Beruflich Dokumente
Kultur Dokumente
Please read: This document contains information about the drugs we cover in this plan.
Important: Priority Health requires the use of an A rated generic drug when one is available.
This list changes frequently. For the most current information, please refer to our drug list at
priorityhealth.com.
ACCU-CHEK
FASTCLIX
LANCETDEVICE KIT KIT Covered
ACCU-CHEK
SOFTCLIX
LANCETDEVICE KIT KIT Covered
ACEBUTOLOL HCL CAPS 400MG Covered
ACEBUTOLOL HCL CAPS 200MG Covered
ACEPHEN SUPP 650MG Covered
ACEPHEN SUPP 120MG Covered
ACEPHEN SUPP 325MG Covered
ACETAMINOPHEN SOLN 160MG/5ML Covered
ACETAMINOPHEN TABS 500MG Covered
ACETAMINOPHEN TABS 325MG Covered
ACETAMINOPHEN
ER TBCR 650MG Covered
ACETAMINOPHEN
EXTRA STRENGTH LIQD 500MG/15ML Covered
ACETAMINOPHEN/C
ODEINE TABS 300MG; 15MG Covered QL
ACETAMINOPHEN/C
ODEINE TABS 300MG; 60MG Covered QL
ACETAMINOPHEN/C
ODEINE SOLN 120MG/5ML; 12MG/5ML Covered QL
ACETAMINOPHEN/C
ODEINE SOLN 120MG/5ML; 12MG/5ML Covered QL
ACETAMINOPHEN/C
ODEINE #3 TABS 300MG; 30MG Covered QL
ACETASOL HC SOLN 2%; 1% Not Covered
ACETAZOLAMIDE TABS 125MG Covered
ACETAZOLAMIDE TABS 250MG Covered
ACETAZOLAMIDE
ER CP12 500MG Covered
ACETIC ACID SOLN 2% Covered
ACETIC
ACID/ALUMINUM
ACETATE SOLN 2%; 0 Covered
ACETYLCYSTEINE SOLN 20% Covered
ACETYLCYSTEINE SOLN 10% Covered
ACIPHEX TBEC 20MG Not Covered
ACITRETIN CAPS 17.5MG Covered
ACITRETIN CAPS 10MG Covered
ACITRETIN CAPS 25MG Covered
ACLOVATE CREA 0.05% Not Covered
0; 0; 0; 0; 0; 0; 0; 10MG;
ADVANCED AM/PM MISC 100MG; 650MG; 0; 50UNIT Covered
ADVATE SOLR 1000UNIT Not Covered
ADVICOR TB24 20MG; 500MG Not Covered
ADVICOR TB24 20MG; 1000MG Not Covered
ALLEGRA ALLERGY
CHILDRENS SUSP 30MG/5ML Covered
ALLEGRA-D 12
HOUR ALLERGY &
CONGESTION TB12 60MG; 120MG Not Covered
ALLEGRA-D 24
HOUR ALLERGY &
CONGESTION TB24 180MG; 240MG Not Covered
ALLER-CHLOR SYRP 2MG/5ML Covered
ALLER-CHLOR TABS 4MG Covered
ALLERGY TABS 4MG Covered
ALLERGY TABS 10MG Covered
ALLERGY
MEDICATION
CHILDRENS LIQD 12.5MG/5ML Covered
ALLERGY RELIEF TABS 10MG Covered
ALLERGY RELIEF TABS 4MG Covered
ALLERGY RELIEF
FOR KIDS SYRP 5MG/5ML Covered QL AL
ALLERGY
RELIEF/NASAL
DECONGESTANT TB24 10MG; 240MG Not Covered
ALLERGY-TIME TABS 4MG Covered
ALLOPURINOL TABS 100MG Covered QL
ALLOPURINOL TABS 300MG Covered QL
AMILORIDE/HYDRO
CHLOROTHIAZIDE TABS 5MG; 50MG Covered QL
AMINOCAPROIC
ACID SYRP 25% Not Covered
AMINOCAPROIC
ACID TABS 500MG Not Covered
AMIODARONE HCL TABS 200MG Covered
AMIODARONE HCL TABS 100MG Covered
AMIODARONE HCL TABS 400MG Covered
AMITIZA CAPS 24MCG Covered
AMITIZA CAPS 8MCG Covered
AMPHETAMINE/DEX
TROAMPHETAMINE TABS 5MG; 5MG; 5MG; 5MG Not Covered
AMPHETAMINE/DEX
TROAMPHETAMINE CP24 5MG; 5MG; 5MG; 5MG Not Covered
ANIMAS VIBE
INSULIN PUMP/BLUE KIT Not Covered
1000UNIT; 500MCG;
350MG; 35MG; 1MG;
ANIMI-3 CAPS 500MG; 200MG; 12.5MG Covered
45MG/ML; 3MG/ML;
15MCG/ML; 3MG/ML;
400UNIT/ML; 2MG/ML;
6MG/ML; 400MCG/ML;
0.6MG/ML; 0.6MG/ML;
10MCG/ML; 0.6MG/ML;
50UNIT/ML; 5751UNIT/ML;
AQUADEKS LIQD 15MG/ML; 5MG/ML Not Covered
AQUANIL HC LOTN 1% Covered
ARANELLE TABS 0; 0 Covered
ARANESP ALBUMIN
FREE SOLN 40MCG/ML Covered PA
ARANESP ALBUMIN
FREE SOLN 25MCG/ML Covered PA
ARANESP ALBUMIN
FREE SOLN 200MCG/ML Covered PA
ARANESP ALBUMIN
FREE SOSY 40MCG/0.4ML Covered PA
ARANESP ALBUMIN
FREE SOSY 500MCG/ML Covered PA
ARANESP ALBUMIN
FREE SOSY 60MCG/0.3ML Covered PA
ARANESP ALBUMIN
FREE SOSY 150MCG/0.3ML Covered PA
ARANESP ALBUMIN
FREE SOSY 100MCG/0.5ML Covered PA
ARANESP ALBUMIN
FREE SOSY 200MCG/0.4ML Covered PA
ARANESP ALBUMIN
