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M0001_S5810_7B_61205 (01/2007)

18.05.303.1 (1/07) 2007 Aetna Inc.

Preferred Drug List

2007 Formulary(3-Tier Open)

Adrenal Regulating Drugs page 9

Alcohol, Smoking Deterrents and Antidotes pages 9 10

Allergy / Asthma / COPD Drugs pages 10 25

Alzheimers / Antidementia Drugs pages 25 26

Anesthetic Drugs page 26

Anti-anxiety Drugs pages 26 27

Antibiotics pages 27 34

Anti-cancer Drugs pages 34 38

Antidepressant Drugs pages 38 40

Antifungal Drugs pages 40 42

Anti-inflammatory Drugs pages 42 45

Antipsychotic / Bipolar Drugs pages 46 47

Attention Deficit Disorder / Narcolepsy Drugs pages 47 48

Blood Products pages 48 49

Bowel Disease Drugs pages 50 52

Dental and Drugs for the Mouth page 52

Diabetes Drugs pages 52 55

Drugs for Skin Conditions pages 55 65

Drugs for the treatment of Parasites page 66

Enzymes pages 67 68

(Prostaglandins) pages 68 73

(Prostaglandins); Ulcer and Stomach Drugs page 73

Eye and Ear Drugs pages 73 80

Gout Drugs page 80

Heart Blood Pressure and Cholesterol Drugs pages 80 93

Migraine Drugs pages 93 94

Miscellaneous Drugs page 94

Muscle Relaxers pages 94 95

Myesthenia Gravis Drugs page 95

Nausea/Vomiting Drugs pages 95 96

Osteoporosis (Bone loss) Drugs pages 96 97

Pain Drugs (Analgesics) pages 97 103

Parathyroid Suppressant Drugs page 103

Parkinsons Drugs page 103

Pituitary Drugs pages 103 105

Seizure Control Drugs pages 105 106

Sleep Aids page 106

Therapeutic Supplements pages 106 116

Thyroid Drugs page 116

Tuberculosis Drugs pages 116 117

Ulcer and Stomach Drugs pages 117 119

Urinary and Prostate Drugs pages 120 122

Vaccines and Immunology Drugs pages 122 125

Viral Infection Drugs pages 125 127

Drug Category List 1

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLANCoverage for prescription drugs continues to be one of the most important benefits in a health care plan. YourMedicare prescription drug coverage can be through a stand-alone Aetna Medicare RxSM Plan (PDP) or an AetnaMedicare Advantage Plan with Medicare prescription drug coverage (MA-PD).

You can use the Centers for Medicare and Medicaid Services (CMS) approved 2007 Aetna Medicare PreferredDrug List to help you determine what medications will be covered. We have selected these drugs based on theireffectiveness, quality, safety and value.

Translation of this material into another language may be available. For assistance, please call Member Services at the toll-free telephone number on your Aetna Medicare Member ID card (or 1-800-628-3323 TTY/TDD),Monday to Friday, 8 a.m. to 6 p.m. or visit our website at www.aetnamedicare.com.

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it stillcontains the drugs you take.

This document includes the Aetna Medicare Plans comprehensive formulary as of January 1, 2007.You can always access current formulary drug status by visiting our website at www.aetnamedicare.comor by calling the toll-free number on the back of your Aetna Medicare member ID card, Monday to Friday,8 a.m. to 6 p.m. TTY/TDD users should call 1-800-628-3323.

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name of your drug in the first column of the list.

What are generic drugs? Aetna Medicare covers both brand and generic drugs. A generic drug has the same active ingredient as the brand drug.Generic drugs usually cost less than brand drugs and are approved by the Food and Drug Administration (FDA).

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

n Precertification (or Prior Authorization)

Once you have enrolled for coverage through an Aetna Medicare Plan, you may be required to get precertificationfor certain medications. Precertification encourages the appropriate cost-effective use of medications by allowingcoverage only when certain conditions are met.

There are several reasons why we require precertification of certain medications:

n Some are more likely to be taken incorrectly.

n Some may be prescribed for inappropriate reasons or used in amounts that exceed recommendations for dosageor length of treatment.

n Some are more expensive than other medications that have been shown to be clinically or therapeutically similar.

n The precertification program is based on current medical findings, FDA-approved manufacturer labeling information and cost and manufacturer rebate arrangements.

n For medications requiring precertification, your doctor must request authorization of coverage for the medication.If the request is approved, you and your doctor will be notified and the medication will then be covered at theapplicable copay or coinsurance under your plan. If the request is denied, you and your doctor will be notified.

n The medications that require precertification are noted in the Aetna Medicare Preferred Drug List.

The medications requiring precertification are subject to change. Please refer to our website at www.aetnamedicare.comor contact an Aetna Medicare representative at the toll-free telephone number on your Aetna Medicare MemberID card. TTY/TDD users should call 1-800-628-3323.

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What is the Aetna Medicare Preferred Drug List (formulary)? The Aetna Medicare Preferred Drug List (formulary) is a list of covered drugs selected by Aetna Medicare in consultationwith a team of health care providers, which represents the prescription therapies believed to be a necessary part of aquality treatment program. Aetna Medicare will generally cover the drugs listed in our formulary as long as thedrug is medically necessary, the prescription is filled at an Aetna Medicare network pharmacy, and other plan rulesare followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the formulary change? Generally, if you are taking a drug on our 2007 formulary that was covered at the beginning of the year, we willnot discontinue or reduce coverage of the drug during the 2007 coverage year except when a new, less expensivegeneric drug becomes available or when new adverse information about the safety or effectiveness of a drug is released.

Other types of formulary changes, such as removing a drug from our formulary, will not affect members who arecurrently taking the drug. It will remain available at the same cost-sharing for those members taking it for theremainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverageyear to the formulary drugs that were available when you chose our plan, except for cases in which you can saveadditional money or improve the safety of your drugs.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictionson a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on ourformulary to be unsafe or the drugs manufacturer removes the drug from the market, we will immediately removethe drug from our formulary and provide notice to members who take the drug.

The enclosed formulary is current as of January 1, 2007. To get updated information about the drugs covered by AetnaMedicare, please visit our website at www.aetnamedicare.com or call Aetna Medicare Services at the toll-free telephone number on your Aetna Medicare Member ID card, Monday to Friday, 8 a.m. to 6 p.m. TTY/TDD usersshould call 1-800-628-3323.

How do I use the formulary? There are two ways to find your drug within the formulary:

n Medical Condition

The formulary begins on page 9. The drugs in this formulary are grouped into categories depending on the typeof medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed underthe category, Heart, Blood Pressure and Cholesterol Drugs, etc. If you know what your drug is used for, look for thecategory name in the list that appears inside the front cover. Then look under the category name for your drug.

n Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page128. The Index provides an alphabetical list of all the drugs included in this document. Both brand-name drugsand generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will seethe page number where you can find coverage information. Turn to the page listed in the Index and find the

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Are there any other restrictions on coverage? In accordance with Medicare coverage guidelines, the following medications are not covered in an Aetna MedicarePlan with prescription drug coverage.

n Agents when used for anorexia, weight loss, or weight gain.

n Agents when used to promote fertility.

n Agents when used for cosmetic purposes or hair growth.

n Agents when used for symptomatic relief of cough and colds.

n Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.

n Non-prescription drugs

n Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests ormonitoring services be purchased exclusively from the manufacturer or its designee.

n Barbiturates

n Benzodiazepines

n Agents when used for the treatment of sexual or erectile dysfunction, unless such agents are used to treat a condition, other than sexual or erectile dysfunction, for which the agents have been approved by the Food and Drug Administration.

What if my drug is not on the formulary? If your drug is not included in this formulary, you should first contact Aetna Medicare Customer Service and ask if your drug is covered. You can contact Aetna Medicare at the toll-free telephone number on your Aetna MedicareMember ID card, Monday to Friday, 8 a.m. to 6 p.m. TTY/TDD users should call 1-800-628-3323.

If you learn that Aetna Medicare does not cover your drug, you have two options:

n You can ask Aetna Medicare for a list of similar drugs that are covered by Aetna Medicare. When you receive thelist, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Aetna Medicare.

n You can ask Aetna Medicare to make an exception and cover your drug. See below for information about how torequest an exception.

NOTE: Due to a change in Medicare, most Medicare Drug Plans will no longer cover erectile dysfunction (ED) drugs likeViagra, Cialis, Levitra, and Caverject starting January 1, 2007. Call your Medicare drug plan for more information.

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n Quantity Limits

Quantity limits apply to certain medications as part of the precertification program and are designed to help promote appropriate and efficient medication use and enhance patient safety. Once you have enrolled in one of the Aetna Medicare Plans with prescription drug coverage, in order to receive coverage for amounts above the quantities on this drug list, your physician must obtain prior authorization.

Quantity limits are based on generally accepted pharmaceutical guidelines, efficient dosing regimens and dosingrecommendations. Three types of quantity limits are in place. They are:

1. Dose Efficiency Edits: limits coverage of prescriptions to one pill per dose or per day for medications that are approved for once-daily dosing.

2. Maximum Daily Dose: an information message is sent to the pharmacy if a prescription lies outside recommended minimum and maximum doses.

3. Quantity Limits Over Time: limits coverage of prescriptions to a specific number of units per a definedamount of time.

The medications that have quantity limits are subject to change. Please refer to our website at www.aetnamedicare.comor contact an Aetna representative at the toll-free telephone number on your Aetna Medicare Member ID card.TTY/TDD users should call 1-800-628-3323.

n Step Therapy

With step therapy, you must first try one or more prerequisite medications before a step therapy medicationwill be covered. Prerequisite medications and their corresponding step therapy medications are FDA-approvedand are used to treat the same conditions. Step therapy does not apply to all medications, however.

If it is medically necessary, you can obtain coverage for step therapy medication without trying a prerequisitemedication first. In this case, your doctor must request coverage for a step therapy medication as a medicalexception. If the request is approved, you and your doctor will be notified and the medication will then be covered atthe applicable copay or coinsurance under your plan. If the request is denied, you and your doctor will be notified.

Step therapy is based upon current medical findings, FDA-approved manufacturer labeling information, and costand manufacturer rebate arrangements. The medications requiring step therapy are subject to change. Please referto our website at www.aetnamedicare.com or contact an Aetna Medicare representative at 1-800-213-4599.

You can find out if your drug has any additional requirements or limits bylooking in the formulary that begins on page 9.

You can ask Aetna Medicare to make an exception to these restrictions orlimits. See the section, How do I request an exception to the Aetna MedicareFormulary? on page 6 for information about how to request an exception.

