AWIS Application – Find Prescription Relief

AGENT APPLICATION

AWIS Enrollment Application Form

First Name*

Last Name*

Mobile Phone*

Home Phone*

Primary Email*

Street Address*

City*

State*

Zip*

County

Patient Additional Details

Gender

Date of Birth*

Social Sec Num*

Medication Details #1

Medication 1 Name*

Medication 1 OOP

Medication 1 Dosage

Medication 1 Frequency

Physician Details #1

Physician 1 Full Name

Physician 1 Phone

Physician 1 State

Physician 1 Zip

Medication Details #2

Medication 2 Name

Medication 2 OOP

Medication 2 Dosage

Medication 2 Frequency

Physician Details #2

Physician 2 Name

Physician 2 Phone

Physician 2 Fax

Physician 2 Email

Physician 2 City

Physician 2 State

Physician 2 Zip

Medication Details #3

Medication 3 Name

Medication 3 OOP

Medication 3 Dosage

Medication 3 Frequency

Physician Details #3

Physician 3 Name

Physician 3 Phone

Physician 3 Fax

Physician 3 Email

Physician 3 City

Physician 3 State

Physician 3 Zip

Medication Details #4

Medication 4 Name

Medication 4 OOP

Medication 4 Dosage

Medication 4 Frequency

Physician Details #4

Physician 4 Name

Physician 4 Phone

Physician 4 Fax

Physician 4 Email

Physician 4 City

Physician 4 State

Physician 4 Zip

Medication Details #5

Medication 5 Name

Medication 5 OOP

Medication 5 Dosage

Medication 5 Freq

Payment & Plan Information

Payment Bank

Bank Routing Num

Bank Acct Num

Card Type

Name On Card

Credit Card CVV

Credit Card Num

Card Exp Date

Support Product Sold*

Enrollment Fee

Description

Rep

FPL/MEDS

BRAND NAME	GENERIC	PRIVATE INS	PART D	LIS DENIAL	% OOP	$ OOP	MEDICARE	FPL	SUPPLY	COST
Novolin 70-30	human insulin isophane suspension and 30% regular, human insulin injection	NO	YES	NO	NO	1000	YES	300	90 Day	152
Auvi-Q Injectable	epinephrine	NO	YES	YES	5	NO	YES	250	120 Day	4500
Cialis	tadalafil	NO	YES	NO	NO	1100	YES	300	120 Day	109.56
Cymbalta	duloxetine	NO	YES	NO	NO	1100	YES	300	120 Day	502.63
Effient	prasugrel	NO	YES	NO	NO	1100	YES	300	120 Day	416.93
Evista	raloxifene	NO	YES	NO	NO	1100	YES	300	120 Day	53
Humalog	insulin lispro	NO	YES	NO	NO	1100	YES	300	120 Day	77.14
Humalog Mix50/50	insulin lispro	NO	YES	NO	NO	1100	YES	300	120 Day	264.04
Humalog Mix75/25	insulin lispro	NO	YES	NO	NO	1100	YES	300	120 Day	264.04
Humatrope	somatropin√•	NO	YES	NO	NO	1100	YES	300	120 Day	784.98
Humulin 70/30	insulin human	NO	YES	NO	NO	1100	YES	300	120 Day	138.35
Humulin N	nph human insulin	NO	YES	NO	NO	1100	YES	300	120 Day	138.35
Humulin R	regular insulin human√•	NO	YES	NO	NO	1100	YES	300	120 Day	138.35
Prozac	fluoxetine	NO	YES	NO	NO	1100	YES	300	120 Day	435.36
Quinidine Gluconate	quinidine gluconate	NO	YES	NO	NO	1100	YES	300	120 Day	23
Strattera	atomoxetine	NO	YES	NO	NO	1100	YES	300	120 Day	428.88
Symbyax	olonzapine/fluoxetine	NO	YES	NO	NO	1100	YES	300	120 Day	698.24
Zyprexa	olanzapine	NO	YES	NO	NO	1100	YES	300	120 Day	423.18
Zyprexa Relprevv	olanzapine	NO	YES	NO	NO	1100	YES	300	120 Day	637.86
Zyprexa Zydis	olanzapine	NO	YES	NO	NO	1100	YES	300	120 Day	670.99
Basaglar	insulin glargine injection	NO	YES	NO	NO	1100	YES	300	120 Day	234.6
Humalog KwikPen	recombinant	NO	YES	NO	NO	1100	YES	300	120 Day	292.53
Humalog Mix 50/50	recombinant	NO	YES	NO	NO	1100	YES	300	120 Day	292.53
Humalog Mix 50/50 KwikPen	recombinant	NO	YES	NO	NO	1100	YES	300	120 Day	292.53
Humalog Mix 50/50 Pen	recombinant	NO	YES	NO	NO	1100	YES	300	120 Day	292.53
Humalog Mix 75/25	recombinant	NO	YES	NO	NO	1100	YES	300	120 Day	292.53
Humalog Mix 75/25 Pen	recombinant	NO	YES	NO	NO	1100	YES	300	120 Day	292.53
Humalog Pen	recombinant	NO	YES	NO	NO	1100	YES	300	120 Day	292.53
Humalog U-200 KwikPen	recombinant	NO	YES	NO	NO	1100	YES	300	120 Day	292.53
Humulin R (U-100)	insulin human isophane-human insulin	NO	YES	NO	NO	1100	YES	300	120 Day	179
Humulin R (U-500)	insulin human isophane-human insulin	NO	YES	NO	NO	1100	YES	300	120 Day	179
Trulicity	Dulaglutide	NO	YES	NO	NO	1100	YES	300	120 Day	770
Fiasp	Insulin aspart	NO	YES	NO	NO	1000	YES	400	120 Day	304.65
GlucaGen Hypokit	glucagon	NO	YES	NO	NO	1000	YES	400	120 Day	286.39
Prozac Weekly	Fluoxetine	NO	YES	NO	NO	1100	YES	300	120 Days	34.92
Taltz	ixekizumab	NO	YES	NO	NO	1100	YES	300	120 Days	4200
Alphanate	antihemophilic factor human	YES	NO	NO	NO	NO	YES	400	30 Day	608.49
AlphaNine SD	coagulation factor IX (human	YES	NO	NO	NO	NO	NO	400	30 Day	699.52
Duzallo	allopurinol/lesinurad	YES	YES	NO	NO	NO	YES	300	30 Day	387
Butrans Transdermal	buprenorphine	NO	YES	NO	NO	NO	YES	139	30 Day	288
OxyContin Tablets	oxycodone	NO	YES	NO	NO	NO	YES	139	30 Day	80.5
Analpram HC	hydrocortisone/pramoxine	NO	YES	NO	NO	NO	Determined case by case	100	30 Day	46.19
Suboxone	Buprenorphine		NO	NO	NO	NO	NO	250	30 Day	151
Belviq	lorcaserin	Yes if not listed in the formulary	YES	NO	NO	NO	YES	150	30 Day	294.73
Auryxia	ferric citrate	NO	YES	NO	NO	NO	YES	400	30 Day	1100
Aptiom	eslicarbazepine acetate	NO	NO	NO	NO	NO	NO	250	30 Day	945.55
AndroGel	testosterone	YES	YES	NO	NO	NO	YES	300	90 Day	4801.94
Creon	pancrelipase	YES	YES	NO	NO	NO	YES	300	90 Day	481.89
Gengraf Capsules	cyclosporine	YES	YES	NO	NO	NO	YES	300	90 Day	165.3
HUMIRA	adalimumab	YES	YES	NO	NO	NO	YES	300	90 Day	2477.43
Lupron	leuprolide acetate)	YES	YES	NO	NO	NO	YES	300	90 Day
Lupron Depot	leuprolide acetate)	YES	YES	NO	NO	NO	YES	300	90 Day
Lupron Depot-PED	leuprolide acetate)	YES	YES	NO	NO	NO	YES	300	90 Day
Norvir	ritonavir	YES	YES	NO	NO	NO	YES	300	90 Day	277
Synthroid	levothyroxine	YES	YES	NO	NO	NO	YES	300	90 Day	34.58
KALETRA	lopinavir/ritonavir	YES	YES	NO	NO	NO	YES	500	90 Day	476.79
Complera	emtricitabine/rilpivirine/tenofovir disoproxil fumarate	YES	YES	NO	NO	NO	YES	500	90 Day	2670
Zioptan Opthalmic Solution	tafluprost	YES	YES	NO	NO	NO	YES	400	90 Day	200
Aerochamber Plus Flow-Vu	medical device	Must have no prescription coverage	YES	YES	NO	NO	YES	400	90 Day	39.61
Estrace	Estradiol	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 dAY	337
Zenpep	pancrelipase	YES	YES	YES	NO	NO	YES	400	90 Day	544
Avycaz	ceftazidime/avibactam	NO	YES	YES	NO	NO	YES	400	90 Day	359
Canasa	mesalamine	NO	YES	YES	NO	NO	YES	400	90 Day	1062
Armour Thyroid	thyroid desiccated	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 Day	44
Bystolic Tablets	nebivolol	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 Day	118.55
Fetzima ER Capsules	levomilnacipran	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 Day	323.36
Fetzima ER Capsules Titration Pack	levomilnacipran	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 Day	301.87
Linzess Capsules	linaclotide	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 Day	348.83
Namenda Oral Solution	memantine	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 Day	904.46
Namenda Tablets	memantine	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 Day	468.08
Namenda Titration Pak	memantine	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 Day	234.5
Namenda XR ER Capsules Titration Pack	memantine	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 Day	387.08
Namenda XRER Capsules	memantine	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 Day	387.08
Namzaric	memantine-donepezil	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 Day	449
Savella Tablets	milnaciprab	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 Day	318.26
Savella Titration Pack	milnaciprab	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 Day	291.82
Viibryd Patient Starter Kit	vilazodone	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 Day	224.42
Viibryd Tablets	vilazodone	Yes if not listed in the formulary	YES	YES	NO	NO	YES	400	90 Day	224.42
Corlanor	ivabradine	YES	YES	NO	NO	NO	YES	500	90 Day	435
AmBisome	amphotericin B liposome	YES	YES	NO	NO	NO	YES	250	90 Day
Cresemba	isavuconazonium sulfate	YES	YES	NO	NO	NO	YES	250	90 Day	304
Bydureon Vial ER	exenatide synthetic	NO	YES	NO	3	NO	YES	300	90 Day	613.83
Byetta Injection	exenatide	NO	YES	NO	3	NO	YES	300	90 Day	658.59
Farxiga Tablet	dapagliflozin	NO	YES	NO	3	NO	YES	300	90 Day	424.63
Kombiglyze XRTablet	saxagliptin/metformin	NO	YES	NO	3	NO	YES	300	90 Day	190.49
Movantik	naloxegol oxalate	NO	YES	NO	3	NO	YES	300	90 Day	362.04
Symlin Pen Injection	pramlintide acetate	NO	YES	NO	3	NO	YES	300	90 Day	943.78
Daliresp Tablets	roflumilast	NO	YES	NO	3	NO	YES	300	90 Day	317.56
Kombiglyze XR	Metformin,Saxaglipton	NO	YES	NO	3	NO	YES	300	90 Day	411.06
Lynparza	NO PROGRAM AVAILABLE	NO	YES	NO	3	NO	YES	300	90 Day
Onglyza	saxagliptin)	NO	YES	NO	3	NO	YES	300	90 Day
Pulmicort Flexhaler	budesonide	NO	YES	NO	3	NO	YES	300	90 Day	281
Symbicort	NO PROGRAM AVAILABLE	NO	YES	NO	3	NO	YES	300	90 Day	241
Tudorza Pressair	aclidinium bromide	NO	YES	NO	3	NO	YES	300	90 Day	278.87
Arimidex Tablet	anastrozole	NO	YES	NO	3	NO	YES	300	90 Day	549.97
Bevespi Aerosphere	glycopyrrolate/formoterol fumarate	NO	YES	NO	3	NO	YES	300	90 Day	360
Brilinta Tablet	ticagrelor	NO	YES	NO	3	NO	YES	300	90 Day	170.89
Faslodex Injection	fulvestrant	NO	YES	NO	3	NO	YES	300	90 Day	2013.52
Merrem Injection	meropenem	NO	YES	NO	3	NO	YES	300	90 Day	386.89
Pulmicort FlexhalerPowder	budesonide	NO	YES	NO	3	NO	YES	300	90 Day	186.94
Pulmicort RespulesInhalation	budesonide	NO	YES	NO	3	NO	YES	300	90 Day	354.88
Seroquel XR Tablet ER	quetiapine fumarate	NO	YES	NO	3	NO	YES	300	90 Day	485.95
Symbicort Inhaler	budesonide/formoterol fumarate dihydrate	NO	YES	NO	3	NO	YES	300	90 Day	308.45
Benlysta	belimumab	NO	YES	NO	NO	NO	YES	400	90 Day	3380
Aptivus Capsule	tipranavir	YES	YES	NO	NO	NO	YES	400	90 Day	1519.72
Aptivus Oral Solution	tipranavir	YES	YES	NO	NO	NO	YES	400	90 Day	507.22
Atrovent HFAAerosol	ipratropium bromide HFA	YES	YES	NO	NO	NO	YES	400	90 Day	383
Combivent RespimatSpray	ipratropium bromide/albuterol	YES	YES	NO	NO	NO	YES	400	90 Day	340.4
Glyxambi	Empagliflozin,Linaglipton	YES	YES	NO	NO	NO	YES	400	90 Day	370.41
Jardiance	Empagliflozin	YES	YES	NO	NO	NO	YES	400	90 Day	466.53
Jentadueto	Linaglipton,Metformin	YES	YES	NO	NO	NO	YES	400	90 Day	438
Jentadueto XR	Linaglipton,Metformin	YES	YES	NO	NO	NO	YES	400	90 Day	438
Pradaxa	dabigatran etexilate)	YES	YES	NO	NO	NO	YES	400	90 Day	370.41
Pradaxa Capsule	dabigatran etexilate	YES	YES	NO	NO	NO	YES	400	90 Day	370.41
Spiriva HandiHaler	tiotropium bromide	YES	YES	NO	NO	NO	YES	400	90 Day	286
Spiriva HandiHaler Powder	tiotropium bromide	YES	YES	NO	NO	NO	YES	400	90 Day	1101.18
Spiriva Respimat	tiotropium bromide	YES	YES	NO	NO	NO	YES	400	90 Day	286
Stiolto Respimat	tiotropium bromide/olodaterol	YES	YES	NO	NO	NO	YES	400	90 Day	370.41
Tradjenta Tablet	linagliptin	YES	YES	NO	NO	NO	YES	400	90 Day	375.9
Viramune XR Tablet ER	nevirapine	YES	YES	NO	NO	NO	YES	400	90 Day	861.06
Bethkis	tobramycin	Yes if not listed in the formulary	NO	NO	NO	NO	NO	400	90 Day	5643
Azor	amlodipine/olmesartan medoxmil	YES	NO	NO	NO	NO	YES	200	90 day	240
Benicar Tablets	olmesartan	NO	NO	NO	NO	NO	YES	200	90 day	320.2
Savaysa	edoxaban	NO	NO	NO	NO	NO	YES	200	90 Day	362.06
Welchol Oral Suspension	colesevelam	NO	NO	NO	NO	NO	YES	200	90 Day	576.32
Welchol Tablet	colesevelam	NO	NO	NO	NO	NO	YES	200	90 day	576.32
Gocovri	amantadine	Must be uninsured or underinsured	NO	NO	NO	NO	YES	500	90 Day	2146.87
Advair Diskus	fluticasone propionate/salmeterol xinafoate	NO	YES	NO	NO	600	YES	250	90 Day	296.83
Advair DiskusPowder	fluticasone propionate/salmeterol xinafoate	NO	YES	NO	NO	600	YES	250	90 Day	296.83
Advair HFA	fluticasone propionate/salmeterol xinafoate	NO	YES	NO	NO	600	YES	250	90 Day	360.95
Advair HFAAerosol	fluticasone propionate/salmeterol xinafoate	NO	YES	NO	NO	600	YES	250	90 Day	360.95
Anoro Ellipta	umeclidinium bromide/vilanterol trifenatate	NO	YES	NO	NO	600	YES	250	90 Day	345.27
Avandia	rosiglitazone maleate	NO	YES	NO	NO	600	YES	250	90 Day	180
Avandia Tablets	rosiglitazon/glimepiride	NO	YES	NO	NO	600	YES	250	90 Day	161.72
AvandiaTablet	rosiglitazone maleate	NO	YES	NO	NO	600	YES	250	90 Day	161.72
Avodart Soft Gelatin Tablets	dutasteride	NO	YES	NO	NO	600	YES	250	90 Day	211.87
Avodart Tablet	dutasteride	NO	YES	NO	NO	600	YES	250	90 Day	211.87
Bactroban Cream	mupirocin calcium	NO	YES	NO	NO	600	YES	250	90 Day	222.17
Bactroban Cream2	mupirocin calcium	NO	YES	NO	NO	600	YES	250	90 Day	222.17
Bactroban Nasal Ointment	mupirocin calcium	NO	YES	NO	NO	600	YES	250	90 Day	168.98
Bactroban Ointment	mupirocin calcium	NO	YES	NO	NO	600	YES	250	90 Day	168.98
Bactroban Ointment; Nasal2	mupirocin calcium	NO	YES	NO	NO	600	YES	250	90 Day	168.98
Bactroban Ointment2	mupirocin calcium	NO	YES	NO	NO	600	YES	250	90 Day	168.98
Beconase AQ	beclomethasone	NO	YES	NO	NO	600	YES	250	90 Day	314
Beconase AQSpray; Nasal0.042	beclomethasone	NO	YES	NO	NO	600	YES	250	90 Day	314
Breo Ellipta	fluticasone furoate/vilanterol trifenatate	NO	YES	NO	NO	600	YES	250	90 Day	317.59
Breo ElliptaInhalation Powder	fluticasone furoate/vilanterol trifenatate	NO	YES	NO	NO	600	YES	250	90 Day	317.59
Coreg CR	carvedilol phosphate	NO	YES	NO	NO	600	YES	250	90 Day	317.76
Coreg CR Capsule ER	carvedilol	NO	YES	NO	NO	600	YES	250	90 Day	317.76
DuacGel1/5	clindamycin phosphate/benzoyl peroxide	NO	YES	NO	NO	600	YES	250	90 Day	387.06
Epivir-HBVOral Solution	lamivudine	NO	YES	NO	NO	600	YES	250	90 Day	128.71
Epivir-HBVTablet	lamivudine	NO	YES	NO	NO	600	YES	250	90 Day	479.31
Flovent Diskus	fluticasone propionate	NO	YES	NO	NO	600	YES	250	90 Day	163.36
Flovent HFA	fluticasone propionate	NO	YES	NO	NO	600	YES	250	90 Day	230.15
Imitrex Nasal Spray	sumatriptan	NO	YES	NO	NO	600	YES	250	90 Day	521.31
Imitrex Spray	sumatriptan	NO	YES	NO	NO	600	YES	250	90 Day	417.91
Incruse Ellipta	umeclidinium bromide	NO	YES	NO	NO	600	YES	250	90 Day	12049
Jalyn	dutasteride/tamsulosin	NO	YES	NO	NO	600	YES	250	90 Day	12049
Jalyn Capsule	dutasteride and tamsulosin	NO	YES	NO	NO	600	YES	250	90 Day	211.67
Lamictal ODTPatient Titration Kit	lamotrigine	NO	YES	NO	NO	600	YES	250	90 Day	719.23
Lamictal Tablet	lamotrigine	NO	YES	NO	NO	600	YES	250	90 Day	854.82
Lamictal XRPatient Titration Kit	lamotrigine	NO	YES	NO	NO	600	YES	250	90 Day	719.23
Lamictal XRTablet ER	lamotrigine	NO	YES	NO	NO	600	YES	250	90 Day	854.82
Malarone Tablet	atovaquone and proguanil	NO	YES	NO	NO	600	YES	250	90 Day	180
Mepron Suspension	atovaquone	NO	YES	NO	NO	600	YES	250	90 Day	1564.26
Potiga Tablet	ezogabine	NO	YES	NO	NO	600	YES	250	90 Day	1084.33
Relenza	zanamivir	NO	YES	NO	NO	600	YES	250	90 Day	60.05
Requip XL	ropinirole	NO	YES	NO	NO	600	YES	250	90 Day	555.11
Requip XL Tablet ER	ropinirole	NO	YES	NO	NO	600	YES	250	90 Day	162.94
Rythmol SR Capsule ER	propafeNO	NO	YES	NO	NO	600	YES	250	90 Day	800.84
Soriatane Capsule	acitretin	NO	YES	NO	NO	600	YES	250	90 Day	1621.74
Ventolin HFA Inhalant	albuterol sulfate	NO	YES	NO	NO	600	YES	250	90 Day	53.25
Veramyst Nasal Spray	fluticasone furoate	NO	YES	NO	NO	600	YES	250	90 Day	217.95
Veramyst Spray; Nasal	fluticasone furoate	NO	YES	NO	NO	600	YES	250	90 Day	218.15
Concerta	methylphenidate	YES	YES	NO	4	NO	YES	300	90 Day	354.66
Doxil	doxorubicin	YES	YES	NO	4	NO	YES	300	90 Day	1240.98
Duragesic CIIPatch	fentanyl transdermal system	YES	YES	NO	4	NO	YES	300	90 Day	3375.36
Edurant	rilpivirne	YES	YES	NO	4	NO	YES	300	90 Day	992.24
Elmiron	pentosan polysulfate sodium	YES	YES	NO	4	NO	YES	300	90 Day	50
Haldol Injection	haloperidol	YES	YES	NO	4	NO	YES	300	90 Day	212.9
Imbruvica	ibrutinib	YES	YES	NO	4	NO	YES	300	90 Day	14397.38
Intelence	etravirine	YES	YES	NO	4	NO	YES	300	90 Day	587.79
Invega	paliperidone palmitate	YES	YES	NO	4	NO	YES	300	90 Day	1170.92
Invega Sustenna ER	paliperidone palmitate	YES	YES	NO	4	NO	YES	300	90 Day	1147.07
Invokamet	canagliflozin; metformin hydrochloride	YES	YES	NO	4	NO	YES	300	90 Day	438.62
Invokamet XR	canagliflozin; metformin hydrochloride	YES	YES	NO	4	NO	YES	300	90 Day	438.62
Invokana	canagliflozin	YES	YES	NO	4	NO	YES	300	90 Day	462.74
Olysio Capsule	simeprevir	YES	YES	NO	4	NO	YES	300	90 Day	76315.2
Orthovisc Injection	high molecular weight hyaluronan	YES	YES	NO	4	NO	YES	300	90 Day	592
Pancreaze Capsule	pancrelipase	YES	YES	NO	4	NO	YES	300	90 Day	286.65
Prezista Tablet	darunavir	YES	YES	NO	4	NO	YES	300	90 Day	1096.99
Procrit Injection	epoetin alfa	YES	YES	NO	4	NO	YES	300	90 Day	5724.17
Remicade Vial	infliximab	YES	YES	NO	4	NO	YES	300	90 Day	1136.9
Risperdal ConstaInjection	risperidone	YES	YES	NO	4	NO	YES	300	90 Day	416.61
Risperdal M-TAB	risperidone	YES	YES	NO	4	NO	YES	300	90 Day	634.76
Risperdal Oral Solution	risperidone	YES	YES	NO	4	NO	YES	300	90 Day	380.32
Risperdal Tablet	risperidone	YES	YES	NO	4	NO	YES	300	90 Day	340.49
Simponi	golimumab	YES	YES	NO	4	NO	YES	300	90 Day	4642.89
Simponi ARIA	golimumab	YES	YES	NO	4	NO	YES	300	90 Day	1832.1
Sporanox Capsule	itraconazole	YES	YES	NO	4	NO	YES	300	90 Day	1677.28
Sporanox Oral Solution	itraconazole	YES	YES	NO	4	NO	YES	300	90 Day	341.37
Stelara	ustekinumab	YES	YES	NO	4	NO	YES	300	90 Day	10970.59
Sylvant	siltuximab	YES	YES	NO	4	NO	YES	300	90 Day	860.63
