hometownrx formulary - september 2020 · 9/11/2020  · aldactazide tablet [t3] [bp] aldactone...

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For plan specific information, call (844) 373-0970, or visit us at: www.hometownhealth.com 5 This formulary is intended to assist you to better understand your pharmacy coverage. Knowing your pharmacy benefit and effective use of the formulary (drug list) will help you be engaged in your treatment options and health. This document will help you get the answers to these questions: What medications are covered? What are my lower cost medication options? How is this formulary developed to ensure I have the best products? What can I do if the medication I need is not covered? Why do I need to obtain an approval (prior authorization) to get what my provider ordered? What is a Formulary? The formulary is a list of preferred brand and generic drug products for HometownRx members. The drug list includes drugs used to treat common diseases or health problems. A team of doctors and pharmacists (Pharmacy and Therapeutics (P&T) Committee) meet to decide which drugs should be on the drug list. The P&T Committee reviews new and existing drugs and chooses drugs that work best and are proven to be safe. Consequently, the formulary is updated regularly and subject to change without notice. The formulary is a good source for you and your provider to determine the best drug for your condition, at the lowest out-of-pocket expense to you. Ultimately, specific drug product selection for an individual member is dependent on your prescriber. How to Search For Drugs This document provides an alphabetical listing of medications covered on the HometownRx formulary. Inclusion on this list does not guarantee coverage and individual plans may vary. Agents listed are primarily oral, self-injected, inhaled or topical pharmaceutical formulations. Drugs requiring provider administration are generally covered under the medical benefit and may not appear on this list. PLEASE NOTE: Certain specialty medications may only be available through your plan’s preferred specialty pharmacy. Some medications may be subject to the Affordable Care Act (ACA) provisions or your plan's preventive benefit and covered by your plan at 100%. HometownRx Formulary - September 2020

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  • For plan specific information, call (844) 373-0970, or visit us at: www.hometownhealth.com 5

    This formulary is intended to assist you to better understand your pharmacy coverage.

    Knowing your pharmacy benefit and effective use of the formulary (drug list) will help you be engaged in

    your treatment options and health. This document will help you get the answers to these questions:

    What medications are covered?

    What are my lower cost medication options?

    How is this formulary developed to ensure I have the best products?

    What can I do if the medication I need is not covered?

    Why do I need to obtain an approval (prior authorization) to get what my provider ordered?

    What is a Formulary?

    The formulary is a list of preferred brand and generic drug products for HometownRx members. The drug

    list includes drugs used to treat common diseases or health problems. A team of doctors and pharmacists

    (Pharmacy and Therapeutics (P&T) Committee) meet to decide which drugs should be on the drug list. The

    P&T Committee reviews new and existing drugs and chooses drugs that work best and are proven to be

    safe. Consequently, the formulary is updated regularly and subject to change without notice. The

    formulary is a good source for you and your provider to determine the best drug for your condition, at the

    lowest out-of-pocket expense to you. Ultimately, specific drug product selection for an individual member

    is dependent on your prescriber.

    How to Search For Drugs

    This document provides an alphabetical listing of medications covered on the HometownRx formulary.

    Inclusion on this list does not guarantee coverage and individual plans may vary. Agents listed are

    primarily oral, self-injected, inhaled or topical pharmaceutical formulations. Drugs requiring provider

    administration are generally covered under the medical benefit and may not appear on this list.

    PLEASE NOTE:

    Certain specialty medications may only be available through your plan’s preferred specialty

    pharmacy.

    Some medications may be subject to the Affordable Care Act (ACA) provisions or your plan's

    preventive benefit and covered by your plan at 100%.

    HometownRx Formulary - September 2020

    http://www.hometownhealth.com/

  • For plan specific information, call (844) 373-0970, or visit us at: www.hometownhealth.com 6

    Individual plans may vary.

    For questions regarding plan-specific restrictions, coverage criteria, and cost sharing information,

    please log into your member portal and use the “What’s my Cost” feature or call the phone

    number printed on your member ID card.

    Each medication may have specific coverage requirements not reflected in this document. The key

    below explains common coverage indicators present on this file. Drugs shown in lower-case are

    generically available and typically covered at the lowest member cost share.

    T1 Tier 1 medication, typically generics or drugs available at lowest member cost share.

    T2 Tier 2 medication, typically preferred or formulary brand drugs.

    T3 Tier 3 medication, typically non-preferred or non-formulary drugs.

    T4 Tier 4 medication, typically specialty medications.

    PA Drug requires prior authorization to confirm medical necessity prior to coverage.

    QL Quantity limits may apply.

    BP Brand Penalty: Member may be responsible for the cost difference between brand and generic

    SP Specialty Medication: This drug may only be available at the plan's preferred specialty

    pharmacy.

    ACA Covered by the Plan at 100%.

    Benefit Coverage and Limitations

    Certain drug products have been excluded from this formulary. If you choose to use an excluded drug

    product HometownRx may not reimburse for these drug products and may require you to pay 100% of

    the cost. Furthermore, if you choose to use a drug that is not on formulary or excluded, the cost, does not

    accumulate towards meeting your annual deductible or out-of-pocket maximums.

    Certain classes of medication are not covered under your pharmacy benefit. These medication classes

    may include but are not limited to: non-FDA approved drugs, over the counter (OTC) medications, drugs to

    treat impotency or sexual disorders, fertility agents, weight loss drugs, hematinics, reusable needles,

    disposable syringes, ostomy supplies, infant formulas, dietary supplements, hypopigmentation agents,

    diagnostic agents, cosmetic medications, and compounded medications.

    An ancillary charge (as know as a Brand Penalty [BP]) may apply to brand medications when an equivalent

    generic is available. If a member or provider chooses a brand medication over the generic medication, the

    member may be responsible for their copay/coinsurance plus the cost difference between the brand

    medication and the generic medication (ancillary charge). Ancillary charges do not accumulate towards

    meeting your annual deductible or out-of-pocket maximums.

    The formulary applies only to outpatient drugs provided to members, and does not apply to medications

    used in inpatient settings.

    http://www.hometownhealth.com/

  • For plan specific information, call (844) 373-0970, or visit us at: www.hometownhealth.com 7

    What if my drug is not listed on the formulary?

    To avoid delays in access to your treatment, your provider may check the formulary to prescribe a

    covered drug that is best for you. The HometownRx formulary offers a wide coverage of available drugs.

    However, in instances where the drug is rejected due to “Drug Not Covered”, you may either:

    Ask your pharmacy to contact your provider to change the prescription to a covered formulary

    alternative.

    If your provider believes the non-covered product is “medically necessary” for your condition, your

    provider may request an “Exception” for coverage. See the next section for information on how to

    request an exception.

    How do I request an exception?

    Members or providers can ask HometownRx to make an exception to our coverage rules. Exceptions are

    reviewed for medical necessity, your inability to use covered drugs (e.g., side effects, contraindications,

    allergies), current covered products may not be effective for you, and new drug entrants that have not yet

    been reviewed and placed on the formulary. Reviews will consider superiority of the request over current

    covered options.

    Exception requests can be submitted by making the request to HometownRx:

    You or your provider can call us at 1-844-373-0970, or submit a written request for prior

    authorization review via fax at 1-866-521-9916.

    Why do some drugs require prior authorization?

    Drug coverage review is used to encourage appropriate and cost-effective use of prescription drugs by

    allowing coverage only when certain conditions are met. Some reasons for pre-authorization may include:

    Compliance with dosing guidelines

    Avoid duplicate therapies

    Help health care providers check medically accepted criteria that helps ensure high efficacy and

    low side effects

    HometownRx implements prior authorization criteria based on the Food and Drug Administration (FDA)

    approved labelling, evidence-based national best-practice guidelines, and peer-reviewed journals.

    http://www.hometownhealth.com/

  • For plan specific information, call (844) 373-0970, or visit us at: www.hometownhealth.com 8

    What can I expect to pay?

    What you expect to pay depends on the type of drugs your provider ordered for you. Each drug is placed

    in a tier level; different tiers represent the different levels of payment for covered medications. Tier

    structures are developed to encourage you to use quality products at the most cost-effective option to

    you. The lower cost option does not represent a lower quality product. Rather it is the best cost option

    considering covered products within that treatment category. You can be assured that drugs provided

    through your pharmacy benefit has been through rigorous processes to be approved by the FDA.

    How can I save on prescriptions?

    Here are some other tips to pay less out of pocket for your prescription drugs:

    Ask your provider to consider prescribing generic drugs instead of brand-name drugs, and

    whether the generic drug is right for you.

    Ask your provider to consider prescribing drugs that are on the HometownRx Formulary.

    Check to see if your plan includes our mail-order pharmacy service. Depending upon your plan,

    mail order may save you money.

    What if I have additional questions?

    Please contact us:

    Phone: 1-844-373-0970

    If you have impaired hearing, dial TTY # 711

    E-mail: [email protected]

    Web site: www.hometownhealth.com

    http://www.hometownhealth.com/mailto:[email protected]://www.hometownhealth.com/

  • Aabacavir solution [T1]

    abacavir sulfate tablet [T1]

    abacavir tablet [T1]

    abacavir-lamivudine tablet [T1]

    abacavir-lamivudine-zidovudine tablet

    [T1]

    ABILIFY MYCITE TABLET [T3] [PA]

    ABIRATERONE TABLET [T4] [PA][SP]

    ABSORICA CAPSULE [T3]

    ABSORICA LD CAPSULE [T3] [PA]

    acamprosate calcium dr tablet

    [T1]

    ACANYA GEL [T3] [BP]

    acarbose tablet [T1]

    ACCOLATE TABLET [T3] [BP]

    ACCUPRIL TABLET [T3] [BP]

    ACCURETIC TABLET [T3] [BP]

    ACD FORMULA A SOLUTION [T2]

    ACD SOLUTION [T2]

    acebutolol capsule [T1]

    ACESO AG PADS [T3]

    acetaminophen w/codeine tablet

    [T1]

    acetaminophen/codeine solution

    [T1]

    acetaminophen/codeine tablet

    [T1]

    acetazolamide er capsule [T1]

    acetazolamide tablet [T1]

    acetic acid 0.25% solution [T1]

    acetic acid solution [T1]

    acetic acid/hydrocortisone solution

    [T1]

    acetylcysteine solution [T1]

    acitretin capsule [T1]

    ACTEMRA ACTPEN INJECTION

    [T4] [PA][SP]

    ACTEMRA INJECTION [T4] [PA][SP]

    ACTHIB SOLUTION [T2] [ACA]

    ACTICLATE TABLET [T3] [BP]

    ACTICOAT [T3]

    ACTICOAT 7 [T3]

    ACTICOAT ABSORBENT MISC [T3]

    ACTICOAT FLEX 3 [T3]

    ACTICOAT FLEX 7 [T3]

    ACTICOAT MOISTURE CONTROL PADS

    [T3]

    ACTICOAT SITE [T3]

    ACTIGALL CAPSULE [T3] [BP]

    ACTIMMUNE SOLUTION [T4] [PA][SP]

    ACTIQ LOLLIPOP [T3] [QL][BP]

    ACTIVELLA TABLET [T3] [BP]

    ACTONEL TABLET [T3] [QL][BP]

    ACTOPLUS MET TABLET [T3] [BP]

    ACTOS TABLET [T3] [BP]

    ACULAR LS SOLUTION [T3] [BP]

    ACULAR SOLUTION [T3] [BP]

    acyclovir capsule [T1]

    acyclovir ointment [T1] [QL]

    acyclovir suspension [T1]

    acyclovir tablet [T1]

    ACZONE GEL [T3] [BP]

    ADACEL SUSPENSION [T2] [ACA]

    adapalene cream [T1]

    adapalene gel [T1]

    adapalene pads [T1]

    adapalene pump gel [T1]

    adapalene solution [T1]

    adapalene-benzoyl peroxide gel

    [T1]

    ADASUVE AEROSOL [T3] [PA]

    adc/fluoride solution [T1]

    ADDERALL XR 24 HOUR CAP [T3] [QL][BP]

    ADEFOVIR DIPIVOXIL TABLET [T4] [PA][SP]

    ADEMPAS TABLET [T4] [PA][SP]

    adrenalin solution [T1] [QL][BP]

    adult aspirin regimen tablet [T1] [ACA]

    ADVAIR DISKUS AEROSOL [T3] [QL][BP]

    ADVAIR HFA AEROSOL [T2] [QL]

    AEMCOLO TABLET [T3]

    AFINITOR DISPERZ TABLET [T4] [PA][SP]

    AFINITOR TABLET [T4] [PA][SP][BP]

    afirmelle tablet [T1] [ACA]

    AFLURIA QUAD 2020-2021 SUSPENSION

    [T2] [ACA]

    AFLURIA QUAD 2020-21 (3YR UP) INJECTION

    [T2] [ACA]

    AFLURIA QUAD 2020-21 (6-35MO) INJECTION

    [T2] [ACA]

    AFREZZA POWDER [T3]

    aftera tablet [T1] [ACA]

    AGGRENOX CAPSULE [T3] [BP]

    AGRYLIN CAPSULE [T3] [BP]

    AIMOVIG INJECTION [T2] [PA]

    AIMSCO LUBRICATED MISC [T2] [ACA]

    AIRDUO DIGIHALER 113/14 AEROSOL

    [T3] [QL]

    AIRDUO DIGIHALER 232/14 AEROSOL

    [T3] [QL]

    AIRDUO DIGIHALER 55/14 AEROSOL

    [T3] [QL]

    AIRDUO RESPICLICK 113/14 AEROSOL

    [T3] [QL]

    AIRDUO RESPICLICK 232/14 AEROSOL

    [T3] [QL]

    AIRDUO RESPICLICK 55/14 AEROSOL

    [T3] [QL]

    AJOVY INJECTION [T2] [PA]

    AKLIEF CREAM [T3] [PA]

    AKTEN GEL [T3]

    ALA SCALP LOTION [T3]

    ala-cort cream [T1]

    ALA-SCALP LOTION [T3]

    albendazole tablet [T1] [PA]

    ALBENZA TABLET [T3] [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

    [T1]

    alclometasone dipropionate ointment

    [T1]

    ALDACTAZIDE TABLET [T3] [BP]

    ALDACTONE TABLET [T3] [BP]

    ALDARA CREAM [T3] [BP]

    ALECENSA CAPSULE [T4] [PA][SP]

