydropyridines | Exforge | 缬沙坦/氨氯地平 | TABLET | 5-320 MG | NOT COVERED | PAP | Prescribe amlodipine and irbesartan or Lotrel, Contact manufacturer for PAP |
98.580 | 62.809 | 242808 - dihydropyridines | Exforge | 缬沙坦/氨氯地平 | TABLET | 10-320 MG | NOT COVERED | PAP | Prescribe amlodipine and irbesartan or Lotrel, Contact manufacturer for PAP |
39.046 | 74.408 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Entresto | SACUBITRIL /缬沙坦 | TABLET | 24 MG-26MG | NOT COVERED | PAP | Formulary: Losartan, Irbesartan, Valsartan. Contact manufacturer for PAP |
39.047 | 74.409 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Entresto | SACUBITRIL /缬沙坦 | TABLET | 49 MG-51MG | NOT COVERED | PAP | Formulary: Losartan, Irbesartan, Valsartan. Contact manufacturer for PAP |
39.048 | 74.410 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Entresto | SACUBITRIL /缬沙坦 | TABLET | 97MG-103MG | NOT COVERED | PAP | Formulary: Losartan, Irbesartan, Valsartan. Contact manufacturer for PAP |
17.285 | 50.289 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Benicar | OLMESARTAN MEDOXOMIL | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
17.286 | 50.290 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Benicar | OLMESARTAN MEDOXOMIL | TABLET | 40 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
17.284 | 50.288 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Benicar | OLMESARTAN MEDOXOMIL | TABLET | 5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
28.837 | 66.538 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Tribenzor | OLMESARTAN/AMLODIPIN/HCTHIAZID | TABLET | 20-5-12.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
28.838 | 66.539 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Tribenzor | OLMESARTAN/AMLODIPIN/HCTHIAZID | TABLET | 40-5-12.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
28.839 | 66.540 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Tribenzor | OLMESARTAN/AMLODIPIN/HCTHIAZID | TABLET | 40-5-25 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
28.854 | 66.541 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Tribenzor | OLMESARTAN/AMLODIPIN/HCTHIAZID | TABLET | 40-10-12.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
28.855 | 66.542 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Tribenzor | OLMESARTAN/AMLODIPIN/HCTHIAZID | TABLET | 40-10-25 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
20.074 | 52.833 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Benicar HCT | OLMESARTAN/氢氯噻嗪 | TABLET | 20-12.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
20.075 | 52.834 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Benicar HCT | OLMESARTAN/氢氯噻嗪 | TABLET | 40-12.5 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
20.076 | 52.835 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Benicar HCT | OLMESARTAN/氢氯噻嗪 | TABLET | 40-25 MG | NOT COVERED | NON-FORMULARY | Formulary: Losartan, Irbesartan, Valsartan. |
37.158 | 72.862 | 280808 -阿片受体激动剂 | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 10 MG | NOT COVERED | NON-FORMULARY | 规定:吗啡 |
37.159 | 72.863 | 280808 -阿片受体激动剂 | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 15 MG | NOT COVERED | NON-FORMULARY | 规定:吗啡 |
37.161 | 72.864 | 280808 -阿片受体激动剂 | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 20 MG | NOT COVERED | NON-FORMULARY | 规定:吗啡 |
37.162 | 72.865 | 280808 -阿片受体激动剂 | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 30 MG | NOT COVERED | NON-FORMULARY | 规定:吗啡 |
37.163 | 72.866 | 280808 -阿片受体激动剂 | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 40 MG | NOT COVERED | NON-FORMULARY | 规定:吗啡 |
37.164 | 72.867 | 280808 -阿片受体激动剂 | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 60 MG | NOT COVERED | NON-FORMULARY | 规定:吗啡 |
37.165 | 72.868 | 280808 -阿片受体激动剂 | Oxycodone ER | OXYCODONE HCL | TAB ER 12H | 80 MG | NOT COVERED | NON-FORMULARY | 规定:吗啡 |
9.070 | 20.647 | 281208-BENZODIAZEPINES (ANTICONVULSANTS) | Onfi | CLOBAZAM | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | |
9.071 | 17.026 | 281208-BENZODIAZEPINES (ANTICONVULSANTS) | Onfi | CLOBAZAM | TABLET | 10 MG | NOT COVERED | NON-FORMULARY | |
28.643 | 66.386 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Vimpat | LACOSAMIDE | ORAL SOLUTION | 10 MG/ML | COVERED | FORMULARY | |
14.338 | 64.432 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Vimpat | LACOSAMIDE | TABLET | 50 MG | COVERED | FORMULARY | |
14.339 | 64.433 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Vimpat | LACOSAMIDE | TABLET | 100 MG | COVERED | FORMULARY | |
14.341 | 64.434 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Vimpat | LACOSAMIDE | TABLET | 150 MG | COVERED | FORMULARY | |
14.342 | 64.435 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Vimpat | LACOSAMIDE | TABLET | 200 MG | COVERED | FORMULARY | |
24.693 | 65.250 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 25 MG | NOT COVERED | PAP | 处方:拉莫三嗪. Contact manufacturer for PAP |
24.739 | 65.253 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 200 MG | NOT COVERED | PAP | 处方:拉莫三嗪. Contact manufacturer for PAP |
24.697 | 65.251 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 50 MG | NOT COVERED | PAP | 处方:拉莫三嗪. Contact manufacturer for PAP |