FREE SOLN 10MCG/0.4ML Covered PA
ARANESP ALBUMIN
FREE SOLN 60MCG/ML Covered PA
ARANESP ALBUMIN
FREE SOLN 100MCG/ML Covered PA
ARANESP ALBUMIN
FREE SOLN 150MCG/0.75ML Covered PA
BAYER CHEWABLE
LOW DOSE CHEW 81MG Covered QL AL
BD INSULIN
SYRINGE
MICROFINE IV/U-
100/0.5ML/28G X 1/2" MISC Covered
BD INSULIN
SYRINGE
MICROFINE/U-
100/0.3ML/28G X 1/2" MISC Covered
BD INSULIN
SYRINGE
ULTRAFINE/1ML/30G
X 1/2" MISC Covered
BD INTEGRA 3ML
SYRINGE
W/RETRACTING
NEEDLE/21G X 1-1/2" MISC Covered
BD INTEGRA 3ML
SYRINGE
W/RETRACTING
NEEDLE/25G X 1" MISC Covered
BD PEN
NEEDLE/NANO/ULT
RA FINE/32G X 4MM MISC Covered
BD PEN
NEEDLE/SHORT/ULT
RAFINE/31G X 5/16" MISC Covered
BD PEN
NEEDLE/ULTRAFINE
/29GX1/2" 12.7MM MISC Covered
BD SAFETYGLIDE
21G X 1-1/2" MISC Covered
BD SAFETYGLIDE
ALLERGY
SYRINGE/1ML/27GX
1/2" MISC Covered
BEBULIN SOLR 200-1200 UNIT Not Covered
BELLADONNA
ALKALOIDS &
OPIUM SUPP 16.2MG; 60MG Not Covered
BELSOMRA TABS 10MG Not Covered
BELSOMRA TABS 5MG Not Covered
BELSOMRA TABS 15MG Not Covered
BELSOMRA TABS 20MG Not Covered
BELVIQ TABS 10MG Not Covered
BENAZEPRIL HCL TABS 40MG Covered QL
BENAZEPRIL HCL TABS 10MG Covered QL
BENAZEPRIL HCL TABS 20MG Covered QL
BENAZEPRIL HCL TABS 5MG Covered QL
BENAZEPRIL
HCL/HYDROCHLOR
OTHIAZIDE TABS 10MG; 12.5MG Not Covered
BISOPROLOL
FUMARATE/HYDRO
CHLOROTHIAZIDE TABS 2.5MG; 6.25MG Covered QL
BISOPROLOL
FUMARATE/HYDRO
CHLOROTHIAZIDE TABS 5MG; 6.25MG Covered
BISOPROLOL
FUMARATE/HYDRO
CHLOROTHIAZIDE TABS 10MG; 6.25MG Covered QL
BLEPHAMIDE SUSP 0.2%; 10% Covered
0; 0; 1000UNIT; 500MCG;
350MG; 35MG; 1MG;
BP VIT 3 PLUS CAPS 500MG; 200MG; 12.5MG; 0 Covered
BPO GEL 8% Not Covered
BPO GEL 4% Not Covered
CAPTOPRIL/HYDRO
CHLOROTHIAZIDE TABS 50MG; 15MG Not Covered
CAPTOPRIL/HYDRO
CHLOROTHIAZIDE TABS 25MG; 25MG Not Covered
CAPTOPRIL/HYDRO
CHLOROTHIAZIDE TABS 50MG; 25MG Not Covered
CAPTOPRIL/HYDRO
CHLOROTHIAZIDE TABS 25MG; 15MG Not Covered
CARAC CREA 0.50% Not Covered
CARAFATE SUSP 1GM/10ML Not Covered
CARBAGLU TABS 200MG Not Covered
CARBAMAZEPINE SUSP 100MG/5ML Not Covered
CARBAMAZEPINE CHEW 100MG Not Covered
CARBAMAZEPINE TABS 200MG Not Covered
CARBAMAZEPINE
ER TB12 400MG Not Covered
CARBIDOPA/LEVOD
OPA/ENTACAPONE TABS 12.5MG; 200MG; 50MG Not Covered
CARBIDOPA/LEVOD
OPA/ENTACAPONE TABS 18.75MG; 200MG; 75MG Not Covered
CARBIDOPA/LEVOD
OPA/ENTACAPONE TABS 25MG; 200MG; 100MG Not Covered
CARBIDOPA/LEVOD
OPA/ENTACAPONE TABS 50MG; 200MG; 200MG Not Covered
CARBIDOPA/LEVOD
OPA/ENTACAPONE TABS 31.25MG; 200MG; 125MG Not Covered
CARBIDOPA/LEVOD
OPA/ENTACAPONE TABS 37.5MG; 200MG; 150MG Not Covered
CARBINOXAMINE
MALEATE TABS 4MG Covered
CARBINOXAMINE
MALEATE SOLN 4MG/5ML Covered
500MG; 500MCG; 2MG; 0;
CARDIOTEK-RX TABS 50MG Covered
CARDIZEM CD CP24 120MG Not Covered
CARDIZEM CD CP24 240MG Not Covered
CARDIZEM CD CP24 300MG Not Covered
CARDIZEM CD CP24 360MG Not Covered
CARDIZEM CD CP24 180MG Not Covered
CARDIZEM LA TB24 300MG Not Covered
CARDIZEM LA TB24 360MG Not Covered
CARDIZEM LA TB24 180MG Not Covered
CARDIZEM LA TB24 120MG Not Covered
CARDIZEM LA TB24 240MG Not Covered
CARDIZEM LA TB24 420MG Not Covered
CARISOPRODOL TABS 350MG Not Covered
CARISOPRODOL/AS
PIRIN TABS 325MG; 200MG Not Covered
CARTEOLOL HCL SOLN 1% Covered
CARTIA XT CP24 120MG Not Covered
CARTIA XT CP24 300MG Not Covered
CARTIA XT CP24 180MG Not Covered
CARTIA XT CP24 240MG Not Covered
CARVEDILOL TABS 3.125MG Covered
CARVEDILOL TABS 25MG Covered
CARVEDILOL TABS 12.5MG Covered
CARVEDILOL TABS 6.25MG Covered
CASODEX TABS 50MG Not Covered
CATAPRES TABS 0.2MG Not Covered
