2013 Formulary (List of Covered Drugs) - Advantage Peach State ...

More documents

Recommendations

Info

aminosyn m injection 65meq/l; 448mg/100ml; 343mg/100ml; 40meq/l; 448mg/100ml;105mg/100ml; 252mg/100ml; 329mg/100ml; 252mg/100ml; 3meq/l; 140mg/100ml;154mg/100ml; 3.5mmole/l; 13meq/l; 300mg/100ml; 147mg/100ml; 40meq/l; 182mg/100ml;56mg/100ml; 31mg/100ml; 280mg/100ml .....................................................................................................138aminosyn-hbc injection 7.1meq/100ml; 660mg/100ml; 507mg/100ml; 4meq/100ml;660mg/100ml; 154mg/100ml; 789mg/100ml; 1576mg/100ml; 265mg/100ml; 206mg/100ml;1.12gm/100ml; 228mg/100ml; 448mg/100ml; 221mg/100ml; 272mg/100ml; 88mg/100ml;33mg/100ml; 789mg/100ml ............................................................................................................................138aminosyn-pf 7% injection 32.5meq/l; 490mg/100ml; 861mg/100ml; 370mg/100ml;576mg/100ml; 270mg/100ml; 220mg/100ml; 534mg/100ml; 831mg/100ml; 475mg/100ml;125mg/100ml; 10.69gm/l; 300mg/100ml; 570mg/100ml; 70gm/l; 347mg/100ml;50mg/100ml; 360mg/100ml; 125mg/100ml; 44mg/100ml; 452mg/100ml ....................................................138aminosyn-pf injection 46meq/l; 698mg/100ml; 1227mg/100ml; 527mg/100ml; 820mg/100ml;385mg/100ml; 312mg/100ml; 760mg/100ml; 1200mg/100ml; 677mg/100ml; 180mg/100ml;427mg/100ml; 812mg/100ml; 495mg/100ml; 3.4meq/l; 70mg/100ml; 512mg/100ml;180mg/100ml; 44mg/100ml; 673mg/100ml ...................................................................................................138amiodarone hcl injection 50mg/ml ........................................................................................................................81amiodarone hcl tablet 200mg .................................................................................................................................81amiodarone hcl tablet 400mg .................................................................................................................................81amitiza capsule 24mcg .........................................................................................................................................101amitiza capsule 8mcg ...........................................................................................................................................101amitriptyline hcl tablet 100mg ...............................................................................................................................31amitriptyline hcl tablet 10mg .................................................................................................................................31amitriptyline hcl tablet 150mg ...............................................................................................................................31amitriptyline hcl tablet 25mg .................................................................................................................................31amitriptyline hcl tablet 50mg .................................................................................................................................31amitriptyline hcl tablet 75mg .................................................................................................................................31amlodipine besylate tablet 10mg ...........................................................................................................................85amlodipine besylate tablet 2.5mg ..........................................................................................................................85amlodipine besylate tablet 5mg .............................................................................................................................85amlodipine besylate/benazepril hcl capsule 10mg; 40mg .....................................................................................85amlodipine besylate/benazepril hcl capsule 5mg; 40mg .......................................................................................85amlodipine besylate/benazepril hydrochloride capsule 10mg; 20mg ....................................................................85amlodipine besylate/benazepril hydrochloride capsule 2.5mg; 10mg ...................................................................85amlodipine besylate/benazepril hydrochloride capsule 5mg; 10mg ......................................................................85amlodipine besylate/benazepril hydrochloride capsule 5mg; 20mg ......................................................................85ammonium chloride injection 5meq/ml ...............................................................................................................136ammonium lactate cream 12% ...............................................................................................................................96ammonium