Attachment P – Pharmacy Claim Repricing & Disruption Analysis - DELETE YELLOW ONCE APPROVED.xlsx
XLSX spreadsheet 10 MB Posted
- Attached to
- RFP 26-025-CJ GCPS- Employee Medical, Stop Loss, Dental, Vision, Disability & Voluntary Benefits Coverage
- Solicitation number
- RFP-115259
- Issued by
- Frederick County, Virginia
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Rx Cost and Disruption
| Directions: Please complete columns CK to CO with Offeror Data. DELETE YELLOW COLUMNS FIRST BEFORE POSTING AFTER KELLY AT ANTHEM CONFIRMS> | |||||||||||||||||||||||||||||||||||||||||||||||||
| Row_Number | Rx Filld Dt | Adjdctn Dt | Clm Nbr | Clm Seq Nbr | Clnt Id | Carr Id | Carr Nm | Acct Id | Acct Nm | Grp Id | Dept Cd | Clnt Plan Id | Bnft Cd | Fundg Cd | Sgmnt Nm | Brand/Generic Ind | Bnft Spclt Drug Ind | Cost Relief Eligible Ind | Cost Relief Applied Ind | Clm Chnl Cd | Phrmcy Nabp Id | Pharmacy NPI | Phrmcy Dea Nbr | Phrmcy Lctn St Cd | Phrmcy Zip Cd | Phrmcy Prmry Prov Type | Brndd Phrmcy Nm | Phrmcy Chain Nm | Mdspn Thrptc Clsfctn Gpi 02 Nm | Mdspn Thrptc Clsfctn Gpi 04 Nm | Mdspn Thrptc Clsfctn Gpi 10 Nm | Mdspn Brnd Nm | Lbl Nm | Ndc | Adjdctd Gpi | Drug Ctc Nm | Rx Nbr | Filld Refils Nbr | Cmpnd Cd | DAW | Frmlry Cd | Adjdctd Cpay Tier | Inn Cd | B340B Ind | Maint Drug Cd | Maint Drug Desc | Otc Desc | Admnstrn Rte Desc | |
| Not Specialty | Offeror Tier | ||||||||||||||||||||||||||||||||||||||||||||||||
| 1, 2, 3, 4 | Offeror in or out of network | Offeror on or off formulary | |||||||||||||||||||||||||||||||||||||||||||||||
| Grand Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | Total | |
| 1 | 1/1/2025 | 1/1/2025 | 250010997144584 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4842591 | 361924025 | FW2399067 | VA | 23072 | 01 - Community/retail pharmacy | WALGREENS | WALGREENS CORPORATION | ANTIDEPRESSANTS | Antidepressants Misc | Bupropion HCl | BUPROPION HYDROCHLORIDE E | BUPROPION TAB 150MG XL | 68180031909 | 58300040107520 | DEPRESSION | 000000001024241 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 2 | 1/1/2025 | 1/1/2025 | 250011632572565 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTIDEPRESSANTS | SerotoninNorepinephrine Reuptake Inhibitors SNRIs | Desvenlafaxine Succinate | DESVENLAFAXINE ER | DESVENLAFAX TAB 100MG ER | 51991031233 | 58180020207540 | DEPRESSION | 000000007138253 | 2 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 3 | 1/1/2025 | 1/1/2025 | 250011632996474 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | DIURETICS | Loop Diuretics | Furosemide | FUROSEMIDE | FUROSEMIDE TAB 20MG | 00054429731 | 37200030000305 | HYPERTENSION/HEART DISEASE | 000000007170496 | 5 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 4 | 1/1/2025 | 1/1/2025 | 250011639233564 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ULCER DRUGSANTISPASMODICSANTICHOLINERGICS | Proton Pump Inhibitors | Omeprazole | OMEPRAZOLE | OMEPRAZOLE CAP 20MG | 70700015010 | 49270060006520 | HEARTBURN/ULCER DISEASE | 000000007122951 | 2 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 5 | 1/1/2025 | 1/1/2025 | 250011905243577 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4842591 | 361924025 | FW2399067 | VA | 23072 | 01 - Community/retail pharmacy | WALGREENS | WALGREENS CORPORATION | ANTIHYPERLIPIDEMICS | HMG CoA Reductase Inhibitors | Atorvastatin Calcium | ATORVASTATIN CALCIUM | ATORVASTATIN TAB 10MG | 43598009805 | 39400010100310 | HIGH CHOLESTEROL | 000000001000942 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 6 | 1/1/2025 | 1/1/2025 | 250011905460470 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4842591 | 361924025 | FW2399067 | VA | 23072 | 01 - Community/retail pharmacy | WALGREENS | WALGREENS CORPORATION | DIURETICS | Thiazides and ThiazideLike Diuretics | Hydrochlorothiazide | HYDROCHLOROTHIAZIDE | HYDROCHLOROT TAB 12.5MG | 00228282011 | 37600040000303 | HYPERTENSION/HEART DISEASE | 000000000998571 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 7 | 1/1/2025 | 1/1/2025 | 250012709424439 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4842591 | 361924025 | FW2399067 | VA | 23072 | 01 - Community/retail pharmacy | WALGREENS | WALGREENS CORPORATION | HEMATOLOGICAL AGENTS MISC | Platelet Aggregation Inhibitors | Clopidogrel Bisulfate | CLOPIDOGREL | CLOPIDOGREL TAB 75MG | 65862035705 | 85158020100320 | BLOOD MODIFYING | 000000000985224 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 8 | 1/1/2025 | 1/1/2025 | 250012956425480 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTIHYPERTENSIVES | Antihypertensive Combinations | Amlodipine BesylateBenazepril HCl | AMLODIPINE BESYLATE/BENAZ | AMLOD/BENAZP CAP 5-20MG | 55111034001 | 36991502200140 | HYPERTENSION/HEART DISEASE | 000000007176103 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 9 | 1/1/2025 | 1/1/2025 | 250012958166448 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTIHYPERLIPIDEMICS | HMG CoA Reductase Inhibitors | Simvastatin | SIMVASTATIN | SIMVASTATIN TAB 20MG | 65862005299 | 39400075000330 | HIGH CHOLESTEROL | 000000007176102 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 10 | 1/1/2025 | 1/1/2025 | 250013088195585 | 998 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Brand | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTIPSYCHOTICSANTIMANIC AGENTS | Antipsychotics Misc | Lumateperone Tosylate | CAPLYTA | CAPLYTA CAP 42MG | 72060014240 | 59400022400120 | PSYCHIATRIC/NEURO DISORDERS | 000000007140623 | 2 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 3 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 11 | 1/1/2025 | 1/1/2025 | 250013095608424 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTICONVULSANTS | Anticonvulsants Misc | Topiramate | TOPIRAMATE | TOPIRAMATE TAB 200MG | 65862017460 | 72600075000340 | SEIZURES | 000000007215596 | 2 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 12 | 1/1/2025 | 1/1/2025 | 250013106559519 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | BETA BLOCKERS | Beta Blockers CardioSelective | Metoprolol Succinate | METOPROLOL SUCCINATE ER | METOPROL SUC TAB 25MG ER | 68382056401 | 33200030057510 | HYPERTENSION/HEART DISEASE | 000000007069904 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 13 | 1/1/2025 | 1/1/2025 | 250013133570483 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTIANXIETY AGENTS | Antianxiety Agents Misc | Hydroxyzine Pamoate | HYDROXYZINE PAMOATE | HYDROXYZ PAM CAP 100MG | 00555032402 | 57200040200115 | ANXIETY | 000000007130075 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Oral | ||
| 14 | 1/1/2025 | 1/1/2025 | 250013621747529 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4849723 | 311569568 | FK7509411 | VA | 23072 | 01 - Community/retail pharmacy | KROGER PHARMACY | KROGER COMPANY-KROGER EAST | ANTIDEPRESSANTS | Selective Serotonin Reuptake Inhibitors SSRIs | Sertraline HCl | SERTRALINE HCL | SERTRALINE CON 20MG/ML | 64980040906 | 58160070101320 | DEPRESSION | 000000006319798 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 15 | 1/1/2025 | 1/1/2025 | 250013643332440 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | PENICILLINS | Penicillin Combinations | Amoxicillin Pot Clavulanate | AMOXICILLIN/CLAVULANATE P | AMOX/K CLAV TAB 875-125 | 65862050320 | 01990002200340 | INFECTIONS | 000000007244201 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Oral | ||
| 16 | 1/1/2025 | 1/1/2025 | 250014336148517 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANALGESICS ANTIINFLAMMATORY | Nonsteroidal Antiinflammatory Agents NSAIDs | Meloxicam | MELOXICAM | MELOXICAM TAB 7.5MG | 68382005005 | 66100052000320 | INFLAMMATION/PAIN | 000000007186601 | 4 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 17 | 1/1/2025 | 1/1/2025 | 250014484165598 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#BE8BCR | ASO | Large Group | Brand | Y | N | N | S | 3137141 | 953382344 | FC0275304 | NJ | 070043516 | 15 - Specialty pharmacy | CarelonRx Specialty Pharmacy | CAREMARK INC | ANALGESICS ANTIINFLAMMATORY | AntiTNFalpha Monoclonal Antibodies | Adalimumab | HUMIRA PEN | HUMIRA PEN INJ 40/0.4ML | 83457055402 | 6627001500F530 | INFLAMMATORY CONDITIONS | 000000020026102 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 4 | IN | N | X | Maintenance drug | Prescription Required | Subcutaneous | ||
| 18 | 1/1/2025 | 1/1/2025 | 250015582519480 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTIASTHMATIC AND BRONCHODILATOR AGENTS | Sympathomimetics | BudesonideFormoterol Fumarate Dihydrate | BREYNA | BREYNA AER 80/4.5 | 00378750232 | 44209902413220 | ASTHMA | 000000007218342 | 2 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Inhalation | ||
| 19 | 1/2/2025 | 1/2/2025 | 250020279726594 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#BEZE2R | ASO | Large Group | Brand | Y | N | N | S | 3137141 | 953382344 | FC0275304 | NJ | 070043516 | 15 - Specialty pharmacy | CarelonRx Specialty Pharmacy | CAREMARK INC | ANALGESICS ANTIINFLAMMATORY | AntiTNFalpha Monoclonal Antibodies | Adalimumab | HUMIRA PEN | HUMIRA PEN INJ 40/0.4ML | 83457055402 | 6627001500F530 | INFLAMMATORY CONDITIONS | 000000019990532 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 4 | IN | N | X | Maintenance drug | Prescription Required | Subcutaneous | ||
| 20 | 1/2/2025 | 1/2/2025 | 250020465131576 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#BEZE2M | ASO | Large Group | Generic | N | N | N | M | 0366054 | 473025203 | FC2714916 | AZ | 857045727 | 05 - Mail-order pharmacy | CARELONRX PHARMACY INC | INDEPENDENTS | ANTIDIABETICS | Sulfonylureas | Glimepiride | GLIMEPIRIDE | GLIMEPIRIDE TAB 4MG | 55111032205 | 27200027000340 | DIABETES | 000000101194855 | 3 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 21 | 1/2/2025 | 1/2/2025 | 250021060741470 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Brand | N | N | N | R | 4842591 | 361924025 | FW2399067 | VA | 23072 | 01 - Community/retail pharmacy | WALGREENS | WALGREENS CORPORATION | MEDICAL DEVICES AND SUPPLIES | Parenteral Therapy Supplies | Insulin Pen Needle | BD PEN NEEDLE/NANO 2ND GE | BD PEN NEEDL MIS 32GX4MM | 08290320550 | 97051050146366 | DIABETES | 000000001007978 | 2 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 2 | IN | N | 0 | Non-Maintenance Drug | Over the Counter (OTC) | Does not apply | ||
