JMSIMMS

Agent Enrollment Application Form
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Description
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BRAND NAMEGENERICPRIVATE INSPART DLIS DENIAL% OOP$ OOP MEDICAREFPLSHIPRENEWSUPPLYCOSTColumn1Column2Column3Column4Column5Column6Column7Column8Column9Column10
HUMIRAadalimumabYESYESNONENONENONEYES300Doctor1 Year90 Day2477.43
Gengraf CapsulescyclosporineYESYESNONENONENONEYES300Doctor1 Year90 Day165.3
SynthroidlevothyroxineYESYESNONENONENONEYES300Doctor1 Year90 Day34.58
KALETRAlopinavir/ritonavirYESYESNONENONENONEYES500Doctor1 Year90 Day476.79
LUPRON DEPOT GYNnorethindrone acetateYESYESNONENONENONEYES300Doctor1 YearVaries1546
CreonpancrelipaseYESYESNONENONENONEYES300Patient1 Year90 Day481.89
NorvirritonavirYESYESNONENONENONEYES300Doctor1 Year90 Day277
AndroGeltestosteroneYESYESNONENONENONEYES300Patient1 Year90 Day4801.94
Lupaneta PackYESYESNONENONENONEYES300Doctor1 YearVaries1286
GengrafcyclosporineYes if not listed in the formularyYESNONENONENONEYES300% FPLPatient/Doctor1 Year 90 Day 22
Humira ContaineradalimumabYes if not listed in the formularyYES NO OOPNONENONENONEYES300% FPLPatient/Doctor1 Year 90 Day 4976.48
Lupronleuprolide acetate)YESYES NO OOPYES300Doctor1 Year90 Day
Lupron Depotleuprolide acetate)YESYES NO OOPYES300Doctor1 Year90 Day
Lupron Depot-PEDleuprolide acetate)YESYES NO OOPYES300Doctor1 Year90 Day
Descovyemtricitabine/tenofovir alafenamideMust be uninsured or underinsured Determined case by caseNONENONENONEYES4-500% FPLPatient/Doctor1 Year 90 Day 1672
EmtrivaemtricitabineMust be uninsured or underinsuredYESNONENONENONEYES4-500% FPLPatient/Doctor1 Year 90 Day 554
Genvoyaelvitegravir/cobicistat/emtricitabine/tenofovir alafenamideMust be uninsured or underinsuredDetermined case by caseNONENONENONEYES4-500% FPLPatient/Doctor1 Year 90 Day 2933.58
Hepseraadefovir dipivoxilMust be uninsured or underinsuredYESNONENONENONEYES4-500% FPLPatient/Doctor1 Year 90 Day 346.62
Compleraemtricitabine/rilpivirine/tenofovir disoproxil fumarateYes if not listed in the formulary Determined case by caseNONENONENONEYES4-500% FPLPatient/Doctor1 Year90 Day2670
Zioptan Opthalmic SolutiontafluprostDetermined case by caseYES400Patient1 Year90 Day200
EstraceEstradiolYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor1 Year90 dAY337
Fetzima ER CapsuleslevomilnacipranYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor3 Month90 Day323.36
Fetzima ER Capsules Titration PacklevomilnacipranYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor3 Month90 Day301.87
Linzess CapsuleslinaclotideYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor3 Month90 Day348.83
Namenda Oral SolutionmemantineYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor3 Month90 Day904.46
Namenda TabletsmemantineYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor3 Month90 Day468.08
Namenda Titration PakmemantineYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor3 Month90 Day234.5
Namenda XR ER Capsules Titration PackmemantineYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor3 Month90 Day387.08
Namenda XRER CapsulesmemantineYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor3 Month90 Day387.08
Namzaricmemantine-donepezilYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor3 Month90 Day449
Savella TabletsmilnaciprabYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor3 Month90 Day318.26
Savella Titration PackmilnaciprabYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor3 Month90 Day291.82
Bystolic TabletsnebivololYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor3 Month90 Day118.55
Armour Thyroidthyroid desiccatedYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor3 Month90 Day44
Viibryd Patient Starter KitvilazodoneYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor3 Month90 Day224.42
Viibryd TabletsvilazodoneYes if not listed in the formularyYESMust be denied LISNONENONEYES400Doctor3 Month90 Day224.42
Aerochamber Plus Flow-Vumedical deviceMust have no prescription coverageYESMust be denied LISNONENONEYES400% FPLDoctor1 Year90 Day39.61
Alphagan Pbrimonidine tartrateNOYESMust be denied from LISNONENONEYES400% FPLDoctor1 Year 90 Day 159.94
Avycazceftazidime/avibactamNOYESMust be denied from LISNONENONEYES400% FPLDoctor1 Year 90 Day359
BystolicnebivololNOYESMust be denied from LISNONENONEYES400% FPLDoctor1 Year 90 Day 139.35
Byvalsonnebivolol/valsartanNOYESMust be denied from LISNONENONEYES400% FPLDoctor1 Year 90 Day 128.01
CanasamesalamineNOYESMust be denied from LISNONENONEYES400% FPLDoctor1 Year 90 Day1062
Combiganbrimonidine tartrate/timolol maleate)NOMust be denied from LISNONENONENONEYES400% FPLDoctor1 Year 90 Day
Crinoneprogesterone vaginalNOYESYESNONENONEYES400% FPLDoctor1 Year 90 Day 550
DalvancedalbavancinNOYESYESNONENONEYES400% FPLDoctor1 Year 90 Day 3056
DelzicolmesalamineNOYESYESNONENONEYES400% FPLDoctor1 Year 90 Day 660
FetzimalevomilnacipranNOYESYESNONENONEYES400% FPLDoctor1 Year 90 Day 375.39
Fetzima Titration PacklevomilnacipranNOYESYESNONENONEYES400% FPLDoctor1 Year 90 Day 375.39
Gelniqueoxybutynin chlorideNOYESYESNONENONEYES400% FPLDoctor1 Year 90 Day 394.09
RestasiscyclosporineNOYESYESNONOYES400DOCTOR/PHARMACYVARIES90 DAYS514.32
TrelstartriptorelinYESYESYESNONOYES400Doctor/Pharmacy1 year90 Days850
ZenpeppancrelipaseYESYESYESNONOYES400Doctor/Pharmacy1 year90544
ProliaDenosumabVariesYES500VariesVariesVaries3000
Aranespdarbepoetin alfaNOYes case by caseNONENONENONEYES500% FPLDoctor1 Year90 Day 1270.16
BlincytoblinatumomabYes if not listed in the formularyYESNONENONENONEYES 500% FPLPatient/Doctor1 Year90 Day 178000
CorlanorivabradineMust be uninsured or underinsured Determined case by caseNONONENONEYES 500% FPLPatient/Doctor1 Year 90 Day435
EnbreletanerceptMust be uninsured or underinsuredDetermined case by caseNONENONENONEYES500% FPLPatient/Doctor1 Year 90 Day 4976
Epogenepoetin alfaMust be uninsured or underinsuredDetermined case by caseNONENONENONEYES500% FPLPatient/Doctor1 Year 90 Day 38.02
NeulastapegfilgrastimVariesNONONOYES500VariesVariesVaries5000
Neulasta Onpro KitpegfilgrastimVariesNONONOYES500VariesVariesVaries5000
NeupogenfilgrastimVariesNONONOYES500VariesVariesVaries5000
AmBisomeamphotericin B liposomeYes if not listed in the formularyYES NO OOPNONENONENONEYES250% FPLDoctor 1 Year90 Day
Cresembaisavuconazonium sulfateYes if not listed in the formularyYES NO OOPNONENONENONEYES250% FPLDoctor 1 Year90 Day304
TagrissoosimertinibNONONONONONOVariesDoctor/Patient90 Days14522
Tudorza Pressairaclidinium bromideNOYESNONE3% OOPNONEYES300Doctor3 Month90 Day278.87
Arimidex TabletanastrozoleNOYESNONE3% OOPNONEYES300PatientEnd Of Year90 Day549.97
Pulmicort FlexhalerPowderbudesonideNOYESNONE3% OOPNONEYES300PatientEnd Of Year90 Day186.94
Pulmicort RespulesInhalationbudesonideNOYESNONE3% OOPNONEYES300PatientEnd Of Year90 Day354.88
Symbicort Inhalerbudesonide/formoterol fumarate dihydrateNOYESNONE3% OOPNONEYES300PatientEnd Of Year90 Day308.45
Farxiga TabletdapagliflozinNOYESNONE3% OOPNONEYES300Patient1 Year90 Day424.63
Byetta InjectionexenatideNOYESNONE3% OOPNONEYES300Patient1 Year90 Day658.59
Bydureon Vial ERexenatide syntheticNOYESNONE3% OOPNONEYES300Patient1 Year90 Day613.83
Faslodex InjectionfulvestrantNOYESNONE3% OOPNONEYES300PatientEnd Of Year90 Day2013.52
Merrem InjectionmeropenemNOYESNONE3% OOPNONEYES300PatientEnd Of Year90 Day386.89
Movantiknaloxegol oxalateNOYESNONE3% OOPNONEYES300Patient1 Year90 Day362.04
Symlin Pen Injectionpramlintide acetateNOYESNONE3% OOPNONEYES300Patient1 Year90 Day943.78
Seroquel XR Tablet ERquetiapine fumarateNOYESNONE3% OOPNONEYES300PatientEnd Of Year90 Day485.95
Daliresp TabletsroflumilastNOYESNONE3% OOPNONEYES300Doctor3 Month90 Day317.56
Onglyza TabletsaxagliptinNOYESNONE3% OOPNONEYES300Patient1 YearVaries384.59
Kombiglyze XRTabletsaxagliptin/metforminNOYESNONE3% OOPNONEYES300Patient1 Year90 Day190.49
Brilinta TabletticagrelorNOYESNONE3% OOPNONEYES300PatientEnd Of Year90 Day170.89
Bevespi Aerosphereglycopyrrolate/formoterol fumarateNOYESNONE3% OOPNONEYES300% FPLPatientEnd Of Year90 Day360
BrilintaticagrelorNOYESNO3% OOPNONEYES 250% FPLPatient/Doctor1 Year 90 Day 360
Bydureonexenatide syntheticNOYESNONE3% OOPNONEYES 250% FPLPatient/Doctor1 Year90 Day 664.09
Bydureon BCiseexenatideNOYESNONE3% OOPNONEYES 250% FPLPatient/Doctor1 Year90 Day 664.09
Bydureon Penexenatide syntheticNOYESNONE3% OOPNONEYES 250% FPLPatient/Doctor1 Year90 Day 664.09
ByettaexenatideNOYESNONE3% OOPNONEYES 250% FPLPatient/Doctor1 Year90 Day 732.05
CalquenceacalabrutinibNOYESNO3% OOPNOYES250% FPLPatient/Doctor1 Year90 Day 13974
DaliresproflumilastNOYESNONE3% OOPNONEYES 250% FPLPatient/Doctor1 Year90 Day 367
FarxigadapagliflozinNOYESNONE3% OOPNONEYES 250% FPLPatient/Doctor1 Year90 Day 469.84
FasenrabenralizumabNOYESNONE3% OOPNONEYES 250% FPLPatient/Doctor1 Year90 Day 2833
FaslodexfulvestrantNOYESNONE3% OOPNONEYES 250% FPLPatient/Doctor1 Year90 Day 1955
Kombiglyze XRMetformin,SaxagliptonNOYES + 3% OOPYES300Doctor3 Month90 Day411.06
LynparzaNO PROGRAM AVAILABLENOYES + 3% OOPYES300Doctor3 Month90 Day
Onglyzasaxagliptin)NOYES + 3% OOPYES300Doctor3 Month90 Day
Pulmicort FlexhalerbudesonideNOYESNO0.03NOYES300Doctor3 Month90 Day281
SymbicortNO PROGRAM AVAILABLENOYESNO0.03NOYES300Doctor3 Month90 Day241
Alrexloteprednol etabonateMust have no prescription coverageDetermined case by caseNONENONENONEDetermined case by caseVaries1 Year 90 Day 225.48
BenlystabelimumabNOYESNONENONENONEYES500% FPLDoctor1 Year90 Day3380
Spiriva HandiHalertiotropium bromideYESYESNONONOYES200Patient1 Year90 Day286
Spiriva Respimattiotropium bromideYESYESNONONOYES200Patient1 Year90 Day286
DroxiahydroxyureaNOYESNONENONENONEYES300% FPLDoctor1 Year 90 Day 85
EmplicitielotuzumabNOYESNONENONENONEYES300% FPLDoctor1 Year 90 Day 10000
EtopophosetoposideNOYESNONENONENONEYES 300% FPLDocotr1 Year 90 Day 145
SpryceldasatinibYes if not listed in the formularyYESNONE3% OOPNONEYES300Doctor1 YearVaries13217.4
YervoyipilimumabYes if not listed in the formularyYESNONE3% OOPNONEYES300Doctor1 YearVaries30000
Pradaxa Capsuledabigatran etexilateYes if not listed in the formularyYESNONENONENONEYES200Patient1 Year90 Day370.41
Atrovent HFAAerosolipratropium bromide HFAYes if not listed in the formularyYESNONENONENONEYES200Patient1 Year90 Day383
Combivent RespimatSprayipratropium bromide/albuterolYes if not listed in the formularyYESNONENONENONEYES200Patient1 Year90 Day340.4
Tradjenta TabletlinagliptinYes if not listed in the formularyYESNONENONENONEYES200Patient1 Year90 Day375.9
