COMPREHENSIVE FORMULARY - RxAmerica

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Drug Name Drug Tier Notes PROSTIGMIN INJ 0.5MG/ML(Neostigmine Methylsulfate) PROSTIGMIN INJ 1MG/ML(Neostigmine Methylsulfate) PROSTIGMIN TAB 15MG(Neostigmine Bromide) PROVENTIL AER 90MCG(Albuterol) PROVENTIL AER HFA(Albuterol Sulfate) PROVENTIL NEB 0.083%(Albuterol Sulfate) pyridostigmine bromide tab 60 mg RAZADYNE SOL 4MG/ML(Galantamine Hydrobromide) RAZADYNE TAB 12MG(Galantamine Hydrobromide) RAZADYNE TAB 4MG(Galantamine Hydrobromide) RAZADYNE TAB 8MG(Galantamine Hydrobromide) RAZADYNE ER CAP 16MG(Galantamine Hydrobromide) RAZADYNE ER CAP 24MG(Galantamine Hydrobromide) RAZADYNE ER CAP 8MG(Galantamine Hydrobromide) REGONOL INJ 5MG/ML(Pyridostigmine Bromide) ROBAXIN INJ 100MG/ML(Methocarbamol) ROBAXIN TAB 500MG(Methocarbamol) ROBAXIN-750 TAB 750MG(Methocarbamol) ROBINUL INJ 0.2MG/ML(Glycopyrrolate) ROBINUL TAB 1MG(Glycopyrrolate) ROBINUL FORT TAB 2MG(Glycopyrrolate) SAL-TROPINE TAB 0.4MG(Atropine Sulfate) SALAGEN TAB 5MG(Pilocarpine HCl (Oral)) SALAGEN TAB 7.5MG(Pilocarpine HCl (Oral)) scopolamine hbr inj 0.4 mg/ml SEREVENT DIS AER 50MCG(Salmeterol Xinafoate) SKELAXIN TAB 800MG(Metaxalone) SOMA TAB 350MG(Carisoprodol) SOMA CPD TAB(Carisoprodol w/ Aspirin) SOMA CPD/COD TAB(Carisoprodol w/ Aspirin & Codeine) SPIRIVA CAP HANDIHLR(Tiotropium Bromide Monohydrate) terbutaline sulfate inj 1 mg/ml terbutaline sulfate tab 2.5 mg terbutaline sulfate tab 5 mg THERABENZAPR PAK -60(Cyclobenzaprine-Nutritional Supplement) THERABENZAPR PAK -90(Cyclobenzaprine-Nutritional Supplement) tizanidine hcl tab 2 mg tizanidine hcl tab 4 mg trihexyphenidyl hcl elixir 0.4 mg/ml trihexyphenidyl hcl tab 2 mg trihexyphenidyl hcl tab 5 mg TWINJECT INJ 0.15MG(Epinephrine) TWINJECT INJ 0.3MG(Epinephrine) URECHOLINE TAB 10MG(Bethanechol Chloride) URECHOLINE TAB 25MG(Bethanechol Chloride) URECHOLINE TAB 50MG(Bethanechol Chloride) URECHOLINE TAB 5MG(Bethanechol Chloride) VENTOLIN HFA AER(Albuterol Sulfate) VOSPIRE ER TAB 4MG(Albuterol Sulfate) VOSPIRE ER TAB 8MG(Albuterol Sulfate) 04 04 02 04 02 02 01 02 02 02 02 02 02 02 02 02 04 04 04 04 04 04 04 04 01 02 04 04 04 04 02 01 01 01 04 04 01 01 01 01 01 04 04 04 04 04 04 02 04 04 (PA) 33
Drug Name Drug Tier Notes XOPENEX NEB 0.31MG(Levalbuterol HCl) XOPENEX NEB 0.63MG(Levalbuterol HCl) XOPENEX NEB 1.25/3ML(Levalbuterol HCl) XOPENEX CONC NEB 1.25/0.5(Levalbuterol HCl) XOPENEX HFA AER(Levalbuterol Tartrate) ZANAFLEX CAP 2MG(Tizanidine HCl) ZANAFLEX CAP 4MG(Tizanidine HCl) ZANAFLEX CAP 6MG(Tizanidine HCl) ZANAFLEX TAB 2MG(Tizanidine HCl) ZANAFLEX TAB 4MG(Tizanidine HCl) Blood Formation, Coagulation & Thrombosis ABBOKINASE INJ 250000(Urokinase) ACD-A SOL(Anticoagulant Citrate Dextrose Solution A) AGGRENOX CAP 25-200MG(Aspirin-Dipyridamole) AGRYLIN CAP 0.5MG(Anagrelide HCl) AGRYLIN CAP 1MG(Anagrelide HCl) AMICAR TAB 1000MG(Aminocaproic Acid) AMICAR TAB 500MG(Aminocaproic Acid) aminocaproic acid tab 500 mg anagrelide hcl cap 0.5 mg anagrelide hcl cap 1 mg ANGIOMAX INJ 250MG(Bivalirudin) ARANESP INJ 100MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 100MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 100MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 150MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 150MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 200MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 200MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 200MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 25MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 25MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 25MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 300MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 300MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 300MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 40MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 40MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 40MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 500MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 60MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 60MCG(Darbepoetin Alfa-Polysorbate 80) ARANESP INJ 60MCG(Darbepoetin Alfa-Polysorbate 80) ARIXTRA SOL 10/0.8(Fondaparinux Sodium) ARIXTRA SOL 2.5/0.5(Fondaparinux Sodium) ARIXTRA SOL 5.0/0.4(Fondaparinux Sodium) ARIXTRA SOL 7.5/0.6(Fondaparinux Sodium) BENEFIX INJ 2000UNIT(Coagulation Factor IX (Recombinant)) cilostazol tab 100 mg 04 04 04 04 02 04 04 04 04 04 04 02 02 02 02 04 04 01 01 01 02 03 03 03 03 03 03 03 03 03 03 03 03 03 03 03 03 03 03 03 03 03 03 03 03 03 04 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) (PA) (PA) (PA) (QL) (QL) (QL) (QL) 34
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 30 and 31: Drug Name Drug Tier Notes TESLAC TA
Page 32 and 33: Drug Name Drug Tier Notes COGNEX CA
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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