COMPREHENSIVE FORMULARY - RxAmerica

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Drug Name Drug Tier Notes TESLAC TAB 50MG(Testolactone) thioguanine tab 40 mg thiotepa for inj 15 mg TORISEL SOL 25MG/ML(Temsirolimus) TRELSTAR DEP INJ 3.75MG(Triptorelin Pamoate) TRELSTAR LA INJ 11.25MG(Triptorelin Pamoate) tretinoin cap 10 mg TREXALL TAB 10MG(Methotrexate Sodium) TREXALL TAB 15MG(Methotrexate Sodium) TREXALL TAB 5MG(Methotrexate Sodium) TREXALL TAB 7.5MG(Methotrexate Sodium) TRISENOX SOL 10MG/10M(Arsenic Trioxide) TYKERB TAB 250MG(Lapatinib Ditosylate) VANTAS KIT 50MG(Histrelin Acetate) VECTIBIX INJ 100MG(Panitumumab) VECTIBIX INJ 200MG(Panitumumab) VECTIBIX INJ 400MG(Panitumumab) VELCADE INJ 3.5MG(Bortezomib) VEPESID CAP 50MG(Etoposide) VESANOID CAP 10 MG(Tretinoin (Chemotherapy)) VIADUR KIT(Leuprolide Acetate) VIDAZA INJ 100MG(Azacitidine) vinblastine sulfate for inj 10 mg vinblastine sulfate inj 1 mg/ml vincristine sulfate iv soln 1 mg/ml VINORELBINE INJ 50MG/ML(Vinorelbine Tartrate) vinorelbine tartrate inj 10 mg/ml VUMON INJ 50MG/5ML(Teniposide) XELODA TAB 150MG(Capecitabine) XELODA TAB 500MG(Capecitabine) ZANOSAR INJ 1GM(Streptozocin) ZEVALIN KIT IN-111(Ibritumomab Tiuxetan for Indium-111 (In-111)) ZEVALIN KIT Y-90(Ibritumomab Tiuxetan for Yttrium-90 (Y-90)) ZOLADEX IMP 10.8MG(Goserelin Acetate) ZOLADEX IMP 3.6MG(Goserelin Acetate) ZOLINZA CAP 100MG(Vorinostat) Autonomic Drugs ACCUNEB NEB 0.63MG/3(Albuterol Sulfate) ACCUNEB NEB 1.25MG/3(Albuterol Sulfate) ADRENALIN INJ 1MG/ML(Epinephrine HCl) ADVAIR DISKU MIS 100/50(Fluticasone-Salmeterol) ADVAIR DISKU MIS 250/50(Fluticasone-Salmeterol) ADVAIR DISKU MIS 500/50(Fluticasone-Salmeterol) ADVAIR HFA AER 115/21(Fluticasone-Salmeterol) ADVAIR HFA AER 230/21(Fluticasone-Salmeterol) ADVAIR HFA AER 45/21(Fluticasone-Salmeterol) AKINETON TAB 2MG(Biperiden HCl) albuterol inhal aerosol 90 mcg/act albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) 02 01 01 02 04 04 01 02 02 02 02 03 02 04 02 02 02 03 02 02 03 04 01 01 01 04 01 02 02 02 04 03 03 03 03 02 02 02 04 02 02 02 02 02 02 04 01 01 (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) (PA) 29
Drug Name Drug Tier Notes albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) albuterol sulfate soln nebu 0.5% (5 mg/ml) albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) albuterol sulfate syrup 2 mg/5ml albuterol sulfate tab 2 mg albuterol sulfate tab 4 mg albuterol sulfate tab sr 12hr 4 mg albuterol sulfate tab sr 12hr 8 mg ALBUTEROL/ SOL IPRATROP(Albuterol-Ipratropium) ALUPENT INH AER 0.65/ACT(Metaproterenol Sulfate) ANASPAZ TAB 0.125MG(Hyoscyamine Sulfate) ARICEPT TAB 10MG(Donepezil Hydrochloride) ARICEPT TAB 5MG(Donepezil Hydrochloride) ARICEPT ODT TAB 10MG(Donepezil Hydrochloride) ARICEPT ODT TAB 5MG(Donepezil Hydrochloride) ATROVENT HFA AER 17MCG(Ipratropium Bromide HFA) B & O 15-A SUP SUPPRETT(Belladonna Alkaloids & Opium) B & O 16-A SUP SUPPRETT(Belladonna Alkaloids & Opium) baclofen tab 10 mg baclofen tab 20 mg belladonna alkaloids & opium suppos 16.2-30 mg belladonna alkaloids & opium suppos 16.2-60 mg BENTYL CAP 10MG(Dicyclomine HCl) BENTYL INJ 10MG/ML(Dicyclomine HCl) BENTYL SYP 10MG/5ML(Dicyclomine HCl) BENTYL TAB 20MG(Dicyclomine HCl) benztropine mesylate tab 0.5 mg benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg bethanechol chloride tab 10 mg bethanechol chloride tab 25 mg bethanechol chloride tab 5 mg bethanechol chloride tab 50 mg BRETHINE INJ 1MG/ML(Terbutaline Sulfate) BRETHINE TAB 2.5MG(Terbutaline Sulfate) BRETHINE TAB 5MG(Terbutaline Sulfate) BROVANA NEB 15MCG(Arformoterol Tartrate) CANTIL TAB(Mepenzolate Bromide) carisoprodol tab 350 mg carisoprodol w/ aspirin & codeine tab 200-325-16 mg carisoprodol w/ aspirin tab 200-325 mg CHANTIX PAK(Varenicline Tartrate) CHANTIX PAK 1MG(Varenicline Tartrate) CHANTIX TAB 0.5MG(Varenicline Tartrate) CHANTIX TAB 1MG(Varenicline Tartrate) chlorzoxazone tab 250 mg chlorzoxazone tab 500 mg COGENTIN INJ 1MG/ML(Benztropine Mesylate) COGNEX CAP 10MG(Tacrine Hydrochloride) COGNEX CAP 20MG(Tacrine Hydrochloride) 01 01 01 01 01 01 01 01 02 02 04 02 02 02 02 02 04 04 01 01 01 01 04 04 04 04 01 01 01 01 01 01 01 04 04 04 04 04 01 01 01 02 02 02 02 01 01 02 04 04 (PA) (PA) (PA) (PA) (QL) (QL) (QL) (QL) 30
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 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 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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