Search Results

Your search result can be sorted in ascending/descending order by clicking on the column headings, with the exception of Review Status/Past Decision(s).
* Please click on the DIN/PIN hyperlink to look up for more details of any group coverage(s) which may apply to that particular drug product.

Products Found: 5412

PTC

MFR

Review Status/
Past Decision(s)

5-FLUOROURACIL
EFUDEX
50 MG / G
TOP  CRM
0.9006
N/A
G
NO

REGULAR BENEFIT *

 

5-FLUOROURACIL/ SALICYLIC ACID
ACTIKERALL
0.5 % * 10 %
TOP  SOL
1.5581
N/A
ML
NO

REGULAR BENEFIT *

ABATACEPT
ORENCIA
125 MG / SYR
INJ 
373.7875
N/A
SYR
NO

SPECIAL AUTHORIZATION *

ABATACEPT
ORENCIA
250 MG / VIAL
INJ 
500.3400
N/A
VIAL
NO

SPECIAL AUTHORIZATION *

ABOBOTULINUMTOXINA
DYSPORT THERAPEUTIC
300 IU / VIAL
INJ 
385.5600
N/A
VIAL
NO

REGULAR BENEFIT *

ABOBOTULINUMTOXINA
DYSPORT THERAPEUTIC
500 IU / VIAL
INJ 
642.6000
N/A
VIAL
NO

REGULAR BENEFIT *

ACAMPROSATE CALCIUM
CAMPRAL
333 MG
ORL  DRT
0.8000
N/A
TAB
NO

SPECIAL AUTHORIZATION *

ACARBOSE
GLUCOBAY
100 MG
ORL  TAB
0.3733
N/A
TAB
NO

REGULAR BENEFIT *

 

ACARBOSE
GLUCOBAY
50 MG
ORL  TAB
0.2695
N/A
TAB
NO

REGULAR BENEFIT *

 

ACEBUTOLOL HCL
APO-ACEBUTOLOL
100 MG
ORL  TAB
0.0787
0.0787
TAB
YES

REGULAR BENEFIT *

 

ACEBUTOLOL HCL
TEVA-ACEBUTOLOL
100 MG
ORL  TAB
0.0787
0.0787
TAB
YES

REGULAR BENEFIT *

 

ACEBUTOLOL HCL
APO-ACEBUTOLOL
200 MG
ORL  TAB
0.1177
0.1177
TAB
YES

REGULAR BENEFIT *

 

ACEBUTOLOL HCL
TEVA-ACEBUTOLOL
200 MG
ORL  TAB
0.1177
0.1177
TAB
YES

REGULAR BENEFIT *

 

ACEBUTOLOL HCL
APO-ACEBUTOLOL
400 MG
ORL  TAB
0.2466
0.2466
TAB
YES

REGULAR BENEFIT *

 

ACEBUTOLOL HCL
TEVA-ACEBUTOLOL
400 MG
ORL  TAB
0.2466
0.2466
TAB
YES

REGULAR BENEFIT *

 

ACENOCOUMAROL
SINTROM
1 MG
ORL  TAB
0.5616
N/A
TAB
NO

REGULAR BENEFIT *

 

ACENOCOUMAROL
SINTROM
4 MG
ORL  TAB
1.7663
N/A
TAB
NO

REGULAR BENEFIT *

 

ACETAMINOPHEN
ACET 120
120 MG
RT  SUP
0.8872
N/A
SUP
NO

REGULAR BENEFIT *

 

ACETAMINOPHEN
CHILDRENS TEMPRA
16 MG / ML
ORL  SYR
0.0393
N/A
ML
NO

REGULAR BENEFIT *

 

ACETAMINOPHEN
PEDIATRIX
32 MG / ML
ORL  SOL
0.0434
N/A
ML
NO

REGULAR BENEFIT *

 

ACETAMINOPHEN
TEMPRA D.S.
32 MG / ML
ORL  SYR
0.0393
N/A
ML
NO

REGULAR BENEFIT *

 

ACETAMINOPHEN
ACET 325
325 MG
RT  SUP
0.8872
N/A
SUP
NO

REGULAR BENEFIT *

 

ACETAMINOPHEN
APO-ACETAMINOPHEN (CAPLET)
500 MG
ORL  TAB
0.0285
0.0285
TAB
YES

REGULAR BENEFIT *

 

ACETAMINOPHEN
APO-ACETAMINOPHEN
500 MG
ORL  TAB
0.0285
0.0285
TAB
YES

REGULAR BENEFIT *

 

ACETAMINOPHEN
JAMP-ACETAMINOPHEN BLAZON
500 MG
ORL  TAB
0.0271
N/A
TAB
NO

REGULAR BENEFIT *

 

ACETAMINOPHEN
JAMP-ACETAMINOPHEN EXTRA STRENGTH
500 MG
ORL  TAB
0.0271
N/A
TAB
NO

REGULAR BENEFIT *

 

ACETAMINOPHEN
NOVO GESIC FORTE
500 MG
ORL  TAB
0.0285
0.0285
TAB
YES

REGULAR BENEFIT *

 

ACETAMINOPHEN
TYLENOL EXTRA STRENGTH
500 MG
ORL  TAB
0.1165
0.0285
TAB
YES

REGULAR BENEFIT *

 

ACETAMINOPHEN
TYLENOL EXTRA-STRENGTH (CAPLET)
500 MG
ORL  TAB
0.1165
0.0285
TAB
YES

REGULAR BENEFIT *

 

ACETAMINOPHEN
ACET 650
650 MG
RT  SUP
0.8872
N/A
SUP
NO

REGULAR BENEFIT *

 

ACETAMINOPHEN
PEDIATRIX
80 MG / ML
ORL  DPS
0.1510
N/A
ML
NO

REGULAR BENEFIT *

 

ACETAZOLAMIDE
ACETAZOLAMIDE
250 MG
ORL  TAB
0.1320
N/A
TAB
NO

REGULAR BENEFIT *

 

ACETYLCYSTEINE
ACETYLCYSTEINE
20 %
INH  SOL
0.7000
N/A
ML
NO

REGULAR BENEFIT *

 

