allumatm care formulary - jan to mar 2021...drug requires prior authorization to confirm medical...
TRANSCRIPT
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T1
T2
T3
PAQLBPSP
Tier 1 medication, typically generics or drugs available at lowest member cost share.
Tier 2 medication, typically preferred or formulary brand drugs.
Tier 3 medication, typically non-preferred or non-formulary drugs.
Drug requires prior authorization to confirm medical necessity prior to coverage.Quantity limits may apply.Brand Penalty: Member may be responsible for the cost difference between brand and generic. Specialty Medication: This drug may only be available at the plan's preferred specialty pharmacy. Step Therapy: One or more first-line drugs must be tried before coverage is authorized.ST
22TEK SOLUTION T3
330ML SYRINGES LUER LOCK MISC
T3
Aabacavir solution T1
abacavir sulfate tablet T1
abacavir tablet T1
abacavir-lamivudine tablet T1
abacavir-lamivudine-zidovudine tablet
T1
ABILIFY MYCITE TABLET T3, PA
ABILIFY TABLET T2, BP
abiraterone tablet T1, QL, SP, PA
ABSORICA CAPSULE T2
ABSORICA LD CAPSULE T3
acamprosate calcium dr tablet
T1
ACANYA GEL T3, BP
acarbose tablet T1
ACCOLATE TABLET T3, BP
ACCU-CHEK AVIVA CONNECT KIT
T2, QL
ACCU-CHEK AVIVA PLUS KIT
T2, QL
ACCU-CHEK AVIVA PLUS STRIP
T2
ACCU-CHEK AVIVA SOLUTION
T3
ACCU-CHEK COMBO KIT T3
ACCU-CHEK COMPACT PLUS CONTROL SOLUTION
T3
ACCU-CHEK COMPACT PLUS STRIP
T2
ACCU-CHEK FASTCLIX KIT
T2
ACCU-CHEK FASTCLIX MISC
T2
ACCU-CHEK GUIDE CONTROL SOLN LIQUID
T3
ACCU-CHEK GUIDE KIT T2, QL
ACCU-CHEK GUIDE ME KIT
T2, QL
ACCU-CHEK GUIDE STRIP
T2
ACCU-CHEK MISC T2
ACCU-CHEK MULTICLIX LANC KIT
T2
ACCU-CHEK NANO SMARTVIEW KIT
T2, QL
ACCU-CHEK RAPID D MISC
T3
ACCU-CHEK SMARTVIEW LIQUID
T3
ACCU-CHEK SMARTVIEW STRIP
T2
ACCU-CHEK SOFTCLIX KIT
T2
ACCU-CHEK SOFTCLIX MISC
T2
ACCU-CHEK SPIRIT ADAPTER MISC
T3
ACCU-CHEK SPIRIT BATTERY MISC
T3
ACCU-CHEK TENDER KIT
T3
ACCU-CHEK TENDER MISC
T3
ACCU-CHEK ULTRAFLEX MISC
T3
Page 1 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
AllumaTM Care Formulary - Jan to Mar 2021
covered at the lowest member cost share.common coverage indicators present on this file. Drugs shown in lower-case are generically available and typicallyEach medication may have specific coverage requirements not reflected in this document. The key below explains
card.your member portal and use the “Calculate my Copay” feature or call the phone number printed on your member IDcriteria, cost sharing information, or information about drugs that do not appear on this abbreviated list please log intocovered by your plan at 100%. Individual plans may vary. For questions regarding plan-specific restrictions, coverageSome medications may be subject to the Affordable Care Act (ACA) provisions or your plan's preventive benefit andPLEASE NOTE: Certain specialty medications may only be available through your plan’s preferred specialty pharmacy.
requiring provider administration are generally covered under the medical benefit and may not appear on this list.may be covered. Agents listed are primarily oral, self-injected, inhaled or topical pharmaceutical formulations. Drugs list does not guarantee coverage. Individual plans may vary and medications that do not appear on this abbreviated list This document provides an alphabetical listing of medications covered on the Alluma Care Formulary. Inclusion on this
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ACCUPRIL TABLET T2, BP
ACCURETIC TABLET T2, BP
ACCUTREND GLUCOSE SOLUTION
T3
ACCUTREND GLUCOSE STRIP
T2
ACD FORMULA A SOLUTION
T3
ACD SOLUTION T3
ACD-A NOCLOT-50 SOLUTION
T3
acebutolol capsule T1
acetaminophen w/codeine tablet
T1, QL
acetaminophen/codeine solution
T1, QL
acetaminophen/codeine tablet
T1, QL
acetazolamide er capsule T1
acetazolamide tablet T1
ACETIC ACID 0.25% SOLUTION
T2
acetic acid solution T1
acetic acid/hydrocortisone solution
T1
acetylcysteine solution T1
ACIPHEX SPRINKLE CAPSULE
T3
ACIPHEX TABLET T3, BP
acitretin capsule T1
ACTEMRA ACTPEN INJECTION
T2, SP, PA
ACTEMRA INJECTION T2, SP, PA
ACTHIB SOLUTION T2
ACTIGALL CAPSULE T2, BP
ACTI-LANCE MISC T2
ACTIMMUNE SOLUTION T2, QL, PA, SP
ACTIQ LOLLIPOP T3, BP
ACTIVE FE TABLET T3
ACTIVELLA TABLET T2, BP
ACTONEL TABLET T2, BP
ACTOPLUS MET TABLET T2, BP
ACTOS TABLET T2, BP
ACUICYN ANTIMICROBIAL EY SOLUTION
T3
ACUICYN SOLUTION T3
ACULAR LS SOLUTION T2, BP
ACULAR SOLUTION T2, BP
acyclovir capsule T1
ACYCLOVIR CREAM T2
acyclovir ointment T1
acyclovir suspension T1
acyclovir tablet T1
ACZONE GEL T3, BP
ADACEL SUSPENSION T2
adapalene cream T1
adapalene gel T1
adapalene pump gel T1
ADASUVE AEROSOL T3
ADCIRCA TABLET T2, QL
ADDERALL TABLET T2, BP
ADDERALL XR 24 HOUR CAP
T2, BP
ADDYI TABLET T2, QL
adefovir dipivoxil tablet T1, SP
ADEMPAS TABLET T2, QL, PA, SP
ADHANSIA XR 24 HOUR CAP
T3, PA
ADIPEX-P CAPSULE T2, BP
ADJUSTABLE LANCING DEVICE MISC
T2
ADLYXIN INJECTION T3, PA
ADLYXIN STARTER PACK INJECTION
T3, PA
ADMELOG SOLOSTAR INJECTION
T3, PA
ADMELOG SOLUTION T3, PA
ADRENALIN SOLUTION T2
adult aspirin regimen tablet
T1
advair diskus aerosol T1
ADVAIR HFA AEROSOL T2
ADVANCED LANCING DEVICE MISC
T2
ADVOCATE CONTROL SOLUTION LIQUID
T3
ADVOCATE DUO/TALKING
T3
ADVOCATE DUO/TALKING KIT
T3
ADVOCATE LANCING DEVICE MISC
T2
ADVOCATE RAPID-SAFE MISC
T2
ADVOCATE REDI-CODE+ CTRL SOLN SOLUTION
T3
ADVOCATE SYRINGES MISC
T2
ADZENYS ER SUSPENSION
T3
ADZENYS XR-ODT TABLET
T3, QL
AEMCOLO TABLET T3
AEROCHAMBER MINI AEROSOL
T3
AEROCHAMBER MISC T3
AEROCHAMBER MV MISC
T3
AEROCHAMBER PLUS FLOW VU MISC
T3
AEROCHAMBER PLUS FLOW-VU MISC
T3
AEROCHAMBER Z-STAT PLUS MISC
T3
AEROCHAMBER/FLOWSIGNAL MISC
T3
AEROECLIPSE II MISC T3
AERONEB GO MISC T3
AERONEB GO NEBULISER MISC
T3
AEROVENT PLUS T3
AFINITOR DISPERZ TABLET
T2, QL, SP, PA
AFINITOR TABLET T2, QL, SP, PA, BP
afirmelle tablet T1
AFLURIA QUAD 2020-2021 SUSPENSION
T2
AFLURIA QUAD 2020-21 (3YR UP) INJECTION
T2
AFLURIA QUAD 2020-21 (6-35MO) INJECTION
T2
AFREZZA POWDER T3, PA
AFTERA TABLET T3
AGAMATRIX CONTROL HIGH SOLUTION
T3
AGAMATRIX CONTROL NORMAL SOLUTION
T3
AGRYLIN CAPSULE T2, BP
AIMOVIG INJECTION T2, QL, PA
AIRDUO DIGIHALER 113/14 AEROSOL
T2, PA
AIRDUO DIGIHALER 232/14 AEROSOL
T2, PA
AIRDUO DIGIHALER 55/14 AEROSOL
T2, PA
AIRDUO RESPICLICK 113/14 AEROSOL
T2
AIRDUO RESPICLICK 232/14 AEROSOL
T2
AIRDUO RESPICLICK 55/14 AEROSOL
T2
AJOVY INJECTION T2, QL, PA
AKLIEF CREAM T3
AKTEN GEL T2
AKYNZEO CAPSULE T3
ALA SCALP LOTION T3
ala-cort cream T1
ALA-QUIN CREAM T3
ALA-SCALP LOTION T3
Page 2 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
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albendazole tablet T1
ALBENZA TABLET T2, BP
albuterol sulfate er 12 hr tab
T1
albuterol sulfate hfa aerosol
T1, QL
albuterol sulfate nebulized T1
albuterol sulfate syrup T1
albuterol sulfate tablet T1
ALCLOMETASONE DIPROPIONATE CREAM
T3
ALCLOMETASONE DIPROPIONATE OINTMENT
T3
ALDACTAZIDE TABLET T2, BP
ALDACTONE TABLET T2, BP
ALDARA CREAM T2, BP
ALECENSA CAPSULE T2, QL, SP, PA
ALENDRONATE SODIUM SOLUTION
T2
alendronate sodium tablet T1
ALFUZOSIN ER 24 HR TAB
T3
ALINIA SUSPENSION T2
ALINIA TABLET T2, BP
aliskiren tablet T1
ALKERAN TABLET T2, BP, SP
ALKINDI SPRINKLE CAPSULE
T3, QL, PA
ALLERGIST TRAY SYR-DETACH NDL KIT
T3
allopurinol tablet T1
ALLZITAL TABLET T3
almotriptan malate tablet T1, QL, ST
almotriptan tablet T1, QL, ST
ALOCRIL SOLUTION T3
ALOGLIPTIN TABLET T3, PA
ALOGLIPTIN/METFORMIN TABLET
T3, PA
ALOGLIPTIN/PIOGLITAZONE TABLET
T3, PA
ALOMIDE SOLUTION T2
alophen tablet T1
ALORA PATCH T2
alosetron tablet T1
ALPHAGAN P SOLUTION T2, BP
ALPRAZOLAM ER 24 HR TAB
T3
ALPRAZOLAM INTENSOL
T3
ALPRAZOLAM ODT TABLET
T3
alprazolam tablet T1
ALPRAZOLAM XR 24 HR TAB
T3
ALREX SUSPENSION T3
ALTABAX OINTMENT T3
ALTACAINE SOLUTION T2
ALTACE CAPSULE T2, BP
ALTAFLUOR BENOX SOLUTION
T3
altavera tablet T1
ALTERA NEBULIZER MISC
T3
ALTERNATE SITE LANCING DEVICE MISC
T2
ALTRENO LOTION T3
ALUNBRIG TABLET T2, QL, SP, PA
ALVESCO AEROSOL T3, ST
alvimopan capsule T1, SP
alyacen 1/35 tablet T1
alyacen 7/7/7 tablet T1
ALYQ TABLET T2, QL
amabelz tablet T1
amantadine capsule T1
amantadine syrup T1
amantadine tablet T1
AMARYL TABLET T2, BP
AMBIEN CR TABLET T2, BP
AMBIEN TABLET T2, BP
ambrisentan tablet T1, PA, SP
AMCINONIDE CREAM T3
AMCINONIDE LOTION T3
AMCINONIDE OINTMENT T3
AMELUZ GEL T2, PA
AMERGE TABLET T2, QL, BP
amethia lo tablet T1
amethia tablet T1
