• No results found

Pack, 43 Omnipod Dash 5 Pack, 43

In document Value Formulary. (Page 77-88)

OB Complete, 49 Obizur, 34 Obredon, 53 Ocaliva, 56 Ocufen, 50 Ocuflox, 50 Odactra SL, 53 Odomzo, 20 Ofev, 53

ofloxacin, 40, 50 ofloxacin otic, 40

olmesartan/hctz, 34 olopatadine, 40, 50 olopatadine hcl, 50 Olumiant, 56 Olux [E], 38

omega-3 acid ethyl esters, 34 omeprazole, 45

Omnaris, 40

Omnipod 5 Pack, 43 Omnipod Dash 5 Pack, 43 Omnipod Dash System, 43 Omnipod Starter Kit, 43 Omnipred, 50

Omnitrope, 43 ondansetron HCl, 45 One Touch Glucometer, 43 One Touch Test Strips, 43 Onexton, 38

Onfi, 27 Onfi susp, 27 Ongentys, 27 Onglyza, 43 Onmel, 17 Onureg, 20 Onzetra Xsail, 27 Opana, 27

Opana ER, 27 ophth oint, 49–50 Opsumit, 34 Oracea, 17 Oralair, 53 Orap, 27

Orapred ODT, 43 Orencia, 47 Orenitram, 34

Orfadin 20mg capsule, Orfadin 4mg/ml suspension, 56

Orfadin capsule 2mg, 5mg, 10mg, 56 Oriahnn cap, 47

Orilissa, 43

Orkambi tablet/packet, 17 orlistat, 45

orphenadrine ER, 47

Index

Ortho-Cyclen, 49 Ortikos ER Cap, 20 oseltamivir caps/susp, 17 Oseni, 43

Osmolex ER, 27 Osmoprep, 45 Otezla, 47 Otrexup, 47 Ovide, 38 Ovidrel, 49 Oxandrin, 43 oxandrolone, 43 oxaprozin, 27, 47 Oxaydo, 27 oxazepam, 27 Oxbryta, 56 oxcarbazepine, 27

Oxervate soln 200mcg/ml, 50 oxiconazole nitrate, 38 Oxistat, 38

Oxsoralen Ultra, 38 Oxtellar XR, 27 oxybutynin [ER], 54 oxybutynin syrup, 54 oxycodone ER tablet, 27 oxycodone IR, 27

oxycodone/acetaminophen, 27

oxycodone/APAP 2.5-300mg, 5-300mg, 10-300mg tab, 27

oxycodone/aspirin, 27 oxycodone/ibuprofen, 27 OxyContin, 27

oxymorphone ER, 27 oxymorphone IR, 27 Ozempic Soln, 43 Ozobax Soln, 27

P

Pacerone, 34

Palforzia cap/powder, 53 paliperidone ER tablet, 27 Palynziq, 43

pantoprazole pak, 45 paricalcitol, 43 Parlodel, 27 Parnate, 27 paroxetine, 27 paroxetine ER, 27 Patanase, 40 Patanol, 50 Paxil CR, 27

Paxil suspension, 27 Paxil tablet, 27

PEG 3350 & electrolytes, 45

peg-kcl-nacl-nasulf-na asc-c soln reconstituted, 45 Pegasys, 17

PegIntron, 17 Pemazyre, 20

penicillamine capsule, 56 penicillamine tablet, 56

penicillin v potassium tablet, 18 Penlac, 38

Pennsaid, 47

pentamidine INH, 18 Pentasa, 45

pentazocine-naloxone, 27 pentoxifylline ER, 34 Pepcid tabs, suspension, 45 Percocet, 27

perindopril, 34 permethrin, 38 perphenazine, 27 Persantine, 34 Pertzye, 45

phendimetrazine tartrate, 27 phenelzine, 27

phenobarbital, 27 phenoxybenzamine, 34 phentermine hcl, 27 Phenytek, 27 phenytoin, 27 PhosLo, 56 phospha, 56