CATAPRES TABS 0.3MG Not Covered
CATAPRES TABS 0.1MG Not Covered
CATAPRES-TTS-1 PTWK 0.1MG/24HR Not Covered
CATAPRES-TTS-2 PTWK 0.2MG/24HR Not Covered
CATAPRES-TTS-3 PTWK 0.3MG/24HR Not Covered
CHANTIX STARTING
MONTH PAK TABS 0 Covered
CHEMET CAPS 100MG Covered
CHEMSTRIP BG LOG
BOOK MISC Covered
CHEMSTRIP-K STRP 0 Covered
COSENTYX
SENSOREADY PEN SOAJ 150MG/ML Not Covered
COUMADIN TABS 4MG Not Covered
COUMADIN TABS 1MG Not Covered
COUMADIN TABS 10MG Not Covered
COUMADIN TABS 7.5MG Not Covered
COUMADIN TABS 6MG Not Covered
COUMADIN TABS 5MG Not Covered
COUMADIN TABS 2MG Not Covered
COUMADIN TABS 2.5MG Not Covered
COUMADIN TABS 3MG Not Covered
COVARYX HS TABS 0.625MG; 1.25MG Not Covered
30000UNIT; 6000UNIT;
CREON CPEP 19000UNIT Covered QL
15000UNIT; 3000UNIT;
CREON CPEP 9500UNIT Covered QL
DERMA-
SMOOTHE/FS BODY OIL 0.01% Not Covered
DERMA-
SMOOTHE/FS
SCALP OIL 0.01% Not Covered
DERMATOP OINT 0.10% Not Covered
DERMATOP CREA 0.10% Not Covered
DERMOTIC OIL 0.01% Not Covered
DESIPRAMINE HCL TABS 50MG Not Covered
DESIPRAMINE HCL TABS 150MG Not Covered
DESIPRAMINE HCL TABS 100MG Not Covered
DESIPRAMINE HCL TABS 10MG Not Covered
DESIPRAMINE HCL TABS 75MG Not Covered
DESIPRAMINE HCL TABS 25MG Not Covered
DESMOPRESSIN
ACETATE TABS 0.2MG Covered QL
DESMOPRESSIN
ACETATE SOLN 0.01% Covered
DESOGESTREL/ETH
INYL ESTRADIOL TABS 0.15MG; 30MCG Covered
DESOGESTREL/ETH
INYL ESTRADIOL TABS 0; 0 Covered
DESONIDE LOTN 0.05% Not Covered
DESONIDE OINT 0.05% Not Covered
DESONIDE CREA 0.05% Not Covered
DROSPIRENONE/ET
HINYL ESTRADIOL TABS 3MG; 0.03MG Covered
DROXIA CAPS 400MG Covered
DROXIA CAPS 300MG Covered
DROXIA CAPS 200MG Covered
DRYSOL SOLN 20% Covered
DSS CAPS 100MG Covered
DSS CAPS 250MG Covered
DUAC GEL 5%; 1.2% Not Covered
DUAVEE TABS 20MG; 0.45MG Not Covered
DUETACT TABS 2MG; 30MG Not Covered
DUETACT TABS 4MG; 30MG Not Covered
DUEXIS TABS 26.6MG; 800MG Not Covered
EARWAX
TREATMENT DROPS SOLN 6.50% Not Covered
EASIVENT MISC Covered QL
EC-NAPROSYN TBEC 500MG Not Covered
EC-NAPROSYN TBEC 375MG Not Covered
ECONAZOLE
NITRATE CREA 1% Covered QL
ECOTRIN LOW
STRENGTH TBEC 81MG Covered AL
EDARBI TABS 80MG Not Covered
EDARBI TABS 40MG Not Covered
EDARBYCLOR TABS 40MG; 12.5MG Not Covered
EDARBYCLOR TABS 40MG; 25MG Not Covered
EDECRIN TABS 25MG Not Covered
EDLUAR SUBL 10MG Not Covered
EDLUAR SUBL 5MG Not Covered
EDURANT TABS 25MG Not Covered
EEMT HS TABS 0.625MG; 1.25MG Not Covered
EFFERVESCENT
POTASSIUM TBEF 2GM; 2.5GM Covered
EFFERVESCENT
POTASSIUM/CHLORI 0.55GM; 0.91GM; 0.5GM;
DE TBEF 1.5GM Covered
EFFEXOR XR CP24 150MG Not Covered
EFFEXOR XR CP24 37.5MG Not Covered
EFFEXOR XR CP24 75MG Not Covered
EFFIENT TABS 10MG Not Covered
EFFIENT TABS 5MG Not Covered
ELAPRASE SOLN 6MG/3ML Not Covered
ERYTHROMYCIN/BE
NZOYL PEROXIDE GEL 5%; 3% Covered QL
ERYTHROMYCIN/SU
LFISOXAZOLE SUSR 200MG/5ML; 600MG/5ML Not Covered
ESBRIET CAPS 267MG Not Covered
ESCITALOPRAM
OXALATE TABS 5MG Not Covered
ESCITALOPRAM
OXALATE TABS 10MG Not Covered
ESCITALOPRAM
OXALATE TABS 20MG Not Covered
ESCITALOPRAM
OXALATE SOLN 5MG/5ML Not Covered
ESGIC TABS 325MG; 50MG; 40MG Covered QL AL
ESGIC CAPS 325MG; 50MG; 40MG Covered QL AL
ESOMEPRAZOLE
STRONTIUM CPDR 49.3MG Not Covered
ESTARYLLA TABS 35MCG; 0.25MG Covered
ESTAZOLAM TABS 1MG Not Covered
ESTAZOLAM TABS 2MG Not Covered
ESTERIFIED
ESTROGENS/METH
YLTESTOSTERONE
DS TABS 1.25MG; 2.5MG Covered
ESTERIFIED
ESTROGENS/METH
YLTESTOSTERONE
HS TABS 0.625MG; 1.25MG Covered
ESTRACE CREA 0.1MG/GM Covered QL
ESTRADIOL TABS 2MG Covered AL
ESTRADIOL PTWK 0.1MG/24HR Covered QL
