Transcription
VIRGINIA PREMIER HEALTH PLANMEDICAID FORMULARYPLEASE NOTE: Check your benefit materials for the specific drugs covered and thecopayments for your prescription drug program. For specific questions about yourcoverage, please call the phone number printed on your ID card. The list may not be allinclusive. THIS LIST IS SUBJECT TO CHANGE.For the member: Generic medications contain the same active ingredients as theircorresponding brand-name medications, although they may look different in color or shape.They have been FDA-approved under strict standards.For the physician: Please prescribe preferred products and allow generic substitutions whenmedically appropriate. Thank you.
CURRENT AS OF 3/1/2019lowercase italics Generic FormularydrugsUPPERCASE Brand name FormularydrugsRequirements/LimitsAGE Age limit requirementCustom Drug has unique restrictionsOTC Over the CounterPA Prior Authorization requiredQL Quantity Level LimitSP Specialty Drug. Preferred SpecialtyPharmacy will be listed if applicableST Step Therapy may apply to some or allstrengths of the drugFormulary StatusFormulary CoveredDrug NameFormulary Status Requirements/Limits1st relief spray external liquid 4-1 %FormularyOTC1st tier unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6mm , 31g x 8 mm , 32g x 4 mmFormularyOTC; QL (200 EA per 30 days)1st tier unilet comfortouchFormularyOTC; QL (150 EA per 30 days)2-deoxy-d-glucose powderFormulary50 adult eye health oral capsuleFormulary7-keto dhea powderFormularyA & D ZINC OXIDE EXTERNAL CREAMFormularyOTCa thru z advanced oral tabletFormularyOTCa thru z advantage oral tabletFormularyOTCa thru z select oral tablet chewableFormularyOTCA D CRACKED SKIN RELIEF EXTERNAL CREAM 20.13 %FormularyOTCa1c test at-home in vitro kitFormularyOTCa-25 oral capsule 25000 unitFormularyOTCabacavir sulfate oral solution 20 mg/mlFormularyabacavir sulfate oral tablet 300 mgFormularyabacavir sulfate-lamivudine oral tablet 600-300 mgFormularyabacavir-lamivudine-zidovudine oral tablet 300-150-300mgFormularyABANATUSS PED ORAL LIQUID 15-0.5-6.25 MG/ML,60-2-25 MG/5MLFormularyOTCABATRACE ORAL CAPSULEFormularyOTCABATREX ORAL TABLET 8-200-4-100-600 MGFormularyOTCABATRON AF ORAL TABLET 150-1 MGFormularyOTCABATRON ORAL LIQUIDFormularyOTCABATUSS DMX ORAL LIQUID 30-1-15 MG/5MLFormularyOTCABILIFY MAINTENA INTRAMUSCULAR PREFILLEDSYRINGE 300 MG, 400 MGFormularyAGE (Min 18 Years)ABILIFY MAINTENA INTRAMUSCULARSUSPENSION RECONSTITUTED ER 300 MG, 400 MGFormularyAGE (Min 18 Years)abiraterone acetate oral tablet 250 mgFormularyABRAXANE INTRAVENOUS SUSPENSIONRECONSTITUTED 100 MGFormularyABREVA EXTERNAL CREAM 10 %Formularyacacia powderFormularyOTCOTC1
