2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child...

An Introduction to Independent Healthrsquos 2019 MediSource and Child Health Plus Formulary

The following information applies to

Independent Healthrsquos New York State

Sponsored Plans Child Health Plus and

MediSource (Medicaid) Check your summary

of benefits to ensure this formulary is

associated with your plan prior to using your

prescription drug benefit

This dru g formulary lists covered generic and

brand-name drugs covered under our Managed

Medicaid Plans MediSource and Child Health

Plus Independent Health makes every attempt to

provide you with as accurate a listing of

medications as possible However the list of drugs

and availability of generic medications can change

frequently When a generic medication becomes

available for a formulary brand-name medication

the generic medication will be covered and the

brand-name medication will become non-formulary

and will require prior authorization to be covered

Please discuss any questions you may have about

the formulary with your provider

Prior-Authorization

Independent Health requires you to get prior

authorization for certain medications To obtain

coverage for a medication requiring prior

authorization a prior authorization request for

medical exception must be submitted by your

health care provider and approved by

Independent Healthrsquos Medical Director

Medications that require Prior Authorization are

listed with a ldquoPArdquo in the formulary

Step Therapy

In some cases Independent Health requires you to

first try certain medications to treat your medical

condition before we cover another medication for

that condition Step therapy is a way to help you

get the best quality and value from your

prescription medication benefit This usually means

that an equally effective generic medication is

prescribed before a more expensive brand-name

medication Step therapy may also ensure that two

medications are used together if they are more

effective Medications that require Step Therapy are

listed with a ldquoSTrdquo in the formulary

Quantity Limitations

Quantity limitations may apply to certain

medications Some medications are covered up

to a specific quantity per 30 days Some

examples of medications with a quantity

limitation are sumatriptan (generic Imitrexreg) and

zolpidem tartrate (generic Ambienreg) Medications

with quantity limitations are listed with a ldquoQLrdquo in

the formulary

For items that come pre-packaged (for example

tubecontainer inhaler device single dose units or

liquid container) one package size is allowed per

fill of these items If a quantity limit is designated

on the formulary this restriction will take

precedence over the pre-packaged limitations

when applicable

Age Restriction

Some prescription medications are restricted by

age due to safety reasons or Food and Drug

Administration (FDA) recommended labeling

Medications with an Age Limit are listed with an

ldquoALrdquo in the formulary

Dental Formulary

Drugs covered on our Dental Formulary are

available when prescribed by a dental provider

Drugs included in our Dental Formulary are listed

with a ldquoDFrdquo on the formulary Drugs without a ldquoDFrdquo

will not be covered when written by a Dental

Provider

Limited Distribution Drugs

Some specialty medications can only be obtained

through designated specialty pharmacies due to

limited distribution placed on the medication by the

manufacturer These medications are listed with a

ldquoLDDrdquo on the formulary

Maximum Daily Dose (MDD)

Certain medications are dose limited by a

maximum daily dose (MDD) as recommended by

the Food and Drug Administration (FDA) for safety

reasons Limits may be set by the number of

tabletscapsules per day or the total daily dose

Over-the-Counter (OTC) Medications

Certain medications listed in the formulary are

available over the counter A prescription is

required for coverage of the OTC products

SedativeHypnotic Medications

Sedativehypnotic medications are limited for all

prescribers except sleep specialists to 14

tabletscapsules per month with a maximum of 3 fills

per year (3 fills365 days)

Compounded Prescription Medications

Compounded prescriptions (medications that are

not commercially manufactured) must be prepared

by a participating pharmacy and contain at least

one prescription component The dispensing

pharmacy is required to submit for prior approval

and when covered will take the applicable

copayment Coverage is provided in accordance

with our Compounding Medication Products

Policy Bulk products and powders are excluded

from coverage because they are not prescription

medication products that are approved under

sections 505 505(j) or 507 of the Federal Food

Drug and Cosmetic Act

Diabetic SuppliesMedications

Products listed in this section are a covered benefit

based on your plan Products not listed require prior

authorization Copayments vary by plan

BD needles and syringes are our preferred

needlesyringe products

OneTouch glucose meters lancets test strips and

supplies are our preferred diabetic supplies and do

not require prior authorization

OneTouch will provide a glucose meter to you with

no copayment Quantities are limited to one meter

per member You can obtain a meter by calling

LifeScan Inc at 1-888-377-5227 offer code

289IHA001 Please have your ID number available

when you call

Diabetic test strips are limited to a maximum of

100 per fill30 days

Affordable Care Act (ACA)

Preventive Services

Medications listed on the formulary that are

covered as preventive services under the

Affordable Care Act may be covered Certain

restrictions may apply

LostStolenDamaged Medications and

Vacation Supplies

Replacement of any lost stolen or damaged

medications is the responsibility of the member

Vacation supplies are not covered under this

benefit Prior authorization cannot be used to

obtain early refills for lost stolen or damaged

medications or for extended supplies or vacation

supplies

Emergency Room Prescriptions

Emergency Room prescriptions are limited to a

10-day supply

Enteral and Parenteral

Nutritional Formulas

Enteral Nutritional Formula and Parenteral

Nutritional Formula benefit coverage is based on

medical necessity and prior authorization is

required Supplies that are necessary to administer

the specific type of feeding and maintain the

feeding site are covered This includes but is not

limited to syringes measuring containers tip

adapters anchoring devices gauze pads

protective-dressing wipes tape and tube cleaning

brushes

Pharmacy Administered Immunizations

Influenza and pneumococcal vaccinations are

covered when administered by licensed pharmacists

who obtain additional certification to administer

influenza and pneumococcal vaccinations to adults

18 years of age and older

Additional Formulary Information

bull Appetite suppressantsweight-loss medications

are excluded from coverage

bull Medications used for cosmetic purposes

bull Medical foods other than PKU supplements

(which may or may not require a prescription)

bull Prenatal vitamins classified as medical foods

are not covered

bull Medications used for the treatment of sexual or

erectile dysfunction are not covered

bull Up to three cycles of the following drugs used

to promote fertility are covered

Bromocriptine Clomiphene Citrate Letrozole

and Tamoxifen Prior authorization may be

needed before we will cover these drugs for

infertility All other drugs used to promote

fertility are not covered

bull Growth hormones are excluded from

coverage when prescribed for the treatment

of short stature

bull Medications that are excluded from coverage

under state andor federal law are not covered

by Independent Health

bull In order to ensure the safest and most

appropriate care Independent Healthrsquos drug

coverage criteria is limited to medically-

accepted indications based on FDA approved

labeling and guidelines not otherwise excluded

from New York State Medicaid

bull Medications listed on the drug formulary as

covered without restriction may require prior

authorization or may not be covered if it is

determined that they are being used in

conjunction with a procedure or treatment not

covered under the memberrsquos Health Contract

bull Medications not recognized by the FDA without

a National Drug Code (NDC) are excluded from

coverage

bull Generic substitution is used only as required by

state pharmacy laws Therapeutic interchange

is not utilized

bull Prescriptions are generally limited to a maximum

of a 30-day supply per fill

bull Diabetic Test Strips are limited to a maximum of

100 per fill30 days

bull FreeStyle Libre continuous glucose monitors and

sensors are also available at retail pharmacies if

member is concurrently on insulin

bull Dexcom G6 continuous glucose monitoring

system covered with concurrent use of bolus

insulin

Cost-share change for diabetic

equipment supplies and medications

The cost share for insulin and oral anti-diabetic

medications will depend on where you obtain these

medications This is a change from your current

coverage

bull If you obtain your medication at the pharmacy

you will pay your appropriate pharmacy cost

share

bull If you obtain the medication at a medical supply

provider you will pay your office visit cost share

Key

AL ndash Age Limit

DF ndash Dental Formulary

LDD ndash Limited Distribution Drugs

PA ndash Prior Authorization Required

PR ndash Prescriber Prevails

QL ndash Quantity Limits Apply

RF ndash Restricted to Females

RM ndash Restricted to Males

ST ndash Step Therapy XCHP ndash Not covered for Child Health Plus Additional Services for MediSource Members on Next Page

MEDICAL SUPPLIES FOR MEDISOURCE MEMBERS ONLY

(NOT APPLICABLE TO CHILD HEALTH PLUS)

Covered medical supplies must have a prescription

Formulary restrictions quantity limits or coverage limits may apply

Adhesive TapeRemover

Adhesive remover or solvent (for tape cement or

other adhesive) per ounce tape non-waterproof

per 18 square inches tape waterproof per 18

square inches

Antiseptics

Alcohol or peroxide per pint alcohol wipes per

box (100rsquos) Betadinereg or pHisohexreg solution

per pint

Breast Pump

Breast pump electric (ACDC) any type breast

pump manual any type

CanesCrutchesAccessories

Cane includes canes of all materials adjustable or

fixed with tip crutch forearm includes crutches of

various materials crutch underarm replacement

handgrip cane crutch or walker replacement tip

cane crutch or walker underarm pad crutch

replacement

Commode Accessories

Bed pan standardfracture metal or plastic pail or

pan for use with commode chair sitz type bath or

equipment portable urinal female jug-type any

material male jug-type any material

Diabetic Daily Care

box (100rsquos) infusion set for external insulin pump

needle and non-needle type infusion set for

external insulin pump non-needle cannula type

Ostomy Supplies

Ostomy supplies pouch belt clamp filter vent

ring face plate deodorant skin barrier misc

adhesive remover wipes any type adhesive

liquid or equal any type per ounce continent

devices enema bags irrigation supply lubricant

per ounce stoma cap

RespiratoryTracheostomy Care

Supplies

Administration set with small volume non-filtered

pneumatic nebulizer aerosol mark used with

DME nebulizer canister disposable used with

suction pump cannula nasal face tent cleaning

device used with tracheoesophageal voice

prosthesis pipet brush or equal replacement

only filter disposable and non-disposable used

with aerosol compressor airway pressure device

holding chamber or spacer for use with an inhaler

or nebulizer nebulizer disposable oropharyngeal

suction catheter peak expiratory flow rate meter

hand-held tracheostomy care kit for new

tracheostomy tracheostomy cleaning brush

tracheostomy mask tracheostomy supplies

vaporizer room type

Heat Application

Electric heat pad moist or standard hot water

bottle ice cap or collar non-electric heating

pad moist surgical dressing holder reusable

surgical stockings below knee length surgical

stockings full length surgical stockings thigh

length heel or elbow protector

Synthetic Sheep Skin and Decubitius

Care

Synthetic sheepskin pad

Thermometers

Oral thermometer reusable any type rectal

thermometer reusable any type basal

thermometer

Support Goods

Cervical flexible non-adjustable foam collar

slings splint

UnderpadsDiapersLiners

Adult disposable incontinence product

briefdiaper disposable incontinence product

briefdiaper bariatric adhesive liquid or equal

any type per ounce disposable liner shield

guard or pad undergarment for incontinence

disposable underpads all sizes incontinence

product diaperbrief reusable any size

incontinence product protective underpad

reusable chair size stoma cap pediatric sized

disposable incontinence product briefdiaper

youth sized disposable incontinence product

briefdiaper

Incontinence Appliances and Care

Supplies

Bedside drainage bag extension urethral clamp

or compression device incontinence supply

misc indwelling catheter Foley type insertion

tray with or without drainage bag intermittent

urinary catheter with insertion supplies irrigation

syringe bulb or piston irrigation tray with bulb or

piston syringe any purpose male external

catheter urinary catheter anchoring device

adhesive skin attachment oral thermometer

reusable any type urinary catheter anchoring

device leg strap urinary drainage bag adhesive

or non-adhesive disk or foam pad appliance

cleaner incontinence and ostomy appliances leg

strap foam or fabric replacement leg strap latex

replacement only per set percutaneous

cathetertube anchoring device adhesive

Family Planning Products

Contraceptive supply condom female

contraceptive supply condom male diaphragm

kit

Gloves

Gloves sterile and non-sterile

Diabetic Diagnostics

Insulin pen reusable insulin syringes lancets needle sterile any-size spring-powered device for lancet supplies for self-administration syringe with needle sterile syringe sterile syringe with or without needle blood ketone test or reagent strip urine test or reagent strips or tablets normal low and high calibrator

solutionchips replacement battery for use with home blood glucose monitor

Hearing Aids

Battery for use in hearing device zinc air battery for cochlear

Mastectomy Care

Breast prosthesis mastectomy bra breast

prosthesis mastectomy foam breast prosthesis

silicone or equal with integral adhesive

camisole post-mastectomy

Various Miscellaneous

Automatic blood pressure monitor incentive spirometer nasal aspirator plastic strips restraints any type (body chest wrist ankle) misc DMS supply or accessory not otherwise specified sterile 6-inch wood applicator wcotton tips surgical supply misc sphygmomanometerblood pressure apparatus with cuff and stethoscope kit syringecartridge for external drug infusion pump sterile water saline andor dextrose (diluent) sterile watersaline 500ml supplies for maintenance of drug infusion catheter alginate or other fiber gel dressing collagen-based wound filler collagen dressing sterile composite dressing sterile conforming bandages contact layer sterile eye pad sterile and non-sterile eye patch occlusive roam dressing wound cover gauze pads sterile and non-sterile gauze impregnated and non-impregnated high compression bandage elastic knittedwoven hydrocolloid dressing wound cover hydrocolloid dressing wound filler light compression bandage elastic packing strips non-impregnated padding bandage self-adherent bandage elastic specialty absorptive dressing wound cover transparent film sterile tubular dressing with or without elastic zinc paste impregnated bandage

Table of Contents

AdhdAnti-NarcolepsyAnti-ObesityAnorexiants 3Agents For Narcotic Withdrawal 3Agents For Opioid Withdrawal 3Aminoglycosides 3Analgesics - Anti-Inflammatory 3Analgesics - Nonnarcotic 3Analgesics - Opioid 4Androgens-Anabolic 4Anorectal Agents 5Antacids 5Anthelmintics 5Antianginal Agents 5Antianxiety Agents 5Antiarrhythmics 5Antiasthmatic And Bronchodilator Agents 5Anticoagulants 6Anticonvulsants 6Antidepressants 7Antidiabetics 7AntidiarrhealProbiotic Agents 8Antidiarrheals 8Antidotes And Specific Antagonists 8Antidotes 8Antiemetics 8Antifungals 8Antihistamines 8Antihyperlipidemics 9Antihypertensives 9Anti-Infective Agents - Misc 9Antimalarials 9Antimyasthenic Agents 10AntimyasthenicCholinergic Agents 10Antimycobacterial Agents 10Antineoplastics And Adjunctive Therapies 10Antiparkinson Agents 10AntipsychoticsAntimanic Agents 11Antiretrovirals Adjuvants11Antiseptics amp Disinfectants 11Antivirals 11Assorted Classes 12Atopic Dermatitis - Monoclonal Antibodies 12Beta Blockers 12Calcitonin Gene-Related Peptide (Cgrp) Receptor Antag13Calcium Channel Blockers 13Cardiotonics 13Cardiovascular Agents - Misc 13Cephalosporins 13Contraceptives 13Corticosteroids 15CoughColdAllergy 15Cystic Fibrosis Agent - Combinations15

1

Dermatologicals 15Diagnostic Products 17Digestive Aids 17Direct-Acting P2y12 Inhibitors 17Diuretics 17Endocrine And Metabolic Agents - Misc 17Estrogens 18Fluoroquinolones 18Gastrointestinal Agents - Misc 18Genitourinary Agents - Miscellaneous 18Glycopeptides 18Gout Agents 18Hematological Agents - Misc 19Hematopoietic Agents 19Hemostatics 19Hepatitis C Agent - Combinations19Hereditary Orotic Aciduria Treatment - Agents 19Hypnotics 19Hypophosphatasia (Hpp) Agents 19Interleukin-5 Antagonists (Igg1 Kappa) 19Laxatives 19Local Anesthetics-Parenteral 20Macrolides 20Medical Devices 20Migraine Products 20Minerals amp Electrolytes 20Monobactams20MouthThroatDental Agents 20Multivitamins 20Musculoskeletal Therapy Agents 20Nasal Agents - Systemic And Topical 20Neuromuscular Agents 21Nutrients 21Ophthalmic Agents 21Otic Agents 22Oxytocics 22Passive Immunizing Agents 22Penicillins 22Pharmaceutical Adjuvants 22Phosphodiesterase 4 (Pde4) Inhibitors - Topical 22Potassium Removing Agents 22Progestins 22Psychotherapeutic And Neurological Agents - Misc 22Respiratory Agents - Misc 22Serotonin Modulators 22Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb 23Steroids - MouthThroatDental 23Sulfonamides 23Tetracyclines 23Thyroid Agents 23Topical Anesthetic Gases 23Ulcer Drugs 23Urinary Anti-Infectives 23Urinary Antispasmodics 23Vaginal Products 23Vasopressors 23Vitamins 23

2

AdhdAnti-NarcolepsyAnti-ObesityAnorexiantsamphetamine-dextroamphet er oral capsule extended release 24 hour

1 AL

amphetamine-dextroamphetamine oral tablet

1 AL

armodafinil oral tablet 1 PAatomoxetine hcl oral capsule 1 ALdexmethylphenidate hcl oral tablet 1 ALdextroamphetamine sulfate er oral capsule extended release 24 hour

1 AL

dextroamphetamine sulfate oral tablet

1 AL

guanfacine hcl er oral tablet extended release 24 hour

1

methamphetamine hcl oral tablet 1 ALmethylphenidate hcl er (cd) oral capsule extended release

1 AL

methylphenidate hcl er (la) oral capsule extended release 24 hour

1 AL

methylphenidate hcl er oral tablet extended release

1 AL

methylphenidate hcl oral solution 1 ALmethylphenidate hcl oral tablet 1 ALmodafinil oral tablet 1 PA AL

Agents For Narcotic WithdrawalLUCEMYRA ORAL TABLET 2 PA QL

Agents For Opioid WithdrawalLUCEMYRA ORAL TABLET 2 PA QL

Aminoglycosidesneomycin sulfate oral tablet 1paromomycin sulfate oral capsule 1TOBI PODHALER INHALATION CAPSULE

2 PA QL

tobramycin inhalation nebulization solution

1 PA QL

Analgesics - Anti-InflammatoryARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED

2 PA PR

celecoxib oral capsule 1diclofenac potassium oral tablet 1diclofenac sodium er oral tablet extended release 24 hour

1

diclofenac sodium oral tablet delayed release

1

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA PR

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

2 PA PR

etodolac oral capsule 1etodolac oral tablet 1flurbiprofen oral tablet 1HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG08ML 80 MG08ML 80 MG08ML amp 40MG04ML

2 PA PR

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT

2 PA PR

HUMIRA PEN-CDUCHS STARTER SUBCUTANEOUS PEN-INJECTOR KIT

2 PA PR

HUMIRA PEN-PSUVADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT

2 PA PR

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT

2 PA PR

ibuprofen childrens oral suspension

1 XCHP

ibuprofen junior strength oral tablet chewable

1 XCHP

ibuprofen oral capsule 1 XCHPibuprofen oral suspension 1ibuprofen oral tablet 400 mg 600 mg 800 mg

1

INDOCIN ORAL SUSPENSION 2 ALindomethacin er oral capsule extended release

1 AL

indomethacin oral capsule 1 ALketoprofen er oral capsule extended release 24 hour

1

ketorolac tromethamine oral tablet 1 PA QL ALleflunomide oral tablet 1 PAmeloxicam oral tablet 1nabumetone oral tablet 1naproxen dr oral tablet delayed release

1

naproxen oral tablet 1piroxicam oral capsule 1RIDAURA ORAL CAPSULE 2sulindac oral tablet 1

Analgesics - Nonnarcoticacetaminophen extra strength oral tablet

1 XCHP

acetaminophen oral solution 160 mg5ml

1 XCHP

acetaminophen oral tablet 1 XCHPacetaminophen oral tablet chewable 80 mg

1 XCHP

acetaminophen rectal suppository 120 mg 650 mg

1 XCHP

aspirin 81 oral tablet chewable 1 XCHPaspirin adult low dose oral tablet delayed release