ESTRADIOL PTWK 0.075MG/24HR Covered QL
ESTRADIOL TABS 0.5MG Covered AL
ESTRADIOL TABS 1MG Covered AL
ESTRADIOL PTWK 0.025MG/24HR Covered QL
ESTRADIOL PTWK 0.05MG/24HR Covered QL
ESTRADIOL PTWK 37.5MCG/24HR Covered QL
FIRST-
TESTOSTERONE MC
COMPOUNDING KIT CREA 2% Not Covered
FLAGYL ER TB24 750MG Not Covered
FLAREX SUSP 0.10% Covered
FLAVOXATE HCL TABS 100MG Covered
FLECAINIDE
ACETATE TABS 150MG Covered
FLECAINIDE
ACETATE TABS 100MG Covered
FLUOCINOLONE
ACETONIDE SCALP OIL 0.01% Not Covered
FLUOCINONIDE GEL 0.05% Not Covered
FLUOCINONIDE OINT 0.05% Covered QL
FLUOCINONIDE CREA 0.10% Not Covered
FLUOCINONIDE CREA 0.05% Covered QL
FLUOCINONIDE SOLN 0.05% Covered
FLUOCINONIDE-E CREA 0.05% Covered QL
FLUORIDE CHEW 2.2MG Covered QL AL
FLUORIDE CHEW 1.1MG Covered QL AL
FLUORIDEX DAILY
DEFENSE
ENHANCED
WHITENING GEL 1.10% Covered AL
FLUOROMETHOLON
E SUSP 0.10% Covered QL
FLUOROURACIL SOLN 2% Not Covered
FLUOROURACIL SOLN 5% Not Covered
FLUOROURACIL CREA 0.50% Covered QL
FLUOROURACIL CREA 5% Covered
FLUOXETINE HCL CAPS 10MG Not Covered
FLUOXETINE HCL SOLN 20MG/5ML Not Covered
FLUOXETINE HCL CAPS 20MG Not Covered
FLUOXETINE HCL TABS 10MG Not Covered
FLUOXETINE HCL CAPS 40MG Not Covered
FLUOXETINE HCL TABS 20MG Not Covered
FLUZONE HIGH-
DOSE PF 2013-2014 SUSY 0 Covered AL
FLUZONE HIGH-
DOSE PF 2015-2016 SUSY 0 Covered AL
FLUZONE
INTRADERMAL SUPN 0 Not Covered
FLUZONE
PEDIATRIC PF 2013-
2014 SUSY 0 Not Covered
FLUZONE PF 2013-
2014 SUSP 0 Covered AL
FLUZONE
QUADRIVALENT
2014-2015 SUSP 0 Not Covered
FLUZONE
QUADRIVALENT
2015-2016 SUSP 0 Covered QL AL
FLUZONE SPLIT
2013-2014 SUSP 0 Covered AL
FLUZONE SPLIT
2015-2016 SUSP 0 Covered QL AL
FML OINT 0.10% Covered
FML FORTE SUSP 0.25% Covered QL
120MG; 12MCG; 50MG; 0;
FOCALGIN DSS TABS 1MG; 90MG; 0 Covered
FOCALIN XR CP24 5MG Not Covered
FOCALIN XR CP24 15MG Not Covered
HYDROCORTISONE
ACETATE/PRAMOXI
NE CREA 2.5%; 1% Not Covered
HYDROCORTISONE
ACETATE/PRAMOXI
NE CREA 1%; 1% Not Covered
HYDROCORTISONE
BUTYRATE CREA 0.10% Not Covered
HYDROCORTISONE
BUTYRATE SOLN 0.10% Not Covered
HYDROCORTISONE
BUTYRATE OINT 0.10% Not Covered
HYDROCORTISONE
VALERATE CREA 0.20% Covered
HYDROCORTISONE
VALERATE OINT 0.20% Not Covered
HYDROCORTISONE/
ACETIC ACID SOLN 2%; 1% Covered
HYDROFERA BLUE
FOAM DRESSING PADS Not Covered
HYDROMORPHONE
HCL TABS 8MG Not Covered
HYDROMORPHONE
HCL TABS 4MG Covered QL
HYDROMORPHONE
HCL TABS 2MG Covered QL
HYDROMORPHONE
HCL SUPP 3MG Covered QL
HYDROMORPHONE
HCL LIQD 1MG/ML Covered QL
HYDROMORPHONE
HCL ER T24A 12MG Not Covered
HYDROMORPHONE
HCL ER T24A 16MG Not Covered
HYDROMORPHONE
HCL ER T24A 8MG Not Covered
HYDROMORPHONE
HCL ER T24A 32MG Not Covered
HYDROQUINONE CREA 4% Not Covered
HYDROXYCHLOROQ
UINE SULFATE TABS 200MG Covered
HYDROXYUREA CAPS 500MG Not Covered
IMITREX STATDOSE
SYSTEM SOAJ 4MG/0.5ML Not Covered
IMITREX STATDOSE
SYSTEM SOAJ 6MG/0.5ML Not Covered
IMOVAX RABIES
(H.D.C.V.) INJ 2.5UNIT/ML Covered AL
200MG/5ML; 60MCG/5ML;
200UNIT/5ML; 5MCG/5ML;
15MG/5ML; 600MCG/5ML;
40MG/5ML; 150MCG/5ML;
6MG/5ML; 3.6MG/5ML;
6MG/5ML; 10UNIT/5ML;
INFUVITE ADULT INJ 3300UNIT/5ML Covered
INJECTAFER SOLN 750MG/15ML Covered
INLYTA TABS 1MG Not Covered
INLYTA TABS 5MG Not Covered
INNOPRAN XL CP24 80MG Not Covered
INNOPRAN XL CP24 120MG Not Covered
INSPRA TABS 25MG Not Covered
INSPRA TABS 50MG Not Covered
40MG; 62.5MG; 1000MCG;
INTEGRA F CAPS 3MG; 62.5MG Covered
IRBESARTAN/HYDR
OCHLOROTHIAZIDE TABS 12.5MG; 150MG Covered QL
IRBESARTAN/HYDR
OCHLOROTHIAZIDE TABS 12.5MG; 300MG Covered QL
IRENKA CPEP 40MG Not Covered
IRESSA TABS 250MG Not Covered