Topamax Capsule	topiramate	YES	YES	NO	4	NO	YES	300	90 Day	413.41
Topamax Tablet	topiramate	YES	YES	NO	4	NO	YES	300	90 Day	720.73
Tremfya	guselkumab	YES	YES	NO	4	NO	YES	300	90 Day	10095
Xarelto	rivroxaban	YES	YES	NO	4	NO	YES	300	90 Day	388.25
Yondelis	trabectedin	YES	YES	NO	4	NO	YES	300	90 Day	2679.46
Zytiga	abiraterone acetate	YES	YES	NO	4	NO	YES	300	90 Day	9138.7
Forteo	teriparatide	NO	YES	NO	NO	1100	YES	300	90 Day	2947.07
Asmanex TwisthalerInhalation	mometasone	YES	YES	NO	NO	NO	YES	400	90 Day	309.92
Belsomra	suvorexant	YES	YES	NO	NO	NO	YES	400	90 Day	337
Crixivan	indinavir sulfate	YES	YES	NO	NO	NO	YES	400	90 Day	475
Diprolene Cream0.05	betamethasone	YES	YES	NO	NO	NO	YES	400	90 Day	197.16
Diprolene Lotion0.05	betamethasone	YES	YES	NO	NO	NO	YES	400	90 Day	199.41
Diprolene Ointment0.05	betamethasone	YES	YES	NO	NO	NO	YES	400	90 Day	197.16
Dulera Aerosol	mometasone furoate/formoterol fumarate dihydrate	YES	YES	NO	NO	NO	YES	400	90 Day	299.19
Janumet	Metformin,Sitaglipton	YES	YES	NO	NO	NO	YES	400	90 Day	457
Janumet Tablet	metformin/sitagliptin phosphate	YES	YES	NO	NO	NO	YES	400	90 Day	391.89
Janumet XR	Metformin,Sitaglipton	YES	YES	NO	NO	NO	YES	400	90 Day	457
Janumet XRTablet ER	metformin/sitagliptin phosphate	YES	YES	NO	NO	NO	YES	400	90 Day	391.89
Januvia	Sitaglipton	YES	YES	NO	NO	NO	YES	400	90 Day	457
Januvia Tablet	sitagliptin	YES	YES	NO	NO	NO	YES	400	90 Day	388.66
Lotrisone Cream	clotrimazole/betamethasone	YES	YES	NO	NO	NO	YES	400	90 Day	123.16
Maxalt Tablet	rizatriptan benzoate	YES	YES	NO	NO	NO	YES	400	90 Day	226.29
Maxalt-MLTTablet	rizatriptan benzoate	YES	YES	NO	NO	NO	YES	400	90 Day	226.28
Nasonex Spray	mometasone furoate monohydrate	YES	YES	NO	NO	NO	YES	400	90 Day	244.58
Nitro-Dur	nitroglycerin	YES	YES	NO	NO	NO	YES	400	90 Day	182.52
Proventil	albuterol sulfate	YES	YES	NO	NO	NO	YES	400	90 Day
Proventil HFA	albuterol sulfate	YES	YES	NO	NO	NO	YES	400	90 Day
Proventil HFA Aerosol	albuterol sulfate	YES	YES	NO	NO	NO	YES	400	90 Day	88.06
Remeron Tablet	mirtazapine	YES	YES	NO	NO	NO	YES	400	90 Day	173.59
Singulair	Montelukast Sodium	YES	YES	NO	NO	NO	YES	400	90 Day	246
Singulair Asthma Oral Granules	montelukast sodium	YES	YES	NO	NO	NO	YES	400	90 Day	222.17
Stromectol Tablet	ivermectin	YES	YES	NO	NO	NO	YES	400	90 Day	15.71
Trusopt Ophthalmic Solution	dorzolamide	YES	YES	NO	NO	NO	YES	400	90 Day	60
Vytorin Tablet	ezetimibe/simvastatin	YES	YES	NO	NO	NO	YES	400	90 Day	319.95
Zetia	ezetimibe	YES	YES	NO	NO	NO	YES	400	90 Day	369
Zetia Tablet	ezetimibe	YES	YES	NO	NO	NO	YES	400	90 Day	323.02
EpiPen 2-PakInjection	epinephrine	YES	YES	NO	NO	NO	NO	400	90 Day	697
EpiPen Jr 2-Pak	NO PROGRAM AVAILABLE	YES	YES	NO	NO	NO	NO	400	90 Day	697
EpiPen Jr 2-Pak Injection	epinephrine	YES	YES	NO	NO	NO	NO	400	90 Day	697
Gleostine	lomustine	NO	NO	NO	NO	NO	YES	200	90 Day	350
Neoral	cyclosporine	YES	NO	NO	NO	NO	YES	400	90 Day	75
Tobi	tobramycin	YES	NO	NO	NO	NO	YES	400	90 Day	386
Tobi Podhaler	tobramycin	YES	NO	NO	NO	NO	YES	400	90 Day	386
Afinitor	everolimus	YES	NO	NO	NO	NO	YES	400	90 Day	3715.52
Afinitor Disperz	everolimus	YES	NO	NO	NO	NO	YES	400	90 Day	3715.52
Arzerra	NO PROGRAM AVAILABLE	YES	NO	NO	NO	NO	YES	400	90 Day	20000
AZO Suspension/ Drops	brinzolamide	YES	NO	NO	NO	NO	YES	400	90 Day	292
Azopt	brinzolamide	YES	NO	NO	NO	NO	YES	400	90 Day	292
Cipro	ciprofloxacin/dexamethasone sterile otic suspension	YES	NO	NO	NO	NO	YES	400	90 Day	257
Coartem	artmether/lumefantrine	YES	NO	NO	NO	NO	YES	400	90 Day	130
Durezol	difluprednate	YES	NO	NO	NO	NO	YES	400	90 Day	180
Entresto	sacubitril/valsartan	YES	NO	NO	NO	NO	YES	400	90 Day	468.57
Exjade	deferasirox	YES	NO	NO	NO	NO	YES	400	90 Day	18644.58
Extavia	interferon beta-1b	YES	NO	NO	NO	NO	YES	400	90 Day	6268.54
Farydak	panobinostat lactate	YES	NO	NO	NO	NO	YES	400	90 Day	8011.48
Gilenya	fingolimod	YES	NO	NO	NO	NO	YES	400	90 Day	5412.92
Glatopa	glatiramer acetate	YES	NO	NO	NO	NO	YES	400	90 Day	1953.29
Gleevec	imatinib	YES	NO	NO	NO	NO	YES	400	90 Day	1406.6
Hycamtin	topotecan	YES	NO	NO	NO	NO	YES	400	90 Day	75.95
Myfortic	mycophenolic acid	YES	NO	NO	NO	NO	YES	400	90 Day	292
Pazeo	olopatadine	YES	NO	NO	NO	NO	YES	400	90 Day	292
Tegretol	carbamazepine	YES	NO	NO	NO	NO	YES	400	90 Day
Tegretol XR	carbamazepine	Yes if not listed in the formulary	NO	NO	NO	NO	YES	400	90 Day
Gluca Gen HypokitInjection	glucagon	NO	YES	NO	NO	1000	YES	400	90 Day	257.57
Levemir FlexPenInjection	insulin detemir	NO	YES	NO	NO	1000	YES	400	90 Day	411.59
Levemir Injection	insulin detemir	NO	YES	NO	NO	1000	YES	400	90 Day	274.56
Novolin 70/30 VialInjection	human/insulin susp isophane	NO	YES	NO	NO	1000	YES	400	90 Day	140.79
Novolin N	insulin human	NO	YES	NO	NO	1000	YES	400	90 Day	291.71
Novolin N VialInjection	insulin human	NO	YES	NO	NO	1000	YES	400	90 Day	140.79
Novolin R	insulin human	NO	YES	NO	NO	1000	YES	400	90 Day	291.71
Novolin R VialInjection	insulin human	NO	YES	NO	NO	1000	YES	400	90 Day	140.79
NovoLog	insulin human	NO	YES	NO	NO	1000	YES	400	90 Day	291.71
NovoLog FlexPenInjection	insulin aspart√•	NO	YES	NO	NO	1000	YES	400	90 Day	542.72
NovoLog Injection	insulin aspart√•	NO	YES	NO	NO	1000	YES	400	90 Day	281.26
NovoLog Mix 70/30	insulin human	NO	YES	NO	NO	1000	YES	400	90 Day	291.71
NovoLog Mix 70/30 FlexPen Cartridges	insulin aspart protamine	NO	YES	NO	NO	1000	YES	400	90 Day	291.71
NovoLog Mix 70/30Vial	insulin aspart protamine	NO	YES	NO	NO	1000	YES	400	90 Day	291.71
Tresiba	Degludec	NO	YES	NO	NO	1000	YES	400	90 Day	489.84
Tresiba FlexTouch Pen	Degludec	NO	YES	NO	NO	1000	YES	400	90 Day	489.84
Victoza Injection	liraglutide	NO	YES	NO	NO	1000	YES	400	90 Day	762.19
Victoza	liraglutide	NO	YES	NO	NO	1000	YES	400	90 Day	872
Aromasin Tablet	exemestane	YES	YES	NO	NO	NO	YES	400	90 Day	1058.72
Arthrotec Tablet	diclofenac sodium/misoprostol	YES	YES	NO	NO	NO	YES	400	90 Day	143
Bosulif Tablet	bosutinib	YES	YES	NO	NO	NO	YES	400	90 Day	3196.96
Caduet Tablets	amlodipine besylate/atorvastatin calcium	YES	YES	NO	NO	NO	YES	400	90 Day	408.15
Caverjec tInjection	alprostadil	YES	YES	NO	NO	NO	YES	400	90 Day	595
Celebrex Capsule	celecoxib	YES	YES	NO	NO	NO	YES	400	90 Day	761.35
Celontin Capsule	methsuximide	YES	YES	NO	NO	NO	YES	400	90 Day	453
Chantix Tablet	varenicline	YES	YES	NO	NO	NO	YES	400	90 Day	369.34
Cleocin Capsule	clindamycin phosphate	YES	YES	NO	NO	NO	YES	400	90 Day	248.61
Cleocin PediatricSolution	clindamycin phosphate	YES	YES	NO	NO	NO	YES	400	90 Day	137.71
Cleocin PhosphateInjection	clindamycin phosphate	YES	YES	NO	NO	NO	YES	400	90 Day	121.95
Cleocin Suppository; Vaginal	clindamycin phosphate	YES	YES	NO	NO	NO	YES	400	90 Day	170
Cleocin Swab1	clindamycin phosphate	YES	YES	NO	NO	NO	YES	400	90 Day	497
Colestid Granules; Flavored	colestipol	YES	YES	NO	NO	NO	YES	400	90 Day	385.12
Colestid Tablet	colestipol	YES	YES	NO	NO	NO	YES	400	90 Day	244.04
Cortef Tablet	hydrocortisone	YES	YES	NO	NO	NO	YES	400	90 Day	97.55
Depo-EstradiolInjection	estradiol cypionate	YES	YES	NO	NO	NO	YES	400	90 Day	92.6
Depo-MedrolInjection	methylprednisolone acetate	YES	YES	NO	NO	NO	YES	400	90 Day	1201.59
Depo-ProveraInjection	medroxyprogesterone acetate	YES	YES	NO	NO	NO	YES	400	90 Day	5012.83
Detrol Tablet	tolterodine tartrate	YES	YES	NO	NO	NO	YES	400	90 Day	446.57
Dilantin Capsule	phenytoin	YES	YES	NO	NO	NO	YES	400	90 Day	93.8
Dilantin-125Oral Suspension	phenytoin	YES	YES	NO	NO	NO	YES	400	90 Day	124.44
Effexor XRCapsule ER	venlafaxine	YES	YES	NO	NO	NO	YES	400	90 Day	406.59
Ellence Injection	epirubicin	YES	YES	NO	NO	NO	YES	400	90 Day	56
Emcyt Capsule	estramustine phosphate sodium	YES	YES	NO	NO	NO	YES	400	90 Day	2404.72
Estring Vaginal Ring	Estradiol	YES	YES	NO	NO	NO	YES	400	90 Day	372.09
Feldene Capsule	piroxicam	YES	YES	NO	NO	NO	YES	400	90 Day	814
Glyset Tablet	miglitol	YES	YES	NO	NO	NO	YES	400	90 Day	295
Idamycin PFSInjection	idarubicin	YES	YES	NO	NO	NO	YES	400	90 Day	33
Inlyta Tablet	axitinib	YES	YES	NO	NO	NO	YES	400	90 Day	6561.79
Inspra Tablet	eplereNO	YES	YES	NO	NO	NO	YES	400	90 Day	365
Lincocin Injection	lincomycin	YES	YES	NO	NO	NO	YES	400	90 Day	219
Lyrica	Pregabalin	YES	YES	NO	NO	NO	YES	400	90 Day
Lyrica Capsule	pregabalin	YES	YES	NO	NO	NO	YES	400	90 Day	566.18
Lyrica Oral Solution	pregabalin	YES	YES	NO	NO	NO	YES	400	90 Day	792.15
Mycobutin Capsule	rifabutin	YES	YES	NO	NO	NO	YES	400	90 Day	1829.65
Nicotrol Inhalation System	nicotine cartridge	YES	YES	NO	NO	NO	YES	400	90 Day	443
Norpace Capsule	disopyramide phosphate	YES	YES	NO	NO	NO	YES	400	90 Day	463.22
Norpace CRCapsule ER	disopyramide phosphate	YES	YES	NO	NO	NO	YES	400	90 Day	603.92
Premarin	conjugated estrogens	YES	YES	NO	NO	NO	YES	400	90 Day
Premarin Cream	estrogens conjugated	YES	YES	NO	NO	NO	YES	400	90 Day	345.75
Premarin Tablet	estrogens conjugated	YES	YES	NO	NO	NO	YES	400	90 Day	156.78
Premphase Tablet	estrogens conjugated/medroxyprogesterone acetate	YES	YES	NO	NO	NO	YES	400	90 Day	200
Pristiq	desvenlafaxine succinate	YES	YES	NO	NO	NO	YES	400	90 Day	1128
Pristiq Tablet ER	desvenlafaxine	YES	YES	NO	NO	NO	YES	400	90 Day	319.1
Procardia Capsule	nifedipine	YES	YES	NO	NO	NO	YES	400	90 Day	238.51
Procardia XL Tablet ER	nifedipine	YES	YES	NO	NO	NO	YES	400	90 Day	179.7
Quillichew ER	methylphenidate	YES	YES	NO	NO	NO	YES	400	90 Day	1128
Quillivant XR	methylphenidate	YES	YES	NO	NO	NO	YES	400	90 Day	311
Quillivant XR Suspension ER	methylphenidate	YES	YES	NO	NO	NO	YES	400	90 Day	314
Rapamune Solution	sirolimus	YES	YES	NO	NO	NO	YES	400	90 Day	1582.52
Rapamune Tablet	sirolimus	YES	YES	NO	NO	NO	YES	400	90 Day	1582.54
Relpax	eletriptan hydrobromide	YES	YES	NO	NO	NO	YES	400	90 Day	399
Relpax Tablet	eletriptan HBr	YES	YES	NO	NO	NO	YES	400	90 Day	359.99
Revatio Tablet	sildenafil	YES	YES	NO	NO	NO	YES	400	90 Day	4122.77
Skelaxin Tablet	metaxalone	YES	YES	NO	NO	NO	YES	400	90 Day	879.75
Sutent Capsule	sunitinib malate	YES	YES	NO	NO	NO	YES	400	90 Day	16240.58
Synarel Spray	nafarelin acetate	YES	YES	NO	NO	NO	YES	400	90 Day	227.39
Tikosyn	dofetilide	YES	YES	NO	NO	NO	YES	400	90 Day	160
Tikosyn Capsule	dofetilide	YES	YES	NO	NO	NO	YES	400	90 Day	442
Toviaz Tablet ER	fesoterodine fumarate	YES	YES	NO	NO	NO	YES	400	90 Day	281.56
Trecator	ethionamide	YES	YES	NO	NO	NO	YES	400	90 Day	90
Trecator Tablet	ethionamide	YES	YES	NO	NO	NO	YES	400	90 Day	277.14
VFEND Filmtab	voriconazole	YES	YES	NO	NO	NO	YES	400	90 Day	1976.55
Viagra	sildenafil citrate	YES	YES	NO	NO	NO	YES	400	90 Day	90
Viagra Tablet	sildenafil citrate	YES	YES	NO	NO	NO	YES	400	90 Day	628.05
Xalatan Ophthalmic Drops0.005	latanoprost	YES	YES	NO	NO	NO	YES	400	90 Day	180.71
Xalkori Capsule	crizotinib	YES	YES	NO	NO	NO	YES	400	90 Day	9600
Xeljanz	tofacitinib	YES	YES	NO	NO	NO	YES	400	90 Day	4284
Zarontin	ethosuximide	YES	YES	NO	NO	NO	YES	400	90 Day	90
Zarontin Capsule	ethosuximide	YES	YES	NO	NO	NO	YES	400	90 Day	240
Zinecard Injection	dexrazoxane	YES	YES	NO	NO	NO	YES	400	90 Day	271.31
Zyvox	linezolid	YES	YES	NO	NO	NO	YES	400	90 Day	150
Adlyxin	lixisenatide	YES	YES	NO	5	NO	YES	250	90 Day	593.94
Apidra	insulin glulisine recombinant	YES	YES	NO	5	NO	YES	250	90 Day	423.51
Clolar	clofarabine	YES	YES	NO	5	NO	YES	250	90 Day	1005
Carbatrol	carbamazepine	Determined case by case	YES	NO	NO	NO	YES	300	90 Day	230
Fosrenol	lanthanum carbonate	Determined case by case	YES	NO	NO	NO	YES	300	90 Day	1136
Intuniv	guanfacine	Determined case by case	YES	NO	NO	NO	YES	300	90 Day	1022
Lialda	mesalamine	Determined case by case	YES	NO	NO	NO	YES	300	90 Day	1181
Pentasa	mesalamine	Determined case by case	YES	NO	NO	NO	YES	300	90 Day	769
Vyvanse	lisdexamfetamine dimesylate	Determined case by case	YES	NO	NO	NO	YES	300	90 Day	270
Amitiza	Lubiprostone	YES	YES	NO	3	NO	YES	300	90 Day	349.69
Colcrys	colchicine	YES	YES	NO	3	NO	YES	300	90 Day	234.84
Dexilant	dexlansoprazole	YES	YES	NO	3	NO	YES	300	90 Day	244.1
Kazano	algoliptin/metformin hci	YES	YES	NO	3	NO	YES	300	90 Day	431.48
Nesina	algoliptin	YES	YES	NO	3	NO	YES	300	90 Day	431.48
Oseni	algoliptin/pioglitazone	YES	YES	NO	3	NO	YES	300	90 Day	431.48
Prevacid	lansoprazole	YES	YES	NO	3	NO	YES	300	90 Day	478.36
Rozerem	ramelteon	YES	YES	NO	3	NO	YES	300	90 Day	478.36
Trintellix	vortioxetine	YES	YES	NO	3	NO	YES	300	90 Day	346.4
Uloric	febuxostat	YES	YES	NO	3	NO	YES	300	90 Day	285.02
Gabitril	tiagabine	YES	NO	NO	NO	NO	YES	300	90 Day	270.56
Nuvigil	armodafinil	YES	NO	NO	NO	NO	YES	300	90 Day	765.75
ORAP	pimozide	YES	NO	NO	NO	NO	YES	300	90 Day	134.03
Proair HFA	albuterol sulfate	YES	NO	NO	NO	NO	YES	300	90 Day	56.3
Proair Respiclick	albuterol	YES	NO	NO	NO	NO	YES	300	90 Day	56.3
Proglycem	diazoxide	YES	NO	NO	NO	NO	YES	300	90 Day	305.26
QNASL	beclomethasone dipropionate	YES	NO	NO	NO	NO	YES	300	90 Day	222.23
QVAR	beclomethasone	YES	NO	NO	NO	NO	YES	300	90 Day	181.25
Neupro	rotigotine	YES	YES	NO	NO	NO	YES	300	90 Day	$858.30
Keppra Oral Solution	levetiracetam	YES	YES	NO	NO	NO	YES	300	90 Day	562.6
Keppra Tablet	levetiracetam	YES	YES	NO	NO	NO	YES	300	90 Day	122.46
Keppra XR Tablet	levetiracetam	YES	YES	NO	NO	NO	YES	300	90 Day	122.46
Vimpat	Lacosamide	YES	YES	NO	NO	NO	YES	300	90 Day	858.3
Gengraf	cyclosporine	Yes if not listed in the formulary	YES	NO	NO	NO	YES	300	90 Day	22
Humira Container	adalimumab	Yes if not listed in the formulary	YES	NO	NO	NO	YES	300	90 Day	4976.48
Descovy	emtricitabine/tenofovir alafenamide	YES	YES	NO	NO	NO	YES	450	90 Day	1672
Genvoya	elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide	YES	YES	NO	NO	NO	YES	450	90 Day	2933.58
Emtriva	emtricitabine	YES	YES	NO	NO	NO	YES	450	90 Day	554
Hepsera	adefovir dipivoxil	YES	YES	NO	NO	NO	YES	450	90 Day	346.62
Alphagan P	brimonidine tartrate	NO	YES	YES	NO	NO	YES	400	90 Day	159.94
Bystolic	nebivolol	NO	YES	YES	NO	NO	YES	400	90 Day	139.35
Byvalson	nebivolol/valsartan	NO	YES	YES	NO	NO	YES	400	90 Day	128.01
CriNO	progesterone vaginal	NO	YES	YES	NO	NO	YES	400	90 Day	550
Dalvance	dalbavancin	NO	YES	YES	NO	NO	YES	400	90 Day	3056
Delzicol	mesalamine	NO	YES	YES	NO	NO	YES	400	90 Day	660
Fetzima	levomilnacipran	NO	YES	YES	NO	NO	YES	400	90 Day	375.39
Fetzima Titration Pack	levomilnacipran	NO	YES	YES	NO	NO	YES	400	90 Day	375.39
Gelnique	oxybutynin chloride	NO	YES	YES	NO	NO	YES	400	90 Day	394.09
Combigan	brimonidine tartrate/timolol maleate)	NO	YES	NO	NO	NO	YES	400	90 Day
Aranesp	darbepoetin alfa	YES	YES	NO	NO	NO	YES	500	90 Day	1270.16
Enbrel	etanercept	YES	YES	NO	NO	NO	YES	500	90 Day	4976
Epogen	epoetin alfa	YES	YES	NO	NO	NO	YES	500	90 Day	38.02
Blincyto	blinatumomab	YES	YES	NO	NO	NO	YES	500	90 Day	178000
Bydureon	exenatide synthetic	NO	YES	NO	3	NO	YES	250	90 Day	664.09
Bydureon BCise	exenatide	NO	YES	NO	3	NO	YES	250	90 Day	664.09
Bydureon Pen	exenatide synthetic	NO	YES	NO	3	NO	YES	250	90 Day	664.09
Byetta	exenatide	NO	YES	NO	3	NO	YES	250	90 Day	732.05
Calquence	acalabrutinib	NO	YES	NO	3	NO	YES	250	90 Day	13974
Daliresp	roflumilast	NO	YES	NO	3	NO	YES	250	90 Day	367
Farxiga	dapagliflozin	NO	YES	NO	3	NO	YES	250	90 Day	469.84
Fasenra	benralizumab	NO	YES	NO	3	NO	YES	250	90 Day	2833
Faslodex	fulvestrant	NO	YES	NO	3	NO	YES	250	90 Day	1955
Brilinta	ticagrelor	NO	YES	NO	3	NO	YES	250	90 Day	360
Alrex	loteprednol etabonate	NO	YES	NO	NO	NO	YES	400	90 Day	225.48
Ancobon	flucytosine	NO	YES	NO	NO	NO	YES	400	90 Day
Android	methyltestosterone	NO	YES	NO	NO	NO	YES	400	90 Day
Apriso	mesalamine	NO	YES	NO	NO	NO	YES	400	90 Day
Bepreve	bepotastine besilate	NO	YES	NO	NO	NO	YES	400	90 Day
Besivance	besifloxacin	NO	YES	NO	NO	NO	YES	400	90 Day
Carac	fluorouracil	NO	YES	NO	NO	NO	YES	400	90 Day
Clindagel	clindamycin	NO	YES	NO	NO	NO	YES	400	90 Day
Cuprimine	penicillamine	NO	YES	NO	NO	NO	YES	400	90 Day
Cycloset	bromocriptine	NO	YES	NO	NO	NO	YES	400	90 Day
Demser	metyrosine	NO	YES	NO	NO	NO	YES	400	90 Day
Elidel	pimecrolimus	NO	YES	NO	NO	NO	YES	400	90 Day
Jublia	efinaconazole	NO	YES	NO	NO	NO	YES	400	90 Day
Lacrisert	hydroxypropyl cellulose	NO	YES	NO	NO	NO	YES	400	90 Day
Locoid	hydrocortisone butyrate	NO	YES	NO	NO	NO	YES	400	90 Day
Lodosyn	carbidopa	NO	YES	NO	NO	NO	YES	400	90 Day
Lotemax	loteprednol etabonate	NO	YES	NO	NO	NO	YES	400	90 Day
Luzu	luliconazole	NO	YES	NO	NO	NO	YES	400	90 Day
Macugen	pegaptanib sodium	NO	YES	NO	NO	NO	YES	400	90 Day
Mephyton	phytonadione	NO	YES	NO	NO	NO	YES	400	90 Day
MoviPrep	sodium/ascorbic acid	NO	YES	NO	NO	NO	YES	400	90 Day
Noritate	metronidazole	NO	YES	NO	NO	NO	YES	400	90 Day
Onexton	clindamycin/benzoyl peroxide	NO	YES	NO	NO	NO	YES	400	90 Day
Oxsoralen	methoxsalen	NO	YES	NO	NO	NO	YES	400	90 Day
Prolensa	bromfenac sodium	NO	YES	NO	NO	NO	YES	400	90 Day
Relistor	methylnaltrexone bromide	NO	YES	NO	NO	NO	YES	400	90 Day
Renova	tretinoin	NO	YES	NO	NO	NO	YES	400	90 Day
Retin-A MICRO	tretinoin	NO	YES	NO	NO	NO	YES	400	90 Day
Retisert	fluocinolone acetonide	NO	YES	NO	NO	NO	YES	400	90 Day
Solodyn	minocycline	NO	YES	NO	NO	NO	YES	400	90 Day
Syprine	trientine	NO	YES	NO	NO	NO	YES	400	90 Day
Targretin	bexarotene	NO	YES	NO	NO	NO	YES	400	90 Day