| 22 | 1/2/2025 | 1/2/2025 | 250021243934483 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4842591 | 361924025 | FW2399067 | VA | 23072 | 01 - Community/retail pharmacy | WALGREENS | WALGREENS CORPORATION | ANTIHYPERTENSIVES | Angiotensin II Receptor Antagonists | Losartan Potassium | LOSARTAN POTASSIUM | LOSARTAN POT TAB 50MG | 65862020299 | 36150040200330 | HYPERTENSION/HEART DISEASE | 000000000963860 | 2 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 23 | 1/2/2025 | 1/2/2025 | 250021627653566 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | THYROID AGENTS | Thyroid Hormones | Levothyroxine Sodium | LEVOTHYROXINE SODIUM | LEVOTHYROXIN TAB 50MCG | 47781064390 | 28100010100310 | THYROID DISORDERS | 000000007111257 | 10 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 24 | 1/2/2025 | 1/2/2025 | 250021630607597 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTIHYPERTENSIVES | ACE Inhibitors | Lisinopril | LISINOPRIL | LISINOPRIL TAB 20MG | 68645061190 | 36100030000315 | HYPERTENSION/HEART DISEASE | 000000007206361 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 25 | 1/2/2025 | 1/2/2025 | 250022184428573 | 998 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4849723 | 311569568 | FK7509411 | VA | 23072 | 01 - Community/retail pharmacy | KROGER PHARMACY | KROGER COMPANY-KROGER EAST | HEMATOPOIETIC AGENTS | Cobalamins | Cyanocobalamin | B-12 QUICK DISSOLVE | VITAMIN B-12 SUB 1000MCG | 11845009661 | 82100010000705 | ANEMIA | 000000006338732 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Sublingual | ||
| 26 | 1/2/2025 | 1/2/2025 | 250022210859453 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4840408 | 361924025 | FW0875154 | VA | 236924801 | 01 - Community/retail pharmacy | WALGREENS | WALGREENS CORPORATION | ANTIDEPRESSANTS | Antidepressants Misc | Bupropion HCl | BUPROPION HYDROCHLORIDE E | BUPROPION TAB 300MG XL | 68180032002 | 58300040107530 | DEPRESSION | 000000000807842 | 2 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 27 | 1/2/2025 | 1/2/2025 | 250022322628560 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Brand | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | VACCINES | Viral Vaccines | Zoster Vaccine Recombinant Adjuvanted | SHINGRIX | SHINGRIX INJ 50/0.5ML | 58160082311 | 17100095401920 | VACCINATIONS | 000000007244309 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 3 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Intramuscular Injectable | ||
| 28 | 1/2/2025 | 1/2/2025 | 250022402202557 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Brand | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | VACCINES | Viral Vaccines | Zoster Vaccine Recombinant Adjuvanted | SHINGRIX | SHINGRIX INJ 50/0.5ML | 58160082311 | 17100095401920 | VACCINATIONS | 000000007243505 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 3 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Intramuscular Injectable | ||
| 29 | 1/2/2025 | 1/2/2025 | 250022448402451 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | CONTRACEPTIVES | Combination Contraceptives Oral | DrospirenoneEthinyl Estradiol | LORYNA | LORYNA TAB 3-0.02MG | 70700011485 | 25990002150316 | CONTRACEPTION | 000000007159187 | 5 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 30 | 1/2/2025 | 1/2/2025 | 250022448579446 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTIDEPRESSANTS | Selective Serotonin Reuptake Inhibitors SSRIs | Sertraline HCl | SERTRALINE HCL | SERTRALINE TAB 50MG | 68645052254 | 58160070100310 | DEPRESSION | 000000007220488 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 31 | 1/2/2025 | 1/2/2025 | 250022759734524 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4841791 | 361924025 | FW1726225 | VA | 236083719 | 01 - Community/retail pharmacy | WALGREENS | WALGREENS CORPORATION | ANALGESICS ANTIINFLAMMATORY | Nonsteroidal Antiinflammatory Agents NSAIDs | Diclofenac Sodium | DICLOFENAC SODIUM DR | DICLOFENAC TAB 75MG DR | 16571020150 | 66100007200630 | INFLAMMATION/PAIN | 000000000997526 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 32 | 1/2/2025 | 1/2/2025 | 250022874550451 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4821888 | 231940653 | AD5973501 | VA | 230615121 | RITE AID PHARMACY | RITE AID HEADQUARTER CORP | TETRACYCLINES | Tetracyclines | Doxycycline Hyclate | DOXYCYCLINE HYCLATE | DOXYCYCL HYC CAP 100MG | 69238110005 | 04000020100110 | INFECTIONS | 000000001294419 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Oral | |||
| 33 | 1/2/2025 | 1/2/2025 | 250022909617519 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4821888 | 231940653 | AD5973501 | VA | 230615121 | RITE AID PHARMACY | RITE AID HEADQUARTER CORP | ANTIASTHMATIC AND BRONCHODILATOR AGENTS | Leukotriene Modulators | Montelukast Sodium | MONTELUKAST SODIUM | MONTELUKAST TAB 10MG | 31722072610 | 44505050100330 | ASTHMA | 000000001281628 | 2 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | |||
| 34 | 1/2/2025 | 1/2/2025 | 250022919064414 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4821888 | 231940653 | AD5973501 | VA | 230615121 | RITE AID PHARMACY | RITE AID HEADQUARTER CORP | ANTIDEPRESSANTS | Antidepressants Misc | Bupropion HCl | BUPROPION HYDROCHLORIDE E | BUPROPION TAB 300MG XL | 42806041630 | 58300040107530 | DEPRESSION | 000000001288538 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | |||
