non-covered medications · exoderm®´´ extendryl ®´´ extendryl dm®´´ extendryl hc ®´´...

Non-covered M

edications

1�

(QCD) Quality Care Dosing limits apply for members with approved formulary exceptions(ST) step therapy required for members with approved formulary exceptions(PA) prior authorization required for members with approved formulary exceptions

Non-covered Medications

Your�BlueValue�Rx�Pharmacy�Program�provides�coverage�for�over��,�00�prescription�medications��Most�medications�on�our�non-covered�list�have�equally�safe,�effective,�covered�alternatives�for�treating�the�same�medical�conditions��Check�with�your�doctor�about�appropriate�alternatives�if�you�currently�take�any�of�these�medications��

For�the�most�up-to-date�list�of�medications�that�are�not�covered�and�their�covered�alternatives,�visit�our�website�at�www.bluecrossma.com,�click�on�Pharmacy�Program,�and�proceed�to�the�Medications�That�Are�Not�Covered�section��

Please note: Your doctor may request coverage for a non-covered medication if no covered alternative is appropriate for treating your condition.

Non-covered Medication ListThis list of non-covered medications is up-to-date as of 3/1/07, and may change from time to time.

�,4-Dinitrochlorobenzene®´´

A-Hydrocort®´´

A-Methapred®´´

A/T/S®´´

Abelcet®´´

Aber-Fed®´´

Aber-Tuss�DR®´´

Abilify®´´�Discmelt™

Abraxane®´´

Accolate®´´�(ST)

Accuhist®´´

Accuhist�DM®´´

Accuhist�PDX®´´

Accuneb®´´

Accupril®´´

Accuretic®´´

Accutane®´´

Accuzyme®´´

Acd-A®´´

Aceon®´´

Acid�Jelly®´´

Aciphex®´´�(QCD) (ST)

Aclaro®´´

Aclovate®´´

Acthar�HP®´´

Acthrel®´´

Actigall®´´

Activase®´´

Activella®´´

Acuflex®´´

Acular®´´�(QCD)

Acular�LS®´´�(QCD)

Acular�PF®´´�(QCD)

Acunol®´´

Adagen®´´

Adalat�CC®´´

NonCovered.indd 12 2007-01-05 4:33:15 PM

13

Non-covered M

edications


Adderall®´´

Adderall�XR®´´�(QCD)

Adeflor�M®´´

Adenocard®´´

Adenoscan®´´

Adenosine�Phosphate®´´

Adoxa®´´

Adoxa�Pak®´´

Adrenalin�Chloride�Injection®´´

Adrenalin�Chloride�Nasal�Solution®´´

Adriamycin�RDF®´´

Aerobid®´´�(QCD)

Aerobid-M®´´�(QCD)

Aerokid®´´

AeroTuss�1�®´´

Aggrastat®´´

Aggrenox®´´

Agrylin®´´

Ah-Chew®´´

Ah-Chew�II®´´

Ah-Chew�D®´´

Ahist®´´

Airet®´´

Ak-Taine®´´

Akineton®´´

Akne-Mycin®´´

Ala-Quin®´´

Ala-Scalp�HP®´´

Ala-Tet®´´

Alacol®´´

Alamast®´´�(QCD)

Alba-3®´´

Albafort®´´

Albafort�S®´´

Albalon®´´

Albalybe®´´

Albatussin®´´

Albatussin�CF®´´

Albatussin�DM®´´

Albatussin�NN®´´

Albatussin-NN®´´

Albatussin�Pediatric®´´

Albatussin�SR®´´

Albatussin�SR�F®´´

Albatussin�SR�Senior®´´

Albuterol�Sulfate�1��5/3ml�Solution®´´

Alcaine®´´

Alcet®´´

Alcortin®´´

Aldactazide®´´

Aldactone®´´

Aldex®´´

Aldex�CT®´´

Aldex�D®´´

Aldex�DM®´´

Aldex�G®´´

Aldoclor-�50®´´

Aldomet®´´

Aldoril-�5®´´

Aldoril-D50®´´

Alesse®´´

Allclenz®´´

Allegra®´´�(QCD)

Allegra-D�1��Hour®´´�(QCD)

Allegra-D��4�Hour®´´�(QCD)

Allepak®´´

Allertan®´´

AlleRx®´´

AlleRx-D®´´

AlleRx�PE®´´

Allfen®´´

Allfen�C®´´

Allfen�CX®´´

Allfen-DM®´´

Allfen�Jr®´´

Alocril®´´�(QCD)

Alomide®´´�(QCD)

Aloprim®´´

Alphagan�P®´´

Alphatrex®´´

Alrex®´´�(QCD)

Altace®´´

Altafluor®´´

Altoprev®´´�(ST)

Alupent®´´�(QCD)

Amaryl®´´

Ambi®´´

Ambien�CR®´´�(QCD) (ST)

Ambifed-G®´´

Ambifed-G�DM®´´

Ambisome®´´

Amerge®´´�(QCD)

Amerifed®´´

Amerifed�DM®´´


Non-covered M

edications

14


Amerituss�AD®´´

Amicar®´´

Amikin®´´

Amikin�Pediatric®´´

Aminess®´´

Amino�Acid�Cervical®´´

Amino-Cerv®´´

Aminosyn®´´

Aminosyn�II®´´

Aminosyn�II�in�Dextrose®´´

Aminosyn�II�w/Elec�in�Dex�w/Ca®´´

Aminosyn-HBc®´´

Aminosyn-HF®´´

Aminosyn�M®´´

Aminosyn-PF®´´

Aminosyn-RF®´´

Aminosyn�w/Electrolytes®´´

Amitiza®´´

Ammonium�Chloride�Injection®´´

Amoxil®´´

Amphocin®´´

Amphotec®´´

Amytal�Sodium�Injection®´´

Anacaine®´´

Anadrol-50®´´

Anafranil®´´

Analpram�HC®´´

Anamantle�HC®´´

Anamantle�HC�Forte®´´

Anana�Forte®´´

Anaplex�DM®´´

Anaplex�DMX®´´

Anaplex�HD®´´

Anaprox®´´

Anaprox�DS®´´

Anaspaz®´´

Ancef®´´

Andehist®´´

Andehist�DM®´´

Androderm®´´

Androgel®´´

Android®´´

Anectine®´´

Anemagen�OB®´´

Anergan�50®´´

Anestacon®´´

Anexsia®´´

Angeliq®´´

Angiomax®´´

Ansaid®´´

Antara®´´

Antibiotic�HC®´´

Antivert�1��5mg�Tablets®´´

Antizol®´´

Anusol-HC®´´

Anzemet®´´�(QCD)

Apexicon®´´

Apexicon�E®´´

Aphthasol®´´

Apidra®´´

Apokyn®´´

Apresoline®´´

Aquachloral®´´

Aquaphilic�w/Triamcinolone®´´

Aquasol�A®´´

Aquatab�C®´´

Aquatab�D®´´

Aquatab�DM®´´

Aralen�Phosphate®´´

Aramine®´´

Arava®´´�(QCD)

Aredia®´´

Aridex®´´

Aristocort®´´

Aristocort�A®´´

Aristocort�Forte®´´

Aristocort�HP®´´

Aristospan®´´

Armour�Thyroid®´´

Arthrotec®´´

Ascensia�Autodisc®´´�(QCD)

Ascensia�Contour®´´�(QCD)

Ascensia�Elite®´´�(QCD)

Asmanex®´´�(QCD)

Asthmapack�II®´´

Astramorph®´´

At�Last�Test�Strips®´´

Atabex®´´

Atacand®´´�(ST)

Atacand�HCT®´´�(ST)

Atgam®´´

Ativan®´´

Atopiclair®´´

Atrovent�Nasal�Spray®´´�(QCD)


15

Non-covered M

edications


Atuss-1��DM®´´

Atuss-1��DX®´´

Atuss�DR®´´

Atuss�DS®´´

Atuss�G®´´

Atuss�HC®´´

Atuss�HD®´´

Atuss�HS®´´

Atuss�HX®´´

Atuss�MR®´´

Atuss�MS®´´

Atuss�NX®´´

Augmentin®´´

Augmentin�ES-600®´´

Augmentin�XR®´´

Avage®´´

Avalide®´´�(ST)