Drug NameFormulary Status Requirements/Limitsacamprosate calcium oral tablet delayed release 333 mgFormularyacarbose oral tablet 100 mg, 25 mg, 50 mgFormularyACCU-CHEK FASTCLIX LANCET KITFormularyOTCACCU-CHEK SOFT TOUCH LANCETSFormularyOTC; QL (150 EA per 30 days)ACCU-CHEK SOFTCLIX LANCETSFormularyOTC; QL (150 EA per 30 days)ACCUTREND CHOLESTEROL CONTROL IN VITROSOLUTIONFormularyOTCACCUTREND CHOLESTEROL IN VITRO STRIPFormularyOTCACCUTREND PLUS DEVICEFormularyOTCACE AEROSOL CLOUD ENHANCERFormularyQL (2 EA per 365 days)ACE KNEE BRACE W/STABILIZERSFormularyOTCacebutolol hcl oral capsule 200 mg, 400 mgFormularyACEROLA C 500 ORAL WAFER 500 MGFormularyacesulfame potassium powderFormularyACETA-GESIC ORAL TABLET 12.5-325 MGFormularyOTCacetaminophen oral liquid 160 mg/5mlFormularyOTCacetaminophen oral solution 160 mg/5mlFormularyOTCacetaminophen oral tablet 325 mgFormularyOTCacetaminophen powderFormularyacetaminophen-codeine #2 oral tablet 300-15 mgFormularyPA; QL (280 EA per 7 days)acetaminophen-codeine #3 oral tablet 300-30 mgFormularyPA; QL (140 EA per 7 days)acetaminophen-codeine #4 oral tablet 300-60 mgFormularyPA; QL (70 EA per 7 days)acetaminophen-codeine oral solution 120-12 mg/5mlFormularyPA; QL (1750 ML per 7 days)ACETASOL HC OTIC SOLUTION 2-1 %Formularyacetazolamide crystalsFormularyacetazolamide er oral capsule extended release 12 hour 500mgFormularyacetazolamide oral tablet 250 mgFormularyacetic acid glacial solution 99 %Formularyacetic acid irrigation solution 0.25 %Formularyacetic acid otic solution 2 %Formularyacetic acid solution 3 %Formularyacetone solutionFormularyacetylcysteine inhalation solution 10 %, 20 %Formularyacetyl-l-carnitine hcl powderFormularyACID GONE ORAL SUSPENSION 95-358 MG/15MLFormularyOTCacid reducer maximum strength oral tablet 20 mgFormularyOTCacidophilus oral capsuleFormularyOTCacidophilus probiotic oral tablet 10 mgFormularyOTCacidophilus/bifidus oral tablet chewableFormularyOTCacidophilus/citrus pectin oral tabletFormularyOTCacidophilus/pectin oral capsuleFormularyOTCacitretin oral capsule 10 mg, 17.5 mg, 25 mgFormularyPA; QL (68 EA per 34 days)acne medication 10 external gel 10 %FormularyOTC; AGE (Max 18 Years)2OTCOTCOTC
Drug NameFormulary Status Requirements/Limitsacne medication 10 external lotion 10 %FormularyOTC; AGE (Max 18 Years)acne medication 5 external gel 5 %FormularyAGE (Max 18 Years)acne medication 5 external lotion 5 %FormularyOTC; AGE (Max 18 Years)ACNEFREE ACNE CLEARING SYSTEM EXTERNALKIT 2.5 & 3.7 %FormularyOTCACNEFREE SEVERE CLEARING SYST EXTERNALKIT 2.5 & 10 %FormularyOTCACT TOTAL CARE MOUTH/THROAT SOLUTION 0.05%FormularyOTCACTHIB INTRAMUSCULAR SOLUTIONRECONSTITUTEDFormularyAGE (Min 19 Years)ACTICARNITINE SF ORAL SOLUTION 1 GM/10MLFormularyOTCACTICON ORAL SOLUTION 1-30 MG/5MLFormularyOTCACTICON ORAL TABLET 2-60 MGFormularyOTCactidom dmx oral liquid 10-30-200 mg/5mlFormularyOTCactidose/sorbitol oral liquid 50 gm/240mlFormularyOTCactidose-aqua oral liquid 15 gm/72mlFormularyOTCACTIFLOVIT EAR HEALTH ORAL TABLETFormularyOTCACTIFOAM COLLAGEN SPONGE EXTERNALFormularyacti-lance lite lancets 28gFormularyOTC; QL (150 EA per 30 days)acti-lance