COMPREHENSIVE FORMULARY - RxAmerica

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Drug Name Drug Tier Notes MYCOBUTIN CAP 150MG(Rifabutin) nafcillin sodium for inj 1 gm nafcillin sodium for inj 10 gm nafcillin sodium for inj 2 gm nafcillin sodium for inj 200 gm nafcillin sodium for iv soln 1 gm nafcillin sodium for iv soln 2 gm NALLPEN/DEX INJ 1GM/50ML(Nafcillin Sodium in Dextrose) NALLPEN/DEX INJ 2GM(Nafcillin Sodium in Dextrose) NALLPEN/DEX INJ 2GM/100(Nafcillin Sodium in Dextrose) NEBUPENT INH 300MG(Pentamidine Isethionate) NEO-FRADIN SOL 125/5ML(Neomycin Sulfate) neomycin sulfate tab 500 mg NEUTREXIN INJ 25MG(Trimetrexate Glucuronate) nitrofurantoin macrocrystalline cap 100 mg nitrofurantoin macrocrystalline cap 50 mg nitrofurantoin monohydrate macrocrystalline cap 100 mg NIZORAL TAB 200MG(Ketoconazole) NOROXIN TAB 400MG(Norfloxacin) NORVIR CAP 100MG(Ritonavir) NORVIR SOL 80MG/ML(Ritonavir) nystatin susp 100000 unit/ml nystatin tab 500000 unit ofloxacin tab 200 mg ofloxacin tab 300 mg ofloxacin tab 400 mg OMNI-PAC CAP 300MG(Cefdinir) OMNICEF CAP 300MG(Cefdinir) OMNICEF SUS 125/5ML(Cefdinir) OMNICEF SUS 250/5ML(Cefdinir) ORACEA CAP 40MG(Doxycycline (Rosacea)) OXACILLIN INJ 10GM(Oxacillin Sodium) OXACILLIN INJ 1GM(Oxacillin Sodium) OXACILLIN INJ 2GM(Oxacillin Sodium) oxacillin sodium for inj 1 gm oxacillin sodium for inj 10 gm oxacillin sodium for inj 2 gm oxacillin sodium for iv soln 1 gm oxacillin sodium for iv soln 2 gm paromomycin sulfate cap 250 mg PASER GRA 4GM(Aminosalicylic Acid) PCE TAB 333MG EC(Erythromycin Base (Coated)) PCE TAB 500MG EC(Erythromycin Base (Coated)) PEDIAZOLE SUS 200/600(Erythromycin-Sulfisoxazole) PEG-INTRON KIT 120 RP(Peginterferon alfa-2b) PEG-INTRON KIT 120MCG(Peginterferon alfa-2b) PEG-INTRON KIT 150 RP(Peginterferon alfa-2b) PEG-INTRON KIT 150MCG(Peginterferon alfa-2b) PEG-INTRON KIT 50MCG(Peginterferon alfa-2b) PEG-INTRON KIT 50MCG RP(Peginterferon alfa-2b) 02 01 01 01 01 01 01 04 04 04 04 02 01 04 01 01 01 04 04 02 02 01 01 01 01 01 02 02 02 02 04 04 04 04 01 01 01 01 01 01 04 04 04 04 03 03 03 03 03 03 (PA) (PA) (PA) (PA) (PA) (PA) 19
Drug Name Drug Tier Notes PEG-INTRON KIT 80MCG(Peginterferon alfa-2b) PEG-INTRON KIT 80MCG RP(Peginterferon alfa-2b) PEGASYS INJ 180MCG/M(Peginterferon alfa-2a) PEGASYS KIT(Peginterferon alfa-2a) PEN G PROC INJ 600000(Penicillin G Procaine) penicillin g potassium for inj 20 mu penicillin g potassium for inj 5000000 unit penicillin g potassium inj 20000 unit/ml in dextrose penicillin g potassium inj 40000 unit/ml in dextrose penicillin g potassium inj 60000 unit/ml in dextrose penicillin g sodium for inj 5000000 unit penicillin v potassium for soln 125 mg/5ml penicillin v potassium for soln 250 mg/5ml penicillin v potassium tab 250 mg penicillin v potassium tab 500 mg PENTAM 300 INJ 300MG(Pentamidine Isethionate) pentamidine isethionate for soln 300 mg PERIOSTAT TAB(Doxycycline Hyclate) PFIZERPEN G INJ 20MU(Penicillin G Potassium) piperacillin sodium 40 mg/ml-d5w iv soln piperacillin sodium for inj 2 gm piperacillin sodium for inj 3 gm piperacillin sodium for inj 4 gm piperacillin sodium for iv soln 40 gm PLAQUENIL TAB 200MG(Hydroxychloroquine Sulfate) polymyxin b sulfate for inj 500000 unit PREZISTA TAB 300MG(Darunavir) PRIFTIN TAB 150MG(Rifapentine) primaquine phosphate tab 26.3 mg PRIMAXIN IM INJ 500MG(Imipenem-Cilastatin) PRIMAXIN IM INJ 750MG(Imipenem-Cilastatin) PRIMAXIN IV INJ 250MG(Imipenem-Cilastatin) PRIMAXIN IV INJ 500MG(Imipenem-Cilastatin) PRIMSOL SOL 50MG/5ML(Trimethoprim HCl) PROQUIN XR TAB 500MG(Ciprofloxacin HCl) PROSED/DS TAB(Methenamine-Hyosc-Methylene Blue-Benzoic Acid-Phenyl Sal) PYLERA CAP(Bismuth Subcitrate Potassium-Metronidazole-Tetracycline) pyrazinamide tab 500 mg QUALAQUIN CAP 324MG(Quinine Sulfate) QUINERVA TAB 260MG(Quinine Sulfate) RANICLOR CHW 250MG(Cefaclor) RANICLOR CHW 375MG(Cefaclor) REBETOL CAP 200MG(Ribavirin (Hepatitis C)) REBETOL SOL 40MG/ML(Ribavirin (Hepatitis C)) RELENZA MIS DISKHALE(Zanamivir) RESCRIPTOR TAB 100 MG(Delavirdine Mesylate) RESCRIPTOR TAB 200MG(Delavirdine Mesylate) RETROVIR CAP 100MG(Zidovudine) RETROVIR INJ 10MG/ML(Zidovudine) 03 03 03 03 04 01 01 01 01 01 01 01 01 01 01 04 01 04 04 01 01 01 01 01 04 01 02 04 01 04 04 04 04 04 04 04 04 01 04 04 04 04 02 02 04 02 02 04 02 (PA) (PA) (PA) (PA) (PA) (PA) 20
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 and 18: Drug Name Drug Tier Notes ethambuto
Page 19: Drug Name Drug Tier Notes MANDELAMI
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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