amethyst tablet T1
AMICAR SOLUTION T2, BP
AMICAR TABLET T2, BP
amiloride tablet T1
amiloride w/hctz tablet T1
AMINOACETIC ACID SOLUTION
T2
aminocaproic acid solution
T1
aminocaproic acid tablet T1
amiodarone tablet T1
AMITIZA CAPSULE T2
amitriptyline tablet T1
AMITRIPTYLINE/CHLORDIAZEPOXIDE TABLET
T3
amitriptyline-perphenazine tablet
T1
amlodipine besylate tablet T1
amlodipine besylate-benazepril capsule
T1
AMLODIPINE-OLMESARTAN TABLET
T3
AMLODIPINE-VALSARTAN TABLET
T3
AMLODIPINE-VALSARTAN-HCTZ TABLET
T3
amnesteem capsule T1
AMOXAPINE TABLET T3
amoxicillin capsule T1
amoxicillin chew tab T1
amoxicillin suspension T1
amoxicillin tablet T1
AMOXICILLIN-CLAVULANATE POT ER 12 HR TAB
T3
amoxicillin-clavulanate potass chew tab
T1
amoxicillin-clavulanate potass suspension
T1
amoxicillin-clavulanate potass tablet
T1
AMPHETAMINE ER SUSPENSION
T3
AMPHETAMINE SULFATE TABLET
T3
AMPICILLIN CAPSULE T3
AMPYRA 12 HR TAB T2, SP, PA, BP
AMZEEQ FOAM T3, PA
ANADROL-50 TABLET T2, PA
ANAFRANIL CAPSULE T2, BP
anagrelide capsule T1
ANA-LEX KIT T3
ANALPRAM HC CREAM T2
ANALPRAM HC SINGLES CREAM
T2
ANALPRAM-HC LOTION T3
ANASPAZ TABLET T2
anastrozole tablet T1
ANCOBON CAPSULE T2, PA, BP
ANDRODERM PATCH T2
ANDROGEL GEL T2
ANDROGEL PUMP GEL T2, BP
ANGELIQ TABLET T2
ANHYDROUS BASE OINTMENT
T3
ANHYDROUS CREAM BASE
T3
Page 3 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
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ANORO ELLIPTA AEROSOL
T2
ANTARA CAPSULE T3
ANTICOAGULANT SODIUM SOLUTION
T3
anucort-hc suppository T1
ANUSOL-HC CREAM T2, BP
anusol-hc suppository T1
ANZEMET TABLET T3
APADAZ TABLET T3
APAP-CAFFEINE-DIHYDROCODEINE CAPSULE
T3
APAP-CAFFEINE-DIHYDROCODEINE TABLET
T3
APEXICON E CREAM T3
APIDRA SOLOSTAR INJECTION
T2, PA
APIDRA SOLUTION T2, PA
APLENZIN 24 HR TAB T3
APOKYN INJECTION T2, PA, SP
apraclonidine solution T1
aprepitant capsule T1, QL, PA
apri tablet T1
APRISO 24 HOUR CAP T2, BP
APTENSIO XR 24 HOUR CAP
T3
APTIOM TABLET T2, QL, ST
APTIVUS CAPSULE T2
APTIVUS SOLUTION T2
AQUA CARE STERILE WATER IRRIG SOLUTION
T2
ARAKODA TABLET T3
aranelle tablet T1
ARANESP ALBUMIN FREE INJECTION
T2, SP
ARANESP ALBUMIN FREE SOLUTION
T2, SP
ARAVA TABLET T2, BP
ARAZLO LOTION T3
ARCALYST SOLUTION T2, QL, PA, SP
ARCAPTA NEOHALER CAPSULE
T3
ARESTIN MISC T3, PA, SP
ARICEPT TABLET T2, BP
ARIKAYCE SUSPENSION
T3, SP, QL, PA
ARIMIDEX TABLET T2, BP
ARIPIPRAZOLE ODT TABLET
T3
aripiprazole solution T1
aripiprazole tablet T1
ARIXTRA SOLUTION T3, BP
ARMODAFINIL TABLET T3
ARMONAIR DIGIHALER AEROSOL
T3
ARMOUR THYROID TABLET
T2
ARNICA FLOWER TINCTURE
T3
ARNICA LG LIQUID T3
ARNUITY ELLIPTA AEROSOL
T2
AROMASIN TABLET T2, BP
ARTHROTEC 50 TABLET T2, BP
ARTHROTEC 75 TABLET T2, BP
ARYMO ER T3
ARZOL SILVER NITRATE APP MISC
T3
asa-butalb-caff-cod capsule
T1, QL
ASACOL HD TABLET T2, BP
ascomp/codeine capsule T1, QL
ashlyna tablet T1
ASMANEX AEROSOL T2
ASMANEX HFA AEROSOL
T2
aspirin 81 low dose chew tab
T1
aspirin 81 tablet T1
aspirin adult low dose tablet
T1
aspirin adult tablet T1
aspirin chew tab T1
aspirin childrens chew tab T1
aspirin e.c. tablet T1
aspirin ec low dose tablet T1
aspirin ec tablet T1
aspirin low dose chew tab T1
aspirin low dose tablet T1
aspirin low strength chew tab
T1
aspirin regular strength tablet
T1
aspirin tablet T1
aspirin/dipyridamole capsule
T1
aspirin/dipyridamole er capsule
T1
ASSURE 4 LIQUID T3
ASSURE DOSE SOLUTION
T3
ASSURE HAEMOLANCE PLUS MISC
T2
ASSURE ID INSULIN SAFETY MISC
T2
ASSURE PRISM CONTROL LEV SOLUTION
T3
ASTAGRAF XL 24 HOUR CAP
T2, PA
ATABEX EC TABLET T2
ATACAND HCT TABLET T2, BP
ATACAND TABLET T2, BP
atazanavir capsule T1
atazanavir sulfate capsule T1
ATELVIA TABLET T3, BP
atenolol tablet T1
atenolol/chlorthalidone tablet
T1
ATIVAN TABLET T2, BP
atomoxetine capsule T1
atorvastatin calcium tablet T1
atovaquone suspension T1
atovaquone/proguanil tablet
T1
ATRALIN GEL T2, BP
ATRIPLA TABLET T3, BP
ATROPINE SULFATE OINTMENT
T2
atropine sulfate solution T1
ATROVENT HFA AEROSOL
T2
AUBAGIO TABLET EXaubra eq tablet T1
aubra tablet T1
AUGMENTIN ES-600 SUSPENSION
T2, BP
AUGMENTIN SUSPENSION
T2, BP
AUGMENTIN TABLET T2
AURA PORTANEB MISC T3
aurovela 1.5/30 tablet T1
aurovela 1/20 tablet T1
aurovela 24 fe tablet T1
aurovela fe 1.5/30 tablet T1
aurovela fe 1/20 tablet T1
AURYXIA TABLET T3
AUSTEDO TABLET T3, QL, PA, SP
AUTO-LANCET MINI MISC
T2
AUTOLET IMPRESSION MISC
T2
AUTOLET LANCING DEVICE MISC
T2
AUTOLET PLUS MISC T2
Page 4 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
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AUTOPEN T2
AUTOSOFT 30 MISC T3
AUTOSOFT 90 MISC T3
AUTOSOFT XC MISC T3
AUVI-Q INJECTION T3, QL, PA
AVALIDE TABLET T3, BP
AVAPRO TABLET T3, BP
avar cleanser emulsion T1
AVAR LS CLEANSER LIQUID
T3
AVAR-E EMOLLIENT CREAM
T3
AVAR-E GREEN CREAM T3
AVENOVA SOLUTION T3
aviane tablet T1
AVIDOXY DK KIT T3
avidoxy tablet T1
avita cream T1
avita gel T1
AVODART CAPSULE T2, BP
AVONEX INJECTION T2, SP
AVONEX PEN INJECTION
T2, SP
AYGESTIN TABLET T2, BP
ayuna tablet T1
AYVAKIT TABLET T2, QL, SP, PA
AZACITIDINE SUSPENSION
T2, PA, SP
AZASAN TABLET T2
AZASITE SOLUTION T3
azathioprine tablet T1
AZELAIC ACID GEL T2
azelastine solution T1
AZELEX CREAM T2
AZILECT TABLET T3, BP
azithromycin packet T1
azithromycin suspension T1
azithromycin tablet T1
AZOPT SUSPENSION T2
AZOR TABLET T3, BP
AZULFIDINE EN-TABS TABLET
T2, BP
AZULFIDINE TABLET T2, BP
azurette tablet T1
Bbacitracin ointment T1
bacitracin/polymyxin b ointment
T1
baclofen tablet T1
BACTRIM DS TABLET T2, BP
BACTRIM TABLET T2, BP
BAFIERTAM CAPSULE (DELAYED RELEASE)
T3, QL, SP, PA
BALCOLTRA TABLET T2
balsalazide disodium capsule
T1
BALVERSA TABLET T3, QL, SP, PA
balziva tablet T1
BANZEL SUSPENSION T2, BP
BANZEL TABLET T2
BAQSIMI ONE PACK POWDER
T2, QL
BAQSIMI TWO PACK POWDER
T2, QL
BARACLUDE SOLUTION T2, SP
BARACLUDE TABLET T2, BP, SP
BASAGLAR KWIKPEN INJECTION
T3
BAXDELA TABLET T3, PA
bayer aspirin tablet T1
BAYER CHEWABLE LOW DOSE CHEW TAB
T2
bayer low dose tablet T1
B-D INSULIN SYRINGE MISC
T2
BD INSULIN SYRINGE ULTRA MISC
T2
BD LO-DOSE INSULIN SYRIN MISC
T2
BD MAGNI-GUIDE MAGNIFIER MISC
T2
B-D SAFETYGLIDE MISC T2
BD SAFETYGLIDESYRINGE MISC
T2
BD SAFETY-LOK MISC T3
BD VACUTAINER COLLECTION SET MISC
T3
BECONASE AQ SUSPENSION
T3
bekyree tablet T1
BELBUCA FILM T3
BELLADONNA/OPIUM SUPPOSITORY
T2
BELSOMRA TABLET T2, ST
benazepril tablet T1
benazepril-hctz tablet T1
BENLYSTA INJECTION T2, SP, PA
BENSAL HP OINTMENT T3
BENTLEY THE BEAR MISC
T3
BENZACLIN GEL T2, BP
BENZACLIN WITH PUMP GEL
T2, BP
BENZAMYCIN GEL T2, BP
BENZHYDROCODONE-ACETAMINOPHEN TABLET
T3
BENZNIDAZOLE TABLET T3
BENZOIN T3
BENZOIN COMPOUND TINCTURE
T3
benzonatate capsule T1
BENZPHETAMINE TABLET
T3, PA
benztropine mesylate tablet
T1
BEPREVE SOLUTION T3
BESER LOTION T3
BESIVANCE SUSPENSION
T3
betamethasone dipropionate cream
T1
betamethasone dipropionate gel
T1
betamethasone dipropionate lotion
T1
betamethasone dipropionate ointment
T1
betamethasone dp augmented ointment
T1
betamethasone valerate cream
T1
BETAMETHASONE VALERATE FOAM
T3
betamethasone valerate lotion
T1
betamethasone valerate ointment
T1
BETAPACE AF TABLET T2, BP
BETAPACE TABLET T2, BP
BETASERON KIT T2, SP
betaxolol solution T1
BETAXOLOL TABLET T3
bethanechol chloride tablet
T1
BETHKIS NEBULIZED T3, PA, BP, SP
BETIMOL SOLUTION T2
BETOPTIC-S SUSPENSION
T2
BEVESPI AEROSPHERE AEROSOL
T2
bexarotene capsule T1, QL, SP, PA
BEXSERO INJECTION T2
BEYAZ TABLET T2, BP
bicalutamide tablet T1
BIDIL TABLET T3
Page 5 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
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BIKTARVY TABLET T2
BILTRICIDE TABLET T2, BP
BIMATOPROST SOLUTION
T2
BINOSTO TABLET (EFF) T3, PA
bisacodyl ec tablet T1
bisoprolol fumarate tablet T1
bisoprolol fumarate/hctz tablet
T1
BLANCHE CREAM T3
BLEPH-10 SOLUTION T2, BP
BLEPHAMIDE S.O.P. OINTMENT
T2
BLEPHAMIDE SUSPENSION
T2
blisovi 24 fe tablet T1
blisovi fe 1.5/30 tablet T1
blisovi fe 1/20 tablet T1
BONIVA TABLET T2, BP
BONJESTA TABLET T3
BOOSTRIX SUSPENSION
T2
BORIC ACID GRANULES T3
bosentan tablet T1, QL, PA, SP
BOSULIF TABLET T2, QL, SP, PA
BP 10-1 EMULSION T3
BP VIT 3 CAPSULE T3
BRAFTOVI CAPSULE T2, QL, SP, PA
BREATHERITE COLLAPSIBLE MISC
T3
BREATHERITE MISC T3
BREATHERITE RIGID SPACER MISC
T3
BREATHERITE W/LARGE MASK MISC
T3
BREATHERITE W/SMALL MASK MISC
T3
BREO ELLIPTA AEROSOL
T2
BREZTRI AEROSPHERE AEROSOL
T3, PA
briellyn tablet T1
BRILINTA TABLET T2