    5www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    HometownRx Formulary-September 2020

    www.hometownhealth.comdrbouttesmothersTypewriterHTH 4 Tier August 2020 Formulary

  • alendronate sodium solution [T1] [QL]

    alendronate sodium tablet [T1] [QL]

    alfuzosin er 24 hr tab [T1]

    ALINIA SUSPENSION [T2]

    ALINIA TABLET [T2]

    aliskiren tablet [T1]

    ALKERAN TABLET [T4] [PA][SP][BP]

    allopurinol tablet [T1]

    almotriptan malate tablet [T1] [QL]

    almotriptan tablet [T1] [QL]

    ALOMIDE SOLUTION [T3]

    alophen tablet [T1] [ACA]

    ALORA PATCH [T3] [QL]

    alosetron tablet [T1]

    ALPHAGAN P SOLUTION [T2] [BP]

    alprazolam er 24 hr tab [T1]

    alprazolam intensol [T1]

    alprazolam odt tablet [T1]

    alprazolam tablet [T1]

    alprazolam xr 24 hr tab [T1]

    ALREX SUSPENSION [T2]

    ALTACE CAPSULE [T3] [BP]

    altafluor benox solution [T1]

    altavera tablet [T1] [ACA]

    ALTRENO LOTION [T3]

    ALUNBRIG TABLET [T4] [PA][SP]

    ALVESCO AEROSOL [T3] [QL]

    alyacen 1/35 tablet [T1] [ACA]

    alyacen 7/7/7 tablet [T1] [ACA]

    alyq tablet [T1] [PA]

    ALZAIR POWDER [T3]

    amabelz tablet [T1]

    amantadine capsule [T1]

    amantadine syrup [T1]

    amantadine tablet [T1]

    AMARYL TABLET [T3] [BP]

    AMBRISENTAN TABLET [T4] [PA][SP]

    AMELUZ GEL [T3]

    AMERGE TABLET [T3] [QL][BP]

    amethia lo tablet [T1] [ACA]

    amethia tablet [T1] [ACA]

    amethyst tablet [T1] [ACA]

    AMICAR SOLUTION [T2] [BP]

    AMICAR TABLET [T3] [BP]

    amiloride tablet [T1]

    amiloride w/hctz tablet [T1]

    aminoacetic acid solution [T1]

    aminocaproic acid solution [T1]

    aminocaproic acid tablet [T1]

    amiodarone tablet [T1]

    AMITIZA CAPSULE [T3] [QL]

    amitriptyline tablet [T1]

    amitriptyline/chlordiazepoxide tablet

    [T1]

    amitriptyline-perphenazine tablet

    [T1]

    amlodipine besylate tablet [T1]

    amlodipine besylate-benazepril capsule

    [T1]

    amlodipine-atorvastatin tablet

    [T1] [QL]

    amlodipine-olmesartan tablet

    [T1]

    amlodipine-valsartan tablet [T1]

    amlodipine-valsartan-hctz tablet

    [T1]

    ammonium lactate cream [T1]

    ammonium lactate lotion [T1]

    amnesteem capsule [T1]

    amoxapine tablet [T1]

    amoxicillin capsule [T1]

    amoxicillin chew tab [T1]

    amoxicillin suspension [T1]

    amoxicillin tablet [T1]

    amoxicillin-clavulanate pot er 12 hr tab

    [T1]

    amoxicillin-clavulanate potass chew tab

    [T1]

    amoxicillin-clavulanate potass suspension

    [T1]

    amoxicillin-clavulanate potass tablet

    [T1]

    ampicillin capsule [T1]

    ANADROL-50 TABLET [T3]

    ANAFRANIL CAPSULE [T3] [BP]

    anagrelide capsule [T1]

    anaspaz tablet [T1]

    anastrozole tablet [T1]

    ANCOBON CAPSULE [T3] [BP]

    ANDROGEL GEL [T3] [QL]

    ANDROGEL PUMP GEL [T3] [QL][BP]

    ANGELIQ TABLET [T3]

    ANNOVERA [T3] [ACA]

    ANORO ELLIPTA AEROSOL [T2] [QL]

    ANTABUSE TABLET [T3] [BP]

    ANTICOAGULANT SODIUM SOLUTION

    [T3]

    ANZEMET TABLET [T3] [QL]

    apap-caffeine-dihydrocodeine capsule

    [T1]

    APLIGRAF [T3]

    APOKYN INJECTION [T4] [PA][SP]

    apraclonidine solution [T1]

    aprepitant capsule [T1] [QL]

    apri tablet [T1] [ACA]

    APRISO 24 HOUR CAP [T2] [BP]

    APTIOM TABLET [T3]

    APTIVUS CAPSULE [T2]

    APTIVUS SOLUTION [T2]

    ARAKODA TABLET [T3]

    aranelle tablet [T1] [ACA]

    ARAVA TABLET [T3] [BP]

    ARCALYST SOLUTION [T4] [PA][SP]

    ARCAPTA NEOHALER CAPSULE

    [T3] [QL]

    ARICEPT TABLET [T3] [BP]

    ARIDA GEL [T3]

    ARIDOL KIT [T3]

    ARIKAYCE SUSPENSION [T4] [PA][SP]

    aripiprazole odt tablet [T1]

    aripiprazole solution [T1]

    aripiprazole tablet [T1]

    ARIXTRA SOLUTION [T3] [BP]

    armodafinil tablet [T1] [QL]

    ARMOUR THYROID TABLET [T2]

    ARNUITY ELLIPTA AEROSOL [T2] [QL]

    AROMASIN TABLET [T3] [BP]

    ARTHROTEC 50 TABLET [T3] [BP]

    ARTHROTEC 75 TABLET [T3] [BP]

    ARTISS SOLUTION [T3]

    asa-butalb-caff-cod capsule [T1]

    ascomp/codeine capsule [T1]

    ashlyna tablet [T1] [ACA]

    ASMANEX AEROSOL [T2] [QL]

    ASMANEX HFA AEROSOL [T2] [QL]

    aspirin 81 low dose chew tab [T1] [ACA]

    aspirin 81 tablet [T1] [ACA]

    aspirin adult low dose tablet [T1] [ACA]

    aspirin adult tablet [T1] [ACA]

    aspirin chew tab [T1] [ACA]

    aspirin childrens chew tab [T1] [ACA]

    aspirin e.c. tablet [T1] [ACA]

    6www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • aspirin ec low dose tablet [T1] [ACA]

    aspirin ec tablet [T1] [ACA]

    aspirin low dose chew tab [T1] [ACA]

    aspirin low dose tablet [T1] [ACA]

    aspirin low strength chew tab

    [T1] [ACA]

    aspirin regular strength tablet

    [T1] [ACA]

    aspirin tablet [T1] [ACA]

    aspirin/dipyridamole capsule [T1]

    aspirin/dipyridamole er capsule

    [T1]

    ATABEX EC TABLET [T3]

    atazanavir capsule [T1]

    atazanavir sulfate capsule [T1]

    ATELVIA TABLET [T3] [QL][BP]

    atenolol tablet [T1]

    atenolol/chlorthalidone tablet

    [T1]

    ATIVAN TABLET [T3] [BP]

    atomoxetine capsule [T1]

    ATOPADERM CREAM [T3]

    atopavo emulsion [T1]

    atorvastatin calcium tablet [T1] [ACA][QL]

    atovaquone suspension [T1]

    atovaquone/proguanil tablet [T1]

    atropine sulfate solution [T1]

    ATROVENT HFA AEROSOL [T3] [QL]

    AUBAGIO TABLET [T4] [PA][SP]

    aubra eq tablet [T1] [ACA]

    aubra tablet [T1] [ACA]

    AUGMENTIN ES-600 SUSPENSION

    [T3]

    AUGMENTIN SUSPENSION [T2] [BP]

    AUGMENTIN TABLET [T3]

    aurovela 1.5/30 tablet [T1] [ACA]

    aurovela 1/20 tablet [T1] [ACA]

    aurovela 24 fe tablet [T1] [ACA]

    aurovela fe 1.5/30 tablet [T1] [ACA]

    aurovela fe 1/20 tablet [T1] [ACA]

    AURYXIA TABLET [T3]

    AUSTEDO TABLET [T4] [PA][SP]

    AVANDIA TABLET [T3] [QL]

    aviane tablet [T1] [ACA]

    avidoxy tablet [T1]

    avita cream [T1]

    avita gel [T1]

    AVITENE FLOUR POWDER [T3]

    AVITENE PADS [T3]

    avo cream emulsion [T1]

    AVONEX INJECTION [T4] [PA][SP]

    AVONEX PEN INJECTION [T4] [PA][SP]

    AYGESTIN TABLET [T3] [BP]

    ayuna tablet [T1] [ACA]

    AYVAKIT TABLET [T4] [PA][SP]

    AZACITIDINE SUSPENSION [T4] [PA][SP]

    AZASITE SOLUTION [T2]

    azathioprine tablet [T1]

    azelaic acid gel [T1]

    azelastine solution [T1] [QL]

    azelastine-fluticasone suspension

    [T1] [QL]

    AZELEX CREAM [T3]

    AZESCO TABLET [T3]

    AZILECT TABLET [T3] [BP]

    azithromycin packet [T1]

    azithromycin suspension [T1]

    azithromycin tablet [T1]

    AZOPT SUSPENSION [T3]

    AZULFIDINE EN-TABS TABLET [T3] [BP]

    AZULFIDINE TABLET [T3] [BP]

    azurette tablet [T1] [ACA]

    Bbacitracin ointment [T1]

    bacitracin/polymyxin b ointment

    [T1]

    baclofen tablet [T1]

    BACTRIM DS TABLET [T3] [BP]

    BACTRIM TABLET [T3] [BP]

    BAL-CARE DHA MISC [T2]

    balsalazide disodium capsule [T1]

    BALVERSA TABLET [T4] [PA][SP]

    balziva tablet [T1] [ACA]

    BANZEL SUSPENSION [T2]

    BANZEL TABLET [T2]

    BAQSIMI ONE PACK POWDER [T2]

    BAQSIMI TWO PACK POWDER

    [T2]

    BARACLUDE SOLUTION [T4] [PA][SP]

    BASADROX GEL [T3]

    BASAGLAR KWIKPEN INJECTION

    [T3] [QL]

    BAXDELA TABLET [T2] [PA]

    bayer aspirin tablet [T1] [ACA]

    bayer chewable low dose chew tab

    [T1] [ACA]

    bayer low dose tablet [T1] [ACA]

    BD MAGNI-GUIDE MAGNIFIER MISC

    [T2] [QL]

    bekyree tablet [T1] [ACA]

    BELBUCA FILM [T2] [QL]

    BELSOMRA TABLET [T3] [QL]

    benazepril tablet [T1]

    benazepril-hctz tablet [T1]

    BENLYSTA INJECTION [T4] [PA][SP]

    BENZACLIN GEL [T3] [BP]

    BENZACLIN WITH PUMP GEL [T3] [BP]

    BENZAMYCIN GEL [T3] [BP]

    BENZEPRO FOAM [T3]

    BENZNIDAZOLE TABLET [T2]

    benzonatate capsule [T1]

    benztropine mesylate tablet [T1]

    BEPREVE SOLUTION [T2]

    beser lotion [T1]

    BESIVANCE SUSPENSION [T3]

    betamethasone dipropionate cream

    [T1]

    betamethasone dipropionate gel

    [T1]

    betamethasone dipropionate lotion

    [T1]

    betamethasone dipropionate ointment

    [T1]

    betamethasone valerate cream

    [T1]

    betamethasone valerate lotion

    [T1]

    betamethasone valerate ointment

    [T1]

    BETAPACE AF TABLET [T3] [BP]

    BETAPACE TABLET [T3] [BP]

    BETASERON KIT [T4] [PA][SP]

    betaxolol solution [T1]

    betaxolol tablet [T1]

    bethanechol chloride tablet [T1]

    BETHKIS NEBULIZED [T4] [PA][SP]

    BETIMOL SOLUTION [T3]

    BETOPTIC-S SUSPENSION [T3]

    BEVESPI AEROSPHERE AEROSOL

    [T2] [QL]

    BEXAROTENE CAPSULE [T4] [PA][SP]

    BEXSERO INJECTION [T2] [ACA]

    BIAFINE EMULSION [T3]

    bicalutamide tablet [T1]

    7www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • BIDIL TABLET [T3]

    BIKTARVY TABLET [T2] [QL]

    BILTRICIDE TABLET [T3] [BP]

    bimatoprost solution [T1]

    BIONECT CREAM [T3]

    BIONECT FOAM [T3]

    BIONECT GEL [T3]

    BIOSTEP [T3]

    BIOSTEP AG [T3]

    bisacodyl ec tablet [T1] [ACA]

    bisoprolol fumarate tablet [T1]

    bisoprolol fumarate/hctz tablet

    [T1]

    BLEPH-10 SOLUTION [T3] [BP]

    BLEPHAMIDE S.O.P. OINTMENT

    [T3]

    BLEPHAMIDE SUSPENSION [T3]

    blisovi 24 fe tablet [T1] [ACA]

    blisovi fe 1.5/30 tablet [T1] [ACA]

    blisovi fe 1/20 tablet [T1] [ACA]

    BONIVA TABLET [T3] [QL][BP]

    BOOSTRIX SUSPENSION [T2] [ACA]

    BOSENTAN TABLET [T4] [PA][SP]

    BOSULIF TABLET [T4] [PA][SP]

    BRAFTOVI CAPSULE [T4] [PA][SP]

    BREO ELLIPTA AEROSOL [T2] [QL]

    briellyn tablet [T1] [ACA]

    BRILINTA TABLET [T2]

    brimonidine tartrate solution [T1]

    BRINEURA KIT [T4] [PA][SP]

    BRIVIACT SOLUTION [T3]

    BRIVIACT TABLET [T3]

    bromfed dm syrup [T1]

    bromfenac solution [T1]

    bromocriptine mesylate capsule

    [T1]

    bromocriptine mesylate tablet

    [T1]

    bromphen/pseudoephedrine syrup

    [T1]

    brompheniramine w/pseudoephed liquid

    [T1]

    BROMSITE SOLUTION [T3]

    BROVANA NEBULIZED [T3]

