MEDISCOR PMB MAIN LIST - bpmas.co.za

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MEDISCOR PMB MAIN LIST

Effective: 1 January 2019

Please note Products contained on the PMB main list will not be reimbursed from the acute medication benefit after one claim from acute benefits for one of the following reasons:

1. Specific clinical criteria are required to be met before funding will be approved from the chronic medication benefit. Applications for this medication should be submitted with the specified clinical information (as indicated) to the Medicine Risk Management Department for pre-authorisation.

2. Pre-auth required * indicates that the product may be considered for reimbursement from the chronic medication benefit upon motivation, if the requested diagnosis is covered within the Fund's schedule of benefits.

MEDICINE NAME ACTIVE INGREDIENT THERAPEUTIC GROUP NAPPI CODE PACK SIZE

PRE-AUTH REQUIRED

FEIBA 1000U VH VIAL *ANTIINHIBITOR COAGULANT COMPLEX FOR INJ** PARENTERAL HAEMOSTATICS 852899009 1 Y

FEIBA 500U VH VIAL *ANTIINHIBITOR COAGULANT COMPLEX FOR INJ** PARENTERAL HAEMOSTATICS 852902018 1 Y

ADCO-PHENOBARB VITAL *PHENOBARBITAL W/ VITAMINS ELIXIR 16 MG/5ML** BARBITURATES 751081019 100 Y

ORENCIA 250MG VIAL 15ML POWD ABATACEPT FOR IV SOLN 250 MG RHEUMATOID ARTHRITIS AGENTS 715401001 1 Y

ORENCIA 125MG PREFILLED SYRING ABATACEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 125 RHEUMATOID ARTHRITIS AGENTS 722109001 4 Y

GLUCOBAY 100MG TABS ACARBOSE TABS 100 MG ORAL ANTI-DIABETIC AGENTS 808164015 90 Y

GLUCOBAY 50MG TABS ACARBOSE TABS 50 MG ORAL ANTI-DIABETIC AGENTS 808156012 90 Y

SECTRAL 100MG CAPS ACEBUTOLOL HCL CAP 100MG OTHER BETA-RECEPTOR BLOCKERS 762016019 60 Y

SECTRAL 200MG CAPS ACEBUTOLOL HCL CAP 200MG OTHER BETA-RECEPTOR BLOCKERS 763020001 60 Y

BUTOBLOC 400MG TABS ACEBUTOLOL HCL TAB 400 MG OTHER BETA-RECEPTOR BLOCKERS 705056001 30 Y

SECTRAL 400MG TABS ACEBUTOLOL HCL TAB 400 MG OTHER BETA-RECEPTOR BLOCKERS 763039004 30 Y

SYMADIN 100MG CAPS AMANTADINE HCL CAP 100MG AMANTADINE HCL 700500003 20 Y

SYMMETREL 100MG CAPS AMANTADINE HCL CAP 100MG AMANTADINE HCL 768243009 20 Y

AMILORETIC HS TABS AMILORIDE & HYDROCHLOROTHIAZIDE TAB 2.5-25 MG DIURETIC COMBINATIONS 702811009 30 Y

AMILORETIC TABS AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG DIURETIC COMBINATIONS 702803014 100 Y

AMILORETIC TABS AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG DIURETIC COMBINATIONS 702803022 1000 Y

SPEC-CO-AMILORIDE TABS AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG DIURETIC COMBINATIONS 706531001 500 Y

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PRE-AUTH REQUIRED

DEZRETIC 5MG/50MG TABS AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG DIURETIC COMBINATIONS 719984001 1000 Y

MODURETIC TABS AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG DIURETIC COMBINATIONS 744344018 100 Y

MODURETIC TABS AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG DIURETIC COMBINATIONS 744379008 500 Y

ADCO-RETIC TABS AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG DIURETIC COMBINATIONS 780618009 100 Y

ADCO-RETIC TABS AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG DIURETIC COMBINATIONS 780618017 1000 Y

BETARETIC TABS AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG DIURETIC COMBINATIONS 808695029 1000 Y

ARYCOR 100MG TABS AMIODARONE HCL TAB 100 MG ANTI-ARRHYTHMICS 703515001 30 Y

CORDARONE X 100MG TABS AMIODARONE HCL TAB 100 MG ANTI-ARRHYTHMICS 800554019 30 Y

HEXARONE 100MG TABS AMIODARONE HCL TAB 100 MG ANTI-ARRHYTHMICS 863157009 30 Y

ARYCOR 200MG TABS AMIODARONE HCL TAB 200 MG ANTI-ARRHYTHMICS 703513001 30 Y

BIO-AMIODARONE 200MG TABS AMIODARONE HCL TAB 200 MG ANTI-ARRHYTHMICS 707851001 30 Y

CORDARONE X 200MG TABS AMIODARONE HCL TAB 200 MG ANTI-ARRHYTHMICS 716111004 30 Y

HEXARONE 200MG TABS AMIODARONE HCL TAB 200 MG ANTI-ARRHYTHMICS 863165001 30 Y

SOLIAN 200MG TABS AMISULPRIDE TAB 200 MG ATYPICAL ANTI-PSYCHOTICS 892310001 30 Y



AMLOSYN 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 704621001 30 Y

PENDINE 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 707980001 30 Y

CALBLOC 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 708040001 30 Y

AMLODAC 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 708051001 30 Y

AUSTELL AMLODIPINE 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 708095001 30 Y

ALMADIN 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 708142001 30 Y

CIPLAVASC 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 708152001 30 Y

NORCARD 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 708191001 30 Y

LOMANOR 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 708353001 30 Y

AMLODIPINE 10MG PHARMA DYNAMIC AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 710238001 30 Y

KEYSAL 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 712216001 30 Y

GULF AMLODIPINE 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 712954001 30 Y

STAMLO 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 713491001 30 Y

AMTAS 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 713972001 30 Y

APRATE 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 714311001 30 Y

ADCO NORPENE 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 720694001 30 Y

AMLODIPINE UNICORN 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 723784001 30 Y

NORVASC 10MG TABS AMLODIPINE BESYLATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 799122009 30 Y

AMLOSYN 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 704620001 30 Y

PENDINE 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 707979001 30 Y

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PRE-AUTH REQUIRED

CALBLOC 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 708039001 30 Y

AMLODAC 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 708050001 30 Y

AUSTELL AMLODIPINE 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 708094001 30 Y

ALMADIN 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 708141001 30 Y

CIPLAVASC 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 708150001 30 Y

KLODIP 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 708162001 30 Y

NORCARD 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 708190001 30 Y

LOMANOR 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 708352001 30 Y

AMLODIPINE ASCENDIS 5 TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 708648001 30 Y

AMLODIPINE 5MG PHARMA DYNAMICS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 710236001 30 Y

KEYSAL 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 712215001 30 Y

GULF AMLODIPINE 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 712953001 30 Y

STAMLO 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 713490001 30 Y

AMTAS 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 713971001 30 Y

APRATE 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 714310001 30 Y

ADCO NORPENE 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 720693001 30 Y

AMLODIPINE UNICORN 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 723783001 30 Y

NORVASC 5MG TABS AMLODIPINE BESYLATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 791245004 30 Y

CADUET 10MG/10MG TABS AMLODIPINE BESYLATE-ATORVASTATIN CALCIUM TAB 10-10 OTHER HYPERTENSIVE AGENTS 705835001 30 Y








COVERAM 10/10MG TABS AMLODIPINE BESYLATE-PERINDOPRIL ARGININE TAB 10-10 ACE INHIBITOR/CCB COMBINATIONS 719853001 30 Y

COVERAM 5/10MG TABS AMLODIPINE BESYLATE-PERINDOPRIL ARGININE ACE INHIBITOR/CCB COMBINATIONS 719852001 30 Y

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PRE-AUTH REQUIRED

TAB 10-5

COVERAM 10/5MG TABS AMLODIPINE BESYLATE-PERINDOPRIL ARGININE TAB 5-10 ACE INHIBITOR/CCB COMBINATIONS 719854001 30 Y

COVERAM 5/5MG TABS AMLODIPINE BESYLATE-PERINDOPRIL ARGININE TAB 5-5 M ACE INHIBITOR/CCB COMBINATIONS 719855001 30 Y

EXFORGE 5MG/160MG TABS AMLODIPINE BESYLATE-VALSARTAN ANGIOTENSIN RECEPTOR ANTAGONISTS 711253001 28 Y

EXFORGE 10MG/160MG TABS AMLODIPINE BESYLATE-VALSARTAN ANGIOTENSIN RECEPTOR ANTAGONISTS 711254001 28 Y

EXFORGE 5MG/320MG EC TABS AMLODIPINE BESYLATE-VALSARTAN ANGIOTENSIN RECEPTOR ANTAGONISTS 719125001 28 Y

EXFORGE 10MG/320MG EC TABS AMLODIPINE BESYLATE-VALSARTAN ANGIOTENSIN RECEPTOR ANTAGONISTS 719126001 28 Y

COPALIA 5MG/160MG TABS AMLODIPINE BESYLATE-VALSARTAN ANGIOTENSIN RECEPTOR ANTAGONISTS 721593001 28 Y

COPALIA 10MG/160MG TABS AMLODIPINE BESYLATE-VALSARTAN ANGIOTENSIN RECEPTOR ANTAGONISTS 721594001 28 Y

EXFORGE 10MG/160MG TABS AMLODIPINE BESYLATE-VALSARTAN TAB 10-160 MG ANGIOTENSIN RECEPTOR ANTAGONISTS 711254001 28 Y

COPALIA 10MG/160MG TABS AMLODIPINE BESYLATE-VALSARTAN TAB 10-160 MG ANGIOTENSIN RECEPTOR ANTAGONISTS 721594001 28 Y

EXFORGE 10MG/320MG EC TABS AMLODIPINE BESYLATE-VALSARTAN TAB 10-320 MG ANGIOTENSIN RECEPTOR ANTAGONISTS 719126001 28 Y

EXFORGE 5MG/320MG EC TABS AMLODIPINE BESYLATE-VALSARTAN TAB 5-320 MG ANGIOTENSIN RECEPTOR ANTAGONISTS 719125001 28 Y

AMLOC 10MG TABS AMLODIPINE MALEATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 703917001 30 Y

AMLATE 10MG TABS AMLODIPINE MALEATE TAB 10 MG CALCIUM CHANNEL BLOCKERS 707278001 30 Y

AMLOC 5MG TABS AMLODIPINE MALEATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 703916001 30 Y

AMLATE 5MG TABS AMLODIPINE MALEATE TAB 5 MG CALCIUM CHANNEL BLOCKERS 707277001 30 Y

CO EXFORGE 10/160/12.5MG TABS AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE TAB 10-16 ANGIOTENSIN RECEPTOR ANTAGONISTS 717633001 28 Y

CO EXFORGE 10/160/25MG TABS AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE TAB 10-16 ANGIOTENSIN RECEPTOR ANTAGONISTS 717634001 28 Y

CO EXFORGE 10MG/320MG/25MG AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE TAB 10-32 ANGIOTENSIN RECEPTOR ANTAGONISTS 719127001 28 Y

CO EXFORGE 5/160/12.5MG TABS AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE TAB 5-160 ANGIOTENSIN RECEPTOR ANTAGONISTS 717631001 28 Y

CO EXFORGE 5/160/25MG TABS AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE TAB 5-160 ANGIOTENSIN RECEPTOR ANTAGONISTS 717632001 28 Y

KOGENATE 1000IU FS POWDER FOR ANTIHEMOPHILIC FACTOR (RECOMBINANT) FOR INJ 1000 U PARENTERAL HAEMOSTATICS 711417001 1 Y

KOGENATE 250IU FS POWDER FOR I ANTIHEMOPHILIC FACTOR (RECOMBINANT) FOR INJ 250 UN PARENTERAL HAEMOSTATICS 711415001 1 Y

KOGENATE 500IU FS POWDER FOR ANTIHEMOPHILIC FACTOR (RECOMBINANT) FOR INJ 500 UN PARENTERAL HAEMOSTATICS 711416001 1 Y

OCTANATE VIAL 10ML 1000IU ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 1000 UNI PARENTERAL HAEMOSTATICS 713084001 1 Y

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PRE-AUTH REQUIRED

FACTOR DRIED ANTI-HAEMOPH V111 ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 250 UNIT PARENTERAL HAEMOSTATICS 702398001 1 Y

OCTANATE VIAL 5ML 250IU I ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 250 UNIT PARENTERAL HAEMOSTATICS 713085001 1 Y

HAEMOSOLVATE 300IU ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 300 UNIT PARENTERAL HAEMOSTATICS 841560005 1 Y

FACTOR DRIED ANTI-HAEMOPHIL ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 500 UNIT PARENTERAL HAEMOSTATICS 702399001 1 Y

OCTANATE VIAL 10ML 500IU ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 500 UNIT PARENTERAL HAEMOSTATICS 713086001 1 Y

HAEMOSOLVATE 500U ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 500 UNIT PARENTERAL HAEMOSTATICS 800759028 1 Y

HAEMOSOLVATE 1000U ANTIHEMOPHILIC FACTOR/VWF (HUMAN) FOR INJ 500-1000 PARENTERAL HAEMOSTATICS 813648009 1 Y

ABILIFY 10MG TABS ARIPIPRAZOLE TAB 10 MG ATYPICAL ANTI-PSYCHOTICS 705634001 30 Y

ARIZOFY 10MG TABS ARIPIPRAZOLE TAB 10 MG ATYPICAL ANTI-PSYCHOTICS 723962001 30 Y

ABILIFY 15MG TABS ARIPIPRAZOLE TAB 15 MG ATYPICAL ANTI-PSYCHOTICS 705635001 30 Y

ARIZOFY 15MG TABS ARIPIPRAZOLE TAB 15 MG ATYPICAL ANTI-PSYCHOTICS 723963001 30 Y

ABILIFY 10MG TABS ARIPIPRAZOLE TABS ATYPICAL ANTI-PSYCHOTICS 705634001 30 Y



ARIZOFY 5MG TABS ARIPIPRAZOLE TABS ATYPICAL ANTI-PSYCHOTICS 723961001 30 Y



TENORETIC TABS ATENOLOL & CHLORTHALIDONE TAB 100-25 MG BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 769568009 30 Y

TENCHLOR TABS ATENOLOL & CHLORTHALIDONE TAB 100-25 MG BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 786217014 30 Y

SANDOZ CO-TENIDONE 100/25 ATENOLOL & CHLORTHALIDONE TAB 100-25 MG BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 789615002 30 Y

TENORET TABS ATENOLOL & CHLORTHALIDONE TAB 50-12.5 MG BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 769592007 30 Y

SANDOZ CO-TENIDONE 50/12. ATENOLOL & CHLORTHALIDONE TAB 50-12.5 MG BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 789607018 30 Y

TENCHLOR-HS TABS ATENOLOL & CHLORTHALIDONE TAB 50-12.5 MG BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 807591017 30 Y

B-BLOCK 100MG TABS ATENOLOL TAB 100 MG OTHER BETA-RECEPTOR BLOCKERS 704651001 30 Y

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PRE-AUTH REQUIRED

TENOPRESS 100MG TABS ATENOLOL TAB 100 MG OTHER BETA-RECEPTOR BLOCKERS 705873001 30 Y

GULF ATENOLOL 100MG TABS ATENOLOL TAB 100 MG OTHER BETA-RECEPTOR BLOCKERS 715626001 28 Y

ZETENOL 100MG TABS ATENOLOL TAB 100 MG OTHER BETA-RECEPTOR BLOCKERS 719657001 30 Y

TENORMIN 100MG TABS ATENOLOL TAB 100 MG OTHER BETA-RECEPTOR BLOCKERS 769576001 30 Y

TEN-BLOKA 100MG TABS ATENOLOL TAB 100 MG OTHER BETA-RECEPTOR BLOCKERS 786195010 30 Y

ADCO-ATENOLOL 100MG TABS ATENOLOL TAB 100 MG OTHER BETA-RECEPTOR BLOCKERS 786586001 28 Y

SANDOZ ATENOLOL 100MG TABS ATENOLOL TAB 100 MG OTHER BETA-RECEPTOR BLOCKERS 787914002 30 Y

SANDOZ ATENOLOL 100MG TABS ATENOLOL TAB 100 MG OTHER BETA-RECEPTOR BLOCKERS 787914029 500

HEXABLOK 100MG TABS ATENOLOL TAB 100 MG OTHER BETA-RECEPTOR BLOCKERS 806897007 30 Y

BIO-ATENOLOL 100MG TABS ATENOLOL TAB 100 MG OTHER BETA-RECEPTOR BLOCKERS 826901034 30 Y



B-BLOCK 50MG TABS ATENOLOL TAB 50 MG OTHER BETA-RECEPTOR BLOCKERS 704653001 30 Y



GULF ATENOLOL 50MG TABS ATENOLOL TAB 50 MG OTHER BETA-RECEPTOR BLOCKERS 715625001 28 Y

ZETENOL 50MG TABS ATENOLOL TAB 50 MG OTHER BETA-RECEPTOR BLOCKERS 719656001 30 Y


TEN-BLOKA 50MG TABS ATENOLOL TAB 50 MG OTHER BETA-RECEPTOR BLOCKERS 786187026 30 Y

ADCO-ATENOLOL 50MG TABS ATENOLOL TAB 50 MG OTHER BETA-RECEPTOR BLOCKERS 786578017 30 Y

SANDOZ ATENOLOL 50MG TABS ATENOLOL TAB 50 MG OTHER BETA-RECEPTOR BLOCKERS 787892009 30 Y

HEXABLOK 50MG TABS ATENOLOL TAB 50 MG OTHER BETA-RECEPTOR BLOCKERS 806889004 30 Y

BIO-ATENOLOL 50MG TABS ATENOLOL TAB 50 MG OTHER BETA-RECEPTOR BLOCKERS 826898025 30 Y

ASPAVOR 10MG TABS ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) HMG-COA REDUCTASE INHIBITORS 708121001 30 Y

ATORVASTATIN UNICORN 10MG TABS ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) HMG-COA REDUCTASE INHIBITORS 711621001 30 Y

LIPOGEN 10MG TABS ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) HMG-COA REDUCTASE INHIBITORS 714071001 30 Y

RAN-ATORVASTATIN 10MG TABS ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) HMG-COA REDUCTASE INHIBITORS 714075001 30 Y

ATORVASTATIN SUN 10MG TABS ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) HMG-COA REDUCTASE INHIBITORS 714370001 30 Y

ATORVASTATIN WINTHROP 10MG ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) HMG-COA REDUCTASE INHIBITORS 716615001 30 Y

ADCO ATORVASTATIN 10MG TABS ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) HMG-COA REDUCTASE INHIBITORS 718073001 30 Y

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PRE-AUTH REQUIRED

DYNATOR 10MG TABS ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) HMG-COA REDUCTASE INHIBITORS 718218001 30 Y

VASTOR 10MG TABS ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) HMG-COA REDUCTASE INHIBITORS 718933001 30 Y

ASTOR 10MG TABS ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) HMG-COA REDUCTASE INHIBITORS 719185001 30 Y

LESTAVOR 10MG TABS ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) HMG-COA REDUCTASE INHIBITORS 719366001 30 Y

ATORVASTATIN LHC 10MG TABS ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) HMG-COA REDUCTASE INHIBITORS 723710001 30 Y

LIPITOR 10MG TABS ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) HMG-COA REDUCTASE INHIBITORS 831484006 30 Y













LIPITOR 20MG TABS ATORVASTATIN CALCIUM TAB 20 MG HMG-COA REDUCTASE INHIBITORS 831492008 30 Y

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PRE-AUTH REQUIRED

(BASE EQUIVALENT)



















