COMPREHENSIVE FORMULARY - RxAmerica

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Drug Name Drug Tier Notes GRIS-PEG TAB 125MG(Griseofulvin Ultramicrosize) GRIS-PEG TAB 250MG(Griseofulvin Ultramicrosize) griseofulvin microsize susp 125 mg/5ml HELIDAC MIS(Metronidazole-Tetracycline w/ Bismuth Subsalicylate) HEPSERA TAB 10MG(Adefovir Dipivoxil) HIPREX TAB 1GM(Methenamine Hippurate) HUMATIN CAP 250MG(Paromomycin Sulfate) hydroxychloroquine sulfate tab 200 mg INFERGEN INJ 15MCG(Interferon alfacon-1) INFERGEN INJ 9MCG(Interferon alfacon-1) INVANZ INJ 1GM(Ertapenem Sodium) INVIRASE CAP 200MG(Saquinavir Mesylate) INVIRASE TAB 500MG(Saquinavir Mesylate) isoniazid & rifampin cap 150-300 mg isoniazid inj 100 mg/ml isoniazid syrup 50 mg/5ml isoniazid tab 100 mg isoniazid tab 300 mg itraconazole cap 100 mg KALETRA CAP(Lopinavir-Ritonavir) KALETRA SOL(Lopinavir-Ritonavir) KALETRA TAB 200-50MG(Lopinavir-Ritonavir) kanamycin sulfate inj 333 mg/ml KEFLEX CAP 250MG(Cephalexin) KEFLEX CAP 500MG(Cephalexin) KEFLEX CAP 750MG(Cephalexin) KEFLEX SUS 125/5ML(Cephalexin) KEFLEX SUS 250/5ML(Cephalexin) KETEK TAB 300MG(Telithromycin) KETEK TAB 400MG(Telithromycin) ketoconazole tab 200 mg LAMISIL TAB 250MG(Terbinafine HCl) LARIAM TAB 250MG(Mefloquine HCl) LEVAQUIN INJ 25MG/ML(Levofloxacin) LEVAQUIN SOL 25MG/ML(Levofloxacin) LEVAQUIN TAB 250MG(Levofloxacin) LEVAQUIN TAB 500MG(Levofloxacin) LEVAQUIN TAB 750MG(Levofloxacin) LEVAQUIN TAB LEVA-PAK(Levofloxacin) LEVAQUIN/D5W INJ 250/50ML(Levofloxacin in D5W) LEVAQUIN/D5W INJ 500/100(Levofloxacin in D5W) LEVAQUIN/D5W INJ 750/150(Levofloxacin in D5W) LEXIVA TAB 700MG(Fosamprenavir Calcium) LINCOCIN INJ 300MG/ML(Lincomycin HCl) MACROBID CAP 100MG(Nitrofurantoin Monohyd Macro) MACRODANTIN CAP 100MG(Nitrofurantoin Macrocrystal) MACRODANTIN CAP 25MG(Nitrofurantoin Macrocrystal) MACRODANTIN CAP 50MG(Nitrofurantoin Macrocrystal) MALARONE TAB 250-100(Atovaquone-Proguanil HCl) MALARONE TAB 62.5/25(Atovaquone-Proguanil HCl) 02 02 01 04 03 04 04 01 04 04 04 02 02 01 01 01 01 01 01 02 02 04 01 04 04 04 04 04 02 02 01 02 04 02 02 02 02 02 02 04 04 04 02 04 04 04 02 04 04 04 (PA) (PA) (PA) (PA) (PA) 17
Drug Name Drug Tier Notes MANDELAMINE TAB 0.5GM(Methenamine Mandelate) MANDELAMINE TAB 1GM(Methenamine Mandelate) MANDOL/D5W INJ 1GM(Cefamandole Nafate in D5W) MAXIPIME INJ 1GM(Cefepime HCl) MAXIPIME INJ 1GM(Cefepime HCl) MAXIPIME INJ 2GM(Cefepime HCl) MAXIPIME INJ 2GM(Cefepime HCl) MAXIPIME INJ 500MG(Cefepime HCl) mebendazole chew tab 100 mg mefloquine hcl tab 250 mg MEFOXIN INJ 10GM(Cefoxitin Sodium) MEFOXIN INJ 1GM(Cefoxitin Sodium) MEFOXIN INJ 2GM(Cefoxitin Sodium) MEFOXIN/DEX INJ 1GM(Cefoxitin Sodium in Dextrose) MEFOXIN/DEX INJ 2GM(Cefoxitin Sodium in Dextrose) MEPRON SUS(Atovaquone) MERREM INJ 1GM(Meropenem) MERREM INJ 500MG(Meropenem) methenamine hippurate tab 1 gm methenamine mandelate tab 0.5 gm methenamine mandelate tab 1 gm methenamine mandelate-sodium biphosphate tab 500-500 mg methenamine-bella alk-meth blue-phenyl sal tab methenamine-hyosc-meth blue-sod phos-phenyl sal tab 120 mg methenamine-hyosc-meth blue-sod phos-phenyl sal tab 81.6 mg METRO IV INJ 5MG/ML(Metronidazole in NaCl) metronidazole cap 375 mg metronidazole in nacl 0.79% iv soln 500 mg/100ml metronidazole tab 250 mg metronidazole tab 500 mg MINOCIN CAP 100MG(Minocycline HCl) MINOCIN CAP 50MG(Minocycline HCl) MINOCIN PAC KIT 100MG(Minocycline HCl w/ Acne Care Products) MINOCIN PAC KIT 50MG(Minocycline HCl w/ Acne Care Products) minocycline hcl cap 100 mg minocycline hcl cap 50 mg minocycline hcl cap 75 mg minocycline hcl tab 100 mg minocycline hcl tab 50 mg minocycline hcl tab 75 mg MINTEZOL CHW 500MG(Thiabendazole) MINTEZOL SUS 500/5ML(Thiabendazole) MONODOX CAP 100MG(Doxycycline (Monohydrate)) MONODOX CAP 50MG(Doxycycline (Monohydrate)) MONODOX CAP 75MG(Doxycycline (Monohydrate)) MONUROL PAK GRANULES(Fosfomycin Tromethamine) MYAMBUTOL TAB 100MG(Ethambutol HCl) MYAMBUTOL TAB 400MG(Ethambutol HCl) MYCAMINE INJ 100MG(Micafungin Sodium) MYCAMINE INJ 50MG(Micafungin Sodium) 04 04 04 02 02 02 02 02 01 01 04 04 04 04 04 02 04 04 01 01 01 01 01 01 01 04 01 01 01 01 04 04 04 04 01 01 01 01 01 01 02 02 04 04 04 04 04 04 04 04 (PA) (PA) (PA) (PA) (PA) 18
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 and 16: Drug Name Drug Tier Notes CLEOCIN C
Page 17: Drug Name Drug Tier Notes ethambuto
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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