    BRUKINSA CAPSULE [T4] [PA][SP]

    budesonide capsule [T1]

    budesonide er 24 hr tab [T1]

    budesonide suspension [T1]

    bumetanide tablet [T1]

    BUNAVAIL FILM [T3] [QL]

    BUPHENYL POWDER [T4] [PA][SP][BP]

    BUPHENYL TABLET [T4] [PA][SP][BP]

    buprenorphine patch [T1] [QL]

    buprenorphine sl [T1] [QL]

    buprenorphine-naloxone film

    [T1] [QL]

    buprenorphine-naloxone sl [T1] [QL]

    bupropion sr 12 hr tab [T1] [ACA]

    bupropion tablet [T1]

    bupropion xl 24 hr tab [T1] [QL]

    buspirone tablet [T1]

    butalbital compound capsule [T1]

    butalbital compound w/codeine capsule

    [T1]

    butalbital/acetaminophen tablet

    [T1]

    butalbital/apap/caffeine capsule

    [T1]

    butalbital/apap/caffeine tablet

    [T1]

    butalbital/caff/apap/codeine capsule

    [T1]

    butalbital-asp-caffeine capsule

    [T1]

    butalbital-asp-caffeine tablet [T1]

    butorphanol tartrate solution

    [T1] [QL]

    BYDUREON BCISE INJECTION [T2] [QL]

    BYDUREON PEN INJECTION [T2] [QL]

    BYETTA INJECTION [T2] [QL]

    BYSTOLIC TABLET [T2]

    Ccabergoline tablet [T1]

    CABOMETYX TABLET [T4] [PA][SP]

    CADUET TABLET [T3] [QL][BP]

    CAFERGOT TABLET [T3] [BP]

    caffeine solution [T1]

    CALAN SR TABLET [T3] [BP]

    calcipotriene cream [T1]

    calcipotriene ointment [T1]

    calcipotriene solution [T1]

    calcitonin salmon solution [T1]

    calcitonin-salmon solution [T1]

    calcitrene ointment [T1]

    calcitriol capsule [T1]

    calcitriol ointment [T1]

    calcitriol solution [T1]

    calcium capsule [T1]

    calcium tablet [T1]

    CALQUENCE CAPSULE [T4] [PA][SP]

    camila tablet [T1] [ACA]

    camrese lo tablet [T1] [ACA]

    camrese tablet [T1] [ACA]

    CANASA SUPPOSITORY [T3] [BP]

    candesartan cilexetil tablet [T1]

    candesartan-hydrochlorothiazid tablet

    [T1]

    CANTHARIDIN SOLUTION [T3]

    CAPECITABINE TABLET [T4] [PA][SP]

    CAPRELSA TABLET [T4] [PA][SP]

    captopril tablet [T1]

    captopril/hydrochlorothiazide tablet

    [T1]

    CARAFATE SUSPENSION [T2] [BP]

    CARAFATE TABLET [T2] [BP]

    CARBAGLU TABLET [T4] [PA][SP]

    carbamazepine chew tab [T1]

    carbamazepine er 12 hr tab [T1]

    carbamazepine er capsule [T1]

    carbamazepine suspension [T1]

    carbamazepine tablet [T1]

    CARBATROL CAPSULE [T3] [BP]

    carbidopa tablet [T1]

    carbidopa/levodopa er tablet [T1]

    carbidopa/levodopa odt tablet

    [T1]

    carbidopa/levodopa tablet [T1]

    carbidopa-levodopa-entacapone tablet

    [T1]

    carbinoxamine maleate solution

    [T1]

    carbinoxamine maleate tablet

    [T1]

    cardioplegic solution [T1]

    CARDIZEM CD 24 HOUR CAP [T3]

    CARDIZEM LA 24 HR TAB [T3] [BP]

    CARDIZEM TABLET [T3] [BP]

    CARDURA TABLET [T3] [BP]

    CARDURA XL 24 HR TAB [T3]

    carisoprodol tablet [T1]

    carisoprodol-aspirin-codeine tablet

    [T1]

    CARNITOR SF SOLUTION [T3] [BP]

    CARNITOR SOLUTION [T3] [BP]

    8www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • CARNITOR TABLET [T3] [BP]

    CAROSPIR SUSPENSION [T3] [PA]

    carteolol solution [T1]

    cartia xt 24 hour cap [T1]

    carvedilol phosphate 24 hour cap

    [T1]

    carvedilol tablet [T1]

    CASODEX TABLET [T3] [BP]

    CATAPRES TABLET [T3] [BP]

    CATAPRES-TTS-1 PATCH [T3] [BP]

    CATAPRES-TTS-2 PATCH [T3] [BP]

    CATAPRES-TTS-3 PATCH [T3] [BP]

    CAYA [T3] [ACA]

    CAYSTON SOLUTION [T4] [PA][SP]

    caziant tablet [T1] [ACA]

    cefaclor capsule [T1]

    cefaclor er 12 hr tab [T1]

    cefaclor suspension [T1]

    cefadroxil capsule [T1]

    cefadroxil suspension [T1]

    cefadroxil tablet [T1]

    cefdinir capsule [T1]

    cefdinir suspension [T1]

    cefditoren pivoxil tablet [T1]

    cefixime capsule [T1]

    cefixime suspension [T1]

    cefpodoxime proxetil suspension

    [T1]

    cefpodoxime proxetil tablet [T1]

    cefprozil suspension [T1]

    cefprozil tablet [T1]

    cefuroxime axetil tablet [T1]

    celecoxib capsule [T1] [QL]

    CELLCEPT CAPSULE [T3] [BP]

    CELLCEPT SUSPENSION [T3] [BP]

    CELLCEPT TABLET [T3] [BP]

    CELONTIN CAPSULE [T2]

    CENTANY OINTMENT [T3]

    cephalexin capsule [T1]

    cephalexin suspension [T1]

    cephalexin tablet [T1]

    CEQUA SOLUTION [T3] [QL]

    CERDELGA CAPSULE [T4] [PA][SP]

    CERVIDIL [T3]

    cetirizine solution [T1]

    cevimeline capsule [T1]

    CHANTIX CONTINUING MONTH TABLET

    [T2] [ACA]

    CHANTIX TABLET [T2] [ACA]

    chateal eq tablet [T1] [ACA]

    chateal tablet [T1] [ACA]

    CHEMET CAPSULE [T2]

    CHEMSTRIP BG LOG BOOK MISC

    [T3] [QL]

    CHENODAL TABLET [T4] [PA][SP]

    children's aspirin chew tab [T1] [ACA]

    chlordiazepoxide capsule [T1]

    chlorhexidine gluconate solution

    [T1]

    chloroquine phosphate tablet

    [T1] [QL]

    chlorpromazine tablet [T1]

    chlorthalidone tablet [T1]

    chlorzoxazone tablet [T1]

    CHOLBAM CAPSULE [T4] [PA][SP]

    cholestyramine light packet [T1]

    cholestyramine light powder [T1]

    cholestyramine packet [T1]

    cholestyramine powder [T1]

    ciclodan solution [T1]

    ciclopirox gel [T1]

    ciclopirox nail lacquer solution

    [T1]

    ciclopirox olamine cream [T1]

    ciclopirox shampoo [T1]

    ciclopirox suspension [T1]

    cilostazol tablet [T1]

    CILOXAN OINTMENT [T3]

    CILOXAN SOLUTION [T3] [BP]

    CIMDUO TABLET [T2] [QL]

    cimetidine solution [T1]

    cimetidine tablet [T1]

    CINACALCET TABLET [T4] [PA][SP]

    CIPRO HC SUSPENSION [T3]

    CIPRO SUSPENSION [T3]

    CIPRO TABLET [T3] [BP]

    CIPRODEX SUSPENSION [T2] [BP]

    ciprofloxacin solution [T1]

    ciprofloxacin tablet [T1]

    ciprofloxacin-dexamethasone suspension

    [T1]

    citalopram solution [T1]

    citalopram tablet [T1]

    CITRANATAL 90 DHA MISC [T3]

    CITRANATAL ASSURE MISC [T3]

    CITRANATAL B-CALM MISC [T3]

    CITRANATAL BLOOM TABLET [T3]

    CITRANATAL DHA MISC [T3]

    CITRANATAL HARMONY CAPSULE

    [T3]

    CITRANATAL RX TABLET [T3]

    citroma solution [T1] [ACA]

    claravis capsule [T1]

    CLARINEX TABLET [T3] [BP]

    CLARINEX-D 12 HOUR TAB [T3]

    clarithromycin er 24 hr tab [T1]

    clarithromycin suspension [T1]

    clarithromycin tablet [T1]

    clearlax powder [T1] [ACA]

    clemastine fumarate tablet [T1]

    CLENPIQ SOLUTION [T2]

    CLEOCIN CAPSULE [T3] [BP]

    CLEOCIN CREAM [T3] [BP]

    CLEOCIN PALMITATE SOLUTION

    [T3] [BP]

    CLEOCIN SUPPOSITORY [T3]

    CLEOCIN-T GEL [T3] [BP]

    CLEOCIN-T LOTION [T3] [BP]

    clidinium w/chlordiazepoxide capsule

    [T1]

    CLIMARA PATCH [T3] [QL][BP]

    clindacin etz pledgets swab [T1]

    clindacin-p swab [T1]

    clindamycin capsule [T1]

    clindamycin palmitate solution

    [T1]

    clindamycin pediatric solution

    [T1]

    clindamycin phosphate cream

    [T1]

    clindamycin phosphate foam [T1]

    clindamycin phosphate gel [T1]

    clindamycin phosphate lotion

    [T1]

    clindamycin phosphate solution

    [T1]

    clindamycin phosphate swab [T1]

    clindamycin phos-tretinoin gel

    [T1]

    clindamycin-benzoyl peroxide gel

    [T1]

    CLINDESSE CREAM [T3]

    clobazam suspension [T1]

    clobazam tablet [T1]

    9www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • clobetasol cream [T1]

    clobetasol gel [T1]

    clobetasol ointment [T1]

    clobetasol solution [T1]

    clomipramine capsule [T1]

    clonazepam odt tablet [T1]

    clonazepam tablet [T1]

    clonidine 12 hr tab [T1]

    clonidine er 12 hr tab [T1]

    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 [T4] [PA][SP]

    clozapine odt tablet [T1]

    clozapine tablet [T1]

    CLOZARIL TABLET [T3] [BP]

    C-NATE DHA CAPSULE [T2]

    COARTEM TABLET [T2]

    COCAINE SOLUTION [T3]

    codeine sulfate tablet [T1] [BP]

    COLAZAL CAPSULE [T3] [BP]

    colchicine tablet [T1]

    COLCRYS TABLET [T2] [BP]

    colesevelam packet [T1]

    colesevelam tablet [T1]

    COLESTID FLAVORED GRANULES

    [T3]

    COLESTID FLAVORED PACKET [T3]

    COLESTID GRANULES [T3] [BP]

    COLESTID PACKET [T3] [BP]

    COLESTID TABLET [T3] [BP]

    colestipol granules [T1]

    colestipol packet [T1]

    colestipol tablet [T1]

    COMBIGAN SOLUTION [T2]

    COMBIPATCH PATCH [T2]

    COMBIVENT RESPIMAT AEROSOL

    [T2] [QL]

    COMBIVIR TABLET [T3] [BP]

    COMETRIQ KIT [T4] [PA][SP]

    COMPLETE NATAL DHA MISC [T2]

    COMPLETENATE CHEW TAB [T2]

    compro suppository [T1]

    COMTAN TABLET [T3] [BP]

    CONCEPT DHA CAPSULE [T3]

    CONCEPT OB CAPSULE [T3]

    CONCEPTROL GEL [T2] [ACA]

    CONCERTA TABLET [T3] [QL][BP]

    CONDOM MISC [T2] [ACA]

    CONDYLOX GEL [T3]

    CONSENSI TABLET [T3]

    constulose solution [T1]

    COPAXONE INJECTION [T4] [PA][SP][BP]

    COPIKTRA CAPSULE [T4] [PA][SP]

    CORDRAN CREAM [T3]

    COREG CR 24 HOUR CAP [T3] [BP]

    CORGARD TABLET [T3] [BP]

    CORLANOR SOLUTION [T2] [QL]

    CORLANOR TABLET [T2] [QL]

    correctol tablet [T1] [ACA]

    CORTEF TABLET [T3] [BP]

    CORTENEMA ENEMA [T3] [BP]

    cortisone tablet [T1]

    CORTISPORIN CREAM [T3]

    CORTISPORIN OINTMENT [T3]

    CORTISPORIN-TC SUSPENSION

    [T3]

    COSENTYX INJECTION [T4] [PA][SP]

    COSENTYX SENSOREADY PEN INJECTION

    [T4] [PA][SP]

    COSOPT PF SOLUTION [T3] [BP]

    COTELLIC TABLET [T4] [PA][SP]

    covaryx hs tablet [T1]

    covaryx tablet [T1]

    CREON CAPSULE [T2]

    CRESEMBA CAPSULE [T2] [PA]

    CRINONE GEL [T2]

    CRIXIVAN CAPSULE [T2]

    cromolyn sodium [T1]

    cromolyn sodium nebulized [T1]

    cromolyn sodium solution [T1]

    crotan lotion [T1]

    cryselle-28 tablet [T1] [ACA]

    CUROSURF SUSPENSION [T3]

    CUVPOSA SOLUTION [T3]

    cvs aspirin ec tablet [T1] [ACA]

    cvs aspirin low dose tablet [T1] [ACA]

    cvs aspirin low strength tablet

    [T1] [ACA]

    cvs aspirin tablet [T1] [ACA]

    cvs bisacodyl tablet [T1] [ACA]

    cvs folic acid tablet [T1] [ACA]

    cvs gentle laxative tablet [T1] [ACA]

    cvs magnesium solution [T1] [ACA]

    cvs nicotine lozenge [T1] [ACA]

    cvs nicotine polacrilex gum [T1] [ACA]

    cvs nicotine polacrilex lozenge

    [T1] [ACA]

    cvs nicotine transdermal patch

    [T1] [ACA]

    cvs of magnesia solution [T1] [ACA]

    cvs purelax packet [T1] [ACA]

    cvs purelax powder [T1] [ACA]

    cyclafem 1/35 tablet [T1] [ACA]

    cyclafem 7/7/7 tablet [T1] [ACA]

    cyclobenzaprine 24 hour cap [T1]

    cyclobenzaprine tablet [T1]