Tasmar	tolcapone	NO	YES	NO	NO	NO	YES	400	90 Day
Timoptic in Ocudose	ophthalmic solution/drops timolol maleate	NO	YES	NO	NO	NO	YES	400	90 Day
Uceris	budesonide	NO	YES	NO	NO	NO	YES	400	90 Day
Visudyne	verteporfin	NO	YES	NO	NO	NO	YES	400	90 Day
Vyzulta	latanoprostene bunod	NO	YES	NO	NO	NO	YES	400	90 Day
Xifaxan	rifaximin	NO	YES	NO	NO	NO	YES	400	90 Day
Zelapar	selegiline	NO	YES	NO	NO	NO	YES	400	90 Day
Zirgan	ganciclovir	NO	YES	NO	NO	NO	YES	400	90 Day
Zyclara	imiquimod	NO	YES	NO	NO	NO	YES	400	90 Day
Zylet	loteprednol etabonate/tobramycin	NO	YES	NO	NO	NO	YES	400	90 Day
Atrovent	ipratropium bromide	YES	YES	NO	NO	NO	YES	400	90 Day	376.04
Aptivus	tipranavir	NO	YES	NO	NO	NO	YES	400	90 Day	409.45
Atrovent HFA	ipratropium bromide	YES	YES	NO	NO	NO	YES	400	90 Day	376.04
Combivent	pratropium bromide/albuterol	YES	YES	NO	NO	NO	YES	400	90 Day
Combivent Respimat	pratropium bromide/albuterol	YES	YES	NO	NO	NO	YES	400	90 Day
Gilotrif	afatinib	YES	YES	NO	NO	NO	YES	400	90 Day	8324.85
Synjardy	empagliflozin/metformin	YES	YES	NO	NO	NO	YES	400	90 Day	250
Tradjenta	linagliptin	YES	YES	NO	NO	NO	YES	400	90 Day	250
Droxia	hydroxyurea	NO	YES	NO	NO	NO	YES	400	90 Day	85
Eliquis	apixaban	NO	YES	NO	3	NO	YES	400	90 Day	440
Empliciti	elotuzumab	NO	YES	NO	NO	NO	YES	400	90 Day	10000
Etopophos	etoposide	NO	YES	NO	NO	NO	YES	400	90 Day	145
Evotaz	atazanavir sulfate/cobicistat	NO	YES	NO	3	NO	YES	400	90 Day	1647
Granix	TBO-filgrastim	NO	NO	NO	NO	NO	NO	400	90 Day	859.33
Bendeka	bendamustine	NO	NO	NO	NO	NO	NO	400	90 Day	50
Exalgo	hydromorphone	NO	YES	NO	NO	NO	YES	200	90 Day	217.62
Banzel	rufinamide	Yes if not listed in the formulary	YES	NO	NO	NO	YES	300	90 Day	1600
Equetro	carbamazepine	NO	NO	NO	NO	NO	YES	200	90 Day	252.48
Lamictal	lamotrigine	NO	YES	NO	NO	600	YES	250	90 Day
Lamictal CD	lamotrigine	NO	YES	NO	NO	600	YES	250	90 Day
Lamictal ODT	lamotrigine	NO	YES	NO	NO	600	YES	250	90 Day
Lamictal XR	lamotrigine	NO	YES	NO	NO	600	YES	250	90 Day
Arnuity Ellipta	fluticasone furoate	NO	YES	NO	NO	600	YES	250	90 Day
Flovent	fluticasone propionate	NO	YES	NO	NO	600	YES	250	90 Day	241.48
Havrix	hepatitis A vaccine inactivated	NO	YES	NO	NO	600	YES	250	90 Day	74.28
Duac	benzoyl peroxide/clindamycin	NO	YES	NO	NO	600	YES	250	90 Day	72.83
Engerix-B	hepatitis B vaccine recombinant	NO	YES	NO	NO	600	YES	250	90 Day	61.98
Akynzeo	netupitant/palonosetron	YES	YES	NO	NO	NO	YES	400	90 Day	2189.18
Cinvanti	aprepitant	YES	NO	NO	NO	NO	NO	500	90 Day	1286
Hymovis	high molecular weight viscoelastic hyaluronan	NO	YES	NO	NO	NO	NO	250	90 Day	4559.31
Emverm	mebendazole	YES	YES	NO	NO	NO	YES	300	90 Day	1951
Darzalex	daratumumab	YES	YES	NO	4	NO	YES	300	90 Day	5850
Erleada	apalutamide	YES	YES	NO	4	NO	YES	300	90 Day	10852
Haldol	haloperidol	YES	YES	NO	4	NO	YES	300	90 Day	26
Haldol Decanoate	haloperidol	YES	YES	NO	4	NO	YES	300	90 Day	26
Lipitor	pitavastatin	NO	YES	NO	NO	NO	YES	150	90 Day
Livalo	pitavastatin	NO	YES	NO	NO	NO	YES	150	90 Day
Dificid	fidaxomicin	YES	YES	NO	NO	NO	YES	400	90 Day	3664
Dulera	formoterol fumarate/mometasone furoate	YES	YES	NO	NO	NO	YES	400	90 Day	317
Elocon	mometasone furoate	YES	YES	NO	NO	NO	YES	400	90 Day	28
Emend	aprepitant	YES	YES	NO	NO	NO	YES	400	90 Day	41.38
Aubagio	teriflunomide	NO	NO	NO	NO	NO	YES	250	90 Day	6500
EMSAM	selegiline	NO	NO	NO	NO	NO	NO	400	90 Day	1692
EpiPen	epinephrine	NO	NO	NO	NO	NO	YES	400	90 Day	141.22
EpiPen 2-Pak	epinephrine	NO	NO	NO	NO	NO	YES	400	90 Day	141.22
Arranon	nelarabine	YES	NO	NO	NO	NO	YES	400	90 Day
Cyramza	ramucirumab	NO	NO	NO	NO	NO	YES	250	90 Day	33066
Alimta	pemetrexed	NO	YES	NO	NO	NO	YES	250	90 Day	697.04
Aromasin	exemestane	YES	YES	NO	NO	NO	YES	400	90 Day
Caduet	amlodipine besylate/atorvastatin calcium	YES	YES	NO	NO	NO	YES	400	90 Day	80
Camptosar	irinotecan	YES	YES	NO	NO	NO	YES	400	90 Day	35
Caverject Impulse	alprostadil	YES	YES	NO	NO	NO	YES	400	90 Day	595
Celebrex	celecoxib	YES	YES	NO	NO	NO	YES	400	90 Day	201
Celontin	methsuximide	YES	YES	NO	NO	NO	YES	400	90 Day	127
Chantix	varenicline tartrate	YES	YES	NO	NO	NO	YES	400	90 Day	406
Cleocin	clindamycin	YES	YES	NO	NO	NO	YES	400	90 Day	85
Detrol	tolterodine tartrate	YES	YES	NO	NO	NO	YES	400	90 Day	50.48
Detrol LA	tolterodine tartrate	YES	YES	NO	NO	NO	YES	400	90 Day	50.48
Dilantin	phenytoin sodium	YES	YES	NO	NO	NO	YES	400	90 Day	25.34
Duavee	bazedoxifene acetate/conjugated estrogens	YES	YES	NO	NO	NO	YES	400	90 Day	158.77
Elelyso	taliglucerase alfa	YES	YES	NO	NO	NO	YES	400	90 Day	782.54
Ellence	epirubicin	YES	YES	NO	NO	NO	YES	400	90 Day	421
Emcyt	estramustine phosphate sodium	YES	YES	NO	NO	NO	YES	400	90 Day	1841
Estring	estradiol	YES	YES	NO	NO	NO	YES	400	90 Day	436
Eucrisa	crisaborole	YES	YES	NO	NO	NO	YES	400	90 Day	636
Feldene	piroxicam	YES	YES	NO	NO	NO	YES	400	90 Day	32.5
Flector Patch	diclofenac epolamine	YES	YES	NO	NO	NO	YES	400	90 Day	672.31
Fragmin	dalteparin	YES	YES	NO	NO	NO	YES	400	90 Day	4530
Genotropin	somatropin recombinant	YES	YES	NO	NO	NO	YES	400	90 Day	522.29
Glyset	miglitol	YES	YES	NO	NO	NO	YES	400	90 Day	67.3
Heparin	sodium	YES	YES	NO	NO	NO	YES	400	90 Day	53.15
Ibrance	NO PROGRAM AVAILABLE	YES	YES	NO	NO	NO	YES	400	90 Day	11966.61
Benefix	factor IX	Yes if not listed in the formulary	YES	NO	NO	NO	YES	400	90 Day	2700
Arthrotec	diclofenac sodium/misoprostol	YES	YES	NO	NO	NO	YES	400	90 Day	55
Besponsa	inotuzumab ozogamicin	Yes if not listed in the formulary	YES	NO	NO	NO	YES	400	90 Day	168300
Bosulif	bosutinib monohydrate	Yes if not listed in the formulary	YES	NO	NO	NO	YES	400	90 Day	14124
Adacel	tetanus toxoid-reduced diptheria toxoid-acellular pertussis	YES	YES	NO	5	NO	YES	250	90 Day	49.32
Elitek	rasburicase	YES	YES	NO	5	NO	YES	250	90 Day	2601
Fentora	fentanyl	YES	YES	NO	NO	NO	YES	300	90 Day	15052
Galzin	zinc acetate	YES	YES	NO	NO	NO	YES	300	90 Day	255.01
Briviact	brivaracetam	YES	YES	NO	NO	NO	YES	300	90 Day	1071
Epivir	lamivudine	NO	YES	NO	NO	NO	YES	500	90 Day	55.12
Epivir-HBV	lamivudine	NO	YES	NO	NO	NO	YES	500	90 Day	55.12
Epzicom	abacavir sulfate/lamivudine	NO	YES	NO	NO	NO	YES	500	90 Day	55.12
Trelstar	triptorelin	YES	YES	YES	NO	NO	YES	400	90 Days	850
Restasis	cyclosporine	NO	YES	YES	NO	NO	YES	400	90 DAYS	514.32
Tagrisso	osimertinib	NO	NO	NO	NO	NO	YES	250	90 Days	14522
Trelegy Ellipta	fluticasone furoate/umeclidinium/vilanterol	NO	YES	NO	NO	600	YES	250	90 Days	266
Juluca	dolutegravir/rilpivirine	Contact Program	YES	NO	NO	NO	YES	500	90 Days	2569.5
EMSAM Transdermal	selegiline	NO	NO	NO	NO	NO	YES	200	90 Dya	493
Albenza	albendazole	YES	YES	NO	NO	NO	YES	300	Amount Requested is sent	152.97
Strensiq disposal container	container for strensiq sharps	YES	YES	NO	NO	NO	YES	400	Re-application
Nutropin AQ NuSpin Pen pen	somatropin	NO	YES	NO	NO	NO	YES	400	Refill Process
Nutropin AQ Pen pen	somatropin	NO	YES	NO	NO	NO	YES	400	Refill Process
Phoslyra oral solution	calcium acetate	YES	UNKNOWN	May have insurance	Yes, but contact program for details	Not disclosed	Patient's home	400
Equetro capsule; extended release	carbamazepine	NO	YES	NO	NO	NO	YES	200
Kepivance	palifermin	YES	YES	NO	NO	NO	YES	400
Orfadin	nitisinone	YES	YES	NO	NO	NO	YES	400
Aldurazyme	laronidase	YES	YES	NO	NO	NO	YES	400
Cerezyme	imiglucerase	YES	YES	NO	NO	NO	YES	400
Lumizyme	alglucosidase alfa	YES	YES	NO	NO	NO	YES	400
Fabrazyme	agalsidase beta	YES	YES	NO	NO	NO	YES	400
Cystadane powder	betaine anhydrous	YES	YES	NO	NO	NO	Patient's home	400
Cholbam capsule	cholic acid	YES	YES	NO	NO	NO	Patient's home	400
Thiola tablet	tiopronin	YES	YES	NO	NO	NO	Doctor's office or patient's home	400
HepaGam B	immune globulin; intravenous	YES	YES	NO	NO	NO	YES	200
Varizig	immune globulin; human varicella zoster	YES	YES	NO	NO	NO	YES	200
Lioresal injectable; intrathecal	baclofen	NO	YES	NO	NO	NO	YES	400
Analpram HC cream	hydrocortisone/pramoxine	YES	YES	NO	NO	NO	YES	150
Eligard injection	leuprolide acetate	YES	YES	NO	NO	NO	YES	500
Keveyis tablet	dichlorphenamide	YES	YES	NO	NO	NO	YES	400
Episil concentrated oral liquid	wound dressing oral	YES	YES	NO	NO	NO	Doctor's office or patient's home	400
Alinia tablet	nitazoxanide	NO	YES	NO	NO	NO	Patient's home, doctor's office, or the advocate's facility	400
Arestin powder; extended release	minocycline	NO	NO	NO	NO	NO	YES	400
Trulance	plecanatide	YES	YES	NO	NO	NO	YES	400
Otrexup Container disposal container	container for otrexup sharps	YES	YES	NO	NO	NO	YES	400
Haegarda	C1 esterase inhibitor	YES	YES	NO	NO	NO	YES	400
Kristalose oral solution	lactulose	YES	YES	NO	NO	NO	YES	400
Berinert vial; single-use	C1 esterase inhibitor	YES	YES	NO	NO	NO	YES	400
Nityr	nitisinone	YES	YES	NO	NO	NO	YES	400
Boost Kid Essentials	nutritional supplement	NO	YES	NO	NO	NO	YES	250
Boost Kid Essentials 1.5	nutritional supplement	NO	YES	NO	NO	NO	YES	250
Boost Kid Essentials 1.5 Fiber	nutritional supplement	NO	YES	NO	NO	NO	YES	250
Boost Original	nutritional supplement	NO	YES	NO	NO	NO	YES	250
Boost Plus	nutritional supplement	NO	YES	NO	NO	NO	YES	250
Boost VHC	nutritional supplement	NO	YES	NO	NO	NO	YES	250
Alfamino Infant	medical food	NO	YES	NO	NO	NO	YES	250
Alfamino Junior	medical food	NO	YES	NO	NO	NO	YES	250
Compleat	medical food	NO	YES	NO	NO	NO	YES	250
Compleat Pediatric	medical food	NO	YES	NO	NO	NO	YES	250
Compleat Pediatric Reduced Calorie	medical food	NO	YES	NO	NO	NO	YES	250
Diabetisource AC	medical food	NO	YES	NO	NO	NO	YES	250
Glytrol	medical food	NO	YES	NO	NO	NO	YES	250
Impact Peptide 1.5	medical food	NO	YES	NO	NO	NO	YES	250
Nutren 1.0 Fiber	medical food	NO	YES	NO	NO	NO	YES	250
Nutren 1.5	medical food	NO	YES	NO	NO	NO	YES	250
Nutren Junior	medical food	NO	YES	NO	NO	NO	YES	250
Nutren Junior Fiber	medical food	NO	YES	NO	NO	NO	YES	250
Peptamen	medical food	NO	YES	NO	NO	NO	YES	250
Peptamen 1.5	medical food	NO	YES	NO	NO	NO	YES	250
Peptamen Junior	medical food	NO	YES	NO	NO	NO	YES	250
Peptamen Junior 1.5	medical food	NO	YES	NO	NO	NO	YES	250
Peptamen Junior Fiber	medical food	NO	YES	NO	NO	NO	YES	250
Peptamen Junior PreBio	medical food	NO	YES	NO	NO	NO	YES	250
Peptamen PreBio	medical food	NO	YES	NO	NO	NO	YES	250
Tolerex	medical food	NO	YES	NO	NO	NO	YES	250
Vivonex Pediatric	medical food	NO	YES	NO	NO	NO	YES	250
Vivonex Plus	medical food	NO	YES	NO	NO	NO	YES	250
Vivonex RTF	medical food	NO	YES	NO	NO	NO	YES	250
Vivonex TEN	medical food	NO	YES	NO	NO	NO	YES	250
Pulmocare	nutritional supplement	YES	YES	NO	NO	NO	YES	400
Calcilo XD	medical food	YES	YES	NO	NO	NO	YES	400
Cyclinex	medical food	YES	YES	NO	NO	NO	YES	400
EleCare	medical food	YES	YES	NO	NO	NO	YES	400
EleCare Jr.	medical food	YES	YES	NO	NO	NO	YES	400
Ensure Original	medical food	YES	YES	NO	NO	NO	YES	400
Ensure Plus	medical food	YES	YES	NO	NO	NO	YES	400
Glucerna 1.2	medical food	YES	YES	NO	NO	NO	YES	400
Glucerna Shake	medical food	YES	YES	NO	NO	NO	YES	400
Glutarex	medical food	YES	YES	NO	NO	NO	YES	400
Hi-Cal	medical food	YES	YES	NO	NO	NO	YES	400
Hominex	medical food	YES	YES	NO	NO	NO	YES	400
I-Valex	medical food	YES	YES	NO	NO	NO	YES	400
Jevity 1.2 Cal	medical food	YES	YES	NO	NO	NO	YES	400
Ketonex	medical food	YES	YES	NO	NO	NO	YES	400
Nepro with Carb Steady	medical food	YES	YES	NO	NO	NO	YES	400
Osmolite 1.2 cal	medical food	YES	YES	NO	NO	NO	YES	400
PediaSure	medical food	YES	YES	NO	NO	NO	YES	400
PediaSure 1.5 cal	medical food	YES	YES	NO	NO	NO	YES	400
PediaSure Enteral Formula w-Fiber	medical food	YES	YES	NO	NO	NO	YES	400
PediaSure Peptide	medical food	YES	YES	NO	NO	NO	YES	400
Perative	medical food	YES	YES	NO	NO	NO	YES	400
Phenex	medical food	YES	YES	NO	NO	NO	YES	400
Promote	medical food	YES	YES	NO	NO	NO	YES	400
Promote with Fiber	medical food	YES	YES	NO	NO	NO	YES	400
Propimex	medical food	YES	YES	NO	NO	NO	YES	400
ProViMin	medical food	YES	YES	NO	NO	NO	YES	400
Suplena	medical food	YES	YES	NO	NO	NO	YES	400
TwoCal	medical food	YES	YES	NO	NO	NO	YES	400
Tyrex	medical food	YES	YES	NO	NO	NO	YES	400
Vital AF 1.2 cal	medical food	YES	YES	NO	NO	NO	YES	400
Vital High Protein	medical food	YES	YES	NO	NO	NO	YES	400
Pivot 1.5 cal	medical drink	YES	YES	NO	NO	NO	YES	400
Uptravi	selexipag	YES	YES	NO	NO	NO	YES	400
Opsumit tablet	macitentan	YES	YES	NO	NO	NO	YES	400
Ventavis solution; inhalation	iloprost	YES	YES	NO	NO	NO	YES	400
Veletri injection	epoprostenol sodium	YES	YES	NO	NO	NO	YES	400
Tracleer tablet	bosentan	YES	YES	NO	NO	NO	YES	400
Gocovri capsule; extended release	amantadine	YES	YES	NO	NO	NO	YES	400
Kanuma	sebelipase alfa	YES	YES	NO	NO	NO	YES	400
Soliris injectable; iv	eculizumab	YES	YES	NO	NO	NO	YES	400
Strensiq injection	asfotase alfa	YES	YES	NO	NO	NO	YES	400
Iluvien implant	fluocinolone acetonide	YES	YES	NO	NO	NO	YES	400
Adempas	riociguat	NO	YES	NO	NO	NO	YES	400
Aliqopa	copanlisib	NO	YES	NO	NO	NO	YES	400
Kogenate FS	antihemophilic factor recombinant	NO	YES	NO	NO	NO	YES	400
Kovaltry	antihemophilic factor	NO	YES	NO	NO	NO	YES	400
Provenge autologous cellular immunotherapy	sipuleucel-T	YES	YES	NO	NO	NO	YES	400
Halaven	eribulin	YES	UNKNOWN	*See Additional Information section below	Not specified	Determined case by case	Not specified	400
Truvada	emtricitabine/tenofovir disoproxil fumarate	YES	YES	NO	NO	NO	YES	400
Descovy	emtricitabine/tenofovir alafenamide	YES	YES	NO	NO	NO	YES	400
Complera	emtricitabine/rilpivirine/tenofovir disoproxil fumarate	YES	YES	NO	NO	NO	YES	400
Odefsey	emtricitabine/rilpivirine/tenofovir alafenamide	YES	YES	NO	NO	NO	YES	400
Emtriva	emtricitabine	YES	YES	NO	NO	NO	YES	400
Stribild	elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate	YES	YES	NO	NO	NO	YES	400
Genvoya	elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide	YES	YES	NO	NO	NO	YES	400
Atripla	efavirenz/emtricitabine/tenofovir disoproxil fumarate	YES	YES	NO	NO	NO	YES	400
Tybost	cobicistat	YES	YES	NO	NO	NO	YES	400
Biktarvy	bictegravir/emtricitabine/tenofovir alafenamide	YES	YES	NO	NO	NO	YES	400
Revatio	sildenafil citrate	NO	NO	NO	NO	NO	YES	400
Ibrance	palbociclib	NO	NO	NO	NO	NO	YES	400
Lonsurf	trifluridine and tipiracil	YES	NO	NO	NO	NO	YES	400
Orenitram	treprostinil diolamine	YES	NO	NO	NO	NO	YES	400
Remodulin	treprostinil	YES	NO	NO	NO	NO	YES	400
Mekinist	trametinib dimethyl sulfoxide	YES	NO	NO	NO	NO	YES	400
Fareston	toremifene citrate	YES	NO	NO	NO	NO	YES	400
Thalomid	thalidomide	YES	NO	NO	NO	NO	YES	400
Aubagio	teriflunomide	YES	NO	NO	NO	NO	YES	400
Viread	tenofovir disoproxil fumarate	YES	NO	NO	NO	NO	YES	400
Adcirca	tadalafil	YES	NO	NO	NO	NO	YES	400
Zanosar	streptozocin	YES	NO	NO	NO	NO	YES	400
Serostim	somatropin	YES	NO	NO	NO	NO	YES	400
Zorbtive	somatropin	YES	NO	NO	NO	NO	YES	400
Pomalyst	pomalidomide	YES	NO	NO	NO	NO	YES	400
Vectibix	panitumumab	YES	NO	NO	NO	NO	YES	400
Eloxatin	oxaliplatin	YES	NO	NO	NO	NO	YES	400
Synribo	omacetaxine mepesuccinate	YES	NO	NO	NO	NO	YES	400
Opdivo	nivolumab	YES	NO	NO	NO	NO	YES	400
Korlym	mifepristone	YES	NO	NO	NO	NO	YES	400
Purinethol	mercaptopurine	YES	NO	NO	NO	NO	YES	400
Revlimid	lenalidomide	YES	NO	NO	NO	NO	YES	400
Ixempra	ixabepilone	YES	NO	NO	NO	NO	YES	400
Isordil	isosorbide dinitrate	YES	NO	NO	NO	NO	YES	400
Yervoy	ipilimumab	YES	NO	NO	NO	NO	YES	400
Actimmune	interferon gamma-1b	YES	NO	NO	NO	NO	YES	400
Avonex	interferon beta-1a	YES	NO	NO	NO	NO	YES	400
Infergen	interferon alfacon-1	YES	NO	NO	NO	NO	YES	400
Intron A	interferon alfa-2b	YES	NO	NO	NO	NO	YES	400
Droxia	hydroxyurea	YES	NO	NO	NO	NO	YES	400
Glatopa	glatiramer acetate	YES	NO	NO	NO	NO	YES	400
Gilenya	fingolimod	YES	NO	NO	NO	NO	YES	400
Afinitor	everolimus	YES	NO	NO	NO	NO	YES	400
Flolan	epoprostenol sodium	YES	NO	NO	NO	NO	YES	400
Empliciti	elotuzumab	YES	NO	NO	NO	NO	YES	400
Firmagon	degarelix acetate	YES	NO	NO	NO	NO	YES	400
Desferal	deferoxamine	YES	NO	NO	NO	NO	YES	400
Ferriprox	deferiprone	YES	NO	NO	NO	NO	YES	400
Darzalex	daratumumab	YES	NO	NO	NO	NO	YES	400
Tafinlar	dabrafenib	YES	NO	NO	NO	NO	YES	400
Clolar	clofarabine	YES	NO	NO	NO	NO	YES	400
Zykadia	ceritinib	YES	NO	NO	NO	NO	YES	400
Blincyto	blinatumomab	YES	NO	NO	NO	NO	YES	400
Vidaza	azacitidine	YES	NO	NO	NO	NO	YES	400
Agrylin	anagrelide	YES	NO	NO	NO	NO	YES	400
Lemtrada	alemtuzumab	YES	NO	NO	NO	NO	YES	400
Gilotrif	afatinib	YES	NO	NO	NO	NO	YES	400
Ninlaro	ixazomib	YES	NO	NO	NO	NO	YES	400
Hydrea	hydroxyurea	YES	NO	NO	NO	NO	YES	400
Dacogen	decitabine	YES	NO	NO	NO	NO	YES	400
Xeloda	capecitabine	YES	NO	NO	NO	NO	YES	400
Alunbrig	brigatinib	YES	NO	NO	NO	NO	YES	400
Arimidex	anastrozole	YES	NO	NO	NO	NO	YES	400
Flebogamma DIF	immune globulin; iv	YES	YES	NO	NO	NO	YES	400
Actonel	risedronate sodium	YES	YES	NO	NO	NO	YES	400
Nucala	mepolizumab	YES	YES	NO	NO	NO	YES	400
Xopenex	levalbuterol	YES	YES	NO	NO	NO	YES	400
Femara	letrozole	YES	YES	NO	NO	NO	YES	400
Somatuline Depot	lanreotide acetate	YES	YES	NO	NO	NO	YES	400
Colcrys	colchicine	YES	YES	NO	NO	NO	YES	400
Imuran	azathioprine	YES	YES	NO	NO	NO	YES	400
Hexalen	altretamine	YES	YES	NO	NO	NO	YES	400
Fosamax	alendronate sodium	YES	YES	NO	NO	NO	YES	400
DuoNeb	albuterol sulfate/ipratropium bromide	YES	YES	NO	NO	NO	YES	400
Hycamtin	topotecan	YES	YES	NO	NO	NO	YES	400