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Aetna Transition of Care Policy Aetna understands the importance of maintaining a consistent drug regimen, the challenges associated with changingcoverage and the uncertainty changing coverage can have on drug coverage. All Medicare prescription drug plansinclude a Transition provision for medications that are not on our Aetna Medicare Preferred Drug List or are includedin our Precertification or Step Therapy programs.

To diminish the impact changing coverage can have upon you, Aetna has established a liberal transition benefit thatprovides you with up to one courtesy fill (maximum of a 31 day supply) for each prescription you may already betaking and that is not on our Preferred Drug List, or that requires Precertification or Step Therapy. The courtesy fillcan be used anytime during your first 90 days in the plan. If you reside in a Long Term Care facility, we will extendthe courtesy fill up to two additional fills as long as they occur during your first 90 days in the plan. You will sharein the cost of the drug in the same manner as if the drug were on our Preferred Drug List.

Following your courtesy fill, you will receive a letter from Aetna instructing you of the action(s) you must takeprior to filling that prescription again, in order to not interrupt your drug regimen. Of course, you always have theoption to switch prescriptions to a drug on our Preferred Drug List in advance of filling your prescription, whichwill serve to reduce your drug costs and limit any future interruptions. You may also be eligible to receive courtesyfill(s) at other times during the year, such as changes in setting of care, emergencies, etc. The important thing tokeep in mind is Aetnas commitment to working with you and your physician to assure you have the safest andmost effective drug necessary to treat your health care needs.

For more information For more detailed information about your Aetna Medicare prescription drug coverage, please review your AetnaMedicare Evidence of Coverage (EOC) and other plan materials.

If you have questions about Aetna Medicare, please call Aetna Medicare at the toll-free telephone number on your AetnaMedicare Member ID card, Monday to Friday, 8 a.m. to 6 p.m. TTY/TDD users should call 1-800-628-3323. Orvisit www.aetnamedicare.com.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE(1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.

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How do I request an exception to the Aetna Medicare formulary?You can ask Aetna Medicare to make an exception to our coverage rules. There are a few types of exceptions thatyou can ask us to make.

n You can ask us to cover your drug even if it is not on our formulary.

n You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, AetnaMedicare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us towaive the limit and cover more.

n You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferredtier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier subject to thetiering exceptions process tier instead. This would lower the amount you must pay for your drug. Please note, ifwe grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher levelof coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in thetier designated as the high-cost/unique drug tier.

Generally, Aetna Medicare will only approve your request for an exception if the alternative drugs included on theplans formulary, or additional utilization restrictions would not be as effective in treating your condition and/orwould cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception.When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement fromyour physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribingphysicians supporting statement. You can request an expedited (fast) exception if you or your doctor believe thatyour health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted,we must give you a decision no later than 24 hours after we get your prescribing physicians supporting statement.

What do I do before I can talk to my doctor about changingmy drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you maybe taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a priorauthorization from us before you can fill your prescription. You should talk to your doctor to decide if you shouldswitch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug youtake. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover atemporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy.After your first 31-day supply, we will not pay for these drugs, even if you have been a member of the plan lessthan 90 days.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless youhave a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 daysyou are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs islimited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply ofthat drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

KEY: UPPERCASE = Brand name medicationsLower case italics = Generic medications

1, 2, 3 = Copay tier levelQL = Quantity limits

ST = Step therapyPR = Precertification

NC = Not covered 9

ADRENAL REGULATING DRUGS

A-METHAPRED 1

ARISTOSPAN INTRA-ARTICULA 3

BUBBLI-PRED 1

CELESTONE 3

CORTEF 3

cortisone acetate 1

CYTADREN 2

FLORINEF 3

fludrocortisone acetate 1

KENALOG-10 2

KENALOG-40 2

LYSODREN 3 (PR)

ALCOHOL, SMOKING DETERRENTS AND ANTIDOTES

ACETADOTE 3

ANTABUSE 3 (QL) 1/1 day(s)

ANTIZOL 3

BUPROBAN 1 (PR)

CAMPRAL 3

CHANTIX 3 (QL) (PR) (ST) 2/1 day(s)

CHEMET 3

DEPADE 1

DICHLOROACETIC ACID 1

EXJADE 2

KAYEXALATE 3

KIONEX 1

methylene blue 1

naltrexone hydrochloride 1

NARCAN 3

nicotine td patch 1 (PR)

NICOTROL INHALER 3 (PR)

NICOTROL NS 3 (PR)

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How do you read the Aetna formulary? The formulary that begins on page 9 provides coverage information about the drugs covered by Aetna Medicare. If you have trouble finding your drug in the list, turn to the Index that begins on page 128.

n The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIPITOR) and genericdrugs are listed in lower-case italics (e.g., simvastatin).

n The information in the Utilization Management column tells you if Aetna Medicare has any special requirementsfor coverage of your drug.

What is the difference between Aetna Medicares open and closed formularies? Aetna Medicares closed formulary limits coverage of Medicare Part D medications to only those medicationsdesignated as covered on the Aetna Medicare Preferred Drug List. The copay tiers for covered prescription medicationsare listed below:

Copay Tier Type of Drug Tier 1 (Lowest Copay Amount) Generic medications Tier 2 Brand Name medications Tier 3 Specialty medications (both Brand Name & Generic)

Aetna Medicares open formulary covers all Medicare Part D medications. Non-preferred levels of copay applyto some medications on the Aetna Medicare Preferred Drug List. The copay tiers for covered prescription medicationare listed below:

Copay Tier Type of Drug Tier 1 (Lowest Copay Amount) Generic medications Tier 2 Preferred Brand Name medications Tier 3 Non-preferred Brand Name medications Tier 4 Specialty medications (both Brand Name & Generic)

3-Tier Utilization QL/Drug Name Open Management Day(s)




NC = Not covered


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ALDEX-CT CHEW 3

ALENAZE-D 3

ALLANTAN PEDIATRIC 1

ALLANVAN-S 1

ALLEGRA 180MG 3 (QL) (PR) 1/1 day(s)

ALLEGRA 30, 60MG 3 (QL) (PR) 2/1 day(s)

ALLEGRA-D 12 HOUR 3 (QL) (PR) 2/1 day(s)

ALLEGRA-D 24 HOUR 3 (QL) (PR) 1/1 day(s)

ALLERSCRIPT 3

ALLERX PE 3

ALLERX SUSPENSION 3

ALLERX TABLETS 3

ALLFEN JR 3

ALTEX-PSE 1

ALUPENT 3 (PR)

AMBI 1

AMBIFED-G 3

AMDRY-C 1

AMERIFED 3

AMIDAL 1

aminophylline 1

AMI-TEX LA 1

AMITEX PSE 1

ANDEHIST NR 1

AQUATAB D 3

ARALAST 3

ASMANEX 2

ASTELIN 3

ATROVENT HFA 3

ATROVENT NASAL SOLUTION 3

AZMACORT 2

BECONASE AQ 3




NC = Not covered


10

physostigmine salicylate 1

REVEX 3

REVIA 3

sodium polystyrene sulfonate 1

SPS 1

SYPRINE 3

VIVITROL 3 (QL) (PR) (ST) 1/30 day(s)

ZYBAN 3 (PR)

ALLERGY / ASTHMA / COPD DRUGS

ABER-FED 1

ACCOLATE 3

ACCUHIST 3

ACCUNEB 3 (PR)

acetylcysteine 1 (PR)

ADRENALIN 3

ADVAIR DISKUS 2

ADVAIR HFA 2

AEROHIST 3

AEROHIST PLUS 1

AEROKID 3

AH-CHEW 1

AH-CHEW II 3

AHIST 3

AIRET 1 (PR)

ALACOL 3

albuterol hfa 1

albuterol inhaler 1

albuterol neb solution 1 (PR)

albuterol syrup 1

albuterol tablets 1

ALDEX 3

ALDEX G 3




NC = Not covered


13

CENTEX-PSE ER 1

CERON 1

CHLOR-MES JR 1

chlorpheniramine maleate 1

chlorpheniramine maleate and methscopolamine nitrate and phenylephrine hydrochloride 1

chlorpheniramine maleate and methscopolamine nitrate and pseudoephedrine hydrochloride 1

chlorpheniramine maleate and pseudoephedrine hydrochloride 1

chlorpheniramine maleate and pseudoephedrine hydrochloride sr 1

chlorpheniramine tannate and phenylephrine tannate 1

CLARINEX 5MG 3 (QL) (PR) 1/1 day(s)

CLARINEX REDITABS 3 (QL) (PR) 1/1 day(s)

CLARINEX SYRUP 3 (QL) (PR) 10/1 day(s)

CLARINEX-D 12 HOUR 3 (QL) (PR) 2/1 day(s)

CLARINEX-D 24 HOUR 3 (QL) (PR) 1/1 day(s)

clemastine fumarate 1

CODIMAL L.A. 1

COLDAMINE 1

COLDMIST JR 1

COLDMIST LA 1

COLDMIST S 1

COLFED-A 1

COMBIVENT 3

CONEX 3

CONPEC 3

CONPEC LA NR 1

COPD 1

COPHENE #2 1




NC = Not covered


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BENADRYL 3

BEN-TANN 1

BIDHIST 1

BIDHIST-D 1

BIOHIST LA 3

BPM 1

BPM PSEUDO 1

BRETHINE 3

BROFED 3

BROMAXEFED RF 1

BROMDEC 1

BROMFED 3

BROMFED PD 3

BROMFENEX 1

BROMFENEX PD 1

BROMHIST PEDIATRIC 1

BROMHIST-NR 1

brompheniramine 1

brompheniramine tannate and phenylephrine tannate 1

BRONCAP 3

BRONCHOLATE 3

BRONCODUR 3

BRONCOMAR-1 3

BRONDIL 3

BROVEX 3

BROVEX CT 3

BROVEX SR 3

BROVEX-D 3

B-VEX 1

carbinoxamine maleate 1

CARDEC 1




NC = Not covered


15

DILEX-G 1

DILOR 3

DILOR-G 1

diphenhydramine hydrochloride 1

DIPHENTANN-D 1

DONATUSSIN 1

DREXOPHED SR 1

DRIHIST SR 1

DRIXOMED 1

DRYSEC 1

D-TANN 1

DUOMAX 1

DUONATE-12 1

DUONEB 3 (PR)

DUOTAN 1

DUOTAN PD 1 (PR)

DURADRYL 1

DURAFED 1

DURAHIST 3

DURAHIST D 3 (PR)

DURAHIST PE 3

DURAPHEN II 3

DURASAL II 1

DURATUSS 3

DURATUSS GP 3

DYFLEX-G 1

DY-G 1

DYLIX 3

DYNAHIST ER 1

DYNEX 3

DYPHYLLINE/GG 1

DYTAN 3




NC = Not covered


14

C-PHED TANNATE 1

C-PHEN 1

CPM 8/PE 20/MSC 1.25 1

CPM 8/PSE 90/MSC 2.5 1

CRANTEX 1

CRANTEX ER 1

CRANTEX LA 1

CRANTEX LAC 1

cromolyn sodium neb solution 1 (PR)

cyproheptadine hydrochloride 1 (PR)