    CYCLOGYL SOLUTION [T3] [BP]

    CYCLOMYDRIL SOLUTION [T3]

    cyclopentolate solution [T1]

    CYCLOPENTOLATE-TROPICAMIDE-PE SOLUTION

    [T3]

    cyclophosphamide capsule [T1] [BP]

    cycloserine capsule [T1]

    cyclosporine capsule [T1]

    cyclosporine modified capsule

    [T1]

    cyclosporine modified solution

    [T1]

    cyproheptadine syrup [T1]

    cyproheptadine tablet [T1]

    cyred eq tablet [T1] [ACA]

    cyred tablet [T1] [ACA]

    CYSTADANE POWDER [T4] [PA][SP]

    CYSTAGON CAPSULE [T4] [PA][SP]

    CYSTARAN SOLUTION [T4] [PA][SP]

    CYSTO-CONRAY II SOLUTION [T3]

    CYSTOGRAFIN SOLUTION [T3]

    CYSTOGRAFIN-DILUTE SOLUTION

    [T3]

    CYTOTEC TABLET [T3] [BP]

    DD.H.E. 45 SOLUTION [T3] [QL][BP]

    10www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • DALFAMPRIDINE ER 12 HR TAB

    [T4] [PA][SP]

    DALIRESP TABLET [T2]

    danazol capsule [T1]

    DANTRIUM CAPSULE [T3] [BP]

    dantrolene sodium capsule [T1]

    dapsone gel [T1]

    dapsone tablet [T1]

    DAPTACEL SUSPENSION [T2] [ACA]

    DARAPRIM TABLET [T4] [PA][SP][BP]

    darifenacin 24 hr tab [T1]

    dasetta 1/35 tablet [T1] [ACA]

    dasetta 7/7/7 tablet [T1] [ACA]

    DAURISMO TABLET [T4] [PA][SP]

    DAYPRO TABLET [T3] [BP]

    daysee tablet [T1] [ACA]

    DAYTRANA PATCH [T2] [QL]

    DDAVP SOLUTION [T2] [BP]

    DDAVP TABLET [T3] [BP]

    deblitane tablet [T1] [ACA]

    decadron tablet [T1]

    DEFERASIROX PACKET [T4] [PA][SP]

    DEFERASIROX TABLET [T4] [PA][SP]

    deluo solution [T1]

    delyla tablet [T1] [ACA]

    demeclocycline tablet [T1]

    DEMSER CAPSULE [T4] [PA][SP]

    DENAVIR CREAM [T3]

    DEPAKOTE ER 24 HR TAB [T3] [BP]

    DEPAKOTE SPRINKLES CAPSULE

    [T3] [BP]

    DEPAKOTE TABLET [T3] [BP]

    DEPEN TITRATABS TABLET [T2] [BP]

    DEPO-PROVERA INJECTION [T3] [BP]

    DEPO-PROVERA SUSPENSION [T3] [BP]

    DEPO-SUBQ PROVERA 104 INJECTION

    [T3] [ACA]

    DEPO-TESTOSTERONE SOLUTION

    [T3] [BP]

    DERMAGRAFT [T3]

    DERMOTIC OIL [T3] [BP]

    DESCOVY TABLET [T2] [QL]

    desflurane solution [T1]

    desipramine tablet [T1]

    desloratadine odt tablet [T1]

    desloratadine tablet [T1]

    desmopressin solution [T1]

    desmopressin tablet [T1]

    desogestrel-ethinyl estradiol tablet

    [T1] [ACA]

    desogestr-eth estrad eth estra tablet

    [T1] [ACA]

    desonide ointment [T1]

    desoximetasone cream [T1]

    desoximetasone ointment [T1]

    DESOXYN TABLET [T3] [BP]

    desvenlafaxine er 24 hr tab [T1]

    dexamethasone elixir [T1]

    dexamethasone intensol [T1]

    dexamethasone sodium phosphate solution

    [T1]

    dexamethasone solution [T1]

    dexamethasone tablet [T1]

    DEXEDRINE 24 HOUR CAP [T3] [BP]

    dexmethylphenidate er 24 hour cap

    [T1] [QL]

    dexmethylphenidate tablet [T1]

    DEXTENZA [T3] [PA]

    dextroamphetamine sulfate er 24 hour cap

    [T1]

    dextroamphetamine sulfate solution

    [T1]

    dextroamphetamine sulfate tablet

    [T1]

    dextroamphetamine-amphet er 24 hour cap

    [T1] [QL]

    dextroamphetamine-amphetamine tablet

    [T1]

    DIACOMIT CAPSULE [T4] [PA][SP]

    DIACOMIT PACKET [T4] [PA][SP]

    DIASTAT ACUDIAL GEL [T3]

    DIASTAT PEDIATRIC GEL [T3]

    diazepam [T1]

    diazepam intensol [T1]

    diazepam rectal [T1]

    diazepam solution [T1]

    diazepam tablet [T1]

    diazoxide suspension [T1]

    DIBENZYLINE CAPSULE [T4] [PA][SP][BP]

    diclofenac potassium tablet [T1]

    diclofenac sodium dr tablet [T1]

    diclofenac sodium er 24 hr tab

    [T1]

    diclofenac sodium gel [T1] [PA]

    diclofenac sodium solution [T1]

    diclofenac sodium-misoprostol tablet

    [T1]

    dicloxacillin sodium capsule [T1]

    dicyclomine capsule [T1]

    dicyclomine solution [T1]

    dicyclomine tablet [T1]

    didanosine capsule (delayed release)

    [T1]

    DIFFERIN CREAM [T3] [BP]

    DIFFERIN GEL [T3] [BP]

    DIFFERIN LOTION [T3]

    DIFICID TABLET [T3] [QL]

    diflorasone diacetate ointment

    [T1]

    DIFLUCAN SUSPENSION [T3] [BP]

    DIFLUCAN TABLET [T3] [BP]

    diflunisal tablet [T1]

    digitek tablet [T1]

    digox tablet [T1]

    digoxin solution [T1]

    digoxin tablet [T1]

    dihydroergotamine mesylate solution

    [T1] [QL]

    DILANTIN CAPSULE [T2] [BP]

    DILANTIN INFATABS CHEW TAB

    [T3] [BP]

    DILANTIN-125 SUSPENSION [T3] [BP]

    DILATRATE SR CAPSULE [T2]

    DILAUDID LIQUID [T3] [BP]

    DILAUDID TABLET [T3] [BP]

    diltiazem 24hr er (cd) 24 hour cap

    [T1]

    diltiazem cd 24 hour cap [T1]

    diltiazem er 24 hour cap [T1]

    diltiazem er 24 hr tab [T1]

    diltiazem er capsule [T1]

    diltiazem tablet [T1]

    dilt-xr 24 hour cap [T1]

    DIMETHYL FUMARATE CAPSULE (DELAYED RELEASE)

    [T4] [PA][SP]

    DIPENTUM CAPSULE [T3]

    diphen elixir [T1]

    diphenhydramine elixir [T1]

    diphenhydramine solution [T1]

    diphenoxylate w/atropine tablet

    [T1]

    diphenoxylate/atropine liquid

    [T1]

    diphenoxylate/atropine tablet

    [T1]

    DIPHTHERIA-TETANUS TOXOIDS-PED SUSPENSION

    [T2] [ACA]

    11www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • DIPROLENE OINTMENT [T3] [BP]

    dipyridamole tablet [T1]

    disopyramide phosphate capsule

    [T1]

    disulfiram tablet [T1]

    DITROPAN XL 24 HR TAB [T3] [BP]

    DIURIL SUSPENSION [T3]

    divalproex sodium capsule [T1]

    divalproex sodium dr tablet [T1]

    divalproex sodium er 24 hr tab

    [T1]

    DIVIGEL GEL [T2]

    dofetilide capsule [T1]

    DOLOPHINE TABLET [T3] [BP]

    donepezil tablet [T1]

    DOPTELET TABLET [T4] [PA][SP]

    DORAL TABLET [T3]

    DORYX TABLET [T3] [BP]

    dorzolamide solution [T1]

    dorzolamide-timolol solution [T1]

    dotti patch [T1] [QL]

    DOVATO TABLET [T2] [QL]

    DOVONEX CREAM [T3] [BP]

    doxazosin mesylate tablet [T1]

    doxazosin tablet [T1]

    doxepin [T1]

    doxepin capsule [T1]

    doxepin cream [T1] [QL]

    doxepin tablet [T1]

    doxercalciferol capsule [T1]

    doxycycline hyclate capsule [T1]

    doxycycline hyclate dr tablet [T1]

    doxycycline hyclate tablet [T1]

    doxycycline monohydrate capsule

    [T1]

    doxycycline monohydrate tablet

    [T1]

    doxycycline suspension [T1]

    doxycycline tablet [T1]

    doxylamine succ-pyridoxine tablet

    [T1]

    DRISDOL CAPSULE [T3] [BP]

    dronabinol capsule [T1] [QL]

    drospirenone-ethinyl estradiol tablet

    [T1] [ACA]

    DROXIA CAPSULE [T2]

    DUAKLIR PRESSAIR AEROSOL [T3] [PA][QL]

    DUAVEE TABLET [T2]

    ducodyl tablet [T1] [ACA]

    DUET DHA 400 MISC [T3]

    DUET DHA BALANCED MISC [T3]

    DUETACT TABLET [T3] [BP]

    DULERA AEROSOL [T2] [QL]

    duloxetine capsule [T1]

    DUOPA SUSPENSION [T3]

    DUPIXENT INJECTION [T4] [PA][SP]

    DURAGESIC PATCH [T3] [QL][BP]

    DUREX REALFEEL NONLATEX [T3] [ACA]

    DUREZOL EMULSION [T3]

    dutasteride capsule [T1]

    dutasteride-tamsulosin capsule

    [T1]

    DYAZIDE CAPSULE [T3] [BP]

    DYMISTA SUSPENSION [T2] [QL][BP]

    DYRENIUM CAPSULE [T3] [BP]

    EE.E.S. GRANULES SUSPENSION

    [T3] [BP]

    EC-NAPROSYN TABLET [T3] [BP]

    ec-naproxen tablet [T1]

    ECONASIL KIT [T3]

    econazole nitrate cream [T1]

    econtra ez tablet [T1] [ACA]

    econtra one-step tablet [T1] [ACA]

    ecotrin low strength tablet [T1] [ACA]

    ecotrin tablet [T1] [ACA]

    ecpirin tablet [T1] [ACA]

    EDARBI TABLET [T2]

    EDECRIN TABLET [T3] [BP]

    ed-spaz tablet [T1]

    EDURANT TABLET [T2]

    eemt hs tablet [T1]

    eemt tablet [T1]

    efavirenz capsule [T1]

    efavirenz tablet [T1]

    EFFER-K TABLET (EFF) [T3]

    EFFIENT TABLET [T3] [BP]

    EFUDEX CREAM [T3] [BP]

    eletriptan tablet [T1] [QL]

    ELIGARD KIT [T4] [PA][SP][QL]

    ELIMITE CREAM [T3] [BP]

    elinest tablet [T1] [ACA]

    ELIQUIS STARTER PACK TABLET

    [T2]

    ELIQUIS TABLET [T2]

    ELITE-OB TABLET [T2]

    ELIXOPHYLLIN ELIXIR [T3]

    ELLA TABLET [T3]

    ELMIRON CAPSULE [T2]

    eluryng [T1] [ACA][QL]

    EMCYT CAPSULE [T4] [PA][SP]

    EMGALITY INJECTION [T2] [PA]

    emoquette tablet [T1] [ACA]

    EMSAM PATCH [T3] [QL]

    EMTRIVA CAPSULE [T2] [BP]

    EMTRIVA SOLUTION [T2]

    EMVERM CHEW TAB [T2] [PA]

    ENABLEX 24 HR TAB [T3] [BP]

    enalapril maleate tablet [T1]

    enalapril maleate/hctz tablet [T1]

    ENBRACE HR CAPSULE [T3]

    ENBREL INJECTION [T4] [PA][SP]

    ENBREL MINI INJECTION [T4] [PA][SP]

    ENBREL SOLUTION [T4] [PA][SP]

    ENBREL SURECLICK INJECTION

    [T4] [PA][SP]

    ENDARI PACKET [T4] [PA][SP]

    ENDO-AVITENE MISC [T3]

    endocet tablet [T1]

    ENDOFORM [T3]

    ENDOFORM DERMAL TEMPLATE

    [T3]

    ENGERIX-B SUSPENSION [T2] [ACA]

    ENLITE GLUCOSE SENSOR MISC

    [T3] [PA]

    enoxaparin sodium solution [T1]

    enpresse-28 tablet [T1] [ACA]

    enskyce tablet [T1] [ACA]

    entacapone tablet [T1]

    ENTECAVIR TABLET [T4] [PA][SP]

    ENTEREG CAPSULE [T4] [PA][SP]

    ENTOCORT EC CAPSULE [T3] [BP]

    ENTRESTO TABLET [T2] [QL]

    enulose solution [T1]

    EPCLUSA TABLET [T4] [PA][SP]

    EPIDIOLEX SOLUTION [T4] [PA][SP]

    EPIDUO FORTE GEL [T2]

    EPIDUO GEL [T3] [BP]

    EPIFIX 14MM [T3]

    EPIFIX 2CM X 3CM [T3]

    EPIFIX 4CM X 4CM [T3]

    12www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • EPIFIX 5CM X 6CM [T3]

    EPIFIX 7CM X 7CM [T3]

    EPIFOAM FOAM [T3]

    epinastine solution [T1]

    epinephrine injection [T1] [QL]

    epinephrine solution [T1] [QL]

    EPIPEN 2-PAK INJECTION [T2] [QL][BP]

    EPIPEN-JR 2-PAK INJECTION [T2] [QL][BP]

    epitol tablet [T1]

    EPIVIR HBV SOLUTION [T4] [PA][SP]

    EPIVIR HBV TABLET [T4] [PA][SP][BP]

    EPIVIR SOLUTION [T3] [BP]

    EPIVIR TABLET [T3] [BP]

    eplerenone tablet [T1]