24.703 | 65.252 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 100 MG | NOT COVERED | PAP | 处方:拉莫三嗪. Contact manufacturer for PAP |
29.725 | 67.221 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 300 MG | NOT COVERED | PAP | 处方:拉莫三嗪. Contact manufacturer for PAP |
30.787 | 68.093 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Lamictal XR | LAMOTRIGINE | TAB ER 24 | 250 MG | NOT COVERED | PAP | 处方:拉莫三嗪. Contact manufacturer for PAP |
14.305 | 64.416 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra XR | LEVETIRACETAM | TAB ER 24H | 500 MG | NOT COVERED | NON-FORMULARY | Formulary: Levetiracetam IR. |
20.765 | 64.990 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Keppra XR | LEVETIRACETAM | TAB ER 24H | 750 MG | NOT COVERED | NON-FORMULARY | Formulary: Levetiracetam IR. |
36.556 | 40.901 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Topamax洒盖 | TOPIRAMATE | CAP SPRINK | 15 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
36.557 | 40.902 | 281292-ANTICONVULSANTS, MISCELLANEOUS | Topamax洒盖 | TOPIRAMATE | CAP SPRINK | 25 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
35.328 | 71.496 | 281604 -抗抑郁药 | Fetzima | LEVOMILNACIPRAN HYDROCHLORIDE | CAP SA 24H | 40 MG | NOT COVERED | NON-FORMULARY | Formulary: Venlafaxine ER capsules, Duloxetine DR. |
35.327 | 71.495 | 281604 -抗抑郁药 | Fetzima | LEVOMILNACIPRAN HYDROCHLORIDE | CAP SA 24H | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Venlafaxine ER capsules, Duloxetine DR. |
35.329 | 71.497 | 281604 -抗抑郁药 | Fetzima | LEVOMILNACIPRAN HYDROCHLORIDE | CAP SA 24H | 80 MG | NOT COVERED | NON-FORMULARY | Formulary: Venlafaxine ER capsules, Duloxetine DR. |
35.334 | 71.498 | 281604 -抗抑郁药 | Fetzima | LEVOMILNACIPRAN HYDROCHLORIDE | CAP SA 24H | 120 MG | NOT COVERED | NON-FORMULARY | Formulary: Venlafaxine ER capsules, Duloxetine DR. |
35.335 | 71.499 | 281604 -抗抑郁药 | Fetzima | LEVOMILNACIPRAN HYDROCHLORIDE | CAP24HDSPK | 20-40 MG | NOT COVERED | NON-FORMULARY | Formulary: Venlafaxine ER capsules, Duloxetine DR. |
20.869 | 53.401 | 281604 -抗抑郁药 | Symbyax | 奥氮平/盐酸氟西汀 | CAPSULE | 6-50 MG | NOT COVERED | PAP | Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP |
20.868 | 53.400 | 281604 -抗抑郁药 | Symbyax | 奥氮平/盐酸氟西汀 | CAPSULE | 6-25 MG | NOT COVERED | PAP | Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP |
20.870 | 53.402 | 281604 -抗抑郁药 | Symbyax | 奥氮平/盐酸氟西汀 | CAPSULE | 12-25 MG | NOT COVERED | PAP | Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP |
20.872 | 53.403 | 281604 -抗抑郁药 | Symbyax | 奥氮平/盐酸氟西汀 | CAPSULE | 12-50 MG | NOT COVERED | PAP | Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP |
98.648 | 62.878 | 281604 -抗抑郁药 | Symbyax | 奥氮平/盐酸氟西汀 | CAPSULE | 3-25 MG | NOT COVERED | PAP | Prescribe fluoxetine and olanzapine seperately, Contact manufacturer for PAP |
38.253 | 73.810 | 281604 -抗抑郁药 | 弧菌滴定包 | 维拉佐酮盐酸盐 | TAB DS PK | 10 MG-20 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
29.918 | 67.378 | 281604 -抗抑郁药 | Viibryd | 维拉佐酮盐酸盐 | TABLET | 40 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
29.916 | 67.376 | 281604 -抗抑郁药 | Viibryd | 维拉佐酮盐酸盐 | TABLET | 10 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
29.917 | 67.377 | 281604 -抗抑郁药 | Viibryd | 维拉佐酮盐酸盐 | TABLET | 20 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
28.034 | 65.908 | 281608 -抗精神病药物 | Fanapt | ILOPERIDONE | TAB DS PK | 1-2-4-6 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
28.025 | 65.901 | 281608 -抗精神病药物 | Fanapt | ILOPERIDONE | TABLET | 1 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
28.026 | 65.902 | 281608 -抗精神病药物 | Fanapt | ILOPERIDONE | TABLET | 2 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
28.027 | 65.903 | 281608 -抗精神病药物 | Fanapt | ILOPERIDONE | TABLET | 4 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
28.028 | 65.904 | 281608 -抗精神病药物 | Fanapt | ILOPERIDONE | TABLET | 6 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
28.029 | 65.905 | 281608 -抗精神病药物 | Fanapt | ILOPERIDONE | TABLET | 8 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
28.030 | 65.906 | 281608 -抗精神病药物 | Fanapt | ILOPERIDONE | TABLET | 10 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
28.033 | 65.907 | 281608 -抗精神病药物 | Fanapt | ILOPERIDONE | TABLET | 12 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
29.366 | 66.932 | 281608 -抗精神病药物 | Latuda | LURASIDONE HCL | TABLET | 40 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
29.367 | 66.933 | 281608 -抗精神病药物 | Latuda | LURASIDONE HCL | TABLET | 80 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
31.226 | 68.448 | 281608 -抗精神病药物 | Latuda | LURASIDONE HCL | TABLET | 20 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
33.147 | 69.894 | 281608 -抗精神病药物 | Latuda | LURASIDONE HCL | TABLET | 120 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
35.192 | 71.415 | 281608 -抗精神病药物 | Latuda | LURASIDONE HCL | TABLET | 60 MG | NOT COVERED | NON-FORMULARY | Formulary: Olanzapine, Quetiapine, and Risperidone. |
34.022 | 47.285 | 281608 -抗精神病药物 | Zyprexa Zydis | OLANZAPINE | TAB RAPDIS | 15 MG | NOT COVERED | PAP | Formulary: Olanzapine tablet. Contact manufacturer for PAP |
34.023 | 47.286 | 281608 -抗精神病药物 | Zyprexa Zydis | OLANZAPINE | TAB RAPDIS | 20 MG | NOT COVERED | PAP | Formulary: Olanzapine tablet. Contact manufacturer for PAP |