special lancets 17gFormularyOTC; QL (150 EA per 30 days)acti-lance universal 23gFormularyOTC; QL (150 EA per 30 days)ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000UNIT/0.5MLFormularyACTINEL ORAL LIQUID 30-15-200 MG/5MLFormularyOTCACTISEP MOUTH/THROAT SOLUTION 2-0.5-0.1 %FormularyOTCACTITROM ORAL CAPSULEFormularyOTCACTIVE Q MAXIMUM STRENGTH ORAL CAPSULE300 MGFormularyOTCACTIVE Q ORAL SYRUP 100 MG/5MLFormularyOTCACTIVE-Q EXTRA STRENGTH ORAL CAPSULE 200MGFormularyOTCACTIVE-Q ORAL CAPSULE 200-30 MGFormularyOTCACTIVITE EC ORAL TABLET 1 MGFormularyOTCACTIVON ARTHRITIS ULTRA ST EXTERNAL STICK0.028-4.574 %FormularyOTCacyclovir external ointment 5 %Formularyacyclovir oral capsule 200 mgFormularyacyclovir oral suspension 200 mg/5mlFormularyacyclovir oral tablet 400 mg, 800 mgFormularyADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5LF-MCG/0.5FormularyADAGEN INTRAMUSCULAR SOLUTION 250UNIT/MLFormularyPAadapalene external cream 0.1 %FormularyAGE (Max 18 Years)adapalene external gel 0.1 %, 0.3 %FormularyAGE (Max 18 Years)3
Drug NameFormulary Status Requirements/LimitsADCIRCA ORAL TABLET 20 MGFormularyPAADDERALL XR ORAL CAPSULE EXTENDEDRELEASE 24 HOUR 10 MG, 15 MG, 5 MGFormularyST; QL (30 EA per 30 days); AGE (Min 4Years and Max 17 Years)ADDERALL XR ORAL CAPSULE EXTENDEDRELEASE 24 HOUR 20 MG, 25 MG, 30 MGFormularyST; QL (60 EA per 30 days); AGE (Min 4Years and Max 17 Years)adefovir dipivoxil oral tablet 10 mgFormularyadenosylcobalamin powderFormularyOTCadhesive bandages sheerFormularyOTCadjustable lancing deviceFormularyOTC; QL (1 EA per 365 days)ADRENAL C FORMULA ORAL TABLETFormularyADRENALIN INJECTION SOLUTION 1 MG/ML, 30MG/30MLFormularyADRUCIL INTRAVENOUS SOLUTION 2.5 GM/50ML, 5GM/100ML, 500 MG/10MLFormularyadult gummy oral tablet chewableFormularyOTCadult mask deviceFormularyQL (2 EA per 365 days)adult wash cloths with aloe external 3 %FormularyOTCadult-lock weekly pill remindFormularyOTCADVAIR DISKUS INHALATION AEROSOL POWDERBREATH ACTIVATED 100-50 MCG/DOSEFormularyAGE (Min 4 Years)ADVAIR DISKUS INHALATION AEROSOL POWDERBREATH ACTIVATED 250-50 MCG/DOSE, 500-50MCG/DOSEFormularyAGE (Min 12 Years)advanced acne wash external liquid extended release 4.4 %FormularyOTCADVANCED CALCIUM/D/MAGNESIUM ORALTABLETFormularyOTCadvanced hand sanitizer external liquid 70 %FormularyOTCADVIL ALLERGY & CONGESTION ORAL TABLET 410-200 MGFormularyOTCADVIL ALLERGY SINUS ORAL TABLET 2-30-200 MGFormularyOTCADVIL COLD & SINUS LIQUI-GELS ORAL CAPSULE30-200 MGFormularyOTCADVIL COLD/SINUS ORAL TABLET 30-200 MGFormularyOTCADVIL ORAL CAPSULE 200 MGFormularyOTCADVIL ORAL TABLET 200 MGFormularyOTCADVIL PM ORAL CAPSULE 200-25 MGFormularyOTCADVIL PM ORAL TABLET 200-38 MGFormularyOTCADVIL SINUS CONGESTION & PAIN ORAL TABLET10-200 MGFormularyOTCADVOCATE INSULIN SYRINGE 29G X 1/2" 0.5 ML29G X 1/2" 0.5 MLFormularyOTCADVOCATE INSULIN SYRINGE 30G X 5/16" 0.3 ML30G X 5/16" 0.3 MLFormularyOTCADVOCATE INSULIN SYRINGE 30G X 5/16" 1 ML 30GX 5/16" 1 MLFormularyOTCADVOCATE INSULIN SYRINGE 31G X 5/16" 1 ML 31GX 5/16" 1 MLFormularyOTCAEROCHAMBER PLUS FLO-VUFormularyQL (2 EA per 365 days)4