    EPZICOM TABLET [T3] [BP]

    eq aspirin low dose chew tab [T1] [ACA]

    eq aspirin tablet [T1] [ACA]

    eq childrens aspirin chew tab [T1] [ACA]

    eq clearlax powder [T1] [ACA]

    eq gentle laxative tablet [T1] [ACA]

    eq magnesium solution [T1] [ACA]

    eq nicotine lozenge [T1] [ACA]

    eq nicotine lozenges [T1] [ACA]

    eq nicotine patch [T1] [ACA]

    eq nicotine polacrilex gum [T1] [ACA]

    eq nicotine polacrilex lozenge

    [T1] [ACA]

    eq nicotine step 3 patch [T1] [ACA]

    eql aspirin ec tablet [T1] [ACA]

    eql aspirin low dose chew tab

    [T1] [ACA]

    eql aspirin low dose tablet [T1] [ACA]

    eql aspirin tablet [T1] [ACA]

    eql clearlax powder [T1] [ACA]

    eql gentle laxative tablet [T1] [ACA]

    eql magnesium solution [T1] [ACA]

    eql nicotine polacrilex gum [T1] [ACA]

    eql nicotine polacrilex lozenge

    [T1] [ACA]

    ergoloid mesylates tablet [T1]

    ERGOMAR SL [T3]

    ergotamine-caffeine tablet [T1]

    ERIVEDGE CAPSULE [T4] [PA][SP]

    ERLEADA TABLET [T4] [PA][SP]

    ERLOTINIB TABLET [T4] [PA][SP]

    errin tablet [T1] [ACA]

    ERTACZO CREAM [T3]

    ery pads [T1]

    erygel gel [T1] [BP]

    ERYPED 200 SUSPENSION [T3] [BP]

    ERYPED 400 SUSPENSION [T3] [BP]

    ery-tab tablet [T1]

    erythrocin stearate tablet [T1]

    erythromycin base tablet [T1]

    erythromycin capsule [T1]

    erythromycin dr tablet [T1]

    erythromycin ethylsuccinate suspension

    [T1]

    erythromycin ethylsuccinate tablet

    [T1]

    erythromycin gel [T1]

    erythromycin ointment [T1]

    erythromycin solution [T1]

    erythromycin-benzoyl peroxide gel

    [T1]

    ESBRIET CAPSULE [T4] [PA][SP]

    ESBRIET TABLET [T4] [PA][SP]

    escitalopram oxalate solution

    [T1]

    escitalopram oxalate tablet [T1]

    ESGIC TABLET [T3] [BP]

    esomeprazole magnesium capsule (delayed release)

    [T1]

    esomeprazole magnesium packet

    [T1]

    ESOMEPRAZOLE STRONTIUM CAPSULE (DELAYED RELEASE)

    [T3]

    estarylla tablet [T1] [ACA]

    estazolam tablet [T1]

    ESTRACE CREAM [T3] [BP]

    ESTRACE TABLET [T3] [BP]

    estradiol cream [T1]

    estradiol patch [T1] [QL]

    estradiol tablet [T1]

    estradiol-norethindrone acetat tablet

    [T1]

    ESTRING [T2] [QL]

    estrogen & methyltestosterone tablet

    [T1]

    ESTROSTEP FE TABLET [T3] [BP]

    eszopiclone tablet [T1] [QL]

    ethacrynic acid tablet [T1]

    ethambutol tablet [T1]

    ethosuximide capsule [T1]

    ethosuximide solution [T1]

    ethynodiol-ethinyl estradiol tablet

    [T1] [ACA]

    etodolac capsule [T1]

    etodolac er 24 hr tab [T1]

    etodolac tablet [T1]

    etonogestrelethinyl estradiol

    [T1] [ACA][QL]

    ETOPOSIDE CAPSULE [T4] [PA][SP]

    EUCRISA OINTMENT [T3]

    euthyrox tablet [T1]

    everolimus tablet [T1] [PA][SP]

    EVERSENSE SENSOR/HOLDER MISC

    [T3] [PA]

    EVERSENSE SMART TRANSMITTER MISC

    [T3] [PA]

    EVISTA TABLET [T3] [BP]

    EVOCLIN FOAM [T3] [BP]

    EVOTAZ TABLET [T3]

    EVOXAC CAPSULE [T3] [BP]

    EXELDERM CREAM [T3]

    EXELDERM SOLUTION [T3]

    EXELON PATCH [T3] [BP]

    exemestane tablet [T1]

    ezetimibe tablet [T1] [QL]

    ezetimibe/simvastatin tablet [T1] [QL]

    E-Z-HD SUSPENSION [T3]

    E-Z-PAQUE SUSPENSION [T3]

    Ffa-8 capsule [T1] [ACA]

    falmina tablet [T1] [ACA]

    famciclovir tablet [T1]

    famotidine suspension [T1]

    famotidine tablet [T1]

    FANAPT TABLET [T3] [QL]

    FANAPT TITRATION PACK TABLET

    [T3] [QL]

    FANTASY LUBRICATED MISC [T2] [ACA]

    FANTASY MISC [T2] [ACA]

    FARESTON TABLET [T3] [BP]

    FARXIGA TABLET [T2] [QL]

    FARYDAK CAPSULE [T4] [PA][SP]

    FASENRA PEN INJECTION [T4] [PA][SP]

    fayosim tablet [T1] [ACA]

    FC2 FEMALE CONDOM MISC [T2] [ACA]

    febuxostat tablet [T1]

    felbamate suspension [T1]

    felbamate tablet [T1]

    13www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • FELBATOL SUSPENSION [T3] [BP]

    FELBATOL TABLET [T3] [BP]

    FELDENE CAPSULE [T3] [BP]

    felodipine er 24 hr tab [T1]

    FEMARA TABLET [T3] [BP]

    FEMCAP [T2] [ACA]

    FEMHRT LOW DOSE TABLET [T3] [BP]

    femynor tablet [T1] [ACA]

    fenofibrate capsule [T1]

    fenofibrate micronized capsule

    [T1]

    fenofibrate tablet [T1]

    fenofibric acid dr capsule (delayed release)

    [T1]

    fenofibric acid tablet [T1]

    fenoprofen calcium tablet [T1]

    fentanyl lollipop [T1] [QL]

    fentanyl patch [T1] [QL]

    FERRIPROX SOLUTION [T4] [PA][SP]

    FERRIPROX TABLET [T4] [PA][SP]

    FERRIPROX TWICE-A-DAY TABLET

    [T4] [PA][SP]

    FETZIMA 24 HOUR CAP [T2] [QL]

    FETZIMA TITRATION PACK CAPSULE

    [T2] [QL]

    FIASP PENFILL INJECTION [T3] [QL]

    FIBRICOR TABLET [T3]

    FINACEA FOAM [T2]

    FINACEA GEL [T3] [BP]

    finasteride tablet [T1]

    FIORICET/CODEINE CAPSULE [T3]

    FIORINAL CAPSULE [T3] [BP]

    FIORINAL/CODEINE #3 CAPSULE

    [T3] [BP]

    FIRAZYR SOLUTION [T4] [PA][SP][BP]

    FIRDAPSE TABLET [T4] [PA][SP]

    FIRVANQ SOLUTION [T3]

    flac oil [T1]

    FLAGYL CAPSULE [T3] [BP]

    FLAGYL TABLET [T3] [BP]

    FLAREX SUSPENSION [T3]

    flavoxate tablet [T1]

    flecainide tablet [T1]

    FLECTOR PATCH [T2]

    FLOMAX CAPSULE [T3] [BP]

    FLORIVA PLUS SOLUTION [T3]

    FLOVENT DISKUS AEROSOL [T2] [QL]

    FLOVENT HFA AEROSOL [T2] [QL]

    FLUAD 2020-2021 INJECTION [T2] [ACA]

    FLUAD QUAD 2020-2021 INJECTION

    [T2] [ACA]

    FLUARIX INJECTION [T2] [ACA]

    FLUBLOK QUAD 2020-2021 INJECTION

    [T2] [ACA]

    FLUCELVAX QUAD 2020-2021 INJECTION

    [T2] [ACA]

    FLUCELVAX QUAD 2020-2021 SUSPENSION

    [T2] [ACA]

    fluconazole suspension [T1]

    fluconazole tablet [T1]

    flucytosine capsule [T1] [PA]

    fludrocortisone tablet [T1]

    FLULAVAL INJECTION [T2] [ACA]

    FLUMIST QUADRIVALENT SUSPENSION

    [T3] [ACA]

    flunisolide solution [T1] [QL]

    fluocinolone acetonide cream

    [T1]

    fluocinolone acetonide oil [T1]

    fluocinolone acetonide oil [T1]

    fluocinolone acetonide ointment

    [T1]

    fluocinolone acetonide solution

    [T1]

    fluocinonide cream [T1] [QL]

    fluocinonide emulsified cream

    [T1]

    fluocinonide ointment [T1]

    fluocinonide solution [T1]

    fluocinonide-e cream [T1]

    FLUOPAR KIT [T3]

    fluoride chew tab [T1] [ACA]

    fluoritab chew tab [T1] [ACA]

    fluorometholone suspension [T1]

    FLUOROPLEX CREAM [T3]

    fluorouracil cream [T1]

    fluorouracil solution [T1]

    fluoxetine capsule [T1]

    fluoxetine solution [T1]

    fluoxetine tablet [T1]

    fluphenazine [T1]

    fluphenazine elixir [T1]

    fluphenazine tablet [T1]

    flurazepam capsule [T1]

    flurbiprofen sodium solution [T1]

    flurbiprofen tablet [T1]

    flutamide capsule [T1]

    fluticasone cream [T1]

    fluticasone ointment [T1]

    fluticasone suspension [T1] [QL]

    fluticasone-salmeterol aerosol

    [T1] [QL]

    fluvastatin capsule [T1] [QL]

    fluvoxamine maleate tablet [T1]

    FLUZONE HIGH-DOSE QUAD 2020-21 INJECTION

    [T2] [ACA]

    FLUZONE QUAD 2020-2021 INJECTION

    [T2] [ACA]

    FLUZONE QUAD 2020-2021 SUSPENSION

    [T2] [ACA]

    FML LIQUIFILM SUSPENSION [T3]

    folate tablet [T1] [ACA]

    folic acid capsule [T1] [ACA]

    folic acid tablet [T1] [ACA]

    FOLIVANE-OB CAPSULE [T2]

    fondaparinux sodium solution

    [T1]

    forane solution [T1] [BP]

    FORAXA EMULSION [T3]

    FORTAVIT CAPSULE [T3]

    FORTEO INJECTION [T4] [PA][SP]

    FOSAMAX TABLET [T3] [QL][BP]

    fosamprenavir calcium tablet [T1]

    fosinopril sodium tablet [T1]

    fosinopril-hydrochlorothiazide tablet

    [T1]

    FRAGMIN SOLUTION [T2]

    FREESTYLE FREEDOM KIT [T2] [QL]

    FREESTYLE FREEDOM LITE KIT

    [T2] [QL]

    FREESTYLE INSULINX BLOOD KIT

    [T2] [QL]

    FREESTYLE INSULINX BLOOD STRIP

    [T2] [QL]

    FREESTYLE LIBRE READER [T2] [PA]

    FREESTYLE LIBRE SENSOR MISC

    [T2] [PA]

    FREESTYLE LITE METER [T2] [QL]

    FREESTYLE LITE STRIPS [T2] [QL]

    FREESTYLE LITE TEST STRIPS [T2] [QL]

    FREESTYLE TEST STRIPS [T2] [QL]

    FROVA TABLET [T3] [QL][BP]

    frovatriptan tablet [T1] [QL]

    FULPHILA INJECTION [T4] [PA][SP]

    furosemide solution [T1]

    furosemide tablet [T1]

    FUZEON SOLUTION [T4] [PA][SP]

    14www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • fyavolv tablet [T1]

    FYCOMPA SUSPENSION [T2]

    FYCOMPA TABLET [T2]

    Ggabapentin capsule [T1]

    gabapentin solution [T1]

    gabapentin tablet [T1]

    GABITRIL TABLET [T3] [BP]

    GALAFOLD CAPSULE [T4] [PA][SP]

    galantamine 24 hour cap [T1]

    galantamine solution [T1]

    galantamine tablet [T1]

    GALZIN CAPSULE [T3]

    GARDASIL 9 INJECTION [T2] [ACA]

    GARDASIL 9 SUSPENSION [T2] [ACA]

    GASTROCROM [T3] [BP]

    GASTROGRAFIN SOLUTION [T3] [BP]

    gatifloxacin solution [T1]

    GATTEX KIT [T4] [PA][SP]

    gavilax powder [T1] [ACA]

    gavilyte-c solution [T1] [ACA]

    gavilyte-g solution [T1] [ACA]

    gavilyte-h kit [T1] [ACA]

    gavilyte-n/flavor pack solution

    [T1] [ACA]

    GELFILM ENVELOPE FILM [T3]

    GEL-FLOW NT INJECTION [T3]

    GELFOAM DENTAL PACK MISC

    [T3]

    GELFOAM MISC [T3]

    GELFOAM POWDER [T3]

    GELFOAM SPONGE MISC [T3]

    GELNIQUE GEL [T2]

    gemfibrozil tablet [T1]

    GENERESS FE CHEW TAB [T3] [BP]

    generlac solution [T1]

    gengraf capsule [T1]

    gengraf solution [T1]

    GENOTROPIN MINIQUICK SOLUTION

    [T4] [PA][SP]

    GENOTROPIN SOLUTION [T4] [PA][SP]

    gentak ointment [T1]

    gentamicin sulfate cream [T1]

    gentamicin sulfate ointment [T1]

    gentamicin sulfate solution [T1]

    gentle laxative tablet [T1] [ACA]

    gentlelax powder [T1] [ACA]

    GENVOYA TABLET [T2] [QL]

    GEODON CAPSULE [T3] [BP]

    gianvi tablet [T1] [ACA]

    GILENYA CAPSULE [T4] [PA][SP]

    GILOTRIF TABLET [T4] [PA][SP]

    GLATIRAMER INJECTION [T4] [PA][SP]

    GLATOPA INJECTION [T4] [PA][SP]

    GLEOLAN SOLUTION [T3]

    GLEOSTINE CAPSULE [T4] [PA][SP]

    glimepiride tablet [T1]

    glipizide er 24 hr tab [T1]

    glipizide tablet [T1]

    glipizide xl 24 hr tab [T1]

    glipizide-metformin tablet [T1]

    GLOPERBA SOLUTION [T3] [PA]