Viramune XR Tablet ERnevirapineYes if not listed in the formularyYESNONENONENONEYES200Patient1 Year90 Day861.06
Spiriva HandiHaler Powdertiotropium bromideYes if not listed in the formularyYESNONENONENONEYES200Patient1 Year90 Day1101.18
Aptivus CapsuletipranavirYes if not listed in the formularyYESNONENONENONEYES200Patient1 Year90 Day1519.72
Aptivus Oral SolutiontipranavirYes if not listed in the formularyYESNONENONENONEYES200Patient1 Year90 Day507.22
JardianceEmpagliflozinYes if not listed in the formularyYESNONENONENONEYES200Patient1 Year90 Day466.53
JentaduetoLinaglipton,MetforminYes if not listed in the formularyYESNONENONENONEYES200Patient1 Year90 Day438
Jentadueto XRLinaglipton,MetforminYes if not listed in the formularyYESNONENONENONEYES200Patient1 Year90 Day438
AptivustipranavirNOYESNONENONENONEYES300% FPLPatient1 Year 90 Day 409.45
Atroventipratropium bromideYes if not listed in the formularyYES NO OOPNONENONENONEYES200% FPLPatient/Doctor1 Year90 Day 376.04
Atrovent HFAipratropium bromideYes if not listed in the formularyYES NO OOPNONENONENONEYES200% FPLPatient/Doctor1 Year 90 Day 376.04
Combiventpratropium bromide/albuterolYes if not listed in the formularyYES NO OOPYES200% FPLPatient/Doctor1 Year 90 Day
Combivent Respimatpratropium bromide/albuterolYes if not listed in the formularyYES NO OOPYES200% FPLPatient/Doctor1 Year 90 Day
GilotrifafatinibYes if not listed in the formularyYESNONENONENONEYES200% FPLPatient/Doctor1 Year 90 Day 8324.85
GlyxambiEmpagliflozin,LinagliptonYes if not listed in the formularyYES NO OOPYES200% FPLPatient1 Year90 Day370.41
Pradaxadabigatran etexilate)YESYES NO OOPYES200Patient1 Year90 Day370.41
Stiolto Respimattiotropium bromide/olodaterolYESYESNONONOYES200Patient1 Year90 Day370.41
Synjardyempagliflozin/metforminYes if not in formularyYESNONONOYES200Patient/Doctor1 Year 90 Day 250
TradjentalinagliptinYes if not in formularyYESNONONOYES200% FPLPatient/Doctor1 Year 90 Day 250
EliquisapixabanNOYESNONE3% OOPNONEYES300% FPLPatient/Doctor1 Year 90 Day 440
Evotazatazanavir sulfate/cobicistatNOYESNONE3% OOPNONEYES300% FPLPatient/Doctor1 Year 90 Day 1647
OrenciaabataceptYes if not listed in the formularyYESNONE3% OOPNONEYES300Doctor1 YearVaries4403.86
Eliquis TabletapixabanYes if not listed in the formularyYESNONE3% OOPNONEYES300Doctor1 YearVaries383.13
Nulojix InjectionbelataceptYes if not listed in the formularyYESNONE3% OOPNONEYES300Doctor1 YearVaries1022.91
PlavixYes if not listed in the formularyYESNONE3% OOPNONEYES300Doctor1 YearVaries159
DaklinzadaclatasvirYes if not listed in the formularyYESNONE3% OOPNONEYES300% FPLDoctor1 YearVaries22959
SustivaEfavirenzYESYESNO0.03NOYES300Doctor1 YearVaries1176.74
BethkistobramycinYes if not listed in the formularyNONONENONENONENO800% FPLPatient1 Year 90 Day5643
GranixTBO-filgrastimNONONONENONENONENO500% FPLDoctor1 Year 90 Day 859.33
BendekabendamustineNO NONONENONENONENO500% FPLDoctor1 Year90 Day 50
ExalgohydromorphoneNOYES if in donut holeNONENONENONEYES 200% FPLPatient sent card1 Year90 Day 217.62
Azoramlodipine/olmesartan medoxmilNONONONENONENONENO200Doctor1 Year90 day240
Welchol Oral SuspensioncolesevelamNONONONENONENONENO200Doctor1 Year90 Day576.32
Welchol TabletcolesevelamNONONONENONENONENO200Doctor1 Year90 day576.32
SavaysaedoxabanNONONONENONENONENO200Doctor1 Year90 Day362.06
Benicar TabletsolmesartanNONONONENONENONENO200Doctor1 Year90 day320.2
BelviqlorcaserinYes if not listed in the formularyYESNONENONENONEYES150% FPLPatient1 Year30 Day 294.73
BanzelrufinamideYes if not listed in the formularyYESNONENONENONEYES300% FPLPatient1 Year 90 Day 1600
ELIgard InjectionleuprolideYESMust be denied LIS5% OOPNONEYES250Doctor1 YearVaries230
EquetrocarbamazepineNONONONENONENONENO200% FPLDoctor1 Year90 Day 252.48
GocovriamantadineMust be uninsured or underinsuredNONONENONENONEYES500% FPLPatient 1 Year90 Day2146.87
Alphanateantihemophilic factor humanMust be uninsured NONONENONENONENO400% FPLDoctor1 Year 30 Day608.49
AlphaNine SDcoagulation factor IX (humanMust be uninsured NONONENONENONENO400% FPLDoctor1 Year 30 Day699.52
Soriatane CapsuleacitretinNOYESNONENONE$600 OOPYES250Patient1 Year90 Day1621.74
Ventolin HFA Inhalantalbuterol sulfateNOYESNONENONE$600 OOPYES250Patient1 Year90 Day53.25
Mepron SuspensionatovaquoneNOYESNONENONE$600 OOPYES250Patient1 Year90 Day1564.26
Malarone Tabletatovaquone and proguanilNOYESNONENONE$600 OOPYES250Patient1 Year90 Day180
Beconase AQbeclomethasoneNOYESNONENONE$600 OOPYES250Patient1 Year90 Day314
Beconase AQSpray; Nasal0.042beclomethasoneNOYESNONENONE$600 OOPYES250Patient1 Year90 Day314
Coreg CR Capsule ERcarvedilolNOYESNONENONE$600 OOPYES250Patient1 Year90 Day317.76
Coreg CRcarvedilol phosphateNOYESNONENONE$600 OOPYES250Patient1 Year90 Day317.76
DuacGel1/5clindamycin phosphate/benzoyl peroxideNOYESNONENONE$600 OOPYES250Patient1 Year90 Day387.06
Avodart Soft Gelatin TabletsdutasterideNOYESNONENONE$600 OOPYES250Patient1 Year90 Day211.87
Avodart TabletdutasterideNOYESNONENONE$600 OOPYES250Patient1 Year90 Day211.87
Jalyn Capsuledutasteride and tamsulosinNOYESNONENONE$600 OOPYES250Patient1 Year90 Day211.67
Potiga TabletezogabineNOYESNONENONE$600 OOPYES250Patient1 Year90 Day1084.33
Veramyst Nasal Sprayfluticasone furoateNOYESNONENONE$600 OOPYES250Patient1 Year90 Day217.95
Veramyst Spray; Nasalfluticasone furoateNOYESNONENONE$600 OOPYES250Patient1 Year90 Day218.15
Breo Elliptafluticasone furoate/vilanterol trifenatateNOYESNONENONE$600 OOPYES250Patient1 Year90 Day317.59
Breo ElliptaInhalation Powderfluticasone furoate/vilanterol trifenatateNOYESNONENONE$600 OOPYES250Patient1 Year90 Day317.59
Flovent Diskusfluticasone propionateNOYESNONENONE$600 OOPYES250Patient1 Year90 Day163.36
Flovent HFAfluticasone propionateNOYESNONENONE$600 OOPYES250Patient1 Year90 Day230.15
Advair Diskusfluticasone propionate/salmeterol xinafoateNOYESNONENONE$600 OOPYES250Patient1 Year90 Day296.83
Advair DiskusPowderfluticasone propionate/salmeterol xinafoateNOYESNONENONE$600 OOPYES250Patient1 Year90 Day296.83
Advair HFAfluticasone propionate/salmeterol xinafoateNOYESNONENONE$600 OOPYES250Patient1 Year90 Day360.95
Advair HFAAerosolfluticasone propionate/salmeterol xinafoateNOYESNONENONE$600 OOPYES250Patient1 Year90 Day360.95
Epivir-HBVOral SolutionlamivudineNOYESNONENONE$600 OOPYES250Patient1 Year90 Day128.71
Epivir-HBVTabletlamivudineNOYESNONENONE$600 OOPYES250Patient1 Year90 Day479.31
Lamictal ODTPatient Titration KitlamotrigineNOYESNONENONE$600 OOPYES250Patient1 Year90 Day719.23
Lamictal TabletlamotrigineNOYESNONENONE$600 OOPYES250Patient1 Year90 Day854.82
Lamictal XRPatient Titration KitlamotrigineNOYESNONENONE$600 OOPYES250Patient1 Year90 Day719.23
Lamictal XRTablet ERlamotrigineNOYESNONENONE$600 OOPYES250Patient1 Year90 Day854.82
Bactroban Creammupirocin calciumNOYESNONENONE$600 OOPYES250Patient1 Year90 Day222.17
Bactroban Cream2mupirocin calciumNOYESNONENONE$600 OOPYES250Patient1 Year90 Day222.17
Bactroban Nasal Ointmentmupirocin calciumNOYESNONENONE$600 OOPYES250Patient1 Year90 Day168.98
Bactroban Ointmentmupirocin calciumNOYESNONENONE$600 OOPYES250Patient1 Year90 Day168.98
Bactroban Ointment; Nasal2mupirocin calciumNOYESNONENONE$600 OOPYES250Patient1 Year90 Day168.98
Bactroban Ointment2mupirocin calciumNOYESNONENONE$600 OOPYES250Patient1 Year90 Day168.98
Rythmol SR Capsule ERpropafenoneNOYESNONENONE$600 OOPYES250Patient1 Year90 Day800.84
Requip XLropiniroleNOYESNONENONE$600 OOPYES250Patient1 Year90 Day555.11
Requip XL Tablet ERropiniroleNOYESNONENONE$600 OOPYES250Patient1 Year90 Day162.94
Avandia Tabletsrosiglitazon/glimepirideNOYESNONENONE$600 OOPYES250Patient1 Year90 Day161.72
AvandiaTabletrosiglitazone maleateNOYESNONENONE$600 OOPYES250Patient1 Year90 Day161.72
Imitrex Nasal SpraysumatriptanNOYESNONENONE$600 OOPYES250Patient1 Year90 Day521.31
Imitrex SpraysumatriptanNOYESNONENONE$600 OOPYES250Patient1 Year90 Day417.91
Anoro Elliptaumeclidinium bromide/vilanterol trifenatateNOYESNONENONE$600 OOPYES250Patient1 Year90 Day345.27
RelenzazanamivirNOYESNONENONE$600 OOPYES250Patient1 Year90 Day60.05
Arnuity Elliptafluticasone furoateNOYESNONENONE$600 OOPYES250% FPLPatient/Doctor1 Year90 Day
Avandiarosiglitazone maleateNOYESNONENONE$600 OOPYES250% FPLPatient/Doctor1 Year90 Day180
Duacbenzoyl peroxide/clindamycinNOYESNONENONE$600 OOPYES250% FPLPatient/Doctor1 Year 90 Day 72.83
Engerix-Bhepatitis B vaccine recombinantNOYESNONENONE$600 OOPYES250% FPLPatient/Doctor1 Year 90 Day 61.98
Floventfluticasone propionateNOYESNONENONE$600 OOPYES250% FPLPatient/Doctor1 Year90 Day 241.48
Havrixhepatitis A vaccine inactivatedNOYESNONENONE$600 OOPYES250% FPLPatient/Doctor1 Year90 Day 74.28
Incruse Elliptaumeclidinium bromideNOYESNONO600YES250Patient1 Year90 Day12049
Jalyndutasteride/tamsulosinNOYESNONO600YES250Patient1 Year90 Day12049
LamictallamotrigineNOYES $600 OOPYES250% FPLPatient/Doctor1 Year90 Day
Lamictal CDlamotrigineNOYES $600 OOPYES250% FPLPatient/Doctor1 Year90 Day
Lamictal ODTlamotrigineNOYES $600 OOPYES250% FPLPatient/Doctor1 Year90 Day
Lamictal XRlamotrigineNOYES $600 OOPYES250% FPLPatient/Doctor1 Year90 Day
Trelegy Elliptafluticasone furoate/umeclidinium/vilanterolNOYESNONO600YES250% FPLPatient/Doctor1 Year90 Days266
Akynzeonetupitant/palonosetronDetermined case by caseDetermined case by caseNONENONENONEDetermined case by caseDoctor1 Year90 Day 2189.18
CinvantiaprepitantYESNONONONENONENO500% FPLDoctor1 Year 90 Day 1286
Hymovishigh molecular weight viscoelastic hyaluronanNOYes if med is not coveredNONENONENONENONE250% FPLDoctor1 Year 90 Day 4559.31
EmvermmebendazoleMust be uninsured or underinsuredDetermined case by caseNONENONENONEYES300% FPLPatient1 Year 90 Day 1951
AlbenzaalbendazoleDetermined case by caseDetermined case by caseNONENONENONEYES300% FPLPatients Home1 YearAmount Requested is sent 152.97
Duzalloallopurinol/lesinuradMust be uninsured or underinsuredDetermined case by caseNONENONENONEYES300% FPLPatient1 Year30 Day387
Zytigaabiraterone acetateYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day9138.7
InvokanacanagliflozinYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day462.74
Prezista TabletdarunavirYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day1096.99
DoxildoxorubicinYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day1240.98
Procrit Injectionepoetin alfaYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day5724.17
IntelenceetravirineYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day587.79