Drug NameFormulary Status Requirements/LimitsAEROCHAMBER PLUS FLO-VU LARGEFormularyQL (2 EA per 365 days)AEROCHAMBER PLUS FLO-VU SMALLFormularyQL (2 EA per 365 days)AEROCHAMBER PLUS FLO-VU W/MASKFormularyQL (2 EA per 365 days)AFEDITAB CR ORAL TABLET EXTENDED RELEASE24 HOUR 30 MG, 60 MGFormularyAFLURIA INTRAMUSCULAR SUSPENSIONFormularyAGE (Min 19 Years)AFLURIA PRESERVATIVE FREE INTRAMUSCULARSUSPENSION PREFILLED SYRINGE 0.5 MLFormularyAGE (Min 19 Years)AFREZZA INHALATION POWDER 12 UNIT, 8 UNITFormularyAFRIN CHILDRENS NASAL SOLUTION 0.25 %FormularyOTCAFRIN MENTHOL SPRAY NASAL SOLUTION 0.05 %FormularyOTCAFTERA ORAL TABLET 1.5 MGFormularyOTC; QL (2 EA per 34 days)AGAMATRIX ULTRA-THIN LANCETSFormularyOTC; QL (150 EA per 30 days)AHIST ORAL TABLET 25 MGFormularyOTCaimsco lubricatedFormularyOTCAIRAVITE ORAL TABLET 2.5-25-1 MGFormularyAIRBORNE ORAL LOZENGEFormularyOTCAIRS DISPOSABLE NEBULIZERFormularyOTC; QL (2 EA per 365 days)AIRS DISPOSABLE NEBULIZER KITFormularyQL (2 EA per 365 days)AIRZONE PEAK FLOW METER DEVICEFormularyOTC; QL (2 EA per 365 days)ak-poly-bac ophthalmic ointment 500-10000 unit/gmFormularyAL12 EXTERNAL LOTION 12 %FormularyOTCALA SEB EXTERNAL SHAMPOO 2-2 %FormularyOTCALA SEB T EXTERNAL SHAMPOO 1-2-2 %FormularyOTCALAHIST DM ORAL LIQUID 7.5-2-15 MG/5MLFormularyOTCALA-HIST IR ORAL TABLET 2 MGFormularyOTCALA-HIST PE ORAL TABLET 2-10 MGFormularyOTCalanine 1000 oral packet 1000 mgFormularyOTCalba-lybe nr oral liquid 325-10-50 mg/5mlFormularyOTCalbendazole oral tablet 200 mgFormularyALBOLENE EXTERNAL CREAMFormularyALBUKED 25 INTRAVENOUS SOLUTION 25 %FormularyALBUKED 5 INTRAVENOUS SOLUTION 5 %Formularyalbuterol sulfate er oral tablet extended release 12 hour 4mg, 8 mgFormularyalbuterol sulfate inhalation nebulization solution (2.5mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25mg/3mlFormularyalbuterol sulfate oral syrup 2 mg/5mlFormularyalbuterol sulfate oral tablet 2 mg, 4 mgFormularyalclometasone dipropionate external cream 0.05 %Formularyalclometasone dipropionate external ointment 0.05 %Formularyalcohol (rubbing) solution 70 %FormularyOTCalcohol anhydrous liquidFormularyOTCalcohol prep pad 70 %FormularyOTCOTC; QL (454 GM per 34 days)5
Drug NameFormulary Status Requirements/Limitsalcohol prep pad 70 % 70 %FormularyOTCalcohol swabs padFormularyOTCalcohol swabs pad 70 % 70 %FormularyOTCalcohol wipes pad 70 % 70 %FormularyOTCalcohol, usp solution 95 %Formularyalendronate sodium oral tablet 10 mg, 35 mg, 40 mg, 5 mg,70 mgFormularyaler-cap oral capsule 25 mgFormularyOTCaler-dryl oral tablet 50 mgFormularyOTCalertness aid oral tablet 200 mgFormularyOTCalevazol external ointment 1 %FormularyOTCALEVE ORAL CAPSULE 220 MGFormularyOTCALEVE ORAL TABLET 220 