COMPREHENSIVE FORMULARY - RxAmerica

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Drug Name Drug Tier Notes DOXYCYCL HYC CAP 75MG(Doxycycline Hyclate) doxycycline hyclate cap 100 mg doxycycline hyclate cap 50 mg doxycycline hyclate for inj 100 mg doxycycline hyclate tab 100 mg doxycycline hyclate tab 20 mg doxycycline monohydrate cap 100 mg doxycycline monohydrate cap 50 mg doxycycline monohydrate tab 100 mg doxycycline monohydrate tab 150 mg doxycycline monohydrate tab 50 mg doxycycline monohydrate tab 75 mg DURICEF SUS 250/5ML(Cefadroxil) DURICEF SUS 500/5ML(Cefadroxil) DYNABAC TAB 250MG EC(Dirithromycin) DYNACIN CAP 75MG(Minocycline HCl) DYNACIN TAB 100MG(Minocycline HCl) DYNACIN TAB 50MG(Minocycline HCl) DYNACIN TAB 75MG(Minocycline HCl) E.E.S. GRAN SUS 200/5ML(Erythromycin Ethylsuccinate) EMTRIVA CAP 200MG(Emtricitabine) EMTRIVA SOL 10MG/ML(Emtricitabine) EPIVIR SOL 10MG/ML(Lamivudine) EPIVIR TAB 150MG(Lamivudine) EPIVIR TAB 300MG(Lamivudine) EPIVIR HBV SOL 5MG/ML(Lamivudine) EPIVIR HBV TAB 100MG(Lamivudine) EPZICOM TAB(Abacavir Sulfate-Lamivudine) ERAXIS INJ 50MG(Anidulafungin) ERY-TAB TAB 500MG EC(Erythromycin Base) ERYPED 200 SUS 200/5ML(Erythromycin Ethylsuccinate) ERYTHROCIN INJ 1000MG(Erythromycin Lactobionate) ERYTHROCIN INJ 500MG(Erythromycin Lactobionate) ERYTHROMYCIN CAP 250MG EC(Erythromycin Base) erythromycin ethylsuccinate for susp 100 mg/2.5ml erythromycin ethylsuccinate for susp 400 mg/5ml erythromycin ethylsuccinate susp 200 mg/5ml erythromycin ethylsuccinate susp 400 mg/5ml erythromycin ethylsuccinate tab 400 mg erythromycin lactobionate for inj 500 mg erythromycin stearate tab 250 mg erythromycin stearate tab 500 mg erythromycin tab 250 mg ERYTHROMYCIN TAB 250MG(Erythromycin Base) erythromycin tab 500 mg erythromycin tab delayed release 250 mg erythromycin tab delayed release 333 mg erythromycin tab delayed release 500 mg erythromycin w/ delayed release particles cap 250 mg erythromycin-sulfisoxazole for susp 200-600 mg/5ml 04 01 01 01 01 01 01 01 01 01 01 01 04 04 04 04 04 04 04 04 02 04 02 02 02 02 02 02 02 02 04 04 04 02 01 01 01 01 01 01 01 01 01 02 01 01 01 01 01 01 (PA) 15
Drug Name Drug Tier Notes ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg FACTIVE TAB 320MG(Gemifloxacin Mesylate) FAMVIR TAB 125MG(Famciclovir) FAMVIR TAB 250MG(Famciclovir) FAMVIR TAB 500MG(Famciclovir) FANSIDAR TAB 500/25(Sulfadoxine & Pyrimethamine) FLAGYL CAP 375MG(Metronidazole) FLAGYL TAB 250MG(Metronidazole) FLAGYL TAB 500MG(Metronidazole) FLAGYL ER TAB 750MG(Metronidazole) fluconazole for susp 10 mg/ml fluconazole for susp 40 mg/ml fluconazole in dextrose inj 200 mg/100ml fluconazole in