Phospholine Iodide, 50 phytonadione, 55

Index

pindolol ER, 34 pioglitazone, 40, 43

pioglitazone/glimepiride, 43 Piqray, 20

piroxicam, 27, 47 Plan B One-Step, 49 Plaquenil, 18

Plavix, 34 Plegridy, 27 Plenvu Soln, 45 podofilox soln, 39

polymyxin B/neo/bacitracin, 50 polymyxin B/neo/gramicidin, 50 Polytrim, 50

Pomalyst, 20 posaconazole, 18 Potaba, 56

potassium bicarbonate/potassium citrate effervescent, 55

potassium chloride, 55 potassium citrate, 54–55 Pradaxa, 34

Praluent, 34 pramipexole, 27 pramipexole ER, 27 Prandin, 43

prasugrel, 34 Pravachol, 34 pravastatin, 34 praziquantel, 18 prazosin, 34

Precision Glucometer, 43 Precision XTRA Test Strips, 43 Precose, 43

Pred-Forte, 50

prednicarbate ointment, 39 prednisolone, 43, 50–51 prednisolone acetate, 50

prednisolone sodium phosphate, 51 prednisolone/sodium sulfacetamide, 51 prednisone, 20

prednisone therapy pack/solution/concentrate, 20 pregabalin, 27

Pretomanid, 18 Prevacid caps, 45 Prevacid SoluTab, 45 Prevalite, 34

Prevymis, 18 Prezista, 18

prilocaine/lidocaine, 39 Prilosec packets, 45 primidone, 27 Primlev, 28 Prinivil, 34 Pristiq, 28

ProAir Digihaler, 53 ProAir HFA, 51, 53 ProAir RespiClick, 53 probenecid, 46–47 Procardia, 34 Procardia XL, 34 Procentra 1mg/ml, 28

prochlorperazine suppository, 45 prochlorperazine tabs, 45

Proctofoam HC, 39 Procysbi, 43 Profilnine, 34

progesterone, micronized, 49 Proglycem Susp, 43

Prograf capsule/packet, 20 Prolate tab, 28

Prolensa sol 0.07%, 51 Promacta, 34

promethazine, 53

promethazine/codeine, 53

promethazine/dextromethorphen, 53 promethazine/phenylephrine, 53

promethazine/phenylephrine/ codeine, 53 promethegan supp, 28

Prometrium, 49 propafenone, 34 propafenone SR, 34 proparacaine, 51 propranolol, 34 propranolol ER, 34 propranolol/HCTZ, 34

Index

Proventil HFA, 51, 53 Provera, 48–49

Provigil, 28 Prozac, 28

Prudoxin cream 5%, 39 Pulmicort Flexhaler, 53 Pulmicort Respules, 53

PulmoSal nebulization solution, 55 Pulmozyme, 53

Purixan, 20

pyridostigmine soln, 28 pyridostigmine tab, 28 pyrimethamin, 18

Q

Qbrelis, 34

Qbrexza Pad 2.4%, 39 Qinlock tab, 20 Qmiiz ODT, 28 Qnasl, 40 Qsymia ER, 28 Qtern, 43 Qualaquin, 18 Quartette, 49 quazepam, 28 Qudexy XR, 28 Questran, 34 Questran Light, 34 quetiapine ER, 28 quetiapine fumarate, 28 Quflora, 55

Quillichew ER, 28 Quillivant XR, 28 quinapril HCl, 34 quinapril/HCTZ, 34 quinine sulfate, 18 Qvar, 53

R

rabeprazole DR tab 20mg, 45 Rabeprazole Sprinkle Cap 10mg, 45

Ranexa, 34

ranitidine 300mg, 45 ranolazine, 34 Rapaflo, 54

Rapamune tab/sol, 20 rasagiline, 28

Rasuvo, 47 Rayaldee, 55 Rayos, 43 Razadyne, 28 Razadyne ER, 28 Rebetol, 53

Rebif Rebidose, 28 Rebinyn Soln, 34 Recombinate, 34 Regimex, 28 Reglan, 45 Regranex gel, 43 Relafen, 28 Relafen DS, 28 Relenza, 18 Relistor, 45 Relpax, 28 Remeron, 28

Remeron SolTab, 28 Renagel, 56

Renvela, 56 repaglinide, 43 Repatha, 34 Requip, 28 Requip XL, 28 Rescula, 51 Restasis, 51 Restoril, 28 Retevmo cap, 20 Retin-A, 39

Retin-A Micro 0.04%, 0.1%, 39 Retin-A Micro 0.08%, 39 Retrovir, 18

Revatio, 34 Revlimid, 20 Rexulti, 28 Reyataz, 18

Index

Ribasphere Ribapak 200mg & 400mg/400mg &

600mg, 18 ribavirin, 40 Ridaura, 56 rifabutin, 18 Rifadin, 18 rifampin, 18 Rilutek, 28 riluzole, 28 rimantadine, 18 Rinvoq, 56