MGFormularyOTCALFERON N INJECTION SOLUTION 5000000UNIT/MLFormularyPAalfuzosin hcl er oral tablet extended release 24 hour 10 mgFormularyalga oral capsule 0.225-2000 mg-unitFormularyOTCALGAL-900 DHA ORAL CAPSULE 300 MGFormularyOTCALIMTA INTRAVENOUS SOLUTIONRECONSTITUTED 100 MG, 500 MGFormularyALIVE MULTI-VITAMIN CHILDRENS ORAL TABLETCHEWABLE 60 MGFormularyOTCALIVIO EXTERNAL PATCH 0.03-5 %FormularyOTCalka-aid oral tablet 180-360 mgFormularyOTCALKA-SELTZER HEARTBURN GAS ORAL TABLETCHEWABLE 750-80 MGFormularyOTCALKA-SELTZER ORAL TABLET EFFERVESCENT325-1000-1916 MGFormularyOTCall day allergy childrens oral solution 5 mg/5mlFormularyOTCall day pain relief oral tablet 220 mgFormularyOTCallantoin powderFormularyALL-DRY SIZE 3FormularyOTCALLEGRA ALLERGY CHILDRENS ORALSUSPENSION 30 MG/5MLFormularyOTCALLEGRA ALLERGY CHILDRENS ORAL TABLETDISPERSIBLE 30 MGFormularyOTCALLEGRA ALLERGY ORAL TABLET 180 MG, 60 MGFormularyOTCALLEGRA-D ALLERGY & CONGESTION ORALTABLET EXTENDED RELEASE 12 HOUR 60-120 MGFormularyOTCALLEGRA-D ALLERGY & CONGESTION ORALTABLET EXTENDED RELEASE 24 HOUR 180-240 MGFormularyOTCaller-ease oral tablet 60 mgFormularyOTC; QL (68 EA per 34 days)allergy childrens oral liquid 12.5 mg/5mlFormularyOTCallergy eye ophthalmic solution 0.025-0.3 %FormularyOTCallergy multi-symptom day/nght oralFormularyOTCallergy spray 24 hour aerosol 55 mcg/act nasal 55 mcg/actFormularyOTC6
Drug NameFormulary Status Requirements/LimitsALLEVYN PLUS CAVITY PAD 6"X8"FormularyOTCALLI ORAL CAPSULE 60 MGFormularyOTCallopurinol oral tablet 100 mg, 300 mgFormularyALMACONE ORAL TABLET CHEWABLE 200-200-25MGFormularyalmond oil bitter flavor liquidFormularyALOCANE PLUS EXTERNAL GEL 4-0.13 %FormularyOTCALOE GRANDE EXTERNAL CREAM 100000-1500UNIT/GMFormularyOTCALOE GRANDE EXTERNAL LOTION 10000-1500UNIT/30MLFormularyOTCaloe vera external cream 72 %FormularyOTCaloe vera external gel 99.5 %FormularyOTCaloe vera freeze dried powderFormularyaloe vera moisturizing external gel 99.5 %FormularyOTCALOE VESTA 2-N-1 PROTECTIVE EXTERNALOINTMENTFormularyOTCALOE VESTA CLEAR ANTIFUNGAL EXTERNALOINTMENT 2 %FormularyOTCALOE VESTA MULTI PURPOSE EXTERNAL FOAMFormularyOTCALOE VESTA PROTECTIVE EXTERNAL OINTMENTFormularyOTCALOE VESTA SKIN PROTECTANT EXTERNALAEROSOL 36 %FormularyOTCaloe/lidocaine pain reliever external gel 0.5 %FormularyOTCalosetron hcl oral tablet 0.5 mg, 1 mgFormularyPAalp high3 oral capsule delayed release 600 mgFormularyOTCALPAWASH EXTERNAL OINTMENTFormularyALPHAGAN P OPHTHALMIC SOLUTION 0.1 %, 0.15%Formularyalpha-lipoic acid oral capsule 100 mgFormularyOTCalpha-lipoic acid oral tablet 200 mgFormularyOTCalpha-lipoic acid powderFormularyALPHANATE/VWF COMPLEX/HUMANINTRAVENOUS SOLUTION RECONSTITUTED 1000UNIT, 1500 UNIT, 250 UNIT, 500 UNITFormularyALPHANINE SD INTRAVENOUS SOLUTIONRECONSTITUTED 1000 UNIT, 500 UNITFormularyalph-e oral capsule 400 unitFormularyOTCalph-e-mixed 1000 oral capsule 1000 unitFormularyOTCalph-e-mixed oral capsule 200 unitFormularyOTCalprazolam er oral tablet extended release 24 hour 0.5 mg,1 mg, 2 mgFormularyQL (170 EA per 30 days)alprazolam er oral tablet extended release 24 hour 3 mgFormularyQL (170 EA per 34 days)ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1MG/MLFormularyQL (170 ML per 34 days)alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mgFormularyQL (170 EA per 34 days)OTC7