Duragesic CIIPatchfentanyl transdermal systemYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day3375.36
SimponigolimumabYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day4642.89
Simponi ARIAgolimumabYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day1832.1
Haldol InjectionhaloperidolYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day212.9
Orthovisc Injectionhigh molecular weight hyaluronanYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day592
ImbruvicaibrutinibYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day14397.38
Remicade VialinfliximabYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day1136.9
Sporanox CapsuleitraconazoleYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day1677.28
Sporanox Oral SolutionitraconazoleYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day341.37
ConcertamethylphenidateYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day354.66
Invegapaliperidone palmitateYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day1170.92
Invega Sustenna ERpaliperidone palmitateYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day1147.07
Pancreaze CapsulepancrelipaseYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day286.65
Elmironpentosan polysulfate sodiumYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day50
EdurantrilpivirneYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day992.24
Risperdal ConstaInjectionrisperidoneYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day416.61
Risperdal M-TABrisperidoneYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day634.76
Risperdal Oral SolutionrisperidoneYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day380.32
Risperdal TabletrisperidoneYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day340.49
XareltorivroxabanYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day388.25
SylvantsiltuximabYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day860.63
Olysio CapsulesimeprevirYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day76315.2
Topamax CapsuletopiramateYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day413.41
Topamax TablettopiramateYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day720.73
YondelistrabectedinYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day2679.46
StelaraustekinumabYes if not listed in the formularyYESNONE4% OOPNONEYES300Card/Doctor1 Year90 Day10970.59
Invokamet canagliflozin; metformin hydrochlorideYESYES + 4% OOPYES300Card/Doctor1 Year90 Day438.62
Invokamet XR canagliflozin; metformin hydrochlorideYESYES + 4% OOPYES300Card/Doctor1 Year90 Day438.62
TremfyaguselkumabYESYESNO0.04NOYES300Card/Doctor1 Year90 Day10095
DarzalexdaratumumabYes if not in formularyYESNONE4% OOPNONEYES300% FPLPatient/Doctor1 Year 90 Day 5850
ErleadaapalutamideYes if not listed in the formularyYESNONE4% OOPNONEYES300% OOPPatient/Doctor1 Year 90 Day 10852
HaldolhaloperidolYes if not listed in the formularyYESNONE4% OOPNONEYES300% OOPPatient/Doctor1 Year 90 Day 26
Haldol DecanoatehaloperidolYes if not listed in the formularyYESNONE4% OOPNONEYES300% OOPPatient/Doctor1 Year 90 Day 26
Auvi-Q InjectableepinephrineYESMust be denied LIS5% OOPNONEYES250Doctor1 Year120 Day4500
Auryxiaferric citrateNODetermined case by caseNONENONENONEYES400% FPLPatient/Doctor1 Year 30 Day 1100
LipitorpitavastatinNOYes med must not be coveredYES150% FPLPatient1 Year90 Day
LivalopitavastatinNOYes med must not be coveredYES150% FPLPatient1 Year90 Day
StratteraatomoxetineNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day428.88
CymbaltaduloxetineNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day502.63
ProzacfluoxetineNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day435.36
Humulin 70/30insulin humanNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day138.35
Humaloginsulin lisproNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day77.14
Humalog Mix50/50insulin lisproNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day264.04
Humalog Mix75/25insulin lisproNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day264.04
TrulicityDulaglutide NOYESNONENONE$1100 OOPYES300Doctor1 Year 120 Day770
Humulin Nnph human insulinNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day138.35
ZyprexaolanzapineNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day423.18
Zyprexa RelprevvolanzapineNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day637.86
Zyprexa ZydisolanzapineNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day670.99
Symbyaxolonzapine/fluoxetineNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day698.24
EffientprasugrelNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day416.93
Quinidine Gluconatequinidine gluconateNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day23
EvistaraloxifeneNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day53
Humulin Rregular insulin humanåNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day138.35
HumatropesomatropinåNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day784.98
CialistadalafilNOYESNONENONE$1100 OOPYES300Doctor1 Year120 Day109.56
ForteoteriparatideNOYESNONENONE$1100 OOPYES300Patient1 Year90 Day2947.07
Basaglarinsulin glargine injectionNOYESNONENONE$1100 OOPYES300% FPLDoctor1 Year 120 Day234.6
Humalog KwikPenrecombinantNOYESNONENONE$1100 OOPYES300% FPLDoctor1 Year 120 Day292.53
Humalog Mix 50/50recombinantNOYESNONENONE$1100 OOPYES300% FPLDoctor1 Year 120 Day292.53
Humalog Mix 50/50 KwikPenrecombinantNOYESNONENONE$1100 OOPYES300% FPLDoctor1 Year 120 Day292.53
Humalog Mix 50/50 PenrecombinantNOYESNONENONE$1100 OOPYES300% FPLDoctor1 Year 120 Day292.53
Humalog Mix 75/25recombinantNOYESNONENONE$1100 OOPYES300% FPLDoctor1 Year 120 Day292.53
Humalog Mix 75/25 PenrecombinantNOYESNONENONE$1100 OOPYES300% FPLDoctor1 Year 120 Day292.53
Humalog PenrecombinantNOYESNONENONE$1100 OOPYES300% FPLDoctor1 Year 120 Day292.53
Humalog U-200 KwikPenrecombinantNOYESNONENONE$1100 OOPYES300% FPLDoctor1 Year 120 Day292.53
Humulin R (U-100)insulin human isophane-human insulinNOYESNONENONE$1100 OOPYES300% FPLDoctor1 Year 120 Day179
Humulin R (U-500)insulin human isophane-human insulinNOYESNONENONE$1100 OOPYES300% FPLDoctor1 Year 120 Day179
Prozac WeeklyFluoxetineNOCase by CaseNONONONOVariesDoctor120 Days34.92
TaltzixekizumabNOCase by CaseNONONONOVariesDoctor120 Days4200
Proventil HFA Aerosolalbuterol sulfateYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day88.06
Diprolene Cream0.05betamethasoneYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day197.16
Diprolene Lotion0.05betamethasoneYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day199.41
Diprolene Ointment0.05betamethasoneYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day197.16
Lotrisone Creamclotrimazole/betamethasoneYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day123.16
Trusopt Ophthalmic SolutiondorzolamideYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day60
Zetia TabletezetimibeYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day323.02
Vytorin Tabletezetimibe/simvastatinYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day319.95
Stromectol TabletivermectinYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day15.71
Janumet Tabletmetformin/sitagliptin phosphateYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day391.89
Janumet XRTablet ERmetformin/sitagliptin phosphateYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day391.89
Remeron TabletmirtazapineYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day173.59
Asmanex TwisthalerInhalationmometasoneYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day309.92
Nasonex Spraymometasone furoate monohydrateYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day244.58
Dulera Aerosolmometasone furoate/formoterol fumarate dihydrateYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day299.19
Singulair Asthma Oral Granulesmontelukast sodiumYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day222.17
Nitro-DurnitroglycerinYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day182.52
Maxalt Tabletrizatriptan benzoateYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day226.29
Maxalt-MLTTabletrizatriptan benzoateYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day226.28
Januvia TabletsitagliptinYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day388.66
JanumetMetformin,SitagliptonYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day457
Janumet XRMetformin,SitagliptonYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day457
JanuviaSitagliptonYes if not listed in the formularyYES NO OOPNONENONENONEYES400Patient1 Year90 Day457
BelsomrasuvorexantYes if not listed in the formularyYES NO OOPNONENONENONEYES400% FPLPatient1 Year90 Day337
Crixivanindinavir sulfateYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient1 Year90 Day475
DificidfidaxomicinYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 3664
Duleraformoterol fumarate/mometasone furoateYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 317
Eloconmometasone furoateYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 28
EmendaprepitantYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 41.38
Proventilalbuterol sulfateYESYES NO OOPYES400Patient1 Year90 Day
Proventil HFAalbuterol sulfateYESYES NO OOPYES400Patient1 Year90 Day
SingulairMontelukast SodiumYESYESNONONOYES400Patient1 Year90 Day246
ZetiaezetimibeYESYESNONONOYES400Patient1 year90 Day369
AubagioteriflunomideNONONONENONENONEYES500% FPLPatient1 Year 90 Day 6500
EMSAM TransdermalselegilineNONONENONENONENO200Doctor1 Year90 Dya493
EMSAMselegilineNONONONENONENONENO400% FPLDoctor1 Year 90 Day 1692
EpiPenepinephrineNONONONENONENONEYES if plan is generics only 400% FPLDoctor1 Year90 Day 141.22
EpiPen 2-PakepinephrineNONONONENONENONEYES if plan is generics only 400% FPLDoctor1 Year90 Day 141.22
EpiPen 2-PakInjectionepinephrineYES(Must have generic plan only)YES(Must have generic plan only)NONENONENONENO4Doctor1 Year90 Day697
EpiPen Jr 2-Pak InjectionepinephrineYES(Must have generic plan only)YES(Must have generic plan only)NONENONENONENO4Doctor1 Year90 Day697
EpiPen Jr 2-PakNO PROGRAM AVAILABLEYES(Must have generic plan only)YES(Must have generic plan only)NONENONENONENO4Doctor1 Year90 Day697
GleostinelomustineMust be uninsured or underinsuredMust be ineligibleNONENONENONEYES200% FPLDoctor1 Year90 Day350
Coartem Tabletartmether and lumefantrineYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries1224.43