ACITRETIN
MINT-ACITRETIN
10 MG
ORL  CAP
1.2965
1.2965
CAP
YES

REGULAR BENEFIT *

ACITRETIN
SORIATANE
10 MG
ORL  CAP
2.3069
1.2965
CAP
YES

REGULAR BENEFIT *

 

ACITRETIN
TARO-ACITRETIN
10 MG
ORL  CAP
1.2965
1.2965
CAP
YES

REGULAR BENEFIT *

ACITRETIN
MINT-ACITRETIN
25 MG
ORL  CAP
2.2770
2.2770
CAP
YES

REGULAR BENEFIT *

ACITRETIN
SORIATANE
25 MG
ORL  CAP
4.0510
2.2770
CAP
YES

REGULAR BENEFIT *

 

ACITRETIN
TARO-ACITRETIN
25 MG
ORL  CAP
2.2770
2.2770
CAP
YES

REGULAR BENEFIT *

ACLIDINIUM BROMIDE
TUDORZA GENUAIR
400 MCG / DOSE
INH  MIP
0.8850
N/A
DOSE
NO

REGULAR BENEFIT *

ACLIDINIUM BROMIDE/ FORMOTEROL FUMARATE DIHYDRATE
DUAKLIR GENUAIR
400 MCG / DOSE * 12 MCG / DOSE
INH  MIP
1.0000
N/A
DOSE
NO

STEP THERAPY/ SPECIAL AUTHORIZATION *

ACYCLOVIR
APO-ACYCLOVIR
200 MG
ORL  TAB
0.6397
0.6397
TAB
YES

REGULAR BENEFIT *

 

ACYCLOVIR
MYLAN-ACYCLOVIR
200 MG
ORL  TAB
0.6397
0.6397
TAB
YES

REGULAR BENEFIT *

 

ACYCLOVIR
TEVA-ACYCLOVIR
200 MG
ORL  TAB
0.6397
0.6397
TAB
YES

REGULAR BENEFIT *

ACYCLOVIR
ZOVIRAX
40 MG / ML
ORL  SUS
0.2595
N/A
ML
NO

REGULAR BENEFIT *

 

ACYCLOVIR
APO-ACYCLOVIR
400 MG
ORL  TAB
1.2700
1.2700
TAB
YES

REGULAR BENEFIT *

 

ACYCLOVIR
MYLAN-ACYCLOVIR
400 MG
ORL  TAB
1.2700
1.2700
TAB
YES

REGULAR BENEFIT *

 

ACYCLOVIR
TEVA-ACYCLOVIR
400 MG
ORL  TAB
1.2700
1.2700
TAB
YES

REGULAR BENEFIT *

ACYCLOVIR
APO-ACYCLOVIR
800 MG
ORL  TAB
1.2673
1.2673
TAB
YES

REGULAR BENEFIT *

 

ACYCLOVIR
MYLAN-ACYCLOVIR
800 MG
ORL  TAB
1.2673
1.2673
TAB
YES

REGULAR BENEFIT *

 

ACYCLOVIR
TEVA-ACYCLOVIR
800 MG
ORL  TAB
1.2673
1.2673
TAB
YES

REGULAR BENEFIT *

ADALIMUMAB
HUMIRA (40 MG/0.4 ML INJ PEN)
40 MG / SYR
INJ  NDL
N/A
N/A
SYR
NO

UNDER REVIEW

ADALIMUMAB
HUMIRA (40 MG/0.4 ML INJ SYR)
40 MG / SYR
INJ  NDL
N/A
N/A
SYR
NO

UNDER REVIEW

ADALIMUMAB
HUMIRA (40 MG/0.8 ML INJ SYR)
40 MG / SYR
INJ  NDL
762.5700
N/A
SYR
NO

SPECIAL AUTHORIZATION *

ADEFOVIR DIPIVOXIL
APO-ADEFOVIR
10 MG
ORL  TAB
18.2518
18.2518
TAB
YES

RESTRICTED BENEFIT *

ADEFOVIR DIPIVOXIL
HEPSERA
10 MG
ORL  TAB
23.8405
18.2518
TAB
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER
AEROCHAMBER PLUS FLOW-VU W/ MOUTHPIECE

DEV
23.5500
0.0000
DEV
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER
AEROCHAMBER PLUS FLOW-VU YOUTH W/ MOUTHPIECE

DEV
23.5500
0.0000
DEV
YES

RESTRICTED BENEFIT *

00990104
AEROSOL HOLDING CHAMBER
ANTI-STATIC COMPACT SPACE CHAMBER PLUS MOUTHPIECE

DEV
N/A
N/A
DEV
NO

NOT A BENEFIT

AEROSOL HOLDING CHAMBER
INSPIRA CHAMBER WITH MOUTHPIECE

DEV
23.5500
0.0000
DEV
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER
OPTICHAMBER ADVANTAGE II (CHAMBER ONLY)

DEV
15.6000
0.0000
DEV
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER
OPTICHAMBER DIAMOND (CHAMBER ONLY)

DEV
17.2000
0.0000
DEV
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER
VORTEX

DEV
19.4977
0.0000
DEV
YES

RESTRICTED BENEFIT *

 

AEROSOL HOLDING CHAMBER/MASK
AEROCHAMBER PLUS FLOW-VU W/ ADULT SMALL MASK

ADUDEV
39.8600
0.0000
DEV
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER/MASK
AEROCHAMBER PLUS FLOW-VU W/ LARGE MASK

ADUDEV
39.8600
0.0000
DEV
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER/MASK
AEROCHAMBER PLUS FLOW-VU W/ MEDIUM MASK

PEDDEV
37.6700
0.0000
DEV
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER/MASK
AEROCHAMBER PLUS FLOW-VU W/ SMALL MASK