DALLERGY 3

DALLERGY JR 3

D-AMINE-SR 1

DECON-A 3

DECONAMINE SR 3

DECON-E 3

DECONEX 3

DECONGEST II 1

DECONGESTINE TR 1

DECONSAL CT CHEW 3

DECONSAL II 3

DEHISTINE 1

DENAZE 1

DESAL-II 1

DESPEC 1

DESPEC SR 3

DEXAPHEN SA 1

dexchlorpheniramine maleate 1 (PR)

D-FEDA II 1

DG 200 1

DIFIL G FORTE 1

DIFIL-G 3




NC = Not covered


17

GENERIC ENTEX LA 1

GENTEX LA 3

GFN 1200/PHENYLEPHRINE 40 1

GFN 1200/PSE 50 1

GFN 550/PSE 60 3

GFN 595/PSE 48 1

GFN 800/PE 25 1

GFN/PSE 1

GILPHEX TR 3

GP-1200 1

G-PHED 1

G-PHED-PD 1

GRIPEX PE PEDIATRIC 1

GUAIFED 3

GUAIFED-PD 3

guaifenesin and phenylephrine hydrochloride 1

guaifenesin and pseudoephedrine hydrochloride 1

guaifenesin nr 1

guaifenesin tab 1

GUAIFENEX GP 1

GUAIFENEX PSE 1

GUAIMAX-D 1

GUAIMIST S 1

GUAIPHEN-D 1

GUAIPHEN-D 1200 1

GUAIPHEN-PD 1

GUAPETEX 1

GUIADEX D 1

GUIADEX PD 1

GUIADRINE GP 1




NC = Not covered


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DYTAN-D 3

DYTUSS 1

ED A-HIST 3

ED CHLORPED 3

ED-BRON G 3

ED-CHLOR-TAN 3

ELIXOPHYLLIN 3

ELIXOPHYLLIN-GG 3

ENTEX 3

ENTEX ER 3

ENTEX LA 3

ENTEX PSE 3

epinephrine hydrochloride 1

EUDAL-SR 3

EXEFEN-PD 1

EXETUSS 1

EXTENDRYL 3

EXTENDRYL JR 3

EXTENDRYL SR 3

fexofenadine hydrochloride 180mg 1 (QL) (PR) 1/1 day(s)

fexofenadine hydrochloride 30, 60mg 1 (QL) (PR) 1/1 day(s)

FLONASE 3

FLOVENT 2

FLOVENT HFA 2

FLOVENT ROTADISK 2

flunisolide 1

fluticasone spray 1

FORADIL AEROLIZER 2

G P TEX 1

G/P 1

G/P 1200/60 1

GANDIDIN NR 1




NC = Not covered


19

LIQUIBID-D 1200 3

LIQUIBID-PD 3

LODRANE 3

LODRANE 12 HOUR 3

LODRANE 12D 3

LODRANE 24 3

LODRANE D 3

LODRANE LD 1

LODRANE XR 3

LOHIST-12 1

LOHIST-12D 1

LOHIST-D 1

LOHIST-LQ 1

LOHIST-PD 1

LUFYLLIN 3

LUFYLLIN-GG 3

LUSONEX 3

MAXAIR AUTOHALER 2

MAXIFED 3

MAXIFED-G 3

MAXIPHEN 3

MAXIPHEN-G 3

MEDENT LD 3

metaproterenol sulfate neb solution 1 (PR)

metaproterenol sulfate syrup 1

metaproterenol sulfate tablets 1

MINDAL 1

MINTAB D 1

MINTEX 1

MIRAPHEN PE 1

MIRAPHEN PSE 1

MONTEPHEN 1




NC = Not covered


18

H 9600 SR 3

HCA ALLERGY RELIEF 1

HEXAFED 3 (PR)

HISTADE MX 1

HISTADE SR 1

HISTALET 3

HISTATAB PH 1

HISTA-VENT DA 1

HISTA-VENT PSE 1

HISTEX 3

HISTEX SR 3

INTAL 3 (PR)

INTAL 112 2

INTAL 200 2

INTAL INHALER 2

IOFED 1

IOPHEN-NR 1

IOSAL II 1

IOTEX PSE 1

ipratropium bromide inhalant 1 (PR)

ipratropium bromide spray 1

isoproterenol hcl 1

ISUPREL 3

JAY-PHYL 1

J-MAX 3

J-TAN 3

J-TAN D 3

KRONOFED-A 1

K-TAN 1

LEV/PSE/GG 1

LEVALL G 3

LIQUIBID 1




NC = Not covered


21

PHENAVENT D 1

PHENAVENT LA 1

PHENAVENT PED 1

PHENCLOR TANNATE PEDIATRI 1

PHENYDEX PEDIATRIC 1

PHENYDRYL 1

phenylephrine cm (chlorpheniramine maleate and methscopolamine nitrate and phenylephrine hydrochloride) 1

POLY-HISTINE 3

POLY-VENT 3

POLY-VENT JR. 3

PRE-HIST D 1

PROFEN FORTE 3

PROFEN II 3

PROLASTIN 3

PROLEX D 3

PROLEX PD 3

PROMETHAZINE VC 3

PROSET D 1

PRO-TANNATE PEDIATRIC 1

PROVENTIL 3

PROVENTIL HFA 2

PROVENTIL NEB 3 (PR)

PSE 15/CPM 2 1

PSE 90/CPM 8/MSC 2.5 1

PSE BPM 1

PSE CPM 1

PSEUBROM 1

PSEUBROM-PD 1

PSEUDATEX 1

PSEUDO CM 1

PSEUDO GG TR 1




NC = Not covered


20

MUCOMYST-10 3 (PR)

NALEX-CR 1

NARIZ 3

NASACORT AQ 3

NASAREL 3

NASATAB LA 3

NASEX 1

NASEX-G 1

NASONEX 3

ND-STAT 1

NESCON-PD 1

NOHIST 1

NOHIST-EXT 1

NOREL SD 1

NUHIST PEDIATRIC 1

NUMOBID 3

NUMONYL 1

NY-TANNIC 1

OMNIHIST II LA 3

OMNIHIST L.A. 1

ORGAN-I NR 1

ORGANIDIN NR 3

PALGIC 1

PANFIL-G 3

PCM 1

PCM ALLERGY 1

PCM LA 1

PENDEX 1

P-EPD TAN/CHLOR-TAN 1

PHANASIN 3

PHENABID 1

PHENAVENT 1




NC = Not covered


23

RONDEC 3

RONDEX 1

R-TANNA 1

R-TANNA PEDIATRIC 1

R-TANNA S 1

RU-TUSS JR. 1

RYNA-12 3

RYNA-12 S 3

RYNATAN 3

RYNATAN CHEWABLE 3

RYNATAN SUSPENSION 3

RYNEZE 1

RY-T-12 1

SEMPREX-D 3 (QL) (PR) 4/1 day(s)

SEREVENT DISKUS 3

SILDEC 1

SIL-TEX 1

SIMUC 1

SINA-12X 3

SINGULAIR 2

SINUVENT PE 3

SITREX 3

SLO-BID GYROCAPS 3

SPIRIVA HANDIHALER 2

STAMOIST E 1

SUCLOR 1

SUDAL 12 3

SUDATEX 1

TANA PSE 1

TANA R-12 1

TANACOF-XR 3

TANAFED DP 3 (PR)




NC = Not covered


22

PSEUDO MAX 1

PSEUDOVENT 1

PSEUDOVENT 400 1

PSEUDOVENT PED 1

PULMICORT 3 (PR)

PULMICORT TURBUHALER 3

PYRILAFEN TANNATE-12 1

QC ALLERGY RELIEF INTENSE 1

QDALL 3

QDALL AR 3

QUIBRON 3

QUIBRON-T 3

QUINTEX 1

QV-ALLERGY 1

QVAR 3

RE TANN D CHEW 3

RE2+30 1

RELERA 1

RELURI 1

RESCON-ED 1

RESCON-JR 3

RESCON-MX 3

RESPA-1ST 3

RESPAHIST 1

RESPAIRE-60 3

RESPA-PE 3

RHINABID 1

RHINABID PD 1

RHINOCORT AQUA 3

RICOBID 3

RICOBID NR 3

RICOBID-H 3




NC = Not covered


25

VENTOLIN HFA 3

VIRAVAN-S 3

VITA-NUMONYL 3

VITA-NUMONYL EX 3

VOSPIRE ER 1

V-TANN B.I.D 1

WE ALLERGY 1

WE MIST II LA 1

WELLBID-D 1

XEDEC 3

XIRAL SR 1

XOLAIR 3

XOPENEX 3 (PR)

XOPENEX HFA 3

XPECT-PE 1

ZEMAIRA 3

ZEPHREX 1

ZEPHREX LA 3

ZOTEX -GP 3

ZOTEX GPX 3

ZYFLO 3 (QL) 4/1 day(s)

ZYMINE 3

ZYMINE-D 3

ZYRTEC 3 (QL) (PR) 1/1 day(s)

ZYRTEC SYRUP 3 (QL) (PR) 10/1 day(s)

ZYRTEC-D 3 (QL) (PR) 2/1 day(s)

ALHEIMERS / ANTIDEMENTIA DRUGS

ARICEPT 2

ARICEPT ODT 2

COGNEX 3

ERGOLOID MESYLATES 1

EXELON 2




NC = Not covered


24

TANATAN RF 1

TANAVAN 1

TANNATE PEDIATRIC 1

terbutaline sulfate 1

THEO-24 3

THEOCAP 1

THEOCHRON 1

THEOMAR GG 3

theophylline 1

theophylline cr 1

theophylline er 1

theophylline sr 1

theophylline td 1

TILADE 2

TIME-HIST 1

TOURO ALLERGY 3

TOURO LA 3

TOURO LA-LD 3

TRACLEER 2 (PR)

TRI-HISTINE 1

TUSNEL PEDIATRIC 3

TUSSBID 1

TYZINE 3

TYZINE PEDIATRIC NASAL DR 3

ULTRABROM 1

ULTRABROM PD 1

UNI-HIST 1

UNIPHYL 3

UNI-TEX 120/10 ER 1

VAZOL 3

VAZOL-D 3

VENTOLIN 3 (PR)




NC = Not covered


27

EFFEXOR 50MG 3 (QL) (ST) 6/1 day(s)

EFFEXOR 75MG 3 (QL) (ST) 5/1 day(s)