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PRE-AUTH REQUIRED





CIBADREX 10MG TABS BENAZEPRIL & HCTZ ACE INHIBITOR/DIURETIC COMBINATIONS 800279019 28 Y

CIBACE 10MG TABS BENAZEPRIL HCL TAB 10 MG SINGLE ACE INHIBITORS 794058020 28 Y

MADOPAR HBS CAPS BENSERAZIDE & LEVODOPA CAP 25-100 MG ANTI-PARKINSON DOPAMINERGICS 828483019 100 Y

MADOPAR TABS BENSERAZIDE & LEVODOPA TAB 50-200 MG ANTI-PARKINSON DOPAMINERGICS 739596004 100 Y

BETOPTIC 5MG/ML 5ML DROPS BETAXOLOL HCL OPHTH SOLN 0.5% BETA BLOCKERS FOR GLAUCOMA 708445004 1 Y

LOXOPTIC 0.5% 5ML DROPS BETAXOLOL HCL OPHTH SOLN 0.5% BETA BLOCKERS FOR GLAUCOMA 722010001 1 Y

BETOPTIC S SINGLE DOSE BETAXOLOL HCL OPHTH SUSP 0.25% BETA BLOCKERS FOR GLAUCOMA 822868008 50 Y

BETOPTIC S 2.5MG/ML 5ML DROPS BETAXOLOL HCL OPHTH SUSP 0.25% BETA BLOCKERS FOR GLAUCOMA 836052005 1 Y

BEZALIP 200MG TABS BEZAFIBRATE TAB 200 MG FIBRATES 708453007 90 Y

DYNA-BEZAFIBRATE SR 400MG TABS BEZAFIBRATE TAB CR 400 MG FIBRATES 710122001 30 Y

BEZACHOLE SR 400MG TABS BEZAFIBRATE TAB CR 400 MG FIBRATES 710337001 30 Y

BEZALIP RET 400MG TABS BEZAFIBRATE TAB CR 400 MG FIBRATES 779644018 30 Y

SANDOZ BEZAFIBRATE 400 CR TABS BEZAFIBRATE TAB CR 400 MG FIBRATES 828300003 30 Y

LUMIGAN 0.01% BIMATOPROST OPHTH SOLN 0.01% PROSTAGLANDINS FOR GLAUCOMA 716754001 1 Y

LUMIGAN 0.03% 3ML BIMATOPROST OPHTH SOLN 0.03% PROSTAGLANDINS FOR GLAUCOMA 703666003 1 Y

GANFORT 3ML OPTH DROPS BIMATOPROST-TIMOLOL MALEATE OPHTH SOLN 0.03-0.5%

COMBINATION BETA BLOCKER/PROSTAGLANDIN FOR GLAUCOM 714110001 1 Y

AKINETON 2MG TABS BIPERIDEN HCL TAB 2 MG ANTI-PARKINSON ANTI-CHOLINERGICS 701491019 50 Y

LENNON-BIPERIDEN 2MG TABS BIPERIDEN HCL TAB 2 MG ANTI-PARKINSON ANTI-CHOLINERGICS 713209001 500 Y

BISOZYD CO 2.5/6.25 TABS BISOPROLOL & HCTZ BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 718082001 30 Y

BISOZYD CO 5/6.25 TABS BISOPROLOL & HCTZ BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 718086001 30 Y

BISOZYD 10/6.25MG TABS BISOPROLOL & HCTZ BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 718087001 30 Y

BILOCOR CO 2.5MG/6.25MG TABS BISOPROLOL & HCTZ BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 719200001 30 Y

BILOCOR CO 5MG/6.25MG TABS BISOPROLOL & HCTZ BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 719201001 30 Y

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PRE-AUTH REQUIRED

BILOCOR CO 10MG/6.25MG TABS BISOPROLOL & HCTZ BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 719202001 30 Y

ZIABETA 2.5/6.25MG TABS BISOPROLOL & HCTZ BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 720031001 30 Y

ZIABETA 5/6.25MG TABS BISOPROLOL & HCTZ BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 720032001 30 Y

ZIABETA 10/6.25MG TABS BISOPROLOL & HCTZ BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 720033001 30 Y

BISOPROLOL CO UNICORN 5MG/6.25 BISOPROLOL & HCTZ BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 721588001 30 Y

BISOPROLOL CO UNICORN 10MG/6.2 BISOPROLOL & HCTZ BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 721589001 30 Y

ZIAK 2.5MG TABS BISOPROLOL & HCTZ BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 840300018 30 Y

ZIAK 5MG TABS BISOPROLOL & HCTZ BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 840319002 30 Y

ZIAK 10MG TABS BISOPROLOL & HCTZ BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 852929005 30 Y

ADCO-BISOCOR 10MG TABS BISOPROLOL FUMARATE TAB 10 MG OTHER BETA-RECEPTOR BLOCKERS 703914001 30 Y

BISOHEXAL 10MG TABS BISOPROLOL FUMARATE TAB 10 MG OTHER BETA-RECEPTOR BLOCKERS 704133001 30 Y

BILOCOR 10MG TABS BISOPROLOL FUMARATE TAB 10 MG OTHER BETA-RECEPTOR BLOCKERS 704373001 30 Y

CARDICOR 10MG TABS BISOPROLOL FUMARATE TAB 10 MG OTHER BETA-RECEPTOR BLOCKERS 704441001 30 Y

BETACOR 10MG TABS BISOPROLOL FUMARATE TAB 10 MG OTHER BETA-RECEPTOR BLOCKERS 706179001 30 Y

BISOPROLOL HEXAL 10MG TABS BISOPROLOL FUMARATE TAB 10 MG OTHER BETA-RECEPTOR BLOCKERS 707393001 30 Y

ZIAPRO 10MG TABS BISOPROLOL FUMARATE TAB 10 MG OTHER BETA-RECEPTOR BLOCKERS 715276001 30 Y

BISOPROLOL UNICORN 10MG TABS BISOPROLOL FUMARATE TAB 10 MG OTHER BETA-RECEPTOR BLOCKERS 716166001 30 Y

BISLO 10MG TABS BISOPROLOL FUMARATE TAB 10 MG OTHER BETA-RECEPTOR BLOCKERS 719155001 30 Y

BISOZYD 10MG TABS BISOPROLOL FUMARATE TAB 10 MG OTHER BETA-RECEPTOR BLOCKERS 720044001 30 Y

BISBETA 10MG TABS BISOPROLOL FUMARATE TAB 10 MG OTHER BETA-RECEPTOR BLOCKERS 720660001 30 Y

RETOCAR 10MG TABS BISOPROLOL FUMARATE TAB 10 MG OTHER BETA-RECEPTOR BLOCKERS 720821001 30 Y

MYLAN BISOPROLOL 10MG TABS BISOPROLOL FUMARATE TAB 10 MG OTHER BETA-RECEPTOR BLOCKERS 721438001 30 Y

BISOPROLOL UNICHEM 10MG TABS BISOPROLOL FUMARATE TAB 10 MG OTHER BETA-RECEPTOR BLOCKERS 722056001 30 Y

CONCOR 10MG TABS BISOPROLOL FUMARATE TAB 10 MG OTHER BETA-RECEPTOR BLOCKERS 818437006 30 Y

ADCO-BISOCOR 5MG TABS BISOPROLOL FUMARATE TAB 5 MG OTHER BETA-RECEPTOR BLOCKERS 703913001 30 Y

BISOHEXAL 5MG TABS BISOPROLOL FUMARATE TAB 5 MG OTHER BETA-RECEPTOR BLOCKERS 704132001 30 Y

BILOCOR 5MG TABS BISOPROLOL FUMARATE TAB 5 MG OTHER BETA-RECEPTOR BLOCKERS 704372001 30 Y

CARDICOR 5MG TABS BISOPROLOL FUMARATE TAB 5 MG OTHER BETA-RECEPTOR BLOCKERS 704440001 30 Y

of 53


PRE-AUTH REQUIRED

BETACOR 5MG TABS BISOPROLOL FUMARATE TAB 5 MG OTHER BETA-RECEPTOR BLOCKERS 706178001 30 Y

BISOPROLOL HEXAL 5MG TABS BISOPROLOL FUMARATE TAB 5 MG OTHER BETA-RECEPTOR BLOCKERS 707391001 30 Y

ZIAPRO 5MG TABS BISOPROLOL FUMARATE TAB 5 MG OTHER BETA-RECEPTOR BLOCKERS 715274001 30 Y

BISOPROLOL UNICORN 5MG TABS BISOPROLOL FUMARATE TAB 5 MG OTHER BETA-RECEPTOR BLOCKERS 716167001 30 Y

BISLO 5MG TABS BISOPROLOL FUMARATE TAB 5 MG OTHER BETA-RECEPTOR BLOCKERS 719154001 30 Y

BISOZYD 5MG TABS BISOPROLOL FUMARATE TAB 5 MG OTHER BETA-RECEPTOR BLOCKERS 720043001 30 Y

BISBETA 5MG TABS BISOPROLOL FUMARATE TAB 5 MG OTHER BETA-RECEPTOR BLOCKERS 720659001 30 Y

RETOCAR 5MG TABS BISOPROLOL FUMARATE TAB 5 MG OTHER BETA-RECEPTOR BLOCKERS 720820001 30 Y

MYLAN BISOPROLOL 5MG TABS BISOPROLOL FUMARATE TAB 5 MG OTHER BETA-RECEPTOR BLOCKERS 721437001 30 Y

BISOPROLOL UNICHEM 5MG TABS BISOPROLOL FUMARATE TAB 5 MG OTHER BETA-RECEPTOR BLOCKERS 722055001 30 Y

CONCOR 5MG TABS BISOPROLOL FUMARATE TAB 5 MG OTHER BETA-RECEPTOR BLOCKERS 818429003 30 Y

ADCO-BISOCOR 5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 703913001 30 Y

ADCO-BISOCOR 10MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 703914001 30 Y

BISOHEXAL 5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 704132001 30 Y

BISOHEXAL 10MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 704133001 30 Y

BILOCOR 5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 704372001 30 Y

BILOCOR 10MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 704373001 30 Y

CARDICOR 2.5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 704439001 30 Y

CARDICOR 5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 704440001 30 Y

CARDICOR 10MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 704441001 30 Y

BETACOR 5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 706178001 30 Y

BETACOR 10MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 706179001 30 Y

BISOPROLOL HEXAL 5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 707391001 30 Y

BISOPROLOL HEXAL 10MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 707393001 30 Y

ZIAPRO 5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 715274001 30 Y

ZIAPRO 10MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 715276001 30 Y

BISOPROLOL UNICORN 10MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 716166001 30 Y

BISOPROLOL UNICORN 5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 716167001 30 Y

BISLO 5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 719154001 30 Y

BISLO 10MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 719155001 30 Y

BISOZYD 5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 720043001 30 Y

BISOZYD 10MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 720044001 30 Y

BISBETA 5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 720659001 30 Y

BISBETA 10MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 720660001 30 Y

RETOCAR 5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 720820001 30 Y

RETOCAR 10MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 720821001 30 Y

MYLAN BISOPROLOL 5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 721437001 30 Y

of 53


PRE-AUTH REQUIRED

MYLAN BISOPROLOL 10MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 721438001 30 Y

BISOPROLOL UNICHEM 5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 722055001 30 Y

BISOPROLOL UNICHEM 10MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 722056001 30 Y

CONCOR 5MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 818429003 30 Y

CONCOR 10MG TABS BISOPROLOL FUMARATE TABS OTHER BETA-RECEPTOR BLOCKERS 818437006 30 Y

ALPHAGAN PURITE 1.5MG/1ML 5ML BRIMONIDINE TARTRATE OPHTH SOLN 0.15% ALPHA AGONISTS FOR GLAUCOMA 709410001 1 Y

BRIMOCT 2MG/1ML OPHTH DRP 5ML BRIMONIDINE TARTRATE OPHTH SOLN 0.2% ALPHA AGONISTS FOR GLAUCOMA 721293001 1 Y

COMBIGAN 2MG/5MG 5ML OPD BRIMONIDINE TARTRATE-TIMOLOL MALEATE OPHTH SOLN 0. COMBINATION ALPHA AG/BETA BLOC 709863001 1 Y

AKINETON 2MG TABS BRINZOLAMIDE OPHTH SUSP 1% ANTI-PARKINSON ANTI-CHOLINERGICS 701491027 500 Y

AZOPTIC 5ML EYE SUSPENSION BRINZOLAMIDE OPHTH SUSP 1% CARBONIC ANHYDRASE INHIBITORS FOR GLAUCOMA 701523001 1 Y

AZARGA DROPS 5ML BRINZOLAMIDE-TIMOLOL OPHTH SUSP 1-0.5% COMBINATION BETA BLOCKER/CAI FOR GLAUCOMA 717260001 1 Y

BURINEX 1MG TABS BUMETANIDE TAB 1 MG LOOP DIURETICS 711152004 100 Y

BURINEX 1MG TABS BUMETANIDE TAB 1 MG LOOP DIURETICS 711152005 30 Y

PHOSPHOSORB 660 TABS CALCIUM ACETATE (PHOSPHATE BINDER) TAB 667 MG OTHER CHELATING AGENTS/ION EXCHANGE PREPARATIONS 718735001 200 Y

MYLACAND 16MG TABS CANDESARTAN CILEXETIL TAB 16 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 719210001 30 Y

CANDAGEN 16MG TABS CANDESARTAN CILEXETIL TAB 16 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 720319001 30 Y

ABECARD 16MG TABS CANDESARTAN CILEXETIL TAB 16 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 721630001 30 Y

ATERWIN 16MG TABS CANDESARTAN CILEXETIL TAB 16 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 723124001 30 Y

ATACAND 16MG TABS CANDESARTAN CILEXETIL TAB 16 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 856118002 28 Y




MYLACAND 8MG TABS CANDESARTAN CILEXETIL TAB 8 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 719209001 30 Y

CANDAGEN 8MG TABS CANDESARTAN CILEXETIL TAB 8 MG SINGLE ANGIOTENSIN RECEPTOR 720318001 30 Y

of 53


PRE-AUTH REQUIRED

ANTAGONISTS




ATACAND PLUS 32/12.5MG TABS CANDESARTAN CILEXETIL-HYDROCHL ARB/DIURETIC COMBINATIONS 717580001 28 Y

ATACAND PLUS 32/25MG TABS CANDESARTAN CILEXETIL-HYDROCHL ARB/DIURETIC COMBINATIONS 717723001 28 Y

CANDEPRES PLUS 16MG/12.5MG CANDESARTAN CILEXETIL-HYDROCHL ARB/DIURETIC COMBINATIONS 719453001 30 Y

MYLACAND PLUS 16MG/12.5MG CANDESARTAN CILEXETIL-HYDROCHL ARB/DIURETIC COMBINATIONS 719506001 30 Y

ATACAND PLUS 16/12.5MG TABS CANDESARTAN CILEXETIL-HYDROCHL ARB/DIURETIC COMBINATIONS 898635005 28 Y

ZAPTO-CO TABS CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 50-25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 839795009 28 Y

CAPTOHEXAL 12.5MG TABS CAPTOPRIL TAB 12.5 MG SINGLE ACE INHIBITORS 837628008 100 Y

CAPACE 25MG TABS CAPTOPRIL TAB 25 MG SINGLE ACE INHIBITORS 795267002 60 Y

CAPTOMAX 25MG TABS CAPTOPRIL TAB 25 MG SINGLE ACE INHIBITORS 836451007 60 Y


CAPTOHEXAL 25MG TABS CAPTOPRIL TAB 25 MG SINGLE ACE INHIBITORS 837636019 60 Y

ZAPTO 25MG TABS CAPTOPRIL TAB 25 MG SINGLE ACE INHIBITORS 839779003 60 Y

SANDOZ CAPTOPRIL 25MG TABS CAPTOPRIL TAB 25 MG SINGLE ACE INHIBITORS 850896002 60 Y

ACETEN 25MG TABS CAPTOPRIL TAB 25 MG SINGLE ACE INHIBITORS 852333005 60 Y

MYLAN CAPTOPRIL 25MG TABS CAPTOPRIL TAB 25 MG SINGLE ACE INHIBITORS 852619006 60 Y



CAPTOHEXAL 50MG TABS CAPTOPRIL TAB 50 MG SINGLE ACE INHIBITORS 837644003 60 Y

ZAPTO 50MG TABS CAPTOPRIL TAB 50 MG SINGLE ACE INHIBITORS 839787006 60 Y

SANDOZ CAPTOPRIL 50MG TABS CAPTOPRIL TAB 50 MG SINGLE ACE INHIBITORS 850918006 60 Y

MYLAN CAPTOPRIL 50MG TABS CAPTOPRIL TAB 50 MG SINGLE ACE INHIBITORS 899429009 60 Y

TEGRETOL 100MG/5ML SUSP CARBAMAZEPINE SUSP 100 MG/5ML CARBAMAZEPINE 769401007 250 Y

DEGRANOL 200MG TABS CARBAMAZEPINE TAB 200 MG CARBAMAZEPINE 712493018 100 Y

SANDOZ CARBAMAZEPINE 200MG CARBAMAZEPINE TAB 200 MG CARBAMAZEPINE 712523006 100 Y

ZEPTOL 200MG TABS CARBAMAZEPINE TAB 200 MG CARBAMAZEPINE 715962001 50 Y

ZEPTOL 200MG TABS CARBAMAZEPINE TAB 200 MG CARBAMAZEPINE 715962002 100 Y

TEGRETOL 200MG TABS CARBAMAZEPINE TAB 200 MG CARBAMAZEPINE 769398007 50 Y

SANDOZ CARBAMAZEPINE CR 200MG CARBAMAZEPINE TAB ER 12HR 200 MG CARBAMAZEPINE 705597001 30 Y

TEGRETOL CR 200MG TABS CARBAMAZEPINE TAB ER 12HR 200 MG CARBAMAZEPINE 779652002 30 Y

SANDOZ CARBAMAZEPINE CR 400MG CARBAMAZEPINE TAB ER 12HR 400 MG CARBAMAZEPINE 705602001 30 Y

of 53


PRE-AUTH REQUIRED

TEGRETOL CR 400MG TABS CARBAMAZEPINE TAB ER 12HR 400 MG CARBAMAZEPINE 779660005 30 Y

TEVA CARBI-LEVO 25/100 TABS CARBIDOPA & LEVODOPA TAB 25-100 MG ANTI-PARKINSON DOPAMINERGICS 710286001 100 Y

TEVA CARBI-LEVO 25/250 TABS CARBIDOPA & LEVODOPA TAB 25-250 MG ANTI-PARKINSON DOPAMINERGICS 710468001 100 Y

SINEMET 25/100 TABS CARBIDOPA-LEVODOPA ANTI-PARKINSON DOPAMINERGICS 764078003 100 Y

SINEMET 25/250 TABS CARBIDOPA-LEVODOPA ANTI-PARKINSON DOPAMINERGICS 764086006 100 Y

SINEMET CR 50/200MG TABS CARBIDOPA-LEVODOPA ANTI-PARKINSON DOPAMINERGICS 794635008 100 Y

CARBILEV 25/100 TABS CARBIDOPA-LEVODOPA ANTI-PARKINSON DOPAMINERGICS 824321006 100 Y

CARBILEV 25/250 TABS CARBIDOPA-LEVODOPA ANTI-PARKINSON DOPAMINERGICS 824348001 100 Y

LECARDOP 25/100MG TABS CARBIDOPA-LEVODOPA ANTI-PARKINSON DOPAMINERGICS 3000000001 100 Y

LECARDOP 25/250MG TABS CARBIDOPA-LEVODOPA ANTI-PARKINSON DOPAMINERGICS 3000001001 100 Y

STALEVO 50/12.5 TABS CARBIDOPA-LEVODOPA-ENTACAPONE TABS 12.5-50-200 MG OTHER ANTI-PARKINSON AGENTS 707999001 100 Y

STALEVO 100/25MG TABS CARBIDOPA-LEVODOPA-ENTACAPONE TABS 25-100-200 MG OTHER ANTI-PARKINSON AGENTS 708000001 100 Y

STALEVO 150/37.5 TABS CARBIDOPA-LEVODOPA-ENTACAPONE TABS 37.5-150-200 MG OTHER ANTI-PARKINSON AGENTS 708001001 100 Y

TEOPTIC EYE DROPS 5ML CARTEOLOL HCL OPHTH SOLN 2% BETA BLOCKERS FOR GLAUCOMA 834335018 1

CARLOC 12.5MG TABS CARVEDILOL TAB 12.5 MG ALPHA/BETA-RECEPTOR BLOCKERS 700168001 30 Y

CARVETREND 12.5MG TABS CARVEDILOL TAB 12.5 MG ALPHA/BETA-RECEPTOR BLOCKERS 704671001 30 Y

CARVEDILOL-HEXAL 12.5MG TABS CARVEDILOL TAB 12.5 MG ALPHA/BETA-RECEPTOR BLOCKERS 705770001 30 Y

ASPEN-CARVEDILOL 12.5MG TABS CARVEDILOL TAB 12.5 MG ALPHA/BETA-RECEPTOR BLOCKERS 710339001 30 Y

VEDIBLOK 12.5MG TABS CARVEDILOL TAB 12.5 MG ALPHA/BETA-RECEPTOR BLOCKERS 710959001 30 Y

CARVEDILOL UNICORN 12.5MG TABS CARVEDILOL TAB 12.5 MG ALPHA/BETA-RECEPTOR BLOCKERS 716743001 30 Y

DILATREND 12.5MG TABS CARVEDILOL TAB 12.5 MG ALPHA/BETA-RECEPTOR BLOCKERS 836354001 30 Y

CARVETREND 25MG TABS CARVEDILOL TAB 25 MG ALPHA/BETA-RECEPTOR BLOCKERS 704672001 30 Y

CARVEDILOL-HEXAL 25MG TABS CARVEDILOL TAB 25 MG ALPHA/BETA-RECEPTOR BLOCKERS 705767001 30 Y

ASPEN-CARVEDILOL 25MG TABS CARVEDILOL TAB 25 MG ALPHA/BETA-RECEPTOR BLOCKERS 710340001 30 Y

VEDIBLOK 25MG TABS CARVEDILOL TAB 25 MG ALPHA/BETA-RECEPTOR BLOCKERS 710960001 30 Y

CARVEDILOL UNICORN 25MG TABS CARVEDILOL TAB 25 MG ALPHA/BETA-RECEPTOR BLOCKERS 716744001 30 Y

DILATREND 25MG TABS CARVEDILOL TAB 25 MG ALPHA/BETA-RECEPTOR BLOCKERS 788856006 30 Y

CARLOC 25MG TABS CARVEDILOL TAB 25 MG ALPHA/BETA-RECEPTOR BLOCKERS 897117006 30 Y

CARVETREND 6.25MG TABS CARVEDILOL TAB 6.25 MG ALPHA/BETA-RECEPTOR BLOCKERS 704670001 30 Y

CARLOC 6.25MG TABS CARVEDILOL TAB 6.25 MG ALPHA/BETA-RECEPTOR BLOCKERS 705459001 30 Y

CARVEDILOL-HEXAL 6.25MG TABS CARVEDILOL TAB 6.25 MG ALPHA/BETA-RECEPTOR BLOCKERS 705749001 30 Y

ASPEN-CARVEDILOL 6.25MG TABS CARVEDILOL TAB 6.25 MG ALPHA/BETA-RECEPTOR BLOCKERS 710338001 30 Y

VEDIBLOK 6.25MG TABS CARVEDILOL TAB 6.25 MG ALPHA/BETA-RECEPTOR BLOCKERS 710958001 30 Y

CARVEDILOL UNICORN 6.25MG TABS CARVEDILOL TAB 6.25 MG ALPHA/BETA-RECEPTOR BLOCKERS 716742001 30 Y

of 53


PRE-AUTH REQUIRED

DILATREND 6.25MG TABS CARVEDILOL TAB 6.25 MG ALPHA/BETA-RECEPTOR BLOCKERS 833428004 30 Y

LARGACTIL 100MG TABS CHLORPROMAZINE HCL TAB 100 MG PHENOTHIAZINES 735884006 56 Y




HYGROTON 50MG TABS CHLORTHALIDONE TAB 50 MG THIAZIDE/RELATED DIURETICS 731919009 30 Y

INHIBACE 5MG TABS CILAZAPRIL TAB 5 MG SINGLE ACE INHIBITORS 792756002 28 Y

INHIBACE PLUS TABS CILAZAPRIL-HYDROCHLOROTHIAZIDE TAB 5-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 815055005 28 Y