1 XCHP

aspirin adult low strength oral tablet chewable

1 XCHP

aspirin ec adult low strength oral tablet delayed release

1 XCHP

aspirin ec oral tablet delayed release 325 mg

1 XCHP

aspirin oral tablet 325 mg 1 XCHPaspirin rectal suppository 300 mg 600 mg

1 XCHP

butalbital-acetaminophen oral tablet 50-325 mg

1 AL

butalbital-apap-caffeine oral capsule 50-325-40 mg

1 AL

Drug Tier Notes Drug Tier Notes

12012019

3

butalbital-apap-caffeine oral tablet 50-325-40 mg

1 AL

butalbital-asa-caffeine oral capsule 1 ALcholine-mag trisalicylate oral liquid 1diflunisal oral tablet 1duraxin oral capsule 1EXCEDRIN EXTRA STRENGTH ORAL TABLET

2 XCHP

headache formula oral tablet 1 XCHPmigraine formula oral tablet 1 XCHPsalsalate oral tablet 1

Analgesics - Opioidacetaminophen-codeine 2 oral tablet

1 AL

acetaminophen-codeine 3 oral tablet

1 AL

acetaminophen-codeine oral solution

1

buprenorphine transdermal patch weekly

1

butalbital-apap-caff-cod oral capsule 50-325-40-30 mg

1 AL

butalbital-asa-caff-codeine oral capsule

1 AL

butorphanol tartrate nasal solution 1 PAcodeine sulfate oral tablet 30 mg 60 mg

1

fentanyl citrate buccal lozenge on a handle

1 PA

fentanyl transdermal patch 72 hour 100 mcghr 12 mcghr 25 mcghr 50 mcghr 75 mcghr

1 ST

hydrocodone-acetaminophen oral solution 75-325 mg15ml

1

hydrocodone-acetaminophen oral tablet 10-325 mg 5-325 mg 75-325 mg

1

hydrocodone-ibuprofen oral tablet 75-200 mg

1

hydromorphone hcl oral liquid 1hydromorphone hcl oral tablet 1hydromorphone hcl rectal suppository

1

HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT

2

methadone hcl oral concentrate 1methadone hcl oral solution 1methadone hcl oral tablet 1methadone hcl oral tablet soluble 1morphine sulfate er oral capsule extended release 24 hour 10 mg 20 mg 30 mg 50 mg 60 mg

1

morphine sulfate er oral capsule extended release 24 hour 100 mg 80 mg

1 ST

morphine sulfate er oral tablet extended release 100 mg 200 mg

1 ST

morphine sulfate er oral tablet extended release 15 mg 30 mg 60 mg

1

morphine sulfate intramuscular device

1

morphine sulfate oral solution 1morphine sulfate oral tablet 1morphine sulfate rectal suppository

1

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG 150 MG 200 MG 250 MG

2 ST

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 50 MG

2

NUCYNTA ORAL TABLET 2oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg 20 mg 40 mg

1

oxycodone hcl er oral tablet er 12 hour abuse-deterrent 80 mg

1 ST

oxycodone hcl oral tablet 1oxycodone-acetaminophen oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg

1

oxycodone-aspirin oral tablet 48355-325 mg

1

oxycodone-ibuprofen oral tablet 1OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG 15 MG 20 MG 30 MG 40 MG

2

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 60 MG 80 MG

2 ST

oxymorphone hcl er oral tablet extended release 12 hour 10 mg 15 mg 20 mg 30 mg 40 mg 75 mg

1 ST

oxymorphone hcl oral tablet 1 PApentazocine-naloxone hcl oral tablet

1 AL

tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg 200 mg 300 mg

1 ST

tramadol hcl er oral tablet extended release 24 hour

1

tramadol hcl oral tablet 1tramadol-acetaminophen oral tablet

1 PA PA except Pain Medicine

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL

2

Androgens-Anabolicdanazol oral capsule 1methitest oral tablet 2 PAoxandrolone oral tablet 1testosterone cypionate injection solution 200 mgml

1 PA

testosterone cypionate intramuscular solution 100 mgml 200 mgml

1 PA

12012019

4

testosterone enanthate intramuscular solution

1 PA

testosterone transdermal gel 125 mgact (1) 25 mg25gm (1)

1 PA PR

Anorectal Agentshydrocortisone acetate rectal suppository

1

hydrocortisone rectal enema 1lidocaine-hydrocortisone ace rectal cream

1

lidocaine-hydrocortisone ace rectal gel

1

lidocaine-hydrocortisone ace rectal kit 3-05 3-1 3-25

1

procto-pak rectal cream 1proctosol hc rectal cream 1proctozone-hc rectal cream 1

Antacidsaluminum hydroxide gel oral suspension 320 mg5ml

1 XCHP

antacid calcium extra strength oral tablet chewable

1 XCHP

antacid calcium oral tablet chewable

1 XCHP

antacid liquid oral suspension 1 XCHPcalcium carbonate antacid oral tablet chewable 500 mg

1 XCHP

mag-al oral liquid 1 XCHPmagnesium oxide oral tablet 400 mg

1 XCHP

sodium bicarbonate oral tablet 325 mg

1 XCHP

Anthelminticsalbendazole oral tablet 1 PA PA except

Gastroenterology or Infectious Disease

benznidazole oral tablet 2 PA LDDEMVERM ORAL TABLET CHEWABLE

2

ivermectin oral tablet 1

Antianginal AgentsISORDIL TITRADOSE ORAL TABLET40 MG

2

isosorbide dinitrate er oral tablet extended release

1

isosorbide dinitrate oral tablet 1isosorbide mononitrate er oral tablet extended release 24 hour

1

isosorbide mononitrate oral tablet 1NITRO-BID TRANSDERMAL OINTMENT

2

nitroglycerin er oral capsule extended release

1

nitroglycerin sublingual tablet sublingual

1

nitroglycerin transdermal patch 24 hour

1

Antianxiety Agentsalprazolam er oral tablet extended release 24 hour

1

ALPRAZOLAM INTENSOL ORAL CONCENTRATE

2

alprazolam oral tablet 1alprazolam oral tablet dispersible 1 PAalprazolam xr oral tablet extended release 24 hour

1

buspirone hcl oral tablet 1chlordiazepoxide hcl oral capsule 1 ALclorazepate dipotassium oral tablet 1DIAZEPAM INTENSOL ORAL CONCENTRATE

2 PR

diazepam oral tablet 1 PRhydroxyzine hcl oral syrup 1 ALhydroxyzine hcl oral tablet 1 ALhydroxyzine pamoate oral capsule 1 ALlorazepam oral concentrate 2 mgml

1

lorazepam oral tablet 1oxazepam oral capsule 1

Antiarrhythmicsamiodarone hcl oral tablet 200 mg 400 mg

1

disopyramide phosphate oral capsule

1 AL

dofetilide oral capsule 1flecainide acetate oral tablet 1mexiletine hcl oral capsule 1NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR

2 AL

pacerone oral tablet 100 mg 200 mg

1

propafenone hcl er oral capsule extended release 12 hour

1

propafenone hcl oral tablet 1quinidine gluconate er oral tablet extended release

1

quinidine sulfate oral tablet 1

Antiasthmatic And Bronchodilator Agentsalbuterol sulfate er oral tablet extended release 12 hour

1

albuterol sulfate hfa inhalation aerosol solution 108 (90 base) mcgact

1

albuterol sulfate inhalation nebulization solution

1

albuterol sulfate oral syrup 1albuterol sulfate oral tablet 1ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED

2

ATROVENT HFA INHALATION AEROSOL SOLUTION

2

budesonide inhalation suspension 025 mg2ml 05 mg2ml

1 QL AL

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION

2

12012019

5

cromolyn sodium inhalation nebulization solution

1 PA QL

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

2

FLOVENT HFA INHALATION AEROSOL

2

fluticasone-salmeterol inhalation aerosol powder breath activated

1

ipratropium bromide inhalation solution

1

ipratropium-albuterol inhalation solution

1

metaproterenol sulfate oral syrup 1montelukast sodium oral packet 1 ALmontelukast sodium oral tablet 1 ALmontelukast sodium oral tablet chewable 4 mg 5 mg

1 AL

PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED

2

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED

2

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

2 ST

SPIRIVA HANDIHALER INHALATION CAPSULE

2 AL

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 125 MCGACT 25 MCGACT

2 AL

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 25-25 MCGACT

2 AL

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION

2 AL

terbutaline sulfate oral tablet 1theophylline er oral tablet extended release 12 hour 300 mg 450 mg

1

theophylline er oral tablet extended release 24 hour

1

theophylline oral solution 1WIXELA INHUB INHALATION AEROSOL POWDER BREATH ACTIVATED

1

AnticoagulantsELIQUIS ORAL TABLET 2 PRELIQUIS STARTER PACK ORAL TABLET

2 PR

enoxaparin sodium injection solution

1 PR

enoxaparin sodium subcutaneous solution

1 PR

fondaparinux sodium subcutaneous solution

1 PA PR QL

FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNITML 12500 UNIT05ML 15000 UNIT06ML 18000 UNT072ML 2500 UNIT02ML 5000 UNIT02ML 7500 UNIT03ML 95000 UNIT38ML

2 PA PR QL

JANTOVEN ORAL TABLET 1 PRPRADAXA ORAL CAPSULE 2 PRwarfarin sodium oral tablet 1 PRXARELTO ORAL TABLET 2 PRXARELTO STARTER PACK ORAL TABLET THERAPY PACK

2 PR

AnticonvulsantsBANZEL ORAL SUSPENSION 2 PRBANZEL ORAL TABLET 2 PRcarbamazepine er oral capsule extended release 12 hour

1 PR

carbamazepine er oral tablet extended release 12 hour 200 mg 400 mg

1 PR

carbamazepine oral suspension 1 PRcarbamazepine oral tablet 1 PRcarbamazepine oral tablet chewable

1 PR

CELONTIN ORAL CAPSULE 2clobazam oral suspension 1 PA ALclobazam oral tablet 1 PA ALclonazepam oral tablet 1clonazepam oral tablet dispersible 1 STDILANTIN ORAL CAPSULE 30 MG 2divalproex sodium er oral tablet extended release 24 hour

1

divalproex sodium oral tablet delayed release

1

ethosuximide oral capsule 1ethosuximide oral solution 1felbamate oral suspension 1 PRfelbamate oral tablet 1 PRgabapentin oral capsule 1 PRgabapentin oral solution 250 mg5ml

1 PR

gabapentin oral tablet 1 PRlamotrigine oral tablet 1 PRlamotrigine oral tablet chewable 1 PRlevetiracetam er oral tablet extended release 24 hour

1 PR

levetiracetam oral solution 1 PRlevetiracetam oral tablet 1 PRoxcarbazepine oral tablet 1 PRphenytoin infatabs oral tablet chewable

1

phenytoin oral suspension 125 mg5ml

1

phenytoin oral tablet chewable 1phenytoin sodium extended oral capsule

1

primidone oral tablet 1tiagabine hcl oral tablet 1 PRtopiramate oral capsule sprinkle 1 PR

12012019

6

topiramate oral tablet 1 PRvalproic acid oral capsule 1valproic acid oral solution 1vigabatrin oral packet 1 PA LDD PRvigabatrin oral tablet 1 PA LDD PRVIMPAT ORAL SOLUTION 2 PR ALVIMPAT ORAL TABLET 2 PR ALzonisamide oral capsule 1 PR

Antidepressantsamitriptyline hcl oral tablet 1 ALamoxapine oral tablet 1bupropion hcl er (sr) oral tablet extended release 12 hour

1

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg 300 mg

1

bupropion hcl oral tablet 1citalopram hydrobromide oral solution

1 PR

citalopram hydrobromide oral tablet

1 PR

clomipramine hcl oral capsule 1 ALdesipramine hcl oral tablet 1doxepin hcl oral capsule 1 ALdoxepin hcl oral concentrate 1 ALduloxetine hcl oral capsule delayed release particles

1 PR

escitalopram oxalate oral solution 1 PRescitalopram oxalate oral tablet 1 PRfluoxetine hcl oral capsule 1 PRfluoxetine hcl oral capsule delayed release

1 PR

fluoxetine hcl oral solution 1 PRfluvoxamine maleate oral tablet 1 PRimipramine hcl oral tablet 1 ALmaprotiline hcl oral tablet 1 PA PA Except

Psychiatrymirtazapine oral tablet 1mirtazapine oral tablet dispersible 1nortriptyline hcl oral capsule 1 ALnortriptyline hcl oral solution 1 ALparoxetine hcl er oral tablet extended release 24 hour

1 ST PR

paroxetine hcl oral tablet 1 PRPAXIL ORAL SUSPENSION 2 PRphenelzine sulfate oral tablet 1protriptyline hcl oral tablet 1sertraline hcl oral concentrate 1 PRsertraline hcl oral tablet 1 PRtranylcypromine sulfate oral tablet 1trazodone hcl oral tablet 1trimipramine maleate oral capsule 1 ALvenlafaxine hcl er oral capsule extended release 24 hour

1 PR

venlafaxine hcl oral tablet 1 PR

Antidiabeticsacarbose oral tablet 1 PRADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PR

ADMELOG SUBCUTANEOUS SOLUTION

2 PR

BAQSIMI ONE PACK NASAL POWDER

1

BAQSIMI TWO PACK NASAL POWDER

1

BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PR

glimepiride oral tablet 1 PRglipizide er oral tablet extended release 24 hour

1

glipizide oral tablet 1glipizide-metformin hcl oral tablet 1GLUCAGON EMERGENCY INJECTION KIT

1

glyburide micronized oral tablet 1 ALglyburide oral tablet 1 ALglyburide-metformin oral tablet 1 ALGVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

1

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 200 UNITML

2 PR

HUMALOG MIX 5050 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

2 PR

HUMALOG MIX 5050 SUBCUTANEOUS SUSPENSION

2 PR

HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE

2 PR

HUMULIN 7030 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

2 XCHP

HUMULIN 7030 SUBCUTANEOUS SUSPENSION

2 XCHP

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

2 XCHP

HUMULIN N SUBCUTANEOUS SUSPENSION

2 XCHP

HUMULIN R INJECTION SOLUTION 2 XCHPHUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION

2 PR

JENTADUETO ORAL TABLET 2 PRKORLYM ORAL TABLET 2 PA LDDmetformin hcl er oral tablet extended release 24 hour

1 PR

metformin hcl oral tablet 1 PRnateglinide oral tablet 1 PA PROZEMPIC (025 OR 05 MGDOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 ST Step except Endocrine

12012019

7

OZEMPIC (1 MGDOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR

pioglitazone hcl oral tablet 1 PRpioglitazone hcl-glimepiride oral tablet

1 PR

pioglitazone hcl-metformin hcl oral tablet

1 PR

repaglinide oral tablet 1 PRrepaglinide-metformin hcl oral tablet

1 PR

RIOMET ORAL SOLUTION 2 PRRYBELSUS ORAL TABLET 2 ST ST except

endocrinologySTEGLATRO ORAL TABLET 2 PRSYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA PR

SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA PR

TRADJENTA ORAL TABLET 2 PRTRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 ST Step except Endocrine PR

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR

AntidiarrhealProbiotic Agentsbismuth subsalicylate oral tablet chewable 262 mg

1 XCHP

diarrhea oral suspension 1 XCHPsb bismuth oral tablet 1 XCHP

Antidiarrhealsanti-diarrheal oral capsule 1 XCHPbismuth subsalicylate oral tablet chewable 262 mg

1 XCHP

diarrhea oral suspension 1 XCHPdiphenoxylate-atropine oral liquid 1diphenoxylate-atropine oral tablet 1loperamide hcl oral capsule 1loperamide hcl oral liquid 1 mg5ml

1 XCHP

opium oral tincture 1sb bismuth oral tablet 1 XCHP

Antidotes And Specific AntagonistsVISTOGARD ORAL PACKET 2 LDD

AntidotesJADENU ORAL TABLET 180 MG 2 PA ALJADENU SPRINKLE ORAL PACKET 2 PA ALnaloxone hcl injection solution 04 mgml

1 QL

naloxone hcl injection solution cartridge

1 QL

naloxone hcl injection solution prefilled syringe

1 QL

naltrexone hcl oral tablet 1NARCAN NASAL LIQUID 2VISTOGARD ORAL PACKET 2 LDDVIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED

2 QL

Antiemeticsaprepitant oral capsule 125 mg 80 amp 125 mg 80 mg

1 ST ST applies except hematologyoncolog

y QLaprepitant oral capsule 40 mg 1 QLBONJESTA ORAL TABLET EXTENDED RELEASE

2 QL

doxylamine-pyridoxine oral tablet delayed release

1 QL

dronabinol oral capsule 1 PAEMEND ORAL SUSPENSION RECONSTITUTED

y QL ALgranisetron hcl oral tablet 1 ST QLmeclizine hcl oral tablet 1ondansetron hcl oral solution 1ondansetron hcl oral tablet 1ondansetron oral tablet dispersible 1trimethobenzamide hcl oral capsule

1 AL

Antifungalsfluconazole oral suspension reconstituted

1

fluconazole oral tablet 1griseofulvin ultramicrosize oral tablet

1

itraconazole oral capsule 1 PA PA except IDHematology or

Oncologyitraconazole oral solution 1 PA PA except

IDHematology or Oncology

ketoconazole oral tablet 1 PANOXAFIL ORAL SUSPENSION 2 PAnystatin oral tablet 1posaconazole oral tablet delayed release

1 PA

terbinafine hcl oral tablet 1voriconazole oral suspension reconstituted

1 PA PA except Infectious Disease

ALvoriconazole oral tablet 1 PA AL

Antihistaminescarbinoxamine maleate oral tablet 4 mg

1 AL

cetirizine hcl oral solution 1cetirizine hcl oral tablet 1 XCHPchlorpheniramine maleate oral tablet

1 XCHP

cyproheptadine hcl oral syrup 1 ALcyproheptadine hcl oral tablet 1 ALdiphenhydramine hcl oral capsule 50 mg

1 AL

levocetirizine dihydrochloride oral solution

1

levocetirizine dihydrochloride oral tablet

1

loratadine oral tablet 1 XCHPpromethazine hcl oral tablet 1 AL

12012019

8

Antihyperlipidemicsatorvastatin calcium oral tablet 1cholestyramine light oral packet 1cholestyramine light oral powder 1cholestyramine oral packet 1cholestyramine oral powder 1colesevelam hcl oral packet 1colesevelam hcl oral tablet 1colestipol hcl oral granules 1 ALcolestipol hcl oral packet 1 ALcolestipol hcl oral tablet 1 ALezetimibe oral tablet 1fenofibrate micronized oral capsule 134 mg

1

fenofibrate oral capsule 134 mg 67 mg

1

fenofibrate oral tablet 145 mg 160 mg 48 mg 54 mg

1

fenofibric acid oral capsule delayed release 45 mg

1

fluvastatin sodium oral capsule 40 mg

1

gemfibrozil oral tablet 1lovastatin oral tablet 1pravastatin sodium oral tablet 1rosuvastatin calcium oral tablet 1simvastatin oral tablet 10 mg 20 mg 40 mg 5 mg

1

simvastatin oral tablet 80 mg 1 PAVASCEPA ORAL CAPSULE 1 GM 2

Antihypertensivesaliskiren fumarate oral tablet 1 STamlodipine besy-benazepril hcl oral capsule

1

atenolol-chlorthalidone oral tablet 1benazepril hcl oral tablet 1benazepril-hydrochlorothiazide oral tablet

1

bisoprolol-hydrochlorothiazide oral tablet

1

candesartan cilexetil oral tablet 1candesartan cilexetil-hctz oral tablet

1

captopril oral tablet 1captopril-hydrochlorothiazide oral tablet

1

clonidine hcl oral tablet 1clonidine transdermal patch weekly

1

doxazosin mesylate oral tablet 1enalapril maleate oral tablet 1enalaprilat intravenous injectable 1enalapril-hydrochlorothiazide oral tablet

