| LINE
# |
PA |
BRAND
(TRADE) NAME REFERENCE
ONLY |
GEQ ONLY |
DRUG NAME
(COVERED BENEFIT) |
STRENGTH |
ADD DATE |
DELETE DATE |
COMMENTS |
CODE |
OTC AGENTS |
| |
|
|
|
|
|
|
|
|
|
|
| 1 |
|
A/T/S |
* |
ERYTHROMYCIN TOPICAL SOLN |
2% |
|
|
|
TOPICAL - ANTIBIOTIC |
|
| 2 |
|
ACCUBRON |
|
ACCURBRON LIQ |
10MG/ML |
|
|
|
BRONCHODIL - XANTHINE |
|
| 3 |
|
ACCUPRIL |
|
ACCUPRIL TAB |
10 MG |
|
12/31/00 |
|
ACE INH |
|
| 4 |
|
ACCUPRIL |
|
ACCUPRIL TAB |
20 MG |
|
12/31/00 |
|
ACE INH |
|
| 5 |
|
ACCUPRIL |
|
ACCUPRIL TAB |
40 MG |
|
12/31/00 |
|
ACE INH |
|
| 6 |
|
ACCUPRIL |
|
ACCUPRIL TAB |
5 MG |
|
12/31/00 |
|
ACE INH |
|
| 7 |
|
ACHROMYCIN |
* |
TETRACYCLINE HCL
SYRUP |
125 MG/5ML |
|
|
|
ANTIBIOTIC - TCN |
|
| 8 |
|
ACHROMYCIN |
* |
TETRACYCLINE HCL
CAP |
250 MG |
|
|
|
ANTIBIOTIC - TCN |
|
| 9 |
|
ACHROMYCIN |
* |
TETRACYCLINE HCL
CAP |
500 MG |
|
|
|
ANTIBIOTIC - TCN |
|
| 10 |
|
ACHROMYCIN |
|
ACHROMYCIN OPTH
GTT |
1% |
|
|
|
OPTH -
ANTIBIOTIC |
|
| 11 |
|
ACIPHEX |
|
ACIPHEX TAB |
20MG |
10/15/00 |
09/30/01 |
|
PROTON PUMP
INHIBITOR |
|
| 12 |
|
ACTIDIL |
* |
TRIPROLIDINE HCL
SYRUP |
1.25MG/5ML |
|
|
|
ANTIHISTAMINE -
DECONGESTANT |
|
| 13 |
|
ACTIFED |
* |
TRIPROLIDINE/PSEUDOEPHEDRINE |
2.5MG/60MG |
|
|
|
ANTIHISTAMINE -
DECONGESTANT |
OTC |
| 14 |
PA |
ACTIGALL |
|
ACTIGALL CAP |
300 MG |
|
|
|
MISC |
|
| 15 |
|
ADALAT CC |
* |
ADALAT CC TAB |
30 MG |
|
PA - 4/1/00 |
|
CALCIUM CHANNEL
BLOCKER |
|
| 16 |
|
ADALAT CC |
* |
ADALAT CC TAB |
60 MG |
|
PA - 4/1/00 |
|
CALCIUM CHANNEL
BLOCKER |
|
| 17 |
|
ADALAT CC |
* |
ADALAT CC TAB |
90 MG |
|
PA - 4/1/00 |
|
CALCIUM CHANNEL
BLOCKER |
|
| 18 |
|
ADSORBOCARPINE |
|
ADSORBOCARPINE
OPTH |
1% |
|
|
|
OPTH - GLAUCOMA |
|
| 19 |
|
ADSORBOCARPINE |
|
ADSORBOCARPINE
OPTH |
2% |
|
|
|
OPTH - GLAUCOMA |
|
| 20 |
|
ADSORBOCARPINE |
|
ADSORBOCARPINE
OPTH |
4% |
|
|
|
OPTH - GLAUCOMA |
|
| 21 |
|
ADVAIR |
|
ADVAIR |
250-50 MCG |
09/01/01 |
