To order additional copies, please call Massachusetts Medical

Xxxxxx Anti-infectives Xxxxxx (Penicillins)
Name AETNA BCBSMA BMCHP FCHP HPHC HNE NHP NTWK MAHLTH THP
AMOXICILLIN/CLAVULANATE X* X* X X X X X X X X*
AMOXICILLIN/CLAVULANATE FE X PA X NC X X
[Augmentin Es-600]
AMOXICILLIN/CLAVULANATE
[Augmentin XR]
FE NC X X X X X PA X
AMPICILLIN X* X* X X X X X X X X*
DICLOXACILLIN X* X* X X X X X X X X*
PENICILLIN VK X* X* X X X X X X X X*
Anti-infectives (Sulfas)
sULFADIAzINE X* X* X X X X X X X X
sULFAsALAzINE DL* X* X X X X X X X X
sULFAsALAzINE ENTERIC COATED DL* X* X X X X X X X X
sULFIsOXAzOLE NC X* X X X X X X X X
sULFIsOXAzOLE/ERyTHROMyCIN X* X* X X X X X X X X
sULFAMETHOXAzOLE/TMP X* X* X X X X X X X X*
Anti-infectives (Tetracyclines)
DEMECLOCyCLINE PA* 4 X* X X X X X X X
DOXyCyCLINE HyCLATE PA* 4 X* X X X X X X X X*
DOXyCyCLINE MONOHyDRATE PA* 4 X* X X X X X X X X
DOXyCyCLINE MONOHyDRATE FE PA4 X PA PA X NC PA X
[Adoxa] sT
DOXyCyCLINE MONOHyDRATE PA4 [Doryx]
NC PA X NC PA X
DOXyCyCLINE MONOHyDRATE DL FE NC PA PA X NC PA NC
[Oracea] PA
MINOCyCLINE PA* 4 X* X X X X X X X X*
MINOCyCLINE [solodyn] PA4 NC PA PA PA NC PA NC
TETRACyCLINE PA* 4 X* X X X X X X X X*
Antipsychotics
ARIPIPRAzOLE [Abilify] DL sT X* DL PA X DL DL DL X
ARIPIPRAzOLE injection [Abilify] NC5 X* X6 DL X X
4 ≤8 yrs old
5 Not covered under pharmacy benefit; may be covered under medical benefit
6 Covered under medical benefit
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