|
Anti-Nausea
Therapy Drugs |
Cancer Therapy
Drugs Miscellaneous |
Emergency /
Allergic Reaction Kits |
Estrogen
Topical Therapy Drugs |
Inhaled Asthma
Therapy Drugs |
|
Anzemet
Emend
Kytril
Zofran (odansetron) |
Iressa |
Anakit
Epipen
Limited to two
(2) per calendar year |
Alora
Climara
CombiPatch
Esclim
Estrasorb
Estraderm
Vivelle - Dot
generic estrogen patches |
Intal
Tilade
Other Inhaled Medications
|
|
Insulin and
Supplies |
Intranasal
Therapy Drugs |
Migraine
Therapy Drugs |
Miscellaneous
Device(s) |
Multiple
Sclerosis Therapy Drugs |
|
Cartridges
Needles
Pens
Syringes
Pre Filled Syringes
Diabetic Supplies
(over
the counter) |
Beconase (AQ)
Flonase (fluticasone)
Nasacort (AQ)
Nasarel (flunisolide)
Nasonex
Rhinocort (Aqua) |
Amerge
Axert
Frova
Imitrex
Maxalt
Migranal NS
Relpax
Stadol NS
Zomig |
Inhaler Spacers
Limited to two
(2) per calendar year |
Avonex
Betaseron
Copaxone
Rebif |
|
Ophthalmic
Therapy Drugs |
Osteoporosis
Therapy Drugs |
Rheumatoid
Arthritis Therapy Drugs |
Sedatives -
Hypnotic Drugs |
Therapeutic
Patches and Recommended Maximum Per Copay |
|
Restasis |
Actonel Products -excluding 30 mg
Boniva
Forteo
Fosamax -All
Products
Miacalcin NS |
Arava
Enbrel
Humira
Kineret |
Ambien
Ambien CR
Butisol
chloral hydrate
Dalmane (flurazepam)
Doral
Halcion (triazolam)
Lunesta
Prosom
Restoril
Rozerem
Sonata |
Androderm
Androgel
Catapres TTS
Daytrana
EmSam
fentanyl
Lidoderm
nitroglycerin
Ortho-Evra
OxyTrol
Striant
Testim Gel
Transderm-Scope |