250MG; 25MCG; 1MG;
IRON 100 PLUS TABS 100MG Covered AL
IRON SUPPLEMENT
CHILDRENS SOLN 15MG/ML Covered AL
300MCG; 100MG; 155MG;
7MG; 10MCG; 65MG;
1000MCG; 25MG; 65MG;
30MG; 5MG; 100MG;
IROSPAN 24/6 MISC 150MG; 5MG Covered
ISENTRESS TABS 400MG Not Covered
ISOMETHEPTENE/C
AFFEINE/ACETAMIN
OPHEN TABS 500MG; 20MG; 130MG Not Covered
ISOMETHEPTENE/DI
CHLORALPHENAZO
NE/ACETAMINOPHE
N CAPS 325MG; 100MG; 0; 65MG Not Covered
ISONIAZID TABS 100MG Covered
ISONIAZID TABS 300MG Covered
ISONIAZID SYRP 50MG/5ML Covered
ISOPROPYL
ALCOHOL WIPES MISC 70% Covered
LEVOCETIRIZINE
DIHYDROCHLORIDE TABS 5MG Not Covered
LEVOFLOXACIN TABS 250MG Not Covered
LEVOFLOXACIN SOLN 25MG/ML Not Covered
LEVOFLOXACIN TABS 500MG Not Covered
LEVOFLOXACIN TABS 750MG Not Covered
LEVOFLOXACIN SOLN 0.50% Covered
LEVOMEFOLATE
CALCIUM/ACETYLC
YSTEINE/MECOBAL
AMIN/ALGAL 600MG; 6MG; 2MG;
POWDER TABS 90.314MG Covered
LISINOPRIL/HYDRO
CHLOROTHIAZIDE TABS 25MG; 20MG Covered QL
LISINOPRIL/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 10MG Covered QL
LISINOPRIL/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 20MG Covered QL
LITHIUM SOLN 8MEQ/5ML Not Covered
LITHIUM
CARBONATE CAPS 300MG Not Covered
LITHIUM
CARBONATE CAPS 600MG Not Covered
LITHIUM
CARBONATE CAPS 150MG Not Covered
LITHIUM
CARBONATE ER TBCR 450MG Not Covered
LITHIUM
CARBONATE ER TBCR 300MG Not Covered
LITHOSTAT TABS 250MG Not Covered
LIVALO TABS 2MG Not Covered
LIVALO TABS 1MG Not Covered
LIVALO TABS 4MG Not Covered
LIVIXIL PAK KIT 2.5%; 2.5% Not Covered
LMTHF/PYRIDOXINE
HCL/CYANOCOBALA
MIN TABS 2MG; 1.13MG; 25MG Covered
LO LOESTRIN FE TABS 10MCG; 75MG; 1MG Covered
LODOSYN TABS 25MG Not Covered
LOESTRIN 1/20-21 TABS 20MCG; 1MG Covered
LOFIBRA CAPS 200MG Not Covered
LOFIBRA TABS 160MG Not Covered
LOFIBRA CAPS 134MG Not Covered
LOFIBRA CAPS 67MG Not Covered
LOMEDIA 24 FE TABS 20MCG; 75MG; 1MG Covered
LOMUSTINE CAPS 100MG Covered
LOMUSTINE CAPS 10MG Covered
LOMUSTINE CAPS 40MG Covered
LONSURF TABS 6.14MG; 15MG Not Covered
LONSURF TABS 8.19MG; 20MG Not Covered
LOPERAMIDE HCL CAPS 2MG Covered
LORATADINE TABS 10MG Covered
LORATADINE
CHILDRENS SOLN 5MG/5ML Covered QL AL
LORATADINE HIVES
RELIEF SOLN 5MG/5ML Covered QL AL
LORATADINE-D
12HR TB12 5MG; 120MG Not Covered
LORATADINE-D
24HR TB24 10MG; 240MG Not Covered
LORAZEPAM TABS 2MG Not Covered
LORAZEPAM TABS 0.5MG Not Covered
LORAZEPAM TABS 1MG Not Covered
LORAZEPAM
INTENSOL CONC 2MG/ML Not Covered
LORYNA TABS 3MG; 0.02MG Covered
LORZONE TABS 375MG Not Covered
LORZONE TABS 750MG Not Covered
LOSARTAN
POTASSIUM TABS 25MG Covered QL
LOSARTAN
POTASSIUM TABS 50MG Covered QL
LOSARTAN
POTASSIUM TABS 100MG Covered QL
LOSARTAN
POTASSIUM/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 100MG Covered QL
LOSARTAN
POTASSIUM/HYDRO
CHLOROTHIAZIDE TABS 25MG; 100MG Covered QL
LOSARTAN
POTASSIUM/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 50MG Covered QL
LOSEASONIQUE TABS 0; 0 Not Covered
LOTEMAX OINT 0.50% Not Covered
LOTEMAX GEL 0.50% Not Covered
LOTEMAX SUSP 0.50% Not Covered
LOTREL CAPS 5MG; 40MG Not Covered
LOTREL CAPS 10MG; 40MG Not Covered
LOTRONEX TABS 0.5MG Not Covered
LOTRONEX TABS 1MG Not Covered
LOVASTATIN TABS 40MG Covered QL
LOVASTATIN TABS 20MG Covered QL
LOVASTATIN TABS 10MG Covered QL
LOVAZA CAPS 375MG; 465MG; 1GM Not Covered
LOVENOX SOLN 40MG/0.4ML Not Covered
LOVENOX SOLN 80MG/0.8ML Not Covered
LOVENOX SOLN 100MG/ML Not Covered
LOVENOX SOLN 30MG/0.3ML Not Covered
LOVENOX SOLN 60MG/0.6ML Not Covered
LOVENOX SOLN 120MG/0.8ML Not Covered
LOVENOX SOLN 150MG/ML Not Covered