dextrose inj 400 mg/200ml fluconazole in nacl 0.9% inj 200 mg/100ml fluconazole in nacl 0.9% inj 400 mg/200ml fluconazole tab 100 mg fluconazole tab 150 mg fluconazole tab 200 mg fluconazole tab 50 mg FLUMADINE SYP 50MG/5ML(Rimantadine Hydrochloride) FLUMADINE TAB 100MG(Rimantadine Hydrochloride) FORTAZ INJ 1GM(Ceftazidime) FORTAZ INJ 1GM(Ceftazidime Sodium in D5W) FORTAZ INJ 2GM(Ceftazidime) FORTAZ INJ 2GM(Ceftazidime Sodium in D5W) FORTAZ INJ 6GM(Ceftazidime) foscarnet sodium inj 24 mg/ml FOSCAVIR INJ 24MG/ML(Foscarnet Sodium) FUNGIZONE INJ 50MG(Amphotericin B) FURADANTIN SUS 25MG/5ML(Nitrofurantoin) FUZEON KIT(Enfuvirtide) ganciclovir cap 250 mg ganciclovir cap 500 mg GANTRIS PED SUS 500/5ML(Sulfisoxazole Acetyl) gentamicin in saline inj 0.6 mg/ml gentamicin in saline inj 0.8 mg/ml gentamicin in saline inj 0.9 mg/ml gentamicin in saline inj 1 mg/ml gentamicin in saline inj 1.2 mg/ml gentamicin in saline inj 1.4 mg/ml gentamicin in saline inj 1.6 mg/ml gentamicin in saline inj 2 mg/ml gentamicin sulfate inj 10 mg/ml gentamicin sulfate inj 40 mg/ml gentamicin sulfate iv soln 10 mg/ml GEOCILLIN TAB 382MG(Carbenicillin Indanyl Sodium) GRIFULVIN V SUS 125/5ML(Griseofulvin Microsize) GRIFULVIN V TAB 500MG(Griseofulvin Microsize) 01 01 04 04 04 04 02 04 04 04 04 01 01 01 01 01 01 01 01 01 01 02 04 04 04 04 04 04 01 04 02 04 03 01 01 04 01 01 01 01 01 01 01 01 01 01 01 02 04 02 (PA) (PA) 16
Page 1 and 2: www.Meds4Medicare.com COMPREHENSIVE
Page 3 and 4: If we remove drugs from our formula
Page 5 and 6: condition. For example, if Drug A a
Page 7 and 8: RxAmerica’s Formulary The formula
Page 9 and 10: Drug Name Drug Tier Notes Antihista
Page 11 and 12: Drug Name Drug Tier Notes AMOXIL SU
Page 13 and 14: Drug Name Drug Tier Notes cefazolin
Page 15: Drug Name Drug Tier Notes CLEOCIN C
Page 19 and 20: Drug Name Drug Tier Notes MANDELAMI
Page 21: Drug Name Drug Tier Notes PEG-INTRO
Page 24 and 25: Drug Name Drug Tier Notes URISYM CA
Page 26 and 27: Drug Name Drug Tier Notes ARIMIDEX
Page 28 and 29: Drug Name Drug Tier Notes IDAMYCIN
Page 30 and 31: Drug Name Drug Tier Notes TESLAC TA
Page 32 and 33: Drug Name Drug Tier Notes COGNEX CA
Page 34 and 35: Drug Name Drug Tier Notes PROSTIGMI
Page 36 and 37: Drug Name Drug Tier Notes cilostazo
Page 38 and 39: Drug Name Drug Tier Notes warfarin
Page 40 and 41: Drug Name Drug Tier Notes CADUET TA
Page 42 and 43: Drug Name Drug Tier Notes COZAAR TA
Page 44 and 45: Drug Name Drug Tier Notes HYPERTENS
Page 46 and 47: Drug Name Drug Tier Notes LOTREL CA
Page 48 and 49: Drug Name Drug Tier Notes NITROSTAT
Page 50 and 51: Drug Name Drug Tier Notes sotalol h
