Below is a list of abbreviations that may appear on the following pages in the Requirement/Limits columnthat tells you if there are any special requirements for coverage of your drug. List of Abbreviations PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug. GC: Gap Coverage. We provide coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, call Customer Service. ED: Enhanced Drug. This prescription drug is not normally covered in a Medicare prescription drug plan. The amount you pay when you fill a prescription for this drug does not count toward your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.
.Commonly Prescribed Therapeutic Drug Reqs./ Drug Categories Anti - Infectives Antifungal Agents Drug Reqs./ Generics Antivirals Generics Cephalosporins Generics ceftriaxone in iso-osmotic dextrose 1
Drug Reqs./ Drug Reqs./ Erythromycins / Other Macrolides Generics Miscellaneous Anti - Infectives Generics Drug Reqs./ Drug Reqs./ Sulfa's / Related Agents Generics Penicillins Generics amoxicillin/potassium clavulanate 1
Tetracyclines Generics doxycycline hyclate caps, INJ, tabs 1
Urinary Tract Agents Generics Vancomycin Generics Quinolones Generics Drug Reqs./ Drug Reqs./ Antineoplastic / Immunosuppressant Drugs Adjunctive Agents Generics Brands ELITEK Antineoplastic / Immunosuppressant Generics Drug Reqs./ Drug Reqs./ Autonomic / CNS Drugs, Neurology / Psych Anticonvulsants Generics Drug Reqs./ Drug Reqs./ Antiparkinsonism Agents Generics Muscle Relaxants / Antispasmodic Generics Brands MESTINON Migraine / Cluster Headache Therapy Generics dihydroergotamine mesylate Narcotic Analgesics Generics hydromorphone hcl tabs 2mg, 8mg 1levorphanol tartrateMiscellaneous Neurological Therapy Drug Reqs./ Drug Reqs./ Propoxyphene Generics Psychotherapeutic Drugs Generics Non-Narcotic Analgesics Generics Drug Reqs./ Drug Reqs./ Cardiovascular, Hypertension Antiarrhythmic Agents Generics Drug Reqs./ Drug Reqs./ Antihypertensive Therapy Generics benazepril hcl/hydrochlorothiazide 1
Drug Reqs./ Drug Reqs./ Lipid/Cholesterol Lowering Agents Generics Cardiac Glycosides Generics Coagulation Therapy Generics Miscellaneous Cardiovascular Agents Drug Reqs./ Drug Reqs./ Nitrates Generics Therapy For Acne Generics Dermatologicals/Topical Antipsoriatic / Antiseborrheic Generics Topical Anesthetics Burn Therapy Generics lidocaine Generics Brands EMLA /TEGADERM Miscellaneous Dermatologicals Generics Topical Antibacterials Generics Brands 8-MOP Topical Antifungals Generics Drug Reqs./ Drug Reqs./ Topical Enzymes Topical Antivirals Topical Scabicides / Pediculicides Generics Topical Corticosteroids Generics Diagnostics / Miscellaneous Miscellaneous Agents Generics dextrose 5%/sodium chloride 0.2% 1
dextrose 5%/sodium chloride 0.9% 1
Drug Reqs./ Drug Reqs./ Ear, Nose / Throat Medications Miscellaneous Agents Generics sodium polystyrene sulfonate powd, 1
Miscellaneous Otic Preparations Generics Otic Steroid / Antibiotic Generics Endocrine/Diabetes Smoking Deterrents Adrenal Hormones Generics Generics Drug Reqs./ Drug Reqs./ Antithyroid Agents Generics Diabetes Therapy Generics Drug Reqs./ Drug Reqs./ Thyroid Hormones Generics Gastroenterology Antidiarrheals / Antispasmodics Generics Miscellaneous Hormones Generics Miscellaneous Gastrointestinal Agents Generics Drug Reqs./ Drug Reqs./ Ulcer Therapy Generics Immunology, Vaccines / Biotechnology Biotechnology Drugs Drug Reqs./ Drug Reqs./ Musculoskeletal / Rheumatology Vaccines / Miscellaneous Gout Therapy Immunologicals Generics Generics Osteoporosis Therapy Generics Other Rheumatologicals Generics Drug Reqs./ Drug Reqs./ Miscellaneous Ob/Gyn Generics Obstetrics / Gynecology Estrogens / Progestins Generics Oral Contraceptives / Related Agents Generics Drug Reqs./ Drug Reqs./ Antivirals Generics Beta-Blockers Generics Oxytocics Cycloplegic Mydriatics Generics Ophthalmology Antibiotics Generics Direct Acting Miotics Miscellaneous Ophthalmologics Generics Non-Steroidal Anti-Inflammatory Drug Reqs./ Drug Reqs./ Generics Oral Drugs For Glaucoma Sulfonamides Generics Generics Sympathomimetics Generics Other Glaucoma Drugs Vasoconstrictor Decongestants Generics Respiratory And Allergy Antihistamine / Antiallergenic Agents Steroid-Antibiotic Combinations Generics Generics Steroid-Sulfonamide Combinations Generics sulfacetamide sodium/prednisolone 1