EFFEXOR XR 150MG 2 (QL) (ST) 2/1 day(s)

EFFEXOR XR 37.5, 75MG 2 (QL) (ST) 1/1 day(s)

hydroxyzine hydrochloride 1

hydroxyzine pamoate 1 (PR)

HYZINE 1

meprobamate 1 (PR)

paroxetine 10, 20mg 1 (QL) 1/1 day(s)

paroxetine 30, 40mg 1 (QL) 2/1 day(s)

PAXIL 10,20MG 3 (QL) (ST) 1/1 day(s)

PAXIL 30, 40MG 3 (QL) (ST) 2/1 day(s)

PAXIL CR 3 (QL) (ST) 2/1 day(s)

PAXIL SUSPENSION 3 (QL) 30/1 day(s)

perphenazine and amitriptyline hydrochloride 1

PEXEVA 10, 20MG 3 (QL) (ST) 1/1 day(s)

PEXEVA 30,40MG 3 (QL) (ST) 2/1 day(s)

VANSPAR 3

venlafaxine 150mg 1 (QL) 3/1 day(s)


venlafaxine 37.5mg 1 (QL) 4/1 day(s)



VISTARIL 3 (PR)

ANTIBIOTICS

ADOXA 3 (PR)

amikacin sulfate 1

AMIKIN 3

AMOCLAN 1

amoxicillin 1

amoxicillin and clavulanic acid 1




NC = Not covered


26

HYDERGINE 3

NAMENDA 2

NAMENDA TITRATION PAK 2

RAZADYNE 3

RAZADYNE ER 3

ANISTHETIC DRUGS

AMERICAINE 3

ANACAINE 3

ANESTACON 1

BUCALCIDE 3

EMLA 3

EMLA/TEGADERM 3

EXACTACAIN 1

LIDAMANTLE 3

lidocaine and prilocaine 1

lidocaine cream 1

lidocaine hydrochloride jelly 1

LIDODERM 2

LIDOMAR VISCOUS 1

LIDOSITE 3 (QL) (PR) (ST) 25/30 day(s)

ORASEP 3

SENATEC 1

SYNERA 3 (QL) (PR) (ST) 1/1 day(s)

XYLOCAINE GEL 3

XYLOCAINE INJECTION 3

ANTI-ANXIETY DRUGS

ATARAX 3

BUSPAR 3

buspirone hydrochloride 1

DUO-VIL 1

EFFEXOR 25, 100MG 3 (QL) (ST) 3/1 day(s)

EFFEXOR 37.5MG 3 (QL) (ST) 4/1 day(s)




NC = Not covered


29

cefoxitin 1

cefpodoxime proxetil 1

cefprozil 1

ceftazidime 1

CEFTIN 3

ceftriaxone sodium 1

ceftriaxone sodium and dextrose (anhydrous) 1

cefuroxime sodium 1

cefuroxime sodium and dextrose monohydrate 1

CEFZIL 3

cephalexin monohydrate 1

cephradine 1

chloramphenicol sodium succinate 1

CHLOROMYCETIN 3

CIPRO 3 (PR)

CIPRO I.V. 3 (PR)

CIPRO XR 3 (PR)

ciprofloxacin 1 (PR)

CLAFORAN 3

CLAFORAN/D5W 3

clarithromycin 1

CLEOCIN 3

CLEOCIN SUPPOSITORY 3

clindamycin hydrochloride 1

CLINDESSE 3

COLISTIMETHATE SODIUM 1

COLY-MYCIN-M 3

CUBICIN 3

DECLOMYCIN 3 (PR)

demeclocycline hydrochloride 1 (PR)

dicloxacillin sodium 1




NC = Not covered


28

AMOXIL 1

ampicillin 1

ampicillin sodium and sulbactam sodium 1

AUGMENTIN 3

AUGMENTIN ES-600 3

AUGMENTIN XR 3

AVELOX 2 (PR)

AVELOX ABC PACK 2 (PR)

AZACTAM 3

AZACTAM IN DEXTROSE 3

azithromycin 1

BACIIM 1

BACI-RX 3

BACITRACIN INJECTION 3

BACTOCILL IN DEXTROSE 3

BACTRIM 3

BACTRIM DS 3

BACTROBAN NASAL 3

BIAXIN 3

BIAXIN XL 3

BICILLIN C-R 3

BICILLIN L-A 3

CEDAX 3

cefaclor 1

cefaclor er 1

cefadroxil hemihydrate 1

cefadroxil monohydrate 1

cefazolin sodium 1

CEFAZOLIN SODIUM-DEXTROSE 3

CEFIZOX 3

CEFIZOX IN DEXTROSE 5% 3

cefotaxime sodium 1




NC = Not covered


31

HUMATIN 3

INVANZ 3

kanamycin sulfate 1

KEFLEX 3

KETEK 3

LEVAQUIN 3 (PR)

LEVAQUIN PREMIX 3 (PR)

LINCOCIN 3

LORABID 3

MACROBID 3

MACRODANTIN 3

MANDOL/D5W 3

MAXIPIME 2

MEFOXIN 3

MEFOXIN IN DEXTROSE 3

MERREM 3

METRO IV 3

METROGEL VAGINAL 3

metronidazole 1

MINOCIN 3 (PR)

minocycline hydrochloride 1 (PR)

MONODOX 3 (PR)

MONUROL 3

MYRAC 1 (PR)

nafcillin sodium 1

NALLPEN ISO-OSMOTIC IN DE 3

NALLPEN/DEXTROSE 3

NEBCIN 3

NEGGRAM 3

NEO-FRADIN 3

neomycin sulfate 1

nitrofurantoin macrocrystalline 1




NC = Not covered


30

DISPERMOX 3

DORYX 3 (PR)

DOXY-CAPS 1 (PR)

doxycycline hyclate 1 (PR)

doxycycline monohydrate 1 (PR)

DURICEF 3

DYNABAC D5-PAK 3

DYNACIN 1 (PR)

E.E.S. 1

E-MYCIN 3

ERYC 3

ERYPED 3

ERY-TAB 3

ERYTHROCIN 3

erythromycin and sulfisoxazole 1

erythromycin dr 1

erythromycin ec 1

erythromycin ethylsuccinate 1

erythromycin lactobionate 1

erythromycin stearate 1

FACTIVE 3 (PR)

FLAGYL 3

FLAGYL ER 3

FLOXIN 3 (PR)

FORTAZ 3

FORTAZ GALAXY 3

FURADANTIN 3

GANTRISIN PEDIATRIC 3

GARAMYCIN 3

gentamicin sulfate 1

gentamicin sulfate and sodium chloride 1

GEOCILLIN 2




NC = Not covered


33

SMZ-TMP DS 1

SOLODYN 3 (PR)

SPECTRACEF 3

streptomycin sulfate 1

sulfadiazine 1

sulfamethoxazole and trimethoprim 1

sulfasalazine dr 1 (QL) 12/1 day(s)

sulfasalazine ec 1 (QL) 12/1 day(s)

SULFATRIM 1

sulfisoxazole 1

SUMYCIN 3 (PR)

SUPRAX 3

SYNERCID 3

TAZICEF 1

tetracycline hydrochloride 1 (PR)

TIMENTIN 3

TOBI 3 (PR)

tobramycin sulfate 1

tobramycin sulfate and sodium chloride 1

trimethoprim 1

TRIMOX 1

TYGACIL 2

UNASYN 3

VANCOCIN CAPSULE 2

VANCOCIN HCL ISO-OSMOTIC 3

VANCOCIN INJECTION 3

vancomycin hydrochloride 1

VANDAZOLE 1

VANTIN 3

VEETIDS 1

VELOSEF 3

VIBRAMYCIN 3 (PR)




NC = Not covered


32

NOROXIN 3 (PR)

ofloxacin 1 (PR)

OMNICEF 3

OMNI-PAC 3

oxacillin sodium 1

PANIXINE DISPERDOSE 3

paromomycin sulfate 1

PCE 3

PEDIAZOLE 3

penicillin g potassium 1

penicillin g potassium and dextrose (anhydrous) 1

PENICILLIN G PROCAINE 3

penicillin g sodium 1

penicillin v potassium 1

PENICILLIN VK 1

PERIOSTAT 3 (PR)

PFIZERPEN-G 1

PFIZERPEN-G 3

piperacillin sodium 1

PIPRACIL/D5W 3

polymyxin b sulfate 1

PRIMAXIN I.M. 3

PRIMAXIN IV 3

PRIMSOL 3

PROLOPRIM 3

PROQUIN XR 3 (PR)

RANICLOR 3

ROCEPHIN 3

ROCEPHIN IN ISO-OSMOTIC D 3

SEPTRA 3

SEPTRA DS 3




NC = Not covered


35

cisplatin 1

cladribine 1

CLOLAR 3

COSMEGEN 3

cyclophosphamide 1 (PR)

cytarabine 1

CYTOXAN 3 (PR)

dacarbazine 1

DACOGEN 3

daunorubicin hydrochloride 1

DAUNOXOME 3

dexrazoxane 1

DOXIL 3

doxorubicin hydrochloride 1

DROXIA 3 (PR)

DTIC-DOME 3

ELITEK 2

ELLENCE 3

ELOXATIN 3

ELSPAR 3

EMCYT 2

ERBITUX 3

ETHYOL 3

ETOPOPHOS 3

etoposide 1

FARESTON 3

FASLODEX 3

FEMARA 2

FLUDARA 3

FLUDARABINE PHOSPHATE 1

fluorouracil injection 1

GEMZAR 3




NC = Not covered


34

VIBRATAB 3 (PR)

XIFAXAN 3

ZINACEF 3

ZINACEF/D5W 3

ZITHROMAX 3

ZITHROMAX TRI-PAK 3

ZITHROMAX Z-PAK 3

ZMAX 3

ZOSYN 2

ZYVOX 2 (PR)

ANTI-CANCER DRUGS

ABRAXANE 3

ADRIAMYCIN 1

ADRUCIL 1

ALIMTA 3

ALKERAN INJECTION 2 (PR)

ALKERAN TABLETS 2 (PR)

ARIMIDEX 3

AROMASIN 3

ARRANON 3

AVASTIN 3

BEXXAR 3

BEXXAR 131 IODINE 3

BICNU 3

BLENOXANE 3

bleomycin sulfate 1

BUSULFEX 3 (PR)

CAMPATH 3

CAMPTOSAR 3

carboplatin 1

CEENU 3

CERUBIDINE 3




NC = Not covered


37

MYLOTARG 3

NAVELBINE 3

NEXAVAR 3

NIPENT 3

NOVANTRONE 3

ONCASPAR 3

ONTAK 3

ONXOL 1

PACLITAXEL 1

PARAPLATIN 3

PHOTOFRIN 3

PLATINOL AQ 3

PROLEUKIN 3 (PR)

