Attachment D - Formulary with NDC~2.xlsx
XLSX spreadsheet 8 MB Posted
- Attached to
- Medicare Advantage Prescription Drug Services
- Solicitation number
- S000000107
- Issued by
- Pulaski County, Arkansas
About this file
This document appears to be an attachment to a Request for Proposal (RFP) issued by the Employee Benefits Division of Arkansas for Medicare Advantage Prescription Drug (MA-PD) services for its Medicare-eligible retirees and dependents. The RFP seeks pricing and a contract for these services. The attachment provides a detailed formulary list of various pharmaceutical products, their NDC codes, generic names, strengths, package sizes, and coverage information such as prior authorization requirements, quantity limits, and tier status.
The pricing terms, set-asides, and incumbents are not explicitly stated in the document provided. However, the attachment indicates that certain drugs are designated as "preferred" or "non-preferred," and there are references to plan exclusions, prior authorization requirements, and specialty drug designations. The contract term and any renewal options are also not specified in the information given.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment C - Claims File Layouts.pdf | ||
| S000000107 Questions and Answers.pdf | ||
| S000000107 Official Solicitation Price Sheet.xlsx | XLSX spreadsheet | |
| Attachment B - Schedule of Benefits Revised 4.14.22.pdf | ||
| Attachment A - Non-Disclosure Agreement.docx | DOCX document | |
| S000000107 RFP Medicare Advantage Prescription Drug Services Revised.pdf | ||
| RFP Response Packet S000000107.docx | DOCX document |
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Text version
Formulary list 03-01-2022
| NDC CODE | GPID | BRAND NAME | GENERIC NAME | OTC/RX | STRENGTH DESCRIPTION | DOSAGE | PACKAGE SIZE | NDC LABELER CODE | GENERIC EQUIVALENT | REPACKAGED | INSTITUTIONAL | FORMULARY STATUS | FORMULARY STATUS REASON | TIER | TIER DESCRIPTION | COPAY LIMIT INDICATOR | COPAY LIMIT | COPAY LIMIT MESSAGING | PRIOR AUTHORIZATION INDICATOR | PRIOR AUTHORIZATION | PRIOR AUTHORIZATION MESSAGING | QUANTITY LIMITS | DAYS LIMITS | FILL LIMIT | AGE LIMITS | SPECIAL LIMITS | GENDER LIMITS | MESSAGING | STEP THERAPY REQUIREMENTS | CONCURRENT USE | AGE GENDER LIMITS | BENEFIT TYPE | BENEFIT CODE |
| 2120001 | 32177 | AMYVID | FLORBETAPIR F-18 | F | 10 MCI | VIAL | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 2120030 | 32177 | AMYVID | FLORBETAPIR F-18 | F | 10 MCI | VIAL | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 2120050 | 32177 | AMYVID | FLORBETAPIR F-18 | F | 10 MCI | VIAL | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 2140701 | 980 | QUINIDINE GLUCONATE | QUINIDINE GLUCONATE | F | 80 MG/ML | VIAL | 10 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 1 | GENERICS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 2143301 | 37169 | TRULICITY | DULAGLUTIDE | F | 0.75MG/0.5 | PEN INJCTR | 0.5 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | R | ASPREMR | |||||||||||||||
| 2143361 | 37169 | TRULICITY | DULAGLUTIDE | F | 0.75MG/0.5 | PEN INJCTR | 0.5 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | R | ASPREMR | |||||||||||||||
| 2143380 | 37169 | TRULICITY | DULAGLUTIDE | F | 0.75MG/0.5 | PEN INJCTR | 0.5 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | R | ASPREMR | |||||||||||||||
| 2143401 | 37171 | TRULICITY | DULAGLUTIDE | F | 1.5 MG/0.5 | PEN INJCTR | 0.5 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | R | ASPREMR | |||||||||||||||
| 2143480 | 37171 | TRULICITY | DULAGLUTIDE | F | 1.5 MG/0.5 | PEN INJCTR | 0.5 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | R | ASPREMR | |||||||||||||||
| 2143601 | 40418 | EMGALITY PEN | GALCANEZUMAB-GNLM | F | 120 MG/ML | PEN INJCTR | 1 | 2 | 0 | 0 | F | 3 | NONPREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 2 IN 30 DAYS | R | ASPREMR | ||||||||||||||
| 2143611 | 40418 | EMGALITY PEN | GALCANEZUMAB-GNLM | F | 120 MG/ML | PEN INJCTR | 1 | 2 | 0 | 0 | F | 3 | NONPREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 2 IN 30 DAYS | R | ASPREMR | ||||||||||||||
| 2144501 | 40848 | TALTZ AUTOINJECTOR | IXEKIZUMAB | F | 80 MG/ML | AUTO INJCT | 1 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 2144509 | 40848 | TALTZ AUTOINJECTOR (3 PACK) | IXEKIZUMAB | F | 80 MG/ML | AUTO INJCT | 1 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 2144511 | 40848 | TALTZ AUTOINJECTOR | IXEKIZUMAB | F | 80 MG/ML | AUTO INJCT | 1 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 2144527 | 40848 | TALTZ AUTOINJECTOR (2 PACK) | IXEKIZUMAB | F | 80 MG/ML | AUTO INJCT | 1 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 2197561 | 29647 | AXIRON | TESTOSTERONE | F | 30MG/1.5ML | SOL MD PMP | 90 | 2 | Y | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | |||||||||||||||
| 2197590 | 29647 | AXIRON | TESTOSTERONE | F | 30MG/1.5ML | SOL MD PMP | 90 | 2 | Y | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | |||||||||||||||
| 2223601 | 48574 | TRULICITY | DULAGLUTIDE | F | 3 MG/0.5ML | PEN INJCTR | 0.5 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | R | ASPREMR | |||||||||||||||
| 2223680 | 48574 | TRULICITY | DULAGLUTIDE | F | 3 MG/0.5ML | PEN INJCTR | 0.5 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | R | ASPREMR | |||||||||||||||
| 2237701 | 40419 | EMGALITY SYRINGE | GALCANEZUMAB-GNLM | F | 120 MG/ML | SYRINGE | 1 | 2 | 0 | 0 | F | 3 | NONPREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | R | ASPREMR | |||||||||||||||
| 2237711 | 40419 | EMGALITY SYRINGE | GALCANEZUMAB-GNLM | F | 120 MG/ML | SYRINGE | 1 | 2 | 0 | 0 | F | 3 | NONPREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | R | ASPREMR | |||||||||||||||
| 2298026 | 48026 | RETEVMO | SELPERCATINIB | F | 80 MG | CAPSULE | 120 | 2 | 0 | 0 | NC | 2 | PREFERRED DRUGS | 31 DAYS | S | ASPREMACS | |||||||||||||||||