CLOMENT 100MG TABS CLOZAPINE TAB 100 MG ATYPICAL ANTI-PSYCHOTICS 700178001 100 Y

ASPEN CLOZAPINE 100MG TABS CLOZAPINE TAB 100 MG ATYPICAL ANTI-PSYCHOTICS 717082001 100 Y

LEPONEX 100MG TABS CLOZAPINE TAB 100 MG ATYPICAL ANTI-PSYCHOTICS 736716009 100 Y

CLOMENT 25MG TABS CLOZAPINE TAB 25 MG ATYPICAL ANTI-PSYCHOTICS 700176001 100 Y

ASPEN CLOZAPINE 25MG TABS CLOZAPINE TAB 25 MG ATYPICAL ANTI-PSYCHOTICS 717081001 100 Y

LEPONEX 25MG TABS CLOZAPINE TAB 25 MG ATYPICAL ANTI-PSYCHOTICS 736708006 100 Y

OCTANINE F VIAL 30ML 1000IU COAGULATION FACTOR IX FOR INJ 1000 UNIT PARENTERAL HAEMOSTATICS 713099001 1 Y

OCTANINE F 30ML VIAL 250IU COAGULATION FACTOR IX FOR INJ 250 UNIT PARENTERAL HAEMOSTATICS 713054001 1 Y

OCTANINE F 30ML VIAL 500IU COAGULATION FACTOR IX FOR INJ 500 UNIT PARENTERAL HAEMOSTATICS 713100001 1 Y

HAEMOSOLVEX FACTOR IX 500U COAGULATION FACTOR IX FOR INJ 500-1500 UNIT PARENTERAL HAEMOSTATICS 800767004 1 Y

PRADAXA 110MG CAPS DABIGATRAN ETEXILATE MESYLATE CAP 110 MG (ETEXILAT) ORAL ANTI-COAGULANTS 714547001 30 Y



PRADAXA 75MG CAPS DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE) ORAL ANTI-COAGULANTS 714548001 30 Y

PRADAXA 75MG CAPS DABIGATRAN ETEXILATE MESYLATE CAP 75 MG (ETEXILATE) ORAL ANTI-COAGULANTS 714548002 60 Y

LANOXIN 0.05MG/ML SYRP PAED DIGOXIN ELIXIR 0.05 MG/ML CARDIAC GLYCOSIDES 735744009 50 Y

LANOXIN 0.05MG/ML SYRP PAED DIGOXIN ELIXIR 0.05 MG/ML CARDIAC GLYCOSIDES 735744010 60 Y

LANOXIN 0.25MG TABS DIGOXIN TAB 250 MCG (0.25 MG) CARDIAC GLYCOSIDES 735752001 100 Y



PURGOXIN 0.25MG TABS DIGOXIN TAB 250 MCG (0.25 MG) CARDIAC GLYCOSIDES 758272014 100 Y

PURGOXIN 0.25MG TABS DIGOXIN TAB 250 MCG (0.25 MG) CARDIAC GLYCOSIDES 758280009 1000 Y

LANOXIN 0.0625MG TABS DIGOXIN TAB 62.5 MCG (0.0625 MG) CARDIAC GLYCOSIDES 735760004 100 Y

LANOXIN 0.0625MG TABS DIGOXIN TAB 62.5 MCG (0.0625 MG) CARDIAC GLYCOSIDES 735760005 120 Y

of 53


PRE-AUTH REQUIRED

TILAZEM 180 CR CAPS DILTIAZEM HCL CAP SR 24HR 180 MG CALCIUM CHANNEL BLOCKERS 813125006 30 Y

ADCO-ZILDEM 180MG SR CAPS DILTIAZEM HCL CAP SR 24HR 180 MG CALCIUM CHANNEL BLOCKERS 839183003 30 Y

ADCO-ZILDEM 240MG SR CAPS DILTIAZEM HCL CAP SR 24HR 240 MG CALCIUM CHANNEL BLOCKERS 839191006 30 Y

ADCO-ZILDEM 60MG TABS DILTIAZEM HCL TAB 60 MG CALCIUM CHANNEL BLOCKERS 822213001 50 Y

ADCO-ZILDEM 60MG TABS DILTIAZEM HCL TAB 60 MG CALCIUM CHANNEL BLOCKERS 822213029 60 Y

ZILDEM 90MG TABS DILTIAZEM HCL TAB 90 MG CALCIUM CHANNEL BLOCKERS 824364007 60 Y

TILAZEM 240 CR TABS DILTIAZEM HCL TAB SR 24HR 240 MG CALCIUM CHANNEL BLOCKERS 813133009 30 Y

RYTHMODAN 100MG CAPS DISOPYRAMIDE PHOSPHATE CAP 100 MG ANTI-ARRHYTHMICS 761419015 100 Y

GLAUCOPRESS 2% OPHT DRP 5ML DORZOLAMIDE HCL OPHTH SOLN 2% CARBONIC ANHYDRASE INHIBITORS FOR GLAUCOMA 720983001 1 Y

TRUSOPT 2% 5ML EYE DRP DORZOLAMIDE HCL OPHTH SOLN 2% CARBONIC ANHYDRASE INHIBITORS FOR GLAUCOMA 819832006 1 Y

GLAUMIDE-CO 5ML DRP DORZOLAMIDE-TIMOLOL OPHTH SOLN 2-0.5% (BASE EQUIV)

COMBINATION BETA BLOCKER/CAI FOR GLAUCOMA 721902001 1 Y

GLAUOPT CO 5ML OPHTHAL DRP DORZOLAMIDE-TIMOLOL OPHTH SOLN 2-0.5% (BASE EQUIV)

CARBONIC ANHYDRASE INHIBITORS FOR GLAUCOMA 721977001 1 Y

COSOPT 5ML DROPS DORZOLAMIDE-TIMOLOL OPHTH SOLN 2-0.5% (BASE EQUIV)


OCUDOR CO 5ML DROPS DORZOLAMIDE-TIMOLOL OPHTH SOLN 2-0.5% (BASE EQUIV)


CARDUGEN 1MG TABS DOXAZOSIN MESYLATE TAB 1 MG ALPHA-RECEPTOR BLOCKERS FOR HT/BPH 701425001 30 Y

ADCO-DOXAZOSIN 1MG TABS DOXAZOSIN MESYLATE TAB 1 MG ALPHA-RECEPTOR BLOCKERS FOR HT/BPH 701626001 30 Y


CARDUGEN 4MG TABS DOXAZOSIN MESYLATE TAB 4 MG ALPHA-RECEPTOR BLOCKERS FOR HT/BPH 701426001 30 Y


CARZIN XL 4MG TABS DOXAZOSIN MESYLATE TAB ER 4 MG ALPHA-RECEPTOR BLOCKERS FOR HT/BPH 714292001 30 Y

CARDURA XL 4MG TABS DOXAZOSIN MESYLATE TAB ER 4 MG ALPHA-RECEPTOR BLOCKERS FOR HT/BPH 869856006 30 Y

CARDURA XL 8MG TABS DOXAZOSIN MESYLATE TAB ER 8 MG ALPHA-RECEPTOR BLOCKERS FOR HT/BPH 869864009 30 Y

JARDIANCE 10MG TABS EMPAGLIFLOZIN TAB 10 MG SGLT2 INHIBITORS 720929001 30 Y




CO-RENITEC TABS ENALAPRIL MALEATE & HCTZ ACE INHIBITOR/DIURETIC COMBINATIONS 787035009 28 Y

PHARMAPRESS CO TABS ENALAPRIL MALEATE & HCTZ ACE INHIBITOR/DIURETIC COMBINATIONS 885019005 30 Y

ENAP CO 20MG/12.5MG TABS ENALAPRIL MALEATE & HCTZ ACE INHIBITOR/DIURETIC COMBINATIONS 891287008 30 Y

ENVAS 10MG TABS ENALAPRIL MALEATE TAB 10 MG SINGLE ACE INHIBITORS 712763001 30 Y

AUSTELL ENALAPRIL 10MG TABS ENALAPRIL MALEATE TAB 10 MG SINGLE ACE INHIBITORS 721626001 30 Y

of 53


PRE-AUTH REQUIRED

ENALAPRIL BIOTECH 10MG TABS ENALAPRIL MALEATE TAB 10 MG SINGLE ACE INHIBITORS 723157001 30 Y

RENITEC 10MG TABS ENALAPRIL MALEATE TAB 10 MG SINGLE ACE INHIBITORS 759767009 28 Y

HR-ENALAPRIL 10MG TABS ENALAPRIL MALEATE TAB 10 MG SINGLE ACE INHIBITORS 867853018 30 Y

PHARMAPRESS 10MG TABS ENALAPRIL MALEATE TAB 10 MG SINGLE ACE INHIBITORS 868914002 30 Y

ALAPREN 10MG TABS ENALAPRIL MALEATE TAB 10 MG SINGLE ACE INHIBITORS 881481009 28 Y

ADCO-ENALAPRIL 10MG TABS ENALAPRIL MALEATE TAB 10 MG SINGLE ACE INHIBITORS 886843001 28 Y

ENAP 10MG TABS ENALAPRIL MALEATE TAB 10 MG SINGLE ACE INHIBITORS 891279005 30 Y

CIPLATEC 10MG TABS ENALAPRIL MALEATE TAB 10 MG SINGLE ACE INHIBITORS 894324008 30 Y










ENVAS 5MG TABS ENALAPRIL MALEATE TAB 5 MG SINGLE ACE INHIBITORS 712762001 30 Y




HYPACE 5MG TABS ENALAPRIL MALEATE TAB 5 MG SINGLE ACE INHIBITORS 862622034 200 Y





CIPLATEC 5MG TABS ENALAPRIL MALEATE TAB 5 MG SINGLE ACE INHIBITORS 894316006 30 Y

ZANERIL 10MG/10MG TABS ENALAPRIL MALEATE-LERCANIDIPINE TAB 10-10 MG CALCIUM CHANNEL BLOCKERS 711444001 28 Y

ZANERIL 10MG/20MG TABS ENALAPRIL MALEATE-LERCANIDIPINE TAB 10-20 MG CALCIUM CHANNEL BLOCKERS 711445001 28 Y

RENITEC 2.5MG TABS ENALAPRIL TAB 2.5 MG SINGLE ACE INHIBITORS 810355019 14 Y

COMTAN 200MG TABS ENTACAPONE TAB 200 MG OTHER ANTI-PARKINSON AGENTS 868590002 100 Y

INSPRA 25MG TABS EPLERENONE TAB 25 MG POTASSIUM SPARING DIURETICS 706121001 30 Y



TEVETEN 600 EPROSARTAN MESYLATE TAB 600 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 701855001 28

TEVETEN PLUS 600MG/12.5MG EPROSARTAN MESYLATE-HYDROCHLOR ARB/DIURETIC COMBINATIONS 708096001 28 Y

of 53


PRE-AUTH REQUIRED

ZARONTIN SYR ETHOSUXIMIDE SOLN 250 MG/5ML OTHER ANTI-EPILEPTICS 779105001 200 Y

BYETTA 2.4ML DISP PEN 10MCG D EXENATIDE SOLN PEN-INJECTOR 10 MCG/0.04ML GLP-1 AGONISTS (WAS OTHER ANTI-DIABETIC) 711684001 1 Y

BYETTA 1.2ML DISP PEN 5MCG D EXENATIDE SOLN PEN-INJECTOR 5 MCG/0.02ML GLP-1 AGONISTS (WAS OTHER ANTI-DIABETIC) 711678001 1 Y