Avandaryl®´´

Avar®´´

Avar-E®´´

Avc®´´

Avinza®´´

Avita®´´

Avodart®´´

Axert®´´�(QCD)

Axid®´´

Axocet®´´

Aygestin®´´

Azactam®´´

Azasan®´´

Azelex®´´

Azmacort®´´�(QCD)

Azopt®´´

Azulfidine®´´

B�&�O�Supprettes®´´

Bacmin®´´

Bactocill®´´

Bactrim®´´

Bactrim�DS®´´

Bactroban®´´

Bactroban�Nasal®´´

Bal�in�Oil®´´

Balacet®´´

Balamine�DM®´´

Baltussin®´´

Barbidonna®´´

Baros�Granules®´´

Beconase�AQ®´´�(QCD)

Benadryl�Injection®´´

Benicar�HCT®´´�(ST)

Benoquin®´´

Bensal�HP®´´

Bentyl®´´

Benzac�AC®´´

Benzac�W®´´

Benzac�W�Wash®´´

Benzaclin®´´

Benzagel-5®´´

Benzamycin®´´

Benzamycinpak®´´

Benzashave®´´

Benziq®´´

Benziq�LS®´´

Benzotic®´´

Benzyl�Benzoate®´´

Betac®´´

Betadine®´´

Betagan®´´

Betapace®´´

Betapace�AF®´´

Betatan®´´

Betavent®´´

Betimol®´´

Betoptic�S®´´

Biafine®´´

Biafine�RE®´´

Biaxin®´´

Biaxin�XL®´´

Bichloracetic�Acid®´´

Bicillin�C-R®´´

Bicillin�L-A®´´

Bicitra®´´

Bicnu®´´

Bidex�DM®´´

Bidil®´´

Biltricide®´´

Bio-Statin®´´

Bio-Throid®´´

Biodec®´´

Biodec-DM®´´

Biohist-LA®´´

Bionect®´´

Biotuss®´´

Blenoxane®´´

Bleph-10®´´

Blephamide®´´


Non-covered M

edications

16


Blephamide�SOP®´´

Blocadren®´´

Boniva®´´�(QCD)

Branchamin®´´

Brethine®´´

Brevicon®´´

Brevoxyl®´´

Brofed®´´

Bromfed®´´

Bromfed-DM®´´

Bromfed-PD®´´

Bromphed-PD®´´

Broncap®´´

Broncholate®´´

Broncodur®´´

Broncomar-1®´´

Broncomar�GG®´´

Broncopectol®´´

Broncotron-D®´´

Brondil®´´

Bronkophylline�GG®´´

Bronkosol®´´

Brontex®´´

Brontuss�SF®´´

Brovex®´´

Brovex�Ct®´´

Brovex-D®´´

Brovex�HC®´´

Brovex�SR®´´

Bss®´´

Bss�Plus®´´

Bucalcide®´´

Bucalsep®´´

Bumex®´´

Buprenex®´´

Buspar®´´

Busulfex®´´

Butisol�Sodium®´´

Caduet®´´�(QCD)

Cafergot®´´

Calafol�Rx®´´

Calan®´´

Calan�SR®´´

Calci-Max®´´

Calcifol®´´

Calcijex®´´

Calphosan®´´

Campath®´´

Camptosar®´´

Canasa®´´

Cantil®´´

Capastat®´´

Capex�Shampoo®´´

Caphosol®´´

Capital�w/Codeine®´´

Capitrol®´´

Capoten®´´

Capozide®´´

Carac®´´

Carafate®´´

Carba-XP®´´

Carbaphen�1�®´´

Carbaphen�1��Ped®´´

Carbastat®´´

Carbatab�1�®´´

Carbatrol®´´

Carbatuss�1�®´´

Carbatuss-CL®´´

Carbocaine®´´

Carboxine-PSE®´´

Cardene®´´

Cardene�SR®´´

Cardiodoron®´´

Cardiotek�Rx®´´

Cardizem®´´

Cardizem�Cd®´´

Cardizem�LA®´´

Cardizem�SR®´´

Cardura®´´�(QCD)

Cardura�XL®´´�(QCD)

Carmol®´´

Carmol�40®´´

Carmol�HC®´´

Carmol�Scalp®´´

Carnitor®´´

Caromega®´´

Cataflam®´´

Catapres®´´

Catapres-Tts®´´�(QCD)

Caverject®´´

Cavirinse®´´

Cebocap®´´

Ceclor®´´

Cedax®´´

Cefizox®´´

Cefol®´´


17

Non-covered M

edications


Cefotan®´´

Ceftin®´´

Cefzil®´´

Celebrex®´´�(QCD) (ST)

Celestone®´´

Celexa®´´�(QCD) (ST)

Cenestin®´´

Cenocort�A-40®´´

Cenocort�Forte�Suspension®´´

Cenogen�Ultra®´´

Cenolate®´´

Centany®´´

Cephradine��50mg�Capsule®´´

Cerebyx®´´

Cerefolin®´´

Cerefolin�Nac®´´

Certuss®´´

Certuss-D®´´

Cerubidine®´´

Cerumenex®´´

Cervidil®´´

Cesamet™

Cetacaine®´´

Cetacort®´´

Chlordex�Gp®´´

Chloromycetin®´´

Choleodoron®´´

Cialis®´´

Ciloxan®´´

Cipro®´´

Cipro�XR®´´

Ciprodex®´´

Citracal�Prenatal�+�DHA®´´

Citracal�Prenatal�Rx®´´

Citrolith®´´

Claforan®´´

Clarinex®´´�(QCD)

Clarinex-D�1��Hour®´´�(QCD)

Clarinex-D��4�Hour®´´�(QCD)

Claripel®´´

Clenia®´´

Cleocin®´´

Cleocin�Ovule®´´

Cleocin�T®´´

Climara®´´�(QCD)

Climara�Pro®´´

Clinac�Bpo®´´

Clindagel®´´

Clindamax®´´

Clindesse®´´

Clindets®´´

Clinimix®´´

Clinimix�E®´´

Clinisol®´´

Clinoril®´´

Clobevate®´´

Clobex®´´

Cloderm®´´

Clomid®´´

Clorpres®´´

Clozaril®´´

Codiclear�Dh®´´

Codimal-A®´´

Codimal�Dh®´´

Codimal�LA®´´

Cogentin®´´

Cognex®´´

Colazal®´´

Coldamine®´´

Colestid®´´

Colocort®´´

Coly-Mycin�M®´´

Coly-Mycin�S®´´

Colyte®´´

Colyte�with�Flavor�Packets®´´

Colytrol®´´

Combipatch®´´

Combunox®´´

Comhist®´´

Compazine®´´

Condylox®´´

Conex®´´

Conison®´´

Conpec®´´

Conpec�LA®´´

Cophene-B®´´

Cordarone®´´

Cordran®´´

Cordran�Sp®´´

Cordron-D®´´

Cordron-DM®´´

Cordron-HC®´´

Corgard®´´

Corlopam®´´


Non-covered M

edications

18


Cormax®´´

Cortane-B®´´

Cortef®´´

Cortifoam®´´

Cortisporin®´´

Cortisporin-TC®´´

Cortrosyn®´´

Corvert®´´

Corvite®´´

Corzide®´´

Cosmegen®´´

Cosopt®´´

Covera-Hs®´´

Cozaar®´´�(ST)

Creon®´´

Cresylate®´´

Crinone®´´

Crofab®´´

Crolom®´´�(QCD)