INFDEV
37.6700
0.0000
DEV
YES

RESTRICTED BENEFIT *

00990107
AEROSOL HOLDING CHAMBER/MASK
ANTI-STATIC COMPACT SPACE CHAMBER PLUS W/ LG MASK

ADUDEV
N/A
N/A
DEV
NO

NOT A BENEFIT

00990106
AEROSOL HOLDING CHAMBER/MASK
ANTI-STATIC COMPACT SPACE CHAMBER PLUS W/ MED MASK

PEDDEV
N/A
N/A
DEV
NO

NOT A BENEFIT

00990105
AEROSOL HOLDING CHAMBER/MASK
ANTI-STATIC COMPACT SPACE CHAMBER PLUS W/ SM MASK

INFDEV
N/A
N/A
DEV
NO

NOT A BENEFIT

AEROSOL HOLDING CHAMBER/MASK
INSPIRA CHAMBER W/ MED INSPIRAMASK/SOOTHERMASK DEV

PEDDEV
37.6700
0.0000
DEV
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER/MASK
INSPIRA CHAMBER W/ SM INSPIRAMASK/SOOTHERMASK DEV

INFDEV
37.6700
0.0000
DEV
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER/MASK
OPTICHAMBER ADVANTAGE II (WITH LARGE MASK)

ADUDEV
29.6000
0.0000
DEV
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER/MASK
OPTICHAMBER ADVANTAGE II (WITH MEDIUM MASK)

PEDDEV
26.8000
0.0000
DEV
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER/MASK
OPTICHAMBER ADVANTAGE II (WITH SMALL MASK)

INFDEV
26.8000
0.0000
DEV
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER/MASK
OPTICHAMBER DIAMOND (WITH LARGE MASK)

ADUDEV
32.4000
0.0000
DEV
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER/MASK
OPTICHAMBER DIAMOND (WITH MEDIUM MASK)

PEDDEV
29.4000
0.0000
DEV
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER/MASK
OPTICHAMBER DIAMOND (WITH SMALL MASK)

INFDEV
29.4000
0.0000
DEV
YES

RESTRICTED BENEFIT *

AEROSOL HOLDING CHAMBER/MASK
VORTEX CHILD/PEDIATRIC MASK DEVICE

PEDDEV
13.0047
0.0000
DEV
YES

RESTRICTED BENEFIT *

 

AEROSOL HOLDING CHAMBER/MASK
VORTEX TODDLER/INFANT MASK DEVICE

INFDEV
13.0047
0.0000
DEV
YES

RESTRICTED BENEFIT *

 

AFLIBERCEPT
EYLEA
2 MG / VIAL
INJ 
1418.0000
N/A
VIAL
NO

RESTRICTED BENEFIT *

ALEMTUZUMAB
LEMTRADA
12 MG / VIAL
INJ 
13031.1100
N/A
VIAL
NO

SPECIAL AUTHORIZATION *

ALENDRONATE SODIUM
ALENDRONATE SODIUM
10 MG
ORL  TAB
0.4986
0.4986
TAB
YES

SPECIAL AUTHORIZATION *

ALENDRONATE SODIUM
APO-ALENDRONATE
10 MG
ORL  TAB
0.4986
0.4986
TAB
YES

SPECIAL AUTHORIZATION *

ALENDRONATE SODIUM
AURO-ALENDRONATE
10 MG
ORL  TAB
0.4986
0.4986
TAB
YES

SPECIAL AUTHORIZATION *

ALENDRONATE SODIUM
SANDOZ ALENDRONATE
10 MG
ORL  TAB
0.4986
0.4986
TAB
YES

SPECIAL AUTHORIZATION *

ALENDRONATE SODIUM
ACT ALENDRONATE
40 MG
ORL  TAB
3.0832
N/A
TAB
NO

SPECIAL AUTHORIZATION *

ALENDRONATE SODIUM
ALENDRONATE
70 MG
ORL  TAB
2.1014
2.1014
TAB
YES

REGULAR BENEFIT *

ALENDRONATE SODIUM
ALENDRONATE
70 MG
ORL  TAB
2.1014
2.1014
TAB
YES

REGULAR BENEFIT *

ALENDRONATE SODIUM
ALENDRONATE SODIUM
70 MG
ORL  TAB
2.1014
2.1014
TAB
YES

REGULAR BENEFIT *

ALENDRONATE SODIUM
APO-ALENDRONATE
70 MG
ORL  TAB
2.1014
2.1014
TAB
YES

REGULAR BENEFIT *

ALENDRONATE SODIUM
AURO-ALENDRONATE
70 MG
ORL  TAB
2.1014
2.1014
TAB
YES

REGULAR BENEFIT *

ALENDRONATE SODIUM
FOSAMAX
70 MG
ORL  TAB
11.0114
2.1014
TAB
YES

REGULAR BENEFIT *

ALENDRONATE SODIUM
JAMP-ALENDRONATE
70 MG
ORL  TAB
2.1014
2.1014
TAB
YES

REGULAR BENEFIT *

ALENDRONATE SODIUM
MINT-ALENDRONATE
70 MG
ORL  TAB
2.1014
2.1014
TAB
YES

REGULAR BENEFIT *

ALENDRONATE SODIUM
PMS-ALENDRONATE-FC
70 MG
ORL  TAB
2.1014
2.1014
TAB
YES

REGULAR BENEFIT *

ALENDRONATE SODIUM
SANDOZ ALENDRONATE
70 MG
ORL  TAB
2.1014
2.1014
TAB
YES

REGULAR BENEFIT *

ALENDRONATE SODIUM
TEVA-ALENDRONATE
70 MG
ORL  TAB
2.1014
2.1014
TAB
YES

REGULAR BENEFIT *

02276429
ALENDRONATE SODIUM/ VITAMIN D3
FOSAVANCE
70 MG * 2,800 UNIT
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