brimonidine tartrate solution
T1
BRIMONIDINE-DORZOLAMIDE SOLUTION
T3
BRINEURA KIT T3, PA, SP
BRISDELLE CAPSULE T3, BP
BRIVIACT SOLUTION T2, PA
BRIVIACT TABLET T2, PA
BROMFENAC SOLUTION T3
bromocriptine mesylate capsule
T1
bromocriptine mesylate tablet
T1
BROMSITE SOLUTION T3
BROVANA NEBULIZED T2
BRUKINSA CAPSULE T3, QL, SP, PA
BRYHALI LOTION T3, PA
budesonide capsule T1
budesonide er 24 hr tab T1, QL, PA
budesonide suspension T1
BUDESONIDE-FORMOTEROL FUMARATE AEROSOL
T2
bumetanide tablet T1
BUNAVAIL FILM T2
BUPHENYL POWDER T2, BP, SP
BUPHENYL TABLET T2, BP, SP
buprenorphine patch T1
buprenorphine sl T1
buprenorphine-naloxone film
T1
buprenorphine-naloxone sl
T1
bupropion sr 12 hr tab T1
bupropion tablet T1
bupropion xl 24 hr tab T1
buspirone tablet T1
butalbital compound capsule
T1
butalbital compound w/codeine capsule
T1, QL
butalbital/acetaminophen capsule
T1, BP
butalbital/acetaminophen tablet
T1
butalbital/apap/caffeine capsule
T1
butalbital/apap/caffeine tablet
T1
BUTALBITAL/CAFF/APAP/CODEINE CAPSULE
T3
butalbital-asp-caffeine capsule
T1
BUTALBITAL-ASP-CAFFEINE TABLET
T2
butorphanol tartrate solution
T1
BUTRANS PATCH T2, BP
BYSTOLIC TABLET T3
Ccabergoline tablet T1
CABOMETYX TABLET T2, QL, SP, PA
CAFERGOT TABLET T2, BP
caffeine solution T1
CALAN SR TABLET T2, BP
calcipotriene cream T1
CALCIPOTRIENE FOAM T3
calcipotriene ointment T1
calcipotriene solution T1
CALCIPOTRIENE-BETAMETHASONE DP OINTMENT
T3
CALCIPOTRIENE-BETAMETHASONE SUSPENSION
T3
CALCIPOTRIENE-CLOBETASOL PROP SOLUTION
T3
calcitonin salmon solution T1
calcitonin-salmon solution T1
calcitrene ointment T1
calcitriol capsule T1
CALCITRIOL OINTMENT T2
calcitriol solution T1
calcium capsule T1
calcium tablet T1
CALQUENCE CAPSULE T2, QL, SP, PA
CAMBIA PACKET T3
camila tablet T1
camrese lo tablet T1
camrese tablet T1
CANASA SUPPOSITORY T2, BP
candesartan cilexetil tablet
T1
candesartan-hydrochlorothiazid tablet
T1
capecitabine tablet T1, QL, SP
CAPEX SHAMPOO T2
CAPLYTA CAPSULE T3, QL, ST
CAPRELSA TABLET T2, QL, PA, SP
CAPSULE #0 CAPSULE T3
CAPSULE #0 DRCAPS CAPSULE
T3
CAPSULE #00 CAPSULE T3
CAPSULE #1 CAPSULE T3
CAPSULE #2 CAPSULE T3
CAPSULE #3 CAPSULE T3
CAPSULE #4 CAPSULE T3
CAPSULE #5 CAPSULE T3
CAPSULE CONI-SNAP CAPSULE
T3
CAPTAIN EAGLE MISC T3
captopril tablet T1
Page 6 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
-
captopril/hydrochlorothiazide tablet
T1
CARAC CREAM T2
CARAFATE SUSPENSION
T2, BP
CARAFATE TABLET T2, BP
CARBAGLU TABLET T2, QL, PA, SP
carbamazepine chew tab T1
carbamazepine er 12 hr tab
T1
carbamazepine er capsule T1
carbamazepine suspension
T1
carbamazepine tablet T1
CARBATROL CAPSULE T2, BP
carbidopa tablet T1
carbidopa/levodopa er tablet
T1
CARBIDOPA/LEVODOPA ODT TABLET
T3
carbidopa/levodopa tablet T1
CARBIDOPA-LEVODOPA-ENTACAPONE TABLET
T3
CARBINOXAMINE MALEATE SOLUTION
T3
CARBINOXAMINE MALEATE TABLET
T3
CARBOGEL 940 GEL T3
CARBOHOL 940 GEL T3
CARBOMER AQUEOUS T3
CARBOMER-HYDROALCOHOLIC
T3
CARDIZEM CD 24 HOUR CAP
T2
CARDIZEM LA 24 HR TAB
T3, BP
CARDIZEM TABLET T2, BP
CARDURA TABLET T2, BP
CARDURA XL 24 HR TAB T3
CAREONE ADVANCED LANCING MISC
T2
CAREONE MISC T2
CARESENS SOLUTION T3
CARETOUCH INSULIN SYRINGE MISC
T2
CARETOUCH LANCING DEVICE MISC
T2
carisoprodol tablet T1
CARISOPRODOL-ASPIRIN-CODEINE TABLET
T3
CARNITOR SF SOLUTION
T2, BP
CARNITOR SOLUTION T2, BP
CARNITOR TABLET T2, BP
CAROSPIR SUSPENSION
T2
carteolol solution T1
cartia xt 24 hour cap T1
CARVEDILOL PHOSPHATE 24 HOUR CAP
T3
carvedilol tablet T1
CASCARA SAGRADA T3
CASODEX TABLET T2, BP
CATAPRES TABLET T2, BP
CATAPRES-TTS-1 PATCH
T2, BP
CATAPRES-TTS-2 PATCH
T2, BP
CATAPRES-TTS-3 PATCH
T2, BP
CAVERJECT IMPULSE KIT
T2, QL
CAVERJECT SOLUTION T2, QL
CAYA T2
CAYSTON SOLUTION T2, SP, PA
caziant tablet T1
CEFACLOR CAPSULE T3
CEFACLOR ER 12 HR TAB
T3
CEFACLOR SUSPENSION
T3
cefadroxil capsule T1
cefadroxil suspension T1
cefadroxil tablet T1
cefdinir capsule T1
cefdinir suspension T1
cefixime capsule T1, PA
CEFIXIME SUSPENSION T3
CEFPODOXIME PROXETIL SUSPENSION
T3
CEFPODOXIME PROXETIL TABLET
T3
cefprozil suspension T1
CEFPROZIL TABLET T3
cefuroxime axetil tablet T1
CELEBREX CAPSULE T2, BP
celecoxib capsule T1
CELEXA TABLET T2, BP
CELLCEPT CAPSULE T2, BP
CELLCEPT SUSPENSION
T2, BP
CELLCEPT TABLET T2, BP
CELONTIN CAPSULE T3
CENTANY AT KIT T3
CENTANY OINTMENT T2
cephalexin capsule T1
cephalexin suspension T1
CEPHALEXIN TABLET T2
CEQUA SOLUTION T3
CEQUR SIMPLICITY 2U T2
CERDELGA CAPSULE T3, QL, PA, SP
CERVIDIL T2
CETRAXAL SOLUTION T3
CEVIMELINE CAPSULE T3
CHANTIX CONTINUING MONTH TABLET
T2
CHANTIX TABLET T2
charlotte 24 fe chew tab T1
chateal eq tablet T1
chateal tablet T1
CHEMET CAPSULE T2
CHEMSTRIP BG LOG BOOK MISC
T2
CHEMSTRIP UGK STRIP T3
CHEMSTRIP-K STRIP T2
CHENODAL TABLET T3, SP
CHERRY SYRUP T3
children's aspirin chew tab T1
chlordiazepoxide capsule T1
chlorhexidine gluconate solution
T1
chloroquine phosphate tablet
T1
chlorpromazine tablet T1
chlorthalidone tablet T1
CHLORZOXAZONE TABLET
T3
CHOLBAM CAPSULE T3, SP
cholestyramine light packet
T1
cholestyramine light powder
T1
cholestyramine packet T1
cholestyramine powder T1
CHONDROITIN SULFATE SOLUTION
T3
CHROMAGEN CAPSULE T3
CIALIS TABLET T2, QL, BP
ciclodan solution T1
ciclopirox gel T1
ciclopirox nail lacquer solution
T1
ciclopirox olamine cream T1
CICLOPIROX SHAMPOO T3
ciclopirox suspension T1
Page 7 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
-
cilostazol tablet T1
CILOXAN OINTMENT T2
CILOXAN SOLUTION T2, BP
CIMDUO TABLET T2
CIMETIDINE SOLUTION T3
CIMETIDINE TABLET T3
CIMZIA KIT T2, SP, PA
CIMZIA STARTER KIT T2, SP, PA
CINACALCET TABLET T2, SP
CIPRO HC SUSPENSION T2
CIPRO SUSPENSION T2
CIPRO TABLET T2, BP
CIPRODEX SUSPENSION
T2, BP
ciprofloxacin solution T1
ciprofloxacin tablet T1
CIPROFLOXACIN-DEXAMETHASONE SUSPENSION
T2
CIPROFLOXACIN-FLUOCINOLONE SOLUTION
T3
citalopram solution T1
citalopram tablet T1
CITRANATAL 90 DHA MISC
T2
CITRANATAL ASSURE MISC
T2
CITRANATAL B-CALM MISC
T2
CITRANATAL BLOOM TABLET
T2
CITRANATAL DHA MISC T2
CITRANATAL HARMONY CAPSULE
T2
CITRANATAL RX TABLET
T2
citroma solution T1
claravis capsule T1
CLARINEX-D 12 HOUR TAB
T3
CLARITHROMYCIN ER 24 HR TAB
T3
clarithromycin suspension T1
clarithromycin tablet T1
clearlax powder T1
CLEMASTINE FUMARATE TABLET
T3
CLENPIQ SOLUTION T3
CLEOCIN CAPSULE T2, BP
CLEOCIN CREAM T2, BP
CLEOCIN PALMITATE SOLUTION
T2, BP
CLEOCIN SUPPOSITORY
T2
CLEOCIN-T LOTION T2, BP
CLEVER CHEK AUTOCODE
T3
CLEVER CHEK CONTROL SOLUTION LIQUID
T3
CLEVER CHOICE COMFORT EZ MISC
T2
CLEVER CHOICE HOLDING CHAMBER
T3
CLEVER CHOICE NEBULIZER MISC
T3
CLEVER CHOICE WHISPER AIRE PED MISC
T3
CLICKFINE MISC T2
CLIDINIUM W/CHLORDIAZEPOXIDE CAPSULE
T3
CLIMARA PATCH T2, BP
CLIMARA PRO PATCH T2
CLINDACIN ETZ KIT T3
clindacin etz pledgets swab
T1
CLINDACIN PAC KIT T3
clindacin-p swab T1
CLINDAGEL GEL T2
clindamycin capsule T1
clindamycin palmitate solution
T1
clindamycin pediatric solution
T1
clindamycin phosphate cream
T1
CLINDAMYCIN PHOSPHATE FOAM
T3
clindamycin phosphate gel
T1
clindamycin phosphate lotion
T1
clindamycin phosphate solution
T1
clindamycin phosphate swab
T1
clindamycin-benzoyl peroxide gel
T1
CLINDESSE CREAM T3
clobazam suspension T1
clobazam tablet T1
clobetasol cream T1
CLOBETASOL E CREAM T3
CLOBETASOL FOAM T3
clobetasol gel T1
CLOBETASOL LIQUID T3
CLOBETASOL LOTION T3
clobetasol ointment T1
clobetasol shampoo T1
clobetasol solution T1
CLOBEX LIQUID T3, BP
CLOBEX LOTION T3, BP
CLOBEX SHAMPOO T2, BP
CLOCORTOLONE PIVALATE CREAM
T3
CLODAN KIT T3
clodan shampoo T1
CLODERM CREAM T3
CLOMIPHENE TABLET T3
clomipramine capsule T1
CLONAZEPAM ODT TABLET
T3
clonazepam tablet T1
CLONIDINE 12 HR TAB T3
CLONIDINE ER 12 HR TAB
T3
clonidine patch T1
clonidine tablet T1
clopidogrel tablet T1
clorazepate dipotassium tablet
T1
clotrimazole cream T1
clotrimazole lozenge T1
clotrimazole solution T1
clotrimazole/betamethasone cream
T1
clotrimazole/betamethasone lotion
T1
CLOVIQUE CAPSULE T3, PA, SP
clozapine odt tablet T1
clozapine tablet T1
CLOZARIL TABLET T2, BP
C-NATE DHA CAPSULE T2
COAL TAR SOLUTION T3
COARTEM TABLET T2
codeine sulfate tablet T1, QL, BP
COLAZAL CAPSULE T2, BP
COLCHICINE CAPSULE T2
COLCHICINE TABLET T2
COLCRYS TABLET T2, BP
colesevelam packet T1
colesevelam tablet T1
COLESTID FLAVORED GRANULES
T2
COLESTID FLAVORED PACKET
T2
Page 8 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
-
COLESTID GRANULES T2, BP