lactate lotion 12% ...............................................................................................................................96amoxapine tablet 100mg ........................................................................................................................................31amoxapine tablet 150mg ........................................................................................................................................31amoxapine tablet 25mg ..........................................................................................................................................31amoxapine tablet 50mg ..........................................................................................................................................31amoxicillin capsule 250mg ....................................................................................................................................14amoxicillin capsule 500mg ....................................................................................................................................14amoxicillin suspension reconstituted 125mg/5ml ..................................................................................................14amoxicillin suspension reconstituted 200mg/5ml ..................................................................................................14amoxicillin suspension reconstituted 250mg/5ml ..................................................................................................15amoxicillin suspension reconstituted 400mg/5ml ..................................................................................................15amoxicillin tablet 500mg .......................................................................................................................................15147
amoxicillin tablet 875mg .......................................................................................................................................15amoxicillin tablet chewable 125mg .......................................................................................................................15amoxicillin tablet chewable 250mg .......................................................................................................................15amoxicillin/clavulanate potassium er tablet extended release 12 hour 1000mg; 62.5mg ......................................14amoxicillin/clavulanate potassium suspension reconstituted 250mg/5ml; 62.5mg/5ml........................................14amoxicillin/clavulanate potassium suspension reconstituted 400mg/5ml; 57mg/5ml...........................................14amoxicillin/clavulanate potassium suspension reconstituted 600mg/5ml; 42.9mg/5ml........................................14amoxicillin/clavulanate potassium tablet 250mg; 125mg......................................................................................14amoxicillin/clavulanate potassium tablet chewable 200mg; 28.5mg ....................................................................14amoxicillin/clavulanate potassium tablet chewable 400mg; 57mg .......................................................................14amoxicillin/potassium clavulanate suspension reconstituted 200mg/5ml; 28.5mg/5ml ........................................14amoxicillin/potassium clavulanate tablet 500mg; 125mg......................................................................................14amoxicillin/potassium clavulanate tablet 875mg; 125mg......................................................................................14amphetamine/dextroamphetamine tablet 1.25mg; 1.25mg; 1.25mg; 1.25mg .......................................................93amphetamine/dextroamphetamine tablet 1.875mg; 1.875mg; 1.875mg; 1.875mg ...............................................93amphetamine/dextroamphetamine tablet 2.5mg; 2.5mg; 2.5mg; 2.5mg ...............................................................93amphetamine/dextroamphetamine tablet 3.125mg; 3.125mg; 3.125mg; 3.125mg ...............................................93amphetamine/dextroamphetamine tablet 3.75mg; 3.75mg; 3.75mg; 3.75mg .......................................................93amphetamine/dextroamphetamine tablet 5mg; 5mg; 5mg; 5mg ...........................................................................93amphetamine/dextroamphetamine tablet 7.5mg; 7.5mg; 7.5mg; 7.5mg ...............................................................93amphotec injection 50mg .......................................................................................................................................34amphotericin b injection 50mg ..............................................................................................................................34ampicillin capsule 250mg ......................................................................................................................................15ampicillin capsule 500mg ......................................................................................................................................15ampicillin sodium injection 10gm .........................................................................................................................15ampicillin sodium injection 125mg .......................................................................................................................15ampicillin sodium injection 1gm ...........................................................................................................................15ampicillin suspension reconstituted 125mg/5ml ....................................................................................................15ampicillin suspension reconstituted 250mg/5ml ....................................................................................................15ampicillin-sulbactam injection 10gm; 5gm ...........................................................................................................15ampicillin-sulbactam injection 2gm; 1gm .............................................................................................................15anagrelide hydrochloride capsule 0.5mg ...............................................................................................................75anagrelide hydrochloride capsule 1mg ..................................................................................................................75anastrozole tablet 1mg ...........................................................................................................................................45androderm patch 24 hour 2mg/24hr .....................................................................................................................110androderm patch 24 hour 4mg/24hr .....................................................................................................................110androxy tablet 10mg ............................................................................................................................................110apidra injection 100unit/ml ....................................................................................................................................72apidra solostar injection 100unit/ml.......................................................................................................................72apokyn injection 10mg/ml .....................................................................................................................................50apri tablet 0.15mg; 30mcg ...................................................................................................................................111aptivus capsule 250mg ...........................................................................................................................................60aptivus solution 100mg/ml .....................................................................................................................................60aralast np injection 400mg ...................................................................................................................................134aranelle tablet 0; 0 ................................................................................................................................................111aranesp albumin free injection 100mcg/ml ............................................................................................................75aranesp albumin free injection 150mcg/0.3ml .......................................................................................................75aranesp albumin free injection 200mcg/0.4ml .......................................................................................................75aranesp albumin free injection 200mcg/ml ............................................................................................................75aranesp albumin free injection 25mcg/0.42ml .......................................................................................................75148
Page 1 and 2:
Advantage by Peach State Health Pla
Page 3:
What are generic drugs?Peach State
Page 7 and 8:
Opioid Analgesics, Long-actingDrug
Page 9 and 10:
Drug NameDrugTierHYDROMORPHONE HCL
Page 11 and 12:
Opioid AntagonistsDrug NameDrugTier
Page 13 and 14:
Drug NameDrugTiermeloxicam suspensi
Page 15 and 16:
Antibacterials, OtherDrug NameDrugT
Page 17 and 18:
Beta-lactam, CephalosporinsDrug Nam
Page 19 and 20:
Beta-lactam, OtherDrug NameAZACTAM
Page 21 and 22:
Drug NamePENICILLIN G POTASSIUM IN
Page 23 and 24:
QuinolonesDrug NameDrugTierAVELOX I
Page 25 and 26:
AnticonvulsantsAnticonvulsants, Oth
Page 27 and 28:
Drug NameDrugTierdiazepam gel 20mg
Page 29 and 30:
Sodium Channel AgentsDrug NameDrugT
Page 31 and 32:
Antidementia AgentsCholinesterase I
Page 33 and 34:
Monoamine Oxidase InhibitorsDrug Na
Page 35 and 36:
Drug NameDrugTiersertraline hcl con
Page 37 and 38:
Drug NameDrugTierimipramine pamoate
Page 39 and 40:
AntifungalsAntifungalsDrug NameDrug
Page 41 and 42:
Antigout AgentsAntigout AgentsDrug
Page 43 and 44:
AntimycobacterialsAntimycobacterial
Page 45 and 46:
Antiangiogenic AgentsDrug NameDrugT
Page 47 and 48:
Antineoplastics, OtherDrug NameDrug
Page 49 and 50:
Drug NameDrugTierMITOXANTRONE HCL I
Page 51 and 52:
Molecular Target InhibitorsDrug Nam
Page 53 and 54:
AntiprotozoalsDrug NameDrugTierALIN
Page 55 and 56:
Dopamine AgonistsDrug NameDrugTierA
Page 57 and 58:
Antipsychotics1st Generation/Typica
Page 59 and 60:
Drug NameDrugTierRequirements/Limit
Page 61 and 62:
Treatment-ResistantDrug NameDrugTie
Page 63 and 64:
Drug NameDrugTierEPZICOM TABLET 600
Page 65 and 66:
Anti-HIV Agents, Protease Inhibitor
Page 67 and 68:
Page 69 and 70:
AnxiolyticsAnxiolytics, OtherDrug N
Page 71 and 72:
Blood Glucose RegulatorsAntidiabeti
Page 73 and 74:
Page 75 and 76:
Drug NameCLINIMIX E 4.25%/DEXTROSE
Page 77 and 78:
InsulinsDrug NameDrugTierAPIDRA SOL
Page 79 and 80:
Drug NameDrugTierFRAGMIN INJECTION
Page 81 and 82:
Page 83 and 84:
Cardiovascular AgentsAlpha-adrenerg
Page 85 and 86:
Angiotensin-converting Enzyme (ACE)
Page 87 and 88:
Drug NameDrugTiermexiletine hcl cap
Page 89 and 90:
Drug NameDrugTiermetoprolol/hydroch
Page 91 and 92:
Drug NameDrugTierDILTIAZEM HCL INJE
Page 93 and 94:
Diuretics, Carbonic Anhydrase Inhib
Page 95 and 96:
Dyslipidemics, Fibric Acid Derivati
Page 97 and 98:
Vasodilators, Direct-acting Arteria
Page 99 and 100:
Attention Deficit Hyperactivity Dis
Page 101 and 102: Dermatological AgentsDermatological
Page 103 and 104: Enzyme Replacement/ModifiersEnzyme
Page 105 and 106: Gastrointestinal Agents, OtherDrug
Page 107 and 108: LaxativesDrug NameDrugTierconstulos
Page 109 and 110: Genitourinary Agents, OtherDrug Nam
Page 111 and 112: Drug NameDEXAMETHASONE SODIUM PHOSP
Page 113 and 114: Drug NameDrugTierproctozone-hc crea
Page 115 and 116: Hormonal Agents, Stimulant/Replacem
Page 117 and 118: Drug NameDrugTierjunel 1.5/30 table
Page 119 and 120: ProgestinsDrug NameDrugTiercamila t
Page 121 and 122: Drug NameDrugTierlevoxyl tablet 137
Page 123 and 124: Drug NameDrugTierLEUPROLIDE ACETATE
Page 125 and 126: Drug Name120DrugTiergengraf capsule
Page 127 and 128: Drug NameDAPTACEL INJECTION 10MCG/0
Page 129 and 130: Metabolic Bone Disease AgentsMetabo
Page 131 and 132: Ophthalmic AgentsOphthalmic Prostag
Page 133 and 134: Ophthalmic Antiglaucoma AgentsDrug
Page 135 and 136: Drug Name130DrugTierDULERA AEROSOL
Page 137 and 138: Bronchodilators, AnticholinergicDru
Page 139 and 140: Mast Cell StabilizersDrug NameDrugT
Page 141 and 142: Sleep Disorders, OtherDrug NameDrug
Page 143 and 144: Drug NameAMINOSYN M INJECTION 65MEQ
Page 145 and 146: Drug NameFREAMINE III INJECTION 72M
Page 147 and 148: Drug NamePREMASOL INJECTION 56MEQ/L
Page 149 and 150: IndexAa-hydrocort injection 100mg .
Page 151: aloprim injection 500mg ...........
Page 155 and 156: avandia tablet 4mg ................
Page 157 and 158: uphenyl tablet 500mg ..............
Page 159 and 160: cefdinir suspension reconstituted 1
Page 161 and 162: claravis capsule 40mg .............
Page 163 and 164: clonazepam tablet 1mg .............
Page 165 and 166: daraprim tablet 25mg ..............
Page 167 and 168: diltiazem cd capsule extended relea
Page 169 and 170: emend capsule 0 ...................
Page 171 and 172: exemestane tablet 25mg ............
Page 173 and 174: fluphenazine hcl injection 2.5mg/ml
Page 175 and 176: gentamicin sulfate/sodium chloride
Page 177 and 178: hydralazine hcl tablet 50mg .......
Page 179 and 180: intuniv tablet extended release 24
Page 181 and 182: ketoconazole cream 2% .............
Page 183 and 184: levothroid tablet 25mcg ...........
Page 185 and 186: lupron depot injection 7.5mg ......
Page 187 and 188: methazolamide tablet 50mg .........
Page 189 and 190: morphine sulfate er tablet extended
Page 191 and 192: nitroglycerin injection 5mg/ml ....
Page 193 and 194: oxacillin sodium injection 10gm ...
Page 195 and 196: phenytoin sodium extended capsule 1
Page 197 and 198: premarin tablet 1.25mg ............
Page 199 and 200: PROVENTIL HFA AEROSOL SOLUTION 108M
Page 201 and 202: ingers irrigation solution 4.5meq/l
Page 203 and 204:
somavert injection 20mg ...........
Page 205 and 206:
synthroid tablet 75mcg ............
Page 207 and 208:
tikosyn capsule 250mcg ............
Page 209 and 210:
trimethoprim sulfate/polymyxin b su
Page 211 and 212:
verapamil hcl er tablet extended re
Page 213:
ziagen tablet 300mg ...............
show all

2013 Formulary (List of Covered Drugs) - Advantage Peach State ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?