1

eplerenone oral tablet 1 PAeprosartan mesylate oral tablet 1fosinopril sodium oral tablet 1fosinopril sodium-hctz oral tablet 1guanfacine hcl oral tablet 1 ALhydralazine hcl oral tablet 1

irbesartan oral tablet 1irbesartan-hydrochlorothiazide oral tablet

1

lisinopril oral tablet 1lisinopril-hydrochlorothiazide oral tablet

1

losartan potassium oral tablet 1losartan potassium-hctz oral tablet 1methyldopa oral tablet 1 ALmethyldopa-hydrochlorothiazide oral tablet

1 AL

metoprolol-hydrochlorothiazide oral tablet

1

minoxidil oral tablet 1moexipril hcl oral tablet 1olmesartan medoxomil oral tablet 1olmesartan medoxomil-hctz oral tablet

1

perindopril erbumine oral tablet 1phenoxybenzamine hcl oral capsule

1 PA

prazosin hcl oral capsule 1propranolol-hctz oral tablet 1quinapril hcl oral tablet 1quinapril-hydrochlorothiazide oral tablet

1

ramipril oral capsule 1TEKTURNA HCT ORAL TABLET 2 STtelmisartan oral tablet 1telmisartan-hctz oral tablet 1terazosin hcl oral capsule 1trandolapril oral tablet 1valsartan oral tablet 1valsartan-hydrochlorothiazide oral tablet

1

Anti-Infective Agents - MiscALINIA ORAL SUSPENSION RECONSTITUTED

2 PA PA except Gastroenterology or

Infectious DiseaseALINIA ORAL TABLET 2 PA PA except

atovaquone oral suspension 1clindamycin hcl oral capsule 1clindamycin palmitate hcl oral solution reconstituted

1

dapsone oral tablet 1linezolid oral tablet 2 PAmetronidazole oral tablet 1NEBUPENT INHALATION SOLUTION RECONSTITUTED

sulfamethoxazole-trimethoprim oral suspension 200-40 mg5ml

1

sulfamethoxazole-trimethoprim oral tablet

1

tinidazole oral tablet 1trimethoprim oral tablet 1

Antimalarialsatovaquone-proguanil hcl oral tablet

1

12012019

9

chloroquine phosphate oral tablet 1COARTEM ORAL TABLET 2 QLDARAPRIM ORAL TABLET 2 PA LDD PA except

Infectious Diseasehydroxychloroquine sulfate oral tablet

1

mefloquine hcl oral tablet 1primaquine phosphate oral tablet 1quinine sulfate oral capsule 1 PA AL

Antimyasthenic Agentsguanidine hcl oral tablet 1pyridostigmine bromide er oral tablet extended release

1

pyridostigmine bromide oral tablet 60 mg

1

AntimyasthenicCholinergic Agentsguanidine hcl oral tablet 1pyridostigmine bromide er oral tablet extended release

1

Antimycobacterial Agentsethambutol hcl oral tablet 1isoniazid oral syrup 1isoniazid oral tablet 1pretomanid oral tablet 2 PApyrazinamide oral tablet 1rifabutin oral capsule 1 PArifampin oral capsule 1RIFATER ORAL TABLET 2

Antineoplastics And Adjunctive Therapiesabiraterone acetate oral tablet 1 PA LDDAFINITOR ORAL TABLET 2 PAanastrozole oral tablet 1 PAbicalutamide oral tablet 1BRAFTOVI ORAL CAPSULE 75 MG 2 PA LDDcapecitabine oral tablet 1CAPRELSA ORAL TABLET 2 PA LDDcyclophosphamide oral capsule 1EMCYT ORAL CAPSULE 2ERLEADA ORAL TABLET 2 PA LDDerlotinib hcl oral tablet 1 PA LDDetoposide oral capsule 1exemestane oral tablet 1 PA LDDFIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED

2 PA

flutamide oral capsule 1HYCAMTIN ORAL CAPSULE 2 PAhydroxyurea oral capsule 1imatinib mesylate oral tablet 1 PAJAKAFI ORAL TABLET 2 PA LDDletrozole oral tablet 1 PAleucovorin calcium oral tablet 1LEUKERAN ORAL TABLET 2LYSODREN ORAL TABLET 2 LDDMATULANE ORAL CAPSULE 2 LDDmegestrol acetate oral suspension 40 mgml 400 mg10ml

1

megestrol acetate oral tablet 1

MEKTOVI ORAL TABLET 2 PA LDDmelphalan oral tablet 1mercaptopurine oral tablet 1MESNEX ORAL TABLET 2 PA PA except

oncologymethotrexate oral tablet 1methotrexate sodium (pf) injection solution 50 mg2ml

1

methotrexate sodium injection solution 50 mg2ml

1

MYLERAN ORAL TABLET 2nilutamide oral tablet 1 PASPRYCEL ORAL TABLET 2 PASUTENT ORAL CAPSULE 125 MG 25 MG 50 MG

2 PA

SUTENT ORAL CAPSULE 375 MG 2 PA LDDTABLOID ORAL TABLET 2tamoxifen citrate oral tablet 1TASIGNA ORAL CAPSULE 150 MG 200 MG

2 PA

TASIGNA ORAL CAPSULE 50 MG 2 PA LDDtemozolomide oral capsule 1 LDDtoremifene citrate oral tablet 1tretinoin oral capsule 1TREXALL ORAL TABLET 2TYKERB ORAL TABLET 2 PAZOLINZA ORAL CAPSULE 2 PA

Antiparkinson Agentsamantadine hcl oral capsule 1amantadine hcl oral syrup 1amantadine hcl oral tablet 1benztropine mesylate oral tablet 1 ALbromocriptine mesylate oral capsule

1

bromocriptine mesylate oral tablet 1carbidopa-levodopa er oral tablet extended release 25-100 mg 50-200 mg

1

carbidopa-levodopa oral tablet 1carbidopa-levodopa oral tablet dispersible

1 ST

carbidopa-levodopa-entacapone oral tablet

1

entacapone oral tablet 1 STpramipexole dihydrochloride oral tablet

1

rasagiline mesylate oral tablet 1 PA PA except Neurology

ropinirole hcl oral tablet 1selegiline hcl oral capsule 1selegiline hcl oral tablet 1STALEVO 100 ORAL TABLET 2STALEVO 125 ORAL TABLET 2STALEVO 150 ORAL TABLET 2STALEVO 200 ORAL TABLET 2STALEVO 50 ORAL TABLET 2STALEVO 75 ORAL TABLET 2trihexyphenidyl hcl oral tablet 1 ALZELAPAR ORAL TABLET DISPERSIBLE

2 PA PA except Neurology

12012019

10

AntipsychoticsAntimanic AgentsABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE

2 PA PR

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

2 PA PR

aripiprazole oral solution 1 PRaripiprazole oral tablet 1 PRARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE

2 PA

ARISTADA INTRAMUSCULAR PREFILLED SYRINGE

2 PA

chlorpromazine hcl oral tablet 1clozapine oral tablet 1 PR QL ALfluphenazine decanoate injection solution

1 PR

fluphenazine hcl injection solution 1 PRfluphenazine hcl oral tablet 1 PRGEODON INTRAMUSCULAR SOLUTION RECONSTITUTED

2 PA PR

haloperidol decanoate intramuscular solution 100 mgml 50 mgml

1 PR

haloperidol lactate oral concentrate

1 PR

haloperidol oral tablet 1 PRlithium carbonate er oral tablet extended release

1

lithium carbonate oral capsule 1lithium carbonate oral tablet 1lithium oral solution 1loxapine succinate oral capsule 1olanzapine intramuscular solution reconstituted

2 PA PR

olanzapine oral tablet 10 mg 15 mg 25 mg 20 mg 5 mg

2 PR

olanzapine oral tablet 75 mg 1 PRolanzapine oral tablet dispersible 1 PA PRperphenazine oral tablet 1PERSERIS SUBCUTANEOUS PREFILLED SYRINGE

2 PA

prochlorperazine maleate oral tablet

1

prochlorperazine rectal suppository

1

quetiapine fumarate er oral tablet extended release 24 hour

1 PR

quetiapine fumarate oral tablet 1 PRrisperidone oral solution 1 PR ALrisperidone oral tablet 1 PRrisperidone oral tablet dispersible 1 PA PRthioridazine hcl oral tablet 1 ALthiothixene oral capsule 1trifluoperazine hcl oral tablet 1ziprasidone hcl oral capsule 1 PRZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED

2 PA PR

Antiretrovirals AdjuvantsTYBOST ORAL TABLET 2 ST PR

Antiseptics amp Disinfectantsbenzalkonium chloride external solution 50

2

Antiviralsabacavir sulfate oral solution 1 PRabacavir sulfate oral tablet 1 PRabacavir sulfate-lamivudine oral tablet

1 PR

abacavir-lamivudine-zidovudine oral tablet

1 PR

acyclovir oral capsule 1acyclovir oral suspension 1acyclovir oral tablet 1adefovir dipivoxil oral tablet 1APTIVUS ORAL CAPSULE 2 PRAPTIVUS ORAL SOLUTION 2 PRatazanavir sulfate oral capsule 1 PRATRIPLA ORAL TABLET 2 PRBARACLUDE ORAL SOLUTION 2 PABIKTARVY ORAL TABLET 2 PRCOMPLERA ORAL TABLET 2 PRCRIXIVAN ORAL CAPSULE 200 MG 400 MG

2 PR

DELSTRIGO ORAL TABLET 2 PRDESCOVY ORAL TABLET 2 PRdidanosine oral capsule delayed release 200 mg 250 mg 400 mg

1 PR

DOVATO ORAL TABLET 2 PREDURANT ORAL TABLET 2 PRefavirenz oral capsule 1 PRefavirenz oral tablet 1 PREMTRIVA ORAL CAPSULE 2 PREMTRIVA ORAL SOLUTION 2 PRentecavir oral tablet 1 PAEPIVIR HBV ORAL SOLUTION 2 PREVOTAZ ORAL TABLET 2 PRfamciclovir oral tablet 1fosamprenavir calcium oral tablet 1 PRFUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED

2 PA PR

GENVOYA ORAL TABLET 2 PRINTELENCE ORAL TABLET 2 PRINVIRASE ORAL TABLET 2 PRISENTRESS HD ORAL TABLET 2ISENTRESS ORAL PACKET 2 PRISENTRESS ORAL TABLET 2 PRISENTRESS ORAL TABLET CHEWABLE

2 PR

JULUCA ORAL TABLET 2 PRKALETRA ORAL SOLUTION 2 PRKALETRA ORAL TABLET 2 PRlamivudine oral solution 1 PRlamivudine oral tablet 1 PRlamivudine-zidovudine oral tablet 1 PRLEXIVA ORAL SUSPENSION 2 PRlopinavir-ritonavir oral solution 1 PRnevirapine er oral tablet extended release 24 hour 400 mg

1 PR

12012019

11

nevirapine oral suspension 1 PRnevirapine oral tablet 1 PRNORVIR ORAL SOLUTION 2 PRNORVIR ORAL TABLET 2 PRODEFSEY ORAL TABLET 2 PRoseltamivir phosphate oral capsule 1 QLoseltamivir phosphate oral suspension reconstituted

1 QL

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 180 MCG05ML

2 PA

PEGASYS SUBCUTANEOUS SOLUTION

2 PA

PEGINTRON SUBCUTANEOUS KIT50 MCG05ML

2 PA

PIFELTRO ORAL TABLET 2 PRPREZCOBIX ORAL TABLET 2 PRPREZISTA ORAL SUSPENSION 2 PRPREZISTA ORAL TABLET 150 MG 600 MG 75 MG 800 MG

2 PR

RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED

2

RESCRIPTOR ORAL TABLET 200 MG 2 PRREYATAZ ORAL CAPSULE 150 MG 200 MG 300 MG

2 PR

ribavirin oral capsule 1ribavirin oral tablet 200 mg 1rimantadine hcl oral tablet 1ritonavir oral tablet 1 PRSELZENTRY ORAL SOLUTION 2 PRSELZENTRY ORAL TABLET 2 PRstavudine oral capsule 1 PRSTRIBILD ORAL TABLET 2 PRSUSTIVA ORAL CAPSULE 2 PRSUSTIVA ORAL TABLET 2 PRSYMFI LO ORAL TABLET 2 PRSYMFI ORAL TABLET 2 PRSYMTUZA ORAL TABLET 2 PRTEMIXYS ORAL TABLET 2tenofovir disoproxil fumarate oral tablet

1 PR

TIVICAY ORAL TABLET 2 PRTRIUMEQ ORAL TABLET 2 PRTRUVADA ORAL TABLET 2 PRvalacyclovir hcl oral tablet 1valganciclovir hcl oral solution reconstituted

1 PA

valganciclovir hcl oral tablet 1 PA PA except Infectious Disease

Renal Transplant Surgeons and

NephrologyVEMLIDY ORAL TABLET 2 PA PA except

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM

2 PR

VIRACEPT ORAL TABLET 2 PRVIRAMUNE ORAL SUSPENSION 2 PRVIREAD ORAL TABLET 2 PR

zidovudine oral capsule 1 PRzidovudine oral syrup 1 PRzidovudine oral tablet 1 PR

Assorted ClassesARGYLE STERILE WATER IRRIGATION SOLUTION

1

AZASAN ORAL TABLET 2 PRazathioprine oral tablet 1 PRcyclosporine modified oral capsule 1 PRcyclosporine modified oral solution 1 PRcyclosporine oral capsule 1 PRDEPEN TITRATABS ORAL TABLET 2 PAGENGRAF ORAL CAPSULE 100 MG 25 MG

1 PR

GENGRAF ORAL SOLUTION 1 PRKIONEX ORAL SUSPENSION 1lactated ringers irrigation solution 1LOKELMA ORAL PACKET 2mycophenolate mofetil oral capsule

1 PR

mycophenolate mofetil oral tablet 1 PRmycophenolate sodium oral tablet delayed release

1 PA PR PA except Renal Transplant

Surgeons and Nephrology

penicillamine oral capsule 1 PAPHYSIOLYTE IRRIGATION SOLUTION

1

PHYSIOSOL IRRIGATION IRRIGATION SOLUTION

2

REVLIMID ORAL CAPSULE 2 PA LDDringers irrigation irrigation solution 1sirolimus oral solution 1 PA PR PA except

Nephrologysirolimus oral tablet 1 PA PR PA except

Nephrologysodium polystyrene sulfonate oral powder

1

sodium polystyrene sulfonate oral suspension

1

SPS ORAL SUSPENSION 1sterile water for irrigation irrigation solution

1

tacrolimus oral capsule 1 PRTHALOMID ORAL CAPSULE 2 LDDtrientine hcl oral capsule 1 PAVELTASSA ORAL PACKET 2ZORTRESS ORAL TABLET 2 PA PR

Atopic Dermatitis - Monoclonal AntibodiesDUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA

Beta Blockersacebutolol hcl oral capsule 1atenolol oral tablet 1betaxolol hcl oral tablet 1bisoprolol fumarate oral tablet 1

12012019

12

carvedilol oral tablet 1labetalol hcl oral tablet 1metoprolol succinate er oral tablet extended release 24 hour

1

metoprolol tartrate oral tablet 100 mg 25 mg 50 mg

1

nadolol oral tablet 20 mg 40 mg 80 mg

1

pindolol oral tablet 1propranolol hcl er oral capsule extended release 24 hour

1

propranolol hcl oral solution 1propranolol hcl oral tablet 1sotalol hcl (af) oral tablet 1sotalol hcl oral tablet 1timolol maleate oral tablet 1

Calcitonin Gene-Related Peptide (Cgrp) Receptor AntagAIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR

2 PA

Calcium Channel BlockersAFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR

1

amlodipine besylate oral tablet 1CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR

1

diltiazem hcl er beads oral capsule extended release 24 hour

1

diltiazem hcl er coated beads oral capsule extended release 24 hour

1

diltiazem hcl er coated beads oral tablet extended release 24 hour 180 mg

1

diltiazem hcl er oral capsule extended release 12 hour

1

diltiazem hcl er oral capsule extended release 24 hour 120 mg

1

diltiazem hcl oral tablet 1dilt-xr oral capsule extended release 24 hour

1

felodipine er oral tablet extended release 24 hour

1

isradipine oral capsule 1MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR

1

nicardipine hcl oral capsule 1NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 60 MG

1

nifedipine er oral tablet extended release 24 hour

1

nifedipine er osmotic release oral tablet extended release 24 hour

1

nifedipine oral capsule 1 ALnisoldipine er oral tablet extended release 24 hour

1

TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR

1

verapamil hcl er oral capsule extended release 24 hour

1

verapamil hcl er oral tablet extended release 120 mg 180 mg 240 mg

1

verapamil hcl oral tablet 1

Cardiotonicsdigox oral tablet 125 mcg 1digox oral tablet 250 mcg 1 ALdigoxin oral solution 1digoxin oral tablet 125 mcg 1digoxin oral tablet 250 mcg 1 AL

Cardiovascular Agents - Miscambrisentan oral tablet 1 PA LDDbosentan oral tablet 1 PA LDDOPSUMIT ORAL TABLET 2 PA LDDsildenafil citrate oral suspension reconstituted

1 PA AL

sildenafil citrate oral tablet 20 mg 1 PAtadalafil (pah) oral tablet 1 PATRACLEER ORAL TABLET SOLUBLE 2 PA LDD

Cephalosporinscefaclor oral capsule 1cefadroxil oral capsule 1cefadroxil oral suspension reconstituted

1

cefadroxil oral tablet 1cefdinir oral capsule 1cefdinir oral suspension reconstituted

1

cefixime oral capsule 1cefpodoxime proxetil oral suspension reconstituted

1

cefpodoxime proxetil oral tablet 1cefprozil oral suspension reconstituted

1

cefprozil oral tablet 1cefuroxime axetil oral tablet 1cephalexin oral capsule 250 mg 500 mg

1

cephalexin oral suspension reconstituted

1

SUPRAX ORAL TABLET CHEWABLE 2

ContraceptivesALTAVERA ORAL TABLET 1alyacen 135 oral tablet 1alyacen 777 oral tablet 1AMETHIA LO ORAL TABLET 1AMETHIA ORAL TABLET 1ANNOVERA VAGINAL RING 2APRI ORAL TABLET 1ARANELLE ORAL TABLET 1ASHLYNA ORAL TABLET 1AUBRA ORAL TABLET 1AVIANE ORAL TABLET 1AZURETTE ORAL TABLET 1BALCOLTRA ORAL TABLET 2BALZIVA ORAL TABLET 1BEKYREE ORAL TABLET 1BLISOVI 24 FE ORAL TABLET 1BLISOVI FE 1530 ORAL TABLET 1

12012019

13

briellyn oral tablet 1CAMILA ORAL TABLET 1CAMRESE LO ORAL TABLET 1CAMRESE ORAL TABLET 1CAZIANT ORAL TABLET 1CESIA ORAL TABLET 1CHATEAL ORAL TABLET 1CRYSELLE-28 ORAL TABLET 1CYCLAFEM 135 ORAL TABLET 1CYCLAFEM 777 ORAL TABLET 1CYRED ORAL TABLET 1DASETTA 135 ORAL TABLET 1DASETTA 777 ORAL TABLET 1DAYSEE ORAL TABLET 1DEBLITANE ORAL TABLET 1DELYLA ORAL TABLET 1desogestrel-ethinyl estradiol oral tablet 015-002001 mg (215)

1

drospiren-eth estrad-levomefol oral tablet 3-003-0451 mg

1

drospirenone-ethinyl estradiol oral tablet

1

ELINEST ORAL TABLET 1ELLA ORAL TABLET 2 QLEMOQUETTE ORAL TABLET 1ENPRESSE-28 ORAL TABLET 1ENSKYCE ORAL TABLET 015-30 MG-MCG

1

ERRIN ORAL TABLET 1ESTARYLLA ORAL TABLET 1ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg

1

FALMINA ORAL TABLET 1FEMYNOR ORAL TABLET 1GIANVI ORAL TABLET 1HEATHER ORAL TABLET 1INTROVALE ORAL TABLET 1JENCYCLA ORAL TABLET 1JOLESSA ORAL TABLET 1JULEBER ORAL TABLET 1JUNEL 1530 ORAL TABLET 1JUNEL 120 ORAL TABLET 1JUNEL FE 1530 ORAL TABLET 1JUNEL FE 120 ORAL TABLET 1JUNEL FE 24 ORAL TABLET 1KAITLIB FE ORAL TABLET CHEWABLE

1

KARIVA ORAL TABLET 1KELNOR 135 ORAL TABLET 1KURVELO ORAL TABLET 1LARIN 1530 ORAL TABLET 1LARIN 120 ORAL TABLET 1LARIN 24 FE ORAL TABLET 1LARIN FE 1530 ORAL TABLET 1LARIN FE 120 ORAL TABLET 1LARISSIA ORAL TABLET 1LAYOLIS FE ORAL TABLET CHEWABLE

1

LEENA ORAL TABLET 1LESSINA ORAL TABLET 1LEVONEST ORAL TABLET 1

levonorgest-eth estrad 91-day oral tablet

1

levonorgestrel oral tablet 15 mg 1 XCHP QLlevonorgestrel-ethinyl estrad oral tablet

1

LEVORA 01530 (28) ORAL TABLET

1

LO LOESTRIN FE ORAL TABLET 2LORYNA ORAL TABLET 1LOW-OGESTREL ORAL TABLET 1LUTERA ORAL TABLET 1LYZA ORAL TABLET 1marlissa oral tablet 1MIBELAS 24 FE ORAL TABLET CHEWABLE

1

MICROGESTIN 1530 ORAL TABLET

1

MICROGESTIN 120 ORAL TABLET 1MICROGESTIN FE 1530 ORAL TABLET

1

MICROGESTIN FE 120 ORAL TABLET

1

MONO-LINYAH ORAL TABLET 1MONONESSA ORAL TABLET 1NATAZIA ORAL TABLET 2NECON 0535 (28) ORAL TABLET 1NECON 135 (28) ORAL TABLET 1NIKKI ORAL TABLET 1NORA-BE ORAL TABLET 1norethin ace-eth estrad-fe oral tablet

1

norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg

1

norethindrone oral tablet 1norethin-eth estradiol-fe oral tablet chewable

1

norgestimate-eth estradiol oral tablet 025-35 mg-mcg

1

norgestim-eth estrad triphasic oral tablet

1

NORLYROC ORAL TABLET 1NORTREL 0535 (28) ORAL TABLET

1

NORTREL 135 (21) ORAL TABLET 1NORTREL 135 (28) ORAL TABLET 1NORTREL 777 ORAL TABLET 1NUVARING VAGINAL RING 2 QLOCELLA ORAL TABLET 1ORSYTHIA ORAL TABLET 1PHILITH ORAL TABLET 1PIMTREA ORAL TABLET 1PIRMELLA 135 ORAL TABLET 1PIRMELLA 777 ORAL TABLET 1PORTIA-28 ORAL TABLET 1PREVIFEM ORAL TABLET 1RECLIPSEN ORAL TABLET 1SETLAKIN ORAL TABLET 1SHAROBEL ORAL TABLET 1SOLIA ORAL TABLET 1SPRINTEC 28 ORAL TABLET 1SRONYX ORAL TABLET 1

12012019

14

SYEDA ORAL TABLET 1TARINA FE 120 ORAL TABLET 1TILIA FE ORAL TABLET 1TRI FEMYNOR ORAL TABLET 1TRI-ESTARYLLA ORAL TABLET 1TRI-LEGEST FE ORAL TABLET 1TRI-LINYAH ORAL TABLET 1TRI-LO-ESTARYLLA ORAL TABLET 1TRI-LO-MARZIA ORAL TABLET 1TRI-LO-SPRINTEC ORAL TABLET 1TRINESSA (28) ORAL TABLET 1TRI-PREVIFEM ORAL TABLET 1TRI-SPRINTEC ORAL TABLET 1TRIVORA (28) ORAL TABLET 1TRI-VYLIBRA ORAL TABLET 1TYDEMY ORAL TABLET 1VELIVET ORAL TABLET 1VIENVA ORAL TABLET 1viorele oral tablet 1VYFEMLA ORAL TABLET 1WERA ORAL TABLET 1WYMZYA FE ORAL TABLET CHEWABLE

1

XULANE TRANSDERMAL PATCH WEEKLY

1

ZARAH ORAL TABLET 1ZOVIA 135E (28) ORAL TABLET 1

Corticosteroidsbudesonide oral capsule delayed release particles

Colorectal Surgerycortisone acetate oral tablet 1 PRDEXAMETHASONE INTENSOL ORAL CONCENTRATE

2 PR

dexamethasone oral elixir 1 PRdexamethasone oral solution 1 PRdexamethasone oral tablet 1 PREMFLAZA ORAL SUSPENSION 2 PA LDD PREMFLAZA ORAL TABLET 2 PA LDD PRfludrocortisone acetate oral tablet 1hydrocortisone oral tablet 1 PRmethylprednisolone oral tablet 1 PRprednisolone oral solution 1 PRprednisolone sodium phosphate oral solution 10 mg5ml 15 mg5ml 20 mg5ml 25 mg5ml 67 (5 base) mg5ml

1 PR

PREDNISONE INTENSOL ORAL CONCENTRATE

2 PR

prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg

1 PR

CoughColdAllergyacetylcysteine inhalation solution 1benzonatate oral capsule 100 mg 200 mg

1

guaifenesin dac oral solution 1 XCHP ALguaifenesin oral solution 200 mg10ml

1 XCHP

guaifenesin-codeine oral solution 1 XCHP ALNEOTUSS PLUS ORAL LIQUID 2

promethazine vccodeine oral syrup

1 AL

promethazine-codeine oral syrup 1 ALpromethazine-dm oral syrup 1 ALsodium chloride inhalation nebulization solution 10 3 7

1

Cystic Fibrosis Agent - CombinationsORKAMBI ORAL PACKET 2 PA LDD ALORKAMBI ORAL TABLET 100-125 MG 200-125 MG

2 PA LDD AL

SYMDEKO ORAL TABLET THERAPY PACK

2 PA LDD AL

Dermatologicalsacitretin oral capsule 1 PA PA except

dermatologyacyclovir external ointment 1adapalene external cream 1 PAadapalene external gel 1 PAala-cort external cream 1 1ALA-QUIN EXTERNAL CREAM 2alclometasone dipropionate external cream

1

alclometasone dipropionate external ointment

1

amcinonide external lotion 1ammonium lactate external cream 1ammonium lactate external lotion 1ANACAINE EXTERNAL OINTMENT 2antifungal external cream 1 1 XCHPanti-fungal external powder 1 XCHPbenzoyl peroxide external gel 10 1benzoyl peroxide external gel 5 1 XCHPbetamethasone dipropionate aug external cream

1

betamethasone dipropionate aug external gel

1

betamethasone dipropionate aug external lotion

1

betamethasone dipropionate aug external ointment

1

betamethasone dipropionate external cream

1

betamethasone dipropionate external lotion

1

betamethasone dipropionate external ointment

1

betamethasone valerate external cream

1

betamethasone valerate external lotion

1

betamethasone valerate external ointment

1

calcipotriene external cream 1 PA PA except Dermatology

calcipotriene external ointment 1 PA PA except Dermatology

calcipotriene external solution 1 PA PA except Dermatology

calcitriol external ointment 1 PA

12012019

15

capsaicin external cream 0025 01

1 XCHP

capsaicin hot patch external pad 1 XCHPcapsaicin hp external cream 1 XCHPciclopirox external gel 1ciclopirox external shampoo 1ciclopirox external solution 1ciclopirox olamine external cream 1ciclopirox olamine external suspension

1

CLARAVIS ORAL CAPSULE 1 PA PA except Dermatology

clindamycin phos-benzoyl perox external gel 1-5

1

clindamycin phosphate external gel 1clindamycin phosphate external lotion

1

clindamycin phosphate external solution

1

clindamycin phosphate external swab

1

clobetasol propionate external ointment

1

clotrimazole af external cream 1 XCHPclotrimazole external cream 1clotrimazole external solution 1clotrimazole-betamethasone external cream

1 QL

clotrimazole-betamethasone external lotion

1 QL

coal tar external solution 2CORDRAN EXTERNAL TAPE 2CROTAN EXTERNAL LOTION 1CUTTER NATURAL EXTERNAL AEROSOL

1 XCHP

desonide external cream 1 STdesonide external lotion 1 STdesonide external ointment 1 STdesoximetasone external cream 1desoximetasone external gel 1desoximetasone external ointment 025

1

diclofenac sodium transdermal gel 1

1 QL

DRYSOL EXTERNAL SOLUTION 2econazole nitrate external cream 1erythromycin external gel 1erythromycin external solution 1ethyl chloride external aerosol 2EURAX EXTERNAL CREAM 2FABIOR EXTERNAL FOAM 2 PA PA except

Dermatology QLfluocinonide external cream 005 1fluocinonide external gel 1fluocinonide external ointment 1fluocinonide external solution 1fluorouracil external cream 5 1fluorouracil external solution 1fluticasone propionate external cream

1

fluticasone propionate external ointment

1

gentamicin sulfate external cream 1gentamicin sulfate external ointment

1

halobetasol propionate external cream

1

halobetasol propionate external ointment

1

hydrocortisone butyrate external ointment

1

hydrocortisone butyrate external solution

1

hydrocortisone external cream 1 25

1

hydrocortisone external lotion 25

1

hydrocortisone external ointment 1 25

1

hydrocortisone valerate external cream

1

hydrocortisone valerate external ointment

1

HYPERCARE EXTERNAL SOLUTION15

1 XCHP

imiquimod external cream 1 PAketoconazole external cream 1ketoconazole external shampoo 2

1

lidocaine external ointment 1lidocaine external patch 5 1lidocaine hcl external cream 3 1lidocaine hcl external solution 1lidocaine-prilocaine external cream 1LIDOCARE ARMNECKLEG EXTERNAL PATCH

1 XCHP

LIDOCARE BACKSHOULDER EXTERNAL PATCH

1 XCHP

lindane external shampoo 1malathion external lotion 1metronidazole external gel 1 1metronidazole external lotion 1mometasone furoate external cream

1

mometasone furoate external ointment

1

mometasone furoate external solution

1

mupirocin calcium external cream 1mupirocin external ointment 1MYORISAN ORAL CAPSULE 1 PA PA except

Dermatologynystatin external cream 1nystatin external ointment 1nystatin external powder 1nystatin-triamcinolone external cream

1

nystatin-triamcinolone external ointment

1

OFF DEEP WOODS EXTERNAL AEROSOL

1 XCHP

12012019

16

permethrin external cream 1pimecrolimus external cream 1 PA PA except

Dermatology and Allergy

prednicarbate external cream 1prednicarbate external ointment 1REPEL TICK DEFENSE EXTERNAL AEROSOL

1 XCHP

salicylic acid external cream 1 PAsalicylic acid external foam 1 PAsalicylic acid external gel 1 PAsalicylic acid external lotion 1 PAsalicylic acid external shampoo 1 PAsalicylic acid-cleanser external kit 1 PAselenium sulfide external lotion 1silver nitrate external solution 1silver sulfadiazine external cream 1sulfacetamide sodium (acne) external lotion

1 PA

sulfacetamide sodium external liquid

1 PA

sulfacetamide sodium-sulfur external liquid 9-4 98-48

1 PA

sulfacetamide sodium-sulfur external pad 10-4

1 PA

sulfacetamide sodium-sulfur external suspension 8-4

1 PA

sulfacetamide-sulfur in urea external emulsion

1 PA

tacrolimus external ointment 1 PA PA except Dermatology and

Allergy PA not required when

patient is aged over 2YO and less than 18

YOterbinafine hcl external cream 1 XCHPtretinoin external cream 1 PAtretinoin external gel 001 0025

1 PA

triamcinolone acetonide external cream

1

triamcinolone acetonide external lotion

1

triamcinolone acetonide external ointment 0025 01 05

1

zinc oxide external ointment 20 1 XCHPZITHRANOL EXTERNAL SHAMPOO 2 PA

Diagnostic Productsblood glucose test in vitro strip 2 XCHPPRECISION XTRA KETONE IN VITRO STRIP

2 XCHP

Digestive AidsCREON ORAL CAPSULE DELAYED RELEASE PARTICLES

2 PR

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES

2 PR

SUCRAID ORAL SOLUTION 2 PA LDD PR

Direct-Acting P2y12 InhibitorsBRILINTA ORAL TABLET 2 PR

Diureticsacetazolamide er oral capsule extended release 12 hour

1

acetazolamide oral tablet 1ALDACTAZIDE ORAL TABLET 50-50 MG

2

amiloride hcl oral tablet 1amiloride-hydrochlorothiazide oral tablet

1

bumetanide oral tablet 1chlorothiazide oral tablet 1chlorthalidone oral tablet 25 mg 50 mg

1

DIURIL ORAL SUSPENSION 2furosemide oral solution 10 mgml 1furosemide oral tablet 1hydrochlorothiazide oral capsule 1hydrochlorothiazide oral tablet 1indapamide oral tablet 1methazolamide oral tablet 1metolazone oral tablet 1spironolactone oral tablet 1spironolactone-hctz oral tablet 1torsemide oral tablet 1triamterene-hctz oral capsule 375-25 mg

1

triamterene-hctz oral tablet 1

Endocrine And Metabolic Agents - Miscalendronate sodium oral tablet 10 mg 35 mg 5 mg 70 mg

1 PR

cabergoline oral tablet 1 PA QLcalcitonin (salmon) nasal solution 1 PRcalcitriol oral capsule 1calcitriol oral solution 1CARBAGLU ORAL TABLET 2 PA LDDcinacalcet hcl oral tablet 1clomiphene citrate oral tablet 1 PA PA except

OBGYNFertility XCHP

CYSTADANE ORAL POWDER 2 PA LDDdesmopressin ace spray refrig nasal solution

1

desmopressin acetate oral tablet 1desmopressin acetate spray nasal solution

1

etidronate disodium oral tablet 400 mg

1

FORTEO SUBCUTANEOUS SOLUTION 600 MCG24ML

2 PA

INCRELEX SUBCUTANEOUS SOLUTION

2 PA LDD

KUVAN ORAL PACKET 2 PA LDDKUVAN ORAL TABLET SOLUBLE 2 PA LDDlevocarnitine oral tablet 1 PANORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION

2 PA PR

octreotide acetate injection solution 100 mcgml 1000 mcgml 200 mcgml 50 mcgml 500 mcgml

1 PA PA except Hematology or

Oncology

12012019

17

paricalcitol oral capsule 1 STraloxifene hcl oral tablet 1risedronate sodium oral tablet 150 mg 30 mg 35 mg 5 mg

1 PR

risedronate sodium oral tablet delayed release

1 PR

SENSIPAR ORAL TABLET 2SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 20 MG

2 PA LDD PR

SYNAREL NASAL SOLUTION 2 PATYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA

EstrogensCOMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY

2

est estrogens-methyltest ds oral tablet

1 AL

est estrogens-methyltest hs oral tablet

1 AL

estradiol oral tablet 1 ALestradiol transdermal patch twice weekly

1 AL

estradiol transdermal patch weekly 1 ALestradiol-norethindrone acet oral tablet

1 AL

JINTELI ORAL TABLET 1 ALMENOSTAR TRANSDERMAL PATCH WEEKLY

2

MIMVEY ORAL TABLET 1 ALnorethindrone-eth estradiol oral tablet

1 AL

PREMARIN ORAL TABLET 2 ALPREMPRO ORAL TABLET 2 AL

FluoroquinolonesCIPRO ORAL SUSPENSION RECONSTITUTED 250 MG5ML (5)

2

ciprofloxacin hcl oral tablet 1ciprofloxacin oral suspension reconstituted 500 mg5ml (10)

1

levofloxacin oral solution 1levofloxacin oral tablet 1moxifloxacin hcl oral tablet 1

Gastrointestinal Agents - MiscAPRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR

2

balsalazide disodium oral capsule 1 ALcalcium acetate (phos binder) oral tablet

1

cromolyn sodium oral concentrate 1generlac oral solution 1infants simethicone oral suspension 20 mg03ml

1 XCHP

lactulose encephalopathy oral solution

1

lanthanum carbonate oral tablet chewable

1

mesalamine oral capsule delayed release

1

mesalamine oral tablet delayed release 800 mg

1

mesalamine rectal enema 1mesalamine rectal suppository 1mesalamine-cleanser rectal kit 1metoclopramide hcl oral solution 10 mg10ml 5 mg5ml

1

metoclopramide hcl oral tablet 1PENTASA ORAL CAPSULE EXTENDED RELEASE

2

PHOSLYRA ORAL SOLUTION 2sevelamer carbonate oral packet 1sevelamer carbonate oral tablet 1sevelamer hcl oral tablet 1SFROWASA RECTAL ENEMA 2simethicone oral capsule 125 mg 1 XCHPsimethicone oral suspension 40 mg06ml

1 XCHP

simethicone oral tablet chewable 1 XCHPsulfasalazine oral tablet 1sulfasalazine oral tablet delayed release

1

SULFAZINE ORAL TABLET 1ursodiol oral capsule 1ursodiol oral tablet 1

Genitourinary Agents - Miscellaneousacetic acid irrigation solution 1alfuzosin hcl er oral tablet extended release 24 hour

1

aminoacetic acid irrigation solution 1CYSTAGON ORAL CAPSULE 2 PA LDDdutasteride oral capsule 1ELMIRON ORAL CAPSULE 2 PAfinasteride oral tablet 5 mg 1glycine irrigation solution 1glycine urologic irrigation solution 1neomycin-polymyxin b gu irrigation solution

1

ORACIT ORAL SOLUTION 2phenazopyridine hcl oral tablet 100 mg 200 mg

1

potassium citrate er oral tablet extended release

1

potassium citrate-citric acid oral solution

1

RENACIDIN IRRIGATION SOLUTION 2sorbitol irrigation solution 2sorbitol-mannitol irrigation solution

2

tamsulosin hcl oral capsule 1THIOLA ORAL TABLET 2 PA LDDtricitrates oral solution 2

Glycopeptidesvancomycin hcl oral capsule 1 PA

Gout Agentsallopurinol oral tablet 1colchicine oral capsule 1colchicine oral tablet 1colchicine-probenecid oral tablet 1probenecid oral tablet 1

12012019

18

Hematological Agents - Miscanagrelide hcl oral capsule 1 PA PA except

Hematology or Oncology

aspirin-dipyridamole er oral capsule extended release 12 hour

1 PA PR

BRILINTA ORAL TABLET 2 PRcilostazol oral tablet 1clopidogrel bisulfate oral tablet 1 PRdipyridamole oral tablet 1 PR ALpentoxifylline er oral tablet extended release

1

prasugrel hcl oral tablet 1 PR AL

Hematopoietic AgentsARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCGML 200 MCGML 25 MCGML 300 MCGML 40 MCGML 60 MCGML

2 PA PR

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG05ML 150 MCG03ML 200 MCG04ML 25 MCG042ML 300 MCG06ML 40 MCG04ML 500 MCGML 60 MCG03ML

2 PA PR

CORVITA 150 ORAL TABLET 1cyanocobalamin injection solution 1000 mcgml

1

DROXIA ORAL CAPSULE 2EPOGEN INJECTION SOLUTION10000 UNITML 2000 UNITML 20000 UNITML 3000 UNITML 4000 UNITML

2 PA PR

fa-vitamin b-6-vitamin b-12 oral tablet

1

ferrous sulfate oral tablet 325 (65 fe) mg

1 XCHP

folic acid oral tablet 1 mg 1HEMATOGEN FORTE ORAL CAPSULE

1

polysaccharide iron forte oral capsule

1

PROCRIT INJECTION SOLUTION 2 PA PRPROMACTA ORAL PACKET 2 PAPROMACTA ORAL TABLET 2 PARETACRIT INJECTION SOLUTION 2 PA PRZARXIO INJECTION SOLUTION PREFILLED SYRINGE