COLESTID PACKET T2, BP
COLESTID TABLET T2, BP
colestipol granules T1
colestipol packet T1
colestipol tablet T1
COLLODION FLEXIBLE LIQUID
T3
COMBIGAN SOLUTION T3
COMBIPATCH PATCH T2
COMBIVENT RESPIMAT AEROSOL
T2
COMBIVIR TABLET T2, BP
COMETRIQ KIT T2, QL, SP, PA
COMFORT EZ MISC T2
COMFORT EZ/31G X 5MM MISC
T2
COMFORT EZ/31G X 6MM MISC
T2
COMPACT SPACE CHAMBER
T3
COMP-AIR NEBULIZER COMPRESSOR MISC
T3
COMPLERA TABLET T3
COMPLETE NATAL DHA MISC
T2
COMPLETENATE CHEW TAB
T2
compro suppository T1
COMTAN TABLET T2, BP
CONCEPT DHA CAPSULE
T2
CONCEPT OB CAPSULE T2
CONCEPTROL GEL T3
CONCERTA TABLET T2, BP
CONDYLOX GEL T2
CONJUPRI TABLET T3, PA
constulose solution T1
CONTOUR T2
CONTOUR HIGH CONTROL LIQUID
T3
CONTOUR LOW CONTROL LIQUID
T3
CONTOUR NEXT CONTROL SOLUTION
T3
CONTOUR NEXT EZ KIT T2, QL
CONTOUR NEXT EZ STRIP
T2
CONTOUR NEXT KIT T2, QL
CONTOUR NEXT LINK KIT
T2, QL
CONTOUR NEXT ONE KIT
T2, QL
CONTOUR NEXT TEST STRIP
T2
CONTOUR NORMAL CONTROL LIQUID
T3
CONTOUR STRIP T2
CONTRAVE 12 HR TAB T2, QL, PA
CONTROL SOLUTION T3
CONTROL SOLUTION NORMAL
T3
CONZIP 24 HOUR CAP T3, QL
COOL CONTROL SOLUTION A
T3
COOL CONTROL SOLUTION B
T3
COPAXONE INJECTION T2, SP, PA, BP
COPIKTRA CAPSULE T3, QL, SP, PA
CORDRAN CREAM T2, BP
CORDRAN LOTION T2, BP
CORDRAN OINTMENT T2, BP
CORDRAN TAPE T2
COREG CR 24 HOUR CAP
T3, BP
COREG TABLET T2, BP
CORGARD TABLET T2, BP
CORLANOR SOLUTION T3
CORLANOR TABLET T2
CORRECTOL TABLET T2
CORTANE-B LOTION T3
CORTEF TABLET T2, BP
CORTENEMA ENEMA T2, BP
CORTIFOAM FOAM T2
CORTISONE TABLET T2
CORTISPORIN CREAM T3
CORTISPORIN OINTMENT
T2
CORTISPORIN-TC SUSPENSION
T2
CORVITA 150 TABLET T3
CORVITE 150 TABLET T3
CORVITE FE TABLET T3
COSENTYX INJECTION T2, SP, PA
COSENTYX SENSOREADY PEN INJECTION
T2, SP, PA
COSOPT PF SOLUTION T2, BP
COSOPT SOLUTION T2, BP
COTELLIC TABLET T2, QL, SP, PA
COTEMPLA XR-ODT TABLET
T3
COVARYX HS TABLET T3
COVARYX TABLET T3
COZAAR TABLET T2, BP
CREON CAPSULE T2
CRESEMBA CAPSULE T2
CRESTOR TABLET T2, BP
CRINONE GEL T3
CRIXIVAN CAPSULE T2
cromolyn sodium T1
cromolyn sodium nebulized
T1
cromolyn sodium solution T1
crotan lotion T1
cryselle-28 tablet T1
CUPRIMINE CAPSULE T3, BP, SP
CURITY SOLUTION T2
CUROSURF SUSPENSION
T3
CUTIVATE LOTION T3, BP
CUVPOSA SOLUTION T2
cvs aspirin ec tablet T1
cvs aspirin low dose tablet T1
cvs aspirin low strength tablet
T1
cvs aspirin tablet T1
cvs bisacodyl tablet T1
cvs folic acid tablet T1
cvs gentle laxative tablet T1
CVS KETONE CARE STRIP
T3
CVS LANCING DEVICE MISC
T2
cvs magnesium solution T1
cvs nicotine lozenge T1, QL
cvs nicotine polacrilex gum
T1, QL
cvs nicotine polacrilex lozenge
T1, QL
cvs nicotine transdermal patch
T1, QL
cvs of magnesia solution T1
cvs purelax packet T1
cvs purelax powder T1
CYANOCOBALAMIN SOLUTION
T2
cyclafem 1/35 tablet T1
cyclafem 7/7/7 tablet T1
cyclobenzaprine tablet T1
CYCLOGYL SOLUTION T2, BP
CYCLOMYDRIL SOLUTION
T2
cyclopentolate solution T1
cyclophosphamide capsule
T1, BP
Page 9 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
-
CYCLOSERINE CAPSULE
T3
CYCLOSET TABLET T3
cyclosporine capsule T1
CYCLOSPORINE IN KLARITY EMULSION
T2
cyclosporine modified capsule
T1
cyclosporine modified solution
T1
CYMBALTA CAPSULE T2, BP
cyproheptadine syrup T1
cyproheptadine tablet T1
cyred eq tablet T1
cyred tablet T1
CYSTADANE POWDER T2, SP
CYSTADROPS SOLUTION
T2, QL, SP
CYSTAGON CAPSULE T3, SP
CYSTARAN SOLUTION T2, QL, SP
CYTOMEL TABLET T2, BP
CYTOTEC TABLET T2, BP
cytra k crystals packet T1
DD.H.E. 45 SOLUTION T2, QL, BP
dalfampridine er 12 hr tab T1, SP, PA
DALIRESP TABLET T3
danazol capsule T1
DANTRIUM CAPSULE T2, BP
dantrolene sodium capsule
T1
DAPSONE GEL T3
dapsone tablet T1
DAPTACEL SUSPENSION
T2
DARAPRIM TABLET T2, PA, BP, SP
darifenacin 24 hr tab T1
dasetta 1/35 tablet T1
dasetta 7/7/7 tablet T1
DAURISMO TABLET T2, QL, SP, PA
DAYPRO TABLET T2, BP
daysee tablet T1
DAYTRANA PATCH T3
DAYVIGO TABLET T3, QL, PA
DDAVP SOLUTION T2, BP
DDAVP TABLET T2, BP
DEBACTEROL SOLUTION
T3
deblitane tablet T1
decadron tablet T1
deferasirox packet T1, SP
deferasirox tablet T1, SP
DEFERIPRONE TABLET T3, QL, PA, SP
DELSTRIGO TABLET T2
DELTEC COZMO CLEO INFUSION SET MISC
T3
delyla tablet T1
DELZICOL CAPSULE (DELAYED RELEASE)
T2, BP
demeclocycline tablet T1
DEMSER CAPSULE T2, BP, SP
DENAVIR CREAM T2
DEPAKOTE ER 24 HR TAB
T2, BP
DEPAKOTE SPRINKLES CAPSULE
T2, BP
DEPAKOTE TABLET T2, BP
DEPEN TITRATABS TABLET
T2, BP, SP
DEPO-PROVERA INJECTION
T2, BP
DEPO-PROVERA SUSPENSION
T2, BP
DEPO-SUBQ PROVERA 104 INJECTION
T2
DEPO-TESTOSTERONE SOLUTION
T2, BP
DERMA-SMOOTHE/FS BODY OIL
T2, BP
DERMA-SMOOTHE/FS SCALP OIL
T2, BP
DERMAZENE CREAM T3
DERMOTIC OIL T2, BP
DESCOVY TABLET T2
desipramine tablet T1
desmopressin solution T1
desmopressin tablet T1
desogestr-eth estrad eth estra tablet
T1
DESONATE GEL T3, BP
desonide cream T1
DESONIDE GEL T3
desonide lotion T1
desonide ointment T1
DESOWEN CREAM T2, BP
DESOXIMETASONE CREAM
T3
DESOXIMETASONE GEL T3
DESOXIMETASONE LIQUID
T3
DESOXIMETASONE OINTMENT
T3
DESOXYN TABLET T2, BP
desvenlafaxine er 24 hr tab
T1
DETROL LA 24 HOUR CAP
T2, BP
DETROL TABLET T2, BP
dexamethasone elixir T1
DEXAMETHASONE INTENSOL
T2
dexamethasone sodium phosphate solution
T1
dexamethasone solution T1
dexamethasone tablet T1
DEXCHLORPHENIRAMINE MALEATE SOLUTION
T3, PA
DEXCOM G4 T3, QL, PA
DEXCOM G5 T3, QL, PA
DEXCOM G5 RECEIVER KIT
T3, QL, PA
DEXEDRINE 24 HOUR CAP
T2, BP
DEXILANT CAPSULE (DELAYED RELEASE)
T3, PA
DEXMETHYLPHENIDATE ER 24 HOUR CAP
T3
dexmethylphenidate tablet T1
DEXONTO 0.4% SOLUTION
T2
dextroamphetamine sulfate er 24 hour cap
T1
DEXTROAMPHETAMINE SULFATE SOLUTION
T3
dextroamphetamine sulfate tablet
T1
dextroamphetamine-amphet er 24 hour cap
T1
dextroamphetamine-amphetamine tablet
T1
DIACOMIT CAPSULE T2, QL, PA, SP
DIACOMIT PACKET T2, QL, PA, SP
DIASTAT ACUDIAL GEL T2
DIASTAT PEDIATRIC GEL
T2
DIASTIX STRIP T2
DIATRUE SOLUTION T3
diazepam T1
diazepam intensol T1
DIAZEPAM RECTAL T2
diazepam solution T1
diazepam tablet T1
DIAZOXIDE SUSPENSION
T2
DIBENZYLINE CAPSULE T2, BP, SP
DICLOFENAC EPOLAMINE PATCH
T3
Page 10 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
-
diclofenac potassium tablet
T1
diclofenac sodium dr tablet
T1
diclofenac sodium er 24
hr tabT1
diclofenac sodium
solution
T1
diclofenac sodium-
misoprostol tabletT1
DICLOFONO GEL T3
dicloxacillin sodium capsule
T1
dicyclomine capsule T1
dicyclomine solution T1
dicyclomine tablet T1
didanosine capsule (delayed release)
T1
DIETHYLPROPION ER 24 HR TAB
T3
DIETHYLPROPION TABLET
T3
DIFFERIN CREAM T2, BP
DIFFERIN GEL T2, BP
DIFFERIN LOTION T3
DIFICID SUSPENSION T3
DIFICID TABLET T2, PA
DIFLORASONE DIACETATE CREAM
T3
DIFLORASONE DIACETATE OINTMENT
T3
DIFLUCAN T2, BP
DIFLUCAN TABLET T2, BP
diflunisal tablet T1
digitek tablet T1
digox tablet T1
digoxin solution T1
digoxin tablet T1
DIHYDROERGOTAMINE MESYLATE SOLUTION
T2, QL
DILANTIN CAPSULE T2, BP
DILANTIN INFATABS CHEW TAB
T2, BP
DILANTIN-125 SUSPENSION
T2, BP
DILATRATE SR CAPSULE
T3
DILAUDID LIQUID T2, BP
DILAUDID TABLET T2, BP
diltiazem 24hr er (cd) 24 hour cap
T1
diltiazem 24hr er (xr) 24 hour cap
T1
diltiazem cd 24 hour cap T1
diltiazem er 24 hour cap T1
DILTIAZEM ER 24 HR TAB
T3
diltiazem er capsule T1
diltiazem tablet T1
dilt-xr 24 hour cap T1
dimethyl fumarate capsule (delayed release)
T1, QL, SP, PA
dimethyl fumarate misc T1, QL, SP, PA
DIMOXIA GEL T3
DIOVAN HCT TABLET T2, BP
DIOVAN TABLET T2, BP
DI-PHEN LIQUID T3
diphenoxylate w/atropine tablet
T1
DIPHENOXYLATE/ATROPINE LIQUID
T2
diphenoxylate/atropine tablet
T1
DIPHTHERIA-TETANUS TOXOIDS-PED SUSPENSION
T2
DIPROLENE OINTMENT T2, BP
dipyridamole tablet T1
disopyramide phosphate capsule
T1
disulfiram tablet T1
DITROPAN XL 24 HR TAB
T2, BP
DIURIL SUSPENSION T2
divalproex sodium capsule
T1
divalproex sodium dr tablet
T1
divalproex sodium er 24 hr tab
T1
DIVIGEL GEL T2
dofetilide capsule T1
DOLOPHINE TABLET T2, BP
donepezil tablet T1
DONNATAL ELIXIR T2
DONNATAL TABLET T2
DOPTELET TABLET T3, QL, PA, SP
DORAL TABLET T3
dorzolamide solution T1
dorzolamide-timolol solution
T1
dotti patch T1
DOVATO TABLET T2
DOVONEX CREAM T2, BP
doxazosin mesylate tablet T1
doxazosin tablet T1
doxepin T1
doxepin capsule T1
DOXEPIN CREAM T2
doxercalciferol capsule T1
doxycycline monohydrate capsule
T1
doxycycline monohydrate tablet
T1
doxycycline suspension T1
doxycycline tablet T1
DRAXACE SUSPENSION T3
DRCAPS SIZE 1 CLEAR CAPSULE
T3
DRISDOL CAPSULE T2, BP