92.007 | 45.190 | 281608 -抗精神病药物 | Zyprexa Zydis | OLANZAPINE | TAB RAPDIS | 5 MG | NOT COVERED | PAP | Formulary: Olanzapine tablet. Contact manufacturer for PAP |
92.008 | 45.191 | 281608 -抗精神病药物 | Zyprexa Zydis | OLANZAPINE | TAB RAPDIS | 10 MG | NOT COVERED | PAP | Formulary: Olanzapine tablet. Contact manufacturer for PAP |
97.769 | 61.985 | 281608 -抗精神病药物 | Invega | PALIPERIDONE | TAB ER 24 | 3 MG | NOT COVERED | PAP | 规定:利培酮. Contact manufacturer for PAP |
97.770 | 61.986 | 281608 -抗精神病药物 | Invega | PALIPERIDONE | TAB ER 24 | 6 MG | NOT COVERED | PAP | 规定:利培酮. Contact manufacturer for PAP |
97.771 | 61.987 | 281608 -抗精神病药物 | Invega | PALIPERIDONE | TAB ER 24 | 9 MG | NOT COVERED | PAP | 规定:利培酮. Contact manufacturer for PAP |
27.685 | 65.667 | 281608 -抗精神病药物 | Invega | PALIPERIDONE | TAB ER 24 | 1.5 MG | NOT COVERED | PAP | 规定:利培酮. Contact manufacturer for PAP |
98.994 | 63.240 | 281608 -抗精神病药物 | Seroquel XR | 喹硫平延胡索酸酯 | TAB ER 24H | 50 MG | Covered | CommUnityCare药房 | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
16.193 | 64.725 | 281608 -抗精神病药物 | Seroquel XR | 喹硫平延胡索酸酯 | TAB ER 24H | 150 MG | Covered | CommUnityCare药房 | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
98.522 | 62.748 | 281608 -抗精神病药物 | Seroquel XR | 喹硫平延胡索酸酯 | TAB ER 24H | 200 MG | Covered | CommUnityCare药房 | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
98.523 | 62.749 | 281608 -抗精神病药物 | Seroquel XR | 喹硫平延胡索酸酯 | TAB ER 24H | 300 MG | Covered | CommUnityCare药房 | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy |
98.524 | 62.750 | 281608 -抗精神病药物 | Seroquel XR | 喹硫平延胡索酸酯 | TAB ER 24H | 400 MG | Covered | CommUnityCare药房 | Restricted to CUC Prescribers. Send to a CUC in-house pharmacy, |
98.071 | 62.283 | 282004 -安非他命 | Vyvanse | LISDEXAMFETAMINE DIMESYLATE | CAPSULE | 30 MG | NOT COVERED | PAP | 处方:阿德拉XR. Contact manufacturer for PAP |
98.072 | 62.284 | 282004 -安非他命 | Vyvanse | LISDEXAMFETAMINE DIMESYLATE | CAPSULE | 50 MG | NOT COVERED | PAP | 处方:阿德拉XR. Contact manufacturer for PAP |
99.366 | 63.645 | 282004 -安非他命 | Vyvanse | LISDEXAMFETAMINE DIMESYLATE | CAPSULE | 20 MG | NOT COVERED | PAP | 处方:阿德拉XR. Contact manufacturer for PAP |
99.367 | 63.646 | 282004 -安非他命 | Vyvanse | LISDEXAMFETAMINE DIMESYLATE | CAPSULE | 40 MG | NOT COVERED | PAP | 处方:阿德拉XR. Contact manufacturer for PAP |
99.368 | 63.647 | 282004 -安非他命 | Vyvanse | LISDEXAMFETAMINE DIMESYLATE | CAPSULE | 60 MG | NOT COVERED | PAP | 处方:阿德拉XR. Contact manufacturer for PAP |
37.674 | 73.292 | 282004 -安非他命 | Vyvanse | LISDEXAMFETAMINE DIMESYLATE | CAPSULE | 10 MG | NOT COVERED | PAP | 处方:阿德拉XR. Contact manufacturer for PAP |
98.073 | 62.285 | 282004 -安非他命 | Vyvanse | LISDEXAMFETAMINE DIMESYLATE | CAPSULE | 70 MG | NOT COVERED | PAP | 处方:阿德拉XR. Contact manufacturer for PAP |
12.248 | 47.318 | 282032-RESPIRATORY AND CNS STIMULANTS | Concerta | 盐酸哌醋甲酯 | TAB ER 24 | 54 MG | NOT COVERED | PAP | Formulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP |
12.568 | 45.982 | 282032-RESPIRATORY AND CNS STIMULANTS | Concerta | 盐酸哌醋甲酯 | TAB ER 24 | 36 MG | NOT COVERED | PAP | Formulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP |
17.123 | 50.172 | 282032-RESPIRATORY AND CNS STIMULANTS | Concerta | 盐酸哌醋甲酯 | TAB ER 24 | 27 MG | NOT COVERED | PAP | Formulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP |
12.567 | 45.981 | 282032-RESPIRATORY AND CNS STIMULANTS | Concerta | 盐酸哌醋甲酯 | TAB ER 24 | 18 MG | NOT COVERED | PAP | Formulary: Ritalin LA, Metadate CD. Contact manufacturer for PAP |
26.515 | 65.356 | 283620-DOPAMINE RECEPTOR AGONISTS | Neupro | ROTIGOTINE | PATCH TD24 | 1 MG/24 HR | NOT COVERED | PAP | 规定:罗匹尼罗. Contact manufacturer for PAP |
26.516 | 65.357 | 283620-DOPAMINE RECEPTOR AGONISTS | Neupro | ROTIGOTINE | PATCH TD24 | 3 MG/24 HR | NOT COVERED | PAP | Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP |
26.648 | 60.486 | 283620-DOPAMINE RECEPTOR AGONISTS | Neupro | ROTIGOTINE | PATCH TD24 | 2 MG/24 HR | NOT COVERED | PAP | Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP |
26.649 | 60.487 | 283620-DOPAMINE RECEPTOR AGONISTS | Neupro | ROTIGOTINE | PATCH TD24 | 4 MG/24 HR | NOT COVERED | PAP | Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP |
26.654 | 60.488 | 283620-DOPAMINE RECEPTOR AGONISTS | Neupro | ROTIGOTINE | PATCH TD24 | 6 MG/24 HR | NOT COVERED | PAP | Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP |
26.655 | 60.489 | 283620-DOPAMINE RECEPTOR AGONISTS | Neupro | ROTIGOTINE | PATCH TD24 | 8 MG/24 HR | NOT COVERED | PAP | Formulary: Bromocriptine, Pramipexole, Ropinirole. Contact manufacturer for PAP |
27.576 | 65.570 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Intuniv | GUANFACINE HCL | TAB ER 24H | 1 MG | NOT COVERED | PAP | 处方:胍法辛IR. Contact manufacturer for PAP |
27.578 | 65.572 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Intuniv | GUANFACINE HCL | TAB ER 24H | 2 MG | NOT COVERED | PAP | 处方:胍法辛IR. Contact manufacturer for PAP |
27.579 | 65.573 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Intuniv | GUANFACINE HCL | TAB ER 24H | 3 MG | NOT COVERED | PAP | 处方:胍法辛IR. Contact manufacturer for PAP |
27.582 | 65.574 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Intuniv | GUANFACINE HCL | TAB ER 24H | 4 MG | NOT COVERED | PAP | 处方:胍法辛IR. Contact manufacturer for PAP |