Tegretol XR TabletcarbamazepineYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries162.88
Neoral Oral SolutioncyclosporineYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries486.43
Sandimmune Capsule, GelcyclosporineYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries917.87
Sandimmune Oral SolutioncyclosporineYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries644.4
Neoral Capsulecyclosporine USPYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries134.96
Focalin XRdexmethyiphenidate HCIYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries396.5
Focalin XRCapsule ERdexmethyiphenidate HCIYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries396.5
Zortress TableteverolimusYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries1432.97
Myfortic Tablet; Delayed Releasemycophenolic acidYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries1176.55
Trileptal TabletoxcarbazepineYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries293.62
Lamisil Oral GranulesterbinafineYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries859
TOBI Inhalation SolutiontobramycinYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries8439.59
TOBI Podhaler PowdertobramycinYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries9300.99
Travatan ZtravoprostYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries156.71
Reclast Injectable; IVzoledronic acidYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250Card1 YearVaries1247.6
AfinitoreverolimusYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day3715.52
Afinitor DisperzeverolimusYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day3715.52
ArranonnelarabineYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES400% FPLDoctor/Pharm Card1 Year 90 Day
ArzerraNO PROGRAM AVAILABLEYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONENONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day20000
AZO Suspension/ DropsbrinzolamideYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONENONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day292
AzoptbrinzolamideYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONENONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day292
Ciprociprofloxacin/dexamethasone sterile otic suspensionYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONENONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day257
Coartemartmether/lumefantrineYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONENONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day130
DurezoldifluprednateYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONENONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day180
Entrestosacubitril/valsartanYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONENONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day468.57
ExjadedeferasiroxYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONENONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day18644.58
Extaviainterferon beta-1bYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONENONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day6268.54
Farydakpanobinostat lactateYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONENONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day8011.48
GilenyafingolimodYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONENONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day5412.92
Glatopaglatiramer acetateYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONENONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day1953.29
GleevecimatinibYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONENONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day1406.6
HycamtintopotecanYes if not listed in the formularyCost of medication must not exceed 10% Annual HH IncomeNONENONEYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day75.95
JadenudeferasiroxYESYES (Cost Must Exceed 10% of Income)NONONOYES250Card1 YearVaries20000
Jadenu SprinkledeferasiroxYESYES (Cost Must Exceed 10% of Income)NONONOYES250Card1 YearVaries20000
Myforticmycophenolic acidYes if not in formularyCost of medication must not exceed 10% Annual HH IncomeNONONOYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day292
PazeoolopatadineYes if not in formularyCost of medication must not exceed 10% Annual HH IncomeNONONOYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day292
TegretolcarbamazepineYes if not in formularyCost of medication must not exceed 10% Annual HH IncomeNONONOYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day
Tegretol XRcarbamazepineYes if not in formularyCost of medication must not exceed 10% Annual HH IncomeNONONOYES$75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day
TobitobramycinYESNONONONOYES $75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day386
Tobi PodhalertobramycinYESNONONONOYES $75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day386
NeoralcyclosporineYESNONONONOYES $75,000 Individual FPL (Increases by $25,000 each memberDoctor1 Year90 Day75
Gluca Gen HypokitInjectionglucagonNOYESNONENONE$1000 OOPYES400Doctor1 Year90 Day257.57
Novolin 70/30 VialInjectionhuman/insulin susp isophaneNOYESNONENONE$1000 OOPYES400Doctor1 Year90 Day140.79
NovoLog Mix 70/30 FlexPen Cartridgesinsulin aspart protamineNOYESNONENONE$1000 OOPYES400Doctor1 Year90 Day291.71
NovoLog Mix 70/30Vialinsulin aspart protamineNOYESNONENONE$1000 OOPYES400Doctor1 Year90 Day291.71
NovoLog FlexPenInjectioninsulin aspartåNOYESNONENONE$1000 OOPYES400Doctor1 Year90 Day542.72
NovoLog Injectioninsulin aspartåNOYESNONENONE$1000 OOPYES400Doctor1 Year90 Day281.26
Levemir FlexPenInjectioninsulin detemirNOYESNONENONE$1000 OOPYES400Doctor1 Year90 Day411.59
Levemir Injectioninsulin detemirNOYESNONENONE$1000 OOPYES400Doctor1 Year90 Day274.56
Novolin N VialInjectioninsulin humanNOYESNONENONE$1000 OOPYES400Doctor1 Year90 Day140.79
Novolin R VialInjectioninsulin humanNOYESNONENONE$1000 OOPYES400Doctor1 Year90 Day140.79
Victoza InjectionliraglutideNOYESNONENONE$1000 OOPYESDoctor1 Year90 Day762.19
TresibaDegludecNOYESNONENONE$1000 OOPYES400Doctor1 Year90 Day489.84
Tresiba FlexTouch PenDegludecNOYESNONENONE$1000 OOPYES400Doctor1 Year90 Day489.84
FiaspInsulin aspartNOYESNONENONE$1000 OOPYES400% FPLDoctor1 Year 120 Day 304.65
GlucaGen HypokitglucagonNOYESNONENONE$1000 OOPYES400% FPLDoctor1 Year 120 Day 286.39
Novolin Ninsulin humanNOYES + $1000 OOPYES400Doctor1 Year90 Day291.71
Novolin Rinsulin humanNOYES + $1000 OOPYES400Doctor1 Year90 Day291.71
NovoLoginsulin humanNOYES + $1000 OOPYES400Doctor1 Year90 Day291.71
NovoLog Mix 70/30insulin humanNOYES + $1000 OOPYES400Doctor1 Year90 Day291.71
VictozaliraglutideNOYES NONO1000YES400Doctor1 Year90 Day872Novo Nordisk
Novolin 70-30human insulin isophane suspension and 30% regular, human insulin injectionNOYESNONO1000YES300Doctor1 Year90152
Novoeightantihemophilic factor recombinantNONONO400PatientVariesVaries10
ErbituxcetuximabNONONONENONENONEYES500Doctor1 YearVaries80532
CyramzaramucirumabNONONENONENONENONENO500% FPLDoctor1 Year90 Day 33066
AlimtapemetrexedMust have no prescription coverageYESNONENONENONEYES500%FPLDoctor1 Year 90 Day 697.04
Caverjec tInjectionalprostadilYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day595
Caduet Tabletsamlodipine besylate/atorvastatin calciumYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day408.15
Inlyta TabletaxitinibYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day6561.79
Bosulif TabletbosutinibYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day3196.96
Celebrex CapsulecelecoxibYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day761.35
Cleocin Capsuleclindamycin phosphateYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day248.61
Cleocin PediatricSolutionclindamycin phosphateYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day137.71
Cleocin PhosphateInjectionclindamycin phosphateYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day121.95
Cleocin Suppository; Vaginalclindamycin phosphateYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day170
Cleocin Swab1clindamycin phosphateYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day497
Colestid Granules; FlavoredcolestipolYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day385.12
Colestid TabletcolestipolYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day244.04
Xalkori CapsulecrizotinibYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day9600
Pristiq Tablet ERdesvenlafaxineYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day319.1
Zinecard InjectiondexrazoxaneYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day271.31
Arthrotec Tabletdiclofenac sodium/misoprostolYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day143
Norpace Capsuledisopyramide phosphateYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day463.22
Norpace CRCapsule ERdisopyramide phosphateYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day603.92
Tikosyn CapsuledofetilideYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day442
Relpax Tableteletriptan HBrYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day359.99
Ellence InjectionepirubicinYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day56
Inspra TableteplerenoneYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day365
Estring Vaginal RingEstradiolYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day372.09
Depo-EstradiolInjectionestradiol cypionateYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day92.6
Emcyt Capsuleestramustine phosphate sodiumYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day2404.72
Premarin Creamestrogens conjugatedYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day345.75
Premarin Tabletestrogens conjugatedYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day156.78
Premphase Tabletestrogens conjugated/medroxyprogesterone acetateYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day200
Trecator TabletethionamideYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day277.14
Zarontin CapsuleethosuximideYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day240
Aromasin TabletexemestaneYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day1058.72
Toviaz Tablet ERfesoterodine fumarateYes if not listed in the formularyYESNONENONENONEYES400Patient1 Year90 Day281.56
Cortef TablethydrocortisoneYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day97.55
Idamycin PFSInjectionidarubicinYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day33