Drug NameFormulary Status Requirements/Limitsalprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2mgFormularyALTACAINE OPHTHALMIC SOLUTION 0.5 %FormularyALTAFLUOR OPHTHALMIC SOLUTION 0.25-0.4 %FormularyALTAVERA ORAL TABLET 0.15-30 MG-MCGFormularyQL (28 EA per 28 days)alum ammonium powderFormularyOTCaluminum acetate external solutionFormularyOTCaluminum bottle sealFormularyOTCaluminum chloride hexahydrate crystalsFormularyaluminum chloride hexahydrate powderFormularyaluminum chlorohydrate powderFormularyaluminum hydroxide dried gel powderFormularyaluminum hydroxide gel oral suspension 320 mg/5mlFormularyALVESCO INHALATION AEROSOL SOLUTION 160MCG/ACT, 80 MCG/ACTFormularyALWAYS MAXI MAXIMUM PROTECTION PADFormularyOTCalyacen 1/35 oral tablet 1-35 mg-mcgFormularyQL (28 EA per 28 days)alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcgFormularyQL (28 EA per 28 days)amantadine hcl oral capsule 100 mgFormularyamantadine hcl oral syrup 50 mg/5mlFormularyamantadine hcl oral tablet 100 mgFormularyambi 12.5cpd/100gfn/30pse oral liquid 30-12.5-100 mg/5mlFormularyOTCambi 12.5cpd/1dcpm/30pse oral liquid 30-1-12.5 mg/5mlFormularyOTCambi 40pse/400gfn oral tablet 40-400 mgFormularyOTCambi 60pse/400gfn oral tablet 60-400 mgFormularyOTCambi 60pse/4cpm oral tablet 60-4 mgFormularyOTCAMBI FADE EXTERNAL CREAM 2 %FormularyOTCamcinonide external cream 0.1 %FormularyAMERICERIN EXTERNAL CREAMFormularyOTCAMERIWASH EXTERNAL LOTIONFormularyOTCAMETHIA LO ORAL TABLET 0.1-0.02 & 0.01 MGFormularyQL (91 EA per 91 days)AMETHIA ORAL TABLET 0.15-0.03 &0.01 MGFormularyQL (91 EA per 91 days)AMETHYST ORAL TABLET 90-20 MCGFormularyQL (28 EA per 28 days)AMICAR ORAL SOLUTION 0.25 GM/MLFormularyamiloride hcl oral tablet 5 mgFormularyamiloride-hydrochlorothiazide oral tablet 5-50 mgFormularyaminoacetic acid irrigation solution 1.5 %FormularyAMINOPMRMS ORAL CAPSULEFormularyAMINORELIEF RMS ORAL CAPSULEFormularyaminosalicylic acid-5 powderFormularyamiodarone hcl oral tablet 100 mg, 200 mg, 400 mgFormularyAMITIZA ORAL CAPSULE 24 MCG, 8 MCGFormularyamitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg,50 mg, 75 mgFormulary8QL (170 EA per 34 days)OTCPA; AGE (Min 18 Years)