18.776 | 51.489 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Strattera | ATOMOXETINE HCL | CAPSULE | 10 MG | COVERED | FORMULARY | |
18.777 | 51.490 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Strattera | ATOMOXETINE HCL | CAPSULE | 18 MG | COVERED | FORMULARY | |
18.778 | 51.491 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Strattera | ATOMOXETINE HCL | CAPSULE | 25 MG | COVERED | FORMULARY | |
18.779 | 51.492 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Strattera | ATOMOXETINE HCL | CAPSULE | 40 MG | COVERED | FORMULARY | |
18.781 | 51.493 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Strattera | ATOMOXETINE HCL | CAPSULE | 60 MG | COVERED | FORMULARY | |
26.538 | 60.390 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Strattera | ATOMOXETINE HCL | CAPSULE | 80 MG | COVERED | FORMULARY | |
26.539 | 60.391 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Strattera | ATOMOXETINE HCL | CAPSULE | 100 MG | COVERED | FORMULARY | |
95.200 | 40.962 | 366000 -甲状腺功能 | Thyrogen | THYROTROPIN ALFA | VIAL | 1.1 MG | NOT COVERED | PAP | |
43.725 | 77.644 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | QVAR Redihaler | BECLOMETHASONE DIPROPIONATE | HFA AEROBA | 80 MCG | NOT COVERED | PAP | 配方:芳香HFA. Contact manufacturer for PAP |
43.724 | 77.643 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | QVAR Redihaler | BECLOMETHASONE DIPROPIONATE | HFA AEROBA | 40 MCG | NOT COVERED | PAP | 配方:芳香HFA. Contact manufacturer for PAP |
98.024 | 62.240 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Pulmicort Flexhaler | BUDESONIDE | AER POW BA | 90 MCG | NOT COVERED | PAP | 配方:芳香HFA. Contact manufacturer for PAP |
98.025 | 62.241 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Pulmicort Flexhaler | BUDESONIDE | AER POW BA | 180 MCG | NOT COVERED | PAP | 配方:芳香HFA. Contact manufacturer for PAP |
98.499 | 62.725 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Symbicort MDI | BUDESONIDE/FORMOTEROL FUMARATE | HFA AER AD | 80-4.5 MCG | NOT COVERED | PAP | 配方:芳香HFA, Dulera Contact manufacturer for PAP |
98.500 | 62.726 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Symbicort MDI | BUDESONIDE/FORMOTEROL FUMARATE | HFA AER AD | 160-4.5 MCG | NOT COVERED | PAP | 配方:芳香HFA, DuleraContact manufacturer for PAP |
53.633 | 19.317 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent DIKUS | 丙酸 | BLST W/DEV | 100 MCG | NOT COVERED | PAP | 配方:芳香HFA. Contact manufacturer for PAP |
53.634 | 19.318 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent DIKUS | 丙酸 | BLST W/DEV | 250 MCG | NOT COVERED | PAP | 配方:芳香HFA. Contact manufacturer for PAP |
53.635 | 19.319 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Flovent DIKUS | 丙酸 | BLST W/DEV | 50 MCG | NOT COVERED | PAP | 配方:芳香HFA. Contact manufacturer for PAP |
50.594 | 43.367 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Advair DISKUS | FLUTICASONE /氟替卡松加沙美特罗 | BLST W/DEV | 250-50 MCG | NOT COVERED | PAP | 配方:芳香HFA, DuleraContact manufacturer for PAP |
50.604 | 43.368 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Advair DISKUS | FLUTICASONE /氟替卡松加沙美特罗 | BLST W/DEV | 500-50 MCG | NOT COVERED | PAP | 配方:芳香HFA, Dulera Contact manufacturer for PAP |
50.584 | 43.366 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Advair DISKUS | FLUTICASONE /氟替卡松加沙美特罗 | BLST W/DEV | 100-50 MCG | NOT COVERED | PAP | 配方:芳香HFA, DuleraContact manufacturer for PAP |
97.135 | 61.343 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Advair HFA | FLUTICASONE /氟替卡松加沙美特罗 | HFA AER AD | 45-21 MCG | NOT COVERED | PAP | 配方:芳香HFA, Dulera Contact manufacturer for PAP |
97.136 | 61.344 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Advair HFA | FLUTICASONE /氟替卡松加沙美特罗 | HFA AER AD | 115-21 MCG | NOT COVERED | PAP | 配方:芳香HFA, Dulera Contact manufacturer for PAP |
97.137 | 61.345 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Advair HFA | FLUTICASONE /氟替卡松加沙美特罗 | HFA AER AD | 230-21 MCG | NOT COVERED | PAP | 配方:芳香HFA, Dulera Contact manufacturer for PAP |
34.647 | 70.972 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Breo Ellipta | FLUTICASONE / VILANTEROL | BLST W/DEV | 100-25 MCG | NOT COVERED | PAP | 配方:芳香HFA, Dulera Contact manufacturer for PAP |
35.808 | 71.815 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Breo Ellipta | FLUTICASONE / VILANTEROL | BLST W/DEV | 200-25 MCG | NOT COVERED | PAP | 配方:芳香HFA, Dulera Contact manufacturer for PAP |
37.565 | 73.197 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Asmanex HFA | MOMETASONE糠酸盐 | HFA AER AD | 200 MCG | NOT COVERED | PAP | 配方:芳香HFA. Contact manufacturer for PAP |
37.566 | 73.198 | 481008-CORTICOSTEROIDS (RESPIRATORY TRACT) | Asmanex HFA | MOMETASONE糠酸盐 | HFA AER AD | 100 MCG | NOT COVERED | PAP | 配方:芳香HFA. Contact manufacturer for PAP |
40.321 | 29.803 | 481024-LEUKOTRIENE MODIFIERS | Zyflo Filmtab | ZILEUTON | TABLET | 600 MG | NOT COVERED | NON-FORMULARY | 规定:Montelukast. |
98.822 | 63.062 | 481024-LEUKOTRIENE MODIFIERS | Zyflo Filmtab | ZILEUTON | TBMP 12HR | 600 MG | NOT COVERED | NON-FORMULARY | 规定:Montelukast. |
28.934 | 66.612 | 483200-PHOSPHODIESTERASE TYPE 4 INHIBITORS | Daliresp | ROFLUMILAST | TABLET | 500 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