ALENDRONATE SODIUM/ VITAMIN D3
APO-ALENDRONATE/VITAMIN D3
70 MG * 5,600 UNIT
ORL  TAB
1.2174
1.2174
TAB
YES

REGULAR BENEFIT *

ALENDRONATE SODIUM/ VITAMIN D3
FOSAVANCE
70 MG * 5,600 UNIT
ORL  TAB
4.8970
1.2174
TAB
YES

REGULAR BENEFIT *

ALENDRONATE SODIUM/ VITAMIN D3
SANDOZ ALENDRONATE/CHOLECALCIFEROL
70 MG * 5,600 UNIT
ORL  TAB
1.2174
1.2174
TAB
YES

REGULAR BENEFIT *

ALENDRONATE SODIUM/ VITAMIN D3
TEVA-ALENDRONATE/CHOLECALCIFEROL
70 MG * 5,600 UNIT
ORL  TAB
1.2174
1.2174
TAB
YES

REGULAR BENEFIT *

ALFACALCIDOL
ONE-ALPHA
0.25 MCG
ORL  CAP
0.4735
N/A
CAP
NO

REGULAR BENEFIT *

 

ALFACALCIDOL
ONE-ALPHA
1 MCG
ORL  CAP
1.4172
N/A
CAP
NO

REGULAR BENEFIT *

 

ALFACALCIDOL
ONE-ALPHA
2 MCG / ML
INJ 
17.3640
N/A
ML
NO

REGULAR BENEFIT *

 

ALFACALCIDOL
ONE-ALPHA
2 MCG / ML
ORL  DPS
5.4146
N/A
ML
NO

REGULAR BENEFIT *

 

ALFUZOSIN HCL
ALFUZOSIN
10 MG
ORL  SRT
0.2601
0.2601
TAB
YES

STEP THERAPY/ SPECIAL AUTHORIZATION *

ALFUZOSIN HCL
APO-ALFUZOSIN
10 MG
ORL  SRT
0.2601
0.2601
TAB
YES

STEP THERAPY/ SPECIAL AUTHORIZATION *

ALFUZOSIN HCL
AURO-ALFUZOSIN
10 MG
ORL  SRT
0.2601
0.2601
TAB
YES

STEP THERAPY/ SPECIAL AUTHORIZATION *

ALFUZOSIN HCL
SANDOZ ALFUZOSIN
10 MG
ORL  SRT
0.2601
0.2601
TAB
YES

STEP THERAPY/ SPECIAL AUTHORIZATION *

ALFUZOSIN HCL
XATRAL
10 MG
ORL  SRT
1.0404
0.2601
TAB
YES

STEP THERAPY/ SPECIAL AUTHORIZATION *

ALIROCUMAB
PRALUENT
150 MG / ML
INJ 
279.3600
N/A
ML
NO

SPECIAL AUTHORIZATION *

ALIROCUMAB
PRALUENT
150 MG / SYR
INJ 
279.3600
N/A
SYR
NO

SPECIAL AUTHORIZATION *

ALIROCUMAB
PRALUENT
75 MG / ML
INJ 
279.3600
N/A
ML
NO

SPECIAL AUTHORIZATION *

ALIROCUMAB
PRALUENT
75 MG / SYR
INJ 
279.3600
N/A
SYR
NO

SPECIAL AUTHORIZATION *

02302063
ALISKIREN FUMARATE
RASILEZ
150 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02302071
ALISKIREN FUMARATE
RASILEZ
300 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02337649
ALITRETINOIN
TOCTINO
30 MG
ORL  CAP
N/A
N/A
CAP
NO

NOT A BENEFIT

ALLERGY SERUM
ALLERGY SERUM

INJ 
0.0000
N/A
ML
NO

REGULAR BENEFIT *

 

ALLOPURINOL
APO-ALLOPURINOL
100 MG
ORL  TAB
0.0780
0.0780
TAB
YES

REGULAR BENEFIT *

ALLOPURINOL
MAR-ALLOPURINOL
100 MG
ORL  TAB
0.0780
0.0780
TAB
YES

REGULAR BENEFIT *

ALLOPURINOL
ZYLOPRIM
100 MG
ORL  TAB
0.0780
0.0780
TAB
YES

REGULAR BENEFIT *

 

ALLOPURINOL
APO-ALLOPURINOL
200 MG
ORL  TAB
0.1300
0.1300
TAB
YES

REGULAR BENEFIT *

ALLOPURINOL
MAR-ALLOPURINOL
200 MG
ORL  TAB
0.1300
0.1300
TAB
YES

REGULAR BENEFIT *

ALLOPURINOL
ZYLOPRIM
200 MG
ORL  TAB
0.1300
0.1300
TAB
YES

REGULAR BENEFIT *

 

ALLOPURINOL
APO-ALLOPURINOL
300 MG
ORL  TAB
0.2125
0.2125
TAB
YES

REGULAR BENEFIT *

ALLOPURINOL
MAR-ALLOPURINOL
300 MG
ORL  TAB
0.2125
0.2125
TAB
YES

REGULAR BENEFIT *

ALLOPURINOL
ZYLOPRIM
300 MG
ORL  TAB
0.2125
0.2125
TAB
YES

REGULAR BENEFIT *

 

ALMOTRIPTAN MALATE
ALMOTRIPTAN
12.5 MG
ORL  TAB
2.3478
2.3478
TAB
YES

RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION *

ALMOTRIPTAN MALATE
APO-ALMOTRIPTAN
12.5 MG
ORL  TAB
2.3478
2.3478
TAB
YES

RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION *

ALMOTRIPTAN MALATE
MYLAN-ALMOTRIPTAN
12.5 MG
ORL  TAB
2.3478
2.3478
TAB
YES

RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION *

ALMOTRIPTAN MALATE
SANDOZ ALMOTRIPTAN
12.5 MG
ORL  TAB
2.3478
2.3478
TAB
YES

RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION *

ALMOTRIPTAN MALATE
TEVA-ALMOTRIPTAN
12.5 MG
ORL  TAB
N/A
N/A
TAB
NO

UNDER REVIEW

ALMOTRIPTAN MALATE
APO-ALMOTRIPTAN
6.25 MG
ORL  TAB
7.0433
7.0433
TAB
YES

RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION *

ALMOTRIPTAN MALATE
MYLAN-ALMOTRIPTAN
6.25 MG
ORL  TAB
7.0433
7.0433
TAB
YES

RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION *

02417197
ALOGLIPTIN BENZOATE
NESINA
12.5 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02417200
ALOGLIPTIN BENZOATE
NESINA
25 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02417189
ALOGLIPTIN BENZOATE
NESINA
6.25 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02417235
ALOGLIPTIN BENZOATE/ METFORMIN HCL
KAZANO
12.5 MG * 1,000 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02417219
ALOGLIPTIN BENZOATE/ METFORMIN HCL
KAZANO
12.5 MG * 500 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02417227
ALOGLIPTIN BENZOATE/ METFORMIN HCL
KAZANO
12.5 MG * 850 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02204606
ALPHA 1-PROTEINASE
PROLASTIN-C
1 G / VIAL
INJ 
N/A
N/A
VIAL
NO

