PRESCRIPTION DRUG - Public Employees' Benefits Program (PEBP)

$$ UROXATRAL(ST) history of doxazosin orterazosinX$$$ VIAGRA NOT COVERED18.1 DIABETIC SUPPLIES$$ ASCENSIA AUTODISC TEST STRIPQLL=150/Rx For meters call 1-800-336-0123 X$$ ASCENSIA CONTOUR TEST STRIPQLL=150/Rx For meters call 1-800-336-0123 X$$ ASCENSIA ELITE TEST STRIPQLL=150/Rx For meters call 1-800-336-0123 X$$ AT LAST TEST STRIPQLL=150/Rx For meters call 1-800-336-0123 X$$ BIOSCANNER GLUCOSE STRIPS X$$ CHEMSTRIP UGK X$$ CLINITEST REAGENT TABLET X$$ CLINISTIX REAGENT STRIPS X$$ DIASTIX X$$ EXCEL G TEST STRIPSQLL=150/Rx For meters call 1-800-336-0123 X$$ FAST TAKE TEST STRIPSQLL=150/Rx For meters call 1-800-336-0123 X(ST) history of use of Bayer orASCENSIA , FAST TAKE, ONE$$$ FREESTYLE TEST STRIPSLifescan products(ST) history of use of Bayer or$$$ GLUCOMETER ENCORELifescan products$$ GLUCOSTIX REAGENT STRIPS X$$ HEMA-CHECK PATIENT DISP PAK X$$ HEMA-COMBISTIX STRIPS X$$ HEMASTIX STRIPS X$$ HEMATEST REAGENT TABLET X$$ Insulin syringes (various) X$$ KETO-DIASTIX REAGENT STRIPS X$$ MULTISTIX REAGENT STRIPS X$$ ONE TOUCH BASIC SYSTEM X$$ ONE TOUCH PROFILE SYSTEM X$$ ONE TOUCH TEST STRIPSQLL=150/Rx For meters call 1-800-336-0123 X$$ ONE TOUCH ULTRA SYSTEM X$$ ONE TOUCH ULTRA TEST STRIPSQLL=150/Rx For meters call 1-800-336-0123 X$$ OPTIUM TEST STRIPSQLL=150/Rx For meters call 1-800-336-0123 X$$ NOVOFINE 30 X$$$ PRECISION Q-I-D(ST) history of use of Bayer orLifescan products(ST) history of use of Bayer or$$$ PRECISION SOF-TACTLifescan productsPRECISION XTRA BLOOD GLUCOSE QLL=150/Rx (ST) history of any$$STRIPSinsulinXQLL=150/Rx For meters call 1-800-$$ SURESTEP PRO TEST STRIPS 336-0123 X$$ SURESTEP TEST STRIPSQLL=150/Rx For meters call 1-800-336-0123 X18.1 MISCELLANEOUS DRUG$$$$$ AMPYRA (PAR) X$$$$$ GILENYA (PAR); Spec. Pharm. XCHAPTER 19: PREVENTIVE SERVICES under the PATIENT PROTECTION and AFFORDABLE CARE ACTASPIRINAspirin to prevent cardiovasculardisease (CVD): MenHometown Health CoverageThe U.S. Preventative Services TaskForce (USPSTF) recommends the use ofaspirin for men age 45 to 79 years whenthe potential benefit due to a reduction inmyocardial infarctions outweighs thepotential harm due to an increase ingastrointestinal hemorrhage.· Age limit greaterthan or equal to 45(menand women)· Quantity Limit1/day· Generic Only· OTC (requires aprescription)Aspirin to prevent cardiovascularProduct Descriptiondisease: WomenThe USPSTF recommends the use ofaspirin for women age 55 to 79 yearswhen the potential benefit of a reduction inAspirin products up to 325mgischemic strokes outweighs the potentialharm or an increase in gastrointestinalhemorrhage.· Aspirin 81mg –325mg· Aspirin Chew 81mg– 325mg· Aspirin DelayedRelease 81mg – 325mg· Aspirin dispersibletab 81mgCO-PAY $0.00FLUORIDEPrevention of dental caries (cavities) Hometown Health CoverageThe USPSTF recommends that primarycare clinicians prescribe oral fluoridesupplementation at currently· Age limit less thanrecommended doses to preschool childrenor equal to 5 yearsolder than 6 months of age whose primarywater source is deficient in fluoride.XXXXCO-PAY $0.00CO-PAY $0.00TOUCHASCENSIA , FAST TAKE, ONETOUCHASCENSIA , FAST TAKE, ONETOUCHASCENSIA , FAST TAKE, ONETOUCHSupplementation with folic acid· Prescriptionproducts onlyProduct DescriptionSodium fluoride products only, notin combination· Sodium fluoride tab 0.5mg· Sodium fluoride chew tab0.25mg – 0.5mg· Sodium fluoride solutionFOLIC ACIDHometown Health Coverage23