Riomet [ER] solution/suspension 500mg/5ml, 43 risedronate, 47

risedronate DR, 47

Risperdal, Risperdal M-Tab, 28 risperidone, 28

Ritalin LA, 28 ritonavir, 17–18 rivastigmine, 28 Rixubis, 34

rizatriptan benzoate, 28 Robaxin, 28, 47

Rocaltrol capsules, 43 Rocklatan Soln, 51 ropinirole, 28 ropinirole ER, 28 rosuvastatin, 34 Roxicodone, 28 Roxybond, 28 Rozerem, 28 Rozlytrek, 20 Rubraca, 20 Ruconest, 56 Rukobia, 18 Ruzurgi, 56 Rybelsus, 43 Ryclora, 53 Rydapt, 20 Rytary, 28 Rythmol SR, 34 Ryvent, 53

S

Samsca, 34 Sandimmune, 20 Saphris, 28

sapropterin pow/tab, 56 Saxenda, 28

scopolamine patch, 45 Seasonique, 49

Secuado Patch, 28 Seebri, 53

Segluromet, 43 selegiline HCl, 28

selenium sulfide shampoo/lotion, 39 Selzentry, 18

Semglee Inj 100U/ML, 43 Semprex-D, 53

Sensipar, 43

Serevent Diskus, 53 Sernivo, 39

Seroquel, 28 Seroquel XR, 28 Serostim, 43 sertraline, 28

sevelamer carbonate, 56 Sevenfact Inj, 34

Seysara, 18

SFRowasa enema, 45 Signifor, 43

Siklos, 56

sildenafil citrate 20mgtab, 10mg/ml susp, 34 sildenafil citrate 25mg, 50mg, 100mg, 35 Silenor, 28

Siliq, 39 silodosin, 28 Silvadene, 39

silver sulfadiazine, 39 Simbrinza Susp 1-0.2 %, 51 Simponi, 47

simvastatin, 32, 35 simvastatin susp, 35 Sinemet, 28

Sinemet CR, 28 Singulair, 53

sirolimus tab/soln, 20

Index

sodium chloride inhalation, 53 sodium fluoride chew tab, 55 sodium phenylbutyrate tab, 55 sodium sulfacetamide suspension, 39

sofosbuvir-velpatasvir tablet 400-100mg, 18 Solaraze, 39

solifenacin, 54 Soliqua, 43 Solodyn, 18 Solosec GRA, 18 Soma, 47

Somavert, 43 Sonata, 28 Soolantra, 39 Soriatane, 39 sotalol HCl, 35 Sotylize, 35 Sovaldi, 18 spinosad, 39 Spiriva, 53

spironolactone, 35

spironolactone/HCTZ, 35 Sporanox, 18

Sprix Nasal Spray, 28 Sprycel, 20

SSKI Solution, 18 Stalevo, 28

Starlix, 43 stavudine, 18 Staxyn, 54 Steglatro, 43 Steglujan, 43 Stelara, 47 Stendra, 54 Stimate, 35

Stiolto Respimat, 53 Stivarga, 21

Strattera, 28 Strensiq, 56

Striant buccal system, 43 Stribild, 18

Striverdi Respimat Aer Solution, 53 Stromectol, 18

sulconazole cream/solution, 39 sulfacetamide, 39, 51

sulfamethoxazole/tmp, 18 Sulfamylon, 39

sulfasalazine, 45 sulindac, 28, 47 sumatriptan, 28

sumatriptan/naproxen, 28 Sunosi, 29

Suprax Susp 100mg/5ml, 200mg/5ml, 18 Sustiva, 18

Sutent, 21 Sylatron, 29 Symbicort, 53 Symbyax, 29 Symdeko, 53 Symfi, 18 Symfi Lo, 18 Symjepi Inj, 53 Symlin, 43

Sympazan Film, 29 Symproic, 45 Symtuza, 18 Synalar, 39 Synarel, 49 Syndros Sol, 46 Synjardy, 43 Synjardy XR, 43 Synthroid, 43 Syprine, 56

T

Tabloid, 21 Tabrecta tab, 21 Taclonex, 39 tacrolimus, 21

tadalafil (generic Adcirca), 53 tadalafil (generic Cialis), 53 Tafinlar, 21

Tagrisso, 21 Takhzyro, 56 Talicia, 18

Index

Tanzeum, 43 Tapazole, 43 Tarceva, 21 Targadox, 18 Targretin cap, 21 Targretin gel, 39 Tarka, 35