Cutivate®´´

Cyclessa®´´

Cyclocort®´´

Cyclogyl®´´

Cyclomydril®´´

Cyklokapron®´´

Cylert®´´

Cystospaz®´´

Cystospaz-M®´´

Cytarabine®´´

Cytotec®´´

Cytovene®´´

Cytoxan®´´

D-Feda�II®´´

Dallergy®´´

Dallergy-Jr®´´

Dalmane®´´

Danocrine®´´

Darvocet�A500®´´

Darvocet-N®´´

Darvon®´´

Darvon�Compound®´´

Darvon-N®´´

Daunoxome®´´

Daypro®´´

Dayto-Sulf®´´

Daytrana®´´

Ddavp®´´

Decadron®´´

Decahist-DM®´´

Declomycin®´´

Decon-G®´´

Deconamine®´´

Deconamine�SR®´´

Deconex®´´

Deconsal�II®´´

Deconsal�CT®´´

Deconsal�DM®´´

Deka®´´

Del-Mycin®´´

Delatestryl®´´

Delestrogen®´´

Delflex�w/Dextrose®´´

Deltuss�DMX®´´

Demadex®´´

Demerol®´´

Demulen®´´

Denavir®´´

Depacon®´´

Depakene®´´

Depen®´´

Depo-Medrol®´´

Depo-Provera®´´

Depo-Subq�Provera�104®´´

Depo-Testosterone®´´

Depocyt®´´

Derma-Cas®´´

Derma-Smoothe/Fs®´´

Dermatop®´´

Dermotic®´´

Desferal®´´

Desogen®´´

Desowen®´´

Desoxyn®´´

Despec®´´

Despec�DM®´´

Despec�SR®´´

Desquam-E®´´

Desquam-X®´´

Desyrel®´´

Dex,�PC®´´

Dexacen�LA®´´

Dexacidin®´´

Dexchlorpheniramine�Syrup®´´

Dexedrine®´´

Dexedrine�Spansule®´´


1�

Non-covered M

edications


Dexpak®´´

Dexpak�Jr®´´

Dextrostat®´´

DHE�45®´´

Dht®´´

Diabeta®´´

Diabetic�Tussin�C®´´

Diabinese®´´

Diamox�Sequels®´´

Dicel®´´

Differin®´´

Difil-G®´´

Difil-G�Forte®´´

Diflucan®´´

Digesplen�Plus®´´

Digex®´´

Digoxin®´´

Dilacor�XR®´´

Dilatrate-SR®´´

Dilaudid®´´

Dilaudid-HP®´´

Dilex-G®´´

Dimethyl�Sulfoxide®´´

Diovan�HCT®´´�(ST)

Dipentum®´´

Diprolene®´´

Diprolene�AF®´´

Diprosone®´´

Disalcid®´´

Disophrol®´´

Dispermox®´´

Ditropan®´´

Ditropan�XL®´´

Diuril®´´

DMax®´´

Dobutrex®´´

Dolgic�LQ®´´

Dolgic�Plus®´´

Dolobid®´´

Dologesic®´´

Dolophine®´´

Dolorex®´´

Domeboro®´´

Dometuss�DM®´´

Donatussin®´´

Donatussin�DC®´´

Donatussin�DM®´´

Donatussin�Max®´´

Donnamar®´´

Donnatal®´´

Doral®´´

Doryx®´´

Dostinex®´´�(QCD)

Dovonex®´´

Doxil®´´

Drisdol®´´

Dritho-Scalp®´´

Drituss�DM®´´

Drituss�HD®´´

Drize-R®´´

Drocon-Cs®´´

Droperidol®´´

Droxia®´´

Drysol®´´

Drysol�Dab-O-Matic®´´

Dtic-Dome�IV®´´

Duac®´´

Duet®´´

Duet�DHA®´´

Duet�DHA�Stuartnatal®´´

Duet�Stuart�Natal�Chewable®´´

Duet�Stuartnatal®´´

Duoneb®´´

Duotan®´´

Durabac®´´

Durabac�Forte®´´

Duraclon®´´

Duradex®´´

Duradex�Forte®´´

Duraflu®´´

Duragesic®´´

Durahist®´´

Durahist�D®´´

Durahist�PE®´´

Duramorph®´´

Duraphen�1000®´´

Duraphen�II®´´

Duraphen�II�DM®´´

Duraphen�DM®´´

Duraphen�Forte®´´

Duratan�DM®´´

Duratan�Forte®´´

Duratan�PE®´´

Duratuss®´´

Duratuss�DM®´´


Non-covered M

edications

�0


Duratuss�Gp®´´

Duratuss�HD®´´

Duraxin®´´

Duricef®´´

Dyazide®´´

Dynabac®´´

Dynacin®´´

Dynacirc®´´

Dynacirc�CR®´´

Dynapen®´´

Dynatuss�Hcg®´´

Dynex®´´

Dynex�HD®´´

Dyrenium®´´

Dytan®´´

Dytan�AT®´´

Dytan-Cs®´´

Dytan-D®´´

Dytan-HC®´´

E-Mycin®´´

Easprin®´´

Ec-Naprosyn®´´

Econopred�Plus®´´

Ed-A-Hist�DM®´´

ED�Cyte�F®´´

Ed-DM®´´

Edecrin®´´

Edex®´´

EES®´´

Efudex®´´

Eldepryl®´´

Elestat®´´�(QCD)

Elimite®´´

Elitek®´´

Elixophyllin®´´

Elixophyllin�GG®´´

Elixophyllin-KI®´´

Ellence®´´

Elmiron®´´

Elocon®´´

Eloxatin®´´

Elspar®´´

Emadine®´´�(QCD)

Emcin�Clear®´´

Emersal®´´

Emgel®´´

Emla®´´

Emsam®´´

Enablex®´´

Encora®´´

Endagen-HD®´´

Endal-HD�Plus®´´

Endo-Avitene®´´

Endrate®´´

Enduron®´´

Enduronyl�Forte®´´

Enjuvia®´´

Enlon®´´

Enlon-Plus®´´

Entex®´´

Entex�ER®´´

Entex�HC®´´

Entex�LA®´´

Entex�PSE®´´

Entuss®´´

Enzymax®´´

Epifoam®´´

Equagesic®´´

Equetro®´´

Ergocaff-PB®´´

Ergomar®´´

Eritrogen®´´

Ertaczo®´´

Eryc®´´

Erycette®´´

Eryderm®´´

Erygel®´´

Eryped®´´

Erysidoron®´´

Erythrocin�Lactobionate®´´

Esgic®´´

Esgic�Plus®´´

Eskalith®´´

Eskalith�CR®´´

Estinyl®´´

Estrace®´´

Estraderm®´´�(QCD)

Estrasorb®´´�(QCD)

Estratest®´´

Estratest�HS®´´

Estring®´´

Estro-5®´´

Estrogel®´´�(QCD)

Estrostep�FE®´´

Ethamolin®´´

Ethedent®´´


�1

Non-covered M

edications


Ethezyme®´´

Ethyol®´´

Etopophos®´´

Eudal-SR®´´

Euflexxa®´´

Eulexin®´´

Evoclin®´´

Evoxac®´´

Exactacain®´´

Excof®´´

Excof-SF®´´

Exelderm®´´

Exjade®´´

Exoderm®´´

Extendryl®´´

Extendryl�DM®´´

Extendryl�HC®´´

Extendryl�Jr®´´

Extendryl�SR®´´

Ezol®´´

Factive®´´

Famvir®´´�(QCD)

Fansidar®´´

Fareston®´´

Faslodex®´´

Fast�Take�Test�Strips®´´�(QCD)

Fazaclo®´´

Feldene®´´

Femcon�FE®´´

Femhrt®´´

Femring®´´

Femtabs®´´

Femtrace®´´

Fenesin�DM®´´

Fertinex®´´

Finacea®´´

Fioricet®´´

Fioricet�w/Codeine®´´

Fiorinal®´´

Fiorinal�w/Codeine�#3®´´

First-Hydrocortisone®´´

First-Mouthwash�BLM®´´

First-Progesterone�MC®´´

First-Testosterone®´´

First-Testosterone�MC®´´

Flagyl®´´

Flagyl�ER®´´

Flarex®´´

Flexeril®´´

Flextra®´´

Flextra-DS®´´

Flolan®´´

Flonase®´´�(QCD)