| 2298060 | 48026 | RETEVMO | SELPERCATINIB | F | 80 MG | CAPSULE | 60 | 2 | 0 | 0 | NC | 2 | PREFERRED DRUGS | 31 DAYS | S | ASPREMACS | |||||||||||||||||
| 2300475 | 12929 | PROZAC WEEKLY | FLUOXETINE HCL | F | 90 MG | CAPSULE DR | 4 | 2 | Y | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 1 | GENERICS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||
| 2311501 | 46397 | EMGALITY SYRINGE | GALCANEZUMAB-GNLM | F | 300MG/3ML | SYRINGE | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 2311509 | 46397 | EMGALITY SYRINGE | GALCANEZUMAB-GNLM | F | 300MG/3ML | SYRINGE | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 2318201 | 48573 | TRULICITY | DULAGLUTIDE | F | 4.5 MG/0.5 | PEN INJCTR | 0.5 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | R | ASPREMR | |||||||||||||||
| 2318280 | 48573 | TRULICITY | DULAGLUTIDE | F | 4.5 MG/0.5 | PEN INJCTR | 0.5 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | R | ASPREMR | |||||||||||||||
| 2322730 | 18776 | STRATTERA | ATOMOXETINE HCL | F | 10 MG | CAPSULE | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | 2 IN 1 DAYS | R | ASPREMR | ||||||||||||||||
| 2322830 | 18778 | STRATTERA | ATOMOXETINE HCL | F | 25 MG | CAPSULE | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | 2 IN 1 DAYS | R | ASPREMR | ||||||||||||||||
| 2322930 | 18779 | STRATTERA | ATOMOXETINE HCL | F | 40 MG | CAPSULE | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | 2 IN 1 DAYS | R | ASPREMR | ||||||||||||||||
| 2323030 | 98648 | SYMBYAX | OLANZAPINE/FLUOXETINE HCL | F | 3 MG-25 MG | CAPSULE | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2323130 | 20868 | SYMBYAX | OLANZAPINE/FLUOXETINE HCL | F | 6MG-25MG | CAPSULE | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2323230 | 20870 | SYMBYAX | OLANZAPINE/FLUOXETINE HCL | F | 12MG-25MG | CAPSULE | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2323330 | 20869 | SYMBYAX | OLANZAPINE/FLUOXETINE HCL | F | 6MG-50MG | CAPSULE | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2323430 | 20872 | SYMBYAX | OLANZAPINE/FLUOXETINE HCL | F | 12MG-50MG | CAPSULE | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2323560 | 23161 | CYMBALTA | DULOXETINE HCL | F | 20 MG | CAPSULE DR | 60 | 2 | Y | 0 | 0 | F | 5 | REFERENCE PRICING | R | ASPREMR | |||||||||||||||||
| 2323830 | 18777 | STRATTERA | ATOMOXETINE HCL | F | 18 MG | CAPSULE | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | 2 IN 1 DAYS | R | ASPREMR | ||||||||||||||||
| 2323930 | 18781 | STRATTERA | ATOMOXETINE HCL | F | 60 MG | CAPSULE | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | 1 IN 1 DAYS | R | ASPREMR | ||||||||||||||||
| 2324030 | 23162 | CYMBALTA | DULOXETINE HCL | F | 30 MG | CAPSULE DR | 30 | 2 | Y | 0 | 0 | F | 5 | REFERENCE PRICING | R | ASPREMR | |||||||||||||||||
| 2324090 | 23162 | CYMBALTA | DULOXETINE HCL | F | 30 MG | CAPSULE DR | 90 | 2 | Y | 0 | 0 | F | 5 | REFERENCE PRICING | R | ASPREMR | |||||||||||||||||
| 2325030 | 26538 | STRATTERA | ATOMOXETINE HCL | F | 80 MG | CAPSULE | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | 1 IN 1 DAYS | R | ASPREMR | ||||||||||||||||
| 2325130 | 26539 | STRATTERA | ATOMOXETINE HCL | F | 100 MG | CAPSULE | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | 1 IN 1 DAYS | R | ASPREMR | ||||||||||||||||
| 2327004 | 23164 | CYMBALTA | DULOXETINE HCL | F | 60 MG | CAPSULE DR | 1000 | 2 | Y | 0 | 0 | F | 5 | REFERENCE PRICING | R | ASPREMR | |||||||||||||||||
| 2327030 | 23164 | CYMBALTA | DULOXETINE HCL | F | 60 MG | CAPSULE DR | 30 | 2 | Y | 0 | 0 | F | 5 | REFERENCE PRICING | R | ASPREMR | |||||||||||||||||
| 2397760 | 48025 | RETEVMO | SELPERCATINIB | F | 40 MG | CAPSULE | 60 | 2 | 0 | 0 | NC | 2 | PREFERRED DRUGS | 31 DAYS | S | ASPREMACS | |||||||||||||||||
| 2411230 | 15084 | ZYPREXA | OLANZAPINE | F | 2.5 MG | TABLET | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2411530 | 15083 | ZYPREXA | OLANZAPINE | F | 5 MG | TABLET | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2411630 | 15081 | ZYPREXA | OLANZAPINE | F | 7.5 MG | TABLET | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2411730 | 15082 | ZYPREXA | OLANZAPINE | F | 10 MG | TABLET | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2416502 | 59011 | EVISTA | RALOXIFENE HCL | F | 60 MG | TABLET | 100 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2416507 | 59011 | EVISTA | RALOXIFENE HCL | F | 60 MG | TABLET | 2000 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2416530 | 59011 | EVISTA | RALOXIFENE HCL | F | 60 MG | TABLET | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2418230 | 43468 | OLUMIANT | BARICITINIB | F | 2 MG | TABLET | 30 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 2418402 | 59011 | EVISTA | RALOXIFENE HCL | F | 60 MG | TABLET | 100 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2418407 | 59011 | EVISTA | RALOXIFENE HCL | F | 60 MG | TABLET | 2000 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2418430 | 59011 | EVISTA | RALOXIFENE HCL | F | 60 MG | TABLET | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2431208 | 47083 | REYVOW | LASMIDITAN SUCCINATE | F | 50 MG | TABLET | 8 | 2 | 0 | 0 | NC | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2441530 | 15085 | ZYPREXA | OLANZAPINE | F | 15 MG | TABLET | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2442030 | 15086 | ZYPREXA | OLANZAPINE | F | 20 MG | TABLET | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2445301 | 92007 | ZYPREXA ZYDIS | OLANZAPINE | F | 5 MG | TAB RAPDIS | 1 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2445385 | 92007 | ZYPREXA ZYDIS | OLANZAPINE | F | 5 MG | TAB RAPDIS | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2445401 | 92008 | ZYPREXA ZYDIS | OLANZAPINE | F | 10 MG | TAB RAPDIS | 1 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2445485 | 92008 | ZYPREXA ZYDIS | OLANZAPINE | F | 10 MG | TAB RAPDIS | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2445501 | 34022 | ZYPREXA ZYDIS | OLANZAPINE | F | 15 MG | TAB RAPDIS | 1 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2445585 | 34022 | ZYPREXA ZYDIS | OLANZAPINE | F | 15 MG | TAB RAPDIS | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2445601 | 34023 | ZYPREXA ZYDIS | OLANZAPINE | F | 20 MG | TAB RAPDIS | 1 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2445685 | 34023 | ZYPREXA ZYDIS | OLANZAPINE | F | 20 MG | TAB RAPDIS | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2446230 | 20736 | CIALIS | TADALAFIL | F | 5 MG | TABLET | 30 | 2 | Y | 0 | 0 | F | 3 | NONPREFERRED DRUGS | 6 IN 30 DAYS | R | ASPREMR | ||||||||||||||||