Xalatan Ophthalmic Drops0.005latanoprostYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day180.71
Lincocin InjectionlincomycinYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day219
Depo-ProveraInjectionmedroxyprogesterone acetateYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day5012.83
Skelaxin TabletmetaxaloneYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day879.75
Celontin CapsulemethsuximideYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day453
Quillivant XR Suspension ERmethylphenidateYes if not listed in the formularyYESNONENONENONEYES400Patient1 Year90 Day314
Depo-MedrolInjectionmethylprednisolone acetateYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day1201.59
Glyset TabletmiglitolYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day295
Synarel Spraynafarelin acetateYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day227.39
Nicotrol Inhalation Systemnicotine cartridgeYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day443
Procardia CapsulenifedipineYes if not listed in the formularyYESNONENONENONEYES400Patient1 Year90 Day238.51
Procardia XL Tablet ERnifedipineYes if not listed in the formularyYESNONENONENONEYES400Patient1 Year90 Day179.7
Dilantin CapsulephenytoinYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day93.8
Dilantin-125Oral SuspensionphenytoinYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day124.44
Feldene CapsulepiroxicamYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day814
Lyrica CapsulepregabalinYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day566.18
Lyrica Oral SolutionpregabalinYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day792.15
Mycobutin CapsulerifabutinYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day1829.65
Revatio TabletsildenafilYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day4122.77
Viagra Tabletsildenafil citrateYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day628.05
Rapamune SolutionsirolimusYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day1582.52
Rapamune TabletsirolimusYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day1582.54
Sutent Capsulesunitinib malateYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day16240.58
XeljanztofacitinibYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day4284
Detrol Tablettolterodine tartrateYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day446.57
Chantix TabletvareniclineYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day369.34
Effexor XRCapsule ERvenlafaxineYes if not listed in the formularyYESNONENONENONEYES400Doctor1 Year90 Day406.59
VFEND FilmtabvoriconazoleYes if not listed in the formularyYESNONENONENONEYES400Varies1 Year90 Day1976.55
AromasinexemestaneYes if not listed in the formularyYES NO OOP NONENONENONEYES400% FPLPatient/Doctor1 Year90 Day
Caduetamlodipine besylate/atorvastatin calciumYes if not listed in the formularyYESNONONOYES400% FPLPatient/Doctor1 Year 90 Day 80
CamptosaririnotecanYes if not listed in the formularyYESNONONOYES400% FPLPatient/Doctor1 Year 90 Day 35
Caverject ImpulsealprostadilYes if not listed in the formularyYESNONONOYES400% FPLPatient/Doctor1 Year 90 Day 595
CelebrexcelecoxibYes if not listed in the formularyYESNONONOYES400% FPLPatient/Doctor1 Year 90 Day 201
CelontinmethsuximideYes if not listed in the formularyYESNONONOYES400% FPLPatient/Doctor1 Year 90 Day 127
Chantixvarenicline tartrateYes if not listed in the formularyYESNONONOYES400% FPLPatient/Doctor1 Year 90 Day 406
CleocinclindamycinYes if not listed in the formularyYESNONONOYES400% FPLPatient/Doctor1 Year 90 Day 85
Detroltolterodine tartrateYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 50.48
Detrol LAtolterodine tartrateYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 50.48
Dilantinphenytoin sodiumYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 25.34
Duaveebazedoxifene acetate/conjugated estrogensYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 158.77
Elelysotaliglucerase alfaYes if not in formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 782.54
EllenceepirubicinYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 421
Emcytestramustine phosphate sodiumYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 1841
EstringestradiolYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 436
EucrisacrisaboroleYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 636
FeldenepiroxicamYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 32.5
Flector Patchdiclofenac epolamineYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 672.31
FragmindalteparinYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 4530
Genotropinsomatropin recombinantYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 522.29
GlysetmiglitolYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 67.3
HeparinsodiumYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 53.15
IbranceNO PROGRAM AVAILABLEYESYESNONONOYES400Patient/Doctor1 Year 90 Day 11966.61
LyricaPregabalinYESYES NO OOPYES400Varies1 Year90 Day
Premarinconjugated estrogensYESYES NO OOPYES400Varies1 Year90 Day
Pristiqdesvenlafaxine succinateYESYES NONONOYES400Varies1 Year90 Day1128
Quillichew ERmethylphenidateYESYES NONONOYES400Varies1 Year90 Day1128
Quillivant XRmethylphenidateYESYES NONONOYES400Varies1 Year90 Day311
Relpaxeletriptan hydrobromideYESYESNONONOYES400Varies1 Year90 Day399
SkelaxinNO PROGRAM AVAILABLENOYESNONONOVARIESVARIESVARIESVARIESVARIES150
SomavertpegvisomantNOYESNONONOVARIESVARIESVARIESVARIESVARIES3174
TikosyndofetilideYESYESNONONOYES400Varies1 Year90 Day160
TrecatorethionamideYESYESNONONOYES400Varies1 Year90 Day90
Viagrasildenafil citrateYESYES NO OOPNONONOYES400Varies1 Year90 Day90
ZarontinethosuximideYESYESNONONOYES400Varies1 Year90 Day90
ZyvoxlinezolidYESYESNONONOYES400Varies1 Year90 Day150
Nicotrolnicotine inhalation systemYESYESNONONOYES400VariesVariesVaries443
NitrostatnitroglycerinYESYESNONONOYES400VariesVariesVaries70
NorpaceDisopyramideYESYESNONONOYES400VariesVariesVaries471
Norpace CRDisopyramide CRYESYESNONONOYES400VariesVariesVaries471
Arthrotecdiclofenac sodium/misoprostolYESYES NO OOP NONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 55
Benefixfactor IXYes if not listed in the formularyYES NO OOP NONENONE NONEYES400% FPLPatient/Doctor1 Year 90 Day 2700
Besponsainotuzumab ozogamicinYes if not listed in the formularyYES NO OOP NONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 168300
Bosulifbosutinib monohydrateYes if not listed in the formularyYESNONENONENONEYES400% FPLPatient/Doctor1 Year 90 Day 14124
Butrans TransdermalbuprenorphineNOYESNONENONENONEYES139Patient1 Year30 Day288
OxyContin TabletsoxycodoneNOYESNONENONENONEYES139Patient1 Year30 Day80.5
Analpram HChydrocortisone/pramoxineNODetermined case by caseNONENONENONEDetermined case by case100% FPLDoctor Every 6 Mths30 Day46.19
Thymoglobulin Vialanti-thymocyte globulin (rabbit)Yes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries815.9
Jevtana InjectioncabazitaxelYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries10519.98
ClolarVialclofarabineYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries3170.53
Menactra Injectiondiphtheria toxid conjugate vaccineYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries113.36
MultaqdronedaroneYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries566.43
Enoxaparin SodiumInjectableenoxaparin sodiumYes if not listed in the formularyYESNONE5% OOPNONEYES250Card1 YearVaries683.21
Lovenox Injectionenoxaparin sodiumYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries381.37
Lantus SoloSTAR Peninsulin glargineYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries372.27
Lantus U-100Vialinsulin glargineYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries248.51
Toujeo Solostarinsulin glargineYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries335.14
Apidra SoloStar Peninsulin glulisine [rDNA origin]Yes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries567.75
ApidraVialsinsulin glulisine [rDNA origin]Yes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries294.38
Menomune Injectionmeningococcal polysacchaaide vaccineYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries123.55
Mozobil InjectionplerixaforYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries7846.82
Imogam Injectionrabies immune globulinYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries809.05
Imovax Injectionrabies vaccineYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries964.03
Elitek VialrasburicaseYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries2491.76
PriftinrifapentineYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries122.06
Leukine VialsargramostimYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries1337.54
Tenivac Injectiontetanus and diphtheria toxoids adsorbedYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries319.96
Adacel Injectiontetanus toxoid/reduced diptheria toxoid/acellular pertussisYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries129.61
Zaltrap IVziv-afliberceptYes if not listed in the formularyYESNONE5% OOPNONEYES250Doctor1 YearVaries1792
Adaceltetanus toxoid-reduced diptheria toxoid-acellular pertussisYes if not listed in the formularyYESNONE5% OOPNONEYES250% FPLDoctor1 Year90 Day 49.32
AdlyxinlixisenatideYes if not listed in the formularyYESNONE5% OOPNONEYES250% FPLDoctor1 Year90 Day593.94
Apidrainsulin glulisine (recombinantYes if not listed in the formularyYESNONE5% OOPNONEYES250% FPL Doctor1 Year90 Day423.51
ClolarclofarabineYes if not listed in the formularyYESNONE5% OOPNONEYES250% FPL Doctor1 Year90 Day1005
ElitekrasburicaseYes if not listed in the formularyYESNONE5% OOPNONEYES250% FPLPatient/Doctor1 Year 90 Day 2601
JevtanacabazitaxelNOYESYES5NOYES250Doctor1 YearVaries3170.53
LantusBasaglarYESYES + 5% OOPYES250Card1 YearVaries400
Lantus U-100BasaglarYESYES + 5% OOPYES250Card1 YearVaries400
Toujeoinsulin glargineYESYESNO0.05NOYES250Doctor1 YearVaries397
CarbatrolcarbamazepineDetermined case by caseYESNONENONENONEYES300Card1 Year90 Day230
IntunivguanfacineDetermined case by caseYESNONENONENONEYES300Card1 Year90 Day1022
Fosrenollanthanum carbonateDetermined case by caseYESNONENONENONEYES300Card1 Year90 Day1136
Vyvanselisdexamfetamine dimesylateDetermined case by caseYESNONENONENONEYES300Card1 Year90 Day270
LialdamesalamineDetermined case by caseYESNONENONENONEYES300Card1 Year90 Day1181
PentasamesalamineDetermined case by caseYESNONENONENONEYES300Card1 Year90 Day769