Tasigna, 21 Tasmar, 29 Tavalisse, 56 Taytulla, 49

tazarotene cream 0.1%, 39 Tazorac cream/gel, 39 Taztia XT, 35

Tazverik 200mg, 21 Tecfidera, 29 Technivie, 18 Tegretol [XR], 29 Tegretol susp, 29 Tegsedi, 56 Tekturna, 35 Tekturna HCT, 35 telmisartan, 35

telmisartan-amlodipine, 35

telmisartan/hydrochlorothiazide, 35 temazepam, 29

Temixys, 18 Temodar, 21 Temovate, 39 temozolomide, 21 tenofovir, 18 Tenoretic, 35 Tenormin, 35 terazosin, 54 terbinafine tabs, 18

terbutaline sulfate tablet, 53 terconazole cream, 49 Teriparatide Inj, 43 Tessalon Perles, 53 Testim Gel, 43

testosterone enanthate solution, 43 testosterone gel 1%, 1.62%, 43 testosterone gel 10mg/act (2%), 43

theophylline extended release, 53 theophylline soln, 53

Thiola [EC], 53 thioridazine, 29 thiothixene, 29 tiadylt ER, 35 tiagabine hcl, 29 Tiazac, 35 Tibsovo, 21

ticlopidine HCl, 35 Tigan, 46

Tiglutik Susp, 29 Tikosyn, 35 timolol, 35, 51 timolol ophth, 51 Timoptic, 51 Timoptic XE, 51 Tindamax, 18 tinidazole, 18

Tirosint capsule/soln, 43 Tivicay PD, 18

Tivorbex, 29 tizanidine, 47 Tobi, 18

Tobradex ointment, 39

tobramycin nebulization soln., 18 tobramycin ophthalmic, 51 tobramycin-dexamethasone, 51 Tobrex, 51

Tofranil, 29 tolbutamide, 43 tolcapone, 29 tolmetin, 29, 47 tolmetin sodium, 29 Tolsura, 18

tolterodine tartrate, 54 tolterodine tartrate LA, 54 tolvaptan tab, 35

Topamax, 29

Topamax Sprinkle Capsules, 29 Topicort cream/ointment, 39 Topicort spray, 39

topiramate, 29

Index

Toujeo Solostar, 44 Toviaz, 47

Tracleer, 53

Tradjenta tablet, 44 tramadol, 29

tramadol ER (biphasic) tablet, 29 tramadol ER cap, 29

tramadol ER tablet, 29 tramadol/acetaminophen, 29 trandolapril, 35

trandolapril/verapamil ER, 35 Transderm-Scop patch, 46 Tranxene T, 29

tranycypromine sulfate, 29 Travatan Z, 51

travoprost, 51 trazodone, 29 Trelegy Ellipta, 53 Tremfya, 39 Tresiba, 44 tretinoin caps, 21 tretinoin gel, cream, 39 tretinoin microspheres gel, 39 Tretten, 35

Trexall tab, 21 Treximet, 29 Trezix, 29 Tri-Norinyl, 49

Tri-Vi-Flor, Poly-Vi-Flor with and without iron, 55 triamcinolone acetonide, 39

triamcinolone oint 0.05%, 39 triamterene cap, 35

triamterene/HCTZ, 35 Trianex, 39

triazolam, 29 Tribenzor, 35 Tricor, 35

triderm cream, 39 trientine, 56 trifluoperazine, 29 trifluridine, 51 trihexyphenidyl, 29 Trijardy XR, 44

trimipramine, 29 Trintellix, 29 Triumeq, 18 Trizivir, 18 Trokendi XR, 29 tromethamine, 47 tropicamide, 51 trospium chloride, 54 Trulance, 46

Trulicity, 44 Trusopt, 51 Truvada, 18

trymine CG liquid, 29 Tudorza Pressair, 53 Tukysa, 21

Turalio, 21 Tussicap, 53 Tuxarin ER, 53 Tuzistra XR, 53 Twirla Dis, 49 Twynsta, 35 Tykerb, 21

Tylenol w/Codeine, 29 Tymlos, 44

Tyvaso, 35

U

Ubrelvy, 29 Uceris, 44 Uloric, 47 Ultracet, 29 Ultram, 29 Ultravate, 39 Unithroid, 44 Upneeq Soln, 51 Uptravi, 35 Urecholine, 54 Urocit-K, 54 Uroxatral, 54 ursodiol, 46