2

Hemostaticstranexamic acid oral tablet 1

Hepatitis C Agent - CombinationsMAVYRET ORAL TABLET 2 PA LDD

Hereditary Orotic Aciduria Treatment - AgentsXURIDEN ORAL PACKET 2 PA LDD

HypnoticsBUTISOL SODIUM ORAL TABLET 30 MG

2

estazolam oral tablet 1 QL

flurazepam hcl oral capsule 1 QL ALmidazolam hcl oral syrup 1phenobarbital oral elixir 1 ALphenobarbital oral solution 1 ALphenobarbital oral tablet 162 mg 324 mg 648 mg 972 mg

1 AL

temazepam oral capsule 1 QLtriazolam oral tablet 1 QLzaleplon oral capsule 1 QL ALzolpidem tartrate oral tablet 1 QL AL

Hypophosphatasia (Hpp) AgentsSTRENSIQ SUBCUTANEOUS SOLUTION

2 PA LDD

Interleukin-5 Antagonists (Igg1 Kappa)FASENRA PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR

2 PA

NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR

2 PA

NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA

Laxativesbisacodyl ec oral tablet delayed release

1 XCHP

docusate calcium oral capsule 1 XCHPdocusate sodium oral capsule 1 XCHPdocusate sodium oral liquid 50 mg5ml

1 XCHP

docusate sodium oral tablet 1 XCHPenema disposable rectal enema 1 XCHPfiber laxative oral tablet 1 XCHPFLEET BISACODYL RECTAL ENEMA 1 XCHPGAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED

1

KRISTALOSE ORAL PACKET 20 GM 2lactulose oral packet 1lactulose oral solution 1laxative rectal suppository 1 XCHPmilk of magnesia oral suspension 400 mg5ml

1 XCHP

mineral oil oral oil 1 XCHPnatural fiber laxative oral powder 283 309 4857 586

1 XCHP

natural fiber therapy oral powder 4857

1 XCHP

peg 3350-kcl-na bicarb-nacl oral solution reconstituted

1

peg-3350electrolytes oral solution reconstituted

1

polyethylene glycol 3350 oral powder

1

senna laxative tablet 86 mg oral 1 OTC XCHPsenna oral syrup 1 XCHPsorbitol oral solution 1 XCHPsorbitol rectal solution 1 XCHPstool softener laxative oral tablet 1 XCHPSUPREP BOWEL PREP KIT ORAL SOLUTION

2

12012019

19

Local Anesthetics-Parenterallidocaine hcl injection solution 1 2

2

Macrolidesazithromycin oral suspension reconstituted

1

azithromycin oral tablet 250 mg 500 mg 600 mg

1

clarithromycin er oral tablet extended release 24 hour

1

clarithromycin oral suspension reconstituted

1

clarithromycin oral tablet 1ERYTHROCIN STEARATE ORAL TABLET 250 MG

2

erythromycin base oral tablet 1erythromycin ethylsuccinate oral suspension reconstituted

1

erythromycin ethylsuccinate oral tablet

1

Medical DevicesOMNIPOD DASH 5 PACK 2V-GO 20 KIT 2V-GO 30 KIT 2V-GO 40 KIT 2

Migraine ProductsCAFERGOT ORAL TABLET 2 QLdihydroergotamine mesylate nasal solution

1 PA QL

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL

2 LDD

naratriptan hcl oral tablet 1 QLrizatriptan benzoate oral tablet 1 QLrizatriptan benzoate oral tablet dispersible

1 QL

sumatriptan succinate oral tablet 1 QLsumatriptan succinate refill subcutaneous solution cartridge 6 mg05ml

1 QL

sumatriptan succinate subcutaneous solution 6 mg05ml

1 QL

sumatriptan succinate subcutaneous solution auto-injector 6 mg05ml

1 QL

zolmitriptan oral tablet 1 QL

Minerals amp Electrolytescalcium citrate + d oral tablet 315-200 mg-unit 315-250 mg-unit

1 XCHP

GALZIN ORAL CAPSULE 2magnesium oxide oral tablet 400 (240 mg) mg 400 (2413 mg) mg 500 mg

1 XCHP

pot bicarb-pot chloride oral tablet effervescent

1

potassium bicarbonate oral tablet effervescent

1

potassium chloride crys er oral tablet extended release

1

potassium chloride er oral capsule extended release

1

potassium chloride er oral tablet extended release

1

potassium chloride oral solution 20 meq15ml (10)

1

sodium fluoride oral tablet chewable

1

virt-phos 250 neutral oral tablet 1

MonobactamsCAYSTON INHALATION SOLUTION RECONSTITUTED

2 PA LDD QL AL

MouthThroatDental Agentscevimeline hcl oral capsule 1chlorhexidine gluconate mouththroat solution

1

clotrimazole mouththroat lozenge 1clotrimazole mouththroat troche 1nystatin mouththroat suspension 1pilocarpine hcl oral tablet 1sf 5000 plus dental cream 1 DFtriamcinolone acetonide mouththroat paste

1

MultivitaminsDIALYVITE ORAL TABLET 1 PA PA except

Nephrologymultivitaminfluoride oral tablet chewable 025 mg 05 mg

1

prenatal 19 oral tablet 2prenatal 19 oral tablet chewable 2prenatal oral tablet 27-1 mg 2prenatal plus iron oral tablet 2prenatal plusiron oral tablet 2rena-vite rx oral tablet 1 PA PA except

Nephrology XCHPvol-plus oral tablet 2

Musculoskeletal Therapy Agentsbaclofen oral tablet 1chlorzoxazone oral tablet 250 mg 500 mg

1 AL

cyclobenzaprine hcl oral tablet 1 ALdantrolene sodium oral capsule 1metaxalone oral tablet 1 ALmethocarbamol oral tablet 1 ALorphenadrine citrate er oral tablet extended release 12 hour

1 AL

tizanidine hcl oral capsule 1tizanidine hcl oral tablet 1

Nasal Agents - Systemic And Topicalazelastine hcl nasal solution 01 1budesonide nasal suspension 1flunisolide nasal solution 25 mcgact (0025)

1

fluticasone propionate nasal suspension

1

ipratropium bromide nasal solution 1NASACORT ALLERGY 24HR NASAL AEROSOL

2 XCHP

12012019

20

Neuromuscular Agentsriluzole oral tablet 1

Nutrientslevocarnitine fumarate oral tablet 1 PA XCHP

Ophthalmic AgentsACUVAIL OPHTHALMIC SOLUTION 2 PA except

OphthalmologyALOMIDE OPHTHALMIC SOLUTION 2 STapraclonidine hcl ophthalmic solution

1

azelastine hcl ophthalmic solution 1AZOPT OPHTHALMIC SUSPENSION 2bacitracin-polymyxin b ophthalmic ointment 500-10000 unitgm

1

bacitra-neomycin-polymyxin-hc ophthalmic ointment

1

balanced salt intraocular solution 1bimatoprost ophthalmic solution 1 ALBLEPHAMIDE OPHTHALMIC SUSPENSION

2

BLEPHAMIDE SOP OPHTHALMIC OINTMENT

2

brimonidine tartrate ophthalmic solution

1

bromfenac sodium (once-daily) ophthalmic solution

1

carteolol hcl ophthalmic solution 1ciprofloxacin hcl ophthalmic solution

1

COMBIGAN OPHTHALMIC SOLUTION

2

cromolyn sodium ophthalmic solution

1 PA except ophthamology

CYSTARAN OPHTHALMIC SOLUTION

2 PA LDD

dexamethasone sodium phosphate ophthalmic solution

1

diclofenac sodium ophthalmic solution

1 PA PA Except Opthalmology

dorzolamide hcl ophthalmic solution

1

dorzolamide hcl-timolol mal ophthalmic solution

1

epinastine hcl ophthalmic solution 1erythromycin ophthalmic ointment 1FLAREX OPHTHALMIC SUSPENSION

2

fluorometholone ophthalmic suspension

1

flurbiprofen sodium ophthalmic solution

1

FML FORTE OPHTHALMIC SUSPENSION

2

FML OPHTHALMIC OINTMENT 2gentamicin sulfate ophthalmic solution

1

homatropine hbr ophthalmic solution

1

ketorolac tromethamine ophthalmic solution

1

ketotifen fumarate ophthalmic solution

1

LACRISERT OPHTHALMIC INSERT 2latanoprost ophthalmic solution 1 ALlevobunolol hcl ophthalmic solution 05

1

levofloxacin ophthalmic solution 1LUMIGAN OPHTHALMIC SOLUTION 001

2 AL

NATACYN OPHTHALMIC SUSPENSION

2 PA

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

1

neomycin-polymyxin-dexameth ophthalmic ointment

1

neomycin-polymyxin-dexameth ophthalmic suspension 35-10000-01

1

neomycin-polymyxin-gramicidin ophthalmic solution 175-10000-025

1

neomycin-polymyxin-hc ophthalmic suspension 35-10000-1

1

ofloxacin ophthalmic solution 1 PAolopatadine hcl ophthalmic solution

1

phenylephrine hcl ophthalmic solution 10 25

1

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED

2

pilocarpine hcl ophthalmic solution 1 2 4

1

polymyxin b-trimethoprim ophthalmic solution

1

PRED MILD OPHTHALMIC SUSPENSION

2

prednisolone acetate ophthalmic suspension

1

prednisolone sodium phosphate ophthalmic solution

1

SIMBRINZA OPHTHALMIC SUSPENSION

2

sulfacetamide sodium ophthalmic solution

1

sulfacetamide-prednisolone ophthalmic solution

1

timolol maleate ophthalmic gel forming solution

1

timolol maleate ophthalmic solution 025 05

1

tobramycin ophthalmic solution 1tobramycin-dexamethasone ophthalmic suspension

1

TRAVATAN Z OPHTHALMIC SOLUTION

2 AL

trifluridine ophthalmic solution 1tropicamide ophthalmic solution 1

1

12012019

21

Otic Agentsacetic acid otic solution 1CIPRODEX OTIC SUSPENSION 2 PA PA except

otolaryngologyciprofloxacin hcl otic solution 1hydrocortisone-acetic acid otic solution

1

neomycin-polymyxin-hc otic solution

1

neomycin-polymyxin-hc otic suspension

1

ofloxacin otic solution 1

Oxytocicsmethylergonovine maleate oral tablet

1 QL

Passive Immunizing AgentsSYNAGIS INTRAMUSCULAR SOLUTION

2 PA

Penicillinsamoxicillin oral capsule 1amoxicillin oral suspension reconstituted

1

amoxicillin oral tablet 1amoxicillin oral tablet chewable 125 mg 250 mg

1

amoxicillin-pot clavulanate er oral tablet extended release 12 hour

1

amoxicillin-pot clavulanate oral suspension reconstituted

1

amoxicillin-pot clavulanate oral tablet

1

amoxicillin-pot clavulanate oral tablet chewable

1

ampicillin oral capsule 500 mg 1dicloxacillin sodium oral capsule 1penicillin v potassium oral solution reconstituted

1

penicillin v potassium oral tablet 1

Pharmaceutical Adjuvantscherry flavor liquid 2polyethylene glycol 3350 powder 1

Phosphodiesterase 4 (Pde4) Inhibitors - TopicalEUCRISA EXTERNAL OINTMENT 2 ST AL

Potassium Removing AgentsKIONEX ORAL SUSPENSION 1LOKELMA ORAL PACKET 2sodium polystyrene sulfonate oral powder

1

SPS ORAL SUSPENSION 1VELTASSA ORAL PACKET 2

Progestinsmedroxyprogesterone acetate oral tablet

1

megestrol acetate oral suspension 625 mg5ml

1

norethindrone acetate oral tablet 1

progesterone micronized oral capsule

1

Psychotherapeutic And Neurological Agents - Miscacamprosate calcium oral tablet delayed release

1

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT

2 PA PR

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT

2 PA PR

bupropion hcl er (smoking det) oral tablet extended release 12 hour

1

CHANTIX CONTINUING MONTH PAK ORAL TABLET

2 AL

CHANTIX ORAL TABLET 2 ALCHANTIX STARTING MONTH PAK ORAL TABLET

2 AL

chlordiazepoxide-amitriptyline oral tablet

1 AL

disulfiram oral tablet 1donepezil hcl oral tablet 10 mg 5 mg

1

donepezil hcl oral tablet dispersible 1 PAergoloid mesylates oral tablet 1galantamine hydrobromide er oral capsule extended release 24 hour

1

galantamine hydrobromide oral solution

1

galantamine hydrobromide oral tablet

1

glatiramer acetate subcutaneous solution prefilled syringe

1 PA PA except neurologyPR

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

memantine hcl er oral capsule extended release 24 hour

1

memantine hcl oral solution 2 mgml

1

memantine hcl oral tablet 1nicotine polacrilex mouththroat gum 4 mg

1 XCHP

nicotine polacrilex mouththroat lozenge 2 mg

1 XCHP

nicotine transdermal patch 24 hour 1 XCHPNICOTROL INHALATION INHALER 2NICOTROL NS NASAL SOLUTION 2NUEDEXTA ORAL CAPSULE 2 PA PRperphenazine-amitriptyline oral tablet

1 AL

pimozide oral tablet 1 ALrivastigmine tartrate oral capsule 1tetrabenazine oral tablet 1 PAXYREM ORAL SOLUTION 2 PA LDD

Respiratory Agents - MiscKALYDECO ORAL PACKET 2 PA LDDKALYDECO ORAL TABLET 2 PA LDDPULMOZYME INHALATION SOLUTION

2

Serotonin Modulatorstrazodone hcl oral tablet 1

12012019

22

Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide CombSEGLUROMET ORAL TABLET 2 PR

Steroids - MouthThroatDentaltriamcinolone acetonide mouththroat paste

1

Sulfonamidessulfadiazine oral tablet 1

Tetracyclinesdoxycycline hyclate oral capsule 1doxycycline hyclate oral tablet 100 mg 20 mg 75 mg

1

minocycline hcl oral capsule 1 ALtetracycline hcl oral capsule 1

Thyroid AgentsARMOUR THYROID ORAL TABLET 2levothyroxine sodium oral tablet 1LEVOXYL ORAL TABLET 1liothyronine sodium oral tablet 1methimazole oral tablet 1np thyroid oral tablet 30 mg 60 mg 90 mg

1

propylthiouracil oral tablet 1SYNTHROID ORAL TABLET 2UNITHROID ORAL TABLET 2

Topical Anesthetic Gasesethyl chloride external aerosol 2

Ulcer Drugschlordiazepoxide-clidinium oral capsule

1 AL

cimetidine hcl oral solution 1cimetidine oral tablet 1dicyclomine hcl oral capsule 1dicyclomine hcl oral solution 1dicyclomine hcl oral tablet 1esomeprazole magnesium oral capsule delayed release

1

famotidine oral suspension reconstituted

1

famotidine oral tablet 20 mg 40 mg

1

glycopyrrolate injection solution 1glycopyrrolate oral tablet 1 mg 2 mg

1

hyoscyamine sulfate oral elixir 1 ALhyoscyamine sulfate oral solution 1 ALhyoscyamine sulfate oral tablet 1 ALlansoprazole oral capsule delayed release 30 mg

1

methscopolamine bromide oral tablet

1

misoprostol oral tablet 1nizatidine oral capsule 1nizatidine oral solution 1omeprazole oral capsule delayed release

1

pantoprazole sodium oral tablet delayed release

1

propantheline bromide oral tablet 1

PYLERA ORAL CAPSULE 2 PArabeprazole sodium oral tablet delayed release

1

ranitidine hcl oral syrup 1ranitidine hcl oral tablet 150 mg 300 mg

1

sucralfate oral tablet 1

Urinary Anti-Infectivesmethenamine mandelate oral tablet 1 gm

1

nitrofurantoin macrocrystal oral capsule

1 AL

nitrofurantoin monohyd macro oral capsule

1 AL

nitrofurantoin oral suspension 1 AL

Urinary Antispasmodicsbethanechol chloride oral tablet 1flavoxate hcl oral tablet 1oxybutynin chloride er oral tablet extended release 24 hour

1

oxybutynin chloride oral syrup 1oxybutynin chloride oral tablet 1tolterodine tartrate er oral capsule extended release 24 hour

1 AL

tolterodine tartrate oral tablet 1 ALtrospium chloride er oral capsule extended release 24 hour

1 AL

trospium chloride oral tablet 1 AL

Vaginal ProductsCLEOCIN VAGINAL SUPPOSITORY 2clindamycin phosphate vaginal cream

1

estradiol vaginal cream 1estradiol vaginal tablet 1ESTRING VAGINAL RING 2FEMRING VAGINAL RING 2metronidazole vaginal gel 1PREMARIN VAGINAL CREAM 2terconazole vaginal cream 1terconazole vaginal suppository 1YUVAFEM VAGINAL TABLET 1

Vasopressorsepinephrine injection solution auto-injector 015 mg03ml 03 mg03ml

1 QL

midodrine hcl oral tablet 1SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE

2 QL

Vitaminsascorbic acid oral tablet 500 mg 1 XCHPergocalciferol oral capsule 1phytonadione oral tablet 1vitamin a oral capsule 10000 unit 1 XCHPvitamin d (cholecalciferol) oral capsule 10 mcg (400 unit) 25 mcg (1000 ut)

1 XCHP

vitamin d (cholecalciferol) oral tablet 10 mcg (400 unit)

2 XCHP

12012019

23

vitamin d (ergocalciferol) oral capsule 125 mg (50000 ut)

1

vitamin d oral capsule 50 mcg (2000 ut)

1 XCHP

vitamin d oral tablet 50 mcg (2000 ut)

1 XCHP

vitamin d2 oral tablet 1 XCHPvitamin d3 oral capsule 125 mg (50000 ut) 125 mcg (5000 ut) 250 mcg (10000 ut)

1 XCHP

vitamin d3 oral tablet 10 mcg (400 unit) 125 mcg (5000 ut) 75 mcg (3000 ut)

1 XCHP

12012019

24

Index

abacavir sulfate 11abacavir sulfate-lamivudine 11abacavir-lamivudine-zidovudine 11ABILIFY MAINTENA 11abiraterone acetate 10acamprosate calcium22acarbose 7acebutolol hcl 12acetaminophen3acetaminophen extra strength 3acetaminophen-codeine 4acetaminophen-codeine 2 4acetaminophen-codeine 3 4acetaminophen-codeine 4 4acetazolamide 17acetazolamide er 17acetic acid 18 22acetylcysteine 15acitretin 15ACUVAIL 21acyclovir 11 15adapalene 15adefovir dipivoxil 11ADMELOG 7ADMELOG SOLOSTAR 7AFEDITAB CR 13AFINITOR 10AIMOVIG 13ala-cort 15ALA-QUIN 15albendazole 5albuterol sulfate 5albuterol sulfate er 5albuterol sulfate hfa 5alclometasone dipropionate 15ALDACTAZIDE 17alendronate sodium 17alfuzosin hcl er 18ALINIA 9aliskiren fumarate 9allopurinol 18ALOMIDE 21alprazolam 5alprazolam er 5ALPRAZOLAM INTENSOL 5alprazolam xr 5ALTAVERA 13aluminum hydroxide gel 5alyacen 135 13alyacen 777 13amantadine hcl 10ambrisentan 13amcinonide 15AMETHIA 13AMETHIA LO 13amiloride hcl 17amiloride-hydrochlorothiazide 17aminoacetic acid 18amiodarone hcl 5amitriptyline hcl 7amlodipine besy-benazepril hcl 9amlodipine besylate 13