SuboxoneBuprenorphineNONONENONENONENO250Card1 Year30 Day151
Arcapta NeohalerPowderindaceterolYes if not listed in the formularyYES (Cost Must Exceed 10% of Income)YES250Card1 YearVaries247.02
LatudalurasidoneYES (Cost Must Exceed 10% of Income)YES250Card1 YearVaries247.02
Aptiomeslicarbazepine acetateNONONONENONENONENO300% FPL Pharmacy 1 Year 30 Day 945.55
Arcaptaindacaterol (inhalation)Yes if not listed in the formularyYES (Cost Must Exceed 10% of Income)NONENONENONEYES250% FPLCard1 YearVaries277
LatudaLurasidoneYES (Cost Must Exceed 10% of Income)YES250Card1 YearVaries1285
SeebriGlycopyrrolateYES (Cost Must Exceed 10% of Income)NONONOYES250Card1 YearVaries49
Utibronglycopyrrolate and indacaterolYES cost must exceed 10% of incomeNONONOYES250Card1 YearVaries$46 
NesinaalgoliptinYes if not listed in the formularyYESNONE3% OOPNONEYES300Patient1 Year90 Day431.48
Kazanoalgoliptin/metformin hciYes if not listed in the formularyYESNONE3% OOPNONEYES300Patient1 Year90 Day431.48
Osenialgoliptin/pioglitazoneYes if not listed in the formularyYESNONE3% OOPNONEYES300Patient1 Year90 Day431.48
ColcryscolchicineYes if not listed in the formularyYESNONE3% OOPNONEYES300Patient1 Year90 Day234.84
DexilantdexlansoprazoleYes if not listed in the formularyYESNONE3% OOPNONEYES300Patient1 Year90 Day244.1
UloricfebuxostatYes if not listed in the formularyYESNONE3% OOPNONEYES300Patient1 Year90 Day285.02
PrevacidlansoprazoleYes if not listed in the formularyYESNONE3% OOPNONEYES300Patient1 Year90 Day478.36
AmitizaLubiprostoneYes if not listed in the formularyYESNONE3% OOPNONEYES300Patient1 Year90 Day349.69
RozeremramelteonYes if not listed in the formularyYESNONE3% OOPNONEYES300Patient1 Year90 Day478.36
TrintellixvortioxetineYes if not listed in the formularyYESNONE3% OOPNONEYES300Patient1 Year90 Day346.4
FentorafentanylYes if not listed in the formularyYESNONENONENONEYES300% FPLPatient/Doctor1 Year 90 Day 15052
Galzinzinc acetateYes if not listed in the formularyYESNONENONENONEYES300% FPLPatient/Doctor1 Year 90 Day 255.01
Proair HFAalbuterol sulfateYes if not listed in the formularyNONONENONENONEYES300Patient1 Year90 Day56.3
NuvigilarmodafinilYes if not listed in the formularyNONONENONENONEYES300Patient1 Year90 Day765.75
QVARbeclomethasoneYes if not listed in the formularyNONONENONENONEYES300Patient1 Year90 Day181.25
QNASLbeclomethasone dipropionateYes if not listed in the formularyNONONENONENONEYES300Patient1 Year90 Day222.23
ProglycemdiazoxideYes if not listed in the formularyNONONENONENONEYES300Patient1 Year90 Day305.26
ORAPpimozideYes if not listed in the formularyNONONENONENONEYES300Patient1 Year90 Day134.03
GabitriltiagabineYes if not listed in the formularyNONONENONENONEYES300Patient1 Year90 Day270.56
Proair RespiclickalbuterolYESNOYES300Patient1 Year90 Day56.3
BriviactbrivaracetamYes if not listed in the formularyDetermined case by caseNONONOYES 300% FPLPatient1 Year 90 Day 1071
VimpatLacosamideYes if not listed in the formularyYES/No CoverageNONENONENONEYES300Doctor6 Months90 Day858.3
Keppra Oral SolutionlevetiracetamYes if not listed in the formularyYES/No CoverageNONENONENONEYES300Doctor6 Months90 Day562.6
Keppra TabletlevetiracetamYes if not listed in the formularyYES/No CoverageNONENONENONEYES300Doctor6 Months90 Day122.46
Keppra XR TabletlevetiracetamYes if not listed in the formularyYES/No CoverageNONENONENONEYES300Doctor6 Months90 Day122.46
NeuprorotigotineUnderinsuredYESNONONOYES300Patient6 Months90 Day$858.30 
EpivirlamivudineNOYESNONENONENONEYES500% FPLPatient1 Year90 Day 55.12
Epivir-HBVlamivudineNOYESNONENONENONEYES500% FPLPatient1 Year90 Day 55.12
Epzicomabacavir sulfate/lamivudineNOYESNONENONENONEYES500% FPLPatient1 Year90 Day 55.12
Julucadolutegravir/rilpivirineContact ProgramYES NONONOYES500Patient1 year90 Days2569.5
CombivirNO PROGRAM AVAILABLENOYESNONENONE$600 OOPYES500% FPL Patient1 Year 90 Day
Treximet TabletNO PROGRAM AVAILABLE
IxempraNO PROGRAM AVAILABLE
3232 A Infant FormulaNO PROGRAM AVAILABLE
8-MOPNO PROGRAM AVAILABLE
A+D Original OintmentNO PROGRAM AVAILABLE
A+D Zinc Oxide CreamNO PROGRAM AVAILABLE
AbilifyNO PROGRAM AVAILABLE
Abilify MaintenaNO PROGRAM AVAILABLE
AbraxaneNO PROGRAM AVAILABLE
Abreva CreamNO PROGRAM AVAILABLE
AbsoricaNO PROGRAM AVAILABLE
AbstralNO PROGRAM AVAILABLE
AcanyaNO PROGRAM AVAILABLE
AccolateNO PROGRAM AVAILABLE
Accu-Chek Aviva Plus Test StripNO PROGRAM AVAILABLE
Accu-Chek Compact Test StripNO PROGRAM AVAILABLE
Accu-Chek Nano SmartView SystemNO PROGRAM AVAILABLE
Accu-Chek Nano Test StripNO PROGRAM AVAILABLE
Accu-Chek Test StripNO PROGRAM AVAILABLE
AccunebNO PROGRAM AVAILABLE
AccuprilNO PROGRAM AVAILABLE
AccureticNO PROGRAM AVAILABLE
ACE Brand Braces or SupportsNO PROGRAM AVAILABLE
ACE Brand Compression ProductsNO PROGRAM AVAILABLE
ACE Brand Custom Dial SupportNO PROGRAM AVAILABLE
ACE Brand Elastic BandagesNO PROGRAM AVAILABLE
AceonNO PROGRAM AVAILABLE
AcetadoteNO PROGRAM AVAILABLE
AcipHexNO PROGRAM AVAILABLE
AcipHex SprinkleNO PROGRAM AVAILABLE
AclovateNO PROGRAM AVAILABLE
ActemraNO PROGRAM AVAILABLE
Acthar GelNO PROGRAM AVAILABLE
ActhrelNO PROGRAM AVAILABLE
ActiclateNO PROGRAM AVAILABLE
ActigallNO PROGRAM AVAILABLE
ActimmuneNO PROGRAM AVAILABLE
ActivaseNO PROGRAM AVAILABLE
ActivellaNO PROGRAM AVAILABLE
ActonelNO PROGRAM AVAILABLE
ActosNO PROGRAM AVAILABLE
AcularNO PROGRAM AVAILABLE
AcuvailNO PROGRAM AVAILABLE
AczoneNO PROGRAM AVAILABLE
Adalat CCNO PROGRAM AVAILABLE
AdasuveNO PROGRAM AVAILABLE
AdcetrisNO PROGRAM AVAILABLE
AdcircaNO PROGRAM AVAILABLE
Adderall XRNO PROGRAM AVAILABLE
AdempasNO PROGRAM AVAILABLE
Adipex-PNO PROGRAM AVAILABLE
AdrenaclickNO PROGRAM AVAILABLE
AdriamycinNO PROGRAM AVAILABLE
AdrucilNO PROGRAM AVAILABLE
AdvairNO PROGRAM AVAILABLE
AdvateNO PROGRAM AVAILABLE
AdvicorNO PROGRAM AVAILABLE
Advil Allergy and Congestion ReliefNO PROGRAM AVAILABLE
Advil Allergy SinusNO PROGRAM AVAILABLE
Advil Cold and SinusNO PROGRAM AVAILABLE
Advil Congestion ReliefNO PROGRAM AVAILABLE
Advil Film-Coated TabletsNO PROGRAM AVAILABLE
Advil Liqui-GelsNO PROGRAM AVAILABLE
Advil MigraineNO PROGRAM AVAILABLE
Advil PM CapletsNO PROGRAM AVAILABLE
Advil PM Liqui-GelsNO PROGRAM AVAILABLE
Adzenys XR-ODTNO PROGRAM AVAILABLE
AdynovateNO PROGRAM AVAILABLE
Aerospan HFANO PROGRAM AVAILABLE
AfrezzaNO PROGRAM AVAILABLE
Afrin Extra Moisturizing No DripNO PROGRAM AVAILABLE
Afrin OriginalNO PROGRAM AVAILABLE
Afrin Original No DripNO PROGRAM AVAILABLE
Afrin Original Pump MistNO PROGRAM AVAILABLE
Afrin SinusNO PROGRAM AVAILABLE
AfstylaNO PROGRAM AVAILABLE
AggrenoxNO PROGRAM AVAILABLE
AgrylinNO PROGRAM AVAILABLE
A-HydrocortNO PROGRAM AVAILABLE
Air Optix Aqua Multifocal LensesNO PROGRAM AVAILABLE
AirDuo RespiClickNO PROGRAM AVAILABLE
AlavertNO PROGRAM AVAILABLE
AlawayNO PROGRAM AVAILABLE
Alaway Children\'s Eye Itch Relief DropsNO PROGRAM AVAILABLE
Alcortin ANO PROGRAM AVAILABLE
AldactazideNO PROGRAM AVAILABLE
AldactoneNO PROGRAM AVAILABLE
AldaraNO PROGRAM AVAILABLE
AldurazymeNO PROGRAM AVAILABLE
AlecensaNO PROGRAM AVAILABLE
AleveNO PROGRAM AVAILABLE
Aleve Direct Therapy Refill Gel PadsNO PROGRAM AVAILABLE
Aleve PMNO PROGRAM AVAILABLE
Aleve-D Sinus and ColdNO PROGRAM AVAILABLE
Alfamino InfantNO PROGRAM AVAILABLE
Alfamino JuniorNO PROGRAM AVAILABLE
Alferon N InjectionNO PROGRAM AVAILABLE
AliniaNO PROGRAM AVAILABLE
AliqopaNO PROGRAM AVAILABLE
Alka-Seltzer ProductsNO PROGRAM AVAILABLE
AlkeranNO PROGRAM AVAILABLE
AllegraNO PROGRAM AVAILABLE
Allegra Allergy 12 HourNO PROGRAM AVAILABLE
Allegra Allergy 24 HourNO PROGRAM AVAILABLE
Allegra Anti-itch ProductsNO PROGRAM AVAILABLE
Allegra ProductsNO PROGRAM AVAILABLE
Allegra-D 12 HourNO PROGRAM AVAILABLE
Allegra-D 24 HourNO PROGRAM AVAILABLE
AlloDermNO PROGRAM AVAILABLE
AlloSkinNO PROGRAM AVAILABLE
AlloWrapNO PROGRAM AVAILABLE
AloraNO PROGRAM AVAILABLE
AloxiNO PROGRAM AVAILABLE
AlprolixNO PROGRAM AVAILABLE
AltabaxNO PROGRAM AVAILABLE
AltaceNO PROGRAM AVAILABLE
Altera Nebulizer for CaystonNO PROGRAM AVAILABLE
AltoprevNO PROGRAM AVAILABLE
AlunbrigNO PROGRAM AVAILABLE
AlvescoNO PROGRAM AVAILABLE
Always Sanitary ProductsNO PROGRAM AVAILABLE
AmarylNO PROGRAM AVAILABLE
AmbienNO PROGRAM AVAILABLE
Ambien CRNO PROGRAM AVAILABLE
AmeliorNO PROGRAM AVAILABLE
A-MethapredNO PROGRAM AVAILABLE
AmicarNO PROGRAM AVAILABLE
AmidateNO PROGRAM AVAILABLE
AmLactin Cerapeutic Restoring Body LotionNO PROGRAM AVAILABLE
AmLactin Foot Cream TherapyNO PROGRAM AVAILABLE
AmLactin Hydrating Body CreamNO PROGRAM AVAILABLE
AmLactin Moisturizing Body LotionNO PROGRAM AVAILABLE
AmmonulNO PROGRAM AVAILABLE
AmnesteemNO PROGRAM AVAILABLE
AmniobandNO PROGRAM AVAILABLE
AmnioExcelNO PROGRAM AVAILABLE
AmnioMatrixNO PROGRAM AVAILABLE
AmpyraNO PROGRAM AVAILABLE
AnafranilNO PROGRAM AVAILABLE
AnaproxNO PROGRAM AVAILABLE
Anaprox DSNO PROGRAM AVAILABLE
AnaspazNO PROGRAM AVAILABLE
AncobonNO PROGRAM AVAILABLE
AndroidNO PROGRAM AVAILABLE
AndroxyNO PROGRAM AVAILABLE
AngeliqNO PROGRAM AVAILABLE
Animi-3NO PROGRAM AVAILABLE
Animi-3 with Vitamin DNO PROGRAM AVAILABLE
AntaraNO PROGRAM AVAILABLE
AntivertNO PROGRAM AVAILABLE
Anusol-HCNO PROGRAM AVAILABLE
AnzemetNO PROGRAM AVAILABLE
ApexiconNO PROGRAM AVAILABLE
ApexiCon ENO PROGRAM AVAILABLE
ApligrafNO PROGRAM AVAILABLE
ApokynNO PROGRAM AVAILABLE
ApresolineNO PROGRAM AVAILABLE
AprisoNO PROGRAM AVAILABLE
Aptensio XRNO PROGRAM AVAILABLE
AquaSol ANO PROGRAM AVAILABLE
AquoralNO PROGRAM AVAILABLE
Aralast NPNO PROGRAM AVAILABLE
AravaNO PROGRAM AVAILABLE
ArediaNO PROGRAM AVAILABLE
ArestinNO PROGRAM AVAILABLE
AriceptNO PROGRAM AVAILABLE
ArimidexNO PROGRAM AVAILABLE
Aristada (1064mg)NO PROGRAM AVAILABLE
Aristada (441mg)NO PROGRAM AVAILABLE
Aristada (662mg)NO PROGRAM AVAILABLE
Aristada (882mg)NO PROGRAM AVAILABLE
AristocortNO PROGRAM AVAILABLE
Arnicare Topical ProductsNO PROGRAM AVAILABLE
ArthritenNO PROGRAM AVAILABLE
ArthroFlexNO PROGRAM AVAILABLE
Arymo ERNO PROGRAM AVAILABLE
AsacolNO PROGRAM AVAILABLE
Asacol HDNO PROGRAM AVAILABLE
AsmalpredNO PROGRAM AVAILABLE
AsmanexNO PROGRAM AVAILABLE
Asmanex HFANO PROGRAM AVAILABLE
Asmanex TwisthalerNO PROGRAM AVAILABLE
Astagraf XLNO PROGRAM AVAILABLE
AstelinNO PROGRAM AVAILABLE
Astroglide ProductsNO PROGRAM AVAILABLE
AtacandNO PROGRAM AVAILABLE
Atacand HCTNO PROGRAM AVAILABLE
AtelviaNO PROGRAM AVAILABLE
AtgamNO PROGRAM AVAILABLE
AtivanNO PROGRAM AVAILABLE
AtralinNO PROGRAM AVAILABLE
AtriplaNO PROGRAM AVAILABLE
AustedoNO PROGRAM AVAILABLE
Auvi-QNO PROGRAM AVAILABLE
AvalideNO PROGRAM AVAILABLE
AvaproNO PROGRAM AVAILABLE
Avar Family ProductsNO PROGRAM AVAILABLE