    GLUCAGEN DIAGNOSTIC SOLUTION

    [T2]

    GLUCAGEN HYPOKIT SOLUTION

    [T2]

    GLUCAGON EMERGENCY KIT [T2]

    GLUCOCOM AUTOLINK MISC [T3] [QL]

    GLUCOTROL TABLET [T3] [BP]

    GLUCOTROL XL 24 HR TAB [T3] [BP]

    glyburide micronized tablet [T1]

    glyburide tablet [T1]

    glyburide-metformin tablet [T1]

    GLYCATE TABLET [T3]

    glycine solution [T1]

    glycolax powder [T1] [ACA]

    glycopyrrolate tablet [T1]

    glydo injection [T1]

    GLYNASE TABLET [T3] [BP]

    GLYSET TABLET [T3] [BP]

    GLYTACTIN 10 PE COMPLETE BAR

    [T3]

    GLYTACTIN 15 PE COMPLETE BAR

    [T2]

    GLYTACTIN COMPLETE 10PE BAR

    [T3]

    GLYXAMBI TABLET [T2] [QL]

    gnp aspirin low dose tablet [T1] [ACA]

    gnp aspirin tablet [T1] [ACA]

    gnp bisa-lax tablet [T1] [ACA]

    gnp clearlax packet [T1] [ACA]

    gnp clearlax powder [T1] [ACA]

    gnp folic acid tablet [T1] [ACA]

    gnp gentle laxative tablet [T1] [ACA]

    gnp laxative tablet [T1] [ACA]

    gnp magnesium solution [T1] [ACA]

    gnp nicotine gum [T1] [ACA]

    gnp nicotine polacrilex gum [T1] [ACA]

    gnp nicotine polacrilex lozenge

    [T1] [ACA]

    gnp nicotine transdermal patch

    [T1] [ACA]

    GOLYTELY SOLUTION [T3] [BP]

    GONITRO PACKET [T3]

    goodsense aspirin chew tab [T1] [ACA]

    goodsense aspirin tablet [T1] [ACA]

    goodsense bisacodyl ec tablet

    [T1] [ACA]

    goodsense clearlax powder [T1] [ACA]

    goodsense nicotine gum [T1] [ACA]

    goodsense nicotine lozenge [T1] [ACA]

    GOPRELTO SOLUTION [T3]

    GRAFIX CORE 1.5CM X 2CM MISC

    [T3]

    GRAFIX CORE 16MM MISC [T3]

    GRAFIX CORE 2CM X 3CM MISC

    [T3]

    GRAFIX CORE 3CM X 4CM MISC

    [T3]

    GRAFIX CORE 5CM X 5CM MISC

    [T3]

    GRAFIX PRIME 1.5CM X 2CM MISC

    [T3]

    GRAFIX PRIME 16MM MISC [T3]

    GRAFIX PRIME 2CM X 3CM MISC

    [T3]

    GRAFIX PRIME 3CM X 4CM MISC

    [T3]

    GRAFIX PRIME 5CM X 5CM MISC

    [T3]

    GRAFIX XC 7.5 X 15CM MISC [T3]

    granisetron tablet [T1] [QL]

    griseofulvin microsize suspension

    [T1]

    griseofulvin microsize tablet [T1]

    griseofulvin ultramicrosize tablet

    [T1]

    guanfacine 24 hr tab [T1] [QL]

    guanfacine er 24 hr tab [T1] [QL]

    guanfacine tablet [T1]

    guanidine tablet [T1]

    GUARDIAN CONNECT TRANSMITTER MISC

    [T3] [PA]

    GUARDIAN LINK 3 MISC [T3] [PA]

    GUARDIAN REAL-TIME KIT [T3] [PA]

    15www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • GUARDIAN RT CHARGER MISC

    [T3] [PA]

    GUARDIAN RT STARTER KIT [T3] [PA]

    GUARDIAN RT SYSTEM [T3] [PA]

    GUARDIAN SENSOR 3 MISC [T3] [PA]

    GUARDIAN TEST PLUG MISC [T3] [PA]

    GVOKE HYPOPEN 1-PACK INJECTION

    [T2]

    GVOKE HYPOPEN 2-PACK INJECTION

    [T2]

    GVOKE PFS INJECTION [T2]

    GYNAZOLE-1 CREAM [T3]

    HHAEGARDA SOLUTION [T4] [PA][SP]

    hailey 1.5/30 tablet [T1] [ACA]

    hailey 24 fe tablet [T1] [ACA]

    hailey fe 1.5/30 tablet [T1] [ACA]

    hailey fe 1/20 tablet [T1] [ACA]

    halcinonide cream [T1]

    HALCION TABLET [T3] [BP]

    HALOG SOLUTION [T3]

    haloperidol [T1]

    haloperidol tablet [T1]

    HALUCORT GEL [T3]

    HARVONI PACKET [T4] [PA][SP]

    HARVONI TABLET [T4] [PA][SP]

    HAVRIX SUSPENSION [T2] [ACA]

    hc pramoxine cream [T1]

    healthylax packet [T1] [ACA]

    heather tablet [T1] [ACA]

    HELIDAC THERAPY MISC [T3]

    HEMANGEOL SOLUTION [T4] [PA][SP]

    heparin sodium dcu solution [T1]

    HEPARIN SODIUM INJECTION [T3]

    heparin sodium solution [T1]

    HEPLISAV-B INJECTION [T3] [ACA]

    HEPSERA TABLET [T4] [PA][SP][BP]

    HETLIOZ CAPSULE [T4] [PA][SP]

    HIBERIX SOLUTION [T2] [ACA]

    HIPREX TABLET [T3] [BP]

    hm aspirin chew tab [T1] [ACA]

    hm aspirin ec low dose tablet [T1] [ACA]

    hm aspirin ec tablet [T1] [ACA]

    hm aspirin tablet [T1] [ACA]

    hm clearlax powder [T1] [ACA]

    hm folic acid tablet [T1] [ACA]

    hm laxative tablet [T1] [ACA]

    hm magnesium solution [T1] [ACA]

    hm nicotine polacrilex gum [T1] [ACA]

    hm nicotine polacrilex lozenge

    [T1] [ACA]

    hpr foam [T1]

    hpr plus cream [T1]

    hpr plus foam [T1]

    HPR PLUS/MB HYDROGEL KIT [T3]

    HUMALOG INJECTION [T2] [QL]

    HUMALOG JUNIOR KWIKPEN INJECTION

    [T2] [QL]

    HUMALOG KWIKPEN INJECTION

    [T2] [QL]

    HUMALOG MIX 50/50 SUSPENSION

    [T2] [QL]

    HUMALOG MIX 50-50 SUSPENSION

    [T2] [QL]

    HUMALOG MIX 75/25 SUSPENSION

    [T2] [QL]

    HUMALOG MIX 75-25 SUSPENSION

    [T2] [QL]

    HUMALOG SOLUTION [T2] [QL]

    HUMIRA INJECTION [T4] [PA][SP]

    HUMIRA PEDIATRIC INJECTION

    [T4] [PA][SP]

    HUMIRA PEN INJECTION [T4] [PA][SP]

    HUMIRA PEN-PS/UV STARTER INJECTION

    [T4] [PA][SP]

    HUMULIN 70/30 KWIKPEN SUSPENSION

    [T2] [QL]

    HUMULIN 70/30 SUSPENSION

    [T2] [QL]

    HUMULIN N KWIKPEN SUSPENSION

    [T2] [QL]

    HUMULIN N SUSPENSION [T2] [QL]

    HUMULIN R SOLUTION [T2] [QL]

    HUMULIN R U-500 KWIKPEN INJECTION

    [T2] [QL]

    HYCAMTIN CAPSULE [T4] [PA][SP]

    HYCLODEX SOLUTION [T3]

    hydralazine tablet [T1]

    HYDREA CAPSULE [T3] [BP]

    hydrochlorothiazide capsule [T1]

    hydrochlorothiazide tablet [T1]

    hydrocodone bitartrate capsule (cr)

    [T1] [QL]

    hydrocodone w/acetaminophen solution

    [T1]

    hydrocodone w/acetaminophen tablet

    [T1]

    hydrocodone/homatropine syrup

    [T1]

    hydrocodone/homatropine tablet

    [T1]

    hydrocodone/ibuprofen tablet

    [T1]

    hydrocodone-chlorpheniramine suspension

    [T1] [QL]

    hydrocortisone butyrate cream

    [T1]

    hydrocortisone butyrate solution

    [T1]

    hydrocortisone cream [T1]

    hydrocortisone enema [T1]

    hydrocortisone lotion [T1]

    hydrocortisone ointment [T1]

    hydrocortisone tablet [T1]

    hydromet syrup [T1]

    hydromorphone liquid [T1]

    hydromorphone tablet [T1]

    hydroxychloroquine sulfate tablet

    [T1] [QL]

    hydroxyurea capsule [T1]

    hydroxyzine pamoate capsule

    [T1]

    hydroxyzine syrup [T1]

    hydroxyzine tablet [T1]

    HYGEL GEL [T3]

    HYLAGUARD CREAM [T3]

    HYLATOPIC PLUS CREAM [T3]

    HYLATOPIC PLUS LOTION [T3]

    hyoscyamine sulfate elixir [T1]

    hyoscyamine sulfate odt tablet

    [T1]

    hyoscyamine sulfate tablet [T1]

    hypocyn solution [T1]

    HYSINGLA ER 24 HR TAB [T2] [QL]

    Iibandronate sodium tablet [T1] [QL]

    IBRANCE CAPSULE [T4] [PA][SP]

    IBRANCE TABLET [T4] [PA][SP]

    ibu tablet [T1]

    ibuprofen suspension [T1]

    ibuprofen tablet [T1]

    ICATIBANT SOLUTION [T4] [PA][SP]

    ICLUSIG TABLET [T4] [PA][SP]

    IDHIFA TABLET [T4] [PA][SP]

    ILEVRO SUSPENSION [T2]

    16www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • IMATINIB MESYLATE TABLET [T4] [PA][SP]

    IMBRUVICA CAPSULE [T4] [PA][SP]

    IMBRUVICA TABLET [T4] [PA][SP]

    imipramine pamoate capsule [T1]

    imipramine tablet [T1]

    imiquimod cream [T1]

    IMPAVIDO CAPSULE [T2] [PA]

    IMURAN TABLET [T3] [BP]

    IMVEXXY MAINTENANCE PACK

    [T3]

    IMVEXXY STARTER PACK [T3]

    INBRIJA CAPSULE [T4] [PA][SP]

    incassia tablet [T1] [ACA]

    INCRELEX SOLUTION [T4] [PA][SP]

    INCRUSE ELLIPTA AEROSOL [T2] [QL]

    indapamide tablet [T1]

    INDOCIN SUPPOSITORY [T3]

    INDOCIN SUSPENSION [T3]

    indomethacin capsule [T1]

    indomethacin er capsule [T1]

    INFANRIX SUSPENSION [T2] [ACA]

    INFASURF SUSPENSION [T3]

    INLYTA TABLET [T4] [PA][SP]

    INREBIC CAPSULE [T4] [PA][SP]

    INSPRA TABLET [T3] [BP]

    INSULIN LISPRO JUNIOR KWIKPEN INJECTION

    [T3] [QL]

    INSULIN LISPRO PROTAMINE MIX SUSPENSION

    [T3] [QL]

    INTELENCE TABLET [T2]

    INTRON A SOLUTION [T4] [PA][SP]

    introvale tablet [T1] [ACA]

    INVEGA 24 HR TAB [T3] [BP]

    INVIRASE TABLET [T2]

    INVOKAMET TABLET [T2] [QL]

    INVOKAMET XR 24 HR TAB [T2] [QL]

    INVOKANA TABLET [T2] [QL]

    IODOFLEX PADS [T3]

    IODOSORB GEL [T3]

    IOPIDINE SOLUTION [T3]

    IPOL INACTIVATED IPV INJECTION

    [T2] [ACA]

    ipratropium bromide solution

    [T1] [QL]

    ipratropium-albuterol solution

    [T1]

    irbesartan tablet [T1]

    irbesartan-hydrochlorothiazide tablet

    [T1]

    IRESSA TABLET [T4] [PA][SP]

    ISENTRESS CHEW TAB [T2]

    ISENTRESS HD TABLET [T2]

    ISENTRESS PACKET [T2]

    ISENTRESS TABLET [T2]

    isibloom tablet [T1] [ACA]

    isoflurane solution [T1]

    isoniazid syrup [T1]

    isoniazid tablet [T1]

    ISOPTO ATROPINE SOLUTION [T3]

    ISOPTO CARPINE SOLUTION [T3] [BP]

    ISORDIL TITRADOSE TABLET [T3] [BP]

    isosorbide dinitrate tablet [T1]

    isosorbide mononitrate 24 hr tab

    [T1]

    isosorbide mononitrate tablet

    [T1]

    isotretinoin capsule [T1]

    isradipine capsule [T1]

    itraconazole capsule [T1]

    itraconazole solution [T1]

    ivermectin tablet [T1]

    Jjaimiess tablet [T1] [ACA]

    JAKAFI TABLET [T4] [PA][SP]

    jantoven tablet [T1]

    JANUMET TABLET [T2] [QL]

    JANUMET XR 24 HR TAB [T2] [QL]

    JANUVIA TABLET [T2] [QL]

    JARDIANCE TABLET [T2] [QL]

    jasmiel tablet [T1] [ACA]

    JATENZO CAPSULE [T4] [PA][SP]

    jencycla tablet [T1] [ACA]

    JENTADUETO TABLET [T2] [QL]

    JENTADUETO XR 24 HR TAB [T2] [QL]

    jinteli tablet [T1]

    jolessa tablet [T1] [ACA]

    juleber tablet [T1] [ACA]

    JULUCA TABLET [T2]

    junel 1.5/30 tablet [T1] [ACA]

    junel 1/20 tablet [T1] [ACA]

    junel fe 1.5/30 tablet [T1] [ACA]

    junel fe 1/20 tablet [T1] [ACA]

    junel fe 24 tablet [T1] [ACA]

    JUXTAPID CAPSULE [T4] [PA][SP]

    JYNARQUE TABLET [T4] [PA][SP]

    KKALETRA SOLUTION [T3] [BP]

    KALETRA TABLET [T2]

    kalliga tablet [T1] [ACA]