|
Limit 1 per month |
|
|
| 22 |
|
ADVAIR |
|
ADVAIR |
500-50 MCG |
09/01/01 |
|
Limit 1 per month |
|
|
| 23 |
|
ADVAIR |
|
ADVAIR |
100-50 MCG |
09/01/01 |
|
Limit 1 per month |
|
|
| 24 |
|
AGENERASE |
|
AGENERASE SOLN |
15MG/ML |
|
|
DISP RESTRICTED TO KNIGHT -DRH |
AIDS |
|
| 25 |
|
AGENERASE |
|
AGENERASE CAP |
50MG |
|
|
DISP RESTRICTED TO KNIGHT -DRH |
AIDS |
|
| 26 |
|
AGENERASE |
|
AGENERASE CAP |
150MG |
|
|
DISP RESTRICTED TO KNIGHT -DRH |
AIDS |
|
| 27 |
|
AKINETONE |
|
AKINETONE TAB |
2 MG |
|
|
|
ANTICHOLINERGIC |
|
| 28 |
|
ALCAINE
|
|
ALCAINE OPTH
SOLN |
0.5% |
|
|
|
OPTH |
|
| 29 |
|
ALCOHOL SWABS |
* |
ALCOHOL SWABS |
|
|
02/01/99 |
|
DIABETIC
SUPPLIES |
OTC |
| 30 |
|
ALDACTAZIDE |
* |
SPIRONOLACTONE
W/HCTZ TAB |
25/25 |
|
|
|
DIURETIC - K+
SPARING |
|
| 31 |
|
ALDACTONE |
* |
SPIRONOLACTONE
TAB |
25 MG |
|
|
|
DIURETIC - K+
SPARING |
|
| 32 |
|
ALDOCLOR |
|
METHYLDOPA W/
CHLOROTHIAZIDE TAB |
250/150 |
|
|
|
HTN - COMBO |
|
| 33 |
|
ALDOCLOR |
|
METHYLDOPA W/
CHLOROTHIAZIDE TAB |
250/250 |
|
|
|
HTN - COMBO |
|
| 34 |
|
ALDOMET |
* |
METHYLDOPA TAB |
125 MG |
|
|
|
HTN - ANTRIADREN
- CENTRAL |
|
| 35 |
|
ALDOMET |
* |
METHYLDOPA TAB |
250 MG |
|
|
|
HTN - ANTRIADREN
- CENTRAL |
|
| 36 |
|
ALDOMET |
* |
METHYLDOPA TAB |
500 MG |
|
|
|
HTN - ANTRIADREN
- CENTRAL |
|
| 37 |
|
ALDORIL |
* |
METHYLDOPA W/
HCTZ TAB |
250/15 |
|
|
|
HTN - COMBO |
|
| 38 |
|
ALDORIL |
* |
METHYLDOPA W/
HCTZ TAB |
250/25 |
|
|
|
HTN - COMBO |
|
| 39 |
|
ALDORIL D |
* |
METHYLDOPA W/
HCTZ TAB |
500/30 |
|
|
|
HTN - COMBO |
|
| 40 |
|
ALDORIL D |
* |
METHYLDOPA W/
HCTZ TAB |
500/50 |
|
|
|
HTN - COMBO |
|
| 41 |
|
ALKERAN |
|
ALKERAN TAB |
2MG |
|
|
|
ANTINEOPLASTIC |
|
| 42 |
|
ALORA |
|
ALORA PATCH |
0.05MG/24HR |
09/01/01 |
|
MAX. 8 PATCHS PER MONTH/FEMALES ONLY |
ESTROGEN |
|
| 43 |
|
ALORA |
|
ALORA PATCH |
0.075MG/24HR |
09/01/01 |
|
MAX. 8 PATCHS PER MONTH/FEMALES ONLY |