AvastinNO PROGRAM AVAILABLE
AveedNO PROGRAM AVAILABLE
Aveeno ProductsNO PROGRAM AVAILABLE
AveloxNO PROGRAM AVAILABLE
AvodartNO PROGRAM AVAILABLE
AvonexNO PROGRAM AVAILABLE
AxidNO PROGRAM AVAILABLE
AxonaNO PROGRAM AVAILABLE
AygestinNO PROGRAM AVAILABLE
AzasanNO PROGRAM AVAILABLE
AzaSiteNO PROGRAM AVAILABLE
AzelexNO PROGRAM AVAILABLE
AzilectNO PROGRAM AVAILABLE
AzmacortNO PROGRAM AVAILABLE
AZO Bladder ControlNO PROGRAM AVAILABLE
AZO CranberryNO PROGRAM AVAILABLE
AZO Itch Relief Max StrengthNO PROGRAM AVAILABLE
AZO PMSNO PROGRAM AVAILABLE
AZO Test StripNO PROGRAM AVAILABLE
AZO Urinary Pain ReliefNO PROGRAM AVAILABLE
AZO Urinary Pain Relief Maximum StrengthNO PROGRAM AVAILABLE
AZO Urinary Tract DefenseNO PROGRAM AVAILABLE
AZO YeastNO PROGRAM AVAILABLE
AzulfidineNO PROGRAM AVAILABLE
Azulfidine En-TabNO PROGRAM AVAILABLE
Bacitracin for InjectionNO PROGRAM AVAILABLE
BactrimNO PROGRAM AVAILABLE
BactrobanNO PROGRAM AVAILABLE
Balmex Diaper Rash Cream StickNO PROGRAM AVAILABLE
Balmex Diaper Rash Cream with ActivGuardNO PROGRAM AVAILABLE
Balmex Multi-Purpose Healing OintmentNO PROGRAM AVAILABLE
BalneolNO PROGRAM AVAILABLE
Band-Aid Brand ProductsNO PROGRAM AVAILABLE
Band-Aid Flexible FabricNO PROGRAM AVAILABLE
BaracludeNO PROGRAM AVAILABLE
BavencioNO PROGRAM AVAILABLE
BaxdelaNO PROGRAM AVAILABLE
Bayer Aspirin ProductsNO PROGRAM AVAILABLE
BCAD 1 Infant FormulaNO PROGRAM AVAILABLE
BCAD 2 Medical FoodNO PROGRAM AVAILABLE
BeanoNO PROGRAM AVAILABLE
Beano MeltawaysNO PROGRAM AVAILABLE
BebulinNO PROGRAM AVAILABLE
BelbucaNO PROGRAM AVAILABLE
BeleodaqNO PROGRAM AVAILABLE
Belviq XRNO PROGRAM AVAILABLE
Benadryl Allergy Dye-Free Liqui-GelsNO PROGRAM AVAILABLE
Benadryl Anti-Itch Gel for KidsNO PROGRAM AVAILABLE
Benadryl Extra Strength Itch Relief StickNO PROGRAM AVAILABLE
Benadryl Extra Strength SprayNO PROGRAM AVAILABLE
Benadryl Itch Stopping Cream Extra StrengthNO PROGRAM AVAILABLE
Benadryl Itch Stopping Cream Original StrengthNO PROGRAM AVAILABLE
Benadryl Itch Stopping Gel Extra StrengthNO PROGRAM AVAILABLE
Benadryl READYMISTNO PROGRAM AVAILABLE
Benadryl ULTRATABNO PROGRAM AVAILABLE
Bengay productsNO PROGRAM AVAILABLE
Bengay Zero DegreesNO PROGRAM AVAILABLE
BenicarNO PROGRAM AVAILABLE
Benicar HCTNO PROGRAM AVAILABLE
BentylNO PROGRAM AVAILABLE
BenzoDox 30KitNO PROGRAM AVAILABLE
BenzoDox 60KitNO PROGRAM AVAILABLE
BepreveNO PROGRAM AVAILABLE
BerinertNO PROGRAM AVAILABLE
BesivanceNO PROGRAM AVAILABLE
BetapaceNO PROGRAM AVAILABLE
BetaseronNO PROGRAM AVAILABLE
BetimolNO PROGRAM AVAILABLE
Betoptic SNO PROGRAM AVAILABLE
BevyxxaNO PROGRAM AVAILABLE
BexxarNO PROGRAM AVAILABLE
BeyazNO PROGRAM AVAILABLE
BicnuNO PROGRAM AVAILABLE
BiDilNO PROGRAM AVAILABLE
BiktarvyNO PROGRAM AVAILABLE
BiltricideNO PROGRAM AVAILABLE
BinostoNO PROGRAM AVAILABLE
BioDFenceNO PROGRAM AVAILABLE
BioDFence DryFlexNO PROGRAM AVAILABLE
Bionect CreamNO PROGRAM AVAILABLE
Biotrue Multi-Purpose SolutionNO PROGRAM AVAILABLE
BioVanceNO PROGRAM AVAILABLE
BivigamNO PROGRAM AVAILABLE
BlenoxaneNO PROGRAM AVAILABLE
BlephamideNO PROGRAM AVAILABLE
Blephamide S.O.P.NO PROGRAM AVAILABLE
Bodhe Therapeutic Medical ApparelNO PROGRAM AVAILABLE
BonivaNO PROGRAM AVAILABLE
Boost Kid EssentialsNO PROGRAM AVAILABLE
Boost Kid Essentials 1.5NO PROGRAM AVAILABLE
Boost Kid Essentials 1.5 FiberNO PROGRAM AVAILABLE
Boost OriginalNO PROGRAM AVAILABLE
Boost PlusNO PROGRAM AVAILABLE
Boost VHCNO PROGRAM AVAILABLE
BoostrixNO PROGRAM AVAILABLE
BotoxNO PROGRAM AVAILABLE
BrainStrong Prenatal SupplementNO PROGRAM AVAILABLE
Brava AccessoriesNO PROGRAM AVAILABLE
BravelleNO PROGRAM AVAILABLE
Breathe Right AdvanceNO PROGRAM AVAILABLE
Breathe Right ClearNO PROGRAM AVAILABLE
Breathe Right ExtraNO PROGRAM AVAILABLE
Breathe Right Extra ClearNO PROGRAM AVAILABLE
Breathe Right KidsNO PROGRAM AVAILABLE
Breathe Right MentholNO PROGRAM AVAILABLE
Breathe Right Original TanNO PROGRAM AVAILABLE
BreviblocNO PROGRAM AVAILABLE
BridionNO PROGRAM AVAILABLE
BrineuraNO PROGRAM AVAILABLE
BrisdelleNO PROGRAM AVAILABLE
Bromfed DMNO PROGRAM AVAILABLE
BromSiteNO PROGRAM AVAILABLE
BumpKlear LotionNO PROGRAM AVAILABLE
BumpKlear WashNO PROGRAM AVAILABLE
BunavailNO PROGRAM AVAILABLE
BuphenylNO PROGRAM AVAILABLE
BusulfexNO PROGRAM AVAILABLE
ButransNO PROGRAM AVAILABLE
CabometyxNO PROGRAM AVAILABLE
CalanNO PROGRAM AVAILABLE
Calan SRNO PROGRAM AVAILABLE
CalcijexNO PROGRAM AVAILABLE
Calcilo XDNO PROGRAM AVAILABLE
CalcitreneNO PROGRAM AVAILABLE
Calendula CreamNO PROGRAM AVAILABLE
Calendula GelNO PROGRAM AVAILABLE
Calendula LotionNO PROGRAM AVAILABLE
Calendula OintmentNO PROGRAM AVAILABLE
CallexNO PROGRAM AVAILABLE
CambiaNO PROGRAM AVAILABLE
Camilia-Teething ReliefNO PROGRAM AVAILABLE
CampathNO PROGRAM AVAILABLE
CampralNO PROGRAM AVAILABLE
CancidasNO PROGRAM AVAILABLE
CapexNO PROGRAM AVAILABLE
CapotenNO PROGRAM AVAILABLE
CaprelsaNO PROGRAM AVAILABLE
CaracNO PROGRAM AVAILABLE
CarafateNO PROGRAM AVAILABLE
CarbagluNO PROGRAM AVAILABLE
CardizemNO PROGRAM AVAILABLE
Cardizem CDNO PROGRAM AVAILABLE
Cardizem LANO PROGRAM AVAILABLE
CarduraNO PROGRAM AVAILABLE
CarimuneNO PROGRAM AVAILABLE
Carimune NFNO PROGRAM AVAILABLE
Carmex Classic Lip Balm productNO PROGRAM AVAILABLE
Carmex Cold Sore TreatmentNO PROGRAM AVAILABLE
Carmex Daily Care StickNO PROGRAM AVAILABLE
Carmex Lip Comfort Care productNO PROGRAM AVAILABLE
CarnitorNO PROGRAM AVAILABLE
Carnitor SFNO PROGRAM AVAILABLE
CarospirNO PROGRAM AVAILABLE
Cartia XTNO PROGRAM AVAILABLE
CasodexNO PROGRAM AVAILABLE
CataflamNO PROGRAM AVAILABLE
CatapresNO PROGRAM AVAILABLE
Catapres-TTS-3NO PROGRAM AVAILABLE
CathfloNO PROGRAM AVAILABLE
CaystonNO PROGRAM AVAILABLE
CeeNUNO PROGRAM AVAILABLE
CelestoneNO PROGRAM AVAILABLE
Celestone SoluspanNO PROGRAM AVAILABLE
CelexaNO PROGRAM AVAILABLE
CellceptNO PROGRAM AVAILABLE
CenestinNO PROGRAM AVAILABLE
Centrum Kids ProductsNO PROGRAM AVAILABLE
Centrum Men\'s ProductsNO PROGRAM AVAILABLE
Centrum Silver ProductsNO PROGRAM AVAILABLE
Centrum Specialty ProductsNO PROGRAM AVAILABLE
Centrum Women\'s ProductsNO PROGRAM AVAILABLE
Cepacol Antibacterial MouthwashNO PROGRAM AVAILABLE
Cepacol SensationsNO PROGRAM AVAILABLE
Cepacol Sore Throat SprayNO PROGRAM AVAILABLE
CeraVe MoisturizersNO PROGRAM AVAILABLE
CerdelgaNO PROGRAM AVAILABLE
CerefolinNACNO PROGRAM AVAILABLE
CerezymeNO PROGRAM AVAILABLE
CerubidineNO PROGRAM AVAILABLE
CesametNO PROGRAM AVAILABLE
CetrotideNO PROGRAM AVAILABLE
ChemetNO PROGRAM AVAILABLE
Chestal Products-Adult\'sNO PROGRAM AVAILABLE
Chestal Products-Children\'sNO PROGRAM AVAILABLE
Children\'s Advil SuspensionNO PROGRAM AVAILABLE
Children\'s Allegra ProductsNO PROGRAM AVAILABLE
Children\'s BenadrylNO PROGRAM AVAILABLE
Children\'s Benadryl-DNO PROGRAM AVAILABLE
Children\'s Dimetapp Cold and Allergy Chewable TabletsNO PROGRAM AVAILABLE
Children\'s Dimetapp Cold and Allergy SyrupNO PROGRAM AVAILABLE
Children\'s Dimetapp Cough and ColdNO PROGRAM AVAILABLE
Children\'s Dimetapp Long Acting Cough Plus ColdNO PROGRAM AVAILABLE
Children\'s Dimetapp Multi-Symptom Cold and FluNO PROGRAM AVAILABLE
Children\'s Dimetapp Nighttime Cold and CongestionNO PROGRAM AVAILABLE
Children\'s OscillococcinumNO PROGRAM AVAILABLE
Children\'s Sudafed PE Cold and CoughNO PROGRAM AVAILABLE
Children\'s Sudafed PE Nasal DecongestantNO PROGRAM AVAILABLE
Childrens Claritin ProductsNO PROGRAM AVAILABLE
Chloraseptic Sore Throat LozengesNO PROGRAM AVAILABLE
Chloraseptic Sore Throat SprayNO PROGRAM AVAILABLE
Chloraseptic Throat Spray for KidsNO PROGRAM AVAILABLE
CholbamNO PROGRAM AVAILABLE
CiloxanNO PROGRAM AVAILABLE
CimziaNO PROGRAM AVAILABLE
Cimzia ContainerNO PROGRAM AVAILABLE
CinqairNO PROGRAM AVAILABLE
CinryzeNO PROGRAM AVAILABLE
CiprodexNO PROGRAM AVAILABLE
Citracal Plus MagnesiumNO PROGRAM AVAILABLE
CitraNatal 90 DHANO PROGRAM AVAILABLE
CitraNatal AssureNO PROGRAM AVAILABLE
CitraNatal B-CalmNO PROGRAM AVAILABLE
CitraNatal DHANO PROGRAM AVAILABLE
CitraNatal HarmonyNO PROGRAM AVAILABLE
ClaravisNO PROGRAM AVAILABLE
ClarinexNO PROGRAM AVAILABLE
ClariSprayNO PROGRAM AVAILABLE
ClaritinNO PROGRAM AVAILABLE
Claritin ProductsNO PROGRAM AVAILABLE
Claritin-D ProductsNO PROGRAM AVAILABLE
ClarixFloNO PROGRAM AVAILABLE
Clean and Clear Advantage Acne Spot TreatmentNO PROGRAM AVAILABLE
Clean and Clear Advantage KitNO PROGRAM AVAILABLE
Clean and Clear Continuous ControlNO PROGRAM AVAILABLE
Clean and Clear Deep ActionNO PROGRAM AVAILABLE
Clean and Clear Morning BurstNO PROGRAM AVAILABLE
Clear CareNO PROGRAM AVAILABLE
Clear Eyes All Season OutdoorNO PROGRAM AVAILABLE
Clear Eyes CompleteNO PROGRAM AVAILABLE
Clear Eyes Contact Lens Multi-Action ReliefNO PROGRAM AVAILABLE
Clear Eyes Cooling Comfort Itchy Eye ReliefNO PROGRAM AVAILABLE
Clear Eyes Cooling Comfort Redness ReliefNO PROGRAM AVAILABLE
Clear Eyes Maximum Itchy Eye ReliefNO PROGRAM AVAILABLE
Clear Eyes Maximum Strength Redness ReliefNO PROGRAM AVAILABLE
Clear Eyes Natural TearsNO PROGRAM AVAILABLE
Clear Eyes Pure Relief Dry EyesNO PROGRAM AVAILABLE
Clear Eyes Pure Relief Multi-SymtomNO PROGRAM AVAILABLE
Clear Eyes Redness ReliefNO PROGRAM AVAILABLE
Clear Eyes Traveler\'s Eye Relief DropsNO PROGRAM AVAILABLE
Clear Eyes Triple Action ReliefNO PROGRAM AVAILABLE
ClenpiqNO PROGRAM AVAILABLE
CleviprexNO PROGRAM AVAILABLE
ClimaraNO PROGRAM AVAILABLE
Climara ProNO PROGRAM AVAILABLE
ClindagelNO PROGRAM AVAILABLE
ClindesseNO PROGRAM AVAILABLE
ClobexNO PROGRAM AVAILABLE
ClodanNO PROGRAM AVAILABLE
ClodermNO PROGRAM AVAILABLE
CloSYS Alcohol-Free Oral Health ProductsNO PROGRAM AVAILABLE
CocyntalNO PROGRAM AVAILABLE
CogentinNO PROGRAM AVAILABLE
ColaceNO PROGRAM AVAILABLE
Colace ClearNO PROGRAM AVAILABLE
ColazalNO PROGRAM AVAILABLE
ColdcalmNO PROGRAM AVAILABLE
ColestidNO PROGRAM AVAILABLE
Colgate Enamel Health ProductsNO PROGRAM AVAILABLE
Colgate OrabaseNO PROGRAM AVAILABLE
Colgate Peroxyl ProductsNO PROGRAM AVAILABLE
Colgate PreviDent ProductsNO PROGRAM AVAILABLE
Colgate Sensitive ProductsNO PROGRAM AVAILABLE
Collagenase SANTYLNO PROGRAM AVAILABLE
CometriqNO PROGRAM AVAILABLE
CompazineNO PROGRAM AVAILABLE
CompleatNO PROGRAM AVAILABLE
Compleat PediatricNO PROGRAM AVAILABLE
Compleat Pediatric Reduced CalorieNO PROGRAM AVAILABLE
Compound W Freeze Off Advanced ProductsNO PROGRAM AVAILABLE
Compound W ProductsNO PROGRAM AVAILABLE
ComproNO PROGRAM AVAILABLE
ComtanNO PROGRAM AVAILABLE
Concept DHANO PROGRAM AVAILABLE
Contour Next EZ MeterNO PROGRAM AVAILABLE
Contour Next One MeterNO PROGRAM AVAILABLE
Contour Next One Test StripNO PROGRAM AVAILABLE
Contour Next USB MeterNO PROGRAM AVAILABLE
Contour Test StripNO PROGRAM AVAILABLE
