Drug Formulary Alphabetical Listing 2013
The drug formulary can also be accessed at directprovider.com.
Not al dosage forms are available generical y (PA) Prior authorization required (OTC) Available over the counter with a prescription (SP) Must be dispensed by participating specialty pharmacy Please Note: This is not meant to be a list of all the drugs on the formulary. All forms of a drug may not be covered.
Drugs are listed by their Brand names for ease of use. This list was correct when printed but may have changed. Some
drugs require prior authorization or have quantity limits.
Not al dosage forms are available generical y (PA) Prior authorization required (OTC) Available over the counter with a prescription (SP) Must be dispensed by participating specialty pharmacy Please Note: This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the
drugs listed above are covered. Brand names are listed for informational reference. This is the most current list at the
time of printing and is subject to change. Some medications may require prior authorization or have quantity limits.
Not al dosage forms are available generical y (PA) Prior authorization required (OTC) Available over the counter with a prescription (SP) Must be dispensed by participating specialty pharmacy Please Note: This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the
drugs listed above are covered. Brand names are listed for informational reference. This is the most current list at the
time of printing and is subject to change. Some medications may require prior authorization or have quantity limits.
OTC Drug Formulary Antihistamines Laxative Products Miscellaneous Antimicrobial Products Products Cough and Cold Analgesics Products Cessation Miscellaneous Products Products Mouth and Throat Eye, Ear, and Products Nose Products Antacids/Anti-gas Pediculicide Products Products Topical Antifungal Vaginal Anti- Products Infectives Antidiarrheal Products Vitamin and
Imodium® A-D, Kaopectate®, Pedialyte®, Pepto-Bismol®
Mineral Products
ADEKS®, Caltrate 600-D®, Citrocal®, Feosol®, Fergon®, Fer-In-Sol®, Fish Oil (USP certified only), Os-Cal®,
Poly-Vi-Sol®, Poly-Vi-Sol Iron®, Prenatal Vitamins®
Self-Administered Injectables
All require prior authorization and specialty pharmacy procurement
+ Available at Retail WITHOUT prior authorization
^Available at Retail without prior authorization for 21days of treatment
Not al dosage forms are available generical y (PA) Prior authorization required (OTC) Available over the counter with a prescription (SP) Must be dispensed by participating specialty pharmacy Note: This is not meant to be a list of all t
he drugs on the formulary. All forms of a drug may
Drugs are listed by their Brand names for ease of use. This list was correct when printed but may have changed. Some
drugs require prior authorization or have quantity limits.
Chemical Descriptions for Marcellus Shale Wells The purpose of this document is to allow a better understanding of the chemistry that is commonly used in stimulating a Marcellus shale well. An explanation of the entire completion process is needed to understand the closed system in which the chemicals are injected into the fluid system and enter an isolated and specific formation. Additional doc
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Drug Formulary