PURINETHOL 3

QUADRAMET 3

RITUXAN 3 (PR)

SOLTAMOX 3

SPRYCEL 2

SUTENT 3

TABLOID 3 (PR)

tamoxifen citrate 1

TARCEVA 2

TARGRETIN CAPSULES 2 (PR)

TAXOTERE 3

TESLAC 3 (PR)

THERACYS 2 (PR)

thiotepa 1

TICE BCG 2 (PR)

TOPOSAR 1

TRELSTAR DEPOT 3 (PR)

TRELSTAR LA 3 (PR)

TREXALL 3 (PR)




NC = Not covered


36

GLEEVEC 2

HERCEPTIN 3

HEXALEN 3

HYCAMTIN 3

HYDREA 3 (PR)

hydroxyurea 1 (PR)

IDAMYCIN PFS 3

IDARUBICIN 1

IFEX 3

IFEX/MESNEX 3

IFEX/MESNEX COMBO PACK 3

ifosfamide 1

IFOSFAMIDE/MESNA 1

IRESSA 3

KEPIVANCE 3

leucovorin calcium injection 1 (PR)

leucovorin calcium tablets 1

LEUKERAN 3 (PR)

MATULANE 3

MEGACE ES 3

MEGACE ORAL 3

megestrol acetate 1

mercaptopurine 1

mesna 1

MESNEX 3

methotrexate sodium 1 (PR)

methotrexate sodium 2.5mg 1

mitomycin 1

mitomycin c 1

mitoxantrone hydrochloride 1

MUSTARGEN 3

MUTAMYCIN 3




NC = Not covered


39

clomipramine hcl 1

CYMBALTA 2 (QL) (ST) 2/1 day(s)

desipramine hydrochloride 1

DESYREL 3 (ST)

EMSAM 3 (QL) (PR) (ST) 1/1 day(s)

fluoxetine hcl 10mg 1 (QL) 1/1 day(s)



fluoxetine hcl solution 1 (QL) 10/1 day(s)

fluvoxamine maleate 1 (QL) 3/1 day(s)

imipramine hydrochloride 1

LEXAPRO 3 (QL) (ST) 1/1 day(s)

LEXAPRO SOLUTION 3 (QL) (ST) 20/1 day(s)

LIMBITROL 3

LIMBITROL DS 3

maprotiline hydrochloride 25mg 1 (QL) 1/1 day(s)



MARPLAN 3

mirtazapine 1 (QL) 1/1 day(s)

mirtazapine orally disenegrating tablet 1 (QL) 1/1 day(s)

NARDIL 2

nefazodone hydrochloride 1 (ST)

NORPRAMIN 3

nortriptyline hydrochloride 1

PAMELOR 3

PARNATE 3

protriptylin 1

PROZAC 10MG 3 (QL) (ST) 1/1 day(s)



PROZAC SOLUTION 3 (QL) (ST) 10/1 day(s)




NC = Not covered


38

TRISENOX 3

trolamine (triethanolamine) 1

UVADEX 3

VECTIBIX 3

VELCADE 3

VESANOID 2

VIDAZA 3

vinblastine sulfate 1

VINCASAR PFS 1

vincristine sulfate 1

vinorelbine tartrate 1

VUMON 3

ZANOSAR 3

ZEVALIN IN-111 3

ZINECARD 3

ZOLINZA 3 (QL) (PR) 4/1 day(s)

ANTIDEPRESSANT DRUGS

amitriptyline 1

amitriptyline and chlordiazepoxide 1

amoxapine 1

ANAFRANIL 3

AVENTYL 3

BUDEPRION 1 (QL) 2/1 day(s)

bupropion hcl 75, 100mg 1 (QL) 6/1 day(s)

bupropion hcl er 100, 150mg 1 (QL) 2/1 day(s)

bupropion hcl sr 150, 200mg 1 (QL) 2/1 day(s)

CELEXA 10, 20, 40MG 3 (QL) (ST) 1/1 day(s)

CELEXA SOLUTION 3 (ST)

chlordiazepoxide and amitriptyline hydrochloride 1

citalopram hydrobromide 10, 20, 40mg 1 (QL) 1/1 day(s)

citalopram hydrobromide solution 1




NC = Not covered


41

BIO-STATIN 3

CANCIDAS 3

clotrimazole 1

clotrimazole lozenge 1

clotrimazole troche 1

DIFLUCAN 3 (PR)

DIFLUCAN 150MG 3 (QL) 1/30 day(s)

DIFLUCAN IN ISO-OSMOTIC D 3 (PR)

DIFLUCAN IN NACL 3 (PR)

EQ MICONAZOLE 3 COMBO PAC 1

EQ TIOCONAZOLE 1 1

ERAXIS 3 (PR)

fluconazole 1 (PR)

fluconazole 150mg 1 (QL) 1/30 day(s)

fluconazole and sodium chloride 1 (PR)

FUNGIZONE 3

GRIFULVIN-V 3

GRISEOFULVIN MICROSIZE 1

GRISEOFULVIN ULTRAMICROSI 1

GRIS-PEG 3

GYNAZOLE-1 3

itraconazole 1 (PR)

ketoconazole 1

LAMISIL 2 (PR)

MICONAZOLE 3 1

MONISTAT 3 3

MONISTAT 7 COMBINATION PA 3

MYCAMINE 2 (PR)

MYCELEX 3

MYCOSTATIN SUSPENSION 3

NEBUPENT 3 (PR)

NIZORAL 3




NC = Not covered


40

PROZAC WEEKLY 3 (QL) (ST) 4/28 day(s)

RAPIFLUX 3 (QL) (ST) 4/1 day(s)

REMERON 3 (QL) (ST) 1/1 day(s)

REMERON SOLTAB 3 (QL) (ST) 1/1 day(s)

RISPERDAL M-TAB 0.5, 1, 2, 3MG 2 (QL) 2/1 day(s)

SARAFEM 10MG 3 (QL) 1/1 day(s)

SARAFEM 20MG 3 (QL) 4/1 day(s)

sertraline hcl 100mg 1 (QL) 2/1 day(s)

sertraline hcl 25mg 1 (QL) 1/1 day(s)

sertraline hcl 50mg 1 (QL) 1.5/1 day(s)

sertraline hcl oral conc 1 (QL) 10/1 day(s)

SURMONTIL 3

TOFRANIL 3

TOFRANIL-PM 3

tranylcypromine sulfate 1

trazodone hydrochloride 1

trimipramine maleate 1

VIVACTIL 3

WELLBUTRIN 75, 100MG 3 (QL) (ST) 6/1 day(s)

WELLBUTRIN SR 100, 150, 200MG 3 (QL) (ST) 2/1 day(s)

WELLBUTRIN XL 150, 300MG 2 (QL) (ST) 1/1 day(s)

ZOLOFT 100MG 3 (QL) (ST) 2/1 day(s)

ZOLOFT 25MG 3 (QL) (ST) 1/1 day(s)

ZOLOFT 50MG 3 (QL) (ST) 1.5/1 day(s)

ZOLOFT SOLUTION 3 (QL) (ST) 10/1 day(s)

ANTIFUNGUL DRUGS

ABELCET 3

AMBISOME 3

AMPHOCIN 1

AMPHOTEC 3

amphotericin b 1

ANCOBON 3




NC = Not covered


43

CELEBREX 200MG 3 (QL) (PR) 1/1 day(s)

choline magnesium trisalicylate 1

CLINORIL 3

CMT 1

CUPRIMINE 3

DAYPRO 3 (PR)

DECADRON 3

DELTASONE 1

DEPEN TITRATABS 3

DEPO-MEDROL 3

dexamethasone injection 1

dexamethasone solution 3

dexamethasone tablets 1

DEXPAK 3

diclofenac potassium 1

diclofenac sodium dr 1

diclofenac sodium ec 1

diclofenac sodium er 1

diclofenac sodium sr 1

diclofenac sodium xr 1

diflunisal 1

DOLOBID 3

EC-NAPROSYN 3

ENTOCORT EC 3

etodolac 1

etodolac er 1

FELDENE 3 (PR)

fenoprofen calcium 1

flurbiprofen 1

IBU 1

ibuprofen 1

INDOCIN 3 (PR)




NC = Not covered


42

NOXAFIL SUSPENSION 3 (PR)

nystatin 1

nystatin oral powder 1

nystatin suspension 1

PENLAC NAIL LACQUER 3 (PR)

PENTAM 300 3

pentamidine isethionate 1

RA CLOTRIMAZOLE 3 1

SB MICONAZOLE 3-DAY COMBO 1

SPORANOX 3 (PR)

SPORANOX INJECTION 3 (PR)

SPORANOX PULSEPAK 3 (PR)

SPORANOX SOLUTION 3 (PR)

TERAZOL 3 3

TERAZOL 7 3

terconazole 1

VAGISTAT-1 3

VAGISTAT-3 1

VFEND 3 (PR)

VFEND IV 3 (PR)

ZAZOLE 1

ANTI- INFLAMMATORY DRUGS

AEROBID 3

AEROBID-M 3

AMIGESIC 1

ANAPROX 3

ANAPROX DS 3

ANSAID 3

ARTHROTEC 3

C.M.T 1

CATAFLAM 3

CELEBREX 100, 400MG 3 (QL) (PR) 2/1 day(s)




NC = Not covered


45

ORAPRED ODT 3

ORUDIS 3

ORUVAIL 3

oxaprozin 1 (PR)

PEDIAPRED 3

piroxicam 1 (PR)

PONSTEL 3

prednisolone acetate 1

prednisolone anhydrous syrup 1

prednisolone sodium phosphate 1

prednisone 1

PREDNISONE INTENSOL 3

PRELONE 3

PREVACID NAPRAPAC 3 (PR)

RELAFEN 3

RUFEN 1

SALFLEX 1

salsalate 1

SOLU-CORTEF 3

SOLU-MEDROL 3

SOLUREX LA 3

STERAPRED 3

sulindac 1

TOLECTIN DS 3

tolmetin sodium 1

TORADOL ORAL 3 (QL) 20/30 day(s)

TRICOSAL 1

TRILISATE 3

VOLTAREN 3

VOLTAREN-XR 3

ZORPRIN 3




NC = Not covered


44

INDOCIN IV 3 (PR)

INDOCIN SR 3 (PR)

indomethacin 1 (PR)

indomethacin cr 1 (PR)

indomethacin er 1 (PR)

indomethacin sa 1 (PR)

indomethacin sr 1 (PR)

ketoprofen 1

ketorolac tromethamine injection 1 (PR)

ketorolac tromethamine tablets 1 (QL) (PR) 20/30 day(s)

KEY-PRED 3

MAGAN 3

meclofenamate sodium 1 (PR)