| 2446234 | 20736 | CIALIS | TADALAFIL | F | 5 MG | TABLET | 30 | 2 | Y | 0 | 0 | F | 3 | NONPREFERRED DRUGS | 6 IN 30 DAYS | R | ASPREMR | ||||||||||||||||
| 2446279 | 20736 | CIALIS | TADALAFIL | F | 5 MG | TABLET | 15 | 2 | Y | 0 | 0 | F | 3 | NONPREFERRED DRUGS | 6 IN 30 DAYS | R | ASPREMR | ||||||||||||||||
| 2446330 | 18995 | CIALIS | TADALAFIL | F | 10 MG | TABLET | 30 | 2 | Y | 0 | 0 | F | 3 | NONPREFERRED DRUGS | 6 IN 30 DAYS | R | ASPREMR | ||||||||||||||||
| 2446430 | 18996 | CIALIS | TADALAFIL | F | 20 MG | TABLET | 30 | 2 | Y | 0 | 0 | F | 3 | NONPREFERRED DRUGS | 6 IN 30 DAYS | R | ASPREMR | ||||||||||||||||
| 2446534 | 99409 | CIALIS | TADALAFIL | F | 2.5 MG | TABLET | 30 | 2 | Y | 0 | 0 | F | 3 | NONPREFERRED DRUGS | 6 IN 30 DAYS | R | ASPREMR | ||||||||||||||||
| 2446579 | 99409 | CIALIS | TADALAFIL | F | 2.5 MG | TABLET | 15 | 2 | Y | 0 | 0 | F | 3 | NONPREFERRED DRUGS | 6 IN 30 DAYS | R | ASPREMR | ||||||||||||||||
| 2448354 | 43918 | VERZENIO | ABEMACICLIB | F | 50 MG | TABLET | 14 | 2 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 2449108 | 47084 | REYVOW | LASMIDITAN SUCCINATE | F | 100 MG | TABLET | 8 | 2 | 0 | 0 | NC | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2473230 | 47205 | OLUMIANT | BARICITINIB | F | 1 MG | TABLET | 30 | 2 | 0 | 0 | NC | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2481554 | 43917 | VERZENIO | ABEMACICLIB | F | 100 MG | TABLET | 14 | 2 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 2512101 | 17056 | EFFIENT | PRASUGREL HCL | F | 5 MG | TABLET | 1 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2512130 | 17056 | EFFIENT | PRASUGREL HCL | F | 5 MG | TABLET | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2512152 | 17056 | EFFIENT | PRASUGREL HCL | F | 5 MG | TABLET | 24 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2512301 | 17157 | EFFIENT | PRASUGREL HCL | F | 10 MG | TABLET | 1 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2512330 | 17157 | EFFIENT | PRASUGREL HCL | F | 10 MG | TABLET | 30 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2512377 | 17157 | EFFIENT | PRASUGREL HCL | F | 10 MG | TABLET | 90 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2533754 | 43916 | VERZENIO | ABEMACICLIB | F | 150 MG | TABLET | 14 | 2 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 2614501 | 46726 | BAQSIMI | GLUCAGON | F | 3 MG | SPRAY | 1 | 2 | 0 | 0 | F | 3 | NONPREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2614502 | 46726 | BAQSIMI | GLUCAGON | F | 3 MG | SPRAY | 1 | 2 | 0 | 0 | F | 3 | NONPREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2614511 | 46726 | BAQSIMI | GLUCAGON | F | 3 MG | SPRAY | 1 | 2 | 0 | 0 | F | 3 | NONPREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2614527 | 46726 | BAQSIMI | GLUCAGON | F | 3 MG | SPRAY | 2 | 2 | 0 | 0 | F | 3 | NONPREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2621654 | 43915 | VERZENIO | ABEMACICLIB | F | 200 MG | TABLET | 14 | 2 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 2719001 | 43179 | LARTRUVO | OLARATUMAB | F | 190MG/19ML | VIAL | 19 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | 31 DAYS | PLAN EXCLUSION. | S | ASPREMACS | |||||||||||||||
| 2733511 | 25963 | HUMATROPE | SOMATROPIN | F | 5 MG | VIAL | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | PLAN EXCLUSION | S | ASPREMACS | ||||||||||||
| 2734901 | 25963 | HUMATROPE | SOMATROPIN | F | 5 MG | VIAL | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | PLAN EXCLUSION | S | ASPREMACS | ||||||||||||
| 2750101 | 38530 | GEMZAR | GEMCITABINE HCL | F | 200 MG | VIAL | 1 | 2 | Y | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | Plan Exclusion. | R | ASPREMR | |||||||||||||||
| 2750201 | 38532 | GEMZAR | GEMCITABINE HCL | F | 1 G | VIAL | 1 | 2 | Y | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | Plan Exclusion. | R | ASPREMR | |||||||||||||||
| 2751001 | 5679 | HUMALOG | INSULIN LISPRO | F | 100/ML | VIAL | 10 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2751017 | 5679 | HUMALOG | INSULIN LISPRO | F | 100/ML | VIAL | 3 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2751101 | 22681 | HUMALOG MIX 75-25 | INSULIN LISPRO PROTAMIN/LISPRO | F | 75-25/ML | VIAL | 10 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2751201 | 97507 | HUMALOG MIX 50-50 | INSULIN LISPRO PROTAMIN/LISPRO | F | 50-50/ML | VIAL | 10 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2751601 | 5678 | HUMALOG | INSULIN LISPRO | F | 100/ML | CARTRIDGE | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2751659 | 5678 | HUMALOG | INSULIN LISPRO | F | 100/ML | CARTRIDGE | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2752901 | 25474 | GLUCAGON EMERGENCY KIT | GLUCAGON | F | 1 MG | VIAL | 1 | 2 | 0 | 0 | F | 3 | NONPREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2758901 | 51908 | BEBTELOVIMAB (EUA) | BEBTELOVIMAB | F | 175MG/2 ML | VIAL | 2 | 2 | 0 | 0 | NC | 1 | GENERICS | R | ASPREMR | ||||||||||||||||||
| 2759701 | 17407 | ZYPREXA | OLANZAPINE | F | 10 MG | VIAL | 1 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2762301 | 21179 | ALIMTA | PEMETREXED DISODIUM | F | 500 MG | VIAL | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | Plan Exclusion. | R | ASPREMR | ||||||||||||||||