Mozobil	plerixafor	YES	YES	NO	NO	NO	YES	400
Sylatron	peginterferon alfa-2b	YES	YES	NO	NO	NO	YES	400
Votrient	pazopanib	YES	YES	NO	NO	NO	YES	400
Signifor LAR	pasireotide	YES	YES	NO	NO	NO	YES	400
Creon	pancrelipase	YES	YES	NO	NO	NO	YES	400
Pancreaze	pancrelipase	YES	YES	NO	NO	NO	YES	400
Pertzye	pancrelipase	YES	YES	NO	NO	NO	YES	400
Arzerra	ofatumumab	YES	YES	NO	NO	NO	YES	400
Sandostatin LAR	octreotide acetate	YES	YES	NO	NO	NO	YES	400
Zejula	niraparib	YES	YES	NO	NO	NO	YES	400
Ofev	nintedanib esylate	YES	YES	NO	NO	NO	YES	400
Arranon	nelarabine	YES	YES	NO	NO	NO	YES	400
Gammagard	immune globulin	YES	YES	NO	NO	NO	YES	400
Zydelig	idelalisib	YES	YES	NO	NO	NO	YES	400
Imbruvica	ibrutinib	YES	YES	NO	NO	NO	YES	400
Haldol	haloperidol	YES	YES	NO	NO	NO	YES	400
Etopophos	etoposide	YES	YES	NO	NO	NO	YES	400
Procrit	epoetin alfa	YES	YES	NO	NO	NO	YES	400
Promacta	eltrombopag	YES	YES	NO	NO	NO	YES	400
Doxil	doxorubicin	YES	YES	NO	NO	NO	YES	400
Neoral	cyclosporine	YES	YES	NO	NO	NO	YES	400
Sandimmune	cyclosporine	YES	YES	NO	NO	NO	YES	400
Ilaris	canakinumab	YES	YES	NO	NO	NO	YES	400
Rayaldee	calcifediol	YES	YES	NO	NO	NO	YES	400
Proventil HFA	albuterol sulfate	YES	YES	NO	NO	NO	YES	400
Ventolin HFA	albuterol	YES	YES	NO	NO	NO	YES	400
Reclast	zoledronic acid	YES	YES	NO	NO	NO	YES	400
Evista	raloxifene	NO	YES	NO	NO	NO	YES	400
Akynzeo	netupitant/palonosetron	YES	YES	NO	NO	NO	YES	400
Sustol	granisetron	YES	YES	NO	NO	NO	YES	400
Cinvanti	aprepitant	YES	YES	NO	NO	NO	YES	400
Jakafi tablet	ruxolitinib	YES	YES	NO	NO	NO	YES	400
Onivyde injection	irinotecan liposome	YES	YES	NO	NO	NO	YES	400
Sabril oral solution	vigabatrin	YES	YES	NO	NO	NO	YES	400
Galzin	zinc acetate	YES	NO	NO	NO	NO	YES	400
Zyflo	zileuton	YES	NO	NO	NO	NO	YES	400
AlloDerm	wound matrix	YES	NO	NO	NO	NO	YES	400
AlloSkin	wound matrix	YES	NO	NO	NO	NO	YES	400
AlloWrap	wound matrix	YES	NO	NO	NO	NO	YES	400
ArthroFlex	wound matrix	YES	NO	NO	NO	NO	YES	400
BioDFence	wound matrix	YES	NO	NO	NO	NO	YES	400
Cymetra	wound matrix	YES	NO	NO	NO	NO	YES	400
Helicoll	wound matrix	YES	NO	NO	NO	NO	YES	400
Integra	wound matrix	YES	NO	NO	NO	NO	YES	400
Integra Flowable	wound matrix	YES	NO	NO	NO	NO	YES	400
Oasis	wound matrix	YES	NO	NO	NO	NO	YES	400
Promogran	wound matrix	YES	NO	NO	NO	NO	YES	400
Talymed	wound matrix	YES	NO	NO	NO	NO	YES	400
TheraSkin	wound matrix	YES	NO	NO	NO	NO	YES	400
Unite Biomatrix	wound matrix	YES	NO	NO	NO	NO	YES	400
Fortaderm	wound dressing	YES	NO	NO	NO	NO	YES	400
Wilate	von willebrand factor/coagulation factor Vlll complex	YES	NO	NO	NO	NO	YES	400
Ocuvite Lutien	vitamin/mineral supplement	YES	NO	NO	NO	NO	YES	400
AquaSol A	vitamin A supplement	YES	NO	NO	NO	NO	YES	400
Marqibo	vincristine	YES	NO	NO	NO	NO	YES	400
Verelan	verapamil	YES	NO	NO	NO	NO	YES	400
Entyvio	vedolizumab	YES	NO	NO	NO	NO	YES	400
Trelstar	triptorelin	YES	NO	NO	NO	NO	YES	400
Syprine	trientine	YES	NO	NO	NO	NO	YES	400
Trianex	triamcinolone acetonide	YES	NO	NO	NO	NO	YES	400
Triderm	triamcinolone acetonide	YES	NO	NO	NO	NO	YES	400
Cyklokapron	tranexamic acid	YES	NO	NO	NO	NO	YES	400
Demadex	torsemide	YES	NO	NO	NO	NO	YES	400
Tasmar	tolcapone	YES	NO	NO	NO	NO	YES	400
Tobradex	tobramycin/dexamethasone	YES	NO	NO	NO	NO	YES	400
DermaCell	tissue; human allograft	YES	NO	NO	NO	NO	YES	400
Kymriah	tisagenlecleucel	YES	NO	NO	NO	NO	YES	400
Thyrogen	thyrotropin alfa	YES	NO	NO	NO	NO	YES	400
Elixophyllin	theophylline	YES	NO	NO	NO	NO	YES	400
Theo-24	theophylline	YES	NO	NO	NO	NO	YES	400
Theochron	theophylline	YES	NO	NO	NO	NO	YES	400
Gattex	teduglutide	YES	NO	NO	NO	NO	YES	400
Tazorac	tazarotene	YES	NO	NO	NO	NO	YES	400
Astagraf XL	tacrolimus	YES	NO	NO	NO	NO	YES	400
Envarsus XR	tacrolimus	YES	NO	NO	NO	NO	YES	400
Hecoria	tacrolimus	YES	NO	NO	NO	NO	YES	400
Protopic	tacrolimus	YES	NO	NO	NO	NO	YES	400
Azulfidine	sulfasalazine	YES	NO	NO	NO	NO	YES	400
Blephamide S.O.P.	sulfacetamide sodium/prednisolone acetate	YES	NO	NO	NO	NO	YES	400
Velphoro	sucroferric oxyhydroxide	YES	NO	NO	NO	NO	YES	400
Chemet	succimer	YES	NO	NO	NO	NO	YES	400
Zerit	stavudine	YES	NO	NO	NO	NO	YES	400
Aldactazide	spironolactone/hydrochlorothiazide	YES	NO	NO	NO	NO	YES	400
Carospir	spironolactone	YES	NO	NO	NO	NO	YES	400
Sotylize	sotalol	YES	NO	NO	NO	NO	YES	400
Odomzo	sonidegib	YES	NO	NO	NO	NO	YES	400
Kayexalate	sodium polystyrene sulfonate	YES	NO	NO	NO	NO	YES	400
Sps	sodium polystyrene sulfonate	YES	NO	NO	NO	NO	YES	400
Renagel	sevelamer	YES	NO	NO	NO	NO	YES	400
Eldepryl	selegiline	YES	NO	NO	NO	NO	YES	400
Zelapar	selegiline	YES	NO	NO	NO	NO	YES	400
Serevent	salmeterol xinafoate	YES	NO	NO	NO	NO	YES	400
Scalacort	salicylic acid/sulfur/hydrocortisone	YES	NO	NO	NO	NO	YES	400
Xadago	safinamide	YES	NO	NO	NO	NO	YES	400
Istodax	romidepsin	YES	NO	NO	NO	NO	YES	400
Varubi	rolapitant	YES	NO	NO	NO	NO	YES	400
Vexol	rimexolone	YES	NO	NO	NO	NO	YES	400
Xifaxan	rifaximin	YES	NO	NO	NO	NO	YES	400
Ribatab	ribavirin	YES	NO	NO	NO	NO	YES	400
Cinqair	reslizumab	YES	NO	NO	NO	NO	YES	400
Hemangeol	propranolol	YES	NO	NO	NO	NO	YES	400
Inderal LA	propranolol	YES	NO	NO	NO	NO	YES	400
InnoPran XL	propranolol	YES	NO	NO	NO	NO	YES	400
Phenergan	promethazine	YES	NO	NO	NO	NO	YES	400
Promethegan	promethazine	YES	NO	NO	NO	NO	YES	400
Compazine	prochlorperazine	YES	NO	NO	NO	NO	YES	400
Compro	prochlorperazine	YES	NO	NO	NO	NO	YES	400
Veripred	prednisolone sodium phosphate	YES	NO	NO	NO	NO	YES	400
Flo-Pred	prednisolone acetate	YES	NO	NO	NO	NO	YES	400
Omnipred	prednisolone acetate	YES	NO	NO	NO	NO	YES	400
Pred Mild	prednisolone acetate	YES	NO	NO	NO	NO	YES	400
Prelone	prednisolone	YES	NO	NO	NO	NO	YES	400
Dermatop	prednicarbate	YES	NO	NO	NO	NO	YES	400
Grafix CORE	placental membrane allograft	YES	NO	NO	NO	NO	YES	400
Grafix PRIME	placental membrane allograft	YES	NO	NO	NO	NO	YES	400
Livalo	pitavastatin	YES	NO	NO	NO	NO	YES	400
Elidel	pimecrolimus	YES	NO	NO	NO	NO	YES	400
Nuplazid	pimavanserin	YES	NO	NO	NO	NO	YES	400
Mephyton	phytonadione	YES	NO	NO	NO	NO	YES	400
Aceon	perindopril erbumine	YES	NO	NO	NO	NO	YES	400
Cuprimine	penicillamine	YES	NO	NO	NO	NO	YES	400
Depen	penicillamine	YES	NO	NO	NO	NO	YES	400
Oncaspar	pegaspargase	YES	NO	NO	NO	NO	YES	400
Aloxi	palonosetron	YES	NO	NO	NO	NO	YES	400
Daypro	oxaprozin	YES	NO	NO	NO	NO	YES	400
Zuplenz	ondansetron	YES	NO	NO	NO	NO	YES	400
Dipentum	olsalazine sodium	YES	NO	NO	NO	NO	YES	400
Adalat CC	nifedipine	YES	NO	NO	NO	NO	YES	400
Simcor	niacin-simvastatin	YES	NO	NO	NO	NO	YES	400
Niacor	niacin	YES	NO	NO	NO	NO	YES	400
Viramune	nevirapine	YES	NO	NO	NO	NO	YES	400
Nerlynx	neratinib maleate	YES	NO	NO	NO	NO	YES	400
Neosporin	neomycin sulfate/polymyxin B sulfate	YES	NO	NO	NO	NO	YES	400
Bystolic	nebivolol	YES	NO	NO	NO	NO	YES	400
Aleve	naproxen sodium	YES	NO	NO	NO	NO	YES	400
Anaprox	naproxen sodium	YES	NO	NO	NO	NO	YES	400
Naprelan	naproxen sodium	YES	NO	NO	NO	NO	YES	400
Corzide	nadolol/bendroflumethiazide	YES	NO	NO	NO	NO	YES	400
Corgard	nadolol	YES	NO	NO	NO	NO	YES	400
Asmanex	mometasone	YES	NO	NO	NO	NO	YES	400
Univasc	moexipril	YES	NO	NO	NO	NO	YES	400
Lysodren	mitotane	YES	NO	NO	NO	NO	YES	400
Kynamro	mipomersen sodium	YES	NO	NO	NO	NO	YES	400
Zavesca	miglustat	YES	NO	NO	NO	NO	YES	400
Mifeprex	mifepristone	YES	NO	NO	NO	NO	YES	400
Demser	metyrosine	YES	NO	NO	NO	NO	YES	400
Metopirone	metyrapone	YES	NO	NO	NO	NO	YES	400
Lopressor HCT	metoprolol tartrate/hydrochlorothiazide	YES	NO	NO	NO	NO	YES	400
Metozolv tablet; orally disintegrating	metoclopramide	YES	NO	NO	NO	NO	YES	400
A-Methapred	methylprednisolone sodium succinate	YES	NO	NO	NO	NO	YES	400
8-MOP	methoxsalen	YES	NO	NO	NO	NO	YES	400
Oxsoralen	methoxsalen	YES	NO	NO	NO	NO	YES	400
Apriso	mesalamine	YES	NO	NO	NO	NO	YES	400
Asacol HD	mesalamine	YES	NO	NO	NO	NO	YES	400
Canasa	mesalamine	YES	NO	NO	NO	NO	YES	400
Delzicol	mesalamine	YES	NO	NO	NO	NO	YES	400
Lialda	mesalamine	YES	NO	NO	NO	NO	YES	400
Pentasa	mesalamine	YES	NO	NO	NO	NO	YES	400
Rowasa	mesalamine	YES	NO	NO	NO	NO	YES	400
Sfrowasa	mesalamine	YES	NO	NO	NO	NO	YES	400
Namzaric	memantine-donepezil	YES	NO	NO	NO	NO	YES	400
Replesta	medical food	YES	NO	NO	NO	NO	YES	400
DermaPure	matrix; tissue wound	YES	NO	NO	NO	NO	YES	400
Graftjacket	matrix; regenerative tissue	YES	NO	NO	NO	NO	YES	400
MatriStem Burn Matrix	matrix; lyophilized extracellular	YES	NO	NO	NO	NO	YES	400
MatriStem MicroMatrix	matrix; lyophilized extracellular	YES	NO	NO	NO	NO	YES	400
DermaVest	matrix; human placental tissue	YES	NO	NO	NO	NO	YES	400
PuraPly	matrix-wound	YES	NO	NO	NO	NO	YES	400
Advicor	lovastatin niacin	YES	NO	NO	NO	NO	YES	400
Altoprev	lovastatin	YES	NO	NO	NO	NO	YES	400
Mevacor	lovastatin	YES	NO	NO	NO	NO	YES	400
Juxtapid	lomitapide	YES	NO	NO	NO	NO	YES	400
Qbrelis	lisinopril	YES	NO	NO	NO	NO	YES	400
Levo-T	levothyroxine sodium	YES	NO	NO	NO	NO	YES	400
Tirosint	levothyroxine	YES	NO	NO	NO	NO	YES	400
Unithroid	levothyroxine	YES	NO	NO	NO	NO	YES	400
Fusilev	levoleucovorin calcium	YES	NO	NO	NO	NO	YES	400
Trandate	labetalol	YES	NO	NO	NO	NO	YES	400
Corlanor	ivabradine	YES	NO	NO	NO	NO	YES	400
Absorica	isotretinoin	YES	NO	NO	NO	NO	YES	400
Amnesteem	isotretinoin	YES	NO	NO	NO	NO	YES	400
Claravis	isotretinoin	YES	NO	NO	NO	NO	YES	400
Myorisan	isotretinoin	YES	NO	NO	NO	NO	YES	400
Zenatane	isotretinoin	YES	NO	NO	NO	NO	YES	400
BiDil	isosorbide dinitrate/hydralazine	YES	NO	NO	NO	NO	YES	400
Dilatrate SR	isosorbide dinitrate	YES	NO	NO	NO	NO	YES	400
Renflexis	infliximab-ABDA	YES	NO	NO	NO	NO	YES	400
Tivorbex	indomethacin	YES	NO	NO	NO	NO	YES	400
Atgam	immune globulin; lymphocyte	YES	NO	NO	NO	NO	YES	400
Bivigam	immune globulin; intravenous	YES	NO	NO	NO	NO	YES	400
Carimune NF	immune globulin; intravenous	YES	NO	NO	NO	NO	YES	400
Gammaked	immune globulin; intravenous	YES	NO	NO	NO	NO	YES	400
Aldara	imiquimod	YES	NO	NO	NO	NO	YES	400
Corvert	ibutilide fumarate	YES	NO	NO	NO	NO	YES	400
Texacort	hydrocortizone	YES	NO	NO	NO	NO	YES	400
Cortisporin	hydrocortisone/neomycin/polymyxin b sulfate	YES	NO	NO	NO	NO	YES	400
Westcort	hydrocortisone valerate	YES	NO	NO	NO	NO	YES	400
A-Hydrocort	hydrocortisone sodium succinate	YES	NO	NO	NO	NO	YES	400
Pandel	hydrocortisone probutate	YES	NO	NO	NO	NO	YES	400
U-Cort	hydrocortisone acetate/urea	YES	NO	NO	NO	NO	YES	400
MiCort HC	hydrocortisone acetate	YES	NO	NO	NO	NO	YES	400
Nucort	hydrocortisone acetate	YES	NO	NO	NO	NO	YES	400
Pediaderm HC	hydrocortisone	YES	NO	NO	NO	NO	YES	400
GammaGraft	human skin allograft	YES	NO	NO	NO	NO	YES	400
ClarixFlo	human amniotic membrane	YES	NO	NO	NO	NO	YES	400
Vantas	histrelin	YES	NO	NO	NO	NO	YES	400
Halog	halcinonide	YES	NO	NO	NO	NO	YES	400
Granisol	granisetron	YES	NO	NO	NO	NO	YES	400
Sancuso	granisetron	YES	NO	NO	NO	NO	YES	400
Zoladex	goserelin acetate	YES	NO	NO	NO	NO	YES	400
Nutrestore	glutamine	YES	NO	NO	NO	NO	YES	400
Pred-G	gentamicin sulfate/prednisolone acetate	YES	NO	NO	NO	NO	YES	400
Foradil	formoterol fumarate	YES	NO	NO	NO	NO	YES	400
Perforomist	formoterol fumarate	YES	NO	NO	NO	NO	YES	400
Lescol	fluvastatin	YES	NO	NO	NO	NO	YES	400
Cutivate	fluticasone propionate	YES	NO	NO	NO	NO	YES	400
Cordran	flurandrenolide	YES	NO	NO	NO	NO	YES	400
Androxy	fluoxymesterone	YES	NO	NO	NO	NO	YES	400
Flarex	fluorometholone acetate	YES	NO	NO	NO	NO	YES	400
FML	fluorometholone	YES	NO	NO	NO	NO	YES	400
Vanos	fluocinonide	YES	NO	NO	NO	NO	YES	400
Derma-Smoothe	fluocinolone acetonisde	YES	NO	NO	NO	NO	YES	400
Neo-Synalar	fluocinolone acetonide/neomycin sulfate	YES	NO	NO	NO	NO	YES	400
Tri-Luma	fluocinolone acetonide/hydroquinone/tretinoin	YES	NO	NO	NO	NO	YES	400
Capex	fluocinolone acetonide	YES	NO	NO	NO	NO	YES	400
Synalar	fluocinolone acetonide	YES	NO	NO	NO	NO	YES	400
Tambocor	flecainide	YES	NO	NO	NO	NO	YES	400
Auryxia	ferric citrate	YES	NO	NO	NO	NO	YES	400
Nalfon	fenoprofen calcium	YES	NO	NO	NO	NO	YES	400
Fenoglide	fenofibric acid	YES	NO	NO	NO	NO	YES	400
Antara	fenofibrate	YES	NO	NO	NO	NO	YES	400
Lipofen	fenofibrate	YES	NO	NO	NO	NO	YES	400
TUMS Products	famotidine/calcium carbonate/magnesium hydroxide	YES	NO	NO	NO	NO	YES	400
Advate	factor VIII	YES	NO	NO	NO	NO	YES	400
Mononine	factor IX	YES	NO	NO	NO	NO	YES	400
Liptruzet	ezetimibe/atorvastatin	YES	NO	NO	NO	NO	YES	400
Amidate	etomidate	YES	NO	NO	NO	NO	YES	400
Lodine	etodolac	YES	NO	NO	NO	NO	YES	400
Enbrel	etanercept	YES	NO	NO	NO	NO	YES	400
Divigel	estradiol	YES	NO	NO	NO	NO	YES	400
Elestrin	estradiol	YES	NO	NO	NO	NO	YES	400
Estrasorb	estradiol	YES	NO	NO	NO	NO	YES	400
Evamist	estradiol	YES	NO	NO	NO	NO	YES	400
Minivelle	estradiol	YES	NO	NO	NO	NO	YES	400
Brevibloc	esmolol	YES	NO	NO	NO	NO	YES	400
Teveten HCT	eprosartan/hydrochlorothiazide	YES	NO	NO	NO	NO	YES	400
Teveten	eprosartan	YES	NO	NO	NO	NO	YES	400
Comtan	entacapone	YES	NO	NO	NO	NO	YES	400
Epaned	enalapril maleate	YES	NO	NO	NO	NO	YES	400
Vitekta	elvitegravir	YES	NO	NO	NO	NO	YES	400
Cerdelga	eliglustat tartrate	YES	NO	NO	NO	NO	YES	400
Lufyllin	dyphylline	YES	NO	NO	NO	NO	YES	400
Dupixent	dupilumab	YES	NO	NO	NO	NO	YES	400
Anzemet	dolasetron	YES	NO	NO	NO	NO	YES	400
Diphen	diphenhydramine	YES	NO	NO	NO	NO	YES	400
Silphen	diphenhydramine	YES	NO	NO	NO	NO	YES	400
Cardizem LA	diltiazem	YES	NO	NO	NO	NO	YES	400
Cartia XT	diltiazem	YES	NO	NO	NO	NO	YES	400
Dilt-CD	diltiazem	YES	NO	NO	NO	NO	YES	400
Diltzac	diltiazem	YES	NO	NO	NO	NO	YES	400
Matzim	diltiazem	YES	NO	NO	NO	NO	YES	400
Taztia	diltiazem	YES	NO	NO	NO	NO	YES	400
Tiazac	diltiazem	YES	NO	NO	NO	NO	YES	400
Psorcon	diflorasone diacetate	YES	NO	NO	NO	NO	YES	400
ApexiCon E	diflorasone	YES	NO	NO	NO	NO	YES	400
Videx	didanosine	YES	NO	NO	NO	NO	YES	400
Zipsor	diclofenac potassium	YES	NO	NO	NO	NO	YES	400
Cambia	diclofenac	YES	NO	NO	NO	NO	YES	400
Cataflam	diclofenac	YES	NO	NO	NO	NO	YES	400
Zorvolex	diclofenac	YES	NO	NO	NO	NO	YES	400
Proglycem	diazoxide	YES	NO	NO	NO	NO	YES	400
Maxitrol	dexamethasone/neomycin/polymyxin B	YES	NO	NO	NO	NO	YES	400
Topicort	desoximetasone	YES	NO	NO	NO	NO	YES	400
Desonate	desonide	YES	NO	NO	NO	NO	YES	400
DesOwen	desonide	YES	NO	NO	NO	NO	YES	400
Tridesilon	desonide	YES	NO	NO	NO	NO	YES	400
Verdeso	desonide	YES	NO	NO	NO	NO	YES	400
Stimate	desmopressin acetate	YES	NO	NO	NO	NO	YES	400
Dermagraft	dermal substitute	YES	NO	NO	NO	NO	YES	400
EZ Derm	dermal substitute	YES	NO	NO	NO	NO	YES	400
Restasis Multidose	cyclosporine	YES	NO	NO	NO	NO	YES	400
Cyclogyl	cyclopentolate	YES	NO	NO	NO	NO	YES	400
Acthrel	corticoreline ovine triflutate	YES	NO	NO	NO	NO	YES	400
Enjuvia	conjugated synthetic b estrogens	YES	NO	NO	NO	NO	YES	400
Cenestin	conjugated synthetic A estrogens	YES	NO	NO	NO	NO	YES	400
Santyl	collagenase	YES	NO	NO	NO	NO	YES	400
Mitigare	colchicine	YES	NO	NO	NO	NO	YES	400
Alprolix	coagulation factor IX	YES	NO	NO	NO	NO	YES	400
Idelvion	coagulation factor IX	YES	NO	NO	NO	NO	YES	400
Cloderm	clocortolone pivalate	YES	NO	NO	NO	NO	YES	400
Clobex	clobetasol propionate	YES	NO	NO	NO	NO	YES	400
Clodan	clobetasol propionate	YES	NO	NO	NO	NO	YES	400
Cormax	clobetasol propionate	YES	NO	NO	NO	NO	YES	400
Temovate	clobetasol propionate	YES	NO	NO	NO	NO	YES	400
Alvesco	ciclesonide	YES	NO	NO	NO	NO	YES	400
Questran	cholestyramine	YES	NO	NO	NO	NO	YES	400
Diuril	chlorothiazide	YES	NO	NO	NO	NO	YES	400
Duopa	carbidopa/levodopa	YES	NO	NO	NO	NO	YES	400
Lodosyn	carbidopa	YES	NO	NO	NO	NO	YES	400
Eliphos	calcium acetate	YES	NO	NO	NO	NO	YES	400
Phoslyra	calcium acetate	YES	NO	NO	NO	NO	YES	400
Taclonex	calcipotriene hydrate/betamethasone dipropionate	YES	NO	NO	NO	NO	YES	400
Calcitrene	calcipotriene	YES	NO	NO	NO	NO	YES	400
Dovonex	calcipotriene	YES	NO	NO	NO	NO	YES	400
Sorilux	calcipotriene	YES	NO	NO	NO	NO	YES	400
Busulfex	busulfan	YES	NO	NO	NO	NO	YES	400
Myleran	busulfan	YES	NO	NO	NO	NO	YES	400
Pulmicort	budesonide	YES	NO	NO	NO	NO	YES	400
Uceris	budesonide	YES	NO	NO	NO	NO	YES	400
Parlodel	bromocriptine	YES	NO	NO	NO	NO	YES	400
Siliq	brodalumab	YES	NO	NO	NO	NO	YES	400
Excellagen	bovine collagen	YES	NO	NO	NO	NO	YES	400
Zebeta	bisoprolol fumarate	YES	NO	NO	NO	NO	YES	400
Apligraf	bilayered skin substitute	YES	NO	NO	NO	NO	YES	400
Luxiq	betamethasone valerate	YES	NO	NO	NO	NO	YES	400
Enstilar	betamethasone dipropionate and calcipotriol	YES	NO	NO	NO	NO	YES	400
Sernivo	betamethasone dipropionate	YES	NO	NO	NO	NO	YES	400
Cogentin	benztropine	YES	NO	NO	NO	NO	YES	400
Beleodaq	belinostat	YES	NO	NO	NO	NO	YES	400
Benlysta	belimumab	YES	NO	NO	NO	NO	YES	400
QVAR	beclomethasone dipropionate	YES	NO	NO	NO	NO	YES	400
Regranex	becaplermin	YES	NO	NO	NO	NO	YES	400
TheraCys	BCG	YES	NO	NO	NO	NO	YES	400
TICE BCG	BCG	YES	NO	NO	NO	NO	YES	400
Giazo	balsalazide disodium	YES	NO	NO	NO	NO	YES	400
Gablofen	baclofen	YES	NO	NO	NO	NO	YES	400
Lioresal	baclofen	YES	NO	NO	NO	NO	YES	400
Edarbi	azilsartan medoxomil	YES	NO	NO	NO	NO	YES	400
Edarbyclor	azilsartan kamedoxomil/chlorthalidone	YES	NO	NO	NO	NO	YES	400
Isopto Atropine	atropine sulfate	YES	NO	NO	NO	NO	YES	400
Evotaz	atazanavir sulfate/cobicistat	YES	NO	NO	NO	NO	YES	400
Erwinaze	asparaginase erwinia chrysanthemi	YES	NO	NO	NO	NO	YES	400
Otezla	apremilast	YES	NO	NO	NO	NO	YES	400
Apokyn	apomorphine	YES	NO	NO	NO	NO	YES	400