EZETROL 10MG TABS EZETIMIBE TAB 10 MG OTHER HYPERLIPIDAEMIC AGENTS 704378001 30 Y

INEGY 10/10 MG TABS EZETIMIBE-SIMVASTATIN TAB 10-10 MG HMG-COA REDUCTASE INHIBITORS 715237001 30 Y



FELODIPINE-HEXAL 10MG TABS FELODIPINE TAB ER 24HR 10 MG CALCIUM CHANNEL BLOCKERS 703902001 30 Y

PLENDIL 2.5MG TABS FELODIPINE TAB ER 24HR 2.5 MG CALCIUM CHANNEL BLOCKERS 821896008 30 Y

FELODIPINE-HEXAL 5MG TABS FELODIPINE TAB ER 24HR 5 MG CALCIUM CHANNEL BLOCKERS 703221001 30 Y

PLENDIL 5MG TABS FELODIPINE TAB ER 24HR 5 MG CALCIUM CHANNEL BLOCKERS 805548009 30 Y

LIPANTHYL 200MG CAPS FENOFIBRATE MICRONIZED CAP 200 MG FIBRATES 705708001 30 Y

TAMBOCOR CR 100MG CAPS FLECAINIDE ACETATE CAP SR 24HR 100 MG ANTI-ARRHYTHMICS 717802001 30 Y

TAMBOCOR CR 200MG CAPS FLECAINIDE ACETATE CAP SR 24HR 200 MG ANTI-ARRHYTHMICS 717803001 30 Y

TAMBOCOR 100MG TABS FLECAINIDE ACETATE TAB 100 MG ANTI-ARRHYTHMICS 813915007 60 Y

FLUANXOL DEP 20MG/1ML INJ FLUPENTIXOL DECANOATE IM SOLN 20 MG/ML OTHER ANTI-PSYCHOTICS 726672009 1 Y

FLUANXOL DEP 20MG/1ML INJ FLUPENTIXOL DECANOATE IM SOLN 20 MG/ML OTHER ANTI-PSYCHOTICS 726672025 5 Y

MODECATE 25MG INJ 1ML FLUPHENAZINE DECANOATE INJ 25 MG/ML PHENOTHIAZINES 743666003 5 Y

MODECATE+SYRIN 25MG 1ML INJ FLUPHENAZINE DECANOATE INJ 25 MG/ML PHENOTHIAZINES 744301009 1 Y

MODECATE 25MG INJ 10ML FLUPHENAZINE DECANOATE INJ 25 MG/ML PHENOTHIAZINES 744328004 1 Y

LESCOL 20MG CAPS FLUVASTATIN SODIUM CAP 20 MG HMG-COA REDUCTASE INHIBITORS 813664004 28 Y

LESCOL 40MG CAPS FLUVASTATIN SODIUM CAP 40 MG HMG-COA REDUCTASE INHIBITORS 813672007 28 Y

LESCOL XL 80MG TABS FLUVASTATIN SODIUM TAB SR 24 HR 80 MG HMG-COA REDUCTASE INHIBITORS 700963002 28 Y

VATICOL XL 80MG TABS FLUVASTATIN SODIUM TAB SR 24 HR 80 MG HMG-COA REDUCTASE INHIBITORS 718208001 28 Y

MYLAN FOSINOPRIL 10MG TABS FOSINOPRIL SODIUM TAB 10 MG SINGLE ACE INHIBITORS 705450001 30 Y

MYLAN FOSINOPRIL 20MG TABS FOSINOPRIL SODIUM TAB 20 MG SINGLE ACE INHIBITORS 705453001 30 Y

MONOPRIL 20MG TABS FOSINOPRIL SODIUM TAB 20 MG SINGLE ACE INHIBITORS 791962016 30 Y

LASIX RET 60MG CAPS FUROSEMIDE CAP ER 60 MG LOOP DIURETICS 735973008 30 Y

LASIX ORAL SOL FUROSEMIDE ORAL SOLN 10 MG/ML LOOP DIURETICS 839515006 100 Y

AUSTELL-FUROSEMIDE 20MG TABS FUROSEMIDE TAB 20 MG LOOP DIURETICS 707421002 28 Y

LASIX 20MG TABS FUROSEMIDE TAB 20 MG LOOP DIURETICS 735930007 30 Y

DIURESIX 40MG TABS FUROSEMIDE TAB 40 MG LOOP DIURETICS 705967001 250 Y

AUSTELL-FUROSEMIDE 40MG TABS FUROSEMIDE TAB 40 MG LOOP DIURETICS 707423001 30 Y

DINO-RETIC 40MG TABS FUROSEMIDE TAB 40 MG LOOP DIURETICS 716048001 1000 Y


of 53


PRE-AUTH REQUIRED


SANDOZ FUROSEMIDE 40MG TABS FUROSEMIDE TAB 40 MG LOOP DIURETICS 731668006 30 Y






PURESIS 40MG TABS FUROSEMIDE TAB 40 MG LOOP DIURETICS 758167024 30 Y

PURESIS 40MG TABS FUROSEMIDE TAB 40 MG LOOP DIURETICS 758272006 250 Y

BEURESIS 40MG TABS FUROSEMIDE TAB 40 MG LOOP DIURETICS 821845012 250 Y

MYLAN FUROSEMIDE 40 MG TABS FUROSEMIDE TAB 40 MG LOOP DIURETICS 857769022 250 Y



EPLEPTIN 100MG CAPS GABAPENTIN CAP 100 MG OTHER ANTI-EPILEPTICS 707622001 100 Y

NEUREXAL 100MG CAPS GABAPENTIN CAP 100 MG OTHER ANTI-EPILEPTICS 708949001 100 Y

RAN-GABAPENTIN 100MG CAPS GABAPENTIN CAP 100 MG OTHER ANTI-EPILEPTICS 710525001 100 Y

BIOTECH GABAPENTIN 100MG CAPS GABAPENTIN CAP 100 MG OTHER ANTI-EPILEPTICS 721740001 100 Y

EPIGAB 100MG CAPS GABAPENTIN CAP 100 MG OTHER ANTI-EPILEPTICS 722865001 100 Y

NEURONTIN 100MG CAPS GABAPENTIN CAP 100 MG OTHER ANTI-EPILEPTICS 807443018 100 Y













NEURONTIN 600MG TABS GABAPENTIN TABS OTHER ANTI-EPILEPTICS 705262001 100 Y

NEURONTIN 800MG TABS GABAPENTIN TABS OTHER ANTI-EPILEPTICS 705263001 100 Y

LOPID 600MG TABS GEMFIBROZIL TAB 600 MG FIBRATES 788627007 60 Y

AUSTELL-GLICLAZIDE 40MG TABS GLICLAZIDE TAB 40 MG SULFONYLUREAS 705759001 30 Y

MYLAN GLICLAZIDE 80MG TABS GLICLAZIDE TAB 80 MG SULFONYLUREAS 700639003 60 Y

GLYGARD 80MG TABS GLICLAZIDE TAB 80 MG SULFONYLUREAS 700717003 60 Y

of 53


PRE-AUTH REQUIRED

AUSTELL-GLICLAZIDE 80MG TABS GLICLAZIDE TAB 80 MG SULFONYLUREAS 705760001 60 Y

GLYCOBETA 80MG TABS GLICLAZIDE TAB 80 MG SULFONYLUREAS 707587001 60 Y

ARROW GLICLAZIDE 80MG TABS GLICLAZIDE TAB 80 MG SULFONYLUREAS 709538001 60 Y

GLICLAZIDE UNICORN 80 GLICLAZIDE TAB 80 MG SULFONYLUREAS 719463009 60 Y

DIAGLUMED 80MG TABS GLICLAZIDE TAB 80 MG SULFONYLUREAS 720665001 60 Y

GLUCOMED 80MG TABS GLICLAZIDE TAB 80 MG SULFONYLUREAS 834599007 60 Y

GLUCOMED 80MG TABS GLICLAZIDE TAB 80 MG SULFONYLUREAS 834599015 500 Y

SANDOZ GLICLAZIDE 80MG TABS GLICLAZIDE TAB 80 MG SULFONYLUREAS 834866005 60 Y

SANDOZ GLICLAZIDE 80MG TABS GLICLAZIDE TAB 80 MG SULFONYLUREAS 834866014 504 Y

GLYCRON 80MG TABS GLICLAZIDE TAB 80 MG SULFONYLUREAS 838209009 60 Y

DIAGLUCIDE 80MG TABS GLICLAZIDE TAB 80 MG SULFONYLUREAS 868906018 60 Y

DIAMICRON MR 30MG TABS GLICLAZIDE TAB ER 24HR 30 MG SULFONYLUREAS 702923001 60 Y

DIAGLUCIDE MR 30MG TABS GLICLAZIDE TAB ER 24HR 30 MG SULFONYLUREAS 714582001 60 Y

DIARAN MR 30MG TABS GLICLAZIDE TAB ER 24HR 30 MG SULFONYLUREAS 714909001 60 Y

DYNA GLICLAZIDE SR 30MG TABS GLICLAZIDE TAB ER 24HR 30 MG SULFONYLUREAS 716953001 60 Y

DIAMICRON MR 60MG TABS GLICLAZIDE TAB ER 24HR 60 MG SULFONYLUREAS 718245001 30 Y

DIAGLUCIDE MR 60MG TABS GLICLAZIDE TAB ER 24HR 60 MG SULFONYLUREAS 718247001 30 Y

GLAMARYL 1MG TABS GLIMEPIRIDE TAB 1 MG SULFONYLUREAS 704362001 30 Y

SANDOZ GLIMEPIRIDE 1MG TABS GLIMEPIRIDE TAB 1 MG SULFONYLUREAS 704673001 30 Y

MYLAN GLIMEPIRIDE 1MG TABS GLIMEPIRIDE TAB 1 MG SULFONYLUREAS 709984001 30 Y

EUGLIM 1GM TABS GLIMEPIRIDE TAB 1 MG SULFONYLUREAS 710207001 30 Y

SULPHONUR 1MG TABS GLIMEPIRIDE TAB 1 MG SULFONYLUREAS 710904001 30 Y

ZYDUS-GLIMEPIRIDE 1MG TABS GLIMEPIRIDE TAB 1 MG SULFONYLUREAS 711908001 30 Y

ASPEN GLIMEPIRIDE 1MG TABS GLIMEPIRIDE TAB 1 MG SULFONYLUREAS 714854001 30 Y

ACCORD GLIMEPIRIDE 1MG TABS GLIMEPIRIDE TAB 1 MG SULFONYLUREAS 716714001 30 Y

AUSTELL GLIMEPIRIDE 1MG TABS GLIMEPIRIDE TAB 1 MG SULFONYLUREAS 717076001 30 Y

AMARYL 1MG TABS GLIMEPIRIDE TAB 1 MG SULFONYLUREAS 831557001 30 Y




EUGLIM 2MG TABS GLIMEPIRIDE TAB 2 MG SULFONYLUREAS 710208001 30 Y







of 53


PRE-AUTH REQUIRED




EUGLIM 4MG TABS GLIMEPIRIDE TAB 4 MG SULFONYLUREAS 710209001 30 Y







AMARYL COMBI 2MG/500MG TABS GLIMEPIRIDE-METFORMIN HCL TAB 2-500 MG METFORMIN/SULFONYLUREA COMBINATIONS 718106001 30 Y

MINIDIAB 5MG TABS GLIPIZIDE TAB 5 MG SULFONYLUREAS 739928007 100 Y

SEEBRI BREEZHALER 30 CAPS & IN GLYCOPYRROLATE INHAL CAP 50 MCG ANTICHOLINERGICS FOR COPD 721596001 1 Y

SERENACE 0.5MG CAPS HALOPERIDOL CAP 0.5 MG BUTYROPHENONES 763411019 60 Y

SANDOZ HALOPERIDOL 1.5MG TABS HALOPERIDOL TAB 1.5 MG BUTYROPHENONES 730335003 60 Y

SERENACE 10MG TABS HALOPERIDOL TAB 10 MG BUTYROPHENONES 763535001 100 Y

GULF HALOPERIDOL 5MG TABS HALOPERIDOL TAB 5 MG BUTYROPHENONES 719549001 100 Y

SANDOZ HALOPERIDOL 5MG TABS HALOPERIDOL TAB 5 MG BUTYROPHENONES 730327019 30 Y



SERENACE 5MG TABS HALOPERIDOL TAB 5 MG BUTYROPHENONES 763454001 100 Y

HYPERPHEN 10MG TABS HYDRALAZINE HCL TAB 10 MG DIRECT ACTING VASODILATORS 731714008 100 Y

SANDOZ HYDRALAZINE 25MG TABS HYDRALAZINE HCL TAB 25 MG DIRECT ACTING VASODILATORS 759783004 30 Y











RIDAQ 12.5MG TABS HYDROCHLOROTHIAZIDE TAB 12.5 MG THIAZIDE/RELATED DIURETICS 710437001 30 Y

RIDAQ 25MG TABS HYDROCHLOROTHIAZIDE TAB 25 MG THIAZIDE/RELATED DIURETICS 880949007 500 Y

HEXAZIDE 25MG TABS HYDROCHLOROTHIAZIDE TAB 25 MG THIAZIDE/RELATED DIURETICS 890470007 100 Y

of 53


PRE-AUTH REQUIRED

URIREX-K TABS HYDROCHLOROTHIAZIDE-POTASSIUM CHLORIDE TAB 50-300 DIURETIC COMBINATIONS 774057009 1000 Y

ONBREZ BREEZHALER 30 CAPS & IN INDACATEROL MALEATE INHAL POWDER CAP 150 MCG (BASE) BRONCHIAL/UTERINE SYMPATHOMIMETICS 717402001 1 Y

CATEXAN 2.5MG TABS INDAPAMIDE TAB 2.5 MG THIAZIDE/RELATED DIURETICS 700820005 30 Y

MYLAN INDAPAMIDE 2.5 TABS INDAPAMIDE TAB 2.5 MG THIAZIDE/RELATED DIURETICS 703329001 30 Y

MYLAN INDAPAMIDE 2.5 TABS INDAPAMIDE TAB 2.5 MG THIAZIDE/RELATED DIURETICS 703329002 600 Y

CIPLA-INDAPAMIDE 2.5MG TABS INDAPAMIDE TAB 2.5 MG THIAZIDE/RELATED DIURETICS 710313001 30 Y

ADCO-DAPAMAX 2.5MG TABS INDAPAMIDE TAB 2.5 MG THIAZIDE/RELATED DIURETICS 819417009 30 Y



HYDRO-LESS 2.5MG TABS INDAPAMIDE TAB 2.5 MG THIAZIDE/RELATED DIURETICS 822825007 30 Y

SANDOZ INDAPAMIDE 2.5 TABS INDAPAMIDE TAB 2.5 MG THIAZIDE/RELATED DIURETICS 831026006 30 Y

DAPTRIL 2.5MG TABS INDAPAMIDE TAB 2.5 MG THIAZIDE/RELATED DIURETICS 833045008 30 Y

DAPTRIL 2.5MG TABS INDAPAMIDE TAB 2.5 MG THIAZIDE/RELATED DIURETICS 833045016 600 Y

DYNA INDAPAMIDE SR 1.5MG TABS INDAPAMIDE TAB CR 1.5 MG THIAZIDE/RELATED DIURETICS 716962001 30 Y

NATRILIX SR 1.5MG TABS INDAPAMIDE TAB CR 1.5 MG THIAZIDE/RELATED DIURETICS 830836004 30 Y

NOVORAPID 10ML INJ INSULIN ASPART INJ 100 UNIT/ML INSULINS 707927001 1 Y

NOVOMIX 30 FLEXPEN 3ML INSULIN ASPART PROT & ASPART SUS PEN-INJ 100 UNIT/ INSULINS 702086003 5 Y

NOVOMIX 30 PENFILL 3ML INSULIN ASPART PROT & ASPART SUSP CART 100 UNIT/ML INSULINS 702089003 5 Y

NOVORAPID PENFILL 3ML INSULIN ASPART SOLN CARTRIDGE 100 UNIT/ML INSULINS 897775004 5 Y

NOVORAPID FLEXPEN 3ML INSULIN ASPART SOLN PEN-INJECTOR 100 UNIT/ML INSULINS 897767001 5 Y

RYZODEG FLEXTOUCH 100IU/ML PRE INSULIN DEGLUDEC & ASPART SOLN PEN-INJ 100 UNIT/ML INSULINS 722292001 1 Y

RYZODEG FLEXTOUCH 100IU/ML PRE INSULIN DEGLUDEC & ASPART SOLN PEN-INJ 100 UNIT/ML INSULINS 722292002 5 Y

LEVEMIR 3ML PREFILLED CART INSULIN DETEMIR SOLN CARTRIDGE 100 UNIT/ML INSULINS 705313001 5 Y

LEVEMIR 3ML FLEXPEN INSULIN DETEMIR SOLN PEN-INJECTOR 100 UNIT/ML INSULINS 705312001 5 Y

LANTUS VIAL 1000IU/10ML INSULIN GLARGINE INJ 100 UNIT/ML INSULINS 700310001 1 Y

LANTUS CART 300IU/3ML INSULIN GLARGINE SOLN CARTRIDGE 100 UNIT/ML INSULINS 700308001 5 Y

BASAGLAR 100U/ML 3ML CARTRIDGE INSULIN GLARGINE SOLN CARTRIDGE 100 UNIT/ML INSULINS 722456001 5 Y

OPTISULIN CARTRIDGE 100IU/1ML INSULIN GLARGINE SOLN CARTRIDGE 100 UNIT/ML INSULINS 723474001 5 Y

LANTUS SOLOSTAR 100IU/ML 3ML INSULIN GLARGINE SOLN PEN-INJECTOR 100 UNIT/ML INSULINS 709860001 5 Y

OPTISULIN PEN 100IU/ML 3ML INJ INSULIN GLARGINE SOLN PEN-INJECTOR 100 UNIT/ML INSULINS 721502001 5 Y

BASAGLAR 100U/ML 3ML PREFILL INSULIN GLARGINE SOLN PEN-INJECTOR 100 UNIT/ML INSULINS 722454001 5 Y

of 53


PRE-AUTH REQUIRED

APIDRA 3ML CART INSULIN GLULISINE SOLN CARTRIDGE INJ 100 UNIT/ML INSULINS 706039001 5 Y

APIDRA SOLOSTAR DISP PEN 3ML INSULIN GLULISINE SOLN PEN-INJECTOR INJ 100 UNIT/M INSULINS 709861001 5 Y

APIDRA 10ML VIAL INSULIN GLULISINE SUBCUTANEOUS INJ 100 UNIT/ML INSULINS 706040001 1 Y

ACTRAPHANE 10ML INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100 UNIT/ML INSULINS 733512003 1 Y

HUMULIN 30/70 10ML VIAL INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100 UNIT/ML INSULINS 783811004 1 Y

BIOSULIN 30-70 CARTRIDGE INSULIN ISOPHANE & REGULAR SUSP CART 100 UNIT/ML INSULINS 712770001 5 Y

HUMULIN 30/70 CART 3ML INSULIN ISOPHANE & REGULAR SUSP CART 100 UNIT/ML INSULINS 863572006 5 Y

HUMULIN 30/70 KWIKPEN 3ML INSULIN ISOPHANE & REGULAR SUSP PEN-INJ 100 UNIT/M INSULINS 704456001 5 Y

INSUMAN COMB 30/70 3ML CART INSULIN ISOPHANE & REGULAR SUSP PEN-INJ 100 UNIT/M INSULINS 710299001 5 Y

ACTRAPHANE HM FLEXPEN 3ML INSULIN ISOPHANE & REGULAR SUSP PEN-INJ 100 UNIT/M INSULINS 714977001 5 Y

ACTRAPHANE PSET 3ML INSULIN ISOPHANE & REGULAR SUSP PEN-INJ 100 UNIT/M INSULINS 816213003 5 Y

HUMULIN N 10ML VIAL INSULIN ISOPHANE (HUMAN) INJ 100 UNIT/ML INSULINS 733458009 1 Y

PROTAPHANE 10ML VIAL INSULIN ISOPHANE (HUMAN) INJ 100 UNIT/ML INSULINS 733482007 1 Y

BIOSULIN N CARTRIDGE 3ML INSULIN ISOPHANE (HUMAN) SUSP CARTRIDGE 100 UNIT/M INSULINS 712768001 5 Y

HUMULIN N CART 3ML INSULIN ISOPHANE (HUMAN) SUSP CARTRIDGE 100 UNIT/M INSULINS 863556019 5 Y

PROTAPHANE FLEXPEN 3ML INSULIN ISOPHANE (HUMAN) SUSP PEN-INJECTOR 100 UNIT INSULINS 700183001 5 Y

HUMULIN N KWIKPEN 3ML INSULIN ISOPHANE (HUMAN) SUSP PEN-INJECTOR 100 UNIT INSULINS 853453004 5 Y

HUMALOG MIX25 10ML VIAL INSULIN LISPRO & LISPRO PROT (HUMAN) INJ 100 UNIT INSULINS 853437009 1 Y

HUMALOG 10ML INSULIN LISPRO (HUMAN) INJ 100 UNIT/ML INSULINS 819468002 1 Y

HUMALOG 3ML CARTRIDGE INSULIN LISPRO (HUMAN) INJ 100 UNIT/ML INSULINS 862355001 5 Y

HUMALOG KWIKPEN 100U/ML 3ML INSULIN LISPRO (HUMAN) SOLN PEN-INJECTOR 100 UNIT INSULINS 706760001 5 Y

HUMALOG MIX50 CART 3ML INSULIN LISPRO PROT & LISPRO SUS PEN-INJ 100 UNIT INSULINS 705074001 5 Y

of 53


PRE-AUTH REQUIRED

HUMALOG MIX 25 KWIKPEN INSULIN LISPRO PROT & LISPRO SUS PEN-INJ 100 UNIT INSULINS 706761001 5 Y

HUMALOG MIX 50 KWIKPEN INSULIN LISPRO PROT & LISPRO SUS PEN-INJ 100 UNIT INSULINS 706762001 5 Y

HUMALOG MIX25 CART 3ML INSULIN LISPRO PROT & LISPRO SUS PEN-INJ 100 UNIT INSULINS 861782003 5 Y

HUMULIN R 10ML VIAL INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML INSULINS 733431003 1 Y

BIOSULIN R CARTRIDGE 3ML INSULIN REGULAR (HUMAN) SOLN CARTRIDGE 100 UNIT/ML INSULINS 712767001 5 Y

HUMULIN R CART 3ML INSULIN REGULAR (HUMAN) SOLN CARTRIDGE 100 UNIT/ML INSULINS 863564003 5 Y

BIOSULIN L CARTRIDGE 3ML INSULIN ZINC (HUMAN) INJ 100 UNIT/ML INSULINS 712769001 5 Y

IRBEWIN 150MG TABS IRBESARTAN TAB 150 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 712385001 28 Y


DYNARB 150MG TABS IRBESARTAN TAB 150 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 717793001 30 Y

IRTANEL 150MG TABS IRBESARTAN TAB 150 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 718506001 28 Y

ADCO IRBESARTAN 150MG TABS IRBESARTAN TAB 150 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 718667001 28 Y

ISART 150MG TABS IRBESARTAN TAB 150 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 719162001 28 Y

ANTOSART 150MG TABS IRBESARTAN TAB 150 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 720582001 28 Y

JUBITAN 150MG TABS IRBESARTAN TAB 150 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 723194001 28 Y

APROVEL 150MG TABS IRBESARTAN TAB 150 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 837814006 28 Y



DYNARB 300MG TABS IRBESARTAN TAB 300 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 717794001 30 Y

IRTANEL 300MG TABS IRBESARTAN TAB 300 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 718507001 28 Y

ADCO IRBESARTAN 300MG TABS IRBESARTAN TAB 300 MG SINGLE ANGIOTENSIN RECEPTOR 718668001 28 Y

of 53


PRE-AUTH REQUIRED

ANTAGONISTS

ISART 300MG TABS IRBESARTAN TAB 300 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 719163001 28 Y

ANTOSART 300MG TABS IRBESARTAN TAB 300 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 720583001 28 Y

JUBITAN 300MG TABS IRBESARTAN TAB 300 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 723203001 28 Y

APROVEL 300MG TABS IRBESARTAN TAB 300 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 837822009 28 Y

CO-IRBEWIN 150/12.5MG TABS IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG ARB/DIURETIC COMBINATIONS 712386001 28 Y


ISART CO 150MG/12.5MG TABS IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG ARB/DIURETIC COMBINATIONS 718571001 28 Y

CO-APROVEL 150/12.5 TABS IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG ARB/DIURETIC COMBINATIONS 891353004 28 Y



ISART CO 300MG/12.5MG TABS IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG ARB/DIURETIC COMBINATIONS 718573001 28 Y

CO-APROVEL 300/12.5 TABS IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG ARB/DIURETIC COMBINATIONS 898597005 28 Y

CO-IRBEWIN 300/25MG TABS IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-25 MG ARB/DIURETIC COMBINATIONS 720930001 28 Y

ISORDIL 5MG SL TABS ISOSORBIDE DINITRATE SL TAB 5 MG ORGANIC NITRATES 734411006 50 Y

SANDOZ ISOSORBIDE 5MG SL TABS ISOSORBIDE DINITRATE SL TAB 5 MG ORGANIC NITRATES 784192006 50 Y

ISORDIL 10MG TABS ISOSORBIDE DINITRATE TAB 10 MG ORGANIC NITRATES 734381018 50 Y


SANDOZ ISOSORBIDE 10MG TABS ISOSORBIDE DINITRATE TAB 10 MG ORGANIC NITRATES 784206007 50 Y




ISORDIL 40MG TABS ISOSORBIDE DINITRATE TAB ER 40 MG ORGANIC NITRATES 734438001 30 Y

ISORDIL 40MG TABS ISOSORBIDE DINITRATE TAB ER 40 MG ORGANIC NITRATES 734438028 100 Y

of 53


PRE-AUTH REQUIRED

ELANTAN LA 50MG CAPS ISOSORBIDE MONONITRATE CAP CR 50 MG ORGANIC NITRATES 860115003 30 Y

ISMO 20MG TABS ISOSORBIDE MONONITRATE TAB 20 MG ORGANIC NITRATES 734055005 60 Y

ELANTAN 20MG TABS ISOSORBIDE MONONITRATE TAB 20 MG ORGANIC NITRATES 793418003 60 Y

ELANTAN 20MG TABS ISOSORBIDE MONONITRATE TAB 20 MG ORGANIC NITRATES 793418011 500 Y

MONICOR SR 60MG TABS ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG ORGANIC NITRATES 710251001 30 Y

IMDUR 60MG TABS ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG ORGANIC NITRATES 821500007 30 Y