LOW-OGESTREL TABS 30MCG; 0.3MG Covered
LOXAPINE CAPS 50MG Not Covered
LOXAPINE
SUCCINATE CAPS 5MG Not Covered
LOXAPINE
SUCCINATE CAPS 25MG Not Covered
LOXAPINE
SUCCINATE CAPS 10MG Not Covered
LOXAPINE
SUCCINATE CAPS 50MG Not Covered
LOXITANE CAPS 5MG Not Covered
LUMIGAN SOLN 0.01% Not Covered
LUMIZYME SOLR 50MG Not Covered
LUNESTA TABS 3MG Not Covered
200MG/10ML;
60MCG/10ML;
5MCG/10ML; 15MG/10ML;
5MCG/10ML;
600MCG/10ML;
40MG/10ML;
150MCG/10ML; 6MG/10ML;
3.6MG/10ML; 6MG/10ML;
M.V.I. ADULT INJ 10MG/10ML; 1MG/10ML Covered
MACA CAPS 500MG Not Covered
MEDROXYPROGEST
ERONE ACETATE TABS 5MG Covered
MEDROXYPROGEST
ERONE ACETATE TABS 2.5MG Covered
MEDROXYPROGEST
ERONE ACETATE TABS 10MG Covered
MEDROXYPROGEST
ERONE ACETATE SUSP 150MG/ML Not Covered
MEFENAMIC ACID CAPS 250MG Not Covered
MEFLOQUINE HCL TABS 250MG Covered
MEGACE ES SUSP 625MG/5ML Not Covered
MEGESTROL
ACETATE TABS 40MG Covered
MEGESTROL
ACETATE SUSP 40MG/ML Covered
MEGESTROL
ACETATE TABS 20MG Covered
MEKINIST TABS 2MG Not Covered
MEKINIST TABS 0.5MG Not Covered
MELOXICAM TABS 7.5MG Covered QL
MELOXICAM TABS 15MG Covered QL
MELOXICAM SUSP 7.5MG/5ML Not Covered
MELPAQUE HP CREA 4% Not Covered
MEMANTINE HCL TABS 5MG Covered QL AL
MEMANTINE HCL TABS 10MG Covered QL AL
MEMANTINE HCL
TITRATION PAK TABS 0 Covered QL AL
MEMANTINE
HYDROCHLORIDE SOLN 2MG/ML Not Covered QL AL
MENACTRA INJ 0 Covered QL AL
MENEST TABS 0.625MG Covered QL
MENEST TABS 0.3MG Covered QL
MENEST TABS 1.25MG Covered QL
MENEST TABS 2.5MG Covered QL
METHYLDOPA/HYDR
OCHLOROTHIAZIDE TABS 25MG; 250MG Covered
METHYLDOPA/HYDR
OCHLOROTHIAZIDE TABS 15MG; 250MG Covered
METHYLERGONOVI
NE MALEATE TABS 0.2MG Covered AL
METHYLIN CHEW 10MG Not Covered
METHYLIN CHEW 2.5MG Not Covered
METHYLIN SOLN 5MG/5ML Not Covered
METHYLIN CHEW 5MG Not Covered
120MG; 0; 200MG;
400UNIT; 2MG; 12MCG;
50MG; 1MG; 90MG; 30MG;
20MG; 20MG; 3.4MG; 3MG;
MYNATAL ADVANCE TABS 30UNIT; 2700UNIT; 25MG Covered QL AL
120MG; 200MG; 400UNIT;
2MG; 12MCG; 1MG; 65MG;
20MG; 10MG; 3MG;
1.84MG; 4000UNIT; 11MG;
MYNATAL PLUS TABS 25MG Covered QL AL
120MG; 0; 200MG;
400UNIT; 2MG; 12MCG;
50MG; 1MG; 90MG; 20MG;
150MCG; 20MG; 3.4MG;
MYNATAL 3MG; 30UNIT; 2700UNIT;
ULTRACAPLET TABS 25MG Covered QL AL
70MG; 200MG; 2.2MCG;
65MG; 1MG; 100MG;
17MG; 175MCG; 2.2MG;
1.6MG; 65MCG; 1.5MG;
4000UNIT; 400UNIT;
MYNATAL-Z TABS 10UNIT; 15MG Covered QL AL
120MG; 250MG; 2MG;
12MCG; 50MG; 400UNIT;
90MG; 1MG; 20MG;
0.15MG; 20MG; 3.4MG;
3MG; 4000UNIT; 30UNIT;
MYNATE 90 PLUS TBCR 25MG Covered QL AL
100MG; 150MCG; 5MG;
6MCG; 1MG; 20MG; 10MG;
MYNEPHROCAPS CAPS 1.7MG; 1.5MG Covered
MYORISAN CAPS 10MG Not Covered
MYORISAN CAPS 20MG Not Covered
MYORISAN CAPS 40MG Not Covered
MYOZYME SOLR 50MG Not Covered
MYRBETRIQ TB24 50MG Not Covered
MYRBETRIQ TB24 25MG Not Covered
NEOMYCIN/POLYMY
XIN/BACITRACIN/HY 400UNIT/GM; 1%; 0.5%;
DROCORTISONE OINT 10000UNIT/GM Not Covered
NEOMYCIN/POLYMY
XIN/DEXAMETHASO 0.1%; 3.5MG/ML;
NE SUSP 10000UNIT/ML Covered
NEOMYCIN/POLYMY
XIN/DEXAMETHASO 0.1%; 3.5MG/GM;
NE OINT 10000UNIT/GM Covered
NEOMYCIN/POLYMY 0.025MG/ML; 1.75MG/ML;
XIN/GRAMICIDIN SOLN 10000UNIT/ML Not Covered
NEOMYCIN/POLYMY 1%; 3.5MG/ML;
XIN/HC SOLN 10000UNIT/ML Covered
NEOMYCIN/POLYMY
XIN/HYDROCORTIS 1%; 3.5MG/ML;
ONE SUSP 10000UNIT/ML Covered
NEOMYCIN/POLYMY
XIN/HYDROCORTIS 1%; 3.5MG/ML;
ONE SUSP 10000UNIT/ML Covered
NEORAL CAPS 100MG Not Covered
NEORAL SOLN 100MG/ML Not Covered
NEORAL CAPS 25MG Not Covered
NORGESTIMATE/ET
HINYL ESTRADIOL TABS 0; 0 Covered
NORGESTIMATE/ET
HINYL ESTRADIOL TABS 0; 0 Covered
NORGESTIMATE/ET