| 35 | 1/2/2025 | 1/2/2025 | 250023011669550 | 998 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4849696 | 311569568 | FK7509219 | VA | 23692 | 01 - Community/retail pharmacy | KROGER PHARMACY | KROGER COMPANY-KROGER EAST | ANTIASTHMATIC AND BRONCHODILATOR AGENTS | Sympathomimetics | Fluticasone FuroateVilanterol | FLUTICASONE FUROATE/VILAN | FLUTIC/VILAN INH 100-25 | 66993013597 | 44209902758020 | ASTHMA | 000000006131349 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Inhalation | ||
| 36 | 1/2/2025 | 1/2/2025 | 250023039540449 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Brand | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTIASTHMATIC AND BRONCHODILATOR AGENTS | Sympathomimetics | BudesonideGlycopyrrolateFormoterol Fumarate | BREZTRI AEROSPHERE | BREZTRI AERO AER SPHERE | 00310461612 | 44209903303220 | ASTHMA | 000000007244426 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 2 | IN | N | X | Maintenance drug | Prescription Required | Inhalation | ||
| 37 | 1/2/2025 | 1/2/2025 | 250023057975530 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | MACROLIDES | Azithromycin | Azithromycin | AZITHROMYCIN | AZITHROMYCIN TAB 250MG | 50111078751 | 03400010000320 | INFECTIONS | 000000007244435 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Oral | ||
| 38 | 1/2/2025 | 1/2/2025 | 250023146608457 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4850067 | 831309299 | FM7950593 | VA | 23109 | 01 - Community/retail pharmacy | MATHEWS PHARMACY | INDEPENDENTS | DERMATOLOGICALS | Corticosteroids Topical | Betamethasone Dipropionate Topical | BETAMETHASONE DIPROPIONAT | BETAMETH DIP CRE 0.05% | 70710123304 | 90550020003705 | DERMATOLOGIC CONDITIONS | 000000008013351 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | External | ||
| 39 | 1/2/2025 | 1/2/2025 | 250023150829416 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTIHYPERTENSIVES | Antiadrenergic Antihypertensives | Guanfacine HCl | GUANFACINE HYDROCHLORIDE | GUANFACINE TAB 1MG | 72888012301 | 36201025100320 | HYPERTENSION/HEART DISEASE | 000000007244449 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 40 | 1/2/2025 | 1/2/2025 | 250023191675469 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4821888 | 231940653 | AD5973501 | VA | 230615121 | RITE AID PHARMACY | RITE AID HEADQUARTER CORP | ANTIDEPRESSANTS | Selective Serotonin Reuptake Inhibitors SSRIs | Escitalopram Oxalate | ESCITALOPRAM OXALATE | ESCITALOPRAM TAB 20MG | 65862037501 | 58160034100330 | DEPRESSION | 000000001248836 | 2 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | |||
| 41 | 1/2/2025 | 1/2/2025 | 250023207759434 | 998 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4821888 | 231940653 | AD5973501 | VA | 230615121 | RITE AID PHARMACY | RITE AID HEADQUARTER CORP | MUSCULOSKELETAL THERAPY AGENTS | Central Muscle Relaxants | Methocarbamol | METHOCARBAMOL | METHOCARBAM TAB 500MG | 70010075401 | 75100070000305 | MUSCLE RELAXANT | 000000001274363 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Oral | |||
| 42 | 1/2/2025 | 1/2/2025 | 250023342234466 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4821888 | 231940653 | AD5973501 | VA | 230615121 | RITE AID PHARMACY | RITE AID HEADQUARTER CORP | ANTIDEPRESSANTS | Selective Serotonin Reuptake Inhibitors SSRIs | Fluoxetine HCl | FLUOXETINE HYDROCHLORIDE | FLUOXETINE TAB 10MG | 16714011201 | 58160040000310 | DEPRESSION | 000000001277470 | 2 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | |||
| 43 | 1/2/2025 | 1/2/2025 | 250023444859557 | 998 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4850067 | 831309299 | FM7950593 | VA | 23109 | 01 - Community/retail pharmacy | MATHEWS PHARMACY | INDEPENDENTS | THYROID AGENTS | Thyroid Hormones | Levothyroxine Sodium | LEVOTHYROXINE SODIUM | LEVOTHYROXIN TAB 150MCG | 68180097303 | 28100010100330 | THYROID DISORDERS | 000000008001323 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 44 | 1/2/2025 | 1/2/2025 | 250023464557408 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | MACROLIDES | Azithromycin | Azithromycin | AZITHROMYCIN | AZITHROMYCIN SUS 200/5ML | 70710145802 | 03400010001930 | INFECTIONS | 000000007244502 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Oral | ||
| 45 | 1/2/2025 | 1/2/2025 | 250023509675575 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4842591 | 361924025 | FW2399067 | VA | 23072 | 01 - Community/retail pharmacy | WALGREENS | WALGREENS CORPORATION | DIURETICS | Potassium Sparing Diuretics | Spironolactone | SPIRONOLACTONE | SPIRONOLACT TAB 25MG | 69584085250 | 37500020000305 | HYPERTENSION/HEART DISEASE | 000000001035208 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 46 | 1/2/2025 | 1/2/2025 | 250023510100457 | 998 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4842591 | 361924025 | FW2399067 | VA | 23072 | 01 - Community/retail pharmacy | WALGREENS | WALGREENS CORPORATION | ANTIHYPERLIPIDEMICS | Intestinal Cholesterol Absorption Inhibitors | Ezetimibe | EZETIMIBE | EZETIMIBE TAB 10MG | 59651005205 | 39300030000320 | HIGH CHOLESTEROL | 000000001035207 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 47 | 1/2/2025 | 1/2/2025 | 250023564746561 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | MACROLIDES | Azithromycin | Azithromycin | AZITHROMYCIN | AZITHROMYCIN TAB 250MG | 50111078751 | 03400010000320 | INFECTIONS | 000000007244559 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Oral | ||