DRITHO-CREME HP CREAM
T2
DRIZALMA SPRINKLE CAPSULE
T3
dronabinol capsule T1
DROPLET INSULIN SYRINGE MISC
T2
DROPLET LANCING DEVICE MISC
T2
drospirenone-eth estra-levomef tablet
T1
drospirenone-ethinyl estradiol tablet
T1
DROXIA CAPSULE T2
DRYSOL SOLUTION T2
DSUVIA SL T3, PA
DUAKLIR PRESSAIR AEROSOL
T3, QL, PA
DUAVEE TABLET T2
ducodyl tablet T1
DUET DHA 400 MISC T2
DUET DHA BALANCED MISC
T2
DUETACT TABLET T3, BP
DULERA AEROSOL T2
duloxetine capsule T1
DUOPA SUSPENSION T2, PA
DUPIXENT INJECTION T2, SP, PA, QL
DURAGESIC PATCH T2, BP
DUREZOL EMULSION T2
dutasteride capsule T1
DUTASTERIDE-TAMSULOSIN CAPSULE
T3
DUTOPROL 24 HR TAB T3
DYANAVEL XR SUSPENSION
T3
DYAZIDE CAPSULE T2, BP
DYRENIUM CAPSULE T2, BP
Page 11 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
-
EE.E.S. GRANULES SUSPENSION
T2, BP
EASIVENT MISC T3
EASIVENT/MASK-LARGE MISC
T3
EASIVENT/MASK-MEDIUM MISC
T3
EASIVENT/MASK-SMALL MISC
T3
EASY COMFORT INSULIN SYRINGE MISC
T2
EASY COMFORT MISC T2
EASY GLIDE INSULIN SYRINGE MISC
T2
EASY MINI EJECT LANCING DEVICE MISC
T2
EASY MINI LANCING DEVICE MISC
T2
EASY PLUS II SOLUTION T3
EASY STEP CONTROL SOLUTION
T3
EASY TALK SOLUTION T3
EASY TOUCH 32GX5MM MISC
T2
EASY TOUCH 32GX6MM MISC
T2
EASY TOUCH FLIPLOCK INSULIN MISC
T2
EASY TOUCH INSULIN SAFETY MISC
T2
EASY TOUCH LANCING DEVICE MISC
T2
EASY TOUCH MISC T2
EASY TOUCH SHEATHLOCK INSULIN MISC
T2
EASY TOUCH SOLUTION
T3
EASY TRAK II CONTROL SOL LIQUID
T3
EASY TRAK SOLUTION T3
EASYGLUCO KIT T2, QL
EASYGLUCO PLUS CONTROL NORMAL SOLUTION
T3
EASYGLUCO STARTER KIT
T2, QL
EASYMAX CONTROL SOLUTION
T3
EASYMAX SOLUTION T3
ECEOXIA CREAM T3
EC-NAPROSYN TABLET T2, BP
ec-naproxen tablet T1
econazole nitrate cream T1
econtra ez tablet T1
econtra one-step tablet T1
ecotrin low strength tablet T1
ECOTRIN TABLET T2
ECOZA FOAM T3
ecpirin tablet T1
EDARBI TABLET T3
EDARBYCLOR TABLET T3
EDECRIN TABLET T2, BP
EDEX KIT T2, QL
ed-spaz tablet T1
EDURANT TABLET T2
EEMT HS TABLET T3
EEMT TABLET T3
efavirenz capsule T1
efavirenz tablet T1
EFAVIRENZ-EMTRIC-TENOFOV DISOP TABLET
T3
efavirenz-lamivu-tenofov disop tablet
T1
EFFER-K TABLET (EFF) T3
EFFEXOR XR 24 HOUR CAP
T2, BP
EFFIENT TABLET T2, PA, BP
EFUDEX CREAM T2, BP
ELEMENT COMPACT CONTROL SOLN SOLUTION
T3
ELEMENT HIGH CONTROL LIQUID
T3
ELEMENT LOW CONTROL LIQUID
T3
ELEMENT NORMAL CONTROL LIQUID
T3
ELESTRIN GEL T2
eletriptan tablet T1, QL
ELIDEL CREAM T2, BP
ELIMITE CREAM T2, BP
elinest tablet T1
ELIQUIS STARTER PACK TABLET
T2
ELIQUIS TABLET T2
ELITE-OB TABLET T2
ELIXOPHYLLIN ELIXIR T2
ELLA TABLET T2
ELMIRON CAPSULE T2
eluryng T1
EMBRACE CONTROL SOLUTION
T3
EMBRACE EVO LIQUID T3
EMBRACE LIQUID T3
EMBRACE MISC T2
EMBRACE PRO LIQUID T3
EMBRACE TALK CONTROL SOLUTION
T3
EMCYT CAPSULE T3, SP
EMEND CAPSULE T2, QL, PA, BP
EMEND SUSPENSION T2, QL, PA
EMEND TRIPACK CAPSULE
T3
EMFLAZA SUSPENSION T3, PA, SP
EMFLAZA TABLET T3, PA, SP
EMGALITY INJECTION T2, QL, PA
emoquette tablet T1
EMPTY CAPSULE SIZE 1 RED
T3
EMPTY CAPSULE SIZE 3 RED
T3
EMSAM PATCH T2
emtricitabine capsule T1
emtricitabine-tenofovir disop tablet
T1
EMTRIVA CAPSULE T2, BP
EMTRIVA SOLUTION T3
EMVERM CHEW TAB T2
ENABLEX 24 HR TAB T2, BP
enalapril maleate tablet T1
enalapril maleate/hctz tablet
T1
ENBRACE HR CAPSULE T2
ENBREL INJECTION T2, SP, PA
ENBREL MINI INJECTION
T2, SP, PA
ENBREL SOLUTION T2, SP, PA
ENBREL SURECLICK INJECTION
T2, SP, PA
ENDARI PACKET T2, QL, PA, SP
endocet tablet T1
ENDOMETRIN T3
ENGERIX-B SUSPENSION
T2
ENLITE MISC T3
ENLITE SERTER MISC T3
ENOXAPARIN SODIUM SOLUTION
T2
enpresse-28 tablet T1
enskyce tablet T1
ENSPRYNG INJECTION T3, SP, PA
ENSTILAR FOAM T3
entacapone tablet T1
entecavir tablet T1, SP
Page 12 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
-
ENTEREG CAPSULE T2, BP, SP
ENTOCORT EC CAPSULE
T2, BP
ENTRESTO TABLET T2, QL
enulose solution T1
ENVARSUS XR 24 HR TAB
T2, PA
EPANED SOLUTION T2
EPCLUSA TABLET T2, QL, SP, PA
EPIDIOLEX SOLUTION T2, SP, PA
EPIFOAM FOAM T2
EPINASTINE SOLUTION T3
epinephrine chloride solution
T1
EPINEPHRINE INJECTION
T2, QL
epitol tablet T1
EPIVIR HBV SOLUTION T2, SP
EPIVIR HBV TABLET T2, BP, SP
EPIVIR SOLUTION T2, BP
EPIVIR TABLET T2, BP
eplerenone tablet T1
EPOGEN SOLUTION T2, SP
EPZICOM TABLET T2, BP
eq aspirin low dose chew tab
T1
eq aspirin tablet T1
eq childrens aspirin chew tab
T1
eq clearlax powder T1
eq gentle laxative tablet T1
eq magnesium solution T1
eq nicotine lozenge T1, QL
eq nicotine lozenges T1, QL
eq nicotine patch T1, QL
eq nicotine polacrilex gum T1, QL
eq nicotine polacrilex lozenge
T1, QL
eq nicotine step 3 patch T1, QL
eql aspirin ec tablet T1
eql aspirin low dose chew tab
T1
eql aspirin low dose tablet T1
eql clearlax powder T1
eql gentle laxative tablet T1
eql magnesium solution T1
eql nicotine polacrilex gum
T1, QL
eql nicotine polacrilex lozenge
T1, QL
EQUACARE JR POWDER
T2, PA
EQUETRO CAPSULE T2
ERAPID NEBULIZER MISC
T3
ERGOCAL CAPSULE T2
ergoloid mesylates tablet T1
ERGOMAR SL T2
ergotamine-caffeine tablet T1
ERIVEDGE CAPSULE T2, QL, SP, PA
ERLEADA TABLET T2, QL, SP, PA
erlotinib tablet T1, QL, SP, PA
errin tablet T1
ERTACZO CREAM T3
ery pads T1
ERYGEL GEL T2, BP
ERYPED 200 SUSPENSION
T2, BP
ERYPED 400 SUSPENSION
T2, BP
ery-tab tablet T1
ERYTHROCIN STEARATE TABLET
T2
erythromycin base tablet T1
erythromycin capsule T1
erythromycin dr tablet T1
erythromycin ethylsuccinate suspension
T1
ERYTHROMYCIN ETHYLSUCCINATE TABLET
T2
erythromycin gel T1
erythromycin ointment T1
erythromycin solution T1
erythromycin-benzoyl peroxide gel
T1
ESBRIET CAPSULE T2, QL, SP, PA
ESBRIET TABLET T2, QL, SP, PA
escitalopram oxalate solution
T1
escitalopram oxalate tablet
T1
ESGIC CAPSULE T3
ESGIC TABLET T2, BP
ESPUMIL FOAM T3
ESSENTIAL CARE JR POWDER
T2, PA
estarylla tablet T1
estazolam tablet T1
ESTRACE CREAM T2, BP
ESTRACE TABLET T2, BP
estradiol cream T1
estradiol patch T1
estradiol tablet T1
estradiol-norethindrone acetat tablet
T1
ESTRING T2
ESTROGEL GEL T2
ESTROGEN & METHYLTESTOSTERONE TABLET
T3
ESTROSTEP FE TABLET T2, BP
eszopiclone tablet T1
ethacrynic acid tablet T1
ethambutol tablet T1
ethosuximide capsule T1
ethosuximide solution T1
ETHOXIA CREAM T3
ETHYL CHLORIDE AEROSOL
T3
ETHYL CHLORIDE/MIST AEROSOL
T3
ethynodiol-ethinyl estradiol tablet
T1
etodolac capsule T1
etodolac er 24 hr tab T1
etodolac tablet T1
etonogestrelethinyl estradiol
T1
ETOPOSIDE CAPSULE T2, SP
EUCRISA OINTMENT T2, PA
euthyrox tablet T1
EVAMIST SOLUTION T3
EVEKEO ODT TABLET T3
EVEKEO TABLET T3, BP
EVENCARE G2 SOLUTION
T3
EVENCARE G3 SOLUTION
T3
everolimus tablet T1, SP, PA, QL
EVISTA TABLET T2, BP
EVOCLIN FOAM T3, BP
EVOLUTION CONTROL SOLUTION
T3
EVOTAZ TABLET T2
EVOXAC CAPSULE T3, BP
EVRYSDI SOLUTION T2, QL, PA, SP
EXELDERM CREAM T3
EXELDERM SOLUTION T3
EXELON PATCH T2, BP
exemestane tablet T1
EXFORGE HCT TABLET T3, BP
EXFORGE TABLET T3, BP
EXJADE TABLET T2, SP, BP
EXODERM LOTION T3
Page 13 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
-
EXTAVIA KIT T2, SP
EXTINA FOAM T3, BP
EYSUVIS SUSPENSION T3, QL, PA
EZALLOR SPRINKLE CAPSULE
T3, PA
ezetimibe tablet T1
ezetimibe/simvastatin tablet
T1
EZ-LETS MISC T2
FFA-8 CAPSULE T3
FABB TABLET T3
FABIOR FOAM T3
falmina tablet T1
famciclovir tablet T1
famotidine suspension T1
famotidine tablet T1
FANAPT TABLET T3
FANAPT TITRATION PACK TABLET
T3
FARESTON TABLET T3, PA, BP
FARXIGA TABLET T2, PA
FARYDAK CAPSULE T2, QL, SP, PA
fayosim tablet T1
febuxostat tablet T1
felbamate suspension T1
felbamate tablet T1
FELBATOL SUSPENSION
T2, BP
FELBATOL TABLET T2, BP
FELDENE CAPSULE T3, BP
felodipine er 24 hr tab T1
FEM PH GEL T3
FEMARA TABLET T2, BP
FEMCAP T3
FEMHRT LOW DOSE TABLET
T2, BP
FEMRING T3
femynor tablet T1
fenofibrate capsule T1
fenofibrate micronized capsule
T1
fenofibrate tablet T1
FENOFIBRIC ACID DR CAPSULE (DELAYED RELEASE)
T3
FENOGLIDE TABLET T3, BP
FENOPROFEN CALCIUM CAPSULE
T3
FENOPROFEN CALCIUM TABLET
T3
FENORTHO CAPSULE T3
FENTANYL LOLLIPOP T3
fentanyl patch T1
FENTANYL TABLET T2
FENTORA TABLET T2
FERIVA 21/7 TABLET T3
FEROCON CAPSULE T3
FERRALET 90 TABLET T3
FERRAPLUS 90 TABLET T3
FERRIPROX SOLUTION T3, SP
FERRIPROX TABLET T3, QL, PA, SP
FERRIPROX TWICE-A-DAY TABLET
T3, SP
FERROCITE PLUS TABLET
T3
FETZIMA 24 HOUR CAP T3
FETZIMA TITRATION PACK CAPSULE
T3
FIASP FLEXTOUCH INJECTION
T2
FIASP PENFILL INJECTION
T2
FIASP SOLUTION T2
FIFTY50 SUPERIOR COMFORT MISC
T2
FILTER; MILLEX-FG 0.2UM MISC
T3
FINACEA FOAM T3
FINACEA GEL T2, BP
finasteride tablet T1