Page 52 and 53: Drug Name Drug Tier Notes WELCHOL T
Page 54 and 55: Drug Name Drug Tier Notes AZILECT T
Page 56 and 57: Drug Name Drug Tier Notes CYMBALTA
Page 58 and 59: Drug Name Drug Tier Notes EMSAM DIS
Page 60 and 61: Drug Name Drug Tier Notes GEODON IN
Page 62 and 63: Drug Name Drug Tier Notes ketoprofe
Page 64 and 65: Drug Name Drug Tier Notes METADATE
Page 66 and 67:
Drug Name Drug Tier Notes naproxen
Page 68 and 69:
Drug Name Drug Tier Notes PAXIL TAB
Page 70 and 71:
Drug Name Drug Tier Notes RITALIN T
Page 72 and 73:
Drug Name Drug Tier Notes thiothixe
Page 74 and 75:
Drug Name Drug Tier Notes ZYDONE TA
Page 76 and 77:
Drug Name Drug Tier Notes CLINIMIX
Page 78 and 79:
Drug Name Drug Tier Notes LITHOSTAT
Page 80 and 81:
Drug Name Drug Tier Notes Enzymes A
Page 82 and 83:
Drug Name Drug Tier Notes BLEPH-10
Page 84 and 85:
Drug Name Drug Tier Notes OPTIPRANO
Page 86 and 87:
Drug Name Drug Tier Notes amylase-l
Page 88 and 89:
Drug Name Drug Tier Notes opium tin
Page 90 and 91:
Drug Name Drug Tier Notes sodium th
Page 92 and 93:
Drug Name Drug Tier Notes CYTOMEL T
Page 94 and 95:
Drug Name Drug Tier Notes FEMCON FE
Page 96 and 97:
Drug Name Drug Tier Notes JANUMET T
Page 98 and 99:
Drug Name Drug Tier Notes NORDITROP
Page 100 and 101:
Drug Name Drug Tier Notes PREMPRO T
Page 102 and 103:
Drug Name Drug Tier Notes tolbutami
Page 104 and 105:
Drug Name Drug Tier Notes PANGLOBUL
Page 106 and 107:
Drug Name Drug Tier Notes benzoyl p
Page 108 and 109:
Drug Name Drug Tier Notes DIPROLENE
Page 110 and 111:
Drug Name Drug Tier Notes lidocaine
Page 112 and 113:
Drug Name Drug Tier Notes ROZEX EMU
Page 114 and 115:
Drug Name Drug Tier Notes XYRALID L
Page 116 and 117:
Drug Name Drug Tier Notes NASCOBAL
Page 118 and 119:
Drug Name Drug Tier Notes IMURAN TA
Page 120 and 121:
Drug Name Drug Tier Notes THALOMID
Page 122 and 123:
Drug Name Drug Tier Notes insulin s
Page 124 and 125:
Drug Name Drug Tier Notes BENZOIC A
Page 126 and 127:
Drug Name Drug Tier Notes HYOSCYAMI
Page 128 and 129:
INDEX A ABBOKINASE 34 ABELCET 9 ABI
Page 130 and 131:
BD PEN MINI 119 BD PEN 119 BD ULTRA
Page 132 and 133:
clobetasol propionate emollient bas
Page 134 and 135:
EDECRIN 75 edetate calcium disodium
Page 136 and 137:
HALDOL DECAN 59 HALDOL 59 HALFLYTEL
Page 138 and 139:
LEXAPRO 61 LEXIVA 17 LEXXEL 44 LIAL
Page 140 and 141:
naloxone hcl 64 naltrexone hcl 64 N
Page 142 and 143:
peritoneal dialysis solutions 73 PE
Page 144 and 145:
S SAIZEN 99 SAL-TROPINE 33 SALAGEN
Page 146 and 147:
TRAVASOL 2.75%/DEXTROSE 5 78 TRAVAS
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COMPREHENSIVE FORMULARY - RxAmerica

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