Index

ammonium lactate 15amoxapine 7amoxicillin 22amoxicillin-pot clavulanate 22amoxicillin-pot clavulanate er 22amphetamine-dextroamphet er 3amphetamine-dextroamphetamine 3ampicillin 22ANACAINE 15anagrelide hcl 19anastrozole 10ANNOVERA 13ANORO ELLIPTA 5antacid calcium5antacid calcium extra strength 5antacid liquid 5anti-diarrheal 8antifungal 15anti-fungal 15apraclonidine hcl 21aprepitant 8APRI 13APRISO 18APTIVUS 11ARANELLE 13ARANESP (ALBUMIN FREE) 19ARCALYST 3ARGYLE STERILE WATER 12aripiprazole 11ARISTADA 11ARISTADA INITIO 11armodafinil 3ARMOUR THYROID 23ascorbic acid 23ASHLYNA 13aspirin 3aspirin 81 3aspirin adult low dose 3aspirin adult low strength 3aspirin ec 3aspirin ec adult low strength 3aspirin-dipyridamole er 19atazanavir sulfate 11atenolol 12atenolol-chlorthalidone 9atomoxetine hcl 3atorvastatin calcium 9atovaquone9atovaquone-proguanil hcl 9ATRIPLA 11ATROVENT HFA 5AUBRA 13AVIANE 13AVONEX PEN 22AVONEX PREFILLED 22AZASAN 12azathioprine 12azelastine hcl 20 21azithromycin 20AZOPT 21AZURETTE 13bacitracin-polymyxin b 21

Index

bacitra-neomycin-polymyxin-hc 21baclofen 20balanced salt 21BALCOLTRA 13balsalazide disodium18BALZIVA 13BANZEL 6BAQSIMI ONE PACK 7BAQSIMI TWO PACK 7BARACLUDE 11BASAGLAR KWIKPEN 7BEKYREE 13benazepril hcl 9benazepril-hydrochlorothiazide 9benzalkonium chloride 11benznidazole 5benzonatate 15benzoyl peroxide 15benztropine mesylate 10betamethasone dipropionate 15betamethasone dipropionate aug 15betamethasone valerate 15betaxolol hcl 12bethanechol chloride 23bicalutamide 10BIKTARVY 11bimatoprost 21bisacodyl ec 19bismuth subsalicylate 8bisoprolol fumarate 12bisoprolol-hydrochlorothiazide 9BLEPHAMIDE 21BLEPHAMIDE SOP 21BLISOVI 24 FE 13BLISOVI FE 1530 13blood glucose test 17BONJESTA 8bosentan 13BRAFTOVI 10briellyn 14BRILINTA 17 19brimonidine tartrate 21bromfenac sodium (once-daily) 21bromocriptine mesylate 10budesonide 5 15 20bumetanide 17buprenorphine 4bupropion hcl 7bupropion hcl er (smoking det) 22bupropion hcl er (sr) 7bupropion hcl er (xl) 7buspirone hcl 5butalbital-acetaminophen 3butalbital-apap-caff-cod 4butalbital-apap-caffeine 3 4butalbital-asa-caff-codeine 4butalbital-asa-caffeine 4BUTISOL SODIUM 19butorphanol tartrate 4cabergoline 17CAFERGOT 20calcipotriene 15

12012019

25

Index

calcitonin (salmon) 17calcitriol 15 17calcium acetate (phos binder) 18calcium carbonate antacid 5calcium citrate + d 20CAMILA 14CAMRESE 14CAMRESE LO 14candesartan cilexetil 9candesartan cilexetil-hctz 9capecitabine 10CAPRELSA 10capsaicin 16capsaicin hot patch 16capsaicin hp 16captopril 9captopril-hydrochlorothiazide 9CARBAGLU 17carbamazepine 6carbamazepine er 6carbidopa-levodopa10carbidopa-levodopa er 10carbidopa-levodopa-entacapone 10carbinoxamine maleate 8carteolol hcl 21CARTIA XT 13carvedilol 13CAYSTON 20CAZIANT 14cefaclor 13cefadroxil 13cefdinir 13cefixime 13cefpodoxime proxetil 13cefprozil 13cefuroxime axetil 13celecoxib 3CELONTIN 6cephalexin 13CESIA 14cetirizine hcl 8cevimeline hcl 20CHANTIX 22CHANTIX CONTINUING MONTH PAK 22CHANTIX STARTING MONTH PAK 22CHATEAL 14cherry flavor 22chlordiazepoxide hcl 5chlordiazepoxide-amitriptyline 22chlordiazepoxide-clidinium23chlorhexidine gluconate 20chloroquine phosphate 10chlorothiazide 17chlorpheniramine maleate 8chlorpromazine hcl 11chlorthalidone 17chlorzoxazone20cholestyramine 9cholestyramine light 9choline-mag trisalicylate 4ciclopirox 16ciclopirox olamine 16cilostazol 19cimetidine 23

Index

cimetidine hcl 23cinacalcet hcl 17CIPRO 18CIPRODEX 22ciprofloxacin 18ciprofloxacin hcl 18 21 22citalopram hydrobromide 7CLARAVIS 16clarithromycin 20clarithromycin er 20CLEOCIN 23clindamycin hcl 9clindamycin palmitate hcl 9clindamycin phos-benzoyl perox 16clindamycin phosphate 16 23clobazam6clobetasol propionate 16clomiphene citrate 17clomipramine hcl 7clonazepam6clonidine 9clonidine hcl 9clopidogrel bisulfate 19clorazepate dipotassium5clotrimazole 16 20clotrimazole af 16clotrimazole-betamethasone 16clozapine 11coal tar 16COARTEM 10codeine sulfate 4colchicine 18colchicine-probenecid 18colesevelam hcl 9colestipol hcl 9COMBIGAN 21COMBIPATCH 18COMBIVENT RESPIMAT 5COMPLERA 11CORDRAN 16cortisone acetate 15CORVITA 150 19CREON 17CRIXIVAN 11cromolyn sodium 6 18 21CROTAN 16CRYSELLE-28 14CUTTER NATURAL 16cyanocobalamin 19CYCLAFEM 135 14CYCLAFEM 777 14cyclobenzaprine hcl 20cyclophosphamide 10cyclosporine 12cyclosporine modified 12cyproheptadine hcl 8CYRED 14CYSTADANE 17CYSTAGON 18CYSTARAN 21danazol 4dantrolene sodium 20dapsone 9DARAPRIM 10

Index

DASETTA 135 14DASETTA 777 14DAYSEE 14DEBLITANE 14DELSTRIGO 11DELYLA 14DEPEN TITRATABS 12DESCOVY 11desipramine hcl 7desmopressin ace spray refrig 17desmopressin acetate 17desmopressin acetate spray 17desogestrel-ethinyl estradiol 14desonide 16desoximetasone16dexamethasone 15DEXAMETHASONE INTENSOL 15dexamethasone sodium phosphate 21dexmethylphenidate hcl 3dextroamphetamine sulfate 3dextroamphetamine sulfate er 3DIALYVITE 20diarrhea 8diazepam 5DIAZEPAM INTENSOL 5diclofenac potassium3diclofenac sodium3 16 21diclofenac sodium er 3dicloxacillin sodium22dicyclomine hcl 23didanosine 11diflunisal 4digox 13digoxin 13dihydroergotamine mesylate 20DILANTIN 6diltiazem hcl 13diltiazem hcl er 13diltiazem hcl er beads 13diltiazem hcl er coated beads 13dilt-xr 13diphenhydramine hcl 8diphenoxylate-atropine 8dipyridamole 19disopyramide phosphate 5disulfiram22DIURIL 17divalproex sodium 6divalproex sodium er 6docusate calcium 19docusate sodium19dofetilide 5donepezil hcl 22dorzolamide hcl 21dorzolamide hcl-timolol mal 21DOVATO 11doxazosin mesylate 9doxepin hcl 7doxycycline hyclate 23doxylamine-pyridoxine 8dronabinol 8drospiren-eth estrad-levomefol 14drospirenone-ethinyl estradiol 14DROXIA 19

12012019

26

Index

DRYSOL 16duloxetine hcl 7DUPIXENT 12duraxin 4dutasteride 18econazole nitrate 16EDURANT 11efavirenz 11ELINEST 14ELIQUIS 6ELIQUIS STARTER PACK 6ELLA 14ELMIRON 18EMCYT 10EMEND 8EMFLAZA 15EMOQUETTE 14EMTRIVA 11EMVERM 5enalapril maleate 9enalaprilat 9enalapril-hydrochlorothiazide 9ENBREL 3ENBREL SURECLICK 3enema disposable 19enoxaparin sodium 6ENPRESSE-28 14ENSKYCE 14entacapone10entecavir 11epinastine hcl 21epinephrine 23EPIVIR HBV 11eplerenone 9EPOGEN 19eprosartan mesylate 9ergocalciferol 23ergoloid mesylates 22ERGOMAR 20ERLEADA 10erlotinib hcl 10ERRIN 14ERYTHROCIN STEARATE 20erythromycin 16 21erythromycin base 20erythromycin ethylsuccinate 20escitalopram oxalate 7esomeprazole magnesium23est estrogens-methyltest ds 18est estrogens-methyltest hs 18ESTARYLLA 14estazolam19estradiol 18 23estradiol-norethindrone acet 18ESTRING 23ethambutol hcl 10ethosuximide 6ethyl chloride 16 23ethynodiol diac-eth estradiol 14etidronate disodium 17etodolac 3etoposide 10EUCRISA 22EURAX 16

Index

EVOTAZ 11EXCEDRIN EXTRA STRENGTH 4exemestane 10ezetimibe 9FABIOR 16FALMINA 14famciclovir 11famotidine 23FASENRA PEN 19fa-vitamin b-6-vitamin b-12 19felbamate 6felodipine er 13FEMRING 23FEMYNOR 14fenofibrate 9fenofibrate micronized 9fenofibric acid 9fentanyl 4fentanyl citrate 4ferrous sulfate 19fiber laxative 19finasteride 18FIRMAGON 10FLAREX 21flavoxate hcl 23flecainide acetate 5FLEET BISACODYL 19FLOVENT DISKUS 6FLOVENT HFA 6fluconazole 8fludrocortisone acetate 15flunisolide 20fluocinonide 16fluorometholone21fluorouracil 16fluoxetine hcl 7fluphenazine decanoate 11fluphenazine hcl 11flurazepam hcl 19flurbiprofen 3flurbiprofen sodium21flutamide 10fluticasone propionate 16 20fluticasone-salmeterol 6fluvastatin sodium 9fluvoxamine maleate 7FML 21FML FORTE 21folic acid 19fondaparinux sodium6FORTEO 17fosamprenavir calcium 11fosinopril sodium 9fosinopril sodium-hctz 9FRAGMIN 6furosemide17FUZEON 11gabapentin 6galantamine hydrobromide22galantamine hydrobromide er 22GALZIN 20GAVILYTE-N WITH FLAVOR PACK 19gemfibrozil 9generlac 18

Index

GENGRAF 12gentamicin sulfate 16 21GENVOYA 11GEODON 11GIANVI 14glatiramer acetate 22GLATOPA 22glimepiride 7glipizide 7glipizide er 7glipizide-metformin hcl 7GLUCAGON EMERGENCY 7glyburide 7glyburide micronized 7glyburide-metformin 7glycine 18glycine urologic 18glycopyrrolate 23granisetron hcl 8griseofulvin ultramicrosize 8guaifenesin 15guaifenesin dac 15guaifenesin-codeine 15guanfacine hcl 9guanfacine hcl er 3guanidine hcl 10GVOKE PFS 7halobetasol propionate 16haloperidol 11haloperidol decanoate 11haloperidol lactate 11headache formula 4HEATHER 14HEMATOGEN FORTE 19homatropine hbr 21HUMALOG 7HUMALOG KWIKPEN 7HUMALOG MIX 5050 7HUMALOG MIX 5050 KWIKPEN 7HUMALOG MIX 7525 7HUMALOG MIX 7525 KWIKPEN 7HUMIRA 3HUMIRA PEDIATRIC CROHNS START 3HUMIRA PEN 3HUMIRA PEN-CDUCHS STARTER 3HUMIRA PEN-PSUVADOL HS START 3HUMULIN 7030 7HUMULIN 7030 KWIKPEN 7HUMULIN N 7HUMULIN N KWIKPEN 7HUMULIN R 7HUMULIN R U-500 (CONCENTRATED) 7HYCAMTIN 10hydralazine hcl 9hydrochlorothiazide 17hydrocodone-acetaminophen 4hydrocodone-ibuprofen 4hydrocortisone 5 15 16hydrocortisone acetate 5hydrocortisone butyrate 16hydrocortisone valerate 16hydrocortisone-acetic acid 22hydromorphone hcl 4hydroxychloroquine sulfate 10

12012019

27

Index

hydroxyurea 10hydroxyzine hcl 5hydroxyzine pamoate 5hyoscyamine sulfate 23HYPERCARE 16HYSINGLA ER 4ibuprofen 3ibuprofen childrens 3ibuprofen junior strength 3imatinib mesylate 10imipramine hcl 7imiquimod16INCRELEX 17indapamide17INDOCIN 3indomethacin 3indomethacin er 3infants simethicone 18INTELENCE 11INTROVALE 14INVIRASE 11ipratropium bromide 6 20ipratropium-albuterol 6irbesartan 9irbesartan-hydrochlorothiazide 9ISENTRESS 11ISENTRESS HD 11isoniazid 10ISORDIL TITRADOSE 5isosorbide dinitrate 5isosorbide dinitrate er 5isosorbide mononitrate 5isosorbide mononitrate er 5isradipine 13itraconazole 8ivermectin 5JADENU 8JADENU SPRINKLE 8JAKAFI 10JANTOVEN 6JENCYCLA 14JENTADUETO 7JINTELI 18JOLESSA 14JULEBER 14JULUCA 11JUNEL 1530 14JUNEL 120 14JUNEL FE 1530 14JUNEL FE 120 14JUNEL FE 24 14KAITLIB FE 14KALETRA 11KALYDECO 22KARIVA 14KELNOR 135 14ketoconazole 8 16ketoprofen er 3ketorolac tromethamine3 21ketotifen fumarate 21KIONEX 12 22KORLYM 7KRISTALOSE 19KURVELO 14

Index

KUVAN 17labetalol hcl 13LACRISERT 21lactated ringers 12lactulose 19lactulose encephalopathy 18lamivudine 11lamivudine-zidovudine 11lamotrigine 6lansoprazole 23lanthanum carbonate 18LARIN 1530 14LARIN 120 14LARIN 24 FE 14LARIN FE 1530 14LARIN FE 120 14LARISSIA 14latanoprost 21laxative 19LAYOLIS FE 14LEENA 14leflunomide3LESSINA 14letrozole 10leucovorin calcium10LEUKERAN 10levetiracetam6levetiracetam er 6levobunolol hcl 21levocarnitine 17levocarnitine fumarate 21levocetirizine dihydrochloride 8levofloxacin 18 21LEVONEST 14levonorgest-eth estrad 91-day 14levonorgestrel 14levonorgestrel-ethinyl estrad 14LEVORA 01530 (28) 14levothyroxine sodium 23LEVOXYL 23LEXIVA 11lidocaine 16lidocaine hcl 16 20lidocaine-hydrocortisone ace 5lidocaine-prilocaine 16LIDOCARE ARMNECKLEG 16LIDOCARE BACKSHOULDER 16lindane 16linezolid 9liothyronine sodium23lisinopril 9lisinopril-hydrochlorothiazide 9lithium11lithium carbonate 11lithium carbonate er 11LO LOESTRIN FE 14LOKELMA 12 22loperamide hcl 8lopinavir-ritonavir 11loratadine 8lorazepam 5LORYNA 14losartan potassium 9losartan potassium-hctz 9

Index

lovastatin 9LOW-OGESTREL 14loxapine succinate 11LUCEMYRA 3LUMIGAN 21LUTERA 14LYSODREN 10LYZA 14mag-al 5magnesium oxide 5 20malathion 16maprotiline hcl 7marlissa 14MATULANE 10MATZIM LA 13MAVYRET 19meclizine hcl 8medroxyprogesterone acetate 22mefloquine hcl 10megestrol acetate 10 22MEKTOVI 10meloxicam 3melphalan 10memantine hcl 22memantine hcl er 22MENOSTAR 18mercaptopurine 10mesalamine 18mesalamine-cleanser 18MESNEX 10metaproterenol sulfate 6metaxalone 20metformin hcl 7metformin hcl er 7methadone hcl 4methamphetamine hcl 3methazolamide 17methenamine mandelate 23methimazole 23methitest 4methocarbamol 20methotrexate 10methotrexate sodium10methotrexate sodium (pf) 10methscopolamine bromide 23methyldopa 9methyldopa-hydrochlorothiazide 9methylergonovine maleate 22methylphenidate hcl 3methylphenidate hcl er 3methylphenidate hcl er (cd) 3methylphenidate hcl er (la) 3methylprednisolone 15metoclopramide hcl 18metolazone17metoprolol succinate er 13metoprolol tartrate 13metoprolol-hydrochlorothiazide 9metronidazole 9 16 23mexiletine hcl 5MIBELAS 24 FE 14MICROGESTIN 1530 14MICROGESTIN 120 14MICROGESTIN FE 1530 14

12012019

28

Index

MICROGESTIN FE 120 14midazolam hcl 19midodrine hcl 23migraine formula 4milk of magnesia 19MIMVEY 18mineral oil 19minocycline hcl 23minoxidil 9mirtazapine 7misoprostol 23modafinil 3moexipril hcl 9mometasone furoate 16MONO-LINYAH 14MONONESSA 14montelukast sodium 6morphine sulfate 4morphine sulfate er 4moxifloxacin hcl 18multivitaminfluoride 20mupirocin 16mupirocin calcium 16mycophenolate mofetil 12mycophenolate sodium 12MYLERAN 10MYORISAN 16nabumetone 3nadolol 13naloxone hcl 8naltrexone hcl 8naproxen3naproxen dr 3naratriptan hcl 20NARCAN 8NASACORT ALLERGY 24HR 20NATACYN 21NATAZIA 14nateglinide 7natural fiber laxative 19natural fiber therapy 19NEBUPENT 9NECON 0535 (28) 14NECON 135 (28) 14neomycin sulfate 3neomycin-bacitracin zn-polymyx 21neomycin-polymyxin b gu 18neomycin-polymyxin-dexameth 21neomycin-polymyxin-gramicidin 21neomycin-polymyxin-hc 21 22NEOTUSS PLUS 15nevirapine 12nevirapine er 11nicardipine hcl 13nicotine 22nicotine polacrilex 22NICOTROL 22NICOTROL NS 22NIFEDICAL XL 13nifedipine 13nifedipine er 13nifedipine er osmotic release 13NIKKI 14nilutamide10

Index

nisoldipine er 13NITRO-BID 5nitrofurantoin 23nitrofurantoin macrocrystal 23nitrofurantoin monohyd macro 23nitroglycerin 5nitroglycerin er 5nizatidine 23NORA-BE 14NORDITROPIN FLEXPRO 17norethin ace-eth estrad-fe 14norethindrone 14norethindrone acetate 22norethindrone acet-ethinyl est 14norethindrone-eth estradiol 18norethin-eth estradiol-fe 14norgestimate-eth estradiol 14norgestim-eth estrad triphasic 14NORLYROC 14NORPACE CR 5NORTREL 0535 (28) 14NORTREL 135 (21) 14NORTREL 135 (28) 14NORTREL 777 14nortriptyline hcl 7NORVIR 12NOXAFIL 8np thyroid 23NUCALA 19NUCYNTA 4NUCYNTA ER 4NUEDEXTA 22NUVARING 14nystatin 8 16 20nystatin-triamcinolone 16OCELLA 14octreotide acetate 17ODEFSEY 12OFF DEEP WOODS 16ofloxacin 21 22olanzapine 11olmesartan medoxomil 9olmesartan medoxomil-hctz 9olopatadine hcl 21omeprazole 23OMNIPOD DASH 5 PACK 20ondansetron 8ondansetron hcl 8opium8OPSUMIT 13ORACIT 18ORKAMBI 15orphenadrine citrate er 20ORSYTHIA 14oseltamivir phosphate 12oxandrolone 4oxazepam5oxcarbazepine 6oxybutynin chloride 23oxybutynin chloride er 23oxycodone hcl 4oxycodone hcl er 4oxycodone-acetaminophen4oxycodone-aspirin 4