19.216 | 51.820 | 520892-EENT ANTI-INFLAMMATORY AGENTS, MISC. | Restasis | CYCLOSPORINE | DROPERETTE | 0.05 % | NOT COVERED | PAP | Prior auths restricted to opthamology prescriber, Contact manufacturer for PAP |
27.131 | 65.392 | 524028-PROSTAGLANDIN ANALOGS | Lumigan | BIMATOPROST | DROPS | 0.01 % | NOT COVERED | PAP | 规定:Latanoprost. Prior Auths restricted to opthamology, Contact manufacturer for PAP |
27.594 | 65.587 | 524028-PROSTAGLANDIN ANALOGS | Zioptan | TAFLUPROST/PF | DROPS | 0.0015% | NOT COVERED | PAP | 规定:Latanoprost. Prior Auths restricted to opthamology, Contact manufacturer for PAP |
13.002 | 47.612 | 524028-PROSTAGLANDIN ANALOGS | Travatan Z | TRAVOPROST | DROPS | 0.004% | NOT COVERED | PAP | 规定:Latanoprost. Prior Auths restricted to opthamology, Contact manufacturer for PAP |
26.473 | 60.341 | 561200-CATHARTICS AND LAXATIVES | Amitiza | LUBIPROSTONE | CAPSULE | 24 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
99.658 | 63.946 | 561200-CATHARTICS AND LAXATIVES | Amitiza | LUBIPROSTONE | CAPSULE | 8 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
16.305 | 64.793 | 562836-PROTON-PUMP INHIBITORS | Dexilant | DEXLANSOPRAZOLE | CAP DR BP | 30 MG | NOT COVERED | PAP | 规定:Pantoprazole. Contact manufacturer for PAP |
16.306 | 64.794 | 562836-PROTON-PUMP INHIBITORS | Dexilant | DEXLANSOPRAZOLE | CAP DR BP | 60 MG | NOT COVERED | PAP | 规定:Pantoprazole. Contact manufacturer for PAP |
16.305 | 64.793 | 562836-PROTON-PUMP INHIBITORS | Dexilant | DEXLANSOPRAZOLE | CAP DR BP | 30 MG | NOT COVERED | PAP | 规定:Pantoprazole. Contact manufacturer for PAP |
16.306 | 64.794 | 562836-PROTON-PUMP INHIBITORS | Dexilant | DEXLANSOPRAZOLE | CAP DR BP | 60 MG | NOT COVERED | PAP | 规定:Pantoprazole. Contact manufacturer for PAP |
95.348 | 40.304 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Colazal | BALSALAZIDE二钠 | CAPSULE | 750 MG | NOT COVERED | NON-FORMULARY | 规定:柳氮磺胺吡啶. |
99.847 | 64.139 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Rowasa | MESALAMINE W/CLEANSING WIPES | ENEMA KIT | 4 G/60 ML | NOT COVERED | NON-FORMULARY | |
16.159 | 64.701 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Apriso ER | MESALAMINE | CAP ER 24H | 0.375 G | NOT COVERED | PAP | 规定:柳氮磺胺吡啶. Contact manufacturer for PAP |
34.113 | 70.543 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Delzicol DR | MESALAMINE | CAPSULE DR | 400 MG | NOT COVERED | PAP | 规定:柳氮磺胺吡啶. Contact manufacturer for PAP |
23.422 | 58.091 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Pentasa | MESALAMINE | CAPSULE ER | 500 MG | NOT COVERED | PAP | 规定:柳氮磺胺吡啶. Contact manufacturer for PAP |
48.490 | 21.776 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Canasa栓剂 | MESALAMINE | SUPP.RECT | 1000 MG | NOT COVERED | PAP | 规定:柳氮磺胺吡啶. Contact manufacturer for PAP |
97.842 | 62.058 | 563600-ANTI-INFLAMMATORY AGENTS (GI DRUGS) | Lialda | MESALAMINE | TABLET DR | 1.2 G | NOT COVERED | PAP | 规定:柳氮磺胺吡啶. Contact manufacturer for PAP |
39.354 | 74.654 | 569200-GI DRUGS, MISCELLANEOUS | Viberzi | ELUXADOLINE | TABLET | 75 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
39.355 | 74.655 | 569200-GI DRUGS, MISCELLANEOUS | Viberzi | ELUXADOLINE | TABLET | 100 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
33.187 | 69.922 | 569200-GI DRUGS, MISCELLANEOUS | Linzess | LINACLOTIDE | CAPSULE | 145 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
33.188 | 69.923 | 569200-GI DRUGS, MISCELLANEOUS | Linzess | LINACLOTIDE | CAPSULE | 290 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
99.450 | 63.735 | 682003 - amylinomimetics | Symlin | PRAMLINTIDE醋酸 | PEN INJCTR | 2700 MCG/2.7ML | NOT COVERED | PAP | Contact manufacturer for PAP |
99.514 | 63.804 | 682003 - amylinomimetics | Symlin | PRAMLINTIDE醋酸 | PEN INJCTR | 1500 MCG/1.5ML | NOT COVERED | PAP | Contact manufacturer for PAP |
34.086 | 70.525 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Nesina | ALOGLIPTIN | TABLET | 6.25 MG | NOT COVERED | PAP | |
34.085 | 70.524 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Nesina | ALOGLIPTIN | TABLET | 12.5 GM | NOT COVERED | PAP | |
34.076 | 70.517 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Nesina | ALOGLIPTIN | TABLET | 25 MG | NOT COVERED | PAP | |
27.393 | 65.430 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Onglyza | SAXAGLIPTIN HCL | TABLET | 2.5 MG | NOT COVERED | PAP | |
27.394 | 65.431 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Onglyza | SAXAGLIPTIN HCL | TABLET | 5 MG | NOT COVERED | PAP | |
29.224 | 66.817 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Kombiglyze XR | SAXAGLIPTIN HCL/METFORMIN HCL | TBMP 24HR | 5-1000 MG | NOT COVERED | PAP | |
29.225 | 66.818 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Kombiglyze XR | SAXAGLIPTIN HCL/METFORMIN HCL | TBMP 24HR | 2.5-1000 MG | NOT COVERED | PAP | |
29.118 | 66.816 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Kombiglyze XR | SAXAGLIPTIN HCL/METFORMIN HCL | TBMP 24HR | 5-500 MG | NOT COVERED | PAP | |
37.169 | 72.872 | 682006年的今天,肠促胰岛素模拟 | Trulicity | DULAGLUTIDE | PEN INJCTR | 0.75MG/0.5 | NOT COVERED | PAP | 配方:再见,Victoza. Contact manufacturer for PAP |
37.171 | 72.873 | 682006年的今天,肠促胰岛素模拟 | Trulicity | DULAGLUTIDE | PEN INJCTR | 1.5 MG/0.5 | NOT COVERED | PAP | 配方:再见,Victoza. Contact manufacturer for PAP |