Steroids Generics Drug Reqs./ Drug Reqs./ Pulmonary Agents Generics Urologicals Anticholinergics / Antispasmodics Generics Benign Prostatic Hyperplasia(BPH) Generics Cholinergic Stimulants Generics Miscellaneous Urologicals Generics potassium citrate extended-release 1
Drug Reqs./ Drug Reqs./ Vitamins, Hematinics / Electrolytes Electrolytes Generics potassium chloride 0.15% d5w/nacl1
potassium chloride 0.15% d5w/nacl1
Miscellaneous Nutrition Products Generics potassium chloride er cpcr 10meq 1
Drug Reqs./ Drug Reqs./ Vitamins / Hematinics Generics
25%CLINIMIX 5%/DEXTROSE 15% 2CLINIMIX 5%/DEXTROSE 20% 2CLINIMIX 5%/DEXTROSE 25% 2CLINISOL SF 15%
/ELECTROLYTE #75 VIAFLEXFREAMINE HBC 6.9%
amiloride /hydrochlorothiazide .10
amlodipine besylate/benazepril hydrochloride .10
amoxicillin/potassium clavulanate . 4
bacitracin /neomycin /polymyxin.20
benazepril hcl/hydrochlorothiazide.10
augmented betamethasone dipropionate.13
bisoprolol fumarate/hydrochlorothiazide .10
ceftriaxone in iso-osmotic dextrose . 2
chlordiazepoxide /amitriptyline. 8
clobetasol propionate emollient .13
clotrimazole/betamethasone dipropionate .13
dexamethasone sodium phosphate .15
dexamethasone sodium phosphate .21
dextrose 2.5%/sodium chloride 0.45%.13
dextrose 5%/sodium chloride 0.2%.13
dextrose 5%/sodium chloride 0.45%.13
dextrose 5%/sodium chloride 0.9%.13
diclofenac sodium. 8diclofenac sodium.21
E e.e.s. 200 . 3 erythromycin ethylsuccinate . enalapril maleate/hydrochlorothiazide .10
FLOXIN OTIC SINGLES.14fluconazole. 2
gentamicin sulfate/0.9% sodium chloride . 3
fosinopril sodium/hydrochlorothiazide .10
heparin sodium/sodium chloride 0.9% premix.11HEPATAMINE .24
ipratropium bromide/albuterol sulfate .22
LINDANE .13liothyronine sodium .16
lisinopril /hydrochlorothiazide .10
lactated ringer's dextrose 5% viaflex .14
lamotrigine chewable dispersible. 6
methotrexate sodium. 5methyclothiazide .10
methylprednisolone sodiumsuccinate .15
metoprolol /hydrochlorothiazide .10
moexipril /hydrochlorothiazide .10
nitrofurantoin macrocrystalline . 4
neomycin /polymyxin /dexamethasone .21
neomycin /polymyxin /gramicidin .20
neomycin /polymyxin /hydrocortisone.14
neomycin /polymyxin /hydrocortisone.21
pancrelipase.16pancrelipase mst-16.16
potassium chloride 0.15% d5w/nacl 0.33% .23
potassium chloride 0.15% d5w/nacl 0.45%potassium chloride 0.15% nacl 0.9% .23
potassium chloride 0.15%/nacl 0.9% .23
potassium chloride 0.224%d5w/nacl 0.33% .23
potassium citrate extended-release .22
polymyxin b sulfate/trimethoprim sulfate.20
probenecid/colchicine .18procainamide hcl. 9
propranolol /hydrochlorothiazide .10
quinapril /hydrochlorothiazide .10
spironolactone /hydrochlorothiazide.10
sulfacetamide sodium/prednisolone sodiumsulfamethoxazole /trimethoprim . 4
triamterene /hydrochlorothiazide .10
vancomycin hcl . 4VANCOMYCIN HCL ISO-OSMOTIC
zolpidem tartrate . 9ZOMIG. 7ZOMIG ZMT . 7ZONALON.12zonisamide. 6ZOSTAVAX .18ZOSYN. 4zovia 1/35e.20zovia 1/50e.20ZOVIRAX.13ZYLET .21ZYMAR .20ZYPREXA . 9ZYPREXA ZYDIS. 9ZYVOX. 4
Poster Sessions Ⅲ JVIR three main areas relating to periprocedural care, namely sign in, timeStent deployment was successful in all cases. No significant dif-out, and sign out, and requires participation from all members of theferences in prostate size between groups were identified at anyinterventional radiology team. Based on analysis of our initial data,studied timepoints. At day 30 a
FAEL – FACULDADE EDUCACIONAL DA LAPA CURSO DE PEDAGOGIA - EAD FUNDAMENTOS E METODOLOGIA DA EDUCAÇÃO DE JOVENS E MATERIAL COMPLEMENTAR - AULA 4 O Pensamento político e pedagógico de Paulo Freire Para Paulo Freire, as questões e problemas principais da educação não são questões pedagógicas, ao contrário, são questões políticas. Para ele, a educação e o sistema d