NOT A BENEFIT

ALPRAZOLAM
ALPRAZOLAM
0.25 MG
ORL  TAB
0.0609
0.0609
TAB
YES

REGULAR BENEFIT *

ALPRAZOLAM
APO-ALPRAZ
0.25 MG
ORL  TAB
0.0609
0.0609
TAB
YES

REGULAR BENEFIT *

 

ALPRAZOLAM
JAMP-ALPRAZOLAM
0.25 MG
ORL  TAB
0.0609
0.0609
TAB
YES

REGULAR BENEFIT *

ALPRAZOLAM
TEVA-ALPRAZOL
0.25 MG
ORL  TAB
0.0609
0.0609
TAB
YES

REGULAR BENEFIT *

 

ALPRAZOLAM
ALPRAZOLAM
0.5 MG
ORL  TAB
0.0728
0.0728
TAB
YES

REGULAR BENEFIT *

ALPRAZOLAM
APO-ALPRAZ
0.5 MG
ORL  TAB
0.0728
0.0728
TAB
YES

REGULAR BENEFIT *

 

ALPRAZOLAM
JAMP-ALPRAZOLAM
0.5 MG
ORL  TAB
0.0728
0.0728
TAB
YES

REGULAR BENEFIT *

ALPRAZOLAM
TEVA-ALPRAZOL
0.5 MG
ORL  TAB
0.0728
0.0728
TAB
YES

REGULAR BENEFIT *

 

02243611
ALPRAZOLAM
APO-ALPRAZ
1 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

 

02243612
ALPRAZOLAM
APO-ALPRAZ TS
2 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

 

ALPROSTADIL
PROSTIN VR
500 MCG / ML
INJ 
268.1784
N/A
ML
NO

REGULAR BENEFIT *

 

AMANTADINE HCL
PDP-AMANTADINE HYDROCHLORIDE
10 MG / ML
ORL  SYR
0.1223
N/A
ML
NO

REGULAR BENEFIT *

 

AMANTADINE HCL
PDP-AMANTADINE HYDROCHLORIDE
100 MG
ORL  CAP
0.6120
N/A
CAP
NO

REGULAR BENEFIT *

 

AMCINONIDE
TARO-AMCINONIDE
0.1 %
TOP  CRM
0.2253
N/A
G
NO

REGULAR BENEFIT *

 

02242971
AMIKACIN SULFATE
AMIKACIN SULFATE
250 MG / ML
INJ 
N/A
N/A
ML
NO

NOT A BENEFIT

 

AMILORIDE HCL
MIDAMOR
5 MG
ORL  TAB
0.2897
N/A
TAB
NO

REGULAR BENEFIT *

AMINOPHYLLINE
AMINOPHYLLINE
25 MG / ML
INJ 
0.4600
N/A
ML
NO

REGULAR BENEFIT *

 

AMIODARONE HCL
PMS-AMIODARONE
100 MG
ORL  TAB
0.8593
N/A
TAB
NO

REGULAR BENEFIT *

 

AMIODARONE HCL
AMIODARONE
200 MG
ORL  TAB
0.3706
0.3706
TAB
YES

REGULAR BENEFIT *

AMIODARONE HCL
AMIODARONE
200 MG
ORL  TAB
0.3706
0.3706
TAB
YES

REGULAR BENEFIT *

AMIODARONE HCL
APO-AMIODARONE
200 MG
ORL  TAB
0.3706
0.3706
TAB
YES

REGULAR BENEFIT *

 

AMIODARONE HCL
PMS-AMIODARONE
200 MG
ORL  TAB
0.3706
0.3706
TAB
YES

REGULAR BENEFIT *

 

AMIODARONE HCL
SANDOZ AMIODARONE
200 MG
ORL  TAB
0.3706
0.3706
TAB
YES

REGULAR BENEFIT *

 

AMIODARONE HCL
TEVA-AMIODARONE
200 MG
ORL  TAB
0.3706
0.3706
TAB
YES

REGULAR BENEFIT *

 

AMITRIPTYLINE HCL
APO-AMITRIPTYLINE
10 MG
ORL  TAB
0.0664
0.0664
TAB
YES

REGULAR BENEFIT *

AMITRIPTYLINE HCL
ELAVIL
10 MG
ORL  TAB
0.0664
0.0664
TAB
YES

REGULAR BENEFIT *

 

02429861
AMITRIPTYLINE HCL
MAR-AMITRIPTYLINE
10 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

00654523
AMITRIPTYLINE HCL
PMS-AMITRIPTYLINE
10 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02326043
AMITRIPTYLINE HCL
TEVA-AMITRIPTYLINE
10 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

AMITRIPTYLINE HCL
PMS-AMITRIPTYLINE
100 MG
ORL  TAB
N/A
N/A
TAB
NO

UNDER REVIEW

AMITRIPTYLINE HCL
APO-AMITRIPTYLINE
25 MG
ORL  TAB
0.1211
0.1211
TAB
YES

REGULAR BENEFIT *

AMITRIPTYLINE HCL
ELAVIL
25 MG
ORL  TAB
0.1211
0.1211
TAB
YES

REGULAR BENEFIT *

 

02429888
AMITRIPTYLINE HCL
MAR-AMITRIPTYLINE
25 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

00654515
AMITRIPTYLINE HCL
PMS-AMITRIPTYLINE
25 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02326051
AMITRIPTYLINE HCL
TEVA-AMITRIPTYLINE
25 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