ESTROGEN |
|
| 44 |
|
ALORA |
|
ALORA PATCH |
0.1MG/24HR |
09/01/01 |
|
MAX. 8 PATCHS PER MONTH/FEMALES ONLY |
ESTROGEN |
|
| 45 |
|
ALPHAGAN |
|
ALPHAGAN OPHTH |
|
|
|
|
ALPHA-2
ADRENERGIC AGONIST |
|
| 46 |
|
ALTERNAGEL |
* |
ALUM HYDROXIDE
GEL |
4% |
|
|
|
ANTACID |
|
| 47 |
|
ALUPENT |
* |
METAPROTERENOL
SULF TAB |
10 MG |
|
|
|
BRONCHODIL -
SYMPATH |
|
| 48 |
|
ALUPENT |
* |
METAPROTERENOL
SULF SYRUP |
10 MG/5ML |
|
|
|
BRONCHODIL -
SYMPATH |
|
| 49 |
|
ALUPENT |
* |
METAPROTERENOL
SULF TAB |
20 MG |
|
|
|
BRONCHODIL -
SYMPATH |
|
| 50 |
|
ALUPENT |
* |
METAPROTERENOL
SULF SOLN |
0.4% |
|
|
|
INH - BRONCHODIL
- SYMPATH |
|
| 51 |
|
ALUPENT |
* |
METAPROTERENOL
SULF SOLN |
0.6% |
|
|
|
INH - BRONCHODIL
- SYMPATH |
|
| 52 |
|
ALUPENT |
|
ALUPENT
INHALER/REFILL |
15MG/ML |
|
|
|
INH - BRONCHODIL
- SYMPATH |
|
| 53 |
|
ALUPENT |
* |
METAPROTERENOL
SULF SOLN |
5% |
|
|
|
INH - BRONCHODIL
- SYMPATH |
|
| 54 |
|
AMEN |
|
AMEN TAB |
10 MG |
|
|
|
HORMONE -
PROGESTIN |
|
| 55 |
|
AMINO CERV |
|
AMINO CERV VAG
CR |
|
|
|
|
VAGINAL |
|
| 56 |
|
AMINOPHYLLINE |
* |
AMINOPHYLLINE
TAB |
100 MG |
|
|
|
BRONCHODIL -
XANTHINE |
|
| 57 |
|
AMINOPHYLLINE |
* |
AMINOPHYLLINE
TAB |
200 MG |
|
|
|
BRONCHODIL -
XANTHINE |
|
| 58 |
|
AMINOPHYLLINE |
* |
AMINOPHYLLINE
SUPP |
250 MG |
|
|
|
BRONCHODIL -
XANTHINE |
|
| 59 |
|
AMINOPHYLLINE |
* |
AMINOPHYLLINE
VIAL |
250MG/10ML |
|
|
|
BRONCHODIL -
XANTHINE |
|
| 60 |
|
AMINOPHYLLINE |
* |
AMINOPHYLLINE
SUPP |
500 MG |
|
|
|
BRONCHODIL -
XANTHINE |
|
| 61 |
|
AMOXIL |
* |
AMOXICILLIN CAP |
250 MG |
|
|
|
ANTIBIOTIC - PCN |
|
| 62 |
|
AMOXIL |
* |
AMOXICILLIN SUSP |
250MG/5ML |
|
|
|
ANTIBIOTIC - PCN |
|
| 63 |
|
AMOXIL |
* |
AMOXICILLIN CAP |
500 MG |
|
|
|
ANTIBIOTIC - PCN |
|
| 64 |
|
ANA KIT |
|
ANA KIT INSECT
STING TREATMT |
|
|
|
|
MISC |
|
| 65 |
|
ANDROID |
* |
METHYLTESTOSTERONE
BUCCAL TAB |
10 MG |
|
|
|
CORTICOSTEROID |
|
| 66 |
|
ANDROID |
* |