| 2763511 | 27855 | ZYPREXA RELPREVV | OLANZAPINE PAMOATE | F | 210 MG | VIAL | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 2763611 | 27849 | ZYPREXA RELPREVV | OLANZAPINE PAMOATE | F | 300 MG | VIAL | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 2763711 | 27848 | ZYPREXA RELPREVV | OLANZAPINE PAMOATE | F | 405 MG | VIAL | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 2764001 | 99268 | ALIMTA | PEMETREXED DISODIUM | F | 100 MG | VIAL | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | Plan Exclusion. | R | ASPREMR | ||||||||||||||||
| 2765801 | 27855 | ZYPREXA RELPREVV | OLANZAPINE PAMOATE | F | 210 MG | VIAL | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 2765901 | 27849 | ZYPREXA RELPREVV | OLANZAPINE PAMOATE | F | 300 MG | VIAL | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 2766001 | 27848 | ZYPREXA RELPREVV | OLANZAPINE PAMOATE | F | 405 MG | VIAL | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 2766901 | 36444 | CYRAMZA | RAMUCIRUMAB | F | 100MG/10ML | VIAL | 10 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | 31 DAYS | PLAN EXCLUSION | S | ASPREMACS | |||||||||||||||
| 2767801 | 36445 | CYRAMZA | RAMUCIRUMAB | F | 500MG/50ML | VIAL | 50 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | 31 DAYS | PLAN EXCLUSION | S | ASPREMACS | |||||||||||||||
| 2771201 | 37798 | HUMALOG KWIKPEN U-200 | INSULIN LISPRO | F | 200/ML (3) | INSULN PEN | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2771227 | 37798 | HUMALOG KWIKPEN U-200 | INSULIN LISPRO | F | 200/ML (3) | INSULN PEN | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2771299 | 37798 | HUMALOG KWIKPEN U-200 | INSULIN LISPRO | F | 200/ML (3) | INSULN PEN | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2771401 | 43753 | HUMALOG JUNIOR KWIKPEN | INSULIN LISPRO | F | 100/ML | INS PEN HF | 3 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2771459 | 43753 | HUMALOG JUNIOR KWIKPEN | INSULIN LISPRO | F | 100/ML | INS PEN HF | 3 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2771501 | 98637 | BASAGLAR KWIKPEN U-100 | INSULIN GLARGINE,HUM.REC.ANLOG | F | 100/ML (3) | INSULN PEN | 3 | 2 | 0 | 0 | NC | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2771559 | 98637 | BASAGLAR KWIKPEN U-100 | INSULIN GLARGINE,HUM.REC.ANLOG | F | 100/ML (3) | INSULN PEN | 3 | 2 | 0 | 0 | NC | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2771601 | 40219 | PORTRAZZA | NECITUMUMAB | F | 800MG/50ML | VIAL | 50 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | 31 DAYS | PLAN EXCLUSION | S | ASPREMACS | |||||||||||||||
| 2772401 | 40849 | TALTZ SYRINGE | IXEKIZUMAB | F | 80 MG/ML | SYRINGE | 1 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 2772409 | 40849 | TALTZ SYRINGE (3 PACK) | IXEKIZUMAB | F | 80 MG/ML | SYRINGE | 1 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 2772411 | 40849 | TALTZ SYRINGE | IXEKIZUMAB | F | 80 MG/ML | SYRINGE | 1 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 2772427 | 40849 | TALTZ SYRINGE (2 PACK) | IXEKIZUMAB | F | 80 MG/ML | SYRINGE | 1 | 2 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 2772801 | 48226 | LYUMJEV | INSULIN LISPRO-AABC | F | 100/ML | VIAL | 10 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2773701 | 5679 | INSULIN LISPRO | INSULIN LISPRO | F | 100/ML | VIAL | 10 | 2 | 0 | 0 | F | 1 | GENERICS | R | ASPREMR | ||||||||||||||||||
| 2775201 | 43753 | INSULIN LISPRO JUNIOR KWIKPEN | INSULIN LISPRO | F | 100/ML | INS PEN HF | 3 | 2 | 0 | 0 | F | 1 | GENERICS | R | ASPREMR | ||||||||||||||||||
| 2775205 | 43753 | INSULIN LISPRO JUNIOR KWIKPEN | INSULIN LISPRO | F | 100/ML | INS PEN HF | 3 | 2 | 0 | 0 | F | 1 | GENERICS | R | ASPREMR | ||||||||||||||||||
| 2791001 | 48856 | BAMLANIVIMAB (EUA) | BAMLANIVIMAB | F | 700MG/20ML | VIAL | 20 | 2 | 0 | 0 | NC | 1 | GENERICS | R | ASPREMR | ||||||||||||||||||
| 2795001 | 49177 | ETESEVIMAB (EUA) | ETESEVIMAB | F | 700MG/20ML | VIAL | 20 | 2 | 0 | 0 | NC | 1 | GENERICS | R | ASPREMR | ||||||||||||||||||
| 2803101 | 25474 | GLUCAGON EMERGENCY KIT | GLUCAGON | F | 1 MG | VIAL | 1 | 2 | 0 | 0 | F | 3 | NONPREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2814701 | 25969 | HUMATROPE | SOMATROPIN | F | 6 MG | CARTRIDGE | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | PLAN EXCLUSION | S | ASPREMACS | ||||||||||||
| 2814801 | 575 | HUMATROPE | SOMATROPIN | F | 12 MG | CARTRIDGE | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | PLAN EXCLUSION | S | ASPREMACS | ||||||||||||
| 2814901 | 25957 | HUMATROPE | SOMATROPIN | F | 24 MG | CARTRIDGE | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | PLAN EXCLUSION | S | ASPREMACS | ||||||||||||
| 2820701 | 48229 | LYUMJEV KWIKPEN U-100 | INSULIN LISPRO-AABC | F | 100/ML | INSULN PEN | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2820705 | 48229 | LYUMJEV KWIKPEN U-100 | INSULIN LISPRO-AABC | F | 100/ML | INSULN PEN | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2821501 | 11642 | HUMULIN R | INSULIN REGULAR, HUMAN | O | 100/ML | VIAL | 10 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 2821517 | 11642 | HUMULIN R | INSULIN REGULAR, HUMAN | O | 100/ML | VIAL | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 2822201 | 96719 | INSULIN LISPRO KWIKPEN U-100 | INSULIN LISPRO | F | 100/ML | INSULN PEN | 3 | 2 | 0 | 0 | F | 1 | GENERICS | R | ASPREMR | ||||||||||||||||||
| 2822259 | 96719 | INSULIN LISPRO KWIKPEN U-100 | INSULIN LISPRO | F | 100/ML | INSULN PEN | 3 | 2 | 0 | 0 | F | 1 | GENERICS | R | ASPREMR | ||||||||||||||||||
| 2822801 | 48231 | LYUMJEV KWIKPEN U-200 | INSULIN LISPRO-AABC | F | 200/ML (3) | INSULN PEN | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2822827 | 48231 | LYUMJEV KWIKPEN U-200 | INSULIN LISPRO-AABC | F | 200/ML (3) | INSULN PEN | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2823301 | 93717 | INSULIN LISPRO PROTAMINE MIX | INSULIN LISPRO PROTAMIN/LISPRO | F | 75-25/ML | INSULN PEN | 3 | 2 | 0 | 0 | F | 1 | GENERICS | R | ASPREMR | ||||||||||||||||||