Humate-P	antihemophilic factor-von Willebrand factor complex human	YES	NO	NO	NO	NO	YES	400
Xyntha Solofuse	antihemophilic factor recombinant	YES	NO	NO	NO	NO	YES	400
Afstyla	antihemophilic factor	YES	NO	NO	NO	NO	YES	400
Helixate FS vial	antihemophilic factor	YES	NO	NO	NO	NO	YES	400
Eloctate	antihemophilic factor	YES	NO	NO	NO	NO	YES	400
Adynovate	antihemophilic factor	YES	NO	NO	NO	NO	YES	400
Koate DVI injection	antihemophilic factor	YES	NO	NO	NO	NO	YES	400
Monoclate-P vial; single-use	antihemophilic factor	YES	NO	NO	NO	NO	YES	400
Zithranol-RR	anthralin	YES	NO	NO	NO	NO	YES	400
BioVance	amniotic membrane allograft	YES	NO	NO	NO	NO	YES	400
EpiFix	amiotic membrane allograft	YES	NO	NO	NO	NO	YES	400
Cordarone	amiodarone	YES	NO	NO	NO	NO	YES	400
Nexterone	amiodarone	YES	NO	NO	NO	NO	YES	400
Amicar	aminocaproic acid	YES	NO	NO	NO	NO	YES	400
Niravam	alprazolam	YES	NO	NO	NO	NO	YES	400
Campath	alemtuzumab	YES	NO	NO	NO	NO	YES	400
Xerese	acyclovir hydrocortisone	YES	NO	NO	NO	NO	YES	400
Sectral	acebutolol	YES	NO	NO	NO	NO	YES	400
Verzenio	abemaciclib	YES	NO	NO	NO	NO	YES	400
Taltz	ixekizumab		NO	NO	NO	NO	YES	400
Bosulif	bosutinib monohydrate	YES	NO	NO	NO	NO	YES	400
Elelyso	taliglucerase alfa	YES	NO	NO	NO	NO	YES	400
Besponsa	inotuzumab ozogamicin	YES	NO	NO	NO	NO	YES	400
Eucrisa	crisaborole	YES	NO	NO	NO	NO	YES	400
Premarin	conjugated estrogens	NO	NO	NO	NO	NO	YES	400
Rapamune	sirolimus	NO	NO	NO	NO	NO	YES	400
Feldene	piroxicam	NO	NO	NO	NO	NO	YES	400
Menest	estrogens/esterified	NO	NO	NO	NO	NO	YES	400
Depo-Estradiol	estradiol cypionate	NO	NO	NO	NO	NO	YES	400
Inspra	eplerenone	NO	NO	NO	NO	NO	YES	400
Tikosyn	dofetilide	NO	NO	NO	NO	NO	YES	400
Norpace CR	disopyramide	NO	NO	NO	NO	NO	YES	400
Arthrotec	diclofenac sodium/misoprostol	NO	NO	NO	NO	NO	YES	400
Duavee	bazedoxifene acetate/conjugated estrogens	NO	NO	NO	NO	NO	YES	400
Caduet	amlodipine besylate/atorvastatin calcium	NO	NO	NO	NO	NO	YES	400
Inflectra	infliximab-dyyb	NO	NO	NO	NO	NO	YES	400
Benefix	factor IX	NO	NO	NO	NO	NO	YES	400
Zyprexa Zydis	olanzapine	NO	NO	NO	NO	NO	YES	400
Orenitram tablet; extended release	treprostinil diolamine	YES	YES	NO	NO	NO	YES	400
Remodulin injection	treprostinil	YES	YES	NO	NO	NO	YES	400
Adcirca tablet	tadalafil	YES	YES	NO	NO	NO	YES	400
Livalo tablet	pitavastatin	NO	YES	NO	NO	NO	YES	150
Myalept injection	metreleptin	YES	YES	NO	NO	NO	YES	400
Primlev tablet	oxycodone and acetaminophen	NO	YES	NO	NO	NO	YES	400
Nuedexta	dextromethorpan hydrobromide/quinidine	YES	UNKNOWN	NO	NO	NO	YES	400
Nexavar	sorafenib	NO	YES	NO	NO	NO	YES	400
Menostar	estradiol	NO	YES	NO	NO	NO	YES	400
Thalomid capsule	thalidomide	YES	YES	NO	NO	NO	YES	400
Pomalyst capsule	pomalidomide	YES	YES	NO	NO	NO	YES	400
Abraxane	paclitaxel	YES	YES	NO	NO	NO	YES	400
Revlimid capsule	lenalidomide	YES	YES	NO	NO	NO	YES	400
Idhifa	enasidenib	YES	YES	NO	NO	NO	YES	400
Vidaza injectable; subcutaneous	azacitidine	YES	YES	NO	NO	NO	YES	400
Bethkis solution; inhalation	tobramycin	YES	YES	NO	NO	NO	YES	400
Pertzye capsule; delayed release	pancrelipase	YES	YES	NO	NO	NO	YES	400
Xiaflex	collagenase clostridium histolyticum	YES	UNKNOWN	May have insurance	Yes	Varies		400
Cabometyx	cabozantinib s-malate	YES	UNKNOWN	May have insurance	Must be uninsured or underinsured	No	Amount requested is sent	400
Tecentriq	atezolizumab	YES	YES	NO	NO	NO	YES	400
Cellcept	mycophenolate mofetil	YES	YES	NO	NO	NO	YES	400
Zydelig tablet	idelalisib	YES	YES	NO	NO	NO	YES	400
Visudyne	verteporfin	YES	NO	NO	NO	NO	YES	400
Soltamox	tamoxifen citrate	YES	NO	NO	NO	NO	YES	400
Epclusa	sofosbuvir/velpatasvir	YES	NO	NO	NO	NO	YES	400
Sovaldi	sofosbuvir	YES	NO	NO	NO	NO	YES	400
Buphenyl	sodium phenylbutyrate	YES	NO	NO	NO	NO	YES	400
Olysio	simeprevir sodium	YES	NO	NO	NO	NO	YES	400
Moderiba	ribavirin	YES	NO	NO	NO	NO	YES	400
Rebetol	ribavirin	YES	NO	NO	NO	NO	YES	400
Ribasphere	ribavirin	YES	NO	NO	NO	NO	YES	400
Cyramza	ramucirumab	YES	NO	NO	NO	NO	YES	400
Matulane	procarbazine	YES	NO	NO	NO	NO	YES	400
Alimta	pemetrexed	YES	NO	NO	NO	NO	YES	400
Keytruda	pembrolizumab	YES	NO	NO	NO	NO	YES	400
Plegridy	peginterferon beta-1a	YES	NO	NO	NO	NO	YES	400
PegIntron	peginterferon alfa-2b	YES	NO	NO	NO	NO	YES	400
Pegasys	peginterferon alfa-2a	YES	NO	NO	NO	NO	YES	400
Macugen	pegaptanib sodium	YES	NO	NO	NO	NO	YES	400
Taxol	paclitaxel	YES	NO	NO	NO	NO	YES	400
Viekira Pak	ombitasvir/paritaprevir/ritonavir and dasabuvir	YES	NO	NO	NO	NO	YES	400
Portrazza	necitumumab	YES	NO	NO	NO	NO	YES	400
Tysabri	natalizumab	YES	NO	NO	NO	NO	YES	400
Harvoni	ledipasvir/sofosbuvir	YES	NO	NO	NO	NO	YES	400
Rebif	interferon beta-1a	YES	NO	NO	NO	NO	YES	400
Roferon-A	interferon alfa-2a	YES	NO	NO	NO	NO	YES	400
Ravicti	glycerol phenylbutyrate	YES	NO	NO	NO	NO	YES	400
Copaxone	glatiramer acetate	YES	NO	NO	NO	NO	YES	400
Gemzar	gemcitabine	YES	NO	NO	NO	NO	YES	400
Zepatier	elbasvir/grazoprevir	YES	NO	NO	NO	NO	YES	400
Adriamycin	doxorubicin	YES	NO	NO	NO	NO	YES	400
Docefrez	docetaxel	YES	NO	NO	NO	NO	YES	400
Taxotere	docetaxel	YES	NO	NO	NO	NO	YES	400
Tecfidera	dimethyl fumarate	YES	NO	NO	NO	NO	YES	400
Ozurdex	dexamethasone	YES	NO	NO	NO	NO	YES	400
Daklinza	daclatasvir	YES	NO	NO	NO	NO	YES	400
DTIC-Dome	dacarbazine	YES	NO	NO	NO	NO	YES	400
Cytoxan	cyclophosphamide	YES	NO	NO	NO	NO	YES	400
Erbitux	cetuximab	YES	NO	NO	NO	NO	YES	400
Kyprolis	carfilzomib	YES	NO	NO	NO	NO	YES	400
Cometriq	cabozantinib s-malate	YES	NO	NO	NO	NO	YES	400
Adcetris	brentuximab vedotin	YES	NO	NO	NO	NO	YES	400
Velcade	bortezomib	YES	NO	NO	NO	NO	YES	400
Victrelis	boceprevir	YES	NO	NO	NO	NO	YES	400
Proleukin	aldesleukin	YES	NO	NO	NO	NO	YES	400
Navelbine	vinorelbine tartrate	YES	NO	NO	NO	NO	YES	400
Sutent	sunitinib malate	YES	NO	NO	NO	NO	YES	400
Camptosar	irinotecan	YES	NO	NO	NO	NO	YES	400
Aromasin	exemestane	YES	NO	NO	NO	NO	YES	400
Xalkori	crizotinib	YES	NO	NO	NO	NO	YES	400
Gamunex-C	immune globulin; intravenous	YES	YES	NO	NO	NO	YES	400
Forteo	teriparatide	YES	YES	NO	NO	NO	YES	400
Torisel	temsirolimus	YES	YES	NO	NO	NO	YES	400
Somavert	pegvisomant	YES	YES	NO	NO	NO	YES	400
Idamycin PFS	idarubicin	YES	YES	NO	NO	NO	YES	400
Mylotarg	gemtuzumab ozogamicin	YES	YES	NO	NO	NO	YES	400
Ellence	epirubicin	YES	YES	NO	NO	NO	YES	400
Premarin cream; vaginal	conjugated estrogens	YES	YES	NO	NO	NO	YES	400
Inlyta	axitinib	YES	YES	NO	NO	NO	YES	400
Ingrezza	valbenazine	YES	YES	NO	NO	NO	YES	400
Kenalog	triamcinolone acetonide	YES	YES	NO	NO	NO	YES	400
Triesence	triamcinolone acetonide	YES	YES	NO	NO	NO	YES	400
Aristocort	triamcinolone	YES	YES	NO	NO	NO	YES	400
Pediaderm TA	triamcinolone	YES	YES	NO	NO	NO	YES	400
Kitabis Pak	tobramycin	YES	YES	NO	NO	NO	YES	400
Tobi	tobramycin	YES	YES	NO	NO	NO	YES	400
Tobi Podhaler	tobramycin	YES	YES	NO	NO	NO	YES	400
Gabitril	tiagabine	YES	YES	NO	NO	NO	YES	400
Granix	TBO-filgrastim	YES	YES	NO	NO	NO	YES	400
Nolvadex	tamoxifen citrate	YES	YES	NO	NO	NO	YES	400
Imlygic	talimogene laherparepvec	YES	YES	NO	NO	NO	YES	400
Metastron	strontium chloride SR-89	YES	YES	NO	NO	NO	YES	400
Vosevi	sofosbuvir/velpatasvir/voxilaprevir	YES	YES	NO	NO	NO	YES	400
NebuSal	sodium chloride	YES	YES	NO	NO	NO	YES	400
PulmoSal	sodium chloride	YES	YES	NO	NO	NO	YES	400
Ammonul	sodium benzoate/sodium phenylacetate	YES	YES	NO	NO	NO	YES	400
Leukine	sargramostim	YES	YES	NO	NO	NO	YES	400
Quadramet	samarium sm-153 lexidronam pentasodium	YES	YES	NO	NO	NO	YES	400
Sucraid	sacrosidase	YES	YES	NO	NO	NO	YES	400
Nplate	romiplostim	YES	YES	NO	NO	NO	YES	400
Atelvia	risedronate sodium	YES	YES	NO	NO	NO	YES	400
Flumadine	rimantadine	YES	YES	NO	NO	NO	YES	400
Copegus	ribavirin	YES	YES	NO	NO	NO	YES	400
Virazole	ribavirin	YES	YES	NO	NO	NO	YES	400
H.P. Acthar Gel	repository corticotropin	YES	YES	NO	NO	NO	YES	400
Deltasone	prednisone	YES	YES	NO	NO	NO	YES	400
Rayos	prednisone	YES	YES	NO	NO	NO	YES	400
Millipred	prednisolone sodium phosphate	YES	YES	NO	NO	NO	YES	400
Econopred	prednisolone acetate	YES	YES	NO	NO	NO	YES	400
Orapred	prednisolone	YES	YES	NO	NO	NO	YES	400
Pediapred	prednisolone	YES	YES	NO	NO	NO	YES	400
Folotyn	pralatrexate	YES	YES	NO	NO	NO	YES	400
Potaba	potassium p-aminobenzoate	YES	YES	NO	NO	NO	YES	400
Photofrin	porfimer sodium	YES	YES	NO	NO	NO	YES	400
Nipent	pentostatin	YES	YES	NO	NO	NO	YES	400
Krystexxa	pegloticase	YES	YES	NO	NO	NO	YES	400
Neulasta	pegfilgrastim	YES	YES	NO	NO	NO	YES	400
Zemplar	paricalcitol	YES	YES	NO	NO	NO	YES	400
Ultresa	pancrelipase	YES	YES	NO	NO	NO	YES	400
Viokace	pancrelipase	YES	YES	NO	NO	NO	YES	400
Aredia	pamidronate disodium	YES	YES	NO	NO	NO	YES	400
Botox	onabotulinumtoxinA	YES	YES	NO	NO	NO	YES	400
Technivie	ombitasvir-paritaprevir-ritonavir	YES	YES	NO	NO	NO	YES	400
Sandostatin	octreotide acetate	YES	YES	NO	NO	NO	YES	400
Axid	nizatidine	YES	YES	NO	NO	NO	YES	400
Cesamet	nabilone	YES	YES	NO	NO	NO	YES	400
Avelox	moxifloxacin	YES	YES	NO	NO	NO	YES	400
Rydapt	midostaurin	YES	YES	NO	NO	NO	YES	400
Solu-Medrol	methylprednisolone sodium succinate	YES	YES	NO	NO	NO	YES	400
Depo-Medrol	methylprednisolone acetate	YES	YES	NO	NO	NO	YES	400
Medrol	methylprednisolone	YES	YES	NO	NO	NO	YES	400
Trexall	methotrexate sodium	YES	YES	NO	NO	NO	YES	400
Methotrexate LPF	methotrexate	YES	YES	NO	NO	NO	YES	400
Rasuvo	methotrexate	YES	YES	NO	NO	NO	YES	400
Rheumatrex	methotrexate	YES	YES	NO	NO	NO	YES	400
Rheumatrex Dose Pack	methotrexate	YES	YES	NO	NO	NO	YES	400
Xatmep	methotrexate	YES	YES	NO	NO	NO	YES	400
Mesnex	mesna	YES	YES	NO	NO	NO	YES	400
Alkeran	melphalan	YES	YES	NO	NO	NO	YES	400
Evomela	melphalan	YES	YES	NO	NO	NO	YES	400
Megace	megestrol acetate	YES	YES	NO	NO	NO	YES	400
Megace ES	megestrol acetate	YES	YES	NO	NO	NO	YES	400
Mustargen	mechlorethamine	YES	YES	NO	NO	NO	YES	400
Valchlor	mechlorethamine	YES	YES	NO	NO	NO	YES	400
Orkambi	lumacaftor/vacaftor	YES	YES	NO	NO	NO	YES	400
CeeNU	lomustine	YES	YES	NO	NO	NO	YES	400
Gleostine	lomustine	YES	YES	NO	NO	NO	YES	400
Xopenex HFA	levalbuterol tartrate	YES	YES	NO	NO	NO	YES	400
Eligard	leuprolide acetate	YES	YES	NO	NO	NO	YES	400
Lupron Depot	leuprolide acetate	YES	YES	NO	NO	NO	YES	400
Zurampic	lesinurad	YES	YES	NO	NO	NO	YES	400
Lenvima	lenvatinib	YES	YES	NO	NO	NO	YES	400
Kalydeco	ivacaftor	YES	YES	NO	NO	NO	YES	400
Combivent	ipratropium bromide/albuterol sulfate	YES	YES	NO	NO	NO	YES	400
Alferon N Injection	Interferon Alfa-N3	YES	YES	NO	NO	NO	YES	400
WinRho SDF	immune globulin; rh	YES	YES	NO	NO	NO	YES	400
Carimune	immune globulin; intravenous	YES	YES	NO	NO	NO	YES	400
Privigen	immune globulin; intravenous	YES	YES	NO	NO	NO	YES	400
Gammaplex	immune globulin; intravenous	YES	YES	NO	NO	NO	YES	400
Gamunex	immune globulin; intravenous	YES	YES	NO	NO	NO	YES	400
Octagam	immune globulin; intravenous	YES	YES	NO	NO	NO	YES	400
Rhophylac	immune globulin-rhoD Intravenous	YES	YES	NO	NO	NO	YES	400
Ifex	ifosfamide	YES	YES	NO	NO	NO	YES	400
Boniva	ibandronate sodium	YES	YES	NO	NO	NO	YES	400
Vistaril	hydroxyzine	YES	YES	NO	NO	NO	YES	400
Cortef	hydrocortisone	YES	YES	NO	NO	NO	YES	400
Solu-Cortef	hydrocortisone	YES	YES	NO	NO	NO	YES	400
Panhematin	hemin	YES	YES	NO	NO	NO	YES	400
Mavyret	glecaprevir/pibrentasvir	YES	YES	NO	NO	NO	YES	400
Adrucil	fluorouracil	YES	YES	NO	NO	NO	YES	400
Carac	fluorouracil	YES	YES	NO	NO	NO	YES	400
Efudex	fluorouracil	YES	YES	NO	NO	NO	YES	400
Fluoroplex	fluorouracil	YES	YES	NO	NO	NO	YES	400
Fludara	fludarabine	YES	YES	NO	NO	NO	YES	400
Zarxio	filgrastim-sndz	YES	YES	NO	NO	NO	YES	400
Neupogen	filgrastim	YES	YES	NO	NO	NO	YES	400
Uloric	febuxostat	YES	YES	NO	NO	NO	YES	400
Toposar	etoposide	YES	YES	NO	NO	NO	YES	400
Femhrt	ethinyl estradiol/norethindrone acetate	YES	YES	NO	NO	NO	YES	400
Parsabiv	etelcalcetide	YES	YES	NO	NO	NO	YES	400
Prefest	estradiol/norgestimate	YES	YES	NO	NO	NO	YES	400
Activella	estradiol/norethindrone acetate	YES	YES	NO	NO	NO	YES	400
Delestrogen	estradiol valerate	YES	YES	NO	NO	NO	YES	400
Alora	estradiol	YES	YES	NO	NO	NO	YES	400
Climara	estradiol	YES	YES	NO	NO	NO	YES	400
Vivelle	estradiol	YES	YES	NO	NO	NO	YES	400
Vivelle-Dot	estradiol	YES	YES	NO	NO	NO	YES	400
Drisdol	ergocalciferol	YES	YES	NO	NO	NO	YES	400
Epogen	epoetin alfa	YES	YES	NO	NO	NO	YES	400
Radicava	edaravone	YES	YES	NO	NO	NO	YES	400
Hectorol	doxercalciferol	YES	YES	NO	NO	NO	YES	400
Decadron	dexamethasone	YES	YES	NO	NO	NO	YES	400
DexPak	dexamethasone	YES	YES	NO	NO	NO	YES	400
Maxidex	dexamethasone	YES	YES	NO	NO	NO	YES	400
Austedo	deutetrabenazine	YES	YES	NO	NO	NO	YES	400
Clarinex	desloratadine	YES	YES	NO	NO	NO	YES	400
Prolia	denosumab	YES	YES	NO	NO	NO	YES	400
Xgeva	denosumab	YES	YES	NO	NO	NO	YES	400
Vyxeos	daunorubicin/cytarabine	YES	YES	NO	NO	NO	YES	400
Cerubidine	daunorubicin	YES	YES	NO	NO	NO	YES	400
Viekira XR	dasabuvir/ombitasvir/paritaprevir/ritonavir	YES	YES	NO	NO	NO	YES	400
Ampyra	dalfampridine	YES	YES	NO	NO	NO	YES	400
Cosmegen	dactinomycin	YES	YES	NO	NO	NO	YES	400
Zinbryta	daclizumab	YES	YES	NO	NO	NO	YES	400
DepoCyt	cytarabine liposome	YES	YES	NO	NO	NO	YES	400
Cytosar-U	cytarabine	YES	YES	NO	NO	NO	YES	400
Gengraf	cyclosporine	YES	YES	NO	NO	NO	YES	400
Neosar	cyclophosphamide	YES	YES	NO	NO	NO	YES	400
Leustatin	cladribine	YES	YES	NO	NO	NO	YES	400
Platinol	cisplatin	YES	YES	NO	NO	NO	YES	400
Platinol-AQ	cisplatin	YES	YES	NO	NO	NO	YES	400
Cipro	ciprofloxacin	YES	YES	NO	NO	NO	YES	400
Sensipar	cinacalcet	YES	YES	NO	NO	NO	YES	400
Leukeran	chlorambucil	YES	YES	NO	NO	NO	YES	400
Bicnu	carmustine	YES	YES	NO	NO	NO	YES	400
Gliadel	carmustine	YES	YES	NO	NO	NO	YES	400
Paraplatin	carboplatin	YES	YES	NO	NO	NO	YES	400
Calcijex	calcitriol	YES	YES	NO	NO	NO	YES	400
Vectical	calcitriol	YES	YES	NO	NO	NO	YES	400
Fortical	calcitonin salmon	YES	YES	NO	NO	NO	YES	400
Cycloset	bromocriptine	YES	YES	NO	NO	NO	YES	400
Blenoxane	bleomycin sulfate	YES	YES	NO	NO	NO	YES	400
Celestone	betamethasone	YES	YES	NO	NO	NO	YES	400
Cystadane	betaine	YES	YES	NO	NO	NO	YES	400
Bendeka	bendamustine	YES	YES	NO	NO	NO	YES	400
Treanda	bendamustine	YES	YES	NO	NO	NO	YES	400
Zithromax	azithromycin	YES	YES	NO	NO	NO	YES	400
Azelex	azelaic acid	YES	YES	NO	NO	NO	YES	400
Azasan	azathioprine	YES	YES	NO	NO	NO	YES	400
Ethyol	amifostine	YES	YES	NO	NO	NO	YES	400
Duzallo	allopurinol/lesinurad	YES	YES	NO	NO	NO	YES	400
Lopurin	allopurinol	YES	YES	NO	NO	NO	YES	400
Fosamax Plus D	alendronate sodium/cholecalciferol	YES	YES	NO	NO	NO	YES	400
Binosto	alendronate sodium	YES	YES	NO	NO	NO	YES	400
Accuneb	albuterol sulfate	YES	YES	NO	NO	NO	YES	400
Proair HFA	albuterol sulfate	YES	YES	NO	NO	NO	YES	400
Vospire ER	albuterol sulfate	YES	YES	NO	NO	NO	YES	400
Proventil	albuterol	YES	YES	NO	NO	NO	YES	400
Acetadote	acetylcysteine	YES	YES	NO	NO	NO	YES	400
Mucomyst	acetylcysteine	YES	YES	NO	NO	NO	YES	400
Vincasar PFS	vincristine sulfate	YES	YES	NO	NO	NO	YES	400
Velban	vinblastine sulfate	YES	YES	NO	NO	NO	YES	400
Mycobutin	rifabutin	NO	YES	NO	NO	NO	YES	400
Depo-Provera	medroxyprogesterone acetate	NO	YES	NO	NO	NO	YES	400
Premphase	conjugated estrogens/medroxyprogesterone acetate	NO	YES	NO	NO	NO	YES	400
Prempro	conjugated estrogens/medroxyprogesterone acetate	NO	YES	NO	NO	NO	YES	400
Tygacil	tigecycline	NO	YES	NO	NO	NO	YES	400
Increlex injection	mecasermin	YES	YES	NO	NO	NO	YES	400
Somatuline Depot injection	lanreotide acetate	YES	YES	NO	NO	NO	YES	400
Xenazine tablet	tetrabenazine	YES	YES	NO	NO	NO	YES	400
Relizorb cartridge	immobilized lipase	YES	YES	NO	NO	NO	YES	400
Otrexup	methotrexate	YES	YES	NO	NO	NO	YES	400
Ixinity	coagulation factor IX	YES	YES	NO	NO	NO	YES	300
Gliadel wafer: polifeprosan 20 with carmustine implant	carmustine	YES	YES	NO	NO	NO	YES	200
Sotylize oral solution	sotalol	YES	YES	NO	NO	NO	YES	400
BiDil tablet	isosorbide dinitrate/hydralazine	YES	YES	NO	NO	NO	YES	400
Horizant	gabapentin enacarbil	YES	YES	NO	NO	NO	YES	400
E.E.S. granule; oral	erythromycin ethylsuccinate	YES	YES	NO	NO	NO	YES	400
EryPed granule; oral	erythromycin ethylsuccinate	YES	YES	NO	NO	NO	YES	400
ERY-TAB	erythromycin	YES	YES	NO	NO	NO	YES	400
PCE	erythromycin	YES	YES	NO	NO	NO	YES	400
Edarbi tablet	azilsartan medoxomil	YES	YES	NO	NO	NO	YES	400
Edarbyclor tablet	azilsartan kamedoxomil/chlorthalidone	YES	YES	NO	NO	NO	YES	400
Vistogard	uridine triacetate	YES	YES	NO	NO	NO	YES	400
Alprolix powder; lyophilized	coagulation factor IX	YES	YES	NO	NO	NO	YES	400
Cresemba	isavuconazonium sulfate		UNKNOWN	NO	NO	NO	YES	400
Myrbetriq tablet; extended release	mirabegron	YES	UNKNOWN	NO	NO	NO	YES	400
Xtandi	enzalutamide	YES	UNKNOWN	NO	NO	NO	YES	400
Mycamine injection	micafungin sodium	YES	UNKNOWN	NO	NO	NO	YES	400
AmBisome injection	amphotericin B liposome	YES	UNKNOWN	NO	NO	NO	YES	400
Gammaplex iv	immune globulin; intravenous	YES	YES	NO	NO	NO	YES	400
Vosevi tablet	sofosbuvir/velpatasvir/voxilaprevir	YES	YES	NO	NO	NO	YES	500
Epclusa tablet	sofosbuvir/velpatasvir	YES	YES	NO	NO	NO	YES	500
Sovaldi tablet	sofosbuvir	YES	YES	NO	NO	NO	YES	500
Harvoni tablet	ledipasvir/sofosbuvir	YES	YES	NO	NO	NO	YES	500
Tagrisso	osimertinib	YES	NO	NO	NO	NO	YES	400
Lynparza	olaparib	YES	YES	NO	NO	NO	YES	400
Iressa	gefitinib	YES	YES	NO	NO	NO	YES	400
Imfinzi	durvalumab	YES	YES	NO	NO	NO	YES	400