| 48 | 1/2/2025 | 1/2/2025 | 250023578159583 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4850067 | 831309299 | FM7950593 | VA | 23109 | 01 - Community/retail pharmacy | MATHEWS PHARMACY | INDEPENDENTS | ANTIHYPERLIPIDEMICS | HMG CoA Reductase Inhibitors | Simvastatin | SIMVASTATIN | SIMVASTATIN TAB 40MG | 70377000415 | 39400075000340 | HIGH CHOLESTEROL | 000000008002218 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 49 | 1/2/2025 | 1/2/2025 | 250023578467426 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4850067 | 831309299 | FM7950593 | VA | 23109 | 01 - Community/retail pharmacy | MATHEWS PHARMACY | INDEPENDENTS | ANALGESICS ANTIINFLAMMATORY | Nonsteroidal Antiinflammatory Agents NSAIDs | Meloxicam | MELOXICAM | MELOXICAM TAB 15MG | 69097015915 | 66100052000330 | INFLAMMATION/PAIN | 000000008002219 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 50 | 1/2/2025 | 1/2/2025 | 250023579592579 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4850067 | 831309299 | FM7950593 | VA | 23109 | 01 - Community/retail pharmacy | MATHEWS PHARMACY | INDEPENDENTS | DIURETICS | Thiazides and ThiazideLike Diuretics | Chlorthalidone | CHLORTHALIDONE | CHLORTHALID TAB 25MG | 43598071901 | 37600025000305 | HYPERTENSION/HEART DISEASE | 000000008002220 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 51 | 1/2/2025 | 1/2/2025 | 250023623908586 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4849723 | 311569568 | FK7509411 | VA | 23072 | 01 - Community/retail pharmacy | KROGER PHARMACY | KROGER COMPANY-KROGER EAST | VAGINAL AND RELATED PRODUCTS | Vaginal Estrogens | Estradiol Vaginal | ESTRADIOL | ESTRADIOL TAB 10MCG | 00093322308 | 55350020000310 | VAGINAL DISORDERS | 000000006337283 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Vaginal | ||
| 52 | 1/2/2025 | 1/2/2025 | 250023636966555 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Brand | N | N | N | R | 4844696 | 710862119 | FW4147991 | VA | 231882879 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | MEDICAL DEVICES AND SUPPLIES | Diabetic Supplies | Continuous Glucose System Sensor | FREESTYLE LIBRE 3/SENSOR/ | FREESTY LIBR KIT 3 SENSOR | 57599081800 | 97202012046300 | DIABETES | 000000007049797 | 8 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 2 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Does not apply | ||
| 53 | 1/2/2025 | 1/2/2025 | 250023679776494 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4818778 | 461560685 | FM3728269 | VA | 230713122 | 01 - Community/retail pharmacy | MEDICINE SHOPPE PHARMACY | MEDICINE SHOPPE / MEDICAP | MIGRAINE PRODUCTS | Serotonin Agonists | Rizatriptan Benzoate | RIZATRIPTAN BENZOATE | RIZATRIPTAN TAB 10MG | 67877026218 | 67406060100320 | MIGRAINE HEADACHES | 000000000408780 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Oral | ||
| 54 | 1/2/2025 | 1/2/2025 | 250023709218568 | 997 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4842591 | 361924025 | FW2399067 | VA | 23072 | 01 - Community/retail pharmacy | WALGREENS | WALGREENS CORPORATION | NASAL AGENTS SYSTEMIC AND TOPICAL | Nasal Steroids | Fluticasone Propionate Nasal | FLUTICASONE PROPIONATE | FLUTICASONE SPR 50MCG | 60505082901 | 42200032301810 | ALLERGIES | 000000001035518 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Nasal | ||
| 55 | 1/2/2025 | 1/2/2025 | 250023712462442 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4821888 | 231940653 | AD5973501 | VA | 230615121 | RITE AID PHARMACY | RITE AID HEADQUARTER CORP | ADHDANTINARCOLEPSYANTIOBESITYANOREXIANTS | Stimulants Misc | Methylphenidate HCl | METHYLPHENIDATE HYDROCHLO | METHYLPHENID TAB 36MG ER | 31722095401 | 61400020100470 | ATTENTION DEFICIT DISORDERS | 000000001277362 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | |||
| 56 | 1/2/2025 | 1/2/2025 | 250023824437543 | 998 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Brand | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTIDIABETICS | Incretin Mimetic Agents | Semaglutide | OZEMPIC | OZEMPIC INJ 4MG/3ML | 00169413013 | 2717007000D222 | DIABETES | 000000007244594 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 2 | IN | N | X | Maintenance drug | Prescription Required | Subcutaneous | ||
| 57 | 1/2/2025 | 1/2/2025 | 250023935058456 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4844696 | 710862119 | FW4147991 | VA | 231882879 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | BETA BLOCKERS | Beta Blockers NonSelective | Propranolol HCl | PROPRANOLOL HYDROCHLORIDE | PROPRANOLOL TAB 10MG | 69238207701 | 33100040100305 | HYPERTENSION/HEART DISEASE | 000000007110162 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 58 | 1/2/2025 | 1/2/2025 | 250023937914518 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4844696 | 710862119 | FW4147991 | VA | 231882879 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ADHDANTINARCOLEPSYANTIOBESITYANOREXIANTS | Amphetamines | AmphetamineDextroamphetamine | AMPHETAMINE/DEXTROAMPHETA | AMPHET/DEXTR TAB 10MG | 42806034101 | 61109902100310 | ATTENTION DEFICIT DISORDERS | 000000002243963 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 59 | 1/2/2025 | 1/2/2025 | 250023951479411 | 998 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ULCER DRUGSANTISPASMODICSANTICHOLINERGICS | Ulcer Drugs Prostaglandins | Misoprostol | MISOPROSTOL | MISOPROSTOL TAB 200MCG | 70954044410 | 49250030000320 | HEARTBURN/ULCER DISEASE | 000000007244638 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 60 | 1/2/2025 | 1/2/2025 | 250023975956457 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4849723 | 311569568 | FK7509411 | VA | 23072 | 01 - Community/retail pharmacy | KROGER PHARMACY | KROGER COMPANY-KROGER EAST | CONTRACEPTIVES | Combination Contraceptives Oral | DrospirenoneEthinyl Estradiol | SYEDA | SYEDA TAB 3-0.03MG | 70700011585 | 25990002150320 | CONTRACEPTION | 000000006339071 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 61 | 1/2/2025 | 1/2/2025 | 250023999441559 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4842591 | 361924025 | FW2399067 | VA | 23072 | 01 - Community/retail pharmacy | WALGREENS | WALGREENS CORPORATION | PENICILLINS | Aminopenicillins | Amoxicillin | AMOXICILLIN | AMOXICILLIN CAP 500MG | 65862001705 | 01200010100110 | INFECTIONS | 000000001035552 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Oral | ||
| 62 | 1/2/2025 | 1/2/2025 | 250024092696467 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4849723 | 311569568 | FK7509411 | VA | 23072 | 01 - Community/retail pharmacy | KROGER PHARMACY | KROGER COMPANY-KROGER EAST | DERMATOLOGICALS | Antibiotics Topical | Mupirocin | MUPIROCIN | MUPIROCIN OIN 2% | 51672131200 | 90100065104210 | SKIN INFECTIONS | 000000006339080 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | External | ||
| 63 | 1/2/2025 | 1/2/2025 | 250024233591431 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4844696 | 710862119 | FW4147991 | VA | 231882879 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTICONVULSANTS | Anticonvulsants Benzodiazepines | Clonazepam | CLONAZEPAM | CLONAZEPAM TAB 0.5MG | 59651072201 | 72100010000305 | SEIZURES | 000000004439480 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Oral | ||
| 64 | 1/2/2025 | 1/2/2025 | 250024244979489 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTIASTHMATIC AND BRONCHODILATOR AGENTS | Sympathomimetics | Albuterol Sulfate | ALBUTEROL SULFATE HFA | ALBUTEROL AER HFA | 66993001968 | 44201010103410 | ASTHMA | 000000007244706 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Inhalation | ||
| 65 | 1/2/2025 | 1/2/2025 | 250024384377421 | 998 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Brand | N | N | N | R | 4821888 | 231940653 | AD5973501 | VA | 230615121 | RITE AID PHARMACY | RITE AID HEADQUARTER CORP | ANTIDIABETICS | Insulin | Insulin Lispro | HUMALOG KWIKPEN | HUMALOG KWIK INJ 100/ML | 00002879959 | 2710400500D222 | DIABETES | 000000001260973 | 6 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 2 | IN | N | X | Maintenance drug | Prescription Required | Subcutaneous | |||
| 66 | 1/2/2025 | 1/2/2025 | 250024424473445 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Brand | N | N | N | R | 4843290 | 203649917 | FV2883569 | VA | 231887226 | 01 - Community/retail pharmacy | CVS PHARMACY | CVS PHARMACY | VACCINES | Viral Vaccines | Zoster Vaccine Recombinant Adjuvanted | SHINGRIX | SHINGRIX INJ 50/0.5ML | 58160082311 | 17100095401920 | VACCINATIONS | 000000001357727 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 3 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Intramuscular Injectable | ||
| 67 | 1/2/2025 | 1/2/2025 | 250024519998592 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4849723 | 311569568 | FK7509411 | VA | 23072 | 01 - Community/retail pharmacy | KROGER PHARMACY | KROGER COMPANY-KROGER EAST | ANTIHYPERTENSIVES | Antiadrenergic Antihypertensives | Guanfacine HCl | GUANFACINE HYDROCHLORIDE | GUANFACINE TAB 1MG | 00591044401 | 36201025100320 | HYPERTENSION/HEART DISEASE | 000000006339115 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 68 | 1/2/2025 | 1/2/2025 | 250024545515543 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4849723 | 311569568 | FK7509411 | VA | 23072 | 01 - Community/retail pharmacy | KROGER PHARMACY | KROGER COMPANY-KROGER EAST | BETA BLOCKERS | Beta Blockers CardioSelective | Metoprolol Succinate | METOPROLOL SUCCINATE ER | METOPROL SUC TAB 50MG ER | 68382056501 | 33200030057520 | HYPERTENSION/HEART DISEASE | 000000006339117 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 69 | 1/2/2025 | 1/2/2025 | 250024951668540 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTIINFECTIVE AGENTS MISC | Antiinfective Misc Combinations | SulfamethoxazoleTrimethoprim | SULFAMETHOXAZOLE/TRIMETHO | SMZ/TMP DS TAB 800-160 | 65162027250 | 16990002300320 | INFECTIONS | 000000007244816 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Oral | ||