Drug NameFormulary Status Requirements/Limitsamlodipine besy-benazepril hcl oral capsule 10-20 mg, 1040 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mgFormularyamlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mgFormularyamlodipine besylate-valsartan oral tablet 10-160 mg, 10320 mg, 5-160 mg, 5-320 mgFormularyamlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg,10-40 mg, 5-10 mg, 5-20 mg, 5-40 mgFormularyamlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mgFormularySTammonia aromatic inhalation inhalerFormularyOTCammonia aromatic inhalation spiritFormularyOTCammonium carbonate powderFormularyOTCammonium chloride granulesFormularyammonium hydroxide solutionFormularyammonium lactate external cream 12 %Formularyamoxicillin oral capsule 250 mg, 500 mgFormularyamoxicillin oral suspension reconstituted 125 mg/5ml, 200mg/5ml, 250 mg/5ml, 400 mg/5mlFormularyamoxicillin oral tablet 500 mg, 875 mgFormularyamoxicillin oral tablet chewable 125 mg, 250 mgFormularyamoxicillin-pot clavulanate oral suspension reconstituted200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 60042.9 mg/5mlFormularyamoxicillin-pot clavulanate oral tablet 250-125 mg, 500125 mg, 875-125 mgFormularyamoxicillin-pot clavulanate oral tablet chewable 200-28.5mg, 400-57 mgFormularyamphetamine-dextroamphetamine oral tablet 10 mg, 12.5mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mgFormularyampicillin oral capsule 500 mgFormularyANA-LEX RECTAL KIT 2-2 %FormularyANASEPT ANTIMICROBIAL EXTERNAL GEL 0.057 %FormularyANASEPT EXTERNAL LIQUID 0.057 %Formularyanastrozole oral tablet 1 mgFormularyANBESOL MAXIMUM STRENGTH MOUTH/THROATLIQUID 20 %FormularyOTCANBESOL MOUTH/THROAT GEL 10 %FormularyOTCANBESOL MOUTH/THROAT LIQUID 10 %FormularyOTCANDROGEL PUMP TRANSDERMAL GEL 20.25MG/ACT (1.62%)FormularyPAANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM(1.62%), 25 MG/2.5GM (1%), 40.5 MG/2.5GM (1.62%),50 MG/5GM (1%)FormularyPAANECREAM EXTERNAL CREAM 4 %FormularyOTCanimal chews oral tablet chewableFormularyOTCanise oilFormularyOTCANORO ELLIPTA INHALATION AEROSOL POWDERBREATH ACTIVATED 62.5-25 MCG/INHFormularyAGE (Min 18 Years)AGE (Min 4 Years and Max 17 Years)OTC9
Drug NameFormulary Status Requirements/Limitsantacid anti-gas max strength oral suspension 400-400-40mg/5mlFormularyOTCantacid anti-gas oral suspension 200-200-20 mg/5mlFormularyOTCantacid extra strength oral tablet chewable 675-135 mgFormularyOTCantacid multi-symptom oral tablet chewable 675-135-60 mgFormularyOTCantacid oral tablet chewable 500 mgFormularyOTCantacid soft chews oral tablet chewable 1177 mgFormularyOTCANTARA ORAL CAPSULE 30 MG, 90 MGFormularyanthelios 50 mineral external liquidFormularyOTCanti-allergy oral tablet 100-100-50 mgFormularyOTCantibacterial liquid soap external liquid 0.15 %FormularyOTCanti-diarrheal oral liquid 1 mg/5mlFormularyOTCanti-diarrheal oral tablet 2 mgFormularyOTCantifungal external ae
AEROCHAMBER PLUS FLO-VU LARGE. Formulary: QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU SMALL: Formulary. QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU W/MASK. Formulary: QL (2 EA per 365 days) AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG: Formulary. AFLURIA