| 2823305 | 93717 | INSULIN LISPRO PROTAMINE MIX | INSULIN LISPRO PROTAMIN/LISPRO | F | 75-25/ML | INSULN PEN | 3 | 2 | 0 | 0 | F | 1 | GENERICS | R | ASPREMR | ||||||||||||||||||
| 2831501 | 11660 | HUMULIN N | INSULIN NPH HUMAN ISOPHANE | O | 100/ML | VIAL | 10 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 2831517 | 11660 | HUMULIN N | INSULIN NPH HUMAN ISOPHANE | O | 100/ML | VIAL | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 2840001 | 14404 | FORTEO | TERIPARATIDE | F | 20MCG/DOSE | PEN INJCTR | 2.4000000954 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | PLAN EXCLUSION. | S | ASPREMACS | ||||||||||||
| 2850101 | 9633 | HUMULIN R U-500 | INSULIN REGULAR, HUMAN | F | 500/ML | VIAL | 20 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 2871501 | 50001 | HUMULIN 70-30 | INSULIN NPH HUM/REG INSULIN HM | O | 70-30/ML | VIAL | 10 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 2871517 | 50001 | HUMULIN 70-30 | INSULIN NPH HUM/REG INSULIN HM | O | 70-30/ML | VIAL | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 2879701 | 93717 | HUMALOG MIX 75-25 KWIKPEN | INSULIN LISPRO PROTAMIN/LISPRO | F | 75-25/ML | INSULN PEN | 3 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2879759 | 93717 | HUMALOG MIX 75-25 KWIKPEN | INSULIN LISPRO PROTAMIN/LISPRO | F | 75-25/ML | INSULN PEN | 3 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2879801 | 50461 | HUMALOG MIX 50-50 KWIKPEN | INSULIN LISPRO PROTAMIN/LISPRO | F | 50-50/ML | INSULN PEN | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2879859 | 50461 | HUMALOG MIX 50-50 KWIKPEN | INSULIN LISPRO PROTAMIN/LISPRO | F | 50-50/ML | INSULN PEN | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2879901 | 96719 | HUMALOG KWIKPEN U-100 | INSULIN LISPRO | F | 100/ML | INSULN PEN | 3 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2879959 | 96719 | HUMALOG KWIKPEN U-100 | INSULIN LISPRO | F | 100/ML | INSULN PEN | 3 | 2 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 2880301 | 890 | HUMULIN 70/30 KWIKPEN | INSULIN NPH HUM/REG INSULIN HM | O | 70-30/ML | INSULN PEN | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 2880359 | 890 | HUMULIN 70/30 KWIKPEN | INSULIN NPH HUM/REG INSULIN HM | O | 70-30/ML | INSULN PEN | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 2880501 | 18488 | HUMULIN N KWIKPEN | INSULIN NPH HUMAN ISOPHANE | O | 100/ML (3) | INSULN PEN | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 2880559 | 18488 | HUMULIN N KWIKPEN | INSULIN NPH HUMAN ISOPHANE | O | 100/ML (3) | INSULN PEN | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 2882401 | 40542 | HUMULIN R U-500 KWIKPEN | INSULIN REGULAR, HUMAN | F | 500/ML (3) | INSULN PEN | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2882427 | 40542 | HUMULIN R U-500 KWIKPEN | INSULIN REGULAR, HUMAN | F | 500/ML (3) | INSULN PEN | 3 | 2 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 2892601 | 42539 | LARTRUVO | OLARATUMAB | F | 500MG/50ML | VIAL | 50 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | 31 DAYS | PLAN EXCLUSION | S | ASPREMACS | |||||||||||||||
| 2956001 | 94200 | HUMATROPEN | PEN INJECTOR DEVICE | O | 6 | PEN INJCTR | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | ||||||||||||||||
| 2956101 | 94200 | HUMATROPEN | PEN INJECTOR DEVICE | O | 12 | PEN INJCTR | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | ||||||||||||||||
| 2956201 | 94200 | HUMATROPEN | PEN INJECTOR DEVICE | O | 24 | PEN INJCTR | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | ||||||||||||||||
| 2967301 | 94200 | HUMAPEN LUXURA HD | INSULIN ADMIN. SUPPLIES | F | INSULN PEN | 1 | 2 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 3001101 | 41335 | DAKLINZA | DACLATASVIR DIHYDROCHLORIDE | F | 90 MG | TABLET | 28 | 3 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | PLAN EXCLUSION | S | ASPREMACS | ||||||||||||
| 3021301 | 37073 | DAKLINZA | DACLATASVIR DIHYDROCHLORIDE | F | 30 MG | TABLET | 28 | 3 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | PLAN EXCLUSION | S | ASPREMACS | ||||||||||||
| 3021501 | 37074 | DAKLINZA | DACLATASVIR DIHYDROCHLORIDE | F | 60 MG | TABLET | 28 | 3 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | PLAN EXCLUSION | S | ASPREMACS | ||||||||||||
| 3029305 | 27452 | KENALOG-40 | TRIAMCINOLONE ACETONIDE | F | 40 MG/ML | VIAL | 1 | 3 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 3029320 | 27452 | KENALOG-40 | TRIAMCINOLONE ACETONIDE | F | 40 MG/ML | VIAL | 5 | 3 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 3029328 | 27452 | KENALOG-40 | TRIAMCINOLONE ACETONIDE | F | 40 MG/ML | VIAL | 10 | 3 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 3031505 | 46467 | KENALOG-80 | TRIAMCINOLONE ACETONIDE | F | 80 MG/ML | VIAL | 1 | 3 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 3031520 | 46467 | KENALOG-80 | TRIAMCINOLONE ACETONIDE | F | 80 MG/ML | VIAL | 5 | 3 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 3037113 | 30094 | NULOJIX | BELATACEPT | F | 250 MG | VIAL | 1 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | R | ASPREMR | |||||||||||||||
| 3049420 | 27450 | KENALOG-10 | TRIAMCINOLONE ACETONIDE | F | 10 MG/ML | VIAL | 5 | 3 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | ||||||||||||||||
| 3052411 | 27259 | SPRYCEL | DASATINIB | F | 70 MG | TABLET | 60 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 3052620 | 94200 | NITRATEST PAPER | URINE PHENAPHTHAZINE-PH TEST | O | 15 FEET | EACH | 1 | 3 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | ||||||||||||||||
| 3052711 | 27257 | SPRYCEL | DASATINIB | F | 20 MG | TABLET | 60 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 3052811 | 27258 | SPRYCEL | DASATINIB | F | 50 MG | TABLET | 60 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 3083050 | 38400 | HYDREA | HYDROXYUREA | F | 500 MG | CAPSULE | 100 | 3 | Y | 0 | 0 | F | 1 | GENERICS | R | ASPREMR | |||||||||||||||||