Flor-Dac®´´

Florinef�Acetate®´´

Floxin®´´

Flucaine®´´

Fludara®´´

Flumadine®´´

Fluor-A-Day®´´

Fluor-Op®´´

Fluorabon®´´

Fluoracaine®´´

Fluorets®´´

Fluori-Methane®´´

Fluoritab®´´

Flura®´´

Flura-Drops®´´

Flura-Tab®´´

Flurate®´´

Fluress®´´

Fluro-Ethyl®´´

Flutuss�HC®´´

Flutuss�XP®´´

Fml®´´

Fml�Forte®´´

Fml-S®´´

Fml�SOP®´´

Focalin®´´

Focalin�XR®´´

Follistim®´´

Follistim®´´�AQ

Folysine®´´

Foradil®´´�(QCD)

Forma-Ray®´´

Formadon®´´

Formalyde-10®´´

Fortamet®´´

Fortaz®´´

Fosamax®´´�(QCD)

Fosamax�Plus�D®´´�(QCD)

Foscavir®´´

Freamine�III®´´

Freamine�III�w/Electrolytes®´´


Non-covered M

edications

��


Freestyle®´´�Test�Strips�(QCD)

Frenadol®´´

FreshKote®´´

Frova®´´�(QCD)

Fulvicin�U/F®´´

Gabarone®´´

Galzin®´´

Ganirelix�Acetate®´´

Garamycin®´´

Garylin®´´

Gastrinex®´´

Gastrocrom®´´

Gel-Kam®´´

Gelclair®´´

Gemzar®´´

Genecof-HC®´´

Genelan®´´

Genexpect�DM®´´

Genexpect-PE®´´

Genexpect-SF®´´

Genoptic®´´

Genoptic�SOP®´´

Gentafair®´´

Gentex�HC®´´

Gentex�LA®´´

Gentex�LQ®´´

Geocillin®´´

Geodon®´´

Gilchew�IR®´´

Gilphex�Tr®´´

Giltuss®´´

Giltuss�HC®´´

Giltuss�Ped-C®´´

Giltuss�Pediatric®´´

Giltuss�Tr®´´

Glucolet�Endcaps®´´

Glucometer�Dex®´´�(QCD)

Glucometer�Elite®´´�(QCD)

Glucometer�Encore®´´�(QCD)

Glucophage®´´

Glucophage�XR®´´

Glucotrol®´´

Glucotrol�XL®´´

Glucovance®´´

Glumetza™

Glutofac-MX®´´

Glutofac-ZX®´´

Glynase®´´

Glyset®´´

Golytely®´´

Goniosol®´´

Gordo-Urea®´´

Gordofilm®´´

Granulex®´´

Grifulvin�V®´´

Guaifed®´´

Guaifed-PD®´´

Guaimax-D®´´

Guanidine®´´

Gynazole-1®´´

Gynodiol®´´

H��600�SR®´´

Halcion®´´

Haldol®´´

Haldol�Decanoate®´´

Halflytely®´´

Halflytely�with�Flavor�Packs®´´

Halog®´´

HDc�DM®´´

Helidac®´´

Hemorrhoidal®´´

Hep-Lock®´´

Hepatamine®´´

Hepatasol®´´

Herceptin®´´

Hexafed®´´

Hexaflu®´´

Hextend�Lactated�Electrolyte®´´

Hiprex®´´

Histade�MX®´´

Histalet®´´

Histamax�D®´´

Histatab�Plus®´´

Histex®´´

Histex�Ct®´´

Histex�HC®´´

Histex�IE®´´

Histex�PD®´´

Histex�PD�1�®´´

Histex�SR®´´

Histor-D®´´

Histussin�D®´´

Histussin�HC®´´

HPr�End®´´


�3

Non-covered M

edications


Humatin®´´

Humibid®´´

Humibid�DM®´´

Humorsol®´´

Hyalgan®´´

Hycamtin®´´

Hycet®´´

Hycodan®´´

Hycotuss®´´

Hydrea®´´

Hydro-Tussin�DM®´´

Hydro,�PC�II®´´

Hydrocet®´´

Hydrochlorothiazide�Oral�Solution

Hydrocortisone�Sod�Succinate

Hylira™

Hyperlyte®´´

Hyperlyte�CR®´´

Hyperlyte�R®´´

Hyperstat�IV®´´

Hytan®´´

Hytone®´´

Hytrin®´´�(QCD)

Hyzaar®´´�(ST)

Ib-Stat®´´

Icar-C�Plus�SR®´´

Icar�Prenatal®´´

Idamycin�PFS®´´

Ifex®´´

Ifex/Mesnex®´´

Ilopan�Injection®´´

Imdur®´´

Imitrex®´´�(QCD)

Imodium®´´

Imuran®´´

Increlex®´´

Inderal®´´

Inderide®´´

Indocin®´´

Indocin�SR®´´

Inflamase�Forte®´´

Inflamase�Mild®´´

Innopran�XL®´´

Inova®´´

Inpersol-Lm�w/Dextrose®´´

Inpersol�w/Dextrose®´´

Inspra®´´�(ST)

Intal®´´�(QCD)

Intralipid®´´

Introl®´´

Invanz®´´

Inversine®´´

Iodosorb®´´

Ionosol�B�w/Dextrose®´´

Ionosol�Mb�w/Dextrose®´´

Ionosol�T�w/Dextrose®´´

Iopidine®´´

Irrigating�Solution�G®´´

Ismo®´´

Isochron®´´

Isolyte�E®´´

Isolyte�G®´´

Isolyte�H®´´

Isolyte�M®´´

Isolyte�P®´´

Isolyte�R®´´

Isolyte�S®´´

Isoptin�SR®´´

Isopto�Atropine®´´

Isopto�Carbachol®´´

Isopto�Carpine®´´

Isopto�Homatropine®´´

Isopto�Hyoscine®´´

Isordil®´´

Isovex®´´

Istalol®´´

Isuprel®´´

J-Max®´´

J-Tan®´´

J-Tan�D®´´

Jaycof®´´

Jaycof-HC®´´

Jaycof-XP®´´

Just�for�Kids®´´

K-Dur®´´

K-Lor®´´

K-Lyte®´´

K-Lyte�DS®´´

K-Lyte/CL®´´

K-Phos�Neutral®´´

K-Tab®´´

Kadian®´´

Kaochlor®´´

Kaochlor-Eff®´´

Kaon®´´


Non-covered M

edications

�4


Kaon-CL®´´

Kay�Ciel®´´

Kayexalate®´´

Keflex®´´

Kefzol®´´

Kemadrin®´´

Kenalog®´´

Kenalog�in�Orabase®´´

Kerafoam™

Keralac®´´

Keralyt®´´

Kerlone®´´

Kerol™

Ketalar®´´

Ketek®´´

Key-Pred®´´

Kie®´´

Kinevac®´´

Kionex®´´

Klaron®´´

Klonopin®´´

Klotrix®´´

Kristalose®´´

Kronofed-A®´´

Kronofed-A-Jr®´´

Ku-Zyme®´´

Ku-Zyme�HP®´´

Kuric®´´

Kutrase®´´

Kwelcof®´´

Kytril®´´�(QCD)

Lacrisert®´´

Lacticare-HC®´´

Lactinol®´´

Lactinol-E®´´

Lactocal-F®´´

Lagesic®´´

Lamisil®´´�(QCD) (PA)

Lanoxicaps®´´

Lanoxin®´´

Lanzatuss-NF®´´

Lariam®´´

Lartus®´´

Lasix®´´

Lazerformalyde®´´

Lemohist�Plus®´´

Lemotussin-DM®´´

Lescol®´´�(QCD) (ST)

Lescol�XL®´´�(QCD) (ST)

Leukeran®´´

Leustatin®´´

Levacet®´´

Levall®´´

Levall-1�®´´

Levall�G®´´

Levaquin®´´

Levatol®´´

Levbid®´´

Levemir®´´

Levitra®´´

Levlen®´´

Levlite®´´

Levo-Dromoran®´´

Levophed®´´

Levsin®´´

Levsin/Sl®´´

Levsinex®´´

Lexapro®´´�(QCD) (ST)