Calquence	acalabrutinib	YES	YES	NO	NO	NO	YES	400
Zevalin injectable; iv	yttrium-90	YES	YES	NO	NO	NO	YES	400
Marqibo injectable; iv	vincristine sulfate	YES	YES	NO	NO	NO	YES	400
Folotyn solution; iv	pralatrexate	YES	YES	NO	NO	NO	YES	400
Beleodaq powder; injection	belinostat	YES	YES	NO	NO	NO	YES	400
Venclexta	venetoclax	YES	YES	NO	NO	NO	YES	400
Zelboraf	vemurafenib	YES	YES	NO	NO	NO	YES	400
Herceptin	trastuzumab	YES	YES	NO	NO	NO	YES	400
Actemra	tocilizumab	YES	YES	NO	NO	NO	YES	400
TNKase	tenecteplase	YES	YES	NO	NO	NO	YES	400
Rituxan Hycela	rituximab/hyaluronidase	YES	YES	NO	NO	NO	YES	400
Rituxan	rituximab	YES	YES	NO	NO	NO	YES	400
Lucentis	ranibizumab	YES	YES	NO	NO	NO	YES	400
Esbriet	pirfenidone	YES	YES	NO	NO	NO	YES	400
Perjeta	pertuzumab	YES	YES	NO	NO	NO	YES	400
Xolair	omalizumab	YES	YES	NO	NO	NO	YES	400
Ocrevus	ocrelizumab	YES	YES	NO	NO	NO	YES	400
Gazyva	obinutuzumab	YES	YES	NO	NO	NO	YES	400
Tarceva	erlotinib	YES	YES	NO	NO	NO	YES	400
Hemlibra	emicizumab	YES	YES	NO	NO	NO	YES	400
Pulmozyme	dornase alfa	YES	YES	NO	NO	NO	YES	400
Cotellic	cobimetinib	YES	YES	NO	NO	NO	YES	400
Avastin	bevacizumab	YES	YES	NO	NO	NO	YES	400
Activase	alteplase	YES	YES	NO	NO	NO	YES	400
Cathflo	alteplase	YES	YES	NO	NO	NO	YES	400
Alecensa	alectinib	YES	YES	NO	NO	NO	YES	400
Kadcyla	ado-trastuzumab emtansine	YES	YES	NO	NO	NO	YES	400
Erivedge	vismodegib	YES	YES	NO	NO	NO	YES	400
Invirase	saquinavir	YES	YES	NO	NO	NO	YES	400
Fuzeon	enfuvirtide	YES	YES	NO	NO	NO	YES	400
Brineura	cerliponase alpa	YES	YES	NO	NO	NO	YES	400
Enfamil	formula infant	YES	YES	NO	NO	NO	YES	400
CitraNatal 90 DHA tablet	vitamin/mineral supplement	YES	YES	NO	NO	NO	YES	400
CitraNatal B-Calm tablet	vitamin/mineral supplement	YES	YES	NO	NO	NO	YES	400
CitraNatal Harmony capsule; gel	vitamin/mineral supplement	YES	YES	NO	NO	NO	YES	400
Avar Family Products topical	sulfacetamide/sulfur	YES	YES	NO	NO	NO	YES	400
Ovace Plus Products topical	sodium sulfacetamide	YES	YES	NO	NO	NO	YES	400
Utira-C	methenamine/sodium phosphate monobasic/phenyl salicylate/methylene blue/hyoscyamine sulfate	YES	YES	NO	NO	NO	YES	400
Hyophen	methenamine/benzoic acid/phenyl salicylate/methylene blue/hyoscyamine sulfate	YES	YES	NO	NO	NO	YES	400
Texacort solution; topical	hydrocortizone	YES	YES	NO	NO	NO	YES	400
Eletone	emolent	YES	YES	NO	NO	NO	YES	400
CitraNatal Assure tablet	dual-iron/DHA	YES	YES	NO	NO	NO	YES	400
Ferralet 90 tablet	dual-iron	YES	YES	NO	NO	NO	YES	400
Aquoral spray	artificial saliva	YES	YES	NO	NO	NO	YES	400
Eloctate injection	antihemophilic factor	YES	YES	NO	NO	NO	YES	400
Rubraca	rucaparib		YES	NO	NO	NO	YES	400
Xtampza ER	oxycodone	YES	YES	NO	NO	NO	YES	400
ConvaTec Ostomy Products ostomy products	pouches-skin barriers		YES	NO	NO	NO	YES	400
Korlym tablet	mifepristone	YES	YES	NO	NO	NO	YES	400
Orencia	abatacept	NO	NO	NO	NO	NO	YES	400
BCAD 2 Medical Food powder	medical food	NO	YES	NO	NO	NO	YES	400
HCY 2 Medical Food powder	medical food	NO	YES	NO	NO	NO	YES	400
OA 2 Medical Food powder	medical food	NO	YES	NO	NO	NO	YES	400
PFD 2 Medical Food powder	medical food	NO	YES	NO	NO	NO	YES	400
PFD Toddler Medical Food powder	medical food	NO	YES	NO	NO	NO	YES	400
Tyros 1 Medical Food powder	medical food	NO	YES	NO	NO	NO	YES	400
Tyros 2 Medical Food powder	medical food	NO	YES	NO	NO	NO	YES	400
3232 A Infant Formula powder	formula infant	NO	YES	NO	NO	NO	YES	400
BCAD 1 Infant Formula powder	formula infant	NO	YES	NO	NO	NO	YES	400
Enfagrow Toddler Transitions Gentlease powder	formula infant	NO	YES	NO	NO	NO	YES	400
Enfagrow Toddler Transitions Soy powder	formula infant	NO	YES	NO	NO	NO	YES	400
Enfamil 24 liquid	formula infant	NO	YES	NO	NO	NO	YES	400
Enfamil A.R. powder	formula infant	NO	YES	NO	NO	NO	YES	400
Enfamil EnfaCare powder	formula infant	NO	YES	NO	NO	NO	YES	400
Enfamil Gentlease liquid	formula infant	NO	YES	NO	NO	NO	YES	400
Enfamil Human Milk Fortifier powder	formula infant	NO	YES	NO	NO	NO	YES	400
Enfamil Premature 30 liquid	formula infant	NO	YES	NO	NO	NO	YES	400
Enfamil Premature High Protein 24 liquid	formula infant	NO	YES	NO	NO	NO	YES	400
Enfamil Premature Low Iron 20 liquid	formula infant	NO	YES	NO	NO	NO	YES	400
Enfamil Premature Low Iron 24 liquid	formula infant	NO	YES	NO	NO	NO	YES	400
Enfamil Premature with Iron 20 liquid	formula infant	NO	YES	NO	NO	NO	YES	400
Enfamil Premature with Iron 24 liquid	formula infant	NO	YES	NO	NO	NO	YES	400
Enfamil ProSobee liquid	formula infant	NO	YES	NO	NO	NO	YES	400
Enfamil Reguline powder	formula infant	NO	YES	NO	NO	NO	YES	400
Enfaport liquid	formula infant	NO	YES	NO	NO	NO	YES	400
GA Infant Formula powder	formula infant	NO	YES	NO	NO	NO	YES	400
HCY 1 Infant Formula powder	formula infant	NO	YES	NO	NO	NO	YES	400
LMD Infant Formula powder	formula infant	NO	YES	NO	NO	NO	YES	400
Nutramigen with Enflora LGG powder	formula infant	NO	YES	NO	NO	NO	YES	400
Nutramigen with Enflora LGG Toddler powder	formula infant	NO	YES	NO	NO	NO	YES	400
OA 1 Infant Formula powder	formula infant	NO	YES	NO	NO	NO	YES	400
Pregestimil powder	formula infant	NO	YES	NO	NO	NO	YES	400
PurAmino powder	formula infant	NO	YES	NO	NO	NO	YES	400
WND 1 Infant Formula powder	formula infant	NO	YES	NO	NO	NO	YES	400
Stiolto Respimat	tiotropium bromide/olodaterol	YES	NO	NO	NO	NO	YES	400
Zilretta	triamcinolone acetonide	YES	UNKNOWN	Determined case by case	No	Not disclosed	Doctor's office or specific site	400
Myobloc injection	rimabotulinumtoxinB	YES	YES	NO	NO	NO	YES	400
Otezla tablet	apremilast	YES	YES	NO	NO	NO	YES	400
Sylvant disposal container	container for Sylvant	YES	YES	NO	NO	NO	YES	400
Stelara	ustekinumab	NO	NO	NO	NO	NO	YES	400
Tremfya	guselkumab	NO	NO	NO	NO	NO	YES	400
Simponi	golimumab	NO	NO	NO	NO	NO	YES	400
Cosentyx	secukinumab	NO	NO	NO	NO	NO	YES	400
Evzio injectable; subcutaneous	naloxone	YES	YES	NO	NO	NO	YES	150
Auryxia tablet	ferric citrate	NO	YES	NO	NO	NO	YES	400
Makena solution	hydroxyprogesterone caproate	YES	YES	NO	NO	NO	YES	400
Mytesi tablet; delayed-release	crofelemer	YES	YES	NO	NO	NO	YES	200
Rasuvo injection	methotrexate	YES	YES	NO	NO	NO	YES	200
Cayston	aztreonam	YES	YES	NO	NO	NO	YES	400
AlphaNine SD	coagulation factor IX	YES	YES	NO	NO	NO	YES	400
Alphanate	antihemophilic factor human	YES	YES	NO	NO	NO	YES	400
Urocit-K	potassium citrate	YES	YES	NO	NO	NO	YES	150
Uribel capsule	methenamine/sodium phosphate/monobasic/monohydrate/phenyl salicylate	YES	YES	NO	NO	NO	YES	150
Lithostat tablet	acetohydroxamic acid	YES	YES	NO	NO	NO	YES	150
Defitelio	defibrotide	NO	NO	NO	NO	NO	YES	400
Erwinaze injection	asparaginase erwinia chrysanthemi	NO	NO	NO	NO	NO	YES	400
Prialt injectable; intrathecal	ziconotide	NO	NO	NO	NO	NO	YES	400
Xyrem oral solution	sodium oxybate	NO	NO	NO	NO	NO	YES	400
Entereg capsule	alvimopan	YES	YES	NO	NO	NO	YES	400
Gleostine capsule	lomustine	NO	YES	NO	NO	NO	YES	200
Isentress	raltegravir	YES	NO	NO	NO	NO	YES	400
Dulera	formoterol fumarate/mometasone furoate	YES	NO	NO	NO	NO	YES	400
Fareston tablet	toremifene citrate	YES	YES	NO	NO	NO	YES	400
Roxicodone tablet	oxycodone	NO	YES	NO	NO	NO	YES	200
Tofranil tablet	imipramine	NO	YES	NO	NO	NO	YES	200
Exalgo tablet	hydromorphone	NO	YES	NO	NO	NO	YES	200
Anafranil capsule	clomipramine	NO	YES	NO	NO	NO	YES	200
Zubsolv tablet; sublingual	buprenorphine/naloxone	NO	NO	NO	NO	NO	YES	300
Sucraid oral solution	sacrosidase	NO	YES	NO	NO	NO	Patient's home, unless otherwise noted	400
Northera capsule	droxidopa	NO	YES	NO	NO	NO	YES	400
Onfi tablet	clobazam	YES	YES	NO	NO	NO	YES	400
Orbactiv	oritavancin diphosphate	NO	YES	NO	NO	NO	YES	400
Baxdela	delafloxacin	YES	YES	NO	NO	NO	YES	400
Otiprio	ciprofloxacin	NO	NO	NO	NO	NO	YES	400
Photofrin injection	porfimer sodium		YES	NO	NO	NO	YES	200
Prothelial paste	polymerized sucralfate malate	YES	YES	NO	NO	NO	YES	400
EMSAM transdermal	selegiline	NO	YES	NO	NO	NO	YES	400
EpiPen 2-Pak injection	epinephrine	NO	YES	NO	NO	NO	YES	400
EpiPen Jr 2-Pak injection	epinephrine	NO	YES	NO	NO	NO	YES	400
Samsca tablet	tolvaptan	NO	NO	NO	NO	NO	YES	400
Vivotif capsule	typhoid vaccine live oral Ty21a	YES	UNKNOWN	NO	NO	NO	YES	400
Chemet capsule	succimer		YES	NO	NO	NO	YES	400
Desoxyn tablet	methamphetamine		YES	NO	NO	NO	YES	400
NeoProfen injection	ibuprofen lysine		YES	NO	NO	NO	YES	400
Panhematin powder; injection	hematin	hemin/sodium carbonate/sorbitol))	YES	NO	NO	NO	YES	400
Peganone tablet	ethotoin		YES	NO	NO	NO	YES	400
Cosmegen injection	dactinomycin		YES	NO	NO	NO	YES	400
Tranxene	clorazepate dipotassium		YES	NO	NO	NO	YES	400
Odomzo capsule	sonidegib	YES	UNKNOWN	Determined case by case	Contact program for details.	Not disclosed	Patient's home	400
Rexulti tablet	brexpiprazole	NO	NO	NO	NO	NO	YES	400
Abilify Maintena injection; extended release	aripiprazole	NO	NO	NO	NO	NO	YES	400
Cimzia	certolizumab pegol		NO	NO	NO	NO	YES	400
Rasuvo Container disposal container	container for Rasuvo sharps		YES	NO	NO	NO	YES	400
Saizen	somatropin	YES	NO	NO	NO	NO	YES	400
Hizentra vial; single-use 20%	immune globulin; subcutaneous	YES	YES	NO	NO	NO	YES	400
Privigen vial; single-use	immune globulin; intravenous	YES	YES	NO	NO	NO	YES	400
LMX cream; anesthetic	lidocaine	YES	UNKNOWN	May have insurance	Yes	At or below 100% of FPL	Doctor's office or patient's home	150
Detachol unit dose	adhesive remover	YES	UNKNOWN	May have insurance	Yes	At or below 100% of FPL	Doctor's office or patient's home	150
Mastisol liquid	adhesive	YES	UNKNOWN	May have insurance	Yes	At or below 100% of FPL	Doctor's office or patient's home	150
Serostim injection	somatropin	YES	UNKNOWN	Determined case by case	No	Not disclosed	Doctor's office or patient's home	400
Saizen injection	somatropin	YES	UNKNOWN	Contact program for details.	No	Not disclosed	Patient's home	400
Zomacton	somatropin	YES	UNKNOWN	Must be uninsured or have a temporary lapse in insurance coverage.	No	Varies	Patient's home, unless otherwise noted	400
Hyalgan vial	sodium hyaluronate	NO	UNKNOWN	Must have no prescription coverage for needed medication	Contact program for details.	At or below 250% of FPL	Doctor's office	250
Procysbi	cysteamine bitartrate	YES	NO	NO	NO	NO	YES	400
Vimovo	naproxen/esomeprazole	YES	YES	NO	NO	NO	YES	400
Duexis	ibuprofen/famotidine	YES	YES	NO	NO	NO	YES	400
Pennsaid	diclofenac sodium	YES	YES	NO	NO	NO	YES	400
Letairis	ambrisentan	YES	YES	NO	NO	NO	YES	500
Ranexa tablet; extended release	ranolazine	YES	YES	NO	NO	NO	YES	500
Suboxone film; sublingual	buprenorphine/naloxone	YES	YES	NO	NO	NO	YES	250
Nascobal spray; nasal	cyanocobalamin	NO	UNKNOWN	Must have no prescription coverage	No	At or below 200% of FPL	Doctor's office	200
Velphoro tablet; chewable	sucroferric oxyhydroxide	YES	UNKNOWN	May have insurance	Yes, but contact program for details	Not disclosed	Patient's home	400
Ocaliva	obeticholic acid	NO	YES	NO	NO	NO	YES	400
Diclegis tablet	doxylamine succinate/pyridoxine	NO	YES	NO	NO	NO	YES	250
Hymovis	high molecular weight viscoelastic hyaluronan	NO	UNKNOWN	Must have no prescription coverage for needed medication	Yes, if medication is not covered	At or below 250% of FPL	Doctor's office	250
Prolastin C	alpha1-proteinase inhibitor	YES	YES	NO	NO	NO	YES	400
Emverm	mebendazole	YES	YES	NO	NO	NO	YES	300
Rytary	carbidopa/levodopa	YES	YES	NO	NO	NO	YES	300
Albenza	albendazole	YES	YES	NO	NO	NO	YES	300
Zomig	zolmitriptan	YES	YES	NO	NO	NO	YES	300
Xeomin injection	incobotulinumtoxinA	YES	YES	NO	NO	NO	YES	400
Dermagraft dermal substitute	dermagraft bilayered skin substitute	NO	NO	NO	NO	NO	YES	400
Apligraf dermal substitute	bilayered skin substitute	NO	NO	NO	NO	NO	YES	400
Advair Diskus	fluticasone propionate/salmeterol xinafoate	YES	NO	NO	NO	NO	YES	400
Advair HFA	fluticasone propionate/salmeterol xinafoate	YES	NO	NO	NO	NO	YES	400
Flovent Diskus	fluticasone propionate	YES	NO	NO	NO	NO	YES	400
Flovent HFA	fluticasone propionate	YES	NO	NO	NO	NO	YES	400
Breo Ellipta	fluticasone furoate/vilanterol trifenatate	YES	NO	NO	NO	NO	YES	400
Arnuity Ellipta	fluticasone furoate	YES	NO	NO	NO	NO	YES	400
Coreg CR	carvedilol	YES	NO	NO	NO	NO	YES	400
Soriatane	acitretin	YES	NO	NO	NO	NO	YES	400
Bavencio	avelumab	NO	UNKNOWN	Must have no prescription coverage for needed medication	Contact program for details.	Not disclosed	Doctor's office or specific site	400
Wilate liquid	von willebrand factor/coagulation factor Vlll complex	NO	NO	NO	NO	NO	YES	400
Nuwiq	antihemophilic factor	NO	NO	NO	NO	NO	YES	400
Sancuso transdermal patch	granisetron	YES	YES	NO	NO	NO	YES	300
Lenvima capsule	lenvatinib	YES	UNKNOWN	May have insurance	Yes	Not disclosed	Patient's home, unless otherwise noted	400
Belviq tablet	lorcaserin	YES	UNKNOWN	May have insurance	Yes	At or below 150% of FPL	Patient's home	150
Fycompa	perampanel	YES	UNKNOWN	Must be uninsured, denied coverage or are awaiting public assistance determination	No	At or below 300% of FPL	Patient is sent savings card to be used at pharmacy	300
MatriStem MicroMatrix tissue matrix; extracellular	matrix; lyophilized extracellular		YES	NO	NO	NO	YES	400
Carbaglu	carglumic acid	YES	YES	NO	NO	NO	YES	400
Lupaneta Pack		YES	YES	NO	NO	NO	YES	300	Varies	1286
LUPRON DEPOT GYN	norethindrone acetate	YES	YES	NO	NO	NO	YES	300	Varies	1546
Prolia	Denosumab	YES	YES	NO	NO	NO	YES	500	Varies	3000
Neulasta	pegfilgrastim	YES	YES	NO	NO	NO	YES	500	Varies	5000
Neulasta Onpro Kit	pegfilgrastim	YES	YES	NO	NO	NO	YES	500	Varies	5000
Neupogen	filgrastim	YES	YES	NO	NO	NO	YES	500	Varies	5000
Onglyza Tablet	saxagliptin	NO	YES	NO	3	NO	YES	300	Varies	384.59
Daklinza	daclatasvir	NO	YES	NO	3	NO	YES	400	Varies	22959
Eliquis Tablet	apixaban	NO	YES	NO	3	NO	YES	400	Varies	383.13
Nulojix Injection	belatacept	NO	YES	NO	3	NO	YES	400	Varies	1022.91
Orencia	abatacept	NO	YES	NO	3	NO	YES	400	Varies	4403.86
Plavix		NO	YES	NO	3	NO	YES	400	Varies	159
Sustiva	Efavirenz	YES	YES	NO	3	NO	YES	400	Varies	1176.74
Sprycel	dasatinib	NO	YES	NO	3	NO	YES	400	Varies	13217.4
Yervoy	ipilimumab	NO	YES	NO	3	NO	YES	400	Varies	30000
ELIgard Injection	leuprolide	NO'	YES	YES	5	NO	YES	250	Varies	230
Coartem Tablet	artmether and lumefantrine	YES	NO	NO	NO	NO	YES	250	Varies	1224.43
Focalin XR	dexmethyiphenidate HCI	YES	NO	NO	NO	NO	YES	250	Varies	396.5
Focalin XRCapsule ER	dexmethyiphenidate HCI	YES	NO	NO	NO	NO	YES	250	Varies	396.5
Jadenu	deferasirox	YES	NO	NO	NO	NO	YES	250	Varies	20000
Jadenu Sprinkle	deferasirox	YES	NO	NO	NO	NO	YES	250	Varies	20000
Lamisil Oral Granules	terbinafine	YES	NO	NO	NO	NO	YES	250	Varies	859
Myfortic Tablet; Delayed Release	mycophenolic acid	YES	NO	NO	NO	NO	YES	250	Varies	1176.55
Neoral Capsule	cyclosporine USP	YES	NO	NO	NO	NO	YES	250	Varies	134.96
Neoral Oral Solution	cyclosporine	YES	NO	NO	NO	NO	YES	250	Varies	486.43
Reclast Injectable; IV	zoledronic acid	YES	NO	NO	NO	NO	YES	250	Varies	1247.6
Sandimmune Capsule, Gel	cyclosporine	YES	NO	NO	NO	NO	YES	250	Varies	917.87
Sandimmune Oral Solution	cyclosporine	YES	NO	NO	NO	NO	YES	250	Varies	644.4
Tegretol XR Tablet	carbamazepine	YES	NO	NO	NO	NO	YES	250	Varies	162.88
TOBI Inhalation Solution	tobramycin	YES	NO	NO	NO	NO	YES	250	Varies	8439.59
TOBI Podhaler Powder	tobramycin	YES	NO	NO	NO	NO	YES	250	Varies	9300.99
Travatan Z	travoprost	YES	NO	NO	NO	NO	YES	250	Varies	156.71
Trileptal Tablet	oxcarbazepine	YES	NO	NO	NO	NO	YES	250	Varies	293.62
Zortress Tablet	everolimus	YES	NO	NO	NO	NO	YES	250	Varies	1432.97
Novoeight	antihemophilic factor recombinant	NO	NO	NO	NO	NO	NO	400	Varies	10
Erbitux	cetuximab	NO	NO	NO	NO	NO	YES	500	Varies	80532
Nicotrol	nicotine inhalation system	YES	YES	NO	NO	NO	YES	400	Varies	443
Nitrostat	nitroglycerin	YES	YES	NO	NO	NO	YES	400	Varies	70
Norpace	Disopyramide	YES	YES	NO	NO	NO	YES	400	Varies	471
Norpace CR	Disopyramide CR	YES	YES	NO	NO	NO	YES	400	Varies	471
Skelaxin	NO PROGRAM AVAILABLE	NO	YES	NO	NO	NO	VARIES	400	VARIES	150
Somavert	pegvisomant	NO	YES	NO	NO	NO	VARIES	400	VARIES	3174
Jevtana	cabazitaxel	NO	YES	YES	5	NO	YES	250	Varies	3170.53
Adacel Injection	tetanus toxoid/reduced diptheria toxoid/acellular pertussis	YES	YES	NO	5	NO	YES	250	Varies	129.61
Apidra SoloStar Pen	insulin glulisine [rDNA origin]	YES	YES	NO	5	NO	YES	250	Varies	567.75
ApidraVials	insulin glulisine [rDNA origin]	YES	YES	NO	5	NO	YES	250	Varies	294.38
ClolarVial	clofarabine	YES	YES	NO	5	NO	YES	250	Varies	3170.53
Elitek Vial	rasburicase	YES	YES	NO	5	NO	YES	250	Varies	2491.76
Enoxaparin SodiumInjectable	enoxaparin sodium	YES	YES	NO	5	NO	YES	250	Varies	683.21
Imogam Injection	rabies immune globulin	YES	YES	NO	5	NO	YES	250	Varies	809.05
Imovax Injection	rabies vaccine	YES	YES	NO	5	NO	YES	250	Varies	964.03
Jevtana Injection	cabazitaxel	YES	YES	NO	5	NO	YES	250	Varies	10519.98
Lantus	Basaglar	YES	YES	NO	5	NO	YES	250	Varies	400
Lantus SoloSTAR Pen	insulin glargine	YES	YES	NO	5	NO	YES	250	Varies	372.27
Lantus U-100	Basaglar	YES	YES	NO	5	NO	YES	250	Varies	400
Lantus U-100Vial	insulin glargine	YES	YES	NO	5	NO	YES	250	Varies	248.51
Leukine Vial	sargramostim	YES	YES	NO	5	NO	YES	250	Varies	1337.54