AMITRIPTYLINE HCL
APO-AMITRIPTYLINE
50 MG
ORL  TAB
0.2347
0.2347
TAB
YES

REGULAR BENEFIT *

AMITRIPTYLINE HCL
ELAVIL
50 MG
ORL  TAB
0.2347
0.2347
TAB
YES

REGULAR BENEFIT *

 

02429896
AMITRIPTYLINE HCL
MAR-AMITRIPTYLINE
50 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

00654507
AMITRIPTYLINE HCL
PMS-AMITRIPTYLINE
50 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02326078
AMITRIPTYLINE HCL
TEVA-AMITRIPTYLINE
50 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

AMITRIPTYLINE HCL
APO-AMITRIPTYLINE
75 MG
ORL  TAB
0.3634
0.3634
TAB
YES

REGULAR BENEFIT *

AMITRIPTYLINE HCL
ELAVIL
75 MG
ORL  TAB
0.3634
0.3634
TAB
YES

REGULAR BENEFIT *

 

02429918
AMITRIPTYLINE HCL
MAR-AMITRIPTYLINE
75 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

AMLODIPINE BESYLATE
ACT AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
AMLODIPINE BESYLATE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
APO-AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
AURO-AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
GD-AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
JAMP-AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
MAR-AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
MINT-AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
MYLAN-AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
NORVASC
10 MG
ORL  TAB
2.0528
0.1993
TAB
YES

REGULAR BENEFIT *

 

AMLODIPINE BESYLATE
PHARMA-AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
RAN-AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
SANDOZ AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
SEPTA-AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
TEVA-AMLODIPINE
10 MG
ORL  TAB
0.1993
0.1993
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
ACT AMLODIPINE
2.5 MG
ORL  TAB
0.0767
0.0767
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
AMLODIPINE
2.5 MG
ORL  TAB
0.0767
0.0767
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
AMLODIPINE BESYLATE
2.5 MG
ORL  TAB
0.0767
0.0767
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
JAMP-AMLODIPINE
2.5 MG
ORL  TAB
0.0767
0.0767
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
MAR-AMLODIPINE
2.5 MG
ORL  TAB
0.0767
0.0767
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
PHARMA-AMLODIPINE
2.5 MG
ORL  TAB
0.0767
0.0767
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
PMS-AMLODIPINE
2.5 MG
ORL  TAB
0.0767
0.0767
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
SANDOZ AMLODIPINE
2.5 MG
ORL  TAB
0.0767
0.0767
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
ACT AMLODIPINE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
AMLODIPINE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
AMLODIPINE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
AMLODIPINE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
AMLODIPINE BESYLATE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
APO-AMLODIPINE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
AURO-AMLODIPINE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
GD-AMLODIPINE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
MAR-AMLODIPINE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
MINT-AMLODIPINE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
MYLAN-AMLODIPINE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
NORVASC
5 MG
ORL  TAB
1.4064
0.1343
TAB
YES

REGULAR BENEFIT *

 

AMLODIPINE BESYLATE
PHARMA-AMLODIPINE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
RAN-AMLODIPINE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
SANDOZ AMLODIPINE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
SEPTA-AMLODIPINE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

AMLODIPINE BESYLATE
TEVA-AMLODIPINE
5 MG
ORL  TAB
0.1343
0.1343
TAB
YES

REGULAR BENEFIT *

02273284
AMLODIPINE BESYLATE/ ATORVASTATIN CALCIUM
CADUET
10 MG * 10 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02273292
AMLODIPINE BESYLATE/ ATORVASTATIN CALCIUM
CADUET
10 MG * 20 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02273306
AMLODIPINE BESYLATE/ ATORVASTATIN CALCIUM
CADUET
10 MG * 40 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02273314
AMLODIPINE BESYLATE/ ATORVASTATIN CALCIUM
CADUET
10 MG * 80 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02273233
AMLODIPINE BESYLATE/ ATORVASTATIN CALCIUM
CADUET
5 MG * 10 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02273241
AMLODIPINE BESYLATE/ ATORVASTATIN CALCIUM
CADUET
5 MG * 20 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02273268
AMLODIPINE BESYLATE/ ATORVASTATIN CALCIUM
CADUET
5 MG * 40 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02273276
AMLODIPINE BESYLATE/ ATORVASTATIN CALCIUM
CADUET
5 MG * 80 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

AMOXICILLIN TRIHYDRATE
APO-AMOXI
25 MG / ML
ORL  SUS
0.0352
N/A
ML
NO

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE
AMOXICILLIN
250 MG
ORL  CAP
0.1750
0.1750
CAP
YES

REGULAR BENEFIT *

AMOXICILLIN TRIHYDRATE
AMOXICILLIN
250 MG
ORL  CAP
0.1750
0.1750
CAP
YES

REGULAR BENEFIT *

AMOXICILLIN TRIHYDRATE
APO-AMOXI
250 MG
ORL  CAP
0.1750
0.1750
CAP
YES

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE
AURO-AMOXICILLIN
250 MG
ORL  CAP
0.1750
0.1750
CAP
YES

REGULAR BENEFIT *

AMOXICILLIN TRIHYDRATE
JAMP-AMOXICILLIN
250 MG
ORL  CAP
N/A
N/A
CAP
NO

UNDER REVIEW

AMOXICILLIN TRIHYDRATE
NOVAMOXIN
250 MG
ORL  CAP
0.1750
0.1750
CAP
YES

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE
NOVAMOXIN
250 MG
ORL  CTB
0.7512
N/A
TAB
NO

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE
AMOXICILLIN
50 MG / ML
ORL  SUS
0.0540
0.0540
ML
YES

REGULAR BENEFIT *

AMOXICILLIN TRIHYDRATE
AMOXICILLIN
50 MG / ML
ORL  SUS
0.0540
0.0540
ML
YES

REGULAR BENEFIT *

AMOXICILLIN TRIHYDRATE
AMOXICILLIN SUGAR-REDUCED
50 MG / ML
ORL  SUS
0.0540
0.0540
ML
YES

REGULAR BENEFIT *

AMOXICILLIN TRIHYDRATE
APO-AMOXI
50 MG / ML
ORL  SUS
0.0540
0.0540
ML
YES

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE
NOVAMOXIN
50 MG / ML
ORL  SUS
0.0540
0.0540
ML
YES