    KALYDECO PACKET [T4] [PA][SP]

    KALYDECO TABLET [T4] [PA][SP]

    KARBINAL ER SUSPENSION [T3]

    kariva tablet [T1] [ACA]

    KEFLEX CAPSULE [T3] [BP]

    kelnor 1/35 tablet [T1] [ACA]

    kelnor 1/50 tablet [T1] [ACA]

    KERYDIN SOLUTION [T3] [PA]

    ketoconazole cream [T1]

    ketoconazole shampoo [T1]

    ketoconazole tablet [T1]

    ketoprofen capsule [T1]

    ketoprofen er 24 hour cap [T1]

    ketorolac tromethamine solution

    [T1] [SP]

    ketorolac tromethamine tablet

    [T1] [QL]

    KEVEYIS TABLET [T4] [PA][SP]

    KEVZARA INJECTION [T4] [PA][SP]

    KIMONO LUBRICATED MISC [T2] [ACA]

    KIMONO MICRO THIN MISC [T2] [ACA]

    KIMONO MICROTHIN AQUA LUBE MISC

    [T2] [ACA]

    KIMONO MICROTHIN MISC [T2] [ACA]

    KIMONO TEXTURED MISC [T2] [ACA]

    KINRIX SUSPENSION [T3] [ACA]

    kionex suspension [T1]

    KITABIS PAK NEBULIZED [T4] [PA][SP]

    KLARON LOTION [T3] [BP]

    KLONOPIN TABLET [T3] [BP]

    klor-con 10 tablet [T1]

    klor-con 8 tablet [T1]

    klor-con m10 tablet [T1]

    klor-con m15 tablet [T1]

    klor-con m20 tablet [T1]

    klor-con packet [T1]

    klor-con sprinkle capsule [T1]

    kls aspirin ec tablet [T1] [ACA]

    kls aspirin low dose tablet [T1] [ACA]

    kls laxaclear powder [T1] [ACA]

    kls quit2 gum [T1] [ACA]

    kls quit2 lozenge [T1] [ACA]

    17www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • kls quit4 gum [T1] [ACA]

    kls quit4 lozenge [T1] [ACA]

    KORLYM TABLET [T4] [PA][SP]

    KOSHER PRENATAL PLUS IRON TABLET

    [T3]

    kp aspirin tablet [T1] [ACA]

    kp bisacodyl tablet [T1] [ACA]

    kp folic acid tablet [T1] [ACA]

    KRINTAFEL TABLET [T3]

    kristalose packet [T1]

    k-tab tablet [T1]

    kurvelo tablet [T1] [ACA]

    KUVAN PACKET [T4] [PA][SP][BP]

    KUVAN TABLET [T4] [PA][SP]

    Llabetalol tablet [T1]

    LACRISERT [T3] [PA]

    lactated ringers solution [T1]

    lactulose packet [T1]

    lactulose solution [T1]

    LAMICTAL XR KIT [T3] [QL]

    lamivudine solution [T1]

    lamivudine tablet [T1] [PA][SP]

    lamivudine/zidovudine tablet [T1]

    lamotrigine (blue) kit [T1] [QL]

    lamotrigine (green) kit [T1] [QL]

    lamotrigine (orange) kit [T1] [QL]

    lamotrigine chew tab [T1]

    lamotrigine er 24 hr tab [T1]

    lamotrigine odt tablet [T1]

    lamotrigine tablet [T1]

    lanoxin tablet [T1] [BP]

    lansoprazol-amoxicil-clarithro misc

    [T1]

    lansoprazole capsule (delayed release)

    [T1]

    lanthanum carbonate chew tab

    [T1]

    LANTUS SOLOSTAR INJECTION

    [T2] [QL]

    LANTUS SOLUTION [T2] [QL]

    larin 1.5/30 tablet [T1] [ACA]

    larin 1/20 tablet [T1] [ACA]

    larin 24 fe tablet [T1] [ACA]

    larin fe 1.5/30 tablet [T1] [ACA]

    larin fe 1/20 tablet [T1] [ACA]

    larissia tablet [T1] [ACA]

    LASIX TABLET [T3] [BP]

    LASTACAFT SOLUTION [T3]

    latanoprost solution [T1]

    LATUDA TABLET [T2] [QL]

    leena tablet [T1] [ACA]

    leflunomide tablet [T1]

    LENVIMA 10 MG DAILY DOSE CAPSULE

    [T4] [PA][SP]

    LENVIMA 12MG DAILY DOSE CAPSULE

    [T4] [PA][SP]

    LENVIMA 14 MG DAILY DOSE CAPSULE

    [T4] [PA][SP]

    LENVIMA 18 MG DAILY DOSE CAPSULE

    [T4] [PA][SP]

    LENVIMA 20 MG DAILY DOSE CAPSULE

    [T4] [PA][SP]

    LENVIMA 24 MG DAILY DOSE CAPSULE

    [T4] [PA][SP]

    LENVIMA 4 MG DAILY DOSE CAPSULE

    [T4] [PA][SP]

    LENVIMA 8 MG DAILY DOSE CAPSULE

    [T4] [PA][SP]

    lessina tablet [T1] [ACA]

    LETAIRIS TABLET [T4] [PA][SP][BP]

    letrozole tablet [T1]

    leucovorin calcium tablet [T1]

    LEUKERAN TABLET [T2]

    LEUPROLIDE KIT [T4] [PA][SP]

    levalbuterol nebulized [T1]

    LEVEMIR FLEXTOUCH INJECTION

    [T2] [QL]

    LEVEMIR SOLUTION [T2] [QL]

    levetiracetam er 24 hr tab [T1]

    levetiracetam solution [T1]

    levetiracetam tablet [T1]

    levobunolol solution [T1]

    levocarnitine sf solution [T1]

    levocarnitine solution [T1]

    levocarnitine tablet [T1]

    levocetirizine dihydrochloride solution

    [T1]

    levocetirizine dihydrochloride tablet

    [T1]

    levofloxacin solution [T1]

    levofloxacin tablet [T1]

    levonest tablet [T1] [ACA]

    levonorgestrel tablet [T1] [ACA]

    levonorgestrel-eth estradiol tablet

    [T1] [ACA]

    levonorg-eth estrad eth estrad tablet

    [T1] [ACA]

    levora 0.15/30-28 tablet [T1] [ACA]

    levo-t tablet [T1]

    levothyroxine sodium tablet [T1]

    levoxyl tablet [T1]

    LEVSIN TABLET [T3]

    LEVULAN KERASTICK SOLUTION

    [T4] [PA][SP]

    LEXIVA SUSPENSION [T2]

    LEXIVA TABLET [T3] [BP]

    LIALDA TABLET [T3] [BP]

    lidocaine injection [T1]

    lidocaine jelly gel [T1]

    lidocaine jelly injection [T1]

    lidocaine ointment [T1] [QL]

    lidocaine patch [T1]

    lidocaine patch 5% [T1]

    lidocaine solution [T1]

    lidocaine viscous solution [T1]

    lidocaine/dextrose solution [T1]

    lidocaine/prilocaine cream [T1]

    LIDOTREX GEL [T3]

    lillow tablet [T1] [ACA]

    lindane shampoo [T1]

    linezolid suspension [T1]

    linezolid tablet [T1]

    LINZESS CAPSULE [T2] [QL]

    liothyronine sodium tablet [T1]

    LIPOCREAM BASE CREAM [T3]

    LIPOFEN CAPSULE [T2]

    LIQUID E-Z-PAQUE SUSPENSION

    [T3]

    lisinopril tablet [T1]

    lisinopril-hctz tablet [T1]

    lithium carbonate capsule [T1] [BP]

    lithium carbonate er tablet [T1]

    lithium carbonate tablet [T1]

    lithium solution [T1]

    LITHOBID TABLET [T3] [BP]

    LITHOSTAT TABLET [T3]

    LMR PLUS KIT [T3]

    LO LOESTRIN FE TABLET [T2] [ACA]

    LODINE TABLET [T3] [BP]

    LODOSYN TABLET [T3] [BP]

    lojaimiess tablet [T1] [ACA]

    LOKELMA PACKET [T2]

    18www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • LOMOTIL TABLET [T3] [BP]

    LONHALA MAGNAIR REFILL SOLUTION

    [T3]

    LONHALA MAGNAIR STARTER SOLUTION

    [T3]

    LONSURF TABLET [T4] [PA][SP]

    loperamide capsule [T1]

    LOPERAMIDE SOLUTION [T2]

    LOPID TABLET [T3] [BP]

    lopinavir/ritonavir solution [T1]

    lopreeza tablet [T1]

    LOPRESSOR HCT TABLET [T3] [BP]

    LOPRESSOR TABLET [T3] [BP]

    LOPROX [T3] [BP]

    LOPROX CREAM [T3] [BP]

    LOPROX SUSPENSION [T3] [BP]

    lorazepam [T1]

    lorazepam intensol [T1]

    lorazepam tablet [T1]

    LORBRENA TABLET [T4] [PA][SP]

    lorcet hd tablet [T1]

    lorcet tablet [T1]

    loryna tablet [T1] [ACA]

    losartan potassium tablet [T1]

    losartan-hydrochlorothiazide tablet

    [T1]

    LOSEASONIQUE TABLET [T3] [BP]

    LOTEMAX GEL [T2]

    LOTEMAX OINTMENT [T2]

    LOTEMAX SM GEL [T2]

    LOTEMAX SUSPENSION [T2] [BP]

    LOTENSIN HCT TABLET [T3] [BP]

    LOTENSIN TABLET [T3] [BP]

    loteprednol etabonate suspension

    [T1]

    LOTRONEX TABLET [T3] [BP]

    lovastatin tablet [T1] [ACA][QL]

    LOVAZA CAPSULE [T3] [QL][BP]

    low dose aspirin tablet [T1] [ACA]

    low-ogestrel tablet [T1] [ACA]

    loxapine capsule [T1]

    lo-zumandimine tablet [T1] [ACA]

    ludent chew tab [T1] [ACA]

    LUMIGAN SOLUTION [T2]

    LUPANETA PACK KIT [T4] [PA][SP]

    LUPRON DEPOT (1-MONTH) KIT

    [T4] [PA][SP][QL]

    LUPRON DEPOT (3-MONTH) KIT

    [T4] [PA][SP][QL]

    LUPRON DEPOT (4-MONTH) KIT

    [T4] [PA][SP][QL]

    LUPRON DEPOT-PED KIT [T4] [PA][SP][QL]

    lutera tablet [T1] [ACA]

    LUZU CREAM [T3]

    LYNPARZA TABLET [T4] [PA][SP]

    LYSODREN TABLET [T4] [PA][SP]

    LYSTEDA TABLET [T3] [BP]

    lyza tablet [T1] [ACA]

    MMACRILEN PACKET [T4] [PA][SP]

    MACROBID CAPSULE [T3] [BP]

    MACRODANTIN CAPSULE [T3] [BP]

    mafenide packet [T1]

    magnesium solution [T1] [ACA]

    MALARONE TABLET [T3] [BP]

    malathion lotion [T1] [QL]

    maprotiline tablet [T1]

    MARINOL CAPSULE [T3] [QL][BP]

    marlissa tablet [T1] [ACA]

    MARNATAL-F CAPSULE [T3]

    MARPLAN TABLET [T3]

    MATULANE CAPSULE [T4] [PA][SP]

    matzim la 24 hr tab [T1]

    MAVENCLAD TABLET [T4] [PA][SP]

    MAXITROL OINTMENT [T3] [BP]

    MAXITROL SUSPENSION [T3] [BP]

    MAXX LUBRICATED MISC [T2] [ACA]

    MAXZIDE TABLET [T3] [BP]

    MAXZIDE-25 TABLET [T3] [BP]

    MAYZENT TABLET [T4] [PA][SP]

    md-gastroview solution [T1]

    meclizine tablet [T1]

    meclofenamate sodium capsule

    [T1]

    MEDIHONEY PADS [T2]

    MEDIHONEY WOUND/BURN GEL

    [T3]

    MEDIHONEY WOUND/BURN PASTE

    [T3]

    MEDROL DOSEPAK TABLET [T3] [BP]

    MEDROL TABLET [T3] [BP]

    medroxyprogesterone injection

    [T1] [ACA]

    medroxyprogesterone suspension

    [T1] [ACA]

    medroxyprogesterone tablet [T1]

    mefenamic acid capsule [T1]

    mefloquine tablet [T1] [QL]

    megestrol suspension [T1]

    megestrol tablet [T1]

    MEKINIST TABLET [T4] [PA][SP]

    MEKTOVI TABLET [T4] [PA][SP]

    meloxicam tablet [T1]

    MELPHALAN TABLET [T4] [PA][SP]

    memantine er 24 hour cap [T1]

    memantine solution [T1]

    memantine tablet [T1]

    MEMBRANEBLUE SOLUTION [T3]

    MENACTRA INJECTION [T2] [ACA]

    MENEST TABLET [T3]

    MENOSTAR PATCH [T3] [QL]

    MENTAX CREAM [T3]

    MENVEO SOLUTION [T3] [ACA]

    meperidine solution [T1]

    meperidine tablet [T1]

    MEPHYTON TABLET [T3] [BP]

    meprobamate tablet [T1]

    MEPRON SUSPENSION [T3] [BP]

    mercaptopurine tablet [T1]

    mesalamine dr capsule (delayed release)

    [T1]

    mesalamine dr tablet [T1]

    mesalamine enema [T1]

    mesalamine er 24 hour cap [T1]

    mesalamine suppository [T1]

    MESNEX TABLET [T4] [PA][SP]

    MESTINON SOLUTION [T3] [BP]

    MESTINON TABLET [T3] [BP]

    MESTINON TIMESPAN TABLET

    [T3] [BP]

    metadate er tablet [T1]

    metaproterenol sulfate syrup [T1]

    metaxalone tablet [T1]

    metformin er 24 hr tab [T1]

    metformin tablet [T1]

    METHACHOLINE CHLORIDE KIT

    [T3]

    methadone [T1]

    methadone intensol [T1]

    methadone solution [T1] [BP]

    methadone tablet [T1]

    19www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • methadose [T1] [BP]

    methadose sugarfree [T1] [BP]

    methadose tablet [T1]

    methamphetamine tablet [T1]

    methazolamide tablet [T1]

    methenamine hippurate tablet

    [T1]

    methergine tablet [T1]

    methimazole tablet [T1]