Utibron Neohaler, 54

Index

Valchlor, 21 Valcyte, 18 valganciclovir, 18 Valium, 29 valproic acid, 29 valsartan, 30, 35

valsartan/hydrochlorothiazide, 35 Valtoco, 29

Valtrex, 18 Vanatol S/LQ, 29 vancomycin, 18 Vandazole, 49 vardenafil, 54 vardenafil ODT, 54 Varubi, 46

Vascepa, 35 Vaseretic, 35 Vasotec, 35 Vecamyl, 35 Vectical, 39 Veltin, 39 Vemlidy, 18 Venclexta, 21 venlafaxine, 29 venlafaxine ER, 29 Ventavis, 35

Ventolin HFA, 51, 54 verapamil HCl, 35 verapamil HCl ER, 35 Verelan ER, PM, 35

Veripred soln 20mg/5ml, 44 Verzenio, 21

Vesicare, 54 Vfend, 18 Viagra, 54 Viberzi, 46 Vibramycin, 18 Victoza, 44 Videx EC, 18 Viekira Pak, 19 Viekira XR, 19 vigabatrin, 29 vigadrone, 29

Viramune tablet, 19 Viramune XR, 19 Virazole, 40 Viread, 19 Viroptic, 51 Vistaril, 54 Vitrakvi, 21 Vituz, 54 Vivelle Dot, 49 Vivlodex, 29 Vizimpro, 21 Vogelxo, 44 Voltaren Gel, 47 Vonvendi, 35 voriconazole, 19 Vosevi, 19 VoSpire ER, 54 Votrient, 21 Vraylar, 29 Vumerity, 44 Vusion, 39 Vyleesi, 49

Vyndaqel, Vyndamax, 35 Vytorin, 35

Vyvanse, 29

Vyzulta Soln 0.024% OP, 51

W

Wakix, 29 warfarin, 35 Welchol, 35 Wellbutrin SR, 29 Wellbutrin XL, 29 Wilate, 35

wixela inhub aer, 54

X

Xadago, 29 Xalatan, 51 Xalkori, 21 Xanax, 29

Index

Xeloda, 21

Xelpros Emulsion, 51 Xenazine, 29

Xenical, 46 Xenleta, 19

Xepi Cream 0.1%, 19 Xermelo, 46

Xhance, 40, 54 Xifaxan 200mg, 19 Xifaxan 550mg, 19 Xigduo XR, 44 Xiidra, 51 Ximino ER, 19 Xodol, Norco, 29

Xofluza Therapy Pack, 19 Xolegel, 39

Xopenex, 54 Xopenex HFA, 54 Xospata, 21 Xpovio Pak, 21 Xtampza ER, 30 Xtandi, 21 xulane, 49 Xultophy, 44 Xuriden, 56 Xyntha, 35 Xyosted Soln, 44 Xyrem, 30 Xywav Soln, 30

Y

Yasmin, 49 YAZ, 49 Yonsa, 21 Yupelri Soln, 54 yuvafem, 49

Z

Z-Tuss AC, 54 zafirlukast, 54 zaleplon, 30

Zegerid packets, 46 Zejula, 21

Zelboraf, 21 Zelnorm, 46

Zembrace Symtouch, 30 Zemplar, 44

Zenpep, 46 Zenzedi, 30 Zepatier, 19 Zeposia, 47 Zerit, 19

Zerviate Drops 0.24%, 51 Zestoretic, 35

Zestril, 35 Zetia, 35 Zetonna, 40 Ziac, 35 Ziagen, 19 Ziana, 39

zidovudine, 15, 17, 19 zileuton ER 600mg, 54 Zilxi Aer, 39

Zioptan, 51 ziprasidone, 30 Zipsor, 48 Zithromax, 19 Zmax, 19 Zocor, 35 Zofran, 46 Zohydro ER, 30 Zolinza, 21 zolmitriptan, 30 Zoloft, 30

zolpidem tartrate, 30 zolpidem tartrate ER, 30 zolpidem tartrate SL, 30 Zolpimist, 30

Zomacton, 44 Zomig, 30

Zonalon cream 5%, 39 Zonegran, 30

zonsinamide, 30 Zorbtive, 46

Index

Zubsolv, 30 Zuplenz, 46

Zurampic 200mg, 48 Zutripro, 54

Zyban, 30 Zydelig, 21 Zyflo 600mg, 54 Zyflo CR 600mg, 54 Zykadia, 21

Zyloprim, 48 Zymaxid, 51 Zypitamag, 35 Zyprexa, 30 Zyprexa Zydis, 30 Zytiga, 21

Zyvox, 19

Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

In document Value Formulary. (Page 77-88)

Related documents