| 3085222 | 99867 | SPRYCEL | DASATINIB | F | 100 MG | TABLET | 30 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 3085522 | 29405 | SPRYCEL | DASATINIB | F | 80 MG | TABLET | 30 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 3085722 | 29406 | SPRYCEL | DASATINIB | F | 140 MG | TABLET | 30 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 3089321 | 30239 | ELIQUIS | APIXABAN | F | 2.5 MG | TABLET | 60 | 3 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 3089331 | 30239 | ELIQUIS | APIXABAN | F | 2.5 MG | TABLET | 100 | 3 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 3089421 | 33935 | ELIQUIS | APIXABAN | F | 5 MG | TABLET | 60 | 3 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 3089431 | 33935 | ELIQUIS | APIXABAN | F | 5 MG | TABLET | 100 | 3 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 3089470 | 33935 | ELIQUIS | APIXABAN | F | 5 MG | TABLET | 74 | 3 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 3161112 | 24466 | BARACLUDE | ENTECAVIR | F | 0.5 MG | TABLET | 30 | 3 | Y | 0 | 0 | F | 4 | SPECIALTY DRUGS | R | ASPREMR | |||||||||||||||||
| 3161113 | 24466 | BARACLUDE | ENTECAVIR | F | 0.5 MG | TABLET | 90 | 3 | Y | 0 | 0 | F | 4 | SPECIALTY DRUGS | R | ASPREMR | |||||||||||||||||
| 3161212 | 24467 | BARACLUDE | ENTECAVIR | F | 1 MG | TABLET | 30 | 3 | Y | 0 | 0 | F | 4 | SPECIALTY DRUGS | R | ASPREMR | |||||||||||||||||
| 3161412 | 24465 | BARACLUDE | ENTECAVIR | F | 0.05 MG/ML | SOLUTION | 210 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | R | ASPREMR | ||||||||||||||||||
| 3196401 | 26711 | ZERIT | STAVUDINE | F | 15 MG | CAPSULE | 60 | 3 | Y | 0 | 0 | F | 4 | SPECIALTY DRUGS | R | ASPREMR | |||||||||||||||||
| 3196501 | 26712 | ZERIT | STAVUDINE | F | 20 MG | CAPSULE | 60 | 3 | Y | 0 | 0 | F | 4 | SPECIALTY DRUGS | R | ASPREMR | |||||||||||||||||
| 3196601 | 26713 | ZERIT | STAVUDINE | F | 30 MG | CAPSULE | 60 | 3 | Y | 0 | 0 | F | 4 | SPECIALTY DRUGS | R | ASPREMR | |||||||||||||||||
| 3196701 | 26714 | ZERIT | STAVUDINE | F | 40 MG | CAPSULE | 60 | 3 | Y | 0 | 0 | F | 4 | SPECIALTY DRUGS | R | ASPREMR | |||||||||||||||||
| 3196801 | 26716 | ZERIT | STAVUDINE | F | 1 MG/ML | SOLN RECON | 200 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | <= 6 YEARS | R | ASPREMR | |||||||||||||||||
| 3218710 | 26306 | ORENCIA | ABATACEPT/MALTOSE | F | 250 MG | VIAL | 1 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 3218713 | 26306 | ORENCIA | ABATACEPT/MALTOSE | F | 250 MG | VIAL | 1 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 3218811 | 30289 | ORENCIA | ABATACEPT | F | 125 MG/ML | SYRINGE | 1 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 3218851 | 41656 | ORENCIA CLICKJECT | ABATACEPT | F | 125 MG/ML | AUTO INJCT | 1 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 3223011 | 41700 | AZACTAM-ISO-OSMOTIC DEXTROSE | AZTREONAM/DEXTROSE-WATER | F | 1 G/50 ML | FROZ.PIGGY | 50 | 3 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 3224011 | 41701 | AZACTAM-ISO-OSMOTIC DEXTROSE | AZTREONAM/DEXTROSE-WATER | F | 2 G/50 ML | FROZ.PIGGY | 50 | 3 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 3229111 | 40227 | EMPLICITI | ELOTUZUMAB | F | 300 MG | VIAL | 1 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 3232711 | 29688 | YERVOY | IPILIMUMAB | F | 50 MG/10ML | VIAL | 10 | 3 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 3232822 | 29689 | YERVOY | IPILIMUMAB | F | 200MG/40ML | VIAL | 40 | 3 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 3256016 | 41911 | AZACTAM | AZTREONAM | F | 1 G | VIAL | 1 | 3 | Y | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | |||||||||||||||
| 3257016 | 41912 | AZACTAM | AZTREONAM | F | 2 G | VIAL | 1 | 3 | Y | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | |||||||||||||||
| 3281411 | 43389 | ORENCIA | ABATACEPT | F | 50MG/0.4ML | SYRINGE | 0.400000006 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 3281811 | 43397 | ORENCIA | ABATACEPT | F | 87.5MG/0.7 | SYRINGE | 0.6999999881 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 3362212 | 97430 | REYATAZ | ATAZANAVIR SULFATE | F | 300 MG | CAPSULE | 30 | 3 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 3362412 | 19952 | REYATAZ | ATAZANAVIR SULFATE | F | 150 MG | CAPSULE | 60 | 3 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 3363112 | 19953 | REYATAZ | ATAZANAVIR SULFATE | F | 200 MG | CAPSULE | 60 | 3 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 3363810 | 36647 | REYATAZ | ATAZANAVIR SULFATE | F | 50 MG | POWD PACK | 30 | 3 | 0 | 0 | F | 3 | NONPREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | R | ASPREMR | |||||||||||||||
| 3364111 | 37797 | EVOTAZ | ATAZANAVIR SULFATE/COBICISTAT | F | 300-150 MG | TABLET | 30 | 3 | 0 | 0 | F | 3 | NONPREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 3373413 | 44267 | OPDIVO | NIVOLUMAB | F | 240MG/24ML | VIAL | 24 | 3 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 3375614 | 50434 | OPDIVO | NIVOLUMAB | F | 120MG/12ML | VIAL | 12 | 3 | 0 | 0 | NC | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 3376474 | 44357 | ELIQUIS | APIXABAN | F | 5 MG (74) | TAB DS PK | 74 | 3 | 0 | 0 | NC | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 3377211 | 37626 | OPDIVO | NIVOLUMAB | F | 40 MG/4 ML | VIAL | 4 | 3 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | Plan Exclusion. | R | ASPREMR | ||||||||||||||||
| 3377412 | 37627 | OPDIVO | NIVOLUMAB | F | 100MG/10ML | VIAL | 10 | 3 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | Plan Exclusion. | R | ASPREMR | ||||||||||||||||
| 3452211 | 40228 | EMPLICITI | ELOTUZUMAB | F | 400 MG | VIAL | 1 | 3 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 3517805 | 48672 | PRAVACHOL | PRAVASTATIN SODIUM | F | 20 MG | TABLET | 90 | 3 | Y | 0 | 0 | F | 5 | REFERENCE PRICING | R | ASPREMR | |||||||||||||||||
| 3519410 | 48673 | PRAVACHOL | PRAVASTATIN SODIUM | F | 40 MG | TABLET | 90 | 3 | Y | 0 | 0 | F | 5 | REFERENCE PRICING | R | ASPREMR | |||||||||||||||||