METHYLTESTOSTERONE
TAB |
10 MG |
|
|
|
HORMONE -
TESTOSTERONE |
|
| 67 |
|
ANDROID |
* |
METHYLTESTOSTERONE
TAB |
25 MG |
|
|
|
HORMONE -
TESTOSTERONE |
|
| 68 |
|
ANTABUSE |
* |
DISULFIRAM TAB |
250 MG |
|
|
|
ALCOHOLISM |
|
| 69 |
|
ANTABUSE |
* |
DISULFIRAM TAB |
500 MG |
|
|
|
ALCOHOLISM |
|
| 70 |
|
ANTIMINTH |
|
ANTIMINTH PO
SUSP |
50MG/ML |
|
|
|
ANTIHELMINITC |
|
| 71 |
|
ANTIVERT |
* |
MECLIZINE TAB |
12.5 MG |
|
|
|
ANTIEMETIC -
ANTIVERTIGO |
|
| 72 |
|
ANTIVERT |
* |
MECLIZINE TAB |
25 MG |
|
|
|
ANTIEMETIC -
ANTIVERTIGO |
|
| 73 |
|
ANTIVERT |
* |
MECLIZINE TAB |
25 MG CHEW |
|
|
|
ANTIEMETIC -
ANTIVERTIGO |
|
| 74 |
|
ANTURANE |
* |
SULFINPYRAZONE
CAP |
200 MG |
|
|
|
GOUT -
UROCOSURIC |
|
| 75 |
|
ANUSOL HC |
* |
HEMORRHOIDAL HC
SUPP |
25 MG |
|
|
|
RECTAL -
HEMMRHOIDAL |
|
| 76 |
|
APRESAZIDE |
* |
HYDRALAZINE
/HCTZ CAP |
100/50 |
|
|
|
HTN - COMBO |
|
| 77 |
|
APRESAZIDE |
* |
HYDRALAZINE
/HCTZ CAP |
25/15 |
|
|
|
HTN - COMBO |
|
| 78 |
|
APRESAZIDE |
* |
HYDRALAZINE
/HCTZ CAP |
25/25 |
|
|
|
HTN - COMBO |
|
| 79 |
|
APRESAZIDE |
* |
HYDRALAZINE
/HCTZ CAP |
50/50 |
|
|
|
HTN - COMBO |
|
| 80 |
|
APRESOLINE |
* |
HYDRALAZINE TAB |
10 MG |
|
|
|
HTN -
VASODILATOR |
|
| 81 |
|
APRESOLINE |
* |
HYDRALAZINE TAB |
100 MG |
|
|
|
HTN -
VASODILATOR |
|
| 82 |
|
APRESOLINE |
* |
HYDRALAZINE TAB |
25 MG |
|
|
|
HTN -
VASODILATOR |
|
| 83 |
|
APRESOLINE |
* |
HYDRALAZINE TAB |
50 MG |
|
|
|
HTN -
VASODILATOR |
|
| 84 |
|
AQUAPHYLLIN |
* |
THEOPHYLLINE
ELIX |
80MG/15ML |
|
|
|
BRONCHODIL -
XANTHINE |
|
| 85 |
|
ARISTO PAK |
|
ARISTO PAK |
4MG |
|
|
|
CORTICOSTEROID |
|
| 86 |
|
ARISTOCORT |
|
ARISTOCORT TAB |
2 MG |
|
|
|
TOPICAL -
STEROID |
|
| 87 |
|
ARISTOCORT |
|
ARISTOCORT TAB |
4 MG |
|
|
|
TOPICAL -
STEROID |
|
| 88 |
|
ARISTOCORT |
|
ARISTOCORT TAB |
8 MG |
|
|
|
TOPICAL -
STEROID |
|
| 89 |
|
ARLIDIN |
* |
NYLIDRIN |
12 MG |
|
|
|
VASODILATOR -
PERIPH |
|
| 90 |