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE
NOVAMOXIN SUGAR-REDUCED
50 MG / ML
ORL  SUS
0.0540
0.0540
ML
YES

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE
AMOXICILLIN
500 MG
ORL  CAP
0.3417
0.3417
CAP
YES

REGULAR BENEFIT *

AMOXICILLIN TRIHYDRATE
AMOXICILLIN
500 MG
ORL  CAP
0.3417
0.3417
CAP
YES

REGULAR BENEFIT *

AMOXICILLIN TRIHYDRATE
APO-AMOXI
500 MG
ORL  CAP
0.3417
0.3417
CAP
YES

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE
AURO-AMOXICILLIN
500 MG
ORL  CAP
0.3417
0.3417
CAP
YES

REGULAR BENEFIT *

AMOXICILLIN TRIHYDRATE
JAMP-AMOXICILLIN
500 MG
ORL  CAP
N/A
N/A
CAP
NO

UNDER REVIEW

AMOXICILLIN TRIHYDRATE
MYLAN-AMOXICILLIN
500 MG
ORL  CAP
0.3417
0.3417
CAP
YES

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE
NOVAMOXIN
500 MG
ORL  CAP
0.3417
0.3417
CAP
YES

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE
PMS-AMOXICILLIN
500 MG
ORL  CAP
0.3417
0.3417
CAP
YES

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM
CLAVULIN-125F
25 MG / ML * 6.25 MG / ML
ORL  SUS
0.0969
N/A
ML
NO

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM
APO-AMOXI CLAV
250 MG * 125 MG
ORL  TAB
0.9375
N/A
TAB
NO

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM
CLAVULIN-200
40 MG / ML * 5.7 MG / ML
ORL  SUS
0.1498
N/A
ML
NO

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM
CLAVULIN-250F
50 MG / ML * 12.5 MG / ML
ORL  SUS
0.2039
N/A
ML
NO

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM
APO-AMOXI CLAV
500 MG * 125 MG
ORL  TAB
1.1333
1.1333
TAB
YES

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM
CLAVULIN-500F
500 MG * 125 MG
ORL  TAB
1.5420
1.1333
TAB
YES

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM
SANDOZ AMOXI-CLAV
500 MG * 125 MG
ORL  TAB
N/A
N/A
TAB
NO

UNDER REVIEW

AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM
CLAVULIN-400
80 MG / ML * 11.4 MG / ML
ORL  SUS
0.2869
N/A
ML
NO

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM
APO-AMOXI CLAV
875 MG * 125 MG
ORL  TAB
1.1103
1.1103
TAB
YES

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM
CLAVULIN-875
875 MG * 125 MG
ORL  TAB
2.2735
1.1103
TAB
YES

REGULAR BENEFIT *

 

AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM
SANDOZ AMOXI-CLAV
875 MG * 125 MG
ORL  TAB
N/A
N/A
TAB
NO

UNDER REVIEW

02248808
AMPHETAMINE SULFATE/ AMPHETAMINE ASPARTATE/ DEXTROAMPHETAMINE SULFATE/ DEXTROAMPHETAMINE SACCHARATE
ADDERALL XR
1.25 MG * 1.25 MG * 1.25 MG * 1.25 MG
ORL  ERC
N/A
N/A
CAP
NO

NOT A BENEFIT

02248809
AMPHETAMINE SULFATE/ AMPHETAMINE ASPARTATE/ DEXTROAMPHETAMINE SULFATE/ DEXTROAMPHETAMINE SACCHARATE
ADDERALL XR
2.5 MG * 2.5 MG * 2.5 MG * 2.5 MG
ORL  ERC
N/A
N/A
CAP
NO

NOT A BENEFIT

02248810
AMPHETAMINE SULFATE/ AMPHETAMINE ASPARTATE/ DEXTROAMPHETAMINE SULFATE/ DEXTROAMPHETAMINE SACCHARATE
ADDERALL XR
3.75 MG * 3.75 MG * 3.75 MG * 3.75 MG
ORL  ERC
N/A
N/A
CAP
NO

NOT A BENEFIT

02248811
AMPHETAMINE SULFATE/ AMPHETAMINE ASPARTATE/ DEXTROAMPHETAMINE SULFATE/ DEXTROAMPHETAMINE SACCHARATE
ADDERALL XR
5 MG * 5 MG * 5 MG * 5 MG
ORL  ERC
N/A
N/A
CAP
NO

NOT A BENEFIT

02248812
AMPHETAMINE SULFATE/ AMPHETAMINE ASPARTATE/ DEXTROAMPHETAMINE SULFATE/ DEXTROAMPHETAMINE SACCHARATE
ADDERALL XR
6.25 MG * 6.25 MG * 6.25 MG * 6.25 MG
ORL  ERC
N/A
N/A
CAP
NO

NOT A BENEFIT

02248813
AMPHETAMINE SULFATE/ AMPHETAMINE ASPARTATE/ DEXTROAMPHETAMINE SULFATE/ DEXTROAMPHETAMINE SACCHARATE
ADDERALL XR
7.5 MG * 7.5 MG * 7.5 MG * 7.5 MG
ORL  ERC
N/A
N/A
CAP
NO

NOT A BENEFIT

AMPHOTERICIN B
FUNGIZONE IV
50 MG / VIAL
INJ 
80.0438
N/A
VIAL
NO

REGULAR BENEFIT *

 

AMPICILLIN
NOVO-AMPICILLIN
250 MG
ORL  CAP
0.4223
N/A
CAP
NO

RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION *

AMPICILLIN
NOVO-AMPICILLIN
500 MG
ORL  CAP
0.8006
N/A
CAP
NO

RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION *

02227002
AMPICILLIN SODIUM
AMPICILLIN
1 G / VIAL
INJ 
N/A
N/A
VIAL
NO

NOT A BENEFIT

AMPICILLIN SODIUM
AMPICILLIN SODIUM
1 G / VIAL
INJ 
5.5886
N/A
VIAL
NO

REGULAR BENEFIT *

 