FINE 30 MISC T2
FINTEPLA SOLUTION T3, PA, SP
FIORICET CAPSULE T2, BP
FIORICET/CODEINE CAPSULE
T3
FIRAZYR SOLUTION T2, QL, SP, PA, BP
FIRDAPSE TABLET T2, QL, SP, PA
FIRST-LANSOPRAZOLE SUSPENSION
T2
FIRST-MOUTHWASH BLM SUSPENSION
T2
FIRST-OMEPRAZOLE SUSPENSION
T2
FIRST-PROGESTERONE VGS SUPPOSITORY
T2
FIRVANQ SOLUTION T2
FLAC OIL T3
FLAGYL CAPSULE T2, BP
FLAGYL TABLET T2, BP
FLAREX SUSPENSION T3
FLAVOR BLEND SUSPENSION
T3
FLAVOR PLUS LIQUID T3
FLAVOR SWEET SYRUP T3
FLAVOR SWEET-SF SYRUP
T3
FLAVOXATE TABLET T3
flecainide tablet T1
FLEXICHAMBER T3
FLEXICHAMBER MISC T3
FLOLIPID SUSPENSION T3
FLOMAX CAPSULE T2, BP
FLOVENT DISKUS AEROSOL
T2
FLOVENT HFA AEROSOL
T2
FLUAD 2020-2021 INJECTION
T2
FLUAD QUAD 2020-2021 INJECTION
T2
FLUARIX INJECTION T2
FLUBLOK QUAD 2020-2021 INJECTION
T2
FLUCELVAX QUAD 2020-2021 INJECTION
T2
FLUCELVAX QUAD 2020-2021 SUSPENSION
T2
fluconazole suspension T1
fluconazole tablet T1
flucytosine capsule T1, PA
fludrocortisone tablet T1
FLULAVAL INJECTION T2
FLUMIST QUADRIVALENT SUSPENSION
T2
FLUNISOLIDE SOLUTION
T2
fluocinolone acetonide cream
T1
fluocinolone acetonide oil T1
fluocinolone acetonide oil T1
fluocinolone acetonide ointment
T1
fluocinolone acetonide solution
T1
fluocinonide cream T1
fluocinonide emulsified cream
T1
fluocinonide gel T1
fluocinonide ointment T1
fluocinonide solution T1
fluocinonide-e cream T1
FLUORABON SOLUTION T2
Page 14 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
-
fluoritab chew tab T1
fluorometholone suspension
T1
FLUOROPLEX CREAM T2
fluorouracil cream T1
fluorouracil solution T1
fluoxetine capsule T1
FLUOXETINE DR CAPSULE (DELAYED RELEASE)
T3
fluoxetine solution T1
fluoxetine tablet T1, BP
FLUPHENAZINE T2
FLUPHENAZINE ELIXIR T2
fluphenazine tablet T1
flurandrenolide cream T1
flurandrenolide lotion T1
flurandrenolide ointment T1
FLURAZEPAM CAPSULE T3
FLURBIPROFEN SODIUM SOLUTION
T3
flurbiprofen tablet T1
flutamide capsule T1
fluticasone cream T1
FLUTICASONE LOTION T3
fluticasone ointment T1
FLUTICASONE-SALMETEROL AEROSOL
T2
FLUVASTATIN CAPSULE T3
FLUVASTATIN SODIUM ER 24 HR TAB
T3
FLUVOXAMINE MALEATE ER 24 HOUR CAP
T3
fluvoxamine maleate tablet
T1
FLUZONE HIGH-DOSE QUAD 2020-21 INJECTION
T2
FLUZONE QUAD 2020-2021 INJECTION
T2
FLUZONE QUAD 2020-2021 SUSPENSION
T2
FLYP NEBULIZER MISC T3
FML FORTE SUSPENSION
T2
FML LIQUIFILM SUSPENSION
T2
FML OINTMENT T2
FOCALIN TABLET T2, BP
FOCALIN XR 24 HOUR CAP
T3, BP
folate tablet T1
folbee tablet T1
FOLGARD RX TABLET T3
FOLIC ACID CAPSULE T3
folic acid tablet T1
FOLIC ACID-CYANCOBAL-PYRIDOXIN TABLET
T3
FOLIVANE-F CAPSULE T3
FOLIVANE-OB CAPSULE T2
FOLIVANE-PLUS CAPSULE
T3
FOLPLEX 2.2 TABLET T3
FONDAPARINUX SODIUM SOLUTION
T3
FOOD COLOR BLUE LIQUID
T3
FORA CONTROL SOLUTION
T3
FORA D10 T3
FORA D15 T3
FORA D20 T3
FORA D40 T3
FORA GTEL KETONE TEST STRIP
T2
FORA LANCING DEVICE MISC
T2
FORA V10-V12-D10-D20 KIT
T2, QL
FORACARE SOLUTION T3
FORANE SOLUTION T3, BP
FORFIVO XL 24 HR TAB T3
FORMALDEHYDE SOLUTION
T2
FORTEO INJECTION T2, QL, SP, PA
FORTESTA GEL T3, BP
FORTISCARE SOLUTION T3
FOSAMAX PLUS D TABLET
T3
FOSAMAX TABLET T2, BP
fosamprenavir calcium tablet
T1
fosfomycin tromethamine packet
T1, QL
fosinopril sodium tablet T1
FOSINOPRIL-HYDROCHLOROTHIAZIDE TABLET
T3
FOSRENOL CHEW TAB T2, BP
FOSRENOL PACKET T3
FRAGMIN SOLUTION T3
FREESTYLE CONTROL SOLUTION LIQUID
T3
FREESTYLE FLASH SYSTEM KIT
T2, QL
FREESTYLE LIBRE READER
T2, QL, PA
FREESTYLE LIBRE SENSOR MISC
T2, QL, PA
FREESTYLE PRECISION MISC
T2
FREESTYLE PRECISION NEO STRIP
T2, PA
FREESTYLE SYSTEM KIT
T2, QL
FREESTYLE UNISTIK 2 MISC
T2
FROVA TABLET T3, BP
FROVATRIPTAN TABLET T3
furosemide solution T1
furosemide tablet T1
FUSION PLUS CAPSULE T3
FUZEON SOLUTION T2, SP
fyavolv tablet T1
FYCOMPA SUSPENSION T2, PA
FYCOMPA TABLET T2, PA
Ggabapentin capsule T1
gabapentin solution T1
gabapentin tablet T1
GABITRIL TABLET T2, BP
GALAFOLD CAPSULE T2, QL, PA, SP
galantamine 24 hour cap T1
GALANTAMINE SOLUTION
T2
galantamine tablet T1
GALZIN CAPSULE T2
GARDASIL 9 INJECTION T2
GARDASIL 9 SUSPENSION
T2
GASTROCROM T2, BP
gatifloxacin solution T1
GATTEX KIT T3, PA, SP
gavilax powder T1
gavilyte-c solution T1
gavilyte-g solution T1
GAVILYTE-H KIT T3
gavilyte-n/flavor pack solution
T1
GAVRETO CAPSULE T2, QL, SP, PA
GE100 CONTROL SOLUTION NORMAL
T3
GELFILM OP FILM T3
GELNIQUE GEL T3
gemfibrozil tablet T1
gemmily capsule T1
GENADUR LIQUID T3
Page 15 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
-
GENERESS FE CHEW TAB
T2, BP
generlac solution T1
gengraf capsule T1
gengraf solution T1
GENOTROPIN MINIQUICK SOLUTION
T2, SP, PA
GENOTROPIN SOLUTION
T2, SP, PA
gentak ointment T1
gentamicin sulfate cream T1
gentamicin sulfate ointment
T1
gentamicin sulfate solution
T1
GENTEEL VACUUM LANCING DEVICE KIT
T2
GENTEEL VACUUM LANCING DEVICE MISC
T2
gentle laxative tablet T1
gentlelax powder T1
GENVOYA TABLET T2
GEODON CAPSULE T2, BP
gianvi tablet T1
GILENYA CAPSULE T2, QL, SP, PA
GILOTRIF TABLET T2, QL, SP, PA
GILPHEX TR TABLET T3
GIMOTI SOLUTION T3, QL, PA
GLATIRAMER INJECTION
T2, SP
GLATOPA INJECTION T2, SP
GLEEVEC TABLET T2, QL, SP, PA, BP
GLEOSTINE CAPSULE T2, QL, SP
glimepiride tablet T1
glipizide er 24 hr tab T1
glipizide tablet T1
glipizide xl 24 hr tab T1
GLIPIZIDE-METFORMIN TABLET
T3
GLOBAL LANCING DEVICE MISC
T2
GLOPERBA SOLUTION T3
GLUCAGEN HYPOKIT SOLUTION
T2, QL
GLUCAGON EMERGENCY KIT
T2, QL
GLUCOCARD 01 CONTROL LIQUID
T3
GLUCOCARD 01 CONTROL SOLUTION
T3
GLUCOCARD EXPRESSION SOLUTION
T3
GLUCOCARD SHINE SOLUTION
T3
GLUCOCOM AUTOLINK MISC
T2
GLUCOCOM HIGH CONTROL LIQUID
T3
GLUCOCOM NORMAL CONTROL LIQUID
T3
GLUCOSE CONTROL LIQUID
T3
GLUCOSE CONTROL NORMAL SOLUTION
T3
GLUCOSE CONTROL SOLUTION
T3
GLUCOSE CONTROL SOLUTION LIQUID
T3
GLUCOTROL TABLET T2, BP
GLUCOTROL XL 24 HR TAB
T2, BP
GLUTARALDEHYDE SOLUTION
T3
glyburide micronized tablet
T1
glyburide tablet T1
glyburide-metformin tablet T1
GLYCINE SOLUTION T2
glycolax powder T1
GLYCOLIC ACID SOLUTION
T3
glycopyrrolate tablet T1
glydo injection T1
GLYNASE TABLET T2, BP
GLYXAMBI TABLET T3, PA
gnp aspirin low dose tablet
T1
gnp aspirin tablet T1
gnp bisa-lax tablet T1
gnp clearlax packet T1
gnp clearlax powder T1
gnp folic acid tablet T1
gnp gentle laxative tablet T1
gnp laxative tablet T1
gnp magnesium solution T1
gnp nicotine gum T1, QL
gnp nicotine polacrilex gum
T1, QL
gnp nicotine polacrilex lozenge
T1, QL
gnp nicotine transdermal patch
T1, QL
GOJJI BLOOD KETONE TEST STRIP
T2
GOJJI GLUCOSE CONTROL SOLUTION
T3
GOJJI LANCING DEVICE MISC
T2
GOLYTELY SOLUTION T2, BP
GONITRO PACKET T3
goodsense aspirin chew tab
T1
goodsense aspirin tablet T1
goodsense bisacodyl ec tablet
T1
goodsense clearlax powder
T1
GOODSENSE LANCING DEVICE MISC
T2
goodsense nicotine gum T1, QL
goodsense nicotine lozenge
T1, QL
GORDOFILM SOLUTION T3
GRALISE TABLET T3
granisetron tablet T1
GRANIX SOLUTION T3, SP
GRASTEK SL T2, PA
griseofulvin microsize suspension
T1
griseofulvin microsize tablet
T1
griseofulvin ultramicrosize tablet
T1
GUANFACINE 24 HR TAB
T3
GUANFACINE ER 24 HR TAB
T3
guanfacine tablet T1
GUANIDINE TABLET T2
GUARDIAN CONNECT TRANSMITTER MISC
T3, PA
GUARDIAN LINK 3 MISC T3, PA
GUARDIAN RT CHARGER MISC
T3, PA
GUARDIAN SENSOR (3) MISC
T3, QL, PA
GUARDIAN TEST PLUG MISC
T3, PA
GVOKE HYPOPEN 1-PACK INJECTION
T2, QL
GVOKE HYPOPEN 2-PACK INJECTION
T2, QL
GVOKE PFS INJECTION T2, QL
GYNAZOLE-1 CREAM T2
HHAEGARDA SOLUTION T2, QL, PA, SP
hailey 1.5/30 tablet T1
hailey 24 fe tablet T1
hailey fe 1.5/30 tablet T1
Page 16 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
-
hailey fe 1/20 tablet T1
HALCINONIDE CREAM T3
HALCION TABLET T3, BP
HALOBETASOL CREAM T3, PA
HALOBETASOL FOAM T3, QL, PA
HALOBETASOL OINTMENT
T3, PA
HALOG CREAM T3, BP
HALOG OINTMENT T3
HALOG SOLUTION T3
haloperidol T1
haloperidol tablet T1
HARVONI PACKET T3, QL, SP, PA
HARVONI TABLET T2, QL, SP, PA
HAVRIX SUSPENSION T2
hc pramoxine cream T1
HEALTHWISE INSULIN SYRINGE MISC
T2
HEALTHY ACCENTS AUTOLET MISC
T2
HEALTHY ACCENTS UNIFINE PENTIP MISC
T2
healthylax packet T1
heather tablet T1
H-E-B IN CONTROL UNIFINE MISC
T2
H-E-B INCONTROL ADVANCED MISC
T2
HEMANGEOL SOLUTION T3, SP
HEMATINIC PLUS TABLET
T3
HEMATINIC/FOLIC ACID TABLET
T3
hemmorex-hc suppository T1
HEMOCYTE PLUS CAPSULE
T3
HEMOCYTE-F TABLET T3
HEPARIN SODIUM INJECTION
T3, PA
HEPARIN SODIUM SOLUTION
T2
HEPLISAV-B INJECTION T2
HEPSERA TABLET T2, BP, SP
HETLIOZ CAPSULE T3, QL, PA, SP
HIBERIX SOLUTION T2