Lovenox Injection	enoxaparin sodium	YES	YES	NO	5	NO	YES	250	Varies	381.37
Menactra Injection	diphtheria toxid conjugate vaccine	YES	YES	NO	5	NO	YES	250	Varies	113.36
Menomune Injection	meningococcal polysacchaaide vaccine	YES	YES	NO	5	NO	YES	250	Varies	123.55
Mozobil Injection	plerixafor	YES	YES	NO	5	NO	YES	250	Varies	7846.82
Multaq	dronedarone	YES	YES	NO	5	NO	YES	250	Varies	566.43
Priftin	rifapentine	YES	YES	NO	5	NO	YES	250	Varies	122.06
Tenivac Injection	tetanus and diphtheria toxoids adsorbed	YES	YES	NO	5	NO	YES	250	Varies	319.96
Thymoglobulin Vial	anti-thymocyte globulin rabbit	YES	YES	NO	5	NO	YES	250	Varies	815.9
Toujeo	insulin glargine	YES	YES	NO	5	NO	YES	250	Varies	397
Toujeo Solostar	insulin glargine	YES	YES	NO	5	NO	YES	250	Varies	335.14
Zaltrap IV	ziv-aflibercept	YES	YES	NO	5	NO	YES	250	Varies	1792
Arcapta NeohalerPowder	indaceterol	Yes if not listed in the formulary	YES	NO	NO	NO	YES	250	Varies	247.02
Latuda	lurasidone		YES	NO	NO	NO	YES	250	Varies	247.02
Seebri	Glycopyrrolate		YES	NO	NO	NO	YES	250	Varies	49
Utibron	glycopyrrolate and indacaterol		YES	NO	NO	NO	YES	250	Varies	$46
Arcapta	indacaterol (inhalation)	Yes if not listed in the formulary	YES	NO	NO	NO	YES	250	Varies	277
Pro-Phree	medical food	YES	YES	NO	NO	NO	YES	400
Nuplazid tablet	pimavanserin	YES	YES	NO	NO	NO	YES	400
Qutenza patch	capsaicin	YES	YES	NO	NO	NO	YES	400
Feraheme	ferumoxytol	NO	YES	NO	NO	NO	YES	400
MuGard oral solution	mucadhesive	NO	YES	NO	NO	NO	YES	400
Venofer	iron sucrose	NO	NO	NO	NO	NO	YES	400
Injectafer injection	ferric carboxymaltose	NO	NO	NO	NO	NO	YES	400
Lexiscan solution; iv	regadenoson	NO	UNKNOWN	NO	NO	NO	YES	400
Onzetra Xsail	sumatriptan	NO	UNKNOWN	NO	NO	NO	NO	400
Xofigo	radium ra-223 dichloride	NO	YES	NO	NO	NO	YES	400
Stivarga	regorafenib	NO	YES	NO	NO	NO	YES	400
Biltricide	praziquantel	NO	YES	NO	NO	NO	YES	400
Mirena	levonorgestrel-releasing intrauterine system	NO	YES	NO	NO	NO	YES	400
Kyleena	levonorgestrel	NO	YES	NO	NO	NO	YES	400
Skyla	levonorgestrel	NO	YES	NO	NO	NO	YES	400
Betaseron	interferon beta-1b	NO	YES	NO	NO	NO	YES	400
Climara Pro	estradiol/levonorgestrel	NO	YES	NO	NO	NO	YES	400
Natazia	estradiol valerate and estradiol valerate/dienogest	NO	YES	NO	NO	NO	YES	400
Safyral	drospirenone/ethinyl estradiol/levomefolate calcium	NO	YES	NO	NO	NO	YES	400
Angeliq	drospirenone/estradiol	NO	YES	NO	NO	NO	YES	400
Spinraza	nusinersen	NO	YES	NO	NO	NO	YES	400
Kuvan	sapropterin dihydrochloride	NO	YES	NO	NO	NO	YES	400
Gelsyn-3	sodium hyaluronate	NO	YES	NO	NO	NO	YES	400
Supartz injection	sodium hyaluronate	NO	YES	NO	NO	NO	YES	400
Vectra DA	Blood Test	NO	YES	NO	NO	NO	YES	400
Ferriprox tablet; oral	deferiprone	NO	YES	NO	NO	NO	YES	400
Banzel oral suspension	rufinamide	NO	UNKNOWN		May have insurance	Yes	Varies	400
Rebif syringe; subcutaneous	interferon beta-1a	NO	UNKNOWN		Varies	Not disclosed	Patient's home	400
Supprelin LA implant; subcutaneous	histrelin acetate	NO	UNKNOWN		Determined case by case	No	1 dose	400
Valcyte	valganciclovir	NO	YES	NO	NO	NO	YES	400
Vemlidy	tenofovir alafenamide	NO	YES	NO	NO	NO	YES	400
Hepsera	adefovir dipivoxil	NO	YES	NO	NO	NO	YES	400
Iclusig	ponatinib	NO	NO	NO	NO	NO	YES	400
Entocort EC	budesonide	NO	NO	NO	NO	NO	YES	400
Caprelsa	vandetanib	NO	NO	NO	NO	NO	YES	400
Jetrea	ocriplasmin	NO	NO	NO	NO	NO	YES	400
Faslodex	fulvestrant	NO	NO	NO	NO	NO	YES	400
Zaltrap	ziv-aflibercept	NO	NO	NO	NO	NO	YES	400
Marqibo Kit	vincristine	NO	NO	NO	NO	NO	YES	400
Tyvaso	treprostinil	NO	NO	NO	NO	NO	YES	400
Tyzeka	telbivudine	NO	NO	NO	NO	NO	YES	400
Incivek	telaprevir	NO	NO	NO	NO	NO	YES	400
Norditropin	somatropin	NO	NO	NO	NO	NO	YES	400
Nutropin	somatropin	NO	NO	NO	NO	NO	YES	400
Omnitrope	somatropin	NO	NO	NO	NO	NO	YES	400
Tev-Tropin	somatropin	NO	NO	NO	NO	NO	YES	400
Valtropin	somatropin	NO	NO	NO	NO	NO	YES	400
Provenge	sipuleucel-T	NO	NO	NO	NO	NO	YES	400
Jakafi	ruxolitinib	NO	NO	NO	NO	NO	YES	400
PegIntron-Rebetol combo pack	ribavirin/peginterferon alfa-2b	NO	NO	NO	NO	NO	YES	400
Signifor	pasireotide diaspartate	NO	NO	NO	NO	NO	YES	400
Tasigna	nilotinib monohydrate	NO	NO	NO	NO	NO	YES	400
Opsumit	macitentan	NO	NO	NO	NO	NO	YES	400
Tykerb	lapatinib ditosylate	NO	NO	NO	NO	NO	YES	400
Epivir	lamivudine	NO	NO	NO	NO	NO	YES	400
Onmel	itraconzazole	NO	NO	NO	NO	NO	YES	400
Sporanox	itraconazole	NO	NO	NO	NO	NO	YES	400
Extavia	interferon beta-1b	NO	NO	NO	NO	NO	YES	400
Remicade	infliximab	NO	NO	NO	NO	NO	YES	400
Gleevec	imatinib	NO	NO	NO	NO	NO	YES	400
Ventavis	iloprost	NO	NO	NO	NO	NO	YES	400
Cytovene	ganciclovir	NO	NO	NO	NO	NO	YES	400
Foscavir	foscarnet sodium	NO	NO	NO	NO	NO	YES	400
Zortress	everolimus	NO	NO	NO	NO	NO	YES	400
Veletri	epoprostenol sodium	NO	NO	NO	NO	NO	YES	400
Baraclude tablet	entecavir	NO	NO	NO	NO	NO	YES	400
Exjade	deferasirox	NO	NO	NO	NO	NO	YES	400
Jadenu	deferasirox	NO	NO	NO	NO	NO	YES	400
Sprycel	dasatinib	NO	NO	NO	NO	NO	YES	400
Cystagon	cysteamine bitartrate	NO	NO	NO	NO	NO	YES	400
Cystaran	cysteamine	NO	NO	NO	NO	NO	YES	400
Vistide	cidofovir	NO	NO	NO	NO	NO	YES	400
Tracleer	bosentan	NO	NO	NO	NO	NO	YES	400
Eylea	aflibercept	NO	NO	NO	NO	NO	YES	400
Humira	adalimumab	NO	NO	NO	NO	NO	YES	400
Zytiga	abiraterone acetate	NO	NO	NO	NO	NO	YES	400
Bactrim	sulfamethoxazole/trimethoprim	NO	NO	NO	NO	NO	YES	400
Increlex	mecasermin	NO	NO	NO	NO	NO	YES	400
Genotropin	somatropin recombinant	NO	NO	NO	NO	NO	YES	400
Humatrope	somatropin	NO	NO	NO	NO	NO	YES	400
Miacalcin	calcitonin salmon	NO	YES	NO	NO	NO	YES	400
Rocaltrol	calcitriol	NO	YES	NO	NO	NO	YES	400
Bethkis	tobramycin	NO	YES	NO	NO	NO	YES	400
Xenazine	tetrabenazine	NO	YES	NO	NO	NO	YES	400
Temodar	temozolomide	NO	YES	NO	NO	NO	YES	400
Priftin	rifapentine	NO	YES	NO	NO	NO	YES	400
Vigamox	moxifloxacin	NO	YES	NO	NO	NO	YES	400
Haldol Decanoate	haloperidol decanoate	NO	YES	NO	NO	NO	YES	400
Zometa	zoledronic acid	NO	YES	NO	NO	NO	YES	400
Nebcin	tobramycin	NO	YES	NO	NO	NO	YES	400
Pred Forte	prednisolone acetate	NO	YES	NO	NO	NO	YES	400
Farydak	panobinostat lactate	NO	YES	NO	NO	NO	YES	400
Zenpep	pancrelipase	NO	YES	NO	NO	NO	YES	400
Zevalin	ibritumomab tiuxetan	NO	YES	NO	NO	NO	YES	400
Tymlos	abaloparatide	NO	YES	NO	NO	NO	YES	400
Actigall	ursodiol	NO	YES	NO	NO	NO	YES	400
Zantac	ranitidine	NO	YES	NO	NO	NO	YES	400
Provigil	modafinil	NO	YES	NO	NO	NO	YES	400
Lithobid	lithium carbonate	NO	YES	NO	NO	NO	YES	400
Xyzal	levocetirizine	NO	YES	NO	NO	NO	YES	400
Allegra	fexofenadine	NO	YES	NO	NO	NO	YES	400
Zyrtec	cetirizine	NO	YES	NO	NO	NO	YES	400
Nuvigil	armodafinil	NO	YES	NO	NO	NO	YES	400
Zyloprim	allopurinol	NO	YES	NO	NO	NO	YES	400
Myfortic	mycophenolic acid	NO	YES	NO	NO	NO	YES	400
Viagra	sildenafil citrate	NO	YES	NO	NO	NO	YES	400
Dysport injection	abobotulinumtoxinA	NO	YES	NO	NO	NO	YES	400
Tremfya disposal container	container for Tremfya	NO	YES	NO	NO	NO	YES	400
Stelara disposal container	container for Stelara	NO	YES	NO	NO	NO	YES	400
Simponi Container disposal container	container for simponi sharps	NO	YES	NO	NO	NO	YES	400
Doxil disposal container	container for Doxil	NO	YES	NO	NO	NO	YES	400
Darzalex disposal container	container for Darzalex	NO	YES	NO	NO	NO	YES	400
Auvi-Q	epinephrine	NO	YES	NO	NO	NO	YES	400
Xermelo	telotristat ethyl	NO	YES	NO	NO	NO	YES	400
Pamelor capsule	nortriptyline	NO	YES	NO	NO	NO	YES	400
WND 2 Medical Food powder	medical food	NO	YES	NO	NO	NO	YES	400
EpiLocker	epinephrine carton	NO	YES	NO	NO	NO	YES	400
Neocate Infant DHA and ARA powder	formula infant	NO	NO	NO	NO	NO	YES	400
Omidria solution	phenylephrine/ketorolac tromethamine	NO	NO	NO	NO	NO	YES	400
Abilify tablet	aripiprazole	NO	NO	NO	NO	NO	YES	400
Retrovir	zidovudine	NO	NO	NO	NO	NO	YES	400
Zolinza	vorinostat	NO	NO	NO	NO	NO	YES	400
Synagis	palivizumab	NO	NO	NO	NO	NO	YES	400
Viracept	nelfinavir	NO	NO	NO	NO	NO	YES	400
Selzentry	maraviroc	NO	NO	NO	NO	NO	YES	400
Combivir	lamivudine/zidovudine	NO	NO	NO	NO	NO	YES	400
Epivir-HBV tablet	lamivudine	NO	NO	NO	NO	NO	YES	400
Flebogamma DIF iv; 5%	immune globulin; iv	NO	NO	NO	NO	NO	YES	400
Lexiva	fosamprenavir calcium	NO	NO	NO	NO	NO	YES	400
Juluca	dolutegravir/rilpivirine	NO	NO	NO	NO	NO	YES	400
Tivicay	dolutegravir sodium	NO	NO	NO	NO	NO	YES	400
Praluent disposal container	container for Praluent sharps	NO	NO	NO	NO	NO	YES	400
Symbicort	budesonide/formoterol fumarate dihydrate	NO	NO	NO	NO	NO	YES	400
Fasenra	benralizumab	NO	NO	NO	NO	NO	YES	400
Trizivir	abacavir sulfate/lamivudine/zidovudine	NO	NO	NO	NO	NO	YES	400
Epzicom	abacavir sulfate/lamivudine	NO	NO	NO	NO	NO	YES	400
Triumeq	abacavir sulfate/dolutegravir sodium/lamivudine	NO	NO	NO	NO	NO	YES	400
Ziagen	abacavir sulfate	NO	NO	NO	NO	NO	YES	400
Sabril tablet	vigabatrin	NO	NO	NO	NO	NO	YES	400
VPRIV	velaglucerase alfa	NO	NO	NO	NO	NO	YES	400
Aptivus	tipranavir	NO	NO	NO	NO	NO	YES	400
Entresto	sacubitril/valsartan	NO	NO	NO	NO	NO	YES	400
Norvir	ritonavir	NO	NO	NO	NO	NO	YES	400
Edurant	rilpivirine	NO	NO	NO	NO	NO	YES	400
Kisqali Femara tablet; co-pack	ribociclib-letrozole	NO	NO	NO	NO	NO	YES	400
Kisqali	ribociclib	NO	NO	NO	NO	NO	YES	400
Veltassa	patiromer	NO	NO	NO	NO	NO	YES	400
Kaletra	lopinavir/ritonavir	NO	NO	NO	NO	NO	YES	400
Fosrenol	lanthanum carbonate	NO	NO	NO	NO	NO	YES	400
Combivent Respimat	ipratropium bromide/albuterol	NO	NO	NO	NO	NO	YES	400
Atrovent HFA	ipratropium bromide	NO	NO	NO	NO	NO	YES	400
Avonex pen	interferon beta-1a	NO	NO	NO	NO	NO	YES	400
Crixivan	indinavir sulfate	NO	NO	NO	NO	NO	YES	400
Iluvien	fluocinolone acetonide	NO	NO	NO	NO	NO	YES	400
Vytorin	ezetimibe/simvastatin	NO	NO	NO	NO	NO	YES	400
Intelence	etravirine	NO	NO	NO	NO	NO	YES	400
Sustiva	efavirenz	NO	NO	NO	NO	NO	YES	400
Multaq	dronedarone	NO	NO	NO	NO	NO	YES	400
Durezol	difluprednate	NO	NO	NO	NO	NO	YES	400
Prezcobix	darunavir ethanolate/cobicistat	NO	NO	NO	NO	NO	YES	400
Prezista	darunavir ethanolate	NO	NO	NO	NO	NO	YES	400
NovoSeven RT	coagulation factor viia	NO	NO	NO	NO	NO	YES	400
Jevtana	cabazitaxel	NO	NO	NO	NO	NO	YES	400
Ridaura	auranofin	NO	NO	NO	NO	NO	YES	400
Emend	aprepitant	NO	NO	NO	NO	NO	YES	400
Novoeight	antihemophilic factor	NO	NO	NO	NO	NO	YES	400
Neupro	rotigotine	NO	NO	NO	NO	NO	YES	400
Triglide	fenofibrate	NO	NO	NO	NO	NO	YES	400
Repatha Sureclick auto-injector; pre-filled	evolocumab	NO	NO	NO	NO	NO	YES	400
EstroGel	estradiol	NO	NO	NO	NO	NO	YES	400
Olux	clobetasol	NO	NO	NO	NO	NO	YES	400
Reyataz	atazanavir sulfate	NO	NO	NO	NO	NO	YES	400
Kineret	anakinra	NO	NO	NO	NO	NO	YES	400
Calan	verapamil	NO	NO	NO	NO	NO	YES	400
Calan SR	verapamil	NO	NO	NO	NO	NO	YES	400
Aldactone	spironolactone	NO	NO	NO	NO	NO	YES	400
Altace	ramipril	NO	NO	NO	NO	NO	YES	400
Accupril	quinapril	NO	NO	NO	NO	NO	YES	400
Procardia XL	nifedipine	NO	NO	NO	NO	NO	YES	400
Levoxyl	levothyroxine	NO	NO	NO	NO	NO	YES	400
Accuretic	hydrochlorothiazide/quinapril	NO	NO	NO	NO	NO	YES	400
Lopid	gemfibrozil	NO	NO	NO	NO	NO	YES	400
Colestid	colestipol	NO	NO	NO	NO	NO	YES	400
Lipitor	atorvastatin calcium	NO	NO	NO	NO	NO	YES	400
Norvasc	amlodipine besylate	NO	NO	NO	NO	NO	YES	400
Xanax	alprazolam	NO	NO	NO	NO	NO	YES	400
Accolate	zafirlukast	NO	NO	NO	NO	NO	YES	400
Jantoven	warfarin sodium	NO	NO	NO	NO	NO	YES	400
Coumadin	warfarin	NO	NO	NO	NO	NO	YES	400
Diovan HCT	valsartan/hydrochlorothiazide	NO	NO	NO	NO	NO	YES	400
Diovan	valsartan	NO	NO	NO	NO	NO	YES	400
Dyrenium	triamterene	NO	NO	NO	NO	NO	YES	400
Mavik	trandolapril	NO	NO	NO	NO	NO	YES	400
Zanaflex	tizanidine	NO	NO	NO	NO	NO	YES	400
Micardis	telmisartan	NO	NO	NO	NO	NO	YES	400
Betapace	sotalol	NO	NO	NO	NO	NO	YES	400
Sorine	sotalol	NO	NO	NO	NO	NO	YES	400
Kionex	sodium polystyrene sulfonate	NO	NO	NO	NO	NO	YES	400
Zocor	simvastatin	NO	NO	NO	NO	NO	YES	400
Kevzara	sarilumab	NO	NO	NO	NO	NO	YES	400
Crestor	rosuvastatin calcium	NO	NO	NO	NO	NO	YES	400
Requip	ropinirole	NO	NO	NO	NO	NO	YES	400
Exelon	rivastigmine	NO	NO	NO	NO	NO	YES	400
Azilect	rasagiline	NO	NO	NO	NO	NO	YES	400
Rythmol	propafenone	NO	NO	NO	NO	NO	YES	400
Pravachol	pravastatin sodium	NO	NO	NO	NO	NO	YES	400
Mirapex ER	pramipexole dihydrochloride	NO	NO	NO	NO	NO	YES	400
Lovaza	omega-3-acid ethyl esters	NO	NO	NO	NO	NO	YES	400
Benicar	olmesartan medoxomil	NO	NO	NO	NO	NO	YES	400
Nilandron	nilutamide	NO	NO	NO	NO	NO	YES	400
Niaspan	niacin	NO	NO	NO	NO	NO	YES	400
Anaprox DS	naproxen sodium	NO	NO	NO	NO	NO	YES	400
Naprosyn	naproxen	NO	NO	NO	NO	NO	YES	400
Lopressor	metoprolol tartrate	NO	NO	NO	NO	NO	YES	400
Toprol XL	metoprolol sussinate	NO	NO	NO	NO	NO	YES	400
Dutoprol	metoprolol succinate/hydrochlorothiazide	NO	NO	NO	NO	NO	YES	400
Zaroxolyn	metolazone	NO	NO	NO	NO	NO	YES	400
Reglan	metoclopramide	NO	NO	NO	NO	NO	YES	400
Mobic	meloxicam	NO	NO	NO	NO	NO	YES	400
Cozaar	losartan	NO	NO	NO	NO	NO	YES	400
Ativan	lorazepam	NO	NO	NO	NO	NO	YES	400
Prinivil	lisinopril	NO	NO	NO	NO	NO	YES	400
Zestril	lisinopril	NO	NO	NO	NO	NO	YES	400
Synthroid	levothyroxine	NO	NO	NO	NO	NO	YES	400
Arava	leflunomide	NO	NO	NO	NO	NO	YES	400
Onivyde	irinotecan liposome	NO	NO	NO	NO	NO	YES	400
Avalide	irbesartan/hydrochlorothiazide	NO	NO	NO	NO	NO	YES	400
Avapro	irbesartan	NO	NO	NO	NO	NO	YES	400
Indocin	indomethacin	NO	NO	NO	NO	NO	YES	400
Plaquenil	hydroxychloroquine	NO	NO	NO	NO	NO	YES	400
Dyazide	hydrochlorothiazide/triamterene	NO	NO	NO	NO	NO	YES	400
Maxzide	hydrochlorothiazide/triamterene	NO	NO	NO	NO	NO	YES	400
Benicar HCT	hydrochlorothiazide/olmesartan medoxomil	NO	NO	NO	NO	NO	YES	400
Hyzaar	hydrochlorothiazide/losartan	NO	NO	NO	NO	NO	YES	400
Zestoretic	hydrochlorothiazide/lisinopril	NO	NO	NO	NO	NO	YES	400
Microzide	hydrochlorothiazide	NO	NO	NO	NO	NO	YES	400
Ultravate	halobetasol propionate	NO	NO	NO	NO	NO	YES	400
Lasix	furosemide	NO	NO	NO	NO	NO	YES	400
AirDuo RespiClick	fluticasone propionate/salmeterol	NO	NO	NO	NO	NO	YES	400
Flonase	fluticasone propionate	NO	NO	NO	NO	NO	YES	400
Fibricor	fenofibric acid	NO	NO	NO	NO	NO	YES	400
Tricor	fenofibrate	NO	NO	NO	NO	NO	YES	400
Estrace	estradiol	NO	NO	NO	NO	NO	YES	400
Vaseretic	enalapril maleate/hydrochlorothiazide	NO	NO	NO	NO	NO	YES	400
Vasotec	enalapril maleate	NO	NO	NO	NO	NO	YES	400
Aricept	donepezil	NO	NO	NO	NO	NO	YES	400
Dilacor XR	diltiazem	NO	NO	NO	NO	NO	YES	400
Lanoxin	digoxin	NO	NO	NO	NO	NO	YES	400
Voltaren XR	diclofenac sodium	NO	NO	NO	NO	NO	YES	400
Welchol	colesevelam	NO	NO	NO	NO	NO	YES	400
Trilipix	choline fenofibrate	NO	NO	NO	NO	NO	YES	400
Prevalite	cholestyramine	NO	NO	NO	NO	NO	YES	400
Celebrex	celecoxib	NO	NO	NO	NO	NO	YES	400
Stalevo	carbidopa/levodopa/entacapone	NO	NO	NO	NO	NO	YES	400
Atacand HCT	candesartan cilexetil/hydrochlorothiazide	NO	NO	NO	NO	NO	YES	400
Atacand	candesartan cilexetil	NO	NO	NO	NO	NO	YES	400
Phoslo	calcium acetate	NO	NO	NO	NO	NO	YES	400
Ziac	bisoprolol fumarate/hydrochlorothiazide	NO	NO	NO	NO	NO	YES	400
Casodex	bicalutamide	NO	NO	NO	NO	NO	YES	400
Targretin	bexarotene	NO	NO	NO	NO	NO	YES	400
Diprolene AF	betamethasone dipropionate	NO	NO	NO	NO	NO	YES	400
Lotensin HCT	benazepril/hydrochlorothiazide	NO	NO	NO	NO	NO	YES	400
Lotensin	benazepril	NO	NO	NO	NO	NO	YES	400
Colazal	balsalazide disodium	NO	NO	NO	NO	NO	YES	400
Tenoretic	atenolol/chlorthalidone	NO	NO	NO	NO	NO	YES	400
Tenormin	atenolol	NO	NO	NO	NO	NO	YES	400
Pacerone	amiodarone	NO	NO	NO	NO	NO	YES	400
Proair Respiclick	albuterol	NO	NO	NO	NO	NO	YES	400
memantine	Namenda	NO	NO	NO	NO	NO	YES	400
Singulair	montelukast sodium	NO	NO	NO	NO	NO	YES	400
Elocon	mometasone furoate	NO	NO	NO	NO	NO	YES	400
Zetia	ezetimibe	NO	NO	NO	NO	NO	YES	400
Prograf	tacrolimus	NO	NO	NO	NO	NO	YES	400
Rescriptor	delavirdine	NO	NO	NO	NO	NO	YES	400
Sinemet	carbidopa/levodopa	NO	NO	NO	NO	NO	YES	400
Ruconest	C1 esterase inhibitor recombinant	NO	YES	NO	NO	NO		400
Emflaza oral suspension	deflazacort	NO	YES	NO	NO	NO	Varies	400
Eylea injection	aflibercept	NO	YES	NO	NO	NO	Not applicable	400
Omnitrope cartridge	somatropin	NO	YES	NO	NO	NO	Not specified	400
Lotronex	alosetron	NO	YES	NO	NO	NO	YES	400
Kineret injection	anakinra	NO	YES	NO	NO	NO	YES	400
Trokendi XR capsule; extended release	topiramate	NO	YES	NO	NO	NO	YES	400
Oxtellar XR tablet; extended release	oxcarbazepine	NO	YES	NO	NO	NO	YES	400
Egrifta injection	tesamorelin	NO	YES	NO	NO	NO	YES	400
Mepsevii	vestronidase alfa-vjbk	NO	YES	NO	NO	NO	YES	400
Tyvaso solution; inhalation	treprostinil	NO	YES	NO	NO	NO	YES	400
Sabril	vigabatrin	NO	YES	NO	NO	NO	YES	400
AndroGel pump	testosterone topical	NO	YES	NO	NO	NO	YES	400
Firazyr Container disposal container	container for firazyr sharps	NO	YES	NO	NO	NO	YES	400
rufinamide	Banzel	NO	YES	NO	NO	NO	YES	400
Emend suspension	aprepitant	NO	YES	NO	NO	NO	YES	400
Praluent	alirocumab	NO	YES	NO	NO	NO	YES	400
Lamictal	lamotrigine	NO	YES	NO	NO	NO	YES	400
Lamictal starter kit	lamotrigine	NO	YES	NO	NO	NO	YES	400
Lamictal XR	lamotrigine	NO	YES	NO	NO	NO	YES	400
Humalog injection; cartridge	insulin lispro protamine	NO	YES	NO	NO	NO	YES	400
Hetlioz capsule	tasimelteon	NO	YES	NO	NO	NO	YES	400
Orkambi tablet	lumacaftor/vacaftor	NO	YES	NO	NO	NO	YES	400
Kalydeco tablet	ivacaftor	NO	YES	NO	NO	NO	YES	400
Daraprim tablet	pyrimethamine	NO	YES	NO	NO	NO	YES	400