44.039 | 77.890 | 682006年的今天,肠促胰岛素模拟 | Bydureon Bcise | EXENATIDE微球 | AUTO INJCT | 2MG/0.85ML | NOT COVERED | PAP | 配方:再见,Victoza. Contact manufacturer for PAP |
36.352 | 72.230 | 682006年的今天,肠促胰岛素模拟 | Bydureon Pen | EXENATIDE微球 | PEN INJCTR | 2MG/0.65ML | NOT COVERED | PAP | 配方:再见,Victoza. Contact manufacturer for PAP |
26.189 | 65.344 | 682006年的今天,肠促胰岛素模拟 | Victoza | LIRAGLUTIDE | PEN INJCTR | 0.6 MG/0.1ML | Covered | FORMULARY | |
98.637 | 62.867 | 682008-INSULINS | Lantus Solostar | 甘精胰岛素.REC.ANLOG | INSULN PEN | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | 规定:Levemir. Contact manufacturer for PAP |
37.988 | 73.567 | 682008-INSULINS | Toujeo Solostar | 甘精胰岛素.REC.ANLOG | INSULN PEN | 300 UNIT/ML | NOT COVERED | NON-FORMULARY | PA仅限于博士. Dubois. Levemir is formulary, Contact manufacturer for PAP |
13.072 | 47.780 | 682008-INSULINS | Lantus | 甘精胰岛素.REC.ANLOG | VIAL | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | 规定:Levemir. Contact manufacturer for PAP |
26.508 | 60.371 | 682008-INSULINS | Apidra Solostar | INSULIN GLULISINE | INSULN PEN | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | 规定:Novolog Contact manufacturer for PAP |
25.936 | 59.985 | 682008-INSULINS | Apidra | INSULIN GLULISINE | VIAL | 100 UNIT/ML | NOT COVERED | NON-FORMULARY | 规定:Novolog. Contact manufacturer for PAP |
9.633 | 29.916 | 682008-INSULINS | Humulin R U500 | 胰岛素正常人 | VIAL | 500 UNIT/ML | NOT COVERED | PAP | Prescribe U500 Syringes, Contact manufacturer for PAP |
34.439 | 70.791 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokana | CANAGLIFLOZIN | TABLET | 100 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
34.441 | 70.792 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokana | CANAGLIFLOZIN | TABLET | 300 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
42.315 | 76.623 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Inokamet XR | CANAGLIFLOZIN/METFORMIN HCL | TAB BP 24H | 150-1000MG | NOT COVERED | PAP | Contact manufacturer for PAP |
42.312 | 76.620 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokamet XR | CANAGLIFLOZIN/METFORMIN HCL | TAB BP 24H | 50MG-500MG | NOT COVERED | PAP | Contact manufacturer for PAP |
42.313 | 76.621 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokamet XR | CANAGLIFLOZIN/METFORMIN HCL | TAB BP 24H | 50-1000 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
42.314 | 76.622 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokamet XR | CANAGLIFLOZIN/METFORMIN HCL | TAB BP 24H | 150-500 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
36.857 | 72.587 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokamet | CANAGLIFLOZIN/METFORMIN HCL | TABLET | 50-1000 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
36.859 | 72.589 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokamet | CANAGLIFLOZIN/METFORMIN HCL | TABLET | 150-1000MG | NOT COVERED | PAP | Contact manufacturer for PAP |
36.953 | 72.677 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokamet | CANAGLIFLOZIN/METFORMIN HCL | TABLET | 150-500 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
36.954 | 72.678 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Invokamet | CANAGLIFLOZIN/METFORMIN HCL | TABLET | 50MG-500MG | NOT COVERED | PAP | Contact manufacturer for PAP |
34.394 | 70.755 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Farxiga | DAPAGLIFLOZIN丙二醇 | TABLET | 10 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
35.698 | 71.740 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Farxiga | DAPAGLIFLOZIN丙二醇 | TABLET | 5 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
37.343 | 73.031 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Xigduo XR | DAPAGLIFLOZIN /盐酸二甲双胍 | TAB BP 24H | 5-1000 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
37.339 | 73.029 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Xigduo XR | DAPAGLIFLOZIN /盐酸二甲双胍 | TAB BP 24H | 5-500 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
37.342 | 73.030 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Xigduo XR | DAPAGLIFLOZIN /盐酸二甲双胍 | TAB BP 24H | 10-500 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
37.344 | 73.032 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Xigduo XR | DAPAGLIFLOZIN /盐酸二甲双胍 | TAB BP 24H | 10-1000 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
36.716 | 72.488 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Jardiance | EMPAGLIFLOZIN | TABLET | 10 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
36.723 | 72.489 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Jardiance | EMPAGLIFLOZIN | TABLET | 25 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
37.832 | 73.432 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Glyxambi | EMPAGLIFLOZIN / LINAGLIPTIN | TABLET | 10 MG-5 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
37.833 | 73.433 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Glyxambi | EMPAGLIFLOZIN / LINAGLIPTIN | TABLET | 25 MG-5 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
38.929 | 74.316 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Synjardy | EMPAGLIFLOZIN /盐酸二甲双胍 | TABLET | 5MG-1000MG | NOT COVERED | PAP | Contact manufacturer for PAP |
38.932 | 74.318 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Synjardy | EMPAGLIFLOZIN /盐酸二甲双胍 | TABLET | 12.5-1000 | NOT COVERED | PAP | Contact manufacturer for PAP |