Lexxel®´´

Librax®´´

Librium®´´

Lidamantle®´´

Lidamantle�HC®´´

Lidex®´´

Lidex-E®´´

Limbitrol®´´

Limbitrol�DS®´´

Limbrel®´´

Lincocin®´´

Lioresal®´´

Lipex®´´

Liposyn�II®´´

Liposyn�III®´´

Liquibid-D®´´

Liquibid-D�1�00®´´

Liquibid-PD®´´

Liquicough�DM®´´

Liquid�Prenatal�Vitamin®´´

Lithobid®´´

Lithostat®´´

Livostin®´´�(QCD)

Lo/Ovral®´´

Locoid®´´

Lodine®´´

Lodine�XL®´´

Lodrane®´´


�5

Non-covered M

edications


Lodrane�D®´´

Lodrane�XR®´´

Loestrin®´´

Loestrin��4�FE®´´

Loestrin�FE®´´

Lofibra®´´

Lokara®´´

Lomotil®´´

Lopid®´´

Lopressor®´´

Lopressor�HCT®´´

Loprox®´´

Lorabid®´´

Lorcet®´´

Lorcet�HD®´´

Lorcet�Plus®´´

Lortab®´´

Lortuss�DM®´´

Lortuss�HC®´´

Lotemax®´´

Lotensin®´´

Lotensin�HCT®´´

Lotrel®´´

Lotrisone®´´

Loxitane®´´

Lozol®´´

Lufyllin®´´

Lufyllin-GG®´´

Lumigan®´´

Luminal®´´

Lupron®´´

Luride®´´

Lusonal®´´

Lusonex®´´

Lusonex�Plus®´´

Lutrepulse®´´

Luxiq®´´

Lynox®´´

Lyrica®´´

M-Clear®´´

Macrobid®´´

Macrodantin®´´

Magan®´´

Magnebind�400�Rx®´´

Malarone®´´

Mandelamine®´´

Mandol®´´

Mannitol®´´

Mar-Spas®´´

Marcaine®´´

Marcainew/Epinephrine®´´

Marinol®´´

Marnatal-F�Plus®´´

Marplan®´´

Materna®´´

Mavik®´´

Max�HC®´´

Maxair�Autohaler®´´�(QCD)

Maxalt®´´�(QCD)

Maxalt�Mlt®´´�(QCD)

Maxaquin®´´

Maxi-Tuss�DM®´´

Maxi-Tuss�HC®´´

Maxi-Tuss�Hcg®´´

Maxi-Tuss�Hcx®´´

Maxidex®´´

Maxidone®´´

Maxifed®´´

Maxifed�DM®´´

Maxifed�DMX®´´

Maxifed-G®´´

Maxiflor®´´

Maxinate®´´

Maxiphen®´´

Maxiphen�ADT®´´

Maxiphen�DM®´´

Maxiphen�G®´´

Maxiphen-G�DM®´´

Maxipime®´´

Maxitrol®´´

Maxzide®´´

MC�Jr�Cough®´´

Mebaral®´´

Medent�DM®´´

Medent�Ld®´´

Medrol®´´

Mefoxin®´´

Megace®´´

Megace�ES®´´

Menopur®´´

Menostar®´´�(QCD)

Meprobamate�w/Aspirin

Merrem®´´

Mesna®´´

Mestinon®´´

Metadate�ER�(10mg�


Non-covered M

edications

�6


Tablets�)®´´

Metaglip®´´

Methylene�Blue®´´

Methylin®´´

Methylprednisolone�Sod�Succ®´´

Metro�IV®´´

Metrocream®´´

Metrogel®´´

Metrogel-Vaginal®´´

Metrolotion®´´

Mevacor®´´�(QCD) (ST)

Mexitil®´´

Miacalcin®´´

Micardis®´´�(ST)

Micardis�HCT®´´�(ST)

Micro-K®´´

Micronase®´´

Micronor®´´

Microzide®´´

Midamor®´´

Midrin®´´

Migralam®´´

Migranal®´´�(QCD)

Migraten®´´

Miltown®´´

Miltuss-Ex®´´

Mimyx®´´

Minipress®´´

Minirin®´´

Minitran®´´

Minizide®´´

Minocin®´´

Minocin®´´�Combo�Pack

Mintuss�DR®´´

Mintuss�MR®´´

Miostat®´´

Miralax®´´

Mircette®´´

Moban®´´

Mobic®´´�(QCD)

Modicon®´´

Moduretic®´´

Monistat�Dual-Pak®´´

Monodox®´´

Monoket®´´

Monopril®´´

Monopril�HCT®´´

MonteFlu�HC®´´

Montephen®´´

Monurol®´´

Motofen®´´

Motrin®´´

MoviPrep®´´

MS�Contin®´´

MSir®´´

MTE®´´

Muco-Fen�DM®´´

Mucomyst®´´

Multi-1�®´´

Multitrace®´´

Murocoll-�®´´

Muse®´´

Mustargen®´´

Mutamycin®´´

MVI�1�®´´

MVI�Pediatric®´´

Myambutol®´´

Mycamine®´´

Mycelex®´´

Mycolog�II®´´

Mycostatin®´´

Mydfrin®´´

Mydriacyl®´´

Mylocel®´´

Mylotarg®´´

Myophen®´´

Mysoline®´´

Mytelase®´´

Mytrex®´´

Naftin®´´

Nalex-A®´´

Nalex�Dh®´´

Nalfon®´´

Nallpen®´´

Nandrolone�Decanoate®´´

Naprelan®´´

Naprosyn®´´

Narcan®´´

Nasacort®´´�(QCD)

Nasacort�AQ®´´�(QCD)

Nasarel®´´�(QCD)

Nascobal®´´

Nasop®´´

Natachew®´´

Natacyn®´´


�7

Non-covered M

edications


Natafort®´´

Natalcare�Rx®´´

Natalvit®´´

Natelle®´´

Natelle�C®´´

Natelle-Ez®´´

Natelle�Prefer®´´

Naturetin®´´

Navane®´´

Navelbine®´´

Nd-Gesic®´´

Nebcin®´´

Neevo®´´

Neggram®´´

Nembutal�Sodium®´´

Neo-DM®´´

Neo-Fradin®´´

Neo-Synephrine�Eye�Drops®´´

Neobenz�Micro®´´

Neoral®´´

Neosar®´´

Neosporin�Eye�Drops®´´

Neosporin�GU�Irrigant®´´

Neotrace®´´

Neotron-S®´´

Neotuss-D®´´

Nephramine®´´

Neptazane®´´

Nesacaine®´´

Nesacaine-Mpf®´´

Nestabs�CBF®´´

Nestabs�FA®´´

Nestabs�Rx®´´

Neurontin®´´

Neut®´´

Neutrexin®´´

Nevanac®´´

Nexavir®´´

Nexium®´´�(QCD) (ST)

Niferex-PN�Forte®´´

Nipent®´´

Niravam®´´

Nitro-Dur®´´

Nitrolingual®´´

Nitrostat®´´

Nizoral®´´

Nolvadex®´´

Nor-Q-D®´´

Norco®´´

Nordette®´´

Norel�LA®´´

Norel�Sd®´´

Norel�SR®´´

Norflex®´´

Norgesic®´´

Norgesic�Forte®´´

Norinyl®´´

Noritate®´´

Normodyne®´´

Normosol-M�and�Dextrose®´´

Normosol-R®´´

Normosol-R�and�Dextrose®´´

Normosol-R�PH�7��4®´´

Noroxin®´´

Norpace®´´

Norpace�CR®´´

Norpramin®´´

Notuss®´´

Notuss�PD®´´

Novacort®´´

Novamine®´´

Novanatal®´´

Novasal®´´

Novastart®´´

Novocain®´´

Novolin�70/30®´´

Novolin�N®´´

Novolin�R®´´

Novolog®´´

Novolog�Mix�70/30®´´

Nubain®´´

Nucofed®´´

Nuhist®´´

Nulev®´´

Nulytely®´´

Nulytely�with�Flavor�Packs®´´

Numobid®´´

Numobid�DX®´´

Numoisyn®´´

Numonyl®´´

Numonyl�DX®´´

Numonyl�Pediatric®´´

Numonyl�SR®´´


Non-covered M

edications

�8


Numorphan®´´

Nuox®´´

Nutracare®´´

Nutricap®´´

Nutrivit®´´

Nuvaring®´´

Nuzon®´´

Nydamax®´´

Nydrazid®´´

Nystat-Rx®´´

O-Cal�FA®´´

O-Cal�Prenatal®´´

OB�Complete®´´

Obstetrix-100®´´

Obstetrix�EC®´´

Obtrex®´´

Ocl®´´

Ocufen®´´

Ocuflox®´´

Ocutricin®´´

Ogen®´´

Olux®´´

Omacor®´´

Omnicef®´´

Omnihist�II�LA®´´

Omnii�Gel®´´

Omnii�Med®´´

Oncaspar®´´

One�Touch�Test�Strips®´´�(QCD)