	100%	133%	138%	150%	200%	250%	300%	400%
1	1,012	1,346	1,396	1,518	2,023	2,529	3,035	4,047
2	1,372	1,824	1,893	2,058	2,743	3,429	4,115	5,487
3	1,732	2,303	2,390	2,598	3,463	4,329	5,195	6,927
4	2,092	2,782	2,887	3,138	4,183	5,229	6,275	8,367
5	2,452	3,261	3,383	3,678	4,903	6,129	7,355	9,807
6	2,812	3,740	3,880	4,218	5,623	7,029	8,435	11,247
7	3,172	4,218	4,377	4,758	6,343	7,929	9,515	12,687
8	3,532	4,697	4,874	5,298	7,063	8,829	10,595	14,127

SCRIPT

Monthly Payment For Cost Assistance Services:

1 Medication - Monthly Payment in amount of 49.95

We work with prescription drug advocates to find a financial alternative to pay for medications. This is mostly for people struggling to pay for their high-cost brand medications. One of the reasons our clients work with us is, we can help determine if you qualify for a Prescription Assistance Program that pays the cost of your Brand-name medications.

Did you know (Our Agency) is partnered with a patient assistance company called Find Prescription Relief for assistance with medications? We are the only company that has this type of relationship with a company that specializes in getting costly drugs for qualified patients who cannot afford them, directly from the manufacturer of your medication. There are a few questions I need to ask you to see if you qualify….

1.How many people currently reside in your home?

2.Some programs will qualify you based on income. What is the monthly gross (before taxes) of your household income?

3.What Brand name medications are you taking? If you already know this information CONFIRM, ask if this is the only brand medication.

4.How much are you paying out of pocket for the cost of these medicines? If you know this info CONFIRM and move on to the next question.

5.Is that for 30,60,90,120 day supply? If you know this info CONFIRM and move on to the next question.

6.How much, in total for just this (these) medication(s), would you say that you've spent this year?

7.What type of prescription coverage do you have through insurance? How much do they pay?

Great News, I have qualified you based on the information you provided to me which means that you would pay a no copay for your medications for the next 12 months at the very least. Once approved for the program, you'll receive your medications by mail direct from the manufacturing company every 90 or 120 days. These are annual enrollment programs, and through our partnership with Find Prescription Relief, and the great part about working with them is you will be re-enrolled each year until you either stop taking the medication or if you require other medications as an alternative.

To get you started and enrolled today, it will be the monthly amount of 49.95. That covers filing all the necessary paperwork needed to get you approved for the program. That also pays for Find Prescription Relief to file your refills every 90 days in a timely manner so you have medications on time and without issue. How does that sound?

After submitting the the application through the online webportal, using the inbound verification line below, please conduct a warm transfer with the patient on hold into our to administration for a recorded verification to confirm enrollment.

We request you to keep the patient (client) on a hold while communications between you are discussing with our rep what is going on. Before transferring your applicant, we ask your rep to give the follow over the phone before leaving the conference call.

VERIFICATION CONFERENCE NUMBER: 877-404-9557

1. Name of client

2. Plan we will be enrolling them with along with the monthly payment and enrollment fee

3. Medication names

4. Household Income amount

5. Are you ready for me to send over? HERE IS MY NAME/NUMBER/ EXTENSION (incase of issue)

6. We ask for the initial start of our enrollments that you stay on the verification silently for the first 3 to 5 minutes. (UNTIL WE VERIFY PAYMENT INFORMATION….)

This is only to prevent errors and ensure submission completions. Once ready, please have your rep bring the applicant on the line and make a warm introduction as to who we are and what the enrollment process is. Ask them to hold any questions until the end and make sure that your rep gives their phone number and extension and the patient as well.