39.377 | 74.675 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Synjardy | EMPAGLIFLOZIN /盐酸二甲双胍 | TABLET | 5 MG-500MG | NOT COVERED | PAP | Contact manufacturer for PAP |
39.378 | 74.676 | 682018-SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB | Synjardy | EMPAGLIFLOZIN /盐酸二甲双胍 | TABLET | 12.5-500MG | NOT COVERED | PAP | Contact manufacturer for PAP |
14.404 | 64.481 | 682400 -甲状旁腺 | Forteo | TERIPARATIDE | PEN INJCTR | 20 MCG/DOSE | NOT COVERED | PAP | Contact manufacturer for PAP |
96.805 | 34.383 | 683200 -黄体酮 | Crinone Gel | 孕激素,让 | GEL/PF APP | 4% | NOT COVERED | PAP | Endometrin首选 |
63.011 | 31.769 | 683200 -黄体酮 | Crinone Gel | 孕激素,让 | GEL/PF APP | 8% | NOT COVERED | PAP | Endometrin首选 |
47.632 | 20.176 | 683604 -甲状腺制剂 | Synthroid | 左旋甲状腺素钠 | TABLET | 137 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.321 | 6.648 | 683604 -甲状腺制剂 | Synthroid | 左旋甲状腺素钠 | TABLET | 25 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.322 | 6.649 | 683604 -甲状腺制剂 | Synthroid | 左旋甲状腺素钠 | TABLET | 50 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.324 | 6.650 | 683604 -甲状腺制剂 | Synthroid | 左旋甲状腺素钠 | TABLET | 75 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
47.631 | 15.523 | 683604 -甲状腺制剂 | Synthroid | 左旋甲状腺素钠 | TABLET | 88 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.323 | 6.651 | 683604 -甲状腺制剂 | Synthroid | 左旋甲状腺素钠 | TABLET | 100 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.326 | 6.653 | 683604 -甲状腺制剂 | Synthroid | 左旋甲状腺素钠 | TABLET | 125 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.327 | 6.654 | 683604 -甲状腺制剂 | Synthroid | 左旋甲状腺素钠 | TABLET | 150 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.328 | 6.655 | 683604 -甲状腺制剂 | Synthroid | 左旋甲状腺素钠 | TABLET | 175MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.325 | 6.656 | 683604 -甲状腺制剂 | Synthroid | 左旋甲状腺素钠 | TABLET | 200 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.329 | 6.657 | 683604 -甲状腺制剂 | Synthroid | 左旋甲状腺素钠 | TABLET | 300 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
26.320 | 6.652 | 683604 -甲状腺制剂 | Synthroid | 左旋甲状腺素钠 | TABLET | 112 MCG | NOT COVERED | PAP | Contact manufacturer for PAP |
13.480 | 19.141 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Soriatane | ACITRETIN | CAPSULE | 10 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
13.481 | 19.142 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Soriatane | ACITRETIN | CAPSULE | 25 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
18.782 | 51.494 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Avage | TAZAROTENE | CREAM (G) | 0.1 % | NOT COVERED | NON-FORMULARY | |
85.362 | 46.983 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Tazorac Cream | TAZAROTENE | CREAM (G) | 0.05 % | NOT COVERED | NON-FORMULARY | |
85.363 | 46.984 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Tazorac Cream | TAZAROTENE | CREAM (G) | 0.1 % | NOT COVERED | NON-FORMULARY | |
32.178 | 69.204 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Fabior Foam | TAZAROTENE | FOAM | 0.1 % | NOT COVERED | NON-FORMULARY | |
29.222 | 31.601 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Tazorac Cream | TAZAROTENE | GEL (GRAM) | 0.1 % | NOT COVERED | NON-FORMULARY | |
29.221 | 31.600 | 849200-SKIN AND MUCOUS MEMBRANE AGENTS, MISC. | Tazorac Cream | TAZAROTENE | GEL (GRAM) | 0.05 % | NOT COVERED | NON-FORMULARY | |
23.276 | 57.982 | 861204 - antimuscarinics | Vesicare | SOLIFENACIN琥珀酸 | TABLET | 5 MG | NOT COVERED | PAP | 奥施布宁ER优先 |
23.277 | 57.983 | 861204 - antimuscarinics | Vesicare | SOLIFENACIN琥珀酸 | TABLET | 10 MG | NOT COVERED | PAP | 奥施布宁ER优先 |
32.766 | 69.630 | 861208-BETA-3-ADRENERGIC AGONISTS | Myrbetriq ER | MIRABEGRON | TAB ER 24H | 25 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
32.767 | 69.631 | 861208-BETA-3-ADRENERGIC AGONISTS | Myrbetriq ER | MIRABEGRON | TAB ER 24H | 50 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
16.808 | 64.829 | 921600 - antigout代理 | Uloric | FEBUXOSTAT | TABLET | 40 MG | NOT COVERED | PAP | Allopurinol is formulary, Contact manufacturer for PAP |
16.809 | 64.830 | 921600 - antigout代理 | Uloric | FEBUXOSTAT | TABLET | 80 MG | NOT COVERED | PAP | Allopurinol is formulary, Contact manufacturer for PAP |
29.073 | 66.709 | 922000-IMMUNOMODULATORY AGENTS | Gilenya | FINGOLIMOD HCL | CAPSULE | 0.5 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
28.656 | 66.396 | 922400-BONE RESORPTION INHIBITORS | Prolia | DENOSUMAB | SYRINGE | 60 MG/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
97.005 | 61.205 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Humira | ADALIMUMAB | PEN IJ KIT | 40 MG/0.8ML | NOT COVERED | PAP | Contact manufacturer for PAP |
18.924 | 51.599 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Humira | ADALIMUMAB | SYRINGEKIT | 40 MG/0.8ML | NOT COVERED | PAP | Contact manufacturer for PAP |
37.262 | 72.952 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Humira | ADALIMUMAB | SYRINGEKIT | 10 MG/0.2ML | NOT COVERED | PAP | Contact manufacturer for PAP |
99.439 | 63.724 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Humira | ADALIMUMAB | SYRINGEKIT | 20 MG/0.4ML | NOT COVERED | PAP | Contact manufacturer for PAP |