ContraveNO PROGRAM AVAILABLE
ConvaTec Ostomy ProductsNO PROGRAM AVAILABLE
Conveen ActiveNO PROGRAM AVAILABLE
ConZip ProductsNO PROGRAM AVAILABLE
CoolSculptingNO PROGRAM AVAILABLE
CopaxoneNO PROGRAM AVAILABLE
CopegusNO PROGRAM AVAILABLE
CordaroneNO PROGRAM AVAILABLE
CordranNO PROGRAM AVAILABLE
Cordran CreamNO PROGRAM AVAILABLE
Cordran LotionNO PROGRAM AVAILABLE
Cordran OintmentNO PROGRAM AVAILABLE
CoregNO PROGRAM AVAILABLE
CorgardNO PROGRAM AVAILABLE
Coricidin HBP Chest Congestion and CoughNO PROGRAM AVAILABLE
Coricidin HBP Cold and FluNO PROGRAM AVAILABLE
Coricidin HBP Cough and ColdNO PROGRAM AVAILABLE
Coricidin HBP Day and Night Multi-Symptom ColdNO PROGRAM AVAILABLE
Coricidin HBP Maximum Strength FluNO PROGRAM AVAILABLE
Coricidin HBP NightTime Multi-Sympton ColdNO PROGRAM AVAILABLE
Corifactivabradine
CormaxNO PROGRAM AVAILABLE
CortefNO PROGRAM AVAILABLE
CortisporinNO PROGRAM AVAILABLE
Cortizone-10 ProductsNO PROGRAM AVAILABLE
CortoneNO PROGRAM AVAILABLE
CorvertNO PROGRAM AVAILABLE
Corvite FENO PROGRAM AVAILABLE
CorzideNO PROGRAM AVAILABLE
Cosamin ASUNO PROGRAM AVAILABLE
Cosamin AvocaNO PROGRAM AVAILABLE
Cosamin DSNO PROGRAM AVAILABLE
Cosamin VerdeNO PROGRAM AVAILABLE
CosentyxNO PROGRAM AVAILABLE
Cosentyx ContainerNO PROGRAM AVAILABLE
CosmegenNO PROGRAM AVAILABLE
CosoptNO PROGRAM AVAILABLE
Cosopt PFNO PROGRAM AVAILABLE
CotellicNO PROGRAM AVAILABLE
Cotempla XR-ODTNO PROGRAM AVAILABLE
CoumadinNO PROGRAM AVAILABLE (Warfarin)
CovaryxNO PROGRAM AVAILABLE
Covaryx HSNO PROGRAM AVAILABLE
CozaarNO PROGRAM AVAILABLE
CranRx ProductsNO PROGRAM AVAILABLE
CrestorNO PROGRAM AVAILABLE
CubicinNO PROGRAM AVAILABLE
Culturelle Digestive HealthNO PROGRAM AVAILABLE
Culturelle Kids HealthNO PROGRAM AVAILABLE
Culturelle Pro-Well Health WellnessNO PROGRAM AVAILABLE
CuprimineNO PROGRAM AVAILABLE
CutivateNO PROGRAM AVAILABLE
CuvitruNO PROGRAM AVAILABLE
CuvposaNO PROGRAM AVAILABLE
CyclinexNO PROGRAM AVAILABLE
CyclogylNO PROGRAM AVAILABLE
CyclosetNO PROGRAM AVAILABLE
CyklokapronNO PROGRAM AVAILABLE
CymetraNO PROGRAM AVAILABLE
CystadaneNO PROGRAM AVAILABLE
CystagonNO PROGRAM AVAILABLE
CystaranNO PROGRAM AVAILABLE
Cystex Liquid SupplementNO PROGRAM AVAILABLE
Cystex PlusNO PROGRAM AVAILABLE
CytadrenNO PROGRAM AVAILABLE
CytogamNO PROGRAM AVAILABLE
CytomelNO PROGRAM AVAILABLE
Cytosar-UNO PROGRAM AVAILABLE
CytotecNO PROGRAM AVAILABLE
CytoveneNO PROGRAM AVAILABLE
CytoxanNO PROGRAM AVAILABLE
Cytra-KNO PROGRAM AVAILABLE
DacogenNO PROGRAM AVAILABLE
Dailies AquaComfort Plus Contact LensesNO PROGRAM AVAILABLE
Dailies Total 1 Contact LensesNO PROGRAM AVAILABLE
DaraprimNO PROGRAM AVAILABLE
DayproNO PROGRAM AVAILABLE
DaytranaNO PROGRAM AVAILABLE
Debrox Removal KitNO PROGRAM AVAILABLE
DecadronNO PROGRAM AVAILABLE
DefitelioNO PROGRAM AVAILABLE
DelestrogenNO PROGRAM AVAILABLE
Delsym 12-Hour ProductsNO PROGRAM AVAILABLE
Delsym Childrens\' ProductsNO PROGRAM AVAILABLE
Delsym Cough+ ProductsNO PROGRAM AVAILABLE
Delsym Soothing Action LozengesNO PROGRAM AVAILABLE
DeltasoneNO PROGRAM AVAILABLE
DemadexNO PROGRAM AVAILABLE
DemserNO PROGRAM AVAILABLE
DepakeneNO PROGRAM AVAILABLE
DepakoteNO PROGRAM AVAILABLE
Depakote ERNO PROGRAM AVAILABLE
Depakote Sprinkle CapsulesNO PROGRAM AVAILABLE
DepenNO PROGRAM AVAILABLE
Depend Real Fit for MenNO PROGRAM AVAILABLE
Depend Silhouette for WomenNO PROGRAM AVAILABLE
Depend Underwear for Men and WomenNO PROGRAM AVAILABLE
DeplinNO PROGRAM AVAILABLE
DepoCytNO PROGRAM AVAILABLE
Depo-EstradiolNO PROGRAM AVAILABLE
Depo-MedrolNO PROGRAM AVAILABLE
Depo-ProveraNO PROGRAM AVAILABLE
Depo-SubQ Provera 104NO PROGRAM AVAILABLE
Depo-TestosteroneNO PROGRAM AVAILABLE
DermaCellNO PROGRAM AVAILABLE
DermagraftNO PROGRAM AVAILABLE
DermaPureNO PROGRAM AVAILABLE
Dermarest Eczema Medicated LotionNO PROGRAM AVAILABLE
Dermarest Eczema Medicated Moisturizer for Sensative SkinNO PROGRAM AVAILABLE
Dermarest-Psoriasis Medicated MoisturizerNO PROGRAM AVAILABLE
Dermarest-Psoriasis Medicated Shampoo plus ConditionerNO PROGRAM AVAILABLE
Dermarest-Psoriasis Medicated Treatment GelNO PROGRAM AVAILABLE
Derma-SmootheNO PROGRAM AVAILABLE
Derma-Smoothe/FS-Scalp OilNO PROGRAM AVAILABLE
Derma-Smoothe-FS-Body OilNO PROGRAM AVAILABLE
Dermasorb TANO PROGRAM AVAILABLE
DermatopNO PROGRAM AVAILABLE
DermaVestNO PROGRAM AVAILABLE
DerMendNO PROGRAM AVAILABLE
DermOtic Oil Ear DropNO PROGRAM AVAILABLE
DesferalNO PROGRAM AVAILABLE
Desitin Maximum Strength Original PasteNO PROGRAM AVAILABLE
Desitin Multi-Purpose OintmentNO PROGRAM AVAILABLE
Desitin Soothing Rash Bath TreatmentNO PROGRAM AVAILABLE
DesonateNO PROGRAM AVAILABLE
DesOwenNO PROGRAM AVAILABLE
DesoxynNO PROGRAM AVAILABLE
DetacholNO PROGRAM AVAILABLE
DexPakNO PROGRAM AVAILABLE
DexPak TaperPaksNO PROGRAM AVAILABLE
DiabetaNO PROGRAM AVAILABLE
Diabetisource ACNO PROGRAM AVAILABLE
DiastatNO PROGRAM AVAILABLE
DibenzylineNO PROGRAM AVAILABLE
DiclegisNO PROGRAM AVAILABLE
DifferinNO PROGRAM AVAILABLE
DiflucanNO PROGRAM AVAILABLE
DigoxNO PROGRAM AVAILABLE
Dilacor XRNO PROGRAM AVAILABLE
Dilantin-125NO PROGRAM AVAILABLE
Dilatrate SRNO PROGRAM AVAILABLE
Dilt-CDNO PROGRAM AVAILABLE
Dilt-XRNO PROGRAM AVAILABLE
DiltzacNO PROGRAM AVAILABLE
DiovanNO PROGRAM AVAILABLE
Diovan HCTNO PROGRAM AVAILABLE
DipentumNO PROGRAM AVAILABLE
DiphenNO PROGRAM AVAILABLE
DiproleneNO PROGRAM AVAILABLE
Diprolene AFNO PROGRAM AVAILABLE
DitropanNO PROGRAM AVAILABLE
Diurex ProductsNO PROGRAM AVAILABLE
DiurilNO PROGRAM AVAILABLE
DivigelNO PROGRAM AVAILABLE
DocefrezNO PROGRAM AVAILABLE
Doctor\'s Night Guard Dental Protector,TheNO PROGRAM AVAILABLE
Domeboro Cooling GelNO PROGRAM AVAILABLE
Domeboro Soothing SoakNO PROGRAM AVAILABLE
DonnatalNO PROGRAM AVAILABLE
Donnatal ElixirNO PROGRAM AVAILABLE
DoryxNO PROGRAM AVAILABLE
Doryx MPCNO PROGRAM AVAILABLE
DovonexNO PROGRAM AVAILABLE
DoxycyclineNO PROGRAM AVAILABLE
Dramamine for KidsNO PROGRAM AVAILABLE
Dramamine Less Drowsy FormulaNO PROGRAM AVAILABLE
Dramamine Original FormulaNO PROGRAM AVAILABLE
DrisdolNO PROGRAM AVAILABLE
DTIC-DomeNO PROGRAM AVAILABLE
Duet DHA Balanced Prescription Prenatal VitaminsNO PROGRAM AVAILABLE
DuexisNO PROGRAM AVAILABLE
DulcoEase Pink ProductsNO PROGRAM AVAILABLE
DulcoEase ProductsNO PROGRAM AVAILABLE
Dulcolax Laxatives TabletsNO PROGRAM AVAILABLE
Dulcolax Stool Softener ProductsNO PROGRAM AVAILABLE
DuoNebNO PROGRAM AVAILABLE
DuopaNO PROGRAM AVAILABLE
DupixentNO PROGRAM AVAILABLE
Duragesic CIINO PROGRAM AVAILABLE
DurlazaNO PROGRAM AVAILABLE
DutoprolNO PROGRAM AVAILABLE
Dyanavel XRNO PROGRAM AVAILABLE
DyazideNO PROGRAM AVAILABLE
DymistaNO PROGRAM AVAILABLE
DynacinNO PROGRAM AVAILABLE
Dynacirc CRNO PROGRAM AVAILABLE
DyreniumNO PROGRAM AVAILABLE
DysportNO PROGRAM AVAILABLE
E.E.S.NO PROGRAM AVAILABLE
Ec-NaprosynNO PROGRAM AVAILABLE
EconopredNO PROGRAM AVAILABLE
EcotrinNO PROGRAM AVAILABLE
EcozaNO PROGRAM AVAILABLE
EdarbiNO PROGRAM AVAILABLE
EdarbyclorNO PROGRAM AVAILABLE
Effexor XRNO PROGRAM AVAILABLE
EfudexNO PROGRAM AVAILABLE
EgriftaNO PROGRAM AVAILABLE
ElapraseNO PROGRAM AVAILABLE
EldeprylNO PROGRAM AVAILABLE
EldopaqueNO PROGRAM AVAILABLE
EleCareNO PROGRAM AVAILABLE
EleCare Jr.NO PROGRAM AVAILABLE
EleCare w/ DHANO PROGRAM AVAILABLE
ElestrinNO PROGRAM AVAILABLE
EletoneNO PROGRAM AVAILABLE
ElidelNO PROGRAM AVAILABLE
EligardNO PROGRAM AVAILABLE
EliphosNO PROGRAM AVAILABLE
ElixophyllinNO PROGRAM AVAILABLE
EloctateNO PROGRAM AVAILABLE
EloxatinNO PROGRAM AVAILABLE
ElsparNO PROGRAM AVAILABLE
EmbedaNO PROGRAM AVAILABLE
Embeda CIINO PROGRAM AVAILABLE
EmflazaNO PROGRAM AVAILABLE
EnablexNO PROGRAM AVAILABLE
EndometrinNO PROGRAM AVAILABLE
EnemeezNO PROGRAM AVAILABLE
Enfagrow Toddler Transitions GentleaseNO PROGRAM AVAILABLE
Enfagrow Toddler Transitions SoyNO PROGRAM AVAILABLE
EnfamilNO PROGRAM AVAILABLE
Enfamil 24NO PROGRAM AVAILABLE
Enfamil A.R.NO PROGRAM AVAILABLE
Enfamil Dietary Needs FormulasNO PROGRAM AVAILABLE
Enfamil EnfaCareNO PROGRAM AVAILABLE
Enfamil Enfagrow Toddler TransitionsNO PROGRAM AVAILABLE
Enfamil Enfaport DHA and ARANO PROGRAM AVAILABLE
Enfamil GentleaseNO PROGRAM AVAILABLE
Enfamil Human Milk FortifierNO PROGRAM AVAILABLE
Enfamil Infant FormulaNO PROGRAM AVAILABLE
Enfamil Metabolic FormulasNO PROGRAM AVAILABLE
Enfamil Nutramigen Hypoallergenic FormulaNO PROGRAM AVAILABLE
Enfamil Nutramigen with Enflora LGGNO PROGRAM AVAILABLE
Enfamil Pregestimil DHA and ARANO PROGRAM AVAILABLE
Enfamil PrematureNO PROGRAM AVAILABLE
Enfamil Premature 30NO PROGRAM AVAILABLE
Enfamil Premature High Protein 24NO PROGRAM AVAILABLE
Enfamil Premature LIPIL with IronNO PROGRAM AVAILABLE
Enfamil Premature Low Iron 20NO PROGRAM AVAILABLE
Enfamil Premature Low Iron 24NO PROGRAM AVAILABLE
Enfamil Premature with Iron 20NO PROGRAM AVAILABLE
Enfamil Premature with Iron 24NO PROGRAM AVAILABLE
Enfamil Premium InfantNO PROGRAM AVAILABLE
Enfamil Premium NewbornNO PROGRAM AVAILABLE
Enfamil ProSobeeNO PROGRAM AVAILABLE
Enfamil RegulineNO PROGRAM AVAILABLE
Enfamil Solutions FormulasNO PROGRAM AVAILABLE
EnfaportNO PROGRAM AVAILABLE
EnjuviaNO PROGRAM AVAILABLE
EnstilarNO PROGRAM AVAILABLE
Ensure Active ProductsNO PROGRAM AVAILABLE
Ensure Complete ProductsNO PROGRAM AVAILABLE
Ensure Nutrition ShakeNO PROGRAM AVAILABLE
Ensure OriginalNO PROGRAM AVAILABLE
Ensure PlusNO PROGRAM AVAILABLE
Ensure Plus ProductsNO PROGRAM AVAILABLE
EnteraGamNO PROGRAM AVAILABLE
EnteregNO PROGRAM AVAILABLE
Entocort ECNO PROGRAM AVAILABLE
EntyvioNO PROGRAM AVAILABLE
EnuloseNO PROGRAM AVAILABLE
Envarsus XRNO PROGRAM AVAILABLE
EpanedNO PROGRAM AVAILABLE
EpclusaNO PROGRAM AVAILABLE
EpiCeram Skin Barrier EmulsionNO PROGRAM AVAILABLE
EpiduoNO PROGRAM AVAILABLE
Epiduo ForteNO PROGRAM AVAILABLE
EpiFixNO PROGRAM AVAILABLE
EpiLockerNO PROGRAM AVAILABLE
EpisilNO PROGRAM AVAILABLE
EpitolNO PROGRAM AVAILABLE
EraxisNO PROGRAM AVAILABLE
ErgamisolNO PROGRAM AVAILABLE
ErivedgeNO PROGRAM AVAILABLE
ErwinazeNO PROGRAM AVAILABLE
EryPedNO PROGRAM AVAILABLE
ERY-TABNO PROGRAM AVAILABLE
Erythromycin Family ProductsNO PROGRAM AVAILABLE
EsbrietNO PROGRAM AVAILABLE
EstradermNO PROGRAM AVAILABLE
EstrasorbNO PROGRAM AVAILABLE
EstroGelNO PROGRAM AVAILABLE
Estroven EnergyNO PROGRAM AVAILABLE
Estroven FemcareNO PROGRAM AVAILABLE
Estroven Intimacy KitNO PROGRAM AVAILABLE
Estroven Maximum StrengthNO PROGRAM AVAILABLE
Estroven Mood and MemoryNO PROGRAM AVAILABLE
Estroven NighttimeNO PROGRAM AVAILABLE
Estroven Peri-Menopause Support+Weight ManagementNO PROGRAM AVAILABLE
Estroven Weight ManagementNO PROGRAM AVAILABLE
EthyolNO PROGRAM AVAILABLE
EulexinNO PROGRAM AVAILABLE
EuraxNO PROGRAM AVAILABLE
EvamistNO PROGRAM AVAILABLE