    METHITEST TABLET [T2]

    methocarbamol tablet [T1]

    methotrexate sodium solution

    [T1]

    methotrexate sodium tablet [T1]

    methotrexate solution [T1]

    methotrexate tablet [T1]

    methoxsalen capsule [T1]

    methscopolamine bromide tablet

    [T1]

    methyldopa tablet [T1]

    methyldopa/hydrochlorothiazide tablet

    [T1]

    methylergonovine maleate tablet

    [T1]

    METHYLIN SOLUTION [T3] [BP]

    methylphenidate cd capsule [T1] [QL]

    methylphenidate chew tab [T1]

    methylphenidate er 24 hour cap

    [T1] [QL]

    methylphenidate er 24 hr tab

    [T1] [QL]

    methylphenidate er capsule [T1] [QL]

    methylphenidate er tablet [T1] [QL]

    methylphenidate la 24 hour cap

    [T1] [QL]

    methylphenidate solution [T1]

    methylphenidate tablet [T1]

    methylprednisolone tablet [T1]

    methyltestosterone capsule [T1]

    metoclopramide solution [T1]

    metoclopramide tablet [T1]

    metolazone tablet [T1]

    METOPIRONE CAPSULE [T3]

    metoprolol er 24 hr tab [T1]

    metoprolol tartrate tablet [T1]

    metoprolol-hydrochlorothiazide tablet

    [T1]

    METROCREAM CREAM [T3] [BP]

    METROGEL GEL [T3] [BP]

    METROLOTION LOTION [T3] [BP]

    metronidazole capsule [T1]

    metronidazole cream [T1]

    metronidazole gel [T1]

    metronidazole lotion [T1]

    metronidazole tablet [T1]

    metronidazole vaginal gel [T1]

    METYROSINE CAPSULE [T4] [PA][SP]

    mexiletine capsule [T1]

    miconazole 3 suppository [T1]

    MICONAZOLE-ZINC OXIDE-PETROLTM OINTMENT

    [T3]

    microgestin 1.5/30 tablet [T1] [ACA]

    microgestin 1/20 tablet [T1] [ACA]

    microgestin fe 1.5/30 tablet [T1] [ACA]

    microgestin fe tablet [T1] [ACA]

    midazolam syrup [T1]

    midodrine tablet [T1]

    mifepristone tablet [T1]

    migergot suppository [T1]

    miglitol tablet [T1]

    MIGLUSTAT CAPSULE [T4] [PA][SP]

    mili tablet [T1] [ACA]

    mimvey tablet [T1]

    MINIPRESS CAPSULE [T3] [BP]

    minitran patch [T1]

    MINIVELLE PATCH [T3] [QL]

    minocycline capsule [T1]

    minocycline tablet [T1]

    minoxidil tablet [T1]

    MIRAPEX ER 24 HR TAB [T3] [BP]

    MIRAPEX TABLET [T3] [BP]

    MIRCETTE TABLET [T3] [BP]

    mirtazapine odt tablet [T1]

    mirtazapine tablet [T1]

    MIRVASO GEL [T2]

    misoprostol tablet [T1]

    MITIGARE CAPSULE [T2]

    MITOSOL KIT [T3]

    M-M-R II SOLUTION [T2] [ACA]

    M-NATAL PLUS TABLET [T2]

    MOBIC TABLET [T3] [BP]

    modafinil tablet [T1] [QL]

    moexipril tablet [T1]

    molindone tablet [T1]

    mometasone furoate cream [T1]

    mometasone furoate ointment

    [T1]

    mometasone furoate solution

    [T1]

    mometasone furoate suspension

    [T1] [QL]

    mondoxyne nl capsule [T1]

    mono-linyah tablet [T1] [ACA]

    montelukast sodium chew tab

    [T1]

    montelukast sodium packet [T1]

    montelukast sodium tablet [T1]

    MONUROL PACKET [T3]

    morgidox 1x100mg capsule [T1]

    morgidox 2x100mg capsule [T1]

    morphine sulfate er 24 hour cap

    [T1] [QL]

    morphine sulfate er tablet [T1] [QL]

    morphine sulfate solution [T1]

    morphine sulfate tablet [T1] [BP]

    MOTEGRITY TABLET [T3] [PA]

    MOVANTIK TABLET [T2] [QL]

    MOVIPREP SOLUTION [T3] [BP]

    moxifloxacin solution [T1]

    moxifloxacin tablet [T1]

    MS CONTIN TABLET [T3] [QL][BP]

    MULTAQ TABLET [T3]

    multivit w/fluoride & iron solution

    [T1]

    multi-vit/iron/fluoride solution

    [T1]

    multivitamin w/fluoride & iron solution

    [T1]

    multivitamin with fluoride chew tab

    [T1]

    multivitamin with fluoride solution

    [T1]

    multivitamin/fluoride chew tab

    [T1]

    multivitamin/fluoride solution

    [T1]

    mupirocin cream [T1]

    mupirocin ointment [T1]

    mvc-fluoride chew tab [T1]

    my choice tablet [T1] [ACA]

    my way tablet [T1] [ACA]

    MYAMBUTOL TABLET [T3] [BP]

    MYCOBUTIN CAPSULE [T3] [BP]

    mycophenolate mofetil capsule

    [T1]

    mycophenolate mofetil suspension

    [T1]

    20www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • mycophenolate mofetil tablet

    [T1]

    mycophenolic acid dr tablet [T1]

    MYDRIACYL SOLUTION [T3] [BP]

    MYFORTIC TABLET [T3] [BP]

    MYLERAN TABLET [T4] [PA][SP]

    MYNATAL ADVANCE TABLET [T2]

    MYNATAL CAPSULE [T2]

    MYNATAL PLUS TABLET [T2]

    MYNATAL ULTRACAPLET TABLET

    [T2]

    MYNATAL-Z TABLET [T2]

    MYNATE 90 PLUS TABLET [T2]

    myorisan capsule [T1]

    MYRBETRIQ 24 HR TAB [T2]

    MYSOLINE TABLET [T3] [BP]

    MYTESI TABLET [T3]

    MYXREDLIN SOLUTION [T3]

    Nnabumetone tablet [T1]

    nadolol tablet [T1]

    naftifine gel [T1]

    NALFON TABLET [T3]

    naltrexone tablet [T1]

    NAMENDA TABLET [T3] [BP]

    NAMENDA TITRATION PAK TABLET

    [T3] [BP]

    NAMENDA XR 24 HOUR CAP [T3]

    NAMZARIC 24 HOUR CAP [T2]

    NAMZARIC CAPSULE [T2]

    NAPROSYN SUSPENSION [T3] [BP]

    naproxen dr tablet [T1]

    naproxen sodium tablet [T1]

    naproxen suspension [T1]

    naproxen tablet [T1]

    naratriptan tablet [T1] [QL]

    NARCAN LIQUID [T2]

    NARDIL TABLET [T3] [BP]

    NATACHEW CHEW TAB [T3]

    NATACYN SUSPENSION [T2]

    NATAZIA TABLET [T3] [ACA]

    nateglinide tablet [T1]

    NATPARA INJECTION [T4] [PA][SP]

    NATROBA SUSPENSION [T3]

    nature-throid nt-2.5 tablet [T1]

    nature-throid tablet [T1]

    NAYZILAM SOLUTION [T2] [QL]

    NEBUPENT SOLUTION [T4] [PA][SP][BP]

    necon 0.5/35-28 tablet [T1] [ACA]

    NEEVO DHA CAPSULE [T3]

    nefazodone tablet [T1]

    neo/polymyxin/dexamethasone ointment

    [T1]

    neo/polymyxin/dexamethasone suspension

    [T1]

    neomycin sulfate tablet [T1]

    neomycin/bacitracin/poly/hc ointment

    [T1]

    neomycin/bacitracin/polymyxin ointment

    [T1]

    neomycin/polymyxin/gramicidin solution

    [T1]

    neomycin/polymyxin/hc solution

    [T1]

    neomycin/polymyxin/hc suspension

    [T1]

    neomycin-polymyxin b solution

    [T1]

    neomycin-polymyxin-dexamethaso ointment

    [T1]

    neo-polycin hc ointment [T1]

    neo-polycin ointment [T1]

    NEORAL CAPSULE [T3]

    NEORAL SOLUTION [T3]

    NERLYNX TABLET [T4] [PA][SP]

    NESTABS DHA MISC [T3]

    NESTABS ONE CAPSULE [T3]

    NESTABS TABLET [T3]

    neuac gel [T1]

    NEULASTA INJECTION [T4] [PA][SP]

    NEULASTA ONPRO KIT INJECTION

    [T4] [PA][SP]

    NEUPRO PATCH [T3]

    nevirapine er 24 hr tab [T1]

    nevirapine suspension [T1]

    nevirapine tablet [T1]

    new day tablet [T1] [ACA]

    NEXAVAR TABLET [T4] [PA][SP]

    NEXIUM CAPSULE (DELAYED RELEASE)

    [T3] [BP]

    NEXIUM PACKET [T2] [BP]

    NEXLETOL TABLET [T2] [PA]

    niacin er tablet [T1]

    niacin tablet [T1]

    NIACOR TABLET [T3]

    NIASPAN TABLET [T3] [BP]

    nicardipine capsule [T1]

    nicotine gum [T1] [ACA]

    nicotine kit [T1] [ACA]

    nicotine lozenge [T1] [ACA]

    nicotine mini lozenge [T1] [ACA]

    nicotine patch [T1] [ACA]

    nicotine polacrilex gum [T1] [ACA]

    nicotine polacrilex lozenge [T1] [ACA]

    nicotine step 3 patch [T1] [ACA]

    NICOTROL INHALER [T3] [ACA]

    NICOTROL NS SOLUTION [T3] [ACA]

    nifedipine capsule [T1]

    nifedipine er 24 hr tab [T1]

    nikki tablet [T1] [ACA]

    NILANDRON TABLET [T4] [PA][SP][BP]

    NILUTAMIDE TABLET [T4] [PA][SP]

    nimodipine capsule [T1]

    NINLARO CAPSULE [T4] [PA][SP]

    nisoldipine er 24 hr tab [T1]

    NITISINONE CAPSULE [T4] [PA][SP]

    nitro-bid ointment [T1]

    NITRO-DUR PATCH [T3]

    nitrofurantoin capsule [T1]

    nitrofurantoin macrocrystal capsule

    [T1]

    nitrofurantoin suspension [T1]

    nitroglycerin lingual solution [T1]

    nitroglycerin patch [T1]

    nitroglycerin sl [T1]

    NITROLINGUAL PUMPSPRAY SOLUTION

    [T3] [BP]

    NITROMIST AEROSOL [T3]

    NITROSTAT SL [T3] [BP]

    NITYR TABLET [T4] [PA][SP]

    NIVA-PLUS TABLET [T3]

    nivatopic plus cream [T1]

    NIVESTYM INJECTION [T4] [PA][SP]

    NIVESTYM SOLUTION [T4] [PA][SP]

    nizatidine capsule [T1]

    nizatidine solution [T1]

    nora-be tablet [T1] [ACA]

    NORDITROPIN FLEXPRO SOLUTION

    [T4] [PA][SP]

    norethindrone tablet [T1] [ACA]

    norethindrone-ethin estradiol tablet

    [T1] [ACA]

    21www.hometownhealth.comFor plan specific information, call (844) 373-0970, or visit us at:

    www.hometownhealth.com

  • norethin-eth estra ferrous fum chew tab

    [T1] [ACA]

    norethin-eth estra ferrous fum tablet

    [T1] [ACA]

    NORGESIC FORTE TABLET [T3] [BP]

    norgestimate-ethinyl estradiol tablet

    [T1] [ACA]

    norlyda tablet [T1] [ACA]

    norlyroc tablet [T1] [ACA]

    NORPACE CAPSULE [T3] [BP]

    NORPACE CR CAPSULE [T3]

    NORPRAMIN TABLET [T3] [BP]

    NORTHERA CAPSULE [T4] [PA][SP]

    nortrel 0.5/35 (28) tablet [T1] [ACA]

    nortrel 1/35 tablet [T1] [ACA]

    nortrel 7/7/7 tablet [T1] [ACA]

    nortriptyline capsule [T1]

    nortriptyline solution [T1]

    NORVIR PACKET [T2]

    NORVIR SOLUTION [T2]

    NORVIR TABLET [T3] [BP]

    NOURIANZ TABLET [T4] [PA][SP]

    NOXAFIL SUSPENSION [T2] [PA]

    NOXAFIL TABLET [T3] [PA][BP]

    np thyroid 120 tablet [T1]

    np thyroid 15 tablet [T1]

    np thyroid 30 tablet [T1]

    np thyroid 60 tablet [T1]

    np thyroid 90 tablet [T1]

    NUBEQA TABLET [T4] [PA][SP]

    NUCALA INJECTION [T4] [PA][SP]

    NUCYNTA ER 12 HR TAB [T2] [QL]

    NUCYNTA TABLET [T2]

    NUEDEXTA CAPSULE [T2]

    nulev tablet [T1]

    NULYTELY SOLUTION [T3] [BP]

    NULYTELY/FLAVOR PACKS SOLUTION

    [T3] [BP]

    NUMBRINO SOLUTION [T3]

    NUPLAZID CAPSULE [T4] [PA][SP]

    NUPLAZID TABLET [T4] [PA][SP]

    NURTEC TABLET [T3] [PA][QL]

    NUVARING [T2] [QL][BP]

    NUZYRA TABLET [T3] [SP]

    nyamyc powder [T1]

    NYMALIZE SOLUTION [T3]

    nystatin cream [T1]

    nystatin ointment [T1]

    nystatin powder [T1]

    nystatin suspension [T1]

    nystatin tablet [T1]

    nystatin w/triamcinolone cream

    [T1]

    nystatin w/triamcinolone ointment

    [T1]

    nystatin/triamcinolone cream

    [T1]

    nystatin/triamcinolone ointment

    [T1]

    nystop powder [T1]

    OOASIS [T3]

    OASIS WOUND MATRIX [T3]

    OB COMPLETE ONE CAPSULE [T3]

    OB COMPLETE PETITE CAPSULE

    [T3]

    OB COMPLETE PREMIER TABLET

    [T3]

    OB COMPLETE TABLET [T3]

    OB COMPLETE/