| 70 | 1/2/2025 | 1/2/2025 | 250025225217513 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4846094 | 311569568 | FK5173771 | VA | 23693 | 01 - Community/retail pharmacy | KROGER PHARMACY | KROGER COMPANY-KROGER EAST | ANTIDEPRESSANTS | Serotonin Modulators | Trazodone HCl | TRAZODONE HYDROCHLORIDE | TRAZODONE TAB 50MG | 50111056001 | 58120080100305 | SLEEP DISORDERS | 000000006258382 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 71 | 1/2/2025 | 1/2/2025 | 250025290345447 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4849723 | 311569568 | FK7509411 | VA | 23072 | 01 - Community/retail pharmacy | KROGER PHARMACY | KROGER COMPANY-KROGER EAST | GASTROINTESTINAL AGENTS MISC | Gallstone Solubilizing Agents | Ursodiol | URSODIOL | URSODIOL CAP 300MG | 42806050301 | 52100040000120 | GI DISORDERS | 000000006335422 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 72 | 1/2/2025 | 1/2/2025 | 250025299048470 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4821888 | 231940653 | AD5973501 | VA | 230615121 | RITE AID PHARMACY | RITE AID HEADQUARTER CORP | DIURETICS | Thiazides and ThiazideLike Diuretics | Chlorthalidone | CHLORTHALIDONE | CHLORTHALID TAB 50MG | 65162025009 | 37600025000310 | HYPERTENSION/HEART DISEASE | 000000001265144 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | |||
| 73 | 1/2/2025 | 1/2/2025 | 250025299088438 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4821888 | 231940653 | AD5973501 | VA | 230615121 | RITE AID PHARMACY | RITE AID HEADQUARTER CORP | ANTIDEPRESSANTS | Antidepressants Misc | Bupropion HCl | BUPROPION HYDROCHLORIDE E | BUPROPION TAB 300MG XL | 42806041630 | 58300040107530 | DEPRESSION | 000000001265139 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | |||
| 74 | 1/2/2025 | 1/2/2025 | 250025309765457 | 997 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#BE8BCR | ASO | Large Group | Brand | Y | N | N | S | 3137141 | 953382344 | FC0275304 | NJ | 070043516 | 15 - Specialty pharmacy | CarelonRx Specialty Pharmacy | CAREMARK INC | ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | Antineoplastic Enzyme Inhibitors | Abemaciclib | VERZENIO | VERZENIO TAB 100MG | 00002481554 | 21531010000310 | CANCER | 000000019903377 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 3 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Oral | ||
| 75 | 1/2/2025 | 1/2/2025 | 250025525854510 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Brand | N | N | N | R | 4832906 | 361924025 | BW5989174 | VA | 236028315 | 01 - Community/retail pharmacy | WALGREENS | WALGREENS CORPORATION | ADHDANTINARCOLEPSYANTIOBESITYANOREXIANTS | Stimulants Misc | Serdexmethylphenidate ChlorideDexmethylphenidate HCl | AZSTARYS | AZSTARYS CAP 39.2-7.8 | 65038042999 | 61409802800130 | ATTENTION DEFICIT DISORDERS | 000000002199708 | 0 | 1 | 0 - Indicated No Drug Chosen | NONF | 3 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 76 | 1/2/2025 | 1/2/2025 | 250025538943481 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Brand | N | N | N | R | 4841828 | 203649917 | FV1698250 | VA | 236922701 | 01 - Community/retail pharmacy | CVS PHARMACY | CVS PHARMACY | ANTIVIRALS | Misc Antivirals | Molnupiravir | LAGEVRIO | LAGEVRIO CAP 200MG | 00006505509 | 12700046000120 | VIRAL INFECTIONS | 000000001258661 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 3 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Oral | ||
| 77 | 1/2/2025 | 1/2/2025 | 250025596039413 | 998 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4850067 | 831309299 | FM7950593 | VA | 23109 | 01 - Community/retail pharmacy | MATHEWS PHARMACY | INDEPENDENTS | BETA BLOCKERS | AlphaBeta Blockers | Labetalol HCl | LABETALOL HYDROCHLORIDE | LABETALOL TAB 200MG | 70377006113 | 33300010100310 | HYPERTENSION/HEART DISEASE | 000000008013716 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 78 | 1/2/2025 | 1/2/2025 | 250025650680569 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4841828 | 203649917 | FV1698250 | VA | 236922701 | 01 - Community/retail pharmacy | CVS PHARMACY | CVS PHARMACY | ANTIDEPRESSANTS | Serotonin Modulators | Trazodone HCl | TRAZODONE HYDROCHLORIDE | TRAZODONE TAB 50MG | 50111056001 | 58120080100305 | SLEEP DISORDERS | 000000001258678 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 79 | 1/2/2025 | 1/2/2025 | 250025718387474 | 998 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Brand | N | N | N | R | 4840460 | 710862119 | FW0540561 | VA | 224823871 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | VACCINES | Viral Vaccines | Influenza Virus Vaccine Recombinant Hemagglutinin HA | FLUBLOK 2024-2025 | FLUBLOK INJ 2024-25 | 49281072410 | 1710002085E520 | VACCINATIONS | 000000007433372 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 2 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Intramuscular Injectable | ||
| 80 | 1/2/2025 | 1/2/2025 | 250025718556445 | 998 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Brand | N | N | N | R | 4840460 | 710862119 | FW0540561 | VA | 224823871 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | VACCINES | Viral Vaccines | COVID19 SARSCoV2 mRNA Virus Vaccine | SPIKEVAX COVID-19 VACCINE | SPIKEVAX INJ 2024-25 | 80777011096 | 1710000240E640 | VACCINATIONS COVID19 | 000000007433373 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 2 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Intramuscular Injectable | ||
| 81 | 1/2/2025 | 1/2/2025 | 250025727013542 | 997 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | HEMATOPOIETIC AGENTS | Cobalamins | Cyanocobalamin | CYANOCOBALAMIN | CYANOCOBALAM INJ 1000MCG | 69680011225 | 82100010002015 | ANEMIA | 000000007244964 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Injection | ||