02226995
AMPICILLIN SODIUM
AMPICILLIN
2 G / VIAL
INJ 
N/A
N/A
VIAL
NO

NOT A BENEFIT

AMPICILLIN SODIUM
AMPICILLIN SODIUM
2 G / VIAL
INJ 
11.1781
N/A
VIAL
NO

REGULAR BENEFIT *

 

02227029
AMPICILLIN SODIUM
AMPICILLIN
250 MG / VIAL
INJ 
N/A
N/A
VIAL
NO

NOT A BENEFIT

AMPICILLIN SODIUM
AMPICILLIN SODIUM
250 MG / VIAL
INJ 
3.1830
N/A
VIAL
NO

REGULAR BENEFIT *

 

02227010
AMPICILLIN SODIUM
AMPICILLIN
500 MG / VIAL
INJ 
N/A
N/A
VIAL
NO

NOT A BENEFIT

AMPICILLIN SODIUM
AMPICILLIN SODIUM
500 MG / VIAL
INJ 
3.3384
N/A
VIAL
NO

REGULAR BENEFIT *

 

ANAKINRA
KINERET
100 MG / SYR
INJ  NDL
50.0700
N/A
SYR
NO

SPECIAL AUTHORIZATION *

APIXABAN
ELIQUIS
2.5 MG
ORL  TAB
1.6336
N/A
TAB
NO

STEP THERAPY/ SPECIAL AUTHORIZATION *

APIXABAN
ELIQUIS
5 MG
ORL  TAB
1.6336
N/A
TAB
NO

STEP THERAPY/ SPECIAL AUTHORIZATION *

APRACLONIDINE HCL
IOPIDINE
0.5 %
OPH  SOL
4.9880
N/A
ML
NO

REGULAR BENEFIT *

 

02434334
APREMILAST
OTEZLA
30 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02434318
APREMILAST/ APREMILAST/ APREMILAST
OTEZLA (STARTER PACK)
10 MG * 20 MG * 30 MG
ORL  TAB
N/A
N/A
TAB
NO

NOT A BENEFIT

02298805
APREPITANT
EMEND
125 MG
ORL  CAP
N/A
N/A
CAP
NO

NOT A BENEFIT

APREPITANT
EMEND
80 MG
ORL  CAP
33.0788
N/A
CAP
NO

RESTRICTED BENEFIT *

APREPITANT/ APREPITANT
EMEND TRI-PACK
80 MG * 125 MG
ORL  CAP
33.0788
N/A
CAP
NO

RESTRICTED BENEFIT *

ARIPIPRAZOLE
ABILIFY
10 MG
ORL  TAB
4.1016
1.0754
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
APO-ARIPIPRAZOLE
10 MG
ORL  TAB
1.0754
1.0754
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
AURO-ARIPIPRAZOLE
10 MG
ORL  TAB
1.0754
1.0754
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
PMS-ARIPIPRAZOLE
10 MG
ORL  TAB
1.0754
1.0754
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
SANDOZ ARIPIPRAZOLE
10 MG
ORL  TAB
1.0754
1.0754
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
TEVA-ARIPIPRAZOLE
10 MG
ORL  TAB
1.0754
1.0754
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
ABILIFY
15 MG
ORL  TAB
4.1016
1.2692
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
APO-ARIPIPRAZOLE
15 MG
ORL  TAB
1.2692
1.2692
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
AURO-ARIPIPRAZOLE
15 MG
ORL  TAB
1.2692
1.2692
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
PMS-ARIPIPRAZOLE
15 MG
ORL  TAB
1.2692
1.2692
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
SANDOZ ARIPIPRAZOLE
15 MG
ORL  TAB
1.2692
1.2692
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
TEVA-ARIPIPRAZOLE
15 MG
ORL  TAB
1.2692
1.2692
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
ABILIFY
2 MG
ORL  TAB
3.1618
0.8092
TAB
YES

RESTRICTED BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
APO-ARIPIPRAZOLE
2 MG
ORL  TAB
0.8092
0.8092
TAB
YES

RESTRICTED BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
AURO-ARIPIPRAZOLE
2 MG
ORL  TAB
0.8092
0.8092
TAB
YES

RESTRICTED BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
PMS-ARIPIPRAZOLE
2 MG
ORL  TAB
0.8092
0.8092
TAB
YES

RESTRICTED BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
SANDOZ ARIPIPRAZOLE
2 MG
ORL  TAB
0.8092
0.8092
TAB
YES

RESTRICTED BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
TEVA-ARIPIPRAZOLE
2 MG
ORL  TAB
0.8092
0.8092
TAB
YES

RESTRICTED BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
ABILIFY
20 MG
ORL  TAB
4.1016
1.0017
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
APO-ARIPIPRAZOLE
20 MG
ORL  TAB
1.0017
1.0017
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
AURO-ARIPIPRAZOLE
20 MG
ORL  TAB
1.0017
1.0017
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
PMS-ARIPIPRAZOLE
20 MG
ORL  TAB
1.0017
1.0017
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
SANDOZ ARIPIPRAZOLE
20 MG
ORL  TAB
1.0017
1.0017
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
TEVA-ARIPIPRAZOLE
20 MG
ORL  TAB
1.0017
1.0017
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
ABILIFY
30 MG
ORL  TAB
4.1016
1.0017
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
APO-ARIPIPRAZOLE
30 MG
ORL  TAB
1.0017
1.0017
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
AURO-ARIPIPRAZOLE
30 MG
ORL  TAB
1.0017
1.0017
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
PMS-ARIPIPRAZOLE
30 MG
ORL  TAB
1.0017
1.0017
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
SANDOZ ARIPIPRAZOLE
30 MG
ORL  TAB
1.0017
1.0017
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *

ARIPIPRAZOLE
TEVA-ARIPIPRAZOLE
30 MG
ORL  TAB
1.0017
1.0017
TAB
YES

REGULAR BENEFIT/RESTRICTED BENEFIT *