HIPREX TABLET T2, BP
hm adult aspirin tablet T1
hm aspirin chew tab T1
hm aspirin ec low dose tablet
T1
hm aspirin ec tablet T1
hm aspirin tablet T1
hm clearlax powder T1
hm folic acid tablet T1
hm laxative tablet T1
hm magnesium solution T1
hm nicotine polacrilex gum
T1, QL
hm nicotine polacrilex lozenge
T1, QL
homatropaire solution T1
HORIZANT TABLET T2, PA
HUMALOG INJECTION T2, PA
HUMALOG KWIKPEN INJECTION
T2, PA
HUMALOG MIX 50/50 SUSPENSION
T2, PA
HUMALOG MIX 50-50 SUSPENSION
T2, PA
HUMALOG MIX 75/25 SUSPENSION
T2, PA
HUMATROPE COMBO PACK SOLUTION
T2, SP, PA
HUMATROPE SOLUTION T2, SP, PA
HUMIRA INJECTION T2, SP, PA
HUMIRA PEDIATRIC INJECTION
T2, SP, PA
HUMIRA PEN INJECTION T2, SP, PA
HUMIRA PEN-PS/UV STARTER INJECTION
T2, SP, PA
HUMULIN 70/30 KWIKPEN SUSPENSION
T2, PA
HUMULIN 70/30 SUSPENSION
T2, PA
HUMULIN N KWIKPEN SUSPENSION
T2
HUMULIN N SUSPENSION
T2, PA
HUMULIN R SOLUTION T2, PA
HUMULIN R U-500 KWIKPEN INJECTION
T2, PA
HYCAMTIN CAPSULE T2, QL, SP, PA
HYCLODEX SOLUTION T3
HYCODAN SYRUP T3
hydralazine tablet T1
HYDREA CAPSULE T2, BP
HYDRO 40 FOAM T3
hydrochlorothiazide capsule
T1
hydrochlorothiazide tablet T1
HYDROCODONE BITARTRATE CAPSULE
T3, QL
hydrocodone w/acetaminophen solution
T1
hydrocodone w/acetaminophen tablet
T1
HYDROCODONE/HOMATROPINE SYRUP
T3
hydrocodone/homatropine tablet
T1
hydrocodone/ibuprofen tablet
T1
HYDROCODONE-CHLORPHENIRAMINE SUSPENSION
T3
HYDROCORTISONE BUTYRATE CREAM
T3
HYDROCORTISONE BUTYRATE LOTION
T3
HYDROCORTISONE BUTYRATE OINTMENT
T3
HYDROCORTISONE BUTYRATE SOLUTION
T3
hydrocortisone cream T1
hydrocortisone enema T1
hydrocortisone lotion T1
hydrocortisone ointment T1
hydrocortisone suppository
T1
hydrocortisone tablet T1
hydrocortisone valerate cream
T1
hydrocortisone valerate ointment
T1
HYDROCORTISONE W/IODOQUINOL CREAM
T3
HYDROGEL GEL T3
HYDROGEN PEROXIDE SOLUTION
T3
HYDROMET SYRUP T3
HYDROMORPHONE ER 24 HR TAB
T3
hydromorphone liquid T1
HYDROMORPHONE SUPPOSITORY
T2
hydromorphone tablet T1
HYDROQUINONE CREAM
T3
hydroxychloroquine sulfate tablet
T1
hydroxyurea capsule T1
hydroxyzine pamoate capsule
T1
hydroxyzine syrup T1
hydroxyzine tablet T1
hyoscyamine sulfate elixir T1
hyoscyamine sulfate er 12 hr tab
T1
hyoscyamine sulfate odt tablet
T1
hyoscyamine sulfate sl T1
Page 17 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
-
hyoscyamine sulfate solution
T1
hyoscyamine sulfate sr 12 hr tab
T1
hyoscyamine sulfate tablet
T1
hyosyne elixir T1
hyosyne solution T1
HYPERSAL NEBULIZED T2
HYPOLANCE KIT T2
HYSINGLA ER 24 HR TAB
T3
HYZAAR TABLET T2, BP
Iibandronate sodium tablet T1
IBRANCE CAPSULE T2, QL, SP, PA
IBRANCE TABLET T2, SP, PA
ibu tablet T1
ibuprofen suspension T1
ibuprofen tablet T1
ICAR-C PLUS TABLET T3
ICATIBANT SOLUTION T2, QL, SP, PA
ICLUSIG TABLET T2, QL, SP, PA
ICOSAPENT ETHYL CAPSULE
T3
ID NOW COVID-19 KIT T3
IDHIFA TABLET T2, QL, SP, PA
IFEREX 150 FORTE CAPSULE
T3
ILEVRO SUSPENSION T3
imatinib mesylate tablet T1, QL, SP, PA
IMBRUVICA CAPSULE T2, QL, PA, SP
IMBRUVICA TABLET T2, QL, PA, SP
imipramine pamoate capsule
T1
imipramine tablet T1
imiquimod cream T1
IMITREX SOLUTION T2, QL, BP
IMITREX STATDOSE REFILL INJECTION
T2, QL, BP
IMITREX STATDOSE SYSTEM INJECTION
T2, QL, BP
IMITREX TABLET T2, QL, BP
IMPAVIDO CAPSULE T3, PA
IMPOYZ CREAM T2
IMURAN TABLET T2, BP
IMVEXXY MAINTENANCE PACK
T3
IMVEXXY STARTER PACK
T3
INBRIJA CAPSULE T2, QL, PA, SP
incassia tablet T1
INCRELEX SOLUTION T3, SP, PA
INCRUSE ELLIPTA AEROSOL
T2
indapamide tablet T1
INDERAL LA 24 HOUR CAP
T2, BP
INDERAL XL 24 HOUR CAP
T3
INDOCIN SUPPOSITORY T2
INDOCIN SUSPENSION T2
indomethacin capsule T1
indomethacin er capsule T1
INFANRIX SUSPENSION T2
INFASURF T3
INFINITY CONTROL SOLUTION
T3
INFINITY VOICE LEVEL 2 LIQUID
T3
INGREZZA CAPSULE T3, PA, SP
INLYTA TABLET T2, QL, SP, PA
INNOPRAN XL 24 HOUR CAP
T3
INNOSPIRE ELEGANCE MISC
T3
INNOSPIRE ESSENCE MISC
T3
INNOSPIRE MINI MISC T3
INOVA 4-1 KIT T3
INOVA 8-2 KIT T3
INOVA KIT T3
INPEN 100/BLUE/NOVO T2
INPEN 100/GRAY/LILLY T2
INPEN 100/GREY/NOVO T2
INPEN 100/PINK/LILLY T2
INPEN 100/PINK/NOVO T2
INQOVI TABLET T2, QL, SP, PA
INREBIC CAPSULE T2, QL, SP, PA
INSPIRACHAMBER T3
INSPIRACHAMBER/LARGE
T3
INSPRA TABLET T2, BP
INSUFLON 25G X 0.71" MISC
T3
INSULIN ASPART FLEXPEN INJECTION
T2
INSULIN ASPART PENFILL INJECTION
T2
INSULIN ASPART PROT-INSULN ASP SUSPENSION
T2
INSULIN ASPART SOLUTION
T2
INSULIN CARTRIDGE 3ML MISC
T3
INSULIN LISPRO JUNIOR KWIKPEN INJECTION
T2, PA
INSULIN LISPRO KWIKPEN INJECTION
T2, PA
INSULIN LISPRO PROTAMINE MIX SUSPENSION
T2, PA
INSULIN LISPRO SOLUTION
T2, PA
INSULIN- SYRINGE MISC T2
INSUPEN 29G X 12MM MISC
T2
INSUPEN 31G X 5MM MISC
T2
INSUPEN 31G X 8MM MISC
T2
INSUPEN 32G X 4MM MISC
T2
INSUPEN 33GX4MM MISC
T2
INSUPEN MISC T2
INSUPEN ULTRAFIN 30GX8MM MISC
T2
INSUPEN ULTRAFIN 31GX6MM MISC
T2
INSUPEN ULTRAFIN 31GX8MM MISC
T2
INTEGRA F CAPSULE T3
INTEGRA PLUS CAPSULE
T3
INTELENCE TABLET T2
INTRAROSA T2
INTRON A SOLUTION T2, SP
introvale tablet T1
INTUNIV 24 HR TAB T3, BP
INVEGA 24 HR TAB T3, BP
INVELTYS SUSPENSION T3
INVIRASE TABLET T2
INVOKAMET TABLET T2, PA
INVOKAMET XR 24 HR TAB
T2, PA
INVOKANA TABLET T2, PA
IODINE STRONG SOLUTION
T3
IODOFLEX PADS T3
IODOSORB GEL T3
IOPIDINE SOLUTION T2
IPOL INACTIVATED IPV INJECTION
T2
I-PORT ADVANCE 6MM MISC
T3
I-PORT ADVANCE 9MM MISC
T3
Page 18 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
-
ipratropium bromide solution
T1
ipratropium-albuterol solution
T1
IRBESARTAN TABLET T3
IRBESARTAN-HYDROCHLOROTHIAZIDE TABLET
T3
IRESSA TABLET T2, QL, SP, PA
IROSPAN 24/6 MISC T3
ISENTRESS CHEW TAB T2
ISENTRESS HD TABLET T2
ISENTRESS PACKET T2
ISENTRESS TABLET T2
isibloom tablet T1
ISOFLURANE SOLUTION T3
ISONIAZID SYRUP T2
isoniazid tablet T1
ISOPROPANOL SOLUTION
T3
ISOPROPYL ALCOHOL SOLUTION
T3
ISOPTO ATROPINE SOLUTION
T2
ISOPTO CARPINE SOLUTION
T2, BP
ISORDIL TITRADOSE TABLET
T2, BP
isosorbide dinitrate tablet T1
isosorbide mononitrate 24 hr tab
T1
isosorbide mononitrate tablet
T1
isotretinoin capsule T1
ISOXSUPRINE TABLET T3
isradipine capsule T1
ISTALOL SOLUTION T2
ISTURISA TABLET T3, QL, PA, SP
ITHOXIA CREAM T3
itraconazole capsule T1
itraconazole solution T1
IV ADMINISTRATION SET MISC
T3
IV CATHETER MISC T3
ivermectin lotion T1
ivermectin tablet T1
JJADENU SPRINKLE PACKET
T2, SP, BP
JADENU TABLET T2, SP, BP
jaimiess tablet T1
JAKAFI TABLET T2, QL, SP, PA
JALYN CAPSULE T3, BP
jantoven tablet T1
JANUMET TABLET T2
JANUMET XR 24 HR TAB T2
JANUVIA TABLET T2
JARDIANCE TABLET T2, PA
jasmiel tablet T1
JATENZO CAPSULE T3, PA
jencycla tablet T1
JENTADUETO TABLET T3, PA
JENTADUETO XR 24 HR TAB
T3, PA
jinteli tablet T1
jolessa tablet T1
JORNAY PM 24 HOUR CAP
T3
JUBLIA SOLUTION T3
juleber tablet T1
JULUCA TABLET T2
junel 1.5/30 tablet T1
junel 1/20 tablet T1
junel fe 1.5/30 tablet T1
junel fe 1/20 tablet T1
junel fe 24 tablet T1
JUXTAPID CAPSULE T3, PA, SP
JYNARQUE TABLET T2, QL, PA, SP
Kkaitlib fe chew tab T1
KALETRA SOLUTION T2, BP
KALETRA TABLET T2
kalliga tablet T1
KALYDECO PACKET T2, SP, PA
KALYDECO TABLET T2, SP, PA
KAPSPARGO SPRINKLE CAPSULE
T3
KAPVAY 12 HR TAB T3
KARBINAL ER SUSPENSION
T3
kariva tablet T1
KATERZIA SUSPENSION T2
KAXM EMULSION T3
KAZANO TABLET T3, PA
KEFLEX CAPSULE T2, BP
kelnor 1/35 tablet T1
kelnor 1/50 tablet T1
KENALOG AEROSOL T2, BP
KEPPRA SOLUTION T2, BP
KEPPRA TABLET T2, BP
KEPPRA XR 24 HR TAB
KERALYT GEL
KERYDIN SOLUTION
KESIMPTA INJECTION
ketoconazole cream
T2, BP
T2
T3, BP
T2, QL, SP T1
KETOCONAZOLE FOAM T3
ketoconazole shampoo T1
ketoconazole tablet T1
KETONE STRIP T2
KETONE TEST STRIPS T2
KETOPROFEN CAPSULE T3
KETOPROFEN ER 24 HOUR CAP
T3
ketorolac tromethamine solution
T1, QL, PA, SP
KETOROLAC TROMETHAMINE TABLET
T3
KETOSTIX STRIP T2
KEVEYIS TABLET T3, PA, SP
KEVZARA INJECTION T2, SP, PA
KINERET INJECTION T2, PA, SP
KINRIX SUSPENSION T3
kionex suspension T1
KISQALI FEMARA 200 DOSE TABLET
T3, PA, SP
KISQALI FEMARA 400 DOSE TABLET
T3, PA, SP
KISQALI FEMARA 600 DOSE TABLET
T3, PA, SP
KISQALI TABLET T2, QL, SP, PA
KITABIS PAK NEBULIZED
T2, PA, SP
KLARITY-A SOLUTION T3
KLARON LOTION T2, BP
KLONOPIN TABLET T2, BP
klor-con 10 tablet T1
klor-con 8 tablet T1
klor-con m10 tablet T1
KLOR-CON M15 TABLET T2
klor-con m20 tablet T1
klor-con packet T1
KLOR-CON/EF TABLET (EFF)
T3
kls aspirin ec tablet T1
kls aspirin low dose tablet T1
kls laxaclear powder T1
kls quit2 gum T1, QL
kls quit2 lozenge T1, QL
kls quit4 gum T1, QL