MEDROL 3

MEDROL DOSEPAK 1

meloxicam 1

methylprednisolone 1

methylprednisolone acetate 1

methylprednisolone sodium succinate 1

MOBIC 3 (ST)

MOTRIN 3

MST 600 1

nabumetone 1

NALFON 3

NAPRELAN 3 (ST)

NAPROSYN 3

naproxen 1

naproxen dr 1

naproxen ec 1

naproxen er 1

NOVASAL 3

ORAPRED 3




NC = Not covered


47

ORAP 3

perphenazine 1

RISPERDAL 0.25, 0.5, 1, 2, 3MG 2 (QL) 2/1 day(s)

RISPERDAL 4MG 2 (QL) 4/1 day(s)

RISPERDAL INJECTION 3

RISPERDAL M-TAB 4MG 2 (QL) 4/1 day(s)

RISPERDAL SOLUTION 2

SEROQUEL 200MG 2 (QL) 4/1 day(s)

SEROQUEL 25MG 2 (QL) 6/1 day(s)

SEROQUEL 300, 400MG 2 (QL) 2/1 day(s)

SEROQUEL 50, 100MG 2 (QL) 3/1 day(s)

SYMBYAX 3 (QL) 1/1 day(s)

thioridazine hydrochloride 1 (PR)

thiothixene 1

trifluoperazine hydrochloride 1

VESPRIN 3

ZYPREXA 2

ZYPREXA 2.5MG 2 (QL) 2/1 day(s)

ZYPREXA 5, 7.5, 10, 15, 20MG 2 (QL) 1/1 day(s)

ZYPREXA ZYDIS 2 (QL) 1/1 day(s)

ATTENTION DEFICIT DISORDER / NARCOLEPSY DRUGS

ADDERALL 20MG 3 (QL) (ST) 3/1 day(s)

ADDERALL 5, 7.5, 10, 12.5, 15, 30MG 3 (QL) (ST) 2/1 day(s)

ADDERALL XR 3 (QL) (ST) 2/1 day(s)

AMPHETAMINE SALT COMBO 5, 7.5, 10, 12.5, 15, 30MG 1 (QL) (PR) 2/1 day(s)

AMPHETAMINE SALTS COMBO 20MG 1 (QL) (PR) 3/1 day(s)

CONCERTA 18MG 3 (QL) (ST) 3/1 day(s)

CONCERTA 27, 36, 54MG 3 (QL) (ST) 2/1 day(s)

DAYTRANA 3 (QL) (ST) 1/1 day(s)

DESOXYN 3 (QL) (PR) (ST) 4/1 day(s)

DEXEDRINE 10MG 3 (QL) (PR) 3/1 day(s)




NC = Not covered


46

ANTIPSYCHOTIC / BIPOLAR DRUGS

ABILIFY 3 (QL) (ST) 1/1 day(s)

ABILIFY DISCMELT 3 (QL) (ST) 2/1 day(s)

ABILIFY SOLUTION 3 (QL) (ST) 30/1 day(s)

chlorpromazine hydrochloride 1

clozapine 100mg 1 (QL) 9/1 day(s)

clozapine 12.5mg 1 (QL) 2/1 day(s)

clozapine 200mg 1 (QL) 4/1 day(s)

clozapine 25, 50mg 1 (QL) 3/1 day(s)

CLOZARIL 100MG 3 (QL) 9/1 day(s)

CLOZARIL 25MG 3 (QL) 3/1 day(s)

EQUETRO 3

ESKALITH 3

ESKALITH CR 3

FAZACLO 3 (QL) 9/1 day(s)

fluphenazine decanoate 1

fluphenazine hydrochloride 1

GEODON 3 (QL) (ST) 2/1 day(s)

GEODON INJECTION 2

HALDOL 3

HALDOL DECANOATE-100 3

haloperidol 1

haloperidol decanoate 1

haloperidol lactate 1

lithium carbonate 1

lithium carbonate er 1

lithium citrate 1

LITHOBID 3

loxapine succinate 1

LOXITANE 3

MOBAN 3

NAVANE 3




NC = Not covered


49

cilostazol 1

COUMADIN 3

CYKLOKAPRON 3

dextrose (anhydrous) and heparin sodium (porcine) 1

dipyridamole 1

EPOGEN 3 (PR)

FRAGMIN 3

HEPARIN SODIUM 1

heparin sodium (porcine) 1

heparin sodium (porcine) and sodium chloride 1

INNOHEP 3

JANTOVEN 1

LEUKINE 3 (PR)

LOVENOX 2

NEULASTA 3

NEUMEGA 3

NEUPOGEN 3

PENTOPAK 1

pentoxifylline cr 1

pentoxifylline er 1

PENTOXIL 1

PERSANTINE 3

PLAVIX 3

PLETAL 3

PROCRIT 2 (PR)

TICLID 3 (PR)

ticlopidine hydrochloride 1 (PR)

TRENTAL 3

warfarin sodium 1

XIGRIS 3




NC = Not covered


48

DEXEDRINE 5MG 3 (QL) (PR) 4/1 day(s)

DEXEDRINE CR 5, 15MG 3 (QL) (PR) 3/1 day(s)

dextroamphetamine sulfate 1 (QL) (PR) 4/1 day(s)

dextroamphetamine sulfate cr 1 (QL) (PR) 3/1 day(s)

DEXTROSTAT 1 (QL) (PR) 4/1 day(s)

FOCALIN 3 (QL) (ST) 2/1 day(s)

FOCALIN XR 3 (QL) (ST) 1/1 day(s)

METADATE CD 10, 20, 30MG 3 (QL) (ST) 1/1 day(s)

METADATE ER 10MG 3 (QL) (ST) 3/1 day(s)

METADATE ER 20MG 1 (QL) 3/1 day(s)

methamphetamine hydrochloride 1 (QL) (PR) 4/1 day(s)

METHYLIN 1 (QL) 3/1 day(s)

METHYLIN CHEWABLE 3 (QL) (ST) 6/1 day(s)

METHYLIN 10MG/5ML SOLUTION 3 (QL) (ST) 30/1 day(s)

METHYLIN 5MG/5ML SOLUTION 3 (QL) (ST) 60/1 day(s)

METHYLIN CHEWS 3 (QL) (ST) 6/1 day(s)

METHYLIN ER 1 (QL) 3/1 day(s)

methylphenidate hydrochloride 1 (QL) 3/1 day(s)

methylphenidate hydrochloride er 1 (QL) 3/1 day(s)

methylphenidate hydrochloride sr 1 (QL) 3/1 day(s)

PROVIGIL 3 (QL) (PR) 2/1 day(s)

RITALIN 3 (QL) (ST) 3/1 day(s)

RITALIN LA 3 (QL) (ST) 2/1 day(s)

RITALIN SR 3 (QL) (ST) 3/1 day(s)

STRATTERA 3 (QL) (ST) 2/1 day(s)

XYREM 3 (PR)

BLOOD PRODUCTS

AGGRENOX 2

AGRYLIN 3

anagrelide 1

ARANESP 2, 3 (PR)

ARIXTRA 3




NC = Not covered


51

DIPENTUM 3 (QL) 12/1 day(s)

DIPHENATOL 1

GASTROCROM 2

GLYCOLAX 1

GOLYTELY 3

HALFLYTELY BOWEL PREP KIT 3

HEMORRHOIDAL-HC 1

hydrocortisone enema 1

LIDAZONE HC 1

LOFENE 1

LOMOTIL 3

LONOX 1

loperamide hydrochloride 1

mesalamine (5-asa) 1

MIRALAX 3

MOTOFEN 3

MOVIPREP 3

NULYTELY 3

opium tincture 1

OSMOPREP 3

paregoric 1

PEG 3350/ELECTROLYTES 1

PENTASA 250MG 3 (QL) 20/1 day(s)

PENTASA 500MG 3 (QL) 10/1 day(s)

polyethylene glycol 1

PROCTOCARE-HC 1

PROCTOCREAM-HC 1% 3

PROCTOCREAM-HC 2.5% 1

PROCTOFOAM HC 3

PROCTO-KIT 1

PROCTOSOL HC 2.5% 1

PROCTOZONE-HC 2.5% 1




NC = Not covered


50

BOWEL DISEASE DRUGS

AMITIZA 3 (PR) (ST)

ANALPRAM-HC 3

ANAMANTLE HC 3

ANASPAZ 3 (PR)

ANUSOL-HC 3

ASACOL 3 (QL) 12/1 day(s)

A-SPAS 1 (PR)

ATREZA 1 (PR)

atropine sulfate and diphenoxylate hydrochloride 1

atropine sulfate injection 1 (PR)

AZULFIDINE 3 (QL) 12/1 day(s)

AZULFIDINE EN-TABS 3 (QL) 12/1 day(s)

B & O 15-A SUPPRETTE 3 (PR)

B & O 16-A SUPPRETTE 3 (PR)

belladonna 1 (PR)

BELLADONNA ALKALOIDS & OP 1 (PR)

belladonna extract and opium 1 (PR)

CANASA 1000MG 2 (QL) 2/1 day(s)

CANASA 500MG 2 (QL) 3/1 day(s)

CANTIL 3

cascara sagrada 1

COLAZAL 2 (QL) 9/1 day(s)

COLIDROPS 1 (PR)

COLOCORT 1

COLYTE 3

COLYTROL 3

COLYTROL PEDIATRIC 3 (PR)

CORTIFOAM 3

CYSTOSPAZ-M 3 (PR)

DI-ATRO 1




NC = Not covered


53

AVANDIA 2

insulin pen needle 3

syringe w-ndl, disp., insulin 3

B-D INSLUIN PEN NEEDLE 2

B-D SYRINGE W-NEEDLE, INSULIN 2

BYETTA 2 (QL) 1/30 day(s)

chlorpropamide 1 (PR)

DIABETA 3

DIABINESE 3 (PR)

DUETACT 3

EXUBERA KIT 3 (QL) (PR) 1/365 day(s)

EXUBERA COMBINATION PACK 3 (PR)

FORTAMET 3 (ST)

gauze pads & dressings - pads 2" x 2" 1

glimepiride 1

glipizide 1

glipizide and metformin hydrochloride 1

glipizide er 1

glipizide xl 1

GLUCAGON EMERGENCY KIT 2

GLUCOPHAGE 3 (ST)

GLUCOPHAGE XR 3 (ST)

GLUCOTROL 3

GLUCOTROL XL 3

GLUCOVANCE 3

GLUMETZA 3

glyburide 1

glyburide and metformin hydrochloride 1

glyburide micronized 1

GLYCRON 1

GLYNASE 3

GLYSET 2




NC = Not covered


52

RECTAGEL HC 3

ROWASA 3

simethicone 1

sulfasalazine 1 (QL) 12/1 day(s)

sulfasalazine ec 1 (QL) 12/1 day(s)