One�Touch�Ultra�Test�Strips®´´�(QCD)

Ontak®´´

Opana®´´

Opana�ER®´´

Ophthetic®´´

Opium®´´

Optinate®´´

Optipranolol®´´

Optivar®´´�(QCD)

Oracea™

Oracit®´´

Oramagicrx®´´

Oramorph�SR®´´

Orap®´´

Orapred®´´

Orapred®´´�ODT

Oratuss®´´

Orencia®´´

Ortho-Cept®´´

Ortho-Cyclen®´´

Ortho-Est®´´

Ortho�Evra®´´

Ortho�Micronor®´´

Ortho-Novum®´´

Ortho-Prefest®´´

Ortho�Tri-Cyclen®´´

Ortho�Tri-Cyclen�Lo®´´

Orthoclone�Okt-3®´´

Orthovisc®´´

Orudis®´´

Oruvail®´´

Osmitrol®´´

Osmoglyn®´´

Osmoprep®´´

Otilam®´´

Otocain®´´

Otogesic®´´

Ovace®´´

Ovcon®´´

Ovide®´´

Ovral®´´

Ovrette®´´

Oxalis®´´

Oxandrin®´´

Oxical®´´

Oxiplen®´´

Oxistat®´´

Oxsoralen®´´

Oxsoralen-Ultra®´´

Oxycontin®´´

Oxyfast®´´

Oxyir®´´

Oxytrol®´´

P-Tex®´´

P-V-Tussin®´´

Pain�Ease®´´

Palgic®´´

Palgic�D®´´

Palgic�DS®´´

Palladone®´´

Pamelor®´´

Pamine®´´

Pamine�Forte®´´

Panafil®´´

Panatuss®´´

Panatuss�DX®´´


��

Non-covered M

edications


Panatuss�DXP®´´

Pancof®´´

Pancof�Exp®´´

Pancof�HC®´´

Pancof�XP®´´

Pancrease®´´

Pancrease�MT®´´

Pancreatin®´´

Pancrecarb�MS®´´

Pandel®´´

Panfil�G®´´

Panixine®´´

Panlor�DC®´´

Panlor�SS®´´

Panmist�DM®´´

Panmist�Jr®´´

Panmist�LA®´´

Pannaz®´´

Pannaz�S®´´

Panoxyl�5®´´

Panoxyl�AQ��5®´´

Panoxyl�AQ�5®´´

Panretin®´´

Parafon�Forte�DSC®´´

Paraplatin®´´

Parcopa®´´

Parlodel®´´

Paser®´´

Patanol®´´�(QCD)

Paxil®´´�(QCD) (ST)

Paxil�CR®´´�(QCD) (ST)

Paxipam®´´

Pce®´´

Pedameth®´´

Pediaflor®´´

Pediahist�DM®´´

Pediapred®´´

Pediatan®´´

Pediatan�D®´´

Pediatex®´´

Pediatex�1�®´´

Pediatex�1��D®´´

Pediatex�1��DM®´´

Pediatex-D®´´

Pediatex�DM®´´

Pediazole®´´

Pediotic®´´

Pediox®´´

Penlac®´´�(QCD) (PA)

Pentam®´´

Pentothal®´´

Percocet®´´

Percodan®´´

Percolone®´´

Peridex®´´

Periostat®´´

Permax®´´

Perry�Prenatal�Tablet®´´

Persantine®´´

Pexeva®´´�(QCD) (ST)

Pfizerpen®´´

Phanasin®´´

Phanatuss�HC®´´

Phena-HC®´´

Phena-Plus®´´

Phena-S®´´

Phenabid®´´

Phenabid�DM®´´

Phenergan®´´

Phenergan�VC�w/Codeine®´´

Phenergan�w/Codeine®´´

Phenydex®´´

Phenytek®´´

Phisohex®´´

Phos-Flur®´´

Phospholine�Iodide®´´

Photofrin®´´

Phrenilin®´´

Phrenilin�Forte®´´

Phrenilin�w/Caffeine�&�Codeine®´´

Physiolyte®´´

Physiosol®´´

Pilocar®´´

Pilopine�Hs®´´

Pima®´´

Pipracil®´´

Pirosal®´´

Pitocin®´´

Pitressin®´´

Plaquenil®´´

Plasma-Lyte®´´

Plasma-Lyte�A�PH®´´

Plasma-Lyte�M®´´

Plasma-Lyte�R®´´

Platinol-AQ®´´


Non-covered M

edications

30


Plendil®´´

Pletal®´´

Plexion®´´

Plexion�Sct®´´

Plexion�Ts®´´

Pneumotussin®´´

Podoben�Resin®´´

Podocon-�5®´´

Pododerm®´´

Polocaine®´´

Poly�Hist�DM®´´

Poly�Hist�Forte®´´

Poly�Hist�HC®´´

Poly�Hist�PD®´´

Poly-Histine®´´

Poly-Pred®´´

Poly-Tussin®´´

Poly-Tussin�DM®´´

Poly-Tussin�HD®´´

Poly-Tussin�XP®´´

Poly-Vent®´´

Poly-Vi-Flor®´´

Poly-Vi-Flor�w/Iron®´´

Polycitra®´´

Polycitra-K®´´

Polycitra-LC®´´

Polysporin®´´

Polytrim®´´

Pontocaine®´´

Potaba®´´

Pramosone®´´

Pramotic®´´

Pravigard�Pac®´´�(QCD)

Precare®´´

Precare�Conceive®´´

Precare�Premiere®´´

Precare�Prenatal®´´

Precision�Q-I-D®´´�(QCD)

Precision�Sof-Tact®´´�(QCD)

Precision�Xtr�B-Ketone®´´

Precision,�PCX®´´�(QCD)

Precision,�PCX�Plus®´´�(QCD)

Pred�Forte®´´

Pred-G®´´

Prednisone�Intensol®´´

Prehist®´´

Prekunil®´´

Prelone®´´

Premarin®´´

Premasol®´´

Premesis�Rx®´´

Premphase®´´

Prempro®´´

Prena-Cap®´´

Prenatal®´´

Prenatal�MR��0�FE®´´

Prenatal�MTR®´´

Prenatal�Rx®´´

Prenate�Elite®´´

Prenate�GT®´´

Prepidil®´´

Prevacid®´´�(QCD) (ST)

Prevacid�Naprapac®´´

Prevident®´´

Prevident�5000�Plus®´´

Prilosec®´´�(QCD) (ST)

Primacare®´´

Primacare�One®´´

Primacor®´´

Primaquine®´´

Primaxin®´´

Primsol®´´

Principen®´´

Prinivil®´´

Prinzide®´´

Pro-Banthine®´´

Pro-Clear®´´

Pro-Hyo®´´

Pro-Red®´´

Proamatine®´´

Procalamine®´´

Procanbid®´´

Procardia®´´

Procardia�XL®´´

Prochieve®´´

Proctocort®´´

Proctocream-HC®´´

Proctofoam-HC®´´

Proctosol-HC®´´

Prodigy�Test�Strips®´´

Profasi®´´

Profen�II®´´

Profen�II�DM®´´

Profen�Forte®´´

Profen�Forte�DM®´´


31

Non-covered M

edications


Proglycem®´´

Prolex�D®´´

Prolex�Dh®´´

Prolex�DM®´´

Prolex�PD®´´

Proloprim®´´

Promar®´´

Pronestyl®´´

Pronestyl-SR®´´

Propine®´´

Proquin�XR®´´

Prosed�EC®´´

Prosed/DS®´´

Prosol™

Prosom®´´

Prostin�E��Vaginal�Suppository®´´

Prostin�Vr�Pediatric®´´

Protid®´´

Protopam�Chloride®´´

Protopic®´´�(PA)