DYNACIRC SRO 5MG CAPS ISRADIPINE CAP CR 5 MG CALCIUM CHANNEL BLOCKERS 788325019 30 Y

DYNACIRC 2.5MG TABS ISRADIPINE TAB 2.5 MG CALCIUM CHANNEL BLOCKERS 782963005 60 Y

CORALAN 5MG TABS IVABRADINE HCL TAB 5 MG (BASE ORGANIC NITRATES 710620001 56 Y

CORALAN 7.5MG TABS IVABRADINE HCL TAB 5 MG (BASE ORGANIC NITRATES 710621001 56 Y

TRANDATE 100MG TABS LABETALOL HCL TAB 100 MG ALPHA/BETA-RECEPTOR BLOCKERS 771627017 60 Y

LAMICTIN P 100MG DISP TABS LAMOTRIGINE ORALLY DISINTEGRATING TAB 100 MG OTHER ANTI-EPILEPTICS 813907004 60 Y



EPITEC 100MG TABS LAMOTRIGINE TAB 100 MG OTHER ANTI-EPILEPTICS 704381001 60 Y

LAMITOR 100MG TABS LAMOTRIGINE TAB 100 MG OTHER ANTI-EPILEPTICS 704488001 60 Y

SANDOZ LAMOTRIG 100MG TABS LAMOTRIGINE TAB 100 MG OTHER ANTI-EPILEPTICS 705248001 60 Y

ASPEN LAMOTRIGINE 100MG TABS LAMOTRIGINE TAB 100 MG OTHER ANTI-EPILEPTICS 705441001 60 Y

AUSTELL-LAMOTRIGINE 100MG TABS LAMOTRIGINE TAB 100 MG OTHER ANTI-EPILEPTICS 707789001 60 Y

DYNA-LAMOTRIGINE 100MG TABS LAMOTRIGINE TAB 100 MG OTHER ANTI-EPILEPTICS 710389001 60 Y

LAMIDUS 100MG TABS LAMOTRIGINE TAB 100 MG OTHER ANTI-EPILEPTICS 710887002 60 Y

GIROTEC 100MG TABS LAMOTRIGINE TAB 100 MG OTHER ANTI-EPILEPTICS 722726001 60 Y

LAMICTIN 100MG TABS LAMOTRIGINE TAB 100 MG OTHER ANTI-EPILEPTICS 805521003 60 Y















of 53


PRE-AUTH REQUIRED











LAMICTIN P 2MG DISP TABS LAMOTRIGINE TAB CHEWABLE DISPE OTHER ANTI-EPILEPTICS 704533001 30 Y



FOSRENOL 500MG CHEW LANTHANUM CARBONATE CHEW TAB 500 MG OTHER CHELATING AGENTS/ION EXCHANGE PREPARATIONS 711080001 45 Y


FOSRENOL 750MG CHEWS LANTHANUM CARBONATE CHEW TAB 750 MG OTHER CHELATING AGENTS/ION EXCHANGE PREPARATIONS 711081001 15 Y


OCUPROST 3ML DROPS LATANOPROST OPHTH SOLN 0.005% PROSTAGLANDINS FOR GLAUCOMA 715961001 1 Y

ATANA 50MCG/ML OPHTH DRP 2.5ML LATANOPROST OPHTH SOLN 0.005% PROSTAGLANDINS FOR GLAUCOMA 720971001 1 Y

SPERSATAN 50MCG/ML 2.5ML LATANOPROST OPHTH SOLN 0.005% PROSTAGLANDINS FOR GLAUCOMA 723018001 1 Y

XALATAN 2.5ML DROPS LATANOPROST OPHTH SOLN 0.005% PROSTAGLANDINS FOR GLAUCOMA 833223003 1 Y

XALACOM 2.5ML EYE DROPS LATANOPROST-TIMOLOL MALEATE OPHTH SOLN 0.005-0.5%


CO-ATANA 2.5ML EYE DRP LATANOPROST-TIMOLOL MALEATE OPHTH SOLN 0.005-0.5%


RHEUMALEF 10MG TABS LEFLUNOMIDE TAB 10 MG RHEUMATOID ARTHRITIS AGENTS 721609001 30 Y

ARAVA 10MG TABS LEFLUNOMIDE TAB 10 MG RHEUMATOID ARTHRITIS AGENTS 898171008 30 Y

RHEUMALEF 20MG TABS LEFLUNOMIDE TAB 20 MG RHEUMATOID ARTHRITIS AGENTS 721610001 30 Y

LUNAR 20MG TABS LEFLUNOMIDE TAB 20 MG RHEUMATOID ARTHRITIS AGENTS 721806001 30 Y

ARAVA 20MG TABS LEFLUNOMIDE TAB 20 MG RHEUMATOID ARTHRITIS AGENTS 898175005 30 Y

ZANIDIP 10MG TABS LERCANIDIPINE HCL TABS CALCIUM CHANNEL BLOCKERS 704035002 28 Y

ZANIDIP 20MG TABS LERCANIDIPINE HCL TABS CALCIUM CHANNEL BLOCKERS 708037001 28 Y

LERCANIDIPINE TEVA 10MG TABS LERCANIDIPINE HCL TABS CALCIUM CHANNEL BLOCKERS 723574001 28 Y

of 53


PRE-AUTH REQUIRED

LERCANIDIPINE TEVA 20MG TABS LERCANIDIPINE HCL TABS CALCIUM CHANNEL BLOCKERS 723575001 28 Y

KEPPRA 100MG/ML SOLN LEVETIRACETAM ORAL SOLN 100 MG/ML OTHER ANTI-EPILEPTICS 714166001 300 Y

DYNA LEVETIRACETAM 1000MG TABS LEVETIRACETAM TAB 1000 MG OTHER ANTI-EPILEPTICS 720700001 60 Y

KEPPRA 250MG TABS LEVETIRACETAM TAB 250 MG OTHER ANTI-EPILEPTICS 700958003 60 Y

REDILEV 250MG TABS LEVETIRACETAM TAB 250 MG OTHER ANTI-EPILEPTICS 714662001 30 Y


TORCETAM 250MG TABS LEVETIRACETAM TAB 250 MG OTHER ANTI-EPILEPTICS 720320001 60 Y

LEVETIRACETAM BIOTECH 250MG LEVETIRACETAM TAB 250 MG OTHER ANTI-EPILEPTICS 720697001 60 Y

EPIKEPP 250MG TABS LEVETIRACETAM TAB 250 MG OTHER ANTI-EPILEPTICS 721701001 60 Y

LEVETIRACETAM UNICORN 250MG TA LEVETIRACETAM TAB 250 MG OTHER ANTI-EPILEPTICS 722150001 60 Y










LEVETIRACETAM BIOTECH 750MG LEVETIRACETAM TAB 750 MG OTHER ANTI-EPILEPTICS 720696001 60 Y


LEVETIRACETAM UNICORN 750MG TA LEVETIRACETAM TAB 750 MG OTHER ANTI-EPILEPTICS 722151001 60 Y

BETAGAN LIQUIFILM 0.5% OPHTH 5 LEVOBUNOLOL HCL OPHTH SOLN 0.5% BETA BLOCKERS FOR GLAUCOMA 723286001 1 Y

BETAGAN 7.5ML DROPS LEVOBUNOLOL HCL OPHTH SOLN 0.5% BETA BLOCKERS FOR GLAUCOMA 781134005 1 Y

EUTHYROX 100MCG TABS LEVOTHYROXINE SODIUM TAB 100 MCG AGENTS FOR HYPOTHYROIDISM 713169002 30 Y

SYNTHROID 100MCG TABS LEVOTHYROXINE SODIUM TAB 100 MCG AGENTS FOR HYPOTHYROIDISM 716576001 90 Y

ELTROXIN 100MCG TABS LEVOTHYROXINE SODIUM TAB 100 MCG AGENTS FOR HYPOTHYROIDISM 722952007 100 Y

ELTROXIN 100MCG TABS NEW FORMU LEVOTHYROXINE SODIUM TAB 100 MCG AGENTS FOR HYPOTHYROIDISM 723171001 30 Y


ELTROXIN 200MCG TABS NEW FORMU LEVOTHYROXINE SODIUM TAB 200 MCG AGENTS FOR HYPOTHYROIDISM 723172001 30 Y



ELTROXIN 25MCG TABS NEW FORMUL LEVOTHYROXINE SODIUM TAB 25 MCG AGENTS FOR HYPOTHYROIDISM 723167001 30 Y



ELTROXIN 50MCG TABS LEVOTHYROXINE SODIUM TAB 50 MCG AGENTS FOR HYPOTHYROIDISM 722944004 100 Y

of 53


PRE-AUTH REQUIRED




DIOTROXIN TABS LEVOTHYROXINE-LIOTHYRONINE TAB 90-10 MCG AGENTS FOR HYPOTHYROIDISM 720224004 100 Y

TERTROXIN 20MCG TABS LIOTHYRONINE SODIUM TAB 20 MCG AGENTS FOR HYPOTHYROIDISM 769983006 50 Y

TERTROXIN 20MCG TABS LIOTHYRONINE SODIUM TAB 20 MCG AGENTS FOR HYPOTHYROIDISM 769983007 100 Y

VICTOZA 6MG/ML PRE-FILLED PEN LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML)

GLP-1 AGONISTS (WAS OTHER ANTI-DIABETIC) 716645001 2 Y

VICTOZA 6MG/ML PRE-FILLED PEN LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML)

GLP-1 AGONISTS (WAS OTHER ANTI-DIABETIC) 716645002 3 Y

LISINOZIDE 20MG/12.5MG TABS LISINOPRIL & HCTZ ACE INHIBITOR/DIURETIC COMBINATIONS 711989001 30 Y

LISINOZIDE 10MG/12.5MG TABS LISINOPRIL & HCTZ ACE INHIBITOR/DIURETIC COMBINATIONS 711990001 30 Y

AURO-LISINOPRIL CO 10MG TABS LISINOPRIL & HCTZ ACE INHIBITOR/DIURETIC COMBINATIONS 716120001 30 Y

AURO-LISINOPRIL CO 20MG TABS LISINOPRIL & HCTZ ACE INHIBITOR/DIURETIC COMBINATIONS 716121001 30 Y

LISINOPRIL CO UNICORN 10/12.5M LISINOPRIL & HCTZ ACE INHIBITOR/DIURETIC COMBINATIONS 716943001 30 Y

LISINOPRIL CO UNICORN 20/12.5M LISINOPRIL & HCTZ ACE INHIBITOR/DIURETIC COMBINATIONS 716945001 30 Y

ZESTORETIC 20MG TABS LISINOPRIL & HCTZ ACE INHIBITOR/DIURETIC COMBINATIONS 797685006 30 Y

ZESTORETIC 10MG TABS LISINOPRIL & HCTZ ACE INHIBITOR/DIURETIC COMBINATIONS 817848002 30 Y

LISORETIC 10/HCTZ TABS LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 704437001 30 Y

ADCO-ZETOMAX-CO 10/12.5MG TABS LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 704597001 30 Y

HEXAL-LISINOPRIL CO 10MG TABS LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 704703001 30 Y

LISOZIDE 10MG/12.5MG TABS LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 707292001 30 Y

LISORETIC 20/HCTZ TABS LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 704438001 30 Y

ADCO-ZETOMAX-CO 20/12.5MG TABS LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 704598001 30 Y

HEXAL-LISINOPRIL CO 20MG TABS LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 704704001 30 Y

LISOZIDE 20MG/12.5MG TABS LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 707291001 30 Y

ZESTOZIDE 20MG TABS LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 708260001 30 Y

DIACE CO 20/12.5 MG TABS LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 710978001 28 Y

SINOPREN 10MG TABS LISINOPRIL TAB 10 MG SINGLE ACE INHIBITORS 700692001 30 Y

HEXAL-LISINOPRIL 10MG TABS LISINOPRIL TAB 10 MG SINGLE ACE INHIBITORS 701392003 30 Y

CIPLA LISINOPRIL 10MG TABS LISINOPRIL TAB 10 MG SINGLE ACE INHIBITORS 703645001 30 Y

SIMAYLA LISINOPRIL 10MG TABS LISINOPRIL TAB 10 MG SINGLE ACE INHIBITORS 707311001 30 Y

AUSTELL-LISINOPRIL 10MG TABS LISINOPRIL TAB 10 MG SINGLE ACE INHIBITORS 712598001 30 Y

LIZRO 10MG TABS LISINOPRIL TAB 10 MG SINGLE ACE INHIBITORS 714678001 30 Y

ZESTRIL 10MG TABS LISINOPRIL TAB 10 MG SINGLE ACE INHIBITORS 781703018 30 Y

of 53


PRE-AUTH REQUIRED

ADCO-ZETOMAX 10MG TABS LISINOPRIL TAB 10 MG SINGLE ACE INHIBITORS 862053005 30 Y

AUSTELL-LISINOPRIL 2.5MG TABS LISINOPRIL TAB 2.5 MG SINGLE ACE INHIBITORS 704354001 28



ZEMAX 20MG TABS (LISINOHEXAL) LISINOPRIL TAB 20 MG SINGLE ACE INHIBITORS 705318001 30 Y

SIMAYLA LISINOPRIL 20MG TABS LISINOPRIL TAB 20 MG SINGLE ACE INHIBITORS 707312001 30

AUSTELL-LISINOPRIL 20MG TABS LISINOPRIL TAB 20 MG SINGLE ACE INHIBITORS 708189001 30 Y


APEX-LISINOPRIL 20MG TABS LISINOPRIL TAB 20 MG SINGLE ACE INHIBITORS 715938001 30 Y

LYSIN 20MG TABS LISINOPRIL TAB 20 MG SINGLE ACE INHIBITORS 716794001 30 Y





CIPLA LISINOPRIL 5MG TABS LISINOPRIL TAB 5 MG SINGLE ACE INHIBITORS 703646001 30 Y


LYSIN 5MG TABS LISINOPRIL TAB 5 MG SINGLE ACE INHIBITORS 716792001 30 Y



CAMCOLIT 250MG TABS LITHIUM CARBONATE TAB 250 MG LITHIUM 712078002 100 Y



QUILONUM RET 450MG TABS LITHIUM CARBONATE TAB ER 450 MG LITHIUM 758280017 60 Y

COZAAR COMP 100MG/12.5MG TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-1 ARB/DIURETIC COMBINATIONS 723331001 30 Y

LOZAAN CO 100/25 TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-2 ARB/DIURETIC COMBINATIONS 715739001 30 Y

NETRASOL CO 100/25MG TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-2 ARB/DIURETIC COMBINATIONS 715849001 30 Y

LOSAAR PLUS 100/25 TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-2 ARB/DIURETIC COMBINATIONS 715857001 30 Y

LOHYPE FORTE PLUS 100MG/25MG LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-2 ARB/DIURETIC COMBINATIONS 716059001 30 Y

ZARTAN CO 100MG/25MG TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-2 ARB/DIURETIC COMBINATIONS 716217001 30 Y

SARTOC-CO 100/25 TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE ARB/DIURETIC COMBINATIONS 716515001 30 Y

of 53


PRE-AUTH REQUIRED

TAB 100-2

CIPLAZAR CO 100MG/25MG TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-2 ARB/DIURETIC COMBINATIONS 716613001 30 Y

HYTENZA CO 100MG/25MG TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-2 ARB/DIURETIC COMBINATIONS 717084001 30 Y

LOSARTAN CO UNICORN 100/25MG T LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-2 ARB/DIURETIC COMBINATIONS 718368001 30 Y

FORTZAAR TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-2 ARB/DIURETIC COMBINATIONS 887096005 30 Y

CO-NORMOTEN 100MG/25MG TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-2 ARB/DIURETIC COMBINATIONS 3000159001 30 Y

SARTOC-CO 50/12.5 TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12 ARB/DIURETIC COMBINATIONS 715064001 30 Y

LOZAAN CO 50/12.5 TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12 ARB/DIURETIC COMBINATIONS 715740001 30 Y

NETRASOL CO 50/12.5MG TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12 ARB/DIURETIC COMBINATIONS 715848001 30 Y

LOSAAR PLUS 50/12.5 TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12 ARB/DIURETIC COMBINATIONS 715856001 30 Y

LOHYPE PLUS 50MG/12.5MG TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12 ARB/DIURETIC COMBINATIONS 716058001 30 Y

ZARTAN CO 50MG/12.5MG TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12 ARB/DIURETIC COMBINATIONS 716216001 30 Y

LOSACAR CO 50MG/12.5MG TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12 ARB/DIURETIC COMBINATIONS 716274001 30 Y

HYTENZA CO 50MG/12.5MG TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12 ARB/DIURETIC COMBINATIONS 716476001 30 Y

CIPLAZAR CO 50MG/12.5MG TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12 ARB/DIURETIC COMBINATIONS 716612001 30 Y

AUSTELL LOSARTAN CO 50MG/12.5 LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12 ARB/DIURETIC COMBINATIONS 717070001 30 Y

LOSARTAN CO UNICORN 50MG/12.5 LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12 ARB/DIURETIC COMBINATIONS 718367001 30 Y

COZAAR COMP 50MG/12.5MG TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12 ARB/DIURETIC COMBINATIONS 828181004 30 Y

CO-NORMOTEN 50MG/12.5MG TABS LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12 ARB/DIURETIC COMBINATIONS 3000158001 30 Y

of 53


PRE-AUTH REQUIRED

CIPLA LOSARTAN 100MG TABS LOSARTAN POTASSIUM TAB 100 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 709845001 30 Y

ZARTAN 100MG TABS LOSARTAN POTASSIUM TAB 100 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 709964001 30 Y

COZAAR 100MG TABS LOSARTAN POTASSIUM TAB 100 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 710079001 30 Y

SPEC-LOSARTAN 100MG TABS LOSARTAN POTASSIUM TAB 100 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 713254001 30 Y

ANNIN 100MG TABS LOSARTAN POTASSIUM TAB 100 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 716495001 30 Y

CIPLAZAR 100MG TABS LOSARTAN POTASSIUM TAB 100 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 716644001 30 Y

HYTENZA 100MG FILM COATED TABS LOSARTAN POTASSIUM TAB 100 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 717042001 30 Y

AUSTELL LOSARTAN 100MG TABS LOSARTAN POTASSIUM TAB 100 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 717069001 30 Y

RASOL 100MG TABS LOSARTAN POTASSIUM TAB 100 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 717296001 30 Y

LOSARTAN UNICORN 100MG TABS LOSARTAN POTASSIUM TAB 100 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 718366001 30 Y

LOZAAN 100MG TABS LOSARTAN POTASSIUM TAB 100 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 720776001 30 Y

NORMOTEN 100MG TABS LOSARTAN POTASSIUM TAB 100 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 721260001 30 Y

ZARTAN 50MG TABS LOSARTAN POTASSIUM TAB 50 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 709225001 30 Y

CIPLA LOSARTAN 50MG TABS LOSARTAN POTASSIUM TAB 50 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 709844001 30 Y

LOSARTAN-WINTHROP TABS LOSARTAN POTASSIUM TAB 50 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 709909001 30 Y

LOS-ARB 50MG TABS LOSARTAN POTASSIUM TAB 50 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 709924001 30 Y

SPEC-LOSARTAN 50MG TABS LOSARTAN POTASSIUM TAB 50 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 713255001 30 Y

RENICARD 50MG TABS LOSARTAN POTASSIUM TAB 50 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 715871001 30 Y

ANNIN 50MG TABS LOSARTAN POTASSIUM TAB 50 MG SINGLE ANGIOTENSIN RECEPTOR 716494001 30 Y

of 53


PRE-AUTH REQUIRED

ANTAGONISTS

CIPLAZAR 50MG TABS LOSARTAN POTASSIUM TAB 50 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 716643001 30 Y

HYTENZA 50MG FILM COATED TABS LOSARTAN POTASSIUM TAB 50 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 717024001 30 Y

AUSTELL LOSARTAN 50MG TABS LOSARTAN POTASSIUM TAB 50 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 717068001 30 Y

RASOL 50MG TABS LOSARTAN POTASSIUM TAB 50 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 717295001 30 Y

LOSARTAN UNICORN 50MG TABS LOSARTAN POTASSIUM TAB 50 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 718365001 30 Y

LOZAAN 50MG TABS LOSARTAN POTASSIUM TAB 50 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 720775001 30 Y

NORMOTEN 50MG TABS LOSARTAN POTASSIUM TAB 50 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 721259001 30 Y

COZAAR 50MG TABS LOSARTAN POTASSIUM TAB 50 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 818739002 30 Y