|
ARLIDIN |
* |
NYLIDRIN |
6 MG |
|
|
|
VASODILATOR -
PERIPH |
|
| 91 |
|
ASA |
* |
ASPIRIN
SUPPOSITORY |
10 GR |
|
|
|
ANALGESIC |
|
| 92 |
|
ASA |
* |
ASPIRIN
SUPPOSITORY |
5 GR |
|
|
|
ANALGESIC |
|
| 93 |
|
ASPIRIN |
* |
ASPIRIN TAB |
10 GR |
|
|
|
ANALGESIC |
OTC |
| 94 |
|
ASPIRIN |
* |
ASPIRIN TAB |
5 GR |
|
|
|
ANALGESIC |
OTC |
| 95 |
|
ASPIRIN |
* |
ASPIRIN TAB |
81 MG |
|
|
|
ANALGESIC |
OTC |
| 96 |
|
ATABRINE |
|
ATABRINE TAB |
100 MG |
|
|
|
MISC |
|
| 97 |
|
ATABRINE |
|
ATABRINE TAB |
100 MG |
|
|
|
MISC |
|
| 98 |
|
ATARAX |
* |
HYDROXYZINE HCL
TAB |
10 MG |
|
|
|
ANTIHISTAMINE -
PSYCH |
|
| 99 |
|
ATARAX |
* |
HYDROXYZINE
SYRUP |
10MG/5ML |
|
|
|
ANTIHISTAMINE -
PSYCH |
|
| 100 |
|
ATARAX |
* |
HYDROXYZINE HCL
TAB |
25 MG |
|
|
|
ANTIHISTAMINE -
PSYCH |
|
| 101 |
|
ATROMID S |
* |
CLOFIBRATE CAP |
500 MG |
|
|
|
ANTIHYPERLIPIDEMIC |
|
| 102 |
|
ATROPINE SULF |
|
ATROPINE SULFATE
OPTH UNG |
0.5% |
|
|
|
OPTH - MYDRIATIC |
|
| 103 |
|
ATROPINE SULF |
|
ATROPINE SULFATE
OPTH UNG |
1% |
|
|
|
OPTH - MYDRIATIC |
|
| 104 |
|
ATROPISOL |
|
ATROPISOL OPTH
SOLN/FS |
|
|
|
|
OPTH - MYDRIATIC |
|
| 105 |
|
ATROPISOL |
|
ATROPISOL OPTH
DROPPERETTE |
1% |
|
|
|
OPTH - MYDRIATIC |
|
| 106 |
|
ATROPISOL |
|
ATROPISOL OPTH
DROPPERETTE |
1/2% |
|
|
|
OPTH - MYDRIATIC |
|
| 107 |
|
ATROPISOL |
|
ATROPISOL OPTH
DROPPERETTE |
2% |
|
|
|
OPTH - MYDRIATIC |
|
| 108 |
|
ATROVENT |
|
ATROVENT INHALER |
|
|
|
|
INH - ANTICHOLIN |
|
| 109 |
PA |
AUGMENTIN |
|
AMOXICILLIN/K
CLAVULANATE |
250MG |
10/01/01 |
|
NO PA WITH PREREQUISITE STEP THERAPY |
ANTIBIOTIC -
PENICILLINS |
|
| 110 |
PA |
AUGMENTIN |
|
AMOXICILLIN/K
CLAVULANATE |
500MG |
10/01/01 |
|
NO PA WITH PREREQUISITE STEP THERAPY |
ANTIBIOTIC -
PENICILLINS |
|
| 111 |
PA |
AUGMENTIN |
|
AMOX
TR/POTASSIUM CLAVULANATE |
875MG |
10/01/01 |
|
NO PA WITH PREREQUISITE STEP THERAPY |
ANTIBIOTIC -
PENICILLINS |
|
| 112 |
|
AURALGEN |
* |
|