2012 Formulary Print document - Alameda Alliance for Health
2012 Formulary Print document - Alameda Alliance for Health
2012 Formulary Print document - Alameda Alliance for Health
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Drug Name<br />
Drug<br />
Tier<br />
Requirements/Limits<br />
nateglinide (Starlix) 1 QL: 90 in<br />
30 days<br />
ONGLYZA 2 ST, QL:<br />
30 in 30<br />
days<br />
PRANDIMET 2 ST, QL:<br />
150 in 30<br />
days<br />
PRANDIN 2 ST, QL:<br />
240 in 30<br />
days<br />
SYMLIN 2 PA, QL:<br />
20 in 28<br />
days<br />
SYMLINPEN 120 2 PA, QL:<br />
5.4 in 28<br />
days<br />
SYMLINPEN 60 2 PA, QL:<br />
3 in 28<br />
days<br />
TRADJENTA 2 ST, QL:<br />
30 in 30<br />
days<br />
VICTOZA 3-PAK 2 PA, QL:<br />
9 in 28<br />
days<br />
Insulins<br />
HUMALOG MIX 50-50 2 QL: 30 in insuln pen<br />
28 days<br />
HUMALOG MIX 50-50 2 QL: 40 in vial<br />
28 days<br />
HUMALOG MIX 75-25 2 QL: 30 in insuln pen<br />
28 days<br />
HUMALOG MIX 75-25 2 QL: 40 in vial<br />
28 days<br />
HUMALOG 2 QL: 30 in insuln pen<br />
28 days<br />
HUMALOG 2 QL: 40 in vial<br />
28 days<br />
HUMULIN 50-50 2 QL: 40 in<br />
28 days<br />
47<br />
<strong>Alliance</strong> CompleteCare <strong>2012</strong> Part D <strong>Formulary</strong> Effective: May 01, <strong>2012</strong><br />
<strong>Formulary</strong> ID: 12140.000, Version: 10
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