TRILYTE 1

VISICOL 3

DENTAL AND DRUGS FOR THE MOUTH

APHTHASOL 3

ARESTIN 3

ATRIDOX 3

CAPHOSOL 3

CAVAREST 1

chlorhexidine gluconate 1

DEBACTEROL 3

EVOXAC 3

KENALOG IN ORABASE 3

PERIDEX 3

PERIOGARD 1

PERISOL 1

pilocarpine hydrochloride 1

SALAGEN 3

triamcinolone acetonide dental paste 1

DIABETES DRUGS

ACTOPLUS MET 2

ACTOS 2

ALCOHOL SWABS 1

AMARYL 3

APIDRA 2

APIDRA OPTICLIK 2

AVANDAMET 2

AVANDARYL 2




NC = Not covered


55

NOVOLOG PENFILL 2

PRANDIN 2

PRECOSE 3

PROGLYCEM 2

RELION 70/30 3

RELION 70/30 INNOLET 3

RELION N 3

RELION N INNOLET 3

RELION R 3

RIOMET 3

STARLIX 2

SYMLIN 2 (QL) 20/30 day(s)

tolazamide 1

tolbutamide 1

TOLINASE 3

DRUGS FOR SKIN CONDITIONS

50% UREA NAIL STICK 1

8-MOP 3

ACCUTANE 3 (PR)

ACCUZYME 3

ACLOVATE 3

ACNE MEDICATION-5 1

AKNE-MYCIN 3

ALA-CORT 1

ALA-SCALP 3

alclometasone 1

ALDARA 2

ALLANFIL 405 1

ALLANFIL SPRAY 1

ALLANZYME OINTMENT 1

ALLANZYME SPRAY 1

ALPHATREX 1




NC = Not covered


54

HUMALOG 2

HUMALOG MIX 50/50 PEN 2

HUMALOG MIX 75/25 PEN 2

HUMALOG PEN 2

HUMULIN 50/50 2

HUMULIN 70/30 PEN 2

HUMULIN N 2

HUMULIN R 2

ILETIN II LENTE/PORK 3

JANUVIA 3 (QL) (ST) 1/1 day(s)

LANTUS 3

LANTUS OPTICLIK 3

LEVEMIR 2

LEVEMIR FLEXPEN 2

METAGLIP 3

metformin hydrochloride 1

metformin hydrochloride er 1

MICRONASE 3

NOVOLIN 70/30 2

NOVOLIN 70/30 INNOLET 2

NOVOLIN 70/30 PENFILL 2

NOVOLIN N 2

NOVOLIN N INNOLET 2

NOVOLIN N U-100 PENFILL 2

NOVOLIN R 2

NOVOLIN R INNOLET 2

NOVOLIN R U-100 PENFILL 2

NOVOLOG 2

NOVOLOG FLEXPEN 2

NOVOLOG MIX 70/30 2

NOVOLOG MIX 70/30 PENFILL 2

NOVOLOG MIX 70/30 PREFILL 2




NC = Not covered


57

benzoyl peroxide and urea (carbamide) 1

BENZOYL PEROXIDE WASH 1

betamethasone dipropionate 1

betamethasone dipropionate and clotrimazole 1

betamethasone valerate 1

BETA-VAL 1

BINORA CREAMY WASH 3

BREVOXYL 3

BREVOXYL CREAMY WASH 3

BUCALSEP 3

CAPEX 3

CAPITROL 3

CARAC 3

CARMOL 40 1

CARMOL SCALP TREATMENT 3

CARMOL-HC 3

CENTANY 1

CEROVEL 1

CETACORT 1

chlorophyllin copper and papain and urea (carbamide) 1

ciclopirox olamine 1

CLARAVIS 1 (PR)

CLEARPLEX X 1

CLENIA 1

CLENIA FOAMING WASH 1

CLEOCIN-T 3

CLINAC BPO 3

CLINDAGEL 3

CLINDAMAX 1

clindamycin phosphate 1




NC = Not covered


56

amcinonide 1

AMEVIVE 3

AMMONIUM LACTATE 1

AMNESTEEM 1 (PR)

anthralin 1

APEXICON 1

APEXICON E 1

ARISTOCORT 3

ARISTOCORT A 3

augmented betamethasone dipropionate 1

AVAR 3

AVAR CLEANSER 1

AVAR GREEN 3

AVAR-E EMOLLIENT 1

AVAR-E GREEN 1

AVITA 1 (PR)

AZELEX 3

BACTROBAN 3

BENSAL HP 3

BENZAC AC 3

BENZAC AC WASH 3

BENZAC W 3

BENZAC W WASH 3

BENZACLIN 3

BENZAGEL 3

BENZAGEL WASH 1

BENZAMYCIN 3

BENZASHAVE 1

BENZIQ 3

BENZIQ LS 3

BENZIQ WASH 3

benzoyl peroxide 1




NC = Not covered


59

econazole nitrate 1

EFUDEX 3

EFUDEX OCCLUSION PACK 3

ELIDEL 3

ELOCON 3

EMBELINE 1

EMBELINE E 1

EMCIN CLEAR 1

EPIFOAM 3

ERTACZO 3

ERYDERM 1

ERYGEL 3

erythromycin 1

erythromycin and benzoyl peroxide 1

ETHEXDERM BPW-10 1

ETHEZYME 3

EVOCLIN 3

EXELDERM 3

FINACEA 3

FIRST-HYDROCORTISONE 3

fluocinolone acetonide 1

fluocinonide 1

FLUOCINONIDE-E 1

FLUOROPLEX 3

fluorouracil solution 1

fluticasone cream/ointment 1

gentamicin sulfate cream/ointment 1

GERI-HYDROLAC 1

GLADASE 1

GLADASE-C 1

GORDON'S UREA 3

halobetasol propionate 1




NC = Not covered


58

CLINDETS 1

clobetasol propionate 1

CLOBEVATE 1

CLOBEX 3

CLODERM 3

clotrimazole solution 1

CONDYLOX 3

CORDRAN 3

CORDRAN SP 3

CORDRAN TAPE 3

CORMAX 1

CORTANE-B LOTION 3

CORTISPORIN CREAM/OINTMENT 3

CUTIVATE 3

CYCLOCORT 3

DEL-AQUA 1

DEL-BETA 1

DERMA-SMOOTHE/FS SCALP OI 3

DERMATOP 3

desonide 1

DESOWEN 3

desoximetasone 1

DESQUAM-E 3

DESQUAM-X 3

DIFFERIN 3

diflorasone diacetate 1

DIPROLENE 3

DIPROLENE AF 3

DOVONEX 3

doxepin hydrochloride 1

DRITHO-SCALP 3

DUAC 3




NC = Not covered


61

LIDAMANTLE HC 3

LIDEX 3

LIDEX-E 3

LOCOID 1

LOCOID LIPOCREAM 3

LOKARA 1

LOPROX 3

LOPROX SHAMPOO 3

LOTRISONE 3

LUXIQ 3

MAXIFLOR 3

MENTAX 3

METROCREAM 3

METROGEL 3

METROLOTION 3

metronidazole lotion 1

MEXAR WASH 1

mometasone furoate 1

MONISTAT-DERM 3

mupirocin 1

MYCOSTATIN CREAM 3

MYTREX 1

NAFTIN 3

NAFTIN-MP 3

NEOBENZ MICRO 3

NIZORAL SHAMPOO 3

NORITATE 3

NUOX 3

NUTRACORT 1

NYAMYC 1

nystatin and triamcinolone acetonide 1

nystatin cream 1




NC = Not covered


60

HALOG 3

HC PRAMOXINE 1

hydrocortisone 1

hydrocortisone butyrate 1

hydrocortisone butyrate solution 1

hydrocortisone cream 1

hydrocortisone valerate 1

HYPERCARE 1

HYTONE 3

isotretinoin 1 (PR)

ISOVATE 1

KENALOG 3

KERALAC 3

KERALAC NAILSTIK 3

KERALYT 3

KERATOL 40 1

KERATOL HC 1

KEROL REDI-CLOTHS 3 (ST)

ketoconazole cream 1

KLARON 3

KOVIA 1

KURIC 1

LACCREAM 1

LAC-HYDRIN 3

LACLOTION 1

LACTIC ACID 1

LACTIC ACID E 1

LACTICARE-HC 1

LACTINOL 3

LACTREX 1

LAMISIL SPRAY 3 (PR)

LEVULAN KERASTICK 3




NC = Not covered


63

PROTOPIC 3

PRUDOXIN 1

PSORCON E 3

PSORIATEC 3

RAPTIVA 3

RE 10 WASH 1

RE 40 1

RE SA CREAM 1

REGRANEX 3

RETIN-A 3 (PR)

RETIN-A MICRO 3 (PR)

RINGERS IRRIGATION 1

ROSAC 3

ROSADERM 1

ROSANIL CLEANSER 1

ROSULA 3

ROSULA NS 3

ROZEX 3

SALEX 3

SALEX SHAMPOO 3

SANTYL 2

SB CLOTRIMAZOLE FOOT 1

SCALP TREATMENT 1

SEBA-GEL 1

SEB-PREV 1

selenium sulfide 1

SELENIUM SULFIDE 1

SELSEB 3

SELSUN SHAMPOO 3

SENATEC HC 1

SILVADENE 3

silver nitrate 1




NC = Not covered


62

NYSTOP 1

OLUX 3

ORACEA 3 (QL) (PR) 1/1 day(s)

OSCION CLEANSER 1

OVACE 3

OVACE WASH 3

OXISTAT 3

OXSORALEN ULTRA 2

PANAFIL 3

PANDEL 3

PANOXYL 1

PANOXYL AQ 1

PANRETIN 3

PAP-UREA 1

PEDI-DRI 1

PHYSIOLYTE 1

physiosol irrigation (magnesium chloride and potassium chloride and sodium acetate and sodium chloride and sodium gluconate) 1

PLEXION CLEANSER 3

PLEXION CLEANSING CLOTH 3

PLEXION SCT 3

PLEXION TS 3

PODOCON 25 IN BENZOIN TIN 1

PODODERM 1

podofilox 1

PRASCION 1

PRASCION AV CLEANSER 1

PRASCION PADS 1

PRASCION RA WITH SUNSCREE 1

PROCTOCORT 3

PROCTO-PAK 1




NC = Not covered


65

TRIAZ CLEANSER 3

TRIDERM 1

TRIDESILON 3

TRIPLE ANTIBIOTIC 1

U-CORT 1

U-KERA E 1

ULTRALYTIC 2 3

ULTRAVATE 3

UMECTA 3

UMECTA NAIL FILM 3

urea carbamide 1

urea nail gel 1

UREA-C40 1

UREALAC 1

UREALAC NAIL GEL 1

VANAMIDE 1

VANOS 3

VANOXIDE-HC 3

VERDESO 3

VERSICLEAR 1

WESTCORT 3

XERAC AC 3

XOLEGEL 3

X-VIATE 1

ZACLIR CLEANSING 3

Z-CLINZ 10 3

ZETACET 1

ZIOX 1

ZODERM 3

ZODERM CLEANSER 3

ZONALON 3




NC = Not covered


64

silver nitrate-potassium nitrate applicator 1

silver sulfadiazine 1

SOLARAZE 2

SORIATANE 3

SOTRET 10, 20, 40MG 1 (PR)