| 3519510 | 15412 | PRAVACHOL | PRAVASTATIN SODIUM | F | 80 MG | TABLET | 90 | 3 | Y | 0 | 0 | F | 5 | REFERENCE PRICING | R | ASPREMR | |||||||||||||||||
| 3633517 | 38402 | DROXIA | HYDROXYUREA | F | 200 MG | CAPSULE | 60 | 3 | 0 | 0 | F | 1 | GENERICS | R | ASPREMR | ||||||||||||||||||
| 3633617 | 38403 | DROXIA | HYDROXYUREA | F | 300 MG | CAPSULE | 60 | 3 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 3633717 | 38404 | DROXIA | HYDROXYUREA | F | 400 MG | CAPSULE | 60 | 3 | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | ||||||||||||||||||
| 4003822 | 13088 | VALCYTE | VALGANCICLOVIR HCL | F | 450 MG | TABLET | 60 | 4 | Y | 0 | 0 | F | 1 | GENERICS | R | ASPREMR | |||||||||||||||||
| 4003909 | 14453 | VALCYTE | VALGANCICLOVIR HCL | F | 50 MG/ML | SOLN RECON | 88 | 4 | Y | 0 | 0 | F | 4 | SPECIALTY DRUGS | <= 6 YEARS | R | ASPREMR | ||||||||||||||||
| 4005801 | 17471 | KLONOPIN | CLONAZEPAM | F | 1 MG | TABLET | 100 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4005832 | 17471 | KLONOPIN | CLONAZEPAM | F | 1 MG | TABLET | 10000 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4006801 | 17470 | KLONOPIN | CLONAZEPAM | F | 0.5 MG | TABLET | 100 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4006832 | 17470 | KLONOPIN | CLONAZEPAM | F | 0.5 MG | TABLET | 10000 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4008694 | 18969 | COPEGUS | RIBAVIRIN | F | 200 MG | TABLET | 168 | 4 | Y | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | |||||||||||||
| 4009801 | 17472 | KLONOPIN | CLONAZEPAM | F | 2 MG | TABLET | 100 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4018682 | 24444 | BONIVA | IBANDRONATE SODIUM | F | 150 MG | TABLET | 3 | 4 | Y | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 5 | REFERENCE PRICING | PLAN EXCLUSION | R | ASPREMR | |||||||||||||||
| 4018683 | 24444 | BONIVA | IBANDRONATE SODIUM | F | 150 MG | TABLET | 3 | 4 | Y | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 5 | REFERENCE PRICING | PLAN EXCLUSION | R | ASPREMR | |||||||||||||||
| 4019109 | 36226 | BONIVA | IBANDRONATE SODIUM | F | 3 MG/3 ML | SYRINGE | 3 | 4 | Y | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 5 | REFERENCE PRICING | PLAN EXCLUSION | R | ASPREMR | |||||||||||||||
| 4024451 | 23952 | INVIRASE | SAQUINAVIR MESYLATE | F | 500 MG | TABLET | 120 | 4 | 0 | 0 | F | 4 | SPECIALTY DRUGS | R | ASPREMR | ||||||||||||||||||
| 4024515 | 26760 | INVIRASE | SAQUINAVIR MESYLATE | F | 200 MG | CAPSULE | 270 | 4 | 0 | 0 | F | 4 | SPECIALTY DRUGS | R | ASPREMR | ||||||||||||||||||
| 4025752 | 95213 | XENICAL | ORLISTAT | F | 120 MG | CAPSULE | 90 | 4 | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | ||||||||||||||||
| 4025901 | 47560 | CELLCEPT | MYCOPHENOLATE MOFETIL | F | 250 MG | CAPSULE | 100 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4025943 | 47560 | CELLCEPT | MYCOPHENOLATE MOFETIL | F | 250 MG | CAPSULE | 500 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4026001 | 47561 | CELLCEPT | MYCOPHENOLATE MOFETIL | F | 500 MG | TABLET | 100 | 4 | Y | 0 | 0 | F | 4 | SPECIALTY DRUGS | R | ASPREMR | |||||||||||||||||
| 4026043 | 47561 | CELLCEPT | MYCOPHENOLATE MOFETIL | F | 500 MG | TABLET | 500 | 4 | Y | 0 | 0 | F | 4 | SPECIALTY DRUGS | R | ASPREMR | |||||||||||||||||
| 4026129 | 47563 | CELLCEPT | MYCOPHENOLATE MOFETIL | F | 200 MG/ML | SUSP RECON | 160 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4029809 | 47569 | CELLCEPT | MYCOPHENOLATE MOFETIL HCL | F | 500 MG | VIAL | 1 | 4 | Y | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | |||||||||||||||
| 4029830 | 47569 | CELLCEPT | MYCOPHENOLATE MOFETIL HCL | F | 500 MG | VIAL | 1 | 4 | Y | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | |||||||||||||||
| 4035009 | 18287 | PEGASYS | PEGINTERFERON ALFA-2A | F | 180MCG/ML | VIAL | 1 | 4 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 4035730 | 17887 | PEGASYS | PEGINTERFERON ALFA-2A | F | 180MCG/0.5 | SYRINGE | 0.5 | 4 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 4036030 | 30739 | PEGASYS PROCLICK | PEGINTERFERON ALFA-2A | F | 135MCG/0.5 | PEN INJCTR | 0.5 | 4 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 4036530 | 30738 | PEGASYS PROCLICK | PEGINTERFERON ALFA-2A | F | 180MCG/0.5 | PEN INJCTR | 0.5 | 4 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 4038101 | 31488 | FUZEON | ENFUVIRTIDE | F | 90 MG | VIAL | 1 | 4 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | R | ASPREMR | |||||||||||||||
| 4038140 | 31488 | FUZEON | ENFUVIRTIDE | F | 90 MG | VIAL | 60 | 4 | 0 | 0 | F | 2 | PREFERRED DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | R | ASPREMR | |||||||||||||||
| 4040109 | 98874 | MIRCERA | METHOXY PEG-EPOETIN BETA | F | 50 MCG/0.3 | SYRINGE | 0.3000000119 | 4 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 4040209 | 98890 | MIRCERA | METHOXY PEG-EPOETIN BETA | F | 75 MCG/0.3 | SYRINGE | 0.3000000119 | 4 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 4040309 | 98891 | MIRCERA | METHOXY PEG-EPOETIN BETA | F | 100MCG/0.3 | SYRINGE | 0.3000000119 | 4 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 4040509 | 98893 | MIRCERA | METHOXY PEG-EPOETIN BETA | F | 200MCG/0.3 | SYRINGE | 0.3000000119 | 4 | 0 | 0 | F | 4 | SPECIALTY DRUGS | X | PA:X | PA REQUIRED MD CALL EBRX AT 866-564-8258 FOR ARBENEFITS, 833-339-8402 FOR ASU, 833-995-0946 FOR ARK STATE POLICE | 31 DAYS | S | ASPREMACS | ||||||||||||||
| 4080085 | 73441 | TAMIFLU | OSELTAMIVIR PHOSPHATE | F | 75 MG | CAPSULE | 10 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4080185 | 98981 | TAMIFLU | OSELTAMIVIR PHOSPHATE | F | 45 MG | CAPSULE | 10 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4080285 | 98980 | TAMIFLU | OSELTAMIVIR PHOSPHATE | F | 30 MG | CAPSULE | 10 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4082205 | 29729 | TAMIFLU | OSELTAMIVIR PHOSPHATE | F | 6 MG/ML | SUSP RECON | 60 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4110020 | 31611 | XELODA | CAPECITABINE | F | 150 MG | TABLET | 60 | 4 | Y | 0 | 0 | F | 4 | SPECIALTY DRUGS | 31 DAYS | S | ASPREMACS | ||||||||||||||||
