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Xxxxxx Attention Xxxxxx Deficit Hyperactivity Disorder
26
Name AETNA BCBSMA BMCHP FCHP HPHC HNE NHP NTWK MAHLTH THP
METHyLPHENIDATE DL* X* DL X X X X X DL X
METHyLPHENIDATE [Concerta] DL FE DL DL DL X DL DL DL DL X
sT
METHyLPHENIDATE [Metadate CD] DL FE X DL X X DL DL DL X
sT
METHyLPHENIDATE [Metadate ER] DL* X DL X X NC PA X
METHyLPHENIDATE [Ritalin LA] DL FE NC DL X X DL DL DL X
sT
METHyLPHENIDATE ER DL* X* DL X X X X X DL X
METHyLPHENIDATE sR DL* X* DL X X X X X DL X
METHyLPHENIDATE transdermal DL* NC X PA X PA PA sT
[Daytrana]
Dermatologic Agents (Acne Treatments)
ADAPALENE [Differin] PA* X PA PA 1 sT PA PA 1
ADAPALENE/BENzOyL PEROXIDE PA NC NC PA 2 PA NC
[Epiduo]
AzELAIC ACID cream [Azelex] X* X PA X DL PA X
AzELAIC ACID gel [Finacea] X* X PA X DL PA X
BENzOyL PEROXIDE topical X* NC X X X X X X PA 2 X
BENzOyL PEROXIDE [Benzefoam] X NC PA NC NC PA NC
BENzOyL PEROXIDE [Benzac AC] X* NC PA X NC PA X
BENzOyL PEROXIDE [Oscion] X* NC X PA X NC X
BENzOyL PEROXIDE/CLINDAMyCIN
[Acanya]
X NC PA X NC PA NC
BENzOyL PEROXIDE/CLINDAMyCIN
PHOsPHATE [Benzaclin gel]
X* X PA PA X NC PA PA X
BENzOyL PEROXIDE/CLINDAMyCIN
PHOsPHATE [Duac Cs]
X* X NC PA X NC PA X*
BENzOyL PEROXIDE/ERyTHROMyCIN X* X* X X X X NC DL PA X*
BENzOyL PEROXIDE/ERyTHROMyCIN
[Benzamycin]
FE X PA X NC PA X
BENzOyL PEROXIDE/
HyDROCORTIsONE [Vanoxide-HC]
FE X X NC NC PA X
BENzOyL PEROXIDE/sULFUR [NuOx] FE X PA NC NC PA X
1 ≥30 yrs
2 ≥22 yrs