SOTRET 30MG 3 (PR)

SPECTAZOLE 3

SSD 1

SSD AF 1

sulfacetamide sodium and sulfur 1

sulfacetamide sodium and urea (carbamide) 1

SULFACET-R 3

SULFAMYLON 3

SULFATOL 1

SULFATOL CLEANSER 1

SULFOXYL REGULAR 3

SUPHERA 1

SYNALAR 3

TACLONEX 3 (ST)

TARGRETIN GEL 2

TAZORAC 2

TEMOVATE 3

TEMOVATE E 3

TEXACORT 1

THERMAZENE 1

TIS-U-SOL 1

TOPICORT 3

TOPICORT LP 3

tretinoin 1 (PR)

triamcinolone acetonide 1

triamcinolone acetonide and nystatin 1

TRIAZ 3




NC = Not covered


67

ENZYMES

ALDURAZYME 3

CEREDASE 3

CEREZYME 3

CREON 3

CYSTADANE 2

CYSTAGON 2

DYGASE 1

ELAPRASE 3 (PR)

ENZYCAP 1

ENZYMAX 3

FABRAZYME 3

KUTRASE 3

KU-ZYME 3

KU-ZYME HP 3

LAPASE 1

LIPRAM 4500 1

MYOZYME 3

NAGLAZYME 3

PALCAPS 10 3

PALIPASE 1

PALIPASE MT 16 1

PALPEON DR 10 1

PALPEON MT 20 1

PALTRASE V8 1

PANCREASE 3

PANCREASE MT 10 3

PANCRECARB MS-16 3

PANCRELIPASE 1

PANCRON 10 1

PANGESTYME CN 10 1

PANOCAPS 3




NC = Not covered


66

DRUGS FOR THE TREATMENT OF PARASITES

ACTICIN 1

ALBENZA 3

ALINIA 3

ARALEN 3

BILTRICIDE 3

chloroquine phosphate 1

DARAPRIM 3

ELIMITE 3

EURAX 3

FANSIDAR 3

hydroxychloroquine sulfate 1

LARIAM 3

lindane 1

MALARONE 3

malathion 1

mebendazole 1

mefloquine hcl 1

MEPRON 3

MINTEZOL 3

NEUTREXIN 3

OVIDE 3

permethrin 1

PLAQUENIL 3

primaquine phosphate 1

QUINERVA 1

quinine sulfate 1

STROMECTOL 3

TINDAMAX 3

VERMOX 3

YODOXIN 3




NC = Not covered


69

CRINONE 3

CRYSELLE 1

CYCLESSA 3

danazol 1

DELESTROGEN 3

DEMULEN 3

DEPO-ESTRADIOL 3

DEPO-PROVERA 3

DEPO-PROVERA CONTRACEPTIVE 3

DEPO-SUBQ PROVERA 104 3

DEPO-TESTOSTERONE 3

DESOGEN 3

ENJUVIA 3

ENPRESSE-28 1

ERRIN 1

ESCLIM 3 (QL) 8/28 day(s)

ESTRACE 3 (QL) 1/1 day(s)

ESTRACE VAGINAL CREAM 3

ESTRADERM 3 (QL) 8/28 day(s)

estradiol 1 (QL) 1/1 day(s)

estradiol patch 1 (QL) 4/28 day(s)

ESTRASORB 3

ESTRING 3

ESTRO-5 1

ESTROGEL 3

estropipate 1

ESTROSTEP FE 3

FEMHRT 1/5 3

FEMHRT LOW DOSE 3

FEMRING 3

FEMTRACE 3

FIRST-PROGESTERONE MC 10 3




NC = Not covered


68

PANOKASE 1

PLARETASE 8000 1

PULMOZYME 3 (PR)

SUCRAID 3

ULTRACAPS MT 20 3

ULTRASE 1

VIOKASE 16 2

ZAVESCA 3 (PR)

(PROSTAGLANDINS)

ACTIVELLA 3

ALESSE 3

ALORA 3 (QL) 8/28 day(s)

ANADROL-50 3

ANDRODERM 2

ANDROGEL 2

ANDROGEL PUMP 2

ANDROID 3 (PR)

ANDROXY 3

ANGELIQ 3

APRI 1

ARANELLE 1

AVIANE 1

AYGESTIN 3

BALZIVA 3

BREVICON 3

CAMILA 1

CASODEX 3

CENESTIN 3 (QL) 1/1 day(s)

CESIA 1

CLIMARA 3 (QL) 4/28 day(s)

CLIMARA PRO 3 (QL) 4/28 day(s)

COMBIPATCH 3 (QL) 8/28 day(s)




NC = Not covered


71

NECON 1/35-28 1

NECON 1/50-28 1

NECON 10/11-28 1

NECON 7/7/7 1

NORA-BE 1

NORDETTE 3

norethindrone acetate 1

NORINYL 3

NOR-QD 3

NORTREL 1

NUVARING 3

OGEN 3

OGESTREL 1

ORTHO EVRA 3

ORTHO MICRONOR 3

ORTHO TRI-CYCLEN 3

ORTHO TRI-CYCLEN LO 3

ORTHO-CEPT 3

ORTHO-CEPT-28 3

ORTHO-CYCLEN 3

ORTHO-EST 1

ORTHO-NOVUM 3

OVCON 3

OVCON FE CHEW 3

OXANDRIN 3 (PR)

PLAN B 3

PORTIA 1

PREFEST 3

PREMARIN 3 (QL) 1/1 day(s)

PREMARIN INJECTION 3

PREMARIN VAG CREAM 3

PREMPHASE 3




NC = Not covered


70

FIRST-PROGESTERONE VGS 10 3

FIRST-TESTOSTERONE 3 (ST)

GYNODIOL 0.5, 1, 2MG 1 (QL) 1/1 day(s)

GYNODIOL 1.5MG 3 (QL) 1/1 day(s)

IMPLANON 3

JOLESSA 1

JOLIVETTE 1

JUNEL 1

KARIVA 1

KELNOR 1/35 1

KESTRONE 5 1

LEENA 1

LESSINA 1

LEVLEN 3

LEVLEN CONTRACT PACK 3

LEVLITE 3

LEVORA 1

LO/OVRAL 3

LOESTRIN 3

LOW-OGESTREL 1

LUTERA 1

medroxyprogesterone acetate 1

MENEST 3 (QL) 1/1 day(s)

MENOSTAR 3 (QL) 4/28 day(s)

METHITEST 3 (PR)

MICROGESTIN 1.5/30 1

MIRCETTE 3

MIRENA 3

MODICON-28 3

MONONESSA 1

nandrolone decanoate 1 (PR)

NECON 0.5/35-28 1




NC = Not covered


73

VALERTEST #1 3

VELIVET 1

VIVELLE 3 (QL) 8/28 day(s)

VIVELLE-DOT 3 (QL) 8/28 day(s)

YASMIN 3

YAZ 3

ZOVIA 1

(PROSTAGLANDINS), ULCER AND STOMACH DRUGS

CYTOTEC 3

misoprostol 1

EYE AND EAR DRUGS

A/B EAR DROPS 1

A/B OTIC 1

ACETASOL HC 1

acetic acid and aluminum acetate 1

acetic acid and hydrocortisone 1

acetic acid hc 1

ACULAR 2

ACULAR LS 2

ACULAR PF 2

AERO OTIC HC 1

AK-CON 1

AK-DILATE 1

AK-POLY-BAC 1

AK-TAINE 1

AK-TOB 1

ALAMAST 3

ALBALON 3

ALCAINE 3

ALLERGEN 1

ALLERSOL 1




NC = Not covered


72

PREMPRO 3

PREVIFEM 1

PROCHIEVE 3

PROCHIEVE VAGINAL 3

progesterone 1

progesterone vaginal suppository 3

PROMETRIUM 3

propylthiouracil 1

PROVERA 3

QUASENSE 1

RECLIPSEN 1

SEASONALE 3

SEASONIQUE 3

SOLIA 1

SPRINTEC 1

SRONYX 1

STRIANT 3 (ST)

TESTIM 3 (ST)

TESTOPEL 3

testosterone 1

testosterone cypionate 1

testosterone enanthate 1

testosterone propionate 1

TESTRED 3 (PR)

TRI-LEVLEN 3

TRINESSA 1

TRI-NORINYL 3

TRIPHASIL 3

TRI-PREVIFEM 1

TRI-SPRINTEC 1

TRIVORA 1

VAGIFEM 3




NC = Not covered


75

BETOPTIC-S 3

BLEPH-10 3

BLEPHAMIDE 3

BLEPHAMIDE LIQUIFILM 3

BLEPHAMIDE S.O.P. 3

BOROFAIR 1

BOTOX 3 (PR)

brimonidine tartrate 1

CARBASTAT 1

CARBOPTIC 1

carteolol hcl 1

CILOXAN 3

CIPRO HC 3

CIPRODEX 3

ciprofloxacin optical solution 1

CLEERAVUE-M 3 (QL) (PR) (ST) 1/30 day(s)

COLY-MYCIN S 3

CORTANE-B AQUEOUS 3

CORTANE-B-OTIC 3

CORTIC 1

CORTIC-ND 1

CORTISPORIN OPTHL 3

CORTISPORIN OTIC 3

CORTOMYCIN 1

COSOPT 2

CRESYLATE 3

CROLOM 3

cromolyn sodium opthl 1

CYOTIC 1

DERMOTIC 3

dexamethasone and neomycin sulfate and polymyxin b sulfate 1




NC = Not covered


74

ALOCRIL 3

ALOMIDE 3

ALPHAGAN P 2

ALREX 2

ALTAFRIN 1

AMERICAINE OTIC 3

ANTIBEN 1

ANTIBIOTIC EAR 1

antipyrine and benzocaine 1

Preferred Drug List - Aetnacustom.aetna.com/Emeriti/images/aet_3TierOpen_2_1.pdf · What is the...

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Transcript of Preferred Drug List - Aetnacustom.aetna.com/Emeriti/images/aet_3TierOpen_2_1.pdf · What is the...