| 82 | 1/2/2025 | 1/2/2025 | 250025742709427 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4850067 | 831309299 | FM7950593 | VA | 23109 | 01 - Community/retail pharmacy | MATHEWS PHARMACY | INDEPENDENTS | CONTRACEPTIVES | Combination Contraceptives Oral | NorgestimateEthinyl Estradiol Triphasic | TRI-MILI | TRI-MILI TAB | 65862077785 | 25992002300320 | CONTRACEPTION | 000000008013724 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 83 | 1/2/2025 | 1/2/2025 | 250025904459444 | 998 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4842591 | 361924025 | FW2399067 | VA | 23072 | 01 - Community/retail pharmacy | WALGREENS | WALGREENS CORPORATION | ANTIDEPRESSANTS | Selective Serotonin Reuptake Inhibitors SSRIs | Sertraline HCl | SERTRALINE HYDROCHLORIDE | SERTRALINE TAB 25MG | 31722014505 | 58160070100305 | DEPRESSION | 000000001035775 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 84 | 1/2/2025 | 1/2/2025 | 250026346709588 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTIDEPRESSANTS | Serotonin Modulators | Trazodone HCl | TRAZODONE HYDROCHLORIDE | TRAZODONE TAB 50MG | 50111056001 | 58120080100305 | SLEEP DISORDERS | 000000007244971 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 85 | 1/2/2025 | 1/3/2025 | 250030306694575 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#BE8BCM | ASO | Large Group | Generic | N | N | N | M | 0366054 | 473025203 | FC2714916 | AZ | 857045727 | 05 - Mail-order pharmacy | CARELONRX PHARMACY INC | INDEPENDENTS | CORTICOSTEROIDS | Glucocorticosteroids | Prednisone | PREDNISONE | PREDNISONE TAB 5MG | 60219170607 | 22100045000315 | INFLAMMATION/IMMUNE DISORDERS | 000000103927039 | 0 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | 0 | Non-Maintenance Drug | Prescription Required | Oral | ||
| 86 | 1/2/2025 | 1/6/2025 | 250022904548530 | 998 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4821888 | 231940653 | AD5973501 | VA | 230615121 | RITE AID PHARMACY | RITE AID HEADQUARTER CORP | ANTIDEPRESSANTS | Antidepressants Misc | Bupropion HCl | BUPROPION HYDROCHLORIDE | BUPROPION TAB 75MG | 23155019101 | 58300040100305 | DEPRESSION | 000000001260971 | 5 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | |||
| 87 | 1/2/2025 | 1/15/2025 | 250024379231515 | 998 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Brand | N | N | N | R | 4821888 | 231940653 | AD5973501 | VA | 230615121 | RITE AID PHARMACY | RITE AID HEADQUARTER CORP | ANTIDIABETICS | Incretin Mimetic Agents | Semaglutide | OZEMPIC | OZEMPIC INJ 2MG/3ML | 00169418113 | 2717007000D221 | DIABETES | 000000001282654 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 2 | IN | N | X | Maintenance drug | Prescription Required | Subcutaneous | |||
| 88 | 1/2/2025 | 4/29/2025 | 251192106970006 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTIASTHMATIC AND BRONCHODILATOR AGENTS | Sympathomimetics | Albuterol Sulfate | ALBUTEROL SULFATE HFA | ALBUTEROL AER HFA | 68180096301 | 44201010103410 | ASTHMA | 000000007178932 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Inhalation | ||
| 89 | 1/2/2025 | 4/29/2025 | 251192106998017 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4826674 | 710862119 | BW5373802 | VA | 230616113 | 01 - Community/retail pharmacy | WALMART PHARMACY | WALMART | ANTICONVULSANTS | Anticonvulsants Misc | Levetiracetam | LEVETIRACETAM | LEVETIRACETA TAB 750MG | 65862024708 | 72600043000340 | SEIZURES | 000000007172613 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 90 | 1/3/2025 | 1/3/2025 | 250030558843497 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M002 | IBC0098380 | IRX#NLMKE | ASO | Large Group | Generic | N | N | N | R | 4845775 | 203649917 | FV4903705 | VA | 236024317 | 01 - Community/retail pharmacy | CVS PHARMACY | CVS PHARMACY | ANTIDEPRESSANTS | Antidepressants Misc | Bupropion HCl | BUPROPION HYDROCHLORIDE E | BUPROPION TAB 300MG XL | 69097007212 | 58300040107530 | DEPRESSION | 000000001337829 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 91 | 1/3/2025 | 1/3/2025 | 250031146198463 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4842591 | 361924025 | FW2399067 | VA | 23072 | 01 - Community/retail pharmacy | WALGREENS | WALGREENS CORPORATION | ANTIHYPERLIPIDEMICS | HMG CoA Reductase Inhibitors | Atorvastatin Calcium | ATORVASTATIN CALCIUM | ATORVASTATIN TAB 10MG | 43598009805 | 39400010100310 | HIGH CHOLESTEROL | 000000000998393 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral | ||
| 92 | 1/3/2025 | 1/3/2025 | 250031827676492 | 999 | VOY | 8310 | IngRx-VA Commercial | L03319 | GLOUCESTER COUNTY SCHOOL | L03319M001 | IBC0098381 | IRX#NK217 | ASO | Large Group | Generic | N | N | N | R | 4849723 | 311569568 | FK7509411 | VA | 23072 | 01 - Community/retail pharmacy | KROGER PHARMACY | KROGER COMPANY-KROGER EAST | ANTIDEPRESSANTS | Selective Serotonin Reuptake Inhibitors SSRIs | Sertraline HCl | SERTRALINE HYDROCHLORIDE | SERTRALINE TAB 100MG | 69097083512 | 58160070100320 | DEPRESSION | 000000006335225 | 1 | 1 | 0 - Indicated No Drug Chosen | FRMLY | 1 | IN | N | X | Maintenance drug | Prescription Required | Oral |
This is the start of the file's text. The full file is on GovTribe.
File details come from the government source that posted it. Updated .