Proventil®´´�(QCD)

Proventil�HFA®´´�(QCD)

Provera®´´

Provocholine®´´

Prozac®´´�(QCD) (ST)

Prozac�Weekly®´´�(QCD) (ST)

Prudoxin®´´

PSE��0/CPM�8/MSC��5®´´

PSE�CPM®´´

PSEudo-G®´´

Psorcon®´´

Psorcon�E®´´

Psoriatec®´´

PTE-5®´´

Pulmicort®´´�Turbuhaler�(QCD)

Purinethol®´´

Pyrelle�HB®´´

Pyridium®´´

Pyridium�Plus®´´

Qdall®´´

Qdall�Ar®´´

Qualaquin™

Questran®´´

Questran�Light®´´

Quibron®´´

Quibron-300®´´

Quibron-T®´´

Quibron-T/SR®´´

Quick-K®´´

Quick�Mix�w/Lytes®´´

Quindal®´´

Quinidex®´´

Quixin®´´

R-Gene�10®´´

R-Tannamine®´´

R-Tannate®´´

Radiaplexrx®´´

Ranexa®´´

Raniclor®´´

Rapiflux®´´�(QCD) (ST)

Rebetol®´´

Rectagel�HC®´´

Refludan®´´

Reglan®´´

Regonol®´´

Relacon-DM®´´

Relacon-HC®´´

Relafen®´´

Relagard®´´

Relagesic®´´

Relpax®´´�(QCD)

Remeron®´´�(QCD)

Renacidin®´´

Renamin®´´

Renax®´´

Renoquid®´´

Reprexain®´´

Rescon-Jr®´´

Rescon-MX®´´

Resectisol®´´

Respa-1st®´´

Respa�AR®´´

Respa-DM®´´

Respa-PE®´´

Respaire®´´

Respi-Tann®´´

Respi-Tann�G®´´

Respi-Tann�PD®´´

Restoril®´´

Retin-A®´´�(PA)

Retin-A�Micro®´´�(PA)

Rev-Eyes®´´

Revatio®´´�(PA)

Revex®´´


Non-covered M

edications

3�


Revia®´´

Rheumatrex®´´

Rhinocort�Aqua®´´�(QCD)

Ribatab®´´

Ricobid®´´

Ricobid-H®´´

Ricotuss®´´

Rifadin®´´

Rifamate®´´

Rifater®´´

Rimso-50®´´

Rinate®´´

Ringers®´´

Ringers�Irrigation®´´

Riomet®´´

Risperdal�M®´´

Ritalin®´´

Ritalin�LA®´´

Ritalin-SR®´´

Rituxan®´´

Robaxin®´´

Robaxisal®´´

Robinul®´´

Robinul�Forte®´´

Rocaltrol®´´

Rocephin®´´

Romazicon®´´

Romilar�AC®´´

Rondec®´´

Rondec-DM®´´

Rondec-Tr®´´

Rosac®´´

Rosanil®´´

Rosula®´´

Rosula�Ns®´´

Rowasa®´´

Roxanol®´´

Roxanol-T®´´

Roxicet®´´

Roxicodone®´´

Roxicodone�Intensol®´´

Rozerem®´´�(QCD) (ST)

Ru-Tuss�800�DM®´´

Rum-K®´´

Ryna-1�®´´

Ryna-1��S®´´

Ryna-1�x®´´

Rynatan®´´

Rynatan�Pediatric®´´

Rynatuss®´´

Rynessa�1�®´´

Ryneze®´´

Rythmol®´´

S-T�Forte��®´´

Sal-Tropine®´´

Salagen®´´

Salex®´´

Salflex®´´

Salicept®´´

Saluron®´´

Sanctura®´´

Sandimmune®´´

Santuss®´´

Santyl®´´

Sarafem®´´�(QCD) (ST)

Scleromate®´´

Scopace®´´

Seasonale®´´

Seb-Prev®´´

Sebizon®´´

Seconal�Sodium®´´

Sectral®´´

Sel-Pen®´´

Select-OB®´´

Selepen®´´

Selseb®´´

Semprex-D®´´

Sensorcaine®´´

Sensorcaine�w/Dextrose®´´

Sensorcaine�w/Epinephrine®´´

Septra®´´

Septra�DS®´´

Serax®´´

Seromycin®´´

Shohl’s�Modified®´´

Silvadene®´´

Silver�Nitrate®´´

Simetyl®´´

Simulect®´´

Sina-1�x®´´

Sinemet®´´

Sinemet�CR®´´

Sinequan®´´

Sitrex®´´

Sitrex�PD®´´


33

Non-covered M

edications


Skelid®´´

Slofed�60®´´

Sodium�Polystyrene�Sulfonate®´´

Sodium�Thiosulfate®´´

Sof-Tact®´´�Test�Strips�(QCD)

Solaraze®´´

Solodyn™

Solu-Cortef®´´

Solu-Medrol®´´

Soma®´´

Soma�Compound®´´

Soma�Compound�w/Codeine®´´

Somnote®´´

Sonata®´´�(QCD) (ST)

Sorbutuss®´´

Spacol®´´

Spacol�T/S®´´

Spectazole®´´

Spectracef®´´

Sporanox®´´�(QCD) (PA)

Spray�and�Stretch®´´

Sps®´´

SSki®´´

Sta-D®´´

Stadol®´´

Staflex®´´

Stagesic-10®´´

Stahist®´´

Starlix®´´

Statuss�Green®´´

Sterapred®´´

Sterapred�DS®´´

Strattera®´´�(QCD) (ST)

Streptase®´´

Streptomycin�Sulfate®´´

Striant®´´

Strongstart®´´

Strovite�Advance®´´

Strovite�Forte®´´

Stuartnatal�Plus�3®´´

Sucraid®´´

Sudal®´´

Sudal�1�®´´

Sudal-1�®´´

Sudal�DM®´´

Sudal�SR®´´

Sular®´´

Sulfacet-R®´´

Sulfoxyl�Regular®´´

Sulfoxyl�Strong®´´

Sulindac®´´

Sumycin®´´

Supprelin®´´

Suprax®´´

Surestep®´´�Test�Strips�(QCD)

Surmontil®´´

Sutent®´´

Suttar-�®´´

Suttar-SF®´´

Symax�Duotab®´´

Symbyax®´´�(QCD)

Symmetrel®´´

Symtan®´´

Symtan�A®´´

Synalar®´´

Synalgos-DC®´´

Synarel®´´

Synercid®´´

Syprine®´´

Taclonex®´´

Tagamet®´´

Talacen®´´

Taladine®´´

Talwin®´´

Talwin�NX®´´

Tambocor®´´

Tanafed®´´

Tanafed�DMX®´´

Tanafed�DP®´´

Tandem�F®´´

Tandem�Forte®´´

Tandem�OB®´´

Tandem�Plus®´´

Tapazole®´´

Tarabine�PFS®´´

Tarka®´´

Tavist®´´

Taxol®´´

Taxotere®´´

Tazicef®´´

Tazorac®´´

Temovate®´´

Temovate�Emollient®´´

Tenex®´´


Non-covered M

edications

34


Tenoretic®´´

Tenormin®´´

Tequin®´´

Terazol�3®´´

Terazol�7®´´

Terramycin®´´

Terramycin�w/Polymyxin®´´

Tessalon®´´

Tessalon�Perle®´´

Testopel®´´

Testred®´´

Teveten®´´�(ST)

Teveten�HCT®´´�(ST)

Texacort®´´

Thalitone®´´

Theo-�4®´´

Theocap®´´

Theomar�GG®´´

Thera-Flur-N®´´

Theracys®´´

Thiocyl®´´

Thiola®´´

Thiotepa®´´

Thymoglobulin®´´

Thyrel�TRH®´´

Thyrogen®´´

Thyrolar®´´

Tiazac®´´

Ticar®´´

Ticlid®´´

Tigan®´´

Tilade®´´�(QCD)