97.724 | 61.938 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Enbrel | ETANERCEPT | PEN INJCTR | 50 MG/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
98.398 | 62.624 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Enbrel | ETANERCEPT | SYRINGE | 25 MG/0.5ML | NOT COVERED | PAP | Contact manufacturer for PAP |
23.574 | 58.214 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Enbrel | ETANERCEPT | SYRINGE | 50 MG/ML | NOT COVERED | PAP | Contact manufacturer for PAP |
52.651 | 40.869 | 923600-DISEASE-MODIFYING ANTIRHEUMATIC AGENTS | Enbrel | ETANERCEPT | VIAL | 25 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
47.560 | 23.724 | 924400-IMMUNOSUPPRESSIVE AGENTS | Cellcept | 霉酚酸酯 | CAPSULE | 250 MG | Covered | FORMULARY | |
47.561 | 32.599 | 924400-IMMUNOSUPPRESSIVE AGENTS | Cellcept | 霉酚酸酯 | CAPSULE | 500 MG | Covered | FORMULARY | |
41.229 | 21.175 | 925600 -保护剂 | Elmiron | PENTOSAN POLYSULFATE SODIUM | CAPSULE | 100 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
45.026 | 78.657 | 681804 - antigonadotropins | Orilissa | ELAGOLIX | TABLET | 150 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
45.026 | 78.657 | 681804 - antigonadotropins | Orilissa | ELAGOLIX | TABLET | 200 MG | NOT COVERED | PAP | Contact manufacturer for PAP |
42.676 | 76.864 | 682008-INSULINS | Soliqua | INSULIN GLARGINE/LIXISENATIDE | INSULN PEN | 100单位-33微克/毫升 | NOT COVERED | PAP | Contact manufacturer for PAP |
29.890 | 67.353 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Tradjenta | LINAGLIPTIN | TABLET | 5 MG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
31.315 | 68.516 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Jentadueto | LINAGLIPTIN /二甲双胍 | TABLET | 2.5-500 MG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
31.316 | 68.517 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Jentadueto | LINAGLIPTIN /二甲双胍 | TABLET | 2.5-850 MG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
31.317 | 68.518 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Jentadueto | LINAGLIPTIN /二甲双胍 | TABLET | 2.5-1000 MG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
41.637 | 76.256 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Jentadueto XR | LINAGLIPTIN /二甲双胍呃 | TABLET | 2.5-1000 MG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
41.639 | 76.257 | 682005-DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS | Jentadueto XR | LINAGLIPTIN /二甲双胍呃 | TABLET | 5-1000 MG | COVERED | FORMULARY | CUC prescribers must send to in-house pharmacies only. Non-CUC may fill at network pharmacies |
34.525 | 70.868 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Namenda XR | MEMANTINE ER | TABLET | 14 mg | NOT COVERED | PAP | Formulary: Memantine IR, Donepezil, Rivastigmine. Contact manufacturer for PAP |
34.527 | 70.870 | 289200-CENTRAL NERVOUS SYSTEM AGENTS, MISC. | Namenda XR | MEMANTINE ER | TABLET | 28 mg | NOT COVERED | PAP | Formulary: Memantine IR, Donepezil, Rivastigmine. Contact manufacturer for PAP |
41.370 | 9.326 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Vancocin | VANCOMYCIN | CAPSULE | 125 MG | Covered | FORMULARY | |
41.371 | 9.327 | 081228-ANTIBACTERIALS, MISCELLANEOUS | Vancocin | VANCOMYCIN | CAPSULE | 250 MG | Covered | FORMULARY | |
46.908 | 80.199 | 68221200-GLYCOGENOLYTIC AGENTS, 92120000-ANTIDOTES | Gvoke | GLUCAGON | 2装式自动进样器 | 1 MG/0.2 ML | Covered | FORMULARY | |
46.907 | 80.198 | 68221200-GLYCOGENOLYTIC AGENTS, 92120000-ANTIDOTES | Gvoke | GLUCAGON | 2装式自动进样器 | 0.5 MG/0.1 ML | Covered | FORMULARY | |
14.781 | 11.876 | 281608 -抗精神病药物 | Haldol Decanoate | 氟哌啶醇癸酸盐 | Vial | 100 mg/ml | Covered | FORMULARY | |
31.612 | 39.781 | 100000-ANTINEOPLASTIC AGENTS | Xeloda | Capecitabine | Tablet | 500 mg | Covered | FORMULARY | 仅限于肿瘤学 & Hematology prescribers only |
23.549 | 58.193 | 681200 -避孕 | PLAN B ONE-STEP, ECONTRA ONE-STEP, NEW DAY, My Choice | Levonorgestrel | Tablet | 1.5 mg | Covered | FORMULARY | |
27.585 | 65.578 | 681200 -避孕 | Ella | Ulipristal | Tablet | 30 mg | Covered | FORMULARY | |
18.092 | 50.805 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan | Valsartan | Tablet | 40 mg | Covered | FORMULARY | |
13.846 | 48.401 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan | Valsartan | Tablet | 80 mg | Covered | FORMULARY | |
13.844 | 48.400 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan | Valsartan | Tablet | 160 mg | Covered | FORMULARY | |
13.838 | 48.399 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan | Valsartan | Tablet | 320 mg | Covered | FORMULARY | |
7.833 | 37.354 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan-HCT | Valsartan-氢氯噻嗪 | Tablet | 80 - 12.5 mg | Covered | FORMULARY | |
9.760 | 38.925 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan-HCT | Valsartan-氢氯噻嗪 | Tablet | 160 - 12.5 mg | Covered | FORMULARY | |
17.245 | 50.256 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan-HCT | Valsartan-氢氯噻嗪 | Tablet | 160 - 25 mg | Covered | FORMULARY | |
27.015 | 60.781 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan-HCT | Valsartan-氢氯噻嗪 | Tablet | 320 - 12.5 mg | Covered | FORMULARY | |
27.014 | 60.780 | 243208-ANGIOTENSIN II RECEPTOR ANTAGONISTS | Diovan-HCT | Valsartan-氢氯噻嗪 | Tablet | 320 - 25 mg | Covered | FORMULARY | |
Generic Code | 通用序号 | 治疗类 | BrandName | GenericName | Formulation | Strength | Coverage | Location | Comments |