LOVACHOL 20MG TABS LOVASTATIN TAB 20 MG HMG-COA REDUCTASE INHIBITORS 703906002 30 Y

LOVACHOL 40MG TABS LOVASTATIN TAB 40 MG HMG-COA REDUCTASE INHIBITORS 703905002 30 Y

GLUCOPHAGE 1000MG TABS METFORMIN HCL TAB 1000 MG METFORMIN 703909001 60 Y


BIGSENS 1000MG TABS METFORMIN HCL TAB 1000 MG METFORMIN 709172001 60 Y

METORED 1000MG TABS METFORMIN HCL TAB 1000 MG METFORMIN 711773001 60 Y

MENGEN 1000MG TABS METFORMIN HCL TAB 1000 MG METFORMIN 714683001 60 Y

ROMIDAB 1000MG TABS METFORMIN HCL TAB 1000 MG METFORMIN 719645001 60 Y

DIAPHAGE 1000MG TABS METFORMIN HCL TAB 1000 MG METFORMIN 719786001 60 Y

MYLAN METFORMIN 1000MG TABS METFORMIN HCL TAB 1000 MG METFORMIN 721443001 60 Y

METFORAL 500MG TABS METFORMIN HCL TAB 500 MG METFORMIN 702385001 100 Y

AUSTELL-METFORMIN 500MG TABS METFORMIN HCL TAB 500 MG METFORMIN 705757001 100 Y


ARROW METFORMIN 500MG TABS METFORMIN HCL TAB 500 MG METFORMIN 706672001 100 Y

APEX-METFORMIN 500MG TABS METFORMIN HCL TAB 500 MG METFORMIN 707670001 100 Y

APEX-METFORMIN 500MG TABS METFORMIN HCL TAB 500 MG METFORMIN 707670002 500 Y

FORMINAL 500MG TABS METFORMIN HCL TAB 500 MG METFORMIN 708009002 100 Y



METPHAGE 500MG TABS METFORMIN HCL TAB 500 MG METFORMIN 709246001 100 Y

of 53


PRE-AUTH REQUIRED

METFORMIN ASCENDIS 500 METFORMIN HCL TAB 500 MG METFORMIN 709338001 100 Y

METFORMIN ASCENDIS 500 METFORMIN HCL TAB 500 MG METFORMIN 709338002 500 Y


DIAMIN 500MG TABS METFORMIN HCL TAB 500 MG METFORMIN 714186001 100 Y


ACCORD METFORMIN 500MG TABS METFORMIN HCL TAB 500 MG METFORMIN 714427001 100 Y

GLUCONORM 500MG TABS METFORMIN HCL TAB 500 MG METFORMIN 714525001 100 Y


DIAFORMIN 500MG TABS METFORMIN HCL TAB 500 MG METFORMIN 715936001 100 Y

METCHEK 500MG TABS METFORMIN HCL TAB 500 MG METFORMIN 718231001 100 Y

METFORMIN ALKEM 500MG TABS METFORMIN HCL TAB 500 MG METFORMIN 718828001 100 Y


SANDOZ METFORMIN 500MG TABS METFORMIN HCL TAB 500 MG METFORMIN 719285003 100 Y





SANDOZ METFORMIN 500 FC TABS METFORMIN HCL TAB 500 MG METFORMIN 815225008 100 Y




METFORAL 850MG TABS METFORMIN HCL TAB 850 MG METFORMIN 702363001 60 Y

DIABETMIN 850MG TABS METFORMIN HCL TAB 850 MG METFORMIN 705358001 100 Y



ARROW METFORMIN 850MG TABS METFORMIN HCL TAB 850 MG METFORMIN 706673001 60 Y

APEX-METFORMIN FORTE 850MG METFORMIN HCL TAB 850 MG METFORMIN 707669001 60 Y

APEX-METFORMIN FORTE 850MG METFORMIN HCL TAB 850 MG METFORMIN 707669002 300 Y




METPHAGE 850MG TABS METFORMIN HCL TAB 850 MG METFORMIN 709247001 60 Y

METFORMIN ASCENDIS 850MG FCT METFORMIN HCL TAB 850 MG METFORMIN 709339001 60 Y

METFORMIN ASCENDIS 850 MG FCT METFORMIN HCL TAB 850 MG METFORMIN 709339002 300 Y



of 53


PRE-AUTH REQUIRED


ACCORD METFORMIN 850MG TABS METFORMIN HCL TAB 850 MG METFORMIN 714426001 60 Y

GLUCONORM 850MG TABS METFORMIN HCL TAB 850 MG METFORMIN 714526001 60 Y


DIAFORMIN FORTE 850MG TABS METFORMIN HCL TAB 850 MG METFORMIN 715937001 60 Y

METCHEK 850MG TABS METFORMIN HCL TAB 850 MG METFORMIN 718232001 60 Y




SANDOZ METFORMIN 850MG TABS METFORMIN HCL TAB 850 MG METFORMIN 719293006 30 Y



GLUCOPHAGE F 850MG TABS METFORMIN HCL TAB 850 MG METFORMIN 729167003 60 Y

GLUCOPHAGE F 850MG TABS METFORMIN HCL TAB 850 MG METFORMIN 729167011 300 Y

SANDOZ METFORMIN 850 FC TABS METFORMIN HCL TAB 850 MG METFORMIN 815233019 60 Y



GLUCOPHAGE XR 750MG TABS METFORMIN HCL TAB SR 24HR 750 MG METFORMIN 720925001 30 Y

GLUCOPHAGE XR 750MG TABS METFORMIN HCL TAB SR 24HR 750 MG METFORMIN 720925002 60 Y

GLUCOPHAGE XR 1000MG TABS METFORMIN HCL TAB SR 24HR MODIFIED RELEASE 1000 MG METFORMIN 720926001 30 Y




HY-PO-TONE 250MG TABS METHYLDOPA TAB 250 MG CENTRAL ACTING ANTI-HYPERTENSIVES 732052009 100 Y


SANDOZ METHYLDOPA 250MG TABS METHYLDOPA TAB 250 MG CENTRAL ACTING ANTI-HYPERTENSIVES 764116010 500 Y

SANDOZ METHYLDOPA 250MG TABS METHYLDOPA TAB 250 MG CENTRAL ACTING ANTI-HYPERTENSIVES 764116037 90 Y

MYLAN METHYLDOPA 250MG TABS METHYLDOPA TAB 250 MG CENTRAL ACTING ANTI-HYPERTENSIVES 785962018 100 Y

MYLAN METHYLDOPA 250MG TABS METHYLDOPA TAB 250 MG CENTRAL ACTING ANTI-HYPERTENSIVES 785962026 500 Y


BETA-OPTHIOLE 0.3% DRP METIPRANOLOL OPHTH SOLN 0.3% BETA BLOCKERS FOR GLAUCOMA 816728003 1 Y

BETA-OPTHIOLE 0.6% DRP METIPRANOLOL OPHTH SOLN 0.6% BETA BLOCKERS FOR GLAUCOMA 816736006 1 Y

LOPRESOR 100MG TABS METOPROLOL TARTRATE TAB 100 MG OTHER BETA-RECEPTOR BLOCKERS 739251016 40 Y

of 53


PRE-AUTH REQUIRED

LONITEN 10MG TABS MINOXIDIL TAB 10 MG DIRECT ACTING VASODILATORS 739243004 100 Y

LONITEN 5MG TAB MINOXIDIL TAB 5 MG DIRECT ACTING VASODILATORS 739235001 100 Y

PERDIX 15MG TABS MOEXIPRIL HCL TAB 15 MG SINGLE ACE INHIBITORS 890229001 30 Y

PERDIX 7.5MG TABS MOEXIPRIL HCL TAB 7.5 MG SINGLE ACE INHIBITORS 890222001 30 Y

MOXOTENS 0.2MG TABS MOXONIDINE TAB 0.2 MG CENTRAL ACTING ANTI-HYPERTENSIVES 710744001 28 Y

CYNT 0.2MG TABS MOXONIDINE TAB 0.2 MG CENTRAL ACTING ANTI-HYPERTENSIVES 712382001 28 Y

PHYSIOTENS 0.2MG TABS MOXONIDINE TAB 0.2 MG CENTRAL ACTING ANTI-HYPERTENSIVES 851892019 28 Y




CYNT 0.4MG TABS MOXONIDINE TAB 0.4 MG CENTRAL ACTING ANTI-HYPERTENSIVES 712383001 28 Y


STARLIX 120MG F/COATED TABS NATEGLINIDE TAB 120 MG ORAL ANTI-DIABETIC AGENTS 893900001 84 Y

NEBILET 5MG TABS NEBIVOLOL HCL TAB 5 MG (BASE EQUIVALENT) BETA-RECEPTOR BLOCKERS 700558003 30 Y

LOVISPES 5MG TABS NEBIVOLOL HCL TAB 5 MG (BASE EQUIVALENT) BETA-RECEPTOR BLOCKERS 716483001 30 Y

ADCO-VASCARD 20MG SR CAPS NIFEDIPINE CAP ER 12HR 20 MG CALCIUM CHANNEL BLOCKERS 840963009 60 Y



ADALAT RETARD 10MG TABS NIFEDIPINE TAB SR 12HR 10 MG CALCIUM CHANNEL BLOCKERS 796891001 60 Y

ADALAT RETARD 20MG TABS NIFEDIPINE TAB SR 12HR 20 MG CALCIUM CHANNEL BLOCKERS 783889003 60 Y

NIFEDALAT 20SR TABS NIFEDIPINE TAB SR 12HR 20 MG CALCIUM CHANNEL BLOCKERS 829501002 60 Y

CIPALAT RETARD 20MG TABS NIFEDIPINE TAB SR 12HR 20 MG CALCIUM CHANNEL BLOCKERS 864153007 60 Y

ADALAT XL 20MG TABS NIFEDIPINE TAB SR 24HR 20 MG CALCIUM CHANNEL BLOCKERS 711607001 28 Y

FEDALOC SR 30MG TABS NIFEDIPINE TAB SR 24HR 30 MG CALCIUM CHANNEL BLOCKERS 711682001 30 Y

MACOREL 30 SR TABS NIFEDIPINE TAB SR 24HR 30 MG CALCIUM CHANNEL BLOCKERS 715000001 30 Y

SPEC NIFEDIPINE SR 30MG SR NIFEDIPINE TAB SR 24HR 30 MG CALCIUM CHANNEL BLOCKERS 715002001 30 Y

BIO NIFEDIPINE XL 30MG TABS NIFEDIPINE TAB SR 24HR 30 MG CALCIUM CHANNEL BLOCKERS 718083001 30 Y

GITSALAT 30MG TABS NIFEDIPINE TAB SR 24HR 30 MG CALCIUM CHANNEL BLOCKERS 719449001 28 Y

CIPALAT XR 30MG TABS NIFEDIPINE TAB SR 24HR 30 MG CALCIUM CHANNEL BLOCKERS 723283001 30 Y


FEDALOC SR 60MG TABS NIFEDIPINE TAB SR 24HR 60 MG CALCIUM CHANNEL BLOCKERS 711714001 30 Y

MACOREL 60 SR TABS NIFEDIPINE TAB SR 24HR 60 MG CALCIUM CHANNEL BLOCKERS 715001001 30 Y

SPEC NIFEDIPINE SR 60MG SRT NIFEDIPINE TAB SR 24HR 60 MG CALCIUM CHANNEL BLOCKERS 715003001 30 Y

BIO NIFEDIPINE XL 60MG TABS NIFEDIPINE TAB SR 24HR 60 MG CALCIUM CHANNEL BLOCKERS 718085001 30 Y

GITSALAT 60MG TABS NIFEDIPINE TAB SR 24HR 60 MG CALCIUM CHANNEL BLOCKERS 719450001 28 Y

CIPALAT XR 60MG TABS NIFEDIPINE TAB SR 24HR 60 MG CALCIUM CHANNEL BLOCKERS 723284001 30 Y


of 53


PRE-AUTH REQUIRED

ANGISED 0.5MG TABS NITROGLYCERIN SL TAB 0.5 MG ORGANIC NITRATES 703605003 50 Y

NITROLINGUAL .4MG 200 AER NITROGLYCERIN TL AEROSOL SOLN 0.4MG/DOSE ORGANIC NITRATES 787256005 1 Y

MYLAN OXCARBAZEPINE 300MG OXCARBAZEPINE TAB 300 MG OTHER ANTI-EPILEPTICS 717226001 50 Y

TRILEPTAL FCT 300MG OXCARBAZEPINE TAB 300 MG OTHER ANTI-EPILEPTICS 892484008 50 Y

MYLAN OXCARBAZEPINE 600MG OXCARBAZEPINE TAB 600 MG OTHER ANTI-EPILEPTICS 717227001 50 Y

TRILEPTAL FCT 600MG OXCARBAZEPINE TAB 600 MG OTHER ANTI-EPILEPTICS 892491020 50 Y

XEPLION 100MG/1ML PREFILL SYR PALIPERIDONE PALMITATE IM EXTENDED-RELEASE SUSP 10 ATYPICAL ANTI-PSYCHOTICS 718471001 1 Y

XEPLION 150MG/1.5ML PREFILL SY PALIPERIDONE PALMITATE IM EXTENDED-RELEASE SUSP 15 ATYPICAL ANTI-PSYCHOTICS 718472001 1 Y

XEPLION 50MG/0.5ML PREFILL SYR PALIPERIDONE PALMITATE IM EXTENDED-RELEASE SUSP 50 ATYPICAL ANTI-PSYCHOTICS 718469001 1 Y

XEPLION 75MG/0.75ML PREFILL SY PALIPERIDONE PALMITATE IM EXTENDED-RELEASE SUSP 75 ATYPICAL ANTI-PSYCHOTICS 718470001 1 Y

INVEGA 3MG SR TABS PALIPERIDONE TAB SR 24HR 3 MG ATYPICAL ANTI-PSYCHOTICS 715666001 28



COVERSYL 10MG TABS PERINDOPRIL ARGININE TAB 10 MG SINGLE ACE INHIBITORS 705915001 30 Y

PREXUM 10MG TABS PERINDOPRIL ARGININE TAB 10 MG SINGLE ACE INHIBITORS 714646001 30 Y

COVERSYL 5MG TABS PERINDOPRIL ARGININE TAB 5 MG SINGLE ACE INHIBITORS 705914001 30 Y

PREXUM 5MG TABS PERINDOPRIL ARGININE TAB 5 MG SINGLE ACE INHIBITORS 720387001 30 Y

BIOPREXUM PLUS 10MG/2.5MG TABS PERINDOPRIL ARGININE-INDAPAMIDE TAB 10-2.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 721508001 30 Y

PREXUM PLUS 2.5MG/0.625MG TABS PERINDOPRIL ARGININE-INDAPAMIDE TAB 2.5-0.625 MG ACE INHIBITOR/DIURETIC COMBINATIONS 721507001 30 Y

PREXUM PLUS 5MG/1.25MG TABS PERINDOPRIL ARGININE-INDAPAMIDE TAB 5-1.25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 720388001 30 Y

COVERSYL PLUS 5MG/1.25MG TABS PERINDOPRIL ARGININE-INDAPAMIDE TAB 5-1.25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 720389001 30 Y

PREXUM 4MG TABS PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 703541003 30 Y

CIRCATOR 4MG TABS PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 708649001 30 Y

VECTORYL 4MG TABS PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 710297001 30 Y

CIPLA-PERINDOPRIL 4MG TABS PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 710302001 30 Y

RAN-PERINDOPRIL 4MG TABS PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 710611001 30 Y

SPEC-PERINDOPRIL 4MG PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 712615001 30 Y

PEARINDA 4MG TABS PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 714527001 30 Y

ACTI-PREX 4MG TABS GLENMARK P PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 714869001 30 Y

ACESYL 4MG TABS PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 715649001 30 Y

CIPLASYL 4MG TABS PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 715786001 30 Y

AURO PERINDOPRIL 4MG TABS PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 716505001 30 Y

of 53


PRE-AUTH REQUIRED

ZYACE 4MG TABS (ZYDUS PERIND) PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 716680001 30 Y

BINDACE 4MG TABS PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 717293001 30 Y

PERINDOPRIL UNICORN 4MG TABS PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 717783001 30 Y

PERISTAR 4MG TABS PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 721339001 30 Y

COVERSYL 4MG TABS PERINDOPRIL ERBUMINE TAB 4 MG SINGLE ACE INHIBITORS 785121005 30 Y

CIPLA-PERINDOPRIL 8MG TABS PERINDOPRIL ERBUMINE TAB 8 MG SINGLE ACE INHIBITORS 710510001 30 Y

VECTORYL 8MG TABS PERINDOPRIL ERBUMINE TAB 8 MG SINGLE ACE INHIBITORS 710925001 30 Y

SPEC-PERINDOPRIL 8MG TABS PERINDOPRIL ERBUMINE TAB 8 MG SINGLE ACE INHIBITORS 712616001 30 Y

PEARINDA 8MG TABS PERINDOPRIL ERBUMINE TAB 8 MG SINGLE ACE INHIBITORS 714528001 30 Y

CIPLASYL 8MG TABS PERINDOPRIL ERBUMINE TAB 8 MG SINGLE ACE INHIBITORS 715795001 30 Y

AURO PERINDOPRIL 8MG TABS PERINDOPRIL ERBUMINE TAB 8 MG SINGLE ACE INHIBITORS 716506001 30 Y

BINDACE 8MG TABS PERINDOPRIL ERBUMINE TAB 8 MG SINGLE ACE INHIBITORS 717294001 30 Y

PERINDOPRIL UNICORN 8MG TABS PERINDOPRIL ERBUMINE TAB 8 MG SINGLE ACE INHIBITORS 717784001 30 Y

PERISTAR 8MG TABS PERINDOPRIL ERBUMINE TAB 8 MG SINGLE ACE INHIBITORS 721340001 30 Y

CIRCATOR 8MG TABS PERINDOPRIL ERBUMINE TAB 8 MG SINGLE ACE INHIBITORS 3000236001 30 Y

VECTORYL PLUS TABS PERINDOPRIL ERBUMINE-INDAPAMID ACE INHIBITOR/DIURETIC COMBINATIONS 710298001 30 Y

ACESYL CO 2MG/0.625MG TABS PERINDOPRIL ERBUMINE-INDAPAMID ACE INHIBITOR/DIURETIC COMBINATIONS 715650001 30 Y

ACESYL CO 4MG/1.25MG TABS PERINDOPRIL ERBUMINE-INDAPAMID ACE INHIBITOR/DIURETIC COMBINATIONS 715651001 30 Y

CIPLASYL PLUS 4MG/1.25MG PERINDOPRIL ERBUMINE-INDAPAMID ACE INHIBITOR/DIURETIC COMBINATIONS 717095001 30 Y

PERINDOPRIL CO UNICORN 4/1.25 PERINDOPRIL ERBUMINE-INDAPAMID ACE INHIBITOR/DIURETIC COMBINATIONS 717782001 30 Y

ARIPREL PLUS 4MG/1.25MG TABS PERINDOPRIL ERBUMINE-INDAPAMID ACE INHIBITOR/DIURETIC COMBINATIONS 717795001 30 Y

COVERSYL PLUS TABS PERINDOPRIL ERBUMINE-INDAPAMID ACE INHIBITOR/DIURETIC COMBINATIONS 877549001 30 Y

PRETERAX TABS PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 2-0.625 MG ACE INHIBITOR/DIURETIC COMBINATIONS 700512001 30 Y

PRETERAX TABS PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 2-0.625 MG ACE INHIBITOR/DIURETIC COMBINATIONS 700512001 30 Y

SPEC-PERINDOPRIL PLUS 2MG/0.62 PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 2-0.625 MG ACE INHIBITOR/DIURETIC COMBINATIONS 713762001 30 Y


ACESYL CO 2MG/0.625MG TABS PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 2-0.625 MG ACE INHIBITOR/DIURETIC COMBINATIONS 715650001 30 Y

PREXUM PLUS TABS PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 4-1.25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 704929001 30 Y

PREXUM PLUS TABS PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 4-1.25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 704929001 30 Y

CIRCATOR PLUS 4MG/1.25MG TABS PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 4-1.25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 708650001 30 Y

CIRCATOR PLUS 4MG/1.25MG TABS PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 4-1.25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 708650001 30 Y

VECTORYL PLUS TABS PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 4-1.25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 710298001 30 Y



PEARINDA PLUS 4MG/1.25MG TABS PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 4-1.25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 714952001 30 Y

PEARINDA PLUS 4MG/1.25MG TABS PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 4-1.25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 714952001 30 Y

ACESYL CO 4MG/1.25MG TABS PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 4-1.25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 715651001 30 Y

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PRE-AUTH REQUIRED

CIPLASYL PLUS 4MG/1.25MG PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 4-1.25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 717095001 30 Y

PERINDOPRIL CO UNICORN 4/1.25 PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 4-1.25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 717782001 30 Y

ARIPREL PLUS 4MG/1.25MG TABS PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 4-1.25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 717795001 30 Y

COVERSYL PLUS TABS PERINDOPRIL ERBUMINE-INDAPAMIDE TAB 4-1.25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 877549001 30 Y

LETHYL 30MG TABS PHENOBARBITAL TAB 30 MG BARBITURATES 737844019 1000 Y

SEDABARB 30MG TABS PHENOBARBITAL TAB 30 MG BARBITURATES 814946003 1000 Y

EPANUTIN 100MG CAPS PHENYTOIN SODIUM PROMPT CAP 100 MG PHENYTOIN SODIUM 723525005 100 Y

PHENYTOIN SOD 100MG TABS PHENYTOIN SODIUM PROMPT TAB 100 MG PHENYTOIN SODIUM 754803007 1000 Y

PHENYTOIN SOD 100MG TABS PHENYTOIN SODIUM PROMPT TAB 100 MG PHENYTOIN SODIUM 754870015 90 Y

EPANUTIN 125MG/5ML SUSP PHENYTOIN SODIUM SUSP 125 MG/5ML PHENYTOIN SODIUM 723533016 237 Y

ORAP 1MG TABS PIMOZIDE TAB 1 MG PHENOTHIAZINES 745588018 75 Y

ORAP 4MG TABS PIMOZIDE TAB 4 MG PHENOTHIAZINES 751073008 100 Y

CIPLA PIOGLITAZONE 15MG TABS PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV) THIAZOLIDINEDIONES 707974001 30 Y

ACCORD PIOGLITAZONE 15MG TABS PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV) THIAZOLIDINEDIONES 718148001 30 Y

ACTOS 15MG TABS PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV) THIAZOLIDINEDIONES 878243003 28 Y