Timentin®´´

Timolide®´´

Timoptic®´´

Timoptic-Xe®´´

Tindamax®´´

Tobradex®´´

Tobrex®´´

Tofranil®´´

Tofranil-Pm®´´

Tolectin®´´

Topicort®´´

Topicort�LP®´´

Toposar®´´

Toradol®´´

Torecan®´´

Totacillin-N®´´

Touro�CC®´´

Touro�CC-Ld®´´

Touro�DM®´´

Touro�HC®´´

Touro�LA®´´

Touro�La-Ld®´´

Tpn�Electrolytes®´´

Tpn�Electrolytes�II®´´

Trac��x®´´

Trace�Elements®´´

Trace�Elements-4®´´

Trace�Metals®´´

Trandate®´´

Tranxene�Sd®´´

Tranxene�T-Tab®´´

Travasol®´´

Travasol�w/Dextrose®´´

Travasol�w/Electrolytes®´´

Travatan®´´

Travatan�Z®´´

Travert®´´

Trecator®´´

Trental®´´

Tretin-X®´´�(PA)

Trexall®´´

Tri-Chlor®´´

Tri-K®´´

Tri-Levlen®´´

Tri-Norinyl®´´

Tri-Vi-Flor®´´

Tri-Vi-Flor�w/Iron®´´

Triad®´´

Triant-HC®´´

Triaz®´´

Tricare®´´

Tricitrasol®´´

Tricor®´´

Tricosal®´´

Tridal®´´

Tridesilon®´´

Trikof-D®´´

Trilisate®´´

Trilyte�with�Flavor�Packets®´´

Triostat®´´

Triphasil®´´

Triple�Sulfa®´´

Trispec�DMX®´´


35

Non-covered M

edications


Trispec�PSE®´´

Trispec�SFX®´´

Trital�DM®´´

Trituss®´´

Trituss-A®´´

Trituss-ER®´´

Trobicin®´´

Trophamine®´´

TRUE�Test®´´

Trycet®´´

Tusnel®´´

Tusnel-DM®´´

Tusnel-HC®´´

Tusnel�Ped-C®´´

Tusnel�Pediatric®´´

Tuss-Mine�DM®´´

Tussafed�Ex®´´

Tussafed-Hcg®´´

Tussall®´´

Tussall-ER®´´

Tussend®´´

Tussi-1�®´´

Tussi-1��S®´´

Tussi-1�d®´´

Tussi-1�d�S®´´

Tussi-Organidin�NR®´´

Tussi-Pres®´´

Tussi-Pres�Pediatric®´´

Tussidex®´´

Tussigon®´´

Tussilan�NF®´´

Tussinate®´´

Tussionex®´´

Tussirex®´´

Tusso-DF®´´

Tusso-DM®´´

Tusso-HC®´´

Tusso-XR®´´

Tustan�1�®´´

Tygacil®´´

Tylenol�w/Codeine®´´

Tylox®´´

Tympagesic®´´

Tyzine®´´

U-Cort®´´

Ucephan®´´

Ultiva®´´

Ultrabrom®´´

Ultrabrom�PD®´´

Ultracet®´´

Ultralytic��®´´

Ultram®´´

Ultram�ER®´´

Ultrase®´´

Ultrase�MT®´´

Ultravate®´´

Umecta®´´

Unasyn®´´

Unguentum�Bossi®´´

Uniphyl®´´

Uniretic®´´

Univasc®´´

Urecholine®´´

Urelle®´´

Uretron�D/S®´´

Urex®´´

Urimax®´´

Urised®´´

Urispas®´´

Urisym®´´

Uro�Blue®´´

Uro-KP-Neutral®´´

Urodol®´´

Urolene�Blue®´´

Uroqid-Acid�No��®´´

Urosex®´´

Urso®´´

Urso�Forte®´´

Uta®´´

Valium®´´

Valtrex®´´�(QCD)

Vanacet®´´

Vanamide®´´

Vanex�HD®´´

Vanos®´´

Vanoxide-HC®´´

Vanspar®´´

Vantin®´´

Vaseretic®´´

Vasocidin®´´

Vasodilan®´´

Vasotec®´´

Vasotuss�HC®´´

Vazol®´´

Vazol-D®´´

Veetids�500®´´


Non-covered M

edications

36


Velcade®´´

Velosef®´´

Ventolin®´´�(QCD)

Ventolin�HFA®´´�(QCD)

Vepesid®´´

Verdeso®´´

Verelan®´´

Verelan�Pm®´´

Vermox®´´

Versiclear®´´

Vesicare®´´

Vexol®´´

Vi-Daylin�F�ADC®´´

Vi-Daylin/F®´´

Vi-Daylin/F�+�Iron®´´

Vi-Daylin/F�ADC�Plus�Iron®´´

Viagra®´´

Vibra-Tabs®´´

Vibramycin®´´

Vicodin®´´

Vicodin�ES®´´

Vicodin�HP®´´

Vicoprofen®´´

Vigamox®´´�(QCD)

Viokase®´´

Viravan�DM®´´

Viravan-S®´´

Viravan-T®´´

Virazole®´´

Viroptic®´´

Viscoat®´´

Visicol®´´

Vistaril®´´

Vistide®´´

Visudyne®´´

Vita-Pren®´´

Vivactil®´´

Vivelle®´´�(QCD)

Vivelle-Dot®´´�(QCD)

Volmax®´´

Voltaren®´´

Voltaren-XR®´´

Vopac®´´

Vospire�ER®´´

Vumon®´´

Vusion®´´

Vytone®´´

Welchol®´´

Wellbutrin®´´�(ST)

Wellbutrin�SR®´´�(QCD) (ST)

Wellbutrin�XL®´´�(QCD) (ST)

Westcort®´´

Xanax®´´

Xanax�XR®´´

Xclair®´´

Xenaderm®´´

Xerac�AC®´´

Xibrom®´´

Xifaxan®´´

Xirahist®´´

Xirahist�DM®´´

Xiratuss®´´

Xodol®´´

Xolegel®´´

Xopenex®´´�(ST)

Xopenex�HFA®´´�(ST)

XPect-AT®´´

XPect-HC®´´

Xylocaine®´´

Yasmin��8®´´

Yaz®´´

Yodefan®´´

Yodefan-NF®´´

Yodoxin®´´

Z-Clinz®´´

Z-Cof�DM®´´

Z-Cof�DMX®´´

Z-Cof�HC®´´

Z-Cof�HCX®´´

Z-Cof�LA®´´

Z-Cof�LAX®´´

Zanaflex®´´

Zanosar®´´

Zantac®´´

Zarontin®´´

Zaroxolyn®´´

Zazole®´´

Zebeta®´´

Zebutal®´´

Zegerid®´´�(QCD) (ST)

Zelapar®´´

Zemplar®´´

Zenapax®´´

Zephrex®´´

Zephrex-LA®´´


37


Zerlor®´´

Zestoretic®´´

Zestril®´´

Zetacet®´´

Zetia®´´�(QCD) (ST)

Ziac®´´

Zinacef®´´

Zinecard®´´

Zmax®´´

Zoderm®´´

Zoloft®´´�(QCD) (ST)

Zonalon®´´

Zorprin®´´

Zostrix®´´

Zosyn®´´

Zotex®´´

Zotex-G®´´

Zotex-Gp®´´

Zotex�GPX®´´

Zotex-LA®´´

Zotex�LAX®´´

Zoto-HC®´´

Zovirax®´´

Ztuss®´´

Zyban®´´

Zydone®´´

Zyflo®´´�(ST)

Zylet®´´

Zyloprim®´´

Zymar®´´�(QCD)

Zymine®´´

Zymine-D®´´

Zymine�HC®´´

Zyprexa�IM®´´

Zyprexa�Zydis®´´

Zyrtec®´´�(QCD)

Zyrtec-D®´´�(QCD)

Zyvox®´´

Non-covered M

edications


non-covered medications · exoderm®´´ extendryl ®´´ extendryl dm®´´ extendryl hc ®´´...

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