| 4110150 | 31612 | XELODA | CAPECITABINE | F | 500 MG | TABLET | 120 | 4 | Y | 0 | 0 | F | 4 | SPECIALTY DRUGS | 31 DAYS | S | ASPREMACS | ||||||||||||||||
| 4620301 | 47131 | ANAPROX DS | NAPROXEN SODIUM | F | 550 MG | TABLET | 100 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4631601 | 35793 | NAPROSYN | NAPROXEN | F | 500 MG | TABLET | 100 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4641501 | 61850 | EC-NAPROSYN | NAPROXEN | F | 375 MG | TABLET DR | 100 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4641601 | 61851 | EC-NAPROSYN | NAPROXEN | F | 500 MG | TABLET DR | 100 | 4 | Y | 0 | 0 | F | 2 | PREFERRED DRUGS | R | ASPREMR | |||||||||||||||||
| 4694003 | 44620 | CYTOVENE | GANCICLOVIR SODIUM | F | 500 MG | VIAL | 1 | 4 | Y | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | |||||||||||||||
| 4694004 | 44620 | CYTOVENE | GANCICLOVIR SODIUM | F | 500 MG | VIAL | 1 | 4 | Y | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION | R | ASPREMR | |||||||||||||||
| 5010001 | 37413 | TRUMENBA | N.MENINGITIDIS B,LIPID FHBP RC | F | 120MCG/0.5 | SYRINGE | 0.5 | 5 | 0 | 0 | F | 0 | ZERO DOLLAR COPAY DRUGS | R | ASPREMR | ||||||||||||||||||
| 5010005 | 37413 | TRUMENBA | N.MENINGITIDIS B,LIPID FHBP RC | F | 120MCG/0.5 | SYRINGE | 0.5 | 5 | 0 | 0 | F | 0 | ZERO DOLLAR COPAY DRUGS | R | ASPREMR | ||||||||||||||||||
| 5010010 | 37413 | TRUMENBA | N.MENINGITIDIS B,LIPID FHBP RC | F | 120MCG/0.5 | SYRINGE | 0.5 | 5 | 0 | 0 | F | 0 | ZERO DOLLAR COPAY DRUGS | R | ASPREMR | ||||||||||||||||||
| 5197101 | 28232 | PREVNAR 13 | PNEUMOC 13-VAL CONJ-DIP CRM/PF | F | 0.5 ML | SYRINGE | 0.5 | 5 | 0 | 0 | F | 0 | ZERO DOLLAR COPAY DRUGS | R | ASPREMR | ||||||||||||||||||
| 5197102 | 28232 | PREVNAR 13 | PNEUMOC 13-VAL CONJ-DIP CRM/PF | F | 0.5 ML | SYRINGE | 0.5 | 5 | 0 | 0 | F | 0 | ZERO DOLLAR COPAY DRUGS | R | ASPREMR | ||||||||||||||||||
| 5197105 | 28232 | PREVNAR 13 | PNEUMOC 13-VAL CONJ-DIP CRM/PF | F | 0.5 ML | SYRINGE | 0.5 | 5 | 0 | 0 | F | 0 | ZERO DOLLAR COPAY DRUGS | R | ASPREMR | ||||||||||||||||||
| 5200001 | 49791 | PREVNAR 20 | PNEUMOC 20-VAL CONJ-DIP CRM/PF | F | 0.5 ML | SYRINGE | 0.5 | 5 | 0 | 0 | F | 0 | ZERO DOLLAR COPAY DRUGS | R | ASPREMR | ||||||||||||||||||
| 5200002 | 49791 | PREVNAR 20 | PNEUMOC 20-VAL CONJ-DIP CRM/PF | F | 0.5 ML | SYRINGE | 0.5 | 5 | 0 | 0 | F | 0 | ZERO DOLLAR COPAY DRUGS | R | ASPREMR | ||||||||||||||||||
| 5200010 | 49791 | PREVNAR 20 | PNEUMOC 20-VAL CONJ-DIP CRM/PF | F | 0.5 ML | SYRINGE | 0.5 | 5 | 0 | 0 | F | 0 | ZERO DOLLAR COPAY DRUGS | R | ASPREMR | ||||||||||||||||||
| 5250002 | 8342 | FIBERCON | CALCIUM POLYCARBOPHIL | O | 625 MG | TABLET | 36 | 5 | N | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 1 | GENERICS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||
| 5250023 | 8342 | FIBERCON | CALCIUM POLYCARBOPHIL | O | 625 MG | TABLET | 140 | 5 | N | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||
| 5250033 | 8342 | FIBERCON | CALCIUM POLYCARBOPHIL | O | 625 MG | TABLET | 90 | 5 | N | 0 | 0 | NC | HARD_MSG: [DRUG NOT COVERED] [INTERNAL_REJECT_CODE=284 NCPDP_REJECT_CODE=70] | 1 | GENERICS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||
| 5417990 | 24314 | CENTRUM SILVER | MULTIVIT-MIN/FA/LYCOPEN/LUTEIN | Q | .4-300-250 | TABLET | 220 | 5 | 0 | 0 | F | 1 | GENERICS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 5423720 | 46836 | CENTRUM KIDS | PEDI MV180/IRON,CARBONYL/VIT K | Q | 8 MG-10MCG | TAB CHEW | 80 | 5 | 0 | 0 | NC | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 5434462 | 28413 | CENTRUM | MULTIVIT-MIN/FERROUS GLUCONATE | Q | 9 MG/15 ML | LIQUID | 236 | 5 | 0 | 0 | NC | 1 | GENERICS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 5436556 | 31999 | CENTRUM SPECIALIST PRENATAL | PRENATAL VIT101/IRON/FOLIC/DHA | Q | 27-800-200 | COMBO. PKG | 56 | 5 | 0 | 0 | NC | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 5445174 | 23034 | CENTRUM COMPLETE | MULTIVITAMIN/IRON/FOLIC ACID | Q | 18MG-0.4MG | TABLET | 200 | 5 | 0 | 0 | NC | 1 | GENERICS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 5446119 | 13537 | CENTRUM SILVER | FOLIC ACID/MULTIVIT-MIN/LUTEIN | Q | 400-250MCG | TAB CHEW | 60 | 5 | N | 0 | 0 | NC | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | ||||||||||||||||
| 5446381 | 24314 | CENTRUM SILVER | MULTIVIT-MIN/FA/LYCOPEN/LUTEIN | Q | .4-300-250 | TABLET | 80 | 5 | 0 | 0 | F | 1 | GENERICS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 5446391 | 24314 | CENTRUM SILVER | MULTIVIT-MIN/FA/LYCOPEN/LUTEIN | Q | .4-300-250 | TABLET | 125 | 5 | 0 | 0 | F | 1 | GENERICS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 5447060 | 33305 | CENTRUM SPECIALIST ENERGY | MV-MN/IRON/FA/VIT K/K.GINSENG | Q | 18-400-25 | TABLET | 60 | 5 | 0 | 0 | NC | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 5449860 | 99563 | CENTRUM SPECIALIST HEART | MULTIVIT,IRON,MINS/FOLIC ACID | Q | 3-200-400 | TABLET | 60 | 5 | 0 | 0 | NC | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 5452835 | 45637 | CENTRUM CHEWABLES | MULTIVIT-MIN/IRON/FOLIC/VIT K1 | Q | 8MG-400-10 | TAB CHEW | 100 | 5 | 0 | 0 | NC | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 5452890 | 51355 | CENTRUM CHEWABLES | MULTIVIT-MIN/IRON/FOLIC/VIT K1 | Q | 8MG-400-80 | TAB CHEW | 90 | 5 | 0 | 0 | NC | 2 | PREFERRED DRUGS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 5475557 | 16200 | CENTRUM WOMEN | MULTIVITAMIN/IRON/FOLIC ACID | Q | 18MG-0.4MG | TABLET | 120 | 5 | 0 | 0 | NC | 1 | GENERICS | PLAN EXCLUSION. | R | ASPREMR | |||||||||||||||||
| 5475592 | 16200 | CENTRUM WOMEN | MULTIVITAMIN/IRON/FOLIC ACID | Q | 18MG-0.4MG | TABLET | 120 | 5 | 0 | 0 | NC | 1 | GENERICS | PLAN EXCLUSION. | R | ASPREMR |
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