CIPLA PIOGLITAZONE 30MG TABS PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV) THIAZOLIDINEDIONES 707981001 30 Y


ACTOS 30MG TABS PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV) THIAZOLIDINEDIONES 878251006 28 Y


ARELIX 3MG TABS PIRETANIDE TAB 3 MG LOOP DIURETICS 807796018 30 Y

ARELIX 6MG TABS PIRETANIDE TAB 6 MG LOOP DIURETICS 807818003 30 Y

PRAMIOLA 0.125MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG ANTI-PARKINSON DOPAMINERGICS 717741001 100 Y

OXPOLA 0.125MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG ANTI-PARKINSON DOPAMINERGICS 719542001 100 Y

PRAMEX 0.125MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG ANTI-PARKINSON DOPAMINERGICS 719844001 100 Y

PAZORAM 0.125MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG ANTI-PARKINSON DOPAMINERGICS 721393001 100 Y

MYLAN PRAMIPEXOLE 0.125MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG ANTI-PARKINSON DOPAMINERGICS 722748001 100 Y

PEXASP 0.125MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG ANTI-PARKINSON DOPAMINERGICS 723741001 100 Y

PEXOLA 0.125MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG ANTI-PARKINSON DOPAMINERGICS 898836007 100 Y

PRAMIOLA 0.25MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG ANTI-PARKINSON DOPAMINERGICS 717742001 100 Y

OXPOLA 0.25MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG ANTI-PARKINSON DOPAMINERGICS 719543001 100 Y

PRAMEX 0.25MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG ANTI-PARKINSON DOPAMINERGICS 719843001 100 Y

PAZORAM 0.25MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG ANTI-PARKINSON DOPAMINERGICS 721392001 100 Y

MYLAN PRAMIPEXOLE 0.25MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG ANTI-PARKINSON DOPAMINERGICS 722749001 100 Y

PEXASP 0.25MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG ANTI-PARKINSON DOPAMINERGICS 723740001 100 Y

PEXOLA 0.25MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG ANTI-PARKINSON DOPAMINERGICS 898848008 100 Y

OXPOLA 1MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG ANTI-PARKINSON DOPAMINERGICS 719545001 100 Y

PRAMEX 1MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG ANTI-PARKINSON DOPAMINERGICS 719845001 100 Y

of 53


PRE-AUTH REQUIRED

PAZORAM 1MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG ANTI-PARKINSON DOPAMINERGICS 721391001 100 Y

MYLAN PRAMIPEXOLE 1MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG ANTI-PARKINSON DOPAMINERGICS 722750001 100 Y

PEXASP 1MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG ANTI-PARKINSON DOPAMINERGICS 723742001 100 Y

PEXOLA 1MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG ANTI-PARKINSON DOPAMINERGICS 898828012 100 Y

PEXOLA ER 0.375MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB SR 24HR 0.375 MG ANTI-PARKINSON DOPAMINERGICS 718253001 30 Y

PEXOLA ER 0.75MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB SR 24HR 0.75MG ANTI-PARKINSON DOPAMINERGICS 718255001 30 Y


PEXOLA ER 3MG TABS PRAMIPEXOLE DIHYDROCHLORIDE TAB SR 24HR 3 MG ANTI-PARKINSON DOPAMINERGICS 718257001 30 Y


PRANALIP 10MG TABS PRAVASTATIN SODIUM TAB 10 MG HMG-COA REDUCTASE INHIBITORS 704583001 30 Y

ASPEN PRAVASTATIN 10MG TABS PRAVASTATIN SODIUM TAB 10 MG HMG-COA REDUCTASE INHIBITORS 705212001 30 Y

SANDOZ PRAVASTATIN 10MG TABS PRAVASTATIN SODIUM TAB 10 MG HMG-COA REDUCTASE INHIBITORS 705901001 30 Y

COLITE 10MG TABS PRAVASTATIN SODIUM TAB 10 MG HMG-COA REDUCTASE INHIBITORS 710974001 30 Y

PIXETA 10MG TABS PRAVASTATIN SODIUM TAB 10 MG HMG-COA REDUCTASE INHIBITORS 715709001 30 Y

AUSTELL PRAVASTATIN 10MG TABS PRAVASTATIN SODIUM TAB 10 MG HMG-COA REDUCTASE INHIBITORS 717073001 30 Y




NOVALES 20MG FC TABS PRAVASTATIN SODIUM TAB 20 MG HMG-COA REDUCTASE INHIBITORS 712952001 30 Y








PRAVA 40MG TABS PRAVASTATIN SODIUM TAB 40 MG HMG-COA REDUCTASE INHIBITORS 839655002 30 Y


PRATSIOL 1MG TABS PRAZOSIN HCL ALPHA-RECEPTOR BLOCKERS FOR HT 782122019 100 Y



MYSOLINE 250MG TABS PRIMIDONE TAB 250 MG OTHER ANTI-EPILEPTICS 744379016 100 Y

RYTHMOL 150MG TABS PROPAFENONE HCL TAB 150 MG ANTI-ARRHYTHMICS 784869014 100 Y

RYTHMOL 300MG TABS PROPAFENONE HCL TAB 300 MG ANTI-ARRHYTHMICS 784877017 100 Y

INDERAL LA 160MG CAPS PROPRANOLOL HCL CAP ER 24HR 160 MG PROPRANOLOL 732605008 28 Y

of 53


PRE-AUTH REQUIRED

INDERAL LA 80MG CAPS PROPRANOLOL HCL CAP ER 24HR 80 MG PROPRANOLOL 732648009 28 Y

INDERAL 10MG TABS PROPRANOLOL HCL TAB 10 MG PROPRANOLOL 732567009 50 Y

PUR-BLOKA 10MG TABS PROPRANOLOL HCL TAB 10 MG PROPRANOLOL 754870016 50 Y


PRODOROL 10MG TABS PROPRANOLOL HCL TAB 10 MG PROPRANOLOL 787167010 1000 Y

INDOBLOK 10MG TABS PROPRANOLOL HCL TAB 10 MG PROPRANOLOL 806552034 1000 Y




PRODOROL 40MG TABS PROPRANOLOL HCL TAB 40 MG PROPRANOLOL 787175013 500 Y

INDOBLOK 40MG TABS PROPRANOLOL HCL TAB 40 MG PROPRANOLOL 806560029 1000 Y

QUINASPEN 10MG TABS QUINAPRIL HCL TAB 10 MG SINGLE ACE INHIBITORS 705457001 30 Y

ACCUMAX 10MG TABS QUINAPRIL HCL TAB 10 MG SINGLE ACE INHIBITORS 708119001 30 Y

QUINAGEN 10MG TABS QUINAPRIL HCL TAB 10 MG SINGLE ACE INHIBITORS 708982001 30 Y

ACCUPRIL 10MG TABS QUINAPRIL HCL TAB 10 MG SINGLE ACE INHIBITORS 783307004 28 Y

QUINASPEN 20MG TABS QUINAPRIL HCL TAB 20 MG SINGLE ACE INHIBITORS 705447001 30 Y

ACCUMAX 20MG TABS QUINAPRIL HCL TAB 20 MG SINGLE ACE INHIBITORS 708120001 30 Y







ADCO-QUINARETIC 10/12.5 TABS QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 706235001 30 Y

QUINAZIDE 10/12.5 TABS QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 707550001 30 Y

ACCUMAX CO 10/12.5MG TABS QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 708116001 30 Y

AURO QUINAPRIL CO 10MG/12.5MG QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 718056001 30 Y

BIQURETIC 10MG/12.5MG TABS QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 719873001 30 Y

ACCURETIC 10/12.5 TABS QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 795755007 28 Y

ADCO-QUINARETIC 20/12.5 TABS QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 706236001 30 Y

QUINAZIDE 20/12.5 TABS QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 707551001 30 Y

ACCUMAX CO 20/12.5MG QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 708118001 30 Y

AURO QUINAPRIL CO 20MG/12.5MG QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 718057001 30 Y

BIQURETIC 20MG/12.5MG TABS QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 719874001 30 Y

ACCURETIC 20/12.5 TABS QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 805297006 28 Y

RAMPIL 1.25MG CAPS RAMIPRIL CAP 1.25 MG SINGLE ACE INHIBITORS 705426001 30 Y

AUSTELL-RAMIPRIL 1.25MG CAPS RAMIPRIL CAP 1.25 MG SINGLE ACE INHIBITORS 705752001 30 Y

of 53


PRE-AUTH REQUIRED

RAN-RAMIPRIL 10MG CAPS RAMIPRIL CAP 10 MG SINGLE ACE INHIBITORS 704975001 30 Y

RAMPIL 10MG CAPS RAMIPRIL CAP 10 MG SINGLE ACE INHIBITORS 705429001 30 Y

AUSTELL-RAMIPRIL 10MG CAPS RAMIPRIL CAP 10 MG SINGLE ACE INHIBITORS 705755001 30 Y

SIMAYLA RAMIPRIL 10MG CAPS RAMIPRIL CAP 10 MG SINGLE ACE INHIBITORS 707869001 30 Y

APEX-RAMIPRIL 10MG CAPS RAMIPRIL CAP 10 MG SINGLE ACE INHIBITORS 715957001 28 Y

TRITACE 10MG CAPS RAMIPRIL CAP 10 MG SINGLE ACE INHIBITORS 782602002 30 Y

RAMIWIN 2.5MG CAPS RAMIPRIL CAP 2.5 MG SINGLE ACE INHIBITORS 704023001 30 Y

RAMPIL 2.5MG CAPS RAMIPRIL CAP 2.5 MG SINGLE ACE INHIBITORS 705427001 30 Y

AUSTELL-RAMIPRIL 2.5MG CAPS RAMIPRIL CAP 2.5 MG SINGLE ACE INHIBITORS 705753001 30 Y

APEX-RAMIPRIL 2.5MG CAPS RAMIPRIL CAP 2.5 MG SINGLE ACE INHIBITORS 715954001 28 Y

RAMIWIN 5MG CAPS RAMIPRIL CAP 5 MG SINGLE ACE INHIBITORS 704025001 30 Y

RAMPIL 5MG CAPS RAMIPRIL CAP 5 MG SINGLE ACE INHIBITORS 705428001 30 Y

AUSTELL-RAMIPRIL 5MG CAPS RAMIPRIL CAP 5 MG SINGLE ACE INHIBITORS 705754001 30 Y

APEX-RAMIPRIL 5MG CAPS RAMIPRIL CAP 5 MG SINGLE ACE INHIBITORS 715955001 28 Y

RAMIPRIL HEXAL 2.5MG TABS RAMIPRIL TAB 2.5 MG SINGLE ACE INHIBITORS 704374001 30 Y

RETACE 2.5MG TABS RAMIPRIL TAB 2.5 MG SINGLE ACE INHIBITORS 707383001 30 Y

TRITACE 2.5MG TABS RAMIPRIL TAB 2.5 MG SINGLE ACE INHIBITORS 841587019 30 Y

RAMIPRIL HEXAL 5MG TABS RAMIPRIL TAB 5 MG SINGLE ACE INHIBITORS 704375001 30 Y

RETACE 5MG TABS RAMIPRIL TAB 5 MG SINGLE ACE INHIBITORS 707385001 30 Y

TRITACE 5MG TABS RAMIPRIL TAB 5 MG SINGLE ACE INHIBITORS 841595003 30 Y

TRI-PLEN 2.5MG TABS RAMIPRIL-FELODIPINE TAB 2.5-2.5 MG ACE INHIBITOR/CCB COMBINATIONS 862207002 30 Y

TRI-PLEN FORTE 5MG TABS RAMIPRIL-FELODIPINE TAB 5-5 MG ACE INHIBITOR/CCB COMBINATIONS 862215005 30 Y

TRITACE PLUS 10MG/12.5MG TABS RAMIPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 718093001 28 Y

CO-RAMIWIN 10MG/12.5MG TABS RAMIPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 723566001 30 Y

CO-RAMIWIN 2.5MG/12.5MG TABS RAMIPRIL-HYDROCHLOROTHIAZIDE TAB 2.5-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 723564001 30 Y

TRITACE PLUS 5MG/12.5MG TABS RAMIPRIL-HYDROCHLOROTHIAZIDE TAB 5-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 718094001 28 Y

CO-RAMIWIN 5MG/12.5MG TABS RAMIPRIL-HYDROCHLOROTHIAZIDE TAB 5-12.5 MG ACE INHIBITOR/DIURETIC COMBINATIONS 723565001 30 Y

TRITACE PLUS 5MG/25MG TABS RAMIPRIL-HYDROCHLOROTHIAZIDE TAB 5-25 MG ACE INHIBITOR/DIURETIC COMBINATIONS 718092001 28 Y

AZILECT 1MG TABS RASAGILINE MESYLATE TAB 1 MG ( OTHER ANTI-PARKINSON AGENTS 711769001 28 Y

NOVONORM 0.5MG TABS REPAGLINIDE TABS 0.5 MG ORAL ANTI-DIABETIC AGENTS 861324005 90

NOVONORM 1MG TABS REPAGLINIDE TABS 1 MG ORAL ANTI-DIABETIC AGENTS 861332008 90

NOVONORM 2MG TABS REPAGLINIDE TABS 2 MG ORAL ANTI-DIABETIC AGENTS 861340019 90

BRINERDIN TABS RESERPINE-DIHYDROERGOCRISTINE-CLOPAMIDE TAB 0.1-0. SYMPATHETIC NERVOUS BLOCKERS 710458002 30

XARELTO 10MG TABS RIVAROXABAN TAB 10 MG ORAL ANTI-COAGULANTS 714238001 10 Y



of 53


PRE-AUTH REQUIRED


DAXAS 0.5MG TABS ROFLUMILAST TAB 500 MCG OTHER RESPIRATORY SYSTEM AGENTS 715321002 30 Y

REQUIP 0.25MG TABS ROPINIROLE HYDROCHLORIDE TAB 0.25 MG ANTI-PARKINSON DOPAMINERGICS 700647003 210 Y


ACCORD ROPINIROLE 0.25MG TABS ROPINIROLE HYDROCHLORIDE TAB 0.25 MG ANTI-PARKINSON DOPAMINERGICS 719569001 84 Y


ACCORD ROPINIROLE 0.5MG TABS ROPINIROLE HYDROCHLORIDE TAB 0.5 MG ANTI-PARKINSON DOPAMINERGICS 719570001 84 Y

REQUIP 1.0MG TABS ROPINIROLE HYDROCHLORIDE TAB 1 MG ANTI-PARKINSON DOPAMINERGICS 700652003 84 Y

ACCORD ROPINIROLE 1MG TABS ROPINIROLE HYDROCHLORIDE TAB 1 MG ANTI-PARKINSON DOPAMINERGICS 719571001 84 Y





REQUIP XL 2MG SR TABS ROPINIROLE HYDROCHLORIDE TAB S ANTI-PARKINSON DOPAMINERGICS 711090001 28 Y




CRESTOR 10MG TABS ROSUVASTATIN CALCIUM TAB 10 MG HMG-COA REDUCTASE INHIBITORS 705989001 30 Y

ZUVAMOR 10MG TABS ROSUVASTATIN CALCIUM TAB 10 MG HMG-COA REDUCTASE INHIBITORS 717520001 28 Y

VUSOR 10MG TABS ROSUVASTATIN CALCIUM TAB 10 MG HMG-COA REDUCTASE INHIBITORS 719082001 30 Y

STORWIN 10MG TABS ROSUVASTATIN CALCIUM TAB 10 MG HMG-COA REDUCTASE INHIBITORS 719194001 30 Y

ROSVATOR 10MG TABS ROSUVASTATIN CALCIUM TAB 10 MG HMG-COA REDUCTASE INHIBITORS 719251001 30 Y

ROCREST 10MG TABS ROSUVASTATIN CALCIUM TAB 10 MG HMG-COA REDUCTASE INHIBITORS 721807001 30 Y

ROSTOR 10MG TABS ROSUVASTATIN CALCIUM TAB 10 MG HMG-COA REDUCTASE INHIBITORS 721858001 30 Y

CRESAGEN 10MG TABS ROSUVASTATIN CALCIUM TAB 10 MG HMG-COA REDUCTASE INHIBITORS 723098001 28 Y

ROSUVASTATIN UNICORN 10MG TABS ROSUVASTATIN CALCIUM TAB 10 MG HMG-COA REDUCTASE INHIBITORS 3000401001 30 Y












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PRE-AUTH REQUIRED











GLICLAZIDE UNICORN MR 30MG TAB ROSUVASTATIN CALCIUM TAB 5 MG SULFONYLUREAS 721692001 60 Y





ONGLYZA 2.5MG TABS SAXAGLIPTIN HCL TAB 2.5 MG (BASE EQUIV) DPP4-ANTAGONISTS 716640001 30 Y

ONGLYZA 5MG TABS SAXAGLIPTIN HCL TAB 5 MG (BASE EQUIV) DPP4-ANTAGONISTS 716641001 30 Y

PARKILYNE 5MG TABS SELEGILINE HCL TAB 5 MG OTHER ANTI-PARKINSON AGENTS 706712001 30 Y

RENVELA 800MG TABS SEVELAMER CARBONATE TAB 800 MG OTHER CHELATING AGENTS/ION EXCHANGE PREPARATIONS 720512001 180 Y

RENAGEL 800MG TABS SEVELAMER HCL TAB 800 MG OTHER CHELATING AGENTS/ION EXCHANGE PREPARATIONS 711329001 180 Y

SIMVACOR 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 700519002 30 Y

ADCO-SIMVASTATIN 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 701276003 30 Y

SIMVOTIN 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 703525001 28 Y

LIPIDEX 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 705076001 30 Y

AUSTELL-SIMVASTATIN 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 705464001 30 Y


ASPEN SIMVASTATIN 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 706714001 30 Y

ARROW SIMVASTATIN 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 707089001 28 Y


SIMAYLA SIMVASTATIN 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 707870001 28 Y

CIPLA-SIMVASTATIN 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 708307001 30 Y

BIOVAC SIMVASTATIN 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 709668001 30 Y

ZYSIM 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 710826001 30 Y

NOVATIN 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 710868001 30 Y

REDICOR 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 711232001 30 Y

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PRE-AUTH REQUIRED

SIMCOR 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 713487001 30 Y

CHOLESTE 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 715708001 30

ZOCOR 10MG TABS SIMVASTATIN TAB 10 MG HMG-COA REDUCTASE INHIBITORS 783951019 28 Y




LIPIDEX 20MG TABS SIMVASTATIN TAB 20 MG HMG-COA REDUCTASE INHIBITORS 705077001 30 Y

MYLAN SIMVASTATIN 20MG TABS SIMVASTATIN TAB 20 MG HMG-COA REDUCTASE INHIBITORS 705382001 30 Y













CHOLESTE 20MG TABS SIMVASTATIN TAB 20 MG HMG-COA REDUCTASE INHIBITORS 714705001 30 Y
















CHOLESTE 40MG TABS SIMVASTATIN TAB 40 MG HMG-COA REDUCTASE INHIBITORS 714706001 30 Y

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PRE-AUTH REQUIRED


CIPLA-SIMVASTATIN 80MG TABS SIMVASTATIN TAB 80 MG HMG-COA REDUCTASE INHIBITORS 710513001 30

ZYSIM 80MG TABS SIMVASTATIN TAB 80 MG HMG-COA REDUCTASE INHIBITORS 710829001 30

NOVATIN 80MG TABS SIMVASTATIN TAB 80 MG HMG-COA REDUCTASE INHIBITORS 710871001 30

JANUVIA 100MG TABS SITAGLIPTIN PHOSPHATE TAB 100 MG (BASE EQUIV) DPP4-ANTAGONISTS 717787001 28 Y



JANUMET 50MG/1000MG TABS SITAGLIPTIN-METFORMIN HCL TAB 50-1000 MG DPP4-ANTAGONISTS 717791001 56 Y

JANUMET 50MG/500 MG TABS SITAGLIPTIN-METFORMIN HCL TAB 50-500 MG DPP4-ANTAGONISTS 717788001 56 Y

JANUMET 50MG/850MG TABS SITAGLIPTIN-METFORMIN HCL TAB 50-850 MG DPP4-ANTAGONISTS 717790001 56 Y

SOTAHEXAL 160MG TABS SOTALOL HCL TAB 160 MG OTHER BETA-RECEPTOR BLOCKERS 828009007 100 Y

SOTAHEXAL 80MG TABS SOTALOL HCL TAB 80 MG OTHER BETA-RECEPTOR BLOCKERS 827991002 100 Y

ALDACTONE 100MG TABS SPIRONOLACTONE TAB 100 MG POTASSIUM SPARING DIURETICS 701807016 30 Y

SPIRACTIN 100MG TABS SPIRONOLACTONE TAB 100 MG POTASSIUM SPARING DIURETICS 898937019 60 Y

CIPLATEC 20MG TABS SPIRONOLACTONE TAB 25 MG SINGLE ACE INHIBITORS 701729001 30 Y

ALDACTONE 25MG TABS SPIRONOLACTONE TAB 25 MG POTASSIUM SPARING DIURETICS 701793007 60 Y



SANDOZ SPIRONOLACTONE 25MG SPIRONOLACTONE TAB 25 MG POTASSIUM SPARING DIURETICS 769665004 30 Y

SANDOZ SPIRONOLACTONE 25MG SPIRONOLACTONE TAB 25 MG POTASSIUM SPARING DIURETICS 769665012 200 Y

SALAZOPYRIN 500MG TABS SULFASALAZINE TAB 500 MG SALAZOPYRIN PLAIN 761826009 100 Y

SALAZOPYRIN-EN 500MG TABS SULFASALAZINE TAB DELAYED RELEASE 500 MG RHEUMATOID ARTHRITIS AGENTS 762008008 100 Y

SAFLUTAN 15MCG/ML SINGLE DOSE TAFLUPROST OPHTH SOLN 0.0015% PROSTAGLANDINS FOR GLAUCOMA 720401001 30 Y

PRITOR 40MG TABS TELMISARTAN TAB 40 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 714249001 28 Y