Index

oxycodone-ibuprofen 4OXYCONTIN 4oxymorphone hcl 4oxymorphone hcl er 4OZEMPIC (025 OR 05 MGDOSE) 7OZEMPIC (1 MGDOSE) 8pacerone5PANCREAZE 17pantoprazole sodium23paricalcitol 18paromomycin sulfate 3paroxetine hcl 7paroxetine hcl er 7PAXIL 7peg 3350-kcl-na bicarb-nacl 19peg-3350electrolytes 19PEGASYS 12PEGASYS PROCLICK 12PEGINTRON 12penicillamine 12penicillin v potassium 22PENTASA 18pentazocine-naloxone hcl 4pentoxifylline er 19perindopril erbumine 9permethrin 17perphenazine 11perphenazine-amitriptyline 22PERSERIS 11phenazopyridine hcl 18phenelzine sulfate 7phenobarbital 19phenoxybenzamine hcl 9phenylephrine hcl 21phenytoin 6phenytoin infatabs 6phenytoin sodium extended6PHILITH 14PHOSLYRA 18PHOSPHOLINE IODIDE 21PHYSIOLYTE 12PHYSIOSOL IRRIGATION 12phytonadione 23PIFELTRO 12pilocarpine hcl 20 21pimecrolimus 17pimozide 22PIMTREA 14pindolol 13pioglitazone hcl 8pioglitazone hcl-glimepiride 8pioglitazone hcl-metformin hcl 8PIRMELLA 135 14PIRMELLA 777 14piroxicam 3polyethylene glycol 3350 19 22polymyxin b-trimethoprim 21polysaccharide iron forte 19PORTIA-28 14posaconazole 8pot bicarb-pot chloride 20potassium bicarbonate 20potassium chloride 20potassium chloride crys er 20

12012019

29

Index

potassium chloride er 20potassium citrate er 18potassium citrate-citric acid 18PRADAXA 6pramipexole dihydrochloride 10prasugrel hcl 19pravastatin sodium 9prazosin hcl 9PRECISION XTRA KETONE 17PRED MILD 21prednicarbate 17prednisolone15prednisolone acetate 21prednisolone sodium phosphate 15 21prednisone15PREDNISONE INTENSOL 15PREMARIN 18 23PREMPRO 18prenatal 20prenatal 19 20prenatal plus iron 20prenatal plusiron 20pretomanid 10PREVIFEM 14PREZCOBIX 12PREZISTA 12primaquine phosphate 10primidone 6PROAIR RESPICLICK 6probenecid 18prochlorperazine 11prochlorperazine maleate 11PROCRIT 19procto-pak 5proctosol hc 5proctozone-hc 5progesterone micronized 22PROMACTA 19promethazine hcl 8promethazine vccodeine 15promethazine-codeine 15promethazine-dm 15propafenone hcl 5propafenone hcl er 5propantheline bromide 23propranolol hcl 13propranolol hcl er 13propranolol-hctz 9propylthiouracil 23protriptyline hcl 7PULMOZYME 22PYLERA 23pyrazinamide 10pyridostigmine bromide 10pyridostigmine bromide er 10quetiapine fumarate 11quetiapine fumarate er 11quinapril hcl 9quinapril-hydrochlorothiazide 9quinidine gluconate er 5quinidine sulfate 5quinine sulfate 10QVAR REDIHALER 6rabeprazole sodium23

Index

raloxifene hcl 18ramipril 9ranitidine hcl 23rasagiline mesylate 10RECLIPSEN 14RELENZA DISKHALER 12RENACIDIN 18rena-vite rx 20repaglinide 8repaglinide-metformin hcl 8REPEL TICK DEFENSE 17RESCRIPTOR 12RETACRIT 19REVLIMID 12REYATAZ 12ribavirin 12RIDAURA 3rifabutin 10rifampin 10RIFATER 10riluzole 21rimantadine hcl 12ringers irrigation 12RIOMET 8risedronate sodium18risperidone11ritonavir 12rivastigmine tartrate 22rizatriptan benzoate 20ropinirole hcl 10rosuvastatin calcium9RYBELSUS 8salicylic acid 17salicylic acid-cleanser 17salsalate 4sb bismuth 8SEGLUROMET 23selegiline hcl 10selenium sulfide 17SELZENTRY 12senna 19senna laxative 19SENSIPAR 18SEREVENT DISKUS 6sertraline hcl 7SETLAKIN 14sevelamer carbonate 18sevelamer hcl 18sf 5000 plus 20SFROWASA 18SHAROBEL 14sildenafil citrate 13silver nitrate 17silver sulfadiazine 17SIMBRINZA 21simethicone 18simvastatin 9sirolimus 12sodium bicarbonate 5sodium chloride 15sodium fluoride 20sodium polystyrene sulfonate 12 22SOLIA 14SOMAVERT 18

Index

sorbitol 18 19sorbitol-mannitol 18sotalol hcl 13sotalol hcl (af) 13SPIRIVA HANDIHALER 6SPIRIVA RESPIMAT 6spironolactone17spironolactone-hctz 17SPRINTEC 28 14SPRYCEL 10SPS 12 22SRONYX 14STALEVO 100 10STALEVO 125 10STALEVO 150 10STALEVO 200 10STALEVO 50 10STALEVO 75 10stavudine 12STEGLATRO 8sterile water for irrigation 12STIOLTO RESPIMAT 6stool softener laxative 19STRENSIQ 19STRIBILD 12STRIVERDI RESPIMAT 6SUCRAID 17sucralfate 23sulfacetamide sodium17 21sulfacetamide sodium (acne) 17sulfacetamide sodium-sulfur 17sulfacetamide-prednisolone21sulfacetamide-sulfur in urea 17sulfadiazine 23sulfamethoxazole-trimethoprim 9sulfasalazine 18SULFAZINE 18sulindac 3sumatriptan succinate 20sumatriptan succinate refill 20SUPRAX 13SUPREP BOWEL PREP KIT 19SUSTIVA 12SUTENT 10SYEDA 15SYMDEKO 15SYMFI 12SYMFI LO 12SYMJEPI 23SYMLINPEN 120 8SYMLINPEN 60 8SYMTUZA 12SYNAGIS 22SYNAREL 18SYNTHROID 23TABLOID 10tacrolimus 12 17tadalafil (pah) 13tamoxifen citrate 10tamsulosin hcl 18TARINA FE 120 15TASIGNA 10TAZTIA XT 13TEKTURNA HCT 9

12012019

30

Index

telmisartan 9telmisartan-hctz 9temazepam19TEMIXYS 12temozolomide 10tenofovir disoproxil fumarate 12terazosin hcl 9terbinafine hcl 8 17terbutaline sulfate 6terconazole 23testosterone 5testosterone cypionate 4testosterone enanthate 5tetrabenazine 22tetracycline hcl 23THALOMID 12theophylline 6theophylline er 6THIOLA 18thioridazine hcl 11thiothixene 11tiagabine hcl 6TILIA FE 15timolol maleate 13 21tinidazole 9TIVICAY 12tizanidine hcl 20TOBI PODHALER 3tobramycin 3 21tobramycin-dexamethasone21tolterodine tartrate 23tolterodine tartrate er 23topiramate 6 7toremifene citrate 10torsemide 17TRACLEER 13TRADJENTA 8tramadol hcl 4tramadol hcl er 4tramadol hcl er (biphasic) 4tramadol-acetaminophen4trandolapril 9tranexamic acid 19tranylcypromine sulfate 7TRAVATAN Z 21trazodone hcl 7 22tretinoin 10 17TREXALL 10TRI FEMYNOR 15triamcinolone acetonide 17 20 23triamterene-hctz 17triazolam19tricitrates 18trientine hcl 12TRI-ESTARYLLA 15trifluoperazine hcl 11trifluridine 21trihexyphenidyl hcl 10TRI-LEGEST FE 15TRI-LINYAH 15TRI-LO-ESTARYLLA 15TRI-LO-MARZIA 15TRI-LO-SPRINTEC 15trimethobenzamide hcl 8

Index

trimethoprim 9trimipramine maleate 7TRINESSA (28) 15TRI-PREVIFEM 15TRI-SPRINTEC 15TRIUMEQ 12TRIVORA (28) 15TRI-VYLIBRA 15tropicamide 21trospium chloride 23trospium chloride er 23TRULICITY 8TRUVADA 12TYBOST 11TYDEMY 15TYKERB 10TYMLOS 18UNITHROID 23ursodiol 18valacyclovir hcl 12valganciclovir hcl 12valproic acid 7valsartan 9valsartan-hydrochlorothiazide 9vancomycin hcl 18VASCEPA 9VELIVET 15VELTASSA 12 22VEMLIDY 12venlafaxine hcl 7venlafaxine hcl er 7verapamil hcl 13verapamil hcl er 13V-GO 20 20V-GO 30 20V-GO 40 20VICTOZA 8VIDEX 12VIENVA 15vigabatrin 7VIMPAT 7viorele 15VIRACEPT 12VIRAMUNE 12VIREAD 12virt-phos 250 neutral 20VISTOGARD 8vitamin a 23vitamin d 24vitamin d (cholecalciferol) 23vitamin d (ergocalciferol) 24vitamin d2 24vitamin d3 24VIVITROL 8vol-plus 20voriconazole 8VYFEMLA 15warfarin sodium6WERA 15WIXELA INHUB 6WYMZYA FE 15XARELTO 6XARELTO STARTER PACK 6XULANE 15

Index

XURIDEN 19XYREM 22YUVAFEM 23zaleplon 19ZARAH 15ZARXIO 19ZELAPAR 10zidovudine 12zinc oxide 17ziprasidone hcl 11ZITHRANOL 17ZOLINZA 10zolmitriptan 20zolpidem tartrate 19zonisamide 7ZORTRESS 12ZOVIA 135E (28) 15ZUBSOLV 4ZYPREXA RELPREVV 11

12012019

31

LANGUAGE ASSISTANCE

ATTENTION Language assistance services free of charge are available to you Call 1-800-501-3439 TTY 711

English

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

Llame al 1-800-501-3439 TTY 711 Spanish

注意如果您使用繁體中文您可以免費獲得語言援助服務請致電

1-800-501-3439 TTY 711

Chinese

اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان اتصل برقمملحوظة إذا كنت تتحدث

TTY 711 (gt3439-501-800-1رقم هاتف الصم والبكم Arabic

주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

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

перевода Звоните 1-800-501-3439 (телетайп TTY 711

Russian

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

gratuiti Chiamare il numero 1-800-501-3439 TTY 1-800-432-1110

Italian

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

gratuitement Appelez le 1-800-501-3439 TTY 711

French

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

1-800-501-3439 TTY 711

French Creole

אויפמערקזאם אויב איר רעדט אידיש זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון TTY 711 1-800-501-3439אפצאל רופט

Yiddish

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

pod numer 1-800-501-3439 TTY 711

Polish

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

wika nang walang bayad Tumawag sa 1-800-501-3439 TTY 711

Tagalog

লকষয করনঃ যদি আপদন বাাংলা কথা বলতে পাতেন োহতল দনঃখেচায় ভাষা সহায়ো পদেতষবা উপলবধ আতে ফ ান করন ১-

1-800-501-3439 TTY 711

Bengali

KUJDES Neumlse flitni shqip peumlr ju ka neuml dispozicion sheumlrbime teuml asistenceumls gjuheumlsore pa pageseuml Telefononi neuml 1-800-501-3439 TTY 711

Albanian

ΠΡΟΣΟΧΗ Αν μιλάτε ελληνικά στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης οι οποίες παρέχονται δωρεάν Καλέστε 1-800-501-3439 TTY 711

Greek

خبردار اگر آپ اردو بولتے ہيں تو آپ کو زبان کی مدد کی خدمات مفت ميں دستياب ہيں

TTY 711 3439-501-800-1کريں کال

Urdu

NOTICE OF NON-DISCRIMINATION

Independent Health complies with Federal civil rights laws Independent Health does not exclude people or treat them differently because of race color national origin age disability or sex

Independent Health provides the following

Free aids and services to people with disabilities to help you communicate with us such as Qualified sign language interpreters Written information in other formats (large print audio accessible electronic formats

other formats) Free language services to people whose first language is not English such as

Qualified interpreters Information written in other languages

If you need these services call Independent Health at 1-800-501-3439 For TTY services call 711

If you believe that Independent Health has not given you these services or treated you differently because of race color national origin age disability or sex you can file a grievance with Independent Healthrsquos Member Services Department by

Mail 511 Farber Lakes Drive Buffalo NY 14221

Phone 1-800-501-3439 (for TTY services call 711)

Fax 716-635-3504

In person 250 Essjay Road Buffalo NY 14221

Email memberserviceservicingindependenthealthcom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights by

Web Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf

Mail US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

AdhdAnti-NarcolepsyAnti-ObesityAnorexiants
Agents For Narcotic Withdrawal
Agents For Opioid Withdrawal
Aminoglycosides
Analgesics - Anti-Inflammatory
Analgesics - Nonnarcotic
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Antiasthmatic And Bronchodilator Agents
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
AntidiarrhealProbiotic Agents
Antidiarrheals
Antidotes And Specific Antagonists
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Anti-Infective Agents - Misc
Antimalarials
Antimyasthenic Agents
AntimyasthenicCholinergic Agents
Antimycobacterial Agents
Antineoplastics And Adjunctive Therapies
Antiparkinson Agents
AntipsychoticsAntimanic Agents
Antiretrovirals Adjuvants
Antiseptics amp Disinfectants
Antivirals
Assorted Classes
Atopic Dermatitis - Monoclonal Antibodies
Beta Blockers
Calcitonin Gene-Related Peptide (Cgrp) Receptor Antag
Calcium Channel Blockers
Cardiotonics
Cardiovascular Agents - Misc
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Cystic Fibrosis Agent - Combinations
Dermatologicals
Diagnostic Products
Digestive Aids
Direct-Acting P2y12 Inhibitors
Diuretics
Endocrine And Metabolic Agents - Misc
Estrogens
Fluoroquinolones
Gastrointestinal Agents - Misc
Genitourinary Agents - Miscellaneous
Glycopeptides
Gout Agents
Hematological Agents - Misc
Hematopoietic Agents
Hemostatics
Hepatitis C Agent - Combinations
Hereditary Orotic Aciduria Treatment - Agents
Hypnotics
Hypophosphatasia (Hpp) Agents
Interleukin-5 Antagonists (Igg1 Kappa)
Laxatives
Local Anesthetics-Parenteral
Macrolides
Medical Devices
Migraine Products
Minerals amp Electrolytes
Monobactams
MouthThroatDental Agents
Multivitamins
Musculoskeletal Therapy Agents
Nasal Agents - Systemic And Topical
Neuromuscular Agents
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Passive Immunizing Agents
Penicillins
Pharmaceutical Adjuvants
Phosphodiesterase 4 (Pde4) Inhibitors - Topical
Potassium Removing Agents
Progestins
Psychotherapeutic And Neurological Agents - Misc
Respiratory Agents - Misc
Serotonin Modulators
Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb
Steroids - MouthThroatDental
Sulfonamides
Tetracyclines
Thyroid Agents
Topical Anesthetic Gases
Ulcer Drugs
Urinary Anti-Infectives
Urinary Antispasmodics
Vaginal Products
Vasopressors
Vitamins

Page 2: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

Maximum Daily Dose (MDD)

Certain medications are dose limited by a

maximum daily dose (MDD) as recommended by

the Food and Drug Administration (FDA) for safety

reasons Limits may be set by the number of

tabletscapsules per day or the total daily dose

Over-the-Counter (OTC) Medications

Certain medications listed in the formulary are

available over the counter A prescription is

required for coverage of the OTC products

SedativeHypnotic Medications

Sedativehypnotic medications are limited for all

prescribers except sleep specialists to 14

tabletscapsules per month with a maximum of 3 fills

per year (3 fills365 days)

Compounded Prescription Medications

Compounded prescriptions (medications that are

not commercially manufactured) must be prepared

by a participating pharmacy and contain at least

one prescription component The dispensing

pharmacy is required to submit for prior approval

and when covered will take the applicable

copayment Coverage is provided in accordance

with our Compounding Medication Products

Policy Bulk products and powders are excluded

from coverage because they are not prescription

medication products that are approved under

sections 505 505(j) or 507 of the Federal Food

Drug and Cosmetic Act

Diabetic SuppliesMedications

Products listed in this section are a covered benefit

based on your plan Products not listed require prior

authorization Copayments vary by plan

BD needles and syringes are our preferred

needlesyringe products

OneTouch glucose meters lancets test strips and

supplies are our preferred diabetic supplies and do

not require prior authorization

OneTouch will provide a glucose meter to you with

no copayment Quantities are limited to one meter

per member You can obtain a meter by calling

LifeScan Inc at 1-888-377-5227 offer code

289IHA001 Please have your ID number available

when you call

Diabetic test strips are limited to a maximum of

100 per fill30 days

Affordable Care Act (ACA)