Page 19 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
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kls quit4 lozenge T1, QL
KOMBIGLYZE XR 24 HR TAB
T3, PA
KORLYM TABLET T3, SP
KOSELUGO CAPSULE T2, QL, SP, PA
KOSHER PRENATAL PLUS IRON TABLET
T2
kp aspirin tablet T1
kp bisacodyl tablet T1
kp folic acid tablet T1
K-PHOS NEUTRAL TABLET
T2
K-PHOS NO 2 TABLET T3
KRINTAFEL TABLET T3
KRISGEL 100 GEL T3
KRISTALOSE PACKET T2
KROGER HEALTHPRO GLUCOSE LIQUID
T3
KROGER LANCING DEVICE MISC
T2
K-TAB TABLET T2
kurvelo tablet T1
KUVAN PACKET T2, PA, BP, SP
KUVAN TABLET T2, PA, BP, SP
KYLEENA T2, PA
KYNMOBI FILM T3, QL, PA, SP
LL.E.T. GEL T3
labetalol tablet T1
LACRISERT T3
LACTATED RINGERS SOLUTION
T2
lactulose solution T1
LAMICTAL CHEW TAB T2, BP
LAMICTAL KIT T3, BP
LAMICTAL ODT KIT T3, QL, BP
LAMICTAL ODT TABLET T3, BP
LAMICTAL TABLET T2, BP
LAMICTAL XR 24 HR TAB
T3, BP
LAMICTAL XR KIT T3
lamivudine solution T1
lamivudine tablet T1, SP
lamivudine/zidovudine tablet
T1
LAMOTRIGINE (BLUE) KIT
T3
LAMOTRIGINE (GREEN) KIT
T3
LAMOTRIGINE (ORANGE) KIT
T3
lamotrigine chew tab T1
LAMOTRIGINE ER 24 HR TAB
T3
LAMOTRIGINE ODT TABLET
T3
lamotrigine tablet T1
LAMPIT TABLET T3
LANCET MISC T2
LANCETS 28G MISC T2
LANCETS 30G MISC T2
LANCETS 30G TWIST TOP MISC
T2
LANCETS 30G/TWIST TOP MISC
T2
LANCETS MICRO THIN 33G MISC
T2
LANCETS MISC T2
LANCETS SAFETY SEAL 28G MISC
T2
LANCETS SAFETY SEAL 30G MISC
T2
LANCETS SUPER THIN 28G MISC
T2
LANCETS THIN MISC T2
LANCETS TWIST TOP MISC
T2
LANCETS ULTRA FINE MISC
T2
LANCETS ULTRA THIN 30G MISC
T2
LANCETS ULTRA THIN MISC
T2
LANCING DEVICE MISC T2
LANOLIN ANHYDROUS OINTMENT
T3
LANOLIN OIL T3
LANOXIN TABLET T2, BP
lansoprazol-amoxicil-clarithro misc
T1
LANSOPRAZOLE CAPSULE (DELAYED RELEASE)
T3
lanthanum carbonate chew tab
T1
LANTUS SOLOSTAR INJECTION
T2
LANTUS SOLUTION T2
LANZO MISC T2
lapatinib ditosylate tablet T1, QL, SP, PA
larin 1.5/30 tablet T1
larin 1/20 tablet T1
larin 24 fe tablet T1
larin fe 1.5/30 tablet T1
larin fe 1/20 tablet T1
larissia tablet T1
LASIX TABLET T2, BP
LASTACAFT SOLUTION T3
latanoprost solution T1
LATUDA TABLET T2, ST
layolis fe chew tab T1
LAZANDA SOLUTION T3, PA
LC PLUS MISC T3
LC PLUS NEBULIZER-PED MASK MISC
T3
LECITHIN ORGANOGEL GEL
T3
LEDIPASVIR/SOFOSBUVIR TABLET
T2, QL, SP, PA
leena tablet T1
leflunomide tablet T1
LENVIMA 10 MG DAILY DOSE CAPSULE
T2, QL, SP, PA
LENVIMA 12MG DAILY DOSE CAPSULE
T2, QL, SP, PA
LENVIMA 14 MG DAILY DOSE CAPSULE
T2, QL, SP, PA
LENVIMA 18 MG DAILY DOSE CAPSULE
T2, QL, SP, PA
LENVIMA 20 MG DAILY DOSE CAPSULE
T2, QL, SP, PA
LENVIMA 24 MG DAILY DOSE CAPSULE
T2, QL, SP, PA
LENVIMA 4 MG DAILY DOSE CAPSULE
T2, QL, SP, PA
LENVIMA 8 MG DAILY DOSE CAPSULE
T2, QL, SP, PA
LESCOL XL 24 HR TAB T3, BP
lessina tablet T1
LETAIRIS TABLET T2, PA, BP, SP
letrozole tablet T1
leucovorin calcium tablet T1
LEUKERAN TABLET T2
LEUPROLIDE KIT T2, SP
LEVALBUTEROL NEBULIZED
T2, ST
LEVALBUTEROL TARTRATE HFA AEROSOL
T2, QL, ST
LEVBID 12 HR TAB T2
LEVEMIR FLEXTOUCH INJECTION
T2
LEVEMIR SOLUTION T2
levetiracetam er 24 hr tab T1
levetiracetam solution T1
levetiracetam tablet T1
LEVITRA TABLET T3, QL, BP
LEVOBUNOLOL SOLUTION
T3
levocarnitine sf solution T1
Page 20 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
-
levocarnitine solution T1
levocarnitine tablet T1
levofloxacin solution T1
levofloxacin tablet T1
levonest tablet T1
levonorgestrel tablet T1
levonorgestrel-eth estradiol tablet
T1
levonorg-eth estrad eth estrad tablet
T1
levora 0.15/30-28 tablet T1
LEVORPHANOL TARTRATE TABLET
T3
levo-t tablet T1
LEVOTHYROXINE SODIUM CAPSULE
T3
levothyroxine sodium tablet
T1
levoxyl tablet T1
LEVSIN TABLET T2
LEVSIN/SL SL T2
LEXAPRO TABLET T2, BP
LEXETTE FOAM T3, QL, PA
LEXIVA SUSPENSION T2
LEXIVA TABLET T2, BP
LIALDA TABLET T2, BP
LIBRAX CAPSULE T3, BP
LICART PATCH T3, PA
LIDOCAINE CREAM T3
lidocaine injection T1
lidocaine jelly gel T1
lidocaine jelly injection T1
lidocaine ointment T1
lidocaine patch T1
lidocaine patch 5% T1
lidocaine solution T1
lidocaine viscous solution T1
LIDOCAINE/DEXTROSE SOLUTION
T3
lidocaine/prilocaine cream T1
LIDOCAINE-HC CREAM T3
LIDOCAINE-HC GEL T3
LIDOCAINE-HC KIT T3
LIDOCORT CREAM T3
LIDODERM PATCH T2, BP
LIDOPIN CREAM T3
LIDO-SORB LOTION T3
LIDOTRAL CREAM T3
LIFESHIELD BLUNT CANNULA MISC
T3
LILETTA T2, SP
lillow tablet T1
LINDANE SHAMPOO T2
LINEZOLID SUSPENSION
T3, PA
linezolid tablet T1
LINZESS CAPSULE T2
liothyronine sodium tablet T1
LIPITOR TABLET T2, BP
LIPOFEN CAPSULE T3
LIPOLAYER CREAM T3
LIPOZYME CREAM T3
lisinopril tablet T1
lisinopril-hctz tablet T1
LITE TOUCH LANCING PEN MISC
T2
LITE TOUCH MISC T2
lithium carbonate capsule T1, BP
lithium carbonate er tablet T1
lithium carbonate tablet T1
LITHIUM SOLUTION T2
LITHOBID TABLET T2, BP
LITHOSTAT TABLET T3
LIVALO TABLET T3
LO LOESTRIN FE TABLET
T2
LOCOID LIPOCREAM CREAM
T3
LOCOID LOTION T3, BP
LODINE TABLET T2, BP
LODOSYN TABLET T2, BP
loestrin 1.5/30-21 tablet T1
loestrin 1/20-21 tablet T1
loestrin fe 1.5/30 tablet T1
loestrin fe 1/20 tablet T1
lojaimiess tablet T1
LOKELMA PACKET T2, QL, PA
LOMAIRA TABLET T2
LOMOTIL TABLET T2, BP
LONHALA MAGNAIR REFILL SOLUTION
T3
LONHALA MAGNAIR STARTER SOLUTION
T3
LONSURF TABLET T2, QL, SP, PA
loperamide capsule T1
LOPID TABLET T2, BP
lopinavir/ritonavir solution T1
LOPRESSOR HCT TABLET
T2, BP
LOPRESSOR TABLET T2, BP
LOPROX T3, BP
LOPROX CREAM T2, BP
LOPROX SUSPENSION T2, BP
lorazepam T1
lorazepam intensol T1
lorazepam tablet T1
LORBRENA TABLET T2, QL, SP, PA
LORTAB ELIXIR T2
loryna tablet T1
LORZONE TABLET T3
losartan potassium tablet T1
losartan-hydrochlorothiazide tablet
T1
LOSEASONIQUE TABLET
T2, BP
LOTEMAX GEL T3
LOTEMAX OINTMENT T3
LOTEMAX SM GEL T3
LOTEMAX SUSPENSION T3, BP
LOTENSIN HCT TABLET T2, BP
LOTENSIN TABLET T2, BP
LOTEPREDNOL ETABONATE SUSPENSION
T3
LOTREL CAPSULE T2, BP
LOTRONEX TABLET T2, BP
lovastatin tablet T1
LOVAZA CAPSULE T2, BP
LOVENOX SOLUTION T2, BP
low dose aspirin tablet T1
low-ogestrel tablet T1
LOXAPINE CAPSULE T3
LOZIBASE S MISC T3
lo-zumandimine tablet T1
LUCEMYRA TABLET T3, QL
LUER-LOK SYRINGE MISC
T2
LUER-LOK SYRINGE-NEEDLE MISC
T3
LULICONAZOLE CREAM T3
LUMIGAN SOLUTION T2
LUNESTA TABLET T2, BP
LUPANETA PACK KIT T3, SP
LUPRON DEPOT-PED KIT
T2, SP
lutera tablet T1
LUXIQ FOAM T3, BP
LUZU CREAM T3
lyllana patch T1
LYNPARZA TABLET T2, QL, SP, PA
Page 21 of 40For plan specific information, call the pharmacy phone number listed on your member ID card
or log onto your member portal at: members.allumaco.com.
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LYRICA CAPSULE T2, BP
LYRICA CR 24 HR TAB T3
LYRICA SOLUTION T2, BP
LYSODREN TABLET T2, SP
LYSTEDA TABLET T2, BP
lyza tablet T1
MMACROBID CAPSULE T2, BP
MACRODANTIN CAPSULE
T2, BP
MAFENIDE PACKET T3
MAGELLAN INSULIN SAFETY SYRNG MISC
T2
MAGELLAN INSULIN SYRINGE MISC
T2
MAGELLAN SAFETY SYRINGE MISC
T3
MAGELLAN TUBERCULIN SYRINGE MISC
T3
magnesium solution T1
MALARONE TABLET T2, BP
malathion lotion T1
MAPROTILINE TABLET T2
MARATHON MEDICAL PENTIPS MISC
T2
MARINOL CAPSULE T2, BP
marlissa tablet T1
MARNATAL-F CAPSULE T2
MARPLAN TABLET T2
MATULANE CAPSULE T2, SP
MATZIM LA 24 HR TAB T3
MAVENCLAD TABLET T3, QL, PA, SP
MAVYRET TABLET T2, QL, SP, PA
MAXALT TABLET T2, QL, BP
MAXALT-MLT TABLET T2, QL, BP
MAXICOMFORT INSULIN SYRINGE MISC
T2
MAXIDEX SUSPENSION T2
MAXITROL OINTMENT T2, BP
MAXITROL SUSPENSION
T2, BP
MAXZIDE TABLET T2, BP
MAXZIDE-25 TABLET T2, BP
MAYZENT TABLET T3, PA, SP
ME/NAPHOS/MB/HYO 1 TABLET
T3
meclizine tablet T1
MECLOFENAMATE SODIUM CAPSULE
T3
MEDIHOL BASE GEL T3
MEDISENSE GLUCOSE KETONE LIQUID
T3
MEDISENSE LIQUID T3
MEDLANCE PLUS MISC T2
MEDLANCE PLUS SPECIAL BLADE MISC
T2
MEDLANCE PLUS/LITE 25G MISC
T2
MEDLANCE/LITE MISC T2
MEDLANCE/UNIVERSAL MISC
T2
MEDROL DOSEPAK TABLET
T2, BP
MEDROL TABLET T2, BP
MEDROX-RX OINTMENT T3
MEDROXYPROGESTERONE INJECTION
T2
MEDROXYPROGESTERONE SUSPENSION
T2
medroxyprogesterone tablet
T1
MEFENAMIC ACID CAPSULE
T3
mefloquine tablet T1
megestrol suspension T1
megestrol tablet T1
MEKINIST TABLET T2, QL, SP, PA
MEKTOVI TABLET T2, QL, SP, PA
melodetta 24 fe chew tab T1
meloxicam tablet T1
melphalan tablet T1, SP
memantine er 24 hour cap T1
memantine solution T1
memantine tablet T1
MEMBRANEBLUE SOLUTION
T3
MENACTRA INJECTION T2
MENEST TABLET T2
MENOSTAR PATCH T2
MENQUADFI INJECTION T2
MENTAX CREAM T3
MENVEO SOLUTION T2
MEPHYTON TABLET T2, BP
MEPROBAMATE TABLET T3
MEPRON SUSPENSION T2, BP
mercaptopurine t