MIZART 40MG TABS TELMISARTAN TAB 40 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 720439001 30 Y

TELGEN 40MG TABS TELMISARTAN TAB 40 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 720592001 30 Y

TESAR 40MG TABS TELMISARTAN TAB 40 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 721678001 30 Y

MICARDIS 40MG TABS TELMISARTAN TAB 40 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 860387003 28 Y

PRITOR 80MG TABS TELMISARTAN TAB 80 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 714250001 28 Y

MIZART 80MG TABS TELMISARTAN TAB 80 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 720440001 30 Y

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PRE-AUTH REQUIRED

TELGEN 80MG TABS TELMISARTAN TAB 80 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 720593001 30 Y

TESAR 80MG TABS TELMISARTAN TAB 80 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 721679001 30 Y

MICARDIS 80MG TABS TELMISARTAN TAB 80 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 860395006 28 Y

TWYNSTA 40/10MG TABS TELMISARTAN-AMLODIPINE TAB 40-10 MG ANGIOTENSIN RECEPTOR ANTAGONISTS 717367001 28 Y




CO-PRITOR 40/12.5 MG TABS TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG ARB/DIURETIC COMBINATIONS 714251001 28 Y

CO-MICARDIS 40/12.5MG TABS TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG ARB/DIURETIC COMBINATIONS 894614002 28 Y

TELPRES PLUS 40MG/12.5MG TABS TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG ARB/DIURETIC COMBINATIONS 3000422001 28 Y

CO-PRITOR 80/12.5MG TABS TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG ARB/DIURETIC COMBINATIONS 714252001 28 Y

CO-MICARDIS 80/12.5MG TABS TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG ARB/DIURETIC COMBINATIONS 894621009 28 Y

TELPRES PLUS 80MG/12.5MG TABS TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG ARB/DIURETIC COMBINATIONS 3000423001 28 Y

CO-MICARDIS 80MG/25MG TABS TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 80-25 MG ARB/DIURETIC COMBINATIONS 716791001 28 Y

HYTRIN 1MG TABS TERAZOSIN HCL TAB 1 MG (BASE EQUIVALENT) ALPHA-RECEPTOR BLOCKERS FOR HT/BPH 806358009 10 Y




NYOGEL 5GM EYE GEL TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25% BETA BLOCKERS FOR GLAUCOMA 702142001 1 Y

TIMOPTOL-XE .25% 2.5ML TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25% BETA BLOCKERS FOR GLAUCOMA 819816019 1 Y

TIMOPTOL-XE .5% 2.5ML DROPS TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.5% BETA BLOCKERS FOR GLAUCOMA 819824003 1 Y

TIMOPTOL 0.25% 5ML DROPS TIMOLOL MALEATE OPHTH SOLN 0.25% BETA BLOCKERS FOR GLAUCOMA 770833004 1 Y

OCCUMOL 0.5% DROPS TIMOLOL MALEATE OPHTH SOLN 0.5% BETA BLOCKERS FOR GLAUCOMA 720734001 1 Y

TIMOPTOL 0.5% 5ML DROPS TIMOLOL MALEATE OPHTH SOLN 0.5% BETA BLOCKERS FOR GLAUCOMA 770841007 1 Y

GLAUCOSAN 0.5% 5ML TIMOLOL MALEATE OPHTH SOLN 0.5% BETA BLOCKERS FOR GLAUCOMA 821624008 1 Y

SERVATRIN TABS TIMOLOL-AMILORIDE-HYDROCHLOROT BETA-RECEPTOR BLOCKER/DIURETIC COMBINATIONS 780472004 30 Y

SPIRIVA RESPIMAT INH 60 DOSE TIOTROPIUM BROMIDE MONOHYDRATE INHAL ANTICHOLINERGICS FOR COPD 710897001 1 Y

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PRE-AUTH REQUIRED

AEROSOL 2.5 M

SPIRIVA INH CAPS 30 WITH HANDI TIOTROPIUM BROMIDE MONOHYDRATE INHAL CAP 18 MCG (BASE) ANTICHOLINERGICS FOR COPD 702523006 1 Y

SPIRIVA INH CAPS REFILL TIOTROPIUM BROMIDE MONOHYDRATE INHAL CAP 18 MCG (BASE) ANTICHOLINERGICS FOR COPD 702526003 30 Y

FORVENT 18MCG INH CAPS REFILL TIOTROPIUM BROMIDE MONOHYDRATE INHAL CAP 18 MCG (BASE) ANTICHOLINERGICS FOR COPD 714152001 30 Y

FORVENT HANDIHALER COMPL & TIOTROPIUM BROMIDE MONOHYDRATE INHAL CAP 18 MCG (BASE) ANTICHOLINERGICS FOR COPD 714167001 1 Y

ACTEMRA 200MG/10ML VIAL TOCILIZUMAB IV INJ 200 MG/10ML RHEUMATOID ARTHRITIS AGENTS 715814001 1 Y



TASMAR 100MG TABS TOLCAPONE TAB 100 MG OTHER ANTI-PARKINSON AGENTS 839108001 100 Y

TOPAMAX SC SPRINKLE 15MG CAPS TOPIRAMATE SPRINKLE CAP 15 MG OTHER ANTI-EPILEPTICS 878014004 60 Y



TOPLEP 100MG TABS TOPIRAMATE TAB 100 MG OTHER ANTI-EPILEPTICS 708391001 60 Y

SANDOZ TOPIRAM 100MG TABS TOPIRAMATE TAB 100 MG OTHER ANTI-EPILEPTICS 709286001 60 Y

ADCO-TOPIRAMATE 100MG TABS TOPIRAMATE TAB 100 MG OTHER ANTI-EPILEPTICS 710242001 60 Y

EPITOZ 100MG TABS TOPIRAMATE TAB 100 MG OTHER ANTI-EPILEPTICS 710901001 60 Y

TOPALEX 100MG TABS TOPIRAMATE TAB 100 MG OTHER ANTI-EPILEPTICS 715981001 60 Y

PAMIRAM 100MG TABS TOPIRAMATE TAB 100 MG OTHER ANTI-EPILEPTICS 716468001 60 Y

TOPIROL 100MG TABS TOPIRAMATE TAB 100 MG OTHER ANTI-EPILEPTICS 718291002 30 Y

EPIMATE 100MG TABS TOPIRAMATE TAB 100 MG OTHER ANTI-EPILEPTICS 718857001 60 Y

TOPAMAX 100MG TABS TOPIRAMATE TAB 100 MG OTHER ANTI-EPILEPTICS 822531003 60 Y













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PRE-AUTH REQUIRED














TORAHEXAL 10MG TABS TORSEMIDE TAB 10 MG LOOP DIURETICS 707191001 30 Y

TORASEMIDE BIOTECH 10MG TABS TORSEMIDE TAB 10 MG LOOP DIURETICS 723758001 30 Y

UNAT 10MG TABS TORSEMIDE TAB 10 MG LOOP DIURETICS 820385018 30 Y

UNAT 2.5MG TABS TORSEMIDE TAB 2.5 MG LOOP DIURETICS 820369004 30 Y

TORAHEXAL 5MG TABS TORSEMIDE TAB 5 MG LOOP DIURETICS 707190001 30 Y

TORASEMIDE BIOTECH 5MG TABS TORSEMIDE TAB 5 MG LOOP DIURETICS 723757001 30 Y

UNAT 5MG TABS TORSEMIDE TAB 5 MG LOOP DIURETICS 820377007 30 Y

MAVIK 0.5MG CAPS TRANDOLAPRIL CAP 0.5 MG SINGLE ACE INHIBITORS 805033017 30 Y

MAVIK 2MG CAPS TRANDOLAPRIL CAP 2 MG SINGLE ACE INHIBITORS 805068015 30 Y

TARKA 180MG/2MG CR TABS TRANDOLAPRIL-VERAPAMIL HCL TAB CR 2-180 MG ACE INHIBITOR/CCB COMBINATIONS 714624001 30 Y

TARKA 240MG/4MG CR TABS TRANDOLAPRIL-VERAPAMIL HCL TAB CR 4-240 MG ACE INHIBITOR/CCB COMBINATIONS 714625001 30 Y

TRAVATAN 2.5ML EYE DROPS TRAVOPROST OPHTH SOLN 0.004% PROSTAGLANDINS FOR GLAUCOMA 702534003 1 Y

TRAVOPROST 2.5ML EYE DROPS TRAVOPROST OPHTH SOLN 0.004% PROSTAGLANDINS FOR GLAUCOMA 702803006 30 Y

DUOTRAV 2.5ML OPD TRAVOPROST-TIMOLOL MALEATE OPHTH SOLN 0.004-0.5%


DYAZIDE TABS TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 50-25 MG DIURETIC COMBINATIONS 721824005 28 Y

RENEZIDE TABS TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 50-25 MG DIURETIC COMBINATIONS 780146018 28 Y

RENEZIDE TABS TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 50-25 MG DIURETIC COMBINATIONS 780146026 250 Y

STELAZINE 1MG TABS TRIFLUOPERAZINE HCL TAB 1 MG (BASE EQUIVALENT) PHENOTHIAZINES 766410005 50 Y



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PRE-AUTH REQUIRED

BENZHEXOL 2MG TABS TRIHEXYPHENIDYL HCL TAB 2 MG ANTI-PARKINSON ANTI-CHOLINERGICS 713210001 100 Y

EPILIM 200MG/5ML LIQ VALPROATE SODIUM LIQD 200 MG/5ML OTHER ANTI-EPILEPTICS 780545001 300 Y

CONVULEX 50MG/ML SYR VALPROATE SODIUM ORAL SOLN 250 MG/5ML (BASE EQUIV) OTHER ANTI-EPILEPTICS 781541018 100 Y

EPILIM 100MG CRUSH TABS VALPROATE SODIUM TAB 100 MG OTHER ANTI-EPILEPTICS 821578006 100 Y

EPILIZINE CR 200MG TABS VALPROATE SODIUM TAB CR 200 MG OTHER ANTI-EPILEPTICS 718274001 100 Y

NAVALPRO CR 200MG TABS VALPROATE SODIUM TAB CR 200 MG OTHER ANTI-EPILEPTICS 718465001 100 Y

EPROLEP CR 200MG TABS VALPROATE SODIUM TAB CR 200 MG OTHER ANTI-EPILEPTICS 721460001 100 Y

EPILIM CR 200MG TABS VALPROATE SODIUM TAB CR 200 MG OTHER ANTI-EPILEPTICS 818666005 100 Y



VALEPTIC CR 300MG TABS VALPROATE SODIUM TAB CR 300 MG OTHER ANTI-EPILEPTICS 720026001 100 Y





VALEPTIC CR 500MG TABS VALPROATE SODIUM TAB CR 500 MG OTHER ANTI-EPILEPTICS 720027001 100 Y



CONVULEX 150MG CAPS VALPROIC ACID CAP 150 MG OTHER ANTI-EPILEPTICS 715980009 100 Y

CONVULEX 300MG CAPS VALPROIC ACID CAP 300 MG OTHER ANTI-EPILEPTICS 715999001 100 Y

CONVULEX 500MG CAPS VALPROIC ACID CAP DELAYED RELEASE 500 MG OTHER ANTI-EPILEPTICS 781568005 100 Y

DIOVAN 160MG F/COATED TABS VALSARTAN TAB 160 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 700710001 28 Y

TAREG 160MG TABS VALSARTAN TAB 160 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 704696001 28 Y

ZOMEVEK 160MG TABS VALSARTAN TAB 160 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 715556001 28 Y

MIGROBEN 160MG TABS VALSARTAN TAB 160 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 715569001 28 Y

DIOLO 160MG TABS VALSARTAN TAB 160 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 717035001 28 Y

VALSARTAN UNICORN 160MG TABS VALSARTAN TAB 160 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 718364001 28 Y

VALANT 160MG TABS VALSARTAN TAB 160 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 719851001 28 Y

DYNAVAL 160MG TABS VALSARTAN TAB 160 MG SINGLE ANGIOTENSIN RECEPTOR 723725001 30 Y

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PRE-AUTH REQUIRED

ANTAGONISTS

VASOVAN 160MG TABS VALSARTAN TAB 160 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 723771001 28 Y

ADCO-VALSARTAN 160MG TABS VALSARTAN TAB 160 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 723947001 30 Y

DIOVAN 320MG TABS VALSARTAN TAB 320 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 710051001 28 Y




TAREG 80MG TABS VALSARTAN TAB 80 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 705060001 28 Y

ZOMEVEK 80MG TABS VALSARTAN TAB 80 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 715555001 28 Y

MIGROBEN 80MG TABS VALSARTAN TAB 80 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 715568001 28 Y

DIOLO 80MG TABS VALSARTAN TAB 80 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 717034001 28 Y

VALSARTAN UNICORN 80MG TABS VALSARTAN TAB 80 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 718363001 28 Y


DYNAVAL 80MG TABS VALSARTAN TAB 80 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 723724001 30 Y

VASOVAN 80MG TABS VALSARTAN TAB 80 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 723770001 28 Y

ADCO-VALSARTAN 80MG TABS VALSARTAN TAB 80 MG SINGLE ANGIOTENSIN RECEPTOR ANTAGONISTS 723946001 30 Y

CO-ZOMEVEK 160/12.5MG TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG ARB/DIURETIC COMBINATIONS 715559001 28 Y

CO-MIGROBEN 160MG/12.5MG TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG ARB/DIURETIC COMBINATIONS 715571001 28 Y

CO-TAREG 160MG/12.5MG TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG ARB/DIURETIC COMBINATIONS 715672001 28 Y

DIOLO CO 160MG/12.5MG TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG ARB/DIURETIC COMBINATIONS 718608001 28 Y

CO-DIOVAN 160/12.5MG TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG ARB/DIURETIC COMBINATIONS 891894005 28 Y

CO-DIOVAN 160MG PLUS TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG ARB/DIURETIC COMBINATIONS 706051001 28 Y

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PRE-AUTH REQUIRED

CO-ZOMEVEK 160/25MG TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG ARB/DIURETIC COMBINATIONS 715560001 28 Y

CO-MIGROBEN 160/25MG TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG ARB/DIURETIC COMBINATIONS 715572001 28 Y

CO-TAREG PLUS 160/25MG TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG ARB/DIURETIC COMBINATIONS 715673001 28 Y

CO-DIOVAN 320MG/12.5MG TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-12.5 MG ARB/DIURETIC COMBINATIONS 710048001 28 Y

CO-DIOVAN 320MG/25MG TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-25 MG ARB/DIURETIC COMBINATIONS 710050001 28 Y

CO-TAREG 80/12.5MG TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG ARB/DIURETIC COMBINATIONS 705068001 28 Y

CO-ZOMEVEK 80MG/12.5MG TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG ARB/DIURETIC COMBINATIONS 715558001 28 Y

CO-MIGROBEN 80/12.5MG TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG ARB/DIURETIC COMBINATIONS 715570001 28 Y

DIOLO CO 80MG/12.5MG TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG ARB/DIURETIC COMBINATIONS 718607001 28 Y

CO-DIOVAN 80/12.5MG TABS VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG ARB/DIURETIC COMBINATIONS 839884002 28 Y

ISOPTIN 40MG TABS VERAPAMIL HCL TAB 40 MG CALCIUM CHANNEL BLOCKERS 734071019 100 Y

VASOMIL 40MG TABS VERAPAMIL HCL TAB 40 MG CALCIUM CHANNEL BLOCKERS 774944013 100 Y




VERAHEXAL 240 SR TABS VERAPAMIL HCL TAB ER 240 MG CALCIUM CHANNEL BLOCKERS 700071003 30 Y

VERAHEXAL 240 SR TABS VERAPAMIL HCL TAB ER 240 MG CALCIUM CHANNEL BLOCKERS 700071006 100 Y

ISOPTIN SR 240MG TABS VERAPAMIL HCL TAB ER 240 MG CALCIUM CHANNEL BLOCKERS 734373007 30 Y

ISOPTIN SR 240MG TABS VERAPAMIL HCL TAB ER 240 MG CALCIUM CHANNEL BLOCKERS 734373015 100 Y

CALCICARD SR 240MG VERAPAMIL HCL TAB ER 240 MG CALCIUM CHANNEL BLOCKERS 813354005 30 Y

RAVAMIL SR 240MG TABS VERAPAMIL HCL TAB ER 240 MG CALCIUM CHANNEL BLOCKERS 819573019 30 Y

RAVAMIL SR 240MG TABS VERAPAMIL HCL TAB ER 240 MG CALCIUM CHANNEL BLOCKERS 819573027 100 Y

SABRIL 500MG TABS VIGABATRIN TAB 500 MG OTHER ANTI-EPILEPTICS 809594005 100 Y

GALVUS 50MG TABS VILDAGLIPTIN TAB 50 MG DPP4-ANTAGONISTS 715554001 28 Y

GALVUS 50MG TABS VILDAGLIPTIN TAB 50 MG DPP4-ANTAGONISTS 715554002 56 Y

JALRA 50MG TABS VILDAGLIPTIN TAB 50 MG DPP4-ANTAGONISTS 721592001 28 Y

JALRA 50MG TABS VILDAGLIPTIN TAB 50 MG DPP4-ANTAGONISTS 721592002 56 Y

GALVUS MET 50/1000MG TABS VILDAGLIPTIN-METFORMIN HCL TAB 50-1000 MG DPP4-ANTAGONISTS 717637001 30 Y




CIPLA-WARFARIN 1MG TABS WARFARIN SODIUM TAB 1 MG ORAL ANTI-COAGULANTS 709906001 100 Y



ASPEN WARFARIN 5MG TABS WARFARIN SODIUM TAB 5 MG ORAL ANTI-COAGULANTS 778362019 100 Y

GEODON 20MG CAPS ZIPRASIDONE HCL CAP 20 MG ATYPICAL ANTI-PSYCHOTICS 703465001 60 Y


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PRE-AUTH REQUIRED



CLOPIXOL DEPOT 200MG IJ ZUCLOPENTHIXOL DECANOATE IM IN OIL 200 MG/ML OTHER ANTI-PSYCHOTICS 714852007 1 Y

CLOPIXOL DEPOT 200MG IJ ZUCLOPENTHIXOL DECANOATE IM IN OIL 200 MG/ML OTHER ANTI-PSYCHOTICS 714852023 5 Y

CLOPIXOL 10MG TABS ZUCLOPENTHIXOL DIHYDROCHLORIDE TAB 10 MG OTHER ANTI-PSYCHOTICS 789798018 100 Y

CLOPIXOL 2MG TABS ZUCLOPENTHIXOL DIHYDROCHLORIDE TAB 2 MG OTHER ANTI-PSYCHOTICS 796751005 100 Y

DISCLAIMER: Please note that these formularies are regularly reviewed by the Mediscor Pharmacy and Therapeutics Committee to ensure that they comply with the latest pharmacological norms for the treatment of the listed conditions. Mediscor PBM Pty Ltd reserves the right to amend the formularies to comply with the latest pharmacological norms for the treatment of the listed conditions. Mediscor may at any time remove, add or replace medicines listed in the formulary when new information becomes available, e.g. new findings regarding the safety or therapeutic efficacy of the medicine in question. The information contained in the formularies is intended to serve as a guide to, and not as a substitute for, the knowledge, expertise, skill and judgement of persons prescribing or dispensing medicine. Mediscor shall not under any circumstances be liable for any side-effects or other consequential or incidental harm of any kind or description whatsoever arising from the use of, or failure to use, any medicine on the strength of information contained in a Mediscor formulary. COPYRIGHT: Mediscor reserves its copyright and all its other intellectual-property rights in or in respect of the Mediscor formularies. No part of the Mediscor formularies may be reproduced, photocopied, recorded or stored in any retrieval system, or transmitted by any means, electronic, mechanical or otherwise, without the written permission of Mediscor.

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