HINYL ESTRADIOL TABS 35MCG; 0.25MG Covered
NORTHERA CAPS 300MG Not Covered
NORTHERA CAPS 100MG Not Covered
NORTHERA CAPS 200MG Not Covered
120MG; 2700UNIT;
400UNIT; 12MCG; 50MG;
1MG; 29MG; 30MG; 20MG;
40MG; 3.4MG; 65MCG;
OBSTETRIX EC TABS 3MG; 18UNIT; 25MG Covered QL AL
OMEPRAZOLE/SODI
UM BICARBONATE CAPS 20MG; 1100MG Not Covered
OMNARIS SUSP 50MCG/ACT Not Covered
OMNITROPE SOLN 5MG/1.5ML Not Covered
OPANA ER (CRUSH
RESISTANT) T12A 20MG Not Covered
OPANA ER (CRUSH
RESISTANT) T12A 10MG Not Covered
OPANA ER (CRUSH
RESISTANT) T12A 30MG Not Covered
OPANA ER (CRUSH
RESISTANT) T12A 40MG Not Covered
OPANA ER (CRUSH
RESISTANT) T12A 5MG Not Covered
OPDIVO SOLN 40MG/4ML Not Covered
OPDIVO SOLN 100MG/10ML Not Covered
OPERAND
POVIDONE/IODINE GEL 10% Not Covered
OPIUM TINCTURE TINC 1% Not Covered
OPSUMIT TABS 10MG Not Covered
OPTICHAMBER
ADVANTAGE MISC Covered QL
OPTICHAMBER
FACE MASK/LARGE MISC Covered QL
OPTICHAMBER
FACE
MASK/MEDIUM MISC Covered QL
OPTICHAMBER
FACE MASK/SMALL MISC Covered QL
OPTI-CLEAR SOLN 0.05% Covered
OPTIVAR SOLN 0.05% Not Covered
ORALAIR SUBL 0; 0; 0; 0; 0 Not Covered
ORAP TABS 1MG Not Covered
ORAP TABS 2MG Not Covered
ORENITRAM TBCR 0.125MG Not Covered
ORENITRAM TBCR 0.25MG Not Covered
ORENITRAM TBCR 1MG Not Covered
ORENITRAM TBCR 2.5MG Not Covered
ORFADIN CAPS 2MG Not Covered
ORFADIN CAPS 10MG Not Covered
ORFADIN CAPS 5MG Not Covered
ORKAMBI TABS 125MG; 200MG Not Covered
ORPHENADRINE
CITRATE ER TB12 100MG Covered QL AL
ORPHENADRINE/AS
A/CAFFEINE TABS 385MG; 30MG; 25MG Covered
ORSYTHIA TABS 20MCG; 0.1MG Covered
ORTHO DIAPHRAGM
COIL SPRING KIT
100 KIT Not Covered
ORTHO DIAPHRAGM
COIL SPRING KIT
105 KIT Not Covered
ORTHO DIAPHRAGM
COIL SPRING KIT 50 KIT Not Covered
ORTHO DIAPHRAGM
FLAT SPRING KIT 55 KIT Not Covered
ORTHO DIAPHRAGM
FLAT SPRING KIT 60 KIT Not Covered
ORTHO DIAPHRAGM
FLAT SPRING KIT 65 KIT Not Covered
ORTHO DIAPHRAGM
FLAT SPRING KIT 70 KIT Not Covered
ORTHO DIAPHRAGM
FLAT SPRING KIT 75 KIT Not Covered
ORTHO DIAPHRAGM
FLAT SPRING KIT 80 KIT Not Covered
ORTHO DIAPHRAGM
FLAT SPRING KIT 85 KIT Not Covered
ORTHO DIAPHRAGM
FLAT SPRING KIT 90 KIT Not Covered
ORTHO DIAPHRAGM
FLAT SPRING KIT 95 KIT Not Covered
35MCG/24HR;
ORTHO EVRA PTWK 150MCG/24HR Not Covered
OYSTER SHELL
CALCIUM/VITAMIN D TABS 200UNIT; 500MG Covered
OYSTER SHELL
CALCIUM/VITAMIN D TABS 250MG; 125UNIT; 0 Covered
OYSTER
SHELL/VITAMIN D TABS 600MG; 125UNIT Covered
PACERONE TABS 200MG Not Covered
PACERONE TABS 400MG Not Covered
PACERONE TABS 100MG Not Covered
PAIN & FEVER TABS 325MG Covered
PALIPERIDONE ER TB24 1.5MG Not Covered
PALIPERIDONE ER TB24 9MG Not Covered
PALIPERIDONE ER TB24 3MG Not Covered
PALIPERIDONE ER TB24 6MG Not Covered
70000UNIT; 16800UNIT;
PANCREAZE CPEP 40000UNIT Covered
61000UNIT; 21000UNIT;
PANCREAZE CPEP 37000UNIT Covered
17500UNIT; 4200UNIT;
PANCREAZE CPEP 10000UNIT Covered
43750UNIT; 10500UNIT;
PANCREAZE CPEP 25000UNIT Covered
27000UNIT; 5000UNIT;
PANCRELIPASE CPEP 17000UNIT Covered
PANHEMATIN SOLR 313MG Not Covered
PANTOPRAZOLE
SODIUM TBEC 20MG Covered QL
PANTOPRAZOLE
SODIUM TBEC 40MG Covered QL
PARCOPA TBDP 25MG; 250MG Not Covered
PARCOPA TBDP 25MG; 100MG Not Covered
PARCOPA TBDP 10MG; 100MG Not Covered
PHENYTOIN
SODIUM EXTENDED CAPS 100MG Not Covered
PHILITH TABS 35MCG; 0.4MG Covered
PHOSLO CAPS 667MG Covered
PHOSLYRA SOLN 667MG/5ML Covered
PHOSPHOLINE
IODIDE SOLR 0.13% Covered
PICATO GEL 0.02% Not Covered
PICATO GEL 0.05% Not Covered
PILOCARPINE HCL SOLN 1% Covered
PILOCARPINE HCL SOLN 4% Covered
PILOCARPINE HCL SOLN 2% Covered
PILOCARPINE HCL TABS 7.5MG Not Covered