Preventive Services

Medications listed on the formulary that are

covered as preventive services under the

Affordable Care Act may be covered Certain

restrictions may apply

LostStolenDamaged Medications and

Vacation Supplies

Replacement of any lost stolen or damaged

medications is the responsibility of the member

Vacation supplies are not covered under this

benefit Prior authorization cannot be used to

obtain early refills for lost stolen or damaged

medications or for extended supplies or vacation

supplies

Emergency Room Prescriptions

Emergency Room prescriptions are limited to a

10-day supply

Enteral and Parenteral

Nutritional Formulas

Enteral Nutritional Formula and Parenteral

Nutritional Formula benefit coverage is based on

medical necessity and prior authorization is

required Supplies that are necessary to administer

the specific type of feeding and maintain the

feeding site are covered This includes but is not

limited to syringes measuring containers tip

adapters anchoring devices gauze pads

protective-dressing wipes tape and tube cleaning

brushes

Pharmacy Administered Immunizations

Influenza and pneumococcal vaccinations are

covered when administered by licensed pharmacists

who obtain additional certification to administer

influenza and pneumococcal vaccinations to adults

18 years of age and older

are not covered

of short stature

coverage

is not utilized

100 per fill30 days

insulin

coverage

share

Key

AL ndash Age Limit

square inches

Antiseptics

per pint

Breast Pump

replacement

Commode Accessories

Diabetic Daily Care

Ostomy Supplies

per ounce stoma cap

Supplies

vaporizer room type

Heat Application

Care

Thermometers

thermometer

Support Goods

slings splint

briefdiaper

Supplies

kit

Gloves

Hearing Aids

Mastectomy Care

Table of Contents

1

2

1 AL

1

1 AL

2 PA QL

1 PA QL

2 PA PR

1

2 PA PR

1 XCHP

1

1 AL

1

1 XCHP

1 AL

12012019

3

1 AL

2 XCHP

1 AL

1

1 AL

1

1 PA

1 ST

1

2

1

1 ST

1

2 ST

2

1

1 ST

1

2

2 ST

1 ST

1 AL

1 ST

1

2

1 PA

12012019

4

1 PA

1 PA PR

1

1 XCHP

2

1

2

1

2

1

2 PR

1

1 AL

2 AL

1

2

1 QL AL

2

12012019

5

1 PA QL

2

1

1 AL

2

2 ST

2 AL

1

2 PR

1 PR

1 PA PR QL

2 PA PR QL

2 PR

1 PR

1

1 PR

1

12012019

6

1

1 PR

1 ST PR

1 PR

2 PR

1

2 PR

1

2 PR

2 XCHP

2 PR

1 PR

12012019

7

1 PR

2 PA PR

1 XCHP

1 QL

2 QL

1 QL

1 AL

1

1 PA

1 AL

1 XCHP

1 AL

1

12012019

8

1

1 AL

1

1 PA

1

12012019

9

1

2 PA

1

2 PA

1

1 ST

1

12012019

10

2 PA PR

2 PA

1 PR

2 PA PR

1 PR

1

2 PA PR

2 PR

2 PA

1

1 PR

2 PA PR

2

1 PR

2 PR

1 PR

2 PA PR

2 PR

1 PR

12012019

11

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 3: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

are not covered

of short stature

coverage

is not utilized

100 per fill30 days

insulin

coverage

share

Key

AL ndash Age Limit

square inches

Antiseptics

per pint

Breast Pump

replacement

Commode Accessories

Diabetic Daily Care

Ostomy Supplies

per ounce stoma cap

Supplies

vaporizer room type

Heat Application

Care

Thermometers

thermometer

Support Goods

slings splint

briefdiaper

Supplies

kit

Gloves

Hearing Aids

Mastectomy Care

Table of Contents

1

2

1 AL

1

1 AL

2 PA QL

1 PA QL

2 PA PR

1

2 PA PR

1 XCHP

1

1 AL

1

1 XCHP

1 AL

12012019

3

1 AL

2 XCHP

1 AL

1

1 AL

1

1 PA

1 ST

1

2

1

1 ST

1

2 ST

2

1

1 ST

1

2

2 ST

1 ST

1 AL

1 ST

1

2

1 PA

12012019

4

1 PA

1 PA PR

1

1 XCHP

2

1

2

1

2

1

2 PR

1

1 AL

2 AL

1

2

1 QL AL

2

12012019

5

1 PA QL

2

1

1 AL

2

2 ST

2 AL

1

2 PR

1 PR

1 PA PR QL

2 PA PR QL

2 PR

1 PR

1

1 PR

1

12012019

6

1

1 PR

1 ST PR

1 PR

2 PR

1

2 PR

1

2 PR

2 XCHP

2 PR

1 PR

12012019

7

1 PR

2 PA PR

1 XCHP

1 QL

2 QL

1 QL

1 AL

1

1 PA

1 AL

1 XCHP

1 AL

1

12012019

8

1

1 AL

1

1 PA

1

12012019

9

1

2 PA

1

2 PA

1

1 ST

1

12012019

10

2 PA PR

2 PA

1 PR

2 PA PR

1 PR

1

2 PA PR

2 PR

2 PA

1

1 PR

2 PA PR

2

1 PR

2 PR

1 PR

2 PA PR

2 PR

1 PR

12012019

11

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 4: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

square inches

Antiseptics

per pint

Breast Pump

replacement

Commode Accessories

Diabetic Daily Care

Ostomy Supplies

per ounce stoma cap

Supplies

vaporizer room type

Heat Application

Care

Thermometers

thermometer

Support Goods

slings splint

briefdiaper

Supplies

kit

Gloves

Hearing Aids

Mastectomy Care

Table of Contents

1

2

1 AL

1

1 AL

2 PA QL

1 PA QL

2 PA PR

1

2 PA PR

1 XCHP

1

1 AL

1

1 XCHP

1 AL

12012019

3

1 AL

2 XCHP

1 AL

1

1 AL

1

1 PA

1 ST

1

2

1

1 ST

1

2 ST

2

1

1 ST

1

2

2 ST

1 ST

1 AL

1 ST

1

2

1 PA

12012019

4

1 PA

1 PA PR

1

1 XCHP

2

1

2

1

2

1

2 PR

1

1 AL

2 AL

1

2

1 QL AL

2

12012019

5

1 PA QL

2

1

1 AL

2

2 ST

2 AL

1

2 PR

1 PR

1 PA PR QL

2 PA PR QL

2 PR

1 PR

1

1 PR

1

12012019

6

1

1 PR

1 ST PR

1 PR

2 PR

1

2 PR

1

2 PR

2 XCHP

2 PR

1 PR

12012019

7

1 PR

2 PA PR

1 XCHP

1 QL

2 QL

1 QL

1 AL

1

1 PA

1 AL

1 XCHP

1 AL

1

12012019

8

1

1 AL

1

1 PA

1

12012019

9

1

2 PA

1

2 PA

1

1 ST

1

12012019

10

2 PA PR

2 PA

1 PR

2 PA PR

1 PR

1

2 PA PR

2 PR

2 PA

1

1 PR

2 PA PR

2

1 PR

2 PR

1 PR

2 PA PR

2 PR

1 PR

12012019

11

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 5: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

briefdiaper

Supplies

kit

Gloves

Hearing Aids

Mastectomy Care

Table of Contents

1

2

1 AL

1

1 AL

2 PA QL

1 PA QL

2 PA PR

1

2 PA PR

1 XCHP

1

1 AL

1

1 XCHP

1 AL

12012019

3

1 AL

2 XCHP

1 AL

1

1 AL

1

1 PA

1 ST

1

2

1

1 ST

1

2 ST

2

1

1 ST

1

2

2 ST

1 ST

1 AL

1 ST

1

2

1 PA

12012019

4

1 PA

1 PA PR

1

1 XCHP

2

1

2

1

2

1

2 PR

1

1 AL

2 AL

1

2

1 QL AL

2

12012019

5

1 PA QL

2

1

1 AL

2

2 ST

2 AL

1

2 PR

1 PR

1 PA PR QL

2 PA PR QL

2 PR

1 PR

1

1 PR

1

12012019

6

1

1 PR

1 ST PR

1 PR

2 PR

1

2 PR

1

2 PR

2 XCHP

2 PR

1 PR

12012019

7

1 PR

2 PA PR

1 XCHP

1 QL

2 QL

1 QL

1 AL

1

1 PA

1 AL

1 XCHP

1 AL

1

12012019

8

1

1 AL

1

1 PA

1

12012019

9

1

2 PA

1

2 PA

1

1 ST

1

12012019

10

2 PA PR

2 PA

1 PR

2 PA PR

1 PR

1

2 PA PR

2 PR

2 PA

1

1 PR

2 PA PR

2

1 PR

2 PR

1 PR

2 PA PR

2 PR

1 PR

12012019

11

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 6: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

Table of Contents

1

2

1 AL

1

1 AL

2 PA QL

1 PA QL

2 PA PR

1

2 PA PR

1 XCHP

1

1 AL

1

1 XCHP

1 AL

12012019

3

1 AL

2 XCHP

1 AL

1

1 AL

1

1 PA

1 ST

1

2

1

1 ST

1

2 ST

2

1

1 ST

1

2

2 ST

1 ST

1 AL

1 ST

1

2

1 PA

12012019

4

1 PA

1 PA PR

1

1 XCHP

2

1

2

1

2

1

2 PR

1

1 AL

2 AL

1

2

1 QL AL

2

12012019

5

1 PA QL

2

1

1 AL

2

2 ST

2 AL

1

2 PR

1 PR

1 PA PR QL

2 PA PR QL

2 PR

1 PR

1

1 PR

1

12012019

6

1

1 PR

1 ST PR

1 PR

2 PR

1

2 PR

1

2 PR

2 XCHP

2 PR

1 PR

12012019

7

1 PR

2 PA PR

1 XCHP

1 QL

2 QL

1 QL

1 AL

1

1 PA

1 AL

1 XCHP

1 AL

1

12012019

8

1

1 AL

1

1 PA

1

12012019

9

1

2 PA

1

2 PA

1

1 ST

1

12012019

10

2 PA PR

2 PA

1 PR

2 PA PR

1 PR

1

2 PA PR

2 PR

2 PA

1

1 PR

2 PA PR

2

1 PR

2 PR

1 PR

2 PA PR

2 PR

1 PR

12012019

11

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 7: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

2

1 AL

1

1 AL

2 PA QL

1 PA QL

2 PA PR

1

2 PA PR

1 XCHP

1

1 AL

1

1 XCHP

1 AL

12012019

3

1 AL

2 XCHP

1 AL

1

1 AL

1

1 PA

1 ST

1

2

1

1 ST

1

2 ST

2

1

1 ST

1

2

2 ST

1 ST

1 AL

1 ST

1

2

1 PA

12012019

4

1 PA

1 PA PR

1

1 XCHP

2

1

2

1

2

1

2 PR

1

1 AL

2 AL

1

2

1 QL AL

2

12012019

5

1 PA QL

2

1

1 AL

2

2 ST

2 AL

1

2 PR

1 PR

1 PA PR QL

2 PA PR QL

2 PR

1 PR

1

1 PR

1

12012019

6

1

1 PR

1 ST PR

1 PR

2 PR

1

2 PR

1

2 PR

2 XCHP

2 PR

1 PR

12012019

7

1 PR

2 PA PR

1 XCHP

1 QL

2 QL

1 QL

1 AL

1

1 PA

1 AL

1 XCHP

1 AL

1

12012019

8

1

1 AL

1

1 PA

1

12012019

9

1

2 PA

1

2 PA

1

1 ST

1

12012019

10

2 PA PR

2 PA

1 PR

2 PA PR

1 PR

1

2 PA PR

2 PR

2 PA

1

1 PR

2 PA PR

2

1 PR

2 PR

1 PR

2 PA PR

2 PR

1 PR

12012019

11

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 8: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1 AL

1

1 AL

2 PA QL

1 PA QL

2 PA PR

1

2 PA PR

1 XCHP

1

1 AL

1

1 XCHP

1 AL

12012019

3

1 AL

2 XCHP

1 AL

1

1 AL

1

1 PA

1 ST

1

2

1

1 ST

1

2 ST

2

1

1 ST

1

2

2 ST

1 ST

1 AL

1 ST

1

2

1 PA

12012019

4

1 PA

1 PA PR

1

1 XCHP

2

1

2

1

2

1

2 PR

1

1 AL

2 AL

1

2

1 QL AL

2

12012019

5

1 PA QL

2

1

1 AL

2

2 ST

2 AL

1

2 PR

1 PR

1 PA PR QL

2 PA PR QL

2 PR

1 PR

1

1 PR

1

12012019

6

1

1 PR

1 ST PR

1 PR

2 PR

1

2 PR

1

2 PR

2 XCHP

2 PR

1 PR

12012019

7

1 PR

2 PA PR

1 XCHP

1 QL

2 QL

1 QL

1 AL

1

1 PA

1 AL

1 XCHP

1 AL

1

12012019

8

1

1 AL

1

1 PA

1

12012019

9

1

2 PA

1

2 PA

1

1 ST

1

12012019

10

2 PA PR

2 PA

1 PR

2 PA PR

1 PR

1

2 PA PR

2 PR

2 PA

1

1 PR

2 PA PR

2

1 PR

2 PR

1 PR

2 PA PR

2 PR

1 PR

12012019

11

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 9: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1 AL

2 XCHP

1 AL

1

1 AL

1

1 PA

1 ST

1

2

1

1 ST

1

2 ST

2

1

1 ST

1

2

2 ST

1 ST

1 AL

1 ST

1

2

1 PA

12012019

4

1 PA

1 PA PR

1

1 XCHP

2

1

2

1

2

1

2 PR

1

1 AL

2 AL

1

2

1 QL AL

2

12012019

5

1 PA QL

2

1

1 AL

2

2 ST

2 AL

1

2 PR

1 PR

1 PA PR QL

2 PA PR QL

2 PR

1 PR

1

1 PR

1

12012019

6

1

1 PR

1 ST PR

1 PR

2 PR

1

2 PR

1

2 PR

2 XCHP

2 PR

1 PR

12012019

7

1 PR

2 PA PR

1 XCHP

1 QL

2 QL

1 QL

1 AL

1

1 PA

1 AL

1 XCHP

1 AL

1

12012019

8

1

1 AL

1

1 PA

1

12012019

9

1

2 PA

1

2 PA

1

1 ST

1

12012019

10

2 PA PR

2 PA

1 PR

2 PA PR

1 PR

1

2 PA PR

2 PR

2 PA

1

1 PR

2 PA PR

2

1 PR

2 PR

1 PR

2 PA PR

2 PR

1 PR

12012019

11

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 10: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1 PA

1 PA PR

1

1 XCHP

2

1

2

1

2

1

2 PR

1

1 AL

2 AL

1

2

1 QL AL

2

12012019

5

1 PA QL

2

1

1 AL

2

2 ST

2 AL

1

2 PR

1 PR

1 PA PR QL

2 PA PR QL

2 PR

1 PR

1

1 PR

1

12012019

6

1

1 PR

1 ST PR

1 PR

2 PR

1

2 PR

1

2 PR

2 XCHP

2 PR

1 PR

12012019

7

1 PR

2 PA PR

1 XCHP

1 QL

2 QL

1 QL

1 AL

1

1 PA

1 AL

1 XCHP

1 AL

1

12012019

8

1

1 AL

1

1 PA

1

12012019

9

1

2 PA

1

2 PA

1

1 ST

1

12012019

10

2 PA PR

2 PA

1 PR

2 PA PR

1 PR

1

2 PA PR

2 PR

2 PA

1

1 PR

2 PA PR

2

1 PR

2 PR

1 PR

2 PA PR

2 PR

1 PR

12012019

11

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 11: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1 PA QL

2

1

1 AL

2

2 ST

2 AL

1

2 PR

1 PR

1 PA PR QL

2 PA PR QL

2 PR

1 PR

1

1 PR

1

12012019

6

1

1 PR

1 ST PR

1 PR

2 PR

1

2 PR

1

2 PR

2 XCHP

2 PR

1 PR

12012019

7

1 PR

2 PA PR

1 XCHP

1 QL

2 QL

1 QL

1 AL

1

1 PA

1 AL

1 XCHP

1 AL

1

12012019

8

1

1 AL

1

1 PA

1

12012019

9

1

2 PA

1

2 PA

1

1 ST

1

12012019

10

2 PA PR

2 PA

1 PR

2 PA PR

1 PR

1

2 PA PR

2 PR

2 PA

1

1 PR

2 PA PR

2

1 PR

2 PR

1 PR

2 PA PR

2 PR

1 PR

12012019

11

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 12: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1

1 PR

1 ST PR

1 PR

2 PR

1

2 PR

1

2 PR

2 XCHP

2 PR

1 PR

12012019

7

1 PR

2 PA PR

1 XCHP

1 QL

2 QL

1 QL

1 AL

1

1 PA

1 AL

1 XCHP

1 AL

1

12012019

8

1

1 AL

1

1 PA

1

12012019

9

1

2 PA

1

2 PA

1

1 ST

1

12012019

10

2 PA PR

2 PA

1 PR

2 PA PR

1 PR

1

2 PA PR

2 PR

2 PA

1

1 PR

2 PA PR

2

1 PR

2 PR

1 PR

2 PA PR

2 PR

1 PR

12012019

11

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 13: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1 PR

2 PA PR

1 XCHP

1 QL

2 QL

1 QL

1 AL

1

1 PA

1 AL

1 XCHP

1 AL

1

12012019

8

1

1 AL

1

1 PA

1

12012019

9

1

2 PA

1

2 PA

1

1 ST

1

12012019

10

2 PA PR

2 PA

1 PR

2 PA PR

1 PR

1

2 PA PR

2 PR

2 PA

1

1 PR

2 PA PR

2

1 PR

2 PR

1 PR

2 PA PR

2 PR

1 PR

12012019

11

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 14: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1

1 AL

1

1 PA

1

12012019

9

1

2 PA

1

2 PA

1

1 ST

1

12012019

10

2 PA PR

2 PA

1 PR

2 PA PR

1 PR

1

2 PA PR

2 PR

2 PA

1

1 PR

2 PA PR

2

1 PR

2 PR

1 PR

2 PA PR

2 PR

1 PR

12012019

11

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 15: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1

2 PA

1

2 PA

1

1 ST

1

12012019

10

2 PA PR

2 PA

1 PR

2 PA PR

1 PR

1

2 PA PR

2 PR

2 PA

1

1 PR

2 PA PR

2

1 PR

2 PR

1 PR

2 PA PR

2 PR

1 PR

12012019

11

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 16: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

2 PA PR

2 PA

1 PR

2 PA PR

1 PR

1

2 PA PR

2 PR

2 PA

1

1 PR

2 PA PR

2

1 PR

2 PR

1 PR

2 PA PR

2 PR

1 PR

12012019

11

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 17: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1 QL

2 PA

2 PR

2

2 PR

1 PR

1 PA

2 PR

1

1 PR

1

2

1

2 PA

12012019

12

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 18: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1

2 PA

1

1 PA AL

1

12012019

13

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 19: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1

12012019

14

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 20: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1

2 PR

1 PR

2 PR

1 PR

1

1 XCHP

1 AL

1

2 PA LDD AL

1

12012019

15

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 21: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1 XCHP

1

1 QL

1 XCHP

1

1 QL

1

1 XCHP

1

1 XCHP

1

1 XCHP

12012019

16

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 22: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1 XCHP

1 PA

1

2 XCHP

2 PR

1

2

1

1 PR

OBGYNFertility XCHP

1

2 PA

2 PA LDD

2 PA PR

Oncology

12012019

17

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 23: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1 PR

2 PA LDD PR

2 PA

2

1 AL

2

1 AL

2

1

2

1

1 XCHP

1

2

1 XCHP

1

2

12012019

18

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 24: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1 PA PR

1

2 PA PR

1

2 PA PR

1

1 XCHP

1

2

1 AL

2 PA LDD

2 PA

1 XCHP

1

1 XCHP

1

2

12012019

19

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 25: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

2

1

2

1

1 PA QL

2 LDD

1 QL

1 XCHP

1

2 PA LDD QL AL

1

1 AL

1

2 XCHP

12012019

20

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 26: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1

2

1

2

2 PA LDD

1

2

1

2

1

2 AL

2 PA

1

2

1

2

1

2

1

2 AL

1

12012019

21

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 27: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1

1 QL

2 PA

1

2 PA PR

1

2 AL

1 AL

1

1 XCHP

1 AL

2

12012019

22

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 28: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1

1 AL

1

1 AL

1

1 AL

1

1 QL

2 QL

1 XCHP

2 XCHP

12012019

23

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 29: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

1

1 XCHP

12012019

24

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 30: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

Index

12012019

25

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 31: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

Index

12012019

26

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 32: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

Index

12012019

27

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 33: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

Index

12012019

28

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 34: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

Index

12012019

29

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 35: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

Index

12012019

30

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 36: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

Index

12012019

31

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 37: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

LANGUAGE ASSISTANCE

English

1-800-501-3439 TTY 711

Chinese

1-800-501-3439 TTY 711 번으로 전화해 주십시오

Korean

Russian

Italian

French

1-800-501-3439 TTY 711

French Creole

Yiddish

pod numer 1-800-501-3439 TTY 711

Polish

Tagalog

1-800-501-3439 TTY 711

Bengali

Albanian

Greek

TTY 711 3439-501-800-1کريں کال

Urdu

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

Page 38: 2019 Medicaid Formulary · An Introduction to Independent Health’s 2019 MediSource and Child Health Plus Formulary The following information applies to Independent Health’s New

Fax 716-635-3504

Phone 1-800-368-1019 (TTYTDD 800-537-7697)

Aminoglycosides
Analgesics - Opioid
Androgens-Anabolic
Anorectal Agents
Antacids
Anthelmintics
Antianginal Agents
Antianxiety Agents
Antiarrhythmics
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetics
Antidiarrheals
Antidotes
Antiemetics
Antifungals
Antihistamines
Antihyperlipidemics
Antihypertensives
Antimalarials
Antivirals
Assorted Classes
Beta Blockers
Cardiotonics
Cephalosporins
Contraceptives
Corticosteroids
CoughColdAllergy
Dermatologicals
Diagnostic Products
Digestive Aids
Diuretics
Estrogens
Fluoroquinolones
Glycopeptides
Gout Agents
Hemostatics
Hypnotics
Laxatives
Macrolides
Medical Devices
Migraine Products
Monobactams
Multivitamins
Nutrients
Ophthalmic Agents
Otic Agents
Oxytocics
Penicillins
Progestins
Sulfonamides
Tetracyclines
Thyroid Agents
Ulcer Drugs
Vaginal Products
Vasopressors
Vitamins

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