PILOCARPINE
HYDROCHLORIDE TABS 5MG Covered
PIMOZIDE TABS 2MG Not Covered
PIMOZIDE TABS 1MG Not Covered
PIMTREA TABS 0; 0 Covered
PINDOLOL TABS 10MG Covered
PINDOLOL TABS 5MG Covered
PRAMIPEXOLE
DIHYDROCHLORIDE TABS 0.125MG Covered QL
PRAMIPEXOLE
DIHYDROCHLORIDE TABS 1.5MG Covered QL
PRAMIPEXOLE
DIHYDROCHLORIDE TABS 0.75MG Covered QL
PRAMIPEXOLE
DIHYDROCHLORIDE TABS 0.25MG Covered QL
PRAMIPEXOLE
DIHYDROCHLORIDE TABS 1MG Covered QL
PRAMIPEXOLE
DIHYDROCHLORIDE TABS 0.5MG Covered QL
PRAMIPEXOLE
DIHYDROCHLORIDE
ER TB24 1.5MG Not Covered
PRAMIPEXOLE
DIHYDROCHLORIDE
ER TB24 0.75MG Not Covered
PRAMIPEXOLE
DIHYDROCHLORIDE
ER TB24 4.5MG Covered
PRAMIPEXOLE
DIHYDROCHLORIDE
ER TB24 3MG Covered
PRAMIPEXOLE
DIHYDROCHLORIDE
ER TB24 0.375MG Not Covered
PRAMOSONE CREA 2.5%; 1% Not Covered
PRAMOSONE LOTN 2.5%; 1% Not Covered
PRAMOSONE OINT 1%; 1% Not Covered
PRAMOSONE CREA 1%; 1% Not Covered
PRAMOSONE OINT 2.5%; 1% Not Covered
PRAMOSONE LOTN 1%; 1% Not Covered
PRANDIMET TABS 500MG; 2MG Not Covered
PRANDIMET TABS 500MG; 1MG Not Covered
PRANDIN TABS 2MG Not Covered
PRANDIN TABS 0.5MG Not Covered
PRANDIN TABS 1MG Not Covered
PRAVASTATIN
SODIUM TABS 20MG Covered QL
PRAVASTATIN
SODIUM TABS 10MG Covered QL
PRAVASTATIN
SODIUM TABS 40MG Covered QL
PRAVASTATIN
SODIUM TABS 80MG Covered QL
PRAZOSIN HCL CAPS 2MG Covered QL
PRAZOSIN HCL CAPS 1MG Covered QL
PRAZOSIN HCL CAPS 5MG Covered QL
PRECOSE TABS 100MG Not Covered
PRECOSE TABS 25MG Not Covered
PRECOSE TABS 50MG Not Covered
PRED MILD SUSP 0.12% Covered
PRED-G SUSP 0.3%; 1% Not Covered
120MG; 0; 200MG;
400UNIT; 2MG; 12MCG;
50MG; 1MG; 90MG; 30MG;
20MG; 20MG; 3.4MG; 3MG;
PRENATAL AD TABS 30UNIT; 2700UNIT; 25MG Covered QL AL
120MG; 0; 200MG;
400UNIT; 2MG; 12MCG;
27MG; 1MG; 20MG; 10MG;
PRENATAL LOW 3MG; 1.84MG; 22UNIT;
IRON TABS 4000UNIT; 25MG Covered QL AL
STOOL SOFTENER
LAXATIVE DC CAPS 240MG Covered
STRATTERA CAPS 60MG Not Covered
STRATTERA CAPS 10MG Not Covered
STRATTERA CAPS 40MG Not Covered
STRATTERA CAPS 80MG Not Covered
STRATTERA CAPS 18MG Not Covered
STRATTERA CAPS 100MG Not Covered
STRATTERA CAPS 25MG Not Covered
150MG; 150MG; 200MG;
STRIBILD TABS 300MG Not Covered
STRIVERDI
RESPIMAT AERS 2.5MCG/ACT Not Covered
STROMECTOL TABS 3MG Not Covered
SULFAMETHOXAZO
LE/TRIMETHOPRIM SUSP 200MG/5ML; 40MG/5ML Not Covered
SULFAMETHOXAZO
LE/TRIMETHOPRIM TABS 400MG; 80MG Covered
SULFAMETHOXAZO
LE/TRIMETHOPRIM SUSP 200MG/5ML; 40MG/5ML Not Covered
SUMATRIPTAN
SUCCINATE REFILL SOCT 6MG/0.5ML Covered QL
SUMATRIPTAN
SUCCINATE REFILL SOCT 4MG/0.5ML Covered QL
SUMAVEL
DOSEPRO SOTJ 4MG/0.5ML Not Covered
SUMAVEL
DOSEPRO SOTJ 6MG/0.5ML Not Covered
25MCG/15ML; 20MG/15ML;
1MG/15ML; 1000MG/15ML;
100MG/15ML; 2MG/15ML;
10MG/15ML; 10MG/15ML;
SUPERVITE LIQD 75MG/15ML Covered
400MG; 2700UNIT; 20MG;
400UNIT; 6MCG; 1MG;
100MG; 6MG; 5MG; 10MG;
SUPERVITE EC TBEC 100UNIT; 29MG Covered
SUPRAX SUSR 200MG/5ML Not Covered
SUPRAX SUSR 100MG/5ML Not Covered
SUPRAX CHEW 100MG Not Covered
SUPRAX CHEW 200MG Not Covered
TETANUS/DIPHTHE
RIA TOXOIDS-
ADSORBED ADULT SUSP 2LF/0.5ML; 2LF/0.5ML Covered AL
TETRABENAZINE TABS 25MG Covered QL
TETRABENAZINE TABS 12.5MG Covered QL
VALSARTAN/HYDRO
CHLOROTHIAZIDE TABS 25MG; 320MG Not Covered
VALSARTAN/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 320MG Not Covered
VALSARTAN/HYDRO
CHLOROTHIAZIDE TABS 25MG; 160MG Covered
VALSARTAN/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 160MG Covered
VALSARTAN/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 80MG Covered
VALTREX TABS 1GM Not Covered
VALTREX TABS 500MG Not Covered